title: Population Pharmacokinetics and Pharmacodynamics of Praziquantel in Ugandan Children with Intestinal Schistosomiasis: Higher Dosages Are Required for Maximal Efficacy.
abstract: Each year, millions of African children receive praziquantel (PZQ) by mass drug administration (MDA) to treat schistosomiasis at a standard single dose of 40 mg/kg of body weight, a direct extrapolation from studies of adults. A higher dose of 60 mg/kg is also acceptable for refractory cases. We conducted the first PZQ pharmacokinetic (PK) and pharmacodynamic (PD) study in young children comparing dosing. Sixty Ugandan children aged 3 to 8 years old with egg patent Schistosoma mansoni received PZQ at either 40 mg/kg or 60 mg/kg. PK parameters of PZQ racemate and enantiomers (R and S) were quantified. PD outcomes were assessed by standard fecal egg counts and novel schistosome-specific serum (circulating anodic antigen [CAA]) and urine (circulating cathodic antigen [CCA]) antigen assays. Population PK and PD analyses were performed to estimate drug exposure in individual children, and the relationship between drug exposure and parasitological cure was estimated using logistic regression. Monte Carlo simulations were performed to identify better, future dosing regimens. There was marked PK variability between children, but the area under the concentration-time curve (AUC) of PZQ was strongly predictive of the parasitological cure rate (CR). Although no child achieved antigenic cure, which is suggestive of an important residual adult worm burden, higher AUC was associated with greater CAA antigenic decline at 24 days. To optimize the performance of PZQ, analysis of our simulations suggest that higher doses (>60 mg/kg) are needed, particularly in smaller children.
  
  
  
  Schistosomiasis is a neglected tropical disease, typically associated with chronic morbidity, and its control is a global health priority. Praziquantel (PZQ) is the only available antiparasitic drug and is often given out, as a single oral dose (40 mg/kg), to school-aged children by mass drug administration (MDA) schemes operating within preventive chemotherapy campaigns as endorsed by the World Health Organization (WHO). This current strategy has several limitations. (i) It excludes preschool children who can be patently infected. (ii) It delivers PZQ at a dose directly extrapolated from adult pharmacological studies. To address these problems, we conducted the first pharmacokinetic and pharmacodynamic study of young children within an area of Uganda where Schistosoma mansoni is hyperendemic. Our results demonstrate that a higher dose (>60 mg/kg) is required, especially in smaller children, and draw attention to the need for further optimization of PZQ treatment based on schistosome antigenic assays, which are more sensitive to pharmacodynamic markers.
authors: Department of Parasitology, Liverpool School of Tropical Medicine, Liverpool, United Kingdom Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom Amaya.Bustinduy@lshtm.ac.uk.
authors: Amaya L
authors: 0000-0001-6131-4159
authors: AL
authors: Bustinduy
authors: Department of Parasitology, Liverpool School of Tropical Medicine, Liverpool, United Kingdom.
authors: David
authors: D
authors: Waterhouse
authors: Centro de Investigação em Saúde de Angola, Hospital Provincial, Caxito, Bengo, Angola Department of Life Sciences, Natural History Museum, Wolfson Wellcome Biomedical Laboratories, London, United Kingdom.
authors: Jose C
authors: JC
authors: de Sousa-Figueiredo
authors: Center for Biostatistics, Manchester Academic Health Sciences Centre (MAHSC), University of Manchester, Manchester, United Kingdom.
authors: Stephen A
authors: SA
authors: Roberts
authors: Vector Control Division, Ministry of Health, Kampala, Uganda.
authors: Aaron
authors: A
authors: Atuhaire
authors: Department of Parasitology, Leiden University Medical Center, Leiden, The Netherlands.
authors: Govert J
authors: GJ
authors: Van Dam
authors: Department of Molecular Cell Biology, Leiden University Medical Center, Leiden, The Netherlands.
authors: Paul L A M
authors: PL
authors: Corstjens
authors: Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, United Kingdom.
authors: Janet T
authors: JT
authors: Scott
authors: Department of Parasitology, Liverpool School of Tropical Medicine, Liverpool, United Kingdom.
authors: Michelle C
authors: MC
authors: Stanton
authors: Vector Control Division, Ministry of Health, Kampala, Uganda.
authors: Narcis B
authors: NB
authors: Kabatereine
authors: Department of Parasitology, Liverpool School of Tropical Medicine, Liverpool, United Kingdom.
authors: Stephen
authors: S
authors: Ward
authors: Department of Molecular and Clinical Pharmacology, University of Liverpool, Liverpool, United Kingdom.
authors: William W
authors: WW
authors: Hope
authors: Department of Parasitology, Liverpool School of Tropical Medicine, Liverpool, United Kingdom.
authors: J Russell
authors: JR
authors: Stothard
mesh_terms: D000818:Animals; D000871:Anthelmintics / Q000008:administration & dosage* / Q000493:pharmacokinetics* / Q000494:pharmacology; D000947:Antigens, Helminth / Q000097:blood / Q000652:urine; D002648:Child; D002675:Child, Preschool; D005243:Feces / Q000469:parasitology; D005260:Female; D006801:Humans; D008297:Male; D010270:Parasite Egg Count; D011223:Praziquantel / Q000008:administration & dosage* / Q000493:pharmacokinetics* / Q000494:pharmacology; D012550:Schistosoma mansoni / Q000187:drug effects*; D012555:Schistosomiasis mansoni / Q000188:drug therapy* / Q000469:parasitology; D014454:Uganda
chemical_list: D000871:Anthelmintics; D000947:Antigens, Helminth; D011223:Praziquantel