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Habtamu K, Getachew H, Abossie A, Demissew A, Tsegaye A, Degefa T, Wang X, Lee MC, Zhou G, Kibret S, King CL, Kazura JW, Petros B, Yewhalaw D, Yan G. The effect of single low-dose primaquine treatment for uncomplicated Plasmodium falciparum malaria on haemoglobin levels in Ethiopia: a longitudinal cohort study. Malar J 2024; 23:208. [PMID: 38997771 PMCID: PMC11245871 DOI: 10.1186/s12936-024-05021-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 06/20/2024] [Indexed: 07/14/2024] Open
Abstract
BACKGROUND To interrupt residual malaria transmission and achieve successful elimination of Plasmodium falciparum in low-transmission settings, the World Health Organization (WHO) recommends the administration of a single dose of 0.25 mg/kg (or 15 mg/kg for adults) primaquine (PQ) combined with artemisinin-based combination therapy (ACT), without glucose-6-phosphate dehydrogenase (G6PD) testing. However, due to the risk of haemolysis in patients with G6PD deficiency (G6PDd), PQ use is uncommon. Thus, this study aimed to assess the safety of a single low dose of PQ administered to patients with G6PD deficiency. METHODS An observational cohort study was conducted with patients treated for uncomplicated P. falciparum malaria with either single-dose PQ (0.25 mg/kg) (SLD PQ) + ACT or ACT alone. Microscopy-confirmed uncomplicated P. falciparum malaria patients visiting public health facilities in Arjo Didessa, Southwest Ethiopia, were enrolled in the study from September 2019 to November 2022. Patients with uncomplicated P. falciparum malaria were followed up for 28 days through clinical and laboratory diagnosis, such as measurements of G6PD levels and haemoglobin (Hb) concentrations. G6PD levels were measured by a quantiative CareSTART™ POCT S1 biosensor machine. Patient interviews were also conducted, and the type and frequency of clinical complaints were recorded. Hb data were taken on days (D) 7, 14, 21, and 28 following treatment with SLD-PQ + ACT or ACT alone. RESULTS A total of 249 patients with uncomplicated P. falciparum malaria were enrolled in this study. Of these, 83 (33.3%) patients received ACT alone, and 166 (66.7%) received ACT combined with SLD-PQ treatment. The median age of the patients was 20 (IQR 28-15) years. G6PD deficiency was found in 17 (6.8%) patients, 14 males and 3 females. There were 6 (7.2%) and 11 (6.6%) phenotypic G6PD-deficient patients in the ACT alone and ACT + SLD-PQ arms, respectively. The mean Hb levels in patients treated with ACT + SLD-PQ were reduced by an average of 0.45 g/dl (95% CI = 0.39 to 0.52) in the posttreatment phase (D7) compared to a reduction of 0.30 g/dl (95% CI = 0.14 to - 0.47) in patients treated with ACT alone (P = 0.157). A greater mean Hb reduction was observed on day 7 in the G6PDd ACT + SLD-PQ group (- 0.60 g/dL) than in the G6PDd ACT alone group (- 0.48 g/dL); however, there was no statistically significant difference (P = 0.465). Overall, D14 losses were 0.10 g/dl (95% CI = - 0.00 to 0.20) and 0.05 g/dl (95% CI = - 0.123 to 0.22) in patients with and without SLD-PQ, respectively (P = 0.412). CONCLUSIONS This study's findings indicate that using SLD-PQ in combination with ACT is safe for uncomplicated P. falciparum malaria regardless of the patient's G6PD status in Ethiopian settings. Caution should be taken in extrapolating this finding in other settings with diverse G6DP phenotypes.
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Affiliation(s)
- Kassahun Habtamu
- Department of Microbial, Cellular & Molecular Biology, Addis Ababa University, Addis Ababa, Ethiopia.
- Department of Medical Laboratory Sciences, Menelik II Medical and Health Science College, Addis Ababa, Ethiopia.
| | - Hallelujah Getachew
- Department of Medical Laboratory Sciences, Arbaminch College of Health Sciences, Arbaminch, Ethiopia
- School of Medical Laboratory Sciences, Faculty of Health Sciences, Jimma University, Jimma, Ethiopia
| | - Ashenafi Abossie
- Department of Medical Laboratory Sciences, College of Medicine and Health Sciences, Arba Minch University, Arbaminch, Ethiopia
- School of Medical Laboratory Sciences, Faculty of Health Sciences, Jimma University, Jimma, Ethiopia
| | - Assalif Demissew
- Department of Medical Laboratory Sciences, College of Medicine and Health Sciences, Ambo University, Ambo, Ethiopia
| | - Arega Tsegaye
- College of Natural Science, Department of Biology, Jimma University, Jimma, Ethiopia
- School of Medical Laboratory Sciences, Faculty of Health Sciences, Jimma University, Jimma, Ethiopia
| | - Teshome Degefa
- School of Medical Laboratory Sciences, Faculty of Health Sciences, Jimma University, Jimma, Ethiopia
- Tropical and Infectious Diseases Research Center (TIDRC), Jimma University, Jimma, Ethiopia
| | - Xiaoming Wang
- Program in Public Health, University of California at Irvine, Irvine, CA, 92697, USA
| | - Ming-Chieh Lee
- Program in Public Health, University of California at Irvine, Irvine, CA, 92697, USA
| | - Guofa Zhou
- Program in Public Health, University of California at Irvine, Irvine, CA, 92697, USA
| | - Solomon Kibret
- West Valley Mosquito and Vector Control District, Ontario, CA, USA
| | - Christopher L King
- Center for Global Health & Diseases, School of Medicine, Case Western Reserve University, Cleveland, 44106 OH, USA
| | - James W Kazura
- Center for Global Health & Diseases, School of Medicine, Case Western Reserve University, Cleveland, 44106 OH, USA
| | - Beyene Petros
- Department of Microbial, Cellular & Molecular Biology, Addis Ababa University, Addis Ababa, Ethiopia
| | - Delenasaw Yewhalaw
- School of Medical Laboratory Sciences, Faculty of Health Sciences, Jimma University, Jimma, Ethiopia
- Tropical and Infectious Diseases Research Center (TIDRC), Jimma University, Jimma, Ethiopia
| | - Guiyun Yan
- Program in Public Health, University of California at Irvine, Irvine, CA, 92697, USA
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Ranmal SR, Lavarde M, Wallon E, Issa S, Taylor WR, Nguyen Ngoc Pouplin JLA, Tuleu C, Pensé-Lhéritier AM. Responsive Sensory Evaluation to Develop Flexible Taste-Masked Paediatric Primaquine Tablets against Malaria for Low-Resource Settings. Pharmaceutics 2023; 15:1879. [PMID: 37514065 PMCID: PMC10385610 DOI: 10.3390/pharmaceutics15071879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 06/22/2023] [Accepted: 06/25/2023] [Indexed: 07/30/2023] Open
Abstract
Primaquine is an important antimalarial drug for malaria transmission blocking and radical cure, but it is not currently available in child-friendly formulations in appropriate doses. Adult-strength tablets are often crushed and dissolved in water to obtain the required dose, which exposes the drug's bitter taste. As part of the developing paediatric primaquine (DPP) project, this study adopted a responsive sensory pharmaceutics approach by integrating real-time formulation development and pre-clinical taste assessment to develop palatable, flavour-infused primaquine tablets. A design of experiment (DoE) approach was used to screen different taste-masking agents and excipient blends with trained, expert sensory assessors, with quinine hydrochloride as a model bitter tastant. The taste-masking efficacy of selected prototype formulation blends was validated with naïve assessors using the highest 15 mg primaquine dose. The mean bitterness intensity rating, measured on a discrete 11-point scale, was halved from 7.04 for the unflavoured control to 2.74-3.70 for the formulation blends. Sucralose had the biggest impact on bitterness suppression and improving palatability. Two different flavouring systems have been developed, and their acceptability in paediatric patients will be assessed as part of upcoming validation field clinical trials in Africa.
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Affiliation(s)
- Sejal R Ranmal
- UCL School of Pharmacy, University College London, 29-39 Brunswick Square, London WC1N 1AX, UK
| | - Marc Lavarde
- Ecole de Biologie Industrielle-EBI, UPR EBInnov®, 49 Avenue des Genottes CS90009, 95895 Cergy, France
| | - Elodie Wallon
- Ecole de Biologie Industrielle-EBI, UPR EBInnov®, 49 Avenue des Genottes CS90009, 95895 Cergy, France
| | - Samar Issa
- Ecole de Biologie Industrielle-EBI, UPR EBInnov®, 49 Avenue des Genottes CS90009, 95895 Cergy, France
| | - Walter R Taylor
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 420/60 Rajvithi Road, Bangkok 10400, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford OX1 3SY, UK
| | | | - Catherine Tuleu
- UCL School of Pharmacy, University College London, 29-39 Brunswick Square, London WC1N 1AX, UK
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Stepniewska K, Allen EN, Humphreys GS, Poirot E, Craig E, Kennon K, Yilma D, Bousema T, Guerin PJ, White NJ, Price RN, Raman J, Martensson A, Mwaiswelo RO, Bancone G, Bastiaens GJH, Bjorkman A, Brown JM, D'Alessandro U, Dicko AA, El-Sayed B, Elzaki SE, Eziefula AC, Gonçalves BP, Hamid MMA, Kaneko A, Kariuki S, Khan W, Kwambai TK, Ley B, Ngasala BE, Nosten F, Okebe J, Samuels AM, Smit MR, Stone WJR, Sutanto I, Ter Kuile F, Tine RC, Tiono AB, Drakeley CJ, Gosling R, Stergachis A, Barnes KI, Chen I. Safety of single-dose primaquine as a Plasmodium falciparum gametocytocide: a systematic review and meta-analysis of individual patient data. BMC Med 2022; 20:350. [PMID: 36109733 PMCID: PMC9479278 DOI: 10.1186/s12916-022-02504-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 07/29/2022] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND In 2012, the World Health Organization (WHO) recommended single low-dose (SLD, 0.25 mg/kg) primaquine to be added as a Plasmodium (P.) falciparum gametocytocide to artemisinin-based combination therapy (ACT) without glucose-6-phosphate dehydrogenase (G6PD) testing, to accelerate malaria elimination efforts and avoid the spread of artemisinin resistance. Uptake of this recommendation has been relatively slow primarily due to safety concerns. METHODS A systematic review and individual patient data (IPD) meta-analysis of single-dose (SD) primaquine studies for P. falciparum malaria were performed. Absolute and fractional changes in haemoglobin concentration within a week and adverse effects within 28 days of treatment initiation were characterised and compared between primaquine and no primaquine arms using random intercept models. RESULTS Data comprised 20 studies that enrolled 6406 participants, of whom 5129 (80.1%) had received a single target dose of primaquine ranging between 0.0625 and 0.75 mg/kg. There was no effect of primaquine in G6PD-normal participants on haemoglobin concentrations. However, among 194 G6PD-deficient African participants, a 0.25 mg/kg primaquine target dose resulted in an additional 0.53 g/dL (95% CI 0.17-0.89) reduction in haemoglobin concentration by day 7, with a 0.27 (95% CI 0.19-0.34) g/dL haemoglobin drop estimated for every 0.1 mg/kg increase in primaquine dose. Baseline haemoglobin, young age, and hyperparasitaemia were the main determinants of becoming anaemic (Hb < 10 g/dL), with the nadir observed on ACT day 2 or 3, regardless of G6PD status and exposure to primaquine. Time to recovery from anaemia took longer in young children and those with baseline anaemia or hyperparasitaemia. Serious adverse haematological events after primaquine were few (9/3, 113, 0.3%) and transitory. One blood transfusion was reported in the primaquine arms, and there were no primaquine-related deaths. In controlled studies, the proportions with either haematological or any serious adverse event were similar between primaquine and no primaquine arms. CONCLUSIONS Our results support the WHO recommendation to use 0.25 mg/kg of primaquine as a P. falciparum gametocytocide, including in G6PD-deficient individuals. Although primaquine is associated with a transient reduction in haemoglobin levels in G6PD-deficient individuals, haemoglobin levels at clinical presentation are the major determinants of anaemia in these patients. TRIAL REGISTRATION PROSPERO, CRD42019128185.
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Affiliation(s)
- Kasia Stepniewska
- WorldWide Antimalarial Resistance Network, Oxford, UK.
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.
| | - Elizabeth N Allen
- WorldWide Antimalarial Resistance Network, Oxford, UK
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Georgina S Humphreys
- WorldWide Antimalarial Resistance Network, Oxford, UK
- Green Templeton College, University of Oxford, Oxford, UK
| | - Eugenie Poirot
- Malaria Elimination Initiative, Global Health Group, University of California San Francisco, San Francisco, USA
| | - Elaine Craig
- WorldWide Antimalarial Resistance Network, Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Kalynn Kennon
- WorldWide Antimalarial Resistance Network, Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Daniel Yilma
- WorldWide Antimalarial Resistance Network, Oxford, UK
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Jimma University Clinical Trial Unit, Department of Internal Medicine, Jimma University, Jimma, Ethiopia
| | - Teun Bousema
- Department of Infection and Immunity, London School of Hygiene and Tropical Medicine, London, UK
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Philippe J Guerin
- WorldWide Antimalarial Resistance Network, Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Nicholas J White
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
- Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Ric N Price
- WorldWide Antimalarial Resistance Network, Oxford, UK
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
| | - Jaishree Raman
- Parasitology Reference Laboratory, National Institute for Communicable Diseases, A Division of the National Health Laboratory Services, Johannesburg, South Africa
- Wits Research Institute for Malaria, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Andreas Martensson
- Department of Women's and Children's Health, International Maternal and Child Health (IMCH), Uppsala University, Uppsala, Sweden
| | - Richard O Mwaiswelo
- Department of Parasitology and Medical Entomology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Department of Microbiology, Immunology and Parasitology, Hubert Kairuki Memorial University, Dar es Salaam, Tanzania
| | - Germana Bancone
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Guido J H Bastiaens
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands
- Laboratory of Medical Microbiology and Immunology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Anders Bjorkman
- Department of Microbiology Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden
| | - Joelle M Brown
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Umberto D'Alessandro
- Medical Research Council Unit, London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Alassane A Dicko
- Malaria Research and Training Centre, Faculty of Pharmacy and Faculty of Medicine and Dentistry, University of Science, Techniques and Technologies of Bamako, Bamako, Mali
| | - Badria El-Sayed
- Department of Epidemiology, Tropical Medicine Research Institute, National Centre for Research, Khartoum, Sudan
| | - Salah-Eldin Elzaki
- Department of Epidemiology, Tropical Medicine Research Institute, National Centre for Research, Khartoum, Sudan
| | - Alice C Eziefula
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton, UK
| | - Bronner P Gonçalves
- Department of Infection and Immunity, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Akira Kaneko
- Department of Microbiology Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden
| | - Simon Kariuki
- Kenya Medical Research Institute (KEMRI), Kisian, Kenya
| | - Wasif Khan
- Infectious Disease Division, International Centre for Diarrheal Diseases Research, Dhaka, Bangladesh
| | - Titus K Kwambai
- Centers for Disease Control and Prevention, Department of Parasitic Diseases and Malaria, Kisumu, Kenya
| | - Benedikt Ley
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
| | - Billy E Ngasala
- Department of Parasitology and Medical Entomology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- Department of Women's and Children's Health, International Maternal and Child Health (IMCH), Uppsala University, Uppsala, Sweden
| | - Francois Nosten
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Joseph Okebe
- Disease Control & Elimination Theme, Medical Research Council Unit, Fajara, The Gambia
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Aaron M Samuels
- Centers for Disease Control and Prevention, Department of Parasitic Diseases and Malaria, Kisumu, Kenya
| | - Menno R Smit
- Liverpool School of Tropical Medicine, Liverpool, UK
| | - Will J R Stone
- Department of Infection and Immunity, London School of Hygiene and Tropical Medicine, London, UK
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Inge Sutanto
- Department of Parasitology, Faculty of Medicine, University of Indonesia, Depok City, Indonesia
| | | | - Roger C Tine
- Department of Medical Parasitology, Faculty of Medicine, University Cheikh Anta Diop, Dakar, Senegal
| | - Alfred B Tiono
- Department of Biomedical Sciences, Centre National de Recherche et de Formation sur le Paludisme, Ouagadougou, Burkina Faso
| | - Chris J Drakeley
- Department of Infection Biology, London School of Tropical Medicine and Hygiene, London, UK
| | - Roly Gosling
- Malaria Elimination Initiative, Global Health Group, University of California San Francisco, San Francisco, USA
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Andy Stergachis
- Departments of Pharmacy & Global Health, Schools of Pharmacy and Public Health, University of Washington, Seattle, USA
| | - Karen I Barnes
- WorldWide Antimalarial Resistance Network, Oxford, UK
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Ingrid Chen
- Malaria Elimination Initiative, Global Health Group, University of California San Francisco, San Francisco, USA
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