title: Nystatin and miconazole: pharmacological and clinical evidence regarding interactions with warfarin.
abstract: OBJECTIVE
  A retrospective case series published in 2012 concluded that miconazole and nystatin used as topical antifungal drugs appear to interact equally strongly with warfarin. If confirmed, this finding has significant implications for clinical practice. This study evaluates the evidence.
  
  
  METHODS
  Evidence from the pharmacology literature, the medical literature and the 'yellow card' adverse drug reaction surveillance reports was analysed regarding possible interactions of nystatin and miconazole with warfarin.
  
  
  RESULTS
  There is strong evidence to support the derangement of warfarin anticoagulation by miconazole oral gel in all areas of evidence studied. No postulated mechanism of interaction, no additional published reported cases and no supportive data from adverse drug reports were identified which would corroborate the case for a significant interaction between nystatin and warfarin.
  
  
  CONCLUSIONS
  Miconazole and nystatin used as topical antifungal drugs do not interact equally strongly with warfarin. Miconazole oral gel can clearly interact with warfarin to cause derangement of anticoagulation. Nystatin appears unlikely to interact with warfarin.
authors.affiliation: Oral Medicine, University Dental Hospital of Manchester, School of Dentistry, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK. Mike.Pemberton@manchester.ac.uk.
authors.forename: M N
authors.initials: MN
authors.lastname: Pemberton
mesh_terms: D000287:Administration, Topical; D000925:Anticoagulants / Q000494:pharmacology* / Q000627:therapeutic use; D000935:Antifungal Agents / Q000008:administration & dosage / Q000494:pharmacology* / Q000627:therapeutic use; D004347:Drug Interactions; D006801:Humans; D019934:International Normalized Ratio; D008825:Miconazole / Q000008:administration & dosage / Q000494:pharmacology* / Q000627:therapeutic use; D009761:Nystatin / Q000008:administration & dosage / Q000494:pharmacology* / Q000627:therapeutic use; D012189:Retrospective Studies; D014859:Warfarin / Q000494:pharmacology* / Q000627:therapeutic use
chemical_list: D000925:Anticoagulants; D000935:Antifungal Agents; D009761:Nystatin; D014859:Warfarin; D008825:Miconazole
keywords: Warfarin; antifungal agents; drug interaction