From the Guidelines
Itraconazole solution, 200 mg daily, or voriconazole, 200 mg (3 mg/kg) twice daily, are recommended as a second antifungal medication for fluconazole-refractory disease. When considering a second antifungal, it's crucial to assess the patient's response to initial treatment and the specific type of fungal infection. For fluconazole-refractory disease, alternatives such as an echinocandin (micafungin: 150 mg daily; caspofungin: 70-mg loading dose, then 50 mg daily; or anidulafungin: 200 mg daily) for 14–21 days, or AmB deoxycholate, 0.3–0.7 mg/kg daily, for 21 days, can be considered 1.
Key points to consider when selecting a second antifungal include:
- The type of fungal infection and its susceptibility to different antifungals
- The patient's clinical status and ability to tolerate oral or intravenous therapy
- Potential drug interactions and side effects, such as hepatotoxicity
- The need for central nervous system penetration in cases of CNS involvement
In general, voriconazole is preferred for its broad spectrum of activity, including against certain molds, but its use should be guided by susceptibility testing and clinical experience 1. Monitoring of liver function and renal function is essential during treatment with any antifungal medication.
It's also important to note that posaconazole suspension, 400 mg twice daily, or extended-release tablets, 300 mg once daily, could be considered for fluconazole-refractory disease, although this is based on weaker evidence 1. Ultimately, the choice of a second antifungal should be individualized based on the patient's specific circumstances and the latest clinical guidelines.
From the FDA Drug Label
Principal Display Panel TopCare Miconazorb AF ANTIFUNGAL POWDER MICONAZOLE NITRATE 2%/ ANTIFUNGAL Cures Most Athlete's Foot, Jock Itch & Ringworm Relieves Itching, Burning, Scaling & Chafing Comforts & Refreshes Absorbs Moisture Talc-Free NET WT 2.5 OZ (71 g) The FDA drug label does not answer the question.
From the Research
Recommended Second Antifungal Medication
- The choice of a second antifungal medication depends on various factors, including the type of fungal infection, patient's medical history, and the effectiveness of the initial treatment 2.
- Itraconazole is a recommended second-line therapy for patients who do not respond to fluconazole, as it has a wider spectrum of activity and is effective against Candida albicans infections 2.
- Other antifungal medications, such as clotrimazole, nystatin, and miconazole, have also shown efficacy in treating various types of fungal infections, including cutaneous candidiasis 3.
- The selection of an antifungal agent should be based on its spectrum of activity, pharmacokinetics, pharmacodynamics, toxicity profile, and distribution to the infection site 4.
- In some cases, topical azole treatments, such as clotrimazole, may be effective in treating fungal infections, such as otomycosis 5.
Key Considerations
- The effectiveness of antifungal medications can vary depending on the specific type of fungal infection and the patient's individual characteristics 6.
- Drug interactions and toxicity profiles should be carefully considered when selecting an antifungal medication 4.
- Therapeutic drug monitoring may be useful in patients receiving certain antifungal medications, such as itraconazole or voriconazole 4.