ketoconazole (Nizoral, Xolegel)
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Introduction
Tradename: Nizoral.
Indications
- endemic fungal infections not responive to other antifungals or in patients intolerant to other antifungals[10]
- no longer indicated for Candida & dermatophyte infections or for skin & nail infections[10]
- blastomycosis (not severe)
- histoplasmosis (3rd line agent)
- paracoccidioidomycosis
- prophylaxis for fungal infection in immunosuppressed patients
- Acanthamoeba keratitis in combination with topical agents
- metastatic prostate cancer[11]
- Cushing's syndrome
- seborrheic dermatitis, dandruff (topical)
Contraindications
- concurrent therapy with astemizole, terfenadine, or cisapride
- acute or chronic liver disease
- treatment of nail infections (onychomycosis) & skin infections[12]
Dosage
- systemic
- topical
Cream: 2% (15 g, 30 g), 2% gel (Xelogel)
Tabs: 200 mg.
Pharmacokinetics
- absorption is dose & pH dependent
- absorption is reduced 20-40% when taken with food
- absorption is further reduced by increased gastric pH
- metabolized by liver by cyt P450 CYP3A4
- eliminated in feces
- enters sweat rapidly[6]
- elimination 1/2life is 8-10 hours, decreasing to 3-4 hours with long-term therapy
elimination via liver
1/2life = 3-10 hours
Monitor
- liver function tests baseline, after 2 weeks & monthly or more frequently in the event of symptoms[9]
- therapeutic drug monitoring: Therapeutic range:
Antimicrobial activity
- Epidermophyton floccosum
- Microsporum audouinii
- Microsporum canis
- Microsporum gypseum
- Trichophyton mentagrophytes
- Trichophyton rubrum
- Trichophyton tonsurans
- Malassezia furfur
- Malassezia ovalis
- Candida albicans
Adverse effects
- not common (1-10%)
- uncommon (< 1%)
- other
- hepatotoxicity (potentially fatal)[2][10]
- less well tolerated & more hepatotoxicity than fluconazole or itraconazole
- adrenal insufficiency[10]
- rash
Drug interactions
- astemizole, terfenadine, cisapride in combination
- CONTRAINDICATED
- may result in prolongation of QT interval with risk of torsades de pointes
- ketoconazole may increase the anticoagulant effects of warfarin
- alcohol in combination may result in flushing & tachycardia
- ketoconazole increases plasma levels of:
- antacids, H2-receptor antagonists, proton pump inhibitors in combination may decrease absorption by as much as 60%
- didanosine (ddI) in combination may decrease ketoconazole levels; take at least 2 hours apart
- indinavir in combination may affect levels of both
- isoniazid SHOULD NOT BE USED in combination
- decreased ketoconazole levels
- ritonavir SHOULD NOT BE USED in combination
- increased risk of toxicity
- any drug that inhibits cyt P450 CYP3A4 may increase levels of ketoconazole
- any drug that induces cyt P450 CYP3A4 may diminish levels of ketoconazole
- ketoconazole inhibits cyt P450 CYP3A4 & CYP2C9 (weakly)
- inhibits its own metabolism
- inhibits metabolism of other cyt P450 CYP3A4 substrates
- inhibits metabolism of cyt P450 CYP2C9 substrates
- drug interaction(s) of antibiotics with warfarin
- drug interaction(s) of eplerenone with ketoconazole
Laboratory
Mechanism of action
- generally fungistatic
- may be fungicidal at high concentrations
- inhibits synthesis of fungal cell wall ergosterol by inhibiting fungal cyt P450
- inhibits cyt P450 CYP3A4
- inhibits synthesis of adrenal steroids
- inhibits synthesis of testosterone
More general terms
Component of
- ketoconazole/salicylic acid
- ketoconazole/phytosphingosine
- chlorhexidine/ketoconazole/salicyloyl phytosphingosine
- chlorhexidine/cortisol/ketoconazole
- acetic acid/chlorhexidine/ketoconazole
- ketoconazole/zinc pyrithione
- ketoconazole/lactic acid/salicylic acid
- chloroxylenol/ketoconazole
- chlorhexidine/ketoconazole
- cortisol/ketoconazole
References
- ↑ The Pharmacological Basis of Therapeutics, 9th ed. Gilman et al, eds. Permagon Press/McGraw Hill, 1996
- ↑ 2.0 2.1 Medical Knowledge Self Assessment Program (MKSAP) 11, American College of Physicians, Philadelphia 1998
Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022 - ↑ Drug Information & Medication Formulary, Veterans Affairs, Central California Health Care System, 1st ed., Ravnan et al eds, 1998
- ↑ Kaiser Permanente Northern California Regional Drug Formulary, 1998
- ↑ Prescriber's Letter 13(3): 2006 Cytochrome P450 drug interactions Detail-Document#: http://prescribersletter.com/(5bhgn1a4ni4cyp2tvybwfh55)/pl/ArticleDD.aspx?li=1&st=1&cs=&s=PRL&pt=3&fpt=25&dd=220233&pb=PRL (subscription needed) http://www.prescribersletter.com
- ↑ 6.0 6.1 6.2 Prescriber's Letter 11(2):11 2004 Detail-Document#: http://prescribersletter.com/(5bhgn1a4ni4cyp2tvybwfh55)/pl/ArticleDD.aspx?li=1&st=1&cs=&s=PRL&pt=3&fpt=25&dd=200208&pb=PRL (subscription needed) http://www.prescribersletter.com
- ↑ 7.0 7.1 Prescriber's Letter 13(10): 2006 New Formulation: Xolegel (Ketoconazole Gel 2%) Detail-Document#: http://prescribersletter.com/(5bhgn1a4ni4cyp2tvybwfh55)/pl/ArticleDD.aspx?li=1&st=1&cs=&s=PRL&pt=3&fpt=25&dd=221009&pb=PRL (subscription needed) http://www.prescribersletter.com
- ↑ 8.0 8.1 deprecated reference
- ↑ 9.0 9.1 Prescriber's Letter 17(7): 2010 Recommended Lab Monitoring for Common Medications Liver Function Test Scheduling Detail-Document#: http://prescribersletter.com/(5bhgn1a4ni4cyp2tvybwfh55)/pl/ArticleDD.aspx?li=1&st=1&cs=&s=PRL&pt=3&fpt=25&dd=260704&pb=PRL (subscription needed) http://www.prescribersletter.com
- ↑ 10.0 10.1 10.2 10.3 10.4 FDA MedWatch. July 26, 2013 Nizoral (ketoconazole): Drug Safety Communication - Potentially Fatal Liver Injury, Risk of Drug Interactions and Adrenal Gland Problems. http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm362672.htm
- ↑ 11.0 11.1 Matin K and Trump DL, Prostate Cancer, In: Geriatric Medicine: An Evidence-Based Approach, 4th ed, Cassel CK et al (eds), Springer-Verlag, New York, 2003
- ↑ 12.0 12.1 FDA Safety Alert. May 19, 2016 Nizoral (ketoconazole) Oral Tablets: Drug Safety Communication
Prescribing for Unapproved Uses including Skin and Nail Infections Continues; Linked to Patient Death. http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm502073.htm