Treatment of Strongyloidiasis
First-Line Treatment
Ivermectin 200 μg/kg orally for 2 consecutive days is the definitive treatment for strongyloidiasis, providing cure rates of 77-100% compared to albendazole's 38-63%. 1, 2
- The FDA-approved regimen is a single dose of 170-200 μg/kg, which achieved cure rates of 64-100% in clinical trials 2
- However, the most effective regimen based on recent evidence is 200 μg/kg on 2 consecutive days, which achieved 100% cure rates with no side effects 3
- Ivermectin should be taken on an empty stomach with water for optimal absorption 2
Immunocompromised Patients
For immunocompromised patients, administer ivermectin 200 μg/kg on days 1,2,15, and 16 to prevent hyperinfection syndrome 1
- Immunocompromised states include: corticosteroid therapy, chemotherapy, malignancy, HTLV-1 infection, HIV, diabetes mellitus, systemic lupus erythematosus, nephrotic syndrome, and hematologic malignancies 1, 4, 5
- Never initiate corticosteroid therapy without first treating strongyloidiasis, as this can precipitate potentially fatal hyperinfection syndrome 1, 6, 2
- Multiple treatment courses at 2-week intervals may be required in immunocompromised patients, and cure may not be achievable; suppressive therapy once per month may be necessary 2
Alternative Treatment
Albendazole 400 mg daily for 3 days is a less effective alternative with cure rates of only 38-63% 1, 7
- This option should be reserved for situations where ivermectin is contraindicated or unavailable 1
- A 7-day course of albendazole 800 mg daily achieved only 63.3% cure rates compared to 96.8% with single-dose ivermectin 5
Post-Treatment Monitoring
Perform at least three stool examinations over 3 months following treatment to confirm eradication 2
- Use concentration techniques (such as Baermann apparatus) as larval counts may be very low 2
- Recrudescence of larvae has been observed up to 106 days post-treatment 2
- If larvae reappear, retreatment with ivermectin is indicated 2
- Monitor for symptoms of hyperinfection syndrome: gastrointestinal bleeding, pneumonia, sepsis, or meningitis 1, 4
Critical Screening Considerations
Screen all patients from endemic areas for Strongyloides before initiating immunosuppressive therapy, even without confirmed diagnosis 1, 6
- Consider empiric treatment for patients from endemic areas who will receive corticosteroids or other immunosuppression 1
- Eosinophilia is common but not reliable for predicting treatment success or reactivation 3, 8
Important Caveats
- Recent research suggests parasitological cure may be unlikely with current regimens, as DNA detection persists despite negative conventional testing 8
- Patients with persistent eosinophilia after treatment have high failure rates (77%) 3
- The double-dose regimen (days 1 and 2) appears superior to single-dose therapy, particularly in patients with concomitant illness 3, 5