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==Overview==
==Overview==
The recommended treatment for patients outside the United States is [[albendazole]] (a broad spectrum [[anthelmintic]]) combined with [[ivermectin]].<ref name="CDC">{{Citation|author=U.S. Centers for Disease Control|title= Lymphatic Filariasis Treatment|url=http://www.cdc.gov/ncidod/dpd/parasites/lymphaticfilariasis/treatment_lymphatic_filar.htm|accessdate=2008-07-17}}</ref> A combination of [[diethylcarbamazine]] (DEC) and albendazole is also effective. All of these treatments are microfilaricides; they have no effect on the adult worms.
The mainstay treatment for patients with filariasis is [[albendazole]] (a [[broad spectrum]] [[anthelmintic]]) combined with [[ivermectin]].<ref name="CDC">{{Citation|author=U.S. Centers for Disease Control|title= Lymphatic Filariasis Treatment|url=http://www.cdc.gov/ncidod/dpd/parasites/lymphaticfilariasis/treatment_lymphatic_filar.htm|accessdate=2008-07-17}}</ref> A combination of [[diethylcarbamazine]] (DEC) and [[albendazole]] is also effective. All of these treatments are microfilaricides; they have no effect on the adult worms.
 
==Medical Therapy==
==Medical Therapy==
Different drugs are recommended for the treatment of filariasis depending on the specific causal agent.
===Lymphatic Filariasis===
Medicines to treat lymphatic filariasis are most effective when used soon after infection, but they do have some toxic side effects. In addition, the disease is difficult to detect early. Therefore, improved treatments and laboratory tests are needed.
Once Filaria is attacked, the patients are likely to get fever once in a year or two with shivering. They are also administered Florocid injections.
====Antibiotics====
In 2003 it was suggested that the common antibiotic [[doxycycline]] might be effective in treating elephantiasis.<ref name="MedMicrobiolImmunol2003-Hoerauf">{{cite journal | author=Hoerauf A, Mand S, Fischer K, Kruppa T, Marfo-Debrekyei Y, Debrah AY, Pfarr KM, Adjei O, Buttner DW | title=Doxycycline as a novel strategy against bancroftian filariasis-depletion of Wolbachia endosymbionts from Wuchereria bancrofti and stop of microfilaria production | journal=Med Microbiol Immunol (Berl) | year=2003 | pages=211-6 | volume=192 | issue=4 | id=PMID 12684759}}</ref>
The parasites responsible for filariasis have a population of symbiotic bacteria, [[Wolbachia]], that live inside the worm. When the symbiotic bacteria are killed by the antibiotic, the worms themselves also die.
Clinical trials in June 2005 by the Liverpool School of Tropical Medicine reported that an 8 week course almost completely eliminated microfilariaemia.<ref name="Lancet2005-Taylor">{{cite journal | author=Taylor MJ, Makunde WH, McGarry HF, Turner JD, Mand S, Hoerauf A | title=Macrofilaricidal activity after doxycycline treatment of Wuchereria bancrofti: a double-blind, randomised placebo-controlled trial | journal=Lancet | year=2005 | pages=2116-21 | volume=365 |issue=9477 | id=PMID 15964448}}</ref><ref name="JYI2005-Outland">{{cite news | first=Katrina | last=Outland | url=http://www.jyi.org/news/nb.php?id=361 |title=New Treatment for Elephantitis: Antibiotics | publisher=The Journal of Young Investigators | date=2005 Volume 13 }}</ref>
====Diethylcarbamazine Citrate (Hetrazan)====
The main goal of treatment of an infected person is to kill the adult worm. Diethylcarbamazine citrate (DEC), which is both microfilaricidal and active against the adult worm, is the drug of choice for lymphatic filariasis. The late phase of chronic disease is not affected by chemotherapy. Ivermectin is effective against the microfilariae of W. bancrofti, but has no effect on the adult parasite.
Because lymphatic filariasis is rare in the U.S., DEC is no longer approved by the Food and Drug Administration (FDA) and cannot be sold in the U.S. Physicians can obtain the medication from CDC after confirmed positive lab results. Call: 404-718-4745.  DEC is generally well tolerated. Side effects are generally limited and depend on the number of microfilariae in the blood. The most common side effects are dizziness, nausea, fever, headache, or pain in muscles or joints.
Prior to DEC treatment for lymphatic filariasis, onchocerciasis should be excluded in all patients with a consistent exposure history due to the possibility of severe exacerbations of skin and eye involvement (Mazzotti reaction). In addition, DEC should be used with extreme caution in patients with circulating Loa loa microfilarial levels > 2,500/mm3 due to the potential for life-threatening side effects, including encephalopathy and renal failure. Neither steroids pre-treatment nor slow dose escalation prevents these complications
The main goal of treatment of an infected person is to kill the adult worm. Diethylcarbamazine citrate (DEC), which is both microfilaricidal and active against the adult worm, is the drug of choice for lymphatic filariasis. The late phase of chronic disease is not affected by chemotherapy. Ivermectin is effective against the microfilariae of W. bancrofti, but has no effect on the adult parasite.
Because lymphatic filariasis is rare in the U.S., DEC is no longer approved by the Food and Drug Administration (FDA) and cannot be sold in the U.S. Physicians can obtain the medication from CDC after confirmed positive lab results. Call: 404-718-4745.  DEC is generally well tolerated. Side effects are generally limited and depend on the number of microfilariae in the blood. The most common side effects are dizziness, nausea, fever, headache, or pain in muscles or joints.
Prior to DEC treatment for lymphatic filariasis, onchocerciasis should be excluded in all patients with a consistent exposure history due to the possibility of severe exacerbations of skin and eye involvement (Mazzotti reaction). In addition, DEC should be used with extreme caution in patients with circulating Loa loa microfilarial levels > 2,500/mm3 due to the potential for life-threatening side effects, including encephalopathy and renal failure. Neither steroids pre-treatment nor slow dose escalation prevents these complications. One day treatment is generally as effective as the 12-day regimen. For tropical pulmonary eosinophilia (TPE), a longer DEC treatment course of 14-21 days is generally recommended.


;Shown below is a table summarizing the preferred and alternative empiric treatment for Lymphatic filariasis.
===Antimicrobial Regimen===
{| class="wikitable" border="1" style="background:FloralWhite"
|- align="center"
|'''Characteristics of the Patient'''
|'''Possible Pathogens'''
|'''Preferred Treatment'''
|'''Duration of Treatment'''
|- align="center"
| adults and children > 18 months of age
| '''Wuchereria bancrofti'''
'''OR'''
'''Brugia malayi'''
| '''Diethylcarbamazine Citrate'''
(6mg/kg/day)
|Either a 1 day or 12 day treatment course
|}


===Onchocerciasis===
* '''Filariasis'''<ref>{{cite web | title = Drugs for Parasitic Infections (Treatment Guidelines from The Medical Letter) | url = http://secure.medicalletter.org/para }}</ref><ref name="pmid20739055">{{cite journal| author=Taylor MJ, Hoerauf A, Bockarie M| title=Lymphatic filariasis and onchocerciasis. | journal=Lancet | year= 2010 | volume= 376 | issue= 9747 | pages= 1175-85 | pmid=20739055 | doi=10.1016/S0140-6736(10)60586-7 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20739055  }} </ref><ref name="pmid22632644">{{cite journal| author=Knopp S, Steinmann P, Hatz C, Keiser J, Utzinger J| title=Nematode infections: filariases. | journal=Infect Dis Clin North Am | year= 2012 | volume= 26 | issue= 2 | pages= 359-81 | pmid=22632644 | doi=10.1016/j.idc.2012.02.005 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22632644  }}</ref>
;Shown below is a table summarizing the preferred and alternative empiric treatment for Onchocerciasis<ref>http://www.cdc.gov/parasites/onchocerciasis/health_professionals/index.html#dx</ref>
:* 1. '''Lymphatic filariasis caused by Wuchereria bancrofti, Brugia malayi, Brugia timori'''
{| class="wikitable" border="1" style="background:FloralWhite"
::* Preferred regimen: [[Diethylcarbamazine]] 6 mg/kd/day PO tid for 12 days. Single dose of (DEC) has the same long-term effect in decreasing levels of microfilaria in blood as 12-day regimen. If  patient is co-infected with onchocerciasis or loiasis  DEC is contraindicated. DEC induces reversal of early lymphatic dysfunction in a patient with W.bancrofiti filariasis.<ref name="pmid8922794">{{cite journal| author=Moore TA, Reynolds JC, Kenney RT, Johnston W, Nutman TB| title=Diethylcarbamazine-induced reversal of early lymphatic dysfunction in a patient with bancroftian filariasis: assessment with use of lymphoscintigraphy. | journal=Clin Infect Dis | year= 1996 | volume= 23 | issue= 5 | pages= 1007-11 | pmid=8922794 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8922794  }}</ref>
|- align="center"
::* '''Chronic cases''':
|'''Characteristics of the Patient'''
::** Regular exercise and leg elevation during night increase lymph flow. 
|'''Possible Pathogens'''
::** Physiotherapy may be effective in some cases. 
|'''Preferred Treatment'''
::** Reconstructive surgery involving lymphatic-venous anastomoses have been attempted to improve lymphatic drainage, but the long-term benefit is still unclear. 
|'''Duration of Treatment'''
:* 2. '''Loa loa filariasis'''<ref>{{cite web | title = Parasites - Loiasis (CDC) | url = http://www.cdc.gov/parasites/loiasis/health_professionals/index.html }}</ref>
|'''Alternative Treatment'''
::* 2.1 '''Symptomatic loiasis with < 8,000 microfilariae/mL'''
|- align="center"
:::* Preferred regimen: [[Diethylcarbamazine]] 8–10 mg/kd/day PO tid for 21 days.
|'''Adult'''
::* 2.2 '''Symptomatic loiasis, with < 8,000 microfilariae/mL and failed 2 rounds DEC'''
| Onchocerca volvulus (microfilariae)
:::* Preferred regimen: [[Albendazole]] 200 mg PO bid for 21 days.
| '''Ivermectin'''
::* 2.3 '''Symptomatic loiasis, with ≥ 8,000 microfilariae/ml to suppress microfilaremia prior to treatment with DEC'''
150 mcg/kg orally in one dose
:::* Preferred regimen: [[Albendazole]] 200 mg PO bid for 21 days.
| Every 6 months
::* 2.4 '''Symptomatic loiasis, with ≥ 8,000 microfilariae/mL'''
|Doxycycline
:::* Preferred regimen: Apheresis followed by [[Diethylcarbamazine]].
200 mg orally daily for 6 weeks  
:::* Note: Apheresis should be performed at an institution with experience in using this therapeutic modality for loiasis.
|- align="center"
:* 3. '''River blindness (onchocerciasis) caused by Onchocerca volvulus'''
|'''Pediatric'''
::* Preferred regimen: [[Ivermectin]] 150 μg/kg PO single dose, repeated every 6-12 mos until asymptomatic.
|Onchocerca volvulus (microfilariae)
::* Alternative regimen: [[Doxycycline]] 100 mg PO qd for 6 weeks, alone or followed by [[Ivermectin]] 150 μg/kg PO single dose.
| '''Ivermectin'''
::* Note: Do <u>NOT</u> administer Diethylcarbamazine where onchocerciasis is endemic due to increased risk for severe local inflammation in patients with ocular microfilariae.
150 mcg/kg orally in one dose
:* 4. '''Mansonella ozzardi'''
| Every 6 months
::* Preferred regimen: [[Ivermectin]] 200 μg/kg PO single dose.
| Doxycycline
::* Note: Endosymbiotic Wolbachia are essential to filarial growth, development, embryogenesis and survival and represent an additional target for therapy.  [[Doxycycline]] 100–200 mg PO qd for 6–8 weeks results in loss of Wolbachia and decrease in both micro- and macrofilariae.
200 mg orally daily for 6 weeks
:* 5. '''Mansonella perstans'''
|}
::* Preferred regimen: [[Doxycycline]] 100–200 mg PO qd for 6–8 weeks.
:* 6. '''Mansonella streptocerca'''
::* Preferred regimen (1): [[Diethylcarbamazine]] 6 mg/kd/day PO tid for 12 days.
::* Preferred regimen (2): [[Ivermectin]] 150 μg/kg PO single dose.
:* 7. '''Tropical pulmonary eosinophilia caused by Wuchereria bancrofti'''
::* Preferred regimen: [[Diethylcarbamazine]] 6 mg/kd/day PO tid for 12–21 days.


==References==
==References==
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Latest revision as of 21:45, 29 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohammed Abdelwahed M.D[2]

Overview

The mainstay treatment for patients with filariasis is albendazole (a broad spectrum anthelmintic) combined with ivermectin.[1] A combination of diethylcarbamazine (DEC) and albendazole is also effective. All of these treatments are microfilaricides; they have no effect on the adult worms.

Medical Therapy

Antimicrobial Regimen

  • 1. Lymphatic filariasis caused by Wuchereria bancrofti, Brugia malayi, Brugia timori
  • Preferred regimen: Diethylcarbamazine 6 mg/kd/day PO tid for 12 days. Single dose of (DEC) has the same long-term effect in decreasing levels of microfilaria in blood as 12-day regimen. If patient is co-infected with onchocerciasis or loiasis DEC is contraindicated. DEC induces reversal of early lymphatic dysfunction in a patient with W.bancrofiti filariasis.[5]
  • Chronic cases:
    • Regular exercise and leg elevation during night increase lymph flow.
    • Physiotherapy may be effective in some cases.
    • Reconstructive surgery involving lymphatic-venous anastomoses have been attempted to improve lymphatic drainage, but the long-term benefit is still unclear.
  • 2. Loa loa filariasis[6]
  • 2.1 Symptomatic loiasis with < 8,000 microfilariae/mL
  • 2.2 Symptomatic loiasis, with < 8,000 microfilariae/mL and failed 2 rounds DEC
  • Preferred regimen: Albendazole 200 mg PO bid for 21 days.
  • 2.3 Symptomatic loiasis, with ≥ 8,000 microfilariae/ml to suppress microfilaremia prior to treatment with DEC
  • Preferred regimen: Albendazole 200 mg PO bid for 21 days.
  • 2.4 Symptomatic loiasis, with ≥ 8,000 microfilariae/mL
  • Preferred regimen: Apheresis followed by Diethylcarbamazine.
  • Note: Apheresis should be performed at an institution with experience in using this therapeutic modality for loiasis.
  • 3. River blindness (onchocerciasis) caused by Onchocerca volvulus
  • Preferred regimen: Ivermectin 150 μg/kg PO single dose, repeated every 6-12 mos until asymptomatic.
  • Alternative regimen: Doxycycline 100 mg PO qd for 6 weeks, alone or followed by Ivermectin 150 μg/kg PO single dose.
  • Note: Do NOT administer Diethylcarbamazine where onchocerciasis is endemic due to increased risk for severe local inflammation in patients with ocular microfilariae.
  • 4. Mansonella ozzardi
  • Preferred regimen: Ivermectin 200 μg/kg PO single dose.
  • Note: Endosymbiotic Wolbachia are essential to filarial growth, development, embryogenesis and survival and represent an additional target for therapy. Doxycycline 100–200 mg PO qd for 6–8 weeks results in loss of Wolbachia and decrease in both micro- and macrofilariae.
  • 5. Mansonella perstans
  • Preferred regimen: Doxycycline 100–200 mg PO qd for 6–8 weeks.
  • 6. Mansonella streptocerca
  • 7. Tropical pulmonary eosinophilia caused by Wuchereria bancrofti

References

  1. ↑ U.S. Centers for Disease Control, Lymphatic Filariasis Treatment, retrieved 2008-07-17
  2. ↑ "Drugs for Parasitic Infections (Treatment Guidelines from The Medical Letter)".
  3. ↑ Taylor MJ, Hoerauf A, Bockarie M (2010). "Lymphatic filariasis and onchocerciasis". Lancet. 376 (9747): 1175–85. doi:10.1016/S0140-6736(10)60586-7. PMID 20739055.
  4. ↑ Knopp S, Steinmann P, Hatz C, Keiser J, Utzinger J (2012). "Nematode infections: filariases". Infect Dis Clin North Am. 26 (2): 359–81. doi:10.1016/j.idc.2012.02.005. PMID 22632644.
  5. ↑ Moore TA, Reynolds JC, Kenney RT, Johnston W, Nutman TB (1996). "Diethylcarbamazine-induced reversal of early lymphatic dysfunction in a patient with bancroftian filariasis: assessment with use of lymphoscintigraphy". Clin Infect Dis. 23 (5): 1007–11. PMID 8922794.
  6. ↑ "Parasites - Loiasis (CDC)".
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