Diflucan in newborns. Suspension "Diflucan" for children: instructions for use. Release form, composition and packaging

It is difficult to find a child who, during the period of growing up, did not have a white coating in his mouth at all. In the common people, the disease is called "thrush", it causes its pathological growth of Candida yeast-like fungi.

A newborn can become infected with the fungus from the mother during childbirth. In the future, favorable ground for the reproduction of Candida is prepared by viral infections, as well as processes that weaken the immune system.

Left unattended, the disease leads to the development of a number of complications, including death in premature babies. With manifestations of thrush, it is necessary to consult a doctor who will select both an effective and gentle drug. One of these is Diflucan.

Release form and composition of the drug

The main active ingredient of Diflucan is the triazole antifungal agent fluconazole. For the treatment of thrush in children, there are three forms of release of the drug: gelatin capsules, powder for suspension and solution for intravenous administration. Detailed characteristics can be seen in the table below:

Release form	Description	Content of active substance (mg)	Auxiliary components
Gelatin capsules	Hard capsules with white contents. Depending on the content of the active substance (mg per capsule), they are labeled: “FLU-50” - No. 4; "FLU-100" - No. 2; "FLU-150" - No. 1.	1 capsule contains: "FLU-50" - 50 mg; "FLU-100" - 100 mg; "FLU-150" - 150 mg.	corn starch, lactose, colloidal silicon dioxide, sodium lauryl sulfate, magnesium stearate;
Powder for suspension preparation	White powder, free from visible impurities. Available in 5 ml bottles	In 1 ml of the finished suspension - 10 mg.	sodium benzoate, colloidal silicon dioxide, xanthan gum, sucrose, titanium dioxide (E171), sodium citrate dihydrate, orange flavor, citric acid;
Solution for intravenous administration	Colorless liquid in vials of 25, 50, 100 and 200 ml.	1 ml of solution - 2 mg.	sodium chloride, water for injection.

Mechanism of action

Once in the body and accumulating in the upper layers of the skin and nail plates, fluconazole inhibits the synthesis of substances necessary for the growth and reproduction of fungal cells. In addition, there is a continuous process of destruction of their cell membranes. Fungicidal action is on such types of fungus:

candida (albicans, tropicalis, parapsilosis);
cryptococcus (neoformans, gattii);
blastomyses dermatitis;
coccidiodes immitis;
histoplasma capsulatum;
microsporum spp.
trychophyton spp.

Instructions for use Diflucan

Suspension "Diflucan" is the best option for the treatment of limited fungal infections in young children, since the newborn may not swallow the gelatin capsule. The syrup prepared from the powder is given to children once a day with a measuring spoon, regardless of the meal. Special indications for the treatment of infants is the need for intervals between doses:

These conditions are explained by the imperfection of the urinary system, due to which the drug can linger in the child's blood for up to 3 days. The need for daily administration of new doses of Diflucan can lead to an increase in the concentration of the drug, as a result of which an overdose will occur.

In more severe cases of generalized damage to the body by a fungal infection, a solution is used (in a hospital setting through a dropper 1 time per day). The tablets are suitable for both localized and extensive lesions in older children over 5 years of age.

In what cases is the medicine prescribed?

A general indication for prescribing the drug is the presence of the following diseases in a child:

What are the contraindications?

The main contraindication to treatment with Diflucan is the patient's susceptibility to the constituent elements of the suspension. With caution and only as prescribed by a pediatrician, the drug is prescribed to a child suffering from the following ailments:

problems with the liver;
various forms of allergies;
pathology of the heart of organic origin.

Scheme of application and dosage

Doses recommended by the instructions for the drug for treatment:

mucosal candidiasis - on day 1, a loading dose of the drug is given at the rate of 6 mg per 1 kg of the child's weight, in the following days the dose is reduced to 3 mg per 1 kg of weight;
generalized candidiasis and cryptococcal infection - from 6 to 12 mg per 1 kg of the child's weight per day;
for the prevention of fungal infections - from 3 to 12 mg per 1 kg of weight per day (the dose is calculated depending on the duration and degree of neutropenia).

Adverse reactions

Possible side effects from the use of Diflucan include:

From the side of the cardiovascular system:

prolongation of the interval of the electrical systole of the heart on the electrocardiogram;
flutter of the stomach.

From the nervous system:

convulsions;
headache;
dizziness;
change in taste sensations.

From the gastrointestinal tract:

nausea, vomiting, flatulence, diarrhea, dyspepsia;
hepatoxicity, jaundice, hepatitis, increased bilirubin levels.

From the side of hematopoiesis:

thrombocytopenia;
leukopenia.

From the side of metabolism:

hypokalemia;
increase in blood cholesterol.

Allergic reactions:

hives;
swelling of the face;
skin itching.

Dermatological reactions.

1 ml of the finished suspension contains fluconazole 10 mg

Release form

Powder for suspension for oral administration 50 mg in a plastic bottle, complete with a measuring spoon in a cardboard pack.

pharmachologic effect

Antifungal drug.

Fluconazole has been shown to be active in vitro and in clinical infections against most of the following microorganisms: Candida alhicans, Candida glabrata (many strains are moderately sensitive), Candida parapsilosis, Candida tropicalis, Cryptococcus neoformans.

Fluconazole has been shown to be active in vitro against the following microorganisms, but its clinical significance is unknown: Candida dubliniensis, Candida guilliermondii, Candida kefyr, Candida lusitaniae.

Indication for use

cryptococcosis, including cryptococcal meningitis and other localizations of this infection (including lungs, skin), both in patients with a normal immune response and in patients with various forms of immunosuppression (including in patients with AIDS, with organ transplantation ); the drug can be used to prevent cryptococcal infection in AIDS patients;
generalized candidiasis, including candidemia, disseminated candidiasis and other forms of invasive candidal infection (including infections of the peritoneum, endocardium, eyes, respiratory and urinary tract). Treatment can be carried out in patients with malignant neoplasms, patients in intensive care units, patients receiving cytotoxic or immunosuppressive agents, as well as in the presence of other factors predisposing to the development of candidiasis;
candidiasis of the mucous membranes, incl. oral cavity and pharynx (including atrophic candidiasis of the oral cavity associated with wearing dentures), esophagus, non-invasive bronchopulmonary candidiasis, candiduria, skin candidiasis; prevention of recurrence of oropharyngeal candidiasis in AIDS patients;
genital candidiasis: vaginal candidiasis (acute and chronic recurrent), prophylactic use to reduce the frequency of recurrence of vaginal candidiasis (3 or more episodes per year); candidal balanitis;
prevention of fungal infections in patients with malignant neoplasms who are predisposed to such infections as a result of cytotoxic chemotherapy or radiation therapy;
mycoses of the skin, including mycoses of the feet, body, inguinal region, pityriasis versicolor, onychomycosis and candidiasis of the skin;
deep endemic mycoses, coccidioidomycosis, paracoccidioidomycosis, sporotrichosis and histoplasmosis in patients with normal immunity.

Dosage and administration

inside. To prepare a suspension for oral administration, add 24 ml of water to the contents of one vial and shake thoroughly. Shake the suspension before each use.

The daily dose of fluconazole depends on the nature and severity of the fungal infection. With vaginal candidiasis, in most cases, a single dose of the drug is effective. For infections requiring repeat administration of the antifungal drug, treatment should be continued until the clinical or laboratory signs of fungal infection disappear. Patients with AIDS and cryptococcal meningitis or recurrent oropharyngeal candidiasis usually require maintenance therapy to prevent recurrence of the infection.

Contraindications

simultaneous use of terfenadine during repeated use of fluconazole at a dose of 400 mg / day or more;
simultaneous use with drugs that increase the QT interval and are metabolized using the CYP3A4 isoenzyme, such as cisapride, astemizole, erythromycin, pimozide and quinidine;
sucrase/isomaltase deficiency, fructose intolerance, glucose-galactose malabsorption
hypersensitivity to fluconazole, other components of the drug or azole substances with a structure similar to fluconazole.

special instructions

Treatment may be initiated if culture or other laboratory results are not available, but appropriate adjustment of fungicidal therapy is recommended if available.

When using the drug in children aged 4 weeks or less, it should be borne in mind that fluconazole is excreted slowly in newborns. In the first 2 weeks of life, the drug is prescribed at the same dose (in mg / kg) as for older children, but with an interval of 72 hours. For children aged 3 and 4 weeks of life, the same dose is administered with an interval of 48 hours.

Storage conditions

The drug should be stored out of the reach of children at a temperature not exceeding 30°C. The finished suspension should be stored at a temperature not exceeding 30 ° C; do not freeze. The shelf life of the finished suspension is 14 days.

In this article, you can read the instructions for using the drug Diflucan. Reviews of site visitors - consumers of this medicine, as well as opinions of doctors of specialists on the use of Diflucan in their practice are presented. We kindly ask you to actively add your reviews about the drug: the medicine helped or did not help get rid of the disease, what complications and side effects were observed, perhaps not declared by the manufacturer in the annotation. Analogues of Diflucan in the presence of existing structural analogues. Use for the treatment of candidiasis (thrush) and other mycoses in adults, children, as well as during pregnancy and lactation. Dosage forms in the form of suppositories and tablets - do they really exist?

Diflucan- an antifungal drug. Fluconazole (the active ingredient of the drug Diflucan) is a representative of the class of triazole antifungal agents, is a powerful selective inhibitor of sterol synthesis in the fungal cell.

Both oral and intravenous administration of fluconazole has been active in various animal models of fungal infections. The activity of the drug in opportunistic mycoses, incl. caused by Candida spp., including generalized candidiasis in immunocompromised animals; Cryptococcus neoformans, including intracranial infections; Microsporum spp. and Trychoptyton spp. Fluconazole activity has also been established in models of endemic mycoses in animals, including infections caused by Blastomyces dermatitidis, Coccidioides immitis, including intracranial infections, and Histoplasma capsulatum in animals with normal and reduced immunity.

Fluconazole has a high specificity for cytochrome P450 dependent fungal enzymes. Therapy with fluconazole 50 mg daily for up to 28 days did not affect plasma testosterone levels in men or steroid levels in women of childbearing age. Fluconazole at a dose of 200-400 mg per day had no clinically significant effect on endogenous steroid levels and their response to ACTH stimulation in healthy male volunteers.

A single or multiple dose of fluconazole at a dose of 50 mg does not affect the metabolism of antipyrine when they are taken simultaneously.

There have been reports of cases of superinfection caused by strains of Candida other than Candida albicans, which often do not show sensitivity to fluconazole (for example, Candida krusei). In such cases, alternative antifungal therapy may be required.

Pharmacokinetics

The pharmacokinetics of fluconazole is similar when administered intravenously and when taken orally. After oral administration, fluconazole is well absorbed, its plasma levels (and overall bioavailability) exceed 90% of fluconazole plasma levels when administered intravenously. Simultaneous ingestion of food does not affect absorption when taken orally. Fluconazole penetrates well into all body fluids. The levels of fluconazole in saliva and sputum are similar to its plasma concentrations. In patients with fungal meningitis, fluconazole levels in the cerebrospinal fluid are about 80% of its plasma levels. In the stratum corneum, epidermis or dermis and sweat fluid, high concentrations are achieved that exceed serum levels. Fluconazole is excreted mainly by the kidneys; Approximately 80% of the administered dose is found unchanged in the urine. No circulating metabolites were found.

Indications

cryptococcosis, including cryptococcal meningitis and infections of other localization (for example, lungs, skin), incl. in patients with a normal immune response and in AIDS patients, recipients of transplanted organs and patients with other forms of immunodeficiency; maintenance therapy to prevent recurrence of cryptococcosis in AIDS patients;
generalized candidiasis, including candidemia, disseminated candidiasis and other forms of invasive candidal infection, such as infections of the peritoneum, endocardium, eyes, respiratory and urinary tract, incl. in patients with malignant tumors in intensive care units, patients receiving cytotoxic or immunosuppressive agents, as well as in patients with other factors predisposing to the development of candidiasis;
candidiasis of the mucous membranes, including the mucous membranes of the oral cavity and pharynx, esophagus, non-invasive bronchopulmonary infections, candiduria, mucocutaneous and chronic atrophic candidiasis of the oral cavity (associated with wearing dentures), incl. in patients with normal and suppressed immune function; prevention of recurrence of oropharyngeal candidiasis in AIDS patients;
genital candidiasis; acute or recurrent vaginal candidiasis; prophylaxis to reduce the frequency of recurrence of vaginal candidiasis (3 or more episodes per year); candidal balanitis;
prevention of fungal infections in patients with malignant tumors predisposed to the development of such infections as a result of cytotoxic chemotherapy or radiation therapy;
mycoses of the skin, including mycoses of the feet, body, inguinal region, pityriasis versicolor, onychomycosis and skin candidal infections;
deep endemic mycoses in patients with normal immunity, coccidioidomycosis, paracoccidioidomycosis, sporotrichosis and histoplasmosis.

Release forms

Capsules 50 mg, 100 mg and 150 mg.

Powder for oral suspension 50mg/5ml and 200mg/5ml.

Solution for intravenous administration (in injections) 2 mg/ml.

There is no dosage form of Diflucan in the form of suppositories or tablets. Perhaps the drug in such forms under this brand is a fake.

Instructions for use and dosing regimen

Treatment can be started before culture and other laboratory results are available. However, therapy should be changed accordingly when the results of these studies become known.

Adults with cryptococcal meningitis and cryptococcal infections of other localization are prescribed an average of 400 mg on the first day, and then continue treatment at a dose of 200-400 mg 1 time per day. The duration of treatment for cryptococcal infections depends on the presence of a clinical and mycological effect; in cryptococcal meningitis, treatment is usually continued for at least 6-8 weeks.

To prevent the recurrence of cryptococcal meningitis in AIDS patients after completion of the full course of primary treatment, fluconazole therapy at a dose of 200 mg per day can be continued for a very long time.

With candidemia, disseminated candidiasis and other invasive candidal infections, the dose is an average of 400 mg on the first day, and then 200 mg per day. Depending on the severity of the clinical effect, the dose may be increased to 400 mg per day. The duration of therapy depends on clinical efficacy.

With oropharyngeal candidiasis, the drug is prescribed an average of 50-100 mg 1 time per day for 7-14 days. If necessary, in patients with a pronounced decrease in immunity, treatment can be continued for a longer time. With atrophic candidiasis of the oral cavity associated with the wearing of dentures, the drug is prescribed at an average dose of 50 mg 1 time per day for 14 days in combination with local antiseptic agents for the treatment of the prosthesis.

For other candidal infections of the mucous membranes (with the exception of genital candidiasis), such as esophagitis, non-invasive bronchopulmonary infections, candiduria, candidiasis of the skin and mucous membranes, the effective dose is an average of 50-100 mg per day with a duration of treatment of 14-30 days.

To prevent recurrence of oropharyngeal candidiasis in patients with AIDS, after completing the full course of primary therapy, fluconazole can be prescribed 150 mg 1 time / week.

With vaginal candidiasis, fluconazole is taken once orally at a dose of 150 mg.

To reduce the frequency of recurrence of vaginal candidiasis, the drug can be used at a dose of 150 mg 1 time / month. The duration of therapy is determined individually; it varies from 4 to 12 months. Some patients may require more frequent use. The use of the drug in a single dose in children under the age of 18 years and patients over 60 years of age without a doctor's prescription is not recommended.

For balanitis caused by Candida, fluconazole is prescribed as a single dose of 150 mg orally.

For the prevention of candidiasis, the recommended dose of fluconazole is 50-400 mg 1 time per day, depending on the risk of developing a fungal infection. In the presence of a high risk of generalized infection, for example, in patients with severe or long-lasting neutropenia, the recommended dose is 400 mg 1 time per day. Fluconazole is prescribed a few days before the expected appearance of neutropenia and after an increase in the number of neutrophils more than 1000 / µl, treatment is continued for another 7

For skin infections, including mycoses of the feet, smooth skin, inguinal region and candidal infections, the recommended dose is 150 mg 1 time / week. or 50 mg 1 time per day. The duration of therapy in normal cases is 2-4 weeks, however, with mycoses of the feet, longer therapy (up to 6 weeks) may be required.

With pityriasis versicolor, the recommended dose is 300 mg 1 time / week. within 2 weeks; some patients require a third dose of 300 mg / week, while for some patients a single dose of the drug at a dose of 300-400 mg is sufficient. An alternative treatment regimen is the use of the drug 50 mg 1 time per day for 2-4 weeks.

With onychomycosis, the recommended dose is 150 mg 1 time / week. Treatment should be continued until replacement of the infected nail (growth of an uninfected nail). Re-growth of fingernails and toenails usually takes 3-6 months and 6-12 months, respectively. However, the rate of growth can vary widely from person to person and also according to age. After successful treatment of long-standing chronic infections, a change in the shape of the nails is sometimes observed.

With deep endemic mycoses, it may be necessary to use the drug at a dose of 200-400 mg per day for up to 2 years. The duration of therapy is determined individually; it is 11–24 months for coccidioidomycosis, 2–17 months for paracoccidioidomycosis, 1–16 months for sporotrichosis, and 3–17 months for histoplasmosis.

In children, as in similar infections in adults, the duration of treatment depends on the clinical and mycological effect. The daily dose for children should not exceed that for adults. Fluconazole is used daily 1 time per day.

For the treatment of generalized candidiasis and cryptococcal infections, the recommended dose is 6-12 mg / kg per day, depending on the severity of the disease.

For the prevention of fungal infections in patients with reduced immunity, in whom the risk of developing an infection is associated with neutropenia that develops as a result of cytotoxic chemotherapy or radiation therapy, the drug is prescribed at 3-12 mg / kg per day, depending on the severity and duration of induced neutropenia.

In elderly patients in the absence of signs of renal failure, the drug is prescribed in an average dose.

Fluconazole can be taken orally (in the form of capsules and suspension) or administered intravenously (in the form of a solution for intravenous administration) by infusion at a rate not exceeding 10 ml / min; the choice of the route of administration depends on the clinical condition of the patient. When transferring a patient from intravenous administration to taking the drug orally, or vice versa, changes in the daily dose are not required.

Capsules should be swallowed whole.

When preparing a suspension for oral administration, 24 ml of water should be added to the contents of one vial and shaken thoroughly. Shake the suspension before each use.

The solution of the drug for intravenous administration contains 0.9% sodium chloride solution; each 200 mg (100 ml vial) contains 15 mmol Na + and Cl -, therefore, in patients who require restriction of sodium or fluid intake, it is necessary to consider the rate of fluid administration.

Side effect

headache;
dizziness;
convulsions;
taste change;
abdominal pain;
diarrhea;
flatulence;
nausea;
dyspepsia;
vomit;
flickering / flutter of the ventricles;
rash;
leukopenia, including neutropenia and agranulocytosis, thrombocytopenia;
increased plasma cholesterol and triglyceride levels;
hypokalemia;
anaphylactic reactions (including angioedema, swelling of the face, urticaria, itching).

Contraindications

simultaneous use of cisapride;
simultaneous use of terfenadine during repeated use of fluconazole at a dose of 400 mg per day or more;
hypersensitivity to fluconazole, other components of the drug or azole substances with a structure similar to fluconazole.

Use during pregnancy and lactation

Adequate and well-controlled studies of the safety of the drug in pregnant women have not been conducted. Cases of multiple congenital malformations have been described in newborns whose mothers received high-dose fluconazole therapy (400-800 mg per day) for coccidioidomycosis for 3 or more months. The relationship between these disorders and the use of fluconazole has not been established.

The use of fluconazole during pregnancy should be avoided, except in cases of severe and potentially life-threatening fungal infections, when the expected benefit of treatment outweighs the possible risk to the fetus. Therefore, women of childbearing age should use reliable contraception.

Fluconazole is found in breast milk at concentrations close to plasma, so Diflucan is not recommended for use during lactation (breastfeeding).

special instructions

In rare cases, the use of fluconazole was accompanied by toxic changes in the liver, incl. with a fatal outcome, mainly in patients with serious concomitant diseases. There was no obvious dependence of the hepatotoxic effects of fluconazole on the total daily dose, duration of therapy, sex and age of the patient. The hepatotoxic effect of fluconazole was usually reversible; its signs disappeared after cessation of therapy. Patients who experience abnormal liver function tests during treatment with fluconazole should be monitored for signs of more severe liver damage. If there are clinical signs or symptoms of liver damage that may be associated with fluconazole, the drug should be discontinued.

During treatment with fluconazole, patients in rare cases developed exfoliative skin reactions, such as Stevens-Johnson syndrome and toxic epidermal necrolysis. AIDS patients are more likely to develop severe skin reactions with many drugs. If a rash appears in a patient receiving treatment for a superficial fungal infection, which can be associated with the use of fluconazole, the drug should be discontinued. If a rash occurs in patients with invasive / systemic fungal infections, they should be carefully monitored and fluconazole should be discontinued if bullous lesions or erythema multiforme appear.

As with other azoles, fluconazole can rarely cause anaphylactic reactions.

The simultaneous use of Diflucan in doses less than 400 mg per day and terfenadine should be carefully monitored.

Like other azoles, fluconazole can cause an increase in the QT interval on the ECG. When using fluconazole, an increase in the QT interval and ventricular fibrillation / flutter was noted very rarely in patients with multiple risk factors, such as organic heart disease, electrolyte imbalance and concomitant therapy that contributes to the development of such disorders. Therefore, such patients with potentially proarrhythmic conditions should use fluconazole with caution.

Patients with diseases of the liver, heart and kidneys are advised to consult a doctor before using Diflucan. When using fluconazole 150 mg for vaginal candidiasis, patients should be warned that improvement in symptoms is usually observed after 24 hours, but sometimes it takes several days for their complete disappearance. If symptoms persist for several days, you should consult a doctor.

Influence on the ability to drive vehicles and control mechanisms

Experience with the use of fluconazole indicates that the deterioration in the ability to drive a car and mechanisms associated with the use of the drug is unlikely.

drug interaction

Anticoagulants: like other antifungal agents - azole derivatives, fluconazole, when used simultaneously with warfarin, increases prothrombin time (by 12%), and therefore the development of bleeding (hematomas, bleeding from the nose and gastrointestinal tract, hematuria, melena) is possible. In patients receiving coumarin anticoagulants, it is necessary to constantly monitor the prothrombin time.

Azithromycin: with the simultaneous use of oral fluconazole in a single dose of 800 mg with azithromycin in a single dose of 1200 mg, no pronounced pharmacokinetic interaction has been established.

Benzodiazepines (short-acting): After oral administration of midazolam, Diflucan significantly increases the concentration of midazolam and psychomotor effects, and this effect is more pronounced after oral administration of fluconazole than when it is administered intravenously. If concomitant benzodiazepine therapy is required, patients taking fluconazole should be monitored for an appropriate dose reduction of the benzodiazepine.

Cisapride: with the simultaneous use of fluconazole and cisapride, adverse reactions from the heart are possible, incl. flickering / flutter of the ventricles (pirouette-type arrhythmia). The use of fluconazole at a dose of 200 mg 1 time per day and cisapride at a dose of 20 mg 4 leads to a pronounced increase in plasma concentrations of cisapride and an increase in the QT interval on the ECG. Co-administration of cisapride and fluconazole is contraindicated.

Cyclosporine: In patients after kidney transplantation, the use of fluconazole at a dose of 200 mg per day leads to a slow increase in the concentration of cyclosporine. However, with repeated administration of fluconazole at a dose of 100 mg per day, no change in the concentration of cyclosporine in bone marrow recipients was observed. With the simultaneous use of fluconazole and cyclosporine, it is recommended to monitor the concentration of cyclosporine in the blood.

Hydrochlorothiazide: Repeated use of hydrochlorothiazide concomitantly with fluconazole results in an increase in plasma concentration of fluconazole by 40%. The effect of this degree of severity does not require a change in the dosing regimen of fluconazole in patients receiving diuretics at the same time, but this should be taken into account.

Oral contraceptives: with the simultaneous use of a combined oral contraceptive with fluconazole at a dose of 50 mg, no significant effect on hormone levels has been established, while with daily intake of 200 mg of fluconazole, the AUC of ethinylestradiol and levonorgestrel increase by 40% and 24%, respectively, and with 300 mg of fluconazole once a week - AUC of ethinyl estradiol and norethindrone increase by 24% and 13%, respectively. Thus, repeated use of fluconazole at the indicated doses is unlikely to affect the effectiveness of the combined oral contraceptive.

Phenytoin: The simultaneous use of Diflucan and phenytoin may be accompanied by a clinically significant increase in the concentration of phenytoin. If it is necessary to use both drugs simultaneously, the concentration of phenytoin should be monitored and its dose adjusted accordingly in order to ensure therapeutic serum concentrations.

Rifabutin: the simultaneous use of fluconazole and rifabutin can lead to an increase in serum concentrations of the latter. With the simultaneous use of fluconazole and rifabutin, cases of uveitis have been described. Patients simultaneously receiving rifabutin and fluconazole should be carefully monitored.

Rifampicin: The simultaneous use of fluconazole and rifampicin leads to a decrease in AUC by 25% and the duration of T1 / 2 fluconazole by 20%. In patients concomitantly taking rifampicin, it is necessary to consider the advisability of increasing the dose of fluconazole.

Sulfonylureas: Fluconazole, when taken concomitantly, leads to an increase in T1 / 2 of oral sulfonylureas (chlorpropamide, glibenclamide, glipizide and tolbutamide). Fluconazole and oral sulfonylurea preparations can be co-administered to patients with diabetes mellitus, but the possibility of hypoglycemia should be considered.

Tacrolimus: The simultaneous use of fluconazole and tacrolimus leads to an increase in serum concentrations of the latter. Cases of nephrotoxicity have been described. Patients taking tacrolimus and fluconazole concomitantly should be closely monitored.

Terfenadine: With the simultaneous use of azole antifungals and terfenadine, serious arrhythmias may occur as a result of an increase in the QT interval. When taking fluconazole at a dose of 200 mg per day, an increase in the QT interval was not established, however, the use of fluconazole at doses of 400 mg per day and above causes a significant increase in the concentration of terfenadine in plasma. Simultaneous administration of fluconazole in doses of 400 mg per day or more with terfenadine is contraindicated. Treatment with fluconazole at doses less than 400 mg per day in combination with terfenadine should be carefully monitored.

Theophylline: when used simultaneously with fluconazole at a dose of 200 mg for 14 days, the average plasma clearance rate of theophylline is reduced by 18%. When prescribing fluconazole to patients taking high doses of theophylline, or to patients with an increased risk of developing the toxic effects of theophylline, the appearance of symptoms of theophylline overdose should be observed and, if necessary, therapy should be adjusted accordingly.

Zidovudine: when used simultaneously with fluconazole, there is an increase in zidovudine concentrations, which is probably due to a decrease in the metabolism of the latter to its main metabolite. Before and after therapy with fluconazole at a dose of 200 mg per day for 15 days, patients with AIDS and ARC (AIDS-related complex) showed a significant increase in AUC of zidovudine (20%).

When used in HIV-infected patients with zidovudine at a dose of 200 mg every 8 hours for 7 days in combination with fluconazole at a dose of 400 mg per day or without it with an interval of 21 days between the two regimens, a significant increase in AUC of zidovudine was found (74%) when used simultaneously with fluconazole. Patients receiving this combination should be observed to detect side effects of zidovudine.

The simultaneous use of fluconazole with astemizole or other drugs, the metabolism of which is carried out by isoenzymes of the cytochrome P450 system, may be accompanied by an increase in the serum concentrations of these agents. With the simultaneous appointment of fluconazole, in the absence of reliable information, care must be taken. Patients should be carefully observed.

Studies of the interaction of oral forms of fluconazole when taken simultaneously with food, cimetidine, antacids, and also after total body irradiation for bone marrow transplantation showed that these factors do not have a clinically significant effect on the absorption of fluconazole.

These interactions have been established with repeated use of fluconazole; interactions with drugs as a result of a single dose of fluconazole are unknown.

It should be borne in mind that the interaction with other drugs has not been specifically studied, but it is possible.

Diflucan - solution for intravenous administration is compatible with the following solutions: 20% glucose solution, Ringer's solution, Hartmann's solution, potassium chloride solution in glucose, 4.2% sodium bicarbonate solution, aminofusine, isotonic saline.

Diflucan's analogues

Structural analogues for the active substance:

Vero-Fluconazole;
Disorel-Sanovel;
Diflazon;
Maiconil;
Medoflucon;
Mycomax;
Mycosist;
Mycoflucan;
Nofung;
Procanazole;
Fangiflu;
Flucosan;
Flucoside;
Flucomabol;
Flucomicide SEDICO;
Fluconazole;
Fluconazole Hexal;
Fluconazole STADA;
Fluconazole-LEXVM;
Fluconazole-Teva;
Fluconorm;
Flucoral;
Flucorem;
Flucostat;
Forkan;
Fungolon;
Tsiskan.

In the absence of analogues of the drug for the active substance, you can follow the links below to the diseases that the corresponding drug helps with and see the available analogues for the therapeutic effect.

P N013546/01

Trade name of the drug:

Diflucan ®

International non-proprietary name:

fluconazole

Dosage form:

powder for suspension for oral administration.

Compound

1 ml of the finished suspension contains:

active substance: fluconazole 10 mg or 40 mg, respectively;

auxiliary substances: anhydrous citric acid 4.20 mg / 4.21 mg, sodium benzoate 2.37 mg / 2.38 mg, xanthan gum 2.03 mg / 2.01 mg, titanium dioxide (E 171) 1.0 mg / 0 .98 mg, sucrose 576.23 mg / 546.27 mg, colloidal anhydrous silicon dioxide 1.0 mg / 0.98 mg, sodium citrate dihydrate 3.17 mg / 3.17 mg, orange flavor * 10.0 mg / 10.0 mg.

*contains orange essential oil, maltodextrin and water.

Description

White or almost white powder free of visible impurities.

Pharmacotherapeutic group:

antifungal agent.

ATX code: J02AC01

Pharmacological properties

Pharmacodynamics

Fluconazole, a triazole antifungal agent, is a potent selective inhibitor of sterol synthesis in the fungal cell.

Fluconazole has shown activity in vitro and in clinical infections against most of the following organisms: Candida albicans, Candida glabrata(many strains are moderately sensitive), Candida parapsilosis, Candida tropicalis, Cryptococcus neoformans.

Fluconazole has been shown to be active in vitro against the following microorganisms, but the clinical significance of this is unknown: Candida dubliniensis, Candida guilliermondii, Candida kefir, Candida lusitaniae.

When administered orally, fluconazole has been active in various animal models of fungal infections. The activity of the drug in opportunistic mycoses, including those caused by Candida spp . (including generalized candidiasis in immunosuppressed animals); Cryptococcus neoformans(including intracranial infections); microsporum spp . And trychophyton spp. The activity of fluconazole has also been established in models of endemic mycoses in animals, including infections caused by Blastomyces dermatitis, Coccidioides immitis(including intracranial infections) and Histoplasma capsulatum in animals with normal and suppressed immunity.

Fluconazole has a high specificity for fungal enzymes dependent on cytochrome P450. Therapy with fluconazole at a dose of 50 mg / day for up to 28 days does not affect the concentration of testosterone in the blood plasma in men or the concentration of steroids in women of childbearing age. Fluconazole at a dose of 200-400 mg/day has no clinically significant effect on endogenous steroid levels and their response to adrenocorticotropic hormone (ACTH) stimulation in healthy male volunteers.

Mechanisms of development of resistance to fluconazole

Fluconazole resistance can develop in the following cases: a qualitative or quantitative change in the enzyme that is the target of fluconazole (lanosteril 14-α-demethylase), a decrease in access to the target of fluconazole, or a combination of these mechanisms.

Point mutations in the ERG11 gene encoding the target enzyme lead to a modification of the target and a decrease in affinity for azoles. An increase in the expression of the ERG11 gene leads to the production of high concentrations of the target enzyme, which creates a need to increase the concentration of fluconazole in the intracellular fluid to suppress all enzyme molecules in the cell.

The second significant mechanism of resistance is the active removal of fluconazole from the intracellular space through the activation of two types of transporters involved in the active removal (efflux) of drugs from the fungal cell. These transporters include the master messenger encoded by the MDR (multiple drug resistance) genes and the ATP-binding cassette transporter superfamily encoded by the CDR genes (fungal resistance genes). Candida to azole antimycotics).

Overexpression of the MDR gene leads to resistance to fluconazole, while overexpression of the CDR genes can lead to resistance to various azoles.

Resistance to Candida glabrata is usually mediated by overexpression of the CDR gene, resulting in resistance to many azoles. For those strains in which the minimum inhibitory concentration (MIC) is defined as intermediate (16-32 μg / ml), it is recommended to use the maximum dose of fluconazole.

Candida krusei should be considered as resistant to fluconazole. The mechanism of resistance is associated with reduced sensitivity of the target enzyme to the inhibitory effect of fluconazole.

Pharmacokinetics

Fluconazole is a selective inhibitor of CYP2C9 and CYP3A4 isoenzymes, fluconazole is also an inhibitor of CYP2C19 isoenzyme. The pharmacokinetics of fluconazole is similar when administered intravenously and orally. After oral administration, fluconazole is well absorbed, its plasma levels (and overall bioavailability) exceed 90% of those when administered intravenously. Simultaneous food intake does not affect the absorption of fluconazole. The plasma concentration is proportional to the dose and reaches a maximum (Cmax) 0.5-1.5 hours after taking fluconazole on an empty stomach, and the half-life is about 30 hours. 90% of the equilibrium concentration is reached by the 4-5th day after the start of therapy (with multiple doses of the drug once a day).

The introduction of a loading dose (on the 1st day), twice the usual daily dose, makes it possible to achieve 90% of the equilibrium concentration by the 2nd day. The volume of distribution approaches the total water content in the body. Plasma protein binding is low (11-12%).

Fluconazole penetrates well into all body fluids. Fluconazole concentrations in saliva and sputum are similar to those in plasma. In patients with fungal meningitis, fluconazole concentrations in the cerebrospinal fluid are about 80% of its plasma concentrations.

In the stratum corneum, epidermis, dermis and sweat fluid, high concentrations are achieved that exceed serum levels. Fluconazole accumulates in the stratum corneum. When taken at a dose of 50 mg once a day, the concentration of fluconazole after 12 days is 73 mcg / g, and after 7 days after stopping treatment - only 5.8 mcg / g. When used at a dose of 150 mg once a week, the concentration of fluconazole in the stratum corneum on the 7th day is 23.4 μg / g, and 7 days after the second dose - 7.1 μg / g.

The concentration of fluconazole in the nails after 4 months of use at a dose of 150 mg once a week is 4.05 μg / g in healthy and 1.8 μg / g in affected nails; 6 months after completion of therapy, fluconazole is still determined in the nails.

The drug is excreted mainly by the kidneys; Approximately 80% of the administered dose is found in the urine unchanged. Fluconazole clearance is proportional to creatinine clearance. No circulating metabolites were found.

The long plasma half-life allows fluconazole to be taken once for vaginal candidiasis and once a day or once a week for other indications.

When comparing the concentrations in saliva and blood plasma after a single dose of 100 mg of fluconazole in the form of a capsule and suspension (rinsing, keeping in the mouth for 2 minutes and swallowing), it was found that the maximum concentration of fluconazole in saliva when taking the suspension was observed 5 minutes after administration and 182 times higher than after taking the capsule (reached after 4 hours). Approximately after 4 h, the concentrations of fluconazole in saliva were the same. The mean area under the concentration-time curve (AUC (0-96)) in saliva was significantly higher with the suspension than with the capsules. There were no significant differences in the rate of excretion from saliva or pharmacokinetics in blood plasma when using the two dosage forms.

Pharmacokinetics in children

The following pharmacokinetic parameters were obtained in children:

Pharmacokinetics in elderly patients

It was found that with a single dose of fluconazole at a dose of 50 mg orally in elderly patients aged 65 years and older, some of whom were simultaneously taking diuretics, Cmax was reached 1.3 hours after administration and was 1.54 μg / ml, the average AUC values are 76.4 ± 20.3 μg h / ml, and the mean half-life is 46.2 hours. The values of these pharmacokinetic parameters are higher than in young patients, which is probably due to reduced renal function characteristic of the elderly age. Simultaneous intake of diuretics did not cause a pronounced change in AUC and C max . Creatinine clearance (74 ml / min), the percentage of fluconazole excreted by the kidneys unchanged (0 - 24 h, 22%) and renal clearance of fluconazole (0.124 ml / min / kg) in elderly patients are lower than in young patients.

Indications for use

Cryptococcosis, including cryptococcal meningitis and infections of other localizations (for example, lungs, skin), including in patients with a normal immune response and AIDS patients, recipients of transplanted organs and patients with other forms of immunodeficiency; maintenance therapy to prevent recurrence of cryptococcosis in AIDS patients;

Generalized candidiasis, including candidemia, disseminated candidiasis and other forms of invasive candidal infection, such as infections of the peritoneum, endocardium, eyes, respiratory and urinary tract, including in patients with malignant tumors in intensive care units and receiving cytotoxic or immunosuppressive agents, as well as in patients with other factors predisposing to the development of candidiasis;

Mucosal candidiasis, including mucous membranes of the mouth and pharynx, esophagus, non-invasive broncho-pulmonary infections, candiduria, mucocutaneous and chronic atrophic candidiasis of the oral cavity (associated with wearing dentures), including in patients with normal and suppressed immune function; prevention of recurrence of oropharyngeal candidiasis in patients with AIDS;

genital candidiasis; acute or recurrent vaginal candidiasis; prophylaxis to reduce the frequency of recurrence of vaginal candidiasis (3 or more episodes per year); candidal balanitis;

Prevention of fungal infections in patients with malignant tumors predisposed to such infections as a result of cytotoxic chemotherapy or radiation therapy;

Mycoses of the skin, including mycoses of the feet, body, inguinal region, pityriasis versicolor, onychomycosis and skin candidal infections;

Deep endemic mycoses in patients with normal immunity, coccidioidomycosis.

Contraindications

Hypersensitivity to fluconazole, other components of the drug or azole substances with a structure similar to fluconazole;

Simultaneous administration of terfenadine during repeated use of fluconazole at a dose of 400 mg / day or more (see section "Interaction with other drugs");

Simultaneous use with drugs that increase the QT interval and are metabolized using the CYP3A4 isoenzyme, such as cisapride, astemizole, erythromycin, pimozide and quinidine (see section "Interaction with other drugs");

- sucrase / isomaltase deficiency, fructose intolerance, glucose-galactose malabsorption.

Carefully

Violation of indicators of liver function;

Impaired kidney function;

The appearance of a rash against the background of the use of fluconazole in patients with superficial fungal infection and invasive / systemic fungal infections;

Simultaneous use of terfenadine and fluconazole at a dose of less than 400 mg / day;

Potentially proarrhythmic conditions in patients with multiple risk factors (organic heart disease, electrolyte imbalance and concomitant therapy that contributes to the development of such disorders).

Use during pregnancy and during breastfeeding

Adequate and well-controlled studies of the use of fluconazole in pregnant women have not been conducted.

Cases of spontaneous abortion and the development of congenital anomalies have been reported in infants whose mothers received fluconazole at a dose of 150 mg once or repeatedly in the first trimester of pregnancy. Several cases of multiple congenital malformations have been described in newborns whose mothers received high-dose fluconazole therapy (400-800 mg/day) for coccidioidomycosis for most or all of the first trimester. The following developmental abnormalities have been noted: brachycephaly, impaired development of the facial part of the skull, impaired formation of the cranial vault, cleft palate, curvature of the femur, thinning and lengthening of the ribs, arthrogryposis and congenital heart defects.

Fluconazole is found in breast milk at concentrations close to plasma, so its administration to women during breastfeeding is not recommended.

Dosage and administration

Suspension preparation instructions: add 24 ml of water to the contents of one vial of powder for suspension preparation and shake well. Shake before each use.

Therapy can be initiated before culture and other laboratory results are available. However, antifungal therapy should be changed accordingly when the results of these studies become known.

When transferring a patient from intravenous to oral administration of the drug, or vice versa, changes in the daily dose are not required.

Daily dose of Diflucan ® depends on the nature and severity of the fungal infection. With vaginal candidiasis, in most cases, a single dose of the drug is effective. For infections requiring repeat administration of the antifungal drug, treatment should be continued until clinical or laboratory signs of active fungal infection have disappeared. Patients with AIDS and cryptococcal meningitis or recurrent oropharyngeal candidiasis usually require maintenance therapy to prevent recurrence of the infection.

Use in adults

1. For cryptococcal meningitis and cryptococcal infections of other localization, 400 mg is usually used on the first day, and then treatment is continued at a dose of 200-400 mg once a day. The duration of treatment for cryptococcal infections depends on the presence of a clinical and mycological effect; in cryptococcal meningitis, treatment is usually continued for at least 6-8 weeks.

For the prevention of recurrence of cryptococcal meningitis in patients with AIDS, after completion of the full course of primary treatment, therapy with Diflucan ® at a dose of 200 mg / day, you can continue indefinitely.

2. For candidemia, disseminated candidiasis and other invasive candidal infections, the dose is usually 400 mg on the first day, then 200 mg / day. Depending on the severity of the clinical effect, the dose may be increased to 400 mg / day. The duration of therapy depends on clinical efficacy.

3. With oropharyngeal candidiasis, the drug is usually used at 50-100 mg once a day for 7-14 days. If necessary, patients with severe suppression of immune function can continue treatment for a longer time. In atrophic oral candidiasis associated with the wearing of dentures, the drug is usually used at a dose of 50 mg once a day for 14 days in combination with local antiseptic agents for the treatment of the prosthesis.

For other candidal infections of the mucous membranes (with the exception of genital candidiasis, see below), for example, esophagitis, non-invasive bronchopulmonary infections, candiduria, candidiasis of the skin and mucous membranes, etc., the effective dose is usually 50-100 mg / day with a duration of treatment of 14-30 days.

For the prevention of recurrence of oropharyngeal candidiasis in patients with AIDS after completion of the full course of primary therapy Diflucan ® may be prescribed 150 mg once a week.

4. For vaginal candidiasis Diflucan ® used once orally at a dose of 150 mg.

To reduce the frequency of recurrence of vaginal candidiasis, the drug can be used at a dose of 150 mg once a week. The duration of anti-relapse therapy is determined individually and, as a rule, is 6 months. The use of a single dose in children under 18 years of age and in patients over 60 years of age without a doctor's prescription is not recommended.

For balanitis caused by Candida spp., Diflucan ® used once at a dose of 150 mg orally.

5. For the prevention of candidiasis in patients with malignant tumors, the recommended dose of Diflucan ® is 50-400 mg once a day, depending on the degree of risk of developing a fungal infection. For patients at high risk of generalized infection, for example, with severe or long-lasting neutropenia, the recommended dose is 400 mg once a day. Diflucan ® apply a few days before the expected development of neutropenia and, after an increase in the number of neutrophils over 1000 in mm 3, treatment is continued for another 7 days.

6. For skin infections, including athlete's foot, smooth skin, groin and candida infections, the recommended dose is 150 mg once a week or 50 mg once a day. The duration of therapy is usually 2-4 weeks, however, with mycoses of the feet, longer therapy (up to 6 weeks) may be required.

For pityriasis versicolor, the recommended dose is 300 mg once a week for 2 weeks; some patients require a third dose of 300 mg per week, while for some patients a single dose of 300-400 mg is sufficient. An alternative treatment regimen is the use of the drug 50 mg once a day for 2-4 weeks.

For onychomycosis, the recommended dose is 150 mg once a week. Treatment should be continued until replacement of the infected nail (growth of an uninfected nail). Re-growth of fingernails and toenails usually takes 3-6 months and 6-12 months, respectively. However, the rate of growth can vary widely from person to person and also according to age. After successful treatment of long-standing chronic infections, a change in the shape of the nails is sometimes observed.

7. With deep endemic mycoses, it may be necessary to use the drug at a dose of 200-400 mg / day. Therapy can last up to 2 years. The duration of therapy is determined individually; it is 11-24 months for coccidioidomycosis.

Use in children

As with similar infections in adults, the duration of treatment depends on the clinical and mycological effect. For children, the daily dose of the drug should not exceed that for adults. The maximum daily dose is 400 mg. Diflucan ® used daily once a day.

For the treatment of generalized candidiasis and cryptococcal infections, the recommended dose is 6-12 mg / kg / day, depending on the severity of the disease.

To suppress the recurrence of cryptococcal meningitis in children with AIDS, the recommended dose of Diflucan ® is 6 mg/kg once a day.

For the prevention of fungal infections in patients with suppressed immunity, in whom the risk of infection is associated with neutropenia, which develops as a result of cytotoxic chemotherapy or radiation therapy, the drug is used according to
3-12 mg / kg / day, depending on the severity and duration of induced neutropenia (see dose for adults; for children with renal insufficiency - see dose for patients with renal insufficiency).

Use in children aged 4 weeks or less

In newborns, fluconazole is excreted slowly. In the first 2 weeks of life, the drug is used at the same dose (in mg / kg) as for older children, but with an interval of 72 hours. For children aged 3 and 4 weeks, the same dose is administered with an interval of 48 hours.

Use in the elderly

In the absence of signs of renal failure, the drug is used in the usual dose. Patients with renal insufficiency (creatinine clearance<50 мл/мин) дозу препарата корректируют, как описано ниже.

Use in patients with renal insufficiency

With a single dose, dose changes are not required. In patients (including children) with impaired renal function with repeated use of the drug, a loading dose of 50 mg to 400 mg should be initially administered, after which the daily dose (depending on the indication) is set according to the following table:

Patients on regular dialysis should receive 100% of the recommended dose after each dialysis session. On days when dialysis is not performed, patients should receive a reduced (depending on creatinine clearance) dose of the drug.

Use in patients with liver failure

There are limited data on the use of fluconazole in patients with hepatic impairment. In this regard, when using the drug Diflucan ® in this category of patients, care should be taken.

Side effect

Tolerability of the drug is usually very good.

In clinical and post-marketing (*) studies of Diflucan ® noted the following adverse reactions:

From the side of the nervous system: headache, dizziness*, convulsions*, taste change*, paresthesia, insomnia, drowsiness, tremor.

From the digestive system: abdominal pain, diarrhea, flatulence, nausea, dyspepsia*, vomiting*, dryness of the oral mucosa, constipation.

From the hepatobiliary system: hepatotoxicity, in some cases fatal, increased bilirubin concentration, serum aminotransferase activity (alanine aminotransferase (ALT) and aspartate aminotransferase (AST)), alkaline phosphatase, abnormal liver function*, hepatitis*, hepatocellular necrosis*, jaundice*, cholestasis, hepatocellular damage .

From the side of the skin: rash, alopecia*, exfoliative skin lesions* including Stevens-Johnson syndrome and toxic epidermal necrolysis, acute generalized exanthematous pustulosis, increased sweating, drug rash.

From the side of the hematopoietic organs and the lymphatic system*: leukopenia, including neutropenia and agranulocytosis, thrombocytopenia, anemia.

From the immune system*: anaphylaxis (including angioedema, swelling of the face, urticaria, itching).

From the side of the cardiovascular system*: an increase in the QT interval on the ECG, ventricular tachysystolic arrhythmia of the "pirouette" type (torsade de pointes) (see section "Special Instructions"), arrhythmia.

From the side of metabolism*: increase in the concentration of cholesterol and triglycerides in blood plasma, hypokalemia.

From the musculoskeletal system: myalgia.

Others: weakness, asthenia, fatigue, fever, vertigo.

In some patients, especially those with serious illnesses such as AIDS or cancer, while being treated with Diflucan ® and similar drugs, changes in blood counts, kidney and liver function were observed (see section "Special Instructions"), however, the clinical significance of these changes and their relationship with treatment has not been established.

Overdose

There are reports of overdose of fluconazole, and in one case, a 42-year-old patient infected with the human immunodeficiency virus, after taking 8200 mg of the drug, hallucinations and paranoid behavior appeared. The patient was hospitalized; his condition returned to normal within 48 hours.

In case of overdose, symptomatic treatment is carried out (including supportive measures and gastric lavage).

Fluconazole is eliminated primarily via the kidneys, so forced diuresis is likely to accelerate the elimination of the drug. A 3-hour hemodialysis session reduces the plasma concentration of fluconazole by about 50%.

Interaction

A single or multiple dose of fluconazole at a dose of 50 mg does not affect the metabolism of phenazone (Antipyrine) when they are taken simultaneously.

Simultaneous use of fluconazole with the following drugs is contraindicated:

Cisapride: with the simultaneous use of fluconazole and cisapride, adverse reactions from the heart are possible, incl. arrhythmia ventricular tachysystolic type "pirouette" (torsade de pointes). The use of fluconazole at a dose of 200 mg 1 time per day and cisapride at a dose of 20 mg 4 times a day leads to a pronounced increase in plasma concentrations of cisapride and an increase in the QT interval on the ECG. Co-administration of cisapride and fluconazole is contraindicated.

Terfenadine: With the simultaneous use of azole antifungals and terfenadine, serious arrhythmias may occur as a result of an increase in the QT interval. When taking fluconazole at a dose of 200 mg / day, an increase in the QT interval has not been established, however, the use of fluconazole at doses of 400 mg / day and above causes a significant increase in the concentration of terfenadine in blood plasma. Simultaneous administration of fluconazole in doses of 400 mg / day or more with terfenadine is contraindicated (see section "Contraindications"). Treatment with fluconazole at doses less than 400 mg/day in combination with terfenadine should be carefully monitored.

Astemizole: the simultaneous use of fluconazole with astemizole or other drugs, the metabolism of which is carried out by the cytochrome P450 system, may be accompanied by an increase in the serum concentrations of these agents. Elevated plasma concentrations of astemizole can lead to prolongation of the QT interval and, in some cases, to the development of ventricular tachysystolic arrhythmia of the "pirouette" type (torsade de pointes). The simultaneous use of astemizole and fluconazole is contraindicated.

Pimozide: although no relevant studies have been conducted in vitro or in vivo, the simultaneous use of fluconazole and pimozide can lead to inhibition of the metabolism of pimozide. In turn, an increase in plasma concentrations of pimozide can lead to a prolongation of the QT interval and, in some cases, to the development of ventricular tachysystolic arrhythmia of the “pirouette” type (torsade de pointes). The simultaneous use of pimozide and fluconazole is contraindicated.

Quinidine: although no relevant studies have been conducted in vitro or in vivo, the simultaneous use of fluconazole and quinidine can also lead to inhibition of the metabolism of quinidine. The use of quinidine is associated with prolongation of the QT interval and, in some cases, with the development of ventricular tachysystolic arrhythmias of the "pirouette" type (torsade de pointes). The simultaneous use of quinidine and fluconazole is contraindicated.

Erythromycin: the simultaneous use of fluconazole and erythromycin potentially leads to an increased risk of cardiotoxicity (prolongation of the QT interval, torsade de pointes) and, consequently, sudden cardiac death. The simultaneous use of fluconazole and erythromycin is contraindicated.

Caution should be exercised and possibly dose adjustments should be made when the following drugs are co-administered with fluconazole:

Drugs that affect fluconazole:

Hydrochlorothiazide: repeated use of hydrochlorothiazide simultaneously with fluconazole leads to an increase in the concentration of fluconazole in blood plasma by 40%. The effect of this degree of severity does not require a change in the dosing regimen of fluconazole in patients receiving diuretics at the same time, but the doctor should take this into account.

Rifampicin: The simultaneous use of fluconazole and rifampicin leads to a decrease in AUC by 25% and the duration of the half-life of fluconazole by 20%. In patients concomitantly taking rifampicin, it is necessary to consider the advisability of increasing the dose of fluconazole.

Drugs affected by fluconazole:

fluconazole is a potent inhibitor of cytochrome P450 isoenzyme CYP2C9 and CYP2C19 and a moderate inhibitor of CYP3A4 isoenzyme. In addition, in addition to the effects listed below, there is a risk of increasing plasma concentrations of other drugs metabolized by CYP2C9, CYP2C19 and CYP3A4 isoenzymes while taking fluconazole. In this regard, caution should be exercised with the simultaneous use of these drugs, and if necessary, such combinations, patients should be under close medical supervision. It should be borne in mind that the inhibitory effect of fluconazole persists for 4-5 days after discontinuation of the drug due to the long half-life.

Alfentanil: there is a decrease in clearance and volume of distribution, an increase in the half-life of alfentanil. This may be due to the inhibition of the CYP3A4 isoenzyme by fluconazole. Dose adjustment of alfentanil may be required.

Amitriptyline, nortriptyline: increase in effect. The concentration of 5-nortriptyline and / or S-amitriptyline can be measured at the beginning of combination therapy with fluconazole and one week after the start. If necessary, the dose of amitriptyline/nortriptyline should be adjusted.

Amphotericin B: in mice (including those with immunosuppression), the following results were noted: a small additive antifungal effect in systemic infection caused by C. albicans, lack of interaction in intracranial infection caused by Cryptococcus neoformans and antagonism in systemic infection caused by A. fumigatus. The clinical significance of these results is not clear.

Anticoagulants: like other antifungal agents (azole derivatives), fluconazole, when used simultaneously with warfarin, increases prothrombin time (by 12%), and therefore, bleeding may develop (hematomas, bleeding from the nose and gastrointestinal tract, hematuria , melena). In patients receiving coumarin anticoagulants, it is necessary to constantly monitor the prothrombin time. The advisability of adjusting the warfarin dose should also be assessed.

Azithromycin: With the simultaneous use of oral fluconazole in a single dose of 800 mg with azithromycin in a single dose of 1200 mg, a pronounced pharmacokinetic interaction between both drugs has not been established.

Benzodiazepines (short-acting): after oral administration of midazolam, fluconazole significantly increases the concentration of midazolam and psychomotor effects, and this effect is more pronounced after oral administration of fluconazole than when it is administered intravenously. If concomitant benzodiazepine therapy is required, patients taking fluconazole should be monitored to assess the appropriateness of an appropriate dose reduction of the benzodiazepine.

With the simultaneous administration of a single dose of triazolam, fluconazole increases triazolam AUC by approximately 50%, Cmax by 25-32% and half-life by 25-50% due to inhibition of triazolam metabolism. Dose adjustment of triazolam may be necessary.

Carbamazepine: Fluconazole inhibits the metabolism of carbamazepine and increases the serum concentration of carbamazepine by 30%. The risk of carbamazepine toxicity must be considered. The need to adjust the dose of carbamazepine depending on the concentration / effect should be evaluated.

Calcium channel blockers: some calcium channel antagonists (nifedipine, isradipine, amlodipine, verapamil and felodipine) are metabolized by the CYP3A4 isoenzyme. Fluconazole increases the systemic exposure of calcium channel antagonists. It is recommended to control the development of side effects.

Cyclosporine: In kidney transplant patients, the use of fluconazole at a dose of 200 mg / day leads to a slow increase in the concentration of cyclosporine. However, with repeated administration of fluconazole at a dose of 100 mg / day, changes in the concentration of cyclosporine in bone marrow recipients were not observed. With the simultaneous use of fluconazole and cyclosporine, it is recommended to control the concentration of cyclosporine in the blood.

Cyclophosphamide: With the simultaneous use of cyclophosphamide and fluconazole, an increase in serum concentrations of bilirubin and creatinine is noted. This combination is acceptable, taking into account the risk of increasing the concentrations of bilirubin and creatinine.

Fentanyl: There has been a report of one death possibly related to the concomitant use of fentanyl and fluconazole. It is assumed that the violations are associated with fentanyl intoxication. Fluconazole has been shown to significantly prolong the elimination time of fentanyl. It should be borne in mind that an increase in the concentration of fentanyl can lead to respiratory depression.

Halofantrine: fluconazole may increase plasma concentrations of halofantrine due to inhibition of the CYP3A4 isoenzyme.

HMG-CoA reductase inhibitors: with the simultaneous use of fluconazole with HMG-CoA reductase inhibitors metabolized by the CYP3A4 isoenzyme (such as atorvastatin and simvastatin) or the CYP2D6 isoenzyme (such as fluvastatin), the risk of developing myopathy and rhabdomyolysis increases. If concomitant therapy with these drugs is necessary, patients should be observed to detect symptoms of myopathy and rhabdomyolysis. It is necessary to control the concentration of creatinine kinase. In the event of a significant increase in the concentration of creatinine kinase or if myopathy or rhabdomyolysis is diagnosed or suspected, therapy with HMG-CoA reductase inhibitors should be discontinued.

Losartan: fluconazole inhibits the metabolism of losartan to its active metabolite (E-31 74), which is responsible for most of the effects associated with angiotensin II receptor antagonism. Regular monitoring of blood pressure is necessary.

Methadone: fluconazole may increase the plasma concentration of methadone. You may need to adjust your methadone dose.

Non-steroidal anti-inflammatory drugs (NSAIDs): Cmax and AUC of flurbiprofen increase by 23% and 81%, respectively. Similarly, the Cmax and AUC of the pharmacologically active isomer increased by 15% and 82%, respectively, with the simultaneous use of fluconazole with racemic ibuprofen (400 mg).

With the simultaneous use of fluconazole at a dose of 200 mg / day and celecoxib at a dose of 200 mg, Cmax and AUC of celecoxib increase by 68% and 134%, respectively. In this combination, it is possible to reduce the dose of celecoxib by half.

Despite the lack of targeted studies, fluconazole may increase the systemic exposure of other NSAIDs metabolized by the CYP2C9 isoenzyme (eg, naproxen, lornoxicam, meloxicam, diclofenac). You may need to adjust the dose of NSAIDs.

With the simultaneous use of NSAIDs and fluconazole, patients should be under close medical supervision in order to identify and control adverse events and manifestations of toxicity associated with NSAIDs.

Oral contraceptives: with the simultaneous use of a combined oral contraceptive with fluconazole at a dose of 50 mg, a significant effect on hormone levels has not been established, whereas with a daily intake of 200 mg of fluconazole, the AUC of ethinyl estradiol and levonorgestrel increase by 40% and 24%, respectively, and when taking 300 mg of fluconazole once a day week, the AUC of ethinyl estradiol and norethindrone increased by 24% and 13%, respectively. Thus, repeated use of fluconazole at the indicated doses is unlikely to affect the effectiveness of the combined oral contraceptive.

Phenytoin: The simultaneous use of fluconazole and phenytoin may be accompanied by a clinically significant increase in the concentration of phenytoin. If it is necessary to use both drugs simultaneously, the concentration of phenytoin should be monitored and its dose adjusted accordingly in order to ensure therapeutic serum concentrations.

Prednisone: There is a report of the development of acute adrenal insufficiency in a patient after liver transplantation against the background of fluconazole withdrawal after a three-month course of therapy. Presumably, the cessation of fluconazole therapy caused an increase in the activity of the CYP3A4 isoenzyme, which led to an increased metabolism of prednisone.

Patients receiving combination therapy with prednisone and fluconazole should be under close medical supervision when fluconazole is discontinued in order to assess the state of the adrenal cortex.

Rifabutin: the simultaneous use of fluconazole and rifabutin can lead to an increase in serum concentrations of the latter up to 80%. With the simultaneous use of fluconazole and rifabutin, cases of uveitis have been described. Patients simultaneously receiving rifabutin and fluconazole should be carefully monitored.

Saquinavir: AUC increases by approximately 50%, C max by 55%, clearance of saquinavir decreases by approximately 50% due to inhibition of hepatic metabolism of CYP3A4 isoenzyme and inhibition of P-glycoprotein. Dose adjustment of saquinavir may be necessary.

Sirolimus: increased plasma concentrations of sirolimus, presumably due to inhibition of sirolimus metabolism through inhibition of CYP3A4 isoenzyme and P-glycoprotein. This combination can be used with appropriate dose adjustment of sirolimus depending on the effect/concentration.

Sulfonylureas: fluconazole, when taken simultaneously, leads to an increase in the half-life of oral sulfonylurea drugs (chlorpropamide, glibenclamide, glipizide and tolbutamide). Patients with diabetes mellitus can be prescribed the combined use of fluconazole and oral sulfonylurea preparations, but the possibility of developing hypoglycemia should be taken into account, in addition, regular monitoring of blood glucose and, if necessary, dose adjustment of sulfonylurea preparations is necessary.

Tacrolimus: The simultaneous use of fluconazole and tacrolimus (by mouth) leads to an increase in serum concentrations of the latter up to 5 times due to inhibition of the metabolism of tacrolimus that occurs in the intestine through the CYP3A4 isoenzyme. Significant changes in the pharmacokinetics of drugs were observed when tacrolimus was administered intravenously. Cases of nephrotoxicity have been described. Patients receiving oral tacrolimus and fluconazole concomitantly should be closely monitored. The dose of tacrolimus should be adjusted depending on the degree of increase in its concentration in the blood.

Theophylline: when used simultaneously with fluconazole at a dose of 200 mg for 14 days, the average plasma clearance rate of theophylline is reduced by 18%. When prescribing fluconazole to patients taking high doses of theophylline, or to patients with an increased risk of theophylline toxicity, the onset of symptoms of theophylline overdose should be observed and, if necessary, therapy should be adjusted accordingly.

Tofacitinib: Exposure to tofacitinib is increased when co-administered with drugs that are both moderate inhibitors of the CYP3A4 isoenzyme and potent inhibitors of the CYP2C19 isoenzyme (for example, fluconazole). Dose adjustment of tofacitinib may be necessary.

Vinca alkaloid: despite the lack of targeted studies, it is assumed that fluconazole can increase the concentration of vinca alkaloids (for example, vincristine and vinblastine) in blood plasma and, thus, lead to neurotoxicity, which may possibly be associated with inhibition of the CYP3A4 isoenzyme.

Vitamin A: there is a report of one case of the development of adverse reactions from the central nervous system (CNS) in the form of a pseudotumor of the brain with the simultaneous use of all-trans retinoic acid and fluconazole, which disappeared after fluconazole was discontinued. The use of this combination is possible, but one should be aware of the possibility of unwanted reactions from the central nervous system.

Zidovudine: when used simultaneously with fluconazole, there is an increase in C max and AUC of zidovudine by 84% and 74%, respectively. This effect is probably due to a decrease in the metabolism of the latter to its main metabolite. Before and after therapy with fluconazole at a dose of 200 mg / day for 15 days, patients with AIDS and ARC (AIDS-related complex) showed a significant increase in AUC of zidovudine (20%).

Patients receiving this combination should be observed to detect side effects of zidovudine.

Voriconazole (isoenzyme inhibitor CYP 2 C 9, CYP 2 C 19 and CYP 3 A 4): simultaneous use of voriconazole (400 mg 2 times a day on the first day, then 200 mg twice a day for 2.5 days) and fluconazole (400 mg on the first day, then 200 mg daily for 4 days) resulted in an increase in the concentration and AUC of voriconazole by 57% and 79%, respectively. This effect has been shown to persist with dose reduction and/or reduction in the frequency of administration of any of the drugs. Co-administration of voriconazole and fluconazole is not recommended.

Studies of the interaction of oral forms of fluconazole when taken simultaneously with food, cimetidine, antacids, and also after total body irradiation in preparation for bone marrow transplantation have shown that these factors do not have a clinically significant effect on the absorption of fluconazole.

These interactions have been established with repeated use of fluconazole; interactions with drugs as a result of a single dose of fluconazole are unknown.

Physicians should be aware that interactions with other drugs have not been specifically studied, but they are possible.

special instructions

Cases of superinfection caused by other than candida albicans strains Candida, which are often intrinsically resistant to fluconazole (eg, Candida krusei). In such cases, alternative antifungal therapy may be required.

During pregnancy, the use of fluconazole should be avoided, except in cases of severe and potentially life-threatening fungal infections, when the expected benefit of treatment for the mother outweighs the possible risk to the fetus.

It is necessary to consider effective methods of contraception in women of childbearing age during the entire period of treatment and approximately within a week (5-6 half-lives) after taking the last dose of the drug (see section "Use during pregnancy and during breastfeeding"). In rare cases, the use of fluconazole was accompanied by toxic changes in the liver, including fatal, mainly in patients with serious concomitant diseases. In the case of hepatotoxic effects associated with the use of fluconazole, there was no obvious dependence on the total daily dose of the drug, duration of therapy, sex and age of the patient. The hepatotoxic effect of the drug was usually reversible; its signs disappeared after cessation of therapy. Patients whose liver function tests are impaired during treatment with the drug should be observed in order to detect signs of more serious liver damage. If there are clinical signs or symptoms of liver damage that may be associated with the use of fluconazole, the drug should be discontinued.

As with other azoles, fluconazole can rarely cause anaphylactic reactions.

During treatment with fluconazole, patients have rarely developed exfoliative skin lesions such as Stevens-Johnson syndrome and toxic epidermal necrolysis. AIDS patients are more likely to develop severe skin reactions with many drugs. If a patient develops a rash during treatment of a superficial fungal infection that can be associated with the use of fluconazole, the drug should be discontinued. If a rash occurs in patients with invasive or systemic fungal infections, they should be carefully monitored and the drug should be discontinued if bullous lesions or erythema multiforme exudative appear.

The simultaneous use of fluconazole at doses less than 400 mg / day and terfenadine should be carefully monitored (see section "Interaction with other drugs").

Like other azoles, fluconazole can cause an increase in the QT interval on the ECG. When using fluconazole, an increase in the QT interval and ventricular fibrillation or flutter was noted very rarely in patients with severe diseases with multiple risk factors, such as organic heart disease, electrolyte imbalance and concomitant therapy that contributes to the development of such disorders. Therefore, fluconazole should be used with caution in these patients with potentially proarrhythmic conditions.

Patients with diseases of the liver, heart and kidneys are advised to consult a doctor before using the drug. When using fluconazole 150 mg for vaginal candidiasis, patients should be warned that improvement in symptoms is usually observed after 24 hours, but sometimes it takes several days for their complete disappearance. If symptoms persist for several days, you should consult a doctor.

Evidence of the effectiveness of fluconazole in the treatment of other types of endemic mycoses, such as paracoccidioidomycosis, sporotrichosis and histoplasmosis is limited, which does not allow for specific dosing recommendations. Fluconazole is a potent inhibitor of the CYP2C9 isoenzyme and a moderate inhibitor of the CYP3A4 isoenzyme. Fluconazole is also an inhibitor of the CYP2C19 isoenzyme. With simultaneous therapy with drugs with a narrow therapeutic profile, metabolized isoenzymes CYP2C9, CYP2C19 and CYP3A4, caution is recommended.

Influence on the ability to drive vehicles, mechanisms

When using the drug, it is necessary to take into account the possibility of developing dizziness and convulsions.

Release form

Powder for suspension for oral administration 50 mg/5 ml or 200 mg/5 ml in a plastic (HDPE) bottle with a child-resistant screw cap and consisting of an external (HDPE) and an internal (PP) part with a polymer-coated liner , as well as equipped with a plastic ring to control the first opening. 1 bottle with a plastic measuring spoon and instructions for use in a cardboard box.

Best before date

Use the prepared suspension within 14 days.

Do not use after the expiry date stated on the packaging.

Storage conditions

At a temperature not exceeding 30 ° C, out of the reach of children.

Store the prepared suspension at a temperature not exceeding 30 ° C, do not freeze.

Holiday conditions

On prescription

Manufacturer

Pfizer Inc., USA

235 East 42 Street, New York, NY 10017, USA

produced by Fareva Amboise, France

Zon Endustriel, 29 Route de Endustri, 37530 Posay-sur-Cize, France.

Claims of consumers should be sent to the address of Pfizer LLC:

Content

Any mother can easily determine the inflammatory process in the tongue, palate and gums of the baby by small white spots - thrush. When trying to remove white plaque with a napkin, inflamed erythema remains on the tongue. If at the same time the child lost his appetite or his sleep was disturbed, there are signs of the development of a fungal disease - candidiasis. The undeveloped microflora of a newborn is not able to resist fungi; a safe drug, fluconazole, is used to combat a fungal infection.

fluconazole for children

The lack of immunity in a newborn can cause fungal infections of the esophagus and intestines. Newborn girls without treatment develop symptoms of vaginal thrush - vaginal candidiasis. Therapy of fungal infections in children includes ointments and creams, with the ineffectiveness of external agents, fluconazole for children is prescribed - an antifungal agent belonging to the class of triazoles. Capsules are indicated for children from 5 years of age who are able to swallow a hard gelatin shell. Babies are prescribed pills, syrup, suppositories.

Composition and form of release

The drug is produced in the form of capsules, oral and vaginal tablets, solution for intravenous administration, syrup, powder for suspensions. The active substance of any form of antibiotic is fluconazole. The composition of drugs of different forms of release is given in the table:

Release form	The amount of active substance, mg	Excipients	Description
Hard gelatin capsules		Lactose monohydrate, povidone K-17, sodium lauryl sulfate, magnesium stearate, potato starch Capsule: gelatin, methyl parahydroxybenzoate E218, titanium dioxide 171, propyl parahydroxybenzoate E216
Tablets for oral administration		Microcrystalline cellulose (avicel), sodium starch glycolate, dibasic calcium phosphate, povidone, magnesium stearate, red dye (E-124)	Round, flat tablets, odorless, scored on one side and chamfered on both sides
Solution for infusion		Sodium chloride, water for injections	Clear, colorless or slightly yellowish solution
Powder for suspension for oral administration	10 mg/ml, 40 mg/ml	Anhydrous citric acid, sodium benzoate, xanthan gum, titanium dioxide, sucrose, anhydrous colloidal silicon dioxide, sodium citrate dihydrate, orange flavor	White or almost white powder, free from visible impurities
		Liquid sorbitol, glycerol, sodium carmellose, citric acid monohydrate, sodium benzoate, sodium saccharinate, cherry flavor, purified water	Clear colorless syrup

How the drug works

Fluconazole destroys the fungus from the inside, blocking the work of enzymes and disrupting the synthesis of ergosterol, a building component of the cell membrane. With a lack of ergosterol, the growth and replication of the membrane stops, fungal cells stop multiplying and die. It has a high permeability, has a detrimental effect only on the cells of the fungus, without affecting the beneficial microflora. Does not cause dysbacteriosis. After oral administration of a dose of 150 mg once every week after 14 days, it concentrates in the subcutaneous layers, after 4 months - in the nails.

Indications for use

The drug is used for the prevention of fungal infections in adults and children, the treatment of systemic and localized lesions. It is indicated both in the normal state of the immune system, and in various forms of immunosuppression. Children, starting from infancy, are prescribed to prevent cryptococcal meningitis, prevent candidiasis, and treat the following diseases:

stomatitis;
oral candidiasis;
candidiasis of the mucous membranes of the esophagus;
fungal meningitis;
invasive candidiasis;
nail and skin fungus.

Fluconazole - instructions for use for children

The drug is prescribed to the child depending on body weight. With a weight of more than 50 kg, fluconazole for children, as well as adults, is indicated in an amount of 150 mg per day. If the baby weighs less than 50 kg, use tablets with a dose of 50 mg, additionally apply creams, ointments, suppositories. Infants are shown the same amount 1 time in 3 days. A baby from the age of a month can be used every 2 days. Dosage for mucosal mycoses is presented in the table:

	Dosage per day / frequency of administration				Duration of treatment
	weight 15-20 kg	weight 20-30 kg	weight 30-40 kg	weight 40-50 kg	Duration of treatment
Candidiasis of the mucous membranes of the esophagus	50 mg/1 time in 2 days	50-100 mg / 1 time in 2 days	100 mg/1 time in 2 days	100-150 mg / 1 time per day
Candidiasis of the mucous membranes of the mouth	150 mg for the first day, 50 mg on subsequent days	150 mg for the first day, 100 mg on subsequent days	250 mg for the first day, 100 mg on subsequent days	300 mg for the first day, 150 mg on subsequent days

With cryptococcal meningitis, fluconazole capsules are prescribed to children at the rate of 24 mg per 1 kg of body weight, maximum 400 mg / day.

drug interaction

Undesirable reactions when taking fluconazole together with other drugs are possible in the form of arrhythmias, allergies, psychomotor effects, diabetic manifestations, intoxication of the body. Cases of acquisition of blindness are known. Monitoring is required with the possibility of dose adjustments in the treatment of fluconazole in combination with the following drugs:

chlorpropamide, glipizide, glibenclamide, tolbutamide;
phenytoin;
cyclosporine;
warfarin;
rifampicin, rifabutin;
erythromycin;
zidovudine.

Side effects

The digestive system may react with nausea, flatulence, symptoms of jaundice and hepatitis. Against the background of taking the drug, taste sensations change - the child may refuse the dishes that he loves. The reaction of the nervous system is expressed by excessive excitement, nervousness, headaches, inappropriate behavior. There may be a decrease in hemoglobin in the blood, arrhythmia, allergic and skin manifestations: rash, itching, swelling.

Contraindications

The clearance of the drug depends on the work of the kidneys. The appointment of fluconazole to children with kidney disease can lead to the accumulation of residues in the body and intoxication. It is prescribed with caution in combination with other medicines due to the possibility of a resonant increase in the negative effect on the functioning of the heart and liver. Fluconazole therapy is prohibited in the following cases:

hypersensitivity to the components of the drug;
simultaneous use of terfenadine or astemizole;
ischemic heart disease, myocardial infarction;
dysfunction of the kidneys.

Terms of sale and storage

The drug has a shelf life of 36 months, in pharmacies it is dispensed by prescription. Use after the expiration date is prohibited. It is necessary to store the medicine in a dark place, out of the reach of children.

Analogues

Other antifungal drugs are commercially available that are similar in pharmacological properties to fluconazole and are safe in the treatment of fungal infections in children. They are based on different active substances - miconazole, bifonazole, nystatin, natamycin, etc. Effective in the treatment of manifestations of childhood fungal infections are:

Nystatin - a detrimental effect on the Candida fungus. Available in the form of tablets, ointments, suppositories. Not recommended for liver diseases, stomach ulcers, pregnancy, lactation.
Ketaconazole is effective for mycoses of nails, hands, feet, various types of candidiasis, histoplasmosis, and similar infections. It is administered orally, quickly absorbed in the gastrointestinal tract and excreted from the body.
Pimafucin is a fungicidal antibiotic. Effective against yeast fungi Candida albicans, other pathogenic infections. Not absorbed into the blood from the gastrointestinal tract, effective in intestinal candidiasis.

Capsules, 150 mg, 1 unit

CANONPHARMA PRODUCTION, Russia

Solution for injection, 100 ml, 2 mg/ml

VMG, India

Gel, tube 30 g, 5 mg/g

Kusum Pharm, Ukraine

Syrup, bottle 100 ml

ZENTIVA, Czech Republic