부산대학교 도서관

Objective: To compare the tolerability and efficacy of three oral regimens for the treatment of patients with the acquired immunodeficiency syndrome (AIDS) and Pneumocystis carinii pneumonia. Design: A randomized, double-blind study. Setting: 24 U.S. academic medical centers. Patients: 181 patients with morphologically confirmed P. carinii pneumonia and alveolar-arterial oxygen differences (Pa[O.sub.2[-Pa[O.sub.2]) of 45 mm Hg or less. Intervention: Patients were randomly assigned to receive trimethoprim-sulfamethoxazole, dapsone-trimethoprim, or clindamycin-primaquine for 21 days. Patients with a (Pa[O.sub.2]-Pa[O.sub.2] of 35 to 45 mm Hg at study entry also received prednisone. Measurements: Serial clinical and laboratory evaluations for therapeutic response and toxicity. Therapeutic failure at day 21 was defined by any of the following: increase in PA[O.sub.2]-PA[O.sub.2] of greater than 20 mm Hg; no remission of baseline signs and symptoms, and change in antipneumocystis therapy for reasons other than toxicity, intubation, or death. Dose-limiting toxicity was defined as discontinuation of therapy by the primary physician because of one or more adverse reactions. Results: No statistically significant differences were seen among treatment groups in the proportions of patients who had dose-limiting toxicity (P = 0.2), therapeutic failure (P > 0.2), or a complete course of therapy (P > 0.2). Survival during therapy or for 2 months thereafter did not differ among the three groups (P > 0.2). However, elevation of serum aminotransferase levels to more than five times the baseline levels was more frequent in the trimethoprim-sulfamethoxazole group (P = 0.003), and one or more serious hematologic toxicities (neutropenia, anemia, thrombocytopenia, or methemoglobinemia) occurred more frequently in the clindamycin-primaquine group (P = 0.01). Conclusions: The rates of dose-limiting toxicity, therapeutic failure, and survival did not differ among patients with AIDS who were receiving oral trimethoprim-sulfamethoxazole, dapsone-trimethoprim, or clindamycinprimaquine for mild to moderate P. carinii pneumonia. However, the limited sample size prevents the unequivocal demonstration of the equality of these three regimens. Differences in expected categories of toxicities associated with each regimen should guide the clinician in choosing first-line therapy, particularly for patients with baseline hepatic insufficiency or myelosuppression.
Oral treatment with trimethoprim-sulfamethoxazole, dapsone-trimethoprim, or clindamycin-primaquine all seem to produce equally good outcomes and similar complication rates in AIDS patients with Pneumocystis (P.) carinii pneumonia. Researchers randomly assigned 181 AIDS patients over age 13 with mild to moderate P. carinii pneumonia to treatment with one of three drug combinations. About half of patients in each group completed a full course of therapy. At seven days, patients receiving clindamycin-primaquine reported the highest health status scores, but differences between groups narrowed by day 21. Dose-limiting side effects occurred in 24% of patients receiving dapsone-trimethoprim, 33% of patients receiving clindamycin-primaquine, and 36% of patients receiving trimethoprim-sulfamethoxazole. Rash was the most common complication that limited dose, and it occurred in 10% of dapsone-trimethoprim group, half the rate of the other two regimens. Trimethoprim-sulfamethoxazole was most likely to cause liver complications and clindamycin-primaquine to cause blood cell complications.