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Comment on treatment for recurrent vulvovaginal candidiasis

Published:November 16, 2016DOI:https://doi.org/10.1016/j.ajog.2016.11.1029
      To the Editors:
      With great interest we read the article “Recurrent vulvovaginal candidiasis” of Jack D. Sobel.
      • Sobel J.D.
      Recurrent vulvovaginal candidiasis.
      The author presents oral and topical treatment strategies for recurrent vulvovaginal candidiasis. Therapy with oral fluconazole starts with an initial “induction therapy” and is followed by a maintenance phase, wherein the drug is given at certain intervals.
      • Rosa M.I.
      • Silva B.R.
      • Pires P.S.
      • et al.
      Weekly fluconazole therapy for recurrent vulvovaginal candidiasis: a systematic review and meta-analysis.
      • Donders G.
      • Bellen G.
      • Byttebier G.
      • et al.
      Individualized decreasing-dose maintenance fluconazole regimen for recurrent vulvovaginal candidiasis (ReCiDiF trial).
      Although a systematic review confirms the advantage of the use of weekly fluconazole for 6 months,
      • Rosa M.I.
      • Silva B.R.
      • Pires P.S.
      • et al.
      Weekly fluconazole therapy for recurrent vulvovaginal candidiasis: a systematic review and meta-analysis.
      we missed the emphasis on the advantages of another, more individualized and patient-centered regimen that is common in Europe.
      • Donders G.
      • Bellen G.
      • Byttebier G.
      • et al.
      Individualized decreasing-dose maintenance fluconazole regimen for recurrent vulvovaginal candidiasis (ReCiDiF trial).
      In this regimen, the total dose of fluconazole is more individualized to the outcomes (“ReCiDiF” regimen).
      • Donders G.
      • Bellen G.
      • Byttebier G.
      • et al.
      Individualized decreasing-dose maintenance fluconazole regimen for recurrent vulvovaginal candidiasis (ReCiDiF trial).
      Fluconazole is used weekly for only 8 weeks and is followed by dose reduction if the patient is symptom, culture, and microscopy free of Candida. After a period of 4 months of taking 1 dose every 2 weeks, patients can move on to the next level of maintenance treatment (monthly for 6 months), provided they are still symptom, culture, and microscopy free of Candida.
      This regimen has several advantages compared with the 6 months/weekly regimen. Most women who experience recurrent vulvovaginal candidiasis do not need weekly fluconazole for 6 months; the optimal, and even suboptimal, responders received significant less total medication after 6 months than in the 6 months/weekly system.
      Indeed, even if suboptimal responders stay for longer periods on their level of treatment to avoid clinical relapses, most of them do not need to be on weekly treatment. Clinicians and researchers should be aware of early identification of the group who had recurrences despite maintenance therapy and help them in a timely, more efficient way. Women on the ReCiDiF regimen were recurrence-free for a longer period of time and were shown to need less fluconazole per month than in the 6 months/weekly regimen. Furthermore, this regimen appears to prevent the frequent recurrences that are seen after suddenly stopping the 6 month/weekly period; after 1 year, 79% of the women were recurrence free in the ReCiDiF regimen
      • Donders G.
      • Bellen G.
      • Byttebier G.
      • et al.
      Individualized decreasing-dose maintenance fluconazole regimen for recurrent vulvovaginal candidiasis (ReCiDiF trial).
      vs 43% after the 6 month/weekly treatment.
      • Rosa M.I.
      • Silva B.R.
      • Pires P.S.
      • et al.
      Weekly fluconazole therapy for recurrent vulvovaginal candidiasis: a systematic review and meta-analysis.
      This individualized fluconazole maintenance therapy is currently the standard of care in Belgium, Austria, and Germany
      • Mendling W.
      • Friese K.
      • Mylonas I.
      • et al.
      Vulvovaginal candidosis (excluding chronic mucocutaneous candidosis). Guideline of the German Society of Gynecology and Obstetrics (AWMF Registry No. 015/072, S2k Level, December 2013).
      and produces high satisfaction and adherence rates in patients. Hence, we regret that the review failed to inform the reader about the advantages of the ReCiDiF approach and that it is was not highlighted in its summary table.

      References

        • Sobel J.D.
        Recurrent vulvovaginal candidiasis.
        Am J Obstet Gynecol. 2016; 214: 15-21
        • Rosa M.I.
        • Silva B.R.
        • Pires P.S.
        • et al.
        Weekly fluconazole therapy for recurrent vulvovaginal candidiasis: a systematic review and meta-analysis.
        Eur J Obstet Gynecol Reprod Biol. 2013; 167: 132-136
        • Donders G.
        • Bellen G.
        • Byttebier G.
        • et al.
        Individualized decreasing-dose maintenance fluconazole regimen for recurrent vulvovaginal candidiasis (ReCiDiF trial).
        Am J Obstet Gynecol. 2008; 199: 613.e1-613.e9
        • Mendling W.
        • Friese K.
        • Mylonas I.
        • et al.
        Vulvovaginal candidosis (excluding chronic mucocutaneous candidosis). Guideline of the German Society of Gynecology and Obstetrics (AWMF Registry No. 015/072, S2k Level, December 2013).
        Geburtshilfe Frauenheilkd. 2015; 75: 342-354

      Linked Article

      • Recurrent vulvovaginal candidiasis
        American Journal of Obstetrics & GynecologyVol. 214Issue 1
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          Recurrent vulvovaginal candidiasis (RVVC) is a common cause of significant morbidity in women in all strata of society affecting millions of women worldwide. Previously, RVVC occurrence was limited by onset of menopause but the widespread use of hormone replacement therapy has extended the at-risk period. Candida albicans remains the dominant species responsible for RVVC, however optimal management of RVVC requires species determination and effective treatment measures are best if species-specific.
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        American Journal of Obstetrics & GynecologyVol. 216Issue 4
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          In a recent review of recurrent vulvovaginal candidiasis, treatment options were described for women in whom no preventable triggering stimuli were forthcoming.1 A suppressive maintenance prophylactic regimen with fluconazole was recommended and indeed this regimen is widely used and appreciated worldwide. In the review, attention was directed at 1 such regimen consisting of the use of once weekly fluconazole (150 mg) for a period of 6 months.2 Other alternative regimens were also immediately referenced including a more personalized but similar regimen of Dr Donders et al,3 the text emphasizing that these maintenance regimens have documented therapeutic efficacy and safety.
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