What is the recommended dose of caspofungin (antifungal medication) for adults?

Caspofungin Dosing for Adults

For adult patients, caspofungin should be administered as a 70-mg loading dose on day 1, followed by 50 mg once daily thereafter, with dose escalation to 70 mg daily if the 50-mg dose is well tolerated but does not provide adequate clinical response. 1

Standard Dosing Regimen

The FDA-approved dosing for adults consists of:

• Loading dose: 70 mg IV on day 1
• Maintenance dose: 50 mg IV once daily
• Administration: Slow IV infusion over approximately 1 hour (never as IV bolus) 1

This regimen applies across all approved indications including invasive candidiasis, candidemia, esophageal candidiasis, invasive aspergillosis, and empirical therapy for febrile neutropenia 1.

Dose Escalation Strategy

If clinical response is inadequate but the 50-mg dose is well tolerated, increase to 70 mg once daily. 1 This dose escalation is supported by:

• Clinical trial data demonstrating safety and efficacy at 150 mg daily (3 times standard dosing) 2
• Use of 70 mg/day in salvage combination therapy for invasive aspergillosis 3
• Studies showing higher doses (up to 150-200 mg daily) are well-tolerated with linear pharmacokinetics 4

For deep-seated infections requiring higher doses:

• Endocarditis, osteomyelitis, or septic arthritis: 100 mg daily with potential escalation to 150 mg 5
• These higher doses demonstrated 100% success in osteomyelitis/septic arthritis cases 5

Hepatic Impairment Adjustments

Patients with moderate hepatic impairment (Child-Pugh score 7-9) require dose reduction to 35 mg once daily after the standard 70-mg loading dose. 1

• Mild hepatic impairment (Child-Pugh score 5-6): No adjustment needed 1
• Severe hepatic impairment (Child-Pugh score >9): No clinical experience available; use with extreme caution 1

Renal Impairment

No dose adjustment is required for any degree of renal impairment, including acute kidney injury. 4 Caspofungin can be administered at standard doses without concern for accumulation-related toxicity 4.

Duration of Therapy by Indication

Invasive Candidiasis/Candidemia

• Continue for at least 14 days after the last positive culture and resolution of symptoms 4, 1
• Patients with persistent neutropenia may warrant longer courses pending neutrophil recovery 1

Invasive Aspergillosis

• Duration based on severity of underlying disease, recovery from immunosuppression, and clinical response 1
• Caspofungin is indicated specifically for refractory or intolerant cases 3, 4

Esophageal Candidiasis

• 7-14 days after symptom resolution 1
• No loading dose has been studied for this indication 1

Empirical Therapy for Febrile Neutropenia

• Continue until resolution of neutropenia 1
• For documented fungal infection, treat minimum 14 days after last positive culture and at least 7 days after both neutropenia and clinical symptoms resolve 1

Drug Interactions

Caspofungin has minimal CYP450-mediated interactions but requires specific monitoring with certain immunosuppressants: 3, 4

• Tacrolimus: Caspofungin reduces tacrolimus AUC by ~20%; monitor tacrolimus levels 3, 4
• Cyclosporine: Increases caspofungin AUC by ~35%; concomitant use should be done with caution due to transient hepatic aminotransferase elevations 3, 4
• Enzyme inducers (efavirenz, nelfinavir, nevirapine, phenytoin, rifampin, dexamethasone, carbamazepine): May reduce caspofungin concentrations 3

Safety Profile

Caspofungin is generally well tolerated with few discontinuations due to adverse events 4, 6. The most common adverse effects include:

• Increased liver aminotransferase levels 3, 4
• Gastrointestinal upset 3, 4
• Headaches 3, 4
• Fever and infusion-related reactions 6

Histamine-like reactions are rare and typically related to infusion rates faster than recommended. 3

Common Pitfalls to Avoid

• Failing to administer the loading dose: The 70-mg loading dose on day 1 is critical for achieving therapeutic levels rapidly 1
• Premature discontinuation: Ensure treatment continues for the full recommended duration after culture clearance 4
• Rapid infusion: Always infuse over approximately 1 hour to minimize histamine-related reactions 3, 1
• Overlooking dose escalation: If clinical response is inadequate at 50 mg daily, increase to 70 mg rather than switching agents prematurely 1