title: Amodiaquine alone, amodiaquine+sulfadoxine-pyrimethamine, amodiaquine+artesunate, and artemether-lumefantrine for outpatient treatment of malaria in Tanzanian children: a four-arm randomised effectiveness trial.
abstract: BACKGROUND
  Many countries in Africa are considering a change to combination treatment for falciparum malaria because of the increase in drug resistance. However, there are few effectiveness data for these combinations. Our aim was to study the effectiveness of three drug combinations that have proven efficacious in east Africa compared with amodiaquine monotherapy.
  
  
  METHODS
  We undertook a randomised trial of antimalarial drug combinations for children (aged 4-59 months) with uncomplicated malaria in Muheza, Tanzania, an area with a high prevalence of resistance to sulfadoxine-pyrimethamine and chloroquine. Children were randomly allocated 3 days of amodiaquine (n=270), amodiaquine +sulfadoxine-pyrimethamine (n=507), or amodiaquine+artesunate (n=515), or a 3-day six-dose regimen of artemether-lumefantrine (n=519). Drugs were taken orally, at home, unobserved by medical staff. The primary endpoint was parasitological failure by day 14 assessed blind to treatment allocation. Secondary endpoints included day 28 follow-up and gametocyte carriage. Analysis was by intention to treat.
  
  
  RESULTS
  Of 3158 children screened, 1811 were randomly assigned treatment and 1717 (95%) reached the 14-day follow-up. The amodiaquine group was stopped early by the data and safety monitoring board. By day 14, the parasitological failure rates were 103 of 248 (42%) for amodiaquine, 97 of 476 (20%) for amodiaquine+sulfadoxine-pyrimethamine, 54 of 491 (11%) for amodiaquine+artesunate, and seven of 502 (1%) for artemether-lumefantrine. By day 28, the parasitological failure rates were 182 of 239 (76%), 282 of 476 (61%), 193 of 472 (40%), and 103 of 485 (21%), respectively. The difference between individual treatment groups and the next best treatment combination was significant (p<0.001) in every case. Recrudescence rates by day 28, after correction by genotyping, were 48.4%, 34.5%, 11.2%, and 2.8%, respectively.
  
  
  CONCLUSIONS
  The study shows how few the options are for treating malaria where there is already a high level of resistance to sulfadoxine-pyrimethamine and amodiaquine. The WHO-packaged six-dose regimen of artemether-lumefantrine is effective taken unsupervised, although cost is a major limitation.
authors.affiliation: Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Theonest K
authors.initials: TK
authors.lastname: Mutabingwa
authors.forename: Devota
authors.initials: D
authors.lastname: Anthony
authors.forename: Archie
authors.initials: A
authors.lastname: Heller
authors.forename: Rachel
authors.initials: R
authors.lastname: Hallett
authors.forename: Jalal
authors.initials: J
authors.lastname: Ahmed
authors.forename: Chris
authors.initials: C
authors.lastname: Drakeley
authors.forename: Brian M
authors.initials: BM
authors.lastname: Greenwood
authors.forename: Christopher J M
authors.initials: CJ
authors.lastname: Whitty
mesh_terms: D000655:Amodiaquine / Q000008:administration & dosage; D000818:Animals; D000962:Antimalarials / Q000008:administration & dosage*; D000077549:Artemether; D037621:Artemisinins / Q000008:administration & dosage; D000077332:Artesunate; D002675:Child, Preschool; D004334:Drug Administration Schedule; D004338:Drug Combinations; D004351:Drug Resistance; D004359:Drug Therapy, Combination; D004983:Ethanolamines / Q000008:administration & dosage; D005260:Female; D005449:Fluorenes / Q000008:administration & dosage; D006801:Humans; D007223:Infant; D000078102:Lumefantrine; D016778:Malaria, Falciparum / Q000188:drug therapy* / Q000453:epidemiology / Q000469:parasitology; D008297:Male; D010963:Plasmodium falciparum / Q000187:drug effects; D011739:Pyrimethamine / Q000008:administration & dosage; D012717:Sesquiterpenes / Q000008:administration & dosage; D013413:Sulfadoxine / Q000008:administration & dosage; D013636:Tanzania / Q000453:epidemiology
chemical_list: D000962:Antimalarials; D037621:Artemisinins; D004338:Drug Combinations; D004983:Ethanolamines; D005449:Fluorenes; D012717:Sesquiterpenes; D000655:Amodiaquine; C001205:fanasil, pyrimethamine drug combination; D000077332:Artesunate; D013413:Sulfadoxine; D000077549:Artemether; D000078102:Lumefantrine; D011739:Pyrimethamine