Pharmacokinetics Modeling and Simulation of Voriconazole Dosing and Safety in Patients with Liver Cirrhosis

Voriconazole is used to treat invasive fungal disease and the optimal dose regimens are still unknown in cirrhotic Patients. The aim of this study was to determine the safety, to describe pharmacokinetics characteristics, and to optimize dosage regimens of voriconazole in cirrhotic patients. Data pertaining to voriconazole were collected retrospectively and analyzed using a population pharmacokinetics model. A total of 219 trough concentrations (Cmin) from 120 patients were analyzed. Voriconazole-related adverse events developed in 29 patients, with 69.0% of AEs developing within the first week after voriconazole treatment. The threshold Cmin for AEs was 5.12 mg/L. A one-compartment model with first-order absorption and elimination adequately described the data. The Child-Pugh class was the only covariate in final model. Voriconazole clearance in patients with Child-pugh A and B cirrhosis (CP-A/CP-B) and Child-pugh C cirrhosis (CP-C) were 1.79 L/h and 0.99 L/h, respectively, the volume of distribution was 159.6 L, and the oral bioavailability was 91.8%. The elimination half-life was significantly extended for up to 61.8 - 111.7 h in cirrhotic patients. Model-based simulations showed that the appropriate maintenance doses are 75 mg/12 h and 150 mg/24 h intravenously or orally for CP-A/CP-B patients, and 50 mg/12 h and 100 mg/24 h intravenously or orally for CP-C patients. The results support voriconazole maintenance doses in LC patients should be reduced to one-fourth for CP-C patients and to one-third for CP-A/CP-B patients compared to that for patients with normal liver function. Monitoring Cmin early could be a useful strategy to ensure the safety.