CANCIDAS is for intravenous use and comes in a 10 mL vial with a grey butyl stopper and aluminium seal with a plastic flip off lid. Each 10 mL vial contains either 50 mg or 70 mg of caspofungin free base as a solid white to off white cake. The reconstitution liquid is clear.

Dosage and Administration

CANCIDAS should be administered in adults (>=18 years of age) by slow intravenous infusion over approximately 1 hour.

A single 70 mg loading dose should be administered on Day 1, followed by 50 mg daily thereafter. Duration of treatment should be based on the patient's clinical response. Empirical therapy should be continued until resolution of neutropaenia. Patients found to have a fungal infection should be treated for a minimum of 14 days; treatment should continue for at least 7 days after both neutropaenia and clinical symptoms are resolved. If the 50 mg dose is well tolerated but does not provide an adequate clinical response, the daily dose can be increased to 70 mg. Although an increase in efficacy with 70 mg daily has not been demonstrated, safety data suggest that an increase in dose to 70 mg daily is well tolerated.

A single 70-mg loading dose should be administered on Day 1, followed by 50 mg daily thereafter. Duration of treatment of invasive candidiasis should be dictated by the patient's clinical and microbiological response. In general, antifungal therapy should continue for at least 14 days after the last positive culture. Patients who remain persistently neutropaenic may warrant a longer course of therapy pending resolution of the neutropaenia. The usual dose is 50 mg once daily (following a 70-mg loading dose for most indications). The safety and efficacy of a dose of 150 mg daily (range: 1 to 51 days; median: 14 days) have been studied in 100 adult patients with invasive candidiasis. The efficacy of CANCIDAS at this higher dose was not significantly better than the efficacy of the 50-mg daily dose of CANCIDAS. The efficacy of doses higher than 50 mg daily in the other adult patients for whom CANCIDAS is indicated is not known.

A single 70 mg loading dose should be administered on Day 1, followed by 50 mg once daily thereafter. Duration of treatment should be based upon the severity of the patient's underlying disease, recovery from immunosuppression, and clinical response. No dosage adjustment is necessary for elderly patients (65 years of age or more). No dosage adjustment is necessary based on gender, race, or renal impairment. When co-administering CANCIDAS in adult patients with the metabolic inducers efavirenz, nevirapine, rifampin, dexamethasone, phenytoin, or carbamazepine, use of a daily dose of 70 mg of CANCIDAS should be considered.

Adult patients with mild hepatic insufficiency (Child-Pugh score 5 to 6) do not need a dosage adjustment. For adult patients with moderate hepatic insufficiency (Child-Pugh score 7 to 9), CANCIDAS 35 mg daily is recommended based upon pharmacokinetic data. However, where recommended, a 70 mg loading dose should still be administered on Day 1. There is no clinical experience in adult patients with severe hepatic insufficiency (Child- Pugh score greater than 9) and in paediatric patients with any degree of hepatic insufficiency.

CANCIDAS should be administered in paediatric patients (3 months to 17 years of age) by slow IV infusion over approximately 1 hour. Dosing in paediatric patients (3 months to 17 years of age) should be based on the patient's body surface area (see Instructions for Use in Paediatric Patients, Mosteller Formula). For all indications, a single 70-mg/m2 loading dose (not to exceed an actual dose of 70 mg) should be administered on Day 1, followed by 50 mg/m2 daily thereafter (not to exceed an actual dose of 70 mg daily). Duration of treatment should be individualised to the indication, as described for each indication in adults (see General Recommendations in Adult Patients). If the 50-mg/m2 daily dose is well tolerated but does not provide an adequate clinical response, the daily dose can be increased to 70 mg/m2 daily (not to exceed an actual daily dose of 70 mg). Although an increase in efficacy with 70 mg/m2 daily has not been

Mosteller RD: Simplified Calculation of Body Surface Area. N Engl J Med 1987 Oct 22; 317(17): 1098 (letter)

demonstrated, limited safety data suggest that an increase in dose to 70 mg/m2 daily is well tolerated. When CANCIDAS is co-administered to paediatric patients with inducers of medicine clearance, such as rifampin, efavirenz, nevirapine, phenytoin, dexamethasone, or carbamazepine, use of a CANCIDAS dose of 70-mg/m2 daily (not to exceed an actual daily dose of 70 mg) should be considered.

DO NOT USE ANY DILUENTS CONTAINING DEXTROSE, as CANCIDAS is not stable in diluents containing dextrose. DO NOT MIX OR CO-INFUSE CANCIDAS WITH ANY OTHER MEDICATIONS, as there is no data available on the compatibility of CANCIDAS with other intravenous substances, additives, or medications. Visually inspect the infusion solution for particulate matter or discolouration.

To reconstitute the powdered medicine, bring the refrigerated conventional vial of CANCIDAS to room temperature and aseptically add 10.5 mL of either 0.9% Sodium Chloride injection, Sterile Water for Injection, Bacteriostatic Water for Injection with methylparaben and propylparaben, or Bacteriostatic Water for Injection with 0.9% benzyl alcohol. The concentrations of the reconstituted vials will be: 7.2 mg/mL (70 mg vial) or 5.2 mg/mL (50 mg vial). The white to off-white compact powder will dissolve completely. Mix gently until a clear solution is obtained. Reconstituted solutions should be visually inspected for particulate matter or discolouration. This reconstituted solution may be stored for up to 24 hours at or below 25degC (77degF).

Diluents for the final patient infusion solutions are: Sterile Saline for Injection, or Lactated Ringer's Solution. The standard patient infusion is prepared by aseptically adding the appropriate amount of reconstituted medicine (as shown in the table below) to a 250 mL intravenous bag or bottle. Reduced volume infusions in 100 mL may be used, when medically necessary, for 50 mg or 35 mg daily doses. Do not use if the solution is cloudy or precipitated. This infusion solution must be used within 24 hours if stored at or below 25degC (77degF) or within 48 hours if stored refrigerated at 2 to 8degC (36 to 46degF). CANCIDAS should be administered by slow intravenous infusion over approximately 1 hour. PREPARATION OF THE PATIENT INFUSION SOLUTIONS IN ADULTS

* *If 70 mg vial is not available, the 70 mg dose can be prepared from two 50 mg vials

Before preparation of infusion, calculate the body surface area (BSA) of the patient using the following formula: (Mosteller Formula): Preparation of the 70-mg/m2 infusion for paediatric patients 3 months of age or older (using a 70-mg vial).

BSA (m2) X 70 mg / m2 = Loading Dose The maximum loading dose on Day 1 should not exceed 70 mg regardless of the patient's calculated dose. Equilibrate the refrigerated vial of CANCIDAS to room temperature. Aseptically add 10.5 mL of 0.9% Sodium Chloride Injection, Sterile Water for Injection, Bacteriostatic Water for Injection with methylparaben and propylparaben, or Bacteriostatic Water for Injection with 0.9% benzyl alcohol.a This reconstituted solution may be stored for up to 24 hours at or below 25degC (77degF).b This will give a final caspofungin concentration in the vial of 7.2 mg/mL. Remove the volume of medicine equal to the calculated loading dose (Step 1) from the vial. Aseptically transfer this volume (mL)c of reconstituted CANCIDAS to an IV bag (or bottle) containing 250 mL of 0.9%, 0.45%, or 0.225% Sodium Chloride Injection, or Lactated Ringers Injection. Alternatively, the volume (mL)c of reconstituted CANCIDAS can be added to a reduced volume of 0.9%, 0.45%, or 0.225% Sodium Chloride Injection or Lactated Ringers Injection, not to exceed a final concentration of 0.5 mg/mL. This infusion solution must be used within 24 hours if stored at or below 25degC (77degF) or within 48 hours if stored refrigerated at 2 to 8degC (36 to 46degF).

If the calculated loading dose is <50 mg, then the dose may be prepared from the 50- mg vial [follow Steps 2-4 from Preparation of the 50 mg/m2 infusion for paediatric patients >3 months of age (using a 50-mg vial)]. The final caspofungin concentration in the 50-mg vial after reconstitution is 5.2 mg/mL. Preparation of the 50-mg/m2 infusion for paediatric patients >3 months of age (using a 50- mg vial)

BSA (m2) X 50 mg/m2 = Daily Maintenance Dose The daily maintenance dose should not exceed 70 mg regardless of the patient's calculated dose. Equilibrate the refrigerated vial of CANCIDAS to room temperature. Aseptically add 10.5 mL of 0.9% Sodium Chloride Injection, Sterile Water for Injection, Bacteriostatic Water for Injection with methylparaben and propylparaben, or Bacteriostatic Water for Injection with 0.9% benzyl alcohol.a This reconstituted solution may be stored for up to 24 hours at or below 25degC (77degF).b This will give a final caspofungin concentration in the vial of 5.2 mg/mL. Remove the volume of medicine equal to the calculated loading dose (Step 1) from the vial. Aseptically transfer this volume (mL)c of reconstituted CANCIDAS to an IV bag (or bottle) containing 250 mL of 0.9%, 0.45%, or 0.225% Sodium Chloride Injection, or Lactated Ringers Injection. Alternatively, the volume (mL)c of reconstituted CANCIDAS can be added to a reduced volume of 0.9%, 0.45%, or 0.225% Sodium Chloride Injection or Lactated Ringers Injection, not to exceed a final concentration of 0.5 mg/mL. This infusion solution must be used within 24 hours if stored at or below 25degC (77degF) or within 48 hours if stored refrigerated at 2 to 8degC (36 to 46degF).

If the actual daily maintenance dose is >50 mg, then the dose may be prepared from the 70-mg vial [follow Steps 2-4 from Preparation of the 70 mg/m2 infusion for paediatric patients 3 months of age or older (using a 70-mg vial)]. The final caspofungin concentration in the 70-mg vial after reconstitution is 7.2 mg/mL.

Contraindications

CANCIDAS is contraindicated in patients with hypersensitivity to any component of this product.

Warnings and Precautions

Anaphylaxis has been reported during administration of CANCIDAS. If this occurs, CANCIDAS should be discontinued and appropriate treatment administered. Possibly histamine-mediated adverse reactions, including rash, facial swelling, angioedema, pruritus, sensation of warmth, or bronchospasm have been reported and may require discontinuation and/or administration of appropriate treatment. Concomitant use of CANCIDAS with cyclosporine has been evaluated in healthy adult volunteers and in adult patients. Some healthy adult subjects who received two 3 mg/kg doses of cyclosporine with caspofungin showed transient increases in alanine transaminase (ALT) and aspartate transaminase (AST) of less than or equal to 3 fold the upper limit of normal (ULN) that resolved with discontinuation of the medicines. There was also an increase of approximately 35% in the area under the curve (AUC) of caspofungin when CANCIDAS and cyclosporine were co-administered; blood levels of cyclosporine remained unchanged. In a retrospective study of 40 patients treated during marketed use with CANCIDAS and cyclosporine for 1 to 290 days (median 17.5 days), no serious hepatic adverse events were noted. As expected in patients with allogeneic haematopoietic stem cell transplants or solid organ transplants, hepatic enzyme abnormalities occurred commonly; however, no patient had elevations in ALT that were considered medicine related. Elevations in AST considered at least possibly related to therapy with CANCIDAS and/or cyclosporine occurred in 5 patients, but all were less than 3.6 times the ULN. Discontinuations due to laboratory abnormalities in hepatic enzymes from any cause occurred in 4 patients. Of these, 2 were considered possibly related to therapy with CANCIDAS and/or cyclosporine as well as other possible causes. In the prospective invasive aspergillosis and compassionate use studies, there were 6 adult patients treated with CANCIDAS and cyclosporine for 2 to 56 days; none of these patients experienced increases in hepatic enzymes. These data suggest that CANCIDAS can be used in patients receiving cyclosporine when the potential benefit outweighs the potential risk.

There is no clinical experience involving pregnant women. In rats, caspofungin caused decreases in foetal body weights and an increase in the incidence of incomplete ossification of the skull and torso, at a maternally toxic dose of 5 mg/kg/day. In addition, at this same maternally toxic dose, there was an increase in the incidence of cervical rib in rats. Caspofungin has been shown to cross the placental barrier in animal studies. CANCIDAS should not be used during pregnancy unless clearly necessary.

It is not known whether this medicine is excreted in human milk; therefore, women receiving CANCIDAS should not breast feed.

The safety and effectiveness of CANCIDAS in paediatric patients 3 months to 17 years of age are supported by evidence from adequate and well-controlled studies in adults, pharmacokinetic data in paediatric patients, and additional data from prospective studies in paediatric patients 3 months to 17 years of age for the following indications (see Indications): Empirical therapy for presumed fungal infections in febrile, neutropaenic patients Treatment of invasive candidiasis, including candidaemia, in neutropaenic and non- neutropaenic patients Treatment of oesophageal candidiasis Treatment of invasive aspergillosis in patients who are refractory to or intolerant of other therapies The efficacy and safety of CANCIDAS have not been adequately studied in prospective clinical trials involving neonates and infants under 3 months of age. CANCIDAS has not been studied in paediatric patients with endocarditis, osteomyelitis, and meningitis due to Candida. CANCIDAS has also not been studied as initial therapy for invasive aspergillosis in paediatric patients.

The plasma concentration of caspofungin in healthy older men and women (65 years of age or more) was increased slightly (approximately 28% in AUC) compared to young healthy males. In patients who were treated empirically or who had invasive candidiasis, a similar modest effect of age was seen in older patients relative to younger patients. No dosage adjustment is necessary for elderly patients (65 years of age or more).

The approximate intravenous lethal dose50 (LD50) for female mice and rats was calculated as 19 and 38 mg/kg, respectively.

Several treatment-related changes were noted in intravenous toxicity studies in rats and Rhesus monkeys. In these studies, signs of histamine release were observed in rats, serum transaminase levels were increased in monkeys, and injection-site irritation was seen in both species. In 5 and 14 week intravenous toxicity studies in rats, 5 mg/kg/day produced signs of histamine release consisting of hyperaemia and swelling of the extremities, sluggish movement or ataxia, and recumbency. These signs occurred only during the first 7 to 9 days of dosing presumably due to endogenous histamine depletion. Overall, in the rat studies, 2 mg/kg/day was established as the no-effect level for histamine release. No signs of histamine release were reported in 5, 14, and 27 week intravenous dosing studies in monkeys. In ancillary pharmacology studies, a 20 minute infusion at 8 mg/kg produced no adverse effects in monkeys; however, bolus injections of 5 or 8 mg/kg did produce signs of histamine release. Similar signs of histamine release that were produced with a structural analog of caspofungin acetate in monkeys were reversed upon injection of cyproheptadine. In 5, 14, and 27 week intravenous toxicity studies in monkeys, ALT and/or AST levels increased slightly, but these levels returned to baseline or remained slightly elevated over the course of the studies. In one 5 week study, scattered small foci of subcapsular necrosis were observed microscopically in the livers of some animals; however, this histopathological finding was not seen in other studies of up to 27 weeks duration at the same or higher doses. The no-effect level for serum transaminase elevations after intravenous treatment was 1.5 mg/kg/day in monkeys, and greater than 7.2 mg/kg/day in rats (the highest dose tested). During the 5, 14, and 27 week intravenous toxicity studies in rats and monkeys, clinical and histopathological signs of injection-site irritation were observed. Overall, the no-effect dosage level for irritation at the injection site in rats was 1.8 mg/kg/day (0.18 mg/mL), and in monkeys it was 3 mg/kg/day (0.25 mg/mL). Effective pre- and post-dose flushing of catheter lines minimised injection-site irritation in animal studies.

No long-term studies in animals have been performed to evaluate the carcinogenic potential of caspofungin.

Caspofungin acetate was evaluated in the following series of in vitro assays and found to be neither mutagenic nor genotoxic: bacterial (Ames) and mammalian cell (V79 Chinese hamster lung fibroblasts) mutagenesis assays, the alkaline elution/rat hepatocyte DNA strand break test, and the chromosomal aberration assay in Chinese hamster ovary cells. Additionally, in the in vivo mouse bone marrow chromosomal test, caspofungin acetate was not genotoxic at doses up to 12.5 mg/kg, administered intravenously.

Female rats administered 0.5, 2, and 5 mg/kg/day of caspofungin acetate intravenously for 16 days prior to cohabitation, during cohabitation, and through gestation Day 7 showed no medicine-related effects on mating performance, fecundity, fertility, or embryonic survival. Male rats treated intravenously with 0.5, 2, and 5 mg/kg/day (maximum dosage tested) for 28 days prior to mating showed no effect on fertility.

In rats, there were no developmental effects at a dose of 2 mg/kg/day. At a maternally toxic dose of 5 mg/kg/day, which resulted in a plasma exposure approximately 1.5 times the plasma exposure seen in humans administered 70 mg, caspofungin caused decreases in foetal body weights and an increase in the incidence of incomplete ossification of the skull and torso. In addition, at this same maternally toxic dose, there was an increase in the incidence of cervical rib in rats. In rabbits, there were no treatment-related external, visceral, or skeletal foetal morphological findings in an intravenous toxicity study where caspofungin acetate was administered to pregnant rabbits at dosages of 1, 3, and 6 mg/kg/day on gestation days 7 through 20. Therefore, the no-effect level for developmental toxicity was greater than 6 mg/kg/day. The no-effect level for maternal toxicity (based on minimal decreases in average maternal body weight gain and food consumption) was 3 mg/kg/day. Pregnant rabbits administered 5 mg/kg/day had plasma exposures approximately 1.5 times the plasma exposure seen in humans administered 70 mg. Caspofungin acetate has been shown to cross the placental barrier in animal studies.

No data are available on whether CANCIDAS impairs the ability to drive or operate machinery.

Interactions

Studies in vitro show that caspofungin acetate is not an inhibitor of any enzyme in the cytochrome P450 (CYP) system. In clinical studies, caspofungin did not induce the CYP3A4 metabolism of other medicines. Caspofungin is not a substrate for P-glycoprotein and is a poor substrate for cytochrome P450 enzymes. In two adult clinical studies, cyclosporine (one 4 mg/kg dose or two 3 mg/kg doses) increased the AUC of caspofungin by approximately 35%. These AUC increases are probably due to reduced uptake of caspofungin by the liver. CANCIDAS did not increase the plasma levels of cyclosporine. There were transient increases in liver ALT and AST when CANCIDAS and cyclosporine were co-administered. In a retrospective study of 40 patients treated during marketed use with CANCIDAS and/or cyclosporine for 1 to 290 days (median 17.5 days), no serious hepatic adverse events were noted (see Warnings and Precautions). Clinical studies in healthy adult volunteers show that the pharmacokinetics of CANCIDAS are not altered by itraconazole, amphotericin B, mycophenolate, nelfinavir or tacrolimus. CANCIDAS has no effect on the pharmacokinetics of itraconazole, amphotericin B, rifampin or the active metabolite of mycophenolate. CANCIDAS reduced the 12-hour blood concentration (C12 hr) of tacrolimus (FK-506) by 26% in healthy adult volunteers. For patients receiving both therapies, standard monitoring of tacrolimus blood concentrations and appropriate tacrolimus dosage adjustments are recommended. Results from two clinical medicine interaction studies in healthy adult volunteers indicate that rifampin both induces and inhibits caspofungin disposition with net induction at steady state. In one study, rifampin and caspofungin were co-administered for 14 days with both therapies initiated on the same day. In the second study, rifampin was administered alone for 14 days to allow the induction effect to reach steady state, and then rifampin and caspofungin were co-administered for an additional 14 days. When the induction effect of rifampin was at steady state, there was little change in caspofungin AUC or end-of-infusion concentration, but caspofungin trough concentrations were reduced by approximately 30%. The inhibitory effect of rifampin was demonstrated when rifampin and caspofungin treatments were initiated on the same day, and a transient elevation in caspofungin plasma concentrations occurred on Day 1 (approximately 60% increase in AUC). This inhibitory effect was not seen when caspofungin was added to pre-existing rifampin therapy, and no elevation in caspofungin concentrations occurred. In addition, results from population pharmacokinetic screening in adults suggest that co-administration of other inducers of medicine clearance (efavirenz, nevirapine, phenytoin, dexamethasone, or carbamazepine) with CANCIDAS may also result in clinically meaningful reductions in caspofungin concentrations. Available data suggest that the inducible medicine clearance mechanism involved in caspofungin disposition is likely an uptake transport process, rather than metabolism. Therefore, when CANCIDAS is co-administered to adult patients with inducers of medicine clearance, such as efavirenz, nevirapine, rifampin, dexamethasone, phenytoin, or carbamazepine, use of a daily dose of 70 mg of CANCIDAS should be considered (see Dosage and Administration). In paediatric patients, results from regression analyses of pharmacokinetic data suggest that co-administration of dexamethasone with CANCIDAS may result in clinically meaningful reductions in caspofungin trough concentrations. This finding may indicate that paediatric patients will have similar reductions with inducers as seen in adults. When CANCIDAS is co-administered to paediatric patients with inducers of medicine clearance, such as rifampin, efavirenz, nevirapine, phenytoin, dexamethasone, or carbamazepine, a CANCIDAS dose of 70-mg/m2 daily (not to exceed an actual daily dose of 70 mg) should be considered.

Adverse Effects

Hypersensitivity reactions have been reported (see Warnings and Precautions).

Adult Patients

In clinical studies, 1865 adult individuals received single or multiple doses of CANCIDAS: 564 febrile neutropaenic patients (empirical therapy study), 382 patients with invasive candidiasis, 297 patients with oesophageal and/or oropharyngeal candidiasis, 228 patients with invasive aspergillosis and 394 individuals in phase I studies. In the empirical therapy study patients had received chemotherapy for malignancy or had undergone haematopoietic stem-cell transplantation. In the studies involving patients with documented Candida infections, the majority of the patients had serious underlying medical conditions (e.g. haematologic or other malignancy, recent major surgery, HIV) requiring multiple concomitant medications. Patients in the non-comparative Aspergillus study often had serious predisposing medical conditions (e.g. bone marrow or peripheral stem cell transplants, haematologic malignancy, solid tumours or organ transplants) requiring multiple concomitant medications. Reported medicine related clinical and laboratory abnormalities among all adults treated with CANCIDAS (total 1780) were typically mild and rarely led to discontinuation.

Common (> 1/100)

General

: fever, headache, chills

: nausea, diarrhoea, vomiting

Liver

: elevated liver enzyme levels (AST, ALT, alkaline phosphatase, direct and total bilirubin)

Blood: anaemia (decreased haemoglobin and haematocrit) Peripheral Vascular: phlebitis/thrombophlebitis, infusion-site pruritus Bone: arthralgia

Respiration

: dyspnoea

Skin

: rash, pruritus, sweating, erythema

Paediatric Patients

In clinical studies, 171 paediatric patients received single or multiple doses of CANCIDAS: 104 febrile, neutropaenic patients; 56 patients with invasive candidiasis; 1 patient with oesophageal candidiasis; and 10 patients with invasive aspergillosis. The overall clinical safety profile of CANCIDAS in paediatric patients is comparable to that in adult patients. Reported medicine-related clinical and laboratory abnormalities among all paediatric patients treated with CANCIDAS (total 171) were typically mild and rarely led to discontinuation.

Common (> 1/100)

General

: fever, headache, chills

Liver

: elevated liver enzyme levels (AST, ALT) Cardiac: tachycardia

Peripheral Vascular

: catheter site pain, flushing, hypotension

Skin

: rash, pruritus

Post-Marketing Experience:

The following post-marketing adverse events have been reported:

Hepatobiliary: rare cases of hepatic dysfunction Cardiovascular: swelling and peripheral oedema Laboratory abnormalities: hypercalcaemia Laboratory Test Findings

Adult Patients

Other medicine related laboratory abnormalities reported in adult patients were low albumin, low potassium, and decreased white blood cells.

Paediatric Patients

Other medicine-related laboratory abnormalities reported in paediatric patients were decreased potassium, hypomagnesaemia, increased glucose, decreased phosphorus, increased phosphorus, and increased eosinophils.

Overdosage

In clinical studies, the highest dose was 210 mg, which was administered as a single dose to 6 healthy adult subjects, and was generally well tolerated. In addition, a dose of 150 mg daily up to 51 days has been administered to 100 healthy patients and was generally well tolerated. Caspofungin is not dialysable.

Actions

Caspofungin has in vitro activity against Aspergillus species (including Aspergillus fumigatus, Aspergillus flavus, Aspergillus niger, Aspergillus nidulans, Aspergillus terreus

and Aspergillus candidus) and Candida species (including Candida albicans, Candida dubliniensis, Candida glabrata, Candida guilliermondii, Candida kefyr, Candida krusei, Candida lipolytica, Candida lusitaniae, Candida parapsilosis, Candida rugosa, and Candida tropicalis). Susceptibility testing was performed according to a modification of both the Clinical and Laboratory Standards Institute (CLSI, formerly known as the National Committee for Clinical Laboratory Standards [NCCLS]) method M38-A (for Aspergillus species) and method M27-A (for Candida species). Interpretive standards (or breakpoints) for caspofungin against Candida species are applicable only to tests performed using CLSI microbroth dilution reference method M27- A3 for minimum inhibitory concentrations (MIC) read as a partial inhibition endpoint at 24 hours. The MIC values for caspofungin using CLSI microbroth dilution reference method M27-A3 should be interpreted according to the criteria provided in Table 1 below (CLSI M27-S3).

There are no established breakpoints for caspofungin against Candida species using the European Committee for Antimicrobial Susceptibility Testing (EUCAST) method. Standardised techniques for susceptibility testing have been established for yeasts by EUCAST. No standardised techniques for susceptibility testing or interpretive breakpoints have been established for Aspergillus species and other filamentous fungi using either the CLSI or EUCAST method.

Caspofungin was active when parenterally administered to immune-competent and immune-suppressed animals with disseminated infections of Aspergillus and Candida for which the endpoints were prolonged survival of infected animals (Aspergillus and Candida) and clearance of fungi from target organs (Candida). Caspofungin was also active in immunodeficient animals after disseminated infection with C. glabrata, C. krusei, C. lusitaniae, C. parapsilosis, or C. tropicalis in which the endpoint was clearance of Candida from target organs. In a lethal, rat pulmonary-infection model with A. fumigatus, caspofungin was highly active in the prevention and treatment of pulmonary aspergillosis.

Caspofungin acetate is active against strains of Candida with intrinsic or acquired resistance to fluconazole, amphotericin B, or flucytosine consistent with their different mechanisms of action.

A caspofungin MIC of <=2 g/mL ("Susceptible" per Table 1) using the CSLI M27-A3 method indicates that the Candida isolate is likely to be inhibited if caspofungin therapeutic concentrations are achieved. Breakthrough infections with Candida isolates requiring caspofungin concentrations >2 g/mL for growth inhibition have developed in a mouse model of C. albicans infection. Isolates of Candida with reduced susceptibility to caspofungin have been identified in a small number of patients during treatment (MICs for caspofungin >2 g/mL using standardised MIC testing techniques approved by the CLSI). Some of these isolates had mutations in the FKS1/FKS2 gene. Although the incidence is rare, these cases have been routinely associated with poor clinical outcomes. Development of in vitro resistance to caspofungin by Aspergillus species has been identified. In clinical experience, medicine resistance in patients with invasive aspergillosis has been observed. The mechanism of resistance has not been established. The incidence of medicine resistance in various clinical isolates of Candida and Aspergillus species is rare.

In vitro and in vivo studies of caspofungin acetate, in combination with amphotericin B, demonstrate no antagonism of antifungal activity against either A. fumigatus or C. albicans. Results from in vitro studies suggest that there was some evidence of additive/indifferent or synergistic activity against A. fumigatus and additive/indifferent activity against C. albicans. The clinical significance of these results is unknown.

Pharmacokinetics

Absorption is not relevant since caspofungin acetate is administered intravenously.

Plasma concentrations of caspofungin decline in a polyphasic manner following single 1 hour intravenous infusions. A short -phase occurs immediately post-infusion, followed by a -phase with a half-life of 9 to 11 hours that characterises much of the profile and exhibits clear log-linear behaviour from 6 to 48 hours post-dose, during which the plasma concentration decreases by 10-fold. An additional -phase also occurs (half life 40-50 hours). Distribution, rather than excretion or biotransformation, is the dominant mechanism influencing plasma clearance. Caspofungin is extensively bound to albumin (approximately 97%), and distribution into red blood cells is minimal. Mass balance results showed that approximately 92% of the administered radioactivity was distributed to tissues by 36 to 48 hours after a single 70-mg dose of [3H] caspofungin acetate. There is little excretion or biotransformation of caspofungin during the first 30 hours after administration.

Caspofungin is slowly metabolised by hydrolysis and N-acetylation. Caspofungin also undergoes spontaneous chemical degradation to an open-ring peptide compound. At later time points (>=5 days post-dose), there is a low level (<=7 picomoles/mg protein, or <=1.3% of administered dose) of covalent binding of radiolabel in plasma following single-dose administration of [3H] caspofungin acetate, which may be due to two reactive intermediates formed during the chemical degradation of caspofungin. Additional metabolism involves hydrolysis into constitutive amino acids and their derivatives, including dihydroxyhomotyrosine and N-acetyl-dihydroxyhomotyrosine. These two tyrosine derivatives are found only in urine, suggesting rapid clearance of these derivatives by the kidneys.

Two single-dose, radiolabelled pharmacokinetic studies were conducted. In one study, plasma, urine, and faeces were collected over 27 days, and in the second study plasma was collected over 6 months. Approximately 75% of the radioactivity was recovered: 41% in urine and 34% in faeces. Plasma concentrations of radioactivity and of caspofungin were similar during the first 24 to 48 hours post-dose; thereafter medicine levels fell more rapidly. In plasma, caspofungin concentrations fell below the limit of quantitation after 6 to 8 days post-dose, while radiolabel fell below the limit of quantitation at 22.3 weeks post- dose. A small amount of caspofungin is excreted unchanged in urine (approximately 1.4% of dose). Renal clearance of parent medicine is low (approximately 0.15 mL/min).

The plasma concentration of caspofungin was similar in healthy men and women on Day 1 following a single 70 mg dose. After 13 daily 50 mg doses, the caspofungin plasma concentration in some women was elevated approximately 20% relative to men.

Plasma concentrations of caspofungin after a single 70 mg dose in adult patients with mild hepatic insufficiency (Child-Pugh score 5 to 6) were increased by approximately 55% in AUC compared to healthy control subjects. In a 14 day multiple-dose study (70 mg on Day 1 followed by 50 mg daily thereafter), plasma concentrations in adult patients with mild hepatic insufficiency were increased modestly (19 to 25% in AUC) on Days 7 and 14 relative to healthy control subjects.

CANCIDAS has been studied in five prospective studies involving paediatric patients under 18 years of age, including three paediatric pharmacokinetic studies (initial study in adolescents [12-17 years of age] and children [2-11 years of age] followed by a study in younger patients [3-23 months of age] and then followed by a study in neonates and infants [<3 months]). In adolescents (ages 12 to 17 years) receiving caspofungin at 50 mg/m2 daily (maximum 70 mg daily), the caspofungin plasma AUC0-24hr was generally comparable to that seen in adults receiving caspofungin at 50 mg daily. All adolescents received doses >50 mg daily, and, in fact, 6 of 8 received the maximum dose of 70 mg/day. The caspofungin plasma concentrations in these adolescents were reduced relative to adults receiving 70 mg daily, the dose most often administered to adolescents. In children (ages 2 to 11 years) receiving caspofungin at 50 mg/m2 daily (maximum 70 mg daily), the caspofungin plasma AUC0-24hr after multiple doses was comparable to that seen in adults receiving caspofungin at 50 mg/day. On the first day of administration, AUC0-24hr was somewhat higher in children than adults for these comparisons (37% increase for the 50 mg/m2/day to 50 mg/day comparison). However, it should be recognised that the AUC values in these children on Day 1 were still less than those seen in adults at steady-state conditions. In young children and toddlers (ages 3 to 23 months) receiving caspofungin at 50 mg/m2 daily (maximum 70 mg daily), the caspofungin plasma AUC0-24hr after multiple doses was comparable to that seen in adults receiving caspofungin at 50 mg daily. As in the older children, these young children who received 50 mg/m2 daily had slightly higher AUC0-24 hr values on Day 1 relative to adults receiving the standard 50-mg daily dose. The caspofungin pharmacokinetic results from the young children (3 to 23 months of age) that received 50 mg/m2 caspofungin daily were similar to the pharmacokinetic results from older children (2 to 11 years of age) that received the same dosing regimen. In neonates and infants (<3 months) receiving caspofungin at 25 mg/m2 daily, caspofungin peak concentration (C1 hr) and caspofungin trough concentration (C24 hr) after multiple doses were comparable to that seen in adults receiving caspofungin at 50 mg daily. On Day 1, C1 hr was comparable and C24 hr modestly elevated (36%) in these neonates and infants relative to adults. AUC0-24hr measurements were not performed in this study due to the sparse plasma sampling. Of note, the efficacy and safety of CANCIDAS have not been adequately studied in prospective clinical trials involving neonates and infants under 3 months of age.

Pharmaceutical Precautions

The lyophilised compact powder in vials should be stored at 2 to 8degC (36 to 46degF).

Reconstituted CANCIDAS may be stored at or below 25degC (77degF) for up to 24 hours prior to the preparation of the patient infusion solution.

The final patient infusion solution in the intravenous bag or bottle can be stored at or below 25degC (77degF) for up to 24 hours, or for up to 48 hours when refrigerated at 2 to 8degC (36 to 46degF).

Medicine Classification

Package Quantities

10 mL single dose vial containing 50 mg caspofungin acetate 10 mL single dose vial containing 70 mg caspofungin acetate

Further Information

CANCIDAS contains, as the active ingredient, caspofungin acetate, which is described chemically as 1-[(4R,5S)-5-[(2-aminoethyl)amino]-N2-(10,12-dimethyl-1-oxotetradecyl)-4- hydroxy-L-ornithine]-5-[(3R)-3-hydroxy-L-ornithine]pneumocandin B0 diacetate (salt). The empirical formula is C52H88N10O15 *2C2H4O2. The CAS registry number is 179463-17-3. The formula weight is 1213.42.

Each vial of CANCIDAS contains the following inactive ingredients: sucrose, mannitol, glacial acetic acid, and sodium hydroxide (to adjust the pH).

Name and Address

Merck Sharp & Dohme (New Zealand) Limited P O Box 99 851 Newmarket Auckland NEW ZEALAND Tel: 0800 500 673

DOSE *	Volume of reconsti- tuted CANCIDAS for transfer to intraven- ous bag or bottle	Typical preparation (reconstituted CANCIDAS added to 250 mL) final concentration	Reduced volume infusion (reconstituted CANCIDAS added to 100 mL) final concentration
70 mg	10 mL	0.28 mg/mL	not recommended
70 mg (from two 50 mg vials) * *	14 mL	0.28 mg/mL	not recommended
50 mg	10 mL	0.20 mg/mL	0.47 mg/mL
35 mg for moderate hepatic insufficiency (from one 70 mg vial)	5 mL	0.14 mg/mL	0.34 mg/mL
35 mg for moderate hepatic insufficiency (from one 50 mg vial)	7 mL	0.14 mg/mL	0.34 mg/mL

Pathogen	Broth Microdilution MIC *, + ( g/mL) at 24 hours
	Susceptible	Indeterminate	Resistant	Non-susceptible
Candida species	2	-	-	>=2
* A report of "Susceptible" indicates that the pathogen is likely to be inhibited if the antimicrobial compound in the blood reaches the concentrations usually achievable. + There is no Resistant category assigned for the echinocandin agents; isolates with higher MICs may be described as Non-susceptible.

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