Novel insights into the complex pharmacokinetics of voriconazole: a review of its metabolism

Abstract

Voriconazole, a second-generation triazole frequently used for the prophylaxis and treatment of invasive fungal infections, undergoes complex metabolism mainly involving various (polymorphic) cytochrome P450 enzymes in humans. Although high inter- and intraindividual variability in voriconazole pharmacokinetics have been observed and the therapeutic range for this compound is relatively narrow, the metabolism of voriconazole has not been fully elucidated yet. The available literature data investigating the multiple different pathways and metabolites are extremely unbalanced and thus the absolute or relative contribution of the different pathways and enzymes involved in the metabolism of voriconazole remains uncertain. Furthermore, other factors such as nonlinear pharmacokinetics caused by auto-inhibition or -induction and polymorphisms of the metabolizing enzymes hinder safe and effective voriconazole dosing in clinical practice and have not yet been studied sufficiently. This review aimed at amalgamating the available literature on the pharmacokinetics of voriconazole in vitro and in vivo, with a special focus on metabolism in adults and children, in order to congregate an overall landscape of the current body of knowledge and identify knowledge gaps, opening the way towards further research in order to foster the understanding, towards better therapeutic dosing decisions.

Keywords:

• Voriconazole
• metabolism
• pharmacokinetics
• pediatrics
• antiinfectives
• nonlinear pharmacokinetics
• antifungals
• triazoles
• cytochrome P450

Disclosure statement

CK reports grants from an industry consortium (AbbVie Deutschland GmbH & Co. KG, Boehringer Ingelheim Pharma GmbH & Co. KG, Gruenenthal GmbH, F. Hoffmann-La Roche Ltd, Merck KGaA and SANOFI) and the Innovative Medicines Initiative-Joint Undertaking (“DDMoRe”), Diurnal Ltd and CK and RM report grants from the Federal Ministry of Education and Research within the Joint Programming Initiative on Antimicrobial Resistance Initiative (JPIAMR), all outside the submitted work. JS, FK, and GM report no conflict of interest.

Additional information

Funding

The work performed for this manuscript was financed by internal funds.