Retinitis medical therapy: Difference between revisions
Jump to navigation
Jump to search
m (Changes made per Mahshid's request) |
|||
| (16 intermediate revisions by 2 users not shown) | |||
| Line 1: | Line 1: | ||
__NOTOC__ | __NOTOC__ | ||
{{Retinitis}} | {{Retinitis}} | ||
{{CMG}}{{AE}}{{IMD}};{{CP}};{{AZ}};{{Ammu}} | |||
==Overview== | |||
There is no single medical therapy to treat all types of retinitis. Due to the many underlying causes of retinitis, treatment is administered directly according to the underlying cause. These treatments will vary from [[Vitamin A|vitamin therapy]] and [[Preventative treatment|preventative strategies]] to a long list of potential [[antimicrobial]] therapies. | |||
==Medical Therapy== | ==Medical Therapy== | ||
== | ===Retinitis Pigmentosa=== | ||
*There is no known cure for retinitis pigmentosa. | |||
*Current therapies involve lessened exposure to light as well as an increased uptake of [[Vitamin A]] - 15,000 IU/day. | |||
*Preferred | ===Cytomegalovirus Retinitis=== | ||
* | The choice of therapy is based on the location of the lesions and level of immnunosuppresion of the patient. Systemic antiviral therapy is preferred as infection rate of the contralateral eye is reduced. | ||
* | *'''Initial Therapy for patients with immediate sight-threatening lesions''' (Adjacent to the optic nerve or fovea) | ||
* | **Preferred Regimen(1): Ganciclovir intraocular implant + valganciclovir 900 mg PO (BID for 14–21 days, then once daily) {{and}} One dose of intravitreal ganciclovir may be administered immediately after diagnosis until ganciclovir implant can be placed | ||
* | **Alternate Regimen (1): Ganciclovir 5 mg/kg IV q12h for 14–21 days, then 5 mg/kg IV daily {{or}} | ||
*Note: | **Alternate Regimen (2): Ganciclovir 5 mg/kg IV q12h for 14–21 days, then valganciclovir 900 mg PO daily {{or}} | ||
**Alternate Regimen (3): Foscarnet 60 mg/kg IV q8h or 90 mg/kg IV q12h for 14–21 days, then 90–120 mg/kg IV q24h {{or}} | |||
**Alternate Regimen (4): Cidofovir 5 mg/kg/week IV for 2 weeks, then 5 mg/kg every other week with saline hydration before and after therapy and probenecid 2 g PO 3 hours before the dose followed by 1 g PO 2 hours after the dose, and 1 g PO 8 hours after the dose (total of 4 g) | |||
***Note(1): This regimen should be avoided in patients with sulfa allergy because of cross hypersensitivity with probenecid. | |||
***Note(2): If systemic anti-CMV treatment is not available, use sequential ganciclovir intravitreal injections until immune reconstitution in response to ART is achieved. | |||
*'''For Small Peripheral Lesions''' | |||
**Preferred Regimen: Valganciclovir 900 mg PO BID for 14–21 days, then 900 mg PO daily {{and}} One dose of intravitreal ganciclovir may be administered immediately after diagnosis to deliver high local concentration until systemic ganciclovir concentration is reached. | |||
*'''Chronic Maintenance Therapy (Secondary Prophylaxis) for CMV Retinitis''' | |||
**The drug of choice for chronic maintenance therapy and the preferred route (i.e., implant, intravitreal injection, IV, oral, or combination; and which drug) should be made in consultation with an ophthalmologist. Considerations should include the anatomic location of the retinal lesion, vision in the contralateral eye, the patient’s immunologic and virologic status and response to antiretroviral therapy. | |||
**Patients with sight-threatening retinitis will most benefit from ganciclovir implant to control retinitis progression, due to the delivery of high concentration of ganciclovir at the site of infection. | |||
***Preferred Regimen (1): Valganciclovir 900 mg PO daily + ganciclovir intraocular implant (for sight-threatening retinitis) {{or}} | |||
***Preferred Regimen (2): Valganciclovir 900 mg PO daily (for small peripheral lesions) {{and}} | |||
***Note(1): Ganciclovir intraocular implant should be replaced every 6–8 months until sustained immune recovery is documented. | |||
***Alternate Regimen (1): Ganciclovir 5 mg/kg IV 5–7 times weekly {{or}} | |||
***Alternate Regimen (2): Foscarnet 90–120 mg/kg IV once daily {{or}} | |||
***Alternate Regimen (3): Cidofovir 5 mg/kg IV every other week with saline hydration and probenecid as above. | |||
*'''Immune Restoration Uveitis (IRU)''' | |||
**Preferred Regimen (1): Periocular corticosteroid or a short course of systemic steroid | |||
*'''Stopping Chronic Maintenance Therapy for CMV Retinitis''' | |||
**CMV treatment for at least 3–6 months, with CD4 count >100 cells/mm3 for >3 to 6 months in response to ART. | |||
**Therapy should be discontinued only after consultation with an ophthalmologist, taking into account magnitude and duration of CD4 count increase, anatomic location of the lesions, vision in the contralateral eye, and the feasibility of regular ophthalmologic monitoring. | |||
**Routine (i.e., every 3 months) ophthalmologic follow-up is recommended for early detection of relapse or IRU, and then annually after immune reconstitution. | |||
*'''Reinstituting Chronic Maintenance/Secondary Prophylaxis for CMV Retinitis''' | |||
**CD4 + count <100 cells/mm³ | |||
==Ocular tuberculosis== | ===Ocular tuberculosis=== | ||
'''Adult patients''' | |||
*'''Intensive phase''' | |||
:* Preferred regimen: [[Isoniazid]] 5 mg/kg (max: 300 mg) PO qd for 2 months {{and}} [[Rifampin]] 10 mg/kg (max: 600 mg) PO qd for 2 months {{and}} [[Pyrazinamide]] 15–30 mg/kg (max: 2 g) PO qd for 2 months {{and}} [[Ethambutol]] 15-20 mg/kg (max: 1 g) PO qd for 2 months | |||
*'''Continuation phase''' | |||
:* Preferred regimen: [[Isoniazid]] 5 mg/kg (max: 300 mg) PO qd for 4 months {{and}} [[Rifampin]] 10 mg/kg (max: 600 mg) PO qd for 4 months | |||
'''Pediatric patients''' | |||
*'''Intensive phase''' | |||
:* Preferred regimen: [[Isoniazid]] 10-15 mg/kg (max: 300 mg) PO qd for 2 months {{and}} [[Rifampin]] 10-20 mg/kg (max: 600 mg) PO qd for 2 months {{and}} [[Pyrazinamide]] 15-30 mg/kg (max: 2 g) PO qd for 2 months {{and}} [[Ethambutol]] | |||
'''Continuation phase''' | |||
:* Preferred regimen: [[Isoniazid]] 10–15 mg/kg (max: 300 mg) PO qd for 4 months {{and}} [[Rifampin]] 10–20 mg/kg (max: 600 mg) PO qd for 4 months | |||
:* Note (1): [[Ethambutol]] may be administered at a dose of 15-20 mg/kg (max: 1 g) PO qd for 2 months but is generally avoided because of potential ocular toxicity.<ref>{{cite book | last = Bennett | first = John | title = Mandell, Douglas, and Bennett's principles and practice of infectious diseases | publisher = Elsevier/Saunders | location = Philadelphia, PA | year = 2015 | isbn = 978-1455748013 }}</ref> | :* Note (1): [[Ethambutol]] may be administered at a dose of 15-20 mg/kg (max: 1 g) PO qd for 2 months but is generally avoided because of potential ocular toxicity.<ref>{{cite book | last = Bennett | first = John | title = Mandell, Douglas, and Bennett's principles and practice of infectious diseases | publisher = Elsevier/Saunders | location = Philadelphia, PA | year = 2015 | isbn = 978-1455748013 }}</ref> | ||
:* Note (2): A short course of systemic corticosteroids may be necessary initially if there is sight-threatening inflammation. | :* Note (2): A short course of systemic [[Corticosteroid|corticosteroids]] may be necessary initially if there is sight-threatening inflammation.<ref>{{Cite journal| doi = 10.1164/rccm.167.4.603| issn = 1073-449X| volume = 167| issue = 4| pages = 603–662| last1 = Blumberg| first1 = Henry M.| last2 = Burman| first2 = William J.| last3 = Chaisson| first3 = Richard E.| last4 = Daley| first4 = Charles L.| last5 = Etkind| first5 = Sue C.| last6 = Friedman| first6 = Lloyd N.| last7 = Fujiwara| first7 = Paula| last8 = Grzemska| first8 = Malgosia| last9 = Hopewell| first9 = Philip C.| last10 = Iseman| first10 = Michael D.| last11 = Jasmer| first11 = Robert M.| last12 = Koppaka| first12 = Venkatarama| last13 = Menzies| first13 = Richard I.| last14 = O'Brien| first14 = Richard J.| last15 = Reves| first15 = Randall R.| last16 = Reichman| first16 = Lee B.| last17 = Simone| first17 = Patricia M.| last18 = Starke| first18 = Jeffrey R.| last19 = Vernon| first19 = Andrew A.| last20 = American Thoracic Society, Centers for Disease Control and Prevention and the Infectious Diseases Society| title = American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America: treatment of tuberculosis| journal = American Journal of Respiratory and Critical Care Medicine| date = 2003-02-15| pmid = 12588714}}</ref><ref>{{Cite journal| issn = 1057-5987| volume = 52| issue = RR-11| pages = 1–77| last1 = American Thoracic Society| last2 = CDC| last3 = Infectious Diseases Society of America| title = Treatment of tuberculosis| journal = MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control| date = 2003-06-20| pmid = 12836625}}</ref> | ||
===Fungal=== | |||
*Commonly prescribed [[Antifungal drug|antifungal]] agents are [[Amphotericin B|Amphotericin B (AmB-d)]], [[Flucytosine description|Flucytosine]], or [[Fluconazole (oral)|Fluconazol]] | |||
*Other antifungal agents may include the drugs within the [[azole]] class. | |||
*Treatment must be closely monitored due to the significant occurrence of [[toxicity]] in patients. <ref>Treatment of Endogenous Fungal Endophthalmitis: Focus on New Antifungal Agents. James Riddell IV, Grant M. Comer, Carol A. Kauffman1. http://cid.oxfordjournals.org/content/52/5/648.full. Accessed April 18th, 2016. </ref> | |||
===Ocular Syphilis=== | |||
*Pathogen-directed antimicrobial therapy'''<ref>{{cite book | last = Bennett | first = John | title = Mandell, Douglas, and Bennett's principles and practice of infectious diseases | publisher = Elsevier/Saunders | location = Philadelphia, PA | year = 2015 | isbn = 978-1455748013 }}</ref>''' | |||
:* Preferred regimen (1): [[Penicillin]] 4 MU IV q4h for 10-14 days {{and}} [[Benzathine penicillin]] 2.4 MU IM once weekly for 3 weeks | |||
* Note (1): [[Corticosteroids]] (Prednisone 60-80 mg PO qd) are co-administered to decrease intra-ocular inflammation and prevent rebound inflammation from Jarisch Herxheimer reaction. | |||
* Note (2): All patients with presumed ocular syphilis should be tested for HIV, and all should have a lumbar puncture before starting therapy to exclude concurrent neurosyphilis. | |||
===Ocular Toxoplasmosis=== | |||
'''Adults''' | |||
*1. Pathogen-directed antimicrobial therapy'''<ref name="pmid15194258">{{cite journal| author=Montoya JG, Liesenfeld O| title=Toxoplasmosis. | journal=Lancet | year= 2004 | volume= 363 | issue= 9425 | pages= 1965-76 | pmid=15194258 | doi=10.1016/S0140-6736(04)16412-X | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15194258 }} </ref>''' | |||
:* Preferred regimen: [[Pyrimethamine]] 200 mg PO qd on day 1 then 50-75 mg PO qd for 2 weeks beyond resolution of symptoms {{and}} [[Sulfadiazine]] 1-1.5 g PO qid for 2 weeks beyond resolution of symptoms {{and}} [[Leucovorin]] ([[Folinic acid]]) 5-20 mg PO 3 times/week for 3 weeks beyond resolution of symptoms | |||
'''Pediatric''' | |||
* Preferred regimen: [[Pyrimethamine]] 2 mg/kg PO first day then 1 mg/kg each day {{and}} [[Sulfadiazine]] 50 mg/kg PO bid {{and}} folinic acid ([[Leucovorin]] 7.5 mg/day PO ) for 4 to 6 weeks followed by reevaluation of the patient's condition | |||
:* Alternative regimen: The fixed combination of [[Trimethoprim]] with [[Sulfamethoxazole]] has been used as an alternative. | |||
:* Note: If the patient has a hypersensitivity reaction to sulfa drugs, [[Pyrimethamine]] {{and}} [[Clindamycin]] can be used instead.<ref>{{cite web | title = Parasites - Toxoplasmosis (Toxoplasma infection) | url = http://www.cdc.gov/parasites/toxoplasmosis/health_professionals/ }}</ref> | |||
==References== | ==References== | ||
| Line 35: | Line 86: | ||
[[Category:Disease]] | [[Category:Disease]] | ||
[[Category:Ophthalmology]] | [[Category:Ophthalmology]] | ||
{{WH}} | {{WH}} | ||
{{WS}} | {{WS}} | ||
Latest revision as of 18:36, 18 September 2017
|
Retinitis Microchapters |
|
Diagnosis |
|---|
|
Treatment |
|
Case Studies |
|
Retinitis medical therapy On the Web |
|
American Roentgen Ray Society Images of Retinitis medical therapy |
|
Risk calculators and risk factors for Retinitis medical therapy |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Ilan Dock, B.S.;Charmaine Patel, M.D. [2];Ahmed Zaghw, M.D. [3];Ammu Susheela, M.D. [4]
Overview
There is no single medical therapy to treat all types of retinitis. Due to the many underlying causes of retinitis, treatment is administered directly according to the underlying cause. These treatments will vary from vitamin therapy and preventative strategies to a long list of potential antimicrobial therapies.
Medical Therapy
Retinitis Pigmentosa
- There is no known cure for retinitis pigmentosa.
- Current therapies involve lessened exposure to light as well as an increased uptake of Vitamin A - 15,000 IU/day.
Cytomegalovirus Retinitis
The choice of therapy is based on the location of the lesions and level of immnunosuppresion of the patient. Systemic antiviral therapy is preferred as infection rate of the contralateral eye is reduced.
- Initial Therapy for patients with immediate sight-threatening lesions (Adjacent to the optic nerve or fovea)
- Preferred Regimen(1): Ganciclovir intraocular implant + valganciclovir 900 mg PO (BID for 14–21 days, then once daily) AND One dose of intravitreal ganciclovir may be administered immediately after diagnosis until ganciclovir implant can be placed
- Alternate Regimen (1): Ganciclovir 5 mg/kg IV q12h for 14–21 days, then 5 mg/kg IV daily OR
- Alternate Regimen (2): Ganciclovir 5 mg/kg IV q12h for 14–21 days, then valganciclovir 900 mg PO daily OR
- Alternate Regimen (3): Foscarnet 60 mg/kg IV q8h or 90 mg/kg IV q12h for 14–21 days, then 90–120 mg/kg IV q24h OR
- Alternate Regimen (4): Cidofovir 5 mg/kg/week IV for 2 weeks, then 5 mg/kg every other week with saline hydration before and after therapy and probenecid 2 g PO 3 hours before the dose followed by 1 g PO 2 hours after the dose, and 1 g PO 8 hours after the dose (total of 4 g)
- Note(1): This regimen should be avoided in patients with sulfa allergy because of cross hypersensitivity with probenecid.
- Note(2): If systemic anti-CMV treatment is not available, use sequential ganciclovir intravitreal injections until immune reconstitution in response to ART is achieved.
- For Small Peripheral Lesions
- Preferred Regimen: Valganciclovir 900 mg PO BID for 14–21 days, then 900 mg PO daily AND One dose of intravitreal ganciclovir may be administered immediately after diagnosis to deliver high local concentration until systemic ganciclovir concentration is reached.
- Chronic Maintenance Therapy (Secondary Prophylaxis) for CMV Retinitis
- The drug of choice for chronic maintenance therapy and the preferred route (i.e., implant, intravitreal injection, IV, oral, or combination; and which drug) should be made in consultation with an ophthalmologist. Considerations should include the anatomic location of the retinal lesion, vision in the contralateral eye, the patient’s immunologic and virologic status and response to antiretroviral therapy.
- Patients with sight-threatening retinitis will most benefit from ganciclovir implant to control retinitis progression, due to the delivery of high concentration of ganciclovir at the site of infection.
- Preferred Regimen (1): Valganciclovir 900 mg PO daily + ganciclovir intraocular implant (for sight-threatening retinitis) OR
- Preferred Regimen (2): Valganciclovir 900 mg PO daily (for small peripheral lesions) AND
- Note(1): Ganciclovir intraocular implant should be replaced every 6–8 months until sustained immune recovery is documented.
- Alternate Regimen (1): Ganciclovir 5 mg/kg IV 5–7 times weekly OR
- Alternate Regimen (2): Foscarnet 90–120 mg/kg IV once daily OR
- Alternate Regimen (3): Cidofovir 5 mg/kg IV every other week with saline hydration and probenecid as above.
- Immune Restoration Uveitis (IRU)
- Preferred Regimen (1): Periocular corticosteroid or a short course of systemic steroid
- Stopping Chronic Maintenance Therapy for CMV Retinitis
- CMV treatment for at least 3–6 months, with CD4 count >100 cells/mm3 for >3 to 6 months in response to ART.
- Therapy should be discontinued only after consultation with an ophthalmologist, taking into account magnitude and duration of CD4 count increase, anatomic location of the lesions, vision in the contralateral eye, and the feasibility of regular ophthalmologic monitoring.
- Routine (i.e., every 3 months) ophthalmologic follow-up is recommended for early detection of relapse or IRU, and then annually after immune reconstitution.
- Reinstituting Chronic Maintenance/Secondary Prophylaxis for CMV Retinitis
- CD4 + count <100 cells/mm³
Ocular tuberculosis
Adult patients
- Intensive phase
- Preferred regimen: Isoniazid 5 mg/kg (max: 300 mg) PO qd for 2 months AND Rifampin 10 mg/kg (max: 600 mg) PO qd for 2 months AND Pyrazinamide 15–30 mg/kg (max: 2 g) PO qd for 2 months AND Ethambutol 15-20 mg/kg (max: 1 g) PO qd for 2 months
- Continuation phase
Pediatric patients
- Intensive phase
- Preferred regimen: Isoniazid 10-15 mg/kg (max: 300 mg) PO qd for 2 months AND Rifampin 10-20 mg/kg (max: 600 mg) PO qd for 2 months AND Pyrazinamide 15-30 mg/kg (max: 2 g) PO qd for 2 months AND Ethambutol
Continuation phase
- Preferred regimen: Isoniazid 10–15 mg/kg (max: 300 mg) PO qd for 4 months AND Rifampin 10–20 mg/kg (max: 600 mg) PO qd for 4 months
- Note (1): Ethambutol may be administered at a dose of 15-20 mg/kg (max: 1 g) PO qd for 2 months but is generally avoided because of potential ocular toxicity.[1]
- Note (2): A short course of systemic corticosteroids may be necessary initially if there is sight-threatening inflammation.[2][3]
Fungal
- Commonly prescribed antifungal agents are Amphotericin B (AmB-d), Flucytosine, or Fluconazol
- Other antifungal agents may include the drugs within the azole class.
- Treatment must be closely monitored due to the significant occurrence of toxicity in patients. [4]
Ocular Syphilis
- Pathogen-directed antimicrobial therapy[5]
- Preferred regimen (1): Penicillin 4 MU IV q4h for 10-14 days AND Benzathine penicillin 2.4 MU IM once weekly for 3 weeks
- Note (1): Corticosteroids (Prednisone 60-80 mg PO qd) are co-administered to decrease intra-ocular inflammation and prevent rebound inflammation from Jarisch Herxheimer reaction.
- Note (2): All patients with presumed ocular syphilis should be tested for HIV, and all should have a lumbar puncture before starting therapy to exclude concurrent neurosyphilis.
Ocular Toxoplasmosis
Adults
- 1. Pathogen-directed antimicrobial therapy[6]
- Preferred regimen: Pyrimethamine 200 mg PO qd on day 1 then 50-75 mg PO qd for 2 weeks beyond resolution of symptoms AND Sulfadiazine 1-1.5 g PO qid for 2 weeks beyond resolution of symptoms AND Leucovorin (Folinic acid) 5-20 mg PO 3 times/week for 3 weeks beyond resolution of symptoms
Pediatric
- Preferred regimen: Pyrimethamine 2 mg/kg PO first day then 1 mg/kg each day AND Sulfadiazine 50 mg/kg PO bid AND folinic acid (Leucovorin 7.5 mg/day PO ) for 4 to 6 weeks followed by reevaluation of the patient's condition
- Alternative regimen: The fixed combination of Trimethoprim with Sulfamethoxazole has been used as an alternative.
- Note: If the patient has a hypersensitivity reaction to sulfa drugs, Pyrimethamine AND Clindamycin can be used instead.[7]
References
- ↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
- ↑ Blumberg, Henry M.; Burman, William J.; Chaisson, Richard E.; Daley, Charles L.; Etkind, Sue C.; Friedman, Lloyd N.; Fujiwara, Paula; Grzemska, Malgosia; Hopewell, Philip C.; Iseman, Michael D.; Jasmer, Robert M.; Koppaka, Venkatarama; Menzies, Richard I.; O'Brien, Richard J.; Reves, Randall R.; Reichman, Lee B.; Simone, Patricia M.; Starke, Jeffrey R.; Vernon, Andrew A.; American Thoracic Society, Centers for Disease Control and Prevention and the Infectious Diseases Society (2003-02-15). "American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America: treatment of tuberculosis". American Journal of Respiratory and Critical Care Medicine. 167 (4): 603–662. doi:10.1164/rccm.167.4.603. ISSN 1073-449X. PMID 12588714.
- ↑ American Thoracic Society; CDC; Infectious Diseases Society of America (2003-06-20). "Treatment of tuberculosis". MMWR. Recommendations and reports: Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control. 52 (RR-11): 1–77. ISSN 1057-5987. PMID 12836625.
- ↑ Treatment of Endogenous Fungal Endophthalmitis: Focus on New Antifungal Agents. James Riddell IV, Grant M. Comer, Carol A. Kauffman1. http://cid.oxfordjournals.org/content/52/5/648.full. Accessed April 18th, 2016.
- ↑ Bennett, John (2015). Mandell, Douglas, and Bennett's principles and practice of infectious diseases. Philadelphia, PA: Elsevier/Saunders. ISBN 978-1455748013.
- ↑ Montoya JG, Liesenfeld O (2004). "Toxoplasmosis". Lancet. 363 (9425): 1965–76. doi:10.1016/S0140-6736(04)16412-X. PMID 15194258.
- ↑ "Parasites - Toxoplasmosis (Toxoplasma infection)".