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Sutanto I, Soebandrio A, Ekawati LL, Chand K, Noviyanti R, Satyagraha AW, Subekti D, Santy YW, Crenna-Darusallam C, Instiaty I, Budiman W, Prasetya CB, Lardo S, Elyazar I, Duparc S, Cedar E, Rolfe K, Fernando D, Berni A, Jones S, Kleim JP, Fletcher K, Sharma H, Martin A, Taylor M, Goyal N, Green JA, Tan LK, Baird JK. Tafenoquine co-administered with dihydroartemisinin-piperaquine for the radical cure of Plasmodium vivax malaria (INSPECTOR): a randomised, placebo-controlled, efficacy and safety study. THE LANCET. INFECTIOUS DISEASES 2023; 23:1153-1163. [PMID: 37236221 PMCID: PMC10533414 DOI: 10.1016/s1473-3099(23)00213-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 03/07/2023] [Accepted: 03/21/2023] [Indexed: 05/28/2023]
Abstract
BACKGROUND Tafenoquine, co-administered with chloroquine, is approved for the radical cure (prevention of relapse) of Plasmodium vivax malaria. In areas of chloroquine resistance, artemisinin-based combination therapies are used to treat malaria. This study aimed to evaluate tafenoquine plus the artemisinin-based combination therapy dihydroartemisinin-piperaquine for the radical cure of P vivax malaria. METHODS In this double-blind, double-dummy, parallel group study, glucose-6-phosphate dehydrogenase-normal Indonesian soldiers with microscopically confirmed P vivax malaria were randomly assigned by means of a computer-generated randomisation schedule (1:1:1) to dihydroartemisinin-piperaquine alone, dihydroartemisinin-piperaquine plus a masked single 300-mg dose of tafenoquine, or dihydroartemisinin-piperaquine plus 14 days of primaquine (15 mg). The primary endpoint was 6-month relapse-free efficacy following tafenoquine plus dihydroartemisinin-piperaquine versus dihydroartemisinin-piperaquine alone in all randomly assigned patients who received at least one dose of masked treatment and had microscopically confirmed P vivax at baseline (microbiological intention-to-treat population). Safety was a secondary outcome and the safety population comprised all patients who received at least one dose of masked medication. This study is registered with ClinicalTrials.gov, NCT02802501 and is completed. FINDINGS Between April 8, 2018, and Feb 4, 2019, of 164 patients screened for eligibility, 150 were randomly assigned (50 per treatment group). 6-month Kaplan-Meier relapse-free efficacy (microbiological intention to treat) was 11% (95% CI 4-22) in patients treated with dihydroartemisinin-piperaquine alone versus 21% (11-34) in patients treated with tafenoquine plus dihydroartemisinin-piperaquine (hazard ratio 0·44; 95% CI [0·29-0·69]) and 52% (37-65) in the primaquine plus dihydroartemisinin-piperaquine group. Adverse events over the first 28 days were reported in 27 (54%) of 50 patients treated with dihydroartemisinin-piperaquine alone, 29 (58%) of 50 patients treated with tafenoquine plus dihydroartemisinin-piperaquine, and 22 (44%) of 50 patients treated with primaquine plus dihydroartemisinin-piperaquine. Serious adverse events were reported in one (2%) of 50, two (4%) of 50, and two (4%) of 50 of patients, respectively. INTERPRETATION Although tafenoquine plus dihydroartemisinin-piperaquine was statistically superior to dihydroartemisinin-piperaquine alone for the radical cure of P vivax malaria, the benefit was not clinically meaningful. This contrasts with previous studies in which tafenoquine plus chloroquine was clinically superior to chloroquine alone for radical cure of P vivax malaria. FUNDING ExxonMobil, Bill & Melinda Gates Foundation, Newcrest Mining, UK Government all through Medicines for Malaria Venture; and GSK. TRANSLATION For the Indonesian translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Inge Sutanto
- Faculty of Medicine, University of Indonesia, Jakarta, Indonesia
| | | | - Lenny L Ekawati
- Faculty of Medicine, University of Indonesia, Jakarta, Indonesia; University of Oxford Clinical Research Unit-Indonesia, Jakarta, Indonesia
| | - Krisin Chand
- Faculty of Medicine, University of Indonesia, Jakarta, Indonesia; University of Oxford Clinical Research Unit-Indonesia, Jakarta, Indonesia
| | | | | | - Decy Subekti
- Faculty of Medicine, University of Indonesia, Jakarta, Indonesia; University of Oxford Clinical Research Unit-Indonesia, Jakarta, Indonesia
| | - Yulia Widya Santy
- Faculty of Medicine, University of Indonesia, Jakarta, Indonesia; University of Oxford Clinical Research Unit-Indonesia, Jakarta, Indonesia
| | - Chelzie Crenna-Darusallam
- Eijkman Institute for Molecular Biology, Jakarta, Indonesia; Mochtar Riady Institute for Nanotechnology, Banten, Indonesia
| | | | - Waras Budiman
- Health Service, Army of the Republic of Indonesia, Jakarta, Indonesia
| | | | - Soroy Lardo
- Health Service, Army of the Republic of Indonesia, Jakarta, Indonesia
| | - Iqbal Elyazar
- University of Oxford Clinical Research Unit-Indonesia, Jakarta, Indonesia
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - J Kevin Baird
- Faculty of Medicine, University of Indonesia, Jakarta, Indonesia; University of Oxford Clinical Research Unit-Indonesia, Jakarta, Indonesia; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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2
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Madanitsa M, Barsosio HC, Minja DTR, Mtove G, Kavishe RA, Dodd J, Saidi Q, Onyango ED, Otieno K, Wang D, Ashorn U, Hill J, Mukerebe C, Gesase S, Msemo OA, Mwapasa V, Phiri KS, Maleta K, Klein N, Magnussen P, Lusingu JPA, Kariuki S, Mosha JF, Alifrangis M, Hansson H, Schmiegelow C, Gutman JR, Chico RM, Ter Kuile FO. Effect of monthly intermittent preventive treatment with dihydroartemisinin-piperaquine with and without azithromycin versus monthly sulfadoxine-pyrimethamine on adverse pregnancy outcomes in Africa: a double-blind randomised, partly placebo-controlled trial. Lancet 2023; 401:1020-1036. [PMID: 36913959 PMCID: PMC10063957 DOI: 10.1016/s0140-6736(22)02535-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 09/28/2022] [Accepted: 12/06/2022] [Indexed: 03/12/2023]
Abstract
BACKGROUND Intermittent preventive treatment in pregnancy (IPTp) with dihydroartemisinin-piperaquine is more effective than IPTp with sulfadoxine-pyrimethamine at reducing malaria infection during pregnancy in areas with high-grade resistance to sulfadoxine-pyrimethamine by Plasmodium falciparum in east Africa. We aimed to assess whether IPTp with dihydroartemisinin-piperaquine, alone or combined with azithromycin, can reduce adverse pregnancy outcomes compared with IPTp with sulfadoxine-pyrimethamine. METHODS We did an individually randomised, double-blind, three-arm, partly placebo-controlled trial in areas of high sulfadoxine-pyrimethamine resistance in Kenya, Malawi, and Tanzania. HIV-negative women with a viable singleton pregnancy were randomly assigned (1:1:1) by computer-generated block randomisation, stratified by site and gravidity, to receive monthly IPTp with sulfadoxine-pyrimethamine (500 mg of sulfadoxine and 25 mg of pyrimethamine for 1 day), monthly IPTp with dihydroartemisinin-piperaquine (dosed by weight; three to five tablets containing 40 mg of dihydroartemisinin and 320 mg of piperaquine once daily for 3 consecutive days) plus a single treatment course of placebo, or monthly IPTp with dihydroartemisinin-piperaquine plus a single treatment course of azithromycin (two tablets containing 500 mg once daily for 2 consecutive days). Outcome assessors in the delivery units were masked to treatment group. The composite primary endpoint was adverse pregnancy outcome, defined as fetal loss, adverse newborn baby outcomes (small for gestational age, low birthweight, or preterm), or neonatal death. The primary analysis was by modified intention to treat, consisting of all randomised participants with primary endpoint data. Women who received at least one dose of study drug were included in the safety analyses. This trial is registered with ClinicalTrials.gov, NCT03208179. FINDINGS From March-29, 2018, to July 5, 2019, 4680 women (mean age 25·0 years [SD 6·0]) were enrolled and randomly assigned: 1561 (33%; mean age 24·9 years [SD 6·1]) to the sulfadoxine-pyrimethamine group, 1561 (33%; mean age 25·1 years [6·1]) to the dihydroartemisinin-piperaquine group, and 1558 (33%; mean age 24·9 years [6.0]) to the dihydroartemisinin-piperaquine plus azithromycin group. Compared with 335 (23·3%) of 1435 women in the sulfadoxine-pyrimethamine group, the primary composite endpoint of adverse pregnancy outcomes was reported more frequently in the dihydroartemisinin-piperaquine group (403 [27·9%] of 1442; risk ratio 1·20, 95% CI 1·06-1·36; p=0·0040) and in the dihydroartemisinin-piperaquine plus azithromycin group (396 [27·6%] of 1433; 1·16, 1·03-1·32; p=0·017). The incidence of serious adverse events was similar in mothers (sulfadoxine-pyrimethamine group 17·7 per 100 person-years, dihydroartemisinin-piperaquine group 14·8 per 100 person-years, and dihydroartemisinin-piperaquine plus azithromycin group 16·9 per 100 person-years) and infants (sulfadoxine-pyrimethamine group 49·2 per 100 person-years, dihydroartemisinin-piperaquine group 42·4 per 100 person-years, and dihydroartemisinin-piperaquine plus azithromycin group 47·8 per 100 person-years) across treatment groups. 12 (0·2%) of 6685 sulfadoxine-pyrimethamine, 19 (0·3%) of 7014 dihydroartemisinin-piperaquine, and 23 (0·3%) of 6849 dihydroartemisinin-piperaquine plus azithromycin treatment courses were vomited within 30 min. INTERPRETATION Monthly IPTp with dihydroartemisinin-piperaquine did not improve pregnancy outcomes, and the addition of a single course of azithromycin did not enhance the effect of monthly IPTp with dihydroartemisinin-piperaquine. Trials that combine sulfadoxine-pyrimethamine and dihydroartemisinin-piperaquine for IPTp should be considered. FUNDING European & Developing Countries Clinical Trials Partnership 2, supported by the EU, and the UK Joint-Global-Health-Trials-Scheme of the Foreign, Commonwealth and Development Office, Medical Research Council, Department of Health and Social Care, Wellcome, and the Bill-&-Melinda-Gates-Foundation.
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Affiliation(s)
- Mwayiwawo Madanitsa
- School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi; Department of Clinical Sciences, Academy of Medical Sciences, Malawi University of Science and Technology, Thyolo, Malawi
| | - Hellen C Barsosio
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - Daniel T R Minja
- National Institute for Medical Research, Tanga Centre, Tanga, Tanzania
| | - George Mtove
- National Institute for Medical Research, Tanga Centre, Tanga, Tanzania
| | - Reginald A Kavishe
- Kilimanjaro Clinical Research Institute and Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - James Dodd
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Queen Saidi
- Kilimanjaro Clinical Research Institute and Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Eric D Onyango
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - Kephas Otieno
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - Duolao Wang
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Ulla Ashorn
- Centre for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Jenny Hill
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Samwel Gesase
- National Institute for Medical Research, Tanga Centre, Tanga, Tanzania
| | - Omari A Msemo
- National Institute for Medical Research, Tanga Centre, Tanga, Tanzania
| | - Victor Mwapasa
- School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Kamija S Phiri
- School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Kenneth Maleta
- School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Nigel Klein
- Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Pascal Magnussen
- Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen and Department of Infectious Diseases, Copenhagen University Hospital, Copenhagen, Denmark
| | - John P A Lusingu
- National Institute for Medical Research, Tanga Centre, Tanga, Tanzania
| | - Simon Kariuki
- School of Global and Public Health, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Jacklin F Mosha
- Kilimanjaro Clinical Research Institute and Kilimanjaro Christian Medical University College, Moshi, Tanzania
| | - Michael Alifrangis
- Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen and Department of Infectious Diseases, Copenhagen University Hospital, Copenhagen, Denmark
| | - Helle Hansson
- Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen and Department of Infectious Diseases, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christentze Schmiegelow
- Centre for Medical Parasitology, Department of Immunology and Microbiology, University of Copenhagen and Department of Infectious Diseases, Copenhagen University Hospital, Copenhagen, Denmark
| | - Julie R Gutman
- Malaria Branch, Division of Parasitic Diseases and Malaria, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - R Matthew Chico
- Department of Disease Control, London School of Hygiene & Tropical Medicine, London, UK
| | - Feiko O Ter Kuile
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.
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Assefa DG, Zeleke ED, Molla W, Mengistu N, Sefa A, Mebratu A, Bate AF, Bekele E, Yesmaw G, Makonnen E. Safety of dihydroartemisinin-piperaquine versus artemether-lumefantrine for the treatment of uncomplicated Plasmodium falciparum malaria among children in Africa: a systematic review and meta-analysis of randomized control trials. Malar J 2022; 21:4. [PMID: 34983552 PMCID: PMC8725395 DOI: 10.1186/s12936-021-04032-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 12/18/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The efficacies of artemisinin based combinations have been excellent in Africa, but also comprehensive evidence regarding their safety would be important. The aim of this review was to synthesize available evidence on the safety of dihydroartemisinin-piperaquine (DHA-PQ) compared to artemether-lumefantrine (AL) for the treatment of uncomplicated Plasmodium falciparum malaria among children in Africa. METHODS A systematic literature search was done to identify relevant articles from online databases PubMed/ MEDLINE, Embase, and Cochrane Center for Clinical Trial database (CENTRAL) for retrieving randomized control trials comparing safety of DHA-PQ and AL for treatment of uncomplicated P. falciparum malaria among children in Africa. The search was performed from August 2020 to 30 April 2021. Using Rev-Man software (V5.4.1), the extracted data from eligible studies were pooled as risk ratio (RR) with 95% confidence interval (CI). RESULTS In this review, 18 studies were included, which involved 10,498 participants were included. Compared to AL, DHA-PQ was associated with a slightly higher frequency of early vomiting (RR 2.26, 95% CI 1.46 to 3.50; participants = 7796; studies = 10; I2 = 0%, high quality of evidence), cough (RR 1.06, 95% CI 1.01 to 1.11; participants = 8013; studies = 13; I2 = 0%, high quality of evidence), and diarrhoea (RR 1.16, 95% CI 1.03 to 1.31; participants = 6841; studies = 11; I2 = 8%, high quality of evidence) were more frequent in DHA-PQ treatment arm. CONCLUSION From this review, it can be concluded that early vomiting, diarrhoea, and cough were common were significantly more frequent in patients who were treated with the DHA-PQ than that of AL, and both drugs are well tolerated. More studies comparing AL with DHA-PQ are needed to determine the comparative safety of these drugs.
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Affiliation(s)
- Dawit Getachew Assefa
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
- School of Public Health, College of Health Science and Medicine, Dilla University, Dilla, Ethiopia.
| | - Eden Dagnachew Zeleke
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Department of Midwifery, College of Health Science, Bule Hora University, Bule Hora, Ethiopia
| | - Wondwosen Molla
- Department of Midwifery, College of Health Science and Medicine, Dilla University, Dilla, Ethiopia
| | - Nebiyu Mengistu
- Department of Psychiatry, College of Health Science and Medicine, Dilla University, Dilla, Ethiopia
| | - Ahmedin Sefa
- Department of Nursing, College of Health Science and Medicine, Dilla University, Dilla, Ethiopia
| | - Andualem Mebratu
- Department of Midwifery, College of Health Science and Medicine, Dilla University, Dilla, Ethiopia
| | - Asresu Feleke Bate
- Department of Nursing, College of Health Science and Medicine, Dilla University, Dilla, Ethiopia
| | - Etaferaw Bekele
- Department of Nursing, College of Health Science and Medicine, Dilla University, Dilla, Ethiopia
| | - Gizachew Yesmaw
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Eyasu Makonnen
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Department of Pharmacology and Clinical Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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Sugiarto SR, Page-Sharp M, Drinkwater JJ, Davis WA, Salman S, Davis TME. Pharmacokinetic properties of the antimalarial combination therapy artemether-lumefantrine in normal-weight, overweight and obese healthy male adults. Int J Antimicrob Agents 2021; 59:106482. [PMID: 34818520 DOI: 10.1016/j.ijantimicag.2021.106482] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 11/09/2021] [Accepted: 11/13/2021] [Indexed: 11/26/2022]
Abstract
The component drugs in the widely used antimalarial artemisinin combination therapy artemether-lumefantrine are lipophilic, with the possibility that recommended fixed doses in adults may lead to subtherapeutic concentrations and consequent treatment failure in overweight/obese individuals with malaria. The aim of this study was to investigate the pharmacokinetic properties of artemether, lumefantrine and their active metabolites dihydroartemisinin and desbutyl-lumefantrine in 16 normal-weight, overweight and obese healthy male volunteers [body mass index (BMI) categories ≤25 kg/m², >25-≤30 kg/m² and >30 kg/m², respectively; absolute range 19.3-37.2 kg/m²]. Participants received the conventional six doses of artemether-lumefantrine over 3 days, each dose comprising 80 mg artemether plus 480 mg lumefantrine administered with 6.7 g fat, and blood samples were collected at pre-specified time-points over 14 days. Plasma drug/metabolite concentrations were measured using liquid chromatography-mass spectrometry and included in multi-compartmental population pharmacokinetic models. There was a non-significant trend to a lower area under the plasma concentration-time curve with a higher body weight or BMI for dihydroartemisinin and especially artemether which was attenuated when normalized for mg/kg dose, but this relationship was not evident in the case of the more lipophilic lumefantrine and its metabolite desbutyl-lumefantrine. Simulated Day 7 plasma lumefantrine concentrations were >200 µg/L (the threshold at which Plasmodium falciparum recrudescences are minimized) in all participants. These results indicate that there is no need for artemether-lumefantrine dose modification in overweight and obese patients with malaria.
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Affiliation(s)
- Sri Riyati Sugiarto
- University of Western Australia, Medical School, Fremantle Hospital, Fremantle, Western Australia, Australia
| | - Madhu Page-Sharp
- Curtin University, School of Pharmacy and Biomedical Sciences, Bentley, Western Australia, Australia
| | - Jocelyn J Drinkwater
- University of Western Australia, Medical School, Fremantle Hospital, Fremantle, Western Australia, Australia
| | - Wendy A Davis
- University of Western Australia, Medical School, Fremantle Hospital, Fremantle, Western Australia, Australia
| | - Sam Salman
- University of Western Australia, Medical School, Fremantle Hospital, Fremantle, Western Australia, Australia; Clinical Pharmacology and Toxicology Unit, PathWest, Western Australia, Australia
| | - Timothy M E Davis
- University of Western Australia, Medical School, Fremantle Hospital, Fremantle, Western Australia, Australia.
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Chan XHS, Haeusler IL, Win YN, Pike J, Hanboonkunupakarn B, Hanafiah M, Lee SJ, Djimdé A, Fanello CI, Kiechel JR, Lacerda MVG, Ogutu B, Onyamboko MA, Siqueira AM, Ashley EA, Taylor WRJ, White NJ. The cardiovascular effects of amodiaquine and structurally related antimalarials: An individual patient data meta-analysis. PLoS Med 2021; 18:e1003766. [PMID: 34492005 PMCID: PMC8454971 DOI: 10.1371/journal.pmed.1003766] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 09/21/2021] [Accepted: 08/11/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Amodiaquine is a 4-aminoquinoline antimalarial similar to chloroquine that is used extensively for the treatment and prevention of malaria. Data on the cardiovascular effects of amodiaquine are scarce, although transient effects on cardiac electrophysiology (electrocardiographic QT interval prolongation and sinus bradycardia) have been observed. We conducted an individual patient data meta-analysis to characterise the cardiovascular effects of amodiaquine and thereby support development of risk minimisation measures to improve the safety of this important antimalarial. METHODS AND FINDINGS Studies of amodiaquine for the treatment or prevention of malaria were identified from a systematic review. Heart rates and QT intervals with study-specific heart rate correction (QTcS) were compared within studies and individual patient data pooled for multivariable linear mixed effects regression. The meta-analysis included 2,681 patients from 4 randomised controlled trials evaluating artemisinin-based combination therapies (ACTs) containing amodiaquine (n = 725), lumefantrine (n = 499), piperaquine (n = 716), and pyronaridine (n = 566), as well as monotherapy with chloroquine (n = 175) for uncomplicated malaria. Amodiaquine prolonged QTcS (mean = 16.9 ms, 95% CI: 15.0 to 18.8) less than chloroquine (21.9 ms, 18.3 to 25.6, p = 0.0069) and piperaquine (19.2 ms, 15.8 to 20.5, p = 0.0495), but more than lumefantrine (5.6 ms, 2.9 to 8.2, p < 0.001) and pyronaridine (-1.2 ms, -3.6 to +1.3, p < 0.001). In individuals aged ≥12 years, amodiaquine reduced heart rate (mean reduction = 15.2 beats per minute [bpm], 95% CI: 13.4 to 17.0) more than piperaquine (10.5 bpm, 7.7 to 13.3, p = 0.0013), lumefantrine (9.3 bpm, 6.4 to 12.2, p < 0.001), pyronaridine (6.6 bpm, 4.0 to 9.3, p < 0.001), and chloroquine (5.9 bpm, 3.2 to 8.5, p < 0.001) and was associated with a higher risk of potentially symptomatic sinus bradycardia (≤50 bpm) than lumefantrine (risk difference: 14.8%, 95% CI: 5.4 to 24.3, p = 0.0021) and chloroquine (risk difference: 8.0%, 95% CI: 4.0 to 12.0, p < 0.001). The effect of amodiaquine on the heart rate of children aged <12 years compared with other antimalarials was not clinically significant. Study limitations include the unavailability of individual patient-level adverse event data for most included participants, but no serious complications were documented. CONCLUSIONS While caution is advised in the use of amodiaquine in patients aged ≥12 years with concomitant use of heart rate-reducing medications, serious cardiac conduction disorders, or risk factors for torsade de pointes, there have been no serious cardiovascular events reported after amodiaquine in widespread use over 7 decades. Amodiaquine and structurally related antimalarials in the World Health Organization (WHO)-recommended dose regimens alone or in ACTs are safe for the treatment and prevention of malaria.
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Affiliation(s)
- Xin Hui S. Chan
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Ilsa L. Haeusler
- University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Yan Naung Win
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Health and Diseases Control Unit, Naypyidaw, Myanmar
| | - James Pike
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Borimas Hanboonkunupakarn
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok Thailand
| | - Maryam Hanafiah
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Sue J. Lee
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Abdoulaye Djimdé
- Malaria Research and Training Center, Department of Epidemiology of Parasitic Diseases, Faculty of Pharmacy, University of Science Techniques and Technologies of Bamako, Bamako, Mali
| | - Caterina I. Fanello
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | | | - Marcus VG Lacerda
- Fundação de Medicina Tropical Dr Heitor Vieira Dourado, Manaus, Brazil
- Instituto Leônidas e Maria Deane (FIOCRUZ-Amazonas), Fundacão Oswaldo Cruz, Manaus, Brazil
| | | | - Marie A. Onyamboko
- Kinshasa School of Public Health, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - André M. Siqueira
- Instituto Leônidas e Maria Deane (FIOCRUZ-Amazonas), Fundacão Oswaldo Cruz, Manaus, Brazil
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Elizabeth A. Ashley
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Walter RJ Taylor
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Nicholas J. White
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
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6
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Vignier N, Bouchaud O, Angheben A, Bottieau E, Calleri G, Salas-Coronas J, Martin C, Ramos JM, Mechain M, Rapp C, Nothdurft HD, Velasco M, Bardají A, Rojo-Marcos G, Visser LG, Hatz C, Bisoffi Z, Jelinek T, Duparc S, Bourhis Y, Tommasini S, Iannucelli M, Bacchieri A, Mattera GG, Merlo Pich E, Behrens RH. Longitudinal study based on a safety registry for malaria patients treated with artenimol-piperaquine in six European countries. Malar J 2021; 20:214. [PMID: 33964945 PMCID: PMC8105939 DOI: 10.1186/s12936-021-03750-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 04/29/2021] [Indexed: 11/10/2022] Open
Abstract
Background European travellers to endemic countries are at risk of malaria and may be affected by a different range of co-morbidities than natives of endemic regions. The safety profile, especially cardiac issues, of artenimol (previously dihydroartemisinin)–piperaquine (APQ) Eurartesim® during treatment of uncomplicated imported falciparum malaria is not adequately described due to the lack of longitudinal studies in this population. The present study was conducted to partially fill this gap. Methods Participants were recruited through Health Care Provider’s safety registry in 15 centres across 6 European countries in the period 2013–2016. Adverse events (AE) were collected, with a special focus on cardiovascular safety by including electrocardiogram QT intervals evaluated after correction with either Bazett’s (QTcB) or Fridericia’s (QTcF) methods, at baseline and after treatment. QTcB and/or QTcF prolongation were defined by a value > 450 ms for males and children and > 470 ms for females. Results Among 294 participants, 30.3% were women, 13.7% of Caucasian origin, 13.5% were current smoker, 13.6% current alcohol consumer and 42.2% declared at least one illness history. The mean (SD) age and body mass index were 39.8 years old (13.2) and 25.9 kg/m2 (4.7). Among them, 75 reported a total of 129 AE (27 serious), 46 being suspected to be related to APQ (11 serious) and mostly labelled as due to haematological, gastrointestinal, or infection. Women and Non-African participants had significantly (p < 0.05) more AEs. Among AEs, 21 were due to cardiotoxicity (7.1%), mostly QT prolongation, while 6 were due to neurotoxicity (2.0%), mostly dizziness. Using QTcF correction, QT prolongation was observed in 17/143 participants (11.9%), only 2 of them reporting QTcF > 500 ms (milliseconds) but no clinical symptoms. Using QTcB correction increases of > 60 ms were present in 9 participants (6.3%). A trend towards increased prolongation was observed in those over 65 years of age but only a few subjects were in this group. No new safety signal was reported. The overall efficacy rate was 255/257 (99.2%). Conclusions APQ appears as an effective and well-tolerated drug for treatment of malaria in patients recruited in European countries. AEs and QT prolongation were in the range of those obtained in larger cohorts from endemic countries. Trial registration This study has been registered in EU Post-Authorization Studies Register as EUPAS6942 Supplementary Information The online version contains supplementary material available at 10.1186/s12936-021-03750-x.
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Affiliation(s)
- Nicolas Vignier
- Department of Infectious and Tropical Diseases, and Laboratoire Éducations et Pratiques de Santé (LEPS EA 3412), Sorbonne Paris Nord University, Avicenne Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Bobigny, France. .,Centre D'Investigation Clinique Antilles-Guyane, Inserm 1424, Centre Hospitalier de Cayenne, Cayenne, France. .,INSERM, Sorbonne Université, Institut Pierre Louis D'Épidémiologie et de Santé Publique IPLESP, Paris, France.
| | - Olivier Bouchaud
- Department of Infectious and Tropical Diseases, and Laboratoire Éducations et Pratiques de Santé (LEPS EA 3412), Sorbonne Paris Nord University, Avicenne Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Bobigny, France.,TropNet, A European Network for Tropical and Travel Medicine, Verona, Italy
| | - Andrea Angheben
- TropNet, A European Network for Tropical and Travel Medicine, Verona, Italy.,Department of Infectious-Tropical Diseases and Microbiology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Italy
| | - Emmanuel Bottieau
- TropNet, A European Network for Tropical and Travel Medicine, Verona, Italy.,Institute of Tropical Medicine, Antwerp, Belgium
| | - Guido Calleri
- Azienda Sanitaria Locale "Cità Di Torino", Torino, Italy
| | - Joaquín Salas-Coronas
- TropNet, A European Network for Tropical and Travel Medicine, Verona, Italy.,Tropical Medicine Unit, Hospital de Poniente, El Ejido, Almería, Spain
| | | | - José Manuel Ramos
- Consulta de Enfermedades Importadas Y Parasitología Clínica, Unidad de Enfermedades Infecciosas, Hospital General Universitario Alicante, Alicante, Spain
| | | | | | | | - Maria Velasco
- Hospital Universitario Fundación Alcorcón, Madrid, Spain
| | - Azucena Bardají
- TropNet, A European Network for Tropical and Travel Medicine, Verona, Italy.,ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain.,Centro de Investigação Em Saúde de Manhiça, Maputo, Mozambique.,Consorcio de Investigación Biomédica en Red de Epidemiología Y Salud Pública (CIBERESP), Madrid, Spain
| | - Gerardo Rojo-Marcos
- Hospital Universitario Príncipe de Asturias, Alcalà de Henares, Madrid, Spain
| | - Leo G Visser
- TropNet, A European Network for Tropical and Travel Medicine, Verona, Italy.,Department of Infectious Diseases, Leiden University Medical Centre, Leiden, Netherlands
| | - Christoph Hatz
- TropNet, A European Network for Tropical and Travel Medicine, Verona, Italy.,Swiss Tropical and Public Health Institute, Basel, Switzerland.,University of Basel, Basel, Switzerland
| | - Zeno Bisoffi
- TropNet, A European Network for Tropical and Travel Medicine, Verona, Italy.,Department of Infectious-Tropical Diseases and Microbiology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar, Italy
| | - Tomas Jelinek
- TropNet, A European Network for Tropical and Travel Medicine, Verona, Italy.,Berliner Centrum Fürr Reise- Und Tropenmedizin, Berlin, Germany
| | | | | | | | | | | | | | | | - Ronald H Behrens
- TropNet, A European Network for Tropical and Travel Medicine, Verona, Italy.,Clinical Research Dept, Faculty of Infectious & Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
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7
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Adegbola AJ, Soyinka JO, Bolaji OO. Effect of CYP3A5*3 genotypes on lumefantrine plasma concentrations among malaria-HIV-infected women. Pharmacogenomics 2020; 21:1289-1297. [PMID: 33243092 DOI: 10.2217/pgs-2020-0081] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Aim: We aimed to assess the effect of a functional polymorphism of CYP3A5 on lumefantrine pharmacokinetics. Patients & methods: Sixty-nine women diagnosed with malaria received standard doses of artemether-lumefantrine. Concentration-time data for lumefantrine and genotyping data were obtained for each participant. Pharmacokinetic-genotype associative relationships were assessed using linear regressions, Mann-Whitney U-test or Kruskal-Wallis statistics. Results: Average age and weight (standard deviation) of the patients were 33 (6.8) years and 59.5 (11.6) kg, respectively. CYP3A5*3 genotype associated with the log-transformed maximum concentration with the median (interquartile range) values of 8279 (6516-13,420) and 6331 (4093-8631) ng/ml (p = 0.032) among the carriers and noncarriers of CYP3A5*3, respectively. Besides, the NR1I3 c.152-1089T>C genotypes had an associative trend with the lumefantrine area under the curve (AUC0-96h) and clearance. Conclusion: CYP3A5*3 genetic variant is associated with a high maximum plasma concentration of lumefantrine. This warrants further investigations on the association between CYP3A5*3 gene variants, lumefantrine pharmacokinetics and electrophysiological effect.
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Affiliation(s)
- Adebanjo J Adegbola
- Department of Pharmaceutical Chemistry, Obafemi Awolowo University, Ile Ife, Nigeria
| | - Julius O Soyinka
- Department of Pharmaceutical Chemistry, Obafemi Awolowo University, Ile Ife, Nigeria
| | - Oluseye O Bolaji
- Department of Pharmaceutical Chemistry, Obafemi Awolowo University, Ile Ife, Nigeria
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8
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Wattanakul T, Ogutu B, Kabanywanyi AM, Asante KP, Oduro A, Adjei A, Sie A, Sevene E, Macete E, Compaore G, Valea I, Osei I, Winterberg M, Gyapong M, Adjuik M, Abdulla S, Owusu-Agyei S, White NJ, Day NPJ, Tinto H, Baiden R, Binka F, Tarning J. Pooled Multicenter Analysis of Cardiovascular Safety and Population Pharmacokinetic Properties of Piperaquine in African Patients with Uncomplicated Falciparum Malaria. Antimicrob Agents Chemother 2020; 64:e01848-19. [PMID: 32312783 PMCID: PMC7318010 DOI: 10.1128/aac.01848-19] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 04/08/2020] [Indexed: 01/08/2023] Open
Abstract
Dihydroartemisinin-piperaquine has shown excellent efficacy and tolerability in malaria treatment. However, concerns have been raised of potentially harmful cardiotoxic effects associated with piperaquine. The population pharmacokinetics and cardiac effects of piperaquine were evaluated in 1,000 patients, mostly children enrolled in a multicenter trial from 10 sites in Africa. A linear relationship described the QTc-prolonging effect of piperaquine, estimating a 5.90-ms mean QTc prolongation per 100-ng/ml increase in piperaquine concentration. The effect of piperaquine on absolute QTc interval estimated a mean maximum QTc interval of 456 ms (50% effective concentration of 209 ng/ml). Simulations from the pharmacokinetic-pharmacodynamic models predicted 1.98 to 2.46% risk of having QTc prolongation of >60 ms in all treatment settings. Although piperaquine administration resulted in QTc prolongation, no cardiovascular adverse events were found in these patients. Thus, the use of dihydroartemisinin-piperaquine should not be limited by this concern. (This study has been registered at ClinicalTrials.gov under identifier NCT02199951.).
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Affiliation(s)
- Thanaporn Wattanakul
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Bernhards Ogutu
- INDEPTH Network, Accra, Ghana
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | | | | | - Alex Adjei
- Dodowa Health Research Centre, Dodowa, Ghana
| | - Ali Sie
- Nouna Health Research Centre, Nouna, Burkina Faso
| | - Esperanca Sevene
- Centro de Investigaçãoem Saúde de Manhiça, CISM, Manhiça, Mozambique
| | - Eusebio Macete
- Centro de Investigaçãoem Saúde de Manhiça, CISM, Manhiça, Mozambique
| | | | - Innocent Valea
- Clinical Research Unit of Nanoro (IRSS-URCN), Nanoro, Burkina Faso
| | - Isaac Osei
- Navrongo Health Research Centre, Navrongo, Ghana
| | - Markus Winterberg
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Margaret Gyapong
- Dodowa Health Research Centre, Dodowa, Ghana
- University for Health and Allied Sciences, Ho, Ghana
| | | | | | - Seth Owusu-Agyei
- Kintampo Health Research Centre, Kintampo, Ghana
- University for Health and Allied Sciences, Ho, Ghana
| | - Nicholas J White
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Nicholas P J Day
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Halidou Tinto
- Clinical Research Unit of Nanoro (IRSS-URCN), Nanoro, Burkina Faso
| | | | - Fred Binka
- INDEPTH Network, Accra, Ghana
- University for Health and Allied Sciences, Ho, Ghana
| | - Joel Tarning
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- WorldWide Antimalarial Resistance Network, Oxford, United Kingdom
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9
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El-Azzouny AMAES, Aboul-Enein MN, Hamissa MF. Structural and biological survey of 7-chloro-4-(piperazin-1-yl)quinoline and its derivatives. Drug Dev Res 2020; 81:786-802. [PMID: 32385857 DOI: 10.1002/ddr.21678] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 04/09/2020] [Accepted: 04/19/2020] [Indexed: 12/27/2022]
Abstract
The 7-chloro-4-(piperazin-1-yl)quinoline structure is an important scaffold in medicinal chemistry. It exhibited either alone or as hybrid with other active pharmacophores diverse pharmacological profiles such as: antimalarial, antiparasitic, anti-HIV, antidiabetic, anticancer, sirtuin Inhibitors, dopamine-3 ligands, acetylcholinesterase inhibitors, and serotonin antagonists. In the presented review, a comprehensive discussion of compounds having this structural core is surveyed and illustrated.
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Affiliation(s)
- Aida M Abd El-Sattar El-Azzouny
- Medicinal and Pharmaceutical Chemistry Department, Pharmaceutical and Drug Industries Research Division, National Research Centre (ID: 60014618), Giza, Egypt
| | - Mohamed Nabil Aboul-Enein
- Medicinal and Pharmaceutical Chemistry Department, Pharmaceutical and Drug Industries Research Division, National Research Centre (ID: 60014618), Giza, Egypt
| | - Mohamed Farouk Hamissa
- Medicinal and Pharmaceutical Chemistry Department, Pharmaceutical and Drug Industries Research Division, National Research Centre (ID: 60014618), Giza, Egypt.,Department of Chemistry of Natural Compounds, Faculty of Food and Biochemical Technology, University of Chemistry and Technology, Prague, Czech Republic.,Department of Biomolecular Spectroscopy, Institute of Organic Chemistry and Biochemistry, Academy of Sciences, Prague, Czech Republic
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10
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Chan XHS, Win YN, Haeusler IL, Tan JY, Loganathan S, Saralamba S, Chan SKS, Ashley EA, Barnes KI, Baiden R, Bassi PU, Djimde A, Dorsey G, Duparc S, Hanboonkunupakarn B, ter Kuile FO, Lacerda MVG, Nasa A, Nosten FH, Onyeji CO, Pukrittayakamee S, Siqueira AM, Tarning J, Taylor WRJ, Valentini G, van Vugt M, Wesche D, Day NPJ, Huang CLH, Brugada J, Price RN, White NJ. Factors affecting the electrocardiographic QT interval in malaria: A systematic review and meta-analysis of individual patient data. PLoS Med 2020; 17:e1003040. [PMID: 32134952 PMCID: PMC7058280 DOI: 10.1371/journal.pmed.1003040] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 02/05/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Electrocardiographic QT interval prolongation is the most widely used risk marker for ventricular arrhythmia potential and thus an important component of drug cardiotoxicity assessments. Several antimalarial medicines are associated with QT interval prolongation. However, interpretation of electrocardiographic changes is confounded by the coincidence of peak antimalarial drug concentrations with recovery from malaria. We therefore reviewed all available data to characterise the effects of malaria disease and demographic factors on the QT interval in order to improve assessment of electrocardiographic changes in the treatment and prevention of malaria. METHODS AND FINDINGS We conducted a systematic review and meta-analysis of individual patient data. We searched clinical bibliographic databases (last on August 21, 2017) for studies of the quinoline and structurally related antimalarials for malaria-related indications in human participants in which electrocardiograms were systematically recorded. Unpublished studies were identified by the World Health Organization (WHO) Evidence Review Group (ERG) on the Cardiotoxicity of Antimalarials. Risk of bias was assessed using the Pharmacoepidemiological Research on Outcomes of Therapeutics by a European Consortium (PROTECT) checklist for adverse drug events. Bayesian hierarchical multivariable regression with generalised additive models was used to investigate the effects of malaria and demographic factors on the pretreatment QT interval. The meta-analysis included 10,452 individuals (9,778 malaria patients, including 343 with severe disease, and 674 healthy participants) from 43 studies. 7,170 (68.6%) had fever (body temperature ≥ 37.5°C), and none developed ventricular arrhythmia after antimalarial treatment. Compared to healthy participants, patients with uncomplicated falciparum malaria had shorter QT intervals (-61.77 milliseconds; 95% credible interval [CI]: -80.71 to -42.83) and increased sensitivity of the QT interval to heart rate changes. These effects were greater in severe malaria (-110.89 milliseconds; 95% CI: -140.38 to -81.25). Body temperature was associated independently with clinically significant QT shortening of 2.80 milliseconds (95% CI: -3.17 to -2.42) per 1°C increase. Study limitations include that it was not possible to assess the effect of other factors that may affect the QT interval but are not consistently collected in malaria clinical trials. CONCLUSIONS Adjustment for malaria and fever-recovery-related QT lengthening is necessary to avoid misattributing malaria-disease-related QT changes to antimalarial drug effects. This would improve risk assessments of antimalarial-related cardiotoxicity in clinical research and practice. Similar adjustments may be indicated for other febrile illnesses for which QT-interval-prolonging medications are important therapeutic options.
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Affiliation(s)
- Xin Hui S. Chan
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Yan Naung Win
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Health and Diseases Control Unit, Naypyidaw, Myanmar
| | - Ilsa L. Haeusler
- WorldWide Antimalarial Research Network, Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Jireh Y. Tan
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Shanghavie Loganathan
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Christ Church College, University of Oxford, Oxford, United Kingdom
| | - Sompob Saralamba
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Shu Kiat S. Chan
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Singapore Armed Forces Medical Corps, Singapore
| | - Elizabeth A. Ashley
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Lao PDR
| | - Karen I. Barnes
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- WorldWide Antimalarial Resistance Network, Cape Town, South Africa
| | | | - Peter U. Bassi
- Department of Internal Medicine, Faculty of Clinical Sciences, College of Health Sciences, University of Abuja, Abuja, Nigeria
| | - Abdoulaye Djimde
- Malaria Research and Training Center, Department of Epidemiology of Parasitic Diseases, Faculty of Pharmacy, University of Science Techniques and Technologies of Bamako, Bamako, Mali
| | - Grant Dorsey
- Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
| | | | - Borimas Hanboonkunupakarn
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Feiko O. ter Kuile
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Marcus V. G. Lacerda
- Fundação de Medicina Tropical Dr Heitor Vieira Dourado, Manaus, Brazil
- Instituto Leônidas e Maria Deane (FIOCRUZ-Amazonas), Fundação Oswaldo Cruz, Manaus, Brazil
| | - Amit Nasa
- Sun Pharmaceutical Industries Ltd, Gurgaon, Haryana, India
| | - François H. Nosten
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | | | - Sasithon Pukrittayakamee
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- The Royal Society of Thailand, Dusit, Bangkok, Thailand
| | - André M. Siqueira
- Fundação de Medicina Tropical Dr Heitor Vieira Dourado, Manaus, Brazil
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Joel Tarning
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- WorldWide Antimalarial Research Network, Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Walter R. J. Taylor
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | | | - Michèle van Vugt
- Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - David Wesche
- Certara, Princeton, New Jersey, United States of America
| | - Nicholas P. J. Day
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | | | - Josep Brugada
- Cardiovascular Institute, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Ric N. Price
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - Nicholas J. White
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
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11
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Whalen ME, Kajubi R, Chamankhah N, Huang L, Orukan F, Wallender E, Kamya MR, Dorsey G, Jagannathan P, Rosenthal PJ, Mwebaza N, Aweeka FT. Reduced Exposure to Piperaquine, Compared to Adults, in Young Children Receiving Dihydroartemisinin-Piperaquine as Malaria Chemoprevention. Clin Pharmacol Ther 2019; 106:1310-1318. [PMID: 31173649 DOI: 10.1002/cpt.1534] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 05/07/2019] [Indexed: 11/10/2022]
Abstract
Dihydroartemisinin (DHA)-piperaquine is being evaluated as intermittent preventive therapy for malaria, but dosing has not been optimized for children. We assessed exposure to DHA and piperaquine in Ugandan children at two ages during infancy. Intensive sampling was performed in 32 children at 32 weeks of age, 31 children at 104 weeks, and 30 female adult controls. Compared with adults, DHA area under the concentration-time curve (AUC0-8 hr ) was 52% higher at 32 weeks and comparable at 104 weeks. Compared with adults, piperaquine AUC0-21 d was 35% lower at 32 weeks and 53% lower at 104 weeks. Terminal piperaquine concentrations on days 7, 14, and 21 were lower in children compared with adults and lower at 104 compared with 32 weeks. Piperaquine exposure was lower in young children compared with adults, and lower at 104 compared with 32 weeks of age, suggesting a need for age-based DHA-piperaquine dose optimization for chemoprevention.
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Affiliation(s)
- Meghan E Whalen
- Department of Clinical Pharmacy, University of California San Francisco, San Francisco General Hospital, San Francisco, California, USA
| | - Richard Kajubi
- Infectious Disease Research Collaboration, Makerere University College of Health Sciences, Kampala, Uganda.,Department of Pharmacology and Therapeutics, Makerere University College of Health Sciences, Kampala, Uganda
| | - Nona Chamankhah
- Department of Pharmacy, Rady Children's Hospital, San Diego, California, USA
| | - Liusheng Huang
- Department of Clinical Pharmacy, University of California San Francisco, San Francisco General Hospital, San Francisco, California, USA
| | - Francis Orukan
- Infectious Disease Research Collaboration, Makerere University College of Health Sciences, Kampala, Uganda
| | - Erika Wallender
- Department of Medicine, University of California San Francisco, San Francisco General Hospital, San Francisco, California, USA
| | - Moses R Kamya
- Infectious Disease Research Collaboration, Makerere University College of Health Sciences, Kampala, Uganda
| | - Grant Dorsey
- Department of Medicine, University of California San Francisco, San Francisco General Hospital, San Francisco, California, USA
| | | | - Philip J Rosenthal
- Department of Medicine, University of California San Francisco, San Francisco General Hospital, San Francisco, California, USA
| | - Norah Mwebaza
- Infectious Disease Research Collaboration, Makerere University College of Health Sciences, Kampala, Uganda.,Department of Pharmacology and Therapeutics, Makerere University College of Health Sciences, Kampala, Uganda
| | - Francesca T Aweeka
- Department of Clinical Pharmacy, University of California San Francisco, San Francisco General Hospital, San Francisco, California, USA
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12
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Funck-Brentano C, Ouologuem N, Duparc S, Felices M, Sirima SB, Sagara I, Soulama I, Ouedraogo JB, Beavogui AH, Borghini-Fuhrer I, Khan Y, Djimdé AA, Voiriot P. Evaluation of the effects on the QT-interval of 4 artemisinin-based combination therapies with a correction-free and heart rate-free method. Sci Rep 2019; 9:883. [PMID: 30696921 PMCID: PMC6351684 DOI: 10.1038/s41598-018-37113-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 12/04/2018] [Indexed: 12/04/2022] Open
Abstract
Several antimalarial drugs are known to prolong ventricular repolarization as evidenced by QT/QTc interval prolongation. This can lead to Torsades de Pointes, a potentially lethal ventricular arrhythmia. Whether this is the case with artemisinin-based combination therapies (ACTs) remains uncertain. Assessment of the extent of QTc prolongation with antimalarials is hampered by important variations of heart rate during malaria crises and previous studies have reported highly variable values of QTc prolongations with ACTs. We assessed QTc prolongation with four ACTs, using high quality ECG recording and measurement techniques, during the first episode of malaria in 2,091 African patients enrolled in the WANECAM study which also monitored clinical safety. Using an original and robust method of QTc assessment, independent from heart rate changes and from the method of QT correction, we were able to accurately assess the extent of mean maximum QTc prolongation with the four ACTs tested. There was no evidence of proarrhythmia with any treatment during the study although dihydroartemisinin-piperaquine, artesunate-amodiaquine and artemether-lumefantrine significantly prolonged QTc. The extent of prolongation of ventricular repolarization can be accurately assessed in studies where heart rate changes impede QTc assessment.
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Affiliation(s)
- Christian Funck-Brentano
- INSERM, CIC-1421 and UMR ICAN 1166, Sorbonne Université, Faculty of Medicine, AP-HP, Pitié-Salpêtrière Hospital, Department of Pharmacology and Clinical Investigation Center, Institute of Cardiometabolism and Nutrition (ICAN), F-75013, Paris, France.
| | - Nouhoum Ouologuem
- Malaria research and training center. Département d'épidémiologie des affections parasitaires, Faculté de médecine de pharmacie et d'odonto-stomatologie. P.O. Box 1805, Point G, Bamako, Mali
| | - Stephan Duparc
- Medicines for Malaria Venture, International Center Cointrin, 20 route de Pré-Bois, 1215, Geneva 15, Switzerland
| | - Mathieu Felices
- Phinc Development, Immeuble Genavenir 8, 5 rue Henri Desbruères, 91030, Evry Cedex, France
| | - Sodiomon B Sirima
- Centre national de recherche et de formation sur le paludisme, 01 P.O. Box 2208, Ouagadougou 01, Burkina Faso
| | - Issaka Sagara
- Malaria research and training center. Département d'épidémiologie des affections parasitaires, Faculté de médecine de pharmacie et d'odonto-stomatologie. P.O. Box 1805, Point G, Bamako, Mali
| | - Issiaka Soulama
- Centre national de recherche et de formation sur le paludisme, 01 P.O. Box 2208, Ouagadougou 01, Burkina Faso
| | - Jean-Bosco Ouedraogo
- IRSS, Direction Régionale de l'Ouest, 399, Avenue de la Liberté 01, P.O. Box 545, Bobo-Dioulasso 01, Burkina Faso
| | - Abdoul H Beavogui
- Centre National de Formation et de Recherche en Santé Rurale de Mafèrinyah, P.O. Box 2649, Conakry, Guinea
| | - Isabelle Borghini-Fuhrer
- Medicines for Malaria Venture, International Center Cointrin, 20 route de Pré-Bois, 1215, Geneva 15, Switzerland
| | - Yasmin Khan
- Cardiabase, 84 avenue du XXème Corps, 54000, Nancy, France
| | - Abdoulaye A Djimdé
- Malaria research and training center. Département d'épidémiologie des affections parasitaires, Faculté de médecine de pharmacie et d'odonto-stomatologie. P.O. Box 1805, Point G, Bamako, Mali
| | - Pascal Voiriot
- Cardiabase, 84 avenue du XXème Corps, 54000, Nancy, France
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