This document provides information on the treatment of Kala-azar (visceral leishmaniasis) and post-kala-azar dermal leishmaniasis (PKDL). It discusses the clinical features, case definitions, objectives of treatment, and drug treatment options for primary kala-azar, treatment failure, and relapse cases. The first-line drugs recommended are liposomal amphotericin B, miltefosine, and paromomycin. For PKDL, first-line treatment is oral miltefosine for 12 weeks, and second-line options include amphotericin B deoxycholate or sodium stibogluconate. Special considerations for treatment in pregnancy, co-
Gabapentin 300mg capsules smpc taj pharmaceuticalsTaj Pharma
Gabapentin Taj Pharma : Uses, Side Effects, Interactions, Pictures, Warnings, Gabapentin Dosage & Rx Info | Gabapentin Uses, Side Effects -: Indications, Side Effects, Warnings, Gabapentin - Drug Information - Taj Pharma, Gabapentin dose Taj pharmaceuticals Gabapentin interactions, Taj Pharmaceutical Gabapentin contraindications, Gabapentin price, Gabapentin Taj Pharma Gabapentin 300mg capsules SMPC- Taj Pharma . Stay connected to all updated on Gabapentin Taj Pharmaceuticals Taj pharmaceuticals Hyderabad.
Drug profile of pregabalin and lacosamide: A deep insight!RxVichuZ
This is my 48th powerpoint...it deals with the drug profiles of LACOSAMIDE & PREGABALIN (2 anti-epileptic drugs), their pharmacological profiles & role in neuropathic pain..
Happy reading!!
:)
Carbamazepine Controlled-release Tablets USP SmPC Taj PharmaceuticalsTajPharmaQC
Carbamazepine CR Tablets USP 200mg, 400mg Taj Pharma: Uses, Side Effects, Interactions, Pictures, Warnings, Carbamazepine Dosage & Rx Info | Carbamazepine Uses, Side Effects Carbamazepine: Indications, Side Effects, Warnings, Carbamazepine -Drug Information –Taj Pharma, Carbamazepine dose Taj pharmaceuticals Carbamazepine interactions, Taj Pharmaceutical Carbamazepine contraindications, Carbamazepine price, Carbamazepine Taj Pharma Carbamazepine SmPC- Taj Pharma Stay connected to all updated on Carbamazepine Taj Pharmaceuticals Mumbai. Patient Information Leaflets, SMPC.
Gabapin 400 mg Tablet is manufactured in India by Intas Pharmaceuticals Limited. Gabapin 400 mg Tablet is is basically an anticonvulsant normally prescribed for epilepsy and postherpetic neuralgia.
High density lipoprotein cholesterol (HDL-c), often termed “good cholesterol”, is one of the major targets of cardiovascular risk reduction. Constant attempts have been made over the past 3 decades to increase their level in the blood in an attempt to reduce cardiovascular risk. In spite of these efforts, raising HDL-c still remains an enigma.
While several methods are known to raise HDL-c, they are not as dramatic as reduction of low density lipoprotein cholesterol (LDL-c). Statins, fibrates, niacin and cholesteryl-ester transfer protein (CETP) inhibitors are useful in increasing HDL-c. However, it was recently demonstrated that raising HDL-c using these pharmacological means did not have any significant effect on reducing clinical cardiovascular events. The 2013 ACC/AHA guidelines on managing blood cholesterol did not give much importance to HDL-c management too.
An important question is the method with which HDL-c is tested. Is HDL-cholesterol more important or HDL lipoprotein particle number? Are HDL-based therapies dead? Are there newer ongoing techniques that raise HDL cholesterol as well as reduce cardiovascular risk?
Shashikiran Umakanth presented this at the Egyptian Association of Endocrinology, Diabetes & Atherosclerosis (EAEDA) 2014 conference at Alexandria, Egypt. This conference was help in association with Endocrine Society, USA and the European Association for the Study of Diabetes (EASD).
Gabapentin 300mg capsules smpc taj pharmaceuticalsTaj Pharma
Gabapentin Taj Pharma : Uses, Side Effects, Interactions, Pictures, Warnings, Gabapentin Dosage & Rx Info | Gabapentin Uses, Side Effects -: Indications, Side Effects, Warnings, Gabapentin - Drug Information - Taj Pharma, Gabapentin dose Taj pharmaceuticals Gabapentin interactions, Taj Pharmaceutical Gabapentin contraindications, Gabapentin price, Gabapentin Taj Pharma Gabapentin 300mg capsules SMPC- Taj Pharma . Stay connected to all updated on Gabapentin Taj Pharmaceuticals Taj pharmaceuticals Hyderabad.
Drug profile of pregabalin and lacosamide: A deep insight!RxVichuZ
This is my 48th powerpoint...it deals with the drug profiles of LACOSAMIDE & PREGABALIN (2 anti-epileptic drugs), their pharmacological profiles & role in neuropathic pain..
Happy reading!!
:)
Carbamazepine Controlled-release Tablets USP SmPC Taj PharmaceuticalsTajPharmaQC
Carbamazepine CR Tablets USP 200mg, 400mg Taj Pharma: Uses, Side Effects, Interactions, Pictures, Warnings, Carbamazepine Dosage & Rx Info | Carbamazepine Uses, Side Effects Carbamazepine: Indications, Side Effects, Warnings, Carbamazepine -Drug Information –Taj Pharma, Carbamazepine dose Taj pharmaceuticals Carbamazepine interactions, Taj Pharmaceutical Carbamazepine contraindications, Carbamazepine price, Carbamazepine Taj Pharma Carbamazepine SmPC- Taj Pharma Stay connected to all updated on Carbamazepine Taj Pharmaceuticals Mumbai. Patient Information Leaflets, SMPC.
Gabapin 400 mg Tablet is manufactured in India by Intas Pharmaceuticals Limited. Gabapin 400 mg Tablet is is basically an anticonvulsant normally prescribed for epilepsy and postherpetic neuralgia.
High density lipoprotein cholesterol (HDL-c), often termed “good cholesterol”, is one of the major targets of cardiovascular risk reduction. Constant attempts have been made over the past 3 decades to increase their level in the blood in an attempt to reduce cardiovascular risk. In spite of these efforts, raising HDL-c still remains an enigma.
While several methods are known to raise HDL-c, they are not as dramatic as reduction of low density lipoprotein cholesterol (LDL-c). Statins, fibrates, niacin and cholesteryl-ester transfer protein (CETP) inhibitors are useful in increasing HDL-c. However, it was recently demonstrated that raising HDL-c using these pharmacological means did not have any significant effect on reducing clinical cardiovascular events. The 2013 ACC/AHA guidelines on managing blood cholesterol did not give much importance to HDL-c management too.
An important question is the method with which HDL-c is tested. Is HDL-cholesterol more important or HDL lipoprotein particle number? Are HDL-based therapies dead? Are there newer ongoing techniques that raise HDL cholesterol as well as reduce cardiovascular risk?
Shashikiran Umakanth presented this at the Egyptian Association of Endocrinology, Diabetes & Atherosclerosis (EAEDA) 2014 conference at Alexandria, Egypt. This conference was help in association with Endocrine Society, USA and the European Association for the Study of Diabetes (EASD).
Carbamazepine 200 mg tablets smpc taj pharmaceuticalsTaj Pharma
Carbamazepine Uses, Side Effects -: Indications, Side Effects, Warnings, Carbamazepine - Drug Information - Taj Pharma, Carbamazepine dose Taj pharmaceuticals Carbamazepine interactions, Taj Pharmaceutical Carbamazepine contraindications, Carbamazepine price, Carbamazepine Taj Pharma Carbamazepine 200 mg tablets SMPC- Taj Pharma . Stay connected to all updated on Carbamazepine Taj Pharmaceuticals Taj pharmaceuticals Hyderabad.
Nilotinib Capsules 50mg/150mg/200mg Taj Pharma: Uses, Side Effects, Interactions, Pictures, Warnings, Nilotinib Dosage & Rx Info | Nilotinib Uses, Side Effects Nilotinib: Indications, Side Effects, Warnings, Nilotinib -Drug Information –Taj Pharma, Nilotinib dose Taj pharmaceuticals Nilotinib interactions, Taj Pharmaceutical Nilotinib contraindications, Nilotinib price, Nilotinib Taj Pharma Nilotinib SmPC-Taj Pharma Stay connected to all updated on Nilotinib Taj Pharmaceuticals Mumbai. Patient Information Leaflets, SmPC.
Diclofenac potassium 50 mg tablets smpc taj pharmaceuticalsTaj Pharma
Diclofenac Potassium Taj Pharma : Uses, Side Effects, Interactions, Pictures, Warnings, Diclofenac Potassium Dosage & Rx Info | Diclofenac Potassium Uses, Side Effects -: Indications, Side Effects, Warnings, Diclofenac Potassium - Drug Information - Taj Pharma, Diclofenac Potassium dose Taj pharmaceuticals Diclofenac Potassium interactions, Taj Pharmaceutical Diclofenac Potassium contraindications, Diclofenac Potassium price, Diclofenac Potassium Taj Pharma Diclofenac Potassium 50 mg Tablets SMPC- Taj Pharma . Stay connected to all updated on Diclofenac Potassium Taj Pharmaceuticals Taj pharmaceuticals Hyderabad.
Pregabalin SR Capsules Sustained Release 100mg/150mg Taj Pharma: Uses, Side Effects, Interactions, Pictures, Warnings, Pregabalin Dosage & Rx Info | Pregabalin Uses, Side Effects Vecuronium bromide: Indications, Side Effects, Warnings, Pregabalin-Drug Information –Taj Pharma, Pregabalin dose Taj pharmaceuticals Pregabalin interactions, Taj Pharmaceutical Pregabalin contraindications, Pregabalin price, Pregabalin Taj Pharma Pregabalin SmPC-Taj Pharma Stay connected to all updated on Pregabalin Taj Pharmaceuticals Mumbai. Patient Information Leaflets, SmPC.
Increased endurance and strength- because it is a derivative of testosterone you will have more strength and stamina. You will be able to work harder and longer in the gym which will lead to better results. Fat burn-throughout the cycle metabolic process is quicker.
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MDaaS is a medical equipment services company dedicating to improving the affordability, uptimes, and quality of medical equipment in Nigeria and across Africa.
Carbamazepine 200 mg tablets smpc taj pharmaceuticalsTaj Pharma
Carbamazepine Uses, Side Effects -: Indications, Side Effects, Warnings, Carbamazepine - Drug Information - Taj Pharma, Carbamazepine dose Taj pharmaceuticals Carbamazepine interactions, Taj Pharmaceutical Carbamazepine contraindications, Carbamazepine price, Carbamazepine Taj Pharma Carbamazepine 200 mg tablets SMPC- Taj Pharma . Stay connected to all updated on Carbamazepine Taj Pharmaceuticals Taj pharmaceuticals Hyderabad.
Nilotinib Capsules 50mg/150mg/200mg Taj Pharma: Uses, Side Effects, Interactions, Pictures, Warnings, Nilotinib Dosage & Rx Info | Nilotinib Uses, Side Effects Nilotinib: Indications, Side Effects, Warnings, Nilotinib -Drug Information –Taj Pharma, Nilotinib dose Taj pharmaceuticals Nilotinib interactions, Taj Pharmaceutical Nilotinib contraindications, Nilotinib price, Nilotinib Taj Pharma Nilotinib SmPC-Taj Pharma Stay connected to all updated on Nilotinib Taj Pharmaceuticals Mumbai. Patient Information Leaflets, SmPC.
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Increased endurance and strength- because it is a derivative of testosterone you will have more strength and stamina. You will be able to work harder and longer in the gym which will lead to better results. Fat burn-throughout the cycle metabolic process is quicker.
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MDaaS is a medical equipment services company dedicating to improving the affordability, uptimes, and quality of medical equipment in Nigeria and across Africa.
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Fallon Community Sound Approach to Horizon Pharma ProcysbiTrevor Strauss
Approval criteria used by Fallon Community in MA, USA. Sound approach when dealing with HIGH PRICED rare drugs like Horizon Pharma Procysbi. Health Canada recent decision is negligent when it comes to care and cost for Canadian Cystinosis Patients.
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Ondansetron Oral Solution IP 2mg-5ml Manufacturers, Suppliers in India.pdfTajPharmaIndia
Ondansetron is used to treat nausea and vomiting caused by chemotherapy. It is also used to prevent or treat nausea and vomiting after surgery.
Ondansetron should be considered for infants and children age six months and older who present to the ED with vomiting related to suspected acute gastroenteritis, and who have mild to moderate dehydration or who have failed oral rehydration therapy.
An update on the treatment of glomerulonephritisaApollo Hospitals
Glomerulonephritis (GN) is a common cause of end stage renal disease (ESRD). Some of these entities are responsive to immunosuppressive agents and other therapies. There have been recent advances in the treatment options, notably the benefit shown with the use of rituximab in some forms of GN. Moreover, the KDIGO guideline on the management of glomerulonephritis has recently been published which has consolidated the available evidence on the management of this heterogeneous group of disorders. Though there are significant risks and side-effects involved, the treatment of some of the forms of GN can be very gratifying while others progress relentlessly to ESRD. This review summarizes some of the key recommendations from the KDIGO guideline along with a brief discussion of the supporting evidence.
Similar to Management of ka&pkdl by dr shahjadaselim (20)
Infertility is defined as the inability of a couple to conceive after at least one year of regular unprotected intercourse.
Male infertility refers to a male's inability to cause pregnancy in a fertile female.
IDD situation in our country has improved
A good number of thyroid disorder patients are either undiagnosed and or untreated
Thyroid disorder in pregnancy- Rate high
As a sound thyroid functioning status is crucial for growth, development in children; reproduction, psychological and general wellbeing in adults, we must be proactive in screening, diagnosing and treating our patients.
Over the past several years it has been proved that maternal thyroid disorder influence the outcome of mother and fetus, during and also after pregnancy. The most frequent thyroid disorder in pregnancy is maternal hypothyroidism. It is associated with fetal loss, placental abruptions, pre-eclampsia, preterm delivery and reduced intellectual function in the offspring.1 In pregnancy, overt hypothyroidism is seen in 0.2% cases2 and sub clinical hypothyroidism in 2.3% cases3. Fetal loss, fetal growth restriction, pre-eclampsia and preterm delivery are the usual complications of overt hyperthyroidism (low TSH and high T3, T4) seen in 2 of 1000 pregnancies whereas mild or sub clinical hyperthyroidism (suppressed TSH alone) is seen in
1.7% of pregnancies and not associated with adverse outcomes4. Autoimmune positive euthyroid pregnancy shows doubling of incidence of miscarriage and preterm delivery. Worldwide more than 20 million people develop neurological sequel due to intra uterine, iodine deprivation5. Other problems of thyroid disorders in pregnancy are post partum thyroiditis, thyroid nodules and cancer, hyper emesis gravidarum etc. Debates and disputes persist regarding several protocol and management plan in this specific spectrum of diseases.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Ocular injury ppt Upendra pal optometrist upums saifai etawah
Management of ka&pkdl by dr shahjadaselim
1. Treatment of Kala-
azar and PKDL
Dr Shahjada Selim
MBBS MD (EM)
Registrar (Medicine)
Shaheed Suhrawardy Medical College Hospital, Dhaka
email:selimshahjada@gmail.com
2. Clinical Features of
KASymptoms:
Fever-usually insidious, irregular, low
grade, associated with chills & rigor.
Classically the fever is biphasic.
Weight loss.
Abdominal swelling.
Pigmentation.
Bleeding manifestations.
Secondary infections.
3. ..............Clinical Features of KA
Signs:
Increased temperature
Anemia
Gum bleeding
Lymphadenopathy
Splenomegaly
Hepatomegaly
Ascites
Edema
4. Clinical Case Definition
Following clinical case definitions will be used for reporting
and follow up. The case definitions will be as follows:
Primary Kala-azar (PKA):
An individual who is diagnosed to have KA
with the above mentioned case definition
and no history of treatment for KA before
will be considered as primary Kala-azar (PKA).
5. ........Clinical Case Definition
Kala-azar Treatment Failure (KATF):
An individual, who is diagnosed to have KA with
the above mentioned case definition and history
of treatment for KA within last one year, will
be reported as KATF.
All efforts should be made to diagnose
KATF parasitologically by examination of
smear or bone marrow or PCR.
6. ........Clinical Case Definition
Relapse Kala-azar (RKA):
An individual who is diagnosed to have KA with
the above mentioned case definition and history
of treatment for KA anytime in the past but not
within last one year will be reported as RKA. All
efforts should be made to diagnose KATF
parasitologically by examination of splenic
smear or bone marrow or PCR.
7. Objectives of Treatment
To cure the patient
To prevent the complications of the disease and
minimize side effects of medicines
To restrain drug resistance and reduce the risk of
spread of disease.
Complications and concomitant disease conditions (if
any) should also be diagnosed and treated accordingly.
9. 1st
line treatment for
PKADrug of choice
Liposomal Amphotericin B
(10 mg/kg body wt, single dose)
Alternative 1st
line choices
(Depending on availability in our country)
1.Miltefosine
2.Paromomycin
3.Combination treatment
10. 2nd
line treatment for PKA
(if the 1st
line drugs are not available or not
tolerated):
1.Amphotericin B deoxycholate
2.Sodium Stibogluconate (SSG)
11. …….1st
line treatment
Combination treatment
Combination of Miltefosine and Paromomycin
will be 1st
choice.
Other alternative combinations will be-
• Liposomal Amphotericin B*
+ Miltefosine
or
• Liposomal Amphotericin B*
+ Paromomycin
* LAmB 5 mg/kg body weight single dose .
12. Description of the drugs for
PKALiposomal Amphotericin B (LAmB)
To improve the tolerance and widen the narrow therapeutic
window, a lipid formulation of Amphotericin B is formulated.
Amongst the three formulations liposomal Amphotericin B has the
best safety profile.
Liposomal Amphotericin B should be given in a single
intravenous infusion at a dose of 10 mg/kg for a period not less than
2 hours duration. Please see annex XX for details.
In special situations like children of less than 5 years, in
pregnancy, co-infection with HIV/ AIDS etc would be treated with
multiple dose of Liposomal Amphotericin B (5mg/kg body weight on
alternate days for 3 doses). Please see annex XX for details.
13. Indications for alternative 1st
line
drugs:
• When Liposomal Amphotericin B is not indicated
due to hypersensitivity, intolerance or
contraindication.
• When Liposomal Amphotericin B is not available.
14. Miltefosine:
Miltefosine is a relatively safe oral drug for the
treatment of Kala-azar.
Recommended 28 days dose schedule:
Age more than 12 years and weighing ≥25kg:
100 mg daily. (cap 50 mg in morning and 50 mg in
the evening with meal)
Age more than 12 years but weighing <25kg:
50 mg daily. (cap 50 mg in the morning with meal)
Age 2‑12 years:
2. 5 mg/ kg body weight daily in two divided doses
with meal (not exceeding 50mg/day)
15. In case of missed doses, the scheduled 28 doses may be
taken within a period of 35 days. The daily dose should
never exceed the recommended amount.
If an exact dose cannot be administered, the closest 10
mg increment will be chosen at the dose.
Rounding will be done as follows:
If the calculation comes to <5 ‑ to round dose down.
If the calculation comes to >5 ‑ to round the dose up.
16. When to avoid the use of
Miltefosine:
Miltefosine is the preferred drug for the treatment of Kala-
azar/ PKDL in the elimination program except in the
following situations:
Pregnancy
Married women of child bearing age who are not using
contraceptives regularly.
Women who are breast feeding.
Children less than 2 yrs of age
Miltefosine may not be the ideal drug for patients of Kala-
azar
• With severe under nutrition
• Severe anemia and
• Patients with known history of kidney or liver disease
17. Adverse reactions of Miltefosine and
their treatment:
Adverse reactions to Miltefosine are mostly mild.
Mild to moderate vomiting is seen in 40%
patients and mild diarrhea in 15‑20% patients.
These usually occur during first week of
treatment.
18. Paromomycin:
Paromomycin is a promising and effective drug for
the treatment of Kala-azar. It has been registered
for use in India which is a parenteral
aminoglycoside.
Doses and administration:
Paromomycin sulphate should be given at a dose
of 15mg/kg/day. Each dose is to be taken from a
separate ampoule. It should be given I/M in the
gluteal muscle (alternative buttock, cheeks) once
a day for 21 days.
19. Combination therapy:
The 1st
choice of combination therapy will be
Miltefosine and Paromomycin.
The alternate choices-
Liposomal Amphotericin B + Miltefosine
or
Liposomal Amphotericin B + Paromomycin.
20. …..Combination therapy
Dose and administration:
1st
choice:
Cap. Miltefosine following the above
mentioned dose for 10 days
+
Inj. Paromomycin following the above
mentioned dose for 10 days
21. ……..Combination therapy
Alternate choice:
Inj. LAmB 5 mg/ kg body wt IV single dose on day 1
+
Cap. Miltefosine following the above mention dose
from day 2 to day 8.
Or
Inj. LAmB 5 mg/ kg body weight IV single dose on
day 1
+
Inj. Paromomycin following the above mention dose
from day 2 to day 11.
22. Treatment for KATF and RKA
KATF and RKA cases will be treated with
alternative 1st
line agent (eg. Patient who
received LAmB will be treated with Miltefosine or
Paromomycin or combination).
If alternative 1st line agents are not available,
then a 2nd
line agent should be used.
23. Indications of 2nd
line drugs:
When the first line drugs are not available
or not tolerated.
24. Amphotericin B deoxycholate:
Recommended second line drug for treatment of Kala-azar
and KATF is Amphotericin B deoxycholate.
Amphotericin B deoxycholate is also an effective drug. But it
has high toxicity profile and thus pushed to second line.
Amphotericin B deoxycholate 1 mg/kg daily or alternate day
is recommended in the form of infusion (in 5% Dextrose
solution 500 ml) for 15 doses having a cure rate of >90%. A
test dose should be given before administration of
Amphotericin B.
After preparation of solution 5 drops /min for 30 min, then 10
drops/min for another 30 min and if there is no reaction
occurs, then the infusion should be given slowly over a
period of 4-6 hours.
25. Sodium Stibogluconate
(SSG):
SSG is an effective and widely used drug for KA
and KATF. But the drug is pushed to second line
because of its cardiac toxicity and is recommended
by WHO to be phased out gradually.
SSG should be given at a dosage of 20mg/kg body
weight, daily IM injection for 30 days.
It is essential to weigh the patient before starting
treatment. Clinical cardiac monitoring should be
done throughout the treatment period.
26. Route of Administration of SSG:
The preferred route of administration
recommended is by deep intramuscular (IM)
injection. It is better not to give the drug
intravenously (IV) to avoid the risk of
cardiovascular collapse.
27. Assessment of cure after treatmentAssessment of cure after treatment
(Initial cure):
1 week after completion of treatment
Improvement of all clinical parameters
including
absence of fever
Reduction of spleen size
Gain in body weight.
28. Assessment of cure at 6Assessment of cure at 6
monthsmonths (Definitive cure):
No fever
Substantially reduced spleen size or not
palpable
Feeling of general well being.
30. Treatment of PKDL
First line treatment:
Miltefosine
Longer duration of oral Miltefosine is recommended.
The treatment will be supervised. Patient will received
their drugs monthly after being followed up by the
respective physician.
Adult dose: 100 mg daily for 12 weeks in two divided
doses.
Children: 2.5 mg/kg body weight/ day in two divided
doses, not exceeding 50mg/day for 12 weeks.
31. Second line treatment of PKDL
Amphotericin B deoxycholate
Dose: 1 mg/kg body wt daily or alternative IV (in
5%Dextrose solution) for 60-80 doses over 4 months.
Route: IV
Sodium Stibogluconate (SSG)
SSG should be given at a dosage of 20‑mg/kg/day in
intramuscular route. It is essential to weight the
patient every time, before starting a new cycle. Total 6
cycles of treatment should be given. Each cycle
consists of 20 days of treatment and there should be
an interval of 10 days in between two cycles.
32. Treatment of Cutaneous Leishmaniasis
(CL):
The treatment approach largely depends in part on
the Leishmania species/ strain and the geographic
area in which infection was acquired. In general, the
first sign of a therapeutic response to adequate
treatment is decreasing indurations (lesion flattening).
The healing process for large, ulcerative lesions often
continues after the end of therapy.
33. First line choice:
Sodium stibogluconate:
The standard daily dose will be 20 mg/kg/day, IM for 20
days (10 days may suffice based on clinical judgment).
Or
Cap. Miltefosine
The doses should be calculated as follows:
Age more than 12 years and weighing ≥25kg: 100 mg.
(cap 50 mg in morning and 50 mg in evening with meals)
Age more than 12 years but weighing <25kg: 50 mg. (cap
50 mg in the morning with meals)
2‑12 years: 2.5 mg/kg body weight. in two divided dose,
not exceeding 50mg/day with meals.
34. Second line choice for CL:
Ketoconazole: 600 mg daily for 28 days
or,
Itraconazole: 200 mg twice daily for 28
days or,
Fluconazole: 200 mg daily for 6 weeks
(for adult).
35. Treatment of Kala-azar in specialTreatment of Kala-azar in special
situations:situations:The treatment of Kala-azar in special situations is
recommended in centers where appropriate expertise and
facilities are available. The following conditions can be
considered as special situations:
Pregnancy
Risk of treatment should be weighed against benefit.
Treatment should be prioritized according to the severity. If a
pregnant mother is diagnosed as KA during 1st
trimester she
should be treated at 2nd
trimester or if she diagnosed as KA
during 3rd
trimester then she should be treated after delivery.
Drug of choice is Liposomal Amphotericin B (5 mg/kg body
weight on alternate days for 3 doses). Miltefosine and Sodium
stibogluconate is contraindicated in case of pregnancy.
36.
37. Kala-azar with TB
Treatment of both diseases should be continued and KA will
be treated as PKA.
Kala-azar HIV/AIDS co-infection
It will be treated with Liposomal Amphotericin B with multiple
doses. ARV should be continued for HIV/AIDS.
Kala-azar in a patient suffering from another
serious disease
All the case of Kala-azar with serious co-morbidities should
be treated under specialized supervision. Liposomal
Amphotericin B will be the drug of choice and treatment
should be given in a tertiary care facility.
38. Complete Treatment of Kala-Complete Treatment of Kala-
azar:azar:
All efforts should be made to ensure the complete
treatment. The following measures are
recommended to complete the treatment:
Every patient should be counseled so that the
patient/family fully understands the importance of
complete treatment and the consequences of the
incomplete treatment.
All treatment should be provided free of cost to
eliminate the economic constraint as a reason for
discontinuation of treatment
39. Each patient should have a separate treatment
box at the health facility that contains the full dose of
drugs labeled with the name and individual identification
of the patient. A treatment card with a unique
identification number showing the number of days the
treatment taken should be provided to patients.
It is advisable to follow up the patients during
treatment, immediately after completion of treatment
and up to 1 year (at 1st
, 5th
, 9th
, 12th
month)
The treatment should be directly observed as per
SOPs.
There should be coordination amongst the public
and private sector providers and a follow up plan should
be developed for each patient.
40. Monitor the patient regularly for signs and symptoms
(indicative of adverse events of drugs) and should be reported
as major & minor events (Ref. Training module for Kala-azar
elimination program).
Perform the tests if clinically indicated in treatment sites and
monitor the results. This can help to take timely measures even
before the signs appear.
Periodic meetings should be organized to review the reports of
major and minor adverse events obtained from the different
levels. This will help to guide the program in recommending the
tests that should be done to monitor the patients on treatment.
Regularly report the adverse events on the reporting
formats to higher levels once in a month for a review and
feedback.
41. Pharmacovigilance:
Pharmacovigilance is important to ensure the safety of the
medicines used in the treatment of Kala-azar and PKDL. It
should be the responsibility of the national program to
ensure pharmacovigilance. The program can provide very
useful information regarding efficacy of treatment options
and related adverse events during follow up of the patients.
The program must encourage health facilities and personals
to ensure regular reporting of major and minor adverse
events. The following measures will help to recognize early
the occurrence of adverse events.
42. fever>2weeks &
Residing/travelling
in endemic areas
fever>2weeks &
Residing/travelling
in endemic areas
YesYes Evidence of another
disease other than KA?
Evidence of another
disease other than KA?
Diagnosis And Management
Chart
NoNo
Splenomegaly, weight
loss, anemia
Splenomegaly, weight
loss, anemia
Is the patient
pregnant?
Is the patient
pregnant?
PKDL and choice of drugs
1st
line- Miltefosine:
2nd
line
a)Amphotericin-B Deoxycholate
b)LAmB
c) SSG
PKDL and choice of drugs
1st
line- Miltefosine:
2nd
line
a)Amphotericin-B Deoxycholate
b)LAmB
c) SSG
Record as KATF and use:
1.Alternative First line Treatment:
a. Miltefosine b. Paromomycin c. Combination
2. Second line drugs
a. Amphotericin B deoxycholate b. SSG
Record as KATF and use:
1.Alternative First line Treatment:
a. Miltefosine b. Paromomycin c. Combination
2. Second line drugs
a. Amphotericin B deoxycholate b. SSG
Had complete treatment
with Miltefosine or any
other drugs given within
last year?
Had complete treatment
with Miltefosine or any
other drugs given within
last year?
YesYes
PKA and choice of drugs:
LAmB
Alternate choice-
1. Miltefosine 2. Paromomycin
3. Combination of alternative
choice
PKA and choice of drugs:
LAmB
Alternate choice-
1. Miltefosine 2. Paromomycin
3. Combination of alternative
choice
KA with pregnancy and
choice of drugs
LAmB
Alternative:
a. Amphotericin-B
b.Paromomycin c.
SSG
KA with pregnancy and
choice of drugs
LAmB
Alternative:
a. Amphotericin-B
b.Paromomycin c.
SSG
Hypo pigmented patches (macule)
without loss of sensation with or
without
Erythematous patch (papule)
Subcutaneous nodule
fever or h/o KA
Hypo pigmented patches (macule)
without loss of sensation with or
without
Erythematous patch (papule)
Subcutaneous nodule
fever or h/o KA
If yes & rk39
(+)
If yes & rk39
(+)
If yes & rk39
(+)
43. Chart for Kala-azar treatmentChart for Kala-azar treatment
1st
line treatment for Kala-azar
Drug of choice-
1. LAmB
2. Alternative 1st
line choices
• Miltefosine
• Paromomycin
• Combination of Miltefosine and
Paromomycin - 1st
choices
Alternative combinations will be-
LAmB + Miltefosine
Or,
LAmB+ Paromomycin.
*
LAmB 5 mg/kg body weight on
2nd
line treatment for Kala-azar
1. Amphotericin-B deoxycholate
2. Sodium stibogluconate (SSG)
Weight (kg) SAG (ml)
up to 3 0.6
4-5 0.8-1
6-8 1.2-1.6
9-10 1.8-2
11-13 2.2-2.6
14-15 2.8-3.0
16-18 3.2-3.6
19-20 3.8-4.0
21-23 4.2-4.6
24-25 4.8-5.0
26-28 5.2-5.6
29-30 5.8-6.0
31-35 6.2-7.0
36-40 7.2-8.0
41-45 8.2-9.0
46-50 9.2-10
51-55 10.2-11
56-60 11.2-12
44. Treatment ChartTreatment Chart
When LAmB is not available or
contraindicated or in KATF
1st
line drugs:
1. Miltefosine
2. Paromomycin
3. Combination of 1st
choice
2nd
line drugs
a. Amphotericin-B deoxycholate
b. Sodium stibogluconate (SSG)
When LAmB is not available or
contraindicated or in KATF
1st
line drugs:
1. Miltefosine
2. Paromomycin
3. Combination of 1st
choice
2nd
line drugs
a. Amphotericin-B deoxycholate
b. Sodium stibogluconate (SSG)
Rx for RKA
1.Combination 1st
line drugs
cap. Miltefosine + inj.
Paromomycin
2. Alternate combination-
Inj. LAmB + Cap. Miltefosine
Or,
Inj. LAmB + Inj. Paromomycin
Rx for RKA
1.Combination 1st
line drugs
cap. Miltefosine + inj.
Paromomycin
2. Alternate combination-
Inj. LAmB + Cap. Miltefosine
Or,
Inj. LAmB + Inj. Paromomycin
Rx for PKDL
1st
line- Miltefosine:
2nd
line
a.Inj. Amphotericin B Deoxycholate
b.b. Inj. Sodium stibogluconate (SSG)
Rx for PKDL
1st
line- Miltefosine:
2nd
line
a.Inj. Amphotericin B Deoxycholate
b.b. Inj. Sodium stibogluconate (SSG)