# Concentration–Response Analysis of the Combination of Pyronaridine and Piperaquine on Corrected QT Interval From a Randomized, Double‐Blind, Placebo‐Controlled Study in Healthy Adults of African Sub‐Saharan Origin

## TL;DR

This study examines how the antimalarial drugs pyronaridine and piperaquine affect heart rhythms in healthy African adults, finding that their combination does not significantly increase risks compared to piperaquine alone.

## Contribution

The study provides new concentration–response data on the cardiac effects of pyronaridine and piperaquine combination therapy in African sub-Saharan populations.

## Key findings

- Piperaquine alone significantly increased QTcF by over 10 msec, exceeding regulatory thresholds.
- Combining pyronaridine and piperaquine caused a small additional increase in QTcF, mainly due to higher piperaquine levels.
- Pyronaridine alone did not significantly affect QTcF, suggesting it is safer in this regard.

## Abstract

A novel oral combination of the long‐acting antimalarials pyronaridine (PYR) and piperaquine (PQP) has potential for malaria chemoprevention. This single‐center randomized, double‐blind, placebo‐controlled study assessed the effects of PYR and PQP alone and when co‐administered on Fridericia‐corrected QT interval (QTcF). Between February 14, 2022, and May 31, 2022, thirty‐seven healthy black adults of African sub‐Saharan origin were enrolled and randomized to PYR + PQP (n = 15), PYR + placebo (n = 8), PQP + placebo (n = 8) or double placebo (n = 6) administered once daily (fasted) for 3 days at doses approved for malaria treatment. Triplicate digitalized electrocardiogram (ECG) recordings and pharmacokinetic samples were taken at matched timepoints. Concentration–response analysis was performed for QTcF changes from baseline (ΔQTcF), and the impact of PYR, PQP, and PYR + PQP administration on placebo‐corrected ΔQTcF (ΔΔQTcF) was assessed. The final qualified and validated concentration–QTc model included a linear component for PYR and an E
max component for PQP. The maximum predicted effect on ΔΔQTcF on day 3 was +4.94 msec (90% CI 0.338, 9.54) with PYR + placebo, +19.2 msec (14.6, 23.8) with PQP + placebo, and + 23.1 msec (18.5, 27.6) with PYR + PQP. As expected, PQP increased ΔΔQTcF above the regulatory threshold of concern (+10 msec), whereas PYR did not. The small additional increase in ΔΔQTcF with PYR + PQP coadministration was explained mainly by an increase in PQP C
max (1.4‐fold) versus monotherapy. In healthy adults, PYR + PQP coadministration does not appear to increase significantly the effect of PQP on ΔΔQTcF versus PQP administered alone. However, further studies are needed in malaria patients to confirm these findings in the target population.

Trial Registration:
ClinicalTrials.gov identifier: NCT05160363; EudraCT number: 2021‐005698‐21