From the FDA Drug Label
Special Populations Renal Impairment In a clinical study of single 70-mg doses, caspofungin pharmacokinetics were similar in healthy adult volunteers with mild renal impairment (creatinine clearance 50 to 80 mL/min) and control subjects Moderate (creatinine clearance 31 to 49 mL/min), severe (creatinine clearance 5 to 30 mL/min), and end-stage (creatinine clearance less than 10 mL/min and dialysis dependent) renal impairment moderately increased caspofungin plasma concentrations after single-dose administration (range: 30 to 49% for AUC) However, in adult patients with invasive aspergillosis, candidemia, or other Candidainfections (intra-abdominal abscesses, peritonitis, or pleural space infections) who received multiple daily doses of caspofungin 50 mg, there was no significant effect of mild to end-stage renal impairment on caspofungin concentrations. No dosage adjustment is necessary for patients with renal impairment
- Key Points:
- No dosage adjustment is necessary for patients with renal impairment.
- Caspofungin is not dialyzable, thus supplementary dosing is not required following hemodialysis.
- Caspofungin Dosage in CKD Patients: The recommended dosage for caspofungin in patients with fungal pneumonia and CKD is the same as for patients with normal renal function, which is typically a loading dose of 70 mg on the first day, followed by 50 mg daily 1.
From the Research
For fungal pneumonia treatment in chronic kidney disease (CKD) patients, the recommended caspofungin dosage is a 70 mg loading dose on day 1, followed by 50 mg daily for maintenance therapy, with no dosage adjustment needed based on renal function alone, as supported by the most recent and highest quality study 2.
Key Considerations
- Caspofungin is not significantly eliminated by the kidneys, making it a suitable option for CKD patients.
- The treatment duration typically ranges from 2-4 weeks, depending on clinical response, severity of infection, and the specific fungal pathogen.
- Monitor liver function tests during therapy, as transaminase elevations can occur.
- Caspofungin works by inhibiting the synthesis of beta-(1,3)-D-glucan, an essential component of the fungal cell wall, leading to osmotic instability and cell death.
Important Interactions
- Assess for drug interactions, especially with cyclosporine, tacrolimus, and certain anticonvulsants, which may be relevant in transplant recipients with CKD.
- The use of caspofungin in combination with other antifungal agents, such as voriconazole, may be considered in certain cases, but the added value of combination therapy is still unproven 3.
Patient-Specific Factors
- For patients with moderate hepatic insufficiency (Child-Pugh score 7-9), reduce the maintenance dose to 35 mg daily, while keeping the loading dose the same.
- Granulocytes recovery and status of hematologic disease are significantly associated with favorable outcome, as shown in a study of caspofungin as first-line therapy for pulmonary invasive fungal infections in immunocompromised patients with hematologic malignancies 2.