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__NOTOC__
__NOTOC__
{{ Paroxysmal nocturnal hemoglobinuria }}
{{Paroxysmal nocturnal hemoglobinuria}}
{{CMG}}
{{CMG}}; {{AE}}


==Overview==
==Overview==
There is no treatment for [disease name]; the mainstay of therapy is supportive care.


==Medical Therapy==
OR
There is no widely accepted evidence-based indication for the treatment of PNH. In classic PNH it is recommended to treat patients with disabling fatigue, thromboses, transfusion dependence, frequent painful paroxysms, renal insufficiency or other end-organ complications from this disease. Watchful waiting is appropriate for the asymptomatic patient or the patient with mild symptoms.
 
Supportive therapy for [disease name] includes [therapy 1], [therapy 2], and [therapy 3].
 
OR
 
The majority of cases of [disease name] are self-limited and require only supportive care.
 
OR
 
[Disease name] is a medical emergency and requires prompt treatment.
 
OR
 
The mainstay of treatment for [disease name] is [therapy].
 
OR
 
The optimal therapy for [malignancy name] depends on the stage at diagnosis.
 
OR


===Long-term===
[Therapy] is recommended among all patients who develop [disease name].
PNH is a chronic condition. In patients who have only a small clone and few problems, monitoring of the flow cytometry every six months gives information on the severity and risk of potential complications. Given the high risk of thrombosis in PNH, preventative treatment with[[warfarin]] decreases the risk of thrombosis in those with a large clone (50% of white blood cells type III).<ref name=parker2005/><ref>{{cite journal |author=Hall C, Richards S, Hillmen P |title=Primary prophylaxis with warfarin prevents thrombosis in paroxysmal nocturnal hemoglobinuria (PNH) |journal=Blood |volume=102 |issue=10 |pages=3587–91 |year=2003 |month=November |pmid=12893760|doi=10.1182/blood-2003-01-0009 |url=http://bloodjournal.hematologylibrary.org/cgi/content/full/102/10/3587}}</ref>  Episodes of thrombosis are treated as they would in other patients, but given that PNH is a persisting underlying cause it is likely that treatment with [[warfarin]]or similar drugs needs to be continued long-term after an episode of thrombosis.<ref name=parker2005>{{cite journal |author=Parker C, Omine M, Richards S, ''et al'' |title=Diagnosis and management of paroxysmal nocturnal hemoglobinuria |journal=Blood |volume=106 |issue=12|pages=3699–709 |year=2005 |pmid=16051736|doi=10.1182/blood-2005-04-1717|url=http://bloodjournal.hematologylibrary.org/cgi/content/full/106/12/3699}} {{PMC|1895106}}</ref>


In patients with aplastic anemia / PNH treatment should be directed toward the underlying bone marrow failure with careful monitoring of the PNH clone using flow cytometry.  Patients who meet the criteria of severe aplastic anemia should be managed with either an allogeneic bone marrow transplant or immunosuppressive treatment dependent on the age of the patient and the availability of a bone marrow donor.  Treatment of bone marrow failure in PNH is similar to that for aplasia.  Immunosuppressives can be administered such as antithymocyte globulin or cyclosporine.  Supportive measures in terms of GCSF or erythropoeitin (EPO) can also be given.  An allogeneic bone marrow transplant is the only curative treatment and is an option for younger patients.  A bone marrow transplant is curative but is associated with significant morbidity and mortality.  The 2 year survival with this modality is 56%; the majority of deaths occur within the first year of transplant (International Bone Marrow Registry). 
OR


===Acute attacks===
Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].
There is debate as to whether steroids (such as [[prednisolone]]) can be useful in decreasing the severity of hemolytic crises. Steroids can decrease complement activation which, subsequently, decreases hemolysis however high doses are usually necessary.  Transfusion therapy may be needed; in addition to correcting significant [[anemia]] this suppresses the production of PNH cells by the bone marrow, and indirectly the severity of the hemolysis. Some sources advocate the use of washed red cell transfusions.  Leucocyte-depleted transfusions are also recommended for those requiring chronic transfusion therapy.


Iron deficiency develops with time, due to losses in urine, and may have to be treated if present. Iron therapy can result in more hemolysis as more PNH cells are produced.<ref name=parker2005/>  It may be necessary to give folate too in order to augment hematopoiesis.  Erythropoeitin (EPO) can be given (10-20,000 u tiw) to help.  As with steroid therapy tranfusions are given when the iron treatments do not suffice. 
OR


Eculizumab (AKA Soliris) is a monoclonal antibody against the complement protein C5, halting terminal complement-mediated intravascular hemolysis.<ref>{{cite journal |author=Hillmen P, Hall C, Marsh JC, ''et al'' |title=Effect of eculizumab on hemolysis and transfusion requirements in patients with paroxysmal nocturnal hemoglobinuria |journal=N. Engl. J. Med. |volume=350 |issue=6 |pages=552–9 |year=2004|pmid=14762182 |doi=10.1056/NEJMoa031688}}</ref> It binds to a subunit of the C5 convertase enzyme.  It prevents C5 convertase from hydrolyzing C5 to C5a and C5b, the latter combining with C9 to form the terminal complement complex.
Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].


Selection of patients to be treated with Eculizumab should be guided by the degree of hemolysis and the risk of thrombosis.  Although most of the patients with PNH have some degree of ongoing hemolysis not all are transfusion dependent nor even anemic. 
OR


Patients who take Eculizumab are at increase risk of life-threatening meningococcal infection.  Patients must receive the meningococcal vaccine at least 2 weeks before Eculizumab is given.  If the patient had already received the vaccine, they may need a booster.  Patients have a 0.5% yearly risk of acquiring neisserial sepsis even after vaccination.  Patients should be revaccinated against Neisseria meningitidis every 3-5 years after starting the treatment and they should seek medical care if they develop any signs or symptoms suggestive of neisserial infection.  These include headache, nausea, vomiting, fever, stiff back or neck, rash, confusion, visual sensitization to light and myalgias with flu-like manifestations.  Note that the most common toxicity of Eculizumab is headache which occurs in about 50% of patients given the first dose or two but, typically, this rarely recurs afterwards.  Patients still need to be monitored for meningitis for at least 8 weeks after discontinuing Eculizumab.
Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].


Long term terminal complement inhibition by Eculizumab doesn't increase the incidence of myeloproliferative disease, myelodysplasia, acute leukemias or aplasia / pancytopenias in PNH patients.  Eculizumab administration decreases hemolysis leading to stabilization of the hemoglobin concentration and reticulocyte count.  This is manifest clinically with a decrease in the need for transfusions. 
OR


Breakthrough intravascular hemolysis and a return of PNH symptoms occurs in < 2% of PNH patients treated with Eculizumab.  This typically occurs a day or two before the next scheduled dose and is accompanied by a spike in the LDH.  The LDH usually returns to normal or near normal within days to weeks after Eculizumab.  Since the (episodic) hemolysis of PNH is partly intravascular, the finding of urine hemosiderin is consistent with continued erythrocyte destruction.  The reticulocyte count often remains elevated because most PNH patients on Eculizumab continue to have some extravascular hemolysis.  If this occurs on a regular basis then the dosing interval can be shortened or the dose increased in order to compensate.  It is also important to remember that increased complement activation accompanies infection (eg. flu or viral gastroenteritis) or trauma which can result in transient breakthrough hemolysis.  It is not recommended to change the dosing with regard to a single episode of breakthrough hemolysis.
Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].


Anticoagulation is only partly effective in preventing thrombosis in PNH. Some sources state that thrombosis is an absolute indication for initiating treating with Eculizumab.  Prophyllactic anticoagulation has never been proven to prevent thrombosis in all PNH patients and can be dangerous given the thrombocytopenia seen in this malady. Some sources state that patients who do not meet criteria for Eculizumab therapy should not receive anticoagulation. Possible exceptions to this rule might include patients with persistently elevated D-dimer levels, pregnant PNH patients and patients in the perioperative period.
==Medical Therapy==
*Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].
*Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].
*Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].
*Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].
===Disease Name===


Pregnant patients with PNH have an even greater need for folate and iron supplementation because of the hemolysis. Pregnancy, as with oral contraceptive use, increases the risk of thrombosis in PNH.  Anticoagulation with a LMWH is recommended as long as there are no contraindications for full anticoagulation.  Give 1 mg/kg subcutaneously every 12 hours when the pregnancy is confirmed in a PNH patient with a large PNH clone.  Some sources state that it is often necessary to switch to unfractionated heparin around the time of delivery if a C-section is planned.
* '''1 Stage 1 - Name of stage'''
** 1.1 '''Specific Organ system involved 1'''
*** 1.1.1 '''Adult'''
**** Preferred regimen (1): [[drug name]] 100 mg PO q12h for 10-21 days '''(Contraindications/specific instructions)''' 
**** Preferred regimen (2): [[drug name]] 500 mg PO q8h for 14-21 days
**** Preferred regimen (3): [[drug name]] 500 mg q12h for 14-21 days
**** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days  
**** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
**** Alternative regimen (3): [[drug name]] 500 mg PO q6h for 14–21 days
*** 1.1.2 '''Pediatric'''
**** 1.1.2.1 (Specific population e.g. '''children < 8 years of age''')
***** Preferred regimen (1): [[drug name]] 50 mg/kg PO per day q8h (maximum, 500 mg per dose)  
***** Preferred regimen (2): [[drug name]] 30 mg/kg PO per day in 2 divided doses (maximum, 500 mg per dose)
***** Alternative regimen (1): [[drug name]]10 mg/kg PO q6h (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h (maximum, 500 mg per dose)
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h (maximum, 500 mg per dose)
****1.1.2.2 (Specific population e.g. ''''''children < 8 years of age'''''')
***** Preferred regimen (1): [[drug name]] 4 mg/kg/day PO q12h（maximum, 100 mg per dose）
***** Alternative regimen (1): [[drug name]] 10 mg/kg PO q6h (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h (maximum, 500 mg per dose)  
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h (maximum, 500 mg per dose)
** 1.2 '''Specific Organ system involved 2'''
*** 1.2.1 '''Adult'''
**** Preferred regimen (1): [[drug name]] 500 mg PO q8h
*** 1.2.2  '''Pediatric'''
**** Preferred regimen (1): [[drug name]] 50 mg/kg/day PO q8h (maximum, 500 mg per dose)


* Iron deficiency often occurs with PNH patients because of urinary loss and should be treated.  The administration of oral iron is usually sufficient. Although there may be an increase in hemoglobinuria with iron therapy, due to the increased production of PNH cells by the marrow, the net positive effect in red blood cell production may lessen the requirements for blood transfusion. Folate should be given concurrently with the iron to help augment hematopoiesis.  
* 2 '''Stage 2 - Name of stage'''
'''Nitric Oxide depletion / thrombosis;'''   
** 2.1 '''Specific Organ system involved 1 '''
* During episodes of acute hemolysis free plasma hemoglobin that is released as a consequence of erythrocyte lysis may overpower haptoglobin, a hemoglobin-scavenging protein.  Excess free hemoglobin depletes plasma nitric oxide, which can play an important role in the maintenance of normal platelet function.  It has been postulated that nitric oxide down-regulates platelet aggregation, adhesion and regulating molecules in the coagulation cascade.  Nitric oxide depletion may therefore lead to platelet activation and aggregation.  With this in mind the chronic consumption of nitric oxide by intravascular hemoglobin can play a role in the thrombotic events that occur in patients with PNH. Depletion of nitric oxide at the tissue level contributes to numerous PNH manifestations including smooth muscle dystonia (eg esophageal spasm, abdominal pain, male erectile dysfunction), pulmonary hypertension, severe fatigue and renal insufficiency as well as thrombosis.   
**: '''Note (1):'''
**: '''Note (2)''':
**: '''Note (3):'''
*** 2.1.1 '''Adult'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 2 g IV q24h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 2 g IV q8h for 14 (14–21) days
***** Alternative regimen (2): [[drug name]] 18–24 MU/day IV q4h for 14 (14–21) days
**** Oral regimen
***** Preferred regimen (1): [[drug name]] 500 mg PO q8h for 14 (14–21) days
***** Preferred regimen (2): [[drug name]] 100 mg PO q12h for 14 (14–21) days
***** Preferred regimen (3): [[drug name]] 500 mg PO q12h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days  
***** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
***** Alternative regimen (3):[[drug name]] 500 mg PO q6h for 14–21 days
*** 2.1.2 '''Pediatric'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 50–75 mg/kg IV q24h for 14 (14–21) days (maximum, 2 g)
***** Alternative regimen (1): [[drug name]] 150–200 mg/kg/day IV q6–8h for 14 (14–21) days (maximum, 6 g per day)
***** Alternative regimen (2):  [[drug name]] 200,000–400,000 U/kg/day IV q4h for 14 (14–21) days (maximum, 18–24 million U per day) ''''''(Contraindications/specific instructions)''''''
**** Oral regimen
***** Preferred regimen (1): [[drug name]] 50 mg/kg/day PO q8h for 14 (14–21) days (maximum, 500 mg per dose)
***** Preferred regimen (2): [[drug name]] '''(for children aged ≥ 8 years)''' 4 mg/kg/day PO q12h for 14 (14–21) days (maximum, 100 mg per dose)
***** Preferred regimen (3): [[drug name]] 30 mg/kg/day PO q12h for 14 (14–21) days (maximum, 500 mg per dose)
***** Alternative regimen (1):  [[drug name]] 10 mg/kg PO q6h 7–10 days  (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h for 14–21 days (maximum, 500 mg per dose)
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h for 14–21 days (maximum,500 mg per dose)
** 2.2 '<nowiki/>'''''Other Organ system involved 2''''''
**: '''Note (1):'''
**: '''Note (2)''':
**: '''Note (3):'''
*** 2.2.1 '''Adult'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 2 g IV q24h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 2 g IV q8h for 14 (14–21) days
***** Alternative regimen (2): [[drug name]] 18–24 MU/day IV q4h for 14 (14–21) days
**** Oral regimen
***** Preferred regimen (1): [[drug name]] 500 mg PO q8h for 14 (14–21) days
***** Preferred regimen (2): [[drug name]] 100 mg PO q12h for 14 (14–21) days
***** Preferred regimen (3): [[drug name]] 500 mg PO q12h for 14 (14–21) days
***** Alternative regimen (1): [[drug name]] 500 mg PO q6h for 7–10 days  
***** Alternative regimen (2): [[drug name]] 500 mg PO q12h for 14–21 days
***** Alternative regimen (3):[[drug name]] 500 mg PO q6h for 14–21 days
*** 2.2.2 '''Pediatric'''
**** Parenteral regimen
***** Preferred regimen (1): [[drug name]] 50–75 mg/kg IV q24h for 14 (14–21) days (maximum, 2 g)
***** Alternative regimen (1): [[drug name]] 150–200 mg/kg/day IV q6–8h for 14 (14–21) days (maximum, 6 g per day)
***** Alternative regimen (2):  [[drug name]] 200,000–400,000 U/kg/day IV q4h for 14 (14–21) days (maximum, 18–24 million U per day)
**** Oral regimen
***** Preferred regimen (1): [[drug name]] 50 mg/kg/day PO q8h for 14 (14–21) days (maximum, 500 mg per dose)
***** Preferred regimen (2): [[drug name]] 4 mg/kg/day PO q12h for 14 (14–21) days (maximum, 100 mg per dose)
***** Preferred regimen (3): [[drug name]] 30 mg/kg/day PO q12h for 14 (14–21) days  (maximum, 500 mg per dose)
***** Alternative regimen (1):  [[drug name]] 10 mg/kg PO q6h 7–10 days  (maximum, 500 mg per day)
***** Alternative regimen (2): [[drug name]] 7.5 mg/kg PO q12h for 14–21 days  (maximum, 500 mg per dose)
***** Alternative regimen (3): [[drug name]] 12.5 mg/kg PO q6h for 14–21 days (maximum,500 mg per dose)


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
[[Category:Hematology]]
[[Category:Rheumatology]]
[[Category:Mature chapter]]


{{WH}}
{{WH}}
{{WS}}
{{WS}}
[[Category: (name of the system)]]

Revision as of 17:01, 2 July 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Overview

There is no treatment for [disease name]; the mainstay of therapy is supportive care.

OR

Supportive therapy for [disease name] includes [therapy 1], [therapy 2], and [therapy 3].

OR

The majority of cases of [disease name] are self-limited and require only supportive care.

OR

[Disease name] is a medical emergency and requires prompt treatment.

OR

The mainstay of treatment for [disease name] is [therapy].

OR   The optimal therapy for [malignancy name] depends on the stage at diagnosis.

OR

[Therapy] is recommended among all patients who develop [disease name].

OR

Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].

OR

Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].

OR

Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].

OR

Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].

Medical Therapy

  • Pharmacologic medical therapy is recommended among patients with [disease subclass 1], [disease subclass 2], and [disease subclass 3].
  • Pharmacologic medical therapies for [disease name] include (either) [therapy 1], [therapy 2], and/or [therapy 3].
  • Empiric therapy for [disease name] depends on [disease factor 1] and [disease factor 2].
  • Patients with [disease subclass 1] are treated with [therapy 1], whereas patients with [disease subclass 2] are treated with [therapy 2].

Disease Name

  • 1 Stage 1 - Name of stage
    • 1.1 Specific Organ system involved 1
      • 1.1.1 Adult
        • Preferred regimen (1): drug name 100 mg PO q12h for 10-21 days (Contraindications/specific instructions)
        • Preferred regimen (2): drug name 500 mg PO q8h for 14-21 days
        • Preferred regimen (3): drug name 500 mg q12h for 14-21 days
        • Alternative regimen (1): drug name 500 mg PO q6h for 7–10 days
        • Alternative regimen (2): drug name 500 mg PO q12h for 14–21 days
        • Alternative regimen (3): drug name 500 mg PO q6h for 14–21 days
      • 1.1.2 Pediatric
        • 1.1.2.1 (Specific population e.g. children < 8 years of age)
          • Preferred regimen (1): drug name 50 mg/kg PO per day q8h (maximum, 500 mg per dose)
          • Preferred regimen (2): drug name 30 mg/kg PO per day in 2 divided doses (maximum, 500 mg per dose)
          • Alternative regimen (1): drug name10 mg/kg PO q6h (maximum, 500 mg per day)
          • Alternative regimen (2): drug name 7.5 mg/kg PO q12h (maximum, 500 mg per dose)
          • Alternative regimen (3): drug name 12.5 mg/kg PO q6h (maximum, 500 mg per dose)
        • 1.1.2.2 (Specific population e.g. 'children < 8 years of age')
          • Preferred regimen (1): drug name 4 mg/kg/day PO q12h（maximum, 100 mg per dose）
          • Alternative regimen (1): drug name 10 mg/kg PO q6h (maximum, 500 mg per day)
          • Alternative regimen (2): drug name 7.5 mg/kg PO q12h (maximum, 500 mg per dose)
          • Alternative regimen (3): drug name 12.5 mg/kg PO q6h (maximum, 500 mg per dose)
    • 1.2 Specific Organ system involved 2
      • 1.2.1 Adult
        • Preferred regimen (1): drug name 500 mg PO q8h
      • 1.2.2 Pediatric
        • Preferred regimen (1): drug name 50 mg/kg/day PO q8h (maximum, 500 mg per dose)
  • 2 Stage 2 - Name of stage
    • 2.1 Specific Organ system involved 1
      Note (1):
      Note (2):
      Note (3):
      • 2.1.1 Adult
        • Parenteral regimen
          • Preferred regimen (1): drug name 2 g IV q24h for 14 (14–21) days
          • Alternative regimen (1): drug name 2 g IV q8h for 14 (14–21) days
          • Alternative regimen (2): drug name 18–24 MU/day IV q4h for 14 (14–21) days
        • Oral regimen
          • Preferred regimen (1): drug name 500 mg PO q8h for 14 (14–21) days
          • Preferred regimen (2): drug name 100 mg PO q12h for 14 (14–21) days
          • Preferred regimen (3): drug name 500 mg PO q12h for 14 (14–21) days
          • Alternative regimen (1): drug name 500 mg PO q6h for 7–10 days
          • Alternative regimen (2): drug name 500 mg PO q12h for 14–21 days
          • Alternative regimen (3):drug name 500 mg PO q6h for 14–21 days
      • 2.1.2 Pediatric
        • Parenteral regimen
          • Preferred regimen (1): drug name 50–75 mg/kg IV q24h for 14 (14–21) days (maximum, 2 g)
          • Alternative regimen (1): drug name 150–200 mg/kg/day IV q6–8h for 14 (14–21) days (maximum, 6 g per day)
          • Alternative regimen (2):  drug name 200,000–400,000 U/kg/day IV q4h for 14 (14–21) days (maximum, 18–24 million U per day) '(Contraindications/specific instructions)'
        • Oral regimen
          • Preferred regimen (1): drug name 50 mg/kg/day PO q8h for 14 (14–21) days (maximum, 500 mg per dose)
          • Preferred regimen (2): drug name (for children aged ≥ 8 years) 4 mg/kg/day PO q12h for 14 (14–21) days (maximum, 100 mg per dose)
          • Preferred regimen (3): drug name 30 mg/kg/day PO q12h for 14 (14–21) days (maximum, 500 mg per dose)
          • Alternative regimen (1): drug name 10 mg/kg PO q6h 7–10 days (maximum, 500 mg per day)
          • Alternative regimen (2): drug name 7.5 mg/kg PO q12h for 14–21 days (maximum, 500 mg per dose)
          • Alternative regimen (3): drug name 12.5 mg/kg PO q6h for 14–21 days (maximum,500 mg per dose)
    • 2.2 'Other Organ system involved 2'
      Note (1):
      Note (2):
      Note (3):
      • 2.2.1 Adult
        • Parenteral regimen
          • Preferred regimen (1): drug name 2 g IV q24h for 14 (14–21) days
          • Alternative regimen (1): drug name 2 g IV q8h for 14 (14–21) days
          • Alternative regimen (2): drug name 18–24 MU/day IV q4h for 14 (14–21) days
        • Oral regimen
          • Preferred regimen (1): drug name 500 mg PO q8h for 14 (14–21) days
          • Preferred regimen (2): drug name 100 mg PO q12h for 14 (14–21) days
          • Preferred regimen (3): drug name 500 mg PO q12h for 14 (14–21) days
          • Alternative regimen (1): drug name 500 mg PO q6h for 7–10 days
          • Alternative regimen (2): drug name 500 mg PO q12h for 14–21 days
          • Alternative regimen (3):drug name 500 mg PO q6h for 14–21 days
      • 2.2.2 Pediatric
        • Parenteral regimen
          • Preferred regimen (1): drug name 50–75 mg/kg IV q24h for 14 (14–21) days (maximum, 2 g)
          • Alternative regimen (1): drug name 150–200 mg/kg/day IV q6–8h for 14 (14–21) days (maximum, 6 g per day)
          • Alternative regimen (2):  drug name 200,000–400,000 U/kg/day IV q4h for 14 (14–21) days (maximum, 18–24 million U per day)
        • Oral regimen
          • Preferred regimen (1): drug name 50 mg/kg/day PO q8h for 14 (14–21) days (maximum, 500 mg per dose)
          • Preferred regimen (2): drug name 4 mg/kg/day PO q12h for 14 (14–21) days (maximum, 100 mg per dose)
          • Preferred regimen (3): drug name 30 mg/kg/day PO q12h for 14 (14–21) days (maximum, 500 mg per dose)
          • Alternative regimen (1): drug name 10 mg/kg PO q6h 7–10 days (maximum, 500 mg per day)
          • Alternative regimen (2): drug name 7.5 mg/kg PO q12h for 14–21 days (maximum, 500 mg per dose)
          • Alternative regimen (3): drug name 12.5 mg/kg PO q6h for 14–21 days (maximum,500 mg per dose)

References

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