Onychomycosis: improved cure rates with itraconazole and terbinafine.

Onychomycosis is a disease that is important to our patients. Based on the current literature, recent developments of newer antifungal agents have improved cure rates of onychomycosis in the past few years (Table 3). No significant differences in safety and tolerability between itraconazole and terbinafine exist. Terbinafine does appear to have a preferable drug interaction profile. Daily therapy with either agent at standard doses has been shown to be effective when compared with placebo. When studies have directly compared daily administration of terbinafine and itraconazole, both medications have shown similar efficacy. Daily terbinafine therapy, however, appears to be more effective than pulse therapy with itraconazole. In addition, one small study showed a trend in favor of continuous rather than intermittent terbinafine therapy and similar efficacy of intermittent itraconazole and intermittent terbinafine therapy. Furthermore, terbinafine is more cost-effective than itraconazole. Finally, as quality-of-life data suggest, onychomycosis is important to our patients and affects both physical and psychosocial components of our patients' lives.

Cyclooxygenase-2 enzyme inhibitors: place in therapy.

Nonsteroidal anti-inflammatory drugs (NSAIDs) play a major role in the management of inflammation and pain caused by arthritis. A new class of NSAIDs that selectively inhibit the cyclooxygenase-2 (COX-2) enzyme has been developed. The first COX-2 inhibitors, celecoxib and rofecoxib, are said to provide therapeutic benefit with less toxicity than traditional NSAIDs. A third COX-2-selective inhibitor, meloxicam, has recently been introduced. COX-2 inhibitors and traditional NSAIDs do not appear to differ significantly in their effectiveness in alleviating pain or inflammation. They have similar gastrointestinal side effects, including abdominal pain, dyspepsia and diarrhea. However, short-term studies show fewer gastrointestinal ulcers in patients treated with COX-2 inhibitors compared with traditional NSAIDs.

Diagnosis and management of common tinea infections.

The estimated lifetime risk of acquiring a dermatophyte infection is between 10 and 20 percent. Recognition and appropriate treatment of these infections reduces both morbidity and discomfort and lessens the possibility of transmission. Dermatophyte infections are classified according to the affected body site, such as tinea capitis (scalp), tinea barbae (beard area), tinea corporis (skin other than bearded area, scalp, groin, hands or feet), tinea cruris (groin, perineum and perineal areas), tinea pedis (feet), tinea manuum (hands) and tinea unguium (nails). To determine the best treatment approach, the physician must consider several factors: (1) the anatomic locations of the infection, (2) the safety, efficacy and cost of treatment options and (3) the likelihood that the patient will comply with treatment. Newer medications in both oral and topical forms, including imidazoles and allylamines, have greatly increased the cure rate for tinea infections. Certain types of tinea may be treated with "pulse" regimens; these innovative therapies lower treatment costs and improve patient compliance.

Insulin lispro: a fast-acting insulin analog.

Research has established the importance of maintaining blood glucose levels near normal in patients with type 1 (insulin-dependent) diabetes mellitus. Short-acting insulin analogs are designed to overcome the limitations of regular short-acting insulins. Compared with regular human insulin, the analog insulin lispro offers faster subcutaneous absorption, an earlier and greater insulin peak and a more rapid postpeak decrease. Insulin lispro begins to exert its effects within 15 minutes of subcutaneous administration, and peak levels occur 30 to 90 minutes after administration. Duration of activity is less than five hours. Rates of insulin allergy, lipodystrophy, hypoglycemia and abnormal laboratory test results are essentially the same in patients using insulin lispro and in those using regular human insulin.

Drug treatment of migraine: Part II. Preventive therapy.

In most cases, successful preventive therapy for migraines requires daily medication for months or years. Perimenstrual use of a preventive agent is a common exception. Preventive therapy is usually undertaken in patients who have more than two headache episodes per month or those very much disabled by headaches. Beta blockers are usually the first choice for preventive therapy, and amitriptyline is also commonly used. Despite widespread use of calcium channel blockers for prevention of migraine, their benefits are controversial. Although effective for prevention of migraine, methysergide and phenelzine are usually relegated to last-resort use because of potentially serious side effects. The migraine patient who is refractory to standard preventive therapy may have rebound headache related to overuse of abortive migraine medications, or concomitant psychopathology.

Drug treatment of migraine: Part I. Acute therapy and drug-rebound headache.

Most migraine patients need only abortive treatment for their headaches. By the time they present to a physician, they have already tried many over-the-counter medications for headache relief. Prioritizing treatment according to headache severity and associated symptoms will help the physician determine the most appropriate medications to use. Narcotics should be reserved for use only in patients unresponsive to adequate trials of non-narcotic agents. In some patients, the recurrent nausea and vomiting can be as disabling as the pain; antiemetic agents are an important adjunct to analgesic therapy in these patients. Sumatriptan and dihydroergotamine are more expensive than other migraine agents but have distinct therapeutic advantages in patients with moderate to severe headaches. Some patients experience rebound headache from overuse of analgesics and other headache medications. Educating patients about self-help measures and avoidance of triggers is an important element in the effective management of migraine headaches.

Allergic rhinitis.

Allergic rhinitis commonly manifests for the first time in childhood or adolescence with seasonal or perennial sneezing, rhinorrhea, nasal congestion, and pruritus of the nose, eyes and throat. The nasal mucosa are pale blue and boggy, with a clear discharge. Patients should be instructed to avoid breathing tobacco smoke, to remove bedroom carpeting, to use foam pillows, to enclose mattresses and box springs in plastic covers, to keep house windows closed and to reduce indoor humidity by using air conditioning. If these avoidance procedures, together with oral and ocular antihistamines and/or decongestants, do not provide relief of symptoms, intranasal corticosteroids and cromolyn may be prescribed. Pharmacotherapy is more effective if it is used prophylactically. Second-generation antihistamines may reduce sedative and anticholinergic side effects. Intranasal decongestants should be used for only three to four days. Immunotherapy is appropriate for patients who remain unresponsive to therapy. Intranasal cromolyn should be the first drug considered in the treatment of pregnant women.

Management of genital herpes.

Genital herpes affects over 30 million persons in the United States. Genital herpes has three distinct presenting syndromes, depending on the patient's immune status with regard to the herpes simplex virus. Current diagnostic strategy relies on clinical findings and the selective use of viral culture. Acyclovir is the drug of choice for the treatment of genital herpes. Drug resistance is an increasing problem, requiring the use of newer agents. Treatment of the immunocompromised patient is a special area of concern. In addition to the medical aspects in the treatment of genital herpes, psychosocial requirements should also be addressed.

Drug therapy for epilepsy.

Epilepsy, a chronic brain disorder characterized by recurrent seizures, affects 1 to 3 percent of the U.S. population. In addition to six drugs classically used either alone or in combination to control epilepsy, three new agents have recently become available. The choice of therapy for each patient must be individualized, based on an accurate determination of the type of epilepsy, an understanding of drug pharmacokinetics, interactions and side-effect profiles, and issues related to patient acceptability and compliance. Approximately 70 percent of patients currently achieve good control of epilepsy, and it is hoped that new agents and improved therapeutic management can substantially increase this percentage.