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  • Cost effective prescribing

    Our local PCT has issued lists of products/indications that it does not want Drs to prescribe. One is fungal nail infections. pt told to come in and ask for AF cream. Apart from Lamisil/Canestan etc I seem to remember something specific being advertised somewhere. Curanail too expensive for our customers. Any suggestions?
    johnep

  • #2
    Re: Cost effective prescribing

    I thought that under their NHS terms of service that a doctor is obliged to treat an NHS patient under the NHS. It is a breach of service for them to tell someone to buy something at the pharmacy, as far as I can see.

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    • #3
      Re: Cost effective prescribing

      Didn't think AF cream was effective for fungal nail infections? or am i wrong?

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      • #4
        Re: Cost effective prescribing

        As far as I know - cream not able to penetrate nail bed very well.
        Titch

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        • #5
          Re: Cost effective prescribing

          I can't comment on prescribing process there, but we too are charged with cost-effective prescribing where I work. Topical products do nothing for onychomycosis of the toenail. I wrote a table on this very topic for our docs. One must consider the "mycologic cure rate"=getting rid of bug through confirmation, the "clinical cure rate"=toenail actually looks better and the "relapse rate". Pts care more about the clinical cure. Lamisil (oral) has the best mycologic cure (71-82%), clinical cure (45-70%), and relapse rate (6-23%). The next best would be itraconazole, however lots of drug interactions. There is some literature with using fluconazole in this instance, however, the mycologic and clinical cure rates drop substantially. Penlac (ciclopirox) is a topical nail "polish" that has absolutely horrible cure rates. Griseofulvin also and is poorly absorbed and intolerable. Ketoconazole has unknown rates for all categories. We used to "pulse dose" terbinafine for a more cost effective approach as literature (and pharmacokinetics) used to support it (500mg 1st week of month x 4 months for toenails). However, there was a recent study that compared daily dosing to pulse dosing and showed that daily dosing with 250mg x 3 months was the best. Just as a side note: some of our docs anectdotally use "vicks vaporub" (menthol based product) under the toenail which some of them swear by. However, you'll find no data on this as I've looked. Pharout

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