Echinocandins: antifungal medicines for serious Candida infections
Clinical review pending
Caspofungin, micafungin, anidulafungin and rezafungin target the fungal cell wall. How this class works, when it is used and its risks.
What are echinocandins?
Echinocandins are semisynthetic cyclic lipopeptides used to treat fungal infections. They include caspofungin (Cancidas), micafungin (Mycamine) and anidulafungin (Eraxis). They are used mainly for serious Candida infections, combining potent activity with relatively good tolerability. Caspofungin was the first member of the class approved in the United States, in 2001; micafungin followed in 2005 and anidulafungin in 2006. The newer medicine rezafungin (Rezzayo) received US approval in 2023 and is given once a week.
How do echinocandins work?
Echinocandins inhibit 1,3-beta-D-glucan synthase in the fungal cell wall. This enzyme makes 1,3-beta-D-glucan, a sugar polymer that gives the wall its strength. Blocking its production weakens the cell wall until it can no longer withstand pressure from inside the cell. Echinocandins kill most Candida species and inhibit the growth of Aspergillus.
Human cells have neither a cell wall nor an equivalent enzyme. This helps explain the relatively low direct toxicity of this drug class. Caspofungin, micafungin and anidulafungin are given intravenously every day; rezafungin is given weekly. In the pivotal trial, caspofungin was at least as effective as amphotericin B for invasive candidiasis 1 and caused fewer adverse effects. In a separate trial, anidulafungin performed better than fluconazole on the primary endpoint.
Are echinocandins FDA-approved?
Yes. The source article reports FDA approvals for caspofungin, micafungin, anidulafungin and rezafungin. The table summarizes the approval years and their respective indications.
According to the source article, none of these medicines carries a prominent US warning in the “Boxed Warning” category.
What are echinocandins prescribed for?
Echinocandins are used for invasive Candida infections, including candidemia—Candida in the bloodstream—and Candida infections of the esophagus. Caspofungin is also used for suspected fungal infections in people with fever and neutropenia, and for certain Aspergillus infections. Micafungin is also used to prevent Candida infections in the setting of stem cell transplantation.
What side effects are possible?
More common side effects include:
- Fever
- Infusion reactions such as flushing, rash or itching
- Nausea and headaches
- Low potassium levels and elevated liver enzymes Source
Other important risks and precautions include:
- Changes in liver tests and, rarely, more substantial liver dysfunction
- Rare severe allergic reactions
- The need to adjust caspofungin doses in people with impaired liver function, as well as certain drug interactions
Studies at a glance
| Medicine | FDA approval | Approved indications |
|---|---|---|
| Caspofungin | 2001 | Candidemia, invasive candidiasis and esophageal candidiasis; also empirical treatment in febrile neutropenia, and invasive aspergillosis when other treatments fail or cannot be tolerated |
| Micafungin | 2005 | Candidemia, invasive candidiasis and esophageal candidiasis; also Candida prophylaxis in stem cell transplantation |
| Anidulafungin | 2006 | Candidemia, invasive candidiasis and esophageal candidiasis |
| Rezafungin | 2023 | Candidemia and invasive candidiasis in adults with limited or no alternative treatment options |
References provided in the source article
Sources: FDA prescribing information for Cancidas, Mycamine, Eraxis, and Rezzayo; the caspofungin trial (Mora-Duarte et al., The New England Journal of Medicine, 2002, DOI: 10.1056/NEJMoa021585 1 ) and the anidulafungin trial (Reboli et al., The New England Journal of Medicine, 2007, DOI: 10.1056/NEJMoa066906 2 ), both indexed on PubMed.
Provenance and editorial review status
Adapted for Nutrient Desk from the source article. The claims and source attributions in the original text still require clinical review. This draft has not been cleared for indexing.