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Palliative cancer care - oral problems - Management
Which oral antifungal is recommended?
- In immunocompetent people, oral fluconazole is recommended for second-line treatment if candidiasis persists.
- In immunocompromised people, oral fluconazole is generally preferred for first-line treatment.
[BNF 52, 2006]
Basis for recommendation
- Oral antifungals are reserved for widespread (e.g. evidence of oesophageal candidiasis) or severe infection, or when topical anticandidals are not tolerated or are ineffective [BNF 52, 2006]:
- Ketoconazole is less commonly used, following the Committee on Safety of Medicines (CSM) advice that it should not be used for superficial fungal infections because of rare reports of liver damage [CSM, 1983; CSM, 1984].
- Itraconazole is an alternative but it should only be used in cases of fluconazole-resistant candidiasis. It is less suitable for people at high risk of heart failure. Although reports of heart failure have been rare, the risk seems to be higher in elderly people, people with cardiac disease, people taking negative inotropic drugs (e.g. calcium-channel blockers), and people taking high doses or receiving longer treatment courses [CSM, 2001].
- Fluconazole is more reliably absorbed and has a lower risk of systemic adverse effects and drug interactions than itraconazole and it is therefore the preferred treatment when an oral antifungal is considered appropriate.
- CKS recommends seeking specialist advice before initiating itraconazole in people who have not responded to a course of fluconazole due to the possibility of underlying disease and the increased risk of drug interactions and adverse effects.
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