Advances in the treatment of leishmaniasis

PURPOSE OF REVIEW: Treatment of leishmaniasis is far from satisfactory: all antileishmanial drugs are toxic and most have to be used parenterally for prolonged periods, especially for visceral leishmaniasis. In recent years, there has been a steady erosion in the efficacy of pentavalent antimony to cure visceral leishmaniasis in Bihar, India. In addition, several new antileishmanial formulations have become available. RECENT FINDINGS: Through the publication of three studies from Africa, generic sodium stibogluconate, which is a fraction of the price of the branded drug Pentostam, has proven to be equivalent to Pentostam both in terms of safety and efficacy. The first oral drug, miltefosine, has been approved for treating visceral leishmaniasis in India, and preliminary reports of its efficacy against cutaneous leishmaniasis have been published. Interesting studies on successful low/single dose treatment of Indian visceral leishmaniasis with liposomal amphotericin B have been published. Several trials using different approaches towards treating cutaneous leishmaniasis are also reviewed. The results of clinical trials of two oral compounds are reported - fluconazole in treating cutaneous leishmaniasis was found to be safe and effective, whereas sitamaquine (WR6026) for visceral leishmaniasis was found to be toxic with poor efficacy. SUMMARY: Generic stibogluconate enables the cost effective treatment of all forms of leishmaniasis as it remains the most important antileishmanial drug in most parts of the world. In India, successful single dose AmBisome for visceral leishmaniasis makes therapy simple and enables mass treatment, provided the drug cost is brought down. For cutaneous leishmaniasis, two new oral drugs, fluconazole and miltefosine, provide wider options to the clinician.