Retinitis medical therapy: Difference between revisions
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==Overview== | ==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. | 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== | ||
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===Retinitis Pigmentosa=== | ===Retinitis Pigmentosa=== | ||
*There is no known cure for 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. | *Current therapies involve lessened exposure to light as well as an increased uptake of [[Vitamin A]] - 15,000 IU/day. | ||
===Cytomegalovirus Retinitis=== | ===Cytomegalovirus Retinitis=== | ||
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===Fungal=== | ===Fungal=== | ||
*Commonly prescribed antifungal agents are Amphotericin B (AmB-d), Flucytosine, or Fluconazol | *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. | *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> | *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=== | ===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> | *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 | :* 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 (1): [[Corticosteroids]] (Prednisone 60-80 mg PO qd) are co-administered to decrease intra-ocular inflammation and prevent rebound inflammation from Jarisch Herxheimer reaction. | ||
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'''Adults''' | '''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> | *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 | :* 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 | ||
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* 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 | * 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. | :* 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> | :* 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== | ||
Revision as of 20:05, 19 April 2016
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
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
- Preferred regimen (1): Ganciclovir intraocular implant PLUS Valganciclovir 900 mg PO bid for 14-21 days THEN Valganciclovir 900mg PO qq for maintenance therapy - for immediate sight-threatening lesions
- Preferred regimen (2): Valganciclovir 900 mg PO bid for 14-21 days THEN Valganciclovir 900 mg PO qq for maintenance therapy - for peripheral lesions
- Alternative regimen (1): Foscarnet 60 mg/kg IV q8h OR Foscarnet 90 mg/kg IV q12h for 14-21 days THEN Foscarnet 90-120 mg/kg IV q24h *Alternative regimen (2): Cidofovir 5 mg/kg IV for 2 weeks THEN Cidofovir 5 mg/kg IV every other week - each dose should be admnistered with IV saline hydration and probenecid
- Alternative regimen (3): Ganciclovir 5 mg/kg IV q12h for 14-21 days THEN Valganciclovir 900 mg PO bid
- Alternative regimen (4): Fomivirsen intravitreal injection - for relapses
- Note: keep a maintenance dose of Valganciclovir 900 mg PO qd until CD4 >100/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)".