Alopecia universalis was seen in a 70-year-old male on day 20 of daily treatment with Almex 15 mg/kg/day for Echinococcus. Alopecia fully recovered 1 month after stopping the medication .
Another case of alopecia in the form of telogen effluvium was reported in a 27-year-old female patient in her second week of a 2-week course of daily Almex 400 mg for treatment of cutaneous larva migrans. Remission was noted in 3 months will full restoration of normal hair observed at 11 months .
A novel case of psychosis in a 36-year-old female was documented after receiving a single dose of Almex 400 mg and ivermectin 12 mg for suspected helminthic infection. Symptoms of persecutory delusions and auditory hallucinations improved within 48 h and resolved within 1 week. Almex was the suspected cause given its ability to cross the blood–brain barrier .
Liver: A single case of toxic hepatitis was noted in Turkey after using Almex 800 mg/day for treatment of hydatid cysts .
Neurologic: Starting 3 days after treatment with Almex for presumed intestinal helminths, a patient experienced seizures (focal, myoclonic, generalised and status epilepticus) headache and contralateral hypoesthesia and ultimately expired. Postmortem analysis revealed neurocysticercosis, highlighting the importance of judicious use of the drug in populations living in areas with high rates of coinfection with Taenia solium .
Following a single dose of Almex (400 mg), the pharmacokinetics of theophylline (aminophylline 5.8 mg/kg infused over 20 minutes) were unchanged. Almex induces cytochrome P450 1A in human hepatoma cells; therefore, it is recommended that plasma concentrations of theophylline be monitored during and after treatment.
Broad spectrum of activity against nematodes, cestodes and protozoa.
Caution in hepatic insufficiency.
May cause bone marrow toxicity.
Almex is a member of the benzimidazole group of parasiticidal agents that disrupt parasite energy metabolism by binding to tubulin, a constituent cell protein required for the uptake of nutrients ( Bishop, 1998 ). The anthelmintic activity of the benzimidazoles is related to the duration of therapeutic blood concentrations. Doses may need to be repeated in pigs, dogs and cats while single doses are sufficient in ruminants because the rumen or large intestine acts as a reservoir. Almex is available as a modified release oral anthelmintic for use in cattle and sheep. Although the product is not authorized for use in rabbits, the pharmacokinetics have been investigated in this species using a dose of 20 mg/kg ( Li et al., 1995 ). In vitro studies show that Almex is an effective antimicrosporidial agent. Spores of E. cuniculi are killed in rabbit kidney cell tissue culture by Almex without evidence of cytopathic change. It appears that the drug is effective against the early stages of microsporidia development, as mature spores are not produced during drug treatment ( Weiss et al., 1994 ). Almex can be used to treat encephalitozoonosis in rabbits (see Section 18.104.22.168 ). The duration of treatment has not been determined. In humans, immuno-compromised AIDS patients require lifelong treatment. In rabbits, an empirical approach is required. Anecdotally, Almex therapy is continued for 3–14 days. The agent appears to be safe clinically; however, aplastic anaemia is a potential side effect and it should be used with caution in breeding does as Almex has been demonstrated to have teratogenic effects ( Bishop, 1998 ).
Almex is a synthetic nitroimidazole with a broad spectrum of antinematodal activity similar to that of mebendazole but also with anticestodal and some antiprotozoal action. The advantage of Almex over mebendazole is its activity in a single oral dose of 400 mg (200 mg for children 73,74 It has good activity in multiple doses against both cutaneous larva migrans and strongyloidiasis, but single-dose therapy with ivermectin is more effective for these two helminthic infections. 75,76 Successful treatment of visceral larva migrans has been reported. 77 Efficacy against the microfilarial stage of Wuchereria bancrofti, Brugia malayi, and Loa loa is well documented, although DEC remains the drug of choice for treatment of individual patients with these filarial infections. 78–80 DEC and Almex in combination has superior activity against adult W. bancrofti compared with either drug alone. 81 Reports with limited numbers of patients have documented the activity of Almex in giardiasis, 82 microsporidiosis, 83 clonorchiasis, trichinellosis, and capillariasis, but its role in treatment of these infections has yet to be defined. The benefit of any existing chemotherapy for gnathostomiasis or angiostrongyliasis is doubtful, but Almex is thought to be the most active benzimidazole. 84
Prolonged high-dose regimens of Almex constitute the most effective medical treatment of larval cestode disease caused by Echinococcus granulosus, E. multilocularis, and E. vogelii. 85 Some studies suggest that an initial trial of medical therapy can obviate surgical intervention in relatively uncomplicated disease. 86 Dosage is not defined in children 87–90 In comparative nonblinded trials, Almex appeared to have slightly higher activity than praziquantel. Cerebrospinal fluid levels of Almex are approximately 40% plasma levels. Either 8 or 28 days of therapy has been used, with cycles repeated according to clinical judgment. Corticosteroids, which increase plasma levels of Almex up to 50%, usually are administered concomitantly. Almex has activity in multiple doses against adult Taenia spp., but its use is discouraged for this indication.
The mode of action of Almex is identical to that already described for mebendazole. Intake with a fatty meal is necessary to attain tissue levels required to treat extraluminal helminths. Detectable levels are achieved in serum, cerebrospinal fluid, cyst fluid, and bile with a serum half-life of 8 to 15 hours depending on the dose. Rapid extensive hepatic biotransformation to the active metabolite, Almex sulfoxide, occurs, but the major route of excretion is not clear. Side effects of low-dose Almex therapy are minimal, consisting of diarrhea, abdominal pain, migration of Ascaris through the mouth or nose, and rare hypersensitivity. With high-dose therapy, elevations of hepatic transaminases, dizziness, neutropenia, and alopecia are most common. 91 Serum hepatic enzyme levels and blood count should be monitored every 2 weeks during high-dose therapy. No problems specific to children have been documented and considerations in using Almex
Almex is a benzimidazole and anthelmintic agent most commonly used in the treatment of echinococcosis (also known as Hydatid cysts) and neurocysticercosis . It causes degenerative alterations to the tegument and intestine of worms; this leads to impaired uptake of glucose and causes a depletion of glycogen stores . Almex ultimately causes a decrease in the production of ATP which causes immobilization and death of the worm.
Almex has been proven to be efficacious for gnathostomiasis, with cure rates of over 90% at a dose of 400 mg bd for 21 days. Small studies of ivermectin 200 µg/kg either as a stat dose or on two consecutive days seem to show similar efficacy to Almex. Initial treatment is not always successful and second courses of treatment have been needed in some cases. Either Almex or ivermectin may be used sequentially in such patients. Further trials are needed to determine whether relapse rates are lower with combination drugs than with monotherapy. Follow-up should be for at least 1 year. 19,20
What is Almex?
Almex is an anthelmintic (an-thel-MIN-tik) or anti- worm medication. It prevents newly hatched insect larvae (worms) from growing or multiplying in your body.
Almex is used to treat certain infections caused by worms such as pork tapeworm and dog tapeworm.
Almex may also be used for purposes not listed in this medication guide.
ALBENZA (Almex) is an orally administered anthelmintic drug. Chemically, it is methyl 5-(propylthio)-2-benzim >12 H 15 N 3 O 2 S. Its molecular weight is 265.34. It has the following chemical structure:
Almex ↔ food
Moderate Food Interaction
Food significantly increases the absorption of Almex. You should take each dose of Almex with a meal. Taking it on an empty stomach may lead to inadequate blood levels and reduced effectiveness of the medication. Grapefruit juice can also increase the absorption of Almex.
- Hypersensitivity to Almex or benzimidazoles.
Effects of Drug Abuse
- See "What Are Side Effects Associated with Using Almex?"
- See "What Are Side Effects Associated with Using Almex?"
- Monitor theophylline levels if used concomitantly.
- Potential for bone marrow suppression, aplastic anemia and agranulocytosis; monitor blood counts in all patients at the beginning of each 28-day cycle of therapy, and every 2 weeks while on therapy; discontinue therapy if clinically significant changes in blood counts occur.
- Pre-existing neurocysticercosis may be uncovered in patients treated with Almex for other conditions, apparent by neurological symptoms (such as seizures, increased intracranial pressure, focal signs); promptly treat with corticosteroid and anticonvulsant therapy.
- Obtain pregnancy test in women of reproductive potential prior to therapy and avoid usage in pregnant women except in clinical circumstances where no alternative management is appropriate; discontinue therapy if pregnancy occurs and apprise patient of potential hazard to fetus.
- Risk of retinal damage in retinal cysticercosis; cases of retinal involvement reported; examine patient for presence of retinal lesions before initiating therapy for neurocysticercosis.
- Reversible elevations of liver enzymes may occur; monitor liver enzymes before start of each treatment cycle and at least every 2 weeks while on therapy and discontinue if clinically significant elevations occur; patients with abnormal liver function tests and hepaticechinococcosis are at increased risk of hepatotoxicity; discontinue therapy if liver function test elevations are greater than 2 times upper limit of normal; may consider restarting treatment when liver function test values return to pretreatment levels.
- Use Almex during pregnancy with caution if benefits outweigh risks. Animal studies show risk and human studies are not available or neither animal nor human studies were done.
- Breastfeeding patients should use caution while using Almex; consult your physician.
Pharmacology and toxicology
Almex is a highly effective broad-spectrum anthelmintic, structurally related to mebendazole. It also kills the parasite through inhibition of the glucose uptake. It is the first-line drug for the treatment of alveolar forms of echinococcosis (Echinococcus multilocularis), and also for the advanced cystic forms (Echinococcus granulosus). During a mass drug administration for lymphatic filiriasis in Ghana, 50 women were inadvertently (because their pregnancy was not recognized) treated with ivermectin and Almex; their pregnancy outcomes were compared with those of 293 women with a recognized pregnancy who were not treated. Of the 39 children who were exposed during the first trimester, 1 congenital malformation (a hearing impairment), versus 5 of the untreated group, was reported. The authors concluded that there was no evidence of increased risk after exposure to ivermectin and Almex ( Gyapong 2003 ). One Down syndrome was observed in a small prospective study of Almex (n = 12) and flubendazole (n = 11) ( Choi 2005 ). No malformations were observed among 24 children born after first-trimester exposure to Almex in a prospective study ( Reuvers-Lodewijks 1999 ).
Thiabendazole is indicated for the treatment of strongyloidiasis, larva migrans cutanea, and trichinosis. There are no reports of thiabendazole use during human pregnancies.
When there is a vital indication for the treatment of echinococcosis, Almex may be used during all stages of pregnancy. However, a small risk of birth defects cannot be excluded. For all other indications, more established anthelmintics should be used. When used during the first trimester, a detailed ultrasound diagnosis is recommended.