Ivermectin
Ivermectin is an antiparasitic medication. After its discovery in 1975, its first uses were in veterinary medicine to prevent and treat heartworm and acariasis. Approved for human use in 1987, it is used to treat infestations including head lice, scabies, river blindness, strongyloidiasis, trichuriasis, ascariasis and lymphatic filariasis. It works through many mechanisms to kill the targeted parasites, and can be taken by mouth, or applied to the skin for external infestations. It belongs to the avermectin family of medications.
William Campbell and Satoshi Ōmura were awarded the 2015 Nobel Prize in Physiology or Medicine for its discovery and applications. It is on the World Health Organization's List of Essential Medicines. and is approved by the US Food and Drug Administration as an antiparasitic agent. In 2023, it was the 295th most commonly prescribed medication in the United States, with more than 400,000 prescriptions. It is available as a generic medicine. Ivermectin is available in a fixed-dose combination with albendazole.
Misinformation was widely spread claiming that ivermectin is beneficial for treating and preventing COVID-19. Such claims are not backed by credible scientific evidence. Multiple major health organizations, including the US Food and Drug Administration, the US Centers for Disease Control and Prevention, the European Medicines Agency, and the World Health Organization advise against the use of ivermectin for the treatment of COVID-19.
Medical uses
Ivermectin is used to treat human diseases caused by roundworms and a wide variety of external parasites.Worm infections
For river blindness and lymphatic filariasis, ivermectin is typically given as part of mass drug administration campaigns that distribute the drug to all members of a community affected by the disease. Adult worms survive in the skin and eventually recover to produce larval worms again; to keep the worms at bay, ivermectin is given at least once per year for the 1015-year lifespan of the adult worms.The World Health Organization considers ivermectin the drug of choice for strongyloidiasis. Ivermectin is also the primary treatment for Mansonella ozzardi and cutaneous larva migrans. The US Centers for Disease Control and Prevention recommends ivermectin, albendazole, or mebendazole as treatments for ascariasis. Ivermectin is sometimes added to albendazole or mebendazole for whipworm treatment, and is considered a second-line treatment for gnathostomiasis. When co-administered, ivermectin and albendazole act in synergy. Ivermectin targets the parasite's nervous and muscular systems, causing paralysis, while albendazole disrupts the parasite's metabolism and energy production. This dual approach immobilizes and kills the parasite and improves the treatment's effectiveness.
In January 2025, the Committee for Medicinal Products for Human Use of the European Medicines Agency adopted a positive scientific opinion for ivermectin/albendazole for the treatment of infections caused by several types of worm parasites including lymphatic filariasis, a neglected tropical disease. Ivermectin/albendazole is indicated for use in people aged five years of age or older, for the treatment of soil-transmitted helminth infections, caused by different types of intestinal parasitic worms, which are spread through soil contaminated by human feces in areas with poor sanitation. Among the worms responsible for these diseases are hookworms, roundworms, whipworms and a roundworm called Strongyloides stercoralis. Ivermectin/albendazole is also indicated for the treatment of microfilaraemia in people with lymphatic filariasis. Lymphatic filariasis is a neglected tropical disease commonly known as elephantiasis, which impairs the lymphatic system and can lead to the abnormal enlargement of body parts, causing pain, severe disability and social stigma. Ivermectin/albendazole is indicated for the treatment of cases of lymphatic filariasis caused by Wuchereria bancrofti, a parasite which is responsible for 90% of cases worldwide.
Mites and insects
Ivermectin is also used to treat infection with parasitic arthropods. Scabies – infestation with the mite Sarcoptes scabiei – is most commonly treated with topical permethrin or oral ivermectin. A single application of permethrin is more efficacious than a single treatment of ivermectin. For most scabies cases, ivermectin is used in a two-dose regimen: the first dose kills the active mites, but not their eggs. Over the next week, the eggs hatch, and a second dose kills the newly hatched mites. The two-dose regimen of ivermectin has similar efficacy to the single dose permethrin treatment. Ivermectin is, however, more effective than permethrin when used in the mass treatment of endemic scabies. Similarly, oral ivermectin is increasingly used to control scabies outbreaks in semi-closed institutions, where mass topical treatments often fail for logistical reasons.For severe "crusted scabies", where the parasite burden is orders of magnitude higher than usual, the CDC recommends up to seven doses of ivermectin over the course of a month, along with a topical antiparasitic. Both head lice and pubic lice can be treated with oral ivermectin, an ivermectin lotion applied directly to the affected area, or various other insecticides. Ivermectin is also used to treat rosacea and blepharitis, both of which can be caused or exacerbated by Demodex folliculorum mites.
Contraindications
The only absolute contraindication to the use of ivermectin is hypersensitivity to the active ingredient or any component of the formulation. In children under the age of five or those who weigh less than, there is limited data regarding the efficacy or safety of ivermectin, though the available data demonstrate few adverse effects. However, the American Academy of Pediatrics cautions against use of ivermectin in such patients, as the blood–brain barrier is less developed, and thus there may be an increased risk of particular CNS side effects such as encephalopathy, ataxia, coma, or death. The American Academy of Family Physicians also recommends against use in these patients, given a lack of sufficient data to prove drug safety. Ivermectin is secreted in very low concentration in breast milk. It remains unclear if ivermectin is safe during pregnancy.Adverse effects
Side effects, although uncommon, include fever, itching, and skin rash when taken by mouth; and red eyes, dry skin, and burning skin when used topically for head lice. It is unclear if the drug is safe for use during pregnancy, but it is probably acceptable for use during breastfeeding.Ivermectin is considered relatively free of toxicity in standard doses. Based on the data drug safety sheet for ivermectin, side effects are uncommon. However, serious adverse events following ivermectin treatment are more common in people with very high burdens of larval Loa loa worms in their blood. Those who have over 30,000 microfilaria per milliliter of blood risk inflammation and capillary blockage due to the rapid death of the microfilaria following ivermectin treatment.
One concern is neurotoxicity after large overdoses, which in most mammalian species may manifest as central nervous system depression, ataxia, coma, and death, as might be expected from potentiation of inhibitory chloride channels.
Since drugs that inhibit the enzyme CYP3A4 often also inhibit P-glycoprotein transport, the risk of increased absorption past the blood-brain barrier exists when ivermectin is administered along with other CYP3A4 inhibitors. These drugs include statins, HIV protease inhibitors, many calcium channel blockers, lidocaine, benzodiazepines, and glucocorticoids such as dexamethasone.
During a typical treatment course, ivermectin can cause minor aminotransferase elevations. In rare cases it can cause mild clinically apparent liver disease.
To provide context for the dosing and toxicity ranges, the of ivermectin in mice is 25 mg/kg, and 80 mg/kg in dogs, corresponding to an approximated human-equivalent dose LD50 range of 2.02–43.24 mg/kg, which is far more than its FDA-approved usage. While ivermectin has also been studied for use in COVID-19, and while it has some ability to inhibit SARS-CoV-2 in vitro, achieving 50% inhibition in vitro was found to require an estimated oral dose of 7.0 mg/kg, high enough to be considered ivermectin poisoning. Despite insufficient data to show any safe and effective dosing regimen for ivermectin in COVID-19, doses have been taken far more than FDA-approved dosing, leading the CDC to issue a warning of overdose symptoms including nausea, vomiting, diarrhea, hypotension, decreased level of consciousness, confusion, blurred vision, visual hallucinations, loss of coordination and balance, seizures, coma, and death. The CDC advises against consuming doses intended for livestock or doses intended for external use and warns that increasing misuse of ivermectin-containing products is increasing harmful overdoses.
Pharmacology
Mechanism of action
Ivermectin and its related drugs act by interfering with the nerve and muscle functions of helminths and insects. The drug binds to glutamate-gated chloride channels common to invertebrate nerve and muscle cells. The binding pushes the channels open, which increases the flow of chloride ions and hyper-polarizes the cell membranes, paralyzing and killing the invertebrate. Ivermectin is safe for mammals because mammalian glutamate-gated chloride channels only occur in the brain and spinal cord: the causative avermectins usually do not cross the blood–brain barrier, and are unlikely to bind to other mammalian ligand-gated channels.Pharmacokinetics
Ivermectin can be given by mouth, topically, or via injection. Oral doses are absorbed into systemic circulation; the alcoholic solution form is more orally available than tablet and capsule forms. Ivermectin is widely distributed in the body.Ivermectin does not readily cross the blood-brain barrier of mammals due to the presence of P-glycoprotein. Crossing may still become significant if ivermectin is given at high doses, in which case brain levels peak 2–5 hours after administration. In contrast to mammals, ivermectin can cross the blood-brain barrier in tortoises, often with fatal consequences.
Ivermectin is metabolized into eight different products by human CYP3A4, two of which remain toxic to mosquitos. M1 and M2 also have longer elimination half-lives of about 55 hours. CYP3A5 produces a ninth metabolite.