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Dao K, Buettcher M, Golhen K, Kost J, Schittny A, Duthaler U, Atkinson A, Haefliger D, Guidi M, Bardinet C, Chtioui H, Boulekbache A, Buclin T, Huwyler J, Pfister M, Rothuizen LE. Novel Patient-Friendly Orodispersible Formulation of Ivermectin is Associated With Enhanced Palatability, Controlled Absorption, and Less Variability: High Potential for Pediatric Use. J Clin Pharmacol 2024. [PMID: 38813747 DOI: 10.1002/jcph.2462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 04/29/2024] [Indexed: 05/31/2024]
Abstract
Ivermectin has been used since the 1980s as an anthelmintic and antiectoparasite agent worldwide. Currently, the only available oral formulation is tablets designed for adult patients. A patient-friendly orodispersible tablet formulation designed for pediatric use (CHILD-IVITAB) has been developed and is entering early phase clinical trials. To inform the pediatric program of CHILD-IVITAB, 16 healthy adults were enrolled in a phase I, single-center, open-label, randomized, 2-period, crossover, single-dose trial which aimed to compare palatability, tolerability, and bioavailability and pharmacokinetics of CHILD-IVITAB and their variability against the marketed ivermectin tablets (STROMECTOL) at a single dose of 12 mg in a fasting state. Palatability with CHILD-IVITAB was considerably enhanced as compared to STROMECTOL. Both ivermectin formulations were well tolerated and safe. Relative bioavailability of CHILD-IVITAB compared to STROMECTOL was estimated as the ratios of geometric means for Cmax, AUC 0-∞, and AUC0-last, which were 1.52 [90% CI: 1.13-2.04], 1.27 [0.99-1.62], and 1.29 [1.00-1.66], respectively. Maximum drug concentrations occurred earlier with the CHILD-IVITAB formulation, with a median Tmax at 3.0 h [range 2.0-4.0 h] versus 4.0 h [range 2.0-5.0 h] with STROMECTOL (P = .004). With CHILD-IVITAB, variability in exposure was cut in half (coefficient of variation: 37% vs 70%) compared to STROMECTOL. Consistent with a more controlled absorption process, CHILD-IVITAB was associated with reduced variability in drug exposure as compared to STROMECTOL. Together with a favorable palatability and tolerability profile, these findings motivate for further clinical studies to evaluate benefits of such a patient-friendly ODT formulation in pediatric patients with a parasitic disease, including infants and young children <15 kg.
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Affiliation(s)
- Kim Dao
- Clinical Pharmacology Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Michael Buettcher
- Pediatric Pharmacology and Pharmacometrics Research Center, University Children's Hospital Basel (UKBB), Basel, Switzerland
- Pediatric Infectious Diseases, Children's Hospital of Central Switzerland (KidZ), Lucerne, Switzerland
- Faculty of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Klervi Golhen
- Pediatric Pharmacology and Pharmacometrics Research Center, University Children's Hospital Basel (UKBB), Basel, Switzerland
| | - Jonas Kost
- Department of Pharmaceutical Sciences, Division of Pharmaceutical Technology, University of Basel, Basel, Switzerland
| | - Andreas Schittny
- Department of Pharmaceutical Sciences, Division of Pharmaceutical Technology, University of Basel, Basel, Switzerland
| | - Urs Duthaler
- Division of Clinical Pharmacology & Toxicology, Department of Biomedicine, University and University Hospital Basel, Basel, Switzerland
- Division of Clinical Pharmacology & Toxicology, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland
| | - Andrew Atkinson
- Pediatric Pharmacology and Pharmacometrics Research Center, University Children's Hospital Basel (UKBB), Basel, Switzerland
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - David Haefliger
- Clinical Pharmacology Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Monia Guidi
- Clinical Pharmacology Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
- Center for Research and Innovation in Clinical Pharmaceutical Sciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Carine Bardinet
- Clinical Pharmacology Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Haithem Chtioui
- Clinical Pharmacology Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Abdelwahab Boulekbache
- Clinical Pharmacology Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Thierry Buclin
- Clinical Pharmacology Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Jörg Huwyler
- Department of Pharmaceutical Sciences, Division of Pharmaceutical Technology, University of Basel, Basel, Switzerland
| | - Marc Pfister
- Pediatric Pharmacology and Pharmacometrics Research Center, University Children's Hospital Basel (UKBB), Basel, Switzerland
| | - Laura E Rothuizen
- Clinical Pharmacology Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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Sprecher VP, Hofmann D, Savathdy V, Xayavong P, Norkhankhame C, Huy R, Khieu V, Sayasone S, Hattendorf J, Keiser J. Efficacy and safety of moxidectin compared with ivermectin against Strongyloides stercoralis infection in adults in Laos and Cambodia: a randomised, double-blind, non-inferiority, phase 2b/3 trial. THE LANCET. INFECTIOUS DISEASES 2024; 24:196-205. [PMID: 37949090 DOI: 10.1016/s1473-3099(23)00507-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/02/2023] [Accepted: 08/02/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Infection with the soil-transmitted helminth Strongyloides stercoralis affects up to 600 million people globally, most of whom live in rural areas with poor sanitation. If untreated, infection leads to long-lasting morbidity and might even be life-threatening. Moxidectin might be a promising alternative to ivermectin, the only currently recommended single-dose treatment. We aimed to assess whether moxidectin is non-inferior in terms of efficacy and safety compared with ivermectin. METHODS In this randomised, double-blind, parallel-group, non-inferiority, phase 2b/3 trial in communities in Laos and Cambodia, adults aged 18-65 years were screened for the presence of S stercoralis larvae in their stool via sextuplicate quantitative Baermann assays. Using computer-generated group allocation (block randomisation stratified by infection intensity), parasitologically (two or more positive Baermann assays) and clinically eligible participants were randomly assigned (1:1) to receive single oral doses of either moxidectin (8 mg) and ivermectin-matched placebo, or ivermectin (200 μg/kg bodyweight) and moxidectin-matched placebo. The primary endpoint was cure rate assessed at 14-21 days after treatment, using the available-case population analysed according to intention-to-treat principles. Moxidectin was considered non-inferior to ivermectin if the lower limit of the two-sided 95% CI of the difference was greater than the non-inferiority margin of -10 percentage points. Safety endpoints were assessed before treatment, and at 2-3 h, 24 h, and 14-21 days after treatment. This trial is registered at ClinicalTrials.gov, NCT04056325 and NCT04848688. FINDINGS Between Dec 6, 2020, and May 21, 2022, 4291 participants were screened, 726 of whom were enrolled and randomly assigned to moxidectin (n=363) or ivermectin (n=363). For the participants with primary outcome data, we observed a cure rate of 93·6% (95% CI 90·5 to 96·0; 324 of 346 participants) in the moxidectin group and 95·7% (93·0 to 97·6; 335 of 350 participants) in the ivermectin group, resulting in a between-group difference of -2·1 percentage points (95% CI -5·5 to 1·3). The most common adverse events were abdominal pain (32 [9%] of 363 with moxidectin vs 34 [9%] of 363 with ivermectin) and headache (25 [7%] vs 30 [8%]), which were predominantly mild and transient. INTERPRETATION Moxidectin was non-inferior to ivermectin in terms of efficacy in the treatment of strongyloidiasis. Additionally, both drugs had a similar safety profile. The fixed dose and lower cost of moxidectin compared with ivermectin make it a valuable alternative for people with strongyloidiasis. FUNDING Swiss National Science Foundation.
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Affiliation(s)
- Viviane P Sprecher
- Department of Medical Parasitology and Infection Biology, Swiss Tropical and Public Health Institute, Allschwil, Switzerland; University of Basel, Basel, Switzerland
| | - Daniela Hofmann
- Department of Medical Parasitology and Infection Biology, Swiss Tropical and Public Health Institute, Allschwil, Switzerland
| | | | | | | | - Rekol Huy
- National Centre for Parasitology, Entomology and Malaria Control, Ministry of Health, Phnom Penh, Cambodia
| | - Virak Khieu
- National Centre for Parasitology, Entomology and Malaria Control, Ministry of Health, Phnom Penh, Cambodia
| | | | - Jan Hattendorf
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Allschwil, Switzerland; University of Basel, Basel, Switzerland
| | - Jennifer Keiser
- Department of Medical Parasitology and Infection Biology, Swiss Tropical and Public Health Institute, Allschwil, Switzerland; University of Basel, Basel, Switzerland.
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Sulik M, Antoszczak M, Huczyński A, Steverding D. Antiparasitic activity of ivermectin: Four decades of research into a "wonder drug". Eur J Med Chem 2023; 261:115838. [PMID: 37793327 DOI: 10.1016/j.ejmech.2023.115838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 09/17/2023] [Accepted: 09/26/2023] [Indexed: 10/06/2023]
Abstract
Parasitic diseases still pose a serious threat to human and animal health, particularly for millions of people and their livelihoods in low-income countries. Therefore, research into the development of effective antiparasitic drugs remains a priority. Ivermectin, a sixteen-membered macrocyclic lactone, exhibits a broad spectrum of antiparasitic activities, which, combined with its low toxicity, has allowed the drug to be widely used in the treatment of parasitic diseases affecting humans and animals. In addition to its licensed use against river blindness and strongyloidiasis in humans, and against roundworm and arthropod infestations in animals, ivermectin is also used "off-label" to treat many other worm-related parasitic diseases, particularly in domestic animals. In addition, several experimental studies indicate that ivermectin displays also potent activity against viruses, bacteria, protozoans, trematodes, and insects. This review article summarizes the last 40 years of research on the antiparasitic effects of ivermectin, and the use of the drug in the treatment of parasitic diseases in humans and animals.
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Affiliation(s)
- Michał Sulik
- Department of Medical Chemistry, Faculty of Chemistry, Adam Mickiewicz University, Uniwersytetu Poznańskiego 8, 61‒614, Poznań, Poland
| | - Michał Antoszczak
- Department of Medical Chemistry, Faculty of Chemistry, Adam Mickiewicz University, Uniwersytetu Poznańskiego 8, 61‒614, Poznań, Poland
| | - Adam Huczyński
- Department of Medical Chemistry, Faculty of Chemistry, Adam Mickiewicz University, Uniwersytetu Poznańskiego 8, 61‒614, Poznań, Poland.
| | - Dietmar Steverding
- Bob Champion Research & Education Building, Norwich Medical School, University of East Anglia, Norwich, UK
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Fimbo AM, Mlugu EM, Kitabi EN, Kulwa GS, Iwodyah MA, Mnkugwe RH, Kunambi PP, Malishee A, Kamuhabwa AAR, Minzi OM, Aklillu E. Population pharmacokinetics of ivermectin after mass drug administration in lymphatic filariasis endemic communities of Tanzania. CPT Pharmacometrics Syst Pharmacol 2023; 12:1884-1896. [PMID: 37638539 PMCID: PMC10725270 DOI: 10.1002/psp4.13038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 08/08/2023] [Accepted: 08/11/2023] [Indexed: 08/29/2023] Open
Abstract
Ivermectin (IVM) is a drug of choice used with albendazole for mass drug administration (MDA) to halt transmission of lymphatic filariasis. We investigated IVM pharmacokinetic (PK) variability for its dose optimization during MDA. PK samples were collected at 0, 2, 4, and 6 h from individuals weighing greater than 15 kg (n = 468) receiving IVM (3-, 6-, 9-, or 12 mg) and ALB (400 mg) during an MDA campaign in Tanzania. Individual characteristics, including demographics, laboratory/clinical parameters, and pharmacogenetic variations were assessed. IVM plasma concentrations were quantified by liquid-chromatography tandem mass spectrometry and analyzed using population-(PopPK) modeling. A two-compartment model with transit absorption kinetics, and allometrically scaled oral clearance (CL/F) and central volume (Vc /F) was adapted. Fitting of the model to the data identified 48% higher bioavailability for the 3 mg dose compared to higher doses and identified a subpopulation with 97% higher mean transit time (MTT). The final estimates for CL/F, Vc /F, intercompartment clearance, peripheral volume, MTT, and absorption rate constant for a 70 kg person (on dose other than 3 mg) were 7.7 L/h, 147 L, 20.4 L/h, 207 L, 1.5 h, and 0.71/h, respectively. Monte-Carlo simulations indicated that weight-based dosing provides comparable exposure across weight bands, but height-based dosing with capping IVM dose at 12 mg for individuals with height greater than 160 cm underdoses those weighing greater than 70 kg. Variability in IVM PKs is partly explained by body weight and dose. The established PopPK model can be used for IVM dose optimization. Height-based pole dosing results in varying IVM exposure in different weight bands, hence using weighing scales for IVM dosing during MDA is recommended.
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Affiliation(s)
- Adam M. Fimbo
- Department of Global Public HealthKarolinska Institutet, Karolinska University HospitalStockholmSweden
- Tanzania Medicines and Medical Devices Authority (TMDA)Dar es SalaamTanzania
| | - Eulambius M. Mlugu
- Department of Pharmaceutics and Pharmacy Practice, School of PharmacyMuhimbili University of Health and Allied SciencesDar es SalaamTanzania
| | - Eliford Ngaimisi Kitabi
- Division of PharmacometricsOffice of Clinical Pharmacology, US Food and Drug AdministrationSilver SpringMarylandUSA
| | - Gerald S. Kulwa
- Tanzania Medicines and Medical Devices Authority (TMDA)Dar es SalaamTanzania
| | - Mohammed A. Iwodyah
- Tanzania Medicines and Medical Devices Authority (TMDA)Dar es SalaamTanzania
| | - Rajabu Hussein Mnkugwe
- Department of Clinical Pharmacology, School of Biomedical Sciences, Campus College of MedicineMuhimbili University of Health and Allied SciencesDar es SalaamTanzania
| | - Peter P. Kunambi
- Department of Clinical Pharmacology, School of Biomedical Sciences, Campus College of MedicineMuhimbili University of Health and Allied SciencesDar es SalaamTanzania
| | - Alpha Malishee
- National Institute for Medical Research, Tanga CenterTangaTanzania
| | - Appolinary A. R. Kamuhabwa
- Department of Clinical Pharmacy and Pharmacology, School of PharmacyMuhimbili University of Health and Allied SciencesDar es SalaamTanzania
| | - Omary M. Minzi
- Department of Clinical Pharmacy and Pharmacology, School of PharmacyMuhimbili University of Health and Allied SciencesDar es SalaamTanzania
| | - Eleni Aklillu
- Department of Global Public HealthKarolinska Institutet, Karolinska University HospitalStockholmSweden
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Failoc-Rojas VE, Silva-Díaz H, Maguiña JL, Rodriguez-Morales AJ, Díaz-Velez C, Apolaya-Segura M, Valladares-Garrido MJ. Evidence-based indications for ivermectin in parasitic diseases: An integrated approach to context and challenges in Peru. Parasite Epidemiol Control 2023; 23:e00320. [PMID: 37731824 PMCID: PMC10507222 DOI: 10.1016/j.parepi.2023.e00320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 06/07/2023] [Accepted: 07/29/2023] [Indexed: 09/22/2023] Open
Abstract
Ivermectin has emerged as a therapeutic option for various parasitic diseases, including strongyloidiasis, scabies, lice infestations, gnathostomiasis, and myiasis. This study comprehensively reviews the evidence-based indications for ivermectin in treating parasitic diseases, considering the unique context and challenges in Peru. Fourteen studies were selected from a systematic search of scientific evidence on ivermectin in PubMed, from 2010 to July 2022. The optimal dosage of ivermectin for treating onchocerciasis, strongyloidiasis, and enterobiasis ranges from 150 to 200 μg/kg, while lymphatic filariasis requires a higher dose of 400 μg/kg (Brown et al., 2000). However, increased dosages have been associated with a higher incidence of ocular adverse events. Scientific evidence shows that ivermectin can be safely and effectively administered to children weighing less than 15 kg. Systematic reviews and meta-analyses provide strong support for the efficacy and safety of ivermectin in combating parasitic infections. Ivermectin has proven to be an effective treatment for various parasitic diseases, including intestinal parasites, ectoparasites, filariasis, and onchocerciasis. Dosages ranging from 200 μg/kg to 400 μg/kg are generally safe, with adjustments made according to the specific pathology, patient age, and weight/height. Given Peru's prevailing social and environmental conditions, the high burden of intestinal parasites and ectoparasites in the country underscores the importance of ivermectin in addressing these health challenges.
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Affiliation(s)
- Virgilio E. Failoc-Rojas
- Instituto de Evaluación de Tecnologías en Salud e Investigación, EsSalud, Lima, Peru
- Universidad San Ignacio de Loyola, Lima, Peru
| | - Heber Silva-Díaz
- Facultad de Medicina Huamana, Universidad de San Martín de Porres, Chiclayo, Peru
| | - Jorge L. Maguiña
- Instituto de Evaluación de Tecnologías en Salud e Investigación, EsSalud, Lima, Peru
- School of Medicine, Universidad Científica del Sur, Lima, Peru
| | - Alfonso J. Rodriguez-Morales
- Grupo de Investigación Biomedicina, Faculty of Medicine, Fundacion Universitaria Autónoma de las Américas, Pereira, Colombia
- Gilbert and Rose-Marie Chagoury School of Medicine, Lebanese American University, Beirut 1102, Lebanon
| | - Cristian Díaz-Velez
- Facultad de Medicina, Universidad Privada Antenor Orrego, Trujillo, Peru
- Instituto Nacional Cardiovascular, INCOR, EsSalud, Lima, Peru
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Pfarr KM, Krome AK, Al-Obaidi I, Batchelor H, Vaillant M, Hoerauf A, Opoku NO, Kuesel AC. The pipeline for drugs for control and elimination of neglected tropical diseases: 2. Oral anti-infective drugs and drug combinations for off-label use. Parasit Vectors 2023; 16:394. [PMID: 37907954 PMCID: PMC10619278 DOI: 10.1186/s13071-023-05909-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 07/31/2023] [Indexed: 11/02/2023] Open
Abstract
In its 'Road map for neglected tropical diseases 2021-2030', the World Health Organization outlined its targets for control and elimination of neglected tropical diseases (NTDs) and research needed to achieve them. For many NTDs, this includes research for new treatment options for case management and/or preventive chemotherapy. Our review of small-molecule anti-infective drugs recently approved by a stringent regulatory authority (SRA) or in at least Phase 2 clinical development for regulatory approval showed that this pipeline cannot deliver all new treatments needed. WHO guidelines and country policies show that drugs may be recommended for control and elimination for NTDs for which they are not SRA approved (i.e. for 'off-label' use) if efficacy and safety data for the relevant NTD are considered sufficient by WHO and country authorities. Here, we are providing an overview of clinical research in the past 10 years evaluating the anti-infective efficacy of oral small-molecule drugs for NTD(s) for which they are neither SRA approved, nor included in current WHO strategies nor, considering the research sponsors, likely to be registered with a SRA for that NTD, if found to be effective and safe. No such research has been done for yaws, guinea worm, Trypanosoma brucei gambiense human African trypanosomiasis (HAT), rabies, trachoma, visceral leishmaniasis, mycetoma, T. b. rhodesiense HAT, echinococcosis, taeniasis/cysticercosis or scabies. Oral drugs evaluated include sparfloxacin and acedapsone for leprosy; rifampicin, rifapentin and moxifloxacin for onchocerciasis; imatinib and levamisole for loiasis; itraconazole, fluconazole, ketoconazole, posaconazole, ravuconazole and disulfiram for Chagas disease, doxycycline and rifampicin for lymphatic filariasis; arterolane, piperaquine, artesunate, artemether, lumefantrine and mefloquine for schistosomiasis; ivermectin, tribendimidine, pyrantel, oxantel and nitazoxanide for soil-transmitted helminths including strongyloidiasis; chloroquine, ivermectin, balapiravir, ribavirin, celgosivir, UV-4B, ivermectin and doxycycline for dengue; streptomycin, amoxicillin, clavulanate for Buruli ulcer; fluconazole and isavuconazonium for mycoses; clarithromycin and dapsone for cutaneous leishmaniasis; and tribendimidine, albendazole, mebendazole and nitazoxanide for foodborne trematodiasis. Additional paths to identification of new treatment options are needed. One promising path is exploitation of the worldwide experience with 'off-label' treatment of diseases with insufficient treatment options as pursued by the 'CURE ID' initiative.
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Affiliation(s)
- Kenneth M Pfarr
- Institute of Medical Microbiology, Immunology and Parasitology, University Hospital Bonn, Bonn, Germany
- German Center for Infection Research (DZIF), Partner Site Bonn-Cologne, Bonn, Germany
| | - Anna K Krome
- Institute of Medical Microbiology, Immunology and Parasitology, University Hospital Bonn, Bonn, Germany
- German Center for Infection Research (DZIF), Partner Site Bonn-Cologne, Bonn, Germany
- Department of Pharmaceutical Technology and Biopharmaceutics, University of Bonn, Bonn, Germany
| | - Issraa Al-Obaidi
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
| | - Hannah Batchelor
- Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
| | - Michel Vaillant
- Competence Center for Methodology and Statistics, Luxembourg Institute of Health, Strassen, Grand Duchy of Luxembourg
| | - Achim Hoerauf
- Institute of Medical Microbiology, Immunology and Parasitology, University Hospital Bonn, Bonn, Germany
- German Center for Infection Research (DZIF), Partner Site Bonn-Cologne, Bonn, Germany
| | - Nicholas O Opoku
- Department of Epidemiology and Biostatistics School of Public Health, University of Health and Allied Sciences, Hohoe, Ghana
| | - Annette C Kuesel
- UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (WHO/TDR), World Health Organization, Geneva, Switzerland.
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Ceballos L, Alvarez L, Lifschitz A, Lanusse C. Ivermectin systemic availability in adult volunteers treated with different oral pharmaceutical formulations. Biomed Pharmacother 2023; 160:114391. [PMID: 36804122 DOI: 10.1016/j.biopha.2023.114391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/28/2023] [Accepted: 02/08/2023] [Indexed: 02/17/2023] Open
Abstract
Ivermectin (IVM) is currently approved as an antiparasitic agent for human use in the treatment of onchocerciasis, lymphatic filariasis, strongyloidiasis, scabies, and pediculosis. Recent findings indicate that IVM may reach other pharmacological targets, which accounts for its proven anti-inflammatory/immunomodulatory, cytostatic, and antiviral effects. However, little is known about the assessment of alternative drug formulations for human use. OBJECTIVE To compare the systemic availability and disposition kinetics of IVM orally administered as different pharmaceutical formulations (tablet, solution, or capsule) to healthy adults. EXPERIMENTAL DESIGN/MAIN FINDINGS Volunteers were randomly assigned to 1 of 3 experimental groups and orally treated with IVM as either, a tablet, solution, or capsules at 0.4 mg/kg in a three-phase crossover design. Blood samples were taken as dried blood spots (DBS) between 2 and 48 h post-treatment and IVM was analyzed by HPLC with fluorescence detection. IVM Cmax value was higher (P < 0.05) after the administration of the oral solution compared to treatments with both solid preparations. The oral solution resulted in a significantly higher IVM systemic exposure (AUC: 1653 ng h/mL) compared to the tablet (1056 ng h/mL) and capsule (996 ng h/mL) formulations. The simulation of a 5-day repeated administration for each formulation did not show a significant systemic accumulation. CONCLUSION Beneficial effects against systemically located parasitic infections as well as in any other potential therapeutic field of IVM application would be expected from its use in the form of oral solution. This pharmacokinetic-based therapeutic advantage without the risk of excessive accumulation needs to be corroborated in clinical trials specifically designed for each purpose.
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Affiliation(s)
- L Ceballos
- Laboratorio de Farmacología, Centro de Investigación Veterinaria de Tandil (CIVETAN), UNCPBA-CICPBA-CONICET, Tandil, Buenos Aires, Argentina; Universidad Nacional del Centro de la Provincia de Buenos Aires (UNCPBA), Facultad de Ciencias Veterinarias, Tandil, Buenos Aires, Argentina.
| | - L Alvarez
- Laboratorio de Farmacología, Centro de Investigación Veterinaria de Tandil (CIVETAN), UNCPBA-CICPBA-CONICET, Tandil, Buenos Aires, Argentina; Universidad Nacional del Centro de la Provincia de Buenos Aires (UNCPBA), Facultad de Ciencias Veterinarias, Tandil, Buenos Aires, Argentina
| | - A Lifschitz
- Laboratorio de Farmacología, Centro de Investigación Veterinaria de Tandil (CIVETAN), UNCPBA-CICPBA-CONICET, Tandil, Buenos Aires, Argentina; Universidad Nacional del Centro de la Provincia de Buenos Aires (UNCPBA), Facultad de Ciencias Veterinarias, Tandil, Buenos Aires, Argentina
| | - C Lanusse
- Laboratorio de Farmacología, Centro de Investigación Veterinaria de Tandil (CIVETAN), UNCPBA-CICPBA-CONICET, Tandil, Buenos Aires, Argentina; Universidad Nacional del Centro de la Provincia de Buenos Aires (UNCPBA), Facultad de Ciencias Veterinarias, Tandil, Buenos Aires, Argentina
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Hürlimann E, Hofmann D, Keiser J. Ivermectin and moxidectin against soil-transmitted helminth infections. Trends Parasitol 2023; 39:272-284. [PMID: 36804383 DOI: 10.1016/j.pt.2023.01.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 01/19/2023] [Accepted: 01/20/2023] [Indexed: 02/19/2023]
Abstract
Ivermectin and moxidectin, two macrocyclic lactones, are potent antiparasitic drugs currently registered and mainly used against filarial diseases; however, their potential value for improved soil-transmitted helminth (STH) control has been acknowledged. This review provides insights on recent studies evaluating the efficacy of ivermectin and moxidectin as single or coadministered therapy against human soil-transmitted helminthiases (including Strongyloides stercoralis infections) and on pharmacokinetic/pharmacodynamic parameters measured in treated populations. Furthermore, we discuss current gaps for research, highlight advantages - but also existing challenges - for uptake of ivermectin and/or moxidectin treatment schemes into routine STH control in endemic countries.
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Affiliation(s)
- Eveline Hürlimann
- Department of Medical Parasitology and Infection Biology, Swiss Tropical and Public Health Institute, Allschwil, Switzerland; University of Basel, Basel, Switzerland
| | - Daniela Hofmann
- Department of Medical Parasitology and Infection Biology, Swiss Tropical and Public Health Institute, Allschwil, Switzerland; University of Basel, Basel, Switzerland
| | - Jennifer Keiser
- Department of Medical Parasitology and Infection Biology, Swiss Tropical and Public Health Institute, Allschwil, Switzerland; University of Basel, Basel, Switzerland.
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Rowland Yeo K, Wesche D. PBPK modeling of ivermectin-Considerations for the purpose of developing alternative routes to optimize its safety profile. CPT Pharmacometrics Syst Pharmacol 2023; 12:598-609. [PMID: 36840414 DOI: 10.1002/psp4.12950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 02/02/2023] [Accepted: 02/20/2023] [Indexed: 02/26/2023] Open
Abstract
Although single-dose ivermectin has been widely used in mass-drug administration programs for onchocerciasis and lymphatic filariasis for many years, ivermectin may have utility as an endectocide with mosquito-lethal effects at dosages greater and longer than those used to treat helminths. The final physiologically-based pharmacokinetic (PBPK) model for ivermectin described here was able to capture, with reasonable accuracy, observed plasma drug concentration-time profiles and exposures of ivermectin after a single oral dose of the drug in healthy male (dose range 6-30 mg) and female subjects, in both fasted and fed states, in African patients with onchocerciasis (150 μg/kg) and in African children. The PBPK model can be used for further work on lactation, pediatric dosing (considering CYP3A4 and Pg-p ontogenies), and pregnancy, especially if nonstandard doses will be used. The key findings of our study indicate that absorption of ivermectin may be highly dependent on bile micelle-mediated solubility. The drug is highly lipophilic and permeable, and its plasma exposure appears to be associated with the body mass index of an individual. These are all factors that need to be considered when extrapolating to more complex oral formulations or alternative routes of administration. Administering lower doses over a longer period may attenuate the dependence on bile micelle-mediated solubility. With relevant inputs, the verified PBPK model developed here could be used to simulate plasma exposures following administration of ivermectin by complex generics in development.
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10
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Buonfrate D, Anselmi M, Prandi R, Marquez M, Mazzi C, Montresor A. Use of a "tablet pole" for the administration of ivermectin for strongyloidiasis in a field study in Ecuador. Infect Dis Poverty 2023; 12:3. [PMID: 36709311 PMCID: PMC9883947 DOI: 10.1186/s40249-023-01054-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 01/05/2023] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Establishment of efficient control programs for strongyloidiasis, the infection by Strongyloides stercoralis, is among the World Health Organization (WHO) targets for 2030. Ivermectin is a drug of choice for strongyloidiasis, but its weight-based administration can be unfeasible in remote areas. We evaluated a WHO tablet pole for administration of ivermectin in school-age children living in remote villages in Ecuador. METHODS Children were enrolled in 16 villages in Esmeraldas Province of Ecuador, between July 2021 and June 2022. The pole identified four height intervals corresponding to ivermectin doses going from one to four tablets. For each child, we calculated the dose (µg/kg) administered with both weight-based and pole-based administration. Results were classified as follows: optimal dose, acceptable, overdose, underdose. Agreement between the two methods for estimating the number of tablets was assessed with Cohen's kappa coefficient. Estimations were reported with 95% confidence intervals (CIs). RESULTS Total of 778 children (47.3% female) were enrolled, with median age of 9.59 years (interquartile range: 7.42‒11.22). Optimal dose was achieved for a higher proportion of children when assessed with weight (37.9%) than with pole (25.7%). Underdose and overdose were more frequent with the pole (8.3% and 19.2% children, respectively) than with the weight-based (3.7% and 6.0%, respectively) administration. Agreement between weight-based and pole-based administration was moderate: 0.56 (95% CI 0.51, 0.61). The two methods indicated the same number of tablets in 71.6% (95% CI 0.684, 0.748) cases. CONCLUSIONS In our setting, the tablet pole could be a valid alternative. The tool needs further evaluation in different populations.
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Affiliation(s)
- Dora Buonfrate
- Department of Infectious Tropical diseases and Microbiology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Verona, Italy.
| | - Mariella Anselmi
- Centro de Epidemiologia Comunitaria y Medicina Tropical (CECOMET), Esmeraldas, Ecuador
| | - Rosanna Prandi
- Centro de Epidemiologia Comunitaria y Medicina Tropical (CECOMET), Esmeraldas, Ecuador
| | - Monica Marquez
- Centro de Epidemiologia Comunitaria y Medicina Tropical (CECOMET), Esmeraldas, Ecuador
| | - Cristina Mazzi
- grid.416422.70000 0004 1760 2489Clinical Research Unit, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Verona Italy
| | - Antonio Montresor
- grid.3575.40000000121633745Department of Control of Neglected Tropical Diseases, World Health Organization, Geneva, Switzerland
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11
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Thangaraju P, Velmurugan H, N K. Current Status of Pharmacokinetic Research in Children: A Systematic Review of Clinical Trial Records. Curr Rev Clin Exp Pharmacol 2022; 19:CRCEP-EPUB-128427. [PMID: 36573054 DOI: 10.2174/2772432818666221223155455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 09/05/2022] [Accepted: 10/18/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND Many medications have different pharmacokinetics in children than in adults. Knowledge about the safety and efficacy of medications in children requires research into the pharmacokinetic profiles of children's medicines. By analysing registered clinical trial records, this study determined how frequently pharmacokinetic data is gathered in paediatric drug trials. METHODS We searched for the pharmacokinetic data from clinical trial records for preterm infants and children up to the age of 16 from January 2011 to April 2022. The records of trials involving one or more drugs in preterm infants and children up to the age of 16 were examined for evidence that pharmacokinetic data would be collected. RESULTS In a total of 1483 records of interventional clinical trials, 136 (9.17%) pharmacokinetic data involved adults. Of those 136 records, 60 (44.1%) records were pharmacokinetics trials involving one or more medicines in children up to the age of 16. 20 (33.3 %) in America, followed by 19 (31.6 %) in Europe. Most trials researched medicines in the field of infection or parasitic diseases 20 (33.3%). 27 (48.2%) and 26 (46.4%) trials investigated medicines that were indicated as essential medicine. CONCLUSION The pharmacokinetic characteristics of children's drugs need to be better understood. The current state of pharmacokinetic research appears to address the knowledge gap in this area adequately. Despite slow progress, paediatric clinical trials have experienced a renaissance as the significance of paediatric trials has gained international attention. The outcome of paediatric trials will have an impact on children's health in the future. In recent years, the need for greater availability and access to safe child-size pharmaceuticals has received a lot of attention.
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Affiliation(s)
- Pugazhenthan Thangaraju
- Department of Pharmacology, All India institute of medical sciences, Raipur, Chhattisgarh, India
| | - Hemasri Velmurugan
- Department of Pharmacology, All India institute of medical sciences, Raipur, Chhattisgarh, India
| | - Krishnapriya N
- Department of Pharmacology, All India institute of medical sciences, Raipur, Chhattisgarh, India
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12
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Soumare HM, Dabira ED, Camara MM, Jadama L, Gaye PM, Kanteh S, Jawara EA, Njie AK, Sanneh F, Ndiath MO, Lindsay SW, Conteh B, Ceesay S, Mohammed N, Ooko M, Bradley J, Drakeley C, Erhart A, Bousema T, D'Alessandro U. Entomological impact of mass administration of ivermectin and dihydroartemisinin-piperaquine in The Gambia: a cluster-randomized controlled trial. Parasit Vectors 2022; 15:435. [PMID: 36397132 PMCID: PMC9673448 DOI: 10.1186/s13071-022-05557-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 10/16/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Vector control interventions in sub-Saharan Africa rely on insecticide-treated nets and indoor residual spraying. Insecticide resistance, poor coverage of interventions, poor quality nets and changes in vector behavior threaten the effectiveness of these interventions and, consequently, alternative tools are needed. Mosquitoes die after feeding on humans or animals treated with ivermectin (IVM). Mass drug administration (MDA) with IVM could reduce vector survival and decrease malaria transmission. The entomological impact of MDA of combined IVM and dihydroartemisinin-piperaquine was assessed in a community-based, cluster-randomized trial. METHODS A cluster-randomized trial was implemented in 2018 and 2019 in 32 villages in the Upper River Region, The Gambia. The with the inhabitants of 16 intervention villages eligible to receive three monthly rounds of MDA at the beginning of the malaria transmission season. Entomological surveillance with light traps and human landing catches (HLC) was carried out during a 7- to 14-day period after each round of MDA, and then monthly until the end of the year. The mosquitocidal effect of IVM was determined by direct membrane feeding assays. RESULTS Of the 15,017 mosquitoes collected during the study period, 99.65% (n = 14,965) were Anopheles gambiae sensu lato (An. gambiae s.l.), comprising Anopheles arabiensis (56.2%), Anopheles coluzzii (24.5%), Anopheles gambiae sensu stricto (An. gembiae s.s.; 16.0%) and Anopheles funestus sensu lato (An. funestus s.l.; 0.35%). No effect of the intervention on vector parity was observed. Vector density determined on light trap collections was significantly lower in the intervention villages in 2019 (adjusted incidence rate ratio: 0.39; 95% confidence interval [CI]: 0.20, 0.74; P = 0.005) but not in 2018. However, vector density determined in HLC collections was similar in both the intervention and control villages. The entomological inoculation rate was significantly lower in the intervention villages than in the control villages (odds ratio: 0.36, 95% CI: 0.19, 0.70; P = 0·003). Mosquito mortality was significantly higher when blood fed on IVM-treated individuals up to 21 days post-treatment, particularly in adults and individuals with a higher body mass index. CONCLUSION Mass drug administration with IVM decreased vector density and the entomological inoculation rate while the effect on vector parity was less clear. Survival of mosquitoes fed on blood collected from IVM-treated individuals was significantly lower than that in mosquitoes which fed on controls. The influence of host characteristics on mosquito survivorship indicated that dose optimization could improve IVM efficacy. Future detailed entomological evaluation trials in which IVM is administered as stand-alone intervention may elucidate the contribution of this drug to the observed reduction in transmission.
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Affiliation(s)
- Harouna M Soumare
- Medical Research Council Unit The Gambia at the London, School of Hygiene and Tropical Medicine, Banjul, The Gambia.
| | - Edgard Diniba Dabira
- Medical Research Council Unit The Gambia at the London, School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Muhammed M Camara
- Medical Research Council Unit The Gambia at the London, School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Lamin Jadama
- Medical Research Council Unit The Gambia at the London, School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Pa Modou Gaye
- Medical Research Council Unit The Gambia at the London, School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Sainey Kanteh
- Medical Research Council Unit The Gambia at the London, School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Ebrima A Jawara
- Medical Research Council Unit The Gambia at the London, School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Amie Kolleh Njie
- Medical Research Council Unit The Gambia at the London, School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Fatou Sanneh
- Medical Research Council Unit The Gambia at the London, School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Mamadou Ousman Ndiath
- Medical Research Council Unit The Gambia at the London, School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | | | - Bakary Conteh
- Medical Research Council Unit The Gambia at the London, School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Sainey Ceesay
- Medical Research Council Unit The Gambia at the London, School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Nuredin Mohammed
- Medical Research Council Unit The Gambia at the London, School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Michael Ooko
- Medical Research Council Unit The Gambia at the London, School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - John Bradley
- MRC International Statistics and Epidemiology Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Chris Drakeley
- Faculty of Infectious & Tropical Diseases, The London School of Hygiene and Tropical Medicine, London, UK
| | - Annette Erhart
- Medical Research Council Unit The Gambia at the London, School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Teun Bousema
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Umberto D'Alessandro
- Medical Research Council Unit The Gambia at the London, School of Hygiene and Tropical Medicine, Banjul, The Gambia
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Buonfrate D, Rodari P, Barda B, Page W, Einsiedel L, Watts M. Current pharmacotherapeutic strategies for Strongyloidiasis and the complications in its treatment. Expert Opin Pharmacother 2022; 23:1617-1628. [PMID: 35983698 DOI: 10.1080/14656566.2022.2114829] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Strongyloidiasis, an infection caused by the soil-transmitted helminth Strongyloides stercoralis, can lead immunocompromised people to a life-threatening syndrome. We highlight here current and emerging pharmacotherapeutic strategies for strongyloidiasis and discuss treatment protocols according to patient cohort. We searched PubMed and Embase for papers published on this topic between 1990 and May 2022. AREAS COVERED Ivermectin is the first-line drug, with an estimated efficacy of about 86% and excellent tolerability. Albendazole has a lower efficacy, with usage advised when ivermectin is not available or not recommended. Moxidectin might be a valid alternative to ivermectin, with the advantage of being a dose-independent formulation. EXPERT OPINION The standard dose of ivermectin is 200 µg/kg single dose orally, but multiple doses might be needed in immunosuppressed patients. In the case of hyperinfection, repeated doses are recommended up to 2 weeks after clearance of larvae from biological fluids, with close monitoring and further dosing based on review. Subcutaneous ivermectin is used where there is impaired intestinal absorption/paralytic ileus. In pregnant or lactating women, studies have not identified increased risk with ivermectin use. However, with limited available data, a risk-benefit assessment should be considered for each case.
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Affiliation(s)
- Dora Buonfrate
- Department of Infectious, Tropical Diseases and Microbiology, IRCCS Sacro Cuore Don Calabria hospital, via Sempreboni 5, 37024 Negrar, Verona, Italy
| | - Paola Rodari
- Department of Infectious, Tropical Diseases and Microbiology, IRCCS Sacro Cuore Don Calabria hospital, via Sempreboni 5, 37024 Negrar, Verona, Italy
| | - Beatrice Barda
- Ospedale La Carità, Ospedale regionale di Locarno, Locarno 6600, Switzerland
| | - Wendy Page
- Miwatj Health Aboriginal Corporation, 1424 Arnhem Rd, Nhulunbuy NT 0880, Australia
| | - Lloyd Einsiedel
- Peter Doherty Institute, University of Melbourne, 792 Elizabeth St, Melbourne VIC 3000, Australia
| | - Matthew Watts
- Centre for Infectious Diseases and Microbiology, Institute of Clinical Pathology and Medical Research - New South Wales Health Pathology and Sydney Institute for Infectious Diseases, Westmead Hospital, University of Sydney, Sydney, New South Wales, Australia
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14
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Welsche S, Mrimi EC, Keller L, Hürlimann E, Hofmann D, Hattendorf J, Ali SM, Keiser J. Efficacy and safety of moxidectin and albendazole compared to ivermectin and albendazole co-administration in adolescents infected with Trichuris trichiura: a randomized controlled trial protocol. Gates Open Res 2021; 5:106. [PMID: 34632308 PMCID: PMC8488464 DOI: 10.12688/gatesopenres.13299.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2021] [Indexed: 11/20/2022] Open
Abstract
Background: Infections with soil-transmitted helminths (STHs) predominantly affect impoverished populations in tropical environments. The periodic administration of single dose benzimidazoles (i.e., albendazole, mebendazole) to at-risk individuals in endemic regions is at the center of STH control strategies. Given the low efficacy of these drugs against trichuriasis, investigation of drug combinations including moxidectin and ivermectin has recently been initiated, yet the identification of the best treatment option requires more research. We present the protocol for a trial investigating the efficacy and safety of co-administered moxidectin and albendazole compared to co-administered ivermectin and albendazole against
Trichuris trichiura. Methods: We will conduct a randomized controlled trial enrolling 540
T. trichiura-infected adolescents aged 12-19 years on Pemba Island (Tanzania). The trial will be open-label with blinded outcome assessors. The primary objective is to demonstrate non-inferiority of orally co-administered single-dose moxidectin (8 mg)/albendazole (400 mg) compared to orally co-administered single-dose ivermectin (200 µg/kg)/albendazole (400 mg) in terms of egg reduction rates (ERRs) against
T. trichiura infections assessed by Kato-Katz at 14-21 days post-treatment. Secondary objectives include the assessment of the drug combinations’ superiority compared to their respective monotherapies, of the cure rates (CRs) against
T. trichiura, and the safety and tolerability of all treatments, as well as CRs and ERRs against concomitant STH infections (
Ascaris lumbricoides and hookworm). Potential effects of the treatment regimens on follow-up prevalences of STH at 5-6 weeks and 3 months post-treatment and pharmacokinetic/ pharmacodynamic parameters will also be assessed. Conclusions: Results from this trial will help to inform decision- and policymakers on which anthelminthic combination therapy might improve existing deworming programs and provide a valuable adjunct tool for interrupting STH transmission. Clinicaltrials.govregistration: NCT04700423 (07/01/2021)
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Affiliation(s)
- Sophie Welsche
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Emmanuel C Mrimi
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Ladina Keller
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Eveline Hürlimann
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Daniela Hofmann
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Jan Hattendorf
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Said M Ali
- Public Health Laboratory Ivo de Carneri, Chake Chake, Pemba, Tanzania
| | - Jennifer Keiser
- Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
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15
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Welsche S, Mrimi EC, Keller L, Hürlimann E, Hofmann D, Hattendorf J, Ali SM, Keiser J. Efficacy and safety of moxidectin and albendazole compared to ivermectin and albendazole co-administration in adolescents infected with Trichuris trichiura: a randomized controlled trial protocol. Gates Open Res 2021; 5:106. [DOI: 10.12688/gatesopenres.13299.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/05/2021] [Indexed: 11/20/2022] Open
Abstract
Background: Infections with soil-transmitted helminths (STHs) predominantly affect impoverished populations in tropical environments. The periodic administration of single dose benzimidazoles (i.e., albendazole, mebendazole) to at-risk individuals in endemic regions is at the center of STH control strategies. Given the low efficacy of these drugs against trichuriasis, investigation of drug combinations including moxidectin and ivermectin has recently been initiated, yet the identification of the best treatment option requires more research. We present the protocol for a trial investigating the efficacy and safety of co-administered moxidectin and albendazole compared to co-administered ivermectin and albendazole against Trichuris trichiura. Methods: We will conduct a randomized controlled trial enrolling 540 T. trichiura-infected adolescents aged 12-19 years on Pemba Island (Tanzania). The primary objective is to demonstrate non-inferiority of orally co-administered single-dose moxidectin (8 mg)/albendazole (400 mg) compared to orally co-administered single-dose ivermectin (200 µg/kg)/albendazole (400 mg) in terms of egg reduction rates (ERRs) against T. trichiura infections assessed by Kato-Katz at 14-21 days post-treatment. Secondary objectives include the assessment of the drug combinations’ superiority compared to their respective monotherapies, of the cure rates (CRs) against T. trichiura, and the safety and tolerability of all treatments, as well as CRs and ERRs against concomitant STH infections (Ascaris lumbricoides and hookworm). Potential effects of the treatment regimens on follow-up prevalences of STH at 5-6 weeks and 3 months post-treatment, infection status derived by quantitative polymerase chain reaction (qPCR), and pharmacokinetic/ pharmacodynamic parameters will also be assessed. Furthermore, a subsample of stool specimens will be analyzed by an updated version of the FECPAKG2 platform. Conclusions: Results from this trial will help to inform decision- and policymakers on which anthelminthic combination therapy might improve existing deworming programs and provide a valuable adjunct tool for interrupting STH transmission. Clinicaltrials.gov registration: NCT04700423 (07/01/2021)
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16
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Duthaler U, Leisegang R, Karlsson MO, Krähenbühl S, Hammann F. The effect of food on the pharmacokinetics of oral ivermectin. J Antimicrob Chemother 2021; 75:438-440. [PMID: 31691813 DOI: 10.1093/jac/dkz466] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 10/01/2019] [Accepted: 10/15/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Ivermectin is an older anthelminthic agent that is being studied more intensely given its potential for mass drug administration against scabies, malaria and other neglected tropical diseases. Its pharmacokinetics (PK) remain poorly characterized. Furthermore, the majority of PK trials are performed under fasted-state dosing conditions, and the effect of food is therefore not well known. To better plan and design field trials with ivermectin, a model that can account for both conditions would be valuable. OBJECTIVES To develop a PK model and characterize the food effect with single oral doses of ivermectin. PATIENTS AND METHODS We performed a population-based PK analysis of data pooled from two previous trials of a single dose of 12 mg ivermectin, one with dosing after a high-fat breakfast (n=12) and one with fasted-state dosing (n=3). RESULTS The final model described concentration-time profiles after fed and fasted dosing accurately, and estimated the food effect associated with relative bioavailability to 1.18 (95% CI 1.10-1.67). CONCLUSIONS In this analysis, the effect of a high-fat breakfast compared with a fasted-state administration of a single oral dose of 12 mg ivermectin was minimal.
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Affiliation(s)
- Urs Duthaler
- Division of Clinical Pharmacology & Toxicology, Department of Biomedicine, University and University Hospital Basel, Switzerland
| | - Rory Leisegang
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Mats O Karlsson
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Stephan Krähenbühl
- Division of Clinical Pharmacology & Toxicology, Department of Biomedicine, University and University Hospital Basel, Switzerland
| | - Felix Hammann
- Division of Clinical Pharmacology & Toxicology, Department of Biomedicine, University and University Hospital Basel, Switzerland
- Clinical Pharmacology and Toxicology, Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Institute of Pharmacology, University of Bern, Bern, Switzerland
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17
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Influence of Malnutrition on the Pharmacokinetics of Drugs Used in the Treatment of Poverty-Related Diseases: A Systematic Review. Clin Pharmacokinet 2021; 60:1149-1169. [PMID: 34060020 PMCID: PMC8545752 DOI: 10.1007/s40262-021-01031-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2021] [Indexed: 11/06/2022]
Abstract
Background Patients affected by poverty-related infectious diseases (PRDs) are disproportionally affected by malnutrition. To optimize treatment of patients affected by PRDs, we aimed to assess the influence of malnutrition associated with PRDs on drug pharmacokinetics, by way of a systematic review. Methods A systematic review was performed on the effects of malnourishment on the pharmacokinetics of drugs to treat PRDs, including HIV, tuberculosis, malaria, and neglected tropical diseases. Results In 21/29 PRD drugs included in this review, pharmacokinetics were affected by malnutrition. Effects were heterogeneous, but trends were observed for specific classes of drugs and different types and degrees of malnutrition. Bioavailability of lumefantrine, sulfadoxine, pyrimethamine, lopinavir, and efavirenz was decreased in severely malnourished patients, but increased for the P-glycoprotein substrates abacavir, saquinavir, nevirapine, and ivermectin. Distribution volume was decreased for the lipophilic drugs isoniazid, chloroquine, and nevirapine, and the α1-acid glycoprotein-bound drugs quinine, rifabutin, and saquinavir. Distribution volume was increased for the hydrophilic drug streptomycin and the albumin-bound drugs rifampicin, lopinavir, and efavirenz. Drug elimination was decreased for isoniazid, chloroquine, quinine, zidovudine, saquinavir, and streptomycin, but increased for the albumin-bound drugs quinine, chloroquine, rifampicin, lopinavir, efavirenz, and ethambutol. Clinically relevant effects were mainly observed in severely malnourished and kwashiorkor patients. Conclusions Malnutrition-related effects on pharmacokinetics potentially affect treatment response, particularly for severe malnutrition or kwashiorkor. However, pharmacokinetic knowledge is lacking for specific populations, especially patients with neglected tropical diseases and severe malnutrition. To optimize treatment in these neglected subpopulations, adequate pharmacokinetic studies are needed, including severely malnourished or kwashiorkor patients. Supplementary Information The online version contains supplementary material available at 10.1007/s40262-021-01031-z.
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18
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Bousquet-Mélou A, Lespine A, Sutra JF, Bargues I, Toutain PL. A Large Impact of Obesity on the Disposition of Ivermectin, Moxidectin and Eprinomectin in a Canine Model: Relevance for COVID-19 Patients. Front Pharmacol 2021; 12:666348. [PMID: 34093195 PMCID: PMC8173197 DOI: 10.3389/fphar.2021.666348] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 05/05/2021] [Indexed: 11/28/2022] Open
Abstract
Ivermectin (IVM) and moxidectin (MOX) are used extensively as parasiticides in veterinary medicine. Based on in vitro data, IVM has recently been proposed for the prevention and treatment of COVID-19 infection, a condition for which obesity is a major risk factor. In patients, IVM dosage is based on total body weight and there are no recommendations to adjust dosage in obese patients. The objective of this study was to establish, in a canine model, the influence of obesity on the clearance and steady-state volume of distribution of IVM, MOX, and a third analog, eprinomectin (EPR). An experimental model of obesity in dogs was based on a high calorie diet. IVM, MOX, and EPR were administered intravenously, in combination, to a single group of dogs in two circumstances, during a control period and when body weight had been increased by 50%. In obese dogs, clearance, expressed in absolute values (L/day), was not modified for MOX but was reduced for IVM and EPR, compared to the initial control state. However, when scaled by body weight (L/day/kg), plasma clearance was reduced by 55, 42, and 63%, for IVM, MOX and EPR, respectively. In contrast, the steady-state volume of distribution was markedly increased, in absolute values (L), by obesity. For IVM and MOX, this obese dog model suggests that the maintenance doses in the obese subject should be based on lean body weight rather than total weight. On the other hand, the loading dose, when required, should be based on the total body weight of the obese subject.
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Affiliation(s)
| | - Anne Lespine
- INTHERES, INRAE, ENVT, Université de Toulouse, Toulouse, France
| | | | | | - Pierre-Louis Toutain
- INTHERES, INRAE, ENVT, Université de Toulouse, Toulouse, France
- The Royal Veterinary College, Hatfield, United Kingdom
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Matamoros G, Sánchez A, Gabrie JA, Juárez M, Ceballos L, Escalada A, Rodríguez C, Martí-Soler H, Rueda MM, Canales M, Lanusse C, Cajal P, Álvarez L, Cimino RO, Krolewiecki A. Efficacy and safety of albendazole and high-dose ivermectin co-administration in school-aged children infected with Trichuris trichiura in Honduras: A Randomized Controlled Trial. Clin Infect Dis 2021; 73:1203-1210. [PMID: 33906234 DOI: 10.1093/cid/ciab365] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The efficacy of currently available anthelminthics against Trichuris trichiura infections is significatively lower than for other soil-transmitted helminths (STH). The combination of ivermectin (IVM) and albendazole (ALB) has shown significant improvements in efficacy. METHODS Safety and efficacy randomized controlled clinical trial comparing 3 experimental regimens against ALB monotherapy for the treatment of T. trichiura infections in northern Honduras. Infected children were randomized to one of the following treatments: (Arm 1) single-dose ALB 400 mg; (Arm 2) single-dose ALB 400 mg/IVM 600 μg/kg; (Arm 3) ALB 400 mg for 3 consecutive days; or (Arm 4) ALB 400 mg/IVM 600 μg/kg for 3 consecutive days. Efficacy was measured through egg reduction rate (ERR) and cure rate (CR), both assessed 14-21 days after treatment using the Kato-Katz method. Safety was evaluated by analyzing the frequency and severity of adverse events. RESULTS A total of 176 children were randomized to one of the 4 treatment arms, 117 completed treatment and follow-up. The ERR for Arms 1 to 4 were: 47.7%, 96.7%, 72.1% and 100%, respectively; with p-values <0.001 between IVM groups and ALB only arms. The CRs were 4.2%, 88.6%, 33.3% and 100%, respectively. A total of 48 (85.4% mild) AEs were reported in 36 children. CONCLUSIONS The combined use of ALB and high-dose IVM is a highly effective and well tolerated treatment for the treatment of T. trichiura infections offering a significantly improved treatment for the control of this infection.
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Affiliation(s)
- Gabriela Matamoros
- Instituto de Investigaciones en Microbiología, Universidad Nacional Autónoma de Honduras.,Faculty of Applied Health Sciences, Brock University, Ontario. Canada
| | - Ana Sánchez
- Instituto de Investigaciones en Microbiología, Universidad Nacional Autónoma de Honduras.,Faculty of Applied Health Sciences, Brock University, Ontario. Canada
| | | | - Marisa Juárez
- Instituto de Investigaciones de Enfermedades Tropicales (IIET-CONICET), Sede Regional Orán, Universidad Nacional de Salta, Argentina
| | - Laura Ceballos
- Laboratorio de Farmacología, Centro de Investigación Veterinaria de Tandil (CIVETAN), UNCPBA-CICPBA-CONICET, Facultad de Ciencias Veterinarias, Universidad Nacional del Centro de la Provincia de Buenos Aires, Tandil, Argentina
| | - Andrés Escalada
- Instituto de Investigaciones de Enfermedades Tropicales (IIET-CONICET), Sede Regional Orán, Universidad Nacional de Salta, Argentina
| | - Carol Rodríguez
- Escuela de Microbiología, Universidad Nacional Autónoma de Honduras
| | | | | | - Maritza Canales
- Escuela de Microbiología, Universidad Nacional Autónoma de Honduras
| | - Carlos Lanusse
- Laboratorio de Farmacología, Centro de Investigación Veterinaria de Tandil (CIVETAN), UNCPBA-CICPBA-CONICET, Facultad de Ciencias Veterinarias, Universidad Nacional del Centro de la Provincia de Buenos Aires, Tandil, Argentina
| | - Pamela Cajal
- Instituto de Investigaciones de Enfermedades Tropicales (IIET-CONICET), Sede Regional Orán, Universidad Nacional de Salta, Argentina
| | - Luis Álvarez
- Laboratorio de Farmacología, Centro de Investigación Veterinaria de Tandil (CIVETAN), UNCPBA-CICPBA-CONICET, Facultad de Ciencias Veterinarias, Universidad Nacional del Centro de la Provincia de Buenos Aires, Tandil, Argentina
| | - Rubén O Cimino
- Instituto de Investigaciones de Enfermedades Tropicales (IIET-CONICET), Sede Regional Orán, Universidad Nacional de Salta, Argentina
| | - Alejandro Krolewiecki
- Instituto de Investigaciones de Enfermedades Tropicales (IIET-CONICET), Sede Regional Orán, Universidad Nacional de Salta, Argentina.,Laboratorio de Farmacología, Centro de Investigación Veterinaria de Tandil (CIVETAN), UNCPBA-CICPBA-CONICET, Facultad de Ciencias Veterinarias, Universidad Nacional del Centro de la Provincia de Buenos Aires, Tandil, Argentina
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20
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A systematic review and an individual patient data meta-analysis of ivermectin use in children weighing less than fifteen kilograms: Is it time to reconsider the current contraindication? PLoS Negl Trop Dis 2021; 15:e0009144. [PMID: 33730099 PMCID: PMC7968658 DOI: 10.1371/journal.pntd.0009144] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 01/13/2021] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Oral ivermectin is a safe broad spectrum anthelminthic used for treating several neglected tropical diseases (NTDs). Currently, ivermectin use is contraindicated in children weighing less than 15 kg, restricting access to this drug for the treatment of NTDs. Here we provide an updated systematic review of the literature and we conducted an individual-level patient data (IPD) meta-analysis describing the safety of ivermectin in children weighing less than 15 kg. METHODOLOGY/PRINCIPAL FINDINGS A systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) for IPD guidelines by searching MEDLINE via PubMed, Web of Science, Ovid Embase, LILACS, Cochrane Database of Systematic Reviews, TOXLINE for all clinical trials, case series, case reports, and database entries for reports on the use of ivermectin in children weighing less than 15 kg that were published between 1 January 1980 to 25 October 2019. The protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO): CRD42017056515. A total of 3,730 publications were identified, 97 were selected for potential inclusion, but only 17 sources describing 15 studies met the minimum criteria which consisted of known weights of children less than 15 kg linked to possible adverse events, and provided comprehensive IPD. A total of 1,088 children weighing less than 15 kg were administered oral ivermectin for one of the following indications: scabies, mass drug administration for scabies control, crusted scabies, cutaneous larva migrans, myiasis, pthiriasis, strongyloidiasis, trichuriasis, and parasitic disease of unknown origin. Overall a total of 1.4% (15/1,088) of children experienced 18 adverse events all of which were mild and self-limiting. No serious adverse events were reported. CONCLUSIONS/SIGNIFICANCE Existing limited data suggest that oral ivermectin in children weighing less than 15 kilograms is safe. Data from well-designed clinical trials are needed to provide further assurance.
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21
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Pharmacometric Analysis of Tribendimidine Monotherapy and Combination Therapies To Achieve High Cure Rates in Patients with Hookworm Infections. Antimicrob Agents Chemother 2021; 65:AAC.00714-20. [PMID: 33139276 DOI: 10.1128/aac.00714-20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 09/27/2020] [Indexed: 02/06/2023] Open
Abstract
In the treatment of hookworm infections, pharmacotherapy has been only moderately successful and drug resistance is a threat. Therefore, novel treatment options including combination therapies should be considered, in which tribendimidine could play a role. Our aims were to (i) characterize the pharmacokinetics of tribendimidine's metabolites in adolescents receiving tribendimidine monotherapy or in combination with ivermectin or oxantel pamoate, (ii) evaluate possible drug-drug interactions (DDI), (iii) link exposure to response, and (iv) identify a treatment strategy associated with high efficacy, i.e., >90% cure rates (CRs), utilizing model-based simulations. A population pharmacokinetic model was developed for tribendimidine's primary and secondary metabolites, dADT and adADT, in 54 hookworm-positive adolescents, with combination therapy evaluated as a possible covariate. Subsequently, an exposure-response analysis was performed utilizing CRs as response markers. Simulations were performed to identify a treatment strategy to achieve >90% CRs. A two-compartmental model best described metabolite disposition. No pharmacokinetic DDI was identified with ivermectin or oxantel pamoate. All participants receiving tribendimidine plus ivermectin were cured. For the monotherapy arm and the arm including the combination with oxantel pamoate, E max models adequately described the correlation between dADT exposure and probability of being cured, with required exposures to achieve 50% of maximum effect of 39.6 and 15.6 nmol/ml·h, respectively. Based on our simulations, an unrealistically high monotherapy tribendimidine dose would be necessary to achieve CRs of >90%, while combination therapy with ivermectin would meet this desired target product profile. Further clinical studies should be launched to develop this combination for the treatment of hookworm and other helminth infections.
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22
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Gwee A, Duffull S, Zhu X, Tong SYC, Cranswick N, McWhinney B, Ungerer J, Francis J, Steer AC. Population pharmacokinetics of ivermectin for the treatment of scabies in Indigenous Australian children. PLoS Negl Trop Dis 2020; 14:e0008886. [PMID: 33284799 PMCID: PMC7746298 DOI: 10.1371/journal.pntd.0008886] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 12/17/2020] [Accepted: 10/14/2020] [Indexed: 11/30/2022] Open
Abstract
Ivermectin is a broad-spectrum antiparasitic agent used for the treatment and control of neglected tropical diseases. In Australia, ivermectin is primarily used for scabies and is licensed in children aged ≥5 years weighing >15 kg. However, young children, aged <5 years, are particularly vulnerable to scabies and its secondary complications. Therefore, this study aimed to determine an appropriate ivermectin dose for children aged 2 to 4 years and weighing ≤15 kg. We conducted a prospective, pharmacokinetic study of ivermectin in Indigenous Australian children aged between 5 and 15 years and weighing >15 kg. Doses of 200 μg/kg rounded to the nearest whole or half 3 mg tablet were given to children with scabies and ivermectin concentrations determined at two time points after dosing. A population pharmacokinetic model was developed using non-linear mixed effects modelling. A separate covariate database of children aged 2 to 4 years and weighing <15 kg was used to generate 1000 virtual patients and simulate the dose required to achieve equivalent drug exposure in young children as those aged ≥5 years. Overall, 26 children who had 48 ivermectin concentrations determined were included, 11 (42%) were male, the median age was 10.9 years and median body weight 37.6 kg. The final model was a two-compartment model with first-order absorption and linear elimination. For simulated children aged 2 to 4 years, a dose of 3 mg in children weighing 10–15 kg produced similar drug exposures to those >5 years. The median simulated area under the concentration-time curve was 976 μg∙h/L. Using modelling, we have identified a dosing strategy for ivermectin in children aged 2 to 4 years and weighing less than 15 kg that can be prospectively evaluated for safety and efficacy. Ivermectin is an important drug for the control and treatment of neglected tropical diseases. However, despite numerous studies showing that ivermectin is safe and well tolerated in young children, it is not currently recommended in young children <5 years and <15 kg. Therefore, there are no guidelines for the dose of ivermectin in young or small children. In this study, we firstly determined how much ivermectin is present in blood in children aged 5 years and older. We then used this information to model what happens to ivermectin in childrens’ bodies allowing us to calculate the dose required in children aged less than 5 years and weighing under 15 kg. This study provides a new dosing guideline that can now be tested in clinical studies of children <5 years and <15 kg.
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Affiliation(s)
- Amanda Gwee
- Department of General Medicine, The Royal Children’s Hospital Melbourne, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
- Infection and Immunity theme, Murdoch Children’s Research Institute, Parkville, Victoria, Australia
- * E-mail:
| | - Stephen Duffull
- School of Pharmacy, University of Otago, Dunedin, New Zealand
| | - Xiao Zhu
- Infection and Immunity theme, Murdoch Children’s Research Institute, Parkville, Victoria, Australia
- School of Pharmacy, University of Otago, Dunedin, New Zealand
| | - Steven Y. C. Tong
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital, and Doherty Department University of Melbourne, at the Peter Doherty Institute for Infection and Immunity, Victoria, Australia
- Global and tropical health division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - Noel Cranswick
- Department of General Medicine, The Royal Children’s Hospital Melbourne, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
- Infection and Immunity theme, Murdoch Children’s Research Institute, Parkville, Victoria, Australia
| | - Brett McWhinney
- Department of Chemical Pathology, Pathology Queensland, Brisbane, Queensland, Australia
| | - Jacobus Ungerer
- Department of Chemical Pathology, Pathology Queensland, Brisbane, Queensland, Australia
- Faculty of Biomedical Science, University of Queensland, Brisbane, Queensland, Australia
| | - Joshua Francis
- Global and tropical health division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
- Department of Paediatrics, Royal Darwin Hospital, Northern Territory, Australia
| | - Andrew C. Steer
- Department of General Medicine, The Royal Children’s Hospital Melbourne, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia
- Infection and Immunity theme, Murdoch Children’s Research Institute, Parkville, Victoria, Australia
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23
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Dabira ED, Soumare HM, Lindsay SW, Conteh B, Ceesay F, Bradley J, Kositz C, Broekhuizen H, Kandeh B, Fehr AE, Nieto-Sanchez C, Ribera JM, Peeters Grietens K, Smit MR, Drakeley C, Bousema T, Achan J, D'Alessandro U. Mass Drug Administration With High-Dose Ivermectin and Dihydroartemisinin-Piperaquine for Malaria Elimination in an Area of Low Transmission With High Coverage of Malaria Control Interventions: Protocol for the MASSIV Cluster Randomized Clinical Trial. JMIR Res Protoc 2020; 9:e20904. [PMID: 33211022 PMCID: PMC7714640 DOI: 10.2196/20904] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/28/2020] [Accepted: 08/03/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND With a decline in malaria burden, innovative interventions and tools are required to reduce malaria transmission further. Mass drug administration (MDA) of artemisinin-based combination therapy (ACT) has been identified as a potential tool to further reduce malaria transmission, where coverage of vector control interventions is already high. However, the impact is limited in time. Combining an ACT with an endectocide treatment that is able to reduce vector survival, such as ivermectin (IVM), could increase the impact of MDA and offer a new tool to reduce malaria transmission. OBJECTIVE The study objective is to evaluate the impact of MDA with IVM plus dihydroartemisinin-piperaquine (DP) on malaria transmission in an area with high coverage of malaria control interventions. METHODS The study is a cluster randomized trial in the Upper River Region of The Gambia and included 32 villages (16 control and 16 intervention). A buffer zone of ~2 km was created around all intervention clusters. MDA with IVM plus DP was implemented in all intervention villages and the buffer zones; control villages received standard malaria interventions according to the Gambian National Malaria Control Program plans. RESULTS The MDA campaigns were carried out from August to October 2018 for the first year and from July to September 2019 for the second year. Statistical analysis will commence once the database is completed, cleaned, and locked. CONCLUSIONS This is the first cluster randomized clinical trial of MDA with IVM plus DP. The results will provide evidence on the impact of MDA with IVM plus DP on malaria transmission. TRIAL REGISTRATION ClinicalTrials.gov NCT03576313; https://clinicaltrials.gov/ct2/show/NCT03576313. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/20904.
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Affiliation(s)
- Edgard Diniba Dabira
- Medical Research Council Unit Gambia, London School of Hygiene and Tropical Medicine, Banjul, Gambia
| | - Harouna M Soumare
- Medical Research Council Unit Gambia, London School of Hygiene and Tropical Medicine, Banjul, Gambia
| | - Steven W Lindsay
- Department of Biosciences, Durham University, Durham, United Kingdom
| | - Bakary Conteh
- Medical Research Council Unit Gambia, London School of Hygiene and Tropical Medicine, Banjul, Gambia
| | - Fatima Ceesay
- Medical Research Council Unit Gambia, London School of Hygiene and Tropical Medicine, Banjul, Gambia
| | - John Bradley
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Christian Kositz
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Balla Kandeh
- National Malaria Control Program, The Gambia, Banjul, Gambia
| | - Alexandra E Fehr
- Medical Anthropology Unit, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
- Vrije Universiteit Amsterdam, Athena Institute, Amsterdam, Netherlands
| | - Claudia Nieto-Sanchez
- Medical Anthropology Unit, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Joan Muela Ribera
- Medial Anthropology Research Center, Universitat Rovira i Virgili, Tarragona, Spain
| | - Koen Peeters Grietens
- Medical Anthropology Unit, Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Menno Roderick Smit
- Amsterdam Centre for Global Child Health, Emma Children's Hospital, Amsterdam University Medical Centres, Amsterdam, The Netherlands, Amsterdam, Netherlands
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Chris Drakeley
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Teun Bousema
- Radboud University Medical Centre, Nijmegen, Netherlands
| | - Jane Achan
- Medical Research Council Unit Gambia, London School of Hygiene and Tropical Medicine, Banjul, Gambia
| | - Umberto D'Alessandro
- Medical Research Council Unit Gambia, London School of Hygiene and Tropical Medicine, Banjul, Gambia
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24
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El-Saber Batiha G, Alqahtani A, Ilesanmi OB, Saati AA, El-Mleeh A, Hetta HF, Magdy Beshbishy A. Avermectin Derivatives, Pharmacokinetics, Therapeutic and Toxic Dosages, Mechanism of Action, and Their Biological Effects. Pharmaceuticals (Basel) 2020; 13:ph13080196. [PMID: 32824399 PMCID: PMC7464486 DOI: 10.3390/ph13080196] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 08/09/2020] [Accepted: 08/13/2020] [Indexed: 12/15/2022] Open
Abstract
Avermectins are a group of drugs that occurs naturally as a product of fermenting Streptomyces avermitilis, an actinomycetes, isolated from the soil. Eight different structures, including ivermectin, abamectin, doramectin, eprinomectin, moxidectin, and selamectin, were isolated and divided into four major components (A1a, A2a, B1a and B2a) and four minor components (A1b, A2b, B1b, and B2b). Avermectins are generally used as a pesticide for the treatment of pests and parasitic worms as a result of their anthelmintic and insecticidal properties. Additionally, they possess anticancer, anti-diabetic, antiviral, antifungal, and are used for treatment of several metabolic disorders. Avermectin generally works by preventing the transmission of electrical impulse in the muscle and nerves of invertebrates, by amplifying the glutamate effects on the invertebrates-specific gated chloride channel. Avermectin has unwanted effects or reactions, especially when administered indiscriminately, which include respiratory failure, hypotension, and coma. The current review examines the mechanism of actions, biosynthesis, safety, pharmacokinetics, biological toxicity and activities of avermectins.
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Affiliation(s)
- Gaber El-Saber Batiha
- Department of Pharmacology and Therapeutics, Faculty of Veterinary Medicine, Damanhour University, Damanhour 22511, Egypt
- Correspondence: or (G.E.-S.B.); (A.M.B.)
| | - Ali Alqahtani
- Department of Pharmacology, College of Pharmacy, King Khalid University, Guraiger, Abha 62529, Saudi Arabia;
| | - Omotayo B. Ilesanmi
- Department of Biochemistry, Faculty of Science, Federal University Otuoke, Otuoke 561, Nigeria;
| | - Abdullah A. Saati
- Department of Community Medicine & Pilgrims Healthcare, Faculty of Medicine, Umm Al-Qura University Makkah, Mecca 24382, Saudi Arabia;
| | - Amany El-Mleeh
- Department of Pharmacology, Faculty of Veterinary Medicine, Menoufia University, Shibin Al Kawm 32511, Egypt;
| | - Helal F. Hetta
- Department of Medical Microbiology and Immunology, Faculty of Medicine, Assiut University, Assiut 71515, Egypt;
- Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH 45221, USA
| | - Amany Magdy Beshbishy
- National Research Center for Protozoan Diseases, Obihiro University of Agriculture and Veterinary Medicine, Nishi 2-13, Inada-cho, Obihiro 080-8555, Hokkaido, Japan
- Correspondence: or (G.E.-S.B.); (A.M.B.)
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25
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Navarro M, Camprubí D, Requena-Méndez A, Buonfrate D, Giorli G, Kamgno J, Gardon J, Boussinesq M, Muñoz J, Krolewiecki A. Safety of high-dose ivermectin: a systematic review and meta-analysis. J Antimicrob Chemother 2020; 75:827-834. [PMID: 31960060 DOI: 10.1093/jac/dkz524] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 10/17/2019] [Accepted: 11/26/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Ivermectin is a key anthelmintic for the control of neglected tropical diseases. The main indications for population-level control with ivermectin through mass drug administration are onchocerciasis and lymphatic filariasis; however, there is interest in using higher, fixed-dose regimens for the control of scabies, soil-transmitted helminths and malaria. Safety data for these higher-dose regimens are needed. METHODS A systematic literature review and meta-analysis on the safety and doses of ivermectin was conducted. Eligible studies reported patient-level data and, for the meta-analysis, clinical trials reporting data on doses ≥200 and ≥400 μg/kg were included. Incidence ratios were used to compare adverse events by severity and organ system affected. RESULTS The systematic search identified six studies for inclusion, revealing no differences in the number of individuals experiencing adverse events. A descriptive analysis of these clinical trials for a variety of indications showed no difference in the severity of the adverse events between standard (up to 400 μg/kg) and higher doses of ivermectin. Organ system involvement only showed an increase in ocular events in the higher-dose group in one trial for the treatment of onchocerciasis, all of them transient and mild to moderate in intensity. CONCLUSIONS Although within this review the safety of high-dose ivermectin appears to be comparable to standard doses, there are not enough data to support a recommendation for its use in higher-than-approved doses. Ocular adverse events, despite being transient, are of concern in onchocerciasis patients. These data can inform programme managers and guide operational research activities as new approaches for the use of ivermectin are evaluated.
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Affiliation(s)
- Miriam Navarro
- Department of Public Health, Science History and Gynecology, Universidad Miguel Hernández de Elche, Alicante, Spain
| | - Daniel Camprubí
- Barcelona Institute for Global Health (ISGlobal) Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Ana Requena-Méndez
- Barcelona Institute for Global Health (ISGlobal) Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Dora Buonfrate
- Department of Infectious - Tropical Diseases and Microbiology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Verona, Italy
| | - Giovanni Giorli
- Department of Infectious - Tropical Diseases and Microbiology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Verona, Italy
| | - Joseph Kamgno
- Centre de Recherche sur les Filarioses et autres Maladies tropicales, Yaounde, Cameroon
| | - Jacques Gardon
- Institut de Recherche pour le Développement, Montpellier, France
| | | | - Jose Muñoz
- Barcelona Institute for Global Health (ISGlobal) Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | - Alejandro Krolewiecki
- Barcelona Institute for Global Health (ISGlobal) Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
- Instituto de Investigaciones de Enfermedades Tropicales Universidad Nacional de Salta/CONICET, Orán, Argentina
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26
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Brussee JM, Schulz JD, Coulibaly JT, Keiser J, Pfister M. Ivermectin Dosing Strategy to Achieve Equivalent Exposure Coverage in Children and Adults. Clin Pharmacol Ther 2019; 106:661-667. [PMID: 30993667 DOI: 10.1002/cpt.1456] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 03/22/2019] [Indexed: 12/12/2022]
Abstract
Ivermectin is a commonly used broad-spectrum antiparasitic drug, yet doses that produce consistent exposure coverage across age have not been characterized, and no data are available in children weighing < 15 kg. First, a population pharmacokinetic model is developed based on data from 200 children and 11 adults, treated with 100-600 μg/kg ivermectin. Second, model-based simulations are performed to identify a dosing strategy that achieves equivalent exposure coverage in children and adults. Median (90% confidence interval) clearance of 0.346 (0.12-0.73) L/hour/kg in pre-school-aged (2-5 years) children is similar to 0.352 (0.17-0.69) L/hour/kg in school-aged (6-12 years) children but higher than in adults (0.199 (0.10-0.31) L/hour/kg), resulting in significantly lower exposure in children following a 200 μg/kg dose. Simulations indicate that a dose increase to 300 and 250 μg/kg in children aged 2-5 and 6-12 years, respectively, will achieve equivalent ivermectin exposure coverage in children and adults.
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Affiliation(s)
- Janneke M Brussee
- Department of Medical Parasitology and Infection Biology, Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland.,Pediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel (UKBB), University of Basel, Basel, Switzerland
| | - Jessica D Schulz
- Department of Medical Parasitology and Infection Biology, Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Jean T Coulibaly
- Department of Medical Parasitology and Infection Biology, Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland.,Unité de Formation et de Recherche Biosciences, Université Félix Houphouët-Boigny, Abidjan, Côte d'Ivoire.,Centre Suisse de Recherches Scientifiques en Côte d'Ivoire, Abidjan, Côte d'Ivoire
| | - Jennifer Keiser
- Department of Medical Parasitology and Infection Biology, Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Marc Pfister
- University of Basel, Basel, Switzerland.,Pediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel (UKBB), University of Basel, Basel, Switzerland.,Certara LP, Princeton, New Jersey, USA
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