Summary of findings for the main comparison. Dihydroartemisinin‐piperaquine versus Artemether‐lumefantrine for uncomplicated P. falciparum malaria in Africa.
| Dihydroartemisinin‐piperaquine versus Artemether‐lumefantrine for uncomplicated P. falciparum malaria in Africa | |||||
| Patient or population: Patients with uncomplicated P. falciparum malaria Settings: Malaria endemic settings in Africa Intervention: Dihydroartemisinin‐piperaquine (DHA‐P) Comparison: Artemether‐lumefantrine (AL6) | |||||
| Outcomes | Illustrative comparative risks* (95% CI) | Relative effect (95% CI) | No of participants (trials) | Quality of the evidence (GRADE) | |
| Assumed risk | Corresponding risk | ||||
| AL6 | DHA‐P | ||||
|
Treatment failure Day 28 |
PCR‐unadjusted | RR 0.34 (0.30 to 0.39) | 6200 (9 trials) | ⊕⊕⊕⊕ high1,2,3,4 | |
| 23 per 100 | 8 per 100 (7 to 9) | ||||
| PCR‐adjusted | RR 0.42 (0.29 to 0.62) | 5417 (9 trials) | ⊕⊕⊕⊕ high1,2,3,5 | ||
| 3 per 100 | 1 per 100 (1 to 2) | ||||
|
Treatment failure Day 63 |
PCR‐unadjusted | RR 0.71 (0.65 to 0.78) | 3200 (2 trials) | ⊕⊕⊕⊕ high1,3,4,6,7 | |
| 45 per 100 | 32 per 100 (29 to 35) | ||||
| PCR‐adjusted | RR 0.72 (0.50 to 1.04) | 2097 (2 trials) | ⊕⊕⊕⊕ high1,3,7,8,9 | ||
| 6 per 100 | 4 per 100 (3 to 6) | ||||
| *The basis for the assumed risk (for example, the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; RR: Risk ratio. | |||||
| GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate., Very low quality: We are very uncertain about the estimate. | |||||
1 No serious risk of bias: Trials are generally at low risk of bias. Exclusion of studies at high or unclear risk of selection bias or detection bias did not change the result. 2 No serious inconsistency: The trials all had similar results and statistical heterogeneity was low. 3 No serious indirectness: The trials were conducted in different transmission settings in East, West and Southern Africa. Most studies were limited to children. 4 No serious imprecision: Both limits of the 95% CI imply appreciable benefit, and the overall meta‐analysis is adequately powered to detect this result. 5 No serious imprecision: Although there is a benefit in favour of DHA‐P, PCR‐adjusted treatment failure was below 5% with both drugs. 6 No serious inconsistency: At this timepoint there is more inconsistency between trials. Both show a benefit with DHA‐P but there is variation in the size of this benefit. 7 Seven studies from East, West and Southern Africa reported outcomes at day 42. At this timepoint DHA‐P still had an advantage over AL6 on PCR‐unadjusted treatment failure (RR 0.60, 95% CI 0.53 to 0.67, seven studies, 3301, high quality evidence), and PCR‐adjusted treatment failure (RR 0.58, 95% CI 0.41 to 0.81, seven studies, 2559 participants, moderate quality evidence). 8 No serious inconsistency: Statistical heterogeneity was low. 9 No serious imprecision: Both ACTs performed well in these two trials with low levels of treatment failure.