Piperaquine-Induced QTc Prolongation Decreases With Repeated Monthly Dihydroartemisinin-Piperaquine Dosing in Pregnant Ugandan Women

Clin Infect Dis. 2022 Aug 31;75(3):406-415. doi: 10.1093/cid/ciab965.

Abstract

Background: Intermittent preventive treatment with monthly dihydroartemisinin-piperaquine (DHA-PQ) is highly effective at preventing both malaria during pregnancy and placental malaria. Piperaquine prolongs the corrected QT interval (QTc), and it is possible that repeated monthly dosing could lead to progressive QTc prolongation. Intensive characterization of the relationship between piperaquine concentration and QTc interval throughout pregnancy can inform effective, safe prevention guidelines.

Methods: Data were collected from a randomized controlled trial, where pregnant Ugandan women received malaria chemoprevention with monthly DHA-PQ (120/960 mg DHA/PQ; n = 373) or sulfadoxine-pyrimethamine (SP; 1500/75 mg; n = 375) during the second and third trimesters of pregnancy. Monthly trough piperaquine samples were collected throughout pregnancy, and pre- and postdose electrocardiograms were recorded at 20, 28, and 36 weeks' gestation in each woman. The pharmacokinetics-QTc relationship for piperaquine and QTc for SP were assessed using nonlinear mixed-effects modeling.

Results: A positive linear relationship between piperaquine concentration and Fridericia corrected QTc interval was identified. This relationship progressively decreased from a 4.42 to 3.28 to 2.13 millisecond increase per 100 ng/mL increase in piperaquine concentration at 20, 28, and 36 weeks' gestation, respectively. Furthermore, 61% (n = 183) of women had a smaller change in QTc at week 36 than week 20. Nine women given DHA-PQ had grade 3-4 cardiac adverse events. SP was not associated with any change in QTc.

Conclusions: Repeated DHA-PQ dosing did not result in increased risk of QTc prolongation and the postdose QTc intervals progressively decreased. Monthly dosing of DHA-PQ in pregnant women carries minimal risk of QTc prolongation.

Clinical trials registration: NCT02793622.

Keywords: QTc prolongation; dihydroartemisinin-piperaquine; intermittent preventive treatment for malaria in pregnancy; pharmacokinetic/pharmacodynamic modeling.

Publication types

  • Randomized Controlled Trial
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Antimalarials* / therapeutic use
  • Artemisinins* / therapeutic use
  • Drug Combinations
  • Female
  • Humans
  • Long QT Syndrome* / chemically induced
  • Long QT Syndrome* / drug therapy
  • Long QT Syndrome* / prevention & control
  • Malaria* / drug therapy
  • Malaria* / prevention & control
  • Malaria, Falciparum* / drug therapy
  • Piperazines
  • Placenta
  • Pregnancy
  • Pregnant Women
  • Quinolines* / adverse effects
  • Uganda

Substances

  • Antimalarials
  • Artemisinins
  • Drug Combinations
  • Piperazines
  • Quinolines
  • artenimol
  • piperaquine

Associated data

  • ClinicalTrials.gov/NCT02793622