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