Itraconazole

Itraconazole is an antifungal medication used to treat a number of fungal infections.[5] This includes aspergillosis, blastomycosis, coccidioidomycosis, histoplasmosis, and paracoccidioidomycosis.[5] It may be given by mouth or intravenously.[5]

Itraconazole
Clinical data
Trade namesSporanox, Sporaz, Orungal, others
AHFS/Drugs.comMonograph
MedlinePlusa692049
License data
Pregnancy
category
    Routes of
    administration    		By mouth (capsules, solution), local (vaginal suppository), intravenous (IV)
    ATC code
    Legal status
    Legal status
    Pharmacokinetic data
    Bioavailability~55%, maximal if taken with full meal
    Protein binding99.8%
    MetabolismExtensive in liver (CYP3A4)
    MetabolitesHydroxy-itraconazole, keto-itraconazole,
    N-desalkyl-itraconazole[3]
    Elimination half-life21 hours
    ExcretionUrine (35%), faeces (54%)[4]
    Identifiers
    CAS Number
    PubChem CID
    DrugBank
    ChemSpider
    UNII
    KEGG
    ChEBI
    ChEMBL
    CompTox Dashboard (EPA)
    ECHA InfoCard100.123.596
    Chemical and physical data
    FormulaC35H38Cl2N8O4
    Molar mass705.64 g·mol−1
    3D model (JSmol)
    ChiralityRacemic mixture
      (verify)

    Common side effects include nausea, diarrhea, abdominal pain, rash, and headache.[5] Severe side effects may include liver problems, heart failure, Stevens–Johnson syndrome and allergic reactions including anaphylaxis.[5] It is unclear if use during pregnancy or breastfeeding is safe.[1] It is in the triazole family of medications.[5] It stops fungal growth by affecting the cell membrane or affecting their metabolism.[5]

    Itraconazole was patented in 1978 and approved for medical use in the United States in 1992.[5][6] It is on the World Health Organization's List of Essential Medicines.[7]

    Medical uses

    Itraconazole has a broader spectrum of activity than fluconazole (but not as broad as voriconazole or posaconazole). In particular, it is active against Aspergillus, which fluconazole is not. It is also licensed for use in blastomycosis, sporotrichosis, histoplasmosis, and onychomycosis. Itraconazole is over 99% protein-bound and has virtually no penetration into cerebrospinal fluid. Therefore, it should not be used to treat meningitis or other central nervous system infections.[8] According to the Johns Hopkins Abx Guide, it has "negligible CSF penetration, however treatment has been successful for cryptococcal and coccidioidal meningitis".[9]

    It is also prescribed for systemic infections, such as aspergillosis, candidiasis, and cryptococcosis, where other antifungal drugs are inappropriate or ineffective.

    Itraconazole has also recently been explored as an anticancer agent for patients with basal cell carcinoma, non-small cell lung cancer, and prostate cancer.[10] For example, in a phase II study involving men with advanced prostate cancer, high-dose itraconazole (600 mg/day) was associated with significant PSA responses and a delay in tumor progression. Itraconazole also showed activity in a phase II trial in men with non-small cell lung cancer when it was combined with the chemotherapy agent, pemetrexed.[11][12][13]

    Available forms

    Itraconazole is produced as blue 22 mm (0.87 in) capsules with tiny 1.5 mm (0.059 in) blue pellets inside. Each capsule contains 100 mg and is usually taken twice a day at twelve-hour intervals. The Sporanox brand of itraconazole has been developed and marketed by Janssen Pharmaceutica, a subsidiary of Johnson & Johnson. The three-layer structure of these blue capsules is complex because itraconazole is insoluble and is sensitive to pH. The complicated procedure not only requires a specialized machine to create it, but also the method used has manufacturing problems. Also, the pill is quite large, making it difficult for many patients to swallow. Parts of the processes of creating Sporanox were discovered by the Korean Patent Laid-open No. 10-2001-2590.[14] The tiny blue pellets contained in the capsule are manufactured in Beerse, Belgium.[14][15]

    The oral solution is better absorbed. The cyclodextrin contained in the oral solution can cause an osmotic diarrhea, and if this is a problem, then half the dose can be given as oral solution and half as capsule to reduce the amount of cyclodextrin given. "Sporanox" itraconazole capsules should always be taken with food, as this improves absorption, however the manufacturers of "Lozanoc" assert that it may be taken "without regard to meals".[16] Itraconazole oral solution should be taken an hour before food, or two hours after food (and likewise if a combination of capsules and oral solution are used). Itraconazole may be taken with orange juice or cola, as absorption is also improved by acid. Absorption of itraconazole is impaired when taken with an antacid, H2 blocker or proton pump inhibitor.

    Side effects

    Itraconazole is a relatively well-tolerated drug (although not as well tolerated as fluconazole or voriconazole) and the range of adverse effects it produces is similar to the other azole antifungals:[17]

    • elevated alanine aminotransferase levels are found in 4% of people taking itraconazole
    • "small but real risk" of developing congestive heart failure[17]
    • liver failure, sometimes fatal

    The cyclodextrin used to make the syrup preparation can cause diarrhea. Side effects that may indicate a greater problem include:

    Interactions

    The following drugs should not be taken with itraconazole:[18]

    Pharmacology

    Pharmacodynamics

    The mechanism of action of itraconazole is the same as the other azole antifungals: it inhibits the fungal-mediated synthesis of ergosterol, via inhibition of lanosterol 14α-demethylase. Because of its ability to inhibit cytochrome P450 3A4 CC-3, caution should be used when considering interactions with other medications.[20]

    Itraconazole is pharmacologically distinct from other azole antifungal agents in that it is the only inhibitor in this class that has been shown to inhibit both the hedgehog signaling pathway[21][22] and angiogenesis.[23][24] These distinct activities are unrelated to inhibition of the cytochrome P450 lanosterol 14 alpha-demethylase and the exact molecular targets responsible remain unidentified. Functionally, the antiangiogenic activity of itraconazole has been shown to be linked to inhibition of glycosylation, VEGFR2 phosphorylation,[24] trafficking,[25] and cholesterol biosynthesis pathways.[23] Evidence suggests the structural determinants for inhibition of hedgehog signaling by itraconazole are recognizably different from those associated with antiangiogenic activity.[26]

    Pharmacokinetics

    Itraconazole, like cyclosporine, quinidine, and clarithromycin, can inhibit P-glycoprotein, causing drug interactions by reducing elimination and increasing absorption of organic cation drugs. With conventional itraconazole preparations serum levels can vary greatly between patients, often resulting in serum concentrations lower than the therapeutic index.[27] It has therefore been conventionally advised that patients take itraconazole after a fatty meal rather than prior to eating.[28][29]

    A product (Lozanoc) licensed through the European union decentralised procedure[30] has increased bioavailability, decreased sensitivity to co ingestion of food, and hence decreased variability of serum levels.

    Chemistry
    Chiral centers are marked by asterisks

    Itraconazole molecule has three chiral carbons. The two chiral centers in the dioxolane ring are fixed in relation to one another, and the triazolomethylene and aryloxymethylene dioxolane-ring substituents are always cis to each other. The clinical formulation is a 1:1:1:1 mixture of four stereoisomers (two enantiomeric pairs).[31][32]

    Four diastereomers of itraconazole

    History

    Itraconazole was approved for medical use in the United States in 1992.[33]

    It was designated an orphan drug by the both the U.S. Food and Drug Administration (FDA) and the European Medicines Agency (EMA).[34][35][36][37][38]

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    References
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    2. "Sporanox 10 mg/ml Oral Solution - Summary of Product Characteristics (SmPC)". (emc). 1 February 2018. Retrieved 15 May 2020.
    3. Isoherranen, N; Kunze, KL; Allen, KE; Nelson, WL; Thummel, KE (October 2004). "Role of Itraconazole Metabolites in CYP3A4 Inhibition". Drug Metabolism and Disposition. 32 (10): 1121–31. doi:10.1124/dmd.104.000315. PMID 15242978.
    4. "Sporanox (itraconazole) Capsules. Full Prescribing Information" (PDF). Janssen Pharmaceuticals, Inc. Retrieved 28 August 2016.
    5. "Itraconazole". The American Society of Health-System Pharmacists. Retrieved 8 December 2017.
    6. Fischer, Jnos; Ganellin, C. Robin (2006). Analogue-based Drug Discovery. John Wiley & Sons. p. 503. ISBN 9783527607495.
    7. World Health Organization (2019). World Health Organization model list of essential medicines: 21st list 2019. Geneva: World Health Organization. hdl:10665/325771. WHO/MVP/EMP/IAU/2019.06. License: CC BY-NC-SA 3.0 IGO.
    8. Gilbert DN, Moellering, RC, Eliopoulos GM, Sande MA (2006). The Sanford Guide to antimicrobial therapy. ISBN 978-1-930808-30-0.CS1 maint: multiple names: authors list (link)
    9. Pham, P; Bartlett, JG (2007-07-24). "Itraconazole". Johns Hopkins. Archived from the original on 2007-11-28.
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    11. Aftab BT, Dobromilskaya I, Liu JO, Rudin CM (2011). "Itraconazole inhibits angiogenesis and tumor growth in non-small cell lung cancer". Cancer Research. 71 (21): 6764–6772. doi:10.1158/0008-5472.CAN-11-0691. PMC 3206167. PMID 21896639.
    12. Antonarakis ES, Heath EI, Smith DC, Rathkopf D, Blackford AL, Danila DC, King S, Frost A, Ajiboye AS, Zhao M, Mendonca J, Kachhap SK, Rudek MA, Carducci MA (2013). "Repurposing itraconazole as a treatment for advanced prostate cancer: a noncomparative randomized phase II trial in men with metastatic castration-resistant prostate cancer". The Oncologist. 18 (2): 163–173. doi:10.1634/theoncologist.2012-314. PMC 3579600. PMID 23340005.
    13. Rudin CM, Brahmer JR, Juergens RA, Hann CL, Ettinger DS, Sebree R, Smith R, Aftab BT, Huang P, Liu JO (May 2013). "Phase 2 study of pemetrexed and itraconazole as second-line therapy for metastatic nonsquamous non-small-cell lung cancer". Journal of Thoracic Oncology. 8 (5): 619–623. doi:10.1097/JTO.0b013e31828c3950. PMC 3636564. PMID 23546045.
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    22. Kim J, Aftab BT, Tang JY, Kim D, Lee AH, Rezaee M, Kim J, Chen B, King EM, Borodovsky A, Riggins GJ, Epstein EH, Beachy PA, Rudin CM (2013). "Itraconazole and arsenic trioxide inhibit hedgehog pathway activation and tumor growth associated with acquired resistance to smoothened antagonists". Cancer Cell. 23 (1): 23–34. doi:10.1016/j.ccr.2012.11.017. PMC 3548977. PMID 23291299.
    23. Chong CR, Xu J, Lu J, Bhat S, Sullivan DJ, Liu JO (2007). "Inhibition of Angiogenesis by the Antifungal Drug Itraconazole". ACS Chemical Biology. 2 (4): 263–70. doi:10.1021/cb600362d. PMID 17432820.
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    25. Xu J, Dang Y, Ren YR, Liu JO (2010). "Cholesterol trafficking is required for mTOR activation in endothelial cells". Proceedings of the National Academy of Sciences. 107 (10): 4764–9. doi:10.1073/pnas.0910872107. PMC 2842052. PMID 20176935.
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    • "Itraconazole". Drug Information Portal. U.S. National Library of Medicine.
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