Paul A. Pham, Pharm.D. and John G. Bartlett, M.D.
Available formulation in Zambia: 25 mg tablet
- Due to additive bone marrow suppression, co-administer AZT with caution or use other NRTI.
- First line treatment of CNS toxoplasmosis: pyrimethamine + sulfadiazine (plus folinic acid)
Zambia Information Author: Paul A. Pham, Pharm.D.
- Malaria (acute) in combination with sulfadoxine and quinine in treatment of chloroquine-resistant Plasmodium falciparum malaria. Resistance prevalent worldwide; not recommended as prophylactic agent for travelers to most areas.
Toxoplasmosis (in combination with sulfadiazine or clindamycin plus leucovorin).
| Daraprim ||Pyrimethamine||GlaxoSmithKline||oral|
| Fansidar ||Pyrimethamine/sulfadoxine||Roche||oral|
Pyrimethamine 25 mg + sulfadoxine 500 mg
*Prices represent cost per unit specified and are representative of "Average Wholesale Price" (AWP).
AWP Prices were obtained and gathered by Lakshmi Vasist Pharm D using the Red Book, manufacturer's
information, and the McKesson database.
^Dosage is indicated in mg unless otherwise noted.
- CNS toxoplasmosis, induction therapy: 200 mg x1, then 50-75 mg once-daily (+ folinic acid 10-20 mg/d + sulfadiazine 1.5 gm q6h or clindamycin 600 mg IV q6h) x >6 wks.
- CNS toxoplasmosis, maintenance therapy: 25-50 mg (+ folinic acid 15 mg + sulfadiazine 0.5-1 gm q6h or clindamycin 300-450 mg q6h) until immune reconstitution (CD4 >200 x 6 mos, induction therapy completed, and asymptomatic). Reintroduced maintenance therapy if CD4 count decreases to <200.
Toxoplasmosis prophylaxis: 50 mg/wk (+ folinic acid 25 mg/wk + dapsone 50-100 mg once-daily + leucovorin 25 mg/wk OR atovaquone 1500 mg/d +/- pyrimethamine 25 mg/d + leucovorin 10 mg/d). Note: TMP/SMX 1 DS daily preferred.
- Toxoplasmosis primary prophylaxis can be discontinued in pts who have responded to ART with increase in CD4 count to >200 for >3 mos, but should be reintroduced if CD4 decreases to <100â??200.
- Malaria prophylaxis: Fansidar 1 tab (pyrimethamine 25 mg/sulfadoxine 500 mg) weekly or OR 2 tabs every other week; start 1 to 2 days before arrival in endemic area and continue during stay and for 4 to 6 wk after leaving endemic area. Generally not recommended due to high incidence of rash.
- Acute malaria, acute: Fansidar 2 to 3 tabs (pyrimethamine 50-75 mg/sufadoxine 1000-1500 mg) as single dose.
Usual dose; HD: no data, usual dose likely. dose post-HD on days of HD.
No data, usual dose likely (dose post-HD on days of HD).
47% removed after PD.
No data. Usual dose likely.
- Reversible pancytopenia (megaloblastic anemia, leucopenia, agranulocytosis, and thrombocytopenia) secondary to depletion of folic acid stores. Generally prevented with co-administration of leucovorin. Consider increasing leucovorin dose to 50â??100 mg/day if hematologic toxicity observed.
- GI intolerance: abdominal pain and vomiting (improved by administration with meals).
- Headache, dizziness, and insomnia.
- With sulfonamide co-administration: rash, hepatitis.
P. falciparum, T. gondii
- Neurologic: tremors, ataxia, and seizure.
- With sulfonamide co-administration: Stevens-Johnson syndrome, TEN, erythema multiforme and anaphylaxis can occur.
Treatment of choice (with sulfadiazine and leucovorin) for CNS toxoplasmosis. Fansidar (pyrimethamine/sulfadoxine) is not first -line agent for malaria prophylaxis due to high incidence of rash and availability of better tolerated alternatives (e.g. atovaquone/proguanil, mefloquine, and doxycycline).
- National Institutes of Health (NIH), the Centers for Disease Control and Prevention (CDC), and the HIV Medicine Association of the Infectious Diseases Society of America (HIVMA/IDSA) ;
Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents ;
2008 ; Vol.
Basis for recommendation
Comments:Initial therapy of choice for CNS toxoplasmosis is pyrimethamine + sulfadiazine + leucovorin.