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Caspofungin

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Caspofungin, Cancidas

  • See Also
  1. Antifungal Medication
  2. Topical Antifungal
  3. Anidulafungin
  4. Micafungin
  • Indications
  1. Conditions
    1. Aspergillosis
    2. Candidemia (systemic Candidiasis)
    3. Empiric Fungal coverage in Neutropenic Fever
    4. Esophageal Candidiasis
  2. Activity
    1. Candida species (including those resistant to Azole Antifungals)
    2. Aspergillus species (some activity)
  • Contraindications
  1. Resistant organisms
    1. Cryptococcus species
    2. Trichosporon species
    3. Dimorphic Fungi (e.g. Coccidioides, Blastomyces, Histoplasma)
    4. Mucor species
  • Mechanism
  1. Echinocandin (Cyclic Lipopeptide)
    1. Inhibits synthesis of beta-(1,3)-D-Glucan a key cell wall component
    2. Semi-synthetic derived from the fermentation product of the fungus Glarea lozoyensis
  • Medications
  1. Caspofungin 70 mg vials (7 mg/ml)
  2. Caspofungin 50 mg vials (5 mg/ml)
    1. Use for doses <50 mg
  • Dosing
  • Adult
  1. Aspergillosis, Candidemia (systemic Candidiasis) or Empiric Fungal coverage in Neutropenic Fever
    1. Load: 70 mg IV (over 1 hour) on day 1
    2. Next: Maintenance Daily Dosing
      1. Standard Dose: 50 mg IV (over 1 hour) daily
      2. Higher Dose: 70 mg IV (over 1 hour) daily
        1. Rifampin (and consider with other enzyme inducers as below)
        2. Refractory course in Febrile Neutropenia or Aspergillosis
    3. Duration
      1. Continue for at least 14 days after last positive culture if candida infection
      2. Empiric therapy in Febrile Neutropenia
        1. Continue until Neutropenia resolves AND
        2. If Fungal Culture positive, at least 14 days (and 7 days after symptoms resolved)
  2. Esophageal Candidiasis
    1. Infuse 50 mg IV (over 1 hour) daily
    2. Typically treat for at least 14 days (and 7 days after symptoms resolved)
  3. Moderate Hepatic Impairment (Child-Pugh Score 7 to 9)
    1. Decrease maintenance dose to 35 mg IV daily
  • Dosing
  • Child
  1. Indicated in Aspergillosis, Candidemia (systemic Candidiasis) or Empiric Fungal coverage in Neutropenic Fever
  2. Indicated for ages 3 months to 17 years old
  3. Load: 70 mg/m2 IV (over 1 hour) on day 1
  4. Next: Maintenance Daily Dosing
    1. Standard Dose: 50 mg/m2 IV (over 1 hour) daily
    2. Higher Dose: 70 mg/m2 IV (over 1 hour) daily
      1. Rifampin (and consider with other enzyme inducers as below)
      2. Refractory course in Febrile Neutropenia or Aspergillosis
  5. Duration
    1. See adult dosing durations
  6. Moderate Hepatic Impairment (Child-Pugh Score 7 to 9)
    1. See other references (adult maintenance doses are decreased)
  • Adverse Effects
  1. Well tolerated overall
  2. Reported
    1. Nausea or Vomiting
    2. Diarrhea
    3. Fever
    4. Headache
    5. Histamine reactions (Pruritus, Urticaria)
      1. Occurs with more rapid infusions (infuse over 1 hour)
  3. Serious
    1. Hepatotoxicity
      1. Monitor Liver Function Tests if baseline abnormal LFTs
    2. Hypokalemia
    3. Stevens Johnson Syndrome
    4. Exfoliative Dermatitis
    5. Anaphylaxis
  • Safety
  1. Unknown safety in Lactation
  2. Pregnancy Category C
    1. Teratogenic in animals (and insufficient data in humans)
  • Pharmacokinetics
  1. Not absorbed from the Gastrointestinal Tract
  2. Highly Protein bound in serum
  3. Metabolism
    1. Primarily hepatic NON-CYP, enzymatic (peptide hydrolysis, N-Acetylation)
    2. Adjust dose in Moderate Hepatic Impairment
  4. Excretion
    1. Minimal urine excretion (<2%)
    2. No renal dose adjustment needed
  • Drug Interactions
  1. Drugs that increase Caspofungin levels (risk of hepatotoxicity)
    1. Cyclosporine (35% increase in Caspofungin levels)
  2. Drugs that decrease Caspofungin levels (by inducing hepatic enzymes and increasing its clearance)
    1. Rifampin (most significant)
    2. Carbamazepine
    3. Dexamethasone
    4. Efavirenz
    5. Nevirapine
    6. Phenytoin
  3. Caspofungin decreases levels of other drugs
    1. Tacrolimus (levels decreased 20 to 25%)
  • Resources
  1. Caspofungin (DailyMed)
    1. https://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=3bad23a6-09a6-4194-9182-093ed61bc71c
  • References
  1. Hamilton (2020) Tarascon Pocket Pharmacopoeia
  2. (2012) Med Lett Drugs Ther 10(120): 61-8 [PubMed]
  3. (2001) Med Lett Drugs Ther 43(W1108B): 58-9 [PubMed]