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Fluconazole


Pronunciation

 (floo KOE na zole)


U.S. Brand Names

 Diflucan®


Generic Available

 Yes


Canadian Brand Names

 Apo-Fluconazole®; Diflucan®; Gen-Fluconazole; Novo-Fluconazole


Use

 Treatment of candidiasis (vaginal, oropharyngeal, esophageal, urinary tract infections, peritonitis, pneumonia, and systemic infections); cryptococcal meningitis; antifungal prophylaxis in allogeneic bone marrow transplant recipients


Use - Dental

 Treatment of susceptible fungal infections in the oral cavity including candidiasis, oral thrush, and chronic mucocutaneous candidiasis treatment of esophageal and oropharyngeal candidiasis caused by Candida species; treatment of severe, chronic mucocutaneous candidiasis caused by Candida species


Pregnancy Risk Factor

 C


Pregnancy Implications

 When used in high doses, fluconazole is teratogenic in animal studies. Following exposure during the first trimester, case reports have noted similar malformations in humans when used in higher doses (400 mg/day) over extended periods of time. Use of lower doses (150 mg as a single dose or 200 mg/day) may have less risk; however, additional data is needed. Use during pregnancy only if the potential benefit to the mother outweighs any potential risk to the fetus.


Lactation

 Enters breast/not recommended (AAP rates "compatible")


Contraindications

 Hypersensitivity to fluconazole, other azoles, or any component of the formulation; concomitant administration with cisapride


Warnings/Precautions

 Should be used with caution in patients with renal and hepatic dysfunction or previous hepatotoxicity from other azole derivatives. Patients who develop abnormal liver function tests during fluconazole therapy should be monitored closely and discontinued if symptoms consistent with liver disease develop. Use caution in patients at risk of proarrhythmias.


Adverse Reactions

 Frequency not always defined.

Cardiovascular: Angioedema, pallor, QT prolongation, torsade de pointes

Central nervous system: Headache (2% to 13%), seizure, dizziness

Dermatologic: Rash (2%), alopecia, toxic epidermal necrolysis, Stevens-Johnson syndrome

Endocrine & metabolic: Hypercholesterolemia, hypertriglyceridemia, hypokalemia

Gastrointestinal: Nausea (4% to 7%), vomiting (2%), abdominal pain (2% to 6%), diarrhea (2% to 3%), taste perversion, dyspepsia

Hematologic: Agranulocytosis, leukopenia, neutropenia, thrombocytopenia

Hepatic: Hepatic failure (rare), hepatitis, cholestasis, jaundice, increased ALT/AST, increased alkaline phosphatase

Respiratory: Dyspnea

Miscellaneous: Anaphylactic reactions (rare)


Overdosage/Toxicology

 Symptoms of overdose include decreased lacrimation, salivation, respiration and motility, urinary incontinence, and cyanosis. Treatment includes supportive measures. A 3-hour hemodialysis will remove 50%.


Drug Interactions

 Inhibits CYP1A2 (weak), 2C8/9 (strong), 2C19 (strong), 3A4 (moderate)

Benzodiazepines (metabolized by oxidation, eg, alprazolam, triazolam, midazolam, diazepam) serum concentrations are increased by fluconazole which may cause increased CNS sedation. Consider a benzodiazepine not metabolized by CYP3A4 or another antifungal.

Caffeine's metabolism is decreased; monitor for tachycardia, nervousness, and anxiety.

Calcium channel blockers may have increased serum concentrations; consider another agent instead of a calcium channel blocker, another antifungal, or reduce the dose of the calcium channel blocker. Monitor blood pressure.

Cisapride's serum concentration is increased which may lead to malignant arrhythmias; concurrent use is contraindicated.

Cyclosporine's serum concentration is increased; monitor cyclosporine's serum concentration and renal function.

CYP2C8/9 substrates: Fluconazole may increase the levels/effects of CYP2C8/9 substrates. Example substrates include amiodarone, fluoxetine, glimepiride, glipizide, nateglinide, phenytoin, pioglitazone, rosiglitazone, sertraline, and warfarin.

CYP2C19 substrates: Fluconazole may increase the levels/effects of CYP2C19 substrates. Example substrates include citalopram, diazepam, methsuximide, phenytoin, propranolol, and sertraline.

CYP3A4 substrates: Fluconazole may increase the levels/effects of CYP3A4 substrates. Example substrates include benzodiazepines, calcium channel blockers, cyclosporine, mirtazapine, nateglinide, nefazodone, sildenafil (and other PDE-5 inhibitors), tacrolimus, and venlafaxine. Selected benzodiazepines (midazolam and triazolam), cisapride, ergot alkaloids, selected HMG-CoA reductase inhibitors (lovastatin and simvastatin), and pimozide are generally contraindicated with strong CYP3A4 inhibitors.

HMG-CoA reductase inhibitors (except pravastatin and fluvastatin) have increased serum concentrations; switch to pravastatin/fluvastatin or monitor for development of myopathy.

Losartan's active metabolite is reduced in concentration; consider another antihypertensive agent unaffected by the azole antifungals, another antifungal, or monitor blood pressure closely.

Phenytoin's serum concentration is increased; monitor phenytoin levels and adjust dose as needed.

Rifampin decreases fluconazole's serum concentration; monitor infection status.

Tacrolimus's serum concentration is increased; monitor tacrolimus's serum concentration and renal function.

Warfarin's effects are increased; monitor INR and adjust warfarin's dose as needed.


Stability

Powder for oral suspension: Store dry powder at 30°C (86°F). Following reconstitution, store at 5°C to 30°C (41°F to 86°F). Discard unused portion after 2 weeks. Do not freeze.

Injection: Store injection in glass at 5°C to 30°C (41°F to 86°F). Store injection in Viaflex® at 5°C to 25°C (41°F to 77°F). Protect from freezing. Do not unwrap unit until ready for use.


Compatibility

 Stable in D5W, LR, NS

Y-site administration: Compatible: Acyclovir, aldesleukin, allopurinol, amifostine, amikacin, aminophylline, ampicillin/sulbactam, aztreonam, benztropine, cefazolin, cefepime, cefotetan, cefoxitin, cefpirome, chlorpromazine, cimetidine, cisatracurium, dexamethasone sodium phosphate, diltiazem, diphenhydramine, dobutamine, docetaxel, dopamine, doxorubicin liposome, droperidol, etoposide phosphate, famotidine, filgrastim, fludarabine, foscarnet, ganciclovir, gatifloxacin, gemcitabine, gentamicin, granisetron, heparin, hydrocortisone sodium phosphate, immune globulin intravenous, leucovorin, linezolid, lorazepam, melphalan, meperidine, meropenem, metoclopramide, metronidazole, midazolam, morphine, nafcillin, nitroglycerin, ondansetron, oxacillin, paclitaxel, pancuronium, penicillin G potassium, phenytoin, piperacillin/tazobactam, prochlorperazine edisylate, promethazine, propofol, ranitidine, remifentanil, sargramostim, tacrolimus, teniposide, theophylline, thiotepa, ticarcillin/clavulanate, tobramycin, vancomycin, vecuronium, vinorelbine, zidovudine. Incompatible: Amphotericin B, amphotericin B cholesteryl sulfate complex, ampicillin, calcium gluconate, cefotaxime, ceftazidime, ceftriaxone, cefuroxime, chloramphenicol, clindamycin, co-trimoxazole, diazepam, digoxin, erythromycin lactobionate, furosemide, haloperidol, hydroxyzine, imipenem/cilastatin, pentamidine, piperacillin, ticarcillin

Compatibility when admixed: Compatible: Acyclovir, amikacin, amphotericin B, cefazolin, ceftazidime, clindamycin, gentamicin, heparin, meropenem, metronidazole, morphine, piperacillin, potassium chloride, ranitidine with ondansetron, theophylline. Incompatible: Co-trimoxazole


Mechanism of Action

 Interferes with cytochrome P450 activity, decreasing ergosterol synthesis (principal sterol in fungal cell membrane) and inhibiting cell membrane formation


Pharmacodynamics/Kinetics

Distribution: Widely throughout body with good penetration into CSF, eye, peritoneal fluid, sputum, skin, and urine

Relative diffusion blood into CSF: Adequate with or without inflammation (exceeds usual MICs)

CSF:blood level ratio: Normal meninges: 70% to 80%; Inflamed meninges: >70% to 80%

Protein binding, plasma: 11% to 12%

Bioavailability: Oral: >90%

Half-life elimination: Normal renal function: ~30 hours

Time to peak, serum: Oral: 1-2 hours

Excretion: Urine (80% as unchanged drug)


Dosage

 The daily dose of fluconazole is the same for oral and I.V. administration

Neonates: First 2 weeks of life, especially premature neonates: Same dose as older children every 72 hours

Children: Once-daily dosing by indication: See table.


Note:

Fluconazole Once-Daily Dosing Children

Indication Day 1 Daily Therapy Minimum Duration
of Therapy
Oropharyngeal candidiasis 6 mg/kg 3 mg/kg 14 d
Esophageal candidiasis 6 mg/kg 3-12 mg/kg 21 d and for at least 2 wk following resolution of symptoms
Systemic candidiasis - 6 mg/kg every 12 hours 28 d
Cryptococcal meningitis     10-12 wk after CSF culture becomes negative
acute 12 mg/kg 6-12 mg/kg
relapse suppression 6 mg/kg 6 mg/kg N/A
N/A = Not applicable.

Adults: Oral, I.V.: Note: Susceptibility for Candida is divided into susceptible, susceptible-dose dependent (SDD), and resistant. Increased dose (up to 400 mg/day) may be used to treat SDD strains, especially when there has been treatment failure at lower doses.

Once-daily dosing by indication: See table.


Dosing adjustment/interval in renal impairment:

Fluconazole Once-Daily Dosing Adults

Indication Day 1 Daily Therapy Minimum Duration
of Therapy
Oropharyngeal candidiasis (OPC)
(long-term suppression)		 200 mg 200 mg Chronic therapy in AIDS patients with history of OPC
Esophageal candidiasis 200 mg 100-200 mg 14-21 d after clinical improvement
Prevention of candidiasis in bone marrow transplant 400 mg 400 mg 3 d before neutropenia, 7 d after neutrophils >1000 cells/mm 3
Urinary candidiasis -- 200 mg 14 d
Candidemia, primary therapy, non-neutropenic -- 400-800 mg 14 d after last positive blood culture and resolution of signs/symptoms
Candidemia, alternative therapy, non-neutropenic -- 800 mg with AmB for 4-7 d,
followed by
800 mg/day		 14 d after last positive blood culture and resolution of signs/symptoms
Candidemia, secondary, neutropenic -- 6-12 mg/kg/day 14 d after last positive blood culture and resolution of signs/symptoms
Cryptococcal meningitis     10 wk
consolidation (after induction with amphotericin plus flucytosine) -- 400 mg
relapse suppression (maintenance) -- 200-400 mg N/A
Vaginal candidiasis 150 mg Single dose N/A
N/A = not applicable. AmB = conventional deoxycholate amphotericin B.

Dosing adjustment/interval in renal impairment:

No adjustment for vaginal candidiasis single-dose therapy

For multiple dosing, administer usual load then adjust daily doses

Clcr 50 mL/minute (no dialysis): Administer 50% of recommended dose or administer every 48 hours.

Hemodialysis: 50% is removed by hemodialysis; administer 100% of daily dose (according to indication) after each dialysis treatment.

Continuous arteriovenous or venovenous hemofiltration: Dose as for Clcr 10-50 mL/minute.


Administration

 Parenteral fluconazole must be administered by I.V. infusion over approximately 1-2 hours; do not exceed 200 mg/hour when giving I.V. infusion


Monitoring Parameters

 Periodic liver function tests (AST, ALT, alkaline phosphatase) and renal function tests, potassium


Dietary Considerations

 Take with or without regard to food.


Patient Education

 Inform prescriber of all prescriptions, OTC medications, or herbal products you are taking, and any allergies you have. Do not take any new medication during therapy unless approved by prescriber. Take as directed, around-the-clock. Take full course of medication as ordered. Take with or without food. Follow good hygiene measures to prevent reinfection. Frequent blood tests may be required. Maintain adequate hydration (2-3 L/day of fluids) unless instructed to restrict fluid intake. May cause headache, dizziness, drowsiness (use caution when driving or engaging in tasks that require alertness until response to drug is known); or nausea, vomiting, or diarrhea (small, frequent meals, frequent mouth care, sucking lozenges, or chewing gum may help). Report skin rash, redness, or irritation; persistent GI upset; urinary pattern changes; excessively dry eyes or mouth; or changes in color of stool or urine. Pregnancy/breast-feeding precautions: Inform prescriber if you are or intend to become pregnant. Consult prescriber if breast-feeding.


Anesthesia and Critical Care Concerns/Other Considerations

 Do not use if cloudy or precipitated. If administered by I.V. infusion, give over 1-2 hours.


Cardiovascular Considerations

 Fluconazole is contraindicated in patients taking cisapride due to increased risk for significant cardiotoxicity, particularly proarrhythmia.


Dental Health: Effects on Dental Treatment

 Key adverse event(s) related to dental treatment: Abnormal taste.


Dental Health: Vasoconstrictor/Local Anesthetic Precautions

 No information available to require special precautions


Mental Health: Effects on Mental Status

 May cause dizziness and seizures


Mental Health: Effects on Psychiatric Treatment

 None reported; CYP3A4 inhibitor; use caution with triazolam, alprazolam, and midazolam


Oncology: Emetic Potential

 Very low (<10%)


Oncology: Vesicant

 No


Dosage Forms

Infusion [premixed in sodium chloride]: 2 mg/mL (100 mL, 200 mL)

Diflucan® [premixed in sodium chloride or dextrose] 2 mg/mL (100 mL, 200 mL)

Powder for oral suspension (Diflucan®): 10 mg/mL (35 mL); 40 mg/mL (35 mL) [contains sodium benzoate; orange flavor]

Tablet (Diflucan®): 50 mg, 100 mg, 150 mg, 200 mg


References

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Eggimann P, Francioli P, Bille J, et al, "Fluconazole Prophylaxis Prevents Intra-Abdominal Candidiasis in High-Risk Surgical Patients," Crit Care Med , 1999, 27(6):1066-72.

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International Brand Names

 Afungil® (MX); Apo-Fluconazole® (CA); Azoflune® (PT); Baten® (CO, DO, GT, HN, PA, SV); Béagyne® (FR); Besic Derm® (GT); Biozole® (TH); Canazole® (BD); Cancid® (ID); Candidin® (TR); Candimicol® (AR); Canex® (DE); Ciplaflucon® (CO); Conasol® (DK); Cryptal® (ID); Damicol® (AR); Dexmazol® (EC); Diflazon® (CZ, RO, RU, SI); Diflucan® (AT, AU, BE, CA, CH, CL, CO, CY, CZ, DE, DK, DO, EG, ES, FI, GB, HK, HR, HU, ID, IE, IL, IT, JO, JP, KW, LB, LU, MX, NL, NO, NZ, PL, PT, RO, RU, SE, SG, SI, TH, YU, ZA); Diflucan One® (GB); Elazor® (IT); Flucand® (EG, JO, KW, LB, SY); Flucandid® (IE); Flucan® (TR); Flucazol® (BR, CH); Fluc Hexal® (DE); Flucobeta® (DE); Flucoder® (BD); FlucoLich® (DE); Flucomicon® (DO, EC, GT, HN, PA); Fluconacx® (EC); Fluconal® (BD, BR); Fluconazol 1A Farma® (DK); Fluconazol 1A-Pharma® (DE); Fluconazol AbZ® (DE); Fluconazol AL® (DE); Fluconazol Alpharma® (DK); Fluconazol Alternova® (DK); Fluconazol Bexal® (ES); Fluconazol® (BR, CR, DE, EC, PL); Fluconazol Calox® (CR, PA); Fluconazol Chemo Farma® (ES); Fluconazol Chemo Technic® (ES); Fluconazol Copyfarm® (DK); FLuconazol Crotalchem® (ES); Fluconazol Cuve® (ES); Fluconazol Denver® (AR); Fluconazol Derm 1A Pharma® (DE); Fluconazol DF® (AR); Fluconazol Duncan® (AR); Fluconazole® (PL); Fluconazol Fabra® (AR); Fluconazol Fada® (AR); Fluconazol Gea® (DK); Fluconazol Gemepe® (AR); Fluconazol Genfar® (EC); Fluconazol-GRY® (DE); Fluconazol Hexal® (DE); Fluconazol-Isis® (DE); Fluconazol Martian® (AR); Fluconazol Merck® (ES); Fluconazol MK® (CO, CR, GT, HN, SV); Fluconazol Nycomed® (DK); Fluconazol Paranova® (DK); Fluconazol ratiopharm® (AT); Fluconazol-ratiopharm® (DE); Fluconazol ratiopharm® (DK); Fluconazol Richet® (AR); Fluconazol Rivero® (AR); Fluconazol Roux-Ocefa® (AR); Fluconazol-Slovakofarma® (CZ); Fluconazol Stada® (DE, DK); Fluconazol Vannier® (AR); Fluconazol von ct® (DE); Flucon® (BD); Fluconovag® (AR); Flucoral® (ID); Flucoric® (ZA); Flucosept® (AT); Flucostat® (RU); Flucovim® (RO); Flucoxan® (CL); Flucozol® (DO); Flucozole® (TH); Flucozol Rowe® (EC); Fluctin® (CL); Fludizol® (TH); Fludocel® (PT); Flugal® (BD); Flukonazol NM Pharma® (SE); Flumarin® (DO); Flumicot® (AR); Flumycon® (PL); Flumycozal® (YU); Flunazol® (BR, EC); Flunazul® (DE); Flunco® (TH); Flunizol® (CH); Flurit-D® (TR); Flurit-G® (TR); Flusan® (BR); Fluzol® (AR, ZA); Fluzole® (TR); Forcan® (IN); Fujisen® (CO); Funa® (TH); Funex® (CO); Fungal® (DK); Fungata® (AT, DE); Fungocina® (AR); Fungolon® (BG); Fungustatin Orifarm® (DK); Funizol® (CR, GT, PA, SV); Fuzol Pauly® (CO); Gen-Fluconazole (CA); Govazol® (ID); Honguil Plus® (AR); Ibarin® (CL); Kambine® (EC); Kandizol® (TR); Kyrin® (TH); Lavisa® (ES); Lertus® (BR); Logican® (IN); Loitin® (ES); Lumen® (TR); Medoflucon® (RU); Micofin® (CL); Micofull® (DO); Micolis novo® (AR); Monipax® (BR); Mutum® (AR); Mycocyst® (HU); Mycomax® (CZ, PL, RO); Mycorest® (SG); Mycosyst® (CZ, HU, PL, RU); Neofomiral® (MX); Nifurtox® (AR); Nobzol® (CO); Nor-Fluozol® (SV); Novo-Fluconazole (CA); Omastin® (BD); Oxifungol® (MX); Periplum® (AR); Plusatac® (AR); Plusgin® (CL); Reforce® (PT); Solacap® (ES); Stalene® (TH); Supremase® (PT); Syscan® (IN, RO); Tavor® (CL, CO); Trican® (IL); Triflucan® (AR, FR, IL, TR); Trizol® (TR); Unizol® (BR); Zelix® (BR); Zemyc® (ID); Zolanix® (BR); Zolax® (TR); Zolstatin® (BR); Zoltec® (BR); Zonal® (MX)


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