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Shafi J, Virk MK, Kalk E, Carlucci JG, Chepkemoi A, Bernard C, McHenry MS, Were E, Humphrey J, Davies MA, Mehta UC, Patel RC. Pharmacovigilance in Pregnancy Studies, Exposures and Outcomes Ascertainment, and Findings from Low- and Middle-Income Countries: A Scoping Review. Drug Saf 2024:10.1007/s40264-024-01445-1. [PMID: 38907172 DOI: 10.1007/s40264-024-01445-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2024] [Indexed: 06/23/2024]
Abstract
INTRODUCTION Pharmacovigilance (PV), or the ongoing safety monitoring after a medication has been licensed, plays a crucial role in pregnancy, as clinical trials often exclude pregnant people. It is important to understand how pregnancy PV projects operate in low- and middle-income countries (LMICs), where there is a disproportionate lack of PV data yet a high burden of adverse pregnancy outcomes. We conducted a scoping review to assess how exposures and outcomes were measured in recently published pregnancy PV projects in LMICs. METHODS We utilized a search string, secondary review, and team knowledge to review publications focusing on therapeutic or vaccine exposures among pregnant people in LMICs. We screened abstracts for relevance before conducting a full text review, and documented measurements of exposures and outcomes (categorized as maternal, birth, or neonatal/infant) among other factors, including study topic, setting, and design, comparator groups, and funding sources. RESULTS We identified 31 PV publications spanning at least 24 LMICs, all focusing on therapeutics or vaccines for infectious diseases, including HIV (n = 17), tuberculosis (TB; n = 9), malaria (n = 7), pertussis, tetanus, and diphtheria (n = 1), and influenza (n = 3). As for outcomes, n = 15, n = 31, and n = 20 of the publications covered maternal, birth, and neonatal/infant outcomes, respectively. Among HIV-specific publications, the primary exposure-outcome relationship of focus was exposure to maternal antiretroviral therapy and adverse outcomes. For TB-specific publications, the main exposures of interest were second-line drug-resistant TB and isoniazid-based prevention therapeutics for pregnant people living with HIV. For malaria-specific publications, the primary exposure-outcome relationship of interest was antimalarial medication exposure during pregnancy and adverse outcomes. Among vaccine-focused publications, the exposure was assessed during a specific time during pregnancy, with an overall interest in vaccine safety and/or efficacy. The study settings were frequently from Africa, designs varied from cohort or cross-sectional studies to clinical trials, and funding sources were largely from high-income countries. CONCLUSION The published pregnancy PV projects were largely centered in Africa and concerned with infectious diseases. This may reflect the disease burden in LMICs but also funding priorities from high-income countries. As the prevalence of non-communicable diseases increases in LMICs, PV projects will have to broaden their scope. Birth and neonatal/infant outcomes were most reported, with fewer reporting on maternal outcomes and none on longer-term child outcomes; additionally, heterogeneity existed in definitions and ascertainment of specific measures. Notably, almost all projects covered a single therapeutic exposure, missing an opportunity to leverage their projects to cover additional exposures, add scientific rigor, create uniformity across health services, and bolster existing health systems. For many publications, the timing of exposure, specifically by trimester, was crucial to maternal and neonatal safety. While currently published pregnancy PV literature offer insights into the PV landscape in LMICs, further work is needed to standardize definitions and measurements, integrate PV projects across health services, and establish longer-term monitoring.
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Affiliation(s)
| | | | - Emma Kalk
- Centre for Infectious Disease Epidemiology & Research, School of Public Health, University of Cape Town, Cape Town, South Africa
| | | | | | | | | | | | | | - Mary-Ann Davies
- Centre for Infectious Disease Epidemiology & Research, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Ushma C Mehta
- Centre for Infectious Disease Epidemiology & Research, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Rena C Patel
- University of Washington, Seattle, WA, USA.
- University of Alabama at Birmingham, Birmingham, AL, USA.
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Saito M, McGready R, Tinto H, Rouamba T, Mosha D, Rulisa S, Kariuki S, Desai M, Manyando C, Njunju EM, Sevene E, Vala A, Augusto O, Clerk C, Were E, Mrema S, Kisinza W, Byamugisha J, Kagawa M, Singlovic J, Yore M, van Eijk AM, Mehta U, Stergachis A, Hill J, Stepniewska K, Gomes M, Guérin PJ, Nosten F, Ter Kuile FO, Dellicour S. Pregnancy outcomes after first-trimester treatment with artemisinin derivatives versus non-artemisinin antimalarials: a systematic review and individual patient data meta-analysis. Lancet 2023; 401:118-130. [PMID: 36442488 PMCID: PMC9874756 DOI: 10.1016/s0140-6736(22)01881-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 09/15/2022] [Accepted: 09/22/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Malaria in the first trimester of pregnancy is associated with adverse pregnancy outcomes. Artemisinin-based combination therapies (ACTs) are a highly effective, first-line treatment for uncomplicated Plasmodium falciparum malaria, except in the first trimester of pregnancy, when quinine with clindamycin is recommended due to concerns about the potential embryotoxicity of artemisinins. We compared adverse pregnancy outcomes after artemisinin-based treatment (ABT) versus non-ABTs in the first trimester of pregnancy. METHODS For this systematic review and individual patient data (IPD) meta-analysis, we searched MEDLINE, Embase, and the Malaria in Pregnancy Library for prospective cohort studies published between Nov 1, 2015, and Dec 21, 2021, containing data on outcomes of pregnancies exposed to ABT and non-ABT in the first trimester. The results of this search were added to those of a previous systematic review that included publications published up until November, 2015. We included pregnancies enrolled before the pregnancy outcome was known. We excluded pregnancies with missing estimated gestational age or exposure information, multiple gestation pregnancies, and if the fetus was confirmed to be unviable before antimalarial treatment. The primary endpoint was adverse pregnancy outcome, defined as a composite of either miscarriage, stillbirth, or major congenital anomalies. A one-stage IPD meta-analysis was done by use of shared-frailty Cox models. This study is registered with PROSPERO, number CRD42015032371. FINDINGS We identified seven eligible studies that included 12 cohorts. All 12 cohorts contributed IPD, including 34 178 pregnancies, 737 with confirmed first-trimester exposure to ABTs and 1076 with confirmed first-trimester exposure to non-ABTs. Adverse pregnancy outcomes occurred in 42 (5·7%) of 736 ABT-exposed pregnancies compared with 96 (8·9%) of 1074 non-ABT-exposed pregnancies in the first trimester (adjusted hazard ratio [aHR] 0·71, 95% CI 0·49-1·03). Similar results were seen for the individual components of miscarriage (aHR=0·74, 0·47-1·17), stillbirth (aHR=0·71, 0·32-1·57), and major congenital anomalies (aHR=0·60, 0·13-2·87). The risk of adverse pregnancy outcomes was lower with artemether-lumefantrine than with oral quinine in the first trimester of pregnancy (25 [4·8%] of 524 vs 84 [9·2%] of 915; aHR 0·58, 0·36-0·92). INTERPRETATION We found no evidence of embryotoxicity or teratogenicity based on the risk of miscarriage, stillbirth, or major congenital anomalies associated with ABT during the first trimester of pregnancy. Given that treatment with artemether-lumefantrine was associated with fewer adverse pregnancy outcomes than quinine, and because of the known superior tolerability and antimalarial effectiveness of ACTs, artemether-lumefantrine should be considered the preferred treatment for uncomplicated P falciparum malaria in the first trimester. If artemether-lumefantrine is unavailable, other ACTs (except artesunate-sulfadoxine-pyrimethamine) should be preferred to quinine. Continued active pharmacovigilance is warranted. FUNDING Medicines for Malaria Venture, WHO, and the Worldwide Antimalarial Resistance Network funded by the Bill & Melinda Gates Foundation.
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Affiliation(s)
- Makoto Saito
- WorldWide Antimalarial Resistance Network, Oxford, UK; Infectious Diseases Data Observatory, Oxford, UK; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK; Division of Infectious Diseases, Advanced Clinical Research Center, Institute of Medical Science, University of Tokyo, Tokyo, Japan
| | - Rose McGready
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK; Shoklo Malaria Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Halidou Tinto
- Clinical Research Unit of Nanoro, Institut de Recherche en Sciences de la Santé, Nanoro, Burkina Faso
| | - Toussaint Rouamba
- Clinical Research Unit of Nanoro, Institut de Recherche en Sciences de la Santé, Nanoro, Burkina Faso
| | | | - Stephen Rulisa
- School of Medicine and Pharmacy, University Teaching Hospital of Kigali, University of Rwanda, Kigali, Rwanda
| | - Simon Kariuki
- Kenya Medical Research Institute, Centre for Global Health Research, Kisumu, Kenya
| | - Meghna Desai
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | | | - Eric M Njunju
- Department of Basic Sciences, Copperbelt University, Ndola, Zambia
| | - Esperanca Sevene
- Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique; Centro de Investigação em Saúde de Manhiça, Manhiça, Mozambique
| | - Anifa Vala
- Centro de Investigação em Saúde de Manhiça, Manhiça, Mozambique
| | - Orvalho Augusto
- Centro de Investigação em Saúde de Manhiça, Manhiça, Mozambique
| | | | - Edwin Were
- Department of Reproductive Health, Moi University, Eldoret, Kenya
| | | | - William Kisinza
- National Institute of Medical Research, Amani Medical Research Centre, Muheza, Tanzania
| | - Josaphat Byamugisha
- Department of Obstetrics and Gynaecology, Makerere University, Kampala, Uganda
| | - Mike Kagawa
- Department of Obstetrics and Gynaecology, Makerere University, Kampala, Uganda
| | | | - Mackensie Yore
- VA Los Angeles and University of California, Los Angeles National Clinician Scholars Program, VA Greater Los Angeles Healthcare System Health Services Research and Development Service Center of Innovation, Los Angeles, CA, USA
| | - Anna Maria van Eijk
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Ushma Mehta
- Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town, South Africa
| | - Andy Stergachis
- Department of Pharmacy, School of Pharmacy, and Department of Global Health, School of Public Health, University of Washington, Seattle, WA, USA
| | - Jenny Hill
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Kasia Stepniewska
- WorldWide Antimalarial Resistance Network, Oxford, UK; Infectious Diseases Data Observatory, Oxford, UK; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Melba Gomes
- UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases, Geneva, Switzerland; School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Philippe J Guérin
- WorldWide Antimalarial Resistance Network, Oxford, UK; Infectious Diseases Data Observatory, Oxford, UK; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Francois Nosten
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK; Shoklo Malaria Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Feiko O Ter Kuile
- WorldWide Antimalarial Resistance Network, Oxford, UK; Infectious Diseases Data Observatory, Oxford, UK; Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Stephanie Dellicour
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.
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Clark RL. Safety of Treating Malaria with Artemisinin-Based Combination Therapy in the First Trimester of Pregnancy. Reprod Toxicol 2022; 111:204-210. [PMID: 35667524 DOI: 10.1016/j.reprotox.2022.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 05/29/2022] [Accepted: 05/31/2022] [Indexed: 11/25/2022]
Abstract
There have been recent calls for the use of artemisinin-based combination therapies (ACTs) for uncomplicated malaria in the first trimester of pregnancy. Nevertheless, the 2021 WHO Guidelines for Malaria reaffirmed their position that there is not adequate clinical safety data on artemisinins to support that usage. The WHO's position is consistent with several issues with the existing clinical data. First, first trimester safety results from multiple ACTs were lumped in a meta-analysis which does not demonstrate that each of the included ACTs is equally safe. Second, safety results from all periods of the first trimester were lumped in the meta-analysis which does not demonstrate the same level of safety for all subperiods, particularly gestational Weeks 6 to 8 which is likely to be the most sensitive period. Third, even if there is evidence of a lack of an effect on miscarriage for a particular ACT, it does not follow then there are no developmental effects for any ACT. In monkeys, artesunate caused marked embryonal anemia leading to embryo death but the long-term consequences of lower levels of embryonal anemia are not known. Fourth, there have been advances in the sensitivity and usage of rapid diagnostic tests that will lead to diagnoses of malaria earlier in gestation which is less well studied and more likely sensitive to artemisinins. Any clinical studies of the safety of ACTs in the first trimester need to evaluate the results of treatment with individual ACTs during different 1- to 2-week periods of the first trimester.
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Ssentongo P, Heilbrunn ES, Ssentongo AE, Ssenyonga LVN, Lekoubou A. Birth prevalence of neural tube defects in eastern Africa: a systematic review and meta-analysis. BMC Neurol 2022; 22:202. [PMID: 35650541 PMCID: PMC9158202 DOI: 10.1186/s12883-022-02697-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 05/06/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Neural tube defects (NTDs) are associated with high rates of neonatal mortality and morbidity worldwide. The promotion of folic acid fortification and supplementation in pregnant women by the Food and Drug Administration significantly decreased the incidence of NTDs in the United States. This practice is not widely adopted in Eastern Africa countries. We hypothesized that these countries experience a higher burden of NTDs than countries that promote the use of folic acid. We aimed to estimate the birth prevalence of NTDs in the United Nations (UN) Eastern African region. METHODS PubMed (Medline), Embase, and Cochrane Library databases were systematically searched from inception to December 17, 2021. We included randomized controlled trials or observational studies that reported the prevalence estimates of NTDs in Eastern Africa. Random effects model was used to pool the effect estimates. The GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach was used to assess the certainty of the evidence. Outcome measures were overall and specific (spina bifida, anencephaly, encephalocele) rates of NTDs per 10,000 births, including live and stillborn cases. RESULTS The meta-analysis included 20 studies consisting of 752,936 individuals. The pooled prevalence of all NTDs per 10,000 births in Eastern Africa was 33.30 (95% CI: 21.58 to 51.34). Between-study heterogeneity was high (I2 = 97%, p < 0.0001), The rate was highest in Ethiopia (60 per 10,000). Birth prevalence of spina bifida (20 per 10,000) was higher than anencephaly (9 per 10,000) and encephalocele (2.33 per 10,000). No studies on NTDs were identified in 70% of the UN Eastern Africa region. Birth prevalence increased by 4% per year from 1983 to 2018. The level of evidence as qualified with GRADE was moderate. CONCLUSION The birth prevalence of NTDs in the United Nations region of Eastern Africa is 5 times as high as observed in Western countries with mandatory folic acid supplementation in place. Therefore, mandatory folic acid supplementation of stable foods may decrease the risk of NTDs in Eastern Africa.
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Affiliation(s)
- Paddy Ssentongo
- Department of Public Health Sciences, Penn State Hershey College of Medicine and Milton S. Hershey Medical Center, Hershey, PA, USA. .,Center for Neural Engineering, Department of Engineering, Science and Mechanics, The Pennsylvania State University, State College, PA, USA. .,Department of Medicine, Penn State Hershey College of Medicine and Milton S. Hershey Medical Center, Hershey, USA.
| | - Emily S Heilbrunn
- Department of Public Health Sciences, Penn State Hershey College of Medicine and Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Anna E Ssentongo
- Department of Public Health Sciences, Penn State Hershey College of Medicine and Milton S. Hershey Medical Center, Hershey, PA, USA.,Department of Surgery, Penn State Hershey College of Medicine and Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Lydia V N Ssenyonga
- Department of Nursing, Faculty of Health Sciences, Busitema University, TORORO, Uganda
| | - Alain Lekoubou
- Department of Public Health Sciences, Penn State Hershey College of Medicine and Milton S. Hershey Medical Center, Hershey, PA, USA.,Department of Neurology, Penn State Hershey College of Medicine and Milton S. Hershey Medical Center, Hershey, PA, USA
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Shibeshi W, Baye AM, Alemkere G, Engidawork E. Efficacy and Safety of Artemisinin-Based Combination Therapy for the Treatment of Uncomplicated Malaria in Pregnant Women: A Systematic Review and Meta-Analysis. Ther Clin Risk Manag 2021; 17:1353-1370. [PMID: 35221688 PMCID: PMC8866990 DOI: 10.2147/tcrm.s336771] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 12/12/2021] [Indexed: 11/29/2022] Open
Abstract
Introduction Malaria is one of the infectious diseases with substantial risks for pregnant women, the fetus and the newborn child. Thus, prevention and treatment of malaria with safe and effective drugs is of paramount importance. Pregnant women are mostly excluded from clinical trials, and systematic approaches of pharmacovigilance in pregnancy are limited. This means the safety and efficacy of antimalarial agents during pregnancy are unclear. Purpose This study was designed to carry out a systematic review and aggregate data meta-analysis of literature published on efficacy and safety of artemisinin-based combination therapy (ACT) for uncomplicated malaria in pregnant women. Methods A search of literature published between 1998 to 2020 on efficacy and safety of artemisinin-based combination therapy (ACT) in pregnant women was made using Cochrane Library, Medline and the Malaria in Pregnancy Consortium Library. Data were extracted independently by two reviewers, and any discrepancies were resolved by consensus. Meta-analysis was carried out using Open Meta-Analyst software. Random effects model was applied, and the heterogeneity of studies was evaluated using Higgins I2. Results Twenty-four studies that fulfilled the inclusion criteria were included in the final assessment. Overall, days 28 to 63 malaria treatment success rate was 96.1%. Overall days 28 to 63 cure rates for AL, AS+AQ, AS+MQ, DHA+PQ, AS+ATQ+PG and AS+SP were 95.1%, 92.2%, 97.0%,94.3%, 96.5% and 97.4%, respectively. Comparison of ACTs with non-ACTs revealed that the risk of treatment failure was substantially lower in patients treated with ACTs than with non-ACTs (risk ratio 0.20, 95% C.I. 0.09–0.43). The overall prevalences of miscarriage, stillbirth and congenital anomalies were 0.3%, 2.1% and 1.0%, respectively, and found to be comparable among various ACTs. There was comparable tolerability across ACTs during pregnancy. Conclusion ACTs demonstrated a high cure rate, safety and tolerability against Plasmodium falciparum infection in pregnant women. The higher treatment success and comparable tolerability could be used as an input for decision makers to support the continued usage of ACTs for treatment of uncomplicated falciparum malaria in pregnant women.
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Affiliation(s)
- Workineh Shibeshi
- Department of Pharmacology and Clinical Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Correspondence: Workineh Shibeshi Email
| | - Assefa Mulu Baye
- Department of Pharmacology and Clinical Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Getachew Alemkere
- Department of Pharmacology and Clinical Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Ephrem Engidawork
- Department of Pharmacology and Clinical Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
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Barber BE, Grigg MJ, Cooper DJ, van Schalkwyk DA, William T, Rajahram GS, Anstey NM. Clinical management of Plasmodium knowlesi malaria. ADVANCES IN PARASITOLOGY 2021; 113:45-76. [PMID: 34620385 DOI: 10.1016/bs.apar.2021.08.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The zoonotic parasite Plasmodium knowlesi has emerged as an important cause of human malaria in parts of Southeast Asia. The parasite is indistinguishable by microscopy from the more benign P. malariae, but can result in high parasitaemias with multiorgan failure, and deaths have been reported. Recognition of severe knowlesi malaria, and prompt initiation of effective therapy is therefore essential to prevent adverse outcomes. Here we review all studies reporting treatment of uncomplicated and severe knowlesi malaria. We report that although chloroquine is effective for the treatment of uncomplicated knowlesi malaria, artemisinin combination treatment is associated with faster parasite clearance times and lower rates of anaemia during follow-up, and should be considered the treatment of choice, particularly given the risk of administering chloroquine to drug-resistant P. vivax or P. falciparum misdiagnosed as P. knowlesi malaria in co-endemic areas. For severe knowlesi malaria, intravenous artesunate has been shown to be highly effective and associated with reduced case-fatality rates, and should be commenced without delay. Regular paracetamol may also be considered for patients with severe knowlesi malaria or for those with acute kidney injury, to attenuate the renal damage resulting from haemolysis-induced lipid peroxidation.
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Affiliation(s)
- Bridget E Barber
- QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia; Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia.
| | - Matthew J Grigg
- Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - Daniel J Cooper
- Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia; Department of Medicine, University of Cambridge School of Medicine, Cambridge, United Kingdom
| | | | - Timothy William
- Gleneagles Medical Centre, Kota Kinabalu, Malaysia; Clinical Research Centre, Queen Elizabeth Hospital 1, Kota Kinabalu, Malaysia
| | - Giri S Rajahram
- Clinical Research Centre, Queen Elizabeth Hospital 1, Kota Kinabalu, Malaysia; Queen Elizabeth Hospital 2, Kota Kinabalu, Malaysia
| | - Nicholas M Anstey
- Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
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Clark RL. Teratogen update: Malaria in pregnancy and the use of antimalarial drugs in the first trimester. Birth Defects Res 2020; 112:1403-1449. [PMID: 33079495 DOI: 10.1002/bdr2.1798] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 08/20/2020] [Indexed: 02/04/2023]
Abstract
Malaria is a particular problem in pregnancy because of enhanced sensitivity, the possibility of placental malaria, and adverse effects on pregnancy outcome. Artemisinin-containing combination therapies (ACTs) are the most effective antimalarials known. WHO recommends 7-day quinine therapy for uncomplicated Plasmodium falciparum malaria in the first trimester despite the superior tolerability and efficacy of 3-day ACT regimens because artemisinins caused embryolethality and/or cardiovascular malformations at relatively low doses in rats, rabbits, and monkeys. The developmental toxicity of artesunate, artemether, and DHA were similar in rats but artesunate was embryotoxic at lower doses in rabbits (5 mg/kg/day) than artemether (no effect level = 25 mg/kg/day). In clinical studies in Africa, treatment with artemether-lumefantrine in the first trimester was observed to be highly efficacious and the miscarriage rate (≤3.1%) was similar to no antimalarial treatment (2.6%). When data from the first-trimester use of largely artesunate-based therapies in Thailand were pooled together, there was no difference in miscarriage rate compared to quinine. However, individually, artesunate-mefloquine was associated with a higher miscarriage rate (15/71 = 21%) compared to other artemisinin-based therapies including 7-day artesunate + clindamycin (2/50 = 4%) and quinine (92/842 = 11%). Thus, appropriate statistical comparisons of individual ACT groups are needed prior to assuming that they all have the same risk for developmental toxicity. Current limitations in the assessment of the safety of ACTs in the first trimester are a lack of exposures early in gestation (gestational weeks 6-7), limited postnatal evaluation for cardiovascular malformations, and the pooling of all ACTs for the assessment of risk.
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Affiliation(s)
- Robert L Clark
- Artemis Pharmaceutical Research, Saint Augustine, Florida, USA
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D'Alessandro S, Menegola E, Parapini S, Taramelli D, Basilico N. Safety of Artemisinin Derivatives in the First Trimester of Pregnancy: A Controversial Story. Molecules 2020; 25:molecules25153505. [PMID: 32752056 PMCID: PMC7435965 DOI: 10.3390/molecules25153505] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 07/27/2020] [Accepted: 07/30/2020] [Indexed: 12/31/2022] Open
Abstract
Artemisinin combination therapy (ACT) is recommended by the World Health Organization (WHO) as first line treatment for uncomplicated malaria both in adults and children. During pregnancy, ACT is considered safe only in the second and third trimester, since animal studies have demonstrated that artemisinin derivatives can cause foetal death and congenital malformation within a narrow time window in early embryogenesis. During this period, artemisinin derivatives induce defective embryonic erythropoiesis and vasculogenesis/angiogenesis in experimental models. However, clinical data on the safety profile of ACT in pregnant women have not shown an increased risk of miscarriage, stillbirth, or congenital malformation, nor low birth weight, associated with exposure to artemisinins in the first trimester. Although further studies are needed, the evidence collected up to now is prompting the WHO towards a change in the guidelines for the treatment of uncomplicated malaria, allowing the use of ACT also in the first trimester of pregnancy.
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Affiliation(s)
- Sarah D'Alessandro
- Dipartimento di Scienze Biomediche, Chirurgiche e Odontoiatriche, Università degli Studi di Milano, 20133 Milan, Italy
| | - Elena Menegola
- Dipartimento di Scienze e Politiche Ambientali, Università degli Studi di Milano, 20133 Milan, Italy
| | - Silvia Parapini
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, 20133 Milan, Italy
| | - Donatella Taramelli
- Dipartimento di Scienze Farmacologiche e Biomolecolari, Università degli Studi di Milano, 20133 Milan, Italy
| | - Nicoletta Basilico
- Dipartimento di Scienze Biomediche, Chirurgiche e Odontoiatriche, Università degli Studi di Milano, 20133 Milan, Italy
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Augusto O, Stergachis A, Dellicour S, Tinto H, Valá A, Ruperez M, Macete E, Nakanabo-Diallo S, Kazienga A, Valéa I, d'Alessandro U, Ter Kuile FO, Calip GS, Ouma P, Desai M, Sevene E. First trimester use of artemisinin-based combination therapy and the risk of low birth weight and small for gestational age. Malar J 2020; 19:144. [PMID: 32268901 PMCID: PMC7140480 DOI: 10.1186/s12936-020-03210-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 03/28/2020] [Indexed: 11/16/2022] Open
Abstract
Background While there is increasing evidence on the safety of artemisinin-based combination therapy (ACT) for the case management of malaria in early pregnancy, little is known about the association between exposure to ACT during the first trimester and the effect on fetal growth. Methods Data were analysed from prospective studies of pregnant women enrolled in Mozambique, Burkina Faso and Kenya designed to determine the association between anti-malarial drug exposure in the first trimester and pregnancy outcomes, including low birth weight (LBW) and small for gestational age (SGA). Exposure to anti-malarial drugs was ascertained retrospectively by record linkage using a combination of data collected from antenatal and adult outpatient clinic registries, prescription records and self-reported medication usage by the women. Site-level data synthesis (fixed effects and random effects) was conducted as well as individual-level analysis (fixed effects by site). Results Overall, 1915 newborns were included with 92 and 26 exposed to ACT (artemether–lumefantrine) and quinine, respectively. In Burkina Faso, Mozambique and Kenya at recruitment, the mean age (standard deviation) was 27.1 (6.6), 24.2 (6.2) and 25.7 (6.5) years, and the mean gestational age was 24.0 (6.2), 21.2 (5.7) and 17.9 (10.2) weeks, respectively. The LBW prevalence among newborns born to women exposed to ACT and quinine (QNN) during the first trimester was 10/92 (10.9%) and 7/26 (26.9%), respectively, compared to 9.5% (171/1797) among women unexposed to any anti-malarials during pregnancy. Compared to those unexposed to anti-malarials, ACT and QNN exposed women had the pooled LBW prevalence ratio (PR) of 1.13 (95% confidence interval (CI) 0.62–2.05, p-value 0.700) and 2.03 (95% CI 1.09–3.78, p-value 0.027), respectively. Compared to those unexposed to anti-malarials ACT and QNN-exposed women had the pooled SGA PR of 0.85 (95% CI 0.50–1.44, p-value 0.543) and 1.41 (95% CI 0.71–2.77, p-value 0.322), respectively. Whereas compared to ACT-exposed, the QNN-exposed had a PR of 2.14 (95% CI 0.78–5.89, p-value 0.142) for LBW and 8.60 (95% CI 1.29–57.6, p-value 0.027) for SGA. The level of between sites heterogeneity was moderate to high. Conclusion ACT exposure during the first trimester was not associated with an increased occurrence of LBW or SGA. However, the data suggest a higher prevalence of LBW and SGA for children born to QNN-exposed pregnancies. The findings support the use of ACT (artemether–lumefantrine) for the treatment of uncomplicated malaria during the first trimester of pregnancy.
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Affiliation(s)
- Orvalho Augusto
- Department of Global Health, School of Public Health, University of Washington, Seattle, USA. .,Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique. .,Centro de Investigação em Saúde da Manhiça, Manhiça, Mozambique.
| | - Andy Stergachis
- Department of Global Health, School of Public Health, University of Washington, Seattle, USA.,Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, USA
| | - Stephanie Dellicour
- Department of Clinical Medicine, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Halidou Tinto
- Institut de Recherche en Sciences de la Santé/URCN, Nanoro, Burkina Faso
| | - Anifa Valá
- Centro de Investigação em Saúde da Manhiça, Manhiça, Mozambique
| | - Maria Ruperez
- Centro de Investigação em Saúde da Manhiça, Manhiça, Mozambique.,Barcelona Institute of Global Health, University of Barcelona, Barcelona, Spain
| | - Eusébio Macete
- Centro de Investigação em Saúde da Manhiça, Manhiça, Mozambique
| | | | - Adama Kazienga
- Institut de Recherche en Sciences de la Santé/URCN, Nanoro, Burkina Faso
| | - Innocent Valéa
- Institut de Recherche en Sciences de la Santé/URCN, Nanoro, Burkina Faso
| | - Umberto d'Alessandro
- Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Feiko O Ter Kuile
- Department of Clinical Medicine, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Gregory S Calip
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago, IL, USA
| | - Peter Ouma
- Kenya Medical Research Institute Centre for Global Health Research, Kisumu, Kenya
| | - Meghna Desai
- Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Esperança Sevene
- Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique. .,Centro de Investigação em Saúde da Manhiça, Manhiça, Mozambique.
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10
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Kilonzi M, Minzi O, Mutagonda R, Baraka V, Sasi P, Aklillu E, Kamuhabwa A. Usefulness of day 7 lumefantrine plasma concentration as a predictor of malaria treatment outcome in under-fives children treated with artemether-lumefantrine in Tanzania. Malar J 2020; 19:66. [PMID: 32046718 PMCID: PMC7014606 DOI: 10.1186/s12936-020-3150-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 02/04/2020] [Indexed: 12/18/2022] Open
Abstract
Background Day 7 plasma lumefantrine concentration is suggested as a predictor for malaria treatment outcomes and a cut-off of ≥ 200 ng/ml is associated with day 28 cure rate in the general population. However, day 7 lumefantrine plasma concentration can be affected by age, the extent of fever, baseline parasitaemia, and bodyweight. Therefore, this study assessed the usefulness of day 7 lumefantrine plasma concentration as a predictor of malaria treatment outcome in under-fives children treated with generic or innovator drug-containing artemether-lumefantrine (ALu) in Tanzania. Methods This study was nested in an equivalence prospective study that aimed at determining the effectiveness of a generic ALu (Artefan®) in comparison with the innovator’s product (Coartem®). Children with uncomplicated malaria aged 6–59 months were recruited and randomized to receive either generic or innovator’s product. Children were treated with ALu as per World Health Organization recommendations. The clinical and parasitological outcomes were assessed after 28 days of follow up. PCR was performed to distinguish recrudescence and re-infections among children with recurrent malaria. Analysis of day 7 lumefantrine plasma concentration was carried out using a high-performance liquid chromatographic method with UV detection. Results The PCR corrected cure rates were 98.7% for children treated with generic and 98.6% for those treated with the innovator product (p = 1.00). The geometric mean (± SD) of day 7 plasma lumefantrine concentration was 159.3 (± 2.4) ng/ml for the generic and 164 (± 2.5) ng/ml for the innovator groups, p = 0.87. Geometric mean (± SD) day 7 lumefantrine plasma concentration between cured and recurrent malaria was not statistically different in both treatment arms [158.5 (± 2.4) vs 100.0 (± 1.5) ng/ml, (p = 0.28) for generic arm and 158.5 (± 2.3) vs 251.2 (± 4.2) ng/ml, (p = 0.24) for innovator arm]. Nutritional status was found to be a determinant of recurrent malaria (adjusted hazardous ratio (95% confidence interval) = 3(1.1–8.2), p = 0.029. Conclusion Using the recommended cut-off point of ≥ 200 ng/ml, day 7 plasma lumefantrine concentration failed to predict malaria treatment outcome in children treated with ALu in Tanzania. Further studies are recommended to establish the day 7 plasma lumefantrine concentration cut-off point to predict malaria treatment outcome in children.
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Affiliation(s)
- Manase Kilonzi
- Department of Clinical Pharmacy and Pharmacology, School of Pharmacy, Muhimbili University of Health and Allied Sciences, P. O. BOX 65013, Dar es Salaam, Tanzania.
| | - Omary Minzi
- Department of Clinical Pharmacy and Pharmacology, School of Pharmacy, Muhimbili University of Health and Allied Sciences, P. O. BOX 65013, Dar es Salaam, Tanzania
| | - Ritah Mutagonda
- Department of Clinical Pharmacy and Pharmacology, School of Pharmacy, Muhimbili University of Health and Allied Sciences, P. O. BOX 65013, Dar es Salaam, Tanzania
| | - Vito Baraka
- Department of Research, National Institute of Medical Research, Tanga Centre, P O Box 5004, Tanga, Tanzania
| | - Philip Sasi
- Department of Clinical Pharmacology, School of Medicine, Muhimbili University of Health and Allied Sciences, P. O. BOX 6515, Dar es Salaam, Tanzania
| | - Eleni Aklillu
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital-Huddinge, C1:68, SE-141 86, Stockholm, Sweden
| | - Appolinary Kamuhabwa
- Department of Clinical Pharmacy and Pharmacology, School of Pharmacy, Muhimbili University of Health and Allied Sciences, P. O. BOX 65013, Dar es Salaam, Tanzania
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11
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Sridharan K, Sivaramakrishnan G, Kanters S. Adverse pregnancy outcomes between the anti-malarial drugs: Is there a difference between the drugs recommended by World Health Organization? Results of a mixed treatment comparison analysis of randomized clinical trials and cohort studies. INTERNATIONAL JOURNAL OF RISK & SAFETY IN MEDICINE 2020; 30:73-89. [PMID: 30714973 DOI: 10.3233/jrs-180022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Data regarding the relative safety profile of anti-malarial drugs in pregnancy is sparse mainly limited by the absence of head-to-head clinical trials. The present study is a network meta-analysis of safety of anti-malarial drugs used to treat malaria in pregnant women. METHODS A thorough literature search using the search strategy "Malaria [tiab] AND (Pregnant [tiab] OR Pregnancy [tiab])" was carried out for either randomized controlled trials or prospective cohort studies in pregnant malarial women prescribed any of the recommended anti-malarial drugs by World Health Organization (WHO) and that have reported adverse pregnancy outcomes such as miscarriage, still birth, and neonatal deaths. Odds ratio with 95% confidence interval was used as the effect estimate. Random-effects model and Markov Chain Monte Carlo simulation method was used to generate pooled estimates. Sensitivity analysis was performed excluding data from first trimester and GRADE approach was used to categorize the quality of evidence. RESULTS A total of 1242 papers were obtained with the search strategy, of which seven evaluating 10 treatment arms in a total of 5510 participants were included in the present meta-analysis. The pooled estimates revealed significantly lower risks of abortion with quinine and artemisinin-lumefantrine compared to dihydroartemisinin-piperaquine, artesunate with mefloquine and artesunate with amodiaquine. But when a cohort study that was conducted in the first trimester of pregnancy was excluded, no significant differences were observed in the risk of abortion between the anti-malarial drugs. No significant differences in the risk of either stillbirths or neonatal deaths were observed with any of the drugs. The quality of evidence was found to be very low due to serious limitations in both the precision and indirectness. CONCLUSION WHO recommended anti-malarials in pregnancy have similar risk profiles with regard to abortion, stillbirth and neonatal deaths.
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Affiliation(s)
- Kannan Sridharan
- Department of Pharmacology and Therapeutics, College of Medicine and Medical Sciences, Arabian Gulf University, Manama, Bahrain
| | - Gowri Sivaramakrishnan
- Department of Oral Health, College of Medicine, Nursing and Health Sciences, Fiji National University, Suva, Fiji
| | - Steve Kanters
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
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12
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Laelago T, Yohannes T, Tsige G. Determinants of preterm birth among mothers who gave birth in East Africa: systematic review and meta-analysis. Ital J Pediatr 2020; 46:10. [PMID: 31992346 PMCID: PMC6988288 DOI: 10.1186/s13052-020-0772-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 01/08/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Preterm birth (PTB) can be caused by different factors. The factors can be classified into different categories: socio demographic, obstetric, reproductive health, medical, behavioral and nutritional related. The objective of this review was identifying determinants of PTB among mothers who gave birth in East African countries. METHODS We have searched the following electronic bibliographic databases: PubMed, Google scholar, Cochrane library, AJOL (African journal online). Cross sectional, case control and cohort study published in English were included. There was no restriction on publication period. Studies with no abstracts and or full texts, editorials, and qualitative in design were excluded. Funnel plot was used to check publication bias. I-squared statistic was used to check heterogeneity. Pooled analysis was done by using fixed and random effect model. The Joanna Briggs Critical Appraisal Tools for review and meta-analysis was used to check the study quality. RESULTS A total of 58 studies with 134,801 participants were used to identify determinants of PTB. On pooled analysis, PTB was associated with age < 20 years (AOR 1.76, 95% CI: 1.33-2.32), birth interval less than 24 months (AOR 2.03, 95% CI 1.57-2.62), multiple pregnancy (AOR 3.44,95% CI: 3.02-3.91), < 4 antenatal care (ANC) visits (AOR 5.52, 95% CI: 4.32-7.05), and absence of ANC (AOR 5.77, 95% CI: 4.27-7.79). Other determinants of PTB included: Antepartum hemorrhage (APH) (AOR 4.90, 95% CI: 3.48-6.89), pregnancy induced hypertension (PIH) (AOR 3.10, 95% CI: 2.34-4.09), premature rupture of membrane (PROM) (AOR 5.90, 95% CI: 4.39-7.93), history of PTB (AOR 3.45, 95% CI: 2.72-4.38), and history of still birth/abortion (AOR 3.93, 95% CI: 2.70-5.70). Furthermore, Anemia (AOR 4.58, 95% CI: 2.63-7.96), HIV infection (AOR 2.59, 95% CI: 1.84-3.66), urinary tract infection (UTI) (AOR 5.27, 95% CI: 2.98-9.31), presence of vaginal discharge (AOR 5.33, 95% CI: 3.19-8.92), and malaria (AOR 3.08, 95% CI: 2.32-4.10) were significantly associated with PTB. CONCLUSIONS There are many determinants of PTB in East Africa. This review could provide policy makers, clinicians, and program officers to design intervention on preventing occurrence of PTB.
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Affiliation(s)
- Tariku Laelago
- Department of Nursing, Wachemo University, Durame campus, Durame, Ethiopia
| | - Tadele Yohannes
- College of Health Science and Medicine, Hawassa University, Hawassa, Ethiopia
| | - Gulima Tsige
- Hadiya Zone Health Department, Public Health Emergency Management, Hosanna, Ethiopia
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13
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Burrows J, Slater H, Macintyre F, Rees S, Thomas A, Okumu F, Hooft van Huijsduijnen R, Duparc S, Wells TNC. A discovery and development roadmap for new endectocidal transmission-blocking agents in malaria. Malar J 2018; 17:462. [PMID: 30526594 PMCID: PMC6287360 DOI: 10.1186/s12936-018-2598-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 11/24/2018] [Indexed: 11/10/2022] Open
Abstract
Reaching the overall goal of eliminating malaria requires halting disease transmission. One approach to blocking transmission is to prevent passage of the parasite to a mosquito, by preventing formation or transmission of gametocytes. An alternative approach, pioneered in the veterinary field, is to use endectocides, which are molecules that render vertebrate blood meals toxic for the mosquito vector, also killing the parasite. Field studies and modelling suggest that reducing the lifespan of the mosquito may significantly reduce transmission, given the lengthy maturation process of the parasite. To guide the development of new endectocides, or the reformulation of existing molecules, it is important to construct a framework of the required attributes, commonly called the target candidate profile. Here, using a combination of insights from current endectocides, mathematical models of the malaria transmission dynamics, and known impacts of vector control, a target candidate profile (TCP-6) and a regulatory strategy are proposed for a transmission reducing agent. The parameters chosen can be used to assess the potential of a new medicine, independent of whether it has classical endectocide activity, reduces the insect and parasite lifespan or any combination of all three, thereby constituting an ‘endectocidal transmission blocking’ paradigm.
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Affiliation(s)
- Jeremy Burrows
- Medicines for Malaria Venture, Route de Pré Bois 20, 1215, Geneva 15, Switzerland.
| | - Hannah Slater
- PATH, 2201 Westlake Avenue, Seattle, WA, 98121, USA.,Department of Infectious Disease Epidemiology, MRC Centre for Global Disease Analysis, Imperial College London, Norfolk Place, London, W2 1PG, UK
| | - Fiona Macintyre
- Medicines for Malaria Venture, Route de Pré Bois 20, 1215, Geneva 15, Switzerland
| | - Sarah Rees
- Innovative Vector Control Consortium, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK
| | - Anna Thomas
- Medicines for Malaria Venture, Route de Pré Bois 20, 1215, Geneva 15, Switzerland
| | - Fredros Okumu
- Environmental Health and Ecological Sciences Department, Ifakara Health Institute, Off Mlabani Passage, Ifakara, Morogoro, United Republic of Tanzania.,School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Parktown, Republic of South Africa.,Institute of Biodiversity, Animal Health and Comparative Medicine, University of Glasgow, Glasgow, UK
| | | | - Stephan Duparc
- 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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14
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Saito M, Gilder ME, McGready R, Nosten F. Antimalarial drugs for treating and preventing malaria in pregnant and lactating women. Expert Opin Drug Saf 2018; 17:1129-1144. [PMID: 30351243 DOI: 10.1080/14740338.2018.1535593] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Malaria in pregnancy and postpartum cause maternal mortality and adverse fetal outcomes. Efficacious and safe antimalarials are needed to treat and prevent such serious consequences. However, because of the lack of evidence on fetal safety, quinine, an old and less efficacious drug has long been recommended for pregnant women. Uncertainty about safety in relation to breastfeeding leads to withholding of efficacious treatments postpartum or cessation of breastfeeding. Areas covered: A search identified literature on humans in three databases (MEDLINE, Embase and Global health) using pregnancy or lactation, and the names of antimalarial drugs as search terms. Adverse reactions to the mother, fetus or breastfed infant were summarized together with efficacies. Expert opinion: Artemisinins are more efficacious and well-tolerated than quinine in pregnancy. Furthermore, the risks of miscarriage, stillbirth or congenital abnormality were not higher in pregnancies exposed to artemisinin derivatives for treatment of malaria than in pregnancies exposed to quinine or in the comparable background population unexposed to any antimalarials, and this was true for treatment in any trimester. Assessment of safety and efficacy of antimalarials including dose optimization for pregnant women is incomplete. Resistance to sulfadoxine-pyrimethamine in Plasmodium falciparum and long unprotected intervals between intermittent treatment doses begs reconsideration of current preventative recommendations in pregnancy. Data remain limited on antimalarials during breastfeeding; while most first-line drugs appear safe, further research is needed.
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Affiliation(s)
- Makoto Saito
- a Shoklo Malaria Research Unit (SMRU), Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine , Mahidol University , Tak , Thailand.,b Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine , University of Oxford , Oxford , UK.,c WorldWide Antimalarial Resistance Network (WWARN) , Oxford , UK
| | - Mary Ellen Gilder
- a Shoklo Malaria Research Unit (SMRU), Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine , Mahidol University , Tak , Thailand
| | - Rose McGready
- a Shoklo Malaria Research Unit (SMRU), Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine , Mahidol University , Tak , Thailand.,b Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine , University of Oxford , Oxford , UK
| | - François Nosten
- a Shoklo Malaria Research Unit (SMRU), Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine , Mahidol University , Tak , Thailand.,b Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine , University of Oxford , Oxford , UK
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15
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D'Alessandro U, Hill J, Tarning J, Pell C, Webster J, Gutman J, Sevene E. Treatment of uncomplicated and severe malaria during pregnancy. THE LANCET. INFECTIOUS DISEASES 2018; 18:e133-e146. [PMID: 29395998 DOI: 10.1016/s1473-3099(18)30065-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 07/19/2017] [Accepted: 10/13/2017] [Indexed: 12/13/2022]
Abstract
Over the past 10 years, the available evidence on the treatment of malaria during pregnancy has increased substantially. Owing to their relative ease of use, good sensitivity and specificity, histidine rich protein 2 based rapid diagnostic tests are appropriate for symptomatic pregnant women; however, such tests are less appropriate for systematic screening because they will not detect an important proportion of infections among asymptomatic women. The effect of pregnancy on the pharmacokinetics of antimalarial drugs varies greatly between studies and class of antimalarial drugs, emphasising the need for prospective studies in pregnant and non-pregnant women. For the treatment of malaria during the first trimester, international guidelines are being reviewed by WHO. For the second and third trimester of pregnancy, results from several trials have confirmed that artemisinin-based combination treatments are safe and efficacious, although tolerability and efficacy might vary by treatment. It is now essential to translate such evidence into policies and clinical practice that benefit pregnant women in countries where malaria is endemic. Access to parasitological diagnosis or appropriate antimalarial treatment remains low in many countries and regions. Therefore, there is a pressing need for research to identify quality improvement interventions targeting pregnant women and health providers. In addition, efficient and practical systems for pharmacovigilance are needed to further expand knowledge on the safety of antimalarial drugs, particularly in the first trimester of pregnancy.
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Affiliation(s)
- Umberto D'Alessandro
- Medical Research Council Unit, Banjul, The Gambia; London School of Hygiene & Tropical Medicine, London, UK.
| | - Jenny Hill
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Joel Tarning
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Christopher Pell
- Centre for Social Science and Global Health, University of Amsterdam, Amsterdam, Netherlands; Amsterdam Institute for Global Health and Development, Amsterdam, Netherlands
| | - Jayne Webster
- London School of Hygiene & Tropical Medicine, London, UK
| | - Julie Gutman
- Malaria Branch, US Centers for Diseases Control and Prevention, Atlanta, GA, USA
| | - Esperanca Sevene
- Manhiça Health Research Center (CISM), Manhiça, Mozambique; Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
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16
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Manirakiza A, Serdouma E, Ngbalé RN, Moussa S, Gondjé S, Degana RM, Bata GGB, Moyen JM, Delmont J, Grésenguet G, Sepou A. A brief review on features of falciparum malaria during pregnancy. J Public Health Afr 2017; 8:668. [PMID: 29456824 PMCID: PMC5812306 DOI: 10.4081/jphia.2017.668] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 08/16/2017] [Accepted: 08/17/2017] [Indexed: 11/22/2022] Open
Abstract
Malaria in pregnancy is a serious public health problem in tropical areas. Frequently, the placenta is infected by accumulation of Plasmodium falciparum-infected erythrocytes in the intervillous space. Falciparum malaria acts during pregnancy by a range of mechanisms, and chronic or repeated infection and co-infections have insidious effects. The susceptibility of pregnant women to malaria is due to both immunological and humoral changes. Until a malaria vaccine becomes available, the deleterious effects of malaria in pregnancy can be avoided by protection against infection and prompt treatment with safe, effective antimalarial agents; however, concurrent infections such as with HIV and helminths during pregnancy are jeopardizing malaria control in sub-Saharan Africa.
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Affiliation(s)
| | | | | | - Sandrine Moussa
- Pasteur Institute of Bangui, Bangui, Central African Republic
| | - Samuel Gondjé
- Ministry of Public Health, Population and AIDS Control, Bangui, Central African Republic
| | - Rock Mbetid Degana
- Ministry of Public Health, Population and AIDS Control, Bangui, Central African Republic
| | | | - Jean Methode Moyen
- Ministry of Public Health, Population and AIDS Control, Bangui, Central African Republic
| | - Jean Delmont
- Center for Training and Research in Tropical Medicine and Health, Faculty of Medicine North, Marseille, France
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17
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Saito M, Gilder ME, Nosten F, McGready R, Guérin PJ. Systematic literature review and meta-analysis of the efficacy of artemisinin-based and quinine-based treatments for uncomplicated falciparum malaria in pregnancy: methodological challenges. Malar J 2017; 16:488. [PMID: 29237461 PMCID: PMC5729448 DOI: 10.1186/s12936-017-2135-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 12/05/2017] [Indexed: 12/30/2022] Open
Abstract
Background There is no agreed standard method to assess the efficacy of anti-malarials for uncomplicated falciparum in pregnancy despite an increased risk of adverse outcomes for the mother and the fetus. The aim of this review is to present the currently available evidence from both observational and interventional cohort studies on anti-malarial efficacy in pregnancy and summarize the variability of assessment and reporting found in the review process. Methods Efficacy methodology and assessment of artemisinin-based treatments (ABT) and quinine-based treatments (QBT) were reviewed systematically using seven databases and two clinical trial registries (protocol registration—PROSPERO: CRD42017054808). Pregnant women in all trimesters with parasitologically confirmed uncomplicated falciparum malaria were included irrespective of symptoms. This review attempted to re-calculate proportions of treatment success applying the same definition as the standard WHO methodology for non-pregnant populations. Aggregated data meta-analyses using data from randomized control trials (RCTs) comparing different treatments were performed by random effects model. Results A total of 48 eligible efficacy studies were identified including 7279 treated Plasmodium falciparum episodes. While polymerase chain reaction (PCR) was used in 24 studies for differentiating recurrence, the assessment and reporting of treatment efficacy was heterogeneous. When the same definition could be applied, PCR-corrected treatment failure of ≥ 10% at any time points was observed in 3/30 ABT and 3/7 QBT arms. Ten RCTs compared different combinations of ABT but there was a maximum of two published RCTs with PCR-corrected outcomes for each comparison. Five RCTs compared ABT and QBT. Overall, the risk of treatment failure was significantly lower in ABT than in QBT (risk ratio 0.22, 95% confidence interval 0.07–0.63), although the actual drug combinations and outcome endpoints were different. First trimester women were included in 12 studies none of which were RCTs of ABT. Conclusions Efficacy studies in pregnancy are not only limited in number but use varied methodological assessments. In five RCTs with comparable methodology, ABT resulted in higher efficacy than QBT in the second and third trimester of pregnancy. Individual patient data meta-analysis can include data from observational cohort studies and could overcome some of the limitations of the current assessment given the paucity of data in this vulnerable group. Electronic supplementary material The online version of this article (10.1186/s12936-017-2135-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Makoto Saito
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Old Road Campus, Roosevelt Drive, Oxford, OX3 7FZ, UK. .,Shoklo Malaria Research Unit (SMRU), Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Tak, Thailand.
| | - Mary Ellen Gilder
- Shoklo Malaria Research Unit (SMRU), Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Tak, Thailand
| | - François Nosten
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Old Road Campus, Roosevelt Drive, Oxford, OX3 7FZ, UK.,Shoklo Malaria Research Unit (SMRU), Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Tak, Thailand
| | - Rose McGready
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Old Road Campus, Roosevelt Drive, Oxford, OX3 7FZ, UK.,Shoklo Malaria Research Unit (SMRU), Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Tak, Thailand
| | - Philippe J Guérin
- WorldWide Antimalarial Resistance Network (WWARN), Oxford, UK.,Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Old Road Campus, Roosevelt Drive, Oxford, OX3 7FZ, UK
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Clark RL, Edwards TL, Longo M, Kinney J, Walker DK, Rhodes J, Clode SA, Rückle T, Wells T, Andenmatten N, Huber AC. Improved safety margin for embryotoxicity in rats for the new endoperoxide artefenomel (OZ439) as compared to artesunate. Birth Defects Res 2017; 110:553-578. [DOI: 10.1002/bdr2.1170] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 11/01/2017] [Accepted: 11/01/2017] [Indexed: 11/11/2022]
Affiliation(s)
| | | | | | | | | | - Jon Rhodes
- Covance Laboratories Ltd, Reproduction Toxicology; Harrogate North Yorkshire United Kingdom
| | - Sally A. Clode
- Covance Laboratories Ltd, Reproduction Toxicology; Harrogate North Yorkshire United Kingdom
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19
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Clark RL. Animal Embryotoxicity Studies of Key Non-Artemisinin Antimalarials and Use in Women in the First Trimester. Birth Defects Res 2017. [DOI: 10.1002/bdr2.1035] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Dellicour S, Sevene E, McGready R, Tinto H, Mosha D, Manyando C, Rulisa S, Desai M, Ouma P, Oneko M, Vala A, Rupérez M, Macete E, Menéndez C, Nakanabo-Diallo S, Kazienga A, Valéa I, Calip G, Augusto O, Genton B, Njunju EM, Moore KA, d’Alessandro U, Nosten F, ter Kuile F, Stergachis A. First-trimester artemisinin derivatives and quinine treatments and the risk of adverse pregnancy outcomes in Africa and Asia: A meta-analysis of observational studies. PLoS Med 2017; 14:e1002290. [PMID: 28463996 PMCID: PMC5412992 DOI: 10.1371/journal.pmed.1002290] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Accepted: 03/23/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Animal embryotoxicity data, and the scarcity of safety data in human pregnancies, have prevented artemisinin derivatives from being recommended for malaria treatment in the first trimester except in lifesaving circumstances. We conducted a meta-analysis of prospective observational studies comparing the risk of miscarriage, stillbirth, and major congenital anomaly (primary outcomes) among first-trimester pregnancies treated with artemisinin derivatives versus quinine or no antimalarial treatment. METHODS AND FINDINGS Electronic databases including Medline, Embase, and Malaria in Pregnancy Library were searched, and investigators contacted. Five studies involving 30,618 pregnancies were included; four from sub-Saharan Africa (n = 6,666 pregnancies, six sites) and one from Thailand (n = 23,952). Antimalarial exposures were ascertained by self-report or active detection and confirmed by prescriptions, clinic cards, and outpatient registers. Cox proportional hazards models, accounting for time under observation and gestational age at enrollment, were used to calculate hazard ratios. Individual participant data (IPD) meta-analysis was used to combine the African studies, and the results were then combined with those from Thailand using aggregated data meta-analysis with a random effects model. There was no difference in the risk of miscarriage associated with the use of artemisinins anytime during the first trimester (n = 37/671) compared with quinine (n = 96/945; adjusted hazard ratio [aHR] = 0.73 [95% CI 0.44, 1.21], I2 = 0%, p = 0.228), in the risk of stillbirth (artemisinins, n = 10/654; quinine, n = 11/615; aHR = 0.29 [95% CI 0.08-1.02], p = 0.053), or in the risk of miscarriage and stillbirth combined (pregnancy loss) (aHR = 0.58 [95% CI 0.36-1.02], p = 0.099). The corresponding risks of miscarriage, stillbirth, and pregnancy loss in a sensitivity analysis restricted to artemisinin exposures during the embryo sensitive period (6-12 wk gestation) were as follows: aHR = 1.04 (95% CI 0.54-2.01), I2 = 0%, p = 0.910; aHR = 0.73 (95% CI 0.26-2.06), p = 0.551; and aHR = 0.98 (95% CI 0.52-2.04), p = 0.603. The prevalence of major congenital anomalies was similar for first-trimester artemisinin (1.5% [95% CI 0.6%-3.5%]) and quinine exposures (1.2% [95% CI 0.6%-2.4%]). Key limitations of the study include the inability to control for confounding by indication in the African studies, the paucity of data on potential confounders, the limited statistical power to detect differences in congenital anomalies, and the lack of assessment of cardiovascular defects in newborns. CONCLUSIONS Compared to quinine, artemisinin treatment in the first trimester was not associated with an increased risk of miscarriage or stillbirth. While the data are limited, they indicate no difference in the prevalence of major congenital anomalies between treatment groups. The benefits of 3-d artemisinin combination therapy regimens to treat malaria in early pregnancy are likely to outweigh the adverse outcomes of partially treated malaria, which can occur with oral quinine because of the known poor adherence to 7-d regimens. REVIEW REGISTRATION PROSPERO CRD42015032371.
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Affiliation(s)
- Stephanie Dellicour
- Malaria Epidemiology Unit, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- * E-mail: (SD); (AS)
| | - Esperança Sevene
- Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
- Centro de Investigação em Saúde da Manhiça, Manhiça, Mozambique
| | - Rose McGready
- Shoklo Malaria Research Unit, Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Halidou Tinto
- Institut de Recherche en Sciences de la Santé/Centre Muraz, Bobo-Dioulasso, Burkina Faso
| | | | | | - Stephen Rulisa
- University Teaching Hospital of Kigali, University of Rwanda, Kigali, Rwanda
| | - Meghna Desai
- Malaria Branch, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Peter Ouma
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Martina Oneko
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Anifa Vala
- Centro de Investigação em Saúde da Manhiça, Manhiça, Mozambique
| | - Maria Rupérez
- Centro de Investigação em Saúde da Manhiça, Manhiça, Mozambique
- Instituto de Salud Global de Barcelona, Barcelona, Spain
| | - Eusébio Macete
- Centro de Investigação em Saúde da Manhiça, Manhiça, Mozambique
| | - Clara Menéndez
- Centro de Investigação em Saúde da Manhiça, Manhiça, Mozambique
- Instituto de Salud Global de Barcelona, Barcelona, Spain
| | - Seydou Nakanabo-Diallo
- Institut de Recherche en Sciences de la Santé/Centre Muraz, Bobo-Dioulasso, Burkina Faso
| | - Adama Kazienga
- Institut de Recherche en Sciences de la Santé/Centre Muraz, Bobo-Dioulasso, Burkina Faso
| | - Innocent Valéa
- Institut de Recherche en Sciences de la Santé/Centre Muraz, Bobo-Dioulasso, Burkina Faso
| | - Gregory Calip
- Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, Chicago, Illinois, United States of America
| | - Orvalho Augusto
- Centro de Investigação em Saúde da Manhiça, Manhiça, Mozambique
| | - Blaise Genton
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- Infectious Diseases Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Eric M. Njunju
- School of Medicine, Copperbelt University, Ndola, Zambia
| | - Kerryn A. Moore
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
- Macfarlane Burnet Institute for Medical Research and Public Health, Melbourne, Victoria, Australia
| | - Umberto d’Alessandro
- Medical Research Council, Fajara, The Gambia
- Institute of Tropical Medicine, Antwerp, Belgium
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Francois Nosten
- Shoklo Malaria Research Unit, Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Feiko ter Kuile
- Malaria Epidemiology Unit, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Andy Stergachis
- Department of Pharmacy, School of Pharmacy, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, School of Public Health, University of Washington, Seattle, Washington, United States of America
- * E-mail: (SD); (AS)
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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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22
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Gomes C, Boareto AC, Dalsenter PR. Clinical and non-clinical safety of artemisinin derivatives in pregnancy. Reprod Toxicol 2016; 65:194-203. [PMID: 27506918 DOI: 10.1016/j.reprotox.2016.08.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 08/03/2016] [Accepted: 08/05/2016] [Indexed: 10/21/2022]
Abstract
Malaria in pregnancy is a clinically wasting infectious disease, where drug therapy has to be promptly initiated. Currently, the treatment of this infection depends on the use of artemisinin derivatives. The World Health Organization does not recommend the use of these drugs in the first trimester of pregnancy due to non-clinical findings that have shown embryolethality and teratogenic effects. Nevertheless, until now, this toxicity has not been proved in humans. Artemisinin derivatives mechanisms of embryotoxicity are related to depletion of circulating embryonic primitive erythroblasts. Species differences in this sensitive period for toxicity and the presence of malaria infection, which could reduce drug distribution to the fetus, are significant to the risk assessment of artemisinin derivatives treatment to pregnant women. In this review we aimed to assess the results of non-clinical and clinical studies with artemisinin derivatives, their mechanisms of embryotoxicity and discuss the safety of their use during pregnancy.
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Affiliation(s)
- Caroline Gomes
- Department of Pharmacology, Federal University of Paraná, Curitiba, PR, Brazil.
| | - Ana Cláudia Boareto
- Department of Pharmacology, Federal University of Paraná, Curitiba, PR, Brazil.
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23
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Moore BR, Salman S, Davis TME. Treatment regimens for pregnant women with falciparum malaria. Expert Rev Anti Infect Ther 2016; 14:691-704. [PMID: 27322015 DOI: 10.1080/14787210.2016.1202758] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION With increasing parasite drug resistance, the WHO has updated treatment recommendations for falciparum malaria including in pregnancy. This review assesses the evidence for choice of treatment for pregnant women. AREAS COVERED Relevant studies, primarily those published since 2010, were identified from reference databases and were used to identify secondary data sources. Expert commentary: WHO recommends use of intravenous artesunate for severe malaria, quinine-clindamycin for uncomplicated malaria in first trimester, and artemisinin combination therapy for uncomplicated malaria in second/third trimesters. Because fear of adverse outcomes has often excluded pregnant women from conventional drug development, available data for novel therapies are usually based on preclinical studies and cases of inadvertent exposure. Changes in antimalarial drug disposition in pregnancy have been observed but are yet to be translated into specific treatment recommendations. Such targeted regimens may become important as parasite resistance demands that drug exposure is optimized.
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Affiliation(s)
- Brioni R Moore
- a Fiona Stanley Hospital Unit, School of Medicine and Pharmacology , University of Western Australia , Perth , Australia.,b School of Pharmacy , Curtin University , Perth , Australia
| | - Sam Salman
- c Linear Clinical Research Limited, QEII Medical Centre , Nedlands , Australia.,d Fremantle Hospital Unit, School of Medicine and Pharmacology , University of Western Australia , Fremantle , Australia
| | - Timothy M E Davis
- d Fremantle Hospital Unit, School of Medicine and Pharmacology , University of Western Australia , Fremantle , Australia
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Moore KA, Simpson JA, Paw MK, Pimanpanarak M, Wiladphaingern J, Rijken MJ, Jittamala P, White NJ, Fowkes FJI, Nosten F, McGready R. Safety of artemisinins in first trimester of prospectively followed pregnancies: an observational study. THE LANCET. INFECTIOUS DISEASES 2016; 16:576-583. [PMID: 26869377 PMCID: PMC4835584 DOI: 10.1016/s1473-3099(15)00547-2] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 12/14/2015] [Accepted: 12/15/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Artemisinins, the most effective antimalarials available, are not recommended for falciparum malaria during the first trimester of pregnancy because of safety concerns. Therefore, quinine is used despite its poor effectiveness. Assessing artemisinin safety requires weighing the risks of malaria and its treatment. We aimed to assess the effect of first-trimester malaria and artemisinin treatment on miscarriage and major congenital malformations. METHODS In this observational study, we assessed data from antenatal clinics on the Thai-Myanmar border between Jan 1, 1994, and Dec 31, 2013. We included women who presented to antenatal clinics during their first trimester with a viable fetus. Women were screened for malaria, and data on malaria, antimalarial treatment, and birth outcomes were collected. The relationship between artemisinin treatments (artesunate, dihydroartemisinin, or artemether) and miscarriage or malformation was assessed using Cox regression with left-truncation and time-varying exposures. FINDINGS Of 55 636 pregnancies registered between 1994 and 2013, 25 485 pregnancies were analysed for first-trimester malaria and miscarriage, in which 2558 (10%) had first-trimester malaria. The hazard of miscarriage increased 1·61-fold after an initial first-trimester falciparum episode (95% CI 1·32-1·97; p<0·0001), 3·24-fold following falciparum recurrence (2·24-4·68; p<0·0001), and 2·44-fold (1·01-5·88; p=0·0473) following recurrent symptomatic vivax malaria. No difference was noted in miscarriage in first-line falciparum treatments with artemisinin (n=183) versus quinine (n=842; HR 0·78 [95% CI 0·45-1·34]; p=0·3645) or in risk of major congenital malformations (two [2%] of 109 [95% CI 0·22-6·47] versus eight (1%) of 641 [0·54-2·44], respectively). INTERPRETATION First-trimester falciparum and vivax malaria both increase the risk of miscarriage. We noted no evidence of an increased risk of miscarriage or of major congenital malformations associated with first-line treatment with an artemisinin derivative compared with quinine. In view of the low efficacy of quinine and wide availability of highly effective artemisinin-based combination therapies, it is time to reconsider first-trimester antimalarial treatment recommendations. FUNDING The Wellcome Trust and The Bill & Melinda Gates Foundation.
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Affiliation(s)
- Kerryn A Moore
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia; Macfarlane Burnet Institute for Medical Research and Public Health, Melbourne, VIC, Australia.
| | - Julie A Simpson
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
| | - Moo Kho Paw
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - MuPawJay Pimanpanarak
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Jacher Wiladphaingern
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Marcus J Rijken
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Podjanee Jittamala
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Nicholas J White
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Freya J I Fowkes
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia; Macfarlane Burnet Institute for Medical Research and Public Health, Melbourne, VIC, Australia; Department of Epidemiology and Preventive Medicine and Department of Infectious Diseases, Monash University, Melbourne, VIC, Australia
| | - François Nosten
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Rose McGready
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Dellicour S, Desai M, Aol G, Oneko M, Ouma P, Bigogo G, Burton DC, Breiman RF, Hamel MJ, Slutsker L, Feikin D, Kariuki S, Odhiambo F, Pandit J, Laserson KF, Calip G, Stergachis A, ter Kuile FO. Risks of miscarriage and inadvertent exposure to artemisinin derivatives in the first trimester of pregnancy: a prospective cohort study in western Kenya. Malar J 2015; 14:461. [PMID: 26581434 PMCID: PMC4652370 DOI: 10.1186/s12936-015-0950-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2015] [Accepted: 10/21/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The artemisinin anti-malarials are widely deployed as artemisinin-based combination therapy (ACT). However, they are not recommended for uncomplicated malaria during the first trimester because safety data from humans are scarce. METHODS This was a prospective cohort study of women of child-bearing age carried out in 2011-2013, evaluating the relationship between inadvertent ACT exposure during first trimester and miscarriage. Community-based surveillance was used to identify 1134 early pregnancies. Cox proportional hazard models with left truncation were used. RESULTS The risk of miscarriage among pregnancies exposed to ACT (confirmed + unconfirmed) in the first trimester, or during the embryo-sensitive period (≥6 to <13 weeks gestation) was higher than among pregnancies unexposed to anti-malarials in the first trimester: hazard ratio (HR) = 1.70, 95 % CI (1.08-2.68) and HR = 1.61 (0.96-2.70). For confirmed ACT-exposures (primary analysis) the corresponding values were: HR = 1.24 (0.56-2.74) and HR = 0.73 (0.19-2.82) relative to unexposed women, and HR = 0.99 (0.12-8.33) and HR = 0.32 (0.03-3.61) relative to quinine exposure, but the numbers of quinine exposures were very small. CONCLUSION ACT exposure in early pregnancy was more common than quinine exposure. Confirmed inadvertent artemisinin exposure during the potential embryo-sensitive period was not associated with increased risk of miscarriage. Confirmatory studies are needed to rule out a smaller than three-fold increase in risk.
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Affiliation(s)
- Stephanie Dellicour
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.
| | - Meghna Desai
- Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - George Aol
- Kenya Medical Research Institute Centre for Global Health Research, Kisumu, Kenya.
| | - Martina Oneko
- Kenya Medical Research Institute Centre for Global Health Research, Kisumu, Kenya.
| | - Peter Ouma
- Kenya Medical Research Institute Centre for Global Health Research, Kisumu, Kenya.
| | - Godfrey Bigogo
- Kenya Medical Research Institute Centre for Global Health Research, Kisumu, Kenya.
| | - Deron C Burton
- Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | | | - Mary J Hamel
- Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | | | - Daniel Feikin
- Centers for Disease Control and Prevention, Atlanta, GA, USA.
| | - Simon Kariuki
- Kenya Medical Research Institute Centre for Global Health Research, Kisumu, Kenya.
| | - Frank Odhiambo
- Kenya Medical Research Institute Centre for Global Health Research, Kisumu, Kenya.
| | | | | | - Greg Calip
- Pharmacy Systems, Outcomes and Policy Department, University of Illinois at Chicago, Chicago, USA.
| | - Andy Stergachis
- Departments of Pharmacy and Global Health, Schools of Pharmacy and Public Health, University of Washington, Seattle, USA.
| | - Feiko O ter Kuile
- Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, UK.
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Abstract
Severe malaria in pregnancy is a large contributor to maternal morbidity and mortality. Intravenous quinine has traditionally been the treatment drug of choice for severe malaria in pregnancy. However, recent randomized clinical trials (RCTs) indicate that intravenous artesunate is more efficacious for treating severe malaria, resulting in changes to the World Health Organization (WHO) treatment guidelines. Artemisinins, including artesunate, are embryo-lethal in animal studies and there is limited experience with their use in the first trimester. This review summarizes the current literature supporting 2010 WHO treatment guidelines for severe malaria in pregnancy and the efficacy, pharmacokinetics, and adverse event data for currently used antimalarials available for severe malaria in pregnancy. We identified ten studies on the treatment of severe malaria in pregnancy that reported clinical outcomes. In two studies comparing intravenous quinine with intravenous artesunate, intravenous artesunate was more efficacious and safe for use in pregnant women. No studies detected an increased risk of miscarriage, stillbirth, or congenital anomalies associated with first trimester exposure to artesunate. Although the WHO recommends using either quinine or artesunate for the treatment of severe malaria in first trimester pregnancies, our findings suggest that artesunate should be the preferred treatment option for severe malaria in all trimesters.
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27
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Padberg S. Anti-infective Agents. DRUGS DURING PREGNANCY AND LACTATION 2015. [PMCID: PMC7150338 DOI: 10.1016/b978-0-12-408078-2.00007-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 10/29/2022]
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Mosha D, Mazuguni F, Mrema S, Abdulla S, Genton B. Medication exposure during pregnancy: a pilot pharmacovigilance system using health and demographic surveillance platform. BMC Pregnancy Childbirth 2014; 14:322. [PMID: 25223541 PMCID: PMC4177159 DOI: 10.1186/1471-2393-14-322] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Accepted: 09/11/2014] [Indexed: 12/21/2022] Open
Abstract
Background There is limited safety information on most drugs used during pregnancy. This is especially true for medication against tropical diseases because pharmacovigilance systems are not much developed in these settings. The aim of the present study was to demonstrate feasibility of using Health and Demographic Surveillance System (HDSS) as a platform to monitor drug safety in pregnancy. Methods Pregnant women with gestational age below 20 weeks were recruited from Reproductive and Child Health (RCH) clinics or from monthly house visits carried out for the HDSS. A structured questionnaire was used to interview pregnant women. Participants were followed on monthly basis to record any new drug used as well as pregnancy outcome. Results 1089 pregnant women were recruited; 994 (91.3%) completed the follow-up until delivery. 98% women reported to have taken at least one medication during pregnancy, mainly those used in antenatal programmes. Other most reported drugs were analgesics (24%), antibiotics (17%), and antimalarial (15%), excluding IPTp. Artemether-lumefantrine (AL) was the most used antimalarial for treating illness by nearly 3/4 compared to other groups of malaria drugs. Overall, antimalarial and antibiotic exposures in pregnancy were not significantly associated with adverse pregnancy outcome. Iron and folic acid supplementation were associated with decreased risk of miscarriage/stillbirth (OR 0.1; 0.08 – 0.3). Conclusion Almost all women were exposed to medication during pregnancy. Exposure to iron and folic acid had a beneficial effect on pregnancy outcome. HDSS proved to be a useful platform to establish a reliable pharmacovigilance system in resource-limited countries. Widening drug safety information is essential to facilitate evidence based risk-benefit decision for treatment during pregnancy, a major challenge with newly marketed medicines.
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Affiliation(s)
- Dominic Mosha
- Ifakara Health Institute, Rufiji, HDSS, P,O Box 40, Rufiji, Tanzania.
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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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