Journal Article

Pharmacokinetics, Safety, and Efficacy of an Allometric Miltefosine Regimen for the Treatment of Visceral Leishmaniasis in Eastern African Children

Kip, Anke E., Wasunna, Monique, Alvar, Jorge, Olobo, Joseph, Sagaki, Patrick, Solomos, Alexandra, Kirigi, George, Were, Lilian, Alves, Fabiana, Omollo, Raymond, Omollo, Truphosa, Egondi, Thaddaeus W., Mbui, Jane, Dorlo, Thomas P. C., Kimutai, Robert

2019

Overview

Abstract Background Convenient, safe, and effective treatments for visceral leishmaniasis in Eastern African children are lacking. Miltefosine, the only oral treatment, failed to achieve adequate efficacy, particularly in children, in whom linear dosing (2.5 mg/kg/day for 28 days) resulted in a 59% cure rate, with lower systemic exposure than in adults. Methods We conducted a Phase II trial in 30 children with visceral leishmaniasis, aged 4–12 years, to test whether 28 days of allometric miltefosine dosing safely achieves a higher systemic exposure than linear dosing. Results Miltefosine accumulated during treatment. Median areas under the concentration time curve from days 0–210 and plasma maximum concentration values were slightly higher than those reported previously for children on linear dosing, but not dose-proportionally. Miltefosine exposure at the start of treatment was increased, with higher median plasma concentrations on day 7 (5.88 versus 2.67 μg/mL). Concentration-time curves were less variable, avoiding the low levels of exposure observed with linear dosing. The 210-day cure rate was 90% (95% confidence interval, 73–98%), similar to that previously described in adults. There were 19 treatment-related adverse events (AEs), but none caused treatment discontinuation. There were 2 serious AEs: both were unrelated to treatment and both patients were fully recovered. Conclusions Allometric miltefosine dosing achieved increased and less-variable exposure than linear dosing, though not reaching the expected exposure levels. The new dosing regimen safely increased the efficacy of miltefosine for Eastern African children with visceral leishmaniasis. Further development of miltefosine should adopt allometric dosing in pediatric patients. Clinical Trials Registration NCT02431143. Allometric miltefosine dosing for 28 days in Eastern African children with visceral leishmaniasis demonstrated increased and less-variable exposure than linear miltefosine dosing, with improved efficacy and a satisfactory safety profile.

• Publisher: Oxford University Press
• Subject: Africa, Eastern / allometric regimen / and Commentaries / Antiprotozoal Agents - blood / Antiprotozoal Agents - pharmacokinetics / Antiprotozoal Agents - pharmacology / Area Under Curve / ARTICLES AND COMMENTARIES / Child / Child, Preschool / Drug Administration Schedule / drug pharmacokinetics / Eastern African children / Female / Humans / Leishmania donovani - drug effects / Leishmania donovani - growth & development / Leishmania donovani - pathogenicity / Leishmaniasis, Visceral - blood / Leishmaniasis, Visceral - drug therapy / Leishmaniasis, Visceral - parasitology / Leishmaniasis, Visceral - pathology / Male / miltefosine / Patient Safety / Phosphorylcholine - analogs & derivatives / Phosphorylcholine - blood / Phosphorylcholine - pharmacokinetics / Phosphorylcholine - pharmacology / Treatment Outcome / visceral leishmaniasis