Mikomaks - instructions for use, reviews, analogs and forms of release (capsules or tablets 50 mg, 100 mg and 150 mg, syrup, injections in injections and infusions) drugs for treatment of thrush or candidiasis in adults, children and pregnancy

In this article, you can read the instructions for using the drug Mikomaks. There are reviews of visitors to the site - consumers of this medication, as well as opinions of doctors of specialists on the use of Mikomaks in their practice. A big request is to actively add their feedback on the drug: the medicine helped or did not help get rid of the disease, which were observed complications and side effects, possibly not declared by the manufacturer in the annotation. Analogues of Mikomaks in the presence of existing structural analogues. Use to treat thrush or candidiasis and other mycoses in adults, children, as well as during pregnancy and lactation.Composition and interaction of the drug with alcohol.

Mikomaks - antifungal preparation of the triazole group. Selective inhibitor of the synthesis of sterols in membranes of fungal cells.

Composition

Fluconazole + auxiliary substances.

Pharmacokinetics

After oral administration, Mikomaks is well absorbed. Bioavailability of Fluconazole is 90%. Simultaneous food intake does not affect the absorption of the drug taken internally. Concentrations in the plasma are in direct proportion to the dose. 90% level of equilibrium concentration is reached by 4-5 day of daily administration of fluconazole once a day.

Fluconazole well penetrates into all body fluids. Concentrations of the drug in saliva and sputum are similar to its concentration in blood plasma. In patients with fungal meningitis, the fluconazole content in the cerebrospinal fluid reaches 80% of its concentration in the blood plasma. In the stratum corneum, epidermis, dermis and fluids, high concentrations of fluconazole are achieved, which exceed its concentration in serum.

Fluconazole is excreted mainly by the kidneys; approximately 80% of the administered dose is excreted in the urine unchanged.The clearance of fluconazole is proportional to the creatinine clearance.

Indications

• cryptococcosis, including cryptococcal meningitis and other localizations of this infection (including lungs, skin), both in patients with normal immune response, and in patients with various forms of immunodepression (including those with acquired immunodeficiency syndrome (AIDS ), with organ transplantation); the drug can be used to prevent the recurrence of cryptococcal infection in AIDS patients;
• generalized candidiasis, including candidemia, disseminated candidiasis and other forms of invasive candidiasis infections (peritoneal, endocardial, eye, respiratory and urinary tract infections, liver, spleen and other organs). Treatment can be performed in patients with malignant neoplasms, in intensive care units, in patients undergoing cytostatic or immunosuppressive therapy, and in the presence of other factors predisposing to the development of candidiasis;
• Candidiasis of mucous membranes, incl. oral cavity and pharynx, esophagus, non-invasive bronchopulmonary candidiasis, candiduria, candidiasis of skin in patients with normal immune system function and in patients with decreased functionthe immune system; prevention of recurrence of oropharyngeal candidiasis in AIDS patients;
• genital candidiasis: vaginal candidiasis (acute and chronic recurrent), preventive use to reduce the frequency of recurrences of vaginal candidiasis (3 or more episodes a year); Candidiasis balanitis;
• prevention of fungal infections in patients with malignant neoplasms that are predisposed to such infections as a result of chemotherapy with cytostatics or radiation therapy;
• mycosis of the skin, including mycosis of the feet, the body, the groin area; pityriasis lichen, onychomycosis; candidiasis of the skin;
• Deep endemic mycoses, including coccidiomycosis, paracoccidiomycosis, sporotrichosis and histoplasmosis in patients with normal immunity.

Forms of release

Capsules 50 mg, 100 mg and 150 mg (sometimes mistakenly called tablets).

Syrup.

Solution for infusions (injections in ampoules for injections).

Other medicinal forms, whether candles, ointment or cream, do not exist.

Instructions for use and dosing regimen

Capsules

The drug is taken internally.

Adults

In cryptococcal meningitis and cryptococcal infections of other localizations, 400 mg is usually prescribed on the first day, and then continue treatment at a dose of 200-400 mg once a day.The duration of treatment for cryptococcal infections depends on the clinical efficacy, confirmed by mycological examination; In cryptococcal meningitis, treatment usually continues for at least 6-8 weeks. To prevent the recurrence of cryptococcal meningitis in AIDS patients, after completion of the full course of primary treatment, fluconazole is administered at a dose of 200 mg per day for a long period of time.

With candidemia, disseminated candidiasis and other invasive candidiasis infections, the dose is usually 400 mg on the first day, and then at 200 mg per day. With insufficient clinical effectiveness, the dose of the drug can be increased to 400 mg per day. With life-threatening candidiasis infections, the dose can be increased to 800 mg once a day. The duration of therapy depends on clinical effectiveness.

With candidiasis of the oral cavity and pharynx, 100 mg of fluconazole is usually prescribed once a day; the duration of treatment is 7-14 days. If necessary, in patients with a marked decrease in immunity, treatment may be longer.

With other localizations of candidiasis (with the exception of genital candidiasis), for example, with esophagitis, non-invasive bronchopulmonary disease, candiduria, candidiasis of the skin and mucous membranes,etc., the effective dose is usually 100 mg per day with a treatment duration of 14-30 days.

To prevent the recurrence of oropharyngeal candidiasis in patients with AIDS after completing a full course of primary therapy, 150 mg once a week can be prescribed.

With vaginal candidiasis, fluconazole is taken once inside at a dose of 150 mg. To reduce the frequency of recurrences of vaginal candidiasis, the drug can be applied at a dose of 150 mg once a month. The duration of therapy is determined individually; it varies from 4 to 12 months. Some patients may require more frequent use of the drug.

With Candida balanitis, fluconazole is administered once in a dose of 150 mg orally. For the prevention of candidiasis, the recommended dose of fluconazole is 50-400 mg once a day, depending on the degree of risk of fungal infection. If there is a high risk of generalized infection, for example, in patients with expected severe or persistent neutropenia, the recommended dose is 400 mg once daily. Fluconazole is prescribed several days before the expected appearance of neutropenia; after increasing the number of neutrophils more than 1000 / mm3 treatment is continued for another 7 days.

With mycosis of the skin, including mycosis of the feet, skin of the inguinal area, and skin candidiasis, the recommended dose is 150 mg once a week. The duration of therapy in usual cases is 2-4 weeks, however, with foot mycoses, longer therapy (up to 6 weeks) may be required.

With pityriasis, the recommended dose is 300 mg once a week for 2 weeks, some patients require a third dose of 300 mg per week, while in some cases it is sufficient to receive 300-400 mg once a day; an alternative treatment regimen is to administer 50 mg once a day for 2-4 weeks.

With onychomycosis, the recommended dose is 150 mg once a week. Treatment should continue until the full replacement of the affected nail is healthy. Usually this process lasts for 3-6 months, and when the nails of the big toes are damaged - within 6-12 months. The speed of nail growth is very individual and depends on the age of the patient. After curing a chronic nail infection, it is possible to preserve deformities of the nail plates.

With deep endemic mycoses, it may be necessary to use the drug at a dose of 200-400 mg per day for up to 2 years.The duration of therapy is determined individually; it can be 11-24 months with coccidiomycosis; 2-17 months with paracoccidiosis; 1-16 months with sporotrichosis and 3-17 months with histoplasmosis.

Children

In children, as with similar infections in adults, the duration of treatment depends on the clinical and mycological effect. In children, the drug should not be used in a daily dose that would exceed that of adults. The drug is used daily 1 time per day.

In children with candidiasis of mucous membranes, the recommended dose of fluconazole is 3 mg / kg per day. On the first day, a shock dose of 6 mg / kg may be prescribed to achieve a more rapid equilibrium equilibrium concentration.

For treatment of generalized candidiasis or cryptococcal infection, the recommended dose is 6-12 mg / kg per day, depending on the severity of the disease.

For the prevention of fungal infections in children with reduced immunity, where the risk of infection is associated with neutropenia, resulting from cytotoxic chemotherapy or radiation therapy, the drug is prescribed at 3-12 mg / kg per day, depending on the severity and duration of preservation of induced neutropenia.

In children with impaired renal function, the daily dose of the drug should be reduced (in the same proportional relationship as in adults, according to the degree of renal failure, see below).

In elderly patients in the absence of violations of kidney function should follow the usual dosage regimen. Doses for elderly patients with renal insufficiency (creatinine clearance less than 50 ml / min), see below.

Syrup

The drug Mikomaks in the form of syrup is intended for oral administration. The syrup is measured by means of the attached measuring cup. The filled measuring cup contains 20 ml of syrup. The drug is recommended to hold in your mouth for 2 minutes ("rinse"), then swallow.

The bottle is closed with a special lid, which prevents the children from opening the bottle. In order to open the bottle, it is necessary to push the lid with some effort and then turn it in a counter-clockwise direction. After receiving the pre-cap, close the cover tightly, turning it in the opposite direction.

Adults with cryptococcal meningitis and cryptococcal infections of other sites on the first day usually prescribed 400 mg (80 ml), and then continue treatment at a dose of 200-400 mg (40-80 ml) 1 time per day.The duration of treatment for cryptococcal infections depends on the clinical efficacy, confirmed by mycological examination; in cryptococcal meningitis, it usually lasts at least 6-8 weeks.

To prevent the recurrence of cryptococcal meningitis in AIDS patients, after completion of the full course of primary treatment, fluconazole is administered at a dose of 200 mg per day (40 ml) for a long period of time.

In candidemia, disseminated candidiasis and other invasive candidiasis infections, the dose is usually 400 mg (80 ml) on the first day, and then 200 mg (40 ml). With insufficient clinical efficacy, the dose of the drug can be increased to 400 mg per day (80 ml).

The higher initial dose (10 mg / kg / day) and the maintenance dose (5 mg / kg / day) are usually administered to patients with malignant tumors after an intensive course of antitumor chemotherapy or patients after bone marrow transplantation, extensive surgery on the organs of the gastro- intestinal tract and heart. The duration of therapy depends on clinical effectiveness.

With oropharyngeal candidiasis, the drug is usually prescribed 50-100 mg once a day (10-20 ml); the duration of treatment is 7-14 days. If necessary, in patients with a marked decrease in immunity, treatment may be longer.

With atrophic candidiasis of the oral cavity associated with the wearing of dentures, fluconazole is usually prescribed 50 mg (10 ml) once a day for 14 days in combination with local antiseptic agents for prosthesis treatment.

With other localizations of candidiasis (with the exception of genital candidiasis), for example, with esophagitis, non-invasive bronchopulmonary disease, candiduria, candidiasis of the skin and mucous membranes, etc. the effective dose is usually 50-100 mg per day (10-20 ml) with a treatment duration of 14-30 days. To prevent the recurrence of oropharyngeal candidiasis in AIDS patients, after completing the full course of primary therapy, the drug can be prescribed 150 mg (30 ml) once a week.

With vaginal candidiasis, fluconazole is taken once inside at a dose of 150 mg (30 ml). To reduce the frequency of recurrences of vaginal candidiasis, the drug can be used at a dose of 150 mg (30 ml) once a month. The duration of therapy is determined individually; it varies from 4 to 12 months.Some patients may need more frequent use.

With balanitis caused by Candida, fluconazole is administered once in a dose of 150 mg orally.

For the prevention of candidiasis, the recommended dose of fluconazole is 50-400 mg (10-80 ml) 1 time per day, depending on the degree of risk of developing fibrotic infection. If there is a high risk of generalized infection, for example, in patients with expected severe or persistent neutropenia, the recommended dose is 400 mg (80 ml) once a day. Fluconazole is prescribed several days before the expected appearance of neutropenia; after increasing the number of neutrophils more than 1000 / mm3 treatment is continued for another 7 days.

For skin mycoses, including mycosis of the feet, skin of the inguinal region, and skin candidiasis, the recommended dose is 150 mg (30 ml) once a week or 50 mg (10 ml) once a day. The duration of therapy in usual cases is 2-4 weeks, however, with foot mycoses, longer therapy (up to 6 weeks) may be required.

With pityriasis 300 mg (60 ml) once a week for 2 weeks, some patients require a third dose of 300 mg (60 ml) per week, while in some cases it is sufficient to receive 300-400 mg once; an alternative treatment regimen is the use of 50 mg (10ml) once a day for 2-4 weeks.

With onychomycosis, the recommended dose is 150 mg (30 ml) once a week. Treatment should continue until the replacement of the infected nail (growth of uninfected nail). For the repeated growth of nails on the fingers and toes, it normally takes 3-6 months and 6-12 months, respectively.

With deep endemic mycoses, it may be necessary to use the drug at a dose of 200-400 mg per day (40-80 ml) for up to 2 years. The duration of therapy is determined individually; it can be 11-24 months with coccidiomycosis; 2-17 months with paracoccidiosis; 1-16 months with sporotrichosis and 3-17 months with histoplasmosis.

In children, as with similar infections in adults, the duration of treatment depends on the clinical and mycological effect. In children, the drug should not be used in a daily dose that would exceed that of adults. The drug is used daily 1 time per day.

In candidiasis of mucous membranes, the recommended dose of fluconazole is 3 mg / kg per day. On the first day, a shock dose of 6 mg / kg may be prescribed to achieve a more rapid equilibrium equilibrium concentration.

For treatment of generalized candidiasis or cryptococcal infection, the recommended dose is 6-12 mg / kg per day, depending on the severity of the disease.

For the prevention of fungal infections in children with reduced immunity, where the risk of infection is associated with neutropenia, resulting from cytotoxic chemotherapy or radiation therapy, the drug is prescribed at 3-12 mg / kg per day, depending on the severity and duration of preservation of induced neutropenia.

In children with impaired renal function, the daily dose of the drug should be reduced (in the same proportional relationship as in adults), according to the degree of renal insufficiency.

In newborns there is a delayed excretion of fluconazole. During the first 2 weeks of a child's life, the dosage regimen calculated in mg / kg, the same as for older children, the drug should be administered at an interval of 72 hours. For the next 2-4 weeks, the drug is administered at the same dose at intervals of 48 hours.

Solution for infusions

The drug Mikomaks in the form of a solution for infusion is administered intravenously drip at a rate of no more than 20 mg (10 ml) / min.

When transferring from intravenous administration to taking capsules and vice versa, there is no need to change the daily dose.

Mycomomax in the form of a solution for infusions is compatible with the following solvents: 20% glucose solution, Ringer's solution, Hartman's solution, potassium chloride solution in glucose, 4.2% sodium bicarbonate solution, isotonic sodium chloride solution.

The infusions of the Mycosmax preparation can be carried out using conventional sets for transfusion using one of the above liquids.

Side effect

• weakness;
• motor anxiety;
• muscle weakness;
• fever;
• headache;
• dizziness;
• convulsions;
• paresthesia;
• tremor;
• vertigo;
• skin rash;
• itching;
• increased sweating;
• exfoliative skin lesions (Stevens-Johnson syndrome);
• nausea and vomiting;
• stomach ache;
• diarrhea;
• anorexia;
• constipation;
• dyspepsia;
• flatulence;
• dryness of the oral mucosa;
• changes in taste;
• myalgia;
• insomnia;
• drowsiness;
• jaundice;
• necrosis of the liver;
• anemia;
• anaphylaxis;
• convulsive seizures;
• alopecia;
• leukopenia, including neutropenia and agranulocytosis, thrombocytopenia.

Contraindications

• simultaneous reception of terfenadine when necessary to take fluconazole at a dose of 400 mg per day or more,and simultaneous administration of astemizole and cisapride (risk of prolongation of the QT interval and development of ventricular tachycardia, including ventricular pirouette tachycardia);
• hypersensitivity to fluconazole or structurally close to azole compounds, as well as the excipients of the drug and substances that make up the capsule shell;
• children with body weight less than 40 kg (for these doses - 100 mg and 150 mg);
• congenital galactose intolerance, lactase deficiency, glucose-galactose malabsorption (due to the content of lactose in the formulation);
• the period of lactation.

Carefully

• liver failure;
• renal failure (fluconazole dose adjustment required);
• potentially proaritmogenic states in patients with multiple risk factors (organic heart disease, water-electrolyte balance disturbances, simultaneous intake of drugs that cause arrhythmias);
• simultaneous reception of terfenadine with fluconazole in a dose of less than 400 mg per day;
• simultaneous administration of hypoglycemic agents for oral administration, sulfonylurea derivatives (increased risk of hypoglycemia,requires careful monitoring of the concentration of glucose in the blood, if necessary, correction of hypoglycemic therapy);
• pregnancy.

Application in pregnancy and lactation

The drug should not be used in pregnant women, except for severe or life-threatening forms of fungal infections, if the expected beneficial effect for the mother exceeds the possible risk to the fetus.

Fluconazole is found in breast milk in the same concentration as in plasma, therefore it is not recommended that it be given to breast-feeding women.

Application in elderly patients

In elderly patients in the absence of violations of kidney function should follow the usual dosage regimen.

Use in children

Contraindicated for children with a body weight of less than 40 kg (for medicinal forms in the form of capsules). With caution, you can use syrup in children younger than 6 months.

special instructions

For all indications, treatment with the drug should be continued until the onset of clinical and laboratory remission. Premature termination of treatment leads to relapse. During the treatment it is necessary to monitor hematological parameters, kidney and liver function.

In rare cases, the use of fluconazole was accompanied by toxic changes in the liver, including a fatal outcome, mainly in patients with serious concomitant diseases. In the case of hepatotoxic effects associated with fluconazole, there was no apparent dependence on the total daily dose, duration of therapy, sex and age of the patient. The hepatotoxic effect of Mikomax was usually reversible; signs of it disappeared after discontinuation of therapy. If there are violations of the liver, stop taking the drug. If there are violations of the kidneys, you also need to cancel the drug.

It is forbidden to take Mikomaksa together with alcohol (potentiation of the hepatotoxic effect of ethanol is observed).

Patients with AIDS are more likely to develop severe skin reactions with many drugs. In those cases where the rash develops in patients with superficial fungal infection and it is regarded as definitely associated with fluconazole, the drug should be discontinued. When the rash appears in patients with invasive / systemic fungal infections, they should be carefully monitored and discarded when fluconazole appears or bulimous erythema changes occur.Care should be taken when taking fluconazole with rifabutin or other drugs metabolized with the P-450 isoenzyme system.

Some azoles, including fluconazole, were associated with prolongation of the QT interval on the ECG. During the post-marketing use of the drug, there were reported rare cases of prolongation of the QT interval and the development of ventricular pirouette tachycardia during treatment with fluconazole. This effect was more often observed in patients with severe cardiac pathology and multiple risk factors, such as myopathy, water-electrolyte balance disorders, and simultaneous use of drugs that may contribute to the occurrence of rhythm disturbances.

Impact on the ability to drive vehicles and manage mechanisms

The experience of using the drug showed that Mikomaks usually does not affect the ability to drive vehicles and engage in other potentially hazardous activities. However, if the patient experiences dizziness, vertigo, drowsiness during taking the drug, you should refrain from engaging in potentially hazardous activities.

Drug Interactions

Indirect anticoagulants. With the simultaneous administration of fluconazole during treatment with coumarin derivatives (warfarin), prothrombin time increased. Patients concurrently receiving indirect anticoagulants, coumarin derivatives, require careful monitoring of prothrombin time. Azithromycin: There was no significant pharmacokinetic interaction between fluconazole and azithromycin.

Terfenadine. Some azoles in combination with terfenadine were associated with the occurrence of serious rhythm disturbances, including paroxysms of ventricular tachycardia (torsades de points), due to the prolongation of the QT interval on the ECG. Studies with fluconazole showed that a daily dose of fluconazole 200 mg did not show an extension of the QT interval. When fluconazole was administered at a dose of 400 or 800 mg, a significant increase in the plasma concentration of terfenadine was observed. The administration of fluconazole 400 mg or more in combination with terfenadine is contraindicated. Patients should be carefully observed while taking terfenadine and fluconazole at a dose of less than 400 mg per day. Astemizole.Simultaneous treatment with fluconazole and astemizole and other drugs metabolized by isoenzymes of the cytochrome P450 system can lead to an increase in the plasma concentrations of these drugs. Patients simultaneously receiving these drugs with fluconazole should be under close medical supervision.

Hydrochlorothiazide. In patients receiving hydrochlorothiazide, simultaneous administration of Mycomomax, an increase in plasma concentrations of fluconazole by 40% is possible. The effect of such an expression should not affect the dose of fluconazole. Hypoglycemic agents for peroral application, sulfonylurea derivatives. It has been demonstrated that fluconazole increases the plasma concentration and increases the half-life of simultaneously taken glibenclamide, glipizide and tolbutamide. Simultaneous use of fluconazole and hypoglycemic agents for oral administration of sulfonylureas may be possible, but the possibility of developing hypoglycemia should be considered and the concentration of glucose in the blood should be carefully monitored; In rare cases, it may be necessary to correct the hypoglycemic agent for oral administration,a sulfonylurea derivative.

Benzodiazepines of short action. After ingestion of midazolam, fluconazole increases the concentration of midazolam in the blood plasma, which can lead to psychotic affects. This effect of fluconazole on the concentration of midazolam is more pronounced when taking midazolam inwards than with its intravenous administration. It may be necessary to reduce the dose of midazolam, when using this combination, you should carefully monitor the patient's condition.

Phenytoin. Simultaneous use of fluconazole and phenytoin clinically significantly increases the concentration of phenytoin in the blood. It is necessary to monitor the concentration of phenytoin in the blood and, if necessary, adjust the dose of phenytoin in order to maintain its concentration in the blood within the therapeutic range. Rifampicin. Reducing the half-life of fluconazole by approximately 20% and reducing its plasma concentration by 25% when fluconazole is combined with rifampicin. Therefore, it is advisable to increase the dose of fluconazole to patients receiving rifampicin simultaneously.

Rifabutin. Simultaneous use of Mikomax and rifabutin may lead to an increase in the plasma concentration of rifabutin.In patients who simultaneously take fluconazole and rifabutin, uveitis may develop. It is necessary to carefully observe patients who are simultaneously receiving rifabutin and fluconazole.

Cisapride. There were reports of adverse events from the heart, including ventricular tachycardia type "pirouette" (torsades de pointes) in patients concomitantly receiving fluconazole and cisapride. In controlled trials it revealed that simultaneous intake of 200mg fluconazole once daily and cisapride 20 mg 4 times a day resulted in a significant increase in plasma concentrations of cisapride and prolongation of QT interval. Simultaneous administration of cisapride in patients receiving fluconazole is contraindicated.

Cyclosporine. In patients with kidney transplantation with fluconazole 200 mg per day, a slight increase in the concentration of cyclosporine in the blood was observed. However, in patients with bone marrow transplant who took fluconazole at a dose of 100 mg per day, the concentration of cyclosporine in the blood did not change. It is recommended to monitor the plasma concentration of cyclosporine in patients taking fluconazole.

Theophylline.Fluconazole increases plasma concentrations of theophylline. The use of fluconazole at a dose of 200 mg for 14 days resulted in an 18% decrease in the average plasma clearance values ​​of theophylline. Patients who receive high doses of theophylline or who are likely to develop theophylline intoxication should be monitored for the early detection of symptoms of theophylline overdose.

Zidovudine. Higher doses of Mikomax (400 mg and higher) clinically significantly increase plasma concentrations of zidovudine, which is associated with a decrease in the conversion of the latter into its main metabolite. Therefore, an increase in the side effects of zidovudine should be expected. Patients receiving this combination should be monitored for the development of zidovudine-associated adverse reactions.

Tacrolimus. Mycomomax increases plasma concentrations of tacrolimus with possible clinical manifestations of toxicity (nephrotoxicity, hyperglycemia, hyperkalemia). Tacrolimus plasma concentrations should be monitored and, if necessary, a dose reduction may be required.

Oral contraceptives.With the simultaneous use of fluconazole at a dose of 50 mg and oral contraceptives, there were no significant changes in plasma concentrations of ethinylestradiol and levonorgestrel, but with 200 mg of fluconazole, there was an increase in AUC (area under the pharmacokinetic concentration-time curve) of ethinylestradiol by 40% and levonorgestrel by 24 %. Therefore, the effect of fluconazole on the efficacy of combined oral contraceptives is not expected.

The attending physicians should keep in mind that studies on drug interactions with other medications have not been conducted, but the development of such interactions is possible.

Interaction studies have shown that with a simultaneous intake of food, cimetidine, or whole-body irradiation for bone marrow transplantation, there has been no clinically significant deterioration in the absorption of fluconazole.

Analogues of the drug Mikomaks

Structural analogs for the active substance:

• Disorel of Sanovel;
• Diflason;
• Diflucan;
• Mikonil;
• Medoflucon;
• Mycosyst;
• Mycoflucan;
• Nofung;
• Procanazole;
• Fangifflu;
• Flucosan;
• Flukoside;
• Flukomabol;
• Flukomycid Sediko;
• Fluconazole;
• Flukonorm;
• Flukoral;
• Flukorus;
• Flukoreem;
• Flucostat;
• Forkan;
• Fungolon;
• Ciscan.

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