title: Population pharmacokinetics of artesunate and dihydroartemisinin following intra-rectal dosing of artesunate in malaria patients.
abstract: BACKGROUND
  Intra-rectal artesunate has been developed as a potentially life-saving treatment of severe malaria in rural village settings where administration of parenteral antimalarial drugs is not possible. We studied the population pharmacokinetics of intra-rectal artesunate and the relationship with parasitological responses in patients with moderately severe falciparum malaria.
  
  
  RESULTS
  Adults and children in Africa and Southeast Asia with moderately severe malaria were recruited in two Phase II studies (12 adults from Southeast Asia and 11 children from Africa) with intensive sampling protocols, and three Phase III studies (44 children from Southeast Asia, and 86 children and 26 adults from Africa) with sparse sampling. All patients received 10 mg/kg artesunate as a single intra-rectal dose of suppositories. Venous blood samples were taken during a period of 24 h following dosing. Plasma artesunate and dihydroartemisinin (DHA, the main biologically active metabolite) concentrations were measured by high-performance liquid chromatography with electrochemical detection. The pharmacokinetic properties of DHA were determined using nonlinear mixed-effects modelling. Artesunate is rapidly hydrolysed in vivo to DHA, and this contributes the majority of antimalarial activity. For DHA, a one-compartment model assuming complete conversion from artesunate and first-order appearance and elimination kinetics gave the best fit to the data. The mean population estimate of apparent clearance (CL/F) was 2.64 (l/kg/h) with 66% inter-individual variability. The apparent volume of distribution (V/F) was 2.75 (l/kg) with 96% inter-individual variability. The estimated DHA population mean elimination half-life was 43 min. Gender was associated with increased mean CL/F by 1.14 (95% CI: 0.36-1.92) (l/kg/h) for a male compared with a female, and weight was positively associated with V/F. Larger V/Fs were observed for the patients requiring early rescue treatment compared with the remainder, independent of any confounders. No associations between the parasitological responses and the posterior individual estimates of V/F, CL/F, and AUC0-6h were observed.
  
  
  CONCLUSIONS
  The pharmacokinetic properties of DHA were affected only by gender and body weight. Patients with the lowest area under the DHA concentration curve did not have slower parasite clearance, suggesting that rectal artesunate is well absorbed in most patients with moderately severe malaria. However, a number of modelling assumptions were required due to the large intra- and inter-individual variability of the DHA concentrations.
authors.affiliation: Centre for Molecular, Environmental, Genetic and Analytic Epidemiology, The University of Melbourne, Melbourne, Australia. julieas@unimelb.edu.au
authors.forename: Julie A
authors.initials: JA
authors.lastname: Simpson
authors.forename: Tsiri
authors.initials: T
authors.lastname: Agbenyega
authors.forename: Karen I
authors.initials: KI
authors.lastname: Barnes
authors.forename: Gianni
authors.initials: G
authors.lastname: Di Perri
authors.forename: Peter
authors.initials: P
authors.lastname: Folb
authors.forename: Melba
authors.initials: M
authors.lastname: Gomes
authors.forename: Sanjeev
authors.initials: S
authors.lastname: Krishna
authors.forename: Srivicha
authors.initials: S
authors.lastname: Krudsood
authors.forename: Sornchai
authors.initials: S
authors.lastname: Looareesuwan
authors.forename: Sharif
authors.initials: S
authors.lastname: Mansor
authors.forename: Helen
authors.initials: H
authors.lastname: McIlleron
authors.forename: Raymond
authors.initials: R
authors.lastname: Miller
authors.forename: Malcolm
authors.initials: M
authors.lastname: Molyneux
authors.forename: James
authors.initials: J
authors.lastname: Mwenechanya
authors.forename: Visweswaran
authors.initials: V
authors.lastname: Navaratnam
authors.forename: Francois
authors.initials: F
authors.lastname: Nosten
authors.forename: Piero
authors.initials: P
authors.lastname: Olliaro
authors.forename: Lorrin
authors.initials: L
authors.lastname: Pang
authors.forename: Isabela
authors.initials: I
authors.lastname: Ribeiro
authors.forename: Madalitso
authors.initials: M
authors.lastname: Tembo
authors.forename: Michele
authors.initials: M
authors.lastname: van Vugt
authors.forename: Steve
authors.initials: S
authors.lastname: Ward
authors.forename: Kris
authors.initials: K
authors.lastname: Weerasuriya
authors.forename: Kyaw
authors.initials: K
authors.lastname: Win
authors.forename: Nicholas J
authors.initials: NJ
authors.lastname: White
mesh_terms: D000285:Administration, Rectal; D000293:Adolescent; D000328:Adult; D000349:Africa; D000375:Aging / Q000378:metabolism; D000962:Antimalarials / Q000008:administration & dosage* / Q000009:adverse effects / Q000493:pharmacokinetics* / Q000627:therapeutic use; D037621:Artemisinins / Q000008:administration & dosage* / Q000009:adverse effects / Q000493:pharmacokinetics* / Q000627:therapeutic use; D000077332:Artesunate; D001210:Asia, Southeastern; D002648:Child; D002675:Child, Preschool; D003710:Demography; D005260:Female; D006801:Humans; D007223:Infant; D008288:Malaria / Q000188:drug therapy*; D008297:Male; D008875:Middle Aged; D018512:Parasitemia / Q000188:drug therapy / Q000821:virology; D016879:Salvage Therapy; D012717:Sesquiterpenes / Q000008:administration & dosage* / Q000009:adverse effects / Q000493:pharmacokinetics* / Q000627:therapeutic use; D012737:Sex Factors; D013488:Suppositories; D016896:Treatment Outcome
chemical_list: D000962:Antimalarials; D037621:Artemisinins; D012717:Sesquiterpenes; D013488:Suppositories; D000077332:Artesunate; C039060:artenimol