Voriconazole

IV load 6 mg/kg every 12 hours for two doses, then usually 4 mg/kg every 12 hours. Oral maintenance at weight at least 40 kg: 200 mg every 12 hours, up to 300 mg; below 40 kg: 100 mg every 12 hours, up to 150 mg. The detailed table assigns exactly 40 kg to the larger-dose group.

Invasive aspergillosis, scedosporiosis and fusariosis: IV load as above, then 4 mg/kg IV every 12 hours or the weight-specific oral regimen; initiate these serious infections with the IV load to approach steady-state concentrations on day 1.

Candidemia in nonneutropenic patients/deep Candida infection: same IV load, then 3-4 mg/kg IV every 12 hours or weight-specific oral treatment. Trials used 3 mg/kg as primary candidemia therapy and 4 mg/kg as salvage deep-tissue therapy; base selection on nature/severity. Treat for at least 14 days after symptoms resolve or the last positive culture, whichever is later.

Esophageal candidiasis: weight-specific oral regimen; IV/loading regimens were not evaluated in the source. Treat at least 14 days and at least 7 days after symptoms resolve.

Switch IV to oral when clinically appropriate because oral bioavailability is high. Overall duration depends on underlying disease, recovery from immunosuppression and response.

Oral tablets/suspension: at least 1 hour before or after meals. Reconstitute IV product to 10 mg/mL, then dilute to no greater than 5 mg/mL; maximum infusion rate 3 mg/kg/hour over 1-2 hours. Never IV bolus.

Do not simultaneously infuse with blood products or short-term concentrated electrolytes, even through separate lines. Correct low potassium, magnesium and calcium before treatment. Nonconcentrated electrolyte solutions may run simultaneously through a separate line. TPN may run simultaneously only through a separate line or different lumen/port.

Inadequate response: increase oral maintenance 200 to 300 mg every 12 hours, or 100 to 150 mg below 40 kg. If 300 mg is not tolerated, decrease in 50 mg steps to at least 200 mg every 12 hours (100 mg below 40 kg). If IV 4 mg/kg is not tolerated, reduce to 3 mg/kg every 12 hours.

With phenytoin the source increases IV maintenance to 5 mg/kg every 12 hours, or oral 200 to 400 mg every 12 hours (100 to 200 mg below 40 kg). With efavirenz it gives voriconazole 400 mg every 12 hours plus efavirenz 300 mg daily; restore the initial efavirenz dose after voriconazole stops.

No geriatric adjustment. Trials included baseline ALT/AST up to 5 times the upper limit of normal without adjustment, but continued monitoring is needed. Child-Pugh A/B cirrhosis: usual load, half maintenance. Child-Pugh C and chronic hepatitis B/C were not studied in the source. Hepatic injury/jaundice has occurred; use in severe hepatic insufficiency only when benefits outweigh risks and monitor toxicity closely.

Oral pharmacokinetics are not significantly affected by mild-to-severe impairment: no oral adjustment.

Below CrCl 50 mL/min the IV vehicle SBECD accumulates. Prefer oral therapy unless IV benefit justifies risk. The short source summary mentions oral treatment after initial loading; the fuller text requires an explicit IV benefit-risk assessment. Closely monitor serum creatinine and consider changing to oral if it rises.

Voriconazole dialysis clearance 121 mL/min; SBECD 55 mL/min. A 4-hour session does not remove enough voriconazole to require a supplemental adjustment. The GlobalRPh HD summary advises avoiding IV voriconazole.