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Amphotericin B deoxycholate (conventional): Drug information

Amphotericin B deoxycholate (conventional): Drug information
(For additional information see "Amphotericin B deoxycholate (conventional): Patient drug information" and see "Amphotericin B deoxycholate (conventional): Pediatric drug information")

For abbreviations, symbols, and age group definitions used in Lexicomp (show table)
ALERT: US Boxed Warning
Appropriate use:

This drug should be used primarily for treatment of patients with progressive and potentially life-threatening fungal infections; it should not be used to treat noninvasive forms of fungal disease such as oral thrush, vaginal candidiasis, and esophageal candidiasis in patients with normal neutrophil counts.

Error prevention:

Exercise caution to prevent inadvertent overdose with amphotericin B. Verify the product name and dosage if dose exceeds 1.5 mg/kg.

Brand Names: Canada
  • Fungizone IV
Pharmacologic Category
  • Antifungal Agent, Parenteral
Dosing: Adult

Note: Formulation: Conventional amphotericin formulations (deoxycholate [Amphocin, Fungizone]) may be confused with lipid-based formulations (AmBisome, Abelcet, Amphotec). Lipid-based and conventional formulations are not interchangeable and have different dosage recommendations. Overdoses have occurred when conventional formulations were dispensed inadvertently for lipid-based products. Premedication: To minimize infusion-related immediate reactions, premedicate with the following 30 to 60 minutes prior to drug administration: acetaminophen, diphenhydramine, and/or hydrocortisone. If the patient experiences rigors during the infusion, meperidine may be administered (HHS [OI adult] 2022; Sharkey 1996; manufacturer's labeling). Preinfusion administration of 1 L of NS may reduce the risk of nephrotoxicity during treatment (HHS [OI adult] 2022; manufacturer's labeling). Test dose: A test dose of 1 mg in 20 mL D5W administered over 20 to 30 minutes may be considered.

Usual dosage range: IV: 0.5 to 1 mg/kg/day (range: 0.3 to 1.5 mg/kg/day); maximum dose: 1.5 mg/kg/day. Note: Lipid-based formulations of amphotericin B are generally preferred for treatment of systemic infections because they demonstrate comparable efficacy and better tolerability (ECMM/MSG-ERC [Cornely 2019]; IDSA [Pappas 2016]; IDSA [Patterson 2016]; IDSA [Wheat 2007]).

Aspergillosis, endophthalmitis

Aspergillosis, endophthalmitis

Note: Administer a combination of both intraocular (intravitreal and/or intracameral depending on sites of involvement) and systemic (IV or oral) antifungal therapy (IDSA [Patterson 2016]).

Intraocular:

Intravitreal injection: For involvement of the vitreous: 5 to 10 mcg per 0.1 mL sterile water as a single intravitreal dose; may be repeated in several days as clinically indicated (Chakrabarti 2008; Durand 2022a; IDSA [Patterson 2016]).

Intracameral injection: For involvement of the aqueous humor: 5 mcg per 0.1 mL sterile water as a single intracameral (into the anterior chamber) dose (Durand 2022a; Kuriakose 2002; Yilmaz 2007). Note: May also consider intravitreal injection even if vitritis is not apparent, as occult vitreal involvement is possible (Durand 2022a).

Aspergillosis, invasive

Aspergillosis, invasive (including disseminated and extrapulmonary) (alternative agent):

Note: Optimal dose not defined; reserve for use in resource-limited settings when no alternatives are available (IDSA [Patterson 2016]).

IV: 1 to 1.5 mg/kg/day (Burch 1987; Herbrecht 2002). Minimum treatment duration is 6 to 12 weeks depending on site of infection, extent of disease, and level/duration of immunosuppression (IDSA [Patterson 2016]).

Blastomycosis, moderately severe to severe, non-CNS disease

Blastomycosis, moderately severe to severe, non-CNS disease: IV: 0.7 to 1 mg/kg/day for 1 to 2 weeks or until improvement, followed by oral itraconazole (IDSA [Chapman 2008]).

Candidiasis

Candidiasis:

CNS infection (failed to respond to systemic therapy and device removal or when ventricular device cannot be removed) (off-label): Intraventricular: 0.01 to 0.5 mg per 2 mL of an extemporaneously prepared solution in D5W administered through the device into the ventricle (IDSA [Pappas 2016]; IDSA [Tunkel 2017]).

Endophthalmitis ( with or without vitritis):

Note: Administer a combination of both intraocular (intravitreal and/or intracameral depending on sites of involvement) and systemic (IV or oral) antifungal therapy. For patients with endogenous endophthalmitis without vitritis or macular involvement, intraocular antifungals may not be necessary (Durand 2022b; Durand 2022c).

Intraocular:

Intravitreal injection: 5 to 10 mcg per 0.1 mL sterile water as a single intravitreal dose (IDSA [Pappas 2016]). Intravitreal dose may be repeated in several days if no improvement (Durand 2022b; Durand 2022c).

Intracameral injection: For exogenous cases involving primarily the aqueous: 5 mcg per 0.1 mL sterile water as a single intracameral (into the anterior chamber) dose. Note: May also consider intravitreal injection even if vitritis is not apparent, as occult vitreal involvement is possible (Durand 2022c).

Esophageal, refractory disease (alternative agent) (off-label use):

Note: Reserve use for patients who have inadequate response to or who are unable to take other agents (Kauffman 2021a).

IV: 0.3 to 0.7 mg/kg/day. Transition to an oral antifungal once patient tolerates oral intake if susceptibility allows; total antifungal duration is 14 to 28 days (HHS [OI adult] 2022]; IDSA [Pappas 2016]; Kauffman 2021a).

Invasive candidiasis (alternative agent): IV: 0.5 to 0.7 mg/kg/day; dose may be increased to as high as 1 mg/kg/day for infections caused by C. glabrata or C. krusei. Note: Given poor tolerability (eg, nephrotoxicity, infusion-related toxicity), experts preferentially recommend lipid formulations when available (IDSA [Pappas 2016]).

Oropharyngeal, refractory disease (alternative agent) (off-label use):

Note: Reserve use for patients who have inadequate response to or who are unable to take other agents (Kauffman 2021b).

Oral: 500 mg of an extemporaneously compounded 100 mg/mL suspension 3 to 4 times daily for 14 to 28 days; swish in the mouth and retain for as long as possible (several minutes) before swallowing (Fichtenbaum 2000; IDSA [Pappas 2016]; Kauffman 2021b; Talliandier 2000).

Urinary tract infection (off-label use):

Candiduria (asymptomatic) in patients undergoing urologic procedures: IV: 0.3 to 0.6 mg/kg/day for several days before and after the procedure (IDSA [Pappas 2016]).

Cystitis (symptomatic), fluconazole-resistant species (eg, C. glabrata, C. krusei):

Bladder irrigation (off-label route): Irrigate with 50 mg amphotericin B deoxycholate diluted in 1 L of sterile water once daily for 5 days. Note: Use of bladder irrigation is generally discouraged, especially in patients who would not otherwise require an indwelling catheter (IDSA [Pappas 2016]).

IV: 0.3 to 0.6 mg/kg/day for 1 to 7 days (IDSA [Pappas 2016]).

Fungus balls: Irrigation via nephrostomy tubes (off-label route): Irrigate with an extemporaneously prepared solution of 25 to 50 mg in 200 to 500 mL sterile water (final concentration range: 0.05 to 0.25 mg/mL); use in combination with systemic antifungal therapy (IDSA [Pappas 2016]).

Pyelonephritis, fluconazole-resistant species (eg, C. glabrata, C. krusei): IV: 0.3 to 0.6 mg/kg/day for 1 to 7 days (with or without flucytosine for fluconazole-resistant C. glabrata) (IDSA [Pappas 2016]).

Vulvovaginal, caused by C. glabrata (alternative agent) (off-label use): Intravaginal: 3% to 4% extemporaneously compounded cream: 1 applicatorful (~5 g) once daily (at bedtime) for 14 days (IDSA [Pappas 2016]; Sivasubramanian 2009; Sobel 2021). Note: Reserve for patients with no other clear cause of symptoms (Sobel 2021). May also be used in combination with intravaginal flucytosine (Challenor 2012; Hettiarachchi 2010; IDSA [Pappas 2016]; White 2001).

Coccidioidomycosis, severe, nonmeningeal infection

Coccidioidomycosis, severe, nonmeningeal infection: IV: 0.5 to 1 mg/kg/day until clinical improvement, then switch to an oral azole (HHS [OI adult] 2022; IDSA [Galgiani 2016]). Note: Some experts suggest initiating the oral azole at the same time as amphotericin B deoxycholate and continuing the oral azole when amphotericin B deoxycholate is discontinued (HHS [OI adult] 2022).

Cryptococcal meningoencephalitis, disseminated disease, or severe pulmonary disease

Cryptococcal meningoencephalitis, disseminated disease, or severe pulmonary disease:

Resource-rich settings (when a lipid formulation of amphotericin B cannot be used): IV: Induction therapy: 0.7 to 1 mg/kg/day in combination with flucytosine (preferred) or fluconazole (if flucytosine cannot be used) for ≥2 weeks (HHS [OI adult 2022]; IDSA [Perfect 2010]).

Resource-limited settings (if liposomal amphotericin B is not available) in patients with HIV: IV: Induction therapy: 1 mg/kg/day in combination with flucytosine for 7 days followed by fluconazole for ≥7 days. Note: If flucytosine is not available, amphotericin B may be given at the same dose in combination with fluconazole for 14 days (WHO 2022).

Note: Duration of induction therapy may be extended in patients who cannot use combination therapy or who have evidence of neurological complications (HHS [OI adult] 2022; IDSA [Perfect 2010]). Induction therapy is followed by consolidation and maintenance therapy with fluconazole (AST-IDCOP [Baddley 2019]; HHS [OI adult 2022]; IDSA [Perfect 2010]).

Histoplasmosis

Histoplasmosis (alternative agent): Moderately severe to severe pulmonary or disseminated disease: IV: 0.7 to 1 mg/kg/day for 1 to 2 weeks (at least 2 weeks in patients with HIV), followed by oral itraconazole (Baddley 2022; IDSA [Wheat 2007]; Johnson 2002). Some experts prefer to use the higher end of the dosing range (eg, 1 mg/kg/day) in patients with HIV (Baddley 2022).

Leishmaniasis

Leishmaniasis (alternative agent):

Cutaneous: IV: 0.5 to 1 mg/kg/dose once daily or every other day for a total cumulative dose of ~15 to 30 mg/kg (IDSA/ASTMH [Aronson 2016]).

Mucosal: IV: 0.5 to 1 mg/kg/dose once daily or every other day for a total cumulative dose of ~20 to 45 mg/kg (IDSA/ASTMH [Aronson 2016]).

Visceral (off-label use): IV: 1 mg/kg/dose once daily or every other day for a total cumulative dose of 15 to 20 mg/kg (IDSA/ASTMH [Aronson 2016]).

Visceral, patients with HIV (off-label use): IV: 0.5 to 1 mg/kg/dose once daily for a total cumulative dose of 1,500 to 2,000 mg (HHS [OI adult] 2017).

Sporotrichosis, pulmonary, meningeal, osteoarticular, or disseminated

Sporotrichosis, pulmonary, meningeal, osteoarticular, or disseminated: IV: 0.7 to 1 mg/kg/day, followed by oral itraconazole after a favorable response is seen with initial amphotericin therapy (IDSA [Kauffman 2007).

Talaromycosis

Talaromycosis (formerly penicilliosis) (alternative agent) (off-label use): IV: 0.7 mg/kg/day for 2 weeks (if liposomal amphotericin B unavailable) followed by oral azole consolidation therapy (HHS [OI adult] 2022).

Dosing: Kidney Impairment: Adult

The renal dosing recommendations are based upon the best available evidence and clinical expertise. Senior Editorial Team: Bruce Mueller, PharmD, FCCP, FASN, FNKF; Jason A. Roberts, PhD, BPharm (Hons), B App Sc, FSHP, FISAC; Michael Heung, MD, MS.

Note: Due to the risks of nephrotoxicity associated with amphotericin B deoxycholate, a conventional amphotericin formulation, only use when benefits outweigh the risks. Lipid-based amphotericin preparations are associated with a lower risk of nephrotoxicity and are preferred in patients with preexisting kidney impairment (including patients on hemodialysis or peritoneal dialysis who have significant residual renal function). If using amphotericin B deoxycholate, limiting dose and duration of treatment (as clinically appropriate), extending infusion time, avoiding concomitant nephrotoxic drugs, and hydration and sodium loading with 1 L of NS prior to starting therapy may reduce the risk of acute kidney injury. Monitor kidney function closely (Falagas 2013; Llanos 1991; Nemecek 2019; Peleg 2004; Rothenbühler 2018; manufacturer's labeling). For routes of administration other than IV (eg, intraocular), there are no specific dosage adjustments recommended (has not been studied in patients with kidney impairment); however, need for adjustment is unlikely (expert opinion).

Kidney impairment prior to treatment initiation:

Altered kidney function: IV: No dosage adjustment necessary for any degree of kidney impairment (only 2% to 5% excreted in biologically active form) (Nemecek 2019; Sinnollareddy 2012; expert opinion).

Augmented renal clearance (measured urinary CrCl ≥130 mL/minute/1.73 m2):

Note: Augmented renal clearance (ARC) is a condition that occurs in certain critically ill patients without organ dysfunction and with normal serum creatinine concentrations. Younger patients (<55 years of age) admitted post trauma or major surgery are at highest risk for ARC, as well as those with sepsis, burns, or hematologic malignancies. An 8- to 24-hour measured urinary CrCl is necessary to identify these patients (Bilbao-Meseguer 2018; Udy 2010).

IV: No dosage adjustment necessary (expert opinion).

Hemodialysis, intermittent (thrice weekly): Not significantly dialyzable (Gussak 2001):

IV: No dosage adjustment necessary (Heintz 2009).

Peritoneal dialysis: Not likely to be significantly dialyzable (highly protein bound with poor peritoneal penetration) (Li 2016; expert opinion):

IV: No dosage adjustment necessary (expert opinion).

CRRT: IV: No dosage adjustment necessary (Bellman 2003; Heintz 2009; Sinnollareddy 2012).

PIRRT (eg, sustained, low-efficiency diafiltration): IV: No dosage adjustment necessary (expert opinion).

Nephrotoxicity during treatment: Consider switching to an alternative antifungal agent or a lipid-based amphotericin formulation (expert opinion). However, if continued use of amphotericin B deoxycholate is deemed clinically appropriate, may consider interrupting therapy for 24 to 48 hours, then resume at one-half of the usual daily dose; the dosage may then be increased to the maximally tolerated dose (Maddux 1980). This approach will likely decrease amphotericin deoxycholate exposures, and so should be avoided in the acute phase of serious infections (expert opinion).

Dosing: Hepatic Impairment: Adult

No dosage adjustment provided in manufacturer’s labeling.

Dosing: Pediatric

(For additional information see "Amphotericin B deoxycholate (conventional): Pediatric drug information")

Medication errors, including deaths, have resulted from confusion between lipid-based forms of amphotericin (Abelcet, Amphotec, AmBisome) and conventional amphotericin B for injection; conventional amphotericin B for injection doses should not exceed 1.5 mg/kg/day

Note: Premedication: For patients who experience infusion-related immediate reactions, premedicate with the following drugs 30 to 60 minutes prior to drug administration: NSAID (with or without diphenhydramine) or acetaminophen with diphenhydramine or hydrocortisone. If the patient experiences rigors during the infusion, meperidine may be administered.

Test dose: Infants, Children, and Adolescents: IV: 0.1 mg/kg/dose to a maximum of 1 mg; infuse over 20 to 60 minutes; an alternative method to the 0.1 mg/kg test dose is to initiate therapy with 0.25 mg/kg amphotericin administered over 6 hours; frequent observation of the patient and assessment of vital signs during the first several hours of the infusion is recommended; many clinicians believe a test dose is unnecessary

General dosing, susceptible infections:

IV: Infants, Children, and Adolescents:

Initial: 0.25 to 0.5 mg/kg/dose once daily; gradually increase daily, usually in 0.25 mg/kg increments until the desired daily dose is reached (maximum daily dose: 1.5 mg/kg/day); in critically ill patients, more rapid dosage acceleration may be warranted (eg, ≥0.5 mg/kg daily dose increase); others have initiated at target dose for life-threatening infection (HHS [OI pediatric 2013])

Maintenance dose: 0.25 to 1 mg/kg/dose once daily; rapidly progressing disease may require short-term use of doses up to 1.5 mg/kg/day; once therapy has been established, amphotericin B may be administered on an every-other-day basis at 1 to 1.5 mg/kg/dose in some cases

Intrathecal, intraventricular, or intracisternal (preferably into the lateral ventricles through a cisternal Ommaya reservoir): Limited data available; dose variable: Infants, Children, and Adolescents: 0.01 to 1 mg; frequency varies widely in the literature; administration has been reported as daily, every other day and even twice weekly (Chiou 1994; IDSA [Pappas 2016]; Murphy 2000; Red Book [AAP 2015])

Irrigation, bladder: Infants, Children, and Adolescents: Limited data available: 50 mcg/mL solution, administered as either a continuous irrigation or as an intermittent irrigation 3 times daily with a dwell time of 60 to 90 minutes (Fisher 2011; Gubbins 1999); some experts have also recommended daily administration for 5 days for the treatment of cystitis due to fluconazole-resistant Candida species (C. glabrata, C. krusei) (IDSA [Pappas 2016])

Aspergillosis

Aspergillosis:

Prophylaxis, immunocompromised: Limited data available: Infants, Children, and Adolescents: Intranasal: 7 mg amphotericin B in 7 mL sterile water was placed in a De Vilbiss atomizer and the aerosolized solution was instilled intranasally to each nostril 4 times daily delivering an average of 5 mg amphotericin/day to reduce the frequency of invasive aspergillosis in neutropenic patients (Jeffery 1991)

Endocarditis: Children and Adolescents: IV: 1 mg/kg/dose once daily with or without flucytosine (AHA [Baltimore 2015])

Blastomycosis, moderately severe to severe disease

Blastomycosis (independent of HIV status), moderately severe to severe disease: Infants, Children, and Adolescents: IV: 0.7 to 1 mg/kg/dose once daily as initial therapy for 1 to 2 weeks, followed with oral itraconazole for a total of 12 months (IDSA [Chapman 2008])

Candidiasis, treatment

Candidiasis, treatment:

Invasive: Infants, Children, and Adolescents: IV: 0.5 to 1 mg/kg/dose once daily; duration of therapy dependent upon severity and site of infection (IDSA [Pappas 2016])

Endocarditis: Children and Adolescents: IV: 1 mg/kg/dose once daily with or without flucytosine (AHA [Baltimore 2015])

Esophageal:

Non-HIV-exposed/-infected: Infants, Children, and Adolescents: IV: 0.3 to 0.7 mg/kg/dose once daily; consider step down to an oral antifungal once patient is able to tolerate oral intake. In fluconazole-refractory disease, continue amphotericin B for 21 days (IDSA [Pappas 2016])

HIV-exposed/-infected:

Infants and Children: IV: 0.3 to 0.7 mg/kg/dose once daily (HHS [OI pediatric 2013])

Adolescents: IV: 0.6 mg/kg/dose once daily for 14 to 21 days (HHS [OI adult 2016])

Oropharyngeal, fluconazole-refractory:

Non-HIV-exposed/-infected: Infants, Children, and Adolescents: IV: 0.3 mg/kg/dose once daily (IDSA [Pappas 2016])

HIV-exposed/-infected:

Infants and Children: IV: 0.3 to 0.5 mg/kg/dose once daily (HHS [OI pediatric 2013])

Adolescent: IV: 0.6 mg/kg/dose once daily for 14 to 21 days (HHS [OI adult 2016])

Urinary tract infections (IDSA [Pappas 2016]):

Prophylaxis, urologic procedures in patients with candiduria: Infants, Children, and Adolescents: IV: 0.3 to 0.6 mg/kg/dose once daily for several days before and after procedure

Treatment:

Cystitis: Infants, Children, and Adolescents: IV:

Asymptomatic (high-risk patients): 1 mg/kg/dose once daily

Symptomatic (C. krusei or fluconazole-resistant C. glabrata): 0.3 to 0.6 mg/kg/dose once daily for 1 to 7 days

Pyelonephritis: Infants, Children, and Adolescents: IV: 0.3 to 0.6 mg/kg/dose once daily for 1 to 7 days; depending on organism, consider addition of flucytosine

Coccidioidomycosis

Coccidioidomycosis:

Non-HIV-exposed/-infected (IDSA [Galgiani 2005]): Infants, Children, and Adolescents:

Disseminated (non-CNS) disease: IV 0.5 to 1.5 mg/kg/dose every day or every other day; with or without concomitant azole antifungal; duration determined by clinical response

CNS disease: Intrathecal: 0.1 to 1.5 mg/dose; frequency ranging from daily to weekly (with or without concomitant azole therapy); initiate at a low dose and increase until intolerance is noted (eg, severe vomiting, exhaustion, or transient dose-related mental status changes); duration determined by clinical response

Pulmonary disease, diffuse: IV 0.5 to 1.5 mg/kg/dose every day or every other day for several weeks, followed by an oral azole antifungal for a total length of therapy ≥12 months

HIV-exposed/-infected: Disseminated (non-CNS) disease, diffuse pulmonary disease; severely ill:

Infants and Children: IV: 0.5 to 1 mg/kg/dose once daily until clinical improvement; minimum of several weeks of therapy (HHS [OI pediatric 2013])

Adolescents: IV: 0.7 to 1 mg/kg/dose once daily until clinical improvement, then initiate triazole therapy (eg, fluconazole or itraconazole) (HHS [OI adult 2016])

Cryptococcal disease

Cryptococcal disease:

CNS disease:

Non-HIV-exposed/-infected: Infant, Children, and Adolescents: IV: 0.7 to 1 mg/kg/dose once daily plus flucytosine; Note: Minimum 2- to 4-week induction, followed by consolidation and chronic suppressive therapy; may increase amphotericin dose to 1.5 mg/kg/day if flucytosine is not tolerated (IDSA [Perfect 2010])

HIV-exposed/-infected:

Infants and Children: IV: 1 mg/kg/dose once daily plus flucytosine or fluconazole; Note: Minimum 2-week induction, followed by consolidation and chronic suppressive therapy; a longer duration of induction therapy may be necessary if CSF is not negative or lack of clinical improvement; may increase amphotericin dose to 1.5 mg/kg/day alone or in combination with fluconazole if flucytosine is not tolerated (HHS [OI pediatric 2013])

Adolescents: IV: 0.7 to 1 mg/kg/dose once daily with or without flucytosine or fluconazole; Note: Minimum 2-week induction, followed by consolidation and chronic suppressive therapy (HHS [OI adult 2016])

Disseminated (non-CNS disease) or severe pulmonary disease: Independent of HIV status: Infants, Children, and Adolescents: IV: 0.7 to 1 mg/kg/dose once daily with or without flucytosine; duration of therapy depends on the site and severity of the infection and clinical response (HHS [OI adult 2016]; HHS [OI pediatric 2013]; IDSA [Perfect 2010])

Histoplasmosis

Histoplasmosis:

Non-HIV-exposed/-infected: Severe disseminated (non-CNS) or pulmonary disease: Infants, Children, and Adolescents: IV: 0.7 to 1 mg/kg/dose once daily; Note: Minimum 1- to 2-week induction, followed by consolidation therapy (IDSA [Wheat 2007])

HIV-exposed/-infected: CNS or severe disseminated disease: Infants and Children: IV: 0.7 to 1 mg/kg/dose once daily, followed by consolidation therapy (HHS [OI pediatric 2013])

Duration of induction:

Severe or moderately severe pulmonary disease: 1 to 2 week minimum

Disseminated or clinical improvement delayed: ≥2 weeks

CNS involvement: 4 to 6 weeks

Leishmaniasis, visceral, HIV-exposed/-infected

Leishmaniasis, visceral, HIV-exposed/-infected: Adolescents: IV: 0.5 to 1 mg/kg/dose once daily for a total cumulative dose of 1,500 to 2,000 mg (HHS [OI adult 2016])

Peritonitis

Peritonitis (CAPD): Limited data available: Note: Amphotericin B has demonstrated poor peritoneal penetration when given systemically and intraperitoneal administration is associated with abdominal pain and peritoneal irritation; other agents may be preferred (ISPD [Warady 2012]).

Intraperitoneal, dialysate: Infants, Children, and Adolescents: 1 to 4 mg per liter of dialysate has been used in pediatric patients based on case reports and retrospective reviews (Hogg 1982; Kravitz 1986; Raaijmakers 2007; Warady 2000a); lower doses of 0.5 to 3 mg per liter of dialysate has been reported in adults (with or without concomitant systemic amphotericin B therapy); abdominal pain has been associated with doses ≥2 mg per liter of dialysate (Bastani 1986; Johnson 1985).

IV: Infants, Children, and Adolescents: 1 mg/kg/dose once daily (ISPD [Warady 2000b])

Sporotrichosis, severe infection

Sporotrichosis, severe infection (IDSA [Kauffman 2007]): Children and Adolescents: 0.7 mg/kg/dose once daily; followed by oral itraconazole after a favorable response is seen with amphotericin initial therapy

Dosing: Kidney Impairment: Pediatric

Infants, Children, and Adolescents:

If renal dysfunction is due to the drug, the daily total can be decreased by 50% or the dose can be given every other day. IV therapy may take several months.

Renal replacement therapy: Poorly dialyzed; no supplemental dose or dosage adjustment necessary, including patients on intermittent hemodialysis or CRRT.

Dosing: Hepatic Impairment: Pediatric

There are no dosage adjustments provided in the manufacturer's labeling.

Dosing: Older Adult

Refer to adult dosing.

Dosing: Obesity: Adult

The recommendations for dosing in patients with obesity are based upon the best available evidence and clinical expertise. Senior Editorial Team: Jeffrey F. Barletta, PharmD, FCCM; Manjunath P. Pai, PharmD, FCP; Jason A. Roberts, PhD, BPharm (Hons), B App Sc, FSHP, FISAC.

Class 1, 2, or 3 obesity (BMI ≥30 kg/m2): Note: Lipid-based formulations of amphotericin B are generally preferred for treatment of systemic infections because they demonstrate comparable efficacy and better tolerability (ECMM/MSG-ERC [Cornely 2019]; IDSA [Pappas 2016]; IDSA [Patterson 2016]; IDSA [Wheat 2007]).

IV: Use adjusted body weight for weight-based dose calculations (expert opinion). In more severe infections, may consider using actual body weight for weight-based dose calculations, although this may be associated with increased toxicity due to higher doses (Amsden 2011, expert opinion). When dosing with either adjusted or actual body weight, a maximum daily dose of 150 mg is suggested (extrapolated from a study of a similar product [Wasmann 2020, expert opinion]). Refer to "Dosing: Adult" for indication-specific doses.

Rationale for recommendations: There are sparse data describing the effect of obesity on dosing requirements for polyene antifungals (Amsden 2011). There are no human pharmacokinetic studies for amphotericin B deoxycholate in patients with obesity. Even though amphotericin B deoxycholate exhibits a Vd of 2.4 to 5.1 L/kg (Amsden 2011; Dupont 2002), distribution into adipose tissue appears to be limited; therefore, does not support routinely dosing based on actual body weight (Amsden 2011). Use adjusted body weight for weight-based dose calculations (expert opinion). For more severe infections, may consider using actual body weight for dose calculations (Amsden 2011; expert opinion).

Dosage Forms: US

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Solution Reconstituted, Intravenous, as deoxycholate [preservative free]:

Generic: 50 mg (1 ea)

Generic Equivalent Available: US

Yes

Dosage Forms: Canada

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Solution Reconstituted, Intravenous, as deoxycholate:

Fungizone IV: 50 mg (1 ea)

Administration: Adult

IV: May be infused over 2 to 6 hours; an inline filter (≥1 micron mean pore diameter) may be used for administration. To minimize infusion-related immediate reactions, premedicate with the following 30 to 60 minutes prior to drug administration: acetaminophen, diphenhydramine, and/or hydrocortisone. If the patient experiences rigors during the infusion, meperidine may be administered (HHS [OI adult] 2022; Sharkey 1996; manufacturer’s labeling). Preinfusion administration of 1 L of NS appears to reduce the risk of nephrotoxicity during treatment (HHS [OI adult] 2022).

Intraocular (off-label route): Administer amphotericin intravitreally or intracamerally with the dose in a final volume in 0.1 mL (Durand 2022a; Durand 2022b; Durand 2022c; IDSA [Pappas 2016]; IDSA [Patterson 2016]).

Intraventricular (off-label route): Use preservative-free preparations only. When administered through a ventricular drain, clamp drain for 15 to 60 minutes before opening the drain to allow amphotericin B solution to equilibrate in the CSF (IDSA [Tunkel 2017])

Irrigation (off-label route): A solution for irrigation (final concentration range: 0.05 to 0.25 mg/mL) may be administered via nephrostomy tubes for fungal balls associated with urinary tract infection due to candida. A solution for irrigation (final concentration: 0.05 mg/mL solution) may be instilled via bladder irrigation for cystitis (IDSA [Pappas 2016]).

Vaginal (off- label route): Administer intravaginal cream at bedtime, using an appropriately sized intravaginal applicator to deliver the correct dose (Sivasubramanian 2009; White 2001).

Administration: Pediatric

IV: Administer by IV infusion over 2 to 6 hours; an in-line filter (>1 micron mean pore diameter) may be used for administration (Kintzel 1992). For a patient who experiences chills, fever, hypotension, nausea, or other nonanaphylactic infusion-related reactions, premedicate with the following drugs 30 to 60 minutes prior to drug administration: A nonsteroidal (eg, ibuprofen) ± diphenhydramine or acetaminophen with diphenhydramine or hydrocortisone. If the patient experiences rigors during the infusion, meperidine may be administered. Bolus infusion of normal saline immediately preceding, or immediately preceding and following amphotericin B may reduce drug-induced nephrotoxicity. Risk of nephrotoxicity increases with amphotericin B doses >1 mg/kg/day.

Irrigation solution (bladder): Administer as a continuous irrigation or intermittently with a dwell time of 60 to 90 minutes (Fisher 2011; Gubbins 1999; Ku 2004; Martinez-Pajares 2010).

Intranasal: Administer intranasally via a De Vilbiss atomizer (Jeffrey 1991)

Use: Labeled Indications

Fungal infection, invasive: Treatment of patients with progressive, potentially life-threatening fungal infections: Aspergillosis, cryptococcosis, North American blastomycosis, systemic candidiasis, coccidioidomycosis, histoplasmosis, zygomycosis (including mucormycosis due to susceptible species of the genera Absidia, Mucor, and Rhizopus), and infections due to related susceptible species of Conidiobolus, Basidiobolus, and sporotrichosis.

Leishmaniasis: Alternative treatment in patients with American (New World) mucocutaneous leishmaniasis

Use: Off-Label: Adult

Candidiasis, esophageal, refractory disease; Candidiasis, oropharyngeal, refractory disease (oral); Candidiasis, urinary tract; Candidiasis, vulvovaginal, caused by C. glabrata; Leishmaniasis, visceral; Talaromycosis (formerly penicilliosis)

Medication Safety Issues
High alert medication:

The Institute for Safe Medication Practices (ISMP) includes this medication among its list of drugs which have a heightened risk of causing significant patient harm when used in error.

Sound-alike/look-alike issues:

Amphotericin B may be confused with amphotericin B liposomal

Other safety concerns:

Conventional amphotericin formulations (deoxycholate [Amphocin, Fungizone]) may be confused with lipid-based formulations (AmBisome, Abelcet, Amphotec).

Large overdoses have occurred when conventional formulations were dispensed inadvertently for lipid-based products. Single daily doses of amphotericin B deoxycholate should not exceed 1.5 mg/kg.

Adverse Reactions

The following adverse drug reactions and incidences are derived from product labeling unless otherwise specified.

Systemic:

Frequency not defined:

Cardiovascular: Hypotension

Endocrine & metabolic: Hypokalemia, weight loss

Gastrointestinal: Anorexia, diarrhea, dyspepsia, epigastric pain, nausea, stomach cramps, vomiting

Genitourinary: Azotemia

Hematologic & oncologic: Normocytic anemia (normochromic)

Local: Pain at injection site (with or without phlebitis or thrombophlebitis)

Nervous system: Chills, headache, malaise, pain

Neuromuscular & skeletal: Arthralgia, myalgia

Renal: Calcium nephrolithiasis, decreased urine specific gravity (hyposthenuria), renal insufficiency, renal tubular acidosis

Respiratory: Tachypnea

Miscellaneous: Fever

Postmarketing:

Cardiovascular: Cardiac arrhythmia, flushing, heart failure, hypertension, shock, ventricular fibrillation

Dermatologic: Maculopapular rash, pruritus, skin rash

Endocrine & metabolic: Hyperkalemia, hypocalcemia, hypomagnesemia

Gastrointestinal: Hemorrhagic gastroenteritis, melena

Genitourinary: Anuria, oliguria

Hematologic & oncologic: Agranulocytosis, disorder of hemostatic components of blood, eosinophilia, leukocytosis, leukopenia, thrombocytopenia

Hepatic: Acute hepatic failure, hepatitis, increased serum alanine aminotransferase, increased serum alkaline phosphatase, increased serum aspartate aminotransferase, increased serum bilirubin, jaundice

Hypersensitivity: Hypersensitivity reactions, nonimmune anaphylaxis

Nervous system: Encephalopathy, leukoencephalopathy, peripheral neuropathy, seizure, vertigo (transient)

Ophthalmic: Diplopia, visual disturbance

Otic: Hearing loss, tinnitus

Renal: Acute kidney injury, increased blood urea nitrogen, increased serum creatinine

Respiratory: Bronchospasm, dyspnea, hypersensitivity pneumonitis, pulmonary edema, wheezing

Contraindications

Hypersensitivity to amphotericin or any component of the formulation

Warnings/Precautions

Concerns related to adverse effects:

• Anaphylaxis: Has been reported with amphotericin B-containing drugs; facilities for cardiopulmonary resuscitation should be available during administration due to the possibility of anaphylactic reaction. If severe respiratory distress occurs, the infusion should be immediately discontinued; during the initial dosing, the drug should be administered under close clinical observation.

• Infusion reactions: Acute reactions (eg, fever, rigors, hypotension, anorexia, nausea, vomiting, headache, tachypnea) may occur 1 to 3 hours after starting an intravenous infusion. These reactions are usually more common with the first few doses and generally diminish with subsequent doses. Avoid rapid infusion to prevent hypotension, hypokalemia, arrhythmias, and shock.

• Leukoencephalopathy: Has been reported following administration of amphotericin B. Total body irradiation has been reported to be a possible predisposition.

• Nephrotoxicity: May cause nephrotoxicity; risk factors include underlying renal disease, concomitant nephrotoxic medications and daily and/or cumulative dosing of amphotericin. Avoid use with other nephrotoxic drugs; drug-induced renal toxicity usually improves with interrupting therapy, decreasing dosage, or increasing dosing interval. However permanent impairment may occur, especially in patients receiving a large cumulative dose (eg, >5 g) and in those also receiving other nephrotoxic drugs. Hydration and sodium repletion prior to administration may reduce the risk of developing nephrotoxicity. Frequent monitoring of renal function is recommended.

Disease-related concerns:

• Heart failure: In a scientific statement from the American Heart Association, amphotericin has been determined to be an agent that may cause direct myocardial toxicity (magnitude: moderate/major) (AHA [Page 2016]).

• Renal impairment: Use with caution in patients with renal impairment.

Special populations:

• Patients with neutropenia: Pulmonary reactions may occur in patients with neutropenia receiving leukocyte transfusions; separation of the infusions as much as possible is advised.

Other warnings/precautions:

• Therapy interruption: If therapy is stopped for >7 days, restart at the lowest dose recommended and increase gradually.

Warnings: Additional Pediatric Considerations

May premedicate patients who experience mild adverse reactions with acetaminophen and diphenhydramine 30 minutes prior to the amphotericin B infusion; meperidine and ibuprofen may help to reduce fevers and chills; hydrocortisone can be added to the infusion solution to reduce febrile and other systemic reactions. If therapy is stopped for >7 days, restart at the lowest dose recommended and increase gradually. Administer by slow IV infusion; rapid infusion has been associated with hypotension, hypokalemia, arrhythmias, and shock. Avoid extravasation; may cause chemical irritation; monitor infusion site; heparin 1 unit/1 mL of infusion solution can be added to reduce phlebitis. Use caution with intraperitoneal administration; use associated with irritation to the peritoneum and abdominal pain; not routinely used unless intolerance to other therapies (ISPD [Warady 2000b]).

Metabolism/Transport Effects

None known.

Drug Interactions

Note: Interacting drugs may not be individually listed below if they are part of a group interaction (eg, individual drugs within “CYP3A4 Inducers [Strong]” are NOT listed). For a complete list of drug interactions by individual drug name and detailed management recommendations, use the Lexicomp drug interactions program by clicking on the “Launch drug interactions program” link above.

Alfuzosin: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Amifostine: Blood Pressure Lowering Agents may enhance the hypotensive effect of Amifostine. Management: When used at chemotherapy doses, hold blood pressure lowering medications for 24 hours before amifostine administration. If blood pressure lowering therapy cannot be held, do not administer amifostine. Use caution with radiotherapy doses of amifostine. Risk D: Consider therapy modification

Aminoglycosides: Amphotericin B may enhance the nephrotoxic effect of Aminoglycosides. Amphotericin B may enhance the neurotoxic effect of Aminoglycosides. Risk C: Monitor therapy

Amisulpride (Oral): May enhance the hypotensive effect of Hypotension-Associated Agents. Risk C: Monitor therapy

Antifungal Agents (Azole Derivatives, Systemic): May diminish the therapeutic effect of Amphotericin B. Risk C: Monitor therapy

Antipsychotic Agents (Second Generation [Atypical]): Blood Pressure Lowering Agents may enhance the hypotensive effect of Antipsychotic Agents (Second Generation [Atypical]). Risk C: Monitor therapy

Arsenic Trioxide: Amphotericin B may enhance the hypotensive effect of Arsenic Trioxide. Amphotericin B may enhance the QTc-prolonging effect of Arsenic Trioxide. Management: When possible, avoid concurrent use of arsenic trioxide with drugs that can cause electrolyte abnormalities, such as amphotericin B. Risk D: Consider therapy modification

Barbiturates: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Benperidol: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Blood Pressure Lowering Agents: May enhance the hypotensive effect of Hypotension-Associated Agents. Risk C: Monitor therapy

Brimonidine (Topical): May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Bromperidol: May diminish the hypotensive effect of Blood Pressure Lowering Agents. Blood Pressure Lowering Agents may enhance the hypotensive effect of Bromperidol. Risk X: Avoid combination

Cardiac Glycosides: Amphotericin B may enhance the adverse/toxic effect of Cardiac Glycosides. Risk C: Monitor therapy

Colistimethate: Amphotericin B may enhance the nephrotoxic effect of Colistimethate. Management: Avoid coadministration of colistimethate and amphotericin B whenever possible due to the potential for additive or synergistic nephrotoxicity. If coadministration cannot be avoided, closely monitor renal function. Risk D: Consider therapy modification

Corticosteroids (Systemic): May enhance the hypokalemic effect of Amphotericin B. Risk C: Monitor therapy

CycloSPORINE (Systemic): Amphotericin B may enhance the nephrotoxic effect of CycloSPORINE (Systemic). Amphotericin B may increase the serum concentration of CycloSPORINE (Systemic). Risk C: Monitor therapy

Diazoxide: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Dichlorphenamide: Amphotericin B may enhance the hypokalemic effect of Dichlorphenamide. Risk C: Monitor therapy

Dronabinol: May increase the serum concentration of Amphotericin B. Specifically, dronabinol may displace amphotericin B from its protein-binding sites, leading to an increased concentration of active, unbound drug. Risk C: Monitor therapy

DULoxetine: Blood Pressure Lowering Agents may enhance the hypotensive effect of DULoxetine. Risk C: Monitor therapy

Flucytosine: Amphotericin B may enhance the adverse/toxic effect of Flucytosine. Amphotericin B may increase the serum concentration of Flucytosine. Risk C: Monitor therapy

Foscarnet: May enhance the nephrotoxic effect of Amphotericin B. Risk X: Avoid combination

Ganciclovir-Valganciclovir: May enhance the nephrotoxic effect of Amphotericin B. Risk C: Monitor therapy

Herbal Products with Blood Pressure Lowering Effects: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Hypotension-Associated Agents: Blood Pressure Lowering Agents may enhance the hypotensive effect of Hypotension-Associated Agents. Risk C: Monitor therapy

Levodopa-Containing Products: Blood Pressure Lowering Agents may enhance the hypotensive effect of Levodopa-Containing Products. Risk C: Monitor therapy

Lormetazepam: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Methoxyflurane: May enhance the nephrotoxic effect of Amphotericin B. Risk X: Avoid combination

Molsidomine: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Naftopidil: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Nicergoline: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Nicorandil: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Nitroprusside: Blood Pressure Lowering Agents may enhance the hypotensive effect of Nitroprusside. Risk C: Monitor therapy

Obinutuzumab: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Management: Consider temporarily withholding blood pressure lowering medications beginning 12 hours prior to obinutuzumab infusion and continuing until 1 hour after the end of the infusion. Risk D: Consider therapy modification

Pentoxifylline: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Pholcodine: Blood Pressure Lowering Agents may enhance the hypotensive effect of Pholcodine. Risk C: Monitor therapy

Phosphodiesterase 5 Inhibitors: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Prostacyclin Analogues: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Quinagolide: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Risk C: Monitor therapy

Saccharomyces boulardii: Antifungal Agents (Systemic, Oral) may diminish the therapeutic effect of Saccharomyces boulardii. Risk X: Avoid combination

Pregnancy Considerations

Amphotericin crosses the placenta and enters the fetal circulation. Amphotericin B is recommended for the treatment of serious systemic fungal diseases in pregnant women. Refer to current guidelines (IDSA [Pappas 2016]; King 1998; Pilmis 2015).

Breastfeeding Considerations

It is not known if amphotericin is excreted into breast milk. Due to its poor oral absorption, systemic exposure to the nursing infant is expected to be decreased; however, because of the potential for toxicity, breast-feeding is not recommended by the manufacturer (Mactal-Haaf 2001).

Monitoring Parameters

BUN and serum creatinine levels should be determined every other day when therapy is increased and at least weekly thereafter. Renal function (monitor frequently during therapy), electrolytes (especially potassium and magnesium), LFTs, temperature, PT/PTT, CBC; fluid input and output; signs of hypokalemia (muscle weakness, cramping, drowsiness, ECG changes, etc); signs/symptoms of infusion-related reaction (fever, shaking chills, hypotension, anorexia, nausea, vomiting, headache, tachypnea).

Mechanism of Action

Binds to ergosterol altering cell membrane permeability in susceptible fungi and causing leakage of cell components with subsequent cell death. Proposed mechanism suggests that amphotericin causes an oxidation-dependent stimulation of macrophages (Lyman 1992).

Pharmacokinetics

Absorption: Poor oral absorption

Distribution: Minimal amounts enter the aqueous humor, bile, pericardial fluid, pleural fluid, and synovial fluid

CNS penetration:

Preterm neonates (GA: 27.4 ± 5 weeks): High interpatient variability; 40% to 90% of serum concentrations (Baley 1990)

Adults: Poor (inflamed or noninflamed meninges)

Vd: Pediatric patients (0 to 18 years): Highly variable; reported range: 0.38 to 3.99 L/kg (Benson 1989; Koren 1988)

Protein binding, plasma: 90%

Half-life elimination:

Premature neonates (GA: 27.4 ± 5 weeks): 14.8 hours (range: 5 to 82 hours) (Baley 1990)

Infants and Children (4 months to 14 years): 18.1 ± 6.6 hours (range: 11.9 to 40.3 hours) (Benson 1989)

Adults: Biphasic: Initial: 15 to 48 hours; Terminal: 15 days

Time to peak: Within 1 hour following a 4- to 6-hour dose

Excretion: Urine (2% to 5% as biologically active form); ~40% eliminated over a 7-day period and may be detected in urine for at least 7 weeks after discontinued use

Clearance (Benson, 1989):

Infants and Children (8 months to 9 years): 0.57 ± 0.152 mL/minute/kg

Children and Adolescents (10 to 14 years): 0.24 ± 0.02 mL/minute/kg

Pricing: US

Solution (reconstituted) (Amphotericin B Intravenous)

50 mg (per each): $54.63

Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as reference price only. A range is provided when more than one manufacturer's AWP price is available and uses the low and high price reported by the manufacturers to determine the range. The pricing data should be used for benchmarking purposes only, and as such should not be used alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all warranties of any kind or nature, whether express or implied, and assumes no liability with respect to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be liable for special, indirect, incidental, or consequential damages arising from use of price or price range data. Pricing data is updated monthly.

Brand Names: International
  • Amfucin (PH);
  • Ampho-Moronal (CH);
  • Amphocil (MX);
  • Ampholin (TH);
  • Ampholip (PH);
  • Amphotret (PH, ZW);
  • Anfotericina B (DO, GT, PA);
  • Fungilin (QA);
  • Fungilin Lozenges (AU, NZ);
  • Fungitericin (PH);
  • Fungizon (CN, HN);
  • Fungizona (ES);
  • Fungizone (CH, CO, DE, DK, FI, FR, GB, GR, HK, HU, IE, IN, IT, JO, KE, KR, NG, NL, PE, PL, PT, QA, SE, SI, TR, TW, TZ, UY, VE, VN, ZA);
  • Photericin B (EG);
  • Tericin (BD);
  • Terix (MX)


For country code abbreviations (show table)
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