Comparison of Artemether-Lumefantrine with Sulfadoxine-Pyrimethamine for the Treatment of Uncomplicated Falciparum Malaria in Eastern Nepal

Suman Thapa Sukraraj Tropical and Infectious Disease Hospital, Kathmandu, Nepal; Research Triangle Institute International, Kathmandu, Nepal; Research Triangle Institute International, Washington, DC; University Malaysia Sarawak, Malaria Research Centre, Faculty of Medicine and Health Sciences, Kuching, Sarawak, Malaysian Borneo; Nepal Government, Ministry of Health and Population, Department of Health Services, Epidemiology and Disease Control Division, Kathmandu, Nepal; University of Western Australia, School of Medicine and Pharmacology, Fremantle Hospital, Fremantle, Australia

Search for other papers by Suman Thapa in
Current site
Google Scholar
PubMed
Close
,
Judith Hollander Sukraraj Tropical and Infectious Disease Hospital, Kathmandu, Nepal; Research Triangle Institute International, Kathmandu, Nepal; Research Triangle Institute International, Washington, DC; University Malaysia Sarawak, Malaria Research Centre, Faculty of Medicine and Health Sciences, Kuching, Sarawak, Malaysian Borneo; Nepal Government, Ministry of Health and Population, Department of Health Services, Epidemiology and Disease Control Division, Kathmandu, Nepal; University of Western Australia, School of Medicine and Pharmacology, Fremantle Hospital, Fremantle, Australia

Search for other papers by Judith Hollander in
Current site
Google Scholar
PubMed
Close
,
Mary Linehan Sukraraj Tropical and Infectious Disease Hospital, Kathmandu, Nepal; Research Triangle Institute International, Kathmandu, Nepal; Research Triangle Institute International, Washington, DC; University Malaysia Sarawak, Malaria Research Centre, Faculty of Medicine and Health Sciences, Kuching, Sarawak, Malaysian Borneo; Nepal Government, Ministry of Health and Population, Department of Health Services, Epidemiology and Disease Control Division, Kathmandu, Nepal; University of Western Australia, School of Medicine and Pharmacology, Fremantle Hospital, Fremantle, Australia

Search for other papers by Mary Linehan in
Current site
Google Scholar
PubMed
Close
,
Janet Cox-Singh Sukraraj Tropical and Infectious Disease Hospital, Kathmandu, Nepal; Research Triangle Institute International, Kathmandu, Nepal; Research Triangle Institute International, Washington, DC; University Malaysia Sarawak, Malaria Research Centre, Faculty of Medicine and Health Sciences, Kuching, Sarawak, Malaysian Borneo; Nepal Government, Ministry of Health and Population, Department of Health Services, Epidemiology and Disease Control Division, Kathmandu, Nepal; University of Western Australia, School of Medicine and Pharmacology, Fremantle Hospital, Fremantle, Australia

Search for other papers by Janet Cox-Singh in
Current site
Google Scholar
PubMed
Close
,
Mahendra B. Bista Sukraraj Tropical and Infectious Disease Hospital, Kathmandu, Nepal; Research Triangle Institute International, Kathmandu, Nepal; Research Triangle Institute International, Washington, DC; University Malaysia Sarawak, Malaria Research Centre, Faculty of Medicine and Health Sciences, Kuching, Sarawak, Malaysian Borneo; Nepal Government, Ministry of Health and Population, Department of Health Services, Epidemiology and Disease Control Division, Kathmandu, Nepal; University of Western Australia, School of Medicine and Pharmacology, Fremantle Hospital, Fremantle, Australia

Search for other papers by Mahendra B. Bista in
Current site
Google Scholar
PubMed
Close
,
Garib D. Thakur Sukraraj Tropical and Infectious Disease Hospital, Kathmandu, Nepal; Research Triangle Institute International, Kathmandu, Nepal; Research Triangle Institute International, Washington, DC; University Malaysia Sarawak, Malaria Research Centre, Faculty of Medicine and Health Sciences, Kuching, Sarawak, Malaysian Borneo; Nepal Government, Ministry of Health and Population, Department of Health Services, Epidemiology and Disease Control Division, Kathmandu, Nepal; University of Western Australia, School of Medicine and Pharmacology, Fremantle Hospital, Fremantle, Australia

Search for other papers by Garib D. Thakur in
Current site
Google Scholar
PubMed
Close
,
Wendy A. Davis Sukraraj Tropical and Infectious Disease Hospital, Kathmandu, Nepal; Research Triangle Institute International, Kathmandu, Nepal; Research Triangle Institute International, Washington, DC; University Malaysia Sarawak, Malaria Research Centre, Faculty of Medicine and Health Sciences, Kuching, Sarawak, Malaysian Borneo; Nepal Government, Ministry of Health and Population, Department of Health Services, Epidemiology and Disease Control Division, Kathmandu, Nepal; University of Western Australia, School of Medicine and Pharmacology, Fremantle Hospital, Fremantle, Australia

Search for other papers by Wendy A. Davis in
Current site
Google Scholar
PubMed
Close
, and
Timothy M. E. Davis Sukraraj Tropical and Infectious Disease Hospital, Kathmandu, Nepal; Research Triangle Institute International, Kathmandu, Nepal; Research Triangle Institute International, Washington, DC; University Malaysia Sarawak, Malaria Research Centre, Faculty of Medicine and Health Sciences, Kuching, Sarawak, Malaysian Borneo; Nepal Government, Ministry of Health and Population, Department of Health Services, Epidemiology and Disease Control Division, Kathmandu, Nepal; University of Western Australia, School of Medicine and Pharmacology, Fremantle Hospital, Fremantle, Australia

Search for other papers by Timothy M. E. Davis in
Current site
Google Scholar
PubMed
Close
Restricted access

Because available data suggest that resistance of Plasmodium falciparum to sulfadoxine-pyrimethamine (SP) is increasing in Nepal, an open-label, parallel-group efficacy/safety study was conducted in 99 Nepalese patients with uncomplicated falciparum malaria randomized 2:1 to artemetherlumefantrine (AL) or SP. Efficacy was assessed from clinical and microscopic evidence of treatment failure. Four SP-treated patients (12.1%; 95% CI, 4.0–29.1%) redeveloped parasitemia during the 28-day follow-up versus 0% (95% CI, 0–6.9%) in the AL group (P = 0.011), a difference that was confirmed by polymerase chain reaction (PCR) analysis of parasite DNA. PCR detected an additional six patients (two SP and four AL) with sub-microscopic gametocytemia or breakthrough parasitemia between Days 14 and 28, suggesting that AL efficacy was lower than estimated by microscopy. Dhfr and dhps mutations were not associated with outcome. AL is more effective than SP for uncomplicated malaria in Nepal, but regular monitoring of its efficacy should be carried out if this combination therapy is introduced.

Author Notes

Reprint requests: T. M. E. Davis, School of Medicine and Pharmacology, Fremantle Hospital, PO Box 480, Fremantle, Western Australia 6959, Australia. E-mail: tdavis@cyllene.uwa.edu.au.
  • 1

    World Health Organisation, Regional Office for South-East Asia. Malaria Situation in SEAR Countries. Nepal. Available at http://w3.whosea.org/en/Section10/Section21/Section340.htm. Accessed July 2006.

    • PubMed
    • Export Citation
  • 2

    World Health Organisation, Regional Office for South-East Asia. Nepal. Malaria Profile. Available at http://w3.whosea.org/LinkFiles/Malaria_Malaria_nep.pdf. Accessed July 2006.

    • PubMed
    • Export Citation
  • 3

    Proposals to the Global Fund, Coordinated Country Proposal. HIV/AIDS Malaria. Nepal. September 2002. Available at http://www.theglobalfund.org/search/docs/2NEPM_72_147_full.pdf. Accessed July 2006.

    • PubMed
    • Export Citation
  • 4

    Wijeyaratne PM, Chand PB, Valech N, Shahi B, Adak T, Ansari MA, Jha J, Pandey S, Bannerjee S, Bista MB, 2005. Therapeutic efficacy of antimalarial drugs along the eastern Indo-Nepal border: a cross-border collaborative study. Trans R Soc Trop Med Hyg 99 :423–429.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    World Health Organization, 1973. Chemotherapy of malaria and resistance to antimalarials. Report of a WHO scientific working group. World Health Organization, Geneva, Switzerland. WHO Technical Report Series 529 :30–35.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    World Health Organization, 2003. Assessment and Monitoring of Antimalarial Drug Efficacy for the Treatment of Uncomplicated Falciparum Malaria. Geneva: World Health Organization.

    • PubMed
    • Export Citation
  • 7

    Scott Miller R, 2004. Genetics Markers of Malaria Resistance: An In Vitro Malaria Study in Jhapa, Nepal 2002. Environmental Health Project/USAID. His Majesty’s Government Ministry of Health and US Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand.

    • PubMed
    • Export Citation
  • 8

    World Health Organisation, Position of WHO’s Roll Back Malaria Department on malaria treatment policy. Available at http://www.who.int/malaria/docs/who_apt_position.htm. Accessed July 2006.

    • PubMed
    • Export Citation
  • 9

    Wittes J, 2002. Samples size calculations for randomized controlled trials. Epidemiol Rev 24 :34–53.

  • 10

    World Health Organisation, 2000. Severe falciparum malaria. Trans R Soc Trop Med Hyg 94 (Suppl 1):1–90.

  • 11

    Cox-Singh J, Lu HY, Davis TME, Ilett KF, Matusop A, Singh B, 2003. Use of a multi-faceted approach to the assessment of treatment response in falciparum malaria: a study from Malaysian Borneo. Int J Parasitol 33 :1545–1552.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Singh B, Cox-Singh J, Miller AO, Abdullah MS, Snounou G, Rahman HA, 1996. Detection of malaria in Malaysia by nested polymerase chain reaction amplification of dried blood spots on filter papers. Trans R Soc Trop Med Hyg 90 :519–521.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Cox-Singh J, Mahayet S, Abdullah MS, Singh B, 1997. Increased sensitivity of malaria detection by nested polymerase chain reaction using simple sampling and DNA extraction. Int J Parasitol 27 :1575–1577.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Viriyakosol S, Siripoon N, Petcharapirat C, Petcharapirat P, Jarra W, Thaithong S, Brown KN, Snounou G, 1995. Genotyping of Plasmodium falciparum isolates by the polymerase chain reaction and potential uses in epidemiological studies. Bull WHO 73 :85–95.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Snounou G, Zhu X, Siripoon N, Jarra W, Thaithong S, Brown KN, Viriyakosol S, 1999. Biased distribution of msp1 and msp2 allelic variants in Plasmodium falciparum populations in Thailand. Trans R Soc Trop Med Hyg 93 :369–374.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Omari AAA, Gamble C, Garner P, 2005. Artemether-lumefantrine (six-dose regimen) for treating uncomplicated falciparum malaria. Cochrane Database Syst Rev 4 :CD005564.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Adjuik M, Babiker A, Garner P, Olliaro P, Taylor W, White NJ, 2004. Artesunate combinations for treatment of malaria: meta-analysis. Lancet 363 :9–17.

  • 18

    Targett G, Drakeley C, Jawara M, von Seidlein L, Coleman R, Deen J, Pinder M, Doherty T, Sutherland C, Walraven G, Milligan P, 2001. Artesunate reduces but does not prevent post-treatment transmission of Plasmodium falciparum to Anopheles gambiae. J Infect Dis 183 :1254–1259.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Price RN, Nosten F, Luxemburger C, ter Kuile FO, Paiphun L, Chongsuphajaisiddhi T, White NJ, 1996. Effects of artemisinin derivatives on malaria transmissibility. Lancet 347 :1654–1658.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Stohrer JM, Dittrich S, Thongpaseuth V, Vanisaveth V, Phetsouvanh R, Phompida S, Monti F, Christophel E-M, Lindegardh N, Annerberg A, Jelinek T, 2004. Therapeutic efficacy of artemether-lumefantrine and artesunate-mefloquine for treatment of uncomplicated Plasmodium falciparum malaria in Luang Namtha Province, Lao People’s Democratic Republic. Trop Med Int Health 9 :1175–1183.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Price R, van Vugt M, Phaipun L, Luxemburger C, Simpson J, McGready R, ter Kuile F, Kham A, Chongsuphajaisiddhi T, White NJ, Nosten F, 1999. Adverse effects in patients with acute falciparum malaria treated with artemisinin derivatives. Am J Trop Med Hyg 60 :547–555.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Nguyen MH, Davis TM, Cox-Singh J, Hewitt S, Tran QT, Tran BK, Nguyen TH, Vo NP, Doan HN, Le DC, 2003. Artesunate-based combination therapy for uncomplicated falciparum malaria in southern Viet Nam: can chloroquine and sulfadoxine-pyrimethamine be reintroduced? Clin Infect Dis 37 :1461–1466.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Bousema JT, Schneider P, Gouagna LC, Drakeley CJ, Tostmann A, Houben R, Githure JI, Ord R, Sutherland CJ, Omar SA, Sauerwein RW, 2006. Moderate effect of artemisinin-based combination therapy on transmission of Plasmodium falciparum. J Infect Dis 193 :1151–1159.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Brown AE, Kain KC, Pipithkul J, Webster HK, 1992. Demonstration by the polymerase chain reaction of mixed Plasmodium falciparum and P. vivax infections undetected by conventional microscopy. Trans R Soc Trop Med Hyg 86 :609–612.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Hutagalung R, Paiphun L, Ashley EA, McGready R, Brockman A, Thwai KL, Singhasivanon P, Jelinek T, White NJ, Nosten FH, 2005. A randomized trial of artemether-lumefantrine versus mefloquine-artesunate for the treatment of uncomplicated multi-drug resistant Plasmodium falciparum on the western border of Thailand. Malar J 4 :46.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Davis TME, Martin RB, 1997. Clearance of young parasite forms following treatment of falciparum malaria in humans: comparison of three simple mathematical models. Epidemiol Infect 119 :61–69.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    World Health Organization, 2001. Guidelines for the Treatment of Malaria. Geneva: World Health Organization.

    • PubMed
    • Export Citation
  • 28

    von Seidlein L, Milligan P, Pinder M, Bojang K, Anyalebechi C, Gosling R, Coleman R, Ude JI, Sadiq A, Duraisingh M, Warhurst D, Alloueche A, Targett G, McAdam K, Greenwood B, Walraven G, Olliaro P, Doherty T, 2000. Efficacy of artesunate plus pyrimethamine-sulfadoxine for uncomplicated malaria in Gambian children: a double-blind, randomised, controlled trial. Lancet 355 :352–357.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    von Seidlein L, Drakeley C, Greenwood B, Walraven G, Targett G, 2001. Risk factors for gametocyte carriage in Gambian children. Am J Trop Med Hyg 65 :523–527.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    The International Pharmacopoeia, 1994. Tests, Methods, and General Requirements Quality Specifications for Pharmaceutical Substances, Excipients, and Dosage. Volume 4. Third Edition. Geneva: World Health Organization.

    • PubMed
    • Export Citation
  • 31

    Happi CT, Gbotosho GO, Folarin OA, Akinboye DO, Yusuf BO, Ebong OO, Sowunmi A, Kyle DE, Milhous W, Wirth DF, Oduola AM, 2005. Polymorphisms in Plasmodium falciparum dhfr and dhps genes and age related in vivo sulfadoxine-pyrimethamine resistance in malaria-infected patients from Nigeria. Acta Trop 95 :183–193.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32

    Mockenhaupt FP, Teun Bousema J, Eggelte TA, Schreiber J, Ehrhardt S, Wassilew N, Otchwemah RN, Sauerwein RW, Bienzle U, 2005. Plasmodium falciparum dhfr but not dhps mutations associated with sulphadoxine-pyrimethamine treatment failure and gametocyte carriage in northern Ghana. Trop Med Int Health 10 :901–908.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33

    Cowman AF, 1998. The molecular basis of resistance to the sulfones, sulfonamides and dihydrofolate reductase inhibitors. Sherman IW, ed. Malaria: Parasite Biology, Pathogenesis and Protection. Washington, DC: ASM Press, 317–330.

    • PubMed
    • Export Citation
  • 34

    Cox-Singh J, Zakaria R, Abdullah MS, Rahman HA, Nagappan S, Singh B, 2001. Differences in dihydrofolate reductase but not dihydropteroate synthase alleles in Plasmodium falciparum isolates from geographically distinct areas in Malaysia. Am J Trop Med Hyg 64 :28–31.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35

    Davis TME, Karunajeewa HA, Ilett KF, 2005. Artemisinin-based combination therapies for uncomplicated malaria. Med J Aust 182 :181–185.

  • 36

    Tilley L, Davis TME, Bray PG, 2006. Prospects for treatment of drug-resistant malaria parasites. Future Microbiology 1 :127–141.

  • 37

    Hastings IM, Ward SA, 2005. Coartem (artemether-lumefantrine) in Africa: the beginning of the end? J Infect Dis 192 :1303–1304.

  • 38

    Martensson A, Stromberg J, Sisowath C, Msellem MI, Gil JP, Montgomery SM, Olliaro P, Ali AS, Bjorkman A, 2005. In vivo selection of Plasmodium falciparum pfmdr1 86N coding alleles by artemether-lumefantrine (Coartem). J Infect Dis 191 :1014–1017.

    • PubMed
    • Search Google Scholar
    • Export Citation
Past two years Past Year Past 30 Days
Abstract Views 505 424 24
Full Text Views 364 9 0
PDF Downloads 66 9 0
 

 

 

 
 
Affiliate Membership Banner
 
 
Research for Health Information Banner
 
 
CLOCKSS
 
 
 
Society Publishers Coalition Banner
Save