Whipple's disease medical therapy: Difference between revisions
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*Pharmacologic medical therapy for Whipple's disease includes long-term [[Antibiotic|antibiotics]]. Preferred regimens for initial therapy include [[Ceftriaxone]] or [[Penicillin]] G or [[Meropenem]] if allergic. One year of [[Sulfamethoxazole-Trimethoprim|Trimethoprim-sulfamethoxazole]] is used for maintenance therapy. In case of [[sulfa allergy]], the combination of [[Doxycycline]] and [[Hydroxychloroquine]] is used.<ref name="FeurleJunga2010">{{cite journal|last1=Feurle|first1=Gerhard E.|last2=Junga|first2=Natascha S.|last3=Marth|first3=Thomas|title=Efficacy of Ceftriaxone or Meropenem as Initial Therapies in Whipple's Disease|journal=Gastroenterology|volume=138|issue=2|year=2010|pages=478–486|issn=00165085|doi=10.1053/j.gastro.2009.10.041}}</ref><ref name="pmid9193452">{{cite journal |vauthors=Durand DV, Lecomte C, Cathébras P, Rousset H, Godeau P |title=Whipple disease. Clinical review of 52 cases. The SNFMI Research Group on Whipple Disease. Société Nationale Française de Médecine Interne |journal=Medicine (Baltimore) |volume=76 |issue=3 |pages=170–84 |year=1997 |pmid=9193452 |doi= |url=}}</ref><ref name="SchniderReisinger1997">{{cite journal|last1=Schnider|first1=P. J.|last2=Reisinger|first2=E. C.|last3=Berger|first3=T.|last4=Krejs|first4=G. J.|last5=Auff|first5=E.|title=Treatment guidelines in central nervous system Whipple's disease|journal=Annals of Neurology|volume=41|issue=4|year=1997|pages=561–562|issn=0364-5134|doi=10.1002/ana.410410425}}</ref><ref name="pmid14982759">{{cite journal |vauthors=Boulos A, Rolain JM, Raoult D |title=Antibiotic susceptibility of Tropheryma whipplei in MRC5 cells |journal=Antimicrob. Agents Chemother. |volume=48 |issue=3 |pages=747–52 |year=2004 |pmid=14982759 |pmc=353111 |doi= |url=}}</ref><ref name="pmid7519538">{{cite journal |vauthors=Feurle GE, Marth T |title=An evaluation of antimicrobial treatment for Whipple's Disease. Tetracycline versus trimethoprim-sulfamethoxazole |journal=Dig. Dis. Sci. |volume=39 |issue=8 |pages=1642–8 |year=1994 |pmid=7519538 |doi= |url=}}</ref><ref name="pmid2581843">{{cite journal |vauthors=Keinath RD, Merrell DE, Vlietstra R, Dobbins WO |title=Antibiotic treatment and relapse in Whipple's disease. Long-term follow-up of 88 patients |journal=Gastroenterology |volume=88 |issue=6 |pages=1867–73 |year=1985 |pmid=2581843 |doi= |url=}}</ref> | *Pharmacologic medical therapy for Whipple's disease includes long-term [[Antibiotic|antibiotics]]. Preferred regimens for initial therapy include [[Ceftriaxone]] or [[Penicillin]] G or [[Meropenem]] if allergic. One year of [[Sulfamethoxazole-Trimethoprim|Trimethoprim-sulfamethoxazole]] is used for maintenance therapy. In case of [[sulfa allergy]], the combination of [[Doxycycline]] and [[Hydroxychloroquine]] is used.<ref name="FeurleJunga2010">{{cite journal|last1=Feurle|first1=Gerhard E.|last2=Junga|first2=Natascha S.|last3=Marth|first3=Thomas|title=Efficacy of Ceftriaxone or Meropenem as Initial Therapies in Whipple's Disease|journal=Gastroenterology|volume=138|issue=2|year=2010|pages=478–486|issn=00165085|doi=10.1053/j.gastro.2009.10.041}}</ref><ref name="pmid9193452">{{cite journal |vauthors=Durand DV, Lecomte C, Cathébras P, Rousset H, Godeau P |title=Whipple disease. Clinical review of 52 cases. The SNFMI Research Group on Whipple Disease. Société Nationale Française de Médecine Interne |journal=Medicine (Baltimore) |volume=76 |issue=3 |pages=170–84 |year=1997 |pmid=9193452 |doi= |url=}}</ref><ref name="SchniderReisinger1997">{{cite journal|last1=Schnider|first1=P. J.|last2=Reisinger|first2=E. C.|last3=Berger|first3=T.|last4=Krejs|first4=G. J.|last5=Auff|first5=E.|title=Treatment guidelines in central nervous system Whipple's disease|journal=Annals of Neurology|volume=41|issue=4|year=1997|pages=561–562|issn=0364-5134|doi=10.1002/ana.410410425}}</ref><ref name="pmid14982759">{{cite journal |vauthors=Boulos A, Rolain JM, Raoult D |title=Antibiotic susceptibility of Tropheryma whipplei in MRC5 cells |journal=Antimicrob. Agents Chemother. |volume=48 |issue=3 |pages=747–52 |year=2004 |pmid=14982759 |pmc=353111 |doi= |url=}}</ref><ref name="pmid7519538">{{cite journal |vauthors=Feurle GE, Marth T |title=An evaluation of antimicrobial treatment for Whipple's Disease. Tetracycline versus trimethoprim-sulfamethoxazole |journal=Dig. Dis. Sci. |volume=39 |issue=8 |pages=1642–8 |year=1994 |pmid=7519538 |doi= |url=}}</ref><ref name="pmid2581843">{{cite journal |vauthors=Keinath RD, Merrell DE, Vlietstra R, Dobbins WO |title=Antibiotic treatment and relapse in Whipple's disease. Long-term follow-up of 88 patients |journal=Gastroenterology |volume=88 |issue=6 |pages=1867–73 |year=1985 |pmid=2581843 |doi= |url=}}</ref> | ||
* '''1 Classic Whipple's disease''' | |||
*Initial therapy | **'''1.1 Initial therapy''' | ||
**Preferred regimen (1): [[Ceftriaxone]] 2 g IV qd for 14 days | ***1.1.1 Preferred regimen (1): [[Ceftriaxone]] 2 g IV qd for 14 days | ||
**Preferred regimen (2): [[Penicillin]] G 2 million units IV q4h for 14 days | ***1.1.2 Preferred regimen (2): [[Penicillin]] G 2 million units IV q4h for 14 days | ||
**Alternative regimen (1): [[Meropenem]] 1 g IV q8h for 14 days | ***1.1.3 Alternative regimen (1): [[Meropenem]] 1 g IV q8h for 14 days | ||
*Maintenance therapy | **'''1.2 Maintenance therapy''' | ||
**Preferred regimen (1): [[Sulfamethoxazole-Trimethoprim|Trimethoprim-sulfamethoxazole]] one DS tablet (160 mg TMP/800 mg SMX) PO q12h for 1 year | ***1.2.1 Preferred regimen (1): [[Sulfamethoxazole-Trimethoprim|Trimethoprim-sulfamethoxazole]] one DS tablet (160 mg TMP/800 mg SMX) PO q12h for 1 year | ||
**Alternative regimen (1): [[Doxycycline]] 100 mg PO q12h <u>'''AND'''</u> [[Hydroxychloroquine]] 200 mg PO q8h for 1 year | ***1.2.2 Alternative regimen (1): [[Doxycycline]] 100 mg PO q12h <u>'''AND'''</u> [[Hydroxychloroquine]] 200 mg PO q8h for 1 year | ||
* '''2 CNS infection''' | |||
*Initial therapy | ** '''2.1 Initial therapy''' | ||
**Preferred regimen (1): [[Ceftriaxone]] 2 g IV qd for 14-28 days | *** 2.1.1 Preferred regimen (1): [[Ceftriaxone]] 2 g IV qd for 14-28 days | ||
**Preferred regimen (2): [[Penicillin]] G 4 million units IV q4h for 14-28 days | *** 2.1.2 Preferred regimen (2): [[Penicillin]] G 4 million units IV q4h for 14-28 days | ||
**Alternative regimen (1): [[Meropenem]] 1 g IV q8h for 14-28 days | ***2.1.3 Alternative regimen (1): [[Meropenem]] 1 g IV q8h for 14-28 days | ||
*Maintenance therapy | **'''2.2 Maintenance therapy''' | ||
**Preferred regimen (1): [[Sulfamethoxazole-Trimethoprim|Trimethoprim-sulfamethoxazole]] one DS tablet (160 mg TMP/800 mg SMX) PO q12h for 1 year | ***2.2.1 Preferred regimen (1): [[Sulfamethoxazole-Trimethoprim|Trimethoprim-sulfamethoxazole]] one DS tablet (160 mg TMP/800 mg SMX) PO q12h for 1 year | ||
**Alternative regimen (1): [[Doxycycline]] 100 mg PO q12h '''<u>AND</u>''' [[Hydroxychloroquine]] 200 mg PO q8h for 1 year | ***2.2.2 Alternative regimen (1): [[Doxycycline]] 100 mg PO q12h '''<u>AND</u>''' [[Hydroxychloroquine]] 200 mg PO q8h for 1 year | ||
**'''2.3 Note:''' | |||
*** | |||
* '''3 Endocarditis''' | |||
*Initial therapy | ** '''3.1 Initial therapy''' | ||
**Preferred regimen (1): [[Penicillin]] G 2 million units IV q4h for 28 days | *** 3.1.1 Preferred regimen (1): [[Penicillin]] G 2 million units IV q4h for 28 days | ||
***3.1.2 Preferred regimen (2): [[Ceftriaxone]] 2 g IV qd for 28 days | |||
* | ***3.1.3 Alternative regimen (1): [[Meropenem]] 1 g IV q8h for 28 days | ||
**Preferred regimen ( | **'''3.2 Maintenance therapy''' | ||
** | ***3.2.1 Preferred regimen (1): [[Sulfamethoxazole-Trimethoprim|Trimethoprim-sulfamethoxazole]] one DS tablet (160 mg TMP/800 mg SMX) PO q12h for 1 year | ||
*Maintenance therapy | ***3.2.2 Alternative regimen (1): [[Doxycycline]] 100 mg PO q12h '''<u>AND</u>''' [[Hydroxychloroquine]] 200 mg PO q8h for 1 year | ||
**Preferred regimen (1): [[Doxycycline]] 100 mg PO q12h '''<u>AND</u>''' [[ | |||
* '''4 Relapse''' | |||
**'''4.1 Initial therapy''' | |||
***4.1.1 Preferred regimen (1): [[Penicillin]] G 4 million units IV q4h for 28 days | |||
***4.1.2 Preferred regimen (2): [[Ceftriaxone]] 2 g IV qd for 28 days | |||
**'''4.2 Maintenance therapy''' | |||
***4.2.1 Preferred regimen (1): [[Doxycycline]] 100 mg PO q12h '''<u>AND</u>''' [[hydroxychloroquine]] 200 mg PO q8h for 1 year | |||
***4.2.2 Alternative regimen (1): [[Sulfamethoxazole-Trimethoprim|Trimethoprim-sulfamethoxazole]] one DS tablet (160 mg TMP/800 mg SMX) PO q12h for 1 year | |||
{| class="wikitable" | {| class="wikitable" | ||
! rowspan="2" style="text-align: center; font-weight: bold;" | Indication | ! rowspan="2" style="text-align: center; font-weight: bold;" | Indication | ||
Revision as of 20:08, 3 November 2017
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Sadaf Sharfaei M.D.[2]
Overview
Antimicrobial therapy is the mainstay of therapy for Whipple's disease. Without antibiotic therapy Whipple's disease is fatal. Intravenous Ceftriaxone or Penicillin G is indicated in the acute phase of Whipple's therapy. For maintenance therapy, patients are typically treated with Trimethoprim-sulfamethoxazole for at least 1 year. Patients who experience either Whipple's disease or allergy to Trimethoprim-sulfamethoxazole require a combination of Doxycycline and Hydroxychloroquine.
Medical Therapy
- Pharmacologic medical therapy for Whipple's disease includes long-term antibiotics. Preferred regimens for initial therapy include Ceftriaxone or Penicillin G or Meropenem if allergic. One year of Trimethoprim-sulfamethoxazole is used for maintenance therapy. In case of sulfa allergy, the combination of Doxycycline and Hydroxychloroquine is used.[1][2][3][4][5][6]
- 1 Classic Whipple's disease
- 1.1 Initial therapy
- 1.1.1 Preferred regimen (1): Ceftriaxone 2 g IV qd for 14 days
- 1.1.2 Preferred regimen (2): Penicillin G 2 million units IV q4h for 14 days
- 1.1.3 Alternative regimen (1): Meropenem 1 g IV q8h for 14 days
- 1.2 Maintenance therapy
- 1.2.1 Preferred regimen (1): Trimethoprim-sulfamethoxazole one DS tablet (160 mg TMP/800 mg SMX) PO q12h for 1 year
- 1.2.2 Alternative regimen (1): Doxycycline 100 mg PO q12h AND Hydroxychloroquine 200 mg PO q8h for 1 year
- 1.1 Initial therapy
- 2 CNS infection
- 2.1 Initial therapy
- 2.1.1 Preferred regimen (1): Ceftriaxone 2 g IV qd for 14-28 days
- 2.1.2 Preferred regimen (2): Penicillin G 4 million units IV q4h for 14-28 days
- 2.1.3 Alternative regimen (1): Meropenem 1 g IV q8h for 14-28 days
- 2.2 Maintenance therapy
- 2.2.1 Preferred regimen (1): Trimethoprim-sulfamethoxazole one DS tablet (160 mg TMP/800 mg SMX) PO q12h for 1 year
- 2.2.2 Alternative regimen (1): Doxycycline 100 mg PO q12h AND Hydroxychloroquine 200 mg PO q8h for 1 year
- 2.3 Note:
- 2.1 Initial therapy
- 3 Endocarditis
- 3.1 Initial therapy
- 3.1.1 Preferred regimen (1): Penicillin G 2 million units IV q4h for 28 days
- 3.1 Initial therapy
- 3.1.2 Preferred regimen (2): Ceftriaxone 2 g IV qd for 28 days
- 3.1.3 Alternative regimen (1): Meropenem 1 g IV q8h for 28 days
- 3.2 Maintenance therapy
- 3.2.1 Preferred regimen (1): Trimethoprim-sulfamethoxazole one DS tablet (160 mg TMP/800 mg SMX) PO q12h for 1 year
- 3.2.2 Alternative regimen (1): Doxycycline 100 mg PO q12h AND Hydroxychloroquine 200 mg PO q8h for 1 year
- 4 Relapse
- 4.1 Initial therapy
- 4.1.1 Preferred regimen (1): Penicillin G 4 million units IV q4h for 28 days
- 4.1.2 Preferred regimen (2): Ceftriaxone 2 g IV qd for 28 days
- 4.2 Maintenance therapy
- 4.2.1 Preferred regimen (1): Doxycycline 100 mg PO q12h AND hydroxychloroquine 200 mg PO q8h for 1 year
- 4.2.2 Alternative regimen (1): Trimethoprim-sulfamethoxazole one DS tablet (160 mg TMP/800 mg SMX) PO q12h for 1 year
- 4.1 Initial therapy
| Indication | Initial therapy | Maintenance therapy | ||
|---|---|---|---|---|
| Prefered | Alternative | Preferred | Alternative | |
| Classic Whipple's disease | Ceftriaxone 2 g IV qd for 14 days
OR Penicillin G 2 million units IV q4h for 14 days |
Meropenem 1 g IV q8h for 14 days | Trimethoprim-sulfamethoxazole one DS tablet (160 mg TMP/800 mg SMX) PO q12h for 1 year | Doxycycline 100 mg PO q12h AND Hydroxychloroquine 200 mg PO q8h for 1 year |
| CNS Whippl'es disease | Ceftriaxone 2 g IV qd for 14-28 days
OR Penicillin G 4 million units IV q4h for 14-28 days |
Meropenem 1 g IV q8h for 14-28 days | Trimethoprim-sulfamethoxazole one DS tablet (160 mg TMP/800 mg SMX) PO q12h for 1 year | Doxycycline 100 mg PO q12h AND Hydroxychloroquine 200 mg PO q8h for 1 year |
| Endocarditis | Penicillin G 2 million units IV q4h for 28 days
OR Ceftriaxone 2 g IV qd for 28 days |
Meropenem 1 g IV q8h for 28 days | Trimethoprim-sulfamethoxazole one DS tablet (160 mg TMP/800 mg SMX) PO q12h for 1 year | Doxycycline 100 mg PO q12h AND Hydroxychloroquine 200 mg PO q8h for 1 year |
| Relapse | Penicillin G 4 million units IV q4h for 28 days
OR Ceftriaxone 2 g IV qd for 28 days |
Doxycycline 100 mg PO q12h AND hydroxychloroquine 200 mg PO q8h for 1 year | Trimethoprim-sulfamethoxazole one DS tablet (160 mg TMP/800 mg SMX) PO q12h for 1 year | |
References
- ↑ Feurle, Gerhard E.; Junga, Natascha S.; Marth, Thomas (2010). "Efficacy of Ceftriaxone or Meropenem as Initial Therapies in Whipple's Disease". Gastroenterology. 138 (2): 478–486. doi:10.1053/j.gastro.2009.10.041. ISSN 0016-5085.
- ↑ Durand DV, Lecomte C, Cathébras P, Rousset H, Godeau P (1997). "Whipple disease. Clinical review of 52 cases. The SNFMI Research Group on Whipple Disease. Société Nationale Française de Médecine Interne". Medicine (Baltimore). 76 (3): 170–84. PMID 9193452.
- ↑ Schnider, P. J.; Reisinger, E. C.; Berger, T.; Krejs, G. J.; Auff, E. (1997). "Treatment guidelines in central nervous system Whipple's disease". Annals of Neurology. 41 (4): 561–562. doi:10.1002/ana.410410425. ISSN 0364-5134.
- ↑ Boulos A, Rolain JM, Raoult D (2004). "Antibiotic susceptibility of Tropheryma whipplei in MRC5 cells". Antimicrob. Agents Chemother. 48 (3): 747–52. PMC 353111. PMID 14982759.
- ↑ Feurle GE, Marth T (1994). "An evaluation of antimicrobial treatment for Whipple's Disease. Tetracycline versus trimethoprim-sulfamethoxazole". Dig. Dis. Sci. 39 (8): 1642–8. PMID 7519538.
- ↑ Keinath RD, Merrell DE, Vlietstra R, Dobbins WO (1985). "Antibiotic treatment and relapse in Whipple's disease. Long-term follow-up of 88 patients". Gastroenterology. 88 (6): 1867–73. PMID 2581843.