- Email: [email protected]
HIV and testosterone therapy
Reflection & Reaction HIV and testosterone therapy The Cochrane review by Kong and Edmonds1 on testosterone therapy in HIV wasting contains crucial evidence on the potential of testosterone to treat this important syndrome. Although eight randomised trials including 417 patients were compiled, the small numbers of patients in each of the trials and the heterogeneity of the population meant that only a minor effect of testosterone supplementation on weight gain could be detected. The meta-analyses showed a moderate increase of 1·04 kg in total bodyweight and 1·22 kg in lean body mass between the testosterone group and the placebo group. Given these limitations, we designed a double-blind, randomised, placebo-controlled trial of 89 HIVpositive people with wasting assigned to the oral anabolic steroid oxymetholone (50 mg twice or three times per day) or placebo.2 The 16-week double-blind phase was followed by open-labelled treatment with 50 mg twice per day for all participants. An important factor of our study was that oxymetholone is an oral drug that eliminates the need for intramuscular injections. On an intention-to-treat analysis patients achieved an mean (SE) weight gain of 3·0 (0·5) and 3·5 (0·7) kg in the
oxymetholone three-times-per-day and twice-per-day groups, respectively, while those in the placebo group gained an average of 1·0 (0·7) kg (p<0·0001, table). Weight gain started as soon as 2 weeks after treatment and peak weight was reached between weeks 8 and 12 in both oxymetholone groups. More importantly, lean body mass increased as much as 2·9 (0·54) kg in the oxymetholone twice-per-day group (p<0·0001) and body cell mass increased 3·8 (0·4) kg and 2·1 (0·6) kg in the oxymetholone twiceper-day and three-times-per-day groups, respectively (table). The more significant increases in the oxymetholone twice-per-day group are probably due to the more frequent treatment interruptions in the threetimes-per-day group. In this regard, gains in body cell mass as the metabolic reactive tissue are especially important for maintaining body function. No changes were reported in extracellular mass and in the body fat over the course of the study (table). Thus, our study compares favourably with the trials analysed by Kong and Edmonds with 52 patients receiving oxymetholone as opposed to 22 patients receiving placebo.
Mean (SE) body composition changes after therapy with oxymetholone
Body weight (kg)
Baseline Week 16 Change
Oxymetholone 50 mg TID n=27 66·4 (10·4) 69·4 (9·9) 3·0 (0·5)*
Oxymetholone 50 mg BID n=25 66·1 (9·0) 69·6 (10·2) 3·5 (0·7)*
Placebo n=22 60·9 (8·0) 61·9 (8·4) 1·0 (0·7)
BMI (kg/m2)
Baseline Week 16 Change
21·0 (2·5) 22·0 (2·4) 1·0 (0·2)*
21·0 (1·8) 22·0 (2·2) 1·0 (0·2)*
19·4 (1·7) 19·8 (2·1) 0·4 (0·2)
LBM (kg)
Baseline Week 16 Change
54·3 (9·6) 56·1 (8·2) 1·8 (0·8)†
57·0 (6·6) 59·9 (7·6) 2·9 (0·54)*
48·3 (7·1) 48·8 (7·3) 0·5 (0·8)
BCM (kg)
Baseline Week 16 Change
28·3 (5·4) 30·4 (4·9) 2·1 (0·6)‡
30·5 (4·2) 34·3 (5·1) 3·8 (0·4)*
24·2 (3·5) 24·9 (4·4) 0·7 (0·5)
Body fat (kg)
Baseline Week 16 Change
11·8 (6·4) 11·7 (5·0) 0·0 (0·7)
9·7 (3·6) 10·0 (5·2) 0·3 (0·7)
9·5 (3·1) 9·8 (3·9) 0·4 (0·6)
ECM/BCM
Baseline Week 16 Change
0·92 (0·1) 0·84 (0·09) –0·08 (0·03)†
0·88 (0·09) 0·76 (0·07) –0·12 (0·01)*
0·99 (0·14) 0·98 (0·14) –0·01 (0·01)
Parameters of body composition were compared at the beginning and the end (week 16) of the double-blind study. Week 12 value used, if week 16 value was not available. BMI=body mass index; LBM=lean body mass; BCM=body cell mass; ECM=extracellular mass; BID=twice daily; TID=three times daily. *p<0·0001 compared with placebo; †p<0·05 compared with placebo; ‡p<0·005 compared with placebo
THE LANCET Infectious Diseases Vol 3 April 2003
Significant improvements were noted in appetite (by visual analogue scale for appetite), and increased wellbeing and reduced weakness were reported by self examination in a standardised, validated questionnaire. All patients in our trial were eugonadal at the beginning of the trial. Total serum testosterone, luteinising hormone and follicle-stimulating hormone, the regulators of testosterone production and gonadal function, decreased significantly during oxymetholone treatment. As expected from a previous pilot trial,3 toxicity of oxymetholone treatment was primarily liverassociated. Overall, 35% of the patients in the three-times-per-day group, 27% of patients in the twice-per-day oxymetholone group and no patient in the placebo group had a greater than five-times baseline increase for alanine aminotransferase during the doubleblind phase of the study. It seems that liver toxicity was additive and occurred more frequently in patients being treated with highly active antiretroviral therapy (HAART) or other potential hepatotoxic agents such as fluconazole. Oxymetholone, 17-␣-methyl2-hydroxymethylene dihydrotestosterone, has an anabolic potency compared with its androgenic effect of 8·75:1, relative to methyltestosterone.4–7 The selection of a drug with only moderate androgenic properties allowed its use in both male and female patients. The prospectively defined hypotheses were that supraphysiological androgen treatment regimen would increase bodyweight, body cell mass and lean body mass in eugonadal patients of both sexes. The major differences between our trial and the trials analysed by Kong and Edmonds were, first, the fact that our patients were all on concomitant stable HAART, whereas the patients in their study were on various treatment regimens (no antiretroviral therapy, mononucleotide or binucleotide therapy). Therefore, our trial more closely represents the conditions of treatment in the HAART era. Second, an oral testosterone derivative was used. Third, all patients were eugonadal at study entry.
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For personal use. Only reproduce with permission from The Lancet Publishing Group.
187
Reflection & Reaction Current treatment alternatives besides testosterone derivatives include recombinant growth hormone, nutritional supplements, or cytokine inhibitors. While some of these agents are promising,7,8 they are costly. Given the improvements of healthrelated quality of life, the use of anabolic steroids may be justified in selected patients, especially when other first-line therapies such as optimised nutritional status and gonadal function or the use of exercise have failed. The beneficial effects of oxymetholone have to be balanced with its hepatic adverse events.
Ulrich Hengge UH is at the Department of Dermatology, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany. Correspondence: Professor Ulrich Hengge, Department of Dermatology, Heinrich-Heine-Universität Düsseldorf, Moorenstrasse 5, 40225 Düsseldorf, Germany. Email [email protected]
4 5
6
7
References 1 2
3
Kong A, Edmonds P. Testosterone therapy in HIV wasting syndrome: systematic review and metaanalysis. Lancet Infect Dis 2002; 2: 692–99. Hengge UR, Stocks K, Wiehler H, et al. Double-blind, randomised, placebo-controlled phase III trial of oxymetholone for the treatment of HIV-wasting. AIDS 2003 (in print). Hengge UR, Baumann M, Malessa R, Brockmeyer NH, Goos M. Oxymetholone promotes
8
weight gain in patients with advanced human immunodeficiency virus (HIV-1) infection. Br J Nutr 1996; 75: 129–38. Camerino B, Sala G. Anabolic steroids. Prog Drug Res 1960; 2: 71–134. Pavlatos AM, Fultz O, Monberg MJ, Vootkur A, Pharmd. Review of oxymetholone: a 17alphaalkylated anabolic-androgenic steroid. Clin Ther 2001; 23: 789–801. Arnold A, Potts GO, Beyler AL. Evaluation of the protein anabolic properties of certain orally active anabolic agents based on nitrogen balance studies in rats. Endocrinology 1963; 72: 408–17. Helle SI, Ueland T, Ekse D, et al. The insulin-like growth factor system in human immunodeficiency virus infection: relations to immunological parameters, disease progression, and antiretroviral therapy. J Clin Endocrinol Metab 2001; 86: 227–33. Lo JC, Mulligan K, Noor MA, et al. The effects of recombinant human growth hormone on body composition and glucose metabolism in HIV-infected patients with fat accumulation. J Clin Endocrinol Metab 2001; 86: 3480–87.
Heated amphotericin to treat leishmaniasis Guerin and colleagues1 report that lipid formulations of amphotericin B, although very effective against visceral leishmaniasis, are not affordable in lowincome countries. However, in one of our laboratories, an affordable and patent-free formulation of heated amphotericin B has been discovered. Because of its low toxicity heated amphotericin B can be safely delivered at markedly high doses, similar to liposomal amphotericin B. Heating of amphotericin B to 70°C for 20 minutes induces a superaggregation resulting in a sevenfold decrease of the in-vitro toxicity (cell viability assays on the cell line HT29).2 In vivo, in Leishmania donovani-infected mice, heated amphotericin B produces a twofold increase in antileishmanial activity over that of conventional amphotericin B. The maximum tolerated dose of heated amphotericin B is five times that of conventional amphotericin B (2·5 vs 0·5 mg/kg per day, respectively).3 In persistently leucopenic mice with severe invasive candidiasis, almost fourfold higher dosages of heated amphotericin B than those of conventional amphotericin B are tolerated (3 vs 0·8 mg/kg, respectively).4 In rabbits, a single intravenous dose (1 mg/kg bodyweight) of conventional amphotericin B, produced a greater than 50% increase in serum creatinine concentrations compared with baseline; by contrast, the use of heated amphotericin B resulted in unchanged serum creatinine concentrations.5
188
It is of public-health interest to know more about heated amphotericin B, and to start clinical trials, which, if they confirm animal studies, would offer benefits. Where antimony resistance is already high (left bank of Ganga River, Bihar, India) conventional amphotericin B has become the firstline drug.1,6 The required 20–25 day course, however, is too long and too expensive for villagers to be correctly treated so a drug or a combination of drugs allowing a shorter and cheaper course is needed. Miltefosine is a very promising oral treatment for control of visceral leishmaniasis. However, heated amphotericin B is potentially safer for pregnant women. Also the long half-life of miltefosine (2–3 weeks) could quickly lead to resistance if miltefosine alone is used.7 As stated by Bryceson,7 this would be “a tragedy”. Circulating half-lives of conventional amphotericin B and liposomal amphotericin B are 29 h and 6–10 h, respectively. A combination of extreme poverty and long drug courses has led to the use of diluted, counterfeit, or expired drugs, and is indicated by alarming resistance to antileishmanial drugs.1,7,8 Heated amphotericin B is patent-free, and is therefore open to consideration by public-health authorities or a reactive non-governmental organisation for clinical trials, not only for the treatment of leishmaniasis but also for other neglected diseases, such as opportunistic systemic mycosis, which is frequently seen in AIDS patients.
Pierre Bau, Jacques Bolard, and Jean Dupouy-Camet PB and JDC are at the Department of Parasitology and Tropical Medicine, Hopital Cochin, Assistance PubliqueHôpitaux de Paris, Paris, France; JB is at the Laboratoire de Physicochimie Biomoléculaire et Cellulaire, Université Pierre et Marie Curie, Paris, France. Correspondence: Dr Jacques Bolard, LPBC, Université Pierre et Marie Curie, 4 Place Jussieu, 75252 Paris cedex 05, France. Email [email protected]
References 1
2
3
4
5
6
7 8
Guerin PJ, Olliaro P, Sundar S, et al. Visceral leishmaniasis: current status of control, diagnosis, and treatment, and a proposed research and development agenda. Lancet Infect Dis 2002; 2: 494–501. Gaboriau F, Cheron M, Petit C, Bolard J. Heat-induced superaggregation of amphotericin B reduces its in vitro toxicity: a new way to improve its therapeutic index. Antimicrob Agents Chemother 1997; 41: 2345–51. Petit C, Yardley V, Gaboriau F, Bolard J, Croft SL. Activity of a heat-induced reformulation of amphotericin B deoxycholate (fungizone) against Leishmania donovani. Antimicrob Agents Chemother 1999; 43: 390–92. van Etten EWM, van Vianen W, Roovers P, Frederik P. Mild heating of amphotericin B-deoxycholate: effects on ultrastructure, in vitro activity and toxicity, and therapeutic efficacy in severe candidiasis in leukopenic mice. Antimicrob Agents Chemother 2000; 44: 1598–1603. Kwong EH, Ramaswamy M, Bauer EA, Hartsel SC, Wasan KM. Heat treatment of amphotericin b modifies its serum pharmacokinetics, tissue distribution, and renal toxicity following administration of a single intravenous dose to rabbits. Antimicrob Agents Chemother 2001; 45: 2060–63. Thakur CP, Dedet JP, Narain S, Pratlong F. Leishmania species, drug unresponsiveness and visceral leishmaniasis in Bihar, India. Trans R Soc Trop Med Hyg 2001; 95:187–89. Bryceson A. A policy for leishmaniasis with respect to the prevention and control of drug resistance. Trop Med Int Health 2001; 6: 928–34. Boelaert M, Le Ray D, Van Der Stuyft P. How better drugs could change kala-azar control. Lessons from a cost-effectiveness analysis. Trop Med Int Health 2002; 7: 955–59.
THE LANCET Infectious Diseases Vol 3 April 2003
http://infection.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.
oxymetholone three-times-per-day and twice-per-day groups, respectively, while those in the placebo group gained an average of 1·0 (0·7) kg (p<0·0001, table). Weight gain started as soon as 2 weeks after treatment and peak weight was reached between weeks 8 and 12 in both oxymetholone groups. More importantly, lean body mass increased as much as 2·9 (0·54) kg in the oxymetholone twice-per-day group (p<0·0001) and body cell mass increased 3·8 (0·4) kg and 2·1 (0·6) kg in the oxymetholone twiceper-day and three-times-per-day groups, respectively (table). The more significant increases in the oxymetholone twice-per-day group are probably due to the more frequent treatment interruptions in the threetimes-per-day group. In this regard, gains in body cell mass as the metabolic reactive tissue are especially important for maintaining body function. No changes were reported in extracellular mass and in the body fat over the course of the study (table). Thus, our study compares favourably with the trials analysed by Kong and Edmonds with 52 patients receiving oxymetholone as opposed to 22 patients receiving placebo.
Mean (SE) body composition changes after therapy with oxymetholone
Body weight (kg)
Baseline Week 16 Change
Oxymetholone 50 mg TID n=27 66·4 (10·4) 69·4 (9·9) 3·0 (0·5)*
Oxymetholone 50 mg BID n=25 66·1 (9·0) 69·6 (10·2) 3·5 (0·7)*
Placebo n=22 60·9 (8·0) 61·9 (8·4) 1·0 (0·7)
BMI (kg/m2)
Baseline Week 16 Change
21·0 (2·5) 22·0 (2·4) 1·0 (0·2)*
21·0 (1·8) 22·0 (2·2) 1·0 (0·2)*
19·4 (1·7) 19·8 (2·1) 0·4 (0·2)
LBM (kg)
Baseline Week 16 Change
54·3 (9·6) 56·1 (8·2) 1·8 (0·8)†
57·0 (6·6) 59·9 (7·6) 2·9 (0·54)*
48·3 (7·1) 48·8 (7·3) 0·5 (0·8)
BCM (kg)
Baseline Week 16 Change
28·3 (5·4) 30·4 (4·9) 2·1 (0·6)‡
30·5 (4·2) 34·3 (5·1) 3·8 (0·4)*
24·2 (3·5) 24·9 (4·4) 0·7 (0·5)
Body fat (kg)
Baseline Week 16 Change
11·8 (6·4) 11·7 (5·0) 0·0 (0·7)
9·7 (3·6) 10·0 (5·2) 0·3 (0·7)
9·5 (3·1) 9·8 (3·9) 0·4 (0·6)
ECM/BCM
Baseline Week 16 Change
0·92 (0·1) 0·84 (0·09) –0·08 (0·03)†
0·88 (0·09) 0·76 (0·07) –0·12 (0·01)*
0·99 (0·14) 0·98 (0·14) –0·01 (0·01)
Parameters of body composition were compared at the beginning and the end (week 16) of the double-blind study. Week 12 value used, if week 16 value was not available. BMI=body mass index; LBM=lean body mass; BCM=body cell mass; ECM=extracellular mass; BID=twice daily; TID=three times daily. *p<0·0001 compared with placebo; †p<0·05 compared with placebo; ‡p<0·005 compared with placebo
THE LANCET Infectious Diseases Vol 3 April 2003
Significant improvements were noted in appetite (by visual analogue scale for appetite), and increased wellbeing and reduced weakness were reported by self examination in a standardised, validated questionnaire. All patients in our trial were eugonadal at the beginning of the trial. Total serum testosterone, luteinising hormone and follicle-stimulating hormone, the regulators of testosterone production and gonadal function, decreased significantly during oxymetholone treatment. As expected from a previous pilot trial,3 toxicity of oxymetholone treatment was primarily liverassociated. Overall, 35% of the patients in the three-times-per-day group, 27% of patients in the twice-per-day oxymetholone group and no patient in the placebo group had a greater than five-times baseline increase for alanine aminotransferase during the doubleblind phase of the study. It seems that liver toxicity was additive and occurred more frequently in patients being treated with highly active antiretroviral therapy (HAART) or other potential hepatotoxic agents such as fluconazole. Oxymetholone, 17-␣-methyl2-hydroxymethylene dihydrotestosterone, has an anabolic potency compared with its androgenic effect of 8·75:1, relative to methyltestosterone.4–7 The selection of a drug with only moderate androgenic properties allowed its use in both male and female patients. The prospectively defined hypotheses were that supraphysiological androgen treatment regimen would increase bodyweight, body cell mass and lean body mass in eugonadal patients of both sexes. The major differences between our trial and the trials analysed by Kong and Edmonds were, first, the fact that our patients were all on concomitant stable HAART, whereas the patients in their study were on various treatment regimens (no antiretroviral therapy, mononucleotide or binucleotide therapy). Therefore, our trial more closely represents the conditions of treatment in the HAART era. Second, an oral testosterone derivative was used. Third, all patients were eugonadal at study entry.
http://infection.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.
187
Reflection & Reaction Current treatment alternatives besides testosterone derivatives include recombinant growth hormone, nutritional supplements, or cytokine inhibitors. While some of these agents are promising,7,8 they are costly. Given the improvements of healthrelated quality of life, the use of anabolic steroids may be justified in selected patients, especially when other first-line therapies such as optimised nutritional status and gonadal function or the use of exercise have failed. The beneficial effects of oxymetholone have to be balanced with its hepatic adverse events.
Ulrich Hengge UH is at the Department of Dermatology, Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany. Correspondence: Professor Ulrich Hengge, Department of Dermatology, Heinrich-Heine-Universität Düsseldorf, Moorenstrasse 5, 40225 Düsseldorf, Germany. Email [email protected]
4 5
6
7
References 1 2
3
Kong A, Edmonds P. Testosterone therapy in HIV wasting syndrome: systematic review and metaanalysis. Lancet Infect Dis 2002; 2: 692–99. Hengge UR, Stocks K, Wiehler H, et al. Double-blind, randomised, placebo-controlled phase III trial of oxymetholone for the treatment of HIV-wasting. AIDS 2003 (in print). Hengge UR, Baumann M, Malessa R, Brockmeyer NH, Goos M. Oxymetholone promotes
8
weight gain in patients with advanced human immunodeficiency virus (HIV-1) infection. Br J Nutr 1996; 75: 129–38. Camerino B, Sala G. Anabolic steroids. Prog Drug Res 1960; 2: 71–134. Pavlatos AM, Fultz O, Monberg MJ, Vootkur A, Pharmd. Review of oxymetholone: a 17alphaalkylated anabolic-androgenic steroid. Clin Ther 2001; 23: 789–801. Arnold A, Potts GO, Beyler AL. Evaluation of the protein anabolic properties of certain orally active anabolic agents based on nitrogen balance studies in rats. Endocrinology 1963; 72: 408–17. Helle SI, Ueland T, Ekse D, et al. The insulin-like growth factor system in human immunodeficiency virus infection: relations to immunological parameters, disease progression, and antiretroviral therapy. J Clin Endocrinol Metab 2001; 86: 227–33. Lo JC, Mulligan K, Noor MA, et al. The effects of recombinant human growth hormone on body composition and glucose metabolism in HIV-infected patients with fat accumulation. J Clin Endocrinol Metab 2001; 86: 3480–87.
Heated amphotericin to treat leishmaniasis Guerin and colleagues1 report that lipid formulations of amphotericin B, although very effective against visceral leishmaniasis, are not affordable in lowincome countries. However, in one of our laboratories, an affordable and patent-free formulation of heated amphotericin B has been discovered. Because of its low toxicity heated amphotericin B can be safely delivered at markedly high doses, similar to liposomal amphotericin B. Heating of amphotericin B to 70°C for 20 minutes induces a superaggregation resulting in a sevenfold decrease of the in-vitro toxicity (cell viability assays on the cell line HT29).2 In vivo, in Leishmania donovani-infected mice, heated amphotericin B produces a twofold increase in antileishmanial activity over that of conventional amphotericin B. The maximum tolerated dose of heated amphotericin B is five times that of conventional amphotericin B (2·5 vs 0·5 mg/kg per day, respectively).3 In persistently leucopenic mice with severe invasive candidiasis, almost fourfold higher dosages of heated amphotericin B than those of conventional amphotericin B are tolerated (3 vs 0·8 mg/kg, respectively).4 In rabbits, a single intravenous dose (1 mg/kg bodyweight) of conventional amphotericin B, produced a greater than 50% increase in serum creatinine concentrations compared with baseline; by contrast, the use of heated amphotericin B resulted in unchanged serum creatinine concentrations.5
188
It is of public-health interest to know more about heated amphotericin B, and to start clinical trials, which, if they confirm animal studies, would offer benefits. Where antimony resistance is already high (left bank of Ganga River, Bihar, India) conventional amphotericin B has become the firstline drug.1,6 The required 20–25 day course, however, is too long and too expensive for villagers to be correctly treated so a drug or a combination of drugs allowing a shorter and cheaper course is needed. Miltefosine is a very promising oral treatment for control of visceral leishmaniasis. However, heated amphotericin B is potentially safer for pregnant women. Also the long half-life of miltefosine (2–3 weeks) could quickly lead to resistance if miltefosine alone is used.7 As stated by Bryceson,7 this would be “a tragedy”. Circulating half-lives of conventional amphotericin B and liposomal amphotericin B are 29 h and 6–10 h, respectively. A combination of extreme poverty and long drug courses has led to the use of diluted, counterfeit, or expired drugs, and is indicated by alarming resistance to antileishmanial drugs.1,7,8 Heated amphotericin B is patent-free, and is therefore open to consideration by public-health authorities or a reactive non-governmental organisation for clinical trials, not only for the treatment of leishmaniasis but also for other neglected diseases, such as opportunistic systemic mycosis, which is frequently seen in AIDS patients.
Pierre Bau, Jacques Bolard, and Jean Dupouy-Camet PB and JDC are at the Department of Parasitology and Tropical Medicine, Hopital Cochin, Assistance PubliqueHôpitaux de Paris, Paris, France; JB is at the Laboratoire de Physicochimie Biomoléculaire et Cellulaire, Université Pierre et Marie Curie, Paris, France. Correspondence: Dr Jacques Bolard, LPBC, Université Pierre et Marie Curie, 4 Place Jussieu, 75252 Paris cedex 05, France. Email [email protected]
References 1
2
3
4
5
6
7 8
Guerin PJ, Olliaro P, Sundar S, et al. Visceral leishmaniasis: current status of control, diagnosis, and treatment, and a proposed research and development agenda. Lancet Infect Dis 2002; 2: 494–501. Gaboriau F, Cheron M, Petit C, Bolard J. Heat-induced superaggregation of amphotericin B reduces its in vitro toxicity: a new way to improve its therapeutic index. Antimicrob Agents Chemother 1997; 41: 2345–51. Petit C, Yardley V, Gaboriau F, Bolard J, Croft SL. Activity of a heat-induced reformulation of amphotericin B deoxycholate (fungizone) against Leishmania donovani. Antimicrob Agents Chemother 1999; 43: 390–92. van Etten EWM, van Vianen W, Roovers P, Frederik P. Mild heating of amphotericin B-deoxycholate: effects on ultrastructure, in vitro activity and toxicity, and therapeutic efficacy in severe candidiasis in leukopenic mice. Antimicrob Agents Chemother 2000; 44: 1598–1603. Kwong EH, Ramaswamy M, Bauer EA, Hartsel SC, Wasan KM. Heat treatment of amphotericin b modifies its serum pharmacokinetics, tissue distribution, and renal toxicity following administration of a single intravenous dose to rabbits. Antimicrob Agents Chemother 2001; 45: 2060–63. Thakur CP, Dedet JP, Narain S, Pratlong F. Leishmania species, drug unresponsiveness and visceral leishmaniasis in Bihar, India. Trans R Soc Trop Med Hyg 2001; 95:187–89. Bryceson A. A policy for leishmaniasis with respect to the prevention and control of drug resistance. Trop Med Int Health 2001; 6: 928–34. Boelaert M, Le Ray D, Van Der Stuyft P. How better drugs could change kala-azar control. Lessons from a cost-effectiveness analysis. Trop Med Int Health 2002; 7: 955–59.
THE LANCET Infectious Diseases Vol 3 April 2003
http://infection.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.