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In subjects with CL(CR) 30 - 80 ml/min, the mean maximal telithromycin concentration at steady state (C(max),ss) was 3.6 mg/l and the steady state area under the plasma concentration-time curve from time zero to 24 hours (AUC(0-24 h) ss) was 33.4 mg x h/l. The mean C(max), ss and AUC(0-12 h)ss for clarithromycin were 6.2 mg/l and 56.1 mg x h/l, respectively. The increases in telithromycin C(max) ss and AUC(0-24 h) ss compared to corresponding data for healthy young subjects were 1.6- and 2.7-fold, respectively, whereas corresponding increases for clarithromycin were 2.2- and 3.3-fold, respectively. In the telithromycin plus ketoconazole group deltaQTc values were equal or < 60 ms. All QTc values were equal or < 450 ms in males and equal or < 470 ms in females.
Oral swabs of 73 HIV-1 infected men (32 under conditions of antimycotic treatment (43.8%)) and 58 controls were cultured for Candida species and Enterobacteriaceae. In Group A without antimycotics, yeasts were isolated from 35/41 swabs (85.4%) (range 2 x 10(1) - 4 x 10(6) cfu/ml). In Group B with antimycotics, yeasts were cultured from 27/32 swabs (84.4%) (4 x 10(1) - 1 x 10(6) cfu/ml). Oral Enterobacteriaceae (o.e.) were grown from 22% of the swabs of both Group A (2 x 10(1) - 2 x 10(6) cfu/ml) and Group B (4 x 10(1) - 1.6 x 10(6) cfu/ml). Growth of o.e. and yeasts (2 x 10(3) - 4 x 10(6) cfu/ml). Correlation between yeasts and o.e. were isolated in 14% (2 x 10(1) - 6.4 x 10(6) cfu/ml). Correlation between yeasts species to local and systemic treatment deserves further investigations.
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The effect of ketoconazole on the fertility of male rats was evaluated. Three days of oral dosing with ketoconazole at 200 mg/kg reduced fertility compared to controls. A complete loss of fertility was observed after doses of 400 mg/kg. There was no change in the testicular weight, epididymal sperm concentration or epididymal weight between the control and treatment groups. Motility was reduced in the high-dose group and forward progression was reduced in both dosing groups compared to control. These data support previous observations in the dog and primate that orally administered ketoconazole alters sperm viability. Although ketoconazole is too toxic for contraceptive application, its derivatives may be useful for this purpose.
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A total of forty patients participated in an open, randomized study to compare the efficacy and toleration of a single dose of topical tioconazole 6% vaginal ointment with 5 days treatment of systemic ketoconazole (400 mg/day) in patients with symptomatic vaginal candidal infection. Disease in patients of both treatment groups was effectively eradicated after 5 weeks of therapy. Symptoms of patients receiving topical therapy responded more quickly than those of patients receiving oral therapy. Side-effects were more prevalent with ketoconazole systemic therapy. Overall, topical therapy with tioconazole was preferred over systemic ketoconazole therapy for these women with symptomatic vulvovaginitis due to Candida albicans.
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Most antifungal agents were active against the dermatophytes, except for terbinafine against Trichophyton rubrum (geometric mean MIC, MICGM 3.17 μg/mL). The dematiaceous moulds were relatively susceptible to amphotericin B and azoles (MICGM 0.17-0.34 μg/mL), but not to terbinafine (MICGM 3.62 μg/mL). Septate hyaline moulds showed variable results between the relatively more susceptible Aspergillus spp. (MICGM 0.25-4 μg/mL) and the more resistant Fusarium spp. (MICGM 5.66-32 μg/mL). The zygomycetes were susceptible to amphotericin B (MICGM 0.5 μg/mL) and clotrimazole (MICGM 0.08 μg/mL), but not to other azoles (MICGM 2.52-4 μg/mL).
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Fifty-seven trials investigating itraconazole, ketoconazole, fluconazole, and pramiconazole were included. Cumulative dose, treatment duration, and daily/weekly concentrations were shown to significantly influence mycologic cure rates for ketoconazole and pramiconazole but not for itraconazole and fluconazole.
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Biotransformation of triazolam to its alpha-hydroxy and 4-hydroxy metabolites by human liver microsomes in vitro was used as an index of human cytochrome P450 3A (CYP3A) activity.
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To examine the pathophysiology of RIP and evaluate the treatment options.
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CYP51 (sterol 14α-demethylase) is a cytochrome P450 enzyme essential for sterol biosynthesis and the primary target for clinical and agricultural antifungal azoles. The azoles that are currently in clinical use for systemic fungal infections represent modifications of two basic scaffolds, ketoconazole and fluconazole, all of them being selected based on their antiparasitic activity in cellular experiments. By studying direct inhibition of CYP51 activity across phylogeny including human pathogens Trypanosoma brucei, Trypanosoma cruzi and Leishmania infantum, we identified three novel protozoa-specific inhibitory scaffolds, their inhibitory potency correlating well with antiprotozoan activity. VNI scaffold (carboxamide containing β-phenyl-imidazoles) is the most promising among them: killing T. cruzi amastigotes at low nanomolar concentration, it is also easy to synthesize and nontoxic. Oral administration of VNI (up to 400 mg/kg) neither leads to mortality nor reveals significant side effects up to 48 h post treatment using an experimental mouse model of acute toxicity. Trypanosomatidae CYP51 crystal structures determined in the ligand-free state and complexed with several azole inhibitors as well as a substrate analog revealed high rigidity of the CYP51 substrate binding cavity, which must be essential for the enzyme strict substrate specificity and functional conservation. Explaining profound potency of the VNI inhibitory scaffold, the structures also outline guidelines for its further development. First steps of the VNI scaffold optimization have been undertaken; the results presented here support the notion that CYP51 structure-based rational design of more efficient, pathogen-specific inhibitors represents a highly promising direction.
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With the increased awareness of onychomycosis and the increasing use of antifungals for this indication, it is prudent to be concerned about the possible emergence of resistant strains. There has been substantial work on the development of standardized methods for testing the in vitro resistance of various fungi and yeasts to the currently available antifungal agents. However, relatively little research has been published concerning the resistance of dermatophyte species.
Molecular modeling and human microsomal studies predicted ixabepilone to be a good substrate for CYP3A4. In patients, ketoconazole coadministration resulted in a maximum ixabepilone dose administration to 25 mg/m(2) when compared with single-agent therapy of 40 mg/m(2). Coadministration of ketoconazole with ixabepilone resulted in a 79% increase in AUC(0-infinity). The relationship of microtubule bundle formation in peripheral blood mononuclear cells to plasma ixabepilone concentration was well described by the Hill equation. Microtubule bundle formation in peripheral blood mononuclear cells correlated with neutropenia.
Patients were considered controlled if 24-h urinary free cortisol was normalized.
Current treatment modalities for bronchopulmonary aspergillosis are not very satisfying. We determined the in vitro activity of recently available azoles against Aspergillus fumigatus, Aspergillus flavus and Aspergillus niger. Subsequently, these agents were evaluated in an animal model of bronchopulmonary aspergillosis using A. fumigatus as test organism. In vitro, detectable activity was only found for itraconazole (all minimal inhibitory concentrations, MICs, less than or equal to 3.2 micrograms/ml). The MICs for SCH39304 were greater than or equal to 12.8 micrograms/ml and greater than or equal to 25.6 micrograms/ml for ketoconazole and fluconazole. In vivo, amphotericin B was the most active agent tested, and SCH39304 was the most active azole in terms of survival and reduction in lung weight, followed by itraconazole. Ketoconazole and fluconazole did not improve survival nor reduce the lung weight of infected animals. We conclude, (1) that in vitro activity of azoles against aspergilli does not always correlate with in vivo activity; (2) that in vivo, SCH39304 was the most active azole tested, followed by itraconazole; (3) that for those agents for which data about effectiveness in human pulmonary aspergillosis are available (amphotericin B, ketoconazole, itraconazole) antifungal activity in our model corresponds to activity as seen in human beings, and (4) that SCH39304 and itraconazole are rational choices for clinical trials in human pulmonary aspergillosis.
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To improve our understanding of the prescribing and patient-monitoring practices of physicians prescribing medications with a BBW to patients age >or=65 years in an ambulatory care setting.
Chloroquine has been used for many decades in the prophylaxis and treatment of malaria. It is metabolized in humans through the N-dealkylation pathway, to desethylchloroquine (DCQ) and bisdesethylchloroquine (BDCQ), by cytochrome P450 (CYP). However, until recently, no data are available on the metabolic pathway of chloroquine. Therefore, the metabolic pathway of chloroquine was evaluated using human liver microsomes and cDNA-expressed CYPs. Chloroquine is mainly metabolized to DCQ, and its Eadie-Hofstee plots were biphasic, indicating the involvement of multiple enzymes, with apparent Km and Vmax values of 0.21 mM and 1.02 nmol/min/mg protein 3.43 mM and 10.47 nmol/min/mg protein for high and low affinity components, respectively. Of the cDNA-expressing CYPs examined, CYP1A2, 2C8, 2C19, 2D6 and 3A4/5 exhibited significant DCQ formation. A study using chemical inhibitors showed only quercetin (a CYP2C8 inhibitor) and ketoconazole (a CYP3A4/5 inhibitor) inhibited the DCQ formation. In addition, the DCQ formation significantly correlated with the CYP3A4/5-catalyzed midazolam 1-hydroxylation (r = 0.868) and CYP2C8-catalyzed paclitaxel 6alpha-hydroxylation (r = 0.900). In conclusion, the results of the present study demonstrated that CYP2C8 and CYP3A4/5 are the major enzymes responsible for the chloroquine N-deethylation to DCQ in human liver microsomes.
Malassezia species, organisms normally colonizing the skin surface, are thought to play a role as either the cause or an exacerbating factor in a number of skin conditions, including pityriasis versicolor, Malassezia folliculitis, seborrheic dermatitis (SD) and atopic dermatitis (AD). Using a non-cultural PCR method, we analyzed Malassezia spp. extracted from the skin surface of SD and AD patients. The species most commonly detected in both patient groups were M. globosa and M. restricta, and the number of Malassezia spp. In these patients was higher than in healthy subjects. After a topical application of 2% ketoconazole cream, changes in the population of Malassezia spp. in 20 intractable cases of AD were recorded. The addition of the 2% ketoconazole cream to the standard topical treatments was found to have reduced the Malassezia spp. population by 90%, and showed a clinical efficacy rate of 70%. Furthermore, a combination of azole agents and tacrolimus produced a synergistic anti-fungal effect against Malassezia spp. in vitro. A clinical trial using this drug combination conducted on the face and neck of patients with intractable AD showed a 66.6% efficacy rate in both the reduction of the flora and in clinical improvement. From these results it was evident that Malassezia is one of the factors exacerbating AD, and that removal of the organism results in an improvement in the clinical condition of the patient.
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Ten patients had evaluable pharmacokinetic data and were, therefore, included in pharmacokinetic statistical analyses. The maximum observed plasma concentration (Cmax) and area under the plasma concentration-time curve (AUC) from time 0 to infinite time (AUC∞) of navitoclax in the presence of ketoconazole was 94% (90% confidence interval (CI)=53165%) and 155% (90% CI=91264%), respectively of those observed with navitoclax when administered alone. The increase in navitoclax AUC∞ was primarily driven by two patients, who had 5-fold and 11-fold increases, respectively, in navitoclax AUC∞ in the presence of ketoconazole. These two participants had unusually low plasma drug exposure when navitoclax was administered alone, and their navitoclax exposure in the presence of ketoconazole increased to be within the range of the other 8 patients. There were no adverse events related to navitoclax exposure reported in these 2 patients.
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Ketoconazole, administered as a single oral dose depressed ovarian concentration of estradiol-17 beta in rats. Estradiol-17 beta was quantitated, following dansylation, by a high-performance-liquid-chromatographic method. Control proestrous concentration was 111.2 +/- 6.9 pg/mg. With ketoconazole doses of 5 mg/kg and 20 mg/kg, the estrogen concentration was reduced to 84.0 +/- 8.4 pg/mg and 34.6 +/- 5.0 pg/mg respectively.
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Fungal vulvovaginitis remains one of the most frequent conditions affecting the lower genital tract. Recent advances in the understanding of the pathophysiology of the condition have improved our ability to treat recurrent or persistent cases. More clinical data have become available on the optimal duration of treatment with some of the newer antifungal agents.
Itraconazole and voriconazole had the highest antifungal activity against the isolates tested. The essential agreement between the two methods for azoles antifungal activity was in the region of 60-85% and the categorical agreement was around 70-80%, while the essential and categorical agreement for amphotericin B was 10%.
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We conducted a cohort study among Kaiser Permanente Northern California members who initiated an oral azole antifungal in an outpatient setting during 2004-2010. We determined development of: (1) liver aminotransferases >200 U/L, (2) severe acute liver injury (coagulopathy with hyperbilirubinemia), and (3) acute liver failure. We calculated incidence rates of endpoints. Cox regression was used to determine whether chronic liver disease was a risk factor for outcomes.
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To determine the degree to which the dose of oral cyclosporine (CyA), in healthy dogs, can be decreased by concurrent oral administration of ketoconazole. Dogs in this study were observed for physical or biochemical side effects that might have been caused by the administration of CyA and ketoconazole.
When co-administered with ketoconazole, mean C(max) and AUC(0,∞) of tolvaptan were increased 3.48- and 5.40-fold, respectively. Twenty-four hour urine volume increased from 5.9 to 7.7 l. Erythromycin breath testing showed no difference following a single dose of tolvaptan. With rifampicin, tolvaptan mean C(max) and AUC were reduced to 0.13- and 0.17-fold of tolvaptan administered alone. Twenty-four hour urine volume decreased from 12.3 to 8.8 l.
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dl-Praeruptorin A (Pd-Ia) is the major active constituent of the traditional Chinese medicine Peucedanum praeruptorum Dunn. Recently it has been identified as a novel agent in the treatment and prevention of cardiovascular diseases. Accordingly, we investigated the metabolism of Pd-Ia in rat liver microsomes. The involvement of cytochrome P450 (CYP) and CYP isoforms were identified using a CYP-specific inhibitor (SKF-525A), CYP-selective inhibitors (α-naphthoflavone, metyrapone, fluvastatin, quinidine, disulfiram, ketoconazole and ticlopidine) and CYP-selective inducers (phenobarbital, dexamethasone and β-naphthoflavone). Residual concentrations of the substrate and metabolites were determined by HPLC, and further identified by their mass spectra and chromatographic behavior. These experiments showed that CYP450 is involved in Pd-Ia metabolism, and that the major CYP isoform responsible is CYP3A1/2, which acts in a concentration-dependent manner. Four Pd-Ia metabolites (M1, M2, M3, and M4) were detected after incubation with rat liver microsomes. Hydroxylation was the primary metabolic pathway of Pd-Ia, and possible chemical structures of the metabolites were identified. Further research is now needed to link the metabolism of Pd-Ia to its drug-drug interactions.
Dexamethasone (DEX) is extensively metabolized to 6-hydroxyDEX (6OH-DEX) and side-chain cleaved metabolites in human liver both in vitro and in vivo with CYP3A4 responsible for the formation of 6-hydroxylated products. In the present study, the metabolism of [3H]DEX has been examined in the liver fractions from various mammalian species and metabolite profiles compared with those obtained with human liver microsomes. Metabolites were quantified by radiometric high-pressure liquid chromatography (HPLC) and characterized by liquid chromatography-mass spectrometry (LC-MS) and co-chromatography with chemical standards, where available. 6OH-DEX formation was quantified for each species and the inhibitory potency of ketoconazole at 1 and 20 microM determined. Glycyrrhetinic acid, a specific inhibitor of 11-dehydrogenase, was also used to determine the extent of reductive DEX metabolism. Species differences in metabolite profiles obtained from microsomal incubations were both quantitative and qualitative. 6-Hydroxylation was variable (highest in the hamster) and was not always the major route of metabolism, and formation was sex-specific in the rat (male > female). The inhibition of 6-hydroxylation (CYP3A) by ketoconazole was variable, and indicates that ketoconazole cannot be regarded as a selective inhibitor of CYP3A proteins in all species. Cytosolic incubations produced similar profiles in different species with the formation of a metabolite (M5) which was inhibited by glycyrrhetinic acid and tentatively identified in this study as 11-dehydro-side-chain cleaved DEX (11DH-9alphaF-A). In conclusion, the male rat gave a metabolite profile which was closest to that seen in the human. However, 6-hydroxylation was most extensive in the hamster which may therefore be a suitable model to use for further studies on DEX metabolism by CYP3A.