title: Comparison of oral fluconazole and itraconazole for progressive, nonmeningeal coccidioidomycosis. A randomized, double-blind trial. Mycoses Study Group.
abstract: 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.
  
  
  METHODS
  Randomized, double-blind, placebo-controlled trial.
  
  
  METHODS
  7 treatment centers in California, Arizona, and Texas.
  
  
  METHODS
  198 patients with chronic pulmonary, soft tissue, or skeletal coccidioidal infections.
  
  
  METHODS
  Oral fluconazole, 400 mg/d, or itraconazole, 200 mg twice daily.
  
  
  METHODS
  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.
authors.affiliation: Valley Fever Center for Excellence, 3601 South Sixth Avenue, Tucson, AZ 85723, USA.
authors.forename: J N
authors.initials: JN
authors.lastname: Galgiani
authors.forename: A
authors.initials: A
authors.lastname: Catanzaro
authors.forename: G A
authors.initials: GA
authors.lastname: Cloud
authors.forename: R H
authors.initials: RH
authors.lastname: Johnson
authors.forename: P L
authors.initials: PL
authors.lastname: Williams
authors.forename: L F
authors.initials: LF
authors.lastname: Mirels
authors.forename: F
authors.initials: F
authors.lastname: Nassar
authors.forename: J E
authors.initials: JE
authors.lastname: Lutz
authors.forename: D A
authors.initials: DA
authors.lastname: Stevens
authors.forename: P K
authors.initials: PK
authors.lastname: Sharkey
authors.forename: V R
authors.initials: VR
authors.lastname: Singh
authors.forename: R A
authors.initials: RA
authors.lastname: Larsen
authors.forename: K L
authors.initials: KL
authors.lastname: Delgado
authors.forename: C
authors.initials: C
authors.lastname: Flanigan
authors.forename: M G
authors.initials: MG
authors.lastname: Rinaldi
mesh_terms: D000284:Administration, Oral; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D000935:Antifungal Agents / Q000009:adverse effects / Q000097:blood / Q000627:therapeutic use*; D001847:Bone Diseases / Q000097:blood / Q000188:drug therapy*; D002648:Child; D003047:Coccidioidomycosis / Q000097:blood / Q000188:drug therapy*; D003627:Data Interpretation, Statistical; D004311:Double-Blind Method; D004334:Drug Administration Schedule; D005260:Female; D015725:Fluconazole / Q000009:adverse effects / Q000097:blood / Q000627:therapeutic use*; D006801:Humans; D017964:Itraconazole / Q000009:adverse effects / Q000097:blood / Q000627:therapeutic use*; D008172:Lung Diseases, Fungal / Q000097:blood / Q000188:drug therapy*; D008875:Middle Aged; D012008:Recurrence; D018461:Soft Tissue Infections / Q000097:blood / Q000188:drug therapy*; D016896:Treatment Outcome
chemical_list: D000935:Antifungal Agents; D017964:Itraconazole; D015725:Fluconazole