| Pneumocystis jirovecii infection3 | Preferred regimen: Trimethoprim-sulfamethoxazole, 15 mg/kg/day (based on trimethoprim component) intravenously or one double-strength tablet orally three times a day for 21 days. Add prednisone when PaO2 < 70 mm Hg on room air or alveolar-arterial O2 gradient > 35 mm Hg: 40 mg orally twice a day on days 1–5, 40 mg orally daily on days 6–10, 20 mg orally daily on days 11–21 | Nausea, neutropenia, anemia, hepatitis, rash, Stevens-Johnson syndrome |
| | Pentamidine, 3–4 mg/kg/day intravenously for 21 days plus prednisone when indicated as above | Hypotension, hypoglycemia, anemia, neutropenia, pancreatitis, hepatitis |
| | Primaquine, 30 mg/day orally, and clindamycin, 600 mg every 8 hours orally, for 21 days plus prednisone when indicated as above | Primaquine: hemolytic anemia in G6PD-deficient patients,3 methemoglobinemia, neutropenia, colitis Clindamycin: rash, nausea, abdominal pain, colitis |
| | Not recommended for severe disease: Trimethoprim, 15 mg/kg/day orally in three divided doses, with dapsone, 100 mg/day orally, for 21 days,3 plus prednisone when indicated as above | Nausea, rash, hemolytic anemia in G6PD3-deficient patients; methemoglobinemia (weekly levels should be less than 10% of total hemoglobin) |
| | Not recommended for severe disease: Atovaquone, 750 mg orally twice daily with food for 21 days, plus prednisone when indicated as above | Rash, elevated aminotransferases, anemia, neutropenia |
| Mycobacterium avium complex infection | Clarithromycin, 500 mg orally twice daily with ethambutol, 15 mg/kg/day orally (maximum, 1 g). May also add: | Clarithromycin: hepatitis, nausea, diarrhea Ethambutol: hepatitis, optic neuritis |
| | Rifabutin, 300 mg orally daily | Rash, hepatitis, uveitis |
| Toxoplasmosis | Preferred regimen: Pyrimethamine, 200 mg orally as loading dose, followed by 50 mg daily (weight ≤ 60 kg) or 75 mg daily (weight > 60 kg), combined with sulfadiazine, 1000 mg orally four times daily (weight ≤ 60 kg) or 1500 mg orally four times daily (weight > 60 kg) and leucovorin 10–25 mg orally daily for at least 6 weeks. Longer courses are necessary for extensive disease or incomplete clinical or radiographic resolution. Maintenance therapy with pyrimethamine 25–50 mg orally plus sulfadiazine 2000–4000 mg in two to four divided doses plus leucovorin 10–25 mg orally daily. Long-term treatment should be maintained until immune reconstitution with antiretroviral treatment occurs. | Pyrimethamine: leukopenia, anorexia, vomiting Sulfadiazine: nausea, vomiting, Stevens-Johnson syndrome |
| | For patients who are intolerant of sulfa who cannot be desensitized: Substitute clindamycin 600 mg intravenously or orally every 6 hours for the sulfadiazine in the above regimen | Pyrimethamine: leukopenia, anorexia, vomiting Clindamycin: rash, nausea, abdominal pain, colitis |
| | If pyrimethamine not available: Trimethoprim-sulfamethoxazole, 10 mg/kg/day (based on trimethoprim component) | Nausea, neutropenia, anemia, hepatitis, rash, Stevens-Johnson syndrome |
| Non-Hodgkin lymphoma | Combination chemotherapy (eg, EPOCH with rituximab and G-CSF). Central nervous system disease: Radiation treatment with dexamethasone for edema | Nausea, vomiting, anemia, neutropenia, thrombocytopenia, cardiac toxicity (with doxorubicin) |
| Cryptococcal meningitis | Preferred regimen: Liposomal amphotericin B, 3–4 mg/kg/day intravenously, with flucytosine, 25 mg/kg/dose orally four times daily for 2 weeks (adjust dose for kidney function), then fluconazole, 400 mg orally daily for 8 weeks, then 200 mg orally daily to complete 1 year of therapy | Liposomal amphotericin: fever, chills, hypokalemia, kidney disease Flucytosine: bone marrow suppression, kidney disease, hepatitis Fluconazole: hepatitis |
| | Amphotericin B, 0.7 mg/kg/day intravenously, with flucytosine, 25 mg/kg/dose orally four times daily for 2 weeks (adjust dose for kidney function), then fluconazole, 400 mg orally daily for 8 weeks, then 200 mg orally daily to complete 1 year of therapy | Amphotericin: fever, chills, hypokalemia, kidney disease Flucytosine: bone marrow suppression, kidney disease, hepatitis Fluconazole: hepatitis |
| | Fluconazole, used alone, is inferior to amphotericin B as induction therapy; it is recommended only for patients who cannot tolerate or do not respond to the preferred regimen above. If used for primary induction therapy, give fluconazole, 1200 mg orally daily for 2 weeks, then 400 mg orally daily for 8 weeks, then 200 mg orally daily to complete 1 year of therapy. Give with flucytosine, 25 mg/kg/dose orally four times daily for > 2 weeks (adjust dose for kidney function). | Hepatitis |
| Cytomegalovirus retinitis (immediate sight-threatening) | Preferred regimen: Intravitreal ganciclovir (2 mg/injection) or foscarnet (2.4 mg/injection) for 1–4 doses for 7–10 days plus valganciclovir, 900 mg orally twice a day with food for 14–21 days followed by 900 mg daily (maintenance) | Neutropenia, anemia, thrombocytopenia |
| | Ganciclovir, 10 mg/kg/day intravenously in two divided doses for 14 days, followed by 5 mg/kg daily or valganciclovir 900 mg orally daily (maintenance) | Neutropenia (especially when used concurrently with zidovudine), anemia, thrombocytopenia Adjust ganciclovir dose for kidney function |
| | Foscarnet, 60 mg/kg intravenously every 8 hours or 90 mg/kg intravenously every 12 hours for 14–21 days, followed by 90–120 mg/kg once daily | Nausea, hypokalemia, hypocalcemia, hyperphosphatemia, azotemia Adjust foscarnet dose for kidney function |
| | Cidofovir, 5 mg/kg/week intravenously for 2 weeks, then 5 mg/kg every other week with probenecid 2 g orally 3 hours before dose, 1 g orally 2 hours after dose, and 1 g orally 8 hours after dose | Nephrotoxicity (to reduce likelihood, pre- and post-saline hydration, along with probenecid), neutropenia Avoid in patients with sulfa allergy because of cross hypersensitivity with probenecid |
| Esophageal candidiasis or recurrent vaginal candidiasis | Fluconazole, 100–200 mg orally daily for 14–21 days for esophageal disease and > 7 days for recurrent vaginal disease | Hepatitis, development of azole resistance |
| Herpes simplex infection | Acyclovir, 400 mg orally three times daily for 5–10 days; or acyclovir, 5 mg/kg intravenously every 8 hours for severe cases | Resistant herpes simplex with long-term therapy |
| | Famciclovir, 500 mg orally twice daily for 5–10 days | Nausea |
| | Valacyclovir, 1 g orally twice daily for 5–10 days | Nausea |
| | Foscarnet, 40 mg/kg intravenously every 8 hours, for acyclovir-resistant cases | Nausea, hypokalemia, hypocalcemia, hyperphosphatemia, azotemia Adjust foscarnet dose for kidney function |
| Herpes zoster | Preferred regimen: Valacyclovir, 1000 mg orally three times daily for 7–10 days | Nausea |
| | Preferred regimen: Famciclovir, 500 mg orally three times daily for 7–10 days | Nausea |
| | Acyclovir, 800 mg orally five times daily for 7–10 days. Intravenous therapy at 10 mg/kg every 8 hours for extensive cutaneous or visceral disease until clinical improvement, then switch to oral therapy to complete a 10- to 14-day course. For ocular involvement, consult an ophthalmologist immediately. | Nausea |
| Kaposi sarcoma | | |
| Mild to moderate | Initiation or optimization of antiretroviral treatment | Side effects of antiretroviral treatment |
| Advanced disease | Combination chemotherapy (eg, daunorubicin, bleomycin, vinblastine) | Bone marrow suppression, cardiac toxicity (with daunorubicin), fever |
| | Pomalidomide, 5 mg/day orally on days 1–21 of every 28-day cycle; alternative to chemotherapy | Fatigue, asthenia, dyspnea, anemia, neutropenia; contraindicated in pregnancy |