Onychomycosis

Management of Onychomycosis in Canada in 2014 http://www.ncbi.nlm.nih.gov/pubmed/25775640

Drug name: Brand: SA SA Criteria SA Approval period Direction SE Monitoring
Ciclopirox 8% Penlac (nail lacquer) No Not covered N/A Nail lacquer: Apply bid to adjacent skin and affected nails daily. Remove with alcohol every 7 days (treat 4 weeks) dermatitis, dry skin, local burning sensation
Efinaconazole Jublia (nail lacquer) Not covered Not covered N/A Apply to affected toenails once daily for 48 weeks Ingorwn nail (2%), dermatitis
Terbinafine tablets Lamisil tablets Yes Severe onychomycosis
PLUS
functional disability
PLUS
positive KOH or dermatophyte culture of nail from a licensed lab.
First approval: Three months
Renewals: If required, up to three months.
250mg once daily for 6 weeks (fingernail); 250mg once daily for 12 weeks (toenails) Headache (13%), diarrhea (6%), nausea, liver enzyme disorder (3%) Monitor AST/ALT prior to initiation, repeat if used >6 weeks
Itraconazole Sporanox Yes 1. Immunocompromised pts/ Or 2. Pulse treatment for severe onychomycosis with functional disability
PLUS
confirmed lab results for candida or dermatophyte infection.
1. Immunocompromised pts approval is indefinite 2. 3 months approval for 2nd group of pts (No need for SA approval if prescribed by HIV/AIDS Dr) Fingernail involvement: 200mg capsule twice daily for 1 week. repeat 1 week course after 3 week off time Toenails due to Trichophyton rubrum or T mentagrophytes: 200mg once daily for 12 consecutive weeks With or without fingernaikl involvement: 200mg once daily for 12 consecutive weeks Canadian labelling “Pulse dosing”: 200mg twice daily for 1 week, then repeat 1 week course twice with 3 week off time between each course Diarrhea, nausea, headache, skin rash Liver function in patients with pre-existing hepatic dysfunction, and in all patients being treated for longer than 1 month
fluconazole Diflucan Yes 1. Immunocompromised patients.
OR2. Exceptions on an individual basis for fungal infections resistant to first-line medications.
1 day to indefinite (no need for HIV and AIDS Dr to apply for SA)

Diabetes Medications and BC Coverage Information

We are back! (Or your money back!)

In this episode, Billy and Tina discuss the PharmaCare coverage status of different classes of diabetes medications.

Sources:

BC PharmaCare Formulary: https://pcbl.hlth.gov.bc.ca/pharmacare/benefitslookup/

BC PharmaCare Special Authority: http://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/pharmacare/prescribers/special-authority

CDA Formulary Listings for Diabetes Medications in Canada by provinces and territories (Jan 2016): http://www.diabetes.ca/getmedia/c87009a8-29b6-4061-a52a-963d0b077e47/pt-formulary-listing-jan-18-2016.pdf.aspx
*In case the link doesn’t work: pt-formulary-listing-jan-18-2016

Class drugs Other therapeutic considerations coverage SA criteria
Biguanide metformin covered
Alpha-glucosidase inhibitor (acarbose) acarbose Improved postprandial control, GI side-effects delisted
Incretin agent: DPP-4 Inhibitors linagliptin (Trajenta) SA same as onglyza
sitagliptin (Januvia) delisted
saxagliptin (Onglyza) SA As part of a combination treatment for type 2 diabetes mellitus, 1) When insulin NPH is not an option
AND
2) After inadequate glycemic control on maximum tolerated doses of dual therapy of metformin AND a sulfonylurea.
Incretin agent: GLP-1 receptor agonists liraglutide (Victoza) GI side-effects not listed
Insulin rapid acting (Humalog, novorapid, apidra) No dose ceiling, flexible regiments partial coverage
short acting (Humulin R, Novolin Toronto) covered
NPH covered
Premixed (Humulin 30/70, Novolin 30/70, 40/60, 50/50) covered
Premixed (Humalog mix 25, mix 50, Novomix 30) partial coverage
glargine (Lantus) SA A) Type 1 DM or B) Type 2 DM > 17 years old, and 1) requiring insulin and is currently taking insulin NPH and/or pre-mix insulin daily at optimal dosing
AND
2) Has experienced unexplained nocturnal hypoglycemia at least once a month despite optimal management
OR
3) Has experienced or continues to experience severe, systemic or local allergic reaction to existing insulin treatment.
detemir (Levemir) SA same as Lantus
new glargine (Toujeo) not listed
Insulin secretagogue: Meglitinide repaglinide (gluconorm) Less hypoglycemia in context of missed meals but usually requires TID to QID dosing not listed
Insulin secretagogue: Sulfonylurea glyburide Gliclazide and glimepiride associated with less hypoglycemia than glyburide covered
gliclazide SA (listed everywhere else in Canada) Treatment failure or intolerance to at least one other sulfonylurea drug (e.g., glyburide, tolbutamide) at adequate doses.
SGLT2 inhibitors canagliflozin (Invokana) UTI, genital infections, hypotension, hyperlipidemia, caution with renal dysfunction and loop diuretics, dapagliflozin not to be used if bladder cancer, rare diabetic ketoacidosis (may occur with no hyperglycemia) 1 year manufacturer coverage with special plan
dapagliflozin (Forxiga) 1 year manufacturer coverage with special plan
empagliflozin (Jardiance) not listed
TZD rosiglitazone CHF, edema, fractures, rare bladder cancer (pioglitazone), cardiovascular controversy (rosiglitazone), 6-12 weeks required for maximal effect delisted
pioglitazone SA same as onglyza
Weight loss agent (orlistat) orlistat GI side effects not listed
Combination Drugs sitagliptin and metformin (Janumet) delisted
linagliptin and metformin (Jentadueto) SA same as onglyza

What I learned from St Paul’s CME 2014 Part 1

This is planned to be an 8-part series highlighting the take-home points I picked up during the St. Paul’s Hospital CME Conference 2014.

Pearls from Part 1 “Internal Medicine”:

Alcoholism – Dr. Paul Farnan

  1. Screen alcohol use disorders routinely to catch those of whom do not appear to have a significant social or occupational impairment.
  2. Use assertive statements to convey the concern regarding someone’s alcohol use.
  3. Peer support is strongly recommended. Patients should try multiple meetings at different groups before concluding that they are not helpful, as the groups vary in their structure and member characteristics.
  4. Medical treatments may be considered in select patients: naltrexone, acamprosate, disulfiram.

Gout – Dr. Hyon Choi

  1. Screen for HLA-B*5801 in Asians (esp. Chinese, Thai, and Korean patients) before starting alopurinol.
  2. Look for concurrent metabolic disorders.
  3. “Medication in the pocket” strategy for acute flares: colchicine 1.2mg po x1 then 0.6mg po in 1 hour.
  4. Use losartan or CCB for concurrent hypertension.
  5. Low-carb diet and avoid foods with highest purine content.

Cellulitis – Dr. Val Montessori

  1. Non-purulent cellulitis, most likely caused by Group A Strep, treat with cephalexin (Keflex) 500mg po QID
  2. Purulent cellulitis, most likely Staph Aureus but still possibly GAS, treat with Septra DS PO BID, and cover GAS with Keflex.
  3. Complicated wounds, consult ID.

HCV – Dr. Edward Tam

  1. New therapy more tolerable and has a 95% cure rate, but also exceedingly expensive.
  2. Refer all HCV RNA positive patients to hepatologists for assessment of treatment.

This Changed My Practice – Dr. Steve Wong

OSA – Dr. Pearce Wilcox

  1. Co-morbidities with metabolic syndrome -> screen for metabolic syndromes in patients with OSA, and vice versa