Interventions for treating oral candidiasis for patients with cancer receiving treatment

Worthington HV, Clarkson JE, Eden OB

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Summary

The antifungal drugs ketoconazole and clotrimazole might be able to cure oral thrush caused by cancer treatment

Cancer treatment can lead to severe fungal infections (candidiasis, called thrush) in the mouth. This can cause pain, difficulties in eating and longer hospital stays. Infection can sometimes spread through the body and become life-threatening. Different drugs are used to try and relieve candidiasis. There is weak evidence that some of the antifungal drugs may cure fungal infections in the mouth for people with cancer. It may be that drugs like ketoconazole and clotrimazole, which are absorbed fully (or partially) through the gastrointestinal tract are more effective than those which are not absorbed (like nystatin), but more research is needed.

This is a Cochrane review abstract and plain language summary, prepared and maintained by The Cochrane Collaboration, currently published in The Cochrane Database of Systematic Reviews 2008 Issue 3, Copyright © 2008 The Cochrane Collaboration. Published by John Wiley and Sons, Ltd.. The full text of the review is available in The Cochrane Library (ISSN 1464-780X).
This record should be cited as: Worthington HV, Clarkson JE, Eden OB. Interventions for treating oral candidiasis for patients with cancer receiving treatment. Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.: CD001972. DOI: 10.1002/14651858.CD001972.pub3

This version first published online: January 21. 2002
Date of last substantive update: February 05. 2007

Abstract

Background

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

Objectives

To assess the effectiveness of interventions for the treatment 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

All randomised controlled trials comparing agents prescribed to treat oral candidiasis in people receiving chemotherapy or radiotherapy for cancer. The outcomes were eradication of oral candidiasis, dysphagia, systemic infection, amount of analgesia, length of hospitalisation, cost and patient quality of life.

Data collection and analysis

Data were independently extracted, in duplicate, by two review authors. Authors were contacted for details of randomisation and withdrawals and a quality assessment was carried out. Risk ratios were calculated using random-effects models.

Main results

Nine trials involving 658 patients, satisfied the inclusion criteria and are included in this review. Only two agents, each in single trials, were found to be effective for eradicating oral candidiasis. A drug absorbed from the gastrointestinal tract, ketoconazole, was more beneficial than placebo in eradicating oral candidiasis (risk ratio (RR) = 3.61, 95% confidence interval (CI) 1.47 to 8.88) and clotrimazole, at a higher dose of 50 mg was more effective than a lower 10 mg dose in eradicating oral candidiasis, when assessed mycologically (RR = 2.00, 95% CI 1.11 to 3.60). Of the five trials included in these meta-analyses, three were at high risk of bias and two of moderate risk of bias. Another trial demonstrated no statistically significant difference between a 10 mg dose of the partially absorbed drug, clotrimazole, and placebo. No differences were found when comparing different absorbed drugs; and comparing absorbed drugs with drugs which are not absorbed.

Authors' conclusions

There is weak and unreliable evidence that the absorbed drug, ketoconazole, may eradicate oral candidiasis and that a higher dose of the partially absorbed drug, clotrimazole, may give greater benefit than a lower 10 mg dose, however, researchers may wish to prevent rather than treat oral candidiasis. Further well designed, placebo-controlled trials assessing the effectiveness of old and new interventions for treating oral candidiasis are needed.

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