Artemisinin Resistance In Malaria Treated With IV Artesunate
- Conditions
- Malaria
- Interventions
- Registration Number
- NCT02640495
- Lead Sponsor
- University of Oxford
- Brief Summary
The spread of artemisinin resistant falciparum malaria presents new challenges to both the control and treatment of malaria. Loss of ring stage susceptibility to the artemisinins might jeopardize the use of parenteral artesunate as the first line drug for the treatment of severe falciparum malaria.
The purpose of this study is to assess the effect of artemisinin resistance (defined by a Kelch13 mutation with known functional significance) in P. falciparum malaria requiring parenteral artesunate treatment on lactate clearance parameters.
- Detailed Description
The investigators propose a multi-center observational study to assess the effect of artemisinin resistance (as defined by the presence of relevant Kelch13 mutations) on the efficacy of parenteral artesunate for the treatment of malaria, stratified for disease severity on admission.
The patients will receive the standard intravenous treatment for severe malaria (parenteral artesunate). Primary endpoints will be the plasma lactate concentration at 12 hours as a proportion of the plasma lactate at the start of treatment. Secondary endpoints will be improvement of Glasgow or Blantyre Coma Scores and other indicators of neurological recovery or deterioration, parasite clearance rates, time until resolution of fever, development of new severity or neurological signs under treatment, development of severe anemia, renal and hepatic injury, total duration of hospitalization , outcome of pregnancy in pregnant female patients, mortality rates and the necessity to treat with antibiotics, need for renal replacement therapy, mechanical ventilation, blood transfusion and rescue treatments.
On admission blood will be taken for the determination of genetic markers of antimalarial resistance (including Kelch13 mutations of known functional significance) and in vitro sensitivity tests to artemisinins and other antimalarials. Additional blood samples will be used for measuring plasma organic acid biomarkers of severe falciparum malaria measured by mass spectrometry. Difference in the kinetics of these acids will be an additional endpoint. Difference in the transcriptome of p. falciparum will be assessed by RNA measurements at baseline and 3 timepoints during treatment.
The proposed sites in Vietnam and Cambodia have been chosen based on the prevalence of artemisinin resistant falciparum malaria, incidence of severe malaria and local experience in participating in clinical trials.
Interim analysis:
To ensure timely recognition of the effect of artemisinin resistance on the outcome in malaria treated with parenteral artesunate, an interim analysis will be performed after the inclusion of 60 patients or one malaria transmission season (whatever comes first). An independent Data Safety Board will assess whether the difference in outcome between infections with artemisinin resistant versus sensitive strains warrants early termination and reporting of the study.
Recruitment & Eligibility
- Status
- WITHDRAWN
- Sex
- All
- Target Recruitment
- Not specified
-
Male or female, aged over 6 months old
-
Acute severe P. falciparum malaria or another indication to treat with IV artesunate. Defined as one or more of the following, occurring in the absence of an identified alternative cause, and in the presence of P. falciparum asexual parasitaemia:
-
Prostration OR obtundation
-
BCS<3 (preverbal children) or GCS<11 (adults)
-
Convulsion in last 24 hours
-
Suspected acidosis, manifesting as acidotic breathing
-
Respiratory distress manifesting clinically (nasal flaring/indrawing) or oxygen saturation <92% or respiratory rate >30/min
-
History of anuria
-
Jaundice and/or hemoglobinuria
-
Hemoglobin <7 g/dl or hematocrit <20%
-
Significant bleeding including recurrent or prolonged bleeding from nose gums or venipuncture sites; hematemesis or melena
-
Shock defined as systolic blood pressure <70 mm Hg (children) OR <80 mm Hg (adults)
-
P. falciparum parasitaemia >10%
-
Indication for parenteral antimalarial treatment (as assessed by clinician) other than nausea and vomiting. These may include laboratory findings such as:
- Creatinine >2.5 mg/dL (>220uM/L) or blood urea >56mg/dL (>20 mM/L)
- Glucose <4.0 mmol/L (<72mg/dL)
- Bilirubin > 3 mg/dL (>50uM/L)
- Hemoglobin <7g/dL or Hematocrit <20%
- P. falciparum parasitaemia >4%
- Venous plasma lactate >5 mM, Base deficit of >8meq/L or bicarbonate <15mM
-
Written informed consent or consent by locally accepted representative in the case of patients rendered incapable of providing consent due to illness
-
- History of 2 or more doses of parenteral antimalarial treatment in the previous 24 hours
- History of allergy or known contraindication to artemisinins
Study & Design
- Study Type
- OBSERVATIONAL
- Study Design
- Not specified
- Arm && Interventions
Group Intervention Description Study subjects Intravenous Artesunate as part of standard medical practice Patients admitted with malaria, caused by Plasmodium falciparum, treated with parenteral artesunate.
- Primary Outcome Measures
Name Time Method Absolute reduction of lactate 12 hours Absolute reduction of lactate at 12 hours after the first artesunate treat-ment compared to baseline.
- Secondary Outcome Measures
Name Time Method Time to resuming the ability to sit, eat, drink, stand unsupported and walk 42 days The parasite clearance half-life 48 hours The parasite clearance ratios at H28 and H48 compared to parasite count on admission 48 hours Time needed until a plasma lactate concentration <2 mmol/L 42 days Change in Glasgow Coma Score (GCS) or Blantyre Coma Score (BCS) 12 hours at 12 hours after initial treatment and coma recovery time defined as GCS\>10 or BCS\>3 and GCS=15 and BCS=5
The parasite clearance time for parasite count to fall to 50%, 90% and 99% of initial parasite density 7 days Differences in transcriptome patterns between artemisinin resistant parasites and artemisinin sensitive parasites at baseline H0 Differences in transcriptome patterns between artemisinin resistant parasites and artemisinin sensitive parasites at H6 H6 Differences in transcriptome patterns between artemisinin resistant parasites and artemisinin sensitive parasites at H12 H12 Time until resolution of fever 14 days (time until tympanic temperature first \<37.5 Celsius and below 37.5C for 24 h)
Base excess clearance after 12 hours 42 days Base excess clearance after 12 hours as proportion of the base excess at presentation
Proportion of patients developing new malaria 42 days Proportion of patients developing new malaria severity signs as defined in the 2014 WHO severe malaria guidelines
Prevalence of neurological sequelae assessed by neurological examination at discharge 42 days Time until a base excess concentration ≥ minus 2 mmol/L 42 days Differences in transcriptome patterns between artemisinin resistant parasites and artemisinin sensitive parasites at H48 H48 Proportion of patients developing new neurological signs assessed by neurological examination during hospitalization 42 days Prevalence of neurological sequelae assessed by neurological examination at day 7 7 days Severity of neurological sequelae assessed by neurological examination at discharge 42 days Prevalence of neurological sequelae assessed by neurologicalexamination at day 14 14 days Prevalence of neurological sequelae assessed by neurological examination at day 28 if day 14 is abnormal 28 days Prevalence of neurological sequelae assessed by neurological examination at day 42 if day 28 is abnormal 42 days Severity of neurological sequelae assessed by neurological examination at day 7 7 days Severity of neurological sequelae assessed by neurological examination at day 14 14 days Severity of neurological sequelae assessed by neurological examination at day 28 if day 14 is abnormal 28 days Severity of neurological sequelae assessed by neurological examination at day 42 if day 28 is abnormal 42 days Proportion treated with quinine 42 days as a rescue treatment, antibiotics, blood products, anticonvulsants, renal replacement therapy, mechanical ventilation therapy, vasopressive drugs and oxygen therapy
In hospital mortality 42 days Day 7, 14 hemoglobin or hematocrit levels 42 days and in addition at day 28 and 42 if abnormal at day 14 or day 28 respectively
Creatinine levels daily 42 days during the first four days and thereafter on day 7 and 14 and in addition on day 28 and 42 if abnormal on day 14 or day 28 respectively
Bilirubin, Alanine transaminase (ALT), aspartate aminotransferase (AST) and alkaline phosphatase levels daily 42 days during the first four days and thereafter on day 7, 14 and in addition on day 28 and 42 if abnormal on day 14 or 28 respectively
Plasma biomarkers of severe (artemisinin resistant) malaria 42 days outcome of pregnancy during hospitalization 42 days If pregnant
Time until discharge 42 days