Caspofungin Dosing Recommendations
The standard recommended dosage of caspofungin for treating fungal infections in adults is a 70 mg loading dose on day 1, followed by 50 mg daily administered by slow IV infusion over approximately 1 hour. 1
Adult Dosing by Indication
Invasive Candidiasis/Candidemia
- Administer a single 70 mg loading dose on day 1, followed by 50 mg once daily 1
- Continue treatment for at least 14 days after the last positive culture and resolution of symptoms 2
- For infections due to C. parapsilosis, fluconazole or lipid formulation of amphotericin B may be preferred as initial therapy, though continuing caspofungin is reasonable if the patient is clinically stable 2
Invasive Aspergillosis
- Administer a single 70 mg loading dose on day 1, followed by 50 mg once daily 1
- Indicated for patients with probable or proven invasive aspergillosis that is refractory to or intolerant of other approved therapies 2
- Duration of treatment should be based on severity of underlying disease, recovery from immunosuppression, and clinical response 1
Esophageal Candidiasis
- 50 mg once daily for 7-14 days after symptom resolution (no loading dose needed for this indication) 1
Empirical Therapy for Presumed Fungal Infections
- Administer a single 70 mg loading dose on day 1, followed by 50 mg once daily 1
- Continue until resolution of neutropenia and for at least 7 days after both neutropenia and clinical symptoms are resolved 1
Pediatric Dosing (3 months to 17 years)
- Single 70 mg/m² loading dose on day 1, followed by 50 mg/m² once daily 1
- Maximum loading dose and daily maintenance dose should not exceed 70 mg, regardless of calculated dose 1
- Caspofungin at 50 mg/m²/day in children provides exposure comparable to 50 mg/day in adults 2
Dosage Adjustments
Hepatic Impairment
- No dose adjustment needed for mild hepatic impairment (Child-Pugh score 5-6) 1
- For moderate hepatic impairment (Child-Pugh score 7-9), reduce maintenance dose to 35 mg daily (still use 70 mg loading dose on day 1) 1
- No clinical experience in adult patients with severe hepatic impairment or in pediatric patients with any degree of hepatic impairment 1
Renal Impairment
- No dose adjustment required for renal impairment, including acute kidney injury 3
- Unlike many other antimicrobials, caspofungin can be administered at standard doses without concern for toxicity due to accumulation in renal impairment 3
Special Considerations
Higher Dose Regimens
- If the 50 mg dose is well tolerated but does not provide adequate clinical response, the daily dose can be increased to 70 mg 1
- Higher doses of caspofungin (up to 150-200 mg daily) have been studied and found to be well-tolerated with linear pharmacokinetics across this dosage range 4, 5
- Maertens et al. reported using higher doses of caspofungin (70 mg/day) for salvage combination therapy of invasive aspergillosis 2
Drug Interactions
- Caspofungin has minimal potential for drug interactions mediated by the CYP450 enzyme system 2
- Caspofungin can reduce the area under the curve of tacrolimus by ~20% 2
- Cyclosporine increases the area under the curve of caspofungin by ~35%; concomitant use should be done with caution due to transient elevations of hepatic aminotransferase levels 2
- Inducers of drug clearance (efavirenz, nelfinavir, nevirapine, phenytoin, rifampin, dexamethasone, carbamazepine) may reduce caspofungin concentrations 2
Common Adverse Effects
- Generally well tolerated with few discontinuations due to adverse events 2
- Most common adverse effects include increased liver aminotransferase levels, gastrointestinal upset, and headaches 2
- Potential for histamine release, though histamine-like symptoms are rare and may be related to rapid infusion rates 2