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PREFERRED
- Isoniazid (INH 300 mg po + pyridoxine 50 mg / day x 9 mo
- INH 900 mg po + pyridoxine 100 mg twice weekly with DOT x 9 mo
- Exposure to drug resistant TB: Consult expert
- Alternative to INH: Rifampin 300 mg/day or rifabutin (dose adjusted, see pg ____)
- Note that the Pyrazinamide (PZA) + rifampin regimen is no longer recommended due to reports of 40 cases of severe hepatotoxicity, including 7 deaths with the PZA + rifampin 2-month regimen (MMWR 2002;51:998; MMWR 2002;51:998; Am Rev Respir Crit Care Med 2001;164:1319). None of these patients was known to have HIV infection, and a subsequent analysis found that only 15 of 721 HIV-infected patients who received rifampin/PZA had ALT levels >250 U/L, a rate similar to that observed in INH recipients (12/745). The conclusion was that hepatotoxicity is rare in HIV-infected patients given rifampin/PZA (CID 2004;39:561).
PREGNANCY: INH regimens
MONITORING:Laboratory monitoring includes baseline tests of liver function (bilirubin ALT, AST and alkaline phosphotase) for INH recipients and liver function tests (as above) plus a CBC for rifampin/ rifabutin recipients (MMWR 2000;49 RR-6:1). Patients should be clinically monitored monthly to detect hepatotoxicity or neuropathy, and they should stop treatment and report any symptoms of hepatitis: jaundice, dark urine, nausea, vomiting, abdominal pain, and/or fever >3 days. INH should be discontinued with ALT elevations to >5x ULN without symptoms or ALT to >3x ULN with symptoms. Monitoring of LFTs is recommended for patients with abnormal baseline LFTs and those receiving ART (Am J Respir Crit Care Med 2006;174: 935).
Toxoplasma gondii
INDICATION: Toxoplasma lgG positive plus CD4 <100 cells/mm3
NOTE: Seronegative patients on PCP prophylaxis that does not cover Toxoplasma should have the serologic test repeated if the CD4 count decreases to <100 cells/mm3
RISK: CD4 count <100 cells/mm3 plus positive anti-Toxoplasma lgG conferes a risk of toxoplasmosis encephalitis of 33%per year (JID 1996;173:91; CID 2001;33:1747).
PREFERRED: TMP-SMX 1 DS/day
ALTERNATIVES
- TMP-SMX 1 SS/day
- Dapsone 50 mg/day po + pyrimethamine 50 mg/week + leucovorin 25 mg/week
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