Journal Article

Single Low Dose Primaquine (0.25mg/kg) Does Not Cause Clinically Significant Haemolysis in G6PD Deficient Subjects

White, Nicholas J., Rakthinthong, Santisuk, Bancone, Germana, Kajeechiwa, Ladda, Ling, Clare L., Gornsawun, Gornpan, Nyo, Slight Naw, Moore, Kerryn A., Kiricharoen, Naw Lily, Moo, Paw Khu, Thwin, May Myo, Nosten, Suphak, Thinraow, Suradet, Nosten, Francois, Somsakchaicharoen, Raweewan, Chowwiwat, Nongnud, Wiladphaingern, Jacher, Poodpanya, Lalita

2016

Overview

Primaquine is the only drug consistently effective against mature gametocytes of Plasmodium falciparum. The transmission blocking dose of primaquine previously recommended was 0.75 mg/kg (adult dose 45 mg) but its deployment was limited because of concerns over haemolytic effects in patients with glucose-6-phosphate dehydrogenase (G6PD) deficiency. G6PD deficiency is an inherited X-linked enzymatic defect that affects an estimated 400 million people around the world with high frequencies (15-20%) in populations living in malarious areas. To reduce transmission in low transmission settings and facilitate elimination of P. falciparum, the World Health Organization now recommends adding a single dose of 0.25 mg/kg (adult dose 15 mg) to Artemisinin-based Combination Therapies (ACTs) without G6PD testing. Direct evidence of the safety of this low dose is lacking. Adverse events and haemoglobin variations after this treatment were assessed in both G6PD normal and deficient subjects in the context of targeted malaria elimination in a malaria endemic area on the North-Western Myanmar-Thailand border where prevalence of G6PD deficiency (Mahidol variant) approximates 15%. The tolerability and safety of primaquine (single dose 0.25 mg base/kg) combined with dihydroartemisinin-piperaquine (DHA-PPQ) given three times at monthly intervals was assessed in 819 subjects. Haemoglobin concentrations were estimated over the six months preceding the ACT + primaquine rounds of mass drug administration. G6PD deficiency was assessed with a phenotypic test and genotyping was performed in male subjects with deficient phenotypes and in all females. Fractional haemoglobin changes in relation to G6PD phenotype and genotype and primaquine round were assessed using linear mixed-effects models. No adverse events related to primaquine were reported during the trial. Mean fractional haemoglobin changes after each primaquine treatment in G6PD deficient subjects (-5.0%, -4.2% and -4.7%) were greater than in G6PD normal subjects (0.3%, -0.8 and -1.7%) but were clinically insignificant. Fractional drops in haemoglobin concentration larger than 25% following single dose primaquine were observed in 1.8% of the population but were asymptomatic. The single low dose (0.25mg/kg) of primaquine is clinically well tolerated and can be used safely without prior G6PD testing in populations with high prevalence of G6PD deficiency. The present evidence supports a broader use of low dose primaquine without G6PD testing for the treatment and elimination of falciparum malaria. ClinicalTrials.gov NCT01872702.

• Publisher: Public Library of Science,Public Library of Science (PLoS)
• Subject: Adult / Antimalarials - administration & dosage / Antimalarials - adverse effects / Antimalarials - therapeutic use / Approximation / Artemisinin / Biology and Life Sciences / Care and treatment / Child / Child, Preschool / Clinical significance / Dehydrogenases / Dihydroartemisinin / Dosage and administration / Dose-Response Relationship, Drug / Drug dosages / Drug therapy / Female / Females / Gametocytes / Genotyping / Glucose / Glucose 6 phosphate dehydrogenase / Glucose-6-phosphate dehydrogenase deficiency / Glucosephosphate dehydrogenase / Glucosephosphate Dehydrogenase Deficiency - blood / Glucosephosphate Dehydrogenase Deficiency - complications / Hemoglobin / Hemoglobins - analysis / Hemolysis - drug effects / Hemolysis and hemolysins / Humans / Infant / Infectious diseases / Insurance commissioners / Malaria / Malaria, Falciparum - blood / Malaria, Falciparum - complications / Malaria, Falciparum - drug therapy / Male / Medicine / Medicine and Health Sciences / Middle Aged / Mutation / Patient outcomes / Phosphates / Physicians / Plasmodium falciparum / Plasmodium falciparum - drug effects / Populations / Primaquine / Primaquine - administration & dosage / Primaquine - adverse effects / Primaquine - therapeutic use / Research and Analysis Methods / Safety / Vector-borne diseases / Young Adult