The Bay Area Reporter - November 3, 1995
G'dali Braverman, ACT UP/Golden Gate Writers Pool

Having a fungal infection on your tongue, in your mouth, or down your throat may seem like child's play when compared to some of the life-threatening infections PWAs face. Talk to someone suffering through recurrent or persistent yeast infections and you'll hear otherwise! That thick coat of white cheesy substance can make your life miserable. Thrush can have a dangerous impact on one's ability to eat, affect one's approach to intimacy, and be generally painful and upsetting.

To date, many physicians have relied upon mycelex troches (clotrimazole) for treatment of thrush. Patients are prescribed the lozenges, which are sucked on throughout the day. While patients don't complain about taste, convenience is an issue and efficacy rates vary widely. Some physicians prescribe nystatin rinse, a liquid solution that patients swish and gargle. Still others rely upon fluconazole (diflucan) or itraconazole (sporanox; informally called "itra") for patients at later stages of HIV disease or patients with more severe thrush. Clinical trials comparing these treatment have been, at best, limited.

Recent data from three studies was presented at the September '95 ICAAC (Interscience Conference on Antimicrobial Agents and Chemotherapy) meeting. The studies shed new light on the management of thrush in HIV/AIDS patients.

The first study compared two dose regimens of a new oral solution of itraconazole to fluconazole capsules. A total of 244 patients with Oral Candidiasis were randomly assigned to receive either itraconazole solution 100 mg twice a day for 7 days, itra solution 100 mg per day for 14 days, or fluconazole capsules 100 mg per day for 14 days. The results showed that while only 84% of patients receiving itra for seven days responded to treatment, there was no difference between the 14 day treatments of either drug; 91% of patients showed clinical response, and 24% of patients relapsed by day 18, regardless of treatment.

The second study used slightly different regimens of the same treatments and focused on patients with Oral-pharyngeal Candidiasis. Patients either received itra 200 mg per day for seven days, itra 200 mg per day for 14 days, or fluconazole 100 mg per day for 14 days. The mean CD4 count for patients entering this study was 146. The results of this study indicated that itra was at least as effective as fluconazole, with the 14-day itra patients showing the best clinical responses (97%) and least relapse. Half the patients who responded to treatment did relapse after 35 days.

The results of these two studies have significant clinical implications. Many physicians have previously resisted prescribing fluconazole for several reasons. First off, fluconazole is very expensive when used as a chronic (daily) suppressive therapy. For public health centers this cost is a major consideration. Of course, HMOs don't look kindly upon expensive prescriptions either. From an epidemiological vantage point, physicians have been concerned by the potential development of fluconazole resistance. Since fluconazole has been used as the standard of care maintenance therapy for life-threatening infections such as cryptococcal meningitis, it is important to preserve its viability.

Finally, fluconazole poses drug interaction concerns with compounds such as rifabutin and possibly protease inhibitors. These first two studies of candidiasis provide clinicians with an ethical and scientifically sound rationale for not prescribing fluconazole capsules as first-line therapy.

The third study compared 100 mg daily fluconazole suspension (liquid formulation) to nystatin liquid 5 ml four times per day. The 166 AIDS patients enrolled were treated for 14 days and evaluated at days 0, 3, 7, and 14. Patients showing complete response were then seen 28 and 42 days later. Results showed that at day 14, 87% of patients receiving fluconazole (and only 49% of those receiving nystatin) had complete resolution. Laboratory analysis showed culture negativity in 61% of patient isolates taken from those treated with fluconazole, as opposed to only 7% negative in the nystatin group. Relapse rates amongst responders favored those treated with fluconazole at day 28, with no significant difference at day 42. The clear conclusion was superiority of fluconazole liquid over nystatin rinse.

While these three studies provide patients and clinicians with new data to guide us through treatment options, there are still many questions left unanswered. We know that itraconazole in the pill formulation is susceptible to degradation when taken with rifabutin (for MAI) or rifampin (for TB). Does the same effect hold true for the liquid formulation of itraconazole? We also know that bioavailability of itra pills increases 30% when taken with food and Coca-Cola. Will acid-levels impact on effect of the liquid formulation? Researchers will need to study these issues more closely.

While all this scientific information is truly important, it is critical to note that changes in diet can be central to effecting thrush. Cutting back on foods that yeast feeds on is an excellent adjunctive therapy. Particularly at earlier stages of HIV infection, dietary management of thrush can be highly effective. This means reducing sugar and alcohol intake. It's amazing to see just how much relief one can get by reducing a yeast culprit such as beer. For more tips on management of persistent and recurrent oral-pharyngeal candidiasis ask your physician to refer you to an HIV nutritionist. Ongoing consultations should be made as one's health status changes.
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