CLINICAL PHARMACOLOGY SECTION.

12 CLINICAL PHARMACOLOGY. 12.1 Mechanism of Action. Voriconazole is an antifungal drug [see Microbiology (12.4)].. 12.2 Pharmacodynamics Exposure-Response Relationship for Efficacy and Safety. In 10 clinical trials (N 1121), the median values for the average and maximum voriconazole plasma concentrations in individual patients across these studies was 2.51 ug/mL (inter-quartile range 1.21 to 4.44 ug/mL) and 3.79 ug/mL (inter-quartile range 2.06 to 6.31 ug/mL), respectively. pharmacokinetic-pharmacodynamic analysis of patient data from of these 10 clinical trials (N 280) could not detect positive association between mean, maximum or minimum plasma voriconazole concentration and efficacy. However, pharmacokinetic/pharmacodynamic analyses of the data from all 10 clinical trials identified positive associations between plasma voriconazole concentrations and rate of both liver function test abnormalities and visual disturbances [see Adverse Reactions (6)].. Cardiac Electrophysiology. placebo-controlled, randomized, crossover study to evaluate the effect on the QT interval of healthy male and female subjects was conducted with three single oral doses of voriconazole and ketoconazole. Serial ECGs and plasma samples were obtained at specified intervals over 24-hour post dose observation period. The placebo-adjusted mean maximum increases in QTc from baseline after 800, 1200, and 1600 mg of voriconazole and after ketoconazole 800 mg were all 10 msec. Females exhibited greater increase in QTc than males, although all mean changes were 10 msec. Age was not found to affect the magnitude of increase in QTc. No subject in any group had an increase in QTc of >= 60 msec from baseline. No subject experienced an interval exceeding the potentially clinically relevant threshold of 500 msec. However, the QT effect of voriconazole combined with drugs known to prolong the QT interval is unknown [see Contraindications (4) and Drug Interactions (7)]. 12.3 Pharmacokinetics. The pharmacokinetics of voriconazole have been characterized in healthy subjects, special populations and patients.The pharmacokinetics of voriconazole are non-linear due to saturation of its metabolism. The interindividual variability of voriconazole pharmacokinetics is high. Greater than proportional increase in exposure is observed with increasing dose. It is estimated that, on average, increasing the oral dose from 200 mg every 12 hours to 300 mg every 12 hours leads to an approximately 2.5-fold increase in exposure (AUC); similarly, increasing the intravenous dose from mg/kg every 12 hours to mg/kg every 12 hours produces an approximately 2.5-fold increase in exposure (Table 12).Table 12: Geometric Mean (% CV) Plasma Voriconazole Pharmacokinetic Parameters in Adults Receiving Different Dosing RegimensNote: Parameters were estimated based on non-compartmental analysis from pharmacokinetic studies.AUC12 area under the curve over 12 hour dosing interval, Cmax maximum plasma concentration, Cmin minimum plasma concentration. CV coefficient of variation6 mg/kg IV (loading dose)3 mg/kg IV every 12 hours4 mg/kg IV every 12 hours400 mg Oral (loading dose)200 mg Oral every 12 hours300 mg Oral every 12 hoursN 352340174816AUC12 (ug.h/mL) 13.9 (32)13.7 (53)33.9 (54)9.31 (38)12.4 (78)34.0 (53)Cmax (ug/mL) 3.13 (20)3.03 (25)4.77 (36)2.30 (19)2.31 (48)4.74 (35)Cmin (ug/mL) --0.46 (97)1.73 (74)--0.46 (120)1.63 (79)When the recommended intravenous loading dose regimen is administered to healthy subjects, plasma concentrations close to steady state are achieved within the first 24 hours of dosing (e.g., mg/kg IV every 12 hours on day followed by mg/kg IV every 12 hours). Without the loading dose, accumulation occurs during twice daily multiple dosing with steady state plasma voriconazole concentrations being achieved by day in the majority of subjects.. Absorption. The pharmacokinetic properties of voriconazole are similar following administration by the intravenous and oral routes. Based on population pharmacokinetic analysis of pooled data in healthy subjects (N 207), the oral bioavailability of voriconazole is estimated to be 96% (CV 13%). Bioequivalence was established between the 200 mg tablet and the 40 mg/mL oral suspension when administered as 400 mg every 12 hours loading dose followed by 200 mg every 12 hours maintenance dose.Maximum plasma concentrations (Cmax) are achieved 1-2 hours after dosing. When multiple doses of voriconazole are administered with high-fat meals, the mean Cmax and AUC are reduced by 34% and 24%, respectively when administered as tablet and by 58% and 37% respectively when administered as the oral suspension [see Dosage and Administration (2)].In healthy subjects, the absorption of voriconazole is not affected by coadministration of oral ranitidine, cimetidine, or omeprazole, drugs that are known to increase gastric pH.. Distribution. The volume of distribution at steady state for voriconazole is estimated to be 4.6 L/kg, suggesting extensive distribution into tissues. Plasma protein binding is estimated to be 58% and was shown to be independent of plasma concentrations achieved following single and multiple oral doses of 200 mg or 300 mg (approximate range: 0.9-15 ug/mL). Varying degrees of hepatic and renal impairment do not affect the protein binding of voriconazole.. Elimination. Metabolism In vitro studies showed that voriconazole is metabolized by the human hepatic cytochrome P450 enzymes, CYP2C19, CYP2C9 and CYP3A4 [see Drug Interactions (7)].In vivo studies indicated that CYP2C19 is significantly involved in the metabolism of voriconazole. This enzyme exhibits genetic polymorphism [see Clinical Pharmacology (12.5)].The major metabolite of voriconazole is the N-oxide, which accounts for 72% of the circulating radiolabelled metabolites in plasma. Since this metabolite has minimal antifungal activity, it does not contribute to the overall efficacy of voriconazole.. Excretion Voriconazole is eliminated via hepatic metabolism with less than 2% of the dose excreted unchanged in the urine. After administration of single radiolabelled dose of either oral or IV voriconazole, preceded by multiple oral or IV dosing, approximately 80% to 83% of the radioactivity is recovered in the urine. The majority (> 94%) of the total radioactivity is excreted in the first 96 hours after both oral and intravenous dosing.As result of non-linear pharmacokinetics, the terminal half-life of voriconazole is dose dependent and therefore not useful in predicting the accumulation or elimination of voriconazole. Specific Populations. Male and Female Patients In multiple oral dose study, the mean Cmax and AUC for healthy young females were 83% and 113% higher, respectively, than in healthy young males (18-45 years), after tablet dosing. In the same study, no significant differences in the mean Cmax and AUC were observed between healthy elderly males and healthy elderly females (> 65 years). In similar study, after dosing with the oral suspension, the mean AUC for healthy young females was 45% higher than in healthy young males whereas the mean Cmax was comparable between genders. The steady state trough voriconazole concentrations (Cmin) seen in females were 100% and 91% higher than in males receiving the tablet and the oral suspension, respectively.In the clinical program, no dosage adjustment was made on the basis of gender. The safety profile and plasma concentrations observed in male and female subjects were similar. Therefore, no dosage adjustment based on gender is necessary.. Geriatric Patients In an oral multiple dose study the mean Cmax and AUC in healthy elderly males (>= 65 years) were 61% and 86% higher, respectively, than in young males (18-45 years). No significant differences in the mean Cmax and AUC were observed between healthy elderly females (>= 65 years) and healthy young females (18-45 years).In the clinical program, no dosage adjustment was made on the basis of age. An analysis of pharmacokinetic data obtained from 552 patients from 10 voriconazole clinical trials showed that the median voriconazole plasma concentrations in the elderly patients (> 65 years) were approximately 80% to 90% higher than those in the younger patients (<= 65 years) after either IV or oral administration. However, the safety profile of voriconazole in young and elderly subjects was similar and, therefore, no dosage adjustment is necessary for the elderly [see Use in Specific Populations (8.5)].. Pediatric Patients Voriconazole exposures in the majority of pediatric patients aged 12 to less than 17 years were comparable to those in adults receiving the same dosing regimens. However, lower voriconazole exposure was observed in some pediatric patients aged 12 to less than 17 years with low body weight compared to adults [see Dosage and Administration (2.4)].Additional pediatric use information is approved for PF PRISM C.V.s VFEND (voriconazole). However, due to PF PRISM C.V.s marketing exclusivity rights, this drug product is not labeled with that information.. Patients with Hepatic Impairment After single oral dose (200 mg) of voriconazole in patients with mild (Child-Pugh Class A) and patients with moderate (Child-Pugh Class B) hepatic impairment, the mean systemic exposure (AUC) was 3.2-fold higher than in age and weight matched controls with normal hepatic function. There was no difference in mean peak plasma concentrations (Cmax) between the groups. When only the patients with mild (Child-Pugh Class A) hepatic impairment were compared to controls, there was still 2.3-fold increase in the mean AUC in the group with hepatic impairment compared to controls.In an oral multiple dose study, AUC was similar in subjects with moderate hepatic impairment (Child-Pugh Class B) given lower maintenance dose of 100 mg twice daily compared to subjects with normal hepatic function given the standard 200 mg twice daily maintenance dose. The mean peak plasma concentrations (Cmax) were 20% lower in the hepatically impaired group. No pharmacokinetic data are available for patients with severe hepatic cirrhosis (Child-Pugh Class C) [see Dosage and Administration (2.5)].. Patients with Renal Impairment In single oral dose (200 mg) study in 24 subjects with normal renal function and mild to severe renal impairment, systemic exposure (AUC) and peak plasma concentration (Cmax) of voriconazole were not significantly affected by renal impairment. Therefore, no adjustment is necessary for oral dosing in patients with mild to severe renal impairment.In multiple dose study of IV voriconazole (6 mg/kg IV loading dose 2, then mg/kg IV 5.5 days) in patients with moderate renal dysfunction (creatinine clearance 30-50 mL/min), the systemic exposure (AUC) and peak plasma concentrations (Cmax) were not significantly different from those in subjects with normal renal function.However, in patients with moderate renal dysfunction (creatinine clearance 30-50 mL/min), accumulation of the intravenous vehicle, SBECD, occurs. The mean systemic exposure (AUC) and peak plasma concentrations (Cmax) of SBECD were increased 4-fold and almost 50%, respectively, in the moderately impaired group compared to the normal control group.A pharmacokinetic study in subjects with renal failure undergoing hemodialysis showed that voriconazole is dialyzed with clearance of 121 mL/min. The intravenous vehicle, SBECD, is hemodialyzed with clearance of 55 mL/min. 4-hour hemodialysis session does not remove sufficient amount of voriconazole to warrant dose adjustment [see Dosage and Administration (2.6)].. Patients at Risk of Aspergillosis The observed voriconazole pharmacokinetics in patients at risk of aspergillosis (mainly patients with malignant neoplasms of lymphatic or hematopoietic tissue) were similar to healthy subjects.. Drug Interaction Studies. Effects of Other Drugs on Voriconazole Voriconazole is metabolized by the human hepatic cytochrome P450 enzymes CYP2C19, CYP2C9, and CYP3A4. Results of in vitro metabolism studies indicate that the affinity of voriconazole is highest for CYP2C19, followed by CYP2C9, and is appreciably lower for CYP3A4. Inhibitors or inducers of these three enzymes may increase or decrease voriconazole systemic exposure (plasma concentrations), respectively.The systemic exposure to voriconazole is significantly reduced by the concomitant administration of the following agents and their use is contraindicated:. Rifampin (Potent CYP450 Inducer). Rifampin (600 mg once daily) decreased the steady state Cmax and AUC of voriconazole (200 mg every 12 hours 7 days) by an average of 93% and 96%, respectively, in healthy subjects. Doubling the dose of voriconazole to 400 mg every 12 hours does not restore adequate exposure to voriconazole during coadministration with rifampin [see Contraindications (4)].. Ritonavir (Potent CYP450 Inducer; CYP3A4 Inhibitor and Substrate). The effect of the coadministration of voriconazole and ritonavir (400 mg and 100 mg) was investigated in two separate studies. High-dose ritonavir (400 mg every 12 hours for days) decreased the steady state Cmax and AUC of oral voriconazole (400 mg every 12 hours for day, then 200 mg every 12 hours for days) by an average of 66% and 82%, respectively, in healthy subjects. Low-dose ritonavir (100 mg every 12 hours for days) decreased the steady state Cmax and AUC of oral voriconazole (400 mg every 12 hours for day, then 200 mg every 12 hours for days) by an average of 24% and 39%, respectively, in healthy subjects. Although repeat oral administration of voriconazole did not have significant effect on steady state Cmax and AUC of high-dose ritonavir in healthy subjects, steady state Cmax and AUC of low-dose ritonavir decreased slightly by 24% and 14% respectively, when administered concomitantly with oral voriconazole in healthy subjects [see Contraindications (4)].. St. Johns Wort (CYP450 Inducer; P-gp Inducer). In an independent published study in healthy volunteers who were given multiple oral doses of St. Johns Wort (300 mg LI 160 extract three times daily for 15 days) followed by single 400 mg oral dose of voriconazole, 59% decrease in mean voriconazole AUC0- was observed. In contrast, coadministration of single oral doses of St. Johns Wort and voriconazole had no appreciable effect on voriconazole AUC0-. Long-term use of St. Johns Wort could lead to reduced voriconazole exposure [see Contraindications (4)].Significant drug interactions that may require voriconazole dosage adjustment, or frequent monitoring of voriconazole-related adverse reactions/toxicity:. Fluconazole (CYP2C9, CYP2C19 and CYP3A4 Inhibitor). Concurrent administration of oral voriconazole (400 mg every 12 hours for day, then 200 mg every 12 hours for 2.5 days) and oral fluconazole (400 mg on day 1, then 200 mg every 24 hours for days) to healthy male subjects resulted in an increase in Cmax and AUC of voriconazole by an average of 57% (90% CI: 20%, 107%) and 79% (90% CI: 40%, 128%), respectively. In follow-on clinical study involving healthy male subjects, reduced dosing and/or frequency of voriconazole and fluconazole did not eliminate or diminish this effect [see Drug Interactions (7)].. Letermovir (CYP2C9/2C19 Inducer). Coadministration of oral letermovir with oral voriconazole decreased the steady state Cmax and AUC0-12 of voriconazole by an average of 39% and 44%, respectively [see Drug Interactions (7)].Minor or no significant pharmacokinetic interactions that do not require dosage adjustment:. Cimetidine (Non-specific CYP450 Inhibitor and Increases Gastric pH). Cimetidine (400 mg every 12 hours 8 days) increased voriconazole steady state Cmax and AUC by an average of 18% (90% CI: 6%, 32%) and 23% (90% CI: 13%, 33%), respectively, following oral doses of 200 mg every 12 hours 7 days to healthy subjects.. Ranitidine (Increases Gastric pH). Ranitidine (150 mg every 12 hours) had no significant effect on voriconazole Cmax and AUC following oral doses of 200 mg every 12 hours 7 days to healthy subjects.. Macrolide Antibiotics. Coadministration of erythromycin (CYP3A4 inhibitor; gram every 12 hours for days) or azithromycin (500 mg every 24 hours for days) with voriconazole 200 mg every 12 hours for 14 days had no significant effect on voriconazole steady state Cmax and AUC in healthy subjects. The effects of voriconazole on the pharmacokinetics of either erythromycin or azithromycin are not known.. Effects of Voriconazole on Other Drugs In vitro studies with human hepatic microsomes show that voriconazole inhibits the metabolic activity of the cytochrome P450 enzymes CYP2C19, CYP2C9, and CYP3A4. In these studies, the inhibition potency of voriconazole for CYP3A4 metabolic activity was significantly less than that of two other azoles, ketoconazole and itraconazole. In vitro studies also show that the major metabolite of voriconazole, voriconazole N-oxide, inhibits the metabolic activity of CYP2C9 and CYP3A4 to greater extent than that of CYP2C19. Therefore, there is potential for voriconazole and its major metabolite to increase the systemic exposure (plasma concentrations) of other drugs metabolized by these CYP450 enzymes.The systemic exposure of the following drug is significantly increased by coadministration of voriconazole and their use is contraindicated:. Sirolimus (CYP3A4 Substrate). Repeat dose administration of oral voriconazole (400 mg every 12 hours for day, then 200 mg every 12 hours for days) increased the Cmax and AUC of sirolimus (2 mg single dose) an average of 7-fold (90% CI: 5.7, 7.5) and 11-fold (90% CI: 9.9, 12.6), respectively, in healthy male subjects [see Contraindications (4)].Coadministration of voriconazole with the following agents results in increased exposure to these drugs. Therefore, careful monitoring and/or dosage adjustment of these drugs is needed:. Alfentanil (CYP3A4 Substrate). Coadministration of multiple doses of oral voriconazole (400 mg every 12 hours on day 1, 200 mg every 12 hours on day 2) with single 20 mcg/kg intravenous dose of alfentanil with concomitant naloxone resulted in 6-fold increase in mean alfentanil AUC0- and 4-fold prolongation of mean alfentanil elimination half-life, compared to when alfentanil was given alone [see Drug Interactions (7)].. Fentanyl (CYP3A4 Substrate). In an independent published study, concomitant use of voriconazole (400 mg every 12 hours on Day 1, then 200 mg every 12 hours on Day 2) with single intravenous dose of fentanyl (5 ug/kg) resulted in an increase in the mean AUC0- of fentanyl by 1.4-fold (range 0.81- to 2.04-fold) [see Drug Interactions (7)].. Oxycodone (CYP3A4 Substrate). In an independent published study, coadministration of multiple doses of oral voriconazole (400 mg every 12 hours, on Day followed by five doses of 200 mg every 12 hours on Days to 4) with single 10 mg oral dose of oxycodone on Day resulted in an increase in the mean Cmax and AUC0- of oxycodone by 1.7- fold (range 1.4- to 2.2-fold) and 3.6-fold (range 2.7- to 5.6-fold), respectively. The mean elimination half-life of oxycodone was also increased by 2.0-fold (range 1.4- to 2.5-fold) [see Drug Interactions (7)].. Cyclosporine (CYP3A4 Substrate). In stable renal transplant recipients receiving chronic cyclosporine therapy, concomitant administration of oral voriconazole (200 mg every 12 hours for days) increased cyclosporine Cmax and AUC an average of 1.1 times (90% CI: 0.9, 1.41) and 1.7 times (90% CI: 1.5, 2.0), respectively, as compared to when cyclosporine was administered without voriconazole [see Drug Interactions (7)].. Methadone (CYP3A4, CYP2C19, CYP2C9 Substrate). Repeat dose administration of oral voriconazole (400 mg every 12 hours for day, then 200 mg every 12 hours for days) increased the Cmax and AUC of pharmacologically active Rmethadone by 31% (90% CI: 22%, 40%) and 47% (90% CI: 38%, 57%), respectively, in subjects receiving methadone maintenance dose (30-100 mg every 24 hours). The Cmax and AUC of (S)-methadone increased by 65% (90% CI: 53%, 79%) and 103% (90% CI: 85%, 124%), respectively [see Drug Interactions (7)]. Tacrolimus (CYP3A4 Substrate). Repeat oral dose administration of voriconazole (400 mg every 12 hours 1 day, then 200 mg every 12 hours 6 days) increased tacrolimus (0.1 mg/kg single dose) Cmax and AUC in healthy subjects by an average of 2-fold (90% CI: 1.9, 2.5) and 3-fold (90% CI: 2.7, 3.8), respectively [see Drug Interactions (7)].. Warfarin (CYP2C9 Substrate). Coadministration of voriconazole (300 mg every 12 hours 12 days) with warfarin (30 mg single dose) significantly increased maximum prothrombin time by approximately times that of placebo in healthy subjects [see Drug Interactions (7)].. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs; CYP2C9 Substrates). In two independent published studies, single doses of ibuprofen (400 mg) and diclofenac (50 mg) were coadministered with the last dose of voriconazole (400 mg every 12 hours on Day 1, followed by 200 mg every 12 hours on Day 2). Voriconazole increased the mean Cmax and AUC of the pharmacologically active isomer, (+)-ibuprofen by 20% and 100%, respectively. Voriconazole increased the mean Cmax and AUC of diclofenac by 114% and 78%, respectively [see Drug Interactions (7)].No significant pharmacokinetic interactions were observed when voriconazole was coadministered with the following agents. Therefore, no dosage adjustment for these agents is recommended: Prednisolone (CYP3A4 Substrate). Voriconazole (200 mg every 12 hours 30 days) increased Cmax and AUC of prednisolone (60 mg single dose) by an average of 11% and 34%, respectively, in healthy subjects [see Warnings and Precautions (5.8)].. Digoxin (P-glycoprotein Mediated Transport). Voriconazole (200 mg every 12 hours 12 days) had no significant effect on steady state Cmax and AUC of digoxin (0.25 mg once daily for 10 days) in healthy subjects.. Mycophenolic Acid (UDP-glucuronyl Transferase Substrate). Voriconazole (200 mg every 12 hours 5 days) had no significant effect on the Cmax and AUC of mycophenolic acid and its major metabolite, mycophenolic acid glucuronide after administration of 1 gram single oral dose of mycophenolate mofetil.. Two-Way Interactions: Concomitant use of the following agents with voriconazole is contraindicated: Rifabutin (Potent CYP450 Inducer). Rifabutin (300 mg once daily) decreased the Cmax and AUC of voriconazole at 200 mg twice daily by an average of 67% (90% CI: 58%, 73%) and 79% (90% CI: 71%, 84%), respectively, in healthy subjects. During coadministration with rifabutin (300 mg once daily), the steady state Cmax and AUC of voriconazole following an increased dose of 400 mg twice daily were on average approximately times higher, compared with voriconazole alone at 200 mg twice daily. Coadministration of voriconazole at 400 mg twice daily with rifabutin 300 mg twice daily increased the Cmax and AUC of rifabutin by an average of 3-times (90% CI: 2.2, 4.0) and times (90% CI: 3.5, 5.4), respectively, compared to rifabutin given alone [see Contraindications (4)].Significant drug interactions that may require dosage adjustment, frequent monitoring of drug levels and/or frequent monitoring of drug-related adverse reactions/toxicity: Efavirenz, Non-Nucleoside Reverse Transcriptase Inhibitor (CYP450 Inducer; CYP3A4 Inhibitor and Substrate). Standard doses of voriconazole and efavirenz (400 mg every 24 hours or higher) must not be coadministered [see Drug Interactions (7)]. Steady state efavirenz (400 mg PO every 24 hours) decreased the steady state Cmax and AUC of voriconazole (400 mg PO every 12 hours for day, then 200 mg PO every 12 hours for days) by an average of 61% and 77%, respectively, in healthy male subjects. Voriconazole at steady state (400 mg PO every 12 hours for day, then 200 mg every 12 hours for days) increased the steady state Cmax and AUC of efavirenz (400 mg PO every 24 hours for days) by an average of 38% and 44%, respectively, in healthy subjects.The pharmacokinetics of adjusted doses of voriconazole and efavirenz were studied in healthy male subjects following administration of voriconazole (400 mg PO every 12 hours on Days to 7) with efavirenz (300 mg PO every 24 hours on Days 1-7), relative to steady state administration of voriconazole (400 mg for day, then 200 mg PO every 12 hours for days) or efavirenz (600 mg every 24 hours for days). Coadministration of voriconazole 400 mg every 12 hours with efavirenz 300 mg every 24 hours, decreased voriconazole AUC by 7% (90% CI: -23%, 13%) and increased Cmax by 23% (90% CI: -1%, 53%); efavirenz AUC was increased by 17% (90% CI: 6%, 29%) and Cmax was equivalent [see Dosage and Administration (2.7), Contraindications (4), and Drug Interactions (7)].. Phenytoin (CYP2C9 Substrate and Potent CYP450 Inducer). Repeat dose administration of phenytoin (300 mg once daily) decreased the steady state Cmax and AUC of orally administered voriconazole (200 mg every 12 hours 14 days) by an average of 50% and 70%, respectively, in healthy subjects. Administration of higher voriconazole dose (400 mg every 12 hours 7 days) with phenytoin (300 mg once daily) resulted in comparable steady state voriconazole Cmax and AUC estimates as compared to when voriconazole was given at 200 mg every 12 hours without phenytoin [see Dosage and Administration (2.7) and Drug Interactions (7)].Repeat dose administration of voriconazole (400 mg every 12 hours 10 days) increased the steady state Cmax and AUC of phenytoin (300 mg once daily) by an average of 70% and 80%, respectively, in healthy subjects. The increase in phenytoin Cmax and AUC when coadministered with voriconazole may be expected to be as high as times the Cmax and AUC estimates when phenytoin is given without voriconazole [see Drug Interactions (7)].. Omeprazole (CYP2C19 Inhibitor; CYP2C19 and CYP3A4 Substrate). Coadministration of omeprazole (40 mg once daily 10 days) with oral voriconazole (400 mg every 12 hours 1 day, then 200 mg every 12 hours 9 days) increased the steady state Cmax and AUC of voriconazole by an average of 15% (90% CI: 5%, 25%) and 40% (90% CI: 29%, 55%), respectively, in healthy subjects. No dosage adjustment of voriconazole is recommended.Coadministration of voriconazole (400 mg every 12 hours 1 day, then 200 mg 6 days) with omeprazole (40 mg once daily 7 days) to healthy subjects significantly increased the steady state Cmax and AUC of omeprazole an average of times (90% CI: 1.8, 2.6) and times (90% CI: 3.3, 4.4), respectively, as compared to when omeprazole is given without voriconazole [see Drug Interactions (7)].. Oral Contraceptives (CYP3A4 Substrate; CYP2C19 Inhibitor). Coadministration of oral voriconazole (400 mg every 12 hours for day, then 200 mg every 12 hours for days) and oral contraceptive (Ortho-Novum1/35(R) consisting of 35 mcg ethinyl estradiol and mg norethindrone, every 24 hours) to healthy female subjects at steady state increased the Cmax and AUC of ethinyl estradiol by an average of 36% (90% CI: 28%, 45%) and 61% (90% CI: 50%, 72%), respectively, and that of norethindrone by 15% (90% CI: 3%, 28%) and 53% (90% CI: 44%, 63%), respectively in healthy subjects. Voriconazole Cmax and AUC increased by an average of 14% (90% CI: 3%, 27%) and 46% (90% CI: 32%, 61%), respectively [see Drug Interactions (7)].No significant pharmacokinetic interaction was seen and no dosage adjustment of these drugs is recommended: Indinavir (CYP3A4 Inhibitor and Substrate). Repeat dose administration of indinavir (800 mg TID for 10 days) had no significant effect on voriconazole Cmax and AUC following repeat dose administration (200 mg every 12 hours for 17 days) in healthy subjects.Repeat dose administration of voriconazole (200 mg every 12 hours for days) did not have significant effect on steady state Cmax and AUC of indinavir following repeat dose administration (800 mg TID for days) in healthy subjects.. 12.4 Microbiology. Mechanism of Action. Voriconazole is an azole antifungal drug. The primary mode of action of voriconazole is the inhibition of fungal cytochrome P-450-mediated 14 alpha-lanosterol demethylation, an essential step in fungal ergosterol biosynthesis. The accumulation of 14 alpha-methyl sterols correlates with the subsequent loss of ergosterol in the fungal cell wall and may be responsible for the antifungal activity of voriconazole.. Resistance. potential for development of resistance to voriconazole is well known. The mechanisms of resistance may include mutations in the gene ERG11 (encodes for the target enzyme, lanosterol 14--demethylase), upregulation of genes encoding the ATP-binding cassette efflux transporters i.e., Candida drug resistance (CDR) pumps and reduced access of the drug to the target, or some combination of those mechanisms. The frequency of drug resistance development for the various fungi for which this drug is indicated is not known. Fungal isolates exhibiting reduced susceptibility to fluconazole or itraconazole may also show reduced susceptibility to voriconazole, suggesting cross-resistance can occur among these azoles. The relevance of cross-resistance and clinical outcome has not been fully characterized. Clinical cases where azole cross-resistance is demonstrated may require alternative antifungal therapy.. Antimicrobial Activity. Voriconazole has been shown to be active against most isolates of the following microorganisms, both in vitro and in clinical infections. Aspergillus fumigatusAspergillus flavusAspergillus nigerAspergillus terreusCandida albicansCandida glabrata (In clinical studies, the voriconazole MIC90 was ug/mL) Candida krusei Candida parapsilosis Candida tropicalis Fusarium spp. including Fusarium solani Scedosporium apiospermum In clinical studies, voriconazole MIC90 for C. glabrata baseline isolates was ug/mL; 13/50 (26%) C. glabrata baseline isolates were resistant (MIC >= ug/mL) to voriconazole. However, based on 1054 isolates tested in surveillance studies the MIC90 was ug/mL.The following data are available, but their clinical significance is unknown. At least 90 percent of the following fungi exhibit an in vitro minimum inhibitory concentration (MIC) less than or equal to the susceptible breakpoint for voriconazole against isolates of similar genus or organism group. However, the effectiveness of voriconazole in treating clinical infections due to these fungi has not been established in adequate and well-controlled clinical trials:Candida lusitaniaeCandida guilliermondii. Susceptibility Testing. For specific information regarding susceptibility test interpretive criteria and associated test methods and quality control standards recognized by FDA for this drug, please see: https://www.fda.gov/STIC.. 12.5Pharmacogenomics CYP2C19, significantly involved in the metabolism of voriconazole, exhibits genetic polymorphism. Approximately 15-20% of Asian populations may be expected to be poor metabolizers. For Caucasians and Blacks, the prevalence of poor metabolizers is 3-5%. Studies conducted in Caucasian and Japanese healthy subjects have shown that poor metabolizers have, on average, 4-fold higher voriconazole exposure (AUC) than their homozygous extensive metabolizer counterparts. Subjects who are heterozygous extensive metabolizers have, on average, 2-fold higher voriconazole exposure than their homozygous extensive metabolizer counterparts [see Clinical Pharmacology (12.3)].

DOSAGE & ADMINISTRATION SECTION.

2 DOSAGE AND ADMINISTRATION. oDosage in Adults (2.3)InfectionLoading DoseMaintenance DoseIntravenous infusionIntravenous infusionOralInvasive Aspergillosis6 mg/kg every 12 hours for the first 24 hours4 mg/kg every 12 hours200 mg every 12 hoursCandidemia in nonneutropenics and other deep tissue Candida infections3-4 mg/kg every 12 hours200 mg every 12 hoursScedosporiosis and Fusariosis4 mg/kg every 12 hours200 mg every 12 hoursEsophageal CandidiasisNot EvaluatedNot Evaluated200 mg every 12 hours oAdult patients weighing less than 40 kg: oral maintenance dose 100 mg or 150 mg every 12 hoursoHepatic Impairment: Use half the maintenance dose in adult patients with mild to moderate hepatic impairment (Child-Pugh Class and B) (2.5)oRenal Impairment: Avoid intravenous administration in adult patients with moderate to severe renal impairment (creatinine clearance 50 mL/min) (2.6) oDosage in Pediatric Patients (2.4)oFor pediatric patients aged 12 to 14 years weighing greater than or equal to 50 kg and those aged 15 years and older regardless of body weight use adult dosage. (2.4)oDosage adjustment of voriconazole tablets in pediatric patients with renal or hepatic impairment has not been established (2.5, 2.6). oDosage in Adults (2.3). oAdult patients weighing less than 40 kg: oral maintenance dose 100 mg or 150 mg every 12 hoursoHepatic Impairment: Use half the maintenance dose in adult patients with mild to moderate hepatic impairment (Child-Pugh Class and B) (2.5)oRenal Impairment: Avoid intravenous administration in adult patients with moderate to severe renal impairment (creatinine clearance 50 mL/min) (2.6). oAdult patients weighing less than 40 kg: oral maintenance dose 100 mg or 150 mg every 12 hours. oHepatic Impairment: Use half the maintenance dose in adult patients with mild to moderate hepatic impairment (Child-Pugh Class and B) (2.5). oRenal Impairment: Avoid intravenous administration in adult patients with moderate to severe renal impairment (creatinine clearance 50 mL/min) (2.6). oDosage in Pediatric Patients (2.4)oFor pediatric patients aged 12 to 14 years weighing greater than or equal to 50 kg and those aged 15 years and older regardless of body weight use adult dosage. (2.4)oDosage adjustment of voriconazole tablets in pediatric patients with renal or hepatic impairment has not been established (2.5, 2.6). oFor pediatric patients aged 12 to 14 years weighing greater than or equal to 50 kg and those aged 15 years and older regardless of body weight use adult dosage. (2.4). oDosage adjustment of voriconazole tablets in pediatric patients with renal or hepatic impairment has not been established (2.5, 2.6). 2.1 Important Administration Instructions for Use in All Patients. Administer voriconazole tablets at least one hour before or after meal.. 2.3 Recommended Dosing Regimen in Adults. Invasive Aspergillosis and Serious Fungal Infections Due to Fusarium spp. and Scedosporium apiospermum. See Table 1. Therapy must be initiated with the specified loading dose regimen of intravenous voriconazole on Day followed by the recommended maintenance dose (RMD) regimen. Intravenous treatment should be continued for at least days. Once the patient has clinically improved and can tolerate medication given by mouth, the oral tablet form or oral suspension form of voriconazole may be utilized. The recommended oral maintenance dose of 200 mg achieves voriconazole exposure similar to mg/kg intravenously; 300 mg oral dose achieves an exposure similar to mg/kg intravenously. Switching between the intravenous and oral formulations is appropriate because of the high bioavailability of the oral formulation in adults [see Clinical Pharmacology (12)]. Candidemia in Non-neutropenic Patients and Other Deep Tissue Candida Infections. See Table 1. Patients should be treated for at least 14 days following resolution of symptoms or following last positive culture, whichever is longer.. Esophageal Candidiasis. See Table 1. Patients should be treated for minimum of 14 days and for at least days following resolution of symptoms.Table 1: Recommended Dosing Regimen (Adults)Infection Loading Dose Maintenance DoseIncrease dose when voriconazole is co-administered with phenytoin or efavirenz (7); Decrease dose in patients with hepatic impairment (2.5)In healthy volunteer studies, the 200 mg oral every 12 hours dose provided an exposure (AUC) similar to 3 mg/kg intravenous infusion every 12 hours dose; the 300 mg oral every 12 hours dose provided an exposure (AUC) similar to 4 mg/kg intravenous infusion every 12 hours dose (12).Intravenous infusionIntravenous infusionOralAdult patients who weigh less than 40 kg should receive half of the oral maintenance dose.Invasive AspergillosisIn clinical study of IA, the median duration of intravenous voriconazole therapy was 10 days (range to 85 days). The median duration of oral voriconazole therapy was 76 days (range to 232 days) (14.1).6 mg/kg every 12 hours for the first 24 hours mg/kg every 12 hours 200 mg every 12 hours Candidemia in nonneutropenic patients and other deep tissue Candida infections mg/kg every 12 hours for the first 24 hours 3-4 mg/kg every 12 hoursIn clinical trials, patients with candidemia received mg/kg intravenous infusion every 12 hours as primary therapy, while patients with other deep tissue Candida infections received mg/kg every 12 hours as salvage therapy. Appropriate dose should be based on the severity and nature of the infection. 200 mg every 12 hours Esophageal CandidiasisNot EvaluatedNot evaluated in patients with EC. Not Evaluated 200 mg every 12 hours Scedosporiosis and Fusariosis mg/kg every 12 hours for the first 24 hours4 mg/kg every 12 hours 200 mg every 12 hours Method for Adjusting the Dosing Regimen in Adults If patients response is inadequate, the oral maintenance dose may be increased from 200 mg every 12 hours (similar to mg/kg intravenously every 12 hours) to 300 mg every 12 hours (similar to mg/kg intravenously every 12 hours). For adult patients weighing less than 40 kg, the oral maintenance dose may be increased from 100 mg every 12 hours to 150 mg every 12 hours. If patient is unable to tolerate 300 mg orally every 12 hours, reduce the oral maintenance dose by 50 mg steps to minimum of 200 mg every 12 hours (or to 100 mg every 12 hours for adult patients weighing less than 40 kg).If patient is unable to tolerate mg/kg intravenously every 12 hours, reduce the intravenous maintenance dose to mg/kg every 12 hours.. 2.4 Recommended Dosing Regimen in Pediatric Patients. For pediatric patients 12 to 14 years of age with body weight greater than or equal to 50 kg and those 15 years of age and above regardless of body weight, administer the adult dosing regimen of voriconazole tablets [see Dosage and Administration (2.3)].Initiate therapy with an intravenous infusion regimen. Consider an oral regimen only after there is significant clinical improvement.. Method for Adjusting the Dosing Regimen in Pediatric Patients. Pediatric Patients 12 to 14 Years of Age Weighing Greater Than or Equal to 50 kg and 15 Years of Age and Older Regardless of Body Weight Use the optimal method for titrating dosage recommended for adults [see Dosage and Administration (2.3)].Additional pediatric use information is approved for PF PRISM C.V.s VFEND (voriconazole). However, due to PF PRISM C.V.s marketing exclusivity rights, this drug product is not labeled with that information.. 2.5Dosage Modifications in Patients With Hepatic Impairment Adults. The maintenance dose of voriconazole tablets should be reduced in adult patients with mild to moderate hepatic impairment, Child-Pugh Class and B. There are no PK data to allow for dosage adjustment recommendations in patients with severe hepatic impairment (Child-Pugh Class C). Duration of therapy should be based on the severity of the patients underlying disease, recovery from immunosuppression, and clinical response.Adult patients with baseline liver function tests (ALT, AST) of up to times the upper limit of normal (ULN) were included in the clinical program. Dose adjustments are not necessary for adult patients with this degree of abnormal liver function, but continued monitoring of liver function tests for further elevations is recommended [see Warnings and Precautions (5.1)].It is recommended that the recommended voriconazole loading dose regimens be used, but that the maintenance dose be halved in adult patients with mild to moderate hepatic cirrhosis (Child-Pugh Class and B) [see Clinical Pharmacology (12.3)].Voriconazole tablets have not been studied in adult patients with severe hepatic cirrhosis (Child-Pugh Class C) or in patients with chronic hepatitis or chronic hepatitis disease. Voriconazole tablets have been associated with elevations in liver function tests and with clinical signs of liver damage, such as jaundice. Voriconazole tablets should only be used in patients with severe hepatic impairment if the benefit outweighs the potential risk. Patients with hepatic impairment must be carefully monitored for drug toxicity.. Pediatric Patients. Dosage adjustment of voriconazole tablets in pediatric patients with hepatic impairment has not been established [see Use in Specific Populations (8.4)].. 2.6Dosage Modifications in Patients With Renal Impairment. Adult Patients The pharmacokinetics of orally administered voriconazole tablets are not significantly affected by renal impairment. Therefore, no adjustment is necessary for oral dosing in patients with mild to severe renal impairment [see Clinical Pharmacology (12.3)].In patients with moderate or severe renal impairment (creatinine clearance 50 mL/min) who are receiving an intravenous infusion of voriconazole, accumulation of the intravenous vehicle, SBECD, occurs. Oral voriconazole should be administered to these patients, unless an assessment of the benefit/risk to the patient justifies the use of intravenous voriconazole. Serum creatinine levels should be closely monitored in these patients, and, if increases occur, consideration should be given to changing to oral voriconazole therapy [see Warnings and Precautions (5.7)].Voriconazole and the intravenous vehicle, SBECD, are dialyzable. 4-hour hemodialysis session does not remove sufficient amount of voriconazole to warrant dose adjustment [see Clinical Pharmacology (12.3)].. Pediatric Patients. Dosage adjustment of voriconazole tablets in pediatric patients with renal impairment has not been established [see Use in Specific Populations (8.4) ].. 2.7Dosage Adjustment When Co-Administered With Phenytoin or Efavirenz. The maintenance dose of voriconazole should be increased when co-administered with phenytoin or efavirenz. Use the optimal method for titrating dosage [see Drug Interactions (7) and Dosage and Administration (2.3)].

DRUG INTERACTIONS SECTION.

7 DRUG INTERACTIONS. Voriconazole is metabolized by cytochrome P450 isoenzymes, CYP2C19, CYP2C9, and CYP3A4. Therefore, inhibitors or inducers of these isoenzymes may increase or decrease voriconazole plasma concentrations, respectively. Voriconazole is strong inhibitor of CYP3A4, and also inhibits CYP2C19 and CYP2C9. Therefore, voriconazole may increase the plasma concentrations of substances metabolized by these CYP450 isoenzymes.Tables 10 and 11 provide the clinically significant interactions between voriconazole and other medical products.Table 10: Effect of Other Drugs on Voriconazole Pharmacokinetics [see Clinical Pharmacology (12.3)]Drug/Drug Class(Mechanism of Interaction by the Drug)Voriconazole Plasma Exposure(Cmax and AUCafter 200 mg every 12 hours)Recommendations for VoriconazoleDosage Adjustment/CommentsRifampinResults based on in vivo clinical studies generally following repeat oral dosing with 200 mg every 12 hours voriconazole to healthy subjects and Rifabutin (CYP450 Induction) Significantly Reduced Contraindicated Efavirenz (400 mg every 24 hours)Results based on in vivo clinical study following repeat oral dosing with 400 mg every 12 hours for day, then 200 mg every 12 hours for at least days voriconazole to healthy subjects (CYP450 Induction) Efavirenz (300 mg every 24 hours) (CYP450 Induction)Significantly Reduced Slight Decrease in AUC Contraindicated When voriconazole is coadministered with efavirenz, voriconazole oral maintenance dose should be increased to 400 mg every 12 hours and efavirenz should be decreased to 300 mg every 24 hours. High-dose Ritonavir (400 mg every 12 hours) (CYP450 Induction) Significantly Reduced Contraindicated Low-dose Ritonavir (100 mg every 12 hours) (CYP450 Induction)ReducedCoadministration of voriconazole and low-dose ritonavir (100 mg every 12 hours) should be avoided, unless an assessment of the benefit/risk to the patient justifies the use of voriconazole.Carbamazepine (CYP450 Induction) Not Studied In Vivo or In Vitro, but Likely to Result in Significant ReductionContraindicated Long Acting Barbiturates (e.g., phenobarbital, mephobarbital)(CYP450 Induction) Not Studied In Vivo or In Vitro, but Likely to Result in Significant Reduction Contraindicated Phenytoin (CYP450 Induction) Significantly Reduced Increase voriconazole maintenance dose from mg/kg to mg/kg IV every 12 hours or from 200 mg to 400 mg orally every 12 hours (100 mg to 200 mg orally every 12 hours in patients weighing less than 40 kg).Letermovir(CYP2C9/2C19 Induction)ReducedIf concomitant administration of voriconazole with letermovir cannot be avoided, monitor for reduced effectiveness of voriconazole.St. Johns Wort (CYP450 inducer; P-gp inducer) Significantly Reduced Contraindicated Oral Contraceptives containing ethinyl estradiol and norethindrone (CYP2C19 Inhibition) Increased Monitoring for adverse reactions and toxicity related to voriconazole is recommended when coadministered with oral contraceptives.Fluconazole (CYP2C9, CYP2C19 and CYP3A4 Inhibition)Significantly IncreasedAvoid concomitant administration of voriconazole and fluconazole. Monitoring for adverse reactions and toxicity related to voriconazole is started within 24 hours after the last dose of fluconazole.Other HIV Protease Inhibitors (CYP3A4 Inhibition) In Vivo Studies Showed No Significant Effects of Indinavir on Voriconazole ExposureNo dosage adjustment in the voriconazole dosage needed when coadministered with indinavir.In Vitro Studies Demonstrated Potential for Inhibition of Voriconazole Metabolism(Increased Plasma Exposure)Frequent monitoring for adverse reactions and toxicity related to voriconazole when coadministered with other HIV protease inhibitors.Other NNRTIsNon-Nucleoside Reverse Transcriptase Inhibitors (CYP3A4 Inhibition or CYP450 Induction) In Vitro Studies Demonstrated Potential for Inhibition of Voriconazole Metabolism by Delavirdine and Other NNRTIs (Increased Plasma Exposure) Frequent monitoring for adverse reactions and toxicity related to voriconazole.A Voriconazole-Efavirenz Drug Interaction Study Demonstrated the Potential for the Metabolism of Voriconazole to be Induced by Efavirenz and Other NNRTIs (Decreased Plasma Exposure)Careful assessment of voriconazole effectiveness. Table 11: Effect of Voriconazole on Pharmacokinetics of Other Drugs [see Clinical Pharmacology (12.3)]Drug/Drug Class (Mechanism of Interaction by Voriconazole)Drug Plasma Exposure (Cmax and AUC )Recommendations for Drug Dosage Adjustment/CommentsSirolimusResults based on in vivo clinical studies generally following repeat oral dosing with 200 mg BID voriconazole to healthy subjects (CYP3A4 Inhibition) Significantly Increased Contraindicated Rifabutin (CYP3A4 Inhibition) Significantly Increased Contraindicated Efavirenz (400 mg every 24 hours)Results based on in vivo clinical study following repeat oral dosing with 400 mg every 12 hours for day, then 200 mg every 12 hours for at least days voriconazole to healthy subjects (CYP3A4 Inhibition) Efavirenz (300 mg every 24 hours) (CYP3A4 Inhibition)Significantly Increased Slight Increase in AUC Contraindicated When voriconazole is coadministered with efavirenz, voriconazole oral maintenance dose should be increased to 400 mg every 12 hours and efavirenz should be decreased to 300 mg every 24 hours.High-dose Ritonavir (400 mg every 12 hours) (CYP3A4 Inhibition) No Significant Effect of Voriconazole onRitonavir Cmax or AUC Contraindicated because of significant reduction of voriconazole Cmax and AUC.Low-dose Ritonavir (100 mg every 12 hours) Slight Decrease in Ritonavir Cmax andAUC Coadministration of voriconazole and low-dose ritonavir (100 mg every 12 hours) should be avoided (due to the reduction in voriconazole Cmax and AUC) unless an assessment of the benefit/risk to the patient justifies the use of voriconazole.Cisapride, Pimozide, Quinidine, Ivabradine(CYP3A4 Inhibition) Not Studied In Vivo or In Vitro, but Drug Plasma Exposure Likely to be IncreasedContraindicated because of potential for QT prolongation and rare occurrence of torsade de pointes.Ergot Alkaloids(CYP450 Inhibition) Not Studied In Vivo or In Vitro, but Drug Plasma Exposure Likely to be IncreasedContraindicated Naloxegol(CYP3A4 Inhibition)Not Studied In Vivo or In Vitro, but Drug Plasma Exposure Likely to be Increased which may Increase the Risk of Adverse ReactionsContraindicatedTolvaptan(CYP3A4 Inhibition)Although Not Studied Clinically, Voriconazole is Likely to Significantly Increase the Plasma Concentrations of TolvaptanContraindicatedVenetoclax(CYP3A4 Inhibition)Not Studied In Vivo or In Vitro, but Venetoclax Plasma Exposure Likely to be Significantly IncreasedCoadministration of voriconazole is contraindicated at initiation and during the ramp-up phase in patients with chronic lymphocytic leukemia (CLL) or small lymphocytic lymphoma (SLL). Refer to the venetoclax labeling for safety monitoring and dose reduction in the steady daily dosing phase in CLL/SLL patients. For patients with acute myeloid leukemia (AML), dose reduction and safety monitoring are recommended across all dosing phases when coadministering voriconazole with venetoclax. Refer to the venetoclax prescribing information for dosing instructions.Lurasidone(CYP3A4 Inhibition)Not Studied In Vivo or In Vitro, but Voriconazole is Likely to Significantly Increase the Plasma Concentrations of LurasidoneContraindicatedCyclosporine (CYP3A4 Inhibition) AUC Significantly Increased; No Significant Effect on Cmax When initiating therapy with voriconazole in patients already receiving cyclosporine, reduce the cyclosporine dose to one-half of the starting dose and follow with frequent monitoring of cyclosporine blood levels. Increased cyclosporine levels have been associated with nephrotoxicity. When voriconazole is discontinued, cyclosporine concentrations must be frequently monitored and the dose increased as necessary.MethadoneResults based on in vivo clinical study following repeat oral dosing with 400 mg every 12 hours for day, then 200 mg every 12 hours for days voriconazole to subjects receiving methadone maintenance dose (30-100 mg every 24 hours) (CYP3A4 Inhibition) Increased Increased plasma concentrations of methadone have been associated with toxicity including QT prolongation. Frequent monitoring for adverse reactions and toxicity related to methadone is recommended during coadministration. Dose reduction of methadone may be needed.Fentanyl (CYP3A4 Inhibition)IncreasedReduction in the dose of fentanyl and other long-acting opiates metabolized by CYP3A4 should be considered when coadministered with voriconazole. Extended and frequent monitoring for opiate-associated adverse reactions may be necessary.Alfentanil (CYP3A4 Inhibition)Significantly IncreasedAn increase in the incidence of delayed and persistent alfentanil-associated nausea and vomiting were observed when coadministered with voriconazole. Reduction in the dose of alfentanil and other opiates metabolized by CYP3A4 (e.g., sufentanil) should be considered when coadministered with voriconazole. longer period for monitoring respiratory and other opiate-associated adverse reactions may be necessary.Oxycodone (CYP3A4 Inhibition)Significantly IncreasedIncreased visual effects (heterophoria and miosis) of oxycodone were observed when coadministered with voriconazole.Reduction in the dose of oxycodone and other long-acting opiates metabolized by CYP3A4 should be considered when coadministered with voriconazole. Extended and frequent monitoring for opiate-associated adverse reactions may be necessary.NSAIDsNon-Steroidal Anti-Inflammatory Drug including: ibuprofen and diclofenac(CYP2C9 Inhibition)IncreasedFrequent monitoring for adverse reactions and toxicity related to NSAIDs. Dose reduction of NSAIDs may be needed.Tacrolimus (CYP3A4 Inhibition) Significantly Increased When initiating therapy with voriconazole in patients already receiving tacrolimus, reduce the tacrolimus dose to one-third of the starting dose and follow with frequent monitoring of tacrolimus blood levels. Increased tacrolimus levels have been associated with nephrotoxicity. When voriconazole is discontinued, tacrolimus concentrations must be frequently monitored and the dose increased as necessary.Phenytoin (CYP2C9 Inhibition) Significantly Increased Frequent monitoring of phenytoin plasma concentrations and frequent monitoring of adverse effects related to phenytoin.Oral Contraceptives containing ethinyl estradiol and norethindrone (CYP3A4 Inhibition) Increased Monitoring for adverse reactions related to oral contraceptives is recommended during coadministration.Prednisolone and other corticosteroids (CYP3A4 Inhibition)In Vivo Studies Showed No Significant Effects of Voriconazole on Prednisolone Exposure No dosage adjustment for prednisolone when coadministered with voriconazole [see Clinical Pharmacology (12.3)]. Not Studied In Vitro or In Vivo for Other Corticosteroids, but Drug Exposure Likely to be IncreasedMonitor for potential adrenal dysfunction when voriconazole is administered with other corticosteroids [see Warnings and Precautions (5.8)].Warfarin (CYP2C9 Inhibition) Other Oral Coumarin Anticoagulants(CYP2C9/3A4 Inhibition)Prothrombin Time Significantly Increased Not Studied In Vivo or In Vitro for other Oral Coumarin Anticoagulants, but Drug Plasma Exposure Likely to be IncreasedIf patients receiving coumarin preparations are treated simultaneously with voriconazole, the prothrombin time or other suitable anticoagulation tests should be monitored at close intervals and the dosage of anticoagulants adjusted accordingly.Ivacaftor(CYP3A4 Inhibition)Not Studied In Vivo or In Vitro, but Drug Plasma Exposure Likely to be Increased which may Increase the Risk of Adverse ReactionsDose reduction of ivacaftor is recommended. Refer to the prescribing information for ivacaftor.Omeprazole (CYP2C19/3A4 Inhibition) Significantly Increased When initiating therapy with voriconazole in patients already receiving omeprazole doses of 40 mg or greater, reduce the omeprazole dose by one-half. The metabolism of other proton pump inhibitors that are CYP2C19 substrates may also be inhibited by voriconazole and may result in increased plasma concentrations of other proton pump inhibitors.Other HIV Protease Inhibitors (CYP3A4 Inhibition) In Vivo Studies Showed No SignificantEffects on Indinavir ExposureNo dosage adjustment for indinavir when coadministered with voriconazole.In Vitro Studies Demonstrated Potential for Voriconazole to Inhibit Metabolism (Increased Plasma Exposure)Frequent monitoring for adverse reactions and toxicity related to other HIV protease inhibitors.Other NNRTIsNon-Nucleoside Reverse Transcriptase Inhibitors (CYP3A4 Inhibition) Voriconazole-Efavirenz Drug Interaction Study Demonstrated the Potential for Voriconazole to Inhibit Metabolism of Other NNRTIs(Increased Plasma Exposure) Frequent monitoring for adverse reactions and toxicity related to NNRTI.Midazolam (CYP3A4 Inhibition) Significantly Increased Increased plasma exposures may increase the risk of adverse reactions and toxicities related to benzodiazepines. Refer to drug-specific labeling for details.Other Benzodiazepines Including Triazolam and Alprazolam(CYP3A4 Inhibition)In Vitro Studies Demonstrated Potential for Voriconazole to Inhibit Metabolism (Increased Plasma Exposure)HMG-CoA Reductase Inhibitors (Statins) (CYP3A4 Inhibition) In Vitro Studies Demonstrated Potential for Voriconazole to Inhibit Metabolism(Increased Plasma Exposure) Frequent monitoring for adverse reactions and toxicity related to statins. Increased statin concentrations in plasma have been associated with rhabdomyolysis. Adjustment of the statin dosage may be needed.Dihydropyridine Calcium Channel Blockers(CYP3A4 Inhibition) In Vitro Studies Demonstrated Potential for Voriconazole to Inhibit Metabolism (Increased Plasma Exposure) Frequent monitoring for adverse reactions and toxicity related to calcium channel blockers. Adjustment of calcium channel blocker dosage may be needed.Sulfonylurea Oral Hypoglycemics (CYP2C9 Inhibition) Not Studied In Vivo or In Vitro, but Drug Plasma Exposure Likely to be IncreasedFrequent monitoring of blood glucose and for signs and symptoms of hypoglycemia. Adjustment of oral hypoglycemic drug dosage may be needed.Vinca Alkaloids (CYP3A4 Inhibition) Not Studied In Vivo or In Vitro, but Drug Plasma Exposure Likely to be IncreasedFrequent monitoring for adverse reactions and toxicity (i.e., neurotoxicity) related to vinca alkaloids. Reserve azole antifungals, including voriconazole, for patients receiving vinca alkaloid who have no alternative antifungal treatment options.Everolimus(CYP3A4 Inhibition)Not Studied In Vivo or In Vitro, but Drug Plasma Exposure Likely to be IncreasedConcomitant administration of voriconazole and everolimus is not recommended. oCYP3A4, CYP2C9, and CYP2C19 inhibitors and inducers: Adjust voriconazole dosage and monitor for adverse reactions or lack of efficacy (4, 7)oVoriconazole may increase the concentrations and activity of drugs that are CYP3A4, CYP2C9 and CYP2C19 substrates. Reduce dosage of these other drugs and monitor for adverse reactions (4, 7)oPhenytoin or Efavirenz: With co-administration, increase maintenance oral and intravenous dosage of voriconazole (2.3, 2.7, 7). oCYP3A4, CYP2C9, and CYP2C19 inhibitors and inducers: Adjust voriconazole dosage and monitor for adverse reactions or lack of efficacy (4, 7). oVoriconazole may increase the concentrations and activity of drugs that are CYP3A4, CYP2C9 and CYP2C19 substrates. Reduce dosage of these other drugs and monitor for adverse reactions (4, 7). oPhenytoin or Efavirenz: With co-administration, increase maintenance oral and intravenous dosage of voriconazole (2.3, 2.7, 7).

ADVERSE REACTIONS SECTION.

6 ADVERSE REACTIONS. The following serious adverse reactions are described elsewhere in the labeling:Hepatic Toxicity [see Warnings and Precautions (5.1)] Arrhythmias and QT Prolongation [see Warnings and Precautions (5.2)] Visual Disturbances [see Warnings and Precautions (5.4)] Severe Cutaneous Adverse Reactions [see Warnings and Precautions (5.5)] Photosensitivity [see Warnings and Precautions (5.6)] Renal Toxicity [see Warnings and Precautions (5.7)] oAdult Patients: The most common adverse reactions (incidence >= 2%) were visual disturbances, fever, nausea, rash, vomiting, chills, headache, liver function test abnormal, tachycardia, hallucinations (6) To report SUSPECTED ADVERSE REACTIONS, contact Mylan at 1-877-446-3679 (1-877-4-INFO-RX) or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch. oAdult Patients: The most common adverse reactions (incidence >= 2%) were visual disturbances, fever, nausea, rash, vomiting, chills, headache, liver function test abnormal, tachycardia, hallucinations (6). 6.1 Clinical Trials Experience. Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in clinical trials of drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.. Clinical Trials Experience in Adults. Overview The most frequently reported adverse reactions (see Table 4) in the adult therapeutic trials were visual disturbances (18.7%), fever (5.7%), nausea (5.4%), rash (5.3%), vomiting (4.4%), chills (3.7%), headache (3.0%), liver function test increased (2.7%), tachycardia (2.4%), hallucinations (2.4%). The adverse reactions which most often led to discontinuation of voriconazole therapy were elevated liver function tests, rash, and visual disturbances [see Warnings and Precautions (5.1, 5.4) and Adverse Reactions (6.1)].The data described in Table reflect exposure to voriconazole in 1655 patients in nine therapeutic studies. This represents heterogeneous population, including immunocompromised patients, e.g., patients with hematological malignancy or HIV and non-neutropenic patients. This subgroup does not include healthy subjects and patients treated in the compassionate use and non-therapeutic studies. This patient population was 62% male, had mean age of 46 years (range 11-90, including 51 patients aged 12-18 years), and was 78% White and 10% Black. Five hundred sixty one patients had duration of voriconazole therapy of greater than 12 weeks, with 136 patients receiving voriconazole for over six months. Table includes all adverse reactions which were reported at an incidence of >= 2% during voriconazole therapy in the all therapeutic studies population, studies 307/602 and 608 combined, or study 305, as well as events of concern which occurred at an incidence of 2%.In study 307/602, 381 patients (196 on voriconazole, 185 on amphotericin B) were treated to compare voriconazole to amphotericin followed by other licensed antifungal therapy (OLAT) in the primary treatment of patients with acute IA. The rate of discontinuation from voriconazole study medication due to adverse reactions was 21.4% (42/196 patients). In study 608, 403 patients with candidemia were treated to compare voriconazole (272 patients) to the regimen of amphotericin followed by fluconazole (131 patients). The rate of discontinuation from voriconazole study medication due to adverse reactions was 19.5% out of 272 patients. Study 305 evaluated the effects of oral voriconazole (200 patients) and oral fluconazole (191 patients) in the treatment of EC. The rate of discontinuation from voriconazole study medication in Study 305 due to adverse reactions was 7% (14/200 patients). Laboratory test abnormalities for these studies are discussed under Clinical Laboratory Values below.Table 4: Adverse Reactions Rate >= 2% on Voriconazole or Adverse Reactions of Concern in Therapeutic Studies Population, Studies 307/602-608 Combined, or Study 305. Possibly Related to Therapy or Causality UnknownStudy 307/602: IA; Study 608: candidemia; Study 305: EC Therapeutic StudiesStudies 303, 304, 305, 307, 309, 602, 603, 604, 608Studies 307/602 and 608 (IV/oral therapy) Study 305 (oral therapy) VoriconazoleN 1655 VoriconazoleN 468 Ampho BAmphotericin followed by other licensed antifungal therapyN 185 Ampho B->FluconazoleN 131 VoriconazoleN 200 FluconazoleN 191 (%) (%) (%) (%) (%) (%) Special SensesSee Warnings and Precautions (5.4) Abnormal vision 310 (18.7) 63 (13.5) (0.5) 31 (15.5) (4.2) Photophobia 37 (2.2) (1.7) 0 (2.5) (1.0) Chromatopsia 20 (1.2) (0.4) 0 (1.0) Body as Whole Fever 94 (5.7) (1.7) 25 (13.5) (3.8) 0 Chills 61 (3.7) (0.2) 36 (19.5) (6.1) (0.5) Headache 49 (3.0) (1.9) (4.3) (0.8) 1 (0.5) Cardiovascular SystemTachycardia 39 (2.4) (1.3) (2.7) 0 Digestive System Nausea 89 (5.4) 18 (3.8) 29 (15.7) (1.5) (1.0) (1.6) Vomiting 72 (4.4) 15 (3.2) 18 (9.7) (0.8) (1.0) (0.5) Liver function tests abnormal 45 (2.7) 15 (3.2) (2.2) (0.8) (3.0) (1.0) Cholestatic jaundice 17 (1.0) (1.7) 1 (0.8) (1.5) Metabolic and Nutritional Systems Alkaline phosphatase increased 59 (3.6) 19 (4.1) (2.2) (2.3) 10 (5.0) (1.6) Hepatic enzymes increased 30 (1.8) 11 (2.4) (2.7) (0.8) (1.5) SGOT increased 31 (1.9) (1.9) 1 (0.8) (4.0) (1.0) SGPT increased 29 (1.8) (1.9) (0.5) (1.5) (3.0) (1.0) Hypokalemia 26 (1.6) (0.6) 36 (19.5) 16 (12.2) 0 Bilirubinemia 15 (0.9) (1.1) (1.6) (1.5) (0.5) Creatinine increased (0.2) 59 (31.9) 10 (7.6) (0.5) Nervous System Hallucinations 39 (2.4) 13 (2.8) (0.5) 0 Skin and Appendages Rash 88 (5.3) 20 (4.3) (3.8) (0.8) (1.5) (0.5) Urogenital Kidney function abnormal 10 (0.6) (1.3) 40 (21.6) (6.9) (0.5) (0.5) Acute kidney failure (0.4) (0.4) 11 (5.9) (5.3) 0 Visual Disturbances. Voriconazole treatment-related visual disturbances are common. In therapeutic trials, approximately 21% of patients experienced abnormal vision, color vision change and/or photophobia. Visual disturbances may be associated with higher plasma concentrations and/or doses.The mechanism of action of the visual disturbance is unknown, although the site of action is most likely to be within the retina. In study in healthy subjects investigating the effect of 28-day treatment with voriconazole on retinal function, voriconazole caused decrease in the electroretinogram (ERG) waveform amplitude, decrease in the visual field, and an alteration in color perception. The ERG measures electrical currents in the retina. These effects were noted early in administration of voriconazole and continued through the course of study drug treatment. Fourteen days after the end of dosing, ERG, visual fields and color perception returned to normal [see Warnings and Precautions (5.4)].. Dermatological Reactions. Dermatological reactions were common in patients treated with voriconazole. The mechanism underlying these dermatologic adverse reactions remains unknown.Severe cutaneous adverse reactions (SCARs), including Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and drug reaction with eosinophilia and systemic symptoms (DRESS) have been reported during treatment with voriconazole. Erythema multiforme has also been reported during treatment with voriconazole [see Warnings and Precautions (5.5) and Adverse Reactions (6.2)].Voriconazole has also been associated with additional photosensitivity related skin reactions such as pseudoporphyria, cheilitis, and cutaneous lupus erythematosus [see Warnings and Precautions (5.6)].. Less Common Adverse Reactions. The following adverse reactions occurred in 2% of all voriconazole-treated patients in all therapeutic studies (N 1655). This listing includes events where causal relationship to voriconazole cannot be ruled out or those which may help the physician in managing the risks to the patients. The list does not include events included in Table above and does not include every event reported in the voriconazole clinical program.Body as Whole: abdominal pain, abdomen enlarged, allergic reaction, anaphylactoid reaction, ascites, asthenia, back pain, chest pain, cellulitis, edema, face edema, flank pain, flu syndrome, graft versus host reaction, granuloma, infection, bacterial infection, fungal infection, injection site pain, injection site infection/inflammation, mucous membrane disorder, multi-organ failure, pain, pelvic pain, peritonitis, sepsis, substernal chest pain.Cardiovascular: atrial arrhythmia, atrial fibrillation, AV block complete, bigeminy, bradycardia, bundle branch block, cardiomegaly, cardiomyopathy, cerebral hemorrhage, cerebral ischemia, cerebrovascular accident, congestive heart failure, deep thrombophlebitis, endocarditis, extrasystoles, heart arrest, hypertension, hypotension, myocardial infarction, nodal arrhythmia, palpitation, phlebitis, postural hypotension, pulmonary embolus, QT interval prolonged, supraventricular extrasystoles, supraventricular tachycardia, syncope, thrombophlebitis, vasodilatation, ventricular arrhythmia, ventricular fibrillation, ventricular tachycardia (including torsade de pointes) [see Warnings and Precautions (5.2)].Digestive: anorexia, cheilitis, cholecystitis, cholelithiasis, constipation, diarrhea, duodenal ulcer perforation, duodenitis, dyspepsia, dysphagia, dry mouth, esophageal ulcer, esophagitis, flatulence, gastroenteritis, gastrointestinal hemorrhage, GGT/LDH elevated, gingivitis, glossitis, gum hemorrhage, gum hyperplasia, hematemesis, hepatic coma, hepatic failure, hepatitis, intestinal perforation, intestinal ulcer, jaundice, enlarged liver, melena, mouth ulceration, pancreatitis, parotid gland enlargement, periodontitis, proctitis, pseudomembranous colitis, rectal disorder, rectal hemorrhage, stomach ulcer, stomatitis, tongue edema.Endocrine: adrenal cortex insufficiency, diabetes insipidus, hyperthyroidism, hypothyroidism.Hemic and Lymphatic: agranulocytosis, anemia (macrocytic, megaloblastic, microcytic, normocytic), aplastic anemia, hemolytic anemia, bleeding time increased, cyanosis, DIC, ecchymosis, eosinophilia, hypervolemia, leukopenia, lymphadenopathy, lymphangitis, marrow depression, pancytopenia, petechia, purpura, enlarged spleen, thrombocytopenia, thrombotic thrombocytopenic purpura.Metabolic and Nutritional: albuminuria, BUN increased, creatine phosphokinase increased, edema, glucose tolerance decreased, hypercalcemia, hypercholesteremia, hyperglycemia, hyperkalemia, hypermagnesemia, hypernatremia, hyperuricemia, hypocalcemia, hypoglycemia, hypomagnesemia, hyponatremia, hypophosphatemia, peripheral edema, uremia.Musculoskeletal: arthralgia, arthritis, bone necrosis, bone pain, leg cramps, myalgia, myasthenia, myopathy, osteomalacia, osteoporosis.Nervous System: abnormal dreams, acute brain syndrome, agitation, akathisia, amnesia, anxiety, ataxia, brain edema, coma, confusion, convulsion, delirium, dementia, depersonalization, depression, diplopia, dizziness, encephalitis, encephalopathy, euphoria, Extrapyramidal Syndrome, grand mal convulsion, Guillain-Barre syndrome, hypertonia, hypesthesia, insomnia, intracranial hypertension, libido decreased, neuralgia, neuropathy, nystagmus, oculogyric crisis, paresthesia, psychosis, somnolence, suicidal ideation, tremor, vertigo.Respiratory System: cough increased, dyspnea, epistaxis, hemoptysis, hypoxia, lung edema, pharyngitis, pleural effusion, pneumonia, respiratory disorder, respiratory distress syndrome, respiratory tract infection, rhinitis, sinusitis, voice alteration.Skin and Appendages: alopecia, angioedema, contact dermatitis, discoid lupus erythematosis, eczema, erythema multiforme, exfoliative dermatitis, fixed drug eruption, furunculosis, herpes simplex, maculopapular rash, melanoma, melanosis, photosensitivity skin reaction, pruritus, pseudoporphyria, psoriasis, skin discoloration, skin disorder, skin dry, Stevens-Johnson syndrome, squamous cell carcinoma, sweating, toxic epidermal necrolysis, urticaria.Special Senses: abnormality of accommodation, blepharitis, color blindness, conjunctivitis, corneal opacity, deafness, ear pain, eye pain, eye hemorrhage, dry eyes, hypoacusis, keratitis, keratoconjunctivitis, mydriasis, night blindness, optic atrophy, optic neuritis, otitis externa, papilledema, retinal hemorrhage, retinitis, scleritis, taste loss, taste perversion, tinnitus, uveitis, visual field defect.Urogenital: anuria, blighted ovum, creatinine clearance decreased, dysmenorrhea, dysuria, epididymitis, glycosuria, hemorrhagic cystitis, hematuria, hydronephrosis, impotence, kidney pain, kidney tubular necrosis, metrorrhagia, nephritis, nephrosis, oliguria, scrotal edema, urinary incontinence, urinary retention, urinary tract infection, uterine hemorrhage, vaginal hemorrhage.. Clinical Laboratory Values in Adults. The overall incidence of transaminase increases 3x upper limit of normal (not necessarily comprising an adverse reaction) was 17.7% (268/1514) in adult subjects treated with voriconazole for therapeutic use in pooled clinical trials. Increased incidence of liver function test abnormalities may be associated with higher plasma concentrations and/or doses. The majority of abnormal liver function tests either resolved during treatment without dose adjustment or resolved following dose adjustment, including discontinuation of therapy.Voriconazole has been infrequently associated with cases of serious hepatic toxicity including cases of jaundice and rare cases of hepatitis and hepatic failure leading to death. Most of these patients had other serious underlying conditions.Liver function tests should be evaluated at the start of and during the course of voriconazole therapy. Patients who develop abnormal liver function tests during voriconazole therapy should be monitored for the development of more severe hepatic injury. Patient management should include laboratory evaluation of hepatic function (particularly liver function tests and bilirubin). Discontinuation of voriconazole must be considered if clinical signs and symptoms consistent with liver disease develop that may be attributable to voriconazole [see Warnings and Precautions (5.1)].Acute renal failure has been observed in severely ill patients undergoing treatment with voriconazole. Patients being treated with voriconazole are likely to be treated concomitantly with nephrotoxic medications and may have concurrent conditions that can result in decreased renal function. It is recommended that patients are monitored for the development of abnormal renal function. This should include laboratory evaluation of serum creatinine.Tables to show the number of patients with hypokalemia and clinically significant changes in renal and liver function tests in three randomized, comparative multicenter studies. In study 305, patients with EC were randomized to either oral voriconazole or oral fluconazole. In study 307/602, patients with definite or probable IA were randomized to either voriconazole or amphotericin therapy. In study 608, patients with candidemia were randomized to either voriconazole or the regimen of amphotericin followed by fluconazole.Table 5: Protocol 305 Patients with Esophageal Candidiasis Clinically Significant Laboratory Test Abnormalitiesn number of patients with clinically significant abnormality while on study therapy = total number of patients with at least one observation of the given lab test while on study therapy ULN upper limit of normalAST Aspartate aminotransferase; ALT alanine aminotransferaseCriteriaWithout regard to baseline valueVoriconazole Fluconazole n/N (%) n/N (%) T. Bilirubin 1.5 ULN 8/185 (4.3) 7/186 (3.8) AST 3.0 ULN 38/187 (20.3) 15/186 (8.1) ALT 3.0 ULN 20/187 (10.7) 12/186 (6.5) Alkaline Phosphatase 3.0 ULN 19/187 (10.2) 14/186 (7.5) Table 6: Protocol 307/602 Primary Treatment of Invasive Aspergillosis Clinically Significant Laboratory Test Abnormalitiesn number of patients with clinically significant abnormality while on study therapy = total number of patients with at least one observation of the given lab test while on study therapyULN upper limit of normal LLN lower limit of normal AST Aspartate aminotransferase; ALT alanine aminotransferaseCriteriaWithout regard to baseline valueVoriconazole Amphotericin BAmphotericin followed by other licensed antifungal therapyn/N (%) n/N (%) T. Bilirubin 1.5 ULN 35/180 (19.4) 46/173 (26.6) AST 3.0 ULN 21/180 (11.7) 18/174 (10.3) ALT 3.0 ULN 34/180 (18.9) 40/173 (23.1) Alkaline Phosphatase> 3.0 ULN 29/181 (16.0) 38/173 (22.0) Creatinine 1.3 ULN 39/182 (21.4) 102/177 (57.6) Potassium 0.9 LLN 30/181 (16.6) 70/178 (39.3) Table 7: Protocol 608 Treatment of Candidemia Clinically Significant Laboratory Test Abnormalitiesn number of patients with clinically significant abnormality while on study therapy = total number of patients with at least one observation of the given lab test while on study therapyAST Aspartate aminotransferase; ALT alanine aminotransferaseULN upper limit of normal LLN lower limit of normalCriteriaWithout regard to baseline valueVoriconazole Amphotericin followed by Fluconazole n/N (%) n/N (%) T. Bilirubin 1.5 ULN 50/261 (19.2) 31/115 (27.0) AST 3.0 ULN 40/261 (15.3) 16/116 (13.8) ALT 3.0 ULN 22/261 (8.4) 15/116 (12.9) Alkaline Phosphatase> 3.0 ULN 59/261 (22.6) 26/115 (22.6) Creatinine 1.3 ULN 39/260 (15.0) 32/118 (27.1) Potassium 0.9 LLN 43/258 (16.7) 35/118 (29.7) Clinical Trials Experience in Pediatric Patients. The safety of voriconazole was investigated in pediatric patients, including 52 pediatric patients less than 18 years of age who were enrolled in the adult therapeutic studies.. Hepatic-Related Adverse Reactions in Pediatric Patients The frequency of hepatic-related adverse reactions in pediatric patients exposed to voriconazole in therapeutic studies was numerically higher than that of adults (28.6% compared to 24.1%, respectively). The higher frequency of hepatic adverse reactions in the pediatric population was mainly due to an increased frequency of liver enzyme elevations (21.9% in pediatric patients compared to 16.1% in adults), including transaminase elevations (ALT and AST combined) 7.6% in the pediatric patients compared to 5.1% in adults.Additional pediatric use information is approved for PF PRISM C.V.s VFEND (voriconazole). However, due to PF PRISM C.V.s marketing exclusivity rights, this drug product is not labeled with that information.. 6.2 Postmarketing Experience in Adult and Pediatric Patients. The following adverse reactions have been identified during post-approval use of voriconazole. Because these reactions are reported voluntarily from population of uncertain size, it is not always possible to reliably estimate their frequency or establish causal relationship to drug exposure.. Adults. Skeletal: fluorosis and periostitis have been reported during long-term voriconazole therapy [see Warnings and Precautions (5.12) ].Eye Disorders: prolonged visual adverse reactions, including optic neuritis and papilledema [see Warnings and Precautions (5.4)].Skin and Appendages: drug reaction with eosinophilia and systemic symptoms (DRESS) has been reported [see Warnings and Precautions (5.5) and Adverse Reactions (6.1)].Endocrine Disorders: adrenal insufficiency, Cushings syndrome (when voriconazole has been used concomitantly with corticosteroids) [see Warnings and Precautions (5.8)].. Pediatric Patients. There have been postmarketing reports of pancreatitis in pediatric patients.

CLINICAL STUDIES SECTION.

14 CLINICAL STUDIES. Voriconazole, administered orally or parenterally, has been evaluated as primary or salvage therapy in 520 patients aged 12 years and older with infections caused by Aspergillus spp., Fusarium spp., and Scedosporium spp.. 14.1 Invasive Aspergillosis (IA). Voriconazole was studied in patients for primary therapy of IA (randomized, controlled study 307/602), for primary and salvage therapy of aspergillosis (non-comparative study 304) and for treatment of patients with IA who were refractory to, or intolerant of, other antifungal therapy (non-comparative study 309/604).. Study 307/602 Primary Therapy of Invasive Aspergillosis. The efficacy of voriconazole compared to amphotericin in the primary treatment of acute IA was demonstrated in 277 patients treated for 12 weeks in randomized, controlled study (Study 307/602). The majority of study patients had underlying hematologic malignancies, including bone marrow transplantation. The study also included patients with solid organ transplantation, solid tumors, and AIDS. The patients were mainly treated for definite or probable IA of the lungs. Other aspergillosis infections included disseminated disease, CNS infections and sinus infections. Diagnosis of definite or probable IA was made according to criteria modified from those established by the National Institute of Allergy and Infectious Diseases Mycoses Study Group/European Organisation for Research and Treatment of Cancer (NIAID MSG/EORTC).Voriconazole was administered intravenously with loading dose of mg/kg every 12 hours for the first 24 hours followed by maintenance dose of mg/kg every 12 hours for minimum of days. Therapy could then be switched to the oral formulation at dose of 200 mg every 12 hours. Median duration of IV voriconazole therapy was 10 days (range 2-85 days). After IV voriconazole therapy, the median duration of PO voriconazole therapy was 76 days (range 2-232 days).Patients in the comparator group received conventional amphotericin as slow infusion at daily dose of 1.0-1.5 mg/kg/day. Median duration of IV amphotericin therapy was 12 days (range 1-85 days). Treatment was then continued with OLAT, including itraconazole and lipid amphotericin formulations. Although initial therapy with conventional amphotericin was to be continued for at least two weeks, actual duration of therapy was at the discretion of the investigator. Patients who discontinued initial randomized therapy due to toxicity or lack of efficacy were eligible to continue in the study with OLAT treatment.A satisfactory global response at 12 weeks (complete or partial resolution of all attributable symptoms, signs, radiographic/bronchoscopic abnormalities present at baseline) was seen in 53% of voriconazole treated patients compared to 32% of amphotericin treated patients (Table 15). benefit of voriconazole compared to amphotericin on patient survival at Day 84 was seen with 71% survival rate on voriconazole compared to 58% on amphotericin (Table 13).Table 13 also summarizes the response (success) based on mycological confirmation and species.Table 13: Overall Efficacy and Success by Species in the Primary Treatment of Acute Invasive Aspergillosis Study 307/602Voriconazole Ampho BAmphotericin followed by other licensed antifungal therapyStratifiedDifference (95% CI)Difference and corresponding 95% confidence interval are stratified by protocoln/N (%) n/N (%) Efficacy as Primary Therapy Satisfactory Global ResponseAssessed by independent Data Review Committee (DRC) 76/144 (53) 42/133 (32) 21.8%(10.5%, 33.0%)p 0.0001 Survival at Day 84Proportion of subjects alive 102/144 (71) 77/133 (58) 13.1% (2.1%, 24.2%) Success by Species Success n/N (%) Overall success 76/144 (53) 42/133 (32) Mycologically confirmedNot all mycologically confirmed specimens were speciated 37/84 (44) 16/67 (24) Aspergillus spp.Some patients had more than one species isolated at baseline A. fumigatus 28/63 (44)12/47 (26) A. flavus3/64/9 A. terreus 2/30/3 A. niger 1/40/9 A. nidulans 1/10/0. Study 304 Primary and Salvage Therapy of Aspergillosis. In this non-comparative study, an overall success rate of 52% (26/50) was seen in patients treated with voriconazole for primary therapy. Success was seen in 17/29 (59%) with Aspergillus fumigatus infections and 3/6 (50%) patients with infections due to non-fumigatus species [A. flavus (1/1); A. nidulans (0/2); A. niger (2/2); A. terreus (0/1)]. Success in patients who received voriconazole as salvage therapy is presented in Table 14.. Study 309/604 Treatment of Patients with Invasive Aspergillosis who were Refractory to, or Intolerant of, other Antifungal Therapy. Additional data regarding response rates in patients who were refractory to, or intolerant of, other antifungal agents are also provided in Table 16. In this non-comparative study, overall mycological eradication for culture-documented infections due to fumigatus and non-fumigatus species of Aspergillus was 36/82 (44%) and 12/30 (40%), respectively, in voriconazole treated patients. Patients had various underlying diseases and species other than A. fumigatus contributed to mixed infections in some cases.For patients who were infected with single pathogen and were refractory to, or intolerant of, other antifungal agents, the satisfactory response rates for voriconazole in studies 304 and 309/604 are presented in Table 14.Table 14: Combined Response Data in Salvage Patients with Single Aspergillus Species (Studies 304 and 309/604)Success n/N A. fumigatus 43/97 (44%)A. flavus 5/12A. nidulans 1/3A. niger 4/5A. terreus 3/8A. versicolor 0/1Nineteen patients had more than one species of Aspergillus isolated. Success was seen in 4/17 (24%) of these patients.. 14.2 Candidemia in Non-neutropenic Patients and Other Deep Tissue Candida Infections. Voriconazole was compared to the regimen of amphotericin followed by fluconazole in Study 608, an open-label, comparative study in nonneutropenic patients with candidemia associated with clinical signs of infection. Patients were randomized in 2:1 ratio to receive either voriconazole (n 283) or the regimen of amphotericin followed by fluconazole (n 139). Patients were treated with randomized study drug for median of 15 days. Most of the candidemia in patients evaluated for efficacy was caused by C. albicans (46%), followed by C. tropicalis (19%), C. parapsilosis (17%), C. glabrata (15%), and C. krusei (1%).An independent Data Review Committee (DRC), blinded to study treatment, reviewed the clinical and mycological data from this study, and generated one assessment of response for each patient. successful response required all of the following: resolution or improvement in all clinical signs and symptoms of infection, blood cultures negative for Candida, infected deep tissue sites negative for Candida or resolution of all local signs of infection, and no systemic antifungal therapy other than study drug. The primary analysis, which counted DRC-assessed successes at the fixed time point (12 weeks after End of Therapy [EOT]), demonstrated that voriconazole was comparable to the regimen of amphotericin followed by fluconazole (response rates of 41% and 41%, respectively) in the treatment of candidemia. Patients who did not have 12-week assessment for any reason were considered treatment failure.The overall clinical and mycological success rates by Candida species in Study 150-608 are presented in Table 15.Table 15: Overall Success Rates Sustained From EOT to the Fixed 12-Week Follow-Up Time Point by Baseline PathogenA few patients had more than one pathogen at baseline. Patients who did not have 12-week assessment for any reason were considered treatment failure. Baseline Pathogen Clinical and Mycological Success (%) Voriconazole Amphotericin ->Fluconazole C. albicans 46/107 (43%) 30/63 (48%) C. tropicalis 17/53 (32%) 1/16 (6%) C. parapsilosis 24/45 (53%) 10/19 (53%) C. glabrata 12/36 (33%) 7/21 (33%) C. krusei 1/40/1 In secondary analysis, which counted DRC-assessed successes at any time point (EOT, or 2, 6, or 12 weeks after EOT), the response rates were 65% for voriconazole and 71% for the regimen of amphotericin followed by fluconazole.In Studies 608 and 309/604 (non-comparative study in patients with invasive fungal infections who were refractory to, or intolerant of, other antifungal agents), voriconazole was evaluated in 35 patients with deep tissue Candida infections. favorable response was seen in of patients with intra-abdominal infections, of patients with kidney and bladder wall infections, of patients with deep tissue abscess or wound infection, of patients with pneumonia/pleural space infections, of patients with skin lesions, of patients with mixed intra-abdominal and pulmonary infection, of patients with suppurative phlebitis, of patients with hepatosplenic infection, of patients with osteomyelitis, of with liver infection, and of with cervical lymph node infection.. 14.3 Esophageal Candidiasis (EC). The efficacy of oral voriconazole 200 mg twice daily compared to oral fluconazole 200 mg once daily in the primary treatment of EC was demonstrated in Study 150-305, double-blind, double-dummy study in immunocompromised patients with endoscopically-proven EC. Patients were treated for median of 15 days (range to 49 days). Outcome was assessed by repeat endoscopy at end of treatment (EOT). successful response was defined as normal endoscopy at EOT or at least 1 grade improvement over baseline endoscopic score. For patients in the Intent-to-Treat (ITT) population with only baseline endoscopy, successful response was defined as symptomatic cure or improvement at EOT compared to baseline. Voriconazole and fluconazole (200 mg once daily) showed comparable efficacy rates against EC, as presented in Table 16.Table 16: Success Rates in Patients Treated for Esophageal CandidiasisPopulation VoriconazoleFluconazoleDifference %(95% CI)Confidence Interval for the difference (Voriconazole Fluconazole) in success rates.PPPP (Per Protocol) patients had confirmation of Candida esophagitis by endoscopy, received at least 12 days of treatment, and had repeat endoscopy at EOT (end of treatment). 113/115 (98.2%)134/141 (95.0%)3.2 (-1.1, 7.5)ITTITT (Intent to Treat) patients without endoscopy or clinical assessment at EOT were treated as failures. 175/200 (87.5%)171/191 (89.5%)-2.0 (-8.3, 4.3)Microbiologic success rates by Candida species are presented in Table 17.Table 17: Clinical and Mycological Outcome by Baseline Pathogen in Patients with Esophageal Candidiasis (Study-150-305)PathogenSome patients had more than one species isolated at baseline.Voriconazole Fluconazole Favorable endoscopic responsePatients with endoscopic and/or mycological assessment at end of therapy.Mycological eradicationFavorable endoscopic responseMycological eradicationSuccess/Total(%)Eradication/Total(%)Success/Total(%)Eradication/Total (%)C. albicans 134/140 (96%) 90/107 (84%) 147/156 (94%) 91/115 (79%) C. glabrata 8/8 (100%) 4/7 (57%) 4/4 (100%) 1/4 (25%) C. krusei 1/11/12/2 (100%)0/0 14.4 Other Serious Fungal Pathogens. In pooled analyses of patients, voriconazole was shown to be effective against the following additional fungal pathogens:. Scedosporium apiospermum. Successful response to voriconazole therapy was seen in 15 of 24 patients (63%). Three of these patients relapsed within weeks, including patient with pulmonary, skin and eye infections, patient with cerebral disease, and patient with skin infection. Ten patients had evidence of cerebral disease and of these had successful outcome (1 relapse). In addition, successful response was seen in of patients with mixed organism infections.. Fusarium spp.. Nine of 21 (43%) patients were successfully treated with voriconazole. Of these patients, had eye infections, had an eye and blood infection, had skin infection, had blood infection alone, had sinus infections, and had disseminated infection (pulmonary, skin, hepatosplenic). Three of these patients (1 with disseminated disease, with an eye infection and with blood infection) had Fusarium solani and were complete successes. Two of these patients relapsed, with sinus infection and profound neutropenia and post surgical patient with blood and eye infections.. 14.5Pediatric Studies A total of 22 patients aged 12 to 18 years with IA were included in the adult therapeutic studies. Twelve out of 22 (55%) patients had successful response after treatment with maintenance dose of voriconazole mg/kg every 12 hours.Additional pediatric use information is approved for PF PRISM C.V.s VFEND (voriconazole). However, due to PF PRISM C.V.s marketing exclusivity rights, this drug product is not labeled with that information.

CONTRAINDICATIONS SECTION.

4 CONTRAINDICATIONS. oVoriconazole tablets are contraindicated in patients with known hypersensitivity to voriconazole or their excipients. There is no information regarding cross-sensitivity between voriconazole and other azole antifungal agents. Caution should be used when prescribing voriconazole tablets to patients with hypersensitivity to other azoles.oCoadministration of cisapride, pimozide, quinidine or ivabradine with voriconazole tablets is contraindicated because increased plasma concentrations of these drugs can lead to QT prolongation and rare occurrences of torsade de pointes [see Drug Interactions (7)].oCoadministration of voriconazole tablets with sirolimus is contraindicated because voriconazole tablets significantly increase sirolimus concentrations [see Drug Interactions (7) and Clinical Pharmacology (12.3)].oCoadministration of voriconazole tablets with rifampin, carbamazepine, long-acting barbiturates, and St. Johns Wort is contraindicated because these drugs are likely to decrease plasma voriconazole concentrations significantly [see Drug Interactions (7) and Clinical Pharmacology (12.3)] .oCoadministration of standard doses of voriconazole with efavirenz doses of 400 mg every 24 hours or higher is contraindicated, because efavirenz significantly decreases plasma voriconazole concentrations in healthy subjects at these doses. Voriconazole also significantly increases efavirenz plasma concentrations [see Drug Interactions (7) and Clinical Pharmacology (12.3)].oCoadministration of voriconazole tablets with high-dose ritonavir (400 mg every 12 hours) is contraindicated because ritonavir (400 mg every 12 hours) significantly decreases plasma voriconazole concentrations. Coadministration of voriconazole and low-dose ritonavir (100 mg every 12 hours) should be avoided, unless an assessment of the benefit/risk to the patient justifies the use of voriconazole [see Drug Interactions (7) and Clinical Pharmacology (12.3)].oCoadministration of voriconazole tablets with rifabutin is contraindicated since voriconazole tablets significantly increase rifabutin plasma concentrations and rifabutin also significantly decreases voriconazole plasma concentrations [see Drug Interactions (7) and Clinical Pharmacology (12.3)].oCoadministration of voriconazole tablets with ergot alkaloids (ergotamine and dihydroergotamine) is contraindicated because voriconazole tablets may increase the plasma concentration of ergot alkaloids, which may lead to ergotism [see Drug Interactions (7)].oCoadministration of voriconazole tablets with naloxegol is contraindicated because voriconazole tablets may increase plasma concentrations of naloxegol which may precipitate opioid withdrawal symptoms [see Drug Interactions (7)].oCoadministration of voriconazole tablets with tolvaptan is contraindicated because voriconazole tablets may increase tolvaptan plasma concentrations and increase risk of adverse reactions [see Drug Interactions (7)].oCoadministration of voriconazole tablets with venetoclax at initiation and during the ramp-up phase is contraindicated in patients with chronic lymphocytic leukemia (CLL) or small lymphocytic lymphoma (SLL) due to the potential for increased risk of tumor lysis syndrome [see Drug Interactions (7) ].oCoadministration of voriconazole tablets with lurasidone is contraindicated since it may result in significant increases in lurasidone exposure and the potential for serious adverse reactions [see Drug Interactions (7)] .. oVoriconazole tablets are contraindicated in patients with known hypersensitivity to voriconazole or their excipients. There is no information regarding cross-sensitivity between voriconazole and other azole antifungal agents. Caution should be used when prescribing voriconazole tablets to patients with hypersensitivity to other azoles.. oCoadministration of cisapride, pimozide, quinidine or ivabradine with voriconazole tablets is contraindicated because increased plasma concentrations of these drugs can lead to QT prolongation and rare occurrences of torsade de pointes [see Drug Interactions (7)].. oCoadministration of voriconazole tablets with sirolimus is contraindicated because voriconazole tablets significantly increase sirolimus concentrations [see Drug Interactions (7) and Clinical Pharmacology (12.3)].. oCoadministration of voriconazole tablets with rifampin, carbamazepine, long-acting barbiturates, and St. Johns Wort is contraindicated because these drugs are likely to decrease plasma voriconazole concentrations significantly [see Drug Interactions (7) and Clinical Pharmacology (12.3)] .. oCoadministration of standard doses of voriconazole with efavirenz doses of 400 mg every 24 hours or higher is contraindicated, because efavirenz significantly decreases plasma voriconazole concentrations in healthy subjects at these doses. Voriconazole also significantly increases efavirenz plasma concentrations [see Drug Interactions (7) and Clinical Pharmacology (12.3)].. oCoadministration of voriconazole tablets with high-dose ritonavir (400 mg every 12 hours) is contraindicated because ritonavir (400 mg every 12 hours) significantly decreases plasma voriconazole concentrations. Coadministration of voriconazole and low-dose ritonavir (100 mg every 12 hours) should be avoided, unless an assessment of the benefit/risk to the patient justifies the use of voriconazole [see Drug Interactions (7) and Clinical Pharmacology (12.3)].. oCoadministration of voriconazole tablets with rifabutin is contraindicated since voriconazole tablets significantly increase rifabutin plasma concentrations and rifabutin also significantly decreases voriconazole plasma concentrations [see Drug Interactions (7) and Clinical Pharmacology (12.3)].. oCoadministration of voriconazole tablets with ergot alkaloids (ergotamine and dihydroergotamine) is contraindicated because voriconazole tablets may increase the plasma concentration of ergot alkaloids, which may lead to ergotism [see Drug Interactions (7)].. oCoadministration of voriconazole tablets with naloxegol is contraindicated because voriconazole tablets may increase plasma concentrations of naloxegol which may precipitate opioid withdrawal symptoms [see Drug Interactions (7)].. oCoadministration of voriconazole tablets with tolvaptan is contraindicated because voriconazole tablets may increase tolvaptan plasma concentrations and increase risk of adverse reactions [see Drug Interactions (7)].. oCoadministration of voriconazole tablets with venetoclax at initiation and during the ramp-up phase is contraindicated in patients with chronic lymphocytic leukemia (CLL) or small lymphocytic lymphoma (SLL) due to the potential for increased risk of tumor lysis syndrome [see Drug Interactions (7) ].. oCoadministration of voriconazole tablets with lurasidone is contraindicated since it may result in significant increases in lurasidone exposure and the potential for serious adverse reactions [see Drug Interactions (7)] .. oHypersensitivity to voriconazole or its excipients (4)oCoadministration with cisapride, pimozide, quinidine, sirolimus or ivabradine due to risk of serious adverse reactions (4, 7)oCoadministration with rifampin, carbamazepine, long-acting barbiturates, efavirenz, ritonavir, rifabutin, ergot alkaloids, and St. Johns Wort due to risk of loss of efficacy (4, 7)oCoadministration with naloxegol, tolvaptan, and lurasidone due to risk of adverse reactions (4, 7) oCoadministration of voriconazole with venetoclax at initiation and during the ramp-up phase in patients with chronic lymphocytic leukemia (CLL) or small lymphocytic lymphoma (SLL) due to increased risk of adverse reactions (4, 7). oHypersensitivity to voriconazole or its excipients (4). oCoadministration with cisapride, pimozide, quinidine, sirolimus or ivabradine due to risk of serious adverse reactions (4, 7). oCoadministration with rifampin, carbamazepine, long-acting barbiturates, efavirenz, ritonavir, rifabutin, ergot alkaloids, and St. Johns Wort due to risk of loss of efficacy (4, 7). oCoadministration with naloxegol, tolvaptan, and lurasidone due to risk of adverse reactions (4, 7) oCoadministration of voriconazole with venetoclax at initiation and during the ramp-up phase in patients with chronic lymphocytic leukemia (CLL) or small lymphocytic lymphoma (SLL) due to increased risk of adverse reactions (4, 7).

USE IN SPECIFIC POPULATIONS SECTION.

8 USE IN SPECIFIC POPULATIONS. oPediatrics: Safety and effectiveness in patients younger than years has not been established (8.4) Additional pediatric use information is approved for PF PRISM C.V.s VFEND(R) (voriconazole). However, due to PF PRISM C.V.s marketing exclusivity rights, this drug product is not labeled with that information.. oPediatrics: Safety and effectiveness in patients younger than years has not been established (8.4). 8.1 Pregnancy. Risk Summary. Voriconazole can cause fetal harm when administered to pregnant woman. There are no available data on the use of voriconazole tablets in pregnant women. In animal reproduction studies, oral voriconazole was associated with fetal malformations in rats and fetal toxicity in rabbits. Cleft palates and hydronephrosis/hydroureter were observed in rat pups exposed to voriconazole during organogenesis at and above 10 mg/kg (0.3 times the RMD of 200 mg every 12 hours based on body surface area comparisons). In rabbits, embryomortality, reduced fetal weight and increased incidence of skeletal variations, cervical ribs and extrasternal ossification sites were observed in pups when pregnant rabbits were orally dosed at 100 mg/kg (6 times the RMD based on body surface area comparisons) during organogenesis. Rats exposed to voriconazole from implantation to weaning experienced increased gestational length and dystocia, which were associated with increased perinatal pup mortality at the 10 mg/kg dose [see Data]. If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, inform the patient of the potential hazard to the fetus [see Warnings and Precautions (5.9) ].The background risk of major birth defects and miscarriage for the indicated populations is unknown. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2-4% and 15-20% respectively.. Data. Animal Data Voriconazole was administered orally to pregnant rats during organogenesis (gestation days 6-17) at 10, 30, and 60 mg/kg/day. Voriconazole was associated with increased incidences in hydroureter and hydronephrosis at 10 mg/kg/day or greater, approximately 0.3 times the recommended human dose (RMD) based on mg/m2, and cleft palate at 60 mg/kg, approximately times the RMD based on mg/m2. Reduced ossification of sacral and caudal vertebrae, skull, pubic, and hyoid bone, supernumerary ribs, anomalies of the sternbrae, and dilatation of the ureter/renal pelvis were also observed at doses of 10 mg/kg or greater. There was no evidence of maternal toxicity at any dose.Voriconazole was administered orally to pregnant rabbits during the period of organogenesis (gestation days 7-19) at 10, 40, and 100 mg/kg/day. Voriconazole was associated with increased post-implantation loss and decreased fetal body weight, in association with maternal toxicity (decreased body weight gain and food consumption) at 100 mg/kg/day (6 times the RMD based on mg/m2). Fetal skeletal variations (increases in the incidence of cervical rib and extra sternebral ossification sites) were observed at 100 mg/kg/day.In peri- and postnatal toxicity study in rats, voriconazole was administered orally to female rats from implantation through the end of lactation at 1, 3, and 10 mg/kg/day. Voriconazole prolonged the duration of gestation and labor and produced dystocia with related increases in maternal mortality and decreases in perinatal survival of F1 pups at 10 mg/kg/day, approximately 0.3 times the RMD. 8.2 Lactation Risk Summary. No data are available regarding the presence of voriconazole in human milk, the effects of voriconazole on the breastfed infant, or the effects on milk production. The developmental and health benefits of breastfeeding should be considered along with the mothers clinical need for voriconazole tablets and any potential adverse effects on the breastfed child from voriconazole or from the underlying maternal condition. 8.3 Females and Males of Reproductive Potential Contraception. Advise females of reproductive potential to use effective contraception during treatment with voriconazole tablets. The coadministration of voriconazole with the oral contraceptive, Ortho-Novum(R) (35 mcg ethinyl estradiol and mg norethindrone), results in an interaction between these two drugs, but is unlikely to reduce the contraceptive effect. Monitoring for adverse reactions associated with oral contraceptives and voriconazole is recommended [see Drug Interactions (7) and Clinical Pharmacology (12.3)]. 8.4 Pediatric Use. The safety and effectiveness of voriconazole tablets have been established in pediatric patients aged 12 to 14 years weighing greater than or equal to 50 kg and those aged 15 years and older regardless of body weight based on evidence from adequate and well-controlled studies in adult and pediatric patients and additional pediatric pharmacokinetic and safety data. total of 51 pediatric patients aged 12 to less than 18 [N 51] from eight adult therapeutic trials provided safety information for voriconazole tablets use in the pediatric population [see Adverse Reactions (6.1), Clinical Pharmacology (12.3), and Clinical Studies (14)]. Safety and effectiveness in pediatric patients below the age of years has not been established. Therefore, voriconazole is not recommended for pediatric patients less than years of age.A higher frequency of liver enzyme elevations was observed in the pediatric patients [see Dosage and Administration (2.5), Warnings and Precautions (5.1), and Adverse Reactions (6.1)].The frequency of phototoxicity reactions is higher in the pediatric population. Squamous cell carcinoma has been reported in patients who experience photosensitivity reactions. Stringent measures for photoprotection are warranted. Sun avoidance and dermatologic follow-up are recommended in pediatric patients experiencing photoaging injuries, such as lentigines or ephelides, even after treatment discontinuation [see Warnings and Precautions (5.6)].Voriconazole tablets have not been studied in pediatric patients with hepatic or renal impairment [see Dosage and Administration (2.5, 2.6)]. Hepatic function and serum creatinine levels should be closely monitored in pediatric patients [see Dosage and Administration (2.6) and Warnings and Precautions (5.1, 5.10) ].Additional pediatric use information is approved for PF PRISM C.V.s VFEND (voriconazole). However, due to PF PRISM C.V.s marketing exclusivity rights, this drug product is not labeled with that information.. 8.5 Geriatric Use. In multiple dose therapeutic trials of voriconazole, 9.2% of patients were >= 65 years of age and 1.8% of patients were >= 75 years of age. In study in healthy subjects, the systemic exposure (AUC) and peak plasma concentrations (Cmax) were increased in elderly males compared to young males. Pharmacokinetic data obtained from 552 patients from 10 voriconazole therapeutic trials showed that voriconazole plasma concentrations in the elderly patients were approximately 80% to 90% higher than those in younger patients after either IV or oral administration. However, the overall safety profile of the elderly patients was similar to that of the young so no dosage adjustment is recommended [see Clinical Pharmacology (12.3)].

WARNINGS AND PRECAUTIONS SECTION.

5 WARNINGS AND PRECAUTIONS. oHepatic Toxicity: Serious hepatic reactions reported. Evaluate liver function tests at start of and during voriconazole therapy (5.1)oArrhythmias and QT Prolongation: Correct potassium, magnesium and calcium prior to use; caution patients with proarrhythmic conditions (5.2)oVisual Disturbances (including optic neuritis and papilledema): Monitor visual function if treatment continues beyond 28 days (5.4)oSevere Cutaneous Adverse Reactions: Discontinue for exfoliative cutaneous reactions (5.5)oPhotosensitivity: Avoid sunlight due to risk of photosensitivity (5.6)oAdrenal Dysfunction: Carefully monitor patients receiving voriconazole and corticosteroids (via all routes of administration) for adrenal dysfunction both during and after voriconazole treatment. Instruct patients to seek immediate medical care if they develop signs and symptoms of Cushings syndrome or adrenal insufficiency (5.8)oEmbryo-Fetal Toxicity: Voriconazole can cause fetal harm when administered to pregnant woman. Inform pregnant patients of the potential hazard to the fetus. Advise females of reproductive potential to use effective contraception during treatment with voriconazole (5.9, 8.1, 8.3)oSkeletal Adverse Reactions: Fluorosis and periostitis with long-term voriconazole therapy. Discontinue if these adverse reactions occur (5.12) oClinically Significant Drug Interactions: Review patients concomitant medications (5.13, 7)oPatients with Hereditary Galactose Intolerance, Lapp Lactase Deficiency or Glucose-Galactose Malabsorption: Voriconazole tablets should not be given to these patients because they contain lactose (5.14). oHepatic Toxicity: Serious hepatic reactions reported. Evaluate liver function tests at start of and during voriconazole therapy (5.1). oArrhythmias and QT Prolongation: Correct potassium, magnesium and calcium prior to use; caution patients with proarrhythmic conditions (5.2). oVisual Disturbances (including optic neuritis and papilledema): Monitor visual function if treatment continues beyond 28 days (5.4). oSevere Cutaneous Adverse Reactions: Discontinue for exfoliative cutaneous reactions (5.5). oPhotosensitivity: Avoid sunlight due to risk of photosensitivity (5.6). oAdrenal Dysfunction: Carefully monitor patients receiving voriconazole and corticosteroids (via all routes of administration) for adrenal dysfunction both during and after voriconazole treatment. Instruct patients to seek immediate medical care if they develop signs and symptoms of Cushings syndrome or adrenal insufficiency (5.8). oEmbryo-Fetal Toxicity: Voriconazole can cause fetal harm when administered to pregnant woman. Inform pregnant patients of the potential hazard to the fetus. Advise females of reproductive potential to use effective contraception during treatment with voriconazole (5.9, 8.1, 8.3). oSkeletal Adverse Reactions: Fluorosis and periostitis with long-term voriconazole therapy. Discontinue if these adverse reactions occur (5.12) oClinically Significant Drug Interactions: Review patients concomitant medications (5.13, 7). oPatients with Hereditary Galactose Intolerance, Lapp Lactase Deficiency or Glucose-Galactose Malabsorption: Voriconazole tablets should not be given to these patients because they contain lactose (5.14). 5.1Hepatic Toxicity. In clinical trials, there have been uncommon cases of serious hepatic reactions during treatment with voriconazole (including clinical hepatitis, cholestasis and fulminant hepatic failure, including fatalities).Instances of hepatic reactions were noted to occur primarily in patients with serious underlying medical conditions (predominantly hematological malignancy). Hepatic reactions, including hepatitis and jaundice, have occurred among patients with no other identifiable risk factors. Liver dysfunction has usually been reversible on discontinuation of therapy [see Adverse Reactions (6.1)].A higher frequency of liver enzyme elevations was observed in the pediatric population [see Adverse Reactions (6.1)]. Hepatic function should be monitored in both adult and pediatric patients.Measure serum transaminase levels and bilirubin at the initiation of voriconazole therapy and monitor at least weekly for the first month of treatment. Monitoring frequency can be reduced to monthly during continued use if no clinically significant changes are noted. If liver function tests become markedly elevated compared to baseline, voriconazole should be discontinued unless the medical judgment of the benefit/risk of the treatment for the patient justifies continued use [see Dosage and Administration (2.5) and Adverse Reactions (6.1)].. 5.2 Arrhythmias and QT Prolongation. Some azoles, including voriconazole, have been associated with prolongation of the QT interval on the electrocardiogram. During clinical development and post-marketing surveillance, there have been rare cases of arrhythmias, (including ventricular arrhythmias such as torsade de pointes), cardiac arrests and sudden deaths in patients taking voriconazole. These cases usually involved seriously ill patients with multiple confounding risk factors, such as history of cardiotoxic chemotherapy, cardiomyopathy, hypokalemia and concomitant medications that may have been contributory.Voriconazole should be administered with caution to patients with potentially proarrhythmic conditions, such as:oCongenital or acquired QT prolongationoCardiomyopathy, in particular when heart failure is presentoSinus bradycardiaoExisting symptomatic arrhythmiasoConcomitant medicinal product that is known to prolong QT interval [see Contraindications (4), Drug Interactions (7), and Clinical Pharmacology (12.3)]Rigorous attempts to correct potassium, magnesium and calcium should be made before starting and during voriconazole therapy [see Clinical Pharmacology (12.3)].. oCongenital or acquired QT prolongation. oCardiomyopathy, in particular when heart failure is present. oSinus bradycardia. oExisting symptomatic arrhythmias. oConcomitant medicinal product that is known to prolong QT interval [see Contraindications (4), Drug Interactions (7), and Clinical Pharmacology (12.3)]. 5.4 Visual Disturbances. The effect of voriconazole on visual function is not known if treatment continues beyond 28 days.There have been post-marketing reports of prolonged visual adverse reactions, including optic neuritis and papilledema. If treatment continues beyond 28 days, visual function including visual acuity, visual field, and color perception should be monitored [see Adverse Reactions (6.2)].. 5.5 Severe Cutaneous Adverse Reactions. Severe cutaneous adverse reactions (SCARs), such as Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and drug reaction with eosinophilia and systemic symptoms (DRESS), which can be life-threatening or fatal, have been reported during treatment with voriconazole. If patient develops severe cutaneous adverse reaction, voriconazole should be discontinued [see Adverse Reactions (6.1, 6.2)].. 5.6 Photosensitivity Voriconazole has been associated with photosensitivity skin reaction. Patients, including pediatric patients, should avoid exposure to direct sunlight during voriconazole treatment and should use measures such as protective clothing and sunscreen with high sun protection factor (SPF). If phototoxic reactions occur, the patient should be referred to dermatologist and voriconazole discontinuation should be considered. If voriconazole is continued despite the occurrence of phototoxicity-related lesions, dermatologic evaluation should be performed on systematic and regular basis to allow early detection and management of premalignant lesions. Squamous cell carcinoma of the skin and melanoma have been reported during long-term voriconazole therapy in patients with photosensitivity skin reactions. If patient develops skin lesion consistent with premalignant skin lesions, squamous cell carcinoma or melanoma, voriconazole should be discontinued. In addition, voriconazole has been associated with photosensitivity related skin reactions such as pseudoporphyria, cheilitis, and cutaneous lupus erythematosus. Patients should avoid strong, direct sunlight during voriconazole therapy.The frequency of phototoxicity reactions is higher in the pediatric population. Because squamous cell carcinoma has been reported in patients who experience photosensitivity reactions, stringent measures for photoprotection are warranted in children. In children experiencing photoaging injuries such as lentigines or ephelides, sun avoidance and dermatologic follow-up are recommended even after treatment discontinuation.. 5.7 Renal Toxicity. Acute renal failure has been observed in patients undergoing treatment with voriconazole. Patients being treated with voriconazole are likely to be treated concomitantly with nephrotoxic medications and may have concurrent conditions that may result in decreased renal function.Patients should be monitored for the development of abnormal renal function. This should include laboratory evaluation of serum creatinine [see Clinical Pharmacology (12.3) and Dosage and Administration (2.6)].. 5.8Adrenal Dysfunction Reversible cases of azole-induced adrenal insufficiency have been reported in patients receiving azoles, including voriconazole. Adrenal insufficiency has been reported in patients receiving azoles with or without concomitant corticosteroids. In patients receiving azoles without corticosteroids adrenal insufficiency is related to direct inhibition of steroidogenesis by azoles. In patients taking corticosteroids, voriconazole associated CYP3A4 inhibition of their metabolism may lead to corticosteroid excess and adrenal suppression [see Drug Interactions (7) and Clinical Pharmacology (12.3)]. Cushings syndrome with and without subsequent adrenal insufficiency has also been reported in patients receiving voriconazole concomitantly with corticosteroids. Patients receiving voriconazole and corticosteroids (via all routes of administration) should be carefully monitored for adrenal dysfunction both during and after voriconazole treatment. Patients should be instructed to seek immediate medical care if they develop signs and symptoms of Cushings syndrome or adrenal insufficiency.. 5.9 Embryo-Fetal Toxicity. Voriconazole can cause fetal harm when administered to pregnant woman.In animals, voriconazole administration was associated with fetal malformations, embryotoxicity, increased gestational length, dystocia and embryomortality [see Use in Specific Populations (8.1)]. If voriconazole is used during pregnancy, or if the patient becomes pregnant while taking voriconazole, inform the patient of the potential hazard to the fetus. Advise females of reproductive potential to use effective contraception during treatment with voriconazole [see Use in Specific Populations (8.3)].. 5.10 Laboratory Tests. Electrolyte disturbances such as hypokalemia, hypomagnesemia and hypocalcemia should be corrected prior to initiation of and during voriconazole therapy.Patient management should include laboratory evaluation of renal (particularly serum creatinine) and hepatic function (particularly liver function tests and bilirubin).. 5.11 Pancreatitis. Pancreatitis has been observed in patients undergoing treatment with voriconazole [see Adverse Reactions (6.1, 6.2)]. Patients with risk factors for acute pancreatitis (e.g., recent chemotherapy, hematopoietic stem cell transplantation [HSCT]) should be monitored for the development of pancreatitis during voriconazole treatment.. 5.12 Skeletal Adverse Reactions. Fluorosis and periostitis have been reported during long-term voriconazole therapy. If patient develops skeletal pain and radiologic findings compatible with fluorosis or periostitis, voriconazole should be discontinued [see Adverse Reactions (6.2)].. 5.13 Clinically Significant Drug Interactions. See Table 10 for listing of drugs that may significantly alter voriconazole concentrations. Also, see Table 11 for listing of drugs that may interact with voriconazole resulting in altered pharmacokinetics or pharmacodynamics of the other drug [see Contraindications (4) and Drug Interactions (7)].. 5.14 Galactose Intolerance. Voriconazole tablets contain lactose and should not be given to patients with rare hereditary problems of galactose intolerance, Lapp lactase deficiency or glucose-galactose malabsorption.

PHARMACOKINETICS SECTION.

12.3 Pharmacokinetics. The pharmacokinetics of voriconazole have been characterized in healthy subjects, special populations and patients.The pharmacokinetics of voriconazole are non-linear due to saturation of its metabolism. The interindividual variability of voriconazole pharmacokinetics is high. Greater than proportional increase in exposure is observed with increasing dose. It is estimated that, on average, increasing the oral dose from 200 mg every 12 hours to 300 mg every 12 hours leads to an approximately 2.5-fold increase in exposure (AUC); similarly, increasing the intravenous dose from mg/kg every 12 hours to mg/kg every 12 hours produces an approximately 2.5-fold increase in exposure (Table 12).Table 12: Geometric Mean (% CV) Plasma Voriconazole Pharmacokinetic Parameters in Adults Receiving Different Dosing RegimensNote: Parameters were estimated based on non-compartmental analysis from pharmacokinetic studies.AUC12 area under the curve over 12 hour dosing interval, Cmax maximum plasma concentration, Cmin minimum plasma concentration. CV coefficient of variation6 mg/kg IV (loading dose)3 mg/kg IV every 12 hours4 mg/kg IV every 12 hours400 mg Oral (loading dose)200 mg Oral every 12 hours300 mg Oral every 12 hoursN 352340174816AUC12 (ug.h/mL) 13.9 (32)13.7 (53)33.9 (54)9.31 (38)12.4 (78)34.0 (53)Cmax (ug/mL) 3.13 (20)3.03 (25)4.77 (36)2.30 (19)2.31 (48)4.74 (35)Cmin (ug/mL) --0.46 (97)1.73 (74)--0.46 (120)1.63 (79)When the recommended intravenous loading dose regimen is administered to healthy subjects, plasma concentrations close to steady state are achieved within the first 24 hours of dosing (e.g., mg/kg IV every 12 hours on day followed by mg/kg IV every 12 hours). Without the loading dose, accumulation occurs during twice daily multiple dosing with steady state plasma voriconazole concentrations being achieved by day in the majority of subjects.. Absorption. The pharmacokinetic properties of voriconazole are similar following administration by the intravenous and oral routes. Based on population pharmacokinetic analysis of pooled data in healthy subjects (N 207), the oral bioavailability of voriconazole is estimated to be 96% (CV 13%). Bioequivalence was established between the 200 mg tablet and the 40 mg/mL oral suspension when administered as 400 mg every 12 hours loading dose followed by 200 mg every 12 hours maintenance dose.Maximum plasma concentrations (Cmax) are achieved 1-2 hours after dosing. When multiple doses of voriconazole are administered with high-fat meals, the mean Cmax and AUC are reduced by 34% and 24%, respectively when administered as tablet and by 58% and 37% respectively when administered as the oral suspension [see Dosage and Administration (2)].In healthy subjects, the absorption of voriconazole is not affected by coadministration of oral ranitidine, cimetidine, or omeprazole, drugs that are known to increase gastric pH.. Distribution. The volume of distribution at steady state for voriconazole is estimated to be 4.6 L/kg, suggesting extensive distribution into tissues. Plasma protein binding is estimated to be 58% and was shown to be independent of plasma concentrations achieved following single and multiple oral doses of 200 mg or 300 mg (approximate range: 0.9-15 ug/mL). Varying degrees of hepatic and renal impairment do not affect the protein binding of voriconazole.. Elimination. Metabolism In vitro studies showed that voriconazole is metabolized by the human hepatic cytochrome P450 enzymes, CYP2C19, CYP2C9 and CYP3A4 [see Drug Interactions (7)].In vivo studies indicated that CYP2C19 is significantly involved in the metabolism of voriconazole. This enzyme exhibits genetic polymorphism [see Clinical Pharmacology (12.5)].The major metabolite of voriconazole is the N-oxide, which accounts for 72% of the circulating radiolabelled metabolites in plasma. Since this metabolite has minimal antifungal activity, it does not contribute to the overall efficacy of voriconazole.. Excretion Voriconazole is eliminated via hepatic metabolism with less than 2% of the dose excreted unchanged in the urine. After administration of single radiolabelled dose of either oral or IV voriconazole, preceded by multiple oral or IV dosing, approximately 80% to 83% of the radioactivity is recovered in the urine. The majority (> 94%) of the total radioactivity is excreted in the first 96 hours after both oral and intravenous dosing.As result of non-linear pharmacokinetics, the terminal half-life of voriconazole is dose dependent and therefore not useful in predicting the accumulation or elimination of voriconazole. Specific Populations. Male and Female Patients In multiple oral dose study, the mean Cmax and AUC for healthy young females were 83% and 113% higher, respectively, than in healthy young males (18-45 years), after tablet dosing. In the same study, no significant differences in the mean Cmax and AUC were observed between healthy elderly males and healthy elderly females (> 65 years). In similar study, after dosing with the oral suspension, the mean AUC for healthy young females was 45% higher than in healthy young males whereas the mean Cmax was comparable between genders. The steady state trough voriconazole concentrations (Cmin) seen in females were 100% and 91% higher than in males receiving the tablet and the oral suspension, respectively.In the clinical program, no dosage adjustment was made on the basis of gender. The safety profile and plasma concentrations observed in male and female subjects were similar. Therefore, no dosage adjustment based on gender is necessary.. Geriatric Patients In an oral multiple dose study the mean Cmax and AUC in healthy elderly males (>= 65 years) were 61% and 86% higher, respectively, than in young males (18-45 years). No significant differences in the mean Cmax and AUC were observed between healthy elderly females (>= 65 years) and healthy young females (18-45 years).In the clinical program, no dosage adjustment was made on the basis of age. An analysis of pharmacokinetic data obtained from 552 patients from 10 voriconazole clinical trials showed that the median voriconazole plasma concentrations in the elderly patients (> 65 years) were approximately 80% to 90% higher than those in the younger patients (<= 65 years) after either IV or oral administration. However, the safety profile of voriconazole in young and elderly subjects was similar and, therefore, no dosage adjustment is necessary for the elderly [see Use in Specific Populations (8.5)].. Pediatric Patients Voriconazole exposures in the majority of pediatric patients aged 12 to less than 17 years were comparable to those in adults receiving the same dosing regimens. However, lower voriconazole exposure was observed in some pediatric patients aged 12 to less than 17 years with low body weight compared to adults [see Dosage and Administration (2.4)].Additional pediatric use information is approved for PF PRISM C.V.s VFEND (voriconazole). However, due to PF PRISM C.V.s marketing exclusivity rights, this drug product is not labeled with that information.. Patients with Hepatic Impairment After single oral dose (200 mg) of voriconazole in patients with mild (Child-Pugh Class A) and patients with moderate (Child-Pugh Class B) hepatic impairment, the mean systemic exposure (AUC) was 3.2-fold higher than in age and weight matched controls with normal hepatic function. There was no difference in mean peak plasma concentrations (Cmax) between the groups. When only the patients with mild (Child-Pugh Class A) hepatic impairment were compared to controls, there was still 2.3-fold increase in the mean AUC in the group with hepatic impairment compared to controls.In an oral multiple dose study, AUC was similar in subjects with moderate hepatic impairment (Child-Pugh Class B) given lower maintenance dose of 100 mg twice daily compared to subjects with normal hepatic function given the standard 200 mg twice daily maintenance dose. The mean peak plasma concentrations (Cmax) were 20% lower in the hepatically impaired group. No pharmacokinetic data are available for patients with severe hepatic cirrhosis (Child-Pugh Class C) [see Dosage and Administration (2.5)].. Patients with Renal Impairment In single oral dose (200 mg) study in 24 subjects with normal renal function and mild to severe renal impairment, systemic exposure (AUC) and peak plasma concentration (Cmax) of voriconazole were not significantly affected by renal impairment. Therefore, no adjustment is necessary for oral dosing in patients with mild to severe renal impairment.In multiple dose study of IV voriconazole (6 mg/kg IV loading dose 2, then mg/kg IV 5.5 days) in patients with moderate renal dysfunction (creatinine clearance 30-50 mL/min), the systemic exposure (AUC) and peak plasma concentrations (Cmax) were not significantly different from those in subjects with normal renal function.However, in patients with moderate renal dysfunction (creatinine clearance 30-50 mL/min), accumulation of the intravenous vehicle, SBECD, occurs. The mean systemic exposure (AUC) and peak plasma concentrations (Cmax) of SBECD were increased 4-fold and almost 50%, respectively, in the moderately impaired group compared to the normal control group.A pharmacokinetic study in subjects with renal failure undergoing hemodialysis showed that voriconazole is dialyzed with clearance of 121 mL/min. The intravenous vehicle, SBECD, is hemodialyzed with clearance of 55 mL/min. 4-hour hemodialysis session does not remove sufficient amount of voriconazole to warrant dose adjustment [see Dosage and Administration (2.6)].. Patients at Risk of Aspergillosis The observed voriconazole pharmacokinetics in patients at risk of aspergillosis (mainly patients with malignant neoplasms of lymphatic or hematopoietic tissue) were similar to healthy subjects.. Drug Interaction Studies. Effects of Other Drugs on Voriconazole Voriconazole is metabolized by the human hepatic cytochrome P450 enzymes CYP2C19, CYP2C9, and CYP3A4. Results of in vitro metabolism studies indicate that the affinity of voriconazole is highest for CYP2C19, followed by CYP2C9, and is appreciably lower for CYP3A4. Inhibitors or inducers of these three enzymes may increase or decrease voriconazole systemic exposure (plasma concentrations), respectively.The systemic exposure to voriconazole is significantly reduced by the concomitant administration of the following agents and their use is contraindicated:. Rifampin (Potent CYP450 Inducer). Rifampin (600 mg once daily) decreased the steady state Cmax and AUC of voriconazole (200 mg every 12 hours 7 days) by an average of 93% and 96%, respectively, in healthy subjects. Doubling the dose of voriconazole to 400 mg every 12 hours does not restore adequate exposure to voriconazole during coadministration with rifampin [see Contraindications (4)].. Ritonavir (Potent CYP450 Inducer; CYP3A4 Inhibitor and Substrate). The effect of the coadministration of voriconazole and ritonavir (400 mg and 100 mg) was investigated in two separate studies. High-dose ritonavir (400 mg every 12 hours for days) decreased the steady state Cmax and AUC of oral voriconazole (400 mg every 12 hours for day, then 200 mg every 12 hours for days) by an average of 66% and 82%, respectively, in healthy subjects. Low-dose ritonavir (100 mg every 12 hours for days) decreased the steady state Cmax and AUC of oral voriconazole (400 mg every 12 hours for day, then 200 mg every 12 hours for days) by an average of 24% and 39%, respectively, in healthy subjects. Although repeat oral administration of voriconazole did not have significant effect on steady state Cmax and AUC of high-dose ritonavir in healthy subjects, steady state Cmax and AUC of low-dose ritonavir decreased slightly by 24% and 14% respectively, when administered concomitantly with oral voriconazole in healthy subjects [see Contraindications (4)].. St. Johns Wort (CYP450 Inducer; P-gp Inducer). In an independent published study in healthy volunteers who were given multiple oral doses of St. Johns Wort (300 mg LI 160 extract three times daily for 15 days) followed by single 400 mg oral dose of voriconazole, 59% decrease in mean voriconazole AUC0- was observed. In contrast, coadministration of single oral doses of St. Johns Wort and voriconazole had no appreciable effect on voriconazole AUC0-. Long-term use of St. Johns Wort could lead to reduced voriconazole exposure [see Contraindications (4)].Significant drug interactions that may require voriconazole dosage adjustment, or frequent monitoring of voriconazole-related adverse reactions/toxicity:. Fluconazole (CYP2C9, CYP2C19 and CYP3A4 Inhibitor). Concurrent administration of oral voriconazole (400 mg every 12 hours for day, then 200 mg every 12 hours for 2.5 days) and oral fluconazole (400 mg on day 1, then 200 mg every 24 hours for days) to healthy male subjects resulted in an increase in Cmax and AUC of voriconazole by an average of 57% (90% CI: 20%, 107%) and 79% (90% CI: 40%, 128%), respectively. In follow-on clinical study involving healthy male subjects, reduced dosing and/or frequency of voriconazole and fluconazole did not eliminate or diminish this effect [see Drug Interactions (7)].. Letermovir (CYP2C9/2C19 Inducer). Coadministration of oral letermovir with oral voriconazole decreased the steady state Cmax and AUC0-12 of voriconazole by an average of 39% and 44%, respectively [see Drug Interactions (7)].Minor or no significant pharmacokinetic interactions that do not require dosage adjustment:. Cimetidine (Non-specific CYP450 Inhibitor and Increases Gastric pH). Cimetidine (400 mg every 12 hours 8 days) increased voriconazole steady state Cmax and AUC by an average of 18% (90% CI: 6%, 32%) and 23% (90% CI: 13%, 33%), respectively, following oral doses of 200 mg every 12 hours 7 days to healthy subjects.. Ranitidine (Increases Gastric pH). Ranitidine (150 mg every 12 hours) had no significant effect on voriconazole Cmax and AUC following oral doses of 200 mg every 12 hours 7 days to healthy subjects.. Macrolide Antibiotics. Coadministration of erythromycin (CYP3A4 inhibitor; gram every 12 hours for days) or azithromycin (500 mg every 24 hours for days) with voriconazole 200 mg every 12 hours for 14 days had no significant effect on voriconazole steady state Cmax and AUC in healthy subjects. The effects of voriconazole on the pharmacokinetics of either erythromycin or azithromycin are not known.. Effects of Voriconazole on Other Drugs In vitro studies with human hepatic microsomes show that voriconazole inhibits the metabolic activity of the cytochrome P450 enzymes CYP2C19, CYP2C9, and CYP3A4. In these studies, the inhibition potency of voriconazole for CYP3A4 metabolic activity was significantly less than that of two other azoles, ketoconazole and itraconazole. In vitro studies also show that the major metabolite of voriconazole, voriconazole N-oxide, inhibits the metabolic activity of CYP2C9 and CYP3A4 to greater extent than that of CYP2C19. Therefore, there is potential for voriconazole and its major metabolite to increase the systemic exposure (plasma concentrations) of other drugs metabolized by these CYP450 enzymes.The systemic exposure of the following drug is significantly increased by coadministration of voriconazole and their use is contraindicated:. Sirolimus (CYP3A4 Substrate). Repeat dose administration of oral voriconazole (400 mg every 12 hours for day, then 200 mg every 12 hours for days) increased the Cmax and AUC of sirolimus (2 mg single dose) an average of 7-fold (90% CI: 5.7, 7.5) and 11-fold (90% CI: 9.9, 12.6), respectively, in healthy male subjects [see Contraindications (4)].Coadministration of voriconazole with the following agents results in increased exposure to these drugs. Therefore, careful monitoring and/or dosage adjustment of these drugs is needed:. Alfentanil (CYP3A4 Substrate). Coadministration of multiple doses of oral voriconazole (400 mg every 12 hours on day 1, 200 mg every 12 hours on day 2) with single 20 mcg/kg intravenous dose of alfentanil with concomitant naloxone resulted in 6-fold increase in mean alfentanil AUC0- and 4-fold prolongation of mean alfentanil elimination half-life, compared to when alfentanil was given alone [see Drug Interactions (7)].. Fentanyl (CYP3A4 Substrate). In an independent published study, concomitant use of voriconazole (400 mg every 12 hours on Day 1, then 200 mg every 12 hours on Day 2) with single intravenous dose of fentanyl (5 ug/kg) resulted in an increase in the mean AUC0- of fentanyl by 1.4-fold (range 0.81- to 2.04-fold) [see Drug Interactions (7)].. Oxycodone (CYP3A4 Substrate). In an independent published study, coadministration of multiple doses of oral voriconazole (400 mg every 12 hours, on Day followed by five doses of 200 mg every 12 hours on Days to 4) with single 10 mg oral dose of oxycodone on Day resulted in an increase in the mean Cmax and AUC0- of oxycodone by 1.7- fold (range 1.4- to 2.2-fold) and 3.6-fold (range 2.7- to 5.6-fold), respectively. The mean elimination half-life of oxycodone was also increased by 2.0-fold (range 1.4- to 2.5-fold) [see Drug Interactions (7)].. Cyclosporine (CYP3A4 Substrate). In stable renal transplant recipients receiving chronic cyclosporine therapy, concomitant administration of oral voriconazole (200 mg every 12 hours for days) increased cyclosporine Cmax and AUC an average of 1.1 times (90% CI: 0.9, 1.41) and 1.7 times (90% CI: 1.5, 2.0), respectively, as compared to when cyclosporine was administered without voriconazole [see Drug Interactions (7)].. Methadone (CYP3A4, CYP2C19, CYP2C9 Substrate). Repeat dose administration of oral voriconazole (400 mg every 12 hours for day, then 200 mg every 12 hours for days) increased the Cmax and AUC of pharmacologically active Rmethadone by 31% (90% CI: 22%, 40%) and 47% (90% CI: 38%, 57%), respectively, in subjects receiving methadone maintenance dose (30-100 mg every 24 hours). The Cmax and AUC of (S)-methadone increased by 65% (90% CI: 53%, 79%) and 103% (90% CI: 85%, 124%), respectively [see Drug Interactions (7)]. Tacrolimus (CYP3A4 Substrate). Repeat oral dose administration of voriconazole (400 mg every 12 hours 1 day, then 200 mg every 12 hours 6 days) increased tacrolimus (0.1 mg/kg single dose) Cmax and AUC in healthy subjects by an average of 2-fold (90% CI: 1.9, 2.5) and 3-fold (90% CI: 2.7, 3.8), respectively [see Drug Interactions (7)].. Warfarin (CYP2C9 Substrate). Coadministration of voriconazole (300 mg every 12 hours 12 days) with warfarin (30 mg single dose) significantly increased maximum prothrombin time by approximately times that of placebo in healthy subjects [see Drug Interactions (7)].. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs; CYP2C9 Substrates). In two independent published studies, single doses of ibuprofen (400 mg) and diclofenac (50 mg) were coadministered with the last dose of voriconazole (400 mg every 12 hours on Day 1, followed by 200 mg every 12 hours on Day 2). Voriconazole increased the mean Cmax and AUC of the pharmacologically active isomer, (+)-ibuprofen by 20% and 100%, respectively. Voriconazole increased the mean Cmax and AUC of diclofenac by 114% and 78%, respectively [see Drug Interactions (7)].No significant pharmacokinetic interactions were observed when voriconazole was coadministered with the following agents. Therefore, no dosage adjustment for these agents is recommended: Prednisolone (CYP3A4 Substrate). Voriconazole (200 mg every 12 hours 30 days) increased Cmax and AUC of prednisolone (60 mg single dose) by an average of 11% and 34%, respectively, in healthy subjects [see Warnings and Precautions (5.8)].. Digoxin (P-glycoprotein Mediated Transport). Voriconazole (200 mg every 12 hours 12 days) had no significant effect on steady state Cmax and AUC of digoxin (0.25 mg once daily for 10 days) in healthy subjects.. Mycophenolic Acid (UDP-glucuronyl Transferase Substrate). Voriconazole (200 mg every 12 hours 5 days) had no significant effect on the Cmax and AUC of mycophenolic acid and its major metabolite, mycophenolic acid glucuronide after administration of 1 gram single oral dose of mycophenolate mofetil.. Two-Way Interactions: Concomitant use of the following agents with voriconazole is contraindicated: Rifabutin (Potent CYP450 Inducer). Rifabutin (300 mg once daily) decreased the Cmax and AUC of voriconazole at 200 mg twice daily by an average of 67% (90% CI: 58%, 73%) and 79% (90% CI: 71%, 84%), respectively, in healthy subjects. During coadministration with rifabutin (300 mg once daily), the steady state Cmax and AUC of voriconazole following an increased dose of 400 mg twice daily were on average approximately times higher, compared with voriconazole alone at 200 mg twice daily. Coadministration of voriconazole at 400 mg twice daily with rifabutin 300 mg twice daily increased the Cmax and AUC of rifabutin by an average of 3-times (90% CI: 2.2, 4.0) and times (90% CI: 3.5, 5.4), respectively, compared to rifabutin given alone [see Contraindications (4)].Significant drug interactions that may require dosage adjustment, frequent monitoring of drug levels and/or frequent monitoring of drug-related adverse reactions/toxicity: Efavirenz, Non-Nucleoside Reverse Transcriptase Inhibitor (CYP450 Inducer; CYP3A4 Inhibitor and Substrate). Standard doses of voriconazole and efavirenz (400 mg every 24 hours or higher) must not be coadministered [see Drug Interactions (7)]. Steady state efavirenz (400 mg PO every 24 hours) decreased the steady state Cmax and AUC of voriconazole (400 mg PO every 12 hours for day, then 200 mg PO every 12 hours for days) by an average of 61% and 77%, respectively, in healthy male subjects. Voriconazole at steady state (400 mg PO every 12 hours for day, then 200 mg every 12 hours for days) increased the steady state Cmax and AUC of efavirenz (400 mg PO every 24 hours for days) by an average of 38% and 44%, respectively, in healthy subjects.The pharmacokinetics of adjusted doses of voriconazole and efavirenz were studied in healthy male subjects following administration of voriconazole (400 mg PO every 12 hours on Days to 7) with efavirenz (300 mg PO every 24 hours on Days 1-7), relative to steady state administration of voriconazole (400 mg for day, then 200 mg PO every 12 hours for days) or efavirenz (600 mg every 24 hours for days). Coadministration of voriconazole 400 mg every 12 hours with efavirenz 300 mg every 24 hours, decreased voriconazole AUC by 7% (90% CI: -23%, 13%) and increased Cmax by 23% (90% CI: -1%, 53%); efavirenz AUC was increased by 17% (90% CI: 6%, 29%) and Cmax was equivalent [see Dosage and Administration (2.7), Contraindications (4), and Drug Interactions (7)].. Phenytoin (CYP2C9 Substrate and Potent CYP450 Inducer). Repeat dose administration of phenytoin (300 mg once daily) decreased the steady state Cmax and AUC of orally administered voriconazole (200 mg every 12 hours 14 days) by an average of 50% and 70%, respectively, in healthy subjects. Administration of higher voriconazole dose (400 mg every 12 hours 7 days) with phenytoin (300 mg once daily) resulted in comparable steady state voriconazole Cmax and AUC estimates as compared to when voriconazole was given at 200 mg every 12 hours without phenytoin [see Dosage and Administration (2.7) and Drug Interactions (7)].Repeat dose administration of voriconazole (400 mg every 12 hours 10 days) increased the steady state Cmax and AUC of phenytoin (300 mg once daily) by an average of 70% and 80%, respectively, in healthy subjects. The increase in phenytoin Cmax and AUC when coadministered with voriconazole may be expected to be as high as times the Cmax and AUC estimates when phenytoin is given without voriconazole [see Drug Interactions (7)].. Omeprazole (CYP2C19 Inhibitor; CYP2C19 and CYP3A4 Substrate). Coadministration of omeprazole (40 mg once daily 10 days) with oral voriconazole (400 mg every 12 hours 1 day, then 200 mg every 12 hours 9 days) increased the steady state Cmax and AUC of voriconazole by an average of 15% (90% CI: 5%, 25%) and 40% (90% CI: 29%, 55%), respectively, in healthy subjects. No dosage adjustment of voriconazole is recommended.Coadministration of voriconazole (400 mg every 12 hours 1 day, then 200 mg 6 days) with omeprazole (40 mg once daily 7 days) to healthy subjects significantly increased the steady state Cmax and AUC of omeprazole an average of times (90% CI: 1.8, 2.6) and times (90% CI: 3.3, 4.4), respectively, as compared to when omeprazole is given without voriconazole [see Drug Interactions (7)].. Oral Contraceptives (CYP3A4 Substrate; CYP2C19 Inhibitor). Coadministration of oral voriconazole (400 mg every 12 hours for day, then 200 mg every 12 hours for days) and oral contraceptive (Ortho-Novum1/35(R) consisting of 35 mcg ethinyl estradiol and mg norethindrone, every 24 hours) to healthy female subjects at steady state increased the Cmax and AUC of ethinyl estradiol by an average of 36% (90% CI: 28%, 45%) and 61% (90% CI: 50%, 72%), respectively, and that of norethindrone by 15% (90% CI: 3%, 28%) and 53% (90% CI: 44%, 63%), respectively in healthy subjects. Voriconazole Cmax and AUC increased by an average of 14% (90% CI: 3%, 27%) and 46% (90% CI: 32%, 61%), respectively [see Drug Interactions (7)].No significant pharmacokinetic interaction was seen and no dosage adjustment of these drugs is recommended: Indinavir (CYP3A4 Inhibitor and Substrate). Repeat dose administration of indinavir (800 mg TID for 10 days) had no significant effect on voriconazole Cmax and AUC following repeat dose administration (200 mg every 12 hours for 17 days) in healthy subjects.Repeat dose administration of voriconazole (200 mg every 12 hours for days) did not have significant effect on steady state Cmax and AUC of indinavir following repeat dose administration (800 mg TID for days) in healthy subjects.

SPL PATIENT PACKAGE INSERT SECTION.

Patient Information. Voriconazole Tablets, for oral use(vor kon zole)Read the Patient Information that comes with voriconazole tablets before you start taking them and each time you get refill. There may be new information. This information does not take the place of talking with your healthcare provider about your condition or treatment.What are voriconazole tabletsVoriconazole tablets are prescription medicine used to treat certain serious fungal infections in your blood and body. These infections are called aspergillosis, esophageal candidiasis, Scedosporium, Fusarium, and candidemia.It is not known if voriconazole is safe and effective in children younger than years old.Do not take voriconazole tablets if you:oare allergic to voriconazole or any of the ingredients in voriconazole tablets. See the end of this leaflet for complete list of ingredients in voriconazole tablets.oare taking any of the following medicines:ocisaprideosirolimusolong-acting barbiturates like phenobarbitalorifabutinonaloxegoloivabradineovenetoclaxopimozideorifampinoefavirenzoergotamine, dihydroergotamine (ergot alkaloids)otolvaptanoquinidineocarbamazepineoritonaviroSt. Johns Wort (herbal supplement)olurasidoneAsk your healthcare provider or pharmacist if you are not sure if you are taking any of the medicines listed above.Do not start taking new medicine without talking to your healthcare provider or pharmacist.Before you take voriconazole tablets, tell your healthcare provider about all of your medical conditions, including if you:ohave or ever had heart disease, or an abnormal heart rate or rhythm. Your healthcare provider may order test to check your heart (EKG) before starting voriconazole tablets.ohave low potassium levels, low magnesium levels, and low calcium levels. Your healthcare provider may do blood tests before starting and during treatment with voriconazole tablets.ohave liver or kidney problems. Your healthcare provider may do blood tests to make sure you can take voriconazole tablets.ohave trouble digesting dairy products, lactose (milk sugar), or regular table sugar. Voriconazole tablets contain lactose. oare pregnant or plan to become pregnant. Voriconazole can harm your unborn baby. Talk to your healthcare provider if you are pregnant or plan to become pregnant. Women who can become pregnant should use effective birth control while taking voriconazole tablets. Talk to your healthcare provider about birth control methods that may be right for you. oare breastfeeding or plan to breastfeed. It is not known if voriconazole passes into breast milk. Talk to your healthcare provider about the best way to feed your baby if you take voriconazole tablets.Tell your healthcare provider about all the medicines you take, including prescription and over-the-counter medicines, vitamins and herbal supplements.Voriconazole tablets may affect the way other medicines work, and other medicines may affect how voriconazole tablets work.Know what medicines you take. Keep list of them to show your healthcare provider or pharmacist when you get new medicine.How should take voriconazole tabletsoVoriconazole may be prescribed to you as:oVoriconazole tablets oTake voriconazole tablets exactly as your healthcare provider tells you to.oTake voriconazole tablets at least hour before or at least hour after meals.oIf you take too many voriconazole tablets, call your healthcare provider or go to the nearest hospital emergency room.What should avoid while taking voriconazole tabletsoYou should not drive at night while taking voriconazole tablets. Voriconazole tablets can cause changes in your vision such as blurring or sensitivity to light.oDo not drive or operate machinery, or do other dangerous activities until you know how voriconazole tablets affect you.oAvoid direct sunlight. Voriconazole tablets can make your skin sensitive to the sun and the light from sunlamps and tanning beds. You could get severe sunburn. Use sunscreen and wear hat and clothes that cover your skin if you have to be in sunlight. Talk to your healthcare provider if you get sunburn.What are possible side effects of voriconazole tabletsVoriconazole tablets may cause serious side effects including:oliver problems. Symptoms of liver problems may include:oitchy skinoflu-like symptomsoyellowing of your eyesonausea or vomitingofeeling very tiredovision changes. Symptoms of vision changes may include:oblurred visionochanges in the way you see colorsosensitivity to light (photophobia)oserious heart problems. Voriconazole tablets may cause changes in your heart rate or rhythm, including your heart stopping (cardiac arrest).oallergic reactions. Symptoms of an allergic reaction may include:ofeverochest tightnessonauseaosweatingotrouble breathingoitchingofeels like your heart is beating fast (tachycardia)ofeel faintoskin rashokidney problems. Voriconazole tablets may cause new or worse problems with kidney function, including kidney failure. Your healthcare provider should check your kidney function while you are taking voriconazole tablets. Your healthcare provider will decide if you can keep taking voriconazole tablets.oserious skin reactions. Symptoms of serious skin reactions may include:orash or hivesomouth soresoblistering or peeling of your skinotrouble swallowing or breathing oadrenal gland problems:oVoriconazole tablets may cause reduced adrenal function (adrenal insufficiency).oVoriconazole tablets may cause overactive adrenal function (Cushings syndrome) when voriconazole is used at the same time with corticosteroids. Symptoms of adrenal insufficiency include:ofeeling tiredonausea and vomitingoabdominal painolack of energyofeeling dizzy or lightheadedoweaknessoweight loss Symptoms of Cushings syndrome include:oweight gainothinning skinoexcessive hair growthofatty hump between the shoulders (buffalo hump) and rounded face (moon face)obruising easilyoexcessive sweatingodarkening of the skin on the stomach, thighs, breasts, and armsohigh blood sugarobone problems. Voriconazole tablets may cause weakening of bones and bone pain. Tell your healthcare provider if you have bone pain.Call your healthcare provider or go to the nearest hospital emergency room right away if you have any of the symptoms listed above. The most common side effects of voriconazole tablets include:ovision changesonauseaohallucinations (seeing or hearing things that are not there)orashoheadacheoabnormal liver function testsochillsovomitingofast heart beat (tachycardia)ofeverTell your healthcare provider if you have any side effect that bothers you or that does not go away.These are not all the possible side effects of voriconazole tablets. Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.How should store voriconazole tabletsoStore voriconazole tablets at room temperature, 20 to 25C (68 to 77F). oKeep voriconazole tablets in tightly closed container.oSafely throw away medicine that is out of date or no longer needed.oKeep voriconazole tablets, as well as all other medicines, out of the reach of children.General information about the safe and effective use of voriconazole tabletsMedicines are sometimes prescribed for purposes other than those listed in Patient Information leaflet. Do not use voriconazole tablets for condition for which they were not prescribed. Do not give voriconazole tablets to other people, even if they have the same symptoms that you have. They may harm them. You can ask your healthcare provider or pharmacist for information about voriconazole tablets that is written for health professionals.What are the ingredients in voriconazole tabletsActive ingredient: voriconazole.Inactive ingredients: croscarmellose sodium, hypromellose, lactose monohydrate, magnesium stearate, povidone, pregelatinized starch (corn), titanium dioxide and triacetin. For more information, call Mylan at 1-877-446-3679 (1-877-4-INFO-RX). Additional pediatric use information is approved for PF PRISM C.V.s VFEND (voriconazole). However, due to PF PRISM C.V.s marketing exclusivity rights, this drug product is not labeled with that information. The brands listed are trademarks of their respective owners. Manufactured for: Mylan Pharmaceuticals Inc., Morgantown, WV 26505Manufactured by: Mylan Laboratories Limited, Hyderabad 500 096, IndiaThis Patient Information has been approved by the U.S. Food and Drug Administration. Manufactured for: Mylan Pharmaceuticals Inc. Morgantown, WV 26505 U.S.A.Manufactured by: Mylan Laboratories Limited Hyderabad 500 096, India 75083195Revised: 10/2021MX:VORIC:R14. oare allergic to voriconazole or any of the ingredients in voriconazole tablets. See the end of this leaflet for complete list of ingredients in voriconazole tablets.. oare taking any of the following medicines:. ocisapride. osirolimus. olong-acting barbiturates like phenobarbital. orifabutin. onaloxegol. oivabradine. ovenetoclax. opimozide. orifampin. oefavirenz. oergotamine, dihydroergotamine (ergot alkaloids). otolvaptan. oquinidine. ocarbamazepine. oritonavir. oSt. Johns Wort (herbal supplement). olurasidone. ohave or ever had heart disease, or an abnormal heart rate or rhythm. Your healthcare provider may order test to check your heart (EKG) before starting voriconazole tablets.. ohave low potassium levels, low magnesium levels, and low calcium levels. Your healthcare provider may do blood tests before starting and during treatment with voriconazole tablets.. ohave liver or kidney problems. Your healthcare provider may do blood tests to make sure you can take voriconazole tablets.. ohave trouble digesting dairy products, lactose (milk sugar), or regular table sugar. Voriconazole tablets contain lactose. oare pregnant or plan to become pregnant. Voriconazole can harm your unborn baby. Talk to your healthcare provider if you are pregnant or plan to become pregnant. Women who can become pregnant should use effective birth control while taking voriconazole tablets. Talk to your healthcare provider about birth control methods that may be right for you. oare breastfeeding or plan to breastfeed. It is not known if voriconazole passes into breast milk. Talk to your healthcare provider about the best way to feed your baby if you take voriconazole tablets.. oVoriconazole may be prescribed to you as:oVoriconazole tablets oVoriconazole tablets oTake voriconazole tablets exactly as your healthcare provider tells you to.. oTake voriconazole tablets at least hour before or at least hour after meals.. oIf you take too many voriconazole tablets, call your healthcare provider or go to the nearest hospital emergency room.. oYou should not drive at night while taking voriconazole tablets. Voriconazole tablets can cause changes in your vision such as blurring or sensitivity to light.. oDo not drive or operate machinery, or do other dangerous activities until you know how voriconazole tablets affect you.. oAvoid direct sunlight. Voriconazole tablets can make your skin sensitive to the sun and the light from sunlamps and tanning beds. You could get severe sunburn. Use sunscreen and wear hat and clothes that cover your skin if you have to be in sunlight. Talk to your healthcare provider if you get sunburn.. oliver problems. Symptoms of liver problems may include:. oitchy skin. oflu-like symptoms. oyellowing of your eyes. onausea or vomiting. ofeeling very tired. ovision changes. Symptoms of vision changes may include:oblurred visionochanges in the way you see colorsosensitivity to light (photophobia). oblurred vision. ochanges in the way you see colors. osensitivity to light (photophobia). oserious heart problems. Voriconazole tablets may cause changes in your heart rate or rhythm, including your heart stopping (cardiac arrest).. oallergic reactions. Symptoms of an allergic reaction may include:. ofever. ochest tightness. onausea. osweating. otrouble breathing. oitching. ofeels like your heart is beating fast (tachycardia). ofeel faint. oskin rash. okidney problems. Voriconazole tablets may cause new or worse problems with kidney function, including kidney failure. Your healthcare provider should check your kidney function while you are taking voriconazole tablets. Your healthcare provider will decide if you can keep taking voriconazole tablets.. oserious skin reactions. Symptoms of serious skin reactions may include:orash or hivesomouth soresoblistering or peeling of your skinotrouble swallowing or breathing orash or hives. omouth sores. oblistering or peeling of your skin. otrouble swallowing or breathing. oadrenal gland problems:oVoriconazole tablets may cause reduced adrenal function (adrenal insufficiency).oVoriconazole tablets may cause overactive adrenal function (Cushings syndrome) when voriconazole is used at the same time with corticosteroids. oVoriconazole tablets may cause reduced adrenal function (adrenal insufficiency).. oVoriconazole tablets may cause overactive adrenal function (Cushings syndrome) when voriconazole is used at the same time with corticosteroids. Symptoms of adrenal insufficiency include:. ofeeling tired. onausea and vomiting. oabdominal pain. olack of energy. ofeeling dizzy or lightheaded. oweakness. oweight loss. Symptoms of Cushings syndrome include:. oweight gain. othinning skin. oexcessive hair growth. ofatty hump between the shoulders (buffalo hump) and rounded face (moon face). obruising easily. oexcessive sweating. odarkening of the skin on the stomach, thighs, breasts, and arms. ohigh blood sugar. obone problems. Voriconazole tablets may cause weakening of bones and bone pain. Tell your healthcare provider if you have bone pain.. ovision changes. onausea. ohallucinations (seeing or hearing things that are not there). orash. oheadache. oabnormal liver function tests. ochills. ovomiting. ofast heart beat (tachycardia). ofever. oStore voriconazole tablets at room temperature, 20 to 25C (68 to 77F). oKeep voriconazole tablets in tightly closed container.. oSafely throw away medicine that is out of date or no longer needed.. oKeep voriconazole tablets, as well as all other medicines, out of the reach of children.