What oral antifungal medications are safe to use with Human Immunodeficiency Virus (HIV) medications?

From the Guidelines

Fluconazole is the safest oral antifungal to use with HIV medications due to its minimal interactions with antiretrovirals. Several oral antifungal medications can be safely used with HIV medications, but careful consideration of drug interactions is essential [ 1 ]. For mild to moderate fungal infections in HIV patients, fluconazole at doses of 100-400 mg daily is typically recommended [ 1 ].

Key Considerations

• Fluconazole has fewer significant interactions compared to other azoles, making it a preferred choice [ 1 ].
• Isavuconazole is another option with a favorable interaction profile, although its use may be limited by specific clinical scenarios [ 1 ].
• When treating more resistant fungal infections, posaconazole or voriconazole may be used, but these require dose adjustments and careful monitoring due to potential interactions with certain antiretrovirals, particularly protease inhibitors and non-nucleoside reverse transcriptase inhibitors [ 1 ].
• Echinocandins like caspofungin, micafungin, and anidulafungin have minimal interactions with HIV medications and can be good alternatives for certain fungal infections [ 1 ].
• Terbinafine, used primarily for dermatophyte infections, generally has few interactions with antiretrovirals [ 1 ].

Monitoring and Precautions

• When prescribing antifungals to HIV patients, it's crucial to check specific drug-drug interactions with the patient's current antiretroviral regimen [ 1 ].
• Monitoring liver function is essential, as some antifungals can cause hepatotoxicity [ 1 ].
• Consider therapeutic drug monitoring for certain combinations to ensure both effective antifungal treatment and maintained HIV suppression [ 1 ].

From the FDA Drug Label

DRUG INTERACTIONS Interaction DrugInteraction Rifabutin, phenytoin, efavirenz, cimetidine Avoid coadministration unless the benefit outweighs the risks( 7.6,7.7.8,7.9) Other drugs metabolized by CYP3A4 Consider dosage adjustment and monitor for adverse effects and toxicity( 7.1,7.10,7.11) Digoxin Monitor digoxin plasma concentrations( 7.12) Fosamprenavir Monitor for breakthrough fungal infections( 7.6,7.13)

The oral antifungal posaconazole may have interactions with certain HIV medications, such as:

• Efavirenz: avoid coadministration unless the benefit outweighs the risks
• Fosamprenavir: monitor for breakthrough fungal infections It is recommended to avoid coadministration or monitor for potential interactions when using posaconazole with these HIV medications. However, the specific safety of using posaconazole with all HIV medications is not explicitly stated in the provided drug labels. 2

From the Research

Oral Antifungal Medications Safe with HIV Medications

The following oral antifungal medications are considered safe to use with Human Immunodeficiency Virus (HIV) medications:

• Fluconazole: due to its relatively weak interactive potential with the CYP450 system, fluconazole is the preferred antifungal drug 3
• Echinocandins: may aid in overcoming the limitations of existing antifungal therapy 3
• Posaconazole: offers a safe and effective treatment option for HIV-infected subjects with azole-refractory oropharyngeal and/or esophageal candidiasis, although it is contraindicated in combination with either efavirenz or fosamprenavir 3, 4

Oral Antifungal Medications to Use with Caution with HIV Medications

The following oral antifungal medications should be used with caution with HIV medications:

• Amphotericin B: concomitant use with tenofovir must be closely monitored for renal functioning 3
• Itraconazole: high doses (> 200 mg/day) are not advised in patients receiving booster protease inhibitor (PI) regimen 3
• Voriconazole: is contraindicated with high-dose ritonavir-boosted PI 3

Treatment of Oral Candidiasis in HIV-Infected Patients

The following treatments have been found to be effective for oral candidiasis in HIV-infected patients:

• Fluconazole: has been extensively evaluated as a treatment for candidiasis, with a cure rate of 82% achieved with a daily oral dose of 50 mg 5
• Clotrimazole: was found to be just as effective for resolution of clinical symptoms as the azoles, except when patient compliance was poor 5
• Posaconazole: offers a safe and effective treatment option for HIV-infected subjects with azole-refractory oropharyngeal and/or esophageal candidiasis 4