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CLINICAL PHARMACOLOGY Mechanism of Action Micafungin is a member of the echinocandin class of antifungal agents. Pharmacokinetics Adults The pharmacokinetics of micafungin were determined in healthy subjects, hematopoietic stem cell transplant recipients, and patients with esophageal candidiasis up to a maximum daily dose of 8 mg/kg body weight. The relationship of area under the concentration-time curve (AUC) to micafungin dose was linear over the daily dose range of 50 mg to 150 mg and 3 mg/kg to 8 mg/kg body weight. Steady-state pharmacokinetic parameters in relevant patient populations after repeated daily administration are presented in Table 7. Table 7: Pharmacokinetic Parameters of Micafungin in Adult Patients Population n Dose (mg) Pharmacokinetic Parameters (Mean ± Standard Deviation) Cmax (mcg/mL) AUC0-24* (mcg•h/mL) t½ (h) Cl (mL/min/kg) Patients with IC† [Day 1] 20 100 5.7 ± 2.2 83 ± 51 14.5 ± 7.0 0.359 ± 0.179 [Steady State] 20 100 10.1 ± 4.4 97 ± 29 13.4 ± 2.0 0.298 ± 0.115 HIV‡-Positive Patients with EC§ [Day 1] 20 50 4.1 ± 1.4 36 ± 9 14.9 ± 4.3 0.321 ± 0.098 20 100 8.0 ± 2.4 108 ± 31 13.8 ± 3.0 0.327 ± 0.093 14 150 11.6 ± 3.1 151 ± 45 14.1 ± 2.6 0.340 ± 0.092 [Day 14 or 21] 20 50 5.1 ± 1.0 54 ± 13 15.6 ± 2.8 0.300 ± 0.063 20 100 10.1 ± 2.6 115 ± 25 16.9 ± 4.4 0.301 ± 0.086 14 150 16.4 ± 6.5 167 ± 40 15.2 ± 2.2 0.297 ± 0.081 per kg HSCT¶ Recipients [Day 7] 8 3 21.1 ± 2.84 234 ± 34 14.0 ± 1.4 0.214 ± 0.031 10 4 29.2 ± 6.2 339 ± 72 14.2 ± 3.2 0.204 ± 0.036 8 6 38.4 ± 6.9 479 ± 157 14.9 ± 2.6 0.224 ± 0.064 8 8 60.8 ± 26.9 663 ± 212 17.2 ± 2.3 0.223 ± 0.081 * AUC0-infinity is presented for day 1; AUC0-24 is presented for steady state. † candidemia or other Candida Infections ‡ human immunodeficiency virus §esophageal candidiasis ¶hematopoietic stem cell transplant Pediatric Patients 4 months of age and older Micafungin pharmacokinetics in 229 pediatric patients 4 months through 16 years of age were characterized using population pharmacokinetics. Micafungin exposure was dose proportional across the dose and age range studied. Table 8: Summary (Mean +/- Standard Deviation) of Micafungin Pharmacokinetics in Pediatric Patients 4 Months of Age and older (Steady-State) Body weight group N Dose§ mg/kg Cmax.ss† (mcg/mL) AUC.ss† (mcg·h /mL) t½‡ (h) CL‡ (mL/min/kg) 30 kg or less 149 1.0 7.1 +/- 4.7 55 +/- 16 12.5 +/- 4.6 0.328 +/- 0.091 2.0 14.2 +/- 9.3 109 +/- 31 3.0 21.3 +/- 14.0 164 +/- 47 Greater than 30 kg 80 1.0 8.7 +/- 5.6 67 +/- 17 13.6 +/- 8.8 0.241 +/- 0.061 2.0 17.5 +/- 11.2 134 +/- 33 2.5 23.0 +/- 14.5 176 +/- 42 §Or the equivalent if receiving the adult dose (50, 100, or 150 mg) † Derived from simulations from the population PK model. ‡ Derived from the population PK model Special Populations Adult Patients with Renal Impairment Mycamine does not require dose adjustment in patients with renal impairment. A single 1-hour infusion of 100 mg Mycamine was administered to 9 adult subjects with severe renal impairment (creatinine clearance less than 30 mL/min) and to 9 age-, gender-, and weight-matched subjects with normal renal function (creatinine clearance greater than 80 mL/min). The maximum concentration (Cmax) and AUC were not significantly altered by severe renal impairment. Since micafungin is highly protein bound, it is not dialyzable. Supplementary dosing should not be required following hemodialysis. Adult Patients with Hepatic Impairment A single 1-hour infusion of 100 mg Mycamine was administered to 8 adult subjects with moderate hepatic impairment (Child-Pugh score 7-9) and 8 age-, gender-, and weight-matched subjects with normal hepatic function. The Cmax and AUC values of micafungin were lower by approximately 22% in subjects with moderate hepatic impairment compared to normal subjects. This difference in micafungin exposure does not require dose adjustment of Mycamine in patients with moderate hepatic impairment. A single 1-hour infusion of 100 mg Mycamine was administered to 8 adult subjects with severe hepatic impairment (Child-Pugh score 10-12) and 8 age-, gender-, ethnic- and weight-matched subjects with normal hepatic function. The mean Cmax and AUC values of micafungin were lower by approximately 30% in subjects with severe hepatic impairment compared to normal subjects. The mean Cmax and AUC values of M-5 metabolite were approximately 2.3-fold higher in subjects with severe hepatic impairment compared to normal subjects; however, this exposure (parent and metabolite) was comparable to that in patients with systemic Candida infection. Therefore, no Mycamine dose adjustment is necessary in patients with severe hepatic impairment. Distribution The mean ± standard deviation volume of distribution of micafungin at terminal phase was 0.39 ± 0.11 L/kg body weight when determined in adult patients with esophageal candidiasis at the dose range of 50 mg to 150 mg. Micafungin is highly (greater than 99%) protein bound in vitro, independent of plasma concentrations over the range of 10 to 100 mcg/mL. The primary binding protein is albumin; however, micafungin, at therapeutically relevant concentrations, does not competitively displace bilirubin binding to albumin. Micafungin also binds to a lesser extent to α1-acid-glycoprotein. Metabolism Micafungin is metabolized to M-1 (catechol form) by arylsulfatase, with further metabolism to M-2 (methoxy form) by catechol-O-methyltransferase. M-5 is formed by hydroxylation at the side chain (ω-1 position) of micafungin catalyzed by cytochrome P450 (CYP) isozymes. Even though micafungin is a substrate for and a weak inhibitor of CYP3A in vitro, hydroxylation by CYP3A is not a major pathway for micafungin metabolism in vivo. Micafungin is neither a P-glycoprotein substrate nor inhibitor in vitro. In four healthy volunteer studies, the ratio of metabolite to parent exposure (AUC) at a dose of 150 mg/day was 6% for M-1, 1% for M-2, and 6% for M-5. In patients with esophageal candidiasis, the ratio of metabolite to parent exposure (AUC) at a dose of 150 mg/day was 11% for M-1, 2% for M-2, and 12% for M-5. Excretion The excretion of radioactivity following a single intravenous dose of 14C-micafungin sodium for injection (25 mg) was evaluated in healthy volunteers. At 28 days after administration, mean urinary and fecal recovery of total radioactivity accounted for 82.5% (76.4% to 87.9%) of the administered dose. Fecal excretion is the major route of elimination (total radioactivity at 28 days was 71% of the administered dose). Microbiology Mechanism of Action Micafungin inhibits the synthesis of 1, 3-beta-D-glucan, an essential component of fungal cell walls, which is not present in mammalian cells. Drug Resistance There have been reports of clinical failures in patients receiving Mycamine therapy due to the development of drug resistance. Some of these reports have identified specific mutations in the FKS protein component of the glucan synthase enzyme that are associated with higher MICs and breakthrough infection. Activity In Vitro and In Clinical Infections Micafungin has been shown to be active against most isolates of the following Candida species, both in vitro and in clinical infections: Candida albicans Candida glabrata Candida guilliermondii Candida krusei Candida parapsilosis Candida tropicalis Susceptibility Testing Methods The interpretive standards for micafungin against Candida species are applicable only to tests performed using Clinical Laboratory and Standards Institute (CLSI) microbroth dilution reference method M27-A3 for minimum inhibitory concentration (MIC; based on partial inhibition endpoint) and CLSI disk diffusion reference method M44-A2; both MIC and zone diameter results are read at 24 hours. When available, the clinical microbiology laboratory should provide the results of in vitro susceptibility test results for antimicrobial drug products used in resident hospitals to the physician as periodic reports that describe the susceptibility profile of pathogens. These reports should aid the physician in selecting an antifungal drug product for treatment. The techniques for Broth Microdilution and Disk Diffusion are described below. Broth Microdilution Technique Quantitative methods are used to determine antifungal MICs. These MICs provide estimates of the susceptibility of Candida species to antifungal agents. MICs should be determined using a standardized CLSI procedure1,2. Standardized procedures are based on a microdilution method (broth) with standardized inoculum concentrations and standardized concentrations of micafungin powder. The MIC values should be interpreted according to the criteria provided in Table 9. Disk Diffusion Technique Qualitative methods that require measurement of zone diameters also provide reproducible estimates of the susceptibility of Candida species to antifungal agents. The CLSI procedure3 uses standardized inoculum concentrations and paper disks impregnated with 10 mcg of micafungin to test the susceptibility of Candida species to micafungin at 24 hours. Disk diffusion interpretive criteria are provided in Table 9. Table 9: Susceptibility Interpretive Criteria for Micafungin Pathogen Broth Microdilution MIC (mcg/mL) at 24 hours Disk Diffusion at 24 hours (Zone diameters in mm) Susceptible (S) Intermediate (I) Resistant (R) Susceptible (S) Intermediate (I) Resistant (R) Candida albicans ≤ 0.25 0.5 ≥ 1 ≥ 22 20-21 ≤ 19 Candida tropicalis ≤ 0.25 0.5 ≥ 1 ≥ 22 20-21 ≤ 19 Candida krusei ≤ 0.25 0.5 ≥ 1 ≥ 22 20-21 ≤ 19 Candida parapsilosis ≤ 2 4 ≥ 8 ≥ 16 14-15 ≤ 13 Candida guilliermondii ≤ 2 4 ≥ 8 ≥ 16 14-15 ≤ 13 Candida glabrata ≤ 0.06 0.12 ≥ 0.25 Not Applicable† Not Applicable† Not Applicable† MIC: minimum inhibitory concentration † Disk diffusion zone diameters have not been established for this strain/antifungal agent combination. A report of “Susceptible” indicates that the isolate is likely to be inhibited if the antimicrobial compound in the blood reaches the concentrations usually achievable. The “Intermediate” category implies that an infection due to the isolate may be appropriately treated in body sites where the drug is physiologically concentrated or when a high dosage of drug is used. The “Resistant” category implies that the isolates are not inhibited by the concentrations of the drug usually achievable with normal dosage schedules and clinical efficacy of the drug against the pathogen has not been reliably shown in treatment studies. Quality Control Standardized susceptibility test procedures require the use of quality control organisms to monitor and ensure the accuracy and precision of supplies and reagents used in the assay, and the technique of the individual performing the test1,2,3. Standard micafungin powder and 10 mcg disks should provide the following range of values noted in Table 10. Table 10: Acceptable Quality Control Ranges for Micafungin to be Used in Validation of Susceptibility Test Results QC strains Broth microdilution (MIC in mcg/mL) at 24- hour Disk Diffusion (Zone diameter in mm) at 24-hour Candida parapsilosis ATCC† 22019 0.5 – 2.0 14 – 23 Candida krusei ATCC 6258 0.12 – 0.5 23 – 29 Candida tropicalis ATCC 750 Not Applicable‡ 24 – 30 Candida albicans ATCC 90028 Not Applicable‡ 24 – 31 MIC: minimum inhibitory concentration † ATCC is a registered trademark of the American Type Culture Collection. ‡ Quality control ranges have not been established for this strain/antifungal agent combination. Animal Toxicology and/or Pharmacology High doses of micafungin sodium (5 to 8 times the highest recommended human dose, based on AUC comparisons) have been associated with irreversible changes to the liver when administered for 3 or 6 months, and these changes may be indicative of pre-malignant processes [see Nonclinical Toxicology]. Reproductive Toxicology Studies Micafungin sodium administration to pregnant rabbits (intravenous dosing on days 6 to 18 of gestation) resulted in visceral abnormalities and abortion at 32 mg/kg, a dose equivalent to about four times the recommended dose based on body surface area comparisons. Visceral abnormalities included abnormal lobation of the lung, levocardia, retrocaval ureter, anomalous right subclavian artery, and dilatation of the ureter. Clinical Studies Adult Treatment of Candidemia and Other Candida Infections Two dose levels of Mycamine were evaluated in a randomized, double-blind study to determine the efficacy and safety versus caspofungin in patients with invasive candidiasis and candidemia. Patients were randomized to receive once daily intravenous infusions (IV) of Mycamine, either 100 mg/day or 150 mg/day or caspofungin (70 mg loading dose followed by 50 mg maintenance dose). Patients in both study arms were permitted to switch to oral fluconazole after at least 10 days of intravenous therapy, provided they were non-neutropenic, had improvement or resolution of clinical signs and symptoms, had a Candida isolate which was susceptible to fluconazole, and had documentation of 2 negative cultures drawn at least 24 hours apart. Patients were stratified by APACHE II score (20 or less or greater than 20) and by geographic region. Patients with Candida endocarditis were excluded from this analysis. Outcome was assessed by overall treatment success based on clinical (complete resolution or improvement in attributable signs and symptoms and radiographic abnormalities of the Candida infection and no additional antifungal therapy) and mycological (eradication or presumed eradication) response at the end of IV therapy. Deaths that occurred during IV study drug therapy were treated as failures. In this study, 111/578 (19.2%) of the patients had baseline APACHE II scores of greater than 20, and 50/578 (8.7%) were neutropenic at baseline (absolute neutrophil count less than 500 cells/mm³). Outcome, relapse and mortality data are shown for the recommended dose of Mycamine (100 mg/day) and caspofungin in Table 11. Table 11: Efficacy Analysis: Treatment Success in Patients in Study 03-0-192 with Candidemia and other Candida Infections Mycamine 100 mg/day n (%) % treatment difference (95%CI) Caspofungin 70/50 mg/day* n (%) Treatment Success at End of IV Therapy† 135/191 (70.7) 7.4 (-2.0, 16.3) 119/188 (63.3) Success in Patients with Neutropenia at Baseline 14/22 (63.6) 5/11 (45.5) Success by Site of Infection Candidemia 116/163 (71.2) 103/161 (64) Abscess 4/5 (80) 5/9 (55.6) Acute Disseminated‡ 6/13 (46.2) 5/9 (55.6) Endophthalmitis 1/3 1/1 Chorioretinitis 0/3 0 Skin 1/1 0 Kidney 2/2 1/1 Pancreas 1/1 0 Peritoneum 1/1 0 Lung/Skin 0/1 0 Lung/Spleen 0/1 0 Liver 0 0/2 Intraabdominal abscess 0 3/5 Chronic Disseminated 0/1 0 Peritonitis 4/6 (66.7) 2/5 (40) Success by Organism§ C. albicans 57/81 (70.4) 45/73 (61.6) C. glabrata 16/23 (69.6) 19/31 (61.3) C. tropicalis 17/27 (63) 22/29 (75.9) C. parapsilosis 21/28 (75) 22/39 (56.4) C. krusei 5/8 (62.5) 2/3 (66.7) C. guilliermondii 1/2 0/1 C. lusitaniae 2/3 (66.7) 2/2 Relapse through 6 Weeks¶ Overall 49/135 (36.3) 44/119 (37) Culture confirmed relapse 5 4 Required systemic antifungal therapy 11 5 Died during follow-up 17 16 Not assessed 16 19 Overall study mortality 58/200 (29) 51/193 (26.4) Mortality during IV therapy 28/200 (14) 27/193 (14) * 70 mg loading dose on day 1 followed by 50 mg/day thereafter (caspofungin) † All patients who received at least one dose of study medication and had documented invasive candidiasis or candidemia. Patients with Candida endocarditis were excluded from the analyses. ‡ A patient may have had greater than 1 organ of dissemination §A patient may have had greater than 1 baseline infection species ¶All patients who had a culture confirmed relapse or required systemic antifungal therapy in the post treatment period for a suspected or proven Candida infection. Also includes patients who died or were not assessed in follow-up. In two cases of ophthalmic involvement assessed as failures in the above table due to missing evaluation at the end of IV treatment with Mycamine, therapeutic success was documented during protocol-defined oral fluconazole therapy. Adult Treatment of Esophageal Candidiasis In two controlled trials involving 763 patients with esophageal candidiasis, 445 adults with endoscopically-proven candidiasis received Mycamine, and 318 received fluconazole for a median duration of 14 days (range 1-33 days). Mycamine was evaluated in a randomized, double-blind study which compared Mycamine 150 mg/day (n = 260) to intravenous fluconazole 200 mg/day (n = 258) in adults with endoscopically-proven esophageal candidiasis. Most patients in this study had HIV infection, with CD4 cell counts less than 100 cells/mm³ . Outcome was assessed by endoscopy and by clinical response at the end of treatment. Endoscopic cure was defined as endoscopic grade 0, based on a scale of 0-3. Clinical cure was defined as complete resolution in clinical symptoms of esophageal candidiasis (dysphagia, odynophagia, and retrosternal pain). Overall therapeutic cure was defined as both clinical and endoscopic cure. Mycological eradication was determined by culture, and by histological or cytological evaluation of esophageal biopsy or brushings obtained endoscopically at the end of treatment. As shown in Table 12, endoscopic cure, clinical cure, overall therapeutic cure, and mycological eradication were comparable for patients in the Mycamine and fluconazole treatment groups. Table 12: Endoscopic, Clinical, and Mycological Outcomes for Esophageal Candidiasis at End-of-Treatment Treatment Outcome* Mycamine 150 mg/day n = 260 Fluconazole 200 mg/day n = 258 % Difference† (95% CI) Endoscopic Cure 228 (87.7%) 227 (88.0%) -0.3% (-5.9, +5.3) Clinical Cure 239 (91.9%) 237 (91.9%) 0.06% (-4.6, +4.8) Overall Therapeutic Cure 223 (85.8%) 220 (85.3%) 0.5% (-5.6, +6.6) Mycological Eradication 141/189 (74.6%) 149/192 (77.6%) -3.0% (-11.6, +5.6) * Endoscopic and clinical outcome were measured in modified intent-to-treat population, including all randomized patients who received 1 or more doses of study treatment. Mycological outcome was determined in the per protocol (evaluable) population, including patients with confirmed esophageal candidiasis who received at least 10 doses of study drug, and had no major protocol violations. † Calculated as Mycamine – fluconazole Most patients (96%) in this study had Candida albicans isolated at baseline. The efficacy of Mycamine was evaluated in less than 10 patients with Candida species other than C. albicans, most of which were isolated concurrently with C. albicans. Relapse was assessed at 2 and 4 weeks post-treatment in patients with overall therapeutic cure at end of treatment. Relapse was defined as a recurrence of clinical symptoms or endoscopic lesions (endoscopic grade greater than 0). There was no statistically significant difference in relapse rates at either 2 weeks or through 4 weeks post-treatment for patients in the Mycamine and fluconazole treatment groups, as shown in Table 13. Table 13: Relapse of Esophageal Candidiasis at Week 2 and through Week 4 Post-Treatment in Patients with Overall Therapeutic Cure at the End of Treatment Relapse Mycamine 150 mg/day n = 223 Fluconazole 200 mg/day n = 220 % Difference* (95% CI) Relapse† at Week 2 40 (17.9%) 30 (13.6%) 4.3% (-2.5, 11.1) Relapse† Through Week 4 (cumulative) 73 (32.7%) 62 (28.2%) 4.6% (-4.0, 13.1) * Calculated as Mycamine – fluconazole; N = number of patients with overall therapeutic cure (both clinical and endoscopic cure at end-of-treatment); † Relapse included patients who died or were lost to follow-up, and those who received systemic anti-fungal therapy in the post-treatment period In this study, 459 of 518 (88.6%) patients had oropharyngeal candidiasis in addition to esophageal candidiasis at baseline. At the end of treatment 192/230 (83.5%) Mycamine treated patients and 188/229 (82.1%) of fluconazole treated patients experienced resolution of signs and symptoms of oropharyngeal candidiasis. Of these, 32.3% in the Mycamine group, and 18.1% in the fluconazole group (treatment difference = 14.2%; 95% confidence interval [5.6, 22.8]) had symptomatic relapse at 2 weeks post-treatment. Relapse included patients who died or were lost to follow-up, and those who received systemic antifungal therapy during the post-treatment period. Cumulative relapse at 4 weeks post-treatment was 52.1% in the Mycamine group and 39.4% in the fluconazole group (treatment difference 12.7%, 95% confidence interval [2.8, 22.7]). Prophylaxis of Candida Infections in Hematopoietic Stem Cell Transplant Recipients In a randomized, double-blind study, Mycamine (50 mg IV once daily) was compared to fluconazole (400 mg IV once daily) in 882 [adult (791) and pediatric (91)] patients undergoing an autologous or syngeneic (46%) or allogeneic (54%) stem cell transplant. All pediatric patients, except 2 per group, received allogeneic transplants. The status of the patients' underlying malignancy at the time of randomization was: 365 (41%) patients with active disease, 326 (37%) patients in remission, and 195 (22%) patients in relapse. The more common baseline underlying diseases in the 476 allogeneic transplant recipients were: chronic myelogenous leukemia (22%), acute myelogenous leukemia (21%), acute lymphocytic leukemia (13%), and non-Hodgkin's lymphoma (13%). In the 404 autologous and syngeneic transplant recipients the more common baseline underlying diseases were: multiple myeloma (37.1%), non-Hodgkin's lymphoma (36.4%), and Hodgkin's disease (15.6%). During the study, 198 of 882 (22.4%) transplant recipients had proven graft-versus-host disease; and 475 of 882 (53.9%) recipients received immunosuppressive medications for treatment or prophylaxis of graft-versus-host disease. Study drug was continued until the patient had neutrophil recovery to an absolute neutrophil count (ANC) of 500 cells/mm³ or greater or up to a maximum of 42 days after transplant. The average duration of drug administration was 18 days (range 1 to 51 days). Duration of therapy was slightly longer in the pediatric patients who received Mycamine (median duration 22 days) compared to the adult patients who received Mycamine (median duration 18 days). Successful prophylaxis was defined as the absence of a proven, probable, or suspected systemic fungal infection through the end of therapy (usually 18 days), and the absence of a proven or probable systemic fungal infection through the end of the 4-week post-therapy period. A suspected systemic fungal infection was diagnosed in patients with neutropenia (ANC less than 500 cells/mm³); persistent or recurrent fever (while ANC less than 500 cells/mm³) of no known etiology; and failure to respond to at least 96 hours of broad spectrum antibacterial therapy. A persistent fever was defined as four consecutive days of fever greater than 38°C. A recurrent fever was defined as having at least one day with temperatures 38.5°C or higher after having at least one prior temperature higher than 38°C; or having two days of temperatures higher than 38°C after having at least one prior temperature higher than 38°C. Transplant recipients who died or were lost to follow-up during the study were considered failures of prophylactic therapy. Successful prophylaxis was documented in 80.7% of adult and pediatric Mycamine recipients, and in 73.7% of adult and pediatric patients who received fluconazole (7.0% difference [95% CI = 1.5, 12.5]), as shown in Table 14, along with other study endpoints. The use of systemic antifungal therapy post-treatment was 42% in both groups. The number of proven breakthrough Candida infections was 4 in the Mycamine and 2 in the fluconazole group. The efficacy of Mycamine against infections caused by fungi other than Candida has not been established. Table 14:  Results from Clinical Study of Prophylaxis of Candida Infections in Hematopoietic Stem Cell Transplant Recipients Outcome of Prophylaxis Mycamine 50 mg/day (n = 425) Fluconazole 400 mg/day (n = 457) Success* 343 (80.7%) 337 (73.7%) Failure: 82 (19.3%) 120 (26.3%) All Deaths† 18 (4.2%) 26 (5.7%) Proven/probable fungal infection prior to death 1 (0.2%) 3 (0.7%) Proven/probable fungal infection (not resulting in death) † 6 (1.4%) 8 (1.8%) Suspected fungal infection ‡ 53 (12.5%) 83 (18.2%) Lost to follow-up 5 (1.2%) 3 (0.7%) * Difference (Mycamine – fluconazole): +7.0% [95% CI=1.5, 12.5] † Through end-of-study (4 weeks post-therapy) ‡ Through end-of-therapy REFERENCES 1. Clinical and Laboratory Standards Institute (CLSI). Reference Method for Broth Dilution Antifungal Susceptibility Testing of Yeasts – Approved Standard – Third Edition. CLSI document M27-A3. 2. Clinical and Laboratory Standards Institute, 950 West Valley Rd, Suite 2500, Wayne, PA 19087, USA, 2008. Clinical and Laboratory Standards Institute (CLSI). Reference Method for Broth Dilution Antifungal Susceptibility Testing of Yeasts; Fourth Informational Supplement. CLSI document M27-S4. 3. Clinical and Laboratory Standards Institute, 950 West Valley Rd, Suite 2500, Wayne, PA 19087, USA, 2012. Clinical and Laboratory Standards Institute (CLSI). Method for Antifungal Disk Diffusion Susceptibility Testing of Yeasts; Approved Guideline - Second Edition. CLSI document M44-A2. Clinical and Laboratory Standards Institute, 950 West Valley Road, Suite 2500, Wayne, PA 19087, USA, 2009.

Find Lowest Prices on MYCAMINE (micafungin sodium) for Intravenous Infusion DESCRIPTION Mycamine is a sterile, lyophilized product for intravenous (IV) infusion that contains micafungin sodium. Micafungin sodium is a semisynthetic lipopeptide (echinocandin) synthesized by a chemical modification of a fermentation product of Coleophoma empetri F-11899. Micafungin inhibits the synthesis of 1, 3-beta-D-glucan, an integral component of the fungal cell wall. Each single-use vial contains 50 mg or 100 mg micafungin sodium, 200 mg lactose, with citric acid and/or sodium hydroxide (used for pH adjustment). Mycamine must be diluted with 0.9% Sodium Chloride Injection, USP, or 5% Dextrose Injection, USP [see DOSAGE AND ADMINISTRATION]. Following reconstitution with 0.9% Sodium Chloride Injection, USP, the resulting pH of the solution is between 5-7. Micafungin sodium is chemically designated as: Pneumocandin A0,1-[(4R,5R)-4,5-dihydroxy-N2-[4-[5-[4-(pentyloxy)phenyl]-3isoxazolyl]benzoyl]-L-ornithine]-4-[(4S)-4-hydroxy-4-[4-hydroxy-3-(sulfooxy)phenyl]-Lthreonine]-, monosodium salt. The chemical structure of micafungin sodium is: The empirical/molecular formula is C56H70N9NaO23S and the formula weight is 1292.26. Micafungin sodium is a light-sensitive, hygroscopic white powder that is freely soluble in water, isotonic sodium chloride solution, N,N-dimethylformamide and dimethylsulfoxide, slightly soluble in methyl alcohol, and practically insoluble in acetonitrile, ethyl alcohol (95%), acetone, diethyl ether and n-hexane.

INDICATIONS Attention Deficit Disorders, Narcolepsy Attention Deficit Disorders (previously known as Minimal Brain Dysfunction in Children). Other terms being used to describe the behavioral syndrome below include: Hyperkinetic Child Syndrome, Minimal Brain Damage, Minimal Cerebral Dysfunction, Minor Cerebral Dysfunction. Methylin is indicated as an integral part of a total treatment program which typically includes other remedial measures (psychological, educational, social) for a stabilizing effect in children with a behavioral syndrome characterized by the following group of developmentally inappropriate symptoms: moderate-to-severe distractibility, short attention span, hyperactivity, emotional lability, and impulsivity. The diagnosis of this syndrome should not be made with finality when these symptoms are only of comparatively recent origin. Nonlocalizing (soft) neurological signs, learning disability, and abnormal EEG may or may not be present, and a diagnosis of central nervous system dysfunction may or may not be warranted. Special Diagnostic Considerations Specific etiology of this syndrome is unknown, and there is no single diagnostic test. Adequate diagnosis requires the use not only of medical but of special psychological, educational, and social resources. Characteristics commonly reported include: chronic history of short attention span, distractibility, emotional lability, impulsivity, and moderate-to-severe hyperactivity; minor neurological signs and abnormal EEG. Learning may or may not be impaired. The diagnosis must be based upon a complete history and evaluation of the child and not solely on the presence of one or more of these characteristics. Drug treatment is not indicated for all children with this syndrome. Stimulants are not intended for use in the child who exhibits symptoms secondary to environmental factors and/or primary psychiatric disorders, including psychosis. Appropriate educational placement is essential and psychosocial intervention is generally necessary. When remedial measures alone are insufficient, the decision to prescribe stimulant medication will depend upon the physician's assessment of the chronicity and severity of the child's symptoms. DOSAGE AND ADMINISTRATION Dosage should be individualized according to the needs and responses of the patient. Directions Take this product (child or adult dose) with at least 8 ounces (a full glass) of water or other fluid. Taking this product without enough liquid may cause choking. See choking warning. Adults Administer in divided doses 2 or 3 times daily, preferably 30 to 45 minutes before meals. Average dosage is 20 to 30 mg daily. Some patients may require 40 to 60 mg daily. In others, 10 to 15 mg daily will be adequate. Patients who are unable to sleep if medication is taken late in the day should take the last dose before 6 p.m. Children (6 years and over) Methylin should be initiated in small doses, with gradual weekly increments. Daily dosage above 60 mg is not recommended. If improvement is not observed after appropriate dosage adjustment over a one-month period, the drug should be discontinued. Chewable Tablets: Start with 5 mg twice daily (before breakfast and lunch) with gradual increments of 5 to 10 mg weekly. If paradoxical aggravation of symptoms or other adverse effects occur, reduce dosage, or, if necessary, discontinue the drug. Methylin should be periodically discontinued to assess the child's condition. Improvement may be sustained when the drug is either temporarily or permanently discontinued. Drug treatment should not and need not be indefinite and usually may be discontinued after puberty. HOW SUPPLIED Each Methylin Chewable Tablet 2.5 mg is available as a white to cream colored, grape flavored, rounded square tablet with a convex surface, debossed with a “2.5” and “CHEW” below it on one side, and a debossed logo on the other side. Bottles of 100……………….NDC 59630-760-10 Each Methylin Chewable Tablet 5 mg is available as a white to cream colored, grape flavored, rounded square tablet with a convex surface, debossed with a “5” and “CHEW” below it on one side, and a debossed on the other side. Bottles of 100……………….NDC 59630-761-10 Each Methylin Chewable Tablet 10 mg is available as a white to cream colored, grape flavored, scored rounded square tablet with a convex surface, debossed with a “10” and “CHEW” below it on one side, and a debossed logo on the other side. Bottles of 100……………….NDC 59630-762-10 Protect from moisture. Dispense in tight container with child-resistant closure. Storage Store at 20° to 25°C (68° to 77°F) [see USP Controlled Room Temperature]. Distributed by: Shionogi Inc., Florham Park, NJ 07932. Manufactured by: MCT-PI-02, Mallinckrodt Inc. L20M18, Hazelwood, MO 63042 USA Rev 04/2013

PATIENT INFORMATION Patients should be advised of the potential benefits and risks of Mycamine. Patients should be informed about the serious adverse effects of Mycamine including hypersensitivity reactions (anaphylaxis and anaphylactoid reactions including shock), hematological effects (acute intravascular hemolysis, hemolytic anemia and hemoglobinuria), hepatic effects (abnormal liver function tests, hepatic impairment, hepatitis or worsening hepatic failure) and renal effects (elevations in BUN and creatinine, renal impairment or acute renal failure). Patients should be instructed to inform their health care provider if they develop any unusual symptom, or if any known symptom persists or worsens. Patients should be instructed to inform their health care provider of any other medications they are currently taking with Mycamine, including over-thecounter medications.

OVERDOSE Mycamine is highly protein bound and, therefore, is not dialyzable. No cases of Mycamine overdosage have been reported. Repeated daily doses up to 8 mg/kg (maximum total dose of 896 mg) in adult patients, up to 6 mg/kg in pediatric patients 4 months of age and older, and up to 10 mg/kg in pediatric patients less than 4 months of age have been administered in clinical trials with no reported dose-limiting toxicity. The minimum lethal dose of Mycamine is 125 mg/kg in rats, equivalent to 8 times the recommended highest adult clinical dose (150 mg) and approximately 7 times the highest pediatric clinical dose (3 mg/kg), based on body surface area comparisons. CONTRAINDICATIONS Mycamine is contraindicated in persons with known hypersensitivity to micafungin, any component of Mycamine, or other echinocandins.

SIDE EFFECTS The overall safety of Mycamine was assessed in 3227 adult and pediatric patients and 520 volunteers in 46 clinical trials, including the invasive candidiasis, esophageal candidiasis and prophylaxis trials, who received single or multiple doses of Mycamine, ranging from 0.75 mg/kg to 10 mg/kg in pediatric patients and 12.5 mg to 150 mg/day or greater in adult patients. Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in clinical trials of Mycamine cannot be directly compared to rates in clinical trials of another drug and may not reflect the rates observed in practice. The adverse reaction information from clinical trials does provide a basis for identifying adverse events that appear to be related to drug use and for approximating rates. Infusion Reactions Possible histamine-mediated symptoms have been reported with Mycamine, including rash, pruritus, facial swelling, and vasodilatation. Injection site reactions, including phlebitis and thrombophlebitis have been reported, at Mycamine doses of 50-150 mg/day. These reactions tended to occur more often in patients receiving Mycamine via peripheral intravenous administration. Clinical Trials Experience in Adults In all clinical trials with Mycamine, 2497/2748 (91%) adult patients experienced at least one treatment-emergent adverse reaction. Candidemia and Other Candida Infections In a randomized, double-blind study for treatment of candidemia and other Candida infections, treatment-emergent adverse reactions occurred in 183/200 (92%), 187/202 (93%) and 171/193 (89%) patients in the Mycamine 100 mg/day, Mycamine 150 mg/day, and caspofungin (a 70 mg loading dose followed by a 50 mg/day dose) treatment groups, respectively. Selected treatment-emergent adverse reactions, those occurring in 5% or more of the patients and more frequently in a Mycamine treatment group, are shown in Table 3. Table 3: Selected* Treatment-Emergent Adverse Reactions in Adult Patients with Candidemia and Other Candida Infections System Organ Class¥ (Preferred Term) † Mycamine 100 mg n (%) Mycamine 150 mg n (%) Caspofungin‡ n (%) Number of Patients 200 202 193 Gastrointestinal Disorders 81 (41) 89 (44) 76 (39) Diarrhea 15 (8) 26 (13) 14 (7) Nausea 19 (10) 15 (7) 20 (10) Vomiting 18 (9) 15 (7) 16 (8) Metabolism and Nutrition Disorders 77 (39) 83 (41) 73 (38) Hypoglycemia 12 (6) 14 (7) 9 (5) Hypernatremia 8 (4) 13 (6) 8 (4) Hyperkalemia 10 (5) 8 (4) 5 (3) General Disorders/Administration Site Conditions 59 (30) 56 (28) 51 (26) Pyrexia 14 (7) 22 (11) 15 (8) Investigations 36 (18) 49 (24) 37 (19) Blood Alkaline Phosphatase Increased 11 (6) 16 (8) 8 (4) Cardiac Disorders 35 (18) 48 (24) 36 (19) Atrial Fibrillation 5 (3) 10 (5) 0 Patient base: all randomized patients who received at least 1 dose of trial drug * During IV treatment + 3 days ¥MedDRA v5.0 † Within a system organ class patients may experience more than 1 adverse reaction. ‡ 70 mg loading dose on day 1 followed by 50 mg/day thereafter (caspofungin) In a second, supportive, randomized, double-blind study for treatment of candidemia and other Candida infections, treatment-emergent adverse reactions occurred in 245/264 (93%) and 250/265 (94%) patients in the Mycamine (100 mg/day) and AmBisome (3 mg/kg/day) treatment groups, respectively. The following treatment-emergent adverse reactions in the Mycamine treated patients at least 16 years of age were notable: nausea (10% vs. 8%); diarrhea (11% vs. 11%), vomiting (13% vs. 9%), abnormal liver function tests (4% vs. 3%); increased aspartate aminotransferase (3% vs. 2%), and increased blood alkaline phosphatase (3% vs. 2%), in the Mycamine and AmBisome treatment groups, respectively. Esophageal Candidiasis In a randomized, double-blind study for treatment of esophageal candidiasis, a total of 202/260 (78%) patients who received Mycamine 150 mg/day and 186/258 (72%) patients who received intravenous fluconazole 200 mg/day experienced an adverse reaction. Treatment-emergent adverse reactions resulting in discontinuation were reported in 17 (7%) Mycamine treated patients; and in 12 (5%) fluconazole treated patients. Selected treatment-emergent adverse reactions, those occurring in 5% or more of the patients and more frequently in the Mycamine group, are shown in Table 4. Table 4: Selected* Treatment-Emergent Adverse Reactions in Adult Patients with Esophageal Candidiasis System Organ Class¥ (Preferred Term)† Mycamine 150 mg/day n (%) Fluconazole 200 mg/day n (%) Number of Patients 260 258 Gastrointestinal Disorders 84 (32) 93 (36) Diarrhea 27 (10) 29 (11) Nausea 20 (8) 23 (9) Vomiting 17 (7) 17 (7) General Disorders/Administration Site Conditions 52 (20) 45 (17) Pyrexia 34 (13) 21 (8) Nervous System Disorders 42 (16) 40 (16) Headache 22 (9) 20 (8) Vascular Disorders 54 (21) 21 (8) Phlebitis 49 (19) 13 (5) Skin and Subcutaneous Tissue Disorders 36 (14) 26 (10) Rash 14 (5) 6 (2) Patient base: all randomized patients who received at least 1 dose of trial drug * During treatment + 3 days. ¥MedDRA v5.0 † Within a system organ class patients may experience more than 1 adverse reaction. Prophylaxis of Candida Infections in Hematopoietic Stem Cell Transplant Recipients A double-blind study was conducted in a total of 882 patients scheduled to undergo an autologous or allogeneic hematopoietic stem cell transplant. The median duration of treatment was 18 days (range 1 to 51 days) in both treatment arms. All adult patients who received Mycamine (382) or fluconazole (409) experienced at least one adverse reaction during the study. Treatment-emergent adverse reactions resulting in Mycamine discontinuation were reported in 15 (4%) adult patients; while those resulting in fluconazole discontinuation were reported in 32 (8%). Selected adverse reactions, those reported in 15% or more of adult patients and more frequently on the Mycamine treatment arm, are shown in Table 5. Table 5: Selected Adverse Reactions in Adult Patients During Prophylaxis of Candida Infection in Hematopoietic Stem Cell Transplant Recipients System Organ Class¥ (Preferred Term) † Mycamine 50 mg/day n (%) Fluconazole 400 mg/day n (%) Number of Patients 382 409 Gastrointestinal Disorders 377 (99) 404 (99) Diarrhea 294 (77) 327 (80) Nausea 270 (71) 290 (71) Vomiting 252 (66) 274 (67) Abdominal Pain 100 (26) 93 (23) Blood and Lymphatic System Disorders 368 (96) 385 (94) Neutropenia 288 (75) 297 (73) Thrombocytopenia 286 (75) 280 (69) Skin and Subcutaneous Tissue Disorders 257 (67) 275 (67) Rash 95 (25) 91 (22) Nervous System Disorders 250 (65) 254 (62) Headache 169 (44) 154 (38) Psychiatric Disorders 233 (61) 235 (58) Insomnia 142 (37) 140 (34) Anxiety 84 (22) 87 (21) Cardiac Disorders 133 (35) 138 (34) Tachycardia 99 (26) 91 (22) Patient base: all randomized adult patients who received at least 1 dose of trial drug ¥MedDRA v12.0 † Within a system organ class patients may experience more than 1 adverse reaction. Other selected adverse reactions reported at less than 5% in adult clinical trials are listed below: Blood and lymphatic system disorders: coagulopathy, pancytopenia, thrombotic thrombocytopenic purpura Cardiac disorders: cardiac arrest, myocardial infarction, pericardial effusion General disorders and administration site conditions: infusion reaction, injection site thrombosis Hepatobiliary disorders: hepatocellular damage, hepatomegaly, jaundice, hepatic failure Immune disorders: hypersensitivity, anaphylactic reaction Nervous system disorders: convulsions, encephalopathy, intracranial hemorrhage Psychiatric disorders: delirium Skin and subcutaneous tissue disorders: urticaria Clinical Trials Experience in Pediatric Patients The overall safety of Mycamine was assessed in 479 patients 3 days through 16 years of age who received at least one dose of Mycamine in 11 separate clinical studies. The mean treatment duration was 24.8 days. A total of 246 patients received at least one dose of Mycamine 2 mg/kg or higher. Of the 479 pediatric patients, 264 (55%) were male, 319 (67%) were Caucasians, with the following age distribution: 116 (24%) less than 2 years, 108 (23%) between 2 and 5 years, 140 (29%) between 6 years and 11 years, and 115 (24%) between 12 and 16 years of age. In all pediatric studies with Mycamine, 439/479 (92%) patients experienced at least one treatment-emergent adverse reaction. Two studies that included pediatric patients were randomized, double-blind, and active-controlled: The invasive candidiasis and candidemia study investigated the efficacy and safety of Mycamine (2 mg/kg/day for patients weighing 40 kg or less and 100 mg/day for patients weighing greater than 40 kg) compared to AmBisome (3 mg/kg/day) in 112 pediatric patients. Treatment-emergent adverse reactions occurred in 51/56 (91%) of patients in the Mycamine group and 52/56 (93%) of patients in the AmBisome group. Treatment-emergent adverse reactions resulting in Mycamine discontinuation were reported in 2 (4%) pediatric patients; while those resulting in AmBisome discontinuation were reported in 9 (16%). The prophylaxis study in patients undergoing HSCT investigated the efficacy of Mycamine (1 mg/kg/day for patients weighing 50 kg or less and 50 mg/day for patients weighing greater than 50 kg) as compared to fluconazole (8 mg/kg/day for patients weighing 50 kg or less and 400 mg/day for patients weighing greater than 50 kg). All 91 pediatric patients experienced at least one treatment-emergent adverse reaction. Three (7%) pediatric patients discontinued Mycamine due to adverse reaction; while one (2%) patient discontinued fluconazole. The selected treatment-emergent adverse reactions, those occurring in 15% or more of the patients and more frequently in a Mycamine group, for all Mycamine pediatric studies and for the two comparative studies (candidemia and prophylaxis) described above are shown in Table 6. Table 6: Selected Treatment-Emergent Adverse Reactions in All Pediatric Patients, in Patients with Candidemia and Other Candida Infections (C/IC), and in Hematopoietic Stem-Cell Recipients During Prophylaxis of Candida Infections System Organ Class¥ (Preferred Term) † All Micafungintreated Patients n = 479 n (%) C/IC Prophylaxis Mycamine n = 56 n (%) AmBisome n = 56 n (%) Mycamine n = 43 n (%) Fluconazole n = 48 n (%) Gastrointestinal disorders 285 (60) 22 (40) 18 (32) 43 (100) 45 (94) Vomiting 146 (31) 10 (18) 8 (14) 28 (65) 32 (67) Diarrhea 106 (22) 4 (7) 5 (9) 22 (51) 31 (65) Nausea 91 (19) 4 (7) 4 (7) 30 (70) 25 (52) Abdominal pain 76 (16) 2 (4) 2 (4) 15 (35) 12 (25) Abdominal distension 29 (6) 1 (2) 1 (2) 8 (19) 6 (13) General disorders and administration site conditions 256 (53) 14 (25) 14 (25) 41 (95) 46 (96) Pyrexia 103 (22) 5 (9) 9 (16) 26 (61) 31 (65) Infusion related reaction 24 (5) 0 3 (5) 7 (16) 4 (8) Skin and subcutaneous tissue disorders 197 (41) 11 (20) 8 (14) 33 (77) 38 (79) Pruritus 54 (11) 0 1 (2) 14 (33) 15 (31) Rash 55 (12) 1 (2) 1 (2) 13 (30) 13 (27) Urticaria 24 (5) 0 1 (2) 8 (19) 4 (8) Respiratory, thoracic and mediastinal disorders 194 (41) 9 (16) 13 (23) 30 (70) 33 (69) Epistaxis 45 (9) 0 0 4 (9) 8 (17) Blood and lymphatic system disorders 161 (34) 17 (30) 13 (23) 40 (93) 44 (92) Thrombocytopenia 70 (15) 5 (9) 3 (5) 31 (72) 37 (77) Neutropenia 61 (13) 3 (5) 4 (7) 33 (77) 34 (71) Anemia 63 (13) 10 (18) 6 (11) 22 (51) 24 (50) Febrile neutropenia 23 (5) 0 0 7 (16) 7 (15) Investigations 191 (40) 12 (21) 8 (14) 24 (56) 25 (52) Alanine aminotransferase increased 45 (10) 0 0 7 (16) 1 (2) Urine output decreased 18 (4) 0 0 10 (23) 8 (17) Cardiac disorders 97 (20) 7 (13) 3 (5) 10 (23) 17 (35) Tachycardia 47 (10) 2 (4) 1 (2) 7 (16) 12 (25) Renal and urinary disorders 78 (16) 4 (7) 4 (7) 16 (37) 15 (31) Hematuria 18 (4) 0 0 10 (23) 7 (15) Psychiatric disorders 80 (17) 3 (5) 1 (2) 20 (47) 9 (19) Anxiety 35 (7) 0 0 10 (23) 3 (6) Patient base: all randomized patients who received at least one dose of trial drug. ¥MedDRA v12.0 †Within a system organ class, patients may experience more than 1 adverse reaction. Other clinically significant adverse reactions reported at less than 15% in pediatric clinical trials are listed below: Hepatobiliary disorders: hyperbilirubinemia Investigations: liver function tests abnormal Renal Disorders: renal failure Postmarketing Adverse Reactions The following adverse reactions have been identified during the post-approval use of micafungin sodium for injection. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency. Blood and lymphatic system disorders: disseminated intravascular coagulation Hepatobiliary disorders: hepatic disorder Renal and urinary disorders: renal impairment Skin and subcutaneous tissue disorders: Stevens-Johnson syndrome, toxic epidermal necrolysis Vascular disorders: shock DRUG INTERACTIONS A total of 14 clinical drug-drug interaction studies were conducted in healthy volunteers to evaluate the potential for interaction between Mycamine and amphotericin B, mycophenolate mofetil, cyclosporine, tacrolimus, prednisolone, sirolimus, nifedipine, fluconazole, itraconazole, voriconazole, ritonavir, and rifampin. In these studies, no interaction that altered the pharmacokinetics of Mycamine was observed. There was no effect of a single dose or multiple doses of Mycamine on mycophenolate mofetil, cyclosporine, tacrolimus, prednisolone, fluconazole, and voriconazole pharmacokinetics. Sirolimus AUC was increased by 21% with no effect on Cmax in the presence of steady-state Mycamine compared with sirolimus alone. Nifedipine AUC and Cmax were increased by 18% and 42%, respectively, in the presence of steady-state Mycamine compared with nifedipine alone. Itraconazole AUC and Cmax were increased by 22% and 11%, respectively. Patients receiving sirolimus, nifedipine or itraconazole in combination with Mycamine should be monitored for sirolimus, nifedipine or itraconazole toxicity and the sirolimus, nifedipine or itraconazole dosage should be reduced if necessary [see CLINICAL PHARMACOLOGY]. Micafungin is neither a substrate nor an inhibitor of P-glycoprotein and, therefore, would not be expected to alter P-glycoprotein-mediated drug transport activity. Drug Abuse And Dependence There has been no evidence of either psychological or physical dependence or withdrawal or rebound effects with Mycamine.

WARNINGS Included as part of the PRECAUTIONS section. PRECAUTIONS Hypersensitivity Reactions Isolated cases of serious hypersensitivity (anaphylaxis and anaphylactoid) reactions (including shock) have been reported in patients receiving Mycamine. If these reactions occur, Mycamine infusion should be discontinued and appropriate treatment administered. Hematological Effects Acute intravascular hemolysis and hemoglobinuria was seen in a healthy volunteer during infusion of Mycamine (200 mg) and oral prednisolone (20 mg). This reaction was transient, and the subject did not develop significant anemia. Isolated cases of significant hemolysis and hemolytic anemia have also been reported in patients treated with Mycamine. Patients who develop clinical or laboratory evidence of hemolysis or hemolytic anemia during Mycamine therapy should be monitored closely for evidence of worsening of these conditions and evaluated for the risk/benefit of continuing Mycamine therapy. Hepatic Effects Laboratory abnormalities in liver function tests have been seen in healthy volunteers and patients treated with Mycamine. In some patients with serious underlying conditions who were receiving Mycamine along with multiple concomitant medications, clinical hepatic abnormalities have occurred, and isolated cases of significant hepatic impairment, hepatitis, and hepatic failure have been reported. Patients who develop abnormal liver function tests during Mycamine therapy should be monitored for evidence of worsening hepatic function and evaluated for the risk/benefit of continuing Mycamine therapy. Renal Effects Elevations in BUN and creatinine, and isolated cases of significant renal impairment or acute renal failure have been reported in patients who received Mycamine. In fluconazole-controlled trials, the incidence of drug-related renal adverse reactions was 0.4% for Mycamine treated patients and 0.5% for fluconazole treated patients. Patients who develop abnormal renal function tests during Mycamine therapy should be monitored for evidence of worsening renal function. Nonclinical Toxicology Carcinogenesis, Mutagenesis, Impairment of Fertility Hepatic carcinomas and adenomas were observed in a 6-month intravenous toxicology study with an 18-month recovery period of micafungin sodium in rats designed to assess the reversibility of hepatocellular lesions. Rats administered micafungin sodium for 3 months at 32 mg/kg/day (corresponding to 8 times the highest recommended human dose [150 mg/day], based on AUC comparisons), exhibited colored patches/zones, multinucleated hepatocytes and altered hepatocellular foci after 1 or 3 month recovery periods, and adenomas were observed after a 21-month recovery period. Rats administered micafungin sodium at the same dose for 6 months exhibited adenomas after a 12-month recovery period; after an 18-month recovery period, an increased incidence of adenomas was observed, and additionally, carcinomas were detected. A lower dose of micafungin sodium (equivalent to 5 times the human AUC) in the 6-month rat study resulted in a lower incidence of adenomas and carcinomas following 18 months recovery. The duration of micafungin dosing in these rat studies (3 or 6 months) exceeds the usual duration of Mycamine dosing in patients, which is typically less than 1 month for treatment of esophageal candidiasis, but dosing may exceed 1 month for Candida prophylaxis. Although the increase in carcinomas in the 6-month rat study did not reach statistical significance, the persistence of altered hepatocellular foci subsequent to Mycamine dosing, and the presence of adenomas and carcinomas in the recovery periods suggest a causal relationship between micafungin sodium, altered hepatocellular foci, and hepatic neoplasms. Whole-life carcinogenicity studies of Mycamine in animals have not been conducted, and it is not known whether the hepatic neoplasms observed in treated rats also occur in other species, or if there is a dose threshold for this effect. Micafungin sodium was not mutagenic or clastogenic when evaluated in a standard battery of in vitro and in vivo tests (i.e., bacterial reversion -S. typhimurium, E. coli; chromosomal aberration; intravenous mouse micronucleus). Male rats treated intravenously with micafungin sodium for 9 weeks showed vacuolation of the epididymal ductal epithelial cells at or above 10 mg/kg (about 0.6 times the recommended clinical dose for esophageal candidiasis, based on body surface area comparisons). Higher doses (about twice the recommended clinical dose, based on body surface area comparisons) resulted in higher epididymis weights and reduced numbers of sperm cells. In a 39-week intravenous study in dogs, seminiferous tubular atrophy and decreased sperm in the epididymis were observed at 10 and 32 mg/kg, doses equal to about 2 and 7 times the recommended clinical dose, based on body surface area comparisons. There was no impairment of fertility in animal studies with micafungin sodium. Use In Specific Populations Pregnancy Pregnancy Category C There are no adequate and well-controlled studies of Mycamine in pregnant women. Animal reproduction studies in rabbits showed visceral abnormalities and increased abortion at 4 times the recommended human dose. However, animal studies are not always predictive of human response. Mycamine should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. When pregnant rabbits were given 4 times the recommended human dose, there were increased abortion and visceral abnormalities including abnormal lobation of the lung, levocardia, retrocaval ureter, anomalous right subclavian artery, and dilatation of the ureter [see Nonclinical Toxicology]. Nursing Mothers It is not known whether micafungin is excreted in human milk. Caution should be exercised when Mycamine is administered to a nursing woman. Pediatric Use Safety and effectiveness in pediatric patients younger than 4 months of age have not been established. Safety and effectiveness of Mycamine in pediatric patients 4 months of age and older have been demonstrated based on the evidence from adequate and well-controlled studies in adult and pediatric patients and additional pediatric pharmacokinetic and safety data. Two randomized, double-blind, active control studies investigated the safety and efficacy of Mycamine in both adult and pediatric patients: one for the treatment of invasive candidiasis and candidemia and the other for prophylaxis of Candida infections in patients undergoing HSCT [see DOSAGE AND ADMINISTRATION, ADVERSE REACTIONS, CLINICAL PHARMACOLOGY, Clinical Studies]. Geriatric Use A total of 418 subjects in clinical studies of Mycamine were 65 years of age and older, and 124 subjects were 75 years of age and older. No overall differences in safety and effectiveness were observed between these subjects and younger subjects. Other reported clinical experience has not identified differences in responses between the elderly and younger patients, but greater sensitivity of some older individuals cannot be ruled out. The exposure and disposition of a 50 mg Mycamine dose administered as a single 1-hour infusion to 10 healthy subjects aged 66-78 years were not significantly different from those in 10 healthy subjects aged 20-24 years. No dose adjustment is necessary for the elderly. Use in Patients with Renal Impairment Mycamine does not require dose adjustment in patients with renal impairment. Supplementary dosing should not be required following hemodialysis [see CLINICAL PHARMACOLOGY]. Use in Patients with Hepatic Impairment Dose adjustment of Mycamine is not required in patients with mild, moderate, or severe hepatic impairment [see CLINICAL PHARMACOLOGY]. Race and Gender No dose adjustment of Mycamine is required based on gender or race. After 14 daily doses of 150 mg to healthy subjects, micafungin AUC in women was greater by approximately 23% compared with men, due to smaller body weight. No notable differences among white, black, and Hispanic subjects were seen. The micafungin AUC was greater by 19% in Japanese subjects compared to blacks, due to smaller body weight.