REPLY
Esophageal Ulcers in AIDS
C. Mel Wilcox, MD
15 May 1996 | Volume 124 Issue 10 | Pages 928-929
IN RESPONSE:
The letters by Couderc and associates and Domingo and colleagues reflect the growing clinical experience with thalidomide for the treatment of HIV-associated idiopathic (aphthous) oropharyngeal and esophageal ulcers. Because this agent is not widely available in the United States, published studies to date have been from investigators in Europe and Australia [1]. Our preliminary experience with this drug has been encouraging [2] and is similar to that described by Couderc and associates and by Domingo and colleagues. As with most disorders related to the acquired immunodeficiency syndrome, relapse is common; however, data are insufficient to suggest that the relapse rate is reduced after successful treatment with thalidomide compared with oral corticosteroids. The apparent efficacy, favorable side-effects profile, and reduced cost suggest that thalidomide may be an ideal drug for these disorders, particularly in men. This opinion will best be validated, however, in a prospective trial comparing thalidomide with corticosteroids. The devastating effects of thalidomide on the fetus are cause for caution, regardless of efficacy. Given that thalidomide has important immunoregulatory properties, long-term use may be related to the development of opportunistic infections, similar to those associated with corticosteroids [3]. Thus, long-term follow-up of patients receiving thalidomide daily is needed before it can be concluded that thalidomide is safer than corticosteroids. If these lesions are caused by or perpetuated through tumor necrosis factor [4], pentoxifylline may also be efficacious [5]. I look forward to prospective, comparative drug trials designed to determine the best short- and long-term treatments for these disorders.
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Author and Article Information
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University of Alabama at Birmingham; Birmingham, AL 35294
1. Patterson DL, Georghiou PR, Allworth AM, Kemp RJ. Thalidomide as treatment of refractory aphthous ulceration related to human immunodeficiency virus infection. Clin Infect Dis. 1995; 20:250-4.
2. Wilcox CM, Alexander LN. Prospective evaluation of thalidomide for the treatment of human immunodeficiency (HIV)-associated idiopathic esophageal ulcers: a US experience [Abstract]. Am J Gastroenterol. 1995; 90:1574.
3. Sathe SS, Sarai A, Tsigler D, Nedunchezian D. Pentoxifylline aggravates impairment in tumor necrosis factor-
secretion and increases mycobacterial load in macrophages from AIDS patients with disseminated Mycobacterium avium-intracellulare complex infection. J Infect Dis. 1994; 170:484-7.
4. Sampaio EP, Sarno EN, Galilly R, Cohn ZA, Kaplan G. Thalidomide selectively inhibits tumor necrosis factor production by stimulated human monocytes. J Exp Med. 1991; 173:699-703.
5. Dezube BJ, Lederman MM, Spritzler JG, et al. High-dose pentoxifylline in patients with AIDS: inhibition of tumor necrosis factor production. J Infect Dis. 1995; 171:1628-32.
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