What prescription medication, other than fluconazole (Fluconazole), can be used for prevention of recurrent vulvovaginal candidiasis (VVC) in pregnant women, considering the medication must be available by prescription only for insurance coverage?

From the Guidelines

For preventing recurrent vulvovaginal candidiasis (VVC) in pregnant women, I recommend prescription terconazole vaginal cream (0.4%) applied weekly as prophylaxis, as it is considered safe during pregnancy and provides sustained protection against recurrent infections 1. This approach is based on the most recent guidelines and evidence, which prioritize the use of topical azole therapies for treating VVC in pregnant women. The weekly prophylactic regimen typically continues throughout pregnancy or for at least 6 months. Some key points to consider when using terconazole or other topical azoles for VVC prevention in pregnancy include:

• The importance of using prescription-strength formulations, which are typically higher strength than over-the-counter versions and can be covered by insurance with a prescription 1.
• The mechanism of action, which involves disrupting fungal cell membrane formation and preventing Candida overgrowth without systemic absorption that could affect the fetus.
• The need for patients to insert suppositories or apply creams at bedtime to maximize retention time and effectiveness.
• The possibility of breakthrough infections despite prophylaxis, which may require more frequent application temporarily. Other options, such as clotrimazole vaginal suppositories (100 mg) used weekly, may also be effective, but terconazole is preferred due to its safety profile and efficacy in preventing recurrent VVC during pregnancy 1.

From the Research

Prescription Medication for Prevention of Recurrent Vulvovaginal Candidiasis (VVC) in Pregnant Women

• The following prescription medications can be used for the prevention of recurrent VVC in pregnant women:
  • Clotrimazole 2
  • Miconazole 2, 3, 4
  • Terconazole 2
  • Nystatin ovules 2, 5
• Note that fluconazole, ibrexafungerp, and intravaginal boric acid should be avoided during pregnancy 2
• Local treatment of VVC has several advantageous features when compared with oral therapy, including a low rate of adverse events and safe utilization during pregnancy 3
• Vaginal nystatin suppositories and oral fluconazole regimens have been compared for the treatment of RVVC, with similar mycological cure rates 5
• Miconazole and fluconazole have been used in treatment protocols for vaginal candidiasis 4