[e-drug] Prices of antimalarial combinations (cont'd)

[Steve Toovey <toovey@travelclinic.co.za>]

E-drug: Prices of antimalarial combinations (cont'd)
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I have copied below, on a fair use basis, the latest Cochrane review
I could find. Perhaps somebody has a later review. The conclusion
seems to be that the toxicity issue is far from settled, with the
reviewers calling for continued monitoring.

I also copied an abstract, on a fair usage basis, that illustrates the
problems associated with both Fansidar and Amodiaquine in East
Africa.

I believe it would be a surprise if resistance were not found to be a
problem in Zambia, and that it would not be prudent to introduce
either Fansidar (or generic equivalent) or amodiaquine without
documenting that resistance and toxicity were not problems in
Zambia.

Zambians deserve better than the introduction of old, possibly
toxic, and perhaps ineffective drugs.

Dr Stephen Toovey
SAA-Netcare Travel Clinics
P O Box 786692
Sandton 2146, South Africa
Fax: +27-11-883-6152
e-mail: toovey@travelclinic.co.za
http://www.travelclinic.co.za
http://www.malaria.co.za

===============================

Cochrane Database Syst Rev 2000;(2):CD000016 

Amodiaquine for treating malaria.

Olliaro P, Mussano P.

TDR, World Health Organization, 20, avenue Appia, 1211 Geneve
27, Switzerland. <olliaro@who.ch>

BACKGROUND: Amodiaquine has been widely used to treat malaria.
Due to reports of fatal adverse drug reactions, discontinuation or
modification of its use has been suggested.
OBJECTIVES: The objective of this review was to assess the
effects of amodiaquine for treating malaria.
SEARCH STRATEGY: We searched the Cochrane Infectious
Diseases Group trials register and Medline. We also contacted
researchers in the field and drug companies.
SELECTION CRITERIA: Randomised and quasi-randomised trials
comparing amodiaquine with other treatment for uncomplicated
malarial infections in adults and children.
DATA COLLECTION AND ANALYSIS: Both reviewers independently
extracted data and assessed trial quality.
MAIN RESULTS: Forty trials were included. Allocation was
adequately concealed in three trials. Amodiaquine was more
effective than chloroquine for parasite clearance. The combined
results of parasite clearance at seven days from 24 trials was 83%
for amodiaquine and 56% for chloroquine (odds ratio 4.29, 95%
confidence interval 3.51 to 5.24). The odds ratio for parasite
clearance at 14 days was 6.00, 95% confidence interval 4.38 to
8.21. Amodiaquine and sulfadoxine/pyrimethamine showed similar
results for parasite clearance on day seven, but
sulfadoxine/pyrimethamine appeared to be more effective on day 14
and 28. No significant difference for adverse events was observed
between amodiaquine and chloroquine and
sulfadoxine/pyrimethamine. Reported adverse effects were minor or
moderate, not life threatening.
REVIEWER'S CONCLUSIONS: There is some evidence to support
the continued use of amodiaquine in the treatment of uncomplicated
malaria, although drug resistance should be considered. Monitoring
for toxicity should also continue.

--------------------------

Trans R Soc Trop Med Hyg 1999 Mar-Apr;93(2):185-8.

A comparison of amodiaquine and sulfadoxine-pyrimethamine as
first-line treatment of falciparum malaria in Kenya.

van Dillen J, Custers M, Wensink A, Wouters B, van Voorthuizen T,
Voorn W, Khan B, Muller L, Nevill C.

Department of Social Medicine, Medical Faculty, University of
Amsterdam, The Netherlands.

A randomized 14-day study in vivo compared the response of
Plasmodium falciparum malaria to amodiaquine (35 mg/kg) and
sulfadoxine-pyrimethamine (sulfadoxine, 25 mg/kg) in symptomatic
outpatients at 2 sites in northern and western Kenya during 1993.
Of the 239 patients recruited, 181 (76%) completed the study [84
(46%) on amodiaquine and 97 (54%) on
sulfadoxine-pyrimethamine]. There were no significant differences in
the parasitological, clinical or haematological responses between
the 2 drug groups in both areas, with 18.5% resistance to
amodiaquine versus 9.5% for sulfadoxine-pyrimethamine in the
north and 35.1% against amodiaquine versus 34.5% for
sulfadoxine-pyrimethamine in the west. In both sites defervescence
was significantly more rapid with amodiaquine (P < 0.05) and true
clinical failure (symptomatic illness with recurrent parasitaemia) was
unusual (9%). As high-level resistance to chloroquine is
widespread, both drugs are valuable alternatives. However, the
significantly higher levels of resistance in the west may be a sign of
the increased drug pressure in this holoendemic area and send an
important warning concerning resistance to
sulfadoxine-pyrimethamine.


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