HIV-associated Cryptococcal Meningitis: a Review of Novel Short-Course and Oral Therapies
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HIV Medicine (C Yoon, Section Editor)
HIV-associated Cryptococcal Meningitis: a Review of Novel Short-Course and Oral Therapies Letumile R. Moeng, MBBS1,* James Milburn, MBChB2,3 Joseph N. Jarvis, MBBS, MSc, PhD2,3 David S. Lawrence, MBChB, MSc2,3 Address *,1 Center for Infectious Disease Management and Research, Department of Internal Medicine, Howard University Hospital, Washington, DC, USA Email: [email protected] 2 Clinical Research Department, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK 3 Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
* The Author(s) 2020
This article is part of the Topical Collections on HIV Medicine Keywords HIV I Cryptococcal meningitis I Fluconazole I Flucytosine I Amphotericin
Abstract Purpose of review HIV-associated cryptococcal meningitis remains a significant public health problem in parts of Africa and Asia and a major cause of AIDS-related mortality, accounting for 15% of all AIDS-related deaths worldwide. Cryptococcal meningitis is uniformly fatal if untreated, and access to antifungal therapy in regions with the highest burden is often limited. Outcomes with fluconazole monotherapy are poor, and induction treatment with amphotericin B and high-dose fluconazole for 2 weeks is associated with significant drug-related toxicities and prolonged hospital admissions. This review focuses on the potential of novel short-course and oral combination therapies for cryptococcal meningitis. Recent findings Recent clinical trials have shown that shorter courses of amphotericin, if paired with oral flucytosine, rather than fluconazole, can achieve non-inferior mortality outcomes. In addition, an oral combination of fluconazole and flucytosine is a potential alternative. Liposomal amphotericin B may further simplify treatment; it is associated with fewer drug-related toxicities, and a recent phase II randomised controlled trial demonstrated that a single, high dose of liposomal amphotericin is non-inferior to 14 standard daily doses at clearing Cryptococcus from cerebrospinal fluid. This has been taken forward to an ongoing phase III, clinical endpoint study.
HIV Medicine (C Yoon, Section Editor) Summary The incidence and mortality associated with cryptococcal meningitis is still unacceptably high. There is evidence supporting the use of short-course amphotericin B and oral combination antifungal treatment regimens for cryptococcal meningitis (CM). Ongoing research into short-course, high-dose treatment with liposomal amphotericin may also help reduce the impact of this devastating disease.
Introduction HIV-associated cryptococcal meningitis (CM) remains a significant public health problem and a major cause of AIDS-related mortality, despite increasing access to antiretroviral therapy (ART) [1, 2]. There are an estimated 220,000 cases each year, with the greatest burden of disease found within resource-limited, high HIV prevalence settings. Across sub-Saharan Africa, CM remains the most common cause of meningitis i
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