ITRACONAZOLE
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I have had several patients with itraconazole eruptions. We
have just had a fulminant liver failure, presenting in her third month of
pulsed itraconazole. Liver enzymes sky high, bilirubin 30 (!), transplant
team ready to go to work...happy ending, gradually improving, no
transplant.

Diane Thaler
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What is the patient profile?  Were there any specific risks factors?

Rhett Drugge, M.D.
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 I treated the now 62 year old
patient in 1994 with itraconazole pulse for T.pedis and onychomycosis which
was quite severe. I never got to see her again. She presented in l995 with
similar symptoms to a P.A. who reviewed my old note and treated her again
(July). She then was found to be hypothyroid, presumed autoantibody type of
itis. She presented again to her Internist in December-January of this year
and was re prescribed itraconazole (third course) after normal LFTs. After
her third month of the third course she developed ascites, jaundice, and
liver failure. They were planning on transplanting her, but she
refused...wait and see trial. She was positive only for Hep A antibodies,
not B or C. The G.I. people thought the fibrosis on the liver biopsy was
compatible with that caused by autoantibody type of hepatitis, but there is
no prior history of clinical hepatitis.

Diane Thaler
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I have had several patients with large elevations of liver enzymes with
Sporanox. One patient, treated by another dermatologist at the BI in Boston 
almost died from a hypersensitivity reaction probably related to Sporanox.

Lamisil, in my opinion is too new.  Ketoconazole is notorious for
idiosyncratic hepatic toxicity (including such adverse events resulting in
liver transplant or death).

I now use Diflucan, 100mg qod (or talk the patient out of treatment) for nail
dermatophytosis.  I have had great success and no adverse events with the
Diflucan regime.

Rick Sharpe, M.D.
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I too have had great luck with Diflucan for onychomycosis with
a dose of only 100mg q week!!  So far no side effects or liver
enzyme elevations (and I've been checking).  Total cohort of
50-60.

Kip Cullimore, MD
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 You may want to try and cut the dose of diflucan from 100 qod to
100 2 times per week.  My results have been quite satisfactory. 

Bill Liss
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The patients that I have had problems with when treated with itraconazole had
no underlying problems based on their medical history.  Additionally,
baseline LFT's were fine.

We might consider archiving the adverse events (AE's) for this drug and/or
filling out FDA AE forms.

Rick Sharpe
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