What is the most appropriate medication for a patient with esophageal candidiasis, as indicated by linear yellow to white plaques on the esophagus, and a medical history including asthma, hepatitis C, and HIV infection?

Treatment of Esophageal Candidiasis in an HIV-Positive Patient

Fluconazole is the most appropriate medication for this patient with esophageal candidiasis, as indicated by linear yellow to white plaques on the esophageal mucosa. 1

Diagnosis

The patient's presentation is consistent with esophageal candidiasis:

• Linear yellow to white plaques on esophageal mucosa seen on EGD 1
• Difficulty swallowing for three weeks 1
• HIV infection (a major risk factor) 1
• Inhaled budesonide use (another risk factor) 2

First-line Treatment

Recommended regimen:

• Oral fluconazole 200-400 mg (3-6 mg/kg) daily for 14-21 days 1
  • Strong recommendation with high-quality evidence
  • Most effective first-line therapy for esophageal candidiasis
  • Superior to ketoconazole and comparable to itraconazole solution 1
  • Most patients show improvement within 7 days of starting therapy 1

Alternative Options (if oral therapy cannot be tolerated)

• Intravenous fluconazole 400 mg (6 mg/kg) daily 1
• Echinocandins (for patients who cannot tolerate azoles): 1
  • Micafungin: 150 mg daily
  • Caspofungin: 70-mg loading dose, then 50 mg daily
  • Anidulafungin: 200 mg daily
• Amphotericin B deoxycholate 0.3-0.7 mg/kg daily (less preferred) 1

For Fluconazole-Refractory Disease

If the patient fails to respond to fluconazole:

• Itraconazole solution 200 mg daily for 14-21 days 1
• Voriconazole 200 mg twice daily (oral or IV) for 14-21 days 1
• Posaconazole suspension 400 mg twice daily 1

Special Considerations for This Patient

• The patient has HIV infection, which is a major risk factor for esophageal candidiasis 1
• Inhaled corticosteroid (budesonide) may contribute to candidal infection 2
• Antiretroviral therapy should be optimized to reduce recurrence risk 1
• Monitor for drug interactions between fluconazole and the patient's other medications 1

Prevention of Recurrence

For patients with recurrent esophageal candidiasis:

• Chronic suppressive therapy with fluconazole 100-200 mg three times weekly 1
• Antiretroviral therapy is strongly recommended to reduce recurrence 1

Monitoring

• Assess clinical response within 7 days (most patients improve within this timeframe) 1
• Monitor for adverse effects of fluconazole: 1
  • Nausea, vomiting, diarrhea, abdominal pain
  • Transaminase elevations (periodic liver function monitoring recommended if treatment exceeds 21 days)
• Complete the full treatment course even if symptoms resolve quickly 1

Clinical Pearls and Pitfalls

• A diagnostic trial of fluconazole is appropriate and cost-effective before endoscopy in patients with suspected esophageal candidiasis 1
• Echinocandins are effective but associated with higher relapse rates than fluconazole 1
• Ketoconazole and itraconazole capsules have variable absorption and are less effective than fluconazole 1
• Acyclovir would be appropriate for herpes esophagitis but not for candidal infection 3
• Omeprazole and lidocaine may provide symptomatic relief but do not treat the underlying infection 3