Medical treatment of filariasis

Diethylcarbamazine (DEC) (Hetrazan, Benocide) rapidly kills microfilaria and can kill some, but not all adults of both Wuchereria and Brugia. DEC exerts no direct lethal effect on microfilarae but apparently modifies them so that they are eliminated by host's immune defense mechanism. The standard dose is 6 mg/kg, which is to be given in three divided doses after food over a period of 10-14 days, which reduces microfilaremia levels by approximately 80-90% in several days. Initially lower dose (1-3 mg/kg) once a day should be started in order to decrease side effects of the drug in cases of heavy parasitic load. Drug reactions due to dying worm may commence after the start of the medical treatment. These reactions may be local or systemic. Systemic reactions include fever, headache, myalgia, vomiting, weakness and asthma; usually result from rapid destruction of microfilariae and perhaps adult worms, specially in heavily infected individuals. Local reactions include lymphadenitis, abscess formation and transient lymhadema. These symptoms develop within 2 days, often within 12 h, after initiation of the treatment and persist for 3-4 days. The drug is not recommended during pregnancy though no teratogenic effect so far has been reported. Side effects of DEC therapy may be reduced with spacing in between the two doses like single dose of 6 mg/g once weekly, twice monthly or once monthly. DEC treatment of micofillraemic patients and with acute symptoms eliminates the episodes of acute lymphatic inflammation that may prevent the development of obstructive lesions hence reducing the incidence of chyluria. The drug is rapidly excreted and nontoxic; can be repeated at 1 month following completion of the first course. Multiple courses of treatment may be required which may be repeated at 6 months interval. Peripheral eosinophilia often accompanies the infection with this parasite that should resolve with the response of the treatment. If peripheral eosinophilia and/or clinical symptoms persist after treatment, peripheral blood should be re-examined for microfilaremia/or circulating antigen.

The two other drugs which have used been in the treatment of filarial infestation are ivermecten and albendazole. Ivermectin kills microfilarae only and can be given as single dose of 400 mg/kg. All though ivermectin leads to rapid clearance of microfilarae, sustained reductions at six moths or longer after treatment are equivalent or better with single 6 mg/kg dose of DEC. This is consistent with DEC having a greater effect on adult worms. Ivermectin can also be used with DEC as single dose that gives more rapid clearance of microfilarae and recurrence is delayed. Side effects of ivermectin are similar to that of DEC with additional neurotoxicity. Albendazole 400 mg as single dose in combination with ivermectin is more effective in clearing microfilarae than ivermectin alone. Correction of anaemia Correction of anaemia needs administration of hematenics along with multivitamins. Oral iron supplementation along with generous intake of green leafy vegetables and sticking to other dietary measures described above usually improve the haemoglobin level in these patients. Patients with gross haematuria (haematochyluria) warrant blood transfusion.

Supportive treatment In addition to DEC therapy symptomatic treatment with antiinflammatory, analgesics and antipyretics along with bed rest should also be considered in case of acute attack and lymhadenitis. Use of abdominal binders during acute attacks of chyluria; elevation of affected limb, application of elastic bandage and special message help in the management of swollen lymphadematous limb. Patients with urinary retention secondary to chylous clot need cystoscopy and bladder wash. Bladder irrigation through a three way foley catheter may also be useful in cases of recurrent urinary retention.

Therapeutic control at community level

Therapy of a community in high prevalent area may consist of selective or mass treatment. In mass therapy DEC is administered to the total population barring children and pregnant women. In mass treatment parasitological diagnosis may be omitted in order to make the treatment cost effective. In selective treatment microfilarial carriers or patients with symptomatic disease are identified through various screening programmes. The drug may be

administered in widely spaced doses (100 mg for adults and 50 mg for children once weekly, once monthly or bimonthly over a period of 1 year) or added to the table salt. Annual mass drug administration (MDA) using diethylcarbamizine (DEC, 6 mg/kg) combined with albendazole (alb 400 mg) is recommended by the Global Programme to Eliminate Lymphatic Filariasis (GPELF). WHO programme strategies focus on both transmission and morbidity control. For interruption of transmission it is recommended that the entire population at risk to be treated once yearly with single dose of two drug regimens, i.e. albendazole 400 mg plus ivermectin 150 mg/kg in African endemic countries and albendazole plus DEC 6 mg/kg in other parts of the world.

Studies in India and abroad (China, Tazania) demonstrated the benefit of cooking salt fortified with DEC citrate for the control of lymphatic filariasis. In India, DEC-medicated salt has been introduced on a commercial basis in certain parts of India, which is endemic for filariasis. Salt fortified with (0.25-0.33% w/w) DEC is administered with the food. After 1 year of treatment, the prevalence and intensity of microfilaremia were both reduced by more than 95%, while antigenemia levels were reduced by 60%.