Caspofungin
CANCIDAS
What it isIV echinocandin blocking fungal beta-(1,3)-D-glucan synthase; invasive candidiasis and salvage aspergillosis.
Why this oneUnlike other echinocandins, it has a defined salvage role in refractory or intolerant invasive aspergillosis.
What limits itNo renal adjustment, but reduce it in moderate hepatic impairment; enzyme inducers lower exposure, and it is IV only.
FDA label
Read the full label on DailyMed ↗
| FDA dosing | Population | Start | Target | Max |
|---|---|---|---|---|
| Empirical therapy, presumed fungal infection in febrile neutropenia | Adults ≥18 y | 70 mg IV load Day 1, then 50 mg IV QD (infuse over ~1 h) | 50 mg IV QD until neutropenia resolves (≥14 d after last positive culture if fungal infection found) | 70 mg IV QD if 50 mg tolerated but response inadequate |
| Candidemia & other Candida infections (intra-abdominal abscess, peritonitis, pleural space) | Adults ≥18 y | 70 mg IV load Day 1, then 50 mg IV QD | 50 mg IV QD ≥14 days after last positive culture | 50 mg IV QD (longer course if persistent neutropenia) |
| Esophageal candidiasis | Adults ≥18 y | 50 mg IV QD (no loading dose studied) | 50 mg IV QD for 7–14 days after symptom resolution | 50 mg IV QD |
| Invasive aspergillosis (refractory to or intolerant of other therapies) | Adults ≥18 y | 70 mg IV load Day 1, then 50 mg IV QD | 50 mg IV QD; duration per disease severity and response | 70 mg IV QD if inadequate response |
| All of the above indications | Peds 3 mo–17 y (BSA-based, Mosteller) | 70 mg/m2 IV load Day 1, then 50 mg/m2 IV QD | 50 mg/m2 IV QD (may increase to 70 mg/m2 QD if response inadequate) | 70 mg absolute cap per dose regardless of calculated dose |
Renal No adjustment needed (not dialyzable; no post-hemodialysis supplement).
Hepatic Mild (Child-Pugh 5–6): no adjustment. Moderate (7–9), adults: 35 mg QD (70 mg load Day 1 where appropriate). Severe (>9) and any pediatric hepatic impairment: no clinical experience.
On rifampin: 70 mg QD (peds 70 mg/m2, ≤70 mg). Consider 70 mg QD (peds 70 mg/m2) with nevirapine, efavirenz, carbamazepine, dexamethasone, or phenytoin.
Instructions
- Slow IV infusion over ~1 h; do NOT give IV bolus
- Do not mix or co-infuse with other medications
- Do not use dextrose-containing diluents
Cautions
- Hypersensitivity: anaphylaxis, histamine-mediated reactions (rash, facial swelling, angioedema, pruritus, warmth, bronchospasm), SJS/TEN (some fatal) — discontinue at first sign
- Hepatic effects: LFT abnormalities; isolated hepatic dysfunction/hepatitis/failure — monitor and reassess benefit/risk
- Elevated liver enzymes with concomitant cyclosporine — use only if benefit outweighs risk; monitor LFTs
Adverse reactions
- Adults (≥10%): diarrhea, pyrexia, ALT/AST increased, alkaline phosphatase increased, blood potassium decreased
- Peds (≥10%): pyrexia, diarrhea, rash, ALT/AST increased, potassium decreased, hypotension, chills
Pregnancy May cause fetal harm based on animal data (embryofetal toxicity in rats/rabbits); insufficient human data; advise of fetal risk.
Lactation No human data; present in rat milk; weigh benefits of breastfeeding against risk.
NO BOXED WARNINGS
Principal riskNo FDA boxed warning.
Cost, est. cash$20–$1,500/dose or month
Generic entry2017
Classes and tags
Clinical profile
Legacy pregnancy categoryC
Defining liabilityHepatotoxicity and clinically important CYP/QT interactions; organ toxicity varies markedly by agent.
Mechanism of action: Caspofungin ballicule
