Active Ingredients: Ivermectin
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Obviously, many components overlap between these two target groups, but there are also essential differences. Treatment must be safe and effective and fit all the requirements of the medical world today Table 1.
It must be remembered that useful adjunct approaches can help manage this complex disease, such as vector control in village transmission sites, and the use of ameliorating agents to reduce pruritus and improve skin condition.
However, antiparasite chemotherapy clearly remains the central approach for onchocerciasis treatment.
It is perhaps obvious to say that the optimal form of a new treatment is an oral tablet that could be given to children as well as adults, including pregnant women, in a single dose Table 2; this might be too high a bar to set if the goal is to quickly develop a new drug that could contribute to eradication within the desired time frame.
Other characteristics, such as stability at high temperatures, low cost-of-goods, and efficacy against only adult stages of the parasite could be included in an optimal target product profile.
However, it is important to consider what is available now and what might be a useful improvement on the current situation. Certainly high on the list of characteristics is a drug that would safely and with a minimal number of treatments kill adult Onchocerca.
There is a concern that quickly and simultaneously killing multiple adult filariae would induce unacceptable tissue reactions such as abscesses.
This has been seen with lymphatic filariasis, in which treatment with an adulticidal regimen of DEC in Haiti induced lymphangitis and abscesses. The minimal efficacy required of a macrofilaricide is also a matter of discussion.
Currently, we have no drug that kills adult worms safely in only a few doses one to three. It is important to stress that ivermectin markedly reduces the mf load and causes little to no pathology.
This has led to drastic reductions in symptoms and transmission, an amazing improvement from the time when only DEC was available. However, it would be a considerable achievement to be able to reduce the time that programs need to distribute ivermectin from the current 12 or more years to perhaps two to three rounds of treatment with a macrofilaricide.
It should be noted that doxycycline, as noted, is a macrofilaricide; there is no doubt that it kills adult worms, but the fact that it needs to be distributed on a daily basis for 4—6 weeks must be regarded as less than optimal.
It is also important to discuss the possibility of the development of resistance to ivermectin. This unfortunate phenomenon has been commonly recorded in the veterinary literature, 42 and is probably the result from the extensive use of this anthelmintic in cattle, sheep, and also in dogs.
A discussion of a new drug for the treatment of onchocerciasis in MDA programs must include a consideration of its ease of production as well as a funding source for its production and distribution to calculate the cost effectiveness of its use.
For example, when praziquantel was first introduced for the treatment of schistosomiasis, the cost of the drug was initially high.