## First-Line Treatment of Kala-azar in India **Key Point:** Miltefosine is now the preferred first-line agent for visceral leishmaniasis (kala-azar) in India, replacing sodium stibogluconate due to superior efficacy and reduced toxicity. ### Miltefosine - **Mechanism:** Alkylphospholipid that disrupts membrane integrity and inhibits protein kinase C in Leishmania parasites - **Dosing:** 2.5 mg/kg/day orally for 28 days - **Advantages:** - Oral bioavailability (non-invasive) - Cure rate >95% in Indian kala-azar - Better tolerability than antimonials - Effective against antimony-resistant strains - **Side effects:** Mild GI disturbance, hepatotoxicity (reversible), teratogenicity (contraindicated in pregnancy) ### Comparison with Other Agents | Drug | Route | Efficacy | Toxicity | Current Role | |------|-------|----------|----------|---------------| | **Miltefosine** | Oral | >95% | Mild GI, hepatic | **First-line** | | Sodium stibogluconate | IV/IM | 90–95% | Cardiotoxicity, pancreatitis | Second-line (resistance) | | Amphotericin B | IV | >95% | Nephrotoxicity, electrolyte loss | Severe/refractory cases | | Pentamidine | IM | 60–70% | Hypoglycemia, renal toxicity | Rare, antimony-resistant | **High-Yield:** Indian guidelines (NVBDCP 2020) recommend miltefosine as first-line monotherapy for uncomplicated kala-azar in immunocompetent patients. Combination therapy (miltefosine + amphotericin B or + paromomycin) is reserved for complicated cases, immunocompromised patients, or treatment failure. **Clinical Pearl:** Miltefosine has revolutionized kala-azar management in endemic regions because it eliminates the need for hospitalization and repeated injections, improving compliance and reducing healthcare burden. [cite:Park 26e Ch 5]
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