E 'was published in a Cochrane review on the drugs used for chemoprophylaxis of malaria in non immune subjects.
Objectives of the review: To evaluate efficacy, safety and tolerability of the drugs most commonly used in the chemoprophylaxis of malaria, namely
- the combination of atovaquone + proguanil
- mefloquine
- doxycycline
comparing these drugs with each other, as well as the association chloroquine + proguanil and with primaquine.
As you would expect from a Cochrane review, the selection criteria were rigorous clinical trials, as well as the analysis methodology.
What are the results of the review?
8 clinical trials are included in the review, a total of 4240 participants. The overall quality of evidence was low to moderate, due to the limited number of studies that have compared the regimes of their standard of chemoprophylaxis and the limited number of participants / events for each study. No trial compared a standard regimen with any primaquine, so it was excluded from the analysis.
Effectiveness: the review has not produced conclusive evidence about which drugs, including those considered to be more effective in preventing malaria in non-immune individuals who travel in areas where Plasmodium falciparum is resistant to chloroquine.
What have we learned from the analysis of effectiveness?
Since evidence has emerged on what is the best drug, the choice of chemoprophylaxis regime must take into account other factors such as the profile of drug resistance of Plasmodium falciparum in the area where the traveler will travel, security, tolerability and cost of treatment.
Safety and tolerability: despite the revision did not produce conclusive evidence on what is the drug safer and better tolerated in individuals with no immunity who travel to areas where Plasmodium falciparum is resistant to chloroquine, however, showed that
- atovaquone + proguanil and doxycycline have a better tolerability compared to mefloquine;
- atovaquone + proguanil and doxycycline have a tolerability profile similar;
- atovaquone + proguanil, mefloquine and doxycycline are better tolerated in comparison to the association chloroquine + proguanil.
mefloquine is associated with neuropsychiatric adverse reactions.
patients treated with atovaquone + proguanil had a significantly lower frequency of any adverse reaction, as well as less gastrointestinal and neuropsychiatric events, as well as better scores in surveys that detect the presence of any mood changes.
What have we learned from the safety and tolerability?
The fact that some important differences emerged between the drugs in question allows us to use these data to choose the most suitable drug for each individual traveler, both in relation to his medical history and travel characteristics (in particular route and duration). What impact
This Cochrane review has on our daily activities?
Although the audit results must be interpreted with caution due to suboptimal quality of the evidence, it is still a valuable work of great interest to those who daily are to recommend and prescribe medications for malaria chemoprophylaxis .
The review contains an important confirmation to the observations that each of us over the years has performed at the clinic, through the feedback provided by travelers: the atovaquone + proguanil combination is better tolerated than other regimens in current use.
were influenced by two other findings of the review: The first concerns the doxycycline. Some operators have some qualms when prescribing doxycycline, fearing the occurrence of side effects such as photosensitivity ol'esofagite reflux, probably we can now consider a different way this drug, which also has a major limitation: it must be continued for four weeks after return, and the administration is daily. This fact has obvious implications in terms of compliance.
The second result concerns the association chloroquine + proguanil: I have met several times during the pre-travel counseling clinic, travelers believe they have found a drug "alternative" and "better tolerated" by what I proposed to them. Almost always it was chloroquine + proguanil, often in the French version that combines both drugs in the same preparation. We already knew that the efficacy of chloroquine + proguanil in chloroquine-resistant areas is unsatisfactory, but we now have a figure that also shows the low tolerability.
Finally, as regards the mefloquine, this is a drug for its mode of recruitment is still valuable in several situations, such as in long-term travelers, and can still be used with a certain tranquility in individuals who have previously taken without significant adverse events. The fact that both were associated with certain adverse reactions should not obscure both the practical benefits and the benefits arising from its use in the prevention of a serious and potentially fatal disease such as malaria. Bibliographic Reference
Jacquerioz FA, Croft AM. Drugs for Preventing malaria in travelers. Cochrane Database of Systematic Reviews 2009, Issue 4. Art No.: CD006491.
DOI: 10.1002/14651858.CD006491.pub2.
http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD006491/frame.html
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