Version July 2025
| Patient characteristics | Clinical evaluation and staging | CSF findings | Preferred therapy | Alternative therapy* | Rescue therapy¶ |
| <6 years old or <20 kg body weight | Perform lumbar puncture | First-stage disease: WBC ≤5 cells/microL and no trypanosomes | SuraminΔ: 5 injections of 20 mg/kg (max 1 g) IV weekly (eg, on days 1, 8, 15, 22, and 29). The first dose on day 1 is given first as a test dose of 4 to 5 mg/kg IV followed by the rest of the dose a few hours later, if the patient tolerated the test dose. | Pentamidine◊: 4 mg/kg/day IM or IV (infuse over 1 to 2 hours) once daily for 7 days | Fexinidazole (under compassionate use; dose as below)§ |
| Second-stage disease: WBC >5 cells/microL, and/or trypanosomes | Melarsoprol: 2.2 mg/kg/day IV once daily for 10 days (maximum dose: 180 mg) co-administered with oral prednisolone¥ | Fexinidazole (under compassionate use)§‡ | Fexinidazole (under compassionate use; dose as below)§ | ||
| ≥6 years old and ≥20 kg body weight | Lumbar puncture not needed | None | Fexinidazole§ (taken with food) Body weight ≥35 kg:
Body weight 20 to <35 kg:
| Lumbar puncture needed† First-stage disease (WBC ≤5 cells/microL and no trypanosomes): SuraminΔ (dosing as above) Second-stage disease (WBC >5 cells/microL, and/or trypanosomes): Melarsoprol (dosing as above) | Lumbar puncture needed† First-stage disease (WBC ≤5 cells/microL and no trypanosomes): SuraminΔ (dosing as above) Second-stage disease (WBC >5 cells/microL, and/or trypanosomes): Melarsoprol (dosing as above) |
CSF: cerebrospinal fluid; IM: intramuscular; IV: intravenous; WBC: white blood cell count.
* Alternative treatment should be given in cases where the preferred treatment is not available or not appropriate for a particular patient. It is not the same as rescue treatment which is when a patient fails first-line therapy. When recommended medicines are not readily available, immediate interim treatment with pentamidine should be provided. Treatment should be switched to preferred therapy as soon as it becomes available.
¶ Rescue treatment is given in cases of treatment failure with a preferred or alternative agent.
Δ In regions where pentamidine is more accessible than suramin, pentamidine may be used as initial therapy (especially in the setting of acute illness) until suramin therapy can be obtained and administered. A urinalysis (and creatinine if feasible) should be performed to check for proteinuria prior to each suramin dose, given the potential for nephrotoxicity. Additionally, in patients with onchocerciasis coinfection, treatment with suramin may cause a severe immunologic reaction; however, in general the prevalence of onchocerciasis overlaps with regions of gambiense HAT, not rhodesiense HAT.
◊ Pentamidine is usually given as an IM injection because IV administration is frequently associated with severe hypotension and can cause extravasation injury. Patients should lie down for at least 1 hour after injection (IM or IV) to prevent hypotension and should eat or drink sugar to prevent hypoglycemia. Monitor vital signs before and 1 hour after administration (and continue if hemodynamic instability). Electrocardiogram and serum glucose monitoring should be considered when feasible.
§ Concomitant solid food intake (minimum 250 mL) is required for adequate absorption; avoid liquid food as it decreases absorption. Fexinidazole should be administered under directly observed treatment. Refer to UpToDate text for further discussion.
¥ Melarsoprol should be co-administered with oral prednisolone to reduce risk of encephalopathy. Prednisolone dosing is 1 mg/kg per day orally once daily (maximum dose: 50 mg) for 9 days, followed by a 3-day taper (day 10: 0.75 mg/kg; day 11: 0.5 mg/kg; day 12: 0.25 mg/kg). Melarsoprol should not come into contact with water due to risk of precipitation. Care must be taken if using plastic syringes; after drawing up the liquid, it must be administered immediately but slowly. Refer to UpToDate text for further discussion.
‡ No alternative therapy is available for second stage rhodesiense human African trypanosomiasis in this patient group. If melarsoprol is not an option, the World Health Organization recommends administering fexinidazole under compassionate use.
† If fexinidazole cannot be given, lumbar puncture is required to determine therapy.