Empirical antiparasitic prophylaxis proposed for immunosuppressed rheumatic disease patients

Patients with immune-mediated rheumatic diseases who require immunosuppressive therapy face a hidden threat in endemic regions such as Brazil: intestinal parasitic infections. A new narrative review published in Advances in Rheumatology argues that empirical antiparasitic prophylaxis—treatment given before infection is confirmed—deserves a place in clinical planning for these vulnerable patients, with the drug ivermectin positioned as the cornerstone of prevention against Strongyloides stercoralis, the parasite that poses the gravest danger under immunosuppression.

The concern centers on how immunosuppression can alter the natural history of parasitic infections. Because latent or low-burden infections are difficult to detect in endemic settings, the review’s authors contend that waiting for a positive diagnosis before starting immunosuppressive therapy may leave some patients dangerously exposed.

The review, conducted by integrating data from epidemiological studies, clinical reports, reviews, and national and international recommendations, describes persistent endemicity and frequent polyparasitism in regions like Brazil, alongside substantial diagnostic limitations. These constraints, the authors argue, support a pragmatic approach: rather than relying solely on screening, clinicians in endemic areas could consider empirical treatment before immunosuppression begins in selected patients with substantial epidemiological risk.

The proposed regimen places ivermectin at the center, at a dose of 200 micrograms per kilogram per day for two consecutive days, reflecting its efficacy against Strongyloides stercoralis. However, the authors emphasize that ivermectin has limited activity against other common parasites, including soil-transmitted helminths such as Ascaris lumbricoides and Ancylostoma or Necator species, as well as intestinal protozoa like Giardia intestinalis and Entamoeba histolytica. To broaden coverage, they propose complementary agents: albendazole at 400 milligrams daily for three to five days, or nitazoxanide at 500 milligrams twice daily for three days.

The resulting strategy is empirical combination prophylaxis administered before immunosuppressive therapy, targeted at selected patients whose epidemiological circumstances justify it. For patients with ongoing exposure to parasites, the review suggests that periodic repetition of treatment should be individualized, and it is candid about the weakness of the supporting evidence: direct data backing repeated prophylaxis are limited. The authors also stress that this is not a formal guideline. Instead, they present it as a technically grounded framework intended to support individualized clinical decision-making and to help mitigate the burden of intestinal parasitic infections among immunosuppressed populations in endemic areas.

Subject of Research: Empirical antiparasitic prophylaxis for immunosuppressed patients with immune-mediated rheumatic diseases in endemic areas

Article Title: Beyond strongyloides: rationale for empirical antiparasitic prophylaxis in immunosuppressed patients with rheumatic diseases in endemic areas

Article References: Cruz, V. A., de Azevedo Valadares, L. D., Machado, C. M. M., Lino, K., de Brito, M. S. A. G., de Abreu Vieira, R. M. R., de Oliveira Ribeiro, T., & de Souza, V. A. (2026). Beyond strongyloides: rationale for empirical antiparasitic prophylaxis in immunosuppressed patients with rheumatic diseases in endemic areas. Advances in Rheumatology. https://doi.org/10.1186/s42358-026-00578-4

Image Credits: AI Generated

DOI: 10.1186/s42358-026-00578-4

Keywords: Strongyloides stercoralis, ivermectin, albendazole, nitazoxanide, immunosuppression, rheumatic diseases, intestinal parasites, prophylaxis, Brazil, hyperinfection, narrative review, endemic regions