Diflucan

[docB]

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As my training become more and more like a Model T Ford (out of date and obsolete but not without its charm) I find myself questioning the everyday stuff I do. So I have some questions about PO Diflucan. I remember being taught that it was important to evaluate liver function before using it (ie. Make sure the LFTs are normal). Since that’s a pain to do for every vag itch that rolls in I routinely write for topicals instead. This makes me unpopular sometimes which is growing more and more unacceptable as we all serve our Press-Ganey masters. You just can’t write for a cream when there’s an American Dream drug (all your problems fixed with just one magic pill) out there.

So here are my questions:

Do you guys routinely check LFTs before you write for Diflucan?

Do you give it to all the women who demand it with every course of antibiotics to “prevent” a yeast infection?

On a separate but related note do you guys write for Lamisil for toenail fungus? I seem to get a ridiculous number of patients demanding that.

 

[GeneralVeers]

As my training become more and more like a Model T Ford (out of date and obsolete but not without its charm) I find myself questioning the everyday stuff I do. So I have some questions about PO Diflucan. I remember being taught that it was important to evaluate liver function before using it (ie. Make sure the LFTs are normal). Since that’s a pain to do for every vag itch that rolls in I routinely write for topicals instead. This makes me unpopular sometimes which is growing more and more unacceptable as we all serve our Press-Ganey masters. You just can’t write for a cream when there’s an American Dream drug (all your problems fixed with just one magic pill) out there.

So here are my questions:

Do you guys routinely check LFTs before you write for Diflucan?

Do you give it to all the women who demand it with every course of antibiotics to “prevent” a yeast infection?

On a separate but related note do you guys write for Lamisil for toenail fungus? I seem to get a ridiculous number of patients demanding that.

1. No

2. Yes, but I tell them it could cause liver damage, and that they must follow up with their regular doctor within one week.

3. Yes, all the time.

 

[Old Timer]

With the amount of Fluconazole I dispense on a daily basis, I doubt most of these patients are getting LFT's done.

It's personal preference. There is NO difference in effectiveness of PO fluconazole vs topical azole creams/suppositories.

 

[Seaglass]

1. no

2. yes

3. no

I usually write for one pill only. My understanding is that monitoring is important for prolonged use but not for one dose.

 

[WilcoWorld]

1.no

2.I've never been asked to Rx for this indication, so I haven't. I certainly don't do it myself, as I think a yeast infection is a treatable, non-life-threatening condition whose prophylaxis doesn't warrant Diflucan's risks. Now, if any of my patients happen to be knowledgable enough to request it then I'd gladly write for it (given no known or suspected liver disease) and place the responsibility on them to follow up.

3. no, but I probably should start...I've seen some nasty toenails (completely unrelated to chief complints) lately

 

[kungfufishing]

No

No - "If the yeast infection happens, we'll treat it, but otherwise the stuff could cause liver damage. Wouldn't you rather prevent that?"

Haven't, hopefully this gets siphoned off by fast track.

 

[willow18]

On a separate but related note do you guys write for Lamisil for toenail fungus? I seem to get a ridiculous number of patients demanding that.

Good article re toenail fungus.
http://nejm.highwire.org/cgi/content/extract/360/20/2108

• Topical therapy have pretty low cure rates in anything but mild infection.
• Systemic rates for terbinafine (Lamisil) have cure rates of 54% and 60% with 12 or 16 weeks of therapy respectively.

 

[EM2BE]

another note about the Lamisil - I know a few years ago still insurance companies wouldn't pay for the treatment of "onychomycosis" alone - but if "painful," they would pay for it. Anyone know if this is still the case?

 

[BADMD]

Do you guys routinely check LFTs before you write for Diflucan?

Do you give it to all the women who demand it with every course of antibiotics to “prevent” a yeast infection?

On a separate but related note do you guys write for Lamisil for toenail fungus? I seem to get a ridiculous number of patients demanding that.

1) No. Not for a single dose to treat vaginal candidiasis. I just ask questions to risk stratify: APAP, EtOH, chronic Hepatitis, other liver issues. It is pretty unlikely that someone will develop a clinically significant hepatitis from a single dose. If they do, it would most likely be idiosyncratic and normal LFTs probably won't make a difference (except to the lawyers).

2) No. I've had too many issues with giving one drug to prevent side effects of another.

3) Definitely not. That really requires 3+ months of therapy and does need LFT monitoring. While a few patients may disagree, onychomycosis is not an ED issue for me.

 

[12R34Y]

probably one of the more common things I give.

one dose 150mg po diflucan in ER.

no discussion with anybody about liver stuff, never tested lfts'.

they're treated, they're happy and no scripts etc..

later