Is it safe to prescribe fluconazole to a patient with an extensive intermammary yeast infection who is currently taking Percocet (oxycodone and acetaminophen) and Seroquel (quetiapine)?

From the Guidelines

Fluconazole should be avoided in this patient due to potential drug interactions with Percocet and Seroquel, and instead, a topical antifungal treatment should be prioritized for the extensive cutaneous candidiasis under the breast. For the treatment of cutaneous candidiasis, topical antifungal agents are recommended as the first-line treatment, with no one agent superior to another, as stated in the clinical practice guideline for the management of candidiasis: 2016 update by the infectious diseases society of America 1. Some key points to consider for the treatment of this patient include:

• A topical antifungal like clotrimazole 1% or miconazole 2% cream applied twice daily for 2-4 weeks would be a safer first-line treatment, avoiding the drug interaction concerns while effectively treating the infection.
• If a topical approach is insufficient, and oral therapy is necessary, fluconazole could be considered at 150-300mg once weekly for 2-4 weeks with careful monitoring, as it may increase oxycodone levels (through CYP3A4 inhibition) potentially causing increased sedation or respiratory depression.
• The patient should also be advised to keep the affected area clean and dry, wear cotton bras, and consider using absorbent powders between skin folds to prevent recurrence.
• Addressing underlying factors like diabetes control or obesity would also help prevent future infections, as these conditions can increase the risk of developing cutaneous candidiasis. It is essential to prioritize the patient's safety and minimize the risk of potential drug interactions, and therefore, a topical antifungal treatment should be the primary approach for managing the extensive cutaneous candidiasis under the breast.

From the FDA Drug Label

Fluconazole is a moderate CYP2C9 and CYP3A4 inhibitor. Fluconazole is also a strong inhibitor of CYP2C19. Patients treated with fluconazole, who are also concomitantly treated with drugs with a narrow therapeutic window metabolized through CYP2C9 and CYP3A4, should be monitored for adverse reactions associated with the concomitantly administered drugs

Alfentanil: A study observed a reduction in clearance and distribution volume as well as prolongation of t½ of alfentanil following concomitant treatment with fluconazole A possible mechanism of action is fluconazole’s inhibition of CYP3A4. Dosage adjustment of alfentanil may be necessary.

Amitriptyline, nortriptyline: Fluconazole increases the effect of amitriptyline and nortriptyline. 5-Nortriptyline and/or S-amitriptyline may be measured at initiation of the combination therapy and after 1 week. Dosage of amitriptyline/nortriptyline should be adjusted, if necessary

The patient is taking Percocet (which contains oxycodone, a CYP3A4 substrate) and Seroquel (which is a CYP3A4 substrate). Fluconazole may increase the levels of these medications by inhibiting CYP3A4.

• The benefits of using fluconazole may not outweigh the risks due to potential drug interactions with Percocet and Seroquel.
• It is recommended to monitor the patient closely for adverse reactions associated with Percocet and Seroquel if fluconazole is prescribed.
• Consider alternative antifungal treatments or dose adjustments of Percocet and Seroquel to minimize the risk of adverse interactions 2.

From the Research

Patient Medication Interaction

The patient is currently taking Percocet (oxycodone/acetaminophen) and Seroquel. There are no direct studies provided that assess the interaction between fluconazole and these medications.

Fluconazole Interaction with Percocet

• There is no evidence provided to suggest a direct interaction between fluconazole and Percocet 3, 4, 5, 6, 7.
• However, it is essential to consider the potential for increased risk of adverse effects when combining medications, especially in patients taking multiple drugs.

Considerations for Fluconazole Use

• Fluconazole is an antifungal medication commonly used to treat fungal infections, including yeast infections.
• The decision to prescribe fluconazole should be based on the severity of the yeast infection and the potential benefits and risks of treatment.
• It is crucial to monitor the patient for any adverse effects or interactions when adding a new medication to their regimen.

Monitoring and Precautions

• Close monitoring of the patient's condition and potential interactions between fluconazole and their current medications is necessary.
• The patient's healthcare provider should be aware of the potential risks and benefits of adding fluconazole to their treatment plan.
• Regular follow-up appointments can help identify any issues promptly and adjust the treatment plan as needed.