Determination of Voriconazole in Human Plasma by Liquid Chromatography Tandem Mass Spectrometry: Application in Therapeutic Drug Monitoring

A sensitive, accurate and robust Liquid Chromatography Tandem Mass Spectrometry method has been developed and validated to measure voriconazole trough levels in human plasma. The plasma samples were mixed with fluconazole as an Internal Standard and directed to protein precipitation and drug extraction. An aliquot of 1 μl was injected into the chromatographic system and separated by the Acquity BEH C18 column at a flow rate of 0.30 ml/min in a gradient mobile phase consisting of acetonitrile, Ultrapure water (UPW), methanol and formic acid. Voriconazole was detected by a Triple Quadrupole Detector (TQD) operating on Multiple Reaction Monitoring (MRM) and a positive ion mode Electrospray ionization (ESI) Q1 mass: 350.1 m/z, Q3 mass: 281.1 m/z. Method linearity of the calibration curve (0.10 - 8.00 μg/ml) indicated a correlation coefficient r ≥ 0.99. The intra and inter-assay accuracy was within 85% - 115% and the intra and inter-assay precision was ≤5.76%. Voriconazole recovery percentage was between 97.69 - 119.62%. The method was successively applied in routine voriconazole TDM.

Evidence of voriconazole pharmacokinetic variability in children and adolescents with haematological disease: proposal for therapeutic drug monitoring optimisation

Objective:Voriconazole(VCZ)is a triazole antifungal agent widely used in immunocompromised patients with suspected or proven invasive fungal infections.The achievement of therapeutic range(1-5 mg/L)is essential to maximize VCZ efficacy,as its pharmacokinetics is characterized by a wide inter-and intra-individual variability.This study aims to quantify the variability of VCZ trough concentrations in children and adolescents with haematological diseases and optimize therapeutic drug monitoring in clinical practice.Methods:We analysed the monitoring concentrations of all children(<18 years old)treated with VCZ in the Haematology Department of Robert DebréHospital between January 2014 and December 2016.Demographic,clinical data,and VCZ dosing and monitoring concentrations measured by high-performance liquid chromatography with ultraviolet detection(HPLC-UV)were analysed.Non-parametric tests were performed using SPSS IBM 24.0.Results:380 trough VCZ concentrations at steady-state(Ctrough,ss)were available in 79 children:45.6%had first Ctrough,ss in the therapeutic range at first monitoring,46.8%had Ctrough,ss below 1 mg/L and 7.6%had Ctrough,ss over 5 mg/L.Forty-one patients were treated with recommended doses but only 53%of them reached the therapeutic range.There was no impact of age,sex,biological parameters,or indication of VCZ on Ctrough,ss values.The number of Ctrough,ss in the therapeutic range increases with the number of monitoring per patient following dosage adaptations.Conclusion:The wide inter-and intra-individual variability of VCZ trough concentrations at recommended doses confirm the need to standardize VCZ monitoring and identify factors to be considered to prospectively adapt treatment for each patient.

Argon laser photocoagulation versus intrastromal voriconazole injection in treatment of mycotic keratitis

AIM： To compare argon laser photocoagulation and intrastromal injection of voriconazole as adjunctive treatment modalities in cases of resistant mycotic corneal ulcers. METHODS： Two groups each of them included 20 cases of resistant mycotic corneal ulcers. Both groups treated with local and systemic specific antimicrobial drugs guided with culture and sensitivity results. In one group argon laser photocoagulation was used as an adjunctive therapy to the specific antifungal drugs and in the other group, intrastromal injection of voriconazole was done besides the specific antifungal drugs. The 40 cases included in the study were proven according to culture and sensitivity to be 28 cases with pure fungal results and 12 cases with mixed （fungal and bacterial）. In argon laser group, argon laser irradiation of the corneal ulcer was performed using argon laser 532 nm wavelength （Carl Zeiss LSL 532s AG; Meditec, Inc.） after fluorescein staining. In the other group, voriconazole solution （500 pg/mL） was prepared and injected in the corneal stroma. All cases were followed up for 3mo after healing was achieved. RESULTS： Complete healing of the epithelial defect and resolution of stromal infiltration with no adverse effects were achieved in argon laser group in duration ranged from 2-4wk in 90% of cases. In voriconazole group 4 cases needed amniotic membrane graft due to thinning and 16 cases healed in duration ranged from 2- 6wk （80% of cases）. CONCLUSION： Argon superior to intrastromal treatment of resistant fungal laser photocoagulation is voriconazole injection in corneal ulcers.

Voriconazole and the liver

Voriconazole is an azole useful for the prophylaxis and the treatment of aspergillosis and other fungal infections in immunosuppressed subjects, as those found in aplasia after aggressive polychemotherapy treatments, after hematopoietic stem cell, liver or lung transplantation. Its administration in therapeutic doses lead to extremely varied serum levels from patient to patient and even to the same patient. The explanations are varied: nonlinearpharmacokinetics, certain patient-related factors, including genetic polymorphisms in the cytochrome P450 2C19 gene, the kidney and liver function, simultaneous administration with other drugs metabolised by the same cytochrome. It is recommended to maintain the serum concentrations of voriconazole between 1.5 and 4 μg/m L. At lower values its efficacy decreases and at higher values the risk of neurological toxicity increases. Even at these concentrations it is not excluded the possible appearance of a variety of toxic effects, including on the liver, manifested by cholestasis, hepatocytolisis, or their combination. It is recommended to monitor the clinical and laboratory evolution of all patients treated with voriconazole, and of the serum levels of the drug of those who belong to risk groups, even if there is still no consensus on this issue, given the lack of correlation between the serum level and the occurrence of adverse effects in many patients.

Remission of hepatotoxicity in chronic pulmonary aspergillosis patients after lowering trough concentration of voriconazole

BACKGROUND Chronic pulmonary aspergillosis(CPA)is a rare syndrome that is often accompanied by gradual lung tissue destruction.Voriconazole is usually employed as the first-line agent for CPA treatment.However,some patients can develop hepatotoxicity and often were forced to stop voriconazole treatment.AIM To record the improving trend of liver function and the therapeutic effects in patients after lowering the trough concentration of voriconazole.METHODS This study retrospectively analyzed 12 adult CPA patients who developed hepatotoxicity during the voriconazole treatment.In these patients,the oral dose was reduced to 3/4 or 1/2 of the standard dose(4 mg/kg,twice daily),and the lower limit of voriconazole trough concentration was maintained more than 0.5μg/m L.The trend of remission of liver toxicity after drug reduction in 12 patients was recorded.During the same period,25 patients who received standard doses served as the control group.Data from the two groups were collected and analyzed for different parameters such as demographic characteristics,underlying pulmonary disorders,laboratory tests,and therapeutic effect.The differences between the two groups were statistically compared.RESULTS Hepatotoxicity occurred in 12 patients within 28-65 d after oral voriconazole treatment.Hepatotoxicity was mainly manifested by the significantly increased level of gamma-glutamyltransferase and a slight increase of alanine aminotransferase and aspartate aminotransferase.The oral dose of voriconazole was reduced to approximately 3 mg/kg in seven patients and approximately 2 mg/kg in five patients.The average trough concentrations for the 12 patients before and after voriconazole oral dose reduction were 3.17±1.47μg/m L(1.5-6.0μg/m L)and 1.70±0.78μg/m L(0.6-3.3μg/m L),respectively(P=0.02).After lowering the trough concentrations,the hepatotoxicity was alleviated in all the patients.However,gamma-glutamyltransferase levels declined slowly.After 4 mo of treatment,7 of the 12 patients were successfully treated in the low trough concentrations group(41.7%).Similarly,8 of the 25 patients in the standard treatment dose group(32.0%)were effectively treated.There was no statistical difference between the groups(P=0.72).CONCLUSION Reducing the lower limit of the voriconazole trough concentration to 0.5μg/m L can alleviate the hepatotoxicity and maintained certain clinical efficacy in CPA patients;however,patients should be closely monitored.

Voriconazole-Induced Periostitis &Enthesopathy in Solid Organ Transplant Patients: Case Reports

Background: Voriconazole is frequently used to treat fungal infections in solid organ transplant patients. Recently, there have been reports suggesting that prolonged voriconazole therapy may lead to periostitis. Aim: Here we present two cases of voriconazole-induced periostitis in solid organ transplant patients. Case Presentation: Voriconazole was given to two transplant patients-one with a liver transplant and the second with a heart transplant, to treat their fungal infections. Both developed voriconazole-induced toxicity. While undergoing voriconazole therapy, they had incapacitating bone pain. The liver transplant patient had to be taken off voriconazole, and the heart transplant patient succumbed to non-voriconazole related causes. Conclusions: Voriconazole therapy in two solid organ transplant patients resulted in periostitis. We provide potential etiologies underlying voriconazole-induced periostitis, including fluoride toxicity, abnormalities in the pulmonary vascular bed leading to the production of downstream inflammatory mediators, and abnormal pharmacokinetics of hepatic drug metabolism. In addition to monitoring blood voriconazole trough levels, we suggest careful assessment for musculoskeletal pain in patients undergoing voriconazole treatment for two months or more, particularly if their daily dosages of voriconazole exceed 500 mg per day. Appropriate workup should include measurement of alkaline phosphatase and fluoride levels, voriconazole trough and bone scan. Overall, early recognition of voriconazole-induced musculoskeletal toxicity is important for better morbidity outcomes.

Efficacy of voriconazole on leishmaniasis by Leishmania major: An in vitro and in vivo study

Objective: To appraise the activity of voriconazole against Leishmania major(L. major) in vitro and its effectiveness on wound regeneration in cutaneous leishmaniasis in BALB/c mice Methods: The IC_(50) of voriconazole against promastigotes and intra-macrophage amastigotes of L. major was investigated in vitro. The in vivo study was performed by treating the L. major infected BALB/c mice. When the wounds appeared in the base of tail, treatment was started by administration of 30 mg/kg voriconazole for 28 consecutive days orally. Results: The IC_(50) of voriconazole against promastigotes and intra-macrophage amastigotes were 0.74 and 0.89μM, respectively. Voriconazole decreased lipid peroxidation and IL-6 level. Histopathologica findings indicated accelerated healing in the voriconazole treated group compared to other groups. Conclusions: Our results demonstrate that voriconazole can be an option in treating the cutaneous leishmaniasis by L. major.

Voriconazole-associated periostitis:Pathophysiology,risk factors,clinical manifestations,diagnosis,and management

Voriconazole use has been associated with osteoarticular pain and periostitis,likely due to high fluoride content in the drug formulation.This phenomenon has been described primarily with high dosage or prolonged course of voriconazole therapy in immunocompromised and transplant patient populations.Patients typically present with diffuse bony pains associated with elevated serum alkaline phosphatase and plasma fluoride levels in conjunction with radiographic findings suggestive of periostitis.We provide a comprehensive review of the literature to highlight salient characteristics commonly associated with voriconazole-induced periostitis.

Successful Treatment with Triple Therapy of Amphotericin B, Voriconazole and Flucytosine on an AIDS Patients with Severe Cryptococcal Meningitis

A 35-year-old man(body weight=63 kg)with AIDS complaining fever and headache after having commenced anti-retroviral therapy(ART)for a week was admitted to our hospital.Five lumbar punctures performed during38 days could not confirm a cryptococcal meningitis(CM)based on staining or culture methods for cerebrospinal fluid(CSF).The disease quickly progressed with serious hearing/vision impairment and frequent onset of seizure and coma after being treated with corticosteroids for five days,and then CM was confirmed.Subsequent lumbar puncture showed elevated intracranial pressure as high as 870 mm H2O,even though treated with standard antifungal regimens for CM.His disease was finally controlled by a new triple therapy with amphotericin B(0.7mg?kg-1?day-1,intravenously),flucytosine(100 mg/kg perday,orally in four divided doses),and voriconazole(200mg every 12 hours)and ART containing lamivudine(300 mg/day),stavuding(30 mg,twice a day)and efavirenz(300 mg,orally every night).Although it is rare,negative CSF stain or culture for cryptococci in AIDS patients with CM can persist for a long time.Corticosteroids should be used cautiously when an effective anti-fungal therapy is not administered.Triple therapy with amphotericin B,flucytosine and voriconazole may be selectively applied in severe CM.Voriconazole can be co-administered with efavirenz with modified dosing.

Voriconazole导致假卟啉病:1例报道

Voriconazole, a second-generation triazole, has recently been appro ved by t he Food and Drug Administration (FDA) to treat invasive aspergillosis and refrac tory infections with Scedosporium apiospermum or Fusarium spp. The reported side -effects of voriconazole include visual changes, headaches, elevated hepatic e nzymes, Steven-Johnson syndrome, toxic epidermal necrolysis, chelitis, photose nsitivity, discoid lupus erythematosus and anaphylactoid infusion reactions. Pse udoporphyria was first described in association with nalidixic acid. It has the same clinical and histologic features as porphyria cutanea tarda (PCT) but is di stinguished by normal porphyrin levels in the serum, urine and stool. We present the case of a patient who developed pseudoporphyria after receiving treatment w ith voriconazole.

Voriconazole的玻璃体内用药：视网膜电图和组织病理学研究

背景：Voriconazole是一种新型的抗真菌三唑，具有广泛地抗酵母菌和霉菌活性。目的：研究Voriconazole对于治疗真菌性眼内炎是否是一种安全的玻璃体腔内注射用药物。

Astragalus Polysaccharide Enhances Voriconazole Metabolism under Inflammatory Conditions through the Gut Microbiota

Background and Aims:Voriconazole(VRC),a widely used antifungal drug,often causes hepatotoxicity,which presents a significant clinical challenge.Previous studies demonstrated that Astragalus polysaccharide(APS)can regulate VRC metabolism,thereby potentially mitigating its hepatotoxic effects.In this study,we aimed to explore the mechanism by which APS regulates VRC metabolism.Methods:First,we assessed the association of abnormal VRC metabolism with hepatotoxicity using the Roussel Uclaf Causality Assessment Method scale.Second,we conducted a series of basic experiments to verify the promotive effect of APS on VRC metabolism.Various in vitro and in vivo assays,including cytokine profiling,immunohistochemistry,quantitative polymerase chain reaction,metabolite analysis,and drug concentration measurements,were performed using a lipopolysaccharideinduced rat inflammation model.Finally,experiments such as intestinal biodiversity analysis,intestinal clearance assessments,and Bifidobacterium bifidum replenishment were performed to examine the ability of B.bifidum to regulate the expression of the VRC-metabolizing enzyme CYP2C19 through the gut–liver axis.Results:The results indicated that APS does not have a direct effect on hepatocytes.However,the assessment of gut microbiota function revealed that APS significantly increases the abundance of B.bifidum,which could lead to an anti-inflammatory response in the liver and indirectly enhance VRC metabolism.The dual-luciferase reporter gene assay revealed that APS can hinder the secretion of pro-inflammatory mediators and reduce the inhibitory effect on CYP2C19 transcription through the nuclear factor-κB signaling pathway.Conclusions:The study offers valuable insights into the mechanism by which APS alleviates VRC-induced liver damage,highlighting its immunomodulatory influence on hepatic tissues and its indirect regulatory control of VRC-metabolizing enzymes within hepatocytes.

Investigation into the structures and physicochemical properties of multi-component crystals of voriconazole

Voriconazole(VZL)is a second-generation and broad-spectrum triazole against fungal infections.Being a BCS(biopharmaceutics classification system)class II compound,the poor aqueous solubility has limited its bioavailability and clinical efficacy.Aims to overcome this disadvantage,a cocrystallization strategy based on crystal engineering principles has resulted in five new multi-component crystals of VZL with maleic acid,L-tartaric,protocatechuic,gallic,and 3,5-dinitrobenzoic acids.Structure analysis revealed that the hydroxyl/carboxylic acid···triazole N_(3)hydrogen bonding interaction appears as a main supramolecular heterosynthon in the VZL multi-component crystals with organic acids.And VZL molecule has a flexible conformation in each of the five multi-component structures.The newly synthesized multi-component crystals showed impressive solubility improvement compared to that of the raw material of VZL.Molecular electrostatic potential surfaces(MEPS)analysis based on density functional(DFT)calculations revealed that hydrogen bond interactions in cocrystals mainly involved pairwise interactions in the global maxima and minima sites,but this rule is not always followed.This study indicates the potential of cocrystals to improve the solubility and dissolution rate of VZL.

Influence of voriconazole on pharmacokinetics and safety of combined drugs: a systematic review

We performed a systematic review to evaluate pharmacokinetics changes of drugs when concomitantly used with voriconazole, including randomized controlled trials（RCTs）, randomized cross-over trials, self-controlled before-and-after studies, cohort studies and case reports. Literature databases, including Medline, Embase, Cochrane library, were searched to identify eligible studies（until Jan, 2016）. A modified risk of bias tool specially developed in this research was used to evaluate the quality of pharmacokinetic randomized crossover trials and self-controlled before-and-after studies. Cochrane risk of bias tool provided by Cochrane Library and Cochrane Reviewer＇s handbook was used to evaluate the quality of RCTs and non-randomized controlled studies. Pharmacokinetic parameters, such as area under curve（AUC）, Cmin, and Cmax before and after using voriconalzole were collected. Meta-analysis was conducted to synthesize results if possible. Among 41 studies included in our search, 17 were randomized crossover trials, 3 were RCTs, 13 were self-controlled before-and-after study（SBAs）, 1 was cohort studies and 7 were case reports. A total of 12 classes of drugs were involved, including opiates, non-steroidal anti-inflammatory drugs（NSAIDs）, psychopathic drugs, anti-HIV drugs, immunosuppressors, oral contraceptive, digoxin, warfarin, oral hypoglycemic agents, antihypertensive agents, lipid regulating agents and cytotoxic agents. According to our results, the impacts of voriconazole on tilidine, buprenorphine, etoricoxib, meloxicam, venlafaxine, midazolam, zolpidem, etravirine and sirolimus were different from the package insert. Our systematic review provided comprehensive data on the pharmacokinetics changes of drugs when used in combination with voriconazole.

Effect of cytochrome P-450 inhibitors on pharmacokinetics and safety of voriconazole

Our objective was to systematically assess the effect of cytochrome P-450（CYP450） inhibitors on pharmacokinetics and safety of voriconazole（VORI）. Cochrane Library, Pub Med, Embase, CNKI, CBM and Wan Fang databases and C linicaltrials.gov were searched up to Jan. 26～（th） 2016. Two reviewers independently identified studies, extracted data and assessed quality of studies. Meta-analysis was performed with Rev Man 5.3, and risk ratios（RRs） and mean differences（MDs） with 95% confidence intervals（CIs） were calculated. A total of 12 studies were included： three crossover randomized controlled trials, three single-arm before-and-after studies and six cohort studies. Compared with non-combination group, the group of VORI plus omeprazole had a significantly higher occurrence of hepatic dysfunction（RR = 4.11, 95% CI 1.12–15.08, P = 0.03）. However, neurologic dysfunction and visual disturbance were not significantly different. Pantoprazole, rabeprazole, cimetidine and contraceptive significantly increased the peak concentration（Cmax） and area under the curve（AUC） of VORI, while indinavir had no significant effect on pharmacokinetics of VORI. The effects of esomeprazole, erythromycin and azithromycin on pharmacokinetic parameters of VORI presented inconsistent results. Co-administration of VORI and CYP450 inhibitors was safe except for omeprazole. Although Cmax and AUC of VORI were increased while co-administered with a couple of CYP450 inhibitors, no significant effect on clinical outcomes was observed.

Voriconazole in an infant with cryptococcal meningitis

Cryptococcus neoformans （C. neoformans） is the most common cause of fungal meningitis worldwide.1 Cryptococcal meningitis is an opportunistic infection commonly found in immunocompromised hosts, especially HIV-infected adults. It also occurs in apparently immunocompetent individuals. Rarely has it been reported in children, and it is almost nonexistent in infants. Voriconazole is a member of a second generation of antifungal triazoles with broad spectrum antifungal activity, oral and parenteral bioavailability and a favorable safety profile in adults.3 This patient shows improved in vitro activity against C. neoformans when compared to fluconazole and it has been used successfully in about half the patients with refractory cryptococcosis.4 However, the efficacy and safety of voriconazole as a antifungal agent in children with cryptococcal meningitis have not been well assessed, This report described cryptococcal meningitis in a 13-day-old premature neonate who recovered without overt toxicity after voriconazole was added to an antifungal regimen that included amphotericin B and flucytosine. We focused on the response of this child with cryptococcal meningitis to voriconazole.

Therapeutic Drug Monitoring of Vancomycin and Voriconazole by Liquid Chromatography-Tandem Mass Spectrometric Method

A reliable liquid chromatography-tandem mass spectrometric（LC-MS/MS） method was developed and va- lidated for the simultaneous determination of vancomycin and voriconazole in human plasma. The analytes and internal standard 10-hydroxycarbazepine were separated at a flow rate of 0.9 mL/min using a Zorbax SB-C18 column （50 min×4.6 mm, 2.7 μm）. Positive ion electrospray ionization was used to detect vancomycin, voriconazole and intrenal standard（IS） 10-hydroxycarbazepine followed by multiple reaction monitoring（MRM） of the transition at m/z 725.5→144.2, 350.3→281.0 and 253.1→208.0, respectively. The total run time for both vancomycin and voriconazole samples was 5 min; 0.30μg/mL was the lower limit of quantification. The precision of intraday and interday was no more than 12.4%. The method was successfully and resoundingly applied in therapeutic drug monitoring of 156 patients treated with vancomycin and voriconazole.

CYP2C19 Genotyping Plus Therapeutic Drug Monitoring Dependent Voriconazole Treatment for Invasive Pulmonary Aspergillosis in a Patient with Liver Failure

Invasive pulmonary aspergillosis(IPA)is a lethal infectious disease with high mortality in patients with liver failure.Early recognition of the risk factors prompting earlier diagnosis and treatment may improve the outcomes.Voriconazole is recommended as the first-line drug for IPA,but hepatotoxicity limits its use in the context of liver diseases.We report a case of a 63-year-old female who was admitted to the Third Affiliated Hospital of Hebei Medical University due to IPA after glucocorticoid therapy for liver failure.The polymorphism of cytochrome P450(CYP)isoenzymes showed CYP2C19∗1/∗2 genotype associated with intermediate metabolism of voriconazole.However,the patient developed side effects such as skin rash,vomiting,hyperbilirubinemia,and alteration of consciousness,even if she received half of the recommended dosage for voriconazole.Therapeutic drug monitoring(TDM)was applied to guide the dosage adjustment of voriconazole in this patient,and consequently,the patient presented a favorable outcome.In conclusion,genotyping screening plus TDM dependent individualized treatment of voriconazole may improve the survival of liver failure patient with IPA.

Progress in diagnosis and treatment of invasive aspergillosis after liver transplantation

Invasive aspergillosis is an opportunistic fungal infection disease,and the risk factors of Invasive aspergillosis after liver transplantation are increasing,which seriously affects the quality of life of patients.Invasive Aspergillus has no specific clinical manifestations and occurs most frequently in the lungs.The diagnostic methods for invasive aspergillosis are continuously updated,including serological tests,polymerase chain reaction(PCR),next-generation sequencing,Matrix-assisted laser desorption ionization time-of-flight mass spectrometry,Aspergillus GM lateral flow test,and some new markers under study have made the diagnosis of invasive aspergillosis infection more definitive.Voriconazole is the drug of choice for the treatment and prevention of invasive aspergillosis,and immunotherapy may become an adjuvant therapy or monotherapy for invasive aspergillosis with the emergence of more and more resistant strains.This article summarizes the progress in the diagnosis and treatment of invasive aspergillosis after liver transplantation,in order to provide a reference for clinical practice.