An evaluation of rectal artesunate for the pre-hospital management of severe malaria

ABSTRACT

Introduction

Severe falciparum malaria stills accounts for around half a million childhood deaths per year in sub-Saharan Africa. Prompt treatment of sick children close to home starting with artesunate given rectally by appropriately trained people can be lifesaving.

Areas covered

Rectal artesunate (RAS) has been developed for use in the WHO approved strategy of pre-referral intervention. This review covers the formulation, pharmacokinetics, safety, efficacy, and implementation of this drug. There is little RCT evidence and the only RCT has been controversial. It is unlikely that there will be further randomized studies in the field. There is a concern that the administration of a single dose of artesunate without adequate follow up therapy may encourage the emergence of artemisinin resistance.

Expert opinion

Artesunate is an essential drug and RAS is a very useful, potentially lifesaving formulation designed to be quickly administered in remote areas to severely unwell children by non-medical personnel. However, its use needs to be monitored and onward referral for definitive antimalarial treatment ensured.

KEYWORDS:

• Artesunate
• dihydroartemisinin
• succinyl
• dihydroartemisinine 12 alpha succinate
• malacef
• malartin
• SM 804
• sodium artesunate
• succinyl dihydroartemisinin

Article Highlights

• Intravenous artesunate is the WHO recommended treatment of choice for severe malaria.

• A rectal formulation has been developed in order to facilitate early delivery of the first dose to children in rural areas.

• This forms part of the early treatment strategy with guidelines for subsequent referral to secondary health care for completion of a full treatment course.

• The pharmacokinetics of this rectal formulation are proven to be adequate in this population.

• The safety profile of rectal artesunate is good.

• There are concerns that patients treated with RAS are not being referred to secondary health care facilities for completion of treatment.

• Inadequate treatment may be associated with the development of artemisinin resistance.

Acknowledgments

I would like to thank Prof Julie Simpson and Prof Stephan Duparc for their helpful suggestions.

Declaration of interest

B Angus has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership, or options, expert testimony, grants, or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This manuscript was not funded.