What is Leishmaniasis?

From the Guidelines

Leishmaniasis treatment should be individualized based on the form of the disease, with pentavalent antimonials, miltefosine, amphotericin B deoxycholate, or liposomal amphotericin B being potential options, as recommended by the Infectious Diseases Society of America (IDSA) and the American Society of Tropical Medicine and Hygiene (ASTMH) 1.

Forms of Leishmaniasis and Treatment Options

• Cutaneous leishmaniasis (CL) can be treated with pentavalent antimonials such as sodium stibogluconate (20 mg/kg/day for 20 days) or meglumine antimoniate, with alternatives including miltefosine (2.5 mg/kg/day for 28 days), amphotericin B deoxycholate (0.5-1 mg/kg every other day for 14-20 doses), or liposomal amphotericin B (3 mg/kg/day for 5 days) 1.
• Visceral leishmaniasis (VL) is typically treated with liposomal amphotericin B (3 mg/kg/day on days 1-5,14, and 21) or a shorter course of 10 mg/kg total dose, with other options including miltefosine and pentavalent antimonials 1.
• Mucocutaneous leishmaniasis (ML) treatment involves systemic antileishmanial therapy, with options including pentavalent antimonials, amphotericin B deoxycholate, and liposomal amphotericin B 1.

Considerations for Treatment

• The choice of treatment should consider factors such as the infecting Leishmania species, geographic region, patient's immune status, and potential side effects of the treatment 1.
• Treatment should be initiated promptly to prevent complications and reduce transmission, with the goal of preventing mortality in VL and minimizing morbidity in CL and ML 1.
• The IDSA and ASTMH guidelines provide recommendations for the diagnosis and treatment of leishmaniasis, including the use of lipid-associated formulations of amphotericin B and other treatments 1.

From the Research

Treatment Options for Leishmaniasis

• Pentavalent antimonial compounds, such as sodium stibogluconate, have been the mainstay of treatment for visceral, cutaneous, and mucosal leishmaniasis for approximately half a century 2.
• The recommended dosage regimen for treating leishmaniasis is 20 mg/kg/day of pentavalent antimony, without an upper limit on the daily dose, for 20 days for cutaneous leishmaniasis and 28 days for visceral and mucosal leishmaniasis 2.
• Alternative treatment protocols, such as miltefosine alone or in combination with sodium stibogluconate and liposomal amphotericin B, are being explored due to the limitations of current treatment options, including cost, toxicity, and emergence of parasite resistance 3.

Efficacy and Safety of Treatment Options

• The combination of pentavalent antimonials with other therapeutic alternatives, such as pentoxifylline, granulocyte macrophage colony-stimulating factor, and imiquimod, has resulted in high rates of clinical cure and reduced adverse effects 4.
• Studies have shown that visceral leishmaniasis in East Africa requires higher doses of liposomal amphotericin for effective treatment results, and that pentavalent antimonial drugs remain efficacious 5.
• The pharmacokinetics of sodium stibogluconate and meglumine antimoniate are similar, with peak concentrations occurring 2 hours after administration and a slow terminal elimination phase that may contribute to toxicity associated with long-term high-dose therapy 6.

Clinical Practice Guidelines

• Clinical practice guidelines for leishmaniasis vary, but recent European guidelines favor species-directed therapy for cutaneous leishmaniasis 5.
• There is a need for additional clinical trials with better design and reported endpoints to lead evidence-based treatment recommendations, especially in cutaneous leishmaniasis and leishmaniasis in the immunocompromised host 5.