[Skip to content]

Print this page
.

5.2 Antifungal drugs

ORAL
Fluconazole capsules, suspension      
Isavuconazole capsules- under specific guidelines or only on the advice of a consultant microbiologist
Itraconazole capsules, suspension (use under specific guidelines or only on the advice of a consultant microbiologist)
Nystatin suspension
Terbinafine tablets                        
Miconazole oral gel - see note        
Posaconazole tablets, oral suspension – fungal prophylaxis in neutropenia secondary to chemotherapy in AML/high-risk myelodysplasia - see note 
Voriconazole tablets - consultant microbiologist only 

Note: Voriconazole is associated with a risk of liver toxicity, phototoxicity and skin cancer. Test liver function before and during treatment, and advise patients to avoid sunlight exposure – see MHRA Drug Safety Update May 2014 

The dose of posaconazole tablets and suspension are not directly interchangeable, as there are important bioavailability differences – see note and link.

Miconazole increases the anticoagulant effect of warfarin. Monitor patients carefully, and adjust the dose of warfarin accordingly – see MHRA DSU

Ketoconazole tablets (no longer recommended for use as an antifungal - risk of liver toxicity outweighs benefits - see MHRA alert and Drug Safety Update; now reserved for specialist use only in Cushing's syndrome - unlicensed indication)
Echinocandin
 Indication
Caspofungin
Empirical treatment of suspected or confirmed invasive fungal infection in neutropenic patients if an echinocandin is indicated
Anidulafungin      
Empirical treatment of suspected or confirmed invasive candiasis in moderate-to-severe illness in non-neutropenic patients, or empirical treatment in neutropenic patients if an echinocandin is indicated and the patient has severe liver disease

 

SUMMARY OF DIFFERENCES BETWEEN ECHINOCANDINS:

 
Licensed indications
Dose
Other info

Anidulafungin(Ecalta®)

Treatment of invasive candidiasis in adult non-neutropenic adults.

200mg on day 1 and then 100mg daily

Eliminated almost entirely by slow chemical degradation in bile rather than via hepatic metabolism.

Fewest drug interactions.

No dosage adjustments for mild, moderate or severe hepatic impairment

Caspofungin(Cancidas®)

Treatment of invasive candidiasis in adults/ paeds.

Treatment of invasive aspergillosis.

Empirical treatment of systemic fungal infections in neutropenic patients.

70mg on day 1 and then 50mg daily thereafter.

(If body weight is over 80kg give 70mg daily)

Most drug interactions

Reduce dose to 35mg daily in moderate  hepatic impairment.

No experience in severe hepatic impairment.

 

CSM advice (heart failure)

Following rare reports of heart failure, the CSM has advised caution when prescribing itraconazole to patients at high risk of heart failure. Those at risk include:

  • patients receiving high doses and longer treatment courses;
  • older patients and those with cardiac disease;
  • patients receiving treatment with negative inotropic drugs, e.g. calcium channel blockers.

 

PARENTERAL
Anidulafungin IV Infusion: under specific guidelines or only on the advice of a consultant microbiologist (see above).
Liposomal amphotericin (AmBisome)]. Under specific guidelines or only on the advice of a Consultant Microbiologist.  
Caspofungin IV Infusion: under specific guidelines or only on the advice of a consultant microbiologist.
Fluconazole IV Infusion: under specific guidelines or only on the advice of a consultant microbiologist.  
Flucytosine IV Infusion: under specific guidelines or only on the advice of a consultant microbiologist.  
Isavuconazole IV Infusion - under specific guidelines or only on the advice of a consultant microbiologist
Voriconazole IV Infusion consultant microbiologist Only

 

Click here for the Trust Guidelines:

Empirical antifungal treatment in febrile neutropenia in oncology/haematology patients

Treatment of candida infections in non-neutropenic patients

 

For link to BNF section: 5.2 Antifungal drugs