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Table 1 Pharmacology of selected candidates for IPTp

From: Intermittent preventive treatment for malaria in pregnancy in Africa: What's new, what's needed?

Drug Mode of action Elimination half life Advantages/disadvantages
Artemether Inhibits falciparum sarcoplasmic-endoplasmic reticulum calcium ATPase 3 – 7 h (converted to DHA) Appears safe in the second and third trimester
Widely available in a cheap, fixed dose co-formulation with lumefantrine (Coartem©/Riamet©)
Artemisinin Inhibits falciparum sarcoplasmic-endoplasmic reticulum calcium ATPase 2 – 3 h (converted to DHA) Appears safe in the second and third trimester
Fixed dose co-formulations unavailable
Artesunate Inhibits falciparum sarcoplasmic-endoplasmic reticulum calcium ATPase 2 – 5 mins (converted to DHA) Appears safe in the second and third trimester
Fixed dose co-formulations unavailable
Atovaquone Selective inhibitor of parasite mitochondrial metabolism 48 – 72 h Appears safe in the third trimester
Available only in fixed dose co-formulation with proguanil (Malarone©), which is expensive outside specific donation programmes
Azithromycin Exact mode of action unknown 68 h Safe in all trimesters where has been used extensively in STI treatment
Expensive; fixed dose co-formulations unavailable
Chlorproguanil Folic acid antagonist (inhibits dihydrofolate reductase) 32 h Cheap; appears safe in the third trimester and likely to be safe earlier in pregnancy based on experience with proguanil
Available only in fixed dose co-formulation with dapsone (Lapdap©), which WHO have recommended be used with caution in areas of high G6PD deficiency
Dapsone Folic acid antagonist (inhibits dihydropteroate synthase) 31 h Cheap; appears safe in the third trimester
Available in fixed dose co-formulation with chlorproguanil (Lapdap©), which WHO have recommended be used with caution in areas of high G6PD deficiency
Dihydroartemisinin (DHA) Inhibits falciparum sarcoplasmic-endoplasmic reticulum calcium ATPase 40 – 60 mins Likely to be safe in the second and third trimester
Available in SE Asia, China in a cheap fixed dose co-formulation with piperaquine (Artekin©/Eurartekin©)
Lumefantrine Inhibits metabolism of haem within parasite acid food vacuole 4 – 6 days Safety in children and adults established but no data available in pregnancy
Widely available in a cheap [through WHO pricing agreement], fixed dose co-formulation with artemether (Coartem©/Riamet©)
Mefloquine Exact mode of action unknown 2 – 4 weeks Appears safe in the second and third trimester
Expensive; fixed dose co-formulations unavailable
Piperaquine Inhibits detoxification of haem 3 – 4 weeks Safety in children and adults established but no data available in pregnancy
Available in SE Asia, China in a cheap, fixed dose co-formulation with dihydroartemisinin (Artekin©/Eurartekin©)
Proguanil Folic acid antagonist (inhibits dihydrofolate reductase) 12 – 21 h Cheap; appears safe in all trimesters
Available alone or in fixed dose co-formulation with atovaquone (Malarone©), which is expensive outside specific donation programmes
Pyrimethamine Folic acid antagonist (inhibits dihydrofolate reductase) 100 h Cheap; widely available in fixed-dose combination with sulphadoxine
Increasing resistance particularly in East Africa
Sulphadoxine Folic acid antagonist (inhibits dihydropteroate synthase) 200 h Cheap; widely available in fixed-dose combination with pyrimethamine
Increasing resistance particularly in East Africa