Second-line therapy

Starting dose 1.25 mg/250 mg PO once or twice daily with meals, second-line therapy ... 

It was hoped that the more complete blockade of angiotensin II s AT effects would confer greater long-term efficacy with ARBs compared to ACE inhibitors. However, prospective, randomized trials suggest that the clinical efficacy of ARBs is similar to that of ACE inhibitors for reduction of hospitalizations for HF, sudden cardiac death, and all cause mortality.23-25 Despite poorer suppression of AT2, comparable efficacy of ACE inhibitors may be due to the additional effects on the kallikrein-kinin system. Although ARBs produce hemodynamic and neurohormonal effects similar to those of ACE inhibitors, they are considered second-line therapy due to the overwhelming clinical trial experience with ACE inhibitors. 

Amantadine 100 mg orally every morning and early afternoon Modafinil 200 mg orally daily Second-line therapies ... 

Refractory status epilepticus is seizure activity that is not controlled by first-fine and second-line therapies, including benzodiazepines and antiepileptic drugs. 

Sulfur, resorcinol, and salicylic acid are not as effective as other topical agents, but can be used as second-line therapies in the treatment of mild to moderate acne.12... 

Clinical improvement should be evident by 72 hours of therapy, as demonstrated by defervescence, reduction in nasal congestion and discharge, and improvements in facial pain or pressure and other symptoms. Patients should be monitored for common adverse events and referred to a specialist if clinical response is not obtained with first- or second-line therapy. Referral is also important for recurrent or chronic sinusitis or acute disease in immunocompromised patients. Surgery may be indicated in complicated cases. 

Response rates are lower for non-albicans infections. Although an optimal regimen is unknown, use of intravaginal azole therapy for 7 to 14 days is recommended. Terconazole may prove more effective than other azoles in the treatment of non-albicans infections since C. glabrata and C. tropicalis are more susceptible to terconazole.17 For second-line therapy, boric acid 600 mg in a gelatin capsule administered vaginally twice daily for 2 weeks followed by once daily during menstruation is effective.18 Local irritation often limits the use of boric acid. Topical 4% flucytosine is also effective but use should be limited due to the potential for resistance. 

Two to three weeks of fluconazole or itraconazole solution are highly effective and demonstrate similar clinical response rates.32 Doses of 100 to 200 mg are effective in immunocompetent patients but doses up to 400 mg are recommended for immunocompromised patients. Due to variable absorption, ketoconazole and itraconazole capsules should be considered second-line therapy. In severe cases, oral azoles may prove ineffective, warranting the use of amphotericin B for 10 days. Although echinocandins and voriconazole are effective in treatment of esophageal candidiasis, experience remains limited. 

Fulvestrant is a new agent approved for the second-line therapy of postmenopausal metastatic breast cancer patients who have tumors that are hormone-receptor-positive. Studies examining the role of fulvestrant in the treatment of metastatic breast cancer have compared this agent with anastrozole. Given anas-trozole s mechanism of action, only postmenopausal women were eligible for these trials. There is no biologic reason why fulvestrant should not produce similar outcomes in premenopausal... 

The treatment of recurrent disease depends on the time to recurrence. If the time to recurrence is less than 6 months, second-line therapy should be considered if the patient has an acceptable performance status (see Patient Care and Monitoring ). The most widely accepted second-line therapies in SCLC are topotecan alone or CAV [cyclophosphamide, doxorubicin (Adriamycin), vincristine]. Relapses occurring more than 6 months after treatment warrant a repeat of the initial regimen. Poor performance status patients (3—4) typically are treated with palliative care therapies. 

First-Line Therapy Second-Line Therapy... 

Newly diagnosed, asymptomatic patients may be observed without treatment. This asymptomatic period may last for months to a couple years. All patients with multiple myeloma will become symptomatic, and once this occurs, treatment is required. First-line treatment may be one of several therapies, including VAD, thalidomide plus steroids, and autologous transplant. Nearly all patients will progress at some point, and second-line therapy usually will include bortezomib. All patients who have bone lesions should receive monthly bis-phosphonates, with the hope of reducing pain and fractures. 

Failure of initial therapy should result in addition of another class of drug. Substitution of a drug from another class should be reserved for drug intolerance. Metformin and an insulin secretagogue are often first- and second-line therapy. 

Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers have shown efficacy in preventing the clinical progression of renal disease in patients with type 2 DM. Diuretics are frequently necessary due to volume-expanded states and are recommended second-line therapy. 

It is considered second-line therapy for patients with partial seizures who have failed initial therapy. 

Selective serotonin reuptake inhibitors are considered to be less effective than TCAs for migraine prophylaxis and should not be considered first- or second-line therapy. However, they may be beneficial when depression is a significant contributor to headache. Preliminary data suggest a possible benefit with venlafaxine. 

Randomized trial results are mixed when candidates for second-line therapy are treated with combinations of antiandrogens plus either LHRH... 

VEDs can be used as second-line therapy after failure of oral or injectable drugs. Adding alprostadil to a VED improves the response rate. 

Topotecan is the second camptothecin derivative it is itself an active drug, and received FDA approval as second line therapy in metastatic ovarian cancer (1996) and in SCLC (1998) [13], In addition, representatives of a second generation of topi inhibitors, the homocamptothecins, are now being developed for chemotherapy, e.g., BN-80915 and BN-809271 [14]. 

Caponigro F, Willemse P, Sorio R, Floquet A, van Belle S, Demol J, Tambaro R, Comandini A, Capriati A, Adank S, Wanders J. (2005) A phase II study of sabarubicin (MEN-10755) as second line therapy in patients with locally advanced or metastatic platinum/taxane resistant ovarian cancer. Invest New Drugs 23 85-89. 

Type 2 diabetes - Initial and second-line therapy. 

Community-acquired pneumonia of mild severity, pharyngitis/tonsillitis (as second-line therapy), and uncomplicated skin and skin structure infections 500 mg as a single dose on the first day followed by 250 mg once daily on days 2 through 5. For community-acquired pneumonia, a single 2 g dose of Zmax may be given. 

There is a lot of evidence now from HIV cohorts on first-line and second-line therapies that are most likely to achieve and maintain virologic suppression and lead to good immunologic and clinical... 

In RLS (where boosted Pis are reserved for second-line therapy) there are situations where triple NRTI regimens are considered. These include ... 

Most ARVs available for adults are also available for children with specific child formulations including dosages that are based on either body surface area or weight. First-line treatment options for children include ZDV/3TC plus either a non-nucleoside (NVP or EFV) or ABC. EFV cannot be used in children under the age of 3 years due to lack of appropriate dosing information. However, EFV would be the non-nucleoside of choice in children on rifampicin, in case ARV needs to start before anti-tuberculous therapy is completed. Second-line therapy for children in the event of first-line regimen failure would include a change in nucleoside backbone (e.g., from ZDV + 3TC to d4T + ddl) plus a protease inhibitor. 

It is an inhibitor of ornithine decarboxylase and is used as second line therapy for advanced CNS African trypanosomiasis. After oral or IV administration, peak plasma level is reached rapidly and elimination half life is approximately three hours. 

Melarsoprol is a trivalent arsenical that has been available since 1949 and is first-line therapy for advanced central nervous system East African trypanosomiasis, and second-line therapy (after eflornithine) for advanced West African trypanosomiasis. 

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