What is the recommended dose of itraconazole (antifungal medication) for treating candida infections?

Itraconazole Dosing for Candida Infections

For oropharyngeal candidiasis, itraconazole oral solution 200 mg daily for 7-14 days is the recommended dose, while esophageal candidiasis requires 100 mg daily for a minimum of 3 weeks (up to 200 mg daily based on response). 1

Oropharyngeal Candidiasis

Standard Dosing

• Itraconazole oral solution 200 mg (20 mL) daily for 1-2 weeks is the FDA-approved regimen, with the solution vigorously swished in the mouth (10 mL at a time) for several seconds before swallowing 1
• Clinical signs and symptoms typically resolve within several days of initiating therapy 1
• In pediatric patients, itraconazole cyclodextrin oral solution 5 mg/kg/day provides potentially therapeutic concentrations, though levels are substantially lower than in adults, particularly in children aged 6 months to 2 years 2
• For HIV-infected children, doses of 2.5-5 mg/kg/day have demonstrated efficacy in treating oropharyngeal candidiasis 2

Fluconazole-Refractory Disease

• For patients unresponsive or refractory to fluconazole, itraconazole oral solution 100 mg (10 mL) twice daily is recommended 1
• Clinical response in fluconazole-refractory patients occurs in 2-4 weeks, with approximately 55% achieving complete resolution of oral lesions 1
• This regimen achieves a 55-75% response rate in resistant disease, though fluconazole-resistant isolates have 30% cross-resistance to itraconazole 3

Clinical Trial Evidence

• In randomized controlled trials (n=344,92% HIV-positive), itraconazole oral solution 200 mg/day for 7 or 14 days achieved an 84% clinical response rate, similar to fluconazole tablets 1
• Another trial showed itraconazole oral solution achieved approximately 71% clinical response, comparable to clotrimazole troches 1
• A 14-day course of itraconazole was associated with lower relapse rates than 7-day therapy 1

Esophageal Candidiasis

Standard Dosing

• Itraconazole oral solution 100 mg (10 mL) daily for a minimum of 3 weeks is the FDA-approved dose, with treatment continuing for 2 weeks following resolution of symptoms 1
• Doses up to 200 mg (20 mL) daily may be used based on clinical response 1
• In a double-blind randomized study (n=119,93% HIV-positive), itraconazole oral solution 100 mg/day (escalated to 200 mg/day for non-responders) achieved approximately 86% clinical response, comparable to fluconazole 1
• Only 11% of itraconazole-treated patients required dose escalation to 200 mg, compared to 21% with fluconazole 1

Critical Administration Details

Formulation Matters

• Itraconazole oral solution and capsules should NOT be used interchangeably 1
• Only the oral solution has been demonstrated effective for oral and esophageal candidiasis 1
• The oral solution should be taken without food if possible for optimal absorption 1
• Itraconazole solution has 30% higher absorption than capsule formulation 3

Intravenous Formulation

• IV itraconazole (in hydroxypropyl-β-cyclodextrin) is dosed at 200 mg every 12 hours for 4 doses (2 days), followed by 200 mg daily 2
• This formulation achieves adequate blood levels more rapidly and with less patient-to-patient variability than oral preparations 2
• However, formal studies of IV itraconazole for invasive candidiasis were incomplete at the time of guideline publication 2

Common Pitfalls to Avoid

• Do not use itraconazole capsules for mucosal candidiasis—they have inadequate absorption and are ineffective 3, 1
• Do not assume itraconazole will work for fluconazole-resistant disease—there is 30% cross-resistance, and susceptibility testing is recommended 3
• Patients may relapse shortly after discontinuing therapy, with all responders in one study relapsing within 1 month (median 14 days) when treatment was stopped 1
• Approximately 23% of patients with esophageal candidiasis relapse within 4 weeks after successful treatment 1
• Exercise caution in patients with renal or hepatic impairment, as limited data exist on itraconazole use in these populations 1
• Monitor liver function tests in patients receiving long-term azole therapy (>21 days) 3

Alternative Considerations

• For invasive candidiasis (candidemia), itraconazole is not a first-line agent—amphotericin B or fluconazole are preferred 2
• For prophylaxis in high-risk neutropenic patients, itraconazole solution 2.5 mg/kg every 12 hours during the period of neutropenia is appropriate 2
• In pediatric candidemia, itraconazole approximately 10 mg/kg orally achieved an 81% cure rate, comparable to fluconazole's 82%, with similar mortality rates (9.5% vs 13.6%) 4