Several antifungal agents are now available for use against fungal disease, including amphotericin B(Drug information on amphotericin b), itraconazole(Drug information on itraconazole) (Sporanox), and fluconazole(Drug information on fluconazole) (Diflucan). It is important to note that there is a lack of agreement in practice over what constitutes ideal therapy. The following overview explains the current options along with the guidelines used at Memorial-Sloan Kettering Cancer Center (MSKCC) in New York.
General recommendations of drugs of choice for the various fungal indications are shown in Table 1.[1] Potential adverse reactions, contra- indications, and drug interactions associated with these agents are shown in Table 2.
Amphotericin B
Conventional Formulation
Amphotericin B is a potent broadspectrum agent that has been in clinical use for 40 years.[2-6] Until the availability of itraconazole, it was the only agent available for treating Aspergillus infection. A major drawback of conventional amphotericin B is its toxicity profile, with renal toxicity (including acute tubular necrosis) constituting the primary adverse effect associated with treatment. Hypokalemia is a recurrent problem that warrants strict attention to use of other drugs that can affect potassium balance (eg, cisplatin [Platinol], ifosfamide [Ifex], corticosteroids, and ticarcillin(Drug information on ticarcillin)/clavulanic acid [Timentin]).
Other characteristic toxicities include nausea, vomiting, and anorexia; increased erythropoietin(Drug information on erythropoietin) production; phlebitis, if the drug is administered through a peripheral intravenous (IV) line; and (rarely) thrombocytopenia or leukopenia. Acute reactions consist of the complex of chills, fever, tachypnea, hypoxemia, and hypotension; premedication protocols including acetaminophen, hydrocortisone(Drug information on hydrocortisone), diphenylamine, or meperidine are helpful in alleviating these reactions.
Lipid Formulations
The lipid formulations of amphotericin B that have become available are associated with a degree of reduction in renal toxicity compared with the conventional formulation.[4,5,7] However, it is far from clear whether this reduced toxicity and improved quality of life is worth a cost that can be up to 50 times that of the standard formulation for the drug alone.
A 70-year-old man with a history of localized prostate cancer treated with whole-pelvis radiation therapy with a boost to the prostate, in conjunction with androgen deprivation therapy 7 years prior, presented with lower back pain. A bone scan revealed an area of activity in the sacrum. What is the most likely diagnosis?
