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falciparum treatment 

First trimester of pregnancy

Treat pregnant women with uncomplicated P. falciparum malaria during the first trimester with 7 days of quinine + clindamycin.

Strong recommendation, very low- quality evidence

Infants less than 5kg body weight

Treat infants weighing < 5 kg with uncomplicated P. falciparum malaria with an ACT at the same mg/kg bw target dose as for children weighing 5 kg.

Strong recommendation, very low- quality evidence

Patients co-infected with HIV

In people who have HIV/AIDS and uncomplicated P. falciparum malaria, avoid artesunate + SP if they are also receiving co-trimoxazole, and avoid artesunate + amodiaquine if they are also receiving efavirenz or zidovudine.

Good practice statement

Non-immune travellers

Treat travellers with uncomplicated P. falciparum malaria returning to non-endemic settings with an ACT.

Strong recommendation, high-quality evidence

Uncomplicated hyperparasitaemia

People with P. falciparum hyperparasitaemia are at increased risk of treatment failure, severe malaria and death so should be closely monitored, in addition to receiving an ACT.

Good practice statement

Several important patient sub-populations, including young children, pregnant women and patients taking potent enzyme inducers (e.g. rifampicin, efavirenz), have altered pharmacokinetics, resulting in sub-optimal exposure to antimalarial drugs. This increases the rate of treatment failure with current dosage regimens. The rates of treatment failure are substantially higher in hyperparasitaemic patients and patients in areas with artemisinin-resistant falciparum malaria, and these groups require greater exposure to antimalarial drugs (longer duration of therapeutic concentrations) than is achieved with current ACT dosage recommendations. It is often uncertain how best to achieve this. Options include increasing individual doses, changing the frequency or duration of dosing, or adding an additional antimalarial drug. Increasing individual doses may not, however, achieve the desired exposure (e.g. lumefantrine absorption becomes saturated), or the dose may be toxic due to transiently high plasma concentrations (piperaquine, mefloquine, amodiaquine, pyronaridine). An additional advantage of lengthening the duration of treatment (by giving a 5-day regimen) is that it provides additional exposure of the asexual cycle to the artemisinin component as well as augmenting exposure to the partner drug. The acceptability, tolerability, safety and effectiveness of augmented ACT regimens in these special circumstances should be evaluated urgently.

5.1. PREGNANT AND LACTATING WOMEN

Malaria in pregnancy is associated with low-birth-weight infants, increased anaemia and, in low-transmission areas, increased risks for severe malaria, pregnancy loss and death. In high-transmission settings, despite the adverse effects on fetal growth, malaria is usually asymptomatic in pregnancy or is associated with only mild, non-specific symptoms. There is insufficient information on the safety, efficacy and pharmacokinetics of most antimalarial agents in pregnancy, particularly during the first trimester.

5.1.1. FIRST TRIMESTER

First trimester of pregnancy

Treat pregnant women with uncomplicated P. falciparum malaria during the first trimester with 7 days of quinine + clindamycin.

Strong recommendation

Evidence supporting the recommendation (see Annex 4, A4.5)

Data available were not suitable for evaluation using the GRADE methodology, as there is no /almost no evidence for alternative treatment using ACT.

Safety assessment from published prospective data on 700 women exposed in the first trimester of pregnancy has not indicated any adverse effects of artemisinin-derivatives on pregnancy or on the health of the fetus or neonate.

The currently available data are only sufficient to exclude a ⩾ 4.2-fold increase in risk of any major defect detectable at birth (background prevalence assumed to be 0.9%), if half the exposures occur during the embryo-sensitive period (4–9 weeks post-conception).

Other considerations

The limited data available on the safety of artemisinin-derivatives in early pregnancy allow for some reassurance in counselling women accidentally exposed to an artemisinin-derivative early in the first trimester. There is no need for them to have their pregnancy interrupted because of this exposure.

In the absence of adequate safety data on the artemisinin-derivatives in the first trimester of pregnancy the Guideline Development Group was unable to make recommendations beyond reiterating the status quo.

5.1.2. SECOND AND THIRD TRIMESTERS

Experience with artemisinin derivatives in the second and third trimesters (over 4000 documented pregnancies) is increasingly reassuring: no adverse effects on the mother or fetus have been reported. The current assessment of risk–benefit suggests that ACTs should be used to treat uncomplicated falciparum malaria in the second and third trimesters of pregnancy. The current standard six-dose artemether + lumefantrine regimen for the treatment of uncomplicated falciparum malaria has been evaluated in > 1000 women in the second and third trimesters in controlled trials and has been found to be well tolerated and safe. In a low-transmission setting on the Myanmar–Thailand border, however, the efficacy of the standard six-dose artemether + lumefantrine regimen was inferior to 7 days of artesunate monotherapy. The lower efficacy may have been due to lower drug concentrations in pregnancy, as was also recently observed in a high-transmission area in Uganda and the United Republic of Tanzania. Although many women in the second and third trimesters of pregnancy in Africa have been exposed to artemether + lumefantrine, further studies are under way to evaluate its efficacy, pharmacokinetics and safety in pregnant women. Similarly, many pregnant women in Africa have been treated with amodiaquine alone or combined with SP or artesunate; however, amodiaquine use for the treatment of malaria in pregnancy has been formally documented in only > 1300 pregnancies. Use of amodiaquine in women in Ghana in the second and third trimesters of pregnancy was associated with frequent minor side-effects but not with liver toxicity, bone marrow depression or adverse neonatal outcomes.

Dihydroartemisinin + piperaquine was used successfully in the second and third trimesters of pregnancy in > 2000 women on the Myanmar–Thailand border for rescue therapy and in Indonesia for first-line treatment. SP, although considered safe, is not appropriate for use as an artesunate partner drug in many areas because of resistance to SP. If artesunate + SP is used for treatment, co-administration of daily high doses (5 mg) of folate supplementation should be avoided, as this compromises the efficacy of SP. A lower dose of folate (0.4–0.5 mg bw/day) or a treatment other than artesunate + SP should be used.

Mefloquine is considered safe for the treatment of malaria during the second and third trimesters; however, it should be given only in combination with an artemisinin derivative.

Quinine is associated with an increased risk for hypoglycaemia in late pregnancy, and it should be used (with clindamycin) only if effective alternatives are not available.

Primaquine and tetracyclines should not be used in pregnancy.

5.1.3. DOSING IN PREGNANCY

Data on the pharmacokinetics of antimalarial agents used during pregnancy are limited. Those available indicate that pharmacokinetic properties are often altered during pregnancy but that the alterations are insufficient to warrant dose modifications at this time. With quinine, no significant differences in exposure have been seen during pregnancy. Studies of the pharmacokinetics of SP used in IPTp in many sites show significantly decreased exposure to sulfadoxine, but the findings on exposure to pyrimethamine are inconsistent. Therefore, no dose modification is warranted at this time.

Studies are available of the pharmacokinetics of artemether + lumefantrine, artesunate + mefloquine and dihydroartemisinin + piperaquine. Most data exist for artemether + lumefantrine; these suggest decreased overall exposure during the second and third trimesters. Simulations suggest that a standard six-dose regimen of lumefantrine given over 5 days, rather than 3 days, improves exposure, but the data are insufficient to recommend this alternative regimen at present. Limited data on pregnant women treated with dihydroartemesinin + piperaquine suggest lower dihydroartemisinin exposure and no overall difference in total piperaquine exposure, but a shortened piperaquine elimination half-life was noted. The data on artesunate + mefloquine are insufficient to recommend an adjustment of dosage. No data are available on the pharmacokinetics of artesunate + amodiaquine in pregnant women with falciparum malaria, although drug exposure was similar in pregnant and non-pregnant women with vivax malaria.

5.1.4. LACTATING WOMEN

The amounts of antimalarial drugs that enter breast milk and are consumed by breastfeeding infants are relatively small. Tetracycline is contraindicated in breastfeeding mothers because of its potential effect on infants' bones and teeth. Pending further information on excretion in breast milk, primaquine should not be used for nursing women, unless the breastfed infant has been checked for G6PD deficiency.

5.2. YOUNG CHILDREN AND INFANTS (INCLUDING THOSE WHO ARE MALNOURISHED)

Artemisinin derivatives are safe and well tolerated by young children; therefore, the choice of ACT is determined largely by the safety and tolerability of the partner drug.

SP (with artesunate) should be avoided in the first weeks of life because it displaces bilirubin competitively and could thus aggravate neonatal hyperbilibinaemia. Primaquine should be avoided in the first 6 months of life (although there are no data on its toxicity in infants), and tetracyclines should be avoided throughout infancy. With these exceptions, none of the other currently recommended antimalarial treatments has shown serious toxicity in infancy.

Delay in treating P. falciparum malaria in infants and young children can have fatal consequences, particularly for more severe infections. The uncertainties noted above should not delay treatment with the most effective drugs available. In treating young children, it is important to ensure accurate dosing and retention of the administered dose, as infants are more likely to vomit or regurgitate antimalarial treatment than older children or adults. Taste, volume, consistency and gastrointestinal tolerability are important determinants of whether the child retains the treatment. Mothers often need advice on techniques of drug administration and the importance of administering the drug again if it is regurgitated within 1 h of administration. Because deterioration in infants can be rapid, the threshold for use of parenteral treatment should be much lower.

5.2.1. OPTIMAL ANTIMALARIAL DOSING IN YOUNG CHILDREN

Although dosing on the basis of body area is recommended for many drugs in young children, for the sake of simplicity, antimalarial drugs have been administered as a standard dose per kg bw for all patients, including young children and infants. This approach does not take into account changes in drug disposition that occur with development. The currently recommended doses of lumefantrine, piperaquine, SP, artesunate and chloroquine result in lower drug concentrations in young children and infants than in older patients. Adjustments to previous dosing regimens for dihydroartemisinin + piperaquine in uncomplicated malaria and for artesunate in severe malaria are now recommended to improve the drug exposure in this vulnerable population. The available evidence for artemether + lumefantrine, SP and chloroquine does not indicate dose modification at this time, but young children should be closely monitored, as reduced drug exposure may increase the risk for treatment failure. Limited studies of amodiaquine and mefloquine showed no significant effect of age on plasma concentration profiles.

In community situations where parenteral treatment is needed but cannot be given, such as for infants and young children who vomit antimalarial drugs repeatedly or are too weak to swallow or are very ill, give rectal artesunate and transfer the patient to a facility in which parenteral treatment is possible. Rectal administration of a single dose of artesunate as pre-referral treatment reduces the risks for death and neurological disability, as long as this initial treatment is followed by appropriate parenteral antimalarial treatment in hospital

5.2.2. OPTIMAL ANTIMALARIAL DOSING IN INFANTS

Infants less than 5kg body weight

Treat infants weighing < 5 kg with uncomplicated P. falciparum malaria with an ACT at the same mg/kg bw target dose as for children weighing 5 kg.

5.2.3. OPTIMAL ANTIMALARIAL DOSING IN MALNOURISHED YOUNG CHILDREN

Malaria and malnutrition frequently coexist. Malnutrition may result in inaccurate dosing when doses are based on age (a dose may be too high for an infant with a low weight for age) or on weight (a dose may be too low for an infant with a low weight for age). Although many studies of the efficacy of antimalarial drugs have been conducted in populations and settings where malnutrition was prevalent, there are few studies of the disposition of the drugs specifically in malnourished individuals, and these seldom distinguished between acute and chronic malnutrition. Oral absorption of drugs may be reduced if there is diarrhoea or vomiting, or rapid gut transit or atrophy of the small bowel mucosa. Absorption of intramuscular and possibly intrarectal drugs may be slower, and diminished muscle mass may make it difficult to administer repeated intramuscular injections to malnourished patients. The volume of distribution of some drugs may be larger and the plasma concentrations lower. Hypoalbuminaemia may reduce protein binding and increase metabolic clearance, but concomitant hepatic dysfunction may reduce the metabolism of some drugs; the net result is uncertain.

Small studies of the pharmacokinetics of quinine and chloroquine showed alterations in people with different degrees of malnutrition. Studies of SP in IPTp and of amodiaquine monotherapy and dihydroartemisinin + piperaquine for treatment suggest reduced efficacy in malnourished children. A pooled analysis of data for individual patients showed that the concentrations of lumefantrine on day 7 were lower in children < 3 years who were underweight for age than in adequately nourished children and adults. Although these findings are concerning, they are insufficient to warrant dose modifications (in mg/kg bw) of any antimalarial drug in patients with malnutrition.

5.3. LARGE AND OBESE ADULTS

Large adults are at risk for under-dosing when they are dosed by age or in standard pre-packaged adult weight-based treatments. In principle, dosing of large adults should be based on achieving the target mg/kg bw dose for each antimalarial regimen. The practical consequence is that two packs of an antimalarial drug might have to be opened to ensure adequate treatment. For obese patients, less drug is often distributed to fat than to other tissues; therefore, they should be dosed on the basis of an estimate of lean body weight, ideal body weight. Patients who are heavy but not obese require the same mg/kg bw doses as lighter patients.

In the past, maximum doses have been recommended, but there is no evidence or justification for this practice. As the evidence for an association between dose, pharmacokinetics and treatment outcome in overweight or large adults is limited, and alternative dosing options have not been assessed in treatment trials, it is recommended that this gap in knowledge be assessed urgently. In the absence of data, treatment providers should attempt to follow up the treatment outcomes of large adults whenever possible.

5.4. PATIENTS CO-INFECTED WITH HIV

There is considerable geographical overlap between malaria and HIV infection, and many people are co-infected. Worsening HIV-related immunosuppression may lead to more severe manifestations of malaria. In HIV-infected pregnant women, the adverse effects of placental malaria on birth weight are increased. In areas of stable endemic malaria, HIV-infected patients who are partially immune to malaria may have more frequent, higher-density infections, while in areas of unstable transmission, HIV infection is associated with increased risks for severe malaria and malaria-related deaths. Limited information is available on how HIV infection modifies therapeutic responses to ACTs. Early studies suggested that increasing HIV-related immunosuppression was associated with decreased treatment response to antimalarial drugs. There is presently insufficient information to modify the general malaria treatment recommendations for patients with HIV/AIDS.

Therapeutic interactions must be taken into consideration (See Annex 5, 5.14). Studies on prophylaxis with trimethoprim + sulfamethoxazole in HIV-infected children and adults show significant protection against malaria, even in areas with high rates of antifolate resistance. In studies of drug interactions between antiretroviral medicines and ACTs, HIV-co-infected individuals on trimethoprim + sulfamethoxazole and antiretroviral treatment, particularly zidovudine-containing regimens, had high rates of neutropenia when artesunate + amodiaquine was used for malaria treatment. HIV-infected children had a seven- to eightfold increased risk for neutropenia 14 days after starting of artesunate + amodiaquine than HIV-uninfected children. Hepatotoxicity has been documented when efavirenz was given with artesunate + amodiaquine, which may be due to inhibition of CYP2C8-mediated amodiaquine metabolism by efavirenz. Data on the safety of nevirapine-based regimens in people receiving amodiaquine + artesunate are lacking, but lower levels of amodiaquine and its metabolite desethylamodiaquine have been reported when they were given together with nevirapine.

More data are available on use of artemether + lumefantrine with antiretroviral treatment. A study in children with uncomplicated malaria in a high-transmission area of Africa showed a decreased risk for recurrent malaria after treatment with artemether + lumefantrine in children receiving lopinavir–ritonavir-based antiretroviral treatment as compared with non-nucleoside reverse transcriptase inhibitor-based antiretroviral treatment. Evaluation of pharmacokinetics in these children and in healthy volunteers showed significantly higher exposure to lumefantrine and lower exposure to dihydroartemisinin with lopinavir–ritonavir-based antiretroviral treatment, but no adverse consequences. Conversely, efavirenz-based antiretroviral treatment was associated with a two- to fourfold decrease in exposure to lumefantrine in healthy volunteers and malaria-infected adults and children, with increased rates of recurrent malaria after treatment. Close monitoring is required. Increasing artemether + lumefantrine dosing with efavirenz-based antiretroviral treatment has not yet been studied. Exposure to lumefantrine and other non-nucleoside reverse transcriptase inhibitor-based antiretroviral treatment, namely nevirapine and etravirine, did not show consistent changes that would require dose adjustment.

Studies of administration of quinine with lopinavir–ritonavir or ritonavir alone in healthy volunteers gave conflicting results. The combined data are insufficient to justify dose adjustment. Single-dose atovaquone – proguanil with efavirenz, lopinavir–ritonavir or atazanavir–ritonavir were all associated with a significantly decreased area under the concentration–time curve for atovaquone (two- to fourfold) and proguanil (twofold), which could well compromise treatment or prophylactic efficacy. There is insufficient evidence to change the current mg/kg bw dosing recommendations; however, these patients should also be monitored closely.

5.5. PATIENTS CO-INFECTED WITH TUBERCULOSIS

Rifamycins, in particular rifampicin, are potent CYP3A4 inducers with weak antimalarial activity. Concomitant administration of rifampicin during quinine treatment of adults with malaria was associated with a significant decrease in exposure to quinine and a five-fold higher recrudescence rate. Similarly, concomitant rifampicin with mefloquine in healthy adults was associated with a there-fold decrease in exposure to mefloquine. In adults co-infected with HIV and tuberculosis who were being treated with rifampicin, administration of artemether + lumefantrine resulted in significantly lower exposure to artemether, dihydroartemisinin and lumefantrine (nine-, six- and there-fold decreases, respectively). There is insufficient evidence at this time to change the current mg/kg bw dosing recommendations; however, as these patients are at higher risk of recrudescent infections they should be monitored closely.

5.6. NON-IMMUNE TRAVELLERS

Non-immune travellers

Treat travellers with uncomplicated P. falciparum malaria returning to non-endemic settings with an ACT.

Strong recommendation, high-quality evidence

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