Hepatobiliary fascioliasis: A neglected re-emerging threat, its diagnostic and management challenges

Table 2 Summary of antiparasitic medications, including dosages and treatment regimens

Drug	Mechanism of action	Dose	Comments
Triclabendazole	Binds to β-tubulin, inhibiting microtubule formation, leading to impaired motility and disruption of vital processes in the parasite	For patients ≥ 6 years: Two doses of 10 mg/kg administered 12 hours apart (alternatively, a single 10 mg/kg dose has been used)	Taken orally with food to improve absorption. It is the drug of choice for fascioliasis, with extensive clinical experience supporting its efficacy against both immature and mature stages. FDA-approved for use in patients aged six and older. Caution is advised in patients with preexisting QTc prolongation. Resistance has been documented in some cases
Nitazoxanide	Inhibits the pyruvate: Ferredoxin oxidoreductase (PFOR) enzyme-dependent electron transfer reaction essential for anaerobic energy metabolism	For adults: 500 mg orally twice daily for 7 days	Proposed as an alternative, especially for chronic infection. However, conflicting evidence on its efficacy (ranging from as high as 94% to as low as 36%) limits its recommendation as a reliable therapeutic option
Praziquantel	Increases calcium ion permeability in parasite membranes, causing muscle contraction and paralysis	Once considered as an alternative, praziquantel is now contraindicated for fascioliasis due to insufficient efficacy against Fasciola species
Bithionol	Disrupts oxidative phosphorylation, impairing energy metabolism in parasites	A halogenated phenol formerly used as primary therapy for fascioliasis in the United States; it has been discontinued
Emetine/Dehydroemetine	Inhibits protein synthesis by interfering with the elongation step in translation	Discontinued because of inadequate efficacy and safety issues
Metronidazole	Undergoes reduction in anaerobic organisms to form reactive nitro radicals that damage DNA and other critical biomolecules
Albendazole	Binds to β-tubulin, inhibiting microtubule polymerization, leading to impaired glucose uptake and energy depletion in parasites
Niclofolan	Disrupts energy metabolism by uncoupling oxidative phosphorylation in parasite mitochondria
Chloroquine	Inhibits DNA and RNA biosynthesis and causes degradation of ribosomes in parasites
Hexachloro-para-xylol	Disrupts parasite metabolism through oxidative damage and interference with enzymatic processes
Artemisinin derivatives (artesunate/artemether)	Activated by heme iron to produce free radicals that alkylate and damage parasite proteins and membranes