Efficacy and safety of dihydroartemisinin–piperaquine versus artemether–lumefantrine for treatment of uncomplicated Plasmodium falciparum malaria in Ugandan children: a systematic review and meta-analysis of randomized control trials

Abstract

Background The emergence of artemisinin resistance in Southeast Asia and Plasmodium falciparum kelch13 propeller gene mutations in sub-Saharan African pose the greatest threat to global efforts to control malaria. This is a critical concern in Uganda, where artemisinin-based combination therapy (ACT) is the first-line treatment for uncomplicated falciparum. The objective of this study was to compare the efficacy and safety of dihydroartemisinin–piperaquine (DHA–PQ) and artemether–lumefantrine (AL) for the treatment of uncomplicated falciparum malaria in Ugandan children. Methods A search of PubMed and the Cochrane Central Register of Controlled Trials for retrieving randomized controlled trials comparing the efficacy and safety of DHA–PQ and AL for treatment of uncomplicated falciparum malaria in Ugandan children was done. The search was performed up to 31 August 2020. The data extracted from eligible studies and pooled as risk ratio (RR) with a 95% confidence interval (CI), using Rev Man Software (5.4). The protocol was registered in PROSPERO, ID: CRD42020182354. Results Eleven trials were included in this review and two of them only included under safety outcome. Total 3798 participants were enrolled. The PCR unadjusted treatment failure was significantly lower with DHA–PQ at day 28 (RR 0.30, 95% CI 0.19–0.49; participants = 7863; studies = 5; I2 = 93%, low quality evidence) and at day 42 (RR 0.53, 95% CI 0.38–0.76; participants = 1618; studies = 4; I2 = 79%, moderate quality of evidence). The PCR adjusted treatment failure at day 42 was significantly lower with DHA–PQ treatment group (RR 0.45, 95% CI 0.28 to 0.72; participants = 1370; studies = 5, high quality of evidence), and it was below 5% in both arms at day 28 (moderate quality of evidence). AL showed a longer prophylactic effect on new infections which may last for up to 63 days (PCR-adjusted treatment failure: RR 2.04, 95% CI 1.13–3.70; participants = 1311; studies = 2, moderate quality of evidence). Compared to AL, DHA–PQ was associated with a slightly higher frequency of cough (RR 1.07, 95% CI 1.01 to 1.13; 2575 participants; six studies; high quality of evidence). In both treatment groups, the risk of recurrent parasitaemia due to possible recrudescence was less than 5% at day 28. The appearance of gametocyte between 29 and 42 days was also significantly lower in DHA–PQ than AL (RR 0.26, 95% CI 0.12 to 0.56; participants = 623; studies = 2; I2 = 0%). Conclusion Compared to AL, DHA–PQ appeared to reduce treatment failure and gametocyte carriage in Ugandan children. This may trigger DHA–PQ to become the first-line treatment option. Both treatments were safe and well-tolerated.

Comparative effect of dihydroartemisinin-piperaquine and artemether-lumefantrine on gametocyte clearance and haemoglobin recovery in children with uncomplicated Plasmodium falciparum malaria in Africa: a systematic review and meta-analysis of randomized control trials

“…Consistently, the findings from a recent review showed that the appearance of gametocyte on day 1-14 and 29-42 was significantly lower in patients who were treated with AL than DHA-PQ (Assefa et al 2021). However, one previous study have reported that prolonged gametocytaemia after treatment could be an early sign of the occurrence drug resistance, which is also the case in the emergence of recrudescent infections (Delves et al 2013).…”

“…However, the activity of ACTs against mature gametocytes is limited [9]. Recently, studies have shown that the transmission reducing effect differs among ACTs (Abdulla et al 2016;Assefa et al 2021;Bousema et al 2006;Makanga 2014;Sawa et al 2013a;Yeka et al 2008). However, it is still unclear whether DHA-PQ and AL are the most appropriate choice for reducing community-wide transmission of P. falciparum in a place where malaria transmission intensity is high.…”

Safety of Dihydroartemisinin-piperaquine Versus Artemether-lumefantrine for the Treatment of Uncomplicated Plasmodium Falciparum Malaria Among Children in Africa: A Systematic Review and Meta-analysis of Randomized Control Trials

“…A recent review on the e cacy and safety of the two ACT's also reported that cough, anorexia, diarrhea, and vomiting were the most common adverse events. In this review more patients from DHA-PQ treatment arm had cough than that of AL [34] and similarly, gastrointestinal adverse events were more frequent in patients who were treated with DHA-PQ in another study done in South East Asia and Africa [35][36][37][38].…”

Safety of dihydroartemisinin-piperaquine versus artemether-lumefantrine for the treatment of uncomplicated Plasmodium falciparum malaria among children in Africa: a systematic review and meta-analysis of randomized control trials

“…A recent review on the efficacy and safety of the two ACT’s also reported that cough, anorexia, diarrhoea, and vomiting were the most common adverse events. In this review more patients from DHA-PQ treatment arm had cough than that of AL [ 49 ] and similarly, gastrointestinal adverse events were more frequent in patients who were treated with DHA-PQ in another study done in South East Asia and Africa [ 50 – 53 ]. Studies from the Thailand-Myanmar border [ 54 , 55 ] and elsewhere in Africa [ 56 – 58 ] have reported that DHA-PQ cause drug induced electrocardiographic QT prolongation, but a recent study also reported that the QT prolongation caused by piperaquine is not associated with an increased risk of sudden death [ 59 ].…”