Telithromycin
From Wikipedia, the free encyclopedia
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Telithromycin
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| Systematic (IUPAC) name | |
| (1S,2R,5R,7R,8R,9S,11R,13R,14R)-8-[(2S,3R,4S,6R)- 4-dimethylamino-3-hydroxy-6-methyl-oxan-2-yl]oxy- 2-ethyl-9-methoxy-1,5,7,9,11,13-hexamethyl-15- [4-(4-pyridin-3-ylimidazol-1-yl)butyl]-3,17-dioxa-15- azabicyclo[12.3.0]heptadecane-4,6,12,16-tetrone |
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| Identifiers | |
| CAS number | |
| ATC code | J01 |
| PubChem | |
| DrugBank | |
| Chemical data | |
| Formula | C43H65N5O10 |
| Mol. mass | 812.004 g/mol |
| Pharmacokinetic data | |
| Bioavailability | 57% |
| Protein binding | 60% to 70% |
| Metabolism | Hepatic (50% CYP3A4-mediated) |
| Half life | 10 hours |
| Excretion | Biliary and renal |
| Therapeutic considerations | |
| Pregnancy cat. |
C (U.S.) |
| Legal status | |
| Routes | Oral |
Telithromycin is the first ketolide antibiotic to enter clinical use. It is used to treat mild to moderate respiratory infections. Telithromycin is sold under the brand name of Ketek®.
Telithromycin is a semi-synthetic erythromycin derivative. It is created by substituting the cladinose sugar with a ketogroup and adding a carbamate ring in the lactone ring. An alkyl-aryl moiety is attached to this carbamate ring. Furthermore, the carbon at position 6 has been methylated, like in clarithromycin, to achieve better acid-stability.
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[edit] History
French pharmaceutical company Hoechst Marion Roussel (later Sanofi-Aventis) started phase II/III trials of telithromycin (HMR-3647) in 1998. Telithromycin was approved by the European Commission in July 2001 and subsequently came on sale in October 2001. In USA, telithromycin gained FDA approval April 1, 2004 .
[edit] Available forms
Telithromycin is administered as tablets. Two 400mg tablets to be taken together, daily, with or without food.
[edit] Mechanism of action
Telithromycin prevents bacteria from growing, by interfering with their protein synthesis. Telithromycin binds to the subunit 50S of the bacterial ribosome, and blocks the progression of the growing polypeptide chain. Telithromycin has over 10 times higher affinity to the subunit 50S than erythromycin. In addition, telithromycin binds simultaneously to two domains of 23S RNA of the 50 S ribosomal subunit, where older macrolides bind only to one. Telithromycin can also inhibit the formation of ribosomal subunits 50S and 30S.
[edit] Pharmacokinetics
Unlike erythromycin, telithromycin is acid-stable and can therefore be taken orally while being protected from gastric acids. It is fairly rapidly absorbed, and diffused into most tissues and phagocytes. Due to the high concentration in phagocytes, telithromycin is actively transported to the site of infection. During active phagocytosis, large concentrations of telithromycin is released. The concentration of telithromycin in the tissues much higher than in plasma.
[edit] Metabolism
It is metabolized mainly in the liver, the main elimination route being the bile, a small portion is also excreted into the urine. About one third is excreted unchanged into the bile and urine, the biliary route being favoured. Telithromycin's half-life is approximately 10 hours.
[edit] Adverse effects
Most common side-effects are gastrointestinal; diarrhoea, nausea, abdominal pain and vomiting. Headache and disturbances in taste also occur. Less common side-effects include palpitations, blurred vision and rashes.
Rare, but severe side effects reported in January 2006 involve damage to the liver. Three different incidents have been reported: one ending in death, one in a liver transplant and one case of drug-induced hepatitis.[1].
In the United States the FDA's Office of Epidemiology and Surveillance identified 12 cases of acute liver failure, resulting in four deaths, and an additional 23 cases of acute, serious liver injury in patients taking telithromycin upto April 2006.[1]
Telithromycin has been known to cause false positive readings in drug screenings for cocaine and amphetamines.
[edit] Questions of telithromycin safety under public and congressional scrutiny
In the first half of July 2006, controversy of telithromycin was sparked when the New York Times[2] reported that David Graham, one of many FDA safety officials concerned about safety of the antibiotic in both adults and children, wrote in an E-mail message to another agency official that the drug's approval was in error. Concern focuses on the drug's liver toxicity[1]. , but also extends to vision problems and other neurogenic effects (reported blackouts/syncopal episodes), including potentially mortal consequences of myasthenia gravis. Liver failure has been reported in fourteen adult patients, four of which died, and another twenty-three sustaining "serious liver injury," according to The Times July 18 article "Approval of Antibiotic Worried Safety Officials". The Times also published excerpts of Dr. Graham's internal memorandum, including this quote: “It’s as if every principle governing the review and approval of new drugs was abandoned or suspended where telithromycin is concerned,” Dr. Graham wrote. In the memo, he subsequently advised "immediate withdrawal[2] The Times characterized the internal FDA climate as a "fierce battle," a climate which is most likely fueled by the increased press attention in recent months (F.D.A. Warns of Liver Failure After Antibiotic (June 30, 2006), and Halt Is Urged for Trials of Antibiotic in Children (June 8, 2006). Including Dr. Graham, three other FDA officials have been named as critics of the drug: Dr. Charles Cooper, Dr. David Ross and Dr. Rosemary Johann-Liang. In The Times article Johann-Liang was quoted as having written "How does one justify balancing the risk of fatal liver failure against one day less of ear pain?". [2] Bipartisan congressional interest has also been triggered. The Times reports that Senator Charles E. Grassley (R-Iowa, chairman, Senate Finance Committee) is "investigating" the issue with Representatives Edward J. Markey (D-Mass) and Henry A. Waxman (D-Calif). Although claiming to receive more than "dozens" of messages (presumably e-mails), The Times did not disclose the source.
[edit] FDA Warning
On February 12, 2007, the Food and Drug Administration announced a revision to the labeling of Ketek to improve patient safety. The changes included the removal of two of the three previously approved indications: acute bacterial sinusitis and acute bacterial exacerbations of chronic bronchitis. The agency determined that the balance of benefits and risks no longer supported approval of the drug for these indications. Ketek will remain on the market for the treatment of community acquired pneumonia of mild to moderate severity (acquired outside of hospitals or long-term care facilities). In addition, the FDA worked with the manufacturer to update the product labeling with a "boxed warning," FDA's strongest form of warning. The warning states that Ketek should not be used in patients with myasthenia gravis, a disease that causes muscle weakness. [2]
[edit] References
- ^ a b Clay KD et al. (2006). "Brief communication: severe hepatotoxicity of telithromycin: three case reports and literature review.". Annals of Internal Medicine 144(6): 415-420. PMID 16481451.
- ^ a b c Harris, G . (2006). "Approval of Antibiotic Worried Safety Officials.". New York Times 19 July 2006.
[edit] External links
- FDA Public Health Advisory for Telithromycin (marketed as Ketek)
- Article in Annals of Internal Medicine regarding cases of hepatotoxicity induced by telithromycin
- New York Times article. Login is required
- FDA officials question safety of antibiotic 'Ketek'
- Drugs and Treatments - KETEK Oral - Patient Handout from WebMD
