From the Guidelines
Candidal esophagitis is primarily associated with immunocompromised states, including HIV/AIDS, diabetes mellitus, malignancies, organ transplantation, and use of immunosuppressive medications such as corticosteroids, and treatment typically involves antifungal therapy with fluconazole as the first-line option, administered at 200-400 mg on day one, followed by 100-200 mg daily for 14-21 days, as recommended by the most recent guidelines 1. The underlying conditions associated with candidal esophagitis include:
- Immunocompromised states, such as HIV/AIDS, diabetes mellitus, malignancies, organ transplantation, and use of immunosuppressive medications such as corticosteroids
- Broad-spectrum antibiotic use
- Proton pump inhibitor therapy
- Esophageal motility disorders
- Advanced age The treatment of candidal esophagitis typically involves antifungal therapy, with fluconazole being the first-line option, due to its effectiveness in disrupting fungal cell membrane synthesis, preventing Candida growth, and allowing the esophageal mucosa to heal 1. For severe cases or fluconazole-resistant infections, alternatives include:
- Itraconazole (200 mg daily)
- Voriconazole (200 mg twice daily)
- Intravenous amphotericin B (0.3-0.7 mg/kg/day) for critically ill patients Patients with HIV should receive antiretroviral therapy to improve immune function, as recurrence rates are high without addressing the underlying immunodeficiency, and those with diabetes should optimize glycemic control 1. It is essential to note that the effectiveness of antifungal therapy and the management of underlying conditions are crucial in preventing recurrence and improving patient outcomes, as supported by the guidelines and studies 1.
From the FDA Drug Label
The efficacy of oral voriconazole 200 mg twice daily compared to oral fluconazole 200 mg once daily in the primary treatment of EC was demonstrated in Study 150-305, a double-blind, double-dummy study in immunocompromised patients with endoscopically-proven EC. Patients were treated for a median of 15 days (range 1 to 49 days) Outcome was assessed by repeat endoscopy at end of treatment (EOT). A successful response was defined as a normal endoscopy at EOT or at least a 1 grade improvement over baseline endoscopic score.
Candidal Esophagitis Associations: The underlying conditions associated with candidal esophagitis include being immunocompromised. The treatment of candidal esophagitis includes oral voriconazole 200 mg twice daily or oral fluconazole 200 mg once daily. Voriconazole and fluconazole showed comparable efficacy rates against EC, with success rates of 98.2% and 95.0% respectively in the per protocol population, and 87.5% and 89.5% respectively in the intent-to-treat population 2. The most common Candida species associated with esophageal candidiasis are C. albicans and C. glabrata. Mycological eradication rates were 84% for C. albicans and 57% for C. glabrata with voriconazole, and 79% for C. albicans and 25% for C. glabrata with fluconazole 2.
From the Research
Underlying Conditions Associated with Candidal Esophagitis
- Immunocompromised patients, including those with HIV/AIDS, leukemia, diabetes, and those receiving corticosteroids, radiation, and chemotherapy, are at high risk of developing candidal esophagitis 3
- Patients with esophageal motility disorders, such as cardiac achalasia and scleroderma, are also at risk 3
- Frequent use of antibiotics can increase the risk of developing candidal esophagitis 3
Symptoms of Candidal Esophagitis
- Pain on swallowing
- Difficulty swallowing
- Pain behind the sternum 3
- Presence of a plaque that often occurs together with oral thrush 3
Diagnosis of Candidal Esophagitis
- Endoscopic examination is the best approach to diagnose candidal esophagitis by directly observing the white mucosal plaque-like lesions and exudates adherent to the mucosa 3
- Histological confirmation by taking a biopsy or brushings of yeast and pseudohyphae invading mucosal cells 3
Treatment of Candidal Esophagitis
- Systemic antifungal drugs, such as fluconazole, given orally in a defined course, are effective in treating candidal esophagitis 3, 4, 5, 6
- Caspofungin is also effective in treating candidal esophagitis, particularly in patients with advanced HIV infection 5
- Itraconazole is another option, although it may have a lower cure rate compared to fluconazole 6
- Newer antifungals, such as voriconazole, may be used in cases of refractory mucosal candidiasis 7