1
|
Cheah PY, Lwin KM, Phaiphun L, Maelankiri L, Parker M, Day NP, White NJ, Nosten F. Community engagement on the Thai-Burmese border: rationale, experience and lessons learnt. Int Health 2013; 2:123-9. [PMID: 22984375 DOI: 10.1016/j.inhe.2010.02.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Community engagement is increasingly promoted in developing countries, especially in international health research, but there is little published experience. The Shoklo Malaria Research Unit (SMRU) conducts research with refugees, migrant workers, displaced people, and day migrants on the Thai-Burmese border, and has recently facilitated the set up of the Tak Province Border Community Ethics Advisory Board (T-CAB). Valuable lessons have been learnt from consultation with the T-CAB especially in the area of participant recruitment and the informed consent process. A lot of new research questions have emerged from consultation with the T-CAB. This paper describes our experience, lessons learnt and the unique challenges faced working with the T-CAB from its initial conception to date. We conclude that consultation with the T-CAB has made improvements in our research in particular operational and ethical aspects of our studies.
Collapse
Affiliation(s)
- Phaik Yeong Cheah
- Shoklo Malaria Research Unit, Mae Sot, Tak, 63110 Thailand ; Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400 Thailand ; Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, OX3 7LJ, United Kingdom
| | | | | | | | | | | | | | | |
Collapse
|
2
|
Douglas NM, Nosten F, Ashley EA, Phaiphun L, van Vugt M, Singhasivanon P, White NJ, Price RN. Plasmodium vivax recurrence following falciparum and mixed species malaria: risk factors and effect of antimalarial kinetics. Clin Infect Dis 2011; 52:612-20. [PMID: 21292666 PMCID: PMC3060895 DOI: 10.1093/cid/ciq249] [Citation(s) in RCA: 116] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2010] [Accepted: 12/17/2010] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Plasmodium vivax malaria commonly follows treatment of falciparum malaria in regions of co-endemicity. This is an important cause of preventable morbidity. METHODS We examined the factors contributing to the risk of recurrence of P. vivax infection after treatment of acute falciparum malaria in a series of clinical trials conducted on the Thai-Myanmar border from 1991 through 2005. RESULTS Overall, 10,549 patients (4960 children aged <15 years and 5589 adults) were treated for falciparum malaria; of these patients, 9385 (89.0%) had Plasmodium falciparum monoinfection and 1164 (11.0%) had mixed P. falciparum/P. vivax infections according to microscopic examinations performed at screening. The cumulative proportion of patients with P. falciparum infection recurrence by day 63 was 21.5% (95% confidence interval [CI], 20.3%-22.8%), and the cumulative proportion with P. vivax infection recurrence was 31.5% (95% CI, 30.1%-33.0%). Significant risk factors for P. vivax infection recurrence were mixed infection at enrollment, male sex, younger age, lower hematocrit, higher asexual P. falciparum parasite density (P < .001 for all factors), and P. falciparum gametocytemia at enrollment (P = .001). By day 63, the cumulative risk of vivax malaria after P. falciparum monoinfection was 51.1% (95% CI, 46.1%-56.2%) after treatment with rapidly eliminated drugs (t(1/2) <1 day), 35.3% (95% CI, 31.8%-39.0%) after treatment with intermediate half-life drugs (t(1/2) 1-7 days), and 19.6% (95% CI, 18.1%-21.3%) after treatment with slowly eliminated drugs (t(1/2) > 7 days) (P < .001, by test for trend). Artemisinin-based combinations containing mefloquine or piperaquine, compared with the artemether-lumefantrine and artesunate-atovaquone-proguanil combinations, were associated with a 3.6-fold to 4.2-fold lower adjusted hazard ratio for P. vivax infection recurrence within 63 days after pure or mixed P. falciparum infections (P < .001, for comparisons with artesunate-mefloquine). CONCLUSIONS On the Thai-Myanmar border, P. vivax is the most common cause of parasitological failure after treatment for falciparum malaria. Slowly eliminated antimalarials reduce the risk of early P. vivax infection recurrence.
Collapse
Affiliation(s)
- Nicholas M. Douglas
- Global Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, United Kingdom
| | - François Nosten
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, United Kingdom
- Shoklo Malaria Research Unit, Tak Province, Thailand
- Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Elizabeth A. Ashley
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, United Kingdom
- Shoklo Malaria Research Unit, Tak Province, Thailand
- Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Lucy Phaiphun
- Shoklo Malaria Research Unit, Tak Province, Thailand
| | - Michèle van Vugt
- Shoklo Malaria Research Unit, Tak Province, Thailand
- Department of Internal Medicine, Division of Infectious Diseases, Tropical Medicine and AIDS and Center for Infection and Immunity, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | | | - Nicholas J. White
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, United Kingdom
- Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Ric N. Price
- Global Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, United Kingdom
| |
Collapse
|
3
|
Ashley EA, Stepniewska K, Lindegardh N, Annerberg A, Tarning J, McGready R, Phaiphun L, Singhasivanon P, White NJ, Nosten F. Comparison of plasma, venous and capillary blood levels of piperaquine in patients with uncomplicated falciparum malaria. Eur J Clin Pharmacol 2010; 66:705-12. [PMID: 20300743 PMCID: PMC2883082 DOI: 10.1007/s00228-010-0804-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2009] [Accepted: 02/17/2010] [Indexed: 11/25/2022]
Abstract
Purpose Dihydroartemisinin-piperaquine (DP) is a fixed-dose artemisinin-based combination treatment. Field pharmacokinetic studies would be simplified and facilitated by being able to use small volume capillary assays rather than venous blood. The aim of this study was to describe the relationship between piperaquine concentrations measured in capillary blood, venous blood and venous plasma. Methods Samples of plasma, whole blood obtained by venesection and capillary blood were taken simultaneously from patients with uncomplicated Plasmodium falciparum malaria treated with DP between 0 and 9 weeks after treatment. Piperaquine concentrations in venous and capillary samples were measured using solid phase extraction and analysis by liquid chromatography with ultraviolet detection. Results A total of 161 sets of the three measures were obtained from 54 patients. Piperaquine concentrations in the venous blood samples were approximately twofold higher and those in the capillary blood samples were threefold higher than the corresponding venous plasma concentrations. Capillary blood piperaquine concentrations were approximately 1.7-fold higher than venous blood concentrations, and this difference also increased with time. Conclusion Differences in whole blood and plasma levels of piperaquine suggest compartmentalisation of the drug within blood cells, as also occurs with the structurally related quinoline chloroquine. The relationship between piperaquine concentrations in the venous plasma, venous blood and capillary blood is variable and unpredictable at low concentrations. However, within the range of concentrations usually present in patients between 3 and 21 days after treatment with currently recommended doses, the relationship between capillary and venous whole blood is predictable; consequently, capillary blood sampling can be used in field assessments.
Collapse
Affiliation(s)
| | - Kasia Stepniewska
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, 10400 Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, OX3 7LJ UK
| | - Niklas Lindegardh
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, 10400 Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, OX3 7LJ UK
| | - Anna Annerberg
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, 10400 Thailand
| | - Joel Tarning
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, 10400 Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, OX3 7LJ UK
| | - Rose McGready
- Shoklo Malaria Research Unit, Mae Sot, Thailand
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, 10400 Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, OX3 7LJ UK
| | | | - Pratap Singhasivanon
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, 10400 Thailand
| | - Nicholas J. White
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, 10400 Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, OX3 7LJ UK
| | - François Nosten
- Shoklo Malaria Research Unit, Mae Sot, Thailand
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, 10400 Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, OX3 7LJ UK
| |
Collapse
|
4
|
Carrara VI, Zwang J, Ashley EA, Price RN, Stepniewska K, Barends M, Brockman A, Anderson T, McGready R, Phaiphun L, Proux S, van Vugt M, Hutagalung R, Lwin KM, Phyo AP, Preechapornkul P, Imwong M, Pukrittayakamee S, Singhasivanon P, White NJ, Nosten F. Changes in the treatment responses to artesunate-mefloquine on the northwestern border of Thailand during 13 years of continuous deployment. PLoS One 2009; 4:e4551. [PMID: 19234601 PMCID: PMC2641001 DOI: 10.1371/journal.pone.0004551] [Citation(s) in RCA: 194] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2008] [Accepted: 01/19/2009] [Indexed: 11/25/2022] Open
Abstract
Background Artemisinin combination treatments (ACT) are recommended as first line treatment for falciparum malaria throughout the malaria affected world. We reviewed the efficacy of a 3-day regimen of mefloquine and artesunate regimen (MAS3), over a 13 year period of continuous deployment as first-line treatment in camps for displaced persons and in clinics for migrant population along the Thai-Myanmar border. Methods and Findings 3,264 patients were enrolled in prospective treatment trials between 1995 and 2007 and treated with MAS3. The proportion of patients with parasitaemia persisting on day-2 increased significantly from 4.5% before 2001 to 21.9% since 2002 (p<0.001). Delayed parasite clearance was associated with increased risk of developing gametocytaemia (AOR = 2.29; 95% CI, 2.00–2.69, p = 0.002). Gametocytaemia on admission and carriage also increased over the years (p = 0.001, test for trend, for both). MAS3 efficacy has declined slightly but significantly (Hazards ratio 1.13; 95% CI, 1.07–1.19, p<0.001), although efficacy in 2007 remained well within acceptable limits: 96.5% (95% CI, 91.0–98.7). The in vitro susceptibility of P. falciparum to artesunate increased significantly until 2002, but thereafter declined to levels close to those of 13 years ago (geometric mean in 2007: 4.2 nM/l; 95% CI, 3.2–5.5). The proportion of infections caused by parasites with increased pfmdr1 copy number rose from 30% (12/40) in 1996 to 53% (24/45) in 2006 (p = 0.012, test for trend). Conclusion Artesunate-mefloquine remains a highly efficacious antimalarial treatment in this area despite 13 years of widespread intense deployment, but there is evidence of a modest increase in resistance. Of particular concern is the slowing of parasitological response to artesunate and the associated increase in gametocyte carriage.
Collapse
Affiliation(s)
| | | | - Elizabeth A. Ashley
- Shoklo Malaria Research Unit, Tak, Thailand
- Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Clinical Vaccinology and Tropical Medicine Churchill Hospital, Headington, Oxford, United Kingdom
| | - Ric N. Price
- Centre for Clinical Vaccinology and Tropical Medicine Churchill Hospital, Headington, Oxford, United Kingdom
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - Kasia Stepniewska
- Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Clinical Vaccinology and Tropical Medicine Churchill Hospital, Headington, Oxford, United Kingdom
| | | | - Alan Brockman
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - Tim Anderson
- Southwest Foundation for Biomedical Research, San Antonio, Texas, United States of America
| | - Rose McGready
- Shoklo Malaria Research Unit, Tak, Thailand
- Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Clinical Vaccinology and Tropical Medicine Churchill Hospital, Headington, Oxford, United Kingdom
| | | | | | | | | | | | | | | | - Mallika Imwong
- Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | | | - Nicholas J. White
- Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Clinical Vaccinology and Tropical Medicine Churchill Hospital, Headington, Oxford, United Kingdom
| | - François Nosten
- Shoklo Malaria Research Unit, Tak, Thailand
- Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Clinical Vaccinology and Tropical Medicine Churchill Hospital, Headington, Oxford, United Kingdom
- * E-mail:
| |
Collapse
|
5
|
McGready R, Tan SO, Ashley EA, Pimanpanarak M, Viladpai-nguen J, Phaiphun L, Wüstefeld K, Barends M, Laochan N, Keereecharoen L, Lindegardh N, Singhasivanon P, White NJ, Nosten F. A randomised controlled trial of artemether-lumefantrine versus artesunate for uncomplicated plasmodium falciparum treatment in pregnancy. PLoS Med 2008; 5:e253. [PMID: 19265453 PMCID: PMC2605900 DOI: 10.1371/journal.pmed.0050253] [Citation(s) in RCA: 108] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2008] [Accepted: 11/12/2008] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND To date no comparative trials have been done, to our knowledge, of fixed-dose artemisinin combination therapies (ACTs) for the treatment of Plasmodium falciparum malaria in pregnancy. Evidence on the safety and efficacy of ACTs in pregnancy is needed as these drugs are being used increasingly throughout the malaria-affected world. The objective of this study was to compare the efficacy, tolerability, and safety of artemether-lumefantrine, the most widely used fixed ACT, with 7 d artesunate monotherapy in the second and third trimesters of pregnancy. METHODS AND FINDINGS An open-label randomised controlled trial comparing directly observed treatment with artemether-lumefantrine 3 d (AL) or artesunate monotherapy 7 d (AS7) was conducted in Karen women in the border area of northwestern Thailand who had uncomplicated P. falciparum malaria in the second and third trimesters of pregnancy. The primary endpoint was efficacy defined as the P. falciparum PCR-adjusted cure rates assessed at delivery or by day 42 if this occurred later than delivery, as estimated by Kaplan-Meier survival analysis. Infants were assessed at birth and followed until 1 y of life. Blood sampling was performed to characterise the pharmacokinetics of lumefantrine in pregnancy. Both regimens were very well tolerated. The cure rates (95% confidence interval) for the intention to treat (ITT) population were: AS7 89.2% (82.3%-96.1%) and AL 82.0% (74.8%-89.3%), p = 0.054 (ITT); and AS7 89.7% (82.6%-96.8%) and AL 81.2% (73.6%-88.8%), p = 0.031 (per-protocol population). One-third of the PCR-confirmed recrudescent cases occurred after 42 d of follow-up. Birth outcomes and infant (up to age 1 y) outcomes did not differ significantly between the two groups. The pharmacokinetic study indicated that low concentrations of artemether and lumefantrine were the main contributors to the poor efficacy of AL. CONCLUSION The current standard six-dose artemether-lumefantrine regimen was well tolerated and safe in pregnant Karen women with uncomplicated falciparum malaria, but efficacy was inferior to 7 d artesunate monotherapy and was unsatisfactory for general deployment in this geographic area. Reduced efficacy probably results from low drug concentrations in later pregnancy. A longer or more frequent AL dose regimen may be needed to treat pregnant women effectively and should now be evaluated. Parasitological endpoints in clinical trials of any antimalarial drug treatment in pregnancy should be extended to delivery or day 42 if it comes later. TRIAL REGISTRATION Current Controlled Trials ISRCTN86353884.
Collapse
Affiliation(s)
- Rose McGready
- Shoklo Malaria Research Unit (SMRU), Mae Sot, Tak, Thailand
- Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Clinical Vaccinology and Tropical Medicine, Churchill Hospital, Oxford, United Kingdom
- * To whom correspondence should be addressed. E-mail:
| | - Saw Oo Tan
- Shoklo Malaria Research Unit (SMRU), Mae Sot, Tak, Thailand
| | - Elizabeth A Ashley
- Shoklo Malaria Research Unit (SMRU), Mae Sot, Tak, Thailand
- Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Clinical Vaccinology and Tropical Medicine, Churchill Hospital, Oxford, United Kingdom
| | | | | | - Lucy Phaiphun
- Shoklo Malaria Research Unit (SMRU), Mae Sot, Tak, Thailand
| | | | - Marion Barends
- Shoklo Malaria Research Unit (SMRU), Mae Sot, Tak, Thailand
- Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | | | - Niklas Lindegardh
- Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Clinical Vaccinology and Tropical Medicine, Churchill Hospital, Oxford, United Kingdom
| | | | - Nicholas J White
- Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Clinical Vaccinology and Tropical Medicine, Churchill Hospital, Oxford, United Kingdom
| | - François Nosten
- Shoklo Malaria Research Unit (SMRU), Mae Sot, Tak, Thailand
- Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Clinical Vaccinology and Tropical Medicine, Churchill Hospital, Oxford, United Kingdom
| |
Collapse
|
6
|
Ashley EA, Lwin KM, McGready R, Simon WH, Phaiphun L, Proux S, Wangseang N, Taylor W, Stepniewska K, Nawamaneerat W, Thwai KL, Barends M, Leowattana W, Olliaro P, Singhasivanon P, White NJ, Nosten F. An open label randomized comparison of mefloquine-artesunate as separate tablets vs. a new co-formulated combination for the treatment of uncomplicated multidrug-resistant falciparum malaria in Thailand. Trop Med Int Health 2007; 11:1653-60. [PMID: 17054744 DOI: 10.1111/j.1365-3156.2006.01724.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Delivering drugs in a fixed combination is essential to the success of the strategy of artemisinin-based combination therapy. This prevents one drug being taken without the protection of the other, reducing the chance of emergence and spread of drug resistant strains of Plasmodium falciparum. A lower tablet burden should also facilitate adherence to treatment. A new fixed combination of mefloquine plus artesunate has been developed. This was compared with the conventional regimen of separate tablets for the treatment of uncomplicated multidrug-resistant falciparum malaria. METHODS On the north-western border of Thailand 500 adults and children with uncomplicated falciparum malaria were randomized to receive either the new fixed combination or separate tablets. They were followed up weekly for 63 days. RESULTS The day 63 polymerase chain reaction-adjusted cure rates were 91.9% (95% CI 88.2-95.6) in the fixed combination group and 89.2% (85.0-93.4) in the loose tablets group (P=0.3). There was a lower incidence of early vomiting in the group receiving the fixed combination. CONCLUSION This new fixed combination of mefloquine and artesunate was efficacious, well tolerated and convenient to administer.
Collapse
|
7
|
Ashley EA, McGready R, Hutagalung R, Phaiphun L, Slight T, Proux S, Thwai KL, Barends M, Looareesuwan S, White NJ, Nosten F. A Randomized, Controlled Study of a Simple, Once-Daily Regimen of Dihydroartemisinin-Piperaquine for the Treatment of Uncomplicated, Multidrug-Resistant Falciparum Malaria. Clin Infect Dis 2005; 41:425-32. [PMID: 16028147 DOI: 10.1086/432011] [Citation(s) in RCA: 98] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2005] [Accepted: 03/31/2005] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Dihydroartemisinin-piperaquine (DP) is a fixed-combination antimalarial drug increasingly deployed in Southeast Asia. The current regimen involves 4 doses given over 3 days. Simplification of the dose regimen should facilitate treatment adherence and thereby increase effectiveness. METHODS In a randomized, controlled, 3-arm trial conducted along the northwestern border of Thailand, the standard 4-dose course of DP (DP4) was compared to an equivalent dose given as a once-daily regimen (DP3) and to the standard treatment of mefloquine-artesunate (MAS3). RESULTS A total of 499 patients were included in the study. Times to fever and parasite clearance were similar in all groups. The PCR genotyping-adjusted cure rates at day 63 after treatment initiation were 95.7% (95% confidence interval [95% CI], 92.2%-98.9%) for MAS3, 100% for DP4, and 99.4% (95% CI, 98.1%-100%) for DP3. The DP4 and DP3 cure rates were significantly higher than that for MAS3 (P=.008 and P=.03, respectively). All regimens were well tolerated. There were 3 deaths (1 in the MAS3 group and 2 in the DP3 group), all of which were considered to be unrelated to treatment. Rates of other adverse events were comparable between the groups, except for diarrhea, which was more common in the DP4 group (P=.05 vs. the MAS3 group). CONCLUSIONS A once-daily, 3-dose regimen of DP is a highly efficacious treatment for multidrug-resistant falciparum malaria. This simple, safe, and relatively inexpensive fixed combination could become the treatment of choice for falciparum malaria.
Collapse
|
8
|
Ashley EA, Krudsood S, Phaiphun L, Srivilairit S, McGready R, Leowattana W, Hutagalung R, Wilairatana P, Brockman A, Looareesuwan S, Nosten F, White NJ. Randomized, Controlled Dose‐Optimization Studies of Dihydroartemisinin‐Piperaquine for the Treatment of Uncomplicated Multidrug‐Resistant Falciparum Malaria in Thailand. J Infect Dis 2004; 190:1773-82. [PMID: 15499533 DOI: 10.1086/425015] [Citation(s) in RCA: 92] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2004] [Accepted: 05/26/2004] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Dihydroartemisinin-piperaquine (DP) is a new and relatively inexpensive artemisinin-containing fixed-combination antimalarial treatment. An adult treatment course contained 6.4 mg/kg dihydroartemisinin (DHA), which is >40% lower than the level in most artemisinin-containing combinations. This raised the possibility that the efficacy of the current coformulation may not be optimal in the treatment of multidrug-resistant falciparum malaria. METHODS In 2 large randomized, controlled studies in Thailand, the recommended dose of DP was compared with a regimen with additional artemisinin derivative (12 mg/kg; DP+) and with mefloquine plus artesunate (MAS3). RESULTS A total of 731 patients were included: 201 in a hospital-based study and 530 in a community study. Day-28 cure rates in the hospital-based study were 100% (95% confidence interval [CI], 93.9%-100%) in the MAS3 and DP+ groups and 98.3% (95% CI, 91%-99.7%) in the DP group, with a single recrudescence on day 21. In the community study, polymerase chain reaction genotyping-adjusted cure rates on day 63 were 96.1% (95% CI, 92.6%-99.7%) in the DP group, 98.3% (95% CI, 96.1%-100%) in the DP+ group, and 94.9% (95% CI, 91.2%-98.6%) in the MAS3 group (P=.2). Adverse events were few, with an excess of mild abdominal pain in the DP group. CONCLUSIONS The current dosage of DP (6.4 mg/kg DHA and 51.2 mg/kg piperaquine phosphate) given over the course of 48 h is highly effective, safe, and well tolerated for the treatment of multidrug-resistant falciparum malaria, and its efficacy is not improved by the addition of more DHA.
Collapse
Affiliation(s)
- Elizabeth A Ashley
- Shoklo Malaria Research Unit, Mae Sot, and Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
9
|
Brockman A, Paul RE, Anderson TJ, Hackford I, Phaiphun L, Looareesuwan S, Nosten F, Day KP. Application of genetic markers to the identification of recrudescent Plasmodium falciparum infections on the northwestern border of Thailand. Am J Trop Med Hyg 1999; 60:14-21. [PMID: 9988316 DOI: 10.4269/ajtmh.1999.60.14] [Citation(s) in RCA: 113] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Parasite genotyping by the polymerase chain reaction was used to distinguish recrudescent from newly acquired Plasmodium falciparum infections in a Karen population resident on the northwestern border of Thailand where malaria transmission is low (one infection/person/year). Plasmodium falciparum infections were genotyped for allelic variation in three polymorphic antigen loci, merozoite surface proteins-1 and -2 (MSP-1 and -2) and glutamaterich protein (GLURP), before and after antimalarial drug treatment. Population genotype frequencies were measured to provide the baseline information to calculate the probability of a new infection with a different or the same genotype to the initial pretreatment isolate. Overall, 38% of the infections detected following treatment had an identical genotype before and up to 121 days after treatment. These post-treatment genotypes were considered recrudescent because of the low (< 5%) probability of repeated occurrence by chance in the same patient. This approach allows studies of antimalarial drug treatment to be conducted in areas of low transmission since recrudescences can be distinguished confidently from newly acquired infections.
Collapse
Affiliation(s)
- A Brockman
- Shoklo Malaria Research Unit, Mae Sot, Tak, Thailand
| | | | | | | | | | | | | | | |
Collapse
|