Nursing Implications for VORICONAZOLE Vfend

VORICONAZOLE (vor-i-con′a-zole) Vfend 

Classifications: ANTIBIOTIC; AZOLE ANTIFUNGAL 

Therapeutic: ANTIFUNGAL 

Prototype: Fluconazole 

Pregnancy Category: D 

AVAILABILITY 

Solution for injection; oral suspension 

ACTION & THERAPEUTIC EFFECT

Inhibits fungal cytochrome P450 enzymes used for an essential step in fungal ergosterol biosynthesis. The subsequent loss of ergosterol in the fungal cell wall is thought to be responsible for the antifungal activity. Voriconazole is active against Aspergillus and Candida. 

USES 

Treatment of invasive aspergillosis, esophageal candidiasis, candidemia in nonneutropenic patients and disseminated skin infections, and abdomen, kidney, bladder wall, and wound infections due to Candida. 

CONTRAINDICATIONS 

Known hypersensitivity to voriconazole; IV form: Should be avoided in moderate or severe renal impairment (CrCl less than 50 mL/min) and severe Child-Pugh class C hepatic impairment. History of galactose intolerance; Lapp lactase deficiency or glucose-galactose malabsorption; sunlight (UV) exposure; pregnancy (category D); lactation. 

CAUTIOUS USE 

Mild to moderate hepatic cirrhosis, hepatitis, Child-Pugh class A and B hepatic disease; renal disease. PO & IV form: Mild or moderate renal impairment; ocular disease; hypersensitivity to other azole antifungal agents such as fluconazole. Safety and efficacy have not been established in children younger than 12 y. 

ROUTE & DOSAGE 

Aspergillosis 

Adult: IV 6 mg/kg q12h day 1, then 3–4 mg/kg q12h. Treatment continues until 7–14 days after symptom resolution. POWeight greater than 40 kg: 400 mg q12h day 1, then 200 mg q12h. May increase to 300 mg q12h if inadequate response. Weight less than 40 kg: 400 mg q12h day 1, then 100 mg q12h. May increase to 150 mg q12h if inadequate response. 

Esophageal Candidiasis 

Adult: POWeight greater than 40 kg: 200 mg q12h for a minimum of 14 days and for at least 7 days after resolution of symptoms; weight less than 40 kg: 100 mg q12h for a minimum of 14 days and for at least 7 days after resolution of symptoms 

Dose Adjustment for Concomitant Fosphenytoin or Phenytoin 

Adult: IV 6 mg/kg q12h day 1, then 5 mg/kg q12h. POWeight greater than 40 kg: 400 mg q12h day 1, then 400 mg q12h; weight less than 40 kg: 400 mg q12h day 1, then 200 mg q12h 

Renal Impairment Dosage Adjustment 

CrCl less than 50 mL/min: Switch to PO therapy after loading dose; hemodialysis does not require supplemental dose 

Hepatic Impairment Dosage Adjustment 

Child-Pugh class A or B: Reduce maintenance dose by 50%; Child-Pugh class C: Avoid drug use

NURSING IMPLICATIONS VORICONAZOLE Vfend

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ADMINISTRATION 

Oral

• Give at least 1 h before or 1 h following a meal. 
• Store tablets at 15°–30° C (59°–86° F). 

Intravenous 
PREPARE: Intermittent: Use a 20 mL syringe to reconstitute each 200 mg powder vial with exactly 19 mL of sterile water for injection to yield 10 mg/mL. Discard vial if a vacuum does not pull the diluent into vial. Shake until completely dissolved.

• Calculate the required dose of voriconazole based on patient’s weight. 
• From an IV infusion bag of NS, D5W, D5/NS, D5/.45NS, LR or other suitable solution, withdraw and discard a volume of IV solution equal to the required dose. 
• Inject the required dose of voriconazole into the IV bag. The IV solution should have a final voriconazole concentration of 0.5–5 mg/mL.
• Infuse immediately. 

ADMINISTER:
Intermittent: Infuse over 1–2 h at a maximum rate of 3 mg/kg/h.

• DO NOT give a bolus dose. 

INCOMPATIBILITIES: 
Solution/additive: Do not dilute with sodium bicarbonate; do not mix with any other drugs. Y-site: Do not infuse with other drugs.

• Store unreconstituted vials at 15°–30° C (59°–86° F). 

ADVERSE EFFECTS (≥1%) 
Body as a Whole: Peripheral edema, fever, chills. CNS: Headache, hallucinations, dizziness. CV: Tachycardia, hypotension, hypertension, vasodilation. GI: Nausea, vomiting, abdominal pain, abnormal LFTs, diarrhea, cholestatic jaundice, dry mouth. Metabolic: Increased alkaline phosphatase, AST, ALT, hypokalemia, hypomagnesemia. Skin: Rash, pruritus. Special Senses: Abnormal vision (enhanced brightness, blurred vision, or color vision changes), photophobia.

INTERACTIONS 
Drug: Due to significant increased toxicity or decreased activity, the following drugs are contraindicated with voriconazole: BARBITURATES, carbamazepine, efavirenz, ERGOT ALKALOIDS, pimozide, quinidine, rifabutin, sirolimus; fosphenytoin, phenytoin, rifampin, ritonavir may significantly decrease voriconazole levels. PROTEASE INHIBITORS (except indinavir) may increase voriconazole toxicity; voriconazole may increase the toxicity of BENZODIAZEPINES, cyclosporine, PROTEASE INHIBITORS (except indinavir), NONNUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS, omeprazole, tacrolimus, vinblastine, vincristine, warfarin, fentanyl, oxycodone, NSAIDS; NONNUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS may increase or decrease voriconazole levels. Food: Absorption reduced with high-fat meals. Herbal: St. John’s wort may decrease efficacy.

PHARMACOKINETICS 
Absorption: 96% absorbed. Has a nonlinear pharmacokinetic profile, a small change in dose may cause a large change in serum levels. Steady state not achieved until day 5–6 if no loading dose is given. Peak: 1–2 h. Metabolism: In liver by (and inhibits) CYP3A4, 2C9 and 2C19. Elimination: Primarily in urine. Half-Life: 6 h–6 days depending on dose.

NURSING IMPLICATIONS 
Assessment & Drug Effects 

• Visual acuity, visual field, and color perception should be monitored if treatment continues beyond 28 days. 
• Withhold drug and notify prescriber if skin rash develops. 
• Monitor cardiovascular status especially with preexisting CV disease. 
• Concurrent drugs: Monitor PT/ INR closely with warfarin as dose adjustments of warfarin may be needed. Monitor frequently blood glucose levels with sulfonylurea drugs as reduction in the sulfonylurea dosage may be needed. Monitor for and report any of the following: S&S of rhabdomyolysis in patient receiving a statin drug; prolonged sedation in patient receiving a benzodiazepine; S&S of heart block, bradycardia, or CHF in patient receiving a calcium channel blocker. 
• Montior lab tests: Baseline and periodic LFTs; frequent renal function tests; serum creatinine; periodic CBC with platelet count, Hct and Hgb, serum electrolytes, blood glucose, and lipid profile. 

Patient & Family Education 

• Use reliable means of birth control to prevent pregnancy. If you suspect you are pregnant, contact prescriber immediately. 
• Do not drive at night while taking voriconazole as the drug may cause blurred vision and photophobia. 
• Do not drive or engage in other potentially hazardous activities until reaction to drug is known. 
• Avoid strong, direct sunlight while taking voriconazole.

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Ditulis oleh Unknown pada tanggal Saturday, July 11, 2015