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.
- ^ Taotao Wang, Liyan Miao, Hua Shao, Xiaohua Wei, Miao Yan, Xiaocong Zuo, Jun Zhang, Xin Hai, Guangjun Fan, Wei Wang, Linlin Hu, Jian Zhou, Yichang Zhao, Yueliang Xie, Jingjing Wang, Sixun Guo, Liu Jin, Hao Li, Hui Liu, Quanfang Wang, Jiaojiao Chen, Sihan Li, Yalin Dong. Voriconazole therapeutic drug monitoring and hepatotoxicity in critically ill patients: A nationwide multi-centre retrospective study. International Journal of Antimicrobial Agents. 2022;60(5-6):106692. doi:10.1016/j.ijantimicag.2022.106692.
