Intramuscular Artesunate for Severe Malaria in African Children: A Multicenter Randomized Controlled Trial

• Published in: PLoS medicine Vol. 13; no. 1; p. e1001938
• Main Authors: Kremsner, Peter G, Adegnika, Akim A, Hounkpatin, Aurore B, Zinsou, Jeannot F, Taylor, Terrie E, Chimalizeni, Yamikani, Liomba, Alice, Kombila, Maryvonne, Bouyou-Akotet, Marielle K, Mawili Mboumba, Denise P, Agbenyega, Tsiri, Ansong, Daniel, Sylverken, Justice, Ogutu, Bernhards R, Otieno, Godfrey A, Wangwe, Anne, Bojang, Kalifa A, Okomo, Uduak, Sanya-Isijola, Frank, Newton, Charles R, Njuguna, Patricia, Kazungu, Michael, Kerb, Reinhold, Geditz, Mirjam, Schwab, Matthias, Velavan, Thirumalaisamy P, Nguetse, Christian, Köhler, Carsten, Issifou, Saadou, Bolte, Stefanie, Engleitner, Thomas, Mordmüller, Benjamin, Krishna, Sanjeev
• Format: Journal Article
• Language: English
• Published: United States Public Library of Science 01.01.2016; Public Library of Science (PLoS)
• Subjects: Africa - epidemiology; Antimalarials - administration & dosage; Artemisinins - administration & dosage; Artesunate; Child; Child, Preschool; Children; Clinical trials; Diseases; Drug dosages; Drug therapy; Female; Fever; Follow-Up Studies; Humans; Infant; Injections, Intramuscular; Malaria; Malaria, Falciparum - diagnosis; Malaria, Falciparum - drug therapy; Malaria, Falciparum - epidemiology; Male; Mortality; Parasites; Parasitic diseases; Population; Researchers; Severity of Illness Index; Studies; India, Andhra Pradesh, Krishna; Africa
• ISSN: 1549-1676; 1549-1277; 1549-1676
• DOI: 10.1371/journal.pmed.1001938

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%). 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. 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. Pan African Clinical Trials Registry PACTR201102000277177.