NAME OF DRUG
caspofungin

CLASSIFICATION
Antifungal

ALTERNATE NAMES
CANCIDAS

INDICATIONS

• VGH indications
  • treatment of invasive candidiasis in:
    • patients refractory to other antifungal therapies (i.e. fluconazole, amphotericin B) or intolerant of amphotericin B despite optimization of pre-medications
    • ICU patients with severe sepsis/septic shock with urine output < 0.5 mL/kg/hour x 2 hours, despite adequate volume replacement and/or vasopressors who are refractory to fluconazole
  • febrile neutropenia in leukemia/stem-cell transplant patient if intolerance or infusion-related reaction to amphotericin B despite optimization of pre-medications
    
• Other indications (not approved for use at VGH)
  • treatment of esophageal candidiasis
  • salvage treatment of invasive aspergillosis
    

RECONSTITUTION AND STABILITY

• vials should be stored in refrigerator
• reconstitute 70 mg and 50 mg vials with 10.5 mL sterile water for injection or NS to produce a final concentration of 7 mg/mL and 5 mg/mL, respectively
• reconstituted solution in vial stable for 1 hour at room temperature
• dilute dose in 250 mL NS; infusion solution stable x 24 hours at room temperature

COMPATIBILITY

• compatible with NS only
• do not use diluents containing dextrose
•  incompatible with other medication
  

ROUTES OF ADMINISTRATION

• IV intermittent
  • in 250 mL NS over 1 hour
  • if fluid restricted - can dilute 35 mg or 50 mg in 100 mL NS
    

VH & HSC ADMINISTRATION POLICY

• Restricted to consult by Infectious Diseases (ID) Service; ICU, Stem Cell Transplant and Solid Organ Transplant patients exempt from ID consult

A - Not to be administered by the direct IV route

DOSAGE

• Loading Dose: 70 mg IV
• Maintenance Dose: 50 mg IV daily
  
• Hepatic dysfunction:
  • Dose adjustment recommended in moderate hepatic insufficiency (Child-Pugh score 7-9) as follows: 70 mg IV loading dose followed by 35 mg IV daily
  • Not recommended for use in patients with severe hepatic insufficiency (Child-Pugh score > 9)
    
• No dose adjustment necessary for renal insufficiency
  

POTENTIAL HAZARDS OF PARENTERAL ADMINISTRATION

• fever, phlebitis, nausea and vomiting, flushing
• hypersensitivity reactions have been reported, such as rash, facial swelling, pruritus, warmth sensation, anaphylaxis, dyspnea and stridor
  

IMPORTANT IMPLICATIONS

• fungicidal against Candida species; fungistatic against Aspergillus species
• may cause elevated hepatic enzymes (ALT, AST) and alkaline phosphatase
  
• Drug Interactions:
  • caspofungin concentrations may be reduced by co-administration of hepatic inducers, such as phenytoin, rifampin and carbamazepine. An increase in the daily dose to 70mg should be considered if patients are not clinically responding and they are receiving a hepatic enzyme inducer
  • concomitant use with cyclosporine is contraindicated unless potential benefit outweighs risk; cyclosporine will increase caspofungin levels resulting in elevation of ALT and AST; note that caspofungin does not increase cyclosporine levels
  • caspofungin may decrease tacrolimus levels; monitor tacrolimus levels closely as the dose may need to be increased
    

May 2005