Antifungal

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Antifungal
Drug class
Other namesAntimycotic medication

An antifungal, is a type of medicine used to treat a fungal infection.[1] Conditions for which an antifungal may be given are many and include athlete's foot, ringworm, candidiasis, aspergillosis, cryptococcosis, and histoplasmosis, among others.[2] An antifungal may be applied in cream form for local infections of the skin, mouth, eye and vagina, or taken by mouth or given by injection into a vein for deeper fungal infections.[2] The choice and method of administration of antifungal is generally determined by which fungal infection is diagnosed.[2] An antifungal may be given to prevent fungal infection in people who have a weakened immune system; are taking medicines that suppress the immune system such as steroids, cancer treatments or medicines needed after organ transplant, have a condition that causes immunodeficiency such as HIV/AIDS, or have a medical device such as an artificial joint or heart valve, or in someone who has a long stay in intensive care.[2][3]

When taken by mouth, antifungals can be toxic.[4] Types include triazoles such as fluconazole, which is absorbed well after being taken by mouth and can reach the brain and bladder.[2] Imidazoles include clotrimazole, econazole and ketoconazole, and echinocandins are generally used for candidadiasis and aspergillosis.[2] The polyene antifungals include amphotericin B and nystatin.[2]

Several require a prescription, and some are available to buy over the counter (OTC).

The first effective antifungal to be approved was amphotericin B.[5][6]

Types of antifungal

Types of antifungal include triazoles, imidazoles, echinocandins and polyene antifungals.[2]

Of the clinically employed azole antifungals, only a handful are used systemically.[7] These include ketoconazole, itraconazole, fluconazole, fosfluconazole, voriconazole, posaconazole, and isavuconazole.[7][8] Examples of non-azole systemic antifungals include griseofulvin and terbinafine.[2]

Classes

Polyenes

A polyene is a molecule with multiple conjugated double bonds. A polyene antifungal is a macrocyclic polyene with a heavily hydroxylated region on the ring opposite the conjugated system. This makes polyene antifungals amphiphilic. The polyene antimycotics bind with sterols in the fungal cell membrane, principally ergosterol. This changes the transition temperature (Tg) of the cell membrane, thereby placing the membrane in a less fluid, more crystalline state. (In ordinary circumstances membrane sterols increase the packing of the phospholipid bilayer making the plasma membrane more dense.) As a result, the cell's contents including monovalent ions (K+, Na+, H+, and Cl) and small organic molecules leak, which is regarded as one of the primary ways a cell dies.[9] Animal cells contain cholesterol instead of ergosterol and so they are much less susceptible. However, at therapeutic doses, some amphotericin B may bind to animal membrane cholesterol, increasing the risk of human toxicity. Amphotericin B is nephrotoxic when given intravenously. As a polyene's hydrophobic chain is shortened, its sterol binding activity is increased. Therefore, further reduction of the hydrophobic chain may result in it binding to cholesterol, making it toxic to animals.

Azoles

Azoles inhibit conversion of lanosterol to ergosterol by inhibition of lanosterol 14α-demethylase.[10]

Imidazoles

Triazoles

Thiazoles

Allylamines

Allylamines[11] inhibit squalene epoxidase, another enzyme required for ergosterol synthesis. Examples include butenafine, naftifine, and terbinafine.[12][13][14]

Echinocandins

Echinocandins inhibit the creation of glucan in the fungal cell wall by inhibiting 1,3-Beta-glucan synthase:

Echinocandins are administered intravenously, particularly for the treatment of resistant Candida species.[15][16]

Triterpenoids

Others

Side effects

Apart from side effects like altered estrogen levels and liver damage, many antifungal medicines can cause allergic reactions in people.[31] For example, the azole group of drugs is known to have caused anaphylaxis.

There are also many drug interactions. Patients must read in detail the enclosed data sheet(s) of any medicine. For example, the azole antifungals such as ketoconazole or itraconazole can be both substrates and inhibitors of the P-glycoprotein, which (among other functions) excretes toxins and drugs into the intestines.[32] Azole antifungals also are both substrates and inhibitors of the cytochrome P450 family CYP3A4,[32] causing increased concentration when administering, for example, calcium channel blockers, immunosuppressants, chemotherapeutic drugs, benzodiazepines, tricyclic antidepressants, macrolides and SSRIs.

Before oral antifungal therapies are used to treat nail disease, a confirmation of the fungal infection should be made.[33] Approximately half of suspected cases of fungal infection in nails have a non-fungal cause.[33] The side effects of oral treatment are significant and people without an infection should not take these drugs.[33]

Azoles are the group of antifungals which act on the cell membrane of fungi. They inhibit the enzyme 14-alpha-sterol demethylase, a microsomal CYP, which is required for biosynthesis of ergosterol for the cytoplasmic membrane. This leads to the accumulation of 14-alpha-methylsterols resulting in impairment of function of certain membrane-bound enzymes and disruption of close packing of acyl chains of phospholipids, thus inhibiting growth of the fungi. Some azoles directly increase permeability of the fungal cell membrane.

History

The first effective antifungal to be approved was amphotericin B.[5]

See also

References

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  2. 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 "5.3 Fungal infection". British National Formulary (BNF) (82 ed.). London: BMJ Group and the Pharmaceutical Press. September 2021 – March 2022. pp. 635–647. ISBN 978-0-85711-413-6.CS1 maint: date format (link)
  3. Seagle, Emma E.; Williams, Samantha L.; Chiller, Tom L. (2021). "Recent trends in the epidemiology of fungal infections". In Ostrosky-Zeichner, Luis (ed.). Fungal Infections, An Issue of Infectious Disease Clinics of North America. Philadelphia: Elsevier. pp. 237–238. ISBN 978-0-323-81294-8.
  4. Ritter, James M.; Flower, Rod; Henderson, Graeme; Loke, Yoon Kong; Rang, Humphrey P. (2020). "54. Antifungal drugs". Rang & Dale's Pharmacology (9th ed.). Elsevier. pp. 690–695. ISBN 978-0-7020-7448-6.
  5. 5.0 5.1 Ostrosky-Zeichner, Luis; Casadevall, Arturo; Galgiani, John N.; Odds, Frank C.; Rex, John H. (September 2010). "An insight into the antifungal pipeline: selected new molecules and beyond". Nature Reviews Drug Discovery. 9 (9): 719–727. doi:10.1038/nrd3074. ISSN 1474-1784.
  6. Di Mambro, Tomas; Guerriero, Ilaria; Aurisicchio, Luigi; Magnani, Mauro; Marra, Emanuele (2019). "The Yin and Yang of Current Antifungal Therapeutic Strategies: How Can We Harness Our Natural Defenses?". Frontiers in Pharmacology. 10: 80. doi:10.3389/fphar.2019.00080. ISSN 1663-9812.
  7. 7.0 7.1 Benitez, Lydia L.; Carver, Peggy L. (2019). "Adverse Effects Associated with Long-Term Administration of Azole Antifungal Agents". Drugs. 79 (8): 833–853. doi:10.1007/s40265-019-01127-8. ISSN 0012-6667. PMID 31093949. S2CID 155093431.
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  15. Echinocandins for the treatment of systemic fungal infection | Canadian Antimicrobial Resistance Alliance (CARA)
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  17. Polak, Annemarie (1983). "Antifungal activity in vitro of Ro 14-4767/002, a phenylpropyl-morpholine". Medical Mycology. 21 (3): 205–213. doi:10.1080/00362178385380321. ISSN 1369-3786. PMID 6635894.
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  29. "Systemic Therapy". Rook's Textbook of Dermatology. 4 (8th ed.). 2010. p. 74.48.
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External links

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