Voriconazole: Difference between revisions
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== Background == |
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* Azole antifungal |
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* Indications include {{#ask: [[Is treated by::voriconazole]]}} |
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*Azole antifungal |
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== Therapeutic Drug Monitoring == |
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*Indications include {{#ask: [[Is treated by::voriconazole]]}} |
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* Measure trough within 7 days of starting, and at regular intervals or following dose adjustment |
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* Target trough > 1 mg/L for prophylaxis and treatment |
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=== Breakpoints === |
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{| class="wikitable" |
{| class="wikitable" |
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! rowspan="2" |Species |
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! Trough (mcg/mL) !! Recommendation |
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! rowspan="2" |ECV (μg/mL) |
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! colspan="4" |Breakpoints (μg/mL) |
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! colspan="4" |Breakpoints (mm) |
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|- |
|- |
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!S |
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| 0.0 to 0.6 || Increase dose by 100 mg and recheck trough on day 5 of new regimen |
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!I |
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!SDD |
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!R |
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!S |
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!I |
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!SDD |
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!R |
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|- |
|- |
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|[[Candida albicans]] |
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| 0.7 to 0.9 || Increase dose by 50 mg and recheck trough on day 5 of new regimen |
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|0.3 |
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|≤0.12 |
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|0.25-0.5 |
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|— |
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|≥1 |
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|≥17 |
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|15-16 |
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|— |
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|≤14 |
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|- |
|- |
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|[[Candida glabrata]] |
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| 1.0 to 4.0 || At target, no dose adjustment needed |
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|0.25 |
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|— |
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|— |
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|— |
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|— |
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|— |
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|— |
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|— |
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|— |
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|- |
|- |
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|[[Candida krusei]] |
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| 4.1 to 5.5 || Decrease dose by 50 mg and recheck trough on day 5 of new regimen |
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|0.5 |
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|≤0.5 |
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|1 |
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|— |
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|≥2 |
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|≥15 |
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|13-14 |
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|— |
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|≤12 |
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|- |
|- |
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|[[Candida parapsilosis]] |
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| 5.6 to 7.9 || Hold dose. Follow daily trough levels, then restart when trough is ≤2.5 at a dose decreased by 100 mg. Recheck trough on day 5 of new regimen. |
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|0.03 |
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|≤0.12 |
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|0.25-0.5 |
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|— |
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|≥1 |
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|≥17 |
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|15-16 |
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|— |
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|≤14 |
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|- |
|- |
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|[[Candida tropicalis]] |
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| ≥8.0 || Hold dose. Follow daily trough levels, then restart when trough is ≤2.5 at a dose decreased by 50%. Recheck trough level on day 5 of new regimen. |
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|0.12 |
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|≤0.12 |
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|0.25-0.5 |
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|— |
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|≥1 |
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|≥17 |
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|15-16 |
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|— |
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|≤14 |
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|- |
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|[[Cryptococcus neoformans]] |
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|0.25 |
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| colspan="8" rowspan="6" | |
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|- |
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|[[Cryptococcus gattii]] |
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|0.5 |
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|- |
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|[[Aspergillus flavus]] |
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|2 |
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|- |
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|[[Aspergillus fumigatus]] |
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|1 |
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|- |
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|[[Aspergillus niger]] |
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|2 |
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|- |
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|[[Aspergillus terreus]] |
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|2 |
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|} |
|} |
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==Therapeutic Drug Monitoring== |
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=== Safety === |
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* Elevated levels predict neurotoxicity, but ''not'' hepatotoxicity |
|||
*Measure trough within 7 days of starting, and at regular intervals or following dose adjustment |
|||
*Target trough > 1 mg/L for prophylaxis and treatment |
|||
{| class="wikitable" |
|||
!Trough (mcg/mL)!!Recommendation |
|||
|- |
|||
|0.0 to 0.6||Increase dose by 100 mg and recheck trough on day 5 of new regimen |
|||
|- |
|||
|0.7 to 0.9||Increase dose by 50 mg and recheck trough on day 5 of new regimen |
|||
|- |
|||
|1.0 to 4.0||At target, no dose adjustment needed |
|||
|- |
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|4.1 to 5.5||Decrease dose by 50 mg and recheck trough on day 5 of new regimen |
|||
|- |
|||
|5.6 to 7.9||Hold dose. Follow daily trough levels, then restart when trough is ≤2.5 at a dose decreased by 100 mg. Recheck trough on day 5 of new regimen. |
|||
|- |
|||
|≥8.0||Hold dose. Follow daily trough levels, then restart when trough is ≤2.5 at a dose decreased by 50%. Recheck trough level on day 5 of new regimen. |
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|} |
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===Safety=== |
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*Elevated levels predict neurotoxicity, but ''not'' hepatotoxicity |
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==Adverse Drug Reactions== |
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*Visual |
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**[[Adverse drug reaction::Floaters]] etc that may improve with time |
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**[[Adverse drug reaction::Visual hallucinations]] |
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**[[Adverse drug reaction::Colour vision loss]] |
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*[[Adverse drug reaction::Photosensitivity]] |
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*[[Adverse drug reaction::Hepatotoxicity]] |
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*[[Adverse drug reaction::QTc prolongation]] |
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==Further Reading== |
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== Adverse Drug Reactions == |
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* Visual |
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** [[Adverse drug reaction::Floaters]] etc that may improve with time |
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** [[Adverse drug reaction::Visual hallucinations]] |
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** [[Adverse drug reaction::Colour vision loss]] |
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* [[Adverse drug reaction::Photosensitivity]] |
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* [[Adverse drug reaction::Hepatotoxicity]] |
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* [[Adverse drug reaction::QTc prolongation]] |
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*Voriconazole Dose Modification Guideline to Optimize Therapeutic Levels in Patients With Hematologic Malignancies. ''Open Forum Infect Dis''. 2015;2(S1):810. doi: [https://doi.org/10.1093/ofid/ofv133.527 10.1093/ofid/ofv133.527] |
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== Further Reading == |
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* Voriconazole Dose Modification Guideline to Optimize Therapeutic Levels in Patients With Hematologic Malignancies. ''Open Forum Infect Dis''. 2015;2(S1):810. doi: [https://doi.org/10.1093/ofid/ofv133.527 10.1093/ofid/ofv133.527] |
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[[Category:Antifungals]] |
[[Category:Antifungals]] |
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Revision as of 20:34, 21 August 2020
Background
- Azole antifungal
- Indications include Alternaria, Blastomyces dermatitidis, Coccidioides immitis, Exophiala, Exserohilum, Fungal endocarditis, Histoplasma capsulatum, Rasamsonia
Breakpoints
| Species | ECV (μg/mL) | Breakpoints (μg/mL) | Breakpoints (mm) | ||||||
|---|---|---|---|---|---|---|---|---|---|
| S | I | SDD | R | S | I | SDD | R | ||
| Candida albicans | 0.3 | ≤0.12 | 0.25-0.5 | — | ≥1 | ≥17 | 15-16 | — | ≤14 |
| Candida glabrata | 0.25 | — | — | — | — | — | — | — | — |
| Candida krusei | 0.5 | ≤0.5 | 1 | — | ≥2 | ≥15 | 13-14 | — | ≤12 |
| Candida parapsilosis | 0.03 | ≤0.12 | 0.25-0.5 | — | ≥1 | ≥17 | 15-16 | — | ≤14 |
| Candida tropicalis | 0.12 | ≤0.12 | 0.25-0.5 | — | ≥1 | ≥17 | 15-16 | — | ≤14 |
| Cryptococcus neoformans | 0.25 | ||||||||
| Cryptococcus gattii | 0.5 | ||||||||
| Aspergillus flavus | 2 | ||||||||
| Aspergillus fumigatus | 1 | ||||||||
| Aspergillus niger | 2 | ||||||||
| Aspergillus terreus | 2 | ||||||||
Therapeutic Drug Monitoring
- Measure trough within 7 days of starting, and at regular intervals or following dose adjustment
- Target trough > 1 mg/L for prophylaxis and treatment
| Trough (mcg/mL) | Recommendation |
|---|---|
| 0.0 to 0.6 | Increase dose by 100 mg and recheck trough on day 5 of new regimen |
| 0.7 to 0.9 | Increase dose by 50 mg and recheck trough on day 5 of new regimen |
| 1.0 to 4.0 | At target, no dose adjustment needed |
| 4.1 to 5.5 | Decrease dose by 50 mg and recheck trough on day 5 of new regimen |
| 5.6 to 7.9 | Hold dose. Follow daily trough levels, then restart when trough is ≤2.5 at a dose decreased by 100 mg. Recheck trough on day 5 of new regimen. |
| ≥8.0 | Hold dose. Follow daily trough levels, then restart when trough is ≤2.5 at a dose decreased by 50%. Recheck trough level on day 5 of new regimen. |
Safety
- Elevated levels predict neurotoxicity, but not hepatotoxicity
Adverse Drug Reactions
- Visual
- Floaters etc that may improve with time
- Visual hallucinations
- Colour vision loss
- Photosensitivity
- Hepatotoxicity
- QTc prolongation
Further Reading
- Voriconazole Dose Modification Guideline to Optimize Therapeutic Levels in Patients With Hematologic Malignancies. Open Forum Infect Dis. 2015;2(S1):810. doi: 10.1093/ofid/ofv133.527
References
- ^ Romeo-Gabriel Mihăilă. Voriconazole and the liver. World Journal of Hepatology. 2015;7(13):1828. doi:10.4254/wjh.v7.i14.1828.
