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Hi all

Has anybody ever experienced any adverse patient reaction to any of these two drugs, and do they have a preference in either prescribing or requesting GP's to prescribe?

Regards

David Donovan

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Griseofulvin has a whole bunch of potential side effects, look it up.
I had most of them, 17 yrs ago. Sleep difficulties, alcohol related hassles (not from heavy drinking), UV sensitivity, short term memory problems, general feeling of poor energy levels (not normal).
Regards Phill Carter

I've come across a good many people who've taken terbinafine, and tolerated it well. In the UK GPs have not always been too keen to prescribe terbinafine, usually citing it's liver toxicity or drug interactions as the reason. However I've not found much evidence to support this (though I have to confess to not looking everywhere!). However, I suspect that its high cost was possibly the real reason for not wanting to prescribe it. After all, most drugs are excreted via the liver, & potentially hepatotoxic. The cost of terbinafine should have come down by now, as it can now be prescribed generically (I think!). Interestingly, the BNF states very few drug interactions for terbinafine. I suggest to patients that they ask for terbinafine via their GP if they have significant onychomycosis.

Both drugs have side effects. That said, my understanding is that Grisiofulvin is a far older drug, and patients have to take it over a long period, so that even if another fungicide had the same side effects (which the newer fungicides don't) they would not be as toxic simply because they are taken over a shorter period.
Cheers,
David

Many patients are rejected for terbinafine treatment that would appear well suited, others that i would not have suggested to seek systemic treatment to, may well receive a good 6 mth dose! There appears to be little in terms of standard treatment pathways. So no suprise there then.

The liver toxicity is always the stated 'contra-indication', i have found a few sources (textbooks typically) that state the type of damage to the hepatic system is completely resolved upon ceasation of terbinafine therapy?

Any more for any more (or should i not trust the beano )

regards steven

The district pharmacist at a recent branch meeting of the BChA was vehemently against oral terbinfine, and this was her advice to the local GP's in the East Anglian region, UK. It doesn't help the patients with extensive infection though (apart from avoiding any possible oral toxicity whatsoever).

Best regards,
Graeme.

What reasons did the pharmacist give for her advice about this drug? I work in East Anglia, & so far the GPs I've dealt with seem quite happy to prescribe terbinafine! :) I think I may have to dig a little deeper into this subject if I really want to find out what's behind the anti-terbinafine school of thought...

Price for one thing Sarah, I belive tebinafine is about twenty times+ more expensive than griseofulvin.

Regards

David

Hi Sarah,

The pharmacist in question advises GP's on "best practice". She thought it was like, and I quote, "using a sledgehammer to crack a nut" and prescribing a systemic drug for a perceived trivial problem was inappropriate. As for GP's still prescribing; it's up to them to take advice or not.

Cheers,
Graeme.

In Australia Oral Terbinafine is on the PBS (Government Funded) for the treatment of O/Mycosis confirmed by pathology M&C. A geat many of my patients take and tolerate it well. It is prescribed widely for the patients with diabetes and O/Myc to stop the risk of recurrent tinea pedis which can be associated with cellulitis.

About 4 years ago Oral terbinafine was taken off the PBS, but after lobbying by the Aust Diabetes Assoc, Dermatology Assoc, and the RACP as well as support from the A.Pod.C. it was returned as no other drug is as successful inthe treatment of O/Myc. Grisiofulvin is only fungistatic, so has to be taken for 18-24 month and still may not work, it has side effects of GI upset, light sensitivity ++, and can cause anhydrosis, it is also fat soluble, meaning that it must be taken with fat, eg full cream milk, it may also be hepatotoxic.

Terbinafine can also have Gi effects, most solved by having half a tablet in the morning and the other half in th pm. In 1 in 10,000 it removes the ability to taste, but that sense returns 3/12 after treatment. Terbinafine is fungicidal against dermatophtes (it is only fungistatic against yeasts) it persits in the skin for up to 3/12 after treatment finishes, but itmay still take 18-24 month before a health nail grows out, as it kills the fungus, but doesn't repair the nail. Their have been some reported hepatic effects, but less than other common antibiotics eg flucloxacillin. If in doubt ensure a LFT is performed before prescribing.

Although there are some topical alternatives (Loceryl paint) many of our patiets feet are the way they are because they can't reach them themselves, an extra tablet in the morning can be a much better option.

There have been numerous studies (Check MedLine) on the benefits of oral terbinafine over grisiofulvin. There have also been a couple of studies showing that topical terbinafine is no successful in treating O/Myc, but very successful on T.Pedis

__________________
Stephen Tucker
Calvary Health Care

My location

Thank you Stephen, this is one of things where I always mean to do some reading, but never seem to get round to it!

It seems, then, that ultimately it is the cost of terbinafine that influences the reluctance of some British GPs to prescribe it. (I checked the British National Formulary & found that Lamasil is considerably more expensive than other antifungals.) Or, I suspect, the fact that onychomycosis is considered trivial, & therefore does not justify the expense of a prescription for an expensive antifungal agent.

It is rather irritating when a patient, having been advised by me to obtain systemic antifungal treatment for troublesome o/mycosis, tells me that their GP is reluctant to prescribe terbinafine because 'it causes liver damage', when I suspect it is the cost/perceived benefit relationship that is really the issue on the prescriber's mind! But who'd be brave enough to explain that to a patient?! Especially when most GPs seem to think that the NHS podiatrists will happily take on patients who cannot manage their thick, mycotic nails! (Dream on, unless they're high risk!)

Thanks for the info, most helpful

Sarah

Are there any over the counter topical treatments for T.P? Also, what is the best choice of OTC antifungals? I'm sure that some work better than others when the patient forgets to apply it for a day.

Dear All,

Griseofulvin is an a not particularly effective drug for the t/t of mycotic infection of nail.

It has to be taken for between 1-2 years as it i has to be taken until all traces of the infected nail have been replaced by non infected normal nail.

according to

Medical Mycology

Midgley Clayton Hay

Griseofulvin is effective against Dermatophytes only.

Terbinafine is effective against Dermatophytes including deep eg Sporotrichosis and Chromoblastomycosis.

Terbinafine is not licensced for young children if memory serves me right but Griseofulvin is.
Terbinafine is not suitable for the over 50's as a liver function test may be required to ascertain pt suitability and liver tolerance. It cannot be prescribed in the presence of herpatic disease.
It is contraindiacted in certain medical conditions and is contraindiacted with many drugs. Drug interactions are an important consideration. Side effects are known and can be explained to the pt and they can ellect to take a chance. This is why in fungal toe nails you have 4 weeks and followed by the 8 weeks if you can tolerate the drug.

Pharmacists dont like to see drugs with known hazards prescribed for cosmetic reasons. They think as Graeme says a sledge hammer to crack a nut.

Fungal infected nails are usually not a health hazard for a pt but are not particularly attractive.

There are the paints but pt compliance is usually appalling so outcomes are poor.

There is or was Sporanox pulse but its use is very limited as it has a cyclical dosage and pt compliance very poor so outcomes again poor.

So what can a pt do if they are keen to t/t O/M but the gp for a variety of valid and intelligent reasons will not prescribe the drug?

And yes it does have cost implications about £45.00 for 28 days.

I would say that the drug could be prescribed but the pt would have to ffot the bill. Then i believe compliance would be greatly improved with improved outcomes as a result.

Remember the GP only prescribes the drug it is up to the pt to take the drug as prescribed for the whol course with out missing a single day.

One interesting side effect is GI disturbance and mal absorption of the contraceptive pill leading to unplanned pregnancy.

regards David

During 3rd year pharmacology this year we discussed the differences between the two medications and after looking at the pros and cons of each drug it was shown that terbiafine was a better drug in the treatment of o/mycosis, both from a pharmacological aspect as well as patient satisfaction.

One of the biggest problems of the use of Griseofulvin according to the lecturing pharmacologist is the fat solubility of the drug (requiring it to be taken orally with a fatty meal) this lead to a massive decline in compliance or incorrect administration of the drug.

After speaking to a number of patients this year in undergraduate clinics at La Trobe University none of them hade any complaints or complications from the long-term use of terbinafine.

Simon

Lamisil seems to work a treat. It comes in both a cream and a derm gel, which has an alcohol base to it. This is the topical version on terbinafine.