Amphotericin B chemical structure
Find information on thousands of medical conditions and prescription drugs.

Amphotericin B

Amphotericin B (Fungilin®, Fungizone®, Abelcet®, AmBisome®, Fungisome®, Amphocil®, Amphotec®) is a polyene antimycotic drug, used intravenously in systemic fungal infections. It was originally extracted from Streptomyces nodosus fungi. Currently the drug is available as plain Amphotericin B, as cholesteryl sulfate complex, as lipid complex, and as liposomal formulation. The latter formulations have been developed to improve tolerability for the patient but may show considerable pharmacokinetic characteristics compared to plain Amphotericin B. more...

Home
Diseases
Medicines
A
8-Hour Bayer
Abacavir
Abamectin
Abarelix
Abciximab
Abelcet
Abilify
Abreva
Acamprosate
Acarbose
Accolate
Accoleit
Accupril
Accurbron
Accure
Accuretic
Accutane
Acebutolol
Aceclidine
Acepromazine
Acesulfame
Acetaminophen
Acetazolamide
Acetohexamide
Acetohexamide
Acetylcholine chloride
Acetylcysteine
Acetyldigitoxin
Aciclovir
Acihexal
Acilac
Aciphex
Acitretin
Actifed
Actigall
Actiq
Actisite
Actonel
Actos
Acular
Acyclovir
Adalat
Adapalene
Adderall
Adefovir
Adrafinil
Adriamycin
Adriamycin
Advicor
Advil
Aerobid
Aerolate
Afrinol
Aggrenox
Agomelatine
Agrylin
Airomir
Alanine
Alavert
Albendazole
Alcaine
Alclometasone
Aldomet
Aldosterone
Alesse
Aleve
Alfenta
Alfentanil
Alfuzosin
Alimta
Alkeran
Alkeran
Allegra
Allopurinol
Alora
Alosetron
Alpidem
Alprazolam
Altace
Alteplase
Alvircept sudotox
Amantadine
Amaryl
Ambien
Ambisome
Amfetamine
Amicar
Amifostine
Amikacin
Amiloride
Amineptine
Aminocaproic acid
Aminoglutethimide
Aminophenazone
Aminophylline
Amiodarone
Amisulpride
Amitraz
Amitriptyline
Amlodipine
Amobarbital
Amohexal
Amoxapine
Amoxicillin
Amoxil
Amphetamine
Amphotec
Amphotericin B
Ampicillin
Anafranil
Anagrelide
Anakinra
Anaprox
Anastrozole
Ancef
Android
Anexsia
Aniracetam
Antabuse
Antitussive
Antivert
Apidra
Apresoline
Aquaphyllin
Aquaphyllin
Aranesp
Aranesp
Arava
Arestin
Arestin
Argatroban
Argatroban
Argatroban
Argatroban
Arginine
Arginine
Aricept
Aricept
Arimidex
Arimidex
Aripiprazole
Aripiprazole
Arixtra
Arixtra
Artane
Artane
Artemether
Artemether
Artemisinin
Artemisinin
Artesunate
Artesunate
Arthrotec
Arthrotec
Asacol
Ascorbic acid
Asmalix
Aspartame
Aspartic acid
Aspirin
Astemizole
Atacand
Atarax
Atehexal
Atenolol
Ativan
Atorvastatin
Atosiban
Atovaquone
Atridox
Atropine
Atrovent
Augmentin
Aureomycin
Avandia
Avapro
Avinza
Avizafone
Avobenzone
Avodart
Axid
Axotal
Azacitidine
Azahexal
Azathioprine
Azelaic acid
Azimilide
Azithromycin
Azlocillin
Azmacort
Aztreonam
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U
V
W
X
Y
Z

Uses

Oral preparations of amphotericin B are used to treat oral thrush; these are virtually nontoxic. The main i.v. use is in systemic fungal infections (e.g. in immunocompromised patients), and in visceral leishmaniasis. Aspergillosis, cryptococcus infections (e.g. meningitis) and candidiasis are treated with amphotericin B. It is also used empirically in febrile immunocompromised patients who do not respond to broad-spectrum antibiotics.

Method of action

As with other polyene antifungals, amphotericin B associates with ergosterol, a membrane chemical of fungi, forming a pore that leads to K+ leakage and fungal cell death. Recently, however, researchers found evidence that pore formation is not necessarily linked to cell death (i.e. Angewandte Chemie Int. Ed. Engl. 2004). The actual mechanism of action may be more complex and multi-faceted.

Side effects

Very often a most serious acute reaction after the infusion (1 to 3 hours later) is noted consisting of fever, shaking chills, hypotension, anorexia, nausea, vomiting, headache, dyspnea, and tachypnea. This reaction sometimes subsides with later applications of the drug and may in part be due to histamine liberation. An increase in prostaglandin-synthesis may also play a role. Often the most difficult decision has to be made, whether the fever is disease- or drug-related. In order to decrease the likelihood and severity of the symptoms, initial doses should be low and increased slowly. The liposomal preperation obviously has a lower incidence of the syndrome. Acetaminophen, pethidine, diphenhydramine and/or hydrocortisone have all be used to treat or prevent the syndrome, but the prophylactic use of these drugs should be limited.

Nephrotoxicity (kidney damage) is a major issue and can be severe and/or irreversible. It is much milder when amphotericin B is delivered in liposomes (AmBisome). Electrolyte imbalances (e.g. hypokalema and hypocalcemia) may also occur.

Increased liver enzymes and hepatotoxicity up to acute liver failure, several forms of anemia and other blood dyscrasias (leukopenia, thrombopenia), serious cardiac arrhythmias (including ventricular fibrillation), and cardiac failure have also been reported frequently. Skin reactions, including serious forms, are also possible.

Interactions

  • Flucytosine : Toxicity of Flucytosine increased and vice versa
  • Diuretics or Cisplatin : Increased renal toxicity and incrised risk of hypokalema
  • Corticosterioids : Increased risk of hypokalema
  • Cytostatic drugs : Increased risk of kidney damage, hypotension and bronchospasms.
  • Other nephrotoxic drugs : Increased risk of serious renal damage. Monitor patients closely.
  • Foscarnet, Ganciclovir, Tenofovir, Adefovir : Risk of hematological and renal side-effects of Amphotericin B increased.
  • Transfusion of Leukocytes : Risk of pulmonal (lung) damage. Space intervalls between the application of Amphotericin B and the transfusion and monitor pulmonal function.

Read more at Wikipedia.org


[List your site here Free!]


Comparison of effects of amphotericin B deoxycholate infused over 4 or 24 hours: randomised controlled trial
From British Medical Journal, 3/10/01 by Urs Eriksson

Abstract

Objective To test the hypothesis that amphotericin B deoxycholate is less toxic when given by continuous infusion than by conventional rapid infusion. Design Randomised, controlled, non-blinded, single centre study.

Setting University hospital providing tertiary clinical care.

Patients 80 mostly neutropenic patients with refractory fever and suspected or proved invasive fungal infections.

Intervention Patients were randomised to receive 0.97 mg/kg amphotericin B by continuous infusion over 24 hours or 0.95 mg/kg by rapid infusion over four hours.

Main outcome measures Patients were evaluated for side effects related to infusion, nephrotoxicity, and mortality up to three months after treatment. Analysis was on an intention to treat basis.

Results Patients in the continuous infusion group had fewer side effects and significantly reduced nephrotoxicity compared with those in the rapid infusion group. Overall mortality was higher during treatment and after three months' follow up in the rapid infusion than in the continuous infusion group.

Conclusion Continuous infusions of amphotericin B reduce nephrotoxicity and side effects related to infusion without increasing mortality.

Introduction

Amphotericin B deoxycholate has remained the mainstay of treatment for life threatening fungal infections in immunocompromised patients because of its broad fungicidal activity and cheapness. Treatment with amphotericin B, however, is associated with acute reactions related to infusion and dose dependent nephrotoxicity. It is recommended that amphotericin B is infused slowly over two to six hours, based on the assumption that the severity and frequency of toxic reactions increase during more rapid infusions.[1-4]

Incorporation of amphotericin B into liposomal formulations reduces its toxicity, but the reasons for this are unclear.[5-11] As liposomes do not specifically target fungal cells it would seem that the reduction in toxicity, at least in part, depends on a slower delivery of amphotericin B to tissues. The question as to whether a slower delivery of amphotericin B from lipid formulations might be reproduced by a slow infusion rate therefore arises. The hypothesis that a continuous infusion of amphotericin B results in reduced toxicity has not been addressed yet in a prospective study. We therefore conducted a randomised, controlled, and open trial to compare the toxicity of amphotericin B given as a continuous infusion with a conventional rapid regimen over four hours.

Patients and methods

Inclusion and exclusion criteria and treatment

All consecutive patients at our tertiary referral centre for adult internal medicine (Zurich University Hospital) were considered eligible for entry to the study, providing their doctors had decided to start treatment with amphotericin B. Exclusion criteria were a baseline serum creatinine concentration in excess of 300 [micro]mol/l or systemic treatment with amphotericin B within the past seven days.

Patients received either a continuous (24 hours) or a rapid (four hours) infusion of amphotericin B. The drug was given in 500 ml of 5% glucose without any additives through a separate intravenous line.

Drugs to prevent chills or fever were prohibited on day 1 of entry to the study.[12] To reduce nephrotoxicity from amphotericin B all patients received infusions of saline as standard care.[13-15] The protocol gave no other restrictions on the use of any concomitant treatment.

Outcome measures

Chills, rigors, and vomiting were monitored prospectively. Each patient completed a standardised questionnaire daily until the end of the study and was interviewed regularly. Temperature was measured; fever was defined as a core temperature of at least 39.3 [degrees] C.

Serum creatinine concentrations were measured daily during treatment and creatinine clearance based on lean body mass was calculated.[16 17] Electrolytes were measured every other day. Further, we recorded overall mortality, mortality due to invasive fungal infections, and breakthrough fungaemia during treatment.

Statistics and study ethics

Analysis was on an intention to treat basis. We planned to randomise 40 patients to each arm to detect a difference in creatinine clearance of at least 20 ml/min between the treatments, with a power of 90% at a two sided ct level of 5%.

We present continuous data as the median (range), which were compared using the Mann-Whitney U test. The effect of treatment was reported as the difference of medians between study groups.[18] For the comparison of dichotomous data the Fisher's exact test was used. We reported the effect of amphotericin B treatment for dichotomous data as relative risk.[19]

Our study was approved by the institutional ethics committee of Zurich University Hospital. We obtained written consent from all patients at enrolment.

Assignment and follow up

The initial dosage for amphotericin B was chosen before randomisation by the doctors in charge, who were not members of the study team. Eligible patients were then randomised in blocks of 10 by sealed envelope. Treatment started immediately after randomisation. Patients were followed up three months after completion of treatment or when treatment was discontinued for any reason.

Results

Patients--Overall, 86 consecutive patients received amphotericin B during the study period (figure). Most of them were severely neutropenic, with haematological neoplasias. We enrolled 80 patients. The groups were comparable at baseline (table 1).

[Figure ILLUSTRATION OMITTED]

Table 1 Dosages of amphotericin B deoxycholate and characteristics of patients receiving rapid (four hours) and continuous (24 hours) infusions of the drug. Values are numbers (percentages) of patients unless stated otherwise

Dosage and dose reductions-Overall duration of treatment and cumulative and daily doses did not differ significantly between the groups. There was a non-significant trend towards longer duration of treatment and higher cumulative doses in the continuous infusion group. We observed significantly more dose reductions or infusion interruptions due to side effects in the rapid infusion group (table 2).

Table 2 Infusion related side effects and drugs to suppress febrile reactions in patients receiving rapid (four hours) or continuous (24 hours) infusions of amphotericin B deoxycholate. Values are numbers (percentages) of patients unless stated otherwise

(*) >39.3 [degrees] C core temperature (corresponding to an axillary temperature of 38.3 [degrees] C).

([dagger]) Fever within 24 hours before treatment was documented for 26 patients in the rapid infusion group and 22 patients in the continuous infusion group.

([double dagger]) Median difference.

Side effects--Side effects occurred mainly during the first three days of treatment. Patients receiving continuous infusions had fewer side effects. For those who had fever at the beginning of treatment there was also a significant difference in the mean time to defervescence (table 2). The concentrations of C reactive protein did not differ between the two groups at entry to the study, but there was a significant increase in the rapid infusion group 24 and 48 hours after the start of treatment (data given on bmj.com). Reflecting the reduced frequency of side effects in the continuous infusion group, these patients were less likely to receive drugs directed against febrile reactions or chills after the first treatment day (table 2).

Nephrotoxicity--Comparison of the calculated creatinine clearance ratios between both infusion groups illustrates a significantly less impaired creatinine clearance for patients with continuous infusions during and at the end of treatment (table 3). The occurrence of electrolyte disturbances did not differ between the two groups.

[TABULAR DATA 3 NOT REPRODUCIBLE IN ASCII]

All seven deaths during treatment occurred in the rapid infusion group. Necropsy was carried out in six of these seven cases and severe pneumonia was found. Invasive fungi were proved in three cases; in one case Pneumocystis carinii was detected. In two patients no infection was found. Breakthrough fungaemia did not occur in any patient of either group.

Treatment was discontinued in two patients assigned to rapid infusion: one because of refractory leukaemia and the other because of severe nephrotoxicity from treatment. Treatment was discontinued in one patient in the continuous infusion group because of refractory leukaemia. After three months' follow up 12 patients in the rapid infusion group had died compared with four patients in the continuous infusion group.

Discussion

Continuous infusions of amphotericin B are significantly better tolerated than rapid infusions. Similar advantages of continuous infusions could be sought for other toxic drugs--for example, antineoplastic agents. Continuous applications are, however, not feasible if high peak values are necessary. The rapid infusion of amphotericin B over fewer hours has been adopted empirically in clinical practice. Despite a retrospective analysis suggesting fewer side effects from continuous infusions, no controlled trials have compared rapid and continuous infusions of amphotericin B.[2]

The reduction of side effects by continuous infusion of amphotericin B seems comparable to recent reports of liposomal amphotericin B.[8] Amphotericin B triggers a proinflammatory response by activating different cytokines.[20 21] Continuous infusions may be better tolerated because of delayed induction or release of such mediators, as reflected by differences in concentrations of C reactive protein and fever. We also observed a noticeable reduction of nephrotoxicity in the continuous infusion group. The mechanisms involved in amphotericin B nephrotoxicity are not yet fully understood.[15] They can be broken down into pretubular and tubular effects. It seems that, as with liposomal amphotericin B, a continuous infusion of amphotericin B primarily reduces pretubular toxicity.

Indications for amphotericin B in our study were proved fungal infections, probable fungal infections, possible fungal infections, and refractory fever during neutropenia. In clinical practice amphotericin B is often prescribed empirically. A definitive baseline diagnosis of invasive mycosis would require invasive diagnostic procedures that are seldom justified in neutropenic and thrombocytopenic patients. It is therefore scarcely ever possible to identify the true prevalence of invasive mycoses. As criteria for efficacy we therefore chose mortality, mortality due to invasive fungal infections, and breakthrough fungaemia. Although our study population was small we found a higher overall mortality during amphotericin B in the rapid infusion group. Mortality also remained significantly higher after three months' follow up. Consequently, our data support the notion that a continuous infusion of amphotericin B may be at least as effective as daily infusions over four hours. We therefore recommend continuous infusions of amphotericin B, where practical, as an effective and well tolerated alternative to the usual rapid infusions.

What is already known on this topic

Amphotericin B is the cornerstone for treatment of invasive fungal infections, especially in neutropenic patients

Its use is limited by general toxic reactions and nephrotoxicity

What this study adds

By giving amphotericin B as a continuous infusion, nephrotoxicity and infusion related toxicity can both be lowered significantly without loss of efficacy

We thank Dr K Barbatti for her help with data acquisition. Parts of this work were presented at the 39th interscience conference on antimicrobial agents and chemotherapy, 1999, San Francisco, California (organised by the American Society of Microbiology).

Contributors: UE was responsible for preparing, coordinating, performing, and analysing the clinical trial and is the principal author of the paper. BS was responsible for statistical design and analysis. AS had the original idea for the study and participated in designing the protocol and analysing the study data and is coauthor of the paper. UE and AS will act as guarantors for the paper.

Funding: None.

Competing interests: UE has been reimbursed by Bristol-Myers Squibb, the manufacturer of amphotericin B deoxycholate (Fungizone), for attending the 39th interscience conference on antimicrobial agents and chemotherapy, 1999, San Francisco, California.

[1] Ellis ME, Al-Hokail AA, Clink HM, Padmos MA, Ernst P, Spence DG, et al. Double-blind randomized study of the effect of infusion rates on toxicity of amphotericin B. Antimicrob Agents Chemother 1992;36:172-9.

[2] Chabot GG, Pazdur R, Valeriote FA, Baker LH. Pharmacokinetics and toxicity of continuous infusion amphotericin B in cancer patients. J Pharm Sci 1989;78:307-10.

[3] Oldfield EC, Garst PD, Hostettler C, White M, Samuelson D. Randomized, double-blind trial of 1- versus 4-hour amphotericin B infusion durations. Antimicrob Agents Chemother 1990;34:1402-8.

[4] Cruz AM, Peacock JE, Loomer L, Holder LH, Evans GW, Powell BL, et al. Rapid intravenous infusion of amphotericin B: a pilot study. Am J Med 1992;93:123-30.

[5] Millis W, LiChopra R, Linch DC, Goldstone AH. Liposomal amphotericin B in the treatment of fungal infections in neutropenic patients: a single center experience of 133 episodes in 116 patients. Br J Haematol 1994;86:754-60.

[6] Prentice HG, Hann IM, Herbrecht R, Aoun M, Kvaloy S, Catovsky D, et al. A randomized comparison of liposomal versus conventional amphotericin B for the treatment of pyrexia of unknown origin in neutropenic patients. Br J Haematol 1997;98:711-8.

[7] Hiemenz JW, Walsh TJ. Lipid formulations of amphotericin B: recent progress and future directions. Clin Infect Dis 1996;22(suppl 2): 133-44S.

[8] Walsh TJ, Finberg RW, Arndt C, Hiemenz J, Schwartz C, Bodensteiner D, et al. Liposomal amphotericin B for empirical therapy in patients with persistent fever and neutropenia. N Engl J Med 1999;340:764-71.

[9] Daneshmend TK, Warnock DW. Clinical pharmacokinetics of systemic antifungal drugs. Clin Pharmacokinet 1983;8:17-42.

[10] Schoffski P, Freund M, Wunder R, Petersen D, Kohne CH, Hecker H, et al. Safety and toxicity of amphotericin B in glucose 5% or intralipid 20% in neutropenic patients with pneumonia or fever of unknown origin: a randomised study. BMJ 1998;317:379-84.

[11] Adler-Moore J. AmBisome targeting to fungal infections. Bone Marrow Transplant 1994; 14:S3-7.

[12] Goodwin DS, Cleary JD, Walawander CA, Taylor JW, Grasela TH. Pretreatment regimens for adverse events related to infusion of amphotericin B. Clin Infect Dis 1995;20:755-61.

[13] Bernardo JF, Murakami S, Branch RA, Sabra R. Potassium depletion potentiates amphotericin B induced toxicity to renal tubules. Nephron 1995;70:234-41.

[14] Feely J, Heidemann H, Gerkens J, Roberts LJ, Branch RA. Sodium depletion enhances nephrotoxicity of amphotericin B. Lancet 1981;i:1422-3.

[15] Arning M, Scharf RE. Prevention of amphotericin B-induced nephrotoxicity by loading with sodium chloride: a report of 1291 days of treatment with amphotericin B without renal failure. Klin Wochenschr 1989;67:1020-8.

[16] Hallynck TH, Soep HH, Thomis J, Boelaert J, Daneels R, Fillastre JP, et al. Prediction of creatinine clearance from serum creatinine concentration based on lean body mass. Clin Pharmacol Ther 1981;30:414-20.

[17] Hallynck TH, Soep HH, Thomis J, Boelaert J, Daneels R, Dettli L. Should clearance be normalised to body surface or to lean body mass? Br J Clin Pharmacol 1981;11:523-6.

[18] Campbell MJ, Gardner MJ. Calculating confidence intervals for some non-parametric analyses. BMJ 1988;296:1454-6.

[19] Greenland S, Robins JM. Estimation of a common effect parameter from sparse follow-up data. Biometrics 1985;41:55-68.

[20] Rogers PD, Jenkins JK, Chapman SW, Ndebele K, Chapman BA, Cleary JD. Amphotericin B activation of human genes encoding for cytokines. J Infect Dis 1998;178:1726-30.

[21] Cleary JD, Chapman SW, Nolan RL. Pharmacologic modulation of interleukin-1 expression by amphotericin B-stimulated human mononuclear cells. Antimicrob Agents Chemother 1992;36:977-81.

(Accepted 4 December 2000)

Medicine B, University Hospital, University of Zurich, CH-8091 Zurich, Switzerland

Urs Eriksson physician

Andreas Schaffner professor

Department of Biostatistics, University of Zurich

Burkhard Seifert statistician

Correspondence to: U Eriksson, Medicine A, University Hospital, CH-4031 Basel, Switzerland klinerr@usz.unizh.ch

BMJ 2001;322:579-82

COPYRIGHT 2001 British Medical Association
COPYRIGHT 2001 Gale Group

Return to Amphotericin B
Home Contact Resources Exchange Links ebay