Fluconazole is one of those drugs that has a ton of drug interactions. If you don’t believe me, here’s a classic blast from the past! Here’s a different scenario where I breakdown the fluconazole clopidogrel interaction and some thoughts on how to best manage this drug interaction.
A 59 year old male with orapharengeal candidiasis is prescribed fluconazole 100 mg daily for 14 days. He is currently taking clopidogrel. Clopidogrel is a prodrug that is metabolized to its active for by CYP2C19. Fluconazole can inhibit this enzyme potentially leading to lower concentrations. Whether this matters and how much it matters clinically is the million dollar question that no one will likely be able to perfectly predict. However, there are some critical questions that we can ask to potentially avoid this combination or minimize the risk of problems due to the interaction.
- Is there an alternative to fluconazole. There may not be, but in this situation assessing if something like topical clotrimazole or nystatin is an option would be my likely first step.
- If fluconazole is absolutely necessary, I would inquire about the severity of the infection and the possibility of limiting the duration to 7 days and reassess.
- Is clopidogrel warranted long term? Depending upon the indication, clopidogrel may not be being used for the long term. In the unlikely event of this and if fluconazole is necessary, clopidogrel could potentially be discontinued.
- Consider an alternative to clopidogrel? This isn’t real high on my list to change a likely long term drug due to a short term drug, but the thought crossed my mind to consider prasugrel. Also, looking at if the patient is on aspirin and the indication for clopidogrel would be significantly important if looking at changing up clopidogrel.
- Do nothing. When it comes to drug interactions, this is often a choice that is made. It is pretty hard to monitor for a drug interaction like this one because if we are wrong and we should have done something, there is a very small chance that a really bad thing could happen (i.e. heart attack or stroke).
Any other ideas on this one?
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I am suspect this a clinically significant drug-drug interaction. It is a short, temporary course. Fluconazole seems to have less severe interactions than other systemic antifungals (e.g. ketoconazole). Genetic polymorphisms for Plavix may account for more variability than these light drug-drug interactions. Still, if it were my grandmother maybe push for nystatin swish and spit if it’s a simple case of thrush.
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