A randomized controlled trial of chloroquine for the treatment of dengue in Vietnamese adults

Vianney Tricou, Nguyet Nguyen Minh, Toi Pham Van, Sue J Lee, Jeremy Farrar, Bridget Wills, Hien Tinh Tran, Cameron P Simmons, Vianney Tricou, Nguyet Nguyen Minh, Toi Pham Van, Sue J Lee, Jeremy Farrar, Bridget Wills, Hien Tinh Tran, Cameron P Simmons

Abstract

Background: There is currently no licensed antiviral drug for treatment of dengue. Chloroquine (CQ) inhibits the replication of dengue virus (DENV) in vitro.

Methods and findings: A double-blind, randomized, placebo-controlled trial of CQ in 307 adults hospitalized for suspected DENV infection was conducted at the Hospital for Tropical Diseases (Ho Chi Minh City, Vietnam) between May 2007 and July 2008. Patients with illness histories of 72 hours or less were randomized to a 3-day course of CQ (n = 153) or placebo (n = 154). Laboratory-confirmation of DENV infection was made in 257 (84%) patients. The primary endpoints were time to resolution of DENV viraemia and time to resolution of DENV NS1 antigenaemia. In patients treated with CQ there was a trend toward a longer duration of DENV viraemia (hazard ratio (HR) = 0.80, 95% CI 0.62-1.05), but we did not find any difference for the time to resolution of NS1 antigenaemia (HR = 1.07, 95% CI 0.76-1.51). Interestingly, CQ was associated with a significant reduction in fever clearance time in the intention-to-treat population (HR = 1.37, 95% CI 1.08-1.74) but not in the per-protocol population. There was also a trend towards a lower incidence of dengue hemorrhagic fever (odds ratio = 0.60, PP 95% CI 0.34-1.04) in patients treated with CQ. Differences in levels of T cell activation or pro- or anti-inflammatory plasma cytokine concentrations between CQ- and placebo-treated patients did not explain the trend towards less dengue hemorrhagic fever in the CQ arm. CQ was associated with significantly more adverse events, primarily vomiting.

Conclusions: CQ does not reduce the durations of viraemia and NS1 antigenaemia in dengue patients. Further trials, with appropriate endpoints, would be required to determine if CQ treatment has any clinical benefit in dengue.

Trial registration: Current Controlled Trials number ISRCTN38002730.

Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Figure 1. Participant flow in the randomized…
Figure 1. Participant flow in the randomized controlled trial of CQ vs. Placebo.
Figure 2. Time to fever clearance.
Figure 2. Time to fever clearance.
Kaplan – Meier survival analysis of time to fever clearance by treatment group (CQ or placebo) and population; A) Intention to treat population and B) Per Protocol population. Three patients afebrile at enrollment developed fever later (1 in the CQ arm and 2 in the Placebo arm) and for the purposes of analysis were considered positive at the time of enrolment.
Figure 3. Time to resolution of viraemia.
Figure 3. Time to resolution of viraemia.
Kaplan – Meier survival analysis of time to resolution of plasma viraemia by treatment group (CQ or placebo) and population; A) Intention to treat population and B) Per Protocol population.
Figure 4. Time to negative NS1 antigenaemia.
Figure 4. Time to negative NS1 antigenaemia.
Kaplan – Meier survival analysis of time to resolution of NS1 antigenaemia by treatment group (CQ or placebo) and population; A) Intention to treat population and B) Per Protocol population. Two patients NS1 negative at enrollment were later positive (both in the CQ arm) and for the purposes of analysis were considered positive at the time of enrolment.
Figure 5. Surface phenotypes of CD4 +…
Figure 5. Surface phenotypes of CD4+ and CD8+ T cells in laboratory-confirmed dengue patients randomized to placebo or CQ.
The Box and Whisker plots show the median number and range (2.5–97.5 percentile) of percentages of surface-activated T cells in peripheral blood from CQ (n = 74) and Placebo (n = 73) treated laboratory-confirmed dengue patients at different time points. The median illness day (range) for enrolment samples was 2 (0–3) days, for hospital discharge was 6 (4–8) days and for follow-up was 15.5 (13–30) days. Shown are percentages of peripheral blood CD4+ T cells that were A) CD38+HLA-DR+, B) CD38+Ki67+, and C) Ki67+ HLA-DR+. Also shown are percentages of CD8+ T cells that were, D) CD38+, HLA-DR+, E) CD38+Ki67+, and F) Ki67+ HLA-DR+. The labels below the graphs indicate the time at which sample collection occurred.
Figure 6. Plasma concentrations of pro- and…
Figure 6. Plasma concentrations of pro- and anti-inflammatory cytokines in laboratory-confirmed dengue patients randomized to placebo or CQ.
The Box and Whisker plots show the median and range (2.5th–97.5th percentile) of plasma concentrations of A) IL-6, B) IL-8, C) IL-10, D) GM-CSF, E) IFN- γ, and F) TNF-α from DF and DHF patients treated with CQ or Placebo. The dashed line represents the assay limit of detection. Concentrations of IL-2 and IL-4 are not shown because they were below the limit of detection.

References

    1. WHO. Dengue: guidelines for diagnosis, treatment, prevention and control - New edition.: 2009. World Health Organization, Geneva.
    1. Vaughn DW, Green S, Kalayanarooj S, Innis BL, Nimmannitya S, et al. Dengue viremia titer, antibody response pattern, and virus serotype correlate with disease severity. J Infect Dis. 2000;181:2–9.
    1. Alcon S, Talarmin A, Debruyne M, Falconar A, Deubel V, et al. Enzyme-linked immunosorbent assay specific to Dengue virus type 1 nonstructural protein NS1 reveals circulation of the antigen in the blood during the acute phase of disease in patients experiencing primary or secondary infections. J Clin Microbiol. 2002;40:376–381.
    1. Chuansumrit A, Chaiyaratana W, Pongthanapisith V, Tangnararatchakit K, Lertwongrath S, et al. The use of dengue nonstructural protein 1 antigen for the early diagnosis during the febrile stage in patients with dengue infection. Pediatr Infect Dis J. 2008;27:43–48.
    1. Libraty DH, Young PR, Pickering D, Endy TP, Kalayanarooj S, et al. High circulating levels of the dengue virus nonstructural protein NS1 early in dengue illness correlate with the development of dengue hemorrhagic fever. J Infect Dis. 2002;186:1165–1168.
    1. Savarino A, Boelaert JR, Cassone A, Majori G, Cauda R. Effects of chloroquine on viral infections: an old drug against today's diseases? Lancet Infect Dis. 2003;3:722–727.
    1. Fedson DS. Confronting an influenza pandemic with inexpensive generic agents: can it be done? Lancet Infect Dis. 2008;8:571–576.
    1. Modis Y, Ogata S, Clements D, Harrison SC. Structure of the dengue virus envelope protein after membrane fusion. Nature. 2004;427:313–319.
    1. Yu IM, Zhang W, Holdaway HA, Li L, Kostyuchenko VA, et al. Structure of the immature dengue virus at low pH primes proteolytic maturation. Science. 2008;319:1834–1837.
    1. Navarro-Sanchez E, Altmeyer R, Amara A, Schwartz O, Fieschi F, et al. Dendritic-cell-specific ICAM3-grabbing non-integrin is essential for the productive infection of human dendritic cells by mosquito-cell-derived dengue viruses. EMBO Rep. 2003;4:723–728.
    1. Randolph VB, Winkler G, Stollar V. Acidotropic amines inhibit proteolytic processing of flavivirus prM protein. Virology. 1990;174:450–458.
    1. Cook JA, Randinitis EJ, Bramson CR, Wesche DL. Lack of a pharmacokinetic interaction between azithromycin and chloroquine. Am J Trop Med Hyg. 2006;74:407–412.
    1. Rengelshausen J, Burhenne J, Frohlich M, Tayrouz Y, Singh SK, et al. Pharmacokinetic interaction of chloroquine and methylene blue combination against malaria. Eur J Clin Pharmacol. 2004;60:709–715.
    1. Diebold SS, Kaisho T, Hemmi H, Akira S, Reis e Sousa C. Innate antiviral responses by means of TLR7-mediated recognition of single-stranded RNA. Science. 2004;303:1529–1531.
    1. Lund JM, Alexopoulou L, Sato A, Karow M, Adams NC, et al. Recognition of single-stranded RNA viruses by Toll-like receptor 7. Proc Natl Acad Sci U S A. 2004;101:5598–5603.
    1. Silva MC, Guerrero-Plata A, Gilfoy FD, Garofalo RP, Mason PW. Differential activation of human monocyte-derived and plasmacytoid dendritic cells by West Nile virus generated in different host cells. J Virol. 2007;81:13640–13648.
    1. Accapezzato D, Visco V, Francavilla V, Molette C, Donato T, et al. Chloroquine enhances human CD8+ T cell responses against soluble antigens in vivo. J Exp Med. 2005;202:817–828.
    1. Jang CH, Choi JH, Byun MS, Jue DM. Chloroquine inhibits production of TNF-alpha, IL-1beta and IL-6 from lipopolysaccharide-stimulated human monocytes/macrophages by different modes. Rheumatology (Oxford) 2006;45:703–710.
    1. Weber SM, Levitz SM. Chloroquine interferes with lipopolysaccharide-induced TNF-alpha gene expression by a nonlysosomotropic mechanism. J Immunol. 2000;165:1534–1540.
    1. Mackenzie AH. Antimalarial drugs for rheumatoid arthritis. Am J Med. 1983;75:48–58.
    1. Wozniacka A, McCauliffe DP. Optimal use of antimalarials in treating cutaneous lupus erythematosus. Am J Clin Dermatol. 2005;6:1–11.
    1. Avina-Zubieta JA, Galindo-Rodriguez G, Newman S, Suarez-Almazor ME, Russell AS. Long-term effectiveness of antimalarial drugs in rheumatic diseases. Ann Rheum Dis. 1998;57:582–587.
    1. Kyburz D, Brentano F, Gay S. Mode of action of hydroxychloroquine in RA-evidence of an inhibitory effect on toll-like receptor signaling. Nat Clin Pract Rheumatol. 2006;2:458–459.
    1. Bojang KA, Schneider G, Forck S, Obaro SK, Jaffar S, et al. A trial of Fansidar plus chloroquine or Fansidar alone for the treatment of uncomplicated malaria in Gambian children. Trans R Soc Trop Med Hyg. 1998;92:73–76.
    1. WHO. Guidelines for the treatment of malaria. 2006
    1. WHO. Dengue Hemorrhagic Fever, Diagnosis, Treatment, and Control. 1997
    1. Hang VT, Nguyet NM, Trung DT, Tricou V, Yoksan S, et al. Diagnostic Accuracy of NS1 ELISA and Lateral Flow Rapid Tests for Dengue Sensitivity, Specificity and Relationship to Viraemia and Antibody Responses. PLoS Negl Trop Dis. 2009;3:e360.
    1. Simmons CP, Popper S, Dolocek C, Chau TN, Griffiths M, et al. Patterns of host genome-wide gene transcript abundance in the peripheral blood of patients with acute dengue hemorrhagic fever. J Infect Dis. 2007;195:1097–1107.
    1. De Lamballerie X, Boisson V, Reynier JC, Enault S, Charrel RN, et al. On chikungunya acute infection and chloroquine treatment. Vector Borne Zoonotic Dis. 2008;8:837–839.
    1. Jessie K, Fong MY, Devi S, Lam SK, Wong KT. Localization of dengue virus in naturally infected human tissues, by immunohistochemistry and in situ hybridization. J Infect Dis. 2004;189:1411–1418.
    1. Falconar AK. The dengue virus nonstructural-1 protein (NS1) generates antibodies to common epitopes on human blood clotting, integrin/adhesin proteins and binds to human endothelial cells: potential implications in haemorrhagic fever pathogenesis. Arch Virol. 1997;142:897–916.
    1. Flamand M, Megret F, Mathieu M, Lepault J, Rey FA, et al. Dengue virus type 1 nonstructural glycoprotein NS1 is secreted from mammalian cells as a soluble hexamer in a glycosylation-dependent fashion. J Virol. 1999;73:6104–6110.
    1. Tricou V, Vu HT, Quynh NV, Nguyen CV, Tran HT, et al. Comparison of two dengue NS1 rapid tests for sensitivity, specificity and relationship to viraemia and antibody responses. BMC Infect Dis. 2010;10:142.
    1. Ramirez AH, Moros Z, Comach G, Zambrano J, Bravo L, et al. Evaluation of dengue NS1 antigen detection tests with acute sera from patients infected with dengue virus in Venezuela. Diagn Microbiol Infect Dis. 2009;65:247–253.
    1. Zainah S, Wahab AH, Mariam M, Fauziah MK, Khairul AH, et al. Performance of a commercial rapid dengue NS1 antigen immunochromatography test with reference to dengue NS1 antigen-capture ELISA. J Virol Methods. 2009;155:157–160.
    1. Tarimo DS, Minjas JN, Bygbjerg IC. Sulfadoxine-pyrimethamine monotherapy in Tanzanian children gives rapid parasite clearance but slow fever clearance that is improved by chloroquine in combination therapy. Trop Med Int Health. 2002;7:592–598.
    1. Hugosson E, Tarimo D, Troye-Blomberg M, Montgomery SM, Premji Z, et al. Antipyretic, parasitologic, and immunologic effects of combining sulfadoxine/pyrimethamine with chloroquine or paracetamol for treating uncomplicated Plasmodium falciparum malaria. Am J Trop Med Hyg. 2003;69:366–371.
    1. Lee J, Chuang TH, Redecke V, She L, Pitha PM, et al. Molecular basis for the immunostimulatory activity of guanine nucleoside analogs: activation of Toll-like receptor 7. Proc Natl Acad Sci U S A. 2003;100:6646–6651.
    1. Zou W, Amcheslavsky A, Bar-Shavit Z. CpG oligodeoxynucleotides modulate the osteoclastogenic activity of osteoblasts via Toll-like receptor 9. J Biol Chem. 2003;278:16732–16740.
    1. Blatteis CM, Li S, Li Z, Feleder C, Perlik V. Cytokines, PGE2 and endotoxic fever: a re-assessment. Prostaglandins Other Lipid Mediat. 2005;76:1–18.
    1. Jeong JY, Choi JW, Jeon KI, Jue DM. Chloroquine decreases cell-surface expression of tumour necrosis factor receptors in human histiocytic U-937 cells. Immunology. 2002;105:83–91.
    1. Dejnirattisai W, Duangchinda T, Lin CL, Vasanawathana S, Jones M, et al. A complex interplay among virus, dendritic cells, T cells, and cytokines in dengue virus infections. J Immunol. 2008;181:5865–5874.
    1. Rothman AL. Immunology and immunopathogenesis of dengue disease. Adv Virus Res. 2003;60:397–419.
    1. Noble CG, Chen YL, Dong H, Gu F, Lim SP, et al. Strategies for development of dengue virus inhibitors. Antiviral Res 2010
    1. Stevens AJ, Gahan ME, Mahalingam S, Keller PA. The medicinal chemistry of dengue fever. J Med Chem. 2009;52:7911–7926.

Source: PubMed

Sponsors en medewerkers

Medische omstandigheden

Geneesmiddelinterventies

3
Abonneren