The Use of Prescription Antifungals for Mold-Injured Patients

By Dr. Susan Tanner, MD

A common question that arises in the treatment of mold-impacted patients is, “Can’t I just take an antifungal medicine to eradicate the mold in my body?”

Unfortunately, I cannot provide a definitive YES or NO answer. The answers for healing from mold are not always as straightforward as being able to take a medication to “kill” the invading pathogen, although, I will freely admit, I wish it were that easy sometimes.  And, while antifungal medications DO have a place in mold treatment protocols for many, they are not the be-all and end-all remedy. The answers for a mold-harmed body tend to be a bit more complicated and bound tightly to the foundational pieces of health that we have written in many previous articles—those being air, food, and water. If steps are not taken to make sure those 3 elements are not clean and toxin-free, then antifungal medications may not help or may even make some symptoms worse.

Prescription Antifungal Treatments for Mold

There are three main forms of prescription antifungals used in the treatment of mold and candida:

1. Oral medications;

2. Nasal sprays;

3. And, Nebulized liquids for breathing into the lower airways.

Some of these are used simultaneously, and some are used for longer periods of time than others.

A Case Study Showing the Use of Prescription Antifungals

To illustrate which form of antifungal to use and how I have used them in my practice to treat mold is as follows:

Marjorie, a 35-year-old patient who had been exposed to substantial levels of mold in her workplace for two years suffered from chronic sinusitis, bronchitis, and irritable bowel syndrome among her other systemic complaints of brain fog and fatigue.  Her lab tests revealed nasal swabs positive for aspergillus and candida, and an organic acids test showed markedly elevated levels of candida reflecting large overgrowth in the small intestine.  Among other nutritional therapies and dietary changes to eliminate the feeders and stimulators of candida in the system, she was also started on several antifungal medications.  These included Amphotericin nasal spray,  Voriconazole by nebulization for the bronchi, and Diflucan (fluconazole) as an oral medication.  Her symptoms remarkably improved over a one-month period of time.  She remained very consistent with her anti-candida diet and removed herself and all contaminated belongings from the workplace.  She was able to discontinue the nebulization at this one-month mark as the lower respiratory symptoms were completely gone.  She stayed on a maintenance regimen of once-daily amphotericin nasal spray, along with nasal rinses of saline with CitriDrops. The Diflucan was changed to oral Nystatin for several more months.

Why were these particular therapies chosen? And why were they discontinued?  What is the safety profile of each?   Firstly, each treatment protocol is unique and individual for every patient.  It is essential that certain labs be done first, not only to determine that mold and candida are causal but also to check that the basic functions of the body, especially the liver and kidneys, are functioning well enough to handle bringing some of these medications onboard.  Like any pharmaceutical, as antifungals work and metabolize in the body, their by-products must be cleared and detoxified through the liver and kidneys.  If the liver and/or kidneys are under-functioning from the get-go, then antifungals may need to be modified in their dosing or not used at all.

Different Forms and Uses of Prescription Antifungals

In general, the sprays and inhaled types of antifungals are considered to be topical in nature.  Such products include the abovementioned amphotericin, voriconazole, and nystatin. I compare them to using a topical antibiotic cream on a wound.  They have minimal absorption into the system, they bypass the GI tract, and they kill on contact rather than relying on the bloodstream to carry them to the points of infection or infestation. That said, there is ALWAYS a small amount absorbed into the system, but, in general, these amounts are very small and usually well-tolerated.

Diflucan, or fluconazole, is taken orally and has its greatest impact on candida, although it does address certain other mold spores to some degree.  The issue with Diflucan is that it does go through the liver and it must be monitored carefully, especially if taken for greater than two weeks at a time.  I prefer to dose it every other day and do this almost always in patients who have never taken it, as it has a long half-life, or duration, in the body.  The dosages usually range from 100 mg to 150 mg in a daily or every other daily dose.  I have given more or less than this, depending on the weight and age of the patient as well as their own individual sensitivities and degree of illness, particularly if they are on other medications that are cleared through similar pathways of the liver and kidneys.  I always look at a patient’s lab work initially to assure that liver and kidney function are robust enough to handle it. If Diflucan is used longer term,  then I repeat labs periodically to be sure that it is not causing issues.  While Diflucan is usually handled very well, it occasionally will cause side effects.  For example, one patient, after only a few doses of Diflucan, developed severe musculoskeletal pain, and upon repeating her lab work, we found that her liver simply could not handle the medication; it was stopped immediately.  This is certainly more the exception than the rule, but it exemplifies the reason that each patient must be evaluated and followed carefully.

Another issue that has happened with Diflucan is that it can become ineffective, especially if the patient has not adhered to an anti-candida diet while taking it.  There is an excellent article about this by Dr. Dennis in a previous newsletter that explains how candida becomes resistant. In these cases, it is necessary to go to another, and potentially more toxic medication, such as Sporanox or Nizoral.  I try to not use these in oral form except in extreme cases where all else has failed. As with all medications, there is a time and a place in which they can and should be used.

Other oral medications that I do use frequently include Nystatin and Amphotericin.  Nystatin has been around for many years and has been used for various yeast and fungal skin and vaginal infections.  The oral form was most commonly in a liquid, the old “swish and spit” formula for oral thrush following antibiotics.  An interesting fact was that back in the 1940s when penicillin and other antibiotics were beginning to be used extremely frequently it was noted that their use caused thrush, or candida overgrowth in the mouth—imagine what it was doing in the gut!! Some of the antibiotic manufacturing companies actually added nystatin to their preparation, but the FDA decided that this was not legal as it was a combination of two pharmaceuticals; so, they removed the nystatin.  Unfortunately, no one really followed up on this and many were left with years of fungal overgrowth from their antibiotics with no treatment ever given. Could antibiotic use without addressing subsequent candida overgrowth have given way to many other health conditions that have developed over time?  I think it is not only possible but probable, given what we now know about fungus and mold!

Anyway, back to Nystatin and Amphotericin.  Nystatin can be safely given for the long term.  I have found that the liquid preparations, which should be made without sugar, are not very gustatory, and that the compounded capsules are the best.  Second best is the readily available hard tablet form of nystatin which can be obtained from any pharmacy.  If possible, these should be crushed to allow better dispersal when taken. Even the pure powder form can be used, as long as the taste is tolerated. (Some compare the taste to green peanuts.)  The dosage for Nystatin is usually three times daily, between meals.  Because nystatin is only effective topically and does not absorb into the bloodstream, it is not directly helpful for treating vaginal or nasal candida.  However, because it reduces the load in the gut, it can help reduce the load in distal locations without killing it directly. Any form of nystatin that is not the hard tablet should be refrigerated which can be a bit inconvenient.

Remember Marjorie, the patient mentioned above? She got much better but found that if she strayed from her anti-candida diet, then she began to have problems again.  What I suggested for her, and it worked well, was that if she had a dietary infraction, she was to take one nystatin immediately to control an outbreak of candida.  This actually worked quite well for her but it does NOT give her free license to throw caution to the wind and return to poor eating habits with lots of sugar and alcohol!

Amphotericin is used in a similar way but is not quite as readily available.  The commercial form of amphotericin is a powder that is given intravenously to seriously ill patients with systemic candida, such as patients with severely suppressed immune systems.  It is not absorbed orally to any great extent but using it orally is similar in effect to nystatin in that it reduces the yeast load in the gut. Disadvantages of its use are that it must be compounded, it is not readily commercially available from a traditional pharmacy, and it is more expensive.

Using and Rotating Multiple Antifungals

In patients who have had long-term candida or mold issues, then I will often use what I term an “anti-fungal parade” in which we go for many weeks or months with a rotation of several antifungals to hit as many forms of fungi, including resistant ones, as we can.  A typical antifungal parade may include Diflucan every other day for 2 weeks, then Nystatin three times daily for two weeks, then another two weeks of Diflucan, followed by 2 weeks of three times daily Amphotericin.  I personally try to alternate an antifungal that does not require liver/kidney clearance with one that does.  In some cases, I do alternate Nizoral or Sporanox into the mix, but this is closely supervised and there must be a clinical reason to do this.

What About Herbal/Natural Antifungals?

There is always the question about herbal vs. pharmaceutical alternatives to treat candida and mycotoxins. In future articles, we will discuss some of the differences between the two and the benefits of a natural route, as herbal antifungals are valuable, no doubt, and can have whole-body benefits and applications.  I do use them, but again, there is a time and place for both herbals and pharmaceuticals for the short and long term in mold and candida patients. Individual assessment and treatment are always best! There is no one-size-fits-all answer.

In conclusion, I would be remiss if I did not remind all readers that while antifungals are an important part of therapy, it is of utmost importance to also address issues of immunity, detoxification, and gut restoration with equal fervor.  Each of these components of healing has been discussed at length in previous articles, so I will not rehash them here but Sinus Defense, CitriDrops Dietary Supplement, Probiotics such as Klaire Pro5, and Colostrum Phospholipid are essential parts of the program for complete healing and wellness.

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