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Pernaute-Lau L, Camara M, Nóbrega de Sousa T, Morris U, Ferreira MU, Gil JP. An update on pharmacogenetic factors influencing the metabolism and toxicity of artemisinin-based combination therapy in the treatment of malaria. Expert Opin Drug Metab Toxicol 2022; 18:39-59. [PMID: 35285373 DOI: 10.1080/17425255.2022.2049235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Artemisinin-based combination therapies (ACTs) are recommended first-line antimalarials for uncomplicated Plasmodium falciparum malaria. Pharmacokinetic/pharmacodynamic variation associated with ACT drugs and their effect is documented. It is accepted to an extent that inter-individual variation is genetically driven, and should be explored for optimized antimalarial use. AREAS COVERED We provide an update on the pharmacogenetics of ACT antimalarial disposition. Beyond presently used antimalarials, we also refer to information available for the most notable next-generation drugs under development. The bibliographic approach was based on multiple Boolean searches on PubMed covering all recent publications since our previous review. EXPERT OPINION The last 10 years have witnessed an increase in our knowledge of ACT pharmacogenetics, including the first clear examples of its contribution as an exacerbating factor for drug-drug interactions. This knowledge gap is still large and is likely to widen as a new wave of antimalarial drug is looming, with few studies addressing their pharmacogenetics. Clinically useful pharmacogenetic markers are still not available, in particular, from an individual precision medicine perspective. A better understanding of the genetic makeup of target populations can be valuable for aiding decisions on mass drug administration implementation concerning region-specific antimalarial drug and dosage options.
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Affiliation(s)
- Leyre Pernaute-Lau
- Department of Microbiology, Tumor and Cell biology, Karolinska Institutet, Solna, Sweden.,Faculty of Sciences, BioISI - Biosystems & Integrative Sciences Institute, University of Lisbon, Lisbon, 1749-016, Portugal
| | - Mahamadou Camara
- Department of Epidemiology of Parasitic Diseases, Faculty of Pharmacy, Malaria Research and Training Center, University of Science, Techniques and Technologies of Bamako, Bamako, Mali
| | - Taís Nóbrega de Sousa
- Molecular Biology and Malaria Immunology Research Group, Instituto René Rachou, Fundação Oswaldo Cruz (FIOCRUZ), Belo Horizonte, Brasil
| | - Ulrika Morris
- Department of Microbiology, Tumor and Cell biology, Karolinska Institutet, Solna, Sweden
| | - Marcelo Urbano Ferreira
- Faculty of Sciences, BioISI - Biosystems & Integrative Sciences Institute, University of Lisbon, Lisbon, 1749-016, Portugal.,Department of Parasitology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
| | - José Pedro Gil
- Department of Microbiology, Tumor and Cell biology, Karolinska Institutet, Solna, Sweden.,Faculty of Sciences, BioISI - Biosystems & Integrative Sciences Institute, University of Lisbon, Lisbon, 1749-016, Portugal.,Global Health and Tropical Medicine, Institute of Hygiene and Tropical Medicine, Nova University of Lisbon, Portugal
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Maniga JN, Akinola SA, Odoki M, Odda J, Adebayo IA. Limited Polymorphism in Plasmodium falciparum Artemisinin Resistance Kelch13-Propeller Gene Among Clinical Isolates from Bushenyi District, Uganda. Infect Drug Resist 2021; 14:5153-5163. [PMID: 34908849 PMCID: PMC8665267 DOI: 10.2147/idr.s341357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 11/25/2021] [Indexed: 11/23/2022] Open
Abstract
Introduction Drug resistance remains a major challenge in malaria treatment, especially after the emergence of resistance to artemisinin-based combined therapies. Plasmodium falciparum Kelch13 gene mutations are implicated in conferring artemisinin resistance. Thus, this study was aimed at determining the occurrence of Kelch13 (K13) propeller resistance gene polymorphism mutations in Bushenyi district, Uganda. Methods Participants suspected to have malaria were recruited. P. falciparum was confirmed using antigen histidine-rich protein 2 (HRP2) (Pf) (Access Bio, Inc, USA) and microscopy. Malaria-positive patients were treated with artemeter-lumefantrine (AL). Blood was withdrawn from participants who tested positive for parasites after day 3 and kept in blood filter papers (ET31CHR; Whatman Limited, Kent, UK). DNA was extracted using chelex-suspension method. Nested polymerase chain reaction (PCR) was conducted and the second-round products sequenced using Sanger’s method. Sequenced products were analyzed using DNAsp 5.10.01 software and then blasted on to the NCBI for K13-propeller gene sequence identity using the Basic Local Alignment Search Tool (BLAST). Results Out of 283 enrolled participants, 194 completed the follow-up schedule. A total of 134 (69%) had no parasites on day 3, while 60 (31%) had parasites on that day. Out of the 60 samples, 40 (62%) were positively amplified as P. falciparum, with polymorphisms in the K13-propeller gene detected in 3 (7.5%) out of the 40 amplicons. Polymorphisms at codon 1929, 1788 and 1801 were detected separately in one sample each. Sequences have been deposited in NCBI with accession numbers PRJNA720348 and PRJNA720800. Conclusion Polymorphisms in the K13-propeller gene previously reported to be associated with artemisinin resistance were not detected in the P. falciparum isolates from Bushenyi district, Uganda. More studies need to be conducted on the new mutations detected so as to understand their association, if any, with ACT resistance.
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Affiliation(s)
- Josephat Nyabayo Maniga
- Department of Microbiology and Immunology, Kampala International University Western Campus, Bushenyi, Uganda
| | - Saheed Adekunle Akinola
- Department of Microbiology and Immunology, Kampala International University Western Campus, Bushenyi, Uganda.,Faculty of Natural and Agricultural Sciences, North- West University, Mmabatho, South Africa
| | - Martin Odoki
- Department of Microbiology and Immunology, Kampala International University Western Campus, Bushenyi, Uganda
| | - John Odda
- Department of Pharmacology and Toxicology, Kampala International University Western Campus, Bushenyi, Uganda.,Department of Pharmacology and Therapeutics, Makerere University, Kampala, Uganda
| | - Ismail Abiola Adebayo
- Department of Microbiology and Immunology, Kampala International University Western Campus, Bushenyi, Uganda
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Hughes E, Wallender E, Mohamed Ali A, Jagannathan P, Savic RM. Malaria PK/PD and the Role Pharmacometrics Can Play in the Global Health Arena: Malaria Treatment Regimens for Vulnerable Populations. Clin Pharmacol Ther 2021; 110:926-940. [PMID: 33763871 PMCID: PMC8518425 DOI: 10.1002/cpt.2238] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 03/05/2021] [Indexed: 12/23/2022]
Abstract
Malaria is an infectious disease which disproportionately effects children and pregnant women. These vulnerable populations are often excluded from clinical trials resulting in one‐size‐fits‐all treatment regimens based on those established for a nonpregnant adult population. Pharmacokinetic/pharmacodynamic (PK/PD) models can be used to optimize dose selection as they define the drug exposure‐response relationship. Additionally, these models are able to identify patient characteristics that cause alterations in the expected PK/PD profiles and through simulations can recommend changes to dosing which compensate for the differences. In this review, we examine how PK/PD models have been applied to optimize antimalarial dosing recommendations for young children, including those who are malnourished, pregnant women, and individuals receiving concomitant therapies such as those for HIV treatment. The malaria field has had great success in utilizing PK/PD models as a foundation to update treatment guidelines and propose the next generation of dosing regimens to investigate in clinical trials. We propose how the malaria field can continue to use modeling to improve therapies by further integrating PK data into clinical studies and including data on drug resistance and host immunity in PK/PD models. Finally, we suggest that other disease areas can achieve similar success in applying pharmacometrics to improve outcomes by implementing three key principals.
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Affiliation(s)
- Emma Hughes
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California, USA
| | - Erika Wallender
- Department of Clinical Pharmacy, University of California San Francisco, San Francisco, California, USA
| | - Ali Mohamed Ali
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California, USA
| | | | - Radojka M Savic
- Department of Bioengineering and Therapeutic Sciences, University of California San Francisco, San Francisco, California, USA
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Usman SO, Oreagba IA, Kadri MR, Adewumi OO, Akinyede A, Agbaje EO, Abideen G, Busari AA, Hassan OO, Akinleye MO, Akanmu AS. Evaluation of the effects of atazanavir-ritonavir on the pharmacokinetics of lumefantrine in patients living with HIV in Lagos University Teaching Hospital, South-Western Nigeria. Eur J Clin Pharmacol 2021; 77:1341-1348. [PMID: 33755736 DOI: 10.1007/s00228-021-03116-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 02/16/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Atazanavir-ritonavir (ATVr)-based antiretroviral therapy and artemether-lumefantrine (AL) are commonly used drugs for the treatment of human immune deficiency virus (HIV) infection and malaria respectively. However, interaction of both drugs, with Cytochrome P 3A4 (CYP 3A4) isoenzyme, may spawn clinically significant pharmacokinetic interactions. This study evaluated the effects of atazanavir-ritonavir on the pharmacokinetics of lumefantrine. METHOD In a case-control study, twenty participants having Plasmodium falciparum malaria were recruited and divided into two groups (ATVr-arm, n=10; and control-arm, n= 10). All the participants were administered six oral doses of AL 80-480 mg (Coartem). Thereafter, their blood samples were collected at different time intervals over seven days. The concentration of lumefantrine in each sample was quantified with high-performance liquid chromatography (HPLC) and used to determine its pharmacokinetic parameters which were compared between the test and control groups. RESULTS ATVr increased the mean day 7 concentration of lumefantrine (ATVr 3847.09 ± 893.35 ng/mL, control 1374.53 ± 265.55 ng/mL, p = 0.016) and the area under its plasma concentration-time curve (ATVr 670529.57 ± 157172.93 ng.h/mL, control 447976.28 ± 80886.99 ng.h/mL, p = 0.224) by 179.88 % and 49.68 %, respectively, but decreased its mean maximum plasma drug concentration (Cmax) (ATVr 13725.70 ± 2658.44 ng/mL, control 15380.48 ± 2332.62 ng/mL, p = 0.645) by 10.76 %. CONCLUSION ATVr increased drug exposure and day 7 plasma concentration of lumefantrine. AL is therefore considered effective for the treatment of malaria in patients taking ATVr-based regimen. However, the safety associated with the interaction requires further elucidation. TRIAL REGISTRATION Clin ClinicalTrials.gov Identifier: NCT04531072, August 27, 2020. "Retrospectively registered".
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Affiliation(s)
- Sikiru Olatunji Usman
- Department of Pharmacology, Therapeutics and Toxicology, College of Medicine of the University of Lagos, Idi-Araba, Lagos State, Nigeria.
| | - Ibrahim Adekunle Oreagba
- Department of Pharmacology, Therapeutics and Toxicology, College of Medicine of the University of Lagos, Idi-Araba, Lagos State, Nigeria
| | - Michael Rotimi Kadri
- Department of Pharmacology, Therapeutics and Toxicology, College of Medicine of the University of Lagos, Idi-Araba, Lagos State, Nigeria
| | - Ololade Oluwatosin Adewumi
- Department of Pharmacology, Therapeutics and Toxicology, College of Medicine of the University of Lagos, Idi-Araba, Lagos State, Nigeria
| | - Akinwumi Akinyede
- Department of Pharmacology, Therapeutics and Toxicology, College of Medicine of the University of Lagos, Idi-Araba, Lagos State, Nigeria
| | - Esther Oluwatoyin Agbaje
- Department of Pharmacology, Therapeutics and Toxicology, College of Medicine of the University of Lagos, Idi-Araba, Lagos State, Nigeria
| | - Ganiyu Abideen
- Department of Pharmacology, Therapeutics and Toxicology, College of Medicine of the University of Lagos, Idi-Araba, Lagos State, Nigeria
| | - AbdulWasiu Adeniyi Busari
- Department of Pharmacology, Therapeutics and Toxicology, College of Medicine of the University of Lagos, Idi-Araba, Lagos State, Nigeria
| | | | - Moshood Olusola Akinleye
- Department of Pharmaceutical Chemistry, Faculty of Pharmacy of the University of Lagos, Idi-Araba, Lagos State, Nigeria
| | - Alani Sulaimon Akanmu
- Department of Haematology and Blood Transfusion, Faculty of Clinical Science, College of Medicine of the University of Lagos, Idi-Araba, Lagos State, Nigeria.,Apin Clinic, Lagos University Teaching Hospital, Idi-Araba, Lagos State, Nigeria
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Mushi V, Mbotwa CH, Zacharia A, Ambrose T, Moshi FV. Predictors for the uptake of optimal doses of sulfadoxine-pyrimethamine for intermittent preventive treatment of malaria during pregnancy in Tanzania: further analysis of the data of the 2015-2016 Tanzania demographic and health survey and malaria indicator survey. Malar J 2021; 20:75. [PMID: 33549094 PMCID: PMC7866669 DOI: 10.1186/s12936-021-03616-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 01/30/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In Tanzania, the uptake of optimal doses (≥ 3) of sulfadoxine-pyrimethamine for intermittent preventive treatment of malaria (IPTp-SP) during pregnancy has remained below the recommended target of 80%. Therefore, this study aimed to investigate the predictors for the uptake of optimal IPTp-SP among pregnant women in Tanzania. METHODS This study used data from the 2015-16 Tanzania demographic and health survey and malaria indicator survey (TDHS-MIS). The study had a total of 4111 women aged 15 to 49 who had live births 2 years preceding the survey. The outcome variable was uptake of three or more doses of IPTp-SP, and the independent variables were age, marital status, education level, place of residence, wealth index, occupation, geographic zone, parity, the timing of first antenatal care (ANC), number of ANC visits and type of the health facility for ANC visits. Predictors for the optimal uptake of IPTp-SP were assessed using univariate and multivariable logistic regression. RESULTS A total of 327 (8%) women had optimal uptake of IPTp-SP doses. Among the assessed predictors, the following were significantly associated with optimal uptake of IPTp-SP doses; education level [primary (AOR: 2.2, 95% CI 1.26-3.67); secondary or higher education (AOR: 2.1, 95% CI 1.08-4.22)], attended ANC at the first trimester (AOR: 2.4, 95% CI 1.20-4.96), attended ≥ 4 ANC visits (AOR: 1.9, 95% CI 1.34-2.83), attended government health facilities (AOR: 1.5, 95% CI 1.07-1.97) and geographic zone [Central (AOR: 5, 95% CI 2.08-11.95); Southern Highlands (AOR: 2.8, 95% CI 1.15-7.02); Southwest Highlands (AOR: 2.7, 95% CI 1.03-7.29); Lake (AOR: 3.5, 95% CI 1.51-8.14); Eastern (AOR: 1.5, 95% CI 1.88-11.07)]. CONCLUSIONS The uptake of optimal IPTp-SP doses is still low in Tanzania. The optimal uptake of IPTp-SP was associated with attending ANC in the first trimester, attending more than four ANC visits, attending government health facility for ANC, having primary, secondary, or higher education level, and geographic zone. Therefore, there is a need for health education and behavior change interventions with an emphasis on the optimal use of IPTp-SP doses.
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Affiliation(s)
- Vivian Mushi
- Department of Parasitology and Medical Entomology, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, P. O. Box 65001, Dar es Salaam, Tanzania.
| | - Christopher H Mbotwa
- Mbeya College of Health and Allied Sciences, University of Dar Es Salaam, Mbeya, Tanzania.,Department of Epidemiology and Biostatistics, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Abdallah Zacharia
- Department of Parasitology and Medical Entomology, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, P. O. Box 65001, Dar es Salaam, Tanzania
| | - Theresia Ambrose
- Department of Epidemiology and Biostatistics, School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Fabiola V Moshi
- Department of Nursing and Midwifery, College of Health Sciences, University of Dodoma, Dodoma, Tanzania
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Moore BR, Davis TM. Updated pharmacokinetic considerations for the use of antimalarial drugs in pregnant women. Expert Opin Drug Metab Toxicol 2020; 16:741-758. [PMID: 32729740 DOI: 10.1080/17425255.2020.1802425] [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: 02/08/2023]
Abstract
INTRODUCTION The association between pregnancy and altered drug pharmacokinetic (PK) properties is acknowledged, as is its impact on drug plasma concentrations and thus therapeutic efficacy. However, there have been few robust PK studies of antimalarial use in pregnancy. Given that inadequate dosing for prevention or treatment of malaria in pregnancy can result in negative maternal/infant outcomes, along with the potential to select for parasite drug resistance, it is imperative that reliable pregnancy-specific dosing recommendations are established. AREAS COVERED PK studies of antimalarial drugs in pregnancy. The present review summarizes the efficacy and PK properties of WHO-recommended therapies used in pregnancy, with a focus on PK studies published since 2014. EXPERT OPINION Changes in antimalarial drug disposition in pregnancy are well described, yet pregnant women continue to receive treatment regimens optimized for non-pregnant adults. Contemporary in silico modeling has recently identified a series of alternative dosing regimens that are predicted to provide optimal therapeutic efficacy for pregnant women.
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Affiliation(s)
- Brioni R Moore
- School of Pharmacy and Biomedical Sciences, Curtin University , Bentley, Western Australia, Australia.,Medical School, University of Western Australia , Crawley, Western Australia, Australia
| | - Timothy M Davis
- Medical School, University of Western Australia , Crawley, Western Australia, Australia
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Usman SO, Oreagba IA, Akinyede AA, Agbaje EO, Akinleye MO, Onwujuobi AG, Ken-Owotor C, Adeuja O, Ogunfowokan T, Kogbe S, Owolabi ET, Adeniji H, Busari AW, Hassan OO, Abideen G, Akanmu AS. Effect of nevirapine, efavirenz and lopinavir/ritonavir on the therapeutic concentration and toxicity of lumefantrine in people living with HIV at Lagos University Teaching Hospital, Nigeria. J Pharmacol Sci 2020; 144:95-101. [PMID: 32921396 DOI: 10.1016/j.jphs.2020.07.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 07/04/2020] [Accepted: 07/30/2020] [Indexed: 11/17/2022] Open
Abstract
Patients living with HIV in malarial endemic regions may experience clinically significant drug interaction between antiretroviral and antimalarial drugs. Effects of nevirapine (NVP), efavirenz (EFV) and lopinavir/ritonavir (LPVr) on lumefantrine (LM) therapeutic concentrations and toxicity were evaluated. In a four-arm parallel study design, the blood samples of 40 participants, treated with artemether/lumefantrine (AL), were analysed. Lumefantrine Cmax was increased by 32% (p = 0.012) and 325% (p < 0.0001) in the NVP and LPVr arms respectively but decreased by 62% (p < 0.0001) in the EFV-arm. AUC of LM was, respectively, increased by 50% (p = 0.27) and 328% (p < 0.0001) in the NVP and LPVr arms but decreased in the EFV-arm by 30% (p = 0.019). Median day 7 LM concentration was less than 280 ng/mL in EFV-arm (239 ng/mL) but higher in control (290 ng/mL), NVP (369 ng/mL, p = 0.004) and LPVr (1331 ng/mL, p < 0.0001) arms. There were no clinically relevant toxicities nor adverse events in both control and test arms. Artemether/lumefantrine is safe and effective for treatment of malaria in PLWHA taking NVP and LPVr based ART regimen but not EFV-based regimen.
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Affiliation(s)
- Sikiru Olatunji Usman
- Department of Pharmacology, Therapeutics and Toxicology, College of Medicine of the University of Lagos, Idi-Araba, Lagos State, Nigeria.
| | - Ibrahim Adekunle Oreagba
- Department of Pharmacology, Therapeutics and Toxicology, College of Medicine of the University of Lagos, Idi-Araba, Lagos State, Nigeria; West African Postgraduate College of Pharmacists, Yaba, Lagos State, Nigeria; National Agency for Food and Drug Administration and Control, Wuse, Abuja, Nigeria
| | - Akinwumi Akinyinka Akinyede
- Department of Pharmacology, Therapeutics and Toxicology, College of Medicine of the University of Lagos, Idi-Araba, Lagos State, Nigeria
| | - Esther Oluwatoyin Agbaje
- Department of Pharmacology, Therapeutics and Toxicology, College of Medicine of the University of Lagos, Idi-Araba, Lagos State, Nigeria
| | | | - Adaobi Goodness Onwujuobi
- Department of Pharmacology, Therapeutics and Toxicology, College of Medicine of the University of Lagos, Idi-Araba, Lagos State, Nigeria
| | - Chioma Ken-Owotor
- Department of Pharmacology, Therapeutics and Toxicology, College of Medicine of the University of Lagos, Idi-Araba, Lagos State, Nigeria
| | - Olatunbosun Adeuja
- Department of Pharmacology, Therapeutics and Toxicology, College of Medicine of the University of Lagos, Idi-Araba, Lagos State, Nigeria
| | - Tosin Ogunfowokan
- Department of Pharmacology, Therapeutics and Toxicology, College of Medicine of the University of Lagos, Idi-Araba, Lagos State, Nigeria
| | - Segun Kogbe
- Department of Pharmacology, Therapeutics and Toxicology, College of Medicine of the University of Lagos, Idi-Araba, Lagos State, Nigeria
| | | | - Hannah Adeniji
- Department of Pharmacology, Therapeutics and Toxicology, College of Medicine of the University of Lagos, Idi-Araba, Lagos State, Nigeria
| | - Abdul Wasiu Busari
- Department of Pharmacology, Therapeutics and Toxicology, College of Medicine of the University of Lagos, Idi-Araba, Lagos State, Nigeria
| | - Olayinka Olayiwola Hassan
- Department of Pharmacology, Therapeutics and Toxicology, College of Medicine of the University of Lagos, Idi-Araba, Lagos State, Nigeria
| | - Ganiu Abideen
- Department of Pharmacology, Therapeutics and Toxicology, College of Medicine of the University of Lagos, Idi-Araba, Lagos State, Nigeria
| | - Alani Sulaimon Akanmu
- Department of Haematology and Blood Transfusion, Faculty of Clinical Science, College of Medicine of the University of Lagos, Idi-Araba, Lagos State, Nigeria; Apin Clinic, Lagos University Teaching Hospital, Idi-Araba, Lagos State, Nigeria
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Efavirenz-Based Antiretroviral Therapy Reduces Artemether-Lumefantrine Exposure for Malaria Treatment in HIV-Infected Pregnant Women. J Acquir Immune Defic Syndr 2020; 83:140-147. [PMID: 31929402 DOI: 10.1097/qai.0000000000002237] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The choice of malaria treatment for HIV-infected pregnant women receiving efavirenz-based antiretroviral therapy must consider the potential impact of drug interactions on antimalarial exposure and clinical response. The aim of this study was to investigate the effects of efavirenz on artemether-lumefantrine (AL) because no studies have isolated the impact of efavirenz for HIV-infected pregnant women. METHODS A prospective clinical pharmacokinetic (PK) study compared HIV-infected, efavirenz-treated pregnant women with HIV-uninfected pregnant women in Tororo, Uganda. All women received the standard 6-dose AL treatment regimen for Plasmodium falciparum malaria with intensive PK samples collected over 21 days and 42-days of clinical follow-up. PK exposure parameters were calculated for artemether, its active metabolite dihydroartemisinin (DHA), and lumefantrine to determine the impact of efavirenz. RESULTS Nine HIV-infected and 30 HIV-uninfected pregnant women completed intensive PK evaluations. Relative to controls, concomitant efavirenz therapy lowered the 8-hour artemether concentration by 76% (P = 0.013), DHA peak concentration by 46% (P = 0.033), and day 7 and 14 lumefantrine concentration by 61% and 81% (P = 0.046 and 0.023), respectively. In addition, there were nonsignificant reductions in DHA area under the concentration-time curve0-8hr (35%, P = 0.057) and lumefantrine area under the concentration-time curve0-∞ (34%, P = 0.063) with efavirenz therapy. CONCLUSIONS Pregnant HIV-infected women receiving efavirenz-based antiretroviral therapy during malaria treatment with AL showed reduced exposure to both the artemisinin and lumefantrine. These data suggest that malaria and HIV coinfected pregnant women may require adjustments in AL dosage or treatment duration to achieve exposure comparable with HIV-uninfected pregnant women.
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Mutagonda RF, Minzi OMS, Massawe SN, Asghar M, Färnert A, Kamuhabwa AAR, Aklillu E. Pregnancy and CYP3A5 Genotype Affect Day 7 Plasma Lumefantrine Concentrations. Drug Metab Dispos 2020; 47:1415-1424. [PMID: 31744845 DOI: 10.1124/dmd.119.088062] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 09/27/2019] [Indexed: 12/21/2022] Open
Abstract
Pregnancy and pharmacogenetics variation alter drug disposition and treatment outcome. The objective of this study was to investigate the effect of pregnancy and pharmacogenetics variation on day 7 lumefantrine (LF) plasma concentration and therapeutic responses in malaria-infected women treated with artemether-lumefantrine (ALu) in Tanzania. A total of 277 (205 pregnant and 72 nonpregnant) women with uncomplicated Plasmodium falciparum malaria were enrolled. Patients were treated with ALu and followed up for 28 days. CYP3A4, CYP3A5, and ABCB1 genotyping were done. Day 7 plasma LF concentration and the polymerase chain reaction (PCR) - corrected adequate clinical and parasitological response (ACPR) at day 28 were determined. The mean day 7 plasma LF concentrations were significantly lower in pregnant women than nonpregnant women [geometric mean ratio = 1.40; 95% confidence interval (CI) of geometric mean ratio (1.119-1.1745), P < 0.003]. Pregnancy, low body weight, and CYP3A5*1/*1 genotype were significantly associated with low day 7 LF plasma concentration (P < 0.01). PCR-corrected ACPR was 93% (95% CI = 89.4-96.6) in pregnant women and 95.7% (95% CI = 90.7-100) in nonpregnant women. Patients with lower day 7 LF concentration had a high risk of treatment failure (mean 652 vs. 232 ng/ml, P < 0.001). In conclusion, pregnancy, low body weight, and CYP3A5*1 allele are significant predictors of low day 7 LF plasma exposure. In turn, lower day 7 LF concentration is associated with a higher risk of recrudescence. SIGNIFICANCE STATEMENT: This study reports a number of factors contributing to the lower day 7 lumefantrine (LF) concentration in women, which includes pregnancy, body weight, and CYP3A5*1/*1 genotype. It also shows that day 7 LF concentration is a main predictor of malaria treatment. These findings highlight the need to look into artemether-LF dosage adjustment in pregnant women so as to be able to maintain adequate drug concentration, which is required to reduce treatment failure rates in pregnant women.
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Affiliation(s)
- Ritah F Mutagonda
- Department of Clinical Pharmacy and Pharmacology, School of Pharmacy (R.F.M., O.O.M.S.M., A.A.R.K.), and Department of Obstetrics and Gynecology, School of Medicine (S.N.M.), Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; Division of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden (M.A., A.F.); Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden (A.F.); and Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet at Karolinska University Hospital, Huddinge, Stockholm, Sweden (E.A.)
| | - Omary M S Minzi
- Department of Clinical Pharmacy and Pharmacology, School of Pharmacy (R.F.M., O.O.M.S.M., A.A.R.K.), and Department of Obstetrics and Gynecology, School of Medicine (S.N.M.), Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; Division of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden (M.A., A.F.); Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden (A.F.); and Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet at Karolinska University Hospital, Huddinge, Stockholm, Sweden (E.A.)
| | - Siriel N Massawe
- Department of Clinical Pharmacy and Pharmacology, School of Pharmacy (R.F.M., O.O.M.S.M., A.A.R.K.), and Department of Obstetrics and Gynecology, School of Medicine (S.N.M.), Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; Division of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden (M.A., A.F.); Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden (A.F.); and Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet at Karolinska University Hospital, Huddinge, Stockholm, Sweden (E.A.)
| | - Muhammad Asghar
- Department of Clinical Pharmacy and Pharmacology, School of Pharmacy (R.F.M., O.O.M.S.M., A.A.R.K.), and Department of Obstetrics and Gynecology, School of Medicine (S.N.M.), Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; Division of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden (M.A., A.F.); Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden (A.F.); and Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet at Karolinska University Hospital, Huddinge, Stockholm, Sweden (E.A.)
| | - Anna Färnert
- Department of Clinical Pharmacy and Pharmacology, School of Pharmacy (R.F.M., O.O.M.S.M., A.A.R.K.), and Department of Obstetrics and Gynecology, School of Medicine (S.N.M.), Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; Division of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden (M.A., A.F.); Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden (A.F.); and Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet at Karolinska University Hospital, Huddinge, Stockholm, Sweden (E.A.)
| | - Appolinary A R Kamuhabwa
- Department of Clinical Pharmacy and Pharmacology, School of Pharmacy (R.F.M., O.O.M.S.M., A.A.R.K.), and Department of Obstetrics and Gynecology, School of Medicine (S.N.M.), Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; Division of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden (M.A., A.F.); Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden (A.F.); and Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet at Karolinska University Hospital, Huddinge, Stockholm, Sweden (E.A.)
| | - Eleni Aklillu
- Department of Clinical Pharmacy and Pharmacology, School of Pharmacy (R.F.M., O.O.M.S.M., A.A.R.K.), and Department of Obstetrics and Gynecology, School of Medicine (S.N.M.), Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania; Division of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden (M.A., A.F.); Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden (A.F.); and Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet at Karolinska University Hospital, Huddinge, Stockholm, Sweden (E.A.)
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10
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Mlugu EM, Minzi O, Kamuhabwa AAR, Aklillu E. Prevalence and Correlates of Asymptomatic Malaria and Anemia on First Antenatal Care Visit among Pregnant Women in Southeast, Tanzania. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17093123. [PMID: 32365839 PMCID: PMC7246851 DOI: 10.3390/ijerph17093123] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 04/28/2020] [Indexed: 01/02/2023]
Abstract
Asymptomatic malaria and anemia during pregnancy increase the risk of negative birth outcomes. This cross-sectional study investigated the prevalence and correlates of asymptomatic malaria and anemia during first antenatal care (ANC) visit among pregnant women in a rural district, Tanzania. HIV-uninfected pregnant women without symptoms of malaria (n = 819) attending their first ANC at Kibiti Health Centre were enrolled from February 2017 to February 2018. Asymptomatic malaria was detected by malaria rapid-diagnostic tests (mRDT) and real-time PCR. Hemoglobin concentration was determined by HemoCue Hemoglobin 201+. The study outcomes were the prevalence of asymptomatic malaria and anemia (Hemoglobin level <11 g/dL). The overall prevalence of asymptomatic malaria was 36.4% (95% CI: 33.1, 39.8). The monthly prevalence of asymptomatic malaria remained >25% throughout the year, and the highest prevalence (40%) was recorded during the rainy season. Asymptomatic malaria was significantly associated with primigravida, younger maternal age, and anemia. The prevalence of anemia was 68.5% (95% CI: 65.2, 71.6). Asymptomatic malaria, primigravida, younger maternal age and low Body Mass Index were significant predictors of low hemoglobin concentration. We report high prevalence of asymptomatic malaria and anemia among pregnant women on the first ANC visit. Screening of malaria and anemia during the first ANC visit is recommended for targeted interventions.
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Affiliation(s)
- Eulambius M. Mlugu
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet at Karolinska, University Hospital, Huddinge, 141 86 Stockholm, Sweden;
- Department of Pharmaceutics, School of Pharmacy, Muhimbili University of Health and Allied Sciences, Dar es Salaam 0702172, Tanzania
| | - Omary Minzi
- Department of Clinical Pharmacy and Pharmacology, School of Pharmacy, Muhimbili University of Health and Allied Sciences, Dar es Salaam 0702172, Tanzania; (O.M.); (A.A.R.K.)
| | - Appolinary A. R. Kamuhabwa
- Department of Clinical Pharmacy and Pharmacology, School of Pharmacy, Muhimbili University of Health and Allied Sciences, Dar es Salaam 0702172, Tanzania; (O.M.); (A.A.R.K.)
| | - Eleni Aklillu
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet at Karolinska, University Hospital, Huddinge, 141 86 Stockholm, Sweden;
- Correspondence:
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11
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Bajaria S, Festo C, Mrema S, Shabani J, Hertzmark E, Abdul R. Assessment of the impact of availability and readiness of malaria services on uptake of intermittent preventive treatment in pregnancy (IPTp) provided during ANC visits in Tanzania. Malar J 2019; 18:229. [PMID: 31288835 PMCID: PMC6617666 DOI: 10.1186/s12936-019-2862-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 07/03/2019] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Intermittent preventive treatment during pregnancy (IPTp) is a highly-recommended intervention to prevent maternal and neonatal complications associated with malaria infection. Despite fairly high antenatal care (ANC) coverage in Tanzania, low IPTp uptake rates represent a gap in efforts to decrease complications attributed to malaria in pregnancy. The objective of this study was to examine if availability, readiness and managing authority are associated with uptake of IPTp during ANC. METHODS Data for this analysis come from a cross-sectional survey, the Tanzania Service Provision Assessment conducted between 2014 and 2015. Principal component analysis was used to create scores for availability of malaria services and readiness for the provision of services. Generalized estimating equation models with logit link and the binomial distribution assessed factors that impact the uptake of IPTp by pregnant women attending ANC. RESULTS Higher fraction of women in their third trimester than second (68% versus 49%, OR = 2.6; 95% CI (2.1-3.3)), had received at least one dose of IPTp. There was a wide variation in the availability and readiness of malaria services provision and diagnostic tools by managing authorities. Public facilities were more likely than private to offer malaria rapid diagnostic test, and more providers at public facilities than private diagnosed and/or treated malaria. Women who attended facilities where direct observation therapy was practiced were more likely to have received at least one dose of IPTp (64% versus 46% who received none; p < 0.001). Women who attended ANC at a facility with a high readiness score were more likely to take IPTp than those attending facilities with low readiness scores (OR = 2.1; 95% CI (1.4-3.3)). Reported stock out on the day of interview was negatively associated with IPTp uptake (OR 0.09; 95% CI 0.07-0.1). CONCLUSION Readiness of health facilities to provide malaria related services, the number of ANC visits and gestational age were associated with uptake of IPTp among women attending ANC. There are disparities in malaria service availability and readiness across geographical location and managing authorities. These findings could be used to assist the malaria programme and policymakers to appropriately decide when planning for malaria service deliveries and interventions.
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Affiliation(s)
| | - Charles Festo
- Ifakara Health Institute, Box 78373, Dar es Salaam, Tanzania
| | - Sigilbert Mrema
- Ifakara Health Institute, Box 78373, Dar es Salaam, Tanzania
| | | | - Ellen Hertzmark
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Ramadhani Abdul
- Ifakara Health Institute, Box 78373, Dar es Salaam, Tanzania
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12
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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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13
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Arnaldo P, Rovira-Vallbona E, Langa JS, Salvador C, Guetens P, Chiheb D, Xavier B, Kestens L, Enosse SM, Rosanas-Urgell A. Uptake of intermittent preventive treatment and pregnancy outcomes: health facilities and community surveys in Chókwè district, southern Mozambique. Malar J 2018. [PMID: 29530044 PMCID: PMC5848514 DOI: 10.1186/s12936-018-2255-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background Malaria in pregnancy leads to serious adverse effects on the mother and the child and accounts for 75,000–200,000 infant deaths every year. Currently, the World Health Organization recommends intermittent preventive treatment of malaria in pregnancy (IPTp) with sulfadoxine–pyrimethamine (SP) at each scheduled antenatal care (ANC) visit. This study aimed to assess IPTp-SP coverage in mothers delivering in health facilities and at the community. In addition, factors associated with low IPTp-SP uptake and malaria adverse outcomes in pregnancy were investigated. Methods A community and a health facility-based surveys were conducted in mothers delivering in Chókwè district, southern Mozambique. Social-demographic data, malaria prevention practices and obstetric history were recorded through self-report and antenatal records. For women delivering at health facilities, a clinical examination of mother and child was performed, and malaria infection at delivery was determined by rapid diagnostic test, microscopy, quantitative PCR and placental histology. Results Of 1141 participants, 46.6, 30.2, 13.5 and 9.6% reported taking ≥ 3, two, one and none SP doses, respectively. Low IPTp uptake (< 3 doses) was associated with non-institutional deliveries (AOR = 2.9, P < 0.001), first ANC visit after week 28 (AOR = 5.4, P < 0.001), low awareness of IPTp-SP (AOR = 1.6, P < 0.002) and having no or only primary education (AOR = 1.3, P = 0.041). The overall prevalence of maternal malaria (peripheral and/or placental) was 16.8% and was higher among women from rural areas compared to those from urban areas (AOR = 1.9, P < 0.001). Younger age (< 20 years; AOR = 1.6, P = 0.042) and living in rural areas (AOR = 1.9, P < 0.001) were predictors of maternal malaria at delivery. Being primigravidae (AOR = 2.2, P = 0.023) and preterm delivery (AOR = 2.6, P < 0.001) predicted low birth weight while younger age was also associated with premature delivery (AOR = 1.4, P = 0.031). Conclusion The coverage for two and ≥ 3 doses of IPTp-SP is moderately higher than estimates from routine health facility records in Gaza province in 2015. However, this is still far below the national target of 80% for ≥ 3 doses. Ongoing campaigns aiming to increase the use of malaria prevention strategies during pregnancy should particularly target rural populations, increasing IPTp-SP knowledge, stimulate early visits to ANC, improve access to health services and the quality of the service provided. Electronic supplementary material The online version of this article (10.1186/s12936-018-2255-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Paulo Arnaldo
- Department of Biomedical Sciences, Institute of Tropical Medicine Antwerp, Antwerp, Belgium.,Plataforma de Parasitologia Molecular, Instituto Nacional de Saúde, Maputo, Mozambique.,University of Antwerp, Antwerp, Belgium
| | - Eduard Rovira-Vallbona
- Department of Biomedical Sciences, Institute of Tropical Medicine Antwerp, Antwerp, Belgium
| | - Jerónimo S Langa
- Plataforma de Parasitologia Molecular, Instituto Nacional de Saúde, Maputo, Mozambique
| | - Crizolgo Salvador
- Plataforma de Parasitologia Molecular, Instituto Nacional de Saúde, Maputo, Mozambique
| | - Pieter Guetens
- Department of Biomedical Sciences, Institute of Tropical Medicine Antwerp, Antwerp, Belgium
| | - Driss Chiheb
- Department of Biomedical Sciences, Institute of Tropical Medicine Antwerp, Antwerp, Belgium
| | - Bernardete Xavier
- Plataforma de Parasitologia Molecular, Instituto Nacional de Saúde, Maputo, Mozambique
| | - Luc Kestens
- Department of Biomedical Sciences, Institute of Tropical Medicine Antwerp, Antwerp, Belgium.,University of Antwerp, Antwerp, Belgium
| | - Sónia M Enosse
- Plataforma de Parasitologia Molecular, Instituto Nacional de Saúde, Maputo, Mozambique
| | - Anna Rosanas-Urgell
- Department of Biomedical Sciences, Institute of Tropical Medicine Antwerp, Antwerp, Belgium.
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14
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Saito M, Gilder ME, Nosten F, Guérin PJ, McGready R. Methodology of assessment and reporting of safety in anti-malarial treatment efficacy studies of uncomplicated falciparum malaria in pregnancy: a systematic literature review. Malar J 2017; 16:491. [PMID: 29254487 PMCID: PMC5735519 DOI: 10.1186/s12936-017-2136-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 12/05/2017] [Indexed: 01/21/2023] Open
Abstract
Background Considering the uncertainty of safety of anti-malarial drugs in pregnancy, efficacy studies are one of the few sources of clinical safety data. Complete safety evaluation is not usually incorporated in efficacy studies due to financial and human resource constraints. This review reports the methods used for the assessment of safety of artemisinin-based and quinine-based treatments in efficacy studies in pregnancy. Methods Methodology of assessment and reporting of safety in efficacy studies of artemisinin-based and quinine-based treatment in pregnancy was reviewed using seven databases and two clinical trial registries. The protocol was registered to PROSPERO (CRD42017054808). Results Of 48 eligible efficacy studies the method of estimation of gestational age was reported in only 32 studies (67%, 32/48) and ultrasound was used in 18 studies (38%, 18/48). Seventeen studies (35%, 17/48) reported parity, 9 (19%, 9/48) reported gravidity and 13 (27%, 13/48) reported both. Thirty-eight studies (79%, 38/48) followed participants through to pregnancy outcome. Fetal loss was assessed in 34 studies (89%, 34/38), but the definition of miscarriage and stillbirth were defined only in 11 (32%, 11/34) and 7 (21%, 7/34) studies, respectively. Preterm birth was assessed in 26 studies (68%, 26/38) but was defined in 16 studies (62%, 16/26). Newborn weight was assessed in 30 studies (79%, 30/38) and length in 10 studies (26%, 10/38). Assessment of birth weight took gestational age into account in four studies (13%, 4/30). Congenital abnormalities were reported in 32 studies (84%, 32/38). Other common risk factors for adverse pregnancy outcomes were not well-reported. Conclusion Incomplete reporting and varied methodological assessment of pregnancy outcomes in anti-malarial drug efficacy studies limits comparison across studies. A standard list of minimal necessary parameters to assess and report the safety component of efficacy studies of anti-malarials in pregnancy is proposed. Electronic supplementary material The online version of this article (10.1186/s12936-017-2136-x) 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
| | - 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
| | - 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
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15
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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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16
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Mutagonda RF, Kamuhabwa AAR, Minzi OMS, Massawe SN, Asghar M, Homann MV, Färnert A, Aklillu E. Effect of pharmacogenetics on plasma lumefantrine pharmacokinetics and malaria treatment outcome in pregnant women. Malar J 2017; 16:267. [PMID: 28673292 PMCID: PMC5496343 DOI: 10.1186/s12936-017-1914-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 06/27/2017] [Indexed: 01/09/2023] Open
Abstract
Background Pregnancy has considerable effects on the pharmacokinetic properties of drugs used to treat uncomplicated Plasmodium falciparum malaria. The role of pharmacogenetic variation on anti-malarial drug disposition and efficacy during pregnancy is not well investigated. The study aimed to examine the effect of pharmacogenetics on lumefantrine (LF) pharmacokinetics and treatment outcome in pregnant women. Methods Pregnant women with uncomplicated falciparum malaria were enrolled and treated with artemether-lumefantrine (ALu) at Mkuranga and Kisarawe district hospitals in Coast Region of Tanzania. Day-7 LF plasma concentration and genotyping forCYP2B6 (c.516G>T, c.983T>C), CYP3A4*1B, CYP3A5 (*3, *6, *7) and ABCB1 c.4036A4G were determined. Blood smear for parasite quantification by microscopy, and dried blood spot for parasite screening and genotyping using qPCR and nested PCR were collected at enrolment up to day 28 to differentiate between reinfection from recrudescence. Treatment response was recorded following the WHO protocol. Results In total, 92 pregnant women in their second and third trimester were included in the study and 424 samples were screened for presence of P. falciparum. Parasites were detected during the follow up period in 11 (12%) women between day 7 and 28 after treatment and PCR genotyping confirmed recrudescent infection in 7 (63.3%) women. The remaining four (36.4%) pregnant women had reinfection: one on day 14 and three on day 28. The overall PCR-corrected treatment failure rate was 9.0% (95% CI 4.4–17.4). Day 7 LF concentration was not significantly influenced by CYP2B6, CYP3A4*1B and ABCB1 c.4036A>G genotypes. Significant associations between CYP3A5 genotype and day 7 plasma LF concentrations was found, being higher in carriers of CYP3A5 defective variant alleles than CYP3A5*1/*1 genotype. No significant influence of CYP2B6, CYP3A5 and ABCB1 c.4036A>Genotypes on malaria treatment outcome were observed. However, CYP3A4*1B did affect malaria treatment outcome in pregnant women followed up for 28 days (P = 0.018). Conclusions Genetic variations in CYP3A4 and CYP3A5may influence LF pharmacokinetics and treatment outcome in pregnant women.
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Affiliation(s)
- Ritah F 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.
| | - Appolinary A R 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
| | - Omary M S 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
| | - Siriel N Massawe
- Department of Obstetrics and Gynaecology, School of Medicine, Muhimbili University of Allied Sciences, P.O Box 65013, Dar es Salaam, Tanzania
| | - Muhammad Asghar
- Unit of Infectious Diseases, Department of Medicine, Karolinska Institutet, Solna, 171 76, Stockholm, Sweden
| | - Manijeh V Homann
- Unit of Infectious Diseases, Department of Medicine, Karolinska Institutet, Solna, 171 76, Stockholm, Sweden
| | - Anna Färnert
- Unit of Infectious Diseases, Department of Medicine, Karolinska Institutet, Solna, 171 76, Stockholm, Sweden.,Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Eleni Aklillu
- Section of Pharmacogenetics, Department of Physiology and Pharmacology, Karolinska Institutet, 171 77, Stockholm, Sweden
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