| Objective: Through the established RP-HPLC method for determine of voriconazole in human plasma and CYP2C19 genotype detection method,to investigate the effect of CYP2C19 gene polymorphism on the blood concentration,efficacy and safety of voriconazole.At the same time,combine CYP2C19 gene detection with blood drug concentration monitoring results to comprehensively assess the difference of efficacy and safety in voriconazole clinical application,and to provide a reference for voriconazole individualized dosage regimen in fungal infection patients.Methods: Established HPLC method for determination of voriconazole plasma concentration in fungal infection patients,and validated the methodology.the CYP2C19 genotype was detected by PCR-chip hybridization.Fungal infection patients treated with voriconazole from a top three hospital were screened according to the inclusion and exclusion criteria.Blood samples were collected after treating with voriconazole for four days and voriconazole blood concentration was measured,meanwhile the CYP2C19 genotype was detected by PCR-chip hybridization.Then the effects of CYP2C19 genotype on voriconazole blood concentration was investigated.The safety and efficacy of voriconazole were evaluated according to the clinical observation index,laboratory examination and follow-up.The Hardy-Weinberg genetic balance test was performed on the CYP2C19 genotype using HWE software,and the results were analyzed by SPSS 17.0 software.30 patients were randomly divided into experimental group and control group,In the experimental group,the initial dose of voriconazole was adjusted according to the CYP2C19 genotype,and the concentration of voriconazole was determined on the fourth day after the administration,the dose was further adjusted according to the concentration of voriconazole.The control group received routine treatment,no dose adjustment.Evaluate the differences of voriconazole clinical efficacy and safety.Results: Established a reversed phase high performance liquid chromatographic method for quantitative detection of plasma concentrations of voriconazole in patients,A linearity was obtained within the range of voriconazole concentrations from 0.2 to 12?g·m L-1,LLOQ was 0.2?g·m L-1,the standard curve was As=0.13C-0.0022(r2=0.9996,n=5),LLOQ,low concentration,medium concentration,high concentration of intra-day and inter-day RSD were less than 9.0%,the accuracy of voriconazole was between99.0% and 105.0%,and the extraction recoveries of voriconazole was between 83.0% and 92.0%,reduplicate freeze thawing,room temperature,stock solution Stable inspection RSD was less than 12.0%.A total of 42 patients were included,12 males and 30 females with an average age of 41.9 ± 28.1 years and body weight of 47.6 ± 23.8 kg.27 cases of extensive metabolism,12 cases of intermediate metabolism,3 cases of poor metabolism.The target concentration analysis showed that the effective concentration range are 1.5-5.0mg·L-1.The results showed that the mean Cmin of extensive metabolism,intermediate metabolism and poor metabolism was 2.22±2.19 mg.L-1,2.93±1.91 mg.L-1,8.10±2.90 mg.L-1.There was no significant difference of Cmin between extensive metabolism and intermediate metabolism(P=0.18).There was significant differences of Cmin between poor metabolism and extensive metabolism or intermediate metabolism(P=0.003,P=0.04).The treatment efficiency of extensive metabolism,intermediate metabolism and poor metabolism was 55.56%(15/27),75%(9/12),100%(3/3)respectively,and the incidence of adverse reactions was 11.11%(3/27),25%(3/12),66.67%(2/3)respectively.The statistical analysis of the efficiency and safety by chi-square test showed that the effect of CYP2C19 gene polymorphism on the efficacy and safety of voriconazole was statistically significant(P <0.05).Finally 30 patients were performed in a randomized controlled trial,the experimental group and the control group were even 15 cases,with average age 46 + 15 years old,18 males and 12 females.The two groups had no statistical significance in the differences of patients with voriconazole used reason,route of administration,voriconazole blood trough concentration level,using the course of treatment of voriconazole(P>0.05).The incidence of drug adverse reactions in the experimental group and the control group was 26.67%(4/15)and 40.00%(6/15)respectively,and the difference was not statistically significant(P =0.44).The hepatotoxicity incidence rates were 0%(0/15),26.67%(4/15)respectively,and the difference was statistically significant(P=0.03).The treatment success rate of the experimental group and the control group were 75%(9/12)and 61.53%(8/13)respectively,and the difference was not statistically significant(P=0.47).Conclusions: The establishment of voriconazole in human plasma RP-HPLC determination method has high sensitivity and accuracy,with strong specificity,simple operation,rapid analysis,and can meet the requirements the analysis of biological samples,as well as the need of routine monitoring of blood drug concentration.The method lay the foundation for the study of the effect of CYP2C19 gene polymorphism on the plasma concentration,efficacy and safety of voriconazole.Voriconazole concentrations of Cmin had no differences between extensive metabolism and intermediate metabolism,while poor metabolism patients' Cmin had differences compared with extensive metabolism and intermediate metabolism.In addition,the influence of different CYP2C19 genotypes on the efficacy and safety of voriconazole is different.But individual cases analysis showed that only through the influence of CYP2C19 gene polymorphism on voriconazole efficacy can not explain clearly,may be related to factors that influence the efficacy of voriconazole,so only according to CYP2C19 genotype guided voriconazole clinical medication doesn't have to achieve a better treatment effect.The way combined with CYP2C19 genotype detection and blood concentration monitoring to guide clinical individual voriconazole administration is better.Combined with CYP2C19 genotype detection and plasma concentration monitoring results have little influence on reducing the incidence of adverse reactions,and improving the success rate of antifungal infection,but reduce the incidence of liver toxicity in patients.Therefore,develop individualized dosing regimen need to combine the plasma concentration,CYP2C19 genotype and the specific conditions of clinical patients.In addition,due to the small sample size,the results may not be representative,so it is necessary to carry out a large sample of multi-center randomized controlled trials to verify. |
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