Treatment of Oral Candidiasis in Patients Taking Amitriptiline

First-Line Treatment

• The Infectious Diseases Society of America recommends clotrimazol in pastilles (troches) 10 mg 5 times a day for 7-14 days as the first-line treatment for oral candidiasis in patients taking amitriptiline 1, 2
• An alternative equally effective treatment is nistatina suspension 100,000 U/mL (4-6 mL four times a day) or pastilles of 200,000 U (one or two pastilles 4-5 times a day) for 7-14 days 1, 2

Second-Line Treatment

• If first-line treatment fails after 7-14 days or if the infection is moderate-severe, fluconazol oral 100-200 mg daily for 7-14 days is the treatment of choice 2, 4
• Fluconazol oral is superior to ketoconazol and itraconazol capsules due to its better absorption and demonstrated efficacy in multiple randomized studies 1, 2

Refractory Disease

• For infections that do not respond to fluconazol after 14 days, switching to itraconazol solution 200 mg once a day for 14-21 days is recommended 2, 4
• Additional alternatives include posaconazol suspension 400 mg twice a day for 3 days, then 400 mg daily; or voriconazol 200 mg twice a day 2, 4

Critical Warnings

• The American College of Clinical Pharmacy warns that fluconazol should not be used in patients taking clopidogrel, as fluconazol inhibits CYP2C19 moderately to strongly, reducing the antiplatelet effect and increasing cardiovascular risk 5
• In patients taking clopidogrel, topical agents (clotrimazol, miconazol) are preferred, with cure rates of 92-99% 5

Prevention of Recurrences

• Suppressive therapy with fluconazol 100-200 mg three times a week is indicated only if recurrences are frequent or incapacitating, to reduce the risk of developing antifungal resistance 2, 4
• Clinical improvement is expected within 7-14 days of starting appropriate treatment, with complete resolution expected 3-4 weeks after completing treatment 5, 6