Mycamine

Micafungin sodium.

Each vial contains micafungin sodium equivalent to 50 mg micafungin.
After reconstitution each ml contains micafungin sodium equivalent to 10 mg micafungin.
Excipients: Each vial contains 200 mg lactose.
Excipients/Inactive Ingredients: Lactose monohydrate, Citric acid (to adjust the pH), Sodium hydroxide (to adjust the pH).

Pharmacotherapeutic group: Other antimycotics for systemic use. ATC code: J02AX05.
PHARMACOLOGY: Pharmacodynamics: Mode of action: Micafungin non-competitively inhibits the synthesis of 1,3-β-D-glucan, an essential component of the fungal cell wall. 1,3-β-D-glucan is not present in mammalian cells.
Micafungin exhibits fungicidal activity against most Candida species and prominently inhibits actively growing hyphae of Aspergillus species.
PK/PD relationship: An additive or synergistic pharmacodynamic interaction of micafungin and amphotericin B was found in a mouse model of pulmonary aspergillosis (immunosuppression with hydrocortisone, intranasal infection with Aspergillus fumigatus).
Mechanism(s) of resistance: As for all antimicrobial agents, cases of reduced susceptibility and resistance have been reported and cross-resistance with other echinocandins cannot be excluded. Reduced susceptibility to echinocandins has been associated with mutations in the Fks1 and Fks2 genes coding for a major subunit of glucan synthase.
Breakpoints: Susceptibility testing was performed with modifications according to the Clinical and Laboratory Standards Institute (CLSI) methods M27-A2 (Candida species) and M38-A (Aspergillus species), respectively. To date, standardised techniques for susceptibility testing for 1,3-β-D-glucan synthesis inhibitors have not been established and results of susceptibility testing do not necessarily correlate with clinical outcome.
Although no MIC breakpoints for echinocandins have been established, a MIC of ≤2 mg/l encompasses >99% of all clinical isolates of Candida spp. without bisecting any species group and represents a concentration that is easily maintained throughout the dosing interval. Infections due to Candida spp. in this MIC range are likely to respond to therapy.
The prevalence of resistance may vary geographically and with time for selected species and local information on resistance is desirable, particularly when treating severe infections. This information is only a guide to the probabilities of whether micro-organisms will be susceptible to micafungin or not. Where applicable the information on the European range of acquired resistance for the individual micro-organisms is indicated in brackets. (See Table 1.)

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Information from clinical studies: Candidemia and Invasive Candidiasis: Micafungin (100 mg/day or 2 mg/kg/day) was as effective as and better tolerated than liposomal amphotericin B (3 mg/kg) as first-line treatment of candidemia and invasive candidiasis in a randomised, double-blind, multinational non-inferiority study. Micafungin and liposomal amphotericin B were received for a median duration of 15 days (range, 4 to 42 days in adults; 12 to 42 days in children).
Non-inferiority was proven for adult patients, and similar findings were demonstrated for the pediatric subpopulations (including neonates and premature infants). Efficacy findings were consistent, independent of the infective Candida species, primary site of infection and neutropenic status (see Table 2). Micafungin demonstrated a smaller mean peak decrease in estimated glomerular filtration rate during treatment (p<0.001) and a lower incidence of infusion-related reactions (p=0.001) than liposomal amphotericin B. (See Table 2.)

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The large, well-controlled, double blind, clinical trial has shown intravenous micafungin 100 mg and 150 mg daily to be as efficacious as caspofungin 70 mg/day on day 1 and 50 mg/day thereafter in the primary treatment of candidemia and invasive candidiasis. This large, double-blind, clinical experiences confirm that micafungin 100 and 150 mg/day are as safe and well-tolerated as caspofungin 70-50 mg/day in the treatment of patients with candidemia and invasive candidiasis. The result of this study confirm that micafungin is a safe and effective alternative for primary treatment of candidemia and invasive candidiasis.
Esophageal Candidiasis: In a randomised, double-blind study of micafungin versus fluconazole in the first-line treatment of esophageal candidiasis, 518 patients received at least a single dose of study drug. The median treatment duration was 14 days and the median average daily dose was 150 mg for micafungin (N=260) and 200 mg for fluconazole (N=258). An endoscopic grade of 0 (endoscopic cure) at the end of treatment was observed for 87.7% (228/260) and 88.0% (227/258) of patients in the micafungin and fluconazole groups, respectively (95% CI for difference: [-5.9%, 5.3%]). The lower limit of the 95% CI was above the predefined non-inferiority margin of -10%, proving non-inferiority. The nature and incidence of adverse events were similar between treatment groups.
Invasive Aspergillosis: An open-label, noncomparative, multicenter study evaluated the safety and efficacy of micafungin in 283 adult and pediatric patients with proven or probable (pulmonary only) invasive systemic infection due to Aspergillus species, 228 of whom were evaluable for efficacy. The median duration of therapy was 34 days (range 7 to 284 days) in adult and 37 days (range 7 to 638 days) in pediatrics. Treatment success was defined as a complete, partial or stable response at the end of therapy.
Patients with invasive Aspergillus infections achieved a treatment success rate of 63% with micafungin. Treatment success by site of infection was: pulmonary 64% (110/171), sinus 60% (9/15), pulmonary and sinus 67% (2/3) and disseminated 44% (10/23).
Treatment success was documented across a variety of Aspergillus species, including Aspergillus flavus 75% (18/24), Aspergillus fumigatus 57% (51/90), Aspergillus nidulans 50% (2/4), Aspergillus niger 88% (7/8), nonspeciated Aspergillus 65% (71/109), Aspergillus terreus 14% (1/7), and Aspergillus versicolor 100% (1/1). (See Table 3.)

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Prophylaxis: Micafungin was more effective than fluconazole in preventing invasive fungal infections in a population of patients at high risk of developing a systemic fungal infection (patients undergoing hematopoietic stem cell transplantation [HSCT] in a randomised, double-blind, multicentre study).
Treatment success was defined as the absence of a proven, probable, or suspected systemic fungal infection through the end of therapy and absence of a proven or probable systemic fungal infection through the end of study. Most patients (97%, N=882) had neutropenia at baseline (<200 neutrophils/µl). Neutropenia persisted for a median of 13 days. There was a fixed daily dose of 50 mg (1.0 mg/kg) for micafungin and 400 mg (8 mg/kg) for fluconazole. The mean period of treatment was 19 days for micafungin and 18 days for fluconazole in the adult population (N=798) and 23 days for both treatment arms in the pediatric population (N=84).
The rate of treatment success was statistically significantly higher for micafungin than fluconazole (1.6% versus 2.4% breakthrough infections).
Breakthrough Aspergillus infections were observed in 1 versus 7 patients, and proven or probable breakthrough Candida infections were observed in 4 versus 2 patients in the micafungin and fluconazole groups, respectively. Other breakthrough infections were caused by Fusarium (1 and 2 patients, respectively) and Zygomycetes (1 and 0 patients, respectively). The nature and incidence of adverse reactions were similar between treatment groups.
Pharmacokinetics: Absorption: Micafungin is an intravenously administered medication.
Pharmacokinetics are linear over the daily dose range of 12.5 mg to 200 mg and 3 mg/kg to 8 mg/kg. There is no evidence of systemic accumulation with repeated administration and steady-state is generally reached within 4 to 5 days.
Distribution: Following intravenous administration concentrations of micafungin show a biexponential decline. The drug is rapidly distributed into tissues.
In systemic circulation, micafungin is highly bound to plasma protein (>99%), primarily to albumin. Binding to albumin is independent of micafungin concentration (10-100 µg/ml).
The volume of distribution at steady state (Vss) was approximately 18-19 litres.
Metabolism: Unchanged micafungin is the principal circulating compound in systemic circulation. Micafungin has been shown to be metabolised to several compounds; of these M-1 (catechol form), M-2 (methoxy form of M-1) and M-5 (hydroxylation at the side chain) of micafungin have been detected in systemic circulation. Exposure to these metabolites is low and metabolites do not contribute to the overall efficacy of micafungin.
Even though micafungin is a substrate for CYP3A in vitro, hydroxylation by CYP3A is not a major pathway for micafungin metabolism in vivo.
Elimination and excretion: The mean terminal half-life is approximately 10-17 hours and stays consistent across doses up to 8 mg/kg and after single and repeated administration. Total clearance was 0.15-0.3 ml/min/kg in healthy subjects and adult patients and is independent of dose after single and repeated administration. Following a single intravenous dose of ¹⁴C-micafungin (25 mg) to healthy volunteers, 11.6% of the radioactivity was recovered in the urine and 71.0% in the faeces over 28 days. These data indicate that elimination of micafungin is primarily non-renal. In plasma, metabolites M-1 and M-2 were detected only at trace concentrations and metabolite M-5, the more abundant metabolite, accounted for a total of 6.5% relative to parent compound.
Special populations: Pediatric patients: In pediatric patients AUC values were dose proportional over the dose range of 0.5-4 mg/kg. Clearance was influenced by weight, with mean values of weight-adjusted clearance 1.35 times higher in the younger children (4 months to 5 years) and 1.14 times higher in paediatric patients aged 6 to 11 years. Older children (12-16 years) had mean clearance values similar to those determined in adult patients. Mean weight-adjusted clearance in children less than 4 months of age is approximately 2.6-fold greater than older children (12-16 years) and 2.3-fold greater than in adults.
PK/PD bridging study demonstrated dose-dependent penetration of micafungin into CNS with the minimum AUC of 170 μg*hr/L required to achieve maximum eradication of fungal burden in the CNS tissues. Population PK modeling demonstrated that a dose of 10 mg/kg in children less than 4 months of age would be sufficient to achieve the target exposure for the treatment of CNS Candida infections.
Elderly: When administered as a single 1-hour infusion of 50 mg the pharmacokinetics of micafungin in the elderly (aged 66-78 years) were similar to those in young (20-24 years) subjects. No dose adjustment is necessary for the elderly.
Patients with hepatic impairment: In a study performed in patients with moderate hepatic impairment (Child-Pugh score 7-9), (n=8), the pharmacokinetics of micafungin did not significantly differ from those in healthy subjects (n=8). Therefore, no dose adjustment is necessary for patients with mild to moderate hepatic impairment. A single 1-hour infusion of 100 mg micafungin was administered to 8 subjects with severe hepatic dysfunction (Child-Pugh score 10-12) and 8 age-, gender-, ethnic-, and weight matched subjects with normal hepatic function. The micafungin AUC for subjects with severe hepatic dysfunction was 68.2% [(50.8, 91.5) 90% CI] of that seen in the subjects with normal hepatic function. The M-5 (hydroxide metabolite) AUC for subjects with severe hepatic dysfunction was 231.8% [(152.3, 352.7) 90% CI] of that seen in the subjects with normal hepatic function; however this exposure (parent and M-5) was comparable to that in patients (adults and pediatrics with invasive and esophageal candidiasis infections). The level of M-5 exposure is comparable to rat toxicokinetic data. Therefore, no micafungin dosage adjustment is necessary in patients with severe hepatic impairment.
Patients with renal impairment: Severe renal impairment (Glomerular Filtration Rate [GFR] <30 ml/min) did not significantly affect the pharmacokinetics of micafungin. No dose adjustment is necessary for patients with renal impairment.
Gender/Race: Gender and race (Caucasian, Black and Oriental) did not significantly influence the pharmacokinetic parameters of micafungin. No dose adjustment of micafungin is required based on gender or race.
Toxicology: Preclinical safety data: The development of foci of altered hepatocytes (FAH) and hepatocellular tumors in rats was dependent on both dose and duration of micafungin treatment. FAH recorded after treatment for 13 weeks or longer persisted after a 13-week withdrawal period and developed into hepatocellular tumors following a treatment free period which covered the life span of rats. No standard carcinogenicity studies have been conducted but the development of FAH was assessed in female rats after up to 20 and 18 months after cessation of a 3 and 6 month treatment, respectively. In both studies increased incidences/numbers of hepatocellular tumors were observed after the 18 and 20 month treatment free period in the high dose group of 32 mg/kg/day as well as in a lower dose group (although not statistically significant). The plasma exposure at the assumed threshold for tumor development in rats (i.e. the dose where no FAH and liver tumors were detected) was in the same range as the clinical exposure. The relevance of the hepatocarcinogenic potential of micafungin for the human therapeutic use is not known.
The toxicology of micafungin following repeated intravenous dosing in rats and/or dogs showed adverse responses in liver, urinary tract, red blood cells, and male reproductive organs. The exposure levels at which these effects did not occur (NOAEL) were in the same range as the clinical exposure or lower. Consequently, the occurrence of these adverse responses may be expected in human clinical use of micafungin.
In standard safety pharmacology tests, cardiovascular and histamine releasing effects of micafungin were evident and appeared to be time above threshold dependent. Prolongation of infusion time reducing the plasma concentration peak appeared to reduce these effects.
In repeated dose toxicity studies in rat signs of hepatotoxicity consisted of increased liver enzymes and degenerative changes of hepatocytes which were accompanied by signs of compensatory regeneration. In dog, liver effects consisted of increased weight and centrilobular hypertrophy, no degenerative changes of hepatocytes were observed.
In rats, vacuolation of the renal pelvic epithelium as well as vacuolation and thickening (hyperplasia) of the bladder epithelium were observed in 26-week repeat dose studies. In a second 26-week study hyperplasia of transitional cells in the urinary bladder occurred with a much lower incidence. These findings showed reversibility over a follow-up period of 18 months. The duration of micafungin dosing in these rat studies (6 months) exceeds the usual duration of micafungin dosing in patients (see Pharmacodynamics as previously mentioned).
Micafungin haemolysed rabbit blood in vitro. In rats, signs of hemolytic anemia were observed after repeated bolus injection of micafungin. In repeat dose studies in dogs, hemolytic anemia was not observed.
In reproductive and developmental toxicity studies, reduced birth weight of the pups was noted. One abortion occurred in rabbits at 32 mg/kg/day. Male rats treated intravenously for 9 weeks showed vacuolation of the epididymal ductal epithelial cells, increased epididymis weights and reduced number of sperm cells (by 15%), however, in studies of 13 and 26 weeks duration these changes did not occur. In adult dogs, atrophy of seminiferous tubules with vacuolation of the seminiferous epithelium and decreased sperm in the epididymides were noted after prolonged treatment (39 weeks) but not after 13 weeks of treatment. In juvenile dogs, 39 weeks treatment did not induce lesions in the testis and epididymides in a dose dependent manner at the end of treatment but after a treatment free period of 13 weeks a dose dependent increase in these lesions were noted in the treated recovery groups. No impairment of male or female fertility was observed in the fertility and early embryonic development study in rats.
Micafungin was not mutagenic or clastogenic when evaluated in a standard battery of in vitro and in vivo tests, including an in vitro study on unscheduled DNA synthesis using rat hepatocytes.

Mycamine is indicated for: Adults, adolescents ≥16 years of age and elderly: Treatment of invasive candidiasis; Treatment of esophageal candidiasis in patients for whom intravenous therapy is appropriate; Treatment of Aspergillosis; Prophylaxis of Candida and Aspergillus infections in patients undergoing allogeneic hematopoietic stem cell transplantation or patients who are expected to have neutropenia (absolute neutrophil count <500 cells/µl) for 10 or more days.
Children (including neonates) and adolescents <16 years of age: Treatment of invasive candidiasis; Prophylaxis of Candida infection in patients undergoing allogeneic hematopoietic stem cell transplantation or patients who are expected to have neutropenia (absolute neutrophil count <500 cells/µl) for 10 or more days.
The decision to use Mycamine should take into account a potential risk for the development of liver tumors (see Precautions). Mycamine should therefore only be used if other antifungals are not appropriate.

Consideration should be given to official/national guidance on the appropriate use of antifungal agents.
Treatment with Mycamine should be initiated by a physician experienced in the management of fungal infections.
Specimens for fungal culture and other relevant laboratory studies (including histopathology) should be obtained prior to therapy to isolate and identify causative organism(s). Therapy may be instituted before the results of the cultures and other laboratory studies are known. However, once these results become available, antifungal therapy should be adjusted accordingly.
The dose regimen of Mycamine depends on the body weight of the patient as given in the following tables: Use in adults, adolescents ≥16 years of age and elderly: See Table 4.

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Treatment duration: Invasive candidiasis: The treatment duration of Candida infection should be a minimum of 14 days. The antifungal treatment should continue for at least one week after two sequential negative blood cultures have been obtained and after resolution of clinical signs and symptoms of infection.
Esophageal candidiasis: For the treatment of esophageal candidiasis, Mycamine should be administered for at least one week after resolution of clinical signs and symptoms.
Prophylaxis of Candida and Aspergillus infections: For prophylaxis of Candida and Aspergillus infection, Mycamine should be administered for at least one week after neutrophil recovery.
Use in children ≥4 months of age up to adolescents <16 years of age: See Table 5.

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Use in children (including neonates) <4 months: See Table 6.

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Treatment duration: Invasive candidiasis: The treatment duration of Candida infection should be a minimum of 14 days. The antifungal treatment should continue for at least one week after two sequential negative blood cultures have been obtained and after resolution of clinical signs and symptoms of infection.
Prophylaxis of Candida infections: For prophylaxis of Candida infection, Mycamine should be administered for at least one week after neutrophil recovery. Experience with Mycamine in patients less than 2 years of age is limited.
Gender/Race: No dose adjustment is necessary based on gender or race (see PHARMACOLOGY: Pharmacokinetics under Actions).
Use in patients with hepatic impairment: No dose adjustment is necessary in patients with mild, moderate, or severe hepatic impairment (see PHARMACOLOGY: Pharmacokinetics under Actions).
Use in patients with renal impairment: No dose adjustment is necessary in patients with renal impairment (see PHARMACOLOGY: Pharmacokinetics under Actions).
After reconstitution and dilution, the solution should be administered by intravenous infusion over approximately 1 hour. More rapid infusions may result in more frequent histamine mediated reactions. For reconstitution instructions see Special precautions for disposal and other handling under Cautions for Usage.
A loading dose is not required; typically, 85% of the steady-state concentration is achieved after three daily Mycamine doses.

Repeated daily doses up to 8 mg/kg (maximum total dose 896 mg) in adult patients have been administered in clinical trials with no reported dose-limiting toxicity. In one spontaneous case, it was reported a dosage of 16 mg/kg/day was administered in a newborn patient. No adverse reactions associated with this high dose were noted.
There is no experience with overdoses of micafungin. In case of overdose, general supportive measures and symptomatic treatment should be administered. Micafungin is highly protein-bound and not dialyzable.

Hypersensitivity to the active substance, to other echinocandins or to any of the excipients.

Hepatic effects: The development of foci of altered hepatocytes (FAH) and hepatocellular tumors after a treatment period of 3 months or longer were observed in rats. The assumed threshold for tumour development in rats is approximately in the range of clinical exposure. The relevance of this finding for the therapeutic use in patients cannot be excluded. Liver function should be carefully monitored during micafungin treatment. To minimise the risk of adaptive regeneration and potentially subsequent liver tumor formation, early discontinuation in the presence of significant and persistent elevation of ALT/AST is recommended. Micafungin treatment should be conducted on a careful risk/benefit basis, particularly in patients having severe liver function impairment or chronic liver diseases known to represent preneoplastic conditions, such as advanced liver fibrosis, cirrhosis, viral hepatitis, neonatal liver disease or congenital enzyme defects, or receiving a concomitant therapy including hepatotoxic and/or genotoxic properties.

Micafungin treatment was associated with significant impairment of liver function (increase of ALT, AST or total bilirubin >3 times ULN) in both healthy volunteers and patients. In some patients more severe hepatic dysfunction, hepatitis, or hepatic failure including fatal cases have been reported. Pediatric patients <1 year of age might be more prone to liver injury (see Adverse Reactions).
During administration of micafungin, anaphylactic/anaphylactoid reactions including shock may occur. If these reactions occur, micafungin infusion should be discontinued and appropriate treatment administered.
Exfoliative cutaneous reactions, such as Stevens-Johnson syndrome and toxic epidermal necrolysis have been reported. If patients develop a rash they should be monitored closely and micafungin discontinued if lesions progress.
Rare cases of hemolysis including acute intravascular hemolysis or hemolytic anemia have been reported in patients treated with micafungin. Patients who develop clinical or laboratory evidence of hemolysis during micafungin therapy should be monitored closely for evidence of worsening of these conditions and evaluated for the risk/benefit of continuing micafungin therapy.
Micafungin may cause kidney problems, renal failure, and abnormal renal function test. Patients should be closely monitored for worsening of renal function.
Co-administration of micafungin and amphotericin B desoxycholate should only be used when the benefits clearly outweigh the risks, with close monitoring of amphotericin B desoxycholate toxicities (see Interactions).
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 Interactions).
The incidence of some adverse reactions was higher in pediatric patients than in adult patients (see Adverse Reactions).
Effects on ability to drive and use machines: No studies on the effects on the ability to drive and use machines have been performed. However, adverse reactions may occur, which may influence the ability to drive and use machines (see Adverse Reactions).

There are no data from the use of micafungin in pregnant women. In animal studies micafungin crossed the placental barrier and reproductive toxicity was seen (see PHARMACOLOGY: Toxicology: Preclinical safety data under Actions). The potential risk for humans is unknown.
Mycamine should not be used during pregnancy unless clearly necessary.
It is not known whether micafungin is excreted in human breast milk. Animal studies have shown excretion of micafungin in breast milk. A decision on whether to continue/discontinue breast-feeding or to continue/discontinue therapy with Mycamine should be made taking into account the benefit of breast-feeding to the child and the benefit of Mycamine therapy to the mother.
Testicular toxicity was observed in animal studies (see PHARMACOLOGY: Toxicology: Preclinical safety data under Actions). Micafungin may have the potential to affect male fertility in humans.

The safety profile of micafungin is based on 3028 patients treated with micafungin in clinical studies: 2,002 patients with Candida infections (including candidemia, invasive candidiasis and esophageal candidiasis), 375 with invasive aspergillosis (primarily refractory infections) and 651 for prophylaxis of systemic fungal infections.
The patients treated with micafungin in clinical studies represent a critically ill patient population that requires multiple medicinal products including antineoplastic chemotherapy, potent systemic immunosuppressants and broad spectrum antibiotics. These patients had a wide variety of complex underlying conditions such as hematological malignancies and HIV-infection or were transplant recipients and/or treated in intensive care. Patients treated prophylactically with micafungin were those undergoing hematopoietic stem cell transplantation (HSCT) who were at high risk for fungal infections.
Overall 32.2% of the patients experienced adverse drug reactions. The most frequently reported adverse reactions were nausea (2.8%), blood alkaline phosphatase increased (2.7%), phlebitis (2.5%, primarily in HIV infected patients with peripheral lines), vomiting (2.5%), and aspartate aminotransferase increased (2.3%). No clinically significant differences were seen when the safety data were analysed by gender or race.
In the following table adverse reactions are listed by system organ class and MedDRA preferred term. Within each frequency grouping, undesirable effects are presented in order of decreasing seriousness. (See Table 7.)

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Possible allergic-like symptoms: Symptoms such as rash and rigors have been reported in clinical studies. The majority were of mild to moderate intensity and not treatment limiting. Serious reactions (e.g. anaphylactoid reaction 0.2%, 6/3028) were uncommonly reported during therapy with micafungin and only in patients with serious underlying conditions (e.g. advanced AIDS, malignancies) requiring multiple co-medications.
Hepatic adverse reactions: The overall incidence of hepatic adverse reactions in the patients treated with micafungin in clinical studies was 8.6% (260/3028). The majority of hepatic adverse reactions were mild and moderate. Most frequent reactions were increase in AP (2.7%), AST (2.3%), ALT (2.0%), blood bilirubin (1.6%) and liver function test abnormal (1.5%). Few patients (1.1%; 0.4% serious) discontinued treatment due to a hepatic event. Cases of serious hepatic dysfunction occurred uncommonly (see Precautions).
Injection-site reactions: None of the injection-site adverse reactions were treatment limiting.
Pediatric patients: The incidence of some adverse reactions (listed as follows) was higher in pediatric patients than in adult patients. Additionally, pediatric patients <1 year of age experienced about two times more often an increase in ALT, AST and AP than older pediatric patients (see Precautions). The most likely reason for these differences were different underlying conditions compared with adults or older pediatric patients observed in clinical studies. At the time of entering the study, the proportion of pediatric patients with neutropenia was several-fold higher than in adult patients (40.2% and 7.3% of children and adults, respectively), as well as allogeneic HSCT (29.4% and 13.4%, respectively) and haematological malignancy (29.1% and 8.7%, respectively).
Blood and lymphatic system disorders: Common: Thrombocytopenia.
Cardiac disorders: Common: Tachycardia.
Vascular disorders: Common: Hypertension, hypotension.
Hepatobiliary disorders: Common: Hyperbilirubinemia, hepatomegaly.
Renal and urinary disorders: Common: Acute renal failure, blood urea increased.

Micafungin has a low potential for interactions with medicines metabolised via CYP3A mediated pathways.
Drug interaction studies in healthy human subjects were conducted to evaluate the potential for interaction between micafungin and mycophenolate mofetil, cyclosporine, tacrolimus, prednisolone, sirolimus, nifedipine, fluconazole, ritonavir, rifampicin, itraconazole, voriconazole and amphotericin B. In these studies, no evidence of altered pharmacokinetics of micafungin was observed. No micafungin dose adjustments are necessary when these medicines are administered concomitantly. Exposure (AUC) of itraconazole, sirolimus and nifedipine was slightly increased in the presence of micafungin (22%, 21% and 18% respectively).
Co-administration of Mycamine and amphotericin B desoxycholate was associated with a 30% increase in amphotericin B desoxycholate exposure. Since this may be of clinical significance this co-administration should only be used when the benefits clearly outweigh the risks, with close monitoring of amphotericin B desoxycholate toxicities (see Precautions).
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.

Incompatibilities: This medicinal product must not be mixed or co-infused with other medicinal products except those mentioned in Special precautions for disposal and other handling as follows.
Special precautions for disposal and other handling: Any unused product or waste material should be disposed of in accordance with local requirements.
Mycamine must not be mixed or co-infused with other medicinal products except those mentioned as follows. Using aseptic techniques at room temperature, Mycamine is reconstituted and diluted as follows: 1. The plastic cap must be removed from the vial and the stopper disinfected with alcohol.
2. Five ml of sodium chloride 9 mg/ml (0.9%) solution for infusion or glucose 50 mg/ml (5%) solution for infusion (taken from a 100 ml bottle/bag) should be aseptically and slowly injected into each vial along the side of the inner wall. Although the concentrate will foam, every effort should be made to minimise the amount of foam generated. A sufficient number of vials of Mycamine must be reconstituted to obtain the required dose in mg (see table as follows).
3. The vial should be rotated gently. DO NOT SHAKE. The powder will dissolve completely. The concentrate should be used immediately. The vial is for single use only. Therefore, please discard unused reconstituted concentrate immediately.
4. All of the reconstituted concentrate should be withdrawn from each vial and returned into the infusion bottle/bag from which it was originally taken. The diluted infusion solution should be used immediately. Chemical and physical in-use stability has been demonstrated for 24 hours at 30°C when protected from light and diluted as described previously.
5. The infusion bottle/bag should be gently inverted to disperse the diluted solution but NOT agitated in order to avoid foaming. Do not use if the solution is cloudy or has precipitated.
6. The infusion bottle/bag containing the diluted infusion solution should be inserted into a closable opaque bag for protection from light.
Preparation of the solution for infusion: See Table 8.

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After reconstitution and dilution, the solution should be administered by intravenous infusion over approximately 1 hour.

Unopened vials: Store below 30°C. Protect from light.
For storage conditions of the reconstituted and diluted medicinal product, see Shelf-life as follows.
Shelf-life: Unopened vial: 3 years.
Reconstituted concentrate in vial: Chemical and physical in-use stability has been demonstrated for up to 24 hours at 30°C when reconstituted with sodium chloride 9 mg/ml (0.9%) solution for infusion or glucose 50 mg/ml (5%) solution for infusion.
Diluted infusion solution: Chemical and physical in-use stability has been demonstrated for 24 hours at 30°C when protected from light when diluted with sodium chloride 9 mg/ml (0.9%) solution for infusion or glucose 50 mg/ml (5%) solution for infusion.
Mycamine contains no preservatives. From a microbiological point of view, the reconstituted and diluted solutions should be used immediately. If not used immediately, in-use storage times and conditions prior to use are the responsibility of the user and would normally not be longer than 24 hours at 2 to 8°C, unless the reconstitution and dilution have taken place in controlled and validated aseptic conditions.

Antifungals

J02AX05 - micafungin ; Belongs to the class of other systemic antimycotics.

D