From the Guidelines
For patients allergic to Septra (trimethoprim-sulfamethoxazole) who need PJP treatment, the preferred alternative is atovaquone 750 mg PO twice daily for 21 days for mild cases, or clindamycin and primaquine for 21 days for moderate/severe cases. According to the most recent study 1, atovaquone is a recommended treatment option for patients with sulfonamide allergy. The study suggests that atovaquone 750 mg PO twice daily for 21 days is an effective treatment for mild cases of PJP in patients with sulfonamide allergy. For moderate to severe cases, clindamycin and primaquine for 21 days is recommended. Some key points to consider when using these alternative treatments include:
- Atovaquone requires fatty meals for proper absorption
- Clindamycin and primaquine can be used for moderate to severe cases
- Dapsone can be an alternative option, but it is not the first choice according to the study 1 It is essential to note that the study 1 provides level III evidence for the use of atovaquone and clindamycin and primaquine as alternative treatments for PJP in patients with sulfonamide allergy.
From the FDA Drug Label
Atovaquone oral suspension is indicated for the acute oral treatment of mild-to-moderate PCP in adults and adolescents (aged 13 years and older) who cannot tolerate TMP-SMX. Atovaquone oral suspension is indicated for the prevention of Pneumocystis jirovecii pneumonia (PCP) in adults and adolescents (aged 13 years and older) who cannot tolerate trimethoprim-sulfamethoxazole (TMP-SMX). The treatment for PJP when allergic to Septra (TMP-SMX) is atovaquone oral suspension. The recommended oral dosage for treatment is 750 mg (5 mL) twice daily (total daily dose = 1,500 mg) administered with food for 21 days 2.
- Key points:
- Atovaquone is used for mild-to-moderate PCP.
- It is administered with food to avoid lower plasma atovaquone concentrations.
- The efficacy of atovaquone in subjects who are failing therapy with TMP-SMX has not been studied.
From the Research
PJP Treatment Alternatives
When a patient is allergic to Septra (trimethoprim-sulfamethoxazole), there are several alternative treatments for Pneumocystis jirovecii pneumonia (PJP). These alternatives include:
Second-Line Therapies
Second-line therapies may be better tolerated than first-line therapy, but often sacrifice efficacy 3. The choice of second-line therapy depends on the severity of the disease and the patient's underlying condition. For example:
- Clindamycin-primaquine has been shown to be effective in treating mild to moderate PJP, but is contraindicated in patients with glucose 6-phosphate dehydrogenase (G6PD) deficiency 4, 5
- Pentamidine is considered when there is documented allergy or intolerance to TMP-SMX, but may have a lower response rate compared to clindamycin-primaquine 4, 5
- Atovaquone suspension has been shown to be effective in preventing PJP in HIV-infected subjects intolerant to trimethoprim or sulfonamides 6
Adjunctive Therapies
Adjunctive corticosteroids may be useful in enhancing the efficacy of either TMP-SMX or pentamidine, particularly in severe disease 4, 7. Echinocandins have also been investigated as adjunctive therapy, but further studies are needed to define their role in the treatment of PJP 3