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
  
−
* Target trough > 1 mg/L for prophylaxis and treatment
  
   
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=== Breakpoints ===
 
{| 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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!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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|[[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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|[[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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|[[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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|[[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
  +
|—
  +
|≥1
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|≥17
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|15-16
  +
|—
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|≤14
 
|-
  
|-
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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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|—
  +
|≥1
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|≥17
  +
|15-16
  +
|—
  +
|≤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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==Therapeutic Drug Monitoring==
−
=== Safety ===
  
  +
−
* 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
  +
|-
  +
|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===
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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]]
  
   
  +
*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]
  
   
 
[[Category:Antifungals]]
  
[[Category:Antifungals]]

Revision as of 16:34, 21 August 2020

Background

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

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

  1. ^  Romeo-Gabriel Mihăilă. Voriconazole and the liver. World Journal of Hepatology. 2015;7(13):1828. doi:10.4254/wjh.v7.i14.1828.

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