What is the recommended treatment for liver fluke infection?

From the Guidelines

The recommended treatment for liver fluke infection is praziquantel 25 mg/kg three times a day for 2–3 consecutive days. This treatment is based on the most recent guidelines for the investigation and management of eosinophilia in returning travelers and migrants, which prioritizes praziquantel as the primary treatment for liver fluke infections, including Clonorchis sinensis and Opisthorchis spp. [1@].

Key Considerations

• The prepatent period for liver flukes is 4 weeks, and the incubation period can range from 4 weeks to 25 years after infection [1@].
• The mode of transmission is through the ingestion of raw or undercooked freshwater fish, including lightly pickled, salted, or smoked fish [1@].
• Clinical presentation can vary from acute infection with symptoms like fever, abdominal pain, and urticarial skin rash to chronic infection with asymptomatic hepatomegaly or biliary obstruction [1@].
• There is an increased risk of cholangiocarcinoma and pyogenic cholangitis associated with chronic liver fluke infection [1@].

Treatment and Prevention

• Praziquantel is the recommended treatment, given its efficacy in paralyzing the flukes and damaging their outer covering, allowing the immune system to eliminate them [1@].
• Prevention measures include avoiding raw or undercooked aquatic plants and fish from endemic areas [1@].
• Health education programs, such as the "Lawa model" in northeast Thailand, have been effective in reducing the infection rate through anthelminthic treatment, health education, ecosystem monitoring, and community participation [2@].

Follow-Up and Surveillance

• Follow-up stool examinations are recommended 1-3 months after treatment to confirm cure [1@].
• In patients infected with liver flukes, abdominal ultrasound surveillance at 6-monthly intervals is recommended to monitor for potential complications like intrahepatic cholangiocarcinoma [2@].

From the FDA Drug Label

5.5 Hepatic Effects In clinical trials, treatment with albendazole has been associated with mild to moderate elevations of hepatic enzymes in approximately 16% of patients.

6 ADVERSE REACTIONS 6.1 Clinical Trials Experience The adverse reaction profile of albendazole differs between hydatid disease and neurocysticercosis Adverse reactions occurring with a frequency of 1% or greater in either disease are described in Table 2 below.

Table 2: Adverse Reaction Incidence 1% or Greater in Hydatid Disease andNeurocysticercosis Adverse Reaction Hydatid Disease Neurocysticercosis Gastrointestinal Abdominal Pain 6 0 Nausea 4 6 Vomiting 4 6 General disorders and administration site conditions Fever 1 0 Investigations Elevated Hepatic Enzymes 16 less than 1 Nervous system disorders Dizziness 1 less than 1 Headache 1 11 Meningeal Signs 0 1 Raised Intracranial Pressure 0 2 Vertigo 1 less than 1 Skin and subcutaneous tissue disorders Reversible Alopecia 2 less than 1

The recommended treatment for liver fluke infection is albendazole.

• The dosage is not specified in the provided text for liver fluke infection.
• Monitoring of liver enzymes and blood counts is recommended during treatment with albendazole.
• Contraindications include known hypersensitivity to the benzimidazole class of compounds or any components of albendazole tablets.
• Warnings and precautions include bone marrow suppression, embryo-fetal toxicity, and hepatic effects 1

From the Research

Liver Fluke Infection Treatment

The recommended treatment for liver fluke infection is primarily based on drug therapy, with several options available.

• Praziquantel is a commonly used drug, with a high efficacy rate against clonorchiasis and opisthorchiasis, as shown in a systematic review and network meta-analysis 2.
• The WHO-recommended praziquantel regimen (25 mg/kg three times a day for 2 days) has a high predicted cure rate (98·5% [85·4-99·9]) in C sinensis infection 2.
• Other multiple-dose praziquantel regimens also show high predicted cure rates, including 20 mg/kg three times a day for 3 days (97·6% [74·7-99·8]) and 14 mg/kg three times a day for 5 days (93·9% [44·8-99·7]) 2.
• Albendazole is another option, with long treatment schedules (5 days or 7 days) resulting in high cure rates, although the quality of evidence is low and the risk of bias is high 2.
• Tribendimidine may serve as a treatment alternative, with a high predicted cure rate of 89·8% (77·5-95·8) in a single dose 2.

Pharmacokinetics and Combination Therapy

The pharmacokinetics of praziquantel have been studied in adults infected with Opisthorchis felineus, with a triple-dose scheme showing the highest drug exposure 3.

• Combination therapy with praziquantel and azole substances, such as miconazole or clotrimazole, has been investigated, with synergistic effects observed in vitro but not in vivo 4.
• The combination of tribendimidine and praziquantel has also been studied, with a synergistic effect observed in vitro but antagonistic effects in vivo 5.

Analytical Methods

Enantioselective LC-MS/MS methods have been developed and validated for the analysis of praziquantel and its main metabolite in human plasma, blood, and dried blood spots 6.