Echinocandin, also known as micafungin, is an antifungal drug used to treat invasive candida infections.

Micafungin (Mycamine) Uses:

• Abcesses, Candida peritonitis, candidemia, and acute disseminated candidiasis:

  • It is used to treat abscesses, Candida peritonitis, acute disseminated candidiasis, candidemia, and paediatric patients older than 4 months or younger than 4 months who do not have meningoencephalitis or ocular dissemination.

• Esophageal candidiasis:

  • It can be used to adults and children older than 4 months to treat esophageal candidiasis.It can be used to adults and children older than 4 months to  treat esophageal candidiasis.

• Prophylaxis of Candida infections:

  • It is given to adults and kids older than 4 months who are getting hematopoietic stem cell transplantation as a prophylactic step against Candida  infections.It is given to adults and kids older than 4 months who are getting hematopoietic stem cell transplantation as a prophylactic step against  Candida infections.

• Off Label Use of Micafungin in Adults:

  • Empiric antifungal therapy (neutropenic fever)
  • Candidiasis empiric therapy (non-neutropenic ICU patients)
  • Aspergillosis, invasive (salvage therapy)
  • Candidiasis, osteoarticular infections
  • Candidiasis, chronic disseminated (hepatosplenic)
  • Candidiasis, prophylaxis against invasive candidiasis (high-risk ICU patients)
  • Candidiasis, intravascular infections
  • Candidiasis, oropharyngeal (refractory disease)

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Micafungin Dose in Adults:

Micafungin (Mycamine) Dose in the treatment of Aspergillosis, invasive (salvage therapy) (off-label):

• 100 to 150 mg can be administered intravenously once per day.
• The minimum course of therapy should last 6 to 12 weeks, while this varies considerably on the severity and persistence of immunosuppression, the location of the illness, and the presence or absence of disease improvement.

Micafungin (Mycamine) Dose for treating Candidemia,  abscesses, acute disseminated candidiasis, and Candida peritonitis:

• From clinical studies, the average treatment time was 15 days.
• Notably, after the verified eradication of Candida from the circulation and the relief of candidemia-related symptoms in patients without metastatic implications,  the IDSA Candidiasis recommendations for the treatment of candidemia advise at least 14 days of comprehensive antifungal medication.
• 100 mg IV, once daily.
• Only individuals who are clinically stable, have isolates that are susceptible to fluconazole, and have negative repeat cultures can be switched on fluconazole (e.g.,  after 5 to 7 days in non-neutropenic patients).

Micafungin (Mycamine) Dose for the Off-Label Treatment of Chronic Disseminated Candidiasis (Hepatosplenic):

• Infusion: 100 mg per day for a few weeks, then oral fluconazole medication.

Using Micafungin (Mycamine) at an off-label dose to treat suspected invasive candidiasis in non-neutropenic ICU patients

• IV: 100 mg per day.
• In patients who are improving clinically, the therapy should be continued for a further 14 days. If there is no clinical improvement after 4 to 5 days, stop treatment.

Micafungin (Mycamine) Dose in the treatment of Candidiasis, intravascular infections (native or prosthetic valve endocarditis, infection of implantable cardiac devices, suppurative thrombophlebitis) (off-label):

• 150 mg are administered daily by IV. After valve replacement surgery, treatment should be continued for at least 6 weeks if native or prosthetic valve endocarditis is present
• Following surgery, treatment should be continued for 28 to 42 days for patients with implanted cardiac devices 
• Continue for at least 14 days after candidemia has cleaned up if you have suppurative thrombophlebitis or after removing the catheter.
• It is noteworthy that fluconazole therapy is suggested for patients who are clinically stable and isolates that are responsive to fluconazole but have negative repeat  cultures.It is noteworthy that fluconazole therapy is suggested for patients who are clinically stable and isolates that are responsive to fluconazole but have negative  repeat cultures.

Treatment of Candidiasis and osteoarticular infections (osteomyelitis or septic arthritis) with Micafungin (Mycamine) Dose (alternative therapy):

• 100 mg IV every day for two weeks, then fluconazole treatment.

As an alternate therapy (off-label), the following dosage of micafungin (Mycamine) is used to treat oropharyngeal candidiasis that is refractory:

• IV: 100 mg once a day.

Using Micafungin (Mycamine) at an off-label dose to treat empiric antifungal therapy (neutropenic fever)

• IV: 100 mg once a day.

Micafungin (Mycamine) Dose in the treatment of Esophageal candidiasis:

• 150 mg IV, once daily. According to scientific research, treatment lasts an average of 15 days. The time frame is between 10 and 30 days.

Key point: Once oral consumption is bearable, IDSA Candidiasis recommendations advise thinking about switching to oral fluconazole medication. Start taking micafungin for 14 to 21 days in individuals with the refractory illness.

Micafungin (Mycamine) Dose in the Prophylaxis of Candida infections: IV:

• In the transplantation of hematopoietic stem cells:

  • A daily dose of 50 mg. According to clinical studies, treatment lasted an average of 19 days. 6 to 51 days is the typical range.

• (Alternative therapy; off-label usage) In high-risk ICU patients in settings with a high prevalence of invasive candidiasis:

  • 100 mg once a day.

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Micafungin Dose in Children:

Micafungin (Mycamine) Dose for Aspergillosis Treatment:

• Treatment; invasive disease: Limited data available:

  • Regardless of HIV status, children and infants less than 4 months:

    • IV: It can be injected one time daily at a dose of 1.5 to 3 mg/kg.
    • When the clinical response is insufficient or persistently positive cultures are found, it may be titrated to a higher dose if necessary.
    • The range of the typical maximum dosage is 4 to 8.6 mg/kg/day. Due to pharmacokinetic variations,babies can need their initial doses at the higher end of the dosing range.

  • Adolescents:

    • HIV-exposed/-positive:

      • IV: 100 to 150 mg once daily.

    • Non-HIV-exposed/-positive:

      • The highest daily dose is 150 mg/day.
      • Based on a single case report of a 13-year-old who received 1.5 mg/kg/day for invasive aspergillosis, a non-comparative  study of patients of all ages, and an abstract of a study in paediatric patients 3 months to 16 years, as well as a  noncomparative study of patients of all ages. 
      • IV: 1.5 mg/kg/day. It can be increased if clinically indicated.

Micafungin (Mycamine) Dose for Hematopoietic Stem Cell Transplant (HSCT) Prophylaxis: little information available

• Infants under four months old, kids, and teenagers:

  • IV: 1 to 3 mg/kg once a day with a maximum dose of 50 mg.

Micafungin (Mycamine) Dose in the treatment of Candidiasis:

• Acute disseminated infection, peritonitis, and abscesses; treatment:

  • Non-HIV-exposed/-positive:

    • Infants <4 months:
      • Due to the less data available, it can be administered intravenously (2 mg/kg/day) once day. If there is no change in the patient's state or persistently positive cultures, the dose may be increased to 4 to 10 mg/kg/day.
        The range is reportedly 2 to 10 mg/kg/day.
    • Infants ≥4 months, Children, and Adolescents:
      • IV: 2 mg/kg once day; 100 mg/dose is the maximum dosage

  • HIV-exposed/-positive (DHHS [pediatric] 2013):

    • Children 2 to 8 years and ≤40 kg: IV: 3 to 4 mg/kg once a day.
    • Infants <4 months (critically ill): 5 to 7 mg/kg/day IV, given once daily. The length of treatment might vary. Following the latest successful blood culture, continue therapy for 14 days.
    • >40 kg: IV: 100 mg once a day.
    • Children ≥9 years and Adolescents:
    • Infants ≥4 months and weighing <15 kg: IV: 5 to 7 mg/kg once a day.
    • ≤40 kg: IV: 2 to 3 mg/kg once a day.

Micafungin (Mycamine) Dose in the treatment of Esophageal candidiasis:

• HIV-exposed/-positive:

  • Adolescents:

    • <40 kg: IV: 2 to 3 mg/kg once a day.
    • The treatment duration is 2-3 weeks.
    • ≥40 kg: IV: 150 mg once a day.

  • Infants <4 months:

    • 5 to 7 mg/kg/day IV, given once daily. After the initial three weeks of therapy, the patient receives continued to care for at least another two weeks.

  • Children 2 to 8 years and ≤40 kg:

    • IV: 3 to 4 mg/kg once a day

  • Infants ≥4 months and weighing <15 kg:

    • IV: 5 to 7 mg/kg once a day.

  • Children ≥9 years:

    • ≤40 kg: IV: 2 to 3 mg/kg once a day.
    • >40 kg: IV: 100 mg once a day.

• Non-HIV-exposed/-positive:

  • Infants ≥4 months, Children, and Adolescents:

    • ≤30 kg: IV: 3 mg/kg once a day
    • >30 kg: IV: 2.5 mg/kg once a day with maximum dose of 150 mg/dose

Micafungin (Mycamine) Dose in the Prophylaxis in hematopoietic stem cell transplantation:

• Infants ≥4 months, Children, and Adolescents:

  • IV: 1 mg/kg per day with a 50 mg maximum dosage. But in several experiments, dosages as high as 3 mg/kg/day have been used.

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Micafungin (Mycamine) Pregnancy Category: C

• Negative outcomes have been shown in reproduction studies using animal trials.
• Other than micafungin and other antifungals, candidiasis treatment in pregnancy is preferred.

Micafungin use during breastfeeding:

• It isn't known if it is in breast milk.
• To ensure that there are no risks, it is important to use clinical judgment before starting treatment.

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Dose in Kidney Disease:

No dosage adjustment is necessary. Because of how poorly it is dialyzed, no additional dose adjustment is required, even for patients receiving intermittent hemodialysis.

Dose in Liver disease:

No dosage adjustment is necessary.

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Candidiasis treatment:

Common Side Effects of Micafungin (Mycamine):

• Hepatic:

  • Abnormal hepatic function tests
  • Hyperbilirubinemia
•  

• Cardiovascular:

  • Phlebitis

• Gastrointestinal:

  • Vomiting
  • Diarrhea

• Hematologic & oncologic:

  • Anemia

• Miscellaneous:

  • Fever

• Renal:

• • Renal failure

Less Common Side Effects of Micafungin (Mycamine):

• Hepatic:

  • Increased serum alkaline phosphatase

• Dermatologic:

  • Skin rash
•  

• Cardiovascular:

  • Atrial fibrillation
  • Tachycardia

• Hematologic & oncologic:

  • Thrombocytopenia
  • Neutropenia

• Endocrine & metabolic:

• • Hypoglycemia
  • Hypernatremia
  • Hyperkalemia
  • Abnormal aspartate transaminase

• Central nervous system:

  • Headache

• Gastrointestinal:

  • Nausea
  • Abdominal distention
  • Abdominal painAbdominal pain

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Candidiasis prophylaxis in hematopoietic stem cell transplantation :

Common Side Effects of Micafungin (Mycamine):

• Cardiovascular:

  • Tachycardia

• Central Nervous System:

  • AnxietyAnxiety
  • Insomnia
  • HeadacheHeadache

• Dermatologic:

  • UrticariaUrticaria
  • Skin Rash
  • Pruritus

• Endocrine & Metabolic:

  • Abnormal Alanine Aminotransferase

• Gastrointestinal:

  • Abdominal Distention
  • Diarrhea
  • Diarrhea
  • Vomiting
  • Abdominal Pain
  • Nausea

• Genitourinary:

  • Hematuria
  • Decreased Urine Output

• Hematologic & Oncologic:

  • Thrombocytopenia
  • Anemia
  • Neutropenia
  • Febrile Neutropenia

• Hepatic:

  • Abnormal Hepatic Function Tests
  • Hyperbilirubinemia

• Renal:

  • Renal Failure

• Miscellaneous:

  • Fever
  • Infusion-Related Reaction

Less Common Side Effects Of Micafungin (Mycamine):

• Cardiovascular:

  • Cardiac Arrest
  • Myocardial Infarction
  • Pericardial Effusion

• Central Nervous System:

  • Brain Disease
  • Delirium
  • Intracranial Hemorrhage
  • Seizure

• Hematologic & Oncologic:

  • Blood Coagulation Disorder
  • Pancytopenia
  • Thrombotic Thrombocytopenic Purpura

• Hepatic:

  • Hepatic Failure
  • Hepatic Injury
  • Hepatomegaly
  • Jaundice

• Hypersensitivity:

  • Anaphylaxis
  • Hypersensitivity Reaction

• Local:

  • Infusion Site Reaction
  • Venous Thrombosis At Injection Site

• Respiratory:

  • Epistaxis

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Contraindications to Micafungin (Mycamine):

A contraindication is a hypersensitivity to micafungin and any of its formulations.

Warnings and precautions

• Hemolytic anemia/hemoglobinuria:

  • It is possible to see hemoglobinuria and hemolytic anemia.

• Hepatic impairment

  • It is possible to see a worsening in hepatic function or a new onset liver disorder.
  • Patients with abnormal liver function should be closely monitored and evaluated clinically for continued treatment.

• Hypersensitivity reactions

  • Shock and other serious allergic responses have occurred. Infusion responses have occasionally been shown as rash, pruritus, and facial edema.
  • The infusion shouldn't be administered in cases of severe hypersensitivity responses (like anaphylaxis).
  • The infusion rate may be lowered in order to prevent any histamine-mediated injection responses.

• Injection-site reactions:

  • Injection-site reactions can be compared to phlebitis. It's more common with peripheral administration than with CVP.

• Renal impairment

  • There have been reports of high BUN, elevated serum creatinine, and abrupt renal failure. Patients should be managed carefully if their renal function deteriorates.

Micafungin: Drug Interaction

Risk Factor C (Monitor therapy)
Sirolimus	Micafungin may raise the level of Sirolimus in the blood.
Risk Factor X (Avoid combination)
Saccharomyces boulardii	Antifungal (Systemic, Oral) Agents may lessen Saccharomyces boulardii's therapeutic impact.

 

Monitoring parameters:

• Treatment should be given for infusion responses, which may include rash, pruritus, facial swelling, and vasodilatation (possible histamine-mediated symptoms). 
• Regular evaluations of liver function 
• BUN and Serum creatinine 
• CBC.
• Increased monitoring is advisable in patients who develop abnormalities.

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How to administer Micafungin (Mycamine)?

IV:

• Only for IV usage; infuse for one hour.

• Possibly reduce infusion rate to take infusion response (eg, rash, pruritus, facial swelling, vasodilatation). Before injecting, the line needs to be flushed with NS.

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Mechanism of action of Micafungin (Mycamine):

The important polysaccharide 1,3-beta-D-glucan, which makes up 30 to 60 percent of the walls of Candida cells, is inhibited concentration-dependently by 1,3-beta-D-glucan synthase (absent in mammalian cells). Osmotic instability, cellular lysis, and even cellular death can result from a drop in glucan concentration.

AbsorptionOral:

• Poor

Metabolism:

• By arylsulfatase, hepatic to M-1, catechol form. Catechol-O-methyltransferase converts it to M-2, the methoxy form, while CYP3A hydroxylates it to M-5.

Distribution:

• • It is found in the lungs, liver, and spleen, as well as minimally in the CNS and eyes.

Protein binding:

• Neonates: 96.7%;
• Adults: >99% to albumin

Half-life elimination:

• Children 4 months to 16 years:
  • ≤30 kg: 12.5 ± 4.6 hours;
  • >30 kg: 13.6 ± 8.8 hours
• Adults receiving bone marrow or peripheral stem-cell transplantation: 10.7 to 13.5 hours.
• Healthy Adults: 11 to 21 hours
• Preterm infants:
  • PNA <1 week: 6.7 hours.
  • PNA >3 weeks: Mean 8.3 hours (range: 5.6 to 11 hours)

Excretion:

• Primarily feces (71%);
• urine (<1%, unchanged)

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International Brand Names of Micafungin:

• Mycamine
• Funguard
• Micamin
• Mycamiine
• Mycamine
• Ying Te

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Micafungin Brand Names in Pakistan:

No Brands Available in Pakistan.