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Criteria for Outpatient Use Guidelines

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Nitazoxanide (Alinia®)

[Developed, January 2007; Revised, March 2007, April 2010]

Information on indications for use or diagnosis is assumed to be unavailable. All criteria may be applied retrospectively; prospective application is indicated with [*].

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1.* Dosage

Nitazoxanide is available as a 500 mg tablet and a 100 mg/5 ml oral suspension.  The 500 mg tablet contains greater than recommended amounts of nitazoxanide for pediatric dosing and should not be used in pediatric patients younger than 11 years of age.1-5 

a. Adults1-5
Nitazoxanide is FDA-approved for the management of diarrhea caused by Giardia lamblia or Cryptosporidium parvum in adults.  Adult dosage recommendations for nitazoxanide are summarized in Table 1.  Dosages exceeding these recommendations will be reviewed.

Table 1
Adult Nitazoxanide Dosage Recommendations
Disease Maximum dosage
Diarrhea caused by G. lamblia or C. parvum 1 tablet (500 mg) or 25 ml of oral suspension every 12 hours with food for 3 days

b. Pediatrics1-5
Nitazoxanide is FDA-approved for the management of diarrhea caused by G. lamblia or C. parvum in pediatric patients 1 year of age and older.  Nitazoxanide pediatric dosage recommendations are summarized in Table 2.  Patient profiles containing dosages exceeding these recommendations will be reviewed.

Table 2
Pediatric Nitazoxanide Dosage Recommendations
Disease Maximum dosage
Diarrhea caused by G. lamblia or C. parvum

1-3 years of age: 5 ml of oral suspension (100 mg) every 12 hours (with food) for 3 days

4-11 years of age:  10 ml of oral suspension (200 mg) every 12 hours (with food) for 3 days

> 12 years of age:  1 tablet (500 mg) or 25 ml of oral suspension every 12 hours (with food) for 3 days

* Tablets are only approved for use in children 12 years of age and older.

2. Duration of Therapy

Nitazoxanide is FDA-approved for three days of therapy to manage cryptosporidiosis and giardiasis in immunocompetent adult and pediatric patients, as documented in clinical trials.6-9   Treatment durations exceeding these recommendations will be reviewed.

Although not FDA-approved, nitazoxanide 500 mg twice daily for 10 days has demonstrated comparable efficacy to metronidazole in managing Clostridium difficile colitis, in both patients responsive and resistant to metronidazole therapy.10-11 Additionally, nitazoxanide may be proven comparable in efficacy to vancomycin in treating C. difficile colitis, although current sample sizes are too small to assess clinical significance.12

Nitazoxanide has also shown benefit in treating diarrhea caused by intestinal parasites other than G. lamblia as well as rotavirus, but does not yet possess FDA approval for these indications.9, 13-16

3.* Duplicative Therapy

Concurrent administration of nitazoxanide with other approved antibiotic therapies for cryptosporidiosis and giardiasis (i.e., paromomycin, metronidazole, tinidazole, paromomycin + azithromycin) is not recommended as these combinations do not provide additional therapeutic benefit and may result in enhanced adverse events.  Patient profiles containing concurrent prescriptions for nitazoxanide and additional cryptosporidiosis or giardiasis therapy will be reviewed.

4.* Drug-Drug Interactions

Patient profiles will be assessed to identify those drug regimens which may result in clinically significant drug-drug interactions.

The following drug-drug interactions are considered clinically relevant for nitazoxanide.  Only those drug-drug interactions classified as clinical significance level 1/contraindicated or those considered life-threatening which have not yet been classified will be reviewed:

a. Highly Plasma Protein-Bound Medications (e.g., hydantoins, salicylates, warfarin) [clinical significance level – unknown]

Nitazoxanide is rapidly metabolized to tizoxanide following oral administration.  Because tizoxanide is highly bound to plasma proteins (>99.9%), caution should be exercised when dosing nitazoxanide concurrently with other drugs highly protein bound possessing narrow therapeutic indices as competition for binding sites may occur with potential for toxicity. However, in an open-label, randomized, crossover study, investigators assessed nitazoxanide effects on warfarin pharmacokinetics/pharmacodynamics after a single warfarin 25 mg dose in 14 adult male volunteers and found that warfarin pharmacokinetic/pharmacodynamic parameters did not change significantly following nitazoxanide administration. Until further confirmatory data are available, it may be prudent to monitor patients for signs of warfarin toxicity and changes in INR when warfarin and nitazoxanide are administered concurrently.  Similarly, until contrasting data are available, monitor patients for   signs and symptoms of hydantoin or salicylate toxicity when nitazoxanide is administered adjunctively.

References

  1. AHFS Drug Information 2010 [book online].  Jackson, WY:  Teton Data Systems, Version 6.7.1, 2009.  Based on:  McEvoy GK, editor.  AHFS drug information 2010.  Bethesda (MD):  American Society of Health-System Pharmacists; 2010.  Stat!Ref Electronic Medical Library.
  2. Drug Facts and Comparisons.  Clin-eguide [database online].  St. Louis, MO:  Wolters Kluwer Health, Inc; 2010.  Available at:  http://clineguide.com.  Accessed April 16th, 2010.
  3. Clinical Pharmacology [database online]. Tampa, FL: Gold Standard, Inc; 2010. Available at: http://www.clinicalpharmacology.com. Accessed April 16th, 2010.
  4. Nitazoxanide (Drug Evaluation). In: DRUGDEX® System (electronic version). Thomson Reuters (Healthcare) Inc., Greenwood Village, Colorado, USA. Available at: http://www.thomsonhc.com.libproxy.uthscsa.edu.   Accessed April 16th, 2010.
  5. Nitazoxanide (Alinia®) package insert.  Romark Pharmaceuticals.  October 2007.
  6. Ortiz JJ, Ayoub A, Gargala G, Chegne NL, Favennec L.  Randomized clinical study of nitazoxanide compared to metronidazole in the treatment of symptomatic giardiasis in children from Northern Peru.  Aliment Pharmacol Ther. 2001;15:1409-15.
  7. Rossignol JF, Ayoub A, Ayers MS.  Treatment of diarrhea caused by Cryptosporidium parvum: a prospective randomized, double-blind, placebo-controlled study of nitazoxanide.  J Infect Dis. 2001;184:103-6.
  8. Bailey JM, Erramouspe J.  Nitazoxanide treatment for giardiasis and cryptosporidiosis in children.Ann Pharmacother. 2004;38:634-40.
  9. Abaza H, El-Zayadi AR, Kabil SM, et al. Nitazoxanide in the treatment of patients with intestinal protozoan and helminthic infections: a report on 546 patients in Egypt. Curr Ther Res. 1998; 59(2):116-121.
  10. Musher DM, Logan N, Hamill RJ, DuPont HL, LentnekA, Gupta A, et al.  Nitazoxanide for the treatment of Clostridium difficile colitis.  Clin Infect Dis. 2006;43:421-7.
  11. Musher DM, Logan N, Mehendiratta V, et al.  Clostridium difficile colitis that fails conventional metronidazole therapy: response to nitazoxanide. J Antimicrob Chemother. 2007;59(4):705-10.
  12. Musher DM, Logan N, Bressler AM, Johnson DP, Rossignol JF.  Nitazoxanide versus vancomycin in Clostridium difficile infection: a randomized, double-blind study.  Clin Infect Dis. 2009;48(4):e41-6.
  13. Rossignol JF, Ayoub A, Ayers MS. Treatment of diarrhea caused by Giardia intestinalis and Entamoeba histolytica or E. dispar: a randomized, double-blind, placebo-controlled study of nitazoxanide. J  Infect Dis. 2001;184(3):381-4.
  14. Rossignol JF, Kabil SM, El-Gohary Y, Younis AM.   Nitazoxanide in the treatment of amoebiasis. Trans R Soc Trop Med Hyg.  2007;101(10):1025-31.
  15. Rossignol JF, Abu-Zekry M, Hussein A, Santoro MG.  Effect of nitazoxanide for treatment of severe rotavirus diarrhoea: randomised double-blind placebo-controlled trial. Lancet. 2006;368(9530):124-9.
  16. Rossignol JF, El-Gohary YM.   Nitazoxanide in the treatment of viral gastroenteritis: a randomized double-blind placebo-controlled clinical trial. Aliment Pharmacol Ther. 2006;24(10):1423-30, 2006.
  17. Vets E, Rossignol JF, Jackson AS Effects of nitazoxanide on pharmacokinetics and pharmacodynamics of a single dose of warfarin.  Am J Health Syst Pharm. 2009;66(9):838-42.

Prepared by: Drug Information Service, The University of Texas Health Science Center at San Antonio, and the College of Pharmacy, The University of Texas at Austin.