Treatment of cutaneous leishmaniasis with aminosidine (paromomycin) ointment: double-blind, randomized trial in the Islamic Republic of Iran.

Treatment of cutaneous leishmaniasis with aminosidine (paromomycin) ointment: double-blind, randomized trial in the Islamic Republic of Iran A. Asilian,1 T. Jalayer,1 M. Nilforooshzadeh,1 R.L. Ghassemi,1 R. Peto,2 S. Wayling,3 P. Olliaro,3 & F. Modabber3 Objective To compare the parasitological and clinical efficacy of four weeks versus two weeks of treatment with aminosidine (paromomycin) ointment in patients with cutaneous leishmaniasis caused by Leishmania major in the Islamic Republic of Iran. Methods Double-blind, randomized trial of four weeks of aminosidine ointment (n = 108) vs two weeks of aminosidine ointment and two weeks of placebo (n = 108). Patients were assessed on days 15, 29, 45, and 105 for clinical cures and clinical and parasitological cures. Findings Four weeks’ treatment gave significantly better cure rates than two weeks’ treatment: on day 29, there were 80/108 (74%) vs 64/108 (59%) clinical cures (P=0.05) and 47 (44%) vs 26 (24%) clinical and parasitological cures (P=0.005). By day 45, fewer patients who received four weeks’ treatment had required rescue treatment with antimonials than those who received two weeks’ treatment: 20 (19%) vs 36 (33%) (P=0.02). On day 105, the results still favoured those who had been allocated four weeks of active treatment, but the differences were no longer as clearly significant. No side-effects were observed or reported. Conclusion Approximately two-thirds of patients given ointment for four weeks were cured clinically. Although about half of those cured might have recovered spontaneously even without treatment, four weeks of aminosidine ointment could become the first-line treatment for uncomplicated cutaneous leishmaniasis due to L. major, with antimonials needed in only the one-third of patients not cured by the end of treatment with aminosidine. This would considerably reduce the costs and side-effects associated with antimonial drugs. Keywords Leishmaniasis, Cutaneous/drug therapy; Paromomycin/therapeutic use/administration and dosage; Ointments/adminis- tration and dosage; Administration, Cutaneous; Treatment outcome; Comparative study; Double-blind method; Randomized controlled trials; Iran (source: MeSH, NLM ). Mots cle´s Leishmaniose cutane´e/chimiothe´rapie; Paromomycine/usage the´rapeutique/administration et posologie; Pommade/ administration et posologie; Voie cutane´e; Evaluation re´sultats traitement; Etude comparative; Me´thode double aveugle; Essai clinique randomise´; Iran (source: MeSH, INSERM). Palabras clave Leishmaniasis cuta´nea/quimioterapia; Paromomicina/uso terape´utico/administracio´n y dosificacio´n; Pomadas/ administracio´n y dosificacio´n; Administracio´n cuta´nea; Resultado del tratamiento; Me´todo doble ciego; Ensayos controlados aleatorios; Ira´n (fuente: DeCS, BIREME ). Bulletin of the World Health Organization 2003;81:353-359. Voir page 357 le re´sume´ en franc¸ais. En la pa´gina 358 figura un resumen en espan˜ol. Introduction Cutaneous leishmaniasis due to Leishmania major is a common skin disorder in many parts of south-west Asia (1, 2). At present, the first-line treatment involves antimonials, which require multiple injections, are expensive, and can be toxic. Hence, WHO recommends no treatment for uncomplicated cutaneous leishmaniasis (defined as fewer than five lesions, with no lesion >5 cm in diameter or near a vital organ). Compliance with this recommendation is poor, however, as patients know that untreated lesions may take several months to heal and leave substantial scars. A safe, convenient, and affordable treatment is needed, but few viable options exist today (1). Aminosidine (paromomycin) is effective in experimental leishmaniasis (4–6), and various topical formulations have been developed for clinical study (7–12). Some caused local irritation (9, 11), but encouraging results have been reported with an ointment containing 15% aminosidine plus 10% urea in white paraffin (12–13). In randomized, double-blind, placebo-controlled studies in Tunisia and the Islamic Republic of Iran, a two-week course of aminosidine ointment improved the short-term parasitological cure rates (14, 15), so more prolonged treatment might be more efficacious. We compared the parasitological and clinical efficacy of four weeks versus two weeks of such treatment. An untreated control group was not included, because two weeks of treatment was already known to be of some value, and if four weeks could be shown to be superior to two weeks of treatment, it must a fortiori be superior to no treatment. 1 Departments of Dermatology and Parasitology, School of Medicine, University of Medical Sciences, Isfahan, Islamic Republic of Iran. 2 University of Oxford Clinical Trial Service Unit, Radcliffe Infirmary, Oxford, England. 3 UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases, 1211 Geneva 27, Switzerland. Correspondence should be addressed to Dr Modabber at Infectious Disease Research Institute, 1124 Columbia Street, Suite 600, Seattle, WA, USA 98104 (email: fmodabber@idri.org). Ref. No. 03-000588 353Bulletin of the World Health Organization 2003, 81 (5) Methods Participants The study involved screening the catchment area of three primary health centres around Borkhar district north of Isfahan, Islamic Republic of Iran, which includes approximately 38 000 people. Visiting each house only once, teams of health workers identified and referred all possible cases of cutaneous leishmaniasis to the health centre for clinical and parasitological examination. Those patients with a single parasitologically confirmed lesion <5 cm in diameter were invited to participate unless they had had lesions for over four months, were aged <2 years, were pregnant or nursing mothers, had been treated previously, or had any intercurrent illness or history of allergy to aminoglycosides. All invitees or their parents were given information about the trial before they gave written consent. Of some 500 individuals assessed for eligibility, 233 met the inclusion criteria and were enrolled into the study between October and December, during the peak appearance of cases. Interventions The study was a randomized, double-blind trial, with follow-up visits scheduled at days 15, 29, 45, and 105. Patients were assigned randomly to receive four or two weeks of active treatment. Each patient ultimately received two tubes of ointment, which each contained 15 g of ointment — enough for two applications per day for 14 days. The first tube was given to all patients and contained active ointment. The second tube contained either active ointment or placebo (white paraffin oil) and was given to patients in accordance with a computer- generated randomization list after patients returned their first used tube after two weeks. They were examined clinically and parasitologically when they collected the second tube. The placebo and active ointments looked and smelled identical. In contrast to an earlier trial (15), treatment was unsupervised; however, patients were instructed carefully on the first day about how to apply the ointment twice daily (morning and bedtime) as a cross over the lesion and then to spread it with a plastic spatula to cover the entire lesion as well as the edges. Different members of the research team were each tasked with verifying diagnosis, inclusion criteria, and subsequent assignment of participants to treatment groups. The clinical and parasitological evaluators were blinded to each other’s assessment. All efforts were made to reduce the introduction of bias into this study; however, duration of the lesion, which was self-reported by the patients or their guardians, could introduce bias if the durations were significantly different in the two arms by chance. Outcomes Patients were re-examined clinically and parasitologically on days 15, 29, 45, and 105 after the start of treatment by researchers blind to their treatment. No smear was taken for parasitological examination from completely healed lesions (those with complete re-epithelialization), as this might have re-opened the scar. All smears were assessed by an experienced parasitologist (TJ), with Giemsa stain and direct microscopic examination. As in the earlier study (15), haematology and liver enzymesweremonitored routinely for safety—no evidence of hazard was found. At each visit, any patients whose lesion had worsened and showed no sign of re-epithelialization received systemic or intra-lesional antimonial drugs as rescue treatment, and treatment with the ointment was considered to have failed. ‘‘Clinical cure’’ was defined as >50% re-epithelialization of the original lesion, and ‘‘clinical and parasitological cure’’ as either complete re-epithelialization or clinical cure plus a parasitologically negative smear. The primary study endpoints were clinical cure and clinical and parasitological cure at day 29, when the four weeks of active treatment ended. Statistical methods EpiInfo software was used to calculate sample size and generate random numbers and for form design, double data entry, and calculations of statistical significance (which involved standard analyses of 262 tables). Sample size calculation was determined on the basis of a two-week cure rate of 50% (15) at day 45 and an expected four-week cure rate of 70%. When 10% attrition was allowed for, 233 eligible participants were randomized into two groups: 117 were allocated to receive four weeks of active treatment and 116 to receive two weeks of active treatment. Allocations were concealed by the use of opaque, sealed envelope and blinding of the investigators. Results Analyses were restricted to those patients who, at two weeks, had not lapsed from the study (four vs three never started and three vs three never attended after day 15 in the two- and four- week treatment groups, respectively) and had not had antimonial rescue (one vs three), which left 108 patients in each treatment group for analysis. None of those included in the study missed more than one of the three follow-up visits on days 29, 45, and 105, so the status (with respect to clinical cure without antimonial rescue) at themissed visit could be inferredwithout bias from the other visits. Only 2% of the first two visits were missed: one vs one were taken as clinical cures because the visits before and after involved apparently complete healing, and five vs two as not clinical cure (because the visits before or after involved antimonial rescue for four patients and clinical worsening for the other three) in the four- and two-week treatment groups, respectively). At the final visits, 15 (7%) patients were missing, and for these, the previous status was assumed to persist (five vs four clinically cured without antimonials, and three vs three not clinically cured, in the four- and two-week treatment groups, respectively). Full placebo control, and hence blind- ness of assessment, was maintained throughout. Fig. 1 shows participant flow through the study. Treatment was well tolerated, and no adverse reactions to the ointment were observed or reported in either group. Of those given a tube of active or placebo ointment at day 15, 216 (98%) returned at day 29, and all reported that they had used the ointment. Table 1 gives the characteristics of the 216 patients seen on or after day 29, who contribute to themain analyses: no marked imbalances were seen. Table 2 gives the main results at days 29 (when treatment was completed for those allocated four weeks of active ointment), 45, and 105. At day 29, few of the lesions were bad enough to require antimonial rescue, and no significant difference was seen between the groups in the numbers that did (four weeks vs two weeks: 12 (11%) vs 16 (15%). A significant improvement was seen, however, in the numbers achieving clinical cure (80 (74%) vs 64 (59%); P = 0.05) and clinical and parasitological cure (47 (44%) vs 26 (24%); P = 0.005) by day 29, with four weeks of active treatment significantly better than two weeks of active treatment plus two weeks of placebo 354 Bulletin of the World Health Organization 2003, 81 (5) Research treatment. The absolute improvement in clinical and para- sitological cure was 20% (95% confidence interval 7–32%). After active treatment stopped, some of the lesions in both treatment groups deteriorated, and at day 45, the numbers given antimonial rescue then or earlier were 20 (19%) vs 36 (33%) (P = 0.02). The numbers who had achieved clinical cure at day 45 without antimonial rescue were correspondingly greater for those who had received four weeks of treatment than two weeks (77 (71%) vs 59 (55%) clinical cures, P = 0.03), but in terms of clinical and parasitological cure at day 45, the advantage of longer treatment was no longer significant (40 (37%) vs 31 (29%)). By day 105 — 11 weeks after treatment ended — the results still favoured those who had originally had four weeks of treatment, but the differences were less significant. Table 3 subdivides the results by the status of the lesion at day 15 — after two weeks of active treatment for both groups (i.e. before there was any difference in management). The numbers are too small to be stable statistically, but they do suggest that the advantage of an additional two weeks of ointment was seen chiefly in those who had not already achieved clinical cure with the first two weeks of ointment (upper half of Table 3). It was notable, however, that a substantial minority of those who had achieved clinical cure (i.e. partial, or even complete, re-epithelialization) by day Table 1. Initial characteristics of 216 patients included in statistical analyses after treatment with two or four weeks of treatment with aminosidine ointment Characteristic Allocated treatment duration 4 weeks (n = 108) 2 weeks (n = 108) P-value Age (years)a 9.2 (8.9) 9.0 (8.8) 0.8 Haemoglobin (g/l) 132 (14) 133 (13) 0.6 Serum glutamic oxaloacetic transaminase (U/l) 9.9 (2.4) 9.7 (2.2) 0.5 Sex ratio (male:female) 47:53 44:56 0.7 Ulcerated lesionb,c 85 (79) 95 (88) 0.1 a Values in parentheses are standard deviations. b Values in parentheses are percentages. c Status at day 0; subsequent comparisons between the two treatment arms are standardized for the status of the lesion at day 15. 355Bulletin of the World Health Organization 2003, 81 (5) Treatment of cutaneous leishmaniasis with aminosidine in the Islamic Republic of Iran 15 subsequently deteriorated, irrespective of whether an additional two weeks of treatment were given. Some differences in Table 3 are seen between the two treatment groups in the numbers who had already worsened by day 15 or who had already achieved partial re-epithelialization. These differences were not statistically significant (P = 0.2), however, andmust have been entirely caused by chance, because the treatment of both groups before day 15 was identical and the study was double blind. Moreover, these chance imbalances did not contribute at all to the statistical significance in Table 2 of the results at later times, for the P-value calculations in Table 2 were conditional on the 15-day results in Table 3 (i.e. they showed whether, given the chance imbalances at day 15, the subsequent results significantly favoured longer treatment). When the results on days 29, 45, and 105 were taken together, the average of the difference between the percen- tages cured within four weeks and within two weeks of treatment was 14% (irrespective of whether cure was defined as clinical cure or as clinical and parasitological cure). This can be converted into a number needed to treat of approximately seven— i.e. if seven patients were treated for four weeks rather than two weeks, then one more would be cured by ointment alone, without the use of antimonials. Discussion In the previous randomized, placebo-controlled, double-blind trial with the same ointment (15), two weeks of treatment produced significant benefit by day 15, although many patients remained uncured or relapsed later. The present trial compared treatment with four and two weeks of ointment and found the longer treatment to be somewhatmore effective. Evenwith four weeks of treatment, however, about one-third of all patients remained uncured — most of these eventually needed to be offered antimonials, and, of those who used the ointment and were cured, about half might have recovered spontaneously. As four weeks of treatment is better than twoweeks, and two weeks is better than no treatment (15), the four-week aminosidine regimen could become the first-line treatment for uncomplicated cutaneous leishmaniasis in L. major foci — at least until something better is found (e.g. an ointment with better bioavailability of aminosidine or some completely different active ingredients). Longer periods of treatment might increase the cure rate; as most cases heal spontaneously in 3–4 months (15), however, a more effective rather than longer treatment would be desirable. At the moment, the ointment can be produced in endemic countries, costs only Table 2. Results at days 29 (when trial treatment ended), 45, and 105 in patients who received aminosidine ointment for four weeks (n = 108) or two weeks (n = 108)a Treatment day Antimonial ‘‘rescue’’ treatment Clinical cure without ever Clinical and parasitological cure needed now (or given earlier) needing antimonial without ever needing rescue antimonial rescue Treatment Treatment Treatment 4 weeks 2 weeks P-valueb 4 weeks 2 weeks P-valueb 4 weeks 2 weeks P-valueb Day 29 12 (11) 16 (15) 0.51 80 (74) 64 (59) 0.05 47 (44) 26 (24) 0.005 Day 45 20 (19) 36 (33) 0.02 77 (71) 59 (55) 0.03 40 (37) 31 (29) 0.30 Day 105 28 (26) 42 (39) 0.07 72 (67) 61 (56) 0.18 62 (57) 46 (43) 0.04 a All 216 patients were seen at day 15; no patient missed more than one subsequent visit; few missing values are interpolated (2% at days 29 and 45; 7% at day 105). b Stratified for the status of lesions on day 15. Table 3. Percentage of patients who received aminosidine ointment for four weeks or two weeks with various outcomes, by status at day 15 (after two weeks of identical active treatment for both groups) Treatment day Antimonial ‘‘rescue’’ treatment Clinical cure (without Clinical and parasitological ever given (%) antimonial rescue)a cure without antimonial rescueb Treatment Treatment Treatment 4 weeks 2 weeks 4 weeks 2 weeks 4 weeks 2 weeks No clinical cure at day 15c,d Day 29 11 22 64 35 43 11 Day 45 25 44 55 37 27 17 Day 105 30 50 59 48 52 35 Clinical cure(over 50% re-epithelialization) at day 15d,e Day 29 11 7 81 83 44 37 Day 45 14 22 83 72 44 41 Day 105 23 28 72 65 61 50 a 550% re-epithelization. b Clinical cure plus smear negative for parasites. c 44 vs 54 patients in 4- and 2-week treatment groups, respectively. d The non-significant imbalance in denominators at day 15 is only because of chance, as treatment was double blind and, before day 15, was identical in both groups. e 64 vs 54 patients in 4- and 2-week treatment groups, respectively. 356 Bulletin of the World Health Organization 2003, 81 (5) Research about US$ 1 per week, and reduces the need for medically administered injections of expensive antimonials — especially since the current WHO recommendation of withholding antimonial injections for several weeks (in hope of sponta- neous cure) often is not complied with. Such topical treatment is practicable, even where specialist medical services are not available: as now formulated, the ointment has little or no toxicity, so it can be widely used; use of the ointment satisfies the demand from patients for some action to be taken; and simple clinical assessment at day 29 (without parasitological investigation) generally provides an adequate basis on which a decision about whether antimonial treatment will be needed can be made, because it correlates closely with the clinical assessment on day 45 and day 105 and is modified little by the parasitological assessment. Moreover, those who eventually will need antimonials (about one-quarter) and those who will not (about 75%) may benefit from four weeks of such ointment instead of four weeks of observation with no treatment. Although the trial did not study this, any treatment that helps control local infectionmay limit the depth and size of any eventual scar. Fig. 2 shows the current situation and potential public health benefits. As cutaneous leishmaniasis is a self-healing disease, the duration the lesions had been active before treatment started would have a profound effect on cure rate. We had no way of determining the exact duration, so patients or their guardians were asked to give an estimate. This may have produced a bias if the estimated duration was incorrectly uneven in the two treatment groups. For patients with uncomplicated cutaneous leishmania- sis in L. major foci, four weeks of twice-daily use of this ointment (or of some variant of it with improved bioavail- ability) could be the first-line treatment, after which, if there is no sign of re-epithelialization, antimonial therapy may be considered. Although (to simplify matters) only patients with a single lesion were enrolled in the present study, other patients with uncomplicated cutaneous leishmaniasis also may qualify for such topical treatment. This strategy is, however, valid only for those areas where infection generally involves L. major infection, as the response to aminosidine varies for different species of Leishmania (6). n Acknowledgements Dr Tahmoures Jalayer passed away unexpectedly after this work was completed, and this paper is dedicated to his memory.We are grateful to A.D. Bryceson and L. Moulton for critical reviews of the study, Farmitalia Carlo Erba (now from Pharmacia Upjohn) for the ointment, and T. Kuo and P. Bevin for help preparing the manuscript. This investigation was supported by the UNDP/World Bank/WHO Special Pro- gramme for Research and Training in Tropical Diseases. The recommendations are those of the authors and may not represent the official view of WHO. Conflicts of interest: None declared. Re´sume´ Traitement de la leishmaniose cutane´e par une pommade a` l’aminosidine (paromomycine) : essai randomise´ en double aveugle en Re´publique islamique d’Iran Objectif Comparer l’efficacite´ parasitologique et clinique d’un traitement de quatre semaines par une pommade a` l’aminosidine (paromomycine) et d’un traitement de deux semaines chez des patients atteints de leishmaniose cutane´e a` Leishmania major en Re´publique islamique d’Iran. Me´thodes Un essai randomise´ en double aveugle portant sur un traitement de quatre semaines par une pommade a` l’aminosidine (n = 108) ou un traitement de deux semaines par l’aminosidine et deux semaines par placebo (n = 108) a e´te´ re´alise´. Les patients ont e´te´ examine´s les jours 15, 29, 45 et 105 afin de de´terminer les taux de gue´rison clinique et les taux de gue´rison clinique et parasitologique. Re´sultats Le traitement de quatre semaines donnait des taux de gue´rison significativement plus e´leve´s que le traitement de deux 357Bulletin of the World Health Organization 2003, 81 (5) Treatment of cutaneous leishmaniasis with aminosidine in the Islamic Republic of Iran semaines : le jour 29, les taux de gue´rison clinique e´taient de 80/ 108 (74 %) contre 64/108 (59 %) (p = 0,05) et les taux de gue´rison clinique et parasitologique de 47/108 (44 %) contre 26/ 108 (24 %) (p = 0,005). Le jour 45, un plus petit nombre de patients ayant rec¸u le traitement de quatre semaines avaient duˆ recevoir un traitement de secours par les antimonie´s, par rapport a` ceux qui avaient rec¸u le traitement de deux semaines : 20 (19 %) contre 36 (33 %) (p = 0,02). Le jour 105, les re´sultats e´taient toujours meilleurs chez les patients ayant rec¸u quatre semaines de traitement mais les diffe´rences n’e´taient plus aussi significatives. Aucun effet secondaire n’a e´te´ observe´ ni rapporte´. Conclusion Environ les deux tiers des patients ayant rec¸u la pommade pendant quatre semaines ont e´te´ cliniquement gue´ris. Meˆme si chez pre`s de la moitie´ des sujets gue´ris la gue´rison aurait pu survenir spontane´ment en l’absence de traitement, l’application pendant quatre semaines d’une pommade a` l’aminosidine pourrait devenir le traitement de premie`re intention chez les patients atteints de leishmaniose cutane´e non complique´e due a` L. major, les antimonie´s n’e´tant ne´cessaires que chez le tiers de patients qui n’e´taient pas gue´ris a` la fin du traitement par l’aminosidine. Il serait ainsi possible de re´duire conside´rablement les couˆts ainsi que les effets secondaires associe´s aux antimonie´s. Resumen Tratamiento de la leishmaniasis cuta´nea con pomada de aminosidina (paromomicina): ensayo aleatorizado en doble ciego en la Repu´blica Isla´mica del Ira´n Objetivo Comparar la eficacia parasitolo´gica y clı´nica de cuatro semanas y dos semanas de tratamiento con pomada de aminosidina (paromomicina) en los pacientes con leishmaniasis cuta´nea causada por Leishmania major en la Repu´blica Isla´mica del Ira´n. Me´todos Se llevo´ a cabo un ensayo aleatorizado en doble ciego de un re´gimen de tratamiento de cuatro semanas con pomada de aminosidina (n = 108) en comparacio´n con dos semanas de aminosidina y dos semanas de placebo (n = 108). Los pacientes fueron evaluados a los 15, 29, 45 y 105 dı´as para determinar la curacio´n clı´nica y la curacio´n clı´nica y parasitolo´gica. Resultados El tratamiento de cuatro semanas logro´ tasas de curacio´n significativamente mejores que el de dos semanas: el dı´a 29 se confirmaron 80/108 (74%) frente a 64/108 (59%) curaciones clı´nicas (P = 0,05) y 47 (44%) frente a 26 (24%) curaciones clı´nicas y parasitolo´gicas (P = 0,005). El dı´a 45, entre los tratados durante cuatro semanas habı´a menos pacientes que hubiesen requerido tratamiento de rescate con antimoniales que entre los tratados durante dos semanas: 20 (19%) frente a 36 (33%) (P = 0,02). El dı´a 105, los resultados todavı´a favorecı´an a los asignados al re´gimen de cuatro semanas de tratamiento activo, pero las diferencias ya no eran claramente significativas. No se observo´ ni notifico´ ningu´n efecto secundario. Conclusio´n Aproximadamente las dos terceras partes de los pacientes que recibieron la pomada durante cuatro semanas se curaron clı´nicamente. Aunque alrededor de la mitad de los que sanaron podrı´an haberse recuperado quiza´ esponta´neamente aun sin tratamiento, la administracio´n de pomada de aminosidina durante cuatro semanas podrı´a ser el tratamiento de primera lı´nea de la leishmaniasis cuta´nea sin complicaciones por L. major, reserva´ndose los antimoniales so´lo para el tercio de pacientes no curados al te´rmino del tratamiento con aminosidina. Ello reducirı´a considerablemente los costos y los efectos secundarios asociados a los medicamentos antimoniales. 358 Bulletin of the World Health Organization 2003, 81 (5) Research References 1. Desjeux P. Leishmaniasis: public health aspects and control. In: Dowlati Y, Modabber F, editors. Clinics in dermatology. New York: Elsevier; 1996. p. 417-23. 2. Nadim A. Current situation with regard to leishmaniasis in the countries of the eastern Mediterranean Region: an overview. In: Walton BC, Wijeyaratna PM, Modabber F, editors. Research on control strategies for leishmaniasis. 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