Tafenoquine for preventing relapse in people with vivax malaria

What was the aim of this review?

The aim of this review was to see if tafenoquine could prevent relapses of vivax infections and if this effect is equivalent to that of standard-dose primaquine. Standard-dose primaquine is defined as 15 mg/day for 14 days for adults.

Key messages

Tafenoquine prevents vivax malaria relapses (measured as recurrences of infection in all studies as it is not possible to differentiate a true relapse from a reinfection) in adults compared to no relapse prevention treatment (placebo). There is also probably little or no difference between tafenoquine and primaquine in preventing relapses. The evidence was of moderate certainty due to the low number of studies and few data. There is probably little or no difference in the overall adverse events with tafenoquine compared to placebo or primaquine. However, we are uncertain if tafenoquine causes more serious adverse events such as a drop in blood haemoglobin.

What was studied in this review?

Vivax malaria is caused by the parasite Plasmodium vivax. The disease includes a dormant (inactive) stage of liver infection and this can cause relapse (worsening) unless it is treated.

The most frequently used medicine for relapse prevention until recently was primaquine, but now there is a new alternative named tafenoquine. The US agency responsible for protecting public health, the Food and Drug Administration (FDA), recommends tafenoquine for relapse prevention at a single 300 mg dose. Compared to primaquine, which is usually given daily for 14 days, single-day dosing provides a significant advantage. However, both primaquine and tafenoquine can cause rupture or destruction of red blood cells (called haemolysis) in people with a hereditary condition called glucose-6-phosphate dehydrogenase (G6PD) enzyme deficiency.

We conducted a Cochrane Review on the effect of tafenoquine on clearing the dormant P vivax parasites in infected people to prevent a relapse. However, it is difficult to differentiate between a true relapse and a new infection in the same individual unless the person was removed from a malaria-endemic area after initial treatment. All trials included in this review did not do that and have actually measured recurrences as a proxy measure to infer on relapses. While acknowledging this limitation, in giving recommendations and results in this review we used the word 'relapse' as preventing relapses is the intention for using tafenoquine as a single dose in these trials.

What are the main results of the review?

We examined the research published up to 3 June 2020. We identified three trials conducted in nine countries in 747 adults with confirmed P vivax malaria. All adults received chloroquine (to clear the parasites from the blood) and some groups received either tafenoquine in a single dose of 300 mg, primaquine or placebo (an inactive tablet matched for the duration of primaquine). All were observed for recurrences of P vivax malaria (up to six months) and all trials tested people for G6PD activity and excluded people who were deficient. Pregnant women and children were also excluded.

Adults receiving tafenoquine 300 mg had fewer relapses (inferred from the lower number of recurrences of infection) than adults who had placebo (moderate-certainty evidence). There was probably little or no difference between Tafenoquine 300 mg and primaquine for relapse prevention (moderate-certainty evidence). There is probably little or no difference in overall side effects between tafenoquine and primaquine (moderate-certainty evidence). We are uncertain though if tafenoquine causes more serious adverse events compared to placebo or premaquine (for example, haemolysis; very low-certainty evidence).

Authors' conclusions: 

TQ 300 mg single dose prevents relapses after clinically parasitologically confirmed P vivax malaria compared to no antihypnozoite treatment, and with no difference detected in studies comparing it to PQ to date. However, the inability to differentiate a true relapse from a recurrence in the available studies may affect these estimates. The drug is untested in children and in people with G6PD deficiency. Single-dose treatment is an important practical advantage compared to using PQ for the same purpose without an overall increase in adverse events in non-pregnant, non-G6PD-deficient adults.

Read the full abstract...
Background: 

Plasmodium vivax malaria has a persistent liver stage that causes relapse of the disease and continued P vivax transmission. Primaquine (PQ) is used to clear the liver stage of the parasite, but treatment is required for 14 days. Primaquine also causes haemolysis in people with glucose-6-phosphate dehydrogenase (G6PD) deficiency. Tafenoquine (TQ) is a new alternative to PQ with a longer half-life and can be used as a single-dose treatment.

Objectives: 

To assess the effects of tafenoquine 300 mg (single dose) on preventing P vivax relapse.

Search strategy: 

We searched the following up to 3 June 2020: the Cochrane Infectious Diseases Group Specialized Register; CENTRAL; MEDLINE; Embase; and three other databases. We also searched the WHO International Clinical Trial Registry Platform and the metaRegister of Controlled Trials for ongoing trials using "tafenoquine" and "malaria" as search terms up to 3 June 2020.

Selection criteria: 

Randomized controlled trials (RCTs) that gave TQ to prevent relapse in people with P vivax malaria. We planned to include trials irrespective of whether participants had been screened for G6PD enzyme deficiency.

Data collection and analysis: 

All review authors independently extracted data and assessed risk of bias. As true relapse and reinfection are difficult to differentiate in people living in endemic areas, studies report "recurrences" of infection as a proxy for relapse. We carried out meta-analysis where appropriate, and gave estimates as risk ratios (RR) with 95% confidence intervals (CI). We assessed the certainty of the evidence using the GRADE approach.

Main results: 

Three individually randomized RCTs met our inclusion criteria, all in endemic areas, and thus reporting recurrence. Trials compared TQ with PQ or placebo, and all participants received chloroquine (CQ) to treat the asexual infection). In all trials, pregnant and G6PD-deficient people were excluded.

Tafenoquine 300 mg single dose versus no treatment for relapse prevention

Two trials assessed this comparison. TQ 300 mg single dose reduces P vivax recurrences compared to no antihypnozoite treatment during a six-month follow-up, but there is moderate uncertainty around effect size (RR 0.32, 95% CI 0.12 to 0.88; 2 trials, 504 participants; moderate-certainty evidence).

In people with normal G6PD status, there is probably little or no difference in any type of adverse events (2 trials, 504 participants; moderate-certainty evidence). However, we are uncertain if TQ causes more serious adverse events (2 trials, 504 participants; very low-certainty evidence). Both RCTs reported a total of 23 serious adverse events in TQ groups (One RCT reported 21 events) and a majority (15 events) were a drop in haemoglobin level by > 3g/dl (or >30% reduction from baseline).

Tafenoquine 300 mg single dose versus primaquine 15 mg/day for 14 days for relapse prevention

Three trials assessed this comparison. There is probably little or no difference between TQ and PQ in preventing recurrences (proxy measure for relapse) up to six months of follow-up (RR 1.04, 95% CI 0.8 to 1.34; 3 trials, 747 participants; moderate-certainty evidence).

In people with normal G6PD status, there is probably little or no difference in any type of adverse events (3 trials, 747 participants; moderate-certainty evidence). We are uncertain if TQ can cause more serious adverse events compared to PQ (3 trials, 747 participants; very low-certainty evidence). Two trials had higher point estimates against TQ while the other showed the reverse. Most commonly reported serious adverse event in TQ group was a decline in haemoglobin level (19 out of 29 events). Some other serious adverse events, though observed in the TQ group, are unlikely to be caused by it (Hepatitis E infection, limb abscess, pneumonia, menorrhagia).

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