Anidulafungin-induced Hepatotoxicity and Dose Reduction: A Case Report

Anidulafungin, the newest echinocandin antifungal recently approved by the U.S. FDA, is unique among echinocandins as it undergoes biotransformation rather than being metabolized. In general, patients who received anidulafungin demonstrated low rates of adverse events. Hepatotoxicity is uncommon with anidulafungin and to date; there is no information on hepatic dose adjustments and it is also unknown if the adverse events are dose-related. We describe a patient who developed raised alkaline phosphatase (ALP) upon exposure to a high maintenance dose of anidulafungin at 200 mg every morning. Our patient has a persistent active mitral valve Candida endocarditis, complicated with recurrent candidemia. Patient received multiple courses of anti-fungal agents but breakthrough while on oral anti-fungal suppressive therapy. Prior to the initiation of high dose anidulafungin therapy, patient’s liver function tests were all normal. One month after the initiation of high dose anidulafungin, repeat blood tests revealed a raised ALP level to 3 times the upper normal limit. As prolonged anti-fungal therapy is necessary, the maintenance dose of anidulafungin was reduced to 100 mg every morning, even though patient remained well. Three months after dose reduction, patient’s serum ALP levels showed a steady decrease to 1 time the upper normal limit. In this patient that we have reported – taking into consideration of the temporal relationship of events, coupled with the probability scoring using the Naranjo Algorithm, it is probable that anidulafungin may exhibit dose-related hepatotoxicity resulting in elevated serum ALP levels and such adverse events may be mitigated with dose reduction.