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Candida - female genital - Management
View all prescribing information
Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://emc.medicines.org.uk), or the British National Formulary (BNF) (www.bnf.org).
Which antifungals are recommended?
Which factors influence the decision to use an oral or intravaginal imidazole?
- Oral and intravaginal antifungals are equally effective for treating vulvovaginal candidiasis, and choice of therapy may be influenced by a number of factors. See Table 1 for more information.
Table 1. Factors that may influence the decision to use an oral or intravaginal imidazole for vulvovaginal candidiasis.
Factor | Topical imidazoles | Oral triazoles |
|---|
Preference and compliance issues | Some women prefer not to use pessaries or products delivered with an intravaginal applicator, which can be painful if there is particularly bad inflammation. Some women find topical cream soothing, however. | Simple and painless to use. Available as one or two doses, so few compliance issues. |
Time until effect | Antifungal cream (applied externally) may relieve symptoms sooner than an intravaginal or oral preparation alone. | Oral treatment alone may take slightly longer to take effect. |
Adverse effects | Vulval inflammation and discharge most commonly reported. | More systemic effects such as nausea, headache, and abdominal pain. |
Pregnancy | Suitable during pregnancy and breastfeeding. | Contraindicated during pregnancy and breastfeeding. |
Contraception | Products containing topical imidazoles may damage latex condoms and diaphragms. | — |
Age | Intravaginal imidazoles should generally be avoided in young girls (12–16 years) unless there is no alternative. | Oral antifungals are generally preferred for younger girls (12–16 years). |
|
What short courses of antifungals are recommended?
- Oral antifungals:
- Oral fluconazole 150 mg (single dose).
- Oral itraconazole 200 mg (twice a day for 1 day).
- Intravaginal antifungals:
- Intravaginal pessaries. See Table 1 for more details.
- Intravaginal clotrimazole 10% cream (insert 5 g into the vagina as a single dose at night).
Table 1. Short courses of intravaginal pessaries for vulvovaginal candidiasis.
Preparation | Directions |
|---|
Clotrimazole 500 mg | Insert into the vagina once at night |
Clotrimazole 200 mg | Insert into the vagina once a night for 3 nights |
Econazole 150 mg* | Insert into the vagina once at night |
Econazole 150 mg | Insert into the vagina once a night for 3 nights |
Miconazole 1200 mg | Insert into the vagina once at night |
* Formulated for single dose use. |
|
Basis for recommendation
- These recommendations are based on published expert opinion [CDC, 2006; FFPRHC and BASHH, 2006].
- The doses CKS has recommended for short courses are all licensed.
What long courses of antifungals are recommended?
- Oral antifungals:
- Fluconazole 100 mg once a day for 7 days.
- Itraconazole 200 mg once a day for 7 days.
- Intravaginal antifungals:
- Intravaginal pessaries. See Table 1 for more details.
- Intravaginal miconazole 2% cream:
- Insert 5 g into the vagina twice a day for 7 days.
- Insert 5 g into the vagina once a day for 14 days.
Table 1. Long courses of intravaginal pessaries recommended for vulvovaginal candidiasis.
Preparation | Directions |
|---|
Clotrimazole 200 mg* | Insert into the vagina once a night for 6 nights. |
Clotrimazole 100 mg* | Insert into the vagina once a night for 12 nights. |
Econazole 150 mg* | Insert into the vagina once a night for 6 nights. |
* Off licence use |
Basis for recommendation
- These recommendations are based on published expert opinion [CDC, 2006; FFPRHC and BASHH, 2006].
- The doses CKS has recommended for extended courses are guides, as published reviews and guidelines do not give details of what doses to use. Where possible CKS has recommend preparations that are licensed for extended use.
- Nystatin intravaginal cream (Nystan®) is no longer available in the UK.
Which antifungals can I prescribe if a woman is breastfeeding?
- Prescribe intravaginal imidazoles such as clotrimazole, econazole, or miconazole during breastfeeding.
Clarification / Additional information
- Oral fluconazole and itraconazole are not licensed during breastfeeding.
Topical imidazoles
- Topical products containing imidazoles (clotrimazole, miconazole, and econazole) may damage latex condoms and diaphragms [BNF 53, 2007].
- Local mild burning or irritation may occur on application of vaginal imidazole pessaries and creams. Very rarely the woman may find this intolerable and discontinue treatment.
Basis for recommendation
- The fatty excipients in topical antifungal products may damage latex condoms and diaphragms [Spence, 2006].
Oral fluconazole
- The most common adverse effects of fluconazole are gastrointestinal in nature, and include nausea, vomiting, bloating, diarrhoea, and abdominal discomfort [Micromedex, 2007].
- Fluconazole should not be co-administered with terfenadine. Serious dysrhythmias secondary to prolongation of the QTc interval have been reported in patients receiving other azole antifungals in conjunction with terfenadine [ABPI Medicines Compendium, 2005].
- Discontinue fluconazole if signs or symptoms of liver disease develop. Hepatotoxicity has been reported (very rarely) with fluconazole use [ABPI Medicines Compendium, 2005].
Clarification / Additional information
- Concerns have been raised in the literature that oral fluconazole may cause oral contraceptives to fail [Baxter, 2006]. However, because very few pregnancies have been reported in women taking oral fluconazole and an oral contraceptive, the Faculty of Sexual and Reproductive Healthcare (FSRH), formerly the Faculty of Family Planning and Reproductive Healthcare (FFPRHC), do not consider additional contraceptive precautions necessary when taking fluconazole [ABPI Medicines Compendium, 2005; FFPRHC, 2005].
Oral itraconazole
- The most common adverse effects associated with itraconazole are dyspepsia, abdominal pain, nausea, and constipation.
- There have been rare reports of liver toxicity.
- Advise the person to seek immediate medical attention if symptoms of possible liver toxicity develop, such as anorexia, vomiting, fatigue, abdominal pain, or dark urine [BNF 53, 2007].
- Avoid itraconazole in the following people:
- People with raised liver enzymes or active liver disease, or people who have a history of developing liver toxicity with other drugs, unless the benefits outweigh the risks.
- People with heart failure or a history of heart failure, unless the benefits outweigh the risks, as itraconazole has been shown to have a negative inotropic effect [ABPI Medicines Compendium, 2007].
- People taking astemizole, pimozide, quinidine or terfenadine, because there is a risk of cardiac arrhythmias.
- People taking a statin, as the risk of myopathy is increased [ABPI Medicines Compendium, 2007].
- As a result of rare reports of heart failure, the Committee on the Safety of Medicines (CSM) has advised caution when prescribing itraconazole to patients at high risk of heart failure [CSM, 2001], including:
- People receiving high doses and longer treatment courses.
- Older people and those with cardiac disease.
- People taking negative inotropic drugs (e.g. calcium-channel blockers).
- Baseline liver function tests (LFTs) may be considered for people taking short courses of itraconazole. LFTs should be checked if anorexia, jaundice, nausea, vomiting, fatigue, or abdominal pain occur, or if the urine becomes dark during treatment.
Clarification / Additional information
- There is anecdotal evidence that oral itraconazole may cause oral contraceptive failure, however the Faculty of Sexual and Reproductive Healthcare (FSRH), formerly the Faculty of Family Planning and Reproductive Healthcare (FFPRHC), do not consider additional contraceptive precautions necessary when taking itraconazole [FFPRHC, 2005].
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