Rueangweerayut 2012

Methods	Trial design: Randomized, multicentre, parallel-group, double-blind, double-dummy, non-inferiority trial Duration of trial: January 2007 to October 2008
Participants	Numbers randomized: 1271 Age: Four years to 59 years Gender: Both Inclusion criteria: Fever in the last 24 hrs Microscopically confirmed mono-infection withP. falciparum (parasite density: 1000 to 100,000 asexual parasites/µL of blood) Age range 3 years to 60 years Body weight 20 kg to 90 kg Written informed consent from participants or their guardians, with assent from children able to understand the trial Able to swallow oral medication Willingness to comply with protocol Negative urine test for pregnancy and agreement to practice contraception (women of child-bearing potential) Exclusion criteria: Complicated or severe malaria Mixed infections Anaemia (< 8 g/dL) Severe vomiting Severe malnutrition Any clinically significant illness other than malaria Hepatic or renal impairment Known hypersensitivity or allergy to trial drugs Use of antimalarials in the previous two weeks; or use of any trial drug for previous four weeks Treatment with any drug metabolised by CYP2D6 Pregnant and lactating women Previous participation in the trial
Interventions	Randomized in a 2:1 ratio to: Intervention: 1. Artesunate-pyronaridine combination (7.2: 2.4 mg/kg respectively) once a day for three days (N = 848) Control: 2. Mefloquine plus artesunate combination (6.2 to 12.5 mg/kg and 2.2 to 5.0 mg/kg respectively) once a day for three days (N = 423)
Outcomes	Primary outcome PCR-corrected adequate clinical and parasitological response rate (ACPR; absence of parasitaemia, irrespective of axillary temperature, without previous treatment failure) at day 28 Secondary outcomes Adequate clinical and parasitological response rate without correction for reinfection at day 28 Parasite clearance time (time from first dose to first negative parasite reading for two consecutive readings 7 to 25 hours apart) Fever clearance time (time from first dose to being afebrile for two consecutive readings 7 to 25 hours apart) Proportion of patients who had cleared parasites at day 1, 2, and 3 Proportion of patients without fever at days 1, 2, and 3 Exploratory efficacy outcomes PCR-corrected and uncorrected ACPR rate on day 42 Gametocyte carriage Safety outcomes Incidence of adverse events Outcomes reported but not used in quantitative synthesis Gametocyte clearance time Results of urinalysis and other clinical laboratory tests Results of electrocardiography
Notes	Countries of recruitment: Four countries in Asia (Cambodia, India, Thailand, and Vietnam; 81.3%); and three countries in Africa (Bukina Faso, Ivory Coast, Tanzania; 18.7%) Setting: Local hospitals and health centres Endemicity: High in most sites Source of funding: Primary sponsor: Medicines for Malaria Venture; secondary sponsor: Shin Poong Pharmaceuticals Duration of follow-up: Until day 42 Comments: Age range of participants: 122 (14.4%) in the As-Py arm and 68 (16.1%) in M-AS arm were < 12 years of age Sample size estimation: Assuming an APCR rate to both treatments of 93%, and a non-inferiority limit of 5%, and a dropout rate of 10%, with two patients receiving pyronaridine–artesunate for every one receiving mefloquine plus artesunate, the sample size was estimated to provide 90% power to demonstrate the non-inferiority of pyronaridine–artesunate with a two-sided 95% CI. Recrudescence differentiated from re-infection by PCR genotyping for P. falciparum genes merozoite surface proteins 1 and 2 (msp1, msp2), and glutamate-rich protein (glurp) with at least one matching allelic band in all markers at baseline and after day 7 Grade 3 and 4 toxicity: Adults: Alanine aminotransferase, aspartate aminotransferase, and alkaline phosphatase grade 3 toxicity was 5.1 to 10 times and grade 4 toxicity was = 10 times the upper limit of normal. Total bilirubin grade 3 toxicity was 2.6 to 5 times and grade 4 toxicity was = 5 times the upper limit of normal. Children: Alanine aminotransferase, and aspartate aminotransferase, grade 3 toxicity was 10 to 15 times and grade 4 toxicity was = 15 times the upper limit of normal. Total bilirubin grade 3 toxicity was 3.0 to 7.5 times and grade 4 toxicity was = 7.5 times the upper limit of normal. Trials registration: ClinicalTrials.gov identifier: NCT00403260
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Quote from report: "Averion International (now part of Aptiv Solutions) provided the computer generated randomisation schedule." Quote from trial protocol, "Patients who meet all entry criteria and present no exclusion criteria will be randomised to receive either pyronaridine artesunate or mefloquine plus artesunate in a 2:1 ratio according to the randomisation scheme provided by the sponsor. Patients will be assigned, in ascending order, a randomisation number according to the order recruited".
Allocation concealment (selection bias)	Low risk	Quote from trial protocol: "The patient will be allocated an individual numbered treatment pack which contains sufficient tablets for 3 days therapy plus an overage bottle containing tablets in case the patient vomits the first dose." Quote from trial protocol, "Clinical study material will be administered using a third-party single blind design. That is: after determining the eligibility criteria, the investigator shall communicate the patient randomisation number to a qualified study team member (third party) who is not performing clinical assessments. The third party will open the study package and administer the correct amount of tablets as instructed by the investigator to ensure unbiased randomisation."
Blinding (performance bias and detection bias) Objective outcomes: parasitological and biochemical	Low risk	Quote from report: "Drugs were administered by an investigator who was aware of group assignments; clinical and parasitologic assessments were performed by investigators who were aware of group assignments". Comment: The use of blinded outcome assessors minimised the risk of detection bias for objective outcomes.
Blinding (performance bias and detection bias) Subjective outcomes: adverse events	Low risk	Quote from report: "Clinical and parasitological assessments were performed by investigators who were not aware of group assignments." Comment: Most of the outcomes used in this review were objective outcomes, so participant's knowledge of treatment allocation is not likely to introduce bias.
Incomplete outcome data (attrition bias) All outcomes	Low risk	Comment: Data regarding all participants recruited provided in results for all outcomes.
Selective reporting (reporting bias)	Low risk	Comment: The trial was prospectively registered and the protocol was also available; all pre-stated outcomes were reported adequately.
Other bias	Low risk	Quote from report: "The study was designed by the authors and the study sponsors, the Medicines for Malaria Venture and Shin Poong Pharmaceutical Company. All the authors vouch for the completeness and accuracy of the data and the analysis and for the fidelity of the study to the protocol". Quote from report: "No potential conflict of interest relevant to this article was reported". Comment: Some of the authors are employed by the trial sponsors but all authors had access to data and assumed responsibility for reporting accuracy.