Table 2.

Overview on pharmacokinetics of antifungals in patients with renal or liver failure

Drug	Renal impairment	Liver impairment	Suggestions
Amphotericin	No indication	No dosage adjustment
Liposomal amphotericin	Avoid (nephrotoxicity) No dose adjustment if continuous	No dosage adjustment	ICU patients: decreased plasma levels, increased dosage?
Fluconazole	Dose reduction by 50% for GFR 11–50 ml/min Enhanced dose if continuous RRT	No dosage adjustment	Obese critically ill: actual body weight ICU patient: enhanced doses Strong inhibitor of CYP3A4 and 2C9
Voriconazole	No dose adjustment Consider SBECD accumulation during intravenous infusion	Mild to moderate hepatic impairment: 50% dose reduction, TDM recommended	Strong inhibitor of CYP2C0 and 2C19 Moderate inhibitor of CYP3A4
Isavuconazole	No dose adjustment	Enhanced levels, no dosage reduction	Moderate inhibitor of CYP3A4, P-gp, and BRCP
Posaconazole	No dose adjustment for oral route	No dose adjustment	Strong inhibitor of CYP3A4 causing drug–drug interactions
Caspofungin	No dose adjustment	Enhanced exposure in moderate hepatic impairment: dosage reduction Dosage reduction in critically ill patients with liver dysfunction may cause underexposure
Anidulafungin	No dose adjustment	Slightly lowered concentrations but no dosage adjustment recommended
Micafungin	No dose adjustment RRT: no dose adjustment	Slightly lowered concentrations	Potential risk for liver tumors: use only if other antifungals are not appropriate

Details and reference are displayed in the text

RRT renal replacement therapy, SBECD sulfobutylether-β-cyclodextrin, TDM therapeutic drug monitoring, CYP cytochrome, P-gp P-glycoprotein, BCRP breast cancer resistance protein, UGT urindin diphosphate glucuronosyltransferase, GFR glomerular filtration rate