Fluconazole
Fluconazole is an antifungal agent which is taken systemically (taken by mouth or intravenously). It is fungistatic, which means that it stops fungi (such as Candida albicans) from multiplying, but does not actually kill them. This accounts for the fact that sometimes it takes several days to have an effect.
Side Effects
Fluconazole is generally well tolerated, but there is no such thing as a drug which never has side effects. Concern about liver injury is exaggerated, since this complication seems quite rare, and usually occurs in people who are taking other medications as well, and who have taken fluconazole for months or longer, and who have immune deficiencies. But it is a possibility that needs to be kept in mind and if it does occur, it can be very serious.
Vomiting, diarrhea, abdominal pain and skin rashes are the most common side effects. These are not usually severe, and only occasionally is it necessary to stop the medication because of these side effects. Allergic reactions are possible but uncommon. Call your doctor immediately if you have any concerns.
Fluconazole in the milk
Fluconazole does appear in the milk, and this is as it should be, since the idea is to treat infection in the ducts and nipples. It is thus superior to ketoconazole, which gets into the milk in only tiny amounts. The baby will obviously get some, but this drug is now being promoted for use in babies for the treatment of simple thrush. There have been no complications in the baby reported from exposure to fluconazole in the breastmilk. Continue breastfeeding while taking fluconazole, though you may be told you cannot.
Dose of fluconazole
Candida albicans is learning to become resistant to fluconazole, and the dose we use has increased over the past few years. Only a few years ago, 100 mg daily for 10 days cured 90% of women of their symptoms. We have now found this to be inadequate. For resistant cases, a newer antifungal agent, itraconazole, can be used, though it may not be the answer either, as it does not have a very powerful effect against Candida.
Your prescription will be for fluconazole 400 mg as a first dose, followed by 100 mg twice daily for at least two weeks. If you have nipple pain continue with the "all purpose nipple ointment" while you are taking fluconazole. We like the mother to be symptom free for at least a week before stopping the medication. This seems, on the basis of our experience, a fairly good guarantee against relapse. However, this means that although most mothers require only the usual two weeks, some need longer treatment. Occasionally it may take up to a week for the pain to even start going away. Call your doctor if there is no relief in seven days.
It is sometimes useful to treat the baby as well. The dose for the baby would be 6 mg/kg as a first dose, followed by 3 mg/kg/day as one dose for the same period of time as the mother.
Note: The mother's 2 week prescription is likely to cost between $300 and $350, though there is now a generic fluconazole available which is less expensive.
Revised January 2000
Written by Jack Newman, MD, FRCPC
Used with permission.
