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PROPHYLAXIS AGAINST P. CARINII PNEUMONIA: THREE DRUGS COMPARED.

Most clinicians use trimethoprim-sulfamethoxazole (TMP-SMX) as first-line prophylaxis against Pneumocystis carinii pneumonia in HIV-infected patients, but the drug is tolerated poorly. This randomized, non-blinded study compared three regimens in 843 patients with fewer than 200 CD4 cells per cubic millimeter: one double-strength TMP-SMX tablet twice daily, dapsone (50 mg) twice daily, or monthly aerosolized pentamidine. The estimated 36-month risk for P. carinii pneumonia was similar in patients assigned to TMP-SMX (18 percent), dapsone (17 percent) and pentamidine (21 percent). However, a majority of patients in the TMP-SMX and dapsone groups had dose reductions or were switched to an alternate therapy because of toxicity. Reanalysis according to the drug actually being taken at pneumonia onset found TMP-SMX to be the most effective. Treatment failures on dapsone were more common at 50 mg than 100 mg per day. In patients with baseline CD4 counts below 100, both oral drugs appeared superior to aerosolized pentamidine, even in the intention- to-treat analysis. Comment: This report confirms that TMP-SMX provides the best pneumocystis prophylaxis in patients who can tolerate it. An editorial implies that lower doses of TMP-SMX might reduce drug toxicity without compromising efficacy, and that it might be rational to use inhaled pentamidine until the CD4 count drops to 100, after which TMP-SMX should be introduced.

— AS Brett

Published in Journal Watch General Medicine March 24, 1995

Citation(s):

Clumeck N. Primary prophylaxis against opportunistic infections in patients with AIDS. N Engl J Med 1995 Mar 16 332 739-740.

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• Medline abstract (Free)

Bozzette SA, et al. A randomized trial of three antipneumocystis agents in patients with advanced human immunodeficiency virus infection. N Engl J Med 1995 Mar 16 332 693-699.

• Original article (Subscription may be required)
• Medline abstract (Free)