Randomized Trial on Effectiveness of ACTs in Ghana

• Clinical and PCR-controlled parasitological cure rate at day 14 [ Time Frame: 14 days ]
• Effect on anaemia [ Time Frame: 28 days ]
• Molecular Drug Resistance Markers [ Time Frame: 28 days ]
• Recrudescence and Reinfection [ Time Frame: 28 days ]
• Effects on Gametocytemia [ Time Frame: 28 days ]
• Acceptance of Therapies [ Time Frame: 7 days ]
• Incidences of malaria episodes over a follow-up period of 1 year [ Time Frame: 12 months ]

• Clinical and PCR-controlled parasitological cure rate at day 14
• Effect on anaemia
• Molecular Drug Resistance Markers
• Recrudescence and Reinfection
• Effects on Gametocytaemia
• Acceptance of Therapies
• Incidences of malaria episodes over a follow-up period of 1 year

The purpose of this study is to compare the effectiveness and safety of two Artemisinin Combination Therapies (ACTs) for the treatment of children with uncomplicated Plasmodium falciparum malaria

Childhood mortality related to Plasmodium falciparum malaria is on the rise with more than 1 million deaths per year in Sub-Saharan Africa. In the context of growing drug-resistance to antimalarials health officials are calling for rapid replacement of failing drugs by combining antimalarial drugs. Artemisinin Combination Antimalarial Therapies (ACTs) are in the focus of malaria control programmes and are recommended for first-line treatment in African countries. ACTs have been reported to be highly effective as artemisinin derivatives cause a rapid and substantial decrease in the parasite load when used for treating patients with malaria and resistance to artemisinin is still lacking. However, the short half-lives of artemisinins result in frequent recrudescent infections when used alone and therefore, much interest lays on the choice of the combination partner drug. ACTs also have been proposed as a means of reducing transmission by the reduction of gametocytes and of delaying the spread of drug resistance and prolonging the therapeutic life span of. Nevertheless, drug resistance of parasites to the respective partner drug is a matter of concern. Artesunate-amodiaquine (AQ) and artemether-lumefantrine (AL) are two registered fixed-dose artemisinin combination chemotherapies used in Africa which are GMP-manufactured at industrial scale. There is still limited data from randomised, controlled trials to support the general effectiveness of these two ACTs in Africa, including Ghana. More data is needed to compare these two therapies to make evidence-based first-line treatment decisions. Importantly, it is difficult to predict how combination therapy may affect the spread of drug resistance and monitoring drug resistance markers should be embedded in these trials to guide drug policy decision.

The aim of this open-labelled, randomised drug trial is to compare the effectiveness and safety of artesunate-amodiaquine (Arsucam®) against artemether plus lumefantrine (Coartem®) for the treatment of children under five years of age with uncomplicated Plasmodium falciparum malaria.

• Drug: Artesunate plus Amodiaquine
  Artesunate 50 mg and Amodiaquine 153 mg co-blister tablets: 3 days once daily weight-adjusted dosing according to manufacturer
  Other Name: Arsucam®
• Drug: Artemether-Lumefantrine
  Artemether 20 mg/Lumefantrine 120mg fixe-dose-combination tablets: 3 days twice daily weight-adjusted dosing according to manufacturer
  Other Name: Coartem®

• Experimental: AL
  Artemether plus Lumefantrine 6 dose 3 days treatment
  Intervention: Drug: Artemether-Lumefantrine
• Active Comparator: ASAQ
  Artesunate plus Amodiaquine
  Intervention: Drug: Artesunate plus Amodiaquine

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• Mutabingwa TK, Anthony D, Heller A, Hallett R, Ahmed J, Drakeley C, Greenwood BM, Whitty CJ. Amodiaquine alone, amodiaquine+sulfadoxine-pyrimethamine, amodiaquine+artesunate, and artemether-lumefantrine for outpatient treatment of malaria in Tanzanian children: a four-arm randomised effectiveness trial. Lancet. 2005 Apr 23-29;365(9469):1474-80.
• Makanga M, Premji Z, Falade C, Karbwang J, Mueller EA, Andriano K, Hunt P, De Palacios PI. Efficacy and safety of the six-dose regimen of artemether-lumefantrine in pediatrics with uncomplicated Plasmodium falciparum malaria: a pooled analysis of individual patient data. Am J Trop Med Hyg. 2006 Jun;74(6):991-8.
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Inclusion Criteria:

• Male and female outpatients aged 6 months to 59 months
• Absence of severe malnutrition
• A slide-confirmed P. falciparum asexual parasitaemia between 2,000/µl and 200,000/µl
• A measured axillary temperature ≥ 37.5 °C or rectal/tympanic temperature ≥ 38.0 °C
• Absence of general danger signs (unable to drink; repeated vomiting; recent history of convulsions; lethargic or unconscious state; unable to stand up or to sit)
• Ability to tolerate oral therapy
• Permanent residence in study area
• Informed consent by the legal representative of the subject, if possible, the parents

Exclusion Criteria:

• Adequate anti-malarial treatment within the previous 7 days
• Antibiotic treatment for a current infection
• Previous participation in a clinical trial
• Haemoglobin < 5 g/dl
• Leucocyte count: > 15000/µl
• Mixed plasmodial infection
• Severe malaria as defined by WHO recommendations
• Any other severe underlying disease (cardiac, renal, hepatic diseases, malnutrition, known HIV infection) or concomitant disease masking assessment of response
• History of allergy or intolerance against trial medication

• Presbyterian Health Service (PHS)
• Kumasi Centre for Collaborative Research (KCCR)
• School of Medical Sciences Kumasi (SMS/KNUST)