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Iron tablets, vitamin C affect efficacy of malaria drugs

By Sade Oguntola - Nigeria

The best available treatment for malaria, Artemisinin-based Combination Therapies (ACTs) have come under a little scrutiny with experts warning that taking them in combination with multivitamins that contain iron and vitamins C and E, renders the drug ineffective.

From the woman that sells pepper in the market to the Chief Executive Officer, malaria is a health problem that makes a person rush to the hospital for its treatment. The headache, the body temperature and lack of sleep are some of its symptoms that are better imagined than experienced.

Malaria drugs come in different brands and constituents. From those that have lost their efficacy such as chloroquine, paludrine, amodiaquine, sulphadoxine-pyrimethamine (this includes medicines like Fansider) to the newly recommended highly effective Artemisinin-based Combination Therapies (ACTs), compliance with instructions in their attached leaflets is central to their efficacy and prevention of unwanted side effects.

 

              Vitamin tablets

ACTs are basically drugs that contain the artemisinin in various forms (Artemether, Arteether, Artesunate, Artenilate) as their main ingredients. Attached to artemisinin is another malaria killing drug such as Lumefantrine.

ACT kills malaria parasites in a human bloodstream within 24 to 36 hours. By combining drugs with different mechanisms of action and different time spans of activity, the combination of artemether and lumefantrine deliver a two-punch attack on the malaria parasite. Any malaria parasite not killed by one drug will be killed by the other.

However, ACTs might be rendered less effective in individuals with malaria if taken with multivitamins that contain constituents such as Vitamin C, B-carotene, Vitamin E and Iron.

Most multivitamin preparations contain some amount of minerals and trace element such as zinc, copper and iron, as well as vitamins that interact with some constituents of ACTs, rendering the malaria drug less effective.

Artemisinin is good at killing malaria parasites because it reacts and becomes highly toxic in the presence of iron. Malaria parasites cause illness in humans by consuming red blood cells, which contain iron in the hemoglobin protein that carries oxygen in the blood.

There is a high level of self medication and poor information-seeking attitude in many individuals, it has been said. So, it is common to have Artemisinin-based antimalarial drugs being prescribed along with antioxidant vitamins such as vitamin C, B-Carotene and Vitamin E.

No doubt, supplements which contain L-lysine, Vitamins B1, B6, B12 and Sorbitol, are ideal for malaria patients, as they promote appetite, quick recovery and do not hinder the activity of the antimalarial drug.
But many multivitamins also contain antioxidants such as Vitamin C, B-Carotene and Vitamin E and so are better continued after the ACT is completed because they can cause this antimalarial drug to be less absorbed by body.

Some medicines are better used after a meal. Incidentally, one of such drugs is ACT. Experts have evidences to show that food, especially those with fat, enhances the efficacy of ACT. The effect is more pronounced with lumefantrine.

In a double-blind trial of 260 patients with uncomplicated malaria in Thailand, researchers showed that both the extent and variability of lumefantrine absorption improved with recovery from malaria as normal food intake was resumed by the person affected by malaria. 

Individuals having malaria frequently feel nauseated and unable to eat, making doctors’ advice that these malaria medicines should not be taken on an empty stomach difficult to comply with. Nonetheless, for ACT to be very effective, it has to be taken along with food, particularly those containing fat.

How much fat is necessary to optimise lumefantrine oral bioavailability and assure the efficacy of the ACT? Surprisingly, researchers found that it does not have to be a standard meal like amala or fufu with the African stew. Incidentally, a glass of soya milk will do the work.

Writing in the 2007 Tropical Medicine & International Health, the researchers declared, “Co- administration of artemether–lumefantrine with a relatively small amount of fat (as soya milk) was required to ensure maximum absorption of lumefantrine in healthy adult volunteers.”

Dr. Olayemi Sofola, the former National Coordinator, National Malaria Control Programme, said some basic rules must be complied with to ensure ACT works effectively.

She stated: “The use of ACT in the appropriate way is important. For instance, the use of ACT with Vitamin C is not advisable because of its anti-oxidant properties. That is part of the reasons why people who want to take ACT should be appropriately counseled.”

Dr Sofola declared that in some instances, people had assumed ACT was not effective because the medicine was not used at the appropriate time.

According to her, “with ACTs, timing is important. The second dose of the ACT for instance should be taken eight hours after, not before or after. The timing affects its absorption and bioavailability. The second dose taken eight hours after is to reinforce the first dose to ensure the body is rid of malaria parasite.”

“People also need to be counseled that ACT is better taken after a fatty meal. In developed countries, people could take it with a glass of milk. But African stews have oil in them, so we may not have to worry about looking for an oily food. Most of our foods in Africa have oil in them.’’

Dr Sofola explained that even where a child with malaria cannot tolerate food because he or she has lost his or her appetite or is vomiting, fluids like milk can still be given along with ACT rather than a blanch food.

According to her, “there is the need for people to take ACT appropriately before saying the drug is not working. They need to be sure that it is taken at the right time, and that the appropriate dose is used and in the right way.”

“Also, it is important that they complete the dosage. Without doing this, the malaria parasite would not be cleared from their blood stream and resistance to ACT might start to develop. For now, ACTs are the best options we have to treat malaria.”

Dr Bala Mohammed, a malaria expert, remarked that in a case where a person vomits ACT within 30 minutes of administration, it should be repeated. According to him, this is to ensure adequate malaria treatment.

Nonetheless, Dr Mohammed emphasised that the use of ACT is discouraged in pregnant women until they are in their second or third trimester. “There are alternative medicines to treat malaria in pregnancy,” he declared

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