Treatment of VL in the clinic

Treatment of visceral leishmaniasis in the clinic depends upon a number of factors. These range from the availability of the drug in the country concerned to the existence of resistance to anti-leishmanial drugs. National guidelines have been developed to suit particular endemic settings, to ensure that treatment is implemented correctly (Step 2.13) and to address the complexities raised (Step 2.9) so that clinicians are able to treat appropriately ^[1].

For example, in the Indian Subcontinent: India, Bangladesh, Nepal and Bhutan, typical VL is treated with liposomal amphotericin B single dose as first option. Second option is miltefosie and paromomycin combination. Pentavalent antimonials are not recommended as a first-line treatment as there is widespread drug resistance. Some drug combinations may also be used to treat more complex cases that are not responding to the primary treatment – these can be:

• liposomal amphotericin B + oral miltefosine
• liposomal amphotericin B + paromomycin or
• miltefosine + paromomycin. high dose AmBisome® are used as “rescue” treatment for non-responders.

On the other hand, in East Africa, pentavalent antimonials + paromomycin combination is the first line treatment, AmBisome is employed as second line treatment or as first line treatment for a number of groups. It is clear that treatment outcomes in this region are different to those seen in South Asia when the same drugs and dosing regimens are used. National guidelines need to be consulted prior to commencing treatment.

National treatment guidelines are available for several endemic countries, including: Ethiopia^[2], South Sudan^[1], India^[3], Bangladesh^[4], Nepal^[5] Sudan Kenya^[6] Somalia^[7], Brazil^[8,9]and Colombia^{[8, 10]}

(You can check these individually following links in Reference section).

They give guidance for the treatment of VL, PKDL and relapse patients, as well as how to treat high risk and special groups such as people with immunosuppression, pregnant women and infants or people suffering with co-infections or malnutrition for example (Step 2.9).

More recently autochthonous visceral leishmaniasis has emerged in Thailand^[11]. In the absence of national guidelines, amphotericin B has been the main treatment for these patients to date. Moreover, the WHO has produced an overview of all recommended treatment guidelines^[12] and what to use where.

When the treatment option has been selected and agreed upon it is important to carry out some simple quality control measures to further ensure patient safety. A simple checklist of, for example, the source or supplier of the drug; expiry date; correct storage; correct preparation and formulation (Good Laboratory Practice); correct administration (Good Clinical Practice) can help to safeguard VL treatment (Step 2.13).