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

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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
A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 7: Gastrointestinal Symptoms26 picasREFERENCES1. Gazzard BG. HIV disease and the gastroenterologist. Gut 29:1497-505, 1988.2. May GR, Gill MJ, Church DL, et al. Gastrointestinal symptoms in ambulatory HIV-infected patients.Dig Dis Sci 38:1388-94, 1993.3. Heise W, Arasteh K, Shmidt W, et al. Intestinal enteropathogens as factor of reduced survival in HIV positivepatients. 12 th World AIDS Conference, Durban, South Africa, (Abstract #32117), 1998.4. Dworkin B, Wormser GP, Rosenthal WS, et al. Gastrointestinal manifestations of the acquiredimmunodeficiency syndrome: a review of 22 cases. Am J Gastroenterol 80:774-8, 1985.5. Malebranche R, Guerin JM, Laroche AC, et al. Acquired immunodeficiency syndrome with severegastrointestinal manifestations in Haiti. Lancet 2:873-7, 1983.6. Antony MA, Brandt LJ, Klein RS, et al. Infectious diarrhea in patients with AIDS. Dig Dis Sci 33:1141-6, 1988.7. Koch J, Schmidt J., et al. HIV-associated diarrhea: the changing spectrum and diagnoses. 12 th World AIDSConference, Durban, South Africa, (Abstract #60635) 1998.8. Heiser C, French N Gordon P, et al. Dietary supplementation with probiotics, soluble fiber and L-gluataminereduces diarrhea in HIV-positive men receiving nelfinavir. 1 st IAS Conference on HIV Pathogenesis andTreatment, Buenos Aires, Argentina, (Abstract #535) July 9-12, 2001.9. Huffman F, Walgren M. L-glutamine supplementation improves nelfinavir-associated diarrhea in HIV-infectedindividuals. 1 st IAS Conference on HIV Pathogenesis and Treatment, Buenos Aires, Argentina, (Abstract#536) July 9-12, 2001.10. Friedman LS, Isselbacher KJ. Nausea, Vomiting and Indigestion. In Fauci AS, et al., eds. Harrison’sPrinciples of Internal Medicine, 14 th edition. New York: McGraw-Hill, Health Professions Division, 1998.11. Gralla RJ, Osoba D, Kris MG, et al. Recommendations for the use of antiemetics: evidence-based, clinicalpractice guidelines. J Clin Oncol 17:2971-94, 1999.12. Wilcox CM. Esophageal disease in the acquired immunodeficiency syndrome: Etiology, diagnosis andmanagement. Am J Med 92:412, 1992.13. Bonacini M, Laine LA. Esophageal disease in patients with AIDS: diagnosis and treatment.Gastrointest Endosc Clin N Am 8:811-23, 1998.14. Wilcox CM, Monkemuller KE. Diagnosis and management of esophageal disease in the acquiredimmunodeficiency syndrome. South Med J 91:1002-8, 1998.15. Talal AH, Dieterich DT. Gastrointestinal and Hepatic Manifestations of HIV Infection. In Sande MA,Volberding PA, eds. Medical Management of AIDS, 6 th edition. Philadelphia: Saunders, 1999.16. Kotler D, Reka S, Borcich A, et al. Corticosteroid therapy of idiopathic esophageal ulcerations.Gastrointest Endosc 36:191, 1990.17. Youle M, Clarbour J, Farthing C, et al. Treatment of resistant aphthous ulceration with thalidomide inpatients positive for HIV antibody. Br Med J 298:432, 1989.VIIU.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 165
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DedicationA Clinical Guide to Suppo
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Lynn A Jansen, RN, PhDAssistant Res
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TABLE OF CONTENTSPart IChapter 1Cha
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IChapter 1.26 picasHIV and Palliati
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IA Clinical Guide to Supportive and
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Chapter 14.26 picasCulture and Care
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Chapter 15.26 picasSpecial Populati
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Chapter 17.26 picasEthical IssuesLy
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Chapter 19.Palliative 26 picas Care
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DRUGS AND THERAPIES INDEXNOTES: Ent
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