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PEBC: What You Need to Know: Oral Antifungals

Examples: Nystatin, Terbinafine, Ketoconazole, Fluconazole, Itraconazole, Posaconazole, Voriconazole


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Indications:

oral candidiasis, vaginal candidiasis, skin infections, nail infection, opporutnistic infection


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Dosing:

Nystatin Liquid: Swish and (either spit or swallow) QID after meals (for topical mucous membanes such as mouth and esophageal)

**Other medications can be dosed once daily (sometimes twice daily if a high dose is prescribed)

**Most can be dosed with food (especially ketoconazole, posaconazole and itraconazole tablets which require acidity), except for itraconazole liquid and voriconazole (empty stomach)


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Adverse Effects:

-Elevated liver enzymes

-nausea, headache, rash

-QT prolongation

-heart failure (itraconazole)

-gynecomastia, loss of libido (ketoconazole)

-photosensitivity, visual disturbances (voriconazole)


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Drug Interactions:

*avoid alcohol with all medications due to hepatotoxicity

-Terbinafine is a CYP2D6 inhibitor - be careful with substrates such as tamoxifen, duloxetine, aripiprazole and tricyclic antidepressants

-Fluconazole and voriconazole are CYP2C9, 2C19 and 3A4 inhibitors - careful with many substrates including warfarin, fluoxetine

-Itraconazole, posaconazole and ketoconazole are 3A4 inhibitors

-acid-reducing medications may reduce the absorption of itraconazole and ketoconazole tablets (ex. proton pump inhibitors, antacids, H2 receptor antagonists)

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