isavuconazonium

General

Pronunciation:
eye-sa-vue-kon-a-zoe-nee-um


Trade Name(s)

  • Cresemba

Ther. Class.
antifungals

Pharm. Class.
azoles

Indications

Treatment of invasive aspergillosis and mucormycosis.

Action

A prodrug that is converted (rapidly hydrolyzed) to isavuconazole. Inhibits the synthesis of ergosterol, a key component of fungal cell walls.

Therapeutic Effect(s):

Resolution of invasive fungal infections.

Spectrum:

Active against Aspergillus flavus, Aspergillus fumigatus, Aspergillus niger and Mucormycetes species including Rhizopus oryzae.

Pharmacokinetics

Absorption: Prodrug is rapidly converted to isavuconazole, the active component. 98% absorbed following oral administration. Similar conversion follows intravenous administration, resulting in complete bioavailability.

Distribution: Extensively distributed.

Protein Binding: >99%

Metabolism and Excretion: Extensively metabolized (mostly by CYP3A4 and CYPA5); inactive metabolites are mostly renally eliminated, <1% excreted unchanged in urine.

Half-life: 130 hr

TIME/ACTION PROFILE (blood levels)

ROUTEONSETPEAKDURATION
POunk2 hrunk
IVunkend of infusionunk

Contraindication/Precautions

Contraindicated in:

  • Known hypersensitivity;
  • Strong CYP3A4 inhibitors;
  • Familial short QT syndrome;
  • Strong CYP3A4 inducers;
  • Lactation:Discontinue breast feeding.

Use Cautiously in:

  • Severe hepatic impairment (use only if benefits outweigh risks, monitor carefully for adverse reactions);
  • OB: Use during pregnancy only if maternal benefits outweigh risks to the fetus
  • Pedi: Safe and effective use in children <18 yr has not been established.

Adverse Reactions/Side Effects

CNS: fatigue, insomnia, headache, anxiety, delerium

Resp: cough, dyspnea, respiratory failure

CV: peripheral edema, chest pain, hypotension

GI: constipation, diarrhea, ↑ liver enzymes, nausea, vomiting, ↓ appetite, dyspepsia

GU: renal failure

Derm: pruritus, rash

F and E: hypokalemia, hypomagnesemia

Local: injection site reactions

MS: back pain

Misc: infusion-related reactions

* CAPITALS indicate life-threatening.
Underline indicate most frequent.

Interactions

Drug-Drug

  • ↑ levels and risk of toxicity with strong inhibitors of CYP3A4 , including ketoconazole or high-dose ritonavir; concurrent use is contraindicated.
  • Lopinavir/ritonavir significantly ↑ levels and risk of toxicity; concurrent use should be undertaken with caution.
  • Isavuconazonium ↓ levels and effectiveness of lopinavir/ritonavir .
  • Isavuconzonium ↑ levels and risk of toxicity with atorvastatin , cyclosporine , digoxin , midazolam , mycophenolate , sirolimus , tacrolimus; undertake concurrent use with caution, monitoring drug effects and making adjustments if necessary.
  • Strong inducers of CYP3A4 including long-acting barbiturates , carbamazepine or rifampin ↓ levels and effectiveness; concurrent use is contraindicated.
  • ↓ levels and effectiveness of bupropion; bupropion dose may need to be ↑ but should not exceed maximum recommended dose.

Drug-Natural Products:

St. John's wort ↓ blood levels and effectiveness; concurrent use in contraindicated.

Route/Dosage

186 mg isavuconazonium = 100 mg isavuconazole; doses expressed as isavuconazole.

PO: IV: (Adults ≥18 yr): Loading dose– 200 mg every 8 hr for six doses; maintenance dose– 200 mg once daily starting 12–24 hr after last loading dose.

Availability

186 mg isavuconazonium = 100 mg isavuconazole; strength expressed as isavuconazole

Capsules: 100 mg

Lyophilized powder for intravenous injection (requires reconstitution): 200 mg

Assessment

  • Obtain specimens for culture and sensitivity prior to therapy. First dose may be given before receiving results.
  • Monitor for signs and symptoms of infusion-related reactions (hypotension, dyspnea, chills, dizziness, paresthesia, hypoesthesia) periodically during therapy. Discontinue infusion if symptoms occur.
  • Monitor skin for hypersensitivity reactions during therapy.

Lab Test Considerations: Monitor liver function tests prior to and periodically during therapy. Discontinue therapy if clinical signs of liver disease occur.

  • May cause hypokalemia and hypomagnesemia.

Potential Diagnoses

Implementation

  • Oral and IV formulations are bioequivalent; may be used interchangeably. Loading dose is not needed when switching.
  • PO: Administer without regard to food. Swallow capsule whole; do not open, dissolve, crush or chew.

IV Administration

  • Reconstitute by adding 5 mL sterile water to vial. Shake gently to dissolve powder completely. Solution should be clear and colorless; do not administer solutions that are discolored or contain particulate matter. Solution is stable for 1 hr at room temperature.
  • Intermittent Infusion: Diluent: Remove 5 mL of reconstituted solution from vial and add to 250 mL 0.9% NaCl or D5W.Concentration:1.5 mg isavuconazonium/mL. Diluted solution may show visible translucent to white particulates; removed with in-line filter. Roll bag to mix gently; avoid shaking. Solution is stable if infused at room temperature within 6 hrs; may refrigerate for up to 24 hrs; do not freeze. Flush line with 0.9% NaCl or D5W prior to and following infusion.
  • Rate: Infuse over at least 1 hr to minimize infusion–related reactions. Infuse through a 0.2–1.2 micron in-line filter. Do not administer as a bolus injection.
  • Y-Site IncompatibilityDo not infuse with other medication.

Patient/Family Teaching

  • Instruct patient to take isavuconazonium as directed. Do not stop taking isavuconazonium without consulting heath care professional. Advise patient to read Patient Information before starting and with each Rx refill in case of changes.
  • Advise patient to notify health care professional promptly of signs and symptoms of liver disease (itchy skin, nausea, vomiting, yellowing of eyes, feeling very tired, flu-like symptoms), infusion-related reactions, or rash occur.
  • Instruct patient to notify health care professional of all Rx or OTC medications, vitamins, or herbal products being taken and consult health care professional before taking any new medications.
  • Advise female patient to notify health care professional if pregnancy is planned or suspected or if breast feeding.
  • Emphasize the importance of lab tests to monitor for side effects during therapy.

Evaluation/Desired Outcomes

Resolution of signs and symptoms of invasive fungal infection.

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Citation

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TY - ELEC T1 - isavuconazonium ID - 110193 A1 - Quiring,Courtney, AU - Sanoski,Cynthia A, AU - Vallerand,April Hazard, BT - Davis's Drug Guide UR - https://anesth.unboundmedicine.com/anesthesia/view/Davis-Drug-Guide/110193/all/isavuconazonium PB - F.A. Davis Company ET - 16 DB - Anesthesia Central DP - Unbound Medicine ER -