[FDA News Release, November 15, 2019] – FDA has approved Adakveo (crizanlizumab), previously known as SEG101, to reduce the frequency of vaso-occlusive crises (VOCs), or pain crises, in adult and pediatric patients aged 16 years and older with sickle cell disease.

“Adakveo is the first targeted therapy approved for sickle cell disease, specifically inhibiting selectin, a substance that contributes to cells sticking together and leads to vaso-occlusive crisis,” said Richard Pazdur, M.D., director of the FDA’s Oncology Center of Excellence and acting director of the Office of Oncologic Diseases in the FDA’s Center for Drug Evaluation and Research. “Vaso-occlusive crisis can be extremely painful and is a frequent reason for emergency department visits and hospitalization for patients with sickle cell disease.”

Sickle cell disease is an inherited blood disorder in which the red blood cells are abnormally shaped (in a crescent or “sickle” shape), which restricts the flow in blood vessels and limits oxygen delivery to the body’s tissues, leading to severe pain and organ damage. It is also characterized by severe chronic inflammation that results in vaso-occlusive crisis where patients experience episodes of extreme pain and organ damage. The disease occurs most often in African-Americans, where 1 out of every 365 babies born have the disease.

The FDA’s decision to approve Adakveo 5 mg/kg is based on results of the 52-week, randomized, placebo-controlled SUSTAIN trial, which showed that Adakveo significantly lowered the median annual rate of VOCs to 1.63 vs 2.98 compared to placebo (P=.010), which is equivalent to a 45% reduction. Reductions in the frequency of VOCs were observed among patients regardless of sickle cell disease genotype and/or hydroxyurea use.

“We know this drug can decrease the frequency of sickle cell pain crises in a significant and clinically meaningful way,” said Kenneth Ataga, MD, Director, Center for Sickle Cell Disease, University of Tennessee Health Science Center at Memphis, and Principal Investigator of the SUSTAIN trial. “The approval of crizanlizumab is an important advancement for people living with this very difficult condition.”

The most common adverse reactions among crizanlizumab-treated patients (incidence > 10%) were nausea (18%), arthralgia (18%), back pain (15%) and pyrexia (11%).

Novartis has priced Adakveo, which is dosed by weight, at a wholesale acquisition cost (WAC) of $2,357 per vial. Based on dosing recommendation, most patients would take between 3 and 4 vials per month. This translates to WACs of $7,000 to $9,500 per month. The medicine is expected to be available to patients in the coming weeks.

Sources:

FDA News Release, November 15, 2019

Novartis Media Release: New Novartis medicine Adakveo® (crizanlizumab) approved by FDA to reduce frequency of pain crises in individuals living with sickle cell disease

FDA-approved Prescribing Information for Adakveo available here: https://www.accessdata.fda.gov/drugsatfda_docs/label/2019/761128s000lbl.pdf

A tool to evaluate potential drug interaction causation in a specific patient.

The assessment of causation for a potential drug interaction requires thoughtful consideration of the properties of both the object and precipitant drugs, patient-specific factors, and the possible contribution of other drugs that the patient may be taking.

The Drug Interaction Probability Scale (DIPS) was developed to provide a guide to evaluating drug interaction causation in a specific patient. It is intended to be used to assist practitioners in the assessment of drug interaction–induced adverse outcomes.

The DIPS uses a series of questions relating to the potential drug interaction to estimate a probability score. An accurate assessment using the DIPS requires knowledge of the pharmacologic properties of both the object and precipitant drugs. Inadequate knowledge of either the drugs involved or the basic mechanisms of interaction will be a limitation for some users.

DIPS questionnaire is intended to be used to evaluate adverse events resulting from the interaction of 2 drugs—the drug that is affected (object drug) and the drug that causes the change to the object drug (precipitant drug).

DIPS Online Calculator

The Drug Interaction Probability Scale (DIPS) online calculator for potential drug-drug interactions is available at pmidCALC.org

DIPS Questionnaire

Horn, Hansten and Chan developed the Drug Interaction Probability Scale based on Naranjo ADR Probability Scale.

This tool consists of 10 questions each with three response options to which a score is given. The final score translates into a qualitative scale expressing the probability of the reaction actually being a drug interaction. The score obtained is not absolute, neither can it be extrapolated to other similar cases, but is relevant for determining how likely each individual case of ADR is to have originated from an interaction.

Directions:

1. Circle the appropriate answer for each question and sum the score.
2. Use the Unknown or Not Applicable (NA) category if
   • you do not have the information, or
   • the question is not applicable.

Note:

• Object drug = Drug affected by the interaction
• Precipitant drug = Drug that causes the interaction

Question 1: Are there previous credible reports of this interaction in humans? Yes +1, No –1, Unknown or NA 0

Question 2: Is the observed interaction consistent with the known interactive properties of precipitant drug? Yes +1, No –1, Unknown or NA 0

Question 3: Is the observed interaction consistent with the known interactive properties of object drug? Yes +1, No –1, Unknown or NA 0

Question 4: Is the event consistent with the known or reasonable time course of the interaction (onset and/or offset)? Yes +1, No –1, Unknown or NA 0

Question 5: Did the interaction remit upon dechallenge of the precipitant drug with no change in the object drug? (If no dechallenge, use Unknown or NA and skip Question 6). Yes +1, No –2, Unknown or NA 0

Question 6: Did the interaction reappear when the precipitant drug was readministered with continued use of the object drug? Yes +2, No –1, Unknown or NA 0

Question 7: Are there reasonable alternative causes for the event?^α Yes –1, No +1, Unknown or NA 0

Question 8: Was the object drug detected in the blood or other fluids in concentrations consistent with the proposed interaction? Yes +1, No 0, Unknown or NA 0

Question 9: Was the drug interaction confirmed by any objective evidence consistent with the effects on the object drug (other than drug concentrations from question 8)? Yes +1, No 0, Unknown or NA 0

Question 10: Was the interaction greater when the precipitant drug dose was increased or less when the precipitant drug dose was decreased? Yes +1, No –1, Unknown or NA 0

^α Consider clinical conditions, other interacting drugs, lack of compliance, risk factors (e.g., age, inappropriate doses of object drug). A “No” answer presumes that enough information was presented so that one would expect any alternative causes to be mentioned. When in doubt, use Unknown or NA designation.

 Total Score:

• Highly Probable >8
• Probable 5-8
• Possible 2-4
• Doubtful <2

Source:

1. Horn JR, Hansten PD, Chan LN. Proposal for a new tool to evaluate drug interaction cases. Ann Pharmacother. 2007;41(4):674-80

[NIH News Releases, October 30, 2019] – Exposure to paracetamol in the womb may increase a child’s risk for attention deficit/hyperactivity disorder and autism spectrum disorder, suggests a study funded by U.S. National Institutes of Health and the Agency for Health Care Research and Quality. The study was conducted by Xiaobing Wang, M.D., of the Johns Hopkins University Bloomberg School of Public Health, Baltimore, and colleagues. The findings are published in JAMA Psychiatry.

Attention deficit/hyperactivity disorder (ADHD) is marked by a pattern of hyperactivity and impulsive behavior. Autism spectrum disorder (ASD) is a complex developmental disorder that affects how a person behaves, interacts with others and learns.

Researchers analyzed data from the Boston Birth Cohort, a long-term study of factors influencing pregnancy and child development. They found that cord plasma biomarkers of fetal exposure to paracetamol were associated with significantly increased risk of childhood ADHD and ASD.

The authors conclude that their results support earlier studies linking paracetamol exposure in the womb with ADHD and ASD and underscore the need for additional research.

The U.S. FDA has reviewed earlier studies that reported on the potential risks associated with the following 3 types of pain medicines used during pregnancy:

• Prescription NSAIDs and the risk of miscarriage in the first half of pregnancy. Examples of prescription NSAIDs include ibuprofen, naproxen, diclofenac, and celecoxib.
• Opioids, which are available only by prescription, and the risk of birth defects of the brain, spine, or spinal cord in babies born to women who took these products during the first trimester of pregnancy. Examples of opioids include oxycodone, hydrocodone, hydromorphone, morphine, and codeine.
• Paracetamol in both OTC and prescription products and the risk of attention deficit hyperactivity disorder (ADHD) in children born to women who took this medicine at any time during pregnancy. Paracetamol is a common pain reducer and fever reducer found in hundreds of medicines including those used for colds, flu, allergies, and sleep.

FDA determined that recommendations cannot be made based on these earlier published studies due to their limitations. The Agency urges careful consideration before using any pain-relieving medication during pregnancy.

Sources:

1) NIH News Releases, October 30, 2019

2) JAMA Psychiatry. Published online October 30, 2019. doi:10.1001/jamapsychiatry.2019.3259

3) FDA Drug Safety Communication, January 9, 2015

Excerpts from Nigeria’s National Guidelines for Diagnosis and Treatment of Malaria (FMOH, 2015) & WHO Guidelines for the Treatment of Malaria 2015

DIAGNOSIS

Prompt parasitological diagnosis by microscopy or rapid diagnostic tests (RDTs) is required in all patients suspected of malaria before treatment.

TREATMENT OF UNCOMPLICATED P. FALCIPARUM MALARIA

Artemisinin-based combination therapy (ACT) is recommended as first-line curative treatment for uncomplicated P. falciparum malaria and should be given for at least 3 days. For maximum benefit, ACTs should be administered within 24-48 hours of the onset of malaria symptoms

Artemether-Lumefantrine (AL) is medicine of choice with Artesunate-Amodiaquine (AS-AQ) as alternate

Avoid monotherapy, it promotes resistance. Artemisinin and its derivatives should not be used as monotherapy for uncomplicated malaria. They are rapid-acting and if used alone, can lead to development of drug resistance. Nigeria has banned all oral artemisinin-based monotherapies (oAMT) since 2009.

Chloroquine and Sulfadoxine-Pyrimethamine are no longer recommended for the treatment of malaria in Nigeria due to the prevailing high levels of resistance which have compromised their efficacy even in combinations.

Antipyretic measures are recommended for fever ≥38.5°C (101.3°F) using Paracetamol; tepid sponging is also advised for children.

MANAGING MALARIA IN SPECIAL POPULATIONS

🤰 In pregnancy, the first-line treatment for uncomplicated P. falciparum malaria in the first trimester is Quinine + Clindamycin given for 7 days. ACT may be used if Quinine is not available.

In the second and third trimesters, ACT (AL or AS-AQ) is the first-line treatment for uncomplicated P. falciparum malaria

🤱 In breastfeeding mothers, ACT (AL or AS-AQ) is the first-line treatment for uncomplicated P. falciparum malaria

Treat infants weighing <5 kg with uncomplicated P. falciparum malaria with an ACT at the same mg/kg bw target dose as for children weighing 5 kg; under supervision by a health care provider.

SEVERE MALARIA

Severe malaria is a medical emergency. The recommended first-line treatment for severe P. falciparum malaria is IV Artesunate. If parenteral Artesunate is not available, IM Arthemeter or IV/IM Quinine may be used as alternatives.

Severe malaria must be treated parenterally for minimum of 24 hours, irrespective of patient being able to tolerate oral medication earlier. Treatment is completed by giving a full 3-day course of ACT.

In treating severe malaria, children weighing ≤20 kg should receive a higher dose of artesunate (3 mg/kg bw per dose) than larger children and adults (2.4 mg/kg bw per dose) to ensure equivalent exposure to the drug

In pregnancy, the first-line treatment for severe malaria is IV Artesunate

Pre-referral treatment of severe malaria and prompt referral are recommended at the community or peripheral health facilities. The treatment options in order of preference include:

• For children: artesunate IM; or rectal artesunate; or artemether IM; or quinine IM;
• For adults: artesunate IM; or artemether IM; or quinine IM

CHEMOPREVENTION AND CHEMOPROPHYLAXIS OF MALARIA

Sulfadoxine-pyrimethamine can be used for intermittent preventive treatment of malaria in pregnant women (IPTp). SP should be given twice in pregnancy separated by at least 4 weeks, 1st dose to be given from 16 weeks of pregnancy. SP must not be used in 1st trimester of pregnancy. The guideline recommends that since SP is an anti-folate, high dose folic acid should be withheld for one week after SP administration

The recommended chemoprophylaxis for non-immune visitors to Nigeria is: Mefloquine and Atovaquone-Proguanil. Doses should be taken prior to arrival in Nigeria and continued during the stay and following departure from the country.

Malaria can precipitate crises in sickle-cell disease. Recommended treatment is ACTs and prevention is by vector control measures such as LLINs (long-lasting insecticidal nets).

Seasonal malaria chemoprevention (SMC) is defined as the intermittent administration of full treatment courses of an antimalarial medicine during the malaria season to prevent malarial illness by maintaining therapeutic antimalarial drug concentrations in the blood throughout the period of greatest malarial risk. WHO recommends SMC for children aged 3 to 59 months living in areas of high seasonal malaria transmission. In Nigeria, SMC is recommended in States like Kebbi, Sokoto, Zamfara, Katsina, Kano, Jigawa, Bauchi, Yobe and Borno.

Long-lasting insecticidal nets (LLINs): sleeping under insecticide-treated nets to prevent infectious mosquito bites.

Indoor Residual Spraying (IRS): indoor application of long-lasting chemical insecticides to kill malarious mosquitoes

Further reading:

1. Nigeria 2015 National Guidelines for Diagnosis and Treatment of Malaria May 2015.pdf [Internet]. [cited 2018 Jul 25]. Available from: https://www.severemalaria.org/sites/mmv-smo/files/content/attachments/2017-02-06/Nigeria%202015%20National%20Guidelines%20for%20Diagnosis%20and%20Treatment%20of%20%20Malaria%20%20%20May%202015.pdf
2. WHO Guidelines for the Treatment of Malaria, 3rd Edition [Internet]. [cited 2018 Jul 20]. Available from: http://apps.who.int/iris/bitstream/handle/10665/162441/9789241549127_eng.pdf?sequence=1

[FDA Statement, September 13, 2019] – FDA has learned that some ranitidine medicines, including some products commonly known as the brand-name drug Zantac, contain a nitrosamine impurity called N-nitrosodimethylamine (NDMA) at low levels. NDMA is classified as a probable human carcinogen (a substance that could cause cancer) based on results from laboratory tests. NDMA is a known environmental contaminant and found in water and foods, including meats, dairy products, and vegetables.

The FDA has been investigating NDMA and other nitrosamine impurities in blood pressure and heart failure medicines called Angiotensin II Receptor Blockers (ARBs) since last year. In the case of ARBs, the FDA has recommended numerous recalls as it discovered unacceptable levels of nitrosamines.

When the agency identifies a problem, it takes appropriate action quickly to protect patients. The FDA is evaluating whether the low levels of NDMA in ranitidine pose a risk to patients. FDA will post that information when it is available.

Patients should be able to trust that their medicines are as safe as they can be and that the benefits of taking them outweigh any risk to their health. Although NDMA may cause harm in large amounts, the levels the FDA is finding in ranitidine from preliminary tests barely exceed amounts you might expect to find in common foods.

Ranitidine is an over-the-counter (OTC) and prescription drug. Ranitidine is an H2 (histamine-2) blocker, which decreases the amount of acid created by the stomach. Over-the-counter ranitidine is approved to prevent and relieve heartburn associated with acid ingestion and sour stomach. Prescription ranitidine is approved for multiple indications, including treatment and prevention of ulcers of the stomach and intestines and treatment of gastroesophageal reflux disease.

The agency is working with international regulators and industry partners to determine the source of this impurity in ranitidine. The agency is examining levels of NDMA in ranitidine and evaluating any possible risk to patients. The FDA will take appropriate measures based on the results of the ongoing investigation. The agency will provide more information as it becomes available.

The FDA is not calling for individuals to stop taking ranitidine at this time; however, patients taking prescription ranitidine who wish to discontinue use should talk to their health care professional about other treatment options. People taking OTC ranitidine could consider using other OTC medicines approved for their condition. There are multiple drugs on the market that are approved for the same or similar uses as ranitidine

Healthcare professionals and patients are advised to report adverse events related to the use on any of these products to the nearest NAFDAC office, NAFDAC PRASCOR (20543 TOLL-FREE from all networks) or via pharmacovigilance@nafdac.gov.ng

Source: FDA Statement, September 13, 2019

Excerpts from WHO Guidelines for the Treatment of Malaria 2015 & Nigeria’s National Guidelines for Diagnosis and Treatment of Malaria (FMOH, 2015)

Introduction

The World Malaria Index 2017 depicts a grim profile of Nigeria with 76% of the population living in high (>1 case per 1000 population) and 24% in low (0-1 cases per 1000 population) transmission areas. The country accounts for about 25% of estimated malaria cases globally and the highest proportion of malaria-related mortality based on WHO estimates. Pregnant women and children are especially vulnerable.

Nigeria’s 3T (Test, Treat and Track) approach to malaria case management is in line with WHO recommendation and is embodied in the National Malaria Strategic Plan (NMSP) 2014-2020. The objectives are:

• Test all suspected cases of malaria using Rapid Diagnostic Tests (RDT) or microscopy,
• Treat promptly with recommended artemisinin-based combination therapy (ACT) if the result is positive, and
• Document

Malaria is a life-threatening disease caused by protozoan parasites of the genus Plasmodium. It is spread mainly from the bite of female Anopheles mosquitoes which usually occurs between dusk and dawn. Less common modes of transmission include blood transfusion, organ transplant, use of contaminated needles & syringes, and mother-to-child transmission.

There are 5 known species of Plasmodium that can cause malaria in humans:

• P. falciparum
• P. vivax
• P. ovale
• P. malariae and
• P. knowlesi

P. falciparum causes the most severe infections and accounts for 100% of all cases of malaria in Nigeria (WHO World Malaria Report 2017).

Clinical features of malaria

Signs and symptoms are usually non-specific and may not accurately predict malaria.

Uncomplicated malaria may present with the following: fever/sweats/chills, headache, malaise, body aches & pain, diarrhoea, nausea & vomiting, anorexia, splenomegaly, and hepatomegaly.

Presence of one or more of the following may be indicative of severe falciparum malaria, in the absence of an identified alternative cause, and in the presence of P. falciparum asexual parasitaemia.

• Impaired consciousness: A Glasgow Coma Score <11 in adults or a Blantyre Coma Score <3 in children
• Prostration: Generalized weakness so that the person is unable to sit, stand or walk without assistance
• Multiple convulsions: More than two episodes within 24hours
• Acidosis: A base deficit of >8 meq/L or, if unavailable, a plasma bicarbonate of <15mmol/L or venous plasma lactate > 5 mmol/L. Severe acidosis manifests clinically as respiratory distress: rapid, deep and laboured breathing
• Hypoglycaemia: Blood or plasma glucose <2.2mmol/L (<40mg/dL)
• Severe malarial anaemia: A haemoglobin concentration < 5g/dL or a haematocrit of < 15% in children <12 years of age (<7g/dl and <20% respectively in adults) together with a parasite count >10,000/μL
• Renal impairment: (acute kidney injury): Plasma or serum creatinine >265μmol/L (3mg/dL) or blood urea > 20 mmol/L
• Jaundice: Plasma or serum bilirubin > 50μmol/L (3mg/dL) together with a parasite count >100,000/ μL
• Pulmonary oedema: Radiologically confirmed, or oxygen saturation <92% on room air with a respiratory rate >30/minute, often with chest indrawing and crepitations on auscultation
• Significant bleeding: including recurrent or prolonged bleeding from nose, gums or venepuncture sites; hematemesis or melaena
• Shock: Compensated shock is defined as capillary refill ≥3 seconds or temperature gradient on the leg (mid to proximal limb), but no hypotension. Decompensated shock is defined as systolic blood pressure less than 70 mm Hg in children or < 80 mm Hg in adults with evidence of impaired perfusion (cool peripheries or prolonged capillary refill)
• Hyperparasitaemia: Red blood cell P. falciparum parasitaemia >10%

In regions with high inoculation rates like Nigeria, it is possible to develop partial immunity to the disease from early childhood. Young children who have not developed immunity to the disease are therefore at greater risk of suffering severe malaria. Other risk factors for severe malaria include pregnancy, elderly, HIV/AIDS, and Nigerians who reside in non-endemic areas.

Malaria is a major cause of morbidity and mortality. It causes absenteeism in school children and can impair a child’s development and learning.

Key recommendations for malaria treatment and prevention

1. Diagnosis: prompt parasitological diagnosis by microscopy or rapid diagnostic tests (RDTs) is required in all patients suspected of malaria before treatment
2. Artemisinin-based combination therapy (ACT) is recommended as first-line curative treatment for uncomplicated P. falciparum malaria and should be given for at least 3 days. For maximum benefit, ACTs should be administered within 24-48 hours of the onset of malaria symptoms
3. Artemether-Lumefantrine (AL) is medicine of choice with Artesunate-Amodiaquine (AS-AQ) as alternate
4. Avoid monotherapy, it promotes resistance. Artemisinin and its derivatives should not be used as monotherapy for uncomplicated malaria. They are rapid-acting and if used alone, can lead to development of drug resistance. Nigeria has banned all oral artemisinin-based monotherapies (oAMT) since 2009.
5. Chloroquine and Sulfadoxine-Pyrimethamine are no longer recommended for the treatment of malaria in Nigeria due to the prevailing high levels of resistance which have compromised their efficacy even in combinations.
6. In pregnancy, the first-line treatment for uncomplicated P. falciparum malaria in the first trimester is Quinine + Clindamycin given for 7 days. ACT may be used if Quinine is not available.
7. In the second and third trimesters, ACT (AL or AS-AQ) is the first-line treatment for uncomplicated P. falciparum malaria
8. In breastfeeding mothers, ACT (AL or AS-AQ) is the first-line treatment for uncomplicated P. falciparum malaria
9. Treat infants weighing <5 kg with uncomplicated P. falciparum malaria with an ACT at the same mg/kg bw target dose as for children weighing 5 kg; under supervision by a health care provider.
10. Severe malaria is a medical emergency. The recommended first-line treatment for severe P. falciparum malaria is IV Artesunate. If parenteral Artesunate is not available, IM Arthemeter or IV/IM Quinine may be used as alternatives.
11. Severe malaria must be treated parenterally for minimum of 24 hours, irrespective of patient being able to tolerate oral medication earlier. Treatment is completed by giving a full 3-day course of ACT.
12. In treating severe malaria, children weighing ≤20 kg should receive a higher dose of artesunate (3 mg/kg bw per dose) than larger children and adults (2.4 mg/kg bw per dose) to ensure equivalent exposure to the drug
13. In pregnancy, the first-line treatment for severe malaria is IV Artesunate
14. Pre-referral treatment of severe malaria and prompt referral are recommended at the community or peripheral health facilities. The treatment options in order of preference include: •For children: artesunate IM; or rectal artesunate; or artemether IM; or quinine IM. •For adults: artesunate IM; or artemether IM; or quinine IM
15. Sulfadoxine-pyrimethamine can be used for the intermittent preventive treatment of malaria in pregnant women (IPTp). SP should be given twice in pregnancy separated by at least 4 weeks, 1st dose to be given from 16 weeks of pregnancy. SP must not be used in the 1st trimester of pregnancy. The guideline recommends that since SP is an antifolate, the high-dose folic acid should be withheld for one week after SP administration
16. The recommended chemoprophylaxis for non-immune visitors to Nigeria are: Mefloquine and Atovaquone-Proguanil. Doses should be taken prior to arrival in Nigeria and continued during the stay and following departure from the country.
17. Malaria can precipitate crises in sickle-cell disease. Recommended treatment is ACTs and prevention is by vector control measures such as LLINs (long-lasting insecticidal nets).
18. Seasonal malaria chemoprevention (SMC) is defined as the intermittent administration of full treatment courses of an antimalarial medicine during the malaria season to prevent malarial illness by maintaining therapeutic antimalarial drug concentrations in the blood throughout the period of greatest malarial risk. WHO recommends SMC for children aged 3 to 59 months living in areas of high seasonal malaria transmission. In Nigeria, SMC is recommended in States like Kebbi, Sokoto, Zamfara, Katsina, Kano, Jigawa, Bauchi, Yobe and Borno.
19. Antipyretic measures are recommended for fever ≥38.5°C (101.3°F) using Paracetamol; tepid sponging is also advised for children.
20. Long-lasting insecticidal nets (LLINs): sleeping under insecticide-treated nets to prevent infectious mosquito bites.
21. 21. Indoor Residual Spraying (IRS): indoor application of long-lasting chemical insecticides to kill malarious mosquitoes.

Goals of treatment

Malaria is an entirely preventable and treatable disease. The goals of treatment include:

• Rapid and complete elimination of the Plasmodium parasite from the patient’s blood in order to prevent progression of uncomplicated malaria to severe disease or death,
• Prevent chronic infection that leads to malaria-related anaemia.
• Reduce transmission of the infection to others, by reducing the infectious reservoir,
• Prevent the emergence and spread of resistance to antimalarial medicines.

Importance of diagnostic testing

Patients with suspected malaria should have parasitological confirmation of the diagnosis with either microscopy or rapid diagnostic test (RDT) before antimalarial treatment is started. Treatment based on clinical grounds should only be given if diagnostic testing is not immediately accessible within two hours of patients presenting for treatment. Prompt treatment – within 24 hours of fever onset – with an effective and safe antimalarial is necessary to prevent life-threatening complications.

Treatment of uncomplicated P. falciparum malaria

ACTs are the recommended first-line treatments for uncomplicated falciparum malaria. The artemisinin derivative components of the combination must be given for at least three days for an optimum effect. Artemisinin and its derivatives should not be used as monotherapy. Fixed-dose combinations are highly preferable to the loose individual medicines co-blistered or co-packaged.

First line treatment:

Artemether-Lumefantrine (AL) as a fixed close combination (FDC) given twice daily for three consecutive days with the second dose being given eight hours after the first.

Detailed Dosage Schedule for Artemether/Lumefantrine – see under the drug monograph

Alternate first-line treatment:

Artesunate + Amodiaquine (AS+AQ): Given once daily for three (3) consecutive days. Available as a fixed-dose combination (FDC) and also as co-blistered packs containing the partner drugs as separate tablets

Detailed Dosage Schedule for Artesunate + Amodiaquine – see under the drug monograph

Other ACTs available for the treatment of uncomplicated malaria:

• Artesunate-Mefloquine;
• Dihydroartemisinin-piperaquine;
• Artemisinin-Piperaquine

Second line treatment

The current guideline does not state a second-line treatment for uncomplicated falciparum malaria; it only stated an alternate first line.

Management of treatment failures

Recurrence of P. falciparum malaria can result from reinfection, or recrudescence (i.e., treatment failure). It may not be possible to distinguish recrudescence from re-infection. However, if fever and parasitaemia have not resolved or recur within 4 weeks of treatment, it should be considered as treatment failure with currently recommended ACTs. Treatment failures may result from:

• Drug resistance
• Poor adherence or inadequate drug exposure (e.g., due to under-dosing, vomiting or unusual pharmacokinetics in an individual), or
• Substandard medicines.

Find out if the patient vomited the previous treatment or did not complete a full course of treatment. If possible, confirm treatment failure by microscopy. In many cases, treatment failures are missed because patients who present with malaria are not asked whether they have received anti-malarial treatment within the preceding 1–2 months. This should be a routine question in patients who present with malaria.

Treatment failure within 28 days of receiving an ACT: In the absence of other causes of fever, and in the presence of persistent asexual parasites, the patient should be treated with the alternative medicine; in the case of AL, treat with AS-AQ and vice versa.

Treatment failure after 28 days of initial treatment: Treat as a new infection with the First-line ACT (i.e., AL or AS-AQ).

NOTE: Reuse of Mefloquine within 60 days of first treatment is associated with an increased risk of neuropsychiatric reactions and, in cases where the initial treatment was AS+MQ, second-line treatment not containing Mefloquine should be given instead.

Managing malaria in special populations

Uncomplicated malaria in pregnancy:

1. Treat pregnant women with uncomplicated P. falciparum malaria during the first trimester with 7 days of quinine + clindamycin. However, use an ACT if quinine is not available, or it is not possible to ensure/guarantee adherence to complete 7-day treatment with quinine
2. Quinine is administered orally as 10 mg/kg body weight to a max. dose of 600 mg every 8 hours for 7 days.
3. ACTs can be used in 2nd & 3rd trimesters. May be used in 1st trimester if Quinine is not available.

Malaria in young infants (<5 kg):

1. Treat infants weighing <5 kg with uncomplicated P. falciparum malaria with an ACT at the same mg/kg bw target dose as for children weighing 5 kg
2. Paediatric formulations of ACTs e.g., paediatric Coartem (AL) or AS+AQ FDC – see under the drug monographs for the dosing details

Treatment of severe malaria

Severe malaria is a medical emergency requiring in-patient care. After rapid clinical assessment and confirmation of the diagnosis, parenteral treatment should be started without delay.

The primary objective of antimalarial treatment in severe malaria is to prevent the patient from dying. The secondary objectives are the prevention of disabilities and occurrence of recrudescence.

The antimalarial medicine recommended for the treatment of severe malaria in Nigeria is injectable (IV/IM) Artesunate. Where this is not readily available, intramuscular Artemether or intravenous/ intramuscular Quinine can be used as alternatives.

In treating severe malaria, children weighing ≤20 kg should receive a higher dose of artesunate (3 mg/kg bw per dose) than larger children and adults (2.4 mg/kg bw per dose) to ensure equivalent exposure to the drug

Recommended dosing for IV/IM Artesunate:

• For children ≤20kg, artesunate 3 mg/kg BW IV or IM given on admission (time = 0), then at 12 h and 24 h, then once a day is the recommended treatment.
• For adults and children >20kg, artesunate 2.4 mg/kg Body Weight (BW) IV or IM given on admission (time = 0), then at 12 h and 24 h, then once a day is the recommended treatment.

There is no upper limit to the total dose of artesunate.

Alternate regimen for treating severe falciparum malaria

Artemether, or Quinine, is an acceptable alternative if parenteral artesunate is not available:

• Artemether 3.2 mg/kg BW IM given on admission then 1.6mg/kg BW per day; or
• Quinine 20 mg salt/kg BW on admission (IV infusion or divided IM injection), then 10 mg/kg BW every 8 h; infusion rate should not exceed 5 mg salt/kg BW per hour.

Give parenteral antimalarials in the treatment of severe malaria for a minimum of 24 hours, once started (irrespective of the patient’s ability to tolerate oral medication earlier), and, thereafter, complete treatment by giving a complete course of the recommended ACT. ACTs containing Mefloquine should, however, be avoided if the patient had cerebral malaria because of the increased risk of seizures, encephalopathy and psychosis.

Pre-referral treatment

The risk of death from severe malaria is greatest in the first 24 hours. To survive, a patient with severe illness must get access rapidly to a health facility where parenteral treatment and other supportive care can be given safely and as appropriate. At community or health facility levels where complete management of severe malaria is not possible, patients with severe malaria should be given pre-referral treatment and referred immediately to an appropriate facility for further treatment.

The following options for pre-referral treatment are recommended in order of preference:

• For children: Artesunate IM; or rectal Artesunate; or Artemether IM; or Quinine IM.
• For adults: Artesunate IM; or Artemether IM; or Quinine IM

Intramuscular pre-referral treatment

• Artesunate 2.4mg/kg single dose
• Artemether IM 3.2 mg/kg single dose
• Quinine dihydrochloride at a dosage of 10 mg/kg salt diluted to 60mg/ml intramuscularly at the anterolateral aspect of the thigh given at divided sites

Intra-rectal pre-referral treatment

Artesunate suppositories: Single dose to be administered rectally; expelled from the rectum within 30 minutes of insertion, a second suppository should be inserted and, especially in young children, the buttocks should be held together, or taped together, for 10 minutes to ensure retention of the rectal dose of artesunate.

Recommended dosing: (Usually available as 50 mg or 100 mg suppositories)

<10 kg (<12 months): 50 mg as a single dose

10-19 kg (1-5 years): 100 mg as a single dose

20-29 kg (6-9 years): 200 mg as a single dose

30-39 kg (10-13 years): 300 mg as a single dose

>40 kg (>13 years): 400 mg as a single dose

Alternate intra-rectal pre-referral treatment:

• Artemether Intra-rectal 10-40mg/kg single dose, OR
• Quinine Intra-rectal 12mg/kg single dose

These should be administered with a syringe without the needle.

Treatments not recommended for management of severe malaria

The guideline does not recommend the use of the following drugs in the treatment of severe malaria:

• Corticosteroids and other anti-inflammatory agents
• Agents used for cerebral oedema e.g. Urea
• Adrenaline
• Heparin

Chemoprevention and chemoprophylaxis of malaria

Malaria prophylaxis is generally not necessary in persons living in a malarious area because it may lower one’s resistance to the disease. Prophylaxis should, however, be used in sickle cell anaemia and in non-immune visitors because of risk for severe disease, but it is not 100% protective. Intermittent preventive treatment of malaria in pregnancy is recommended for all pregnant women.

Children and adults with sickle cell anaemia

Individuals, both children and adults, with sickle cell anaemia are widely recognised to be at increased risk of sickle cell crisis from malaria infections. Sleeping under the Long Lasting Insecticide Nets (LLIN) is generally recommended. The current guideline does not recommend any medicine for chemoprophylaxis in this population. Persons living with sickle cell anaemia who suspect malaria should report to the health facilities for prompt diagnosis and treatment.

Chemoprophylaxis for non-immune visitors/residents

Non-immune visitors to areas of malaria transmission are at high risk of malaria infection. In addition to the provision of information concerning effective measures to reduce human-mosquito contact, non-immune visitors to Nigeria should also be given chemoprophylaxis. The following options are recommended for use in Nigeria:

• Mefloquine, and
• Atovaquone-Proguanil

Doses should be taken prior to arrival in Nigeria and continued during the stay and following departure from the country.

Recommended dosing: see under the Mefloquine and Atovaquone/Proguanil monographs

Recommendations for intermittent preventative treatment in pregnancy (IPTp)

Malaria risk is higher during pregnancy and may be asymptomatic. In line with WHO recommendations, Nigeria implements the following interventions for the prevention and treatment of malaria in pregnancy:

• Use of long-lasting insecticidal nets (LLINs)
• IPTp with SP
• Prompt diagnosis and effective treatment of malaria illness.

Intermittent Preventive Treatment (IPT) with Sulfadoxine-Pyrimethamine (SP) reduces malaria-related complications during pregnancy. The guideline recommends that SP shall be administered as part of the antenatal care (ANC) package with other components including anthelmintics in the second or third trimester, nutrition counselling, and daily hematinic supplements (iron and low dose folic acid). It further states that high-dose folic acid when used, should be withheld for one week after SP administration due to the antifolate activity of sulfonamides.

Recommended dosing: SP should be given as a single adult dose of 3 tablets (each tablet contains 500 mg Sulfadoxine + 25 mg Pyrimethamine) at scheduled antenatal care visits. Three (3) or more doses given one month apart are currently recommended. First dose should be given after quickening (early second trimester or following the onset of the first foetal movement).

Pregnant women, who are HIV positive and are on Co-trimoxazole chemoprophylaxis, should not receive IPT with SP, due to the increased risk to the adverse effects of the Sulfonamides.

The use of Long Lasting Insecticide Nets (LLINs) should be promoted as an additional preventive measure.

Seasonal malaria chemoprevention (SMC)

Seasonal malaria chemoprevention (SMC) is defined as the intermittent administration of full treatment courses of an antimalarial medicine during the malaria season to prevent malarial illness by maintaining therapeutic antimalarial drug concentrations in the blood throughout the period of greatest malarial risk.

SMC is recommended in areas of highly seasonal malaria transmission throughout the Sahel sub-region. The target areas should be those where malaria transmission and majority (>60%) of clinical malaria cases occur during a short period of about 4 months. In Nigeria, SMC is recommended in States like Kebbi, Sokoto, Zamfara, Katsina, Kano, Jigawa, Bauchi, Yobe and Borno.

WHO recommends SMC using a full course of Sulfadoxine/Pyrimethamine + Amodiaquine (SP+AQ) once a month for max. 4 months during the malaria transmission season for children aged between 3 and 59 months.

Recommended dosing: see under the Sulfadoxine/Pyrimethamine + Amodiaquine (SP+AQ) monograph

Further reading:

1. Nigeria 2015 National Guidelines for Diagnosis and Treatment of Malaria May 2015.pdf [Internet]. [cited 2018 Jul 25]. Available from: https://www.severemalaria.org/sites/mmv-smo/files/content/attachments/2017-02-06/Nigeria%202015%20National%20Guidelines%20for%20Diagnosis%20and%20Treatment%20of%20%20Malaria%20%20%20May%202015.pdf
2. WHO Guidelines for the Treatment of Malaria, 3rd Edition [Internet]. [cited 2018 Jul 20]. Available from: http://apps.who.int/iris/bitstream/handle/10665/162441/9789241549127_eng.pdf?sequence=1
3. World Malaria Report 2017 [Internet]. [cited 2018 Jul 30]. Available from: http://apps.who.int/iris/bitstream/handle/10665/259492/9789241565523-eng.pdf;jsessionid=C85143F42E96E3D58EE4ACC8A3B1CE4D?sequence=1

[FDA News Release, July 24, 2019] – FDA has approved Eli Lilly’s Baqsimi nasal powder, the first glucagon therapy approved for the emergency treatment of severe hypoglycemia that can be administered without an injection.

Severe hypoglycemia occurs when a patient’s blood sugar levels fall to a level where he or she becomes confused or unconscious or suffers from other symptoms that require assistance from another person to treat. Typically, severe hypoglycemia occurs in people with diabetes who are using insulin treatment. Baqsimi is approved to treat severe hypoglycemia in patients with diabetes ages four and older.

“People who are living with diabetes are at risk of their blood sugar levels falling below the normal range. There are many products on the market for those who need insulin, but until now, people suffering from a severe hypoglycemic episode had to be treated with a glucagon injection that first had to be mixed in a several-step process,” said Janet Woodcock, M.D., director of the FDA’s Center for Drug Evaluation and Research. “This new way to administer glucagon may simplify the process, which can be critical during an episode, especially since the patient may have lost consciousness or may be having a seizure. In those situations, we want the process to treat the suffering person to be as simple as possible.”

Baqsimi, which is a powder administered into the nose, will come in a single-use dispenser that can be given to someone suffering from a severe hypoglycemic episode. Baqsimi increases blood sugar levels in the body by stimulating the liver to release stored glucose into the bloodstream. It has the opposite effect of insulin, which lowers blood sugar levels.

Injectable glucagon has been approved for use in the U.S. for several decades. The efficacy and safety of Baqsimi nasal powder glucagon to treat severe hypoglycemia was evaluated in two studies of 83 and 70 adults with diabetes, comparing a single dose of Baqsimi to a single dose of glucagon injection in causing a blood sugar response to insulin-induced hypoglycemia. Baqsimi adequately increased blood sugar levels. In a pediatric study of 48 patients over the age of four with type 1 diabetes, similar results were observed.

Baqsimi should not be taken by patients with pheochromocytoma, a rare tumor of adrenal gland tissue, or by patients who have insulinoma, a tumor of the pancreas. Baqsimi should not be taken by patients with a known hypersensitivity to glucagon or the inactive ingredients found in Baqsimi, as allergic reactions may occur. Baqsimi also carries a warning that it should be used with caution by those who have been fasting for long periods, have adrenal insufficiency or have chronic hypoglycemia because these conditions result in low levels of releasable glucose in the liver.

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The most common adverse reactions associated with Baqsimi are nausea, vomiting, headache, upper respiratory tract irritation, watery eyes, redness of eyes and itchiness. Side effects of Baqsimi are similar to injectable glucagon, with the addition of nasal and eye-related symptoms, such as watery eyes and nasal congestion, because of the way the drug is administered.

The FDA granted the approval of Baqsimi to Eli Lilly and Company.

Source: FDA News Release, July 24, 2019

[FDA News Release, July 17, 2019] – FDA has approved Recarbrio (imipenem, cilastatin and relebactam), an antibacterial drug product to treat adults with complicated urinary tract infections (cUTI) and complicated intra-abdominal infections (cIAI).

Recarbrio is a three-drug combination injection containing imipenem-cilastatin, a previously FDA-approved antibiotic, and relebactam, a new beta-lactamase inhibitor.

The determination of the efficacy of Recarbrio was supported in part by the findings of the efficacy and safety of imipenem-cilastatin for the treatment of cUTI and cIAI. The contribution of relebactam to Recarbrio was assessed based on data from in vitro studies and animal models of infection. The safety of Recarbrio, administered via injection, was studied in two trials, one each for cUTI and cIAI. The cUTI trial included 298 adult patients with 99 treated with the proposed dose of Recarbrio. The cIAI trial included 347 patients with 117 treated with the proposed dose of Recarbrio.

The most common adverse reactions observed in patients treated with Recarbrio included nausea, diarrhoea, headache, fever and increased liver enzymes.

Recarbrio should not be used in patients taking ganciclovir unless the benefits outweigh the risks as generalized seizures have been reported. Patients should also avoid using Recarbrio when taking valproic acid or divalproex sodium, drugs used to manage seizures, as a reduction in valproic acid level may lead to seizures.

Latest Drug Information News made possible thanks to the generous sponsorship from Pemason Pharmaceutical Limited – owned by Pharmacists and operated by a team of Pharmacists with a commitment to quality pharmaceuticals & drug information

To sponsor EMDEX Topic(s) i.e., Medication Management of Diseases, Drug Information Updates, Therapeutic Notes or Development of Drug Monographs, please contact Editor@EmdexOnline.com

Source: FDA News Release, July 17, 2019

FDA-approved Prescribing Information for Recarbrio available here: https://www.merck.com/product/usa/pi_circulars/r/recarbrio/recarbrio_pi.pdf