Background and Objective: Voriconazole (VRC), a broad-spectrum antifungal drug, exhibits nonlinear pharmacokinetics (PK) due to saturable metabolic processes, autoinhibition and metabolite-mediated inhibition on their own formation. VRC PK is also characterised by high inter- and intraindividual variability, primarily associated with cytochrome P450 (CYP) 2C19 genetic polymorphism. Additionally, recent in vitro findings indicate that VRC main metabolites, voriconazole N-oxide (NO) and hydroxyvoriconazole (OHVRC), inhibit CYP enzymes responsible for VRC metabolism, adding to its PK variability. This variability poses a significant risk of therapeutic failure or adverse events, which are major challenges in VRC therapy. Understanding the underlying processes and sources of these variabilities is essential for safe and effective therapy. This work aimed to develop a whole-body physiologically-based pharmacokinetic (PBPK) modelling framework that elucidates the complex metabolism of VRC and the impact of its metabolites, NO and OHVRC, on the PK of the parent, leveraging both in vitro and in vivo clinical data in a middle-out approach., Methods: A coupled parent-metabolite PBPK model for VRC, NO and OHVRC was developed in a stepwise manner using PK-Sim ® and MoBi ® . Based on available in vitro data, NO formation was assumed to be mediated by CYP2C19, CYP3A4, and CYP2C9, while OHVRC formation was attributed solely to CYP3A4. Both metabolites were assumed to be excreted via renal clearance, with hepatic elimination also considered for NO. Inhibition functions were implemented to describe the complex interaction network of VRC autoinhibition and metabolite-mediated inhibition on each CYP enzyme., Results: Using a combined bottom-up and middle-out approach, incorporating data from multiple clinical studies and existing literature, the model accurately predicted plasma concentration-time profiles across various intravenous dosing regimens in healthy adults, of different CYP2C19 genotype-predicted phenotypes. All (100%) of the predicted area under the concentration-time curve (AUC) and 94% of maximum concentration (C max ) values of VRC met the 1.25-fold acceptance criterion, with overall absolute average fold errors of 1.12 and 1.14, respectively. Furthermore, all predicted AUC and C max values of NO and OHVRC met the twofold acceptance criterion., Conclusion: This comprehensive parent-metabolite PBPK model of VRC quantitatively elucidated the complex metabolism of the drug and emphasised the substantial impact of the primary metabolites on VRC PK. The comprehensive approach combining bottom-up and middle-out modelling, thereby accounting for VRC autoinhibition, metabolite-mediated inhibition, and the impact of CYP2C19 genetic polymorphisms, enhances our understanding of VRC PK. Moreover, the model can be pivotal in designing further in vitro experiments, ultimately allowing for extrapolation to paediatric populations, enhance treatment individualisation and improve clinical outcomes., Competing Interests: Declarations Funding Open Access funding was enabled and organised by Projekt DEAL. Conflicts of Interest Charlotte Kloft and Wilhelm Huisinga report grants from an industry consortium (AbbVie Deutschland GmbH & Co. K.G., AstraZeneca, Boehringer Ingelheim Pharma GmbH & Co. K.G., Grünenthal GmbH, F. Hoffmann-La Roche Ltd, Merck KGaA, Novo Nordisk A/S and Sanofi) for the graduate research training programme PharMetrX. In addition, Charlotte Kloft reports research grants from the Innovative Medicines Initiative-Joint Undertaking (‘DDMoRe’), from H2020-EU.3.1.3 (‘FAIR’), Diurnal Ltd and the Federal Ministry of Education and Research within the Joint Programming Initiative on Antimicrobial Resistance Initiative (‘JPIAMR’), all outside the submitted work. Ayatallah Saleh, Josefine Schulz, Jan-Frederik Schlender, Linda B.S. Aulin, Amrei-Pauline Konrad, Franziska Kluwe, Gerd Mikus, and Robin Michelet declare no competing interests that may be relevant to the contents of this work. Ethics Approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. All trial protocols were approved by the responsible Ethics Committees and the respective competent authorities. Informed Consent Written informed consent was obtained from all individual study participants before inclusion. Written informed consent was obtained from all individual study participants before inclusion. Availability of Data and Material The datasets generated and/or analysed during the current study are not publicly available as patients did not provide consent for sharing their data in a public database. The datasets are available from the corresponding author upon reasonable request. Availability of Code The PBPK model will be available on the AK-Kloft GitHub website and can be freely downloaded. Author Contributions Conceptualisation: AS, RM, CK. Clinical data collection: GM, CK. In vitro data generation: JS, CK. Planning of analysis: AS, FK, RM, CK. Formal analysis and investigation: AS, RM, JFS, WH, GM, CK. Writing – original draft preparation: AS, RM. Writing – review and editing: All authors contributed to discussion of the results as well as reviewing and editing the manuscript., (© 2024. The Author(s).)