What is the recommended treatment for strongyloidiasis?

Treatment of Strongyloidiasis

The recommended treatment for strongyloidiasis is ivermectin at a dose of 200 μg/kg orally for 2 consecutive days, which provides the highest cure rate with excellent tolerability. 1

First-Line Treatment

• Ivermectin is the drug of choice for strongyloidiasis with the FDA-approved dosage of 200 μg/kg as a single oral dose 2
• For non-immunocompromised patients with uncomplicated strongyloidiasis, the standard regimen is:
  • Ivermectin 200 μg/kg orally for 1-2 consecutive days 1, 2
  • Dosing is weight-based (see table below) 2

Body Weight (kg)	Single Oral Dose Number of 3-mg Tablets
15-24	1 tablet
25-35	2 tablets
36-50	3 tablets
51-65	4 tablets
66-79	5 tablets
≥80	200 mcg/kg

Enhanced Efficacy Regimen

• A two-dose regimen of ivermectin (200 μg/kg on two consecutive days) has shown superior efficacy with cure rates of 98-100% compared to single-dose regimens 3, 4
• This two-day consecutive dosing approach is particularly beneficial for achieving complete eradication of the parasite 4

Special Populations

• For immunocompromised patients, the recommended extended regimen is:

  • Ivermectin 200 μg/kg on days 1,2,15, and 16 1
  • This extended regimen helps prevent hyperinfection syndrome, which can be fatal in immunocompromised hosts 5

• Patients receiving or scheduled to receive corticosteroids or other immunosuppressive therapy should be screened and treated for Strongyloides before initiating immunosuppression 6, 1

Alternative Treatment Options

• Albendazole 400 mg daily for 3 days is an alternative but significantly less effective option 1
  • Cure rates for albendazole range from only 38-63% compared to ivermectin's 77-100% 3, 7, 8

Follow-Up and Monitoring

• Follow-up stool examinations should be performed to verify eradication of infection 2
• At least three stool examinations should be conducted over three months following treatment to ensure eradication 2
• Concentration techniques (using a Baermann apparatus) should be employed when performing stool examinations, as the number of larvae per gram of feces may be very low 2
• Persistent eosinophilia after treatment is associated with a high treatment failure rate (77%) and should prompt further evaluation 3

Potential Complications and Precautions

• Monitor for symptoms of hyperinfection syndrome in immunocompromised patients, including gastrointestinal bleeding, pneumonia, sepsis, or meningitis 1
• Avoid initiating corticosteroid therapy without first treating strongyloidiasis, as this can precipitate potentially fatal hyperinfection syndrome 6, 1
• Ivermectin should be taken on an empty stomach with water for optimal absorption 2

Clinical Pearls

• Ivermectin has minimal side effects (2-9% reporting mild, transient symptoms like nausea, vomiting, dizziness) compared to alternatives 3, 4
• If recrudescence of larvae is observed during follow-up, retreatment with ivermectin is indicated 2
• For patients from endemic areas who will be receiving immunosuppressive therapy, consider empiric treatment even without confirmed diagnosis 1