Clotrimazole treatment for prevention of oral candidiasis in patients with acute leukemia undergoing chemotherapy. Results of a double-blind study

Antagonism of the transient receptor potential melastatin‑2 channel leads to targeted antitumor effects in primary human malignant melanoma cells

Melanoma continues to be the most aggressive and devastating form of skin cancer for which the development of novel therapies is required. The present study aimed to determine the effects of antagonism of the transient receptor potential melastatin‑2 (TRPM2) ion channel in primary human malignant melanoma cells. TRPM2 antagonism via use of the antifungal agent, clotrimazole, led to decreases in cell proliferation, as well as dose‑dependent increases in cell death in all melanoma cell lines investigated. The targeting of TRPM2 channels was verified using TRPM2 knockdown, where treatment with TRPM2 small‑interfering RNA led to similar levels of cell death in all melanoma cell lines when compared with clotrimazole treatment. Minimal effects on proliferation and cell death were observed following antagonism or knockdown of TRPM2 in non‑cancerous human keratinocytes. Moreover, characteristics of TRPM2 were explored in these melanoma cells and the results demonstrated that TRPM2, localized to the plasma membrane as a non‑specific ion channel in non‑cancerous cells, displayed a nuclear localization in all human melanoma cell lines analyzed. Additional characterization of these melanoma cell lines confirmed that each expressed one or more established multidrug resistance genes. Results of the present study therefore indicated that antagonism of the TRPM2 channel led to antitumor effects in human melanoma cells, including those that are potentially unresponsive to current treatments due to the expression of drug resistance genes. The unique cellular localization of TRPM2 and the specificity of the antitumor effects elicited by TRPM2 antagonism suggested that TRPM2 possesses a unique role in melanoma cells. Collectively, the targeting of TRPM2 represents a potentially novel, efficacious and readily accessible treatment option for patients with melanoma.

Antifungal agents in preventing oral candidiasis in clinical oncology: A network meta-analysis

OBJECTIVE

This review examined the comparative efficacy and safety of antifungal agents in preventing oral candidiasis among patients on cancer treatment.

METHODS

We performed a systematic review and network meta-analysis based on randomised controlled trials that compared antifungal agents to placebo or other antifungal agents used in patients undergoing cancer treatment. Relative ranking of antifungal agents was evaluated with surface under the cumulative ranking (SUCRA) probability score. A total of 20 randomised controlled trials (3,215 participants) comparing 11 interventions were included.

RESULTS

Compared with placebo, clotrimazole was ranked the best agent for preventing the incidence of oral candidiasis (risk ratio (RR), 0.21 [95% CI 0.08 to 0.55]; SUCRA = 0.89). Fluconazole was ranked the safest among other antifungal agents (SUCRA = 0.80), whereas clotrimazole (SUCRA = 0.36) and amphotericin B (SUCRA = 0.18) were ranked low for safety. Amphotericin B was associated with highest risk of adverse events (RR, 3.52 [95% CI 1.27 to 9.75]).

CONCLUSION

Clotrimazole is the most effective in preventing oral candidiasis, whereas fluconazole has the most favourable risk-benefit profile in patients undergoing cancer treatment. However, we are unable to recommend clotrimazole as the best choice to prevent oral candidiasis due to unavailability of studies comparing clotrimazole with other antifungal agents.

Fluconazole for the treatment of candidiasis: 15 years experience

Candidia spp. are responsible for contributing to the increasing global prevalence of fungal infections. Fluconazole (Diflucan((R)), Pfizer) is a triazole that has established an exceptional therapeutic record for candida infections including oropharyngeal and esophageal candidiasis, vulvovaginal candidiasis, candidemia and disseminated candidiasis. It is both an oral and parenteral fungistatic agent that inhibits ergosterol synthesis in yeasts. Extensive clinical studies have demonstrated fluconazole's remarkable efficacy, favorable pharmacokinetics and reassuring safety profile, all of which have contributed to its widespread use. Fluconazole became the first antifungal with worldwide sales exceeding billions of dollars, therefore providing an incentive for the pharmaceutical industry to develop new antifungals. This review will examine the contributions and limitations of fluconazole in the treatment of superficial and invasive candidiasis syndromes.

Oral candidiasis and angular cheilitis

Candidiasis, an often encountered oral disease, has been increasing in frequency. Most commonly caused by the overgrowth of Candida albicans, oral candidiasis can be divided into several categories including acute and chronic forms, and angular cheilitis. Risk factors for the development of oral candidiasis include immunosuppression, wearing of dentures, pharmacotherapeutics, smoking, infancy and old age, endocrine dysfunction, and decreased salivation. Oral candidiasis may be asymptomatic. More frequently, however, it is physically uncomfortable, and the patient may complain of burning mouth, dysgeusia, dysphagia, anorexia, and weight loss, leading to nutritional deficiency and impaired quality of life. A plethora of antifungal treatments are available. The overall prognosis of oral candidiasis is good, and rarely is the condition life threatening with invasive or recalcitrant disease.

Antifungal Prophylaxis in Cancer Patients After Chemotherapy or Hematopoietic Stem-Cell Transplantation: Systematic Review and Meta-Analysis

Purpose

To evaluate the effect of antifungal prophylaxis on all-cause mortality as primary outcome, invasive fungal infections (IFIs), and adverse events. Many studies have evaluated the role of antifungal prophylaxis in cancer patients, with inconsistent conclusions.

Methods

We performed a systematic review and meta-analysis of randomized, controlled trials comparing systemic antifungals with placebo, no intervention, or other antifungal agents for prophylaxis in cancer patients after chemotherapy. The Cochrane Library, MEDLINE, conference proceedings, and references were searched. Two reviewers independently appraised the quality of trials and extracted data.

Results

Sixty-four trials met inclusion criteria. Antifungal prophylaxis decreased all-cause mortality significantly at end of follow-up compared with placebo, no treatment, or nonsystemic antifungals (relative risk [RR], 0.84; 95% CI, 0.74 to 0.95). In allogeneic hematopoietic stem-cell transplantation (HSCT) recipients, prophylaxis reduced all-cause mortality (RR, 0.62; 95% CI, 0.45 to 0.85), fungal-related mortality, and documented IFI. In acute leukemia patients, there was a significant reduction in fungal-related mortality and documented IFI, whereas the difference in mortality was only borderline significant (RR, 0.88; 95% CI, 0.74 to 1.06). Prophylaxis with itraconazole suspension reduced documented IFI when compared with fluconazole, with no difference in survival, and at the cost of more adverse events. On the basis of two studies, posaconazole prophylaxis reduced all-cause mortality (RR, 0.74; 95% CI, 0.56 to 0.98), fungal-related mortality, and IFI when compared with fluconazole.

Conclusion

Antifungal prophylaxis decreases all-cause mortality significantly in patients after chemotherapy. Antifungal prophylaxis should be administered to patients undergoing allogeneic HSCT, and should probably be administered to high-risk acute leukemia patients.

Use of prophylactic antifungals in the immunocompromised host

Oral candidiasis is a significant infection in patients being treated with chemotherapy and radiotherapy for cancer, and in patients who are immunocompromised because of HIV infection and AIDS. Candida albicans is the most common fungal pathogen and has developed an extensive array of putative virulent mechanisms that allows successful colonization and infection of the host under suitable predisposing conditions. The purpose of this review of the literature was to assess the effectiveness of interventions for the prevention of oral candidiasis in immunocompromised patients and in patients treated for cancer with radiotherapy and/or chemotherapy. These patient categories were selected because they have been the topic of published randomized controlled clinical trials. The studies reviewed provide strong evidence that oral candidiasis is associated with greater morbidity and mortality in these populations, which substantiates the aggressive treatment and prophylaxis of this infection. The literature supports the recommendation that systemically applied antifungal drugs have the greatest efficacy for the treatment of oral candidiasis in cancer and immunocompromised patients; however, these therapies must be prescribed with a thorough assessment for the risk for developing drug-induced toxicities. Guidelines on the prevention of drug-resistant oral candidiasis in these patients are not available and require elucidation. Further studies are required to expand the knowledge base of evidence-based antifungal therapies in a wider variety of immunocompromised patients and conditions, such as Sjögren's syndrome, diabetes, and denture wearers. Additional exploration is needed to determine which antifungal drug formulation, dose, and method of delivery is preferable for the type of fungal infection and the underlying etiology.

Interventions for preventing oral candidiasis for patients with cancer receiving treatment

BACKGROUND

Treatment of cancer is increasingly more effective but is associated with short and long term side effects. Oral side effects remain a major source of illness despite the use of a variety of agents to prevent and treat them. One of these side effects is oral candidiasis.

OBJECTIVES

To assess the effectiveness of interventions (which may include placebo or no treatment) for the prevention of oral candidiasis for patients with cancer receiving chemotherapy or radiotherapy or both.

SEARCH STRATEGY

Computerised searches of Cochrane Oral Health Group and PAPAS Trials Registers, CENTRAL, MEDLINE, EMBASE, CINAHL, CANCERLIT, SIGLE and LILACS were undertaken. Reference lists from relevant articles were searched and the authors of eligible trials were contacted to identify trials and obtain additional information. Date of the most recent searches: June 2006: CENTRAL (The Cochrane Library 2006, Issue 2).

SELECTION CRITERIA

Trials were selected if they met the following criteria: design - random allocation of participants; participants - anyone receiving chemotherapy or radiotherapy treatment for cancer; interventions - agents prescribed to prevent oral candidiasis; primary outcome - prevention of oral candidiasis.

DATA COLLECTION AND ANALYSIS

Data were recorded on the following secondary outcomes if present: relief of pain, amount of analgesia, relief of dysphagia, incidence of systemic infection, duration of stay in hospital (days), cost of oral care, patient quality of life, death, use of empirical antifungal treatment, toxicity and compliance. Information regarding methods, participants, interventions, outcome measures and results were independently extracted, in duplicate, by two review authors. The Cochrane Oral Health Group statistical guidelines were followed and risk ratios (RR) calculated using random-effects models. Potential sources of heterogeneity were examined in random-effects metaregression analyses.

MAIN RESULTS

Twenty-eight trials involving 4226 patients satisfied the inclusion criteria. Drugs absorbed and partially absorbed from the gastrointestinal (GI) tract were found to prevent oral candidiasis when compared to a placebo, or a no treatment control group, with RR for absorbed drugs = 0.47 (95% confidence interval (CI) 0.29 to 0.78). For absorbed drugs in populations with an incidence of 20% (mid range of results in control groups), this implies a NNT of 9 (95% CI 7 to 13) patients need to be treated to avoid one patient getting oral candidiasis. There was no significant benefit shown for drugs not absorbed from the GI tract.

AUTHORS' CONCLUSIONS

There is strong evidence, from randomised controlled trials, that drugs absorbed or partially absorbed from the GI tract prevent oral candidiasis in patients receiving treatment for cancer. There is also evidence that these drugs are significantly better at preventing oral candidiasis than drugs not absorbed from the GI.

Inhibition of tumor growth and prolonged survival of rats with intracranial gliomas following administration of clotrimazole

OBJECT

Clotrimazole, an imidazole derivative and inhibitor of cytochrome P-450, inhibits the proliferation of cancer cells by downregulating the movement of intracellular Ca++ and K+ and by interfering with the translation initiation process. Clotrimazole inhibits the proliferation of human glioblastoma multiforme cells; it induces morphological changes toward differentiation and blocks the cell cycle in the G1/G1 phase. In vitro, clotrimazole enhances the antitumor effect of cisplatin by inducing wild-type p53-mediated apoptosis. The authors examined the effect of clotrimazole on tumor growth, sensitivity to cisplatin, and survival of rats with intracranial gliomas.

METHODS

Cultured C6 and 9L glioma cells were exposed to clotrimazole, and cell growth was assessed using the 3-(4,5-dimethylthiazol-2-yl)2,5-diphenyl tetrazolium bromide colorimetric assay. Clotrimazole produced a dose- and time-dependent inhibition of cell proliferation. The growth inhibitory effect of clotrimazole could not be overcome by exogenous stimulation with epidermal growth factor. Both C6 and 9L glioma cells were implanted into the rat brain and after 5 days, the animals were treated with a daily single dose of clotrimazole for 8 consecutive days. Clotrimazole treatment caused a significant inhibition of intracranial tumor growth. The survival of rats with 9L gliomas was analyzed after 10 days of treatment with clotrimazole, cisplatin, or a combination of clotrimazole and cisplatin. Rats treated with either drug displayed a significantly prolonged survival time; however, the combination treatment resulted only in an additional survival benefit.

CONCLUSIONS

Clotrimazole effectively inhibits cell proliferation and tumor growth, and prolongs survival of rats with intracranial gliomas. Clotrimazole may be considered a potential anticancer drug for treatment of intracranial gliomas.

Interventions for preventing oral candidiasis for patients with cancer receiving treatment

BACKGROUND

Treatment of cancer is increasingly more effective but is associated with short and long term side effects. Oral side effects remain a major source of illness despite the use of a variety of agents to prevent and treat them. One of these side effects is oral candidiasis.

OBJECTIVES

To assess the effectiveness of interventions (which may include placebo or no treatment) for the prevention of oral candidiasis for patients with cancer receiving chemotherapy and/or radiotherapy.

SEARCH STRATEGY

Electronic databases: Cochrane Oral Health Group's Trials Register, CENTRAL, MEDLINE, MEDLINE Pre-indexed, EMBASE, CINAHL, CANCERLIT, SIGLE and LILACS were searched. Date of the most recent searches April 2004 (CENTRAL Issue 2, 2004).

SELECTION CRITERIA

Trials were selected if they met the following criteria: design - random allocation of participants; participants - anyone receiving chemotherapy or radiotherapy treatment for cancer; interventions - agents prescribed to prevent oral candidiasis; primary outcome - prevention of oral candidiasis.

DATA COLLECTION AND ANALYSIS

Data were recorded on the following secondary outcomes if present: relief of pain, amount of analgesia, relief of dysphagia, incidence of systemic infection, duration of stay in hospital (days), cost of oral care, patient quality of life, death, use of empirical antifungal treatment, toxicity and compliance. Information regarding methods, participants, interventions, outcome measures and results were independently extracted, in duplicate, by two reviewers (HW & JC). The Cochrane Oral Health Group statistical guidelines were followed and relative risk values calculated using random effects models. Potential sources of heterogeneity were examined in random effects metaregression analyses.

MAIN RESULTS

Twenty-eight trials involving 4226 patients satisfied the inclusion criteria. Drugs absorbed and partially absorbed from the gastrointestinal (GI) tract were found to prevent oral candidiasis when compared to a placebo, or a no treatment control group, with RR for absorbed drugs = 0.47 (95% CI 0.29 to 0.78). For absorbed drugs in populations with an incidence of 20% (mid range of results in control groups), this implies a NNT of 9 (95% CI 7 to 13) patients need to be treated to avoid one patient getting oral candidiasis. There was no significant benefit shown for drugs not absorbed from the GI tract.

REVIEWERS' CONCLUSIONS

There is strong evidence, from randomised controlled trials, that drugs absorbed or partially absorbed from the GI tract prevent oral candidiasis in patients receiving treatment for cancer. There is also evidence that these drugs are significantly better at preventing oral candidiasis than drugs not absorbed from the GI.

Prophylactic antifungal therapy in the intensive care unit

Antifungal prophylaxis is regularly used during treatment of patients with some cancers, as subgroups with high rates of invasive fungal infections are readily identified; for these patients, prophylaxis has been shown to be of value. High-risk liver transplant recipients also benefit from antifungal prophylaxis. Although the idea of extending this concept to the prevention of candidal infections in the larger population of critically ill patients who are seen in the intensive care unit (ICU) and who do not have neutropenia is attractive, implementation of this strategy is difficult because of the widely varying characteristics of patients in the ICU. Two studies have shown the benefit of such prophylaxis, but the benefit was shown only in selected groups of patients who had an unusually high risk for invasive candidiasis. Although the concept is sound, broad-scale implementation of antifungal prophylaxis would be premature and costly, both financially and with regard to resistance and toxicity. Investigations are needed to define and prove the utility of predictive tools for the identification of patients in the ICU who would benefit from prophylaxis.

Prevention of infection in immunocompromised hosts

The prevention of infection in patients with cancer has changed tremendously over the last decade, but remains in evolution. Despite many clinical trials examining the role of antibacterial, antifungal, and antiviral prophylaxis, there is still discussion among physicians about not only which patients require prophylaxis, but also the optimal regimen. Nevertheless, many of these regimens offer the hope to prevent infection in patients with underlying neoplastic diseases. There is no therapy that is uniformly effective in all settings. This is generally due to the severity of the defects in host defenses and the virulence of the microorganism. Hopefully, the future will hold many new therapeutic options to help prevent infection in patients with cancer.

Antifungal prophylaxis during neutropenia and immunodeficiency

Fungal infections represent a major source of morbidity and mortality in patients with almost all types of immunodeficiencies. These infections may be nosocomial (aspergillosis) or community acquired (cryptococcosis), or both (candidiasis). Endemic mycoses such as histoplasmosis, coccidioidomycosis, and penicilliosis may infect many immunocompromised hosts in some geographic areas and thereby create major public health problems. With the wide availability of oral azoles, antifungal prophylactic strategies have been extensively developed. However, only a few well-designed studies involving strict criteria have been performed, mostly in patients with hematological malignancies or AIDS. In these situations, the best dose and duration of administration of the antifungal drug often remain to be determined. In high-risk neutropenic or bone marrow transplant patients, fluconazole is effective for the prevention of superficial and/or systemic candidal infections but is not always able to prolong overall survival and potentially selects less susceptible or resistant Candida spp. Primary prophylaxis against aspergillosis remains investigative. At present, no standard general recommendation for primary antifungal prophylaxis can be proposed for AIDS patients or transplant recipients. However, for persistently immunocompromised patients who previously experienced a noncandidal systemic fungal infection, prolonged suppressive antifungal therapy is often indicated to prevent a relapse. Better strategies for controlling immune deficiencies should also help to avoid some potentially life-threatening deep mycoses. When prescribing antifungal prophylaxis, physicians should be aware of the potential emergence of resistant strains, drug-drug interactions, and the cost. Well-designed, randomized, multicenter clinical trials in high-risk immunocompromised hosts are urgently needed to better define how to prevent severe invasive mycoses.

[Preventive antimycotic therapy of neutropenic and immunosuppressed patients]

Fungal infections are of increasing importance in severely neutropenic and immunosuppressed patients because of their high incidence and their high mortality once systemic dissemination has occurred. Various prophylactic strategies have been developed that include environmental measures as well as topical and systemic antimycotic prophylaxis. In this review the causative pathogens and patients at risk for developing fungal infections will be identified. Specific strategies will be discussed for each patient population and suggestions made for areas of future research.

Treatment of oropharyngeal candidiasis in HIV-positive patients

Most HIV-positive patients develop some form of oral candidiasis, most commonly pseudomembranous candidiasis, erythematous candidiasis, or angular cheilitis, at some point in their disease. All these manifestations are important risk markers for disease progression. Oral candidiasis is generally caused by Candida albicans. Although oral candidiasis can occur at any stage of HIV infection, it is most common in patients with low CD4 counts. Numerous oral and systemic therapies are used to treat oral candidiasis, the most popular of which are nystatin (topical), clotrimazole (topical), ketoconazole (systemic), fluconazole (systemic), and itraconazole (systemic). The topical agents are available in assorted dosage forms with varying degrees of efficacy and patient acceptability. The limited data currently available suggest an advantage for the systemic agents, although problems with resistance may limit the usefulness of fluconazole. The efficacy, safety, and cost effectiveness of a given agent must be considered when prescribing a specific agent for the treatment of oral candidiasis.

Chemoprophylaxis of fungal infections in neutropenic patients

BACKGROUND

In recent years there has been an increasing incidence and awareness of mucosal candidiasis and invasive fungal infections in neutropenic patients. Early diagnosis (before serious morbidity and mortality) is often difficult, emphasizing the continuing need for adequate prophylaxis.

DESIGN

A review of studies on the chemoprophylaxis of fungal infections in neutropenic patients.

RESULTS

There is a limited number of large, prospective, well-designed studies using proper criteria and end points. No antifungal drug or drug combination has been shown to prevent invasive fungal infection with the exception of fluconazole (mainly Candida Albicans infections) in certain high-risk patients groups.

CONCLUSIONS

Prophylaxis strategies are dependent upon local conditions, patient populations, types of therapies, available resources, etc. Future improvement will be based upon a) improved study quality, b) new strategies for established drugs, c) development of new and safer drugs, d) new strategies to eliminate or reduce immunosuppression and e) cost-benefit studies.

Treatment of oral candidiasis in HIV infection

Oral candidiasis is one of the most common clinical features of HIV infection. The lesion occurs in three predominant forms, and the two intraoral examples, pseudomembranous and erythematous, are equally predictive of the development of AIDS, independent of CD4 counts. The predominant species is C. albicans, although other species are occasionally found. Some studies claim correlation of salivary Candida counts with CD4 numbers or clinical stage of HIV-related disease, but this approach has not been used widely in HIV staging. Therapy with a variety of antifungal agents, including both topical and systemic drugs, is effective. New slow-release oral topical drug delivery systems may prove to be useful. Recently, examples of resistance to some drugs have been reported. Resistance may be associated with the emergence of different species.

Value of antifungal prophylaxis with antifungal drugs against oropharyngeal candidiasis in cancer patients

This report focuses on the value of antifungal prophylaxis with antifungal drugs in preventing oropharyngeal candidiasis. Randomised trials comparing non-AIDS immunocompromised patients receiving or not an oral antifungal agent were reviewed. Colonisation of the throat with Candida albicans is a risk factor, principally when cultures for this species of yeasts remain positive after initiation of the prophylaxis. The results of the trials were meta-analysed and we obtained a combined odds ratio for developing oropharyngeal candidiasis of 0.15 when under antifungal prophylaxis (confidence interval at 95%:0.10-0.22, chi 2 statistic of 90.77, P < 0.0001). We conclude that there is a strong beneficial effect of antifungal prophylaxis against the occurrence of oropharyngeal candidiasis. However, up to now, no study has correctly assessed the value of nystatin as a prophylactic agent against oropharyngeal candidiasis.

Antifungal prophylaxis in immunocompromised hosts

OBJECTIVE

To review the literature on the efficacy and safety of antifungal agents for prophylaxis of fungal infections in populations of immunocompromised hosts (key words: hematology-oncology, surgical, solid organ transplant, HIV infection), and to develop guidelines and recommendations regarding safe and effective drug regimens for antifungal prophylaxis in this patient population.

DATA EXTRACTION

Comprehensive review of clinical trials of antifungal prophylaxis published in the English literature, with an emphasis on controlled trials, and discussion of key clinical trials illustrating efficacy and safety of agents for antifungal prophylaxis in immunocompromised patients.

RESULTS

Much of the clinical data evaluating the efficacy and safety of antifungal prophylaxis has been generated in cancer patients. The choice of antifungal agent for prophylaxis in this population remains controversial. However, azole compounds such as clotrimazole, ketoconazole and fluconazole appear to be more effective and better tolerated than nystatin suspension. Although ketoconazole has been shown to reduce fungal colonization in surgical patients, current data do not support the routine use of antifungal prophylaxis in this population. In renal transplant recipients, clotrimazole troches have been shown to be more effective than placebo or nystatin suspension. Selective bowel decontamination with nonabsorbable antibiotics and nystatin may be useful in reducing Candida colonization in liver transplant patients but no definitive recommendations may be made at this time regarding optimal antifungal prophylaxis in these patients. In patients with advanced HIV disease or history of prior fungal disease prophylaxis for oropharyngeal candidiasis is indicated, although the agent of choice remains controversial. Fluconazole is the drug of choice for prevention of relapse of cryptococcal meningitis in patients with AIDS. Finally, only limited data exist assessing the relationship between local colonization and systemic fungal infection. Adverse effects associated with antifungal prophylaxis, generally limited to nausea and vomiting and transient elevations in hepatic transaminases, occur with similar frequency among available oral or topical agents. However, the incidence of nausea and vomiting with resultant poor patient tolerance and compliance is usually higher with nystatin.

CONCLUSIONS

Based on available data from controlled clinical trials, azole agents are currently the most effective and best-tolerated drugs for antifungal prophylaxis in immunocompromised hosts. Choice of one agent in this group over another may be dictated by cost. As new antifungal treatments are released onto the market, these drugs should be compared with existing agents in controlled clinical trials. Future studies should be designed to evaluate the relationship between local colonization and disseminated infection.

Quality of life as outcome measures in randomized clinical trials. An overview of three general medical journals

A survey of 75 randomized trials published in 1986 in the Annals of Internal Medicine, American Journal of Medicine, and New England Journal of Medicine was carried out by two observers using predetermined criteria about the importance of health status as an outcome measurement and the quality-of-health status measurement that was used. The kappa statistic was used to measure agreement among the two observers. Although a number of investigators used well-established quality-of-life measurements, in only 10 of 55 trials in which health status was judged crucial or important were measures with established validity and responsiveness used. Despite the fact that reliable measurement of quality of life is now feasible, it is underutilized in randomized clinical trials.

Fluconazole in the management of oropharyngeal candidosis in a predominantly HIV antibody-positive group of patients

Seventy-one patients with oropharyngeal candidosis received treatment with fluconazole given as a single 50 mg capsule once daily. Of these patients 61 were HIV-antibody positive. Candidosis had been present in nearly all patients for a least one month prior to fluconazole treatment. The duration of daily therapy was 5-20 days and in many cases this was followed by a period of maintenance treatment using 50 mg fluconazole every 48 h. In all 42 symptomatic patients, clinical resolution of the infection occurred within 7 days. Significantly, this included the disappearance of dysphagia in four patients with proven candidal oesophagitis. A marked reduction, or eradication of oral yeasts occurred concomitantly in virtually all patients. Fluconazole was well tolerated by all patients and there were no significant changes in haematological or hepatic parameters that could be attributed to the drug. The results suggest that fluconazole is an appropriate treatment for oropharyngeal candidosis and comparative studies with other agents should now be conducted.