What are the alternatives to Jublia (efinaconazole) for treating toenail fungus?

Alternatives to Jublia (Efinaconazole) for Treating Toenail Fungus

Oral terbinafine (250mg daily for 12 weeks) is the most effective alternative to Jublia for treating toenail fungus, with superior mycological cure rates of 73-94% compared to topical options. 1

First-Line Oral Treatment Options

Terbinafine

• Dosage: 250mg once daily for 12 weeks for toenails 1, 2
• Efficacy: Highest mycological cure rates (73-94%) 1
• Best for: Dermatophyte infections (most common cause of onychomycosis) 1
• Considerations:
  • Requires baseline liver function tests 1
  • Common side effects: headache, taste disturbance, gastrointestinal upset 2
  • Contraindicated in hepatic impairment 1

Itraconazole

• Dosage: 200mg daily continuous therapy or pulse therapy for 12 weeks 1
• Efficacy: Mycological cure rate of 45.8% at 48 weeks 1
• Best for: Candida infections and nondermatophyte molds 3, 1
• Considerations:
  • Broader antimicrobial coverage than terbinafine 3
  • Avoid in patients with heart failure 1
  • Higher risk of drug interactions than terbinafine 1

Fluconazole

• Dosage: 150-450mg once weekly for at least 6 months 1
• Best for: Patients who cannot tolerate terbinafine or itraconazole 1
• Considerations:
  • Can be used with dose adjustment in hepatic impairment 1
  • Weekly dosing may improve compliance 3

Alternative Topical Options

Amorolfine 5% Nail Lacquer

• Efficacy: Approximately 50% in distal nail infections 1
• Application: Weekly application

Ciclopirox 8% Lacquer

• Efficacy: Mycological cure rates of 34% 1
• Application: Daily application

Tioconazole 28% Solution

• Contraindicated: In pregnancy 1

Treatment Selection Algorithm

1. For mild-moderate infections with no contraindications:

   • First choice: Oral terbinafine 250mg daily for 12 weeks
   • Alternative if Candida suspected: Itraconazole 200mg daily for 12 weeks

2. For patients with hepatic impairment:

   • First choice: Topical therapy (efinaconazole, ciclopirox, or amorolfine)
   • Alternative: Fluconazole with dose adjustment 1

3. For patients with high risk of drug interactions:

   • First choice: Terbinafine (fewer interactions than azoles) 1
   • Alternative: Topical therapy

4. For diabetic patients:

   • First choice: Terbinafine (lower risk of drug interactions) 1
   • Alternative: Topical therapy for mild-moderate infections

Important Considerations

• Diagnostic confirmation: Prior to initiating treatment, appropriate nail specimens for laboratory testing (KOH preparation, fungal culture, or nail biopsy) should be obtained to confirm the diagnosis of onychomycosis 2

• Treatment duration: The slow growth of toenails means longer treatment periods may be necessary for complete cure 4

• Monitoring: Baseline liver function tests are recommended for patients taking oral antifungals, particularly terbinafine 1, 2

• Recurrence prevention: Onychomycosis has high recurrence rates (40-70%), highlighting the need for preventive measures such as keeping nails short, avoiding sharing nail clippers, wearing protective footwear, and treating concomitant fungal infections 1

• Treatment failure: Common reasons include poor compliance, poor absorption, immunosuppression, and dermatophyte resistance 1

Special Populations

• Pediatric patients: Terbinafine dosing is based on weight, with a duration of 12 weeks for toenails 1

• Immunosuppressed patients: Consider topical options when systemic therapy is contraindicated 1

• Elderly patients: May require longer treatment durations due to slower nail growth 4