Given recent data for use of doxycycline as post-exposure STD prophylaxis, how have you applied its use in clinical practice?
Given recent data for use of doxycycline as post-exposure STI prophylaxis, for which patient populations have you applied its use in clinical practice after appropriate risk-benefit discussion?
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Doxycycline as POST-exposure prophylaxis for bacterial STI prevention is the hottest thing in STI prevention. It's good at preventing syphilis and chlamydia (approximately 80%) and okay at preventing gonorrhea (approximately 50% depending on background resistance). Here is the landmark study:
Luetkemeyer et al., PMID 37018493
A couple of notes on how I am doing this based on where the evidence is:
Only for MSM and transgender women. We "think" it's just as good in cis-gender women, but the single study to date in cis-gender women in Kenya (dPEP study) failed to show efficacy (because of low adherence, but nonetheless, still a negative finding). Pharmacology data supports adequate drug levels in cis-gender female genital tissue. I would still personally prescribe to a cis-gender woman at higher risk after a risks/benefits discussion.
Take 200mg once ideally within 24 hours of sex but up to 72 hours. I tell people they should really take it within 24 hours after condomless sex (oral, rectal, vaginal). Similar to HIV PEP, the sooner the better! Note- also need to counsel people that all these STIs are easily transmitted with oral sex.
I prescribe 30 tablets of doxycycline with three refills and see them every three months.
There is no safety monitoring for doxycycline. Some people could check LFTs but I don't think it's necessary unless other co-morbidities. The main reason to see them every three months is for HIV/STI testing! (CDC recommendation to perform STI testing every three months for MSM and TGW at risk of STIs).
We know that a lot of these STIs are transmitted in networks. Therefore, MSM/TGW with a history of STIs (especially syphilis) should be prioritized for STI PEP.
At our clinic, we are on the verge of pushing it aggressively next month.
I expect formal CDC recommendations to be released shortly on this.
I have some concerns, especially training with Bill Mc Cormack in the early 1980s when we were seeing high levels of tetracycline resistance by Chlamydia. We were moving to Erythromycin in those cases, so we need to treat it carefully so that we don't overprescribe and repeat the past.
The New York State Department of Health AIDS Institute Clinical Guidelines Program released comprehensive information/guidelines on DoxyPEP last year (9/25/2023).
I help a non-clinical organization (no medical billing, relies on grants) that does STI screening and syringe access. We are aggressively offering everyone who undergoes routine STI screening doxyPEP and trying to figure how they are actually using it during follow up visits to refine counseling. Uptake has been great so far.