Board Review Course & Update

Explanation

In this patient with oral thrush, the most appropriate treatment is oral fluconazole. Tacrolimus is metabolized through the cytochrome P450 enzyme system (CYP3A) and fluconazole is a potent CYP3A inhibitor. Thus, tacrolimus levels are likely to increase after fluconazole initiation if the dose is not decreased (answer C is correct). Examples of other potent CYP3A inhibitors are macrolide antibiotics (e.g., erythromycin), protease inhibitors (e.g., ritonavir), dihydropyridine calcium channel blockers (e.g., diltiazem), and cannabidiol. There is no evidence of CMV disease or infection, so ganciclovir therapy should not be started (answer A is incorrect). Additional changes to the immunosuppression regimen are not indicated as part of the management of oral thrush, and steroids have not been shown to be helpful (answer E is incorrect). Pantoprazole may be considered in a patient with symptoms suggestive of gastroesophageal reflux disease (answer D is incorrect). Discontinuation of ritonavir in a patient with HIV and undetectable viral load would not be appropriate (answer B is incorrect).