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from other classes, such as triazoles or polyens. The choice of echinocandins depends mainly on local epidemiology (Candida albicans versus non-albicans strains), type of patient (ICU or haematological versus other), comorbid conditions and previous exposure to antifungals (for example, prophylaxis). Echinocandins are recommended as first-line agents for the therapy of adults with invasive candida infections, which was confirmed by randomised clinical trials (RCTs).4

A meta-analysis showed

that treatment of IC with echinocandins (especially anidulafungin) had higher efficacy compared with fluconazole and a pooled analysis obtained from seven randomised clinical studies demonstrated that echinocandins were associated with a reduced mortality.5–7

A comprehensive review of the role of echinocandins in the targeted treatment of IC from economic perspective was recently published.3

The authors summarised the 6

results of 16 economic studies investigating IC and the main results concerning echinocandins in this setting may be concentrated into the following statements: ● Caspofungin and voriconazole were cost-saving or cost-effective compared with conventional amphotericin B; ● Anidulafungin was a cost-effective

option compared to fluconazole (at least from an Australian healthcare perspective); and

● Micafungin was associated with cost-savings relative to liposomal amphotericin B and was cost- equivalent with caspofungin. One study compared all three echinocandins in the treatment of IC, but only the drug-aquisition costs were included and therefore the value of such analysis is limited.8

Overall, limitations

and gaps of published economic studies in IC are known and a real-life study incorporating all treatment options into pharmacoeconomic models remains a challenge. Nevertheless, current literature clearly documents that treatment of IC with echinocandins is cost-effective or cost-saving compared with polyens or azoles. The conclusive data about economic advantage comparing caspofungin, micafungin and anidulafungin are not available. One report from a Spanish ICU setting suggested that anidulafungin was cost-saving compared with caspofungin and micafungin and cost-effective versus fluconazole.9

with cost-savinsgs compared with traditional escalation approach in UK analysis.10

Echinocandins in the prophylaxis of IFDs

Antifungal propylaxis is a standard approach for high-risk populations of patients, especially during induction chemotherapy of acute myeloid leukaemia (AML), during the neutropenic phase after HSCT or in patients with graft versus host disease after allogeneic HSCT. The cost of antifungal drugs is often considered as the hurdle for implementation of this strategy. Despite the high aquisition cost of the drug, the rate of breakthrough IFDs, complications of therapy and length of hospitalisation should be evaluated. Second- and third-generation azoles are preferably recommended for prophylaxis – only micafungin was studied for this indication in haematological patients and caspofungin in a specific population of ICU patients.

The data regarding the The focus on the strategy and

early administration of antifungals may be a cost-effective alternative, for example, de-escalation strategy from initial treatment with micafungin was associated

pharmacoeconomics of echinocandins in prophylaxis are limited. Micafungin was used in a randomised controlled study in prophylaxis of IFD in patients undergoing HSCT during neutropenia; fluconazole was the comparator. A cost-effectiveness analysis showed the lower total hospital

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