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Comparison of Oral Fluconazole and Itraconazole for Progressive, Nonmeningeal Coccidioidomycosis: A Randomized, Double-Blind Trial

John N. Galgiani, MD; Antonino Catanzaro, MD; Gretchen A. Cloud, MS; Royce H. Johnson, MD; Paul L. Williams, MD; Laurence F. Mirels, MD; Faris Nassar, MD; Jon E. Lutz, MD; David A. Stevens, MD; P. Kay Sharkey, MD; Vipul R. Singh, MD; Robert A. Larsen, MD; Kathy L. Delgado, LPN; Cynthia Flanigan, BS; and Michael G. Rinaldi, PhD
[+] Article, Author, and Disclosure Information

for the National Institute of Allergy and Infectious Diseases–Mycoses Study Group

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 2000;133(9):676-686. doi:10.7326/0003-4819-133-9-200011070-00009
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Background: In previous open-label noncomparative clinical trials, both fluconazole and itraconazole were effective therapy for progressive forms of coccidioidomycosis.

Objective: To determine whether fluconazole or itraconazole is superior for treatment of nonmeningeal progressive coccidioidal infections.

Design: Randomized, double-blind, placebo-controlled trial.

Setting: 7 treatment centers in California, Arizona, and Texas.

Patients: 198 patients with chronic pulmonary, soft tissue, or skeletal coccidioidal infections.

Intervention: Oral fluconazole, 400 mg/d, or itraconazole, 200 mg twice daily.

Measurements: After 4, 8, and 12 months, a predefined scoring system was used to assess severity of infection. Findings were compared with those at baseline.

Results: Overall, 50% of patients (47 of 94) and 63% of patients (61 of 97) responded to 8 months of treatment with fluconazole and itraconazole, respectively (difference, 13 percentage points [95% CI, −2 to 28 percentage points]; P = 0.08). Patients with skeletal infections responded twice as frequently to itraconazole as to fluconazole. By 12 months, 57% of patients had responded to fluconazole and 72% had responded to itraconazole (difference, 15 percentage points [CI, 0.003 to 30 percentage points]; P = 0.05). Soft tissue disease was associated with increased likelihood of response, as in previous studies. Azole drug was detected in serum specimens from all but 3 patients; however, drug concentrations were not helpful in predicting outcome. Relapse rates after discontinuation of therapy did not differ significantly between groups (28% after fluconazole treatment and 18% after itraconazole treatment). Both drugs were well tolerated.

Conclusions: Neither fluconazole nor itraconazole showed statistically superior efficacy in nonmeningeal coccidioidomycosis, although there is a trend toward slightly greater efficacy with itraconazole at the doses studied.


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Figure 1.
Box plots of baseline abnormalities associated with coccidioidal infection in patients treated with fluconazole (white bars) or itraconazole (gray bars).

Center lines represent the median value. Error bars indicates the 5th and 95th percentiles, and dots represent individual results that fall outside these ranges.

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Grahic Jump Location
Figure 2.
Flow of patients through the study.

HMO = health maintenance organization.

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Figure 3.
Patients responding after different mean durations of protocol therapy with fluconazole (dotted line) or itraconazole (solid line).
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