243.3 🩺 內科專科考前版

243.3.0.1 1⃣ Voriconazole TDM

  • Trough 1-5.5 mg/L target
  • Non-linear pharmacokinetics + significant inter-patient variability
  • Sub-therapeutic = treatment failure
  • Supra-therapeutic = toxicity (visual, hepatic, periostitis, encephalopathy)
  • Weekly monitoring initially + after dose changes
  • Adjust based on trough

243.3.0.2 2⃣ Isavuconazole — Major Advantages

  • Linear pharmacokinetics (less TDM concern)
  • Lower hepatotoxicity
  • Less drug interactions
  • Less photosensitivity
  • Shorter QTc effect
  • Oral + IV
  • Loading × 6 doses then maintenance

243.3.0.3 3⃣ Combination Therapy IA

  • Voriconazole + echinocandin
  • Controversial: trials negative or mixed
  • May benefit in severe / progressing
  • Caspofungin or anidulafungin commonly
  • Used in clinical practice in some institutions for severe cases

243.3.0.4 4⃣ Influenza + COVID Associated Pulmonary Aspergillosis

  • Critical care recognition
  • BAL GM testing in ICU patients with viral pneumonia + clinical deterioration
  • Empirical voriconazole / isavuconazole in suspected
  • Major cause of mortality in severe viral pneumonia
  • Active surveillance + treatment

243.3.0.5 5⃣ ABPA Management Optimization

  • Anti-IgE (omalizumab) for severe / steroid-dependent
  • Aspergillus eradication with itraconazole
  • Asthma + CF management
  • Long-term steroid minimization
  • Pulmonology follow-up

243.3.0.6 6⃣ Aspergilloma Surgical Risk

  • Surgery in fibrotic / scarred lung high risk
  • Pre-op bronchial artery embolization for hemoptysis
  • Lobectomy vs wedge resection
  • Pulmonary function assessment
  • Major bleeding risk

243.3.0.7 7⃣ Bronchial Artery Embolization

  • For acute hemoptysis from aspergilloma
  • Effective in 80-90% short-term
  • Recurrence possible
  • Less morbidity than surgery
  • Sometimes prelude to elective resection

243.3.0.8 8⃣ CGD + Aspergillus

  • Chronic granulomatous disease — NADPH oxidase defect
  • Aspergillus nidulans + A. fumigatus + Burkholderia + Nocardia + Staph
  • Lifelong itraconazole prophylaxis
  • Bone marrow transplant cure

243.3.0.9 9⃣ 健保 / Taiwan

  • 健保 voriconazole + isavuconazole + posaconazole + AmB
  • TDM available in tertiary centers
  • 通報 hospital-acquired surveillance
  • ID consultation routine

243.3.0.10 10. Future + New Antifungals

  • Olorofim Phase 3 (resistant Aspergillus)
  • Fosmanogepix Phase 3 (broad-spectrum)
  • Improved diagnostics (rapid PCR, LFD)
  • Pan-aspergillosis biomarkers
  • Combination + personalized therapy