Various case reports have been published regarding the incidence of hepatotoxicity and the triazoles. To date, of the more commonly used triazoles, voriconazole has been liked to the highest incidence of transaminase elevations followed by posaconazole, fluconazole, and itraconazole, respectively. Discontinuation of each of the drugs has been shown to resolve the increase of transaminase levels; however, no clear guidance has been suggested on as to when discontinuation of therapy is warranted. Close monitoring particularly patients of Asian decent, underlying liver disease, bone marrow, or lung transplant may be prudent as well as target drug monitoring (TDM) for posaconazole and voriconazole to help assess the necessity of alteration or discontinuation of therapy.
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