Dear Dr. Roach: The dangers of oral medicines that address toe fungus
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Dear Dr. Roach: The dangers of oral medicines that address toe fungus

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Dr. Keith Roach

Dear Dr. Roach: I have been bothered by the fungi on my toenails -- eight of them. I tried every over-the-counter remedy, to no avail. I asked my doctor for an oral medicine that worked for my friend, but then I was hesitant to take it after she said this: I have to take the medicine for six months, and my liver should be tested every month.

That scared me. It must be a dangerous drug to require a liver test every month. Please give me your opinion regarding this. 

A: The prescription medication efinaconazole (Jublia) is specifically designed to treat nail fungus, and is applied to the toenails. Trials show it has 15% to 20% effectiveness, which sounds bad, but is much better than the over-the-counter options. Unfortunately, it is very expensive: A bottle (which lasts about a week) costs about $600 at goodrx.com, and treatment is intended to last 48 weeks. That's a whopping $28,800 to have a less than 50/50 chance of curing toenail fungus -- unless you are lucky enough to have coverage for this new drug.

A second topical medication, tavaborole (Kerydin) has similar effectiveness but is even more expensive.

Oral medications, such as terbinafine (Lamisil) and itraconazole (Sporanox), are more effective than any topical treatment, with cure rates ranging from 60% to over 80%. However, they do have the rare potential to cause liver damage, sometimes permanently, even fatally.  

Many readers have written over the years with over-the-counter and home remedies. These include Vicks VapoRub, tea tree oil, Norway spruce resin, acetic acid (vinegar), oregano oil, Listerine and many others. However, data showing effectiveness is minimal or none. Newer treatments being studied include laser and other light therapies.

Even if a treatment is effective, recurrence is common, and many people will use creams indefinitely to prevent reinfection despite absence of evidence that it helps.

Dear Dr. Roach: I had two cardiac bypasses 30 years ago. The surgeon said the bypasses were good for about 10 years. As predicted, I began to have a little angina about 10 years after the surgery. About that time, I had read an article about external counterpulsation, but my cardiologist totally dismissed it. So I reasoned a way to get more blood to my heart: For 20 years, I have spent three to four hours per week lying on the sofa with my feet elevated about 45 degrees. I'm 87 years old and enjoy almost perfect health. What do you think?

-- C.W.

A: External counterpulsation has never caught on, despite the fact it was shown effective at decreasing angina and the need for nitroglycerine. It works by using cuffs on the calves, thighs and pelvis, and squeezing them in time to the person's EKG. This reduces the amount of work the heart needs to do and provides a bit more blood flow to the heart. It also stimulates new blood vessels, but the exact mechanism of how it works remains a bit mysterious.

Raising your legs increases the return of blood to the heart through the veins. Since it is working on the vein side, not the artery side (where external counterpulsation is thought to work), it is not working the same way as ECP.

I can't argue about your results, though. Being 87 and in almost perfect health is remarkable. I often discuss the value of exercise in older people, but maybe rest is important as well.

             

           

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