1159 - Echinocandins Dosing in Obese Patients: A Systematic Review

Background: Echinocandins are a milestone in antifungal chemotherapy given their fungicidal properties with improved toxicity profiles compared to other antifungal agents. Echinocandins are used in the empiric treatment of invasive candidiasis and aspergillosis in critically ill, neutropenic, and transplant patients. There is emerging evidence that obese patients treated with echinocandins antifungal agents have lower plasma serum concentration and faster clearance. The objective of this review was to systematically evaluate the available evidence for echinocandins dosing in obese patients.  

Methods: A systematic review of PubMed, Embase, Cochrane library from inception until June 8, 2020 was conducted by 2 authors. Studies with data for micafungin, anidulafungin, or caspofungin in obese patients’ exposure [body mass index (BMI) 30 or greater] were included. Studies for patients on renal replacement therapies, extracorporeal membrane oxygenation support, and language other than English were excluded.

Results: Twenty-five studies met the inclusion criteria; micafungin (n=10), caspofungin (n=8), and anidulafungin (n=7). In micafungin, the correlation between obesity and increasing systemic clearance and reduced exposure was reported. Some studies reported even lower systemic exposure with morbid obesity, BMI greater than 40. The evidence was also consistent with anidulafungin, two studies revealed that body weight had inverse correlation with anidulafungin exposure. Anidulafungin exposure was about 30% lower in obese patients. Furthermore, caspofungin exposure was also reduced in obese patient as demonstrated in several studies.

Conclusion: Adequate antifungal exposure is a key in success treatment, and there are several factors that can influence exposure of echinocandin antifungal agents. There is consistent evidence revealing lower echinocandins exposure in obese patient. Research is needed to determine outcomes of fungal infections of obese patients, and perhaps the need for dose adjustment in obese patient population.