Inhaled nitric oxide as adjunctive therapy for severe malaria: a randomized controlled trial

Michael T. Hawkes, Andrea L. Conroy, Robert O. Opoka, Laura Hermann, Kevin E. Thorpe, Chloe McDonald, Hani Kim, Sarah Higgins, Sophie Namasopo, Chandy John, Chris Miller, W. Conrad Liles, Kevin C. Kain

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33 Scopus citations


Background: Severe malaria remains a major cause of childhood mortality globally. Decreased endothelial nitric oxide is associated with severe and fatal malaria. The hypothesis was that adjunctive inhaled nitric oxide (iNO) would improve outcomes in African children with severe malaria. Methods: A randomized, blinded, placebo-controlled trial of iNO at 80 ppm by non-rebreather mask versus room air placebo as adjunctive treatment to artesunate in children with severe malaria was conducted. The primary outcome was the longitudinal course of angiopoietin-2 (Ang-2), an endothelial biomarker of malaria severity and clinical outcome. Results: One hundred and eighty children were enrolled; 88 were assigned to iNO and 92 to placebo (all received IV artesunate). Ang-2 levels measured over the first 72 h of hospitalization were not significantly different between groups. The mortality at 48 h was similar between groups [6/87 (6.9 %) in the iNO group vs 8/92 (8.7 %) in the placebo group; OR 0.78, 95 % CI 0.26-2.3; p = 0.65]. Clinical recovery times and parasite clearance kinetics were similar (p > 0.05). Methaemoglobinaemia >7 % occurred in 25 % of patients receiving iNO and resolved without sequelae. The incidence of neurologic deficits (<14 days), acute kidney injury, hypoglycaemia, anaemia, and haemoglobinuria was similar between groups (p > 0.05). Conclusions: iNO at 80 ppm administered by non-rebreather mask was safe but did not affect circulating levels of Ang-2. Alternative methods of enhancing endothelial NO bioavailability may be necessary to achieve a biological effect and improve clinical outcome. Trial Registration: NCT01255215

Original languageEnglish (US)
Article number421
JournalMalaria Journal
Issue number1
StatePublished - Oct 29 2015


  • Child
  • Endothelium
  • Nitric oxide
  • Randomized controlled trial
  • Severe malaria

ASJC Scopus subject areas

  • Parasitology
  • Infectious Diseases

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    Hawkes, M. T., Conroy, A. L., Opoka, R. O., Hermann, L., Thorpe, K. E., McDonald, C., Kim, H., Higgins, S., Namasopo, S., John, C., Miller, C., Liles, W. C., & Kain, K. C. (2015). Inhaled nitric oxide as adjunctive therapy for severe malaria: a randomized controlled trial. Malaria Journal, 14(1), [421].