- ACRONYMS AND DEFINITIONS
- AAP - American Academy of Pediatrics
- CDC - Centers for Disease Control and Prevention
- CTE - dosing based on clinical trial(s) and/or expert opinion
- IDSA - Infectious Disease Society of America
- PI - Dosing from Package Insert
Terbinafine (Lamisil®)
Dosage forms
Tablet
- 250 mg ($)
Cream, OTC
- 1% cream ($)
Spray, OTC
- 1% spray ($)
Dosing
Pediatric (≥ 2 years)
- Tinea capitis
- Terbinafine tablets NOTE: Tablet dosing based on one study [PMID 12195561]
- Weight 10 - 20 kg: 62.5 mg daily for 4 weeks
- Weight 20 - 40 kg: 125 mg daily for 4 weeks
- Weight > 40 kg: 250 mg daily for 4 weeks
- Terbinafine granules NOTE: Terbinafine granules are FDA-approved for children ≥ 4 years old
- Weight < 25 kg: 125 mg daily for 6 weeks
- Weight 25 - 35 kg: 187.5 mg daily for 6 weeks
- Weight > 35 kg: 250 mg daily for 6 weeks (PI)
- Tinea corporis / pedis / cruris / manuum
- Terbinafine tablets NOTE: Tablet dosing based on study in children ≥ 2 years old with tinea capitis [PubMed 12195561]
- Weight 10 - 20 kg: 62.5 mg daily for 2 - 4 weeks
- Weight 20 - 40 kg: 125 mg daily for 2 - 4 weeks
- Weight > 40 kg: 250 mg daily for 2 - 4 weeks ($)
- Tinea versicolor - topical terbinafine applied twice daily for one week (CTE) NOTE: Oral terbinafine is not effective for tinea versicolor
Adults
- Onychomycosis (toenails) - 250 mg once daily for 12 weeks (PI)
- Onychomycosis (fingernails) - 250 mg once daily for 6 weeks (PI)
- Tinea capitis - 250 mg once daily for 4 weeks (CTE)
- Tinea corporis / pedis / cruris / manuum
- 250 mg once daily for 2 - 4 weeks (CTE)
- Tinea versicolor - topical terbinafine applied twice daily for one week (CTE) NOTE: Oral terbinafine is not effective for tinea versicolor
Other
- May take without regard to food
- Terbinafine granules are FDA-approved in children ≥ 4 years. Terbinafine tablets have been used in children as young as 2 years - (See PubMed 12195561)
- Terbinafine is a moderate CYP2D6 inhibitor
- May cause taste and smell disturbances
- Manufacturer recommends pretreatment transaminases (AST, ALT). If normal, start therapy and recheck if the patient develops clinical signs of liver disease (e.g. persistent nausea, jaundice, dark urine, abdominal pain).
- Kidney disease
- CrCl ≤ 50 ml/min: clearance decreased by 50%. Manufacturer makes no specific dosage recommendations.
Fluconazole (Diflucan®)
Dosage forms
Tablet
- 50 mg ($)
- 100 mg ($)
- 150 mg ($)
- 200 mg ($)
Suspension
- 50 mg/5 ml ($)
- 200 mg/5 ml ($)
Dosing
Pediatric
- Tinea capitis
- 6 mg/kg once daily for 2 - 3 weeks
- Based on PMID 10468805
- Alternative:
- 8 mg/kg once weekly for 8 - 12 weeks
- Based on PMID 10809856
- Tinea corporis / pedis / cruris / manuum
- 6 mg/kg (max 150 mg) once weekly for 2 - 4 weeks (PI, CTE)
Adults
- Tinea corporis / pedis / cruris / manuum
- 150 - 200 mg once weekly for 2 - 4 weeks (CTE)
- Yeast infection (vulvovaginal candidiasis)
- Single episode - 150 mg single dose (CDC)
- Prolonged episodic therapy (for recurrent cases) - 100 - 200 mg every third day for a total of 3 doses (CDC)
- Maintenance therapy (for recurrent cases) - 100 - 200 mg once weekly for 6 months (CDC)
- Tinea versicolor - 300 mg once weekly for 2 weeks (CTE)
Other
- May take without regard to food
- Fluconazole is a CYP2C19 strong inhibitor, CYP2C9 moderate inhibitor, and CYP3A4 moderate inhibitor. It has many potential drug interactions. See Diflucan PI and the Drugs.com interactions checker for more.
- Kidney disease
- CrCl ≤ 50 ml/min - give half of recommended dose
- Regular dialysis - give full dose after each dialysis; on non-dialysis days give half recommended dose
- Liver disease - fluconazole can be hepatotoxic. Use caution in patients with liver disease.
Studies
Pregnancy risk
- Oral Fluconazole Use in the First Trimester and Risk of Congenital Malformations, BMJ (2020) [PubMed abstract]
- Oral fluconazole during pregnancy and risk of spontaneous abortion and stillbirth, JAMA (2016) [PubMed abstract]
- Fluconazole during pregnancy and occurrence of spontaneous abortions, major congenital malformations, and stillbirths, CMAJ (2019) [PubMed abstract]
Itraconazole (Sporanox®)
Dosage forms
Capsule
- 100 mg ($)
Capsule (Tolsura®)
- 65 mg ($$$$)
Tablet (Onmel®)
- 200 mg ($$$$)
Solution
- 10 mg/ml ($$-$$$)
Dosing
Pediatric (infants)
- Tinea capitis
- 5 mg/kg once daily for 3 - 6 weeks
- Dosing based on one small study [PMID 19453785]
Pediatric (≥ 1 year)
- Tinea capitis
- 5 mg/kg once daily for 2 - 4 weeks
- Alternative:
- Weight < 20 kg: 50 mg once daily for 4 weeks
- Weight > 20 kg: 100 mg once daily for 4 weeks
- Based on PMID 11069511
Adults
- Onychomycosis (toenails) - 200 mg once daily for 12 weeks OR a cycle of 200 mg twice daily for 1 week followed by 3 weeks off. Perform a total of 3 cycles (3 months). (PI, CTE)
- Onychomycosis (fingernails) - A cycle of 200 mg twice daily for 1 week followed by 3 weeks off. Perform a total of 2 cycles (2 months). (PI)
- Tinea corporis / pedis / cruris / manuum
- 200 mg once a day for 7 days (CTE)
- Tinea versicolor - 200 mg once daily for 5 - 7 days (CTE)
Adults (Tolsura®)
- NOTE: Tolsura is not interchangeable or substitutable with other itraconazole products due to differences in dosing
- Blastomycosis and Histoplasmosis - 130 mg once daily. If no obvious improvement, or there is evidence of progressive fungal disease, the dose should be increased in 65 mg increments to a maximum of 130 mg twice daily. Doses above 130 mg/day should be given in two divided doses.
- Aspergillosis - 130 mg once daily. Increase to 130 mg twice daily if necessary.
- NOTE: Tolsura is not indicated for the treatment of onychomycosis
Other
- Take with a full meal
- Itraconazole is contraindicated in patients with heart failure because it has negative inotropic effects
- Itraconazole is a strong CYP3A4 inhibitor and P-glycoprotein inhibitor. It has many potential drug interactions. See the Sporanox PI and the Drugs.com interactions checker for more.
- Kidney disease - Has not been studied extensively. Use caution.
- Liver disease - Has not been studied extensively. Use caution.
Oteseconazole (Vivjoa®)
Dosage forms
Capsule
- 150 mg ($$$$)
- Comes in carton with 18 capsules
Dosing
Recurrent vulvovaginal candidiasis in females who are NOT of reproductive potential
- Vivjoa-only regimen
- On Day 1: 600 mg as a single dose
- On Day 2: 450 mg as a single dose
- Beginning on Day 14: 150 mg once weekly for 11 weeks
- Take with food. Do not chew, crush, dissolve, or open the capsules.
- Fluconazole/Vivjoa regimen
- On Day 1, Day 4, and Day 7: fluconazole 150 mg
- On Days 14 through 20: Vivjoa 150 mg once daily for 7 days
- Beginning on Day 28: Vivjoa 150 mg once weekly for 11 weeks
- Take with food. Do not chew, crush, dissolve, or open the capsules.
- See recurrent yeast infections for more
Other
- Females of reproductive potential - DO NOT GIVE. May cause fetal harm.
- Pregnant and lactating women - DO NOT GIVE. May cause fetal harm.
- BCRP substrates - oteseconazole is a BCRP inhibitor and may increase exposure to BCRP substrates (e.g. rosuvastatin). Consider reducing the dose of the concomitant substrate when combining.
- Kidney disease
- CrCl ≥ 30 ml/min: no dose adjustment necessary
- CrCl < 30 ml/min: has not been studied. Not recommended.
- Liver disease
- Child-Pugh A: no dose adjustment necessary
- Child-Pugh B/C: has not been studied. Not recommended.
Studies
Posaconazole (Noxafil®)
Dosage forms
Tablet, delayed-release
- 100 mg ($$$$)
Oral suspension
- 40 mg/ml ($$$$)
- Comes in 105 ml bottle
Dosing
Adults and children ≥ 13 years
- Prophylaxis of invasive Aspergillus and Candida infections
- Tablets, delayed-release
- Loading dose: 300 mg twice a day on the first day
- Maintenance: 300 mg once daily starting on the second day. Duration of therapy is based on recovery from neutropenia or immunosuppression.
- Oral suspension
- Dosing: 200 mg (5 ml) three times a day. Duration of therapy is based on recovery from neutropenia or immunosuppression.
- Oropharyngeal candidiasis (oral suspension only)
- Loading dose: 100 mg (2.5 mL) twice a day on the first day
- Maintenance: 100 mg (2.5 mL) once a day for 13 days.
- Oropharyngeal candidiasis refractory to itraconazole and/or fluconazole (oral suspension only)
- Dosing: 400 mg (10 mL) twice a day. Duration of therapy should be based on the severity of the patient's underlying disease and clinical response.
Other
- Take tablet with food to enhance absorption. Take oral suspension with a full meal or with a liquid nutritional supplement or an acidic carbonated beverage (e.g., ginger ale) in patients who cannot eat a full meal.
- Swallow tablets whole. Do not divide, crush, or chew.
- Posaconazole is a CYP3A4 strong inhibitor and has many potential drug interactions. See Noxafil PI [sec7] and Drugs.com interactions checker for more.
- Posaconazole is primarily metabolized via UDP glucuronosyltransferase, and it is a P-glycoprotein substrate
- Kidney disease - no dose adjustment necessary
- Liver disease - no dose adjustment necessary
Griseofulvin | Grifulvin V® | Gris-Peg®
Griseofulvin microsize
Tablet (Grifulvin V®)
- 250 mg (?)
- 500 mg ($$)
Suspension
- 125 mg/5 ml (600 ml $$)
Griseofulvin ultramicrosize
Tablet (Gris-Peg®)
- 125 mg ($-$$)
- 250 mg ($$)
Dosing
Pediatric (Infants)
- NOTE: Dosing based on small case studies [PMID 22468173]
- Tinea capitis
- Griseofulvin microsize
- 15 mg/kg once daily for 45 - 60 days
- Griseofulvin ultramicrosize
- 10 mg/kg once daily for 30 - 60 days
Pediatric
- Tinea capitis
- Griseofulvin microsize
- 20 - 25 mg/kg once daily for 6 - 8 weeks (CTE)
- Griseofulvin ultramicrosize
- 10 - 15 mg/kg once daily for 6 - 8 weeks (CTE)
- Tinea corporis
- Griseofulvin microsize
- 10 mg/kg once daily (max 500 mg/day) for 2 - 4 weeks (PI)
- Griseofulvin ultramicrosize
- 7.25 mg/kg once daily (max 375 mg/day) for 2 - 4 weeks (PI)
- Tinea pedis
- Griseofulvin microsize
- 10 mg/kg once daily (max 500 mg/day) for 4 - 8 weeks (PI)
- Griseofulvin ultramicrosize
- 7.25 mg/kg once daily (max 375 mg/day) for 4 - 8 weeks (PI)
Adults
- Tinea capitis
- Griseofulvin microsize
- 500 mg once daily for 6 - 8 weeks (CTE)
- Griseofulvin ultramicrosize
- 375 mg once daily for 6 - 8 weeks (CTE)
- Tinea corporis
- Griseofulvin microsize
- 500 mg once daily for 2 - 4 weeks (PI)
- Griseofulvin ultramicrosize
- 375 mg once daily for 2 - 4 weeks (PI)
- Tinea pedis
- Griseofulvin microsize
- 500 mg once daily for 4 - 8 weeks (PI)
- Griseofulvin ultramicrosize
- 375 mg twice daily for 4 - 8 weeks (PI)
- Onychomycosis - toenails
- Griseofulvin microsize
- 500 mg once daily for 6 months (PI)
- Griseofulvin ultramicrosize
- 375 mg twice daily for 6 months (PI)
- Onychomycosis - fingernails
- Griseofulvin microsize
- 500 mg once daily for 4 months (PI)
- Griseofulvin ultramicrosize
- 375 mg twice daily for 4 months (PI)
Other
- May take without regard to food
- Gastrointestinal upset is common
- May cause photosensitivity. Limit sun exposure and use sunscreen.
- Lab monitoring (CBC, ALT, AST) during griseofulvin treatment does not appear to be necessary in healthy patients during shorter courses of therapy (≤ 8 weeks)
- Kidney disease - manufacturer makes no dosage recommendations
- Liver disease - manufacturer makes no dosage recommendations
Ibrexafungerp (Brexafemme®)
Tablet
- 150 mg ($$$$)
- Comes in carton with 4 tablets
Dosing
Vulvovaginal candidiasis (adults and postmenarchal pediatric females)
- Dosing: two 300 mg doses (two 150 mg tablets) given 12 hours apart
- May take without regard to food
- DO NOT GIVE in pregnancy
- See yeast infections for more
Reduction in the incidence of recurrent vulvovaginal candidiasis
- Dosing: two 300 mg doses (two 150 mg tablets) given 12 hours apart for one day every month for six months
- May take without regard to food
- DO NOT GIVE in pregnancy
- See recurrent yeast infections for more
With CYP3A4 strong inhibitors
- Dosing: two 150 mg doses given 12 hours apart
- See CYP3A4 inhibitors
- No dose adjustment necessary with weak or moderate CYP3A4 inhibitors
Other
- PREGNANCY - DO NOT GIVE. May cause fetal harm. Confirm that the patient is not pregnant before each dose. Patients should use contraception throughout the treatment period and for 4 days after the last dose.
- Ibrexafungerp is a triterpenoid antifungal that works by inhibiting glucan synthase, an enzyme involved in the formation of 1,3-β-D-glucan, an essential component of the fungal cell wall
- Ibrexafungerp is a CYP3A4 sensitive substrate. Reduce dose when given with CYP3A4 strong inhibitors (see above). It is not recommended with strong or moderate CYP3A4 inducers.
- Kidney disease - manufacturer makes no recommendation
- Liver disease
- Child-Pugh A/B: no dose adjustment necessary
- Child-Pugh C: has not been studied
Studies
- PRICE ($) INFO
Pricing legend
- $ = 0 - $50
- $$ = $51 - $100
- $$$ = $101 - $150
- $$$$ = > $151
- Pricing based on one month of therapy at standard dosing in an adult
- Pricing based on information from GoodRX.com®
- Pricing may vary by region and availability
- BIBLIOGRAPHY
- 1 - PMID 24918220
- 2 - PMID 22468173