Ivermectin was the first commercially available macrolide anthelmintic. It is a semi-synthetic agent derived from the natural avermectins. It occurs as on off-white to yellowish powder and is highly lipophilic. It is very poorly soluble in water, but is soluble in propylene glycol, polyethylene glycol and vegetable oils.
Pharmacokinetics
Ivermectin is well absorbed (>90%) from GI tract after oral administration in simple stomach animals. In ruminants, absorption from GI tract is moderate (25-30%) due to inactivation of the drugs in the rumen. Parenteral administration (SC) results in higher bioavailability, but the rate of absorption is comparatively slower than that seen after oral administration. Once in circulation, ivermectin is well distributed to most tissues except the CNS. Collie breed of dogs allow more penetration of ivermectin into the CNS than other breeds or species; therefore, they are more susceptible to ivermectin toxicity. Ivermectin is partly metabolised in the liver by oxidation and is excreted in both unchanged and metabolised forms in the faeces. Ivermectin in faeces or soil degrades at a much slower rate, which has been shown to suppress larvae of some dung-breeding insects. Ivermectin has a long terminal half-life in most species (dogs = 2 days, cattle = 2-3 days, sheep = 2-7 days and swine = 0.5 day)
Mechanism of Action
Avermectins and milbemycins act by binding to a special type of glutamate-gated Cl--channel receptors found in susceptible nematode and arthropod nerve cells. The glutame-gated chloride channel (GluCls) are invertebrate-specific numbers of the Cys-loop family of ligand-gated ion channels present in neurons and myocytes. This binding opens the Cl--channel triggering chloride ion influx. Increased intracellular chloride ions cause hyperpolarisation of the parasite neuron and prevent initiation or propagation of normal action potential. The net effect of avermectin is paralysis followed by death of the target parasite. In addition to paralysis, disruption of reproductive function in ticks has been elucidated with avermectins. In addition to the effect on glutamate-gated Cl--channel receptors, avermectins bind with high affinity to GABA-gated Cl--channels in nematodes and insects and block the transmittance of electrical activity in nerves and muscle cells. Avermectin also stimulate the release and binding of gama-aminobutyric acid (GABA) at nerve endings. The GABA-receptor mediated hyperpolarisation, however is less well defined.
Avermectin and milbemycins are not active against cestodes and trematodes presumably because these parasites lack a receptor at glutamate-gated chloride channel. The lack of toxicity in mammals is explained by absence of avermectin sensitive glutamate gated Cl—channels in mammals and low affinity of mammalian GABA receptors to macrocyclic lactones. Further, inability of the drugs penetrate blood-brain barrier and reach CNS where the mammalian glutamate and GABA receptors are located makes the avermectin and milbemycins safe in mammals.
Development of resistance or relative unresponsiveness to avermectins action has been described in some nematodes. Alteration in genes encoding ATP-dependent P-glycoprotein transports which bind avermectins or changes in component of glutamate-gated Cl--channel receptors are primarily associated development of drug resistance.
Clinical Uses
Ivermectin is a commonly used endectocide in veterinary medicine. It is useful against GI roundworms and lungworms in horses, ruminants and pigs and heartworms (mainly preventive) in dogs and cats. It is also used as an ectoparasiticide against mange mites, lice, grubs and horn flies.
Adverse effects
Ivermectin has a high margin of safety (T.I. >30) in cattle. In horses, swelling and pruritus at the ventral mid-line may be seen about 24 hour after ivermectin dosing due to a hypersensitivity reaction to dead parasites. In dogs, toxicity is predominantly seen in rough-haired Collie breed but may occur in other breeds as well (e.g. Australian Shepherd and Shetland sheepdog). The increased sensitivity of some breeds of dogs is related in mutation in a gene named MDRI that encodes for the membrane pump P-glycoprotein in the blood-brain barrier. The toxic signs in dogs include mydriasis, salivation, ataxia, tremors, paresis, stupor, recumbency and coma. Dogs may also exhibit a shock-like reaction when ivermectin is used as a microfilaricide, presumably due to hypersensitivity reaction associated with dying microfilaria. Neonatal pigs are more susceptible to ivermectin toxicity presumably due to more permeability of blood-brain barrier to ivermectin. Ivermectin in birds has been associated with lethargy and anorexia. Kittens are also very sensitive.
Treatment
Overdosage of ivermectin may be treated by supportive and symptomatic therapy. Intravenous administration of physostigmine may provide some relief for dogs suffering from severe ivermectin toxicity.
Contraindication and Precautions
Ivermectin should not be used in Collies or Collie-mixed breeds, unless alternative therapies are unavailable. It is not recommended for calves less than 12 weeks and puppies less than 6 week of age. The injectable products for use in cattle and swine should be given SC only; IV or IM injection is not advised. In horses, ivermectin is used only by oral route.