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Onchocerciasis Treatment & Management

  • Author: Mary D Nettleman, MD, MS; Chief Editor: Mark R Wallace, MD, FACP, FIDSA  more...
 
Updated: Nov 05, 2015
 

Medical Care

Because most of the pathogenesis of onchocerciasis is secondary to microfilariae, the goal of therapy is to eliminate the microfilarial stage of disease to improve symptoms, to prevent progression of eye lesions, and to interrupt disease transmission.

Ivermectin is considered to be the drug of choice as a microfilaricidal agent.[32, 33] Repeated dosing at intervals of 3–12 months is recommended for at least 10-12 years. More frequent dosing is reserved for patients who experience frequent symptomatic recurrences.

Ivermectin is usually well-tolerated. Dying microfilaria may result in pruritus and adenopathy (Mazzotti reaction), leading to angioedema in rare cases. Ocular inflammation may also be triggered by dying microfilariae. To minimize this in individuals with microfilariae observed during slit-lamp examination, some experts recommend using a short course of prednisone (2-3 d) along with ivermectin. More frequent dosing with ivermectin (every 3 mo instead of every 12 mo) may reduce inflammatory complications because it does not permit microfilarial numbers to build, thus reducing the number of dead organisms after treatment.

Concomitant infection with L loa should be ruled out, as ivermectin may precipitate toxic encephalopathy in these patients.

Ivermectin has little effect on adult worms. It reduces the burden of microfilaria and the risk of complications but does not cure the disease. Ivermectin may have a modest effect on infection rates with selected intestinal helminths, such as ascaris, although it is not effective against hookworm.[34]

Targeting endosymbiotic Wolbachia species has emerged as an exciting new approach in the control of onchocerciasis. Studies of doxycycline therapy (100–200 mg/d for 6 wk) have shown great promise.[35, 36, 37, 38] Doxycycline interrupts microfilarial embryogenesis, dramatically decreasing or eliminating microfilaria for at least 18 months after treatment. The drug has modest activity against adult worms, reducing numbers by approximately 50%-60%. The combination of doxycycline and ivermectin given together is more effective than either drug alone.[39] However, doxycycline has side effects and must be given daily, which limits its usefulness for large scale treatment programs.[40]

Investigators have also studied rifampin and azithromycin, but early results appear to be inferior to those of doxycycline.[41, 42, 43] Moxidectin is an antiparasitic drug that is currently being studied by the WHO for use in onchocerciasis.[44] Moxidectin is closely related to ivermectin, but animal studies suggest it might cause more sustained reduction in microfilarial levels.

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Surgical Care

Nodulectomy can result in cure only if excision eliminates all adult worms. Thus, this is not a practical choice in patients with multiple nodules or in patients in whom nodules are not clinically evident.

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Consultations

See the list below:

  • Infectious disease specialist
  • Ophthalmologist
  • Dermatologist
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Contributor Information and Disclosures
Author

Mary D Nettleman, MD, MS MACP, Professor and Chair, Department of Medicine, Michigan State University College of Human Medicine

Mary D Nettleman, MD, MS is a member of the following medical societies: American College of Physicians, Association of Professors of Medicine, Central Society for Clinical and Translational Research, Infectious Diseases Society of America, Society of General Internal Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Apoorv Kalra, MD Assistant Professor of Medicine, Michigan State University

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

John W King, MD Professor of Medicine, Chief, Section of Infectious Diseases, Director, Viral Therapeutics Clinics for Hepatitis, Louisiana State University Health Sciences Center; Consultant in Infectious Diseases, Overton Brooks Veterans Affairs Medical Center

John W King, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Federation for Medical Research, Association of Subspecialty Professors, American Society for Microbiology, Infectious Diseases Society of America, Sigma Xi

Disclosure: Nothing to disclose.

Chief Editor

Mark R Wallace, MD, FACP, FIDSA Clinical Professor of Medicine, Florida State University College of Medicine; Clinical Professor of Medicine, University of Central Florida College of Medicine

Mark R Wallace, MD, FACP, FIDSA is a member of the following medical societies: American College of Physicians, American Medical Association, American Society for Microbiology, Infectious Diseases Society of America, International AIDS Society, Florida Infectious Diseases Society

Disclosure: Nothing to disclose.

Additional Contributors

Daniel R Lucey, MD, MPH, MD, MPH 

Daniel R Lucey, MD, MPH, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians

Disclosure: Nothing to disclose.

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Simulium fly (black fly).
Histopathology of an Onchocerca volvulus nodule. Image courtesy of the CDC and Dr. Mae Melvin.
Simplified life cycle of Onchocerciasis volvulus.
 
 
 
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