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Saito M, Phyo AP, Chu C, Proux S, Rijken MJ, Beau C, Win HH, Archasuksan L, Wiladphaingern J, Phu NH, Hien TT, Day NP, Dondorp AM, White NJ, Nosten F, McGready R. Severe falciparum malaria in pregnancy in Southeast Asia: a multi-centre retrospective cohort study. BMC Med 2023; 21:320. [PMID: 37620809 PMCID: PMC10464355 DOI: 10.1186/s12916-023-02991-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 07/20/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Severe malaria in pregnancy causes maternal mortality, morbidity, and adverse foetal outcomes. The factors contributing to adverse maternal and foetal outcomes are not well defined. We aimed to identify the factors predicting higher maternal mortality and to describe the foetal mortality and morbidity associated with severe falciparum malaria in pregnancy. METHODS A retrospective cohort study was conducted of severe falciparum malaria in pregnancy, as defined by the World Health Organization severe malaria criteria. The patients were managed prospectively by the Shoklo Malaria Research Unit (SMRU) on the Thailand-Myanmar border or were included in hospital-based clinical trials in six Southeast Asian countries. Fixed-effects multivariable penalised logistic regression was used for analysing maternal mortality. RESULTS We included 213 (123 SMRU and 90 hospital-based) episodes of severe falciparum malaria in pregnancy managed between 1980 and 2020. The mean maternal age was 25.7 (SD 6.8) years, and the mean gestational age was 25.6 (SD 8.9) weeks. The overall maternal mortality was 12.2% (26/213). Coma (adjusted odds ratio [aOR], 7.18, 95% CI 2.01-25.57, p = 0.0002), hypotension (aOR 11.21, 95%CI 1.27-98.92, p = 0.03) and respiratory failure (aOR 4.98, 95%CI 1.13-22.01, p = 0.03) were associated with maternal mortality. Pregnant women with one or more of these three criteria had a mortality of 29.1% (25/86) (95%CI 19.5 to 38.7%) whereas there were no deaths in 88 pregnant women with hyperparasitaemia (> 10% parasitised erythrocytes) only or severe anaemia (haematocrit < 20%) only. In the SMRU prospective cohort, in which the pregnant women were followed up until delivery, the risks of foetal loss (23.3% by Kaplan-Meier estimator, 25/117) and small-for-gestational-age (38.3%, 23/60) after severe malaria were high. Maternal death, foetal loss and preterm birth occurred commonly within a week of diagnosis of severe malaria. CONCLUSIONS Vital organ dysfunction in pregnant women with severe malaria was associated with a very high maternal and foetal mortality whereas severe anaemia or hyperparasitaemia alone were not associated with poor prognosis, which may explain the variation of reported mortality from severe malaria in pregnancy. Access to antenatal care must be promoted to reduce barriers to early diagnosis and treatment of both malaria and anaemia.
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Affiliation(s)
- Makoto Saito
- 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 Medicine, University of Oxford, Oxford, UK.
- Division of Infectious Diseases, Advanced Clinical Research Center, Institute of Medical Science, University of Tokyo, Tokyo, Japan.
| | - Aung Pyae Phyo
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Cindy Chu
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Stephane Proux
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Marcus J Rijken
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Obstetrics and Gynecology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Candy Beau
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Htun Htun Win
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Laypaw Archasuksan
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Jacher Wiladphaingern
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Nguyen H Phu
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Tran T Hien
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Nick P Day
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Arjen M Dondorp
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Nicholas J White
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - François 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 Medicine, University of Oxford, Oxford, UK
| | - 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 Medicine, University of Oxford, Oxford, UK
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Nyaaba N, Andoh NE, Amoh G, Amuzu DSY, Ansong M, Ordóñez-Mena JM, Hirst J. Comparative efficacy and safety of the artemisinin derivatives compared to quinine for treating severe malaria in children and adults: A systematic update of literature and network meta-analysis. PLoS One 2022; 17:e0269391. [PMID: 35857773 PMCID: PMC9299386 DOI: 10.1371/journal.pone.0269391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 05/19/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The artemisinin derivatives are the preferred antimalaria drugs for treating severe Plasmodium falciparum malaria. However, their clinical effectiveness compared to each other is unknown. Our objective, therefore, was to evaluate the efficacy and safety of the artemisinin derivatives and quinine for treating severe P. falciparum malaria in children and adults using a network meta-analysis. METHODS AND FINDINGS Review protocol was registered with PROSPERO, CRD42020218190. We updated the search strategies of three Cochrane systematic reviews which included published and unpublished randomised control trials (RCTs) that have compared specific artemisinin derivatives to quinine in treating severe malaria. Search included CENTRAL, MEDLINE, Embase, LILACS, ISI Web of Science and trial registries up to February 2021. We screened studies, extracted data, assessed risk of bias, and quality of evidence in duplicate. Separate network meta-analyses in the frequentist framework, using a random effects model, with quinine as reference, were conducted for adults and children, and rankings were produced using p-scores to assess mortality, parasite clearance, coma recovery, fever clearance, neurological sequela and adverse events. Searches identified 818 citations, 33 RCTs were eligible. We pooled 7795 children and 3182 adults. The networks involved artesunate, artemether, rectal artemisinin, arteether and quinine. Compared to quinine, artesunate reduced mortality in children (risk ratio (RR), 0.76; 95%CI [0.65 to 0.89], moderate quality), adults (RR, 0.55; 95%CI [0.40 to 0.75], moderate quality) and in cerebral malaria (RR, 0.72; 95%CI [0.55 to 0.94], moderate quality). Compared to rectal artemisinin and intramuscular arteether, the efficacy and safety of parenteral artesunate, and intramuscular artemether in treating severe malaria are not clear. Rankings showed that none of the artemisinin drugs were consistently superior in all the outcomes assessed. Indirect evidence produced were of very low ratings due to suspected publication bias and imprecision. CONCLUSIONS Artesunate reduces mortality compared to quinine for both adults and children in Asia and Africa including cerebral malaria. The artemisinin derivatives remain the best treatment for severe malaria but their comparative clinical effectiveness is yet to be fully explored.
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Affiliation(s)
- Nicholas Nyaaba
- Infectious Disease Centre, 37 Military Hospital, Cantonments, Accra, Ghana
| | - Nana Efua Andoh
- Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
| | - Gordon Amoh
- Korle-Bu Polyclinic/ Family Medicine Department, Korle-Bu Teaching Hospital, Korle-Bu, Accra, Ghana
| | - Dominic Selorm Yao Amuzu
- West African Centre for Cell Biology of Infectious Pathogens, Department of Biochemistry, Cell and Molecular Biology, University of Ghana, Legon, Accra, Ghana
| | - Mary Ansong
- The International Sickle Cell Centre, Accra Central, Accra, Ghana
| | - José M. Ordóñez-Mena
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
- National Institute for Health Research (NIRH), Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Jennifer Hirst
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
- National Institute for Health Research (NIRH), Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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Mtalimanja M, Abasse KS, Mtalimanja JL, Yuan XZ, Wenwen D, Xu W. Economic evaluation of severe malaria in children under 14 years in Zambia. Cost Eff Resour Alloc 2022; 20:4. [PMID: 35123482 PMCID: PMC8817518 DOI: 10.1186/s12962-022-00340-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 01/24/2022] [Indexed: 11/12/2022] Open
Abstract
Introduction Malaria exerts a significant economic burden on health care providers and households and our study attempts to make claims on the cost effectiveness of artesunate against quinine in patients under 14 years of age in Zambia. Also, to find the average total costs involved in the treatment of severe malaria in children and their impact on household expenditure. Methods Cost-effectiveness analysis of severe malaria treatment was conducted from a healthcare provider perspective using a Markov model. Standard costing was performed for the identification, measurement and assessment phases with data from quantification reports for anti-malaria commodities as these documents provides drug procurement costs from suppliers and freight costs. Average and incremental cost-effectiveness ratio were estimated and uncertainties were assessed through probabilistic sensitivity analysis. Results In Zambia severe malaria in children has been shown to account for over 45% of the total monthly curative healthcare costs incurred by households compared to the mean per capita monthly income. The cost of treating severe malaria depleted 7.67% of the monthly average household income. According, to the cost effectiveness analysis the of artesunate with quinine the ICER was $105 per death averted. Conclusion The use of artesunate over quinine in the treatment of severe malaria in children under 14 years is a highly cost-effective strategy for the healthcare provider in Zambia.
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Affiliation(s)
- Michael Mtalimanja
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, 211198, Jiangsu, China
| | - Kassim Said Abasse
- Faculté des Sciences de l'administration (FSA), Université Laval, Québec, QC, G1V 0A6, Canada.
| | - James Lamon Mtalimanja
- Department of Monitoring and Evaluation, Ministry of Health, P.O Box, 30205, Lusaka, Zambia
| | - Xu Zheng Yuan
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, 211198, Jiangsu, China
| | - Du Wenwen
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, 211198, Jiangsu, China
| | - Wei Xu
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, 211198, Jiangsu, China.
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Alteration of Blood Lactate Levels in Severe Falciparum Malaria: A Systematic Review and Meta-Analysis. BIOLOGY 2021; 10:biology10111085. [PMID: 34827078 PMCID: PMC8614809 DOI: 10.3390/biology10111085] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 10/19/2021] [Accepted: 10/19/2021] [Indexed: 12/26/2022]
Abstract
Simple Summary Alteration of blood lactate levels in patients with severe falciparum malaria is well recognized. However, data on blood lactate in literatures were based on a limited number of participants. The present systematic review aimed to collate the blood lactate levels recorded in the literature and used a metaanalysis approach to pool the evidence in a larger sample size than that used in the individual studies to determine the trend. Results from this study will provide the pooled evidence of blood lactate levels in patients with severe malaria for further studies that identifying patients with a high risk of developing severe malaria or death. Abstract Metabolic acidosis in severe malaria usually occurs in the form of lactic acidosis. The present study aimed to collate articles from the literature that have reported blood lactate levels in patients with severe malaria and tested the hypothesis that blood lactate levels are elevated in patients with malaria compared to those with uncomplicated malaria. Moreover, the difference in lactate levels between patients who died and those who survived was estimated using a meta-analytic approach. Potentially relevant studies were searched for in PubMed, Web of Science, and Scopus. The quality of the included studies was assessed using the Jadad scale and strengthening the reporting of observational studies in epidemiology (STROBE). The pooled mean blood lactate in patients with severe malaria, the pooled weighted mean difference (WMD) of blood lactate between patients with severe malaria and those with uncomplicated malaria, and the pooled WMD and 95% CI of blood lactate between patients who died from and those who survived severe malaria were estimated using the random-effects model. Heterogeneity among the outcomes of the included studies was assessed using Cochran’s Q and I2 statistics. A meta-regression analysis was performed to identify the source(s) of heterogeneity of outcomes among the included studies. A subgroup analysis was further performed to separately analyze the outcomes stratified by the probable source(s) of heterogeneity. Publication bias was assessed by the visual inspection of the funnel plot asymmetry. Of 793 studies retrieved from the searches, 30 studies were included in qualitative and quantitative syntheses. The pooled mean lactate in patients with severe malaria was 5.04 mM (95% CI: 4.44–5.64; I2: 99.9%; n = 30,202 cases from 30 studies). The mean lactate in patients with severe malaria (1568 cases) was higher than in those with uncomplicated malaria (1693 cases) (p = 0.003; MD: 2.46; 95% CI: 0.85–4.07; I2: 100%; nine studies). The mean lactate in patients with severe malaria who died (272 cases) was higher than in those with severe malaria who survived (1370 cases) (p < 0.001; MD: 2.74; 95% CI: 1.74–3.75; I2: 95.8%; six studies). In conclusion, the present study showed a high mean difference in blood lactate level between patients with severe malaria and patients with uncomplicated malaria. In addition, there was a high mean difference in blood lactate level between patients with severe malaria who died compared to those with severe malaria who survived. Further studies are needed to investigate the prognostic value of blood lactate levels to identify patients who are at high risk of developing severe malaria or dying.
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5
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Conroy AL, Opoka RO, Bangirana P, Namazzi R, Okullo AE, Georgieff MK, Cusick S, Idro R, Ssenkusu JM, John CC. Parenteral artemisinins are associated with reduced mortality and neurologic deficits and improved long-term behavioral outcomes in children with severe malaria. BMC Med 2021; 19:168. [PMID: 34315456 PMCID: PMC8317420 DOI: 10.1186/s12916-021-02033-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 06/11/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND In 2011, the World Health Organization recommended injectable artesunate as the first-line therapy for severe malaria (SM) due to its superiority in reducing mortality compared to quinine. There are limited data on long-term clinical and neurobehavioral outcomes after artemisinin use for treatment of SM. METHODS From 2008 to 2013, 502 Ugandan children with two common forms of SM, cerebral malaria and severe malarial anemia, were enrolled in a prospective observational study assessing long-term neurobehavioral and cognitive outcomes following SM. Children were evaluated a week after hospital discharge, and 6, 12, and 24 months of follow-up, and returned to hospital for any illness. In this study, we evaluated the impact of artemisinin derivatives on survival, post-discharge hospital readmission or death, and neurocognitive and behavioral outcomes over 2 years of follow-up. RESULTS 346 children received quinine and 156 received parenteral artemisinin therapy (artemether or artesunate). After adjustment for disease severity, artemisinin derivatives were associated with a 78% reduction in in-hospital mortality (adjusted odds ratio, 0.22; 95% CI, 0.07-0.67). Among cerebral malaria survivors, children treated with artemisinin derivatives also had reduced neurologic deficits at discharge (quinine, 41.7%; artemisinin derivatives, 23.7%, p=0.007). Over a 2-year follow-up, artemisinin derivatives as compared to quinine were associated with better adjusted scores (negative scores better) in internalizing behavior and executive function in children irrespective of the age at severe malaria episode. After adjusting for multiple comparisons, artemisinin derivatives were associated with better adjusted scores in behavior and executive function in children <6 years of age at severe malaria exposure following adjustment for child age, sex, socioeconomic status, enrichment in the home environment, and the incidence of hospitalizations over follow-up. Children receiving artesunate had the greatest reduction in mortality and benefit in behavioral outcomes and had reduced inflammation at 1-month follow-up compared to children treated with quinine. CONCLUSIONS Treatment of severe malaria with artemisinin derivatives, particularly artesunate, results in reduced in-hospital mortality and neurologic deficits in children of all ages, reduced inflammation following recovery, and better long-term behavioral outcomes. These findings suggest artesunate has long-term beneficial effects in children surviving severe malaria.
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Affiliation(s)
- Andrea L Conroy
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, R4 402C 1044 West Walnut St, Indianapolis, IN, 46202, USA.
| | - Robert O Opoka
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Paul Bangirana
- Department of Psychiatry, Makerere University College of Health Sciences, Kampala, Uganda
| | - Ruth Namazzi
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Allen E Okullo
- Clinical Epidemiology Unit, Makerere University College of Health Sciences, Kampala, Uganda
| | | | - Sarah Cusick
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - Richard Idro
- Department of Paediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - John M Ssenkusu
- Department of Epidemiology and Biostatistics, Makerere University School of Public Health, Kampala, Uganda
| | - Chandy C John
- Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, R4 402C 1044 West Walnut St, Indianapolis, IN, 46202, USA.,Division of Global Pediatrics, University of Minnesota Medical School, Minneapolis, USA
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Khanal P. Antimalarial and anticancer properties of artesunate and other artemisinins: current development. MONATSHEFTE FUR CHEMIE 2021; 152:387-400. [PMID: 33814617 PMCID: PMC8008344 DOI: 10.1007/s00706-021-02759-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 03/22/2021] [Indexed: 02/06/2023]
Abstract
This review provides a recent perspective of artesunate and other artemisinins as antimalarial drugs and their uses in cancer therapy. Artesunate is an artemisinin derivative. Artemisinin is extracted from the plant Artemisia annua. Artemisinin and its derivatives have been the most useful drug for malarial treatment in human history. The artesunate has an advantage of a hydrophilic group over other artemisinins which makes it a more potent drug. On the industrial scale, artemisinins are synthesized in semisynthetic ways. The 1,2,4-endoperoxide bridge of artemisinins is responsible for the drug's antimalarial activity. There is the emergence of artemisinin resistance on Plasmodium falciparum and pieces of evidence suggest that it is mainly due to the mutation at Kelch13 protein of P. falciparum. Clinical trial data show that the artesunate is more favorable than quinine and other artemisinins to treat patients with severe malaria. Pieces of evidence indicate that artemisinins can be developed as anticancer drugs. The mechanism of actions on how artemisinins act as an anticancer drug involves oxidative stress, DNA damage and repair, and various types of cell deaths. GRAPHIC ABSTRACT
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Affiliation(s)
- Pitambar Khanal
- Nagarik College, Tribhuvan University, Gaidakot-2, Nawalparasi Purva, Gandaki, Nepal
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7
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Bhutani A, Kaushik RM, Kaushik R. A study on multi-organ dysfunction syndrome in malaria using sequential organ failure assessment score. Trop Parasitol 2021; 10:86-94. [PMID: 33747874 PMCID: PMC7951073 DOI: 10.4103/tp.tp_12_19] [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: 03/01/2019] [Revised: 12/23/2019] [Accepted: 05/30/2020] [Indexed: 11/12/2022] Open
Abstract
Purpose: The purpose of this study is to examine the prevalence, clinical spectrum, prognostic factors, and outcome of multi-organ dysfunction syndrome (MODS) in patients with malaria. Materials and Methods: One hundred and twenty-four patients with malaria, diagnosed by a positive peripheral blood film and rapid malaria test, were studied for MODS using the sequential organ failure assessment (SOFA) score. The severity of malaria was assessed by the WHO criteria. Results: Severe malaria was present in 54 (43.54%) patients. MODS was detected in 108 (87.09%) patients with malaria (Plasmodium falciparum - 57 [85.07%], Plasmodium vivax - 46 [88.46%] and mixed P. falciparum and P. vivax malaria - 5 [100%] cases). SOFA scores of MODS-and non-MODS-patients differed significantly (P < 0.001). No significant association was seen between MODS and type of malaria (P = 0.894). Mortality among malaria patients with MODS was 5.55% (6/108) (P. falciparum 8.77% [5/57] and P. vivax 2.17% [1/46]). The outcome of MODS was associated significantly with the severity of the SOFA score at admission (P = 0.011) but not with the type of malaria, malaria parasite index, and the number of organs involved (P > 0.05 each). The SOFA score at admission correlated significantly with the duration of hospitalization (P < 0.0001). Conclusions: MODS occurs with high frequency in malaria and is not dependent on the type of malaria. The outcome of MODS and recovery time depends on the severity of MODS. The SOFA score is useful in detecting MODS and ascertaining its severity and prognosis in malaria.
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Affiliation(s)
- Amish Bhutani
- Department of Medicine, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Dehradun, Uttarakhand, India
| | - Rajeev Mohan Kaushik
- Department of Medicine, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Dehradun, Uttarakhand, India
| | - Reshma Kaushik
- Department of Medicine, Himalayan Institute of Medical Sciences, Swami Rama Himalayan University, Dehradun, Uttarakhand, India
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Odedra A, Webb L, Marquart L, Britton LJ, Chalon S, Moehrle JJ, Anstey NM, William T, Grigg MJ, Lalloo DG, Barber BE, McCarthy JS. Liver Function Test Abnormalities in Experimental and Clinical Plasmodium vivax Infection. Am J Trop Med Hyg 2020; 103:1910-1917. [PMID: 32815508 PMCID: PMC7646782 DOI: 10.4269/ajtmh.20-0491] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Liver transaminase elevations after treatment in malaria volunteer infection studies (VISs) have raised safety concerns. We investigated transaminase elevations from two human Plasmodium vivax VISs where subjects were treated with chloroquine (n = 24) or artefenomel (n = 8) and compared them with studies in Thailand (n = 41) and Malaysia (n = 76). In the VISs, alanine transaminase (ALT) increased to ≥ 2.5 × upper limit of normal (ULN) in 11/32 (34%) volunteers, peaking 5–8 days post-treatment. Transaminase elevations were asymptomatic, were not associated with elevated bilirubin, and resolved by day 42. The risk of an ALT ≥ 2.5 × ULN increased more than 4-fold (odds ratio [OR] 4.28; 95% CI: 1.26–14.59; P = 0.02) for every log10 increase in the parasite clearance burden (PCB), defined as the log-fold reduction in parasitemia 24 hours post-treatment. Although an elevated ALT ≥ 2.5 × ULN was more common after artefenomel than after chloroquine (5/8 [63%] versus 6/24 [25%]; OR 5.0; 95% CI: 0.91–27.47; P = 0.06), this risk disappeared when corrected for PCB. Peak ALT also correlated with peak C-reactive protein (R = 0.44; P = 0.012). Elevations in ALT (≥ 2.5 × ULN) were less common in malaria-endemic settings, occurring in 1/41 (2.5%) Thai patients treated with artefenomel, and in none of 76 Malaysians treated with chloroquine or artemisinin combination therapy. Post-treatment transaminase elevations are common in experimental P. vivax infection but do not appear to impact on participant safety. Although the mechanism of these changes remains uncertain, host inflammatory response to parasite clearance may be contributory.
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Affiliation(s)
- Anand Odedra
- QIMR Berghofer Medical Research Institute, Brisbane, Australia.,Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Lachlan Webb
- QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | - Louise Marquart
- QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | - Laurence J Britton
- School of Medicine, The University of Queensland, Brisbane, Australia.,Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Australia
| | | | | | - Nicholas M Anstey
- Global and Tropical Health Division, Menzies School of Health Research, Darwin, Australia
| | - Timothy William
- Gleneagles Hospital, Kota Kinabalu, Malaysia.,Clinical Research Centre, Queen Elizabeth Hospital, Kota Kinabalu, Malaysia
| | - Matthew J Grigg
- Global and Tropical Health Division, Menzies School of Health Research, Darwin, Australia
| | - David G Lalloo
- Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Bridget E Barber
- Global and Tropical Health Division, Menzies School of Health Research, Darwin, Australia.,QIMR Berghofer Medical Research Institute, Brisbane, Australia
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Watson JA, Holmes CC. Graphing and reporting heterogeneous treatment effects through reference classes. Trials 2020; 21:386. [PMID: 32381030 PMCID: PMC7204233 DOI: 10.1186/s13063-020-04306-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Accepted: 04/02/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Exploration and modelling of heterogeneous treatment effects as a function of baseline covariates is an important aspect of precision medicine in randomised controlled trials (RCTs). Randomisation generally guarantees the internal validity of an RCT, but heterogeneity in treatment effect can reduce external validity. Estimation of heterogeneous treatment effects is usually done via a predictive model for individual outcomes, where one searches for interactions between treatment allocation and important patient baseline covariates. However, such models are prone to overfitting and multiple testing and typically demand a transformation of the outcome measurement, for example, from the absolute risk in the original RCT to log-odds of risk in the predictive model. METHODS We show how reference classes derived from baseline covariates can be used to explore heterogeneous treatment effects via a two-stage approach. We first estimate a risk score which captures on a single dimension some of the heterogeneity in outcomes of the trial population. Heterogeneity in the treatment effect can then be explored via reweighting schemes along this axis of variation. This two-stage approach bypasses the search for interactions with multiple covariates, thus protecting against multiple testing. It also allows for exploration of heterogeneous treatment effects on the original outcome scale of the RCT. This approach would typically be applied to multivariable models of baseline risk to assess the stability of average treatment effects with respect to the distribution of risk in the population studied. CASE STUDY We illustrate this approach using the single largest randomised treatment trial in severe falciparum malaria and demonstrate how the estimated treatment effect in terms of absolute mortality risk reduction increases considerably in higher risk strata. CONCLUSIONS 'Local' and 'tilting' reweighting schemes based on ranking patients by baseline risk can be used as a general approach for exploring, graphing and reporting heterogeneity of treatment effect in RCTs. TRIAL REGISTRATION ISRCTN clinical trials registry: ISRCTN50258054. Prospectively registered on 22 July 2005.
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Affiliation(s)
- James A Watson
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400, Thailand.
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Chris C Holmes
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
- Department of Statistics, University of Oxford, Oxford, UK.
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Frosch AEP. Artesunate Versus Quinine: Keeping Our Options Open. Clin Infect Dis 2020; 70:288-289. [PMID: 31044240 DOI: 10.1093/cid/ciz335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 04/27/2019] [Indexed: 11/14/2022] Open
Affiliation(s)
- Anne E P Frosch
- Hennepin Healthcare Research Institute, Minneapolis.,University of Minnesota, Minneapolis
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Sikora SA, Poespoprodjo JR, Kenangalem E, Lampah DA, Sugiarto P, Laksono IS, Ahmad RA, Murhandarwati EEH. Intravenous artesunate plus oral dihydroartemisinin-piperaquine or intravenous quinine plus oral quinine for optimum treatment of severe malaria: lesson learnt from a field hospital in Timika, Papua, Indonesia. Malar J 2019; 18:448. [PMID: 31888655 PMCID: PMC6937738 DOI: 10.1186/s12936-019-3085-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 12/21/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Intravenous artesunate and its follow on full course dihydroartemisinin-piperaquine are the standard treatment for severe malaria in Indonesia. The current policy suggests that intravenous and oral quinine could be used when standard therapy is not available. Its pragmatic use of both treatment combinations in a field hospital is evaluated. METHODS A retrospective study among hospitalized malaria patients receiving intravenous anti-malarial treatments at Mitra Masyarakat Hospital, Timika from April 2004 to December 2013 was conducted. The length of hospital stay (LoS) and the risk of malaria recurrence within 28 days after hospital admission were compared between patients receiving intravenous artesunate and oral dihydroartemisinin-piperaquine (Iv Art + DHP) and those receiving intravenous and oral quinine (Iv + Oral Qu). RESULTS Of 10,514 patients requiring intravenous therapy, 2759 received Iv + Oral Qu and 7755 received Iv Art + DHP. Plasmodium falciparum infection accounted for 65.8% (6915), while Plasmodium vivax, Mixed infections, Plasmodium malariae and Plasmodium ovale were accounted for 17.0% (1789), 16.4% (1729), 0.8% (79) and 0.01% (2) of the infections, respectively. The majority of severe malaria hospital admissions were highland Papuans (78.0%, 8201/10,501). In total 49% (5158) of patients were older than 15 years and 3463 (32.9%) were children under 5 years old. The median LoS was shorter in patients receiving intravenous artesunate compared to those treated with intravenous quinine (median = 2 [IQR 1-3] versus 3 days [IQR 2-4], p < 0.0001). Patients treated with intravenous quinine had higher risk of being hospitalized longer than 2 days (aOR of 1.70 [95% CI 1.54-1.88], p < 0.0001). The risk of recurrences within 28 days after hospital admission was 1.94 times higher (95% CI aHR 1.57-2.39, p < 0.0001) in patients receiving intravenous quinine with follow on oral quinine treatment than in patients treated with DHP after intravenous artesunate therapy. CONCLUSIONS Intravenous artesunate reduced the LoS of malaria patients and in combination with DHP reduced the risk of malaria recurrence within 28 days after hospital admission compared to those with Iv + Oral Qu treatment. Thus, ensuring continuous supply of intravenous artesunate and artemisinin-based combination therapy (ACT) should be a priority.
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Affiliation(s)
- Silvester Alexandro Sikora
- Postgraduate Programme of Tropical Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Jeanne Rini Poespoprodjo
- Department of Paediatrics, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia.
- Timika Malaria Research Programme, Papuan Health and Community Development Foundation, Timika, Papua, Indonesia.
- Mimika District Hospital, Timika, Papua, Indonesia.
| | - Enny Kenangalem
- Timika Malaria Research Programme, Papuan Health and Community Development Foundation, Timika, Papua, Indonesia
| | - Daniel A Lampah
- Timika Malaria Research Programme, Papuan Health and Community Development Foundation, Timika, Papua, Indonesia
| | | | - Ida Safitri Laksono
- Postgraduate Programme of Tropical Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
- Department of Paediatrics, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
- Center for Tropical Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - Riris Andono Ahmad
- Center for Tropical Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
- Dept. of Epidemiology, Biostatistics and Population Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
| | - E Elsa Herdiana Murhandarwati
- Postgraduate Programme of Tropical Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia.
- Center for Tropical Medicine, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia.
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Leopold SJ, Watson JA, Jeeyapant A, Simpson JA, Phu NH, Hien TT, Day NPJ, Dondorp AM, White NJ. Investigating causal pathways in severe falciparum malaria: A pooled retrospective analysis of clinical studies. PLoS Med 2019; 16:e1002858. [PMID: 31442221 PMCID: PMC6707545 DOI: 10.1371/journal.pmed.1002858] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 07/25/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Severe falciparum malaria is a medical emergency characterised by potentially lethal vital organ dysfunction. Patient fatality rates even with parenteral artesunate treatment remain high. Despite considerable research into adjuvant therapies targeting organ and tissue dysfunction, none have shown efficacy apart from renal replacement therapy. Understanding the causal contributions of clinical and laboratory abnormalities to mortality is essential for the design and evaluation of novel therapeutic interventions. METHODS AND FINDINGS We used a structural model causal inference approach to investigate causal relationships between epidemiological, laboratory, and clinical variables in patients with severe falciparum malaria enrolled in clinical trials and their in-hospital mortality. Under this causal model, we analysed records from 9,040 hospitalised children (0-12 years, n = 5,635) and adults (n = 3,405, 12-87 years) with severe falciparum malaria from 15 countries in Africa and Asia who were studied prospectively over the past 35 years. On admission, patient covariates associated with increased in-hospital mortality were severity of acidosis (odds ratio [OR] 2.10 for a 7-mEq/L increase in base deficit [95% CI 1.93-2.28]), renal impairment (OR 1.71 for a 2-fold increase in blood urea nitrogen [95% CI 1.58, 1.86]), coma (OR 3.59 [95% CI 3.07-4.21]), seizures (OR 1.40 [95% CI 1.16-1.68]), shock (OR 1.51 [95% CI 1.14-1.99]), and presumed pulmonary oedema (OR 1.58 [95% CI 1.04-2.39]). Lower in-hospital mortality was associated with moderate anaemia (OR 0.87 for a decrease of 10 percentage points in haematocrit [95% CI 0.80-0.95]). Circulating parasite density was not associated with mortality (OR 1.02 for a 6-fold increase [95% CI 0.94-1.11]), so the pathological effects of parasitaemia appear to be mediated entirely by the downstream effects of sequestration. Treatment with an artemisinin derivative decreased mortality compared with quinine (OR 0.64 [95% CI 0.56-0.74]). These estimates were consistent across children and adults (mainly representing African and Asian patients, respectively). Using inverse probability weighting, transfusion was not estimated to be beneficial in children with admission haematocrit values between 15% and 25% (OR 0.99 [95% CI 0.97-1.02]). Except for the effects of artemisinin treatment and transfusion, causal interpretations of these estimates could be biased by unmeasured confounding from severe bacterial sepsis, immunity, and duration of illness. CONCLUSION These data suggest that moderate anaemia is associated with a reduced risk of death in severe falciparum malaria. This is possibly a direct causal association. The severe anaemia threshold criteria for a definition of severe falciparum malaria should be reconsidered.
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Affiliation(s)
- Stije J. Leopold
- 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
| | - James A. Watson
- 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
| | - Atthanee Jeeyapant
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Julie A. Simpson
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Nguyen H. Phu
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme, Ho Chi Minh City, Vietnam
| | - Tran T. Hien
- Oxford University Clinical Research Unit, Wellcome Trust Major Overseas Programme, Ho Chi Minh City, Vietnam
| | - 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
| | - Arjen M. Dondorp
- 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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Shah PJ, Koshy J, Everett N, Attia E. Severe Plasmodium falciparum Malaria Treated With Investigational Artesunate in the United States. J Pharm Pract 2018; 33:108-112. [PMID: 29898630 DOI: 10.1177/0897190018782367] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE We describe here the case of a 40-year-old Nigerian male with severe Plasmodium falciparum malaria successfully treated with investigational intravenous (IV) artesunate. SUMMARY A 40-year-old Nigerian male was admitted to the medical intensive care unit for the treatment of severe malaria. The patient presented with the classic malaria paroxysm and altered mental status and was in acute renal failure. A blood parasite, thick and thin smear was performed revealing positive ring forms on smear which are characteristic of Plasmodium falciparum, with an estimated parasitemia of 2%. Per the Centers for Disease Control and Prevention (CDC) guidelines, the recommended treatment for severe malaria is with IV quinidine, the only Food and Drug Administration (FDA)-approved medication available for the treatment of severe malaria in the United States. However, quinidine was not immediately available, including from surrounding hospitals. As a result, the infectious diseases physician and pharmacist decided to contact the CDC to initiate the process for obtaining IV artesunate, an investigational drug only available via a FDA-approved Investigational New Drug (IND) protocol. Artesunate was flown into Houston later that night, and this drug was administered successfully to the patient. Patient responded to treatment and was discharged from the hospital on day 4. CONCLUSION A patient with severe falciparum malaria was successfully treated with investigational artesunate procured from the CDC.
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Affiliation(s)
- Punit J Shah
- Department of Pharmacy, Houston Methodist Sugar Land Hospital, Sugar Land, TX, USA
| | - Janice Koshy
- Department of Infectious Diseases, Houston Methodist Sugar Land Hospital, Sugar Land, TX, USA
| | - Nichelle Everett
- Department of Pharmacy, Houston Methodist Hospital, Houston, TX, USA
| | - Engie Attia
- Department of Pharmacy, Houston Methodist Hospital, Houston, TX, USA
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Deeken JF, Wang H, Hartley M, Cheema AK, Smaglo B, Hwang JJ, He AR, Weiner LM, Marshall JL, Giaccone G, Liu S, Luecht J, Spiegel JY, Pishvaian MJ. A phase I study of intravenous artesunate in patients with advanced solid tumor malignancies. Cancer Chemother Pharmacol 2018; 81:587-596. [PMID: 29392450 DOI: 10.1007/s00280-018-3533-8] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 01/26/2018] [Indexed: 11/29/2022]
Abstract
PURPOSE The artemisinin class of anti-malarial drugs has shown significant anti-cancer activity in pre-clinical models. Proposed anti-cancer mechanisms include DNA damage, inhibition of angiogenesis, TRAIL-mediated apoptosis, and inhibition of signaling pathways. We performed a phase I study to determine the maximum tolerated dose (MTD) and dose-limiting toxicities (DLTs) of intravenous artesunate (IV AS). METHODS Patients were enrolled in an accelerated titration dose escalation study with planned dose levels of 8, 12, 18, 25, 34 and 45 mg/kg given on days 1 and 8 of a 21-day cycle. Toxicities were assessed using the NCI CTCAE (ver. 4.0), and response was assessed using RECIST criteria (version 1.1). Pharmacokinetic (PK) studies were performed during cycle 1. RESULTS A total of 19 pts were enrolled, 18 of whom were evaluable for toxicity and 15 were evaluable for efficacy. DLTs were seen at dosages of 12 (1 of 6 patients), 18 (1 of 6) and 25 mg/kg (2 of 2), and were neutropenic fever (Gr 4), hypersensitivity reaction (Gr 3), liver function test abnormalities (Gr 3/4) along with neutropenic fever, and nausea/vomiting (Gr 3) despite supportive care. The MTD was determined to be 18 mg/kg. No responses were observed, while four patients had stable disease, including three with prolonged stable disease for 8, 10, and 11 cycles, for a disease control rate of 27%. PK parameters of AS and its active metabolite, dihydroartemisinin (DHA), correlated with dose. CONCLUSION The MTD of intravenous artesunate is 18 mg/kg on this schedule. Treatment was well tolerated. Modest clinical activity was seen in this pre-treated population. CLINICALTRIALS. GOV IDENTIFIER NCT02353026.
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Affiliation(s)
- John F Deeken
- Inova Schar Cancer Institute, Inova Health System, 3300 Gallows Road, Falls Church, VA, 22042, USA.
| | - Hongkun Wang
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
| | - Marion Hartley
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
| | - Amrita K Cheema
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
| | - Brandon Smaglo
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
| | - Jimmy J Hwang
- Levine Cancer Institute, Carolinas HealthCare System, Charlotte, NC, USA
| | - Aiwu Ruth He
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
| | - Louis M Weiner
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
| | - John L Marshall
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
| | - Giuseppe Giaccone
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
| | - Stephen Liu
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
| | - Jim Luecht
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
| | - Jay Y Spiegel
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
| | - Michael J Pishvaian
- Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, DC, USA
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Abstract
Following anti-malarial drug treatment asexual malaria parasite killing and clearance appear to be first order processes. Damaged malaria parasites in circulating erythrocytes are removed from the circulation mainly by the spleen. Splenic clearance functions increase markedly in acute malaria. Either the entire infected erythrocytes are removed because of their reduced deformability or increased antibody binding or, for the artemisinins which act on young ring stage parasites, splenic pitting of drug-damaged parasites is an important mechanism of clearance. The once-infected erythrocytes returned to the circulation have shortened survival. This contributes to post-artesunate haemolysis that may follow recovery in non-immune hyperparasitaemic patients. As the parasites mature Plasmodium vivax-infected erythrocytes become more deformable, whereas Plasmodium falciparum-infected erythrocytes become less deformable, but they escape splenic filtration by sequestering in venules and capillaries. Sequestered parasites are killed in situ by anti-malarial drugs and then disintegrate to be cleared by phagocytic leukocytes. After treatment with artemisinin derivatives some asexual parasites become temporarily dormant within their infected erythrocytes, and these may regrow after anti-malarial drug concentrations decline. Artemisinin resistance in P. falciparum reflects reduced ring stage susceptibility and manifests as slow parasite clearance. This is best assessed from the slope of the log-linear phase of parasitaemia reduction and is commonly measured as a parasite clearance half-life. Pharmacokinetic-pharmacodynamic modelling of anti-malarial drug effects on parasite clearance has proved useful in predicting therapeutic responses and in dose-optimization.
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Affiliation(s)
- Nicholas J White
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Road, Bangkok, 10400, Thailand.
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Anani WQ, Smith GP, Irani M, Puca KE. A report of cerebral malaria treated with automated red blood cell exchange. Transfusion 2017; 57:985-988. [DOI: 10.1111/trf.14013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 10/26/2016] [Accepted: 11/08/2016] [Indexed: 11/30/2022]
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Hawkes MT, Forgie S, Brophy J, Crockett M. Artesunate treatment of severe pediatric malaria: A review of parasite clearance kinetics and clinical implications. THE CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY = JOURNAL CANADIEN DES MALADIES INFECTIEUSES ET DE LA MICROBIOLOGIE MEDICALE 2015; 26:237-40. [PMID: 26600806 PMCID: PMC4644001 DOI: 10.1155/2015/736159] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Michael T Hawkes
- Department of Pediatrics, University of Alberta, Edmonton, Alberta
- School of Public Health, University of Alberta, Edmonton, Alberta
- Department of Medical Microbiology and Immunology, University of Alberta, Edmonton, Alberta
| | - Sarah Forgie
- Department of Pediatrics, University of Alberta, Edmonton, Alberta
| | - Jason Brophy
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, Ottawa, Ontario
| | - Maryanne Crockett
- Departments of Pediatrics and Child Health, Medical Microbiology and Community Health Sciences, University of Manitoba, Winnipeg, Manitoba
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Antiepileptic properties of Quinine: A systematic review. Ann Neurosci 2014; 19:14-20. [PMID: 25205956 PMCID: PMC4117066 DOI: 10.5214/ans.0972.7531.180404] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Revised: 01/31/2012] [Accepted: 02/07/2012] [Indexed: 11/28/2022] Open
Abstract
Background Quinine has anti-epileptic properties in animals. However, in humans this has not been systematically investigated. Purpose To examine the available research evidence on the effects of quinine on seizures in adults or children. Methods We searched online databases for published and unpublished studies in any language from January 1966 to March 2011. We considered randomized controlled trials (RCTs) evaluating the use of quinine in comparison to other drugs in humans with malaria or other conditions, and that reported the prevalence of seizures. Random effects meta-analysis was used to pool effect estimates in order to determine the effect of quinine on the prevalence of seizures. Results We identified six randomized controlled trials on severe malaria. Quinine was compared to the artemisinin derivatives in all trials. A total of 8,244 patients were included. In the meta-analysis, there was no significant effect of quinine on the prevalence of seizures when compared to the artemisinin derivatives (Odds ratio (OR) =0.90, 95% Confidence Interval (95%CI) =0.63-1.30). There was significant heterogeneity (I2=66%, Chi-square=17.44, p=0.008). Subgroup analysis showed that quinine significantly reduced seizures when compared to artemether (OR = 0.66, 95%CI = 0.49-0.88) but when compared to artesunate, prevalence of seizures increased significantly (OR = 1.24, 95%CI = 1.05-1.47). Conclusion There is no sufficient evidence to conclude that quinine has any antiepileptic properties in humans.
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Kyaw SS, Drake T, Ruangveerayuth R, Chierakul W, White NJ, Newton PN, Lubell Y. Cost of treating inpatient falciparum malaria on the Thai-Myanmar border. Malar J 2014; 13:416. [PMID: 25351915 PMCID: PMC4218997 DOI: 10.1186/1475-2875-13-416] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2014] [Accepted: 10/09/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite demonstrated benefits and World Health Organization (WHO) endorsement, parenteral artesunate is the recommended treatment for patients with severe Plasmodium falciparum malaria in only one fifth of endemic countries. One possible reason for this slow uptake is that a treatment course of parenteral artesunate is costlier than quinine and might, therefore, pose a substantial economic burden to health care systems. This analysis presents a detailed account of the resources used in treating falciparum malaria by either parenteral artesunate or quinine in a hospital on the Thai-Myanmar border. METHODS The analysis used data from four studies, with random allocation of inpatients with falciparum malaria to treatment with parenteral artesunate or quinine, conducted in Mae Sot Hospital, Thailand from 1995 to 2001. Detailed resource use data were collected during admission and unit costs from the 2008 hospital price list were applied to these. Total admission costs were broken down into five categories: 1) medication; 2) intravenous fluids; 3) disposables; 4) laboratory tests; and 5) services. RESULTS While the medication costs were higher for patients treated with artesunate, total admission costs were similar in those treated with quinine, US$ 243 (95% CI: 167.5-349.7) and in those treated with artesunate US$ 190 (95% CI: 131.0-263.2) (P=0.375). For cases classified as severe malaria (59%), the total cost of admission was US$ 298 (95% CI: 203.6-438.7) in the quinine group as compared with US$ 284 (95% CI: 181.3-407) in the artesunate group (P=0.869). CONCLUSION This analysis finds no evidence for a difference in total admission costs for malaria inpatients treated with artesunate as compared with quinine. Assuming this is generalizable to other settings, the higher cost of a course of artesunate should not be considered a barrier for its implementation in the treatment of malaria.
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Affiliation(s)
- Shwe Sin Kyaw
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
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Traitement du paludisme grave et du paludisme non compliqué à P. falciparum chez l’enfant en France. Arch Pediatr 2013; 20:1260-1264. [DOI: 10.1016/j.arcped.2013.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Revised: 08/02/2013] [Accepted: 08/26/2013] [Indexed: 11/22/2022]
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Newton PN, Stepniewska K, Dondorp A, Silamut K, Chierakul W, Krishna S, Davis TME, Suputtamongkol Y, Angus B, Pukrittayakamee S, Ruangveerayuth R, Hanson J, Day NPJ, White NJ. Prognostic indicators in adults hospitalized with falciparum malaria in Western Thailand. Malar J 2013; 12:229. [PMID: 23829311 PMCID: PMC3711784 DOI: 10.1186/1475-2875-12-229] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2013] [Accepted: 06/23/2013] [Indexed: 11/17/2022] Open
Abstract
Background Severe malaria remains a major cause of death and morbidity amongst adults in the Asiatic tropics. Methods A retrospective analysis of the clinical and laboratory data of 988 adult patients, hospitalized with Plasmodium falciparum malaria and prospectively recruited to malaria studies in western Thailand between 1986 and 2002, was performed to assess the factors associated with a fatal outcome. Different severity scores and classifications for defining severe malaria were compared and, using multiple logistic regression, simple models for predicting mortality developed. Results The proportion of patients fulfilling the WHO 2000 definition of severe malaria was 78.1%, and their mortality was 10%. Mortality in patients given parenteral artesunate or artemether (16/317, 5%) was lower than in those given parenteral quinine (59/442, 13%) (P < 0.001). Models using parameter sets based on WHO 1990, 2000 and Adapted AQ criteria plus blood smear parasite-stage assessment gave the best mortality prediction. A malaria prognostic index (MPI), derived from the dataset using five clinical or laboratory variables gave similar prognostic accuracy. Conclusions The mortality of severe malaria in adults has fallen and the switch from quinine to artesunate has probably been an important contributor. Prognostic indices based on WHO 2000 definitions, and other simpler indices based on fewer variables, provide clinically useful predictions of outcome in Asian adults with severe malaria.
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Affiliation(s)
- Paul N Newton
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao PDR.
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Eder M, Farne H, Cargill T, Abbara A, Davidson RN. Intravenous artesunate versus intravenous quinine in the treatment of severe falciparum malaria: a retrospective evaluation from a UK centre. Pathog Glob Health 2013; 106:181-7. [PMID: 23265377 DOI: 10.1179/2047773212y.0000000032] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
INTRODUCTION Despite evidence from developing world trials that intravenous (IV) artesunate (AS) is superior to IV quinine (Q) in severe falciparum malaria (FM), IV AS remains unlicensed in the UK with national guidelines listing it as an acceptable alternative to IV Q as the drug of choice. We retrospectively evaluate the safety and effectiveness of IV AS in returning travellers with severe FM. METHODS We identified adults admitted to the Infectious Diseases unit with severe FM and treated with IV Q (1991-2009) or IV AS (2009-2011). Outcomes included adverse events, mortality, length of stay, admission to intensive care and, where data were available, parasite/fever clearance time and hypoglycaemic events. RESULTS Of 167 patients, 24 received IV AS and 143 IV Q. There was one potential AS-associated adverse event, a case of late onset haemolysis. Median length of stay (LOS) was significantly shorter for AS (3·5 versus 5 days, P = 0·017), even after adjusting for African ethnicity (for LOS ≥3 days, mhor = 0·33, P = 0·027; crude OR = 0·29, P = 0·013). In the AS group, there were no fatalities (versus five in Q group, NS) and fewer intensive care unit (ICU) admissions (NS). Median parasite clearance was significantly faster in AS (65 versus 85 hours in Q, P = 0·0045) with no hypoglycaemic episodes (versus five in Q). DISCUSSION We found IV AS to be safe and effective, with shorter LOS, faster parasite and fever clearance, no fatalities or hypoglycaemic events, and fewer ICU admissions versus IV Q. This corroborates both developing world trials and smaller European case series (although these lacked comparison groups). As well as obvious benefits for patients, there are potential resource savings. A case of late-onset haemolysis may represent an adverse event, particularly as it has been documented elsewhere, warranting further investigation. Nonetheless, our experience suggests IV AS should be first-line for treating severe FM in the UK.
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Affiliation(s)
- Marcus Eder
- Department of Infection and Tropical Medicine, Lister Unit, Northwick Park Hospital, Harrow, UK
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Abstract
Malaria continues to affect public health and economic growth in many regions of the world. The number of infections continues to rise and is associated with increased mortality, despite basic science and public health efforts. Drug therapy remains the mainstay of treatment and prevention of this disease. Plasmodium has a complex life cycle involving an arthropod vector and distinct stages within the human host. Each parasite stage plays a unique role in transmission, disease, and latency. These different stages may vary in their response to the various antimalarial compounds. This article will review antimalarial therapies and drug resistance in the context of the parasites' biology.
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Affiliation(s)
- Johanna P Daily
- Brigham and Women's Hospital, Infectious Disease, 75 Francis Street, Boston, MA 02115, USA
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Taylor WRJ, Hanson J, Turner GDH, White NJ, Dondorp AM. Respiratory manifestations of malaria. Chest 2012; 142:492-505. [PMID: 22871759 DOI: 10.1378/chest.11-2655] [Citation(s) in RCA: 169] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Respiratory distress develops in up to 25% of adults and 40% of children with severe falciparum malaria. Its diverse causes include respiratory compensation of metabolic acidosis, noncardiogenic pulmonary edema, concomitant pneumonia, and severe anemia. Patients with severe falciparum, vivax, and knowlesi malaria may develop acute lung injury (ALI) and ARDS, often several days after antimalarial drug treatment. ARDS rates, best characterized for severe Plasmodium falciparum, are 5% to 25% in adults and up to 29% in pregnant women; ARDS is rare in young children. ARDS pathophysiology centers on inflammatory-mediated increased capillary permeability or endothelial damage leading to diffuse alveolar damage that can continue after parasite clearance. The role of parasite sequestration in the pulmonary microvasculature is unclear, because sequestration occurs intensely in P falciparum, less so in P knowlesi, and has not been shown convincingly in P vivax. Because early markers of ALI/ARDS are lacking, fluid resuscitation in severe malaria should follow the old adage to "keep them dry." Bacteremia and hospital-acquired pneumonia can complicate severe malaria and may contribute to ALI/ARDS. Mechanical ventilation can save life in ALI/ARDS. Basic critical care facilities are increasingly available in tropical countries. The use of lung-protective ventilation has helped to reduce mortality from malaria-induced ALI/ARDS, but permissive hypercapnia in unconscious patients is not recommended because increased intracranial pressure and cerebral swelling may occur in cerebral malaria. The best antimalarial treatment of severe malaria is IV artesunate.
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Affiliation(s)
- Walter R J Taylor
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine, Nuffield Department of Medicine, Oxford University, The Churchill Hospital, Headington, England; Service de la Médicine Internationale et Humanitaire, Hôpitaux Universitaires de Genève, Geneva, Switzerland.
| | - Josh Hanson
- Cairns Base Hospital, Cairns, QLD, Australia
| | - Gareth D H Turner
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine, Nuffield Department of Medicine, Oxford University, The Churchill Hospital, Headington, England
| | - Nicholas J White
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine, Nuffield Department of Medicine, Oxford University, The Churchill Hospital, Headington, England
| | - Arjen M Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine, Nuffield Department of Medicine, Oxford University, The Churchill Hospital, Headington, England
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Yoshimura Y, Tachikawa N, Oosawa T, Kosuge Y, Kamei K. [A case of paracoccidioidomycosis with severe adrenal insufficiency]. ACTA ACUST UNITED AC 2012; 86:291-4. [PMID: 22746052 DOI: 10.11150/kansenshogakuzasshi.86.291] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Paracoccidioidomycosis (PCM) is the most common systemic fungal disease in central-south America, but is rare in Japan. We experiensed a case of PCM in a patient, who came from Bolivia and presented with mouth pain and reduced dietary intake but no fever. Adrenal insufficiency was diagnosed with extremely high serum adrenocorticotropic hormone (ACTH) and was resolved with hormone supplementation. The PCM was treated with trimethoprim-sulfamethoxazole which was switched to itraconazole and improvement was achieved.
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Abstract
BACKGROUND Severe malaria results in over a million deaths every year, most of them in children aged under five years and living in sub-Saharan Africa. This review examines whether treatment with artesunate, instead of the standard treatment quinine, would result in fewer deaths and better treatment outcomes. OBJECTIVES To compare artesunate with quinine for treating severe malaria. SEARCH METHODS We searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library), MEDLINE, EMBASE, LILACS, ISI Web of Science, the metaRegister of Controlled trials (mRCT), conference proceedings, and reference lists of articles to November 2010. SELECTION CRITERIA Randomized controlled trials comparing intravenous, intramuscular, or rectal artesunate with intravenous or intramuscular quinine for treating adults and children with severe malaria who are unable to take medication by mouth. DATA COLLECTION AND ANALYSIS Two authors independently assessed the eligibility and risk of bias of trials, and extracted and analysed data. The primary outcome was all-cause death. Dichotomous outcomes were summarized using risk ratios (RR) and continuous outcomes by mean differences (MD). Where appropriate, we combined data in meta-analyses. MAIN RESULTS Eight trials enrolling 1664 adults and 5765 children are included in this review.Treatment with artesunate significantly reduced the risk of death both in adults (RR 0.61, 95% Confidence Interval (CI) 0.50 to 0.75; 1664 participants, five trials) and children (RR 0.76, 95% CI 0.65 to 0.90; 5765 participants, four trials)In children, treatment with artesunate increased the incidence of neurological sequelae at the time of hospital discharge. The majority of these sequelae were transient and no significant difference between treatments was seen at later follow up. AUTHORS' CONCLUSIONS The evidence clearly supports the superiority of parenteral artesunate over quinine for the treatment of severe malaria in both adults and children and in different regions of the world.
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Affiliation(s)
- David Sinclair
- International Health Group, Liverpool School of Tropical Medicine, Liverpool,
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von Seidlein L, Olaosebikan R, Hendriksen ICE, Lee SJ, Adedoyin OT, Agbenyega T, Nguah SB, Bojang K, Deen JL, Evans J, Fanello CI, Gomes E, Pedro AJ, Kahabuka C, Karema C, Kivaya E, Maitland K, Mokuolu OA, Mtove G, Mwanga-Amumpaire J, Nadjm B, Nansumba M, Ngum WP, Onyamboko MA, Reyburn H, Sakulthaew T, Silamut K, Tshefu AK, Umulisa N, Gesase S, Day NPJ, White NJ, Dondorp AM. Predicting the clinical outcome of severe falciparum malaria in african children: findings from a large randomized trial. Clin Infect Dis 2012; 54:1080-90. [PMID: 22412067 PMCID: PMC3309889 DOI: 10.1093/cid/cis034] [Citation(s) in RCA: 129] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Four predictors were independently associated with an increased risk of death: acidosis, cerebral manifestations of malaria, elevated blood urea nitrogen, or signs of chronic illness. The standard base deficit was found to be the single most relevant predictor of death. Background. Data from the largest randomized, controlled trial for the treatment of children hospitalized with severe malaria were used to identify such predictors of a poor outcome from severe malaria. Methods. African children (<15 years) with severe malaria participated in a randomized comparison of parenteral artesunate and parenteral quinine in 9 African countries. Detailed clinical assessment was performed on admission. Parasite densities were assessed in a reference laboratory. Predictors of death were examined using a multivariate logistic regression model. Results. Twenty indicators of disease severity were assessed, out of which 5 (base deficit, impaired consciousness, convulsions, elevated blood urea, and underlying chronic illness) were associated independently with death. Tachypnea, respiratory distress, deep breathing, shock, prostration, low pH, hyperparasitemia, severe anemia, and jaundice were statistically significant indicators of death in the univariate analysis but not in the multivariate model. Age, glucose levels, axillary temperature, parasite density, heart rate, blood pressure, and blackwater fever were not related to death in univariate models. Conclusions. Acidosis, cerebral involvement, renal impairment, and chronic illness are key independent predictors for a poor outcome in African children with severe malaria. Mortality is markedly increased in cerebral malaria combined with acidosis. Clinical Trial Registration. ISRCTN50258054.
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Affiliation(s)
- Lorenz von Seidlein
- Department of Global Health, Menzies School of Health Research, Casuarina, Northern Territory, Australia.
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Broderick C, Friend P, Smith V, Blaze M, Gothard P, Chiodini PL, Whitty CJM. Geographical concentration of falciparum malaria treated in the UK and delay to treatment with artesunate in severe cases: an observational study. BMJ Open 2012; 2:bmjopen-2012-001854. [PMID: 23148346 PMCID: PMC3533059 DOI: 10.1136/bmjopen-2012-001854] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES To quantify geographical concentration of falciparum malaria cases in the UK at a hospital level. To assess potential delay-to-treatment associated with hub-and-spoke distribution of artesunate in severe cases. DESIGN Observational study using national and hospital data. SETTING AND PARTICIPANTS 3520 patients notified to the Malaria Reference Laboratory 2008-2010, 34 patients treated with intravenous artesunate from a tropical diseases centre 2002-2010. MAIN OUTCOME MEASURES Geographical location of falciparum cases notified in the UK. Diagnosis-to-treatment times for intravenous artesunate. RESULTS Eight centres accounted for 43.9% of the UK's total cases; notifications from 107 centres accounted for 10.2% of cases; 51.5% of hospitals seeing malaria notified 5 or fewer cases in 3 years. Centres that saw <10 cases/year treat 26.3% of malaria cases; 6.1% of cases are treated in hospitals seeing <2 cases/year. Concentration of falciparum malaria was highest in Greater London (1925, 54.7%), South East (515, 14.6%), East of England (402, 11.4%) and North West (192, 5.4%). The North East and Northern Ireland each notified 5 or fewer cases per year. Median diagnosis-to-treatment time was 1 h (range 0.5-5) for patients receiving artesunate in the specialist centre; 7.5 h (range 4-26) for patients receiving it in referring hospitals via the hub-and-spoke system (p=0.02); 25 h (range 9-45) for patients receiving it on transfer to the regional centre from a referring hospital (p=0.002). CONCLUSIONS Most UK hospitals see few cases of falciparum malaria and geographical distances are significant. Over 25% of cases are seen in hospitals where malaria is rare, although 60% are seen in hospitals seeing over 50 cases over 3 years. A hub-and-spoke system minimises drug wastage and ensures availability in centres seeing most cases but is associated with treatment delays elsewhere. As with all observational studies, there are limitations, which are discussed.
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Affiliation(s)
| | - Philip Friend
- HPA Malaria Reference Laboratory, London School of Hygiene & Tropical Medicine, London, UK
| | - Valerie Smith
- HPA Malaria Reference Laboratory, London School of Hygiene & Tropical Medicine, London, UK
| | - Marie Blaze
- HPA Malaria Reference Laboratory, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Peter L Chiodini
- Hospital for Tropical Diseases, London, UK
- HPA Malaria Reference Laboratory, London School of Hygiene & Tropical Medicine, London, UK
| | - Christopher JM Whitty
- HPA Malaria Reference Laboratory, London School of Hygiene & Tropical Medicine, London, UK
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Zoller T, Junghanss T, Kapaun A, Gjorup I, Richter J, Hugo-Persson M, Mørch K, Foroutan B, Suttorp N, Yürek S, Flick H. Intravenous artesunate for severe malaria in travelers, Europe. Emerg Infect Dis 2011; 17:771-7. [PMID: 21529383 PMCID: PMC3321768 DOI: 10.3201/eid1705.101229] [Citation(s) in RCA: 101] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Multicenter trials in Southeast Asia have shown better survival rates among patients with severe malaria, particularly those with high parasitemia levels, treated with intravenous (IV) artesunate than among those treated with quinine. In Europe, quinine is still the primary treatment for severe malaria. We conducted a retrospective analysis for 25 travelers with severe malaria who returned from malaria-endemic regions and were treated at 7 centers in Europe. All patients survived. Treatment with IV artesunate rapidly reduced parasitemia levels. In 6 patients at 5 treatment centers, a self-limiting episode of unexplained hemolysis occurred after reduction of parasitemia levels. Five patients required a blood transfusion. Patients with posttreatment hemolysis had received higher doses of IV artesunate than patients without hemolysis. IV artesunate was an effective alternative to quinine for treatment of malaria patients in Europe. Patients should be monitored for signs of hemolysis, especially after parasitologic cure.
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31
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Abstract
BACKGROUND Severe malaria results in over a million deaths every year, most of them in children aged under five years and living in sub-Saharan Africa. This review examines whether treatment with artesunate, instead of the standard treatment quinine, would result in fewer deaths and better treatment outcomes. OBJECTIVES To compare artesunate with quinine for treating severe malaria. SEARCH STRATEGY We searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library), MEDLINE, EMBASE, LILACS, ISI Web of Science, the metaRegister of Controlled trials (mRCT), conference proceedings, and reference lists of articles to November 2010. SELECTION CRITERIA Randomized controlled trials comparing intravenous, intramuscular, or rectal artesunate with intravenous or intramuscular quinine for treating adults and children with severe malaria who are unable to take medication by mouth. DATA COLLECTION AND ANALYSIS Two authors independently assessed the eligibility and risk of bias of trials, and extracted and analysed data. The primary outcome was all-cause death. Dichotomous outcomes were summarized using risk ratios (RR) and continuous outcomes by mean differences (MD). Where appropriate, we combined data in meta-analyses. MAIN RESULTS Eight trials enrolling 1664 adults and 5765 children are included in this review.Treatment with artesunate significantly reduced the risk of death both in adults (RR 0.61, 95% Confidence Interval (CI) 0.50 to 0.75; 1664 participants, five trials) and children (RR 0.76, 95% CI 0.65 to 0.90; 5765 participants, four trials)In children, treatment with artesunate increased the incidence of neurological sequelae at the time of hospital discharge. The majority of these sequelae were transient and no significant difference between treatments was seen at later follow up. AUTHORS' CONCLUSIONS The evidence clearly supports the superiority of parenteral artesunate over quinine for the treatment of severe malaria in both adults and children and in different regions of the world.
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Affiliation(s)
- David Sinclair
- International Health Group, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK, L3 5QA
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Mwita C, Mwai L, Newton C. Antiepileptic properties of quinine: A systematic review. JBI LIBRARY OF SYSTEMATIC REVIEWS 2011; 9:1999-2022. [PMID: 27819948 DOI: 10.11124/01938924-201109480-00001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
EXECUTIVE SUMMARY Background: Quinine has been found to have anti-epileptic properties in animals. However, in humans this has not been systematically investigated. If quinine has antiepileptic properties in humans, it may reduce the neurological sequelae associated with acute seizures in severe malaria and promote its choice over other antimalarial drugs in treating severe falciparum malaria. OBJECTIVE The review objective was to examine available research evidence on the effects of quinine on seizures in adults or children who present with seizures or who develop seizures in the course of treatment. INCLUSION CRITERIA Participants: This review considered adult and child patients who were prescribed using quinine for malaria, arthritis, nocturnal leg cramps, arrhythmia and systemic lupus erythematosus. INTERVENTION This review evaluated the use of quinine in comparison to other drugs used for malaria, arthritis, nocturnal leg cramps, arrhythmia and systemic lupus erythematosus. OUTCOMES The primary outcome of interest for this review was the proportion of participants who had seizures after the administration of quinine, compared with those who were not given quinine.Types of Studies: This review considered randomised controlled trials. SEARCH STRATEGY We searched online databases for published and unpublished studies written in English and identified articles using predefined criteria.Methodological Quality: Papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review using standardized critical appraisal instruments from the Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument. DATA EXTRACTION/SYNTHESIS The data extracted included specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. A standardized data extraction tool was used. A random effects model was used to statistically pool data in meta-analysis, in order to determine the effect of quinine on prevalence of seizures in comparison to other drugs. RESULTS We identified six randomized controlled trials on severe malaria. Quinine was compared to the artemisinin derivatives in all trials. A total of 8,244 patients were included. In the meta-analysis, there was no significant effect of quinine on the prevalence of seizures (Odds ratio=0.90 95% Confidence Interval=0.63-1.30). There was significant heterogeneity (Chi-squared=17.44, p=0.008). DISCUSSION This is the first review on the antiepileptic effect of quinine in humans. However, this effect is not demonstrated in patients with malaria. A dose-response effect may be responsible for the absence of antiepileptic properties of quinine in humans. The results of the review are confounded by the fact that all the studies reviewed were conducted in patients with malaria, and quinine was only compared against artemisinin compounds which may have neurological effects. Further, incidence of seizures could not be assessed in this review. CONCLUSIONS There is not sufficient evidence to conclude that quinine has any antiepileptic properties. A dose-response effect may be responsible for the absence of antiepileptic properties of quinine in humans with severe malaria. IMPLICATIONS FOR PRACTICE This review provides data that may influence choice of antimalarial drugs in resource poor settings. IMPLICATIONS FOR RESEARCH This review identifies the need for further studies on the antiepileptic properties of quinine with sufficient power, designed to capture seizure prevalence and incidence as outcomes, that have the ability to control for confounders appropriately and that can explore the dose-response effect of quinine on seizures.
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Affiliation(s)
- Clifford Mwita
- 1. Centre for Geographic Medicine Research (Coast), Kenya Medical Research Institute (KEMRI)/ Wellcome Trust Research Programme 2. Joanna Briggs Institute Affiliate Center in Kenya 3. Neurosciences Unit, Institute of Child Health, University College London, United Kingdom 4. Departement of Psychiatry, University of Oxford, Oxford, United Kingdom
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Ogetii GN, Akech S, Jemutai J, Boga M, Kivaya E, Fegan G, Maitland K. Hypoglycaemia in severe malaria, clinical associations and relationship to quinine dosage. BMC Infect Dis 2010; 10:334. [PMID: 21092224 PMCID: PMC2995467 DOI: 10.1186/1471-2334-10-334] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2010] [Accepted: 11/22/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hypoglycaemia is an independent risk factor for death in severe malaria and a recognized adverse treatment effect of parenteral quinine. In 2006 our hospital changed quinine treatment policy from 15 mg/kg loading (plus 10 mg/kg 12-hourly) to 20 mg/kg loading (plus 10 mg/kg 8-hourly) to comply with new WHO guidelines. This presented us with the opportunity to examine whether there was any dose relationship of quinine and hypoglycaemia occurrence. METHODS Retrospective case notes review of all children admitted to hospital with severe falciparum malaria between April 2002 - July 2009, before and after the introduction of the new WHO quinine regimen. Four-hourly bedside glucose levels were measured until intravenous quinine was discontinued. Clinical events immediately preceding or concurrent with each episode of hypoglycaemia (glucose < = 3.0 mmol/l) were recorded. RESULTS 954 children received the old quinine regime and 283 received the new regime. We found no evidence of an increased prevalence of hypoglycaemia (< = 3.0 mmol/L) on the new regime compared to former (15% vs. 15%); similar findings were noted for profound hypoglycaemia (< 2.2 mmols/L) 8% v 5%, P = 0.07. Episodes were co-incident with disease severity markers: coma (57%), circulatory failure (38%) and respiratory distress (21%) but less commonly with seizures (10%). Disruption of maintenance fluids and/or blood transfusion concurred with 42% of the hypoglycaemia episodes. Post admission hypoglycaemia increased odds of fatal outcome (24%) compared to euglycaemic counterparts (8%), odds ratio = 3.45 (95% confidence interval = 2.30-5.16) P < 0.01. CONCLUSION There was no evidence to indicate a dose relationship between quinine and occurrence of hypoglycaemia. Hypoglycaemia concurred with severity features, disruption of glucose infusion and transfusion. Careful glucose monitoring should be targeted to these complications where resources are limited.
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Affiliation(s)
- Gilbert N Ogetii
- Centre for Geographic Medicine Research, Kenya Medical Research Institute- Wellcome Trust Programme, PO Box 230, Kilifi, Kenya
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Dondorp AM, Fanello CI, Hendriksen ICE, Gomes E, Seni A, Chhaganlal KD, Bojang K, Olaosebikan R, Anunobi N, Maitland K, Kivaya E, Agbenyega T, Nguah SB, Evans J, Gesase S, Kahabuka C, Mtove G, Nadjm B, Deen J, Mwanga-Amumpaire J, Nansumba M, Karema C, Umulisa N, Uwimana A, Mokuolu OA, Adedoyin OT, Johnson WBR, Tshefu AK, Onyamboko MA, Sakulthaew T, Ngum WP, Silamut K, Stepniewska K, Woodrow CJ, Bethell D, Wills B, Oneko M, Peto TE, von Seidlein L, Day NPJ, White NJ. Artesunate versus quinine in the treatment of severe falciparum malaria in African children (AQUAMAT): an open-label, randomised trial. Lancet 2010; 376:1647-57. [PMID: 21062666 PMCID: PMC3033534 DOI: 10.1016/s0140-6736(10)61924-1] [Citation(s) in RCA: 660] [Impact Index Per Article: 47.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Severe malaria is a major cause of childhood death and often the main reason for paediatric hospital admission in sub-Saharan Africa. Quinine is still the established treatment of choice, although evidence from Asia suggests that artesunate is associated with a lower mortality. We compared parenteral treatment with either artesunate or quinine in African children with severe malaria. METHODS This open-label, randomised trial was undertaken in 11 centres in nine African countries. Children (<15 years) with severe falciparum malaria were randomly assigned to parenteral artesunate or parenteral quinine. Randomisation was in blocks of 20, with study numbers corresponding to treatment allocations kept inside opaque sealed paper envelopes. The trial was open label at each site, and none of the investigators or trialists, apart from for the trial statistician, had access to the summaries of treatment allocations. The primary outcome measure was in-hospital mortality, analysed by intention to treat. This trial is registered, number ISRCTN50258054. FINDINGS 5425 children were enrolled; 2712 were assigned to artesunate and 2713 to quinine. All patients were analysed for the primary outcome. 230 (8·5%) patients assigned to artesunate treatment died compared with 297 (10·9%) assigned to quinine treatment (odds ratio [OR] stratified for study site 0·75, 95% CI 0·63-0·90; relative reduction 22·5%, 95% CI 8·1-36·9; p=0·0022). Incidence of neurological sequelae did not differ significantly between groups, but the development of coma (65/1832 [3·5%] with artesunate vs 91/1768 [5·1%] with quinine; OR 0·69 95% CI 0·49-0·95; p=0·0231), convulsions (224/2712 [8·3%] vs 273/2713 [10·1%]; OR 0·80, 0·66-0·97; p=0·0199), and deterioration of the coma score (166/2712 [6·1%] vs 208/2713 [7·7%]; OR 0·78, 0·64-0·97; p=0·0245) were all significantly less frequent in artesunate recipients than in quinine recipients. Post-treatment hypoglycaemia was also less frequent in patients assigned to artesunate than in those assigned to quinine (48/2712 [1·8%] vs 75/2713 [2·8%]; OR 0·63, 0·43-0·91; p=0·0134). Artesunate was well tolerated, with no serious drug-related adverse effects. INTERPRETATION Artesunate substantially reduces mortality in African children with severe malaria. These data, together with a meta-analysis of all trials comparing artesunate and quinine, strongly suggest that parenteral artesunate should replace quinine as the treatment of choice for severe falciparum malaria worldwide. FUNDING The Wellcome Trust.
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Affiliation(s)
- Arjen M Dondorp
- Mahidol Oxford Tropical MedicineResearch Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Caterina I Fanello
- Mahidol Oxford Tropical MedicineResearch Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Ilse CE Hendriksen
- Mahidol Oxford Tropical MedicineResearch Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | - Amir Seni
- Hospital Central da Beira, Beira, Mozambique
| | | | | | | | | | | | | | | | | | | | - Samwel Gesase
- Magunga District Hospital, NIMR-Korogwe Research Laboratory, Tanga, Tanzania
| | - Catherine Kahabuka
- Magunga District Hospital, NIMR-Korogwe Research Laboratory, Tanga, Tanzania
| | | | - Behzad Nadjm
- Teule Designated District Hospital, Muheza, Tanzania
| | | | | | - Margaret Nansumba
- Mbarara University of Science and Technology and Epicentre Research Base, Mbarara, Uganda
| | - Corine Karema
- Malaria Control Program, Ministry of Health, Kigali, Rwanda
| | - Noella Umulisa
- Malaria Control Program, Ministry of Health, Kigali, Rwanda
| | - Aline Uwimana
- Malaria Control Program, Ministry of Health, Kigali, Rwanda
| | | | | | | | - Antoinette K Tshefu
- Kinshasa School of Public Health—Kingasani Research Centre, Kinshasa, Democratic Republic of the Congo
| | - Marie A Onyamboko
- Kinshasa School of Public Health—Kingasani Research Centre, Kinshasa, Democratic Republic of the Congo
| | - Tharisara Sakulthaew
- Mahidol Oxford Tropical MedicineResearch Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Wirichada Pan Ngum
- Mahidol Oxford Tropical MedicineResearch Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Kamolrat Silamut
- Mahidol Oxford Tropical MedicineResearch Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Kasia Stepniewska
- Mahidol Oxford Tropical MedicineResearch Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Charles J Woodrow
- Mahidol Oxford Tropical MedicineResearch Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Delia Bethell
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Bridget Wills
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | - Tim E Peto
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | | | - Nicholas PJ Day
- Mahidol Oxford Tropical MedicineResearch Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Nicholas J White
- Mahidol Oxford Tropical MedicineResearch Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Correspondence to: Prof N J White, Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Road, Bangkok 10400, Thailand
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Eltahir HG, Omer AA, Mohamed AA, Adam I. Comparison of artesunate and quinine in the treatment of Sudanese children with severe Plasmodium falciparum malaria. Trans R Soc Trop Med Hyg 2010; 104:684-6. [DOI: 10.1016/j.trstmh.2010.05.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2009] [Revised: 05/26/2010] [Accepted: 05/26/2010] [Indexed: 11/26/2022] Open
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Genetic variations in ABCB1 and CYP3A5 as well as sex influence quinine disposition among Ugandans. Ther Drug Monit 2010; 32:346-52. [PMID: 20357698 DOI: 10.1097/ftd.0b013e3181da79d6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Quinine is one of the most effective antimalarial drugs, although its clinical use is limited as a result of its narrow safety margin. Quinine is a substrate of the polymorphic p-glycoprotein and CYP3A4/3A5. This study aimed to examine the effects of genetic variations in ABCB1 and CYP3A5 genes, sex, demographic, and biochemical variables (serum albumin, creatinine, alanine aminotransferase and albumin) on quinine disposition among Ugandans. Quinine (600 mg) was orally administered to 140 healthy volunteers. Quinine and its metabolite 3-hydroxyquinine concentrations were determined from 16-hour postdose plasma by high-performance liquid chromatography. CYP3A5 activity was measured using quinine/3-hydroxyquinine ratio (metabolic ratio). Genotyping for a total of 20 single nucleotide polymorphisms in ABCB1 (n = 13) and CYP3A5 (n = 7) was done using Taqman and minisequencing on microarray. There were 20.5- and 13-fold variations in body weight-adjusted plasma quinine concentrations (mean +/- standard deviation, 5.26 +/- 2.5 mumol/L; range, 0.88-18.10 mumol/L) and quinine-to-3-hydroxyquinine metabolic ratio (mean +/- standard deviation, 7.68 +/- 3.3 mumol/L; range, 1.66-22.3 mumol/L), respectively. Weight-adjusted plasma quinine concentration was significantly influenced by sex and ABCB1 haplotype. There was a significant sex difference in quinine metabolic ratio, women being faster metabolizers than men (P = 0.01). CYP3A5 genotype/haplotype significantly (P = 0.03) influenced quinine disposition with a clear CYP3A5*1 gene dose effect. The result confirms that quinine disposition is influenced mainly by sex as well as by ABCB1 and CYP3A5 genotypes. Despite being fast metabolizers, women display higher quinine bioavailability than men in Uganda. This may have clinical significance in determining an individual's susceptibility to quinine-associated adverse reactions such as cinchonism.
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Li Q, Weina P. Artesunate: The Best Drug in the Treatment of Severe and Complicated Malaria. Pharmaceuticals (Basel) 2010; 3:2322-2332. [PMID: 27713355 PMCID: PMC4036668 DOI: 10.3390/ph3072322] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2010] [Revised: 07/14/2010] [Accepted: 07/20/2010] [Indexed: 11/24/2022] Open
Abstract
This review summarizes progress in treating severe and complicated malaria, which are global problems, claiming at least one million lives annually, and have been accompanied by advances in our understanding of the pathogenesis of severe malaria complications. New drugs such as intravenous artesunate (AS) and intramuscular artemether (AM) are improving outcomes and decreasing malaria deaths. Trials comparing AM to the traditional parenteral drug, quinine, have not demonstrated however convincing evidence of a mortality advantage for AM. The South East Asian Quinine Artesunate Malaria Trials (SEAQUAMAT), a multicenter, randomized, open-label study comparing AS with quinine showed that parenteral AS was shown to be associated with a 35% reduction in the risk of mortality compare to quinine, and is now the recommended treatment by the WHO for severe and complicated malaria in low-transmission areas and in the second and third trimesters of pregnancy, with almost all the benefit reported in those with high parasite counts. Artesunate is a semisynthetic derivative of artemisinin whose water solubility facilitates absorption and provides an advantage over other artemisinins because it can be formulated as oral, rectal, intramuscular, and intravenous preparations. Artesunate is rapidly hydrolyzed to dihydroartemisinin, which is the most active schizonticidal metabolite. Injectable AS results in a more rapid systemic availability of AS compared with intramuscular AM. This pharmacokinetic advantage may provide a clinical advantage in the treatments of severe and complicated malaria.
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Affiliation(s)
- Qigui Li
- Department of Drug Discovery, Division of Experimental Therapeutics, Walter Reed Army Institute of Research, 503 Robert Grant Avenue, Silver Spring, MD 20910-7500, USA.
| | - Peter Weina
- Department of Drug Discovery, Division of Experimental Therapeutics, Walter Reed Army Institute of Research, 503 Robert Grant Avenue, Silver Spring, MD 20910-7500, USA.
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Hess KM, Goad JA, Arguin PM. Intravenous artesunate for the treatment of severe malaria. Ann Pharmacother 2010; 44:1250-8. [PMID: 20551300 DOI: 10.1345/aph.1m732] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To review the pharmacodynamics and pharmacotherapeutic use of intravenous artesunate for the treatment of severe malaria. DATA SOURCES Literature was retrieved through PubMed (1999-March 2010), MEDLINE (1996-March 2010), and the Centers for Disease Control and Prevention (CDC), using the search terms artemisinin, artesunate, malaria, and severe malaria. In addition, reference citations from publications identified were reviewed. STUDY SELECTION AND DATA EXTRACTION All articles in English that were identified from the data sources were reviewed. Focus was placed on postmarketing trials examining the safety and efficacy of artesunate in comparison with other regimens. DATA SYNTHESIS The treatment of severe malaria requires prompt, safe, and effective intravenous antimalarials. Many oral and intravenous agents are available worldwide for the treatment of malaria; however, quinidine has been the only option for parenteral therapy in the US. Furthermore, this product's lack of availability as well as its adverse safety profile have created a treatment option gap. Recently, intravenous artesunate was approved by the Food and Drug Administration (FDA) for investigational drug use and distribution by the CDC. Three major studies regarding the use of intravenous artesunate are reviewed, in addition to the World Health Organization's malaria treatment guidelines. While there are no published head-to-head trials of intravenous artesunate versus intravenous quinidine for severe malaria, several international studies comparing intravenous quinine and artesunate concluded that artesunate has the highest treatment success, with lower incidence of adverse events. In addition, other literature is reviewed regarding counterfeit and other issues associated with artesunate. CONCLUSIONS Artesunate, a new antimalarial currently available through the CDC, appears to be highly effective, better tolerated than quinidine, and not hampered by accessibility issues. If it were to be FDA approved and commercially available, it would be the preferred agent for the treatment of severe malaria in the US.
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Affiliation(s)
- Karl M Hess
- Department of Pharmacy Practice and Administration, College of Pharmacy, Western University of Health Sciences, Pomona, CA 91766, USA.
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Santoshkumar RJ, Manjunath S, Sharanabasappa MA. Prescription pattern of anti—malarial drugs in a tertiary care hospital. ASIAN PAC J TROP MED 2010. [DOI: 10.1016/s1995-7645(10)60092-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Treeprasertsuk S, Silachamroon U, Krudsood S, Huntrup A, Suwannakudt P, Vannaphan S, Wilairatana P. Ursodeoxycholic acid and artesunate in the treatment of severe falciparum malaria patients with jaundice. J Gastroenterol Hepatol 2010; 25:362-8. [PMID: 19817958 DOI: 10.1111/j.1440-1746.2009.06007.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIMS Plasmodium falciparum (PF) infection can lead to severe complications. Ursodeoxycholic acid (UDCA) is increasingly used for the treatment of cholestatic liver diseases. The present study aims to determine the effects of combined UDCA and artesunate compared to placebo and artesunate on the improvement of liver tests in severe PF jaundiced patients. METHODS All severe PF jaundiced patients, aged > or = 15 years and diagnosed as having severe malaria according to WHO 2000 criteria, were enrolled. Patients with evidence of biliary obstruction, other cholestatic liver diseases and those who were pregnant were excluded. Patients were randomized to receive either oral UDCA or placebo for 2 weeks in additional to artesunate. All patients were admitted for at least 14 days to monitor the result of the treatment. RESULTS Seventy-four severe PF malaria patients with jaundice were enrolled. Both groups had similar demographic and laboratory tests, with the exception being more males in the UDCA group than in the placebo group (P = 0.04). The median of percentage change of total bilirubin and aminotransferase levels at the end of weeks 1, 2, 3 and 4 showed no difference between the two groups. Only the median of percentage change of alkaline phosphatase at the end of week one compared with the baseline values showed less increment in the UDCA group than in the placebo group (P = 0.04). No serious adverse events were seen during the 4 weeks of follow up. CONCLUSIONS In severe PF malaria patients with jaundice, combined therapy with UDCA and artesunate is safe, but does not significantly improve liver tests compared to placebo and artesunate.
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Hartopo AB, Wijisaksono DP. A lethal case of Plasmodium falciparum infection in a young patient with end-stage renal failure who underwent regular hemodialysis. Intern Med 2010; 49:1867-70. [PMID: 20823647 DOI: 10.2169/internalmedicine.49.3888] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Acute renal failure associated with Plasmodium falciparum infection is already well recognized. Nevertheless, end-stage chronic renal failure and falciparum malaria comorbidity is a rare condition. We report a case of Plasmodium falciparum infection in a young male Javanese patient with end-stage chronic renal failure who underwent regular hemodialysis. This rare comorbidity led to rapid deterioration of consciousness and metabolic disturbances which had already existed in end-stage renal failure. Because of the immunosuppressive condition due to organ failure, the patient did not survive despite anti-malarial chemotherapy.
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Affiliation(s)
- Anggoro Budi Hartopo
- Department of Internal Medicine, Gadjah Mada University School of Medicine, Indonesia.
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Pongtavornpinyo W, Hastings IM, Dondorp A, White LJ, Maude RJ, Saralamba S, Day NP, White NJ, Boni MF. Probability of emergence of antimalarial resistance in different stages of the parasite life cycle. Evol Appl 2009; 2:52-61. [PMID: 20526409 PMCID: PMC2880443 DOI: 10.1111/j.1752-4571.2008.00067.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Understanding the evolution of drug resistance in malaria is a central area of study at the intersection of evolution and medicine. Antimalarial drug resistance is a major threat to malaria control and directly related to trends in malaria attributable mortality. Artemisinin combination therapies (ACT) are now recommended worldwide as first line treatment for uncomplicated malaria, and losing them to resistance would be a disaster for malaria control. Understanding the emergence and spread of antimalarial drug resistance in the context of different scenarios of antimalarial drug use is essential for the development of strategies protecting ACTs. In this study, we review the basic mechanisms of resistance emergence and describe several simple equations that can be used to estimate the probabilities of de novo resistance mutations at three stages of the parasite life cycle: sporozoite, hepatic merozoite and asexual blood stages; we discuss the factors that affect parasite survival in a single host in the context of different levels of antimalarial drug use, immunity and parasitaemia. We show that in the absence of drug effects, and despite very different parasite numbers, the probability of resistance emerging at each stage is very low and similar in all stages (for example per-infection probability of 10−10–10−9 if the per-parasite chance of mutation is 10−10 per asexual division). However, under the selective pressure provided by antimalarial treatment and particularly in the presence of hyperparasitaemia, the probability of resistance emerging in the blood stage of the parasite can be approximately five orders of magnitude higher than in the absence of drugs. Detailed models built upon these basic methods should allow us to assess the relative probabilities of resistance emergence in the different phases of the parasite life cycle.
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Affiliation(s)
- Wirichada Pongtavornpinyo
- Mahidol - Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
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Sousa M, Pozniak A, Boffito M. Pharmacokinetics and pharmacodynamics of drug interactions involving rifampicin, rifabutin and antimalarial drugs. J Antimicrob Chemother 2008; 62:872-8. [DOI: 10.1093/jac/dkn330] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Abstract
BACKGROUND Severe malaria kills over a million people every year. We sought evidence of superiority of artesunate compared with the standard treatment quinine. OBJECTIVES To compare artesunate with quinine for treating severe malaria. SEARCH STRATEGY We searched the Cochrane Infectious Diseases Group Specialized Register (January 2007), CENTRAL (The Cochrane Library 2006, Issue 4), MEDLINE (1966 to January 2007), EMBASE (1974 to January 2007), LILACS (1982 to January 2007), ISI Web of Science (1945 to January 2007), the metaRegister of Controlled trials (mRCT), conference proceedings, and reference lists of articles. We contacted researchers and the World Health Organization. SELECTION CRITERIA Randomized controlled trials comparing intravenous, intramuscular, or rectal artesunate with intravenous or intramuscular quinine for treating adults and children with severe malaria who are unable to take medication by mouth. DATA COLLECTION AND ANALYSIS Two authors assessed the eligibility and methodological quality of trials, extracted and analysed data, and drafted the review. The third author contributed to the design and writing of the review. Death was the primary outcome. Dichotomous outcomes were summarized using relative risks and continuous outcomes by mean differences. Where appropriate, we combined data in meta-analyses. Heterogeneity was investigated for the primary outcome using subgroup analyses. MAIN RESULTS Six trials enrolling 1938 participants (1664 adults and 274 children) met our inclusion criteria. All six trials were conducted in Asia, and only one small trial enrolled only children. Five trials used intravenous artesunate and one trial intramuscular artesunate; all six used intravenous quinine. Treatment with artesunate significantly reduced the risk of death (RR 0.62, 95% CI 0.51 to 0.75; 1938 participants, 6 trials), reduced parasite clearance time (WMD 8.14 h, 95% CI 11.55 to 4.73; 292 participants, 3 trials), and hypoglycaemia detected by routine monitoring (RR 0.46, 95% CI 0.25 to 0.87; 185 participants, 2 trials). There was no evidence of a difference in neurological sequelae, coma recovery time, time to hospital discharge, fever clearance time, or adverse effects other than hypoglycaemia. AUTHORS' CONCLUSIONS Intravenous artesunate is the drug of choice for adults with severe malaria, particularly if acquired in Asia. This review did not identify sufficient data to make firm conclusions about the treatment of children or the effectiveness of intramuscular artesunate. There is an urgent need to compare the effects of artesunate with quinine in African children with severe malaria. The applicability of these results to Asian children and the ethics of further research are points of debate.
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Affiliation(s)
- K L Jones
- Liverpool School of Tropical Medicine, International Health Group, Pembroke Place, Liverpool, Merseyside, UK, L3 5QA.
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Mehta U, Durrheim DN, Blumberg L, Donohue S, Hansford F, Mabuza A, Kruger P, Gumede JK, Immelman E, Sánchez Canal A, Hugo JJ, Swart G, Barnes KI. Malaria deaths as sentinel events to monitor healthcare delivery and antimalarial drug safety. Trop Med Int Health 2007; 12:617-28. [PMID: 17445129 DOI: 10.1111/j.1365-3156.2007.01823.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To identify case management, health system and antimalarial drug factors contributing to malaria deaths. METHOD We investigated malaria-related deaths in South Africa's three malaria endemic provinces from January 2002 to July 2004. Data from healthcare facility records and a semi-structured interview with patients' contacts were reviewed by an expert panel, which sought to reach consensus on factors contributing to the death. This included possible health system failures, adverse reactions to antimalarials, inappropriate medicine use and failing to respond to treatment. RESULTS Approximately 177 of 197 cases met inclusion criteria for the study. Delay in seeking formal health care was significantly longer for patients who sought traditional health care [median 4; inter-quartile range (IQR) 3-7 days] than for patients who did not (median 3; IQR 1-5 days; P = 0.033). Patients with confirmed or suspected HIV/AIDS were significantly more likely to use traditional approaches (25%) than those with other comorbidities (0%; P = 0.002). Malaria was neither suspected nor tested for at a primary care facility in 23% of cases with adequate records. Initial hospital assessment was considered inadequate in 74% of cases admitted to hospital and in-patient monitoring and management was adequate in only 27%. There were 32 suspected adverse reactions to antimalarial therapy. CONCLUSION A confidential enquiry into malaria-related deaths is a useful tool for identifying preventable factors, health system failures and adverse events affecting malaria case management.
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Affiliation(s)
- U Mehta
- Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa.
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Checkley AM, Whitty CJM. Artesunate, artemether or quinine in severe Plasmodium falciparum malaria? Expert Rev Anti Infect Ther 2007; 5:199-204. [PMID: 17402835 DOI: 10.1586/14787210.5.2.199] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Quinine and the artemisinin-derivative drugs artesunate and artemether are effective treatments for severe falciparum malaria. Trials comparing artemether with quinine have not demonstrated convincing evidence of a mortality advantage for artemether. The South East Asian Quinine Artesunate Malaria Trial (SEAQUAMAT), a multicenter, randomized, open-label trial in 1461 adults with severe malaria in Asia compared artesunate with quinine. Mortality was 15% in the artesunate group and 22% in the quinine group, a reduction of 34.7% (95% confidence interval: 18.5-47.6%) in the artesunate group, with almost all the benefit reported in those with high parasite counts. Artesunate should constitute first-line treatment for severe malaria in Asia. These results can probably be generalized to the treatment of severe malaria in adults from all areas, especially in those with hyperparasitemia. However, it is unclear whether these results can be generalized to children in Africa, who constitute the majority of those who die from severe malaria worldwide.
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Affiliation(s)
- Anna M Checkley
- SpR Infectious Diseases, The Hospital for Tropical Diseases, Mortimer Market Centre, Capper St., London, WC1E 6AU, UK.
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Falciparum Malaria. INFECTIOUS DISEASES IN CRITICAL CARE 2007. [PMCID: PMC7122550 DOI: 10.1007/978-3-540-34406-3_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Malaria is one of the most common infectious diseases in the world today, being the most important parasitic infection, and Plasmodium falciparum is the organism responsible for most of the mortality [1]. It has been estimated that approximately 300–500 million people contract malaria every year, with approximately 1–2 million deaths, most of these occurring in children [1–5]. Plasmodium falciparum, Mycobacterium tuberculosis and measles currently compete for the title of the single most important pathogen causing human morbidity and mortality [2, 3]. Infection with Plasmodium falciparum has a wide variety of potential clinical consequences [4, 6, 7].
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Newton PN, Barnes KI, Smith PJ, Evans AC, Chierakul W, Ruangveerayuth R, White NJ. The pharmacokinetics of intravenous artesunate in adults with severe falciparum malaria. Eur J Clin Pharmacol 2006; 62:1003-9. [PMID: 17089111 DOI: 10.1007/s00228-006-0203-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2006] [Revised: 07/31/2006] [Accepted: 08/17/2006] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Intravenous artesunate is commonly used in the emergency treatment of patients with severe falciparum malaria in Asia. The choice of doses used has been empirical. To inform dosage recommendations we assessed the pharmacokinetics of intravenous artesunate after the first dose. METHODS As part of a clinical trial of artesunate in adults with severe falciparum malaria in western Thailand, we assayed plasma concentrations of artesunate and the principal biologically active metabolite dihydroartemisinin (DHA) in 17 patients given an initial dose of 2.4 mg/kg body weight of intravenous artesunate. Drug levels were measured using high performance liquid chromatography with mass spectroscopy-electrospray ionisation detection. RESULTS Median (range) observed DHA Cmax was 2128 (513-5789) nmol/L, elimination half-life was 0.34 (0.14-0.87) h, and the time to the last detectable DHA was 2 h. CONCLUSION The large inter-individual variability (10 fold) in DHA Cmax and AUC in patients with potentially lethal, severe malaria, suggests that 2.4 mg/kg should be the minimum daily dose in severe malaria.
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Affiliation(s)
- Paul N Newton
- Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Rd., Bangkok 10400, Thailand
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Mirghani RA, Sayi J, Aklillu E, Allqvist A, Jande M, Wennerholm A, Eriksen J, Herben VMM, Jones BC, Gustafsson LL, Bertilsson L. CYP3A5 genotype has significant effect on quinine 3-hydroxylation in Tanzanians, who have lower total CYP3A activity than a Swedish population. Pharmacogenet Genomics 2006; 16:637-45. [PMID: 16906018 DOI: 10.1097/01.fpc.0000230411.89973.1b] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To study the correlation between CYP3A5 genotype and quinine 3-hydroxylation in black Tanzanian and Swedish Caucasians as well as to investigate the interethnic differences in CYP3A activity between the two populations. METHODS Tanzanian (n=144) and Swedish (n=136) healthy study participants were given a single oral 250 mg dose of quinine hydrochloride and a 16-h post-dose blood sample was collected. The metabolic ratio of quinine/3-hydroxyquinine was determined in plasma by high-performance liquid chromatography. All the participants were genotyped for the known mutations of CYP3A5, which are relevant for the respective population. Correlation between quinine metabolic ratio and CYP3A5 genotype as well as the interethnic difference in CYP3A activity between the two populations was studied. RESULTS Tanzanians had significantly higher (P<0.0001) mean quinine metabolic ratio (9.5+/-3.5) than Swedes (7.6+/-3.1). As expected, the frequency of high CYP3A5 expression alleles was higher in Tanzanians (51%) than in Swedes (7%). The mean+/-SD quinine metabolic ratio (10.7+/-3.9) in Tanzanians homozygous for low CYP3A5 expression gene was significantly higher than the corresponding mean metabolic ratio in participants heterozygous (9.5+/-3.3; P=0.02) or homozygous (8.1+/-3.1; P=0.002) for high expression CYP3A5 alleles, respectively. A tendency to higher quinine metabolic ratio in Swedes with low expression alleles compared with those with one or two high expression alleles was observed. Tanzanians homozygous for low CYP3A5 expression gene (i.e. only CYP3A4 is expressed) had significantly (P<0.0001) higher quinine metabolic ratio (10.7+/-3.9) than corresponding Swedes (7.7+/-3.1). CONCLUSIONS Clear interethnic differences were observed in the activity of CYP3A between Tanzanians and Swedes. A significant association is noted between CYP3A5 genotype and quinine 3-hydroxylation in Tanzanians, indicating a significant contribution of CYP3A5 to total 3A activity. The CYP3A4 catalyzed hydroxylation of quinine (two low CYP3A5 expression alleles) was lower in Tanzanians than in Swedes.
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Affiliation(s)
- Rajaa A Mirghani
- Department of Clinical Toxicology, Central Laboratories & Blood Bank, King Fahad Medical City, Riyadh 11525, Kingdom of Saudi Arabia
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Abstract
Every year people die from malaria in Britain and other industrialised countries. Most of these deaths are avoidable: they occur because a patient or doctor has underestimated the severity of the disease or has not considered the diagnosis early enough. This article provides the essential facts on treating malaria in adults in a non-endemic setting and is based on the best available evidence
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