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Asthma Free Forever

Asthma Free Forever By Jerry Ericson

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PCP = Pneumocystis carinii pneumonia; AIDS = acquired immunodeficiency syndrome; ADR adverse drug reaction; TMP-SMX = trimethoprim sulfamethoxazole.

All groups used Respirgard II nebulizer for aerosolized pentamidine.

PCP = Pneumocystis carinii pneumonia; AIDS = acquired immunodeficiency syndrome; ADR adverse drug reaction; TMP-SMX = trimethoprim sulfamethoxazole.

All groups used Respirgard II nebulizer for aerosolized pentamidine.

pentamidine in either group. Coughing was noted in patients with a history of bronchospasm or smoking, but this was managed successfully with an aerosolized bronchodilator [22]. Conte et al. [17] also studied the effects of inhaled or reduced-dose pentamidine treatment of PCP in AIDS patients. Nine of the 13 patients with mild PCP had a satisfactory response to inhaled aerosolized pentamidine; three patients could not be evaluated because of early withdrawal, and one patient had treatment failure. Two of the nine evaluable patients had neutropenia, but those patients had been receiving zidovudine and had low pretreatment leukocyte counts. Other mild adverse reactions included cough, bronchospasm, rash, and elevated temperature. The fourth study was done by Miller et al. [22], who initially reported little success with aerosolized pentamidine using one type of nebulizer but had better results using a nebulizer that generated smaller particles. Soo Hoo and colleagues [23], in a small unblinded randomized trial, reported that all 10 patients with mild-to-moderate PCP responded to intravenous pentamidine, whereas only 6 of 11 responded to aerosolized pentamidine (Table 2). Likewise, in another unblinded comparative trial, Conte and colleagues [24] reported that 15 of 17 patients responded to aerosolized pentamidine, whereas 17 of 21 patients responded to intravenous pentamidine. They reported a high incidence of relapse in the aerosolized pentamidine group, but the duration of treatment was only 2 wk. Of note, neither of these trials was blinded, and decisions on change of therapy or clinical relapse were made in an open fashion. The only large blinded comparative trial was conducted by Montgomery and colleagues [25], who compared aerosolized pentamidine to TMP-SMX in mild-to-moderate PCP of 247 patients; 14 died who were randomized to the TMP-SMX arm, whereas only six died who were in the aerosolized pentamidine arm (p = 0.07) Clinical response was slower with aerosolized pentamidine, but toxicity rates were high with TMP-SMX. Relapse occurred more often in the aerosolized pentamidine group unless posttherapy prophylaxis was used. In conclusion, aerosolized pentamidine is equal to TMP-SMX in preventing death and superior in the incidence of toxicity; however, clinical response takes longer in sicker patients. These results highlight the need for large randomized trials to evaluate novel therapies, because small trials can be misleading, and response may not correlate with preventing mortality.

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