Ivermectin Dosing and Management Guidelines

Indications and Recommended Dosing

Strongyloidiasis (and most helminth infections): A single oral dose of 200 µg/kg is recommended for patients older than 24 months. 1
Uncomplicated scabies: Administer 200 µg/kg on day 0 and repeat the same dose on day 14; both doses must be given with food. 2
Crusted (Norwegian) scabies (severe disease): Use an intensified schedule of 200 µg/kg on days 1, 2, 8, 9, 15, 22, and 29, combined with daily topical permethrin 5 % cream for 7 days followed by twice‑weekly applications. 3
Loiasis: A single dose of 150–200 µg/kg is advised; some programs repeat the dose monthly, quarterly, or biannually. 4
Loiasis (alternative intensive regimen): In endemic settings, 200 µg/kg may be given daily for up to 10 days, although this approach is controversial. 4

Food effect: Taking ivermectin with a substantial (preferably high‑fat) meal increases systemic exposure by approximately 2.5‑fold; taking it on an empty stomach reduces absorption by about 60 %. 2

Children ≥15 kg: The standard adult dose of 200 µg/kg is appropriate. 5
Children <15 kg: Ivermectin is contraindicated because of potential neurotoxicity in infants with an immature blood‑brain barrier; permethrin 5 % cream is the first‑line therapy for scabies in this group. 3
Renal impairment: No dose adjustment is required regardless of creatinine clearance. 2
Severe hepatic impairment: Safety of repeated dosing is uncertain; use caution or consider alternative agents. 2
Pregnancy & lactation: Available human data suggest low fetal risk and probable compatibility with breastfeeding. 3

Loa loa co‑infection: Patients with recent travel to West or Central Africa must be screened for Loa loa; high microfilaremia (>8 000 mf/mL) can precipitate fatal encephalopathy if ivermectin is administered. 1

Avoid single‑dose scabies therapy: Omitting the day‑14 repeat dose is the leading cause of treatment failure and may promote resistance. 2
Post‑treatment symptoms: Pruritus and rash may persist for up to 2 weeks after successful scabies treatment; this does not indicate failure. Re‑treatment should be considered only after a 2–4‑week inflammatory period. 2
Re‑evaluation timing: Patients should be reassessed 2–4 weeks after the final ivermectin dose to confirm cure. 2
Emerging resistance: Documented resistance to permethrin is increasing, and early reports suggest emerging ivermectin resistance in some regions. 4

Contact treatment: All household and close contacts within the preceding month must receive the same ivermectin regimen (two doses for uncomplicated scabies) even if asymptomatic. 2
Environmental decontamination: Wash and dry all bedding and clothing on hot cycles (or dry‑clean). Items that cannot be laundered should be removed from body contact for at least 72 hours, as mites cannot survive off the host beyond this period. 2

A regimen of 200 µg/kg oral ivermectin repeated after 10 days is effective for treating head lice, but it should not be used in children weighing less than 15 kg because of the risk of neurotoxicity associated with an immature blood‑brain barrier. 6

Neither oral nor topical ivermectin is currently FDA‑approved as a pediculicide for the treatment of head lice. 6