Levels of itraconazole in skin blister fluid after a single oral dose and during repetitive administration

Levels of itraconazole in skin blister fluid after a single oral dose and during repetitive administration Monika Schafcr-Korting, PhD,a Hans Christian Korting, MD,b Andreas Lukacs, MD,b los Heykants, PhD,c and Hans Behrendt, MDb

Frankfurt and Munich, West Germany, and Beerse, Belgium Oral itraconazole is effective in the treatment of mycoses. To measure its concentrations in the tissue, levels of total and non-protein-bound itraconazole were determined in serum, suction-induced blister fluid, and cantharides-induced blister fluid. Six healthy subjects received 200 mg as a single dose, follow~ by 100 mg/day for 10 days. Itraconazole binding in suc" tion-induced blister fluid (99.54%) and cantharides-induced blister fluid (99.77%) was calculated from plasma protein binding (99.8%). The single-dose study showed the drug levels in blister fluid to increase more slowly than those in serum. The terminal half-life of itraconazole in serum was 22.5 ± 3.2 hours. Suction- and cantharides-induced blister fluid levels declined in parallel. After the final dose, itraconazole penetration into cantharides-induced blister fluid was only 70%. Moreover, trough levels of unbound itraconazole in suction- and cantharides-induced blister fluid were 0.239 ± 0.115 and 0.334 ± 0.101 ng/rnl and thus were significantly lower than free itraconazole levels in serum (0.422 ± 0.125 ng/ml). Thus a distribution equilibrium between serum and blister fluids was not obtained. Free drug concentrations in suction- and cantharides-induced blister fluid were far lower than the minimal inhibitory concentration values for Candida ssp. and dermatophytes. (J AM ACAD DERMATOL 1990;22:211-5.)

Itraconazole is an effective triazole antifungal drug l -3 despite its rather low serum concentrations. 4 Itraconazole levels in human tissues, including the skin, often exceed serum concentrations. 4, 5 Free drug levels, however, have not been determined but generally are regarded as the active ones. 6,7 Total and free drug levels in the skin can be determined by blistering techniques 8 used to evaluate ketoconazole pharmacokinetics. 9, 10 Itraconazole protein binding in serum exceeds that of ketoconazole (99.8% vs 99.0%4, II), and serum levels of itraconazole are lower than those of ketoconazole. Thus the question arises, "What is the concentration of active itraconazole in the skin?"

From the Pharmakologischcs Institut filr NaturwissensehaftIer der Johann Wolfgang-Goethe Universitiit, Frankfurt,' the Dermatologische Klinik und Poliklinik der Ludwig-Maximilians-Universitiit, Munich,b and the Departmcnt of Drug Metabolism and Pharmacokinetics, Janssen Pharmaceutica, Beerse,c A=pted for publication March 23, 19R9, Reprint requests: H. C. Korting, MD, Dermatologische Klinik und Poliklinik der LUdwig-Maximilians-Univcrsitiit, Frauenlobstrasse 9-11, D-8000 Miinchen 2, FRO.

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MATERIAL AND METHODS Six healthy volunteers (four men, two women; 25 to 33 year of age) participated in the study after giving written informed consent. During the study period the subjects refrained from other medications and alcohol. The study protocol was approved by the local ethical committee. First, the subjects received single 200 mg oral dose of itraconazole. At lea,st 4 days later the volunteers ingested itraconazole (supplied by Janssen Pharmaceutica, Beerse, Belgium), 100mgjday for 10 days. The drug was taken at breakfast. , Cantharides- and suction-induced blisters were produced as previously described. 10 In the single-dose study, blood samples were obtained before administration and I, 2,3,4,6,9,24,33,48, 72, and 96 hours thereafter. Suction-induced blister fluid (SBF) was collected at 1,2,4, and 24 hours, and cantharides-induced blister fluid (CBF) was collected at 1, 2, 3, 4, 6,9,24, 33, and 48 hours. In the lo-day study, blood samples were taken immediately before the last dose and 1,2,4,6,9, and 24 hours thereafter. Samples of blister fluids were collected before the last dose and at 1,2, and 4 hours; a CBF sample was also obtained at 9 hours. Total (protein-bound plus free) itraconazole concentration in serum and skin blister fluids was determined by high-performance liquid chromatography (detection limit

a

211

Journal of the AmerIcan Academy of Dermatology

212 Schafer-Kortmg et al

100

12

Fig 1 Itraconazole concentratIons (mean ± SEM) In serum (cIrcle), suctIOn-induced blIster flUld (triangle), and canthandes-mduced bhster flUId (dwmond) In SIX healthy subJect~ after smgle 200 mg oral dose

1 ngjrnl) 12 Drug bIndmg m SBF and CBP was calculated from serum protem bmdmg (99 8%)4 as described by McNamara et al \3 Maximum concentratIOns m serum and skm blIster fluIds (Cmax ), trough levels after repeated mtraconazole mgestlon (C mm ), and times to peak concentratlOns (tmax ) were determmed Termmal half hfe (tv,) was calculated from the log-hnear dechne of serum and CBF levels after the smgle dose After the smgle dose, the areas under the serum and CBF concentration-time curves (AUC) were calculated by the trapezOIdal rule up to the ultimately measured concentratIon and extrapolated to mfimty (AUCo_ co) After repeated doses, areas were calculated by the trapezOIdal rule (AUCo -. 24) WIth the assumptiOn that concentratIOn m bltster flUId at 24 hours was IdentIcal to that Immediately before thiS dose Itraconazole penetration mto skin blIster flUId was estimated from the ratio of the areas (SBFjserum and CBFjserum) on the basIs of free drug levels All data are arithmetiC mean values ± SEM Statistical evaluations were performed by Student's t test for matched pairs Slgmficance was determmed atp -< 005

ng/ml

600

6

12

18

24h

Fig 2. Itraconazole concentratIons (mean ± SEM) In serum (cIrcle) suctton-mduced bhster flUId (trIangle), and canthandes-mduced blister flutd (dIamond) m SIX healthy subjects after last dose (100 mg 1traconazole mgested once daJiy for 10 days)

RESULTS FIg I depIcts mean Itraconazole concentrations m serum, SBF, and CBF after the 200 mg smgle oral dose, pharmacokmetlc parameters for the mdlVldual volunteers are gIven m Table I Serum levels could

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Blister fluid levels of itraconazole after oral dose 213

Table I. Pharmacokinetic parameters derived from itraconazole concentrations in healthy subjects after single 200 mg oral dose Serum Subject

No.

1 2 3 4 5 6

Cmax

tmax (hr)

(ne/ mI)

2 3 4 6 5 4

177 309 403 535 284 209 319 54

X

±SEM

AUCo-oo

C••x

(br)

(ng. ml- l hr)

(ng/ml)

28.1 31.1 26.2 14.8 23.3

4592 4287 7653 7906 7544 2559 5757 916

12.3 10.3 27.4 22.2 40.4 ND 18.8 5.3

t'h

I

CBF

SBF

11.4

22.5 3.2

tmax (ng/m1)

I

c_x

t'h

AUCo-··CQ

(ng/ml)

(hr)

(ng . ml- I br)

72.0 25.6 32.4 13.2 17.8 11.3 28.7 9.2

4625 2044 3925 5111 3839 1473 3502 588

65.5 47.5 83.3 184 86.2 88.5 92.5 19.4

6 9 9 9 24 9

AVC, Area under curve; Cmax• maximum concentration; CBF. cantharides·induced blister fluid; ND. not determined; SBF. suction-induced blister fluid; Il;, half-life; Imax . time to peak concentration.

n.

Table Pharmacokinetic parameters derived from itraconazole concentrations in healthy subjects after tenth 100 mg oral dose Serum Suhject

No.

1 2 3 4 5 6 X

±SEM

Cmlnl

(ng/ml)

490 94 196 147 239 69 206 62

I

Cmlnl

(ng/ml)

472 60 202 217 208 104 211 58

I

Cmax

(n2/ml)

967 289 659 592 312 414 539 105

CBF

SBF

I

AUCo-'24

C...

(ng . ml- I hr)

(ng/ml)

14844 2753 7412 8148 6003 4120

149 17.5 46.1 32.9

7213

1733

ND 14.0 51.9 24.9

I Cmax I

AUCo_:14

Cmln

IIg/ml)

(ng . ml- I hr)

(ng/ml)

217 38.2 83.8 86.1 96.2 41.4 93.8 26.6

3681 389 1240 834

345 70.9 38.5 101 176 50.1 145 44

ND 337 1296 618

AVC. Area under curve; C'",ax. maximum concentration; Cmia . trough level; Cminl. trQugh level after ninth dose; CBF. cantharides-induced blister fluid; ND. not detectable/not determined; SBF, suction-induced blister fluid.

be determined for 72 to 96 hours. Peak concentrations obtained at hours 2 to 6 were 319 ng/mL Terminal half-life was 22.5 hours. ltraconazole was detected in SBF in four of six subjects 4 hours after the single dose. Drug levels ranged from 6.8 to 13.0 ng/ml. In one subject, itraconazole levels in SBF were permanently below 1.0 ng/ml. In CBF, itraconazole concentrations were 15.2 to 61.0 ng/ml at 4 hours in five subjects. At 6 hours the drug was detected in CBF in all volunteers. In both blister fluids, drug concentrations increased more slowly than serum levels. Time to peak concentrations were between 6 and 24 hours in CBF and 24 hours in SBF. Peak levels were much lower in blister fluid than in serum (Table 1). Itraconazole

I

C...X

ng/ml)

393 99.2 124 231 200 229 227 39

I

AV CO-'14

(ng . ml- 1 hr)

8746 1999 4019 3945 4464 3216 4388 938

emin ]. trough level after tenth dose;

concentrations in CBF declined in parallel with serum levels. Terminal half-life was 28.7 hours. Fig. 2 presents the mean itraconazole concentrations after the last oral dose of 100 mg. Itraconazole serum levels before this dose equaled those 24 hours thereafter (Table II). Peak concentrations amounted to 539 ng/ml. The area under the serum level-time curve was 7213 ng· ml- I hr, exceeding the dosecorrected area after the single dose 2.S-fold (p> 0.05). A similar increase was shown by the areas under the CBF level-time curves (Table.~ I and II). This difference was statistically significant. In CBF, trough itraconazole concentration amounted to 125 ng/ml; peak concentration was 227 ng/ml. In SBF the respective levels were 51.9 and 93.8 ng/m1.

Journal of the AmerIcan Acadcmy of Derma tology

214 Schafer-Kortzng et al Protem b10dmg of Itraconazole was 99 54% ill SBF and 99 77% 10 CBF On repetltlve drug admlmstratlon, peak concentratlOn of unbound Itraconazole 10 serum was 1 078 ± 0210, m SBF 0431 ± 0 122, and 10 CBF 0522 ± 0089 ng/ml The respective trough levels were 0 422 ± 0 125 ng/mlm serum, 0 239 ± 0 115 ng/ml 10 SBF, and 0334 ± 0 101 ng/mlm CBF Trough levels 10 both blIster flUIds were slgmficantly lower than that of serum (p -< 0 05) Tlus also holds true for the area ratios After repetitIve Itraconazole admmlstratlon, drug penetration was 41 3% mto SBF and 704% mto CBF DISCUSSION

The therapeutic actlVlty of an antuungal agent IS determmed by Its antuungal effect (m vitro) and the concentration of the non-protem-bound drug at the SIte of mfectlon 6 7 With Itraconazole, however, low concentratiOns of free drug 10 tissue have to be expected Moreover, prehmmary data With other drugs suggest that strong protem bmdmg delays drug transfer to tissue flUId 8 Because Itraconazole has a termmal half-lIfe of about 22 hours,4 a cumulation penod of about 5 days IS predictable Correspondmgly, serum levels before the last (tenth) dose were close to those 24 hours thereafter Thus a steady state seems to have occurred, although Itraconazole was detectable m SBF and CBF after a smgle dose, repeated mgestlOn for 10 days dId not result 10 dIstnbutlon eqUIhbnum between blIster flUId and serum ThiS findmg was denved from the area ratIOS, whIch are no more than 70% for CBF and no more than 41 % for SBF (Because the peak concentratIOn m SBF was not measured, the latter value may be an underestimation of the true one) Moreover, trough levels (free Itraconazole) m SBF and CBF were sIgmficantly lower than serum levels On day 10, Itraconazole accumulation 10 blIster flUid (and poSSibly 10 other tissue flUids, e g , cerebrospmal flUid) was shll mcreasmg ThIS findmg m blIster flUId IS m contrast to that 10 serum and stresses the need for drug determmatIOns 10 such body flUIds A prolonged Itraconazole accumulatiOn m human stratum corneum has been recently observed It reqUires up to 7 days of repetItive drug mtake before Itraconazole can be detected m tissue samples 5The slow transfer of Itraconazole from the lower epidermis (lIke SBF) to the upper epidermIS results from the high bmdmg capaCIty of epidermal protems

Free Itraconawle concentratIOns m SBF and CBF were much lower than reported mmlmal mhibitory concentration values Nmety-five percent of dermatophyte strams and 74% of Candida ssp, however, are senSItive to Itraconazole concentratlons of 0 I ,ug/mI 14 Because the therapeutIC effect of Itracondzole m fungal mfectIOns IS unquestlOned,l 2 the concentratIon-response relatIOnshIp IS shU open for dISCUSSIon Recently It has been speculated that total Itraconazole levels, rather than the free levels, are responsIble for the therapeutIC effect 15 Moreover, there are new In vitro methods that allow the detectIon of antImIcrobial effects WIth submhIbltory concentratIOns 16 Thus further mvestlgatlons on 10 VItro methods for testmg antifungal drugs are deSIrable

REFERENCES I Degreef H, Manen K, De Veylder H, et al Itraconazoic treatment m dermatophytoses a companson of two daIly dosages Rev Infect DIS 1987,9 (suppl I) 104 8 2 SIlva Cruz A, Andrade L, Ohvelra JE, et al An open assessment of three dIfferent treatment regImens of Itraconazole for the management of vagmal candldosls Phdrmacotherapeutlca 1988,5 189-92 3 Morales-Dona M Pltynasls versicolor efficacy of two five-day regImens of Itraconazole Rev Infect DIS 1987, 9(suppll) 131-3 4 Heykants J, MIChiels M, Meuldermans W, et al The pharmacokmetlcs of Itraconazole mammals and man an overvtew In FromtlIng RA, ed Recent trends m the diScovery, development and evaluatIon of anttfunga1 agents Barcelona Prous SCIence Pubhshers, 1987 223-49 5 Cauwenbergh G, Degreef H, Heykant~ J, et al PharmacokmetIcs profile of orally admmlstered Itraconazole m human skm JAM ACAD DERMATOL 1988,18263-8 6 CraIg WA, Wellmg PG Protem bmdmg of antmucroblals clImcal, pharmacokmetlc, and therapeutIc ImplIcatIOns Clin Pharmacokmet 1977,2252-68 7 WIse R The chmcal relevance of protem bmdmg and tISsue concentratIOns 10 antImIcrobIal therapy Chn Pharmacakmet 1986,11 470 82 8 Schafer Kortmg M, Kortmg HC Sian blIsters and skm wmdows an access to total and free drug concentratIOns m the skm In Malbach HI, Lowe N, eds Models m dermatology, vol 4 Basel Karger, 1989 45-62 9 Schafer-Korttng M Kortmg HC, Mutschler E Pharmakokmettk oraler Antunykotlka Stuttgart Schattauer, 198531-2 10 Kortmg HC, Lukacs A, Schafer-Korttng M, et al Skm blister flUId levels of ketoconazole dunng repetitIve admmIstratlOn m man Mycoses 1989,3239-45 II Heel RC, Brogden RN, Carmine A, et al Ketoconazole a revIew of Its therapeutic efficacy In superfiCIal and systemIc fungal mfectIOns Drugs 1982,23 1-36 12 Woestenborghs R, Lorreyne W, Heykants J Determmatlon of Itraconazole In plasma and ammal tiSSUes by hlghperformance lIqUId chromatography J Chromatogr 1987,413322-7

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Blister fluid levels of itraconazole after oral dose

13. McNamara PJ, Gibaldi M, Stoeckel K. Fraction unbound in interstitial fluid. J Pharm Sci 1983;72:834-6. 14. Van Cutsem J, Van Gerven F, Janssen PAJ. Activity of orally, topically, and parenterally administered itraconazole in the treatment of superficial and deep mycoses: animal mcxlels. Rev Infect Dis 1987;9(suppl 1):15-32. 15. Heykants .1. Clinical pharmacokinetics of itraconazo1e and

other recent antimycotic drugs. Pre.~ented at Biennial Conference on Chemotherapy of Infectious Diseases and Malignancies, Munich, April 16-29, 1987. 16. Abbink J, Plempel M, Berg D. Expression ofkeratinolytic activity by Trichophyton mentagrophytes. I n: Hay RJ, ed. Advances in topical antifungal therapy. Berlin: Springer, 1986:21-5.

Chronic ulcerative stomatitis associated with a specific immunologic marker William M. Jaremko, MD,a Ernst H. Beutner, PhD,b Vijay Kumar, PhD,b Hans Kipping, MD,e Patrick Condry, MD,d Mohamed Y. Zeid, MD,e C. Lisa Kauffman, MD,f Dimitris N. Tatakis, DDS,g and Tadeusz P. Chorzelski, MDh Lackland Air Force Base, Texas, Buffalo and Rochester, New York, Washington, D.C., and Warsaw, Poland Four elderly women with chronic oral ulcerations are described. The lesions are chronic, erosive, or ulcerative; occur on the gingival, buccal, or lingual mucosa; and may occur in the form of desquamative gingivitis. The histopathologic findings are nondiagnostic. The disease is refractory to local and systemic corticosteroids, but treatment with hydroxychloroquine may be effective. Both in vivo binding to the oral mucosa and skin of a stratified epithelium-specific antinuclear antibody and high titers of these antibodies in serum are markers of this disease, which we refer to as chronic ulcerative stomatitis associated with stratified epitheliumspecific antinuclear antibody. (J AM ACAD DERMATOL 1990;22:215-20.) Several forms of ulcerations and erosions give rise to both desquamative gingivitis and to other lesions of the oral cavity. In some cases other mucous From the Department of Dermatology, Wilford Hall U.S. Air Force Medical Center, Lackland Air Force Base: the DepartmenL~ of Microbiology and Dermato!ogy,b and the Department of Dermatology,C University at Buffalo, State UniversityofNew York, the Department of Dermatology, University of Rochester,d the Department of Pathology, Buffalo General Hospital,C the Department of Dermatology, Washington Hospital Center, Washington, D.C.,r the Department of Oral Biology, University at Bulfalo, State University of New York,8 and the Department of Dermatology, Warsaw Academy of Medi· cine." Supported in part by lmmeo Diagnostics, BulTnlo, N.Y. The studies of Dr. D. N. Tatakis were supported by PHS grant DE07034 from NlDR. The views expressed in this article arc those of the authors and do not reflect the olHcial policy or position of the Department of the Air Force, Department of Defense, or the U.S. Government. Accepted for publication April 3, 1989. Reprint requests: Ernst H. Ikutner, PhD, Department of Microbiology, UniverSity at Buffalo, State University of New York, 219 SherlIlan Hall, Buffalo, NY 14214.

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membranes' and/or skin may be involved. These diseases include cicatricial pemphigoid, lichen planus, pemphigus vulgaris, oral psoriasis, and linear IgA bullous dermatosis, as well as idiopathic forms of desquamative gingivitis. 1-7 We describe four cases of chronic oral ulcerations characterized by an association with a peculiar type of antinuclear antibody (ANA), which we refer to as stratified epithelium-specific antinuclear antibodies (SES-ANA). This association has not been described previously. MATERIAL AND METHODS

Four patients with similar clinical and immunopathologic findings were studied. All were women aged 59 to 80 years, and all had painful oral erosions and ulcerations. Nine biopsy specimens of lesional and nonlesional skin or mucosa received in transport mediums,9 were examined by immunofluorescence. 1o Routine staining with hematoxylin and eosin was done in all cases. Direct immunofluorescence was performed on 4 J.Lm sections with fluorescein isothiocyanatc-conjugated anti215