Just a word from a fledgling prescriber, humble in the presence of
greatness, daring to venture a comment:
Because the prescription oral antifungals are marketed directly to the
public (ostensibly so that the patients/clients can advocate for their own
treatment options) it is easy to imagine that they are pretty benign
substances. But there are some serious things to think about concerning oral
fluconazole and her sister antifungals. One is impairment of liver function,
so the prescriber has to consider monitoring liver function tests, wondering
if baseline info is available. The prescriber might also be starting to
wonder what kind of yeast is really involved and whether a culture of the
milk will yield valuable information. Then he/she wonders whether the
foremilk or the hind milk would be the stuff to culture, and lacking clear
guidelines, figures maybe we need to culture both. The prescriber wonders
what kind of yeast is involved because there are other antifungals to
consider, such as ketoconazole which is indicated for mucosal candidiasis
and candiduria. The poor prescriber searches every where for something to
tell him/her specifically about ductal yeast infections and comes up with
not much more than Dr. Newman's article. Maybe something from Tom Hale. But
seeing the cautions about fatal arrhythmias associated with oral antifungals
and worrying about creating resistant strains with incorrect
prescribing.....this is all hard on the poor prescriber who definitely can't
digest all this in a 15 minute office visit or in a 5 minute phone call.
I don't for one minute say that Dr. Newman's suggestions aren't perfectly
correct. He has taken the time to explore the subject and come up with
well-thought out plans. But there are limitations inherent in being a lone
voice in the wilderness. Very few prescribers are going to risk their
licenses and malpractice records on the exhortations of the one lone voice.
If a patient gets hurt, juries are notoriously unimpressed with that kind of
justification for treatment. That's just the way things are in medicine
today.
So I don't blame the doctor involved one bit. I wish he or she DID feel
comfortable with Dr. Newman's suggestions but I can't blame the poor thing.
I'm sorry you had to be the target of the doctor's frustration with trying
to prescribe in an environment where drug companies enlist the help of
patients/clients to sell their wares and then insurance companies stomp on
any treatments that seem to be outside the norm. Talk about being between a
rock and a hard place!
Is there an adult/women's health nurse practitioner IBCLC in your area? She
would be the one for your client to go to. I am going to be just such a
person but not until June 2001 when I sit for my exams and begin practice
here in the Boston area. I would love to be in contact with other NP-IBCLCs
out there, especially to know how they handle ductal yeast. Maybe I could
put together the case reports for my master's thesis! That's what we really
need, more journal published articles on this subject. That is what would
reassure the doctor in question. Maybe Dr. Newman's article has been
published in a journal already and if so, that is what should be brought to
the attention of the doctors.
Anyone with input is welcome to reply to me privately, since I will be out
of the country NOMAIL until July 12.
Loni, I hope you will let me know how it finally works out. Thank you for
sharing this with us and I hope you will forgive me for piping up like this.
Bonny Nothern, RN, IBCLC
MSN-nurse practitioner candidate, adult primary care and women's health
Massachusetts General Hospital, Institute of Health Professions
Private practice LC 1993-1998, at which point I lost my mind and started
graduate school full-time, having three teenage children, and a husband
working 80 hours a week for an internet start-up (MotherNature.com)........I
really need this vacation..............
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