Spectrum: Local Antimicrobial Stewardship, for Billings Clinic

Amphotericin - Lipid Formulations

Restricted
Restricted

C. diff Risk

Low

Oral Bioavailability

NA

Approximate Cost

very expensive - Ambisome ~$450/100 mg

Spectrum Of Activity

General Spectrum of Activity

Spectrum Of Activity

Dosing

Renal

Adult

Ambisome
3-6mg/kg IV daily infused over several hours

Abelcet (nonformulary)
5mg/kg IV daily infused over several hours

Discuss dosing as well as premedication with ID pharmacist

General Information

Common Usage

Common Usage

Fungicidal therapy of yeast/fungus/mold infection.

Invasive candidiasis, aspergillosis, cryptococcosis.

Visceral/mucocutaneous Leishmaniasis.

Induction therapy for dimorphic fungii (cocci, blasto, histo).

Drug Monitoring

Drug Monitoring

  • Renal function

  • K

  • Mg

  • HCO3

  • Liver enzymes

  • CBC

Frequency depends on course, but daily reasonable during initiation

First Line Indications

First Line Indications

  • Cryptococcal meningitis

  • Life threatening empiric fungal infections

Adverse Effects

Adverse Effects

Toxicities as conventional Amphotericin B but with less frequency.

  •  Nephrotoxicity

  •  Anemia

  •  Phlebitis

  •  Arachnoiditis

  •  Urinary retention

  •  Paresthesias

Electrolyte abnormalities

  •  HypoK and HypoMg

  •  Loss of bicarb

  •  See additional information

Infusion related symptoms

Ambisome - infusion reaction known as "classic triad"

  •  chest pain, dyspnea, hypoxia

  •  sever abdomen, flank, leg pain

  •  flushing and urticaria

Abelcet - similar infusion reactions as ampho deoxycholate but to a lesser degree

  •  Fever

  •  Rigors

  •  N/V

  •  Headache

Major Interactions

Major Interactions

Main concern is concomitant nephrotoxins. Use should be minimized during amphotericin therapy.

Increased digoxin toxicity with hypokalemia.

Additional Information

Additional Information

Liposomal amphotericin is BC formulary agent. May consider premedication with diphenhydramine. Less common infusion reactions with Ambisome than other market agents. Infusion reaction with Ambisome - classic triad:
1. chest pain, dyspnea, hypoxia
2. severe pain in abdomen, back, flank or leg
3. flushing and urticaria
This infusion reaction is due to release of histamine. Stop infusion, give diphenhydramine. In studies, rechallenging after diphenhydramine prevented this reaction from reoccuring.

Lipid associated AmB is taken up preferentially by phagocytic cells and concentrated at sites of infection while minimizing renal exposure.

Pay careful attention to electrolyte and fluid status with boluses (usually 500mL) before and after infusion, as well as K and Mg supplementation PRN.

Pharmacology

Pharmacology

Antimicrobial class: Antifungal. Polyene. Lipid formulations designed to minimize toxicity.

Average serum half life: 150 hours

Biliary penetration: Therapeutic

Lung penetration: Therapeutic