In the setting of rapidly improving or worsening renal function, calculations of CrCl are inaccurate. Dosing should be based on estimated renal function instead.
If improving renal function, actual CrCl is likely higher than calculated CrCl.
If worsening renal function, actual CrCl is likely lower than calculated CrCl.
Not On Dialysis
No adjustment required
6mg/kg IV load and then STOP IV formulation and continue course with 200mg PO q12h
The manufacturer recommends IV voriconazole should be avoided in patients with moderate or severe renal impairment (CrCl less than 50 mL/min), unless an assessment of the benefit risk to the patient justifies the use of intravenous voriconazole. The manufacture recommends oral voriconazole should be considered in place of IV in patients with severe renal insufficiency (CrCl less than 50 mL/min), where appropriate, because accumulation of the IV vehicle cyclodextrin (SBECD) occurs. Consult ID for advice.
Intermittent Dialysis
IV therapy not recommended after first loading dose due to accumulation of cyclodextrin.
Oral dosing does not require supplemental dosing or dose adjustment.
Continuous Dialysis
Consult Pharmacist for guidance.