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MAJOR ARTICLE Efficacy of Miltefosine in the Treatment of Visceral Leishmaniasis in India After a Decade of Use Shyam Sundar,1,a Anup Singh,1,a Madhukar Rai,1 Vijay K. Prajapati,1 Avinash K. Singh,1 Bart Ostyn,2 Marleen Boelaert,2 Jean-Claude Dujardin,2,3 and Jaya Chakravarty1 1 Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India; and 2Institute of Tropical Medicine, and Department of Biomedical Sciences, Antwerp University, Belgium 3 Background. Miltefosine is the only oral drug available for treatment of Indian visceral leishmaniasis (VL), which was shown to have an efficacy of 94% in a phase III trial in the Indian subcontinent. Its unrestricted use has raised concern about its continued effectiveness. This study evaluates the efficacy and safety of miltefosine for the treatment of VL after a decade of use in India. Methods. An open-label, noncomparative study was performed in which 567 patients received oral miltefosine (50 mg for patients weighing <25 kg, 100 mg in divided doses for those weighing ≥25 kg, and 2.5 mg per kg for those aged <12 years, daily for 28 days) in a directly observed manner. Patients were followed up for 6 months to see the response to therapy. Results. At the end of treatment the initial cure rate was 97.5% (intention to treat), and 6 months after the end of treatment the final cure rate was 90.3%. The overall death rate was 0.9% (5 of 567), and 2 deaths were related to drug toxicity. Gastrointestinal intolerance was frequent (64.5%). The drug was interrupted in 9 patients (1.5%) because of drug-associated adverse events. Conclusions. As compared to the phase III trial that led to registration of the drug a decade ago, there is a substantial increase in the failure rate of oral miltefosine for treatment of VL in India. Miltefosine is the first orally effective agent for treating leishmaniasis. It was first approved in India, in 2002, for the treatment of visceral leishmaniasis (VL), following a phase III multicenter study [1, 2]. Since then, it has been registered in various other countries in different parts of the world and has been used in the treatment of nearly all forms of leishmaniasis, although with a variable rate of efficacy [3, 4]. Because of its ease of use and the possibility for ambulatory care, the VL elimination program in India, Nepal, and Bangladesh has recommended Received 15 January 2012; accepted 2 April 2012; electronically published 9 May 2012. a S. S. and A. S. contributed equally to this work. Correspondence: Shyam Sundar, MD, Dept of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221005, India (drshyamsundar@ hotmail.com). Clinical Infectious Diseases 2012;55(4):543–50 © The Author 2012. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: [email protected]. DOI: 10.1093/cid/cis474 miltefosine as the first-line drug for treatment in this region [5]. More than a decade has passed since the pivotal phase III trial leading to the registration of miltefosine in India was done. During 2002–2006, the drug was available over the counter in many private pharmacies, and prescribing practice and drug use was rather irrational, with many incomplete dosages and poor adherence [5]. Currently, the drug is made available only in public hospitals, through the National VL Control Program, and patients are provided the supply of drugs for 1 week at a time. We commissioned this study to evaluate miltefosine efficacy in Bihar, India, an area of VL endemicity, 10 years after the pivotal phase III trial. The study was performed in a dedicated research clinic where directly observed therapy was conducted. MATERIALS AND METHODS Study Design An open-label, noncomparative study was done at the Muzaffarpur site of the Kala Azar Medical Research Miltefosine for Leishmaniasis • CID 2012:55 (15 August) • 543 Center (KAMRC), Institute of Medical Sciences, Banaras Hindu University, from September 2009 through November 2010. The study was approved by the Ethical Committee of the Institute of Medical Sciences and by the Institute of Tropical Medicine of Antwerp, Belgium. Written informed consent was obtained from adult patients and from the guardians of patients aged <18 years. All authors participated fully in the design of the study, had access to all study data, and take responsibility for data analysis. Study Drug Miltefosine (Paladin Labs, Canada, 50-mg and 10-mg capsules) was administered orally for 28 days as directly observed therapy after meals in the following doses: 100 mg daily (one 50-mg capsule in the morning and one 50-mg capsule in the evening after meals), for patients weighing >25 kg; 50 mg every morning, for patients weighing ≤25 kg; and 2.5 mg/kg daily in divided doses, for patients aged <12 years. Study Patients Females and males aged 6–70 years were eligible if they had symptoms and signs suggestive of VL (ie, fever with chills, rigor, and splenomegaly) with Leishmania parasites demonstrable in splenic-aspirate smears. Splenic-aspirate smears were each read by 2 observers in a blinded fashion. Parasites in splenic-aspirate smears were graded on a log scale, from 0 (defined as 0 parasites per 1000 high-power fields in oil immersion) to ≥6 (defined as >100 parasites per high-power field in oil immersion) [6]. Criteria for exclusion were current pregnancy; current breast-feeding; seropositivity for human immunodeficiency virus; presence of a serious illness or concurrent infectious disease, such as tuberculosis or bacterial pneumonia; granulocyte count <1000 granulocytes/mm3; hemoglobin level <5.0 g/dL; platelet count <40 000 platelets/mm3; hepatic transaminase levels >5 the normal level; total bilirubin level >2.0 mg/dL; serum creatinine level above the upper normal limit; prothrombin time >5 seconds above control; and/or inability of the subject or guardian to provide written informed consent. parameters, were recorded weekly. The assessment for initial cure, at day 29, consisted of a clinical examination, including measurement of body temperature and weight, assessment of liver and spleen size, and evaluation of hematological and biochemical parameters. Splenic aspiration was repeated, and smears of aspirates were examined for Leishmania parasites (LD bodies). If splenic-aspirate smears on day 29 showed a parasite density grading of ≥2 (ie, 1–10 parasites per 100 highpower fields), treatment was considered to have failed, and patients were provided rescue treatment; if there were no parasites, patients were assumed to have achieved parasitological cure and were discharged from the clinic. Those with a grade of ≥1 (1–10 parasites per 1000 high-power fields) were discharged but recalled on day 44 to repeat the splenic-aspirate smear, and persistence of parasites meant that treatment had failed. “Initial cure” was defined as resolution of fever, regression of splenic enlargement, and return of laboratory values to normal ranges at the end of treatment and absence of parasites in splenic-aspirate smears at day 29 (or at day 44 for those with a grade of ≥1). All patients with initial cure were discharged from the clinic and invited for a follow-up visit 6 months after treatment to assess final cure. They were assessed by clinical examination and hematological and biochemical evaluation. “Final cure” was defined as the absence of signs or symptoms of relapse at 6 months in those with initial cure. If at any point during follow-up or at the 6-month visit a relapse was suspected, a new parasitological evaluation with a splenicaspirate smear was done to document relapse. “Treatment failure” was defined as either the lack of initial cure or relapse. Patients with treatment failure were given rescue treatment with amphotericin B (0.75 mg/kg administered in 15 daily infusions). Safety End Points Treatment was discontinued and subjects were given rescue treatment if an adverse event if grade ≥3 Common Toxicity Criteria were detected [7], except for cases of elevated hepatic enzyme levels [2]. Study Protocol Statistical Analysis Once patients fulfilled the inclusion and exclusion criteria and provided consent, they were admitted for the full duration of treatment at the KAMRC research clinic. Because of the long half-life of miltefosine and its known teratogenic potential, women of childbearing age were asked to practice contraception during treatment and for an additional 3 months after completion of treatment. Treatment was directly observed by a clinic nurse, who observed the swallowing of the pills. Vital signs, such as body temperature, pulse rate, and blood pressure, were recorded daily. Other parameters, such as body weight, spleen size, and hematological and biochemical The data were analyzed by the statistical software package SPSS (version 16.0). Continuous variables are presented as mean values ± SD, and frequencies with their respective percentages are given for categorical variables. The comparison between the mean values for patients at baseline and day 29 was done by a paired t test and the Wilcoxon signed ranked test. For comparison of clinical outcomes between treatmentnaive patients and those with relapse after prior antileishmanial treatment, the independent 2-sample t test and the Mann-Whitney U test was used. A P value of <.05 was considered statistically significant. 544 • CID 2012:55 (15 August) • Sundar et al Table 1. Comparison of Clinical and Laboratory Data at Baseline and Day 29 Among Indian Patients With Visceral Leishmaniasis Who Received Miltefosine Therapy Variable Baseline (n = 567) Day 29 (n = 553) Change From Baseline to Day 29 (n = 553) … Age, years Mean ± SD 24.2 ± 16.0 … Median (range) 18 (6–70) … … Age ≥12 years Sex 432 (75.2) … … Male 333 (58.7) … … Female Had relapse 234 (41.3) 40 (7.05) … … … … 47.2 ± 52.3 30 (3–365) … … … … 36.1 ± 14.2 37 37 ± 14 37 0.5 ± 5.2 1 2.3 ± 1.2 2 … … … … 4.5 ± 3.2 4 0.4 ± 1.1 0 −4.1 ± 2.5 −4 8.3 ± 1.8 8 10.3 ± 1.5 10 1.9 ± 1.4 2 3452.4 ± 1576 3100 9303.4 ± 3587.8 8800 5857 ± 3471.2 5200 127 670.2 ± 65 140.6 323 083.2 ± 110 442 195 379.1 ± 112 871.3 Median 118 000 305 000 184 000 Creatinine level, mg/dL Mean ± SD 0.8 ± 0.2 0.75 ± 0.3 −0.03 ± 0.3 0.8 0.7 −0.05 8.2 ± 5.9 8.8 ± 5.8 −0.6 ± 5.9 9 9 0 60.7 ± 39.6 41.3 ± 25.3 −19.6 ± 44.4 49 34 −2 40.3 ± 25.8 40.8 ± 23.2 0.5 ± 39.3 34 37 0 P Value Illness duration, days Mean ± SD Median (range) Body weight, kg <.0001 Mean ± SD Median Splenic aspirate score Mean ± SD Median Spleen size, cm below left costal margin <.0001 Mean ± SD Median Hemoglobin level, g/dL <.0001 Mean ± SD Median WBC count, cells/mm3 <.0001 Mean ± SD Median Platelet count, platelets/mm3 Mean ± SD <.0001 Median BUN level, mg/dL Mean ± SD Median AST level, IU/mL Mean ± SD Median ALT level, IU/mL Mean ± SD Median .009 .018 <.0001 .016 Data are No. (%) of patients, unless otherwise indicated. Abbreviations: ALT, alanine aminotransferase; AST, aspartate aminotransferase; BUN, blood urea nitrogen; SD, standard deviation; WBC, white blood cell. RESULTS A total of 760 patients were screened and assessed for eligibility for treatment with miltefosine. Of these, 567 fulfilled the eligibility criteria and were enrolled in the study. Clinical characteristics and laboratory values at baseline are shown in Table 1. Therapy in 9 patients was stopped prematurely (Figure 1). Of these patients, 1 later died (see below), and the Miltefosine for Leishmaniasis • CID 2012:55 (15 August) • 545 Figure 1. Flow of patients through the study. other 8 were given rescue therapy (15 infusions of amphotericin B in a dose of 0.75 mg/kg). Four patients withdrew consent. There were 2 deaths recorded during the course of the treatment. The patient mentioned above developed repeated vomiting and severe pancytopenia during the third week of therapy and later went into shock and finally died. The death was possibly related to the study drug. Another patient had sudden death on the fourth day of therapy, probably because of a cardiac event. Finally, 553 of 567 patients were available for parasitological assessment of initial cure at day 29 (or day 44). Three more patients died before the assessment at the final cure end point 546 • CID 2012:55 (15 August) • Sundar et al (180 days after treatment). There was no loss to follow-up during the study (see Figure 1 flowchart). Efficacy All the 553 evaluable patients were afebrile at day 29 and showed remarkable regression of spleen size and significant improvement in clinical and hematological tests (Table 1). No parasites were demonstrated by splenic-aspirate smear; thus, an initial cure was achieved in all patients who completed therapy (Table 2). This resulted in an initial cure rate of 97.5% (553 of 567; 95% confidence interval [CI], 96.3%–98.8%). Table 2. Clinical Outcomes Among Indian Patients With Visceral Leishmaniasis Who Received Miltefosine Therapy Variable Table 3. Adverse Events Among Indian Patients With Visceral Leishmaniasis Who Received Miltefosine Therapy Patients, No. (%) (n = 567) a Drug stopped because of adverse events 9 (1.4) Withdrew consent Death 4 (0.7) 5b (0.8) Adverse Event Vomiting Any 95% Confidence Interval Value (n = 567) 366 (64.55) 60.6–68.5 366 (64.55) 60.6–68.5 Initial cure 553 (97.5) Duration of 1–2 days Relapse Final cure 39c (6.8) 512 (90.3) CTC gradea Grade 1 254 (44.79) 40.7–48.9 Grade 2 112 (19.75) 16.5–23.0 a Includes 1 patient who died later, after treatment was stopped because of an adverse event; this patient’s outcome is included among the data in the row “Death.” b 1 (0.01) 37 (6.52) −.16 to .52 4.5–8.6 CTC gradea Grade 1 30 (5.29) 3.4–7.1 Grade 2 5 (0.08) Grade 4 Rigors 2 (0.03) Grade 3 Diarrhea Any Two died during treatment, and 3 died during follow-up. c Includes 1 patient who had relapse and later died; this patient’s outcome is included among the data in the row “Death.” During the 6-month follow-up, 39 of these 553 patients (7.24%) relapsed with recurrence of fever, increase in spleen size, worsening of laboratory values, and presence of parasites demonstrated by repeat splenic-aspirate smear. Additionally, there were 3 deaths. One involved a patient for whom relapse was diagnosed at 5 months of follow-up, in association with a grade ≥4 splenic aspirate; he later died from severe pancytopenia and grade 3 renal dysfunction. Two other patients died during the course of follow-up: one died after developing severe pancytopenia 1 week after the end of treatment, and another committed suicide 4 months after the end of treatment. The remaining 512 patients showed consistent clinical and biochemical improvement at the 6-month follow-up visit and were classified as having achieved a definitive cure. This yielded a final cure rate of 90.3% (512 of 567; 95% CI, 87.9%–92.7%). There was no statistically significant difference in baseline clinical and laboratory characteristics between patients who relapsed and those who attained final cure (data not shown). All patients who relapsed after miltefosine treatment were successfully treated with amphotericin B, except for the patient who died before rescue treatment could be started. Of 567 patients, 78 (13.7%) had a history of previously failed antileishmanial treatment. Of these 78, 67 (85.8%) were definitely cured, and 8 patients (10.2%) relapsed; for 2 patients, treatment was stopped because of adverse events, and 1 patient withdrew consent. The cure rate among previously treated patients was not significantly different from that among treatment-naive patients, for whom the rate was 91% (445 of 489). Any Duration of 1–2 days AST level .1–1.7 −.13 to .84 35 (6.17) 4.2–8.2 35 (6.17) 4.2–8.2 Change from baseline, U/L, mean (%) Day 7 Day 14 0.96 (2.3) −15.08 (37.4) −19.6 (32.2) Day 29 −2.6 to 4.5b −19.0 to 11.5b −23.0 to −15.7b a CTC grade Grade 1 325 (57.31) 53.2–61.4 Grade 2 190 (33.50) 29.6–37.4 21 (3.70) 2.1–5.2 Grade 3 ALT level Change from baseline, U/L, mean (%) Day 7 9.84 (23.3) 6.7–12.6b Day 14 7.26 (17.2) 3.7–10.3b Day 29 CTC gradea 0.5 (1.2) −2.7 to 3.7b Grade 1 343 (60.49) 56.4–64.5 Grade 2 Grade 3 121 (21.34) 20 (3.52) 18.0–24.7 2.0–5.0 Serum creatinine level Change from baseline, mg/dL, mean (%) Day 7 −0.02 (2.7) −.03 to −.0002b Day 14 −0.02 (2.7) −.03 to −.0002b Day 29 CTC gradea −0.03 (3.7) −.054 to −.005b Grade 1 166 (29.27) 25.5–33.0 Grade 2 Grade 3 10 (1.76) 6 (1.05) .7–2.8 .2–1.9 Data are No. (%) of patients, unless otherwise indicated. Adverse Events Signs and symptoms with toxicity grading are given in Table 3. Gastrointestinal intolerance was the most common Abbreviations: ALT, alanine aminotransferase; AST, aspartate aminotransferase; CTC, Common Toxicity Criteria. a Specified in [7]. b For the mean change. Miltefosine for Leishmaniasis • CID 2012:55 (15 August) • 547 were lost to follow-up until the assessment of final cure at 6 months. The main findings of the current study as compared to findings from the phase III trial during 1999–2000 were a significant decline in the final cure rate, from 94% to approximately 90% (P = .04), and a doubling of the relapse rate, from 3% (9 of 291) to 6.8% (39 of 567) (P = .02) [2]. As this cure rate was achieved under conditions whereby the drug was administered as directly observed therapy, even lower cure rates can be expected in patients receiving home-based therapy currently being practiced in the VL elimination program in India, Nepal, and Bangladesh. The related low adherence would ultimately facilitate emergence of drug-resistant strains, and we recommend the use of directly observed therapy in this program. A potential explanation to our findings could be the presence of miltefosine-resistant parasites in our cohort of patients. Miltefosine is highly susceptible to the development of resistance because of its long half-life, and this was verified in experimental studies [8]. We cannot confirm that this phenomenon occurred in the present study because in vitro susceptibility studies of clinical isolates of present patients are still in progress. Our findings are consistent with those of a recent phase IV study of miltefosine for treatment of VL in Bangladesh, where the cure rates were 71.8% and 85% in intention-to-treat and per-protocol analyses, respectively [9]. Weekly supply of the drug without direct observation might have contributed to the lower efficacy. These findings from Bangladesh is particularly adverse event, with vomiting in 64.5% of patients and diarrhea in 6.5%. However, these side effects were mild (grade 1 or 2) in most patients. Miltefosine had to be stopped for only 3 patients because of severe gastrointestinal intolerance, one of whom died. The results of laboratory tests are summarized in Table 3. Mean renal function did not change significantly at the end of the therapy, compared with baseline. However, 6 patients (1%) had a grade 3 increase in serum creatinine concentration. In 2 patients, miltefosine was stopped for this reason. In the other 4, renal dysfunction was only detected at the end of therapy; in 3, tests repeated 1 week later revealed an improved condition, whereas the fourth patient, who had concomitant pancytopenia, died 1 week after treatment. Five more patients had a treatment switch because of other serious adverse events (see Figure 1). There was significant improvement in hemoglobin, leukocyte, and platelet levels with the resolution of disease (Table 1). DISCUSSION Miltefosine has been used mainly in the Indian subcontinent, and its efficacy is significantly lower in eastern Africa (Table 4). This study examined the efficacy and safety of miltefosine in a carefully monitored cohort of Indian patients 10 years after the pivotal phase III trial was done [2]. The drug was taken under direct observation, and no enrolled patients Table 4. Result of Various Clinical Trials of Miltefosine for Treatment of Visceral Leishmaniasis Study, by Cohort Age Country Patients, No. Cure,a % (95% CI) Relapse, % (95% CI) 96.7 (90.2–103.1) 3.3 (−3.1 to 9.8) 94.3 (91.7–96.9) 81.9 (79.6–84.1) 3.0 (1.1–4.9) 3.9 (2.8–5.0) Adults India Sundar et al [2] Bhattacharya et al [19] India India Ritmeijer et al [21] Ethiopia 290c 60.0 (54.4–65.6) 10.3 (6.8–13.8) Rahman et al [9] Rijal et ald Bangladesh Nepal 977 101 71.8 (69.0–74.6) … 9.7 (7.9–11.6) … … … 82.1 (74.7–89.6) 11.8 (5.6–18.2) … … 72.3 (63.5–81.0) 21.8 (13.7–29.8) At 6 months At 12 months Children 11.1 (−3.4 to 25.6) 93.8 (88.4–99.1) … 3.8 (−.4 to 7.9) … … 44 93.2 (85.7–100.6) 2.3 (−2.1 to 6.7) … 20 95.0 (85.4–104.5) 0 Bhattacharya et al [12] Singh et al [20] India India Treatment naive Previously treated Computed on an intention-to-treat basis. b Restricted to patients who took 100 mg/kg of miltefosine. c Also includes patients with human immunodeficiency virus infection. d Conducted during 2008–2010 (unpublished data). e Restricted to patients who took 2.5 mg/kg of miltefosine for 4 weeks. • CID 2012:55 (15 August) • 18e 83.3 (66.1–100.5) India 548 299 1132 80 … Sundar et al [11] Abbreviation: CI, confidence interval. a 30b Jha et al [18] Sundar et al intriguing because the drug had not been introduced there at the time our study was conducted. Also, in a small cohort of 101 patients treated with miltefosine in Nepal, the cure rates at 6 and 12 months were 82.1% and 72.3%, respectively, and the relapse frequencies at 6 and 12 months were 11.8% and 21.8%, respectively (Rijal et al, unpublished data). We followed all patients for 1 year after treatment in our study site in India, and only 1 patient had relapse between 6 and 12 months. Thus, for India, a 6-month follow-up period appears to be sufficient to estimate the final cure rate. The findings from the Bangladesh and Nepal studies, in addition to our own findings, indicate the vulnerability of miltefosine to lose its effectiveness. A substantial proportion of patients (65%) in the cohort developed adverse events, which was seen consistently across the clinical studies of miltefosine for treatment of VL [10–12]. In most patients, these side effects are transient, lasting for 1–2 days. Transient asymptomatic elevation of hepatic enzyme levels, although occurring in a large proportion, is rarely noticed by the patient and does not lead to discontinuation of the drug. Because miltefosine is the only oral antileishmanial drug, it was sold over the counter in India. In the VL elimination program, VL patients without contraindications for miltefosine use are provided with weekly supplies until end of treatment. Because of its potential teratogenicity and its long half-life, only nonpregnant women who agree for contraception for the duration of treatment and further 3 months are eligible. A significant proportion of patients discontinue the treatment prematurely and are not traceable [13]. One of the important reasons for this discontinuation is the high incidence of side effects, as was observed in this study. Gastrointestinal intolerance plays an important role in noncompliance if patients are not forewarned and counseled about the impending adverse events. The increasing relapse rates during miltefosine therapy may well be the reflection of suboptimal use in terms of dose and duration in the few years since its commercialization, reminding us of the declining efficacy of pentavalent antimonials [14]. It surely emphasizes the need for training and supervision of correct treatment prescription practices among healthcare staff, for measures to improve treatment adherence among patients, and for tools for monitoring treatment outcomes and drug resistance (if any) among patients. Furthermore, we need to understand the mechanism leading to miltefosine tolerance and the steps to prevent and overcome this phenomenon. This is a clinical study limited by the fact that direct testing of isolates for miltefosine resistance was not performed, and, thus, this study does not provide proof of a change in outcome due to miltefosine resistance. It remains a relevant question whether a course correction is required at this stage of the VL elimination program, in view of the availability of alternative regimens, namely, single- dose liposomal amphotericin B therapy [15] or multidrug therapy, which have the distinct advantage of a shorter course and better compliance [16, 17]. Notes Acknowledgments. We are grateful to Mr N. Tiwary for statistical analysis. Financial support. This work was supported by the European Commission–funded project Kaladrug-R (EC-FP7-222895) and by the Sitaram Memorial Trust, Muzaffarpur. Potential conflicts of interest. S. S. has received grant support for clinical trials and travel funds to attend scientific meetings from Paladin Labs, Institute for One World Health, and GlaxoSmithKline, and his institute has received grants from Bharat Serum and Vaccine Ltd. All other authors report no potential conflicts. All authors have submitted the ICMJE Forms for Disclosure of Potential Conflicts of Interest. 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