What is the role of antiparasitic pentavalent antimonial agents in the treatment of leishmaniasis?

Updated: Feb 18, 2020
  • Author: Craig G Stark, MD, FACP, FFTM, RCPS(Glasg), FISTM; Chief Editor: Pranatharthi Haran Chandrasekar, MBBS, MD  more...
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Answer

The treatment mainstays of leishmaniasis are the pentavalent antimony compounds first introduced in the 1930s. The 2 available preparations, sodium stibogluconate (Pentostam), produced in Great Britain, and meglumine antimonate (Glucantime), produced in France, have similar efficacy. Depending on the species and region, cure rates of 80-100% have generally been reported.

Sodium stibogluconate is only available from the CDC under an Investigational New Drug (IND) protocol. Military personnel may receive sodium stibogluconate from the Walter Reed Army Medical Center. This agent has been for the treatment of cutaneous and mucocutaneous leishmaniasis in the United States; it has also been the drug of choice in the treatment of visceral leishmaniasis, except for in Europe and regions in India with stibogluconate resistance.

In the United States, patients are sometimes monitored as inpatients when pentavalent antimony is administered, but more accepted is the use of infusion centers that complete full evaluations prior to use of the drug. Periodic evaluation of cardiac conduction with electroencephalographic (ECG) monitoring is prudent. Perform laboratory assessments of complete blood counts; renal function; and amylase, lipase, and serum transaminases levels.

Pentavalent antimony should be used according to CDC protocol. If marked variation from the protocol is being considered, CDC experts should be consulted.

A study in Guatemala that involved a combination of intravenous (IV) stibogluconate and allopurinol showed improved efficacy against cutaneous L (Viannia) panamensis infections compared with stibogluconate alone. [29] However, this effect was not reproduced in the treatment of mucosal leishmaniasis. In many regions of the world, direct intralesional injection of pentavalent antimony is used to treat cutaneous disease, although this can be painful and is technically difficult.

In a later study of IV sodium stibogluconate involving US military personnel with cutaneous leishmaniasis caused by L (Viannia) panamensis, the efficacy of a 10-day course was validated, with a significantly reduced side-effect profile over the standard 20-day course. [30] However, the results may not be applicable to infections caused by other species of Leishmania.

Unfortunately, resistance to this agent is on the rise. In the Bihar province of India, where visceral leishmaniasis is endemic, resistance is as high as 43%.


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