|Challenge||Possible explanation||Remarks||Proposed perspectives|
- Reticence from drug manufacturers to provide additional huge quantities of ivermectin for free.|
- Increased local cost for ivermectin distribution, because of more logistical needs and multiplied labour force.
|Multiple CDTI per year would increase absolute cost, but the public health benefits for both malaria and neglected tropical diseases would be huge.||
- Secure external funding to sustain pluri-annual CDTI.|
- Convince drug manufacturers to continue providing the drug for free.
- Fear of side effects.|
- Ignorance, lack of education and sensitization about CDTI.
|Most adverse effects of ivermectin are due to an initially high microfilarial density or loasis co-infection. Rarely, adverse effects may still occur outside these circumstances but often requires abnormally high drug dosages and/or frequency of administration.||
- Use a test-and-not-treat approach in co-endemic settings .|
- Respect dosages of 150–200 μg/kg.
- Educate the population on the health benefits of CDTI.
- Reassure the population that side effects will decrease with subsequent doses of ivermectin, as the microfilarial density keeps reducing.
|Drug resistance||Increased exposure to ivermectin due to a higher frequency of treatment may induce ivermectin resistance in the parasite .||Polytherapy could help prevent drug resistance to a single drug. During the RIMDAMAL study for instance, ivermectin was co-administered with albendazole.||
- Monitor drug resistance.|
- Provide ivermectin in combination with other drugs using an integrated MDA approach .
|Drug interactions||Ivermectin can interact with a number of molecules, including anti-infectious agents .||Important for drugs that are taken regularly, such as anti-epileptic drugs or antiretroviral drugs.||Individuals presenting a risk for drug interactions should not receive a multi-dose ivermectin treatment regimen.|