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Antifungals - systemic & topical

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Antifungals (systemic)

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Ampho B Amphoterecin-B:
Test dose: (optional): 1 mg/20-50 ml D5W over 10-30 minutes.
Monitor temp, pulse, RR and BP q30min x 4 hours. Do not give
premeds with test dose.
TOP
Maintenance dose: Initially give 0.25-0.3 mg/kg/day. Increase
as tolerated by an equivalent amount once daily. Usual daily
dose: 0.5-1 mg/kg/day or up to 1.5 mg/kg every other day. For
life-threatening infection may give full dose the first day (usually
0.6-0.7 mg/kg IBW on Day # 1).

Premedication: Prevention of fever/chills: Tylenol 650mg PO/PR
+ Benadryl 25-50mg PO/IVP 60min prior to maintenance
infusion. May also add: Hydrocortisone 25-50mg IV/IM +/-
Demerol 50mg IV.

Renal dosing: <10/ q24-36h. During therapy if the BUN
increases above 40 mg/dl or the serum creatinine exceeds 2.5-3
mg/dl, Hold Ampho B until renal function improves, then restart
at a reduced dose or change to every other day dosing until
Serum creatinine/BUN improve.

Bladder irrigation: Add 30-50mg Ampho B to 1000ml (or less)
sterile H2O administered intermittently or continuously for 2 to
14 days. (Note: use of D5W for Bladder irrigations is not
recommended because of the possibility of enhancing microbial
and fungal growth in the bladder).
Ampho B lipid Note: Premedication: For patients who experience infusion-related
(Albecet ®): immediate reactions, premedicate with the following drugs 30-60 minutes
prior to drug administration: A nonsteroidal anti-inflammatory agent +/-
TOP diphenhydramine or acetaminophen with diphenhydramine or hydrocortisone
50-100 mg. If the patient experiences rigors during the infusion, meperidine
may be administered.

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Do not Freeze. Empiric therapy should be given until neutropenia resolves.V.Antifungals . may increase up to 70 mg/day if tolerated.: 2. followed by 100 mg daily dose thereafter. osteomyelitis. an enzyme present in fungal. treatment should be given at least 7 days after both signs and symptoms of infection and neutropenia resolve.9% NS.1 mg/minute. Storage/stability: Reconstituted vials & final solution: 24 hours at room temp. TOP an essential component of the fungal cell wall. Dosage adjustment with concomitant use of an enzyme inducer: Patients receiving rifampin: 70 mg caspofungin daily. In general. antifungal therapy should continue for at least 14 days after the last positive culture. Dosage: The recommended dose is a single 200 mg loading dose of ERAXIS on Day 1.V. Invasive Aspergillus. but not mammalian cells. efavirenz. subsequent dosing: 50 mg/day. Supplied: 50mg vial (powder for reconstitution) + 15 ml diluent. Dilution and Infusion: The rate of infusion should not exceed 1. Aseptically reconstitute each 50 mg vial with 15 mL of the companion diluent to provide a conc of 3. Note: The majority of patients studied for this indication also had oropharyngeal involvement. and meningitis due to Candida. Patients should be treated for a minimum of 14 days and for at least 7 days following resolution of symptoms.V.33 mg/mL.5 to 5 mg/kg/day as a single infusion anidulafungin MOA: Anidulafungin is a semi-synthetic echinocandin with antifungal activity.systemic & topical Usual dosage: I. Indications: use in the treatment of the following fungal infections: Candidemia and other forms of Candida infections (intra-abdominal abscess. candidiasis: I. nevirapine. The reconstituted solution must be further diluted and administered within 24 hours. or phenytoin (and possibly other enzyme inducers) may require an increased 2 of 8 5/1/2011 10:45 AM . and has not been studied in sufficient numbers of neutropenic patients to determine efficacy in this group. and peritonitis). caspofungin DOSING: ADULTS — Note: Duration of caspofungin treatment should be Cancidas ® determined by patient status and clinical response. but clinical response is inadequate. dexamethasone.: Initial dose: 70 mg on day 1. Duration of treatment should be based on the patient’s clinical response. Echinocandin treatment should continue until 14 days after last positive culture.: 50 mg/day. Patients receiving carbamazepine. ERAXIS has Echinocandin not been studied in endocarditis. This results in inhibition of the formation of 1. TOP Empiric therapy: Initial dose: 70 mg on day 1. subsequent dosing: 50 mg/day Esophageal candidiasis: I. In patients with positive cultures.3-β-D-glucan. In neutropenic patients. followed by 50 mg daily dose thereafter. Esophageal candidiasis: The recommended dose is a single 100 mg loading dose of ERAXIS on Day 1. Eraxis ™ Anidulafungin inhibits glucan synthase. Preparation: must be reconstituted with the companion diluent (20% (w/w) Dehydrated Alcohol in Water for Injection) and subsequently diluted with only D5W or 0.

Cryptococcal meningitis: 400mg orally x 1. USE — Treatment of invasive Aspergillus infections in patients who are refractory or intolerant of other therapy. an essential component of the cell wall of susceptible fungi. early: 6-12 mg/kg/day for 6 weeks after valve replacement. disseminated: 6 mg/kg/day for 3-6 months. Systemic candidiasis: 400 mg orally or IV once daily.3)-D-glucan. Urinary: 200 mg/day for 1-2 weeks. TOP fluconazole Candidiasis: Candidemia. 3 of 8 5/1/2011 10:45 AM .systemic & topical daily dose of caspofungin (70 mg/day). doses of 800-1000 mg/day have been used for meningeal disease. admin. Note:C. Endophthalmitis: 6-12 mg/kg/day or 400-800 mg/day for 6-12 weeks after surgical intervention. MOA: Inhibits synthesis of B(1. Pneumonia. Coccidioides immitis. then 100-200 mg/day for 2-3 weeks after clinical improvement. Esophageal: 200 mg on day 1. Esophageal candidiasis: 100-200 mg orally once daily (up to 400mg/day).3)-D-glucan. limiting potential toxicity.Antifungals . galbrata infection acquired exogenously should be treated with voriconazole. candidiasis (OPC). Some physicians begin therapy with 800 or 1000 mg/day of fluconazole. Highest activity in regions of active cell growth. followed by 200mg once a day x 10-12 weeks (Suppression: 50-200mg orally once daily). non-neutropenic: 400-800 (Diflucan ®) mg/day for 14 days after last positive blood culture and resolution of signs/symptoms. cryptococcal: 400-800 mg/day for 10-12 weeks or with flucytosine 100-150 mg/day for 6 weeks. Prophylaxis in bone marrow transplant: 400 mg/day. usual duration of therapy ranges from 3-6 months for primary uncomplicated infections and up to 1 year for pulmonary (chronic and diffuse) infection. Candidemia. Onychomycosis: 200-300mg once a week or 100-200mg orally every other day (further studies needed). pleural space). peritonitis. Meningitis. Therapy with oral fluconazole is currently preferred.V. begin 3 days before onset of neutropenia and continue for 7 days after Triazole neutrophils >1000 cells/mm3. Osteomyelitis: 6 mg/kg/day for 6-12 months. esophageal. chronic therapy is same for both recommended in immunocompromised patients with history of oropharyngeal oral and I. primary therapy. empirical treatment for presumed fungal infections in febrile neutropenic patient Clotrimazole (Mycelex ®): oral troches 5 times per day x 14 days. The dosage used in reported clinical trials was 400 mg/day. treatment of candidemia and other Candida infections (intra-abdominal abscesses. Chronic. krusei and C. Coccidiomycosis: 400 mg/day. prosthetic valve. neutropenic: 6-12 mg/kg/day for 14 days after last positive blood culture and resolution of The daily dose of signs/symptoms. secondary. Mammalian cells do not require B(1. fluconazole is the Oropharyngeal (long-term suppression): 200 mg/day. Endocarditis. Alternate therapy: 800 mg/day with amphotericin B for 4-7 TOP days followed by 800 mg/day for 14 days after last positive blood culture and resolution of signs/symptoms. Alternative: (meningitis) 800mg qd for life. maintenance: 200-400 mg/day. cryptococcal (mild-to-moderate): 200-400 mg/day for 6-12 months (life-long in HIV-positive patients) Vaginal candidiasis: 150 mg x 1.

5mg/kg) after each dialysis. Administration guidelines: Administer around-the-clock to promote less variation in peak and trough serum levels.5 mg/kg q12h. Inflamed meninges: >70% to 80%. Some sources recommend giving 25-50 mg/kg after each dialysis. x 3-4 months (toenails). Hemo: Give usual dose (12. 500 mg Griseofulvin: Microsize: Adults: 500mg orally once daily will give a satisfactory response in most patients with tinea corporis. sputum.systemic & topical Renal Dosing: Loading dose: [CRCL >50] No changes.0 g is recommended.5 mg/kg q24-48h. skin. [<10]: 12. and urine Relative diffusion blood into CSF: Adequate with or without inflammation (exceeds usual MICs).5 mg/kg orally every 6 hours (with amphotericin B) TOP for at least 6 weeks after valve replacement. tinea crurirs. [Supplied: Gris-PEG® (griseofulvin ultramicrosize) 125. may discontinue both amphotericin and flucytosine and follow with an extended course of fluconazole (400 mg/day).5-37. a divided dose of 750 mg is recommended.5 to 37. 4 of 8 5/1/2011 10:45 AM . decreasing ergosterol synthesis (principal sterol in fungal cell membrane) and inhibiting cell membrane formation. such as tinea pedis and tinea unguium.5-37. Some sources recommend for CRCL <20: 50% of usual dose q48h. To avoid nausea and vomiting. a daily dose of 1. administer a few capsules at a time over 15 minutes until full dose is taken. if clinical improvement. flucytosine Dosing (Adults): Usual: 12. [CRCL <50]: Multiple dose regimens only: Give 50% of usual dose q24h. eye. [Supplied: Grifulvin V: 250 mg or 500 mg of griseofulvin microsize tablets. peritoneal fluid. [10-20]: 12.5 mg/kg q6h. and tinea capitis. (Ancobon ®): Endocarditis: 25 to 37.Antifungals . alternatively. CSF:blood level ratio: Normal meninges: 70% to 80%. [20-40]: 12. For those TOP fungus infections more difficult to eradicate such as tinea pedis and tinea unguium. and tinea capitis. tinea cruris. For those fungal infections more difficult to eradicate. Meningoencephalitis. cryptococcal: Induction: 25 mg/kg/dose orally (with amphotericin B) every 6 hours for 2 weeks. TOP Onychomycosis: 200mg orally twice daily for 1 week each month for 2 months (fingernails).5 – 37. Hemo: Give usual dose after each hemodialysis session. may continue flucytosine for 6-10 weeks (with amphotericin B) without conversion to fluconazole treatment. 250mg tabs] Itraconazole Systemic mycosis: 200mg orally once daily with food (up to maximum of (Sporanox ®): 400mg/day if unsatisfactory clinical response with lower dose). Supplied: Capsule: Ancobon®: 250 mg. Doses >200mg are given in 2 divided doses.5 mg/kg q24h. PHARMACODYNAMICS / KINETICS: Distribution: Widely throughout body with good penetration into CSF. MECHANISM OF ACTION — Interferes with cytochrome P450 activity.5-37.] Ultramicrosize: Adults: 375 mg (as a single dose or in divided doses) will give a satisfactory response in most patients with tinea corporis. Renal Dosing: [CRCL >40] No change.

gender. Acute Disseminated Candidiasis. itraconazole. an essential polysaccharide comprising 30% to 60% of Candida cell walls (absent in mammalian cells). the mean duration of treatment was 15 days (range 10-47 days). Life-threatening infections: Loading dose: 200mg orally 3 times daily should be given for the first 3 days of therapy.Antifungals . The effect of severe hepatic impairment on micafungin pharmacokinetics has not been studied. then 200-400mg/day. nifedipine. ritonavir. Typically. A loading dose is not required. Supplied: Injection . 85% of the steady-state concentration is achieved after three daily Mycamine doses.systemic & topical Oropharyngeal candidiasis: 200mg (20ml)-oral solution-swish vigorously then swallow once daily x 1-2 weeks. prednisolone.3-beta-D-glucan. † In patients treated successfully for esophageal candidiasis. cyclosporine. No dosing adjustments are required based on race. tacrolimus. the mean duration of treatment was 15 days (range 10-30 days). amphotericin B. Mycamine has been shown to precipitate when mixed directly with a number of other TOP commonly used medications. fluconazole. No dose adjustment for Mycamine is required with concomitant use of mycophenolate mofetil. the dose of Nizoral Tablets may be increased to 400 mg (two tablets) once daily. ketoconazole Recommended starting dose: 200mg once daily. Candida 100 mg Peritonitis and Abscesses* Treatment of Esophageal Candidiasis† 150 mg Prophylaxis of Candida Infections in 50 mg HSCT Recipients‡ *In patients treated successfully for candidemia and other Candida infections. Esophageal candidiasis: 100mg (10ml) oral solution--swish and swallow Triazole once daily x 3 weeks. the mean duration of prophylaxis was 19 days (range 6-51 days).3-beta-D-glucan synthase resulting in reduced formation of 1. ‡ In hematopoietic stem cell transplant (HSCT) recipients who experienced success of prophylactic therapy. Micafungin Dosing (Adults): Mycamine ®: Do not mix or co-infuse Mycamine with other medications.50 mg (powder for reconstitution). or in patients with severe renal dysfunction or mild-to-moderate hepatic insufficiency. decreased glucan content leads to osmotic instability and cellular lysis 5 of 8 5/1/2011 10:45 AM . In very serious infections or (Nizoral ®): if clinical responsiveness is insufficient within the expected time. May increase to 200mg/day. sirolimus. or rifampin. MOA: Concentration-dependent inhibition of 1. Echinocandin Mycamine Dosage Recommended Indication Reconstituted Dose Once Daily Treatment of Candidemia. voriconazole.

Oral suspension: 200 mg/5 mL (70 6 of 8 5/1/2011 10:45 AM . cruris. Oral: Dose may be reduced in 50 mg increments to a minimum dosage of 200 mg every 12 hours in patients weighing >/= 40 kg (100 mg every 12 hours in patients <40 kg). and for at least 7 days following resolution of symptoms. Candidemia and other deep tissue Candida infections: Initial: Loading dose 6 mg/kg IV every 12 TOP hours for 2 doses. increase to 150 mg every 12 hours in patients who fail to respond Triazole adequately. followed by maintenance dose of 3-4 mg/kg every 12 hours. maintenance: 100 mg once daily for 13 days. 200 mg.Antifungals . oral: Noxafil®: 40 mg/mL (123 mL) terbinafine Superficial mycoses (tinea corporus. ®): Posaconazole Dosing (Adults): Noxafil® Aspergillus and Candida prophylaxis in high-risk immunocompromised patients: Oral: 200 mg 3 times/day Treatment of oropharyngeal candidiasis: Oral: Initial: 100 mg twice daily TOP for 1 day. Variability in posaconazole exposure observed with Clcr<20 mL/minute. Systemic mycosis: 250-500mg orally once daily. unless the benefit justifies the risk. (Toenails): 250mg orally once daily x 12 weeks or pulse dosing: 500mg once daily for 1st week of month x 4 months. Esophageal candidiasis: Oral: Patients <40 kg: 100 mg every 12 hours. [CRCL <50 ml/min]: IV voriconazole should be avoided. Supplied: Suspension. capitis. (Oral): Conversion to oral dosing: Patients <40 kg: 100 mg every 12 hours. increase to 300 mg every 12 hours in patients who fail to respond adequately. Supplied: Tablet: 50 mg. Renal Dosing: Oral: no adjustments necessary. voriconazole Dosing (Adults): Invasive aspergillosis and other serious fungal infections - (Vfend ®): 6 mg/kg IV q12h x 2 doses. cutaneous (Lamisil ®): candidiasis): 250 mg orally once daily. use caution in severe renal impairment and monitor for breakthrough fungal infections. Dosage adjustment in patients unable to tolerate treatment: IV: Dose may be reduced to 3 mg/kg every 12 hours. Patients >/= 40 kg: 200 mg every 12 hours. then 4 mg/kg q12h. Patients >/= 40 kg: 200 mg every 12 hours. Onychomycosis: (fingernails) 250mg orally once daily x 6 weeks or pulse TOP dosing: 500mg orally once daily for 1st week of month x 2 months. pedis. Accumulation of the intravenous vehicle may occur. Note: Treatment should continue for a minimum of 14 days.systemic & topical nystatin (Mycostatin Thrush: 4 to 6 ml orally (swish/swallow) 4 times a day. Treatment of refractory oropharyngeal candidiasis: Oral: 400 mg twice daily Treatment of refractory invasive fungal infections (unlabeled use): Oral: 800 mg/day in divided doses Renal Dosing: No adjustment necessary.

Tinea/candida: apply twice a day. Supplied: [cream 1%] (Lamisil ®): tolnaftate Apply twice a day. BY ACCESSING OR USING THIS SITE.(gel) (Naftin ®): candidiasis: apply 2 to 3 times daily.Adult patients ONLY.Antifungals . Supplied: [cream/lotion (Oxistat ®): 1%] terbinafine Tinea: apply once or twice daily. [TOP] 7 of 8 5/1/2011 10:45 AM . Supplied: [1% cream /solution /lotion] (Lotrimin ®): enconazole Tinea: apply once daily. GlobalRPH does not directly or indirectly practice medicine or provide medical services and therefore assumes no liability whatsoever of any kind for the information and data accessed through the Service or for any diagnosis or treatment made in reliance thereon.D.Ph.. McAuley. R. David F. Topical Antifungals TOP butenafine Apply cream once or twice daily. Candida: apply twice daily.systemic & topical mL). Supplied: [2% Miconazole: cream/powder/spray] naftifine Tinea: apply once daily (cream) or twice a day. [cream 1%] (Mentax ®) ciclopirox Apply cream or lotion twice daily [cream/lotion 1%] (Loprox ®): clotrimazole Apply twice daily. PLEASE READ THE DISCLAIMER CAREFULLY BEFORE ACCESSING OR USING THIS SITE. Supplied: [cream / nystatin: powder/ ointment] oxiconazole Tinea: apply once or twice daily. 200 mg (Inj . YOU AGREE TO BE BOUND BY THE TERMS AND CONDITIONS SET FORTH IN THE DISCLAIMER. ketoconazole: Seborrheic dermatitis: apply shampoo/cream once or twice (Nizoril ®) daily. Supplied: [1% cream /powder/ gel (Tinactin ®): /solution] Listed dosages are for . Pharm. GlobalRPh Inc. Dandruff: shampoo 2 times per week.powder for reconstitution). (Spectazole ®): Supplied:[1% cream] Tinea/candida: apply once a day Supplied: [2% cream].