If the excessive anticoagulation occurs, an infusion of fresh-frozen plasma and packed red blood cells may be required to reverse the effects of the interaction. Although CYP2C9 is a minor pathway for voriconazole biotransformation, it significantly inhibits S-warfarin. The interaction between voriconazole and warfarin increases the INR by 41%, and the effects ZD1839 nmr can persist for approximately 1 week after voriconazole discontinuation.134 This interaction

occurs independently of the homozygous PM phenotype.134 There are no published data describing an interaction between posaconazole and warfarin. Interactions involving azoles and phenytoin.  Certain azoles can interact with phenytoin in a bidirectional manner, whereby the azole first inhibits the CYP-mediated

metabolism, and then phenytoin subsequently induces the CYP-mediated BKM120 research buy metabolism of the azole. Data from healthy volunteers demonstrate that fluconazole significantly increased the AUC0–24 and Cmin of phenytoin.135 Although the study demonstrated that phenytoin did not affect fluconazole pharmacokinetics, in practice, induction will likely occur. That study used healthy volunteers and thus the dose and duration of phenytoin were minimised for ethical and safety reasons.135 The bidirectional nature of the azole–phenytoin interaction is best illustrated with voriconazole. Phenytoin 300 mg once daily co-administration with oral voriconazole 400 mg twice daily for 10 days produced increased steady-state phenytoin Cmax and AUCτ values by approximately 70% and 80% respectively.136 However, when multiple doses of phenytoin (300 mg once daily) were administered with voriconazole 200 mg twice daily for 2 weeks, steady-state voriconazole plasma Cmax and systemic AUCτ were significantly reduced to approximately 50% and 30%, respectively, for up to 12 h postdose.136 Although doubling the voriconazole dose from 200 to 400 mg twice daily compensates for the effect of phenytoin,

it subsequently leads to the inhibition of CYP-mediated metabolism of Dichloromethane dehalogenase phenytoin,136 One parallel-designed interaction study demonstrated that posaconazole co-administration produced modest increases in steady state phenytoin Cmax (24%) and systemic AUC (25%), which were not considered clinically significantly.137 However, this study used healthy volunteers, included a small sample size, the volunteers did not serve as their own controls, and substandard doses of posaconazole (200 mg day−1) and phenytoin (200 mg day−1) were employed. Whether these limitations impacted the magnitude of the observed interaction remains unclear. Transport proteins are important contributors to drug disposition. Itraconazole, posaconazole and caspofungin are substrates and/or inhibitors of several transport proteins including P-gp and the OATPs.