Several antifungal agents are now available for use
against fungal disease, including amphotericin B, itraconazole (Sporanox), and
fluconazole (Diflucan). It is important to note that there is a lack of
agreement in practice over what constitutes ideal therapy. The following
overview explains the current options along with the guidelines used at
Memorial-Sloan Kettering Cancer Center (MSKCC) in New York.
General recommendations of drugs of choice for the various fungal indications
are shown in Table 1. Potential adverse reactions, contra- indications, and
drug interactions associated with these agents are shown in Table
Amphotericin B is a potent broadspectrum agent that has been in clinical use
for 40 years.[2-6] Until the availability of itraconazole, it was the only agent
available for treating Aspergillus infection. A major drawback of conventional
amphotericin B is its toxicity profile, with renal toxicity (including acute
tubular necrosis) constituting the primary adverse effect associated with
treatment. Hypokalemia is a recurrent problem that warrants strict attention to
use of other drugs that can affect potassium balance (eg, cisplatin [Platinol],
ifosfamide [Ifex], corticosteroids, and ticarcillin/clavulanic acid [Timentin]).
Other characteristic toxicities include nausea, vomiting, and anorexia;
increased erythropoietin production; phlebitis, if the drug is administered
through a peripheral intravenous (IV) line; and (rarely) thrombocytopenia or
leukopenia. Acute reactions consist of the complex of chills, fever, tachypnea,
hypoxemia, and hypotension; premedication protocols including acetaminophen,
hydrocortisone, diphenylamine, or meperidine are helpful in alleviating these
The lipid formulations of amphotericin B that have become available are
associated with a degree of reduction in renal toxicity compared with the
conventional formulation.[4,5,7] However, it is far from clear whether this
reduced toxicity and improved quality of life is worth a cost that can be up to
50 times that of the standard formulation for the drug alone.
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