Antifungal medications are a relatively new concept in the treatment of chronic rhinosinusitis in the immunocompetent patient. These are given based on the premise that fungi (or molds) can cause chronic inflammation of the sinonasal passages through both allergic and non-allergic immune mechanisms. Much of this new research is being published by the Mayo Clinic in Minnesota. Antifungal medications are roughly divided into topical and systemic.

Systemic antifungals are having quite a bit more success. Itraconazole (Sporanox) seems to be the most effective. Unfortunately, it is also extremely expensive and carries with it some risk. Insurance companies rarely will pay for this indication. The risks are hepatotoxicity and cardiotoxicity. Liver function tests need to be obtained prior to beginning treatment and repeated every four to six weeks. As it can act as a negative inotrope, it should be avoided in patients with any form of heart failure. Thoughts on the beneficial effects of Itraconazole range from its antifungal properties versus its prosteroid effects. It is an axole which inhibits the p-450 dependant synthesis of ergosterol (a cell wall protein). It also increases endogenous steroids without making the patient cushingoid. Dosing schedules range from 100-200mg P.O. BID to 100mg 2 times per week. We have had good success using 100mg PO QD for 3 months. If you are a veteran, the VA will help pay for this prescription.

Lamisil (Terbiniafine) 250 mg PO QD is another effective regimen. Not many negative side effects have been reported. It too has been expensive, however, it is now generic.

Diflucan 100 mg PO QD or even two times per week has been successful and less expensive for many of our patients. This is especially true if they have mold allergies. Candidiasis and Yeast overgrowth are an interesting theory and patients have found a lot of relief with other antifungal regimens.

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