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

Background

Primaquine is the only drug consistently effective against mature gametocytes of Plasmodium falciparum. The transmission blocking dose of primaquine previously recommended was 0.75mg/kg (adult dose 45mg) 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 0.25mg/kg (adult dose 15mg) 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%.

Methods and Findings

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.

Conclusions

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.

Trial Registration

ClinicalTrials.gov {"type":"clinical-trial","attrs":{"text":"NCT01872702","term_id":"NCT01872702"}}NCT01872702     

An azaanthracene alkaloid from Polyalthia suberosa

An azaanthracene alkaloid, 1-aza-9,10-dimethoxy-4-methyl-2-oxo-1,2-dihydroanthracene (kalasinamide) has been isolated from the stems of Polyalthia suberosa. In addition, the known N-trans-feruloyltyramine and N-trans-coumaroyltyramine are also reported from the same source. The structures were elucidated by spectroscopic methods.     

Flavonoids in the black rhizomes of Boesenbergia panduta

5-Hydroxy-7-methoxyflavanone, 5,7-dimethoxyflavanone, 5-hydroxy-7-methoxyflavone 5-hydroxy-7,4′-dimethoxyflavone, 5,7-dimethoxyfiavone, 5,7,4′-trimethoxyflavone, 5,7,3′,4′-tetramethoxyflavone, 5-hydroxy-3,7-dimethoxyflavone, 5-hydroxy-3,7,4′-trimethoxyflavone, 3,5,7-trimethoxyflavone and 5-hydroxy-3,7,3′,4′-tetramethoxyflavone have been isolated from the black rhizomes of Boesenbergia pandurata.     

Anti-inflammatory cyclohexenyl chalcone derivatives in Boesenbergia pandurata.

The cyclohexenyl chalcone derivative [(-)-hydroxypanduratin A], together with the previously known panduratin A, sakuranetin, pinostrobin, pinocembrin, and dihydro-5,6-dehydrokawain were isolated from the chloroform extract of the red rhizome variety of Boesenbergia pandurata (Robx.) Schltr. [currently known as Boesenbergia rotunda (L.) Mansf., Kulturpfl.]. Their structures were assigned on the basis of their spectroscopic data. (-)-Hydroxypanduratin A and (-)-panduratin A showed significant topical anti-inflammatory activity in the assay of TPA-induced ear edema in rats.     

Cardiac glycosides of Beaumontia brevituba and B. murtonii.

Cardiac glycosides from Beaumontia brevituba and B. murtonii were examined. Gentiobiosyl-beta-D-cymaroside and gentiobiosyl-alpha-L-cymaroside of digitoxigenin were isolated from the seeds, unripe fruits, and leaves of B. brevituba, and the leaves of B. murtonii. Oleandrigenin and/or delta 16-digitoxigenin glycosides having the same sugar moieties were not isolated from the leaves of B. brevituba but from the leaves of B. murtonii as well as the seeds of B. brevituba.     

Notes on the genus Acer (Aceraceae) in Thailand

Acer chiangdaoense Santisuk is proposed as a new species from Northern Thailand. The relationships of the other Thai species of Acer is briefly discussed. A. garrettii is reduced to a synonym of A. laurinum.