The first patient was a 19-year old German female with- out migrational background presenting without any co- morbidities or prior medication who stayed in Uganda for three weeks. She did not take any malaria prophy- laxis. Four days after returning to Germany she devel- oped fever and headaches. At the emergency department of a community hospital, she was diagnosed with un- complicated malaria and showed 2% parasitaemia. She was transferred to a tertiary care centre specializing in tropical medicine for treatment of uncomplicated mal- aria. At the first evaluation in the emergency department (day 0), she did not fulfill any of the WHO criteria for severe malaria , and in line with the guidelines by the German Society of Tropical Medicine and International Health (DTG) treatment with mefloquine was initiated (starting with 750 mg) . Over the next three to four hours, the patient’s clinical condition deteriorated. She became somnolent and her blood pressure dropped to 80/50 mmHg with a pulse rate of 108 bpm. At this time point, Giemsa-stained blood microscopy revealed a para- sitaemia of 14%. The patient was now classified as com- plicated life-threatening malaria and was transferred to the intensive care unit. Intravenous artesunate (Guilin pharmaceutical factory, China) was given in four doses of 120 mg on day 0 and after 12, 24 and 48 hours equivalent to a total dose of 8mg/kg body weight. Be- cause of thrombocytopenia of 15,000/μl (normal range: 150,000-400,000), she received one unit of packed thrombocytes. Indirect Coombs’ test was negative at this time. On day 1, her clinical condition improved strik- ingly and she was transferred to a regular ward on day 2. Anti-malarial treatment was continued orally with mef- loquine (500 mg on day 2 followed by 250 mg eight hours later, equivalent to a total dose of 1500 mg includ- ing the initial dose of 750 mg on day 0). Parasitaemia declined rapidly from initially 14% to 10% after 12h and finally to less than 1% on day 3. On day 5, parasites were cleared. Two days later, the patient developed fever again and showed radiological signs of lung infiltration. Piperacillin-Sulbactam was started for hospital acquired pneumonia for 7 days. Hb dropped from 12 mg/dl
Background: Severe malaria is a medical emergency with high mortality. Prompt achievement of therapeutic concentrations of highly effective anti-malarial drugs reduces the risk of death. The aim of this study was to assess the pharmacokinetics and pharmacodynamics of intravenous artesunate in Ugandan adults with severe malaria. Methods: Fourteen adults with severe falciparum malaria requiring parenteral therapy were treated with 2.4 mg/kg intravenous artesunate. Blood samples were collected after the initial dose and plasma concentrations of artesunate and dihydroartemisinin measured by solid-phase extraction and liquid chromatography-tandem mass spectrometry. The study was approved by the Makerere University Faculty of Medicine Research and Ethics Committee (Ref2010-015) and Uganda National Council of Science and Technology (HS605) and registered with ClinicalTrials.gov (NCT01122134). Results: All study participants achieved prompt resolution of symptoms and complete parasite clearance with median (range) parasite clearance time of 17 (8–24) hours. Median (range) maximal artesunate concentration (C max ) was 3260
Background: Treatment for severe malaria must be prompt with effective parenteral antimalarial drugs for at least 24 h to achieve fast parasite clearance, and when the patient can tolerate oral therapy, treatment should be completed with effective artemisinin based combination therapy (ACT) for complete parasite clearance and to prevent recrudescence. We evaluated piperaquine concentration and malaria treatment outcomes among Ugandan children treated for severe malaria with intravenous artesunate (AS) or quinine (QN) plus dihydroartemisinin- piperaquine (DP), in Tororo District Hospital in Eastern Uganda.
Methods: Parasite clearance data obtained from a clinical trial whose objective was to evaluate the 42‑day para‑ sitological treatment outcomes and safety following treatment of severe malaria with intravenous artesunate plus artemisinin‑based combination therapy among patients attending Tororo District Hospital in Eastern Uganda, were analysed. Serial blood smears were performed at 0, 1, 2, 4, 6, 8, 10, 12, 16, 20, 24 h, followed by 6‑hourly blood smears post start of treatment until 6 h post the first negative blood smear when parasite clearance was achieved. Study endpoints were; parasite clearance half‑life (the time required for parasitaemia to decrease by 50% based on the linear portion of the parasite clearance slope) and parasite clearance time (time required for complete clearance of initial parasitaemia).
Considering the severity of illness, in- travenous artesunate was started at a dose of 2.4 mg/kg diluted in 5 mL normal saline, on day 1 (60 mg artesunate dis- solved in 5 mL normal saline and 5 mL sodium bicarbonate to prepare 6 mg/mL solution), followed by 2.4 mg/kg per day for 6 days along with clindamycin (20 mg/kg per day in 2 divided doses as intravenous infusion) given for a total of 7 days. The infant ’ s clinical condition improved 24 hours after the initiation of artesunate therapy. Laboratory param- eters during intravenous artesunate therapy are shown in Table 1. Parenteral antibiotics (cefotaxime 150mg/kg per
Intravenous (IV) artesunate (AS) has been shown to com- pletely inhibit parasite growth in infected human patients within two to four hours after dosing, and its active me- tabolite, dihydroartemisinin (DHA), is the only artemisinin derivative with activity against all asexual blood stage par- asites . AS treatment results in rapid parasite and fever clearance, and these effects have been mostly attributed to its rapid and extensive hydrolysis to DHA [2-4], the most active schizonticidal metabolite. In vitro bioassay tests have shown that the activity of DHA is similar to AS  and three- to five-fold more active than other artemisinin derivatives [6,7]. AS has been shown to be highly effective against multidrug-resistant falciparum malaria and for treatment of severe malaria in Vietnam, Thailand, China, and Myanmar, however, limited studies have been carried out in Africa . Currently, there are three recommended treatments for severe and complicated malaria: AS, arte- mether (AM) and quinine (or quinidine) . The Chinese manufacturer (Guilin Pharmaceutical Co Ltd, Shanghai, China) of the injectable AS that was used in most of the clinical trial studies recently improved its production process, with support from Medicine for Malaria Venture (MMV), and their product has achieved World Health Organization (WHO) recognition. Intravenous quinine or quinidine, however, is still used in Europe and the USA as the main barrier for the use of intravenous AS is the ab- sence of an approved product that is manufactured under good manufacturing practices (GMP) and is legally avail- able in these regions for patient treatment .
The main barrier for the use of IV artesunate in Europe and the US is the absence of a product that is manufac- tured under Good Manufacturing Practices (GMP). The Chinese manufacturer (Guilin Pharmaceutical Company Ltd., Shanghai, China) of the product that was also used in the SEAQUAMAT and AQUAMAT studies recently improved the production process, with support of the Medicine for Malaria Venture (MMV). This convinced the WHO to list it as prequalified medicinal product . This ensures that manufacturing of the product has been evaluated and inspected by WHO and complies with WHO requirements for essential drugs. Nevertheless, this is not the same as GMP certification and in both the EU and the US, IV artesunate does not have a market authorization. A salient fact is that IV quinine is also not registered in most industrialized countries, where it is mainly available through extemporaneous preparation by hospital pharmacies, and there is no IV quinine formula- tion on the WHO list of prequalified medicinal products.
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because the prevalence of these polymorphisms is consist- ently greater that 50% across the country . A study in an area with intense malaria transmission in Malawi demon- strated that monthly chemoprophylaxis with AL post treat- ment for severe malarial anaemia reduced rates of readmittance to hospital for severe anaemia or malaria . Additional studies on IPT for school children living in such high malaria transmission settings demonstrated acceptable protective efficacy against clinical malaria, parasitaemia and anaemia with use of either DP, SP + AS or Amodiaquine + AS. Monthly DP provided the best protective efficacy . Further studies to investigate the acceptability, cost effective- ness and long term safety of these IPT regimens are needed. We demonstrated low levels of recrudescence among our study participants with no difference in the 42-day risk of recrudescence among the four ACT study arms. Among the few participants in whom recrudescence was demon- strated; the highest probability of recrudescence was among participants who received the combination of QNN + DP followed by QNN + AL, although this finding was not sta- tistically significant possibly due to the limitation of the small sample size for this comparison. Our study was also limited by the genotyping method used which is known to have low resolution. The long acting drug should ideally mop up all residual parasites to prevent recrudescence while also preventing re-infection. It is possible that the QNN + ACT regimens predisposed participants to higher rates of recrudescence due to slower initial clearance of parasite biomass by intravenous QNN compared to intra- venous AS. This finding supports the current recommenda- tion to use intravenous AS in preference to intravenous QNN for initial treatment for severe malaria and calls for improved availability and accessibility to intravenous AS es- pecially in the high transmission areas.
2. Dondorp AM, Fanello CI, Hendriksen IC, Gomes E, Seni A, Chhaganlal KD, Bojang K, Olaosebikan R, Anunobi N, Maitland K, Kivaya E, Agbenyega T, Nguah SB, Evans J, Gesase S, Kahabuka C, Mtove G, Nadjm B, Deen J, Mwanga-Amumpaire J, Nansumba M, Karema C, Umulisa N, Uwimana A, Mokuolu OA, Adedoyin OT, Johnson WB, Tshefu AK, Onyamboko MA, Sakulthaew T, et al: Artesunate versus quinine in the treatment of severe falciparum malaria in African children (AQUAMAT): an open-label, randomised trial. Lancet 2010, 376:1647 – 1657.
These various problems could be overcome by designing population PK studies using both information regarding the practical constraints of sampling and optimal design methods. Optimal design methods provide designs for population PK studies that are robust and efficient by taking into account the concentration-time profile of the drug, the statistical methods required to analyse popula- tion PK data, practical constraints of sampling, and uncer- tainty in the PK parameter values and structural PK models. They can also help the researcher understand the benefits and limitations of particular sampling schedules. This paper will provide an introduction to optimal design methods, including the prior information required for optimal design methods, followed by a theoretical appli- cation of the method for designing a population PK study of intravenous artesunate.
used in Europe and the USA because the main barrier for the use of intravenous AS is the absence of a prod- uct that is manufactured under good manufacturing practices (GMP). Since 2004, the Walter Reed Army In- stitute of Research (WRAIR) has been developing a novel GMP injection of AS, which was approved by the US FDA for investigational drug use and distribution by the CDC . As previously reported, a Phase 1a clin- ical trial of this GMP product was conducted, with sin- gle dose (0.5, 1, 2, 4, and 8 mg/kg) administration of intravenous artesunate studied in 40 healthy volunteers . The present Phase 1b study (ClinicalTrials.gov Identifier: NCT00292942) describes the PK of injectable AS, using escalating multiple doses in healthy volun- teers daily for three days with the aim of developing a safe and feasible dose.
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A 150ml aliquot of the drug solution in absolute ethanol containing 5 to 70mg of artesunate was accurately measured into a 100ml iodine flask and 3ml of 10% potassium iodide was added. The content of the flask was then acidified using 2mls of IM sulphuric acid – the resulting mixture was shaken and corked properly and placed in a dark cupboard for 30 minutes. At 10minutes interval the content of the flask was swirled gently. At the expiration of 30 minutes the released iodine was titrated with 0.05M of freshly prepared and standardized sodium thiosuphate solution. In the course of titration 4 drops of 1% starch solution was added near the end point. The titration procedure was repeated two more times. A blank titration was carried out without the drug from where the amount of artesunate per aliquot was calculated.
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As one of the most active endoplasmic reticulum cha- perone protein, GRP78 is overexpressed in different kinds of cancers and involved in tumorigenesis, metastasis, and angiogenesis. 10 GRP78 conferred breast cancer cells resis- tance BIK-mediated apoptosis. Overexpression of GRP78 decreases the sensitivity of glioma cells to cisplatin- induced cell death. Zhu et al reported that GRP78 formed complex with GPX4 in pancreatic cancer cells which further mediating erastin induced ferroptosis resistance. Our study ﬁ rstly con ﬁ rmed that GRP78 could also con- ferred KRAS mutant pancreatic cancer cells resistance to artesunate induced ferroptosis. The exact mechanism needs further investigation.
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The combined artesunate-PZQ treated group 3w pi showed almost normal hepatic architecture with complete absence of granu- lomas this result was also recorded by several studies on artemether (13, 25). Artesunate was one of the artemisinin group as well as arte- mether, and both act as promising candidates for treatment and chemoprophylaxis of schis- tosomiasis. While the combined artesunate- PZQ treated group 6w pi was accompanied by fewer histopathological changes in the liver with marked reduction rates in granuloma number and diameter, atypical granulomas were seen with degenerated eggs.
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speed was employed. The mobile phase consisted of toluene: ethyl acetate: acetic acid (2:8:0.2). The chromatogram was developed in a Camag twin trough glass chamber using a linear ascending technique. The chamber saturation time for mobile phase was optimised to 30 min at room temperature. The length of chromatogram run was 80 mm. Densitometric scanning was performed on Camag TLC scanner III in the absorbance mode at 520 nm. The source of radiation utilized was deuterium or tungsten lamp. A stock solution of artesunate (100 μg/ml) was prepared in methanol. Different volumes of stock solution were spotted in duplicate on TLC plate with the help of automatic sample applicator, to obtain amounts of 100, 200, 300, 400, 500 and 600 ng/spot of artesunate, respectively. The plates were developed in the presaturated twin trough chamber, dried and densitometrically scanned at 520 nm. The data of peak height/area versus drug concentration were treated by linear least-square regression analysis.
Artesunate-amodiaquine (AS-AQ) is currently the first line treatment in 24 countries, mainly in sub-Saharan Africa, and the second most widely used ACT globally after artemether-lumefantrine . AS-AQ is available in three formulations: non-fixed dose combinations (NFDC) either as loose NFDC or as co-blistered NFDC, and as a fixed dose combination (FDC). The efficacy of AS-AQ has been evaluated in a range of epidemiological settings, and although high cure rates have been re- ported in several studies [4,5], some studies have re- ported low efficacy rates [6-11]. It has been suggested that the reduced efficacy observed with AS-AQ in some trials is due to amodiaquine resistance selected by prior use of AQ monotherapy, mainly in East Africa [12-14] and Asia [6,7,13,14]. However, the efficacy of AS-AQ has varied between clinical trials even within the same regions [5,15,16], suggesting that different designs and methodology of clinical trials or other confounding fac- tors are responsible for the varying treatment efficacy.
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Safe, rapid, and reliably effective, the combination of AS and MQ is one of five forms of ACT currently recom- mended by the WHO as a first-line anti-malarial treat- ment. The WHO also recommends that fixed-dose combinations (FDC) be used whenever possible  to in- crease compliance to treatment. In 2002, in order to ad- dress the treatment needs of people most threatened by malaria and underscoring the need for public leadership, the Fixed-Dose Artesunate-Based Combination Therapies (FACT) Consortium, created by the Drugs for Neglected Diseases initiative (DNDi) and the Special Programme for Research and Training in Tropical Diseases (TDR), devel- oped ASMQ as a (FDC). Within the FACT Consortium, Farmanguinhos was the first manufacturing partner of ASMQ FDC. By developing a FDC of well-established use, DNDi and its partners aimed to improve treatment com- pliance, extend its use in malaria endemic countries and fight more efficiently against resistance development. [9,10]. This user-friendly new tablet co-formulation, which simplifies treatment with a single daily dose of 1 or 2 tablets for three days, represents an innovation that could have considerable impact in the treatment of uncompli- cated P. falciparum malaria. Fixed-dose combinations eliminate the possibility of patients taking only one com- ponent of the combination and are expected to improve patient compliance. With specific presentations for children aged between 6 months and 11 years, ASMQ FDC addresses the needs of children, the primary victims of malaria worldwide.
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ACT: Artemisinin-based combination therapy; AL: Artemether-lumefantrine; AOR: Adjusted odds ratio; AQ: Amodiaquine; AS: Artesunate; AS- AQ: Artesunate-amodiaquine; ASAQ-coblistered NFDC: Non-fixed dose combination in a co-blister formulation; ASAQ-FDC: Fixed dose combination; ASAQ-loose NFDC: Non-fixed dose combination in a loose formulation; CI: Confidence interval; DP: Dihydroartemisinin-piperaquine; IPD: Individual participant data; IQR: Interquartile range; LLIN: Long-lasting insecticidal net; OR: Odds ratio; OxTREC: Oxford Tropical Research Ethics Committee; PPR: Parasite positivity rate; PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses; RSD: Relative standard deviation; SD: Standard deviation; SSA: Sub-Saharan Africa; TDR: The Special Programme for Research and Training in Tropical Diseases; WHO: World Health Organization; WWARN: Worldwide Antimalarial Resistance Network.
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Results of both the in vivo and in vitro studies showed that artesunate caused reversible adverse effects on male reproductive functions in a dose and duration dependent manner. The study of biological phenomena in-vivo is often compli- cated by various interactions operative within a living organism. Although highly artificial, tissue culture models provide valuable systems in which the environmental conditions can be controlled and the effects of various factors on a specific cell type can be directly investigated, however, mor- phological and functional characteristics are fre- quently subject to alteration in culture due to changes in pH, temperature, culture medium and atmospheric conditions, but care was taken to maintain these factors at physiological conditions suitable to the cultured cells in this study. The present in-vitro studies were, therefore, supported at least and in part by the in-vivo experiments. Moreover, the long term use of artesunate might have to be done with caution because the greatest adverse effect was observed during the long-term administration of the drug. Sertoli cells are very important in spermatogenesis because they nour- ish the germ cells and form the blood-testis barrier which protects the germ cells and developing spermatocytes from direct contact with the exter- nal environment. However, if this barrier is breached, there would be a greater tendency for the infiltration of toxic substances into the interior of the seminiferous tubules, thereby, affecting the process of spermatogenesis. Further studies could be aimed at co-culturing Sertoli cells with germ cells and then treating them with artesunate. This will shed more light as to how these drugs affect the protective function of Sertoli cells on germ cells.
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After acclimation for 7 days, the rats were divided into four groups. In the vehicle control group (termed as saline group; n = 8), rats were given (intraperitoneal [i.p.]) sterilized saline (pH was adjusted to 6.0; 0.5 mL/100 g) once a day for 6 weeks. In the clozapine group (n = 10), rats were given the same volume of clozapine solution (pH = 6.0; 10 mg/kg, i.p.) once a day during the same period. In the artesunate group (n = 10), rats were given artesunate solution (pH = 6.0; 3 mg/kg, i.p.) once a day during the same period. In the clozapine + artesunate group (n = 9), rats were given clozapine (10 mg/kg, i.p.) and artesunate (3 mg/kg, i.p.) in the order with a 2-h interval to minimize the possible effect of this larger volume of injection, which was the double of that injected for the other three groups, on the rats. During the experimental period the rats were weighed every week. The doses of artesunate and clozap- ine used in this study were based on the results of the primary experiment of this study and of our previous studies. 28,38,39
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