Itraconazole and terbinafine in perspective: from petri dish to patient

Systematic review of severe acute liver injury caused by terbinafine

BACKGROUND

Terbinafine is an effective antimicrobial agent against dermatophytes, cryptococcus and other fungi. It is the preferred drug to treat onychomycosis. However, severe acute hepatitis from oral terbinafine administration has been recently reported.

AIM

To describe a representative case, and review the literature regarding the best evidence on treatment and prognosis of severe acute hepatitis caused by oral terbinafine.

METHODS

The literature was searched for publications on severe hepatitis caused by terbinafine using MEDLINE, China Biology Medicine Disc, and the VIP Medical Information Resource System. Related references were searched manually.

RESULTS

Seventeen English and three Chinese references of case reports were included after eliminating duplicate publications. No randomized control studies were found. Liver enzyme levels were found to have been increased significantly. Abdominal ultrasound demonstrated cholestasis.

CONCLUSIONS

Severe acute liver injury is a known, but unusual complication of terbinafine exposure. The prognosis is often good with appropriate treatment. Liver function assessment before treatment and periodic monitoring 4-6 weeks after initiation of treatment is recommended.

Systematic review of severe acute liver injury caused by terbinafine

BACKGROUND

Terbinafine is an effective antimicrobial agent against dermatophytes, cryptococcus and other fungi. It is the preferred drug to treat onychomycosis. However, severe acute hepatitis from oral terbinafine administration has been recently reported.

AIM

To describe a representative case, and review the literature regarding the best evidence on treatment and prognosis of severe acute hepatitis caused by oral terbinafine.

METHODS

The literature was searched for publications on severe hepatitis caused by terbinafine using MEDLINE, China Biology Medicine Disc, and the VIP Medical Information Resource System. Related references were searched manually.

RESULTS

Seventeen English and three Chinese references of case reports were included after eliminating duplicate publications. No randomized control studies were found. Liver enzyme levels were found to have been increased significantly. Abdominal ultrasound demonstrated cholestasis.

CONCLUSIONS

Severe acute liver injury is a known, but unusual complication of terbinafine exposure. The prognosis is often good with appropriate treatment. Liver function assessment before treatment and periodic monitoring 4-6 weeks after initiation of treatment is recommended.

Oral antifungal drug interactions: a mechanistic approach to understanding their cause

Oral antifungal drugs are generally regarded as effective and safe when used according to their manufacturer's recommendation. However, when an oral antifungal agent is administered with certain interacting agents or classes of drugs, rare severe iatrogenic adverse experiences including death may occur. This article alerts and demystifies some of the clinically significant oral antifungal drug interactions by exploring their underlying pharmacological basis.

Itraconazole pulse therapy improves the quality of life of patients with toenail onychomycosis

BACKGROUND

Toenail onychomycosis is a common disease that can have serious adverse effects on the quality of life (QOL) of patients.

AIM

To evaluate the impact of itraconazole pulse therapy on the QOL of patients with toenail onychomycosis.

METHODS

A total of 20 patients with disto-lateral subungual toenail onychomycosis were treated with itraconazole 200 mg twice daily for 1 week every 4 weeks for 12 weeks. The patients were asked to complete a QOL questionnaire before treatment and on the last follow-up visit (week 48). A score of 0-4 was given according to the five possible responses to each question and these were summed to give the final score of the patient. The mean of the final scores of the patients before and after treatment were compared using the Wilcoxon matched-pairs test.

RESULTS

At 48 weeks after commencing treatment, 14 patients (70%) responded to treatment (nine patients were cured with almost totally clear toenails and five patients improved), and 16 patients (80%) were mycologically cured (negative KOH smear and culture). The mean of the QOL scores of the patients before treatment was 18.0+/-7.8, which reduced to 13.1+/-11.3 after treatment (two-tailed, p=0.009).

CONCLUSION

Itraconazole pulse therapy is an effective treatment and can improve the QOL of patients with toenail onychomycosis.