PHARMACOTHERAPY on TROPICAL DISEASES

Sulanto Saleh-Danu r.,dr., SpFK.

Dept.of Pharmacology & TherapyClinical Pharmacology Division,

Faculty of Medicine, UGM.

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RBLOCK 22

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What’s tropical diseases ??????

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diseases

AREA-CLIMATE ABNORMLITY BY CAUSATIVE AGENTS

TROPIC

SUBTROPIC

4-SEASON COUNTRIES

ARTIC/ANTARTIC

GENETIC

DEGENERATIVE

METABOLISM

MALIGNANCY

INFECTIONOTHERS

PARASITES

FUNGAL

BACTERIAL

VIRAL

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MAYOR TROPICALINFECTIONS.

1. MALARIA2. VISCERAL LEISHMANIASIS3. CUTANEUS LEISHMANIASIS

4. TUBERCULOSIS5. HIV INFECTION and

DISEASES IN THE TROPICS6. FILARIASIS and

ONCHOCERCIASIS7. AFRICAN TRYPANOSOMIASIS8. SOUTH AMERICAN TRYPANO-

SOMIASIS (CHAGAS’ DISEASES)9 SCHISTOSOMIASIS

10. LEPROSY

OTHERS:

Gasterointestinal. 1. Amoebiasis 2. Bacillary Dysentery 3. Cholera 4. Giardiasis and others protozoa infect. 5. Intetstinal cestoda infect. (tapeworm) 6. Soil-transmitted Helminths 7. Viral Hepatitis 8. Liver Flukes 9. Hydatid disease

Respiratory. 1. Pneumonia 2. Lung Flukes 3. Tropical Pulmonary Eosinophilia

Neurological 1. Pyogenic meningitis 2. Cryptococcal meningitis 3. Encephalitis 4. Acute Flaccid Paralysis 5. Spastic paralysis 6. Rabies 7. Tetanus 4

Fever. 1. Brucellosis 2. Typhoid and Paratyphoid Fever 3. Arbovirusis 4. Viral Haemorrhagic Fever 5. Dengue and Yellow Fever 6. Relapsing Fever 7. Rickettsial Infections 8. Leptospirosis 9. Melioidosis

Miscellaneous. 1. Tropical Ulcer 2. Buruli Ulcer 3. Myasis 4. Cutaneous Larva Migrans 5. Scabies and Lice 6. Strongyloides stercoralis 7. Guinea Worm Infection (Dracunculiasis) 8. Histoplasmosis 9. Other Fungal Infections 10. Haemoglobinopathies and Red Cell Enzymopathies 11. Haematinic Defficiencies 12. Bites and Stings 13. Non-Communicable Diseases 14. Refugee Health (Gill and Beeching, 2004)

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OTHERS

CAUSATIVE AGENTS

PARASITES

FUNGAL

BACTERIAL

VIRAL

TROPIC

10’s - the most common diseases

1. MALARIA2. VISCERAL LEISHMANIASIS3. CUTANEUS LEISHMANIASIS

4. TUBERCULOSIS5. HIV INFECTION and DISESEASE IN THE

TROPICS6. FILARIASIS and

ONCHOCERCIASIS7. AFRICAN

TRYPANOSOMIASIS8. SOUTH AMERICAN

TRYPANO- SOMIASIS (CHAGAS’

DISEASES)9 SCHISTOSOMIASIS

10. LEPROSY

- ANAMNESTIC- PHYSIC EXAMINATI

ON- LABORATO

RY: -Blood- Urine- Stool- Others

- RADIOLOGY:

- USG- X-ray- Others

SIGN & SYMPT.

Diagnose/DD

Prog. & Complic.

TREATMENT

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NON PHARMACO- THERAPIES

PHARMACOTHERAPEUTICS

SELECTION OF MEDICINES

ROUTE OF ADMINISTRATION

DOSAGE FORM

FREQUENY

DURATION

ADVERSE DRUG REACTION

INTERACTION

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EFFICACY

SAFETY

COSTLY

TREATMENT

HOSTMICRO-ORGANISM /PARASIT

INVASIVE

PHARMACOTHERAPY

“KILLED & DESTROYED” “ SAFE “

PHARMACOTHERAPYshould be :

PREVENTIVEIMMUNIZATION

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PHARMACOKINETIC

PHARMACODYNAMIC

BODYWEIGHT NUTRIONAL STATUS & DIETARY HABITSTROPICAL ENVIRONMENT: -climatic factors -infections and infestations -environment pollutants (chemicals, mycotoxins, alcoholism, smoking, etc)

DRUG DOSAGE,ABSORPTION,DISTRIBUTION, METABOLISM,

EXCRETIONTROPIC- COUNTRIES

SITUATION

EFFECTS,RESPONSES,INTERACTIONS,ADVERSE EFFECTS, Etc., etc.

PHARMACOTHERAPY

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DRUGS NUTRIONAL STATUS/ EFFECT ON DRUG % CHANGE CONDITION CLEARENCE

- Phenazone undernutrition increased 6 nutritional oedema decreased 21 low protein diet decreased 32 high protein diet increased 46 charcoal broiled beef increased 38

Propranolol high protein diet increased 60 high karbohydrate diet decreased 37

Tetracycline undernutrition increased 60 nutritional oedema decreased 43

Sulfadiazine undernutrition Increased 41

Rifampisin undernutrition increased 63

Chloroquine undernutrition increased 60

Phenylbutazone undernutrition increased 62

Theophylline high protein diet increased 28 low protein diet decreased 22 charcoal broiled beef increased 32

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KINETIK

FACTORS DRUG USE PROBLEMSIN TROPICAL ENVIRONMENT

Drug consumption in tropical countries

Per capita income

Available health services: drug distribution between rural-urban; self-medication

Disease pattern

Economic and education level

Drug production & distribution

Cost of medicine

Inter-related factors in drug consumption pattern. (Krishnaswamy,K., 1997) 11

PHARMACOKINETIC: - absorption of drug - distribution in the body - metabolism of the drug - excretion / elimination

Drug concentration in the body

Drug – receptor interaction

Respones

PHARMACODYNAMIC

PHARMACOTHERAPY OUTCOME

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Free drug

Free drugFree drug

HOSTMICRO-ORGANISM /PARASIT

INVASIVE

“KILLED & DESTROYED” “ SAFE “

PHARMACOTHERAPYshould be :

PREVENTIVEIMMUNIZATION

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MICROORGANISM / PARASITE

TARGETS OF CHEMOTHERAPY

1. UNIQUE ENZYMES ONLY IN THE PARASITE

2. ENZYMES FOUND IN BOTH HOST & PARASITE BUT INDISPENSABLE ONLY FOR THE PARASITE

3. COMMON BIOCHEMICAL FUNCTION FOUND IN BOTH PARASITE & HOST, BUT WITH DIFFERENT PHARMACOLOGIC PROPERTIES

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1. UNIQUE ENZYMES

- Enzymes for dihydropteroate Apicomplexa Sulfones and Sulfonamides syntesis

- Glycolipid synthesis African trypanosmes None

- Pyruvate:ferrodoxin oxidoreductase Anaerobic protozoa Nitroimidazole

- Pyruvate phosphate kinase Anaerobic protozoa None

- Nucleoside phosphotranferase Flagellated protozoa Allopurinol riboside and formycine B

-Trypanothione reductase and Kinetoplastida Nifurtimox peroxidase

ENZYMES PARASITES INHIBITORS

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2. INDISPENSABLE ENZYMES

ENZYMES PARASITES INHIBITORS

Lanosterol C-14α demethylase Leishmania & Trypanosoma cruzii Azoles

Purine phosphoribocyl transferase Protozoa Allopurinol

Purine nucleoside kinase Trichomonas vaginalis and None Entamoeba hystolytica

Ornitine decarboxylase African Trypanosomes α-Difluoroethylornithine

(S)-Adenosylmethionine African trypanosomes Diamidines decarboxylase

Glycolytic enzymes Kineplastida Glycerol plus salicyl- hydroxamic acid and suramine

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3. INDISPENSABLE BIOCHEMICAL FUNCTION WITH DIFFERENT PHARMACOLOGIC PROPERTIES

ENZYMES PARASITES INHIBITORSDihydrofolate reductase-thymidylate Apicomplexa and Kineto- Pyrimethamine synthase bifunctional enzyme plastida

Thiamine transporter Coccidia Amprolium

Mitochondrial electron transporter Apicomplexa 4-Hydroxyquinolines and 2-hydroxynaphthoquinones

Microtubules Helminth Benzimidazoles

Nervous synaptic transmission Helminth and Levamisole, piperazine, ectoparasite the milbemycins, and the avermectine

Pharmacotherapy on Tropical Diseases

PARASITIC INFECTIONS 1. Malaria 2. Filariasis 3. Onchocerciasis 4. Schistosomiasis 5. Leishmaniasis 6. African Trypanosomiasis (Sleeping Sickness) 7. American Trypanosomiasis (Chagas’ Disease) 8. AmoebiasisBACTERIAL INFECTIONS 9. Leprosy 10.TuberculosisVIRAL INFECTION. 11. Dengue 12. HIV

REFFICACY

SAFETY

ECONOMIC

AVAILABILLITY

AFFORDABILLITY

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1. MALARIA- The most important tropical disease, affecting over 2200 million, more than 2 million deaths/year.- Cause : PLASMODIUM : - P. VIVAX - P. OVALE - P. MALARIAE - P. FALCIPARUM severity deaths- COMPLICATION : 1. cerebral malaria 2. hyperpyrexia 3. hemolytic anemia 4. noncardiogenic pulmonary edema 5. acute tubular necrosis & renal failure 6. acute hepatopathy 7. hypoglycaemia 8. cardiac dysrhytmias 9. gastrointestinal syndromes 10. lactic acidosis 11. water and electrolyt imbalance

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MALARIA

Drug classification ( by chemical based ):

4-aminoquinolines : chloroquine; hydroxychloroquine; amodiaquine 8-aminoquinolines : primaquine diaminopyrimidines : pyrimethamine; trimethoprim biguanides (folate antagonist) : proguanil; chlorguanide; chlorproguanil quinoline methanol : quinine; quinidine, mefloquine sulfonamides : sulfadoxine; sulfadiazine; sulfamethoxazole folate antagonist combination : sulfadoxin – pyrimethamine (Fansidar™ ), chloroguanil - dapsone tetracycline : doxycycline, clindamycin phenanthrene methanol : halofantrine; atovaquone sesquiterpene lactone endoperoxiodes : artemisinins (qinghaosu), artesunate, artemether quinone-folate antagonist combination : atovquone-proguanil (Malarone™) amyl alcohol : lumefantrine

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MALARIA

Classification based on the drug actions. Tissues schizonticides : inhibit the growth of pre-erythrocyt stage of parasite (liver) proguanil; primaquine; pyrimethamine (with or without sulfonamides) causal prophylactics Antirelaps drugs : kill the dormant hypnozoites primaquine; 8-aminoquinolones indicated P.vivax & P ovale Blood schizonticides : kill the erythrocytic form, chloroquine; quinine; mefloquine can be used as suppressive prophylactics Gametocytocides : destroy the asexual stage of the parasite in the blood primaquine Sporozonticides : inhibit formation of oocyst and sporozoites in mosquitoes pyrimethamine; proguanil

Next: 3 examples of anti-malaria drugs profiles.21

CHLOROQUINE

MECHANISM OF ACTION : forms a toxic complex with ferriprotoporphyrine IX (haeme), class of blood schizontocide and gametocide. Plasmodium sensitive : P. vivax, falciparum, ovale, malariae. Onset of drug effects : 3 hours.

PHARMACOKINETIC PROFILE : ROUTE OF ADMINSTR.: F (%) : 90 Oral; Parenteral t½ß (h) : 1220 (41-50 ds) DOSAGE : 600 mg initially, Vd (L) : 57.400 6-8 h later : 300 mg CL (L/h) : 65 and next 2 days 300 mg Prot.bind. (%) : 55 (total : 1.500 mg) Route of elim. : kidney (unchanged) Duration of treatment : Metabolite activity : less active 3 days

ADVERSE EFFECTS: pruritis, GI upset, headache, fatigue, visual disturbances, dyskinesia, neurovascular disease

LIMITATIONS : RESISTANCE.22

MEFLOQUINE

MECHANISM OF ACTION : same as chloroquine, sensitive to : Plasmodium falciparum and P. vivax. Class : blood schizontocide; onset : 6 hours.

PHARMACOKINETICS PROFILE : ROUTE OF ADMINSTR.: F (%) : 85 Oral. t½ß (h) : 530 Vd (L) : 1330 DOSAGE : Initial : 750 mg. CL (L/h) : 2.0 6-8 (h) later : 500 mg Prot. Bind. (%): 98 and 250 mg after a Route of elim. : faecal & renal further 6-8 6-8 hr. unchanged and DURATION OF TREATMENT: carboxylic acid 1 (one) day. metabolite (inactive).

ADVERSE EFFECTS: dizziness, GI upset, headache, pruritis, skin rashes, CNS toxicity.

LIMITATIONS. expensive, resistance (now some area was established). 23

PRIMAQUINE

MECHANISM OF ACTION : interferes with plasmodial mitochondria function, binds to DNA. Effectve : exoerythrocytic forms of P.vivax and P.ovale. Gametocides all forms of plasmodia. Class : tissue schizonticides / gametocide. Onset : 1 – 2 hours.

PHARMACOKINETIC PROFILE: ROUTE OF ADMINISTR. F (%) : 90 – 100 Oral. t½ß : 4 – 5 Vd (L) : 322 DOSAGES: 15 mg daily CL (L/h) : 56 for duration of 14 days. Prot. Binding (%) : -- Route of elim. : renal and faecal Metabolite less active.

ADVERSE EFFECTS : mild anaemia, methaemoglobinaemia, depression, confusion, cardiac arrhythmia, granulocytopenia, agranulocytosis.

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OTHERS ANTIMALARIA.

1. Amodiaquine2. Quinine 3. Sulfadoxine – pyrimethamine (Fansidar®) 4. Atovaquone – proquanil (Malarone®)5. Halofantrine

6. The Artemisinin drugs : artesunate artemether artemisinin 7. Artemether & lumefantrine (Co-artem)

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6.The Artemisinin drugs : artesunate : water-soluble; p.oral-iv-im-rectal. artemether : lipid-soluble; p.oral-im-rectal. dihydroartemisinin : water-soluble; p.oral.

QINGHAOSU China herbal medicine used as antipyretic (over 2.000 years) sesquiterpene lactone endoperoxidaside active component : ARTEMISININ

PK (Pharmacokinetik) : absorbed rapid peak conc. : 1-2 hrs t1/2 : 1-3 hrs (p.oral)PD (Pharmacodynamic) : schizonticides no effect on hepatic stages

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REGIMEN: Notes :

Artemether-lumafentrine Coformulated; first-line therapy( Coartem, Riarnet) in many African countries.

Artesunate-amodiaquine Coformulated; first-line therapy(ASAQ, Arsucam) in many African countries.

Artesunate-mefloquine Standart therapy in parts of Southeast Asia.

Artesunate-sulfadoxine- First-line therapy in some pyrimethamine countries; efficacy low compared with others regimens in some area.

Amodiaquine-sulfadoxine- Less-expensive; recommended Pyrimethamine as an interim option when efficacy established and other regimens are not available.

WHO recommendations FALCIPARUM MALARIA

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7. Halofantrine & lumefantrine (Co-artem)

Halofantrine : effective ERYTHROCYTIC stages ( 4 plasmodiums) peak plasma level : 16 hrs after dosing half-life (t1/2) : 4 days. excretion : GIT (feces) AE : - alter the cardiac conduction QT & PR interval must be controlled. - GIT; skin rash/pruritus. CONTRAINDICATED : pregnancy

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Lumefantrine

Lumefantrine : derivate halofantrine available in fixed dose combinatioan with ARTEMETHER (Coartem). indication : uncomplicated falciparum (in Africa) t1/2 (in combination): 4,5 hrs. oral dose : bid for 3 days. AE : prolonged QT interval; GIT disturb,; headache; dizziness; skin rash- pruritis.

CHEMOPROPHYLAXIS

FOR THIS PURPOSE DRUGS ACT IN TWO WAYS :

AS SCHIZONTICIDES, when parasites enter the red cell they are destroyed;

AS CAUSAL PROPHYLACTICS, which prevent the development of the PE schizont in the liver, and may have schizonticidal effects.

Currently, chemoprophylaxis is routinely advise only for : NON-IMMUNE travellers visiting endemic area

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CHEMOPROPHYLAXIS :

1. PROGUANIL ( PALUDRINE, CHLORGUANIDE )2. CHLOROQUINE3. MEFLOQUINE4. DOXYCYCLIN

5. ATOVAQUONE-PROGUANIL6. SULFADOXINE-PYRIMETHAMINE

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CHEMOPROPHYLAXIS / SUPPRESSIVE DOSAGES

FOR ADULTS.

CHLOROQUINE300 mg (base) /

week.

PYRIMETHAMINE25 mg/week in

combination withsulfadoxine

SULFADOXINE500 mg/week in

combination withpyrimetamine

MEFLOQUINE250 mg/week

for 4 weeks, then125 mg/week

PRIMAQUINE45 mg(base)/week

for 8 weeks

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DRUG USE DOSAGE (adult)

Chloroquine Areas without 500 mg weekly cholorquine-resisitant P. falciparum

Malarone Areas with chloroquine- 1 tablt daily resistant P falciparum (250 mg atovaquone/ 100 mg proquanil)

Mefloquine Areas with chloroquine- 250 mg weekly resistant P. falciparum

Doxycycline Areas with multidrug- 100 mg dailay resistant P. falciparum

Primaquine Terminal prophylaxis of 52,6 mg (30 mg base) P.vivax; ovale infections; daily (14 days; after travel)

DRUGS for PREVENTION OF MALARIA in TRAVELERS

WHAT’S THE MAIN PROBLEM

PHARMACOTHERAPY MANAGEMENT in MALARIA ???

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2. FILARIASISCAUSES : - Wuchereria bancrofti Culex - Brugia malayi transmitted Aedes - Brugia timori Anopheles incubation periode : 8 – 16 mo. Cause : high degree of disability - hydrocele - scrotal lymphedema - lymphatic varices - elephantiasis : extrimities, genitals, breasts

R - diethylcarbamasine - ivermectin only as a microfilaricide combine with diethyl carbamasine - albendazole only as a microfilaricide

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Diethylcarbamazine citrate (DEC)

Effective : microfilaricidal, with dose 1-2 mg/kg BW 3 x daily for 2-3 weeks. Adult worms require longer course of therapy and/or multiple therapy.Adverse effects : allergic reactions, headache, vertigo, dizziness, malaise, fever, or myalgia.

PREVENTION : - reduce / eradicate population of mosquito - protect from mosquito bites

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3. ONCHOCERCIASIS

CAUSE : O. VOLVULUS endemic area : Africa & Latin America cause of BLINDNESS, Dermatitis, Lymphadenitis

Transmitter: female black flies ( simulium species )

R - diethylcarbamazine no effect in adult worm - ivermectin suitable for mass treatment dose : 400µg/kg single dose, often combined with a single dose albendazole 400 mg. repeated at 3-month for 2-3 years. - albendazole 400 mg 2x daily for 3 weeks ( have macrofilaricidal effects )

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4. SCHISTOSOMIASIS

CAUSED : Trematodes (blood flukes) S. mansoni (Africa; Arabian peninsula; South America; the Carabbean. S.haematobium ( Middle East and Africa ) S.mekongi (Southeast Asia) S.intercalatum (West and Central Africa) S. japonicum (Japan; China; Philippines) 3 stages : cercariae – mature flukes – eggs R praziquantel ONLY IF LIVE OVA ARE IDENTIFIED. oxamniquine effective only S. mansoni metrifonate -> S. hematobium

PERMASALAHAN : ketersediaan Obat cukup sulit,tersedia pada daerah ttt (Program: Indonesia – hanya di Sulawesi Tengah)

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CLINICAL (3 major disease syndromes): mature flukes : - dermatitis (swimmers’itch) - fever & constituional complaints (Katayama fever) - chronic fibro-obstructive disaese

DERMATITIS : 1-3 days after penetration of cercariae -priritis -papular rash (rarely occur in primary exposure)KATAYAMA FEVER : 4 – 8 weeks after penetration of the human skin - severe in S japonicum; some times in S mansoni; - rare in S haematobicumCHRONIC FIBRO-OBSTRUCTIVE: - damage by deposition of eggs -> chronic granulomatoous disease and fibrosis.

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LABORATORY : - eosinophilia, hematurie, anemia - chronic end-stage : abnormal liver function elevated serum creatinine uremia - characteristic by : schistomia eggs (feces/urine or rectal biopsi)

DIFF.DIAG : hepatic Sch -> hepatoslenomegaly & portal hypertension DD: alkoholic cirrh; Wilson’s disease; hepatitis C. S haematobium -> DD ca bladder / ureteral; CRF sometimes -> hematuria

5. LEISHMANIASIS

Syndromes :

- Visceral leishmaniasis (kala azar): L.donavani; L. infantum; L. chagasi

- Cutaneus leishmaniasis : Old world : L. tropica; L. major; L. aethiopica. New world : L. mexicana.

- Mucocutaneus leishmaniasis (espundia) : Leishmania (viannia) braziliensis; rare L(v) panamensis.

- Diffuse cutaneus leihmaniasis : L. mexicana; L. aethiopica

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VISCERAL LEISHMANIASIS (KALA-AZAR)

ENDEMIC : -in the South-west Asia; the Indian subcontinent; China; the Mediterranean area; east Africa; and Central and South America

Clinic : -Chronic irregular fever, malaise, anorexia, cough, diarrhea and secondary infections later : progressive enlargement of the spleen and liver; lymph-nodes with anemia and emaciation -Untreated fatal -After cure (in Indian subcontinent) chronic granulomatous infiltration of the skin and patchy hypopigmentation without ulceration

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CUTANEOUS LEISHMANIASIS.

The Old World : in the Mediterranean area; western Asia; the Indian subcontinent (west area) and east and west Africa.

The New World : in Central and South America ( except Chile and Uruguay )

Characterized : a cell-mediated reaction at the site of inoculation; immunity develops and healing occurs by fibrosis and leaving a prominent scar.

The New World more severe and slower to heal than The Old World

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MUCOCUTANEOUS LEISHMANIASIS.ENDEMIC : South and Central America; Ethiopia and Kenya caused by L.aethiopica.

Primary lesions : regional lymphangitis and lymphadenitis.

Characterized : progressive ulceration and erosion of the soft tissues of the mucosa of the nose, mouth and pharynx espundia This condition : appear soon after initial infection or many year after apparent resolution of the primary lesions.

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DIFFUSE CUTANEOUS LEISHMANIASISENDEMIC : Brazil; the Dominic Republic; Mexico; and Venezuela; and Ethiopia and Kenya ( L.aethiopica )

Primary lesion : progressive, widespread, thickening and leprosy-like lesion. ( once established do not regress with treatment )

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PHARMACOTHERAPEUTIC (1) MEGLUMINE ANTIMONATE : inject. 85 mg/ml SODIUM STIBOGLUCONATE : inject. 100 mg/ml both contain antimony (Sb pentavalent) in 5 ml ampoule.

Dosage & adminstration : 20 mg Sb pentavalent / kg BW i.m. duration of treatment : - Visceral L., minimum 20 days - Cutaneous L., local (intralesion) 1 – 3 ml interval 1-2 days systemic : 10 -20 mg until clinical cure at least 4 weeks - Mucocutaneous L., 20 mg / kg BW i.m. until split skin smears negative, at least 4 weeks. In relapse should be retreated at least twice as long. - Diffuse cutaneous L., 20 mg / kg BW i.m. several month until clinical improvement occurs.

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PHARMACOTHERAPEUTIC (2)

CONTRAINDICATIONS : - severe renal disorders - severe heart disorders - severe liver disorders

PREGNANCY : no evidence.

ADVERSE EVENTS : dose-dependent and reversible in ECG changes, T-wave inversion & prolongation Q-T interval precede serious dysrhythmia. Hepatic and renal dysfunction impairment. Headache, malaise, dyspnoea, skin rashes, Abdominal pain and facial oedema.

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PHARMACOTHERAPEUTIC (3)

Others : Pentamidine : all type of Leishmaniasis dosage : 3 – 4 mg / kg BW by deep i.m.or slow iv (>60’) for duration : 5 to 25 weeks. CI : renal impairment hypersensitive AE: - mild nephrotoxicity - acute hypotension and syncope ( rapid iv ) - hypoglycaemia ( pancreatic damage ), - hypocalcemia; GI effects; confusion, hallucinations; cardiac dysrhythmias; local induration ( sterile abscess); - rare : thrombocytopenia; leucopenia; Stevens-Johnson syndrome; abnormal hepatic functions.

Amphotericin B also as anti fungal.

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6. TRYPANOSOMIASIS.

AFRICAN ( sleeping sickness ) 7. AMERICAN ( Chagas diseases )

AFRICAN TRYPANOSOMIASIS. Pharmacotherapeutics : 1. PENTAMIDINE. Injection 200, 300 mg each vial. 2. SURAMINE. Injection 1 g / vial. 3. MELARSOPROL. Injection 36 mg / vial. 4. EFLORNITHINE. Injection 200 mg in 100 ml ampoule.

AMERICAN TRYPANOSOMIASIS. Pharmacotherapeutics : 1. BENZNIDAZOLE. Tablet 100 mg 2. NIFURTIMOX. Tablet 30, 120 and 250 mg.

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8. AMOEBIASIS

Caused : ENTAMOEBA HISTOLYTICA (an protozoan) common tropical diseases spread : fecal primary affect : colon; seconadary : liver, lungs and brain

CLASSIFICATION : 1. INTESTINAL & EXTRAINTESTINAL AMOEBIASIS 2. INTESTINAL AMOEBIASIS 3. EXTRAINTESTINAL AMOEBIASIS

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INTESTINAL & EXTRAINTESTINAL AMOEBIASIS : metronidazole; tinidazole; secnidazole; ornidazole; satranidazole; emetine; dehydroemetine.

INTESTINAL AMOEBIASIS: diloxanide furoate; quinodochlor; iodoquinol; tetracyclin; paromomycin.

EXTRAINTESTINAL AMOEBIASIS : chloroquine

REFERENCES.

1. Gill, G.V., Beeching, N.J.; (2004) Lecture Notes TROPICAL MEDICINE, 5th Ed., Blackwell Publishing.

2. WHO; ( 1995 ) , Drugs Used in Parasitic Diseases, 2nd Ed., WHO-Geneva.

3. Eddlestone, M., et al., ( 2005 ) Oxford Handbook of TROPICAL MEDICINE; 2nd Ed., Oxford University Press.

4. Neal, M J., ( 2005 ) Medical Pharmacology at a Glance, 5th Ed, Blackwell Publishing.

5. Udaykumar, P., (2011) Medical Pharmacology, 3rd Ed., CBS Publisher, New Delhi.

6. Katzung, B G., ( 2012 ) Basic and Clinical Pharmacology, 12th Ed., McGraw Hill.

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