ivermectin (Rx)

Brand and Other Names:Stromectol
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Dosing & Uses

AdultPediatric

Dosage Forms & Strengths

tablet

  • 3mg

Strongyloidiasis of the Intestinal Tract

15-24 kg: 3 mg PO once

25-35 kg: 6 mg PO once

36-50 kg: 9 mg PO once

51-65 kg: 12 mg PO once

66-79 kg: 15 mg PO once

>80 kg: 200 mcg/kg PO once  

Dosing considerations

  • In general repeat doses not necessary; perform stool examinations to verify eradication of infection

River Blindness (Onchocerciasis)

15-25 kg: 3 mg PO; may repeat in 3-12 mo

26-44 kg: 6 mg PO; may repeat in 3-12 mo

45-64 kg: 9 mg PO; may repeat in 3-12 mo

65-84 kg: 12 mg PO; may repeat in 3-12 mo

≥85 kg: 150 mcg/kg PO; may repeat in 3-12 mo  

Dosing considerations

  • Note: Does not treat adult worms (must be surgically excised)

Head Lice (Pediculosis capitis; Off-label)

200 mcg/kg PO once; may require 1-2 additional doses repeated after 7 days  

Blepharitis (Demodex folliculorum; Off-label)

200 mcg/kg PO once as a single dose, THEN repeat dose once in 7 days  

Filariasis Due to Mansonella Ozzardi (Off-label)

6 mg PO as single dose

Filariasis Due to Mansonella Streptocera (Off-label)

150 mcg/kg as single dose

Scabies Due to Sarcoptes Scabiel

Immunocompromised patients: 200 mcg/kg as single dose; may repeat in 14 days if necessary

Gnathostoma Spinigerum

Gnathostomiasis: 200 mcg/kg as single dose

Administration

Take on empty stomach

Monitor: Stool exams (Strongyloides)

Dosage Forms & Strengths

tablet

  • 3mg

River Blindness (Onchocerciasis)

<15 kg: Safety and efficacy not established

15-25 kg: 3 mg PO; may repeat in 3-12 mo

26-44 kg: 6 mg PO; may repeat in 3-12 mo

45-64 kg: 9 mg PO; may repeat in 3-12 mo

65-84 kg: 12 mg PO; may repeat in 3-12 mo

≥85 kg: 150 mcg/kg PO; may repeat in 3-12 mo  

Dosing considerations

  • Note: Does not treat adult worms (must be surgically excised)

Strongyloidiasis of the Intestinal Tract

<15 kg: Safety and efficacy not established

15-24 kg: 3 mg PO once

25-35 kg: 6 mg PO once

36-50 kg: 9 mg PO once

51-65 kg: 12 mg PO once

66-79 kg: 15 mg PO once

>80 kg: 200 mcg/kg PO once  

Dosing considerations

  • In general repeat doses not necessary; perform stool examinations to verify eradication of infection

Administration

Take on empty stomach

Monitor: Stool exams (Strongyloides)

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Interactions

Interaction Checker

and ivermectin

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            Adverse Effects

            Frequency Not Defined

            Abdominal pain

            Asthenia

            Hypotension

            Mild EKG changes

            Peripheral & facial edema

            Transient tachycardia

            Dizziness

            Headache

            Hyperthermia

            Insomnia

            Somnolence

            Vertigo

            Pruritus

            Rash

            Urticaria

            Diarrhea

            Nausea

            Vomiting

            Eosinophilia

            Leukopenia

            ALT/AST increased

            Limbitis

            Myalgia

            Tremor

            Blurred vision

            Mild conjunctivitis

            Punctate opacity

            Mazzotti reaction (with onchocerciasis)

            Edema

            Fever

            Lymphadenopathy

            Ocular damage

            Pruritus rash

            Conjunctival hemorrhage (with onchocerciasis)

            Hepatitis

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            Warnings

            Contraindications

            Hypersensitivity to ivermectin

            Cautions

            Strongyloidiasis: The patient should be reminded of the need for repeated stool examinations to document clearance of infection with Strongyloides stercoralis; not active against disseminated Strongyloides, only intestinal

            Onchocerciasis: The patient should be reminded that treatment does not kill the adult Onchocerca volvulus parasite, and therefore repeated follow-up and retreatment is usually required

            Long-term studies in animals have not been performed to evaluate carcinogenic potential of ivermectin

            Therapy had no adverse effects on fertility in rats in studies at repeated doses of up to 3 times maximum recommended human dose of 200 mcg/kg (on a mg/m2/day basis)

            Immunocompromised patients may require repeated treatment; control of extraintestinal strongyloidiasis may require suppressive therapy (eg, once monthly)

            Mazzotti reactions

            • Microfilaricidal drugs, such as diethylcarbamazine citrate (DEC-C), might cause cutaneous and/or systemic reactions of varying severity (the Mazzotti reaction) and ophthalmological reactions in patients with onchocerciasis
            • These reactions are probably due to allergic and inflammatory responses to the death of microfilariae; onchocerciasis treated patients may experience these reactions in addition to clinical adverse reactions possibly related to the drug itself
            • The treatment of severe Mazzotti reactions has not been subjected to controlled clinical trials; oral hydration, recumbency, intravenous normal saline, and/or parenteral corticosteroids have been used to treat postural hypotension; antihistamines and/or aspirin have been used for most mild to moderate cases

            Loiasis

            • Rarely, patients with onchocerciasis who are also heavily infected with Loa loa may develop a serious or even fatal encephalopathy either spontaneously or following treatment with an effective microfilaricide
            • The following adverse experiences have been reported in these patients, pain (including neck and back pain), red eye, conjunctival hemorrhage, dyspnea, urinary and/or fecal incontinence, difficulty in standing/walking, mental status changes, confusion, lethargy, stupor, seizures, or coma
            • This syndrome has been seen very rarely following the use of ivermectin; in individuals who warrant treatment with ivermectin for any reason and have had significant exposure to Loa loa-endemic areas of West or Central Africa, implement pretreatment assessment for loiasis and careful post-treatment follow-up

            Drug interactions overview

            • Post-marketing reports of increased INR (International Normalized Ratio) have been rarely reported when ivermectin was co-administered with warfarin
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            Pregnancy & Lactation

            Pregnancy category: C

            Pregnancy

            There are no studies in pregnant women; epidemiologic studies during pregnancy are insufficient to inform a drug-associated risk of adverse developmental outcomes, because either the timing of administration during gestation was not accurately ascertained or the administration occurred only during the second trimester; however, systemic exposure from topical use of ivermectin is much lower than that from oral use

            In animal reproduction studies, ivermectin induced adverse developmental outcomes when orally administered to pregnant mice, rats and rabbits during the period of organogenesis only at or near doses that were maternally toxic to the pregnant females

            Lactation

            There is information available on the presence of ivermectin in human milk in 4 lactating women after a single 150 mcg/kg oral dose of ivermectin; however, there is insufficient information from this study to determine effects of ivermectin on breastfed infant or on milk production

            Topical ivermectin systemic exposure is much lower than that for oral ivermectin; furthermore, amount of ivermectin present in human milk after topical application to lactating women has not been studied

            The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for therapy and any potential adverse effects on breastfed infant or from underlying maternal condition

            Lactation: Enters breast milk (AAP Committee states compatible with nursing)

            Pregnancy Categories

            A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.

            B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk.

            C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done.

            D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk.

            X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist.

            NA: Information not available.

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            Pharmacology

            Mechanism of Action

            Binds glutamate-gated Cl ion channels in invertebrate nerve and muscle cells; produces paralysis, death of parasite

            Absorption

            Well absorbed

            Peak serum time: 4 hr

            Peak effect: 3-6 months (treatment of orchocerciasis); 3 months (treatment of strongyloides)

            Distribution

            Protein bound: 93%

            Vd: 3-3.5 L/kg

            Does not cross blood-brain barrier

            Metabolism

            Hepatic (CYP3A4, CYP2D6, CYP2E1)

            Elimination

            Half-life: 18 hr

            Excretion: Feces; urine (<1%)

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            Formulary

            FormularyPatient Discounts

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            Tier Description
            1 This drug is available at the lowest co-pay. Most commonly, these are generic drugs.
            2 This drug is available at a middle level co-pay. Most commonly, these are "preferred" (on formulary) brand drugs.
            3 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs.
            4 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            5 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            6 This drug is available at a higher level co-pay. Most commonly, these are "non-preferred" brand drugs or specialty prescription products.
            NC NOT COVERED – Drugs that are not covered by the plan.
            Code Definition
            PA Prior Authorization
            Drugs that require prior authorization. This restriction requires that specific clinical criteria be met prior to the approval of the prescription.
            QL Quantity Limits
            Drugs that have quantity limits associated with each prescription. This restriction typically limits the quantity of the drug that will be covered.
            ST Step Therapy
            Drugs that have step therapy associated with each prescription. This restriction typically requires that certain criteria be met prior to approval for the prescription.
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            Medscape prescription drug monographs are based on FDA-approved labeling information, unless otherwise noted, combined with additional data derived from primary medical literature.