Bibliographic Info
GuidelineRapid advice : diagnosis, prevention and management of cryptococcal disease in HIV-infected adults, adolescents and children
Year of Publication2011
Issuing InstitutionWorld Health Organization
Recommendation
Status
Maintained
Recommended in favor
Strong
Certainty of evidence
Low
In children aged less than two years with successfully treated cryptococcal disease, antifungal maintenance treatment should NOT be discontinued
Notes and Remarks
- 1)In developing these recommendations, the Guideline Development Group placed high value on the avoidance of recurrent disease, but balanced against the increased cost and potential for drug interactions with prolonged fluconazole maintenance treatment.
- 2)The number of patients who have been evaluated for recurrent disease following discontinuation of maintenance treatment remains limited, particularly in RLS. Based on a GRADE profile of five single-arm trials and one observational study, only four out of 185 adults who discontinued maintenance treatment at a CD4 count greater than 100 cells/mm3 relapsed or experienced recurrent disease, and there were no deaths after discontinuation in 106 adults. In the only data from a RLS - an RCT in Thailand, there were no cases of recurrent disease in 20 patients, 48 weeks after discontinuation at a CD4 count greater than 100 cells/mm3 and an undetectable HIV viral load for three months. Therefore, the recommendations for discontinuation of prophylaxis are based on the very low risk of recurrence when patients have successfully completed initial induction and consolidation antifungal therapy, and have had a sustained increase in their CD4 count to greater than 200 cells/mm3. This higher threshold takes into account the greater use of fungistatic fluconazole induction treatment and less frequent CD4 monitoring in RLS. The Guideline Development Group recommended discontinuation at a lower threshold of greater than 100 CD4 cells/mm3, if viral load monitoring is available and confirms a suppressed viral load.
Also Featured In
This recommendation also appears in the following guidelines:
Guideline
Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: recommendations for a public health approach
Year2016
InstitutionWHO