Laguna F
Servicio de Enfermedades Infecciosas, Hospital Carlos III, Sinesio Delgado 12, 28029 Madrid, Spain.
Ann Trop Med Parasitol. 2003 Oct;97 Suppl 1:135-42. doi: 10.1179/000349803225002606.
Although, in southern Europe, there has been considerable experience in the treatment of visceral leishmaniasis (VL) in HIV-positive patients, the optimal therapy has yet to be established. Pentavalent antimony salts, free amphotericin B deoxycholate (ABD) and lipidic formulations of amphotericin B are the drugs most commonly used. Treatment with pentavalent antimonials requires daily injections for 28 days, is not well tolerated and leads to initial clinical cure in only 66% of the co-infected cases. Free ABD has to be given, intravenously, for just as long, has significant toxicity and leads to initial clinical cure in even fewer cases (62%). In a prospective, comparative trial, treatment of co-infected cases with a pentavalent antimonial was found to have similar efficacy and toxicity to treatment with free ABD. The duration of treatment and the associated toxicity may both be reduced by the use of lipidic formulations of amphotericin B. Anecdotal evidence and the results of non-randomized trials indicate that treatment with liposomal amphotericin B is highly effective. In a comparative trial, amphotericin B lipid complex was found to be not only as effective as a pentavalent antimonial but also better tolerated. At the moment, however, such lipidic formulations have only been tested against VL/HIV cases in Europe, not elsewhere in the world, and they remain very expensive. However successful the treatment in terms of initial clinical cure, almost all VL/HIV cases develop VL relapses. Although the data available on secondary prophylaxis are limited and often inconclusive, it appears that regular treatment with a pentavalent antimonial drug, liposomal amphothericin B or amphotericin B lipid complex can reduce the incidence of leishmanial relapses in HIV-positive patients with VL. The development of new regimens, use of new oral drugs (such as miltefosine) and the development of new antileishmanial drugs could all improve the treatment of HIV-related VL in the future.
尽管在欧洲南部，对HIV阳性患者的内脏利什曼病（VL）治疗已有相当多的经验，但最佳治疗方案尚未确立。五价锑盐、游离两性霉素B脱氧胆酸盐（ABD）和两性霉素B的脂质制剂是最常用的药物。五价锑治疗需要每日注射28天，耐受性不佳，仅66%的合并感染病例能实现初始临床治愈。游离ABD也需要静脉注射同样长的时间，毒性显著，初始临床治愈率更低（62%）。在前瞻性比较试验中，发现用五价锑治疗合并感染病例的疗效和毒性与游离ABD治疗相似。使用两性霉素B脂质制剂可缩短治疗时间并降低相关毒性。轶事证据和非随机试验结果表明，脂质体两性霉素B治疗非常有效。在一项比较试验中，发现两性霉素B脂质复合物不仅与五价锑一样有效，而且耐受性更好。然而，目前此类脂质制剂仅在欧洲针对VL/HIV病例进行了测试，世界其他地区尚未测试，且价格仍然非常昂贵。尽管初始临床治愈方面治疗很成功，但几乎所有VL/HIV病例都会出现VL复发。尽管关于二级预防的现有数据有限且往往无定论，但似乎定期使用五价锑药物、脂质体两性霉素B或两性霉素B脂质复合物治疗可降低HIV阳性VL患者利什曼病复发的发生率。新治疗方案的开发、新型口服药物（如米替福新）的使用以及新型抗利什曼病药物的研发未来都可能改善HIV相关VL的治疗。
