Intermittent preventive treatment of malaria in pregnancy with mefloquine in HIV-negative women: a multicentre randomized controlled trial

Raquel González, Ghyslain Mombo-Ngoma, Smaïla Ouédraogo, Mwaka A Kakolwa, Salim Abdulla, Manfred Accrombessi, John J Aponte, Daisy Akerey-Diop, Arti Basra, Valérie Briand, Meskure Capan, Michel Cot, Abdunoor M Kabanywanyi, Christian Kleine, Peter G Kremsner, Eusebio Macete, Jean-Rodolphe Mackanga, Achille Massougbodgi, Alfredo Mayor, Arsenio Nhacolo, Golbahar Pahlavan, Michael Ramharter, María Rupérez, Esperança Sevene, Anifa Vala, Rella Zoleko-Manego, Clara Menéndez, Raquel González, Ghyslain Mombo-Ngoma, Smaïla Ouédraogo, Mwaka A Kakolwa, Salim Abdulla, Manfred Accrombessi, John J Aponte, Daisy Akerey-Diop, Arti Basra, Valérie Briand, Meskure Capan, Michel Cot, Abdunoor M Kabanywanyi, Christian Kleine, Peter G Kremsner, Eusebio Macete, Jean-Rodolphe Mackanga, Achille Massougbodgi, Alfredo Mayor, Arsenio Nhacolo, Golbahar Pahlavan, Michael Ramharter, María Rupérez, Esperança Sevene, Anifa Vala, Rella Zoleko-Manego, Clara Menéndez

Abstract

Background: Intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) is recommended by WHO to prevent malaria in African pregnant women. The spread of SP parasite resistance has raised concerns regarding long-term use for IPT. Mefloquine (MQ) is the most promising of available alternatives to SP based on safety profile, long half-life, and high efficacy in Africa. We evaluated the safety and efficacy of MQ for IPTp compared to those of SP in HIV-negative women.

Methods and findings: A total of 4,749 pregnant women were enrolled in an open-label randomized clinical trial conducted in Benin, Gabon, Mozambique, and Tanzania comparing two-dose MQ or SP for IPTp and MQ tolerability of two different regimens. The study arms were: (1) SP, (2) single dose MQ (15 mg/kg), and (3) split-dose MQ in the context of long lasting insecticide treated nets. There was no difference on low birth weight prevalence (primary study outcome) between groups (360/2,778 [13.0%]) for MQ group and 177/1,398 (12.7%) for SP group; risk ratio [RR], 1.02 (95% CI 0.86-1.22; p=0.80 in the ITT analysis). Women receiving MQ had reduced risks of parasitemia (63/1,372 [4.6%] in the SP group and 88/2,737 [3.2%] in the MQ group; RR, 0.70 [95% CI 0.51-0.96]; p=0.03) and anemia at delivery (609/1,380 [44.1%] in the SP group and 1,110/2743 [40.5%] in the MQ group; RR, 0.92 [95% CI 0.85-0.99]; p=0.03), and reduced incidence of clinical malaria (96/551.8 malaria episodes person/year [PYAR] in the SP group and 130/1,103.2 episodes PYAR in the MQ group; RR, 0.67 [95% CI 0.52-0.88]; p=0.004) and all-cause outpatient attendances during pregnancy (850/557.8 outpatients visits PYAR in the SP group and 1,480/1,110.1 visits PYAR in the MQ group; RR, 0.86 [0.78-0.95]; p=0.003). There were no differences in the prevalence of placental infection and adverse pregnancy outcomes between groups. Tolerability was poorer in the two MQ groups compared to SP. The most frequently reported related adverse events were dizziness (ranging from 33.9% to 35.5% after dose 1; and 16.0% to 20.8% after dose 2) and vomiting (30.2% to 31.7%, after dose 1 and 15.3% to 17.4% after dose 2) with similar proportions in the full and split MQ arms. The open-label design is a limitation of the study that affects mainly the safety assessment.

Conclusions: Women taking MQ IPTp (15 mg/kg) in the context of long lasting insecticide treated nets had similar prevalence rates of low birth weight as those taking SP IPTp. MQ recipients had less clinical malaria than SP recipients, and the pregnancy outcomes and safety profile were similar. MQ had poorer tolerability even when splitting the dose over two days. These results do not support a change in the current IPTp policy.

Trial registration: ClinicalTrials.gov NCT 00811421; Pan African Clinical Trials Registry PACTR 2010020001429343 Please see later in the article for the Editors' Summary.

Trial registration: ClinicalTrials.gov NCT00811421.

Conflict of interest statement

CM is a member of the Editorial Board of PLOS Medicine. The rest of coauthors have declared that no competing interests exist.

Figures

Figure 1. Trial profile (modified ITT cohort).
Figure 1. Trial profile (modified ITT cohort).
Figure 2. Birth weight distribution by study…
Figure 2. Birth weight distribution by study country and IPTp group.
Newborn weights not captured at birth but within the first week of life were estimated using a linear regression model.
Figure 3. Time to first episode of…
Figure 3. Time to first episode of clinical malaria. ITT cohort. Kaplan Meier graph.
Figure 4. Reported medication-related adverse events.
Figure 4. Reported medication-related adverse events.

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