Effects of antifungal stewardship using therapeutic drug monitoring in voriconazole therapy on the prevention and control of hepatotoxicity and visual symptoms: A multicentre study conducted in Japan

• DOI: 10.1111/myc.13129
• Publication Date: 2020-06-08T13:27:00Z
• Authors: Yukihiro Hamada; Takashi Ueda; Yoshitsugu Miyazaki; Kazuhiko Nakajima; Keiko Fukunaga; Taiga Miyazaki; Nana Nakada‐Motokawa; Miki Nagao; Hideki Kawamura; Akari Shigemi; Fumiya Ebihara; Toshimi Kimura; Kazuhiro Ikegame; Motoi Uchino; Hiroki Ikeuchi; Yoshio Takesue
• Keywords: Male; 0301 basic medicine; Antifungal Agents; Drug-Related Side Effects and Adverse Reactions; Original Articles; Middle Aged; 3. Good health; Antimicrobial Stewardship; 03 medical and health sciences; Mycoses; Humans; Female; Voriconazole; Chemical and Drug Induced Liver Injury; Drug Monitoring; Aged; Retrospective Studies

SummaryBackgroundHepatotoxicity and visual symptoms are common adverse effects (AEs) of voriconazole therapy.ObjectiveTo retrospectively evaluate the effects of treatment modification based on therapeutic drug monitoring on AEs in patients undergoing voriconazole therapy.MethodsThe target voriconazole trough concentration (Cmin) was 1‐5 µg/mL. Receiver operating characteristic curves were used to determine Cmin cut‐offs for AEs.ResultsA total of 401 patients were included. Among 108 patients with high initial Cmin, voriconazole was discontinued in 32 and the dose was reduced in 71. Among 44 patients with low initial Cmin, voriconazole was discontinued in 4 and the dose was increased in 19. Hepatotoxicity occurred in 6.0% of patients, after a median of 10 days. Visual symptoms were evident in 9.5% of patients after a median of 4 days. Initial Cmin was significantly associated with visual symptoms but not hepatotoxicity, which suggested the effect of treatment modification on hepatotoxicity. However, both hepatotoxicity and visual symptoms were significantly correlated with Cmin at the onset of AEs, and the Cmin cut‐offs were 3.5 μg/mL for hepatotoxicity and 4.2 μg/mL for visual symptoms. Voriconazole was discontinued after the occurrence of AEs in 62.5% of patients with hepatotoxicity but only 26.3% of patients with visual symptoms. With dose adjustment, treatment was completed in 8/9 patients with hepatotoxicity and 27/28 patients with visual symptoms.ConclusionsA significant preventive effect was demonstrated on hepatotoxicity, but not on visual symptoms because of earlier occurrence. With treatment modification after the occurrence of AEs, most patients completed therapy.