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Nyaaba N, Andoh NE, Amoh G, Amuzu DSY, Ansong M, Ordóñez-Mena JM, Hirst J. Comparative efficacy and safety of the artemisinin derivatives compared to quinine for treating severe malaria in children and adults: A systematic update of literature and network meta-analysis. PLoS One 2022; 17:e0269391. [PMID: 35857773 PMCID: PMC9299386 DOI: 10.1371/journal.pone.0269391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 05/19/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The artemisinin derivatives are the preferred antimalaria drugs for treating severe Plasmodium falciparum malaria. However, their clinical effectiveness compared to each other is unknown. Our objective, therefore, was to evaluate the efficacy and safety of the artemisinin derivatives and quinine for treating severe P. falciparum malaria in children and adults using a network meta-analysis. METHODS AND FINDINGS Review protocol was registered with PROSPERO, CRD42020218190. We updated the search strategies of three Cochrane systematic reviews which included published and unpublished randomised control trials (RCTs) that have compared specific artemisinin derivatives to quinine in treating severe malaria. Search included CENTRAL, MEDLINE, Embase, LILACS, ISI Web of Science and trial registries up to February 2021. We screened studies, extracted data, assessed risk of bias, and quality of evidence in duplicate. Separate network meta-analyses in the frequentist framework, using a random effects model, with quinine as reference, were conducted for adults and children, and rankings were produced using p-scores to assess mortality, parasite clearance, coma recovery, fever clearance, neurological sequela and adverse events. Searches identified 818 citations, 33 RCTs were eligible. We pooled 7795 children and 3182 adults. The networks involved artesunate, artemether, rectal artemisinin, arteether and quinine. Compared to quinine, artesunate reduced mortality in children (risk ratio (RR), 0.76; 95%CI [0.65 to 0.89], moderate quality), adults (RR, 0.55; 95%CI [0.40 to 0.75], moderate quality) and in cerebral malaria (RR, 0.72; 95%CI [0.55 to 0.94], moderate quality). Compared to rectal artemisinin and intramuscular arteether, the efficacy and safety of parenteral artesunate, and intramuscular artemether in treating severe malaria are not clear. Rankings showed that none of the artemisinin drugs were consistently superior in all the outcomes assessed. Indirect evidence produced were of very low ratings due to suspected publication bias and imprecision. CONCLUSIONS Artesunate reduces mortality compared to quinine for both adults and children in Asia and Africa including cerebral malaria. The artemisinin derivatives remain the best treatment for severe malaria but their comparative clinical effectiveness is yet to be fully explored.
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Affiliation(s)
- Nicholas Nyaaba
- Infectious Disease Centre, 37 Military Hospital, Cantonments, Accra, Ghana
- * E-mail:
| | - Nana Efua Andoh
- Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
| | - Gordon Amoh
- Korle-Bu Polyclinic/ Family Medicine Department, Korle-Bu Teaching Hospital, Korle-Bu, Accra, Ghana
| | - Dominic Selorm Yao Amuzu
- West African Centre for Cell Biology of Infectious Pathogens, Department of Biochemistry, Cell and Molecular Biology, University of Ghana, Legon, Accra, Ghana
| | - Mary Ansong
- The International Sickle Cell Centre, Accra Central, Accra, Ghana
| | - José M. Ordóñez-Mena
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
- National Institute for Health Research (NIRH), Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Jennifer Hirst
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
- National Institute for Health Research (NIRH), Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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Abstract
BACKGROUND In 2011 the World Health Organization (WHO) recommended parenteral artesunate in preference to quinine as first-line treatment for people with severe malaria. Prior to this recommendation many countries, particularly in Africa, had begun to use artemether, an alternative artemisinin derivative. This Cochrane Review evaluates intramuscular artemether compared with both quinine and artesunate. OBJECTIVES To assess the efficacy and safety of intramuscular artemether versus any other parenteral medication in the treatment of severe malaria in adults and children. SEARCH METHODS We searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (the Cochrane Library), MEDLINE, Embase, and LILACS, ISI Web of Science, conference proceedings, and reference lists of articles. We also searched the WHO International Clinical Trial Registry Platform, ClinicalTrials.gov, and the metaRegister of Controlled Trials (mRCT) for ongoing trials up to 7 September 2018. We checked the reference lists of all studies identified by the search. We examined references listed in review articles and previously compiled bibliographies to look for eligible studies. SELECTION CRITERIA Randomized controlled trials (RCTs) comparing intramuscular artemether with intravenous/intramuscular quinine or artesunate for treating severe malaria. DATA COLLECTION AND ANALYSIS The primary outcome was all-cause death. Two review authors independently screened each article by title and abstract, and examined potentially relevant studies for inclusion using an eligibility form. Two review authors independently extracted data and assessed risk of bias of included studies. We summarized dichotomous outcomes using risk ratios (RRs) and continuous outcomes using mean differences (MDs), and have presented both measures with 95% confidence intervals (CIs). Where appropriate, we combined data in meta-analyses and used the GRADE approach to summarize the certainty of the evidence. MAIN RESULTS We included 19 RCTs, enrolling 2874 adults and children with severe malaria, carried out in Africa (12 trials) and in Asia (7 trials).Artemether versus quinineFor children, there is probably little or no difference in the risk of death between intramuscular artemether and quinine (RR 0.97, 95% CI 0.77 to 1.21; 13 trials, 1659 participants, moderate-certainty evidence). Coma resolution time may be about five hours shorter with artemether (MD -5.45, 95% CI -7.90 to -3.00; six trials, 358 participants, low-certainty evidence). Artemether may make little difference to neurological sequelae (RR 0.84, 95% CI 0.66 to 1.07; seven trials, 968 participants, low-certainty evidence). Compared to quinine, artemether probably shortens the parasite clearance time by about nine hours (MD -9.03, 95% CI -11.43 to -6.63; seven trials, 420 participants, moderate-certainty evidence), and may shorten the fever clearance time by about three hours (MD -3.73, 95% CI -6.55 to -0.92; eight trials, 457 participants, low-certainty evidence).For adults, treatment with intramuscular artemether probably results in fewer deaths than treatment with quinine (RR 0.59, 95% CI 0.42 to 0.83; four trials, 716 participants, moderate-certainty evidence).Artemether versus artesunateArtemether and artesunate have not been directly compared in randomized trials in children.For adults, mortality is probably higher with intramuscular artemether (RR 1.80, 95% CI 1.09 to 2.97; two trials, 494 participants, moderate-certainty evidence). AUTHORS' CONCLUSIONS Artemether appears to be more effective than quinine in children and adults. Artemether compared to artesunate has not been extensively studied, but in adults it appears inferior. These findings are consistent with the WHO recommendations that artesunate is the drug of choice, but artemether is acceptable when artesunate is not available.
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Affiliation(s)
- Ekpereonne B Esu
- College of Medical Sciences, University of CalabarDepartment of Public HealthCalabarCross River StateNigeria
| | - Emmanuel E Effa
- College of Medical Sciences, University of CalabarInternal MedicinePMB 1115CalabarCross River StateNigeria540001
| | - Oko N Opie
- Federal College of EducationDepartment of General StudiesObuduCross River StateNigeria
| | - Martin M Meremikwu
- University of Calabar Teaching HospitalDepartment of PaediatricsPMB 1115CalabarCross River StateNigeria
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Bobossi-Serengbe G, Gody JC, Fioboy R, Elowa JB, Manirakiza A. [Comparison of the effectiveness of artemether and quinine for treatment of severe malaria in children, Bangui, Central African Republic]. ACTA ACUST UNITED AC 2015; 108:107-11. [PMID: 25925807 DOI: 10.1007/s13149-015-0428-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Accepted: 12/09/2014] [Indexed: 11/28/2022]
Abstract
The management of severe malaria is a major challenge in the health care services in sub-Saharan Africa. This study aimed to assess the efficacy and safety of artemether and quinine in severe malaria at Complexe pédiatrique of Bangui, Central African Republic. A total of 212 children among 1125 hospital admissions (18.8%), and aged 6 to 59 months were randomly treated with artemether and quinine. Anemia (58.5%) and seizures (33.5%) were the major syndromes observed. On the third day of follow up, a regression of clinical signs and parasite clearance were observed in 98.1% of children treated with artemether and 97.1% of children treated with quinine. The death rate was 2.3% due to anemic and neurological forms. These findings show that the artemether and quinine have similar efficacy. Hence, associated with adequate intensive health care, the use of these antimalarial drugs can significantly reduce mortality from severe malaria in the Central African Republic.
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Affiliation(s)
- G Bobossi-Serengbe
- Université de Bangui, Avenue des Martyrs, BP 1450, Bangui, République centrafricaine
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Marcsisin SR, Jin X, Bettger T, McCulley N, Sousa JC, Shanks GD, Tekwani BL, Sahu R, Reichard GA, Sciotti RJ, Melendez V, Pybus BS. CYP450 phenotyping and metabolite identification of quinine by accurate mass UPLC-MS analysis: a possible metabolic link to blackwater fever. Malar J 2013; 12:214. [PMID: 23800033 PMCID: PMC3693902 DOI: 10.1186/1475-2875-12-214] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Accepted: 06/11/2013] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The naturally occurring alkaloid drug, quinine is commonly used for the treatment of severe malaria. Despite centuries of use, its metabolism is still not fully understood, and may play a role in the haemolytic disorders associated with the drug. METHODS Incubations of quinine with CYPs 1A2, 2C9, 2C19, 2D6, and 3A4 were conducted, and the metabolites were characterized by accurate mass UPLC-MS(E) analysis. Reactive oxygen species generation was also measured in human erythrocytes incubated in the presence of quinine with and without microsomes. RESULTS The metabolites 3-hydroxyquinine, 2'-oxoquininone, and O-desmethylquinine were observed after incubation with CYPs 3A4 (3-hydroxyquinine and 2'-oxoquininone) and 2D6 (O-desmethylquinine). In addition, multiple hydroxylations were observed both on the quinoline core and the quinuclidine ring system. Of the five primary abundance CYPs tested, 3A4, 2D6, 2C9, and 2C19 all demonstrated activity toward quinine, while 1A2 did not. Further, quinine produced robust dose-dependent oxidative stress in human erythrocytes in the presence of microsomes. CONCLUSIONS Taken in context, these data suggest a CYP-mediated link between quinine metabolism and the poorly understood haemolytic condition known as blackwater fever, often associated with quinine ingestion.
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Affiliation(s)
- Sean R Marcsisin
- Department of Drug Development, Division of Experimental Therapeutics, Walter Reed Army Institute of Research, Silver Spring, MD 20910, USA
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Cloete TT, Krebs HJ, Clark JA, Connelly MC, Orcutt A, Sigal MS, Kiplin Guy R, N’Da DD. Antimalarial activity of 10-alkyl/aryl esters and -aminoethylethers of artemisinin. Bioorg Chem 2013; 46:10-6. [DOI: 10.1016/j.bioorg.2012.10.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Revised: 09/19/2012] [Accepted: 10/04/2012] [Indexed: 11/17/2022]
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Vijayan VK. Is the incidence of parasitic lung diseases increasing, and how may this affect modern respiratory medicine? Expert Rev Respir Med 2012; 3:339-44. [PMID: 20477325 DOI: 10.1586/ers.09.28] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Abstract
Malaria chemotherapy is under constant threat from the emergence and spread of multidrug resistance of Plasmodium falciparum. Resistance has been observed to almost all currently used antimalarials. Some drugs are also limited by toxicity. A fundamental component of the strategy for malaria chemotherapy is based on prompt, effective and safe antimalarial drugs. To counter the threat of resistance of P. falciparum to existing monotherapeutic regimens, current malaria treatment is based principally on the artemisinin group of compounds, either as monotherapy or artemisinin-based combination therapies for treatment of both uncomplicated and severe falciparum malaria. Key advantages of artemisinins over the conventional antimalarials include their rapid and potent action, with good tolerability profiles. Their action also covers transmissible gametocytes, resulting in decreased disease transmission. Up to now there has been no prominent report of drug resistance to this group of compounds. Treatment of malaria in pregnant women requires special attention in light of limited treatment options caused by potential teratogenicity coupled with a paucity of safety data for the mother and fetus. Treatment of other malaria species is less problematic and chloroquine is still the drug of choice, although resistance of P. vivax to chloroquine has been reported. Multiple approaches to the identification of new antimalarial targets and promising antimalarial drugs are being pursued in order to cope with drug resistance.
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Affiliation(s)
- Kesara Na-Bangchang
- Faculty of Allied Health Sciences, Thammasat University (Rangsit Campus), Paholyothin Road, Klong Luang District, Pathumtanee 12121, Thailand.
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Carbonara T, Pascale R, Argentieri MP, Papadia P, Fanizzi FP, Villanova L, Avato P. Phytochemical analysis of a herbal tea from Artemisia annua L. J Pharm Biomed Anal 2012; 62:79-86. [PMID: 22305080 DOI: 10.1016/j.jpba.2012.01.015] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2011] [Revised: 01/10/2012] [Accepted: 01/11/2012] [Indexed: 12/21/2022]
Abstract
Strategies to control diffusion of malaria needs to account for the increase of resistance of the parasite to the conventional antimalarial drugs. It has been proposed that a traditional aqueous preparation from Artemisia annua, with a low content of the active compound, artemisinin, may reduce the risk of resistance of the protozoa and be relatively more effective in the treatment of the disease. The solubility properties of the molecule have been the matter of concern about the therapeutic usefulness of herbal teas from A. annua. The present study aimed at analysing the chemical profile of a tea infusion from A. annua. Tea from A. annua was prepared through infusion of the plant aerial parts in water for 1, 24 and 48 h. Content of artemisinin was determined by HPLC-ELSD. Overall chemical characterization of the extracts was carried out by a combination of metabolomic techniques. The artemisinin content varied only slightly in the three different extracts (about 0.12%). A series of mono-caffeoyl- and mono-feruloyl-quinic acids, di-caffeoyl- and di-feruloyl-quinic acids was identified as main components of the tea infusion, together with some flavonoids. Reconstitution of the same extracts in less polar or apolar solvents resulted in a different composition with no phenolics and a much lower concentration of artemisinin.
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Affiliation(s)
- Teresa Carbonara
- Dipartimento Farmaco-Chimico, Università Aldo Moro, Via Orabona 4, I-70125 Bari, Italy
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Okombo J, Ohuma E, Picot S, Nzila A. Update on genetic markers of quinine resistance in Plasmodium falciparum. Mol Biochem Parasitol 2011; 177:77-82. [DOI: 10.1016/j.molbiopara.2011.01.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2010] [Revised: 01/13/2011] [Accepted: 01/19/2011] [Indexed: 10/18/2022]
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Olliaro P, Vaillant MT. Alternative visual displays of metaanalysis of malaria treatment trials to facilitate translation of research into policy. Diagn Microbiol Infect Dis 2011; 68:422-31. [PMID: 21094426 DOI: 10.1016/j.diagmicrobio.2010.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2009] [Revised: 03/19/2010] [Accepted: 08/06/2010] [Indexed: 01/22/2023]
Abstract
Typically, metaanalyses show relative effects and heterogeneity, but not absolute effects-an essential element in policy decision. Data obtained through a systematic review of antimalarial treatment trials and virtual trials were used to generate a display that shows and quantifies absolute and relative effects as well as heterogeneity for comparative trials results. A plot of failure rates (with 95% confidence intervals) of the test drug on the y axis against the risk difference (RD) versus the comparator drug on the x axis is proposed; the area is divided into 4 quadrants by a vertical line (no RD) and a horizontal line (maximum tolerated failures, e.g., 10% for antimalarials). This allows identifying where a drug can be used (meeting efficacy requirements) and quantifying differences (versus another treatment option). The area of the polygon connecting the study points expresses heterogeneity. This graphic display is simple to prepare and interpret and combines in 1 graph both measures of absolute treatment effect and difference, as well as heterogeneity. It may complement current methods and provide useful information in policy decision making.
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Affiliation(s)
- Piero Olliaro
- UNICEF/UNDP/WB/WHO Special Programme for Research and Training in Tropical Diseases (TDR), Geneva, Switzerland
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Sheehy SH, Angus BJ. Malaria: severe, life-threatening. BMJ CLINICAL EVIDENCE 2011; 2011:0913. [PMID: 21375787 PMCID: PMC3217801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
INTRODUCTION Severe malaria mainly affects children under 5 years old, non-immune travellers, migrants to malarial areas, and people living in areas with unstable or seasonal malaria. Cerebral malaria, causing encephalopathy and coma, is fatal in around 20% of children and adults, and neurological sequelae may occur in some survivors. Severe malarial anaemia may have a mortality rate of over 13%. METHODS AND OUTCOMES We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of antimalarial treatments and adjunctive treatment for complicated falciparum malaria in non-pregnant people? We searched: Medline, Embase, The Cochrane Library, and other important databases up to December 2009 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA). RESULTS We found 33 systematic reviews, RCTs, or observational studies that met our inclusion criteria. CONCLUSIONS In this systematic review we present information relating to the effectiveness and safety of the following interventions: dexamethasone, exchange blood transfusion, initial blood transfusion, intramuscular artemether, intravenous and intramuscular artesunate, intravenous and intramuscular dihydroartemisinin, quinine, and rectal/intravenous/intramuscular artemisinin and its derivatives.
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John CC, Kutamba E, Mugarura K, Opoka RO. Adjunctive therapy for cerebral malaria and other severe forms of Plasmodium falciparum malaria. Expert Rev Anti Infect Ther 2011; 8:997-1008. [PMID: 20818944 DOI: 10.1586/eri.10.90] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Severe malaria due to Plasmodium falciparum causes more than 800,000 deaths every year. Primary therapy with quinine or artesunate is generally effective in controlling P. falciparum parasitemia, but mortality from cerebral malaria and other forms of severe malaria remains unacceptably high. Long-term cognitive impairment is also common in children with cerebral malaria. Of the numerous adjunctive therapies for cerebral malaria and severe malaria studied over the past five decades, only one (albumin) was associated with a reduction in mortality. In this article, we review past and ongoing studies of adjunctive therapy, and examine the evidence of efficacy for newer therapies, including inhibitors of cytoadherence (e.g., levamisole), immune modulators (e.g., rosiglitazone), agents that increase nitric oxide levels (e.g., arginine) and neuroprotective agents (e.g., erythropoietin).
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Affiliation(s)
- Chandy C John
- Center for Global Pediatrics, 717 Delaware Street SE, Room 363, Minneapolis, MN 55455, USA.
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Izumi E, Ueda-Nakamura T, Dias Filho BP, Veiga Júnior VF, Nakamura CV. Natural products and Chagas' disease: a review of plant compounds studied for activity against Trypanosoma cruzi. Nat Prod Rep 2011; 28:809-23. [PMID: 21290079 DOI: 10.1039/c0np00069h] [Citation(s) in RCA: 97] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Here, we review studies that have investigated the activity of plant-derived compounds against Trypanosoma cruzi, the etiologic agent of Chagas’ disease. In the last decade, more than 300 species belonging to almost 100 families have been evaluated for activity, and here we describe the compounds isolated; 85 references are cited.
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Affiliation(s)
- Erika Izumi
- Programa de Pós-Graduação em Microbiologia, Universidade Estadual de Londrina, Rodovia Celso Garcia Cid s/n, 86051-990, Londrina-PR, Brazil
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Core A, Hempel C, Kurtzhals JA, Penkowa M. Plasmodium berghei ANKA: Erythropoietin activates neural stem cells in an experimental cerebral malaria model. Exp Parasitol 2011; 127:500-5. [DOI: 10.1016/j.exppara.2010.09.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2010] [Revised: 08/31/2010] [Accepted: 09/22/2010] [Indexed: 10/18/2022]
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Buchanan J, Mihaylova B, Gray A, White N. Cost-effectiveness of pre-referral antimalarial, antibacterial, and combined rectal formulations for severe febrile illness. PLoS One 2010; 5:e14446. [PMID: 21206901 PMCID: PMC3012053 DOI: 10.1371/journal.pone.0014446] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2010] [Accepted: 11/24/2010] [Indexed: 11/21/2022] Open
Abstract
Background Malaria and bacterial infections account for most infectious disease deaths in developing countries. Prompt treatment saves lives, but rapid deterioration often prevents the use of oral therapies; delays in reaching health facilities providing parenteral interventions are common. Rapidly and reliably absorbed antimalarial/antibacterial rectal formulations used in the community could prevent deaths and disabilities. Rectal antimalarial treatments are currently available; rectal antibacterial treatments are yet to be developed. Assessment of the likely cost-effectiveness of these interventions will inform research priorities and implementation. Methods and Findings The burden of malaria and bacterial infections worldwide and in Sub-Saharan and Southern Africa (SSA) and South and South-East Asia (SEA) was summarised using published data. The additional healthcare costs (US$) per death and per Disability Adjusted Life Year (DALY) avoided following pre-referral treatment of severe febrile illness with rectal antimalarials, antibacterials or combined antimalarial/antibacterials in populations at malaria risk in SSA/SEA were assessed. 46 million severe malaria and bacterial infections and 5 million deaths occur worldwide each year, mostly in SSA/SEA. At annual delivery costs of $0.02/capita and 100% coverage, rectal antimalarials ($2 per dose) would avert 240,000 deaths in SSA and 7,000 deaths in SEA at $5 and $177 per DALY avoided, respectively; rectal antibacterials ($2 per dose) would avert 130,000 deaths in SSA and 27,000 deaths in SEA at $19 and $97 per DALY avoided, respectively. Combined rectal formulations ($2.50 per dose) would avert 370,000 deaths in SSA and 33,000 deaths in SEA at $8 and $79 per DALY avoided, respectively, and are a cost-effective alternative to rectal antimalarials or antibacterials alone. Conclusions Antimalarial, antibacterial and combined rectal formulations are likely to be cost-effective interventions for severe febrile illness in the community. Attention should focus on developing effective rectal antibacterials and ensuring that these lifesaving treatments are used in a cost-effective manner.
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Affiliation(s)
- James Buchanan
- Department of Public Health, Health Economics Research Centre, University of Oxford, Oxford, United Kingdom
| | - Borislava Mihaylova
- Department of Public Health, Health Economics Research Centre, University of Oxford, Oxford, United Kingdom
- * E-mail:
| | - Alastair Gray
- Department of Public Health, Health Economics Research Centre, University of Oxford, Oxford, United Kingdom
| | - Nicholas White
- Faculty of Tropical Medicine, Mahidol University and Centre for Tropical Medicine, Churchill Hospital, Oxford, United Kingdom
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Naing C, Aung K, Win DK, Wah MJ. Efficacy and safety of chloroquine for treatment in patients with uncomplicated Plasmodium vivax infections in endemic countries. Trans R Soc Trop Med Hyg 2010; 104:695-705. [PMID: 20850161 DOI: 10.1016/j.trstmh.2010.08.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2009] [Revised: 08/11/2010] [Accepted: 08/11/2010] [Indexed: 10/19/2022] Open
Abstract
Chloroquine (CQ) is a relatively inexpensive drug for treatment of malaria. If efficacy of CQ is still assumed, then it should be indicated in malaria treatment policies as the drug of choice for uncomplicated Plasmodium vivax malaria in endemic countries with resource constraints. The objective of this review is to summarize the existing evidence on the relative efficacy and safety of CQ in treating patients with uncomplicated P. vivax malaria in endemic countries. We searched online data bases (PUBMED, MEDLINE, EMBASE, The Cochrane Library) and the reference lists of the retrieved articles. Fifteen randomized controlled trials (n=6215) assessing the relative efficacy and safety of CQ for treatment of uncomplicated P. vivax malaria were included. CQ monotherapy was compared to CQ plus primaquine (PQ), artemisinin/artemether, artemisinin based combination therapy, quinine, CQ plus tafenoquine, chlorguanil plus dapsone, azithromycin, or placebo. Treatment efficacy was not significantly different between the CQ monotherapy group and that of the CQ with PQ 14 day group at 28 day follow-up (55/711, 7.7% vs 35/712, 4.9%; P=0.16). Evidence from the trials identified for this review draw a fairly clear conclusion about the relative efficacy and safety of CQ for treating uncomplicated P. vivax malaria infection. However, further research in this field with well powered, randomized, non-inferiority design, using the standardized protocol is needed.
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Affiliation(s)
- Cho Naing
- International Medical University, Kuala Lumpur 57000, Malaysia
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Soyinka JO, Onyeji CO, Omoruyi SI, Owolabi AR, Sarma PV, Cook JM. Pharmacokinetic interactions between ritonavir and quinine in healthy volunteers following concurrent administration. Br J Clin Pharmacol 2010; 69:262-70. [PMID: 20233197 DOI: 10.1111/j.1365-2125.2009.03566.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
AIMS To evaluate the pharmacokinetic interactions between ritonavir and quinine in healthy volunteers. METHODS Ten healthy volunteers were each given 600-mg single oral doses of quinine alone, ritonavir alone (200 mg every 12 h for 9 days), and quinine in combination with ritonavir, in a three-period pharmacokinetic nonrandomized sequential design study. Quinine was co-administered with the 15th dose of ritonavir. Blood samples collected at predetermined time intervals were analysed for ritonavir, quinine and its major metabolite, 3-hydroxyquinine, using a validated high-performance liquid chromatography method. RESULTS Concurrent ritonavir administration resulted in about fourfold increases in both the C(max) and AUC(T)[C(max) 2.79 +/- 0.22 vs. 10.72 +/- 0.32 mg l(-1), 95% confidence interval (CI) 7.81, 8.04; AUC 50.06 +/- 2.52 vs. 220.47 +/- 6.68 mg h(-1) l(-1), 95% CI 166.3, 175.3], a significant increase (P < 0.01) in the elimination half-life (11.15 +/- 0.80 vs. 13.37 +/- 0.33 h, 95% CI 1.64, 2.77) and about a 4.5-fold decrease in CL/F (12.01 +/- 0.61 vs. 2.71 +/- 0.09 l h(-1)) of quinine. Also, with ritonavir, there was a pronounced reduction of AUC(metabolite)/AUC(unchanged drug) ratio of quinine (1.35 +/- 0.10 vs. 0.13 +/- 0.02) along with a marked decrease in C(max) (1.80 +/- 0.12 vs. 0.96 +/- 0.09 mg l(-1)) and AUC(0-48h) (62.80 +/- 6.30 vs. 25.61 +/- 2.44 mg h(-1) l(-1)) of the metabolite. Similarly, quinine caused modest but significant increases (P < 0.01) in the C(max), AUC and elimination T((1/2)) of ritonavir. CONCLUSIONS Downward dosage adjustment of quinine appears necessary when concurrently administered with ritonavir.
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Affiliation(s)
- Julius O Soyinka
- Department of Pharmaceutical Chemistry, Obafemi Awolowo University, Ile-Ife, Nigeria
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Barennes H, Srour LM, Pussard E. Is it too soon to eliminate quinine? THE LANCET. INFECTIOUS DISEASES 2010; 10:141-2. [PMID: 20185089 DOI: 10.1016/s1473-3099(10)70009-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Soyinka JO, Onyeji CO, Omoruyi SI, Owolabi AR, Sarma PV, Cook JM. Effects of concurrent administration of nevirapine on the disposition of quinine in healthy volunteers. J Pharm Pharmacol 2010. [DOI: 10.1211/jpp.61.04.0004] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
Abstract
Objectives
Nevirapine and quinine are likely to be administered concurrently in the treatment of patients with HIV and malaria. Both drugs are metabolised to a significant extent by cytochrome P450 (CYP)3A4 and nevirapine is also an inducer of this enzyme. This study therefore evaluated the effect of nevirapine on the pharmacokinetics of quinine.
Methods
Quinine (600 mg single dose) was administered either alone or with the 17th dose of nevirapine (200 mg every 12 h for 12 days) to 14 healthy volunteers in a crossover fashion. Blood samples collected at predetermined time intervals were analysed for quinine and its major metabolite, 3-hydroxquinine, using a validated HPLC method.
Key findings
Administration of quinine plus nevirapine resulted in significant decreases (P < 0.01) in the total area under the concentration–time curve (AUCT), maximum plasma concentration (Cmax) and terminal elimination half-life (T1/2β) of quinine compared with values with quinine dosing alone (AUC: 53.29 ± 4.01 vs 35.48 ± 2.01 h mg/l; Cmax: 2.83 ± 0.16 vs 1.81 ± 0.06 mg/l; T1/2β: 11.35 ± 0.72 vs 8.54 ± 0.76 h), while the oral plasma clearance markedly increased (11.32 ± 0.84 vs 16.97 ± 0.98 l/h). In the presence of nevirapine there was a pronounced increase in the ratio of AUC(metabolite)/AUC (unchanged drug) and highly significant increases in Cmax and AUC of the metabolite (P < 0.01).
Conclusions
Nevirapine significantly alters the pharmacokinetics of quinine. An increase in the dose of quinine may be necessary when the drug is co-administered with nevirapine.
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Affiliation(s)
- Julius O Soyinka
- Departments of Pharmaceutical Chemistry; Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Cyprian O Onyeji
- Departments of Pharmaceutical Chemistry; Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Sharon I Omoruyi
- Clinical Pharmacy and Pharmacy Administration, Faculty of Pharmacy; Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Adegbenga R Owolabi
- Department of Physiological Sciences, College of Medicine; Obafemi Awolowo University, Ile-Ife, Nigeria
| | - Pullela V Sarma
- Department of Chemistry, University of Wisconsin, Milwaukee, Wisconsin, USA
| | - James M Cook
- Department of Chemistry, University of Wisconsin, Milwaukee, Wisconsin, USA
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Abstract
Despite great international efforts, malaria still inflicts an enormous toll on human lives, especially in Africa. Throughout history, antimalarial medicines have been one of the most powerful tools in malaria control. However, the acquisition and spread of parasite strains that are resistant to multiple antimalarial drugs have become one of the greatest challenges to malaria treatment, and are associated with the increase in morbidity and mortality in many malaria-endemic countries. To deal with this grave situation, artemisinin-based combinatory therapies (ACTs) have been introduced and widely deployed in malarious regions. Artemisinin is a new class of antimalarial compounds discovered by Chinese scientists from the sweet wormwood Artemisia annua. The potential development of resistance to artemisinins by Plasmodium falciparum threatens the usable lifespan of ACTs, and therefore is a subject of close surveillance and extensive research. Studies at the Thai-Cambodian border, a historical epicenter of multidrug resistance, have detected reduced susceptibility to artemisinins as manifested by prolonged parasite-clearance times, raising considerable concerns on resistance development. Despite this significance, there is still controversy on the mode of action of artemisinins. Although a number of potential cellular targets of artemisinins have been proposed, they remain to be verified experimentally. Here, we review the history of artemisinin discovery, discuss the mode of action and potential drug targets, and present strategies to elucidate resistance mechanisms.
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Affiliation(s)
- Liwang Cui
- Department of Entomology, Pennsylvania State University, 537 ASI Building, University Park, PA 16802, USA, Tel.: +1 814 863 7663, Fax: +1 814 865 3048,
| | - Xin-zhuan Su
- Laboratory of Malaria and Vector Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA, Tel.: +1 301 402 0876, Fax: +1 301 402 2201,
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Picot S, Bienvenu AL, Konate S, Sissoko S, Barry A, Diarra E, Bamba K, Djimdé A, Doumbo OK. Safety of epoietin beta-quinine drug combination in children with cerebral malaria in Mali. Malar J 2009; 8:169. [PMID: 19630971 PMCID: PMC2723129 DOI: 10.1186/1475-2875-8-169] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2009] [Accepted: 07/24/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cerebral malaria carries an unacceptable case fatality rate in children despite timely and adequate chemotherapy. To improve the survival rate, adjunctive therapies previously tested mainly focused on the modulation of the inflammatory response, without definitive effect in humans. In this context, a new adjunctive strategy using a neuroprotective drug: erythropoietin (epoietin-beta, Epo) was proposed. METHODS An open-labelled study including cerebral malaria children (Blantyre coma score below 3) was conducted in Mali. The objective was to assess the short-term safety (seven days) of erythropoietin at high doses (1,500 U/kg/day during three days) combined to quinine. RESULTS 35 patients with unrousable coma were included in the study. None of expected side effects of erythropoietin were observed during the seven days follow-up. No significant increase in the case fatality rate (7/35 patients) was observed compared to other studies with mortality rates ranging from 16 to 22% in similar endemic areas. CONCLUSION These data provide the first evidence of the short-term safety of erythropoietin at high doses combined to quinine. A multicentre study is needed to assess the potential of Epo as an adjunctive therapy to increase the survival during cerebral malaria. CLINICAL REGISTRATION NUMBER: ClinicalTrials.gov ID: NCT00697164.
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Affiliation(s)
- Stéphane Picot
- Malaria Research Unit, EA 4170, University Lyon 1, Faculty of Medicine, Lyon, France.
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Soyinka JO, Onyeji CO, Omoruyi SI, Owolabi AR, Sarma PV, Cook JM. Effects of concurrent administration of nevirapine on the disposition of quinine in healthy volunteers. THE JOURNAL OF PHARMACY AND PHARMACOLOGY 2009; 61:439-43. [PMID: 19298689 DOI: 10.1211/jpp/61.04.0004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVES Nevirapine and quinine are likely to be administered concurrently in the treatment of patients with HIV and malaria. Both drugs are metabolised to a significant extent by cytochrome P450 (CYP)3A4 and nevirapine is also an inducer of this enzyme. This study therefore evaluated the effect of nevirapine on the pharmacokinetics of quinine. METHODS Quinine (600 mg single dose) was administered either alone or with the 17th dose of nevirapine (200 mg every 12 h for 12 days) to 14 healthy volunteers in a crossover fashion. Blood samples collected at predetermined time intervals were analysed for quinine and its major metabolite, 3-hydroxquinine, using a validated HPLC method. KEY FINDINGS Administration of quinine plus nevirapine resulted in significant decreases (P < 0.01) in the total area under the concentration-time curve (AUC(T)), maximum plasma concentration (C(max)) and terminal elimination half-life (T((1/2)beta)) of quinine compared with values with quinine dosing alone (AUC: 53.29 +/- 4.01 vs 35.48 +/- 2.01 h mg/l; C(max): 2.83 +/- 0.16 vs 1.81 +/- 0.06 mg/l; T((1/2)beta): 11.35 +/- 0.72 vs 8.54 +/- 0.76 h), while the oral plasma clearance markedly increased (11.32 +/- 0.84 vs 16.97 +/- 0.98 l/h). In the presence of nevirapine there was a pronounced increase in the ratio of AUC(metabolite)/AUC (unchanged drug) and highly significant increases in C(max) and AUC of the metabolite (P < 0.01). CONCLUSIONS Nevirapine significantly alters the pharmacokinetics of quinine. An increase in the dose of quinine may be necessary when the drug is co-administered with nevirapine.
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Affiliation(s)
- Julius O Soyinka
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy, Obafemi Awolowo University, Ile-Ife, Nigeria
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