Efficacy of Miltefosine in the Treatment of Visceral Leishmaniasis in India After a Decade of Use

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1 MAJOR ARTICLE Efficacy of Miltefosine in the Treatment of Visceral Leishmaniasis in India After a Decade of Use Shyam Sundar, 1,a Anup Singh, 1,a Madhukar Rai, 1 Vijay K. Prajapati, 1 Avinash K. Singh, 1 Bart Ostyn, 2 Marleen Boelaert, 2 Jean-Claude Dujardin, 2,3 and Jaya Chakravarty 1 1 Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India; and 2 Institute of Tropical Medicine, and 3 Department of Biomedical Sciences, Antwerp University, Belgium Background. Miltefosine is the only oral drug available for treatment of Indian visceral leishmaniasis (VL), which was shown to have an efficacy of 94% in a phase III trial in the Indian subcontinent. Its unrestricted use has raised concern about its continued effectiveness. This study evaluates the efficacy and safety of miltefosine for the treatment of VL after a decade of use in India. Methods. An open-label, noncomparative study was performed in which 567 patients received oral miltefosine (50 mg for patients weighing <25 kg, 100 mg in divided doses for those weighing 25 kg, and 2.5 mg per kg for those aged <12 years, daily for 28 days) in a directly observed manner. Patients were followed up for 6 months to see the response to therapy. Results. At the end of treatment the initial cure rate was 97.5% (intention to treat), and 6 months after the end of treatment the final cure rate was 90.3%. The overall death rate was 0.9% (5 of 567), and 2 deaths were related to drug toxicity. Gastrointestinal intolerance was frequent (64.5%). The drug was interrupted in 9 patients (1.5%) because of drug-associated adverse events. Conclusions. As compared to the phase III trial that led to registration of the drug a decade ago, there is a substantial increase in the failure rate of oral miltefosine for treatment of VL in India. Miltefosine is the first orally effective agent for treating leishmaniasis. It was first approved in India, in 2002, for the treatment of visceral leishmaniasis (VL), following a phase III multicenter study [1, 2]. Since then, it has been registered in various other countries in different parts of the world and has been used in the treatment of nearly all forms of leishmaniasis, although with a variable rate of efficacy [3, 4]. Because of its ease of use and the possibility for ambulatory care, the VL elimination program in India, Nepal, and Bangladesh has recommended Received 15 January 2012; accepted 2 April 2012; electronically published 9 May a S. S. and A. S. contributed equally to this work. Correspondence: Shyam Sundar, MD, Dept of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi , India (drshyamsundar@ hotmail.com). Clinical Infectious Diseases 2012;55(4): The Author Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please journals.permissions@oup.com. DOI: /cid/cis474 miltefosine as the first-line drug for treatment in this region [5]. More than a decade has passed since the pivotal phase III trial leading to the registration of miltefosine in India was done. During , the drug was available over the counter in many private pharmacies, and prescribing practice and drug use was rather irrational, with many incomplete dosages and poor adherence [5]. Currently, the drug is made available only in public hospitals, through the National VL Control Program, and patients are provided the supply of drugs for 1 week at a time. We commissioned this study to evaluate miltefosine efficacy in Bihar, India, an area of VL endemicity, 10 years after the pivotal phase III trial. The study was performed in a dedicated research clinic where directly observed therapy was conducted. MATERIALS AND METHODS Study Design An open-label, noncomparative study was done at the Muzaffarpur site of the Kala Azar Medical Research Miltefosine for Leishmaniasis CID 2012:55 (15 August) 543

2 Center (KAMRC), Institute of Medical Sciences, Banaras Hindu University, from September 2009 through November The study was approved by the Ethical Committee of the Institute of Medical Sciences and by the Institute of Tropical Medicine of Antwerp, Belgium. Written informed consent was obtained from adult patients and from the guardians of patients aged <18 years. All authors participated fully in the design of the study, had access to all study data, and take responsibility for data analysis. Study Drug Miltefosine (Paladin Labs, Canada, 50-mg and 10-mg capsules) was administered orally for 28 days as directly observed therapy after meals in the following doses: 100 mg daily (one 50-mg capsule in the morning and one 50-mg capsule in the evening after meals), for patients weighing >25 kg; 50 mg every morning, for patients weighing 25 kg; and 2.5 mg/kg daily in divided doses, for patients aged <12 years. Study Patients Females and males aged 6 70 years were eligible if they had symptoms and signs suggestive of VL (ie, fever with chills, rigor, and splenomegaly) with Leishmania parasites demonstrable in splenic-aspirate smears. Splenic-aspirate smears were each read by 2 observers in a blinded fashion. Parasites in splenic-aspirate smears were graded on a log scale, from 0 (defined as 0 parasites per 1000 high-power fields in oil immersion) to 6 (defined as >100 parasites per high-power field in oil immersion) [6]. Criteria for exclusion were current pregnancy; current breast-feeding; seropositivity for human immunodeficiency virus; presence of a serious illness or concurrent infectious disease, such as tuberculosis or bacterial pneumonia; granulocyte count <1000 granulocytes/mm 3 ; hemoglobin level <5.0 g/dl; platelet count < platelets/mm 3 ; hepatic transaminase levels >5 the normal level; total bilirubin level >2.0 mg/dl; serum creatinine level above the upper normal limit; prothrombin time >5 seconds above control; and/or inability of the subject or guardian to provide written informed consent. Study Protocol Once patients fulfilled the inclusion and exclusion criteria and provided consent, they were admitted for the full duration of treatment at the KAMRC research clinic. Because of the long half-life of miltefosine and its known teratogenic potential, women of childbearing age were asked to practice contraception during treatment and for an additional 3 months after completion of treatment. Treatment was directly observed by a clinic nurse, who observed the swallowing of the pills. Vital signs, such as body temperature, pulse rate, and blood pressure, were recorded daily. Other parameters, such as body weight, spleen size, and hematological and biochemical parameters, were recorded weekly. The assessment for initial cure, at day 29, consisted of a clinical examination, including measurement of body temperature and weight, assessment of liver and spleen size, and evaluation of hematological and biochemical parameters. Splenic aspiration was repeated, and smears of aspirates were examined for Leishmania parasites (LD bodies). If splenic-aspirate smears on day 29 showed a parasite density grading of 2 (ie, 1 10 parasites per 100 highpower fields), treatment was considered to have failed, and patients were provided rescue treatment; if there were no parasites, patients were assumed to have achieved parasitological cure and were discharged from the clinic. Those with a grade of 1 (1 10 parasites per 1000 high-power fields) were discharged but recalled on day 44 to repeat the splenic-aspirate smear, and persistence of parasites meant that treatment had failed. Initial cure was defined as resolution of fever, regression of splenic enlargement, and return of laboratory values to normal ranges at the end of treatment and absence of parasites in splenic-aspirate smears at day 29 (or at day 44 for those with a grade of 1). All patients with initial cure were discharged from the clinic and invited for a follow-up visit 6 months after treatment to assess final cure. They were assessed by clinical examination and hematological and biochemical evaluation. Final cure was defined as the absence of signs or symptoms of relapse at 6 months in those with initial cure. If at any point during follow-up or at the 6-month visit a relapse was suspected, a new parasitological evaluation with a splenicaspirate smear was done to document relapse. Treatment failure was defined as either the lack of initial cure or relapse. Patients with treatment failure were given rescue treatment with amphotericin B (0.75 mg/kg administered in 15 daily infusions). Safety End Points Treatment was discontinued and subjects were given rescue treatment if an adverse event if grade 3 Common Toxicity Criteria were detected [7], except for cases of elevated hepatic enzyme levels [2]. Statistical Analysis The data were analyzed by the statistical software package SPSS (version 16.0). Continuous variables are presented as mean values ± SD, and frequencies with their respective percentages are given for categorical variables. The comparison between the mean values for patients at baseline and day 29 was done by a paired t test and the Wilcoxon signed ranked test. For comparison of clinical outcomes between treatmentnaive patients and those with relapse after prior antileishmanial treatment, the independent 2-sample t test and the Mann-Whitney U test was used. A P value of <.05 was considered statistically significant. 544 CID 2012:55 (15 August) Sundar et al

3 Table 1. Comparison of Clinical and Laboratory Data at Baseline and Day 29 Among Indian Patients With Visceral Leishmaniasis Who Received Miltefosine Therapy Variable Baseline (n = 567) Day 29 (n = 553) Change From Baseline to Day 29 (n = 553) P Value Age, years Mean ± SD 24.2 ± 16.0 Median (range) 18 (6 70) Age 12 years 432 (75.2) Sex Male 333 (58.7) Female 234 (41.3) Had relapse 40 (7.05) Illness duration, days Mean ± SD 47.2 ± 52.3 Median (range) 30 (3 365) Body weight, kg <.0001 Mean ± SD 36.1 ± ± ± 5.2 Median Splenic aspirate score Mean ± SD 2.3 ± 1.2 Median 2 Spleen size, cm below left costal margin <.0001 Mean ± SD 4.5 ± ± ± 2.5 Median Hemoglobin level, g/dl <.0001 Mean ± SD 8.3 ± ± ± 1.4 Median WBC count, cells/mm 3 <.0001 Mean ± SD ± ± ± Median Platelet count, platelets/mm 3 <.0001 Mean ± SD ± ± ± Median Creatinine level, mg/dl.009 Mean ± SD 0.8 ± ± ± 0.3 Median BUN level, mg/dl.018 Mean ± SD 8.2 ± ± ± 5.9 Median AST level, IU/mL <.0001 Mean ± SD 60.7 ± ± ± 44.4 Median ALT level, IU/mL.016 Mean ± SD 40.3 ± ± ± 39.3 Median Data are No. (%) of patients, unless otherwise indicated. Abbreviations: ALT, alanine aminotransferase; AST, aspartate aminotransferase; BUN, blood urea nitrogen; SD, standard deviation; WBC, white blood cell. RESULTS A total of 760 patients were screened and assessed for eligibility for treatment with miltefosine. Of these, 567 fulfilled the eligibility criteria and were enrolled in the study. Clinical characteristics and laboratory values at baseline are shown in Table 1. Therapy in 9 patients was stopped prematurely (Figure 1). Of these patients, 1 later died (see below), and the Miltefosine for Leishmaniasis CID 2012:55 (15 August) 545

4 Figure 1. other 8 were given rescue therapy (15 infusions of amphotericin B in a dose of 0.75 mg/kg). Four patients withdrew consent. There were 2 deaths recorded during the course of the treatment. The patient mentioned above developed repeated vomiting and severe pancytopenia during the third week of therapy and later went into shock and finally died. The death was possibly related to the study drug. Another patient had sudden death on the fourth day of therapy, probably because of a cardiac event. Finally, 553 of 567 patients were available for parasitological assessment of initial cure at day 29 (or day 44). Three more patients died before the assessment at the final cure end point Flow of patients through the study. (180 days after treatment). There was no loss to follow-up during the study (see Figure 1 flowchart). Efficacy All the 553 evaluable patients were afebrile at day 29 and showed remarkable regression of spleen size and significant improvement in clinical and hematological tests (Table 1). No parasites were demonstrated by splenic-aspirate smear; thus, an initial cure was achieved in all patients who completed therapy (Table 2). This resulted in an initial cure rate of 97.5% (553 of 567; 95% confidence interval [CI], 96.3% 98.8%). 546 CID 2012:55 (15 August) Sundar et al

5 Table 2. Clinical Outcomes Among Indian Patients With Visceral Leishmaniasis Who Received Miltefosine Therapy Table 3. Adverse Events Among Indian Patients With Visceral Leishmaniasis Who Received Miltefosine Therapy Variable Patients, No. (%) (n = 567) Drug stopped because of adverse events 9 a (1.4) Withdrew consent 4 (0.7) Death 5 b (0.8) Initial cure 553 (97.5) Relapse 39 c (6.8) Final cure 512 (90.3) a Includes 1 patient who died later, after treatment was stopped because of an adverse event; this patient s outcome is included among the data in the row Death. b Two died during treatment, and 3 died during follow-up. c Includes 1 patient who had relapse and later died; this patient s outcome is included among the data in the row Death. During the 6-month follow-up, 39 of these 553 patients (7.24%) relapsed with recurrence of fever, increase in spleen size, worsening of laboratory values, and presence of parasites demonstrated by repeat splenic-aspirate smear. Additionally, there were 3 deaths. One involved a patient for whom relapse was diagnosed at 5 months of follow-up, in association with a grade 4 splenic aspirate; he later died from severe pancytopenia and grade 3 renal dysfunction. Two other patients died during the course of follow-up: one died after developing severe pancytopenia 1 week after the end of treatment, and another committed suicide 4 months after the end of treatment. The remaining 512 patients showed consistent clinical and biochemical improvement at the 6-month follow-up visit and were classified as having achieved a definitive cure. This yielded a final cure rate of 90.3% (512 of 567; 95% CI, 87.9% 92.7%). There was no statistically significant difference in baseline clinical and laboratory characteristics between patients who relapsed and those who attained final cure (data not shown). All patients who relapsed after miltefosine treatment were successfully treated with amphotericin B, except for the patient who died before rescue treatment could be started. Of 567 patients, 78 (13.7%) had a history of previously failed antileishmanial treatment. Of these 78, 67 (85.8%) were definitely cured, and 8 patients (10.2%) relapsed; for 2 patients, treatment was stopped because of adverse events, and 1 patient withdrew consent. The cure rate among previously treated patients was not significantly different from that among treatment-naive patients, for whom the rate was 91% (445 of 489). Adverse Events Signs and symptoms with toxicity grading are given in Table 3. Gastrointestinal intolerance was the most common Adverse Event Value (n = 567) 95% Confidence Interval Vomiting Any 366 (64.55) Duration of 1 2 days 366 (64.55) Grade (44.79) Grade (19.75) Grade 3 1 (0.01).16 to.52 Diarrhea 37 (6.52) Any Grade 1 30 (5.29) Grade 2 5 (0.08) Grade 4 2 (0.03).13 to.84 Rigors Any 35 (6.17) Duration of 1 2 days 35 (6.17) AST level Change from baseline, U/L, mean (%) Day (2.3) 2.6 to 4.5 b Day (37.4) 19.0 to 11.5 b Day (32.2) 23.0 to 15.7 b Grade (57.31) Grade (33.50) Grade 3 21 (3.70) ALT level Change from baseline, U/L, mean (%) Day (23.3) b Day (17.2) b Day (1.2) 2.7 to 3.7 b Grade (60.49) Grade (21.34) Grade 3 20 (3.52) Serum creatinine level Change from baseline, mg/dl, mean (%) Day (2.7).03 to.0002 b Day (2.7).03 to.0002 b Day (3.7).054 to.005 b Grade (29.27) Grade 2 10 (1.76) Grade 3 6 (1.05) Data are No. (%) of patients, unless otherwise indicated. Abbreviations: ALT, alanine aminotransferase; AST, aspartate aminotransferase; CTC, Common Toxicity Criteria. a Specified in [7]. b For the mean change. Miltefosine for Leishmaniasis CID 2012:55 (15 August) 547

6 adverse event, with vomiting in 64.5% of patients and diarrhea in 6.5%. However, these side effects were mild (grade 1 or 2) in most patients. Miltefosine had to be stopped for only 3 patients because of severe gastrointestinal intolerance, one of whom died. The results of laboratory tests are summarized in Table 3. Mean renal function did not change significantly at the end of the therapy, compared with baseline. However, 6 patients (1%) had a grade 3 increase in serum creatinine concentration. In 2 patients, miltefosine was stopped for this reason. In the other 4, renal dysfunction was only detected at the end of therapy; in 3, tests repeated 1 week later revealed an improved condition, whereas the fourth patient, who had concomitant pancytopenia, died 1 week after treatment. Five more patients had a treatment switch because of other serious adverse events (see Figure 1). There was significant improvement in hemoglobin, leukocyte, and platelet levels with the resolution of disease (Table 1). DISCUSSION Miltefosine has been used mainly in the Indian subcontinent, and its efficacy is significantly lower in eastern Africa (Table 4). This study examined the efficacy and safety of miltefosine in a carefully monitored cohort of Indian patients 10 years after the pivotal phase III trial was done [2]. The drug was taken under direct observation, and no enrolled patients Table 4. Result of Various Clinical Trials of Miltefosine for Treatment of Visceral Leishmaniasis were lost to follow-up until the assessment of final cure at 6 months. The main findings of the current study as compared to findings from the phase III trial during were a significant decline in the final cure rate, from 94% to approximately 90% (P =.04), and a doubling of the relapse rate, from 3% (9 of 291) to 6.8% (39 of 567) (P =.02) [2]. As this cure rate was achieved under conditions whereby the drug was administered as directly observed therapy, even lower cure rates can be expected in patients receiving home-based therapy currently being practiced in the VL elimination program in India, Nepal, and Bangladesh. The related low adherence would ultimately facilitate emergence of drug-resistant strains, and we recommend the use of directly observed therapy in this program. A potential explanation to our findings could be the presence of miltefosine-resistant parasites in our cohort of patients. Miltefosine is highly susceptible to the development of resistance because of its long half-life, and this was verified in experimental studies [8]. We cannot confirm that this phenomenon occurred in the present study because in vitro susceptibility studies of clinical isolates of present patients are still in progress. Our findings are consistent with those of a recent phase IV study of miltefosine for treatment of VL in Bangladesh, where the cure rates were 71.8% and 85% in intention-to-treat and per-protocol analyses, respectively [9]. Weekly supply of the drug without direct observation might have contributed to the lower efficacy. These findings from Bangladesh is particularly Study, by Cohort Age Country Patients, No. Cure, a % (95% CI) Relapse, % (95% CI) Adults Jha et al [18] India 30 b 96.7 ( ) 3.3 ( 3.1 to 9.8) Sundar et al [2] India ( ) 3.0 ( ) Bhattacharya et al [19] India ( ) 3.9 ( ) Ritmeijer et al [21] Ethiopia 290 c 60.0 ( ) 10.3 ( ) Rahman et al [9] Bangladesh ( ) 9.7 ( ) Rijal et al d Nepal 101 At 6 months 82.1 ( ) 11.8 ( ) At 12 months 72.3 ( ) 21.8 ( ) Children Sundar et al [11] India 18 e 83.3 ( ) 11.1 ( 3.4 to 25.6) Bhattacharya et al [12] India ( ) 3.8 (.4 to 7.9) Singh et al [20] India Treatment naive ( ) 2.3 ( 2.1 to 6.7) Previously treated ( ) 0 Abbreviation: CI, confidence interval. a Computed on an intention-to-treat basis. b Restricted to patients who took 100 mg/kg of miltefosine. c Also includes patients with human immunodeficiency virus infection. d Conducted during (unpublished data). e Restricted to patients who took 2.5 mg/kg of miltefosine for 4 weeks. 548 CID 2012:55 (15 August) Sundar et al

7 intriguing because the drug had not been introduced there at the time our study was conducted. Also, in a small cohort of 101 patients treated with miltefosine in Nepal, the cure rates at 6 and 12 months were 82.1% and 72.3%, respectively, and the relapse frequencies at 6 and 12 months were 11.8% and 21.8%, respectively (Rijal et al, unpublished data). We followed all patients for 1 year after treatment in our study site in India, and only 1 patient had relapse between 6 and 12 months. Thus, for India, a 6-month follow-up period appears to be sufficient to estimate the final cure rate. The findings from the Bangladesh and Nepal studies, in addition to our own findings, indicate the vulnerability of miltefosine to lose its effectiveness. A substantial proportion of patients (65%) in the cohort developed adverse events, which was seen consistently across the clinical studies of miltefosine for treatment of VL [10 12]. In most patients, these side effects are transient, lasting for 1 2 days. Transient asymptomatic elevation of hepatic enzyme levels, although occurring in a large proportion, is rarely noticed by the patient and does not lead to discontinuation of the drug. Because miltefosine is the only oral antileishmanial drug, it was sold over the counter in India. In the VL elimination program, VL patients without contraindications for miltefosine use are provided with weekly supplies until end of treatment. Because of its potential teratogenicity and its long half-life, only nonpregnant women who agree for contraception for the duration of treatment and further 3 months are eligible. A significant proportion of patients discontinue the treatment prematurely and are not traceable [13]. One of the important reasons for this discontinuation is the high incidence of side effects, as was observed in this study. Gastrointestinal intolerance plays an important role in noncompliance if patients are not forewarned and counseled about the impending adverse events. The increasing relapse rates during miltefosine therapy may well be the reflection of suboptimal use in terms of dose and duration in the few years since its commercialization, reminding us of the declining efficacy of pentavalent antimonials [14]. It surely emphasizes the need for training and supervision of correct treatment prescription practices among healthcare staff, for measures to improve treatment adherence among patients, and for tools for monitoring treatment outcomes and drug resistance (if any) among patients. Furthermore, we need to understand the mechanism leading to miltefosine tolerance and the steps to prevent and overcome this phenomenon. This is a clinical study limited by the fact that direct testing of isolates for miltefosine resistance was not performed, and, thus, this study does not provide proof of a change in outcome due to miltefosine resistance. It remains a relevant question whether a course correction is required at this stage of the VL elimination program, in view of the availability of alternative regimens, namely, singledose liposomal amphotericin B therapy [15] or multidrug therapy, which have the distinct advantage of a shorter course and better compliance [16, 17]. Notes Acknowledgments. We are grateful to Mr N. Tiwary for statistical analysis. Financial support. This work was supported by the European Commission funded project Kaladrug-R (EC-FP ) and by the Sitaram Memorial Trust, Muzaffarpur. Potential conflicts of interest. S. S. has received grant support for clinical trials and travel funds to attend scientific meetings from Paladin Labs, Institute for One World Health, and GlaxoSmithKline, and his institute has received grants from Bharat Serum and Vaccine Ltd. All other authors report no potential conflicts. All authors have submitted the ICMJE Forms for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed. References 1. Sundar S, Rosenkaimer F, Makharia MK, et al. Trial of oral miltefosine for visceral leishmaniasis. Lancet 1998; 352: Sundar S, Jha TK, Thakur CP, et al. Oral miltefosine for Indian visceral leishmaniasis. N Eng J Med 2002; 347: Soto J, Arana BA, Toledo J, et al. Miltefosine for new world cutaneous leishmaniasis. Clin Infect Dis 2004; 38: Soto J, Toledo J, Gutierrez P, et al. Treatment of American cutaneous leishmaniasis with miltefosine, an oral agent. Clin Infect Dis 2001; 33: E Sundar S, Mondal D, Rijal S, et al. Implementation research to support the initiative on the elimination of kala azar from Bangladesh, India and Nepal the challenges for diagnosis and treatment. Trop Med Int Health 2008; 13: Chulay JD, Bryceson AD. Quantitation of amastigotes of Leishmania donovani in smears of splenic aspirates from patients with visceral leishmaniasis. Am J Trop Med Hyg 1983; 32: Cancer Therapy Evaluation Program. Common toxicity criteria. Rockville, MD. National Cancer Institute, Available at: cancer.gov/reporting/index.html. Accessed 7 October Perez-Victoria FJ, Sanchez-Cañete MP, Seifert K, et al. Mechanisms of experimental resistance of Leishmania to miltefosine: implications for clinical use. Drug Resist Updat 2006; 9: Rahman M, Ahmed BN, Faiz MA, et al. Phase IV trial of miltefosine in adults and children for treatment of visceral leishmaniasis (kalaazar) in Bangladesh. Am J Trop Med Hyg 2011; 85: Sundar S, Makharia A, More DK, et al. Short-course of oral miltefosine for treatment of visceral leishmaniasis. Clin Infect Dis, 2000; 31: Sundar S, Jha TK, Sindermann H, Junge K, Bachmann P, Berman J. Oral miltefosine treatment in children with mild to moderate Indian visceral leishmaniasis. Pediatr Infect Dis J 2003; 22: Bhattacharya SK, Jha TK, Sundar S, et al. Efficacy and tolerability of miltefosine for childhood visceral leishmaniasis in India. Clin Infect Dis 2004; 38: Sundar S, Murray H. Availability of miltefosine for the treatment of kala-azar in India. Bull World Health Organ 2005; 83: Sundar S, Thakur BB, Tandon AK, et al. Clinicoepidemiological study of drug resistance in Indian kala-azar. Br Med J 1994; 308: Sundar S, Chakravarty J, Agarwal D, Rai M, Murray HW. Single-dose liposomal amphotericin B for visceral leishmaniasis in India. N Engl J Med 2010; 362: Miltefosine for Leishmaniasis CID 2012:55 (15 August) 549

8 16. Sundar S, Rai M, Chakravarty J, et al. New treatment approach in Indian visceral leishmaniasis: single-dose liposomal amphotericin B followed by short-course oral miltefosine. Clin Infect Dis 2008; 47: Sundar S, Sinha PK, Rai M, et al. Comparison of short-course multidrug treatment with standard therapy for visceral leishmaniasis in India: an open-label, non-inferiority, randomised controlled trial. Lancet 2011; 377: Jha TK, Sundar S, Thakur CP, et al. Miltefosine, an oral agent, for the treatment of Indian visceral leishmaniasis. N Engl J Med 1999; 341: Bhattacharya SK, Sinha PK, Sundar S, et al. Phase 4 trial of miltefosine for the treatment of Indian visceral leishmaniasis. J Infect Dis 2007; 196: Singh UK, Prasad R, Mishra OP, et al. Miltefosine in children with visceral leishmaniasis: a prospective, multicentric, crosssectional study. Indian J Pediatr 2006; 73: Ritmeijer K, Dejenie A, Assefa Y, et al. A comparison of miltefosine and sodium stibogluconate in treatment of visceral leishmaniasis in an Ethiopian population with high prevalence of HIV infection. Clin Infect Dis 2006; 43: CID 2012:55 (15 August) Sundar et al