Committee
on Drugs
Commentary
on Anthelmintics
Nematode infestation of children in the North American hemisphere is a common problem, although it is not of the magnitude in this area that it is in some other areas of the world. Patients who harbor roundworms are frequently asymptomatic. However, appropriate treatment is required when clinical symptoms occur and significant infestation is found. Correct diagnosis
is of paramount importance because choice of the
the adhesive side of a piece of transparent tape against the skin. The tape is then placed on a glass slide and examined under a microscope. This is best done when the patient awakens in the morning. Ascaris infestations also are asymptomatic in a
majority of patients.3 Medical attention may not
proper drug is predicated on knowledge of the infecting organism. The two roundworms most commonly seen in the United States are Enterobius vermicularis (pinworm) and Ascaris lumbricoides (large roundworm). In warmer climates infestation with Toxocara canis, T. cati (visceral larva migrans), Trichuri.s trichiura (whipworm), Necator americanus, Ancylostorna duodenale (hookworm), and Strongyloides stercoralis occurs. This commentary is limited to the treatment of A. lunthricoides and E. rermicularis infestations because of their widespread occurrence. Enterobius vertnicularis is probably the most ubiquitous parasite in the United States and Canada. In contrast to most other helminthic
infections, enterobiasis is more of a nuisance than often
be sought until a large worm is passed through the nose, mouth, or anus. However, there is a significant incidence of abdominal pain, headache, pallor, and cough in children with heavy infestation.’ Erratic migration of the worms may result in choledochal obstruction, pancreatitis, hepatic abscesses, and bronchopneumonia. ‘ Unusual surgical complications include intestinal obstruction, intestinal perforation, volvulus, intussusception, and appendicitis.’ Migration of the larvae through the lung may produce host sensitization, resulting in pulmonary infiltrates, wheezing, cough, and eosinophilia.’ Ascaris infestation is
diagnosed by identifying the adult worms or
finding the ova in the feces. Several drugs are currently ment of Enterobius and
Although gentian violet
available
Ascaris
for treatinfestations.
marketed
continues
to be
an
actual
health
in children for
threat.
and a wide
It
has
is most
been
frequently
of symptoms.
“over the pinworms,
therapy,
counter” it represents
identified erroneously,
blamed,
because
assortment
The majority of pinworm infestations are tomatic. The most common symptom
pruritus, which in females may also extend
asympis anal
to the
are available.5 mended. Piperazine
ment of both
for the treatment of inferior and outmoded safer and more effective agents Therefore, its use is not recomis effective
and
(Antepar)
ascariasis
for
the
treatThe
enterobiasis.
vulva. Other symptoms with enterobiasis are
diarrhea, and tenesmus.’3
less commonly abdominal pain, as
associated headache,
Symptoms such problems, nocturnal have been ascribed caused by, pinworms.
may coexist.
poor appetite, behavior bruxism, and nightmares to, but are probably not These and other complaints
disadvantages of using piperazine are that it must be given daily for one week, and there is a significant incidence of adverse reactions including vomiting, diarrhea, urticaria, tremor, dizziness, visual disturbances, and weakness.3 Py rvinium pamoate (Povan Suspension) is
extremely effective and may dose of 5 mg/kg. It is indicated of enterobiasis. Pyrvinium vomiting, abdominal cramping, be given as a single only for freatment
The presence of pinworms can be documented either by finding the worms in the feces or, more commonly, by microscopic identification of the eggs deposited on the perianal skin. The eggs can be recovered from the perianal area by pressing
occasionally causes and diarrhea3; it
is a red dye that colors the stool and vomitus bright red, so soiling may result in permanent staining of clothing.
PEDIATRICS
Vol. 62 No. 2 August
1978
251
Pyrantel
effective
pamoate
against both a dye
(Antiminth)
ascariasis and does and not
is
extremely dose of 10
It may
enterobiasis, stain.
and
mg/kg.
may
be
administered
as a single
It is not
2. Many the public infestation, caused by
symptoms commonly considered by to be associated with roundworm particularly pinworms, are in fact not parasitosis. This may lead to children
an and/or anthelmintic causes, self-treatwhen and the
cause
nausea, cramping, and in approximately Mebendazole addition to the
vomiting, diarrhea, abdominal transient elevation of SGOT level 2% to 4% of patients.6 (Vermox), a relatively recent anthelmintic armamentarium, is
receiving a drug unnecessarily ment of a condition with the illness or symptom has
other
person tion.
3.
should
Although
receive
most
appropriate
of the
medical
attenappear
extremely effective against biasis as well as infestations
In clinical zole has trials had in children a lower
ascariasis of other
and incidence adults,
and enteronematodes.
mebendaof reported
anthelmintics
to be relatively safe, there may be a real risk from unsupervised and excessive exposure to these agents following their widespread promotion and
over-the-counter 4. The dose exception weight of sale. each The of the drugs, with the
adverse
mintic
side
agents.7”
effects
pain worm Less
than
any
of the
other
anthel-
abdominal ing a large pinworms.
The only side effects have been and cramping in patients expellload. This is not a problem with than 10% of the drug appears to
of mebendazole, for safe use.
must be based on body possibility of dosage
be absorbed Pharmaceutical
1977). received In
from
four
the gastrointestinal Corp., personal
children aged
tract (Ortho communication,
3 to 6 years who
errors during over-the-counter ent danger therefrom are
The diagnosis and
use obvious.
of
and
these
the
inherinfesta-
treatment
plasma
mebendazole
100 levels
mg orally as a chewable tablet, never exceeded 0.03 jzg/ml of
or 0.09 Corp., of the tg/ml of a metabolite, phenylketone (Orpersonal communicalow systemic bioavail-
lions should properly be carried out care and supervision of a physician, appropriate drug should be administered prescription.
COMMITTEE
under the and the only by
ON
2-amino-5(6)-benzimidazolyl tho Pharmaceutical tion, 1977). Because
DRUGS
ability of this drug, the labeling calls for the same dose for patients of all ages and sizes more than 2 years old. The drug is not recommended for
children less than quate data in this 2 years old because of madegroup. A single, 100-mg dose is treatment be the repeated treatment of enterobiasis. in of twice low of first ascariasis. two weeks The if three
Sydney Segal, M.D., John Freeman, M.D.; Kagan, M.D.; Ralph E. M.D.; Lester F. Soyka,
Chairman; Sanford N. Cohen, M.D.; Reba M. Hill, M.D.; Benjamin M. Kauffman, M.D.; Albert W. Pruitt, M.D.; Stanley M. Vickers, M.D.
REFERENCES
1. Biagi F, Lopez R, Viso J: Analysis of symptoms and signs related with intestinal parasitosis in 5,215 cases, in J ucker E (ed): Progress in Drug Research: Tropical Diseases II. Basel, Switzerland, Birkhauser, 1975, vol 19, pp 10-22.
E: Recent advances in the treatment of
given
treatment necessary.
for
the may For
Ascaris
daily
infestafor
2.
tions,
100 mg
is administered effectiveness,
days. Because
Barrett-Connor
of their
incidence
of for There
side
and the
effects,
mebendazole treatment
and
ease
are
of administration,
the drugs and
pyrantel
choice
of enterobiasis
is little
other. There the available pinworm
basis
have
on
been
which
proposals specifically counter The position treatment
to
select
to
one
make
over
certain pamoate,
the
of of Drugs
anthelmintics, over the infestations. this
pyrantel
for self-treatment Committee on for several requires made or its
disagrees with 1. Appropriate diagnosis, identification consumer do this. which
reasons. proper
of rarely
can the has
only be parasite the equipment
by a positive ova. The lay or expertise to
common intestinal helminths. Am I Gastroenterol 63:105, 1975. 3. Most H: Treatment of common parasitic infections of man encountered in the United States, part 1. N Engl I Med 287:495, 1972. 4. Katz M: Anthelmintics. Drugs 13:124, 1977. 5. Rollo IM: Drugs used in the chemotherapy of helminthiasis, in Goodman LS, Cilman A (eds): The Pharmacological Basis of Therapeutics, ed 5. New York, Macmillan, 1975, p 1018. 6. Pitts NE, Migliardi JR: Antiminth (pyrantel pamoate): The clinical evaluation of a new broad-spectrum anthelmintic. Clin Pediatr 13:87, 1974. 7. Maqbool 5, Lawrence D, Katz M: Treatment of trichuriasis with a new drug, mebendazole. I Pediatr 86:463, 1975. 8. Wolfe MS. Wershing JM: Mebendazole: Treatment of trichuriasis and ascariasis in Bahamian children. JAMA 230:1408, 1974.
252
ANTHELMINTICS