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Jones S, Hodel EM, Sharma R, Kay K, Hastings IM. Optimal Treatments for Severe Malaria and the Threat Posed by Artemisinin Resistance. J Infect Dis 2020; 219:1243-1253. [PMID: 30517708 PMCID: PMC6452316 DOI: 10.1093/infdis/jiy649] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Accepted: 11/07/2018] [Indexed: 01/08/2023] Open
Abstract
Background Standard treatment for severe malaria is with artesunate; patient survival in the 24 hours immediately posttreatment is the key objective. Clinical trials use clearance rates of circulating parasites as their clinical outcome, but the pathology of severe malaria is attributed primarily to noncirculating, sequestered, parasites, so there is a disconnect between existing clinical metrics and objectives. Methods We extend existing pharmacokinetic/pharmacodynamic modeling methods to simulate the treatment of 10000 patients with severe malaria and track the pathology caused by sequestered parasites. Results Our model recovered the clinical outcomes of existing studies (based on circulating parasites) and showed a “simplified” artesunate regimen was noninferior to the existing World Health Organization regimen across the patient population but resulted in worse outcomes in a subgroup of patients with infections clustered in early stages of the parasite life cycle. This same group of patients were extremely vulnerable to resistance emerging in parasite early ring stages. Conclusions We quantify patient outcomes in a manner appropriate for severe malaria with a flexible framework that allows future researchers to implement their beliefs about underlying pathology. We highlight with some urgency the threat posed to treatment of severe malaria by artemisinin resistance in parasite early ring stages.
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Affiliation(s)
- Sam Jones
- Parasitology Department, Liverpool School of Tropical Medicine, United Kingdom
| | - Eva Maria Hodel
- Parasitology Department, Liverpool School of Tropical Medicine, United Kingdom.,Department of Clinical Sciences, Liverpool School of Tropical Medicine, United Kingdom
| | - Raman Sharma
- Parasitology Department, Liverpool School of Tropical Medicine, United Kingdom
| | - Katherine Kay
- Parasitology Department, Liverpool School of Tropical Medicine, United Kingdom
| | - Ian M Hastings
- Parasitology Department, Liverpool School of Tropical Medicine, United Kingdom
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Kremsner PG, Adegnika AA, Hounkpatin AB, Zinsou JF, Taylor TE, Chimalizeni Y, Liomba A, Kombila M, Bouyou-Akotet MK, Mawili Mboumba DP, Agbenyega T, Ansong D, Sylverken J, Ogutu BR, Otieno GA, Wangwe A, Bojang KA, Okomo U, Sanya-Isijola F, Newton CR, Njuguna P, Kazungu M, Kerb R, Geditz M, Schwab M, Velavan TP, Nguetse C, Köhler C, Issifou S, Bolte S, Engleitner T, Mordmüller B, Krishna S. Intramuscular Artesunate for Severe Malaria in African Children: A Multicenter Randomized Controlled Trial. PLoS Med 2016; 13:e1001938. [PMID: 26757276 PMCID: PMC4710539 DOI: 10.1371/journal.pmed.1001938] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2015] [Accepted: 12/02/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Current artesunate (ARS) regimens for severe malaria are complex. Once daily intramuscular (i.m.) injection for 3 d would be simpler and more appropriate for remote health facilities than the current WHO-recommended regimen of five intravenous (i.v.) or i.m. injections over 4 d. We compared both a three-dose i.m. and a three-dose i.v. parenteral ARS regimen with the standard five-dose regimen using a non-inferiority design (with non-inferiority margins of 10%). METHODS AND FINDINGS This randomized controlled trial included children (0.5-10 y) with severe malaria at seven sites in five African countries to assess whether the efficacy of simplified three-dose regimens is non-inferior to a five-dose regimen. We randomly allocated 1,047 children to receive a total dose of 12 mg/kg ARS as either a control regimen of five i.m. injections of 2.4 mg/kg (at 0, 12, 24, 48, and 72 h) (n = 348) or three injections of 4 mg/kg (at 0, 24, and 48 h) either i.m. (n = 348) or i.v. (n = 351), both of which were the intervention arms. The primary endpoint was the proportion of children with ≥ 99% reduction in parasitemia at 24 h from admission values, measured by microscopists who were blinded to the group allocations. Primary analysis was performed on the per-protocol population, which was 96% of the intention-to-treat population. Secondary analyses included an analysis of host and parasite genotypes as risks for prolongation of parasite clearance kinetics, measured every 6 h, and a Kaplan-Meier analysis to compare parasite clearance kinetics between treatment groups. A post hoc analysis was performed for delayed anemia, defined as hemoglobin ≤ 7 g/dl 7 d or more after admission. The per-protocol population was 1,002 children (five-dose i.m.: n = 331; three-dose i.m.: n = 338; three-dose i.v.: n = 333); 139 participants were lost to follow-up. In the three-dose i.m. arm, 265/338 (78%) children had a ≥ 99% reduction in parasitemia at 24 h compared to 263/331 (79%) receiving the five-dose i.m. regimen, showing non-inferiority of the simplified three-dose regimen to the conventional five-dose regimen (95% CI -7, 5; p = 0.02). In the three-dose i.v. arm, 246/333 (74%) children had ≥ 99% reduction in parasitemia at 24 h; hence, non-inferiority of this regimen to the five-dose control regimen was not shown (95% CI -12, 1; p = 0.24). Delayed parasite clearance was associated with the N86YPfmdr1 genotype. In a post hoc analysis, 192/885 (22%) children developed delayed anemia, an adverse event associated with increased leukocyte counts. There was no observed difference in delayed anemia between treatment arms. A potential limitation of the study is its open-label design, although the primary outcome measures were assessed in a blinded manner. CONCLUSIONS A simplified three-dose i.m. regimen for severe malaria in African children is non-inferior to the more complex WHO-recommended regimen. Parenteral ARS is associated with a risk of delayed anemia in African children. TRIAL REGISTRATION Pan African Clinical Trials Registry PACTR201102000277177.
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Affiliation(s)
- Peter G. Kremsner
- Institut für Tropenmedizin, Eberhard Karls Universität Tübingen, Tübingen, Germany
- Centre de Recherches Médicales de Lambaréné, Hôpital Albert Schweitzer, Lambaréné, Gabon
- * E-mail: (PGK); (SK)
| | - Akim A. Adegnika
- Institut für Tropenmedizin, Eberhard Karls Universität Tübingen, Tübingen, Germany
- Centre de Recherches Médicales de Lambaréné, Hôpital Albert Schweitzer, Lambaréné, Gabon
| | - Aurore B. Hounkpatin
- Institut für Tropenmedizin, Eberhard Karls Universität Tübingen, Tübingen, Germany
- Centre de Recherches Médicales de Lambaréné, Hôpital Albert Schweitzer, Lambaréné, Gabon
| | - Jeannot F. Zinsou
- Institut für Tropenmedizin, Eberhard Karls Universität Tübingen, Tübingen, Germany
- Centre de Recherches Médicales de Lambaréné, Hôpital Albert Schweitzer, Lambaréné, Gabon
| | - Terrie E. Taylor
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi
| | - Yamikani Chimalizeni
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi
| | - Alice Liomba
- Blantyre Malaria Project, University of Malawi College of Medicine, Blantyre, Malawi
| | - Maryvonne Kombila
- Department of Parasitology Mycology, Faculty of Medicine, Université des Sciences de la Santé, Libreville, Gabon
| | - Marielle K. Bouyou-Akotet
- Department of Parasitology Mycology, Faculty of Medicine, Université des Sciences de la Santé, Libreville, Gabon
| | - Denise P. Mawili Mboumba
- Department of Parasitology Mycology, Faculty of Medicine, Université des Sciences de la Santé, Libreville, Gabon
| | - Tsiri Agbenyega
- Department of Physiology, University of Science and Technology, School of Medical Sciences, Kumasi, Ghana
- Departments of Child Health and Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Daniel Ansong
- Department of Physiology, University of Science and Technology, School of Medical Sciences, Kumasi, Ghana
- Departments of Child Health and Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Justice Sylverken
- Department of Physiology, University of Science and Technology, School of Medical Sciences, Kumasi, Ghana
- Departments of Child Health and Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Bernhards R. Ogutu
- Centre for Clinical Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Godfrey A. Otieno
- Centre for Clinical Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Anne Wangwe
- Centre for Clinical Research, Kenya Medical Research Institute, Kisumu, Kenya
| | | | - Uduak Okomo
- Medical Research Council Laboratories, Fajara, The Gambia
| | | | - Charles R. Newton
- Centre for Geographic Medicine Research–Coast, Kenya Medical Research Institute, Kilifi, Kenya
| | - Patricia Njuguna
- Centre for Geographic Medicine Research–Coast, Kenya Medical Research Institute, Kilifi, Kenya
| | - Michael Kazungu
- Centre for Geographic Medicine Research–Coast, Kenya Medical Research Institute, Kilifi, Kenya
| | - Reinhold Kerb
- Dr. Margarete Fischer-Bosch-Institut für Klinische Pharmakologie, Stuttgart, Germany
- Eberhard Karls Universität Tübingen, Tübingen, Germany
| | - Mirjam Geditz
- Dr. Margarete Fischer-Bosch-Institut für Klinische Pharmakologie, Stuttgart, Germany
- Eberhard Karls Universität Tübingen, Tübingen, Germany
| | - Matthias Schwab
- Dr. Margarete Fischer-Bosch-Institut für Klinische Pharmakologie, Stuttgart, Germany
- Abteilung Klinische Pharmakologie, Universitätsklinikum Tübingen, Tübingen, Germany
| | | | - Christian Nguetse
- Institut für Tropenmedizin, Eberhard Karls Universität Tübingen, Tübingen, Germany
| | - Carsten Köhler
- Institut für Tropenmedizin, Eberhard Karls Universität Tübingen, Tübingen, Germany
| | - Saadou Issifou
- Institut für Tropenmedizin, Eberhard Karls Universität Tübingen, Tübingen, Germany
- Centre de Recherches Médicales de Lambaréné, Hôpital Albert Schweitzer, Lambaréné, Gabon
| | - Stefanie Bolte
- Institut für Tropenmedizin, Eberhard Karls Universität Tübingen, Tübingen, Germany
| | - Thomas Engleitner
- Institut für Tropenmedizin, Eberhard Karls Universität Tübingen, Tübingen, Germany
| | - Benjamin Mordmüller
- Institut für Tropenmedizin, Eberhard Karls Universität Tübingen, Tübingen, Germany
- Centre de Recherches Médicales de Lambaréné, Hôpital Albert Schweitzer, Lambaréné, Gabon
| | - Sanjeev Krishna
- Institut für Tropenmedizin, Eberhard Karls Universität Tübingen, Tübingen, Germany
- Centre de Recherches Médicales de Lambaréné, Hôpital Albert Schweitzer, Lambaréné, Gabon
- Institute for Infection and Immunity, St George’s, University of London, London, United Kingdom
- * E-mail: (PGK); (SK)
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