Management of ka&pkdl by dr shahjadaselim

Treatment of Kala-azar and PKDL

Dr Shahjada SelimMBBS MD (EM)Registrar (Medicine)Shaheed Suhrawardy Medical College Hospital, Dhaka

email:[email protected]

Clinical Features of KASymptoms:Fever-usually insidious, irregular, low grade, associated with chills & rigor. Classically the fever is biphasic.

Weight loss.Abdominal swelling.Pigmentation.Bleeding manifestations.Secondary infections.

..............Clinical Features of KA

Signs:Increased temperatureAnemiaGum bleedingLymphadenopathySplenomegalyHepatomegalyAscitesEdema

Clinical Case Definition

Following clinical case definitions will be used for reporting and follow up. The case definitions will be as follows:  Primary Kala-azar (PKA): An individual who is diagnosed to have KA with the above mentioned case definition and no history of treatment for KA before will be considered as primary Kala-azar (PKA).

........Clinical Case Definition

Kala-azar Treatment Failure (KATF):

An individual, who is diagnosed to have KA with the above mentioned case definition and history of treatment for KA within last one year, will be reported as KATF.

All efforts should be made to diagnose KATF parasitologically by examination of smear or bone marrow or PCR.

........Clinical Case Definition

Relapse Kala-azar (RKA):  An individual who is diagnosed to have KA with the above mentioned case definition and history of treatment for KA anytime in the past but not within last one year will be reported as RKA. All efforts should be made to diagnose KATF parasitologically by examination of splenic smear or bone marrow or PCR.

Objectives of Treatment

To cure the patient

To prevent the complications of the disease and minimize side effects of medicines

To restrain drug resistance and reduce the risk of spread of disease.

Complications and concomitant disease conditions (if any) should also be diagnosed and treated accordingly.

Drug treatment of Primary

Kala-azar (PKA):

1st line treatment for PKADrug of choice

Liposomal Amphotericin B (10 mg/kg body wt, single dose)

Alternative 1st line choices (Depending on availability in our country)

1.Miltefosine

2.Paromomycin

3.Combination treatment

2nd line treatment for PKA (if the 1st line drugs are not available or not tolerated):  

1.Amphotericin B deoxycholate

2.Sodium Stibogluconate (SSG)

…….1st line treatment

Combination treatment

Combination of Miltefosine and

Paromomycin

will be 1st choice.

Other alternative combinations will be-

• Liposomal Amphotericin B* + Miltefosine

or • Liposomal Amphotericin B* +

Paromomycin

* LAmB 5 mg/kg body weight single dose .

Description of the drugs for PKALiposomal Amphotericin B (LAmB)

To improve the tolerance and widen the narrow therapeutic window, a lipid formulation of Amphotericin B is formulated. Amongst the three formulations liposomal Amphotericin B has the best safety profile.  Liposomal Amphotericin B should be given in a single intravenous infusion at a dose of 10 mg/kg for a period not less than 2 hours duration. Please see annex XX for details.   In special situations like children of less than 5 years, in pregnancy, co-infection with HIV/ AIDS etc would be treated with multiple dose of Liposomal Amphotericin B (5mg/kg body weight on alternate days for 3 doses). Please see annex XX for details.

Indications for alternative 1st line drugs: 

• When Liposomal Amphotericin B is not indicated due to hypersensitivity, intolerance or contraindication.

• When Liposomal Amphotericin B is not

available.

Miltefosine:

Miltefosine is a relatively safe oral drug for the treatment of Kala-azar.

Recommended 28 days dose schedule:Age more than 12 years and weighing ≥25kg:

100 mg daily. (cap 50 mg in morning and 50 mg in the evening with meal)

Age more than 12 years but weighing <25kg:50 mg daily. (cap 50 mg in the morning with meal)

Age 2‑12 years: 2. 5 mg/ kg body weight daily in two divided doses with meal (not exceeding 50mg/day)

In case of missed doses, the scheduled 28 doses

may be taken within a period of 35 days. The daily

dose should never exceed the recommended

amount.

If an exact dose cannot be administered, the

closest 10 mg increment will be chosen at the

dose.

Rounding will be done as follows:

If the calculation comes to <5 ‑ to round dose

down.

If the calculation comes to >5 ‑ to round the dose

up.

When to avoid the use of Miltefosine:Miltefosine is the preferred drug for the treatment of Kala-azar/ PKDL in the elimination program except in the following situations:

Pregnancy Married women of child bearing age who are not using contraceptives regularly. Women who are breast feeding. Children less than 2 yrs of age

Miltefosine may not be the ideal drug for patients of Kala-azar • With severe under nutrition • Severe anemia and• Patients with known history of kidney or liver disease

Adverse reactions of Miltefosine and their treatment:

Adverse reactions to Miltefosine are mostly mild. Mild to moderate vomiting is seen in 40% patients and mild diarrhea in 15‑20% patients. These usually occur during first week of treatment.

Paromomycin:

Paromomycin is a promising and effective drug for the treatment of Kala-azar. It has been registered for use in India which is a parenteral aminoglycoside. 

Doses and administration: Paromomycin sulphate should be given at a dose of 15mg/kg/day. Each dose is to be taken from a separate ampoule. It should be given I/M in the gluteal muscle (alternative buttock, cheeks) once a day for 21 days.

Combination therapy:

The 1st choice of combination therapy will be Miltefosine and Paromomycin.

The alternate choices- Liposomal Amphotericin B + Miltefosine or Liposomal Amphotericin B + Paromomycin.

…..Combination therapy

Dose and administration:

1st choice: Cap. Miltefosine following the above mentioned dose for 10 days+Inj. Paromomycin following the above mentioned dose for 10 days

……..Combination therapy

Alternate choice:

Inj. LAmB 5 mg/ kg body wt IV single dose on day 1 +Cap. Miltefosine following the above mention dose from day 2 to day 8.

OrInj. LAmB 5 mg/ kg body weight IV single dose on day 1 +Inj. Paromomycin following the above mention dose from day 2 to day 11.

Treatment for KATF and RKA

KATF and RKA cases will be treated with alternative 1st line agent (eg. Patient who received LAmB will be treated with Miltefosine or Paromomycin or combination).

If alternative 1st line agents are not available, then a 2nd line agent should be used.

Indications of 2nd line drugs:

When the first line drugs are not available or not tolerated.

Amphotericin B deoxycholate:Recommended second line drug for treatment of Kala-azar and KATF is Amphotericin B deoxycholate. Amphotericin B deoxycholate is also an effective drug. But it has high toxicity profile and thus pushed to second line.Amphotericin B deoxycholate 1 mg/kg daily or alternate day is recommended in the form of infusion (in 5% Dextrose solution 500 ml) for 15 doses having a cure rate of >90%. A test dose should be given before administration of Amphotericin B. After preparation of solution 5 drops /min for 30 min, then 10 drops/min for another 30 min and if there is no reaction occurs, then the infusion should be given slowly over a period of 4-6 hours.

Sodium Stibogluconate (SSG):

SSG is an effective and widely used drug for KA and KATF. But the drug is pushed to second line because of its cardiac toxicity and is recommended by WHO to be phased out gradually.

SSG should be given at a dosage of 20mg/kg body weight, daily IM injection for 30 days.

It is essential to weigh the patient before starting treatment. Clinical cardiac monitoring should be done throughout the treatment period.

Route of Administration of SSG: The preferred route of administration recommended is by deep intramuscular (IM) injection. It is better not to give the drug intravenously (IV) to avoid the risk of cardiovascular collapse.

Assessment of cure after treatment Assessment of cure after treatment (Initial cure): 1 week after completion of treatment  Improvement of all clinical parameters including absence of fever Reduction of spleen size Gain in body weight.

Assessment of cure at 6 Assessment of cure at 6 monthsmonths (Definitive cure):   No fever Substantially reduced spleen size or not palpable Feeling of general well being.

Drug treatment of PKDL

Treatment of PKDL

First line treatment: Miltefosine Longer duration of oral Miltefosine is recommended. The treatment will be supervised. Patient will received their drugs monthly after being followed up by the respective physician.

Adult dose: 100 mg daily for 12 weeks in two divided doses.Children: 2.5 mg/kg body weight/ day in two divided doses, not exceeding 50mg/day for 12 weeks.

Second line treatment of PKDL 

Amphotericin B deoxycholate Dose: 1 mg/kg body wt daily or alternative IV (in 5%Dextrose solution) for 60-80 doses over 4 months. Route: IV  Sodium Stibogluconate (SSG)SSG should be given at a dosage of 20‑mg/kg/day in intramuscular route. It is essential to weight the patient every time, before starting a new cycle. Total 6 cycles of treatment should be given. Each cycle consists of 20 days of treatment and there should be an interval of 10 days in between two cycles.

Treatment of Cutaneous Leishmaniasis (CL):

The treatment approach largely depends in part on the Leishmania species/ strain and the geographic area in which infection was acquired. In general, the first sign of a therapeutic response to adequate treatment is decreasing indurations (lesion flattening). The healing process for large, ulcerative lesions often continues after the end of therapy.

First line choice: 

Sodium stibogluconate: The standard daily dose will be 20 mg/kg/day, IM for 20 days (10 days may suffice based on clinical judgment).

Or

Cap. MiltefosineThe doses should be calculated as follows:Age more than 12 years and weighing ≥25kg: 100 mg. (cap 50 mg in morning and 50 mg in evening with meals)Age more than 12 years but weighing <25kg: 50 mg. (cap 50 mg in the morning with meals) 2‑12 years: 2.5 mg/kg body weight. in two divided dose, not exceeding 50mg/day with meals.

Second line choice for CL: 

Ketoconazole: 600 mg daily for 28 days or, Itraconazole: 200 mg twice daily for 28 days or, Fluconazole: 200 mg daily for 6 weeks (for adult).

Treatment of Kala-azar in special Treatment of Kala-azar in special situations:situations:The treatment of Kala-azar in special situations is recommended in centers where appropriate expertise and facilities are available. The following conditions can be considered as special situations:

Pregnancy Risk of treatment should be weighed against benefit. Treatment should be prioritized according to the severity. If a pregnant mother is diagnosed as KA during 1st trimester she should be treated at 2nd trimester or if she diagnosed as KA during 3rd trimester then she should be treated after delivery. Drug of choice is Liposomal Amphotericin B (5 mg/kg body weight on alternate days for 3 doses). Miltefosine and Sodium stibogluconate is contraindicated in case of pregnancy.

Kala-azar with TBTreatment of both diseases should be continued and KA will be treated as PKA.

Kala-azar HIV/AIDS co-infectionIt will be treated with Liposomal Amphotericin B with multiple doses. ARV should be continued for HIV/AIDS.

Kala-azar in a patient suffering from another serious diseaseAll the case of Kala-azar with serious co-morbidities should be treated under specialized supervision. Liposomal Amphotericin B will be the drug of choice and treatment should be given in a tertiary care facility.

Complete Treatment of Kala-Complete Treatment of Kala-azar:azar:All efforts should be made to ensure the complete treatment. The following measures are recommended to complete the treatment:

Every patient should be counseled so that the patient/family fully understands the importance of complete treatment and the consequences of the incomplete treatment. All treatment should be provided free of cost to eliminate the economic constraint as a reason for discontinuation of treatment

Each patient should have a separate treatment box at the health facility that contains the full dose of drugs labeled with the name and individual identification of the patient. A treatment card with a unique identification number showing the number of days the treatment taken should be provided to patients. It is advisable to follow up the patients during treatment, immediately after completion of treatment and up to 1 year (at 1st, 5th, 9th, 12th month) The treatment should be directly observed as per SOPs. There should be coordination amongst the public and private sector providers and a follow up plan should be developed for each patient.

Monitor the patient regularly for signs and symptoms (indicative of adverse events of drugs) and should be reported as major & minor events (Ref. Training module for Kala-azar elimination program).Perform the tests if clinically indicated in treatment sites and monitor the results. This can help to take timely measures even before the signs appear.Periodic meetings should be organized to review the reports of major and minor adverse events obtained from the different levels. This will help to guide the program in recommending the tests that should be done to monitor the patients on treatment. Regularly report the adverse events on the reporting formats to higher levels once in a month for a review and feedback.

Pharmacovigilance:

Pharmacovigilance is important to ensure the safety of the medicines used in the treatment of Kala-azar and PKDL. It should be the responsibility of the national program to ensure pharmacovigilance. The program can provide very useful information regarding efficacy of treatment options and related adverse events during follow up of the patients.  The program must encourage health facilities and personals to ensure regular reporting of major and minor adverse events. The following measures will help to recognize early the occurrence of adverse events.

fever>2weeks &Residing/travelling in endemic areas

fever>2weeks &Residing/travelling in endemic areas

YesYes Evidence of another disease other than KA?

Evidence of another disease other than KA?

Diagnosis And Management Chart

NoNo

Splenomegaly, weight loss, anemiaSplenomegaly, weight loss, anemia

Is the patient pregnant?

Is the patient pregnant?

PKDL and choice of drugs1st line- Miltefosine: 2nd linea)Amphotericin-B Deoxycholateb)LAmB c) SSG

PKDL and choice of drugs1st line- Miltefosine: 2nd linea)Amphotericin-B Deoxycholateb)LAmB c) SSG

Record as KATF and use:1.Alternative First line Treatment: a. Miltefosine b. Paromomycin c. Combination

2. Second line drugsa. Amphotericin B deoxycholate b. SSG

Record as KATF and use:1.Alternative First line Treatment: a. Miltefosine b. Paromomycin c. Combination

2. Second line drugsa. Amphotericin B deoxycholate b. SSG

Had complete treatment with Miltefosine or any other drugs given within last year?

Had complete treatment with Miltefosine or any other drugs given within last year?

YesYes

PKA and choice of drugs: LAmBAlternate choice- 1. Miltefosine 2. Paromomycin3. Combination of alternative choice

PKA and choice of drugs: LAmBAlternate choice- 1. Miltefosine 2. Paromomycin3. Combination of alternative choice

KA with pregnancy and choice of drugsLAmBAlternative: a. Amphotericin-B b.Paromomycin c. SSG

KA with pregnancy and choice of drugsLAmBAlternative: a. Amphotericin-B b.Paromomycin c. SSG

Hypo pigmented patches (macule) without loss of sensation with or withoutErythematous patch (papule)Subcutaneous nodule fever or h/o KA

Hypo pigmented patches (macule) without loss of sensation with or withoutErythematous patch (papule)Subcutaneous nodule fever or h/o KA

If yes & rk39 (+)If yes &

rk39 (+)If yes & rk39

(+)

Chart for Kala-azar Chart for Kala-azar treatmenttreatment

1st line treatment for Kala-azar

Drug of choice- 1. LAmB 2. Alternative 1st line choices Miltefosine Paromomycin Combination of Miltefosine and

Paromomycin - 1st choices Alternative combinations will be- LAmB + Miltefosine

Or,LAmB+ Paromomycin.

*LAmB 5 mg/kg body weight on

2nd line treatment for Kala-azar1. Amphotericin-B deoxycholate2. Sodium stibogluconate (SSG)

Weight (kg) SAG (ml)

up to 3 0.6

4-5 0.8-1

6-8 1.2-1.6

9-10 1.8-2

11-13 2.2-2.6

14-15 2.8-3.0

16-18 3.2-3.6

19-20 3.8-4.0

21-23 4.2-4.6

24-25 4.8-5.0

26-28 5.2-5.6

29-30 5.8-6.0

31-35 6.2-7.0

36-40 7.2-8.0

41-45 8.2-9.0

46-50 9.2-10

51-55 10.2-11

56-60 11.2-12

Treatment ChartTreatment Chart

When LAmB is not available or contraindicated or in KATF1st line drugs:

1. Miltefosine 2. Paromomycin3. Combination of 1st choice

2nd line drugsa. Amphotericin-B deoxycholateb. Sodium stibogluconate (SSG)

When LAmB is not available or contraindicated or in KATF1st line drugs:

1. Miltefosine 2. Paromomycin3. Combination of 1st choice

2nd line drugsa. Amphotericin-B deoxycholateb. Sodium stibogluconate (SSG)

Rx for RKA

1.Combination 1st line drugs cap. Miltefosine + inj.

Paromomycin2. Alternate combination- Inj. LAmB + Cap. Miltefosine

Or,Inj. LAmB + Inj. Paromomycin

Rx for RKA

1.Combination 1st line drugs cap. Miltefosine + inj.

Paromomycin2. Alternate combination- Inj. LAmB + Cap. Miltefosine

Or,Inj. LAmB + Inj. Paromomycin

Rx for PKDL

1st line- Miltefosine:2nd linea.Inj. Amphotericin B Deoxycholateb.b. Inj. Sodium stibogluconate (SSG)

Rx for PKDL

1st line- Miltefosine:2nd linea.Inj. Amphotericin B Deoxycholateb.b. Inj. Sodium stibogluconate (SSG)

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