Mode of action of anti-Candida drugs: focus on terconazole and other ergosterol biosynthesis inhibitors.

A large proportion of the presently available antifungal agents are claimed to derive their activity from interaction with the biosynthesis of ergosterol, the key sterol in most pathogenic fungi. An important target for the allylamines, naftifine and terbinafine, is the squalene epoxidase. Interaction with the epoxidation step results in a decreased availability of ergosterol and an accumulation of squalene. Although the squalene epoxidase is clearly the primary target for this class of antifungals, it still remains an open question whether the fungistatic or fungicidal effects originate from a decrease in ergosterol or squalene accumulation. Indeed, preliminary evidence suggests that squalene does not change the physicochemical properties of membranes. Much more is known about the primary and secondary effects of the azole antifungals, such as miconazole, ketoconazole, terconazole, and itraconazole. Most of the imidazole and triazole derivatives are highly potent and selective inhibitors of the cytochrome P-450-dependent 14 alpha-demethylation of lanosterol (P-45014DM). Their potency and selectivity are determined by the nitrogen heterocycle and to a much greater extent by the hydrophobic N-1 substituent. The triazole antifungals, terconazole and itraconazole, combine a high affinity for Candida P-45014DM with an exceptionally low effect on mammalian cytochrome P-450.