Health Questions 2

Dr Christelle Bergeron

Pulmonology department

CIUSSS de l'Estrie adult cystic fibrosis clinic — CHUS

With the collaboration of Ms. Josée Lessard and Ms. Vanessa Fontaine, nurses at the adult cystic fibrosis clinic of the CIUSSS de l'Estrie — CHUS

1. What is thrush? How do you recognize it? What medications are at risk? How do we treat it?

Oropharyngeal candidiasis, more commonly known as thrush, is an infection caused by Candida, a fungus (fungus) found in normal gastrointestinal and genitourinary flora. The infection is recognized by the presence of whitish plaques in the mouth, on the palate, on the tongue or in the oropharynx. These plaques don't go away if they're brushed with a toothbrush or scraped with a tongue depressor. The diagnosis is usually clinical, but it can be confirmed by scraping the lesions and then making a KOH (potassium hydroxide) preparation in order to visualize the yeasts. Other symptoms are sometimes present such as the sensation of having a pasty mouth, loss of taste, and pain when swallowing.

The individuals most at risk are elderly people who wear dentures, people on antibiotics or chemotherapy, and those with an immune deficiency (e.g. AIDS). The drugs most at risk are inhaled glucocorticoids (e.g. Flovent).^MD, Alvesco^MD, Pulmicort^MD, etc.). For this reason, it is important to use the inhalation chamber (Aerochamber) with metered-dose aerosol devices and to rinse your mouth after taking these inhalers.

Thrush is usually treated quite easily with an antifungal agent (Nystatin) to be gargled and swallowed 4 times a day for about ten days. For more refractory cases, it is possible to prescribe an antifungal drug from the azole class in tablets, most often fluconazole. However, caution should be taken as there are drug interactions to consider with fluconazole, in particular with CFTR modulators (Kalydeco).^MD, Orkambi^MD, Symdeko^MD, Trikafta^MD).

2. The central venous catheter (PICC line), a source of questions:

• My skin is red and/or infected around the entry point, what can I do?

Since the installation of the central venous catheter (PICC line for central peripherally inserted central catheter) and the change of dressing is done by sterile technique, it is essential to refer to the nurse at the cystic fibrosis clinic or to the nurse specialized in venous access for any problem related to the catheter.

If redness occurs on the skin and/or near the insertion site, it may be an infection. If it is superficial, it is sometimes sufficient to change the dressing more frequently or by disinfecting it with chlorhexidine, but it is important to notify the team in order to follow up closely and eliminate a deeper infection or other complication (e.g. allergy, thrombosis) on a case-by-case basis.

• I have pain at the entry site, what can I do?

The causes of pain at the entry site are multiple: intolerance or allergy to bandages, blockage or thrombosis of the catheter, poor positioning, infection, etc. As mentioned, it is important to contact your nurse in order to reassess the patency of the catheter and to ensure the absence of signs and symptoms of infection.

• What can I do when there are bubbles in the tubing?

If the catheter is used to administer intravenous antibiotics through a bottle process, bubbles are unlikely to be present, but if this situation occurs, it is essential to notify your nurse. She can remove the bubbles with a syringe until blood returns, then irrigate the catheter with saline liquid before and after the next dose of antibiotic.

It is important not to manipulate the catheter yourself and to stop the infusion immediately if bubbles are present. A small amount of air is generally not a problem, but larger bubbles could lead to air embolism, a potentially serious and sometimes fatal complication.

• How do I properly protect the insertion site when washing?

It is best to avoid baths. However, if you want to take a bath, the arm where the catheter is located should not be submerged in water. It should be kept out of the water at all times.

When showering, protect the arm where the catheter is located with a transparent film such as Saran Wrap and an empty plastic bag.

If your bandage is accidentally wet or has moved, it will need to be changed. Once again, contact your nurse to change the dressing.

3. What are the repercussions of drinking alcohol when living with cystic fibrosis?

There are several repercussions of alcohol consumption in individuals with fibrocystic fibrosis.

First, alcohol is a depressant that can affect breathing when consumed in excess. Respiratory rate and range of respiratory movements may be affected, making breathing and managing secretions more difficult.

In addition, because alcohol contains a lot of sugars, diabetes control in patients with diabetes associated with CF can become more difficult, including a high risk of hypoglycemia.

For patients known to have liver disease associated with CF, it is recommended that alcohol consumption be avoided or minimized, as alcohol consumption may exacerbate existing liver damage or accelerate its progression.

Many antibiotics and medications are metabolized by the liver and their effect may be affected by alcohol consumption. Some may amplify the effects of alcohol, while others will not work as effectively in the presence of alcohol. Caution is required with CFTR modulators (e.g.: Trikafta)^MD), which alone can disrupt liver function, which could be made worse by excessive alcohol consumption.

Finally, several other medium and long-term complications are possible: anxiety, sleep disorders, vitamin deficiencies, high blood pressure, gastric ulcers, cancers, etc.

4. Some people have started taking cyproheptadine, a medication to stimulate appetite. What is this medication? Is it useful and suitable for CF?

Cyproheptadine is a drug that is part of the class of first-generation antihistamines.

It is mainly used in the pediatric population to stimulate appetite and improve nutritional status, but is not only used in individuals with fibrocystic fibrosis. However, some studies have been conducted specifically in the fibrocystic population and have shown good effectiveness.

Before using this medication, you should have tried other options (evaluation by a nutritionist, adjustment of intakes, supplements, etc.) and discuss them with your doctor, who will assess the situation and can determine if such treatment is appropriate.

With the advent of high-efficiency CFTR modulators (Trikafta)^MD) and their impacts on nutritional status (weight gain, improved BMI), there should be fewer and fewer reasons to start taking cyproheptadine in the future.

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