Whipple's disease medical therapy: Difference between revisions
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==Medical Therapy== | ==Medical Therapy== | ||
*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><ref name="MarthMoos2016">{{cite journal|last1=Marth|first1=Thomas|last2=Moos|first2=Verena|last3=Müller|first3=Christian|last4=Biagi|first4=Federico|last5=Schneider|first5=Thomas|title=Tropheryma whipplei infection and Whipple's disease|journal=The Lancet Infectious Diseases|volume=16|issue=3|year=2016|pages=e13–e22|issn=14733099|doi=10.1016/S1473-3099(15)00537-X}}</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><ref name="MarthMoos2016">{{cite journal|last1=Marth|first1=Thomas|last2=Moos|first2=Verena|last3=Müller|first3=Christian|last4=Biagi|first4=Federico|last5=Schneider|first5=Thomas|title=Tropheryma whipplei infection and Whipple's disease|journal=The Lancet Infectious Diseases|volume=16|issue=3|year=2016|pages=e13–e22|issn=14733099|doi=10.1016/S1473-3099(15)00537-X}}</ref> | ||
* '''1 Classic Whipple's disease''' | * '''1 Classic Whipple's disease''' | ||
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***4.2.1 Preferred regimen (1): [[Doxycycline]] 100 mg PO q12h '''<u>AND</u>''' [[hydroxychloroquine]] 200 mg PO q8h for 1 year | ***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 | ***4.2.2 Alternative regimen (1): [[Sulfamethoxazole-Trimethoprim|Trimethoprim-sulfamethoxazole]] one DS tablet (160 mg TMP/800 mg SMX) PO q12h for 1 year | ||
===Adverse effects of treatment and complications=== | |||
[[Immune reconstitution inflammatory syndrome]] ([[IRIS]]) is a side effect that occurred following initiation of [[antibiotic]] therapy in Whipple's disease. It is characterized as a flare-up of [[inflammation]] and considered fatal. Previous [[immunosuppressive therapy]] increases the risk of [[IRIS]]. Clinical features of the [[IRIS]] are [[fever]] and [[arthritis]]. Oral [[corticosteroid]] is used to treat [[IRIS]].<ref name="BiagiTrotta2012">{{cite journal|last1=Biagi|first1=Federico|last2=Trotta|first2=Lucia|last3=Di Stefano|first3=Michele|last4=Balduzzi|first4=Davide|last5=Marchese|first5=Alessandra|last6=Vattiato|first6=Claudia|last7=Bianchi|first7=Paola I.|last8=Fenollar|first8=Florence|last9=Corazza|first9=Gino R.|title=Previous immunosuppressive therapy is a risk factor for immune reconstitution inflammatory syndrome in Whipple's disease|journal=Digestive and Liver Disease|volume=44|issue=10|year=2012|pages=880–882|issn=15908658|doi=10.1016/j.dld.2012.05.008}}</ref><ref name="MoosFeurle2013">{{cite journal|last1=Moos|first1=V.|last2=Feurle|first2=G. E.|last3=Schinnerling|first3=K.|last4=Geelhaar|first4=A.|last5=Friebel|first5=J.|last6=Allers|first6=K.|last7=Moter|first7=A.|last8=Kikhney|first8=J.|last9=Loddenkemper|first9=C.|last10=Kuhl|first10=A. A.|last11=Erben|first11=U.|last12=Fenollar|first12=F.|last13=Raoult|first13=D.|last14=Schneider|first14=T.|title=Immunopathology of Immune Reconstitution Inflammatory Syndrome in Whipple's Disease|journal=The Journal of Immunology|volume=190|issue=5|year=2013|pages=2354–2361|issn=0022-1767|doi=10.4049/jimmunol.1202171}}</ref> | |||
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Revision as of 02:32, 10 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][7]
- 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 Anticonvulsant therapy
- 2.3.1 Preferred regimen (1):
- 2.3.2 Preferred regimen (2):
- 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
- 3.1.2 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
- 3.1.1 Preferred regimen (1): Penicillin G 2 million units IV q4h 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
- 3.1 Initial therapy
- 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
Adverse effects of treatment and complications
Immune reconstitution inflammatory syndrome (IRIS) is a side effect that occurred following initiation of antibiotic therapy in Whipple's disease. It is characterized as a flare-up of inflammation and considered fatal. Previous immunosuppressive therapy increases the risk of IRIS. Clinical features of the IRIS are fever and arthritis. Oral corticosteroid is used to treat IRIS.[8][9]
| 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.
- ↑ Marth, Thomas; Moos, Verena; Müller, Christian; Biagi, Federico; Schneider, Thomas (2016). "Tropheryma whipplei infection and Whipple's disease". The Lancet Infectious Diseases. 16 (3): e13–e22. doi:10.1016/S1473-3099(15)00537-X. ISSN 1473-3099.
- ↑ Biagi, Federico; Trotta, Lucia; Di Stefano, Michele; Balduzzi, Davide; Marchese, Alessandra; Vattiato, Claudia; Bianchi, Paola I.; Fenollar, Florence; Corazza, Gino R. (2012). "Previous immunosuppressive therapy is a risk factor for immune reconstitution inflammatory syndrome in Whipple's disease". Digestive and Liver Disease. 44 (10): 880–882. doi:10.1016/j.dld.2012.05.008. ISSN 1590-8658.
- ↑ Moos, V.; Feurle, G. E.; Schinnerling, K.; Geelhaar, A.; Friebel, J.; Allers, K.; Moter, A.; Kikhney, J.; Loddenkemper, C.; Kuhl, A. A.; Erben, U.; Fenollar, F.; Raoult, D.; Schneider, T. (2013). "Immunopathology of Immune Reconstitution Inflammatory Syndrome in Whipple's Disease". The Journal of Immunology. 190 (5): 2354–2361. doi:10.4049/jimmunol.1202171. ISSN 0022-1767.