What is the recommended dosage of caspofungin for treating fungal infections?

Caspofungin Dosing Recommendations

Standard Adult Dosing

For most invasive fungal infections in adults, administer a 70 mg IV loading dose on Day 1, followed by 50 mg IV once daily thereafter, infused slowly over approximately 1 hour. 1

Dosing by Indication

Candidemia and Invasive Candidiasis:

• Loading dose: 70 mg IV on Day 1 1
• Maintenance: 50 mg IV once daily 1
• Duration: Continue for at least 14 days after the last positive blood culture and resolution of symptoms 2, 1
• For neutropenic patients who remain persistently neutropenic, a longer course may be warranted pending resolution of neutropenia 1

Esophageal Candidiasis:

• No loading dose required 1
• Dose: 50 mg IV once daily 1
• Duration: 7 to 14 days after symptom resolution 1
• Note: In HIV patients, consider suppressive oral therapy due to relapse risk 1

Invasive Aspergillosis (Salvage Therapy):

• Loading dose: 70 mg IV on Day 1 1
• Maintenance: 50 mg IV once daily 1
• Duration: Based on severity of underlying disease, recovery from immunosuppression, and clinical response 1
• Caspofungin is indicated only for patients refractory to or intolerant of other therapies, not as initial therapy 2, 1

Empirical Therapy in Febrile Neutropenic Patients:

• Loading dose: 70 mg IV on Day 1 1
• Maintenance: 50 mg IV once daily 1
• Duration: Continue until resolution of neutropenia; if fungal infection is documented, treat for minimum 14 days after last positive culture and at least 7 days after both neutropenia and clinical symptoms resolve 1

Dose Escalation Strategy

If the 50 mg daily dose is well tolerated but does not provide adequate clinical response, increase to 70 mg once daily. 2, 1

• Higher doses up to 150-200 mg daily have been studied and are well-tolerated with linear pharmacokinetics, and may be considered for salvage combination therapy of invasive aspergillosis 2, 3, 4
• A multicenter trial demonstrated that 150 mg daily was as safe and effective as standard dosing, with no additional safety concerns 3

Pediatric Dosing (3 months to 17 years)

Administer 70 mg/m² IV loading dose on Day 1 (maximum 70 mg), followed by 50 mg/m² IV once daily thereafter (maximum 70 mg daily). 1

• Calculate body surface area using the Mosteller Formula 1
• If 50 mg/m² daily is well tolerated but inadequate, increase to 70 mg/m² daily (not to exceed 70 mg total) 1
• Duration of treatment follows the same principles as adults for each indication 1

Hepatic Impairment Adjustments

For moderate hepatic impairment (Child-Pugh score 7-9), reduce maintenance dose to 35 mg once daily after the standard 70 mg loading dose. 1

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

Renal Impairment

No dose adjustment is required for any degree of renal impairment, including acute kidney injury. 2

• Caspofungin can be administered at standard doses without concern for accumulation-related toxicity in renal impairment 2

Critical Drug Interactions

Monitor tacrolimus levels closely when co-administering with caspofungin, as caspofungin reduces tacrolimus AUC by approximately 20%. 2

Avoid concomitant use with cyclosporine unless benefits outweigh risks, as cyclosporine increases caspofungin AUC by 35% and may cause transient hepatic aminotransferase elevations. 2

• Enzyme inducers (efavirenz, nelfinavir, nevirapine, phenytoin, rifampin, dexamethasone, carbamazepine) may reduce caspofungin concentrations 2
• Caspofungin has minimal CYP450-mediated drug interactions otherwise 2

Administration Guidelines

Always administer caspofungin by slow IV infusion over approximately 1 hour; never give as IV bolus. 1

• Histamine-like reactions are rare but typically related to infusion rates faster than recommended 2

Common Pitfalls and Safety Considerations

The most common adverse effects include increased liver aminotransferases, gastrointestinal upset, headaches, fever, and infusion-related reactions. 2

• Caspofungin is generally well tolerated with few discontinuations due to adverse events 2
• Monitor for hypokalemia, particularly in pediatric patients 2
• Caspofungin was better tolerated than amphotericin B deoxycholate with fewer clinical and laboratory drug-related adverse events 2

Special Considerations for Specific Candida Species

For C. parapsilosis infections, fluconazole or lipid formulation amphotericin B may be preferred as initial therapy, though continuing caspofungin is reasonable if the patient is clinically stable. 2