Abstract
The objective of this study was to determine the appropriate dose of artesunate for use in a fixed dose combination therapy with chlorproguanil−dapsone (CPG−DDS) for the treatment of uncomplicated falciparum malaria.MethodsOpen-label clinical trial comparing CPG−DDS alone or with artesunate 4, 2, or 1 mg/kg at medical centers in Blantyre, Malawi and Farafenni, The Gambia. The trial was conducted between June 2002 and February 2005, including 116 adults (median age 27 years) and 107 children (median age 38 months) with acute uncomplicated Plasmodium falciparum malaria. Subjects were randomized into 4 groups to receive CPG–DDS alone or plus 4, 2 or 1 mg/kg of artesunate once daily for 3 days. Assessments took place on Days 0−3 in hospital and follow-up on Days 7 and 14 as out-patients. Efficacy was evaluated in the Day 3 per-protocol (PP) population using mean time to reduce baseline parasitemia by 90% (PC90). A number of secondary outcomes were also included. Appropriate artesunate dose was determined using a pre-defined decision matrix based on primary and secondary outcomes. Treatment emergent adverse events were recorded from clinical assessments and blood parameters. Safety was evaluated in the intent to treat (ITT) population.ResultsIn the Day 3 PP population for the adult group (N = 85), mean time to PC90 was 19.1 h in the CPG−DDS group, significantly longer than for the +artesunate 1 mg/kg (12.5 h; treatment difference −6.6 h [95%CI −11.8, −1.5]), 2 mg/kg (10.7 h; −8.4 h [95%CI −13.6, −3.2]) and 4 mg/kg (10.3 h; −8.7 h [95%CI −14.1, −3.2]) groups. For children in the Day 3 PP population (N = 92), mean time to PC90 was 21.1 h in the CPG−DDS group, similar to the +artesunate 1 mg/kg group (17.7 h; −3.3 h [95%CI −8.6, 2.0]), though the +artesunate 2 mg/kg and 4 mg/kg groups had significantly shorter mean times to PC90 versus CPG−DDS; 14.4 h (treatment difference −6.4 h [95%CI −11.7, −1.0]) and 12.8 h (−7.4 h [95%CI −12.9, −1.8]), respectively. An analysis of mean time to PC90 for the Day 14 PP and ITT populations was consistent with the primary analysis. Treatment emergent, drug-related adverse events were experienced in 35.3% (41/116) of adults and 70.1% (75/107) of children; mostly hematological and gastroenterological. The nature and incidence of adverse events was similar between the groups. No dose-related changes in laboratory parameters were observed. Nine serious adverse events due to any cause occurred in five subjects including two cases of hemolysis believed to be associated with drug treatment (one adult, one child). One adult died of anaphylactic shock, not associated with investigational therapy.ConclusionsCPG–DDS plus artesunate demonstrated advantages over CPG–DDS alone for the primary efficacy endpoint (mean time to PC90) except in children for the 1 mg/kg artesunate dose. Based on a pre-defined decision matrix, the primary endpoint in the child group supported an artesunate dose of 4 mg/kg. Secondary endpoints also supported a 4 mg/kg artesunate dose to take forward into the remainder of the development program.Trial RegistrationClinicalTrials.gov NCT00519467
Highlights
Over one million people die of malaria every year, mostly children [1]
An analysis of mean time to PC90 for the Day 14 PP and intent to treat (ITT) populations was consistent with the primary analysis
It is important that new combinations include agents with different mechanisms of action used at appropriate doses to ensure maximal and rapid parasite killing. In consideration of these points, in 2004 the World Health Organization (WHO) Roll Back Malaria group recommended that first-line treatment of uncomplicated malaria should be with artemisinin-based combination therapy [3]
Summary
Over one million people die of malaria every year, mostly children [1]. Widespread drug resistance in Plasmodium spp. has undermined the effectiveness of many of the antimalarials used commonly, chloroquine [2]. It is important that new combinations include agents with different mechanisms of action used at appropriate doses to ensure maximal and rapid parasite killing In consideration of these points, in 2004 the World Health Organization (WHO) Roll Back Malaria group recommended that first-line treatment of uncomplicated malaria should be with artemisinin-based combination therapy [3]. Artemisinin-derived drugs such as artesunate and artemether are effective against multi-drug resistant strains of P. falciparum [4,5], and are highly potent against asexual forms, rapidly reducing parasitemia [6,7] These agents are active against gametocytes, potentially reducing transmission rates [8,9,10,11,12]. Effective monotherapy requires seven days of treatment, increasing the risk of resistance development through poor compliance and so these agents must be combined with at least one other antimalarial
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