BACKGROUND
Lung transplant recipients (LTR) have an increased risk of cutaneous squamous cell carcinoma (SCC) due to immunosuppressive therapy. Voriconazole, which is associated with phototoxic side effects in some patients, may be an additional risk factor for SCC in this population.
METHODS
To test whether voriconazole is a risk factor for developing SCC in LTR, we evaluated cumulative exposure to voriconazole in 327 adults who underwent lung transplantation at a single center between 1991 and 2010. Voriconazole exposure was assessed as a time-varying covariate. We analyzed risk of developing SCC over time using survival analysis methods.
RESULTS
Exposure to voriconazole was associated with a 2.6-fold increased risk for SCC. This phenomenon was dose-dependent; the risk for SCC increased by 5.6% with each 60-day exposure at a standard dose of 200mg twice daily. At five years posttransplant, voriconazole conferred an absolute risk increase for SCC of 28%.
CONCLUSIONS
These results suggest that caution should be taken when using voriconazole in LTR, as this drug increases the already high risk for SCC in this population.
Voriconazole is a triazole antifungal used to prevent and treat invasive fungal infections after lung transplantation, but has been associated with an increased risk for developing cutaneous squamous cell carcinoma (SCC). Despite widespread use, there are no clear guidelines for optimal prophylactic regimens that balance its competing risks and benefits. We conducted a retrospective cohort study of all lung transplant recipients at the University of California, San Francisco transplanted between October 1991 and December 2012 (n=455) to investigate whether voriconazole exposure impacted development of SCC, Aspergillus colonization, invasive aspergillosis, and all-cause mortality. Voriconazole exposure was associated with a 73% increased risk for developing SCC (HR=1.73; 95% CI: 1.04–2.88; p=0.03), with each additional 30-day exposure at the standard dose increasing the risk by 3.0% (HR=1.03; 95% CI: 1.02–1.04; p<0.001). Voriconazole exposure reduced risk of Aspergillus colonization by 50% (HR=0.50; 95% CI: 0.34–0.72; p<0.001), but we were underpowered to detect risk reduction for invasive aspergillosis. Voriconazole exposure significantly reduced all-cause mortality among subjects who developed Aspergillus colonization (HR=0.34; 95% CI: 0.13–0.91; p=0.03), but had no significant impact on those without colonization. Physicians should consider patient-specific factors that modify the potential risks and benefits of voriconazole in the care of lung transplant recipients.
Background-Venous thromboembolism (VTE) is common following lung transplantation. Enoxaparin is an approved therapy for VTE and anti-factor Xa (AXAL) can be used to monitor enoxaparin activity. Some studies have demonstrated elevated AXALs are associated with an increased risk of hemorrhage. Having identified a high incidence of supratherapeutic AXALs in lung transplant recipients, we aimed to elucidate the relationship between enoxaparin dose and AXAL in this patient population.
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