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Treatment Failure Due to the Potential Under-Dosing of Dihydroartemisinin-Piperaquine in a Patient with Plasmodium Falciparum Uncomplicated Malaria

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Treatment Failure Due to the Potential Under-Dosing of Dihydroartemisinin-Piperaquine in a Patient with Plasmodium Falciparum Uncomplicated Malaria INFECT DIS TROP MED 2019; 5: E525 Treatment failure due to the potential under-dosing of dihydroartemisinin-piperaquine in a patient with Plasmodium falciparum uncomplicated malaria I. De Benedetto1, F. Gobbi2, S. Audagnotto1, C. Piubelli2, E. Razzaboni3, R. Bertucci1, G. Di Perri1, A. Calcagno1 1Department of Medical Sciences, Unit of Infectious Diseases, University of Torino, Amedeo di Savoia Hospital, Torino, Italy 2Department of Infectious–Tropical Diseases and Microbiology, IRCCS Sacro Cuore Don Calabria Hospital, Verona, Italy 3Unit of Infectious Diseases, Azienda Ospedaliera Universitaria Integrata di Verona, Verona, Italy ABSTRACT: — Background: Dihydroartemisinin/piperaquine (DHA-PPQ) 40/320 mg is approved for the treatment of Plasmodium falciparum uncomplicated malaria. Different recommendations are provided by WHO guidelines and drug data sheet about dosing in overweight patients. We report here a treatment failure likely caused by sub-optimal dosing of dihydroartemisinin-piperaquine in a case of uncomplicated P. fal- ciparum malaria in a returning traveler from Burkina Faso. INTRODUCTION kg). They, therefore, provided an updated dosing body weight dosing schedule in their 2015 guidelines for Dihydroartemisinin/piperaquine (DHA-PPQ) 40/320 malaria treatment that provides for a dose of 200/1600 mg tablet formulation is approved for the treatment mg (5 tablets) in individuals > 80 kg1. of Plasmodium falciparum uncomplicated malaria in adults and children > 6 months and > 5 kg of body weight. Following WHO guidelines, the daily dose CASE REPORT must be proportioned to the body weight and 200/1600 mg (5 tablets) must be administered in patients > 80 We report the case of a 54-years old female patient, with kg1. Nonetheless according to the drug data sheet, in a body weight of 86 kg, who was admitted to the Hospi- individuals between 75 and 100 kg of body weight, the tal “Borgo Roma” in Verona, Italy, because of fever and recommended daily dose of DHA-PPQ is 160/1280 mg dizziness two weeks after returning from travelling in (4 tablets) with lack of data in people over 100 kg of Burkina Faso without using any anti-malaria prophylaxis. body weight2. DHA-PPQ is typically dosed proportion- Upon presentation at the hospital, a standard blood smear ally to the body weight of the patient with a maximum was taken for microscopic examination that diagnosed recommended daily dose of 160/1280 mg (4 tablets) an infection with Plasmodium falciparum trophozoites at according to manufacturer’s recommendations2. How- a parasitaemia of greater than 2%. A treatment regimen ever, WHO identified from pharmacological studies that of four tablets of dihydroartemisinin-piperaquine 40/320 the standard dosing regimen was inadequate to maintain mg (total dose 160/1280 mg) taken orally was immedi- a therapeutic dose of active compound for individuals ately begun and continued daily for three days. We note in the higher body weight range (typically those > 80 that the patient had no vomiting following each dose. CORRESPONDING AUTHOR: ILARIA DE BENEDETTO, MD; E-MAIL: [email protected] 1 INFECT DIS TROP MED Figure 1. Patient Plasmodium falciparum parasitaemia (% Red Blood Cells) over time (days). Two malaria episodes are indica- ted by the bars above the figure. Hospital admission ‘A’ is shown by the arrows on the X-axis. Clinical improvement was observed for symptoms and and atovaquone have been submitted for DNA Sanger for parasitaemia followed by blood smears. Parasitaemia sequencing analysis3. In particular, PfDHFR sequenced was determined negative on the third day of treatment. region has been extended to 1-233 codon region. No However, 45 days later the patient was admitted to the point mutations associated with artemisinin, piperaquine Amedeo di Savoia Hospital in Torino (without any further and atovaquone resistance were identified. Pfplasmepsin travel to malaria endemic countries) with fever and loss of II (PfPM2, PF3D7_1408000) copy number variation and consciousness. Microscopic examination of a blood smear Pf3D7_1362500 exo-E415G point mutation have been identified Plasmodium falciparum trophozoites at a parasi- recently associated with piperaquine resistance in Cambo- taemia of greater than 5%. The patient also presented with dia4,5, but analyses performed in our sample by quantitative confusion and aphasia, which led us to undertake a brain polymerase chain reaction (qPCR) and sequencing did not computerized tomography (CT) scan with negative find- reveal any modification in these genes, suggesting that an ings. Neurological assessment was completed with a brain under dosing of dihydroartemisinin-piperaquine was the magnetic resonance imaging (MRI) that revealed a recent 9 most likely cause of treatment failure. Unfortunately, it was mm haemorragic lesion located in the inferior frontal gyrus not possible to perform analysis of samples from the first white matter. A follow-up over time of this lesion was start- malarial episode, as they were no longer available. ed according to neurological and neurosurgical evaluation and repeated brain MRI scans were unchanged supporting the diagnosis of cerebral cavernoma. Due to the patient’s CONCLUSIONS recent history of a Plasmodium falciparum infection, it was suspected that this new episode of malaria infection According to WHO guidelines every case of recurrent was due to treatment failure from either pharmacological malaria must be distinguished between reinfection and resistance or inadequate drug exposure1. A new anti-ma- recrudescence (i.e. treatment failure). Reasons for treat- larial regimen was started using 200 mg of artesunate ment failure include inadequate exposure to the drug due administered intravenously (IV) at Time (T) = 0, 12, 24, to sub-optimal dosing, poor adherence, vomiting, unusu- 48 and 72 hours plus a loading dose of clindamycin (900 al pharmacokinetics, substandard medicines or genuine mg) IV at T=0 and then 450 mg clindamycin iv ter in die resistance1. Due to the widespread treatment failures to (TID) for the next four days. Parasitaemia was monitored DHQ-PPQ in South-Eastern Asia6,7, the WHO revised by microscopic examination of blood smears daily and was their recommended dosing regimens in 20151. This was seen to steadily decrease until it became negative on day based on a review of pharmacokinetic data (6 published 4. Treatment was completed with atovaquone/proguanil studies and 10 studies from the WWARN database; total 250/100 mg for three days. Blood samples daily taken 652 patients) and on subsequent conducted simulations during the second malarial episode have been further ana- of piperaquine exposures for each weight group: young lyzed, in order to investigate the possible pharmacological children (< 25 kg) had a higher risk of lower exposure resistance of the P. falciparum strain. As previously de- and treatment failure. Pharmacokinetic data also suggest- scribed, regions from six genes (PfK13, PfCRT, PfMDR1, ed that patients above 80 kg of body weight may have a PfDHFR, PfDHPS, and PfCYTb) linked to resistance to ar- similar risk and for this reason, increased weight propor- 2 temisinin derivatives, quinolones, antifolates-cycloguanil tioned daily dosages of dihydroartemisinin/piperaquine TREATMENT FAILURE DUE TO THE POTENTIAL UNDER-DOSING OF DIHYDROARTEMISININ-PIPERAQUINE are now recommended (for example, for patients > 80 ACKNOWLEDGEMENTS: kg: 200 mg DHA +1600 mg PPQ). The failure of DHQ- We would like to thank C. Jacob, K.A. Rockett and PPQ treatment in the patient presented here without any R. Amato (Wellcome Sanger Institute, and Wellcome known identifiable mutations in associated gene is similar Centre for Human Genetics, University of Oxford) for to other case reports from Africa for DHQ-PPQ treatment helpful advice on the methodology for the quantitative failure3,8. The first case was an Italian tourist who rapidly PCR for PM2 copy number and also providing helpful responded to DHA-PPQ treatment showing an apparent comments on the final manuscript. complete recovery within a few days. However, 32 days after the end of therapy she presented with a recrudes- CONFLICT OF INTERESTS: cence. Pharmacokinetic analysis had shown that serum The authors declare that they have no conflict of interest. concentrations of DHA-PPQ were adequate. Genotyping analysis demonstrated that the same P. falciparum strain was responsible for the both episodes and the lack of REFERENCES mutations in the PfK13 gene suggested the involvement of an artemisinin-sensitive strain. Taken together, these 1. Guidelines for the treatment of malaria. World Health Orga- gave support to a hypothesis for resistance to PPQ. The nization 2015; 3th edition. second case occurred in a foreign-born patient living in 2. Drug data sheet. European Medical Association (EMA). Italy. Thirty days after malaria recovery following DHA- Dihydroartemisin/Piperaquine (Eurartesim®) PPQ therapy, the patient presented with a recrudescence. 3. Gobbi F, Buonfrate D, Menegon M, Lunardi G, Angheben In this case genotyping analysis not only showed the A, Severini C, Gori S, Bisoffi Z. Failure of dihydroartemis- same strain of P. falciparum was responsible for both ep- inin-piperaquine treatment of uncomplicated Plasmodium falciparum malaria in a traveller coming from Ethiopia. isodes but also identified similar point mutations to those Malar J 2016; 15: 525. 3 reported by Gobbi et al . A further case associated to un- 4. Amato R, Lim P, Miotto O, Amaratunga C, Dek D, Pearson derdosage of DHA-PPQ
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