Open Access Research

Glucose-6-phosphate dehydrogenase deficiency, chlorproguanil-dapsone with artesunate and post-treatment haemolysis in African children treated for uncomplicated malaria

Carine Van Malderen18*, Jean-Pierre Van Geertruyden2, Sonia Machevo3, Raquel González34, Quique Bassat34, Ambrose Talisuna56, Adoke Yeka5, Carolyn Nabasumba7, Patrice Piola7, Atwine Daniel7, Eleanor Turyakira7, Pascale Forret8, Chantal Van Overmeir8, Harry Van Loen8, Annie Robert9 and Umberto D’ Alessandro8

Author Affiliations

1 Faculté de pharmacie et des sciences biomédicales, Université catholique de Louvain, Brussels, Belgium

2 International Health Unit, University of Antwerp, Antwerp, Belgium

3 Centro de Investigação em Saúde da Manhiça (CISM), Maputo, Mozambique

4 Barcelona Centre for International Health Research (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain

5 Department of Epidemiology and Biostatistics, Makerere University School of Public Health, P.O Box 7072, Kampala, Uganda

6 Malaria Public Health and Epidemiology Group (MPHEG), University of Oxford-KEMRI-Wellcome Trust Research Program, Nairobi, Kenya

7 Epicentre Mbarara Research Base, Mbarara, Uganda

8 Institute of Tropical Medicine, Antwerp, Belgium

9 Université catholique de Louvain. Brussels Health Sector – Institut de recherche expérimentale et clinique Pôle, Epidémiologie et biostatistique B1.30.13, Brussels, Belgium

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Malaria Journal 2012, 11:139  doi:10.1186/1475-2875-11-139

Published: 30 April 2012

Abstract

Background

Malaria is a leading cause of mortality, particularly in sub-Saharan African children. Prompt and efficacious treatment is important as patients may progress within a few hours to severe and possibly fatal disease. Chlorproguanil-dapsone-artesunate (CDA) was a promising artemisinin-based combination therapy (ACT), but its development was prematurely stopped because of safety concerns secondary to its associated risk of haemolytic anaemia in glucose-6-phosphate dehydrogenase (G6PD)-deficient individuals. The objective of the study was to assess whether CDA treatment and G6PD deficiency are risk factors for a post-treatment haemoglobin drop in African children <5 years of age with uncomplicated malaria.

Methods

This case–control study was performed in the context of a larger multicentre randomized clinical trial comparing safety and efficacy of four different ACT in children with uncomplicated malaria. Children, who after treatment experienced a haemoglobin drop ≥2 g/dl (cases) within the first four days (days 0, 1, 2, and 3), were compared with those without an Hb drop (controls). Cases and controls were matched for study site, sex, age and baseline haemoglobin measurements. Data were analysed using a conditional logistic regression model.

Results

G6PD deficiency prevalence, homo- or hemizygous, was 8.5% (10/117) in cases and 6.8% (16/234) in controls (p = 0.56). The risk of a Hb drop ≥2 g/dl was not associated with either G6PD deficiency (adjusted odds ratio (AOR): 0.81; p = 0.76) or CDA treatment (AOR: 1.28; p = 0.37) alone. However, patients having both risk factors tended to have higher odds (AOR: 11.13; p = 0.25) of experiencing a Hb drop ≥2 g/dl within the first four days after treatment, however this finding was not statistically significant, mainly because G6PD deficient patients treated with CDA were very few. In non-G6PD deficient individuals, the proportion of cases was similar between treatment groups while in G6PD-deficient individuals, haemolytic anaemia occurred more frequently in children treated with CDA (56%) than in those treated with other ACT (29%), though the difference was not significant (p = 0.49).

Conclusion

The use of CDA for treating uncomplicated malaria may increase the risk of haemolytic anaemia in G6PD-deficient children.

Keywords:
Malaria; Artemisinin-based combination therapy; Chlorproguanil-dapsone; Artesunate; Glucose-6-phosphate dehydrogenase deficiency; Uganda; Mozambique; Restriction fragment length polymorphisms; Conditional logistic regression