Voriconazole - instructions for use, dose, side effects, contraindications

Voriconazole is a broad-spectrum antifungal agent from the group of triazoles. The mechanism of action of voriconazole is associated with the inhibition of demethylation 14α-sterol mediated via fungal cytochrome P450, which is a key stage in the biosynthesis of ergosterol. Accumulation of 14α-methylstero correlates with. subsequent loss of ergosterol in fungal cell membranes, which determines the antifungal activity of voriconazole. It was found that voriconazole more selective for cytochrome P450 isoenzymes of fungi than for various enzyme systems of mammalian cytochrome P450.

A positive relationship between the mean, maximum and minimum values of voriconazole concentration in blood plasma and the effectiveness of the drug in therapeutic studies has not been revealed, and this relationship has not been studied in preventive studies.

Pharmacodynamic and pharmacokinetic analysis of these clinical studies revealed a positive relationship between the concentration of voriconazole in blood plasma and a deviation from the norm of biochemical parameters of liver function, as well as visual disturbances.

In vitro voriconazole has a broad spectrum of antifungal action: active against Candida spp. (including strains FROM. krusei, resistant to fluconazole, and resistant strains FROM. glabrata and C. albicans), and also shows a fungicidal effect against all strains studied Aspergillus spp. and pathogenic fungi that have become relevant in recent times, including Scedosporium spp. or Fusarium spp., which are limitedly sensitive to antifungal agents.

Clinical efficacy (with partial or complete response) of voriconazole has been demonstrated in infections caused by Aspergillus spp., including A. flavus, A. fumigatus, A. terreus, A. niger, A. nidulans, Candida spp., including strains of C. albicans, FROM. glabrata, FROM. krusei, FROM. parapsilosis and C. tropical is, as well as for a limited number of strains FROM. dubliniensis, FROM. inconspicua and FROM. guillermondii, Scedosporium spp., including S. apiospermum, S. prolifecans and Fusarium spp.

Other fungal infections in which voriconazole (sometimes with a partial or complete response), included individual cases of infections caused by Alternaria spp., Blastomyces dermatitidis, Blastoschizomyces capitatus, Cladosporium spp.. Coccidoides immitis, Conidiobolus coronatus, Cryptococcus neoformans, Exserohilum rostratum, Exophiala spinifera, Fonsecaea pedrosoi, Madurella mycetomatis, Paecilomyces lilacinus, Penicillium spp., including P. marneffei, Phialophora richardsiae, Scopulariopsis brevicaulis and Trychosporon spp., including T. beigelii.

Voriconazole activity was demonstrated in vitro in relation to clinical strains Acremonium spp., Alternaria spp., Bipolaris spp., Cladophialophora spp., Histoplasma capsulatum. The growth of most strains was suppressed at voriconazole concentrations from 0.05 μg / ml to 2 μg / ml.

The activity of voriconazole in vitro in a relationship Curvularia spp. and Sporothrix spp., However, the clinical significance of this effect is unknown.

Pharmacokinetics:

General characteristics:

Pharmacokinetic parameters of voriconazole are characterized by significant interindividual variability.

The pharmacokinetics of voriconazole is nonlinear due to the saturation of its metabolism. When the dose is increased, a disproportionate (more pronounced) increase in the area under the concentration-time curve (AUC_T). The increase in the oral dose from 200 mg 2 times / day to 300 mg 2 times / day leads to an increase AUC_T on average 2.5 times. Effects of voriconazole when administered a maintenance dose of 200 mg (or 100 mg for patients weighing less than 40 kg), corresponds to the effect of voriconazole when applied intravenously in a dose of 3 mg / kg. When administered at a maintenance dose of 300 mg (or 150 mg for patients with a body weight of less than 40 kg), exposure corresponds to the action of voriconazole when administered intravenously at a dose of 4 mg / kg.

With intravenous administration or intake of saturating doses of voriconazole, the equilibrium concentration is reached within the first 24 hours. If the drug is administered twice a day in medium (but not in saturating) doses, then voriconazole is cumulated, and equilibrium concentrations are reached by the 6th day of the majority patients.

Suction:

Voriconazole quickly and almost completely absorbed after oral administration: the maximum concentration in the blood plasma (Cmah) is achieved 1-2 hours after ingestion. Bioavailability of voriconazole for oral administration is 96%. With repeated administration of voriconazole with food with a high fat content Cmah and AUC_T decrease by 34% and 24% respectively. Absorption of voriconazole does not depend on the pH of the gastric juice.

Distribution:

The average volume of distribution of voriconazole in the equilibrium state is about 4.6 l / kg, which indicates the active distribution of voriconazole in the tissue. Binding to plasma proteins is 58%.

Voriconazole penetrates the blood-brain barrier (BBB) and is determined in the cerebrospinal fluid.

Metabolism:

According to research data in vitro voriconazole is metabolized by isozymes CYP2C19, CYP2C9, CYP3A4. An important role in the metabolism of voriconazole is played by isoenzyme CYP2C19, showing a pronounced genetic polymorphism, and therefore a reduced metabolism of voriconazole is possible in 15-20% of patients of Asian descent and 3-5% of Caucasoid and Negroid races.It was found that in patients with a reduced metabolism AUC_T voriconazole is on average 4 times higher than in homozygous patients with high metabolism. In heterozygous patients with high metabolism AUC_T Voriconazole is on average twice as high as homozygous.

The main metabolite of voriconazole is Noxide, the proportion of which is about 72% of the total number of metabolites circulating in the blood plasma with a radioactive label. This metabolite has minimal antifungal activity and does not contribute to the clinical effect of voriconazole.

Excretion:

Voriconazole is excreted as metabolites after biotransformation in the liver; In unchanged form, less than 2% of the administered dose is excreted by the kidneys.

After repeated administration of voriconazole or intravenous administration in urine, about 83% and 80% of the dose of the drug are detected, respectively. Most (> 94%) of the total dose is excreted within the first 96 hours after ingestion and intravenously.

The half-life period (T1 / 2) of voriconazole is dose dependent and is approximately 6 hours when taken internally at a dose of 200 mg. In connection with the nonlinearity of pharmacokinetics, the T1 / 2 value does not allow predicting the cumulation or excretion of voriconazole.

Pharmacokinetics in special patient groups:

Floor

With multiple administration of voriconazole inside Cmah and AUC_T in healthy young women were 83% and 113%, respectively, higher than in healthy young men (18-45 years). Significant differences Cmah and AUC_T in healthy elderly men and healthy elderly women (≥65 years) do not. The equilibrium concentration of voriconazole in blood plasma in women was 91% higher than in men after taking the drug as a suspension. There is no need to adjust the dose of voriconazole depending on the sex. Concentrations in blood plasma in men and women are similar.

Age

With multiple administration of voriconazole inside Cmah and AUC_T in healthy elderly men (≥65 years) by 61% and 86%, respectively, higher than in healthy young men (18-45 years). Significant differences Cmah and AUC_T in healthy elderly women (≥65 years of age) and healthy young women (18-45 years) do not. Voriconazole safety profile young and elderly patients is no different.

There is no need to adjust the dose of voriconazole according to age.

Children

Children have greater intra-individual variability than adults. Comparison of the child and adult population showed that the estimated AUC_T in children after administration of a saturating dose of 9 mg / kg was comparable to that in adults after administration of a saturating dose of 6 mg / kg.The estimated total concentration in children after administration of a maintenance dose of 4 mg / kg and 8 mg / kg twice daily was also comparable to that in adults after administration of a maintenance dose of 3 mg / kg and 4 mg / kg twice daily. The concentration of voriconazole with intravenous administration at a dose of 8 mg / kg is twice as high as when ingested at a dose of 9 mg / kg. Bioavailability of voriconazole for oral administration in children may be limited by a malabsorption and a sufficiently low body weight at this age, in which case intravenous administration may be indicated. The findings suggest a higher elimination of voriconazole in children compared with adults due to the large ratio of liver weight and body weight. In most adolescents, the concentration of voriconazole in the blood plasma corresponds to this parameter in adult patients. However, fewer voriconazole concentrations were observed in plasma in some adolescents with a low body weight compared to adults and were closer to the same values in children. Based on the population pharmacokinetic analysis, adolescents aged 12 to 14 years with a body weight of less than 50 kg should receive a dose of voriconazole recommended for use in children.

Impaired renal function

Binding to plasma proteins is similar in patients with varying degrees of renal failure. In patients with moderate or severe renal impairment (serum creatinine concentration ≥ 220 μmol / L or 2.5 mg / dL), an accumulation of the beta-supplement of sodium sulfobutylate, which is part of the lyophilizate for the preparation of the infusion solution, is observed.

Impaired liver function

Dysfunction of the liver does not affect the binding of voriconazole with plasma proteins. There is no information on the pharmacokinetics of voriconazole in patients with severe hepatic impairment (class C according to the Child-Pugh classification).

Indications:

- Invasive aspergillosis;

- Candidemia in patients without neutropenia;

- severe invasive candidiasis infections (including FROM. krusei);

Candidiasis of the esophagus;

- severe fungal infections caused by Scedosporium spp. and Fusarium spp.;

- other severe invasive fungal infections with intolerance or refractory to other medicines;

- Prevention of "breakthrough" fungal infections in patients with reduced immune system function, fever and neutropenia, from high-risk groups (recipients of hematopoietic stem cell transplantation, patients with relapse of leukemia);

- prevention of invasive fungal infections in patients (adults and children over 12 years) at high risk groups, such as recipients of hematopoietic stem cell transplantation.

Contraindications:

A drug Voriconazole contraindicated in patients with sensitivity to voriconazole or any other component of the drug.

Contraindicated simultaneous use of voriconazole and the following drugs (see the section "Interaction with other drugs"): substrates isoenzyme CYP3A4 - terfenadine, astemizole, cisapride, pimozide or quinidine; sirolimus; rifampicin, carbamazepine and long-acting barbiturates (phenobarbital); rifabutin; efavirenz in doses of 400 mg and higher once a day (with voriconazole in standard doses); ritonavir in high doses (400 mg and higher twice a day); ergot alkaloids (ergotamine, dihydroergotamine), which are substrates of the isoenzyme CYP3A4; St. John's wort (the inducer of cytochrome P450 and P-glycoprotein).

A drug Voriconazole is contraindicated in children under 2 years of age.

Carefully:

Hypersensitivity to other drugs - derivatives of azoles.

Severe failure of the liver, severe failure of kidney function.

Voriconazole should be used with caution in patients with proarrhythmic states: congenital or acquired increase in the interval QT, cardiomyopathy, in particular with heart failure, sinus bradycardia, the presence symptomatic arrhythmia, simultaneous use of drugs that cause lengthening interval QT (see section "Special instructions").

Also, use caution when using the drug Voriconazole in patients with electrolyte disorders, such as hypokalemia, hypomagnesemia and hypocalcemia.

Pregnancy and lactation:

There is no sufficient information about the use of voriconazole in pregnant women.

In animal studies, it has been established that the drug has a toxic effect on reproductive function. The possible risk to man is unknown. Voriconazole should not be used in pregnant women, except when the expected benefit to the mother clearly exceeds the possible risk to the fetus. The excretion of voriconazole with breast milk has not been studied. For the duration of the drug, breastfeeding should be discontinued.

Women of reproductive age when using the drug Voriconazole should use reliable methods of contraception.

Dosing and Administration:

A drug Voriconazole It is not recommended to administer in the form of bolus injections (jet). The infusion rate should not exceed 3 mg / kg / h for 1-3 hours.

Before the start of therapy, it is necessary to correct such electrolyte abnormalities as hypokalemia, hypomagnesemia and hypocalcemia (see also the "Side effect" section).

Adult patients

Appointment of the drug Voriconazole should begin with intravenous administration in the recommended saturating dose, so that on the first day, an adequate concentration in the blood plasma can be achieved. Intravenous administration should be continued for at least 7 days, after which it is possible to switch to oral intake of the drug, provided that the patient is able to take medication for oral administration. Given the high bioavailability of the drug with oral intake, reaching 96% (see the section "Pharmacokinetics"), in the presence of clinical indications, it is possible to switch from intravenous to oral administration drug without dose adjustment.

Table 1. Dosing of Voriconazole

	Intravenously	Inside
	Intravenously	Patients with a body weight of 40 kg and more	Patients weighing less than 40 kg
The saturation dose - all indications (the first 24 hours)	6 mg / kg every 12 hours	Not recommended	Not recommended
The maintenance dose (after the first 24 hours)
Prevention of invasive fungal infections in patients (adults and children over 12 years) at high risk, such as recipients of hematopoietic stem cell transplantation / prevention of breakthrough fungal infections in febrile patients	3-4 mg / kg every 12 hours	200 mg every 12 hours	100 mg every 12 hours
Invasive aspergillosis / infections caused by Scedosporium spp. and Fusarium spp. / other severe invasive fungal infections	4 mg / kg every 12 hours	200 mg every 12 hours	100 mg every 12 hours
Candidemia in patients without neutropenia	3-4 mg / kg every 12 hours	200 mg every 12 hours	100 mg every 12 hours
Candidiasis of the esophagus	Not installed	200 mg every 12 hours	100 mg every 12 hours

Dose selection for intravenous administration

With insufficient effectiveness of treatment, the maintenance dose of the drug Voriconazole for intravenous administration can be increased to 4 mg / kg every 12 hours. If the patient does not tolerate the drug in a high dose, it is reduced to 3 mg / kg every 12 hours.

The duration of treatment should be as short as possible depending on the clinical effect and resultsmycological research. The duration of treatment should not exceed 180 days.

Prevention in adults and children

Prophylactic use of the drug should be started on the day of transplantation and can be continued up to 100 days. To prolong prophylaxis to 180 days is possible only if immunosuppressive therapy is continued or the development of the "graft versus host" reaction (TPH). The safety and efficacy of voriconazole for more than 180 days in clinical trials have not been adequately studied.

The dosage regimen for prevention is the same as for treatment in the appropriate age groups.

Use in special patient groups

Impaired renal function

In patients with moderate or severe renal insufficiency (creatinine clearance <50 ml / min), cumulation of an auxiliary component of the betadex preparation of sodium sulfobutylate is observed. So sick voriconazole should be administered orally, except when the intended use of intravenous administration exceeds the potential risk. In such situations, the concentration of creatinine should be monitored regularly and, if it increases, the possibility of switching toreception of voriconazole inside. Voriconazole is deduced in the course of hemodialysis with a clearance of 121 ml / min. 4-hour hemodialysis does not lead to the removal of a significant part of the dose of voriconazole and does not require correction. Betadex sodium sulfobutylate is excreted during hemodialysis with a clearance of 55 ml / min.

Impaired liver function

In acute liver damage, manifested by increased activity of "liver" transaminases: alanine aminotransferase (ALT) and aspartate aminotransferase (ACT), dose adjustment is not required, but it is recommended to continue monitoring liver function. Patients with mild or moderate and impaired liver function (classes A and B according to the Child-Pugh classification) should be prescribed a standard saturating dose of voriconazole, and the maintenance dose should be reduced 2-fold. Patients with a severe degree of impaired liver function (class C according to the Child-Pugh classification) voriconazole should be prescribed only in cases where the expected benefit exceeds the possible risk, and under constant monitoring to identify signs of toxic effects of the drug.

Elderly patients

Dose adjustments in the elderly are not required.

Use in children

The efficacy and safety of voriconazole in children younger than 2 years of age have not been established.

Table 2. The dosage regimen of voriconazole in children (aged 2 to 12 years) and in adolescents aged 12 to 14 years and a body weight of less than 50 kg.

Intravenously

Inside

Saturated dose (first 24 h)

9 mg / kg every 12 hours

Not recommended

The maintenance dose (after the first 24 hours)

8 mg / kg 2 times a day

9 mg / kg twice daily (maximum dose of 350 mg twice daily)

It is recommended to start therapy with intravenous administration of the drug, and the possibility of oral administration of voriconazole should be considered only after the clinical improvement and the patient's ability to take oral medications. It should be taken into account that the effect of the drug when administered intravenously at a dose of 8 mg / kg is approximately twice as high as when administered intravenously at a dose of 9 mg / kg. The use of voriconazole in children aged 2 to 12 years with impaired liver or kidney function has not been studied.

In adolescents (aged 12 to 14 years with a body weight of 50 kg or more, 15 to 18 years, regardless of body weight) voriconazole dosed the same way as for adults.

Correction of dose

If the patient's clinical response is inadequate, the dose may be increased in increments of 1 mg / kg (or 50 mg if the maximum oral dose is initially 350 mg). If the child does not tolerate therapy at the prescribed dose, it should be reduced in steps of 1 mg / kg (or 50 mg if a maximum oral dose of 350 mg was initially used).

Instructions for preparing a solution for infusions

A drug Voriconazole is available in single-use vials. The contents of the vial are reconstituted by dissolving in 19 ml of water for injection and 20 ml of a clear concentrate containing voriconazole in a concentration of 10 mg / ml. If the solvent does not enter the vial under the action of a vacuum, the vial can not be used. Before use, the required volume of concentrate (see Table 3) is added to the recommended compatible infusion solution (see below), and a solution is prepared containing voriconazole in concentrations from 0.5 mg / ml to 5 mg / ml.

Table 3. Necessary volumes of drug concentrate Voriconazole 10 mg / ml

Body weight (kg)	Volumes of the drug concentrate Voriconazole (10 mg / ml) required for cooking:
Body weight (kg)	Dose 3 mg / kg (number of vials)	Dose 4 mg / kg (number of vials)	Dose 6 mg / kg (number of vials)	Dose 8 mg / kg (number of vials)	Dose 9 mg / kg (number of vials)
10	-	4.0 ml (1)	-	8.0 ml (1)	9.0 ml (1)
15	-	6.0 ml (1)	-	12.0 ml (1)	13.5 ml (1)
20	-	8.0 ml (1)	-	16.0 ml (1)	18.0 ml (1)
25	-	10.0 ml (1)	-	20.0 ml (1)	22.5 ml (2)
30	9.0 ml (1)	12.0 ml (1)	18.0 ml (1)	24.0 ml (2)	27.0 ml (2)
35	10.5 ml (1)	14.0 ml (1)	21.0 ml (2)	28.0 ml (2)	31.5 ml (2)
40	12.0 ml (1)	16.0 ml (1)	24.0 ml (2)	32.0 ml (2)	36.0 ml (2)
45	13.5 ml (1)	18.0 ml (1)	27.0 ml (2)	36.0 ml (2)	40.5 ml (3)
50	15.0 ml (1)	20.0 ml (1)	30.0 ml (2)	40.0 ml (2)	45.0 ml (3)
55	16.5 ml (1)	22.0 ml (2)	33.0 ml (2)	44.0 ml (3)	49.5 ml (3)
60	18.0 ml (1)	24.0 ml (2)	36.0 ml (2)	48.0 ml (3)	54.0 ml (3)
65	19.5 ml (1)	26.0 ml (2)	39.0 ml (2)	52.0 ml (3)	58.5 ml (3)
70	21.0 ml (2)	28.0 ml (2)	42.0 ml (3)	-	-
75	22.5 ml (2)	30.0 ml (2)	45.0 ml (3)	-	-
80	24.0 ml (2)	32.0 ml (2)	48.0 ml (3)	-	-
85	25.5 ml (2)	34.0 ml (2)	51.0 ml (3)	-	-
90	27.0 ml (2)	36.0 ml (2)	54.0 ml (3)	-	-
95	28.5 ml (2)	38.0 ml (2)	57.0 ml (3)	-	-
100	30.0 ml (2)	40.0 ml (2)	60.0 ml (3)	-	-

drug voriconazole, lyophilizate for the preparation of solution for infusion, is a sterile lyophilizate without preservative, intended for single use. from the microbiological point of view, the drug should be administered immediately. The reconstituted solution (concentrate) can be stored for no more than 24 hours at a temperature of 2 to 8 ° C if it was prepared under controlled aseptic conditions.

The concentrate can be further diluted with the following solutions:

- 0.9% solution of sodium chloride for intravenous administration;

lactate rationer solution for intravenous administration;

- 5% dextrose solution and lactate rationer solution for intravenous administration;

- 5% dextrose solution and 0.45% sodium chloride solution for intravenous administration;

- 5% dextrose solution for intravenous administration;

- 5% dextrose solution and 0.15% potassium chloride solution for intravenous administration;

- 0.45% solution of sodium chloride for intravenous administration;

- 5% dextrose solution and 0.9% sodium chloride solution for intravenous administration.

compatibility of voriconazole with other solutions, other than those mentioned above, is unknown.

Side effects:

The safety data for voriconazole are based on the results of a study of more than 2000 people (1655 patients using voriconazole for therapeutic purposes and 279 for prophylactic purposes) represented by a heterogeneous population (patients with malignant blood growths, HIV-infected patients with esophageal candidiasis and refractory fungal infections, patients without neutropenia with candidemia or aspergillosis, and healthy volunteers). The most common adverse reactions are abnormalities in the body of the eye, abnormalities in the results of functional liver tests, fever, rash, vomiting, nausea, diarrhea, headache, peripheral edema, abdominal pain and respiratory depression.Undesirable reactions were usually easily or moderately expressed. Clinically significant dependence of drug safety on age, race and sex was not revealed.

Criteria for frequency estimation: very often ≥ 10%; often from ≥ 1% to <10%: infrequently from ≥ 0.1% to <1%; rarely from ≥ 0.01% to <0.1%; rarely -< 0,01 %; it is not known - it is impossible to determine the frequency based on the available data.

From the heart: often - supraventricular arrhythmia, tachycardia, bradycardia; infrequently - Ventricular fibrillation, ventricular extrasystole, supraventricular tachycardia, ventricular tachycardia; rarely - arrhythmia of the type "pirouette", complete atrioventricular block, blockade of the bundle of the bundle, node arrhythmias.

From the side of the vessels: often - arterial hypotension, phlebitis; infrequently - Thrombophlebitis.

On the part of the hematopoiesis and lymphatic system: often - agranulocytosis (including febrile neutropenia and neutropenia), pancytopenia, thrombocytopenia (including immune thrombocytopenic purpura), anemia; infrequently - bone marrow depression, leukopenia, lymphadenopathy, eosinophilia, disseminated intravascular coagulation syndrome.

From the nervous system: very often - headache; often - syncope, tremor, paresthesia, drowsiness, dizziness, convulsions, nystagmus; infrequently - cerebral edema, encephalopathy, extrapyramidal disorder, peripheral neuropathy, ataxia, hypesthesia, dysgeusia (impaired taste perception); rarely - hepatic encephalopathy, Guillain-Barre syndrome.

From the side of the organ of vision: very often - violation of the organ of vision (including blurred vision, blurred vision, photophobia, chloropia, hromatopsiya, photophobia, color blindness, tsianopsiya, the presence in the field of view of bright circles around lights, night blindness, oscillopsia, photopsia, scintillating scotoma, reduced visual vision, visual brightness, defect of visual fields, floating opacities of the vitreous body and xantopsy); often - hemorrhage into the retina of the eye; infrequently - optic neuritis, optic nerve edema nipple, oculogyric crisis, diplopia, scleritis, blepharitis; rarely - atrophy of the optic nerve, corneal opacity.

From the side of the organ of hearing and the vestibular apparatus: infrequently - vertigo, hypoacusia, tinnitus.

On the part of the respiratory system, the thorax and the mediastinum: very often - respiratory depression; often - pulmonary edema, acute respiratory distress syndrome.

From the gastrointestinal tract: very often - nausea, vomiting, diarrhea, pain in the belly; often - cheilitis, indigestion, constipation; infrequently - duodenitis, glossitis, pancreatitis, edema of the tongue.

From the side of the kidneys and urinary system: often - acute renal insufficiency, hematuria; infrequently - Necrosis of the renal tubules, proteinuria, nephritis.

From the skin and subcutaneous tissues: very often - rash; often - exfoliative dermatitis, alopecia, skin itching, maculopapular rash, erythema; infrequently - Stevens-Johnson syndrome, photosensitivity, urticaria, eczema, toxic epidermal necrolysis, angioedema, erythema multiforme, psoriasis, allergic dermatitis, purpura, papular rash, macular rash; rarely pseudoporphyria, persistent drug erythema; frequency unknown - cutaneous form of systemic lupus erythematosus.

From the musculoskeletal and connective tissue: often - backache; infrequently - arthritis; frequency unknown - periostitis.

From the endocrine system: infrequently - Insufficiency of the adrenal cortex, hypothyroidism; rarely - hyperthyroidism.

Disorders of metabolism and nutrition: very often - peripheral edema; often - hypokalemia, hypoglycemia, hyponatremia (revealed in post-registration studies).

Infections and infestations: often - sinusitis, gastroenteritis, gingivitis; infrequently - pseudomembranous colitis, lymphangitis, peritonitis.

General disorders and disorders at the injection site: very often - fever; often - chills, asthenia, chest pain, flu-like illness, facial edema (including periorbital edema, swelling of the lips and swelling of the mouth); infrequently - reaction / inflammation at the injection site.

From the immune system: infrequently - allergic reactions; rarely - anaphylactoid reactions.

From the hepatobiliary system: very often - Deviations from the norm of the results of functional hepatic tests (increased activity of aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, gamma-glutamyltransferase, lactate dehydrogenase, hyperbilirubinemia); often - jaundice, cholestatic jaundice, hepatitis; infrequently - hepatic insufficiency, cholecystitis, cholelithiasis, enlargement of the liver.

Mental disorders: often - hallucinations, confusion, depression, anxiety, insomnia, agitation.

Neoplasms benign, malignant and unspecified (including cysts and polyps): frequency unknown - squamous cell carcinoma of the skin.

Research: often - increasing the concentration of creatinine in the blood; infrequently interval lengthening QT on an electrocardiogram, an increase in the concentration of urea in the blood, an increase in the concentration of cholesterol in the blood.

Side effect when used in children:

It was found that the undesirable effects of the drug in children aged 2 to 12 years are similar to those in adults. Children had a higher frequency of hepatic enzyme activity. In the course of post-registration studies, the development of pancreatitis in children with voriconazole therapy was revealed, as well as the more frequent occurrence of skin reactions.

Overdose:

There are three cases of accidental overdose. All of these cases occurred in children who received a dose of voriconazole intravenously, five times the recommended dose.

There is a report of a single case of photophobia lasting 10 minutes. The antidote of voriconazole is unknown. In case of an overdose, symptomatic and supportive therapy is indicated.

Voriconazole is excreted during hemodialysis with a clearance of 121 ml / min, betadax sodium sulfobutylate - with a clearance of 55 ml / min. In case of an overdose of hemodialysis can promote the removal of voriconazole and betadex sulfobutylate from organism.

Interaction:

Inhibitors or inducers of cytochrome P450 isoenzymes (CYP2C19, CYP2C9 and CYP3A4) can cause, respectively, an increase or decrease in the concentration of voriconazole in the blood plasma.

Voriconazole inhibits the activity of cytochrome P450 - CYP2C19, CYP2C9 and CYP3A4 isoenzymes, - and can increase plasma concentrations of substances that are metabolized with cytochrome P450 isoenzymes

Table 4. Interaction of voriconazole with other drugs and recommendations with simultaneous application.

Drug (mechanism of interaction)	Interaction: changes pharmacokinetic parameters (%)	Recommendations for simultaneous application
Astemizole, cisapride, pimozide, quinidine and terfenadine [substrates of the isoenzyme CYP3A4]	Interactions have not been studied, but there is a high probability that elevated concentrations of these drugs may lead to an elongation of the QTc interval and, in rare cases, the occurrence of ventricular pirouette tachycardia.	Contraindicated.
Carbamazepine and long-acting barbiturates (for example, phenobarbital, mefobarbital) [powerful cytochrome P450 inducers]	Interaction has not been studied, however carbamazepine and long-acting barbiturates are likely to significantly reduce plasma concentrations of voriconazole.	Contraindicated.
Efavirenz (non-nucleoside reverse transcriptase inhibitor) [inducer of cytochrome P450; inhibitor and substrate of the isoenzyme CYP3A4]
Simultaneous use of efavirenz in a dose of 400 mg once a day and voriconazole at a dose of 200 mg twice a day *	Stem efavirenz ↑ 38% AUCt efavirenz ↑ 44% Smax voriconazole ↓ 61% AUCt voriconazole ↓ 77%	The use of standard doses of voriconazole and efavirenz 400 mg once a day is contraindicated. Simultaneous application is possible. if the maintenance dose of voriconazole is increased to 400 mg twice a day, and the dose of efavirenz is reduced to 300 mg once daily.With the withdrawal of therapy with voriconazole, the initial dose of efavirenz should be restored.
Simultaneous application of 300 mg of efavirenz once a day and voriconazole 400 mg twice a day *	In comparison with efavirenz 600 mg once a day: Stems of efavirenz <-> AUCt efavirenz ↑ 17% In comparison with voriconazole 200 mg two once a day: Smax voriconazole ↑ 23% AUCt voriconazole ↓ 7%
Ergot alkaloids (eg, ergotamine and dihydroergotamine) [substrates of the isoenzyme CYP3A4]	The interaction of voriconazole with ergot alkaloids (ergotamine and dihydroergotamine) has not been studied, but there is a high probability that voriconazole can cause an increase in the concentrations of these drugs in the blood plasma and lead to ergotism.	Contraindicated.
Rifabutin [powerful cytochrome P450 inducer]
300 mg once daily	Stach voriconazole ↓ 69% AUCt voriconazole ↓ 78% Stems of rifabutin ↑ 195% AUCt Rifabutin ↑ 331%	Contraindicated.
300 mg once a day (with simultaneous application with voriconazole 400 mg twice daily) *	In comparison with voriconazole 200 mg twice a day: Smax voriconazole ↑ 104% AUCt of voriconazole ↑ 87%	Contraindicated.
Rifampicin (600 mg once daily) [powerful cytochrome P450 inducer]	Smax voriconazole ↓ 93% AUCt voriconazole ↓ 96%	Contraindicated.
Ritonavir (protease inhibitor) [powerful cytochrome P450 inducer; inhibitor and substrate of the isoenzyme СUR3А4]
High doses (400 mg twice daily)	Stax and AUCT of ritonavir <-> Sta voriconazole ↓ 66% AUCt voriconazole ↓ 82%	Simultaneous use of voriconazole and high doses of ritonavir (400 mg and more twice a day) is contraindicated.
Low doses (100 mg twice daily) *	Stents of ritonavir ↓ 25% AUCt of ritonavir ↓ 13% Smax voriconazole ↓ 24% AUCt voriconazole ↓ 39%	Apply simultaneously voriconazole and ritonavir in low doses (100 mg twice a day) should be given only if the expected benefit from taking voriconazole significantly exceeds the risk of their combined use.
St. John's wort perforated [inducer of cytochrome P450 and P-glycoprotein] 300 mg three times a day (simultaneous application with a single dose of voriconazole 400 mg)		Contraindicated.
	According to independent research: AUC_0-∞voriconazole ↓ 59%	Contraindicated.
Everolimus [substrate of the isoenzyme CYP3A4 and P-glycoprotein]	Interaction has not been studied, however voriconazole, probably, can significantly increase the plasma concentrations of everolimus.	Simultaneous use is not recommended, as it is expected that voriconazole significantly increases the concentration of everolimus in the blood plasma. At the moment, there is not enough information to recommend a correction of the dosing regimen.
Fluconazole (200 mg once daily) [inhibitor of isoenzymes CYP2C9, CYP2C19 and CYP3A4]	Smax voriconazole ↑ 57% AUCt voriconazole ↑ 79% Changes of C max and AUCt of fluconazole are not established.	A suitable regimen for dose adjustment and / or reception frequency of voriconazole and fluconazole is not established. In case if voriconazole is used after fluconazole, it is recommended that careful monitoring of unwanted reactions associated with the use of voriconazole is recommended.
Phenytoin [substrate of the isoenzyme CYP2C9 and powerful cytochrome P450 inducer]		Avoid simultaneous administration of voriconazole and phenytoin, except in cases. when the use for the patient exceeds the risk. It is recommended to monitor plasma concentrations of phenytoin. Simultaneous application is possible only if the maintenance dose of voriconazole is increased to 5 mg / kg intravenously or 200 mg to 400 mg orally twice a day (in patients weighing less than 40 kg from 100 mg to 200 mg orally twice a day day).
300 mg once daily	Smax voriconazole ↓ 49% AUCt voriconazole ↓ 69%
300 mg once a day (simultaneous application with voriconazole at a dose of 400 mg twice a day) *	Stages of phenytoin ↑ 67% AUCt of phenytoin ↑ 81% In comparison with voriconazole 200 mg twice a day, Smax voriconazole ↑ 34% AUCt of voriconazole ↑ 39%
Anticoagulants		If patients receiving coumarin preparations are prescribed voriconazole, it is necessary to monitor prothrombin time at short intervals and appropriately select doses of anticoagulants.
Warfarin (30 mg once with voriconazole 300 mg twice daily) [isoenzyme substrate CYP2C9]	The increase in the maximum prothrombin time was approximately two-fold.
Other oral anticoagulants, for example, fenprokumone, acenocoumarol [substrates of isoenzymes CYP2C9 and CYP3A4]	It is assumed that voriconazole can increase plasma concentrations of coumarins, which can lead to an increase in prothrombin time.
Benzodiazepines (e.g., midazolam, trazolam, alprazolam) [substrates of the isoenzyme CYP3A4]	In vitro voriconazole can cause an increase in plasma concentrations of benzodiazepines, which are metabolized by the isozyme CYP3A4, and cause the development of a prolonged sedation.	It is recommended to evaluate the appropriateness of dose adjustment for benzodiazepines.
Immunosuppressants [substrates of the isoenzyme CYP3A4]
Sirolimus (2 mg once)	According to an independent study: Stamens of sirolimus ↑ 6.6 times AUC_0-∞sirolimus ↑ 11 times	The simultaneous use of voriconazole and sirolimus is contraindicated. When voriconazole is prescribed to patients receiving ciclosporin, it is recommended to reduce the dose of cyclosporine by half and monitor its concentration in the blood plasma. An increase in the concentration of cyclosporine is accompanied by nephrotoxicity. After voriconazole cancellation, it is necessary to control the concentration of cyclosporine and, if necessary, increase its dose. With the appointment of voriconazole to patients, receiving tacrolimus, it is recommended to reduce the dose of the latter to one-third and control its concentration in the blood plasma. Increase concentrations tacrolimus accompanied by nephrotoxicity. After voriconazole cancellation, it is necessary to monitor the concentration of tacrolimus and, if necessary, increase its dose.
Cyclosporin (in patients who underwent kidney transplantation and are in a stable state)	Cmax cyclosporine ↑ 13% AUCt cyclosporine ↑ 70%
Tacrolimus (0.1 mg / kg once)	Tram of tacrolimus ↑ 117% AUCt tacrolimus ↑ 221%
Long-acting opiates [substrates of the isoenzyme CYP3A4]
oxycodone (10 mg once)	according to an independent study: oxymodone oxides ↑ 1,7 times auc_0-∞oxycodone \| in 3,6 times	one should evaluate the possibility of reducing the dose of oxycodone and other long-acting opiates metabolized by the isoenzyme cyp3a4 (eg, hydrocodone). It may be necessary to monitor the patient's condition at short intervals for the development of unwanted reactions associated with opiates. an increase in the concentration of methadone in the blood plasma leads to the manifestation of toxic effects, including the prolongation of the interval qt. it is recommended that the patient be frequently monitored for the development of unwanted reactions and toxicity (including the prolongation of the qt interval) associated with methadone. you may need to reduce the dose of methadone.
methadone (32-100 mg once daily) [substrate of cyp3a4 isoenzyme]	of r-methadone (active metabolite) ↑ 31% auct r-methadone (active metabolite) ↑ 47% сmах s-methadone ↑ 65% auct s-methadone ↑ 103%
non-steroidal anti-inflammatory drugs (NVP) [isoenzyme substrates cyp2c9]		patients should be observed in order to identify possible toxic effects and, if necessary, adjust the dose of NVP.
ibuprofen (400 mg once)	of s-ibuprofen ↑ 20% auc_0-∞s-ibuprofen ↑ 100%
diclofenac (50 mg once)	of diclofenac ↑ 114% auc_0-∞diclofenac ↑ 78%
omeprazole (40 mg once daily) * [inhibitor of isoenzyme cyp2c19; substrate cyp2c19 and cyp3a4]	of omeprazole ↑ 116% auct of omeprazole ↑ 280% of variconazole ↑ 15% auct voriconazole ↑ 41% voriconazole can also inhibit the action of other proton pump inhibitors, which are substrates of the cyp2c19 isoenzyme, which can lead to an increase in the plasma concentrations of these drugs.	correction of the dose of voriconazole is not required. when starting voriconazole in patients who are already receiving omeprazole therapy at doses of 40 mg or higher, a dose reduction of omeprazole is recommended in half.
oral contraceptives * [substrates of isoenzyme cyp3a4; inhibitors of the isoenzyme cyp2c19] norethisterone / ethinylestradiol (1 mg / 0.35 mg once daily)	ethanol estradiol ↑ 36% auct of ethinyl estradiol ↑ 61% of norethisterone ↑ 15% auct of norethisterone ↑ 53% of variconazole ↑ 14% auct voriconazole ↑ 46%	it is recommended to monitor the patient's condition for the development of unwanted reactions associated with the use of oral contraceptives and voriconazole.
narcotic analgesics of short action [substrates of isoenzyme cyp3a4]		one should evaluate the possibility of reducing the dose of alfentanil, fentanyl and other short-acting narcotic analgesics having a chemical structure similar to alfentanil and metabolized by the isoenzyme cyp3a4 (eg, sufentanil). patients should be under constant supervision to prevent oppression of respiratory function or other side effects associated with the use of short-acting narcotic analgesics, and if necessary, their dose should be reduced.
alfentanil (a single dose of 20 μg / kg with the simultaneous use of naloxone)	according to an independent study: auc_0-∞ alfentanil ↑ 6 times
fentanyl (a single dose of 5 μg / kg)	according to an independent study: auc_0-∞ fentanyl ↑ 1,34 times
statins (e.g., lovastatin) [substrates of isoenzyme cyp3a4]	the interaction was not studied, however, voriconazole can increase plasma concentrations of statins that are metabolized by the isoenzyme cyp3a4 and can lead to rhabdomyolysis.	should evaluate the possibility of reducing the dose of statins.
derivatives of sulfonylureas (for example, tolbutamide, glipizide, glibenclamide) [isoenzyme substrates cyp2c19]	the interaction was not studied, however, voriconazole can increase plasma concentrations of sulfonylureas and cause hypoglycemia.	it is necessary to carefully monitor the concentration of glucose in the blood plasma.
alkaloids of vinca (for example, vincristine and vinblastine) [substrates of isoenzyme cyp3a4]	voriconazole may increase the vinca alkaloids (vincristine and vinblastine) in the blood plasma and cause neurotoxicity.	it is recommended to evaluate the feasibility of correcting the dose of vinca alkaloids.
other protease inhibitors (ip) vich (for example, saquinavir, amprenavir and nelfinavir)* [inhibitors and substrates of cyp3a4 isoenzyme]	In vitro studies indicate that voriconazole can inhibit the metabolism of protease inhibitors HIV: saquinavir, amprenavir and nelfinavir. in turn, HIV protease inhibitors can suppress the metabolism of voriconazole.	it is recommended that the patient be carefully monitored for any development of any drug toxicity and / or lack of action. you may need to adjust the dose of drugs.
other non-nucleoside reverse transcriptase inhibitors (nniot) (eg, delavirdine, nevirapine)* [inhibitors or inducers of cytochrome p450 and substrates of the isoenzyme cyp3a4]	In vitro studies have shown that the metabolism of voriconazole can be inhibited by the action of the niott, and voriconazole in turn, can inhibit the metabolism of niott. based on the results of the study of the effect of efavirenz on voriconazole it can be assumed that the niote can enhance the metabolism of voriconazole.	it is recommended that the patient be carefully monitored for drug toxicity and / or lack of action. it may be necessary to adjust the dose of drugs.
cimetidine (400 mg twice daily) [nonspecifically inhibits cytochrome p450 and increases the ph of gastric juice]	of variconazole ↑ 18% auct voriconazole ↑ 23%	correction of the dose is not required.
digoxin (0.25 mg once daily) [p-glycoprotein substrate]	of digoxin <-> auct of digoxin <->	correction of the dose is not required.
indinavir (800 mg three times daily) [inhibitor and substrate of the isoenzyme cyp3a4]	of digoxin <-> auct of digoxin <-> of variconazole <-> auct of voriconazole <->	correction of the dose is not required.
antibiotics of the macrolide group		correction of the dose is not required.
erythromycin (1 g twice daily) [inhibitor of cyp3a4 isoenzyme]	smax and auct of voriconazole <->
azithromycin (500 mg once daily)	smax and auct of voriconazole <-> the effect of voriconazole on the metabolism of erythromycin or azithromycin is unknown.
mycophenolic acid (1 g once) [uridine-5 '-diphosphate-glucuronyltransferase substrate]	Mycophenolic acid <-> auct of mycophenolic acid <->	correction of the dose is not required.
prednisolone (60 mg once) [substrate of cyp3a4 isoenzyme]	of prednisolone ↑ 11% auc_0-∞prednisolone ↑ 34%	correction of the dose is not required.
ranitidine (150 mg twice daily) [increases ph of gastric juice]	smax and auct of voriconazole <->	correction of the dose is not required.

The pharmacokinetic parameter based on the 90% confidence interval of the mean geometric value is inside (<->), above (↑) or below (↓) of the 80% -125% interval.

* mutual impact.

auct, auc_0-∞- the area under the "concentration-time" curve during the dosing period, from the moment of drug administration to the visible concentration in the blood plasma, from the moment of drug administration to infinity, respectively.

pharmaceutical incompatibility

voriconazole is incompatible with 4.2% sodium bicarbonate solution, so it is not recommended to use it as a solvent. compatibility with other concentrations of sodium bicarbonate is unknown.

the drug voriconazole can not be administered concomitantly with blood products or high-concentration electrolyte solutions, even if separate catheters are used for infusions.

infusion of the drug voriconazole should not be conducted through a single catheter or cannula with other drugs, including preparations for parenteral nutrition (aminofuzin 10% plus). however, the drug can be administered simultaneously with complete parenteral nutrition and with solutions of electrolytes of low concentration through separate catheters or a separate input of a multichannel catheter.

the drug voriconazole should not be confused with other drugs, except those listed in the section "Instructions for preparing a solution for infusions."

Special instructions:

Taking the material for sowing and other laboratory tests (serology, histopathology) for the purpose of isolating and identifying pathogens should be performed before the start of treatment.Treatment can begin before the results of laboratory tests. However, after receiving these results, it is necessary to adjust the antifungal therapy.

The species that most often cause infection in humans include S. albicans, FROM. parapsilosis, FROM. tropicalis, FROM. glabrata and FROM. krusei, while for all of them the minimal suppressive concentration (MIC) of voriconazole is usually less than 1 mg / ml. but in vitro voriconazole activity against fungi of different species Candida not is the same. In particular, the MIC of voriconazole for fluconazole-resistant isolates FROM. glabrata is proportionally higher than the MIC for isolates sensitive to fluconazole. In this regard, fungi of the genus Candida in all possible cases, identify to the species level. If it is possible to determine the sensitivity of fungi to antifungal drugs, the values of the MIC should be interpreted using threshold criteria.

Isolated clinical strains of microorganisms, which have a reduced sensitivity to voriconazole. However, increased minimal inhibitory concentrations (MICs) do not always allow predicting clinical inefficiency: there are cases when voriconazole was effective in patients infected with microorganisms resistant to other azoles. To evaluate the correlation between voriconazole activity under conditions in vitro and clinical treatment outcomes are difficult, given the complexity of patients who have been included in clinical trials. The borderline concentrations of voriconazole, which make it possible to assess the sensitivity to this drug, have not been established.

Undesirable effects from the cardiovascular system.

The use of voriconazole is associated with lengthening of the interval QT on an electrocardiogram, which is accompanied by rare cases of ventricular fibrillation / flutter in severely ill patients with multiple risk factors, such as cardiotoxic chemotherapy, cardiomyopathy, hypokalemia and concomitant therapy, which could contribute to the development of this complication.

Voriconazole should be used with caution in patients with the following potentially proarrhythmic conditions:

- congenital or acquired lengthening interval QT;

- cardiomyopathy, especially in combination with heart failure;

- sinus bradycardia;

- existing arrhythmias with clinical manifestations;

- simultaneous use of drugs that extend the interval QT (see the section "Interaction with other medicinal products").

Electrolyte disorders, for example, hypokalemia, hypomagnesemia and hypocalcemia, if necessary, should be monitored and eliminated before and during therapy with voriconazole.

When tested on healthy volunteers, the effects of voriconazole on the interval QT on ECG using single doses exceeding the usual daily dose no more than 4 times, it was found that none of the subjects were observed increasing the interval QT at 60 or more milliseconds from the norm. Also, none of the subjects there was no excess of the interval above the clinically significant threshold in 500 msec.

Hepatotoxicity.

The frequency of clinically significant increase in the activity of "hepatic" transaminases in patients receiving voriconazole, is 13.4%. In most cases, the liver function parameters are normalized both during the continuation of treatment without changing the dose or after its correction, and after the cessation of therapy. When voriconazole was used, cases of severe hepatotoxicity (jaundice, hepatitis and liver-cell insufficiency leading to death) were rare in patients with serious underlying diseases.

Undesirable phenomena from the liver are observed, mainly, in patients with serious diseases, mainly malignant blood tumors. In patients without any risk factors, transient reactions from the liver, including hepatitis and jaundice, are observed. Dysfunction of the liver is usually reversible and pass after discontinuation of treatment.

Monitoring of liver function.

During treatment with voriconazole, it is recommended to constantly monitor liver function in both children and adults. Clinical management of such patients should include a laboratory assessment of liver function (in particular, activity determination ACT and ALT) at the beginning of treatment with voriconazole and at least once a week during the first month of therapy. In the case of continuation of treatment in the absence of changes in the biochemical parameters of liver function, the frequency of the laboratory examination can be reduced to once a month. With a marked increase in biochemical parameters of liver function voriconazole should be abolished, unless the ratio of the benefits and risks of therapy according to medical evaluation does not justify its continued use.

Visual disorders.

In the treatment with voriconazole, approximately 21% of patients experience visual impairment: blurred vision, changes in color vision or photophobia.

Visual disturbances are transient and completely reversible: in most cases they spontaneously disappear within 60 minutes. With repeated use of voriconazole, there is a weakening of their severity. Visual disturbances are usually easily expressed, rarely require discontinuation of treatment and do not lead to any remote consequences.

The mechanism of development of visual disturbances is unknown. It was found that voriconazole reduces the amplitude of waves on the electroretinogram (ERG) in healthy volunteers. These changes do not grow ERG with continued treatment for 29 days and completely disappeared after withdrawal of voriconazole.

Long-term therapy with voriconazole (an average of 169 days) in patients with paracoccidioidosis did not have a clinically significant effect on visual function, which was confirmed by the results of tests for visual acuity, visual fields, color perception and contrast sensitivity.

According to post-marketing research data, the development of cases of visual disturbances is reported,which persist for a long time, in particular, the appearance of "shrouds" before the eyes, optic neuritis and edema of the optic disc. It should be noted that these disorders develop most often in seriously ill patients and / or receiving concomitant therapy, which can cause such undesirable phenomena.

Undesirable effects from the kidneys.

In seriously ill patients receiving voriconazole, there were cases of development of acute renal failure, which was probably associated with therapy of primary or concomitant diseases with nephrotoxic drugs.

Monitoring of kidney function.

Patients should be observed to identify signs of impaired renal function. To do this, it is necessary to conduct laboratory tests, in particular, to determine the concentration of creatinine in the blood serum (see section "Method of administration and dose").

Monitoring of pancreatic function.

Adults and children with risk factors for acute pancreatitis (recent chemotherapy, hematopoietic stem cell transplantation) should undergo a test (determination of amylase and lipase activity in blood serum) to address the issue of voriconazole therapy.

Undesirable skin side effects.

When voriconazole therapy often develop skin reactions, mostly in patients with serious underlying diseases, while taking other medicines. In most cases, a mild to moderate skin rash was noted.

During treatment with voriconazole, patients experienced rare cases of exfoliative skin reactions, such as Stevens-Johnson syndrome. If the patient develops exfoliative skin reactions, then voriconazole should be cancel. Since during the therapy with voriconazole the development of photosensitization is possible, it is recommended that during treatment patients (including children) should avoid exposure to direct sunlight and take protective measures such as wearing clothes and applying sunscreens with a high coefficient of protection against ultraviolet radiation (SPF).

Prolonged treatment.

In patients with skin photosensitivity reactions and additional risk factors, the development of squamous cell carcinoma of the skin and melanoma against a background of prolonged therapy is reported. If a patient experiences phototoxic reactions, he should be consulted by appropriate specialists and sent to a dermatologist. Voriconazole should be considered.With the continuation of therapy with voriconazole, despite the occurrence of phototoxic skin lesions, the patient should regularly undergo a dermatological examination with a view to early detection and treatment of precancerous skin diseases. If a patient develops a skin lesion associated with precancerous diseases of the skin, squamous cell carcinoma of the skin melanoma fire, you should consider discontinuing therapy with voriconazole.

Noninfectious periostitis.

There have been reports of cases of periostitis in patients after transplantation receiving long-term therapy with voriconazole. The therapy with voriconazole should be discontinued if the patient has bone pain and the radiograph shows changes that are characteristic of periostitis.

Use in children.

The efficacy and safety of voriconazole in children under 2 years of age have not been studied. Voriconazole is indicated for use in children aged 2 years and older with continuous monitoring of liver function. Bioavailability of voriconazole for oral administration in children aged 2 to 12 years can be reduced by impaired absorption or decreased body weight.In such cases intravenous administration of voriconazole is indicated.

The frequency of phototoxic reactions in children is higher. Due to the fact that phototoxic lesions can degenerate into squamous cell carcinoma (PKC), children should take strict measures to protect the skin from ultraviolet radiation. Children with signs of photoaging of the skin, such as lentigo or freckles, are advised to avoid the sun and be examined by a dermatologist even after discontinuation of treatment.

Narcotic analgesics of short action (substrates of isoenzyme CYP3A4)

Since the half-life of alfentanil when it is used simultaneously with voriconazole is increased 4-fold, careful monitoring undesirable phenomena associated with the use of narcotic analgesics, including longer monitoring of respiratory function.

Long-acting narcotic analgesics (substrates of isoenzyme CYP3A4)

It should be possible to reduce the dose of oxycodone and other long-acting narcotic analgesics, which are metabolized by the isoenzyme CYP3A4 (hydrocodone) with simultaneous application with voriconazole.It is necessary to carefully monitor undesirable phenomena associated with the use of narcotic analgesics (see section "Interaction with other medicinal products").

Phenytoin (powerful cytochrome P450 inducer and isoenzyme substrate CYP2C9)

With the simultaneous use of phenytoin and voriconazole, it is recommended that the concentration of phenytoin be monitored continuously. If possible, simultaneous use of voriconazole and phenytoin should be avoided, unless the anticipated benefit exceeds the potential risk (see "Interactions with Other Drugs").

Efavirenz (non-nucleoside reverse transcriptase inhibitor, cytochrome P450 inducer, inhibitor and isoenzyme substrate CYP3A4)

In case of simultaneous use of voriconazole and efavirenz, the dose of voriconazole should be increased to 400 mg twice a day, and the dose of efavirenz should be reduced to 300 mg every 24 hours (see section "Interaction with other drugs").

Rifabutin

The simultaneous use of voriconazole and rifabutin is contraindicated, since rifabutin significantly reduces the concentration of voriconazole in blood plasma.

Ritonavir (a powerful inducer of cytochrome P450, inhibitor and substrate of isoenzyme CYP3A4)

Apply simultaneously voriconazole and ritonavir in low doses (100 mg twice a day) should be given only if the expected benefit from taking voriconazole significantly exceeds the risk of their combined use (see the sections "Contraindications" and "Interaction with other medicinal products").

Everolimus (isoenzymatic substrate CYP3A4 and P-glycoprotein)

The simultaneous use of voriconazole and everolimus is not recommended, since it is expected that voriconazole significantly increases the concentration of everolimus in plasma blood. At the moment, there is insufficient information for correction of the dosing regimen.

Methadone (isoenzymatic substrate CYP3A4)

An increase in the concentration of methadone in the blood plasma leads to the appearance of toxic effects, including lengthening of the interval QT. With simultaneous use of voriconazole and methadone, it is necessary to closely monitor the manifestation of undesirable and toxic effects. If necessary, the dose of methadone may be reduced (see section "Interaction with other drugs").

Fluconazole (inhibitor of isoenzymes CYP2C9, CYP2C19 and CYP3A4)

Simultaneous use of voriconazole and fluconazole inside of healthy volunteers leads to a significant increase in Cmah and AUCt voriconazole. A suitable regimen for dose adjustment and / or reception frequency of voriconazole and fluconazole is not established. In case if voriconazole is used after fluconazole, it is recommended that careful monitoring of unwanted reactions associated with the use of voriconazole is recommended.

The sodium content

Each vial of the drug contains 217.6 mg of sodium, this must be taken into account when using the drug in patients who adhere to a diet with a reduced sodium content.

Reactions associated with the introduction

When intravenously administered voriconazole, there are infusions associated with infusion, in particular, "tides" of blood to the skin of the face and nausea. If these symptoms are expressed, then the expediency of stopping treatment should be discussed (see the "Side effect" section).

Effect on the ability to drive transp. cf. and fur:

Voriconazole can cause transient and reversible visual impairment, including the appearance of a "veil" in front of the eyes, impaired / increased visual perception and / or photophobia.In the presence of such symptoms, patients should avoid performing potentially dangerous actions, in particular, driving vehicles or using complex equipment. When taking voriconazole, patients should not drive the car at night.

Form release / dosage:Liofilizate for the preparation of concentrate for the preparation of a solution for infusion 200 mg.

Packaging:By 200 mg of voriconazole into the bottles of colorless neutral glass I of the hydrolytic class, sealed with rubber stoppers with a rolling aluminum caps with a plastic lid type "flip-off". For each bottle stick the label self-adhesive.

1 bottle with instructions for use is placed in a pack of cardboard.

Storage conditions:

Store in a dark place at a temperature of no higher than 30 ° C. Keep out of the reach of children.

Shelf life:

3 years.

Do not use after the expiry date printed on the package.

Terms of leave from pharmacies:On prescription

Registration number:LP-004210

Date of registration:24.03.2017

Expiration Date:24.03.2022

The owner of the registration certificate:BIOCAD, CJSC BIOCAD, CJSC Russia

Manufacturer: & nbsp

BIOCAD, CJSC Russia

Information update date: & nbsp04.05.2017

Illustrated instructions

Instructions

Voriconazole (Voriconazole)