What is the recommended dose of Caspofungin (Caspofungin) for antifungal treatment?

Caspofungin Dosing for Antifungal Treatment

For adults, administer a 70 mg loading dose on day 1, followed by 50 mg once daily thereafter, with the option to escalate to 70 mg daily if clinical response is inadequate. 1

Standard Adult Dosing by Indication

Candidemia and Invasive Candidiasis

• Loading dose: 70 mg IV on day 1, followed by 50 mg IV once daily 1
• Continue treatment for at least 14 days after the last positive blood culture and resolution of symptoms 2, 1
• If the 50 mg dose is well tolerated but provides inadequate clinical response, increase to 70 mg once daily 2, 1
• For C. parapsilosis infections specifically, fluconazole or lipid formulation amphotericin B may be preferred, though continuing caspofungin is reasonable if the patient is clinically stable 2

Invasive Aspergillosis

• Loading dose: 70 mg IV on day 1, followed by 50 mg IV once daily 1
• Indicated for refractory or intolerant cases to other approved therapies 2, 1
• For salvage therapy, doses up to 70 mg daily (or even 150-200 mg daily in select cases) have been studied and found well-tolerated 2

Esophageal Candidiasis

• 50 mg IV once daily for 7-14 days after symptom resolution 1
• No loading dose is required for this indication 1

Empirical Therapy in Febrile Neutropenia

• Loading dose: 70 mg IV on day 1, followed by 50 mg IV once daily 1
• Continue until resolution of neutropenia, treating confirmed fungal infections for minimum 14 days after last positive culture 1

Pediatric Dosing (3 months to 17 years)

Administer 70 mg/m² loading dose on day 1, followed by 50 mg/m² once daily (maximum 70 mg regardless of calculated dose). 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 exceeding 70 mg total) 1
• This dosing provides exposure comparable to adult dosing 2
• Duration should follow adult guidelines for each indication 1

Hepatic Impairment Adjustments

• Mild hepatic impairment (Child-Pugh 5-6): No dose adjustment needed 1
• Moderate hepatic impairment (Child-Pugh 7-9): Reduce maintenance dose to 35 mg once daily after standard 70 mg loading dose 3, 1
• Severe hepatic impairment (Child-Pugh >9): No clinical experience available; use with extreme caution 1
• Monitor liver enzymes closely in all patients with hepatic impairment, particularly liver transplant recipients where Grade IV elevations occurred in 27.7% 3

Renal Impairment Adjustments

No dose adjustment required for any degree of renal impairment, including patients on dialysis. 2, 3, 1

Drug Interaction Dose Modifications

• With enzyme inducers (rifampin, efavirenz, nevirapine, phenytoin, carbamazepine, dexamethasone): Increase maintenance dose to 70 mg daily 2, 3
• With cyclosporine: Use only when benefit outweighs risk; cyclosporine increases caspofungin AUC by ~35% 2, 3
• With tacrolimus: Monitor tacrolimus levels closely; caspofungin reduces tacrolimus AUC by ~20% 2, 3

Administration Guidelines

• Administer as slow IV infusion over approximately 1 hour 1
• Never administer as IV bolus 1
• Histamine-like reactions are rare but related to infusion rates faster than recommended 2

Common Pitfalls to Avoid

• Do not omit the loading dose for candidemia, invasive aspergillosis, or empirical therapy—this is critical for achieving adequate drug levels rapidly 1
• Do not prematurely discontinue therapy—continue for full 14 days after last positive culture even if patient appears clinically improved 2, 1
• Do not forget hepatic dose reduction in moderate hepatic impairment (Child-Pugh 7-9), as standard dosing may lead to excessive drug exposure 1
• Do not assume renal dosing is needed—unlike many antimicrobials, caspofungin requires no renal adjustment 2, 1

Safety Profile

• Generally well tolerated with few discontinuations due to adverse events 2
• Most common adverse effects include elevated liver aminotransferases, gastrointestinal upset, headaches, and fever 2
• Better tolerated than amphotericin B deoxycholate with fewer clinical and laboratory adverse events 2
• In pediatric patients, hypokalemia (12%), elevated bilirubin, and decreased hemoglobin have been reported 2