The role of artesunate for the treatment of urinary schistosomiasis in schoolchildren: a systematic review and meta-analysis

Abstract

Objective: Efficacy of artemisinin derivatives alone or in combination compared to praziquantel alone for the treatment of urinary schistosomiasis in schoolchildren.

Methods: Randomized clinical trials comparing praziquantel with artemisinin derivatives in the treatment of urinary schistosomiasis in schoolchildren were included. Medline, EMBASE, LILACS, CENTRAL, African Index Medicus, and Scielo were searched. We also analyzed the abstracts of the main conferences on infectious diseases and tropical medicine during the years 2009-2011. Google Scholar and OpenSIGLE were also searched. The last search was performed in July 2012. The primary endpoint was the cure rate. The main outcome data were retrieved using a standardized form; three independent researchers (WP, HC, and SS) performed the search, retrieved data, and evaluated the risk of bias. Disagreements were resolved by discussion. Risk ratios were used and heterogeneity was evaluated. A fixed or random-effects model was used according to the results of heterogeneity testing. An intention-to-treat analysis was done. Data were analyzed using Revman 5·0·24 (Copenhagen: The Nordic Cochrane Centre).

Results: Seven studies were selected for full text review and only five studies were finally included. The cure rate for praziquantel was superior to that of artesunate (RR: 1·66; 95% CI: 1·18-2·33). Artesunate was not clearly superior to placebo (artesunate versus placebo, RR: 3·21; 95% CI: 0·50-20·74). Combination of artesunate with praziquantel could prove more beneficial than praziquantel alone (RR: 1·15; 95% CI: 1·01-1·31). The frequency of adverse events was equivalent for both drugs (praziquantel versus artesunate, RR: 1·11; 95% CI: 0·80-1·55).

Conclusions: Our meta-analysis showed that praziquantel was significantly more effective than artesunate for the treatment of urinary schistosomiasis in schoolchildren. Artesunate at best had a marginal role in combination therapy.

Figure 1

Flow diagram of the search and study process.

Figure 2

Summary of the risk of bias: +, low risk of bias; −, high risk; ?, unclear risk.

Figure 3

Evaluation of cure rates for praziquantel (PZQ) versus artesunate (ART) in urinary schistosomiasis. In the study by Sissoko et al., the artesunate+sulfamethoxypyrazine/pyrimethamine arm was counted as artesunate. In the study by Inyang-Etoh et al., the artesunate plus placebo and praziquantel plus placebo arms were counted as artesunate and as praziquantel, respectively. In the study by Keiser et al., artesunate plus mefloquine was counted as artesunate.

Figure 4

Evaluation of cure rates for artesunate (ART) versus placebo (PLB) in urinary schistosomiasis. In the study by Inyang-Etoh et al., the arm of artesunate plus placebo was counted as artesunate. Evaluation of cure rates for praziquantel+artesunate (PZQ+ART) versus praziquantel (PZQ) alone in urinary schistosomiasis.

Figure 5

Evaluation of the proportion of patients who developed any adverse event during therapy with praziquantel (PZQ) versus artesunate (ART). In the study by Sissoko et al., the artesunate+sulfamethoxypyrazine/pyrimethamine arm was counted as artesunate. In the study by Inyang-Etoh et al., the artesunate plus placebo and praziquantel plus placebo arms were counted as artesunate and as praziquantel, respectively. In the study by Keiser et al., artesunate plus mefloquine was counted as artesunate.