Compounding Nystatin-Dexamethasone Mouthwash
To compound a nystatin 10,000 units/mL with dexamethasone mouthwash, dilute commercially available nystatin oral suspension (100,000 units/mL) 1:10 with dexamethasone 0.5 mg/5 mL oral solution to achieve the target nystatin concentration while incorporating the steroid component.
Practical Compounding Instructions
Starting Materials
- Nystatin oral suspension: 100,000 units/mL (commercially available) 11
- Dexamethasone oral solution: 0.5 mg/5 mL (alcohol-free preferred)
Compounding Formula
For a 100 mL final volume:
- Take 10 mL of nystatin suspension (100,000 units/mL)
- Add 90 mL of dexamethasone oral solution (0.5 mg/5 mL)
- Mix thoroughly
This yields:
- Nystatin concentration: 10,000 units/mL
- Dexamethasone concentration: approximately 0.045 mg/mL
Stability Considerations
Store the compounded preparation at 5°C (refrigerated) and use within 7 days 2. Research demonstrates that nystatin at lower concentrations (14,400 units/mL) in alkaline environments maintains >90% potency for 7 days when refrigerated, but only 4 days at room temperature 2. Your 10,000 units/mL concentration should follow similar stability parameters.
Clinical Context
This combination addresses two therapeutic goals:
Antifungal activity: Nystatin 10,000 units/mL provides adequate antifungal coverage for mild oropharyngeal candidiasis. Standard dosing for oral candidiasis uses nystatin suspension 100,000 units/mL at 4-6 mL four times daily 33, so your diluted preparation would require proportionally larger volumes (40-60 mL four times daily) to achieve equivalent total daily dosing.
Anti-inflammatory prophylaxis: Dexamethasone mouthwash has proven efficacy in preventing drug-induced stomatitis, particularly with mTOR inhibitors, reducing grade ≥2 stomatitis from 33% to 2% 4. The steroid component reduces mucosal inflammation and may enhance patient tolerance.
Dosing Instructions
Instruct patients to swish 10 mL of the compounded solution for 1-2 minutes, then expectorate (spit out), four times daily 45. This swish-and-spit technique maximizes mucosal contact while minimizing systemic absorption of both agents.
Important Caveats
- Do not swallow: Unlike standard nystatin suspension used for esophageal candidiasis, this steroid-containing mouthwash should be expectorated to avoid unnecessary systemic steroid exposure
- Shake well before each use: Nystatin suspensions require agitation for uniform distribution 11
- Use tinted glass bottles: Protects nystatin from light degradation 2
- Refrigerate consistently: Temperature fluctuations accelerate nystatin degradation
Alternative Consideration
If compounding resources are limited, you could use the commercially available nystatin 100,000 units/mL suspension separately from dexamethasone mouthwash, having the patient swish with dexamethasone first, then follow with a smaller volume (1 mL) of full-strength nystatin. However, the combined preparation improves compliance by reducing the number of daily rinses from 8 to 4.