Antifungals

Introduction

• Are a condition of the immune system

• Fungal skin infections referred to as “tinea”

• Tinea infection names are based on the area of the body that is involved:

1. Tinea capitis is a fungal infection on the scalp

2. Tinea pedis is a fungal infection on the feet (athlete’s foot)

3. Tinea unguium is a fungal infection of the nails (onychomycosis)

4. Tinea corporis is a fungal infection on the body (ringworm)

5. Tinea cruris is a fungal infection on the groin (jock itch)

• Candida infections include vaginal yeast infections and oral thrush

Treatment

• Fungal infections are treated with antifungals

• Fungal infections that occur in the blood or nervous system (meningitis, candidemia, etc) require an oral or intravenous anti-fungal

Dosage Forms

• Injectables: Used for patients with a severely weakened immune system to prevent or treat serious fungal infections (patients with HIV/aids or patients who have had an organ transplant). Used to treat blood or nervous system infections (meningitis, candidemia, etc)

• Topicals: Used to treat fungal skin infections. The dosage form used will depend on the area being treated (creams, gels, ointments, and lotions are used for fungal infections on the skin. Solutions are used for nail fungal infections. Shampoos are used for fungal infections on the scalp or in the hair). Corticosteroids (betamethasone, triamcinolone, etc) are sometimes added to topical antifungals to help with itching and inflammation

• Vaginal: Come in creams, ointments, and suppositories. Usually come with an applicator so the medication reaches the vaginal canal and reduces mess

• Oral Solids & Liquids: Used for hard-to-treat infections or infections that require adequate blood levels of the anti-fungal to the infected area (ex: Fungal skin infections resistant to topical anti-fungal therapy. Fungal infections underneath the nail as most topical medications can’t penetrate the nail to treat it. Systemic fungal infections. Vaginal yeast infections.)

Adverse Reactions

• Skin Issues: Topicals can cause skin irritation, redness, burning, or dryness

• Liver Damage: Some oral anti-fungals can cause hepatoxicity (liver toxicity) that can lead to liver injury, hepatitis, or liver failure

• Gastrointestinal Issues: Nausea and diarrhea are common when taking oral anti-fungals

• Allergic (Hypersensitivity) Reactions: Patients who are allergic to parabens (a preservative) should use nystatin products cautiously. Amphotericin B has also been known to cause allergic reactions, but is rare

Special Populations

Pregnancy: Vaginal yeast infections can be more common during pregnancy. Topical vaginal “azole” anti-fungals (miconazole, etc) are considered safe to use. Oral fluconazole (Diflucan) should not be used because it may cause fetal harm

Labs and Monitoring

• Liver Function: Patients taking certain anti-fungals for long periods of time will need close monitoring of liver function (LFTs) to avoid serious damage (ex: Fluconazole (Diflucan), Ketoconazole (Nizoral, etc) oral tablets, Clotrimazole (Mycelex) troches, Itraconazole (Sporanox, etc), Terbinafine (Lamisil, etc) oral tablets

• Kidney Function: Amphotericin B can cause nephrotoxicity (decreased kidney function). Patients will have labs that involve the kidney monitored

Administration Requirements

• Food: For better absorption, itraconazole should be taken with a full meal. Apply a “Take with food” auxiliary label on prescriptions for itraconazole (Sporanox)

• Alcohol: Consuming alcohol while taking oral ketoconazole (Nizoral, etc) can cause patients to have a disulfiram-like reaction (can cause headache, flushing, nausea, and other reactions). Apply a “Do not drink alcohol” auxiliary label on prescriptions for ketoconazole oral tabs

Study Tips

• Look at brand and generic name parts for clues to determine the medication’s indication or drug class

• Lotrimin AF and Zeasorb AF: Many OTC brand products have AF in their name, with AF standing for AntiFungal

• Fluconazole, ketoconazole, etc: Some generic names ending in “-azole” are part of the azole anti-fungal drug class

• Be aware that meds used to decrease stomach acid also end in “-azole” (pantoprazole, etc) and are not anti-fungals

Clotrimazole

• Brand Name: Lotrimin (has other brand names)

• Drug Class: Azoles (Many oral/IV azoles can affect liver functioning, so LFTs will be monitored. Azole generic drug names usually end in “-azole”. Watch for drug interactions)

• Indications: Fungal Infections

• Special Considerations: None

• OTC version is available

Fluconazole

• Brand Name: Diflucan

• Drug Class: Azoles (Many oral/IV azoles can affect liver functioning, so LFTs will be monitored. Azole generic drug names usually end in “-azole”. Watch for drug interactions)

• Indications: Fungal Infections

• Special Considerations: NIOSH med. Should be avoided in pregnant patients

Ketoconazole

• Brand Name: Nizoral (has other brand names)

• Drug Class: Azoles (Many oral/IV azoles can affect liver functioning, so LFTs will be monitored. Azole generic drug names usually end in “-azole”. Watch for drug interactions)

• Indications: Fungal Infections

• Special Considerations: Patients should avoid alcohol with oral dosage form

Miconazole

• Brand Name: Monists (has other brand names)

• Drug Class: Azoles (Many oral/IV azoles can affect liver functioning, so LFTs will be monitored. Azole generic drug names usually end in “-azole”. Watch for drug interactions)

• Indications: Fungal Infections

• Special Considerations: None

Voriconazole

• Brand Name: Vfend

• Drug Class: Azoles (Many oral/IV azoles can affect liver functioning, so LFTs will be monitored. Azole generic drug names usually end in “-azole”. Watch for drug interactions)

• Indications: Fungal Infections

• Special Considerations: None

Amphotericin B

• Brand Name: Ambisome (has other brand names)

• Drug Class: Polyenes

• Indications: Fungal Infections

• Special Considerations: High alert med (liposomal form). May cause allergic reactions. Kidney will be monitored

Nystatin

• Brand Name: Mycostatin (has other brand names)

• Drug Class: Polyenes

• Indications: Fungal Infections

• Special Considerations: None

Terbinafine

• Brand Name: Lamisil

• Drug Class: Allylamines

• Indications: Fungal Infections

• Special Considerations: LFTs will be monitored (with oral dosage forms)

• OTC topic form exists

Ciclopirox

• Brand Name: Loprox (has other brand names)

• Drug Class: Miscellaneous Antifungals

• Indications: Fungal Infection

• Special Considerations: Lacquer topical form is flammable