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Itraconazole vs Nystatin
Introduction
For patients with fungal infections, certain drugs that interfere with the growth of the fungi can help in managing symptoms and eradicating the infection. Itraconazole and Nystatin are two such antifungal medications often prescribed for this purpose. They each impede fungal growth through different mechanisms but both have effects in healing patients from fungal infections. Itraconazole is a systemic antifungal medication, meaning it works throughout the body to eliminate infection by inhibiting an enzyme critical to fungal cell membrane synthesis, thus destabilizing the fungus structure. On other hand, Nystatin is classified as a polyene antifungal agent which binds directly to sterols found in fungal cell membranes leading to changes in permeability and eventual leakage of cellular contents resulting in death of susceptible fungi.
Itraconazole vs Nystatin Side By Side
| Attribute | Sporanox | Mycostatin nyamyc |
|---|---|---|
| Brand Name | Sporanox | Mycostatin, Nyamyc |
| Contraindications | Not recommended for patients with heart failure or those with a history of ventricular dysfunction such as ventricular tachycardia/fibrillation unless absolutely necessary due to its negative inotropic effect. | Oral suspension should not be used if there's known hypersensitivity to any ingredient of the preparation. It shouldn't be used for systemic mycoses due to poor absorption from gastrointestinal tract when given orally. |
| Cost | For brand name, around $677 for 30 capsules (100 mg). For generic, costs range from $1.80 to $3.60 per day based on dosages between 200–400mg/day. | For Nystatin oral suspension (100,000 units/mL in a 473 mL bottle) is about $70. Generic costs start from as low as about $0.01/mL. |
| Generic Name | Itraconazole | Nystatin |
| Most Serious Side Effect | Liver problems, heart failure symptoms, severe allergic reactions, and severe skin reactions. | Signs of an allergic reaction such as hives; difficulty breathing; swelling in your face or throat, severe nausea or vomiting, rapid heart rate or uneven heartbeat, confusion, dizziness or fainting spells. |
| Severe Drug Interactions | Should not be taken with certain drugs like ergot alkaloids or cisapride due to potential drug interactions. | There are no specific severe drug interactions mentioned, but it's important to inform healthcare providers about all medications being taken. |
| Typical Dose | 200-400 mg/day depending on the type and severity of the fungal infection. | 500,000 to 1,000,000 units orally every day, can be increased up to 4-6 million units per day. |
What is Itraconazole?
Itraconazole (the generic name for Sporanox) is a broad-spectrum antifungal medication that marked significant progress upon the earlier class of antifungal drugs, such as Nystatin. Itraconazole was first approved by the FDA in 1992 and works by inhibiting fungal cell growth, leading to their eventual destruction and relief from symptoms caused by the infection. It is prescribed for treating various forms of fungal infections including those affecting lungs, mouth/throat, toenails, and fingernails. Itraconazole has a selective influence on fungi cells with only minor effects on human cells which results in it having fewer side effects than other antifungal medications like Nystatin that have stronger effects on both fungal and human cells.
What conditions is Itraconazole approved to treat?
Itraconazole is approved for the treatment of several fungal infections, including:
- Blastomycosis
- Histoplasmosis
- Aspergillosis (in patients who are intolerant to or ineffective with amphotericin B)
- Onychomycosis of the toenail and fingernail
- Oral thrush in immunocompromised individuals.
It's also used as a prophylaxis for fungal infections in immunocompromised patients.
How does Itraconazole help with these illnesses?
Itraconazole works to treat fungal infections by inhibiting the synthesis of ergosterol, a key component in the cell membranes of fungi. It does this by binding to and inhibiting an enzyme known as 14-α demethylase, which is needed for ergosterol production. Without adequate levels of ergosterol, the fungal cell's membrane becomes unstable and dysfunctional, leading to its eventual death. This mechanism allows Itraconazole to effectively manage various types of fungal infections.
On the other hand, Nystatin operates differently but with a similar goal—to kill or inhibit growth of fungus. It binds directly to sterols present in fungal cell membranes—primarily ergosterol—creating pores that increase permeability. The increased permeability causes leakage of intracellular contents such as electrolytes and metabolites from the cells into their environment resulting in their death.
Both antifungal agents are effective but they are used for different types of infection: Itraconazole for systemic (throughout body) ones while nystatin typically treats localized (in one area) or superficial mycoses due its poor absorption from gastrointestinal tract when taken orally.
What is Nystatin?
Nystatin, marketed under various brand names such as Mycostatin and Nyamyc among others, is a polyene antifungal medication. It functions by binding to ergosterol, a component of fungal cell membranes, leading to changes in membrane permeability and eventual cell death. Nystatin was first discovered back in 1950 and has been on the World Health Organization's List of Essential Medicines since its inception.
Unlike Itraconazole which can be absorbed systemically and treat systemic fungal infections, Nystatin is not absorbed from the gut or skin into the bloodstream making it ideal for local application in oral or cutaneous candidiasis (thrush). This limited absorption also means that it does not have the potential liver toxicity seen with systemic azoles like Itraconazole. The most common side effects associated with Nystatin are generally mild including stomach upset if taken orally or skin irritation when applied topically.
What conditions is Nystatin approved to treat?
Nystatin is an antifungal medication that is FDA approved for the treatment of:
- Cutaneous, oral and esophageal candidiasis (a yeast infection)
- Intestinal candidiasis Its primary function is to stop the growth of fungus, which makes it a useful tool in managing various fungal infections. It's important to note that Nystatin does not treat bacterial or viral infections.
How does Nystatin help with these illnesses?
Nystatin is a polyene antifungal medication that has been around for quite some time. It functions by binding to sterols in the cell membrane of susceptible fungi, leading to changes in membrane permeability and eventual fungal cell death. This makes Nystatin an effective treatment for various types of superficial candidal infections such as oral thrush and diaper rash. Unlike Itraconazole, which is systemic and can affect internal organs, Nystatin works primarily on the skin or mucosal surfaces where it's applied, making it a safer option with fewer side effects for those dealing with localized yeast infections. Moreover, because Nystatin does not get absorbed into the body like Itraconazole does, there are no concerns about interactions with other drugs metabolized in the liver – an issue often encountered when using systemic antifungals like Itraconazole.
How effective are both Itraconazole and Nystatin?
Both itraconazole and nystatin have a long-standing record of effectively treating fungal infections, with their initial FDA approvals being about 20 years apart. Since they act on different aspects of the fungal cell structure, they may be prescribed for different types of fungi or infection locations. A double-blind clinical study in 1990 compared itraconazole to nystatin for oral candidiasis treatment; both drugs were found effective at managing symptoms, but itraconazole had a slightly higher cure rate.
A review conducted in 2001 showed that systemic absorption makes itraconazole useful for treating various deep-seated mycoses and superficial mycoses where topical therapy is impractical. Itraconazole has also been used successfully to treat non-life-threatening opportunistic fungal infections in HIV-positive patients. The same review indicated that its side effect profile was tolerable and manageable.
In contrast, nystatin's main advantage lies in its limited absorption from the gastrointestinal tract making it an ideal choice for local treatment within the mouth or gut without exposing other bodily systems unnecessarily to antifungal medication. However, due to this characteristic, nystatin might not be as effective against systemic fungal infections unlike itraconazole which can reach therapeutic levels within blood circulation.
Review data from 2016 revealed that although both drugs are effective against Candida species - which cause thrush and yeast infections - some strains may show resistance to either drug necessitating careful selection based on susceptibility testing results when possible. Nonetheless, due to their distinct mechanisms of action (itraconazole inhibits ergosterol synthesis while nystatin binds directly with membrane sterols), one may work better than the other depending on individual patient factors like immune status as well as nature and extent of infection.
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At what dose is Itraconazole typically prescribed?
Oral dosages of Itraconazole typically range from 200-400 mg/day, depending on the type and severity of the fungal infection. For most people, a daily dose of 200mg is sufficient for treating various types of systemic fungal infections. However, in severe cases or when dealing with certain fungi, this may be increased to 400mg per day. In contrast, Nystatin is usually prescribed at an oral dosage ranging from 1–6 million units/day divided into three or four doses throughout the day. The exact dosage will depend on the specific nature and severity of each individual's fungal infection.
At what dose is Nystatin typically prescribed?
Nystatin treatment commences with a dosage of 500,000 to 1,000,000 units orally every day. This dose can then be increased up to 4-6 million units per day, divided into three or four doses spaced evenly throughout the day. The maximum dose is usually around 6 million units each day divided into three separate doses and taken at equally-spaced intervals throughout the course of the day. This may be explored if there is no response to treatment after a few weeks at lower dosages. As always, it's important for patients to follow their healthcare provider's instructions when taking medication.
What are the most common side effects for Itraconazole?
Common side effects of Itraconazole may include:
- Dizziness, headache
- Nausea, vomiting, abdominal pain
- Diarrhea or constipation
- Rashes
- Changes in menstrual cycle for women
- Erectile dysfunction in men
On the other hand, Nystatin typically has fewer systemic side effects as it is not absorbed into the body. However, you might experience some local irritation such as:
- Mouth discomfort or burning sensation (if used orally)
- Skin rash and itching (when applied topically).
Always remember to contact your healthcare provider if any of these symptoms persist or worsen.
Are there any potential serious side effects for Itraconazole?
While Itraconazole is generally well-tolerated, it does carry the risk of certain serious side effects in rare cases. These can include:
- Signs of a severe allergic reaction such as difficulty breathing or swallowing, hives, swelling of your face or throat
- Liver problems: nausea, upper stomach pain, itching, tired feeling, loss of appetite, dark urine, clay-colored stools or jaundice (yellowing of the skin or eyes)
- Nervous system issues like dizziness and fainting
- Heart failure symptoms including fast or pounding heartbeats; fluttering in your chest; shortness of breath while lying down; swelling in your legs; sudden weight gain
- Severe skin reactions with symptoms including fever; sore throat; burning eyes; skin pain followed by a red/purple skin rash that spreads (especially on the face/upper body) causing blistering and peeling
On the other hand for Nystatin:
Like any medication there are potential risks involved. It's crucial to watch for signs such as:
- An allergic reaction such as hives
- Difficulty breathing
- Swelling around lips/tongue/throat
In general though these adverse responses to this antifungal treatment are rare. If you do have concerns about any new symptoms after starting either Itraconazole or Nystatin it's important to seek medical advice promptly.
What are the most common side effects for Nystatin?
While side effects vary between different antifungal medications, those using Nystatin may experience:
- Mouth irritation or discomfort
- Upset stomach, nausea or vomiting
- Diarrhea
- Skin rash
- Increased urination Additionally, though rare, more serious symptoms such as tinnitus (ringing in the ears), muscle or joint pain and sleep problems can occur. If you notice any changes in your heartbeat or signs of an allergic reaction like hives; difficulty breathing; swelling of your face, lips, tongue, or throat while taking Nystatin it is recommended that you seek immediate medical attention.
Are there any potential serious side effects for Nystatin?
Nystatin, while typically well-tolerated, can occasionally cause serious side effects. If you notice any of the following symptoms after taking Nystatin, seek medical attention promptly:
- Signs of an allergic reaction such as hives; difficulty breathing; swelling in your face or throat
- Fever with chills and body aches
- Severe nausea or vomiting that doesn't go away
- Rapid heart rate or uneven heartbeat
- Confusion, dizziness or fainting spells
- Unusual bruising or bleeding indicating blood clotting issues
- Skin rash that is red, swollen and peeling
Remember to consult with your healthcare provider if you experience these symptoms. In most cases though, Nystatin is a safe medication for treating fungal infections when used as directed by a physician.
Contraindications for Itraconazole and Nystatin?
Both itraconazole and nystatin are antifungal medications that can cause serious side effects in some individuals. If you experience signs of an allergic reaction such as rash, itching/swelling (especially of the face/tongue/throat), severe dizziness or trouble breathing while taking either medication, please seek immediate medical assistance.
Neither itraconazole nor nystatin should be taken if you are using certain drugs like ergot alkaloids or cisapride due to potential drug interactions. Always inform your healthcare provider about any medications you are currently on; these include other prescribed medicines, over-the-counter drugs, and herbal supplements. Certain medications may need a washout period before starting treatment with itraconazole or nystatin to prevent harmful interactions.
Itraconazole is not recommended for patients with heart failure or those with a history of ventricular dysfunction such as ventricular tachycardia/ fibrillation unless absolutely necessary due to its negative inotropic effect.
Nystatin oral suspension should not be used if there's known hypersensitivity to any ingredient of the preparation. It shouldn't be used for systemic mycoses due to poor absorption from gastrointestinal tract when given orally.
As always, proper consultation with your physician will ensure safe and effective use of these antifungal treatments.
How much do Itraconazole and Nystatin cost?
For the brand name versions of these drugs:
- The price of 30 capsules of Sporanox (itraconazole, 100 mg) averages around $677, which works out to approximately $22.56/day.
- The price for Nystatin oral suspension (100,000 units/mL in a 473 mL bottle) is about $70, working out to roughly $0.15 per mL or depending on your dose up to several dollars per day.
Thus, if you need a high dosage range for itraconazole treatment (200–400 mg/day), then brand-name Nystatin is less expensive on a per-day treatment basis when used at typical dosages. Please note that cost should not be a primary consideration in determining which of these antifungal medications is right for you.
For the generic versions of itraconazole and nystatin, costs are generally lower:
-
Itraconazole (100mg tablets) can be found in packs starting from 10 capsules and above with approximate costs ranging from $1.80 –$3.60 per day based on whether your daily prescription calls for 100 mg or more typically higher dosages between 200–400mg/day.
-
Generic Nystatin is available as an oral suspension with varying amounts up to bottles containing around five hundred milliliters (~17 ounces). Costs start from as low as about one cent ($0.01)/mL if bought upfront in larger quantities and do not typically exceed several pennies per milliliter even when purchased in smaller volumes like single bottles containing ~50 mLs each.
Popularity of Itraconazole and Nystatin
Itraconazole, both in its generic form and under brand names such as Sporanox, was estimated to have been prescribed to about 2.9 million people in the US in 2020. Itraconazole accounted for approximately 17% of antifungal prescriptions in the US. This medication has a broad-spectrum action and can be used systemically against different types of fungal infections including blastomycosis, histoplasmosis, aspergillosis among others.
Nystatin on the other hand is primarily used for fungal infections of the skin and mucous membranes caused by Candida species; it was prescribed to around 6.4 million people across America during the same year. It represents nearly a quarter (24%) of all prescriptions for topical antifungals filled nationwide that year. Despite being an older drug than itraconazole, nystatin continues to hold its ground due to its effectiveness against superficial candidal infections and relatively low cost.
Conclusion
Both itraconazole and nystatin have long-standing records of usage in patients with fungal infections, supported by numerous clinical studies indicating their effectiveness. In some cases, the drugs may be used concurrently; however, this requires careful consideration by a physician due to potential drug interactions. Due to their different mechanisms of action - with itraconazole inhibiting the synthesis of ergosterol (a key component of fungal cell membranes) and nystatin binding directly to ergosterol disrupting membrane function - they tend to be prescribed for different types or severities of fungal infections.
Itraconazole is often a first-line treatment option for systemic or deep tissue mycoses whereas Nystatin would usually be considered for localized mucocutaneous candidiasis or as prophylaxis in immunocompromised patients due to its lack of absorption from the gastrointestinal tract.
Both drugs are available in generic form which represents significant cost savings especially for patients who must pay out-of-pocket. Both Itraconazole and Nystatin may require an adjustment period so that effects may not be noticeable right away.
The side effect profiles differ between these two antifungal agents: while both are generally well-tolerated, Itraconazole carries risks including hepatotoxicity (liver damage), heart failure, and drug interactions which warrant monitoring during therapy. On the other hand, Nystatin's main side effects include minor gastrointestinal upset like diarrhea or nausea. For both drugs, patients must closely monitor their symptoms when starting treatment and should seek medical help immediately if they notice any severe adverse reactions.
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Refrences
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- Vanden Bossche, H., Marichal, P., Le Jeune, L., Coene, M. C., Gorrens, J., & Cools, W. (1993, October). Effects of itraconazole on cytochrome P-450-dependent sterol 14 alpha-demethylation and reduction of 3-ketosteroids in Cryptococcus neoformans. Antimicrobial Agents and Chemotherapy. American Society for Microbiology.http://doi.org/10.1128/aac.37.10.2101
- Xiao, Y., Yuan, P., Sun, Y., Xu, Y., Deng, X., Wang, X., … Jiang, L. (2022, March). Comparison of topical antifungal agents for oral candidiasis treatment: a systematic review and meta-analysis. Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology. Elsevier BV.http://doi.org/10.1016/j.oooo.2021.10.023
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- Cleary, J. D., Taylor, J. W., & Chapman, S. W. (1992, April). Itraconazole in Antifungal Therapy. Annals of Pharmacotherapy. SAGE Publications.http://doi.org/10.1177/106002809202600411