Group of intravenous antifungals of peptide origin. They are first-line treatment for candidemia and invasive candidiasis in the hospital; caspofungin is also used in aspergillosis and neutropenic fever.
FDA (US): Approved: caspofungin (2001, Cancidas), micafungin (2005, Mycamine), anidulafungin (2006, Eraxis), and rezafungin (2023, Rezzayo), for candidemia/invasive candidiasis and other fungal infections depending on the drug
EMA (EU): Approved: caspofungin (2001, Cancidas), anidulafungin (2007, Ecalta), micafungin (2008, Mycamine), and rezafungin (2023, Rezzayo)
Dose
Candidemia in adults (FDA/EMA labels): caspofungin 70 mg IV on day 1 and then 50 mg/day; micafungin 100 mg/day; anidulafungin 200 mg on day 1 and then 100 mg/day; rezafungin 400 mg the first week and then 200 mg once a week.
Safety
Generally well tolerated. Possible infusion reactions, phlebitis, liver enzyme abnormalities, and fever. Micafungin carries a warning for liver tumors in rats. In pregnancy, only if the benefit outweighs the risk. Hospital use under medical supervision.
Interactions
Caspofungin: cyclosporine raises its levels and transaminases; enzyme inducers (rifampin, carbamazepine, phenytoin, efavirenz) may require a higher dose. May reduce tacrolimus levels.
Effect by goal · level of evidence
Invasive candidiasis: caspofungin versus amphotericin B
improvesHighRCT (AA)in people
73% vs 62% success
In 224 patients, caspofungin achieved a favorable response in 73.4% versus 61.7% with amphotericin B, with fewer drug-related adverse effects.
Weekly rezafungin non-inferior to daily caspofungin
no clear effectHighRCT (AA)in people
Non-inferior
In the ReSTORE trial (187 patients), overall cure at day 14 was 59% with weekly rezafungin and 61% with daily caspofungin; 30-day mortality was similar (24% vs 21%).
They block the enzyme that makes β-1,3-glucan, a key component of the fungal cell wall that does not exist in human cells. Without that scaffold, the wall weakens and the fungus (especially Candida) dies. Rezafungin lasts much longer in the blood and is given once a week.
What the evidence says
In people
Invasive candidiasis: caspofungin versus amphotericin B. In 224 patients, caspofungin achieved a favorable response in 73.4% versus 61.7% with amphotericin B, with fewer drug-related adverse effects. PubMed 12490683
Weekly rezafungin noninferior to daily caspofungin. In the ReSTORE trial (187 patients), overall cure at day 14 was 59% with weekly rezafungin and 61% with daily caspofungin; 30-day mortality was similar (24% vs 21%). PubMed 36442484