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S: Subjective
The patient reports a previous adverse reaction to sulfa drugs, such as erythema, pruritus, or
rash. The patient has no history of anaphylaxis, Stevens-Johnson syndrome, or toxic
epidermal necrolysis, and no reaction involving vesiculation, desquamation, ulceration,
exfoliative dermatitis, etc.
O: Objective
CD4 count <200 cells/µL, or other important indication for TMP-SMX.
A: Assessment
Reaction to sulfa, possibly reversible with desensitization protocol.
P: Plan
Begin 9- to 13-day desensitization protocol, starting with pediatric oral suspension, which
contains 40 mg of TMP and 200 mg of SMX per 5 mL (1 teaspoon). Gradually increase the
dosage according to the protocol.
If there is any question about the severity of a previous reaction, have the patient take the
initial morning dose in the clinic so that the patient may be monitored for 3-4 hours before
going home. (This assumes that emergency treatment, including IV access materials and IV
fluids, antihistamines, and steroids, are readily available.)
Treat with an antihistamine medication 1 day before starting the desensitization regimen and
continue daily until the dose escalation is completed.
More rapid desensitization protocols are available (see " References " below) for patients
urgently needing treatment with TMP-SMX.
Desensitization Regimen
Use commercially available pediatric suspension (containing TMP 8 mg and SMX 40 mg per
mL), followed by double-strength tablets, as follows:
1-3 8 mg/40 mg 1 mL
3-6 16 mg/80 mg 2 mL
5-9 40 mg/200 5 mL
mg
7-12 80 mg/400 1/2 double-strength tablet (or 1 single-
mg strength tablet)
9-10 and 160 mg/800 1 double-strength tablet
thereafter mg
In the event of mild reaction: If the patient experiences a mild reaction or itching, the same
dosage should be given for an additional day. If the reaction diminishes, the patient may
advance to the next dosage; if the reaction worsens, the TMP-SMX should be discontinued.
Antihistamines or antipyretics may be used to treat symptoms of mild reactions.
Patient Education
For home desensitization regimen
Explain the benefits of using TMP-SMX. Be sure the patient understands and is able to follow
instructions.
• Measure your dose carefully and take it each morning, followed by a glass (6-8 oz) of
water. (The patient should do a demonstration, if possible, using the syringe that will
be used for the actual measuring at home.)
• TMP-SMX can make you very ill unless you pay attention to any problems you have.
It is extremely important that you check your temperature each afternoon. If your
temperature is more than 100.5° F by mouth, stop taking the drug and contact your
clinician. Note: If you have shaking chills, check your temperature as soon as the
shaking stops, and contact the clinic. If you continue the medication despite a red
rash and/or fever, serious illness or a life-threatening reaction may occur. Report any
adverse event immediately.
• Stop the regimen and return to the clinic or emergency room immediately if you
develop a red rash, blisters on your skin or in your mouth, or vomiting. Check your
skin each evening, and any time you notice itching.
If you have mild itching or a faint rash, you can take diphenhydramine (Benadryl) 25-50 mg.
every 4 hours as needed. If this persists, stay with the same dosage for an additional day;
and call or go to the clinic if you have questions or concerns.
• Call or go to the clinic for alternate dosage instructions in the event of persistent
itching without rash.
• After desensitization is complete, continue to take the daily dosage. If the drug is
stopped, the entire regimen may have to be repeated.
Sulfa Desensitization
Long Protocol
Solution preparation:
Dosing
เอกสารอ้างอิง
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2. สมเกียรติ วัฒนศิรชิ ัยกุล. Antimicrobial Therapy. ภาวะติดเชื้อ. เม็ดทรายพริ้นติ้ง. กรุงเทพมหานคร.
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3. http://www.hiv.va.gov, accessed 21 พ.ย. 48
4. Dipiro J, et al. Desensitization. Pharmacotherapy A
Pathophysiologic Approach. Fifth edition. 1999; 1594 – 1595
5. Glukstein D , Ruskin J. Rapid Oral Desensitization to
Trimaetroprim-Sulfamethoxazole (TMP-SMZ): Use in Prophylaxis for
Pneumocystis carinii Pneumonia in Patients with AIDS Who were
Previously Intolerant to TMP-SMZ. Clinical Infectious Diseases. 1995;
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