842. Peer reply pharmacy DB5 1 -triana DERMATOLOGY CASE STUDY Chief complaint: My right great toe has been hurting for about 2 months and now its itchy, swollen and yellow. I cant wear closed shoes and I was fine until I started going to the gym. HPI: E.D a 38 -year-old Caucasian female presents to the clinic with complaint of pain, itching, inflammation, and yellow right great toe. She noticed that the toe was moderately itching after she took a shower at the gym. She did not pay much attention. About two weeks after the itching became intense and she applied Benadryl cream with only some relief. She continued going to the gym and noticed that the itching got worse and her toe nail started to change color. She also indicated that the toe got swollen, painful and turned completely yellow 2 weeks ago. She applied lotrimin AF cream and it did not help relief her symptoms. She has not tried other remedies. Denies associated symptoms of fever and chills. 1.According to the AAFP/CDC Guidelines, what antifungal medication(s) should this patient be prescribed, and for how long? Write her complete prescriptions using the prescription writing format in your textbook. Onychomycosis is a fungal infection of the nail, either fingernail or toenail. The common dermatophyte that is found in onychomycosis is tinea unguium , with candida infections also a cause . Effective treatment usually involves months of systemic antifungal medication, commonly griseofulvin, ketoconazole ,itraconazole or terbinafine. Topical treatment is usually not effective except for ciclopirox nail lacquer (Woo & Robinson, 2016). Terbinafine 250mg 1 tab PO daily x 12 weeks Terbinafine 250mg take one tablet by mouth daily for 12 weeks 2. What labs for baseline and follow up of therapy would you order for this patient? Liver enzymes and complete blood count should be monitor every 6 weeks if treatment last longer than 6 weeks. Terbinafine is an orally and topically active allylamine fungicidal agent which is used to treat superficial fungal infections of the skin and nails. Terbinafine has been clearly linked to rare instances of acute liver injury that can be severe and sometimes fatal. Drug induced liver injury due to terbinafine was identified shortly after its introduction into medical use. Oral therapy with terbinafine is associated with elevations in serum aminotransferases in less than 1% of patients and the elevations are generally asymptomatic and resolve without stopping therapy. The estimated probability of developing elevated serum aminotransferase levels requiring stopping treatment is about 0.31% for 2 to 6 weeks’ treatment and 0.44% for treatment longer than 8 weeks (“Terbinafine”, 2019). Reference Woo, T. M., & Robinson, M. V. (2016). Pharmacotherapeutics for advance practice nurse prescribers. Philadelphia: F.A. Davis Company. Terbinafine. (2019, July 1). Retrieved September 30, 2019, from https://livertox.nlm.nih.gov/terbinafine.htm. 2- Rivera Part 2: Labs Because Terbinafine is metabolized by the liver, will be important to perform hepatic function testing for the patient due to the risk of liver enzyme elevation, and establish a baseline. Liver enzymes and complete blood count should be done every 6 weeks, during treatment (Woo and Robinson, 2016). References Woo, T. & Robinson, M., V. (2015). Pharmacotherapeutics for advanced practice nurse prescribers. Philadelphia, PA: F. A. Davis company. Follow up Specify when to refer the patient after therapy and why? Provide rationale. According to the recommended guidelines, what are the non-pharmacological approaches to Onychomycosis? Provide patient education. Keep in mind the past medical history of this patient. Patient should be referring to Podiatrist for follow up. Foot care is essential for the diabetic patient, and should definitely follow up with podiatrist for further treatment. Patient will also be referred to endocrinologist for follow up due to her history of diabetes mellitus type 2. There is no documentation that diabetes is being treated. Patient is obese which may indicate she is not following an appropriate diet. A referral will also be given to a dietician due to obesity (BMI: 31). According to Woo and Robinson Vicks VapoRub is commonly used for onychomycosis. A pilot study was conducted by Derby, Rohal, Jackson, Beutler, and Olsen (2011), to test Vicks VapoRub as a non-pharmacological approach to treat onychomycosis. The study included 18 participants and 83% had a positive response to this treatment after a course of 48 weeks. This study was done with a small sample; however Vicks VapoRub still showed to be a safe and cost-effective non-pharmacological treatment of onychomycosis (Derby, Rohal, Jackson, Beutler, and Olsen, 2011). Patient was educated on importance of an adequate diet that includes appropriate daily servings of fruits and vegetables, food low in saturated fat and low cholesterol. Patient was encouraged to continue being active, getting at least 30 minutes of regular physical activity. Also encouraged to start taking Omega 3 fatty acids to help increase her HDL which is low (38mg/dl) and this is considered a risk factor for heart disease. References Derby, R., Rohal, P., Jackson, C., Beutler, A. & Olsen, C. (2011). Novel treatment of onychomycosis using over the counter mentholated ointment: A clinical case series. Journal of the american board of family medicine (24)1 69-74. doi: 10.3122/jabfm.2011.01.100124 Woo, T. & Robinson, M., V. (2015). Pharmacotherapeutics for advanced practice nurse prescribers. Philadelphia, PA: F. A. Davis company.