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de Sena LWP, Mello AGNC, Ferreira MVD, de Ataide MA, Dias RM, Vieira JLF. Doses of chloroquine in the treatment of malaria by Plasmodium vivax in patients between 2 and 14 years of age from the Brazilian Amazon basin. Malar J 2019; 18:439. [PMID: 31864358 PMCID: PMC6925880 DOI: 10.1186/s12936-019-3072-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 12/13/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A total dose of chloroquine of 25 mg/kg is recommended by the World Health Organization (WHO) to treat malaria by Plasmodium vivax. In several endemic areas, including the Brazilian Amazon basin, anti-malarial drugs are dispensed in small plastic bags at a dosing regimen based on age. This practice can lead to suboptimal dosing of the drug, which can impact treatment outcomes. The aim of the present study was to estimate the extent of sub-dosing of chloroquine in children and adolescents with vivax malaria using an age-based dose regimen, in addition to investigating the influence of age on the plasma concentrations of chloroquine and desethylchloroquine. METHODS A study of cases was conducted with male patients with a confirmed infection by P. vivax, ages 2 to 14 years, using a combined regimen of chloroquine and primaquine. Height, weight and body surface area were determined at admission on the study. The total dose of chloroquine administered was estimated based on the weight and on the body surface area of the study patients. Chloroquine and desethylchloroquine were measured on Day 7 in each patient included in the study by a high-performance liquid chromatographic method with fluorescence detection. RESULTS A total of 81 patients were enrolled and completed the study. The median age was 9 years (2-14 years). All patients presented negative blood smears at 42 days follow-up. The total dose of chloroquine ranged from 13.1 to 38.1 mg/kg. The percentage of patients with a total dose of the drug below 25 mg/kg ranged from 29.4 to 63.6%. The total dose of chloroquine administered based on BSA ranged from 387 to 1079 mg/m2, increasing with age. Plasma chloroquine concentrations ranged from 107 to 420 ng/ml, increasing with age. For desethylchloroquine, the plasma concentrations ranged from 167 to 390 ng/ml, with similar values among age-groups. CONCLUSION The data demonstrated the widespread exposure of children and adolescents to suboptimal doses of chloroquine in the endemic area investigated.
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Affiliation(s)
- Luann Wendel Pereira de Sena
- Pharmacy Faculty, Para Federal University, Campus Universitario do Guama, Augusto Correa Street 01, Belem, Para, 66074740, Brazil
| | | | - Michelle Valéria Dias Ferreira
- Pharmacy Faculty, Para Federal University, Campus Universitario do Guama, Augusto Correa Street 01, Belem, Para, 66074740, Brazil
| | - Marcieni Andrade de Ataide
- Pharmacy Faculty, Para Federal University, Campus Universitario do Guama, Augusto Correa Street 01, Belem, Para, 66074740, Brazil
| | - Rosa Maria Dias
- Pharmacy Faculty, Para Federal University, Campus Universitario do Guama, Augusto Correa Street 01, Belem, Para, 66074740, Brazil
| | - José Luiz Fernandes Vieira
- Pharmacy Faculty, Para Federal University, Campus Universitario do Guama, Augusto Correa Street 01, Belem, Para, 66074740, Brazil.
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Siqueira AM, Alencar AC, Melo GC, Magalhaes BL, Machado K, Alencar Filho AC, Kuehn A, Marques MM, Manso MC, Felger I, Vieira JLF, Lameyre V, Daniel-Ribeiro CT, Lacerda MVG. Fixed-Dose Artesunate-Amodiaquine Combination vs Chloroquine for Treatment of Uncomplicated Blood Stage P. vivax Infection in the Brazilian Amazon: An Open-Label Randomized, Controlled Trial. Clin Infect Dis 2016; 64:166-174. [PMID: 27988484 PMCID: PMC5215218 DOI: 10.1093/cid/ciw706] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Accepted: 10/18/2016] [Indexed: 01/31/2023] Open
Abstract
In the Brazilian Amazon, the artesunate–amodiaquine combination was more effective in preventing Plasmodium vivax recurrence. With a favorable safety profile, this antimalarial treatment proved to be a good first-line alternative. Chloroquine resistance is probably underestimated in the area. Background. Despite increasing evidence of the development of Plasmodium vivax chloroquine (CQ) resistance, there have been no trials comparing its efficacy with that of artemisinin-based combination therapies (ACTs) in Latin America. Methods. This randomized controlled trial compared the antischizontocidal efficacy and safety of a 3-day supervised treatment of the fixed-dose combination artesunate-amodiaquine Winthrop® (ASAQ) versus CQ for treatment of uncomplicated P. vivax infection in Manaus, Brazil. Patients were followed for 42 days. Primary endpoints were adequate clinical and parasitological responses (ACPR) rates at day 28. Genotype-adjustment was performed. Results. From 2012 to 2013, 380 patients were enrolled. In the per-protocol (PP) analysis, adjusted-ACPR was achieved in 100% (165/165) and 93.6% (161/172) of patients in the ASAQ and CQ arm (difference 6.4%, 95% CI 2.7%; 10.1%) at day 28 and in 97.4% (151/155) and 77.7% (129/166), respectively (difference 19.7%, 95% CI 12.9%; 26.5%), at day 42. Apart from ITT D28 assessment, superiority of ASAQ on ACPR was demonstrated. ASAQ presented faster clearance of parasitaemia and fever. Based on CQ blood level measurements, CQ resistance prevalence was estimated at 11.5% (95% CI: 7.5-17.3) up to day 42. At least one emergent adverse event (AE) was recorded for 79/190 (41x6%) in the ASAQ group and for 85/190 (44x7%) in the CQ group. Both treatments had similar safety profiles. Conclusions. ASAQ exhibited high efficacy against CQ resistant P. vivax and is an adequate alternative in the study area. Studies with an efficacious comparator, longer follow-up and genotype-adjustment can improve CQR characterization. Clinical Trials Registration. NCT01378286.
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Affiliation(s)
- Andre M Siqueira
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, .,Universidade do Estado do Amazonas, Manaus.,Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro
| | - Aline C Alencar
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado.,Universidade do Estado do Amazonas, Manaus
| | - Gisely C Melo
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado.,Universidade do Estado do Amazonas, Manaus
| | - Belisa L Magalhaes
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado.,Universidade do Estado do Amazonas, Manaus
| | - Kim Machado
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado
| | | | - Andrea Kuehn
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado.,ISGlobal, Barcelona Center for International Health Research (CRESIB), Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
| | | | | | - Ingrid Felger
- Swiss Tropical and Public Health Institute, Basel, Switzerland
| | | | | | | | - Marcus V G Lacerda
- Fundação de Medicina Tropical Dr. Heitor Vieira Dourado.,Universidade do Estado do Amazonas, Manaus.,Instituto Leônidas e Maria Deane, Fundação Oswaldo Cruz, Manaus, Brazil
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Siqueira AM, Mesones-Lapouble O, Marchesini P, Sampaio VDS, Brasil P, Tauil PL, Fontes CJ, Costa FTM, Daniel-Ribeiro CT, Lacerda MVG, Damasceno CP, Santelli ACS. Plasmodium vivax Landscape in Brazil: Scenario and Challenges. Am J Trop Med Hyg 2016; 95:87-96. [PMID: 27708190 PMCID: PMC5201227 DOI: 10.4269/ajtmh.16-0204] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 08/19/2016] [Indexed: 01/01/2023] Open
Abstract
Brazil is the largest country of Latin America, with a considerable portion of its territoritory within the malaria-endemic Amazon region in the North. Furthermore, a considerable portion of its territory is located within the Amazon region in the north. As a result, Brazil has reported half of the total malaria cases in the Americas in the last four decades. Recent progress in malaria control has been accompanied by an increasing proportion of Plasmodium vivax, underscoring a need for a better understanding of management and control of this species and associated challenges. Among these challenges, the contribution of vivax malaria relapses, earlier production of gametocytes (compared with Plasmodium falciparum), inexistent methods to diagnose hypnozoite carriers, and decreasing efficacy of available antimalarials need to be addressed. Innovative tools, strategies, and technologies are needed to achieve further progress toward sustainable malaria elimination. Further difficulties also arise from dealing with the inherent socioeconomic and environmental particularities of the Amazon region and its dynamic changes.
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Affiliation(s)
- Andre M Siqueira
- Programa de Pós-Graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil.,Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (Fiocruz), Rio de Janeiro, Brazil
| | | | - Paola Marchesini
- Coordenação Geral do Programa Nacional de Controle da Malaria, Ministério da Saúde, Brasilia, Brazil
| | - Vanderson de Souza Sampaio
- Fundação de Vigilância em Saúde, Manaus, Brazil.,Programa de Pós-Graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
| | - Patricia Brasil
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz (Fiocruz), Rio de Janeiro, Brazil
| | - Pedro L Tauil
- Núcleo de Medicina Tropical, Universidade de Brasília, Brasilia, Brazil
| | | | | | | | - Marcus V G Lacerda
- Instituto Leônidas e Maria Deane, Fundação Oswaldo Cruz (Fiocruz), Manaus, Brazil.,Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, Brazil.,Programa de Pós-Graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, Brazil
| | - Camila P Damasceno
- Coordenação Geral do Programa Nacional de Controle da Malaria, Ministério da Saúde, Brasilia, Brazil
| | - Ana Carolina S Santelli
- Coordenação Geral do Programa Nacional de Controle da Malaria, Ministério da Saúde, Brasilia, Brazil
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Añez A, Moscoso M, Garnica C, Ascaso C. Evaluation of the paediatric dose of chloroquine in the treatment of Plasmodium vivax malaria. Malar J 2016; 15:371. [PMID: 27430284 PMCID: PMC4950695 DOI: 10.1186/s12936-016-1420-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 07/04/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Chloroquine (CQ) continues to be the first-line medication used worldwide in the treatment of Plasmodium vivax malaria. The dose recommended by the World Health Organization is 25 mg/kg independently of the age of the subject. Nonetheless, the pharmacokinetics and pharmacodynamics of drugs in children are different from those in adults and may influence the drug concentrations in blood and become risk factors for therapeutic failure and/o resistance to CQ. METHODS This study is a secondary analysis of the data from a clinical trial in which children over 5 years of age were administered 25 mg/kg of CQ, and CQ concentrations in blood were measured at day 7 of follow-up. Models of regression and comparison were used to evaluate and compare the CQ dose taken per kg/body weight, the CQ dose calculated based on body surface area, CQ levels in blood on day 7 and the age of the population. RESULTS The younger the study population the greater the difference between the dose per kg/body weight (real dose) and that calculated according to the BSA (theoretical dose). The difference between the two doses was -181.206 mg in the 5-9 years of age group (CI 95 % -195.39; -167.02 mg) and -71.39 mg (CI 95 % -118.61; -23.99 mg) in the 10-14-year-old group. The CQ concentrations in blood on day 7 differed in patients over and under 15 years (p = 0.008). A negative correlation was found between the real and theoretical dose (difference in dose) and the age in years (R2 = 0.529, p = 0.001). A negative correlation was also found between the difference in dose (mg) and CQ concentrations on day 7 (ng/ml) (r = -0.337, p = 0.001). Children under 15 years were found to have a higher rate of therapeutic failure than those over 15 (28 vs 4.2 %, respectively) (Kaplan-Meier p = 0.005). CONCLUSIONS A CQ dose of 25 mg/kg for the treatment of P. vivax malaria may be too low in children as demonstrated by the reduction in CQ concentrations in blood at day 7 of follow-up. This under-dosage is probably associated with the higher rate of therapeutic failure found in children under 15 years (28 vs 4.3 %). These results suggest the need to review the paediatric doses of CQ currently used.
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Affiliation(s)
- Arletta Añez
- />Departamento de Salud Pública, Universidad de Barcelona, Barcelona, Spain
| | - Manuel Moscoso
- />Laboratorio de Control de Calidad de Medicamentos y Toxicología del Instituto Nacional de Laboratorios en Salud. CONCAMYT-INLASA, La Paz, Bolivia
| | - Cecilia Garnica
- />Laboratorio de Control de Calidad de Medicamentos y Toxicología del Instituto Nacional de Laboratorios en Salud. CONCAMYT-INLASA, La Paz, Bolivia
| | - Carlos Ascaso
- />Departamento de Salud Pública, Universidad de Barcelona. Institut d’ Investicions Biomediques, Augusto Pi i Sunyer, Barcelona, Spain
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