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HelpMayo Test ID VORI Voriconazole, Serum
Specimen Required
Collection Container/Tube: Red top (serum gel/SST not acceptable)
Submission Container/Tube: Plastic vial
Specimen Volume: 2 mL
Collection Instructions: Centrifuge and aliquot serum into plastic vial within 2 hours of collection.
Useful For
Monitoring trough levels of voriconazole is suggested for:
-Individuals with reduced liver function
-Individuals with cytochrome P450 (CYP) 2C19 alterations associated with poor metabolic function
-Patients taking other medications that affect CYP2C19 activity
-Patients experiencing potential toxicity
Monitoring trough levels may be reasonable in patients who are not responding optimally or have drug interactions that may decrease voriconazole levels or to ensure adequate oral absorption
Method Name
Liquid Chromatography Tandem Mass Spectrometry (LC-MS/MS)
Reporting Name
Voriconazole, SSpecimen Type
Serum RedSpecimen Minimum Volume
0.6 mL
Specimen Stability Information
| Specimen Type | Temperature | Time | Special Container |
|---|---|---|---|
| Serum Red | Refrigerated (preferred) | 28 days | |
| Ambient | 28 days | ||
| Frozen | 28 days |
Reject Due To
| Gross hemolysis | OK |
| Gross lipemia | OK |
| Gross icterus | OK |
Clinical Information
Voriconazole (Vfend) is an antifungal agent approved for treatment of invasive aspergillosis and candidemia/candidiasis, as well as for salvage therapy for infections in patients refractory to, or intolerant of, other antifungal therapy. The drug inhibits the fungal enzyme 14a-sterol demethylase, a critical step in ergosterol biosynthesis.
Voriconazole is metabolized in the liver primarily by cytochrome P450 (CYP) 2C19 with CYP2C9 and CYP3A4 having limited roles. The primary metabolite is voriconazole N-oxide, which has no antifungal activity. Drug clearance is primarily dependent on hepatic metabolism. The pharmacokinetics of voriconazole is highly variable and nonlinear, which results in an increased dose leading to a greater than proportional increase in serum concentration.
The bioavailability of oral voriconazole is greater than 95%. Approximately 60% of the drug in serum is protein bound. Voriconazole has a volume of distribution of 4.6 L/kg. Most (80%) of the drug is excreted in the urine, exclusively as metabolites.
Adverse effects of voriconazole include visual disturbances, skin rashes, and elevated liver enzyme levels.
Reference Values
1.0-5.5 mcg/mL
Trough level (ie, immediately before next dose) monitoring is recommended.
Interpretation
Trough levels above 6 mcg/mL (and especially >10 mcg/mL) have been associated with toxicity in several reports.
Trough levels below 1 mcg/mL have been associated with suboptimal response in several reports.
Cautions
Voriconazole metabolism may be altered by coadministration of drugs that metabolically induce or inhibit cytochrome P450 2C19 or by genetic alterations that affect enzyme activity.
Clinical Reference
1. Andes D, Pascual A, Marchetti O: Antifungal therapeutic drug monitoring: established and emerging indications. Antimicrob Agents Chemother. 2009 Jan;53(1):24-34. doi: 10.1128/AAC.00705-08
2. Hope WW, Billaud EM, Lestner J, Denning DW: Therapeutic drug monitoring for triazoles. Curr Opin Infect Dis. 2008 Dec;21(6):580-586. doi: 10.1097/QCO.0b013e3283184611
3. Wilson JW, Estes LL, eds: Mayo Clinic Antimicrobial Therapy. 2nd ed. Oxford University Press; 2011
4. Donnelly JP, De Pauw BE: Voriconazole-a new therapeutic agent with an extended spectrum of antifungal activity. Clin Microbiol Infect. 2004 Mar;10:107-117
5. Physicians Desk Reference, (PDR) 60th edition. Medical Economics Company, 2006 update to 2008
6. Brunton LL, ed: Goodman and Gilman's The Pharmacological Basis of Therapeutics. 11th ed. McGraw-Hill Book Company; 2006
7. Luong ML, Al-Dabbagh M, Groll AH, et al: Utility of voriconazole therapeutic drug monitoring: a meta-analysis. J Antimicrob Chemother. 2016 Jul;71(7):1786-1799. doi: 10.1093/jac/dkw099
Method Description
The serum sample is diluted in an acetonitrile internal standard. The protein precipitate is centrifuged and a portion of the supernatant is diluted with mobile phase 1 for detection by a tandem mass spectrometer.(Unpublished Mayo method)
Day(s) Performed
Monday through Sunday
Report Available
Same day/1 to 2 daysSpecimen Retention Time
2 weeksPerforming Laboratory
Mayo Clinic Laboratories in Rochester
Test Classification
This test was developed and its performance characteristics determined by Mayo Clinic in a manner consistent with CLIA requirements. It has not been cleared or approved by the US Food and Drug Administration.CPT Code Information
80285
LOINC Code Information
| Test ID | Test Order Name | Order LOINC Value |
|---|---|---|
| VORI | Voriconazole, S | 38370-3 |
| Result ID | Test Result Name | Result LOINC Value |
|---|---|---|
| 88698 | Voriconazole, S | 38370-3 |