STI Pharmacotherapy Dr. Dowling

Question 1

What are the common strains of the HPV virus?

Answer 1

Genital wart strain
-> most regress spontaneously within 1-2 years

Cervical neoplasia strain
->also non-cervical malignanceis (throat cancer)

Question 2

Which disease that is caused by HPV can be self-treated?

Answer 2

Genital warts

-Cryotherapy
-topical wart removal
-surgery
-> destruction of lesions

Question 3

What is the only available HPV vaccine?

Answer 3

9-valent HPV vaccine

Gardasil 9

Question 4

How does Herpes simplex (HSV) present in a patient?

Answer 4

-often asymptomatic
-painful lesions

Question 5

When do lesions start to develop in HSV-infected patients?

Answer 5

develop over 7-10 days and last 2-4 weeks

Question 6

Which cells are involved in the long-term persistance (latency) of HSV?

Answer 6

Ganglia (neurons in the brain)

Question 7

HPV vaccine schedule
CDC guideline

Answer 7

-can start at 9
-routine vaccines at 11-12y -> through 26 if not previously vaccinated

-administer to age 27-48y if not previously vaccinated and at risk for HPV (shared clinical decision-making)

Question 8

How many doses should patients from the age of 9-14 receive?

Answer 8

2-dose series

at 0 and 6-12 months

Question 9

How many doses of the HPV vaccine should patients from the age of 15 and older receive?

Answer 9

3 dose series

at 0
1-2 months and
6 months

Question 10

Which type of Genital warts (HPV) may be treated by the patient?

Answer 10

External anogenital warts (anus, genitals)
-> with self-applied topical treatments or through in-office procedures

-Imiquimod 5%
-Podofilox 0.5%
-Sine catechins (Veregen) 15%

Question 11

What are the treatment options for the first clinical episode of Genital herpes?

Answer 11

Acyclovir
Valacyclovir
Famciclovir

duration: 7-10 days

Question 12

What are the treatment approaches for :recurring: Genital herpes?

Answer 12

Episodic Tx:
start within 6-12 hours of prodrome and no more than 24h after the lesion appears
-> patient should have the drug ready, and get a refill after using it to have it ready again

Suppressive Tx: indefinite, patients are taking it until instructed to stop

Question 13

Which patient population benefits from the suppressive Tx?

Answer 13

-patients with frequent recurrences and severe episodes

-reevaluate after 1 year and see if they have any outbreaks and how severe they are
-consider transfer to Episodic Tx if no recurrence

Question 14

What is the drug treatment duration for recurrent infection of Genital Herpes?

Answer 14

different schedules

up to 5 days!

Question 15

How are initial Trichomoniasis infections treated in men and women?

Answer 15

men: single dose of Metronidazole

women: 7 days BID of Metronidazole

if persistent/recurrent: 7 days Metro

Question 16

When should patients with a Trichomoniasis, Chlamydia or Gonorrhea infection get retested?

Answer 16

after 3 months

Question 17

What factor determines treatment in Genital Herpes?

Answer 17

First clinical episode
or recurrent infection

episodic Tx
suppressive Tx

Question 18

What factor determines treatment for a Trichomoniasis infection?

Answer 18

Male or female
and
Initial treatment or persistent/recurrent infection (truly treatment failure, most of the time recurrent infections are reinfection from the partner)

Question 19

What is the recommended treatment for Chlamydia?

Answer 19

Doxycycline 100 mg BID for 7 days

Question 20

What is the time of symptom onset for Gonorrhea?

Answer 20

2-10 days

Question 21

What determines the treatment of a Gonorrhea infection?

Answer 21

the patient’s weight
<150 kg or >150 kg

Question 22

What are the treatment options to treat Gonorrhea?

Answer 22

<150 kg: Ceftriaxone 500 mg single dose
OR Gentamicin 240 mg + Azithromycin 2g

> 150 kg: Ceftriaxone 1g IM single dose
OR Cefixime 800 mg single dose

Question 23

Which drug should be added to the Gonorrhea treatment regimen?

Answer 23

if chlamydia infection has not been ruled out:
Doxycycline 100 mg BID for 7days

Question 24

Which other STI often presents with Syphilis?

Answer 24

HIV
test for HIV when infected with Syphilis and vice versa

Question 25

What is the incubation time and disease presentation in the primary stage of Syphilis?

Answer 25

10-90 days after exposure

present with a single lesion (Chancre) and with lymphadenopathy (lymph swelling)

Question 26

How does the patient present in the secondary stage of untreated Syphilis?

Answer 26

2-8 weeks after the primary stage -> it goes systemic

rash, lesions, lymphadenopathy -> can occur throughout the body

after 4-10 weeks of systemic symptoms: latent phase -> it can disappear and come back anytime within 4 years

Question 27

How does the patient present in the tertiary stage of untreated Syphilis?

Answer 27

appears 10-30 years in 30% of untreated individuals

severe cardiac and neuro involvement (can have non-reversible effects or life-threatening), with “gumma” lesions

Question 28

What is the recommended treatment of primary, secondary, and early latent (< 1 year) stages of Syphilis?

Answer 28

Benzathine penicillin G IM, single dose
(latency: positive test result but no symptoms)

Question 29

What is the recommended treatment for late latent (>1 year), latent, latent unknown or tertiary (without CNS) stage of Syphilis?

Answer 29

Benzathine penicillin G IM, once weekly for 3 weeks
(latency: positive test result but no symptoms)

Question 30

What is the recommended treatment for CNS tertiary (neuro, ear, ocular syphilis) stage of Syphilis?

Answer 30

Aqueous crystalline penicillin G IV, every 4 hr
or continuous infusion for 10-14 days

Question 31

What is the pharmacokinetic difference between IM and the IV formulation of penicillin G?

Answer 31

IM has a very slow release but hangs around in the system for a prolonged time

also pretty slow peak though

Question 32

Which type of skin reaction can be observed when treating Syphilis or other spirochetal infections?

Answer 32

Jarisch-Herxheimer reaction (body reaction to spirochetes dying off and releasing toxins)

-benign and self-limiting
-flu-like symptoms and aggravation of lesions
-occurs 2-4h after initiating therapy and subsides after 12-24h

Question 33

How is the Jarisch-Herxheimer reaction treated?

Answer 33

symptomatic support with antipyretics

Question 34

What is the recommended treatment for HSV Genital herpes in pregnant women?

Answer 34

1st line:
Acyclovir or Valacyclovir
start suppressive tx after 36 weeks

Question 35

What is the recommended treatment for Chlamydia in pregnant women?

Answer 35

Azithromycin
alternative: Amoxicillin

Question 36

Why don’t we use doxycycline for Chlamydia in pregnant women, since it is actually the first line?

Answer 36

because tetracyclines are contraindicated in pregnant women