Clinical and cost considerations in the pharmacotherapy of vulvovaginal candidiasis

Vulvovaginal candidiasis (VVC) is a frequent cause of morbidity in women of reproductive age. Most women will experience 1 or 2 episodes in their lifetime, but a smaller population develop chronic recurrent disease. There are few data on cost or pharmacoeconomic considerations in the management of this condition. The disease does not usually result in long term disability, loss of employment or death, but could affect a woman's work performance through irritability, frustration and unhappiness. This review attempts to estimate the least costly programme or regimen (as the efficacy of different regimens is similar) that would be applicable to patients, third-party payers and society. Nonprescription or over-the-counter (OTC) antifungal preparations could have an impact on overall cost in the management of VVC. In the management of infrequent acute VVC, an OTC preparation would be least costly to the healthcare system (provided that the diagnosis was correct). The strategies used to control symptoms in patients with chronic recurrent VVC should be based on the frequency of recurrent episodes. For patients with less than 12 episodes a year, empirical self-treatment at the onset of symptoms with an OTC agent (e.g. intravaginal clotrimazole 500mg) is less costly and preferable to patients than monthly prophylaxis. Patients with a greater frequency of recurrences may benefit from monthly, daily or twice weekly prophylaxis. At present, for very frequent recurrences, intravaginal clotrimazole 200mg twice weekly appears to be as effective as daily oral ketoconazole, and may be safer and less costly. However, because of the lack of prospective controlled studies, most of these recommendations are based on hypothetical reasonings. Furthermore, the disadvantages of OTC antifungals include the potential for overuse and inappropriate use, possibly resulting in the delayed diagnosis and treatment of other conditions. On balance, OTC preparations may provide patients with faster and more economical care, and improve healthcare delivery.