Pharmacotherapy of Oropharyngeal Candidiasis

PST 06106

Basic Pharmacotherapy

Session 33: Pharmacotherapy of Oropharyngeal Candidiasis

Learning Tasks

By

the end of this session students are expected to be able to:

Define oropharyngeal candidiasis

Explain pathophysiology of oropharyngeal candidiasis

Explain the clinical presentation of oropharyngeal candidiasis

Outline diagnosis of oropharyngeal candidiasis

Describe pharmacological treatment of oropharyngeal candidiasis

Describe the monitoring of oropharyngeal candidiasis therapy

Definition of Oropharyngeal Candidiasis

Oropharyngeal candidiasis

(OPC), or

thrush,

refers to an infection of the oral mucosa.

Candida

is responsible for the majority of

oralfungal

infections, and

C.

albicans

is the principal species causing the infection, commonly referred to as

candidiasis

The infection may extend into the esophagus, causing esophageal candidiasis.

Activity: Buzzing

What

is the pathophysiology of oropharyngeal candidiasis?

Pathophysiology of Oropharyngeal Candidiasis

The pathogenesis of OPC is most clearly elucidated in the setting of HIV infection.

There appear to be several levels of immune defense against the development of OPC in HIV-infected persons, and they involve both systemic and local immunity.

The primary line of host defense against

C.

albicans

is cell-mediated immunity (CMI) at the mucosal surfaces, which is mediated by CD4 T cells.

The efficacy of the CD4 T cells is reduced when the number of cells drops below a protective threshold, and protection against infection becomes dependent on secondary or local immune mechanisms

Pathophysiology of Oropharyngeal

Candidiasis

Cont

….

When the number of CD4 T cells drops too low, recruitment of these cells to the oral cavity is impaired.

The CD4 T-cell count has been considered as the hallmark predictor for development of OPC.

The changeover of the role of

Candida

species from commensal to pathogenic in the human host usually occurs when breakdown in these host defenses occurs.

Other virulence factors are the adhesive ability of

C.

albicans

to epithelial cells and proteins and its ability to invade host cells

by means of phospholipase and proteinase enzymes.

Pathophysiology of Oropharyngeal Candidiasis

Cont

….

This may be one

of the factors leading to OPC in non-HIV-infected individuals.

Other

components of the pathogenesis in the absence of HIV that have been

postulated are the ability of the

Candida

species to adhere to buccal

epithelial cells including those patients receiving broad-spectrum antimicrobial therapy.

Clinical Presentation and Diagnosis of Oropharyngeal Candidiasis

General

The clinical features can be quite diverse

Symptoms

Symptoms are diverse and range from none to sore, painful mouth, burning tongue, metallic taste, and dysphagia and odynophagia with involvement of the hypopharynx

Signs

Signs are variable and can include diffuse erythema and white patches on the surfaces of the buccal mucosa, throat, tongue, or gums; constitutional signs are absent

Clinical Presentation and Diagnosis of Oropharyngeal Candidiasis

Cont

….

Laboratory tests

Scraping of an active lesion for microscopic examination can help confirm the diagnosis (presence of

pseudohyphae

and budding yeast) but is usually not necessary

Cultures are not necessary because isolation of

Candida

species does not distinguish between colonization and true infection; cultures can be taken in patients responding poorly to therapy to determine the infecting species and to predict likely drug resistance

Activity

: Small Group Discussion

What are the drugs treatments for oropharyngeal candidiasis

?

Pharmacological Treatment of Prostate Cancer

The management of OPC should be individualized for each patient, taking into consideration the underlying immune status, other concurrent mucosal and medical diseases, concomitant medications, and exogenous infectious sources.

In HIV-infected patients with inadequately controlled disease, antifungal treatment produces only a transient clinical response, and the relapse rates are higher than in other patient populations.

Topical therapies should be the first choice for milder forms of infections

Therapeutic Options for Mucosal Candidiasis

Monitoring of Oropharyngeal Candidiasis Therapy

Efficacy end points for oropharyngeal and esophageal candidiasis include rapid relief of symptoms and prevention of complications without early relapse after completion of the course of therapy.

Symptomatic relief of presenting signs and symptoms generally occurs within 48 to 72 hours of starting therapy, with complete resolution by 7 to 10 days.

Patients should be advised about the time course and told to return for reassessment when signs and symptoms recur.

It is usually unnecessary for the patient to be reassessed soon after finishing the treatment course.

Monitoring of Oropharyngeal Candidiasis Therapy

Cont

…

However, HIV patients should be questioned and examined for the occurrence of

mucosal

candidiasis

as part of their regular follow-up.

The frequency of monitoring can be more often in neutropenic patients

because

of

concern for dissemination of candidiasis.

During the period of neutropenia, temperature should be monitored daily, as well

as

signs

of dissemination.

Efficacy of the antifungal agent is partly influenced by patient adherence to the medication regimen.

Patients must be counseled on proper administration and dosing, in particular for

topical

agents

Monitoring of Oropharyngeal Candidiasis Therapy

Cont

…

Safety end points include monitoring for occurrence of the relevant drug side effects and drug interactions

Hepatotoxicity can occur when azole therapy is prolonged beyond 7 to 10 days or high doses are used.

Periodic monitoring of liver enzymes (alanine transaminase and aspartate amino-transferase) should be considered, especially if prolonged therapy (longer than 21 days) is anticipated.

Key Points

Oropharyngeal

candidiasis

(OPC), or

thrush,

refers to an infection of the oral mucosa.

Symptoms are diverse and range from none to sore, painful mouth, burning tongue, metallic taste, and dysphagia and odynophagia with involvement of the hypopharynx

The management of OPC should be individualized for each patient, taking into consideration the underlying immune status, other concurrent mucosal and medical diseases, concomitant medications, and exogenous infectious sources

Evaluation

What

is Oropharyngeal Candidiasis?

What is the pathophysiology of Oropharyngeal Candidiasis?

How is Oropharyngeal Candidiasis?

What is the first line treatment of Oropharyngeal Candidiasis?

REFER

Students to Handout 33.1: Risk Factors for the Development of Oropharyngeal and/or Esophageal Candidiasis

References

Wells

BG,

DiPiro

J,

Schwinghammer

T (2013),

Pharmacotherapy Handbook

(6

th

Ed). New York, NY: McGraw-Hill.

DiPiro

JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey ML, (2008):

Pharmacotherapy: A Pathophysiologic Approach

(7

th

ed

): New York, NY: McGraw-Hill.

Katz M D., Matthias KR., Chisholm-Burns M A., Pharmacotherapy(2011)

Principles & Practice Study Guide: A Case-Based Care Plan Approach

: New York, NY: McGraw-Hill.

Schwinghammer

TL, Koehler JM (2009)

Pharmacotherapy Casebook: A Patient-Focused Approach

(7

th

ed

): New York, NY: McGraw-Hill.

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