InternPractice — Always a Step Ahead

Indications And Dose

Treatment of recurrent aphthous ulceration ▶BY MOUTH USING SOLUBLE TABLETS ▶Child 12–17 years: 100 mg 4 times a day usually for 3 days, dispersible tablet can be stirred into a small amount of water then rinsed around the mouth for 2–3 minutes, it should preferably not be swallowed ▶Adult: 100 mg 4 times a day usually for 3 days, dispersible tablet can be stirred into a small amount of water then rinsed around the mouth for 2–3 minutes, it should preferably not be swallowed l UNLICENSED USE Doxycycline may be used as detailed below, although these situations are considered outside the scope of its licence: . recurrent aphthous ulceration.

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Cautions

Alcohol dependence

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Interactions

→Appendix 1: tetracyclines

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Side Effects

▶Common or very common Dyspnoea. hypotension. peripheral oedema. tachycardia ▶Uncommon Gastrointestinal discomfort ▶Rare or very rare Antibiotic associated colitis. anxiety. arthralgia. ﬂushing. intracranial pressure increased with papilloedema. Jarisch-Herxheimer reaction. myalgia. photoonycholysis. severe cutaneous adverse reactions (SCARs). skin hyperpigmentation (long term use). tinnitus. vision disorders

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Renal Impairment

Use with caution (avoid excessive doses).

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Medicinal Forms

There can be variation in the licensing of different medicines containing the same drug. Dispersible tablet CAUTIONARY AND ADVISORY LABELS 6, 9, 11, 13 ▶Vibramycin-D (Pfizer Ltd) Doxycycline (as Doxycycline monohydrate) 100 mg Vibramycin-D 100mg dispersible tablets sugar-free | 8 tablet P £4.91 DT = £4.91 Oropharyngeal fungal infections Oropharyngeal fungal infections Overview Fungal infections of the mouth are usually caused by Candida spp. (candidiasis or candidosis). Different types of oropharyngeal candidiasis are managed as follows: Thrush Acute pseudomembranous candidiasis (thrush), is usually an acute infection but it may persist for months in patients receiving inhaled corticosteroids, cytotoxics or broad- spectrum antibacterials. Thrush also occurs in patients with serious systemic disease associated with reduced immunity such as leukaemia, other malignancies, and HIV infection. Any predisposing condition should be managed appropriately. When thrush is associated with corticosteroid inhalers, rinsing the mouth with water (or cleaning a child’s teeth) immediately after using the inhaler may avoid the problem. Treatment with nystatin p. 1284 or miconazole below may be needed. Fluconazole p. 630 is effective for unresponsive infections or if a topical antifungal drug cannot be used or if the patient has dry mouth. Topical therapy may not be adequate in immunocompromised patients and an oral triazole antifungal is preferred. Acute erythematous candidiasis Acute erythematous (atrophic) candidiasis is a relatively uncommon condition associated with corticosteroid and broad-spectrum antibacterial use and with HIV disease. It is usually treated with ﬂuconazole. Denture stomatitis Patients with denture stomatitis (chronic atrophic candidiasis), should cleanse their dentures thoroughly and leave them out as often as possible during the treatment period. To prevent recurrence of the problem, dentures should not normally be worn at night. New dentures may be required if these measures fail despite good compliance. Miconazole oral gel can be applied to the ﬁtting surface of the denture before insertion (for short periods only). Denture stomatitis is not always associated with candidiasis and other factors such as mechanical or chemical irritation, bacterial infection, or rarely allergy to the dental base material, may be the cause. Chronic hyperplastic candidiasis Chronic hyperplastic candidiasis (candidal leucoplakia) carries an increased risk of malignancy; biopsy is essential— this type of candidiasis may be associated with varying degrees of dysplasia, with oral cancer present in a high proportion of cases. Chronic hyperplastic candidiasis is treated with a systemic antifungal such as ﬂuconazole to eliminate candidal overlay. Patients should avoid the use of tobacco. Angular cheilitis Angular cheilitis (angular stomatitis) is characterised by soreness, erythema and ﬁssuring at the angles of the mouth. It is commonly associated with denture stomatitis but may represent a nutritional deﬁciency or it may be related to orofacial granulomatosis or HIV infection. Both yeasts (Candida spp.) and bacteria (Staphylococcus aureus and beta- haemolytic streptococci) are commonly involved as interacting, infective factors. A reduction in facial height related to ageing and tooth loss with maceration in the deep occlusive folds that may subsequently arise, predisposes to such infection. While the underlying cause is being identiﬁed and treated, it is often helpful to apply miconazole cream or fusidic acid ointment p. 604; if the angular cheilitis is unresponsive to treatment, hydrocortisone with miconazole cream p. 1318 or ointment can be used. Immunocompromised patients See advice on prevention of fungal infections in Immunocompromised patients under Antifungals, systemic use p. 626. Drugs used in oropharyngeal candidiasis Nystatin is not absorbed from the gastro-intestinal tract and is applied locally (as a suspension) to the mouth for treating local fungal infections. Miconazole is applied locally (as an oral gel) in the mouth but it is absorbed to the extent that potential interactions need to be considered. Miconazole also has some activity against Gram-positive bacteria including streptococci and staphylococci. Fluconazole is given by mouth for infections that do not respond to topical therapy or when topical therapy cannot be used. It is reliably absorbed and effective. Itraconazole p. 632 can be used for Ear, nose and oropharynx ﬂuconazole-resistant infections. If candidal infection fails to respond to 1 to 2 weeks of treatment with antifungal drugs the patient should be sent for investigation to eliminate the possibility of underlying disease. Persistent infection may also be caused by reinfection from the genito-urinary or gastro-intestinal tract. Infection can be eliminated from these sources by appropriate anticandidal therapy; the patient’s partner may also require treatment to prevent reinfection. Antiseptic mouthwashes are used in the prevention of oral candidiasis in immunocompromised patients and in the treatment of denture stomatitis. ANTIFUNGALS › IMIDAZOLE ANTIFUNGALS

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Patient And Carer Advice

Counselling on administration advised. Photosensitivity Patients should be advised to avoid exposure to sunlight or sun lamps. l PROFESSION SPECIFIC INFORMATION Dental practitioners’ formulary Dispersible tablets may be prescribed as Dispersible Doxycycline Tablets.

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Children

First line only; read the complete Indications and dose section above.

100 mg 4 times a day usually for

This is a first-line fragment. Read the full Indications and Dose section above.

Candidate age grouping · source page 1304

Indications And Dose

Source page 1304

Cautions

Alcohol dependence

Source page 1304

Interactions

→Appendix 1: tetracyclines

Source page 1304

Side Effects

Source page 1304

Renal Impairment

Use with caution (avoid excessive doses).

Source page 1304

Medicinal Forms

Source pages 1304, 1305

Patient And Carer Advice

Source page 1304

Children

First line only; read the complete Indications and dose section above.

100 mg 4 times a day usually for

This is a first-line fragment. Read the full Indications and Dose section above.

Candidate age grouping · source page 1304

doxycycline

Overview

Indications And Dose

Cautions

Safety

Interactions

Side Effects

Renal Impairment

Dose and formulations

Medicinal Forms

Clinical care

Patient And Carer Advice

Dose text by age group

doxycycline

Overview

Indications And Dose

Cautions

Safety

Interactions

Side Effects

Renal Impairment

Dose and formulations

Medicinal Forms

Clinical care

Patient And Carer Advice

Dose text by age group