Fluconazole mg, AzithromycinAnd Secnidazoles (combikit)

Uses

For the treatment of fungal corneal ulcers/ keratitis.

Secnidazole is used for Intestinal Amoebiasis, Hepatic Amoebiasis, Urethritis and Vaginitis due to Trichomonas vaginalis, Giardiasis

Fluconazole mg, AzithromycinAnd Secnidazoles (combikit) is also used to associated treatment for these conditions: Candida intertrigo, Candida pneumonia, Candida urinary tract infection, Candidemia, Candidiasis, Coccidioidomycosis, Esophageal Candidiasis, Fungal peritonitis caused by Candida, Infections, Fungal, Meningitis, Cryptococcal, Oropharyngeal Candidiasis, Peritoneal candidiasis, Pneumonia cryptococcal, Pruritus, Skin Irritation, Systemic Candida Infections caused by Candida, Vaginal Candidiasis, Disseminated CandidiasisBacterial Vaginosis (BV), Candidiasis, Trichomonas Vaginitis, Trichomoniasis

How Fluconazole mg, AzithromycinAnd Secnidazoles (combikit) works

Fluconazole is a very selective inhibitor of fungal cytochrome P450 dependent enzyme lanosterol 14-α-demethylase. This enzyme normally works to convert lanosterol to ergosterol, which is necessary for fungal cell wall synthesis. The free nitrogen atom located on the azole ring of fluconazole binds with a single iron atom located in the heme group of lanosterol 14-α-demethylase. This prevents oxygen activation and, as a result, inhibits the demethylation of lanosterol, halting the process of ergosterol biosynthesis. Methylated sterols are then found to accumulate in the fungal cellular membrane, leading to an arrest of fungal growth. These accumulated sterols negatively affect the structure and function of the fungal cell plasma membrane.

Fluconazole resistance may arise from an alteration in the amount or function of the target enzyme (lanosterol 14-α-demethylase), altered access to this enzyme, or a combination of the above. Other mechanisms may also be implicated, and studies are ongoing.

Secnidazole enters the bacterial cell as a prodrug without an antimicrobial activity. The drug is converted to an active form via reduction of nitro groups to radical anions by bacterial enzymes. The radical anions are thought to interfere with bacterial DNA synthesis of susceptible isolates .

Dosage

Fluconazole mg, AzithromycinAnd Secnidazoles (combikit) dosage

Instill 1 drop to be instilled into the affected eye(s) 5 times daily.

Secnidazole tablet should be administered orally. The dosage schedule of Secnidazole tablet is mentioned below:

Secnidazole Tablet:

Amoebiasis:Acute intestinal amoebiasis:

• Adults: 2 gm single dose (2x1000 mg tablet), taken preferably just before meal.
• Children: 30 mg/kg single dose, taken preferably just before meal.

Asymptomatic amoebiasis (minute & cystic form):

• Adults: 2 gm once daily (2x1000 mg tablet) for only 3 days, taken preferably just before meal.
• Children: 30 mg/kg once daily for only 3 days, taken preferably just before meal.

Hepatic amoebiasis :

• Adults: 1.50 gm/day, in a single or divided dose, just before meal for 5 days.
• Children: 30 mg/kg/day, in a single or divided dose, just before meal for 5 days.

N.B.: Evacuation of pus must be performed simultaneously with Secnidazole treatment at the suppurative stage of hepatic amoebiasis.Giardiasis :

• Adults: 2 gm single dose (2x1000 mg tablet), taken preferably just before meal.
• Children: 35-50 mg/kg single dose, taken preferably just before meal.

Trichomoniasis :

• Adults: 2 gm single dose (2x1000 mg tablet), taken preferably just before meal.
• Children: 30 mg/kg single dose, taken preferably just before meal. The partner should also receive the same treatment concomitantly.

Secnidazole Suspension:

Suspension should be administered orally. The dosage schedule of Secnidazole suspension is mentioned below:

• Children of 10 to 15 kg body weight: 1 bottle of Secnidazole 500 mg suspension.
• Children of 16 to 25 kg body weight: 1½ bottle of Secnidazole 500 mg suspension.
• Children of 26 kg or more body weight: 2 bottles of Secnidazole 500 mg suspension.

Side Effects

This drug is generally well tolerated. Eosinophillia has been reported in some patients.

The clinical studies have shown that secnidazole is characterized by very good tolerance and no serious adverse reactions have been reported to date. The following side-effects may be observed with secnidazole as with all nitroimidazole derivatives & are rarely serious

Most frequent side-effects: Gastrointestinal disturbances, nausea, epigastric pain, metallic taste, glossitis, and stomatitis.

Occasional side-effects: Urticaria, moderate leukopenia which is reversible on treatment discontinuation.

Rare side-effects: Vertigo, ataxia and motor incoordination, paresthesia, and peripheral neuropathy. With secnidazole, gastrointestinal disorders e.g. nausea, vomiting, epigastric pain, etc. have been reported in very rare cases.

Toxicity

Acute oral toxicity (LD50): 1271 mg/kg (rat)

Overdose information

Fluconazole overdoses have been associated with hallucination and paranoia, sometimes in combination. In cases of overdose, employ supportive treatment. Gastric lavage may be necessary. Other modalities such as forced diuresis or hemodialysis may also be used.

A note on liver toxicity

The FDA label warns that this drug carries a risk of hepatotoxicity. Rare but serious cases of serious hepatic toxicity have been reported, especially in patients with serious underlying medical conditions using fluconazole. This group of patients has an increased risk of fatality when using fluconazole. In patients with existing liver dysfunction, use caution during fluconazole therapy. Those who are found to have abnormal liver function tests during therapy should be carefully monitored for the development of increasingly severe injury to the liver. Fluconazole should be stopped if its use is likely to be the underlying cause of liver injury, and medical attention should be sought. Fluconazole induced hepatotoxicity is usually reversible.

Carcinogenesis, mutagenesis, and impairment of fertility

Fluconazole demonstrated no evidence of carcinogenic risk in mice and rats treated orally for 24 months at doses equivalent to approximately 2-7 time the recommended human dose). Male rats given fluconazole at doses equivalent to supratherapeutic human doses showed an increased incidence of hepatocellular adenomas. Cytogenetic studies in vivo and in vitro demonstrated no sign of chromosomal mutation. The significance of these findings for humans is unknown.

Use in pregnancy

There are no sufficient and well-controlled studies of fluconazole use in pregnant women. Available human data do not show an increased risk of congenital anomalies after pregnant women were treated with standard doses (27 Several case reports describe rare but striking congenital anomalies observed in infants who were exposed to fluconazole at high doses reaching 400-800 mg/day, primarily in the first trimester of pregnancy. Similar findings were observed in animal studies. If this drug is administered during pregnancy, or if the patient becomes pregnant while taking fluconazole, the risk should be discussed thoroughly.

Use in nursing

Fluconazole is secreted in breastmilk at high concentrations. Exercise caution if this drug is used during nursing.

Oral LD50 in mouse, rabbit and rat is 300 mg/kg, 3200 mg/kg and 980 mg/kg, in a respective order . Secnidazole was positive in the Bacterial Reverse Mutation Assay, but was negative for the rat micronucleus test and mouse lymphoma test. No parental toxicity or signs of reproductive toxicity were observed in female rat fertility studies at doses of up to the maximum tolerated dose of 300 mg/kg/day .

Precaution

Use of fluconazole may result in overgrowth of non-susceptible strains of candida other than Candida albicans

Patients should be advised not to take alcohol during treatment with secnidazole (because of possibility of antabuse effect). Administration of secnidazole should be avoided to patients with a history of blood dyscrasia.

Interaction

Fluconazole can alter pharmacokinetics of certain drugs undergoing hepatic metabolism.

Administration of secnidazole with disulfiram is not recommended: confusional state & paranoid reaction may occur.

Use of secnidazole simultaneously with warfarin requires close monitoring: increased effect of oral anticoagulants and of the hemorrhagic risk is likely.

Volume of Distribution

The apparent volume of distribution is said to be similar to the volume of distribution of total body water. One clinical study of healthy volunteers administered 50 mg/kg of fluconazole was 39L, based on a body weight of 60kg.

Fluconazole shows substantial penetration in many body fluids, which is a property that renders it an ideal treatment for systemic fungal infections, especially when administered over a longer time. Fluconazole is found in high concentrations in the stratum corneum and dermis-epidermis of skin, in addition to eccrine sweat. Fluconazole is found to accumulate especially well in the stratum corneum, which is beneficial in superficial fungal infections.[L6496] Saliva and sputum concentrations of fluconazole are found to be similar to the plasma concentrations. In patients diagnosed with fungal meningitis, fluconazole CSF (cerebrospinal fluid) levels are measured to be about 80% of the corresponding plasma levels. Therefore, fluconazole crosses the blood-brain barrier[L6496]. The meninges are increasingly permeable to fluconazole in states of inflammation, facilitating treatment in meningitis.

The apparent volume of distribution of secnidazole is approximately 42-49 L .

Elimination Route

The pharmacokinetic properties of fluconazole are comparable after administration by the intravenous (IV) and oral (PO) routes. In healthy volunteers, the bioavailability of orally administered fluconazole is measured to be above 90%. It is extensively absorbed in the gastrointestinal tract when an oral dose is taken. Oral absorption is not affected by food intake with fluconazole but may increase the time until the maximum concentration is reached.

Tmax (or the time taken to achieve the maximum concentration) in one clinical study of healthy patients receiving 50 mg/kg of fluconazole was 3 hours.

Peak plasma concentrations (Cmax) in fasting and healthy volunteers occur between 1-2 hours post-dose. Steady-state concentrations are achieved within 5 to 10 days after oral doses of 50-400 mg administered once daily. Administration of a loading dose on the first day of fluconazole treatment, or twice the usual daily dose, leads to plasma concentrations close to steady-state by the second day. Mean AUC (area under the curve) was 20.3 in healthy volunteers receiving 25 mg of fluconazole.

A note on the capsule and powder form and malabsorption syndromes

The capsule forms of fluconazole often contain lactose and should not be administered with hereditary galactose intolerance, Lapp lactase enzyme deficiency, or malabsorption of glucose/galactose. The powder form, used for the oral suspension, lists sucrose as an ingredient and should not be used in patients who have been diagnosed with fructose, glucose/galactose malabsorption, and sucrase-isomaltase enzyme deficiency.

Secnidazole is rapidly and completely absorbed after oral administration . Following a single oral dose of 2 g in healthy adult female subjects, the mean (SD) secnidazole peak plasma concentration (Cmax) of 45.4 (7.64) mcg/mL and mean (SD) systemic exposure (AUC0-inf) of 1331.6 (230.16) mcg x hr/mL was reached. Median (range) time to peak concentration (Tmax) was 4.0 (3.0-4.0) hours .

Half Life

The terminal elimination half-life in the plasma is approximately 30 hours (range: 20-50 hours) after oral administration. The long plasma elimination half-life supports a single dose therapy for vaginal candidiasis, once daily and once weekly dosing for other indications.[L6496]. Patients with renal failure may require dosage adjustment, and half-life can be significantly increased in these patients.

The plasma elimination half-life for secnidazole is approximately 17 hours .

Clearance

This drug is mainly eliminated by the kidneys and the mean body clearance in adults is reported to be 0.23 mL/min/kg. One clinical study of healthy subjects showed total clearance of 19.5 ± 4.7 mL/min and renal clearance of 14.7 ± 3.7 mL/min (1.17 ± 0.28 and 0.88 ± 0.22 L/h).

Clearance in the pediatric population varies according to age, as does clearance in patients with renal failure.

The total body clearance of secnidazole is approximately 25 mL/min. The renal clearance of secnidazole is approximately 3.9 mL/min .

Elimination Route

In normal volunteers, fluconazole is cleared primarily by renal excretion, with approximately 80% of the administered dose measured in the urine as unchanged drug. About 11% of the dose is excreted in the urine as metabolites.. A study of a 50mg radiolabeled dose of fluconazole revealed that 93.3% of the dose was found excreted in the urine.

A note on renal failure

The pharmacokinetics of fluconazole are significantly affected by renal dysfunction. The dose of fluconazole may need to be reduced in patients with decreased renal function. A 3-hour hemodialysis treatment lowers plasma fluconazole concentrations by about 50%.

The predominant route of elimination is renal elimination. Following a single oral dose of 2g secnidazole, approximately 15% of the drug is excreted as unchanged compoung in the urine .

Pregnancy & Breastfeeding use

Use in pregnancy: Pregnancy category C. There are no adequate and well-controlled studies in pregnant women. Fluconazole should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

Use in lactation: Nursing mother should not be given as the drug is excreted in breast milk in concentration similar to plasma.

Secnidazole may be prescribed in pregnancy after the first trimester. As with other similar drugs, secnidazole should not be administered during the first trimester of pregnancy or during lactation because secnidazole is found in placenta and breast milk.

Contraindication

The drug is contraindicated in patients with hypersensitivity to azoles.

Secnidazole is contraindicated for those patients who are hypersensitive to imidazole derivatives.

Storage Condition

Keep out of the reach of children. Store in a cool, dry place, away from heat and direct light. Do not use more than 4 weeks after opening the bottle

Store in a cool dry place, protected from heat.

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