Antifungals PDF

ANTIFUNGALS Fight against Fungal infections Can be localized or systemic LOCAL infections SYSTEMIC infections DRUGS...

ANTIFUNGALS Fight against Fungal infections Can be localized or systemic LOCAL infections SYSTEMIC infections DRUGS Nystatin (Nilstatin, Mycostatin) Amphotericin B (Fungizone, Abelcet, Terbinafine (Lamisil) - common, OTC AmBisome) Miconazole (Micatin, Monistat) Fluconazole (Diflucan)* Terconazole (Terazol) Itraconazole (Sporanox)* Clotrimazole (Canesten) OTC and Rx Ketoconazole (Nizoral)* Tolnaftate (Tinactin) Metronidazole* (Flagyl, Metrogel) * **these drugs may also be used for ✓ Has many other indications (ex. STI), but localized/topical infections mainly for yeast infections ✓ Also, an antibiotic INDICATIONS hair, skin, nails or vaginal Dangerous in patients with chronic diseases (Dermatophytic) Athlete’s foot and skin infections – caused by (diabetic) or immunocompromised (HIV, “tinea” cancer) Vaginal – candida albicans (yeast) candidiasis anything that has immunosuppressant ability Oropharyngeal – thrush (candidiasis) will increase the risk of thrush folds of skin or diaper areas o ex. cancer treatment, immunocompromised, steroids Hyperglycemia (diabetes): Elevated blood sugar levels can create an environment that promotes the growth of Candida, as yeast thrives in sugary environments EXTRA ✓ antifungals take time to work, may take a 1 week before seeing results, need to assure patients this ✓ Some antifungals available as PO forms as well as topical for site of infections ✓ "Mycoses" refers to infections caused by fungi. -NAZOL = hepatoxicity (very liver toxic)  AMPHOTERICIN B BRAND NAMES Fungizone Abelcet AmBisome INDICATIONS Severe infections ✓ Fungal septicemia, endocarditis, pulmonary and urinary tract infections MOA Alter permeability of cell membrane creates pores or channels in the membrane, making it leaky. allows ions (like potassium) and other essential cell contents to leak out, leading to cell death SUPPLIED (parenteral only) 500mg = fungizone & Ambisome 500 + 1000mg = Abelcet ADVERSE EFFECTS Chills, fever, nausea, vomiting* (amphotericin B used for Hepatic failure* SERIOUS infections so cause Decreased renal function SERIOUS effects in the body) Thrombophlebitis, anemia Allergic dermatitis (rash) EXTRA -NAZOLE drugs NAZOL = hepatoxicity (very liver toxic) All Same MOA: Selective inhibitor of sterol methylation, disrupt the integrity and function of the fungal cell membrane, ultimately leading to cell death or inhibition of fungal growth. These are used for both local and systemic infections Fluconazole (Diflucan) Itraconazole (Sporanox) Ketoconazole (Nizoral) INDICATIONS Vulvovaginal candidiasis - Oro-esophageal candidiasi systemic candidiasis (po yeast infections (common) Onychomycosis (nail forms) Oropharyngeal or infection) histoplasmosis (po forms) (cat esophageal candidiasis ✓ treated for 4-6 months litter) (thrush) ✓ jublia - efinaconazola seborrheic dermatitis (po Fungal meningitis and other ✓ used like a nails polish forms, or creams, shampoos) systemic candidiasis Blastomycosis (forest dandruff (shampoo) infections infection) candida or tinea dermatophyte Prevention of candidiasis in Pulmonary “aspergillosis” or infections (po forms or creams) bone marrow transplant “histoplasmosis” (lungs) ADVERSE Nausea, vomiting Skin rash, Pruritus (itching) GI EFFECTS Dermatological – rash, urticaria Fever EXTRA “Take with food” Oral forms need acidic environment to be absorbed from the stomach  NYSTATIN (Nilstat, Mycostatin) INDICATIONS intestinal, oral, cutaneous, vaginal candidiasis Mild to moderate cases only Very commonly used MOA Similar to amphotericin B creates pores or channels in the membrane, leading to increased permeability and ultimately causing cell death. SUPPLIED Oral tablets – 500 000 IU Oral suspension – 100 000 IU/ml Compounded into lozenges Topical cream/ointment – 100 000 IU/gram Vaginal tablets & creams – 100 000 IU ADVERSE EFFECTS Usually well tolerated High oral doses – GI intolerance (nausea, vomiting, diarrhea, abdominal pain) it’s important to include special Swishing the suspension around the mouth allows the medication to come into contact instructions for patients to with all affected areas (maximum coverage and effectiveness) swish and swallow the After swishing, swallow the medication to ensure it reaches the throat and esophagus, medication. Terbinafine INDICATIONS fungal infection of skin, hair, and nails MOA interference with cell membrane sterols - (Sterols are vital components of cell membranes, helping to maintain membrane fluidity and stability) SUPPLIED Tablets Cream Spray ADVERSE Oral – GI intolerance, skin rash, pruritis, and hepatotoxicity* (liver function tests required) EFFECTS Topical – burning, redness, itching  LECTURE 7: ANTIVIRAL Drugs Name, Generic Name, classification, dosage form Drug (Generic name Brand Name Classification/Indication Dosage Forms Amantadine Symmetrel Antiviral (Influenza A), Parkinson's Disease Capsules, tablets, oral solution cyclic amines Oseltamivir Tamiflu Antiviral (Influenza A and B) Capsules, suspension Zanamivir Relenza Antiviral (Influenza A and B) Inhalation powder Acyclovir Zovirax Antiviral (Herpes simplex, Varicella-Zoster) Tablets, capsules, suspension, injection, cream, ointment Famciclovir Famvir Antiviral (Herpes zoster, Herpes simplex) Tablets Ribavirin Rebetol Antiviral (Hepatitis C, RSV) Capsules, tablets, oral solution Valacyclovir Valtrex Antiviral (Herpes zoster, Herpes simplex, CMV Tablets prophylaxis) Delavirdine Rescriptor NNRTI (HIV Treatment) Tablets Efavirenz Sustiva NNRTI (HIV Treatment) Capsules, tablets Nevirapine Viramune NNRTI (HIV Treatment) Tablets, oral suspension Abacavir Ziagen NRTI (HIV Treatment) Tablets, oral solution Didanosine Videx NRTI (HIV Treatment) Capsules, chewable tablets, powder for oral solution Lamivudine Epivir NRTI (HIV Treatment, Hepatitis B) Tablets, oral solution Stavudine Zerit NRTI (HIV Treatment) Capsules, oral solution Zidovudine Retrovir NRTI (HIV Treatment, Prevention of Mother-to- Capsules, tablets, oral solution, Child Transmission) injection Nelfinavir Viracept Protease Inhibitor (HIV Treatment) Tablets, oral powder Ritonavir Norvir Protease Inhibitor (HIV Treatment) Capsules, tablets, oral solution, powder Saquinavir Invirase Protease Inhibitor (HIV Treatment) Capsules, tablets  Viruses - Introduction ▪ Small infectious agent that can replicate only inside the living cells of organisms ▪ All microorganisms including bacteria can be infected by viruses ▪ The virus depends on a host to reproduce Viruses - Diseases Let’s hear from our patients: Influenza Shingles Cold Sores Viral Hepatitis HIV These are our main focus, however there are many other viral related diseases/conditions Influenza ▪ Primarily affects upper and lower respiratory tracts a contagious respiratory illness caused by a virus that ▪ Headache, fever, fatigue, sinus pain, coughing infects the throat, nose, and lungs. It spreads through ▪ Reaction usually mild to moderate coughing, sneezing, or close contact with an infected ▪ May be more severe in persons with chronic illness or the elderly person ▪ dehydration, convulsions, death ▪ High incidence of recurrence ▪ Pandemics Occur every 15 to 20 years ▪ Annual variation in viral strains Virus changes and grows quickly Vaccine developed annually – predicted changes Given October through November What is the technician’s role with the flu (and covid) vaccines? ✓ Ordering ✓ Maintain cold chain supply – fridge temp recordings – sign off on deliveries – check packaging etc. ✓ Booking appointments ✓ Initial Hx taking ✓ Drawing up doses, checking drawn up doses ✓ Ensure having supportive equipment on site (1st aid kit, etc) ✓ Billing completed shots ✓ CPR/1st aid if certified ✓ Patient initiation and supervision while waiting before and after ✓ If injection certified, inject patient  Herpes Viruses Herpes Simplex Type 1 Fever blisters, cold sores Encephalitis (inflammation in the brain tissue), retinitis Herpes Simplex Type 2 Genital herpes Herpes Varicella - Zoster Chickenpox Shingles Herpes Infections Transmission direct contact with a lesion or the exudate may also occur through skin-to-skin contact during periods of asymptomatic shedding Viral Hepatitis ⚫ Hepatitis Virus B and Hepatitis Virus C infections ⚫ Acute phase followed by “Chronic Viral Hepatitis” ⚫ If untreated greatly affects liver function and leads to liver failure Acquired Immunodeficiency Syndrome (AIDS) ⚫ Disease characterized by multiple opportunistic infections as a result of depleted lymphocytes which are needed in cell mediated immunity ⚫ Caused by Human Immunodeficiency Virus (HIV) ⚫ A leading cause of death among young adults (US) ⚫ Without treatment, median survival time after infection is 9 to 11 years ⚫ ~50 000 new infections each year ⚫ Transmitted through sexual contact, IV drug use (shared needles), neonatal transmission, blood transfusion 95% - sexual contact or shared needles Presentation Typically – acute phase followed by prolonged latency after exposure to HIV During latency virus prepares for full blown AIDS Only 5-10% of HIV infected persons remain asymptomatic 10 years following exposure Disease is defined clinically by profound depletion of T-lymphocytes (suppression of host immunity) and is staged by blood test/cell counts Symptoms Adenopathy (swelling of lymph nodes), cough, diarrhea, fever, fatigue, headache, oral, skin or retinal lesions, SOB, weight loss, sweating, superinfections, secondary infections (pneumonia) AIDS Treatment ⚫ Antiviral drugs are not curative for AIDS ⚫ Patient needs a “strong” immune system, essential for full recovery ⚫ Antiviral drugs reduce replication of virus and shedding of viral particles thus reducing severity or duration of symptoms ⚫ Clinical effectiveness depends on achieving inhibitory concentration at the site of infection (i.e inside the infected cells)  Antiviral Drugs - MOA Inhibition of Cell Penetration Virus blocked, preventing attachment of virus to host cells and injecting viral DNA/RNA Interference with Viral Transcription Prevent reverse transcriptase enzyme, therefore viral RNA can’t utilize host DNA to replicate Interference with Viral Synthesis Nucleosides analogues of purine and pyrimidine incorporated into viral DNA and cannot be reproduced Protease inhibitors reduce protein production, needed to make new viruses infectious Antiviral Drugs Resistance to Drug Therapy Some viruses (eg: HIV, Flu, Covid) mutate quickly (variants)and possibly evolve to resist medications and/or vaccines Some viruses replicate frequently and in large numbers (viral load is large) so mutations are clinically relevant Antiviral Drug Classes Cyclic Amines: inhibition of viral replication Neuraminidase Inhibitors: prevent host cell penetration Nucleosides: prevents viral replication ALMOST EVERY ANTIVIRAL DRUG CLASS HAS A COMBINATION Non-nucleoside Reverse Transcriptase Inhibitors (RTI): inhibit action of reverse transcriptase thus no production of viral DNA Nucleoside Analogue RTI’s: bind & inhibit the actions of neuramidase preventing release of new virus particles also inhibit reverse transcriptase Protease Inhibitors: prevents full synthesis of certain viral protein that is a precursor necessary for replication of new viruses  LECTURE 8: Antiviral Classes 1. Cyclic Amines 2. Neuraminidase Inhibitors 3. Nucleosides 4. Non-nucleoside Reverse Transcriptase Inhibitors (NRTI)* 5. Nucleoside Analogue RTI’s* 6. Protease Inhibitors* ** *classes specific to HIV 1. Cyclic Amines Amantadine (Symmetrel) ❑ Prophylaxis Influenza A in susceptible groups o elderly, immunocompromised host, patients with chronic disease o Nursing/LTC homes ❑ Reduce severity of symptoms in active cases ❑ 200 mg daily for 10 days o Dose adjustments needed for renal or hepatic compromised patients (often with LTC patients) : (based on kidney or liver failure) ❑ Available: capsules, syrup 2. Neuraminidase Inhibitors Oseltamivir (Tamiflu) Zanamivir (Relenza) ❑ Treatment of acute, uncomplicated viral influenza within 48 hours of onset of symptoms in adults (12+) ❑ Also used as prophylaxis during LTC outbreaks MOA: prevents release of newly formed viruses from host cells ❑ Supplied (limited use for ODB for LTC patients) o Tamiflu – capsules and oral liquid o Relenza – rotadisk inhaler device ADRs: nausea, vomiting, diarrhea o Relenza – bronchospasm (if not used properly) 3. Nucleosides Acyclovir Famciclovir Valacyclovir Ganciclovir Ribavirin(ibayrr) Acyclovir (Zovirax) Indications – treatment of herpes zoster, simplex MOA – substitutes for thymidine (high affinity for viral thymidine kinase) and prevents viral replication Supplied – cream, ointment, tablets, injection, suspension  ADR – N&V with oral forms  DI – nonsignificant Famciclovir (Famvir) ❑ Similar to acyclovir ❑ Supplied – tablets only ❑ Advantage – less frequent dosing o Acyclovir 800 mg 5 times daily o Famciclovir 500 mg q8h ❑ Valacyclovir (Valtrex) ❑ Similar to famciclovir o Herpes zoster and herpes simplex I & II (genital) ( genital herpes are more aggressive) ❑ Supplied – 500 mg tablet ❑ (given out for cold sore) Ganciclovir (Cytovene) ⚫ Indication – treatment of cytomegalovirus (CMV) retinitis in immunocompromised patients ⚫ MOA – inhibition of viral DNA synthesis ⚫ Supplied – Injection Ribavirin (Ibavyr) ⚫ Indication – combo therapy for Hepatitis C ⚫ Supplied – tablets 4. Non-nucleoside RTIs Delavirdine (Rescriptor) Efavirenz (Sustiva) use more frequently in the combination treatment Nevirapine (Viramune) Indication ⚫ Used in combination with other agents in treatment of HIV MOA ⚫ Inhibition of RT enzyme thus blocking viral DNA synthesis Supplied - Oral tablets and capsules Adverse Effects  Skin rash, nausea, and diarrhea  Headache, confusion, insomnia  Renal damage (nevirapine – Viramune)  Psychiatric symptoms (efavirenz – Sustiva) Drug Interactions ⚫ Efavirenz – inducer of CYP 3A4 ⚫ Delavirdine – inhibitor of CYP 3ANevirapine – inducer of CYP 3A4 5. Nucleoside Analogue RTI’s  Abacavir (Ziagen)  Didanosine (Videx)(ddl)  Lamivudine (Heptovir)(3TC)  Stavudine (Zerit)  Zidovudine (Retrovir)(AZT)  Zidovudine/lamivudine (Combivir) Indication ⚫ component of combination therapy for HIV infection ⚫ Lamivudine also unique indication: ⚫ chronic hepatitis B and evidence of Hep B replication MOA ⚫ RTI = reverse transcriptase inhibitors Supplied ⚫ oral tablets/capsules ⚫ oral solutions or powders for reconstitution (oral solution) ⚫ Zidovudine also available as injection 6. Protease Inhibitors Nelfinavir (Viracept) Ritonavir (Norvir) Saquinavir (Invirase or Fortovase) (hard and soft caps) Indication ⚫ combined with other antivirals in HIV MOA ⚫ protease inhibitor Supplied ⚫ Oral tablets, capsules, oral powder (solution)  Combination Therapy ⚫ Most HIV patients are treated with combinations of antivirals, usually at least 3 different ones from same or different classes (cocktail) ⚫ Patients are on antivirals long term, like maintenance therapy ⚫ Many drugs available as combination products to improve compliance i.e. Combivir HIV Meds and Treatment ⚫ Side effects can be mild to severe, including N/V/D, hepatoxicity and possibly pancreatitis ⚫ Indepth counseling needed to prepare patients for possible side effects, plan treatment outcomes, discuss compliance issues, review administration instructions, and prevent drug interactions ⚫ Many possible drug interactions, as many HIV meds affect liver enzymes and metabolism Storage – some HIV medications (capsules and reconstituted liquids) must be refrigerated, ensure you always look at the storage information on the stock label and inform patient. Anthelmintics drugs that treat parasitic worm infections ▪ Worm infections are caused by: o Pinworms, Roundworms, Tapeworms ▪ Ingestion of worm eggs in food, soil ▪ worm multiplies or grows in intestines ▪ Causes diarrhea, cramping, nausea, vomiting, loss of appetite, intense itching ▪ Goal to Treat and Prevent Re-infections o Importance of treating all family members ▪ Importance of careful hand washing Mebendazole (Vermox) ⚫ Indicated for pinworms, roundworm, tapeworm ⚫ MOA – inhibition of glucose uptake, therefore larval development inhibited ⚫ Supplied o Tablets – single dose therapy o Repeat treatment in 2-4 weeks (Pinworm) o For some other infections BID for 3 days ⚫ Adverse Effects o Diarrhea o Abdominal pain SE are GI related but so are the symptoms, hard to differentiate “azole” familiar with antifungals, similar molecular structure Glucose is the nutrient needed, without cannot further develop/mature 1st attack followed by 2nd attack/cleanup Pyrantel Pamoate (Combantrin) ⚫ Indicated for roundworms, pinworms ⚫ MOA – effects cholinesterases causing neuromuscular blockade ⚫ Supplied – oral suspension, tablets (OTC) ⚫ Adverse Effects ⚫ Generally, well tolerated ⚫ May cause GI upset, headache, rash ⚫ For kids base on pounds ( every 25 pounds) Worms cannot move and therefore die Pyrvinium Pamoate (Vanquin) ⚫ Indication – pinworms ⚫ Supplied – oral liquid ⚫ Allows for flexibility in dosing multiple family members ⚫ Given as repeated single dose treatment ⚫ Adverse Effects ⚫ Stain stools bright red (important to note) (black stool ) ⚫ GI intolerance ⚫ Photosensitivity Aux label and counsel on staining of stools to avoid alarm Malaria – Protozoal Infection ⚫ Protozoal infection of circulatory system and liver caused by “plasmodium falciparum ovale malariae” ⚫ transmitted to humans by infected mosquito’s bite ⚫ Initially liver invasion with no clinical symptoms of disease ⚫ Mature protozoa enter bloodstream ⚫ Ruptures RBCs – chills, high fever produced, convulsions ⚫ Mosquitos feed on contaminated blood – infect more humans ⚫ Endemic – zoned areas (often 3rd world or tropical) Antimalarial Drugs ⚫ Prophylaxis – prevention of disease ⚫ Strict protocol for prescribing to travellers ⚫ Treatment – selective against parasite in RBC ⚫ Radical Cure – drug eliminates parasite from all tissues ⚫ Drugs ⚫ Chloroquine (Aralen) ⚫ Hydroxychloroquine (Plaquenil) ⚫ Mefloquine (Larium) * ⚫ Atovaquone/Proguanil (Malarone) * ⚫ Primaquine ⚫ Quinine ⚫ All drugs are protozoacidal and interfere with metabolism or inhibit replication of parasite Most of Rx’s are for travelers, preprinted from travel clinics or doctors 1. Chloroquine (Aralen) Indications: ⚫ prevention and treatment of malaria ⚫ Extraintestinal amebiasis – liver abscess caused by Entamoeba histolytica ⚫ Rheumatoid arthritis – lupus erythrematosus Supplied ⚫ Tablets ⚫ Taken weekly, 2 weeks before and continued for at least 4 weeks after leaving malarial area *Why given for weeks after exposure? Protozo may be dormant in liver and takes weeks to emerge MOA ⚫ Interferes with protein synthesis ⚫ Increases pH of parasitic digestive vacuoles ⚫ Parasite cannot utilize red blood hemoglobin Active against organisms in blood cells only 2. Hydroxychloroquine (Plaquenil) ⚫ Indicated in treatment of acute malarial attacks ⚫ also used in rheumatoid arthritis & lupus erythrematosus ⚫ MOA – similar to chloroquine ⚫ Supplied ⚫ Tablets, once weekly dosing ⚫ Start 2 weeks before and continued for at least 4 weeks after leaving malarial area More commonly used for non-malaria indications -little bones 3. Mefloquine (Lariam) ⚫ Indicated in prophylaxis and treatment of malaria ⚫ MOA – exact mechanism not known, like chloroquine and quinine works on parasites within red blood cell ⚫ Supplied – tablets ⚫ Popular antimalarial for travel prevention ⚫ Taken weekly, start 1 week prior to exposure, continue while exposed and for 4 weeks following exposure Both Larium and Malarone most popular for travelllers. Adverse Effects ⚫ Dizziness, headache, insomnia ⚫ Nausea, vomiting, diarrhea, abdominal pain ⚫ Skin rash, vision changes ⚫ Cardiac conduction changes/increase in QT interval Drug interactions ⚫ Anticonvulsants – valproic acid ⚫ Reduced serum concentration, loss of seizure control Patient needs to be able to tolerate and have no drug interactions, must be established with meds prior to leaving the country 4. Atovaquone/Proguanil (Malarone) ⚫ Effective drug combination as preventive (travelers) ⚫ Also used in chloroquine resistant malaria ⚫ Better tolerated than mefloquine ⚫ Should be taken daily with food ⚫ Starting 1-2 days before leaving & continue 1 week leaving area ⚫ Not recommended in pregnancy & infants < 11 kg in weight Advantage over larium – better tolerated, and shorter course, however, must be with food and contraindicated in pregnancy and infants 5. Primaquine / 6. Quinine Primaquine ⚫ Indicated for radical cure of malaria ⚫ Used in combination with another drug active against forms present in RBC ⚫ Remember….Radical cure – elimination of protozoal parasites in all body tissues Quinine ⚫ Indicated for prophylaxis and treatment of malaria ⚫ Also used for nocturnal leg muscle cramps ⚫ Evidence? Old drugs, no brand names Other Protozoal Organisms Other protozoal organisms that cause disease:  1. Entamoeba Histolytica (dysentery) 2. Giarda Lamblia(dysentery) 3. Toxoplasma 4. Trichomoniasis E histolytica – seen earlier today, protozoa that causes GI and liver invasion What is dysentery?It is an intestinal infection that causes severe diarrhea with blood and/or mucus in the stool. This condition is often associated with abdominal pain, cramping, and fever. It can range from mild to severe, and it is typically caused by either bacterial or parasitic infections. 1. Entamoeba Histolytica ▪ Cause of dysentery ▪ Gains access to GI tract through contaminated food and water ▪ Diarrhea, inflammation, irritation of intestinal muscles ▪ Patient feels dehydrated and fatigued= eventually and you will die……... 2. Gardia Lamblia ▪ Flagellated protozoa resides in intestine ▪ Source is sewage entering local water supply ▪ Organism attaches to intestine wall, multiplies and is excreted into water (feces) ▪ Water borne infection can exist in chlorinated water that has been inadequately filtered ▪ Can be transmitted during sexual intercourse to partner ▪ Patient experiences dysentry 3. Toxoplasma ▪ Caused by Toxoplama gondii ▪ Found in fecal material of cats ▪ Cats ingest meat that contain protozoan cysts, attach to intestinal wall and multiply ▪ Deposit fecal material to litter box or outdoor area ▪ Material is inhaled or handled when scooping fecal matter from litter box or backyard ▪ May also be transmitted by cat scratching people (“cat scratch fever”) ▪ Infection is dangerous in pregnancy ▪ Muscle pain, malaise, fever = If severe, may also present as encephalitis 4. Trichomoniasis ▪ Trichomonas vaginalis protozoan that invades bladder and urethra of male (feels like UTI) ▪ Sexually transmitted to female ▪ Disease is associated with non-barrier methods of contraception ▪ Female – pungent vaginal discharge, itching, intermenstrual spotting ▪ Many females are asymptomatic ▪ Need to treat both partners to effectively cure ▪ Treatment – metronidazole 2 g as single dose or 250 mg TID for 1 week Antiprotozoal Drugs Chloroquine (Aralen) ⚫ Indication o Antimalarial o Treatment of E histolytica infection of intestinal wall and liver (liver abcess) Paramomycin (Humatin) ⚫ Indication o Intestinal E. Histolytica o Intestinal only, does not treat liver invasion Metronidazole (Flagyl) TAKE WITH FOOD ⚫ Indications – antiprotozoal against E. Histolytica, Trichomonas, Giardia ⚫ Also very commonly used as bactericidal for anaerobic bacteria ⚫ Many other indications, some are: ⚫ Rosacea/acne ⚫ Bacterial vaginosis ⚫ Surgical prophylaxis ⚫ Helicobacter pylori GI infections ⚫ Clostridium difficile bacterial colitis Metronidazole ⚫ Supplied ⚫ IV solutions ⚫ Tablets & capsules ⚫ Topical: cream, gel, vaginal cream ⚫ Adverse Effects – nausea, anorexia, metallic taste, dizziness, vertigo, neuropathy (rare), skin rashes ⚫ Drug Interactions ⚫ Alcohol o disulfiram reaction (nausea, flushing, headache, abdominal cramps) o Avoid for 48 hours post last dose Don’t not drink alcohol.