What is the most appropriate initial medication for a 65-year-old man with oral thrush (candidiasis), characterized by white, curd-like plaques on the tongue and buccal mucosa, with a history of chronic obstructive pulmonary disease (COPD) and type 2 diabetes, currently taking metformin, Solu-Medrol (methylprednisolone) and albuterol?

From the Guidelines

The most appropriate initial medication for this 65-year-old man with oral thrush is fluconazole at a dosage of 100-200 mg daily for 7-14 days. This patient has oral candidiasis (thrush), as evidenced by the white, curd-like plaques on the tongue and buccal mucosa, and given his history of chronic obstructive pulmonary disease (COPD) and type 2 diabetes, as well as his current medication regimen including metformin, Solu-Medrol (methylprednisolone), and albuterol, fluconazole offers effective systemic treatment 1. The patient's use of corticosteroids (Solu-Medrol) increases his risk for developing oral candidiasis, and fluconazole is a suitable choice for treating moderate to severe disease, which is likely in this case given the patient's multiple comorbidities.

Some key points to consider in the management of this patient include:

• The importance of good oral hygiene and proper denture care (if applicable) to prevent recurrence of oral candidiasis 1
• The need for blood glucose control, as hyperglycemia promotes fungal growth
• Potential modification of the patient's corticosteroid inhaler use, such as using a spacer and rinsing his mouth after use to prevent recurrence
• Monitoring for potential drug interactions between fluconazole and the patient's other medications, such as metformin and Solu-Medrol.

Alternative options, such as topical antifungals like nystatin suspension or clotrimazole troches, may be considered for mild disease, but given this patient's multiple risk factors for persistent infection, fluconazole is the most appropriate initial choice 1.

From the FDA Drug Label

Nystatin Oral Suspension, USP, is indicated for the treatment of candidiasis in the oral cavity. The most appropriate initial medication for a 65-year-old man with oral thrush (candidiasis) is nystatin (PO), as it is directly indicated for the treatment of candidiasis in the oral cavity 2.

• The patient's history of COPD and type 2 diabetes, and current medications, do not directly affect the choice of nystatin (PO) for oral thrush treatment.
• Nystatin (PO) is a suitable option for this patient, given its direct indication for oral candidiasis.

From the Research

Treatment Options for Oral Thrush

The most appropriate initial medication for a 65-year-old man with oral thrush (candidiasis) can be determined based on the current evidence.

• The patient's history of chronic obstructive pulmonary disease (COPD) and type 2 diabetes, as well as current medications (metformin, Solu-Medrol, and albuterol), should be considered when selecting a treatment option 3, 4.
• Fluconazole oral suspension has been found to be a very effective drug in the treatment of oral candidiasis, and is considered the drug of choice as a systemic treatment 3.
• Topical antifungal drugs, such as nystatin and miconazole, are also effective in treating oral candidiasis, but may require a longer treatment duration 5.
• Other treatment options, such as itraconazole, voriconazole, and posaconazole, may be considered for recalcitrant infections or in cases where the patient is resistant to fluconazole 6, 5.

Considerations for Treatment Selection

When selecting a treatment option, the following factors should be considered:

• The patient's health status, including any underlying medical conditions 4, 7.
• The location and severity of the infection 4, 7.
• The potential for interactions with current medications 4, 5.
• The patient's ability to tolerate the treatment regimen 3, 5.