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Paul A. Pham Pharm.D. and John G. Bartlett M.D.
09-12-2008
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Available formulation in Zambia: Powder for injection: 50 mg in vial.
- Gold standard for most deep-seated mycotic infections.
- Cryptococcal meningitis: amphotericin 0.7 mg/kg/d x 14 days (induction). If renal failure, fluconazole 800 mg x1, then 400 mg daily can be considered, but has been shown to be suboptimal during induction phase.
- Esophageal candidiasis resistant to fluconazole: amphoB 0.7 mg/kg/d x 14 days (lower doses 0.3 mg/kg/d can be considered).
Zambia Information Author: Paul A. Pham Pharm.D.
- Aspergillosis
- Blastomycosis
- Disseminated candidiasis
- Leishmaniasis
- Cryptococcosis
- Histoplasmosis
- Cryptococcal meningitis (treatment and suppression)
- Sporotrichosis; mucromycosis; basidiobolus; conidiobolus
- Coccidioidomycosis
- Treatment of fungal infections involving the CNS, pulmonary, and urinary tract system.
brand
name
| generic
| Mfg
| brand
forms
| cost*
|
| Fungizone and generic | Amphotericin B | BMS and generic manufacturers. | IV
vial
50 mg | $24.50 /50 mg vial |
*Prices represent cost per unit specified and are representative of "Average Wholesale Price" (AWP).
AWP Prices were obtained and gathered by Lakshmi Vasist Pharm D using the Red Book, manufacturer's
information, and the McKesson database.
^Dosage is indicated in mg unless otherwise noted.
Dosing range: 0.3-1.5 mg/kg/d IV (infuse over 2-4hrs). Oral form no longer commercially available.
- Cryptococcal meningitis: 0.7mg/kg IV q24h +/- flucytosine 25mg/kg PO q6h x 2 wks, then fluconazole 400 mg PO q24h x 8 wks or until CSF is sterile. Maintenance therapy with fluconazole 200 mg PO q24h.
- Candida esophagitis (azole-resistant): 0.3-0.7 mg/kg IV q24h (echinocandins can also be considered)
- Systemic fungal infections: 0.5-1.5 mg/kg/d over 2-4 hrs w/ pre- and post-hydration.
Usual dose.
Usual dose. Consider alternative lipid formulation.
If ARF reversible, consider alternative lipid formulation .
Usual dose, no supplement needed post HD.
Usual dose.
No data. Usual dose likely.
- Nephrotoxicity: can occur with or without nephrocalcinosis. Reduced with adequate hydration, salt loading (500 cc NS pre and post amphotericin B infusion) and avoidance of concurrent nephrotoxic agents.
- Renal tubular acidosis.
- Electrolyte abnormalities: hypokalemia, hypomagnesemia, and hypocalcemia.
- Fever and chills: can be managed with meperidine or hydrocortisone 10-50 mg added to infusion. Alternatively, could premedicate with meperidine or ibuprofen.
- Anemia (normocytic normochromic).
- Phlebitis (improved with the addition of 1000 U heparin to infusion).
- Hypotension
- Nausea and vomiting
- Metallic taste
- Headache
- Digoxin: may increase digitalis toxicity secondary to hypokalemia (consider potassium supplementation).
- Diuretics and corticosteroids: may result in additive hypokalemia.
- Nephrotoxic agents (e.g., foscarnet, cidofovir, aminoglycosides, and cyclosporine): may result in additive nephrotoxicity.
Broad-spectrum antifungal that includes: all . (except C. lusitaniae), Aspergillus spp., B. dermatitidis, C. immitis, C. neoformans, H. capsulatum, S. schenckii, and Zygomycetes.
- Some spp. of Fusarium oxysporum and F. solani and most spp. of Pseudallescheria boydii are resistant.
-
Candida lusitaniae
Use is complicated by high rate of infusion and dose-dependent related reactions such as anemia, electrolyte imbalance and renal failure. A switch to lipid formulation (liposomal amphotericin) generally recommended when serum creatinine elevated to arbitrary threshold (>2.5 used at Hopkins). Infusion-related side effects higher than Ambisome and Abelcet but lower than Amphotec. When indicated, alternative agents such as caspofungin may also be considered. Despite lower incidence of nephrotoxicity with lipid formulation, amphotericin B deoxycholate remains drug of choice for treatment of cryptococcal meningitis due to robust clinical data. For other invasive fungal infections, Ambisome and Abelcet generally preferred.
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