Tshefu 2010

Methods	Trial design: Randomized, multi centre, parallel-group, double-blind, double-dummy, non-inferiority trial Period of trial: January 2007 to April 2008
Participants	Number randomized: 1272 Age range: Five to 60 years  Gender: Both Inclusion criteria: Age between 3 to 60 years Fever in the last 24 hrs Microscopically confirmed mono-infection withP. falciparum (parasite density: 1000 to 100,000 asexual parasites/µL of blood) Body weight 20 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 Severe vomiting Malnutrition Hepatitis Hypersensitivity or allergy to trial drugs Use of antimalarials in the previous two weeks by testing; or use of any trial drug for previous four weeks Treatment with any drug metabolised by CYP2D6 Pregnant and lactating women Previous inclusion in a similar trial of artesunate-pyronaridine
Interventions	Randomized in a 2:1 ratio to: Intervention: 1. artesunate-pyronaridine combination (180 mg and 60 mg)* once a day for three days according to bodyweight (N = 849) Control: 2. Artemether-lumefantrine combination (20 mg and 120 mg)** twice a day for three days according to bodyweight (N = 423) *Average dose of pyronaridine: 9 mg/Kg body weight (range 13.8 to 7.2 mg/ Kg); artesunate doses ranged from 2.3 to 4.7 mg/kg body weight **Mean artemether dose: 1.7 mg/kg (range 0.9 to 2.4 mg/kg); lumefantrine doses ranged from 5 to 14.4 mg/kg
Outcomes	Primary outcome PCR-corrected adequate clinical and parasitological response rate (APCR; absence of parasitaemia, irrespective of axillary temperature, without previous treatment failure) at day 28 (Sensitivity analysis done with crude APCR (non-PCR-corrected) at day 28) Secondary outcomes 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) Exploratory efficacy outcomes PCR-corrected and uncorrected APCR rate on day 42 Number of gametocytes per micro-litre at days 0, 3, 7, 14, 21, and 42 Safety outcomes Serious adverse events (death, life threatening, requiring hospital admission or extended hospital stay, resulting in a congenital abnormality or birth defect, persistent disability or incapacity, or other serious adverse event) Other adverse events (during treatment and at follow-up on days 7, 14, 21, 28, 35, and 42) Laboratory abnormalities (days 3, 7; if indicated days 28, 42) Outcome reported but not used in quantitative synthesis in this review Proportion of patients who had cleared parasites at day 1, 2, and 3 Proportion of patients without fever at days 1, 2, and 3 Electrocardiograph abnormalities (days 2, 7, 14, and 28)
Notes	Countries of recruitment: Seven countries in Africa (Democratic Republic of Congo, The Gambia, Ghana; Kenya; Mali; Mozambique; and Senegal) recruited over 1000 participants; remainder were from three sites in two countries in southeast Asia (two in Indonesia; one in the Phillipines) Setting: Local hospitals and clinics Source of funding: Primary sponsor: Medicines for Malaria Venture; secondary sponsor: Shin Poong Pharmaceuticals Endemicity: All are high endemic areas Comments: Age rage of participants: 378 (45%) in the Py-As arm and 182 (43%) in the AL6 arm were aged five to 12 years Food was not required for artemether-lumefantrine (to retain blinding) Non-inferiority was shown if the lower limit of the two-sided 95% CI for the difference between groups was greater than -5% Recrudescence was 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 or 4 toxicity: For alanine aminotransferase, aspartate aminotransferase, and alkaline phosphatase, grade 3 toxicity was 5·1 to 10 times the upper limit of normal and grade 4 toxicity was more than ten times the upper limit of normal. For total bilirubin, grade 3 toxicity was 2·6 to 5 times the upper limit of normal and grade 4 toxicity was more than five times the upper limit of normal. Trials registration: ClinicalTrials.gov identifier: NCT00422084
Risk of bias
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Quote from report: "A computer generated randomisation schedule was provided by Averion AG (Allschwil, Switzerland). Patients were assigned a randomisation code by the investigator in ascending order and allocated to treatment in blocks of nine by study centre."
Allocation concealment (selection bias)	Low risk	Quote from report: "Patients were allocated an individual numbered treatment pack containing sufficient tablets for 3 days therapy plus an overage bottle containing an extra dose in case the patient vomited the first dose. Study packages were allocated on the basis of patient randomisation number. A qualified study team member (third party) who was not undertaking clinical assessments opened the study package and administered the correct amount of tablets, based on patient weight at screening, as instructed by the investigator."
Blinding (performance bias and detection bias) Objective outcomes: parasitological and biochemical	Low risk	Quote from report: "All clinical and laboratory staff and patients were masked to treatment allocation." Quote from report: "Study drugs and placebos were presented in identical packaging. Artemether-lumefantrine placebo was dosed twice daily to maintain blinding. Placebos were of similar shape and colour to their respective active drug." Quote from report: "Sealed opaque envelopes of treatment allocation were provided for use in an emergency, although no code breaks were necessary." Quote from report: "Food was not required for artemether-lumefantrine dosing to retain blinding."
Blinding (performance bias and detection bias) Subjective outcomes: adverse events	Low risk	Comment: See quotes above.
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	Quote from report: "There were no changes to study outcomes after trial commencement." Comment: The trial was prospectively registered. No changes were noted in the details provided in the registration document and the study report for outcomes. Comment: Day 42 efficacy outcomes and gametocyte counts were not listed in trial registration document and are listed in the report as exploratory.
Other bias	Unclear risk	Comment: Sponsors designed the trial, were responsible for data collection and analysis, and developed the report; all authors had access to trial data. Comment: Participants on artemether-lumefantrine were not expected to take medication after food; unclear if this reduced bioavailability of lumefantrine, particularly for day 42 outcomes and reinfection rate when lumefantrine levels may have been low.