Amphotericin B

Note: Conventional amphotericin formulations (desoxycholate [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. Note: Premedication: For patients who experience infusion-related immediate reactions, premedicate with the following drugs 30 to 60 minutes prior to drug administration: NSAID and/or diphenhydramine or acetaminophen with diphenhydramine or hydrocortisone. If the patient experiences rigors during the infusion, meperidine may be administered. Test dose: IV: 1 mg infused over 20 to 30 minutes. Many clinicians believe a test dose is unnecessary. Susceptible fungal infections: IV: Adults: 0.3 to 1.5 mg/kg/day; 1 to 1.5 mg/kg over 4 to 6 hours every other day may be given once therapy is established; aspergillosis, rhinocerebral mucormycosis, often require 1 to 1.5 mg/kg/day; do not exceed 1.5 mg/kg/day Aspergillosis, disseminated: IV: 0.6 to 0.7 mg/kg/day for 3 to 6 months. Note: IDSA recommends amphotericin B (conventional) be reserved for use in resource limited settings when no alternatives are available; voriconazole is preferred therapy for invasive Aspergillus infections (IDSA [Patterson 2016]). Aspergillosis (ocular) (off-label use): Ophthalmic: Intraocular: Inject 5 to 10 mcg in a 0.1 mL volume as a single dose intravitreally or intracamerally to the affected eye; may be repeated in 4 to 7 days as clinically indicated (Kaushik 2001; Patterson 2016). Guidelines recommend concomitant vitrectomy and use in combination with systemic voriconazole (Patterson 2016). Topical (0.1% to 0.2% solution): Apply to affected eye every 30 to 60 minutes until symptoms resolve (may take weeks) (Kaushik 2001; Ritterband 2002; Tamcelik 2002). Note: Ophthalmic natamycin is the preferred treatment (Patterson 2016) Blastomycosis: Moderately severe to severe pulmonary disease, disseminated extrapulmonary disease or immunosuppressed patients: IV: 0.7 to 1 mg/kg/day for 1 to 2 weeks or until improvement is noted, followed by oral itraconazole for 6 to 12 months (IDSA [Chapman 2008]) Candidiasis: CNS infection (when ventricular device cannot be removed) (off-label): Intraventricular: 0.01 to 0.5 mg/2 mL of an extemporaneously prepared solution in D5W administered through the device into the ventricle (IDSA [Pappas 2016]) Endophthalmitis due to Candida (off-label use): Patients with vitritis or with macular involvement (with or without vitritis): Intravitreal: 5 to 10 mcg/0.1 mL of an extemporaneously prepared solution in sterile water; administer with concomitant systemic antifungal therapy (IDSA [Pappas 2016]) Esophageal: Non-HIV-infected patients (alternative therapy) (off-label use): IV: 0.3 to 0.7 mg/kg/day. Consider step down to an oral antifungal once patient is able to tolerate oral intake.