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Antifungal Dosing in Obesity: A Review of the Literature

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Abstract

Obesity is becoming a global pandemic that is projected to increase significantly over the next few decades. Unfortunately, studies of drug dosing and pharmacokinetics have largely excluded obese patients. Currently, literature inadequately characterizes drug disposition in these patients. Only a limited selection of literature addresses antibacterial dosing in obesity, and virtually none characterizes antifungal dosing in obesity. This review discusses the changes in pharmacokinetics that occur in obesity and the available in vitro and in vivo data describing the disposition of antifungal agents in obese animals and patients.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. World Health Organization: Obesity and Overweight. Available at: http://www.who.int/mediacentre/factsheets/fs311/en/index.html. Accessed October 28, 2010.

  2. Wang Y, Beydoun MA, Liang L, Caballero B, Kumanyika SK. Will all Americans become overweight or obese? Estimating the progression and cost of the US obesity epidemic. Obesity. 2008;16:2323–30.

    Article  PubMed  Google Scholar 

  3. Blouin RA, Warren GW. Pharmacokinetic considerations in obesity. J Pharm Sci. 1999;88:1–7.

    Article  PubMed  CAS  Google Scholar 

  4. Cheymol G. Effects of obesity on pharmacokinetics: implications for drug therapy. Clin Pharmacokinet. 2000;39:215–31.

    Article  PubMed  CAS  Google Scholar 

  5. • Hanley MJ, Abernathy DR, Greenblatt DJ. Effect of obesity on the pharmacokinetics of drugs in humans. Clin Pharmacokinet. 2010;49:71–87. This review is the most recent update of the effects of obesity on human pharmacokinetics. The authors provide a thorough discussion of the different derivations of weight descriptors and their utility. This article also provides complete descriptions of drug disposition: volume of distribution, clearance, half-life, and the variations of these parameters in obese patients. It also thoroughly reviews the available literature on dosing of individual drugs and drug classes in obese patients.

    Article  PubMed  CAS  Google Scholar 

  6. Wurtz R, Itokazu G, Rodvold K. Antimicrobial dosing in obesity. Clin Infect Dis. 1999;25:112–8.

    Article  Google Scholar 

  7. Bearden DT, Rodvold KA. Dosage adjustments for antibacterials in obese patients: applying clinical pharmacokinetics. Clin Pharmacokinet. 2000;38:415–26.

    Article  PubMed  CAS  Google Scholar 

  8. Erstad BL. Dosing of medications in morbidly obese patients in the intensive care unit setting. Intensive Care Med. 2004;30:18–32.

    Article  PubMed  Google Scholar 

  9. Pai MP, Bearden DT. Antimicrobial dosing considerations in obese adult patients. Pharmacotherapy. 2007;27:1081–91.

    Article  PubMed  CAS  Google Scholar 

  10. Devine D. Case Study Number 25 Gentamicin Therapy. Drug Intell Clin Pharm. 1974;8:650–5.

    Google Scholar 

  11. Saadeh S. Nonalcoholic fatty liver disease and obesity. Nutr Clin Pract. 2007;22:1–10.

    Article  PubMed  Google Scholar 

  12. Cheng P-Y, Morgan ET. Hepatic cytochrome P450 regulation in disease states. Curr Drug Metab. 2001;2:165–83.

    Article  PubMed  CAS  Google Scholar 

  13. Janmahasatian S, Dufffull SB, Ash S, Ward LC, Byrne NM, Green B. Quantification of lean body weight. Clin Pharmacokinet. 2005;44:1051–65.

    Article  PubMed  Google Scholar 

  14. Han PY, Duffull SB, Kirkpatrick CMJ, Green B. Dosing in obesity: a simple solution to a big problem. Clin Pharmacol Ther. 2007;82:505–8.

    Article  PubMed  CAS  Google Scholar 

  15. • Pai MP. Estimating the glomerular filtration rate in obese adult patients for drug dosing. Adv Chronic Kidney Dis. 2010;5:e53-e62. This article thoroughly reviews the effect of obesity on GFR. The author reviews the derivations of the various GFR equations, Cockcroft and Gault, and their limitations in predicting GFR and creatinine clearance. He compares and contrasts the ability of calculated weight descriptors to predict GFR and provides the equations for each. Finally, he concludes with practical considerations for using our current GFR and creatinine clearance calculations and proposes the use of other weight descriptors in these equations to improve clinical estimates.

    Article  Google Scholar 

  16. Slain D. Lipid-based amphotericin B for the treatment of fungal infections. Pharmacotherapy. 1999;19:306–23.

    Article  PubMed  CAS  Google Scholar 

  17. Atkinson AJ, Bennett JE. Amphotericin B pharmacokinetics in humans. Antimicrob Agents Chemother. 1978;13:271–6.

    PubMed  Google Scholar 

  18. Janknegt R, de Marie S, Bakker-Woudenberg IA, et al. Liposomal and lipid formulations of amphotericin B: clinical pharmacokinetics. Clin Pharmacokinet. 1992;23:279–91.

    Article  PubMed  CAS  Google Scholar 

  19. Daneshmend TK, Warnock DW. Clinical pharmacokinetics of systemic antifungal drugs. Clin Pharmacokinet. 1983;8:17–42.

    Article  PubMed  CAS  Google Scholar 

  20. Brajtburg J, Elberg S, Bolard J, et al. Interaction of plasma proteins and lipoproteins with amphotericin B. J Infect Dis. 1984;149:986–97.

    Article  PubMed  CAS  Google Scholar 

  21. Collette N, Van der Auwera P, Van der Pascual Lopez A, et al. Tissue concentrations and bioactivity of amphotericin B in cancer patients treated with amphotericin B deoxycholate. Antimicrob Agents Chemother. 1989;33:362–8.

    PubMed  CAS  Google Scholar 

  22. Craven PC, Ludden TM, Drutz DJ, et al. Excretion pathways of amphotericin B. J Infect Dis. 1979;140:329–41.

    Article  PubMed  CAS  Google Scholar 

  23. Walsh TJ, Goodman JL, Pappas P, Bekersky I, Buell DN, Roden M, et al. Safety, tolerance, and pharmacokinetics of high-dose liposomal amphotericin B (AmBisome) in patients infected with Aspergillus species and other filamentous fungi: maximum tolerated dose study. Antimicrob Agents Chemother. 2001;45:3487–96.

    Article  PubMed  CAS  Google Scholar 

  24. Gallis HA, Drew RH, Pichard WW. Amphotericin B 30 years of clinical experience. Rev Infect Dis. 1990;12:308–29.

    Article  PubMed  CAS  Google Scholar 

  25. Christiansen KJ, Bernard EM, Gold JWM, et al. Distribution and activity of amphotericin B in humans. J Infect Dis. 1985;152:1037–43.

    Article  PubMed  CAS  Google Scholar 

  26. Vadiei K, Lopez-Berestein G, Luke DR. Disposition and toxicity of amphotericin B in the hyperlipidemic Zucker Rat Model. Int J Obes. 1990;14:465–72.

    PubMed  CAS  Google Scholar 

  27. Ramaswamy M, Peteherych KD, Kennedy AL, et al. Amphotericin B lipid complex or amphotericin B multiple-dose administration to rabbits with elevated plasma cholesterol levels: pharmacokinetics in plasma and blood, plasma lipoprotein levels, distribution in tissues, and renal toxicities. Antimicrob Agents Chemother. 2001;45:1184–91.

    Article  PubMed  CAS  Google Scholar 

  28. Brown CD, Higgins M, Donato KA, et al. Body mass index and the prevalence of hypertension and dyslipidemia. Obes Res. 2000;8:605–19.

    Article  PubMed  CAS  Google Scholar 

  29. Koldin MH, Kobayashi GS, Brajtburg, et al. Effects of elevation of serum cholesterol and administration of amphotericin B complexed to lipoproteins on amphotericin B-induced toxicity in rabbits. Antimicrob Agents Chemother. 1985;28:144–5.

    PubMed  CAS  Google Scholar 

  30. Wasan KM, Kennedy AL, Cassidy SM, et al. Pharmacokinetics, distribution in serum lipoproteins and tissues, and renal toxicities of amphotericin B and amphotericin B lipid complex in a hypercholesterolemic rabbit model: Single-dose studies. Antimicrob Agents Chemother. 1998;42:3146–52.

    PubMed  CAS  Google Scholar 

  31. Groll AH, Mickiene D, Piscitelli SC, et al. Distribution of lipid formulations of amphotericin B into bone marrow and fat tissue in rabbits. Antimicrob Agents Chemother. 2000;44:408–10.

    Article  PubMed  CAS  Google Scholar 

  32. Collette N, Van der Auwera P, Meunier F, et al. Tissue distribution and bioactivity of amphotericin B administration in liposomes to cancer patients. J Antimicrob Chemother. 1991;27:535–48.

    Article  PubMed  CAS  Google Scholar 

  33. Bellmann R. Clinical pharmacokinetics of systemically administered antimycotics. Curr Clin Pharmacol. 2007;2:37–58.

    Article  PubMed  CAS  Google Scholar 

  34. De Beule K, Van Gestel J. The pharmacology of itraconazole. Drugs. 2001;61 Suppl 1:27–37.

    Article  PubMed  Google Scholar 

  35. Theuretzbacher U, Ihle F, Derendorf H. Pharmacokinetic/pharmacodynamic profile of voriconazole. Clin Pharmacokinet. 2006;45:649–63.

    Article  PubMed  CAS  Google Scholar 

  36. Li Y, Theuretzbacher U, Clancy CJ, Nguyen MH, Derendorf H. Pharmacokinetic/pharmacodynamic profile of posaconazole. Clin Pharmacokinet. 2010;49:379–96.

    Article  PubMed  CAS  Google Scholar 

  37. Glassner-Cohen L, DiBiasio A, Lisco SJ, Hurford WE. Fluconazole serum concentrations and pharmacokinetics in an obese patient. Pharmacotherapy. 1997;17:1023–6.

    Google Scholar 

  38. Anaissie EJ, Kontoyiannis DP, Huls C, Vartivarian SE, Karl C, Prince RA, et al. Safety, plasma concentrations, and efficacy of high-dose fluconazole in invasive mold infections. J Infect Dis. 1995;172:599–602.

    Article  PubMed  CAS  Google Scholar 

  39. Wasan KM, Kennedy AL, Cassidy SM, et al. Pharmacokinetics, distribution in serum lipoproteins and tissues, and renal toxicities of amphotericin B and amphotericin B lipid complex in a hypercholesterolemic rabbit model: single-dose studies. Antimicrob Agents Chemother. 1998;42:3146–52.

    PubMed  CAS  Google Scholar 

  40. • Pai MP, Lodise TP. Pharmacokinetics (PK) of voriconazole (VOR) in obese (OB) adults. Poster A1–044. Presented at the 50th Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC); September 12–15, 2010, Boston, MA. Though currently available only in abstract/poster form and described in the article, this is one of the first comparative pharmacokinetic studies describing drug disposition of an antifungal agent (voriconazole) in obese patients. This study compares two different doses of voriconazole in obese patients and in historical, nonobese control patients. The study demonstrates no significant differences in apparent voriconazole pharmacokinetic values between obese and nonobese patients, but differences are noted when adjusted for average TBW. The authors further describe the correlations of TBW and LBW (2005) to AUC values. This article provides some much-needed evidence about the disposition of voriconazole in obese patients.

  41. Estes KE, Penzak SR, Calis KA, et al. Pharmacology and antifungal properties of anidulafungin, A new echinocandin. Pharmacotherapy. 2009;29:17–30.

    Article  PubMed  CAS  Google Scholar 

  42. Gumbo T. Impact of pharmacodynamics and pharmacokinetics on echinocandin dosing strategies. Curr Opin Infect Dis. 2007;20:587–91.

    Article  PubMed  CAS  Google Scholar 

  43. Stone JA, Xu X, Winchell GA, et al. Disposition of caspofungin: role of distribution in determining pharmacokinetics in plasma. Antimicrob Agents Chemother. 2004;48:815–23.

    Article  PubMed  CAS  Google Scholar 

  44. Damle B, Stogniew M, Dowell J. Pharmacokinetics and tissue distribution of anidulafungin in rats. Antimicrob Agents Chemother. 2008;52:2673–6.

    Article  PubMed  CAS  Google Scholar 

  45. Groll AH, Mickiene D, Petraitis V, et al. Compartmental pharmacokinetics and tissue distribution of the antifungal echinocandin lipopeptide micafungin in rabbits. Antimicrob Agents Chemother. 2001;45:3322–7.

    Article  PubMed  CAS  Google Scholar 

  46. Ryan D, Lupinacci R, Kartsonis N. Efficacy and safety of caspofungin in obese patients [Abstract # 1040] in program and abstracts of the 47th annual meeting of the Infectious Diseases Society of America, October 29–November 1, 2009, Philadelphia, PA.

  47. Stone JA, Winchell GA, Bi S, et al. Population pharmacokinetics of caspofungin in candidiasis patients [abstract A-1571]. Available in program and abstracts of the 43rd Annual Meeting of the Interscience Conference on Antimicrobial Agents and Chemotherapy, September 14–17, 2009, Chicago, IL.

  48. Nguyen TH, Hoppe-Tichy T, Geiss HK, et al. Factors influencing caspofungin plasma concentrations in patients of a surgical intensive care unit. J Antimicrob Chemother. 2007;60:100–6.

    Article  PubMed  CAS  Google Scholar 

  49. Gumbo T, Hiemenz J, Ma L, et al. Population pharmacokinetics of micafungin in adult patients. Diagn Microbiol Infect Dis. 2008;60:329–31.

    Article  PubMed  CAS  Google Scholar 

  50. Hebert MF, Smith HE, Marbury TC, et al. Pharmacokinetics of micafungin in healthy volunteers with moderate liver disease, and volunteers with renal dysfunction. J Clin Pharmacol. 2005;45:1145–52.

    Article  PubMed  CAS  Google Scholar 

  51. Dowell JA, Knebel W, Ludden T, et al. Population pharmacokinetic analysis of anidulafungin, an echinocandin antifungal. J Clin Pharmacol. 2004;44:590–8.

    Article  PubMed  CAS  Google Scholar 

  52. Betts RF, Nucci M, Talwar D, et al. A multicenter, double-blind trial of a high-dose caspofungin treatment regimen versus a standard caspofungin treatment regimen for adult patients with invasive candidiasis. Clin Infect Dis. 2009;48:1676–84.

    Article  PubMed  CAS  Google Scholar 

  53. Vermes A, Guchelaar H-J, Dankert J. Flucytosine: a review of its pharmacology, clinical indications, pharmacokinetics, toxicity and drug interactions. J Antimicrob Chemother. 2000;46:171–9.

    Article  PubMed  CAS  Google Scholar 

  54. Gillum JG, Johnson M, Lavoie S, Venitz J. Flucytosine dosing in an obese patient with extrameningeal cryptococcal infection. Pharmacotherapy. 1995;15:251–3.

    PubMed  CAS  Google Scholar 

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Correspondence to Jarrett R. Amsden.

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Amsden, J.R., Slain, D. Antifungal Dosing in Obesity: A Review of the Literature. Curr Fungal Infect Rep 5, 83–91 (2011). https://doi.org/10.1007/s12281-011-0049-7

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