What alternative agents and modalities are used in the treatment of visceral 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

Outside of India, treatment with a pentavalent antimonial compound is usually effective. The use of an alternative parenteral agent should be considered even for first-line therapy in areas where resistance to pentavalent antimony therapy is prevalent, as it is in India, or if nonantimonial therapy would be advantageous for other reasons (eg, toxicity profile, duration of therapy).

The advent of liposomal formulations of amphotericin B, which passively target amphotericin to macrophage-rich organs, have generally replaced the deoxycholate formulations. As noted earlier, liposomal amphotericin B is much more costly than conventional amphotericin B (making them cost-prohibitive in poor countries), but they are associated with less nephrotoxicity and can be given in considerably shorter courses. Although visceral leishmaniasis is traditionally treated with multiple doses of amphotericin B deoxycholate, it appears, based on a single randomized trial, that a single dose of liposomal amphotericin B may be just as effective and cheaper. [31]

Other parenteral alternatives that have merit include amphotericin B (not only in deoxycholate form but also in liposomal forms) and have generally replaced pentamidine. Injectable paromomycin has also been reported to be noninferior to amphotericin B.

Oral miltefosine is FDA approved for visceral, cutaneous, and mucocutaneous leishmaniasis. Sitamaquine is another oral therapy in the research pipeline for the treatment of visceral disease. Originally discovered by the Walter Reed Army Research Institute, this 8-aminoquinoline is currently undergoing phase 3 trials in Kenya and India.


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