Drugs List

Therapeutic Indications

Uses

Empirical treatment of presumed fungal infection in febrile neutropenic pts
Invasive candidiasis: treatment
Treatment of aspergillosis when other treatment unsuitable/ineffective

Treatment of invasive candidiasis.

Treatment of invasive aspergillosis in patients who are refractory to (i.e. failure to improve after a minimum of 7 days previous treatment with therapeutic doses of effective antifungal therapy)or intolerant of amphotericin B, lipid formulations of amphotericin B and/or itraconazole.

Empirical therapy for presumed fungal infections in febrile, neutropenic patients.

Administration

After dilution, the solution should be administered by slow intravenous infusion over approximately 1 hour.

Contraindications

Hereditary fructose intolerance

Precautions and Warnings

Children under 1 year
Breastfeeding
Glucose-galactose malabsorption syndrome
History of allergic skin reaction
Moderate hepatic impairment
Pregnancy

Reduce dose in patients with moderate hepatic impairment
Advise ability to drive/operate machinery may be affected by side effects
Treatment to be initiated and supervised by a specialist
Preparation contains sucrose
Monitor hepatic function
Monitor liver enzymes if ciclosporin given concurrently
Discontinue if serious allergic or anaphylactic reaction occurs

The efficacy of caspofungin against non-Candida yeasts and non-Aspergillus moulds has not been established, limited data suggests they are not covered by caspofungin.

Pregnancy and Lactation

Pregnancy

Use caspofungin with caution in pregnancy.

Briggs (2015) concludes that if caspofungin is indicated then maternal treatment should be avoided in the first trimester. The manufacturer suggests caspofungin should not be used during pregnancy the expected benefit outweighs any potential risk to the foetus.

At the time of writing there is limited published experience concerning the use of caspofungin during pregnancy. Animal developmental studies have shown adverse effects (including a reduction in foetal weight and incomplete ossification) which suggests there is the potential for human risk, especially if exposure occurs in the first trimester. Caspofungin has been shown to cross the placental barrier in animal studies but the potential risk to the human foetus is unknown.

The use of all medication in pregnancy should be avoided whenever possible; particularly in the first trimester. Non-drug treatments should also be considered. When essential, a medication with the best safety record over time should be chosen, employing the lowest effective dose for the shortest possible time. Polypharmacy should be avoided. Teratogens taken in the pre-embryonic period, often quoted as lasting until 14 to 17 days post-conception, are believed to have an all-or-nothing effect. Where drugs have a short half-life, and when the date of conception is certain, this may allow women to be reassured where drug exposure has occurred within this time frame. Further advice may be available from the UK National Teratology Information Service (NTIS) and through ToxBase, available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Lactation

Use caspofungin with caution in breastfeeding.

Briggs (2015) concludes that the risk of harm from exposure to caspofungin appears to be low and women should be allowed to breastfeed. However, the infants should be monitored for signs and symptoms of histamine release and gastro-intestinal complaints. Hale (2014) suggests the low oral bioavailability of caspofungin means it would be unlikely for an infant to absorb enough caspofungin for it to be clinically relevant. The manufacturer suggests women treated with caspofungin should not breastfeed.

At the time of writing there is little published experience concerning the use of caspofungin during breastfeeding. It is excreted in the milk of lactating animals but it is not known whether it is excreted in the human milk. The high molecular weight and extensive plasma protein binding (approximately 97%) should limit the amount of drug excreted into the breast milk. However, the long half life may allow for some drug to remain in the milk (Briggs, 2015).

Neonates, infants born prematurely, those with low birth weight, those with an unstable gastrointestinal function or who have serious illnesses may require special consideration. For any infant, if a drug is prescribed to the nursing mother, it should be at the lowest practical dose and for the shortest time. When drug administration is unavoidable and breastfeeding is to continue, minimisation of exposure of the infant to the drug may sometimes be achieved by timing the maternal doses to just after a feeding episode. Infants exposed to drugs via breast milk should be monitored for unusual signs or symptoms. Interactions between the drug received by the infant from the mother's milk and medication prescribed for the infant should also be considered, for example, when the drug given to the infant may prevent metabolism of the drug received via breast milk.
Specialist advice is available from the UK Drugs in Lactation Advisory Service at https://www.midlandsmedicines.nhs.uk/content.asp?section=6&subsection=17&pageIdx=1

Side Effects

Abdominal distension
Abnormal breath sounds
Adult respiratory distress syndrome
Allergic dermatitis
Anaemia
Anaphylaxis
Angioedema
Anorexia
Anxiety
Arrhythmias
Ascites
Atrial fibrillation
Blood pressure changes
Blurred vision
Bronchospasm
Changes in hepatic function
Chest discomfort
Chills
Cholestasis
Coagulation disorders
Congestive cardiac failure
Cough
Decrease in haemoglobin and haematocrit
Decreased serum albumin
Decreased total serum protein
Disorientation
Dizziness
Dry mouth
Dysgeusia
Dyspepsia
Dysphagia
Dyspnoea
Electrolyte disturbances
Elevation of liver enzymes
Eosinophilia
Erythema
Erythema multiforme
Eyelid oedema
Fluid overload
Flushing
Gamma glutamyl transferase (GGT) increased
Gastrointestinal disorder
Haematuria
Headache
Hepatic disorders
Hepatomegaly
Hepatotoxicity
Hyperbilirubinaemia
Hypercalcaemia
Hyperglycaemia
Hyperhidrosis
Hypersensitivity reactions
Hypoaesthesia
Hypocalcaemia
Hypokalaemia
Hypomagnesaemia
Hypoxia
Increased lacrimation
Increased platelet count
Infusion-related symptoms
Insomnia
Jaundice
Leukopenia
Malaise
Metabolic acidosis
Muscle weakness
Nasal congestion
Oedema
Pain
Palpitations
Paraesthesia
Pharyngolaryngeal pain
Phlebitis
Proteinuria
Prothrombin time decreased
Prothrombin time increased
Pruritus
Pyrexia
Reduced lymphocyte count
Reduced neutrophil count
Reduced plasma potassium levels
Renal failure
Scleral icterus
Serum bilirubin increased
Serum creatinine increased
Skin lesions
Somnolence
Stevens-Johnson syndrome
Tachycardia
Tachypnoea
Thrombocytopenia
Thrombophlebitis
Toxic epidermal necrolysis
Tremor
Urticaria
White blood cell count raised

Presentation

Powder for concentrate for solution for infusion containing caspofungin (as acetate).

Drugs List

Therapeutic Indications

Uses

Empirical treatment of presumed fungal infection in febrile neutropenic pts
Invasive candidiasis: treatment
Treatment of aspergillosis when other treatment unsuitable/ineffective

Treatment of invasive candidiasis.

Treatment of invasive aspergillosis in patients who are refractory to (i.e. failure to improve after a minimum of 7 days previous treatment with therapeutic doses of effective antifungal therapy)or intolerant of amphotericin B, lipid formulations of amphotericin B and/or itraconazole.

Empirical therapy for presumed fungal infections in febrile, neutropenic patients.

Dosage

The duration of therapy should be determined by the patient's clinical response and should be continued for up to 72 hours after resolution of neutropenia (ANC greater or equal to 500). In patients found to have a fungal infection, caspofungin should be administered for a minimum of 14 days and treatment should continue for at least 7 days after both neutropenia and clinical symptoms are resolved.

In patients with invasive aspergillosis, treatment duration should be determined on an individual basis, based on the severity of the underlying disease, recovery from immunosuppression, and clinical response. It is recommended that treatment should be continued for at least 7 days after resolution of symptoms.

In patients with invasive candidiasis, caspofungin therapy should be determined on the patients clinical and microbiological responses. When symptoms of invasive candidiasis have improved and cultures have become negative, consider switching to an oral antifungal therapy. Antifungal therapy should continue for at least 14 days after the last positive fungal culture.

There is limited safety information on caspofungin therapy that has lasted for more than 4 weeks. However, available data suggest that caspofungin continues to be well tolerated with longer courses of therapy (up to 162 days in adult patients and up to 87 days in paediatric patients).

Adults

Children

Neonates

Patients with Hepatic Impairment

Additional Dosage Information

Administration

After dilution, the solution should be administered by slow intravenous infusion over approximately 1 hour.

Contraindications

Hereditary fructose intolerance

Precautions and Warnings

Children under 1 year
Breastfeeding
Glucose-galactose malabsorption syndrome
History of allergic skin reaction
Moderate hepatic impairment
Pregnancy

Reduce dose in patients with moderate hepatic impairment
Advise ability to drive/operate machinery may be affected by side effects
Treatment to be initiated and supervised by a specialist
Preparation contains sucrose
Monitor hepatic function
Monitor liver enzymes if ciclosporin given concurrently
Discontinue if serious allergic or anaphylactic reaction occurs

The efficacy of caspofungin against non-Candida yeasts and non-Aspergillus moulds has not been established, limited data suggests they are not covered by caspofungin.

Pregnancy and Lactation

Pregnancy

Use caspofungin with caution in pregnancy.

Briggs (2015) concludes that if caspofungin is indicated then maternal treatment should be avoided in the first trimester. The manufacturer suggests caspofungin should not be used during pregnancy the expected benefit outweighs any potential risk to the foetus.

At the time of writing there is limited published experience concerning the use of caspofungin during pregnancy. Animal developmental studies have shown adverse effects (including a reduction in foetal weight and incomplete ossification) which suggests there is the potential for human risk, especially if exposure occurs in the first trimester. Caspofungin has been shown to cross the placental barrier in animal studies but the potential risk to the human foetus is unknown.

The use of all medication in pregnancy should be avoided whenever possible; particularly in the first trimester. Non-drug treatments should also be considered. When essential, a medication with the best safety record over time should be chosen, employing the lowest effective dose for the shortest possible time. Polypharmacy should be avoided. Teratogens taken in the pre-embryonic period, often quoted as lasting until 14 to 17 days post-conception, are believed to have an all-or-nothing effect. Where drugs have a short half-life, and when the date of conception is certain, this may allow women to be reassured where drug exposure has occurred within this time frame. Further advice may be available from the UK National Teratology Information Service (NTIS) and through ToxBase, available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Lactation

Use caspofungin with caution in breastfeeding.

Briggs (2015) concludes that the risk of harm from exposure to caspofungin appears to be low and women should be allowed to breastfeed. However, the infants should be monitored for signs and symptoms of histamine release and gastro-intestinal complaints. Hale (2014) suggests the low oral bioavailability of caspofungin means it would be unlikely for an infant to absorb enough caspofungin for it to be clinically relevant. The manufacturer suggests women treated with caspofungin should not breastfeed.

At the time of writing there is little published experience concerning the use of caspofungin during breastfeeding. It is excreted in the milk of lactating animals but it is not known whether it is excreted in the human milk. The high molecular weight and extensive plasma protein binding (approximately 97%) should limit the amount of drug excreted into the breast milk. However, the long half life may allow for some drug to remain in the milk (Briggs, 2015).

Neonates, infants born prematurely, those with low birth weight, those with an unstable gastrointestinal function or who have serious illnesses may require special consideration. For any infant, if a drug is prescribed to the nursing mother, it should be at the lowest practical dose and for the shortest time. When drug administration is unavoidable and breastfeeding is to continue, minimisation of exposure of the infant to the drug may sometimes be achieved by timing the maternal doses to just after a feeding episode. Infants exposed to drugs via breast milk should be monitored for unusual signs or symptoms. Interactions between the drug received by the infant from the mother's milk and medication prescribed for the infant should also be considered, for example, when the drug given to the infant may prevent metabolism of the drug received via breast milk.
Specialist advice is available from the UK Drugs in Lactation Advisory Service at https://www.midlandsmedicines.nhs.uk/content.asp?section=6&subsection=17&pageIdx=1

Side Effects

Abdominal distension
Abnormal breath sounds
Adult respiratory distress syndrome
Allergic dermatitis
Anaemia
Anaphylaxis
Angioedema
Anorexia
Anxiety
Arrhythmias
Ascites
Atrial fibrillation
Blood pressure changes
Blurred vision
Bronchospasm
Changes in hepatic function
Chest discomfort
Chills
Cholestasis
Coagulation disorders
Congestive cardiac failure
Cough
Decrease in haemoglobin and haematocrit
Decreased serum albumin
Decreased total serum protein
Disorientation
Dizziness
Dry mouth
Dysgeusia
Dyspepsia
Dysphagia
Dyspnoea
Electrolyte disturbances
Elevation of liver enzymes
Eosinophilia
Erythema
Erythema multiforme
Eyelid oedema
Fluid overload
Flushing
Gamma glutamyl transferase (GGT) increased
Gastrointestinal disorder
Haematuria
Headache
Hepatic disorders
Hepatomegaly
Hepatotoxicity
Hyperbilirubinaemia
Hypercalcaemia
Hyperglycaemia
Hyperhidrosis
Hypersensitivity reactions
Hypoaesthesia
Hypocalcaemia
Hypokalaemia
Hypomagnesaemia
Hypoxia
Increased lacrimation
Increased platelet count
Infusion-related symptoms
Insomnia
Jaundice
Leukopenia
Malaise
Metabolic acidosis
Muscle weakness
Nasal congestion
Oedema
Pain
Palpitations
Paraesthesia
Pharyngolaryngeal pain
Phlebitis
Proteinuria
Prothrombin time decreased
Prothrombin time increased
Pruritus
Pyrexia
Reduced lymphocyte count
Reduced neutrophil count
Reduced plasma potassium levels
Renal failure
Scleral icterus
Serum bilirubin increased
Serum creatinine increased
Skin lesions
Somnolence
Stevens-Johnson syndrome
Tachycardia
Tachypnoea
Thrombocytopenia
Thrombophlebitis
Toxic epidermal necrolysis
Tremor
Urticaria
White blood cell count raised

Overdosage

It is strongly recommended that the UK National Poisons Information Service be consulted on cases of suspected or actual overdose where there is doubt over the degree of risk or about appropriate management.

The following number will direct the caller to the relevant local centre (0844) 892 0111

Information may be obtained if you have access to ToxBase the primary clinical toxicology database of the National Poisons Information Service. This is available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Further Information

Last Full Review Date: January 2018.

Reference Sources

Drugs in Pregnancy and Lactation: A Reference Guide to Fetal and Neonatal Risk, 10th edition (2015) ed. Briggs, G., Freeman, R. Wolters Kluwer Health, Philadelphia.

Medications and Mothers' Milk, Sixteenth Edition (2014) Hale, T and Rowe, H, Hale Publishing, Plano, Texas.

Summary of Product Characteristics: Cancidas. Merck Sharp and Dohme Limited. Revised June 2016.

Summary of Product Characteristics: Caspofungin Teva 50mg Powder For Concentrate For Solution For Infusion. TEVA UK Limited. Revised January 2017.

Summary of Product Characteristics: Caspofungin Teva 70mg Powder For Concentrate For Solution For Infusion. TEVA UK Limited. Revised January 2017.

Summary of Product Characteristics: Caspofungin 50mg Powder For Concentrate For Solution For Infusion. Dr.Reddy's Laboratories (UK) Ltd. Revised May 2017.

Summary of Product Characteristics: Caspofungin 70mg Powder For Concentrate For Solution For Infusion. Dr.Reddy's Laboratories (UK) Ltd. Revised May 2017.

Summary of Product Characteristics: Caspofungin 50mg Powder For Concentrate For Solution For Infusion. Wockhardt UK Ltd. Revised August 2017.

Summary of Product Characteristics: Caspofungin 70mg Powder For Concentrate For Solution For Infusion. Wockhardt UK Ltd. Revised August 2017.