Nystatin - how to take it

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Below is the nystatin regime developed by Dr John Mansfield at the Burghwood Clinic, Surrey (Burghwood Clinic) over many decades whilst working there as a Consultant Allergist.

Safety of nystatin

Nystatin has an outstanding safety record and has been used by the medical profession for over 55 years since its original discovery. There is virtually no absorption from the gut and thus no systemic side-effects. Nausea and diarrhoea have occasionally been reported when nystatin has been taken in large dosage over prolonged periods, probably due to a local irritating effect on the gut mucosal lining. An indirect side-effect, a Herxheimer reaction, is explained below. There are no known adverse inter-reactions with any other drugs.

How to take nystatin

The powder can be dispersed in a liquid such as vegetable juice (such as V8), tomato juice or kefir - fermented soya milk. For adults, the normal starting dose is half a level teaspoon per day dispersed in approximately one-third of a glass of liquid. This liquid is then taken in four roughly equal doses throughout the day, preferably before food and before bed. The dosage is gradually increased to 2½ level teaspoons per day (see “Powder” below). In practice, the first pot of powder usually lasts approximately 3½ weeks. The second pot lasts 2-2½ weeks, but when full dosage is attained, a pot of powder is consumed in 8 days.

(NB - there are 20 level teaspoons of powder in a pot and so you can work out how long a pot will last depending on what daily dose you are currently taking. In the case of a full dose of 2½ level teaspoons daily this gives a result of 20/2½ = 8 days, as stated.)

Alternatively, many patients prefer to place the nystatin powder into capsules, which they buy empty and fill themselves – we can supply. One hundred empty capsules should be enough to encapsulate all the powder contained in one 25 gram pot of nystatin. You should pull apart the empty capsules and put as much powder as possible into both the larger and the smaller sides before pressing the two sides together. It can take a few minutes to get the hang of this technique, but usually a pot of 100 capsules can be made up in approximately 45 - 55 minutes.

Nystatin dosage schedules


A 5ml plastic teaspoon is needed for measuring the dosage. This contains 8 million i.u. of pure nystatin powder. This is much more than in the NHS prescribed liquid nystatin, which contains 100,000 i.u. per ml. The normal starting dose is ½ level teaspoon per day. The teaspoon should be levelled with a knife and excess powder returned to the pot. A ½ level teaspoon can be reasonably well estimated by removing half of the powder on the teaspoon with the knife and also returning it to the pot. This ½ level teaspoon can then be added to the juice or soyal milk as already described above and shaken or stirred to disperse it. It should be taken at four roughly equal intervals throughout the day, with the dosage gradually increasing. Thus a convenient schedule for adults would be:

Teaspoons per day Divided into For
½ 4 equal amounts 5 days
¾ 4 equal amounts 5 days
1 4 equal amounts 5 days
1 ¼ 4 equal amounts 5 days
4 equal amounts 5 days
4 equal amounts 5 days
2 4 equal amounts 5 days
4 equal amounts 5 days
4 equal amounts some months


If self-made capsules are preferred, the idea is to take these spread evenly over the whole day in three or four doses. Thus a convenient schedule for adults would be:

Number of nystatin capsules per day Morning dose Lunchtime dose Afternoon dose Evening dose
2 per day for 5 days 1 0 1 0
3 per day for 5 days 1 1 1 0
4 per day for 5 days 1 1 1 1
5 per day for 5 days 1 1 1 2
6 per day for 5 days 2 2 2 0
7 per day for 5 days 1 2 2 2
8 per day for 5 days 2 2 2 2
9 per day for 5 days 3 3 3 0
10 per day for 5 days 2 2 3 3


Most patients need to remain on full dosage (2½ teaspoons of powder or 10 capsules per day) for two to four months, although clinical improvement is usually seen by the time the patient has been on this dosage for a week or two.

Possible reaction

The reason for the slow build-up in dosage relates to the possibility of a Herxheimer reaction. Nystatin itself, as stated above, is pretty harmless to humans, but as it makes its way through the gut it effectively kills off any yeast/fungi. Under an electron microscope it can be seen that the yeast cell walls disintegrate when in contact with nystatin. These cells contain an endotoxin called “Candida toxin”, so if large numbers of yeast are killed, a lot of this toxin is released. The toxin is absorbed from the gut in the normal course of events. Thus, killing large numbers of yeasts can lead to an accentuation of the very symptoms we are seeking to treat – such as bloating, fatigue, depression, and bowel disturbance – if the yeasts are killed off too quickly.

In most patients, the problem is a mild transitory nuisance, but there is the occasional highly sensitive patient where it can cause quite a lot of problems and it may be that in these circumstances the patient will need to change to a different medication.

Dealing with a Herxheimer (die off) reaction

A common series of events is depicted below:

daily dose response action to take effect of action
½ teaspoon OK continue and go to next dose up
¾ teaspoon OK continue and go to next dose up
1 teaspoon OK continue and go to next dose up
1¼ teaspoon feeling worse Reduce to ¾ teaspoons a day Symptoms blow over in 1-2 days; Increase to 1 teaspoon a day as soon as feeling well
1 teaspoon OK remain on 1 teaspoon a day for 8 days hopefully OK
Retry 1¼ teaspoons a day will probably now be OK Remain on 1¼ teaspoons a day for 5 days
1½ teaspoons a day hopefully OK remain on 1½ teaspoons a day for 5 days

And so on, up to 2½ teaspoons a day. It is obviously possible that further die-off reactions could occur at 1½, 1¾, 2, 2¼ or 2½ teaspoons a day.

Exactly the same reaction can happen whether you are taking nystatin in powder or capsule form and the manner of dealing with it should be the same. Be aware that: 1 (self-made) capsule = approximately ¼ level teaspoon of powder.

Although the die-off response is a nuisance and will temporarily prolong the treatment, many people regard it as a good sign in that it is difficult to have any problems with die-off unless you have the Candida yeast problem at all and can take very high doses of nystatin without any damaging effects to the body.

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