Unfulfilled promise with fluconazole in cryptococcal meningitis in AIDS Amphotericin B + flucytosine remains the preferred first choice

A randomised trial of fluconazole and amphotericin B/flucytosine in cryptococcal meningitis in patients with AIDS was prematurely terminated when all treatment failures were in the fluconazole-treated group.

Eight of 14 patients assigned to oral fluconazole 400mg/day for 10 weeks were considered treatment failures at 10 weeks, whereas all 6 patients assigned to IV amphotericin B 0.7 mg daily for 7 days and then 3 times weekly for 9 weeks (+ oral flucytosine ! 50 mg/kg/day) were considered cured. Cryptococcal meningitis was fatal in 2 patients administered fluconazole. Positive CSF cultures for cryptococci persisted for a mean of 40.6 days in fluconazole recipients, compared with 15.6 days with the alternative regimen.

Initial severity of cryptococcal meningitis was similar between groups at study entry, but CD4 cell counts tended to be lower in fluconazole recipients than amphotericin B recipients (44 I'S

97/mm 3). Toxicity was lower in fluconazole recipients

than amphotericin B recipients. Two patients experienced nausea with fluconazole, and I had dizziness. Nausea/vomiting and chills/rigors occurred in all amphotericin B recipients and amphotericin B-induced renal injury occurred in 5 patients.

'Although alternatives to amphotericin B plus flucytosine are highly desirable, caution should be used if an agent with mycologically inferior characteristics to this combination is used, even if substantially reduced toxicity is found.' [Sec also Reviews section, this issuc, p21] Larsen RA. Leal MEA. Chan LS. FluconalOie compared with amphoteriCin B plus Ilul'ytosine for cryptococcal meningitis in AIDS. '\ randomized trial. -'-nnals of Internal Medicine 113: 183-187. I ·\ug 1990

12 II Aug 1990 INPHARMA@ ISSN 0156-1703/90/0811-0012/0$01.00/0 © Adis International Ltd