Ketoconazole

About Ketoconazole

Ketoconazole impairs the fungi’s production of ergosterol, a vital part of their cell membranes. The cream is labeled for ringworm, jock itch, athlete’s foot, tinea versicolor and skin yeast infections, once a day for two weeks (six for athlete’s foot), and for seborrheic dermatitis twice a day for four weeks. The prescription 2 percent shampoo treats tinea versicolor with one application left on damp skin for five minutes; the foam treats seborrheic dermatitis in people 12 and older with a normal immune system, twice a day for four weeks; and the 1 percent shampoo sold over the counter controls dandruff from age 12, used every three or four days for up to eight weeks, then only as needed. The tablets are approved only for blastomycosis, coccidioidomycosis, histoplasmosis, chromomycosis and paracoccidioidomycosis when other treatment has failed or is not tolerated: adults take 200 mg once a day, raised to 400 mg if needed, usually for six months or longer, and they have not been studied in children under 2.

Under boxed warnings, the tablets have caused serious liver injury, including deaths and transplants, sometimes in people with no obvious risk factor for liver disease, so liver and hepatitis tests come before the first dose and ALT, a liver enzyme, is checked weekly; treatment is interrupted if it rises or symptoms appear. They raise the levels of drugs such as dofetilide, quinidine, pimozide, methadone, dronedarone and ranolazine, which can prolong the QT interval and cause dangerous heart rhythms, so those combinations are not allowed. They are not taken with liver disease, and the label says they are not for nail fungus, ringworm-type skin infections, Candida infections or fungal meningitis. Doses of 400 mg and above lower the body’s own steroid output, they lower testosterone, alcohol is avoided, and nausea, headache, diarrhea and stomach pain are the most common side effects. Side effects reported with the cream and foam were mainly irritation, itching, stinging or burning; the cream contains sodium sulfite, which can trigger allergic reactions and asthma attacks in sensitive people, and the 2 percent shampoo has been reported to change hair color or texture.

A Medication Guide comes with every tablet fill, Cushing’s syndrome and prostate cancer are not approved uses, mothers taking the tablets should not breastfeed, and the tablet, cream and shampoo labels advise use in pregnancy only if the benefit justifies the risk. The foam is flammable, so no flames or smoking during and right after use. FDA has determined that the discontinued Nizoral tablets, cream and 2 percent shampoo and Extina foam were not withdrawn for safety or effectiveness reasons; Xolegel has no approved generic, and Nizoral Anti-Dandruff 1 percent shampoo is still sold over the counter.

Taking Ketoconazole

How to take it

Tablets: once a day at around the same time until the prescriber says to stop; if you also take an acid-lowering medicine, the label advises taking the tablet with an acidic drink such as non-diet cola. Cream: spread over and around the affected skin as prescribed. Prescription shampoo: lather onto damp skin, leave it five minutes and rinse; foam: dispense it into the cap or onto a cool surface, not directly onto the hands, where it starts to melt.

If you miss a dose

Take or apply a missed dose as soon as you remember, unless the next one is nearly due; then skip it. Do not take a double dose to make up for a missed one.

Storage

At room temperature, tightly closed, away from heat, moisture and light, out of reach of children. Keep the flammable foam can below 120°F (49°C), and do not puncture or burn it.

Interactions to know about

The tablets must not be combined with many drugs, including lovastatin, simvastatin, eplerenone, triazolam, alprazolam, oral midazolam and ergot drugs, and strong inducers such as rifampin, carbamazepine and phenytoin are avoided. Acid reducers lower absorption, and antacids are taken at least 1 hour before or 2 hours after a tablet. Tell the prescriber about every medicine, and about a sulfite allergy or asthma before using the cream.

This summarizes the official prescribing information. Your prescriber’s and pharmacist’s instructions, and the leaflet that comes with your medicine, take priority.

Why the cash price for Ketoconazole differs from pharmacy to pharmacy

Generic tablets, cream, 2 percent shampoo and foam each come from more than one maker, so quotes for the same product differ mainly in each pharmacy’s dispensing fee and markup and in the size written.

Foam, cream and shampoo are separate products that a pharmacist cannot exchange without the prescriber. The 1 percent shampoo is sold over the counter, while the 2 percent shampoo is a prescription product.

Ways to pay less for Ketoconazole without insurance

• Ask for the generic. Xolegel gel is discontinued and has no generic, so a prescription for it would have to be changed by the prescriber.
• For dandruff, ask the prescriber whether the 1 percent shampoo sold over the counter would do; the 2 percent shampoo is labeled only for tinea versicolor.
• If the foam is quoted high, ask the prescriber whether the cream, also labeled for seborrheic dermatitis, would suit you.
• Upload the prescription to Script Unlock so licensed pharmacies can quote their cash price. You pay the pharmacy directly.

Questions to ask your pharmacist about Ketoconazole

1. 1.Is my prescription for the cream, foam or shampoo, and is the generic the same strength?
2. 2.Which of my medicines cannot be taken with ketoconazole tablets?
3. 3.When will my liver tests be done while I take the tablets?
4. 4.Does my cream contain a sulfite, and does that matter if I have asthma?

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