BackgroundTrimethoprim-sulfamethoxazole (TMP-SMX) is widely considered the initial drug of choice for the treatment and prophylaxis of Pneumocystis jiroveci (PCP) in HIV infected patients as well as non-HIV infected patients peritransplantation and post solid organ transplantation. However, there are no published data regarding safe and effective TMP-SMX desensitization regimens in non-HIV, immunocompetent patients with renal failure. We present a safe and successful TMP-SMX desensitization protocol peritransplantation for a patient with renal failure and a history of generalized pruritis and maculopapular rash after consumption of TMP-SMX.MethodsA 41-year-old woman with end-stage renal disease secondary to lupus and TMP-SMX hypersensitivity was desensitized via a 2-day protocol based on the patient's creatinine clearance. The starting dose given was 0.001 mg of TMP-SMX orally, increasing the dose ever 30 minutes until the therapeutic dose of 400 mg orally once daily was achieved.ResultsTryptase levels were drawn before desensitization and after completion of the protocol and these levels remained within normal limits. The patient tolerated the procedure well, experiencing only one episode of pruritis that lasted 5 minutes on day one of desensitization, which resolved without intervention. She was able to continue her TMP-SMX at therapeutic doses before and after her renal transplant without incident.ConclusionThis case report demonstrates successful desensitization with TMP-SMX in a non-HIV, immunocompetent patient with end-stage renal disease. This helped to enable the patient to have optimal PCP prophylaxis, minimize morbidity and mortality, and undergo a successful kidney transplant.
Polypharmacy, defined as consumption of 5 or more medications on a long term basis, has become increasingly prevalent, especially in the elderly population. Medications include prescription and over-the-counter medications as well as vitamins and herbal supplements taken on a weekly or daily basis. The charts of patients attending a large urban clinic in a metropolitan area in the southeast U.S. were reviewed to identify the prevalence of polypharmacy. Out of the 1123 charts of patients age 65 or over, 320 charts (107 male, 212 female) were randomly selected and considered eligible for the study. Fifty-one percent of the patients were African-American, 40% were Caucasian. Only those medical records that occurred within a one-year period from the date of the last clinic visit were used to gather the following information: patient's demographics, medical history, and medication record. Complete information was obtained on 290 patients and used in the statistical analysis of the data. Forty-nine percent of our patient population was on polypharmacy. Significant predictors of polypharmacy included the number of diagnoses, such as hypertension and diabetes, and patient gender. Women took significantly more pills than men (F = 17.217, p < .0005, women = 6.03, men = 4.74). As this pilot study shows, polypharmacy is common among seniors. Our findings suggest that further studies should be conducted to determine the predictors of polypharmacy in a geriatric population. Likewise, future intervention studies are needed to reduce inappropriate medication use, allowing a decrease in likeliness of adverse drug events and lowering health care costs.
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