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Clark RL. Safety of Treating Malaria with Artemisinin-Based Combination Therapy in the First Trimester of Pregnancy. Reprod Toxicol 2022; 111:204-210. [PMID: 35667524 DOI: 10.1016/j.reprotox.2022.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 05/29/2022] [Accepted: 05/31/2022] [Indexed: 11/25/2022]
Abstract
There have been recent calls for the use of artemisinin-based combination therapies (ACTs) for uncomplicated malaria in the first trimester of pregnancy. Nevertheless, the 2021 WHO Guidelines for Malaria reaffirmed their position that there is not adequate clinical safety data on artemisinins to support that usage. The WHO's position is consistent with several issues with the existing clinical data. First, first trimester safety results from multiple ACTs were lumped in a meta-analysis which does not demonstrate that each of the included ACTs is equally safe. Second, safety results from all periods of the first trimester were lumped in the meta-analysis which does not demonstrate the same level of safety for all subperiods, particularly gestational Weeks 6 to 8 which is likely to be the most sensitive period. Third, even if there is evidence of a lack of an effect on miscarriage for a particular ACT, it does not follow then there are no developmental effects for any ACT. In monkeys, artesunate caused marked embryonal anemia leading to embryo death but the long-term consequences of lower levels of embryonal anemia are not known. Fourth, there have been advances in the sensitivity and usage of rapid diagnostic tests that will lead to diagnoses of malaria earlier in gestation which is less well studied and more likely sensitive to artemisinins. Any clinical studies of the safety of ACTs in the first trimester need to evaluate the results of treatment with individual ACTs during different 1- to 2-week periods of the first trimester.
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Alagbonsi AI, Salman TM, Sulaiman SO, Adedini KA, Kebu S. Possible mechanisms of the hypoglycaemic effect of artesunate: Gender implication. Metabol Open 2021; 10:100087. [PMID: 33778463 PMCID: PMC7985403 DOI: 10.1016/j.metop.2021.100087] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 03/08/2021] [Indexed: 02/07/2023] Open
Abstract
Background We investigated the mechanism of artesunate’s glucose-modulating effect especially with gender implication. Methods Twenty-five (25) male and 25 female rats were separately and blindly allocated into five identical groups (n = 5/group). Group I (control) received 0.2 ml/kg distilled water. Groups II and III both received 2.90 mg/kg artesunate on day one, but 1.45 mg/kg from day two till day five and day fifteen respectively. Groups IV and V both received 8.70 mg/kg artesunate on day one, but 4.35 mg/kg artesunate from day two till day five and day fifteen respectively. Results In male rats, glucose was reduced by both doses of artesunate at 5 days but increased by high dose at 15 days. Artesunate increased glycogen concentration at short duration which normalised at long duration in both genders. Artesunate increased G6P concentration only in male rats at 15 days but reduced G6Pase activity in male and female rats (except in those that received low and high doses of artesunate for 15 days). Artesunate increased insulin only in male rats treated with low dose artesunate for 5 days. Artesunate increased cortisol concentration in male but reduced it in female rats. Artesunate decreased glucagon concentration except in female rats treated with high dose for 5 days. Artesunate increased oestrogen concentration in male rats that received low dose artesunate for 5 days but reduced it in female rats that received high dose for 15 days. Conclusions Artesunate reduces plasma glucose by reducing plasma glucagon concentrations and inhibiting liver glycogenolysis via inhibition of G6Pase activity in both sexes. Increase in insulin concentration contributed to the reduction in blood glucose caused by artesunate in male but not female rats; and artesunate-induced increase in G6P, a substrate for G6PD, could enhance NADPH generation and antioxidant enzyme activation in male rats. Reducing glucagon concentration and inhibiting G6Pase activity in both genders. . Increasing plasma insulin in male but not in female. Increasing G6P, a substrate for G6PD, in male rats.
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Affiliation(s)
- Abdullateef Isiaka Alagbonsi
- Department of Clinical Biology (Physiology unit), School of Medicine and Pharmacy, University of Rwanda College of Medicine and Health Sciences, Huye, Rwanda
| | - Toyin Mohammad Salman
- Department of Physiology, College of Health Sciences, University of Ilorin, Ilorin, Kwara, Nigeria
| | - Sheu Oluwadare Sulaiman
- Department of Physiology, Kampala International University Western Campus, Ishaka Bushenyi, Uganda.,Department of Cell Biology, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Kafayat Anike Adedini
- Department of Physiology, College of Health Sciences, University of Ilorin, Ilorin, Kwara, Nigeria
| | - Susan Kebu
- Department of Physiology, College of Health Sciences, University of Ilorin, Ilorin, Kwara, Nigeria
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3
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Clark RL. Teratogen update: Malaria in pregnancy and the use of antimalarial drugs in the first trimester. Birth Defects Res 2020; 112:1403-1449. [PMID: 33079495 DOI: 10.1002/bdr2.1798] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 08/20/2020] [Indexed: 02/04/2023]
Abstract
Malaria is a particular problem in pregnancy because of enhanced sensitivity, the possibility of placental malaria, and adverse effects on pregnancy outcome. Artemisinin-containing combination therapies (ACTs) are the most effective antimalarials known. WHO recommends 7-day quinine therapy for uncomplicated Plasmodium falciparum malaria in the first trimester despite the superior tolerability and efficacy of 3-day ACT regimens because artemisinins caused embryolethality and/or cardiovascular malformations at relatively low doses in rats, rabbits, and monkeys. The developmental toxicity of artesunate, artemether, and DHA were similar in rats but artesunate was embryotoxic at lower doses in rabbits (5 mg/kg/day) than artemether (no effect level = 25 mg/kg/day). In clinical studies in Africa, treatment with artemether-lumefantrine in the first trimester was observed to be highly efficacious and the miscarriage rate (≤3.1%) was similar to no antimalarial treatment (2.6%). When data from the first-trimester use of largely artesunate-based therapies in Thailand were pooled together, there was no difference in miscarriage rate compared to quinine. However, individually, artesunate-mefloquine was associated with a higher miscarriage rate (15/71 = 21%) compared to other artemisinin-based therapies including 7-day artesunate + clindamycin (2/50 = 4%) and quinine (92/842 = 11%). Thus, appropriate statistical comparisons of individual ACT groups are needed prior to assuming that they all have the same risk for developmental toxicity. Current limitations in the assessment of the safety of ACTs in the first trimester are a lack of exposures early in gestation (gestational weeks 6-7), limited postnatal evaluation for cardiovascular malformations, and the pooling of all ACTs for the assessment of risk.
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Affiliation(s)
- Robert L Clark
- Artemis Pharmaceutical Research, Saint Augustine, Florida, USA
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4
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González R, Pons-Duran C, Bardají A, Leke RGF, Clark R, Menendez C. Systematic review of artemisinin embryotoxicity in animals: Implications for malaria control in human pregnancy. Toxicol Appl Pharmacol 2020; 402:115127. [PMID: 32622917 DOI: 10.1016/j.taap.2020.115127] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 05/31/2020] [Accepted: 06/29/2020] [Indexed: 10/23/2022]
Abstract
Pregnant women are one of the most susceptible and vulnerable groups to malaria, the most important parasitic disease worldwide. Artemisinin-based combination therapies (ACTs) are recommended for the treatment of uncomplicated malaria in all population groups including pregnant women. However, due to the embryotoxicity observed in animal studies, ACTs have long been contraindicated during the first trimester in pregnant women. Despite the safety concerns raised in pre-clinical studies, recent findings on ACTs's use in pregnant women appear to be reassuring regarding safety and have prompted a revision of malaria treatment guidelines for first trimester of pregnancy. To contribute to the risk-benefit assessment of ACTs, we conducted a systematic literature review of animal studies published between 2007 and 2019, which evaluated the embryotoxic effects of artemisinin and its derivatives among pregnant mammals. Eighteen experimental studies fitted the inclusion criteria. These studies confirmed and further characterized the severe embryolethal and embryotoxic dose-dependent effects of artemisinin and its derivatives when administered during the organogenesis period in rats, rabbits and monkeys. Timing of administration and dosage of the drug were found to be key factors in the appearance of embryo damage. Overall, the translation of the findings of artemisinin derivatives use in animal studies to pregnant women remains disturbing. Thus, a policy change in the use of ACTs during the first trimester in pregnant women for the treatment of uncomplicated malaria does not seem pertinent and if implemented, it should be accompanied by solid pharmacovigilance systems, which are challenging to establish in malaria endemic countries.
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Affiliation(s)
- Raquel González
- ISGlobal, Hospital Clínic-Universitat de Barcelona, Barcelona, Spain; Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Spain.
| | - Clara Pons-Duran
- ISGlobal, Hospital Clínic-Universitat de Barcelona, Barcelona, Spain; Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Spain
| | - Azucena Bardají
- ISGlobal, Hospital Clínic-Universitat de Barcelona, Barcelona, Spain; Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Spain; Manhiça Health Research Center (CISM), Manhiça, Mozambique
| | - Rose G F Leke
- Department of Microbiology, Immunology and Haematology, Faculty of Medicine and Biomedical Sciences, University of Yaounde, Yaounde, Cameroon
| | - Robert Clark
- Artemis Pharmaceutical Research, Jacksonville, Florida, USA
| | - Clara Menendez
- ISGlobal, Hospital Clínic-Universitat de Barcelona, Barcelona, Spain; Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Spain; Manhiça Health Research Center (CISM), Manhiça, Mozambique
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Boareto AC, Gomes C, Centeno Müller J, da Silva JG, Vergara F, Salum N, Maristany Sargaço R, de Carvalho RR, Queiroz Telles JE, Marinho CRF, Paumgartten FJR, Dalsenter PR. Maternal and fetal outcome of pregnancy in Swiss mice infected with Plasmodium berghei ANKA GFP. Reprod Toxicol 2019; 89:107-114. [PMID: 31310803 DOI: 10.1016/j.reprotox.2019.07.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 06/19/2019] [Accepted: 07/12/2019] [Indexed: 11/19/2022]
Abstract
Malaria in pregnant women is associated with risk of maternal and perinatal morbidity and mortality, and there are few antimalarial drugs considered safe to treat them, so it is necessary to develop safer antimalarial medicines. The goal of this study was to develop an animal model for human malaria during pregnancy by characterizing the maternal and fetal outcomes in malaria infected Swiss mice. For that, in the present study, we evaluated the outcome of pregnancy in Swiss mice infected with Plasmodium berghei ANKAGFP. We observed a reduction of fetal body weight and signs of skeletal ossification retardation in the offspring of mice infected on GD 12. The group of mice infected with malaria presented premature deliveries and histopathology changes consistent with placental malaria. Our study suggests that Swiss Webster mice infected with P. berghei ANKAGFP on GD 12 might be a valuable model to investigate the safety and the efficacy of new antimalarial drugs indicated to pregnant women.
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Affiliation(s)
- Ana Cláudia Boareto
- Department of Pharmacology, Federal University of Paraná, Centro Politécnico, PO Box 19031, Curitiba, PR, 81531-980, Brazil.
| | - Caroline Gomes
- Department of Pharmacology, Federal University of Paraná, Centro Politécnico, PO Box 19031, Curitiba, PR, 81531-980, Brazil
| | - Juliane Centeno Müller
- Department of Pharmacology, Federal University of Paraná, Centro Politécnico, PO Box 19031, Curitiba, PR, 81531-980, Brazil
| | - Jonas Golart da Silva
- Department of Pharmacology, Federal University of Paraná, Centro Politécnico, PO Box 19031, Curitiba, PR, 81531-980, Brazil; Department of Chemistry and Biology, Federal University of Technology - Paraná, Cidade Industrial, Curitiba, PR, 81020-430, Brazil
| | - Fernanda Vergara
- Department of Pharmacology, Federal University of Paraná, Centro Politécnico, PO Box 19031, Curitiba, PR, 81531-980, Brazil
| | - Noruê Salum
- Department of Pharmacology, Federal University of Paraná, Centro Politécnico, PO Box 19031, Curitiba, PR, 81531-980, Brazil
| | - Rafaela Maristany Sargaço
- Department of Pharmacology, Federal University of Paraná, Centro Politécnico, PO Box 19031, Curitiba, PR, 81531-980, Brazil
| | - Rosângela Ribeiro de Carvalho
- Laboratory of Environmental Toxicology, National School of Public Health, Oswaldo Cruz Foundation, Manguinhos, Rio de Janeiro, RJ, 21041-210, Brazil
| | | | - Cláudio Romero Farias Marinho
- Department of Parasitology, Institute of Biomedical Sciences, University of São Paulo, Butantã, São Paulo, SP, 03178-200, Brazil
| | - Francisco José Roma Paumgartten
- Laboratory of Environmental Toxicology, National School of Public Health, Oswaldo Cruz Foundation, Manguinhos, Rio de Janeiro, RJ, 21041-210, Brazil
| | - Paulo Roberto Dalsenter
- Department of Pharmacology, Federal University of Paraná, Centro Politécnico, PO Box 19031, Curitiba, PR, 81531-980, Brazil
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Zheng W, Abd El-Aty AM, Kim SK, Choi JM, Hacımüftüoğlu A, Shim JH, Kang YS, Shin HC. Quantification of artesunate and its metabolite, dihydroartemisinin, in animal products using liquid chromatography-tandem mass spectrometry. J Sep Sci 2018; 41:3538-3546. [DOI: 10.1002/jssc.201800499] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 02/07/2018] [Accepted: 08/07/2018] [Indexed: 02/03/2023]
Affiliation(s)
- Weijia Zheng
- Department of Veterinary Pharmacology and Toxicology; College of Veterinary Medicine; Konkuk University; Seoul Republic of Korea
| | - A. M. Abd El-Aty
- Department of Pharmacology; Faculty of Veterinary Medicine; Cairo University; Giza Egypt
- Department of Medical Pharmacology; Medical Faculty; Ataturk University; Erzurum Turkey
| | - Seong-Kwan Kim
- Department of Veterinary Pharmacology and Toxicology; College of Veterinary Medicine; Konkuk University; Seoul Republic of Korea
| | - Jeong-Min Choi
- Department of Veterinary Pharmacology and Toxicology; College of Veterinary Medicine; Konkuk University; Seoul Republic of Korea
| | - Ahmet Hacımüftüoğlu
- Department of Medical Pharmacology; Medical Faculty; Ataturk University; Erzurum Turkey
| | - Jae-Han Shim
- Natural Products Chemistry Laboratory; College of Agriculture and Life Sciences; Chonnam National University; Republic of Korea
| | - Young-Sun Kang
- Department of Veterinary Pharmacology and Toxicology; College of Veterinary Medicine; Konkuk University; Seoul Republic of Korea
- Department of Biomedical Science and Technology; Konkuk University; Seoul Republic of Korea
| | - Ho-Chul Shin
- Department of Veterinary Pharmacology and Toxicology; College of Veterinary Medicine; Konkuk University; Seoul Republic of Korea
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7
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Dauda K, Busari Z, Morenikeji O, Afolayan F, Oyeyemi O, Meena J, Sahu D, Panda A. Poly(D,L-lactic-co-glycolic acid)-based artesunate nanoparticles: formulation, antimalarial and toxicity assessments. J Zhejiang Univ Sci B 2018; 18:977-985. [PMID: 29119735 DOI: 10.1631/jzus.b1600389] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE The aim of this study was to formulate polymer-based artesunate nanoparticles for malaria treatment. METHODS Artesunate was loaded with poly(D,L-lactic-co-glycolic acid) (PLGA) by solvent evaporation from an oil-in-water single emulsion. Nanoparticles were characterized by X-ray diffraction and differential scanning calorimetry analyses. In vivo antimalarial studies at 4 mg/kg were performed on Swiss male albino mice infected with Plasmodium berghei. Hematological and hepatic toxicity assays were performed. In vitro cytotoxicity of free and encapsulated artesunate (Art-PLGA) to cell line RAW 264.7 was determined at concentrations of 7.8-1000 µg/ml. RESULTS The particle size of the formulated drug was (329.3±21.7) nm and the entrapment efficiency was (38.4±10.1)%. Art-PLGA nanoparticles showed higher parasite suppression (62.6%) compared to free artesunate (58.2%, P<0.05). Platelet counts were significantly higher in controls (305 000.00±148 492.40) than in mice treated with free artesunate (139 500.00±20 506.10) or Art-PLGA (163 500.00±3535.53) (P<0.05). There was no sign of hepatic toxicity following use of the tested drugs. The half maximal inhibitory concentration (IC50) of Art-PLGA (468.0 µg/ml) was significantly higher (P<0.05) than that of free artesunate (7.3 µg/ml) in the in vitro cytotoxicity assay. CONCLUSIONS A simple treatment of PLGA-entrapped artesunate nanoparticles with dual advantages of low toxicity and better antiplasmodial efficacy has been developed.
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Affiliation(s)
- Kabiru Dauda
- Department of Zoology, University of Ibadan, Ibadan 200284, Nigeria
| | - Zulaikha Busari
- Department of Zoology, University of Ibadan, Ibadan 200284, Nigeria
| | | | | | - Oyetunde Oyeyemi
- Department of Basic Sciences (Biology Programme), Babcock University, Ilishan-Remo 121103, Nigeria.,Product Development Cell, National Institute of Immunology, Aruna Asaf Ali Marg, New Delhi 110067, India
| | - Jairam Meena
- Product Development Cell, National Institute of Immunology, Aruna Asaf Ali Marg, New Delhi 110067, India
| | - Debasis Sahu
- Product Development Cell, National Institute of Immunology, Aruna Asaf Ali Marg, New Delhi 110067, India
| | - Amulya Panda
- Product Development Cell, National Institute of Immunology, Aruna Asaf Ali Marg, New Delhi 110067, India
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8
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D'Alessandro U, Hill J, Tarning J, Pell C, Webster J, Gutman J, Sevene E. Treatment of uncomplicated and severe malaria during pregnancy. THE LANCET. INFECTIOUS DISEASES 2018; 18:e133-e146. [PMID: 29395998 DOI: 10.1016/s1473-3099(18)30065-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 07/19/2017] [Accepted: 10/13/2017] [Indexed: 12/13/2022]
Abstract
Over the past 10 years, the available evidence on the treatment of malaria during pregnancy has increased substantially. Owing to their relative ease of use, good sensitivity and specificity, histidine rich protein 2 based rapid diagnostic tests are appropriate for symptomatic pregnant women; however, such tests are less appropriate for systematic screening because they will not detect an important proportion of infections among asymptomatic women. The effect of pregnancy on the pharmacokinetics of antimalarial drugs varies greatly between studies and class of antimalarial drugs, emphasising the need for prospective studies in pregnant and non-pregnant women. For the treatment of malaria during the first trimester, international guidelines are being reviewed by WHO. For the second and third trimester of pregnancy, results from several trials have confirmed that artemisinin-based combination treatments are safe and efficacious, although tolerability and efficacy might vary by treatment. It is now essential to translate such evidence into policies and clinical practice that benefit pregnant women in countries where malaria is endemic. Access to parasitological diagnosis or appropriate antimalarial treatment remains low in many countries and regions. Therefore, there is a pressing need for research to identify quality improvement interventions targeting pregnant women and health providers. In addition, efficient and practical systems for pharmacovigilance are needed to further expand knowledge on the safety of antimalarial drugs, particularly in the first trimester of pregnancy.
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Affiliation(s)
- Umberto D'Alessandro
- Medical Research Council Unit, Banjul, The Gambia; London School of Hygiene & Tropical Medicine, London, UK.
| | - Jenny Hill
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Joel Tarning
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Christopher Pell
- Centre for Social Science and Global Health, University of Amsterdam, Amsterdam, Netherlands; Amsterdam Institute for Global Health and Development, Amsterdam, Netherlands
| | - Jayne Webster
- London School of Hygiene & Tropical Medicine, London, UK
| | - Julie Gutman
- Malaria Branch, US Centers for Diseases Control and Prevention, Atlanta, GA, USA
| | - Esperanca Sevene
- Manhiça Health Research Center (CISM), Manhiça, Mozambique; Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
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9
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Clark RL. Animal Embryotoxicity Studies of Key Non-Artemisinin Antimalarials and Use in Women in the First Trimester. Birth Defects Res 2017. [DOI: 10.1002/bdr2.1035] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Dellicour S, Sevene E, McGready R, Tinto H, Mosha D, Manyando C, Rulisa S, Desai M, Ouma P, Oneko M, Vala A, Rupérez M, Macete E, Menéndez C, Nakanabo-Diallo S, Kazienga A, Valéa I, Calip G, Augusto O, Genton B, Njunju EM, Moore KA, d’Alessandro U, Nosten F, ter Kuile F, Stergachis A. First-trimester artemisinin derivatives and quinine treatments and the risk of adverse pregnancy outcomes in Africa and Asia: A meta-analysis of observational studies. PLoS Med 2017; 14:e1002290. [PMID: 28463996 PMCID: PMC5412992 DOI: 10.1371/journal.pmed.1002290] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Accepted: 03/23/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Animal embryotoxicity data, and the scarcity of safety data in human pregnancies, have prevented artemisinin derivatives from being recommended for malaria treatment in the first trimester except in lifesaving circumstances. We conducted a meta-analysis of prospective observational studies comparing the risk of miscarriage, stillbirth, and major congenital anomaly (primary outcomes) among first-trimester pregnancies treated with artemisinin derivatives versus quinine or no antimalarial treatment. METHODS AND FINDINGS Electronic databases including Medline, Embase, and Malaria in Pregnancy Library were searched, and investigators contacted. Five studies involving 30,618 pregnancies were included; four from sub-Saharan Africa (n = 6,666 pregnancies, six sites) and one from Thailand (n = 23,952). Antimalarial exposures were ascertained by self-report or active detection and confirmed by prescriptions, clinic cards, and outpatient registers. Cox proportional hazards models, accounting for time under observation and gestational age at enrollment, were used to calculate hazard ratios. Individual participant data (IPD) meta-analysis was used to combine the African studies, and the results were then combined with those from Thailand using aggregated data meta-analysis with a random effects model. There was no difference in the risk of miscarriage associated with the use of artemisinins anytime during the first trimester (n = 37/671) compared with quinine (n = 96/945; adjusted hazard ratio [aHR] = 0.73 [95% CI 0.44, 1.21], I2 = 0%, p = 0.228), in the risk of stillbirth (artemisinins, n = 10/654; quinine, n = 11/615; aHR = 0.29 [95% CI 0.08-1.02], p = 0.053), or in the risk of miscarriage and stillbirth combined (pregnancy loss) (aHR = 0.58 [95% CI 0.36-1.02], p = 0.099). The corresponding risks of miscarriage, stillbirth, and pregnancy loss in a sensitivity analysis restricted to artemisinin exposures during the embryo sensitive period (6-12 wk gestation) were as follows: aHR = 1.04 (95% CI 0.54-2.01), I2 = 0%, p = 0.910; aHR = 0.73 (95% CI 0.26-2.06), p = 0.551; and aHR = 0.98 (95% CI 0.52-2.04), p = 0.603. The prevalence of major congenital anomalies was similar for first-trimester artemisinin (1.5% [95% CI 0.6%-3.5%]) and quinine exposures (1.2% [95% CI 0.6%-2.4%]). Key limitations of the study include the inability to control for confounding by indication in the African studies, the paucity of data on potential confounders, the limited statistical power to detect differences in congenital anomalies, and the lack of assessment of cardiovascular defects in newborns. CONCLUSIONS Compared to quinine, artemisinin treatment in the first trimester was not associated with an increased risk of miscarriage or stillbirth. While the data are limited, they indicate no difference in the prevalence of major congenital anomalies between treatment groups. The benefits of 3-d artemisinin combination therapy regimens to treat malaria in early pregnancy are likely to outweigh the adverse outcomes of partially treated malaria, which can occur with oral quinine because of the known poor adherence to 7-d regimens. REVIEW REGISTRATION PROSPERO CRD42015032371.
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Affiliation(s)
- Stephanie Dellicour
- Malaria Epidemiology Unit, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- * E-mail: (SD); (AS)
| | - Esperança Sevene
- Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
- Centro de Investigação em Saúde da Manhiça, Manhiça, Mozambique
| | - Rose McGready
- Shoklo Malaria Research Unit, Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Halidou Tinto
- Institut de Recherche en Sciences de la Santé/Centre Muraz, Bobo-Dioulasso, Burkina Faso
| | | | | | - Stephen Rulisa
- University Teaching Hospital of Kigali, University of Rwanda, Kigali, Rwanda
| | - Meghna Desai
- Malaria Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Peter Ouma
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Martina Oneko
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Anifa Vala
- Centro de Investigação em Saúde da Manhiça, Manhiça, Mozambique
| | - Maria Rupérez
- Centro de Investigação em Saúde da Manhiça, Manhiça, Mozambique
- Instituto de Salud Global de Barcelona, Barcelona, Spain
| | - Eusébio Macete
- Centro de Investigação em Saúde da Manhiça, Manhiça, Mozambique
| | - Clara Menéndez
- Centro de Investigação em Saúde da Manhiça, Manhiça, Mozambique
- Instituto de Salud Global de Barcelona, Barcelona, Spain
| | - Seydou Nakanabo-Diallo
- Institut de Recherche en Sciences de la Santé/Centre Muraz, Bobo-Dioulasso, Burkina Faso
| | - Adama Kazienga
- Institut de Recherche en Sciences de la Santé/Centre Muraz, Bobo-Dioulasso, Burkina Faso
| | - Innocent Valéa
- Institut de Recherche en Sciences de la Santé/Centre Muraz, Bobo-Dioulasso, Burkina Faso
| | - Gregory Calip
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago, Illinois, United States of America
| | - Orvalho Augusto
- Centro de Investigação em Saúde da Manhiça, Manhiça, Mozambique
| | - Blaise Genton
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- Infectious Diseases Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Eric M. Njunju
- School of Medicine, Copperbelt University, Ndola, Zambia
| | - Kerryn A. Moore
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
- Macfarlane Burnet Institute for Medical Research and Public Health, Melbourne, Victoria, Australia
| | - Umberto d’Alessandro
- Medical Research Council, Fajara, The Gambia
- Institute of Tropical Medicine, Antwerp, Belgium
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Francois Nosten
- Shoklo Malaria Research Unit, Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Feiko ter Kuile
- Malaria Epidemiology Unit, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Andy Stergachis
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, School of Public Health, University of Washington, Seattle, Washington, United States of America
- * E-mail: (SD); (AS)
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11
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Prospective open uncontrolled phase I study to define a well-tolerated dose of oral artesunate as add-on therapy in patients with metastatic breast cancer (ARTIC M33/2). Breast Cancer Res Treat 2017; 164:359-369. [DOI: 10.1007/s10549-017-4261-1] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 04/18/2017] [Indexed: 01/21/2023]
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12
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Uhl M, Schwab S, Efferth T. Fatal Liver and Bone Marrow Toxicity by Combination Treatment of Dichloroacetate and Artesunate in a Glioblastoma Multiforme Patient: Case Report and Review of the Literature. Front Oncol 2016; 6:204. [PMID: 27774434 PMCID: PMC5053977 DOI: 10.3389/fonc.2016.00204] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Accepted: 09/09/2016] [Indexed: 12/20/2022] Open
Abstract
A 52-year-old male patient was treated with standard radiochemotherapy with temozolomide for glioblastoma multiforme (GBM). After worsening of his clinical condition, further tumor-specific treatment was unlikely to be successful, and the patient seeked help from an alternative practitioner, who administered a combination of dichloroacetate (DCA) and artesunate (ART). A few days later, the patient showed clinical and laboratory signs of liver damage and bone marrow toxicity (leukopenia, thrombocytopenia). Despite successful restoration of laboratory parameters upon symptomatic treatment, the patient died 10 days after the infusion. DCA bears a well-documented hepatotoxic risk, while ART can be considered as safe concerning hepatotoxicity. Bone marrow toxicity can appear upon ART application as reduced reticulocyte counts and disturbed erythropoiesis. It can be assumed that the simultaneous use of both drugs caused liver injury and bone marrow toxicity. The compassionate use of DCA/ART combination therapy outside of clinical trials cannot be recommended for GBM treatment.
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Affiliation(s)
- Martin Uhl
- Department of Neurology, University of Erlangen-Nuremberg , Erlangen , Germany
| | - Stefan Schwab
- Department of Neurology, University of Erlangen-Nuremberg , Erlangen , Germany
| | - Thomas Efferth
- Institute of Pharmacy and Biochemistry, Johannes Gutenberg University , Mainz , Germany
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13
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Gomes C, Boareto AC, Dalsenter PR. Clinical and non-clinical safety of artemisinin derivatives in pregnancy. Reprod Toxicol 2016; 65:194-203. [PMID: 27506918 DOI: 10.1016/j.reprotox.2016.08.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 08/03/2016] [Accepted: 08/05/2016] [Indexed: 10/21/2022]
Abstract
Malaria in pregnancy is a clinically wasting infectious disease, where drug therapy has to be promptly initiated. Currently, the treatment of this infection depends on the use of artemisinin derivatives. The World Health Organization does not recommend the use of these drugs in the first trimester of pregnancy due to non-clinical findings that have shown embryolethality and teratogenic effects. Nevertheless, until now, this toxicity has not been proved in humans. Artemisinin derivatives mechanisms of embryotoxicity are related to depletion of circulating embryonic primitive erythroblasts. Species differences in this sensitive period for toxicity and the presence of malaria infection, which could reduce drug distribution to the fetus, are significant to the risk assessment of artemisinin derivatives treatment to pregnant women. In this review we aimed to assess the results of non-clinical and clinical studies with artemisinin derivatives, their mechanisms of embryotoxicity and discuss the safety of their use during pregnancy.
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Affiliation(s)
- Caroline Gomes
- Department of Pharmacology, Federal University of Paraná, Curitiba, PR, Brazil.
| | - Ana Cláudia Boareto
- Department of Pharmacology, Federal University of Paraná, Curitiba, PR, Brazil.
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14
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Dellicour S, Desai M, Aol G, Oneko M, Ouma P, Bigogo G, Burton DC, Breiman RF, Hamel MJ, Slutsker L, Feikin D, Kariuki S, Odhiambo F, Pandit J, Laserson KF, Calip G, Stergachis A, ter Kuile FO. Risks of miscarriage and inadvertent exposure to artemisinin derivatives in the first trimester of pregnancy: a prospective cohort study in western Kenya. Malar J 2015; 14:461. [PMID: 26581434 PMCID: PMC4652370 DOI: 10.1186/s12936-015-0950-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 10/21/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The artemisinin anti-malarials are widely deployed as artemisinin-based combination therapy (ACT). However, they are not recommended for uncomplicated malaria during the first trimester because safety data from humans are scarce. METHODS This was a prospective cohort study of women of child-bearing age carried out in 2011-2013, evaluating the relationship between inadvertent ACT exposure during first trimester and miscarriage. Community-based surveillance was used to identify 1134 early pregnancies. Cox proportional hazard models with left truncation were used. RESULTS The risk of miscarriage among pregnancies exposed to ACT (confirmed + unconfirmed) in the first trimester, or during the embryo-sensitive period (≥6 to <13 weeks gestation) was higher than among pregnancies unexposed to anti-malarials in the first trimester: hazard ratio (HR) = 1.70, 95 % CI (1.08-2.68) and HR = 1.61 (0.96-2.70). For confirmed ACT-exposures (primary analysis) the corresponding values were: HR = 1.24 (0.56-2.74) and HR = 0.73 (0.19-2.82) relative to unexposed women, and HR = 0.99 (0.12-8.33) and HR = 0.32 (0.03-3.61) relative to quinine exposure, but the numbers of quinine exposures were very small. CONCLUSION ACT exposure in early pregnancy was more common than quinine exposure. Confirmed inadvertent artemisinin exposure during the potential embryo-sensitive period was not associated with increased risk of miscarriage. Confirmatory studies are needed to rule out a smaller than three-fold increase in risk.
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Affiliation(s)
- Stephanie Dellicour
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.
| | - Meghna Desai
- Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - George Aol
- Kenya Medical Research Institute Centre for Global Health Research, Kisumu, Kenya.
| | - Martina Oneko
- Kenya Medical Research Institute Centre for Global Health Research, Kisumu, Kenya.
| | - Peter Ouma
- Kenya Medical Research Institute Centre for Global Health Research, Kisumu, Kenya.
| | - Godfrey Bigogo
- Kenya Medical Research Institute Centre for Global Health Research, Kisumu, Kenya.
| | - Deron C Burton
- Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | | | - Mary J Hamel
- Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | | | - Daniel Feikin
- Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Simon Kariuki
- Kenya Medical Research Institute Centre for Global Health Research, Kisumu, Kenya.
| | - Frank Odhiambo
- Kenya Medical Research Institute Centre for Global Health Research, Kisumu, Kenya.
| | | | | | - Greg Calip
- Pharmacy Systems, Outcomes and Policy Department, University of Illinois at Chicago, Chicago, USA.
| | - Andy Stergachis
- Departments of Pharmacy and Global Health, Schools of Pharmacy and Public Health, University of Washington, Seattle, USA.
| | - Feiko O ter Kuile
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.
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Abstract
INTRODUCTION Chemotherapy of malaria has become a rapidly changing field. Less than two decades ago, treatment regimens were increasingly bound to fail due to emerging drug resistance against 4-aminoquinolines and sulfa compounds. By now, artemisinin-based combination therapies (ACTs) constitute the standard of care for uncomplicated falciparum malaria and are increasingly also taken into consideration for the treatment of non-falciparum malaria. AREAS COVERED This narrative review provides an overview of the state-of-art antimalarial drug therapy, highlights the global portfolio of current Phase III/IV clinical trials and summarizes current developments. EXPERT OPINION Malaria chemotherapy remains a dynamic field, with novel drugs and drug combinations continuing to emerge in order to outpace the development of large-scale drug resistance against the currently most important drug class, the artemisinin derivatives. More randomized controlled studies are urgently needed especially for the treatment of malaria in first trimester pregnant women. ACTs should be used for the treatment of imported malaria more consequently. Gaining sufficient efficacy and safety information on ACT use for non-falciparum species including Plasmodium ovale and malariae should be a research priority. Continuous investment into malaria drug development is a vital factor to combat artemisinin resistance and successfully improve malaria control toward the ultimate goal of elimination.
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Affiliation(s)
- Benjamin J Visser
- University of Amsterdam, Academic Medical Centre, Center of Tropical Medicine and Travel Medicine, Division of Infectious Diseases , Amsterdam , The Netherlands
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16
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Farombi EO, Abolaji AO, Adedara IA, Maduako I, Omodanisi I. Artemisinin induces hormonal imbalance and oxidative damage in the erythrocytes and uterus but not in the ovary of rats. Hum Exp Toxicol 2014; 34:83-92. [PMID: 24876631 DOI: 10.1177/0960327114532385] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Artemisinin is an antimalarial drug previously reported to induce neurotoxicity and embryotoxicity in animal models. This study investigated the erythrocytes and reproductive toxicity potentials of artemisinin in female rats. Animals were randomly divided into four study groups of eight rats each. The control group (group I) received corn oil, the vehicle, while groups II-IV were orally exposed to 7, 35 and 70 mg kg(-1) day(-1) of artemisinin, respectively, by gastric intubation for 7 consecutive days. Subsequently, we evaluated the impact of artemisinin on the endocrine environment and selected markers of oxidative damage and antioxidant status of the erythrocytes, ovary and uterus. Artemisinin significantly increased hydrogen peroxide (H2O2) and malondialdehyde (MDA) levels and decreased catalase, glutathione peroxidase and superoxide dismutase activities in erythrocytes and uterus of rats compared with control group (p < 0.05). However, artemisinin did not alter ovarian MDA, H2O2, glutathione levels and catalase activity, while ovarian and uterine histological assessment revealed absence of visible lesions. Moreover, artemisinin significantly decreased follicle-stimulating hormone and increased progesterone levels compared with control (p < 0.05). Thus, these data suggest that in the absence of malarial parasite infection, artemisinin induced hormonal imbalance and oxidative damage in the erythrocytes and uterus but spared the ovary of rats.
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Affiliation(s)
- E O Farombi
- Drug Metabolism and Molecular Toxicology Research Laboratories, Department of Biochemistry, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - A O Abolaji
- Drug Metabolism and Molecular Toxicology Research Laboratories, Department of Biochemistry, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - I A Adedara
- Drug Metabolism and Molecular Toxicology Research Laboratories, Department of Biochemistry, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - I Maduako
- Drug Metabolism and Molecular Toxicology Research Laboratories, Department of Biochemistry, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - I Omodanisi
- Drug Metabolism and Molecular Toxicology Research Laboratories, Department of Biochemistry, College of Medicine, University of Ibadan, Ibadan, Nigeria
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18
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Posobiec LM, Clark RL, Bushdid PB, Laffan SB, Wang KF, White TEK. Dihydroartemisinin (DHA) Treatment Causes an Arrest of Cell Division and Apoptosis in Rat Embryonic Erythroblasts in Whole Embryo Culture. ACTA ACUST UNITED AC 2014; 98:445-58. [DOI: 10.1002/bdrb.21088] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Accepted: 11/14/2013] [Indexed: 12/25/2022]
Affiliation(s)
| | | | - Paul B. Bushdid
- Safety Assessment; GlaxoSmithKline; King of Prussia Pennsylvania
| | - Susan B. Laffan
- Safety Assessment; GlaxoSmithKline; King of Prussia Pennsylvania
| | - Kai-Fen Wang
- Safety Assessment; GlaxoSmithKline; King of Prussia Pennsylvania
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19
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Clark RL. Hypothesized cause of delayed hemolysis associated with intravenous artesunate. Med Hypotheses 2013; 82:167-70. [PMID: 24370269 DOI: 10.1016/j.mehy.2013.11.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2013] [Accepted: 11/19/2013] [Indexed: 10/25/2022]
Abstract
In recent publications, investigators described cases in which there was a delayed hemolysis following intravenous (IV) artesunate treatment. The delayed hemolysis event occurred at the nadir of blood hemoglobin concentration, i.e., at the time when blood hemoglobin concentration was switching from a progressive decline to a progressive increase. It is hypothesized that this nadir indicates the time when red cell production is resuming after having been arrested, the delayed hemolysis event is due to lysis of the first (aberrant) reticulocytes released once production is resumed and, therefore, that the hemolysis signals the resumption of red cell production. Since this delayed hemolysis has not been associated with a significant decrease in blood hemoglobin, the hemolytic event is not of particular concern even if it could be attributed to artesunate. More important than this hemolysis event was the preceding progressive anemia that lasted for up to 19 days. Both a decrease in reticulocyte production and a shortened life span of previously infected red cells likely contributed to the anemia. The question that remains to be answered is whether the progressive anemia that lasted 2-3 weeks in these patients was attributable solely to their severe malaria or was possibly enhanced and prolonged by the high plasma concentrations of artesunate associated with IV administration. Controlled clinical studies addressing this question may be needed.
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Affiliation(s)
- Robert L Clark
- Artemis Pharmaceutical Research, 1758 Allentown Road #205, Lansdale, PA 19446, USA.
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20
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Parshikov IA, Netrusov AI, Sutherland JB. Microbial transformation of antimalarial terpenoids. Biotechnol Adv 2012; 30:1516-23. [DOI: 10.1016/j.biotechadv.2012.03.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Revised: 03/19/2012] [Accepted: 03/22/2012] [Indexed: 11/26/2022]
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Castelli F, Tomasoni LR, Matteelli A. Advances in the treatment of malaria. Mediterr J Hematol Infect Dis 2012; 4:e2012064. [PMID: 23170193 PMCID: PMC3499999 DOI: 10.4084/mjhid.2012.064] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2012] [Accepted: 09/24/2012] [Indexed: 12/25/2022] Open
Abstract
Malaria still claims a heavy toll of deaths and disabilities even at the beginning of the third millennium. The inappropriate sequential use of drug monotherapy in the past has facilitated the spread of drug-resistant P. falciparum, and to a lesser extend P. vivax, strains in most of the malaria endemic areas, rendering most anti-malarial ineffective. In the last decade, a new combination strategy based on artemisinin derivatives (ACT) has become the standard of treatment for most P. falciparum malaria infections. This strategy could prevent the selection of resistant strains by rapidly decreasing the parasitic burden (by the artemisinin derivative, mostly artesunate) and exposing the residual parasite to effective concentrations of the partner drug. The widespread use of this strategy is somehow constrained by cost and by the inappropriate use of artemisinin, with possible impact on resistance, as already sporadically observed in South East Asia. Parenteral artesunate has now become the standard of care for severe malaria, even if quinine still retains its value in case artesunate is not immediately available. The appropriateness of pre-referral use of suppository artesunate is under close monitoring, while waiting for an effective anti-malarial vaccine to be made available.
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Affiliation(s)
- Francesco Castelli
- Chair of Infectious Diseases, University of Brescia, Italy
- University Division of Infectious and Tropical Diseases, University of Brescia and Spedali Civili General Hospital, Brescia (Italy)
| | - Lina Rachele Tomasoni
- University Division of Infectious and Tropical Diseases, University of Brescia and Spedali Civili General Hospital, Brescia (Italy)
| | - Alberto Matteelli
- University Division of Infectious and Tropical Diseases, University of Brescia and Spedali Civili General Hospital, Brescia (Italy)
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Manyando C, Kayentao K, D'Alessandro U, Okafor HU, Juma E, Hamed K. A systematic review of the safety and efficacy of artemether-lumefantrine against uncomplicated Plasmodium falciparum malaria during pregnancy. Malar J 2012; 11:141. [PMID: 22548983 PMCID: PMC3405476 DOI: 10.1186/1475-2875-11-141] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Accepted: 05/01/2012] [Indexed: 11/10/2022] Open
Abstract
Malaria during pregnancy, particularly Plasmodium falciparum malaria, has been linked to increased morbidity and mortality, which must be reduced by both preventive measures and effective case management. The World Health Organization (WHO) recommends artemisinin-based combination therapy (ACT) to treat uncomplicated falciparum malaria during the second and third trimesters of pregnancy, and quinine plus clindamycin during the first trimester. However, the national policies of many African countries currently recommend quinine throughout pregnancy. Therefore, the aim of this article is to provide a summary of the available data on the safety and efficacy of artemether-lumefantrine (AL) in pregnancy. An English-language search identified 16 publications from 1989 to October 2011 with reports of artemether or AL exposure in pregnancy, including randomized clinical trials, observational studies and systematic reviews. Overall, there were 1,103 reports of AL use in pregnant women: 890 second/third trimester exposures; 212 first trimester exposures; and one case where the trimester of exposure was not reported. In the second and third trimesters, AL was not associated with increased adverse pregnancy outcomes as compared with quinine or sulphadoxine-pyrimethamine, showed improved tolerability relative to quinine, and its efficacy was non-inferior to quinine. There is evidence to suggest that the pharmacokinetics of anti-malarial drugs may change in pregnancy, although the impact on efficacy and safety needs to be studied further, especially since the majority of studies report high cure rates and adequate tolerability. As there are fewer reports of AL safety in the first trimester, additional data are required to assess the potential to use AL in the first trimester. Though the available safety and efficacy data support the use of AL in the second and third trimesters, there is still a need for further information. These findings reinforce the WHO recommendation to treat uncomplicated falciparum malaria with quinine plus clindamycin in early pregnancy and ACT in later pregnancy.
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