Moser W, et al. - Whether or not triple-drug therapy (TDT) with albendazole, pyrantel pamoate, and oxantel pamoate was more effective than the co-administration of two drugs for the treatment of hookworm infections was assessed. Outcomes suggested TDT with albendazole, pyrantel pamoate, and oxantel pamoate as valuable, especially in the context of soil-transmitted helminth elimination. To prevent benzimidazole resistance, pyrantel pamoate was suggested as a useful alternative. Larger trials are recommended to confirm the findings.

Methods

• From Sept 27 until Nov 17, 2017, researchers performed a randomised, single-blind trial in Laos.
• Children (6–15 years) from six schools were invited to participate.
• By a computer stratified list (block sizes of six and 12), they randomly assigned (2:2:1:1) hookworm-positive children to TDT with albendazole (400 mg), pyrantel pamoate (20 mg/kg), and oxantel pamoate (20 mg/kg); albendazole plus oxantel pamoate; pyrantel pamoate plus oxantel pamoate; or mebendazole (500 mg) combined with both pyrantel pamoate and oxantel pamoate (used as proof of concept to compare the two TDTs).
• At baseline and follow-up (17–30 days after treatment), they collected 2 stool samples which were analysed using the Kato-Katz method.
• They assessed the proportion of hookworm egg-negative children at follow-up in all Kato-Katz slides (cure rate [CR]) in the TDT with albendazole, pyrantel pamoate, and oxantel pamoate group compared with the albendazole plus oxantel pamoate and pyrantel pamoate plus oxantel pamoate groups as the primary outcome.
• Tolerability 3 h and 24 h after treatment, egg reduction rates (ERRs) against hookworm, and efficacy against concomitant soil-transmitted helminth infections were assessed as the secondary outcomes.
• To treatment allocation, participating children and field and laboratory technicians were masked.

Results

• Researchers assessed 1529 children for eligibility; of these, 533 provided complete baseline data and 414 provided complete outcome data.
• In this study, higher CR was noted for the TDT albendazole, pyrantel pamoate, and oxantel pamoate (116 [84%] of 138) than with albendazole plus oxantel pamoate (73 [53%] of 138; odds ratio 4·7, 95% CI 2·7–8·3; p < 0·0001) and pyrantel pamoate plus oxantel pamoate (36 [52%] of 69; 4·8, 2·5–9·3; p < 0·0001).
• Findings suggested higher geometric ERR of the TDT albendazole, pyrantel pamoate, and oxantel pamoate (99·9%) than that for albendazole plus oxantel pamoate (99·0%; difference in ERR 0·9 percentage points, 95% CI 0·5–1·4), and pyrantel pamoate plus oxantel pamoate (99·2%; 0·7 percentage points, 0·3–1·3).
• They identified reports of adverse events in six (1%) children 3 h and none 24 h after treatment; no difference across treatment groups was noted.