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LiverTox: Clinical and Research Information on Drug-Induced Liver Injury [Internet]. Bethesda (MD): National Institute of Diabetes and Digestive and Kidney Diseases; 2012-.

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LiverTox: Clinical and Research Information on Drug-Induced Liver Injury [Internet].

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Last Update: July 5, 2017.



The echinocandins include anidulafungin, caspofungin, and micafungin and are a relatively new class of antifungal agents that are administered parenterally and are used in therapy or prevention of serious, invasive aspergillosis and candidal infections. All three agents can cause transient and asymptomatic serum aminotransferase elevations, and individual instances of acute liver injury have been observed during therapy with these agents, but none has been definitely shown to cause clinically apparent acute drug induced liver injury.


The echinocandins are a relatively new class of antifungal agents, whose activity is due to inhibition of glucan synthetase, the enzyme that is responsible for synthesis of β-1, 3-D-glucan, an essential component of the cell wall of filamentous fungi, such as Aspergillus and Candida species. This enzyme inhibition results in alteration in the fungal membrane integrity, followed by cell ballooning and, for Candida cells, lysis. Three echinocandins are available for use: caspofungin (kas" poe fun' jin), micafungin (mye" ka fun' jin) and anidulafungin (ay nid" ue la fun' jin). Caspofungin was approved for use in the United States in 2001, micafungin in 2005 and anidulafungin in 2006. All three are given intravenously and currently approved for therapy of esophageal candidiasis and for severe, disseminated or invasive candidiasis. Caspofungin is also approved for use as a secondary therapy of invasive aspergillosis and as empirical therapy for presumed fungal infection in febrile, neutropenic patients. Micafungin is also approved for prophylaxis against candidiasis in hematopoietic stem cell transplant recipients. Caspofungin is available under the brand name Cancidas in a formulation for intravenous use, the recommended dose in adults being 70 mg on the first day of treatment followed by 50 or 100 mg daily. Micafungin is available under the brand name of Mycamine in an intravenous formation, the recommended dosage being 50 mg daily for prophylaxis and 100 to 150 mg daily for therapy of candidemia. Anidulafungin is available under the brand name of Eraxis in intravenous formulations and the recommended dosage for disseminated candidal infection is 200 mg on day 1 followed by 100 mg daily. The echinocandins are administered intravenously in a slow infusion over one hour (to decrease the risk of acute infusion reactions). Common side effects include phlebitis and the histamine-like reaction marked by rash, urticaria, flushing, bronchospam, hypotension and facial swelling.


Transient elevations in liver enzymes have occurred in 2% to 15% of patients treated with the echinocandins, typically returning to baseline after withdrawal of therapy. Clinically apparent hepatotoxicity has occurred in isolated cases; however, a causal relationship to the antifungal agent is often difficult to prove, as these agents are typically used in persons who are critically ill and have other conditions that are associated with liver injury. The largest experience has been with caspofungin, which may have a higher rate of serum enzyme elevations than with micafungin or anidulafungin and has more frequently been linked to cases of acute, symptomatic liver injury. Nevertheless, the product label for all three echinocandins mentions adverse events of serum enzyme elevations, hepatitis and acute liver failure.

Likelihood score: D (possible cause of clinically apparent liver injury).

Mechanism of Injury

The cause of serum aminotransferase elevations during echinocandin therapy is unknown. In preclinical studies in animals, highest drug concentrations are found in the liver and a direct toxic effect or production of a toxic intermediate may be the cause of the abnormalities.

Outcome and Management

The liver injury seen with caspofungin, micafungin and anidulafungin rarely progresses beyond mild serum enzyme elevations. Caution should be taken in patients with preexisting hepatic insufficiency in whom the likelihood of severe acute liver injury appears to be greatest. Product labels for the echinocandins recommend monitoring of liver tests during therapy, particularly in patients with underlying liver disease. The effects of rechallenge and cross reactivity to hepatic injury among the echinocandins has not been evaluated.

Drug Class: Antifungal Agents



Anidulafungin – Eraxis®

Caspofungin – Cancidas®

Micafungin – Mycamine®


Antifungal Agents


Product labeling at DailyMed, National Library of Medicine, NIH


Anidulafungin chemical structure
Caspofungin chemical structure
Micafungin chemical structure


References updated: 05 July 2017

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