QUESTION: I will be starting artesunate with a patient in the near future (hopefully in the next week).  She has done HIVC with her chemo.  However, the chemo has not worked well for the patient and she now is willing to entertain further treatments.  I have read your artesunate summary for IV use and you mention that oral administration is recommended to see how it is tolerated.  I am would like your advice on dosing of oral artesunate.…and what issues I should be aware of besides the liver enzymes. Of course at this time G6PD, and a liver panel, CBC have all been done are within N limits.

ANSWER: Regarding IV Artesunate administration: In reality I never (or almost never) do an oral trial for this purpose.  Of all the things I have infused into people I have had the safest and least adverse event profile with ART.  That said I do sometimes co-administer it with an oral dose, and certainly if a person has a Type-1 allergy to ART I wouldn’t use it. I use the Quicksilver brand (no affil) of liposomal ART and dose 5 to 15 mL a day 3 days in a row with 4 days off in cancers of most types as this is the only form that absorbs well.  In GI cancers I will use 5 mL of the liposomal ART with a less absorbable form (I like the Allergy Research (no affil) wormwood oil/Artemisinin caps) dosed at 3-4 caps a day (again 3 on and 4 days off).

Liver Enzymes may go up and down and are almost never of any consequence.  They often indicate collateral immune activity in hepatocytes which may have nothing to do with the CA (like HHV viri) or may be related to mets or potential mets.  I simply watch them over time and make note.  Of course if the patient has preexisting biliary obstruction then you may need further assessment.

Iron – everyone worries about iron and ART.  Part of the MOA is to flip electrons with Fe (and Cu) similar to IVC.  ART patients may have some drop in iron studies over time so watch it (in my experience it is 10-20% of people) but you almost never need to give iron to compensate.  The ART works even in significant anemia.  This(need for iron compensation)  is a fallacy based on inaccurate extrapolation of ART MOA.  In cancer patients the rules for iron administration are clinically guided and I have written about them in other papers.

Otherwise we see very good tolerance to IV ART.  We normally do the ART-IVC twice a week with the same IVC escalation and formulas (unless they have been doing IVC and are set at a dose already, then you don’t need to re-escalate.)  We will try for 16-20 at twice a week and reassess.

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