Zambian HIV Guidelines:: Sulfadiazine

	Zambia HIV National Guidelines
	Introduction HIV Counseling and Testing Sexually Transmitted Infections (STIs) General Principles of Antiretroviral Therapy for Chronic HIV Infection in Adults and Adolescents When to Start ARV Therapy for Chronic HIV Infection in Adults and Adolescents Initial Regimen for ARV Therapy Adherence Baseline evaluation and Monitoring Calculations: Ideal Body Weight, Body Mass Index and Creatinine Clearance ARV Therapy for Individuals with Tuberculosis Co-Infection Adverse Effects and Toxicity Immune Reconstitution Inflammatory Syndrome (IRIS) Changing or Stopping ART Treatment Failure Stopping ARV Therapy Post Exposure Prophylaxis Cotrimoxazole Prophylaxis WHO Staging in Adults and Adolescents Nutrition Care and Support Palliative Care in HIV and AIDS
	Guide Editors
	Editor In Chief Joel E. Gallant, MD, MPH Pharmacology Editor Paul Pham, PharmD, BCPS Zambia Guideline Team Peter Mwaba MMed PhD FRCP Alywn Mwinga MMed Isaac Zulu MMed MPH Velepie Mtonga MMed Albert Mwango MBChB Jabbin Mulwanda MMed FCS

Drugs>Antimicrobial Agents>

Sulfadiazine

Paul A. Pham, Pharm.D. and John G. Bartlett, M.D.
04-03-2008

Available formulation in Zambia: 500 mg tablet
First-line treatment of CNS toxoplasmosis: pyrimethamine + sulfadiazine (plus folinic acid).
Maintain adequate hydration to prevent crystalluria

Zambia Information Author: Paul A. Pham, Pharm.D.

INDICATIONS

FDA

CNS and ocular toxoplasmosis
Malaria (in combination with quinine and pyrimethamine)
Uncomplicated UTI

NON-FDA APPROVED USES

Nocardia

FORMS

brand name	generic	Mfg	brand forms	cost*
Sulfadiazine	Sulfadiazine	Eon Labs	oral tab 500 mg	$1.44 per 500mg tab

*Prices represent cost per unit specified and are representative of "Average Wholesale Price" (AWP). AWP Prices were obtained and gathered by Lakshmi Vasist Pharm D using the Red Book, manufacturer's information, and the McKesson database.

^Dosage is indicated in mg unless otherwise noted.

USUAL ADULT DOSING

CNS and ocular toxoplasmosis (induction phase): sulfadiazine 1-1.5gm po q6h (+ leucovorin 10-20 mg po qd and pyrimethamine 100-200 mg po loading dose, then 50-100 mg po qd x 6 wks)
CNS and ocular toxoplasmosis (maintenance phase): sulfadiazine 500mg po q6h (+ leucovorin 10-20 mg po qd and pyrimethamine 25-50 mg qd) until immune reconstitution (CD4 >200 x 6 mos and on stable HAART)
Treatment of norcardiosis: 1.5gm po q6h x >6 mos;SMX/TMP preferred(CID 1996;22(6):891-903). Target serum level: 100-150 g/mL (2 hrs after dose)
Ocular toxoplasmosis: sulfadiazine 1gm q6h (+ leucovorin 15mg po qd and pyrimethamine 100mg po x1, then 50mg po qd x 4 wks). Additional treatment if pt has dense vitreous floaters, active retinal inflammation, or both (Am J Ophthalmol. 2002;134(1):34-40).

RENAL DOSING

DOSING FOR GLOMERULAR FILTRATION OF 50-80

0.5-1.5 gm q6h

DOSING FOR GLOMERULAR FILTRATION OF 10-50

0.5-1.5gm q8-12h (approx. half dose)

DOSING FOR GLOMERULAR FILTRATION OF <10 ML/MIN

0.5-1.5 gm q12h-24h (approx. 1/3 dose); HD: no data, dose post-HD

DOSING IN HEMODIALYSIS

No data, consider 0.5-1.5 gm q12-24h

DOSING IN PERITONEAL DIALYSIS

No data, consider 0.5-1.5 gm q12-24h

DOSING IN HEMOFILTRATION

No data, consider 0.5-1.5 gm q8h-12h

ADVERSE DRUG REACTIONS

COMMON

GI intolerance with nausea and vomiting
Rash and pruritus

OCCASIONAL

Bone marrow suppression (anemia, thrombocytopenia, leukopenia)
Serum sickness and drug fever
Crystalluria with azotemia, urolithiasis,oliguria. May be prevented by adequate hydration (daily urinary output >1500 ml) and alkalinizing urine to pH >7.15.
Photosensitivity
Hepatitis

RARE

TEN and Stevens-Johnson syndrome
Encephalopathy
Pancreatitis

DRUG INTERACTIONS

Warfarin: may increase INR. Monitor closely.
Sulfonylurea: may increase hypoglycemia. Monitor closely with coadministration.
Cyclosporine: may decrease cyclosporine serum levels. Monitor levels closely; may require dose increase.
Phenytoin: may increase phenytoin serum levels. Monitor free phenytoin levels with co-administration.
Porfimer: may increase the risk of photosensitivity reaction. Avoid co-administration.
Para-aminobenzoic acid (PABA) and derivatives (such as benzocaine, procaine, tetracaine): theoretical antagonism. Avoid co-administration.

SPECTRUM

Toxoplasma gondii; P. falciparum

Detailed Spectrum of Activity

PHARMACOLOGY

Pharmacology

COMMENTS

Agent of choice for toxoplasmosis (with pyrimethamine) due to superior CNS penetration and extensive clinical data. Higher incidence of crystaluria compared to other sulfonamides. This regimen also provides PCP prophylaxis.

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