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Siahaan L. Observation of Malaria Treatment with Dihydroartemisinin-Piperaquine Combination at Primary Health Care. TURKIYE PARAZITOLOJII DERGISI 2022; 46:102-107. [PMID: 35604186 DOI: 10.4274/tpd.galenos.2021.54264] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVE Dihydroartemisinin-Piperaquine (DHP) combination is the first-line treatment for uncomplicated malaria in Indonesia and has been used since 2010. This study was conducted to determine the efficacy of DHP combination for uncomplicated malaria treatment in a community-based evaluation. METHODS Recruitment was done by active or passive case detection. All uncomplicated malaria patients were treated with DHP once a day, for 3 days, administered orally (as is done in primary health care). Patients were followed up until day 28 post-treatment. The primary end point was a 28-day cure rate. RESULTS In this study, 484 subjects were screened through active and passive cases detection. A total of 45 subjects infected by P. vivax and 2 subjects infected by P. falciparum agreed to participate through written informed consent. There was no difference between clinical malaria and asymptomatic malaria in all analyzed characteristics. One patient had a D3 parasite density greater than 25% D0, although no parasites were found on the following day (D4). This study found 46 patients (97.9%) who had adequate clinical and parasitological responses. No adverse event was reported during the follow up of this study. CONCLUSION DHP was effective, safe, and well tolerated in the treatment of uncomplicated malaria at primary health care.
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Affiliation(s)
- Lambok Siahaan
- Universitas Sumatera Utara Medical Faculty, Department of Parasitology, Sumatera Utara, Indonesia
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2
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Assefa DG, Zeleke ED, Molla W, Mengistu N, Sefa A, Mebratu A, Bate AF, Bekele E, Yesmaw G, Makonnen E. Safety of dihydroartemisinin-piperaquine versus artemether-lumefantrine for the treatment of uncomplicated Plasmodium falciparum malaria among children in Africa: a systematic review and meta-analysis of randomized control trials. Malar J 2022; 21:4. [PMID: 34983552 PMCID: PMC8725395 DOI: 10.1186/s12936-021-04032-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 12/18/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The efficacies of artemisinin based combinations have been excellent in Africa, but also comprehensive evidence regarding their safety would be important. The aim of this review was to synthesize available evidence on the safety of dihydroartemisinin-piperaquine (DHA-PQ) compared to artemether-lumefantrine (AL) for the treatment of uncomplicated Plasmodium falciparum malaria among children in Africa. METHODS A systematic literature search was done to identify relevant articles from online databases PubMed/ MEDLINE, Embase, and Cochrane Center for Clinical Trial database (CENTRAL) for retrieving randomized control trials comparing safety of DHA-PQ and AL for treatment of uncomplicated P. falciparum malaria among children in Africa. The search was performed from August 2020 to 30 April 2021. Using Rev-Man software (V5.4.1), the extracted data from eligible studies were pooled as risk ratio (RR) with 95% confidence interval (CI). RESULTS In this review, 18 studies were included, which involved 10,498 participants were included. Compared to AL, DHA-PQ was associated with a slightly higher frequency of early vomiting (RR 2.26, 95% CI 1.46 to 3.50; participants = 7796; studies = 10; I2 = 0%, high quality of evidence), cough (RR 1.06, 95% CI 1.01 to 1.11; participants = 8013; studies = 13; I2 = 0%, high quality of evidence), and diarrhoea (RR 1.16, 95% CI 1.03 to 1.31; participants = 6841; studies = 11; I2 = 8%, high quality of evidence) were more frequent in DHA-PQ treatment arm. CONCLUSION From this review, it can be concluded that early vomiting, diarrhoea, and cough were common were significantly more frequent in patients who were treated with the DHA-PQ than that of AL, and both drugs are well tolerated. More studies comparing AL with DHA-PQ are needed to determine the comparative safety of these drugs.
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Affiliation(s)
- Dawit Getachew Assefa
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
- School of Public Health, College of Health Science and Medicine, Dilla University, Dilla, Ethiopia.
| | - Eden Dagnachew Zeleke
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Department of Midwifery, College of Health Science, Bule Hora University, Bule Hora, Ethiopia
| | - Wondwosen Molla
- Department of Midwifery, College of Health Science and Medicine, Dilla University, Dilla, Ethiopia
| | - Nebiyu Mengistu
- Department of Psychiatry, College of Health Science and Medicine, Dilla University, Dilla, Ethiopia
| | - Ahmedin Sefa
- Department of Nursing, College of Health Science and Medicine, Dilla University, Dilla, Ethiopia
| | - Andualem Mebratu
- Department of Midwifery, College of Health Science and Medicine, Dilla University, Dilla, Ethiopia
| | - Asresu Feleke Bate
- Department of Nursing, College of Health Science and Medicine, Dilla University, Dilla, Ethiopia
| | - Etaferaw Bekele
- Department of Nursing, College of Health Science and Medicine, Dilla University, Dilla, Ethiopia
| | - Gizachew Yesmaw
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Eyasu Makonnen
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Department of Pharmacology and Clinical Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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3
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Comparative effect of dihydroartemisinin-piperaquine and artemether-lumefantrine on gametocyte clearance and haemoglobin recovery in children with uncomplicated Plasmodium falciparum malaria in Africa: a systematic review and meta-analysis of randomized control trials. Int J Infect Dis 2021; 113:136-147. [PMID: 34653658 DOI: 10.1016/j.ijid.2021.10.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 09/04/2021] [Accepted: 10/06/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Plasmodium falciparum gametocytaemia has been associated with anaemia. The aim of this review was to synthesize available evidence on the comparative effect of dihydroartemisinin-piperaquine (DHA-PQ) and artemether-lumefantrine (AL) on gametocyte clearance and haemoglobin recovery in children with uncomplicated P. falciparum malaria in Africa. METHODS A systematic literature search was undertaken to identify relevant articles from online databases. The search was performed from August 2020 to 30 April 2021. Extracted data from eligible studies were pooled as risk ratios with 95% confidence intervals (CI). RESULTS Gametocyte carriage was reduced in both treatment groups, with no significant difference found between the groups. However, on days 28 and 42, a significant increase in serum haemoglobin level from baseline was observed in the DHA-PQ group (standardized mean difference 0.15, 95% CI 0.05-0.26; participants=2715; studies=4; I2=32%, high quality of evidence) compared with the AL group (mean difference 0.35, 95% CI 0.12-0.59; participants=1434; studies=3; I2=35%, high quality of evidence). CONCLUSION DHA-PQ had a greater impact on haemoglobin recovery than AL on days 28 and 42; this difference was significant.
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Mairet-Khedim M, Nsango S, Ngou C, Menard S, Roesch C, Khim N, Srun S, Iriart X, Lanot T, Otam L, Abega F, Ayong L, Morlais I, Gandia P, Witkowski B, Berry A. Efficacy of dihydroartemisinin/piperaquine in patients with non-complicated Plasmodium falciparum malaria in Yaoundé, Cameroon. J Antimicrob Chemother 2021; 76:3037-3044. [PMID: 34453535 DOI: 10.1093/jac/dkab281] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 07/12/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Dihydroartemisinin/piperaquine is increasingly used for the treatment of uncomplicated Plasmodium falciparum malaria in Africa. The efficacy of this combination in Cameroon is poorly documented, while resistance to dihydroartemisinin/piperaquine readily spreads in Southeast Asia. OBJECTIVES This study evaluated the clinical efficacy of dihydroartemisinin/piperaquine in Cameroon, as well as the molecular profile and phenotypic susceptibility of collected isolates to dihydroartemisinin and piperaquine. PATIENTS AND METHODS Dihydroartemisinin/piperaquine efficacy in 42 days was followed-up for 138 patients presenting non-complicated falciparum malaria. Piperaquine concentration was determined at day 7 for 124 patients. kelch13 gene polymorphisms (n = 150) and plasmepsin2 gene amplification (n = 148) were determined as molecular markers of resistance to dihydroartemisinin and piperaquine, respectively. Parasite susceptibility to dihydroartemisinin and piperaquine was determined using validated in vitro survival assays. RESULTS The efficacy of dihydroartemisinin/piperaquine treatment was 100% after PCR correction. The reinfections were not associated with a variation of piperaquine concentration at day 7. Ninety-six percent (144/150) of the samples presented a WT allele of the kelch13 gene. Two percent (3/150) presented the non-synonymous mutation A578S, which is not associated with resistance to dihydroartemisinin. No duplication of the plasmepsin2 gene was observed (0/148). All the samples tested in vitro by survival assays (n = 87) were susceptible to dihydroartemisinin and piperaquine. CONCLUSIONS Dihydroartemisinin/piperaquine has demonstrated excellent therapeutic efficacy with no evidence of emerging artemisinin or piperaquine resistance in Yaoundé, Cameroon. This observation suggests that dihydroartemisinin/piperaquine could be a sustainable therapeutic solution for P. falciparum malaria if implemented in areas previously free of artemisinin- and piperaquine-resistant parasites, unlike Southeast Asia.
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Affiliation(s)
- Mélissa Mairet-Khedim
- Malaria Translational Research Unit, Pasteur International Unit, Pasteur International Network, Phnom Penh, Cambodia and Paris, France.,Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity), Université Toulouse, CNRS UMR5051, INSERM UMR1291, UPS, Toulouse, France.,Structural Microbiology Unit, Institut Pasteur, CNRS UMR 3528, 25 rue du Docteur Roux, 75724 Paris 15, France
| | - Sandrine Nsango
- Department of Biological Sciences, Faculté de Médecine et des Sciences Pharmaceutiques, Université de Douala, Douala, Cameroon.,Malaria Research Unit, Centre Pasteur du Cameroon, Yaoundé, Cameroon
| | - Christelle Ngou
- Malaria Research Unit, Centre Pasteur du Cameroon, Yaoundé, Cameroon.,MIVEGEC, IRD, CNRS, Univ. Montpellier, Montpellier, France
| | - Sandie Menard
- Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity), Université Toulouse, CNRS UMR5051, INSERM UMR1291, UPS, Toulouse, France
| | - Camille Roesch
- Malaria Translational Research Unit, Pasteur International Unit, Pasteur International Network, Phnom Penh, Cambodia and Paris, France.,Malaria Molecular Epidemiology Unit, Institut Pasteur du Cambodge, Phnom Penh, Cambodia
| | - Nimol Khim
- Malaria Translational Research Unit, Pasteur International Unit, Pasteur International Network, Phnom Penh, Cambodia and Paris, France.,Malaria Molecular Epidemiology Unit, Institut Pasteur du Cambodge, Phnom Penh, Cambodia
| | - Sreynet Srun
- Malaria Translational Research Unit, Pasteur International Unit, Pasteur International Network, Phnom Penh, Cambodia and Paris, France.,Malaria Molecular Epidemiology Unit, Institut Pasteur du Cambodge, Phnom Penh, Cambodia
| | - Xavier Iriart
- Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity), Université Toulouse, CNRS UMR5051, INSERM UMR1291, UPS, Toulouse, France.,Service de Parasitologie-Mycologie, Centre Hospitalier Universitaire de Toulouse, Hôpital Purpan, Toulouse F-31300, France
| | - Thomas Lanot
- Laboratoire de Pharmacocinétique et Toxicologie, Centre Hospitalier Universitaire de Toulouse, Hôpital Purpan, Toulouse F-31300, France
| | - Laure Otam
- Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity), Université Toulouse, CNRS UMR5051, INSERM UMR1291, UPS, Toulouse, France.,Département des Sciences Biomédicales, Faculté des Sciences, Université de Ngaoundéré, Ngaoundéré, Cameroon
| | | | - Lawrence Ayong
- Malaria Research Unit, Centre Pasteur du Cameroon, Yaoundé, Cameroon
| | | | - Peggy Gandia
- Laboratoire de Pharmacocinétique et Toxicologie, Centre Hospitalier Universitaire de Toulouse, Hôpital Purpan, Toulouse F-31300, France.,INTHERES, Université de Toulouse, INRA, ENVT, BP 87614, 31076 Toulouse Cedex 3, France
| | - Benoit Witkowski
- Malaria Translational Research Unit, Pasteur International Unit, Pasteur International Network, Phnom Penh, Cambodia and Paris, France.,Malaria Molecular Epidemiology Unit, Institut Pasteur du Cambodge, Phnom Penh, Cambodia
| | - Antoine Berry
- Institut Toulousain des Maladies Infectieuses et Inflammatoires (Infinity), Université Toulouse, CNRS UMR5051, INSERM UMR1291, UPS, Toulouse, France.,Service de Parasitologie-Mycologie, Centre Hospitalier Universitaire de Toulouse, Hôpital Purpan, Toulouse F-31300, France
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Assefa DG, Yismaw G, Makonnen E. Efficacy of dihydroartemisinin-piperaquine versus artemether-lumefantrine for the treatment of uncomplicated Plasmodium falciparum malaria among children in Africa: a systematic review and meta-analysis of randomized control trials. Malar J 2021; 20:340. [PMID: 34384431 PMCID: PMC8359548 DOI: 10.1186/s12936-021-03873-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 08/03/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Emergence of Plasmodium falciparum resistance to artemisinin and its derivatives poses a threat to the global effort to control malaria. The emergence of anti-malarial resistance has become a great public health challenge and continues to be a leading threat to ongoing malaria control efforts. The aim of this review was to synthesize available evidence on the efficacy of dihydroartemisinin-piperaquine (DHA-PQ) compared to artemether-lumefantrine (AL) for the treatment of uncomplicated falciparum malaria among children in Africa. METHODS A systematic literature search was done to identify relevant articles from online databases PubMed/ MEDLINE, Embase, and Cochrane Central Register of Controlled Trials' database (CENTRAL) for retrieving randomized control trials comparing efficacy of DHA-PQ and AL for treatment of uncomplicated falciparum malaria in African children. The search was performed from August 2020 to April 2021. Using Rev-Man software (V5.4.1), R-studio and Comprehensive Meta-analysis software version 3, the extracted data from eligible studies were pooled as risk ratio (RR) with 95% confidence interval (CI). RESULTS In this review, 25 studies which involved a total of 13,198 participants were included. PCR-unadjusted treatment failure in children aged between 6 months and 15 years was significantly lower in the DHA-PQ treatment arm on day 28 than that of AL (RR 0.14, 95% CI 0.08-0.26; participants = 1302; studies = 4; I2 = 0%, high quality of evidence). Consistently, the PCR-adjusted treatment failure was significantly lower with DHA-PQ treatment group on day 28 (RR 0.45, 95% CI 0.29-0.68; participants = 8508; studies = 16; I2 = 51%, high quality of evidence) and on day 42 (RR 0.60, 95% CI 0.47-0.78; participants = 5959; studies = 17; I2 = 0%, high quality of evidence). However, the efficacy was ≥ 95% in both treatment groups on day 28. CONCLUSION From this review, it can be concluded that DHA-PQ reduces new infection and recrudescence on days 28 and 42 more than AL. This may trigger DHA-PQ to become a first-line treatment option.
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Affiliation(s)
- Dawit Getachew Assefa
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia. .,Department of Nursing, College of Health Science and Medicine, Dilla University, Dilla, Ethiopia.
| | - Gizachew Yismaw
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Eyasu Makonnen
- Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.,Department of Pharmacology and Clinical Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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6
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Li H, Chen H, Shi W, Shi J, Yuan J, Duan C, Fan Q, Liu Y. A novel use for an old drug: resistance reversal in Candida albicans by combining dihydroartemisinin with fluconazole. Future Microbiol 2021; 16:461-469. [PMID: 33960815 DOI: 10.2217/fmb-2020-0148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Aim: To investigate the effects of dihydroartemisinin combined with fluconazole against C. albicans in vitro and to explore the underlying mechanisms. Materials & methods: Checkerboard microdilution assay and time-kill curve method were employed to evaluate the static and dynamic antifungal effects against C. albicans. Reactive oxygen species (ROS) was measured by a fluorescent probe. Results: Combination of dihydroartemisinin and fluconazole exerted potent synergy against planktonic cells and biofilms of fluconazole-resistant C. albicans, with the fractional inhibitory concentration index values less than 0.07. A potent fungistatic activity of this drug combination could still be observed after 18 h. The accumulation of ROS induced by the drug combination might contribute to the synergy. Conclusion: Dihydroartemisinin reversed the resistance of C. albicans to fluconazole.
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Affiliation(s)
- Hui Li
- Department of Pharmacy, Shandong Cancer Hospital & Institute, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, 250117, China.,College of Pharmacy, Shandong University of Traditional Chinese Medicine, Jinan, 250355, China
| | - Haisheng Chen
- Department of Pharmacy, Shandong Cancer Hospital & Institute, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, 250117, China
| | - Wenna Shi
- Department of Pharmacy, Shandong Cancer Hospital & Institute, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, 250117, China
| | - Jing Shi
- Department of Pharmacy, Shandong Cancer Hospital & Institute, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, 250117, China
| | - Jupeng Yuan
- Shandong Provincial Key Laboratory of Radiation Oncology, Cancer Research Center, Shandong Cancer Hospital & Institute, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, 250117, China
| | - Cunxian Duan
- Department of Pharmacy, Shandong Cancer Hospital & Institute, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, 250117, China
| | - Qing Fan
- Department of Pharmacy, Shandong Cancer Hospital & Institute, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, 250117, China
| | - Yuguo Liu
- Department of Pharmacy, Shandong Cancer Hospital & Institute, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, 250117, China
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Tielli A, Jullien V, Pull L, Bouchaud O, Siriez JY. Unintentional artenimol/piperaquine overdose in two children occurring without evidence of subsequent cardiotoxicity. Int J Antimicrob Agents 2021; 57:106347. [PMID: 33892107 DOI: 10.1016/j.ijantimicag.2021.106347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 03/20/2021] [Accepted: 04/02/2021] [Indexed: 11/19/2022]
Abstract
At the emergency department of the Robert-Debré children's hospital in Paris, France, artenimol/piperaquine (AP) has been the first-line antimalarial treatment since September 2012. Most children receive the first dose at the hospital and return home if, after 1 hour's observation, there have been no episodes of vomiting. Here we report the case of two children, aged 11 years and 5 years, respectively, in whom the entire cumulative 3 days' treatment course combined was accidentally administered instead of just the first-day treatment dose. Serum piperaquine levels were measured between Hour 40 (H40) and Day 29 (D29) post-ingestion for the first patient, and between H17 and D7 for the second patient. Corrected QT (QTc) values were measured between H12 and D20 for the first patient and between H17 and H64 for the second patient. Despite reports of adverse electrophysiological events, AP overdose occurred without consequence on the QTc interval or clinical cardiac state in these two children.
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Affiliation(s)
- Alexandra Tielli
- Hôpital Robert-Debré, Service d'Accueil des Urgences pédiatriques, Assistance Publique-Hôpitaux de Paris, 48 boulevard Sérurier, 75019 Paris, France.
| | - Vincent Jullien
- Groupe hospitalier Paris Seine Saint-Denis, UF de Pharmacologie, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Lauren Pull
- Hôpital Robert-Debré, Service d'Accueil des Urgences pédiatriques, Assistance Publique-Hôpitaux de Paris, 48 boulevard Sérurier, 75019 Paris, France
| | - Olivier Bouchaud
- Hôpital Avicenne, Service des Maladies Infectieuses et Tropicales, Assistance Publique-Hôpitaux de Paris, 93000 Bobigny, France
| | - Jean-Yves Siriez
- Hôpital Robert-Debré, Service d'Accueil des Urgences pédiatriques, Assistance Publique-Hôpitaux de Paris, 48 boulevard Sérurier, 75019 Paris, France
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8
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Assefa DG, Zeleke ED, Bekele D, Tesfahunei HA, Getachew E, Joseph M, Manyazewal T. Efficacy and safety of dihydroartemisinin-piperaquine versus artemether-lumefantrine for treatment of uncomplicated Plasmodium falciparum malaria in Ugandan children: a systematic review and meta-analysis of randomized control trials. Malar J 2021; 20:174. [PMID: 33794897 PMCID: PMC8017896 DOI: 10.1186/s12936-021-03711-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 03/24/2021] [Indexed: 12/02/2022] Open
Abstract
Background The emergence of artemisinin resistance in Southeast Asia and Plasmodium falciparum kelch13 propeller gene mutations in sub-Saharan African pose the greatest threat to global efforts to control malaria. This is a critical concern in Uganda, where artemisinin-based combination therapy (ACT) is the first-line treatment for uncomplicated falciparum. The objective of this study was to compare the efficacy and safety of dihydroartemisinin–piperaquine (DHA–PQ) and artemether–lumefantrine (AL) for the treatment of uncomplicated falciparum malaria in Ugandan children. Methods A search of PubMed and the Cochrane Central Register of Controlled Trials for retrieving randomized controlled trials comparing the efficacy and safety of DHA–PQ and AL for treatment of uncomplicated falciparum malaria in Ugandan children was done. The search was performed up to 31 August 2020. The data extracted from eligible studies and pooled as risk ratio (RR) with a 95% confidence interval (CI), using Rev Man Software (5.4). The protocol was registered in PROSPERO, ID: CRD42020182354. Results Eleven trials were included in this review and two of them only included under safety outcome. Total 3798 participants were enrolled. The PCR unadjusted treatment failure was significantly lower with DHA–PQ at day 28 (RR 0.30, 95% CI 0.19–0.49; participants = 7863; studies = 5; I2 = 93%, low quality evidence) and at day 42 (RR 0.53, 95% CI 0.38–0.76; participants = 1618; studies = 4; I2 = 79%, moderate quality of evidence). The PCR adjusted treatment failure at day 42 was significantly lower with DHA–PQ treatment group (RR 0.45, 95% CI 0.28 to 0.72; participants = 1370; studies = 5, high quality of evidence), and it was below 5% in both arms at day 28 (moderate quality of evidence). AL showed a longer prophylactic effect on new infections which may last for up to 63 days (PCR-adjusted treatment failure: RR 2.04, 95% CI 1.13–3.70; participants = 1311; studies = 2, moderate quality of evidence). Compared to AL, DHA–PQ was associated with a slightly higher frequency of cough (RR 1.07, 95% CI 1.01 to 1.13; 2575 participants; six studies; high quality of evidence). In both treatment groups, the risk of recurrent parasitaemia due to possible recrudescence was less than 5% at day 28. The appearance of gametocyte between 29 and 42 days was also significantly lower in DHA–PQ than AL (RR 0.26, 95% CI 0.12 to 0.56; participants = 623; studies = 2; I2 = 0%). Conclusion Compared to AL, DHA–PQ appeared to reduce treatment failure and gametocyte carriage in Ugandan children. This may trigger DHA–PQ to become the first-line treatment option. Both treatments were safe and well-tolerated. Supplementary Information The online version contains supplementary material available at 10.1186/s12936-021-03711-4.
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Affiliation(s)
- Dawit Getachew Assefa
- College of Health Sciences, Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa University, P.O. Box 9086, Addis Ababa, Ethiopia. .,Department of Nursing, College of Health Science and Medicine, Dilla University, Dilla, Ethiopia.
| | - Eden Dagnachew Zeleke
- College of Health Sciences, Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa University, P.O. Box 9086, Addis Ababa, Ethiopia.,Department of Midwifery, College of Health Science, Bule-Hora University, Bule-Hora, Ethiopia
| | - Delayehu Bekele
- College of Health Sciences, Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa University, P.O. Box 9086, Addis Ababa, Ethiopia.,Department of Obstetrics and Gynecology, Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Hanna Amanuel Tesfahunei
- College of Health Sciences, Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa University, P.O. Box 9086, Addis Ababa, Ethiopia.,Hager Biomedical Research Institute, Asmara, Eritrea
| | - Emnet Getachew
- College of Health Sciences, Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa University, P.O. Box 9086, Addis Ababa, Ethiopia.,Arsi University, Asella, Ethiopia
| | - Michele Joseph
- College of Health Sciences, Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa University, P.O. Box 9086, Addis Ababa, Ethiopia
| | - Tsegahun Manyazewal
- College of Health Sciences, Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), Addis Ababa University, P.O. Box 9086, Addis Ababa, Ethiopia
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Jackson KD, Higgins CR, Laing SK, Mwila C, Kobayashi T, Ippolito MM, Sylvia S, Ozawa S. Impact of substandard and falsified antimalarials in Zambia: application of the SAFARI model. BMC Public Health 2020; 20:1083. [PMID: 32646393 PMCID: PMC7350731 DOI: 10.1186/s12889-020-08852-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 05/05/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Many countries are striving to become malaria-free, but global reduction in case estimates has stagnated in recent years. Substandard and falsified medicines may contribute to this lack of progress. Zambia aims to eliminate their annual burden of 1.2 million pediatric malaria cases and 2500 child deaths due to malaria. We examined the health and economic impact of poor-quality antimalarials in Zambia. METHODS An agent-based model, Substandard and Falsified Antimalarial Research Impact (SAFARI), was modified and applied to Zambia. The model was developed to simulate population characteristics, malaria incidence, patient care-seeking, disease progression, treatment outcomes, and associated costs of malaria for children under age five. Zambia-specific demographic, epidemiological, and cost inputs were extracted from the literature. Simulations were run to estimate the health and economic impact of poor-quality antimalarials, the effect of potential artemisinin resistance, and six additional malaria focused policy interventions. RESULTS We simulated annual malaria cases among Zambian children under five. At baseline, we found 2610 deaths resulting in $141.5 million in annual economic burden of malaria. We estimated that elimination of substandard and falsified antimalarials would result in an 8.1% (n = 213) reduction in under-five deaths, prevent 937 hospitalizations, and realize $8.5 million in economic savings, annually. Potential artemisinin resistance could further increase deaths by 6.3% (n = 166) and cost an additional $9.7 million every year. CONCLUSIONS Eliminating substandard and falsified antimalarials is an important step towards a malaria-free Zambia. Beyond the dissemination of insecticide-treated bed nets, indoor residual spraying, and other malaria control measures, attention must also be paid to assure the quality of antimalarial treatments.
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Affiliation(s)
- Kathryn D Jackson
- Department of Health Policy and Management, UNC Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Colleen R Higgins
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, CB#7574, Beard Hall, 115H, Chapel Hill, NC, 27599, USA
| | - Sarah K Laing
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Chiluba Mwila
- Department of Pharmacy, School of Health Sciences, University of Zambia, Lusaka, Zambia
| | - Tamaki Kobayashi
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Malaria Research Institute, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Matthew M Ippolito
- Malaria Research Institute, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Division of Clinical Pharmacology and Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sean Sylvia
- Department of Health Policy and Management, UNC Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA.,Carolina Population Center, University of North Carolina, Chapel Hill, NC, USA
| | - Sachiko Ozawa
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, University of North Carolina, CB#7574, Beard Hall, 115H, Chapel Hill, NC, 27599, USA. .,Department of Maternal and Child Health, UNC Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA.
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10
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Nwakwue N, Mgbekem MA, Nsemo AD, Armon M, Ella R, Akpan IW, Adrew-Bassey P. Treatment of Uncomplicated Malaria among Under-Five Children: A Systematic Review. Health (London) 2020. [DOI: 10.4236/health.2020.124031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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11
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Cheaveau J, Marasinghe D, Akakpo S, Deardon R, Naugler C, Chin A, Pillai DR. The Impact of Malaria on Liver Enzymes: A Retrospective Cohort Study (2010-2017). Open Forum Infect Dis 2019; 6:ofz234. [PMID: 31263731 PMCID: PMC6592410 DOI: 10.1093/ofid/ofz234] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 05/15/2019] [Indexed: 12/21/2022] Open
Abstract
Background It is unclear if malaria causes deranged liver enzymes. This has implications both in clinical practice and in research, particularly for antimalarial drug development. Method We performed a retrospective cohort study of returning travelers (n = 4548) who underwent a malaria test and had enzymes measured within 31 days in Calgary, Canada, from 2010 to 2017. Odds ratios of having an abnormal alkaline phosphatase (ALP), alanine aminotransferases (ALT), aspartate aminotransferases (AST), and total bilirubin (TB) were calculated using multivariable longitudinal analysis with binomial response. Results After adjusting for gender, age, and use of hepatotoxic medications, returning travelers testing positive for malaria had higher odds of having an abnormal TB (odds ratio [OR], 12.64; 95% confidence interval [CI], 6.32–25.29; P < .001) but not ALP (OR, 0.32; 95% CI, 0.09–1.10; P = .072), ALT (OR, 1.01; 95% CI, 0.54–1.89; P = .978) or AST (OR, 1.26; 95% CI, 0.22–7.37; P = .794), compared with those who tested negative. TB was most likely to be abnormal in the “early” period (day 0–day 3) but then normalized in subsequent intervals. Returning travelers with severe malaria (OR, 2.56; 95% CI, 0.99–6.62; P = .052) had borderline increased odds of having an abnormal TB, but malaria species (OR, 0.70; 95% CI, 0.24–2.05; P = .511) did not. Conclusions In malaria-exposed returning travelers, the TB is abnormal, especially in the early period, but no abnormalities are seen for ALT, AST, or ALP.
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Affiliation(s)
- James Cheaveau
- Department of Microbiology, Immunology, and Infectious Diseases, University of Calgary, AB, Canada
| | - Dewdunee Marasinghe
- Department of Epidemiology, Biostatistics, and Occupational Health, McGill University, Montreal, PQ, Canada
| | | | - Rob Deardon
- Department of Mathematics and Statistics, University of Calgary, AB, Canada
| | | | - Alex Chin
- Calgary Laboratory Services, Calgary, AB, Canada.,Department of Pathology and Laboratory Medicine, University of Calgary, AB, Canada
| | - Dylan R Pillai
- Department of Microbiology, Immunology, and Infectious Diseases, University of Calgary, AB, Canada.,Calgary Laboratory Services, Calgary, AB, Canada.,Department of Pathology and Laboratory Medicine, University of Calgary, AB, Canada
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12
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Whegang Youdom S, Chiabi A, Basco LK. Monitoring the Efficacy and Safety of Artemisinin-Based Combination Therapies: A Review and Network Meta-analysis of Antimalarial Therapeutic Efficacy Trials in Cameroon. Drugs R D 2019; 19:1-14. [PMID: 30656608 PMCID: PMC6380963 DOI: 10.1007/s40268-018-0259-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Introduction Artemisinin-based combination therapies (ACTs) are the first-line antimalarial drugs used to treat uncomplicated Plasmodium falciparum alaria in many endemic countries worldwide. The present work reviewed the therapeutic efficacy of ACT in Cameroon more than 10 years after the initial change in national drug policy in 2004. Methods A PubMed literature search was performed to analyse clinical trials conducted in Cameroon from 2001 to May 2017. Clinical studies that evaluated ACT for the treatment of uncomplicated falciparum malaria in children or adults, and reported efficacy and/or safety, were included. In addition, a small network meta-analysis (NMA) with a frequentist approach was performed. Results Six papers were selected from 48 articles screened and were full-text reviewed. The efficacy of both artemether-lumefantrine (AL) and artesunate-amodiaquine (ASAQ) ranged from moderate to high, with polymerase chain reaction-corrected cure rates ranging from 96.7 to 100% and 88.2 to 100%, respectively, in per-protocol analysis, and 86.2 to 96.7% and 74.0 to 90.6%, respectively, in intention-to-treat analysis. The malaria evidence network suggested that AL and ASAQ efficacies were comparable. The highest day 3 parasite positivity rate was 8.2% for ASAQ and 4% for AL. A novel ACT, artesunate-atovaquoneproguanil (ASATPG) was tested once and showed a cure rate of 100%. Based on an ITT approach, the NMA revealed that AL was more efficacious than ASAQ, but the difference was not statistical significant (706 participants, three randomised clinical trials (RCT); OR 1.25, 95%CI 0.78–2.00). Adverse events ranged from mild to moderate severity but were not directly attributed to drug intake. Conclusion ACTs are still effective and safe in Cameroon; however, there are insufficient data on their efficacy, safety and tolerability, therefore more RCTs should be conducted, including novel ACTs. Electronic supplementary material The online version of this article (10.1007/s40268-018-0259-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Solange Whegang Youdom
- National Advanced School of Engineering, University of Yaounde I, PO Box 8390, Yaounde, Cameroon.
| | - Andreas Chiabi
- Department of Paediatrics, Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaounde, Cameroon.,Paediatric Unit, Yaounde Gynaeco-Obstetric and Paediatric Hospital, Yaounde, Cameroon
| | - Leonardo K Basco
- Aix-Marseille Université, Institut de Recherche pour le Développement, Assistance Publique - Hôpitaux de Marseille, Service de Santé des Armées, Unité Mixte de Recherche Vecteurs - Infections Tropicales et Méditerranéennes (VITROME), Institut Hospitalo-Universitaire - Méditerranée Infection, Marseille, France
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13
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Dama S, Niangaly H, Djimde M, Sagara I, Guindo CO, Zeguime A, Dara A, Djimde AA, Doumbo OK. A randomized trial of dihydroartemisinin-piperaquine versus artemether-lumefantrine for treatment of uncomplicated Plasmodium falciparum malaria in Mali. Malar J 2018; 17:347. [PMID: 30290808 PMCID: PMC6173860 DOI: 10.1186/s12936-018-2496-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 09/28/2018] [Indexed: 11/28/2022] Open
Abstract
Background Artemether–lumefantrine (AL) and artesunate–amodiaquine are first-line treatment for uncomplicated malaria in many endemic countries, including Mali. Dihydroartemisinin–piperaquine (DHA–PQ) is also an alternative first-line artemisinin-based combination therapy, but only few data are available on DHA–PQ efficacy in sub-Saharan Africa. The main aim of this study was to compare clinical efficacy of DHA–PQ versus AL, using the World Health Organization (WHO) 42-day in vivo protocol. Methods The efficacy of three-dose regimens of DHA–PQ was compared to AL combination in a randomized, comparative open label trial using the WHO 42-day follow-up protocol from 2013 to 2015 in Doneguebougou and Torodo, Mali. The primary endpoint was to access the PCR-corrected Adequate Clinical and Parasitological Responses at day 28. Results A total of 317 uncomplicated malaria patients were enrolled, with 159 in DHA–PQ arm and 158 in AL arm. The parasite positivity rate decreased from 68.4% (95% CI 60.5–75.5) on day 1 to 3.8% (95% CI 1.4–8.1) on day 2 for DHA–PQ and 79.8% (95% CI 72.3–85.7) on day 1 to 9.5% (95% CI 5.4–15.2) on day 2 for AL, (p = 0.04). There was a significant difference in the uncorrected ACPR between DHA–PQ and AL, both at 28-day and 42-day follow-up with 97.4% (95% CI 93.5–99.3) in DHA–PQ vs 84.5% (95% CI 77.8–89.8) in AL (p < 0.001) and 94.2% (95% CI 89.3–97.3) in DHA–PQ vs 73.4% (95% CI 65.7–80.2) in AL, respectively (p < 0.001). After molecular correction, there was no significant difference in ACPRc between DHA–PQ and AL, both at the 28-day and 42-day follow-up with 99.4% (95% CI 96.5–100) in DHA–PQ versus 98.1% (95% CI 94.5–99.6) in AL (p = 0.3) and 99.3% (95% CI 96.5–100) in DHA–PQ vs 97.4% (95% CI 93.5–99.3) in AL (p = 0.2). There was no significant difference between DHA–PQ and AL in QTc prolongation 12.1% vs 7%, respectively (p = 0.4). Conclusion The results showed that dihydroartemisinin–piperaquine and artemether–lumefantrine were clinically efficacious on Plasmodium falciparum parasites in Mali.
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Affiliation(s)
- Souleymane Dama
- Malaria Research and Training Centre, Faculty of Pharmacy and Faculty of Medicine and Dentistry, University of Sciences, Techniques and Technology of Bamako, P.O. Box 1805, Bamako, Mali.
| | - Hamidou Niangaly
- Malaria Research and Training Centre, Faculty of Pharmacy and Faculty of Medicine and Dentistry, University of Sciences, Techniques and Technology of Bamako, P.O. Box 1805, Bamako, Mali
| | - Moussa Djimde
- Malaria Research and Training Centre, Faculty of Pharmacy and Faculty of Medicine and Dentistry, University of Sciences, Techniques and Technology of Bamako, P.O. Box 1805, Bamako, Mali
| | - Issaka Sagara
- Malaria Research and Training Centre, Faculty of Pharmacy and Faculty of Medicine and Dentistry, University of Sciences, Techniques and Technology of Bamako, P.O. Box 1805, Bamako, Mali
| | - Cheick Oumar Guindo
- Malaria Research and Training Centre, Faculty of Pharmacy and Faculty of Medicine and Dentistry, University of Sciences, Techniques and Technology of Bamako, P.O. Box 1805, Bamako, Mali
| | - Amatigue Zeguime
- Malaria Research and Training Centre, Faculty of Pharmacy and Faculty of Medicine and Dentistry, University of Sciences, Techniques and Technology of Bamako, P.O. Box 1805, Bamako, Mali
| | - Antoine Dara
- Malaria Research and Training Centre, Faculty of Pharmacy and Faculty of Medicine and Dentistry, University of Sciences, Techniques and Technology of Bamako, P.O. Box 1805, Bamako, Mali
| | - Abdoulaye A Djimde
- Malaria Research and Training Centre, Faculty of Pharmacy and Faculty of Medicine and Dentistry, University of Sciences, Techniques and Technology of Bamako, P.O. Box 1805, Bamako, Mali
| | - Ogobara K Doumbo
- Malaria Research and Training Centre, Faculty of Pharmacy and Faculty of Medicine and Dentistry, University of Sciences, Techniques and Technology of Bamako, P.O. Box 1805, Bamako, Mali
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14
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Nambozi M, Kabuya JBB, Hachizovu S, Mwakazanga D, Mulenga J, Kasongo W, Buyze J, Mulenga M, Van Geertruyden JP, D'Alessandro U. Artemisinin-based combination therapy in pregnant women in Zambia: efficacy, safety and risk of recurrent malaria. Malar J 2017; 16:199. [PMID: 28511713 PMCID: PMC5434531 DOI: 10.1186/s12936-017-1851-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 05/09/2017] [Indexed: 11/10/2022] Open
Abstract
Background In Zambia, malaria is one of the leading causes of morbidity and mortality, especially among under five children and pregnant women. For the latter, the World Health Organization recommends the use of artemisinin-based combination therapy (ACT) in the second and third trimester of pregnancy. In a context of limited information on ACT, the safety and efficacy of three combinations, namely artemether–lumefantrine (AL), mefloquine–artesunate (MQAS) and dihydroartemisinin–piperaquine (DHAPQ) were assessed in pregnant women with malaria. Methods The trial was carried out between July 2010 and August 2013 in Nchelenge district, Luapula Province, an area of high transmission, as part of a multi-centre trial. Women in the second or third trimester of pregnancy and with malaria were recruited and randomized to one of the three study arms. Women were actively followed up for 63 days, and then at delivery and 1 year post-delivery. Results Nine hundred pregnant women were included, 300 per arm. PCR-adjusted treatment failure was 4.7% (12/258) (95% CI 2.7–8.0) for AL, 1.3% (3/235) (95% CI 0.4–3.7) for MQAS and 0.8% (2/236) (95% CI 0.2–3.0) for DHAPQ, with significant risk difference between AL and DHAPQ (p = 0.01) and between AL and MQAS (p = 0.03) treatments. Re-infections during follow up were more frequent in the AL (HR: 4.71; 95% CI 3.10–7.2; p < 0.01) and MQAS (HR: 1.59; 95% CI 1.02–2.46; p = 0.04) arms compared to the DHAPQ arm. PCR-adjusted treatment failure was significantly associated with women under 20 years [Hazard Ratio (HR) 5.35 (95% CI 1.07–26.73; p = 0.04)] and higher malaria parasite density [3.23 (95% CI 1.03–10.10; p = 0.04)], and still women under 20 years [1.78, (95% CI 1.26–2.52; p < 0.01)] had a significantly higher risk of re-infection. The three treatments were generally well tolerated. Dizziness, nausea, vomiting, headache and asthenia as adverse events (AEs) were more common in MQAS than in AL or DHAPQ (p < 0.001). Birth outcomes were not significantly different between treatment arms. Conclusion As new infections can be prevented by a long acting partner drug to the artemisinins, DHAPQ should be preferred in places as Nchelenge district where transmission is intense while in areas of low transmission intensity AL or MQAS may be used.
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Affiliation(s)
- Michael Nambozi
- Department of Clinical Sciences, Tropical Diseases Research Centre, P.O Box 71769, Ndola, Zambia.
| | | | - Sebastian Hachizovu
- Department of Clinical Sciences, Tropical Diseases Research Centre, P.O Box 71769, Ndola, Zambia
| | - David Mwakazanga
- Department of Clinical Sciences, Tropical Diseases Research Centre, P.O Box 71769, Ndola, Zambia
| | - Joyce Mulenga
- Department of Clinical Sciences, Tropical Diseases Research Centre, P.O Box 71769, Ndola, Zambia
| | - Webster Kasongo
- Department of Clinical Sciences, Tropical Diseases Research Centre, P.O Box 71769, Ndola, Zambia
| | | | - Modest Mulenga
- Department of Clinical Sciences, Tropical Diseases Research Centre, P.O Box 71769, Ndola, Zambia
| | | | - Umberto D'Alessandro
- Institute of Tropical Medicine, Antwerp, Belgium.,Medical Research Council Unit, Serekunda, Gambia.,London School of Hygiene and Tropical Medicine, London, UK
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15
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Burrows JN, Duparc S, Gutteridge WE, Hooft van Huijsduijnen R, Kaszubska W, Macintyre F, Mazzuri S, Möhrle JJ, Wells TNC. New developments in anti-malarial target candidate and product profiles. Malar J 2017; 16:26. [PMID: 28086874 PMCID: PMC5237200 DOI: 10.1186/s12936-016-1675-x] [Citation(s) in RCA: 305] [Impact Index Per Article: 43.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 12/30/2016] [Indexed: 11/10/2022] Open
Abstract
A decade of discovery and development of new anti-malarial medicines has led to a renewed focus on malaria elimination and eradication. Changes in the way new anti-malarial drugs are discovered and developed have led to a dramatic increase in the number and diversity of new molecules presently in pre-clinical and early clinical development. The twin challenges faced can be summarized by multi-drug resistant malaria from the Greater Mekong Sub-region, and the need to provide simplified medicines. This review lists changes in anti-malarial target candidate and target product profiles over the last 4 years. As well as new medicines to treat disease and prevent transmission, there has been increased focus on the longer term goal of finding new medicines for chemoprotection, potentially with long-acting molecules, or parenteral formulations. Other gaps in the malaria armamentarium, such as drugs to treat severe malaria and endectocides (that kill mosquitoes which feed on people who have taken the drug), are defined here. Ultimately the elimination of malaria requires medicines that are safe and well-tolerated to be used in vulnerable populations: in pregnancy, especially the first trimester, and in those suffering from malnutrition or co-infection with other pathogens. These updates reflect the maturing of an understanding of the key challenges in producing the next generation of medicines to control, eliminate and ultimately eradicate malaria.
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Affiliation(s)
- Jeremy N Burrows
- Medicines for Malaria Venture, Route de Pré Bois 20, 1215, Geneva 15, Switzerland
| | - Stephan Duparc
- Medicines for Malaria Venture, Route de Pré Bois 20, 1215, Geneva 15, Switzerland
| | | | | | - Wiweka Kaszubska
- Medicines for Malaria Venture, Route de Pré Bois 20, 1215, Geneva 15, Switzerland
| | - Fiona Macintyre
- Medicines for Malaria Venture, Route de Pré Bois 20, 1215, Geneva 15, Switzerland
| | | | - Jörg J Möhrle
- Medicines for Malaria Venture, Route de Pré Bois 20, 1215, Geneva 15, Switzerland
| | - Timothy N C Wells
- Medicines for Malaria Venture, Route de Pré Bois 20, 1215, Geneva 15, Switzerland.
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16
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Ogouyèmi-Hounto A, Azandossessi C, Lawani S, Damien G, de Tove YSS, Remoue F, Kinde Gazard D. Therapeutic efficacy of artemether-lumefantrine for the treatment of uncomplicated falciparum malaria in northwest Benin. Malar J 2016; 15:37. [PMID: 26801767 PMCID: PMC4722724 DOI: 10.1186/s12936-016-1091-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 01/10/2016] [Indexed: 11/10/2022] Open
Abstract
Background Artemether/lumefantrine (Coartem®) has been used as a treatment for uncomplicated Plasmodium falciparum infection since 2004 in Benin. This open-label, non-randomized study evaluated efficacy of artemether–lumefantrine (AL) in treatment of uncomplicated falciparum malaria in children aged 6–59 months in two malaria transmission sites in northwest Benin. Methods
A 42-day therapeutic efficacy study was conducted between August and November 2014, in accordance with 2009 WHO guidelines. One-hundred and twenty-three children, aged 6 months to 5 years, with uncomplicated falciparum malaria were recruited into the study. The primary endpoint was parasitological cure on day 28 and day 42 while the secondary endpoints included: parasite and fever clearance, improvement in haemoglobin levels. Outcomes were classified as early treatment failure (ETF), late clinical failure, late parasitological failure, and adequate clinical and parasitological response (ACPR). Results Before PCR correction, ACPR rates were 87 % (95 % CI 76.0–94.7) and 75.6 %, respectively (95 % CI 67.0–82.9) on day 28 and day 42. In each study site, ACPR rates were 78.3 % in Djougou and 73 % in Cobly on day 42. There was no ETF and after PCR correction ACPR was 100 % in study population. All treatment failures were shown to be due to new infections. Fever was significantly cleared in 24 h and approximately 90 % of parasites where cleared on day 1 and almost all parasites were cleared on day 2. Haemoglobin concentration showed a slight increase with parasitic clearance. Conclusion AL remains an efficacious drug for the treatment of uncomplicated falciparum malaria in Benin, although higher rates of re-infection remain a concern. Surveillance needs to be continued to detect future changes in parasite sensitivity to artemisinin-based combination therapy.
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Affiliation(s)
- Aurore Ogouyèmi-Hounto
- Unité d'Enseignement et de Recherche en Parasitologie Mycologie/Faculté des Sciences de la Santé, laboratoire du Centre de Lutte intégrée contre le paludisme, 01 BP188, Cotonou, Benin. .,Laboratoire du Centre de Lutte intégrée contre le paludisme, 01 BP188, Cotonou, Benin.
| | | | - Souliatou Lawani
- Laboratoire du Centre de Lutte intégrée contre le paludisme, 01 BP188, Cotonou, Benin.
| | - Georgia Damien
- UMR 224-MIVEGEC, Institut de Recherche pour le Développement, 08 BP 841, Cotonou, Benin.
| | - Yolande Sissinto Savi de Tove
- Unité d'Enseignement et de Recherche en Parasitologie Mycologie/Faculté des Sciences de la Santé, laboratoire du Centre de Lutte intégrée contre le paludisme, 01 BP188, Cotonou, Benin. .,Laboratoire du Centre de Lutte intégrée contre le paludisme, 01 BP188, Cotonou, Benin.
| | - Franck Remoue
- UMR 224-MIVEGEC, Institut de Recherche pour le Développement, 08 BP 841, Cotonou, Benin.
| | - Dorothée Kinde Gazard
- Unité d'Enseignement et de Recherche en Parasitologie Mycologie/Faculté des Sciences de la Santé, laboratoire du Centre de Lutte intégrée contre le paludisme, 01 BP188, Cotonou, Benin. .,Laboratoire du Centre de Lutte intégrée contre le paludisme, 01 BP188, Cotonou, Benin.
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17
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Wiysonge CS, Wiysonge CS, Zani B, Mbacham W, Hodel EM, Terlouw DJ. Cochrane Column. Int J Epidemiol 2015; 44:1502-5. [PMID: 26320106 DOI: 10.1093/ije/dyv163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Charles S Wiysonge
- Centre for Evidence-based Health Care, Stellenbosch University, Stellenbosch, South Africa and Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa. E-mail:
| | - Charles S Wiysonge
- Centre for Evidence-based Health Care, Stellenbosch University, Stellenbosch, South Africa and Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa. E-mail:
| | | | | | - Eva Maria Hodel
- Centre for Evidence-based Health Care, Stellenbosch University, Stellenbosch, South Africa and
| | - Dianne J Terlouw
- Liverpool School of Tropical Medicine, Liverpool, UK and Malawi-Liverpool-Wellcome Trust Clinical Research Programme, College of Medicine, Blantyre, Malawi
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18
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Djimde AA, Makanga M, Kuhen K, Hamed K. The emerging threat of artemisinin resistance in malaria: focus on artemether-lumefantrine. Expert Rev Anti Infect Ther 2015; 13:1031-45. [PMID: 26081265 DOI: 10.1586/14787210.2015.1052793] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The development of artemisinin resistance in the Greater Mekong Subregion poses a significant threat to malaria elimination. Artemisinin-based combination therapies including artemether-lumefantrine (AL) are recommended by WHO as first-line treatment for uncomplicated Plasmodium falciparum malaria. This article provides a comprehensive review of the existing and latest data as a basis for interpretation of observed variability in parasite sensitivity to AL over the last 5 years. Clinical efficacy and preclinical data from a range of endemic countries are summarized, including potential molecular markers of resistance. Overall, AL remains effective in the treatment of uncomplicated P. falciparum malaria in most regions. Establishing validated molecular markers for resistance and strict efficacy monitoring will reinforce timely updates of treatment policies.
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Affiliation(s)
- Abdoulaye A Djimde
- Malaria Research and Training Center, University of Science, Techniques and Technologies of Bamako, Bamako, Mali
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Randomized Noninferiority Trial of Dihydroartemisinin-Piperaquine Compared with Sulfadoxine-Pyrimethamine plus Amodiaquine for Seasonal Malaria Chemoprevention in Burkina Faso. Antimicrob Agents Chemother 2015; 59:4387-96. [PMID: 25918149 DOI: 10.1128/aac.04923-14] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2014] [Accepted: 04/16/2015] [Indexed: 01/30/2023] Open
Abstract
The WHO recommends that children living in areas of highly seasonal malaria transmission in the Sahel subregion should receive seasonal malaria chemoprevention (SMC) with sulfadoxine-pyrimethamine plus amodiaquine (SPAQ). We evaluated the use of dihydroartemisinin-piperaquine (DHAPQ) as an alternative drug that could be used if SPAQ starts to lose efficacy. A total of 1,499 children 3 to 59 months old were randomized to receive SMC with SPAQ or DHAPQ over 3 months. The primary outcome measure was the risk of clinical malaria (fever or a history of fever with a parasite density of at least 3,000/μl). A cohort of 250 children outside the trial was followed up as a control group. Molecular markers of drug resistance were assessed. The risk of a malaria attack was 0.19 in the DHAPQ group and 0.15 in the SPAQ group, an odds ratio of 1.33 (95% confidence interval [CI], 1.02 to 1.72). Efficacy of SMC compared to the control group was 77% (67% to 84%) for DHAPQ and 83% (74% to 89%) for SPAQ. pfdhfr and pfdhps mutations associated with antifolate resistance were more prevalent in parasites from children who received SPAQ than in children who received DHAPQ. Both regimens were highly efficacious and well tolerated. DHAPQ is a potential alternative drug for SMC. (This trial is registered at ClinicalTrials.gov under registration no. NCT00941785.).
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Baiden R, Oduro A, Halidou T, Gyapong M, Sie A, Macete E, Abdulla S, Owusu-Agyei S, Mulokozi A, Adjei A, Sevene E, Compaoré G, Valea I, Osei I, Yawson A, Adjuik M, Akparibo R, Ogutu B, Upunda GL, Smith P, Binka F. Prospective observational study to evaluate the clinical safety of the fixed-dose artemisinin-based combination Eurartesim® (dihydroartemisinin/piperaquine), in public health facilities in Burkina Faso, Mozambique, Ghana, and Tanzania. Malar J 2015; 14:160. [PMID: 25885858 PMCID: PMC4405867 DOI: 10.1186/s12936-015-0664-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2014] [Accepted: 03/24/2015] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND The World Health Organization recommends artemisinin-based combination (ACT) for the treatment of uncomplicated malaria. Post-licensure safety data on newly registered ACT is critical for evaluating their risk/benefit profile in malaria endemic countries. The clinical safety of the newly registered combination, Eurartesim®, following its introduction into the public health system in four African countries was assessed. METHODS This was a prospective, observational, open-label, non-comparative, longitudinal, multi-centre study using cohort event monitoring. Patients with confirmed malaria had their first dose observed and instructed on how to take the second and the third doses at home. Patients were contacted on day 5 ± 2 to assess adherence and adverse events (AEs). Spontaneous reporting of AEs was continued till day 28. A nested cohort who completed full treatment course had repeated electrocardiogram (ECG) measurements to assess effect on QTc interval. RESULTS A total of 10,925 uncomplicated malaria patients were treated with Eurartesim®. Most patients,95% (10,359/10,925), did not report any adverse event following at least one dose of Eurartesim®. A total of 797 adverse events were reported. The most frequently reported, by system organ classification, were infections and infestations (3. 24%) and gastrointestinal disorders (1. 37%). In the nested cohort, no patient had QTcF > 500 ms prior to day 3 pre-dose 3. Three patients had QTcF > 500 ms (509 ms, 501 ms, 538 ms) three to four hours after intake of the last dose. All the QTcF values in the three patients had returned to <500 ms at the next scheduled ECG on day 7 (470 ms, 442 ms, 411 ms). On day 3 pre- and post-dose 3, 70 and 89 patients, respectively, had a QTcF increase of ≥ 60 ms compared to their baseline, but returned to nearly baseline values on day 7. CONCLUSION Eurartesim® single course treatment for uncomplicated falciparum malaria is well-tolerated. QT interval prolongation above 500 ms may occur at a rate of three per 1,002 patients after the third dose with no association of any clinical symptoms. QT interval prolongation above 60 ms was detected in less than 10% of the patients without any clinical abnormalities.
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Affiliation(s)
| | | | - Tinto Halidou
- Nanoro Health Research Centre, Nanoro, Burkina Faso.
| | | | - Ali Sie
- Nouna Health Research Centre, Nouna, Burkina Faso.
| | - Eusebio Macete
- Centro de InvestigaçãoemSaúde de Manhiça, CISM, Manhiça, Mozambique.
| | | | | | | | - Alex Adjei
- Dodowa Health Research Centre, Dodowa, Ghana.
| | - Esperanca Sevene
- Centro de InvestigaçãoemSaúde de Manhiça, CISM, Manhiça, Mozambique.
| | | | | | - Isaac Osei
- Navrongo Health Research Centre, Navrongo, Ghana.
| | - Abena Yawson
- Kintampo Health Research Centre, Kintampo, Ghana.
| | | | | | | | | | - Peter Smith
- London School of Hygiene & Tropical Medicine, London, UK.
| | - Fred Binka
- INDEPTH Network, Accra, Ghana. .,University for Health and Allied Sciences, Ho, Ghana.
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Nji AM, Ali IM, Moyeh MN, Ngongang EO, Ekollo AM, Chedjou JP, Ndikum VN, Evehe MS, Froeschl G, Heumann C, Mansmann U, Ogundahunsi O, Mbacham WF. Randomized non-inferiority and safety trial of dihydroartemisin-piperaquine and artesunate-amodiaquine versus artemether-lumefantrine in the treatment of uncomplicated Plasmodium falciparum malaria in Cameroonian children. Malar J 2015; 14:27. [PMID: 25626448 PMCID: PMC4318246 DOI: 10.1186/s12936-014-0521-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 12/20/2014] [Indexed: 05/28/2023] Open
Abstract
Background Artemether-lumefantrine and artesunate-amodiaquine are first-line treatment for uncomplicated malaria in Cameroon. No study has yet compared the efficacy of these drugs following the WHO recommended 42-day follow-up period. The goal of this study was to compare the clinical efficacy, tolerability and safety of artesunate-amodiaquine (ASAQ), artemether-lumefantrine (AL) and dihydroartemisinin piperaquine (DHAP) among children aged less than ten years in two malaria-endemic ecological regions of Cameroon. Methods A three-arm, randomized, controlled, non-inferiority trial was conducted among children of either gender aged six months (>5 kg) to ten years (n = 720) with acute uncomplicated Plasmodium falciparum infection. Parents/guardians of children provided consent prior to randomization to receive ASAQ, DHAP or AL in the ratio of 2:2:1, respectively. Treatment outcome was assessed based on standard WHO 2003 classification after 42 days of follow-up. The primary outcome was PCR-corrected day-42 cure rates. The non-inferiority, one-sided, lower limit asymptotic 97.5% confidence interval (CI) on the difference in PCR-corrected cure rates of ASAQ and DHAP when compared to AL was accepted if the lower limit of the CI was greater than −10%. Secondary outcomes were parasite and fever clearances and day 7 haemoglobin changes. Results PCR-corrected PP cure rates of 96.7, 98.1 and 96.3, respectively, for AL, ASAQ and DHAP was observed. The lower bound of the one-sided 97.5% CI calculated around the difference between day-42 cure rate point estimates in AL and ASAQ groups, AL and DHAP groups were, −6% and −4% respectively. There were no statistical significant differences in parasite or fever clearance times between treatments, although fever clearance pattern was different between ASAQ and DHAP. No statistical significant differences were observed in the occurrence of adverse events among treatment groups. Conclusion ASAQ and DHAP are considered safe and tolerable and are not inferior to AL in the treatment of uncomplicated P. falciparum malaria in Cameroonian children. Trial registration NCT01845701
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - Wilfred F Mbacham
- The Biotechnology Centre, University of Yaoundé I, Yaoundé, Cameroon.
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Hamainza B, Masaninga F, Moonga H, Mwenda M, Chanda-kapata P, Chalwe V, Chanda E, Kamuliwo M, Babaniyi OA. Therapeutic efficacy of artemether-lumefantrine on treatment of uncomplicated Plasmodium falciparum mono-infection in an area of high malaria transmission in Zambia. Malar J 2014; 13:430. [PMID: 25403945 PMCID: PMC4289181 DOI: 10.1186/1475-2875-13-430] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Accepted: 10/24/2014] [Indexed: 11/23/2022] Open
Abstract
Background Anti-malarial drug resistance continues to be a leading threat to ongoing malaria control efforts and calls for continued monitoring of the efficacy of these drugs in order to inform national anti-malarial drug policy decision-making. This study assessed the therapeutic efficacy and safety of artemether-lumefantrine (AL)(Coartem®) for the treatment of uncomplicated Plasmodium falciparum malaria in two sentinel high malaria transmission districts in the Eastern Province of Zambia in persons aged six months and above, excluding women aged 12 to 18 years. Methods This was an observational cohort of 176 symptomatic patients diagnosed with uncomplicated Plasmodium falciparum mono-infection. A World Health Organization (WHO)-standardized 28-day assessment protocol was used to assess clinical and parasitological responses to directly observed AL treatment of uncomplicated malaria. DNA polymerase chain reaction (PCR) analysis for molecular markers of AL resistance was conducted on positive blood samples and differentiated recrudescence from re-infections of the malaria parasites. Results All patients (CI 97.6-100) had adequate clinical and parasitological responses to treatment with AL. At the time of enrolment, mean slide positivity among study participants was 71.8% and 55.2% in Katete and Chipata, respectively. From a mean parasite density of 55,087, 98% of the study participants presented with zero parasitaemia by day 3 of the study. Fever clearance occurred within 24 hours of treatment with AL. However mean parasite density declines were most dramatic in participants in the older age. No adverse reactions to AL treatment were observed during the study. Conclusion AL remains a safe and efficacious drug for the treatment of uncomplicated Plasmodium falciparum malaria in Zambia, endemic for malaria, with some provinces experiencing high transmission intensity. However, the delayed parasite clearance in younger patients calls for further sentinel and periodical monitoring of AL efficacy in different areas of the country.
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Affiliation(s)
- Busiku Hamainza
- Ministry of Health, National Malaria Control Centre, Chainama Hospital College Grounds, off Great East road, P,O, Box 32509, Lusaka, Zambia.
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Efficacy of artemether-lumefantrine and dihydroartemisinin-piperaquine for treatment of uncomplicated malaria in children in Zaire and Uíge Provinces, angola. Antimicrob Agents Chemother 2014; 59:437-43. [PMID: 25367912 DOI: 10.1128/aac.04181-14] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
The development of resistance to antimalarials is a major challenge for global malaria control. Artemisinin-based combination therapies, the newest class of antimalarials, are used worldwide but there have been reports of artemisinin resistance in Southeast Asia. In February through May 2013, we conducted open-label, nonrandomized therapeutic efficacy studies of artemether-lumefantrine (AL) and dihydroartemisinin-piperaquine (DP) in Zaire and Uíge Provinces in northern Angola. The parasitological and clinical responses to treatment in children with uncomplicated Plasmodium falciparum monoinfection were measured over 28 days, and the main outcome was a PCR-corrected adequate clinical and parasitological response (ACPR) proportion on day 28. Parasites from treatment failures were analyzed for the presence of putative molecular markers of resistance to lumefantrine and artemisinins, including the recently identified mutations in the K13 propeller gene. In the 320 children finishing the study, 25 treatment failures were observed: 24 in the AL arms and 1 in the DP arm. The PCR-corrected ACPR proportions on day 28 for AL were 88% (95% confidence interval [CI], 78 to 95%) in Zaire and 97% (91 to 100%) in Uíge. For DP, the proportions were 100% (95 to 100%) in Zaire, and 100% (96 to 100%) in Uíge. None of the treatment failures had molecular evidence of artemisinin resistance. In contrast, 91% of AL late-treatment failures had markers associated with lumefantrine resistance on the day of failure. The absence of molecular markers for artemisinin resistance and the observed efficacies of both drug combinations suggest no evidence of artemisinin resistance in northern Angola. There is evidence of increased lumefantrine resistance in Zaire, which should continue to be monitored.
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Mori AT, Ngalesoni F, Norheim OF, Robberstad B. Cost-effectiveness of dihydroartemisinin-piperaquine compared with artemether-lumefantrine for treating uncomplicated malaria in children at a district hospital in Tanzania. Malar J 2014; 13:363. [PMID: 25223864 PMCID: PMC4171550 DOI: 10.1186/1475-2875-13-363] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2014] [Accepted: 09/12/2014] [Indexed: 01/01/2023] Open
Abstract
Background Dihydroartemisinin-piperaquine (DhP) is highly recommended for the treatment of uncomplicated malaria. This study aims to compare the costs, health benefits and cost-effectiveness of DhP and artemether-lumefantrine (AL) alongside “do-nothing” as a baseline comparator in order to consider the appropriateness of DhP as a first-line anti-malarial drug for children in Tanzania. Methods A cost-effectiveness analysis was performed using a Markov decision model, from a provider’s perspective. The study used cost data from Tanzania and secondary effectiveness data from a review of articles from sub-Saharan Africa. Probabilistic sensitivity analysis was used to incorporate uncertainties in the model parameters. In addition, sensitivity analyses were used to test plausible variations of key parameters and the key assumptions were tested in scenario analyses. Results The model predicts that DhP is more cost-effective than AL, with an incremental cost-effectiveness ratio (ICER) of US$ 12.40 per DALY averted. This result relies on the assumption that compliance to treatment with DhP is higher than that with AL due to its relatively simple once-a-day dosage regimen. When compliance was assumed to be identical for the two drugs, AL was more cost-effective than DhP with an ICER of US$ 12.54 per DALY averted. DhP is, however, slightly more likely to be cost-effective compared to a willingness-to-pay threshold of US$ 150 per DALY averted. Conclusion Dihydroartemisinin-piperaquine is a very cost-effective anti-malarial drug. The findings support its use as an alternative first-line drug for treatment of uncomplicated malaria in children in Tanzania and other sub-Saharan African countries with similar healthcare infrastructures and epidemiology of malaria. Electronic supplementary material The online version of this article (doi:10.1186/1475-2875-13-363) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Amani T Mori
- Centre for International Health, Department of Global Public Health and Primary Care, University of Bergen, P,O, Box 7804, 5020 Bergen, Norway.
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Zongo I, Somé FA, Somda SAM, Parikh S, Rouamba N, Rosenthal PJ, Tarning J, Lindegardh N, Nosten F, Ouédraogo JB. Efficacy and day 7 plasma piperaquine concentrations in African children treated for uncomplicated malaria with dihydroartemisinin-piperaquine. PLoS One 2014; 9:e103200. [PMID: 25133389 PMCID: PMC4136730 DOI: 10.1371/journal.pone.0103200] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2013] [Accepted: 06/24/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND One promising new Artemisinin-based combination therapies (ACTs) is dihydroartemisinin-piperaquine (DHA-PQ). However, the pharmacokinetics of piperaquine and the relationship between drug levels and clinical efficacy are incompletely characterized, particularly in children. METHODS We performed a single-arm open-label trial in Bobo-Dioulasso, Burkina Faso. A total of 379 participants aged 6 months or more with uncomplicated falciparum malaria were enrolled. Each participant received daily dose of DHA-PQ for three days and followed for 42 days. Parasitological efficacy was analyzed, considering rates of recrudescence and overall recurrence. PK was an exploratory endpoint and a priori, no sample size had been determined. Day 7 capillary and venous plasma concentrations of piperaquine were measured in children aged 2-10 years. RESULTS Of the 379 participants, 365 (96.3%) completed 42 days of follow-up. The median daily dose of PQ was 18.5 mg/kg [6.5-24]. Treatment with DHA-PQ was well tolerated with fever and parasitemia resolution within 48 hours in nearly all children. Recurrent malaria within 42 days of follow-up occurred in 31.3% (10/34) of children less than 2 years old, 16.0% (16/106) of those aged 2-5 years, 9.4% (15/160) of those aged 5-10 years, and none (0/68) of those over 10 years old. After genotyping, 3 of 41 recurrent episodes were recrudescence. An exploratory analysis shows that children with successful treatment outcomes had significantly higher median plasma concentrations of PQ compared to those with recurrent malaria within 42 days after therapy, considering either capillary samples (68 ng/ml [50-85] compared to 48 ng/ml [36-55], p<0.001) or venous samples (42 ng/ml [29-59] compared to 25 ng/ml [19-44], p<0.001). CONCLUSION DHA-PQ was effective for uncomplicated P. falciparum malaria treatment and offers an alternative to other ACTs. Recurrent malaria was mainly due to new infections after treatment and was correlated with low day 7 PQ concentration in the youngest patients. TRIAL REGISTRATION Controlled-Trials.com ISRCTN59761234.
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Affiliation(s)
- Issaka Zongo
- Direction Régionale de l'Ouest, Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso
| | - Fabrice A. Somé
- Direction Régionale de l'Ouest, Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso
| | - Serge A. M. Somda
- Non Transmissible disease department, Centre Muraz Bobo-Dioulasso, Bobo-Dioulasso, Burkina Faso
| | - Sunil Parikh
- Department of Medicine, Yale University School of Public Health, New Haven, Connecticut, United States of America
| | - Noel Rouamba
- Direction Régionale de l'Ouest, Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso
| | - Philip J. Rosenthal
- Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Joel Tarning
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Niklas Lindegardh
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - François Nosten
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Jean Bosco Ouédraogo
- Direction Régionale de l'Ouest, Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso
- Non Transmissible disease department, Centre Muraz Bobo-Dioulasso, Bobo-Dioulasso, Burkina Faso
- * E-mail:
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Abstract
INTRODUCTION Chemotherapy of malaria has become a rapidly changing field. Less than two decades ago, treatment regimens were increasingly bound to fail due to emerging drug resistance against 4-aminoquinolines and sulfa compounds. By now, artemisinin-based combination therapies (ACTs) constitute the standard of care for uncomplicated falciparum malaria and are increasingly also taken into consideration for the treatment of non-falciparum malaria. AREAS COVERED This narrative review provides an overview of the state-of-art antimalarial drug therapy, highlights the global portfolio of current Phase III/IV clinical trials and summarizes current developments. EXPERT OPINION Malaria chemotherapy remains a dynamic field, with novel drugs and drug combinations continuing to emerge in order to outpace the development of large-scale drug resistance against the currently most important drug class, the artemisinin derivatives. More randomized controlled studies are urgently needed especially for the treatment of malaria in first trimester pregnant women. ACTs should be used for the treatment of imported malaria more consequently. Gaining sufficient efficacy and safety information on ACT use for non-falciparum species including Plasmodium ovale and malariae should be a research priority. Continuous investment into malaria drug development is a vital factor to combat artemisinin resistance and successfully improve malaria control toward the ultimate goal of elimination.
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Affiliation(s)
- Benjamin J Visser
- University of Amsterdam, Academic Medical Centre, Center of Tropical Medicine and Travel Medicine, Division of Infectious Diseases , Amsterdam , The Netherlands
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Andagalu B, Mativo J, Kamau E, Ogutu B. Longitudinal study on Plasmodium falciparum gametocyte carriage following artemether-lumefantrine administration in a cohort of children aged 12-47 months living in Western Kenya, a high transmission area. Malar J 2014; 13:265. [PMID: 25007860 PMCID: PMC4105514 DOI: 10.1186/1475-2875-13-265] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Accepted: 07/05/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The effects that artemether-lumefantrine (AL) has on gametocyte dynamics in the short-term have recently been described. However there is limited long-term longitudinal data on the effect of AL on gametocyte dynamics in asymptomatic children. METHODS An epidemiological study was conducted in Kombewa, Western Kenya, in which 270 asymptomatic children aged between 12 and 47 months were enrolled. The subjects were randomized to receive either a course of AL or placebo at enrolment. Active follow-up was conducted for one year. RESULTS The gametocyte prevalence and density dynamics throughout the study period mirrored that of the asexual forms. The proportion of initially parasitaemic subjects becoming gametocytaemic was significantly lower in the AL arm for the first 12 weeks following randomization. The geometric mean gametocyte density was lower in the AL arm for 2 weeks following randomization. None of the variables of interest had a statistically significant effect on the duration of gametocytaemia. There is no effect seen in subjects who are not parasitaemic at the time of drug administration. CONCLUSIONS The treatment of asymptomatic parasitaemic subjects with AL results in a significant reduction in the proportion of subjects who become gametocytaemic for at least 12 weeks.
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Affiliation(s)
| | | | - Edwin Kamau
- Department of Emerging Infectious Diseases-Global Emerging Infections Surveillance and Response System (DEID-GEIS) Program, United States Army Medical Research Unit-Kenya (USAMRU-K), Kenya Medical Research Institute (KEMRI)-Walter Reed Project, P,O, Box 54, Kisumu, 40100, Kenya.
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Does the Use of Dihydroartemisinin-Piperaquine in Treating Patients with Uncomplicated falciparum Malaria Reduce the Risk for Recurrent New falciparum Infection More Than Artemether-Lumefantrine? Malar Res Treat 2014; 2014:263674. [PMID: 25045575 PMCID: PMC4089906 DOI: 10.1155/2014/263674] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2014] [Revised: 05/04/2014] [Accepted: 05/18/2014] [Indexed: 11/17/2022] Open
Abstract
Malaria contributes significantly to the global disease burden. The World Health Organization recommended the use of artemisinin-based combination therapies (ACTs) for treatment of uncomplicated falciparum malaria a decade ago in response to problems of drug resistance. This review compared two of the ACTs-Dihydroartemisinin-Piperaquine (DP) and Artemether-Lumefantrine (AL) to provide evidence which one has the ability to offer superior posttreatment prophylaxis at 28 and 42 days posttreatment. Four databases (MEDLINE, EMBASE, Cochrane Database and Global Health) were searched on June 2, 2013 and a total of seven randomized controlled trials conducted in sub-Sahara Africa were included. Results involving 2, 340 participants indicates that reduction in risk for recurrent new falciparum infections (RNIs) was 79% at day 28 in favour of DP [RR, 0.21; 95% CI: 0.14 to 0.32, P < 0.001], and at day 42 was 44% favouring DP [RR, 0.56; 95% CI: 0.34 to 0.90; P = 0.02]. No significant difference was seen in treatment failure rates between the two drugs at days 28 and 42. It is concluded that use of DP offers superior posttreatment prophylaxis compared to AL in the study areas. Hence DP can help reduce malaria cases in such areas more than AL.
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Kakuru A, Achan J, Muhindo MK, Ikilezi G, Arinaitwe E, Mwangwa F, Ruel T, Clark TD, Charlebois E, Rosenthal PJ, Havlir D, Kamya MR, Tappero JW, Dorsey G. Artemisinin-based combination therapies are efficacious and safe for treatment of uncomplicated malaria in HIV-infected Ugandan children. Clin Infect Dis 2014; 59:446-53. [PMID: 24759826 DOI: 10.1093/cid/ciu286] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Artemisinin-based combination therapies (ACTs) are highly efficacious and safe, but data from human immunodeficiency virus (HIV)-infected children concurrently receiving antiretroviral therapy (ART) and ACTs are limited. METHODS We evaluated 28-day outcomes following malaria treatment with artemether-lumefantrine (AL) or dihydroartemisinin-piperaquine (DP) in 2 cohorts of HIV-infected Ugandan children taking various ART regimens. In one cohort, children <6 years of age were randomized to lopinavir/ritonavir (LPV/r) or nonnucleoside reverse transcriptase inhibitor-based ART and treated with AL for uncomplicated malaria. In another cohort, children <12 months of age were started on nevirapine-based ART if they were eligible, and randomized to AL or DP for the treatment of their first and all subsequent uncomplicated malaria episodes. RESULTS There were 773 and 165 treatments for malaria with AL and DP, respectively. Initial response to therapy was excellent, with 99% clearance of parasites and <1% risk of repeat therapy within 3 days. Recurrent parasitemia within 28 days was common following AL treatment. The risk of recurrent parasitemia was significantly lower among children taking LPV/r-based ART compared with children taking nevirapine-based ART following AL treatment (15.3% vs 35.5%, P = .009), and those treated with DP compared with AL (8.6% vs 36.2%, P < .001). Both ACT regimens were safe and well tolerated. CONCLUSIONS Treatment of uncomplicated malaria with AL or DP was efficacious and safe in HIV-infected children taking ART. However, there was a high risk of recurrent parasitemia following AL treatment, which was significantly lower in children taking LPV/r-based ART compared with nevirapine-based ART.
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Affiliation(s)
| | - Jane Achan
- Infectious Diseases Research Collaboration Department of Pediatrics and Child Health, Makerere University College of Health Sciences, Kampala, Uganda
| | | | | | | | | | | | - Tamara D Clark
- Department of Medicine, University of California, San Francisco
| | | | | | | | - Moses R Kamya
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Jordan W Tappero
- Global AIDS Program, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Grant Dorsey
- Department of Medicine, University of California, San Francisco
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Pfeil J, Borrmann S, Tozan Y. Dihydroartemisinin-piperaquine vs. artemether-lumefantrine for first-line treatment of uncomplicated malaria in African children: a cost-effectiveness analysis. PLoS One 2014; 9:e95681. [PMID: 24748395 PMCID: PMC3991722 DOI: 10.1371/journal.pone.0095681] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Accepted: 03/31/2014] [Indexed: 12/31/2022] Open
Abstract
Background Recent multi-centre trials showed that dihydroartemisinin-piperaquine (DP) was as efficacious and safe as artemether-lumefantrine (AL) for treatment of young children with uncomplicated P. falciparum malaria across diverse transmission settings in Africa. Longitudinal follow-up of patients in these trials supported previous findings that DP had a longer post-treatment prophylactic effect than AL, reducing the risk of reinfection and conferring additional health benefits to patients, particularly in areas with moderate to high malaria transmission. Methods We developed a Markov model to assess the cost-effectiveness of DP versus AL for first-line treatment of uncomplicated malaria in young children from the provider perspective, taking into consideration the post-treatment prophylactic effects of the drugs as reported by a recent multi-centre trial in Africa and using the maximum manufacturer drug prices for artemisinin-based combination therapies set by the Global Fund in 2013. We estimated the price per course of treatment threshold above which DP would cease to be a cost-saving alternative to AL as a first-line antimalarial drug. Results First-line treatment with DP compared to AL averted 0.03 DALYs (95% CI: 0.006–0.07) and 0.001 deaths (95% CI: 0.00–0.002) and saved $0.96 (95% CI: 0.33–2.46) per child over one year. The results of the threshold analysis showed that DP remained cost-saving over AL for any DP cost below $1.23 per course of treatment. Conclusions DP is superior to AL from both the clinical and economic perspectives for treatment of uncomplicated P. falciparum malaria in young children. A paediatric dispersible formulation of DP is under development and should facilitate a targeted deployment of this antimalarial drug. The use of DP as first-line antimalarial drug in paediatric malaria patients in moderate to high transmission areas of Africa merits serious consideration by health policymakers.
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Affiliation(s)
- Johannes Pfeil
- Centre for Childhood and Adolescent Medicine and Department of Infectious Diseases, University Hospital, Heidelberg, Germany
- German Centre for Infection Research (DZIF), Heidelberg, Germany
| | - Steffen Borrmann
- Kenyan Medical Research Institute (KEMRI), Kilifi, Kenya
- Institute of Tropical Medicine, University of Tübingen, Tübingen, Germany
| | - Yeşim Tozan
- Steinhardt School of Culture, Education and Human Development, New York University, New York, New York, United States of America
- Institute of Public Health, Ruprecht-Karls-University, Heidelberg, Germany
- * E-mail:
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Pfeil J, Borrmann S, Tozan Y. Dihydroartemisinin-piperaquine vs. artemether-lumefantrine for first-line treatment of uncomplicated malaria in African children: a cost-effectiveness analysis. PLoS One 2014. [PMID: 24748395 DOI: 10.1371/journal.pone.0095681.ecollection] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Recent multi-centre trials showed that dihydroartemisinin-piperaquine (DP) was as efficacious and safe as artemether-lumefantrine (AL) for treatment of young children with uncomplicated P. falciparum malaria across diverse transmission settings in Africa. Longitudinal follow-up of patients in these trials supported previous findings that DP had a longer post-treatment prophylactic effect than AL, reducing the risk of reinfection and conferring additional health benefits to patients, particularly in areas with moderate to high malaria transmission. METHODS We developed a Markov model to assess the cost-effectiveness of DP versus AL for first-line treatment of uncomplicated malaria in young children from the provider perspective, taking into consideration the post-treatment prophylactic effects of the drugs as reported by a recent multi-centre trial in Africa and using the maximum manufacturer drug prices for artemisinin-based combination therapies set by the Global Fund in 2013. We estimated the price per course of treatment threshold above which DP would cease to be a cost-saving alternative to AL as a first-line antimalarial drug. RESULTS First-line treatment with DP compared to AL averted 0.03 DALYs (95% CI: 0.006-0.07) and 0.001 deaths (95% CI: 0.00-0.002) and saved $0.96 (95% CI: 0.33-2.46) per child over one year. The results of the threshold analysis showed that DP remained cost-saving over AL for any DP cost below $1.23 per course of treatment. CONCLUSIONS DP is superior to AL from both the clinical and economic perspectives for treatment of uncomplicated P. falciparum malaria in young children. A paediatric dispersible formulation of DP is under development and should facilitate a targeted deployment of this antimalarial drug. The use of DP as first-line antimalarial drug in paediatric malaria patients in moderate to high transmission areas of Africa merits serious consideration by health policymakers.
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Affiliation(s)
- Johannes Pfeil
- Centre for Childhood and Adolescent Medicine and Department of Infectious Diseases, University Hospital, Heidelberg, Germany; German Centre for Infection Research (DZIF), Heidelberg, Germany
| | - Steffen Borrmann
- Kenyan Medical Research Institute (KEMRI), Kilifi, Kenya; Institute of Tropical Medicine, University of Tübingen, Tübingen, Germany
| | - Yeşim Tozan
- Steinhardt School of Culture, Education and Human Development, New York University, New York, New York, United States of America; Institute of Public Health, Ruprecht-Karls-University, Heidelberg, Germany
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Ogutu BR, Onyango KO, Koskei N, Omondi EK, Ongecha JM, Otieno GA, Obonyo C, Otieno L, Eyase F, Johnson JD, Omollo R, Perkins DJ, Akhwale W, Juma E. Efficacy and safety of artemether-lumefantrine and dihydroartemisinin-piperaquine in the treatment of uncomplicated Plasmodium falciparum malaria in Kenyan children aged less than five years: results of an open-label, randomized, single-centre study. Malar J 2014; 13:33. [PMID: 24472156 PMCID: PMC3916309 DOI: 10.1186/1475-2875-13-33] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Accepted: 01/07/2014] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND This open-label, randomized study evaluated efficacy and safety of artemether-lumefantrine (AL) and dihydroartemisinin-piperaquine (DP) in treatment of uncomplicated falciparum malaria in children below five years of age, to build evidence on use of AL as first-line treatment and DP as second-line treatment in Kenya. METHODS A total of 454 children aged six to 59 months with uncomplicated falciparum malaria were randomized (1:1) to receive AL dispersible or DP paediatric tablets and followed up for 42 days. Primary efficacy variable was corrected adequate clinical and parasitological response (ACPR) rate on day 28. Secondary variables included corrected (day 14, 28 and 42), uncorrected (day 3, 14, 28 and 42) cure rates, parasitological failure at days 3, 14 and 42. Acceptability and tolerability of both drugs were assessed by caregiver questionnaire. RESULTS On day 28, corrected ACPR rates for AL dispersible and DP paediatric were 97.8% (95% CI: 94.9-99.3) and 99.1% (95% CI: 96.8-99.9), respectively, in intention-to-treat population, with no significant treatment differences noted between AL dispersible and DP paediatric arms. Additionally, no significant differences were observed for PCR corrected cure rates on days 14 and ACPR on day 42 for AL dispersible (100%; 96.8%) and DP paediatric (100%; 98.7%). Similarly, for PCR uncorrected cure rates, no significant differences were seen on days 3, 14, 28, and 42 for AL dispersible (99.1%; 98.7%; 81.1%; 67.8%) and DP paediatric (100%; 100%; 87.7%; 70.5%). Parasite clearance was rapid, with approximately 90% clearance achieved in 40 hours in both treatment arms. Incidence of adverse events was related to underlying disease; malaria being reported in both treatment arms. One serious adverse event was noted in AL dispersible (0.42%) arm, not related to study drug. Adherence to treatment regimen was higher for children treated with AL dispersible (93.6%) compared to DP paediatric (85.6%). Acceptability of AL dispersible regimen was assessed as being significantly better than DP paediatric. CONCLUSIONS AL and DP were both efficacious and well tolerated, and had similar effects at day 42 on risk of recurrent malaria. No signs of Plasmodium falciparum tolerance to artemisinins were noted. TRIAL REGISTRATION PACTR201111000316370.
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Affiliation(s)
- Bernhards R Ogutu
- Centre for Clinical Research, Kenya Medical Research Institute, Kisumu, Kenya
- Walter Reed Project/Centre for Clinical Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Kevin O Onyango
- Centre for Clinical Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Nelly Koskei
- Centre for Clinical Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Edgar K Omondi
- Centre for Clinical Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - John M Ongecha
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Godfrey A Otieno
- Centre for Clinical Research, Kenya Medical Research Institute, Kisumu, Kenya
- Walter Reed Project/Centre for Clinical Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Charles Obonyo
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Lucas Otieno
- Centre for Clinical Research, Kenya Medical Research Institute, Kisumu, Kenya
- Walter Reed Project/Centre for Clinical Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Fredrick Eyase
- Walter Reed Project/Centre for Clinical Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Jacob D Johnson
- Walter Reed Project/Centre for Clinical Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Raymond Omollo
- Drugs for Neglected Disease Initiative, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Willis Akhwale
- Department of Disease Control and Prevention, Ministry of Public Health and Sanitation, Nairobi, Kenya
| | - Elizabeth Juma
- Centre for Clinical Research, Kenya Medical Research Institute, Kisumu, Kenya
- Division of Malaria Control, Ministry of Public Health and Sanitation, Nairobi, Kenya
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Zani B, Gathu M, Donegan S, Olliaro PL, Sinclair D. Dihydroartemisinin-piperaquine for treating uncomplicated Plasmodium falciparum malaria. Cochrane Database Syst Rev 2014; 2014:CD010927. [PMID: 24443033 PMCID: PMC4470355 DOI: 10.1002/14651858.cd010927] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND The World Health Organization (WHO) recommends Artemisinin-based Combination Therapy (ACT) for treating uncomplicated Plasmodium falciparum malaria. This review aims to assist the decision-making of malaria control programmes by providing an overview of the relative effects of dihydroartemisinin-piperaquine (DHA-P) versus other recommended ACTs. OBJECTIVES To evaluate the effectiveness and safety of DHA-P compared to other ACTs for treating uncomplicated P. falciparum malaria in adults and children. SEARCH METHODS We searched the Cochrane Infectious Diseases Group Specialized Register; the Cochrane Central Register of Controlled Trials (CENTRAL) published in The Cochrane Library; MEDLINE; EMBASE; LILACS, and the metaRegister of Controlled Trials (mRCT) up to July 2013. SELECTION CRITERIA Randomized controlled trials comparing a three-day course of DHA-P to a three-day course of an alternative WHO recommended ACT in uncomplicated P. falciparum malaria. DATA COLLECTION AND ANALYSIS Two authors independently assessed trials for eligibility and risk of bias, and extracted data. We analysed primary outcomes in line with the WHO 'Protocol for assessing and monitoring antimalarial drug efficacy' and compared drugs using risk ratios (RR) and 95% confidence intervals (CI). Secondary outcomes were effects on gametocytes, haemoglobin, and adverse events. We assessed the quality of evidence using the GRADE approach. MAIN RESULTS We included 27 trials, enrolling 16,382 adults and children, and conducted between 2002 and 2010. Most trials excluded infants aged less than six months and pregnant women. DHA-P versus artemether-lumefantrineIn Africa, over 28 days follow-up, DHA-P is superior to artemether-lumefantrine at preventing further parasitaemia (PCR-unadjusted treatment failure: RR 0.34, 95% CI 0.30 to 0.39, nine trials, 6200 participants, high quality evidence), and although PCR-adjusted treatment failure was below 5% for both ACTs, it was consistently lower with DHA-P (PCR-adjusted treatment failure: RR 0.42, 95% CI 0.29 to 0.62, nine trials, 5417 participants, high quality evidence). DHA-P has a longer prophylactic effect on new infections which may last for up to 63 days (PCR-unadjusted treatment failure: RR 0.71, 95% CI 0.65 to 0.78, two trials, 3200 participants, high quality evidence).In Asia and Oceania, no differences have been shown at day 28 (four trials, 1143 participants, moderate quality evidence), or day 63 (one trial, 323 participants, low quality evidence).Compared to artemether-lumefantrine, no difference was seen in prolonged QTc (low quality evidence), and no cardiac arrhythmias were reported. The frequency of other adverse events is probably similar with both combinations (moderate quality evidence). DHA-P versus artesunate plus mefloquineIn Asia, over 28 days follow-up, DHA-P is as effective as artesunate plus mefloquine at preventing further parasitaemia (PCR-unadjusted treatment failure: eight trials, 3487 participants, high quality evidence). Once adjusted by PCR to exclude new infections, treatment failure at day 28 was below 5% for both ACTs in all eight trials, but lower with DHA-P in two trials (PCR-adjusted treatment failure: RR 0.41 95% CI 0.21 to 0.80, eight trials, 3482 participants, high quality evidence). Both combinations contain partner drugs with very long half-lives and no consistent benefit in preventing new infections has been seen over 63 days follow-up (PCR-unadjusted treatment failure: five trials, 2715 participants, moderate quality evidence).In the only trial from South America, there were fewer recurrent parastaemias over 63 days with artesunate plus mefloquine (PCR-unadjusted treatment failure: RR 6.19, 95% CI 1.40 to 27.35, one trial, 445 participants, low quality evidence), but no differences were seen once adjusted for new infections (PCR-adjusted treatment failure: one trial, 435 participants, low quality evidence).DHA-P is associated with less nausea, vomiting, dizziness, sleeplessness, and palpitations compared to artesunate plus mefloquine (moderate quality evidence). DHA-P was associated with more frequent prolongation of the QTc interval (low quality evidence), but no cardiac arrhythmias were reported. AUTHORS' CONCLUSIONS In Africa, dihydroartemisinin-piperaquine reduces overall treatment failure compared to artemether-lumefantrine, although both drugs have PCR-adjusted failure rates of less than 5%. In Asia, dihydroartemisinin-piperaquine is as effective as artesunate plus mefloquine, and is better tolerated.
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Affiliation(s)
- Babalwa Zani
- South African Medical Research CouncilSouth African Cochrane CentreP. O. Box 19070TygerbergCape TownWestern CapeSouth Africa7505
| | - Michael Gathu
- KEMRI‐Wellcome Trust Research ProgrammeHealth Services Research GroupKenyatta National Hospital Grounds, P.O. Box 43640 ‐ 00100NairobiKenya
| | - Sarah Donegan
- Liverpool School of Tropical MedicineDepartment of Clinical SciencesPembroke PlaceLiverpoolMerseysideUKL3 5QA
| | - Piero L Olliaro
- World Health OrganizationUNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR)1211 Geneva 27GenevaSwitzerland
| | - David Sinclair
- Liverpool School of Tropical MedicineDepartment of Clinical SciencesPembroke PlaceLiverpoolMerseysideUKL3 5QA
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Halliday KE, Okello G, Turner EL, Njagi K, Mcharo C, Kengo J, Allen E, Dubeck MM, Jukes MCH, Brooker SJ. Impact of intermittent screening and treatment for malaria among school children in Kenya: a cluster randomised trial. PLoS Med 2014; 11:e1001594. [PMID: 24492859 PMCID: PMC3904819 DOI: 10.1371/journal.pmed.1001594] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Accepted: 12/06/2013] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Improving the health of school-aged children can yield substantial benefits for cognitive development and educational achievement. However, there is limited experimental evidence of the benefits of alternative school-based malaria interventions or how the impacts of interventions vary according to intensity of malaria transmission. We investigated the effect of intermittent screening and treatment (IST) for malaria on the health and education of school children in an area of low to moderate malaria transmission. METHODS AND FINDINGS A cluster randomised trial was implemented with 5,233 children in 101 government primary schools on the south coast of Kenya in 2010-2012. The intervention was delivered to children randomly selected from classes 1 and 5 who were followed up for 24 months. Once a school term, children were screened by public health workers using malaria rapid diagnostic tests (RDTs), and children (with or without malaria symptoms) found to be RDT-positive were treated with a six dose regimen of artemether-lumefantrine (AL). Given the nature of the intervention, the trial was not blinded. The primary outcomes were anaemia and sustained attention. Secondary outcomes were malaria parasitaemia and educational achievement. Data were analysed on an intention-to-treat basis. During the intervention period, an average of 88.3% children in intervention schools were screened at each round, of whom 17.5% were RDT-positive. 80.3% of children in the control and 80.2% in the intervention group were followed-up at 24 months. No impact of the malaria IST intervention was observed for prevalence of anaemia at either 12 or 24 months (adjusted risk ratio [Adj.RR]: 1.03, 95% CI 0.93-1.13, p = 0.621 and Adj.RR: 1.00, 95% CI 0.90-1.11, p = 0.953) respectively, or on prevalence of P. falciparum infection or scores of classroom attention. No effect of IST was observed on educational achievement in the older class, but an apparent negative effect was seen on spelling scores in the younger class at 9 and 24 months and on arithmetic scores at 24 months. CONCLUSION In this setting in Kenya, IST as implemented in this study is not effective in improving the health or education of school children. Possible reasons for the absence of an impact are the marked geographical heterogeneity in transmission, the rapid rate of reinfection following AL treatment, the variable reliability of RDTs, and the relative contribution of malaria to the aetiology of anaemia in this setting. TRIAL REGISTRATION www.ClinicalTrials.gov NCT00878007.
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Affiliation(s)
- Katherine E. Halliday
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
- * E-mail:
| | - George Okello
- Health Systems and Social Science Research Group, Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Elizabeth L. Turner
- Department of Biostatistics and Bioinformatics and Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | - Kiambo Njagi
- Division of Malaria Control, Ministry of Public Health & Sanitation, Nairobi, Kenya
| | - Carlos Mcharo
- Health and Literacy Intervention Project, Ukunda, Kenya
| | - Juddy Kengo
- Health and Literacy Intervention Project, Ukunda, Kenya
| | - Elizabeth Allen
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Margaret M. Dubeck
- Department of Teacher Education, College of Charleston, South Carolina, United States of America
| | - Matthew C. H. Jukes
- Graduate School of Education, Harvard University, Cambridge, Massachusetts, United States of America
| | - Simon J. Brooker
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Malaria Public Health Department, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
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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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Egunsola O, Oshikoya KA. Comparative safety of artemether-lumefantrine and other artemisinin-based combinations in children: a systematic review. Malar J 2013; 12:385. [PMID: 24175945 PMCID: PMC3818443 DOI: 10.1186/1475-2875-12-385] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Accepted: 10/28/2013] [Indexed: 11/25/2022] Open
Abstract
Background The purpose of the study was to compare the safety of artemether-lumefantrine (AL) with other artemisinin-based combinations in children. Methods A search of EMBASE (from 1974 to April 2013), MEDLINE (from 1946 to April 2013) and the Cochrane library of registered controlled trials for randomized controlled trials (RCTs) which compared AL with other artemisinin-based combinations was done. Only studies involving children ≤ 17 years old in which safety of AL was an outcome measure were included. Results Four thousand, seven hundred and twenty six adverse events (AEs) were recorded in 6,000 patients receiving AL. Common AEs (≥1/100 and <1/10) included: coryza, vomiting, anaemia, diarrhoea, vomiting and abdominal pain; while cough was the only very commonly reported AE (≥1/10). AL-treated children have a higher risk of body weakness (64.9%) than those on artesunate-mefloquine (58.2%) (p = 0.004, RR: 1.12 95% CI: 1.04-1.21). The risk of vomiting was significantly lower in patients on AL (8.8%) than artesunate-amodiaquine (10.6%) (p = 0.002, RR: 0.76, 95% CI: 0.63-0.90). Similarly, children on AL had a lower risk of vomiting (1.2%) than chlorproguanil-dapsone-artesunate (ACD) treated children (5.2%) (p = 0.002, RR: 0.63, 95% CI: 0.47-0.85). The risk of serious adverse events was significantly lower for AL (1.3%) than ACD (5.2%) (p = 0.002, RR: 0.45, 95% CI: 0.27-0.74). Conclusion Artemether-lumefantrine combination is as safe as ASAQ and DP for use in children. Common adverse events are cough and gastrointestinal symptoms. More studies comparing AL with artesunate-mefloquine and artesunate-azithromycin are needed to determine the comparative safety of these drugs.
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Affiliation(s)
- Oluwaseun Egunsola
- Academic Division of Child Health, University of Nottingham, Derbyshire Children's Hospital, Derby DE22 3DT, UK.
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A randomized trial of artemether-lumefantrine and dihydroartemisinin-piperaquine in the treatment of uncomplicated malaria among children in western Kenya. Malar J 2013; 12:254. [PMID: 23870627 PMCID: PMC3722085 DOI: 10.1186/1475-2875-12-254] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Accepted: 07/09/2013] [Indexed: 12/03/2022] Open
Abstract
Background Artemether-lumefantrine (AL) was adopted as first-line treatment for uncomplicated malaria in Kenya in 2006. Monitoring drug efficacy at regular intervals is essential to prevent unnecessary morbidity and mortality. The efficacy of AL and dihydroartemisinin-piperaquine (DP) were evaluated for the treatment of uncomplicated malaria in children aged six to 59 months in western Kenya. Methods From October 2010 to August 2011, children with fever or history of fever with uncomplicated Plasmodium falciparum mono-infection were enrolled in an in vivo efficacy trial in accordance with World Health Organization (WHO) guidelines. The children were randomized to treatment with a three-day course of AL or DP and efficacy outcomes were measured at 28 and 42 days after treatment initiation. Results A total of 137 children were enrolled in each treatment arm. There were no early treatment failures and all children except one had cleared parasites by day 3. Polymerase chain reaction (PCR)-uncorrected adequate clinical and parasitological response rate (ACPR) was 61% in the AL arm and 83% in the DP arm at day 28 (p = 0.001). PCR-corrected ACPR at day 28 was 97% in the AL group and 99% in the DP group, and it was 96% in both arms at day 42. Conclusions AL and DP remain efficacious for the treatment of uncomplicated malaria among children in western Kenya. The longer half-life of piperaquine relative to lumefantrine may provide a prophylactic effect, accounting for the lower rate of re-infection in the first 28 days after treatment in the DP arm.
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Ubben D, Poll EM. MMV in partnership: the Eurartesim® experience. Malar J 2013; 12:211. [PMID: 23782869 PMCID: PMC3691732 DOI: 10.1186/1475-2875-12-211] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Accepted: 06/11/2013] [Indexed: 12/23/2022] Open
Abstract
Background This case study describes how a public-private partnership between Medicines for Malaria Venture (MMV) and Sigma-Tau Industrie Farmaceutiche Riunite SpA achieved international regulatory approval for use of the fixed-dose artemisinin-based combination therapy dihydroartemisinin-piperaquine (Eurartesim®) for the treatment of malaria, enabling more widespread access to the medicine in malaria-endemic countries. Case description The combination of dihydroartemisinin and piperaquine demonstrated success in clinical trials for the treatment of malaria in Asia and Africa in the 2000s. However, as it had not been developed to international regulatory standards it was out of the reach of the majority of patients in disease-endemic countries, particularly those reliant on public healthcare systems supported by international donor funding. To overcome this, as of 2004 MMV worked in partnership with Sigma-Tau, Holleykin, Oxford University, the Institute of Tropical Medicine Antwerp, and the National Institute of Malaria Research India to develop the dihydroartemisinin-piperaquine combination to international standards. In 2011, the European Commission granted full marketing authorization to Sigma-Tau for Eurartesim. Discussion and evaluation The partnership between MMV, Sigma-Tau, and numerous other academic and industrial partners across the world, led to the successful development to EMA regulatory standards of a high-quality and highly efficacious anti-malarial treatment that otherwise would not have been possible. The dossier has also been submitted to the WHO for prequalification, and a safety statement to guide correct use of Eurartesim has been produced. In July 2012, the first delivery to a disease-endemic country was made to Cambodia, where the medicine is being used to treat patients and help counter the emergence of artemisinin resistance in the area. A paediatric dispersible formulation of Eurartesim is being developed, with the objective to submit the dossier to the EMA by the end of 2014. Conclusions The development of Eurartesim to international regulatory standards exemplifies the strengths of the product development partnership model in utilising the individual skills and expertise of partners with differing objectives to achieve a common goal. Successful uptake of Eurartesim by public health systems in malaria-endemic countries poses new challenges, which may require additional partnerships as we move forward.
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Affiliation(s)
- David Ubben
- Medicines for Malaria Venture, 20 Rte de Pré-Bois, PO Box 1826, Geneva 1215, Switzerland
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Burrows JN, van Huijsduijnen RH, Möhrle JJ, Oeuvray C, Wells TNC. Designing the next generation of medicines for malaria control and eradication. Malar J 2013; 12:187. [PMID: 23742293 PMCID: PMC3685552 DOI: 10.1186/1475-2875-12-187] [Citation(s) in RCA: 207] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Accepted: 05/29/2013] [Indexed: 11/10/2022] Open
Abstract
In the fight against malaria new medicines are an essential weapon. For the parts of the world where the current gold standard artemisinin combination therapies are active, significant improvements can still be made: for example combination medicines which allow for single dose regimens, cheaper, safer and more effective medicines, or improved stability under field conditions. For those parts of the world where the existing combinations show less than optimal activity, the priority is to have activity against emerging resistant strains, and other criteria take a secondary role. For new medicines to be optimal in malaria control they must also be able to reduce transmission and prevent relapse of dormant forms: additional constraints on a combination medicine. In the absence of a highly effective vaccine, new medicines are also needed to protect patient populations. In this paper, an outline definition of the ideal and minimally acceptable characteristics of the types of clinical candidate molecule which are needed (target candidate profiles) is suggested. In addition, the optimal and minimally acceptable characteristics of combination medicines are outlined (target product profiles). MMV presents now a suggested framework for combining the new candidates to produce the new medicines. Sustained investment over the next decade in discovery and development of new molecules is essential to enable the long-term delivery of the medicines needed to combat malaria.
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Affiliation(s)
- Jeremy N Burrows
- Medicines for Malaria Venture-MMV, PO Box 1826, Route de Pré-Bois 20, Geneva 151215, Switzerland
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Kakuru A, Jagannathan P, Arinaitwe E, Wanzira H, Muhindo M, Bigira V, Osilo E, Homsy J, Kamya MR, Tappero JW, Dorsey G. The effects of ACT treatment and TS prophylaxis on Plasmodium falciparum gametocytemia in a cohort of young Ugandan children. Am J Trop Med Hyg 2013; 88:736-43. [PMID: 23382157 DOI: 10.4269/ajtmh.12-0654] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Artemisinin-based combination therapies (ACTs) and trimethoprim-sulfamethoxazole (TS) prophylaxis are important tools for malaria control, but there are concerns about their effect on gametocytes, the stage of the parasite responsible for transmission. We conducted a longitudinal clinical trial in a cohort of HIV-infected and uninfected children living in an area of high malaria transmission intensity in Uganda. Study participants were randomized to artemether-lumefantrine (AL) or dihydroartemisinin-piperaquine (DP) for all treatments of uncomplicated malaria (N = 4,380) as well as TS prophylaxis for different durations. The risks of gametocytemia detected by microscopy in the 28 days after antimalarial therapy were compared using multivariate analyses. The risk of gametocyte detection was significantly higher in patients treated with DP compared with AL (adjusted relative risk = 1.85, P < 0.001) and among children prescribed TS prophylaxis (adjusted relative risk = 1.76, P < 0.001). The risk of gametocytemia and its potential for increasing transmission should be considered when evaluating different ACTs and TS prophylaxis for malaria control.
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Affiliation(s)
- Abel Kakuru
- Infectious Diseases Research Collaboration, Kampala, Uganda.
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Jagannathan P, Muhindo MK, Kakuru A, Arinaitwe E, Greenhouse B, Tappero J, Rosenthal PJ, Kaharuza F, Kamya MR, Dorsey G. Increasing incidence of malaria in children despite insecticide-treated bed nets and prompt anti-malarial therapy in Tororo, Uganda. Malar J 2012; 11:435. [PMID: 23273022 PMCID: PMC3551700 DOI: 10.1186/1475-2875-11-435] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Accepted: 12/26/2012] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The burden of malaria has decreased in parts of Africa following the scaling up of control interventions. However, similar data are limited from high transmission settings. METHODS A cohort of 100 children, aged six weeks to 10 months of age, were enrolled in an area of high malaria transmission intensity and followed through 48 months of age. Children were given a long-lasting insecticide-treated bed net (LLIN) at enrolment and received all care, including monthly blood smears and treatment with artemisinin-based combination therapy (ACT) for uncomplicated malaria, at a dedicated clinic. The incidence of malaria was estimated by passive surveillance and associations between malaria incidence and age, calendar time and season were measured using generalized estimating equations. RESULTS Reported compliance with LLINs was 98% based on monthly routine evaluations. A total of 1,633 episodes of malaria were observed, with a median incidence of 5.3 per person-year (PPY). There were only six cases of complicated malaria, all single convulsions. Malaria incidence peaked at 6.5 PPY at 23 months of age before declining to 3.5 PPY at 48 months. After adjusting for age and season, the risk of malaria increased by 52% from 2008 to 2011 (RR 1.52, 95% CI 1.10-2.09). Asymptomatic parasitaemia was uncommon (monthly prevalence <10%) and rarely observed prior to 24 months of age. CONCLUSIONS In Tororo, despite provision of LLINs and prompt treatment with ACT, the incidence of malaria is very high and appears to be rising. Additional malaria control interventions in high transmission settings are likely needed. TRIAL REGISTRATION Current Controlled Trials Identifier NCT00527800.
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Affiliation(s)
- Prasanna Jagannathan
- Department of Medicine, San Francisco General Hospital, University of California, San Francisco, CA, USA
| | - Mary K Muhindo
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Abel Kakuru
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | | | - Bryan Greenhouse
- Department of Medicine, San Francisco General Hospital, University of California, San Francisco, CA, USA
| | - Jordan Tappero
- Global AIDS Program, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Philip J Rosenthal
- Department of Medicine, San Francisco General Hospital, University of California, San Francisco, CA, USA
| | - Frank Kaharuza
- Centers for Disease Control and Prevention, Kampala, Uganda
| | - Moses R Kamya
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Grant Dorsey
- Department of Medicine, San Francisco General Hospital, University of California, San Francisco, CA, USA
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Keating GM. Eurartesim®: a guide to its use in the treatment of uncomplicated Plasmodium falciparum malaria. DRUGS & THERAPY PERSPECTIVES 2012. [DOI: 10.1007/bf03262125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Naing C, Mak JW, Aung K, Wong JYR. Efficacy and safety of dihydroartemisinin-piperaquine for treatment of uncomplicated Plasmodium falciparum malaria in endemic countries: meta-analysis of randomised controlled studies. Trans R Soc Trop Med Hyg 2012; 107:65-73. [PMID: 23222952 DOI: 10.1093/trstmh/trs019] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
The present review aimed to synthesise available evidence on the efficacy of dihydroartemisinin-piperaquine (DP) in treating uncomplicated Plasmodium falciparum malaria in people living in malaria-endemic countries by performing a meta-analysis of relevant studies. We searched relevant studies in electronic data bases up to December 2011. Published results from randomised controlled trials (RCTs) comparing efficacy of DP with other artemisinin-based combination therapies (ACTs), or non-ACTs, or placebo were selected. The primary endpoint was 28-day and 42-day treatment failure. We identified 26 RCTs. Many of the studies included in the present review were of high quality. Overall, DP, artesunate-mefloquine (MAS3) and artemether-lumefentrine (AL) were equally effective for reducing the risk of recurrent parasitaemia. The PCR confirmed efficacy of DP (99.5%) and MAS3 (97.7%) at day 28 exceeded 90%; both are efficacious. Comparable efficacy was also found for DP (95.6%) and AL (94.3%). The present review has documented that DP is comparable to other currently used ACTs such as MAS3 and AL in treating uncomplicated falciparum malaria. The better safety profile of DP and once-daily dosage improves adherence and its fixed co-formulation ensures that both drugs are taken together. Our conclusion is that DP has the potential to become a first-line antimalarial drug.
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Affiliation(s)
- Cho Naing
- School of Postgraduate Studies and Research, International Medical University, Kuala Lumpur 57000, Malaysia.
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Haynes RK, Cheu KW, Chan HW, Wong HN, Li KY, Tang MMK, Chen MJ, Guo ZF, Guo ZH, Sinniah K, Witte AB, Coghi P, Monti D. Interactions between artemisinins and other antimalarial drugs in relation to the cofactor model--a unifying proposal for drug action. ChemMedChem 2012; 7:2204-26. [PMID: 23112085 DOI: 10.1002/cmdc.201200383] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2012] [Revised: 09/30/2012] [Indexed: 01/14/2023]
Abstract
Artemisinins are proposed to act in the malaria parasite cytosol by oxidizing dihydroflavin cofactors of redox-active flavoenzymes, and under aerobic conditions by inducing their autoxidation. Perturbation of redox homeostasis coupled with the generation of reactive oxygen species (ROS) ensues. Ascorbic acid-methylene blue (MB), N-benzyl-1,4-dihydronicotinamide (BNAH)-MB, BNAH-lumiflavine, BNAH-riboflavin (RF), and NADPH-FAD-E. coli flavin reductase (Fre) systems at pH 7.4 generate leucomethylene blue (LMB) and reduced flavins that are rapidly oxidized in situ by artemisinins. These oxidations are inhibited by the 4-aminoquinolines piperaquine (PPQ), chloroquine (CQ), and others. In contrast, the arylmethanols lumefantrine, mefloquine (MFQ), and quinine (QN) have little or no effect. Inhibition correlates with the antagonism exerted by 4-aminoquinolines on the antimalarial activities of MB, RF, and artemisinins. Lack of inhibition correlates with the additivity/synergism between the arylmethanols and artemisinins. We propose association via π complex formation between the 4-aminoquinolines and LMB or the dihydroflavins; this hinders hydride transfer from the reduced conjugates to the artemisinins. The arylmethanols have a decreased tendency to form π complexes, and so exert no effect. The parallel between chemical reactivity and antagonism or additivity/synergism draws attention to the mechanism of action of all drugs described herein. CQ and QN inhibit the formation of hemozoin in the parasite digestive vacuole (DV). The buildup of heme-Fe(III) results in an enhanced efflux from the DV into the cytosol. In addition, the lipophilic heme-Fe(III) complexes of CQ and QN that form in the DV are proposed to diffuse across the DV membrane. At the higher pH of the cytosol, the complexes decompose to liberate heme-Fe(III) . The quinoline or arylmethanol reenters the DV, and so transfers more heme-Fe(III) out of the DV. In this way, the 4-aminoquinolines and arylmethanols exert antimalarial activities by enhancing heme-Fe(III) and thence free Fe(III) concentrations in the cytosol. The iron species enter into redox cycles through reduction of Fe(III) to Fe(II) largely mediated by reduced flavin cofactors and likely also by NAD(P)H-Fre. Generation of ROS through oxidation of Fe(II) by oxygen will also result. The cytotoxicities of artemisinins are thereby reinforced by the iron. Other aspects of drug action are emphasized. In the cytosol or DV, association by π complex formation between pairs of lipophilic drugs must adversely influence the pharmacokinetics of each drug. This explains the antagonism between PPQ and MFQ, for example. The basis for the antimalarial activity of RF mirrors that of MB, wherein it participates in redox cycling that involves flavoenzymes or Fre, resulting in attrition of NAD(P)H. The generation of ROS by artemisinins and ensuing Fenton chemistry accommodate the ability of artemisinins to induce membrane damage and to affect the parasite SERCA PfATP6 Ca(2+) transporter. Thus, the effect exerted by artemisinins is more likely a downstream event involving ROS that will also be modulated by mutations in PfATP6. Such mutations attenuate, but cannot abrogate, antimalarial activities of artemisinins. Overall, parasite resistance to artemisinins arises through enhancement of antioxidant defense mechanisms.
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Affiliation(s)
- Richard K Haynes
- Department of Chemistry, Institute of Molecular Technology for Drug Discovery and Synthesis, The Hong Kong University of Science and Technology, Clear Water Bay, Kowloon, Hong Kong, PR China.
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Anthony MP, Burrows JN, Duparc S, JMoehrle J, Wells TNC. The global pipeline of new medicines for the control and elimination of malaria. Malar J 2012; 11:316. [PMID: 22958514 PMCID: PMC3472257 DOI: 10.1186/1475-2875-11-316] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Accepted: 07/21/2012] [Indexed: 12/03/2022] Open
Abstract
Over the past decade, there has been a transformation in the portfolio of medicines to combat malaria. New fixed-dose artemisinin combination therapy is available, with four different types having received approval from Stringent Regulatory Authorities or the World Health Organization (WHO). However, there is still scope for improvement. The Malaria Eradication Research agenda identified several gaps in the current portfolio. Simpler regimens, such as a single-dose cure are needed, compared with the current three-day treatment. In addition, new medicines that prevent transmission and also relapse are needed, but with better safety profiles than current medicines. There is also a big opportunity for new medicines to prevent reinfection and to provide chemoprotection. This study reviews the global portfolio of new medicines in development against malaria, as of the summer of 2012. Cell-based phenotypic screening, and 'fast followers' of clinically validated classes, mean that there are now many new classes of molecules starting in clinical development, especially for the blood stages of malaria. There remain significant gaps for medicines blocking transmission, preventing relapse, and long-duration molecules for chemoprotection. The nascent pipeline of new medicines is significantly stronger than five years ago. However, there are still risks ahead in clinical development and sustainable funding of clinical studies is vital if this early promise is going to be delivered.
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Affiliation(s)
- Melinda P Anthony
- Medicines for Malaria Venture (MMV), 20 rte de Pré-Bois 1215, Geneva, Switzerland
| | - Jeremy N Burrows
- Medicines for Malaria Venture (MMV), 20 rte de Pré-Bois 1215, Geneva, Switzerland
| | - Stephan Duparc
- Medicines for Malaria Venture (MMV), 20 rte de Pré-Bois 1215, Geneva, Switzerland
| | - Joerg JMoehrle
- Medicines for Malaria Venture (MMV), 20 rte de Pré-Bois 1215, Geneva, Switzerland
| | - Timothy NC Wells
- Medicines for Malaria Venture (MMV), 20 rte de Pré-Bois 1215, Geneva, Switzerland
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Hamed K, Grueninger H. Coartem ®: a decade of patient-centric malaria management. Expert Rev Anti Infect Ther 2012; 10:645-659. [DOI: 10.1586/eri.12.51] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Stover KR, King ST, Robinson J. Artemether-lumefantrine: an option for malaria. Ann Pharmacother 2012; 46:567-77. [PMID: 22496476 DOI: 10.1345/aph.1q539] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To review the pharmacology, pharmacokinetics, safety, and efficacy of artemether-lumefantrine for the treatment of Plasmodium falciparum malaria. DATA SOURCES English-language articles indexed in PubMed (1947-November 2011) were identified, using the search terms artemether-lumefantrine, artemether-lumefantrine AND malaria, Coartem, and Coartem AND malaria. STUDY SELECTION AND DATA EXTRACTION Available English-language articles were reviewed. In addition, the malaria treatment regimens recommended by region as provided by the World Health Organization and the treatment guidelines from the Centers for Disease Control and Prevention were reviewed. DATA SYNTHESIS Artemether-lumefantrine is an artemisinin-derived combination antimalarial approved by the Food and Drug Administration in 2009 for the treatment of P. falciparum malaria. The dual mechanisms of action of artemether-lumefantrine provide rapid and sustained parasite clearance. In the reviewed studies, the polymerase chain reaction (PCR)-corrected 28-day cure rates of artemether-lumefantrine were noninferior to the most common comparators, including chloroquine, dapsone, and other artemisinin derivatives (86-100% vs 51-100%, respectively). PCR-corrected day-42 cure rates were 92-99.3% for artemether-lumefantrine versus 62-100% for the comparator groups. The major adverse effects (gastrointestinal and central nervous system) were mild to moderate in severity and did not require a change in therapy. Although adherence to artemether-lumefantrine has been described as a potential problem due to the complicated dosing schedule, studies have described clinical cure rates similar to those of other antimalarials. CONCLUSIONS Artemether-lumefantrine is a safe and effective treatment for children and adults with P. falciparum malaria.
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Affiliation(s)
- Kayla R Stover
- School of Pharmacy, University of Mississippi, Jackson, MS, USA.
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Development, evaluation, and application of an in silico model for antimalarial drug treatment and failure. Antimicrob Agents Chemother 2011; 55:3380-92. [PMID: 21537019 DOI: 10.1128/aac.01712-10] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Pharmacological mechanism-based modeling was refined and used to develop an in silico model of antimalarial drug treatment validated against clinical and field data. We used this approach to investigate key features of antimalarial drug action and effectiveness, with emphasis on the current generation of artemisinin combination therapies. We made the following conclusions. (i) The development of artemisinin tolerance and resistance will, unless checked, have an immediate, large impact on the protection afforded to its partner drug and on the likely clinical efficacy of artemisinin combination therapies. (ii) Long follow-up periods are required in clinical trials to detect all drug failures; the follow-up periods of 28 days recommended by the World Health Organization are likely to miss at least 50% of drug failures, and we confirmed recent suggestions that 63 days would be a more appropriate follow-up period. (iii) Day 7 serum drug concentrations are a significant risk factor of failure, although, paradoxically, receiver operating characteristic curve analysis revealed that their predictive power is relatively poor. (iv) The pharmacokinetic properties of the partner drugs in artemisinin-containing combination therapies are the most important determinants of treatment outcome, particularly the maximum killing rate. We discuss the assumptions made in such modeling approaches and how similar approaches may be refined in future work.
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