We further reasoned that favoring the classification of positive represented the appropriately conservative approach to the decision on primaquine therapy with regard to patient safety. At intermediate G6PD activities in our experiments, the subjectivity of reading was most apparent between 2.75 and 3.5 U/gHb (37%–51% of normal; see Fig 3, Fig 4 and Fig 5) with both positive and negative readings

being relatively frequent. Reading with the CSG as negative in this range proved less likely than with FST (odds ratio = 0.44; 95% confidence Anti-diabetic Compound Library order interval = 0.20–0.95; P = 0.04). We viewed erring in favor patient safety in this range to be a likely advantage of CSG over FST, but acknowledge denying primaquine therapy Afatinib concentration to

any patient who may safely receive it would also be a poor outcome. Improving specificity with the CSG could perhaps be achieved by the availability of a dummy cassette permanently exhibiting a color representing that occurring at an intermediate G6PD range, where less intense color should be considered positive and more intense color negative for deficiency. Such a simple device would help guide this difficult subjective decision by the reader. Female heterozygotes impose uncertainty with G6PD diagnostics and primaquine safety. G6PD activity in any given blood sample represents the consensus activity of the many individual RBCs present in the sample. The mosaicism of female heterozygotes for G6PD activity phenotype among RBCs complicates that representation and has implications for the primaquine go vs no go output of a G6DPD diagnostic device. A hypothetical example illustrates this problem: a female presents a consensus G6PD activity of 50% of normal, and thus, she may often test negative for G6PD deficiency despite up to one half of her RBCs perhaps being fully vulnerable to primaquine-induced hemolysis.31 The data illustrated in Fig 5 affirm this problem. Both the FST and CSG performed Ixazomib cost erratically with >30% and <80% of RBCs being G6PD inhibited (by 1.0 mM CuCl). The proportion classified as negative at 50% of normal activity was approximately 50%. If the G6PD-deficient RBCs in such patients were indeed

fully susceptible, neither the CSG nor FST would consistently prevent harmful exposure to primaquine. This problem will require clinical studies that would carefully assess the dangers imposed by this vulnerability. The most severe G6PD deficiency variants appear to be most common where P. vivax occurs in greatest abundance, in South and Southeast Asia. 32 Some evidence suggests that P. vivax drives selection for G6PD deficiency, 33 which would require affecting the reticulocytes strictly preferred by this species—natural G6PD activity decays from the highest level in reticulocytes as RBCs age. Populations most likely to benefit from primaquine therapy against relapse may also be at greatest risk of suffering serious harm caused by it.