Nizoral (ketoconazole) is taken at 200 or 400mg once a day with acidic food or beverage. Antacids should be avoided. It should also not be taken at the same time as other therapies that have a buffer or antacid, like Videx (didanosine, ddI). It may not be well absorbed in people with gut problems or who cannot eat very much.
Fungizone (amphotericin B, AmB) is given directly into a vein to treat systemic candidiasis when other therapies fail or the infection is very aggressive. It can be very difficult to tolerate. People are usually given the drug until they start to improve (usually 2 weeks) and then switched to fluconazole at 200-400mg per day. Other forms of AmB are used when systemic infections become resistant or less responsive to standard therapy, including Amphotec and Abelcet. These may have fewer side effects than standard AmB, but all can be quite toxic.
Fluconazole is usually taken at 200mg the first day, then 100mg once a day thereafter. Treatment typically lasts 2 weeks for oral or therapyskin candidiasis and 3 weeks for esophageal infection
Studies suggest that fluconazole is more effective than ketoconazole, but some doctors prefer to treat with other drugs in order to save the potent fluconazole for later use, if necessary. Once fluconazole resistance develops, then treatment options are very limited.
Itraconazole (Sporanox) appears to be at least as potent as ketoconazole and may be as good as fluconazole. It should be taken with acidic food or beverage. The dose is 200mg per day.
Itraconazole oral solution is more effective and puts higher levels of the drug in the blood than the capsule. There are possible interactions between itraconazole and many HIV drugs.
Topical creams and ointments may cause mild burning, blisters and peeling on sensitive skin. Some creams also contain a steroid to reduce inflammation. Vaginal tablets do not often cause problems, but may lead to vaginal burning, itching or skin rash. Some women experience cramps or headaches.
Lozenges may cause minor changes in liver function. Oral irritation and nausea are rare side effects. Oral rinses may cause gut problems if many doses are taken.
Side effects for the oral azole drugs are similar, but some studies show they're more common with itraconazole. The most common are nausea, vomiting and belly pain. Others include headaches, dizziness, drowsiness, fever, diarrhea, rash and changes in taste. The most serious problem is liver toxicity, but this is rare and usually reverses after the drug is stopped. Liver function tests should be done, particularly with ketoconazole.
AmB has many side effects, and some quite severe. Therefore, it's only used in cases when there's a direct threat to life or all other treatments have failed. Main side effects include kidney side effects and anemia. Others include fever, chills, changes in blood pressure, changes in appetite, nausea, vomiting and headache.
Tips for Preventing Fungal Infections
Overall, the best way to naturally prevent fungal infections is to eat healthfully and regularly, avoid excessive sugar intake, and avoid or decrease alcohol, caffeine, dairy and cigarettes.
- Decrease or avoid sugars (corn and maple syrup, glucose, fructose and sucrose). Sugar is food for Candida and helps it grow. Read the labels on packaged foods for these sugars.
- Decrease or avoid alcohol. Alcohol converts to sugar and helps Candida grow.
- Drink milk or eat yogurt that contains acidophilus bacteria -- "friendly" bacteria that helps your body fight off "unfriendly" germs, like Candida.
- Eat larger amounts of food that may keep yeast from growing. Some nutritionists believe garlic has natural antifungal properties. Fresh garlic is considered best. (NOTE: Large amounts of garlic may interfere with HIV meds, especially Norvir (ritonavir).
- Antibiotics may lead to yeast infections. "Friendly" bacteria are found naturally in the body and help clear unfriendly yeasts. Common antibiotics kill these bacteria which then allow yeast to grow.
Most cases of candidiasis that fail to respond to treatment have been reported. This is partly due to the widespread, long-term use of azoles for treating and preventing candidiasis.
Resistance to azole drugs often requires using AmB. While potent and effective, the drug is toxic, especially to the kidney. Newer versions (ABLC, Ambisome and Abelcet) have proven less so. Some people may better tolerate these versions.
Nevertheless, exposure to azole treatment decreases the antifungal activity of AmB. This may be the case for newer, less toxic forms of the drug. However, 2 other drugs are active against azole-resistant candidiasis: voriconazole (Vfend) and Cancidas (caspofungin acetate).
Using antifungal drugs to prevent fungal infections is approached with great caution and is generally discouraged, especially using fluconazole this way. This makes treating newer and more aggressive infections more difficult and often unsuccessful. However, this may not be possible in some people with recurrent infections who must remain on long-term therapy to prevent them.
Antifungal Drugs and Pregnancy
The Federal Guidelines for the Prevention of Opportunistic Infections recommend not using antifungal drugs during pregnancy due to possible birth defects. They further state that azoles be stopped in women who become pregnant and that women taking these drugs use effective birth control.
Topical therapies may be preferable for pregnant women. For systemic treatment the Guidelines suggest using AmB, especially in the first trimester.
Although no formal studies have been done, pregnant women have used aMb without apparent harm to their unborn children, though the drug has possible severe side effects.