Pharmacokinetics of chlorproguanil, dapsone, artesunate and their major metabolites in patients during treatment of acute uncomplicated Plasmodium falciparum malaria
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Chlorproguanil (CPG)–dapsone (DDS)−artesunate was in development for the treatment of uncomplicated Plasmodium falciparum malaria. The pharmacokinetics of CPG, DDS, artesunate and their metabolites chlorcycloguanil (CCG), monoacetyl dapsone (MADDS) and dihydroartemisinin (DHA) were investigated in patients with P. falciparum given CPG−DDS alone or plus artesunate.
Adult patients from Malawi and The Gambia taking part in a phase II clinical trial were randomised to receive a 3-day treatment of CPG–DDS alone (2/2.5 mg/kg/day) or plus 1, 2 or 4 mg/kg/day artesunate. Blood samples for pharmacokinetic analysis were collected up to 24 h post–first dose.
The pharmacokinetic analysis included 115 patients. For CPG, there was no significant effect of artesunate on Cmax or AUC(0–24), except the 90% confidence interval (CI) for AUC(0−24) for the 4 mg/kg artesunate dose was slightly below that for the standard bioequivalence range (90% CI 0.78, 1.11); this was not considered clinically relevant. Artesunate increased the CCG AUC(0−24) by 6−17% and Cmax by 0−16%. Artesunate had no significant effect on the rate or extent of absorption of DDS. For MADDS, artesunate increased the AUC(0−24) by 13−47% and Cmax by 8−45%. For 1, 2 and 4 mg/kg artesunate dosing, artesunate AUC(0−∞) was 64.6, 151 and 400 ng·h/ml and Cmax 48.9, 106 and 224 ng/ml respectively; DHA AUC(0−∞) was 538, 1,445 and 3,837 ng·h/ml and Cmax 228, 581 and 1,414 ng/ml respectively. Using a power model, the point estimates of slope were greater than 1 for artesunate AUC(0−t) by 16% and Cmax by 5% and for DHA by 39 and 21% respectively.
Artesunate did not significantly affect CPG or DDS pharmacokinetics. For CCG and MADDS, small to moderate increases in exposure with artesunate dosing were observed. There was a greater than proportional increase in artesunate and DHA exposure with increasing artesunate dose. These effects are not considered to be clinically relevant. It should be noted that the CPG−DDS−artesunate programme has now been stopped following unacceptable haematological toxicity in patients with glucose-6-phosphate dehydrogenase deficiency during a phase III trial. In addition, the CPG−DDS combination has been withdrawn from clinical use.
KeywordsPharmacokinetics Malaria Chlorproguanil–dapsone Artesunate Antimalarial combination therapy
Naomi Richardson of Magenta Communications Ltd developed a first draft of this paper based on the study report approved by the investigators, collated author contributions to the manuscript and was funded by GlaxoSmithKline (GSK). The authors wish to thank the study participants and the site and GSK staff involved in the conduct of this study and staff in World Wide Bioanalysis at GSK, in particular, Alex Georgiou, Wayne Wright and Matthew Barfield.
Conflict of interest
Ann K. Miller and Paula Kirby are current employees of GlaxoSmithKline. Stephan Duparc is a former employee of GlaxoSmithKline and a current employee of Medicines for Malaria Venture. Nibedita Bandyopadhyay is a former employee of GlaxoSmithKline and a current employee of Johnson & Johnson, Raritan, NJ, USA.
The development of chlorproguanil–dapsone–artesunate fixed dose combination is by public–private partnership and was commissioned by the Medicines for Malaria Venture. A development agreement was made between the UNICEF – United Nations Development Programme – World Bank – World Health Organisation Special Programme for Research and Training in Tropical Medicine and GlaxoSmithKline PLC. The UK government Department for International Development supplied some initial funding to the project. Liverpool School of Tropical Medicine, Liverpool University, and the London School of Hygiene and Tropical Medicine joined the joint development team as academic partners. A committee comprising representatives from all development partners developed the protocol.
Clinicaltrials.gov (http://clinicaltrials.gov/ct/show/NCT00519467?order=6) identifier NCT00519467; study ID number: SB-714703/003.
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