title: Pulse versus continuous terbinafine for onychomycosis: a randomized, double-blind, controlled trial.
abstract: BACKGROUND
  Effective treatments for onychomycosis are expensive. Previous studies suggest that less costly, pulsed doses of antifungal medications may be as effective as standard, continuous doses. Terbinafine is the current treatment of choice for toenail onychomycosis.
  
  
  OBJECTIVE
  Our purpose was to determine whether pulse-dose terbinafine is as effective as standard continuous-dose terbinafine for treatment of toenail onychomycosis.
  
  
  METHODS
  We conducted a double-blind, randomized, noninferiority, clinical intervention trial in the Minneapolis Veterans Affairs Medical Center. The main inclusion criteria for participants were a positive dermatophyte culture and at least 25% distal subungual clinical involvement. Six hundred eighteen volunteers were screened; 306 were randomized. Terbinafine, 250 mg daily for 3 months (continuous) or terbinafine, 500 mg daily for 1 week per month for 3 months (pulse) was administered. The primary outcome measure was mycological cure of the target toenail at 18 months. Secondary outcome measures included clinical cure and complete (clinical plus mycological) cure of the target toenail and complete cure of all 10 toenails.
  
  
  RESULTS
  Results of an intent-to-treat analysis did not meet the prespecified criterion for noninferiority but did demonstrate the superiority of continuous-dose terbinafine for: mycological cure of the target toenail (70.9% [105/148] vs 58.7% [84/143]; P =.03, relative risk [RR] of 1.21 [95% confidence interval (CI), 1.02-1.43]); clinical cure of the target toenail (44.6% [66/148] vs 29.3% [42/143]; P =.007, RR =1.52 [95% CI, 1.11-2.07); complete cure of the target toenail (40.5% [60/148] vs 28.0% [40/143]; P =.02, RR=1.45 [95% CI, 1.04-2.01); and complete cure of all 10 toenails (25.2% [36/143] vs 14.7% [21/143]; P =.03, RR =1.71 [95% CI, 1.05-2.79). Tolerability of the regimens did not differ significantly between the groups (chi2 =1.63; P =.65).
  
  
  CONCLUSIONS
  The study population primarily consisted of older men with severe onychomycosis.
  
  
  CONCLUSIONS
  This study demonstrated the superiority of continuous- over pulse-dose terbinafine. We also found this expensive therapy to be much less effective than previously believed, particularly for achieving complete cure of all 10 toenails.
authors.affiliation: Center for Chronic Disease Outcomes Research, Minneapolis, Minnesota, USA. erin.warshaw@med.va.gov
authors.forename: Erin M
authors.initials: EM
authors.lastname: Warshaw
authors.forename: Debra D
authors.initials: DD
authors.lastname: Fett
authors.forename: Hanna E
authors.initials: HE
authors.lastname: Bloomfield
authors.forename: Joseph P
authors.initials: JP
authors.lastname: Grill
authors.forename: David B
authors.initials: DB
authors.lastname: Nelson
authors.forename: Vicente
authors.initials: V
authors.lastname: Quintero
authors.forename: Susan M
authors.initials: SM
authors.lastname: Carver
authors.forename: Gary R
authors.initials: GR
authors.lastname: Zielke
authors.forename: Frank A
authors.initials: FA
authors.lastname: Lederle
mesh_terms: D000368:Aged; D000935:Antifungal Agents / Q000008:administration & dosage* / Q000009:adverse effects; D004311:Double-Blind Method; D005260:Female; D005533:Foot Dermatoses / Q000188:drug therapy; D006801:Humans; D008297:Male; D009281:Naphthalenes / Q000008:administration & dosage* / Q000009:adverse effects; D014009:Onychomycosis / Q000188:drug therapy*; D020551:Pulse Therapy, Drug; D013607:Tablets; D000077291:Terbinafine; D016896:Treatment Outcome
chemical_list: D000935:Antifungal Agents; D009281:Naphthalenes; D013607:Tablets; D000077291:Terbinafine