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LETTER
Atovaquone for Pneumocystis carinii Pneumonia
Mark Stoeckle;
Alan Tennenberg;
Michael N. Dohn;
Joseph C. Gathe; and
Dennis P. Haghighat
15 February 1995 | Volume 122 Issue 4 | Pages 314-315
TO THE EDITOR:
The conclusion of the study by Dohn and colleagues [1] that "oral atovaquone and intravenous pentamidine have similar rates for successful treatment of mild and moderate P. carinii pneumonia" is misleading. More treatment failures were noted (29% compared with 17%) and more deaths (13% compared with 8%) occurred in patients treated with atovaquone than in those treated with pentamidine. Although the observed differences in this small study did not reach statistical significance, they are consistent with those obtained in a larger study showing the inferiority of atovaquone compared with trimethoprim-sulfamethoxazole, which is probably therapeutically equivalent to pentamidine [2, 3]. Because the authors discontinued enrollment prematurely, it is inappropriate for them to conclude that they have proved the null hypothesis, that is, that the two treatments do not differ. Atovaquone may be well tolerated, but the available data suggest that it is less effective than either pentamidine or trimethoprim-sulfamethoxazole. Reasonable alternatives for treatment of P. carinii pneumonia in patients with a history of intolerance to trimethoprim-sulfamethoxazole include, in addition to pentamidine, trimethoprim-dapsone, clindamycin-primaquine, and rechallenge or desensitization (or both) with trimethoprim-sulfamethoxazole [4, 5].
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Author and Article Information
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Case Western Reserve University, Cleveland, OH 44106-4984. University of North Carolina, Chapel Hill, NC 27519. Cornell University Medical College, New York, NY 10021. University of Cincinnati, Cincinnati, OH 45267-0564. Park Plaza Medical Center, Houston, TX 77004. Bristol Park Medical Group, Santa Ana, CA 92704.
1. Dohn MN, Weinberg WG, Torres RA, Follansbee SE, Caldwell PT, Scott JD, et al. Oral atovaquone compared with intravenous pentamidine for Pneumocystis carinii pneumonia in patients with AIDS. Ann Intern Med. 1994; 121:174-80.
2. Klein NC, Duncanson FP, Lenox TH, Forszpaniak C, Sherer CB, Quentzel H, et al. Trimethoprim-sulfamethoxazole versus pentamidine for Pneumocystis carinii pneumonia in AIDS patients: results of a large prospective randomized treatment trial. AIDS. 1992; 6:301-5.
3. Hughes W, Leoung G, Karmer F, Bozzette SA, Safrin S, Frame P, et al. Comparison of atovaquone (566C80) with trimethoprim-sulfamethoxazole to treat Pneumocystis carinii pneumonia in patients with AIDS. N Engl J Med. 1993; 328:1521-7.
4. Masur H. Prevention and treatment of Pneumocystis pneumonia. N Engl J Med. 1992; 327:1853-9.
5. Asbar N, Daneshvar H, Beall G. Densensitization to trimethoprim/sulfamethoxazole in HIV-infected patients. J Allergy Clin Immunol. 1994; 93:1001-5.
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