Rectal artemether versus intravenous quinine for the treatment of cerebral malaria in children in Uganda: randomised clinical trial
BMJ 2005; 330 doi: https://doi.org/10.1136/bmj.330.7487.334 (Published 10 February 2005) Cite this as: BMJ 2005;330:334
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The authors should describe clinical condition as far as parasitemia is concerned. Artemether is definitely better, as proved by various studies, however, its cost and availability is limited. Hence, Quinine is the drug of choice in cerebral malaria. if child continues to have symptoms and clearance of parasitemia is poor or not at all, it is always advisable to start artemether. Rectal artemether may not be acceptable to older children. However, it is definitely going to be beneficial in children presenting in shock stage.
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To begin with, I congratulate Dr(s) Aceng R, Byarugaba J & Prof Tumwine upen continuely maintaining a forward fight against one of the most deadlest killers of children in subsaharan Africa, AIDS aside.
Following the decision by the MoH, Uganda, together with its WHO partners to change the firstline treatment of Malaria from the SP/CQ combination to Artemesin Combination Therapy (ART),there is no doubt that more research needs to be done in the direction of ACTs--and this is but one.
As a medical person leaving in Uganda, I have personally fallen ill over several occasions from malaria, but the thought of taking SP/CQ or quinine breaks my heart--the side effects are dreadful. For instance, there was a time when the pruritis from the CQ could keep me indoors for fear of being seen scratch myself in rare perineal areas (not that we all aint gat them). So after this ACTs advent, I have always had objections to prescibing SP/CQ or quinine to any of my patients.
So should the rights of these infants that cant complain be honored, and my advice to the Ugandan ministry of Health would be (glancing at these results) to rush to make this a policy--RECTAL ARTEMETHER for severe malaria in children.
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I would like to ask if institional review board approval was requested and given for this study as I cannot find it stated in the article. Thank you, Desireee Lie, Clinical Professor
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EDITOR- Jane Ruth Aceng’s article1 on the efficacy of rectal artemether for cerebral malaria in children is a useful revelation. There have been reports of delayed parasite clearance in cerebral malaria with quinine2. Under such circumstances rectal artemether is a perfect choice either alone or in combination .Various studies corroborate this finding with intramuscular artemether.It is much easier to administer a drug per rectally in children especially in third world settings where IV administration can be a problem.Artemether is not available as rectal suppositories in Pakistan but multinational brands would not be affordable for a population like ours.
Artemether is also a valuable drug in areas like Sudan where resistance to P. falciparum is growing3. The side effect profile of artemether is also minimal4.
In our opinion random blood sugar evaluation should have been done before labeling children as having cerebral malaria as in this study children with normal CSF were assumed to have only cerebral malaria. Overall the findings of this study will go a long way in solving the problem of IV cannulation especially in children in whom locating veins is diificult.Further studies need to be done on artemesinin based combination therapy in the pediatric age group.
Fahd Khalid Syed; Omar Aftab Aga Khan University; Stadium Road Karachi Pakistan
Corresponding Address: omaraftab@hotmail.com
References: 1. Aceng JR, Byarugaba JS, Tumwine JK. Rectal artemether versus intravenous quinine for the treatment of cerebral malaria in children in Uganda: randomised clinical trial. Bmj 2005;330(7487):334. 2. Khan MA, Smego RA, Jr., Razi ST, Beg MA. Emerging drug--resistance and guidelines for treatment of malaria. J Coll Physicians Surg Pak 2004;14(5):319-24. 3. Adam I, Idris HM, Mohamed-Ali AA, Aelbasit IA, Elbashir MI. Comparison of intramuscular artemether and intravenous quinine in the treatment of Sudanese children with severe falciparum malaria. East Afr Med J 2002;79(12):621-5. 4. Sharma P, Swarup D, Saxena GN, Bhandari S, Sharma UB, Tuteja R. An open study to evaluate the efficacy of artemether in severe falciparum malaria. J Assoc Physicians India 1999;47(9):883-5.
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Artemether has undoubtedly been proven to be of value in treatment of severe cerebral malaria. Similar studies using artemether in adults & children has been in Vietiman & Malawi have been reported. Animal studies have shown severe neurotoxicity in unique pattern of neuronal necrosis in brain stem nuclei. Also cerebral dysfuntion has been reported in persons treated with artesunate(similar coumpound), hence it raises ethical issues regarding its use in children. Moreover, in view of multi-drug resistance and high cost of medication in third world countries, the use of artemether as a first line drug remains to be justified.
References: 1)neurotoxicity of artemisinin analogs in vitro. journal:antimicrob agents chemother 38:1813-9,1994 publication date:1994 August Author(s):wesche DL, DeCoster MA, Tortella FC,Brewer TG.
2)A controlled trial of arthemether or quinine in vietnamese adults with severe falciparum malaria Journel:N Engl J med 335:76-83, 1996 Publication date:1996 july 11
3)Rapid coma resolution with artemether in malawian chidren with cerebral malaria journel:Lancet 341:661-2, 1993 publication date:1993 march 13
4)Artemisinin neurotoxicity Class effect:artemisinin(QHS,qinghaosu),.Artemether(AM),. Dihyroartemisinin(DHA)... www.fda.gov/ohrms/dockets/ac/02/slides/3875s1_04_FDA- johannLiang/tsld022.htm- 07-25-2002
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Good study
I was just browsing through articles on ACTs in Rx of malaria and came accross this interesting article.I wonder if the same study can be done in other parts of the country or other hospitals so that we can have a good sample size and may be make a very good conclusion.My qtn is what would be the cost for both treatments?Other wise it is very promising.God bless
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