Which oral antifungal works best for toenail onychomycosis?
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Terbinafine, 250 mg daily for 12 to 16 weeks, produces higher clinical cure rates than either pulsed-dose itraconazole or weekly fluconazole (strength of recommendation [SOR]: A, multiple randomized controlled trials [RCTs]). Daily oral dosing is more effective than pulsed-dose terbinafine (SOR: A, multiple RCTs). No long-term or large studies have evaluated terbinafine's safety. However, patients who have diabetes or are older than 65 years who take terbinafine along with antihypertensives, lipid-lowering agents, or "diabetic medications," don't manifest abnormal serum liver enzymes, creatinine, or glucose levels in the short term (SOR: C, 2 small cohort studies with disease-oriented outcomes).
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