Atinid (Nitazoxanide) – Antiparasitic Suspension

1. About Atinid (Nitazoxanide)

Atinid is an oral suspension formulation of Nitazoxanide, a broad-spectrum antiprotozoal and anthelmintic agent. Nitazoxanide 100 mg/5 mL suspension is the standard paediatric formulation, manufactured by Biopharma Ltd., Bangladesh. It is effective against a wide range of intestinal protozoa and helminths, including Cryptosporidium parvum, Giardia lamblia, Entamoeba histolytica, and multiple intestinal nematodes.

Nitazoxanide is particularly important for patients with T2DM who are immunocompromised or have recurrent intestinal infections. Cryptosporidium and Giardia infections can cause severe and prolonged diarrhoea in diabetic patients with impaired cell-mediated immunity, leading to dehydration, electrolyte disturbances, and glycaemic instability.

2. Mechanism of Action

Nitazoxanide and its active metabolite tizoxanide interfere with the pyruvate:ferredoxin oxidoreductase (PFOR) enzyme-dependent electron transfer reaction essential for anaerobic energy metabolism in protozoa and helminths. This disrupts intracellular energy production, leading to parasite death. The PFOR enzyme exists in anaerobic organisms but not in mammalian cells, providing selectivity. Additionally, nitazoxanide inhibits type II NADH:quinone oxidoreductase in Giardia — contributing to its excellent efficacy against giardiasis.

3. Spectrum of Activity

• Protozoa: Cryptosporidium parvum, Giardia intestinalis/lamblia, Entamoeba histolytica, Blastocystis hominis, Cyclospora cayetanensis
• Helminths: Ascaris lumbricoides (roundworm), Trichuris trichiura (whipworm), Enterobius vermicularis (pinworm), Hymenolepis nana (tapeworm), Taenia spp.
• Additional coverage: Clostridium difficile (C. diff) in GI infections; investigational antiviral activity (influenza, RSV)

4. Indications

• Cryptosporidiosis — particularly important in T2DM and immunocompromised patients
• Giardiasis (Giardia intestinalis infection) — second-line to metronidazole; preferred in metronidazole-resistant cases
• Intestinal amoebiasis (non-invasive)
• Intestinal helminthiasis — roundworm, whipworm, pinworm infections
• Diarrhoea of protozoal/parasitic aetiology

5. Dosage and Administration (Suspension)

Children 1–3 years: 5 mL (100 mg) twice daily for 3 days.

Children 4–11 years: 10 mL (200 mg) twice daily for 3 days.

Adults and children ≥12 years: Use 500 mg tablet formulation (Atinid 500) — 500 mg twice daily for 3 days. The suspension is the paediatric formulation.

Administration: Take with food — enhances absorption and reduces GI side effects. Shake suspension well before each use. Reconstituted suspension: refrigerate and use within 7 days.

6. Contraindications

• Hypersensitivity to nitazoxanide or excipients

7. Warnings and Precautions

Hepatic/Renal impairment: Use with caution — limited safety data in severe organ impairment. Dose adjustment may be required.

Immunocompromised patients: In HIV/AIDS and severely immunocompromised patients, cryptosporidiosis may require longer treatment courses (>3 days) as standard 3-day courses may be insufficient. Specialist guidance required.

Diabetic patients: Nitazoxanide can cause diarrhoea, nausea, and vomiting — may affect oral medication absorption and glycaemic control. Monitor blood glucose during treatment.

8. Side Effects

Common: Abdominal pain, nausea, diarrhoea (paradoxically, may worsen initial diarrhoea temporarily), headache, urine discolouration (yellow-green — harmless, from metabolite excretion).

Uncommon: Vomiting, elevated transaminases, skin rash.

Rare: Serious allergic reactions, Stevens-Johnson syndrome (very rare).

9. Nitazoxanide in Diabetic Patients

T2DM patients are at increased risk for intestinal parasitic infections due to several mechanisms: impaired neutrophil function, reduced cellular immunity with chronic hyperglycaemia, slowed gut motility (diabetic enteropathy) favouring parasite colonisation, and increased healthcare exposure. Cryptosporidium is particularly virulent in T2DM — causing chronic profuse watery diarrhoea, dehydration, and severe glycaemic dysregulation. Nitazoxanide (Atinid suspension) is the treatment of choice for cryptosporidiosis in immunocompetent and mildly immunocompromised patients. Giardiasis (common in Bangladesh due to water contamination) responds to nitazoxanide when metronidazole has failed.

10. Storage

• Powder: Store below 25°C. Reconstituted suspension: refrigerate, discard after 7 days. Shake well before use. Out of reach of children.

Frequently Asked Questions (FAQ)

Q1: What is Atinid suspension (Nitazoxanide) used for in children?

Atinid suspension (Nitazoxanide 100 mg/5 mL) is used to treat intestinal parasitic infections in children aged 1–11 years. It treats: Cryptosporidiosis (Cryptosporidium parvum — severe watery diarrhoea; the only licensed treatment), Giardiasis (Giardia lamblia — bloating, fatty diarrhoea, malabsorption; effective alternative to metronidazole), Amoebiasis (non-invasive intestinal), and intestinal worms (roundworm, whipworm, pinworm). The 3-day twice-daily course is well-tolerated. Adults and children ≥12 years should use Atinid 500 tablet formulation.

Q2: Does Atinid suspension need to be taken with food?

Yes — take Atinid suspension with food. Food significantly increases nitazoxanide absorption (bioavailability increases ~50% with food vs fasting). Taking with a meal also reduces common GI side effects (nausea, abdominal pain). Do not give on an empty stomach. Shake the suspension well before measuring each dose. Use the measuring cup or oral syringe provided. Reconstituted suspension should be refrigerated and discarded after 7 days.

Q3: Why does Atinid cause yellow-coloured urine?

Yellow or yellow-green urine discolouration is a harmless and expected effect of nitazoxanide. The active metabolite tizoxanide and its glucuronide conjugate are excreted in urine and give it a yellow-green appearance — this is not haematuria (blood in urine) or kidney damage. The discolouration resolves when treatment ends. It is important to differentiate this from other causes of coloured urine — dark brown/tea-coloured urine with jaundice suggests liver disease; frank red urine suggests bleeding. If uncertain, consult your pharmacist or physician.

Q4: Is Atinid effective for treating diarrhoea caused by Giardia?

Yes — Nitazoxanide (Atinid) is effective against Giardia intestinalis and is an excellent alternative to metronidazole for giardiasis. Clinical trial data shows nitazoxanide achieves comparable cure rates to metronidazole (80–90%) for giardiasis in 3-day courses. Advantages over metronidazole: (1) No alcohol interaction risk; (2) No metallic taste or nausea; (3) Also covers Cryptosporidium (metronidazole has no efficacy against Cryptosporidium); (4) Shorter course in some protocols. Preferred when metronidazole-resistant giardiasis is suspected, or in patients who cannot tolerate metronidazole.