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72 Cards in this Set
- Front
- Back
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tx of iris
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prednisone 20-40 mg po daily ( mac 4-8 weeks) or taper have been used (PJP)
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pcp occurs w/ cd4 count of
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< 200
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common coinfection of pcp
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thrush
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pcp primary or 2ndary prophylaxis
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trimethoprim-sulfamethoxazole
tmp-smx ds (160 mg tmp-800 mg smx) 1 tab po daily tmp-smx ds 1 tab po 3 x weekly tmp-smx ss 1 tab po daily |
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alternatives to doc for pcp
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dapsone 100 mg po daily
dapsone 100 mg/day po pyrimethamine 50 mg/week and folinic acid 25 mg/wk atovaquone 1500 mg po daily w/ food aerolized pentamideine 300 mg nebulized w/ respirgard 2 nebulizer q mo |
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2ndary prophylaxis for pcp
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same as primary
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when can you d/c prophylaxis for pcp
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viral load undetectable
cd4 > 200 for at least 3 months in response to haart |
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when should pcp prophylaxis be continued for life
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if pcp occurs w/ cd4 count > 200
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when do you restart prophylaxis for pcp
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if cd4 drops below 200 or reinfection occurs
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tx for mild to mod pcp (able to take po and PaO2 > 70 mmHg)
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preferred: tmp/smx 2 tabs DS TID
alternative regimen: dapsone 100 mg po daily and TMP 5 mg/kg po tid clidamycin 300-450mg po q 6 hrs and primaquine 15-30 mg base daily atovaquone 750 mg po bid w/ food duration 21 days |
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mod to severe pcp (unable to take PO and PaO2 < 70)
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preferred: tmp-smx IV
alternatives: pentamine 4 mg/kg IV q day clindamycin 600-900 mg IV q 6-8 hrs and primaquine 15-30 mg base po q day duration 21 days |
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what's adjunctive tx in severe pcp cases
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prednisone. . . need to taper
methylprednisone at 75% of the respective prednisone dose if needed initiate 72 hrs w/in anti pcp tx |
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ae of tmp smx
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maculopapular rash
bone marrow suppression fever photosensitivy n/v |
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ae of dapsone:
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erythema multiforme
hemolytic anemia |
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atovaquone ae
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rash
fever n/v |
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primaquine ae
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hemolytic anemia
leukopenia methmoglobenemia abd pain n |
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clindamycin ae
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rash
diarrhea |
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pentamidine IV ae
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nephrotoxicity
hypo/hyperglycemia arrhythmia pancreatitis |
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tx for cryptococcal meningitis
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amphotericin B deoxycholate 0.7 mg/kg daily combined w flucytosine 25 mg/kg q 6 hrs hrs in 2 weeks
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tx for cryptococcal meningitis consolidation
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fluconazole 400 mg daily x 8 weeks or until CSF neg
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maintenance or secondary prophylaxis tx for cryptococcal meningitis
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fluconazaole 200 mg po daily
continue life long or until CD2 > 200 for 6 mo of haart (many pt will not reach more than 200) |
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t/f
amphotericin is the primary prophylaxis tx for cryptococcal meningitis |
f
no primary prophylaxis. . expensive and fluconazole has a lot of drug resistance other tham ampho and flucytosine . . . only flucanozole left |
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ae of anticryptococcal meningitis
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nephrotoxicity
hydrate: before infusion w/ 500 ml norm saline |
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ae of anticryptococcal meningitis
-- abnormalities |
electrolyte
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ae of anticryptococcal meningitis
--- related |
infusion
fever, chills, myalgias premedicate w/ apap and diphenhydramine meperidine for tremors |
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flucytosine ae
gi |
n/v/d
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flucytosine ae
---- dysfunction ---penia -----penia |
hepatic dysfunction: jaundice, increased lft's
thrombocytopenia leukopenia |
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flucytosine ae
peak level 2 hr post oral dose at ss not ot exceed 75 ug/ml to avoid -- ---- -- and --- se |
bone marrow suppression
hepatic se |
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fluconazole se
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incease in lfts
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toxoplasmosis primary prophylaxis for cd 4 cout
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< 100 in toxoplasmosis seropositive patients
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toxoplasmosis primary prophylaxis preferred agent
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tmp-smx ds 1 tab po daily
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alternative toxoplasmosis primary prophy
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dapsone 50 mg po daily and pyrimethanmine 50 mg po / week and folinic acid 25 mg po /week
atovaquone 1500 mg po daily |
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when do u d/c toxoplasmosis tx
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increase in cd 4 count to >200 cells for 3 mo in response to haart
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when do you restart toxo tx
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restart if cd 4 count < 100-200 cells/uL
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toxoplasmosis
how long do you tx for |
6 weeks
improvemen to be seen in 10 days |
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tx of toxoplasmosis
1st line |
pyrimethanmine 200 mg po x 1 then 50-75 mg po daily
and sulfadiazine 1-1.5 g po q 6 hrs and leucovorin 10-20 mg po daily |
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alternative tx of toxoplasmosis
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clindamycin 600 mg po q 8 hrs w/ pyrimethamine and leucovorin
tmp-smx IV as 10 mg/kg/day divided in 2 doses in patients who cannot take po medications atovaquone w/ pyrimethamine and leucovorin |
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adjunctive tx of toxoplasmosis w/ mass effect
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dexamethasone 4 mg IV q 6 hrs; 1-3 mg po tid
watch out for other oi due to immunosuppression |
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toxo secondary prophylaxis
1st line: |
pyrimethamine 25-50 mg po daily
+ sufadizaine 500-1000 mg po QID and leucovorin 10-20 mg po qd |
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alternative tx toxo secondary prophylaxis
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clindamycin 600 mg po q 8 hrs
atovaquone 1500 mg po daily w/ or w/o pyrimethamine |
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when do you d/c toxo secondary prophylaxis
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no s/s w/ cd4 counts > 200 x 6 months w/ response to haart
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when do u reinitiate toxo secondary prophylaxis
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when cd4 drops below 200 cells/ul
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ae of pyrimethanime r/t toxo
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rash
n bone marrow suppression (reduced when giving folinic acid) |
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ae of sulfadazine r/t toxo
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rash
fever leukopenia hepatitis n/v/d crystaluria |
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clindamycin ae r/t toxo
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fever
rash n/d hepatotoxicity |
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mac prophy begins:
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cd4 <50 cells/uL
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first line of mac prophy
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azithromycin 1200 mg po q week
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mac prophy alternative tx
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clarithromcying 500 mg po bid
rifabutin 300 mg daily po |
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when to d/c mac prophy primary
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cd4 > 100
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when do you reintroduce mac prophy
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cd4 <50
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what do u makes sure before starting rifabutin in mac
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pt doesn't have tb. . . can cause resistance
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mac tx 1st line
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clarithromycin 500 mg po bid
+ ethambutol 15 mg/kg/d +/- rifabutin 300 mg po q day |
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what do you consider adding w/ mac tx
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3 rd agent when cd4 < 50
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when pi and or nnrti's are used what do you decrease
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decrease ributin dose to 150 mg po 3 x week
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what do you do if pi's and nnrti's are being used due to drug interactions via cyp 450
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sub clarithromycin w/ azithromycin
or gi intolerance w/ clarithromycin |
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mac tx alternative
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azithromycin 600 mg po q day
+ etha;mbutol 15 mg/kg/d +/- rifabutin 300 mg po q day adding 4th agent; streptomycin 15 mg/kg im 3 x week or amikacin 15 mg/kg/day cipro 750 mg po bid for severe disease and/or tx failure |
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secondary tx for mac
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none
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when do you stop mac tx
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after 12 mo of neg bl cultures w/ cd4 > 100 on haart for at least 3 mo
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macrolide ae
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gi intolerance
taste disturbances increase in lft's hypersensitivity rxn |
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ethambutol ae r/t mac
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optic neuritis
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rifabutin ae r/t mac
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discoloration of urine
leukopenia neutropenia arthralgias uveitis |
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cmv primary prophylaxis
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ganciclovir
although not routinely recommended |
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cmv retinitis induction tx
immediate sight threatening |
ganciclovir intraocular implant q 6 mo and valganciclovir 900 mg po q 24
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cmv retinitis induction tx
peripheral lesions |
valganciclovir 900 mg po q 12 hrs x 14-21d
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cmv retinitis induction tx
alternative |
foscarnet 90 mg/kg iv q 12 hr x 14-21 d
cidofovir 5 mg/kg iv q week x 2 weeks and probenecid and hydration w/ ns ganciclovir 5 mg/kg iv q 12 hr x 14-21 d |
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cmv mainenance tx
first line |
ganciclovir 900 mg po q day + intraocular gainciclovir
replace until immune reconstitution occurs |
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cmv mainenance tx
alternative |
ganciclovir 900 mg may be alonge adequate for small lesions
foscarnet 90-120 mg/kg iv q day cidofovir 5 mg/kg q 2 weeks + probenecid + hydration ganciclovir 5 mg/kg iv q day or 6mg/kg iv 5 d/week |
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cmv mainenance tx
when do you stop continue until --- --- occurs cd4 > durable suppression of --- ---- on haart adequate vision in ---- eye |
immune restoration
> 100-150 cells/uL x 3-6 mo durable suppresion of hiv rna viral load on haart adequate vision in contralateral eye |
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how often do you have cmv retinitis maintenance
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monthly opthlamic exam while pt is on anti-cmv
then q 3 mo |
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ganciclovir ae r/t cmv
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neutropenia
thrombocytopenia n/v renal dysfunction |
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foscarnet ae r/t cmv
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anemia
nephrotoxicity electrolyte abnormalities penile ulcerations |
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cidofovir ae r/t cmv
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dose related nephrotoxicity and hypotomy
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