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Nyaaba N, Andoh NE, Amoh G, Amuzu DSY, Ansong M, Ordóñez-Mena JM, Hirst J. Comparative efficacy and safety of the artemisinin derivatives compared to quinine for treating severe malaria in children and adults: A systematic update of literature and network meta-analysis. PLoS One 2022; 17:e0269391. [PMID: 35857773 PMCID: PMC9299386 DOI: 10.1371/journal.pone.0269391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 05/19/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The artemisinin derivatives are the preferred antimalaria drugs for treating severe Plasmodium falciparum malaria. However, their clinical effectiveness compared to each other is unknown. Our objective, therefore, was to evaluate the efficacy and safety of the artemisinin derivatives and quinine for treating severe P. falciparum malaria in children and adults using a network meta-analysis. METHODS AND FINDINGS Review protocol was registered with PROSPERO, CRD42020218190. We updated the search strategies of three Cochrane systematic reviews which included published and unpublished randomised control trials (RCTs) that have compared specific artemisinin derivatives to quinine in treating severe malaria. Search included CENTRAL, MEDLINE, Embase, LILACS, ISI Web of Science and trial registries up to February 2021. We screened studies, extracted data, assessed risk of bias, and quality of evidence in duplicate. Separate network meta-analyses in the frequentist framework, using a random effects model, with quinine as reference, were conducted for adults and children, and rankings were produced using p-scores to assess mortality, parasite clearance, coma recovery, fever clearance, neurological sequela and adverse events. Searches identified 818 citations, 33 RCTs were eligible. We pooled 7795 children and 3182 adults. The networks involved artesunate, artemether, rectal artemisinin, arteether and quinine. Compared to quinine, artesunate reduced mortality in children (risk ratio (RR), 0.76; 95%CI [0.65 to 0.89], moderate quality), adults (RR, 0.55; 95%CI [0.40 to 0.75], moderate quality) and in cerebral malaria (RR, 0.72; 95%CI [0.55 to 0.94], moderate quality). Compared to rectal artemisinin and intramuscular arteether, the efficacy and safety of parenteral artesunate, and intramuscular artemether in treating severe malaria are not clear. Rankings showed that none of the artemisinin drugs were consistently superior in all the outcomes assessed. Indirect evidence produced were of very low ratings due to suspected publication bias and imprecision. CONCLUSIONS Artesunate reduces mortality compared to quinine for both adults and children in Asia and Africa including cerebral malaria. The artemisinin derivatives remain the best treatment for severe malaria but their comparative clinical effectiveness is yet to be fully explored.
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Affiliation(s)
- Nicholas Nyaaba
- Infectious Disease Centre, 37 Military Hospital, Cantonments, Accra, Ghana
| | - Nana Efua Andoh
- Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana
| | - Gordon Amoh
- Korle-Bu Polyclinic/ Family Medicine Department, Korle-Bu Teaching Hospital, Korle-Bu, Accra, Ghana
| | - Dominic Selorm Yao Amuzu
- West African Centre for Cell Biology of Infectious Pathogens, Department of Biochemistry, Cell and Molecular Biology, University of Ghana, Legon, Accra, Ghana
| | - Mary Ansong
- The International Sickle Cell Centre, Accra Central, Accra, Ghana
| | - José M. Ordóñez-Mena
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
- National Institute for Health Research (NIRH), Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Jennifer Hirst
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
- National Institute for Health Research (NIRH), Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
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Kumar SP, Babu PP. NADPH Oxidase: a Possible Therapeutic Target for Cognitive Impairment in Experimental Cerebral Malaria. Mol Neurobiol 2021; 59:800-820. [PMID: 34782951 DOI: 10.1007/s12035-021-02598-1] [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: 06/02/2021] [Accepted: 10/12/2021] [Indexed: 12/19/2022]
Abstract
Long-term cognitive impairment associated with seizure-induced hippocampal damage is the key feature of cerebral malaria (CM) pathogenesis. One-fourth of child survivors of CM suffer from long-lasting neurological deficits and behavioral anomalies. However, mechanisms on hippocampal dysfunction are unclear. In this study, we elucidated whether gp91phox isoform of nicotinamide adenine dinucleotide phosphate oxidase 2 (NOX2) (a potent marker of oxidative stress) mediates hippocampal neuronal abnormalities and cognitive dysfunction in experimental CM (ECM). Mice symptomatic to CM were rescue treated with artemether monotherapy (ARM) and in combination with apocynin (ARM + APO) adjunctive based on scores of Rapid Murine Come behavior Scale (RMCBS). After a 30-day survivability period, we performed Barnes maze, T-maze, and novel object recognition cognitive tests to evaluate working and reference memory in all the experimental groups except CM. Sensorimotor tests were conducted in all the cohorts to assess motor coordination. We performed Golgi-Cox staining to illustrate cornu ammonis-1 (CA1) pyramidal neuronal morphology and study overall hippocampal neuronal density changes. Further, expression of NOX2, NeuN (neuronal marker) in hippocampal CA1 and dentate gyrus was determined using double immunofluorescence experiments in all the experimental groups. Mice administered with ARM monotherapy and APO adjunctive treatment exhibited similar survivability. The latter showed better locomotor and cognitive functions, reduced ROS levels, and hippocampal NOX2 immunoreactivity in ECM. Our results show a substantial increase in hippocampal NeuN immunoreactivity and dendritic arborization in ARM + APO cohorts compared to ARM-treated brain samples. Overall, our study suggests that overexpression of NOX2 could result in loss of hippocampal neuronal density and dendritic spines of CA1 neurons affecting the spatial working and reference memory during ECM. Notably, ARM + APO adjunctive therapy reversed the altered neuronal morphology and oxidative damage in hippocampal neurons restoring long-term cognitive functions after CM.
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Affiliation(s)
- Simhadri Praveen Kumar
- F-23/71, Neuroscience Laboratory, Department of Biotechnology and Bioinformatics, School of Life Sciences, University of Hyderabad, Hyderabad, Telangana, 500 046, India
| | - Phanithi Prakash Babu
- F-23/71, Neuroscience Laboratory, Department of Biotechnology and Bioinformatics, School of Life Sciences, University of Hyderabad, Hyderabad, Telangana, 500 046, India.
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Abstract
BACKGROUND In 2011 the World Health Organization (WHO) recommended parenteral artesunate in preference to quinine as first-line treatment for people with severe malaria. Prior to this recommendation many countries, particularly in Africa, had begun to use artemether, an alternative artemisinin derivative. This Cochrane Review evaluates intramuscular artemether compared with both quinine and artesunate. OBJECTIVES To assess the efficacy and safety of intramuscular artemether versus any other parenteral medication in the treatment of severe malaria in adults and children. SEARCH METHODS We searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (the Cochrane Library), MEDLINE, Embase, and LILACS, ISI Web of Science, conference proceedings, and reference lists of articles. We also searched the WHO International Clinical Trial Registry Platform, ClinicalTrials.gov, and the metaRegister of Controlled Trials (mRCT) for ongoing trials up to 7 September 2018. We checked the reference lists of all studies identified by the search. We examined references listed in review articles and previously compiled bibliographies to look for eligible studies. SELECTION CRITERIA Randomized controlled trials (RCTs) comparing intramuscular artemether with intravenous/intramuscular quinine or artesunate for treating severe malaria. DATA COLLECTION AND ANALYSIS The primary outcome was all-cause death. Two review authors independently screened each article by title and abstract, and examined potentially relevant studies for inclusion using an eligibility form. Two review authors independently extracted data and assessed risk of bias of included studies. We summarized dichotomous outcomes using risk ratios (RRs) and continuous outcomes using mean differences (MDs), and have presented both measures with 95% confidence intervals (CIs). Where appropriate, we combined data in meta-analyses and used the GRADE approach to summarize the certainty of the evidence. MAIN RESULTS We included 19 RCTs, enrolling 2874 adults and children with severe malaria, carried out in Africa (12 trials) and in Asia (7 trials).Artemether versus quinineFor children, there is probably little or no difference in the risk of death between intramuscular artemether and quinine (RR 0.97, 95% CI 0.77 to 1.21; 13 trials, 1659 participants, moderate-certainty evidence). Coma resolution time may be about five hours shorter with artemether (MD -5.45, 95% CI -7.90 to -3.00; six trials, 358 participants, low-certainty evidence). Artemether may make little difference to neurological sequelae (RR 0.84, 95% CI 0.66 to 1.07; seven trials, 968 participants, low-certainty evidence). Compared to quinine, artemether probably shortens the parasite clearance time by about nine hours (MD -9.03, 95% CI -11.43 to -6.63; seven trials, 420 participants, moderate-certainty evidence), and may shorten the fever clearance time by about three hours (MD -3.73, 95% CI -6.55 to -0.92; eight trials, 457 participants, low-certainty evidence).For adults, treatment with intramuscular artemether probably results in fewer deaths than treatment with quinine (RR 0.59, 95% CI 0.42 to 0.83; four trials, 716 participants, moderate-certainty evidence).Artemether versus artesunateArtemether and artesunate have not been directly compared in randomized trials in children.For adults, mortality is probably higher with intramuscular artemether (RR 1.80, 95% CI 1.09 to 2.97; two trials, 494 participants, moderate-certainty evidence). AUTHORS' CONCLUSIONS Artemether appears to be more effective than quinine in children and adults. Artemether compared to artesunate has not been extensively studied, but in adults it appears inferior. These findings are consistent with the WHO recommendations that artesunate is the drug of choice, but artemether is acceptable when artesunate is not available.
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Affiliation(s)
- Ekpereonne B Esu
- College of Medical Sciences, University of CalabarDepartment of Public HealthCalabarCross River StateNigeria
| | - Emmanuel E Effa
- College of Medical Sciences, University of CalabarInternal MedicinePMB 1115CalabarCross River StateNigeria540001
| | - Oko N Opie
- Federal College of EducationDepartment of General StudiesObuduCross River StateNigeria
| | - Martin M Meremikwu
- University of Calabar Teaching HospitalDepartment of PaediatricsPMB 1115CalabarCross River StateNigeria
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Efficacy of a novel sublingual spray formulation of artemether in African children with Plasmodium falciparum malaria. Antimicrob Agents Chemother 2015; 59:6930-8. [PMID: 26303805 DOI: 10.1128/aac.00243-15] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Accepted: 08/20/2015] [Indexed: 11/20/2022] Open
Abstract
The efficacy of sublingual artemether (ArTiMist) was investigated in two studies. In study 1, 31 children were randomized to sublingual artemether (n = 16) or intravenous (i.v.) quinine (n = 15). In study 2, 151 children were randomized to sublingual artemether (n = 77) or i.v. quinine (n = 74). For both studies, patients weighed between 5 and 15 kg and had either severe or complicated malaria based on WHO criteria, or they had uncomplicated malaria but were unable to tolerate oral medication as a result of nausea, vomiting, or diarrhea. Patients received either 3 mg/kg of body weight of sublingual artemether or a loading dose of 20 mg/kg of i.v. quinine followed by 10 mg/kg every 8 h i.v. thereafter. The primary endpoint was parasitological success, defined as a reduction in parasite count of ≥90% of that at baseline at 24 h after the first dose. Other endpoints based on parasite clearance and clinical response were evaluated. In study 1, there were parasitological success rates of 93.3% (14/15) and 66.7% (10/15) for the sublingual artemether and quinine treatments, respectively. In study 2, 94.3% (66/70) of the ArTiMist-treated patients and 39.4% (28/71) of the quinine-treated patients had parasitological success (P < 0.0001). Indicators of parasite clearance (parasite clearance time [PCT], time for parasite count to fall by 50% [PCT50], time for parasite count to fall by 90% [PCT90], and percent reduction in parasitemia from baseline at 24 h [PRR24]) were significantly superior for children treated with sublingual artemether compared to those treated with i.v. quinine. There were no differences between treatments for the clinical endpoints, such as fever clearance time. The local tolerability of sublingual artemether was good. Sublingual artemether leads to rapid parasite clearance and clinical recovery. (Studies 1 and 2 are registered at ClinicalTrials.gov under registration numbers NCT01047436 and NCT01258049, respectively.).
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Abstract
BACKGROUND In 2011 the World Health Organization (WHO) recommended parenteral artesunate in preference to quinine as first-line treatment for people with severe malaria. Prior to this recommendation, many countries, particularly in Africa, had begun to use artemether, an alternative artemisinin derivative. This review evaluates intramuscular artemether compared with both quinine and artesunate. OBJECTIVES To assess the efficacy and safety of intramuscular artemether versus any other parenteral medication in treating severe malaria in adults and children. SEARCH METHODS We searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library), MEDLINE, EMBASE and LILACS, ISI Web of Science, conference proceedings and reference lists of articles. We also searched the WHO clinical trial registry platform, ClinicalTrials.gov and the metaRegister of Controlled Trials (mRCT) for ongoing trials up to 9 April 2014. SELECTION CRITERIA Randomized controlled trials (RCTs) comparing intramuscular artemether with intravenous or intramuscular antimalarial for treating severe malaria. DATA COLLECTION AND ANALYSIS The primary outcome was all-cause death.Two authors independently assessed trial eligibility, risk of bias and extracted data. We summarized dichotomous outcomes using risk ratios (RR) and continuous outcomes using mean differences (MD), and presented both measures with 95% confidence intervals (CI). Where appropriate, we combined data in meta-analyses and assessed the quality of the evidence using the GRADE approach. MAIN RESULTS We included 18 RCTs, enrolling 2662 adults and children with severe malaria, carried out in Africa (11) and in Asia (7). Artemether versus quinine For children in Africa, there is probably little or no difference in the risk of death between intramuscular artemether and quinine (RR 0.96, 95% CI 0.76 to 1.20; 12 trials, 1447 participants, moderate quality evidence). Coma recovery may be about five hours shorter with artemether (MD -5.45, 95% CI -7.90 to -3.00; six trials, 358 participants, low quality evidence), and artemether may result in fewer neurological sequelae, but larger trials would be needed to confirm this (RR 0.84, 95% CI 0.66 to 1.07; seven trials, 968 participants, low quality evidence). Artemether probably shortens the parasite clearance time by about nine hours (MD -9.03, 95% CI -11.43 to -6.63; seven trials, 420 participants, moderate quality evidence), and may shorten the fever clearance time by about three hours (MD -3.73, 95% CI -6.55 to -0.92; eight trials, 457 participants, low quality evidence).For adults in Asia, treatment with intramuscular artemether probably results in fewer deaths than treatment with quinine (RR 0.59, 95% CI 0.42 to 0.83; four trials, 716 participants, moderate quality evidence). Artemether versus artesunate Artemether and artesunate have not been directly compared in randomized trials in African children.For adults in Asia, mortality is probably higher with intramuscular artemether (RR 1.80, 95% CI 1.09 to 2.97, two trials,494 participants, moderate quality evidence). AUTHORS' CONCLUSIONS Although there is a lack of direct evidence comparing artemether with artesunate, artemether is probably less effective than artesunate at preventing deaths from severe malaria. In circumstances where artesunate is not available, artemether is an alternative to quinine.
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Affiliation(s)
- Ekpereonne Esu
- University of CalabarDepartment of Public HealthCalabarNigeria540271
| | - Emmanuel E Effa
- College of Medical Sciences, University of CalabarInternal MedicinePMB 1115CalabarNigeria540001
| | - Oko N Opie
- Federal College of EducationDepartment of General StudiesObuduNigeria
| | - Amirahobu Uwaoma
- University of Calabar Teaching HospitalDepartment of PaediatricsPMB 1115CalabarCross River StateNigeria
| | - Martin M Meremikwu
- University of Calabar Teaching HospitalDepartment of PaediatricsPMB 1115CalabarNigeria
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Manning L, Laman M, Davis WA, Davis TME. Clinical features and outcome in children with severe Plasmodium falciparum malaria: a meta-analysis. PLoS One 2014; 9:e86737. [PMID: 24516538 PMCID: PMC3916300 DOI: 10.1371/journal.pone.0086737] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Accepted: 12/14/2013] [Indexed: 11/29/2022] Open
Abstract
Background Although global malaria mortality is declining, estimates may not reflect better inpatient management of severe malaria (SM) where reported case fatality rates (CFRs) vary from 1–25%. Methods A meta-analysis of prospective studies of SM was conducted to examine i) whether hypothesized differences between clinical features and outcome in Melanesian compared with African or Asian children really exist, and ii) to explore temporal changes in overall and complication-specific CFRs. The proportions of different SM complications and, overall and complication-specific CFRs were incorporated into the meta-analysis. Adjustments were made for study-level covariates including geographic region, SM definition, artemisinin treatment, median age of participants and time period. Findings Sixty-five studies were included. Substantial heterogeneity (I2>80%) was demonstrated for most outcomes. SM definition contributed to between-study heterogeneity in proportions of cerebral malaria (CM), metabolic acidosis (MA), severe anemia and overall CFR, whilst geographic region was a significant moderator in for CM and hypoglycemia (HG) rates. Compared with their African counterparts, Melanesian children had lower rates of HG (10% [CI95 7–13%] versus 1% [0–3%], P<0.05), lower overall CFR (2% [0–4%] versus 7% [6–9%], P<0.05) and lower CM-specific CFR (8% [0–17%] versus 19% [16–21%], P<0.05). There was no temporal trend for overall CFR and CM-specific CFR but declining HG- and MA- specific CFRs were observed. Interpretation These data highlight that recent estimates of declining global malaria mortality are not replicated by improved outcomes for children hospitalized with SM. Significant geographic differences in the complication rates and subsequent CFRs exist and provide the first robust confirmation of lower CFRs in Melanesian children, perhaps due to less frequent HG.
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Affiliation(s)
- Laurens Manning
- School of Medicine and Pharmacology, University of Western Australia, Fremantle Hospital, Fremantle, Western Australia, Australia
- * E-mail:
| | - Moses Laman
- School of Medicine and Pharmacology, University of Western Australia, Fremantle Hospital, Fremantle, Western Australia, Australia
| | - Wendy A. Davis
- School of Medicine and Pharmacology, University of Western Australia, Fremantle Hospital, Fremantle, Western Australia, Australia
| | - Timothy M. E. Davis
- School of Medicine and Pharmacology, University of Western Australia, Fremantle Hospital, Fremantle, Western Australia, Australia
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Artemisinin derivatives Versus quinine for severe malaria in children: A systematic review and meta-analysis. Indian Pediatr 2010; 47:423-8. [DOI: 10.1007/s13312-010-0072-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Kyu HH, Fernández E. Artemisinin derivatives versus quinine for cerebral malaria in African children: a systematic review. Bull World Health Organ 2009; 87:896-904. [PMID: 20454480 DOI: 10.2471/blt.08.060327] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2008] [Revised: 03/18/2009] [Accepted: 03/19/2009] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To summarize the existing evidence on the efficacy of artemether and arteether, two artemisinin derivatives, versus quinine for treating cerebral malaria in children. METHODS We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and the http://clinicaltrials.gov web site. We also checked the reference lists of existing systematic reviews and of all trials identified by the above methods. We searched exclusively for randomized controlled trials (RCTs) comparing artemether/arteether with quinine for treating cerebral malaria in children. Two independent reviewers assessed study eligibility and trial quality and extracted the data. FINDINGS Nine RCTs were included in the analysis, and all were from Africa. Five had adequate allocation concealment. Seven trials compared artemether with quinine (1220 children), and two compared arteether with quinine (194 children). No statistically significant difference was found between artemisinin derivatives and quinine in preventing mortality (relative risk, RR: 0.91; 95% confidence interval, CI: 0.73-1.14; I(2): 0%). The quality of the evidence, as assessed by the Grade evidence profile, was moderate. The only serious adverse event was seen in a patient in the quinine group who developed fatal black water fever. CONCLUSION Artemisinin derivatives are not inferior to quinine in preventing death in children with cerebral malaria.
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PrayGod G, de Frey A, Eisenhut M. Artemisinin derivatives versus quinine in treating severe malaria in children: a systematic review. Malar J 2008; 7:210. [PMID: 18928535 PMCID: PMC2576341 DOI: 10.1186/1475-2875-7-210] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2008] [Accepted: 10/17/2008] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The efficacy of intravenous quinine, which is the mainstay for treating severe malaria in children, is decreasing in South East Asia and Africa. Artemisinin derivatives are a potential alternative to quinine. However, their efficacy compared to quinine in treating severe malaria in children is not clearly understood. The objective of this review was to assess the efficacy of parenteral artemisinin derivatives versus parenteral quinine in treating severe malaria in children. METHODS All randomized controlled studies comparing parenteral artemisinin derivatives with parenteral quinine in treating severe malaria in children were included in the review. Data bases searched were: The Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2007), MEDLINE (1966 to February 2008), EMBASE (1980 to February 2008), and LILACS (1982 to February 2008). Dichotomous variables were compared using risk ratios (RR) and the continuous data using weighted mean difference (WMD). RESULTS Twelve trials were included (1,524 subjects). There was no difference in mortality between artemisinin derivatives and quinine (RR = 0.90, 95% CI 0.73 to 1.12). The artemisinin derivatives resolved coma faster than quinine (WMD = -4.61, 95% CI: -7.21 to -2.00, fixed effect model), but when trials with adequate concealment only were considered this differences disappeared. There was no statistically significant difference between the two groups in parasite clearance time, fever clearance time, incidence of neurological sequelae and 28th day cure rate. One trial reported significantly more local reactions at the injection site with intramuscular quinine compared to artemether. None of the trials was adequately powered to demonstrate equivalence. CONCLUSION There was no evidence that treatment of children with severe malaria with parenteral artemisinin derivatives was associated with lower mortality or long-term morbidity compared to parenteral quinine. Future studies require adequately powered equivalence trial design to decide whether both drugs are equally effective.
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Affiliation(s)
- George PrayGod
- National Institute for Medical Research, P.O Box 1462, Mwanza, Tanzania
| | - Albie de Frey
- School of Public Health, University of the Witwatersrand, 7 York Road, Parktown 2193, Johannesburg, South Africa
| | - Michael Eisenhut
- Luton & Dunstable Hospital NHS Foundation Trust, Lewsey Road, Luton, LU4 0DZ, UK
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Abstract
BACKGROUND Artemisinin derivatives may have advantages over quinoline drugs for treating severe malaria since they are fast acting and effective against quinine resistant malaria parasites. OBJECTIVES The objective of this review was to assess the effects of artemisinin drugs for severe and complicated falciparum malaria in adults and children. SEARCH STRATEGY We searched the Cochrane Infectious Diseases Group trials register, Cochrane Controlled Trials Register, Medline, Embase, Science Citation Index, Lilacs, African Index Medicus, conference abstracts and reference lists of articles. We contacted organisations, researchers in the field and drug companies. SELECTION CRITERIA Randomised and pseudo-randomised trials comparing artemisinin drugs (rectal, intramuscular or intravenous) with standard treatment, or comparisons between artemisinin derivatives in adults or children with severe or complicated falciparum malaria. DATA COLLECTION AND ANALYSIS Eligibility, trial quality assessment and data extraction were done independently by two reviewers. Study authors were contacted for additional information. MAIN RESULTS Twenty three trials are included, allocation concealment was adequate in nine. Sixteen trials compared artemisinin drugs with quinine in 2653 patients. Artemisinin drugs were associated with better survival (mortality odds ratio 0.61, 95% confidence interval 0.46 to 0.82, random effects model). In trials where concealment of allocation was adequate (2261 patients), this was barely statistically significant (odds ratio 0.72, 95% CI 0.54 to 0.96, random effects model). In 1939 patients with cerebral malaria, mortality was also lower with artemisinin drugs overall (odds ratio 0.63, 95% CI 0.44 to 0.88, random effects model). The difference was not significant however when only trials reporting adequate concealment of allocation were analysed (odds ratio 0.78, 95% CI 0.55 to 1.10, random effects model) based on 1607 patients. No difference in neurological sequelae was shown. Compared with quinine, artemisinin drugs showed faster parasite clearance from the blood and similar adverse effects. REVIEWER'S CONCLUSIONS The evidence suggests that artemisinin drugs are no worse than quinine in preventing death in severe or complicated malaria. No artemisinin derivative appears to be better than the others.
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Affiliation(s)
- H M McIntosh
- Cochrane Infectious Diseases Group, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK, L3 5QA.
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