Rifamycins rifabutin

The rifamycins, a class of antibacterials isolated from Streptomyces mediterranei, contain a macrocyclic ring bridging across two nonadjacent positions on an aromatic system. Rifampicin (9.96), a semisynthetic derivative of rifamycin, is a drug of choice in the treatment of tuberculosis as well as leprosy, either alone or in combination with other drugs. Rifampicin is much safer than other antituberculotics since it inhibits DNA-directed RNA polymerase in bacteria but not in mammals. Another rifamycin, rifabutin (9.97), is a spiroimidazopiperidyl derivative of the rifamycin. 

Rifampicin, the only commercially available ansamacroHde, is manufactured by MerreU Dow under the tradename Rifadin, and by CIBA under the trade name Rimactane. Rifampicin is also suppHed in combination with isoniazid or pyrazinamide [98-96-4]. The rifampicin—isoniazid combination is known as Rifamate (MerreU Dow), Rifinah (MerreU Dow), and Rimactazid (CIBA) the rifampicin—pyrazinamide as Rifater (MerreU Dow). Several other rifamycin derivatives including rifabutin and rifapentine are undergoing clinical studies. 

Antimicrobial resistance to rifamycins develops rapidly both in vitro and in vivo [65,85,86], As a consequence, all the three members of the family (i.e. rifampicin, rifabutin and rifapentine) are used clinically as components of combination therapies [65,87], Being structurally related, rifaximin could share this potential. And indeed resistance rates, recorded in fecal strains of Enterobacteriaceae, Enterococcus, Bacteroides, Clostridium and anaerobic cocci, ranged between 30 and 90% after short-term (5 days) antibiotic (800 mg daily) treatment [82], A similar pattern was observed in 10 patients with hepatic encephalopathy after treatment with rifaximin 1,200 mg/day for 5 days [80]. 

The rifamycins are a group of antibiotics of large size (Mr close to 1,000), which, among other chemical similarities, have an acetyl group at position 25. Deacetylation by carboxylesterases is a major metabolic pathway in animals and humans, as seen for example with rifampin, rifabutin, and rifalazil [97] [98],... 

Fig. 4.7 Structures of (A) rifamycin, (B) rifampicin and (C) rifabutin, together with their pharmacokinetic properties. Voiume of distribution V i) and plasma clearance (Cip) are for free unbound drug.

Pharmacology Rifabutin, an antimycobacterial agent, is a semisynthetic ansamycin antibiotic derived from rifamycin S. It is not known whether rifabutin inhibits DNA-dependent RNA polymerase in Mycobacterium avium or in Mycobacterium... 

Drugs that may interact with rifabutin include the following Anticoagulants, azole antifungal agents, benzodiazepines, beta blockers, buspirone, corticosteroids, cyclosporine, delavirdine, doxycycline, hydantoins, indinavir, rifamycins, losartan, macrolide antibiotics, methadone, morphine, nelfinavir, quinine, quinidine, theophylline, aminophylline, tricyclic antidepressants, and zolpidem. 

Drugs that may affect nevirapine include rifamycins (eg, rifampin, rifabutin), fluconazole, St. John s wort. 

Drugs that may affect cyclosporine include allopurinol, amiodarone, androgens (eg, danazol, methyltestosterone), anticonvulsants (eg, carbamazepine, phenobarbital, phenytoin), azole antifungals (eg, fluconazole, ketoconazole), beta-blockers, bosentan, bromocriptine, calcium channel blockers, colchicine, oral contraceptives, corticosteroids, fluoroquinolones (eg, ciprofloxacin), foscarnet, HMG-CoA reductase inhibitors, imipenem-cilastatin, macrolide antibiotics, methotrexate, metoclopramide, nafcillin, nefazodone, orlistat, potassium-sparing diuretics, probucol, rifamycins (rifampin, rifabutin), serotonin reuptake inhibitors (SSRIs eg, fluoxetine, sertraline),... 

Rifabutin is a rifamycin used for prophylaxis against Mycobacterium avium complex infections in patients with low CD4 count. As with rifampicin it induces hepatic enzymes, although to a lesser extent than rifampicin, and the effectiveness of some drugs including oral contraceptives may be reduced. 

Among the antimycobacterials often a differentiation is made between first-choice and second-choice agents. The first-choice agents include iso-niazid, rifampicin, ethambutol, pyrazinamide and streptomycin or as alternatives the other aminoglycosides amikacine or kanamycine. The second-choice agents include the quinolones ciprofloxacin and ofloxacin and also the rifamycin derivative rifabutin. 

Rifabutin, a semi-synthetic derivative of rifamy-cin S, is a bactericidal antibiotic primarily used in the treatment of tuberculosis. Its effect is based on blocking the DNA-dependend RNA-polymerase of the bacteria. Rifabutin is used in the treatment of infections with Mycobacterium avium intracellulare. Rifabutin is well tolerated in patients with HIV-related tuberculosis, but patients with low CD4 cell counts have a high risk of treatment failure or relapse due to acquired rifamycin resistance. 

Rifabutin is derived from rifamycin and is related to rifampin. It has significant activity against M tuberculosis, M avium-intracellulare, and M fortuitum (see below). Its activity is similar to that of rifampin, and cross-resistance with rifampin is virtually complete. Some rifampin-resistant strains may appear susceptible to rifabutin in vitro, but a clinical response is unlikely because the molecular basis of resistance, rpoB mutation, is the same. Rifabutin is both substrate and inducer of cytochrome P450 enzymes. Because it is a less potent inducer, rifabutin is indicated in place of rifampin for treatment of tuberculosis in HIV-infected patients who are receiving concurrent antiretroviral therapy with a protease inhibitor or nonnucleoside reverse transcriptase inhibitor (eg, efavirenz)—drugs that also are cytochrome P450 substrates. 

Synthesis of carbon-14 labelled spiro-piperidyl-rifamycins (LM 118) and rifabutin (LM 427)... 

RIFAMYCINS MACROLIDES 1.1 levels of clarithromycin and telithromycin with rifampicin 2. t rifabutin levels with macrolides 1. Rifampicins induce metabolism of these macrolides 2. Inhibition of CYP3A4-mediated metabolism of rifabutin 1. Watch for poor response to clarithromycin and telithromycin, which may last up to 2 weeks after stopping rifampicin 2. Watch for early features of toxicity of rifabutin in particular, warn patients to report painful eyes... 

RIFAMYCINS ANTIMALARIALS -ATOVAQUONE Both rifampicin and rifabutin L atovaquone levels, although the effect is greater with rifampicin (1AUC 50% cf. with 34% rifabutin) Uncertain because atovaquone is predominantly excreted unchanged via the gastrointestinal route Avoid co-administration with rifampicin. Take care with rifabutin and watch for poor response to atovaquone... 

The interaction of clarithromycin with the rifamycins is complex. Clarithromycin inhibits CYP3A4, while both rifampicin and rifabutin induce P450 cytochromes,... 

In patients with MAC infections taking rifabutin or rifampicin the addition of clarithromycin resulted in rifamycin-related adverse events in 77% of patients... 

Rifabutin, U5P. Rifabutin, the spiroimidazopiperidyl derivative of rifamycin B was approved in the United States for the prophylaxis of disseminated MAC in AIDS patients on the strength of clinical trials establishing its effectiveness. The activity of rifabutin against MAC organisms greatly ex-... 

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