Nizoral is gone. What can I do?
What do I do now that Nizoral is gone?
Recently Nizoral® (ketoconazole 200 mg) was voluntarily withdrawn from the Australian market. This was driven by market forces as alternative human medications have lower risk of adverse effects. This leaves us with the need to find alternatives for veterinary treatment.
So what do I use instead?
There is no one single medication that can replace Nizoral completely. Alternative medications can be more expensive, or less reliable.
For malassezia dermatitis
For Malassezia dermatitis use of topical treatments including Malaseb® shampoo, Sebazole shampoo, (applied twice weekly) or the human medications made for athletes foot (Canesten® Lotion, Daktarin® Lotion etc applied twice daily) remain the mainstays of treatment. In some cases when owners or patients are non-compliant, or the lesions are widespread we may choose to use systemic medications.
My preferred systemic treatment option remains Itraconazole (Sporonox®) 5 mg/kg q24hrs limitations with this is the capsules are 100 mg so they may need to be divided. I find this relatively easy for owners to do by mixing the granules within the capsule with a paste such as pâté, butter, cream cheese to be divided evenly and then storing the unused portion for subsequent doses. A compounding pharmacist will be happy to resize Sporanox to any dose you need but this will add to the cost.
Fluconazole 5mg/kg q24hrs The Bova compounded Flucon appears to work well.
Terbinafine (Lamasil® 250 mg tabs) 30-40 mg/kg q24hrs. There are studies that show poor response to 30 mg/kg q24hrs. The commercial tablets are 250 mg so best suited for small dogs
Compounding pharmacists will be happy to make Itraconazole and ketoconazole for you. BUT as usual with compounded medications bioavailability may not be as good as the commercial product.
If you are using ketoconazole to decrease the rate of metabolism of cyclosporine there is no obvious alternative medication. If a compounded ketoconazole is used there may be decreased bioavailability and therefore decreased efficacy. Alternatively you may need to increase the cyclosporine dose.
- Negre A, Bensignor E, Guillot J: Evidence-based veterinary dermatology: a systematic review of interventions for Malassezia dermatitis in dogs. Vet Dermatol 2008 20;1-12
- Mayer U, Glos K, Schmidt M, Power H, Bettenay SV, Mueller RS: Adverse effects of ketoconazole in dogs – a retrospective study. Vet Dermatol 2008 19;199-208