Reference Point
Guidelines for treatment of leishmaniasis in dogs
Gaetano Oliva, dvm; Xavier Roura dvm, phd; Alberto Crotti, dvm; Michele Maroli, phd;
Massimo Castagnaro, dvm; Luigi Gradoni, phd; George Lubas, dvm; Saverio Paltrinieri, dvm;
Andrea Zatelli, dvm; Eric Zini, dvm, phd
D rug treatment of leishmaniasis in dogs is a chal-
lenge for veterinary practitioners. Because of its
complex pathogenesis, leishmaniasis may manifest with
various clinical signs, ranging from mild and nonspe-
cific to those reflecting severe involvement of several
organs. The immune response plays an important role
in the development, outcome, and response to treat-
ment of Leishmania infection in dogs.1 All known anti-
Leishmania drugs used in dogs can lead to temporary
or permanent remission of clinical signs, but none are
sufficient to eliminate the infection.2 Indeed, all anti-
Leishmania drugs currently used in dogs were discov-
ered and developed to treat leishmaniasis in humans.
Most therapeutic protocols were developed through
human clinical studies and thereafter adapted to dogs,
often without sufficient pharmacokinetic information
relevant to dogs.
In dogs, the objectives of anti-Leishmania treatment
are typically to induce a general reduction of the para-
site load, to treat organ damage caused by the parasite,
to restore efficient immune responses, to stabilize a
drug-induced clinical improvement, and to treat clini-
cal relapse. The most widely used drugs are described
in the present report. In addition, we propose a 5-class
staging of leishmaniasis that can help in choosing the
most appropriate anti-Leishmania treatment. As with
our guidelines for diagnosis of leishmaniasis in dogs,3
the guidelines reported here are an updated version of
those originally published in Italian in Veterinaria, the
official journal of the Italian Society of Veterinarians
From the Department of Veterinary Clinical Sciences, Faculty of
Veterinary Medicine, University of Naples, 80137 Naples, Italy
(Oliva); Veterinary Teaching Hospital, College of Veterinary Medi-
cine, Universitat Autònoma de Barcelona, 08007 Barcelona, Spain
(Roura); Associated Veterinary Clinic, Via P. Revelli Beaumont
43, 16143 Genoa, Italy (Crotti); Vector-borne Diseases & Inter-
national Health, MIPI Department, National Institute of Health,
Viale Regina Elena, 00161 Rome, Italy (Maroli, Gradoni); Depart-
ment of Public Health, Comparative Pathology & Veterinary Hy-
giene, Faculty of Veterinary Medicine, University of Padua, 35020
Legnaro, Italy (Castagnaro); Department of Veterinary Clinic, Fac-
ulty of Veterinary Medicine, University of Pisa, 56126 Pisa, Italy
(Lubas); Department of Veterinary Pathology, Hygiene and Public
Health, School of Veterinary Medicine, University of Milan, 20122
Milan, Italy (Paltrinieri); Veterinary Clinic Pirani, Via Majakowski
2/L,M,N, 42100 Reggio Emilia, Italy (Zatelli); and Clinic for Small
Animal Internal Medicine, Vetsuisse Faculty, University of Zurich,
CH 8057 Zurich, Switzerland (Zini).
Supported by Hill’s Pet Nutrition Incorporated.
All authors contributed equally to the study.
Address correspondence to Dr. Zini (ezini@vetclinics.uzh.ch).
1192 Vet Med Today: Reference Point JAVMA, Vol 236, No. 11, June 1, 2010
Sbv
Abbreviation
Pentavalent antimony
of Companion Animals, and are based on a thorough
review of international literature and, where data are
inadequate or incomplete, are supplemented with the
experience of Canine Leishmaniasis Working Group
members. The present guidelines are limited to spe-
cific antiparasite drugs and are not intended to cover
other ancillary drugs that are often necessary during
treatment of leishmaniasis in dogs.
Review of the Veterinary Literature
Methods—The PubMed database was searched by
use of the following combination of search terms: (dog*
OR canine) AND (drug OR treat* OR therap* OR effi-
cac* OR effect* OR action* OR activit* OR against OR
versus) AND (leishm* OR antileishm*) NOT vaccin*.
After the elimination of 30 publications unrelated to
the topic, 62 were included in the review.
Results—The main limitation encountered was the
lack of similar methods used among different studies,
which rendered comparison of the reported drug proto-
cols and results difficult. In addition, weaknesses of the
literature included unblinded studies, lack of a control
group, low number of enrolled dogs, nonstandardized
criteria for diagnosis of leishmaniasis, poor description
of clinical signs, nonstandardized criteria for definition
of clinical or parasitological cure (elimination of para-
sites from tissues), inadequate follow-up to evaluate
drug efficacy, and large variability of drug dosages and
periods of treatment.
Results of the literature review indicated that the
most commonly investigated anti-Leishmania drugs for
treatment of leishmaniasis in dogs have been, in de-
scending order of citations, antimonial compounds,2–35
allopurinol,27–45 aminosidine (paromomycin),6,17,46,47
amphotericin B,48–50 miltefosine,51–53 pentamidine,54 spi-
ramicin combined with metronidazole,55 marbofloxa-
cin,56 enrofloxacin,57 and domperidone.58
Pharmacological and Therapeutic Aspects
of the Main Anti-Leishmania Drugs
Antimonial compounds—At the time of writing,
antimonial compounds were not licensed by the US FDA
for use in dogs. N-methyl-glucamine (meglumine) anti-
moniatea is the most used Sbv compound for treating
leishmaniasis in dogs and humans. The drug selectively
inhibits leishmanial glycolysis and fatty acid oxidation.
In 94% to 95% of humans with leishmaniasis, a dose of
20 mg of Sbv (approx 60 mg of salt)/kg/d (27.3 mg/lb/d)
for 28 days results in a parasitological and clinical
cure.59,60 Meglumine antimoniate has a short half-life
in dogs: 21, 42, and 122 minutes when it is adminis-
trated IV, IM, and SC, respectively. By 6 to 9 hours after
administration, 80% to 95% of meglumine antimoniate
is eliminated through the kidneys.22,23 Most studies in
dogs have revealed that the drug has good clinical ef-
ficacy. During treatment, clinical amelioration is usu-
ally observed after a period of 1 or more weeks together
with improvement in hematologic and serum biochem-
ical values. However, restoration of serum protein elec-
trophoresis abnormalities to within reference limits can
be slow and is usually dose dependent.2 Several authors
have described that treatment with meglumine antimo-
niate does not result in full elimination of Leishmania
organisms from infected dogs.14,17 Rather, a few months
after treatment, parasites can still be detected in tissues
of clinically cured dogs.14,17 Clinical relapses commonly
occur after treatment in a period ranging from months
to 1 or 2 years and are more common when the dura-
tion of treatment is shorter than 4 weeks.
Treatment with Sbv compounds induces a gener-
alized reduction of the parasite load, together with a
temporary restoration of cell-mediated immunologic
response.7 A decrease in specific serum antibody titers
also develops.2 Pain and swelling of the injection site
are the most common adverse effects of antimonials. Fe-
ver, diarrhea, and loss of appetite have been reported,20,28
and a case of acute pancreatitis attributable to antimoni-
al treatment has also been described.4 To date, there has
been no evidence of renal damage induced by antimoni-
als in dogs. Transient elevation of serum alanine amino-
transferase and amylase activities has been reported.13,40
The most commonly reported treatment regimen
is 100 mg of meglumine antimoniate/kg (45.5 mg/lb),
once a day for 4 weeks. Because of the pharmacokinetic
properties of Sbv compounds, the dosage might be bet-
ter divided in 2 daily doses of 50 mg/kg (22.7 mg/lb).22
Initiation of antimonial treatment at the onset of leish-
maniasis, together with correct management of clinical
relapses, can result in survival for 4 years in 75% of
treated dogs.20 Certain antimonial treatment regimens
reportedly select for Leishmania strains that are resis-
tant to Sbv.11 A liposomal formulation of Sbv has been
tested, revealing good evidence of efficacy,24 but such a
formulation is not yet commercially available.
Allopurinol (FDA approved for use in dogs)—
Allopurinolb is a structural analogue of hypoxanthine
that inhibits the activity of xanthine oxidase, an en-
zyme that catalyzes the production of xanthine from
hypoxanthine and uric acid from xanthine. Its anti-
Leishmania activity is attributable to the inability of
the parasite to synthesize purines ex novo, thereby
requiring purines to be supplied by the host. When
incorporated by intracellular Leishmania amastigotes,
allopurinol is transformed into a toxic compound (4-
amino-pyrazole-pyrimidine) that kills the parasite. In
humans with leishmaniasis, allopurinol has poor effi-
JAVMA, Vol 236, No. 11, June 1, 2010 Vet Med Today: Reference Point 1193
cacy when administered as monotherapy. The low ac-
tivity is probably attributable to the insufficient trans-
formation of allopurinol into oxypurinol, which is the
chemical form producing the aforementioned toxic
compound.61 In humans treated for leishmaniasis, the
combination of allopurinol and antimonials allows a
reduction of the dosage of Sbv.62
When administered to dogs as a single anti-Leishma-
nia agent for a minimum period of 2 to 3 months, allopu-
rinol usually leads to moderate clinical improvement and
partial restoration of some laboratory analytes to within
references ranges, such as acute-phase proteins of in-
flammation.36,40,42,45 Similar to treatment of leishmaniasis
with antimonial drugs, treatment with allopurinol does
not result in a full parasitological cure and relapses occur
when treatment is interrupted. For this reason, allopuri-
nol is usually administered for periods as long as several
months.36,40 The tolerability of the drug is excellent and
seems to slow the deterioration of renal function in dogs
with proteinuria but without renal insufficiency.41 The
most commonly prescribed dosages of allopurinol range
between 5 and 20 mg/kg (2.3 and 9.1 mg/lb), PO, every
12 hours for 2 to 24 months.
Meglumine antimoniate–allopurinol combination—
The combination of meglumine antimoniate and allopu-
rinol is the most common treatment for leishmaniasis in
dogs, although it does not result in a complete parasito-
logical cure. Dogs treated with the combination reportedly
have a longer period of clinical remission than when treat-
ed with either drug alone.28 The most common protocol
consists of meglumine antimoniate administered SC at the
dose of 100 mg/kg, once a day for 1 to 2 months in combi-
nation with allopurinol administered PO at 10 mg/kg (4.5
mg/lb) every 12 hours for several months. Adverse effects
associated with the combination are the same as those re-
ported for administration of either agent alone.
Aminosidine (FDA approved for use in dogs)—
Aminosidinec (also called paromomycin) belongs to the
class of aminoglycosides and possesses antimicrobial and
antiprotozoal activity. Although developed in the 1960s
as an anti-Leishmania agent, it remained neglected until
the 1980s when topical and systemic formulations were
found effective in treating humans with leishmaniasis.
Aminosidine acts against Leishmania donovani by impair-
ing ribosomal subunit association. In addition, it induces
respiratory dysfunction in L donovani promastigotes.63,64
Aminosidine had been successfully used in the treatment
of humans with leishmaniasis, 95% of whom are parasi-
tologically cured when treated with a dosage of 11 mg/kg
(5 mg/lb), IM, once a day for 21 days.63 The drug has
been used in dogs as a single agent and in combination
with meglumine antimoniate.6,17,46,47 The most commonly
used aminosidine protocol in dogs is 5 mg/kg, SC, once
a day for 3 weeks, plus 60 mg of meglumine antimoni-
ate/kg (27.3 mg/lb), IM, every 12 hours for 4 weeks. The
combination allows better clinical and parasitological re-
sults than either drug alone.17 One severe limitation for
more widespread use of aminosidine is related to its renal
and vestibular toxic effects.17
Amphotericin B (FDA approved for use in dogs)—
The polyene amphotericin Bd interacts with fungal
membrane sterols and preferentially with ergosterol. As
with fungi, Leishmania spp have ergostane-based ste-
rols as a major membrane sterol, which likely explains
the efficacy of amphotericin B in treating leishmania-
sis.65 Although highly effective, amphotericin B is toxic
and associated with severe adverse effects. Particular
adverse effects include impairment of renal function,
pyrexia, vomiting, and anorexia. A daily dosage of 0.5
mg/kg (0.23 mg/lb), IV, on alternate days for 4 weeks
results in a parasitological cure in 97% of humans with
leishmaniasis.65
In dogs, amphotericin B diluted with sterile saline
(0.9% NaCl) solution and emulsified with soybean oil has
been administered IV.48,49 Although the formulation allows
the clinical cure of most treated dogs, it is generally not
used as routine treatment because of complexity in prepara-
tion and administration. Since the early 1990s, a liposomal
formulation of amphotericin B has been the first-line anti-
Leishmania drug for the treatment of humans in Western
countries. Because it is expensive, use of amphotericin B is
limited in developing countries. Liposomal amphotericin B
is by far less toxic than the conventional formulation, while
maintaining the same cure rate as in humans with leish-
maniasis.60 When administered in dogs, the same liposomal
formulation results in a rapid clinical cure, although the im-
provement is invariably followed by relapses.50 To avoid the
occurrence of amphotericin B–resistant Leishmania strains,
the World Health Organization has discouraged its use in
the treatment of dogs with leishmaniasis.
Miltefosine—Miltefosine,e an alkylphosphocholine,
is not FDA approved for use in dogs with leishmaniasis.
In humans, it was developed as an anti-cancer agent and
later used to treat leishmaniasis.66 The drug was recently
registered for oral administration in dogs with leishman-
iasis in several European countries. The in vitro and in
vivo anti-Leishmania activity of miltefosine is attribut-
able to impairment of signaling pathways and cell mem-
brane synthesis that lead to parasite death.67 In animals,
the drug has anti-Leishmania activity after oral adminis-
tration.68 In humans, miltefosine induces a rapid clinical
and parasitological cure in 91% to 95% of leishmaniasis
patients; dosages of 100 to 150 mg/d (or 2.5 mg/kg [1.14
mg/lb]) for 28 days are the most effective.69,70
At present, there are few published reports regarding the
efficacy of miltefosine for treatment of leishmaniasis in dogs.
The drug has been administered alone (2 mg/kg [0.91 mg/lb],
q 24 h, for 28 days) or in combination with allopurinol
(10 mg/kg, q 12 h, for several months). Similar to all anti-
Leishmania drugs used in dogs, miltefosine administra-
tion is not able to fully eliminate the parasite from infected
dogs, although a drastic and progressive reduction of the
parasite load in lymph node aspirates has been reported.51–53
Despite partial or good resolution of clinical signs, clinical re-
lapses have also been reported when the drug is used alone.
The clinical efficacy of miltefosine improves when given to-
gether with allopurinol.51,52 This combination reportedly has
the same clinical and parasitological efficacy as the combi-
nation of meglumine antimoniate and allopurinol.52 During
a follow-up period of 7 months, neither relapses nor severe
adverse effects were reported in dogs treated with miltefos-
ine.52 Minor adverse effects consist of self-limited vomiting or
diarrhea.52,53 Whether treatment with miltefosine can lead to
selection of drug-resistant Leishmania strains in dogs requires
investigation.
1194 Vet Med Today: Reference Point JAVMA, Vol 236, No. 11, June 1, 2010
Pentamidine (FDA approved for use in dogs)—
Pentamidinef is an aromatic diamidine that has been
used as a second line of treatment for humans with
leishmaniasis, but its precise mode of action remains to
be elucidated. The leishmanicidal activity of the drug
may be mediated via its influence on polyamine biosyn-
thesis and mitochondrial membrane potential.54 Pent-
amidine was initially found useful in the treatment of
humans with Sbv-resistant leishmaniasis in India,71 but
treatment-limiting factors were the cost of treatment
and the risk of inducing irreversible insulin-dependent
diabetes mellitus. In addition, because of its low effec-
tiveness (only 70% of affected humans cured), use of
the drug has been abandoned.71 Pentamidine was used
to treat dogs with leishmaniasis during the 1980s, but
administration of the drug resulted in severe adverse
effects such as vomiting, diarrhea, hypersalivation, sys-
temic hypotension, and anaphylactic shock. Some ben-
efits were observed in affected dogs.54
Spyramicin–metronidazole combination—Metro-
nidazole but not spyramicin has been FDA approved for
use in dogs. Because of the anti-Leishmania activity of met-
ronidazole in vitro, some researchers evaluated a combi-
nation of spyramicing (150,000 U/kg [68,182 U/lb], PO,
q 24 h) and metronidazole (25 mg/kg [11.4 mg/lb], PO,
q 24 h) in 13 dogs with leishmaniasis.55 Results were
compared with those in 14 infected dogs treated with
an antimonial-allopurinol combination. All dogs were
treated for 90 days, and proportions of dogs that clini-
cally improved were not significantly different between
treatment groups.
Marbofloxacin (FDA approved for use in dogs)—
Marbofloxacinh is a synthetic third-generation fluoro-
quinolone developed for veterinary use. It has potent
activity against several species of bacteria and is com-
monly administered to treat a wide range of gram-nega-
tive and gram-positive bacterial infections. Like other
quinolones, marbofloxacin inhibits the bacterial en-
zyme DNA gyrase.26 Trypanosomidae such as Leishma-
nia infantum have a genomic structure that shares major
similarities with bacteria. An in vitro study36 revealed
direct and indirect leishmanicidal activity of marbo-
floxacin via tumor necrosis factor-α and nitric oxide
synthase pathways.36 A clinical study56 involving a lim-
ited number of dogs was conducted to compare the
safety and efficacy of 4 treatment regimens with mar-
bofloxacin administered PO at the dosage of 2 mg/kg,
once a day. Results suggested that marbofloxacin ad-
ministered at that dosage for 28 days improves clinical
signs of leishmaniasis in dogs.
Enrofloxacin (FDA approved for use in dogs)—
Enrofloxacini is a fluoroquinolone with the capability
of enhancing the macrophage killing activity against
Leishmania spp in vitro through generation of nitric
oxide.57 The anti-Leishmania activity of enrofloxacin,
alone or in combination with metronidazole, has been
evaluated in dogs, all of which had short-lasting, partial
clinical improvement.57
Domperidone—Domperidone,j a dopamine D2
receptor antagonist with gastric prokinetic and anti-
emetic activity, has not been approved by the FDA for
use in dogs. The antidopaminergic effect results in the
release of serotonin, which in turn stimulates prolactin
production.72 Prolactin has been classified as a proin-
flammatory lymphocyte-derived cytokine, but whether
this may mediate the effect against Leishmania spp is
unknown.73 In a recent study,58 the effects of domperi-
done administration were evaluated in dogs naturally
infected with L infantum.58 Ninety-eight dogs were
orally treated with domperidone as a single agent at
1 mg/kg (0.45 mg/lb), every 12 hours for 1 month.
Domperidone was effective in reducing clinical signs
and antibody titers in most treated dogs. No adverse
effects were observed during the study.
poses, we suggest an additional stage (stage E), which
includes dogs unresponsive to recommended treatment
(stage E-a) or dogs that have a relapse of clinical dis-
ease soon after completion of recommended treatment
(stage E-b).
Stage A (exposed dogs)—Dogs in this stage do
not need any treatment. They should be serologically
monitored for 2 to 4 months after the first finding of
low-titer3 antibodies against Leishmania spp. If abnor-
mal clinical findings develop, additional evaluation is
indicated, including parasitological testing performed
with a direct method.

Treatment According to Clinical Stage
Therapeutic options and choice of drug regimens
for dogs with leishmaniasis should be considered in
light of the different clinical forms of the disease. As de-
scribed in the guidelines for diagnosis and clinical clas-
sification of leishmaniasis,3 dogs with positive results of
serologic tests or in which the parasite has been iden-
tified via direct diagnostic methods such as cytologic
or real-time PCR analysis can be classified in 4 clini-
cal stages: A, exposed dogs; B, infected dogs; C, sick
dogs (dogs with clinically evident leishmaniasis); and
D, severely sick dogs (Table 1). For therapeutic pur-
Stage B (infected dogs)—Dogs in this stage need
treatment if the direct detection of parasites is associ-
ated with an increase in antibody titers a few weeks
after the first serologic diagnosis. If the infected dogs
do not seroconvert, treatment is not indicated. In this
situation, dogs should be monitored serologically every
2 to 3 months.
Stage C (sick dogs: dogs affected by clinically evi-
dent leishmaniasis)—Dogs in this stage need treatment
with an appropriate anti-Leishmania drug regimen. A
complete clinicopathologic examination may also sug-
gest the need for ancillary treatment.

Table 1—Staging of disease for treatment of dogs with leishmaniasis.

Stage of leishmaniasis Features

A: Exposed Includes dogs with negative cytologic, histologic, parasitological, and mol-
ecular findings and low-titer3 antibodies against Leishmania spp. Dogs are
clinically normal or have signs associated with other diseases. Usually, dogs in
this category are those living or that have lived during 1 or more trans-
mission seasons in a geographic region in which the presence of Leish-
mania vectors (sand flies) has been confirmed.

B: Infected Includes dogs in which parasites have been detected through direct
diagnostic methods (eg, microscopic evaluation, organism culture, or PCR
assay) and with low-titer3 antibodies against Leishmania spp. Dogs are
clinically normal or have signs associated with other diseases. In endemic
areas, detection of Leishmania DNA via PCR assay in skin or peripherally
obtained blood samples collected during the infection transmission period, in
the absence of evident lesions, may not be sufficient to consider a dog
infected.

C: Sick (clinically evident Includes dogs with positive cytologic results regardless of serologic results,
disease) dogs with high antibody titers3 against Leishmania spp, and rarely, infected
dogs. One or more clinical signs common to leishmaniasis are present.3 Given
the varied clinical manifestations of the disease, observed signs suggestive of
disease can differ from the common clinical signs, as long as they can be
clearly associated with ongoing infection. When physical examination does
not reveal clinical signs, dogs in this category should still be defined as sick
when hematologic, biochemical, and urinary alterations common to leish-
maniasis3 are detected. Laboratory changes other than those considered
common can also be indicative of disease, provided that they are associated
with the infection.

D: Severely sick Includes sick dogs with severe clinical illness, as indicated by 1 of the
following: evidence of proteinuric nephropathy or chronic renal failure;
presence of concurrent problems (eg, ocular disease causing functional loss
or joint disease impairing mobility) related or unrelated to leishmaniasis that
require immunosuppressive treatment; severe concomitant conditions
including various coinfections or neoplastic, endocrine, or metabolic diseas-
es; and clinical unresponsiveness to repeated courses of anti-Leishmania drugs.

E-a: Sick-unresponsive Includes sick dogs unresponsive to recommended anti-Leishmania treatment.

E-b: Sick–early relapse Includes sick dogs treated in accordance with the recommended anti-Leishma-
nia protocol but that relapse soon after treatment ceases.

JAVMA, Vol 236, No. 11, June 1, 2010 Vet Med Today: Reference Point 1195
 Stage D (severely sick dogs)—Dogs in this stage
need both anti-Leishmania treatment and ancillary
treatment, depending on the affected organ or organs
(eg, renal failure or hepatopathy).
Stage E-a (sick dogs unresponsive to recommend-
ed treatment)—To clinically manage dogs in this stage,
several factors need to be taken into account. First, the
dog owner’s compliance in administration of medica-
tions should be verified and the adopted treatment
regimen should be reevaluated to ensure drug doses,
frequencies of administration, and durations of treat-
ment are as recommended. Clinical and laboratory
findings should also be reassessed to verify whether the
abnormalities may suggest a concomitant disease and
to rule out disorders sharing main clinical signs with
leishmaniasis (eg, other types of infection, neoplasia,
or immune-mediated diseases). When diagnosis was
made solely on the basis of serologic findings, serologic
testing should be repeated or PCR assay for detection
of Leishmania DNA should be performed. If the afore-
mentioned actions confirm leishmaniasis and treatment
has been correctly administered, then an alternative
specific anti-Leishmania treatment regimen should be
considered.
Stage E-b (sick dogs that relapse soon after recom-
mended treatment ceases)—The same considerations
indicated for stage E-a should be applied to dogs in this
stage. The main steps should be to reevaluate the diag-
nostic scheme and rule out other metabolic or infectious
disorders. If leishmaniasis is confirmed and treatment
has been administered as recommended, similar to dogs
in stage E-a, dogs in this stage should be treated in accor-
dance with an alternative anti-Leishmania protocol.
Recommended treatment protocol—The most
widely used treatment protocol for dogs with leish-
maniasis is the combination of meglumine antimoni-
ate and allopurinol. This combination may be admin-
istered to all dogs in stage B, C, or D, with meglumine
antimoniate given at 100 mg/kg, SC, once a day for 4
weeks and allopurinol at 10 mg/kg, PO, every 12 hours
for at least 6 months. The dosage of meglumine anti-
moniate can be divided in 2 equal doses of 50 mg/kg
(q 12 h) or administered for a period ranging from
4 to 8 weeks. Because meglumine antimoniate is not
FDA approved for use in the United States, practitio-
ners in that country should refer to alternative treat-
ment protocols.
In most dogs in stages B and C, this protocol, if
correctly applied, should result in a clinical cure that is
stable for > 1 year. Adverse effects are reported with ei-
ther drug of the combination, as previously mentioned.
In addition, the protocol should result in a considerable
decrease in parasite load for several months, which is
necessary for reducing transmission of the parasite to
phlebotomine vectors (sand flies).
For dogs in stage D with a severe clinical form of
the disease, the aforementioned treatment protocol
should yield a good chance of improvement but may
not result in a clinical cure. In stage D dogs, particularly
if renal insufficiency is present, the need for ancillary
treatments and prognosis are strictly dependent on pre-
existing clinical conditions.
1196 Vet Med Today: Reference Point JAVMA, Vol 236, No. 11, June 1, 2010
Alternative treatment protocols—Unresponsiveness
to a previous course of treatment (ie, recommended treat-
ment protocol), occurrence of relapse soon after treat-
ment, development of severe adverse effects, poor owner
compliance with drug administration, and non–govern-
mental approval or availability of drugs in a given country
are the main reasons for choosing a treatment protocol
other than meglumine antimoniate–allopurinol. Choice
of an alternative anti-Leishmania drug or drug combi-
nation should be based on the following criteria: anti-
Leishmania efficacy as established via clinical trials, few
potential adverse effects, and owner compliance with ad-
ministration. The few alternative regimens that fulfill the
aforementioned requirements include allopurinol, admin-
istered alone for at least 6 months (10 mg/kg, PO, q 12 h),
and allopurinol, for at least 6 months and at the same
dosage, administered in combination with miltefosine
given for 28 days (2 mg/kg, PO, q 24 h); however, milte-
fosine is not FDA approved.51,52 Whether miltefosine can
be safely administered for protracted periods or whether
more cycles can be administered needs further study in
dogs. Amphotericin B, aminosidine, and pentamidine are
other drugs that could be used to treat leishmaniasis, but
their use is strongly limited by severe adverse effects.
Follow-up Evaluation
Protocols for managing leishmaniasis in dogs once
treatment has begun have not been published. In gener-
al, dogs are followed up according to individual needs,
which are primarily driven by pretreatment and post-
treatment health status. To simplify treatment, the fol-
lowing scheme is proposed for application to most dogs
with leishmaniasis after treatment has started.
Dogs in stage B or C—Clinical and laboratory find-
ings may suggest that dogs in stage B or C of leishmani-
asis do not need ancillary treatment. In these dogs, perfor-
mance of a complete physical examination, CBC, serum
biochemical analysis, and urinalysis is recommended after
treatment with meglumine antimoniate concludes or after
1 month of treatment with allopurinol. If results of labora-
tory tests are within reference limits, dogs should continue
receiving allopurinol for at least 5 additional months.
Dogs in this category should be reevaluated every 6
months after treatment concludes, including serologic
testing of antibody titers against Leishmania spp. When
a clinical relapse develops, as revealed by clinical signs
or abnormal laboratory findings related to leishmani-
asis, treatment should be reinitiated with the drug ini-
tially used or with one of the drugs previously listed as
an alternative treatment. If treatment does not result in
clinical recovery or a relapse occurs soon after treat-
ment, dogs should be considered in stage E-a or E-b
and action should be taken accordingly.
Dogs in stage D—The degree of follow-up required
for dogs in stage D of leishmaniasis is strictly related
to clinical conditions. Usually, it is necessary to per-
form both clinical and laboratory evaluations during
the course of treatment, particularly if a dog has renal
impairment. At the end of treatment, follow-up should
be performed at 1- to 2-month intervals, with particular
emphasis on evaluating affected organs (eg, kidneys and
liver).
Dogs with Leishmaniasis
in Nonendemic Regions
Because dogs with leishmaniasis are the main reser-
voir of the parasite, reducing the parasite load through
adequate treatment should represent the most impor-
tant objective of practitioners in regions in which Leish-
mania is nonendemic (eg, the United States). Following
treatment, dogs become not infective or low infective
to phlebotomine vectors for 4 to 5 months.7,10,31,33,34,36
Therefore, in nonendemic areas with competent vec-
tors, a course of anti-Leishmania treatment should be
suggested for affected dogs, particularly at the begin-
ning of or during peak vector activity. However, treat-
ment is also necessary if established vector species have
not been detected because the potential for nonvectorial
transmission of Leishmania spp has not been excluded.
Conclusion
Treatment of dogs with leishmaniasis is a challenge for
veterinarians because of the unpredictable course of dis-
ease. On the basis of the reviewed literature and the authors’
experience, some aspects of the present guidelines should
be highlighted to help practitioners manage affected dogs.
Correct determination of the clinical stage of leishmani-
asis is important because treatment recommendations vary
accordingly. Anti-Leishmania drugs should be used only
if their efficacy has been validated in scientific studies. If
the clinical condition of diseased dogs requires it, ancillary
treatment should be added. Veterinarians should verify that
anti-Leishmania drugs have been correctly administered by
dog owners. Finally, dogs should be examined during and
after completion of anti-Leishmania treatment.
a. Glucantime, Merial, Milano, Italy.
b. Zyloprim, GlaxoWellcome, Philadelphia, Pa.
c. Humatin, Monarch Pharmaceuticals, Bristol, Tenn.
d. AmBisome, Astellas Pharma, Deerfield, Ill.
e. Impavido, Zentaris, Frankfurt, Germany.
f. Pentam 300, LyphoMed, Melrose Park, Ill.
g. Spyramicin, CLL Pharma, Nice, France.
h. Zeniquin, Pfizer, Kalamazoo, Mich.
i. Baytril, Bayer, Shawnee, Kan.
j. Motilium, Janssen-Cilag, Baar, Switzerland.
References
1. Amusategui I, Sainz A, Tesouro MA. Effects of antimonial ther-
apy for canine leishmaniasis on antibody titer. Ann N Y Acad Sci
1998;849:444–446.
2. Amusategui I, Sainz A, Tesouro MA. Evolution of serum albu-
min/globulin ratio after antimonial therapy in canine leishmani-
asis. Ann N Y Acad Sci 1998;849:447–449.
3. Paltrinieri S, Solano-Gallego L, Fondati A, et al. Guidelines for
diagnosis and clinical classification of leishmaniasis in dogs.
J Am Vet Med Assoc 2010;236:1184–1191.
4. Aste G, Di Tommaso M, Steiner JM, et al. Pancreatitis associated
with N-methyl-glucamine therapy in a dog with leishmaniasis.
Vet Res Commun 2005;29(suppl 2):269–272.
5. Barbosa Santos EG, Marzochi MC, Conceição NF, et al. N-meth-
ylglucamine antimonate (SbV+): intralesional canine tegumen-
tary leishmaniasis therapy. Parasite 1998;5:175–180.
6. Belloli C, Ceci L, Carli S, et al. Disposition of antimony and
aminosidine in dogs after administration separately and to-
gether: implications for therapy of leishmaniasis. Res Vet Sci
1995;58:123–127.
7. Bourdoiseau G, Bonnefont C, Hoareau E, et al. Specific IgG1
JAVMA, Vol 236, No. 11, June 1, 2010 Vet Med Today: Reference Point 1197
and IgG2 antibody and lymphocyte subset levels in naturally
Leishmania infantum-infected treated and untreated dogs. Vet
Immunol Immunopathol 1997;59:21–30.
8. Carrió J, Riera C, Gállego M, et al. In vitro activity of pentava-
lent antimony derivatives on promastigotes and intracellular
amastigotes of Leishmania infantum strains from humans and
dogs in Spain. Acta Trop 2001;79:179–183.
9. Chapman WL Jr, Hanson WL, Alving CR, et al. Antileishmanial
activity of liposome-encapsulated meglumine antimonate in the
dog. Am J Vet Res 1984;45:1028–1030.
10. Gradoni L, Maroli M, Gramiccia M, et al. Leishmania infan-
tum infection rates in Phlebotomus perniciosus fed on naturally
infected dogs under antimonial treatment. Med Vet Entomol
1987;1:339–342.
11. Gramiccia M, Gradoni L, Orsini S. Decreased sensitivity to me-
glumine antimoniate (Glucantime) of Leishmania infantum iso-
lated from dogs after several courses of drug treatment. Ann Trop
Med Parasitol 1992;86:613–620.
12. Guarga JL, Moreno J, Lucientes J, et al. Evaluation of a spe-
cific immunochemotherapy for the treatment of canine visceral
leishmaniasis. Vet Immunol Immunopathol 2002;88:13–20.
13. Ikeda-Garcia FA, Lopes RS, Ciarlini PC, et al. Evaluation of re-
nal and hepatic functions in dogs naturally infected by visceral
leishmaniasis submitted to treatment with meglumine antimo-
niate. Res Vet Sci 2007;83:105–108.
14. Ikeda-Garcia FA, Lopes RS, Marques FJ, et al. Clinical and para-
sitological evaluation of dogs naturally infected by Leishmania
(Leishmania) chagasi submitted to treatment with meglumine
antimoniate. Vet Parasitol 2007;143:254–259.
15. Mancianti F, Gramiccia M, Gradoni L, et al. Studies on canine
leishmaniasis control. 1. Evolution of infection of different clin-
ical forms of canine leishmaniasis following antimonial treat-
ment. Trans R Soc Trop Med Hyg 1988;82:566–567.
16. Moritz A, Steuber S, Greiner M. Clinical follow-up examination
after treatment of canine leishmaniasis. Tokai J Exp Clin Med
1998;23:279–283.
17. Oliva G, Gradoni L, Cortese L, et al. Comparative efficacy of
meglumine antimoniate and aminosidine sulphate, alone or in
combination, in canine leishmaniasis. Ann Trop Med Parasitol
1998;92:165–171.
18. Riera C, Valladares JE, Gállego M, et al. Serological and parasi-
tological follow-up in dogs experimentally infected with Leish-
mania infantum and treated with meglumine antimoniate. Vet
Parasitol 1999;84:33–47.
19. Schettini DA, Costa Val AP, Souza LF, et al. Pharmacokinetic and
parasitological evaluation of the bone marrow of dogs with vis-
ceral leishmaniasis submitted to multiple dose treatment with
liposome-encapsulated meglumine antimoniate. Braz J Med Biol
Res 2005;38:1879–1883.
20. Slappendel RJ, Teske E. The effect of intravenous or subcuta-
neous administration of meglumine antimonate (Glucantime)
in dogs with leishmaniasis. A randomized clinical trial. Vet Q
1997;19:10–13.
21. Steuber S, Moritz A, Schirrmann I, et al. PCR follow-up exami-
nation after treatment of canine leishmaniosis (CanL). Tokai J
Exp Clin Med 1998;23:285–292.
22. Tassi P, Ormas P, Madonna M, et al. Pharmacokinetics of N-
methylglucamine antimoniate after intravenous, intramus-
cular and subcutaneous administration in the dog. Res Vet Sci
1994;56:144–150.
23. Valladares JE, Alberola J, Esteban M, et al. Disposition of anti-
mony after the administration of N-methylglucamine antimoni-
ate to dogs. Vet Rec 1996;138:181–183.
24. Valladares JE, Riera C, González-Ensenyat P, et al. Long term
improvement in the treatment of canine leishmaniosis using an
antimony liposomal formulation. Vet Parasitol 2001;97:15–21.
25. Vouldoukis I, Drapier JC, Nüssler AK, et al. Canine visceral
leishmaniasis: successful chemotherapy induces macrophage
antileishmanial activity via the L-arginine nitric oxide pathway.
Antimicrob Agents Chemother 1996;40:253–256.
26. Vouldoukis I, Rougier S, Dugas B, et al. Canine visceral leish-
maniasis: comparison of in vitro leishmanicidal activity of mar-
bofloxacin, meglumine antimoniate and sodium stibogluconate.
Vet Parasitol 2006;135:137–146.
27. Cortese L, Pelagalli A, Piantedosi D, et al. The effects of pred-
nisone on haemostasis in leishmaniotic dogs treated with
meglumine antimoniate and allopurinol. Vet J 2008;177:405–
410.
28. Denerolle P, Bourdoiseau G. Combination allopurinol and anti-
mony treatment versus antimony alone and allopurinol alone in
the treatment of canine leishmaniasis (96 cases). J Vet Intern Med
1999;13:413–415.
29. Fernández-Pérez FJ, Gómez-Muñoz MT, Méndez S, et al. Leish-
mania-specific lymphoproliferative responses and IgG1/IgG2
immunodetection patterns by Western blot in asymptomatic,
symptomatic and treated dogs. Acta Trop 2003;86:83–91.
30. Ferrer L, Aisa MJ, Roura X, et al. Serological diagnosis and treat-
ment of canine leishmaniasis. Vet Rec 1995;136:514–516.
31. Manna L, Reale S, Vitale F, et al. Real-time PCR assay in Leish-
mania-infected dogs treated with meglumine antimoniate and
allopurinol. Vet J 2008;177:279–282.
32. Martínez-Subiela S, Bernal LJ, Cerón JJ. Serum concentrations
of acute-phase proteins in dogs with leishmaniosis during short-
term treatment. Am J Vet Res 2003;64:1021–1026.
33. Miranda S, Martorell S, Costa M, et al. Characterization of cir-
culating lymphocyte subpopulations in canine leishmaniasis
throughout treatment with antimonials and allopurinol. Vet
Parasitol 2007;144:251–260.
34. Rodríguez A, Solano-Gallego L, Ojeda A, et al. Dynamics of
Leishmania-specific immunoglobulin isotypes in dogs with clin-
ical leishmaniasis before and after treatment. J Vet Intern Med
2006;20:495–498.
35. Solano-Gallego L, Riera C, Roura X, et al. Leishmania infantum-
specific IgG, IgG1 and IgG2 antibody responses in healthy and
ill dogs from endemic areas. Evolution in the course of infection
and after treatment. Vet Parasitol 2001;96:265–276.
36. Cavaliero T, Arnold P, Mathis A, et al. Clinical, serologic, and
parasitologic follow-up after long-term allopurinol therapy of
dogs naturally infected with Leishmania infantum. J Vet Intern
Med 1999;13:330–334.
37. Gothe R, Nolte I, Kraft W. Leishmaniasis in dogs in Germany:
epidemiological case analysis and alternatives to conventional
causal therapy. Tierarztl Prax 1997;25:68–73.
38. Liste F, Gascon M. Allopurinol in the treatment of canine vis-
ceral leishmaniasis. Vet Rec 1995;137:23–24.
39. Pasa S, Toz SO, Voyvoda H, et al. Clinical and serological follow-
up in dogs with visceral leishmaniosis treated with allopurinol
and sodium stibogluconate. Vet Parasitol 2005;128:243–249.
40. Pennisi MG, Reale S, Giudice SL, et al. Real-time PCR in dogs
treated for leishmaniasis with allopurinol. Vet Res Commun
2005;29(suppl 2):301–303.
41. Plevraki K, Koutinas AF, Kaldrymidou H, et al. Effects of al-
lopurinol treatment on the progression of chronic nephritis in
Canine leishmaniosis (Leishmania infantum). J Vet Intern Med
2006;20:228–233.
42. Sasanelli M, Paradies P, de Caprariis D, et al. Acute-phase pro-
teins in dogs naturally infected with Leishmania infantum during
and after long-term therapy with allopurinol. Vet Res Commun
2007;31(suppl 1):335–338.
43. Vercammen F, DeDeken R. Antibody kinetics during allopurinol
treatment in canine leishmaniasis. Vet Rec 1996;139:264.
44. Vercammen F, De Deken R. Treatment of canine visceral leish-
maniasis with allopurinol. Vet Rec 1995;137:252.
45. Vercammen F, Fernandez-Perez FJ, del Amo C, et al. Follow-up
of Leishmania infantum naturally infected dogs treated with allo-
purinol: immunofluorescence antibody test, ELISA and Western
blot. Acta Trop 2002;84:175–181.
46. Poli A, Sozzi S, Guidi G, et al. Comparison of aminosidine (par-
omomycin) and sodium stibogluconate for treatment of canine
leishmaniasis. Vet Parasitol 1997;71:263–271.
47. Vexenat JA, Olliaro PL, Fonseca de Castro JA, et al. Clini-
cal recovery and limited cure in canine visceral leishmaniasis
treated with aminosidine (paromomycin). Am J Trop Med Hyg
1998;58:448–453.
48. Cortadellas O. Initial and long-term efficacy of a lipid emulsion
of amphotericin B desoxycholate in the management of canine
leishmaniasis. J Vet Intern Med 2003;17:808–812.
1198 Vet Med Today: Reference Point JAVMA, Vol 236, No. 11, June 1, 2010
49. Lamothe J. Activity of amphotericin B in lipid emulsion in the
initial treatment of canine leishmaniasis. J Small Anim Pract
2001;42:170–175.
50. Oliva G, Gradoni L, Ciaramella P, et al. Activity of liposomal am-
photericin B (AmBisome) in dogs naturally infected with Leish-
mania infantum. J Antimicrob Chemother 1995;36:1013–1019.
51. Manna L, Vitale F, Reale S, et al. Study of efficacy of miltefosine
and allopurinol in dogs with leishmaniosis. Vet J 2009;182:441–
445.
52. Mirò G, Oliva G, Cruz I, et al. Multi-centre and controller clini-
cal field study to evaluate the efficacy and safety of the combi-
nation of miltefosine and allopurinol in the treatment of canine
leishmaniosis. Vet Dermatol 2008;19(suppl 1):7–8.
53. Mateo M, Maynard L, Vischer C, et al. Comparative study on the
short term efficacy and adverse effects of miltefosine and meglu-
mine antimoniate in dogs with natural leishmaniosis. Parasitol
Res 2009;105:155–162.
54. Rhalem A, Sahibi H, Lasri S, et al. Analysis of immune responses
in dogs with canine visceral leishmaniasis before, and after, drug
treatment. Vet Immunol Immunopathol 1999;71:69–76.
55. Pennisi MG, De Majo M, Masucci M, et al. Efficacy of the treat-
ment of dogs with leishmaniosis with a combination of metro-
nidazole and spiramycin. Vet Rec 2005;156:346–349.
56. Rougier S, Vouldoukis I, Fournell S, et al. Efficacy of different
treatment regimens of marbofloxacin in canine visceral leish-
maniosis: a pilot study. Vet Parasitol 2008;153:244–254.
57. Bianciardi P, Fasanella A, Foglia Manzillo V, et al. The efficacy
of enrofloxacin, alone or combined with metronidazole, in the
therapy of canine leishmaniasis. Parasitol Res 2004;93:486–
492.
58. Gómez-Ochoa P, Castillo JA, Gascón M, et al. Use of domperi-
done in the treatment of canine visceral leishmaniasis: a clinical
trial. Vet J 2009;179:259–263.
59. Gradoni L, Bryceson A, Desjeux P. Treatment of Mediterranean
visceral leishmaniasis. Bull World Health Organ 1995;73:191–
197.
60. Gradoni L, Gramiccia M, Scalone A. Visceral leishmaniasis
treatment, Italy. Emerg Infect Dis 2003;9:1617–1620.
61. Shapiro TA, Were JB, Danso K, et al. Pharmacokinetics and
metabolism of allopurinol riboside. Clin Pharmacol Ther
1991;49:506–514.
62. Di Martino L, Mantovani MP, Gradoni L, et al. Low dosage
combination of meglumine antimoniate plus allopurinol as
first choice treatment of infantile visceral leishmaniasis in Italy.
Trans R Soc Trop Med Hyg 1990;84:534–535.
63. Sundar S, Rai M. Advances in the treatment of leishmaniasis.
Curr Opin Infect Dis 2002;15:593–598.
64. Davidson RN, den Boer M, Ritmeijer K. Paromomycin. Trans R
Soc Trop Med Hyg 2009;103:653–660.
65. Davidson RN. Practical guide for the treatment of leishmaniasis.
Drugs 1998;56:1009–1018.
66. Sindermann H, Engel J. Development of miltefosine as an
oral treatment for leishmaniasis. Trans R Soc Trop Med Hyg
2006;100(suppl 1):S17–S20.
67. Croft SL, Neal RA, Pendergast W, et al. The activity of alkyl-
phosphorylcholines and related derivatives against Leishmania
donovani. Biochem Pharmacol 1987;36:2633–2666.
68. Kuhlencord A, Maniera T, Eibl H, et al. Hexadecylphosphocho-
line: oral treatment of visceral leishmaniasis in mice. Antimicrob
Agents Chemother 1992;36:1630–1634.
69. Jha TK, Sundar S, Thakur CP, et al. Miltefosine, an oral agent,
for the treatment of Indian Visceral Leishmaniasis. N Engl J Med
1999;341:1795–1800.
70. Sundar S, Chatteryee M. Visceral leishmaniasis-current thera-
peutic modalities. Indian J Med Res 2006;123:345–352.
71. Jha SN, Singh NKP, Jha TK. Changing response to diamidine
compound in cases of kala-azar unresponsive to antimonials.
J Assoc Physicians India 1991;39:314–316.
72. Berczi I, Bertok L, Chow DA. Natural immunity and neuroim-
mune host defense. Ann N Y Acad Sci 2000;917:248–257.
73. Hinterberger-Fischer M. Prolactin as pro-inflammatory cyto-
kine. Consideration on consolidated immunotherapy after high
dosage therapy. Acta Med Austriaca Suppl 2000;52:16–20.