BACKGROUND AND PURPOSE:

• This Cochrane review by Denison et al. (Cochrane Database Sys Rev, 2020) is the second update of the original review
• The authors assessed the effectiveness of oral versus intravaginal antifungals for the treatment of uncomplicated vulvovaginal candidiasis

METHODS:

• Systematic review and meta-analysis
• Inclusion criteria
  • RCTs
  • Any language
  • Trials that compared at least one oral antifungal with one intravaginal antifungal
  • Participants: Women ≥ 16 years  | Positive mycological diagnosis of uncomplicated vulvovaginal candidiasis
  • Exclusion: HIV positive | Imunocompromised | Pregnant | Breast feeding | Diabetic
• Primary outcome
  • Relative effectiveness of clinical cure (presence of symptoms)
• Secondary outcomes
  • Relative effectiveness for mycological cure
  • Safety | Side effects | Treatment preference | Time to first relief of symptoms | Costs

RESULTS:

• 26 trials | 5007 participants
  • Trials were conducted in multiple countries
  • Overall risk of bias deemed to be high
  • 8 different medications were included (imidazole and triazole)

Oral vs Intravaginal Antifungals for Clinical Cure

• There was probably little or no difference between oral and intravaginal anti-fungal treatment for clinical cure
  • Short-term follow-up (5 to 15 days)
    • Odds ratio (OR) 1.14 (95% CI, 0.91 to 1.43; 13 trials; 1859 participants)
    • Moderate-certainty evidence
  • Long-term follow-up (2 to 12 weeks)
    • OR 1.07 (95% CI, 0.77 to 1.50; 9 trials; 1042 participants)
    • Moderate-certainty evidence
• Oral treatment probably improves mycological cure over intravaginal treatment at
  • Short-term follow-up
    • OR 1.24 (95% CI, 1.03 to 1.50: 19 trials; 3057 participants)
    • Moderate-certainty evidence
  • Long-term follow-up
    • OR 1.29 (95% CI, 1.05 to 1.60; 13 trials; 1661 participants)
    • Moderate-certainty evidence

Oral vs IntraVaginal Antifungals for Safety and Satisfaction

• Safety
  • Low risk of participants withdrawing from the studies due to adverse drug effects for either treatment
    • 23 trials; 4637 participants
    • High-certainty evidence
  • It is undetermined whether oral treatments reduced the number of side effects compared with intravaginal treatments
    • OR 1.04 (95% CI, 0.84 to 1.29; 16 trials; 3155 participants)
    • Low-certainty evidence
  • The type of side effects differed
    • Intravaginal: Local reactions
    • Oral: Systemic effects | Especially GI symptoms and headaches
• Patient satisfaction
  • Oral treatment was favored by participants
    • 12 trials; 2206 participants
    • Low-certainty evidence
  • Little or no difference in time to first relief of symptoms was seen between oral vs intravaginal treatments
    • 10 trials; 1910 participants
    • Low-certainty evidence
• Costs were not reported in any trial

CONCLUSION:

• Compared to intra-vaginal anti-fungal treatment, oral treatment does not appear to make a difference when it comes to clinical cure (perceived symptoms) but probably does improve clearance of candida from vaginal canal when compared to vaginal treatment
• Oral treatment was also preferred by participants, though certainty of evidence was low
• Upon review of these the results, Cochrane Reviews states that

The addition of new evidence does not change the conclusions of the review. The results of this review should be considered stable in terms of the antifungal medicines included. The frequency of future updates should be limited. No further updates are planned

Learn More – Primary Sources:

Oral versus intra-vaginal imidazole and triazole anti-fungal treatment of uncomplicated vulvovaginal candidiasis (thrush)

Related ObG Topics:

Are Probiotics Useful for the Treatment of Vulvovaginal Candidiasis?

Are Vaginal Antimycotics Associated with an Increased Risk for Miscarriage?

Diagnosis and Treatment of Vulvovaginal Candidiasis