Voriconazole

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Dosing: Adult Antimicrobial Dosing, Non-dialysis

 

*Note: These dosing recommendations were updated in 2/2025 to better align with available evidence & clinical practice

Indication Dosing Notes
Prophylaxis for Heme/BMT patients, all routes 200 mg IV/PO Q12h* No renal dose adjustment†

Treatment indications, all routes

 

 6mg/kg IV/PO Q12h x 2 doses, then 4mg/kg IV/PO Q12hr^ No renal dose adjustment†

*In patients with obesity (BMI >/= 30 kg/m2), consider a weight-based regimen (4mg/kg q12h based on adjusted body weight), Consult ID or ASP for assistance.
^Consider tablet size(s) when determining dose. Voriconazole comes in 50 mg and 200 mg PO tablets. Oral suspension is also available.
†The manufacturer recommends avoiding IV voriconazole in patients with renal impairment due to potential accumulation of the excipient sulfobutylether-beta-cyclodextrin, which may lead to kidney injury. However, limited data suggest that patients with baseline kidney impairment may safely receive short durations of IV voriconazole (Kim 2016; Lilly 2013; Neofytos 2012; Oude Lashof 2012).

Dosing: Antimicrobial Dosing in Intermittent & Continuous Hemodialysis

Indication Dosing Notes
Prophylaxis for Heme/BMT patients, all routes 200 mg IV/PO Q12h* No dose adjustment in hemodialysis

Treatment indications, all routes

 6mg/kg IV/PO Q12h x 2 doses, then 4mg/kg IV/PO Q12hr^ No dose adjustment in hemodialysis

*In patients with obesity (BMI >/= 30 kg/m2), consider a weight-based regimen (4mg/kg q12h based on adjusted body weight), Consult ID or ASP for assistance.​^Consider tablet size(s) when determining dose. Voriconazole comes in 50 mg and 200 mg PO tablets. Oral suspension is also available.

Dialysis Notes

Intermittent HD assumes high-flux hemodialysis. CRRT assumes CVVHD with ultrafiltration rate 2L/h and residual native GFR.

General Considerations

- For assistance with therapeutic drug monitoring (TDM), see Azole TDM Reference Document.
- Review medications for potential drug interactions.

Restricted to ID or Antimicrobial Stewardship except:

1) Prophylaxis against fungal infections on the hematology/BMT/lung/heart transplant services​

2) Suspected or documented serious fungal infection in the hematology/BMT/lung transplant services​

3) Empiric therapy for prolonged febrile neutropenia in hematology/oncology/BMT patient

References:

  1. Kim SH, Kwon JC, Park C, et al. Therapeutic drug monitoring and safety of intravenous voriconazole formulated with sulfobutylether β-cyclodextrin in haematological patients with renal impairment. Mycoses. 2016;59(10):644-651. doi:10.1111/myc.12517
  2. Lilly CM, Welch VL, Mayer T, Ranauro P, Meisner J, Luke DR. Evaluation of intravenous voriconazole in patients with compromised renal function. BMC Infect Dis. 2013;13:14. doi:10.1186/1471-2334-13-14
  3. Neofytos D, Lombardi LR, Shields RK, et al. Administration of Voriconazole in Patients With Renal Dysfunction. Clinical Infectious Diseases. 2012;54(7):913-921. doi:10.1093/cid/cir969
  4. Oude Lashof AML, Sobel JD, Ruhnke M, et al. Safety and Tolerability of Voriconazole in Patients with Baseline Renal Insufficiency and Candidemia. Antimicrob Agents Chemother. 2012;56(6):3133-3137. doi:10.1128/AAC.05841-11