From the Guidelines
For oropharyngeal candidiasis that has failed treatment with fluconazole and itraconazole, the recommended approach is to use posaconazole suspension at 400 mg twice daily for 3 days, then 400 mg daily for up to 28 days, as it is efficacious in approximately 75% of patients with azole refractory oropharyngeal and/or esophageal candidiasis 1.
Treatment Options
- Posaconazole suspension is the preferred oral alternative due to its efficacy and broad spectrum of activity against Candida species, including those resistant to fluconazole and itraconazole 1.
- Voriconazole is also an option, but its use is limited by potential drug interactions and toxicity 1.
- Amphotericin B, either oral or intravenous, can be used for severe or refractory cases, but its use is associated with more side effects and requires close monitoring 1.
- Echinocandins, such as caspofungin or micafungin, are effective alternatives for refractory candidiasis, but their use is typically reserved for severe cases or those with limited treatment options 1.
Important Considerations
- Addressing underlying factors that contribute to treatment failure, such as immunosuppression, poor oral hygiene, or continued use of inhaled corticosteroids, is crucial for successful treatment 1.
- Patients should be advised to maintain good oral hygiene, avoid alcohol and tobacco, and complete the full course of medication even if symptoms improve quickly 1.
- The use of antiretroviral therapy (HAART) in HIV-infected patients can help reduce the frequency of oropharyngeal candidiasis and improve treatment outcomes 1.
From the FDA Drug Label
For patients with oropharyngeal candidiasis unresponsive/refractory to treatment with fluconazole tablets, the recommended dose is 100 mg (10 mL) b.i.d. Patients may be expected to relapse shortly after discontinuing therapy.
The treatment for oropharyngeal candidiasis after failure of fluconazole and itraconazole is Itraconazole oral solution 100 mg b.i.d. 2.
- Dose: 100 mg (10 mL) twice a day
- Expected response: Clinical response will be seen in 2 to 4 weeks
- Relapse: Patients may be expected to relapse shortly after discontinuing therapy 2.
From the Research
Treatment Options for Oropharyngeal Candidiasis
After failure of fluconazole and itraconazole, the following treatment options can be considered:
- Caspofungin: A study published in 2003 3 reported the successful treatment of a patient with AIDS who had oropharyngeal candidiasis resistant to fluconazole and itraconazole.
- Voriconazole: Although not directly mentioned as a treatment option after failure of fluconazole and itraconazole, a study published in 2003 3 reported the use of voriconazole in a patient with oropharyngeal candidiasis, but it was discontinued due to resistance.
- Amphotericin B: A study published in 2003 3 reported the use of amphotericin B in combination with 5-flucytosine in a patient with oropharyngeal candidiasis, but the patient failed to respond.
- Echinocandins: A review published in 2019 4 mentioned echinocandins, such as anidulafungin and caspofungin, as available novelties for the treatment of oral candidiasis.
- Isavuconazole: A review published in 2019 4 mentioned isavuconazole as a new triazole available for oral and intravenous use.
- Other systemic treatment alternatives: A review published in 2019 4 mentioned other systemic treatment alternatives, such as posaconazole, and new drugs, such as ibrexafungerp, or the use of antibodies, cytokines, and antimicrobial peptides.
Considerations
When treating oropharyngeal candidiasis after failure of fluconazole and itraconazole, it is essential to consider the following:
- Resistance patterns: The patient's infection may be resistant to multiple antifungal agents, making treatment more challenging.
- Treatment history: The patient's previous treatment history should be taken into account when selecting a new treatment option.
- Side effects: The potential side effects of each treatment option should be considered, especially when using systemic antifungal agents.
- Patient factors: The patient's underlying health conditions, such as HIV status, should be considered when selecting a treatment option.