- Design
- Narrative review of studies and international guidelines
- Population
- Patients receiving antifungal therapy, mainly immunocompromised and critically ill
- Primary outcome
- Evidence for therapeutic ranges and TDM use by antifungal class
- Effect
- Routine TDM supported for voriconazole and posaconazole; selective for isavuconazole
A review of studies and international guidelines up to November 2025 set out to harmonise therapeutic ranges for antifungal drug monitoring.
The evidence is strongest for voriconazole and posaconazole, which have wide pharmacokinetic variability and trough targets linked to outcomes; routine monitoring is supported. For isavuconazole, routine monitoring is not universally recommended, but may help in critically ill, paediatric and obese patients and those on extracorporeal circuits. For echinocandins and amphotericin B, routine monitoring is not currently recommended because exposure-response data are limited.
Differing targets, assays and sampling practices are a major reason monitoring is applied inconsistently. Where voriconazole levels are available in India, they are worth using, particularly given CYP2C19 variation.
- Measure voriconazole and posaconazole trough levels routinely during treatment
- Consider isavuconazole levels in critically ill, obese or paediatric patients and those on ECMO or dialysis
- Routine monitoring is not recommended for echinocandins or amphotericin B
- Recheck azole levels after adding or stopping an interacting drug
- Use the same laboratory's reference range consistently, as targets vary between sources
Why it matters
Azole levels vary so much between patients that standard doses often miss the target.
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