Supplemental material to this article can be found at: http://jpet.aspetjournals.org/content/suppl/2018/02/28/jpet.117.245449.DC1 1521-0103/365/2/408–412$35.00 https://doi.org/10.1124/jpet.117.245449 THE JOURNAL OF PHARMACOLOGY AND EXPERIMENTAL THERAPEUTICS J Pharmacol Exp Ther 365:408–412, May 2018 Copyright ª 2018 by The American Society for Pharmacology and Experimental Therapeutics Impact of Infection Status and Cyclosporine on Voriconazole Pharmacokinetics in an Experimental Model of Cerebral Scedosporiosis s Bénédicte Lelièvre, Marie Briet, Charlotte Godon, Pierre Legras, Jérémie Riou, Patrick Vandeputte, Bertrand Diquet, and Jean-Philippe Bouchara Service de Pharmacologie-Toxicologie-Centre Régional de Pharmacovigilance, Institut de Biologie en Santé (B.L., M.B., B.D.), MITOVASC, UMR CNRS 6214, Inserm 1083, Université d’Angers (M.B.), Micro- et Nanomédecines Biomimétiques, UMR INSERM 1066–CNRS 6021, Université d’Angers (J.R.), and Laboratoire de Parasitologie-Mycologie, Institut de Biologie en Santé ’ (J.-P.B.), Centre Hospitalier Universitaire, Angers, France; Groupe d Etude des Interactions Hôte-Pathogène (EA 3142), Downloaded from Université d’Angers, Université de Bretagne Occidentale, Institut de Biologie en Santé, Angers, France (B.L., C.G., P.L., P.V., J.- P.B., B.D.); and Service Commun de l’Animalerie Hospitalo-Universitaire, Université d’Angers, Angers, France (P.L.) Received October 3, 2017; accepted February 15, 2018 ABSTRACT jpet.aspetjournals.org Cerebral Scedosporium infections usually occur in lung trans- mass spectrometry and high-performance liquid chromatography plant recipients as well as in immunocompetent patients in the UV methods and were documented up to 48 hours after adminis- context of near drowning. Voriconazole is the first-line treatment. tration. Pharmacokinetic parameters were estimated using a non- The diffusion of voriconazole through the blood-brain barrier in compartmental approach. Voriconazole pharmacokinetic profiles the context of cerebral infection and cyclosporine administration were similar for plasma, CSF, and brain in all groups studied. The is crucial and remains a matter of debate. To address this issue, voriconazole Cmax and area under the curve (AUC) (AUC0 $ 48 hours) the pharmacokinetics of voriconazole was assessed in the values were significantly higher inplasmathaninCSF[CSF/plasma plasma, cerebrospinal fluid (CSF), and brain in an experimental ratio, median (range) 5 0.5 (0.39–0.55) for AUC0 $ 48 hours and 0.47 at ASPET Journals on October 1, 2021 model of cerebral scedosporiosis in rats receiving or not re- (0.35 and 0.75) for Cmax]. Cyclosporine administration was signif- ceiving cyclosporine. A single dose of voriconazole (30 mg/kg, icantlyassociatedwithanincreaseinvoriconazoleexposureinthe i.v.) was administered to six groups of rats randomized accord- plasma, CSF, and brain. In the plasma, but not in the brain, an ing to the infection status and the cyclosporine dosing regimen (no interaction between the infection and cyclosporine administration cyclosporine, a single dose, or three doses; 15 mg/kg each). reduced the positive impact of cyclosporine on voriconazole Voriconazole concentrations in plasma, CSF, and brain samples were exposure. Together, these results emphasize the impact of cyclo- quantified using ultra-performance liquid chromatography–tandem sporine on brain voriconazole exposure. Introduction may occur (Morin et al., 1999; Symoens et al., 2006; Morio et al., 2010; Luijk et al., 2011; Miraldi et al., 2012; Hirschi Usually a saprophyte, Scedosporium apiospermum is a et al., 2012). In addition, cerebral scedosporiosis is also filamentous soil fungus that may cause a wide variety of reported in immunocompetent patients in the context of near diseases in human, ranging from localized infections such as drowning (Cortez et al., 2008). Until the 1990s, the mortality subcutaneous mycetoma, keratitis, or bone and joint mycoses rate in systemic S. apiospermum infections was higher than to disseminated infections (Steinbach and Perfect, 2003; 75%; however, recent triazole antifungals have improved their Cortez et al., 2008). This old pathogen has gained increasing prognosis (Steinbach and Perfect, 2003; Cortez et al., 2008). attention during the past two decades due to its worldwide Current recommendations for the management of patients recognition as the second most common cause of fungal with a systemic S. apiospermum infection rely on the use of respiratory infections in patients with cystic fibrosis (Cimon voriconazole (Tortorano et al., 2014). et al., 2000; Rainer et al., 2008; Harun et al., 2010). In this Voriconazole is a triazole drug inhibiting cytochrome context, following lung transplantation in cystic fibrosis P450–dependent 14a-lanosterol demethylase, an enzyme that patients previously colonized by S. apiospermum, severe and plays a key role in the synthesis of ergosterol, which is a major often fatal disseminated infections with cerebral involvement constituent of fungal membranes (Manavathu et al., 1998). Although voriconazole is a broad-spectrum antifungal that acts Financial support for this research was provided by the Association pour la on both yeasts and filamentous fungi, differences occur between Recherche en Pharmacologie et Toxicologie d’Angers (Angers, France). https://doi.org/10.1124/jpet.117.245449. fungal species in their susceptibility to this drug. For in- s This article has supplemental material available at jpet.aspetjournals.org. stance, voriconazole usually exhibits high minimum inhibitory ABBREVIATIONS: AUC, area under the curve; CSF, cerebrospinal fluid. 408 Voriconazole Pharmacokinetics in Experimental Scedosporiosis 409 concentrations against Scedosporium isolates (Sheehan et al., isoflurane for induction (5–10 minutes) and then 2% isoflurane in 1999; Lewis et al., 2005). 20:1 air/oxygen for maintenance. As such, exposure to isoflurane never In humans, the pharmacokinetics of voriconazole follow a exceeded 15 minutes for each rat. nonlinear profile, with 58% of the drug bound to plasma Sampling for Pharmacokinetic Studies. Regarding the intra- proteins (Levêque et al., 2006). The drug is metabolized by venous route of administration and published data, the pharmacoki- cytochrome P450s, mainly CYP3A4, CYP2C19, and to a lesser netics of voriconazole were studied for 48 hours, using eight sampling times: 5 and 20 minutes and 1, 3, 6, 10, 24, and 48 hours after extent CYP2C9 (Purkins et al., 2002). Studies using human administration. Blood samples were collected from three rats for liver microsomes have shown that the metabolism of vorico- each sampling time in EDTAK2-containing tubes (Becton-Dickinson, nazole presents biphasic kinetics (Hyland et al., 2003). The Plymouth, UK) and immediately centrifuged at 3240g for 10 minutes entire dose of voriconazole is eliminated by the renal route in at 15°C. CSF samples were collected at the same time points and 48 hours, mainly (98%) as metabolites (Levêque et al., 2006). immediately centrifuged for 10 minutes at 4°C. Plasma and CSF were Due to the nonlinear pharmacokinetics of voriconazole and immediately frozen and stored at 220°C until analysis. After eutha- intra- and interindividual variability, therapeutic drug mon- nizing the animals, the brains were collected, washed with sodium itoring of voriconazole in plasma is recommended. Neverthe- chloride 0.9%, weighed, and ground in 4 ml of water. The volume of less, very limited pharmacokinetics data are available each homogenate was precisely measured, and three aliquots per 2 regarding infections localized to sanctuary organs such as homogenate were immediately frozen and stored at 20°C. Voriconazole Assay. Voriconazole was quantified in plasma or the brain or lungs. In the case of a cerebral infection, the rate of CSF samples after protein precipitation by ultra-performance liquid diffusion of the antifungal drugs through the blood-brain chromatography–tandem mass spectrometry (Quattro Premier; Wa- Downloaded from barrier remains questionable. ters, Guyancourt, France). Protein precipitation was carried out using In the present study, we determined the pharmacokinetics 200 ml of methanol containing d3-voriconazole as the internal of voriconazole in the plasma, cerebrospinal fluid (CSF), and standard (LGC Standards, Molsheim, France). After homogenization brain in a rat model of disseminated scedosporiosis with and centrifugation, the resulting supernatant was filtered and trans- cerebral involvement to evaluate its diffusion through the ferred to microvials to be analyzed using an Acquity UPLC BEH C18 blood-brain barrier. In addition, the study was designed to Column (1.7 mm, 2.1 Â 50 mm; Waters), maintained at 40°C. The jpet.aspetjournals.org investigate the impact of infection and/or cyclosporine admin- mobile phase was nebulized using an electrospray source in positive . istration on the voriconazole pharmacokinetics in the plasma, mode. The multiple reactions monitoring transitions were m/z 350 127 and 350 . 280.9 for voriconazole and m/z 353 . 130 and 353 . CSF, and brain. 283.9 for d3-voriconazole. The calibration curves were quadratic over the range 0.002–20 mg/l with a coefficient of determination .0.99. Materials and Methods Based on quality control samples, the overall relative S.D. was below 10% (intraday and interday precisions were 7.5% and 5.0%, respec- Animal Model of Scedosporiosis and Study Design. Male tively). The overall relative error was within 610%. The lower limit of at ASPET Journals on October