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Table 1 Overview and summary of included studies

From: The influence of pregnancy on the pharmacokinetic properties of artemisinin combination therapy (ACT): a systematic review

Author (year)

Country

(time period)

Type of study

Study population

Drug (dose)

Number of women

Pharmacokinetic analytic methodology

Pharmacokinetic variables

Remarks

Benjamin (2015) [56]

Papua New Guinea (not reported)

Clinical trial

Pregnant women with an EGA >14 weeks without severe malaria or other significant comorbidities and age-matched non-pregnant women without severe malaria and significant comorbidities

DHA-PPQ (7/58 mg/kg q.d. for 3 days)

OR

PPQ (1280 mg p.o. q.d. for 3 days) + SP (25 mg/kg once with first dose of PPQ)

32 pregnant women

33 non-pregnant women

Compartmental

CL/F, Vc/F, Vp/F, t1/2, AUC0-∞

 

Valea (2014) [33]

Burkina Faso (Sept 2008–Jan 2009)

Clinical trial

Pregnant women in second and third trimester of pregnancy with uncomplicated Plasmodium falciparum mono-infection and matched non-pregnant women with P. falciparum infection

Mefloquine + Artesunate (8/3.6 mg/kg q.d. for 3 days)

24 pregnant women

24 non-pregnant women

Non-compartmental analysis

Total dose, Cmax, Cmax/dose, Tmax, CL/F, V/F, t1/2, AUC0-last, AUC0-∞, AUC-∞/dose

 

Tarning (2013) [37]

Uganda (Oct 2006 –May 2009)

Clinical trial

Pregnant women with uncomplicated P. falciparum infection with an EGA >13 weeks and non-pregnant women matched for history of fever, temp. >37.5 °C, smoking status and the level of parasitaemia

AL (80/480 mg p.o. b.i.d. for 3 days) + 200 ml milk tea

OR

Quinine (10 mg/kg p.o. t.i.d. for 7 days)

AL:

21 pregnant women

Lumefantrine:

26 pregnant women

17 non-pregnant women

Quinine:

21 pregnant women

Non-compartmental analysis

Total dose, Cmax, Cmax/dose, Tmax, CL/F, V/F, t1/2, AUC0-last, AUC0-∞, AUC-∞/dose, AUC72-last, AUC72-∞, day 7 concentration

Results for artemether and dihydroartemisinin are reported by Tarning (2012-2) [38]

Nested in larger efficacy/safety study by Piola (2010) [19]

Adam (2012) [55]

Sudan (Aug 2007–Feb 2008)

Clinical trial

Pregnant women in 2nd and 3th trimester of pregnancy (EGA 15–40 weeks) with uncomplicated P. falciparum malaria and Hb > 7 g/dL. and age- and weight-matched non-pregnant women with uncomplicated P. falciparum malaria

DHA-PPQ (2.4/20 mg/kg q.d. for 3 days)

12 pregnant women

12 non-pregnant women

Non-compartmental analysis

Total dose, Cmax (after dose 1, 2 and 3), Tmax (after dose 1, 2 and 3), CL/F, V/F, T1/2, AUC0-last, AUC0-∞, AUC-∞/dose, AUC0-24, AUC24-48, AUC48-72, AUC72-∞, day 7 and 14 concentration

Based on the same clinical study as Hoglund (2012) [53]

Hoglund (2012) [53]

Sudan (Aug 2007–Feb 2008)

Clinical trial

Pregnant women in 2nd and 3rd trimester of pregnancy (EGA 15–40 weeks) with uncomplicated P. falciparum malaria and Hb > 7 g/dL. and age- and weight-matched non-pregnant women with uncomplicated P. falciparum malaria

DHA-PPQ (2.4/20 mg/kg q.d. for 3 days)

12 pregnant women

12 non-pregnant women

Compartmental analysis

Cmax, Tmax, t1/2, AUC 48-90, AUC0-90, day 7 and 28 concentration

Based on the same clinical study as Adam (2012) [55]

McGready (2012) [51]

Thailand (April 2008–March 2008)

Clinical trial

Pregnant women in second and third trimester of pregnancy (Ht > 25 %) with uncomplicated P. falciparum malaria and the same women post partum (3 months) without malaria

Group 1

Artesunate (4 mg/kg) i.v. q.d. on day 0; artesunate (4 mg/kg) p.o q.d. on day 1–6

Group 2

Artesunate (4 mg/kg) p.o. q.d. on day 0; artesunate (4 mg/kg) i.v. q.d. on day 1, artesunate (4 mg/kg) p.o. q.d. on day 2–6)

20 pregnant women

Group 1: 10 women

Group 2: 10 women

14 postpartum women

Non-compartmental analysis

Total dose, Cmax, Cmax/dose, Tmax, CL/F, V/F, t1/2, AUC0-∞, AUC0-∞/dose

 

Tarning (2012-1) [34]

Thailand (June 2008–Dec 2008)

Clinical trial

Pregnant women in second and third trimester of pregnancy (Ht > 25 %) with uncomplicated P. falciparum malaria and matched non-pregnant women with P. falciparum malaria

DHA-PPQ (6.4/51.2 mg/kg p.o. q.d. for 3 days)

24 pregnant women

24 non-pregnant women

Compartmental analysis

Cmax, Tmax, CL/F, V/F, t1/2, AUC0-24, AUC0-92, day 7 and 28 concentration

Based on the same clinical study as Rijken (2011-2) [10]

Tarning (2012-2) [36]

Uganda (March 2008–Sept 2008)

Clinical trial

Pregnant women in second and third trimester of pregnancy (EGA > 13 weeks) with uncomplicated P. falciparum malaria

AL (80/480 mg p.o. b.i.d. for 3 days) + 200 ml milk tea

21 pregnant women

Compartmental analysis

Total dose, Cmax, Tmax, CL/F, V/F, t1/2, AUC60-last, AUC/dose

Nested in larger efficacy study by Piola (2010) [19]

Tarning (2012-3) [38]

Thailand (Oct 2007–May 2008)

Clinical trial

Pregnant women in second and third trimesters of pregnancy with acute P. vivax mono-infection and same women post partum (84–173 days) with (n = 7) or without (n = 12) P. vivax malaria

Amodiaquine (10 mg/kg p.o. q.d. for 3 days)

27 pregnant women

19 postpartum women

Compartmental analysis

Cmax, Tmax, t1/2, AUC-last

Based on the same clinical study as Rijken (2011-1) [40]

Morris (2011) [46]

DRC (May 2007–Nov 2008)

Clinical trial

Pregnant women in second (22–26 weeks) and third (32–36 weeks) trimester of pregnancy with asymptomatic P. falciparum parasitaemia (200–300,000 p/µL; Ht > 30 %) and same women post partum (3 months) with (n = 2) or without (n = 24) P. falciparum parasitaemia and non-pregnant female volunteers with asymptomatic P. falciparum parasitaemia (200–300,000 p/µL)

Artesunate (200 mg) p.o. q.d. on day 0 + SP (1725 mg) p.o. q.d. on day 1

26 pregnant women

26 postpartum women

25 non-pregnant women

Compartmental analysis

T1/2, CL/F, V/F

Based on the same clinical study as Onyamboko (2011) [41]

Onyamboko (2011) [41]

DRC (May 2007–Nov 2008)

Clinical trial

Pregnant women in second (22–26 weeks) and third (32–36 weeks) trimester of pregnancy with asymptomatic P. falciparum parasitaemia (200–300,000 p/µL; Ht > 30 %) and same women post partum (3 months) with (n = 2) or without (n = 24) P. falciparum parasitaemia and non-pregnant female volunteers with asymptomatic P. falciparum parasitaemia (200–300,000 p/µL)

Artesunate (200 mg) p.o. q.d. on day 0 + SP (1725 mg) p.o. q.d. on day 1

26 pregnant women

26 postpartum women

25 non-pregnant women

Non-compartmental analysis

Total dose, Cmax, Tmax, CL/F, V/F, t1/2, AUC0-∞

Based on the same clinical study as Morris (2011) [46]

Rijken (2011-1) [40]

Thailand (Oct 2007–May 2008)

Clinical trial

Pregnant women in second and third trimesters of pregnancy with acute P. vivax mono-infection and same women post partum (84–173 days) with (n = 7) or without (n = 12) P. vivax malaria

Amodiaquine (10 mg/kg p.o. q.d. for 3 days)

24 pregnant women

18 postpartum women

Non-compartmental analysis

Total dose, Cmax, Cmax/dose, Tmax, CL/F, V/F, t1/2, AUC0-last, AUC0-∞, AUC0-∞/dose, day 7 concentration

Based on the same clinical study as Tarning (2012-3) [38]

Rijken (2011-2) [39]

Thailand (June 2008–Dec 2008)

Clinical trial

Pregnant women in second and third trimester of pregnancy (Ht < 25 %) with uncomplicated P. falciparum malaria and matched non-pregnant women with P. falciparum malaria

DHA-PPQ (6.4/51.2 mg/kg p.o. q.d. for 3 days)

24 pregnant women

24 non-pregnant women

Non-compartmental analysis

Total dose, Cmax, Cmax/dose, CL/F, V/F, t1/2, AUC0-last, AUC0-∞, AUC0-∞/dose, AUC0-24, AUC24-48, AUC48-72, AUC72-∞, day 7, 14 and 28 concentration

Based on the same clinical study as Tarning 2012-1 [34]

Nyunt (2010) [42]

Mali, Mozambique, Sudan and Zambia (not reported)

Clinical trial

Pregnant women with an EGA 15–36 weeks without P. falciparum parasitaemia (Hb > 8 g/dL) and same women post partum (6–43 weeks) without P. falciparum parasitaemia and with Hb > 8 g/dL (Mali and Zambia)/postpartum women (>6 months) without P. falciparum parasitaemia and with Hb > 8 g/dL (Mozambique and Sudan) and matched non-pregnant women with acute uncomplicated falciparum malaria (Mozambique)

SP (1500/75 mg p.o. once)

97 pregnant women

77 postpartum women

Compartmental analysis

Total dose, Cmax, CL/F, V/F, t1/2, AUC0-∞, day 7 concentration

 

Piola (2010) [19]

Uganda (Oct 2006–May 2009)

Clinical trial

Pregnant women with uncomplicated P. falciparum infection (<250,000 p/µL) with an EGA > 13 weeks and Hb > 7 g/dL

AL (80/480 mg p.o. b.i.d. for 3 days) + 200 ml milk

97 pregnant women

Non-compartmental analysis

Day 7 concentration

Based on the same clinical study as Tarning (2012-2) [36] and Tarning (2013) [37]

Karunajeewa (2009) [52]

Papua New Guinee (Feb 2006–July 2006)

Clinical trial

Pregnant women in second or third trimester of pregnancy without severe malaria (n = 17: P. falciparum/P. vivax/P. malariae parasitaemia; n = 13: no parasitaemia) and matched non-pregnant women (n = 9: falciparum/vivax/malariae parasitaemia; n = 21: no parasitaemia)

SP (1500/75 mg p.o. once) + Chloroquine (1350 mg p.o. q.d. for 3 days)

30 pregnant women

30 non-pregnant women

Compartmental analysis

CL/F, V/F, t1/2, AUC0-∞

 

Tarning (2009) [35]

Thailand (not reported)

Clinical trial

Pregnant women in second or third trimester of pregnancy with uncomplicated symptomatic P. falciparum malaria

AL (80/480 mg p.o. b.i.d. for 3 days) + 200–250 ml chocolate milk (6–7 g fat)

103 pregnant women

Compartmental analysis

Total dose, CL/F, V/F, day 7 concentration

Nested in larger efficacy -/safety study by McGready (2008) [18]

McGready (2008) [18]

Thailand (April 2004–Aug 2006)

Clinical trial

Pregnant women in second or third trimester of pregnancy with acute uncomplicated P. falciparum malaria

AL (80/480 mg p.o. b.i.d. for 3 days) + 250 ml chocolate milk (7 g fat)

85 pregnant women

Non-compartmental analysis

Day 7 concentration

Based on the same clinical study as McGready (2006-2) [49] and Tarning (2009) [35]

Green (2007) [54]

Kenya (1999–2000)

Clinical trial

Primi- and secondi gravid women with uncomplicated singleton pregnancies with EGA 16–28 weeks and Hb > 8 g/dL without symptomatic malaria (n = 11: parasitaemic; n = 22: aparasitaemic) and same women post partum (2–3 months) without symptomatic malaria (n = 1: parasitaemic; n = 10: aparasitaemic)

SP (1500/75 mg p.o. once)

33 pregnant women

16 HIV-positive

17 HIV-negative

11 postpartum women

6 HIV-positive

5 HIV-negative

Compartmental analysis

CL/F, V/F, t1/2, AUC0-∞

 

McGready (2006-1) [47]

Thailand (Oct 2000–July 2001)

Clinical trial

Pregnant women in second or third trimester of pregnancy with recrudescent uncomplicated P. falciparum malaria after 7-day quinine treatment and Ht > 25 %

Artesunate-AP (4/20/8 mg/kg p.o. q.d. for 3 days) + 200 ml chocolate milk (8 % fat)

24

Non-compartmental and compartmental analysis

Total dose, Cmax, Tmax, CL/F, V/F, t1/2, AUC48-72

 

McGready (2006-2) [49]

Thailand (April 2004–Aug 2004)

Clinical trial

Pregnant women in the second and third trimester of pregnancy with recrudescent uncomplicated multi-drug resistant P. falciparum malaria after 7-day quinine treatment

AL (80/480 mg p.o. b.i.d. for 3 days) + 250 ml chocolate milk (7 g fat)

13 pregnant women

Non-compartmental and compartmental analysis

Total dose, Cmax, Tmax, CL/F, V/F, t1/2, AUC0-24, AUC 60-84, AUC/dose

 

Na Bangchang (2005) [22]

Thailand (Nov 2000–April 2001)

Clinical trial

Pregnant women in third trimester of pregnancy with acute symptomatic P. falciparum mono-infection and Hb > 8 g/dL

AP (1000/400 mg p.o. q.d. for 3 days)

26 pregnant women

Compartmental analysis

Cmax, Tmax, AUC0-∞, PG-CG ratio

 

McGready (2003-1) [23]

Thailand (not reported)

Clinical trial

Pregnant women in second or third trimester of pregnancy with recrudescent multi-drug resistant uncomplicated P. falciparum malaria after 7-day quinine treatment and Ht > 25 %

Artesunate-AP (4/20/8 mg/kg p.o. q.d. for 3 days) + 300 ml chocolate milk (8 % fat)

24 pregnant women

Non-compartmental and compartmental analysis

Cmax, Tmax, CL/F, V/F, AUC0-∞, AUC48-∞

 

McGready (2003-2) [24]

Thailand (not reported)

Clinical trial

Healthy pregnant women with an EGA > 35 weeks and same women post partum (>2 months)

Proguanil (200 mg p.o. once)

45 pregnant women

45 postpartum women

Non-compartmental analysis

Total dose, Cmax (plasma and urine), 6 h concentration (plasma and urine)

 

Na Bangchang (1994) [44]

Thailand (Sept 1986–June 1988)

Clinical trial

Pregnant women in first (n = 2) and third (n = 7) trimester of pregnancy with P. falciparum parasitaemia and non-pregnant women matched for age with P. falciparum parasitaemia

Mefloquine (15 mg/kg)

9 pregnant women

8 non-pregnant women

Compartmental analysis

Total dose, Cmax, Tmax, CL/F, V/F, t1/2

 

Wangboonskul (1993) [32]

Thailand (not reported)

Clinical trial

Pregnant women in third trimester of pregnancy without P. falciparum malaria and same women post partum (>2 months) without P. falciparum malaria and healthy adult male volunteers without P. falciparum malariaa

Proguanil (200 mg p.o. once)

10 pregnant women

4 postpartum women

9 male patientsa

Compartmental analysis

Cmax, Tmax, CL/F, t1/2, AUC

 

Nosten (1990) [43]

Thailand (not reported)

Clinical trial

Pregnant women in third trimester of pregnancy

Group 1:

Mefloquine (250 mg per week)

Group 2:

Mefloquine (125 mg per week)

20 pregnant women

Compartmental analysis

Cmax, Tmax, CL/F, t1/2, AUC

 
  1. q.d. once a day, b.i.d. twice a day, t.i.d. three times a day, p.o. per os (oral), i.v. intravenous, AL artemether-lumefantrine, DHA-PPQ dihydroartemisinin-piperaquine, SP sulfadoxine-pyrimethamine, AP atovaquone-proguanil, PG proguanil, CG cycloguanil, C max maximum concentration after administration, T max time to maximum concentration after administration, CL/F oral clearance, V/F apparent volume of distribution, Vc/F central volume of distribution, Vp/F peripheral volume of distribution, T 1/2 half-life, AUC area under the curve (exposure), Hb haemoglobin, Ht haematocrit
  2. aData for male subjects were included from a previous study for comparison [60]