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Jahan RN, Khan Z, Akhtar MS, Ansari MD, Solanki P, Ahmad FJ, Aqil M, Sultana Y. Development of Bedaquiline-Loaded SNEDDS Using Quality by Design (QbD) Approach to Improve Biopharmaceutical Attributes for the Management of Multidrug-Resistant Tuberculosis (MDR-TB). Antibiotics (Basel) 2023; 12:1510. [PMID: 37887211 PMCID: PMC10603879 DOI: 10.3390/antibiotics12101510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 09/15/2023] [Accepted: 09/26/2023] [Indexed: 10/28/2023] Open
Abstract
Background: The ever-growing emergence of antibiotic resistance associated with tuberculosis (TB) has become a global challenge. In 2012, the USFDA gave expedited approval to bedaquiline (BDQ) as a new treatment for drug-resistant TB in adults when no other viable options are available. BDQ is a diarylquinoline derivative and exhibits targeted action on mycobacterium tuberculosis, but due to poor solubility, the desired therapeutic action is not achieved. Objective: To develop a QbD-based self-nanoemulsifying drug delivery system of bedaquiline using various oils, surfactants, and co-surfactants. Methods: The quality target product profile (QTPP) and critical quality attributes (CQAs) were identified with a patient-centric approach, which facilitated the selection of critical material attributes (CMAs) during pre-formulation studies and initial risk assessment. Caprylic acid as a lipid, propylene glycol as a surfactant, and Transcutol-P as a co-surfactant were selected as CMAs for the formulation of bedaquiline fumarate SNEDDS. Pseudo-ternary phase diagrams were constructed to determine the optimal ratio of oil and Smix. To optimize the formulation, a Box-Benkhen design (BBD) was used. The optimized formulation (BDQ-F-SNEDSS) was further evaluated for parameters such as droplet size, polydispersity index (PDI), percentage transmittance, dilution studies, stability studies, and cell toxicity through the A549 cell. Results: Optimized BDQ-F-SNEDDS showed well-formed droplets of 98.88 ± 2.1 nm with a zeta potential of 21.16 mV. In vitro studies showed enhanced drug release with a high degree of stability at 25 ± 2 °C, 60 ± 5% and 40 ± 2 °C, 75 ± 5%. Furthermore, BDQ-F-SNEDDS showed promising cell viability in A549 cells, indicating BDQ-F-SNEDDS as a safer formulation for oral delivery. Conclusion: Finally, it was concluded that the utilization of a QbD approach in the development of BDQ-F-loaded SNEDDS offers a promising strategy to improve the biopharmaceutical properties of the drug, resulting in potential cost and time savings.
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Affiliation(s)
- Rao Nargis Jahan
- Department of Pharmaceutics, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi 110062, India; (R.N.J.); (M.D.A.); (F.J.A.)
| | - Zafar Khan
- Department of Pharmaceutics, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi 110062, India; (R.N.J.); (M.D.A.); (F.J.A.)
| | - Md. Sayeed Akhtar
- Department of Clinical Pharmacy, College of Pharmacy, King Khalid University, Al-Fara, Abha 62223, Saudi Arabia
| | - Mohd Danish Ansari
- Department of Pharmaceutics, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi 110062, India; (R.N.J.); (M.D.A.); (F.J.A.)
| | - Pavitra Solanki
- Department of Pharmaceutics, Delhi Pharmaceutical Sciences and Research University, New Delhi 110017, India;
| | - Farhan J. Ahmad
- Department of Pharmaceutics, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi 110062, India; (R.N.J.); (M.D.A.); (F.J.A.)
| | - Mohd Aqil
- Department of Pharmaceutics, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi 110062, India; (R.N.J.); (M.D.A.); (F.J.A.)
| | - Yasmin Sultana
- Department of Pharmaceutics, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi 110062, India; (R.N.J.); (M.D.A.); (F.J.A.)
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Verboven L, Callens S, Black J, Maartens G, Dooley KE, Potgieter S, Cartuyvels R, Laukens K, Warren RM, Van Rie A. A machine-learning based model for automated recommendation of individualized treatment of rifampicin-resistant tuberculosis. RESEARCH SQUARE 2023:rs.3.rs-2525765. [PMID: 36824956 PMCID: PMC9949242 DOI: 10.21203/rs.3.rs-2525765/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
Background Rifampicin resistant tuberculosis remains a global health problem with almost half a million new cases annually. In high-income countries patients empirically start a standardized treatment regimen, followed by an individualized regimen guided by drug susceptibility test (DST) results. In most settings, DST information is not available or is limited to isoniazid and fluoroquinolones. Whole genome sequencing could more accurately guide individualized treatment as the full drug resistance profile is obtained with a single test. Whole genome sequencing has not reached its full potential for patient care, in part due to the complexity of translating a resistance profile into the most effective individualized regimen. Methods We developed a treatment recommender clinical decision support system (CDSS) and an accompanying web application for user-friendly recommendation of the optimal individualized treatment regimen to a clinician. Results Following expert stakeholder meetings and literature review, nine drug features and 14 treatment regimen features were identified and quantified. Using machine learning, a model was developed to predict the optimal treatment regimen based on a training set of 3895 treatment regimen-expert feedback pairs. The acceptability of the treatment recommender CDSS was assessed as part of a clinical trial and in a routine care setting. Within the clinical trial setting, all patients received the CDSS recommended treatment. In 8 of 20 cases, the initial recommendation was recomputed because of stock out, clinical contra-indication or toxicity. In routine care setting, physicians rejected the treatment recommendation in 7 out of 15 cases because it deviated from the national TB treatment guidelines. A survey indicated that the treatment recommender CDSS is easy to use and useful in clinical practice but requires digital infrastructure support and training. Conclusions Our findings suggest that global implementation of the novel treatment recommender CDSS holds the potential to improve treatment outcomes of rifampicin resistant tuberculosis.
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Affiliation(s)
| | | | - John Black
- University of Cape Town and Livingstone Hospital
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Superior Efficacy of a TBI-166, Bedaquiline, and Pyrazinamide Combination Regimen in a Murine Model of Tuberculosis. Antimicrob Agents Chemother 2022; 66:e0065822. [PMID: 35924925 PMCID: PMC9487531 DOI: 10.1128/aac.00658-22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
TBI-166, derived from riminophenazine analogues, shows more potent anti-TB activity than clofazimine and is being assessed against tuberculosis (TB) in a phase IIa clinical trial in China. Preclinical regimen studies containing TBI-166 will support the phase IIb clinical trials of TBI-166. In the present study, we compared the efficacy in three murine TB models of an all-oral drug-resistant TB drug regimen of TBI-166 with bedaquiline (BDQ) and pyrazinamide (PZA) with the first-line regimen of isoniazid (INH) with rifampin (RFP) and PZA (HRZ regimen), the most effective reported TBI-166-containing regimen of TBI-166 with BDQ and linezolid (LZD), and the Nix-TB clinical trial regimen of BDQ with pretomanid and LZD (BPaL regimen). In the C3HeB/FeJ murine TB model, for the TBI-166+BDQ+PZA regimen, the lungs of mice were culture negative at 4 weeks, and there were no relapses at 8 weeks of treatment. The reduction in bacterial burden and relapse rate were greater than those of the HRZ regimen and the TBI-166+BDQ+LZD regimen. Compared with the BPaL regimen, the TBI-166+BDQ+PZA regimen had similar or stronger early bactericidal activity, bactericidal activity, and sterilizing activity in the BALB/c murine TB model. The bacterial burden in the TBI-166+BDQ+PZA regimen group decreased significantly more than that in the BPaL regimen group and was almost or totally relapse free (<13.33% after 8 weeks). In conclusion, oral short-course three-drug regimens, including TBI-166 with high efficacy, were identified. The TBI-166+BDQ+PZA regimen is recommended for further study in a TBI-166 phase IIb clinical trial.
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Novel Regimens of Bedaquiline-Pyrazinamide Combined with Moxifloxacin, Rifabutin, Delamanid and/or OPC-167832 in Murine Tuberculosis Models. Antimicrob Agents Chemother 2022; 66:e0239821. [PMID: 35315690 DOI: 10.1128/aac.02398-21] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A recent landmark trial showed a 4-month regimen of rifapentine, pyrazinamide, moxifloxacin, and isoniazid (PZMH) to be noninferior to the 6-month standard of care. Here, two murine models of tuberculosis were used to test whether novel regimens replacing rifapentine and isoniazid with bedaquiline and another drug would maintain or increase the sterilizing activity of the regimen. In BALB/c mice, replacing rifapentine in the PZM backbone with bedaquiline (i.e., BZM) significantly reduced both lung CFU counts after 1 month and the proportion of mice relapsing within 3 months after completing 1.5 months of treatment. The addition of rifabutin to BZM (BZMRb) further increased the sterilizing activity. In the C3HeB/FeJ mouse model characterized by caseating lung lesions, treatment with BZMRb resulted in significantly fewer relapses than PZMH after 2 months of treatment. A regimen combining the new DprE1 inhibitor OPC-167832 and delamanid (BZOD) also had superior bactericidal and sterilizing activity compared to PZM in BALB/c mice and was similar in efficacy to PZMH in C3HeB/FeJ mice. Thus, BZM represents a promising backbone for treatment-shortening regimens. Given the prohibitive drug-drug interactions between bedaquiline and rifampin or rifapentine, the BZMRb regimen represents the best opportunity to combine, in one regimen, the treatment-shortening potential of the rifamycin class with that of BZM and deserves high priority for evaluation in clinical trials. Other 4-drug BZM-based regimens and BZOD represent promising opportunities for extending the spectrum of treatment-shortening regimens to rifamycin- and fluoroquinolone-resistant tuberculosis.
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Bendre AD, Peters PJ, Kumar J. Tuberculosis: Past, present and future of the treatment and drug discovery research. CURRENT RESEARCH IN PHARMACOLOGY AND DRUG DISCOVERY 2021; 2:100037. [PMID: 34909667 PMCID: PMC8663960 DOI: 10.1016/j.crphar.2021.100037] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 05/21/2021] [Accepted: 05/21/2021] [Indexed: 11/25/2022] Open
Abstract
Tuberculosis (TB) is an infectious disease caused by the bacterium Mycobacterium tuberculosis. Despite decades of research driving advancements in drug development and discovery against TB, it still leads among the causes of deaths due to infectious diseases. We are yet to develop an effective treatment course or a vaccine that could help us eradicate TB. Some key issues being prolonged treatment courses, inadequate drug intake, and the high dropout rate of patients during the treatment course. Hence, we require drugs that could accelerate the elimination of bacteria, shortening the treatment duration. It is high time we evaluate the probable lacunas in research holding us back in coming up with a treatment regime and/or a vaccine that would help control TB spread. Years of dedicated and focused research provide us with a lead molecule that goes through several tests, trials, and modifications to transform into a ‘drug’. The transformation from lead molecule to ‘drug’ is governed by several factors determining its success or failure. In the present review, we have discussed drugs that are part of the currently approved treatment regimen, their limitations, vaccine candidates under trials, and current issues in research that need to be addressed. While we are waiting for the path-breaking treatment for TB, these factors should be considered during the ongoing quest for novel yet effective anti-tubercular. If these issues are addressed, we could hope to develop a more effective treatment that would cure multi/extremely drug-resistant TB and help us meet the WHO's targets for controlling the global TB pandemic within the prescribed timeline. Despite numerous drugs and vaccines undergoing clinical trials, we have not been able to control TB. Majority of articles list the advancements in the TB drug-discovery; here we review the limitations of existing treatments. Brief description of aspects to be considered for the development of one but effective drug/preventive vaccine. A glance at pediatric tuberculosis: the most neglected area of TB research which requires dedicated research efforts. A concise narrative for research aspects to be re-evaluated by both academia and pharmaceutical R&D teams.
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Key Words
- BCG, Bacille Calmette-Guérin
- BDQ, Bedaquiline
- BSL, Biosafety level
- CDC, Center for Disease Control and Prevention
- Drug discovery
- Drug resistance
- EMB, Ethambutol
- ESX, ESAT-6 secretion system
- ETC, Electron transport chain
- ETH, Ethionamide
- FAS-1, Fatty acid synthase 1
- FDA, Food and Drug Administration
- INH, Isoniazid
- LPZ, Lansoprazole
- MDR, Multidrug-resistant
- Mtb, Mycobacterium tuberculosis
- POA, pyrazinoic acid
- PZA, Pyrazinamide
- RD, the region of differences
- RIF, Rifampicin
- T7SS, Type 7 secretion system
- TB treatment
- TB, Tuberculosis
- TST, Tuberculin skin test
- Tuberculosis
- WHO, World health organization
- XDR, Extremely drug-resistant
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Affiliation(s)
- Ameya D Bendre
- Laboratory of Membrane Protein Biology, National Centre for Cell Science, NCCS Complex, S. P. Pune University, Maharashtra, Pune, 411007, India
| | - Peter J Peters
- The Maastricht Multimodal Molecular Imaging Institute (M4I), Division of Nanoscopy, Maastricht University, Maastricht, the Netherlands
| | - Janesh Kumar
- Laboratory of Membrane Protein Biology, National Centre for Cell Science, NCCS Complex, S. P. Pune University, Maharashtra, Pune, 411007, India
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Black TA, Buchwald UK. The pipeline of new molecules and regimens against drug-resistant tuberculosis. J Clin Tuberc Other Mycobact Dis 2021; 25:100285. [PMID: 34816020 PMCID: PMC8593651 DOI: 10.1016/j.jctube.2021.100285] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The clinical development and regulatory approval of bedaquiline, delamanid and pretomanid over the last decade brought about significant progress in the management of drug-resistant tuberculosis, providing all-oral regimens with favorable safety profiles. The Nix-TB and ZeNix trials of a bedaquiline - pretomanid - linezolid regimen demonstrated for the first time that certain forms of drug-resistant tuberculosis can be cured in the majority of patients within 6 months. Ongoing Phase 3 studies containing these drugs may further advance optimized regimen compositions. Investigational drugs in clinical development that target clinically validated mechanisms, such as second generation oxazolidinones (sutezolid, delpazolid, TBI-223) and diarylquinolines (TBAJ-876 and TBAJ-587) promise improved potency and/or safety compared to the first-in-class drugs. Compounds with novel targets involved in diverse bacterial functions such as cell wall synthesis (DrpE1, MmpL3), electron transport, DNA synthesis (GyrB), cholesterol metabolism and transcriptional regulation of ethionamide bioactivation pathways have advanced to early clinical studies with the potential to enhance antibacterial activity when added to new or established anti-TB drug regimens. Clinical validation of preclinical in vitro and animal model predictions of new anti-TB regimens may further improve the translational value of these models to identify optimal anti-TB therapies.
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Affiliation(s)
- Todd A. Black
- Global Alliance for TB Drug Development, 40 Wall Street, 24th Floor, New York, NY 10005, USA
| | - Ulrike K. Buchwald
- Global Alliance for TB Drug Development, 40 Wall Street, 24th Floor, New York, NY 10005, USA
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Guglielmetti L, Ardizzoni E, Atger M, Baudin E, Berikova E, Bonnet M, Chang E, Cloez S, Coit JM, Cox V, de Jong BC, Delifer C, Do JM, Tozzi DDS, Ducher V, Ferlazzo G, Gouillou M, Khan A, Khan U, Lachenal N, LaHood AN, Lecca L, Mazmanian M, McIlleron H, Moschioni M, O’Brien K, Okunbor O, Oyewusi L, Panda S, Patil SB, Phillips PPJ, Pichon L, Rupasinghe P, Rich ML, Saluhuddin N, Seung KJ, Tamirat M, Trippa L, Cellamare M, Velásquez GE, Wasserman S, Zimetbaum PJ, Varaine F, Mitnick CD. Evaluating newly approved drugs for multidrug-resistant tuberculosis (endTB): study protocol for an adaptive, multi-country randomized controlled trial. Trials 2021; 22:651. [PMID: 34563240 PMCID: PMC8465691 DOI: 10.1186/s13063-021-05491-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 07/27/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Treatment of multidrug- and rifampin-resistant tuberculosis (MDR/RR-TB) is expensive, labour-intensive, and associated with substantial adverse events and poor outcomes. While most MDR/RR-TB patients do not receive treatment, many who do are treated for 18 months or more. A shorter all-oral regimen is currently recommended for only a sub-set of MDR/RR-TB. Its use is only conditionally recommended because of very low-quality evidence underpinning the recommendation. Novel combinations of newer and repurposed drugs bring hope in the fight against MDR/RR-TB, but their use has not been optimized in all-oral, shorter regimens. This has greatly limited their impact on the burden of disease. There is, therefore, dire need for high-quality evidence on the performance of new, shortened, injectable-sparing regimens for MDR-TB which can be adapted to individual patients and different settings. METHODS endTB is a phase III, pragmatic, multi-country, adaptive, randomized, controlled, parallel, open-label clinical trial evaluating the efficacy and safety of shorter treatment regimens containing new drugs for patients with fluoroquinolone-susceptible, rifampin-resistant tuberculosis. Study participants are randomized to either the control arm, based on the current standard of care for MDR/RR-TB, or to one of five 39-week multi-drug regimens containing newly approved and repurposed drugs. Study participation in all arms lasts at least 73 and up to 104 weeks post-randomization. Randomization is response-adapted using interim Bayesian analysis of efficacy endpoints. The primary objective is to assess whether the efficacy of experimental regimens at 73 weeks is non-inferior to that of the control. A sample size of 750 patients across 6 arms affords at least 80% power to detect the non-inferiority of at least 1 (and up to 3) experimental regimens, with a one-sided alpha of 0.025 and a non-inferiority margin of 12%, against the control in both modified intention-to-treat and per protocol populations. DISCUSSION The lack of a safe and effective regimen that can be used in all patients is a major obstacle to delivering appropriate treatment to all patients with active MDR/RR-TB. Identifying multiple shorter, safe, and effective regimens has the potential to greatly reduce the burden of this deadly disease worldwide. TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT02754765. Registered on 28 April 2016; the record was last updated for study protocol version 3.3, on 27 August 2019.
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Affiliation(s)
- L. Guglielmetti
- Médecins Sans Frontières, Paris, France
- Sorbonne Université, INSERM, U1135, Centre d’Immunologie Et Des Maladies Infectieuses, Paris, France
- Assistance Publique Hôpitaux de Paris, Groupe Hospitalier Universitaire Sorbonne Université, Hôpital Pitié-Salpêtrière, Centre National De Référence Des Mycobactéries Et De La Résistance Des Mycobactéries Aux Antituberculeux, Paris, France
| | - E. Ardizzoni
- Institute of Tropical Medicine, Antwerp, Belgium
| | - M. Atger
- Médecins Sans Frontières, Paris, France
| | | | - E. Berikova
- Partners In Health, Astana, Kazakhstan
- National Scientific Center of Phthisiopulmonology, Almaty, Kazakhstan
| | - M. Bonnet
- Médecins Sans Frontières, Paris, France
- Institut de Recherche pour le Développement/INSERM U1175/UMI233/ Université de Montpellier, Montpellier, France
| | - E. Chang
- Médecins Sans Frontières, Toronto, Ontario Canada
| | - S. Cloez
- Médecins Sans Frontières, Paris, France
| | - J. M. Coit
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
| | - V. Cox
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | | | | | - J. M. Do
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
| | | | - V. Ducher
- Médecins Sans Frontières, Paris, France
| | - G. Ferlazzo
- Southern Africa Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
| | | | - A. Khan
- Interactive Research and Development, Karachi, Pakistan
| | - U. Khan
- Interactive Research and Development, Karachi, Pakistan
| | | | - A. N. LaHood
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
| | - L. Lecca
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
- Socios En Salud-Sucursal Peru, Lima, Peru
| | - M. Mazmanian
- Médecins Sans Frontières, Paris, France
- Assistance Publique Hôpitaux de Paris, Unité de Recherche Clinique, Hôpital Pitié-Salpêtrière, Paris, France
| | - H. McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | | | | | - O. Okunbor
- Social & Scientific Systems-DLH, Silver Spring, MD USA
| | | | - S. Panda
- Epidemiology and Communicable Diseases Division, Indian Council of Medical Research, Pune, India
- Indian Council of Medical Research – National AIDS Research Institute, Pune, India
| | - S. B. Patil
- Indian Council of Medical Research – National AIDS Research Institute, Pune, India
| | - P. P. J. Phillips
- University of San Francisco Center for Tuberculosis, San Francisco, CA USA
| | - L. Pichon
- Médecins Sans Frontières, Paris, France
| | | | - M. L. Rich
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
- Partners In Health, Boston, MA USA
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA USA
| | - N. Saluhuddin
- Department of Infectious Diseases, Indus Hospital, Karachi, Pakistan
| | - K. J. Seung
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
- Partners In Health, Boston, MA USA
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA USA
| | | | - L. Trippa
- Dana-Farber Cancer Institute, Boston, MA USA
- Harvard T.H. Chan School of Public Health, Boston, MA USA
| | | | - G. E. Velásquez
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA USA
- Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, MA USA
| | - S. Wasserman
- Wellcome Centre for Infectious Diseases Research in Africa, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - P. J. Zimetbaum
- Harvard Medical School, Boston, MA USA
- Beth Israel Deaconess Medical Center, Boston, MA USA
| | | | - C. D. Mitnick
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
- Partners In Health, Boston, MA USA
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA USA
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Santucci P, Greenwood DJ, Fearns A, Chen K, Jiang H, Gutierrez MG. Intracellular localisation of Mycobacterium tuberculosis affects efficacy of the antibiotic pyrazinamide. Nat Commun 2021; 12:3816. [PMID: 34155215 PMCID: PMC8217510 DOI: 10.1038/s41467-021-24127-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 05/28/2021] [Indexed: 11/09/2022] Open
Abstract
To be effective, chemotherapy against tuberculosis (TB) must kill the intracellular population of the pathogen, Mycobacterium tuberculosis. However, how host cell microenvironments affect antibiotic accumulation and efficacy remains unclear. Here, we use correlative light, electron, and ion microscopy to investigate how various microenvironments within human macrophages affect the activity of pyrazinamide (PZA), a key antibiotic against TB. We show that PZA accumulates heterogeneously among individual bacteria in multiple host cell environments. Crucially, PZA accumulation and efficacy is maximal within acidified phagosomes. Bedaquiline, another antibiotic commonly used in combined TB therapy, enhances PZA accumulation via a host cell-mediated mechanism. Thus, intracellular localisation and specific microenvironments affect PZA accumulation and efficacy. Our results may explain the potent in vivo efficacy of PZA, compared to its modest in vitro activity, and its critical contribution to TB combination chemotherapy.
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Affiliation(s)
- Pierre Santucci
- Host-Pathogen Interactions in Tuberculosis Laboratory, The Francis Crick Institute, London, UK
| | - Daniel J Greenwood
- Host-Pathogen Interactions in Tuberculosis Laboratory, The Francis Crick Institute, London, UK.,Institute of Molecular Systems Biology, ETH, Zurich, Switzerland
| | - Antony Fearns
- Host-Pathogen Interactions in Tuberculosis Laboratory, The Francis Crick Institute, London, UK
| | - Kai Chen
- School of Molecular Sciences, University of Western Australia, Perth, AU, Australia
| | - Haibo Jiang
- School of Molecular Sciences, University of Western Australia, Perth, AU, Australia. .,Department of Chemistry, The University of Hong Kong, Hong Kong, China.
| | - Maximiliano G Gutierrez
- Host-Pathogen Interactions in Tuberculosis Laboratory, The Francis Crick Institute, London, UK.
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Bedaquiline: Current status and future perspectives. J Glob Antimicrob Resist 2021; 25:48-59. [PMID: 33684606 DOI: 10.1016/j.jgar.2021.02.017] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 01/28/2021] [Accepted: 02/17/2021] [Indexed: 12/21/2022] Open
Abstract
The development of drug-resistant tuberculosis (TB) is a major threat worldwide. Based on World Health Organization (WHO) reports, it is estimated that more than 500 000 new cases of drug-resistant TB occur annually. In addition, there are alarming reports of increasing multidrug-resistant TB (MDR-TB) and the emergence of extensively drug-resistant TB (XDR-TB) from different countries of the world. Therefore, new options for TB therapy are required. Bedaquiline (BDQ), a novel anti-TB drug, has significant minimum inhibitory concentrations (MICs) both against drug-susceptible and drug-resistant TB. Moreover, BDQ was recently approved for therapy of MDR-TB. The current narrative review summarises the available data on BDQ resistance, describes its antimicrobial properties, and provides new perspectives on clinical use of this novel anti-TB agent.
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Mudde SE, Alsoud RA, van der Meijden A, Upton AM, Lotlikar MU, Simonsson USH, Bax HI, de Steenwinkel JEM. Predictive modeling to study the treatment-shortening potential of novel tuberculosis drug regimens, towards bundling of preclinical data. J Infect Dis 2021; 225:1876-1885. [PMID: 33606880 PMCID: PMC9159334 DOI: 10.1093/infdis/jiab101] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 02/15/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Given the persistently high global burden of tuberculosis (TB), effective and shorter treatment options are needed. Here, we explore the relationship between relapse and treatment length as well as inter-regimen differences for two novel anti-TB drug regimens using a mouse model of TB infection and mathematical modeling. METHODS Mycobacterium tuberculosis-infected mice were treated for up to 13 weeks with bedaquiline and pretomanid combined with moxifloxacin and pyrazinamide (BPaMZ) or linezolid (BPaL). Cure rates were evaluated 12 weeks after treatment completion. The standard regimen of isoniazid, rifampicin, pyrazinamide, and ethambutol (HRZE) was evaluated as a comparator. RESULTS Six weeks of BPaMZ was sufficient to cure all mice. In contrast, 13 weeks of BPaL and 24 weeks of HRZE did not achieve 100% cure rates. Based on mathematical model predictions, 95% probability of cure was predicted for BPaMZ, BPaL and HRZE to occur at 1.6, 4.3, and 7.9 months, respectively. CONCLUSION This study provides additional evidence for the treatment-shortening capacity of BPaMZ over BPaL and HRZE. To optimally utilize preclinical data for predicting clinical outcomes, and to overcome the limitations that hamper such extrapolation, we advocate bundling of available published preclinical data into mathematical models.
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Affiliation(s)
- Saskia E Mudde
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Rami Ayoun Alsoud
- Department of Pharmaceutical Biosciences, Uppsala University, Uppsala, Sweden
| | - Aart van der Meijden
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Anna M Upton
- Global Alliance for Tuberculosis Drug Development, New York, USA
| | | | | | - Hannelore I Bax
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Rotterdam, The Netherlands.,Department of Internal Medicine, Section of Infectious Diseases, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jurriaan E M de Steenwinkel
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center, Rotterdam, The Netherlands
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11
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Abstract
Successful treatment of tuberculosis (TB) can be hampered by Mycobacterium tuberculosis populations that are temporarily able to survive antibiotic pressure in the absence of drug resistance-conferring mutations, a phenomenon termed drug tolerance. We summarize findings on M. tuberculosis tolerance published in the past 20 years. Key M. tuberculosis responses to drug pressure are reduced growth rates, metabolic shifting, and the promotion of efflux pump activity. Metabolic shifts upon drug pressure mainly occur in M. tuberculosis's lipid metabolism and redox homeostasis, with reduced tricarboxylic acid cycle activity in favor of lipid anabolism. Increased lipid anabolism plays a role in cell wall thickening, which reduces sensitivity to most TB drugs. In addition to these general mechanisms, drug-specific mechanisms have been described. Upon isoniazid exposure, M. tuberculosis reprograms several pathways associated with mycolic acid biosynthesis. Upon rifampicin exposure, M. tuberculosis upregulates the expression of its drug target rpoB Upon bedaquiline exposure, ATP synthesis is stimulated, and the transcription factors Rv0324 and Rv0880 are activated. A better understanding of M. tuberculosis's responses to drug pressure will be important for the development of novel agents that prevent the development of drug tolerance following treatment initiation. Such agents could then contribute to novel TB treatment-shortening strategies.
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12
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Reves R. Our love-hate relationship with pyrazinamide. Clin Infect Dis 2020; 73:e3518-e3519. [PMID: 33011784 DOI: 10.1093/cid/ciaa1505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Indexed: 11/13/2022] Open
Affiliation(s)
- Randall Reves
- Division of Infectious Diseases, Department of Medicine and School of Public Health, University of Colorado Denver, Aurora, Colorado
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13
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Liu P, Fan S, Wang B, Cao R, Wang X, Li S, Lu Y, Zhong W. Design, synthesis and biological evaluation of novel triaryldimethylaminobutan-2-ol derivatives against Mycobacterium tuberculosis. Bioorg Chem 2020; 102:104054. [PMID: 32663665 DOI: 10.1016/j.bioorg.2020.104054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 06/08/2020] [Accepted: 06/26/2020] [Indexed: 10/24/2022]
Abstract
Bedaquiline (TMC207), a typical diarylquinoline anti-tuberculosis drug, has been approved by FDA to specifically treat MDR-TB. Herein we describe design, synthesis, and in vitro biological evaluation against Mycobacterium tuberculosis of a series of triaryldimethylaminobutan-2-ol derivatives obtaining from the structural modification of TMC207. Compounds 23, 25, 28, 32, 39 and 43 provided superior anti-mycobacterial activity than positive control PC01 which shows the same configuration and contains TMC207. Compounds 16, 20, 29, 34, 37, 45 and 47 exhibited the similar activity to positive control PC01. Most importantly, the series of compounds showed excellent activity against XDR-Mtb. The result of acute toxicity suggested that this class of triaryldimethylaminobutan-2-ol derivatives should be graded as low. Further SAR analysis indicates that a large steric bulk of triaryl and 7-Br, 3-OCH3 on 1-naphthyl are critical.
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Affiliation(s)
- Ping Liu
- National Engineering Research Center for the Emergency Drug, Beijing Institute of Pharmacology and Toxicology, Taiping Road 27, Beijing 100850, PR China
| | - Shiyong Fan
- National Engineering Research Center for the Emergency Drug, Beijing Institute of Pharmacology and Toxicology, Taiping Road 27, Beijing 100850, PR China
| | - Bin Wang
- Tuberculosis and Thoracic Tumor Research Institute, Beijing Chest Hospital, Capital Medical University, Beijing, PR China
| | - Ruiyuan Cao
- National Engineering Research Center for the Emergency Drug, Beijing Institute of Pharmacology and Toxicology, Taiping Road 27, Beijing 100850, PR China
| | - Xiaokui Wang
- National Engineering Research Center for the Emergency Drug, Beijing Institute of Pharmacology and Toxicology, Taiping Road 27, Beijing 100850, PR China
| | - Song Li
- National Engineering Research Center for the Emergency Drug, Beijing Institute of Pharmacology and Toxicology, Taiping Road 27, Beijing 100850, PR China
| | - Yu Lu
- Tuberculosis and Thoracic Tumor Research Institute, Beijing Chest Hospital, Capital Medical University, Beijing, PR China.
| | - Wu Zhong
- National Engineering Research Center for the Emergency Drug, Beijing Institute of Pharmacology and Toxicology, Taiping Road 27, Beijing 100850, PR China.
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14
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Giraud-Gatineau A, Coya JM, Maure A, Biton A, Thomson M, Bernard EM, Marrec J, Gutierrez MG, Larrouy-Maumus G, Brosch R, Gicquel B, Tailleux L. The antibiotic bedaquiline activates host macrophage innate immune resistance to bacterial infection. eLife 2020; 9:e55692. [PMID: 32369020 PMCID: PMC7200153 DOI: 10.7554/elife.55692] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 04/04/2020] [Indexed: 12/12/2022] Open
Abstract
Antibiotics are widely used in the treatment of bacterial infections. Although known for their microbicidal activity, antibiotics may also interfere with the host's immune system. Here, we analyzed the effects of bedaquiline (BDQ), an inhibitor of the mycobacterial ATP synthase, on human macrophages. Genome-wide gene expression analysis revealed that BDQ reprogramed cells into potent bactericidal phagocytes. We found that 579 and 1,495 genes were respectively differentially expressed in naive- and M. tuberculosis-infected macrophages incubated with the drug, with an over-representation of lysosome-associated genes. BDQ treatment triggered a variety of antimicrobial defense mechanisms, including phagosome-lysosome fusion, and autophagy. These effects were associated with activation of transcription factor EB, involved in the transcription of lysosomal genes, resulting in enhanced intracellular killing of different bacterial species that were naturally insensitive to BDQ. Thus, BDQ could be used as a host-directed therapy against a wide range of bacterial infections.
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Affiliation(s)
- Alexandre Giraud-Gatineau
- Unit for Integrated Mycobacterial Pathogenomics, CNRS UMR 3525, Institut PasteurParisFrance
- Université Paris Diderot, Sorbonne Paris Cité, Cellule PasteurParisFrance
| | | | - Alexandra Maure
- Unit for Integrated Mycobacterial Pathogenomics, CNRS UMR 3525, Institut PasteurParisFrance
- Université Paris Diderot, Sorbonne Paris Cité, Cellule PasteurParisFrance
| | - Anne Biton
- Bioinformatics and Biostatistics, Department of Computational Biology, USR 3756 CNRS, Institut PasteurParisFrance
| | - Michael Thomson
- MRC Centre for Molecular Bacteriology and Infection, Department of Life Sciences, Faculty of Natural Sciences, Imperial College LondonLondonUnited Kingdom
| | - Elliott M Bernard
- Host-Pathogen Interactions in Tuberculosis Laboratory, The Francis Crick InstituteLondonUnited Kingdom
| | - Jade Marrec
- Mycobacterial Genetics Unit, Institut PasteurParisFrance
| | - Maximiliano G Gutierrez
- Host-Pathogen Interactions in Tuberculosis Laboratory, The Francis Crick InstituteLondonUnited Kingdom
| | - Gérald Larrouy-Maumus
- MRC Centre for Molecular Bacteriology and Infection, Department of Life Sciences, Faculty of Natural Sciences, Imperial College LondonLondonUnited Kingdom
| | - Roland Brosch
- Unit for Integrated Mycobacterial Pathogenomics, CNRS UMR 3525, Institut PasteurParisFrance
| | - Brigitte Gicquel
- Mycobacterial Genetics Unit, Institut PasteurParisFrance
- Department of Tuberculosis Control and Prevention, Shenzhen Nanshan Center for Chronic Disease ControlShenzhenChina
| | - Ludovic Tailleux
- Unit for Integrated Mycobacterial Pathogenomics, CNRS UMR 3525, Institut PasteurParisFrance
- Mycobacterial Genetics Unit, Institut PasteurParisFrance
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15
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Abstract
Tuberculosis (TB) has now surpassed HIV as the leading infectious cause of death, and treatment success rates are declining. Multidrug-resistant TB, extensively drug-resistant TB, and even totally drug-resistant TB threaten to further destabilize disease control efforts. The second wave in TB drug development, which includes the diarylquinoline, bedaquiline, and the nitroimidazoles delamanid and pretomanid, may offer options for simpler, shorter, and potentially all-oral regimens to treat drug-resistant TB. The "third wave" of TB drug development includes numerous promising compounds, including less toxic versions of older drug classes and candidates with novel mechanisms of action.
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Affiliation(s)
- Elisa H Ignatius
- Department of Medicine, Johns Hopkins University School of Medicine, 1830 Building Room 450B, 1830 East Monument Street, Baltimore, MD 21287, USA
| | - Kelly E Dooley
- Department of Medicine, Center for Tuberculosis Research, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Osler 527, Baltimore, MD, USA.
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16
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Minakshi P, Ghosh M, Brar B, Kumar R, Lambe UP, Ranjan K, Manoj J, Prasad G. Nano-antimicrobials: A New Paradigm for Combating Mycobacterial Resistance. Curr Pharm Des 2020; 25:1554-1579. [PMID: 31218956 DOI: 10.2174/1381612825666190620094041] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 06/11/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Mycobacterium group contains several pathogenic bacteria including M. tuberculosis where the emergence of multidrug-resistant tuberculosis (MDR-TB) and extensively drug-resistant tuberculosis (XDR-TB) is alarming for human and animal health around the world. The condition has further aggravated due to the speed of discovery of the newer drugs has been outpaced by the rate of resistance developed in microorganisms, thus requiring alternative combat strategies. For this purpose, nano-antimicrobials have emerged as a potential option. OBJECTIVE The current review is focused on providing a detailed account of nanocarriers like liposome, micelles, dendrimers, solid lipid NPs, niosomes, polymeric nanoparticles, nano-suspensions, nano-emulsion, mesoporous silica and alginate-based drug delivery systems along with the recent updates on developments regarding nanoparticle-based therapeutics, vaccines and diagnostic methods developed or under pipeline with their potential benefits and limitations to combat mycobacterial diseases for their successful eradication from the world in future. RESULTS Distinct morphology and the underlying mechanism of pathogenesis and resistance development in this group of organisms urge improved and novel methods for the early and efficient diagnosis, treatment and vaccination to eradicate the disease. Recent developments in nanotechnology have the potential to meet both the aspects: nano-materials are proven components of several efficient targeted drug delivery systems and the typical physicochemical properties of several nano-formulations have shown to possess distinct bacteriocidal properties. Along with the therapeutic aspects, nano-vaccines and theranostic applications of nano-formulations have grown in popularity in recent times as an effective alternative means to combat different microbial superbugs. CONCLUSION Nanomedicine holds a bright prospect to perform a key role in global tuberculosis elimination program.
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Affiliation(s)
- Prasad Minakshi
- Department of Animal Biotechnology, LLR University of Veterinary and Animal Sciences, Hisar-125 004, Haryana, India
| | - Mayukh Ghosh
- Department of Veterinary Biochemistry, Ranchi Veterinary College, Birsa Agricultural University, Ranchi-834 006, Jharkhand, India
| | - Basanti Brar
- Department of Animal Biotechnology, LLR University of Veterinary and Animal Sciences, Hisar-125 004, Haryana, India
| | - Rajesh Kumar
- Department of Veterinary Physiology, COVAS, KVASU, Pookode, Wayanad- 673576, Kerala, India
| | - Upendra P Lambe
- Department of Animal Biotechnology, LLR University of Veterinary and Animal Sciences, Hisar-125 004, Haryana, India
| | | | - Jinu Manoj
- RVDEC Mahendergarh, LUVAS, Haryana, India
| | - Gaya Prasad
- SVP University of Agriculture and Technology, Meerut, India
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17
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Re-Understanding the Mechanisms of Action of the Anti-Mycobacterial Drug Bedaquiline. Antibiotics (Basel) 2019; 8:antibiotics8040261. [PMID: 31835707 PMCID: PMC6963887 DOI: 10.3390/antibiotics8040261] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Accepted: 12/07/2019] [Indexed: 12/14/2022] Open
Abstract
Bedaquiline (BDQ) inhibits ATP generation in Mycobacterium tuberculosis by interfering with the F-ATP synthase activity. Two mechanisms of action of BDQ are broadly accepted. A direct mechanism involves BDQ binding to the enzyme’s c-ring to block its rotation, thus inhibiting ATP synthesis in the enzyme’s catalytic α3β3-headpiece. An indirect mechanism involves BDQ uncoupling electron transport in the electron transport chain from ATP synthesis at the F-ATP synthase. In a recently uncovered second direct mechanism, BDQ binds to the enzyme’s ε-subunit to disrupt its ability to link c-ring rotation to ATP synthesis at the α3β3-headpiece. However, this mechanism is controversial as the drug’s binding affinity for the isolated ε-subunit protein is moderate and spontaneous resistance mutants in the ε-subunit cannot be isolated. Recently, the new, structurally distinct BDQ analogue TBAJ-876 was utilized as a chemical probe to revisit BDQ’s mechanisms of action. In this review, we first summarize discoveries on BDQ’s mechanisms of action and then describe the new insights derived from the studies of TBAJ-876. The TBAJ-876 investigations confirm the c-ring as a target, while also supporting a functional role for targeting the ε-subunit. Surprisingly, the new findings suggest that the uncoupler mechanism does not play a key role in BDQ’s anti-mycobacterial activity.
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18
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Gray WA, Waldorf B, Rao MG, Stiles BL, Griffiss JM, Salata RA, Blumer JL. Development and validation of an LC-MS/MS method for the simultaneous determination of bedaquiline and rifabutin in human plasma. J Pharm Biomed Anal 2019; 176:112775. [PMID: 31446299 DOI: 10.1016/j.jpba.2019.07.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 07/11/2019] [Accepted: 07/12/2019] [Indexed: 11/30/2022]
Abstract
This article describes the simultaneous determination of bedaquiline fumarate (TMC-207) and rifabutin in human plasma by stable isotope dilution tandem mass spectrometry. The methodology was developed for an investigation of potential drug-drug interactions of the two anti-tuberculosis drugs when given together to healthy human volunteers. Use of the two drugs in combination to treat disease caused by Mycobacterium tuberculosis is contemplated as the bacterium becomes resistant to many currently available drugs.
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Affiliation(s)
- Wesley A Gray
- The University of Toledo, Department of Pediatrics, 3000 Arlington Ave., Toledo, OH 43614, USA
| | - Byron Waldorf
- The University of Toledo, Department of Pediatrics, 3000 Arlington Ave., Toledo, OH 43614, USA
| | - Manasa Geeta Rao
- The University of Toledo, Department of Pediatrics, 3000 Arlington Ave., Toledo, OH 43614, USA
| | - Brenda L Stiles
- Clinical Research Management, now ICON Government and Public Health Solutions, 1265 Ridge Road, Hinckley, OH 44233, USA
| | - J McLeod Griffiss
- Clinical Research Management, now ICON Government and Public Health Solutions, 1265 Ridge Road, Hinckley, OH 44233, USA.
| | - Robert A Salata
- Case Western Reserve University Department of Medicine, 10900 Euclid Ave Cleveland, OH 44106, USA; Professor and Chair, Case Western Reserve University, Department of Medicine, USA
| | - Jeffrey L Blumer
- The University of Toledo, Department of Pediatrics, 3000 Arlington Ave., Toledo, OH 43614, USA; Professor The University of Toledo, Department of Pediatrics, Toledo, OH, USA
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19
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Dry powder formulation combining bedaquiline with pyrazinamide for latent and drug-resistant tuberculosis. ADV POWDER TECHNOL 2019. [DOI: 10.1016/j.apt.2019.07.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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20
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Rangnekar B, Momin MA, Eedara BB, Sinha S, Das SC. Bedaquiline containing triple combination powder for inhalation to treat drug-resistant tuberculosis. Int J Pharm 2019; 570:118689. [DOI: 10.1016/j.ijpharm.2019.118689] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 09/01/2019] [Accepted: 09/08/2019] [Indexed: 12/23/2022]
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21
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Momin MAM, Rangnekar B, Sinha S, Cheung CY, Cook GM, Das SC. Inhalable Dry Powder of Bedaquiline for Pulmonary Tuberculosis: In Vitro Physicochemical Characterization, Antimicrobial Activity and Safety Studies. Pharmaceutics 2019; 11:pharmaceutics11100502. [PMID: 31581469 PMCID: PMC6836091 DOI: 10.3390/pharmaceutics11100502] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Revised: 09/09/2019] [Accepted: 09/23/2019] [Indexed: 12/19/2022] Open
Abstract
Bedaquiline is a newly developed anti-tuberculosis drug, conditionally approved by the United States Food and Drug Administration (USFDA) for treating drug-resistant tuberculosis in adults. Oral delivery of bedaquiline causes severe side effects such as increased hepatic aminotransferase levels and cardiac arrhythmias (prolongation of QT-interval). This study aimed to develop inhalable dry powder particles of bedaquiline with high aerosolization efficiency to reduce the side-effects of oral bedaquiline. Bedaquiline (with or without l-leucine) powders were prepared using a Buchi Mini Spray-dryer. The powders were characterized for physicochemical properties and for their in vitro aerosolization efficiency using a next-generation impactor (NGI). The formulation with maximum aerosolization efficiency was investigated for physicochemical and aerosolization stability after one-month storage at 20 ± 2 °C/30 ± 2% relative humidity (RH) and 25 ± 2 °C/75% RH in an open Petri dish. The cytotoxicity of the powders on A549 and Calu-3 cell-lines was evaluated using the 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay. The powders were also evaluated for antimicrobial activity against Mycobacterium tuberculosis. The aerodynamic diameter of the l-leucine-containing powder was 2.4 µm, and the powder was amorphous in nature. The aerosolization efficiency (fine-particle fraction) of l-leucine-containing powder (fine-particle fraction (FPF): 74.4%) was higher than the bedaquiline-only powder (FPF: 31.3%). l-leucine containing powder particles were plate-shaped with rough surfaces, but the bedaquiline-only powder was spherical and smooth. The optimized powder was stable at both storage conditions during one-month storage and non-toxic (up to 50 µg/mL) to the respiratory cell-lines. Bedaquiline powders were effective against Mycobacterium tuberculosis and had a minimal inhibitory concentration (MIC) value of 0.1 µg/mL. Improved aerosolization may help to combat pulmonary tuberculosis by potentially reducing the side-effects of oral bedaquiline. Further research is required to understand the safety of the optimized inhalable powder in animal models.
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Affiliation(s)
- Mohammad A M Momin
- School of Pharmacy, University of Otago, Dunedin 9054, New Zealand.
- Department of Pharmaceutics, School of Pharmacy, Virginia Commonwealth University, Richmond, VA 23298-0533, USA.
| | | | - Shubhra Sinha
- School of Pharmacy, University of Otago, Dunedin 9054, New Zealand.
| | - Chen-Yi Cheung
- Department of Microbiology and Immunology, University of Otago, Dunedin 9054, New Zealand.
| | - Gregory M Cook
- Department of Microbiology and Immunology, University of Otago, Dunedin 9054, New Zealand.
| | - Shyamal C Das
- School of Pharmacy, University of Otago, Dunedin 9054, New Zealand.
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22
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Identifying Regimens Containing TBI-166, a New Drug Candidate against Mycobacterium tuberculosis In Vitro and In Vivo. Antimicrob Agents Chemother 2019; 63:AAC.02496-18. [PMID: 31061157 DOI: 10.1128/aac.02496-18] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 04/15/2019] [Indexed: 02/03/2023] Open
Abstract
TBI-166, derived from riminophenazine analogues, is under development in a phase I clinical trial in China. TBI-166 showed more potent anti-tuberculosis (anti-TB) activity than did clofazimine in in vitro and animal experiments. To identify potent regimens containing TBI-166 in TB chemotherapy, TBI-166 was assessed for pharmacological interactions in vitro and in vivo with several anti-TB drugs, including isoniazid (INH), rifampin (RFP), bedaquiline (BDQ), pretomanid (PMD), linezolid (LZD), and pyrazinamide (PZA). Using an in vitro checkerboard method, we found that TBI-166 did not show antagonism or synergy with the tested drugs. The interaction relationship between TBI-166 and each drug was indifferent. In in vivo experiments, aerosol infection models with BALB/c and C3HeB/FeJNju mice were established, testing drugs were administered either individually or combined in treatments containing TBI-166 and one, two, or three other drugs, and the bactericidal activities were determined after 4- and 8-week therapeutic treatments. In BALB/c mice, five TBI-166-containing regimens-TBI-166+BDQ, TBI-166+PZA, TBI-166+BDQ+LZD, TBI-166+BDQ+PMD, and TBI-166+BDQ+PMD+LZD-showed significantly more potent efficacy after 4 weeks of treatment compared to the control regimen, INH+RFP+PZA. At the end of an 8-week treatment, lung log CFU counts decreased to undetectable levels in mice treated with each of the five regimens. The rank order of the potency of the five regimens was as follows: TBI-166+BDQ+LZD > TBI-166+BDQ > TBI-166+PZA > TBI-166+BDQ+PMD+LZD > TBI-166+BDQ+PMD. In C3HeB/FeJNju mice, TBI-166+BDQ+LZD was also the most effective of the TBI-166-containing regimens. In conclusion, five potent chemotherapy regimens that included TBI-166 were identified. The TBI-166+BDQ+LZD regimen is recommended for further testing in a TBI-166 phase IIb clinical trial.
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23
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Bedaquiline kills persistent Mycobacterium tuberculosis with no disease relapse: an in vivo model of a potential cure. J Antimicrob Chemother 2019; 74:1627-1633. [DOI: 10.1093/jac/dkz052] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 01/14/2019] [Accepted: 01/14/2019] [Indexed: 11/12/2022] Open
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24
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Lu X, Williams Z, Hards K, Tang J, Cheung CY, Aung HL, Wang B, Liu Z, Hu X, Lenaerts A, Woolhiser L, Hastings C, Zhang X, Wang Z, Rhee K, Ding K, Zhang T, Cook GM. Pyrazolo[1,5- a]pyridine Inhibitor of the Respiratory Cytochrome bcc Complex for the Treatment of Drug-Resistant Tuberculosis. ACS Infect Dis 2019; 5:239-249. [PMID: 30485737 DOI: 10.1021/acsinfecdis.8b00225] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Respiration is a promising target for the development of new antimycobacterial agents, with a growing number of compounds in clinical development entering this target space. However, more candidate inhibitors are needed to expand the therapeutic options available for drug-resistant Mycobacterium tuberculosis infection. Here, we characterize a putative respiratory complex III (QcrB) inhibitor, TB47: a pyrazolo[1,5- a]pyridine-3-carboxamide. TB47 is active (MIC between 0.016 and 0.500 μg/mL) against a panel of 56 M. tuberculosis clinical isolates, including 37 multi-drug-resistant and two extensively drug-resistant strains. Pharmacokinetic and toxicity studies showed promising profiles, including negligible CYP450 interactions, cytotoxicity, and hERG channel inhibition. Consistent with other reported QcrB inhibitors, TB47 inhibits oxygen consumption only when the alternative oxidase, cytochrome bd, is deleted. A point mutation in the qcrB cd2-loop (H190Y, M. smegmatis numbering) rescues the inhibitory effects of TB47. Metabolomic profiling of TB47-treated M. tuberculosis H37Rv cultures revealed accumulation of steps in the TCA cycle and pentose phosphate pathway that are linked to reducing equivalents, suggesting that TB47 causes metabolic redox stress. In mouse infection models, a TB47 monotherapy was not bactericidal. However, TB47 was strongly synergistic with pyrazinamide and rifampicin, suggesting a promising role in combination therapies. We propose that TB47 is an effective lead compound for the development of novel tuberculosis chemotherapies.
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Affiliation(s)
- Xiaoyun Lu
- School of Pharmacy, Jinan University, 601 Huangpu Avenue West, Guangzhou 510632, China
| | - Zoe Williams
- Department of Microbiology and Immunology, School of Biomedical Sciences, University of Otago, Dunedin 9054, New Zealand
| | - Kiel Hards
- Department of Microbiology and Immunology, School of Biomedical Sciences, University of Otago, Dunedin 9054, New Zealand
- Maurice Wilkins Centre for Molecular Biodiscovery, The University of Auckland, Private Bag 92019, Auckland 1042, New Zealand
| | - Jian Tang
- Tuberculosis Research Laboratory, State Key Laboratory of Respiratory Disease, Guangzhou Regenerative Medicine and Health Guangdong Laboratory, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, 190 Kaiyuan Avenue, Science Park, Huangpu District, Guangzhou 510530, China
- University of Chinese Academy of Sciences (UCAS), 19 Yuquan Road, Shijingshan District, Beijing 100049, China
| | - Chen-Yi Cheung
- Department of Microbiology and Immunology, School of Biomedical Sciences, University of Otago, Dunedin 9054, New Zealand
| | - Htin Lin Aung
- Department of Microbiology and Immunology, School of Biomedical Sciences, University of Otago, Dunedin 9054, New Zealand
- Maurice Wilkins Centre for Molecular Biodiscovery, The University of Auckland, Private Bag 92019, Auckland 1042, New Zealand
| | - Bangxing Wang
- Tuberculosis Research Laboratory, State Key Laboratory of Respiratory Disease, Guangzhou Regenerative Medicine and Health Guangdong Laboratory, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, 190 Kaiyuan Avenue, Science Park, Huangpu District, Guangzhou 510530, China
- Institute of Physical Science and Information Technology, Anhui University, 111 Jiulong Road, Shushan District, Hefei 230009, China
| | - Zhiyong Liu
- Tuberculosis Research Laboratory, State Key Laboratory of Respiratory Disease, Guangzhou Regenerative Medicine and Health Guangdong Laboratory, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, 190 Kaiyuan Avenue, Science Park, Huangpu District, Guangzhou 510530, China
- University of Chinese Academy of Sciences (UCAS), 19 Yuquan Road, Shijingshan District, Beijing 100049, China
| | - Xianglong Hu
- School of Pharmacy, Jinan University, 601 Huangpu Avenue West, Guangzhou 510632, China
| | - Anne Lenaerts
- Colorado State University, 200W Lake Street, Fort Collins, Colorado 80523, United States
| | - Lisa Woolhiser
- Colorado State University, 200W Lake Street, Fort Collins, Colorado 80523, United States
| | - Courtney Hastings
- Colorado State University, 200W Lake Street, Fort Collins, Colorado 80523, United States
| | - Xiantao Zhang
- Guangzhou Eggbio Co., Ltd., 3 Ju Quan Road, Science Park, Guangzhou 510663, China
| | - Zhe Wang
- Weill Department of Medicine, Weill Cornell Medical College, New York, New York 10021, United States
| | - Kyu Rhee
- Weill Department of Medicine, Weill Cornell Medical College, New York, New York 10021, United States
| | - Ke Ding
- School of Pharmacy, Jinan University, 601 Huangpu Avenue West, Guangzhou 510632, China
| | - Tianyu Zhang
- Tuberculosis Research Laboratory, State Key Laboratory of Respiratory Disease, Guangzhou Regenerative Medicine and Health Guangdong Laboratory, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, 190 Kaiyuan Avenue, Science Park, Huangpu District, Guangzhou 510530, China
- University of Chinese Academy of Sciences (UCAS), 19 Yuquan Road, Shijingshan District, Beijing 100049, China
| | - Gregory M. Cook
- Department of Microbiology and Immunology, School of Biomedical Sciences, University of Otago, Dunedin 9054, New Zealand
- Maurice Wilkins Centre for Molecular Biodiscovery, The University of Auckland, Private Bag 92019, Auckland 1042, New Zealand
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25
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Liu W, Li J, He K, Huang F, Ma Y, Li Y, Li Q, Xu F. Synthesis, bioactivity, action mode and 3D-QSAR of novel anthranilic diamide derivatives. CHINESE CHEM LETT 2019. [DOI: 10.1016/j.cclet.2018.05.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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26
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Pandey S, Lavu E, Congdon J, Moke R, Bainomugisa A, Coulter C. Characterization of pncA mutations in multi-drug and pyrazinamide resistant Mycobacterium tuberculosis isolates cultured from Queensland migrants and Papua New Guinea residents. Tuberculosis (Edinb) 2018; 111:109-113. [PMID: 30029894 DOI: 10.1016/j.tube.2018.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 05/31/2018] [Accepted: 06/07/2018] [Indexed: 10/14/2022]
Abstract
Outbreak of drug resistant tuberculosis in the Western province, Papua New Guinea is a concern to Queensland, Australia due to migration. We performed pncA mutation analysis and genotyping of multi-drug/pyrazinamide (MDR/PZA) resistant isolates from 18 Queensland (Qld) migrants and 81 Papua New Guinea (PNG) residents, to compare with phenotypic evidence of PZA resistance and to evaluate the genotypes obtained from the two countries. Seven different mutations were seen from Qld isolates of which 2 have not been described previously. A cluster of mutations were found between amino acids L35 and S65. Amongst the PNG isolates, 10 mutations were identified, of which 6 were unique and have not been described previously. Majority of the mutations formed 2 clusters, between amino acids Q10 to A20 and W68 to W119. Mutations identified at nucleotide (nt) position 202 and 307 were found to be the most common types, occurring in 25% and 51% of the PNG isolates respectively. The majority of the mutations were seen in MDR/PZA resistant isolates. These mutations could be utilized for direct screening of PZA resistance from PNG patient samples. Genotypic analysis of the isolates showed strong clustering amongst the PNG isolates as opposed to Qld isolates. A diversity of mutations and genotypes were seen amongst the Qld migrant isolates. Majority of PNG isolates had one genotype with two distinct pncA mutation patterns (T202C and T307G) which highlight on-going transmission. pncA mutation analysis provided a satisfactory alternative to PZA culture DST with high positive predictive value and an improved result turnaround time.
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Affiliation(s)
- Sushil Pandey
- Queensland Mycobacterium Reference Laboratory, Pathology Queensland, Queensland, Australia.
| | - Evelyn Lavu
- Central Public Health Laboratory, Port Moresby General Hospital, Port Moresby National Capital District, Papua New Guinea
| | - Jacob Congdon
- Queensland Mycobacterium Reference Laboratory, Pathology Queensland, Queensland, Australia
| | - Rendi Moke
- Daru General Hospital, South Fly District, Western Province, Papua New Guinea; Port Moresby General Hospital, Port Moresby National Capital District, Papua New Guinea
| | - Arnold Bainomugisa
- Queensland Mycobacterium Reference Laboratory, Pathology Queensland, Queensland, Australia
| | - Christopher Coulter
- Queensland Mycobacterium Reference Laboratory, Pathology Queensland, Queensland, Australia
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Impact of Clofazimine Dosing on Treatment Shortening of the First-Line Regimen in a Mouse Model of Tuberculosis. Antimicrob Agents Chemother 2018; 62:AAC.00636-18. [PMID: 29735562 DOI: 10.1128/aac.00636-18] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Accepted: 04/30/2018] [Indexed: 01/17/2023] Open
Abstract
The antileprosy drug clofazimine was recently repurposed as part of a newly endorsed short-course regimen for multidrug-resistant tuberculosis. It also enables significant treatment shortening when added to the first-line regimen for drug-susceptible tuberculosis in a mouse model. However, clofazimine causes dose- and duration-dependent skin discoloration in patients, and the optimal clofazimine dosing strategy in the context of the first-line regimen is unknown. We utilized a well-established mouse model to systematically address the impacts of duration, dose, and companion drugs on the treatment-shortening activity of clofazimine in the first-line regimen. In all studies, the primary outcome was relapse-free cure (culture-negative lungs) 6 months after stopping treatment, and the secondary outcome was bactericidal activity, i.e., the decline in the lung bacterial burden during treatment. Our findings indicate that clofazimine activity is most potent when coadministered with first-line drugs continuously throughout treatment and that equivalent treatment-shortening results are obtained with half the dose commonly used in mice. However, our studies also suggest that clofazimine at low exposures may have negative impacts on treatment outcomes, an effect that was evident only after the first 3 months of treatment. These data provide a sound evidence base to inform clofazimine dosing strategies to optimize the antituberculosis effect while minimizing skin discoloration. The results also underscore the importance of conducting long-term studies to allow the full evaluation of drugs administered in combination over long durations.
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28
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Iqbal IK, Bajeli S, Akela AK, Kumar A. Bioenergetics of Mycobacterium: An Emerging Landscape for Drug Discovery. Pathogens 2018; 7:E24. [PMID: 29473841 PMCID: PMC5874750 DOI: 10.3390/pathogens7010024] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 01/29/2018] [Accepted: 01/31/2018] [Indexed: 11/16/2022] Open
Abstract
Mycobacterium tuberculosis (Mtb) exhibits remarkable metabolic flexibility that enables it to survive a plethora of host environments during its life cycle. With the advent of bedaquiline for treatment of multidrug-resistant tuberculosis, oxidative phosphorylation has been validated as an important target and a vulnerable component of mycobacterial metabolism. Exploiting the dependence of Mtb on oxidative phosphorylation for energy production, several components of this pathway have been targeted for the development of new antimycobacterial agents. This includes targeting NADH dehydrogenase by phenothiazine derivatives, menaquinone biosynthesis by DG70 and other compounds, terminal oxidase by imidazopyridine amides and ATP synthase by diarylquinolines. Importantly, oxidative phosphorylation also plays a critical role in the survival of persisters. Thus, inhibitors of oxidative phosphorylation can synergize with frontline TB drugs to shorten the course of treatment. In this review, we discuss the oxidative phosphorylation pathway and development of its inhibitors in detail.
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Affiliation(s)
- Iram Khan Iqbal
- Council of Scientific and Industrial Research, Institute of Microbial Technology, Chandigarh 160036, India.
| | - Sapna Bajeli
- Council of Scientific and Industrial Research, Institute of Microbial Technology, Chandigarh 160036, India.
| | - Ajit Kumar Akela
- Council of Scientific and Industrial Research, Institute of Microbial Technology, Chandigarh 160036, India.
| | - Ashwani Kumar
- Council of Scientific and Industrial Research, Institute of Microbial Technology, Chandigarh 160036, India.
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29
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Motta I, Calcagno A, Bonora S. Pharmacokinetics and pharmacogenetics of anti-tubercular drugs: a tool for treatment optimization? Expert Opin Drug Metab Toxicol 2017; 14:59-82. [PMID: 29226732 DOI: 10.1080/17425255.2018.1416093] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION WHO global strategy is to end tuberculosis epidemic by 2035. Pharmacokinetic and pharmacogenetic studies are increasingly performed and might confirm their potential role in optimizing treatment outcome in specific settings and populations. Insufficient drug exposure seems to be a relevant factor in tuberculosis outcome and for the risk of phenotypic resistance. Areas covered: This review discusses available pharmacokinetic and pharmacogenetic data of first and second-line antitubercular agents in relation to efficacy and toxicity. Pharmacodynamic implications of optimized drugs and new options regimens are reviewed. Moreover a specific session describes innovative investigations on drug penetration. Expert opinion: The optimal use of available antitubercular drugs is paramount for tuberculosis control and eradication. Whilst trials are still on-going, higher rifampicin doses should be reserved to treatment for tubercular meningitis. Therapeutic Drug Monitoring with limiting sampling strategies is advised in patients at risk of failure or with slow treatment response. Further studies are needed in order to provide definitive recommendations of pharmacogenetic-based individualization: however lower isoniazid doses in NAT2 slow acetylators and higher rifampicin doses in individuals with SLCO1B1 loss of function genes are promising strategies. Finally in order to inform tailored strategies we need more data on tissue drug penetration and pharmacological modelling.
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Affiliation(s)
- Ilaria Motta
- a Unit of Infectious Diseases, Department of Medical Sciences , University of Torino , Torino , Italy
| | - Andrea Calcagno
- a Unit of Infectious Diseases, Department of Medical Sciences , University of Torino , Torino , Italy
| | - Stefano Bonora
- a Unit of Infectious Diseases, Department of Medical Sciences , University of Torino , Torino , Italy
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30
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Igarashi M, Ishizaki Y, Takahashi Y. New antituberculous drugs derived from natural products: current perspectives and issues in antituberculous drug development. J Antibiot (Tokyo) 2017; 71:ja2017126. [PMID: 29089593 DOI: 10.1038/ja.2017.126] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 09/05/2017] [Accepted: 09/13/2017] [Indexed: 12/13/2022]
Abstract
Tuberculosis is one of the most common and challenging infectious diseases worldwide. Especially, the lack of effective chemotherapeutic drugs for tuberculosis/human immunodeficiency virus co-infection and prevalence of multidrug-resistant and extensively drug-resistant tuberculosis remain to be serious clinical problems. Development of new drugs is a potential solution to fight tuberculosis. In this decade, the development status of new antituberculous drugs has been greatly advanced by the leading role of international organizations such as the Global Alliance for Tuberculosis Drug Development, Stop Tuberculosis Partnership and Global Health Innovative Technology Fund. In this review, we introduce the development status of new drugs for tuberculosis, focusing on those derived from natural products.The Journal of Antibiotics advance online publication, 1 November 2017; doi:10.1038/ja.2017.126.
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31
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Singh P, Kumari R, Lal R. Bedaquiline: Fallible Hope Against Drug Resistant Tuberculosis. Indian J Microbiol 2017; 57:371-377. [PMID: 29151636 DOI: 10.1007/s12088-017-0674-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 09/19/2017] [Indexed: 12/30/2022] Open
Abstract
Tuberculosis (TB) is a deadly bacterial infectious disease caused by intra-cellular pathogen Mycobacterium tuberculosis (Mtb). There were an estimated 1.4 million TB deaths in 2015 and an additional 0.4 million deaths resulting from TB among individuals with HIV. Drug-discovery for its cure is very slow in comparison with the causative organism's fast pace of mutations conferring drug resistance. Moreover, the field of drug-discovery of anti-TB drugs is constantly being challenged by the drug resistant strains of Mtb. Several molecules/inhibitors are being tested across the pharmaceutical industry and research centres for their suitability as drug candidate. It takes immense effort, high costs and a whole lot of screening to bring a single molecule to the clinics for patient cure. In last 60 years, hundreds of molecules have been patented for their probable use to develop drug for treatment of TB. However, only one drug has been successfully approved that is bedaquiline (1-(6-bromo-2 -methoxy-quinolin-3-yl)-4-dimethylamino-2-naphtalen-1-yl-1-phenyl-butan-2-ol). This is a brief review about bedaquiline (BDQ), the only drug in last 45 years approved for curing drug-resistant pulmonary TB, its development, action mechanism and development of resistance against it.
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Affiliation(s)
- Priya Singh
- Department of Zoology, University of Delhi, Delhi, 110007 India
| | - Rashmi Kumari
- Department of Zoology, University of Delhi, Delhi, 110007 India
| | - Rup Lal
- Department of Zoology, University of Delhi, Delhi, 110007 India
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32
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Robertson GT, Scherman MS, Bruhn DF, Liu J, Hastings C, McNeil MR, Butler MM, Bowlin TL, Lee RB, Lee RE, Lenaerts AJ. Spectinamides are effective partner agents for the treatment of tuberculosis in multiple mouse infection models. J Antimicrob Chemother 2017; 72:770-777. [PMID: 27999020 PMCID: PMC5400088 DOI: 10.1093/jac/dkw467] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 10/03/2016] [Indexed: 12/12/2022] Open
Abstract
Objectives: New drug regimens employing combinations of existing and experimental antimicrobial agents are needed to shorten treatment of tuberculosis (TB) in humans. The spectinamides are narrow-spectrum semisynthetic analogues of spectinomycin, modified to avoid intrinsic efflux by Mycobacterium tuberculosis. Spectinamides, including lead 1599, have been previously shown to exhibit a promising therapeutic profile in mice as single agents. Here we explore the in vivo activity of lead spectinamides when combined with other agents. Methods: The efficacy of 1599 or 1810 was tested in combination in three increasingly advanced TB mouse models. Mice were infected by aerosol and allowed to establish acute or chronic infection, followed by treatment (≤4 weeks) with the spectinamides alone or in two- and three-drug combination regimens with existing and novel therapeutic agents. Bacteria were enumerated from lungs by plating for cfu. Results: Herein we show the following: (i) 1599 exhibits additive or synergistic activity with most of the first-line agents; (ii) 1599 in combination with rifampicin and pyrazinamide or with bedaquiline and pyrazinamide promotes significantly improved efficacy in the high-dose aerosol model; (iii) 1599 enhances efficacy of rifampicin or pyrazinamide in chronically infected BALB/c mice; and (iv) 1599 is synergistic when administered in combination with rifampicin and pyrazinamide in the C3HeB/FeJ mouse model showing caseous necrotic pulmonary lesions. Conclusions: Spectinamides were effective partner agents for multiple anti-TB agents including bedaquiline, rifampicin and pyrazinamide. None of these in vivo synergistic interactions was predicted from in vitro MIC chequerboard assays. These data support further development of the spectinamides as combination partners with existing and experimental anti-TB agents.
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Affiliation(s)
- Gregory T Robertson
- Mycobacterial Research Laboratories, Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins, CO 80523, USA
| | - Michael S Scherman
- Mycobacterial Research Laboratories, Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins, CO 80523, USA
| | - David F Bruhn
- Department of Chemical Biology and Therapeutics, St Jude Children's Research Hospital, Memphis, TN 28105, USA
| | - Jiuyu Liu
- Department of Chemical Biology and Therapeutics, St Jude Children's Research Hospital, Memphis, TN 28105, USA
| | - Courtney Hastings
- Mycobacterial Research Laboratories, Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins, CO 80523, USA
| | - Michael R McNeil
- Mycobacterial Research Laboratories, Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins, CO 80523, USA
| | | | | | - Robin B Lee
- Department of Chemical Biology and Therapeutics, St Jude Children's Research Hospital, Memphis, TN 28105, USA
| | - Richard E Lee
- Department of Chemical Biology and Therapeutics, St Jude Children's Research Hospital, Memphis, TN 28105, USA
| | - Anne J Lenaerts
- Mycobacterial Research Laboratories, Department of Microbiology, Immunology and Pathology, Colorado State University, Fort Collins, CO 80523, USA
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33
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Population Pharmacokinetics of Pyrazinamide in Patients with Tuberculosis. Antimicrob Agents Chemother 2017; 61:AAC.02625-16. [PMID: 28289033 DOI: 10.1128/aac.02625-16] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 02/12/2017] [Indexed: 11/20/2022] Open
Abstract
The current treatment used for tuberculosis (TB) is lengthy and needs to be shortened and improved. Pyrazinamide (PZA) has potent sterilizing activity and has the potential to shorten the TB treatment duration, if treatment is optimized. The goals of this study were (i) to develop a population pharmacokinetic (PK) model for PZA among patients enrolled in PK substudies of Tuberculosis Trial Consortium (TBTC) trials 27 and 28 and (ii) to determine covariates that affect PZA PK. (iii) We also performed simulations and target attainment analysis using the proposed targets of a maximum plasma concentration (Cmax) of >35 μg/ml or an area under the concentration-versus-time curve (AUC) of >363 μg · h/ml to see if higher weight-based dosing could improve PZA efficacy. Seventy-two patients participated in the substudies. The mean (standard deviation [SD]) Cmax was 30.8 (7.4) μg/ml, and the mean (SD) AUC from time zero to 24 h (AUC0-24) was 307 (83) μg · h/ml. A one-compartment open model best described PZA PK. Only body weight was a significant covariate for PZA clearance. Women had a lower volume of distribution (V/F) than men, and both clearance (CL/F) and V/F increased with body weight. Our simulations show that higher doses of PZA (>50 mg/kg of body weight) are needed to achieve the therapeutic target of an AUC/MIC of >11.3 in >80% of patients, while doses of >80 mg/kg are needed for target attainment in 90% of patients, given specific assumptions about MIC determinations. For the therapeutic targets of a Cmax of >35 μg/ml and/or an AUC of >363 μg · h/ml, doses in the range of 30 to 40 mg/kg are needed to achieve the therapeutic target in >90% of the patients. Further clinical trials are needed to evaluate the safety and efficacy of higher doses of PZA.
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34
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Targeting Energy Metabolism in Mycobacterium tuberculosis, a New Paradigm in Antimycobacterial Drug Discovery. mBio 2017; 8:mBio.00272-17. [PMID: 28400527 PMCID: PMC5388804 DOI: 10.1128/mbio.00272-17] [Citation(s) in RCA: 136] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Drug-resistant mycobacterial infections are a serious global health challenge, leading to high mortality and socioeconomic burdens in developing countries worldwide. New innovative approaches, from identification of new targets to discovery of novel chemical scaffolds, are urgently needed. Recently, energy metabolism in mycobacteria, in particular the oxidative phosphorylation pathway, has emerged as an object of intense microbiological investigation and as a novel target pathway in drug discovery. New classes of antibacterials interfering with elements of the oxidative phosphorylation pathway are highly active in combating dormant or latent mycobacterial infections, with a promise of shortening tuberculosis chemotherapy. The regulatory approval of the ATP synthase inhibitor bedaquiline and the discovery of Q203, a candidate drug targeting the cytochrome bc1 complex, have highlighted the central importance of this new target pathway. In this review, we discuss key features and potential applications of inhibiting energy metabolism in our quest for discovering potent novel and sterilizing drug combinations for combating tuberculosis. We believe that the combination of drugs targeting elements of the oxidative phosphorylation pathway can lead to a completely new regimen for drug-susceptible and multidrug-resistant tuberculosis.
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35
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Tantry SJ, Markad SD, Shinde V, Bhat J, Balakrishnan G, Gupta AK, Ambady A, Raichurkar A, Kedari C, Sharma S, Mudugal NV, Narayan A, Naveen Kumar CN, Nanduri R, Bharath S, Reddy J, Panduga V, Prabhakar KR, Kandaswamy K, Saralaya R, Kaur P, Dinesh N, Guptha S, Rich K, Murray D, Plant H, Preston M, Ashton H, Plant D, Walsh J, Alcock P, Naylor K, Collier M, Whiteaker J, McLaughlin RE, Mallya M, Panda M, Rudrapatna S, Ramachandran V, Shandil R, Sambandamurthy VK, Mdluli K, Cooper CB, Rubin H, Yano T, Iyer P, Narayanan S, Kavanagh S, Mukherjee K, Balasubramanian V, Hosagrahara VP, Solapure S, Ravishankar S, Hameed P S. Discovery of Imidazo[1,2-a]pyridine Ethers and Squaramides as Selective and Potent Inhibitors of Mycobacterial Adenosine Triphosphate (ATP) Synthesis. J Med Chem 2017; 60:1379-1399. [PMID: 28075132 DOI: 10.1021/acs.jmedchem.6b01358] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The approval of bedaquiline to treat tuberculosis has validated adenosine triphosphate (ATP) synthase as an attractive target to kill Mycobacterium tuberculosis (Mtb). Herein, we report the discovery of two diverse lead series imidazo[1,2-a]pyridine ethers (IPE) and squaramides (SQA) as inhibitors of mycobacterial ATP synthesis. Through medicinal chemistry exploration, we established a robust structure-activity relationship of these two scaffolds, resulting in nanomolar potencies in an ATP synthesis inhibition assay. A biochemical deconvolution cascade suggested cytochrome c oxidase as the potential target of IPE class of molecules, whereas characterization of spontaneous resistant mutants of SQAs unambiguously identified ATP synthase as its molecular target. Absence of cross resistance against bedaquiline resistant mutants suggested a different binding site for SQAs on ATP synthase. Furthermore, SQAs were found to be noncytotoxic and demonstrated efficacy in a mouse model of tuberculosis infection.
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Affiliation(s)
- Subramanyam J Tantry
- Innovative Medicines, AstraZeneca India Pvt. Ltd. , Bellary Road, Hebbal, Bangalore 560024, India
| | - Shankar D Markad
- Innovative Medicines, AstraZeneca India Pvt. Ltd. , Bellary Road, Hebbal, Bangalore 560024, India
| | - Vikas Shinde
- Innovative Medicines, AstraZeneca India Pvt. Ltd. , Bellary Road, Hebbal, Bangalore 560024, India
| | - Jyothi Bhat
- Innovative Medicines, AstraZeneca India Pvt. Ltd. , Bellary Road, Hebbal, Bangalore 560024, India
| | - Gayathri Balakrishnan
- Innovative Medicines, AstraZeneca India Pvt. Ltd. , Bellary Road, Hebbal, Bangalore 560024, India
| | - Amit K Gupta
- Innovative Medicines, AstraZeneca India Pvt. Ltd. , Bellary Road, Hebbal, Bangalore 560024, India
| | - Anisha Ambady
- Innovative Medicines, AstraZeneca India Pvt. Ltd. , Bellary Road, Hebbal, Bangalore 560024, India
| | - Anandkumar Raichurkar
- Innovative Medicines, AstraZeneca India Pvt. Ltd. , Bellary Road, Hebbal, Bangalore 560024, India
| | - Chaitanyakumar Kedari
- Innovative Medicines, AstraZeneca India Pvt. Ltd. , Bellary Road, Hebbal, Bangalore 560024, India
| | - Sreevalli Sharma
- Innovative Medicines, AstraZeneca India Pvt. Ltd. , Bellary Road, Hebbal, Bangalore 560024, India
| | - Naina V Mudugal
- Innovative Medicines, AstraZeneca India Pvt. Ltd. , Bellary Road, Hebbal, Bangalore 560024, India
| | - Ashwini Narayan
- Innovative Medicines, AstraZeneca India Pvt. Ltd. , Bellary Road, Hebbal, Bangalore 560024, India
| | - C N Naveen Kumar
- Innovative Medicines, AstraZeneca India Pvt. Ltd. , Bellary Road, Hebbal, Bangalore 560024, India
| | - Robert Nanduri
- Innovative Medicines, AstraZeneca India Pvt. Ltd. , Bellary Road, Hebbal, Bangalore 560024, India
| | - Sowmya Bharath
- Innovative Medicines, AstraZeneca India Pvt. Ltd. , Bellary Road, Hebbal, Bangalore 560024, India
| | - Jitendar Reddy
- Innovative Medicines, AstraZeneca India Pvt. Ltd. , Bellary Road, Hebbal, Bangalore 560024, India
| | - Vijender Panduga
- Innovative Medicines, AstraZeneca India Pvt. Ltd. , Bellary Road, Hebbal, Bangalore 560024, India
| | - K R Prabhakar
- Innovative Medicines, AstraZeneca India Pvt. Ltd. , Bellary Road, Hebbal, Bangalore 560024, India
| | - Karthikeyan Kandaswamy
- Innovative Medicines, AstraZeneca India Pvt. Ltd. , Bellary Road, Hebbal, Bangalore 560024, India
| | - Ramanatha Saralaya
- Innovative Medicines, AstraZeneca India Pvt. Ltd. , Bellary Road, Hebbal, Bangalore 560024, India
| | - Parvinder Kaur
- Innovative Medicines, AstraZeneca India Pvt. Ltd. , Bellary Road, Hebbal, Bangalore 560024, India
| | - Neela Dinesh
- Innovative Medicines, AstraZeneca India Pvt. Ltd. , Bellary Road, Hebbal, Bangalore 560024, India
| | - Supreeth Guptha
- Innovative Medicines, AstraZeneca India Pvt. Ltd. , Bellary Road, Hebbal, Bangalore 560024, India
| | - Kirsty Rich
- AstraZeneca , Alderley Park, Mereside, Macclesfield, Cheshire U.K. SK10 4TG
| | - David Murray
- AstraZeneca , Alderley Park, Mereside, Macclesfield, Cheshire U.K. SK10 4TG
| | - Helen Plant
- AstraZeneca , Alderley Park, Mereside, Macclesfield, Cheshire U.K. SK10 4TG
| | - Marian Preston
- AstraZeneca , Alderley Park, Mereside, Macclesfield, Cheshire U.K. SK10 4TG
| | - Helen Ashton
- AstraZeneca , Alderley Park, Mereside, Macclesfield, Cheshire U.K. SK10 4TG
| | - Darren Plant
- AstraZeneca , Alderley Park, Mereside, Macclesfield, Cheshire U.K. SK10 4TG
| | - Jarrod Walsh
- AstraZeneca , Alderley Park, Mereside, Macclesfield, Cheshire U.K. SK10 4TG
| | - Peter Alcock
- AstraZeneca , Alderley Park, Mereside, Macclesfield, Cheshire U.K. SK10 4TG
| | - Kathryn Naylor
- AstraZeneca , Alderley Park, Mereside, Macclesfield, Cheshire U.K. SK10 4TG
| | - Matthew Collier
- AstraZeneca , Alderley Park, Mereside, Macclesfield, Cheshire U.K. SK10 4TG
| | - James Whiteaker
- Infection Innovative Medicines, AstraZeneca , 35 Gatehouse Drive, Waltham, Massachusetts 02451, United States
| | - Robert E McLaughlin
- Infection Innovative Medicines, AstraZeneca , 35 Gatehouse Drive, Waltham, Massachusetts 02451, United States
| | - Meenakshi Mallya
- Innovative Medicines, AstraZeneca India Pvt. Ltd. , Bellary Road, Hebbal, Bangalore 560024, India
| | - Manoranjan Panda
- Innovative Medicines, AstraZeneca India Pvt. Ltd. , Bellary Road, Hebbal, Bangalore 560024, India
| | - Suresh Rudrapatna
- Innovative Medicines, AstraZeneca India Pvt. Ltd. , Bellary Road, Hebbal, Bangalore 560024, India
| | - Vasanthi Ramachandran
- Innovative Medicines, AstraZeneca India Pvt. Ltd. , Bellary Road, Hebbal, Bangalore 560024, India
| | - Radha Shandil
- Innovative Medicines, AstraZeneca India Pvt. Ltd. , Bellary Road, Hebbal, Bangalore 560024, India
| | - Vasan K Sambandamurthy
- Innovative Medicines, AstraZeneca India Pvt. Ltd. , Bellary Road, Hebbal, Bangalore 560024, India
| | - Khisi Mdluli
- Global Alliance for TB Drug Development , 40 Wall Street, 24th Floor, New York, New York 10005, United States
| | - Christopher B Cooper
- Global Alliance for TB Drug Development , 40 Wall Street, 24th Floor, New York, New York 10005, United States
| | - Harvey Rubin
- University of Pennsylvania , 111 Clinical Research Building, 415 Curie Boulevard, Philadelphia Pennsylvania 19104, United States
| | - Takahiro Yano
- University of Pennsylvania , 111 Clinical Research Building, 415 Curie Boulevard, Philadelphia Pennsylvania 19104, United States
| | - Pravin Iyer
- Innovative Medicines, AstraZeneca India Pvt. Ltd. , Bellary Road, Hebbal, Bangalore 560024, India
| | - Shridhar Narayanan
- Innovative Medicines, AstraZeneca India Pvt. Ltd. , Bellary Road, Hebbal, Bangalore 560024, India
| | - Stefan Kavanagh
- AstraZeneca , Alderley Park, Mereside, Macclesfield, Cheshire U.K. SK10 4TG
| | - Kakoli Mukherjee
- Innovative Medicines, AstraZeneca India Pvt. Ltd. , Bellary Road, Hebbal, Bangalore 560024, India
| | - V Balasubramanian
- Innovative Medicines, AstraZeneca India Pvt. Ltd. , Bellary Road, Hebbal, Bangalore 560024, India
| | - Vinayak P Hosagrahara
- Innovative Medicines, AstraZeneca India Pvt. Ltd. , Bellary Road, Hebbal, Bangalore 560024, India
| | - Suresh Solapure
- Innovative Medicines, AstraZeneca India Pvt. Ltd. , Bellary Road, Hebbal, Bangalore 560024, India
| | - Sudha Ravishankar
- Innovative Medicines, AstraZeneca India Pvt. Ltd. , Bellary Road, Hebbal, Bangalore 560024, India
| | - Shahul Hameed P
- Innovative Medicines, AstraZeneca India Pvt. Ltd. , Bellary Road, Hebbal, Bangalore 560024, India
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Maitre T, Aubry A, Jarlier V, Robert J, Veziris N, Bernard C, Sougakoff W, Brossier F, Cambau E, Mougari F, Raskine L. Multidrug and extensively drug-resistant tuberculosis. Med Mal Infect 2017; 47:3-10. [DOI: 10.1016/j.medmal.2016.07.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Accepted: 07/18/2016] [Indexed: 11/16/2022]
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Almeida D, Ioerger T, Tyagi S, Li SY, Mdluli K, Andries K, Grosset J, Sacchettini J, Nuermberger E. Mutations in pepQ Confer Low-Level Resistance to Bedaquiline and Clofazimine in Mycobacterium tuberculosis. Antimicrob Agents Chemother 2016; 60:4590-9. [PMID: 27185800 PMCID: PMC4958187 DOI: 10.1128/aac.00753-16] [Citation(s) in RCA: 125] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Accepted: 05/07/2016] [Indexed: 01/12/2023] Open
Abstract
The novel ATP synthase inhibitor bedaquiline recently received accelerated approval for treatment of multidrug-resistant tuberculosis and is currently being studied as a component of novel treatment-shortening regimens for drug-susceptible and multidrug-resistant tuberculosis. In a limited number of bedaquiline-treated patients reported to date, ≥4-fold upward shifts in bedaquiline MIC during treatment have been attributed to non-target-based mutations in Rv0678 that putatively increase bedaquiline efflux through the MmpS5-MmpL5 pump. These mutations also confer low-level clofazimine resistance, presumably by a similar mechanism. Here, we describe a new non-target-based determinant of low-level bedaquiline and clofazimine cross-resistance in Mycobacterium tuberculosis: loss-of-function mutations in pepQ (Rv2535c), which corresponds to a putative Xaa-Pro aminopeptidase. pepQ mutants were selected in mice by treatment with clinically relevant doses of bedaquiline, with or without clofazimine, and were shown to have bedaquiline and clofazimine MICs 4 times higher than those for the parental H37Rv strain. Coincubation with efflux inhibitors verapamil and reserpine lowered bedaquiline MICs against both mutant and parent strains to a level below the MIC against H37Rv in the absence of efflux pump inhibitors. However, quantitative PCR (qPCR) revealed no significant differences in expression of Rv0678, mmpS5, or mmpL5 between mutant and parent strains. Complementation of a pepQ mutant with the wild-type gene restored susceptibility, indicating that loss of PepQ function is sufficient for reduced susceptibility both in vitro and in mice. Although the mechanism by which mutations in pepQ confer bedaquiline and clofazimine cross-resistance remains unclear, these results may have clinical implications and warrant further evaluation of clinical isolates with reduced susceptibility to either drug for mutations in this gene.
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Affiliation(s)
- Deepak Almeida
- Center for Tuberculosis Research, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Thomas Ioerger
- Department of Computer Science, Texas A&M University, College Station, Texas, USA
| | - Sandeep Tyagi
- Center for Tuberculosis Research, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Si-Yang Li
- Center for Tuberculosis Research, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Khisimuzi Mdluli
- Global Alliance for TB Drug Development, New York, New York, USA
| | | | - Jacques Grosset
- Center for Tuberculosis Research, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jim Sacchettini
- Department of Biochemistry and Biophysics, Texas A&M University, College Station, Texas
| | - Eric Nuermberger
- Center for Tuberculosis Research, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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38
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Nguyen TVA, Cao TBT, Akkerman OW, Tiberi S, Vu DH, Alffenaar JWC. Bedaquiline as part of combination therapy in adults with pulmonary multi-drug resistant tuberculosis. Expert Rev Clin Pharmacol 2016; 9:1025-37. [PMID: 27322153 DOI: 10.1080/17512433.2016.1200462] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Few innovative anti-microbial products have been brought to market in recent years to combat the global multidrug resistant-tuberculosis (MDR-TB) epidemic. Bedaquiline, a novel oral diarylquinoline, was approved by the US FDA as a part of combination therapy in adults with pulmonary MDR-TB based on phase II trials. AREA COVERED Pubmed searches were conducted using search terms bedaquiline, diarylquinoline, R207910, and TMC207 was performed. Supplementary sources included World Health Organization, Clinicaltrial.gov, US Food and Drug Administration. Bedaquiline is an ATP synthase inhibitor specific for M. tuberculosis and some nontuberculous mycobacteria. It is metabolized by CYP3A4 and it's drug exposure can be influenced by inducers and inhibitors of this enzyme. Phase II studies showed promising results on efficacy of bedaquiline when being used in combination with a background regimen for MDR-TB. Main safety concerns include QTc prolongation and hepatotoxicity. Phase III trials are ongoing to confirm efficacy findings from phase II studies and provide additional evidence of safety and efficacy. Expert commentary: Critical data for long-term efficacy and safety are incomplete and scarce, supporting the cautious use of bedaquiline.
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Affiliation(s)
- T V A Nguyen
- a Department of Pharmacological, Medical and Agronomical Biotechnology , University of Science and Technology of Hanoi , Hanoi , Vietnam
| | - T B T Cao
- b Department of Clinical Pharmacy , Hanoi University of Pharmacy , Hanoi , Vietnam
| | - O W Akkerman
- c University of Groningen, University Medical Center Groningen , Department Pulmonary Diseases and Tuberculosis , Groningen , The Netherlands.,d University of Groningen, University Medical Center Groningen, Tuberculosis Center Beatrixoord , Haren , The Netherlands
| | - S Tiberi
- e Division of Infection , Barts Health NHS Trust , London , UK
| | - D H Vu
- b Department of Clinical Pharmacy , Hanoi University of Pharmacy , Hanoi , Vietnam
| | - J W C Alffenaar
- f University of Groningen, University Medical Center Groningen, Clinical Pharmacy and Pharmacology , Groningen , The Netherlands
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39
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High Systemic Exposure of Pyrazinoic Acid Has Limited Antituberculosis Activity in Murine and Rabbit Models of Tuberculosis. Antimicrob Agents Chemother 2016; 60:4197-205. [PMID: 27139472 DOI: 10.1128/aac.03085-15] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 04/24/2016] [Indexed: 11/20/2022] Open
Abstract
Pyrazinamide (PZA) is a prodrug requiring conversion to pyrazinoic acid (POA) by an amidase encoded by pncA for in vitro activity. Mutation of pncA is the most common cause of PZA resistance in clinical isolates. To determine whether the systemic delivery of POA or host-mediated conversion of PZA to POA could circumvent such resistance, we evaluated the efficacy of orally administered and host-derived POA in vivo Dose-ranging plasma and intrapulmonary POA pharmacokinetics and the efficacy of oral POA or PZA treatment against PZA-susceptible tuberculosis were determined in BALB/c and C3HeB/FeJ mice. The activity of host-derived POA was assessed in rabbits infected with a pncA-null mutant and treated with PZA. Median plasma POA values for the area under the concentration-time curve from 0 h to infinity (AUC0-∞) were 139 to 222 μg·h/ml and 178 to 287 μg·h/ml after doses of PZA and POA of 150 mg/kg of body weight, respectively, in mice. Epithelial lining fluid POA concentrations in infected mice were comparable after POA and PZA administration. In chronically infected BALB/c mice, PZA at 150 mg/kg reduced lung CFU counts by >2 log10 after 4 weeks. POA was effective only at 450 mg/kg, which reduced lung CFU counts by ∼0.7 log10 POA had no demonstrable bactericidal activity in C3HeB/FeJ mice, nor did PZA administered to rabbits infected with a PZA-resistant mutant. Oral POA administration and host-mediated conversion of PZA to POA producing plasma POA exposures comparable to PZA administration was significantly less effective than PZA. These results suggest that the intrabacillary delivery of POA and that producing higher POA concentrations at the site of infection will be more effective strategies for maximizing POA efficacy.
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40
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Irwin SM, Prideaux B, Lyon ER, Zimmerman MD, Brooks EJ, Schrupp CA, Chen C, Reichlen MJ, Asay BC, Voskuil MI, Nuermberger EL, Andries K, Lyons MA, Dartois V, Lenaerts AJ. Bedaquiline and Pyrazinamide Treatment Responses Are Affected by Pulmonary Lesion Heterogeneity in Mycobacterium tuberculosis Infected C3HeB/FeJ Mice. ACS Infect Dis 2016; 2:251-267. [PMID: 27227164 PMCID: PMC4874602 DOI: 10.1021/acsinfecdis.5b00127] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Indexed: 12/31/2022]
Abstract
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BALB/c and Swiss mice are routinely
used to validate the effectiveness of tuberculosis drug regimens,
although these mouse strains fail to develop human-like pulmonary
granulomas exhibiting caseous necrosis. Microenvironmental conditions
within human granulomas may negatively impact drug efficacy, and this
may not be reflected in non-necrotizing lesions found within conventional
mouse models. The C3HeB/FeJ mouse model has been increasingly utilized
as it develops hypoxic, caseous necrotic granulomas which may more
closely mimic the pathophysiological conditions found within human
pulmonary granulomas. Here, we examined the treatment response of
BALB/c and C3HeB/FeJ mice to bedaquiline (BDQ) and pyrazinamide (PZA)
administered singly and in combination. BALB/c mice consistently displayed
a highly uniform treatment response to both drugs, while C3HeB/FeJ
mice displayed a bimodal response composed of responsive and less-responsive
mice. Plasma pharmacokinetic analysis of dissected lesions from BALB/c
and C3HeB/FeJ mice revealed that PZA penetrated lesion types from
both mouse strains with similar efficiency. However, the pH of the
necrotic caseum of C3HeB/FeJ granulomas was determined to be 7.5,
which is in the range where PZA is essentially ineffective under standard
laboratory in vitro growth conditions. BDQ preferentially accumulated
within the highly cellular regions in the lungs of both mouse strains,
although it was present at reduced but still biologically relevant
concentrations within the central caseum when dosed at 25 mg/kg. The
differential treatment response which resulted from the heterogeneous
pulmonary pathology in the C3HeB/FeJ mouse model revealed several
factors which may impact treatment efficacy, and could be further
evaluated in clinical trials.
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Affiliation(s)
- Scott M. Irwin
- Mycobacteria
Research Laboratories, Department of Microbiology, Immunology and
Pathology, Colorado State University, Fort Collins, Colorado 80523, United States
| | - Brendan Prideaux
- Public Health Research Institute, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, New Jersey 07103, United States
| | - Edward R. Lyon
- Mycobacteria
Research Laboratories, Department of Microbiology, Immunology and
Pathology, Colorado State University, Fort Collins, Colorado 80523, United States
| | - Matthew D. Zimmerman
- Public Health Research Institute, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, New Jersey 07103, United States
| | - Elizabeth J. Brooks
- Mycobacteria
Research Laboratories, Department of Microbiology, Immunology and
Pathology, Colorado State University, Fort Collins, Colorado 80523, United States
| | - Christopher A. Schrupp
- Mycobacteria
Research Laboratories, Department of Microbiology, Immunology and
Pathology, Colorado State University, Fort Collins, Colorado 80523, United States
| | - Chao Chen
- Public Health Research Institute, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, New Jersey 07103, United States
| | - Matthew J. Reichlen
- Department of Immunology and Microbiology, University of Colorado School of Medicine, Aurora, Colorado 80045, United States
| | - Bryce C. Asay
- Mycobacteria
Research Laboratories, Department of Microbiology, Immunology and
Pathology, Colorado State University, Fort Collins, Colorado 80523, United States
| | - Martin I. Voskuil
- Department of Immunology and Microbiology, University of Colorado School of Medicine, Aurora, Colorado 80045, United States
| | - Eric L. Nuermberger
- Center
for Tuberculosis Research, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland 21231, United States
| | - Koen Andries
- Department
of Infectious Diseases, Janssen Pharmaceutica, 2340 Beerse, Belgium
| | - Michael A. Lyons
- Mycobacteria
Research Laboratories, Department of Microbiology, Immunology and
Pathology, Colorado State University, Fort Collins, Colorado 80523, United States
| | - Véronique Dartois
- Public Health Research Institute, New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, New Jersey 07103, United States
| | - Anne J. Lenaerts
- Mycobacteria
Research Laboratories, Department of Microbiology, Immunology and
Pathology, Colorado State University, Fort Collins, Colorado 80523, United States
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41
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Caminero Luna J. Actualización en el diagnóstico y tratamiento de la tuberculosis pulmonar. Rev Clin Esp 2016; 216:76-84. [DOI: 10.1016/j.rce.2015.09.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Revised: 09/02/2015] [Accepted: 09/11/2015] [Indexed: 10/22/2022]
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42
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Update on the diagnosis and treatment of pulmonary tuberculosis. Rev Clin Esp 2016. [DOI: 10.1016/j.rceng.2015.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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43
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Hoagland D, Zhao Y, Lee RE. Advances in Drug Discovery and Development for Pediatric Tuberculosis. Mini Rev Med Chem 2016; 16:481-97. [PMID: 26202201 PMCID: PMC4964275 DOI: 10.2174/1389557515666150722101723] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 06/11/2015] [Accepted: 07/12/2015] [Indexed: 01/28/2023]
Abstract
Pediatric tuberculosis is an underappreciated global epidemic estimated to afflict around half a million children worldwide. This problem has historically been overlooked, due in part to their low social status and the difficulty in diagnosis of tuberculosis in children. Children are more susceptible to tuberculosis infection and disease progression, including rapid dissemination into extrapulmonary infection sites. Treatment of pediatric tuberculosis infections has been traditionally built around agents used to treat the adult disease, but the disease pathology, drug pharmacokinetics and the safety window in children differs from the adult disease. This produces additional concerns for drug discovery and development of new agents. This review examines: (i) the safety concerns for current front and second line agents used to treat complex drug resistant infections and how this knowledge can be used to identify, prioritize and dose agents that may be better tolerated in pediatric populations; and (ii) the chemistry and suitability of new drugs in the clinical development pipeline for tuberculosis for the treatment of pediatric infections indicating several new agents may offer significant improvements for the treatment of multi-drug resistant tuberculosis in children.
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Affiliation(s)
| | | | - Richard E Lee
- Department of Chemical Biology and Therapeutics, St Jude Children's Research Hospital, MS#1000, Memphis, TN 38105, USA.
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44
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Whitfield MG, Soeters HM, Warren RM, York T, Sampson SL, Streicher EM, van Helden PD, van Rie A. A Global Perspective on Pyrazinamide Resistance: Systematic Review and Meta-Analysis. PLoS One 2015. [PMID: 26218737 PMCID: PMC4517823 DOI: 10.1371/journal.pone.0133869] [Citation(s) in RCA: 93] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Background Pyrazinamide (PZA) is crucial for tuberculosis (TB) treatment, given its unique ability to eradicate persister bacilli. The worldwide burden of PZA resistance remains poorly described. Methods Systematic PubMed, Science Direct and Scopus searches for articles reporting phenotypic (liquid culture drug susceptibility testing or pyrazinamidase activity assays) and/or genotypic (polymerase chain reaction or DNA sequencing) PZA resistance. Global and regional summary estimates were obtained from random-effects meta-analysis, stratified by presence or risk of multidrug resistant TB (MDR-TB). Regional summary estimates were combined with regional WHO TB incidence estimates to determine the annual burden of PZA resistance. Information on single nucleotide polymorphisms (SNPs) in the pncA gene was aggregated to obtain a global summary. Results Pooled PZA resistance prevalence estimate was 16.2% (95% CI 11.2-21.2) among all TB cases, 41.3% (29.0-53.7) among patients at high MDR-TB risk, and 60.5% (52.3-68.6) among MDR-TB cases. The estimated global burden is 1.4 million new PZA resistant TB cases annually, about 270,000 in MDR-TB patients. Among 1,815 phenotypically resistant isolates, 608 unique SNPs occurred at 397 distinct positions throughout the pncA gene. Interpretation PZA resistance is ubiquitous, with an estimated one in six incident TB cases and more than half of all MDR-TB cases resistant to PZA globally. The diversity of SNPs across the pncA gene complicates the development of rapid molecular diagnostics. These findings caution against relying on PZA in current and future TB drug regimens, especially in MDR-TB patients.
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Affiliation(s)
- Michael G. Whitfield
- SA MRC Centre for TB Research, Stellenbosch University, South Africa
- DST/NRF Centre of Excellence for Biomedical TB Research, Stellenbosch University, South Africa
- Division of Molecular Biology and Human Genetics, Stellenbosch University, South Africa
- Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
| | - Heidi M. Soeters
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Robin M. Warren
- SA MRC Centre for TB Research, Stellenbosch University, South Africa
- DST/NRF Centre of Excellence for Biomedical TB Research, Stellenbosch University, South Africa
- Division of Molecular Biology and Human Genetics, Stellenbosch University, South Africa
- Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
- * E-mail:
| | - Talita York
- SA MRC Centre for TB Research, Stellenbosch University, South Africa
- DST/NRF Centre of Excellence for Biomedical TB Research, Stellenbosch University, South Africa
- Division of Molecular Biology and Human Genetics, Stellenbosch University, South Africa
- Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
| | - Samantha L. Sampson
- SA MRC Centre for TB Research, Stellenbosch University, South Africa
- DST/NRF Centre of Excellence for Biomedical TB Research, Stellenbosch University, South Africa
- Division of Molecular Biology and Human Genetics, Stellenbosch University, South Africa
- Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
| | - Elizabeth M. Streicher
- SA MRC Centre for TB Research, Stellenbosch University, South Africa
- DST/NRF Centre of Excellence for Biomedical TB Research, Stellenbosch University, South Africa
- Division of Molecular Biology and Human Genetics, Stellenbosch University, South Africa
- Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
| | - Paul D. van Helden
- SA MRC Centre for TB Research, Stellenbosch University, South Africa
- DST/NRF Centre of Excellence for Biomedical TB Research, Stellenbosch University, South Africa
- Division of Molecular Biology and Human Genetics, Stellenbosch University, South Africa
- Faculty of Medicine and Health Sciences, Stellenbosch University, South Africa
| | - Annelies van Rie
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- International Health Unit, Epidemiology and Social Medicine, Faculty of Medicine, University of Antwerp, Antwerp, Belgium
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45
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Field SK. Bedaquiline for the treatment of multidrug-resistant tuberculosis: great promise or disappointment? Ther Adv Chronic Dis 2015; 6:170-84. [PMID: 26137207 DOI: 10.1177/2040622315582325] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Acquired drug resistance by Mycobacterium tuberculosis (MTB) may result in treatment failure and death. Bedaquiline was recently approved for the treatment of multidrug-resistant tuberculosis (MDR-TB). This report examines the available data on this novel drug for the treatment of MDR-TB. PubMed searches, last updated 18 February 2015, using the terms bedaquiline, TMC 207 and R207910 identified pertinent English citations. Citation reference lists were reviewed to identify other relevant reports. Pertinent MDR-TB treatment reports on the US Food and Drug Administration, Centers for Disease Control and Prevention (CDC), World Health Organization (WHO) and Cochrane websites were also evaluated. Bedaquiline is an adenosine triphosphate (ATP) synthase inhibitor specific for MTB and some nontuberculous mycobacteria. The early bactericidal activity (EBA) of bedaquiline is delayed until ATP stores are depleted but subsequently it is similar to the EBA of isoniazid and rifampin. Bedaquiline demonstrated excellent minimum inhibitory concentrations (MICs) against both drug-sensitive and MDR-TB. Adding it to the WHO-recommended MDR-TB regimen reduced the time for sputum culture conversion in pulmonary MDR-TB. Rifampin, other cytochrome oxidase 3A4 inducers or inhibitors alter its metabolism. Adverse effects are common with MDR-TB treatment regimens with or without bedaquiline. Nausea is more common with bedaquiline and it increases the QTcF interval. It is not recommended for children, pregnant or lactating women. More patients died in the bedaquiline-treatment arms despite better microbiological outcomes in two recent trials. The WHO and CDC published interim guidelines that recommend restricting its use to patients with MDR-TB or more complex drug resistance who cannot otherwise be treated with a minimum of three effective drugs. It should never be added to a regimen as a single drug nor should it be added to a failing regimen to prevent the emergence of bedaquiline-resistant strains.
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Affiliation(s)
- Stephen K Field
- Division of Respiratory Medicine, Cumming School of Medicine, University of Calgary, Health Science Centre, Room 1437, 3330 Hospital Drive NW, Calgary, Alberta T2N 4N1, Canada
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46
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Via LE, Savic R, Weiner DM, Zimmerman MD, Prideaux B, Irwin SM, Lyon E, O’Brien P, Gopal P, Eum S, Lee M, Lanoix JP, Dutta NK, Shim T, Cho JS, Kim W, Karakousis PC, Lenaerts A, Nuermberger E, Barry CE, Dartois V. Host-Mediated Bioactivation of Pyrazinamide: Implications for Efficacy, Resistance, and Therapeutic Alternatives. ACS Infect Dis 2015; 1:203-214. [PMID: 26086040 DOI: 10.1021/id500028m] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Pyrazinamide has played a critical role in shortening therapy against drug-sensitive, drug-resistant, active, and latent tuberculosis (TB). Despite widespread recognition of its therapeutic importance, the sterilizing properties of this 60-year-old drug remain an enigma given its rather poor activity in vitro. Here we revisit longstanding paradigms and offer pharmacokinetic explanations for the apparent disconnect between in vitro activity and clinical impact. We show substantial host-mediated conversion of prodrug pyrazinamide (PZA) to the active form, pyrazinoic acid (POA), in TB patients and in animal models. We demonstrate favorable penetration of this pool of circulating POA from plasma into lung tissue and granulomas, where the pathogen resides. In standardized growth inhibition experiments, we show that POA exhibits superior in vitro potency compared to PZA, indicating that the vascular supply of host-derived POA may contribute to the in vivo efficacy of PZA, thereby reducing the apparent discrepancy between in vitro and in vivo activity. However, the results also raise the possibility that subinhibitory concentrations of POA generated by the host could fuel the emergence of resistance to both PZA and POA. In contrast to widespread expectations, we demonstrate good oral bioavailability and exposure in preclinical species in pharmacokinetic studies of oral POA. Baseline exposure of oral POA can be further increased by the xanthine oxidase inhibitor and approved gout drug allopurinol. These promising results pave the way for clinical investigations of oral POA as a therapeutic alternative or an add-on to overcome PZA resistance and salvage this essential TB drug.
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Affiliation(s)
- Laura E. Via
- Tuberculosis Research
Section, Laboratory of Clinical Infectious Diseases, NIH-NIAID, 33 North
Drive, Bethesda, Maryland 20892-3206, United States
| | - Rada Savic
- Department of Bioengineering and Therapeutic Sciences, Schools of
Pharmacy and Medicine, University of California at San Francisco, 1550
Fourth Street, San Francisco, California 94143-2911, United States
| | - Danielle M. Weiner
- Tuberculosis Research
Section, Laboratory of Clinical Infectious Diseases, NIH-NIAID, 33 North
Drive, Bethesda, Maryland 20892-3206, United States
| | - Matthew D. Zimmerman
- Public Health Research Institute, New Jersey
Medical School, Rutgers, The State University of New Jersey, 225 Warren
Street, Newark, New Jersey 07103, United States
| | - Brendan Prideaux
- Public Health Research Institute, New Jersey
Medical School, Rutgers, The State University of New Jersey, 225 Warren
Street, Newark, New Jersey 07103, United States
| | - Scott M. Irwin
- Department of Microbiology, Immunology and Pathology, Colorado State University, 200 West Lake Street, Ft.
Collins, Colorado 80523-4629, United States
| | - Eddie Lyon
- Department of Microbiology, Immunology and Pathology, Colorado State University, 200 West Lake Street, Ft.
Collins, Colorado 80523-4629, United States
| | - Paul O’Brien
- Public Health Research Institute, New Jersey
Medical School, Rutgers, The State University of New Jersey, 225 Warren
Street, Newark, New Jersey 07103, United States
| | - Pooja Gopal
- Department
of Microbiology, Yong Loo Lin School of Medicine, National University
Health System, National University of Singapore, MD4A #05-01, 5 Science Drive 2, Singapore 117597
| | - Seokyong Eum
- International Tuberculosis
Research Center, 475-1 Gapo-dong, Masan, Kyeungsangnam-do 631-710, Republic of Korea
| | - Myungsun Lee
- International Tuberculosis
Research Center, 475-1 Gapo-dong, Masan, Kyeungsangnam-do 631-710, Republic of Korea
| | - Jean-Philippe Lanoix
- Department
of Medicine, Johns Hopkins University School of Medicine, 1550 Orleans
Street, Baltimore, Maryland 21287, United States
| | - Noton K. Dutta
- Department
of Medicine, Johns Hopkins University School of Medicine, 1550 Orleans
Street, Baltimore, Maryland 21287, United States
| | - TaeSun Shim
- Asan Medical
Center, 388-1 Pungnap-dong, Songpa-gu, Seoul 138-736, Republic of Korea
| | - Jeong Su Cho
- Pusan National University Hospital, 305 Gudeok-Ro, Seo-Gu, Busan 602-739, Republic of Korea
| | - Wooshik Kim
- National Medical Center, 245 Euljiro, Jung-gu, Seoul 100-799, Republic of Korea
| | - Petros C. Karakousis
- Department
of Medicine, Johns Hopkins University School of Medicine, 1550 Orleans
Street, Baltimore, Maryland 21287, United States
| | - Anne Lenaerts
- Department of Microbiology, Immunology and Pathology, Colorado State University, 200 West Lake Street, Ft.
Collins, Colorado 80523-4629, United States
| | - Eric Nuermberger
- Department
of Medicine, Johns Hopkins University School of Medicine, 1550 Orleans
Street, Baltimore, Maryland 21287, United States
| | - Clifton E. Barry
- Tuberculosis Research
Section, Laboratory of Clinical Infectious Diseases, NIH-NIAID, 33 North
Drive, Bethesda, Maryland 20892-3206, United States
| | - Véronique Dartois
- Public Health Research Institute, New Jersey
Medical School, Rutgers, The State University of New Jersey, 225 Warren
Street, Newark, New Jersey 07103, United States
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47
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Franke MF, Becerra MC, Tierney DB, Rich ML, Bonilla C, Bayona J, McLaughlin MM, Mitnick CD. Counting pyrazinamide in regimens for multidrug-resistant tuberculosis. Ann Am Thorac Soc 2015; 12:674-9. [PMID: 25664920 PMCID: PMC4418338 DOI: 10.1513/annalsats.201411-538oc] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Accepted: 01/31/2015] [Indexed: 11/20/2022] Open
Abstract
RATIONALE For treatment of multidrug-resistant tuberculosis, World Health Organization (WHO) guidelines recommend four likely effective drugs plus pyrazinamide (PZA), irrespective of the likely effectiveness of PZA in an individual patient. Whether this regimen should be supplemented in the absence of likely PZA effectiveness is an open question. OBJECTIVES The objectives of this study were to examine (1) whether individuals receiving four likely effective drugs (based on documented susceptibility or no prior exposure) experienced higher mortality during the intensive phase of treatment than those receiving five likely effective drugs and (2) whether the WHO-recommended regimen (four likely effective drugs plus PZA) may be compromised in individuals in whom PZA is not likely effective. METHODS Among 668 patients, we compared the hazard of death across regimen groups characterized by the number of likely effective drugs and whether pyrazinamide was one of the likely effective drugs. MEASUREMENTS AND MAIN RESULTS Relative to five likely effective drugs, regimens of four likely effective drugs and the WHO-recommended regimen used in individuals in whom PZA was not likely effective were associated with higher mortality rates (respectively, adjusted hazard ratio [HR], 2.87; 95% confidence interval [CI], 1.35-6.09 and adjusted HR, 2.76; 95% CI, 0.92-8.27). The mortality rate for a regimen of five likely effective drugs with likely effective PZA was similar to that for the regimen of five likely effective drugs without PZA (HR, 1.00; 95% CI, 0.12-8.00). CONCLUSIONS Mortality may be reduced by the inclusion of five likely effective drugs, including an injectable, during the intensive phase of treatment. If PZA is unlikely to be effective in an individual patient, these results suggest adding a different, likely effective drug.
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Affiliation(s)
- Molly F. Franke
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
- Socios En Salud Sucursal Peru, Lima, Peru
| | - Mercedes C. Becerra
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
- Socios En Salud Sucursal Peru, Lima, Peru
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Dylan B. Tierney
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Michael L. Rich
- Socios En Salud Sucursal Peru, Lima, Peru
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Cesar Bonilla
- National Tuberculosis Strategy, Ministry of Health, Lima, Peru; and
| | | | - Megan M. McLaughlin
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
| | - Carole D. Mitnick
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
- Socios En Salud Sucursal Peru, Lima, Peru
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts
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Diacon AH, Dawson R, von Groote-Bidlingmaier F, Symons G, Venter A, Donald PR, van Niekerk C, Everitt D, Hutchings J, Burger DA, Schall R, Mendel CM. Bactericidal Activity of Pyrazinamide and Clofazimine Alone and in Combinations with Pretomanid and Bedaquiline. Am J Respir Crit Care Med 2015; 191:943-53. [DOI: 10.1164/rccm.201410-1801oc] [Citation(s) in RCA: 145] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Bélard S, Heuvelings CC, Janssen S, Grobusch MP. Bedaquiline for the treatment of drug-resistant tuberculosis. Expert Rev Anti Infect Ther 2015; 13:535-53. [PMID: 25797824 DOI: 10.1586/14787210.2015.1021785] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Bedaquiline is a much-needed novel drug which is highly effective against drug-resistant tuberculosis. While its clinical development has been laudably fast-tracked and the drug is now available for inclusion into treatment regimens when no suitable alternatives exist, clinical experience with bedaquiline is still limited. Phase III trial data and Phase IV studies are needed particularly to study different patient populations and to optimize treatment regimens. Drug resistance to bedaquiline needs to be monitored carefully, and full access to bedaquiline treatment where it is appropriate and needed must be promoted.
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Affiliation(s)
- Sabine Bélard
- Centre of Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Academic Medical Centre, University of Amsterdam, Meibergdreef 9, PO Box 226601100 DD, Amsterdam, The Netherlands
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50
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Evaluation of the pharmacokinetic interaction between repeated doses of rifapentine or rifampin and a single dose of bedaquiline in healthy adult subjects. Antimicrob Agents Chemother 2014; 59:1219-24. [PMID: 25512422 DOI: 10.1128/aac.04171-14] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
This study assessed the effects of rifapentine or rifampin on the pharmacokinetics of a single dose of bedaquiline and its M2 metabolite in healthy subjects using a two-period single-sequence design. In period 1, subjects received a single dose of bedaquiline (400 mg), followed by a 28-day washout. In period 2, subjects received either rifapentine (600 mg) or rifampin (600 mg) from day 20 to day 41, as well as a single bedaquiline dose (400 mg) on day 29. The pharmacokinetic profiles of bedaquiline and M2 were compared over 336 h after the administration of bedaquiline alone and in combination with steady-state rifapentine or rifampin. Coadministration of bedaquiline with rifapentine or rifampin resulted in lower bedaquiline exposures. The geometric mean ratios (GMRs) and 90% confidence intervals (CIs) for the maximum observed concentration (Cmax), area under the concentration-time curve to the last available concentration time point (AUC0-t), and AUC extrapolated to infinity (AUC0-inf) of bedaquiline were 62.19% (53.37 to 72.47), 42.79% (37.77 to 48.49), and 44.52% (40.12 to 49.39), respectively, when coadministered with rifapentine. Similarly, the GMRs and 90% CIs for the Cmax, AUC0-t, and AUC0-inf of bedaquiline were 60.24% (51.96 to 69.84), 41.36% (37.70 to 45.36), and 47.32% (41.49 to 53.97), respectively, when coadministered with rifampin. The Cmax, AUC0-t, and AUC0-inf of M2 were also altered when bedaquiline was coadministered with rifapentine or rifampin. Single doses of bedaquiline, administered alone or with multiple doses of rifapentine or rifampin, were well tolerated, with no safety concerns related to coadministration. Daily administration of rifapentine to patients with tuberculosis presents the same drug interaction challenges as rifampin and other rifamycins. Strong inducers of the cytochrome P450 isoenzyme CYP3A4 should be avoided when considering the use of bedaquiline. (This study is registered at clinicaltrials.gov under identifier NCT02216331.).
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