Generic Name: Terconazole
Class: Azoles
VA Class: GU300
Chemical Name: cis - 1 - [4 - [2 - (2,4 - Dichlorophenyl) - 2 - (1H - 1,2,4 - triazol - 1 - ylmethyl) - 1,3 - dioxolan - 4 - yl]methoxy]phenyl] - 4 - (1 - methylethyl)piperazine
Molecular Formula: C26H31Cl2N5O3
CAS Number: 67915-31-5

Introduction

Antifungal; azole (triazole derivative).1 3 7 8 11 25 28 31

Uses for Terazol

Vulvovaginal Candidiasis

Treatment of uncomplicated vulvovaginal candidiasis (mild to moderate, sporadic or infrequent, most likely caused by Candida albicans, occurring in immunocompetent women).1 3 5 15 16 17 18 19 20 21 22 23 24 27 33 37 47 49 65 67 68 A drug of choice.37 47 51 52 53 54 56 57 58 65 67 68

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Treatment of complicated vulvovaginal candidiasis, including infections that are recurrent (≥4 episodes in 1 year), severe (extensive vulvar erythema, edema, excoriation, fissure formation), caused by Candida other than C. albicans, or occurring in women with underlying medical conditions (uncontrolled diabetes mellitus, HIV infection, immunosuppressive therapy, pregnancy).47 53 54 56 57 58 67 68 Complicated infections generally require more prolonged treatment than uncomplicated infections.47 66 67 68

Optimal regimens for treatment of vulvovaginal candidiasis caused by Candida other than C. albicans (e.g., C. glabrata, C. krusei) not identified.47 68 CDC and others state these infections may respond to an intravaginal azole antifungal given for 7–14 days or to a 14-day regimen of intravaginal boric acid (not commercially available in the US).47 68 69

Terazol Dosage and Administration

Administration

Intravaginal Topical Administration

Administer intravaginally as a cream or suppository.1

Interruption or discontinuance of terconazole therapy during a prescribed regimen, even during menstruation or in response to symptomatic relief, is not advised.1 43 44

Dosage

Adults

Uncomplicated Vulvovaginal Candidiasis
Intravaginal

Cream: one applicatorful of 0.4% cream once daily at bedtime for 7 consecutive days or one applicatorful of 0.8% cream once daily at bedtime for 3 consecutive days.1 3 15 47

Suppository: one 80-mg vaginal suppository once daily at bedtime for 3 consecutive days.1 47

Complicated Vulvovaginal Candidiasis
Recurrent Vulvovaginal Infections Caused by Candida albicans
Intravaginal

CDC and others recommend an initial intensive regimen (7–14 days of an intravaginal azole or 3-dose regimen of oral fluconazole) to achieve mycologic remission, followed by an appropriate maintenance regimen (6-month regimen of once-weekly oral fluconazole or, alternatively, an intravaginal azole given intermittently).47 52 54 58 64 67 68

Other Complicated Vulvovaginal Infections
Intravaginal

CDC and others recommend 7–14 days of an intravaginal azole for vulvovaginal candidiasis that is severe, caused by Candida other than C. albicans, or occurring in women with underlying medical conditions.47 67

HIV-infected patients: Use same regimen recommended for other patients.47 66 Some experts recommend a duration of 3–7 days.66 Maintenance regimen of an intravaginal azole can be considered for those with recurrent episodes;66 routine primary or secondary prophylaxis (long-term suppressive or chronic maintenance therapy) not recommended.47 66

Special Populations

Hepatic Impairment

No specific dosage recommendations at this time.a

Renal Impairment

No specific dosage recommendations at this time.a

Geriatric Patients

No specific dosage recommendations at this time.a

Cautions for Terazol

Contraindications

  • Known hypersensitivity to terconazole or any ingredient in the formulation.1

Warnings/Precautions

Sensitivity Reactions

Allergic Reactions

Possible flu-like syndrome, characterized by fever, chills, headache, and/or hypotension and occasionally by vertigo and nausea.45 May be immunoallergenic45 or may be a reaction to the dying fungi (similar to the Jarisch-Herxheimer reaction observed during penicillin therapy for syphilis).46

If irritation, sensitization, fever, chills, or flu-like symptoms occur and appear to be drug related, discontinue and do not reinstitute terconazole therapy.1

Photosensitivity Reactions

Photosensitivity reactions reported following repeated topical application to the skin of 0.8 or 2% terconazole cream and exposure to filtered artificial ultraviolet light; not reported to date following intravaginal administration of 0.4 or 0.8% cream or 80-mg suppositories.1 3

General Precautions

Use of Latex/Rubber Contraceptive Diaphragms

Hydrogenated vegetable oil base contained in terconazole vaginal suppositories may interact with certain rubber or latex products such as vaginal contraceptive diaphragms; concurrent use not recommended.1 Consider use of terconazole vaginal cream as an alternative to the suppositories.43 44

Selection and Use of Antifungals for Vulvovaginal Candidiasis

Prior to initial use of terconazole in a woman with signs and symptoms of vulvovaginal candidiasis, confirm the diagnosis by demonstrating yeast or pseudohyphae with direct microscopic examination of vaginal discharge (saline or 10% potassium hydroxide [KOH] wet mount or Gram stain) or by culture.1 47

Candida identified by culture in the absence of symptoms is not an indication for antifungal treatment since approximately 10–20% of women harbor Candida or other yeasts in the vagina.47

If clinical symptoms persist, tests should be repeated to rule out other pathogens and to confirm the original diagnosis.1

Specific Populations

Pregnancy

Category C.1

Because terconazole is absorbed systemically following intravaginal administration, manufacturer states the drug should not be used during the first trimester of pregnancy unless the clinician considers it essential to the welfare of the patient.1 CDC and others state that a 7-day regimen of an intravaginal azole antifungal can be used, if necessary, for treatment of vulvovaginal candidiasis in pregnant women.47 67

Lactation

Distributed into milk in rats;1 not known whether distributed into human milk.1 43 Discontinue nursing or the drug.1

Pediatric Use

Safety and efficacy not established in children1 <18 years of age.43

Geriatric Use

Insufficient experience from clinical studies to determine whether patients ≥65 years of age respond differently than younger adults.1 Other clinical experience has not identified age-related differences in response.1

Common Adverse Effects

Headache,1 3 vulvovaginal itching/burning or pain,1 3 dysmenorrhea,1 abdominal pain.1

Interactions for Terazol

Oral Contraceptives

Terconazole efficacy not affected by concomitant oral contraceptives; terconazole has no effect on estradiol or progesterone concentrations in women receiving low-dose oral contraceptives.1 5

Terazol Pharmacokinetics

Absorption

Small amounts of terconazole (about 5–16% of a dose) are slowly absorbed systemically following intravaginal administration.1 3 14 The amount of drug absorbed is proportional to the dose (regardless of dosage form)3 14 and absorption is similar in women with or without vulvovaginal candidiasis.3

Distribution

Extent

Distribution into body tissues and fluids following intravaginal administration has not been determined.a

Not known whether terconazole crosses the placenta43 or is distributed into milk.1

Elimination

Metabolism

The metabolic fate of terconazole following intravaginal administration has not been fully characterized, but systemically absorbed drug appears to be rapidly and extensively metabolized.1 3

Elimination Route

Following oral administration, 32–56% of the dose excreted in urine and 47–52% excreted in feces1 within 24 hours.43

Half-life

Following oral administration, half-life is 6.9 hours.1

Stability

Storage

Cream

15–30°C.1

Suppository

15–30°C.1

Actions

  • Triazole-derivative azole antifungal.1 3 5 7 8 10 11 12 14 15 18 19 21 25 27 28 29 31 33 34 35

  • Usually fungicidal in action.1 3 7 11

  • Presumably exerts its antifungal activity by altering cellular membranes resulting in increased membrane permeability, leakage of essential elements (e.g., amino acids, potassium), and impaired uptake of precursor molecules (e.g., purine and pyrimidine precursors to DNA).3 4 8 12 34 Inhibits cytochrome P-450 14-α-desmethylase in susceptible fungi, which leads to accumulation of C-14 methylated sterols (e.g., lanosterol) and decreased concentrations of ergosterol.3 4 6 8 12 28 34

  • Spectrum of antifungal activity includes many fungi, including yeasts and dermatophytes.3 7 8 10 11 12 14 15 31 At high concentrations, has some in vitro activity against gram-positive and -negative bacteria.7 11 25 31 34

  • Candida: Active in vitro and in vivo against C. albicans,3 8 11 31 32 C. krusei,3 8 11 C. parapsilosis,8 C. pseudotropicalis,8 C. stellatoidea,8 and C. tropicalis.3 8 11 31

  • Dermatophytes and other fungi: Active in vitro against Trichophyton mentagrophytes,3 11 31 T. rubrum,3 11 31 T. tonsurans,3 11 T. verrucosum,3 11 and Epidermophyton floccosum.3 11 Also active against Cryptococcus neoformans.3 11 31

  • Cross resistance can occur among the azole antifungals (e.g., clotrimazole, ketoconazole, miconazole).9 47 Azole-resistant Candida have been reported.9 47

Advice to Patients

  • Importance of reading and understanding manufacturer’s patient instructions regarding use of applicator for intravaginal administration.1

  • Importance of not interrupting or discontinuing the drug and completing full course of therapy, even during menstruation or in response to symptomatic relief.1 43 44

  • Importance of informing clinicians if irritation, sensitization, fever, chills, or flu-like symptoms occur.1

  • Importance of women following clinician's advice regarding sexual intercourse and informing partner to seek medical advice if penile itching, redness, or discomfort occurs.1

  • Importance of not using rubber or latex products such as vaginal contraceptive diaphragms when using terconazole vaginal suppositories;1 use of terconazole vaginal cream should be considered as an alternative.43 44

  • Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs.1

  • Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.1

  • Importance of informing patients of other important precautionary information. (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

Terconazole

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Vaginal

Cream

0.4%*

Terazol 7 (with propylene glycol; with applicator)

Ortho-McNeil

Terconazole Vaginal Cream

Taro, Watson

0.8%*

Terazol 3 (with propylene glycol; with applicator)

Ortho-McNeil

Terconazole Vaginal Cream

Taro, Watson

Suppositories

80 mg*

Terazol 3 (in a hydrogenated vegetable oil base; with applicator)

Ortho-McNeil

Terconazole Vaginal Suppositories (in a hydrogenated vegetable oil base; with applicator)

Perrigo

Comparative Pricing

This pricing information is subject to change at the sole discretion of DS Pharmacy. This pricing information was updated 02/2014. Actual costs to patients will vary depending on the use of specific retail or mail-order locations and health insurance copays.

Terazol 3 0.8% Cream (JANSSEN PHARMACEUTICALS): 20/$51.99 or 60/$149.98

Terazol 3 80MG Suppositories (JANSSEN PHARMACEUTICALS): 3/$53.99 or 9/$149.98

Terazol 7 0.4% Cream (JANSSEN PHARMACEUTICALS): 45/$53.99 or 135/$147.98

Terconazole 0.4% Cream (WATSON LABS): 45/$39.99 or 135/$109.97

Terconazole 0.8% Cream (WATSON LABS): 20/$34.99 or 60/$94.98

AHFS DI Essentials. © Copyright, 2004-2014, Selected Revisions July 1, 2007. American Society of Health-System Pharmacists, Inc., 7272 Wisconsin Avenue, Bethesda, Maryland 20814.

References

1. Ortho-McNeil Pharmaceutical, Inc. Terazol 7 (terconazole) vaginal cream 0.4%, Terazol 3 (terconazole) vaginal cream 0.8%, and Terazol 3 (terconazole) vaginal suppositories prescribing information. Raritan, NJ; 2003 Apr.

3. Ortho Pharmaceutical Corporation. Terazol (terconazole 0.4% cream/80 mg suppositories) clinical monograph. Raritan, NJ; 1988 Jun.

4. Wilborn WH, Shields RL, Hyde BM et al. Mode of action of terconazole on Candida albicans as shown by scanning and transmission electron microscopy during treatment for vulvovaginal candidiasis. Am J Gynecol Health. 1988; 2:51-6.

5. Kjaeldgaard A, Larsson B. Single-blind comparative clinical trial of short-term therapy with terconazole versus clotrimazole vaginal tablets in vulvovaginal candidiasis. Curr Ther Res Clin Exp. 1985; 38:939-44.

6. Borgers M, Van den Bossche H, De Brabander M. The mechanism of action of the new antimycotic ketoconazole. Am J Med. 1983; 74(Suppl 1B):2-8. [IDIS 165048] [PubMed 6295147]

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8. Tolman EL, Isaacson DM, Rosenthale ME et al. Anticandidal activities of terconazole, a broad-spectrum antimycotic. Antimicrob Agents Chemother. 1986; 29:986-91. [PubMed 3729366]

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13. Turner CA, Turner A, Warnock DW. High performance liquid chromatographic determination of ketoconazole in human serum. J Antimicrob Chemother. 1986; 18:757-63. [PubMed 3546244]

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15. Del Palacio-Hernanz, Sanz-Sanz F, Rodriquez-Noriega A. Double-blind investigation of R-42470 (terconazole cream 0.4%) and clotrimazole (cream 1%) for the topical treatment of mycotic vaginitis. Chemioterapia. 1984; 3:192-5. [PubMed 6529776]

16. Loendersloot EW. Demonstration of effectiveness and tolerability of terconazole 80-mg vaginal suppositories (3 days) versus terconazole 240-mg vaginal suppositories (1 day) versus clotrimazole 200-mg vaginal tablets (3 days) in non-pregnant women with vulvovaginal candidosis. Gynakol Rundsch. 1985; 25(Suppl 1):99-104. [PubMed 4007627]

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19. Goormans E. Comparative double-blind evaluation of the efficacy and tolerability of terconazole 240-mg suppository (1 day) and 80-mg suppositories (3 days) versus clotrimazole 200-mg (3 days) in pregnant patients with vulvovaginal candidosis. Gynakol Rundsch. 1985; 25(Suppl 1):74-82. [PubMed 3891540]

20. Wesel S, Benijts G, Ubachs JMH et al. Comparative open evaluation of efficacy and tolerability of terconazole 0.8% cream in a 5-day regimen versus clotrimazole 100-mg tablets in a 6-day regimen. Gynakol Rundsch. 1985; 25(Suppl 1):67-73. [PubMed 4007625]

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25. Cartwright RY. Terconazole, a new triazole antifungal agent. Gynakol Rundsch. 1985; 25(Suppl 1):6-11. [PubMed 4007624]

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33. Vartiainen E, Widholm O. Single-dose therapy of vulvovaginal candidosis: comparison of terconazole and clotrimazole. Curr Ther Res. 1988; 44:185-8.

34. Vanden Bossche H, Lauwers W, Willemsens G et al. Molecular basis for the antimycotic and antibacterial activity of N-substituted imidazoles and triazoles: the inhibition of isoprenoid biosynthesis. Pestic Sci. 1984; 15:188-98.

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41. Sud IJ, Feingold DS. Mechanisms of action of the antimycotic imidazoles. J Invest Dermatol. 1981; 76:438-41. [IDIS 133194] [PubMed 7017013]

42. Pye GW, Marriott. Inhibition of sterol C14 demethylation by imidazole-containing antifungals. Sabouraudia. 1982; 20:325-9. [PubMed 6760419]

43. Murphy RJ. (Ortho Pharmaceutical Corporation, Raritan, NJ): Personal communication; 1988 Dec.

44. Reviewers’ comments (personal observations); 1988 Dec.

45. Moebius UM. Influenza-like syndrome after terconazole. Lancet. 2:966-7. Letter.

46. Geiger AJ. Influenza-like syndrome after terconazole. Lancet. 1988; 2:1192. [IDIS 248142] [PubMed 2903397]

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52. Doering PL, Santiago TM. Drugs for the treatment of vulvovaginal candidiasis: comparative efficacy of agents and regimens. DICP. 1990; 24:1078-83. [IDIS 274670] [PubMed 2275233]

53. Sobel JD. Vaginitis. N Engl J Med. 1997; 337:1896-903. [IDIS 401347] [PubMed 9407158]

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55. Bisschop MPJM, Merkus JMWM, Scheygrond H et al. Co-treatment of the male partner in vaginal candidosis: a double-blind randomized control study. Br J Obstet Gynecol. 1986; 93:79-81.

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58. Sobel JD. Controversial aspects in the management of vulvovaginal candidiasis. J Am Acad Dermatol. 1994; 31: S10-3. [IDIS 335764] [PubMed 8077494]

59. Spinillo A, Capuzzo E, Gulminetti R et al. Prevalence of and risk factors for fungal vaginitis caused by non-albicans species. Am J Obstet Gynecol. 1997; 176: 138-41. [PubMed 9024104]

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a. AHFS drug information 2003. McEvoy GK, ed. Terconazole. Bethesda, MD: American Society of Health-System Pharmacists; 2003:3365-69.

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