Single-dose pharmacokinetics of orally administered

terbinafine in bearded dragons (Pogona vitticeps)

and the antifungal susceptibility patterns
of Nannizziopsis guarroi
Michael S. McEntire, DVM1; Jennifer M. Reinhart, DVM, PhD1; Sherry K. Cox, PhD2; Krista A. Keller, DVM1*

1Department of Veterinary Clinical Medicine, College of Veterinary Medicine, University of Illinois at Champaign-Urbana, Urbana, IL
2Department of Biomedical and Diagnostic Sciences, College of Veterinary Medicine, University of Tennessee, Knoxville, TN
*Corresponding author: Dr. Keller ([email protected])
https://doi.org/10.2460/ajvr.21.02.0023

OBJECTIVE
To identify the antifungal susceptibility of Nanniziopsis guarroi isolates and to evaluate the single-dose pharmaco-
kinetics of orally administered terbinafine in bearded dragons.
ANIMALS
8 healthy adult bearded dragons.
PROCEDURES
4 isolates of N guarroi were tested for antifungal susceptibility. A compounded oral solution of terbinafine (25 mg/
mL [20 mg/kg]) was given before blood (0.2 mL) was drawn from the ventral tail vein at 0, 4, 8, 12, 24, 48, 72,
and 96 hours after administration. Plasma terbinafine concentrations were measured with high-performance liquid
chromatography.
RESULTS
The antifungal minimum inhibitory concentrations against N guarroi isolates ranged from 4,000 to > 64,000 ng/mL
for fluconazole, 125 to 2,000 ng/mL for itraconazole, 125 to 2,000 ng/mL for ketoconazole, 125 to 1,000 ng/mL for
posaconazole, 60 to 250 ng/mL for voriconazole, and 15 to 30 ng/mL for terbinafine. The mean ± SD peak plasma
terbinafine concentration in bearded dragons was 435 ± 338 ng/mL at 13 ± 4.66 hours after administration. Plasma
concentrations remained > 30 ng/mL for > 24 hours in all bearded dragons and for > 48 hours in 6 of 8 bearded
dragons. Mean ± SD terminal half-life following oral administration was 21.2 ± 12.40 hours.
CLINICAL RELEVANCE
Antifungal susceptibility data are available for use in clinical decision making. Results indicated that administration
of terbinafine (20 mg/kg, PO, q 24 to 48 h) in bearded dragons may be appropriate for the treatment of dermato-
mycoses caused by N guarroi. Clinical studies are needed to determine the efficacy of such treatment.

B earded dragons (Pogona vitticeps) are common

companion lizards in the United States and are
commonly infected with Nannizziopsis guarroi, the
pathogens within the genera Nannizziopsis, Ophid-
iomyces, Parananniziopsis, and Emydomyces were
previously assigned to the CANV group.3,7,9,10
causative agent of yellow-fungus disease.1–9 Nan- Despite its recognition as an emerging disease in
nizziopsis spp are a genus of keratinophilic fungi reptilian patients, there is limited understanding of
that cause cutaneous lesions in lizards ranging from the best treatment for N guarroi.3,5,8 Antifungal sus-
mild scale discoloration and dysecdysis to severe, ceptibility information exists for 32 CANV isolates11;
disfiguring, and ulcerative lesions leading to inva- however, given the recent nomenclature changes,
sive mycosis and death.1–9 Recent molecular charac- interpretation of these data is challenging because
terization has led to several nomenclature changes; isolates previously assigned to the CANV group may
infection with this pathogen has been previously re- have been members of various other genera.3,7–10
ported under the names Chrysosporium guarroi and Few antifungal agents have been investigated for
Chrysosporium anamorph of Nannizziopsis vriesii treatment of N guarroi in bearded dragons. The
(CANV).3,7–9 At this time, genetic sequencing sug- azole class of antifungals are the most commonly
gests that most cases of CANV in companion rep- used, although they have been associated with hep-
tiles are caused by N guarroi.3 However, many fungal atotoxicity.1,2,11 Voriconazole has been shown to be

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the most efficacious and the least toxic of this group bearded dragon housing and husbandry was pro-
(14% mortality) in the treatment of what was at the vided by the University of Illinois in accordance with
time termed CANV in bearded dragons, compared Institutional Animal Care and Use Committee proto-
with itraconazole (70% mortality).11 Despite clinical col No. 18056.24 In brief, each bearded dragon was
and microbiological evidence of resolved infections, individually housed in a front-opening 91.45 X 71.12
the literature also supports a high rate of recurrence X 45.72-cm enclosure (V332 Vision Cage; LLL Rep-
of latent infections following treatment with drugs tile and Supply Co) located within a temperature-
in the azole class.2,6,12 Clients and clinicians are un- controlled room (24 to 25.5 °C). The daily diet in-
derstandingly dissatisfied with current treatment cluded a variety of dark leafy greens (collard greens,
options for N guarroi given the expensive nature of kale, turnip greens, and mustard greens) with addi-
azoles, their variable toxicity rates, and the high like- tional shredded vegetables (carrots, sweet potato,
lihood of infection recrudescence. There is a need to and berries) supplemented with calcium carbonate
establish the susceptibility patterns of molecularly powder and twice weekly offering of gut loaded king
confirmed isolates of N guarroi and to investigate worm (Zophobas morio) larvae (High-calcium Crick-
safer, more efficacious antifungals for treatment of et Diet; Fluker’s Farms and NOW Foods). Each enclo-
this disease. sure had a dedicated heat lamp and a dedicated UV
Terbinafine hydrochloride is a synthetic allyl- emitting bulb (both UVA and UVB) situated above
amine antifungal agent, originally developed for use the habitat. Twelve hours of darkness were provided
in the treatment of human mycotic nail infections.13–16 daily with a basking temperature (Zoo Med Labora-
Terbinafine is fungicidal by inhibiting squalene epox- tories Inc) reaching 35 to 37 °C. The animals were
idase, an enzyme required for ergosterol synthesis. determined to be free of significant clinical disease
Accumulation of squalene within fungal cells leads to on the basis of normal activity, appetite, and urinary
cell death.13–16 Terbinafine is an attractive option for and fecal outputs.
antifungal therapy because there are rare reports of
toxicosis in other species owing to its keratinophilic Culture and morphologic identification
nature.16 The accumulation of terbinafine within ke- of N guarroi isolates
ratinized tissues makes it a particularly attractive Fungal isolates were derived from clinical sam-
treatment option for dermatomycoses.13–16 Pharma- ples of 2 bearded dragons and 2 green iguanas
cokinetic studies for terbinafine have been reported (Iguana iguana). Three isolates were obtained from
for several zoological mammal and avian species patients evaluated at the William R. Pritchard Vet-
and a single reptile species, the cottonmouth snake erinary Medical Teaching Hospital at University of
(Agkistrodon piscivorous).17–23 Nebulization of ter- California-Davis, and 1 isolate was obtained as a sub-
binafine has become an effective treatment of an- mission from an outside private practice to the Vet-
other important cutaneous reptile fungal pathogen, erinary Microbiology Laboratory at the University of
Ophidiomyces ophidiocola, in venomous snakes, for California-Davis. All isolates were derived from clini-
which oral administration is both dangerous and un- cal patients with skin lesions considered consistent
reliable.17 Thus, terbinafine may represent an alter- with N guarroi infection (crusting and ulceration) as
native antifungal treatment for N guarroi infection in either skin biopsies (2 isolates) or samples obtained
bearded dragons, but the susceptibility of the fun- during necropsy (1 isolate). The isolate submitted by
gus to terbinafine and the pharmacokinetics of the a private practice was derived from skin and tissue,
drug must be established first. but it was unknown whether the samples were ob-
The objectives of the study reported here were tained before or after death.
to establish the antifungal susceptibility patterns of Samples were inoculated onto inhibitory mold
molecularly confirmed N guarroi from clinical iso- agar (Hardy Diagnostics) and dermatophyte test
lates and to determine the pharmacokinetics of a and rapid sporulation media (Derm Duet; Hardy Di-
single dose of terbinafine following oral administra- agnostics) then incubated at 30 °C under ambient
tion in bearded dragons. We hypothesized that oral atmosphere. Plates were examined daily for fungal
administration of terbinafine would provide plasma growth and fungal colonies subcultured to potato
drug concentrations that exceeded the minimum in- flake agar (Biological Media Services, University of
hibitory concentration (MIC) against N guarroi and California-Davis) and incubated as above. Prelimi-
be safe in bearded dragons. nary identification of fungal isolates as N guarroi was
made by morphologic microscopic examination of
a tape preparation stained with lactophenol cotton
Materials and Methods blue stain (Hardy Diagnostics) from the subculture.9

Animals Molecular identification

This study was carried out with the approval of Fungal DNA was obtained from each culture by
the University of Illinois Institutional Animal Care and use of a NaOH extraction protocol.25 In brief, fresh
Use Committee (protocol No. 17243). Eight bearded mycelium was added to 200 μL of 0.5M NaOH in a
dragons (5 males and 3 females) with ages ranging 1.5-mL microcentrifuge tube, ground by use of a
from 2 to 3 years and body weights ranging from UV-sterilized pestle, incubated at 4 °C for 20 min-
256 to 384 g that were maintained as a teaching and utes, centrifuged at 16,873 X g for 2 minutes; 5 μL
research colony were used for the study. Standard of the resulting supernatant was added to 495 μL of

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100mM Tris HCl buffered with NaOH to a pH of 8.5 to vage, and blood (0.2 mL) was collected from the ven-
8.9 (Tris-HCl-DNA extraction solution). A PCR assay tral tail vein at 0, 0.25, 0.5, 1, 2, 4, 8, 12, and 24 hours
(PTC 200 thermal cycler; Bio-Rad Laboratories Inc) after drug administration. To determine the duration
was performed in which the total reaction volume of sampling needed to evaluate clearance, a fourth
was 25 μL (12.5 μL of a commercially available master lizard received 20 mg of terbinafine/kg by gavage,
mix [GoTaq Green Master Mix; Promega Corp]; 1.2 μL and blood (0.2 mL) was collected from the ventral
each of 10μM primer internal transcribed spacer tail vein at 0, 0.5, 1, 2, 4, 8, 12, 24, 36, 48, 60, 72,
[ITS] 1F and ITS4, 3 μL of the Tris-HCl-DNA extrac- 84, and 96 hours. The total amount of blood drawn
tion solution, and 7.1 μL of DNA-free water) and the was less than 0.8% of the body weight for each indi-
thermal cycle parameters were initial denaturation at vidual animal. Blood was collected into lithium hepa-
94 °C for 2 minutes, 30 cycles of 94 °C for 30 sec- rin microtainers (Becton Dickinson), kept on ice until
onds, 55 °C for 45 seconds, and 72 °C for 1 minute centrifuged (Eppendorf AG22331 Centrifuge; Brink-
with a final extension step of 72 °C for 10 minutes. mann Instruments Inc) within 1 hour after collec-
Gel electrophoresis (1% Tris-borate-EDTA agarose tion, after which plasma was harvested and stored at
gel stained with ethidium bromide) was used to ver- –20 °C until analysis.
ify the presence of a PCR product before purifica-
tion with a clean-up system (Wizard SV Gel and PCR Single-dose pharmacokinetics—Four months
Clean-Up System; Promega Corp). A cycle sequenc- following the pilot study, 8 lizards, including the 7
ing kit (BigDye Terminator version 3.1; Applied Bio- lizards used in the pilot study, received a single oral
systems Inc) was used to sequence the ITS in 1 di- dose of terbinafine (20 mg/kg), administered by ga-
rection with the ITS5 primer on a high-throughput vage directly into the stomach (total volume admin-
capillary sequencer (3730XL; Applied Biosystems) istered, 0.22 to 0.31 mL). Immediately after terbin-
at the Roy J. Carver Biotechnology Center at the afine gavage, a slurry of commercially available in-
University of Illinois. Sequences were examined and tensive care diet (Intensive Care Herbivore; Emeraid
manually corrected with sequence analysis software LLC; fed at 1.5% of body weight; total volume admin-
(Sequencher version 5.1; Gene Codes Corp). Culture istered, 4.1 to 5.9 mL) was administered via gavage
identity was confirmed through nBLAST analysis of needle. Blood (0.2 mL) was collected from the ven-
the ITS1-5.8-ITS2 region using the National Center tral tail vein at 0, 4, 8, 12, 24, 48, 72, and 96 hours
for Biotechnology Information database. after drug administration. The total amount of blood
drawn was less than 0.8% of the body weight for each
Antifungal susceptibility subject. Blood was collected into lithium heparin mi-
All plated isolates were sent on Sabouraud dex- crotainers, kept on ice until centrifuged within 1 hour
trose agar (Remel) to an external laboratory (Fungus after collection, after which plasma was harvested
Testing Laboratory, Department of Pathology and and stored at –20 °C until analysis.
Laboratory Medicine, University of Texas San Anto-
nio, San Antonio, Texas) for antifungal susceptibil- Terbinafine analysis
ity testing. Each isolate was broth dilution tested Plasma samples were analyzed with a reverse-
against fluconazole, ketoconazole, itraconazole, ny- phase high-performance liquid chromatography
statin, posaconazole, terbinafine, and voriconazole method.28 The system consisted of a 2695 sepa-
as described.26 rations module, 2487 absorbance detector, and
computer equipped with software (Empower 3 Chro-
Compounded terbinafine matography Software; Waters Corp). Terbinafine
An oral solution (concentration, 25 mg/mL) of was extracted from plasma samples using liquid ex-
terbinafine was compounded from commercially traction. Briefly, previously frozen plasma samples
available tablets (Sigma-Aldrich; 250 mg of terbin- were thawed and vortexed, and 100 µL was trans-
afine/tablet) crushed and dissolved in commercially ferred to a clean screw-top test tube followed by 75
available suspending vehicles (Ora-Plus and Ora- µL internal standard (butenafine, 1.0 µg/mL). Hex-
Sweet; Paddock Laboratories) using a previously ane (3 mL) was added, and the tubes were rocked
published27 compounding recipe that ensures a for 20 minutes and then centrifuged for 20 minutes
stable suspension for 28 days. The time from com- at 1,000 X g. The organic layer was transferred to a
pounding to administration was < 48 hours. clean tube and evaporated to dryness with nitrogen
gas. Samples were reconstituted in 250 µL of mobile
Pharmacokinetic sampling and analysis phase and 100 µL was analyzed.
Pilot studies—To determine an appropriate The compounds were separated on a C18 column
dose and sampling protocol, 2 pilot studies were (Symmetry Shield C18 Chromatography Kit; Waters
performed. Three lizards were randomly assigned Corp; 4.6 X 100 mm; 5 µm). The mobile phase was a
by pulling numbers from a hat to received 5 mg of mixture of 20mM phosphoric acid with 0.1% triethyl-
terbinafine/kg by gavage, and blood (0.2 mL) was amine adjusted to pH 3.0 (A) and acetonitrile (65:35;
collected from the ventral tail vein at 0 (immediate- B). The flow rate was 1.1 mL/min with the column
ly after), 0.25, 0.5, 1, 2, 4, 8, 12, and 24 hours after maintained at ambient temperature (22 °C). Absor-
terbinafine administration. A second group of 3 dif- bance was measured at wavelength of 224 nm.
ferent lizards randomly assigned by pulling numbers Standard curves for plasma analysis were pre-
from a hat received 20 mg of terbinafine/kg by ga- pared by fortifying untreated, pooled plasma with

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terbinafine to produce a linear concentration range es in appetite or attitude despite the frequent han-
of 5 to 1,500 ng/mL. Calibration samples were pre- dling and venipuncture.
pared in the same manner as plasma samples. Aver-
age recovery for terbinafine was 95%, the intra-assay Antifungal susceptibility test results
variability ranged from 4.5% to 8.5%, and the interas- Susceptibility test results for the 4 N guarroi
say variability ranged from 0.93% to 8.5%. The lower isolates against the antifungals fluconazole, itra-
limit of quantification was 5 ng/mL. conazole, ketoconazole, nystatin, posaconazole,
terbinafine, and voriconazole were summarized
Statistical analysis (Table 1). On the basis of the susceptibility test
Continuous parameters were summarized as the results of the 4 N guarroi isolates to terbinafine,
mean ± SD. For the main study, noncompartmental the target terbinafine concentration threshold for
pharmacokinetic analysis was performed with com- the pharmacokinetic study was set at > 30 ng/mL.
mercial software (Phoenix WinNonLin; Certara LP).
Reported parameters included the terminal rate Pharmacokinetics
constant, terminal half-life (t1/2λ), maximum plasma Pilot studies—In the initial pilot study (terbin-
concentration (Cmax), time to maximum plasma con- afine dose, 5 mg/kg), only 1 of the 3 bearded drag-
centration, area under the concentration-versus- ons achieved plasma terbinafine concentrations > 30
time curve (AUC) from time 0 to the last measured ng/mL starting at approximately 4 hours and lasting
concentration, AUC from time 0 to infinity, AUC from for < 8 hours after drug administration. In the sec-
the last measured time extrapolated to infinity and ond pilot study (terbinafine dose, 20 mg/kg), all 4
expressed as a percentage of the total AUC, and bearded dragons achieved plasma terbinafine con-
mean residence time (MRT). Accumulation ratios centrations > 30 ng/mL by 0.5 to 8 hours after drug
(ARs) were calculated at dosing intervals of 24 and administration and maintained concentrations > 30
48 hours using the following formula: ng/mL for 48 hours.

Single-dose pharmacokinetics—The mean ± SD

plasma terbinafine concentration was plotted over
time (Figure 1) and the pharmacokinetic parameters
where τ is the proposed dosing interval. The
were summarized (Table 2) for all 8 bearded dragons.
maximum concentration at steady state and
The median (range) plasma terbinafine concentra-
concentration just prior to the next dose at
tion at each sample time were also summarized for
steady state were calculated from the AR and
male and female bearded dragons separately (Table
single-dose data.
3). For all 8 bearded dragons, the plasma terbinafine
concentration exceeded the target MIC (30 ng/mL) by
Results 4 hours after drug administration and remained about
the target MIC for > 24 hours. For 6 of the 8 bearded
Bearded dragons dragons (3 males and 3 females), the plasma terbin-
One bearded dragon died following completion afine concentration remained above the target MIC for
of the main study. Postmortem analysis of that ani-
mal revealed a focal gastric perforation with local-
ized peritonitis, consistent with iatrogenic trauma
from gavage; no other gross or histologic lesions
were observed in any of the tissues. No adverse
effects were observed in any of the other bearded
dragons during any of the experiments, and none
of the 3 females laid eggs during the month after
study completion. There were no perceived chang-

Table 1—Antifungal minimum inhibitory concentrations

(MICs; ng/mL) for each of 4 Nannizziopsis guarroi iso-
lates obtained from 2 bearded dragons (Pogona vitti-
ceps; BD) and 2 green iguanas (Iguana iguana; GI) with
clinical skin infections.
N guarroi isolate
Antifungal BD 1 BD 2 GI 1 GI 2 Figure 1—Mean ± SD plasma terbinafine concentration
over time following gavage administration of a single
Fluconazole 4,000 64,000 32,000 > 64,000 dose of terbinafine (20 mg/kg) to 8 bearded dragons
Itraconazole 125 1000 2,000 1,000 (Pogona vitticeps). The target plasma concentration for
Ketoconazole 125 200 2,000 2000 terbinafine (30 ng/mL) selected on the basis of culture
Posaconazole 125 250 500 1,000 and susceptibility results for 4 Nannizziopsis guarroi
Voriconazole 60 125 125 250 isolates obtained from 2 bearded dragons and 2 green
Nystatin 4,000 4,000 2,000 2,000 iguanas (Iguana iguana) with clinical skin infections is
Terbinafine 30 30 15 30 also indicated (dotted line).

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> 48 hours. Accumulation ratios and predicted steady ly useful data for antifungal selection in managing
state concentrations are were summarized (Table 4). these cases.
A previous study evaluated the antifungal sus-
Discussion ceptibility of 32 CANV isolates derived from a variety
of lizards.11 In that study,11 the in vitro MICs ranged
The data presented in this study support that from 31 to 1,600 ng/mL for itraconazole, voricon-
terbinafine orally administered at a dose of 20 mg/ azole, and amphotericin B and from 10 to 500 ng/mL
kg was sufficient to reach the target MIC (30 ng/ for terbinafine and were more variable than the MICs
mL) for N guarroi and may be useful for treatment determined for the molecularly confirmed N guar-
of infections caused by N guarroi. Additionally, the roi isolates evaluated in the present study. It is likely
antifungal susceptibilities of the N guarroi isolates that the CANV isolates evaluated in that study11 rep-
assessed in this study differed from those obtained resented various fungal species within the genera
for other Onygenalean fungi and provided clinical- Nannizziopsis and Paranannizziopsis.3,7–9
Antifungal susceptibility has been investigated for
Table 2—Values for noncompartmental pharmacoki- other Onygenalean fungal pathogens. Ophidiomyces
netic parameters after gavage administration of terbi- ophidiocola, the causative agent of snake fungal dis-
nafine (20 mg/kg) to 8 bearded dragons. ease and also previously assigned to the CANV com-
Parameter Mean ± SD Range plex, has a similar antifungal susceptibility pattern
(ie, the MIC was 500 to 1,000 ng/mL for itraconazole,
Cmax (ng/mL) 434.85 ± 338.27 153–1,158 250 to 500 ng/mL for ketaconzole, 500 ng/mL for
tmax (h) 13 ± 4.66 8–24
t1/2λ (h) 21.24 ± 12.40 5.21–39.50 posaconzole, 250 ng/mL for voriconazole, and 15 ng/
λz (h) 0.049 ± 0.039 0.018–0.13 mL for terbinafine)29 as the N guarroi isolates of the
AUC0–last 10,085.97 ± 8,355.24 3,682–29,896 present study. Conversely, Emydomyces testavorans, a
(h•ng/mL) newly described fungus associated with shell mycosis
AUC0–∞ 11,364.19 ± 9,812.74 3,874.18–34,853.5 in aquatic freshwater turtles, has a different antifungal
(h•ng/mL)
AUC%extrap (%) 10.05 ± 5.90 3.59–17.99
susceptibility pattern (ie, the MIC was 1,000 to 2,000
MRT (h) 25.78 ± 9.53 11.84–40.40 ng/mL for fluconazole, 60 to 250 ng/mL for itracon-
azole, < 30 to 125 ng/mL for posaconazole, < 30 ng/mL
AUC0–last = Area under the concentration-versus-time curve for voriconazole, and 15 to 250 ng/mL),10 compared
from time 0 to the last measured concentration. AUC0–∞ = Area
under the concentration-versus-time curve from time 0 to in- with that for the N guarroi isolates of the present study.
finity. AUC%extrap = Area under the concentration-versus-time Clinicians confronted with a reptilian patient with a cu-
curve from the last measured time extrapolated to infinity and taneous mycosis should pursue molecular confirmation
expressed as a percentage of the total area under the concen- of the etiologic agent and rely on isolate-specific anti-
tration-time curve. Cmax = Maximum plasma concentration. MRT fungal susceptibility data either reported in the litera-
= Mean residence time. tmax = Time to maximum plasma con-
centration. t1/2λ = Terminal half-life. λz = Terminal rate constant.
ture (when available) or from culture and susceptibility
results for selection of appropriate antifungal therapy.
The terbinafine pharmacokinetics determined
Table 3—Median (range) of plasma terbinafine concen- for the bearded dragons of the present study dif-
tration (ng/mL) in male (n = 5) and female (3) bearded fered significantly from those in other species. The
dragons following gavage administration of a single time to maximum plasma concentration of terbin-
dose of terbinafine (20 mg/kg). afine for bearded dragons (13 ± 4.66 hours) was pro-
Time (h) Male Female longed, compared with that in cats30 (1.33 hours),
0 0 (0) 0 (0)
horses31 (1.7 hours), Greyhounds31 (2.0 hours), red-
4 51 (29–116) 309 (94–397) tailed hawks23 (Buteo jamaicensis; 3.4 hours), Afri-
8 96 (84–158) 511 (253–670) can penguins21 (Spheniscus demersus; 4.0 hours),
12 178 (36–378) 634 (265–1,158) and Hispaniolan Amazon parrots19 (Amazona ven-
24 77 (57–271) 234 (79–424) tralis; 6.4 hours). This suggests that absorption of
48 49 (0–95) 61 (40–202)
terbinafine by bearded dragons was delayed rela-
72 27 (0–51) 16 (0–133)
96 16 (0–33) 12 (0–87) tive to other species, likely owing to differences in
gastrointestinal physiology and the lower metabolic

Table 4—Accumulation ratios (ARs) and the predicted maximum concentration at

steady state (Cmax,ss) and concentration just prior to the next dose at steady state (Cτ,ss)
following gavage administration of terbinafine (20 mg/kg) to 8 healthy bearded drag-
ons assuming 24- and 48-dosing intervals.
Parameter 24-hour dosing interval 48-hour dosing interval
AR 1.87 ± 0.69 (1.04–2.91) 1.30 ± 0.29 (1.00–1.76)
Cmax,ss (ng/mL) 871.51 ± 1,030.67 (281.75–3,368.94) 593.26 ± 605.77 (205.92–2,034.05)
Cτ,ss (ng/mL) 348.86 ± 382.50 (80.30–1,233.53) 100.14 ± 111.70 (0–354.82)
Values represent the mean ± SD (range).

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rate of bearded dragons. For the bearded dragons power to compare the findings between males and
of the present study, terbinafine was administered females, the higher plasma terbinafine concentra-
with a meal because administration of terbinafine tions noted in the females may have represented sex
with food enhances the absorption and increases differences associated with seasonal plasma protein
the Cmax for the drug in human patients.32 The inclu- levels. The quantification of plasma proteins was not
sion of a gavage-fed meal with the terbinafine was pursued in this study but may be worthwhile in fu-
added to the methods of the full study to facilitate ture studies. However, assessment of tissue or cel-
peak absorption. The Cmax (434 ± 338 ng/mL) for lular drug concentration is likely the most appropri-
the bearded dragons of the present study follow- ate method for determination of the required kinetic
ing oral administration of terbinafine at a dose of 20 parameters for drugs that are highly protein bound,
mg/kg was similar to the Cmax for African penguins with a free fraction of < 20% in plasma.38 Clinicians
receiving terbinafine a dose of 15 mg/kg, PO (200 prescribing terbinafine should strongly consider per-
ng/mL)21; horses receiving terbinafine at a dose forming plasma protein quantification prior to and
of 20 mg/kg, PO (310 ng/mL)31; and Hispaniolan during terbinafine treatment.
Amazon parrots receiving terbinafine at a dose of The presence of hepatic disease may alter ter-
60 mg/kg, PO (353 ng/mL),19 but much lower than binafine pharmacokinetics owing to alteration of
the Cmax measured in red-tailed hawks (1,200 ng/ hepatic biotransformation or as a consequence of
mL),23 cats (3,220 ng/mL),30 and Greyhound dogs31 hypoproteinemia. Although not evaluated in reptil-
(4,010 ng/mL) that received terbinafine at a dose ian species, results of mammalian studies14,16,34 sup-
of 30 mg/kg, PO. The low Cmax may be the result of port that terbinafine undergoes extensive hepatic
slower absorption or differences in terbinafine dos- biotransformation through multiple enzymatic path-
ages or formulations administered among studies. ways. The bearded dragons of the present study did
It is also possible that the oral bioavailability of ter- not undergo diagnostic testing to ascertain hepatic
binafine in bearded dragons is lower than that for health but were deemed healthy on the basis of nor-
species with a higher Cmax. mal behavior, appetite, and outputs. Additionally,
The plasma t1/2λ of terbinafine (21.2 ± 12.4 the bearded dragon that died and underwent nec-
hours) for the bearded dragons of the present ropsy following completion of the study did not have
study was longer than that observed in cats30 (8.01 any gross or histologic evidence of hepatopathy. Two
hours), Greyhound dogs31 (8.6 hours), horses31 other bearded dragons not enrolled in the study but
(8.1 hours), and Hispaniolan Amazon parrots19 (8.7 maintained in the same research colony as the study
hours) and similar to that observed in African pen- animals were euthanized. One of those bearded
guins21 (17.0 hours) and red-tailed hawks23 (17.5 dragons was euthanized 1 year before study initia-
hours). This may represent slow elimination of ter- tion and was determined to have biliary lithiasis. The
binafine because of slower metabolism of the drug other bearded dragon was euthanized 1 month after
in bearded dragons, although it is unknown wheth- study completion and was found to have an intes-
er terbinafine undergoes hepatic biotransformation tinal intussusception. At the time this manuscript
in this species. The t1/2λ of terbinafine is also likely was written, the 7 remaining bearded dragons of the
influenced by its lipophilic and keratophilic nature,33 present study were alive and appeared healthy with-
which results in a large volume of distribution as the out any signs of illness suggestive of hepatic disease
drug accumulates in peripheral tissues and slowly and were not being treated for any illness over 1 year
redistributes back into the blood. The accumulation later. The findings of this study should be presumed
of terbinafine in keratinized tissues (dermis, epider- to represent terbinafine pharmacokinetics in healthy
mis, nail, and hair) is observed in multiple species bearded dragons, and clinicians utilizing terbinafine
and makes terbinafine an excellent choice for the should consider pursuing diagnostic testing to as-
treatment of fungal dermatomycoses.20,34–37 sess hepatic health in clinically ill patients.
In mammals, terbinafine is highly protein bound, In the present study, pharmacokinetic analysis
with > 99% plasma protein binding occurring in dogs, confirmed that gavage administration of a single
rabbits, and humans.14,16,34 There are no published dose (20 mg/kg) of terbinafine to bearded dragons
data on the protein affinity of terbinafine in any exceeded the MIC of terbinafine (30 ng/mL) neces-
reptile species. However, it must be assumed that sary to inhibit growth of N guarroi for at least 24
a degree of protein binding does occur in bearded hours. The pharmacodynamic parameter most pre-
dragons and a state of hypoproteinemia or hyper- dictive of antibiotic efficacy (T > MIC, AUC/MIC, or
proteinemia will affect terbinafine pharmacokinetics. Cmax/MIC) has not been established for terbinafine
Vitellogenesis results in elevated protein concentra- in humans or animals.39,40 As this strategy is rarely
tions in reproductively active females preparing for applied to antifungal agents, it is not known whether
egg laying.38 Given the time of year that the present terbinafine acts by a concentration- or time-depen-
study was performed (March), the female bearded dent mechanism. Evaluation of AR projections sug-
dragons enrolled in the study may have been in an gested that, for bearded dragons, a dosing interval
active state of vitellogenesis, despite a lack of gross of 24 to 48 hours may be appropriate to maintain
lipemia in all blood samples and egg laying in the concentrations greater than the target MIC through-
month before and month after study completion. out the course of treatment, but additional multi-
Although the small number of bearded dragons en- dose studies are needed to fully evaluate the phar-
rolled in this study did not provide enough statistical macokinetics of terbinafine at steady state.

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 All 8 bearded dragons of the present study tol-
erated terbinafine well and no overt clinical signs
Acknowledgments
suggestive of toxicosis were observed. The admin- Supported by the University of Illinois College of Veteri-
istration of terbinafine via gavage was performed nary Medicine Companion Animal Research Grant.
The authors thank Drs. David Sanchez-Migallon
to improve dosing accuracy but may have resulted Guzman, Joanne Paul-Murphy, and Barbara Byrne for their
in the acute death of 1 study subject. Oral, rather assistance in obtaining the fungal isolates used for culture,
than gavage, administration of terbinafine is rec- identification, and sensitivity in this study.
ommended for clinical patients. In human patients
receiving terbinafine, the most commonly reported
adverse effects are gastrointestinal disturbances,
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