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Hussein EM, Malik MS, Alsantali RI, Asghar BH, Morad M, Ansari MA, Jamal QMS, Alsimaree AA, Abdalla AN, Algarni AS, Jassas RS, Altass HM, Ahmed SA. Bioactive fluorenes. Part IV: Design, synthesis, and a combined in vitro, in silico anticancer and antibacterial evaluation of new fluorene-heterocyclic sulfonamide conjugates. J Mol Struct 2021. [DOI: 10.1016/j.molstruc.2021.131232] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Sondén K, Wyss K, Jovel I, Vieira da Silva A, Pohanka A, Asghar M, Homann MV, Gustafsson LL, Hellgren U, Färnert A. High Rate of Treatment Failures in Nonimmune Travelers Treated With Artemether-Lumefantrine for Uncomplicated Plasmodium falciparum Malaria in Sweden: Retrospective Comparative Analysis of Effectiveness and Case Series. Clin Infect Dis 2016; 64:199-206. [PMID: 27986683 DOI: 10.1093/cid/ciw710] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Accepted: 10/22/2016] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Artemisinin-based combination therapy (ACT) is the first-line treatment of Plasmodium falciparum malaria. Since the introduction of artemether-lumefantrine (AL) for treatment of uncomplicated malaria in Sweden, treatment failures have been reported in adults. METHODS A retrospective comparative analysis of treatment regimen for P. falciparum malaria in adults in Stockholm during 2000-2015 was performed to evaluate the effectiveness of AL. Parasite genotyping and drug concentrations were investigated in the AL treatment failures. RESULTS Among the total 397 P. falciparum episodes, 310 were treated with oral regimen only (95 AL, 162 mefloquine, 36 atovaquone-proguanil [AP], and 17 others), and 87 were administered initial intravenous therapy (38 artesunate and 49 quinine) followed by oral treatments. Five late treatment failures were detected after AL and one slow response to AP. The effectiveness of AL alone was 94.7% (95% confidence interval [CI], 88.1%-98.3%), compared with 99.5% for other oral regimens (P = .003). All AL failures occurred in European men and the effectiveness in this group was only 73.7% (95% CI, 48.8%-90.0%). Genotyping confirmed recrudescence of the initial parasite populations and drug resistance markers revealed no clinically significant resistance patterns. Lumefantrine concentrations suggested subtherapeutic concentrations in at least 2 cases. CONCLUSIONS Our findings indicate a high rate of symptomatic late treatment failures after 6-dose AL regime in nonimmune adults, especially in men. Our report warrants the need to establish optimal dosing of AL in adults and to alert clinicians about the importance of informing patients regarding the risk of parasites reappearing weeks after AL treatment.
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Affiliation(s)
- Klara Sondén
- Unit of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet;
| | - Katja Wyss
- Unit of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet.,Department of Emergency Medicine, Karolinska University Hospital Solna
| | - Irina Jovel
- Department of Microbiology, Tumor and Cell Biology, Karolinska Institutet
| | | | - Anton Pohanka
- Department of Clinical Pharmacology, Karolinska University Hospital Huddinge.,Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet
| | - Muhammad Asghar
- Unit of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet
| | - Manijeh Vafa Homann
- Unit of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet
| | - Lars L Gustafsson
- Department of Clinical Pharmacology, Karolinska University Hospital Huddinge.,Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet
| | - Urban Hellgren
- Department of Infectious Diseases, Karolinska University Hospital; and.,Unit of Infectious Diseases, Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Anna Färnert
- Unit of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet.,Department of Infectious Diseases, Karolinska University Hospital; and
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Zongo I, Somé FA, Somda SAM, Parikh S, Rouamba N, Rosenthal PJ, Tarning J, Lindegardh N, Nosten F, Ouédraogo JB. Efficacy and day 7 plasma piperaquine concentrations in African children treated for uncomplicated malaria with dihydroartemisinin-piperaquine. PLoS One 2014; 9:e103200. [PMID: 25133389 PMCID: PMC4136730 DOI: 10.1371/journal.pone.0103200] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2013] [Accepted: 06/24/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND One promising new Artemisinin-based combination therapies (ACTs) is dihydroartemisinin-piperaquine (DHA-PQ). However, the pharmacokinetics of piperaquine and the relationship between drug levels and clinical efficacy are incompletely characterized, particularly in children. METHODS We performed a single-arm open-label trial in Bobo-Dioulasso, Burkina Faso. A total of 379 participants aged 6 months or more with uncomplicated falciparum malaria were enrolled. Each participant received daily dose of DHA-PQ for three days and followed for 42 days. Parasitological efficacy was analyzed, considering rates of recrudescence and overall recurrence. PK was an exploratory endpoint and a priori, no sample size had been determined. Day 7 capillary and venous plasma concentrations of piperaquine were measured in children aged 2-10 years. RESULTS Of the 379 participants, 365 (96.3%) completed 42 days of follow-up. The median daily dose of PQ was 18.5 mg/kg [6.5-24]. Treatment with DHA-PQ was well tolerated with fever and parasitemia resolution within 48 hours in nearly all children. Recurrent malaria within 42 days of follow-up occurred in 31.3% (10/34) of children less than 2 years old, 16.0% (16/106) of those aged 2-5 years, 9.4% (15/160) of those aged 5-10 years, and none (0/68) of those over 10 years old. After genotyping, 3 of 41 recurrent episodes were recrudescence. An exploratory analysis shows that children with successful treatment outcomes had significantly higher median plasma concentrations of PQ compared to those with recurrent malaria within 42 days after therapy, considering either capillary samples (68 ng/ml [50-85] compared to 48 ng/ml [36-55], p<0.001) or venous samples (42 ng/ml [29-59] compared to 25 ng/ml [19-44], p<0.001). CONCLUSION DHA-PQ was effective for uncomplicated P. falciparum malaria treatment and offers an alternative to other ACTs. Recurrent malaria was mainly due to new infections after treatment and was correlated with low day 7 PQ concentration in the youngest patients. TRIAL REGISTRATION Controlled-Trials.com ISRCTN59761234.
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Affiliation(s)
- Issaka Zongo
- Direction Régionale de l'Ouest, Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso
| | - Fabrice A. Somé
- Direction Régionale de l'Ouest, Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso
| | - Serge A. M. Somda
- Non Transmissible disease department, Centre Muraz Bobo-Dioulasso, Bobo-Dioulasso, Burkina Faso
| | - Sunil Parikh
- Department of Medicine, Yale University School of Public Health, New Haven, Connecticut, United States of America
| | - Noel Rouamba
- Direction Régionale de l'Ouest, Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso
| | - Philip J. Rosenthal
- Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Joel Tarning
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Niklas Lindegardh
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - François Nosten
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Jean Bosco Ouédraogo
- Direction Régionale de l'Ouest, Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso
- Non Transmissible disease department, Centre Muraz Bobo-Dioulasso, Bobo-Dioulasso, Burkina Faso
- * E-mail:
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Biamonte MA, Wanner J, Le Roch KG. Recent advances in malaria drug discovery. Bioorg Med Chem Lett 2013; 23:2829-43. [PMID: 23587422 PMCID: PMC3762334 DOI: 10.1016/j.bmcl.2013.03.067] [Citation(s) in RCA: 129] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Revised: 03/11/2013] [Accepted: 03/20/2013] [Indexed: 01/18/2023]
Abstract
This digest covers some of the most relevant progress in malaria drug discovery published between 2010 and 2012. There is an urgent need to develop new antimalarial drugs. Such drugs can target the blood stage of the disease to alleviate the symptoms, the liver stage to prevent relapses, and the transmission stage to protect other humans. The pipeline for the blood stage is becoming robust, but this should not be a source of complacency, as the current therapies set a high standard. Drug discovery efforts directed towards the liver and transmission stages are in their infancy but are receiving increasing attention as targeting these stages could be instrumental in eradicating malaria.
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Affiliation(s)
- Marco A Biamonte
- Drug Discovery for Tropical Diseases, Suite 230, San Diego, CA 92121, USA.
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Abstract
Malaria continues to affect public health and economic growth in many regions of the world. The number of infections continues to rise and is associated with increased mortality, despite basic science and public health efforts. Drug therapy remains the mainstay of treatment and prevention of this disease. Plasmodium has a complex life cycle involving an arthropod vector and distinct stages within the human host. Each parasite stage plays a unique role in transmission, disease, and latency. These different stages may vary in their response to the various antimalarial compounds. This article will review antimalarial therapies and drug resistance in the context of the parasites' biology.
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Affiliation(s)
- Johanna P Daily
- Brigham and Women's Hospital, Infectious Disease, 75 Francis Street, Boston, MA 02115, USA
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Byakika-Kibwika P, Lamorde M, Mayito J, Nabukeera L, Namakula R, Mayanja-Kizza H, Katabira E, Ntale M, Pakker N, Ryan M, Hanpithakpong W, Tarning J, Lindegardh N, de Vries PJ, Khoo S, Back D, Merry C. Significant pharmacokinetic interactions between artemether/lumefantrine and efavirenz or nevirapine in HIV-infected Ugandan adults. J Antimicrob Chemother 2012; 67:2213-21. [PMID: 22687893 PMCID: PMC3465101 DOI: 10.1093/jac/dks207] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Revised: 04/14/2012] [Accepted: 04/24/2012] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Co-administration of artemether/lumefantrine with antiretroviral therapy has potential for pharmacokinetic drug interactions. We investigated drug-drug interactions between artemether/lumefantrine and efavirenz or nevirapine. METHODS We performed a cross-over study in which HIV-infected adults received standard six-dose artemether/lumefantrine 80/480 mg before and at efavirenz or nevirapine steady state. Artemether, dihydroartemisinin, lumefantrine, efavirenz and nevirapine plasma concentrations were measured and compared. RESULTS Efavirenz significantly reduced artemether maximum concentration (C(max)) and plasma AUC (median 29 versus 12 ng/mL, P < 0.01, and 119 versus 25 ng · h/mL, P < 0.01), dihydroartemisinin C(max) and AUC (median 120 versus 26 ng/mL, P < 0.01, and 341 versus 84 ng · h/mL, P < 0.01), and lumefantrine C(max) and AUC (median 8737 versus 6331 ng/mL, P = 0.03, and 280 370 versus 124 381 ng · h/mL, P < 0.01). Nevirapine significantly reduced artemether C(max) and AUC (median 28 versus 11 ng/mL, P < 0.01, and 123 versus 34 ng · h/mL, P < 0.01) and dihydroartemisinin C(max) and AUC (median 107 versus 59 ng/mL, P < 0.01, and 364 versus 228 ng · h/mL, P < 0.01). Lumefantrine C(max) and AUC were non-significantly reduced by nevirapine. Artemether/lumefantrine reduced nevirapine C(max) and AUC (median 8620 versus 4958 ng/mL, P < 0.01, and 66 329 versus 35 728 ng · h/mL, P < 0.01), but did not affect efavirenz exposure. CONCLUSIONS Co-administration of artemether/lumefantrine with efavirenz or nevirapine resulted in a reduction in artemether, dihydroartemisinin, lumefantrine and nevirapine exposure. These drug interactions may increase the risk of malaria treatment failure and development of resistance to artemether/lumefantrine and nevirapine. Clinical data from population pharmacokinetic and pharmacodynamic trials evaluating the impact of these drug interactions are urgently needed.
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Eshetu T, Abdo N, Bedru KH, Fekadu S, Wieser A, Pritsch M, Löscher T, Berens-Riha N. Open-label trial with artemether-lumefantrine against uncomplicated Plasmodium falciparum malaria three years after its broad introduction in Jimma Zone, Ethiopia. Malar J 2012; 11:240. [PMID: 22824059 PMCID: PMC3438107 DOI: 10.1186/1475-2875-11-240] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2012] [Accepted: 07/23/2012] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND In Jimma Zone, Ethiopia, the first-line treatment of uncomplicated falciparum malaria has been changed from sulphadoxine-pyrimethamine (SP) to artemether-lumefantrine (AL) in 2006. The objective of this study was to assess the effectiveness of AL in Jimma Zone two to three years after its broad introduction. METHODS An open-label, single-arm, 42-day study of AL against falciparum malaria was conducted in four areas with moderate transmission in Jimma Zone between November 2008 and January 2009 and between August and December 2009. Patients (one-81 years) with uncomplicated Plasmodium falciparum mono-infection were consecutively enrolled. Follow-up visits were at day 2, 3, 7, 28 and 42 or any other day if symptoms reoccurred. Primary and secondary endpoints were PCR-corrected and uncorrected cure rates (molecular differentiation between recrudescence and re-infection) on days 28 and 42. Other secondary endpoints were gametocytaemia at day 7 and day 28, parasitaemia at day 2 and 3, and re-infection rates at day 28 and day 42. RESULTS Of 348 enrolled patients, 313 and 301 completed follow-up at day 28 and at day 42, respectively. No early treatment failure occurred. For per protocol analysis, PCR-uncorrected cure rates at day 28 and 42 were 99.1% (95% CI 98.0-100.0) and 91.1% (95% CI 87.9-94.3), respectively. PCR-corrected cure rates at day 28 and 42 were 99.4% (95% CI 98.5-100.0) and 94.7% (95% CI 92.2-97.2), respectively. PCR-corrected cure rate at day 42 for children ≤ 5 years was 90.6% (95% CI 82.4-98.7) only. Adverse events were in general mild to moderate. Incidence of new infections was 3.4% during 42 days, no new infections with Plasmodium vivax were observed. Microscopically detected gametocytaemia was reduced by 80% between day 0 and day 7. CONCLUSION In general, AL was effective and well tolerated in Jimma Zone, Ethiopia. However, the PCR-corrected recrudescence rate per-protocol at day 42 for children ≤ 5 years was 9.4%. Therefore, further development should be monitored on a regular basis as recommended by WHO.
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Affiliation(s)
- Teferi Eshetu
- Division of Infectious Diseases and Tropical Medicine, Medical Center of the University of Munich (LMU), Leopoldstrasse 5, 80802 Munich, Germany
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Kopel E, Marhoom E, Sidi Y, Schwartz E. Successful oral therapy for severe falciparum malaria: the World Health Organization criteria revisited. Am J Trop Med Hyg 2012; 86:409-11. [PMID: 22403309 DOI: 10.4269/ajtmh.2012.11-0567] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
We report a successful treatment of severe falciparum malaria in a non-immune adult patient with 30% parasitemia treated with the 6-dose oral regimen of artemether plus lumefantrine combination therapy alone. We have also retrospectively searched our tertiary center's database for similar cases and we have found two additional severe malaria cases, resolved uneventfully with oral regimen. These cases might indicate a need to specifically address the definition of severe and complicated malaria in non-immune patients either in designated guidelines or as an explicit addition to the historical World Health Organization criteria.
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Affiliation(s)
- Eran Kopel
- Department of Internal Medicine C, The Chaim Sheba Medical Center, Tel Hashomer, Israel
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Lemma H, Löfgren C, San Sebastian M. Adherence to a six-dose regimen of artemether-lumefantrine among uncomplicated Plasmodium falciparum patients in the Tigray Region, Ethiopia. Malar J 2011; 10:349. [PMID: 22141751 PMCID: PMC3248875 DOI: 10.1186/1475-2875-10-349] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2011] [Accepted: 12/05/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In 2004, Ethiopia switched its first-line treatment of uncomplicated Plasmodium falciparum malaria from sulphadoxine-pyrimethamine to a fixed artemisinin-based combination therapy (ACT), artemether-lumefantrine (AL). Patient adherence to AL regimen is a major determining factor to achieve the desired therapeutic outcome. The aim of this study was to measure patient adherence levels to the six-dose AL regimen for the treatment of uncomplicated P. falciparum malaria and to identify its determinant factors in rural areas of the Tigray region, Ethiopia METHODS The study was conducted under routine health service delivery at health posts level. Patients/caregivers were not informed about their home visit and were traced on the day after they finished the AL regimen. By combining the response to a structured questionnaire and the tablet count from the blister, adherence level was classified into three categories: definitely non-adherent, probably non-adherent and probably adherent. Reasons for being definitely non-adherent were also assessed. For the purpose of examine risk factors, definitely non-adherent and probably non-adherent was merged into a non-adherent group. Variables found significantly associated (p < 0.05) with the adherence level on the univariate analysis were fitted into a multivariate logistic regression model. RESULTS Out of the total initially enrolled 180 patients, 86.1% completed the follow-up. Out of these, 38.7% were classified as probably adherent, 34.8% as probably non-adherent, and 26.5% were definitely non-adherent. The most common reasons that definitely non-adherents gave for not taking the full dose were "too many tablets" (37.3%) and to "felt better before finished the treatment course" (25.5%). The adherence of the patients was associated with the ownership of a radio (adjusted odd ratio, AOR: 3.8; 95% CI: 1.66-8.75), the belief that malaria can be treated traditionally (AOR: 0.09; 95% CI: 0.01-0.78) and a delay of more than one day in seeking treatment after the onset of fever (AOR: 5.39; 95% CI: 1.83-15.88). CONCLUSION The very low adherence to AL found in this study raises serious concerns for the malaria control in the region. The implementation of a monitoring adherence system is essential to ensure long-term treatment efficacy.
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Affiliation(s)
| | - Curt Löfgren
- Epidemiology and Global Health, Umeå University, SE-901 85, Umeå, Sweden
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Pottie K, Greenaway C, Feightner J, Welch V, Swinkels H, Rashid M, Narasiah L, Kirmayer LJ, Ueffing E, MacDonald NE, Hassan G, McNally M, Khan K, Buhrmann R, Dunn S, Dominic A, McCarthy AE, Gagnon AJ, Rousseau C, Tugwell P. Evidence-based clinical guidelines for immigrants and refugees. CMAJ 2011; 183:E824-925. [PMID: 20530168 PMCID: PMC3168666 DOI: 10.1503/cmaj.090313] [Citation(s) in RCA: 281] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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Byakika-Kibwika P, Lamorde M, Mayanja-Kizza H, Khoo S, Merry C, Van Geertruyden JP. Artemether-Lumefantrine Combination Therapy for Treatment of Uncomplicated Malaria: The Potential for Complex Interactions with Antiretroviral Drugs in HIV-Infected Individuals. Malar Res Treat 2011; 2011:703730. [PMID: 22312573 PMCID: PMC3265289 DOI: 10.4061/2011/703730] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2010] [Accepted: 02/14/2011] [Indexed: 01/10/2023] Open
Abstract
Treatment of malaria in HIV-infected individuals receiving antiretroviral therapy (ART) poses significant challenges. Artemether-lumefantrine (AL) is one of the artemisisnin-based combination therapies recommended for treatment of malaria. The drug combination is highly efficacious against sensitive and multidrug resistant falciparum malaria. Both artemether and lumefantrine are metabolized by hepatic cytochrome P450 (CYP450) enzymes which metabolize the protease inhibitors (PIs) and nonnucleoside reverse transcriptase inhibitors (NNRTIs) used for HIV treatment. Coadministration of NNRTIs and PIs with AL could potentially cause complex pharmacokinetic drug interactions. NNRTI by inducing CYP450 3A4 enzyme and PIs by inhibiting CYP450 3A4 enzymes could influence both artemether and lumefantrine concentrations and their active metabolites dihydroartemisinin and desbutyl-lumefantrine, predisposing patients to poor treatment response, toxicity, and risk for development of resistance. There are scanty data on these interactions and their consequences. Pharmacokinetic studies to evaluate these interactions in the target populations are urgently needed.
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Affiliation(s)
- Pauline Byakika-Kibwika
- Infectious Diseases Institute and Infectious Diseases Network for Treatment and Research in Africa (INTERACT), Makerere University College of Health Sciences, P.O. Box 7061, Kampala, Uganda
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Turner TJ, Barnes H, Reid J, Garrubba M. Evidence for perinatal and child health care guidelines in crisis settings: can Cochrane help? BMC Public Health 2010; 10:170. [PMID: 20350326 PMCID: PMC3091544 DOI: 10.1186/1471-2458-10-170] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2009] [Accepted: 03/29/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND It is important that healthcare provided in crisis settings is based on the best available research evidence. We reviewed guidelines for child and perinatal health care in crisis situations to determine whether they were based on research evidence, whether Cochrane systematic reviews were available in the clinical areas addressed by these guidelines and whether summaries of these reviews were provided in Evidence Aid. METHODS Broad internet searches were undertaken to identify relevant guidelines. Guidelines were appraised using AGREE and the clinical areas that were relevant to perinatal or child health were extracted. We searched The Cochrane Database of Systematic Reviews to identify potentially relevant reviews. For each review we determined how many trials were included, and how many were conducted in resource-limited settings. RESULTS Six guidelines met selection criteria. None of the included guidelines were clearly based on research evidence. 198 Cochrane reviews were potentially relevant to the guidelines. These reviews predominantly addressed nutrient supplementation, breastfeeding, malaria, maternal hypertension, premature labour and prevention of HIV transmission. Most reviews included studies from developing settings. However for large portions of the guidelines, particularly health services delivery, there were no relevant reviews. Only 18 (9.1%) reviews have summaries in Evidence Aid. CONCLUSIONS We did not identify any evidence-based guidelines for perinatal and child health care in disaster settings. We found many Cochrane reviews that could contribute to the evidence-base supporting future guidelines. However there are important issues to be addressed in terms of the relevance of the available reviews and increasing the number of reviews addressing health care delivery.
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Affiliation(s)
- Tari J Turner
- Monash Institute of Health Services Research, Monash University, Locked Bag 29, Clayton 3168 Australia
- Centre for Clinical Effectiveness, Southern Health, Locked Bag 29, Clayton 3168 Australia
| | - Hayley Barnes
- previously of the Australasian Cochrane Centre, Monash University, Locked Bag 29, Clayton 3168 Australia
| | - Jane Reid
- Centre for Clinical Effectiveness, Southern Health, Locked Bag 29, Clayton 3168 Australia
| | - Marie Garrubba
- Centre for Clinical Effectiveness, Southern Health, Locked Bag 29, Clayton 3168 Australia
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Kabanywanyi AM, Lengeler C, Kasim P, King'eng'ena S, Schlienger R, Mulure N, Genton B. Adherence to and acceptability of artemether-lumefantrine as first-line anti-malarial treatment: evidence from a rural community in Tanzania. Malar J 2010; 9:48. [PMID: 20149235 PMCID: PMC2833168 DOI: 10.1186/1475-2875-9-48] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2009] [Accepted: 02/11/2010] [Indexed: 11/10/2022] Open
Abstract
Background Controlled clinical trials have shown that a six-dose regimen of artemether-lumefantrine (AL) therapy for uncomplicated Plasmodium falciparum malaria results in cure rates >95% with good tolerability. Materials and methods A prospective study was carried out to document the adherence to and acceptability of AL administration. This was undertaken in the context of the ALIVE study, a prospective, community-based, observational study in a rural, malaria-endemic area of Tanzania. Following microscopic confirmation of P. falciparum infection, the first AL dose was taken under supervision, with the subsequent five doses taken unsupervised at home. Patients were randomized to receive a home-based assessment close to the scheduled time for one of the unsupervised doses, but were blinded to which follow-up visit they had been allocated. A structured questionnaire was administered by trained staff and AL consumption was confirmed by inspection of blister packs. Results A total of 552 patients were recruited of whom 352 (63.8%) were <13 years old. The randomization process allocated 112, 109, 110, 100 and 111 patients to a follow-up visit after doses 2, 3, 4, 5 and 6, respectively. For dose 2, 92.0% of patients (103/112) correctly took AL at 8 ± 1 hours after dose 1. The remaining doses were taken within four hours of the correct time in 87-95% of cases. Nine patients (1.7%) missed one dose. Blister packs were available for inspection in 548 of cases (99.3%) and confirmed patient-reported data that the previous dose had been administered. Nearly all patients took AL with water (549/552 [99.5%]). Two patients (0.4%) took the drug with food. The dosing pictogram and clustering of tablets within the blister packs was considered helpful by 91.8% and 100.0% of patients, respectively. Overall, 87.1% of patients (481/552) found AL easier to take/administer than sulphadoxine-pyrimethamine (SP) and 87.7% (484/552) believed that AL was more effective than SP. Discussion Factors contributing to adherence were likely to be helpful packaging, pictorial dosing instructions and patients' conviction that AL is effective. Conclusion Adherence to the dosing regimen and timing of AL administration was very good.
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Affiliation(s)
- Abdunoor M Kabanywanyi
- Ifakara Health Institute, P,O, Box 78373, Kiko Avenue, Old Bagamoyo Road, Mikocheni, Dar es Salaam, Tanzania.
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Byakika-Kibwika P, Lamorde M, Mayanja-Kizza H, Merry C, Colebunders B, Van geertruyden JP. Update on the efficacy, effectiveness and safety of artemether-lumefantrine combination therapy for treatment of uncomplicated malaria. Ther Clin Risk Manag 2010; 6:11-20. [PMID: 20169032 PMCID: PMC2817784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2009] [Indexed: 11/04/2022] Open
Abstract
Artemether-lumefantrine is one of the artemisisnin-based combination therapies recommended for treatment of uncomplicated falciparum malaria. The drug combination is highly efficacious against sensitive and multidrug resistant falciparum malaria. It offers the advantage of rapid clearance of parasites by artemether and the slower elimination of residual parasites by lumefantrine. The combination can be used in all populations except pregnant mothers in the first trimester where safety is still uncertain. There are still concerns about safety and pharmacokinetics of the drug combination in children, especially infants, pregnant mothers and drug interactions with mainly non-nucleoside reverse transcriptase inhibitors and protease inhibitors used for HIV therapy.
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Affiliation(s)
- Pauline Byakika-Kibwika
- Infectious Diseases Institute and Infectious Diseases Network for Treatment and Research in Africa (INTERACT), Faculty of Medicine, Makerere University, Kampala Uganda
- Trinity College Dublin, Ireland
| | - Mohammed Lamorde
- Infectious Diseases Institute and Infectious Diseases Network for Treatment and Research in Africa (INTERACT), Faculty of Medicine, Makerere University, Kampala Uganda
- Trinity College Dublin, Ireland
| | - Harriet Mayanja-Kizza
- Infectious Diseases Institute and Infectious Diseases Network for Treatment and Research in Africa (INTERACT), Faculty of Medicine, Makerere University, Kampala Uganda
| | - Concepta Merry
- Infectious Diseases Institute and Infectious Diseases Network for Treatment and Research in Africa (INTERACT), Faculty of Medicine, Makerere University, Kampala Uganda
- Trinity College Dublin, Ireland
| | - Bob Colebunders
- Dienst Clinical Sciences, Instituut voor Tropische Geneeskunde, Antwerp, Belgium
- International Health, Epidemiology en Social Medicine, Universiteit Antwerpen, Antwerp, Belgium
| | - Jean-Pierre Van geertruyden
- International Health, Epidemiology en Social Medicine, Universiteit Antwerpen, Antwerp, Belgium
- Epidemiology Unit, Dienst Parasitologie, Instituut voor Tropische Geneeskunde, Antwerp, Belgium
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Katrak S, Gasasira A, Arinaitwe E, Kakuru A, Wanzira H, Bigira V, Sandison TG, Homsy J, Tappero JW, Kamya MR, Dorsey G. Safety and tolerability of artemether-lumefantrine versus dihydroartemisinin-piperaquine for malaria in young HIV-infected and uninfected children. Malar J 2009; 8:272. [PMID: 19948038 PMCID: PMC2789094 DOI: 10.1186/1475-2875-8-272] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2009] [Accepted: 11/30/2009] [Indexed: 11/22/2022] Open
Abstract
Background Artemisinin combination therapy has become the standard of care for uncomplicated malaria in most of Africa. However, there is limited data on the safety and tolerability of these drugs, especially in young children and patients co-infected with HIV. Methods A longitudinal, randomized controlled trial was conducted in a cohort of HIV-infected and uninfected children aged 4-22 months in Tororo, Uganda. Participants were randomized to treatment with artemether-lumefantrine (AL) or dihydroartemisinin-piperaquine (DP) upon diagnosis of their first episode of uncomplicated malaria and received the same regimen for all subsequent episodes. Participants were actively monitored for adverse events for 28 days and then passively for up to 63 days after treatment. This study was registered in ClinicalTrials.gov (registration # NCT00527800). Results A total of 122 children were randomized to AL and 124 to DP, resulting in 412 and 425 treatments, respectively. Most adverse events were rare, with only cough, diarrhoea, vomiting, and anaemia occurring in more than 1% of treatments. There were no differences in the risk of these events between treatment groups. Younger age was associated with an increased risk of diarrhoea in both the AL and DP treatment arms. Retreatment for malaria within 17-28 days was associated with an increased risk of vomiting in the DP treatment arm (HR = 6.47, 95% CI 2.31-18.1, p < 0.001). There was no increase in the risk of diarrhoea or vomiting for children who were HIV-infected or on concomitant therapy with antiretrovirals or trimethoprim-sulphamethoxazole prophylaxis. Conclusion Both AL and DP were safe and well tolerated for the treatment of uncomplicated malaria in young HIV-infected and uninfected children. Trial Registration ClinicalTrials.gov: NCT00527800; http://clinicaltrials.gov/ct2/show/NCT00527800
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Ehrhardt S, Meyer CG. Artemether-lumefantrine in the treatment of uncomplicated Plasmodium falciparum malaria. Ther Clin Risk Manag 2009; 5:805-15. [PMID: 19851528 PMCID: PMC2762439 DOI: 10.2147/tcrm.s5375] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
The World Health Organization strongly recommends artemisinin-based combination therapy (ACT) regimens for the treatment of uncomplicated Plasmodium falciparum malaria cases in endemic areas. Among the combinations of compounds that are available at present, excellent results have been obtained for the artemisinin derivative artemether, in a combination galenic preparation with lumefantrine (artemether-lumefantrine, AL). Here, the pharmacological properties and the therapeutic options of both substances are briefly reviewed and a cursory overview is given on recent trials that have compared the therapeutic effects of AL in the standard 6-dose regimen with other antimalarials and combinations. In order to ensure the most achievable and reliable adherence and compliance of children in the treatment of malaria, a dispersible formulation of AL is now attainable. Recent reports on the emergence of resistance to ACT regimens in Asia, however, are alarming.
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Affiliation(s)
- Stephan Ehrhardt
- Bernhard Nocht Institute for Tropical Medicine, Tropical Medicine Section, Hamburg, Germany
| | - Christian G Meyer
- Bernhard Nocht Institute for Tropical Medicine, Tropical Medicine Section, Hamburg, Germany
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Sinclair D, Zani B, Donegan S, Olliaro P, Garner P. Artemisinin-based combination therapy for treating uncomplicated malaria. Cochrane Database Syst Rev 2009; 2009:CD007483. [PMID: 19588433 PMCID: PMC6532584 DOI: 10.1002/14651858.cd007483.pub2] [Citation(s) in RCA: 171] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND The World Health Organization recommends uncomplicated P. falciparum malaria is treated using Artemisinin-based Combination Therapy (ACT). This review aims to assist the decision making of malaria control programmes by providing an overview of the relative benefits and harms of the available options. OBJECTIVES To compare the effects of ACTs with other available ACT and non-ACT combinations for treating uncomplicated P. falciparum malaria. SEARCH STRATEGY We searched the Cochrane Infectious Diseases Group Specialized Register; the Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; LILACS, and the metaRegister of Controlled Trials (mRCT) to March 2009. SELECTION CRITERIA Randomized head to head trials of ACTs in uncomplicated P. falciparum malaria.This review is limited to: dihydroartemisinin-piperaquine; artesunate plus mefloquine; artemether-lumefantrine (six doses); artesunate plus amodiaquine; artesunate plus sulfadoxine-pyrimethamine and amodiaquine plus sulfadoxine-pyrimethamine. DATA COLLECTION AND ANALYSIS Two authors independently assessed trials for eligibility and risk of bias, and extracted data. We analysed primary outcomes in line with the WHO 'Protocol for assessing and monitoring antimalarial drug efficacy' and compared drugs using risk ratios (RR) and 95% confidence intervals (CI). Secondary outcomes were effects on P. vivax, gametocytes, haemoglobin, and adverse events. MAIN RESULTS Fifty studies met the inclusion criteria. All five ACTs achieved PCR adjusted failure rates of < 10%, in line with WHO recommendations, at most study sites.Dihydroartemisinin-piperaquine performed well compared to the ACTs in current use (PCR adjusted treatment failure versus artesunate plus mefloquine in Asia; RR 0.39, 95% CI 0.19 to 0.79; three trials, 1062 participants; versus artemether-lumefantrine in Africa; RR 0.39, 95% CI 0.24 to 0.64; three trials, 1136 participants).ACTs were superior to amodiaquine plus sulfadoxine-pyrimethamine in East Africa (PCR adjusted treatment failure versus artemether-lumefantrine; RR 0.12, 95% CI 0.06 to 0.24; two trials, 618 participants; versus AS+AQ; RR 0.44, 95% CI 0.22 to 0.89; three trials, 1515 participants).Dihydroartemisinin-piperaquine (RR 0.32, 95% CI 0.24 to 0.43; four trials, 1442 participants) and artesunate plus mefloquine (RR 0.30, 95% CI 0.21 to 0.41; four trials, 1003 participants) were more effective than artemether-lumefantrine at reducing the incidence of P.vivax over 42 days follow up. AUTHORS' CONCLUSIONS Dihydroartemisinin-piperaquine is another effective first-line treatment for P. falciparum malaria.The performance of the non-ACT (amodiaquine plus sulfadoxine-pyrimethamine) falls below WHO recommendations for first-line therapy in parts of Africa.In areas where primaquine is not being used for radical cure of P. vivax, ACTs with long half-lives may provide some benefit.
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Affiliation(s)
- David Sinclair
- Liverpool School of Tropical MedicineInternational Health GroupPembroke PlaceLiverpoolUKL3 5QA
| | - Babalwa Zani
- Medical Research CouncilSouth African Cochrane CentreP. O. Box 19070TygerbergCape TownWestern CapeSouth Africa7505
| | - Sarah Donegan
- Liverpool School of Tropical MedicineInternational Health GroupPembroke PlaceLiverpoolUKL3 5QA
| | - Piero Olliaro
- World Health OrganizationSpecial Programme for Research and Training in Tropical Diseases (TDR)1211 Geneva 27GenevaSwitzerland
| | - Paul Garner
- Liverpool School of Tropical MedicineInternational Health GroupPembroke PlaceLiverpoolUKL3 5QA
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19
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Deen JL, von Seidlein L, Dondorp A. Therapy of uncomplicated malaria in children: a review of treatment principles, essential drugs and current recommendations. Trop Med Int Health 2008; 13:1111-30. [DOI: 10.1111/j.1365-3156.2008.02117.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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20
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Maiteki-Sebuguzi C, Jagannathan P, Yau VM, Clark TD, Njama-Meya D, Nzarubara B, Talisuna AO, Kamya MR, Rosenthal PJ, Dorsey G, Staedke SG. Safety and tolerability of combination antimalarial therapies for uncomplicated falciparum malaria in Ugandan children. Malar J 2008; 7:106. [PMID: 18547415 PMCID: PMC2441629 DOI: 10.1186/1475-2875-7-106] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2008] [Accepted: 06/11/2008] [Indexed: 11/15/2022] Open
Abstract
Background Combination antimalarial therapy is recommended for the treatment of uncomplicated falciparum malaria in Africa; however, some concerns about the safety and tolerability of new regimens remain. This study compared the safety and tolerability of three combination antimalarial regimens in a cohort of Ugandan children. Methods A longitudinal, single-blind, randomized clinical trial of children was conducted between November 2004 and May 2007 in Kampala, Uganda. Upon diagnosis of the first episode of uncomplicated malaria, participants were randomized to treatment with amodiaquine + sulphadoxine-pyrimethamine (AQ+SP), artesunate + amodiaquine (AS+AQ), or artemether-lumefantrine (AL). Once randomized, participants received the same regimen for all subsequent episodes of uncomplicated malaria. Participants were actively monitored for adverse events for the first 14 days after each treatment, and then passively followed until their next study medication treatment, or withdrawal from study. Outcome measures included the risk of adverse events at 14 and 42 days after treatment. Results Of 601 enrolled children, 382 were diagnosed with at least one episode of uncomplicated malaria and were treated with study medications. The median age at treatment was 6.3 years (range 1.1 – 12.3 years). At 14 days of follow-up, AQ+SP treatment was associated with a higher risk of anorexia, weakness, and subjective fever than treatment with AL, and a higher risk of weakness, and subjective fever than treatment with AS+AQ. Treatment with AL was associated with a higher risk of elevated temperature. Repeated episodes of neutropaenia associated with AS+AQ were detected in one participant. Considering only children less than five years, those who received AQ+SP were at higher risk of developing moderate or severe anorexia and weakness than those treated with AL (anorexia: RR 3.82, 95% CI 1.59 – 9.17; weakness: RR 5.40, 95% CI 1.86 – 15.7), or AS+AQ (anorexia: RR 2.10, 95% CI 1.04 – 4.23; weakness: RR 2.26, 95% CI 1.01 – 5.05). Extending the analysis to 42 days of follow-up had little impact on the findings. Conclusion This study confirms the safety and tolerability of AS+AQ and AL in Ugandan children, and suggests that AQ+SP is safe, but less well-tolerated, particularly in younger children. As newer antimalarial regimens are deployed, collecting data on their safety and tolerability will be essential. Trial registration Current Controlled Trials Identifier ISRCTN37517549
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Gametocitemia en malaria por Plasmodium falciparum tratada con amodiaquina o artesunato. BIOMEDICA 2008. [DOI: 10.7705/biomedica.v28i2.91] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Fanello CI, Karema C, van Doren W, Van Overmeir C, Ngamije D, D'Alessandro U. A randomised trial to assess the safety and efficacy of artemether–lumefantrine (Coartem®) for the treatment of uncomplicated Plasmodium falciparum malaria in Rwanda. Trans R Soc Trop Med Hyg 2007; 101:344-50. [PMID: 17005222 DOI: 10.1016/j.trstmh.2006.06.010] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2006] [Revised: 06/23/2006] [Accepted: 06/23/2006] [Indexed: 11/29/2022] Open
Abstract
Coartem is a fixed-dose combination of artemether-lumefantrine that, given in six doses, provides effective treatment for children with uncomplicated Plasmodium falciparum infection in areas with highly endemic and multidrug-resistant malaria. In Rwanda since 2001, amodiaquine+sulfadoxine-pyrimethamine (AQ+SP) has been the first-line treatment, but resistance to this combination has rapidly emerged and spread. Coartem was considered as a possible alternative, and a randomised, open-label, clinical trial to test its safety, tolerability and efficacy was carried out in 2004-2005. Five hundred children aged 12-59 months with uncomplicated P. falciparum malaria were randomly allocated to AQ+SP or Coartem. Patients were followed up until day 28 after treatment. Adverse events and clinical and parasitological outcomes were recorded. Adequate clinical and parasitological response (ACPR) was significantly higher in children treated with Coartem than in those treated with AQ+SP: the PCR-adjusted 28-day ACPR was 96.68% for Coartem and 79.35% for AQ+SP. Both treatments rapidly cleared parasitaemia and fever, although parasite clearance was significantly faster in children treated with Coartem. Mean packed cell volume increased in all patients, with no significant differences between treatments. Coartem proved to be more efficacious than AQ+SP, with a good safety and tolerability profile.
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Affiliation(s)
- C I Fanello
- London School of Hygiene and Tropical Medicine, Keppel Street, London, UK.
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Mueller EA, van Vugt M, Kirch W, Andriano K, Hunt P, de Palacios PI. Efficacy and safety of the six-dose regimen of artemether-lumefantrine for treatment of uncomplicated Plasmodium falciparum malaria in adolescents and adults: a pooled analysis of individual patient data from randomized clinical trials. Acta Trop 2006; 100:41-53. [PMID: 17045558 DOI: 10.1016/j.actatropica.2006.09.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2006] [Revised: 06/20/2006] [Accepted: 09/17/2006] [Indexed: 10/24/2022]
Abstract
To demonstrate the superiority of the six-dose over the four-dose regimen of artemether-lumefantrine (co-artemether, Coartem) in patients >12 years, data from 11 randomized clinical trials were pooled and analyzed. A total of 1368 patients with uncomplicated Plasmodium falciparum malaria (six-dose: 598; four-dose: 770) were included in the analysis, together with 717 patients treated with comparators. Analysis of the 28-day cure rate based on the ITT and evaluable populations yielded corrected cure rates for the six-dose regimen of 87% and 97% compared with 74% and 87%, respectively, with the four-dose regimen (P<0.0001, for both comparisons). For mefloquine/artesunate, the most frequently used comparator, cure rates were 87% and 99%, respectively. The six-dose regimen was well tolerated and not markedly different to the four-dose regimen. The main finding of our analysis is that the six-dose regimen of co-artemether is more effective than the four-dose regimen in adolescents and adults without compromising safety.
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Affiliation(s)
- Edgar A Mueller
- Institute for Clinical Pharmacology, Public Health Research Association Saxony, Medical Faculty, Technical University, Fiedlerstrasse 27, D-01307 Dresden, Germany.
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Abstract
Every year people die from malaria in Britain and other industrialised countries. Most of these deaths are avoidable: they occur because a patient or doctor has underestimated the severity of the disease or has not considered the diagnosis early enough. This article provides the essential facts on treating malaria in adults in a non-endemic setting and is based on the best available evidence
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Chan EW. Artemether-Lumefantrine and Primaquine for Mixed Plasmodium falciparumand ovaleMalaria. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2006. [DOI: 10.1002/j.2055-2335.2006.tb00589.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Bukirwa H, Yeka A, Kamya MR, Talisuna A, Banek K, Bakyaita N, Rwakimari JB, Rosenthal PJ, Wabwire-Mangen F, Dorsey G, Staedke SG. Artemisinin combination therapies for treatment of uncomplicated malaria in Uganda. PLOS CLINICAL TRIALS 2006; 1:e7. [PMID: 16871329 PMCID: PMC1488893 DOI: 10.1371/journal.pctr.0010007] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/27/2006] [Accepted: 04/07/2006] [Indexed: 12/03/2022]
Abstract
OBJECTIVES To compare the efficacy and safety of artemisinin combination therapies for the treatment of uncomplicated falciparum malaria in Uganda. DESIGN Randomized single-blind controlled trial. SETTING Tororo, Uganda, an area of high-level malaria transmission. PARTICIPANTS Children aged one to ten years with confirmed uncomplicated P. falciparum malaria. INTERVENTIONS Amodiaquine + artesunate or artemether-lumefantrine. OUTCOME MEASURES Risks of recurrent symptomatic malaria and recurrent parasitemia at 28 days, unadjusted and adjusted by genotyping to distinguish recrudescences and new infections. RESULTS Of 408 participants enrolled, 403 with unadjusted efficacy outcomes were included in the per-protocol analysis. Both treatment regimens were highly efficacious; no recrudescences occurred in patients treated with amodiaquine + artesunate, and only two occurred in those treated with artemether-lumefantrine. However, recurrent malaria due to new infections was common. The unadjusted risk of recurrent symptomatic malaria was significantly lower for participants treated with artemether-lumefantrine than for those treated with amodiaquine + artesunate (27% versus 42%, risk difference 15%, 95% CI 5.9%-24.2%). Similar results were seen for the risk of recurrent parasitemia (51% artemether-lumefantrine versus 66% amodiaquine + artesunate, risk difference 16%, 95% CI 6.2%-25.2%). Amodiaquine + artesunate and artemether-lumefantrine were both well-tolerated. Serious adverse events were uncommon with both regimens. CONCLUSIONS Amodiaquine + artesunate and artemether-lumefantrine were both highly efficacious for treatment of uncomplicated malaria. However, in this holoendemic area, despite the excellent performance of both regimens in terms of efficacy, many patients experienced recurrent parasitemia due to new infections. Artemether-lumefantrine was superior to amodiaquine + artesunate for prevention of new infections. To maximize the benefit of artemisinin combination therapy in Africa, treatment should be integrated with strategies to prevent malaria transmission. The impact of frequent repeated therapy on the efficacy, safety, and cost-effectiveness of new artemisinin regimens should be further investigated.
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Affiliation(s)
| | - Adoke Yeka
- Uganda Malaria Surveillance Project, Kampala, Uganda
| | | | | | - Kristin Banek
- Uganda Malaria Surveillance Project, Kampala, Uganda
| | | | | | - Philip J Rosenthal
- Department of Medicine, San Francisco General Hospital, University of California, San Francisco, United States of America
| | | | - Grant Dorsey
- Department of Medicine, San Francisco General Hospital, University of California, San Francisco, United States of America
| | - Sarah G Staedke
- Department of Medicine, San Francisco General Hospital, University of California, San Francisco, United States of America
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Omari AAA, Gamble C, Garner P. Artemether-lumefantrine (four-dose regimen) for treating uncomplicated falciparum malaria. Cochrane Database Syst Rev 2006; 2006:CD005965. [PMID: 16625646 PMCID: PMC6532603 DOI: 10.1002/14651858.cd005965] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND The World Health Organization recommends artemether-lumefantrine, an expensive drug, as a treatment for uncomplicated malaria. We sought evidence of the superiority of the four-dose regimen over existing treatments. OBJECTIVES To evaluate the four-dose regimen of artemether-lumefantrine for treating uncomplicated falciparum malaria. SEARCH STRATEGY We searched the Cochrane Infectious Diseases Group Specialized Register (October 2005), CENTRAL (The Cochrane Library 2005, Issue 3), MEDLINE (1966 to October 2005), EMBASE (1988 to October 2005), LILACS (1982 to October 2005), conference proceedings, and reference lists of articles. We also contacted experts in malaria research and the pharmaceutical company that manufactures artemether-lumefantrine. SELECTION CRITERIA Randomized controlled trials comparing four doses of artemether-lumefantrine with standard treatment regimens (single drug or combination), or six doses of artemether-lumefantrine, for treating uncomplicated falciparum malaria. DATA COLLECTION AND ANALYSIS Two authors independently applied inclusion criteria to potentially relevant trials, assessed trial quality, and extracted data, including adverse events. Total failure by day 28 (day 42 for sulfadoxine-pyrimethamine and day 63 for mefloquine) was the primary outcome. MAIN RESULTS Seven trials (2057 participants) tested a four-dose regimen. More people tended to fail treatment with artemether-lumefantrine than with other drugs, including sulfadoxine-pyrimethamine (247 participants, 1 trial), halofantrine (86 participants, 1 trial), and mefloquine (233 participants, 1 trial; difference statistically significant for mefloquine). When compared with chloroquine, artemether-lumefantrine was better in two trials (378 participants), but over 50% of the participants treated with chloroquine had total failure by day 28. Fewer people failed treatment with the six-dose regimen compared to the four-dose regimen (RR 7.71, 95% CI 2.99 to 19.88; 306 participants, 1 trial). AUTHORS' CONCLUSIONS The four-dose regimen of artemether-lumefantrine seems to be less effective than regimens against which it has been tested. The six-dose regimen is superior to four-dose regimen.
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Affiliation(s)
- A A A Omari
- Countess of Chester Hospital, NHS Foundation Trust, Paediatric Department, Countess of Chester Health Park, Liverpool Road, Chester, Cheshire, UK, CH2 1UL.
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