Cancidas

Drug overview for CANCIDAS (caspofungin acetate):

Generic name: CASPOFUNGIN ACETATE (KAS-poe-FUN-jin)
Drug class: Antifungals-Systemic
Therapeutic class: Anti-Infective Agents

Caspofungin acetate is a semisynthetic, echinocandin antifungal agent.

No enhanced Uses information available for this drug.

DRUG IMAGES

CANCIDAS IV 50 MG VIAL
CANCIDAS IV 70 MG VIAL

The following indications for CANCIDAS (caspofungin acetate) have been approved by the FDA:

Indications:
Candida peritonitis
Candida pleural space infection
Candidemia
Esophageal candidiasis
Febrile neutropenic patient presumed infection treatment
Intra-abdominal Candida abscess
Refractory aspergillosis

Professional Synonyms:
Abdominal abscess due to Candida
Candida pleural infection
Candida species peritonitis
Candida species pleural space infection
Candida spp. peritonitis
Candida spp. pleural space infection
Empiric therapy in febrile neutropenia
Empiric therapy of infection in febrile neutrophilic leukocytopenia
Empiric therapy of infection in febrile neutrophilopenia
Esophageal candidosis
Esophageal moniliasis
Intra-abdominal Candida spp. abscess
Intractable aspergillosis
Presumed infection in febrile neutropenic patient

Dosing information for CANCIDAS
DRUG LABEL	DOSING TYPE	DOSING INSTRUCTIONS
CANCIDAS IV 50 MG VIAL	Maintenance	Adults infuse 50 mg over 1 hour(s) by intravenous route once daily
CANCIDAS IV 70 MG VIAL	Maintenance	Adults infuse 50 mg over 60 minute(s) by intravenous route once daily

Generic dosing information for CASPOFUNGIN ACETATE
DRUG LABEL	DOSING TYPE	DOSING INSTRUCTIONS
CASPOFUNGIN ACETATE 50 MG VIAL	Maintenance	Adults infuse 50 mg over 1 hour(s) by intravenous route once daily
CASPOFUNGIN ACETATE 70 MG VIAL	Maintenance	Adults infuse 50 mg over 60 minute(s) by intravenous route once daily

The following drug interaction information is available for CANCIDAS (caspofungin acetate):

Contraindicated
Severe
Moderate

There are 0 contraindications.

There are 2 severe interactions. These drug interactions can produce serious consequences in most patients. Actions required for severe interactions include, but are not limited to, discontinuing one or both agents, adjusting dosage, altering administration scheduling, and providing additional patient monitoring. Review the full interaction monograph for more information.

Drug Interaction	Drug Names
Caspofungin/Cyclosporine SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: The exact mechanism is unknown. CLINICAL EFFECTS: The concurrent use of caspofungin and cyclosporine may result in elevated levels of caspofungin, as well as increases in alanine transaminase (ALT) and aspartate transaminase (AST) levels. PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: Caspofungin and cyclosporine should only be used concurrently if the potential benefits outweigh the potential risk to the patient. Patients receiving concurrent therapy who develop elevated liver function tests should be monitored and the risk/benefit of continuing concurrent therapy should be evaluated.(1) DISCUSSION: In a clinical study, four subjects received two 3 mg/kg doses of cyclosporine on Day 10 of caspofungin (70 mg daily). Three of the four subjects developed transient elevations of ALT on Day 11 that were 2-3 times the upper limit of normal. AST levels were also elevated, but to a lesser magnitude. Eight subjects received cyclosporine (3 mg/kg) twice on Day 1 of caspofungin (35 mg daily for 3 days). Two of these subjects had a small increase in ALT (slightly above the upper limit of normal) and a slight elevation in AST. Cyclosporine (one 4 mg/kg dose or two 3 mg/kg doses) has been shown to increase the area-under-curve (AUC) of caspofungin by 35%.(1) In a study in 40 immunocompromised patients, subjects received concurrent caspofungin and cyclosporine from 1 to 290 days (median 17.5 days). Of these, 14 (35%) developed transaminase elevations greater than 5 times the upper limit of normal or greater than 3 times baseline during concurrent therapy or the 14 days afterwards. Five were considered possibly related to concurrent therapy. None developed clinical evidence of hepatotoxicity or serious hepatic events. Discontinuation of therapy because of abnormalities in hepatic enzymes from any cause occurred in 4 patients, 2 were considered related to concurrent therapy.(1) In prospective invasive aspergillosis and compassionate use studies, there were 4 patients who received concurrent therapy for 2 to 56 days. None developed increased hepatic enzymes.(1)	CYCLOSPORINE, CYCLOSPORINE MODIFIED, GENGRAF, NEORAL, SANDIMMUNE
Sodium Iodide I 131/Myelosuppressives; Immunomodulators SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction. MECHANISM OF ACTION: Sodium iodide I 131 can cause depression of the hematopoetic system. Myelosuppressives and immunomodulators also suppress the immune system.(1) CLINICAL EFFECTS: Concurrent use of sodium iodide I 131 with agents that cause bone marrow depression, including myelosuppressives or immunomodulators, may result in an enhanced risk of hematologic disorders, including anemia, blood dyscrasias, bone marrow depression, leukopenia, and thrombocytopenia. Bone marrow depression may increase the risk of serious infections and bleeding.(1) PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: The US manufacturer of sodium iodide I 131 states that concurrent use with bone marrow depressants may enhance the depression of the hematopoetic system caused by large doses of sodium iodide I 131.(1) Sodium iodide I 131 causes a dose-dependent bone marrow suppression, including neutropenia or thrombocytopenia, in the 3 to 5 weeks following administration. Patients may be at increased risk of infections or bleeding during this time. Monitor complete blood counts within one month of therapy. If results indicate leukopenia or thrombocytopenia, dosimetry should be used to determine a safe sodium iodide I 131 activity.(1) DISCUSSION: Hematologic disorders including death have been reported with sodium iodide I 131. The most common hematologic disorders reported include anemia, blood dyscrasias, bone marrow depression, leukopenia, and thrombocytopenia.(1)	HICON, SODIUM IODIDE I-131

Drug Interaction

Drug Names

Caspofungin/Cyclosporine

SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction.

MECHANISM OF ACTION: The exact mechanism is unknown.

CLINICAL EFFECTS: The concurrent use of caspofungin and cyclosporine may result in elevated levels of caspofungin, as well as increases in alanine transaminase (ALT) and aspartate transaminase (AST) levels.

PREDISPOSING FACTORS: None determined.

PATIENT MANAGEMENT: Caspofungin and cyclosporine should only be used concurrently if the potential benefits outweigh the potential risk to the patient. Patients receiving concurrent therapy who develop elevated liver function tests should be monitored and the risk/benefit of continuing concurrent therapy should be evaluated.(1)

DISCUSSION: In a clinical study, four subjects received two 3 mg/kg doses of cyclosporine on Day 10 of caspofungin (70 mg daily). Three of the four subjects developed transient elevations of ALT on Day 11 that were 2-3 times the upper limit of normal. AST levels were also elevated, but to a lesser magnitude.

Eight subjects received cyclosporine (3 mg/kg) twice on Day 1 of caspofungin (35 mg daily for 3 days). Two of these subjects had a small increase in ALT (slightly above the upper limit of normal) and a slight elevation in AST. Cyclosporine (one 4 mg/kg dose or two 3 mg/kg doses) has been shown to increase the area-under-curve (AUC) of caspofungin by 35%.(1)

In a study in 40 immunocompromised patients, subjects received concurrent caspofungin and cyclosporine from 1 to 290 days (median 17.5 days). Of these, 14 (35%) developed transaminase elevations greater than 5 times the upper limit of normal or greater than 3 times baseline during concurrent therapy or the 14 days afterwards. Five were considered possibly related to concurrent therapy.

None developed clinical evidence of hepatotoxicity or serious hepatic events. Discontinuation of therapy because of abnormalities in hepatic enzymes from any cause occurred in 4 patients, 2 were considered related to concurrent therapy.(1) In prospective invasive aspergillosis and compassionate use studies, there were 4 patients who received concurrent therapy for 2 to 56 days. None developed increased hepatic enzymes.(1)

CYCLOSPORINE, CYCLOSPORINE MODIFIED, GENGRAF, NEORAL, SANDIMMUNE

Sodium Iodide I 131/Myelosuppressives; Immunomodulators

SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction.

MECHANISM OF ACTION: Sodium iodide I 131 can cause depression of the hematopoetic system. Myelosuppressives and immunomodulators also suppress the immune system.(1)

CLINICAL EFFECTS: Concurrent use of sodium iodide I 131 with agents that cause bone marrow depression, including myelosuppressives or immunomodulators, may result in an enhanced risk of hematologic disorders, including anemia, blood dyscrasias, bone marrow depression, leukopenia, and thrombocytopenia. Bone marrow depression may increase the risk of serious infections and bleeding.(1)

PREDISPOSING FACTORS: None determined.

PATIENT MANAGEMENT: The US manufacturer of sodium iodide I 131 states that concurrent use with bone marrow depressants may enhance the depression of the hematopoetic system caused by large doses of sodium iodide I 131.(1) Sodium iodide I 131 causes a dose-dependent bone marrow suppression, including neutropenia or thrombocytopenia, in the 3 to 5 weeks following administration. Patients may be at increased risk of infections or bleeding during this time.

Monitor complete blood counts within one month of therapy. If results indicate leukopenia or thrombocytopenia, dosimetry should be used to determine a safe sodium iodide I 131 activity.(1)

DISCUSSION: Hematologic disorders including death have been reported with sodium iodide I 131. The most common hematologic disorders reported include anemia, blood dyscrasias, bone marrow depression, leukopenia, and thrombocytopenia.(1)

HICON, SODIUM IODIDE I-131

There are 6 moderate interactions. The clinician should assess the patient’s characteristics and take action as needed. Actions required for moderate interactions include, but are not limited to, discontinuing one or both agents, adjusting dosage, altering administration.

Drug Interaction	Drug Names
Caspofungin/Efavirenz; Nevirapine SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed. MECHANISM OF ACTION: Efavirenz and nevirapine may induce the metabolism of caspofungin via induction of unspecified hepatic CYP enzymes.(1) CLINICAL EFFECTS: The concurrent administration of caspofungin with either efavirenz or nevirapine may result in decreased levels and clinical effectiveness of caspofungin.(1) PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: In adult patients receiving concurrent therapy with efavirenz or nevirapine, the US manufacturer of caspofungin recommends that an increase in the daily dose of caspofungin to 70 mg (following the usual 70 mg loading dose) be considered.(1) In pediatric patients receiving concurrent therapy with efavirenz or nevirapine, the US manufacturer of caspofungin recommends that an increase in the daily dose of caspofungin to 70 mg/m2 (to a maximum of 70 mg daily, following the usual 70 mg/m2 loading dose) be considered.(1) DISCUSSION: Regression analyses of patient pharmacokinetic data suggests that administration of caspofungin with inducers and or mixed inducers/ inhibitors of drug clearance may result in clinically significant decreases in caspofungin concentrations. Therefore, the manufacturer of caspofungin recommends that an increase in the daily dose of caspofungin to 70 mg (following the usual 70 mg loading dose) be considered in patients receiving concurrent therapy with efavirenz or nevirapine. The efficacy of a 70 mg daily dose in patients who are not responding to the 50 mg daily dose is not known, but limited safety data suggests that it is well tolerated.(1)	EFAVIRENZ, EFAVIRENZ-EMTRIC-TENOFOV DISOP, EFAVIRENZ-LAMIVU-TENOFOV DISOP, NEVIRAPINE, NEVIRAPINE ER, SYMFI, SYMFI LO
Caspofungin/Fosphenytoin; Phenytoin SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed. MECHANISM OF ACTION: Phenytoin may induce the metabolism of caspofungin by CYP3A4.(1) CLINICAL EFFECTS: The concurrent administration of caspofungin with phenytoin may result in decreased levels and clinical effectiveness of caspofungin.(1) PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: In adult patients receiving concurrent therapy with phenytoin, the US manufacturer of caspofungin recommends that an increase in the daily dose of caspofungin to 70 mg (following the usual 70 mg loading dose) be considered.(1) In pediatric patients receiving concurrent therapy with phenytoin, the US manufacturer of caspofungin recommends that an increase in the daily dose of caspofungin to 70 mg/m2 (to a maximum of 70 mg daily, following the usual 70 mg/m2 loading dose) be considered.(1) DISCUSSION: Regression analyses of patient pharmacokinetic data suggests that administration of caspofungin with inducers and or mixed inducers/ inhibitors of drug clearance may result in clinically significant decreases in caspofungin concentrations. Therefore, the manufacturer of caspofungin recommends that an increase in the daily dose of caspofungin to 70 mg (following the usual 70 mg loading dose) be considered in patients receiving concurrent therapy with phenytoin. The efficacy of a 70 mg daily dose in patients who are not responding to the 50 mg daily dose is not known, but limited safety data suggests that it is well tolerated.(1)	CEREBYX, DILANTIN, DILANTIN-125, FOSPHENYTOIN SODIUM, PHENYTEK, PHENYTOIN, PHENYTOIN SODIUM, PHENYTOIN SODIUM EXTENDED
Caspofungin/Rifampin SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed. MECHANISM OF ACTION: Rifampin may induce the metabolism of caspofungin by CYP3A4.(1) CLINICAL EFFECTS: The concurrent administration of caspofungin with rifampin may result in decreased levels and clinical effectiveness of caspofungin.(1) PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: In adult patients receiving concurrent therapy with rifampin, the US manufacturer of caspofungin states that a daily dose of 70 mg of caspofungin should be used.(1) In pediatric patients receiving concurrent therapy with rifampin, the US manufacturer of caspofungin recommends that an increase in the daily dose of caspofungin to 70 mg/m2 (to a maximum of 70 mg daily, following the usual 70 mg/m2 loading dose) be considered.(1) DISCUSSION: In a study in healthy volunteers, rifampin decreased caspofungin trough concentrations by 30%.(1)	RIFADIN, RIFAMPIN
Caspofungin/Dexamethasone SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed. MECHANISM OF ACTION: Dexamethasone may induce the metabolism of caspofungin by CYP3A4.(1) CLINICAL EFFECTS: The concurrent administration of caspofungin with dexamethasone may result in decreased levels and clinical effectiveness of caspofungin.(1) PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: In adult patients receiving concurrent therapy with dexamethasone, the US manufacturer of caspofungin recommends that an increase in the daily dose of caspofungin to 70 mg (following the usual 70 mg loading dose) be considered.(1) In pediatric patients receiving concurrent therapy with dexamethasone, the US manufacturer of caspofungin recommends that an increase in the daily dose of caspofungin to 70 mg/m2 (to a maximum of 70 mg daily, following the usual 70 mg/m2 loading dose) be considered.(1) DISCUSSION: Regression analyses of patient pharmacokinetic data suggests that administration of caspofungin with inducers and or mixed inducers/ inhibitors of drug clearance may result in clinically significant decreases in caspofungin concentrations. Therefore, the manufacturer of caspofungin recommends that an increase in the daily dose of caspofungin to 70 mg (following the usual 70 mg loading dose) be considered in patients receiving concurrent therapy with dexamethasone. The efficacy of a 70 mg daily dose in patients who are not responding to the 50 mg daily dose is not known, but limited safety data suggests that it is well tolerated.(1)	BUPIVACAINE-DEXAMETH-EPINEPHRN, DEXABLISS, DEXAMETHASONE, DEXAMETHASONE ACETATE, DEXAMETHASONE ACETATE MICRO, DEXAMETHASONE INTENSOL, DEXAMETHASONE ISONICOTINATE, DEXAMETHASONE MICRONIZED, DEXAMETHASONE SOD PHOS-WATER, DEXAMETHASONE SODIUM PHOSPHATE, DEXAMETHASONE-0.9% NACL, DMT SUIK, DOUBLEDEX, HEMADY, LIDOCIDEX-I, MAS CARE-PAK, TAPERDEX, ZCORT
Caspofungin/Carbamazepine SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed. MECHANISM OF ACTION: Carbamazepine may induce the metabolism of caspofungin by CYP3A4.(1) CLINICAL EFFECTS: The concurrent administration of caspofungin with carbamazepine may result in decreased levels and clinical effectiveness of caspofungin.(1) PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: In adult patients receiving concurrent therapy with carbamazepine, the US manufacturer of caspofungin recommends that an increase in the daily dose of caspofungin to 70 mg (following the usual 70 mg loading dose) be considered.(1) In pediatric patients receiving concurrent therapy with carbamazepine, the US manufacturer of caspofungin recommends that an increase in the daily dose of caspofungin to 70 mg/m2 (to a maximum of 70 mg daily, following the usual 70 mg/m2 loading dose) be considered.(1) DISCUSSION: Regression analyses of patient pharmacokinetic data suggests that administration of caspofungin with inducers and or mixed inducers/ inhibitors of drug clearance may result in clinically significant decreases in caspofungin concentrations. Therefore, the manufacturer of caspofungin recommends that an increase in the daily dose of caspofungin to 70 mg (following the usual 70 mg loading dose) be considered. The efficacy of a 70 mg daily dose in patients who are not responding to the 50 mg daily dose is not known, but limited safety data suggests that it is well tolerated.(1)	CARBAMAZEPINE, CARBAMAZEPINE ER, CARBATROL, EPITOL, EQUETRO, TEGRETOL, TEGRETOL XR
Tacrolimus/Caspofungin SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed. MECHANISM OF ACTION: The mechanism of the interaction is unknown. CLINICAL EFFECTS: Concurrent use of caspofungin may result in decreased levels and effectiveness of tacrolimus.(1,2) PREDISPOSING FACTORS: None determined. PATIENT MANAGEMENT: Tacrolimus levels should be closely monitored in patients receiving concurrent caspofungin. The dosage of tacrolimus may need to be adjusted during and after caspofungin.(1,2) DISCUSSION: In a placebo-controlled, randomized, parallel panel study in healthy subjects, caspofungin (70 mg daily for 10 days) decreased the area-under-curve (AUC), maximum concentration, (Cmax) and minimum concentration (Cmin) of tacrolimus (2 doses of 0.1 mg/kg 12 hours apart) by 20%, 16%, and 26%, respectively.(1,2) There were no significant effects on caspofungin levels.(1)	ASTAGRAF XL, ENVARSUS XR, PROGRAF, TACROLIMUS, TACROLIMUS XL

Severe List
Child-pugh class B hepatic impairment
Disease of liver

The following adverse reaction information is available for CANCIDAS (caspofungin acetate):

Overview
Severe
Less Severe

Adverse reaction overview.

Adverse effects reported in 5% or more of patients receiving caspofungin include pyrexia, diarrhea, chills, decreased potassium, increased alkaline phosphatase, decreased hemoglobin, hypotension, respiratory failure, increased ALT, fever, decreased hematocrit, phlebitis, vomiting, rash, increased AST, nausea, headache, increased bilirubin, septic shock, decreased leukocyte count, peripheral edema, cough, pneumonia, increased creatinine, anemia, abdominal pain, dyspnea, increased blood urea, pleural effusion, increased conjugated bilirubin, tachycardia, decreased albumin, decreased magnesium, rales, and sepsis.

There are 33 severe adverse reactions.

More Frequent	Less Frequent
Abnormal hepatic function tests Anemia Hypokalemia Increased alanine transaminase Increased alkaline phosphatase Increased aspartate transaminase	Dyspnea Injection site sequelae Neutropenic disorder Peripheral edema

Rare/Very Rare
Acute myocardial infarction Anaphylaxis Angioedema Atrial fibrillation Bradycardia Bronchospastic pulmonary disease Erythema multiforme Exfoliative dermatitis Hematuria Hepatic necrosis Hepatitis Hyperbilirubinemia Hypercalcemia Hypomagnesemia Hypoxia Jaundice Kidney disease with reduction in glomerular filtration rate (GFr) Pancreatitis Renal failure Seizure disorder Stevens-johnson syndrome Thrombocytopenic disorder Toxic epidermal necrolysis

Rare/Very Rare

Acute myocardial infarction
Anaphylaxis
Angioedema
Atrial fibrillation
Bradycardia
Bronchospastic pulmonary disease
Erythema multiforme
Exfoliative dermatitis
Hematuria
Hepatic necrosis
Hepatitis
Hyperbilirubinemia
Hypercalcemia
Hypomagnesemia
Hypoxia
Jaundice
Kidney disease with reduction in glomerular filtration rate (GFr)
Pancreatitis
Renal failure
Seizure disorder
Stevens-johnson syndrome
Thrombocytopenic disorder
Toxic epidermal necrolysis

There are 40 less severe adverse reactions.

More Frequent	Less Frequent
Acute abdominal pain Chills Diarrhea Fever Nausea Vomiting	Abdominal distension Anorexia Body fluid retention Constipation Cough Dizziness Drowsy Erythema Fatigue Flushing General weakness Headache disorder Hyperglycemia Hypertension Hypotension Phlebitis after infusion Pruritus of skin Skin rash Stomatitis Tachycardia

Rare/Very Rare
Acute cognitive impairment Arthralgia Back pain Depression Dyspepsia Epistaxis Facial edema Insomnia Petechiae Sensation of warmth Symptoms of anxiety Tremor Urinary tract infection Urticaria

The following precautions are available for CANCIDAS (caspofungin acetate):

Pediatric
Pregnant
Lactation
Geriatric

Safety and efficacy of caspofungin have not been established in neonates and infants younger than 3 months of age. Although limited pharmacokinetic data are available for this age group, the manufacturer states that data are insufficient to date to establish a safe and effective dosage for treatment of neonatal candidiasis. In addition, invasive candidiasis in neonates has a higher rate of CNS and multi-organ involvement than do such infections in older patients, and data are insufficient to date regarding distribution of caspofungin into the CNS or regarding efficacy in the treatment of meningitis and endocarditis.

Caspofungin has not been evaluated in pediatric patients for the treatment of endocarditis, osteomyelitis, or meningitis caused by Candida or for initial therapy of invasive aspergillosis. The drug also has not been evaluated for use in pediatric patients with hepatic impairment. Safety and efficacy of caspofungin for use in infants and children 3 months to 17 years of age for treatment of invasive aspergillosis in those refractory to or intolerant of other antifungals; for treatment of candidemia and certain other invasive Candida infections (intra-abdominal abscesses, peritonitis, pleural space infections) or esophageal candidiasis; and for empiric treatment of presumed fungal infections in febrile neutropenic patients is based on adequate and well-controlled studies in adults, pharmacokinetic data in pediatric patients, and additional data from prospective studies in this age group.

The manufacturer states that the overall safety profile of caspofungin in pediatric patients is comparable to that in adults. Adverse effects reported in 7% or more of pediatric patients receiving caspofungin include pyrexia, rash, decreased potassium, increased AST, diarrhea, increased ALT, chills, hypotension, vomiting, tachycardia, mucosal inflammation, hypertension, headache, erythema, central line infection, cough, respiratory distress, hypokalemia, abdominal pain, and pruritus. Although data are limited, some experts state that caspofungin can be considered for first-line treatment of invasive candidiasis or for alternative treatment of esophageal candidiasis in children with human immunodeficiency virus (HIV) infection.

Contraindicated

None

Severe Precaution

None

Management or Monitoring Precaution

None

Category C. (See Users Guide.) There are no adequate and well-controlled studies of caspofungin acetate in pregnant women, and the manufacturer states that the drug should be used during pregnancy only if potential benefits justify potential risks to the fetus. In animals, embryofetal toxicity (increased resorptions, increased peri-implantation loss, incomplete ossification at multiple fetal sites) has been reported with caspofungin dosages about 2 times the recommended human dosage (based on body surface area comparisons).

Caspofungin is distributed into milk in rats; it is not known whether the drug is distributed into milk in humans. Caspofungin should be used with caution in nursing women.

Clinical studies of caspofungin did not include a sufficient number of patients 65 years of age or older to determine whether they respond differently than younger individuals. Although no overall differences in efficacy or safety were observed between geriatric and younger adults, the possibility that some older patients may have increased sensitivity to the drug cannot be ruled out. Although caspofungin plasma concentrations are increased slightly in men and women 65 years of age and older compared with young healthy males, dosage adjustments are not necessary in geriatric patients.

The following icd codes are available for CANCIDAS (caspofungin acetate)'s list of indications:

Candida peritonitis
B37.89	Other sites of candidiasis
K65.0	Generalized (acute) peritonitis
T85.71	Infection and inflammatory reaction due to peritoneal dialysis catheter
T85.71xA	Infection and inflammatory reaction due to peritoneal dialysis catheter, initial encounter
Candida pleural space infection
B37.1	Pulmonary candidiasis
J86	Pyothorax
J86.0	Pyothorax with fistula
J86.9	Pyothorax without fistula
Candidemia
B37.7	Candidal sepsis
Esophageal candidiasis
B37.81	Candidal esophagitis
Febrile neutropenic patient presumed infection treatment
D70.1	Agranulocytosis secondary to cancer chemotherapy
D70.2	Other drug-induced agranulocytosis
D70.3	Neutropenia due to infection
D70.8	Other neutropenia
D70.9	Neutropenia, unspecified
R50.81	Fever presenting with conditions classified elsewhere
Intra-abdominal candida abscess
B37.9	Candidiasis, unspecified
D73.3	Abscess of spleen
K50.014	Crohn's disease of small intestine with abscess
K50.114	Crohn's disease of large intestine with abscess
K50.814	Crohn's disease of both small and large intestine with abscess
K50.914	Crohn's disease, unspecified, with abscess
K51.014	Ulcerative (chronic) pancolitis with abscess
K51.214	Ulcerative (chronic) proctitis with abscess
K51.314	Ulcerative (chronic) rectosigmoiditis with abscess
K51.414	Inflammatory polyps of colon with abscess
K51.514	Left sided colitis with abscess
K51.814	Other ulcerative colitis with abscess
K51.914	Ulcerative colitis, unspecified with abscess
K57.0	Diverticulitis of small intestine with perforation and abscess
K57.00	Diverticulitis of small intestine with perforation and abscess without bleeding
K57.01	Diverticulitis of small intestine with perforation and abscess with bleeding
K57.2	Diverticulitis of large intestine with perforation and abscess
K57.20	Diverticulitis of large intestine with perforation and abscess without bleeding
K57.21	Diverticulitis of large intestine with perforation and abscess with bleeding
K57.4	Diverticulitis of both small and large intestine with perforation and abscess
K57.40	Diverticulitis of both small and large intestine with perforation and abscess without bleeding
K57.41	Diverticulitis of both small and large intestine with perforation and abscess with bleeding
K57.8	Diverticulitis of intestine, part unspecified, with perforation and abscess
K57.80	Diverticulitis of intestine, part unspecified, with perforation and abscess without bleeding
K57.81	Diverticulitis of intestine, part unspecified, with perforation and abscess with bleeding
K63.0	Abscess of intestine
K65.1	Peritoneal abscess
K68.1	Retroperitoneal abscess
K68.11	Postprocedural retroperitoneal abscess
K68.12	Psoas muscle abscess
K68.19	Other retroperitoneal abscess
K75.0	Abscess of liver
N15.1	Renal and perinephric abscess
N34.0	Urethral abscess
N41.2	Abscess of prostate
Refractory aspergillosis
B44	Aspergillosis
B44.0	Invasive pulmonary aspergillosis
B44.1	Other pulmonary aspergillosis
B44.2	Tonsillar aspergillosis
B44.7	Disseminated aspergillosis
B44.89	Other forms of aspergillosis
B44.9	Aspergillosis, unspecified