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• Re:What is the risk of PCP in patients with neurological disease?
  Simon Cronin
  Published on: 14 April 2016
• What is the risk of PCP in patients with neurological disease?
  James B Lilleker
  Published on: 14 April 2016

• Published on: 14 April 2016

  Re:What is the risk of PCP in patients with neurological disease?

  • Simon Cronin

  We thank Dr Lilleker for his comments. We agree that use of PCP prophylaxis must provide benefit that would outweigh any attendant risk. As suggested in our article, this risk is likely to vary depending on the dose and duration of steroid therapy, the co-administration of other biologicals and the systemic health of the patient. A patient with e.g., systemic vasculitis-associated mononeuritis multiplex who has also b...

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  We thank Dr Lilleker for his comments. We agree that use of PCP prophylaxis must provide benefit that would outweigh any attendant risk. As suggested in our article, this risk is likely to vary depending on the dose and duration of steroid therapy, the co-administration of other biologicals and the systemic health of the patient. A patient with e.g., systemic vasculitis-associated mononeuritis multiplex who has also been treated with cyclophosphamide is likely to be at much higher risk than in the cited example of an individual with myasthenia. The potential toxicity of trimethoprim-sulfamethoxazole may be augmented through use of a lower 80/400mg daily dose; or through use of alternate day 160mg/800mg dosing. Recent data from the field of rheumatology suggests that the overall risks of prophylaxis are low and the prophylactic benefit high [1]. Ultimately, we agree with the correspondent that knowledge of the incidence for PCP in our immunosuppressed patients would best guide application of such data in clinical practice. Since publication, others have shared empiric experience of adverse outcomes in those not placed on prophylaxis. Awaiting definitive data, the decision remains with the individual clinician; taking into account the risk factor profile mentioned above.

  Reference [1] Katsuyama T, Saito K, Kubo S, Nawata M, Tanaka Y. The prophylaxis for Pneumocystis pneumonia in patients with rheumatoid arthritis treated with biologics, based on risk factors found in a retrospective study. Arthritis Res Ther. 2014 Feb 5;16(1):R43. PubMed PMID: 24495443; PubMed Central PMCID: PMC3978920.

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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• Published on: 14 April 2016

  What is the risk of PCP in patients with neurological disease?

  • James B Lilleker, Neurology SpR

  I thank the authors for highlighting this difficult topic with a very thought provoking article.

  In immunosuppressing a patient with neurological disease, as with anything a physician does to a patient, there are potential risks to take into account and to be weighed up against the proposed benefits. Indeed, this sort of "cost-benefit" analysis is a central tenant of decision making in much of life outside of me...

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  I thank the authors for highlighting this difficult topic with a very thought provoking article.

  In immunosuppressing a patient with neurological disease, as with anything a physician does to a patient, there are potential risks to take into account and to be weighed up against the proposed benefits. Indeed, this sort of "cost-benefit" analysis is a central tenant of decision making in much of life outside of medicine also.

  It is generally accepted that in order to proceed, the benefits should outweigh the "costs". It is clear that PCP prophylaxis is effective at reducing the incidence of PCP, but at what cost? In patients with solid -organ transplant for example, this is fairly clear as the incidence appears high, as noted in the authors references.

  The problem is that we have little knowledge of the incidence of PCP in patients immunosuppressed for myasthenia gravis, for example. My personal feeling is that this risk is much lower, but there is little evidence in the literature to support this.

  When considering that around 15% of patients develop side effects whilst taking trimethoprim-sulfamethoxazole, and these can (in rare cases) be fatal, it is not clear in my mind that the cost-benefit analysis for patients with neurological disease swings in favour of the widespread use of PCP prophylaxis. Put simply, would enough cases of PCP be prevented to outweigh the risks posed by the side effect profile of the medication?

  To help us make this decision we need clearer data on the incidence of PCP in patients with neurological diseases who are being prescribed immunosuppressive medication.

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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