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Ketoconazole

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261. Management of Patients on Non?Vitamin K Antagonist Oral Anticoagulants in the Acute Care and Periprocedural Setting: A Scientific Statement From the American Heart Association Full Text available with Trip Pro

in the Acute Care and Periprocedural Setting Circulation. 2017;135:e604–e633. DOI: 10.1161/CIR.0000000000000477 March 7, 2017 e609 CLINICAL STATEMENTS AND GUIDELINES Table 2. NOAC Drug Interactions NOAC Interacting Medications Effect on NOAC Labeled Guidance; Comments Dabigatran P-gp inducer: rifampin ? Dabigatran exposure Concomitant use should generally be avoided. P-gp inhibitors: ketoconazole, dronedarone ? Dabigatran exposure if concomitant moderate renal impairment If moderate renal impairment (CrCl (...) 30–50 mL/min) ? to 75 mg BID during concomitant use P-gp inhibitors: ketoconazole, dronedarone, verapamil, amiodarone, quinidine, clarithromycin, ticagrelor ? Dabigatran exposure if concomitant severe renal impairment If severe renal impairment (CrCl 15–30 mL/ min) avoid concomitant use Apixaban Strong dual P-gp and CYP3A4 inducers: rifampin, carbamazepine, phenytoin, St. John’s wort ? Apixaban exposure Avoid concomitant use Strong dual P-gp and CYP3A4 inhibitors: ketoconazole, itraconazole

2017 American Heart Association

264. CRACKCast E076 – Pneumonia

Blastomyces dermatitidis – blastomycosis Coccidioides immitis – coccidiodomycosis Treatment: This is a super important differential to think of in the patient with “non-resolving” pneumonia Get help from ID and Respirology (need a bronchcoscopy) Managed with: Amphotericin B, Azoles (itraconazole, ketoconazole, fluconazole, etc) Pneumocystis pneumonia (PCP) Occurs in immunocompro- mised hosts, principally people with immune deficiency syndrome (AIDS) or malignancy. Pneumocystis jiroveci (previously known

2017 CandiEM

265. Edoxaban for preventing stroke and systemic embolism in people with non-valvular atrial fibrillation

of the following clinical factors: moderate or severe renal impairment (creatinine clearance 15–50 ml/min); body weight of 60 kg or less; concomitant use of the P-glycoprotein inhibitors ciclosporin, dronedarone, erythromycin or ketoconazole. 2.2 The summary of product characteristics includes the following adverse reactions for edoxaban: bleeding, anaemia, nausea, rash, hepatobiliary disorders (increased blood bilirubin and gamma-glutamyl transferase) and abnormal liver function test. For full details

2015 National Institute for Health and Clinical Excellence - Technology Appraisals

266. Balanitis: Topical imidazoles

preparations, clinically relevant interactions are rare. The effect of oral anticoagulants (such as warfarin) may be enhanced by topical miconazole or econazole. Monitor the person’s international normalised ratio (INR) during concurrent use of topical miconazole or econazole with an oral anticoagulant, and adjust the warfarin dose accordingly. There are no known significant drug interactions with topical clotrimazole or ketoconazole. [ ; ] Application regimens Topical clotrimazole 1% is licensed (...) to the affected area twice daily for at least two weeks. Topical ketoconazole 2% is licensed for the treatment of fungal infections of the skin. Advise the person to apply topical ketoconazole to the affected area once or twice daily. Treatment should be continued for a few days after the lesions have disappeared. [ ; ; ; ; ] © .

2020 NICE Clinical Knowledge Summaries

267. Chronic obstructive pulmonary disease: Beta-2 agonists

be increased by other potassium-depleting drugs such as corticosteroids, loop diuretics, and theophylline, amiodarone, and SSRIs. Digoxin — monitor potassium levels and be alert to signs of digoxin toxicity, such as loss of appetite, nausea, vomiting, bradycardia, visual disturbance, and drowsiness. Non-selective B-blocking drugs such as propranolol — manufacturer recommends avoid. CYP3A4 inhibitors (such as ketoconazole) — may increase plasma levels of salmeterol and associated systemic effects. For more

2020 NICE Clinical Knowledge Summaries

268. Palliative care - nausea and vomiting: Prescribing a prokinetic

such as syncope or tachyarrhythmias arise during treatment. Should be avoided in people who are taking medication that prolongs the QT interval such as ketoconazole and erythromycin. Should be prescribed with caution in people aged over 60 years and people who have existing prolongation of cardiac conduction intervals (particularly the QTc interval), electrolyte disturbance, and an underlying cardiac disease (such as congestive heart failure). These recommendations are based mainly on palliative care

2020 NICE Clinical Knowledge Summaries

269. Palliative care - oral: Scenario: Prevention

and frequencies of antifungals used in trials vary. Fluconazole 50 to 400 mg daily is licensed (in adults) for prevention of fungal infections in immunocompromised people. Fluconazole 400 mg daily is licensed if the risk of systemic infections is high, for example following bone-marrow transplantation. Itraconazole is licensed (in adults) for prevention of deep fungal infections in special circumstances (see the Summary of Product Characteristics [SPC] for more information). Ketoconazole 200 mg daily (...) is licensed (in adults) for prophylaxis in immunosuppressed people. The European Medicines Agency’s (EMA) Committee for Medicinal Products for Human Use (CHMP) has suspended the marketing authorisation for oral ketoconazole, and it should no longer be used for the treatment of fungal infections [ ]. The decision was made because some people taking these medicines may be at an increased risk of liver damage and the risk outweighs the benefits. Alternative anti-fungal treatments are available. Miconazole 20

2020 NICE Clinical Knowledge Summaries

270. Hyperthyroidism: Beta-blockers

of metoprolol possibly increased; increased risk of AV block. Specific drug interactions with nadolol include: Ketoconazole — plasma concentration of nadolol possibly increased. [ ] © .

2020 NICE Clinical Knowledge Summaries

271. Hypertension in pregnancy: Nifedipine

inhibitors including macrolide antibiotics (such as erythromycin), HIV protease inhibitors (such as ritonavir), azole antimycotics (such as ketoconazole), fluoxetine, nefazodone, valproic acid, cimetidine, diltiazem, and grapefruit juice — can lead to increased plasma concentration of nifedipine. Cytochrome P450 inducers such as phenytoin, carbamazepine, and phenobarbital — can lead to decreased plasma concentration of nifedipine. [ ; ] Dosing information A modified-release preparation should be used

2020 NICE Clinical Knowledge Summaries

272. Dyspepsia - proven GORD: Proton pump inhibitors

is started or stopped. Methotrexate — PPIs possibly reduce excretion of methotrexate, leading to an increased risk of methotrexate toxicity. Phenytoin — omeprazole and esomeprazole can occasionally enhance the effects of phenytoin. The manufacturers recommend that people taking phenytoin are carefully monitored if omeprazole or esomeprazole is started or stopped. Azole antifungals — the absorption of ketoconazole or itraconazole may be reduced during PPI treatment. Dose adjustment of the antifungal drug

2020 NICE Clinical Knowledge Summaries

273. Dyspepsia - proven GORD: H2-receptor antagonists

acidity, the absorption of ketoconazole or itraconazole may be reduced if taken with an H 2 RA. Protease inhibitors — atazanavir plasma levels are reduced by H 2 RAs. The manufacturer of atazanavir advises adjustment of the doses of both drugs when given with an H 2 RA. Seek specialist advice as needed. [ ] © .

2020 NICE Clinical Knowledge Summaries

274. Seborrhoeic dermatitis: What over-the-counter products are available for the treatment of seborrhoeic dermatitis?

-the-counter products available for the treatment of seborrhoeic dermatitis are outlined in Table 1. Table 1 . Shampoo preparations available for seborrhoeic dermatitis include*: Proprietary name Active ingredient(s) Mode of action of ingredients Ketoconazole 2%† Ketoconazole 2%† Antifungal Alphosyl 2 in 1® Alcoholic coal tar extract 5% Anti-eczematous, antipruritic, antimitotic Capasal® Coal tar 1%, Coconut oil 1%,Salicylic acid 0.5% Anti-eczematous, antipruritic, antimitotic; emollient, softening agent (...) , emollient, softening agent, and lubricant * This list is not exhaustive. † Ketoconazole shampoo is only licensed for use in adolescents and adults [ ; ]. © .

2020 NICE Clinical Knowledge Summaries

275. Seborrhoeic dermatitis: Topical imidazoles

Seborrhoeic dermatitis: Topical imidazoles Topical imidazoles | Prescribing information | Seborrhoeic dermatitis | CKS | NICE Search CKS… Menu Topical imidazoles Seborrhoeic dermatitis: Topical imidazoles Last revised in February 2019 Topical imidazoles What should I be aware of before prescribing topical ketoconazole or another imidazole? Ketoconazole cream (for adults) and shampoo (for adolescents and adults only) [ ; ; ] Cautions and contraindications Hypersensitivity to the active (...) substance or to any of the excipients. Avoid contact with eyes and mucous membranes. Use in children — limited data on the use of ketoconazole 2% cream in paediatric patients. Adverse effects Skin reactions, folliculitis and hair changes. Eye irritation. Drug Interactions Systemic absorption can follow topical application, the possibility of interactions with topical ketoconazole should be borne in mind. Pregnancy and breastfeeding No adequate and well-controlled studies in pregnant or lactating women

2020 NICE Clinical Knowledge Summaries

276. Seborrhoeic dermatitis: Scenario: Seborrhoeic dermatitis - face and body

Eczema Association — . For adults, treat seborrhoeic dermatitis of the face and body with: Ketoconazole 2% cream (once or twice a day) or another imidazole cream (clotrimazole or miconazole) for at least 4 weeks. An antifungal shampoo such as ketoconazole 2% can be used as body wash. Advise the person that once they feel symptoms are under control, ketoconazole cream can be used less frequently (for example twice a week, once a week, once every other week) to prevent recurrence. Consider adding (...) on . For children and adolescents, treat seborrhoeic dermatitis of the face and body with: An imidazole cream (clotrimazole [2–3 times per day] or miconazole [twice daily]) for up to 4 weeks. Ketoconazole cream is not licenced for use in children. Consider adding in a mildly potent topical corticosteroid such as hydrocortisone 0.5% or hydrocortisone 1% for flares to help settle inflammation. Mild topical corticosteroids should only be used short-term (one week) — consider potential for adverse effects

2020 NICE Clinical Knowledge Summaries

277. Seborrhoeic dermatitis: Scenario: Seborrhoeic dermatitis - scalp and beard

Eczema Association — . Treat seborrhoeic dermatitis of the scalp and beard in adolescents and adults with: Ketoconazole 2% shampoo (twice a week for 4 weeks, then once every 1-2 weeks for maintenance) or selenium sulphide shampoo (twice a week for 2 weeks [contraindicated in pregnancy]). Scales can be removed before shampooing by applying warm mineral or olive oil (for mild crusting) or a keratolytic preparation (for example salicylic acid and coconut oil for thicker scale) for several hours before (...) shampooing. Shampoo should be left on for 5 minutes before rinsing off. Other medicated shampoos such as zinc pyrithione, coal tar, or salicylic acid can be used, if ketoconazole or selenium sulphide are not appropriate or acceptable to the person — many preparations can be purchased over the counter. For more information see the section on . If the person has severe itching of the scalp: Consider co-prescribing a short course (maximum 4 weeks of treatment) of a topical corticosteroid scalp application

2020 NICE Clinical Knowledge Summaries

278. Seborrhoeic dermatitis: Scenario: Seborrhoeic dermatitis - infants

-limiting and resolves by four months of age. In some babies it may persist for 8–12 months (or longer) [ ; ; ]. Topical preparations CKS has extrapolated recommendations on frequency of application of clotrimazole and miconazole cream from the British National Formulary [ ] and the manufacturers' Summaries of Product Characteristics [ ; ]. Ketoconazole is not licenced for use in infants [ ]. Recurrence CKS could find no systematic reviews of the treatment of recurrent episodes of seborrhoeic dermatitis

2020 NICE Clinical Knowledge Summaries

279. Contraception - combined hormonal methods: Scenario: Combined vaginal ring

(such as fluconazole, itraconazole, ketoconazole, voriconazole) — modest increase in plasma levels of oestrogens and/or progestogens. Possible increased risk of adverse effects. Vaginally administered antifungals (such as miconazole) are unlikely to affect the contraceptive efficacy, however, antifungal ovules may increase the risk of ring breakage. Erythromycin — modest to marked increase in plasma levels of oestrogens and/or progestogens. Possible increase risk of adverse effects. Etoricoxib — oestrogen levels

2020 NICE Clinical Knowledge Summaries

280. Contraception - combined hormonal methods: Scenario: Combined transdermal patch

, itraconazole, ketoconazole, voriconazole) — modest increase in plasma levels of oestrogens and/or progestogens. Possible increased risk of adverse effects. Erythromycin — modest to marked increase in plasma levels of oestrogens and/or progestogens. Possible increase risk of adverse effects. Etoricoxib — oestrogen levels increased by around 40% with etoricoxib doses of 60 mg or more. Increased risk of adverse effects. Statins — minor to modest increase in plasma levels of oestrogens and/or progestogens

2020 NICE Clinical Knowledge Summaries

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