Antifungal oral medication

Antifungal oral medication DEFAULT

Oral antifungal drugs

Created 2009.

Learning objectives

  • Prescribe oral antifungal agents appropriately and safely

Introduction

Oral antifungal drugs currently in use include itraconazole, fluconazole, ketoconazole and terbinafine. They are reserved for extensive or severe infection for which topical antifungal agents are inappropriate or ineffective, because of high cost, potential side effects and drug interactions. Griseofulvin is not discussed as it is no longer available in New Zealand. Nor is nystatin, as it is only appropriate for intestinal candidiasis. Voriconazole has recently become available but is reserve for the treatment of serious and refractory fungal infections in hospitalised patients.

Itraconazole

Oral itraconazole (Sporanox™) is a very useful broad spectrum antifungal drug. It should be taken after a fatty meal, preferably with an acidic drink such as orange juice.

Dosing regimes depend on the skin condition, its duration and severity, and need for prophylaxis. For example:

  • Skin infections: 200 mg daily for one to four weeks
  • Vulvovaginal candidiasis: 200 mg twice daily for one day OR 200 mg daily for 3 days, repeated if necessary or regularly once-weekly to once-monthly
  • Oral candidiasis: 100 mg daily for two weeks
  • Onychomycosis: 200 mg/day for 6-8 weeks (fingernails) or 3-4 months (toenails), OR 200 mg twice daily for 7 days, repeated monthly for 2 months (fingernails) or 3-4 months (toenails)

Nausea is the most common side effect. Abnormal liver function tests affect 5% of those on long term therapy but are rarely severe (monitoring is recommended for prolonged courses). It has been reported to cause congestive cardiac failure and serious rashes. The main concern with azoles is serious interactions with other medications.

As itraconazole needs acid for its absorption, antacids, H2 antagonists and omeprazole should not be taken for 2 hours after itraconazole.

These drugs should not be taken by those on itraconazole:

  • Cisapride
  • HMG Co-A reductase inhibitors (atorvastatin, lovastatin, simvastatin) – the interaction may cause heart failure; fluvastatin and pravastatin are acceptable alternatives.
  • Midazolam, triazolam
  • The antihistamines astemizole and terfenadine (withdrawn from New Zealand market)

The dose of these drugs should be reduced:

  • Warfarin
  • Digoxin
  • Methyl prednisolone
  • Ciclosporin
  • Tacrolimus
  • Vinca alkaloids

The dose of these drugs may need reducing if side effects arise:

  • Quinidine
  • Calcium channel blockers
  • Antidiabetic sulphonylureas

The following drugs decrease the concentration of itraconazole:

  • Rifampicin
  • Isoniazid
  • Phenytoin
  • Carbamazepine

Itraconazole is not thought to interact with the oral contraceptive pill and must be avoided in pregnancy.

Fluconazole

Fluconazole (Diflucan™) is a triazole used for candidiasis and cutaneous dermatophyte infections. It is not registered for nail infections. The dose and duration depends on the nature and severity of infection. Typically:

  • Oropharyngeal candidiasis: 50mg daily for 7-14 days
  • Vaginal candidiasis: 150 mg single dose
  • Dermatomycoses: 150 mg once weekly for 2 to 6 weeks

The main contraindication is concomitant administration with cisapride. It should be avoided in pregnancy / lactation and in the presence of electrolyte abnormalities, heart disease and renal impairment.

Side effects include:

  • GI disturbance
  • Rashes including urticaria, exfoliativedermatitis
  • Arrhythmias
  • Hepatotoxicity

Drug interactions are similar to those for itraconazole. Refer to a current prescribing text.

Ketoconazole

Ketoconazole (Nizoral™) is used to treat fungal infections where other treatments have failed or are contraindicated. It is effective for yeasts and dermatophytes and is usually prescribed in a daily dose of 200mg after food.

Its main concern is hepatic – liver function should be monitored. The incidence of significant hepatitis is about 1:1500, much higher than with itraconazole. It has similar interactions with other drugs.

Terbinafine

Terbinafine can be taken with or without food. Listed side effects include:

  • GI upset
  • Rashes including urticaria, toxicepidermal necrolysis
  • Arthralgia and myalgia
  • Taste disturbance
  • Hepatobiliary dysfunction
  • leukopenia

Drug interactions are not as frequent or as serious as with itraconazole. However, interactions are reported with tricyclic antidepressants, beta-blockers, SSRIa, MAOIs, hepatic enzyme inhibitors (cimetidine) or inducers (rifampicin) and possibly with oral contraceptives.

Activity

Refer to your local laboratory data, MIMS NZ and/or PHARMAC Pharmaceutical schedule. Find out the cost to treat an uncomplicated case of onychomycosis effectively.

  • Pre-treatment and follow-up visits to GP
  • Skin scrapings or nail clippings (single sample)
  • Topical therapy for 12 months
  • Oral therapy for 3 months
  • Monitoring blood count and liver function on two occasions

See smartphone apps to check your skin.
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Related information

References:

On DermNet NZ:

Information for patients

Other websites:

Books about skin diseases:

See the DermNet NZ bookstore

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Systemic antifungal agents for cutaneous fungal infections

Summary
Cutaneous fungal infections are usually treated topically, but nail and hair infections, widespread dermatophytosis and chronic non-responsive yeast infections are best treated with oral antifungal drugs. The oral drugs currently available in Australia for the treatment of cutaneous fungal infections include griseofulvin, ketoconazole, fluconazole, itraconazole and terbinafine.

Introduction
The cutaneous mycoses are superficial fungal infections of the skin, hair or nails. Essentially no living tissue is invaded; however, a variety of pathological changes occur in the host because of the presence of the fungus and/or its metabolic products. The principal aetiological organisms are:

  • dermatophytic moulds belonging to the genera Microsporum, Trichophyton and Epidermophyton which cause ringworm or tinea of the scalp, glabrous (hairless) skin and nails
  • Malassezia furfur, a lipophilic yeast responsible for pityriasis versicolor, follicular pityriasis, seborrhoeic dermatitis and pityriasis capitis (severe dandruff)
  • Candida albicans and related species, causing candidiasis of skin, mucous membranes and nails

The usual approach to the management of cutaneous infections in immuno competent patients is to treat with topical agents. However, nail and hair infections, widespread dermatophytosis and chronic non-responsive yeast infections are best treated with oral antifungal drugs.

When to use systemic therapy

Dermatophytosis (tinea or ringworm) of the scalp, skin and nails
Most dermatophytic skin infections in their early stages are responsive to topical therapy. Examples are interdigital tinea, tinea cruris and localised tinea on other parts of the body. However, once there is involvement of nails or hair, topical therapy is rarely adequate. The major indications for using oral antifungals are:

  • tinea capitis - this never responds adequately to topical therapy
  • tinea affecting the nails - sometimes nail removal combined with topical treatment may be effective when one or, at most, two nails are involved, but in most instances, oral therapy will be required for a true cure
  • tinea involving more than one body region simultaneously, e.g. tinea cruris and corporis, or tinea cruris and tinea pedis. Patient compliance with topical treatment is rarely adequate enough to treat two body regions effectively at the same time
  • tinea corporis where the lesions are particularly extensive
  • tinea pedis when there is extensive involvement of the sole, heel or dorsum of the foot or when there is recurring and troublesome blistering
  • tinea of a localised body area which is sufficiently annoying and recurrent after topical therapy to justify systemic therapy and its attendant risks

Chronic non-responsive yeast infections
Most Candida infections of the skin or mucosa are due to impaired epithelial barrier functions and respond readily to topical antifungal therapy. Basically, healthy individuals do not get candidiasis; therefore, a key strategy in treatment is to correct the underlying predisposing conditions that allow Candida to colonise the skin or mucosa.

Most cases of pityriasis (tinea) versicolor and seborrhoeic dermatitis, with pityriasis capitis being the mildest manifestation, also readily respond to topical treatment. As the causative yeast Malassezia furfur is part of the normal skin flora, prophylactic treatment is often necessary to avoid recurrences.

The major indications for use of oral antifungals are in cases where topical treatment has failed:

  • pityriasis versicolor where the lesions are particularly extensive and resistant to topical treatment
  • candidiasis where the lesions are particularly extensive and resistant to topical treatment
  • vaginal candidiasis which is sufficiently annoying and recurrent after topical therapy
  • candidiasis of the nails

How should the decision to treat be confirmed?
When oral therapy is being contemplated, it is mandatory to confirm that a dermatophyte or yeast infection is present, either by microscopy or culture.

Disadvantages of topical drugs
Although topical drugs can provide an immediate reduction in infectivity, are free of systemic adverse effects and are relatively inexpensive, they have some disadvantages. Local irritation is the most common adverse effect and is easily reversible.

There are major problems with compliance as the patient finds it difficult to continue treatment or to know where to apply the cream once the inflammatory signs have settled. In practice, most topical drugs would need to be continued for some time after disappearance of the symptoms and visible signs. Topical drugs may be difficult to use in certain areas e.g. on the hair and nails, and in some more sensitive areas such as the vagina, groin or the natal cleft.

Advantages and disadvantages of systemic drugs
The advantages of systemic therapy are essentially those of enhanced compliance, particularly in areas where treatment times with topical drugs would need to be long, such as on the foot. Other advantages are the ability to treat several body regions at the same time and areas that are not obviously infected.

The disadvantages are principally those of potential adverse effects. There are also cost considerations, particularly with the newer systemic antifungals.

Oral antifungal drugs

Griseofulvin
This is an oral fungistatic agent derived from a number of Penicillium species. It inhibits cell division and nucleic acid synthesis in fungi. Griseofulvin is active against dermatophytes, but has no effect against yeasts or other fungi. The usual adult dose is 500 mg/day and an ultra micro size formulation of 330 mg/day is also available (not less than 10 mg/kg should be given). However, higher doses of 1000 mg/day are commonly given when treating nail infections. The dose for children under 25 kg is 10 mg/kg and for children over 25 kg is 250-500 mg daily. It is best taken with food to facilitate absorption. The duration of therapy varies from patient to patient and on the site and severity of the infection, with 4-6 weeks required for skin and hair infections and 12 months for nails. Relapse is common, especially for nails where between 40-70% of patients fail treatment.

Griseofulvin is usually well tolerated. Adverse effects include headache, gastrointestinal disturbance and, less commonly, urticaria, diarrhoea and photosensitivity. The drug should be avoided during pregnancy and in patients with liver disease. Griseofulvin can diminish the anticoagulant effect of warfarin and concurrent administration of phenobarbitone may decrease griseofulvin's bioavailability. Griseofulvin may also interact with alcohol, causing a disulfiram type reaction. Therefore, alcohol will be a contraindication to its use in many patients.

Ketoconazole
Ketoconazole is an oral or topical synthetic dioxolane imidazole compound that interferes with the biosynthesis of ergosterol, leading to alterations in certain membrane-associated cell functions. It has a high affinity for keratin and a broad spectrum of activity which includes both dermatophytes and yeasts. The risk of hepatitis, albeit rare (1 in 10 000 to 1 in 15 000 of patients treated with a medium time of onset of one month), makes ketoconazole a secondary choice for dermatophyte infections. However, ketoconazole has become the drug of choice for treating Malassezia infections and is an important adjunct in the treatment of AIDS patients with fluconazole-resistant Candida infections.

Ketoconazole is not absorbed systemically following topical application, but is well absorbed orally under acid conditions. It is poorly absorbed in patients with achlorhydria and in those taking antacids or H2 receptor antagonists. The usual adult dose is 200-400 mg/day depending on the infection being treated. In children, a dose of 3 mg/kg can be used. The duration of treatment will also depend on the nature of the infection.

Liver function must be monitored in patients receiving treatment for more than 30 days. The most common adverse effects are nausea, anorexia and vomiting occurring in about 20% of patients. Adrenal or testicular steroid metabolism may be affected. Co-administration of ketoconazole with either terfenadine or astemizole has been associated with potentially fatal cardiac arrhythmias. Ketoconazole also enhances the effects of warfarin, oral hypoglycaemics and phenytoin.

Fluconazole
Fluconazole is an oral synthetic bis-triazole compound that inhibits the cytochrome P450-dependent 14 alpha-demethylation step in the formation of ergosterol. This leads to alterations in a number of membrane-associated cell functions. Fluconazole has a broad spectrum of activity that includes both dermatophytes and yeasts. The drug is particularly effective in the treatment of mucosal and cutaneous forms of candidiasis. It is currently the drug of choice for controlling oropharyngeal candidiasis in AIDS patients.

Absorption of fluconazole is not dependent on acid conditions and is also unaffected by food intake. The usual adult doses range from 100-400 mg/day, depending on the immune status of the patient, the infecting organism and the patient's response to therapy. With most mucocutaneous diseases in immuno competent patients, the recommended adult dose is 150 mg/week for 4 weeks. Vaginal candidiasis usually responds to a single dose of 150 mg.

Fluconazole is generally well tolerated with minor adverse effects such as nausea and vomiting occurring in a few patients. Unlike ketoconazole and itraconazole, fluconazole has few significant drug interactions. However, the effects of warfarin, oral hypoglycaemics, phenytoin and theophylline may be increased by fluconazole when given in doses of 200mg/day or higher.

Itraconazole
This is an oral synthetic dioxolane triazole compound that functions in much the same way as fluconazole. It has a broad spectrum of activity that includes both dermatophytes and yeasts. Itraconazole can be used to treat various cutaneous infections, including dermatophytosis, pityriasis versicolor and oral and vaginal forms of candidiasis.

Absorption from the gastrointestinal tract is improved if the drug is given with food or under acid conditions. The usual adult dose for cutaneous infections is 100-200 mg/day depending on the infection being treated.

Itraconazole is generally well tolerated with minor adverse effects of nausea, headache and abdominal pain being reported in a few patients. Itraconazole concentrations are reduced following concomitant administration of phenytoin, rifampicin, antacids and H2 antagonists. Co-administration of terfenadine or astemizole with itraconazole is contraindicated and the effects of warfarin, oral hypoglycaemics, phenytoin and digoxin may be enhanced.

Table 1
Oral treatment options for cutaneous fungal infections

(In general, the treatment options are listed in order of currently accepted cost-effectiveness, although in some cases those listed as alternatives may be just as or more effective in terms of treatment outcome.)

Infection Recommended Alternative
Tinea unguium (Onychomycosis) Terbinafine 250 mg/day - 6 weeks for finger nails, 12 weeks for toe nails Itraconazole 200 mg/day/3-5 months or 400 mg/day for one week per month for 3 consecutive months. Griseofulvin 500-1000 mg/day until cure (approximately 12 months)
Tinea capitis Griseofulvin 500 mg/day (not less than 10 mg/kg/day) until cure (4-6 weeks) Terbinafine 250 mg/day/4 weeks, Itraconazole 100 mg/day/4 weeks
Tinea corporis Griseofulvin 500 mg/day until cure (4-6 weeks), often combined with a topical imidazole agent Terbinafine 250 mg/day/2-4 weeks, Itraconazole 100 mg/day/15 days, Fluconazole 150 mg/week for 4 weeks
Tinea cruris Griseofulvin 500 mg/day until cure (4-6 weeks) Terbinafine 250 mg/day/2-4 weeks, Itraconazole 100 mg/day/15 days, Fluconazole 150 mg/week for 4 weeks
Tinea pedis Griseofulvin 500 mg/day until cure (4-6 weeks) Terbinafine 250 mg/day/2-6 weeks, Itraconazole 100 mg/day/4 weeks, Fluconazole 150 mg/week for 4 weeks
Chronic and/or widespread non- responsive tinea Terbinafine 250 mg/day for 4-6 weeks Itraconazole 200 mg/day/4-6 weeks Griseofulvin 500-1000 mg/day
until cure (3-6 months)
Chronic or severe pityriasis versicolor or pityriasis capitis Ketoconazole 400 mg single dose non-responsive or 200 mg/day for 5-10 days Itraconazole 200 mg/day/5-7 days, Fluconazole 400 mg single dose, or 150 mg/week for 4 weeks
Chronic/recurrent mucocutaneous candidiasis Fluconazole 150 mg/week for 4 weeks Itraconazole 200 mg/day/5-7 days, Ketoconazole 200 mg/day/5-10 days
Recurrent vaginal candidiasis Fluconazole 150 mg single dose Itraconazole 400 mg single dose
(two 200 mg doses 8 hours apart)
Candidiasis of the nail Itraconazole 200 mg/day
for 3-5 months or 400 mg/day
for one week per month
for 3 consecutive months
Fluconazole 150 mg/week for 10-12 months
Please consult the relevant product information sheet for prescribing details

Terbinafine
This is an oral or topical synthetic allylamine compound that inhibits the action of squalene epoxidase, a crucial enzyme in the formation of ergosterol, leading to membrane disruption and cell death. It is a fungicidal agent with a limited clinical spectrum of activity primarily against dermatophytes. Oral terbinafine has become the drug of choice for dermatophytosis of nails. It is also the drug of choice for dermatophytosis of the skin and/or scalp where griseofulvin has failed or is contraindicated.

The drug is well absorbed and is strongly lipophilic, being concentrated in the dermis, epidermis and adipose tissue. Terbinafine is metabolised by the liver and the inactive metabolites are excreted in the urine. The usual adult dose is 250 mg/day with the duration of treatment dependent on the site and extent of the infection, ranging from two weeks for inter digital tinea pedis, 4-6 weeks for widespread or chronic non-responsive dermatophytosis of skin and/or scalp, to 12 weeks for nails.

Terbinafine is generally well tolerated with the most common adverse effects being nausea and abdominal pain, and allergic skin reactions, but these are often mild and transient. Taste disturbance and hepatic toxicity have also been reported.

Which drugs should be used when?
The oral treatment options for adults with superficial fungal infections are set out in Table 1.

Conclusion
The treatment of cutaneous fungal infections may require systemic treatment for a number of reasons relating to site, host and invading organism. There is now a large range of therapeutic options available which are, on the whole, safe and effective.

Further reading
Balfour JA, Faulds D. Terbinafine. A review of its pharmacodynamic and pharmacokinetic properties, and therapeutic potential in superficial mycoses. Drugs 1992;43:259-84.

Elewski BE. Cutaneous fungal infections. Topics Clin Dermatol 1992. (unverified)

Grant SM, Clissold SP. Itraconazole. A review of its pharmacodynamic and pharmacokinetic properties, and therapeutic use in superficial and systemic mycoses. Drugs 1989;37:310-44.

Grant SM, Clissold SP. Fluconazole. A review of its pharmacodynamic and pharmacokinetic properties, and therapeutic potential in superficial and systemic mycoses. Drugs 1990;39:877-916.

McGrath J, Murphy GM. The control of seborrhoeic dermatitis and dandruff by antipityrosporal drugs. Drugs 1991;41:178-84.

Sours: https://www.nps.org.au/australian-prescriber/articles/systemic-antifungal-agents-for-cutaneous-fungal-infections
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Fungal infections are caused by fungi that commonly exist in the environment. Infections are usually at superficial layer and often involve the nails, hair and skin. The symptoms of fungal infection depend on the type of infection and location within the body. Common types of fungal infection and associated symptoms are:

1. Athlete’s foot – which usually affects the skin between toes. There may be symptoms of blisters or peeling off of dry and cracked skin, resulting in strong itchiness at the infected sites.

2. Fungal nail infection – which causes the toenails or fingernails to become thickened, discolored, curled, crumbly and sometimes brittle, with pieces of nail breaking off.

3. Ringworm – which causes a ring-shaped red rash on the skin of the body or scalp.


4. Vaginal thrush – which causes irritation and swelling of the vagina and vulva.


Invasive fungal infections are less common, but more serious type of fungal infection may result. They are infections that occur deep inside the body’s tissue or in one of the organs, such as brain and lung.

People who are suffering from diabetes mellitus or other diseases associated with weakened immune system will have greater chance of having fungal infections because of their weakened immunity. Besides, people who have poor nutrition and hygiene, experience occlusion of the skin, and live in places with warm, humid climates are some other predisposing factors for fungal infections.

 

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Most fungal infections can be treated by topical antifungal medications. However, if the infection is very extensive or serious, oral antifungal drugs may be required. Besides, medical treatment is no substitute for good personal hygiene to control the disease and prevent recurrence.

There are many different types of antifungal drugs, targeting at different fungal infections. The choice of antifungal drugs depends on factors such as the type of infection and the medical or drug history of the patient. Therefore, it is of utmost importance that medical advice is sought before using any antifungal drugs.

 

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Common used oral antifungal drugs

Majority of the oral antifungal drugs are prescription-only medicines and are available in various dosage forms such as tablets, capsules and suspensions.  They should only be used under close supervision by healthcare professionals.

Oral antifungals can be generally classified into three main groups: allylamines, azoles and other antifungals. 

Allylamines and azoles kill the fungal cells by different mechanisms of action, such as by affecting a substance in the cell wall, causing the contents of the cell to leak out and so the cell dies.  Example of allylamines is terbinafine and examples of azoles include fluconazole, itraconazole and ketoconazole.  Other antifungals such as griseofulvin act by preventing the fungal cells from growing and reproducing.

 

In ideal case, antifungal treatment should be chosen after the infecting organism has been identified, but it is often necessary to start treatment before the pathogen can be cultured and identified, especially in immunocompromised patients in whom infections are often rapidly progressive.

 

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Common side effects of oral antifungal drugs

As with all medicines, oral antifungal drugs have side effects. In most cases, the side effects are mild and only last for a short period of time, but there are rare cases of causing more serious effects.

Common side effects such as:

  • Feeling sick
  • Nausea
  • Abdominal discomfort or pain
  • Diarrhea
  • Flatulence
  • Headache
  • Rash
  • Indigestion

Oral antifungal drugs can also cause severe reactions such as allergic reaction (swelling of your face, neck or tongue or difficulty in breathing) and severe skin reaction (such as peeling or blistering skin). Besides, in rare cases, liver damage (particularly for ketoconazole and itraconazole) can occur.

 

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Precautions of oral antifungal drugs

Oral antifungal drugs should be avoided or used with caution in patients with liver disease or with history of liver damage with other drugs.  You should inform your doctor if any drugs are taking, and be familiar with the signs of liver disorder and seek medical attention immediately if symptoms such as decreased appetite, nausea, vomiting, fatigue, abdominal pain or dark urine develop.

Some oral antifungal drugs should be used with caution in patients with heart or kidney problems.  Besides, most of them should be avoided in patients with acute porphyria, which is a genetic disorder that can affect your nervous system or skin or both.

Taking other medications, such as the stomach pill antacid, may interfere with the absorption of oral antifungal drugs. Besides, oral antifungal drugs may alter the effectiveness of other medications such as oestrogens, which are hormones found in some contraceptives and warfarin, which is an anticoagulant.

 

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General advice on taking oral antifungal drugs

  • Complete the recommended course of treatment.  Do not stop the treatment too early, otherwise the infection could recur.

  • The duration of treatment required may be notoriously long and you need patience and should comply with doctor’s instruction.

  • Practice good personal hygiene.  Always clean the skin and feet thoroughly when taking a bath.

  • Always keep the body dry, such as dry the body completely after bathing, especially between the toes.

  • Wear clean and dry shoes and cotton socks.

  • Change socks every day. Wash socks, clothing and towels frequently.

  • Avoid wearing tight underwear.  Clothes made of cotton are the best choice.

  • Never share clothing, shoes, socks or towels and other personal belongings such as combs, nail clippers, hair accessories, hats and pillows with other people.

  • Always wash hands after contacting the diseased skin so as to prevent spread of infection.

 

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Communication with your doctor

  • Communicate with your doctor for the best treatment option.  Your doctor will prescribe the most appropriate drugs and dosage.

  • Some antifungal drugs can interact with other medicines.  Inform your doctor of the medicines you are taking, including over-the-counter medicines, so they can decide which an antifungal medicine is safe for you to take.

  • Inform your doctor of your medical history, as some diseases may warrant special precautionary measures.

  • Inform your doctor that you are pregnant or breast feeding as most oral antifungal drugs should not be taken by women who are pregnant or breast feeding.

  • Seek medical advice immediately if you experience any symptoms or side effects suspected to be related to antifungals.

  • Have regular medical follow-ups as advised by your doctor if you need to use antifungals on a long-term basis.

  • Seek medical advice if your symptoms worsen or you have any concerns about the medicines you are taking.

 

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Storage of oral antifungal drugs

Oral antifungal drugs should be kept in a cool and dry place. Unless specified on the label, medicines should not be stored in refrigerators. Furthermore, drugs should be kept properly in places unreachable by children to prevent accidental ingestion.

 

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Acknowledgement: The Drug Office would like to thank the Professional Development and Quality Assurance (PD&QA) for their valuable contribution to the preparation of this article.

 
Sours: https://www.drugoffice.gov.hk/eps/do/en/consumer/news_informations/dm_18.html

Antifungal Medicines

What are antifungal medicines and how do they work?

There are several types of antifungal medicines. They come as creams, sprays, solutions, tablets designed to go into the vagina (pessaries), shampoos, medicines to take by mouth, and injections. Most work by damaging the cell wall of the fungus, which causes the fungal cell to die.

Antifungal creams, liquids or sprays (also called topical antifungals)

These are used to treat fungal infections of the skin, scalp and nails. They include clotrimazole, econazole, ketoconazole, miconazole, tioconazole, terbinafine, and amorolfine. They come in various different brand names.

Sometimes an antifungal cream is combined with other creams when two actions are required. For example, an antifungal cream is often combined with a mild steroid cream, such as hydrocortisone, to treat certain rashes. The antifungal cream clears the infection, and the mild steroid cream reduces the inflammation caused by the infection.

There are also separate leaflets in this series that deal with Candidal Skin Infection (Yeast Infection), Fungal Scalp Infection (Scalp Ringworm) and Fungal Nail Infections (Tinea Unguium).

Antifungal shampoo

A shampoo which contains ketoconazole is sometimes used to help treat scalp fungal infections and certain skin conditions.

Antifungal pessaries

Pessaries are tablets which are designed to be put into the vagina. Some antifungal medicines are used as pessaries to treat vaginal thrush, particularly clotrimazole, econazole, miconazole, and fenticonazole

Antifungal medicines taken by mouth

There are various types. For example:

Miconazole is available as an oral gel, and nystatin as a liquid. They are applied to the mouth. They are used to treat thrush (candidal infection) of the mouth and throat.

Terbinafine, itraconazole, fluconazole, posaconazole, and voriconazole are available as tablets, which are absorbed into the body. They are used to treat various fungal infections. The one chosen depends on what type of infection you have. For example:

  • Terbinafine is commonly used to treat nail infections which are usually caused by a tinea type of fungus.
  • Fluconazole is commonly used to treat vaginal thrush, as an alternative to using antifungal cream. It is also used to treat and prevent certain fungal infections within the body.

There are also separate leaflets in this series dealing with athlete's foot, ringworm and fungal groin infection.

Antifungal injections

These may be used if you have a serious fungal infection within the body. Amphotericin, flucytosine, itraconazole, voriconazole, anidulafungin, caspofungin, and micafungin are medicines that are sometimes used in this way. The one chosen depends on the type of fungus causing the infection. These are specialist medications that are used for people who are usually quite ill in hospital.

Note: antifungal medicines are different to antibiotics, which are antibacterial medicines. Antibiotics do not kill fungi - they kill other types of germs (called bacteria). In fact, you are more prone to getting a fungal infection if you take antibiotics. For example, many women develop thrush after taking a course of antibiotics. This is because the antibiotic may kill the normal harmless bacteria that live on your skin or vagina and make it easier for fungi to flourish.

There are several types of antifungal medicine

What are the possible side-effects of antifungal medication?

You should read the information leaflet that comes with your particular brand for a full list of cautions and possible side-effects. As a general rule:

  • Antifungal creams, sprays, liquids and shampoos. These usually cause no side-effects and are easy to use. Occasionally some people get a little bit of itch, burning or redness where the antifungal preparation has been applied. If this is severe, you should stop using it. Occasionally, some women develop irritation around the vagina after applying vaginal antifungal products.
  • Antifungal medicines by mouth. The most widely used are terbinafine for nail infections, miconazole, and nystatin for oral thrush, and fluconazole for vaginal thrush. These usually cause no side-effects. You can even buy fluconazole without a prescription at pharmacies, as it is considered a medicine which is unlikely to cause problems. Some antifungal preparations cause liver problems or more serious side-effects in a small number of people. A few common possible side-effects of some of the more widely used antifungal medicines are as follows:
    • Terbinafine sometimes causes tummy aches, loss of appetite, feeling sick (nausea), tummy upsets, diarrhoea, headache, rash, taste disturbance and muscle or joint pains.
    • Fluconazole may cause nausea, tummy ache, diarrhoea, wind, headache, or a rash.
    • Miconazole may cause nausea or sickness (vomiting), or a rash.
    • Nystatin may cause soreness of the mouth.
  • Antifungal injections. These have more risk of causing side-effects and sometimes serious problems. However, these are used to treat serious fungal infections and the risk of side-effects needs to be balanced against the need for treatment.

What is the usual length of treatment with antifungal medication?

  • Fungal skin infections like athlete's foot or ringworm: a cream is usually used for two weeks as a minimum. Sometimes up to six weeks' treatment is needed with a cream.
  • Fungal nail infections: if taking an antifungal pill like terbinafine, treatment is usually used for two months.
  • Fungal infections in lungs: this is a more serious condition and the duration of treatment will be decided by a specialist in that field.

Who cannot take or use antifungal medication?

  • Generally everybody can use the antifungal creams without a problem: if in doubt, take advice from your doctor.
  • The antifungal pills are stronger than the creams and can interact with any other pills you are taking. You must check with a doctor before taking an antifungal pill, if you take other medicines.
  • Generally young children should not take antifungal tablets, but are OK to use the creams.
  • Elderly people should ask their doctor before using an antifungal pill, but are generally fine to use the antifungal creams.

Can I buy antifungal medication?

Yes - there a number of antifungal creams you can buy at your pharmacy (for example, clotrimazole, and terbinafine). In addition, you can also buy oral fluconazole from your pharmacy, to treat vaginal thrush. Be aware though that if you use the wrong cream then it can make fungal skin infections worse. For example, steroids should not be used on athlete's foot: only terbinafine cream by itself. If you put steroid cream on athlete's foot it usually makes it worse.

How to use the Yellow Card Scheme

If you think you have had a side-effect to one of your medicines you can report this on the Yellow Card Scheme. You can do this online at www.mhra.gov.uk/yellowcard.

The Yellow Card Scheme is used to make pharmacists, doctors and nurses aware of any new side-effects that medicines or any other healthcare products may have caused. If you wish to report a side-effect, you will need to provide basic information about:

  • The side-effect.
  • The name of the medicine which you think caused it.
  • The person who had the side-effect.
  • Your contact details as the reporter of the side-effect.

It is helpful if you have your medication - and/or the leaflet that came with it - with you while you fill out the report.

Sours: https://patient.info/infections/fungal-infections/antifungal-medicines

Medication antifungal oral

Antifungal medicines

Antifungal medicines are used to treat fungal infections, which most commonly affect your skin, hair and nails.

You can get some antifungal medicines from a pharmacy without needing a GP prescription.

Infections antifungals can treat

Fungal infections commonly treated with antifungals include:

Some fungal infections can grow inside the body and need to be treated in hospital.

Examples include:

You're more at risk of getting one of these more serious fungal infections if you have a weakened immune system – for example, if you're taking medicines to suppress your immune system.

Types of antifungal medicines

You can get antifungal medicines as:

  • a cream, gel, ointment or spray
  • a capsule, tablet or liquid
  • an injection
  • a pessary: a small and soft tablet you put inside the vagina

Common names for antifungal medicines include:

How antifungal medicines work

Antifungal medicines work by either:

  • killing the fungus
  • preventing the fungus from growing

When to see a pharmacist or GP

See a pharmacist or GP if you think you have a fungal infection. They can advise you on which antifungal medicine is best for you.

If you take too much antifungal medicine, call 111 or speak to a pharmacist or GP.

If you're advised to go to hospital, take the medicine's packaging with you so the healthcare professionals who treat you know what you've taken.

Things to consider when using antifungal medicines

Before taking antifungal medicines, speak to a pharmacist or GP about:

  • any existing conditions or allergies that may affect your treatment for fungal infection
  • the possible side effects of antifungal medicines
  • whether the antifungal medicine may interact with other medicines you may already be taking
  • whether your antifungal medicine is suitable to take during pregnancy or while breastfeeding – many are not suitable

You can also check the patient information leaflet that comes with your antifungal medicine for more information.

Side effects of antifungal medicines

Antifungal medicines may cause side effects. These are usually mild and do not last long.

They can include:

  • itching or burning
  • redness
  • feeling sick
  • tummy (abdominal) pain
  • diarrhoea
  • a rash

Occasionally, antifungal medicines may cause a more severe reaction, such as:

  • an allergic reaction – your face, neck or tongue may swell and you may have difficulty breathing
  • a severe skin reaction – such as peeling or blistering skin
  • liver damage (very rarely) – you may have loss of appetite, vomiting, nausea, jaundice, dark pee or pale poo, tiredness or weakness

Stop using the medicine if you have these severe side effects, and see a GP or pharmacist to find an alternative.

If you're having difficulty breathing, go to A&E or call 999.

Reporting side effects

If you think a medicine has made you unwell, you can report this side effect through the Yellow Card Scheme.

Antifungal medicines for children

Some antifungal medicines can be used to treat children and babies – for example, miconazole oral gel can be used for oral thrush in babies.

But different doses are usually needed for children of different ages. Speak to a pharmacist or GP for more advice.

Page last reviewed: 27 July 2020
Next review due: 27 July 2023

Sours: https://www.nhs.uk/conditions/antifungal-medicines/
What is the frequency of anti fungal medications for Oral Thrush? - Dr. Jayaprakash Ittigi

Oral antifungal medication

Oral antifungal medication — codes and concepts

Introduction

Oral antifungal medications may be required for fungal infection if:

The choice of oral antifungal medication, its dose and the duration of treatment depend on:

  • The type of fungus i.e. candida, dermatophyte (tinea), malassezia, or mould.
  • The site affected i.e. skin, mucosa, nails.
  • Other co-existing diseases.
  • Interactions with other medications.

Medication for both candida and dermatophyte infections (azoles)

The trade names of the medications sold in New Zealand are given in parentheses.

Voriconazole (Vfend® tablets) and posaconazole are reserved for serious invasive Candida and mould infections.

Some species of candida are resistant to azoles, and azole resistance is increasing especially in immunosuppressed patients who are prescribed long courses.

Medications only suitable for candida infections

  • Nystatin (Mycostatin®, Nilstat®), a polyene. This is not absorbed into the bloodstream through the gut.
  • Flucytosine (Alcobon® infusion), usually used with amphotericin. It can cause bone marrow depression.
  • Amphotericin B (Ambisome® injection; Fungizone® infusion), a polyene. This is not absorbed into the bloodstream through the gut.
  • Caspofungin, anidulafungin and micafungin (echinocandins)

Medications only suitable for dermatophyte infections

  • Griseofulvin (no longer available in New Zealand), derived from Penicillium
  • Terbinafine (Lamisil®, Terbafin® tablets), an allylamine.

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