The Clinical Guide to Supportive and Palliative Care for HIV/AIDS

A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 7: Gastrointestinal SymptomsCandida albicans is the most frequent esophageal pathogen in HIV disease and, as such, is themost common cause of dysphagia and odynophagia. In evaluating a patient for possible Candidaesophagitis, it should be remembered that while the presence of oral thrush supports its presumptive26diagnosis,picasits absence does not exclude it. While definitive diagnosis can be made onlywith endoscopy, the frequency of Candida infection in advanced AIDS patients makes an empirictrial of antifungal therapy appropriate in these cases.TreatmentTreatment requires a systemic antifungal since topical therapies such as nystatin oral suspensionor clotrimazole troches only act locally and thus will be effective only in treating oralcandidiasis. The medication most frequently chosen to treat Candida esophagitis is fluconazole(Diflucan). The typical treatment course with fluconazole would be to start with a 200 mg loadingdose and then to place the patient on 100 mg daily. In many patients a two-week course oftherapy will be sufficient to effectively treat Candida esophagitis. Treatment may then be discontinuedand the patient observed for recurrence of symptoms. Some patients will requirepersistent fluconazole therapy and/or doses higher than 100 mg daily. Other medications thatcan be used to treat Candida are itraconazole (Sporanox) and ketoconazole (Nizoral). If a patienthas candidiasis that is resistant to the azoles, it may be necessary to use intravenous medicationssuch as amphotericin-B or the new antifungal caspfungin acetate (Cancidas).Odynophagia or dysphagia that is caused by CMV infection should be treated with an appropriatecourse of anti-CMV therapy (see guidelines for treating CMV colitis above). Idiopathic orapthous ulcers can often be effectively treated with either a course of corticosteroids 16 or thalidomide.17 Treating odynophagia without regard to the underlying pathology can be attempted byadministering standard analgesics or viscous lidocaine but those approaches will often be unsatisfactory.There is no good symptomatic treatment for dysphagia that does not address thecausative pathologic process.164U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau