ABSTRACT
Sixty-three patients with severe falciparum malaria were randomly administered one of the two regimens of a sequential combination of artesunate suppository followed by an oral mefloquine tablet. Thirty-two patients received artesunate suppositories (200 mg/capsule) given rectally at 0, 4, 8, 12, 24, 36, 48, and 60 hr (total = 1,600 mg: Group I). Thirty-one patients received the same artesunate suppositories given rectally at 0, 12, 24, 36, 48, and 60 hr (total = 1,200 mg: Group II). Both regimens were followed by two doses of oral mefloquine, 750 mg given at 72 hr and 500 mg at 84 hr. Patient baseline characteristics were comparable in the two groups. All patients were admitted for 28 days to the Bangkok Hospital for Tropical Diseases to assess efficacy, tolerability, and delayed neuropsychiatric effects. The mean [SD] parasite clearance time was significantly shorter in Group I than Group II (47.3 [12.4] hr versus 55.3 [17.4] hr; P = 0.05) and the rate of parasite reduction was significantly faster in Group I (P = 0.05, by log-rank test). Mean [SD] fever clearance times were similar in the two Groups (71.1 [41.2] hr and 76.9 [47.9] hr, respectively). Twenty-two patients with unrousable coma on admission (median Glasgow Coma Score = 9) regained consciousness after 1-4 days. No deaths occurred. Sixty of sixty-three patients were parasitologically and clinically cured within 3-4 days of treatment. Three patients (5%) with deteriorating conditions required rescue treatment (one patient in Group I was administered intravenous artesunate, and two patients in Group II required two extra doses of suppository). No patients had major adverse drug effects. The cure rates at 28 days of follow-up in Group I were 96% (26 of 27 patients) and 89% (24 of 27 patients) in Group II. Artesunate suppository followed by mefloquine was well tolerated and effective. In severe malaria, the sequential treatment is a suitable alternative treatment to parenteral drugs. Further studies in a larger number of patients under field conditions are required.
PIP: The effectiveness of 2 treatment regimens for severe falciparum malaria was compared in a clinical trial involving 63 patients admitted to the Bangkok (Thailand) Hospital for Tropical Diseases in 1995. On admission, malaria patients were randomly assigned to receive artesunate rectal suppositories (200 mg/capsule) at 0, 4, 8, 12, 24, 36, 48, and 60 hours (total dose, 1600 mg) or the same drug administered at 0, 12, 24, 36, 48, and 60 hours (total dose, 1200 mg). Both regimens were followed by 2 doses of oral mefloquine (750 mg at 72 hours and 500 mg at 84 hours). The mean parasite clearance time was significantly shorter in the 1600 mg dose group than in the 1200 mg dose group (47.3 versus 55.3 hours) (p = 0.05) and the rate of parasite reduction was significantly faster in the former group (p = 0.05). The mean fever clearance time was similar in both groups (71.1 and 76.9 hours, respectively). The 22 patients with unrousable coma at admission regained consciousness after 1-4 days of treatment, and 60 patients (95.2%) were parasitologically and clinically cured within 3-4 days of admission. The cure rate after 28 days was 96% (26/27) in the higher-dose group and 89% (24/27) in the lower-dose group. There were no major adverse drug effects. Although further studies under field conditions are recommended, these findings suggest that sequential artesunate treatment is a suitable alternative to parenteral drugs in cases of severe malaria.
