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Journal of Postgraduate Medicine
Medknow Publications and Staff Society of Seth GS Medical College and KEM Hospital, Mumbai, India
ISSN: 0022-3859 EISSN: 0972-2823
Vol. 49, Num. 1, 2003, pp. 61-68
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Journal of Postgraduate Medicine, Vol. 49, No. 1,
Jan-March, 2003, pp. 61-68
Symposium
Recent Understanding in the Treatment of Visceral Leishmaniasis
Rosenthal E, Marty P*
Service d'Hématologie Clinique, Centre Hospitalier Universitaire de
Nice, Groupe de Recherche en Immunopathologie de la Leishmaniose (GRIPL), Faculté de
Médecine, Université de Nice-Sophia-Antipolis, and *Service de
Parasitologie-Mycologie, Centre Hospitalier Universitaire de Nice, France
Address for Correspondence: Eric Rosenthal,
Service d'Hématologie Clinique,
Hôpital l'Archet, Centre Hospitalier Universitaire de Nice, 06202 Nice
cédex 02, France
E-mail : rosenthal.e@chu-nice.fr Code Number: jp03012
Abstract:
Visceral leishmaniasis (VL) is a severe disease associated with infection
of the reticuloendothelial system by Leishmania species. The infection
is acquired through sandfly bites. Recent large scale epidemics of VL in east
Africa and India and the emergence of a HIV epidemic make VL a priority for
the World Health Organization. Pentavalent antimonials have been cornerstone
of treatment for the last six decades. The appearance of antimonial-resistance
and the development of lipid formulations of amphotericin B have changed the
pattern of VL treatment. Within the past five years, miltefosine has been demonstrated
as the first effective and safe oral treatment against VL. The price of miltefosine
is yet to be determined. However, miltefosine will certainly be cheaper than
lipid formulations of amphotericin B, which are beyond the financial capacity
of the poor countries. Because it can be administered orally, miltefosine is
suited for the treatment of large number of patients who get affected during
epidemics, particularly in regions where the parasites are resistant to the
currently used agents. Here, we recommend different treatment schedules according
to the resistance pattern and the region-specific socio-economical and cultural
factors.
(J Postgrad Med 2003;49:61-68)
Key Words: Drug resistance; HIV; developing countries;
liposomal amphotericin B; amphotericin B; pentavalent antimonials; miltefosine.
Visceral leishmaniasis (VL) is a disseminated protozoal infection transmitted
by sandfly bites. The disease, affecting both children and adults, typically
presents with fever, hepato-splenomegaly, and pancytopenia. Once established,
the clinical course of untreated VL leads to death in a majority of patients,
generally because of intercurrent infections. Although VL is endemic in more
than 60 countries, nearly all of the 500, 000 new cases of symptomatic VL occur
each year in the rural areas of just five countries: India, Nepal, Bangladesh,
Brazil, and Sudan.1 Anthroponotic VL occurs in east Africa and the
Indian subcontinent. An epidemic appeared in western Upper Nile region of southern
Sudan in 1984, causing 100, 000 deaths among a population just under 1 million.2 In
the Indian subcontinent, where 50% of reported VL cases occur, many factors
led to low compliance to the therapy, including a lack of resources and health
education. Premature interruptions of the therapy led to emergence and progression
of resistance to first-line drug. In contrast, in Latin America, China and
the Mediterranean basin, VL is a zoonotic
disease. In the mid-1980s the first cases of VL have been reported in southern
Europe in patients infected with human immunodeficiency virus (HIV). To date, Leishmania-HIV
co-infection has been reported from 33 countries,3 with most of
the cases located in southern Europe. In this region, 25-70% of adult patients
with VL are co-infected with HIV and it is estimated that 1.5-9% of patients
with AIDS will develop leishmaniasis.4 Although not recognised as
an AIDS-defining criterion, VL constitutes an opportunistic disease in HIV-infected
patients. Several studies have demonstrated that HIV/AIDS patients living in Leishmania-endemic
areas are at a greater risk of developing VL5 and that dual infection
accelerates the clinical course of HIV disease.6 Clinical presentations
are often atypical, with unusual parasite localisations and frequent relapses.7 The
introduction of highly active anti-retroviral therapy (HAART) as a standard
treatment for HIV has resulted in a significant decrease in the incidence of
VL in HIV-infected individuals in southern Europe.8 Another cause
for concern is the increase in the number of co-infection cases in eastern
Africa, Brazil and Indian subcontinent, owing to the simultaneous spread and
geographical overlap of both diseases as well as the periodic occurrence of
epidemics of VL.3 Currently, however, accessibility and affordability
of HAART in these areas remain limited.
Today, treatment of VL constitutes a difficult challenge. The most recent complicating
difficulties are co-infection with HIV and resistance to penta-valent antimonials.
These problems join the long-standing list of obstacles that have undermined
the measures to control VL: inadequate vector control, poverty and malnutrition,
migration of non-immune refugees, insufficient diagnosis tools and unavailable
or unaffordable drugs.
Available Drugs
A: Classical Agents
1. Pentavalent Antimony
Organic salts of pentavalent antimony have been the cornerstone of treatment
for all forms of leishmaniasis for more than 60 years.9 Antimonials
are thought to act by inhibiting the enzymes of glycolysis and other metabolic
pathways.10 Two major pentavalent antimonials are currently used:
Sodium stibogluconate (Pentostam®) and meglumine antimoniate
(Glucantime®). Sodium stibogluconate contains antimony 100
mg/ml and is primarily used in English-speaking countries. The closely related
compound meglumine antimoniate (Glucantime®) contains antimony
85 mg/ml and is primarily used in French-speaking areas. The drugs are given
intravenously or intramuscularly (i.m.), and they are equal in efficacy when
used in equivalent doses. The recommended regimen consists of once-daily injection
of full-dose drug (20 mg/kg) for 30 days. While active elsewhere in India,
antimonials are no longer useful in north eastern state of Bihar, where as
many as 65% of the previously untreated patients fail to respond to or promptly
relapse after therapy with antimonial compounds.11 Disadvantages
of antimonials include the parenteral mode of administration, the long
duration of therapy and the adverse reactions. Systemic toxicity normally relates
to total dose administrated. Secondary effects (such as fatigue, bodyache,
electro-cardiographic abnormalities, raised aminotransferase levels and chemical
pancreatitis) are frequent, albeit usually reversible. Severe adverse events
remain rare. However, sudden death due to arrhythmia has been reported in a
patient receiving high doses for a prolonged period.12 Acute pancreatitis
with a fatal evolution has been reported in HIV-infected patients.13
Cheaper generic formulations of sodium stibogluconate are available. They
were recently compared in field conditions in east Africa and were found to
be equally safe and as effective as their branded counterparts.14-16 However,
the poor quality
of some generic antimonials led to serious toxicity in some of the recipients
in India.17 Efforts to develop lipid formulations of antimonials
are on. A novel liposome-based meglumine antimoniate formulation appears to
be promising as a pharmaceutical product for the treatment of VL.18
2. Diamidine
Pentamidine isothienate (4 mg/kg im, thrice- weekly for six weeks) was used
in the treatment of antimonial-resistant VL. However, side effects such as
myalgia, nausea, headache and hypoglycaemia were common at this dose, with
an exceptional risk of developing irreversible diabetes. Besides, the drug
achieves poor response rates (around 75%) when used as a second-line drug in
antimonial-resistant areas. This is a major factor limiting interest in pentamidine.19,
20
3. Paromomycin
Aminosidine is an aminoglycosidic antibiotic identical to paromomycin sulfate
and is administered once daily, usually by the intra-muscular route. Combined
with antimonials, aminosidine (12-18mg/kg for 21 days) allows a reduction in
the duration of the therapy 21 and may be more efficient than antimonials
alone in areas with high levels of antimonial resistance.22 Aminosidine
also appears to be active in India when used alone.23 However, its
potential for causing ototoxicity and nephrotoxicity needs further evaluation.24
4. Allopurinol
At the beginning of the 1980s, non-randomised trials showed that a combination
of antimonials and allopurinol (15 mg/day) was efficacious in treating VL.25-28 Recently,
a randomised trial in patients with antimonial-unresponsive VL, suggested that
combined therapy with allopurinol plus pentamidine provided higher cure rate
than with pentamidine alone.20 At the present, allopurinol is not
used in monotherapy in India.
B: Recent Advances in VL Therapy
Amphotericin B and Lpid-associated Formulations
The anti-fungal agent amphotericin B has long been recognised as a powerful
leishmanicidal drug. It probably intercalates with the parasite episterol precursors
of ergosterol. It owes its popularity as an effective agent for treatment of
VL largely to the decline and fall of antimonials in India and the failure
of pentamidine as satisfactory substitute in such cases.19
Amphotericin B Desoxycholate
In India, 98% of long-term cure was obtained in both antimonial-unresponsive
and previously untreated patients, with conventional amphotericin B desoxycholate
(Fungizone®).19, 29 However, infusion-related side effects
(fever, chills, bone pain) and renal toxicity of conventional amphotericin
B are still major problems. Despite manufacturers recommendations against mixing,
short-course treatment with amphotericin B-fat emulsion (five alternate-day
infusions of 2 mg/kg) has been evaluated in an uncontrolled study in India.
Definitive cure was reported in 93% of antimonial-unresponsive patients. Although
debatable, this could represent a cost-effective treatment for patients with
VL, including those with antimonial-unresponsive infection.30
Lipid Formulations of Amphotericin B
First used in antimonial-resitant VL by Davidson et al 31 in
1991, lipid formulations of amphotericin B have been proven to increase the
efficacy and to limit the toxicity of conventional amphotericin B.32-34 These
formulations allow administration of considerably higher daily doses and simultaneously
appear to target infected tissue macrophages via enhanced phagocytic uptake.24 Three
lipid formulations are available: Ambisome®, which is a formulation using
spherical, unilamellar liposomes that are less than 100 nm in size; Amphocil®,
which is a dispersion with cholesterol sulfate in 1:1 molar ratio; Abelcet®,
which is a ribbon-like lipid structure using a phospholipid matrix. A five
days long regimen consisting of daily infusion or a 10-day regimen consisting
of infusions on days 1-5 and day 10 are considered to be remarkably active.32-35 There
are regional differences in responsiveness to the lipid formulations. In Mediterranean
VL, Ambisome® 18-24 mg/kg total dose is efficient compared to Ambisome® 6-14
mg/kg in India.36-38 In HIV-co-infected patients and in recipients
of organ transplants, higher dosages and prolonged treatment are needed.39-41 Recently,
a comparative trial evaluated the efficacy of a single dose of liposomal amphotericin
B (5mg/kg) versus once-daily infusion of 1 mg/kg for 5 days in Indian
VL. Definive cure rates were not different between the groups (91% versus 93%),
warranting further testing of the single-dose regimen.42
Miltefosine
Hexadecylphosphocholine (miltefosine) is one of a series of alkylphosphocholines.
It has been developed as an anti-neoplastic agent and is now used topically
in dermal metasatases of breast cancer. Administered orally, miltefosine has
a long half-life ranging between
150 and 200 hours. It was first identified to have in vitro and in
vivo activity against L. donovani.43 Other studies
showed that oral miltefosine had activity in mice against VL caused by L.
donovani and L. infantum.44-46 The mechanisms of action
of miltefosine against Leishmania have not yet been well defined. Miltefosine
has been shown to block the proliferation of Leishmania and to alter
phospholipid and sterol composition.47 The anti-leishmanial activity
of miltefosine is not only related to a direct cytotoxic effect on the parasite
but is also related to the activation of cellular immunity, which in turn,
takes care of the parasitic infection.48-50
The first phase clinical trial of oral miltefosine was performed in patients
with Kala-azar in India to evaluate safety, tolerance and efficacy.51 Oral
doses of miltefosine were given to six groups of five Indian men (50 mg every
second day to 250 mg/day for 28 days). Vomiting and diarrhoea were observed
in 22 of 30 patients. Twenty-one patients were apparently cured by day 14.
One patient developed severe diarrhoea and renal insufficiency and died on
day 21. At the end of four weeks, 29 of 30 patients were apparently cured,
and by 8 months, 18 of 19 patients treated daily appeared to be cured. Half
of these patients had previously failed to show response to therapy with pentavalent
antimony. The authors concluded that treatment with orally administered miltefosine
at 100-150 mg/day for 4 weeks holds promise as an effective treatment of Indian
VL, including antimonial-resistant VL. Other clinical trials seem to confirm
the efficacy of the drug.52-54 Dosing 100 mg (2.5mg/kg/day) over
days 21-28 days appeared efficient both in untreated VL and in antimony-resistant
VL. More recently, an open-label randomised trial compared the efficacy of
oral miltefosine (in the dose of 50 or 100 mg, approximately 2.5 mg per kilogram
of body weight daily for 28 days) in 299 patients with that of intravenous
amphotericin B (in the dose of 1 mg per kilogram every other day for a total
of 15 injections) in 99 patients.55 At the end of treatment, the
initial cure rate was 100% in both the groups. By 6 months after the completion
of the treatment, 94% and 97% of patients in miltefosine and amphotericin B
groups respectively, had not had a relapse and were classified as cured. The
side effects of miltefosine were generally tolerable and compare favourably
with those of all agents other than liposomal amphotericin B. Vomiting and
diarrhoea are the most frequent side effects, occurring in about 40% and 20%,
respectively. Approximately three quarters of the gastrointestinal events last
one to two
days per patient and
occur once on each of these days. Miltefosine has toxic effects on reproductive
capacity in female animals, and pregnancy should be strictly avoided while on
the drug and for two months after completion of therapy.
C: Other Drugs
Numerous oral agents have been tested as stand-alone agents or as agents for
combination therapy for treatment of VL. Most of them including ketoconazole,
itraconazole, fluconazole, terbinafine and metronidazole have been discarded.56-58 Sitamaquine
(WR6026), an 8 amino-quinoline, first reported in 1994, may constitute a promising
oral drug. Sitamaquine (1 mg/kg/day for 4 weeks) when administrated to 8 patients
provided a 50% cure rate.59 More recently, a phase 2 dose-escalating
trial was performed in Brazil. Cure rates for patients treated for 28 days
were 0% and 67% at 1 mg/kg/day and 2 mg/kg/day, respectively.60 Further
studies are needed to determine the efficacy and toxicity profile of this agent.
D: Immunotherapy
Interferon gamma is a potent macrophage activator with synergistic activity
with antimonials in mice.61 Interferon gamma alone has limited efficacy
in human VL.62 Adjunctive interferon gamma therapy may accelerate
or improve the response to antimonial therapy in some difficult cases.63,
64 However, this approach may offer, at best, a marginal benefit in settings
with high level resistance to antimonial compounds 64 and has been
used sparingly since the advent of amphotericin B lipid formulations.40 The
high cost of interferon gamma precludes its widespread use in the developing
world.
Factors Influencing the Choice of Therapy
Many factors must be taken in account while choosing the most appropriate
agent for the therapeutic management of VL. These include not only medical
factors but also socio-economical and cultural factors. One should know about
the endemicity of Leishmania strains, the immune and nutritional status
of the population, level and pattern of parasite resistance to drugs and obviously
the cost of the drugs.
In Mediterranean L. infantum area, VL is a sporadic disease with a
limited number of cases. In North Africa, VL remains a disease primarily affecting
children in poor families. In these areas children account for as many as 90%
of the cases with no clinical resistance to antimonial compounds.65
The epidemiological situation is quite similar in Brazilian L. chagasi focus.
On the European coast of the Mediterranean basin (Italy, France, Spain, Portugal),
where the socio-economical conditions are better, the annual number of VL cases
in children remains stable. However, adults represent 60-70% of burden of VL
cases.66 In immunosuppressed HIV-infected patients, representing
half of the adults infected with L. infantum, VL is an emerging opportunistic
disease.5, 67, 68 In these patients, the major problems are frequent
relapses and need for secondary chemoprophylaxis depending on CD4 cell count.69,
70
In African and Indian areas with L. donovani infection, VL is a hyperendemic
disease with a high rate of transmission. Most of the areas where VL is rampant
there is lack of basic sanitary infrastructure. 2, 71 About half
a million cases are reported annually, mostly in extremely poor and malnourished
individuals. In many of these areas, HIV epidemic is shaping up and it is feared
that Leishmania-HIV co-infection may explode in the future.1
The total cost of the treatment depends both on the price of the drug (Table
1) and the cost of hospitalisation. The cost can be 14 times more expensive
for a branded drug compared to a generic one.15 For the same drug,
the price could vary depending on the distributor and the client (Bryceson,
personal communication). Different local price scales may be offered and actual
acquisition costs may be around 30 to 40% lower in certain circumstances.24 Hospitalisation
costs also need to be taken into consideration while determining the cost of
regimen. The exorbitantly high price of amphotericin B lipid formulations makes
them inaccessible in developing countries. Although hospital costs can be appreciably
reduced by short courses and especially by single-dose-regimens, the savings
do not offset the cost of the drug in countries such as India, where hospital
charges are low. Drug companies will have to cut prices for the potential benefits
to be realised.45
Recommendations for Treatment of Visceral Leishmaniasis
Current best practices in the treatment of VL may be differentiated according
to the different settings.
1. Mediterranean VL due to Leishmania Infantum
Immunocompetent Patients
In 1995, the WHO agreed that four first-line regimens were acceptable
for the management of VL in immunocompetent patients:72
- Organic pentavalent antimonials in the form of sodium stibogluconate or
meglumine antimoniate solutions. The recommended dose of antimony is 20
mg/kg/day for 20-28 days,
- Antimonials (20 mg/kg/day) in combination with allopurinol (15mg/kg/day)
for 20-28 days,
- Liposomal amphotericin B (Ambisome®) at 3 mg/kg/day on days 0,1,2,3,4
and 10, giving a total dose of 18 mg/kg,
- Aminosidine was considered an acceptable first-line drug, but dose and
treatment duration were not defined. It was used alone or in combination
with pentavalent antimonials at 12-16 mg/kg for 14-63 days.
However, although acceptable, to our knowledge regimens 2 and 4 have are not
commonly used in the treatment mediterranean VL.
Patients of VL with HIV co-infection
In 2001, the fourth WHO joint meeting on Leishmania-HIV co-infection
held in Catania (Italy) examined the therapeutic options.73 The
treatment of Leishmania-HIV co-infected patients remained controversial.
The use of pentavalent antimonials or amphotericin B desoxycholate, although
useful, has a significant toxicity and the therapy is of long duration.74 New
Amphotericin B lipid formulation have a better tolerability and can be used
as short-course treatment. However, there are no reports of large-scale studies
involving use of lipid amphotericin B in these patients.
HIV-infected patients, including those on HAART demonstrate relapse of VL
after successful therapy. This is not a common occurrence and it is likely
to occur at lower CD4 counts.69, 70 In the absence of controlled
study, there is no agreement about the indication and choice of secondary prophylaxis.
The relapse-free period between patients treated with lipid amphotericin B
(Abelcet® 3 mg/kg every 3 weeks) versus no treatment has been evaluated:
after one year follow-up, 50% and 22% respectively, had no relapses. However,
the figures were not statistically different (Laguna, data not published).
Recipients of organ transplant constitute another group of immunocompromised
individuals and this group may face the
prospect of VL occurring as an opportunistic infection in them as well. It
is possible that this group may have to tackle issues similar to those faced
by patients with HIV-Leishmania co-infection.45
American VL due to Leishmania chagasi
American VL due to Leishmania chagasi and Mediterranean VL due to Leishmania
infantum do not differ from the parasitological and epidemiological points
of view. The treatment practices are quite similar in both diseases. A multi-centre
trial in India, Kenya and Brazil suggested that Ambisome® 2 mg/kg on
days 1-10 constitutes an effective therapy for patients with Mediterranean
VL.75
Anthroponotic VL due to Leishmania donovani
The first-line treatment remains antimonial pentavalent compounds with a minimum
dose of 20 mg/kg/day for 28 days. Sub-optimal doses, incomplete treatment and
sub-standard drugs may lead to clinical resistance. Until recently, amphotericin
B desoxycholate was the only other available alternative drug in these areas.
The availability of new oral anti-leishmanial drug, miltefosine could change
the situation in near future and it may become a preferred first-line drug.
Miltefosine is now registered in India. Lipid associated amphotericin B has
an excellent safety and efficacy profile, but remains too expensive for most
patients.76
Discussion
Socio-economic and cultural conditions have a tremendous bearing not only
on the prevalence of VL but also on the choice of therapeutic option.77 Taking
into consideration the 1995 WHO recommendations, liposomal amphotericin B should
be considered the preferred first line drug.72 This drug provides
spectacular cure rates at an extremely rapid pace, especially in children,
and is associated with low potential for toxicity. It constitutes a cost-effective
regimen in comparison to antimonials, if one takes into account the hospitalisation
costs. The recommendation could change once an effective orally administered
agent becomes available. There is nor running
away from the fact that several issues regarding treatment of VL in HIV-infected
patients remain unresolved. These are related to the duration of therapy and
exact indications for institution and stoppage of prophylactic regimens. Liposomal
amphotericin B constitutes the first-line therapy, but we cannot recommend a
precise duration of treatment. Secondary prophylaxis can probably be interrupted,
when CD4 cell
counts exceed 300 per mm.3,70 In HIV-infected people living in endemic
areas and asymptomatic carriers of Leishmania, HAART probably prevents
overt
VL.8
In developing countries, the cost of lipid formulations of amphotericin B
precludes their use. Miltefosine is an affordable drug, which appears as an
effective and safe agent for use in regions with high level of antimonial resistance.
Under these conditions, it may constitute the first-line therapy. However,
due to the long half-life, sub-therapeutic levels of miltefosine may be encouraged
for a few weeks after a 4-week course. It is feared that this characteristic
might encourage the emergence of resistance in future. The risk of emergence
of secondary resistance must be evaluated and the possible use of combination
therapies needs to be explored to forestall it.78 In areas without
antimonial resistance, antimonial compounds may remain the first-line choice.
However, considering its striking advantages in terms of safety, ease of oral
administration and affordability, miltefosine may soon become an alternative
choice.
The issue of treatment of VL in developing countries is no longer an issue
limited to an individual patient. It is a public health problem considering
the fact that inadequate and ineffective therapy is fraught with emergence
of secondary resistance. The issue of controlling VL also goes beyond development
of new effective drugs and therapies and implementation of vector control measures.
The world has to face the problem of high costs of therapy squarely as control
of VL cannot wait till the economic situation improves and social and cultural
issues tackled.
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