What is Candida Die Off? Options for treatment

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Many patients ask about "die off reactions" and attribute a variety of symptoms to this process. Candida die-off is technically called a herxheimer reaction, and is related to inflammatory symptoms that arise from candida metabolic products beign released by break down of the candida cell wall. In practice, it is relatively rare that I see candida die off as being the main reason a patient is experiencing symptoms, unless they are on a new medication regime for candida.

Chronic symptoms of diarrhea, bloating, fatigue and cognitive impairment after meals, is a common complaint that patients describe. There are many conditions to consider in such patients, such as irritable bowel syndrome, inflammatory bowel disease, small intestinal bacterial overgrowth, in addition to the lesser appreciated candida overgrowth in the gastrointestinal tract.

The term "candida related complex" usually refers to a constellation of systemic symptoms that are associated with either candida overgrowth in the gut, or an abnormal hypersensitivity to normal amounts of candida in the gut.

I would consider candida related symptoms if the gastrointestinal symptoms typically get worse as the day goes on, and especially if patients present with the pattern where they may wake up with a flat, non-distended abdomen; but then as they eat through the day, especially after carb-rich meals, they get more and more distended. Often by the end of the day, despite diarrhea and multiple bowel movements, they may be so distended that they look 6 months pregnant.

Symptoms and Treatments for Chronic Candida Complex

Two popular approaches to managing chronic candida complex symptoms are the candida diet and antimicrobial treatment.

Antimicrobial treatment involves the use of medications or supplements that kill or inhibit the growth of microorganisms, including Candida. Antifungal medications like Fluconazole, Itraconazole, are commonly used for candida treatment. Nystatin and Caprylic Acid are two other antimicrobial treatments that are effective against candida overgrowth.

Nystatin is an oral medication that targets the cell wall of Candida, while Caprylic Acid is a natural supplement that is also found in coconut oil. I do find very good results with nystatin, but similar to other antimicrobial agents, there is often a relapse that has to be treated. Usually, the time between relapses extends as we continue treatment.

A great article which was a randomized trial using nystatin in patients with multiple symptoms found efficacy in reduction of overall symptom score.

Another study found that patients who typically responded to nystatin therapy often had elevated candida IgG antibodies.

Antimicrobial treatment can also be combined with probiotics to restore the gut's healthy bacteria. The prescription antimicrobials can carry some risk, especially the azole drugs, and are monitored by your doctor who would normally assess liver enzymes if on the therapy for an extended time. I have not seen many reactions to nystatin, but there are occasionally allergic type reactions despite minimal absorption.

The candida diet involves avoiding certain foods to reduce the growth of Candida in the body. Foods that are high in sugar, refined carbohydrates, and processed foods are avoided, and instead, a diet rich in vegetables, proteins, and healthy fats is recommended. While the candida diet can be a good option for patients with mild symptoms or those who want to avoid medications, it may not be enough to address severe candida overgrowth. Additionally, the candida diet can be challenging to follow and may not provide quick relief from symptoms.

Patients often come in with relief after being on a very restrictive candida diet, but make the appointment because whenever the diet is broken, there is a very fast relapse in their symptoms.

Overlap with SIBO

Symptoms of chronic candida complex can be similar to those of small intestine bacterial overgrowth (SIBO). These symptoms include bloating, abdominal pain, diarrhea, or in some cases, constipation. The classic diet for SIBO involves limiting fermentable foods, or a low FODMAP diet.

Treatment for SIBO involves antibiotics either drug or herbal. The drugs have no effect on candida, but the herbs used are essentially the same. This gives the herbal approach a large advantage as it covers for both SIBO and candida related complex.

Testing options

Typically, I find candida culture and microscopy in the stool to be helpful. The measurement of IgG antibodies (in the study linked above) can be useful also. There is also an organic acids urine test, which has a component of the test which measures fungal metabolites in the urine.

Summary

Chronic candida, or candida related complex, while not accepted as a conventional medical diagnosis, is a useful consideration to see if fungal overgrowth might be contributing to symptoms that present as a condition like irritable bowel syndrome. Even in positive tests, it is important to keep in mind other diagnoses if there is not the usual rapid (although with relapses!) improvement with antifungal treatment.

I tend to use stool and urine testing, and occasionally blood, when it is not clear if candida overgrowth might be contributing to symptoms. Caprylic acid and nystatin are options to discuss with your practitioner, and eventually dietary therapy as well as gut support to help keep the gut healthy.