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Palliative cancer care - oral problems - Management
When should I prescribe treatment to prevent oral candidiasis following radiotherapy and chemotherapy?

  • Seek specialist advice to discuss the prophylactic prescribing of an antifungal drug.
  • Choose an antifungal drug that is partially (e.g. topical miconazole) or fully (e.g. systemic fluconazole) absorbed from the gastrointestinal tract.
Clarification / Additional information
  • Prophylactic prescribing of an antifungal is likely to be appropriate in people at high risk of oral candida infection and in those for whom it is important to prevent the disease.
  • Oral candidiasis is a potential adverse effect of cancer treatment, and complications may result in a further deterioration of the physical state. Prevention of superficial infection is important because of its possible role in the development of systemic fungal infection. Systemic infection is difficult to diagnose early and consequently cure because it rapidly becomes advanced and disseminated, leading to considerable morbidity and mortality [Worthington et al, 2004a].
  • Doses and frequencies of antifungals used in trials vary.
  • Fluconazole 50 to 400 mg daily is licensed (in adults) for prevention of fungal infections in immunocompromised people.
    • Fluconazole 400 mg daily is licensed if the risk of systemic infections is high e.g. following bone-marrow transplantation.
  • Itraconazole is licensed (in adults) for prevention of deep fungal infections in special circumstances (see the Summary of Product Characteristics [SPC] for more information).
  • Ketoconazole 200 mg daily is licensed (in adults) for prophylaxis in immunosuppressed people.
  • Miconazole 20 mg/g, 5 to 10 mL four times a day is licensed for prevention of fungal infections.
Basis for recommendation
  • The basis for recommendation is a Cochrane review [Worthington et al, 2004a]:
    • There is evidence that treatment with oral antifungal drugs that are completely or partially absorbed from the gastrointestinal tract are effective in preventing oral candidiasis.
    • There is no evidence on the effect of prevention of oral candidiasis on general well-being or that effective prophylaxis is associated with a reduction in systemic disease. Little evidence is available on drug toxicity and development of microbial drug resistance, and further information is required.
    • In people with immunosuppression after cancer treatment, non-absorbed antifungal drugs (nystatin, amphotericin B) may be no more effective than placebo at preventing candidiasis. There is insufficient evidence to recommend whether antifungal prophylaxis is effective in adults having radiotherapy.
    • Evidence is insufficient to determine whether intermittent or continuous prophylaxis with antifungal agents is more likely to prevent antifungal resistance.

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