Triazole antifungal drugs have a role in the prevention and
systemic treatment of fungal infections.
Fluconazole is very well absorbed after oral
administration. It also achieves good penetration into the
cerebrospinal fluid to treat fungal meningitis. Fluconazole is
excreted largely unchanged in the urine and can be used to
Itraconazole is active against a wide range of
dermatophytes. Itraconazole capsules require an acid
environment in the stomach for optimal absorption.
Itraconazole has been associated with liver damage and
should be avoided or used with caution in patients with liver
disease; fluconazole is less frequently associated with
Posaconazole is licensed for the treatment of invasive
fungal infections unresponsive to conventional treatment.
Voriconazole is a broad-spectrum antifungal drug which is
licensed for use in life-threatening infections.
The imidazole antifungals include clotrimazole p. 829,
econazole nitrate p. 830, ketoconazole p. 830, and
tioconazole p. 1233. They are used for the local treatment of
vaginal candidiasis and for dermatophyte infections.
Miconazole p. 1219 can be used locally for oral infections; it
is also effective in intestinal infections. Systemic absorption
may follow use of miconazole oral gel and may result in
significant drug interactions.
The polyene antifungals include amphotericin p. 593 and
nystatin p. 1219; neither drug is absorbed when given by
mouth. Nystatin is used for oral, oropharyngeal, and perioral
infections by local application in the mouth. Nystatin is also
used for Candida albicans infection of the skin.
Amphotericin by intravenous infusion is used for the
treatment of systemic fungal infections and is active against
most fungi and yeasts. It is highly protein bound and
penetrates poorly into body fluids and tissues. When given
parenterally amphotericin is toxic and side-effects are
common. Lipid formulations of amphotericin (Abelcet ® and
AmBisome ®) are significantly less toxic and are
recommended when the conventional formulation of
amphotericin is contra-indicated because of toxicity,
especially nephrotoxicity or when response to conventional
amphotericin is inadequate; lipid formulations are more
The echinocandin antifungals include anidulafungin below,
caspofungin below and micafungin p. 593. They are only
active against Aspergillus spp. and Candida spp.; however,
anidulafungin and micafungin are not used for the treatment
of aspergillosis. Echinocandins are not effective against
Flucytosine p. 601 is used with amphotericin in a synergistic
combination. Bone marrow depression can occur which
limits its use, particularly in HIV-positive patients; weekly
blood counts are necessary during prolonged therapy.
Resistance to flucytosine can develop during therapy and
sensitivity testing is essential before and during treatment.
Flucytosine has a role in the treatment of systemic
candidiasis and cryptococcal meningitis.
Griseofulvin p. 601 is effective for widespread or
intractable dermatophyte infections but has been
superseded by newer antifungals, particularly for nail
infections. It is the drug of choice for trichophyton infections
in children. Duration of therapy is dependent on the site of
the infection and may extend to a number of months.
Terbinafine p. 1234 is the drug of choice for fungal nail
infections and is also used for ringworm infections where
oral treatment is considered appropriate.
ANTIFUNGALS › ECHINOCANDIN ANTIFUNGALS
▶ Adult: Initially 200 mg once daily for 1 day, then
▶ Uncommon Abdominal pain upper. coagulation disorder. vasodilation
l PREGNANCY Manufacturer advises avoid unless potential
benefit outweighs risk—toxicity in animal studies.
l BREAST FEEDING Manufacturer advises avoid unless
potential benefit outweighs risk—present in milk in animal
l DIRECTIONS FOR ADMINISTRATION For intravenous infusion
(Ecalta ®), give intermittently in Glucose 5% or Sodium
chloride 0.9%. Reconstitute each 100 mg with 30 mL water
for injections and allow up to 5 minutes for reconstitution;
dilute dose in infusion fluid to a concentration of
770 micrograms/mL; give at a rate not exceeding
1.1 mg/minute. Follow product information if using stock
supplied with ethanol solvent.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
Powder for solution for infusion
▶ Anidulafungin (Non-proprietary)
Anidulafungin 100 mg Anidulafungin 100mg powder for
concentrate for solution for infusion vials | 1 vial P £284.99
Anidulafungin 100 mg Ecalta 100mg powder for concentrate for
solution for infusion vials | 1 vial P £299.99 (Hospital only)
Invasive aspergillosis | Invasive candidiasis | Empirical
treatment of systemic fungal infections in patients with
▶ Adult (body-weight up to 81 kg): 70 mg once daily for
▶ Adult (body-weight 81 kg and above): 70 mg once daily
DOSE ADJUSTMENTS DUE TO INTERACTIONS
▶ Manufacturer advises increase dose to 70 mg daily with
concurrent use of some enzyme inducers (such as
carbamazepine, dexamethasone, phenytoin, and
rifampicin); no dose adjustment required for patients
l INTERACTIONS → Appendix 1: caspofungin
discomfort. haematuria . hepatic disorders .
pain . leucopenia . malaise . metabolic acidosis . muscle
▶ Frequency not known Severe cutaneous adverse reactions
l PREGNANCY Manufacturer advises avoid unless
essential—toxicity in animal studies.
l BREAST FEEDING Present in milk in animal studies—
l HEPATIC IMPAIRMENT No information available for severe
Dose adjustments 70 mg on first day then 35 mg once daily
l DIRECTIONS FOR ADMINISTRATION For intravenous infusion
(Cancidas ®), give intermittently in Sodium chloride 0.9%.
Allow vial to reach room temperature; initially
reconstitute each vial with 10.5 mL water for injections,
mixing gently to dissolve then dilute requisite dose in
250 mL infusion fluid (35- or 50-mg doses may be diluted
in 100 ml infusion fluid if necessary); give over 60 minutes;
incompatible with glucose solutions.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
Powder for solution for infusion
▶ Caspofungin (Non-proprietary)
Caspofungin (as Caspofungin acetate) 50 mg Caspofungin 50mg
powder for concentrate for solution for infusion vials | 1 vial P £69.77–£327.67
Caspofungin (as Caspofungin acetate) 70 mg Caspofungin 70mg
powder for concentrate for solution for infusion vials | 1 vial P £92.91–£416.78
▶ Cancidas (Merck Sharp & Dohme Ltd)
Caspofungin (as Caspofungin acetate) 50 mg Cancidas 50mg
powder for solution for infusion vials | 1 vial P £327.67
Caspofungin (as Caspofungin acetate) 70 mg Cancidas 70mg
powder for solution for infusion vials | 1 vial P £416.78
▶ Adult (body-weight up to 40 kg): 2 mg/kg once daily for
at least 14 days; increased if necessary to 4 mg/kg once
daily, increase dose if response inadequate
▶ Adult (body-weight 40 kg and above): 100 mg once daily
for at least 14 days; increased if necessary to 200 mg
once daily, increase dose if response inadequate
▶ Adult (body-weight up to 40 kg): 3 mg/kg once daily
▶ Adult (body-weight 40 kg and above): 150 mg once daily
▶ Adult (body-weight up to 40 kg): 1 mg/kg once daily
continue for at least 7 days after neutrophil count is in
▶ Adult (body-weight 40 kg and above): 50 mg once daily
continue for at least 7 days after neutrophil count is in
l INTERACTIONS → Appendix 1: micafungin
reactions .taste altered .thrombocytopenia .tremor. vomiting
l PREGNANCY Manufacturer advises avoid unless
essential—toxicity in animal studies.
l BREAST FEEDING Manufacturer advises use only if
potential benefit outweighs risk—present in milk in animal
l HEPATIC IMPAIRMENT Manufacturer advises caution in
chronic impairment; avoid in severe impairment (limited
l RENAL IMPAIRMENT Use with caution; renal function may
▶ Monitor liver function—discontinue if significant and
persistent abnormalities in liver function tests develop.
l DIRECTIONS FOR ADMINISTRATION For intravenous infusion
(Mycamine ®), give intermittenly in Glucose 5% or Sodium
chloride 0.9%. Reconstitute each vial with 5 mL infusion
fluid; gently rotate vial, without shaking, to dissolve;
dilute requisite dose with infusion fluid to 100 mL (final
concentration of 0.5–2 mg/mL); protect infusion from
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
Powder for solution for infusion
▶ Mycamine (Astellas Pharma Ltd)
Micafungin (as Micafungin sodium) 50 mg Mycamine 50mg
powder for solution for infusion vials | 1 vial P £196.08
Micafungin (as Micafungin sodium) 100 mg Mycamine 100mg
powder for solution for infusion vials | 1 vial P £341.00
ANTIFUNGALS › POLYENE ANTIFUNGALS
Severe invasive candidiasis | Severe systemic fungal
infections in patients not responding to conventional
amphotericin or to other antifungal drugs or where
toxicity or renal impairment precludes conventional
amphotericin, including invasive aspergillosis,
cryptococcal meningitis and disseminated
cryptococcosis in HIV patients
▶ Adult: Test dose 1 mg, to be given over 15 minutes,
then 5 mg/kg once daily for at least 14 days
Severe systemic or deep mycoses where toxicity
(particularly nephrotoxicity) precludes use of
conventional amphotericin | Suspected or proven
infection in febrile neutropenic patients unresponsive to
▶ Adult: Test dose 1 mg, to be given over 10 minutes,
then 3 mg/kg once daily; maximum 5 mg/kg per day
▶ Adult: Test dose 1 mg, to be given over 10 minutes,
then 3 mg/kg once daily; maximum 5 mg/kg per day
Visceral leishmaniasis (unresponsive to the antimonial
▶ Adult: 1–3 mg/kg daily for 10–21 days to a cumulative
dose of 21–30 mg/kg, alternatively 3 mg/kg for
5 consecutive days, followed by 3 mg/kg after 6 days for
▶ Adult: Test dose 1 mg, to be given over 20–30 minutes,
then 250 micrograms/kg daily, gradually increased over
2–4 days, increased if tolerated to 1 mg/kg daily, max.
(severe infection) 1.5 mg/kg daily or on alternate days.
Prolonged treatment usually necessary; if interrupted
for longer than 7 days recommence at
250 micrograms/kg daily and increase gradually
AMBISOME ® Use at the maximum dose of 5 mg/kg once
MHRA/CHM ADVICE: PARENTERAL AMPHOTERICIN B: REMINDER
OF RISK OF POTENTIALLY FATAL ADVERSE REACTION IF
FORMULATIONS CONFUSED (JULY 2018)
The MHRA is aware of three fatal overdoses which were
caused by medication error in which Fungizone ® was
administered (a non-lipid-based formulation of
amphotericin B) instead of a lipid-based formulation.
Healthcare professionals are advised:
. when prescribing and dispensing amphotericin
products, both the complete generic name and the
proprietary name should be used;
. the product name and dose should be verified before
administration, especially if the dose prescribed
exceeds the maximum recommended dose for
supervision necessary and close observation required for
at least 30 minutes after test dose)
▶ Anaphylaxis Anaphylaxis can occur with any intravenous
amphotericin product and a test dose is advisable before
the first infusion; the patient should be carefully observed
for at least 30 minutes after the test dose. Prophylactic
antipyretics or hydrocortisone should only be used in
patients who have previously experienced acute adverse
reactions (in whom continued treatment with
l INTERACTIONS → Appendix 1: amphotericin
imbalance . fever. headache . hepatic function abnormal
acidosis . skin reactions . vomiting
▶ Rare or very rare Arthralgia . cardiac arrest. coagulation
l PREGNANCY Not known to be harmful but manufacturers
advise avoid unless potential benefit outweighs risk.
l BREAST FEEDING No information available.
l RENAL IMPAIRMENT Use only if no alternative;
nephrotoxicity may be reduced with use of lipid
l MONITORING REQUIREMENTS Hepatic and renal function
tests, blood counts, and plasma electrolyte (including
plasma-potassium and magnesium concentration)
l DIRECTIONS FOR ADMINISTRATION
ABELCET ® Amphotericin (lipid complex)
For intravenous infusion, give intermittently in Glucose
5%. Allow suspension to reach room temperature, shake
gently to ensure no yellow settlement, withdraw requisite
dose (using 17-19 gauge needle) into one or more 20-mL
syringes; replace needle on syringe with a 5-micron filter
needle provided (fresh needle for each syringe) and dilute
to a concentration of 1 mg/mL (2 mg/mL can be used in
fluid restriction and in children); preferably give via an
infusion pump at a rate of 2.5 mg/kg/hour (initial test dose
of 1 mg over 15 minutes); an in-line filter (pore size no less
than 15 micron) may be used; do not use sodium chloride
or other electrolyte solutions, flush existing intravenous
line with glucose 5% or use separate line.
AMBISOME ® Amphotericin (liposomal)
For intravenous infusion (AmBisome ®), give
intermittently in Glucose 5% or 10%. Reconstitute each
vial with 12 mL water for injections and shake vigorously
to produce a preparation containing 4 mg/mL; withdraw
requisite dose from vial and introduce into infusion fluid
through the 5 micron filter provided to produce a final
concentration of 0.2–2 mg/mL; infuse over 30–60 minutes,
or if non-anaphylactic infusion-related reactions occur
infuse over 2 hours (initial test dose of 1 mg over
10 minutes); an in-line filter (pore size no less than
1 micron) may be used; incompatible with sodium chloride
solutions, flush existing intravenous line with glucose 5%
FUNGIZONE ® Amphotericin (as sodium deoxycholate
For intravenous infusion (Fungizone ®), give intermittently
in Glucose 5%. Reconstitute each vial with 10 mL water of
injections and shake immediately to produce a 5 mg/mL
colloidal solution; dilute further in infusion fluid to a
concentration of 100 micrograms/mL; pH of the glucose
must not be below 4.2 (check each container—consult
product literature for details of the buffer); infuse over
2–4 hours, or longer if not tolerated (initial test dose of
1 mg over 20–30 minutes); begin infusion immediately
after dilution; protect from light; incompatible with
sodium chloride solutions, flush existing intravenous line
with glucose 5% or use separate line; an in-line filter (pore
size no less than 1 micron) may be used.
l PRESCRIBING AND DISPENSING INFORMATION Different
preparations of intravenous amphotericin vary in their
pharmacodynamics, pharmacokinetics, dosage, and
administration; these preparations should not be
considered interchangeable. To avoid confusion,
prescribers should specify the brand to be dispensed.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
ELECTROLYTES: May contain Sodium
Amphotericin B (as Amphotericin B phospholipid complex) 5 mg
per 1 ml Abelcet 100mg/20ml concentrate for suspension for infusion
vials | 10 vial P £775.04 (Hospital only)
Powder for solution for infusion
EXCIPIENTS: May contain Sucrose
ELECTROLYTES: May contain Sodium
▶ AmBisome (Gilead Sciences International Ltd)
Amphotericin B liposomal 50 mg AmBisome 50mg powder for
solution for infusion vials | 10 vial P £821.87
▶ Fungizone (Bristol-Myers Squibb Pharmaceuticals Ltd)
Amphotericin B 50 mg Fungizone Intravenous 50mg powder for
solution for infusion vials | 1 vial P £3.88
ANTIFUNGALS › TRIAZOLE ANTIFUNGALS
▶ Child 16–17 years: 150 mg for 1 dose
Vulvovaginal candidiasis (recurrent)
▶ Adult: Initially 150 mg every 72 hours for 3 doses, then
150 mg once weekly for 6 months
Mucosal candidiasis (except genital)
▶ BY MOUTH, OR BY INTRAVENOUS INFUSION
▶ Child 1 month–11 years: 3–6 mg/kg, dose to be given on
first day, then 3 mg/kg daily (max. per dose 100 mg) for
7–14 days in oropharyngeal candidiasis (max. 14 days
except in severely immunocompromised patients); for
14–30 days in other mucosal infections (e.g.
oesophagitis, candiduria, non-invasive
▶ Child 12–17 years: 50 mg daily for 7–14 days in
oropharyngeal candidiasis (max. 14 days except in
severely immunocompromised patients); for
14–30 days in other mucosal infections (e.g.
oesophagitis, candiduria, non-invasive
bronchopulmonary infections); increased to 100 mg
daily, increased dose only for unusually difficult
▶ Adult: 50 mg daily given for 7–14 days in
oropharyngeal candidiasis (max. 14 days except in
severely immunocompromised patients); for 14 days in
atrophic oral candidiasis associated with dentures; for
14–30 days in other mucosal infections (e.g.
oesophagitis, candiduria, non-invasive
bronchopulmonary infections; increased to 100 mg
daily, increased dose only for unusually difficult
Tinea pedis, corporis, cruris, pityriasis versicolor | Dermal
▶ Adult: 50 mg daily for 2–4 weeks (for up to 6 weeks in
tinea pedis); max. duration of treatment 6 weeks
Invasive candidal infections (including candidaemia and
disseminated candidiasis) and cryptococcal infections
▶ BY MOUTH, OR BY INTRAVENOUS INFUSION
▶ Child: 6–12 mg/kg daily (max. per dose 800 mg),
treatment continued according to response (at least
8 weeks for cryptococcal meningitis)
▶ Adult: 400 mg, dose to be given on first day, then
200–400 mg daily (max. per dose 800 mg once daily),
treatment continued according to response (at least
8 weeks for cryptococcal meningitis), maximum dose
Prevention of fungal infections in immunocompromised
▶ BY MOUTH, OR BY INTRAVENOUS INFUSION
▶ Child: 3–12 mg/kg daily (max. per dose 400 mg),
commence treatment before anticipated onset of
neutropenia and continue for 7 days after neutrophil
count in desirable range, dose given according to
extent and duration of neutropenia
▶ Adult: 50–400 mg daily, commence treatment before
anticipated onset of neutropenia and continue for
7 days after neutrophil count in desirable range, dose
Prevention of fungal infections in immunocompromised
patients (for patients with high risk of systemic
infections e.g. following bone-marrow transplantation)
▶ BY MOUTH, OR BY INTRAVENOUS INFUSION
▶ Adult: 400 mg daily, commence treatment before
anticipated onset of neutropenia and continue for
7 days after neutrophil count in desirable range
▶ BY MOUTH, OR BY INTRAVENOUS INFUSION
l CONTRA-INDICATIONS Acute porphyrias p. 1058
l CAUTIONS Susceptibility to QT interval prolongation
l INTERACTIONS → Appendix 1: antifungals, azoles
▶ Common or very common Diarrhoea . gastrointestinal
discomfort. headache . nausea . skin reactions . vomiting
▶ Uncommon Dizziness . flatulence . hepatic disorders . seizure .taste altered
prolongation . severe cutaneous adverse reactions (SCARs) .thrombocytopenia .torsade de pointes
▶ With parenteral use Angioedema .face oedema .tremor
▶ With oral use Cardio-respiratory distress . oedema
SIDE-EFFECTS, FURTHER INFORMATION If rash occurs,
discontinue treatment (or monitor closely if infection
invasive or systemic); severe cutaneous reactions are more
l PREGNANCY Manufacturer advises avoid—multiple
congenital abnormalities reported with long-term high
l BREAST FEEDING Present in milk but amount probably too
l HEPATIC IMPAIRMENT Manufacturer advises caution—
limited information available.
Dose adjustments ▶ In adults Usual initial dose then halve
subsequent doses if eGFR less than 50 mL/minute/1.73 m2
▶ In children Usual initial dose then halve subsequent
doses if estimated glomerular filtration rate less than
l MONITORING REQUIREMENTS Monitor liver function with
high doses or extended courses—discontinue if signs or
symptoms of hepatic disease (risk of hepatic necrosis).
l DIRECTIONS FOR ADMINISTRATION
▶ With intravenous use in children For intravenous infusion, give
over 10–30 minutes; do not exceed an infusion rate of
l PRESCRIBING AND DISPENSING INFORMATION Flavours of
oral liquid formulations may include orange.
Medicines for Children leaflet: Fluconazole for yeast and fungal
infections www.medicinesforchildren.org.uk/fluconazole-yeastand-fungal-infections
l PROFESSION SPECIFIC INFORMATION
Dental practitioners’ formulary
Fluconazole Capsules 50 mg may be prescribed.
Fluconazole Oral Suspension 50 mg/5 mL may be
l EXCEPTIONS TO LEGAL CATEGORY Fluconazole capsules
can be sold to the public for vaginal candidiasis and
associated candidal balanitis in those aged 16–60 years, in
a container or packaging containing not more than 150 mg
and labelled to show a max. dose of 150 mg.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
▶ Fluconazole (Non-proprietary)
Fluconazole 2 mg per 1 ml Fluconazole 200mg/100ml infusion bags
| 5 bag P £19.45 (Hospital only)
Fluconazole 400mg/200ml infusion bags | 5 bag P £72.50
ELECTROLYTES: May contain Sodium
▶ Fluconazole (Non-proprietary)
Fluconazole 2 mg per 1 ml Fluconazole 200mg/100ml solution for
infusion vials | 1 vial P £15.00–£29.28
Fluconazole 100mg/50ml solution for infusion vials | 5 vial P £12.60 (Hospital only)
Fluconazole 50mg/25ml solution for infusion vials | 1 vial P £7.31–£7.32
Fluconazole 200mg/100ml solution for infusion bottles |
10 bottle P £373.60 | 20 bottle P £603.17
Fluconazole 2 mg per 1 ml Diflucan 200mg/100ml solution for
infusion vials | 1 vial P £29.28 (Hospital only)
CAUTIONARY AND ADVISORY LABELS 9
▶ Fluconazole (Non-proprietary)
Fluconazole 10 mg per 1 ml Fluconazole 50mg/5ml oral suspension
Fluconazole 10 mg per 1 ml Diflucan 50mg/5ml oral suspension | 35 ml P £16.61 DT = £20.51
Fluconazole 40 mg per 1 ml Diflucan 200mg/5ml oral suspension | 35 ml P £66.42 DT = £66.42
CAUTIONARY AND ADVISORY LABELS 9 (50 mg and 200 mg strengths
▶ Fluconazole (Non-proprietary)
Fluconazole 50 mg Fluconazole 50mg capsules | 7 capsule P £5.00 DT = £0.72
Fluconazole 150 mg Fluconazole 150mg capsules | 1 capsule p s
DT = £0.69 | 1 capsule P £8.50 DT = £0.69
Fluconazole 200 mg Fluconazole 200mg capsules | 7 capsule P £6.02 DT = £3.94
▶ Canesten (fluconazole) (Bayer Plc)
Fluconazole 150 mg Canesten Thrush Oral 150mg capsules | 1 capsule p £6.33 DT = £0.69
Fluconazole 50 mg Diflucan 50mg capsules | 7 capsule P £16.61 DT = £0.72
Fluconazole 150 mg Diflucan 150mg capsules | 1 capsule P £7.12 DT = £0.69
Fluconazole 200 mg Diflucan 200mg capsules | 7 capsule P £66.42 DT = £3.94
l DRUG ACTION Isavuconazole is a triazole antifungal that
blocks the synthesis of ergosterol, a key component of the
Invasive aspergillosis | Mucormycosis in patients for whom
amphotericin B is inappropriate
▶ BY MOUTH, OR BY INTRAVENOUS INFUSION
▶ Adult: Loading dose 200 mg every 8 hours for 48 hours
(6 administrations in total), then maintenance 200 mg
once daily, maintenance dose to be started at least
12 hours after the last loading dose; long-term
treatment should be reviewed after 6-months
l CONTRA-INDICATIONS Acute porphyrias p. 1058 . short QT
l CAUTIONS Elderly—limited information
l INTERACTIONS → Appendix 1: antifungals, azoles
▶ With intravenous use Hyperbilirubinaemia
▶ With intravenous use Peripheral oedema
SIDE-EFFECTS, FURTHER INFORMATION Infusion-related
reactions have been reported, including hypotension,
dyspnoea, dizziness, paraesthesia, nausea, and headache—
manufacturer advises discontinue treatment if these
l PREGNANCY Manufacturer advises avoid unless severe or
life-threatening infection—toxicity in animal studies.
l BREAST FEEDING Manufacturer advises avoid—present in
l HEPATIC IMPAIRMENT Manufacturer advises caution in
severe impairment (no information available)—monitor
l DIRECTIONS FOR ADMINISTRATION
▶ With intravenous use For intravenous infusion, reconstitute
each 200 mg with 5 mL Water for Injection; dilute dose to
concentration of 0.8 mg/mL with Glucose 5% or Sodium
Chloride 0.9% and give via a 0.2–1.2 micron filter over at
▶ With intravenous use Manufacturer advises store in a
refrigerator (2–8°C)—consult product literature for storage
after reconstitution or dilution.
Driving and skilled tasks Manufacturer advises patients and
carers should be cautioned on the effects on driving and
performance of skilled tasks—increased risk of confusion,
l NATIONAL FUNDING/ACCESS DECISIONS
All Wales Medicines Strategy Group (AWMSG) decisions
The All Wales Medicines Strategy Group has advised
(January 2017) that isavuconazole (Cresemba ®) is
recommended as an option for use in adults within NHS
Wales for the treatment of invasive aspergillosis, and the
treatment of mucormycosis in patients for whom
amphotericin B is inappropriate, only if the approved
Wales Patient Access Scheme (WPAS) is used or where the
list/contract price is equivalent or lower.
l MEDICINAL FORMS There can be variation in the licensing of
different medicines containing the same drug.
Powder for solution for infusion
CAUTIONARY AND ADVISORY LABELS 3
Isavuconazole (as Isavuconazonium sulfate) 200 mg Cresemba
200mg powder for concentrate for solution for infusion vials | 1 vial P £297.84 (Hospital only)
CAUTIONARY AND ADVISORY LABELS 3, 25
Isavuconazole (as Isavuconazonium sulfate) 100 mg Cresemba
100mg capsules | 14 capsule P £599.28 (Hospital only)
▶ Adult: 200 mg twice daily for 1 day
Vulvovaginal candidiasis (recurrent)
▶ Adult: 50–100 mg daily for 6 months
Oral or oesophageal candidiasis that has not responded to
▶ BY MOUTH USING ORAL SOLUTION
▶ Adult: 100–200 mg twice daily for 2 weeks (continue
for another 2 weeks if no response; the higher dose
should not be used for longer than 2 weeks if no signs
Oral or oesophageal candidiasis in HIV-positive or other
▶ BY MOUTH USING ORAL SOLUTION
▶ Adult: 200 mg daily in 1–2 divided doses for 1 week
(continue for another week if no response)
Systemic candidiasis where other antifungal drugs
▶ Adult: 100–200 mg once daily
▶ Adult: 200 mg every 12 hours for 2 days, then 200 mg
Systemic candidiasis (invasive or disseminated) where
other antifungal drugs inappropriate or ineffective
▶ Adult: 200 mg once daily for 7 days
▶ Adult: 100 mg once daily for 30 days, alternatively
▶ Adult: 100 mg once daily for 15 days, alternatively
▶ Adult: 200 mg once daily for 3 months, alternatively
200 mg twice daily for 7 days, subsequent courses
repeated after 21-day intervals; fingernails 2 courses,
Systemic aspergillosis where other antifungal drugs
▶ Adult: 200 mg every 12 hours for 2 days, then 200 mg
▶ Adult: 200 mg 3 times a day for 3 days, then 200 mg
▶ Adult: 200 mg every 12 hours for 2 days, then 200 mg
Systemic cryptococcosis including cryptococcal meningitis
where other antifungal drugs inappropriate or
▶ Adult: 200 mg once daily, dose increased in invasive or
disseminated disease and in cryptococcal meningitis,
increased to 200 mg twice daily
▶ Adult: 200 mg every 12 hours for 2 days, then 200 mg
Maintenance in HIV-infected patients to prevent relapse
of underlying fungal infection and prophylaxis in
neutropenia when standard therapy inappropriate
▶ Adult: 200 mg once daily, then increased to 200 mg
twice daily, dose increased only if low plasmaitraconazole concentration
Prophylaxis of deep fungal infections (when standard
therapy inappropriate) in patients with haematological
malignancy or undergoing bone-marrow transplantation
who are expected to become neutropenic
▶ BY MOUTH USING ORAL SOLUTION
▶ Adult: 5 mg/kg daily in 2 divided doses, to be started
before transplantation or before chemotherapy (taking
care to avoid interaction with cytotoxic drugs) and
continued until neutrophil count recovers, safety and
efficacy not established in elderly patients
DOSE ADJUSTMENTS DUE TO INTERACTIONS
▶ Manufacturer advises max. dose 200 mg daily with
l UNLICENSED USE Itraconazole doses in BNF may differ
from those in product literature.
Following reports of heart failure, caution is advised
when prescribing itraconazole to patients at high risk of
heart failure. Those at risk include:
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