Pyronaridine‐artesunate for treating uncomplicated Plasmodium falciparum malaria

Joseph Pryce; Paul Hine

doi:10.1002/14651858.CD006404.pub3

. 2019 Jan 8;2019(1):CD006404. doi: 10.1002/14651858.CD006404.pub3

Pyronaridine‐artesunate for treating uncomplicated Plasmodium falciparum malaria

Joseph Pryce ¹, Paul Hine ^1,^✉

Editor: Cochrane Infectious Diseases Group

PMCID: PMC6353203 PMID: 30620055

Abstract

Background

The World Health Organization (WHO) recommends artemisinin‐based combination therapies (ACTs) to treat uncomplicated Plasmodium falciparum (P falciparum) malaria. Concerns about artemisinin resistance have led to global initiatives to develop new partner drugs to protect artemisinin derivatives in ACT. Pyronaridine‐artesunate is a novel ACT.

Objectives

To evaluate the efficacy of pyronaridine‐artesunate compared to alternative ACTs for treating people with uncomplicated P falciparum malaria, and to evaluate the safety of pyronaridine‐artesunate and other pyronaridine treatments compared to alternative treatments.

Search methods

We searched the Cochrane Infectious Diseases Group Specialized Register; Cochrane Central Register of Controlled Trials (CENTRAL), published in the Cochrane Library; MEDLINE; Embase; and LILACS. We also searched ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform Search Portal, and the International Standard Randomized Controlled Trial Number (ISRCTN) registry for ongoing or recently completed trials. The date of the last search was 8 May 2018.

Selection criteria

Efficacy analysis: randomized controlled trials (RCTs) of pyronaridine‐artesunate for treating uncomplicated P falciparum malaria.

Safety analysis: RCTs of pyronaridine‐artesunate or pyronaridine for treating P falciparum or P vivax malaria.

Data collection and analysis

For this update, two review authors independently re‐extracted all data and assessed certainty of evidence. We meta‐analysed data to calculate risk ratios (RRs) for treatment failures between comparisons, and for safety outcomes between and across comparisons.

Main results

We included 10 relevant studies. Seven studies were co‐funded by Shin Poong Pharmaceuticals which manufactures the drug. Three studies were funded by government agencies.

For efficacy analysis we identified five RCTs with 5711 participants. This included 4465 participants from 13 sites in Africa, and 1246 participants from five sites in Asia. It included 541 children aged less than five years.

For polymerase chain reaction (PCR)‐adjusted failures at day 28, pyronaridine‐artesunate may have fewer failures compared to artemether‐lumefantrine (RR 0.59, 95% confidence interval (CI) 0.26 to 1.31; 4 RCTs, 3068 participants, low‐certainty evidence), artesunate‐amodiaquine (RR 0.55, 95% CI 0.11 to 2.77; 1 RCT, 1245 participants, low‐certainty evidence), and mefloquine plus artesunate (RR 0.37, 95% CI 0.13 to 1.05; 1 RCT, 1117 participants, low‐certainty evidence).

For unadjusted failures at day 28, pyronaridine‐artesunate may have fewer failures compared to artemether‐lumefantrine (RR 0.27, 95% CI 0.13 to 0.58; 4 RCTs, 3149 participants, low‐certainty evidence), and probably has fewer failures compared to artesunate‐amodiaquine (RR 0.49, 95% CI 0.30 to 0.81; 1 RCT, 1257 participants, moderate‐certainty evidence) and mefloquine plus artesunate (RR 0.36, 95% CI 0.17 to 0.78; 1 RCT, 1120 participants, moderate‐certainty evidence).

For PCR‐adjusted failures at day 42, pyronaridine‐artesunate may make little or no difference compared to artemether‐lumefantrine (RR 0.86, 95% CI 0.49 to 1.51; 4 RCTs, 2575 participants, low‐certainty evidence) and artesunate‐amodiaquine (RR 0.98, 95% CI 0.20 to 4.83; 1 RCT, 1091 participants, low‐certainty evidence), but may have higher failures than mefloquine plus artesunate (RR 1.80, 95% CI 0.90 to 3.57; 1 RCT, 1037 participants, low‐certainty evidence). Overall, pyronaridine‐artesunate had a PCR‐adjusted treatment failure rate of less than 5%.

For unadjusted failures at day 42, pyronaridine‐artesunate may have fewer failures compared to artemether‐lumefantrine (RR 0.61, 95% CI 0.46 to 0.82; 4 RCTs, 3080 participants, low‐certainty evidence), may make little or no difference compared to mefloquine plus artesunate (RR 0.84, 95% CI 0.54 to 1.31; 1 RCT, 1059 participants, low‐certainty evidence), and probably makes little or no difference compared to artesunate‐amodiaquine (RR 0.98, 95% CI 0.78 to 1.23; 1 RCT, 1235 participants, moderate‐certainty evidence).

For the safety analysis of severe adverse events and liver function, we identified eight RCTs with 6614 participants comparing pyronaridine‐artesunate to other antimalarials, four of which were not in the previous version of this review. A further two RCTs, comparing pyronaridine alone to other treatments, contributed to the synthesis of all adverse events.

Raised alanine aminotransferase (ALT) greater than five times the upper limit of normal (> 5 x ULN) is more frequent with pyronaridine‐artesunate compared to other antimalarials (RR 3.34, 95% CI 1.63 to 6.84; 8 RCTS, 6581 participants, high‐certainty evidence). There is probably little or no difference for raised bilirubin > 2.5 x ULN between pyronaridine‐artesunate and other antimalarials (RR 1.03, 95% CI 0.49 to 2.18; 7 RCTs, 6384 participants, moderate‐certainty evidence). There was one reported case in which raised ALT occurred with raised bilirubin, meeting criteria for moderate drug‐induced liver injury. No study reported severe drug‐induced liver injury. Electrocardiograph (ECG) abnormalities were less common with pyronaridine‐artesunate compared to other antimalarials. We identified no other safety concerns.

Authors' conclusions

Pyronaridine‐artesunate was efficacious against uncomplicated P falciparum malaria, achieved a PCR‐adjusted treatment failure rate of less than 5% at days 28 and 42, and may be at least as good as, or better than other marketed ACTs.

Pyronaridine‐artesunate increases the risk of episodes of raised ALT > 5 x ULN. This meets criteria for mild drug‐induced liver injury. On one instance this was linked to raised bilirubin, indicating moderate drug‐induced liver injury. No episodes of severe drug‐induced liver injury were reported. The findings of this review cannot fully inform a risk‐benefit assessment for an unselected population. Readers should remain aware of this uncertainty when considering use of pyronaridine‐artesunate in patients with known or suspected pre‐existing liver dysfunction, and when co‐administering with other medications which may cause liver dysfunction.

12 April 2019

Up to date

All studies incorporated from most recent search

All eligible published studies found in the last search (8 May, 2018) were included

Plain language summary

Pyronaridine‐artesunate for treating uncomplicated Plasmodium falciparum (P falciparum) malaria

What is the aim of this review?

The aim of this Cochrane Review was to find out if the antimalarial drug pyronaridine‐artesunate is effective and safe to treat uncomplicated cases of an important type of malaria (P falciparum). We collected and analysed all relevant studies to answer this question and found 10 studies.

Key messages

Pyronaridine‐artesunate is effective in treating uncomplicated P falciparum malaria. Pyronaridine‐artesunate is generally safe, but some people who receive it have blood tests suggesting liver damage. This appears to neither be long‐lasting nor make people ill.

What was studied in the review?

The World Health Organization (WHO) recommends that malaria is treated with combinations of drugs called artemisinin‐based combination therapies (ACTs). Pyronaridine‐artesunate is a new ACT. New ACTs are needed to treat malaria that has become resistant to currently available ACTs, and to help prevent malaria becoming more resistant to treatment.

We compared pyronaridine‐artesunate to other ACTs to evaluate its efficacy against P falciparum malaria, and compared pyronaridine‐artesunate and pyronaridine alone to other drugs to evaluate its safety.

What are the main results of the review?

We included 10 relevant studies. Seven studies were co‐funded by Shin Poong Pharmaceuticals which manufactures the drug. Three studies were funded by government agencies.

Three studies compared pyronaridine‐artesunate to artemether‐lumefantrine in adults and children of all ages in Africa and Asia. One study compared pyronaridine‐artesunate to artesunate‐amodiaquine in adults and older children in Africa. One study compared pyronaridine‐artesunate to mefloquine plus artesunate in adults and older children in Africa and Asia. We included another five studies when we looked at the safety of the drug.

Pyronaridine‐artesunate effectively treated uncomplicated P falciparum malaria, and may be at least as good as or better than existing ACTs (low‐ to moderate‐certainty evidence).

Pyronaridine‐artesunate increases the risk of having blood tests which suggest mild liver injury (moderate‐ to high‐certainty evidence). We did not find evidence that any such liver injury was severe or irreversible. We do not know how pyronaridine‐artesunate might affect people who already have liver damage.

We found two trials that exclusively recruited children under 12, with a total of 732 participants. Using the data from these trials, we did not find differences in treatment efficacy or safety between pyronaridine‐artesunate and artemether‐lumefantrine.

How up‐to‐date is the review?

We searched for studies that had been published up to 8 May 2018.

Summary of findings

Background

Description of the condition

Malaria poses a global health challenge, with an estimated 216 million cases and 445,000 deaths in 2016. Plasmodium falciparum (P falciparum) is the most important species of malaria, causing 99% of malaria cases in the World Health Organization (WHO) Africa region, and 66% in the South‐East Asia region (WHO 2017).

The WHO defines uncomplicated malaria by the absence of clinical features of severe malaria, in the presence of an asexual P falciparum parasitaemia (WHO 2015). Severe malaria is P falciparum parasitaemia with one or more of: impaired consciousness, prostration, multiple convulsions, acidosis, hypoglycaemia, severe malarial anaemia, renal impairment, jaundice, pulmonary oedema, significant bleeding, shock, raised lactate, or a parasitaemia of greater than 10%. If untreated, uncomplicated malaria can develop into severe malaria.

The WHO has recommended artemisinin‐based combination therapies (ACTs) as first‐line treatment of uncomplicated P falciparum malaria since 2006, recognising the risk of resistance with monotherapy (WHO 2006). Artemisinin resistance has emerged in South‐East Asia, initially from the Thai‐Cambodian border, and has since become prevalent in Laos, Myanmar, Thailand, and Vietnam (Dondorp 2009; Noedl 2008). This resistance remains a key concern, as further spread of artemisinin resistance could lead to high mortality (Lubell 2014). These concerns have led to global initiatives to contain the spread of artemisinin resistance, which includes the development of new drugs to partner and protect the artemisinin derivatives in ACT (WHO 2011).

Description of the intervention

The WHO currently recommends the following five ACTs for first‐line treatment of malaria.

Artemether‐lumefantrine
Artesunate‐amodiaquine
Artesunate‐mefloquine
Artesunate‐sulphadoxine‐pyrimethamine
Dihydroartemisinin‐piperaquine

The artemisinin in ACTs rapidly clears parasites from the blood. It also kills some sexual forms of the parasite, and may reduce onward transmission to mosquitoes. The longer‐acting partner drug clears residual infections, and protects against resistance to artemisinin (WHO 2015). Drug combinations with long half‐lives (artesunate‐mefloquine and dihydroartemisinin‐piperaquine) can provide a period of post‐treatment prophylaxis which may last for up to six weeks (Sinclair 2009).

Pyronaridine is a potential partner drug for artesunate. Researchers in China developed pyronaridine during the mid‐1970s, using the nucleus of an earlier antimalarial compound (mepacrine) with an added amodiaquine side‐chain (Fu 1991). Clinicians thereafter used pyronaridine extensively as monotherapy for P falciparum and P vivax infections in China (Chen 1992). Concerns about observed in vitro resistance to pyronaridine lead Chinese researchers to use pyronaridine in combinations with sulphadoxine and pyrimethamine, and primaquine (Fu 1991).

A public‐private partnership including the Medicines for Malaria Venture (MMV) and Shin Poong Pharmaceuticals Incorporated developed pyronaridine‐artesunate in combination from 2002 onwards (MMV 2002), with its first national registration in 2011 (with the Korean Food and Drug Administration). For uncomplicated malaria, the treatment is taken once‐daily for three days. Treatment is provided as tablets for adults and children over 20 kg, or in granules for children and infants between 5 kg and 20 kg.

How the intervention might work

The mode of action of pyronaridine is unclear, with several possible mechanisms (Croft 2012). Pyronaridine has been shown to have potent in vitro activity versus P falciparum (Basco 1992; Chen 1992; Childs 1988; Pradines 1998; Ringwald 1999), even in strains with resistance to other antimalarials, including chloroquine, cycloguanil, amodiaquine, and sulfadoxine‐pyrimethamine (Chavalitshewinkoon‐Petmitr 2000; Kurth 2009; Price 2010). In vitro studies also indicate synergy between pyronaridine and artesunate versus parasites which are resistant to either agent (Peters 1997; Vivas 2008).

Why it is important to do this review

In the absence of resistance, ACTs are effective drugs. However, with emerging resistance to the above currently recommended ACTs, it is necessary to identify new drug combinations with equivalent efficacy. This review is an update of a Cochrane Review first published in 2007 (Unnikrishnan 2007), and previously updated in 2014 (Bukirwa 2014). The latest update of this review concluded that pyronaridine‐artesunate performed well in these trials compared to artemether‐lumefantrine and mefloquine plus artesunate. At day 28, polymerase chain reaction (PCR)‐adjusted treatment failure (where PCR is used to confirm recrudescence rather than reinfection) was below the 5% standard set by the WHO. However, the review recommended further efficacy and safety studies in African and Asian children to clarify whether the combination is an option for first‐line treatment of uncomplicated P falciparum malaria.

Following this review, the latest edition of the WHO guidelines for the treatment of malaria did not recommend pyronaridine‐artesunate for general use (WHO 2015). The Guideline Development Group recommended further data were required for efficacy in children less than five years of age, and safety, including safety of repeat dosing. They noted the undesirable effects of elevated liver function tests.

Since the previous update and WHO Guidelines, the West African Network for Clinical Trials of Antimalarial Drugs has published a new study of pyronaridine‐artesunate (Sagara 2018), and the European Medicines Agency (EMA) has adopted a positive scientific opinion of pyronaridine‐artesunate (EMA 2015). In view of this, we have updated the review to inform future guideline development.

Objectives

Methods

Criteria for considering studies for this review

Types of studies

Randomized controlled trials (RCTs).

Types of participants

Adults and children with uncomplicated Plasmodium falciparum (P falciparum) malaria, as confirmed by either microscopy or rapid diagnostic tests.

For an additional safety analysis we extended the inclusion criteria to adults and children with P vivax malaria.

Types of interventions

Intervention

Pyronaridine‐artesunate

Control

World Health Organization (WHO)‐recommended artemisinin‐based combination therapies (ACTs) for treating malaria

For the analysis of adverse events, we extended the inclusion criteria to all RCTs comparing pyronaridine alone or in combination with any other antimalarial.

Types of outcome measures

Primary outcomes

Total treatment failure at day 28 (PCR‐adjusted and unadjusted)
Total treatment failure at day 42 (PCR‐adjusted and unadjusted)

Secondary outcomes

Early treatment failure (WHO 2009):
- danger signs or severe malaria on day 1, 2 or 3, in the presence of parasitaemia
- parasitaemia on day 2 higher than on day 0, irrespective of axillary temperature
- parasitaemia on day 3 with axillary temperature ≥ 37.5 °C
- parasitaemia on day 3 ≥ 25% of count on day 0

Adverse events (safety analysis)

Serious adverse events (leading to death, requiring hospitalization or prolongation of existing hospitalization, are life threatening, or result in persistent or significant disability or incapacity)
Adverse events leading to withdrawal from treatment (discontinuation of trial drug or withdrawal from trial)
Elevated liver function tests
Other adverse events

Comment on outcome measures

We base our primary outcome measures on WHO recommendations (WHO 2003; WHO 2009), which advise a 28‐day follow‐up to capture most failures, and 42‐day follow‐up to capture failures for drugs with a longer elimination half‐life (mefloquine and piperaquine). This is also consistent with previous Cochrane Reviews. We do not report ‘adequate clinical and parasitological response' as this is defined in terms of absence of failure and therefore represents duplication.

The previous published protocol for this review listed a priori secondary outcomes to include parasite clearance, fever clearance, and gametocyte carriage (Bukirwa 2014). The protocol did not clearly define these outcomes, including whether they refer to durations, rates, or proportions of patients at given time points. We encountered considerable heterogeneity in these measures between studies, and therefore present a narrative synthesis.

We encountered heterogeneity in the threshold at which elevated liver function tests were deemed by study authors to be significant, which we have detailed in Table 5. The reader should note that these thresholds do not necessarily correspond with internationally accepted definitions of drug‐induced liver injury (Aithal 2011, summarized in Appendix 1).

1. Alanine aminotransferase (ALT), aspartate aminotransferase (AST), and bilirubin increase grading.

Trial	ALT increased (grade 3 and above)	AST increased (grade 3 and above)	Blood bilirubin increased
Kayentao 2012	10 × ULN	10 × ULN	3 × ULN
Poravuth 2011 Rueangweerayut 2012 Sagara 2018 Tshefu 2010	5 × ULN	5 × ULN	2.5 × ULN
Roth 2018 Shin 2011	3 × ULN	3 × ULN	‐
Nelwan 2015	3 × ULN if associated with bilirubin > 2 × ULN	‐	‐

*Pyronaridine‐artesunate (PY‐AS) compared to artemether‐lumefantrine (AL) for adults and children with uncomplicated Plasmodium falciparum* malaria**
Patient or population: adults and children with uncomplicated P falciparum malaria  Setting: malaria transmission settings  Intervention: pyronaridine‐artesunate (PY‐AS)  Comparison: artemether‐lumefantrine (AL)
Outcomes	*Anticipated absolute effects^ (95% CI)**		Relative effect  (95% CI)	№ of participants  (trials)	Certainty of the evidence  (GRADE)	Comments
Outcomes	Risk with AL	Risk with PY‐AS	Relative effect  (95% CI)	№ of participants  (trials)	Certainty of the evidence  (GRADE)	Comments
Total failure: day 28 (PCR‐adjusted)	15 per 1000	9 per 1000  (4 to 19)	RR 0.59  (0.26 to 1.31)	3068  (4 RCTs)	⊕⊕⊝⊝  LOW^a,b,c Due to indirectness and imprecision	Compared to AL, PY‐AS may have fewer PCR‐adjusted failures at day 28.
Total failure: day 42 (PCR‐adjusted)	23 per 1000	20 per 1000  (12 to 35)	RR 0.86  (0.49 to 1.51)	2575  (4 RCTs)	⊕⊕⊝⊝  LOW^a,b Due to indirectness and imprecision	There may be little or no difference in PCR‐adjusted failures at day 42 between PY‐AS and AL.
Total failure: day 28 (unadjusted)	126 per 1000	34 per 1000  (16 to 73)	RR 0.27  (0.13 to 0.58)	3149  (4 RCTs)	⊕⊕⊝⊝  LOW^a,d,e Due to indirectness and inconsistency	Compared to AL, PY‐AS may have fewer unadjusted failures at day 28.
Total failure: day 42 (unadjusted)	254 per 1000	155 per 1000  (117 to 208)	RR 0.61  (0.46 to 0.82)	3080  (4 RCTs)	⊕⊕⊝⊝  LOW^a,d,e Due to indirectness and inconsistency	Compared to AL, PY‐AS may have fewer unadjusted failures at day 42.
Serious adverse events (42 days)	3 per 1000	3 per 1000  (1 to 12)	RR 0.90  (0.19 to 4.22)	2004  (3 RCTs)	⊕⊕⊝⊝  LOW^f Due to imprecision	We do not know if there is a difference in serious adverse events between PY‐AS and AL.
First treatment, ALT increase > 5 × ULN (42 days)	3 per 1000	9 per 1000  (3 to 22)	RR 2.92  (1.15 to 7.41)	3341  (4 RCTs)	⊕⊕⊝⊝  LOW^a,g Due to indirectness and imprecision	Compared to AL, PY‐AS may lead to higher events of ALT increase > 5 × ULN. (Aggregate analysis indicates this estimate may be accurate).
First treatment, AST increase > 5 × ULN (42 days)	4 per 1000	9 per 1000  (3 to 23)	RR 2.20  (0.83 to 5.82)	3327  (4 RCTs)	⊕⊝⊝⊝  VERY LOW^a,b,h Due to indirectness, inconsistency, and imprecision	We do not know if there is a difference in AST between PY‐AS and AL.
First treatment, bilirubin increase > 2.5 × ULN (42 days)	6 per 1000	5 per 1000  (2 to 12)	RR 0.82  (0.33 to 2.04)	3130  (3 RCTs)	⊕⊕⊝⊝  LOW^a,b Due to indirectness and imprecision	We do not know if there is a difference in bilirubin between PY‐AS and AL.
*The risk in the intervention group (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).  Abbreviations: AL: artemether‐lumefantrine;ALT: alanine aminotransferase; AST: aspartate transaminase; CI: confidence interval; PCR: polymerase chain reaction; PY‐AS: pyronaridine‐artesunate; RCT: randomized controlled trial; RR: risk ratio; ULN: upper limit of normal
GRADE Working Group grades of evidence  High certainty: we are very confident that the true effect lies close to that of the estimate of the effect.  Moderate certainty: we are moderately confident in the effect estimate. The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.  Low certainty: our confidence in the effect estimate is limited. The true effect may be substantially different from the estimate of the effect.  Very low certainty: we have very little confidence in the effect estimate. The true effect is likely to be substantially different from the estimate of effect.

*Pyronaridine‐artesunate (PY‐AS) compared to artesunate‐amodiaquine (AS‐AQ) for adults and children with uncomplicated Plasmodium falciparum* malaria**
Patient or population: adults and children with uncomplicated P falciparum malaria  Setting: malaria transmission settings  Intervention: pyronaridine‐artesunate (PY‐AS)  Comparison: artesunate‐amodiaquine (AS‐AQ)
Outcomes^a	*Anticipated absolute effects^ (95% CI)**		Relative effect  (95% CI)	№ of participants  (trials)	Certainty of the evidence  (GRADE)	Comments
Outcomes^a	Risk with artesunate‐amodiaquine (AS‐AQ)	Risk with pyronaridine‐artesunate (PY‐AS)	Relative effect  (95% CI)	№ of participants  (trials)	Certainty of the evidence  (GRADE)	Comments
Total failure: day 28 (PCR‐adjusted)	8 per 1000	4 per 1000  (1 to 22)	RR 0.55  (0.11 to 2.77)	1245  (1 RCT)	⊕⊕⊝⊝  LOW^b,c Due to indirectness and imprecision	Compared to AS‐AQ, PY‐AS may have fewer PCR‐adjusted failures at day 28.
Total failure: day 42 (PCR‐adjusted)	6 per 1000	5 per 1000  (1 to 27)	RR 0.98  (0.20 to 4.83)	1091  (1 RCT)	⊕⊕⊝⊝  LOW^b,d Due to indirectness and imprecision	There may be little or no difference in PCR‐adjusted failures at day 42 between PY‐AS and AS‐AQ.
Total failure: day 28 (unadjusted)	75 per 1000	37 per 1000  (22 to 61)	RR 0.49  (0.30 to 0.81)	1257  (1 RCT)	⊕⊕⊕⊝  MODERATE^b Due to indirectness	Compared to AS‐AQ, PY‐AS probably has fewer unadjusted failures at day 28.
Total failure: day 42 (unadjusted)	195 per 1000	192 per 1000  (152 to 240)	RR 0.98  (0.78 to 1.23)	1235  (1 RCT)	⊕⊕⊕⊝  MODERATE^b Due to indirectness	There is probably little or no difference in unadjusted failures at day 42 between PY‐AS and AS‐AQ.
First treatment, ALT increase > 5 × ULN (42 days)	1 per 1000	1 per 1000  (0 to 7)	RR 1.41  (0.28 to 7.09)	1317  (1 RCT)	⊕⊕⊝⊝  LOW^b,e Due to indirectness and imprecision	Compared to AL, PY‐AS may have lead to higher events of ALT increase > 5 × ULN. (Aggregate analysis indicates this estimate may be accurate).
First treatment, AST increase > 5 × ULN (42 days)	4 per 1000	2 per 1000  (0 to 8)	RR 0.43  (0.08 to 2.07)	1317  (1 RCT)	⊕⊝⊝⊝  VERY LOW^b,f Due to indirectness and imprecision	We do not know if there is a difference in AST between PY‐AS and AS‐AQ.
First treatment, bilirubin increase > 2.5 × ULN (42 days)	1 per 1000	1 per 1000  (0 to 16)	RR 0.99  (0.06 to 15.76)	1317  (1 RCT)	⊕⊝⊝⊝  VERY LOW^b,f Due to indirectness and imprecision	We do not know if there is a difference in bilirubin between PY‐AS and AS‐AQ.
*The risk in the intervention group (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).  Abbreviations: ALT: alanine aminotransferase; AS‐AQ: artesunate‐amodiaquine; AST: aspartate transaminase; CI: confidence interval; PCR: polymerase chain reaction; PY‐AS: pyronaridine‐artesunate; RCT: randomized controlled trial; RR: risk ratio; ULN: upper limit of normal
GRADE Working Group grades of evidence  High certainty: we are very confident that the true effect lies close to that of the estimate of the effect.  Moderate certainty: we are moderately confident in the effect estimate. The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.  Low certainty: our confidence in the effect estimate is limited. The true effect may be substantially different from the estimate of the effect.  Very low certainty: we have very little confidence in the effect estimate. The true effect is likely to be substantially different from the estimate of effect.

Pyronaridine‐artesunate (PY‐AS) compared to other antimalarials for adults and children with uncomplicated malaria
Patient or population: adults and children with uncomplicated malaria  Setting: high and low transmission settings for P falciparum and P vivax malaria  Intervention: pyronaridine‐artesunate (PY‐AS)  Comparison: other antimalarials
Outcomes^a,b,c	*Anticipated absolute effects^ (95% CI)**		Relative effect  (95% CI)	№ of participants  (trials)	Certainty of the evidence  (GRADE)	Comments
Outcomes^a,b,c	Risk with other antimalarials	Risk with pyronaridine‐artesunate (PY‐AS)	Relative effect  (95% CI)	№ of participants  (trials)	Certainty of the evidence  (GRADE)	Comments
Serious adverse events	5 per 1000	7 per 1000  (3 to 15)	RR 1.24  (0.54 to 2.84)	3941  (7 RCTs)	⊕⊕⊕⊝  MODERATE^d Due to imprecision	There was probably little or no difference in the rate of serious adverse events with PY‐AS compared to other antimalarials.
First treatment, ALT increase > 5 × ULN	2 per 1000	7 per 1000  (3 to 14)	RR 3.34  (1.63 to 6.84)	6614  (8 RCTs)	⊕⊕⊕⊕  HIGH^e	ALT increase > 5 × ULN is more frequent with PY‐AS compared to other antimalarials.
First treatment, AST increase > 5 × ULN	3 per 1000	5 per 1000  (3 to 11)	RR 1.80  (0.89 to 3.65)	6614  (8 RCTs)	⊕⊕⊕⊝  MODERATE^f Due to imprecision	There is probably a small increased risk of AST increase > 5 × ULN with PY‐AS compared to other antimalarials.
First treatment, bilirubin increase > 2.5 × ULN	4 per 1000	4 per 1000  (2 to 9)	RR 1.03  (0.49 to 2.18)	6417  (7 RCTs)	⊕⊕⊕⊝  MODERATE^d Due to imprecision	There is probably little or no difference for bilirubin between PY‐AS and other antimalarials.
Subsequent treatment(s), ALT > 5 × ULN	4 per 1000	8 per 1000  (3 to 23)	RR 2.18  (0.76 to 6.27)	1649  (1 RCT)	⊕⊕⊝⊝  LOW^d,f Due to imprecision and indirectness	There may be an increased risk of raised ALT with subsequent treatments with PY‐AS compared to other antimalarials.
Subsequent treatment(s), AST > 5 × ULN	6 per 1000	11 per 1000  (4 to 27)	RR 1.82  (0.74 to 4.44)	1649  (1 RCT)	⊕⊕⊝⊝  LOW^d,f Due to imprecision and indirectness	There may be an increased risk of raised AST with subsequent treatments with PY‐AS compared to other antimalarials.
Subsequent treatment(s), bilirubin > 5 × ULN	8 per 1000	9 per 1000  (3 to 24)	RR 1.13  (0.42 to 3.01)	1649  (1 RCT)	⊕⊕⊝⊝  LOW^d,f Due to imprecision and indirectness	There may be little or no difference for bilirubin between PY‐AS and other antimalarials.
*The risk in the intervention group (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).  Abbreviations: ALT: alanine aminotransferase; AST: aspartate transaminase; CI: confidence interval; PY‐AS: pyronaridine‐artesunate; RCT: randomized controlled trial; RR: risk ratio; ULN: upper limit of normal
GRADE Working Group grades of evidence  High certainty: we are very confident that the true effect lies close to that of the estimate of the effect.  Moderate certainty: we are moderately confident in the effect estimate. The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.  Low certainty: our confidence in the effect estimate is limited. The true effect may be substantially different from the estimate of the effect.  Very low certainty: we have very little confidence in the effect estimate. The true effect is likely to be substantially different from the estimate of effect.

Study	Pyronaridine‐artesunate	Comparator(s)
Kayentao 2012	Severe malaria (1)^a	Artemether‐lumefantrine ‐
Nelwan 2015	Head trauma (1)^a Typhoid fever (1)^b Nephrolithiasis (1)^b	Artesunate only Metacarpal fracture (1)^a Acute gastroenteritis (1)^a Suspected ureteric stone (1)^b Dihydroartemisinin‐piperaquine Dengue fever (1)^a
Poravuth 2011	Pyrexia (1)^a Typhoid fever (1)^a	Chloroquine ‐
Ringwald 1996	‐	‐
Ringwald 1998	‐	‐
Roth 2018	‐	‐
Rueangweerayut 2012	Autoimmune haemolytic anaemia (1)^a  Cholera (1)^a  Pneumonia (1)^a  Acute pyelonephritis (1)^a  Wound infection (1)^a  Abortion (1)^a  Depression (1)^a	Mefloquine plus artesunate Cerebral malaria (1)^a  Seizure (1)^c  Grand mal seizure (1)^c
Tshefu 2010	Parotitis (1)^a Typhoid fever (1)^a Urinary tract infection (1)^a	Artemether‐lumefantrine Cerebral malaria (1)^a Immunosuppression (1)^a
Sagara 2018^d	Elevated ALT (2)^c Elevated AST (2)^c Transaminases increased (4)^c Drug‐induced liver injury (1)^c Hypercreatininemia (1)^c	Artemether‐lumefantrine Drug‐induced liver injury (1)^c Toxic epidermal necrolysis (1)^c Artesunate‐amodiaquine Drug‐induced liver injury (1)^c Transaminases increased (2)^c

Trial	Fever clearance time		Parasite clearance time
Trial	PY‐AS	AL	PY‐AS	AL
Kayentao 2012	Median 8.1 h (95% CI 8.0 to 8.1)	Median 8.1 h (95% CI 8.0 to 15.8)	Median 24.1 h (95% CI 24.0 to 24.1)	Median 24.2 h (95% CI 24.1 to 32.0)
Roth 2018	Median 1 day (1‐1)	Median 1 day (1‐1)	Median 1 day (1‐2)	Median 2 days (1‐2)
Tshefu 2010	Mean 13.6 h (SD 8.9)	Mean 14.8 h (SD 10.1)	23.3 h (SD 8.8)	26.5 h (10.1)

Comparator drug	Trial	Pyronaridine‐artesunate		Comparator
Comparator drug	Trial	ECG abnormalities	Number of participants	ECG abnormalities	Number of participants
Artemether‐lumefantrine	Sagara 2018	55	673	99	671
Amodiaquine‐artesunate	Sagara 2018	34	669	91	668
Chloroquine	Poravuth 2011^a	1	228	6	228
Chloroquine	Shin 2011^a	0	15	1	15
Dihydroartemisinin‐piperaquine or artesunate alone	Nelwan 2015^b	0	60	1	120
Total		90	1645	198	1702

Date	Event	Description
8 January 2019	New citation required and conclusions have changed	We included four new studies: three published after the previous version of this review, Bukirwa 2014, and one that was not identified in the previous review. During re‐extraction of data from the previous studies we used a transparent, itemized, and replicable procedure that differed from Bukirwa 2014. The inclusion of new studies has allowed a new comparison of pyronaridine‐artesunate and artesunate‐amodiaquine, and has led to changes in the certainty of the evidence in relation to the primary outcomes. This review update gives higher‐certainty evidence in relation to the effect of pyronaridine‐artesunate on raised alanine aminotransferase (ALT).
8 January 2019	New search has been performed	There is a new author team: Joseph Pryce, Paul Hine (new contact person). We use the term pyronaridine‐artesunate in preference to artesunate‐pyronaridine to reflect how most authors refer to the intervention. We updated the background to reflect changes in global epidemiology, current World Health Organization (WHO) guidelines, and other developments. We added the term ‘pyramax' to the search strategy. We replaced the quantitative analysis of secondary outcomes ‘parasite clearance', ‘fever clearance', and ‘gametocyte carriage' with a narrative synthesis, and comment on the reasons for doing so. We simplified the ‘Adverse events' outcomes to reflect that elevated liver function tests are a primary area of interest. We itemized the procedure for data extraction to ensure that the process is transparent and replicable in future review updates. We have added further commentary regarding the data extraction process. We simplified the ‘Risk of bias' assessment for adverse events. We abbreviated the content of tables to enable clear and succinct presentation. We incorporated risk of bias for adverse events assessments into the main ‘Risk of bias' tables. We added an appendix to summarize our ‘Risk of bias' assessment process.

Category	Severity	Description
1	Mild	Elevated ALT/ALP concentration reaching clinical chemistry criteria for drug‐induced liver injury, but bilirubin concentration < 2 × ULN
2	Moderate	Elevated ALT/ALP concentration reaching criteria for drug‐induced liver injury, and bilirubin concentration ≥ 2 × ULN, or symptomatic hepatitis
3	Severe	Elevated ALT/ALP concentration reaching criteria for drug‐induced liver injury, bilirubin concentration ≥ 2× ULN, and one of the following. International normalized ratio ≥ 1.5 Ascites and/or encephalopathy, disease duration < 26 weeks, and absence of underlying cirrhosis Other organ failure considered to be due to drug‐induced liver injury
4	Fatal or transplantation	Death or transplantation due to drug‐induced liver injury

Search set	CIDG SR^a	CENTRAL	MEDLINE^b	Embase^b	LILACS^b
1	Malaria	Malaria ti, ab, kw	Malaria ti, ab, Mesh	Malaria.mp Emtree	malaria
2	pyronaridine	Pyronaridine ti, ab, kw	"pyronaridine"ti, ab, Supplementary Concept	pyronaridine/ or artesunate plus pyronaridine/ or pyronaridine.mp.	pyronaridine
3	pyramax	Pyramax ti, ab, kw	"Naphthyridines" Mesh	Pyramax.mp	pyramax
4	2 or 3	2 or 3	Pyramax ti, ab	2 or 3	2 or 3
5	1 and 4	1 and 4	2 or 3 or 4	1 and 4	1 and 4
6	—	—	1 and 5		—

Potential bias	Authors' judgement^a
Random sequence generation (selection bias)	High – not randomized or quasi‐randomized Unclear – states "randomized", but does not report method Low – describes method of randomization
Allocation concealment (selection bias)	High – not concealed, open‐label trial for individually randomized, method of concealment not adequate Unclear – details of method not reported or insufficient details Low – central allocation, sequentially numbered opaque sealed envelopes
Blinding (performance bias and detection bias)	High – personnel, participants or outcome assessors not blinded Unclear – no details reported, insufficient details reported Low – personnel, participants and outcome assessors blinded
Incomplete outcome data (attrition bias)	High – losses to follow‐up not evenly distributed across intervention and control group Unclear ‐ no details reported, insufficient details reported Low – losses to follow‐up evenly distributed across groups, reasons for loss to follow‐up and exclusions clearly stated
Selective reporting (reporting bias)	High – did not fully report measured or relevant outcomes Unclear – not enough information reported to judge Low – all stated outcomes reported
Other bias	High – other source of bias identified by review authors Low – no obvious other source of bias of concern to review authors
Adverse event monitoring (detection bias)	High – passive methods relying on spontaneous patient report only, undefined adverse events Unclear – not enough information reported to judge Low – key adverse events defined, prespecified active detection method
Incomplete adverse event reporting (reporting bias)	High – adverse event severity undefined, combination of treatment groups, post hoc cut‐offs for reporting adopted Unclear – not enough information reported to judge Low – clear reporting on important adverse events with numerical data by intervention group

Analysis^a	Participants	PCR^b‐unadjusted		PCR‐adjusted
Analysis^a	Participants	Numerator	Denominator	Numerator	Denominator
Primary analysis	Exclusions after enrolment	Excluded^c	Excluded	Excluded	Excluded
	Missing or indeterminate PCR	Included as failures	Included	Excluded	Excluded
	New infections	Included as failures	Included	Excluded	Excluded
Sensitivity analysis 1^d	As ‘Primary analysis' except: missing or indeterminate PCR	—	—	Included as failures	Included
Sensitivity analysis 2^e	As ‘Sensitivity analysis 1' except: new infections	—	—	Included as successes	Included
Sensitivity analysis 3^f	As ‘Sensitivity analysis 2' except: exclusions after enrolment	Included as failures	Included	Included as failures	Included
Sensitivity analysis 4^g	As ‘Sensitivity analysis 2' except: exclusions after enrolment	Included as successes	Included	Included as successes	Included

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Total failure: day 42 (PCR‐adjusted)	7	2575	Risk Ratio (M‐H, Random, 95% CI)	0.86 [0.49, 1.51]
2 Total failure: day 28 (PCR‐adjusted)	7	3068	Risk Ratio (M‐H, Random, 95% CI)	0.59 [0.26, 1.31]
3 Total failure: day 28 (unadjusted)	7	3149	Risk Ratio (M‐H, Random, 95% CI)	0.27 [0.13, 0.58]
4 Total failure: day 42 (unadjusted)	7	3080	Risk Ratio (M‐H, Random, 95% CI)	0.61 [0.46, 0.82]
5 Early treatment failure	7	3149	Risk Ratio (M‐H, Fixed, 95% CI)	2.53 [0.12, 52.39]
6 Serious adverse events	3	2004	Risk Ratio (M‐H, Fixed, 95% CI)	0.90 [0.19, 4.22]
7 Adverse events leading to withdrawal	3	2004	Risk Ratio (M‐H, Fixed, 95% CI)	1.41 [0.68, 2.90]
8 First treatment, ALT increase > 5 × ULN	7	3327	Risk Ratio (M‐H, Fixed, 95% CI)	2.92 [1.15, 7.41]
9 First treatment, AST increase > 5 × ULN	7	3327	Risk Ratio (M‐H, Fixed, 95% CI)	2.20 [0.83, 5.82]
10 First treatment, bilirubin increase > 2.5 × ULN	6	3130	Risk Ratio (M‐H, Fixed, 95% CI)	0.82 [0.33, 2.04]
11 Subsequent treatment(s), ALT increase > 5 × ULN	4	865	Risk Ratio (M‐H, Random, 95% CI)	2.54 [0.49, 13.10]
12 Subsequent treatment(s), AST increase > 5 × ULN	4	865	Risk Ratio (M‐H, Random, 95% CI)	1.88 [0.50, 7.06]
13 Subsequent treatment(s), bilirubin increase > 2.5 × ULN	4	865	Risk Ratio (M‐H, Random, 95% CI)	0.77 [0.16, 3.63]
14 Paediatric trials ‐ total failure: day 28 (PCR‐adjusted)	2	684	Risk Ratio (M‐H, Random, 95% CI)	1.02 [0.13, 7.84]
15 Paediatric trials ‐ total failure: day 42 (PCR‐adjusted)	2	558	Risk Ratio (M‐H, Random, 95% CI)	1.03 [0.41, 2.59]
16 Paediatric trials ‐ total failure: day 28 (unadjusted)	2	693	Risk Ratio (M‐H, Random, 95% CI)	0.77 [0.50, 1.18]
17 Paediatric trials ‐ total failure: day 42 (unadjusted)	2	654	Risk Ratio (M‐H, Random, 95% CI)	0.99 [0.74, 1.33]
18 Paediatric trials ‐ first treatment, ALT increase > 5 × ULN	2	732	Risk Ratio (M‐H, Fixed, 95% CI)	0.51 [0.03, 8.06]
19 Paediatric trials ‐ first treatment, AST increase > 5 × ULN	2	732	Risk Ratio (M‐H, Fixed, 95% CI)	1.52 [0.16, 14.52]

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Total failure: day 28 (PCR‐adjusted)	6	1245	Risk Ratio (M‐H, Random, 95% CI)	0.55 [0.11, 2.77]
2 Total failure: day 42 (PCR‐adjusted)	6	1091	Risk Ratio (M‐H, Random, 95% CI)	0.98 [0.20, 4.83]
3 Total failure: day 28 (unadjusted)	6	1257	Risk Ratio (M‐H, Random, 95% CI)	0.49 [0.30, 0.81]
4 Total failure: day 42 (unadjusted)	6	1235	Risk Ratio (M‐H, Random, 95% CI)	0.98 [0.78, 1.23]
5 First treatment, ALT increase > 5 × ULN	6	1317	Risk Ratio (M‐H, Fixed, 95% CI)	1.41 [0.28, 7.09]
6 First treatment, AST increase > 5 × ULN	6	1317	Risk Ratio (M‐H, Fixed, 95% CI)	0.40 [0.08, 2.07]
7 First treatment, bilirubin increase > 2.5 × ULN	6	1317	Risk Ratio (M‐H, Fixed, 95% CI)	0.99 [0.06, 15.76]
8 Subsequent treatment(s), ALT increase > 5 × ULN	6	784	Risk Ratio (M‐H, Fixed, 95% CI)	1.93 [0.48, 7.76]
9 Subsequent treatment(s), AST increase > 5 × ULN	6	784	Risk Ratio (M‐H, Fixed, 95% CI)	1.80 [0.49, 6.62]
10 Subsequent treatment(s), bilirubin increase > 2.5 × ULN	6	784	Risk Ratio (M‐H, Fixed, 95% CI)	1.80 [0.33, 9.83]

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Total failure: day 28 (PCR‐adjusted)	1	1117	Risk Ratio (M‐H, Random, 95% CI)	0.37 [0.13, 1.05]
2 Total failure: day 42 (PCR‐adjusted)	1	1037	Risk Ratio (M‐H, Random, 95% CI)	1.80 [0.90, 3.57]
3 Total failure: day 28 (unadjusted)	1	1120	Risk Ratio (M‐H, Random, 95% CI)	0.36 [0.17, 0.78]
4 Total failure: day 42 (unadjusted)	1	1059	Risk Ratio (M‐H, Random, 95% CI)	0.84 [0.54, 1.31]
5 Serious adverse events	1	1271	Risk Ratio (M‐H, Fixed, 95% CI)	1.00 [0.25, 3.97]
6 Adverse events leading to withdrawal	1	1271	Risk Ratio (M‐H, Fixed, 95% CI)	0.62 [0.17, 2.31]
7 First treatment, ALT increase > 5 × ULN	1	1271	Risk Ratio (M‐H, Fixed, 95% CI)	7.48 [0.99, 56.45]
8 First treatment, AST increase > 5 × ULN	1	1271	Risk Ratio (M‐H, Fixed, 95% CI)	9.49 [0.55, 162.64]
9 First treatment, bilirubin increase > 2.5 × ULN	1	1271	Risk Ratio (M‐H, Fixed, 95% CI)	3.49 [0.43, 28.29]

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Serious adverse events	7	3941	Risk Ratio (M‐H, Fixed, 95% CI)	1.24 [0.54, 2.84]
2 Adverse events leading to withdrawal	6	3911	Risk Ratio (M‐H, Fixed, 95% CI)	1.06 [0.58, 1.94]
3 First treatment, ALT increase > 5 × ULN	14	6581	Risk Ratio (M‐H, Fixed, 95% CI)	3.34 [1.63, 6.84]
4 First treatment, AST increase > 5 × ULN	14	6581	Risk Ratio (M‐H, Fixed, 95% CI)	1.80 [0.89, 3.65]
5 First treatment, bilirubin increase > 2.5 × ULN	13	6384	Risk Ratio (M‐H, Fixed, 95% CI)	1.03 [0.49, 2.18]
6 Subsequent treatment(s), ALT increase > 5 × ULN	7	1649	Risk Ratio (M‐H, Fixed, 95% CI)	2.18 [0.76, 6.27]
7 Subsequent treatment(s), AST increase > 5 × ULN	7	1649	Risk Ratio (M‐H, Fixed, 95% CI)	1.82 [0.74, 4.44]
8 Subsequent treatment(s), bilirubin increase > 2.5 × ULN	7	1649	Risk Ratio (M‐H, Fixed, 95% CI)	1.13 [0.42, 3.01]
9 Sensitivity analysis: first treatment, ALT increase > 5 × ULN	10	5672	Risk Ratio (M‐H, Fixed, 95% CI)	4.07 [1.83, 9.05]
10 Other adverse events	10		Risk Ratio (M‐H, Fixed, 95% CI)	Subtotals only
10.1 Blood and lymphatic: anaemias	4	4517	Risk Ratio (M‐H, Fixed, 95% CI)	1.15 [0.86, 1.54]
10.2 Blood and lymphatic: eosinophilic disorders	2	2543	Risk Ratio (M‐H, Fixed, 95% CI)	1.29 [0.86, 1.93]
10.3 Blood and lymphatic: leukocytoses	2	2615	Risk Ratio (M‐H, Fixed, 95% CI)	0.76 [0.42, 1.37]
10.4 Blood and lymphatic: neutropaenias	2	2616	Risk Ratio (M‐H, Fixed, 95% CI)	0.83 [0.63, 1.10]
10.5 Cardiac: cardiac arrhythmias	1	180	Risk Ratio (M‐H, Fixed, 95% CI)	5.95 [0.25, 143.93]
10.6 Cardiac: cardiac signs and symptoms	5	2108	Risk Ratio (M‐H, Fixed, 95% CI)	0.57 [0.37, 0.89]
10.7 Cardiac: myocardial disorders	1	30	Risk Ratio (M‐H, Fixed, 95% CI)	0.33 [0.01, 7.58]
10.8 Ear: ear disorders	1	197	Risk Ratio (M‐H, Fixed, 95% CI)	0.32 [0.01, 7.69]
10.9 Gastrointestinal: diarrhoea (excl infective)	4	411	Risk Ratio (M‐H, Fixed, 95% CI)	2.56 [1.10, 5.99]
10.10 Gastrointestinal: dyspeptic signs and symptoms	1	30	Risk Ratio (M‐H, Fixed, 95% CI)	3.0 [0.13, 68.26]
10.11 Gastrointestinal: GI and abdominal pains	7	4544	Risk Ratio (M‐H, Fixed, 95% CI)	1.12 [0.87, 1.45]
10.12 Gastrointestinal: nausea and vomiting symptoms	9	5534	Risk Ratio (M‐H, Fixed, 95% CI)	0.91 [0.71, 1.17]
10.13 General: asthenic conditions	2	653	Risk Ratio (M‐H, Fixed, 95% CI)	1.32 [0.64, 2.75]
10.14 General: general signs and symptoms	1	535	Risk Ratio (M‐H, Fixed, 95% CI)	1.20 [0.54, 2.70]
10.15 General: feelings and sensations	1	197	Risk Ratio (M‐H, Fixed, 95% CI)	4.75 [0.23, 97.79]
10.16 General: febrile disorders	2	715	Risk Ratio (M‐H, Fixed, 95% CI)	1.39 [0.65, 2.96]
10.17 General: pain and discomfort	1	197	Risk Ratio (M‐H, Fixed, 95% CI)	0.19 [0.01, 3.91]
10.18 Infections and infestations: eye and eyelid	1	30	Risk Ratio (M‐H, Fixed, 95% CI)	3.0 [0.13, 68.26]
10.19 Infections and infestations: LRTI and lung	2	3216	Risk Ratio (M‐H, Fixed, 95% CI)	0.96 [0.83, 1.11]
10.20 Infections and infestations: URTI	7	5350	Risk Ratio (M‐H, Fixed, 95% CI)	1.03 [0.88, 1.20]
10.21 Investigations: ECG	4	3347	Risk Ratio (M‐H, Fixed, 95% CI)	0.46 [0.36, 0.58]
10.22 Investigations: skeletal/cardiac muscle analyses	2	636	Risk Ratio (M‐H, Fixed, 95% CI)	1.32 [0.55, 3.15]
10.23 Investigations: physical exam	1	30	Risk Ratio (M‐H, Fixed, 95% CI)	0.33 [0.01, 7.58]
10.24 Investigations: platelet	2	565	Risk Ratio (M‐H, Fixed, 95% CI)	0.92 [0.55, 1.56]
10.25 Investigations: protein	1	535	Risk Ratio (M‐H, Fixed, 95% CI)	0.67 [0.36, 1.24]
10.26 Metabolism and nutrition: appetite disorders	3	683	Risk Ratio (M‐H, Fixed, 95% CI)	1.47 [0.80, 2.68]
10.27 Metabolism and nutrition: hypoglycaemia conditions	1	535	Risk Ratio (M‐H, Fixed, 95% CI)	0.85 [0.50, 1.46]
10.28 Metabolism and nutrition: metabolic disorders	1	2681	Risk Ratio (M‐H, Fixed, 95% CI)	0.88 [0.61, 1.29]
10.29 MSK and connective tissue: muscle pains	3	1924	Risk Ratio (M‐H, Fixed, 95% CI)	1.40 [0.97, 2.01]
10.30 MSK and connective tissue: pain and discomfort	1	197	Risk Ratio (M‐H, Fixed, 95% CI)	0.32 [0.01, 7.69]
10.31 Nervous system: headaches	9	6271	Risk Ratio (M‐H, Fixed, 95% CI)	1.09 [0.90, 1.32]
10.32 Nervous system: sleep disturbance	1	180	Risk Ratio (M‐H, Fixed, 95% CI)	0.66 [0.03, 15.99]
10.33 Nervous system: paraesthesias and dysasthesias	1	30	Risk Ratio (M‐H, Fixed, 95% CI)	0.33 [0.01, 7.58]
10.34 Respiratory: coughing and assoc symptoms	6	6412	Risk Ratio (M‐H, Fixed, 95% CI)	0.99 [0.82, 1.19]
10.35 Respiratory: upper respiratory tract signs and symptoms	3	407	Risk Ratio (M‐H, Fixed, 95% CI)	1.80 [0.32, 10.07]
10.36 Renal and urinary: urinary abnormalities	1	197	Risk Ratio (M‐H, Fixed, 95% CI)	1.90 [0.18, 20.63]
10.37 Skin and subcutaneous tissue: dermatitis and eczema	2	276	Risk Ratio (M‐H, Fixed, 95% CI)	1.01 [0.15, 6.99]
10.38 Skin and subcutaneous tissue: pruritis	2	184	Risk Ratio (M‐H, Fixed, 95% CI)	0.25 [0.13, 0.49]
10.39 Skin and subcutaneous tissue: rashes, eruptions, exanthems	1	197	Risk Ratio (M‐H, Fixed, 95% CI)	1.90 [0.18, 20.63]
10.40 Skin and subcutaneous tissue: urticaria	1	30	Risk Ratio (M‐H, Fixed, 95% CI)	0.33 [0.01, 7.58]
10.41 Vascular: vascular hypotensive disorders	1	30	Risk Ratio (M‐H, Fixed, 95% CI)	0.33 [0.01, 7.58]

Methods	RCT Duration: 1 year, November 2007 to November 2008
Participants	Children with P falciparum malaria Number: 535, randomized 2:1 Inclusion criteria: age ≤ 12 years; bodyweight 5 kg ‐ 25 kg; fever or history of fever within 24 hours Exclusion criteria: severe/complicated malaria; mixed Plasmodium infection; other clinically significant disorder; severe vomiting; severe diarrhoea; viral hepatitis/HIV; malnutrition; QTc ≥ 450 ms; other febrile conditions; hepatic impairment (AST/ALT > 2.5x ULN); renal impairment; electrolyte imbalance; anaemia (Hb < 8 g/dL); allergy to study drugs; antimalarial therapy in previous 2 weeks, investigational drug in previous 4 weeks; taking any drug metabolized by cytochrome enzyme CYP2D6; previous participation in pyronardine‐artesunate studies; pregnancy/lactation; unable to comply with follow‐up visits Diagnosis: microscopy (asexual parasite density 1000‐200,000/µL blood) Children under 5: 152 (pyronaridine‐artesunate); 64 (artemether‐lumefantrine)
Interventions	Pyronaridine‐artesunate granule formulation (60 mg:20 mg) once‐daily for 3 days. Dose according to bodyweight: 5 kg ‐ 9 kg one sachet; 9 kg ‐ 17 kg 2 sachets; 17 kg ‐ 25 kg, 3 sachets. Range = 6.7/2.2 mg/kg/dose to 13.3/4.4 mg/kg/dose Artemether‐lumefantrime crushed tablets (20 mg/120 mg) twice daily for 3 days at recommended intervals. Dose according to bodyweight: 5 kg ‐15 kg one tablet, 15 kg ‐25 kg 2 tablets. Range = 1.3/8.0 mg to 3.0/24.0 mg/kg/dose
Outcomes	ACPR day 28 PCR‐adjusted ACPR day 28 unadjusted ACPR day 42 PCR‐adjusted ACPR day 42 unadjusted Parasite clearance time (from first dose to aparasitaemia)†, ‡ Fever clearance time (from first dose to apyrexia)†, ‡ Proportion of patients with parasite clearance on days 1, 2, and 3, ‡ Proportion of patients with fever clearance on days 1, 2, and 3, ‡ Gametocyte density, ‡ Proportion of patients with gametocytes Adverse events (including laboratory and ECG abnormalities) †Two consecutive normal readings taken between 7 and 25 hours apart ‡Not assessed in quantitative synthesis in this review
Notes	Location: Africa (n = 514, 96%) and Asia (n = 21, 4%). Africa: Burkina Faso, DRC, Gabon, Côte d’Ivoire, Kenya, Mali. Asia: the Philippines Setting: Local hospitals and clinics Malaria endemicity: high Resistance profile: not described Source of funding: Medicines for Malaria Venture, Shin Poong Pharmaceutical Company Ltd, Seoul, Republic of Korea Follow‐up: 42 days
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Computer generated randomization schedule
Allocation concealment (selection bias)	Low risk	Individually numbered treatment packs of similar appearance masked on allocation
Blinding (performance bias and detection bias)   All outcomes	Low risk	Patients not blinded ("drugs given open‐label") Clinical and parasitological assessments blinded
Incomplete outcome data (attrition bias)   All outcomes	Low risk	Report lists reasons for attrition and exclusions
Selective reporting (reporting bias)	Low risk	Prospectively registered. Report includes all prestated outcomes of interest
Other bias	Low risk	3 authors declared conflicting interests (employees of funders); blind to treatment allocation
Adverse event monitoring (detection bias)   Adverse Events	Unclear risk	Authors do not fully describe method for detection of adverse events, includes biochemical and ECG monitoring. Authors do not give definitions of all adverse events. Uses higher ULN values for grading of hepatic enzyme severity compared to other studies
Incomplete adverse event reporting (reporting bias)   Adverse events	Low risk	All adverse events reported. Supplementary tables detail laboratory variables at each assessment

Methods	RCT Duration: 1 year, 4 months. March 2013 to July 2014
Participants	Adult soldiers with P vivax malaria Number: 180 Inclusion criteria: age 18 ‐ 65 years; travelled to NE Papua within 12 months; bodyweight 40 kg ‐ 90 kg Exclusion criteria: G6PD deficiency; P falciparum monoinfection, hospitalization, anaemia (Hb < 7 g/dL), planned absence from military base; clinically significant disorders; QTc ≥ 450 ms; family history prolonged QTc/sudden death; concomitant drugs known to prolong QT; hepatic impairment (AST/ALT > 2.5 x ULN); renal impairment; viral hepatitis; allergy to study drugs; previous participation; recent antimalarials Diagnosis: microscopy of P vivax, confirmed by a second microscopist
Interventions	Artesunate tablets (200 mg day 0, 100 mg days 1‐6), followed by primaquine Pyronaridine‐artesunate tablets (180 mg:60 mg) once‐daily for 3 days. Dose according to bodyweight: 24 kg ‐ 45 kg 2 tablets, 45 kg ‐ 65 kg 3 tablets, ≥ 65 kg 4 tablets. Concurrent primaquine. Dihydroartemisinin‐piperaquine tablets (40 mg:320 mg) once‐daily for 3 days. Dose according to bodyweight: < 75 kg ‐ 3 tablets, ≥ 75 kg ‐ 4 tablets. Concurrent primaquine.
Outcomes	Adverse events Relapse of P vivax* (incidence density) *Not assessed in quantitative synthesis in this review
Notes	Location: Indonesia, in travellers returning from Papua Setting: army base Malaria endemicity: no known risk of malaria in study site Resistance profile: the infections were by the chloroquine‐resistant and primaquine‐tolerant Chesson‐like P vivax strains Source of funding: sponsored by the ALERT Asia Foundation (Indonesia), funded by Medicines for Malaria Venture (Switzerland) Follow‐up: 1 year
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	"Statistician block‐allocated treatment assignments by varying blocking number at random"
Allocation concealment (selection bias)	Low risk	Sealed envelope
Blinding (performance bias and detection bias)   All outcomes	Low risk	Unclear if participants or assessing clinicians were blinded. Parasitological assessments blinded
Incomplete outcome data (attrition bias)   All outcomes	Low risk	Report lists reasons for attrition and exclusions
Selective reporting (reporting bias)	Low risk	Prospective registration, reports all a priori outcomes
Other bias	Low risk	MMV played an advisory role, but had no role in study conduct or analysis
Adverse event monitoring (detection bias)   Adverse Events	Unclear risk	Authors do not fully describe schedule for detection of adverse events, includes biochemical and ECG monitoring. Authors do not clearly define adverse events, including significant raise in hepatic enzymes
Incomplete adverse event reporting (reporting bias)   Adverse events	Unclear risk	Reports numbers of adverse events by grade, but do not define grading used

Methods	RCT Duration: 1 year, March 2007 to March 2008
Participants	Adults and children with P vivax malaria Number: 456 Inclusion criteria: age 3 ‐ 60 years; fever or history of fever within 24 hours; bodyweight 20 kg ‐ 90 kg Exclusion criteria: severe/complicated malaria; mixed Plasmodium infection; severe vomiting; other clinical condition recurring hospitalization; other clinically significant disorder; viral hepatitis/HIV; malnutrition; QTc ≥ 450 ms; other febrile conditions; hepatic impairment (AST/ALT > 2.5 x ULN); renal impairment; anaemia (Hb < 8 g/dL); allergy to study drugs; antimalarial therapy in previous 2 weeks (or antibacterial with antimalarial effect); investigational drug in previous 4 weeks; previous participation in pyronaridine‐artesunate studies; pregnancy/lactation; unable to comply with follow‐up visits Diagnosis: microscopy of P vivax (parasite density ≥ 250/mL blood, including > 50% asexual parasites)
Interventions	Pyronaridine‐artesunate tablets (180 mg:60 mg) once‐daily for 3 days. Dose according to bodyweight: 20 kg ‐ 25 kg one tablet; 26 kg ‐ 44 kg two tablets; 65 kg ‐ 90 kg, 3 tablets. Range = 7.2/2.4 to 13.8/4.6 mg/kg/dose Chloroquine 620 mg on day 0 and 1, and 310 mg on day 2. The chloroquine target dose for children was 10 mg/kg on days 0 and 1, and 5 mg/kg on day 2
Outcomes	Adverse events Cure rate day 14* Cure rates day 21, 35, and 42* Fever clearance time (from first dose to apyrexia)†* Proportions afebrile and aparasitaemic on days 1, 2, and 3* *Not assessed in quantitative synthesis in this review †Two consecutive normal readings taken between 7 and 25 hours apart
Notes	Location: Asia (Cambodia, India, Indonesia, and Thailand) Setting: local hospitals Malaria endemicity: high Resistance profile: not described Source of funding: Medicines for Malaria Venture, Shin Poong Pharmaceutical Company Ltd, Seoul, Republic of Korea Follow‐up: 42 days
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Computer generated randomization scheme
Allocation concealment (selection bias)	Low risk	Sealed opaque envelopes
Blinding (performance bias and detection bias)   All outcomes	Low risk	Doubly‐dummy ‐ study drug and matching placebo, packaged similarly All study investigators, laboratory technicians, and patients blind to treatment assignment Investigator calculated the appropriate dose and study drug was administered by a different member of staff
Incomplete outcome data (attrition bias)   All outcomes	Low risk	Report lists reasons for attrition and exclusions
Selective reporting (reporting bias)	Low risk	Prospectively registered. Report includes all prestated outcomes of interest
Other bias	Low risk	3 authors declared conflicting interests (employees of funders); blind to treatment allocation
Adverse event monitoring (detection bias)   Adverse Events	Unclear risk	Authors do not fully describe method for detection of adverse events, but describe interval for ECG assessment. Authors do not give definitions of all adverse events
Incomplete adverse event reporting (reporting bias)   Adverse events	Low risk	All‐cause adverse events enumerated. Report table only includes adverse events occurring in ≥ 2% (or ≥ 1% if judged to be drug‐related)

Methods	RCT Duration: 1 year, 1 month: April 1994 to May 1995
Participants	Adults (> 15 years) with P falciparum malaria Number: 96 Inclusion criteria: fever or history of fever within 24 hours Exclusion criteria: severe/complicated malaria; mixed Plasmodium infection; recent self‐medication; pregnancy Diagnosis: thin film microscopy of P falciparum (asexual parasite density > 5000/µL blood)
Interventions	Pyronaridine: 32 mg/kg in divided doses over 3 days: 16 mg/kg on day 0; 8 mg/kg on days 1 and 2 Chloroquine: 25 mg/kg in divided doses over 3 days: 10 mg/kg on days 0 and 1; 5 mg/kg on day 2
Outcomes	Adverse events Fever clearance (time from onset of treatment until temp remained below 37.5°C)* Parasite clearance (time until the first negative tick blood smear, with subsequent smears negative)* Early treatment failure* Parasitaemia on day 14* Gametocyte carriage at day 14* In vitro drug susceptibility* *Not assessed in quantitative synthesis in this review
Notes	Location: Cameroon Setting: dispensary (outpatients) Malaria endemicity: high Resistance profile: 57% of isolates chloroquine‐resistant Source of funding: French Ministere de la Co‐operation (Grant 93A43); pyronaridine was supplied by the Institute of Parasitic Diseases, Chinese Academy of Preventive Medicine, Shangai, China Follow‐up: 14 days
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Block randomization (blocks of 10); from communication with authors recorded by previous version of this review
Allocation concealment (selection bias)	Low risk	Central randomization; from communication with authors recorded by previous version of this review
Blinding (performance bias and detection bias)   All outcomes	Low risk	Blinded, but tablets were different and patients treated with chloroquine suffered pruritis; from communication with authors recorded by previous version of this review
Incomplete outcome data (attrition bias)   All outcomes	Low risk	Report lists reasons for attrition and exclusions; unlikely to have differentially influenced liver toxicity outcomes used in this review
Selective reporting (reporting bias)	Low risk	Trial not prospectively registered, trial protocol not available. However, all outcomes stated in methods reported
Other bias	Low risk	None identified
Adverse event monitoring (detection bias)   Adverse Events	Unclear risk	Authors do not fully describe method for detection of adverse events. Authors do not give definitions of all adverse events
Incomplete adverse event reporting (reporting bias)   Adverse events	Unclear risk	Authors give brief narrative description of adverse events only. Report does not detail extent of elevation in liver transaminases or the proportions retested at day 14

Methods	RCT Duration not stated. Year 1996
Participants	Children (< 15 years) with P falciparum malaria Number: 88 Inclusion criteria: fever or history of fever within 24 hours Exclusion criteria: severe/complicated malaria; mixed Plasmodium infection; recent self‐medication; pregnancy; anaemia (Hb < 5g/dL), moderate to severe malnutrition. Diagnosis: thin film microscopy of P falciparum (asexual parasite density > 5000/µL blood)
Interventions	Pyronaridine: 32 mg/kg in divided doses over 3 days: 16 mg/kg on day 0; 8 mg/kg on days 1 and 2 Chloroquine: 25 mg/kg in divided doses over 3 days: 10 mg/kg on days 0 and 1; 5 mg/kg on day 2
Outcomes	Adverse events Fever clearance (time from onset of treatment until temp remained below 37.5°C)* Parasite clearance (time until the first negative tick blood smear, with subsequent smears negative)* Early treatment failure* Parasitaemia on day 14* Gametocyte carriage at day 14* *Not assessed in quantitative synthesis in this review
Notes	Location: Cameroon Setting: dispensary (outpatients) Malaria endemicity: high Resistance profile: 49% of isolates chloroquine‐resistant Source of funding: French Ministere de la Co‐operation (Grant 93A43); pyronaridine was supplied by the Institute of Parasitic Diseases, Chinese Academy of Preventive Medicine, Shangai, China Follow‐up: 14 days
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Block randomization (blocks of 10); from communication with authors recorded by previous version of this review
Allocation concealment (selection bias)	Low risk	Central randomization; from communication with authors recorded by previous version of this review
Blinding (performance bias and detection bias)   All outcomes	Low risk	Blinded, but tablets were different and patients treated with chloroquine suffered pruritis; from communication with authors recorded by previous version of this review
Incomplete outcome data (attrition bias)   All outcomes	Low risk	Report and subsequent correspondence from authors lists reasons for attrition and exclusions; unlikely to have differentially influenced liver toxicity outcomes used in this review
Selective reporting (reporting bias)	Low risk	Trial not prospectively registered, trial protocol not available. However, all outcomes stated in methods reported
Other bias	Low risk	None identified
Adverse event monitoring (detection bias)   Adverse Events	Unclear risk	Authors do not fully describe method for detection of adverse events. Authors do not give definitions of all adverse events
Incomplete adverse event reporting (reporting bias)   Adverse events	Unclear risk	Authors give brief narrative description of adverse events only. Report does not detail extent of elevation in liver transaminases or the proportions retested at day 14

Methods	RCT Duration: 1 year, 5 months. October 2015 to June 2016, January 2017 to August 2017
Participants	Children with P falciparum malaria Number: 197 Inclusion criteria: age 6 months ‐ 12 years; bodyweight ≥ 5 kg Exclusion criteria: severe/complicated malaria; non‐falciparum/mixed Plasmodium infection; other clinically significant disorder; malnutrition; hepatic impairment (AST/ALT not specified); renal impairment; anaemia (Hb <6 g/dL); allergy to study drugs; current participation in other antimalarial study; previous participation in study, not available for follow‐up Diagnosis: microscopically‐confirmed P falciparum monoinfection (asexual parasite density 1000 µL‐200,000/µL) Children under 5: 31 (pyronardine‐artesunate); 31 (artemether‐lumefantrine)
Interventions	Pyronaridine‐artesunate granules (60 mg:20 mg) or tablets (180 mg:60 mg) once‐daily for 3 days. Dose according to bodyweight: 5 kg ‐ 8 kg one sachet, 8 kg ‐15 kg 2 sachets, 15 kg ‐ 20 kg 3 sachets, 20 kg ‐ 24 kg one tablet, 24 kg ‐ 45 kg 2 tablets Artemether‐lumefantrine crushed tablets (20 mg/120 mg) twice daily for 3 days at recommended intervals. Dose according to bodyweight: 5 kg ‐ 15 kg one tablet, 15 kg ‐ 25 kg 2 tablets, 25 kg ‐ 35 kg 3 tablets, ≥ 35 kg 4 tablets
Outcomes	ACPR* day 28 PCR‐adjusted ACPR day 28 unadjusted ACPR day 42 PCR‐adjusted ACPR day 42 unadjusted Parasite clearance time (from first dose to aparasitaemia)†, ‡ Fever clearance time (from first dose to apyrexia)† "Transmission potential to mosquitoes" (undefined)‡ Adverse events (including laboratory abnormalities) Proportion of patients with parasite clearance on days 1, 2, and 3, ‡ Proportion of patients with fever clearance on days 1, 2, and 3, ‡ *Adequate clinical and parasitological response rate †Two consecutive normal readings taken between 7 and 25 hours apart ‡Not assessed in quantitative synthesis in this review
Notes	Location: Kenya Setting: Local clinic Malaria endemicity: high Resistance profile: not described Source of funding: EU FP7‐Health‐2013. 0‐1 Project “Translation of the direct‐on‐blood PCR‐NALFIA system into an innovative near point‐of‐care diagnostic for malaria” (DIAGMAL) [Grant Number 601714] Follow‐up: 42 days
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Computer generated randomization schedule provided by sponsor
Allocation concealment (selection bias)	Low risk	Sequentially numbered sealed opaque envelopes
Blinding (performance bias and detection bias)   All outcomes	Low risk	Patients probably not blinded (drugs were administered by pharmacy personnel aware of group  assignments) Clincial and parasitological assessments performed by study staff blinded to treatment allocation
Incomplete outcome data (attrition bias)   All outcomes	Low risk	Report lists reasons for attrition and exclusions
Selective reporting (reporting bias)	Low risk	Authors report fever clearance time which was not in trial registration document. Unlikely to introduce significant bias
Other bias	Low risk	Target recruitment not reached Shin Poong Pharmaceutical Company (Seoul, South Korea) provided pyronaridine–artesunate tablets and granules, but had no further role in study design, data collection, data analysis and writing of the report
Adverse event monitoring (detection bias)   Adverse Events	Unclear risk	Authors describe full schedule for ALT/AST monitoring. Due to logistic constraints, ALT and AST were only measured for the first 150 participants
Incomplete adverse event reporting (reporting bias)   Adverse events	Unclear risk	Authors do not give reporting threshold for adverse events

Methods	RCT Duration: 1 year, 10 months. January 2007 to October 2008
Participants	Adults and children with P falciparum malaria Number: 1271 Inclusion criteria: age 3‐60 years; bodyweight 20 kg ‐ 90 kg; fever or history of fever within 24 hours Exclusion criteria: severe/complicated malaria; anaemia (Hb < 8 g/dL); severe vomiting; diarrhoea; pregnancy/lactation; other clinically significant disorder; hepatic impairment (undefined); renal impairment; antimalarial therapy in previous 2 weeks; investigational drug in previous 4 weeks; previous participation in study; allergy to study drugs Diagnosis: thick and thin film microscopy of P falciparum (asexual parasite density 1000 mm³‐ 100,000 mm³ blood)
Interventions	Randomized in a 2:1 ratio to: pyronaridine‐artesunate combination (7.2: 2.4 mg/kg respectively) once a day for three days (N = 848) mefloqune ‐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	ACPR* day 28 PCR‐adjusted ACPR day 28 unadjusted ACPR day 42 PCR‐adjusted ACPR day 42 unadjusted Parasite clearance time (from first dose to aparasitaemia)†, ‡ Fever clearance time (from first dose to apyrexia)†, ‡ Proportion of patients with parasite clearance on days 1, 2, and 3, ‡ Proportion of patients with fever clearance on days 1, 2, and 3, ‡ Proportion of patients with gametocytes, ‡ Gametocyte clearance time (not defined)‡ Adverse events *Adequate clinical and parasitological response rate †Two consecutive normal readings taken between 7 and 25 hours apart ‡Not assessed in quantitative synthesis in this review
Notes	Location: Asia (81%) and Africa (19%). Asia: Cambodia, India, Thailand, Vietnam. Africa: Bukina Faso, Ivory Coast, Tanzania Setting: local hospitals and health centres Malaria endemicity: high Resistance profile: in Cambodia, significantly extended parasite clearance times (for both treatment arms) were suggestive of in vivo resistance to artemisinin Source of funding: Medicines for Malaria Venture, Shin Poong Pharmaceutical Company Ltd, Seoul, Republic of Korea Follow‐up: 42 days
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Computer generated randomization schedule
Allocation concealment (selection bias)	Low risk	Individually numbered treatment packs Randomization communicated by investigator to a third party who administered the correct amount of tablets
Blinding (performance bias and detection bias)   All outcomes	Low risk	Unclear if patients blinded Outcome assessors blinded to group assignment
Incomplete outcome data (attrition bias)   All outcomes	Low risk	Report lists reasons for attrition and exclusions
Selective reporting (reporting bias)	Low risk	Prospectively registered. Report includes all prestated outcomes of interest
Other bias	Low risk	Some authors employed by trial sponsors, but all authors assumed responsibility for reporting accuracy
Adverse event monitoring (detection bias)   Adverse Events	Unclear risk	Authors do not describe methods for monitoring adverse events, but includes biochemical monitoring Authors do describe time point of assessments in protocol
Incomplete adverse event reporting (reporting bias)   Adverse events	Unclear risk	Report percentage of adverse events. Supplementary data table provided. Reports "any cause" adverse events if they occurred in > 2% of patients. Reports "treatment related" adverse events if they occurred in > 1% of patients. Does not report method of judging relation of adverse events to treatment

Methods	RCT* Duration: 4 years, 4 months. 24 October 2011 to 01 February 2016 *Different arms at different study centres; therefore we requested disaggregated data
Participants	Adults and children with P falciparum malaria Number: 4710 (2640 within pyronaridine‐artesunate subsection) Inclusion criteria: age > 2 years; bodyweight ≥ 15 kg (decreased to ≥ 5 kg after review); fever or history of fever within 24 hours Exclusion criteria: severe/complicated malaria; severe vomiting; severe diarrhoea; other clinically significant disorder including QTc ≥ 450 ms, active TB, jaundice and others; anaemia (Hb < 70 g/dL); other febrile conditions; allergy to study drugs; antimalarial therapy in previous 2 weeks; investigational drug in previous 4 weeks; pregnancy/lactation; alcohol abuse; viral hepatitis/HIV; hepatic impairment (ALT > 2 x ULN); renal impairment (1.5 x ULN) Diagnosis: positive microscopy for Plasmodium* spp. (> 0 to < 200,000 parasites/μL blood) *For pyronaridine‐artesunate group, inclusion criteria changed during the study. (i) Beginning of the study, inclusion age of 15 years or older and bodyweight of 24 kg or over, (ii) after 20 retreatments, inclusion age of 2 years or older and bodyweight of 15 kg or over, and (iii) After 40 retreatments, inclusion age of at least 6 months with bodyweight of 5 kg or over Children under 5: 344 (Pyr‐AS); 129 (AL); 249 (AS‐AQ) The total number of participants receiving at least one study treatment in each comparison are as below. Pyronaridine‐artesunate (n = 658) versus artemether‐lumefantrine (n = 665) Pyronaridine‐artesunate (n = 659) versus artesunate‐amodiaquine (n = 658) The breakdown of total participants receiving each treatment at each site is as below. Bobo‐Dioulasso, Burkina Faso: pyronardine‐artesunate (n = 212) versus artemether‐lumefantrine (n = 220) Ouagadougou, Burkina Faso: pyronaridine‐artesunate (n = 215) versus artesunate‐amodiaquine (n = 214) Bougoula, Mali: 1. PY‐AS (n = 214) versus AL (213); 2. PY‐AS (n = 94) versus artesunate‐amodiaquine (n = 98) Djoliba, Mali: pyronaridine‐artesunate (n = 87) versus AS‐AQ (n = 85) Kolle, Mali: 1. pyronaridine‐artesunate (n = 86) versus AL (87); 2. pyronaridine‐artesunate (n = 11) versus AS‐AQ (n = 11) Sotuba, Mali: 1. pyronaridine‐artesunate (n = 146) versus AL (145); 2. pyronaridine‐artesunate (n = 17) versus AS‐AQ (n = 17) Mafrinyah, Guinea: pyronaridine‐artesunate (n = 235) versus AS‐AQ (n = 233 The total numbers of participants and numbers disaggregated by each site were obtained from the trial authors in response to a request for further information in May 2017
Interventions	Pyronaridine‐artesunate granules (60 mg:20 mg) or tablets (180 mg:60 mg) once‐daily for 3 days. Dose according to bodyweight: 5 kg ‐ 8 kg one sachet, 8 kg ‐ 15 kg 2 sachets, 15 kg ‐ 20 kg 3 sachets, 20 kg ‐ 24 kg one tablet, 24 kg ‐ 45 kg 2 tablets, 45 kg ‐ 65 kg 3 tablets, ≥ 65kg 4 tablets Artemether‐lumefantrine tablets (20 mg/120 mg) twice daily for 3 days at recommended intervals. Dose according to bodyweight: 5 kg ‐ 15 kg one tablet, 15 kg ‐ 25 kg 2 tablets, 25 kg ‐ 35 kg 3 tablets, ≥ 35 kg 4 tablets Amodiaquine‐artesunate tablets once‐daily for 3 days. Dose according to bodyweight: 5 kg ‐ 9 kg one 25 mg:67.5 mg tablet, 9 kg ‐ 18 kg one 50 mg:135 mg tablet, 18 kg ‐ 36 kg one 100 mg:270 mg tablet, ≥ 36 kg two 100 mg:270 mg tablets Dihydroartemisinin‐piperaquine* *Not compared against pyronaridine‐artesunate in this trial
Outcomes	Two‐year incidence rate of all repeat malaria episodes (uncomplicated and complicated) irrespective of parasite species* Crude and PCR‐corrected ACPR for P falciparum and crude ACPR for other Plasmodium species at days 28 and 42, irrespective of axillary temperature, without previous early treatment failure, late clinical failure, or late parasitological failure Parasite clearance time (time from first dose until parasite negative, with aparasitaemia maintained for at least 48 hrs)* Reinfection and recrudescence rates over 42 days* Gametocyte density and carriage* Difference in time to the second infection between treatments* Difference in the mean interval between reinfection* Adverse events *Not assessed in quantitative synthesis in this review
Notes	Location: West Africa (Burkina Faso, Guinea, Mali), conducted by the West African Network for Clinical Trials of Antimalarial Drugs (WANECAM). Setting: tertiary health facilities Malaria endemicity: high Resistance profile: not described Source of funding: European and Developing Countries Clinical Trial Partnership, Medicines for Malaria Venture, United Kingdom Medical Research Councils, Swedish International Development Co‐operation Agency, German Ministry for Education and Research, University Claude Bernard (France), University of Science Techniques and Technologies of Bamako, Centre National de Recherche et de Formation sur le Paludisme (Burkina Faso), Institut de Recherche en Sciences de la Santé (Bobo‐ Dioulasso, Burkina Faso), and Centre National de Formation et de Recherche en Santé Rurale (Republic of Guinea) Follow‐up: 42 days active; 2 year passive
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Computer generated randomization list for each site within each country was used; block size of two
Allocation concealment (selection bias)	Low risk	Sealed, opaque, sequentially numbered envelopes
Blinding (performance bias and detection bias)   All outcomes	Low risk	Open‐label: patients and investigators not blinded to treatment allocation Microscopists assessing parasite outcomes masked to treatment allocation
Incomplete outcome data (attrition bias)   All outcomes	Low risk	Reasons provided for all withdrawals across study arms. Withdrawal numbers small and balanced across the intervention arms with reasons for withdrawal similar between groups
Selective reporting (reporting bias)	Low risk	All outcomes reported as listed in the trial register, however day 63 outcomes are not reported
Other bias	Low risk	Some authors employed by trial sponsors, but all authors assumed responsibility for reporting accuracy
Adverse event monitoring (detection bias)   Adverse Events	Low risk	Authors report that physical examinations made and adverse events recorded at all assessments. Describes ECG and biochemistry monitoring schedule. Used Medical Dictionary for Regulatory Activities (MedDRA)
Incomplete adverse event reporting (reporting bias)   Adverse events	Low risk	Authors enumerate adverse events clearly, and report events of interest. Provide supplementary tables. We were unable to extract adverse events by study site.

Methods	RCT* ‐ represents disaggregated data from Sagara 2018 (see above)
Participants	Number receiving at least one study treatment: 232
Interventions	Pyronaridine‐artesunate (n = 212) Artemether‐lumefantrine (n = 220)
Outcomes	‐
Notes	Location: Bobo, Burkina Faso
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Represents disaggregated data from Sagara 2018 (see above)
Allocation concealment (selection bias)	Low risk	‐
Blinding (performance bias and detection bias)   All outcomes	Low risk	‐
Incomplete outcome data (attrition bias)   All outcomes	Low risk	‐
Selective reporting (reporting bias)	Low risk	‐
Other bias	Low risk	‐
Adverse event monitoring (detection bias)   Adverse Events	Low risk	‐
Incomplete adverse event reporting (reporting bias)   Adverse events	Low risk	‐

PERMALINK

Pyronaridine‐artesunate for treating uncomplicated Plasmodium falciparum malaria

Joseph Pryce

Paul Hine

Abstract

Background

Objectives

Search methods

Selection criteria

Data collection and analysis

Main results

Authors' conclusions

Plain language summary

Summary of findings

Background

Description of the condition

Description of the intervention

How the intervention might work

Why it is important to do this review

Objectives

Methods

Criteria for considering studies for this review

Types of studies

Types of participants

Types of interventions

Intervention

Control

Types of outcome measures

Primary outcomes

Secondary outcomes

Adverse events (safety analysis)

Comment on outcome measures

1. Alanine aminotransferase (ALT), aspartate aminotransferase (AST), and bilirubin increase grading.

Search methods for identification of studies

Electronic searches

Searching other resources

Conference proceedings

Reference lists

Contacting organizations and experts

Data collection and analysis

Selection of studies

Data extraction and management

Unadjusted total failure rate: day 28, day 42

PCR‐adjusted total failure rate: day 28, day 42

Adverse events data

Comment on data extraction

Assessment of risk of bias in included studies

Measures of treatment effect

Unit of analysis issues

Dealing with missing data

Assessment of heterogeneity

Assessment of reporting biases

Data synthesis

Subgroup analysis and investigation of heterogeneity

Sensitivity analysis

Certainty of the evidence

Results

Description of studies

Results of the search

1.

Included studies

Studies meeting the inclusion criteria for efficacy outcomes

Comparison 1: Pyronaridine‐artesunate versus artemether‐lumefantrine

Comparison 2: Pyronaridine‐artesunate versus artesunate‐amodiaquine

Comparison 3: Pyronaridine‐artesunate versus mefloquine plus artesunate

Studies meeting the inclusion criteria for safety outcomes

Excluded studies

Risk of bias in included studies

2.

Allocation

Blinding

Incomplete outcome data

Selective reporting

Other potential sources of bias

Adverse event monitoring (detection bias)

Incomplete adverse event reporting (reporting bias)

Effects of interventions

Summary of findings for the main comparison. Pyronaridine‐artesunate (PY‐AS) compared to artemether‐lumefantrine (AL) for adults and children with uncomplicated Plasmodium falciparum malaria.

Summary of findings 2. Pyronaridine‐artesunate (PY‐AS) compared to artesunate‐amodiaquine (AS‐AQ) for adults and children with uncomplicated Plasmodium falciparum malaria.

Summary of findings 3. Pyronaridine‐artesunate (PY‐AS) compared to mefloquine plus artesunate (MQ+AS) for adults and children with uncomplicated Plasmodium falciparum malaria.

Methods	RCT Duration: 1 year, 3 months. January 2007 to April 2008
Participants	Adults and children with P falciparum malaria Number: 1272 Inclusion criteria: age 3‐60 years; bodyweight 20 kg ‐ 90 kg; fever or history of fever within 24 hours Exclusion criteria: severe/complicated malaria; mixed Plasmodium infection; malnutrition; anaemia (Hb < 8 g/dL); severe vomiting; severe diarrhoea; other clinically significant disorder; hepatic impairment (limit not stated); renal impairment; other febrile conditions; viral hepatitis/HIV; electrolyte imbalance; allergy to study drugs; antimalarial therapy in previous 2 weeks, investigational drug in previous 4 weeks; taking any drug metabolized by cytochrome enzyme CYP2D6; previous participation in pyronaridine‐artesunate studies; pregnancy/lactation Diagnosis: microscopy (asexual parasite density 1000 µL to 100,000/µL blood)
Interventions	Randomized in a 2:1 ratio to: pyronaridine‐artesunate tablets (180 mg:60 mg) once‐daily for 3 days. Dose according to bodyweight: 20 kg ‐ 25 kg one tablet, 26 kg ‐ 45 kg 2 tablets, 45 kg ‐ 65 kg 3 tablets, ≥ 65kg 4 tablets (N = 849) Artemether‐lumefantrine tablets (20 mg/120 mg) twice daily for 3 days at recommended intervals. Dose according to bodyweight: 20 kg ‐ 25 kg 2 tablets, 25 kg ‐ 35 kg 3 tablets, ≥ 35 kg 4 tablets
Outcomes	ACPR* day 28 PCR‐adjusted ACPR day 28 unadjusted ACPR day 42 PCR‐adjusted ACPR day 42 unadjusted Parasite clearance time (from first dose to aparasitaemia)†, ‡ Fever clearance time (from first dose to apyrexia)†, ‡ Proportion of patients with parasite clearance on days 1, 2, and 3, ‡ Proportion of patients with fever clearance on days 1, 2, and 3, ‡ Gametocyte density, ‡ Adverse events (including laboratory and ECG abnormalities) *Adequate clinical and parasitological response rate †Two consecutive normal readings taken between 7 and 25 hours apart ‡Not assessed in quantitative synthesis in this review
Notes	Location: Africa (n = 1080, 85%) and Asia (n = 192, 15%). Africa: DRC, The Gambia, Ghana, Kenya, Mali, Mozambique, Senegal. Asia: Indonesia, the Phillipines Setting: local hospitals and clinics Malaria endemicity: high Resistance profile: not described Funding: Medicines for Malaria Venture, Shin Poong Pharmaceutical Company Ltd, Seoul, Republic of Korea Follow‐up: 42 days
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Computer generated randomization schedule. Block randomization of 9 by study centre
Allocation concealment (selection bias)	Low risk	Individually numbered treatment packs Randomization communicated by investigator to a third party who administered the correct amount of tablets, and who was not involved in clinical assessment
Blinding (performance bias and detection bias)   All outcomes	Low risk	Patients blinded: artemether‐lumefantrine placebo dosed twice daily to maintain blinding. Food not required for artemether‐lumefantrine dosing to retain blinding Outcome assessors blinded to group assignment
Incomplete outcome data (attrition bias)   All outcomes	Low risk	Report lists reasons for attrition and exclusions
Selective reporting (reporting bias)	Low risk	Prospectively registered. Report includes prestated outcomes of interest. Day 42 efficacy outcomes and gametocyte counts not listed in trial registration document; listed in the report as exploratory
Other bias	Unclear risk	Sponsors designed the trial, were responsible for data collection and analysis, and developed the report; all authors had access to trial data Participants on artemether‐lumefantrine were not expected to take medication after food; unclear if this reduced bioavailability of lumefantrine
Adverse event monitoring (detection bias)   Adverse Events	Low risk	Report that adverse events recorded during treatment and at all follow‐up visits
Incomplete adverse event reporting (reporting bias)   Adverse events	Unclear risk	Authors report all‐cause adverse events as percentages. Report table only includes adverse events occurring in ≥ 5% (or ≥ 1% if judged to be drug related). Authors explain method for determining relation to study drug

Study	Reason for exclusion
Huang 1988	Quasi‐RCT. Randomized according to order of admission
Huang 1989	Quasi‐RCT. Odd and even numbers used for allocation
Huang 1993	RCT: conducted in people with complicated falciparum malaria
Laman 2014	Trial registration (ACTRN12610000913077) planned to use pyronaridine‐artesunate, but not available due to concerns over hepatotoxicity at time of trial
Leang 2016	Not a RCT: single‐arm observational study
Looareesuwan 1996	Not a RCT: clinical trial of two doses of pyronaridine monotherapy with group given second dose recruited after results of first dose were analysed
Looareesuwan 2007	RCT: phase II dose ranging trial
Piola 2008	Not a RCT: phase II dose ranging study
Ramharter 2008	Not a RCT: open‐label dose‐escalation study
Sagara 2014	Not a RCT: pooled analysis