Today on the Doc on the Run podcast, we’re talking about a couple of options you have if you are thinking about taking oral medications for toenail fungus.
Lots of runners get funky toenails, we know this. People get bruised toenails, they get black toenails. All of this happens from banging your toes on the inside of the shoes during long runs, speed sessions, and when you are stopping, changing direction, and frankly, sometimes when you have shoes that don’t fit you correctly.
Well, all of that damage to the nail can show up in a couple of ways. When it first shows up and you have a bruise under the nail, it is lifting the nail plate up off of the nail bed, it is also traumatizing it, it is beating it up, that is why it is black and blue. As a consequence of that, it can get thicker.
The worst thing though is if the nail lifts up off the nail bed and you get fungal filaments that cause athlete’s foot underneath the toenail, then you get toenail fungus or onychomycosis. Well, if you happen to see somebody who your doctor recommends oral antifungal medications, a lot of people get worried about this. And the reason for this episode is I saw a runner today and I was talking to his primary care doctor about potentially modifying the normal routine for oral medication for him so that he could reduce his concern for having liver problems as a consequence of taking this medication because obviously runners are healthy.
You don’t want to be unhealthy just because you took a pill. Well, his primary care doctor said to me, and by the way, this is not medical advice for you, I’m just telling you about this discussion we had today because I think it is interesting and maybe something to discuss with your own doctor.
The first thing is his doctor reflexively said, it is totally safe, it is very rare when people get liver failure. That is true, it is very safe. However, it is not risk-free and the runner was actually very concerned and he said, “I’m not taking it. My doctor said that you could get liver damage and if you check a blood test later and you find out you have liver damage, it is too late.” And I said, “Well, that is kind of true.” However, a lot of times if you think about this, the routine is really simple.
For this particular medication, the normal routine as recommended by the manufacturers of the medication that got FDA approval for that medication say, you should check the patient’s liver function tests at the beginning of taking the oral antifungal medication to see if your liver’s healthy enough that we should suspect that it would tolerate it. Okay, great. So, you don’t have any history of liver problems like cirrhosis or something like that or hepatitis and you seem healthy, and the blood test confirms that you are healthy.
You don’t have any history that would prevent you from taking this medication. We take a blood test, your liver function looks normal and then we start the medication. Okay. That is all that is actually required. There’s no further testing required. However, when the medication first came out for many years, there was an additional step and that was that halfway through the course of medication, which is the typical routine is 90 days is that halfway through at about six weeks, we would actually check your liver function again and make sure that it is still okay.
If it was not okay, then we would stop it and I, truthfully, I did have one patient who actually had an elevation in his liver enzymes and we stopped the medication. Fortunately, his liver enzymes did normalize and there wasn’t any more concern, but he was not able to finish the course of medication. So in his case, it was effectively reversible, this elevation of the liver blood test, but this runner, again, very concerned about this. And so, I talked to his doctor and I said, “Okay, well, look, why don’t we do this? How about if we give him not 90 days, not even six weeks, but we just do the two-week short course, 14 days that we would normally give somebody for really bad athlete’s foot. We just give him two weeks of it.” Like that is not going to kill anybody.
He is a low risk. He doesn’t have any of these other risk factors for trouble with his liver. Let’s give him 14 days and at the end of 14 days, then we would check it and look at his liver function to make sure his liver enzymes as shown in the blood test are not elevated at all. And if they’re not elevated at all at two weeks, well, then maybe we could continue him on a course, even a modified course with a little bit dosing regimen to keep his concern down again, but we actually keep him on the medication. And then we check it again at four weeks or six weeks or eight weeks or other intervals to make sure that his liver enzymes don’t ever go up.
Now, that is not a normal routine, but it is the sort of thing where if you really stop and think about it, if you are worried about a bad thing happening and you check it frequently more often, that is way better than going for weeks or months and then finding out you had a big problem. And so, his primary care doctor said, yeah, that is a great idea. Let’s do that. That seems about the right way to go about this with him and that is what we’re going to do.
It doesn’t mean it’d be right for you, but this is the sort of thing that you as a runner have to think about. If you really want to stay healthy, you have to think about what is actually best for you, not just what is the process that people normally use. Runners have to be treated different.
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