What is Lamisil, Lamisil AT (terbinafine)?

Lamisil, Lamisil AT (terbinafine) is an antifungal agent taken by mouth or applied to the skin to treat fungal nails, jock itch, and athlete's foot. Terbinafine acts by interfering with the ability of fungi to make chemicals called sterols that are an important part of the membrane that surrounds fungal cells and holds them together. This weakens the cell membrane. 

Oral terbinafine is more effective for treating fungal nail infections than griseofulvin and itraconazole, two other antifungal agents used for treating fungal nail infections. Terbinafine tablets are available by prescription; Lamisil topical is available over-the-counter (OTC).

Common side effects of Lamisil include:

Serious side effects of oral terbinafine include:

  • liver failure, sometimes leading to liver transplantation or death.

Drug interactions of Lamisil include rifampin, which reduces oral terbinafine blood concentrations, potentially reducing its efficacy. 

Cimetidine may increase side effects of terbinafine. 

Fluconazole increases the blood levels of oral terbinafine potentially leading to increased side effects. 

There are no adequate studies of Lamisil in pregnant women. Since nail fungus treatment can be delayed until after pregnancy there is no reason to use oral terbinafine during pregnancy. 

Breastfeeding mothers should not use oral terbinafine because it passes into breast milk.

What are the important side effects of Lamisil (terbinafine)?

The most common side effects of terbinafine are:

Oral terbinafine can cause liver failure sometimes leading to liver transplantation or death.

Lamisil (terbinafine) side effects list for healthcare professionals

Clinical Trials Experience

Because clinical trials are conducted under widely varying conditions, adverse reaction rates in the clinical trials of a drug cannot be directly compared to rates in the clinical trials of another drug and may not reflect the rates observed in practice.

The most frequently reported adverse events observed in the 3 US/Canadian placebo-controlled trials are listed in the table below. The adverse events reported encompass gastrointestinal symptoms (including diarrhea, dyspepsia, and abdominal pain), liver test abnormalities, rashes, urticaria, pruritus, and taste disturbances. Changes in the ocular lens and retina have been reported following the use of Lamisil Tablets in controlled trials. The clinical significance of these changes is unknown. In general, the adverse events were mild, transient, and did not lead to discontinuation from study participation.

  Adverse Event Discontinuation
Lamisil Tablets (%)
n=465
Placebo (%)
n=137
Lamisil Tablets (%)
n=465
Placebo (%)
n=137
Headache 12.9 9.5 0.2 0.0
Gastrointestinal Symptoms:
Diarrhea 5.6 2.9 0.6 0.0
Dyspepsia 4.3 2.9 0.4 0.0
Abdominal Pain 2.4 1.5 0.4 0.0
Nausea 2.6 2.9 0.2 0.0
Flatulence 2.2 2.2 0.0 0.0
Dermatological Symptoms:
Rash 5.6 2.2 0.9 0.7
Pruritus 2.8 1.5 0.2 0.0
Urticaria 1.1 0.0 0.0 0.0
Liver Enzyme Abnormalities* 3.3 1.4 0.2 0.0
Taste Disturbance 2.8 0.7 0.2 0.0
Visual Disturbance 1.1 1.5 0.9 0.0
*Liver enzyme abnormalities ≥ 2x the upper limit of normal range.

Postmarketing Experience

The following adverse events have been identified during postapproval use of Lamisil Tablets. Because these events are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.

Blood and lymphatic system disorders: Pancytopenia, agranulocytosis, severe neutropenia, thrombocytopenia, anemia

Immune system disorders: Serious hypersensitivity reactions e.g., angioedema and allergic reactions (including anaphylaxis), precipitation and exacerbation of cutaneous and systemic lupus erythematosus, serum sickness-like reaction

Psychiatric disorders: Anxiety and depressive symptoms independent of taste disturbance have been reported with use of Lamisil Tablets. In some cases, depressive symptoms have been reported to subside with discontinuance of therapy and to recur with reinstitution of therapy.

Nervous system disorders: Cases of taste disturbance, including taste loss, have been reported with the use of Lamisil Tablets. It can be severe enough to result in decreased food intake, weight loss, anxiety, and depressive symptoms. Cases of smell disturbance, including smell loss, have been reported with the use of Lamisil Tablets. Cases of paresthesia and hypoesthesia have been reported with the use of Lamisil Tablets.

Eye disorders: Visual field defects, reduced visual acuity

Ear and labyrinth disorders: Hearing impairment, vertigo, tinnitus

Vascular disorders: Vasculitis

Gastrointestinal disorders: Pancreatitis, vomiting

Hepatobiliary disorders: Cases of liver failure some leading to liver transplant or death, idiosyncratic and symptomatic hepatic injury. Cases of hepatitis, cholestasis, and increased hepatic enzymes have been seen with the use of Lamisil Tablets.

Skin and subcutaneous tissue disorders: Serious skin reactions [e.g., Stevens-Johnson syndrome, toxic epidermal necrolysis, erythema multiforme, exfoliative dermatitis, bullous dermatitis, and drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome], acute generalized exanthematous pustulosis, psoriasiform eruptions or exacerbation of psoriasis, photosensitivity reactions, hair loss

Musculoskeletal and connective tissue disorders: Rhabdomyolysis, arthralgia, myalgia

General disorders and administration site conditions: Malaise, fatigue, influenza-like illness, pyrexia

Investigations: Altered prothrombin time (prolongation and reduction) in patients concomitantly treated with warfarin and increased blood creatine phosphokinase have been reported

What drugs interact with Lamisil (terbinafine)?

Drug-Drug Interactions

In vivo studies have shown that terbinafine is an inhibitor of the CYP450 2D6 isozyme. Drugs predominantly metabolized by the CYP450 2D6 isozyme include the following drug classes: tricyclic antidepressants, selective serotonin reuptake inhibitors, beta-blockers, antiarrhythmics class 1C (e.g., flecainide and propafenone) and monoamine oxidase inhibitors Type B. Coadministration of Lamisil Tablets should be done with careful monitoring and may require a reduction in dose of the 2D6- metabolized drug.

In a study to assess the effects of terbinafine on desipramine in healthy volunteers characterized as normal metabolizers, the administration of terbinafine resulted in a 2-fold increase in Cmax and a 5-fold increase in area under the curve (AUC). In this study, these effects were shown to persist at the last observation at 4 weeks after discontinuation of Lamisil Tablets.

In studies in healthy subjects characterized as extensive metabolizers of dextromethorphan (antitussive drug and CYP2D6 probe substrate), terbinafine increases the dextromethorphan/dextrorphan metabolite ratio in urine by 16- to 97-fold on average. Thus, terbinafine may convert extensive CYP2D6 metabolizers to poor metabolizer status.

In vitro studies with human liver microsomes showed that terbinafine does not inhibit the metabolism of tolbutamide, ethinylestradiol, ethoxycoumarin, cyclosporine, cisapride and fluvastatin. In vivo drug-drug interaction studies conducted in healthy volunteer subjects showed that terbinafine does not affect the clearance of antipyrine or digoxin. Terbinafine decreases the clearance of caffeine by 19%. Terbinafine increases the clearance of cyclosporine by 15%.

The influence of terbinafine on the pharmacokinetics of fluconazole, cotrimoxazole (trimethoprim and sulfamethoxazole), zidovudine or theophylline was not considered to be clinically significant.

Coadministration of a single dose of fluconazole (100 mg) with a single dose of terbinafine resulted in a 52% and 69% increase in terbinafine Cmax and AUC, respectively. Fluconazole is an inhibitor of CYP2C9 and CYP3A enzymes. Based on this finding, it is likely that other inhibitors of both CYP2C9 and CYP3A4 (e.g., ketoconazole, amiodarone) may also lead to a substantial increase in the systemic exposure (Cmax and AUC) of terbinafine when concomitantly administered.

There have been spontaneous reports of increase or decrease in prothrombin times in patients concomitantly taking oral terbinafine and warfarin, however, a causal relationship between Lamisil Tablets and these changes has not been established.

Terbinafine clearance is increased 100% by rifampin, a CYP450 enzyme inducer, and decreased 33% by cimetidine, a CYP450 enzyme inhibitor. Terbinafine clearance is unaffected by cyclosporine. There is no information available from adequate drug-drug interaction studies with the following classes of drugs: oral contraceptives, hormone replacement therapies, hypoglycemics, phenytoins, thiazide diuretics, and calcium channel blockers.

Food Interactions

An evaluation of the effect of food on Lamisil Tablets was conducted. An increase of less than 20% of the AUC of terbinafine was observed when Lamisil Tablets were administered with food. Lamisil Tablets can be taken with or without food.

Summary

Lamisil, Lamisil AT (terbinafine) is an antifungal agent taken by mouth or applied to the skin to treat fungal nails, jock itch, and athlete's foot. Common side effects of Lamisil include headache, cough, diarrhea, abdominal pain, hives, itching and altered senses of taste and smell. Serious side effects of oral terbinafine include liver failure sometimes leading to liver transplantation or death. There are no adequate studies of Lamisil in pregnant women. Since nail fungus treatment can be delayed until after pregnancy there is no reason to use oral terbinafine during pregnancy. Breastfeeding mothers should not use oral terbinafine because it passes into breast milk.

Treatment & Diagnosis

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Medically Reviewed on 5/12/2020
References
FDA Prescribing Information

Professional side effects and drug interactions sections courtesy of the U.S. Food and Drug Administration.
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