title: Pyronaridine-artesunate versus mefloquine plus artesunate for malaria.
abstract: BACKGROUND
  Pyronaridine-artesunate is an artemisinin-based combination therapy under evaluation for the treatment of Plasmodium falciparum and P. vivax malaria.
  
  
  METHODS
  We conducted a phase 3, open-label, multicenter, noninferiority trial that included 1271 patients between 3 and 60 years of age from Asia (81.3%) or Africa (18.7%) with microscopically confirmed, uncomplicated P. falciparum malaria. Patients underwent randomization for treatment with a fixed-dose combination of 180 mg of pyronaridine and 60 mg of artesunate or with 250 mg of mefloquine plus 100 mg of artesunate. Doses were calculated according to body weight and administered once daily for 3 days.
  
  
  RESULTS
  Pyronaridine-artesunate was noninferior to mefloquine plus artesunate for the primary outcome: adequate clinical and parasitologic response in the per-protocol population on day 28, corrected for reinfection with the use of polymerase-chain-reaction (PCR) genotyping. For this outcome, efficacy in the group receiving pyronaridine-artesunate was 99.2% (743 of 749 patients; 95% confidence interval [CI], 98.3 to 99.7) and that in the group receiving mefloquine plus artesunate was 97.8% (360 of 368 patients; 95% CI, 95.8 to 99.1), with a treatment difference of 1.4 percentage points (95% CI, 0.0 to 3.5; P=0.05). In the intention-to-treat population, efficacy on day 42 in the group receiving pyronaridine-artesunate was 83.1% (705 of 848 patients; 95% CI, 80.4 to 85.6) and that in the group receiving mefloquine plus artesunate was 83.9% (355 of 423 patients; 95% CI, 80.1 to 87.3). In Cambodia, where there were 211 study patients, the median parasite clearance time was prolonged for both treatments: 64 hours versus 16.0 to 38.9 hours in other countries (P<0.001, on the basis of Kaplan-Meier estimates). Kaplan-Meier estimates of the recrudescence rate in the intention-to-treat population in Cambodia until day 42 were higher with pyronaridine-artesunate than with mefloquine plus artesunate (10.2% [95% CI, 5.4 to 18.6] vs. 0%; P=0.04 as calculated with the log-rank test), but similar for the other countries combined (4.7% [95% CI, 3.3 to 6.7] and 2.8% [95% CI, 1.5 to 5.3], respectively; P=0.24). Elevated levels of aminotransferases were observed in those receiving pyronaridine-artesunate. Two patients receiving mefloquine plus artesunate had seizures.
  
  
  CONCLUSIONS
  Fixed-dose pyronaridine-artesunate was efficacious in the treatment of uncomplicated P. falciparum malaria. In Cambodia, extended parasite clearance times were suggestive of in vivo resistance to artemisinin. (Funded by Shin Poong Pharmaceutical Company and the Medicines for Malaria Venture; ClinicalTrials.gov number, NCT00403260.).
authors.affiliation: Department of Internal Medicine, Mae Sot General Hospital, Tak, Thailand.
authors.forename: Ronnatrai
authors.initials: R
authors.lastname: Rueangweerayut
authors.forename: Aung Pyae
authors.initials: AP
authors.lastname: Phyo
authors.forename: Chirapong
authors.initials: C
authors.lastname: Uthaisin
authors.forename: Yi
authors.initials: Y
authors.lastname: Poravuth
authors.forename: Tran Quang
authors.initials: TQ
authors.lastname: Binh
authors.forename: Halidou
authors.initials: H
authors.lastname: Tinto
authors.forename: Louis K
authors.initials: LK
authors.lastname: Pénali
authors.forename: Neena
authors.initials: N
authors.lastname: Valecha
authors.forename: Nong Thi
authors.initials: NT
authors.lastname: Tien
authors.forename: Salim
authors.initials: S
authors.lastname: Abdulla
authors.forename: Isabelle
authors.initials: I
authors.lastname: Borghini-Fuhrer
authors.forename: Stephan
authors.initials: S
authors.lastname: Duparc
authors.forename: Chang-Sik
authors.initials: CS
authors.lastname: Shin
authors.forename: Lawrence
authors.initials: L
authors.lastname: Fleckenstein
mesh_terms: D000293:Adolescent; D000328:Adult; D000349:Africa; D000962:Antimalarials / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D037621:Artemisinins / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D000077332:Artesunate; D001208:Asia; D002648:Child; D002675:Child, Preschool; D004338:Drug Combinations; D004351:Drug Resistance; D005260:Female; D006801:Humans; D057194:Intention to Treat Analysis; D053208:Kaplan-Meier Estimate; D016778:Malaria, Falciparum / Q000188:drug therapy*; D008297:Male; D015767:Mefloquine / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D008875:Middle Aged; D009287:Naphthyridines / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D016016:Proportional Hazards Models; D055815:Young Adult
chemical_list: D000962:Antimalarials; D037621:Artemisinins; D004338:Drug Combinations; D009287:Naphthyridines; D000077332:Artesunate; C027871:pyronaridine; D015767:Mefloquine