Cochrane Database of Systematic Reviews

Methylene blue for treating malaria (Protocol)

Calderón M, Weitzel T, Rodriguez MF, Ciapponi A

Calderón M, Weitzel T, Rodriguez MF, Ciapponi A.

Methylene blue for treating malaria.
Cochrane Database of Systematic Reviews 2017, Issue 10. Art. No.: CD012837.
DOI: 10.1002/14651858.CD012837.

www.cochranelibrary.com

Methylene blue for treating malaria (Protocol)

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
ADDITIONAL TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Methylene blue for treating malaria (Protocol) i

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
[Intervention Protocol]

Methylene blue for treating malaria

María Calderón1 , Thomas Weitzel2 , Maria F Rodriguez3 , Agustín Ciapponi4

1 Department of Health Technology Assessment, Systematic Reviews and Economic Evaluation, Institute for Clinical Effectiveness
and Health Policy (IECS), Buenos Aires, Argentina. 2 Clinical Laboratory, Clínica Alemana de Santiago, Facultad de Medicina Clínica
Alemana, Universidad del Desarrollo, Santiago, Chile. 3 Infectious Diseases Department, University of Chile School of Medicine,
Santiago, Chile. 4 Argentine Cochrane Centre, Institute for Clinical Effectiveness and Health Policy (IECS-CONICET), Buenos Aires,
Argentina

Contact address: María Calderón, Department of Health Technology Assessment, Systematic Reviews and Economic Evaluation,
Institute for Clinical Effectiveness and Health Policy (IECS), Dr. Emilio Ravignani 2024, Capital Federal, Buenos Aires, C1414CPV,
Argentina. [email protected], [email protected].

Editorial group: Cochrane Infectious Diseases Group.

Publication status and date: New, published in Issue 10, 2017.

Citation: Calderón M, Weitzel T, Rodriguez MF, Ciapponi A. Methylene blue for treating malaria. Cochrane Database of Systematic
Reviews 2017, Issue 10. Art. No.: CD012837. DOI: 10.1002/14651858.CD012837.

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

ABSTRACT

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:

To assess the efficacy and safety of methylene blue for treating people with malaria.

BACKGROUND falciparum. Falciparum malaria is therefore a medical emergency

that requires immediate treatment (White 2014).
The development of synthetic antimalarial drugs in the first half
Description of the condition of the 20th century was one of the cornerstones for the success
of malaria control programmes in various parts of the world in
Malaria is a vector-borne disease caused by infection with Plas-
the 1950s and 1960s. However, re-emergence of the disease has
modium parasites, and is endemic in tropical and subtropical re-
occurred since then due to antimalarial drug resistance (Krogstad
gions worldwide. According to the World Health Organization
1996).
(WHO), approximately 91 countries are exposed to the disease,
The rediscovery of artemisinin derivatives (in traditional Chi-
which resulted in 212 million cases (149 million to 304 million) of
nese medicine named “qinghaosu”) in the 1990s, was expected
malaria occurred worldwide and 429,000 (235,000 to 639,000)
to stop the emergence of malaria in Africa and other parts of the
deaths from malaria globally in 2015 (WHO 2016). Most of the
world. These ’new’ drugs were highly effective and well-tolerated.
severe and fatal infections are caused by Plasmodium falciparum,
Given together with longer-acting second drugs as artemisinin-
which is the most dangerous of the four Plasmodium species that
based combination therapies (ACTs), they became the first-line
are infective to people, and mainly affects children living in sub-
in malaria therapy, and contributed to a decrease in the num-
Saharan Africa (WHO 2016).
ber of malaria cases and deaths (Eastman 2009; WHO 2016).
If untreated, malaria can progress rapidly into severe, life-threat-
Artemisinin resistance has emerged in recent years (Dondorp
ening manifestations, particularly if the person is infected with P.
Methylene blue for treating malaria (Protocol) 1
Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
2009), and is now spreading throughout Southeast Asia (Ashley 2012). In a murine model of cerebral malaria, methylene blue
2014). To maintain the progress of global malaria eradication ef- was effective and superior to dihydroartemisinin (Dormoi 2013).
forts, new antimalarial drugs are urgently needed (malERA 2011). Up to now, the few clinical studies in humans have revealed
Moreover, limited availability of new substances is expected within promising antimalarial activity in mono- and combination ther-
the next years (Klein 2013; Wongsrichanalai 2013); therefore, it apy (Akoachere 2005; Bountogo 2010; Coulibaly 2015; Garavito
has been suggested to repurpose or to utilize drugs that are already 2012; Zoungrana 2008).
licensed but not licensed as antimalarial drugs (Hobbs 2011).
Among these drugs, which should ideally be immediately avail-
able, effective, and affordable (Olliaro 2003), methylene blue is a How the intervention might work
promising candidate.
It has been hypothesized that methylene blue is active against Plas-
modium parasites in various ways; with a pleiotropic effect and no
Description of the intervention unique target encoded in the parasite genome (Schirmer 2003).
Possible mechanisms include increased concentrations of oxidants
Paul Ehrlich discovered that dyes that target certain microorgan- and toxic products targeting both erythrocytic stages and gameto-
isms and leave the surrounding tissue unharmed could be used as cytes (Adjalley 2011; Coulibaly 2009; Ohrt 2014; Schirmer 2003),
drugs. In 1891, methylene blue was discovered to fit into this cat- and competitive inhibition in glutathione reductase sensitizing the
egory for malaria treatment (Krafts 2012). It has high affinity for parasite to the action of other antimalarials, such as chloroquine
Plasmodium parasites and low toxicity to patients (Gensini 2007). (Schirmer 2003), resulting in a strong gametocytocidal effect.
Ehrlich’s students continued to trial methylene blue, but it was The gametocytocidal effect is invariably seen as beneficial because
not sufficiently effective to supplant the standard treatment with it may have a public health benefit in decreasing parasite trans-
quinine (Krafts 2012). Since then, methylene blue has been ap- mission and, it is hypothesized, because targeting the transmis-
proved for the treatment of methaemoglobinaemia, prevention of sion stages would reduce the rate at which parasite drug resistance
urinary tract infections in the elderly, treatment and prevention of spreads (Hastings 2006). This is why the WHO considers the ga-
ifosfamide-induced neurotoxicity, and intraoperative visualization metocytocidal effect as a property with the “potential to delay or
of nerve tissues, endocrine glands, and fistulae (Schirmer 2003; prevent the development of resistance” (WHO 2001).
Schirmer 2011). Methylene blue is a tricyclic phenothiazine drug Methylene blue displays in vitro activity against P. falciparum,
with a characteristic blue colour. It is transformed to a colourless synergistic activity when combined with artemisinin and related
compound, leucomethylene blue, and excreted in the urine as a endoperoxides, but antagonistic effects with chloroquine and other
mixture of methylene blue and leucomethylene blue. The usual quinolone antimalarials (Akoachere 2005). Similar results were
daily oral dose is 200 mg (Schirmer 2011). Methylene blue’s half- detected for Plasmodium vivax (Suwanarusk 2015).
life in humans is five to 10 hours (Schirmer 2011; Suwanarusk It is important to highlight that methylene blue has been associated
2015). The bioavailability of methylene blue after oral adminis- with haemolysis in G6PD-deficient subjects. G6PD deficiency
tration is 72%, with peak plasma concentrations after two hours can be common in some malaria-endemic areas, with associated
and an elimination half-life of 18 hours (Walter-Sack 2009). reactions to drugs ranging from mil and transient to severe and
When administered in high intravenous doses, severe gastroin- life-threatening. However, in areas of high malaria transmission,
testinal symptoms have been reported in adults (Schirmer 2011). the clinical benefit may outweigh the risk of haemolysis in patients
It may also precipitate serotonin syndrome, especially when given with G6PD-deficiency, as suggested for other situations of low
together with serotonin reuptake inhibitors (Ng 2010). Further- haemolysis risks (WHO 2015).
more, it can cause haemolytic anaemia in patients with glucose-
6-phosphate dehydrogenase (G6PD) enzymatic deficiency (Gallo
2009). In sheep the LD50 value (lethal dose 50%, which is the dose
at which 50% of a group will die) was found to be 42 mg/kg body
Why it is important to do this review
weight (Schirmer 2011), and in rats 1250 mg/kg (Suwanarusk Malaria is a life-threatening disease and combating the incidence
2015). Contraindications include the concomitant use of sero- of malaria is part of the third target of the Sustainable Develop-
tonin reuptake inhibitors (Schirmer 2011), while patients with ment Goals to end the epidemics of AIDS, tuberculosis, malaria,
homozygous G6PD deficiency might require monitoring due to and neglected tropical diseases (UN 2016). This Cochrane Re-
reduced haemoglobin level (Müller 2013). view aims to contribute directly to improving the management of
In different animal models, the efficacy of methylene blue one of the most important targets in this global effort. In light
monotherapy was equivalent to artesunate and the combination of the alarming increase in antimalarial drug resistance and cross-
with artesunate was synergistic (Ohrt 2014). In rodents, there resistance, which includes the current first-line drugs, and the high
was also synergistic activity of methylene blue together with qui- burden of malaria worldwide, the introduction of additional ef-
nine and pyrimethamine but not with chloroquine (Garavito fective drugs becomes a public health imperative (WHO 2016).

Methylene blue for treating malaria (Protocol) 2

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Methylene blue is a potential candidate due to its low toxicity, Primary outcomes
pharmacokinetics, little potential of inducing resistance, and low
• Clinical and parasitological treatment response, according
cost (Schirmer 2003; Suwanarusk 2015). Furthermore, being a
to the criteria of the WHO’s protocol for assessing and
synthetic compound, methylene blue allows large-scale unlimited
monitoring antimalarial drug efficacy (WHO 2003). We have
production regardless of supply or location of natural resources
based the outcomes approach on a previously published
(Krafts 2012).
Cochrane Review (Zani 2014).
• Polymerase chain reaction (PCR)-unadjusted total failure:
the sum of early treatment failure and late treatment failures
without PCR adjustment, divided by the population in the
OBJECTIVES group. In the calculation, we will include as denominators
missing or indeterminate PCR; or new infections as failures.
To assess the efficacy and safety of methylene blue for treating
• PCR-adjusted total failure: the sum of early treatment
people with malaria.
failures and late treatment failures due to PCR recrudescence,
divided by the population in the group.

METHODS We will exclude missing or indeterminate PCR or new infections

from the numerator and the denominator.
We will remove participants who do not satisfy the inclusion cri-
Criteria for considering studies for this review teria after randomization from all calculations. A summary table
of these definitions is shown in Table 1, Additional tables section.

Types of studies
Randomized controlled trials (RCTs) that evaluate the use of Secondary outcomes
methylene blue for treating malaria.
• Fever clearance time.
• Parasite clearance time.
Types of participants • Gametocyte carriage at day seven or day 14.
• Gametocyte development (negative at baseline and positive
Adults and children diagnosed with malaria by any microscopy
at follow-up).
or molecular method, or rapid diagnostic tests. We will exclude
• Change in haemoglobin from baseline.
studies in which participants were diagnosed solely by clinical
presentation and without laboratory confirmation.

Adverse events
Types of interventions
• Occurrence of serious adverse events: defined as fatal, life-
threatening, or leading to hospitalization.
Intervention • Adverse events that lead to discontinuation of the drug.
• Occurrence of haemolysis in patients with G6PD
Any scheme that includes methylene blue for treating malaria (in-
deficiency (haemolysis defined a major haemolysis (Delta
cluding combination of methylene blue with other antimalarial
haemoglobin > 6 g/dL) and minor haemolysis (Delta
drugs).
haemoglobin < 2.5 g/dL (Grattagliano 2004)).
• Other haematological and biochemical adverse effects (for
Control example, neutropenia or liver toxicity).
• Other adverse events.
No drug or placebo or any therapeutic regimen that does not
include methylene blue. Any co-interventions should be identical
in both the control and intervention groups.

Search methods for identification of studies

Types of outcome measures We will attempt to identify all relevant trials regardless of language
The description of these outcomes is based on that proposed by or publication status (published, unpublished, in press, and in
the WHO 2009. progress).

Methylene blue for treating malaria (Protocol) 3

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Electronic searches the published reports, including the mean and standard deviation
The following databases will be searched using the search terms values for continuous outcomes, and the number of events and
and strategy described in Appendix 1: the Cochrane Infectious people at risk for dichotomous data. Whenever possible, we will
Diseases Group Specialized Register; the Central Register of Con- extract the data based on an intention-to-treat analysis.
trolled Trials (CENTRAL), published in the Cochrane Library; Another important characteristic to be extracted from the included
MEDLINE (PubMed); Embase (Elsevier); LILACS; and African trials will be whether the participant was tested for G6PD, and if
Index Medicus. We will also search the WHO International Clin- the trial authors excluded such participants.
ical Trials Registry Platform (ICTRP) (www.who.int/ictrp/en/) We will contact the trial authors if necessary to obtain missing or
and ClinicalTrials.gov (https://clinicaltrials.gov/ct2/home) for tri- supplementary information.
als in progress, using ’methylene blue’ and ’malaria’ as search terms.
Assessment of risk of bias in included studies
Searching other resources Two review authors will independently assess the risk of bias of
We will search the reference lists of included trials to find additional each included trial using the Cochrane ’Risk of bias’ tool. We
articles of relevance. will assess the risk of bias on each of the following criteria: blind-
In addition, we will contact experts from the main regional soci- ing (of participants, personnel, and outcome assessors), allocation
eties, ministries of health, the Medicines for Malaria Venture, and concealment, random sequence generation, incomplete outcome
the WHO for information about ongoing and unpublished trials. data, and selective outcome reporting (Higgins 2011). Regarding
Furthermore, we will also search relevant proceedings from 1990 the risk of bias, we will assess this as either low, high, or unclear
onwards for trial information: the Multilateral Initiative on risk (due to either lack of information or uncertainty over the po-
Malaria (MIM) Pan-African Malaria Conference, the American tential for bias) (Atkins 2004). Any disagreements will be resolved
Society of Tropical Medicine and Hygiene Annual Meeting, the by discussion between the review authors.
American Society of Tropical Medicine and Hygiene Annual Meet-
ings, the ASEAN Congress of Tropical Medicine and Parasitology
(ACTMP), and the International Congress on Infectious Diseases. Measures of treatment effect
We will calculate mean differences (when studies use the same
measure) or standardized mean difference (SMD) values (when
Data collection and analysis the included trials use different measurement scales) and 95% con-
fidence intervals (CIs) for continuous outcome measures. When
We will use the Early Review Organizing Software (EROS) de-
necessary, effect estimates from P values, t statistics, or other avail-
signed ad-hoc to select and extract data, and to assess the risk of
able statistics will be calculated. For those trials that only provide
bias of the included trials (Ciapponi 2011).
change scores, we will perform separate analyses to trials that only
provide final values. We will combine both values using the generic
Selection of studies inverse variance method (Higgins 2011).
Two review authors will independently screen articles identified by
the literature search by title and abstract according to the inclusion
Unit of analysis issues
criteria. We will resolve any discrepancies by consensus of the
review author team. The full text of any articles that potentially We will take into account the level at which randomization oc-
fulfil the inclusion criteria will be obtained and assessed. We will list curred. If more than one comparison from the same trial is eligi-
all articles excluded after full-text assessment in the ’Characteristics ble for inclusion in the same meta-analysis, we will either com-
of excluded studies’ table. We will illustrate the study selection bine groups to create a single pair-wise comparison or appropri-
process in a PRISMA diagram. ately reduce the sample size so that the same participants do not
contribute multiply (splitting the ’shared’ group into two or more
groups). While the latter approach offers some solution to adjust-
Data extraction and management ing the precision of the comparison, it does not account for corre-
Two review authors will independently extract data and will assess lation arising from the same set of participants being in multiple
the methodological quality of each included trial. We will resolve comparisons (Higgins 2011).
any discrepancies by consensus between the whole review author
team.
Data will be extracted on the following: trial characteristics, trial Dealing with missing data
population characteristics, details about the interventions, fund- We will perform a complete-case analysis. We will avoid making
ing sources, and outcomes of interest. When we need more infor- assumptions about the outcomes of participants lost to follow-up.
mation, we will contact the trial authors. We will extract data from Where possible, the study authors will be contacted for missing

Methylene blue for treating malaria (Protocol) 4

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
data. If we consider that the missing data render the result unin- Data synthesis
terpretable, we will exclude the data from the meta-analysis and Where we consider studies to be sufficiently homogenous in terms
clearly state the reason for exclusion. of participants, interventions, and outcomes, we will pool data in
We will remove from all calculations any participants who do not a meta-analysis using Review Manager 5 (RevMan 5) (RevMan
satisfy the inclusion criteria after randomization. 2014). Both the fixed-effect model and the random-effects model
For the PCR-unadjusted total failure outcome: we will include will be used and compared in order to assess the degree of statis-
missing or indeterminate PCR or new infections as failures in the tical heterogeneity. We assume that clinical heterogeneity is very
numerator and in the denominator. likely to impact on our review results given the nature of the inter-
For the PCR-adjusted total failure outcome: we will exclude miss- ventions included; therefore we will primarily report the random-
ing or indeterminate PCR or new infections from the numerator effects model results, regardless of statistical evidence for hetero-
and the denominator. geneity. We will apply DerSimonian-Laird weights for the ran-
The potential effects of missing data will be explored through a dom-effects model where we find heterogeneity between studies
series of sensitivity analyses. (DerSimonian 1986). We will calculate all effects using inverse
variance methods.
For continuous data reported as change scores in some included
Assessment of heterogeneity trials and as final values in other included trials, we will analyse
these data separately. Also we will combine these values using the
We will calculate the I² statistic value as a measure of the proportion
generic inverse variance method (Higgins 2011).
of the overall variation in the proportion that was attributable to
between-study heterogeneity (Higgins 2011).
We will appraise the extent of clinical heterogeneity among the Certainty of the evidence
included trials by comparing the distribution of participants char-
The certainty of the evidence will be assessed using the GRADE
acteristics and study factors. Since the most likely cause of het-
approach. We will prepare a ’Summary of findings’ table to present
erogeneity will be the failure rate in the control group, we will
the results of meta-analysis or narrative synthesis, or both, for the
take this into consideration for this parameter. Other factors that
major comparisons of the review and for the primary outcomes.
could be associated to heterogeneity are randomization, allocation
We will provide a source and rationale for each assumed risk cited
concealment, blinding of outcome assessment, loss to follow-up,
in the table(s), and we will use GRADEpro Guideline Develop-
treatment type, type of control group, co-interventions and differ-
ment Tool (GDT) software (GRADEpro 2015). The certainty of
ent types of outcome measurements. We will assess these variables
the evidence considers the within-study risk of bias (methodolog-
by subgroup analysis if the I² statistic value is greater than 30%.
ical quality), the directness of the evidence, heterogeneity of the
Also, we will consider a low P value for the Chi² test (< 0.1) as
data, precision of effect estimates, and risk of publication bias based
sufficient reason to explore causes of heterogeneity.
on the methods described in Chapter 11 of the Cochrane Hand-
We will describe statistical heterogeneity of intervention effects
book for Systematic Reviews of Interventions (Schünemann 2011). If
by calculating the I² statistic and using the Chi² test. Thresholds
meta-analysis is not possible, we will present the results narratively
for the interpretation of I² statistic can be misleading, since the
in the ’Summary of findings’ table.
importance of inconsistency depends on several factors. We will
interpret it as follows.
• 0% to 30%: might not be important.
Subgroup analysis and investigation of heterogeneity
• 30% to 60%: may represent moderate heterogeneity.
• more than 60%: may represent substantial or considerable We plan to perform the following subgroup analyses.
heterogeneity. • Country or region.
• Comparator drug.
• Population by age range (under 18 years old, 18 to 65 years
old, over 65 years old). For the age group of under18 years old,
Assessment of reporting biases we will subdivide into under five years old and over five years old.
We will make a funnel plot to assess reporting biases when per-
forming an analysis on 10 or more studies. Several explanations
may account for funnel plot asymmetry, including true hetero- Sensitivity analysis
geneity of effect with respect to trial size, poor methodological de- We will perform a sensitivity analysis to investigate the robustness
sign (and hence bias of small trials), and publication bias. There- of the results to the risk of bias components by including only
fore we will interpret results according to these possible explana- the studies that concealed the allocation and losses to follow-up or
tions. However, given the topic we do not expect to have this num- had low incomplete outcome data (less than 10%). Also, we will
ber of studies for analysis. analyse the effect of missing data by examining the following.

Methylene blue for treating malaria (Protocol) 5

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 • Missing or indeterminate PCR are included as failures in using different measures of effect size (risk ratio, odds ratio) and
the numerator and in the denominator for the PCR-adjusted different statistical models (fixed-effect and random-effects mod-
outcome. els).
• New infections are included in the numerator as successes The PRISMA statement for reporting systematic reviews and
and in the denominator for the PCR-adjusted outcome. meta-analysis of interventional studies will be followed (Liberati
• Exclusions after enrolment are included as failures in the 2009; Moher 2010).
numerator and denominator for both PCR-adjusted and
unadjusted outcomes.
• Exclusions after enrolment are included as successes in the
numerator and denominator for both PCR-adjusted and ACKNOWLEDGEMENTS
unadjusted outcomes.
We are grateful to Daniel Comandee, for his invaluable collabo-
ration in the search strategy design.
We will report where the analysis alters the quantitative result.
Also a sensitivity check will be conducted by using the fixed-effect The editorial base of the Cochrane Infectious Diseases Group is
model to reveal differences in results with the random-effects ap- funded by UK aid from the UK Government for the benefit of
proach. developing countries (Grant: 5242). The views expressed in this
We will also test the robustness of results by repeating the analysis review do not necessarily reflect UK government policy.

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Indicates the major publication for the study

ADDITIONAL TABLES
Table 1. Primary outcomes summary

Participants PCR-unadjusted PCR-adjusted

Numerator Denominator Numerator Denominator

Exclusions after enrol- Excluded Excluded Excluded Excluded

ment

Missing or indetermi- Included as failures Included Excluded Excluded

nate PCR

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Table 1. Primary outcomes summary (Continued)

New infections Included as failures Included Excluded Excluded

APPENDICES

Appendix 1. Search strategy

Cochrane
ID Search Hits
#1 MeSH descriptor: [Methylene Blue] explode all trees
#2 Methylthioninium Chloride:ti,ab,kw (Word variations have been searched)
#3 Methylene Blue:ti,ab,kw (Word variations have been searched)
#4 Urolene Blue:ti,ab,kw (Word variations have been searched)
#5 Chromosmon:ti,ab,kw (Word variations have been searched)
#6 Swiss Blue:ti,ab,kw (Word variations have been searched)
#7 #1 or #2 or #3 or #4 or #5 or #6
#8 MeSH descriptor: [Malaria] explode all trees
#9 malaria*:ti,ab,kw (Word variations have been searched)
#10 Paludi*:ti,ab,kw (Word variations have been searched)
#11 Remittent Fever*:ti,ab,kw (Word variations have been searched)
#12 Marsh fever*:ti,ab,kw (Word variations have been searched)
#13 blackwater fever*:ti,ab,kw (Word variations have been searched)
#14 black water fever*:ti,ab,kw (Word variations have been searched)
#15 MeSH descriptor: [Plasmodium] explode all trees
#16 plasmodi*:ti,ab,kw (Word variations have been searched)
#17 Haemamoeb*:ti,ab,kw (Word variations have been searched)
#18 #8 or #9 or #10 or #11 or #12 or #13 or #14 or #15 or #16 or #17
#19 #7 and #18

MEDLINE (PubMed)

Search Query

#21 Search (#19 AND #20)

#20 Search (((Randomized Controlled Trial[pt] OR Controlled Clinical Trial[pt] OR Randomized Controlled Tri-
als[Mesh] OR Random Allocation[Mesh] OR Double-Blind Method[Mesh] OR Single-Blind Method[Mesh] OR
Clinical Trial[pt] OR Clinical Trials[Mesh]) OR (Clinical Trial[tw]) OR ((Singl*[tw] OR Doubl*[tw] OR Trebl*[tw]
OR Tripl*[tw]) AND (Mask*[tw] OR Blind*[tw])) OR (Placebos[Mesh] OR Placebo*[tw] OR Random*[tw] OR

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Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
(Continued)

Research Design [mh:noexp]) NOT (Animals [Mesh] OR NOT Human[Mesh])))

#19 Search (#7 AND #18)

#18 Search (#8 OR #9 OR #10 OR #11 OR #12 OR #13 OR #14 OR #15 OR #16 OR #17)

#17 Search Haemamoeb*[tiab]

#16 Search plasmodi*[tiab]

#15 Search Plasmodium[Mesh]

#14 Search black water fever*[tiab]

#13 Search blackwater fever*[tiab]

#12 Search Marsh fever*[tiab]

#11 Search Remittent Fever*[tiab]

#10 Search Paludi*[tiab]

#9 Search malaria*[tiab]

#8 Search Malaria[Mesh]

#7 Search (#1 OR #2 OR #3 OR #4 OR #5 OR #6)

#6 Search Swiss Blue[tiab]

#5 Search Chromosmon[tiab]

#4 Search Urolene Blue[tiab]

#3 Search Methylene Blue[tiab]

#2 Search Methylthioninium Chloride[tiab]

#1 Search Methylene Blue[Mesh]

Embase

Methylene blue for treating malaria (Protocol) 10

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
No. Query

#21 #19 AND #20

#20 ’randomized-controlled-trial’/de OR ’randomization’/de OR ’controlled-study’/de OR ’multicenter study’/de OR ’phase-3-

clinical-trial’/de OR ’phase-4-clinical-trial’/de OR ’double-blind-procedure’/de OR ’single blind-procedure’/de OR random$:
ab,ti OR crossover$:ab,ti OR ’cross over$’:ab,ti OR factorial$:ab,ti OR placebo$:ab,ti OR volunteer$:ab,ti OR (singl$:ab,ti
OR doubl$:ab,ti OR trebl$:ab,ti OR tripl$:ab,ti AND (blind$:ab,ti OR mask$:ab,ti)) NOT (’animals’/exp NOT (’humans’/
exp AND ’animals’/exp))

#19 #7 AND #18

#18 #8 OR #9 OR #10 OR #11 OR #12 OR #13 OR #14 OR #15 OR #16 OR #17

#17 haemamoeb*:ab,ti

#16 plasmodi*:ab,ti

#15 ’plasmodium’/exp

#14 ’black water fever$’:ab,ti

#13 ’blackwater fever$’:ab,ti

#12 ’marsh fever$’:ab,ti

#11 ’remittent fever$’:ab,ti

#10 paludi*:ab,ti

#9 malaria*:ab,ti

#8 ’malaria’/exp

#7 #1 OR #2 OR #3 OR #4 OR #5 OR #6

#6 ’swiss blue’:ab,ti

#5 chromosmon:ab,ti

#4 ’urolene blue’:ab,ti

#3 ’methylene blue’:ab,ti

#2 ’methylthioninium chloride’:ab,ti

#1 ’methylene blue’/exp

Methylene blue for treating malaria (Protocol) 11

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
LILACS
(MH Azul de Metileno OR Chromosmon OR Cromosmon OR Impaludismo OR Maleita OR ((Methyl$ OR Metileno OR Swiss OR
Metiltionina OR Suíço OR Suizo) AND (Cloruro OR Cloreto OR Chloride OR Blue OR Azul))) AND (MH Malaria OR Malaria
OR Paludi$ OR Malárica OR MH Plasmodium OR plasmodi$ OR ((blackwater OR Marjales OR Remitente OR Remittent OR
Mangue) AND (Febre OR Fiebre OR Fever)))

African Index Medicus

Database :
AIM
Search on :
Methyl$ [Key Word]
References found :
9 [refine]
Displaying:
1 .. 9 in format [Detailed]

CONTRIBUTIONS OF AUTHORS
All authors made substantial contributions to the conception and design of this protocol, drafted the protocol, and revised the content.
All authors read and approved the final version of the protocol.

DECLARATIONS OF INTEREST
MC declares no conflict of interest known.
TW declares no conflict of interest known.
MFR declares no conflict of interest known.
AC declares no conflict of interest known.

SOURCES OF SUPPORT

Internal sources
• Institute for Clincal Effectiveness and Health Policy. Buenos Aires, Argentina.
• Liverpool School of Tropical Medicine, UK.

Methylene blue for treating malaria (Protocol) 12

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
External sources
• Department for International Development, UK.
Grant: 5242

Methylene blue for treating malaria (Protocol) 13

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.