VA Class: AM700
CAS Number: 65277-42-1
Serious hepatotoxicity has occurred in patients receiving oral ketoconazole, including cases that were fatal or required liver transplantation.263 384 Inform patients of the risk and monitor closely.263 384 (See Hepatotoxicity under Cautions.)
Concomitant use with certain drugs (cisapride, dofetilide, pimozide, quinidine) contraindicated because increased plasma concentrations of these drugs may occur and can lead to QT interval prolongation, sometimes resulting in life-threatening ventricular tachyarrhythmias such as torsades de pointes.263 384 (See Interactions.)
Uses for Ketoconazole
Alternative for treatment of blastomycosis caused by Blastomyces dermatitidis.220 234 263 288 291 292 299 300 384 424 Use only when other effective antifungals not available or not tolerated and potential benefits of oral ketoconazole outweigh potential risks.263 384
Drugs of choice are IV amphotericin B or oral itraconazole;288 292 296 297 298 299 332 333 424 436 oral fluconazole is an alternative.288 292 297 299 436 424 Ketoconazole has been used as an alternative,424 but may be less effective.424
Do not use to treat fungal infections that involve the CNS, including cerebral blastomycosis; ketoconazole CSF concentrations unpredictable following oral administration and treatment failures or relapses reported.192 263 288 295 384
Has been used for treatment of certain Candida infections† (e.g., oropharyngeal and/or esophageal candidiasis, vulvovaginal candidiasis, candiduria, chronic mucocutaneous candidiasis);292 320 322 323 328 334 no longer recommended and no longer labeled by FDA for Candida infections.263 384
Alternative for treatment of chromomycosis (chromoblastomycosis) caused by Phialophora;263 288 335 384 a response may not be attained in those with more extensive disease.335 Use only when other effective antifungals not available or not tolerated and potential benefits of oral ketoconazole outweigh potential risks.263 384
Alternative for treatment of coccidioidomycosis caused by Coccidioides immitis.263 280 292 293 303 304 305 384 426 Use only when other effective antifungals not available or not tolerated and potential benefits of oral ketoconazole outweigh potential risks.263 384
Drugs of choice for initial treatment of symptomatic pulmonary, chronic fibrocavitary, or disseminated coccidioidomycosis are oral fluconazole or oral itraconazole;426 436 440 441 IV amphotericin B recommended as an alternative and preferred for initial treatment of severely ill patients who have hypoxia or rapidly progressing disease, for immunocompromised patients, or when azole antifungals cannot be used (e.g., pregnant women).280 288 292 294 302 303 426 436 440 441
Do not use to treat fungal infections that involve the CNS, including coccidioidal meningitis; ketoconazole CSF concentrations unpredictable following oral administration and treatment failures or relapses reported.263 288 302 384
Alternative for treatment of histoplasmosis caused by Histoplasma capsulatum.234 263 288 291 292 293 384 428 Use only when other effective antifungals not available or not tolerated and potential benefits of oral ketoconazole outweigh potential risks.263 384
Drugs of choice are IV amphotericin B or oral itraconazole428 436 440 IV amphotericin B preferred for initial treatment of severe, life-threatening infections, especially in immunocompromised patients (including HIV-infected patients).428 436 440 Other azoles (fluconazole, ketoconazole, posaconazole, voriconazole) considered second-line alternatives to oral itraconazole.428 436
Alternative for treatment of paracoccidioidomycosis (South American blastomycosis) caused by Paracoccidioides brasiliensis.263 288 291 311 335 384 436 Use only when other effective antifungals not available or not tolerated and potential benefits of oral ketoconazole outweigh potential risks.263 384
Drug of choice for initial treatment of severe paracoccidioidomycosis is IV; amphotericin B.288 291 293 310 311 335 436 Oral itraconazole is drug of choice for less severe or localized infections and for follow-up therapy of severe infections after response has been obtained with IV amphotericin B.288 291 335 436
Has been used for treatment of sporotrichosis† caused by Sporothrix schenckii.312 313 335 429 Not recommended since it is less effective and associated with more adverse effects than some other azoles.429 Oral itraconazole is drug of choice for treatment of cutaneous, lymphocutaneous, or mild pulmonary or osteoarticular sporotrichosis and for follow-up therapy in more severe infections after a response has been obtained with IV amphotericin B.429
Has been used orally for treatment of dermatophyte infections† (e.g., tinea capitis†, tinea corporis†, tinea pedis†, tinea unguium† [onychomycosis]†);291 324 325 no longer recommended and no longer labeled by FDA for these infections.263 384
Has been used in conjunction with a topical anti-infective (e.g., miconazole, neomycin, metronidazole, propamidine isethionate) in the treatment of >Acanthamoeba keratitis†.134 135 136 137 138 139 140 225 Optimum therapy for Acanthamoeba keratitis remains to be clearly established, but prolonged local and systemic therapy with multiple anti-infectives and often surgical treatment (e.g., penetrating keratoplasty) usually required.134 135 136 137 138 139 140
A regimen of oral ketoconazole, rifampin, and co-trimoxazole has been used for treatment of chronic Acanthamoeba meningitis† in several immunocompetent children.187 442 (See Meningitis and Other CNS Infections under Cautions.)
Because of ketoconazole’s ability to inhibit testicular and adrenal steroid synthesis, the drug has been used in the treatment of advanced prostatic carcinoma†.106 107 108 151 179 180 181 182 183 184 284 285 286 368 369 Safety and efficacy not established and not labeled by FDA for this use.263 384
Has been used effectively for palliative treatment of Cushing’s syndrome† (hypercortisolism), including adrenocortical hyperfunction associated with adrenal or pituitary adenoma or ectopic corticotropin-secreting tumors.112 113 114 151 154 224 342 Safety and efficacy not established and not labeled by FDA for this use.263 384
Has been used with some success for treatment of hypercalcemia in adults with sarcoidosis†.363 364 365 366 394 395 Has reduced serum calcium concentrations in some, but not all, patients with sarcoidosis-associated hypercalcemia;364 365 366 394 395 hypercalcemia and increased serum 1,25-dihydroxyvitamin D concentrations may recur when ketoconazole dosage is decreased or the drug discontinued.365 366 Considered an alternative in patients who fail to respond to or cannot tolerate corticosteroids.363 365 393 394 395
Hirsutism and Precocious Puberty
Ketoconazole Dosage and Administration
To ensure absorption in patients with achlorhydria (see Absorption under Pharmacokinetics), some clinicians suggest administering each 200 mg of ketoconazole with an acidic beverage (e.g., Coca-Cola, Pepsi) or dissolving the dose in 60 mL of citrus juice; however, this strategy may not be adequate in all patients with achlorhydria and patients should be monitored closely for therapeutic failure.273
General Pediatric Dosage
Treatment of Fungal InfectionsOral
General Adult Dosage
Treatment of Fungal InfectionsOral
Initial dosage of 400 mg daily; if response is inadequate, some clinicians suggest dosage may be increased to 800 mg daily.220 234 288 424 Dosage of 400–800 mg daily has been used as follow-up after a response was obtained with IV amphotericin B.296 Usual duration of treatment is 6–12 months.424
200–400 mg daily.335
HIV-infected patients adequately treated for coccidioidomycosis should receive long-term suppressive or maintenance therapy (secondary prophylaxis) with oral itraconazole or oral fluconazole to prevent relapse.440
Usually treated for 6–12 weeks; more prolonged treatment (at least 12 months) may be necessary for chronic cavitary pulmonary disease or disseminated histoplasmosis.428
HIV-infected patients adequately treated for histoplasmosis should receive long-term suppressive or maintenance therapy (secondary prophylaxis) with oral itraconazole to prevent relapse.440
200–400 mg once daily.335
400 mg every 8 hours has been used for treatment of prostatic carcinoma†106 108 180 181 182 183 285 or as an adjunct in the management of disseminated intravascular coagulation (DIC) associated with prostatic carcinoma†.152 178 Risk of depressed adrenocortical function at this high dosage should be considered.263 (See Endocrine and Metabolic Effects under Cautions.)
Cautions for Ketoconazole
Concomitant use with certain drugs metabolized by CYP3A4 (e.g., alprazolam, oral midazolam, oral triazolam, eplerenone, ergot alkaloids, lovastatin, simvastatin, nisoldipine); increased plasma concentrations of these drugs may occur and increase or prolong their therapeutic and/or adverse effects.263 384 (See Interactions.)
Concomitant use with certain drugs (e.g., cisapride, dofetilide, pimozide, quinidine); increased plasma concentrations of these drugs may occur and can lead to QT interval prolongation, sometimes resulting in life-threatening ventricular tachyarrhythmias such as torsades de pointes.263 384 (See Interactions.)
Serious Adverse Effects
Serious adverse effects (e.g., hepatotoxicity, adrenal insufficiency) and drug interactions have been reported with oral ketoconazole.263 384 Use only when other effective antifungals not available or not tolerated and potential benefits of oral ketoconazole outweigh potential risks.263 384
Symptomatic hepatotoxicity usually apparent within first few months of ketoconazole therapy,50 61 164 167 168 169 170 188 189 190 191 263 384 but occasionally may be apparent within first week of therapy.164 166 167 191 263 384 Although ketoconazole-induced hepatotoxicity usually reversible following discontinuance of the drug,50 164 165 166 167 188 189 190 191 263 384 recovery may take several months;164 165 167 188 190 263 384 rarely, death has occurred.164 165 167 168 169 170 191 193 263 384
Ketoconazole-induced hepatotoxicity has been reported in patients who had no obvious risk factors for liver disease.263 384 Some cases reported in patients receiving high oral ketoconazole dosage for short treatment durations; others reported in those receiving low oral dosage for long durations.263 384 Many cases were reported in patients receiving the drug for tinea unguium (onychomycosis)†50 167 168 169 188 189 190 191 193 263 384 or chronic, refractory dermatophytoses†.167 191
Prior to initiation of oral ketoconazole, perform liver function tests, including serum AST, ALT, alkaline phosphatase, γ-glutamyltransferase (γ-glutamyltranspeptidase, GGT, GGTP), and total bilirubin, as well as PT, INR, and tests for viral hepatitides.164 166 167 169 170 188 189 190 193 263 384
During ketoconazole therapy, monitor serum ALT concentrations weekly.263 384 Prompt recognition of liver injury is essential.263 384 If ALT increases above ULN or 30% above baseline or if patient develops symptoms, interrupt ketoconazole therapy and perform full set of liver tests.263 384 Repeat liver tests to ensure that values normalize.263 384
Minor, asymptomatic elevations in liver function test results may return to pretreatment concentrations during continued ketoconazole therapy.164 167 191 193 If oral ketoconazole is restarted, monitor patient frequently to detect any recurring liver injury; hepatotoxicity has occurred following reinitiation of the drug (rechallenge).263 384
Endocrine and Metabolic Effects
Decreased adrenal corticosteroid secretion reported with ketoconazole dosage ≥400 mg.263 384 Can inhibit cortisol synthesis, particularly in patients receiving relatively high daily dosage or divided daily dosing.109 112 113 114 151 154 156 157 158 159 166 173 229 230 The adrenocortical response to corticotropin (ACTH) may be at least transiently diminished and a reduction in urinary free and serum cortisol concentrations may occur.109 110 112 113 114 151 154 156 157 158 159 166 173 Adrenocortical insufficiency reported rarely.109 159 160 166 173 229
In 350 patients receiving high-dose ketoconazole (1.2 g daily) for metastatic prostatic carcinoma, 11 deaths occurred within 2 weeks after initiation of the drug.263 384 These patients had serious underlying disease; not possible to ascertain from available information whether these deaths were related to ketoconazole or adrenocortical insufficiency.263 384
Gynecomastia reported in patients receiving ketoconazole.263 384 The drug can inhibit testosterone synthesis and transient decreases in serum testosterone may occur;109 110 151 174 263 384 concentrations usually return to baseline values after the drug discontinued.263 384 Ketoconazole dosages of 800 mg daily decrease serum testosterone levels; clinical manifestations of these decreased levels may include gynecomastia, impotence, and oligospermia.263 384
Other hypersensitivity reactions, including anaphylactoid reaction, erythema multiforme, rash, dermatitis, erythema, urticaria, and pruritus, have occurred.263 384 Acute generalized exanthematous pustulosis, photosensitivity, angioneurotic edema, alopecia, and xeroderma also reported.263 384
Meningitis and Other CNS Infections
Because CSF concentrations of ketoconazole are unpredictable following oral administration and because treatment failures or relapses have been reported, do not use to treat fungal infections that involve the CNS, including cerebral blastomycosis or coccidioidal meningitis.192 263 288 291 295 302 306 384 384
Not systematically studied in children of any age.263 384 Has been used in a limited number of children >2 years of age;263 384 essentially no information available on use in children <2 years of age.263 384
Common Adverse Effects
Interactions for Ketoconazole
Drugs Metabolized by Hepatic Microsomal Enzymes
Potential pharmacokinetic interaction with drugs metabolized by CYP3A4; possible increased concentrations of the concomitant drug and increased or prolonged therapeutic and/or adverse effects associated with the drugs.263 384
Drugs Affecting Hepatic Microsomal Enzymes
Drugs that Prolong the QT Interval
Potential interaction with drugs that are CYP3A4 substrates that prolong the QT interval; possible increased concentrations of the concomitantly administered CYP3A4 substrate which can lead to QT interval prolongation, sometimes resulting in life-threatening ventricular dysarrhythmias such as torsades de pointes.263 384 Concomitant use with these drugs contraindicated.263 384
Disulfiram reactions (flushing, rash, peripheral edema, nausea, headache) have occurred rarely in patients who ingested alcohol while receiving ketoconazole;263 267 268 384 usually resolved within a few hours263 384
Anticoagulants, oral (warfarin)
Anticonvulsants (carbamazepine, phenytoin)
Antidiabetic agents, sulfonylureas
Mefloquine: Do not use ketoconazole concomitantly with mefloquine or within 15 weeks after last mefloquine dose446
Quinine: Dosage adjustment of quinine not required; monitor closely for quinine-associated adverse effects447
Quinine: Increased quinine AUC and decreased quinine clearance447
Mefloquine: Do not use ketoconazole concomitantly with mefloquine or within 15 weeks after last mefloquine dose446
Quinine: Dosage adjustment of quinine not required; monitor closely for quinine-associated adverse effects447
Antimycobacterials (rifabutin, rifampin, isoniazid)
Antiretrovirals, HIV entry inhibitors
Maraviroc: Possible increased maraviroc concentrations200
Maraviroc: Reduce maraviroc dosage to 150 mg twice daily200
Antiretrovirals, HIV protease inhibitors (PIs)
Possible pharmacokinetic interactions if ketoconazole used in patients receiving PIs (e.g., ritonavir-boosted darunavir, fosamprenavir [with or without low-dose ritonavir], indinavir, lopinavir/ritonavir, nelfinavir, ritonavir-boosted saquinavir, ritonavir-boosted tipranavir);204 205 206 207 208 210 211 altered concentrations of the PI and/or the antifungal204 205 206 207 208 210 211
Ritonavir-boosted darunavir: Do not exceed ketoconazole dosage of 200 mg daily204
Fosamprenavir (without low-dose ritonavir): May need decreased ketoconazole dosage in those receiving >400 mg of ketoconazole daily
Indinavir (without low-dose ritonavir): Use indinavir dosage of 600 mg every 8 hours206
Lopinavir/ritonavir: Do not exceed ketoconazole dosage of 200 mg daily207
Ritonavir-boosted saquinavir: Do not exceed ketoconazole dosage of 200 mg daily210
Ritonavir-boosted tipranavir: Use concomitantly with caution; do not exceed ketoconazole dosage of 200 mg daily211
Antiretrovirals, nonnucleoside reverse transcriptase inhibitors (NNRTIs)
Delavirdine: Possible increased delavirdine concentrations212
Efavirenz: Possible decreased ketoconazole concentrations213
Etravirine: Possible increased etravirine concentrations and decreased ketoconazole concentrations214
Nevirapine: Possible decreased ketoconazole concentrations and decreased efficacy of the antifungal263
Rilpivirine: Increased rilpivirine concentrations and AUC; decreased ketoconazole concentrations and AUC226
Etravirine: Dosage adjustment of ketoconazole may be needed depending on other concomitantly administered drugs214
Nevirapine: Concomitant use not recommended263
Benzodiazepines (alprazolam, midazolam, triazolam)
Alprazolam, midazolam, triazolam: Increased benzodiazepine concentrations; possible prolonged sedative and hypnotic effects, especially in those receiving repeated or chronic therapy with the drugs263 384
HCV protease inhibitors
Boceprevir: Increased boceprevir concentrations and AUC; possible increased ketoconazole concentrations444
Telaprevir: Increased concentrations and AUCs of both drugs443
Boceprevir: If concomitant use required, do not exceed ketoconazole dosage of 200 mg daily444
Telaprevir: If concomitant use required, do not exceed ketoconazole dosage of 200 mg daily443
Histamine H2-receptor antagonists (e.g., cimetidine, ranitidine)
HMG-CoA reductase inhibitors (statins)
Immunosuppressive agents (cyclosporine, sirolimus, tacrolimus)
Cyclosporine: Careful monitoring, with possible dosage adjustment, recommended;263 384 monitor renal function and cyclosporine concentrations;146 consider reduced cyclosporine dosage or use of another immunosuppressive agent;146 patients stabilized on both drugs may require an increase in cyclosporine dosage when ketoconazole discontinued146
In vitro evidence that ketoconazole can inhibit metabolism of paclitaxel269
Clinical importance unclear; use concomitantly with caution269
Phosphodiesterase type 5 (PDE5) inhibitors (sildenafil, tadalafil, vardenafil)
Sildenafil: Manufacturer of ketoconazole recommends that initial dose of sildenafil be reduced by 50%;263 384 manufacturer of sildenafil recommends initial sildenafil dosage of 25 mg in those receiving ketoconazole445
Tadalafil: Patients receiving ketoconazole should receive no more than 10 mg of tadalafil once every 72 hours;378 if a once-daily tadalafil regimen is used, those receiving ketoconazole should receive no more than 2.5 mg of tadalafil once daily378
Vardenafil: Patients receiving ketoconazole 400 mg daily should receive no more than a single 2.5-mg dose of vardenafil in a 24-hour period; those receiving ketoconazole 200 mg daily should receive no more than a single 5-mg dose of vardenafil in a 24-hour period379
Possible decreased absorption of ketoconazole362
Pending further accumulation of data, monitor theophylline concentrations and adjust theophylline dosage if necessary when ketoconazole is initiated or discontinued in patients receiving theophylline147
Possible substantially increased plasma trazodone concentrations and potential for adverse effects380
Consider reducing trazodone dosage in patients receiving ketoconazole380
Ketoconazole must be dissolved in gastric secretions and converted to the hydrochloride salt prior to absorption from the stomach.a Bioavailability depends on the pH of the gastric contents in the stomach; an increase in pH results in decreased absorption of the drug.a (See Absorption: Special Populations.)
Effect of food on rate and extent of GI absorption of ketoconazole has not been clearly determined.162
Considerable interindividual variations in peak plasma concentrations and AUCs have been reported.a
Oral bioavailability may be decreased in patients with achlorhydria,a including those with HIV-associated gastric hypochlorhydria.198 Concomitant administration of an acidic beverage may increase bioavailability in some individuals.273 (See Oral Administration under Dosage and Administration.)
Distributed into urine, bile, saliva, sebum, cerumen, and synovial fluid.a
May be distributed into CSF following oral administration, but CNS penetration is unpredictable and has generally been considered to be minimal.a
Plasma Protein Binding
Partially metabolized in the liver to several inactive metabolites by oxidation and degradation of the imidazole and piperazine rings, by oxidative O-dealkylation, and by aromatic hydroxylation.a
Major route of elimination of ketoconazole and its metabolites appears to be excretion into the feces via the bile.a
In fasting adults with normal renal function, approximately 57% of a single 200-mg oral dose is excreted in feces within 4 days (20–65% of this is unchanged drug); approximately 13% of the dose is excreted in urine within 4 days (2–4% of this is unchanged drug).a
Plasma concentrations and half-life not substantially affected by renal or hepatic impairment.a
Actions and Spectrum
Presumably exerts its antifungal activity by altering cellular membranes resulting in increased membrane permeability, leakage of essential elements (e.g., amino acids, potassium), and impaired uptake of precursor molecules (e.g., purine and pyrimidine precursors to DNA).127 128 130 131 Inhibits cytochrome P-450 14-α-desmethylase in susceptible fungi, which leads to accumulation of C-14 methylated sterols (e.g., lanosterol) and decreased concentrations of ergosterol.128 129 130 151
Spectrum of antifungal activity includes many fungi, including yeasts and dermatophytes.263 384 a Has some in vitro activity against some gram-positive bacteria (e.g., staphylococci, Nocardia) and some protozoa (e.g., Acanthamoeba, Leishmania).134 135 136 a
Candida: Active in vitro and in vivo against C. albicans,120 121 122 123 124 373 C. dubliniensis,283 and some strains of C. glabrata,120 122 123 124 373 C. lusitaniae,289 C. parapsilosis,373 and C. tropicalis.373
Other fungi: Active against Blastomyces dermatitidis,263 371 384 Coccidioides immitis,263 384 Cryptococcus neoformans,263 373 384 Histoplasma capsulatum,263 384 Paracoccidioides brasiliensis,263 384 Penicillium marneffei,389 390 and Phialophoa.263 384 Also active against Actinomadura madurae, Aspergillus flavus,120 122 124 A. fumigatus,122 124 Malassezia furfur (Pityrosporum orbiculare),a Petriellidium boydii,120 122 and Sporothrix schenckii.120 122 124 May be active against some strains of Exophiala castellanii275 and Scopulariopsis, including some strains of S. acremonium and S. brevicaulis.374
Ketoconazole-resistant Candida may be cross-resistant to other azole antifungals (e.g., fluconazole, itraconazole).337
In vitro and in vivo studies indicate ketoconazole can directly inhibit synthesis of adrenal steroids and testosterone.109 110 112 113 114 115 116 117 148 151 154 156 157 158 159 160 161 171 172 173 174 175 176 Appears to inhibit steroid synthesis principally by blocking several P-450 enzyme systems (e.g., 11β-hydroxylase, C-17,20-lyase, cholesterol side-chain cleavage enzyme).112 114 117 151 152 154 155 157 158 159 171 172 173 174 175 176 201
Inhibits cortisol synthesis in a dose-dependent manner in individuals with normal adrenocortical function and in patients with Cushing’s syndrome (hypercortisolism).109 112 113 114 151 154 156 157 158 159 166 173
Advice to Patients
Advise patients that oral ketoconazole is used only for treatment of certain serious fungal infections and is prescribed only when other effective antifungals not available or not tolerated and potential benefits of the drug outweigh potential risks.263 384
Risk of hepatotoxicity; importance of reporting any signs or symptoms of possible hepatic dysfunction (e.g., unusual fatigue, anorexia, nausea and/or vomiting, abdominal pain, jaundice, dark urine, pale feces) to their clinician.167 168 188 189 263 384
Risk of QT interval prolongation, especially if certain medications are used concomitantly.263 384 Importance of informing their clinicians if they have had an abnormal ECG or have a family member with a history of congenital long QT syndrome.263 384 Importance of contacting their clinicians if symptoms of QT interval prolongation occur (e.g., feeling faint, lightheaded, dizzy, irregular or fast heart beat).263 384
Risk of adrenal insufficiency if high dosage is used.263 384 Importance of informing their clinicians if they have a history of adrenal insufficiency.263 384 Importance of contacting their clinicians if symptoms of adrenal insufficiency occur (e.g., tiredness, weakness, dizziness, nausea, vomiting).263 384
Risk of hypersensitivity reactions.263 384 Importance of discontinuing ketoconazole and immediately contacting their clinicians if signs of an allergic reaction occur (e.g., rash, itching, hives, fever, swelling of lips or tongue, chest pain, trouble breathing).263 384
Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.
Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.
* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name
AHFS DI Essentials. © Copyright, 2004-2016, Selected Revisions February 27, 2014. American Society of Health-System Pharmacists, Inc., 7272 Wisconsin Avenue, Bethesda, Maryland 20814.
Only references cited for selected revisions after 1984 are available electronically.
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