What prescription medication, other than fluconazole (Diflucan), can be used to prevent vaginal candidiasis (Vaginal Yeast Infection) in pregnant women, requiring a prescription for insurance coverage?

From the Guidelines

For vaginal yeast infection prevention during pregnancy when fluconazole is contraindicated, I recommend prescription-strength clotrimazole or miconazole vaginal suppositories or creams, as they are considered safe and effective options with minimal systemic absorption. The most recent and highest quality study, published in 2022 1, provides guidance on the treatment of vulvovaginal candidiasis, including recommendations for pregnant women. Some key points to consider when prescribing these medications include:

• Clotrimazole 100mg vaginal tablets used nightly for 7 days or miconazole 2% vaginal cream applied nightly for 7 days are effective options that require a prescription at higher strengths.
• Nystatin vaginal suppositories (100,000 units) used daily for 14 days are another prescription-only alternative with excellent safety profiles in pregnancy.
• When prescribing, specify "prescription strength" or higher concentration formulations on the prescription to ensure insurance coverage, as these differ from over-the-counter versions.
• These medications work by disrupting the fungal cell membrane, preventing yeast growth while having minimal impact on maternal or fetal systems due to their localized application. Other studies, such as those published in 1993 1 and 2002 1, also support the use of topical azole therapies for the treatment of vaginal yeast infections during pregnancy, but the 2022 study 1 provides the most up-to-date and comprehensive guidance. Additionally, the 2009 study 1 provides a detailed list of recommended regimens for the treatment of vulvovaginal candidiasis, including prescription-strength clotrimazole and miconazole. It's worth noting that the 2022 study 1 highlights the importance of accurate diagnosis and the limitations of current diagnostic methods, but this does not change the recommendation for treatment. Overall, the evidence supports the use of prescription-strength clotrimazole or miconazole vaginal suppositories or creams as safe and effective options for preventing vaginal yeast infections during pregnancy.

From the Research

Prescription Medications for Vaginal Candidiasis in Pregnant Women

• Clotrimazole is a viable option for treating vaginal candidiasis in pregnant women, as it has been shown to be effective and safe in this population 2, 3.
• Nystatin is another option, as it is minimally absorbed and can be used vaginally 4.
• Micafungin and posaconazole are also being discussed as potential treatment options, although they are not yet approved for this indication and are very expensive 2.
• Vaginal suppositories of boric acid and flucytosine are recommended in other countries, but their use may be restricted in certain regions 2.
• Local treatment with imidazoles, such as clotrimazole, or ciclopirox olamine may be used to treat non-albicans species, such as Candida glabrata 2.

Safety Considerations

• Fluconazole is not recommended for use during pregnancy due to potential teratogenic effects, although it may be safe at lower doses 4, 5.
• Ketoconazole, flucytosine, and griseofulvin have been shown to be teratogenic and/or embryotoxic in animals and should be avoided during pregnancy 4.
• Iodides should not be used during pregnancy due to the risk of congenital goiter 4.

Treatment Efficacy

• Vaginal treatment with clotrimazole or miconazole nitrate has been shown to be effective in treating vulvovaginal candidiasis in pregnant women, with similar efficacy to oral fluconazole 6, 3.
• Local treatment has several advantages, including a low rate of adverse events and safe use during pregnancy and breastfeeding 6.