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Verrest L, Roseboom IC, Wasunna M, Mbui J, Njenga S, Musa AM, Olobo J, Mohammed R, Ritmeijer K, Chu WY, Huitema ADR, Solomos A, Alves F, Dorlo TPC. Population pharmacokinetics of a combination of miltefosine and paromomycin in Eastern African children and adults with visceral leishmaniasis. J Antimicrob Chemother 2023; 78:2702-2714. [PMID: 37726401 PMCID: PMC10631828 DOI: 10.1093/jac/dkad286] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 08/30/2023] [Indexed: 09/21/2023] Open
Abstract
OBJECTIVES To improve visceral leishmaniasis (VL) treatment in Eastern Africa, 14- and 28-day combination regimens of paromomycin plus allometrically dosed miltefosine were evaluated. As the majority of patients affected by VL are children, adequate paediatric exposure to miltefosine and paromomycin is key to ensuring good treatment response. METHODS Pharmacokinetic data were collected in a multicentre randomized controlled trial in VL patients from Kenya, Sudan, Ethiopia and Uganda. Patients received paromomycin (20 mg/kg/day for 14 days) plus miltefosine (allometric dose for 14 or 28 days). Population pharmacokinetic models were developed. Adequacy of exposure and target attainment of paromomycin and miltefosine were evaluated in children and adults. RESULTS Data from 265 patients (59% ≤12 years) were available for this pharmacokinetic analysis. Paromomycin exposure was lower in paediatric patients compared with adults [median (IQR) end-of-treatment AUC0-24h 187 (162-203) and 242 (217-328) µg·h/mL, respectively], but were both within the IQR of end-of-treatment exposure in Kenyan and Sudanese adult patients from a previous study. Cumulative miltefosine end-of-treatment exposure in paediatric patients and adults [AUCD0-28 517 (464-552) and 524 (456-567) µg·day/mL, respectively] and target attainment [time above the in vitro susceptibility value EC90 27 (25-28) and 30 (28-32) days, respectively] were comparable to previously observed values in adults. CONCLUSIONS Paromomycin and miltefosine exposure in this new combination regimen corresponded to the desirable levels of exposure, supporting the implementation of the shortened 14 day combination regimen. Moreover, the lack of a clear exposure-response and exposure-toxicity relationship indicated adequate exposure within the therapeutic range in the studied population, including paediatric patients.
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Affiliation(s)
- Luka Verrest
- Department of Pharmacy and Pharmacology, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Ignace C Roseboom
- Department of Pharmacy and Pharmacology, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | | | - Jane Mbui
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Simon Njenga
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Ahmed M Musa
- Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan
| | - Joseph Olobo
- Department of Immunology and Molecular Biology, Makerere University, Kampala, Uganda
| | - Rezika Mohammed
- Leishmaniasis Research and Treatment Center, University of Gondar, Gondar, Ethiopia
| | | | - Wan-Yu Chu
- Department of Pharmacy and Pharmacology, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
| | - Alwin D R Huitema
- Department of Pharmacy and Pharmacology, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
- Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Pharmacology, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | | | - Fabiana Alves
- Drugs for Neglected Diseases Initiative, Geneva, Switzerland
| | - Thomas P C Dorlo
- Department of Pharmacy and Pharmacology, Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
- Department of Pharmacy, Uppsala University, Uppsala, Sweden
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Miltefosine and Nifuratel Combination: A Promising Therapy for the Treatment of Leishmania donovani Visceral Leishmaniasis. Int J Mol Sci 2023; 24:ijms24021635. [PMID: 36675150 PMCID: PMC9865052 DOI: 10.3390/ijms24021635] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/09/2023] [Accepted: 01/10/2023] [Indexed: 01/18/2023] Open
Abstract
Visceral leishmaniasis is a neglected vector-borne tropical disease caused by Leishmania donovani and Leishmania infantum that is endemic not only in East African countries, but also in Asia, regions of South America and the Mediterranean Basin. For the pharmacological control of this disease, there is a limited number of old and, in general, poorly adherent drugs, with a multitude of adverse effects and low oral bioavailability, which favor the emergence of resistant pathogens. Pentavalent antimonials are the first-line drugs, but due to their misuse, resistant Leishmania strains have emerged worldwide. Although these drugs have saved many lives, it is recommended to reduce their use as much as possible and replace them with novel and more friendly drugs. From a commercial collection of anti-infective drugs, we have recently identified nifuratel-a nitrofurantoin used against vaginal infections-as a promising repurposing drug against a mouse model of visceral leishmaniasis. In the present work, we have tested combinations of miltefosine-the only oral drug currently used against leishmaniasis-with nifuratel in different proportions, both in axenic amastigotes from bone marrow and in intracellular amastigotes from infected Balb/c mouse spleen macrophages, finding a potent synergy in both cases. In vivo evaluation of oral miltefosine/nifuratel combinations using a bioimaging platform has revealed the potential of these combinations for the treatment of this disease.
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Guhe V, Ingale P, Tambekar A, Singh S. Systems biology of autophagy in leishmanial infection and its diverse role in precision medicine. Front Mol Biosci 2023; 10:1113249. [PMID: 37152895 PMCID: PMC10160387 DOI: 10.3389/fmolb.2023.1113249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 04/05/2023] [Indexed: 05/09/2023] Open
Abstract
Autophagy is a contentious issue in leishmaniasis and is emerging as a promising therapeutic regimen. Published research on the impact of autophagic regulation on Leishmania survival is inconclusive, despite numerous pieces of evidence that Leishmania spp. triggers autophagy in a variety of cell types. The mechanistic approach is poorly understood in the Leishmania parasite as autophagy is significant in both Leishmania and the host. Herein, this review discusses the autophagy proteins that are being investigated as potential therapeutic targets, the connection between autophagy and lipid metabolism, and microRNAs that regulate autophagy and lipid metabolism. It also highlights the use of systems biology to develop novel autophagy-dependent therapeutics for leishmaniasis by utilizing artificial intelligence (AI), machine learning (ML), mathematical modeling, network analysis, and other computational methods. Additionally, we have shown many databases for autophagy and metabolism in Leishmania parasites that suggest potential therapeutic targets for intricate signaling in the autophagy system. In a nutshell, the detailed understanding of the dynamics of autophagy in conjunction with lipids and miRNAs unfolds larger dimensions for future research.
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Omics Approaches in Drug Development against Leishmaniasis: Current Scenario and Future Prospects. Pathogens 2022; 12:pathogens12010039. [PMID: 36678387 PMCID: PMC9866966 DOI: 10.3390/pathogens12010039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 12/12/2022] [Accepted: 12/15/2022] [Indexed: 12/28/2022] Open
Abstract
Leishmaniasis is a zoonotic disease transmitted in humans by the bite of Leishmania-infected phlebotomine sandflies. Each year approximately 58,500 cases of leishmaniasis are diagnosed across the globe, with a mortality rate of nearly seven percent. There are over 20 parasitic strains of Leishmania which are known to cause distinct types of leishmaniasis and pose an endemic threat to humans worldwide. Therefore, it is crucial to develop potential medications and vaccines to combat leishmaniasis. However, the task of developing therapeutic solutions is challenging due to Leishmania's digenetic lifecycle. The challenge is further intensified by cases of resistance against the available drugs. Owing to these challenges, the conventional drug development regimen is further limited by target discovery and ligand suitability for the targets. On the other hand, as an added advantage, the emergence of omics-based tools, such as high-end proteomics, transcriptomics and genomics, has hastened the pace of target discovery and target-based drug development. It is now becoming apparent that multi-omics convergence and an inter-connected systems approach is less time-consuming and more cost-effective for any drug-development process. This comprehensive review is an attempt to summarize the current knowledge on the muti-omics approach in drug development against leishmaniasis. In particular, it elaborates the potential target identification from secreted proteins in various stages of Leishmania infection and also illustrates the convergence of transcriptomic and genomic data towards the collective goal of drug discovery. This review also provides an understanding of the potential parasite's drug targets and drug resistance characteristics of the parasite, which can be used in designing effective and specific therapeutics.
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Musa AM, Mbui J, Mohammed R, Olobo J, Ritmeijer K, Alcoba G, Muthoni Ouattara G, Egondi T, Nakanwagi P, Omollo T, Wasunna M, Verrest L, Dorlo TPC, Musa Younis B, Nour A, Taha Ahmed Elmukashfi E, Ismail Omer Haroun A, Khalil EAG, Njenga S, Fikre H, Mekonnen T, Mersha D, Sisay K, Sagaki P, Alvar J, Solomos A, Alves F. Paromomycin and Miltefosine Combination as an Alternative to Treat Patients With Visceral Leishmaniasis in Eastern Africa: A Randomized, Controlled, Multicountry Trial. Clin Infect Dis 2022; 76:e1177-e1185. [PMID: 36164254 PMCID: PMC9907539 DOI: 10.1093/cid/ciac643] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND This study aimed to determine whether paromomycin plus miltefosine (PM/MF) is noninferior to sodium stibogluconate plus paromomycin (SSG/PM) for treatment of primary visceral leishmaniasis in eastern Africa. METHODS An open-label, phase 3, randomized, controlled trial was conducted in adult and pediatric patients at 7 sites in eastern Africa. Patients were randomly assigned to either 20 mg/kg paromomycin plus allometric dose of miltefosine (14 days), or 20 mg/kg sodium stibogluconate plus 15 mg/kg paromomycin (17 days). The primary endpoint was definitive cure after 6 months. RESULTS Of 439 randomized patients, 424 completed the trial. Definitive cure at 6 months was 91.2% (155 of 170) and 91.8% (156 of 170) in the PM/MF and SSG/PM arms in primary efficacy modified intention-to-treat analysis (difference, 0.6%; 97.5% confidence interval [CI], -6.2 to 7.4), narrowly missing the noninferiority margin of 7%. In the per-protocol analysis, efficacy was 92% (149 of 162) and 91.7% (155 of 169) in the PM/MF and SSG/PM arms (difference, -0.3%; 97.5% CI, -7.0 to 6.5), demonstrating noninferiority. Treatments were well tolerated. Four of 18 serious adverse events were study drug-related, and 1 death was SSG-related. Allometric dosing ensured similar MF exposure in children (<12 years) and adults. CONCLUSIONS PM/MF and SSG/PM efficacies were similar, and adverse drug reactions were as expected given the drugs safety profiles. With 1 less injection each day, reduced treatment duration, and no risk of SSG-associated life-threatening cardiotoxicity, PM/MF is a more patient-friendly alternative for children and adults with primary visceral leishmaniasis in eastern Africa. CLINICAL TRIALS REGISTRATION NCT03129646.
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Affiliation(s)
- Ahmed M Musa
- Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan
| | - Jane Mbui
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Rezika Mohammed
- Leishmaniasis Research and Treatment Center, University of Gondar, Gondar, Ethiopia
| | - Joseph Olobo
- Department of Immunology and Molecular Biology, Leishmaniasis Unit, College of Health Sciences, Makerere University, Kampala, Uganda
| | | | | | | | | | | | | | | | - Luka Verrest
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Thomas P C Dorlo
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute–Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - Brima Musa Younis
- Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan
| | - Ali Nour
- Institute of Endemic Diseases, University of Khartoum, Khartoum, Sudan
| | | | | | | | - Simon Njenga
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | - Helina Fikre
- Leishmaniasis Research and Treatment Center, University of Gondar, Gondar, Ethiopia
| | - Tigist Mekonnen
- Leishmaniasis Research and Treatment Center, University of Gondar, Gondar, Ethiopia
| | | | | | | | - Jorge Alvar
- Drugs for Neglected Diseases Initiative, Geneva, Switzerland
| | | | - Fabiana Alves
- Correspondence: F. Alves, DNDi, 15 chemin Camille Vidart, 1202, Geneva, Switzerland ()
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Fernandes VDS, da Rosa R, Zimmermann LA, Rogério KR, Kümmerle AE, Bernardes LSC, Graebin CS. Antiprotozoal agents: How have they changed over a decade? Arch Pharm (Weinheim) 2021; 355:e2100338. [PMID: 34661935 DOI: 10.1002/ardp.202100338] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 09/29/2021] [Accepted: 09/30/2021] [Indexed: 12/21/2022]
Abstract
Neglected tropical diseases are a diverse group of communicable diseases that are endemic in low- or low-to-middle-income countries located in tropical and subtropical zones. The number and availability of drugs for treating these diseases are low, the administration route is inconvenient in some cases, and most of them have safety, efficacy, or adverse/toxic reaction issues. The need for developing new drugs to deal with these issues is clear, but one of the most drastic consequences of this negligence is the lack of interest in the research and development of new therapeutic options among major pharmaceutical companies. Positive changes have been achieved over the last few years, although the overall situation remains alarming. After more than one decade since the original work reviewing antiprotozoal agents came to light, now it is time to question ourselves: How has the scenario for the treatment of protozoal diseases such as malaria, leishmaniasis, human African trypanosomiasis, and American trypanosomiasis changed? This review covers the last decade in terms of the drugs currently available for the treatment of these diseases as well as the clinical candidates being currently investigated.
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Affiliation(s)
- Vitória de Souza Fernandes
- Department of Pharmaceutical Sciences, Pharmaceutical and Medicinal Chemistry Laboratory, Federal University of Santa Catarina, Florianópolis, Santa Catarina, Brazil
| | - Rafael da Rosa
- Department of Organic Chemistry, Medicinal Chemistry and Molecular Diversity Laboratory, Federal Rural University of Rio de Janeiro, Seropédica, Rio de Janeiro, Brazil
| | - Lara A Zimmermann
- Department of Organic Chemistry, Medicinal Chemistry and Molecular Diversity Laboratory, Federal Rural University of Rio de Janeiro, Seropédica, Rio de Janeiro, Brazil
| | - Kamilla R Rogério
- Department of Pharmaceutical Sciences, Pharmaceutical and Medicinal Chemistry Laboratory, Federal University of Santa Catarina, Florianópolis, Santa Catarina, Brazil
| | - Arthur E Kümmerle
- Department of Pharmaceutical Sciences, Pharmaceutical and Medicinal Chemistry Laboratory, Federal University of Santa Catarina, Florianópolis, Santa Catarina, Brazil
| | - Lilian S C Bernardes
- Department of Organic Chemistry, Medicinal Chemistry and Molecular Diversity Laboratory, Federal Rural University of Rio de Janeiro, Seropédica, Rio de Janeiro, Brazil
| | - Cedric S Graebin
- Department of Pharmaceutical Sciences, Pharmaceutical and Medicinal Chemistry Laboratory, Federal University of Santa Catarina, Florianópolis, Santa Catarina, Brazil
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Profiro de Oliveira JH, Arruda IES, Izak Ribeiro de Araújo J, Chaves LL, de La Rocca Soares MF, Soares-Sobrinho JL. Why do few drug delivery systems to combat neglected tropical diseases reach the market? An analysis from the technology's stages. Expert Opin Ther Pat 2021; 32:89-114. [PMID: 34424127 DOI: 10.1080/13543776.2021.1970746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Many drugs used to combat schistosomiasis, Chagas disease, and leishmaniasis (SCL) have clinical limitations such as: high toxicity to the liver, kidneys and spleen; reproductive, gastrointestinal, and heart disorders; teratogenicity. In this sense, drug delivery systems (DDSs) have been described in the literature as a viable option for overcoming the limitations of these drugs. An analysis of the level of development (TRL) of patents can help in determine the steps that must be taken for promising technologies to reach the market. AREAS COVERED This study aimed to analyze the stage of development of DDSs for the treatment of SCL described in patents. In addition, we try to understand the main reasons why many DDSs do not reach the market. In this study, we examined DDSs for drugs indicated by WHO and treatment of SCL, by performing a search for patents. EXPERT OPINION In this present work we provide arguments that support the hypothesis that there is a lack of integration between academia and industry to finance and continue research, especially the development of clinical studies. We cite the translational research consortia as the potential alternative for developing DDSs to combat NTDs.
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Affiliation(s)
| | | | | | - Luise Lopes Chaves
- Department of Pharmacy, Federal University of Pernambuco, Recife, Recife-Pernambuco
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Pradhan S, Schwartz RA, Patil A, Grabbe S, Goldust M. Treatment options for leishmaniasis. Clin Exp Dermatol 2021; 47:516-521. [PMID: 34480806 DOI: 10.1111/ced.14919] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/27/2021] [Accepted: 09/01/2021] [Indexed: 12/15/2022]
Abstract
Leishmaniasis is broadly classified into three types: cutaneous, mucocutaneous and visceral. The visceral form is most dangerous and can result in death. Although leishmaniasis is an ancient disease, its treatment is still challenging. Several drugs, differing in their cost, toxicity, treatment duration and emergence of drug resistance, are used for different types of leishmaniasis. To overcome these limitations, the search for newer drugs and other treatments continues. In this article, we discuss conventional drugs, other treatments, including newer options such as immunotherapy and immunochemotherapy, and future prospects for leishmaniasis treatment.
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Affiliation(s)
| | - R A Schwartz
- Department of Dermatology and Venereology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
| | - A Patil
- Department of Dermatology, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - S Grabbe
- Department of Pharmacology, DY Patil Deemed, To Be University, Navi Mumbai, Maharashtra, India.,Department of Dermatology, University Medical Center Mainz, Mainz, Germany
| | - M Goldust
- Department of Dermatology, University Medical Center Mainz, Mainz, Germany
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Sarangi NK, Prabhakaran A, Keyes TE. Interaction of Miltefosine with Microcavity Supported Lipid Membrane: Biophysical Insights from Electrochemical Impedance Spectroscopy. ELECTROANAL 2020. [DOI: 10.1002/elan.202060424] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Nirod Kumar Sarangi
- School of Chemical Sciences and National Centre for Sensor Research Dublin City University DCU Glasnevin Campus Dublin 9 D09 W6Y4 Ireland
| | - Amrutha Prabhakaran
- School of Chemical Sciences and National Centre for Sensor Research Dublin City University DCU Glasnevin Campus Dublin 9 D09 W6Y4 Ireland
| | - Tia E. Keyes
- School of Chemical Sciences and National Centre for Sensor Research Dublin City University DCU Glasnevin Campus Dublin 9 D09 W6Y4 Ireland
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Mesquita JT, Romanelli MM, de Melo Trinconi Trinconi Cm C, Guerra JM, Taniwaki NN, Uliana SRB, Reimão JQ, Tempone AG. Repurposing topical triclosan for cutaneous leishmaniasis: Preclinical efficacy in a murine Leishmania (L.) amazonensis model. Drug Dev Res 2020; 83:285-295. [PMID: 32767443 DOI: 10.1002/ddr.21725] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/19/2020] [Accepted: 07/07/2020] [Indexed: 01/07/2023]
Abstract
Leishmaniasis remains an important neglected tropical infection caused by the protozoan Leishmania and affects 12 million people in 98 countries. The treatment is limited with severe adverse effects. In the search for new therapies, the drug repositioning and combination therapy have been successfully applied to neglected diseases. The aim of the present study was to evaluate the in vitro and in vivo anti-Leishmania (Leishmania) amazonensis potential of triclosan, an approved topical antimicrobial agent used for surgical procedures. in vitro phenotypic studies of drug-treated parasites were performed to evaluate the lethal action of triclosan, accompanied by an isobolographic ex-vivo analysis with the association of triclosan and miltefosine. The results showed that triclosan has activity against L. (L.) amazonensis intracellular amastigotes, with a 50% inhibitory concentration of 16 μM. By using fluorescent probes and transmission electron microscopy, a pore-forming activity of triclosan toward the parasite plasma membrane was demonstrated, leading to depolarization of the mitochondrial membrane potential and reduction of the reactive oxygen species levels in the extracellular promastigotes. The in vitro interaction between triclosan and miltefosine in the combination therapy assay was classified as additive against intracellular amastigotes. Leishmania-infected mice were treated with topical triclosan (1% base cream for 14 consecutive days), and showed 89% reduction in the parasite burden. The obtained results contribute to the investigation of new alternatives for the treatment of cutaneous leishmaniasis and suggest that the coadministration of triclosan and miltefosine should be investigated in animal models.
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Affiliation(s)
| | | | | | | | | | - Silvia Reni Bortolin Uliana
- Departamento de Parasitologia, Instituto de Ciências Biomédicas, Universidade de São Paulo, São Paulo, Brazil
| | - Juliana Quero Reimão
- Departamento de Morfologia e Patologia Básica, Faculdade de Medicina de Jundiaí, Jundiaí, Brazil
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Mostafavi M, Farajzadeh S, Sharifi I, Khazaeli P, Sharifi H. Leishmanicidal effects of amphotericin B in combination with selenium loaded on niosome against Leishmania tropica. J Parasit Dis 2019; 43:176-185. [PMID: 31263321 DOI: 10.1007/s12639-018-1071-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Accepted: 12/10/2018] [Indexed: 01/26/2023] Open
Abstract
The strategy for improving the treatment of leishmaniasis by the World Health Organization, is the development of new drugs and combination therapy. The aim of this survey was to investigate the effect of amphotericin B (AmB) in combination with selenium, in a simple or niosomal form, on Leishmania tropica (L. tropica) by in vitro advanced assays. In this study, a niosomal formulation of AmB with selenium was prepared and characterized based on size and morphology. Using MTT assay, macrophage model, flow cytometry, and qPCR, the cytotoxicity and efficiency of the niosomal formulation and simple form of combination were evaluated. No toxicity was reported for both the niosomal and simple form of the combination. The niosomal formulation significantly showed higher inhibitory effect on the promastigote and amastigote forms of L. tropica than simple combination form. Interleukin (IL)-10 significantly decreased while the level of IL-12 and metacasoase as Th-1 activator significantly increased (P < 0.001). The findings of this study indicated that niosomes are the stable carriers for this combination, easy to produce and provide promising results as an effective formulation in the inhibition of extracellular and intracellular forms of L. tropica in compared with simple combination form.
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Affiliation(s)
- Mahshid Mostafavi
- 1Leishmaniasis Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Saeedeh Farajzadeh
- 2Department of Pediatric Dermatology, Kerman University of Medical Sciences, Kerman, 76169-14115 Iran
| | - Iraj Sharifi
- 1Leishmaniasis Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Payam Khazaeli
- 3Pharmaceutical Research Center, School of Pharmacy, Kerman University of Medical Sciences, Kerman, Iran
| | - Hamid Sharifi
- 4HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
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Ponte-Sucre A, Gamarro F, Dujardin JC, Barrett MP, López-Vélez R, García-Hernández R, Pountain AW, Mwenechanya R, Papadopoulou B. Drug resistance and treatment failure in leishmaniasis: A 21st century challenge. PLoS Negl Trop Dis 2017; 11:e0006052. [PMID: 29240765 PMCID: PMC5730103 DOI: 10.1371/journal.pntd.0006052] [Citation(s) in RCA: 489] [Impact Index Per Article: 69.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Reevaluation of treatment guidelines for Old and New World leishmaniasis is urgently needed on a global basis because treatment failure is an increasing problem. Drug resistance is a fundamental determinant of treatment failure, although other factors also contribute to this phenomenon, including the global HIV/AIDS epidemic with its accompanying impact on the immune system. Pentavalent antimonials have been used successfully worldwide for the treatment of leishmaniasis since the first half of the 20th century, but the last 10 to 20 years have witnessed an increase in clinical resistance, e.g., in North Bihar in India. In this review, we discuss the meaning of “resistance” related to leishmaniasis and discuss its molecular epidemiology, particularly for Leishmania donovani that causes visceral leishmaniasis. We also discuss how resistance can affect drug combination therapies. Molecular mechanisms known to contribute to resistance to antimonials, amphotericin B, and miltefosine are also outlined. Chemotherapy is central to the control and management of leishmaniasis. Antimonials remain the primary drugs against different forms of leishmaniasis in several regions. However, resistance to antimony has necessitated the use of alternative medications, especially in the Indian subcontinent (ISC). Compounds, notably the orally available miltefosine (MIL), parenteral paromomycin, and amphotericin B (AmB), are increasingly used to treat leishmaniasis. Although treatment failure (TF) has been observed in patients treated with most anti-leishmanials, its frequency of appearance may be important in patients treated with MIL, which has replaced antimonials within the kala-azar elimination program in the ISC. AmB is highly efficacious, and the associated toxic effects—when administered in its free deoxycholate form—are somewhat ameliorated in its liposomal formulation. Regrettably, laboratory experimentation has demonstrated a risk of resistance towards AmB as well. The rise of drug resistance impacts treatment outcome, and understanding its causes, spread, and impact will help us manage the risks it imposes. Here, we review the problem of TF in leishmaniasis and the contribution of drug resistance to the problem. Molecular mechanisms causing resistance to anti-leishmanials are discussed along with the appropriate use of additional available drugs, as well as the urgent need to consolidate strategies to monitor drug efficacy, epidemiological surveillance, and local policies. Coordination of these activities in national and international programs against leishmaniasis might represent a successful guide to further research and prevention activities.
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Affiliation(s)
- Alicia Ponte-Sucre
- Department of Physiological Sciences, Laboratory of Molecular Physiology, Institute of Experimental Medicine, Luis Razetti School of Medicine, Universidad Central de Venezuela, Caracas, Venezuela
- * E-mail: (BP); (APS)
| | - Francisco Gamarro
- Department of Biochemistry and Molecular Pharmacology, Instituto de Parasitología y Biomedicina López-Neyra, Spanish National Research Council (IPBLN-CSIC), Granada, Spain
| | - Jean-Claude Dujardin
- Molecular Parasitology Unit, Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium
| | - Michael P. Barrett
- Wellcome Centre for Molecular Parasitology, Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, United Kingdom
| | - Rogelio López-Vélez
- Department of Infectious Diseases, National Referral Unit for Tropical Diseases, Ramón y Cajal University Hospital, Madrid, Spain
| | - Raquel García-Hernández
- Department of Biochemistry and Molecular Pharmacology, Instituto de Parasitología y Biomedicina López-Neyra, Spanish National Research Council (IPBLN-CSIC), Granada, Spain
| | - Andrew W. Pountain
- Wellcome Centre for Molecular Parasitology, Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow, United Kingdom
| | - Roy Mwenechanya
- Department of Biomedical Sciences, School of Veterinary Medicine, University of Zambia, Lusaka, Zambia
| | - Barbara Papadopoulou
- Research Center in Infectious Diseases, CHU de Quebec Research Center and Department of Microbiology-Infectious Disease and Immunology, University Laval, Quebec, Canada
- * E-mail: (BP); (APS)
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Nanotized Curcumin and Miltefosine, a Potential Combination for Treatment of Experimental Visceral Leishmaniasis. Antimicrob Agents Chemother 2017; 61:AAC.01169-16. [PMID: 28031196 DOI: 10.1128/aac.01169-16] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2016] [Accepted: 12/14/2016] [Indexed: 10/20/2022] Open
Abstract
Leishmaniasis chemotherapy remains very challenging due to high cost of the drug and its associated toxicity and drug resistance, which develops over a period of time. Combination therapies (CT) are now in use to treat many diseases, such as cancer and malaria, since it is more effective and affordable than monotherapy. CT are believed to represent a new explorable strategy for leishmaniasis, a neglected tropical disease caused by the obligate intracellular parasite Leishmania In the present study, we investigated the effect of a combination of a traditional Indian medicine (ayurveda), a natural product curcumin and miltefosine, the only oral drug for visceral leishmaniasis (VL) using a Leishmania donovani-hamster model. We developed an oral nanoparticle-based formulation of curcumin. Nanoformulation of curcumin alone exhibited significant leishmanicidal activity both in vitro and in vivo In combination with miltefosine, it exhibited a synergistic effect on both promastigotes and amastigotes under in vitro conditions. The combination of these two agents also demonstrated increased in vivo leishmanicidal activity accompanied by increased production of toxic reactive oxygen/nitrogen metabolites and enhanced phagocytic activity. The combination also exhibited increased lymphocyte proliferation. The present study thus establishes the possible use of nanocurcumin as an adjunct to antileishmanial chemotherapy.
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Abstract
Cutaneous and visceral leishmaniasis are amongst the most devastating infectious diseases of our time, affecting millions of people worldwide. The treatment of these serious diseases rely on a few chemotherapeutic agents, most of which are of parenteral use and induce severe side-effects. Furthermore, rates of treatment failure are high and have been linked to drug resistance in some areas. Here, we reviewed data on current chemotherapy practice in leishmaniasis. Drug resistance and mechanisms of resistance are described as well as the prospects for applying drug combinations for leishmaniasis chemotherapy. It is clear that efforts for discovering new drugs applicable to leishmaniasis chemotherapy are essential. The main aspects on the various steps of drug discovery in the field are discussed.
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Efficacy and Safety of AmBisome in Combination with Sodium Stibogluconate or Miltefosine and Miltefosine Monotherapy for African Visceral Leishmaniasis: Phase II Randomized Trial. PLoS Negl Trop Dis 2016; 10:e0004880. [PMID: 27627654 PMCID: PMC5023160 DOI: 10.1371/journal.pntd.0004880] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 07/06/2016] [Indexed: 01/31/2023] Open
Abstract
Background SSG&PM over 17 days is recommended as first line treatment for visceral leishmaniasis in eastern Africa, but is painful and requires hospitalization. Combination regimens including AmBisome and miltefosine are safe and effective in India, but there are no published data from trials of combination therapies including these drugs from Africa. Methods A phase II open-label, non-comparative randomized trial was conducted in Sudan and Kenya to evaluate the efficacy and safety of three treatment regimens: 10 mg/kg single dose AmBisome plus 10 days of SSG (20 mg/kg/day), 10 mg/kg single dose AmBisome plus 10 days of miltefosine (2.5mg/kg/day) and miltefosine alone (2.5 mg/kg/day for 28 days). The primary endpoint was initial parasitological cure at Day 28, and secondary endpoints included definitive cure at Day 210, and pharmacokinetic (miltefosine) and pharmacodynamic assessments. Results In sequential analyses with 49–51 patients per arm, initial cure was 85% (95% CI: 73–92) in all arms. At D210, definitive cure was 87% (95% CI: 77–97) for AmBisome + SSG, 77% (95% CI 64–90) for AmBisome + miltefosine and 72% (95% CI 60–85) for miltefosine alone, with lower efficacy in younger patients, who weigh less. Miltefosine pharmacokinetic data indicated under-exposure in children compared to adults. Conclusion No major safety concerns were identified, but point estimates of definitive cure were less than 90% for each regimen so none will be evaluated in Phase III trials in their current form. Allometric dosing of miltefosine in children needs to be evaluated. Trial Registration The study was registered with ClinicalTrials.gov, number NCT01067443 Visceral leishmaniasis, or kala-azar, is a parasitic disease which is fatal without treatment. A 17-day treatment of sodium stibogluconate (SSG) with paromomycin (PM) is the recommended treatment in eastern Africa, but requires painful injections, causes adverse events, and patients need to stay in the hospital during treatment. An affordable, safe and effective oral treatment would be preferable. Whilst research to identify entirely new drugs is underway, existing treatments are being optimized as a short-term solution. Combination regimens based on AmBisome and miltefosine have been shown to be safe and effective in treating Indian patients, but there are no published data from use of these drugs in combination regimens from Africa, where efficacy of treatments can be different from India. Three regimens were evaluated for treating VL in eastern Africa, using AmBisome in combination with SSG or miltefosine, or miltefosine alone. Once again, drugs which are effective in India were found to be less so in African patients, and none of the regimes tested showed sufficiently high definitive cure rates to evaluate in Phase III trials. The results also suggest miltefosine was under-dosed in children and so allometric dosing, which takes into account the differences in drug metabolism seen in children compared to adults, needs to be studied.
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Valicherla GR, Tripathi P, Singh SK, Syed AA, Riyazuddin M, Husain A, Javia D, Italiya KS, Mishra PR, Gayen JR. Pharmacokinetics and bioavailability assessment of Miltefosine in rats using high performance liquid chromatography tandem mass spectrometry. J Chromatogr B Analyt Technol Biomed Life Sci 2016; 1031:123-130. [DOI: 10.1016/j.jchromb.2016.07.042] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 07/19/2016] [Accepted: 07/23/2016] [Indexed: 01/01/2023]
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Sundar S, Singh A. Recent developments and future prospects in the treatment of visceral leishmaniasis. Ther Adv Infect Dis 2016; 3:98-109. [PMID: 27536354 DOI: 10.1177/2049936116646063] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Limited therapeutic options in visceral leishmaniasis (VL) make the treatment of this neglected disease very challenging. In addition to this, long treatment duration and toxic adverse effects make it even more difficult. With no effective vaccine available to date, treatment of VL is based only on chemotherapy. In the Indian subcontinent, a single dose of liposomal amphotericin B (L-AmB) and multidrug therapy (L-AmB + miltefosine, L-AmB + paromomycin [PM], or miltefosine + PM) are the treatments of choice for VL. In East Africa, however, combination therapy of pentavalent antimonials (Sb(v)) and PM remains the treatment of choice, and in the Mediterranean region and South America, L-AmB is the recommended drug. Fexinidazole and PA-824 are new promising drugs which have shown encouraging results in preclinical studies.
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Affiliation(s)
- Shyam Sundar
- Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221005 India
| | - Anup Singh
- Department of Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
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18
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Validation and Clinical Evaluation of a Novel Method To Measure Miltefosine in Leishmaniasis Patients Using Dried Blood Spot Sample Collection. Antimicrob Agents Chemother 2016; 60:2081-9. [PMID: 26787691 PMCID: PMC4808221 DOI: 10.1128/aac.02976-15] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 01/09/2016] [Indexed: 12/31/2022] Open
Abstract
To facilitate future pharmacokinetic studies of combination treatments against leishmaniasis in remote regions in which the disease is endemic, a simple cheap sampling method is required for miltefosine quantification. The aims of this study were to validate a liquid chromatography-tandem mass spectrometry method to quantify miltefosine in dried blood spot (DBS) samples and to validate its use with Ethiopian patients with visceral leishmaniasis (VL). Since hematocrit (Ht) levels are typically severely decreased in VL patients, returning to normal during treatment, the method was evaluated over a range of clinically relevant Ht values. Miltefosine was extracted from DBS samples using a simple method of pretreatment with methanol, resulting in >97% recovery. The method was validated over a calibration range of 10 to 2,000 ng/ml, and accuracy and precision were within ±11.2% and ≤7.0% (≤19.1% at the lower limit of quantification), respectively. The method was accurate and precise for blood spot volumes between 10 and 30 μl and for Ht levels of 20 to 35%, although a linear effect of Ht levels on miltefosine quantification was observed in the bioanalytical validation. DBS samples were stable for at least 162 days at 37°C. Clinical validation of the method using paired DBS and plasma samples from 16 VL patients showed a median observed DBS/plasma miltefosine concentration ratio of 0.99, with good correlation (Pearson's r = 0.946). Correcting for patient-specific Ht levels did not further improve the concordance between the sampling methods. This successfully validated method to quantify miltefosine in DBS samples was demonstrated to be a valid and practical alternative to venous blood sampling that can be applied in future miltefosine pharmacokinetic studies with leishmaniasis patients, without Ht correction.
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Trinconi CT, Reimão JQ, Coelho AC, Uliana SRB. Efficacy of tamoxifen and miltefosine combined therapy for cutaneous leishmaniasis in the murine model of infection withLeishmania amazonensis. J Antimicrob Chemother 2016; 71:1314-22. [DOI: 10.1093/jac/dkv495] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 12/21/2015] [Indexed: 11/13/2022] Open
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Collier MA, Peine KJ, Gautam S, Oghumu S, Varikuti S, Borteh H, Papenfuss TL, Sataoskar AR, Bachelder EM, Ainslie KM. Host-mediated Leishmania donovani treatment using AR-12 encapsulated in acetalated dextran microparticles. Int J Pharm 2016; 499:186-194. [PMID: 26768723 DOI: 10.1016/j.ijpharm.2016.01.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 12/29/2015] [Accepted: 01/04/2016] [Indexed: 12/15/2022]
Abstract
Leishmaniasis is a disease caused by parasites of Leishmania sp., which effects nearly 12 million people worldwide and is associated with treatment complications due to widespread parasite resistance toward pathogen-directed therapeutics. The current treatments for visceral leishmaniasis (VL), the systemic form of the disease, involve pathogen-mediated drugs and have long treatment regimens, increasing the risk of forming resistant strains. One way to limit emergence of resistant pathogens is through the use of host-mediated therapeutics. The host-mediated therapeutic AR-12, which is FDA IND-approved for cancer treatment, has shown activity against a broad spectrum of intracellular pathogens; however, due to hydrophobicity and toxicity, it is difficult to reach therapeutic doses. We have formulated AR-12 into microparticles (AR-12/MPs) using the novel biodegradable polymer acetalated dextran (Ace-DEX) and used this formulation for the systemic treatment of VL. Treatment with AR-12/MPs significantly reduced liver, spleen, and bone marrow parasite loads in infected mice, while combinatorial therapies with amphotericin B had an even more significant effect. Overall, AR-12/MPs offer a unique, host-mediated therapy that could significantly reduce the emergence of drug resistance in the treatment of VL.
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Affiliation(s)
- M A Collier
- Division of Molecular Pharmaceutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, United States
| | - K J Peine
- Division of Molecular Pharmaceutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, United States
| | - S Gautam
- Division of Pharmaceutics, College of Pharmacy, The Ohio State University, Columbus, OH 43210, United States
| | - S Oghumu
- Department of Pathology, The Ohio State's Wexner Medical Center, The Ohio State University, Columbus, OH 43210, United States
| | - S Varikuti
- Department of Pathology, The Ohio State's Wexner Medical Center, The Ohio State University, Columbus, OH 43210, United States
| | - H Borteh
- Division of Pharmaceutics, College of Pharmacy, The Ohio State University, Columbus, OH 43210, United States
| | - T L Papenfuss
- Department of Pathology, The Ohio State's Wexner Medical Center, The Ohio State University, Columbus, OH 43210, United States
| | - A R Sataoskar
- College of Veterinary Medicine, The Ohio State University, Columbus, OH 43210, United States
| | - E M Bachelder
- Division of Molecular Pharmaceutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, United States
| | - K M Ainslie
- Division of Molecular Pharmaceutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, United States.
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Ekins S, Siqueira-Neto JL. Shedding Light on Synergistic Chemical Genetic Connections with Machine Learning. Cell Syst 2015; 1:377-9. [PMID: 27136350 DOI: 10.1016/j.cels.2015.12.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Machine learning can be used to predict compounds acting synergistically, and this could greatly expand the universe of available potential treatments for diseases that are currently hidden in the dark chemical matter.
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Affiliation(s)
- Sean Ekins
- Collaborations in Chemistry, 5616 Hilltop Needmore Road, Fuquay-Varina, NC 27526, USA; Collaborative Drug Discovery, 1633 Bayshore Highway, Suite 342, Burlingame, CA 94010, USA; Collaborations Pharmaceuticals, Inc., 5616 Hilltop Needmore Road, Fuquay-Varina, NC 27526, USA; Phoenix Nest, Inc., P.O. Box 150057, Brooklyn, NY 11215, USA; Hereditary Neuropathy Foundation, 401 Park Avenue South, 10th Floor, New York, NY 10016, USA.
| | - Jair Lage Siqueira-Neto
- Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California San Diego, San Diego, CA 92093, USA
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Allison A, Edwards T, Omollo R, Alves F, Magirr D, E Alexander ND. Generalizing boundaries for triangular designs, and efficacy estimation at extended follow-ups. Trials 2015; 16:522. [PMID: 26573827 PMCID: PMC4647805 DOI: 10.1186/s13063-015-1018-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 10/20/2015] [Indexed: 12/01/2022] Open
Abstract
Background Visceral leishmaniasis (VL) is a parasitic disease transmitted by sandflies and is fatal if left untreated. Phase II trials of new treatment regimens for VL are primarily carried out to evaluate safety and efficacy, while pharmacokinetic data are also important to inform future combination treatment regimens. The efficacy of VL treatments is evaluated at two time points, initial cure, when treatment is completed and definitive cure, commonly 6 months post end of treatment, to allow for slow response to treatment and detection of relapses. This paper investigates a generalization of the triangular design to impose a minimum sample size for pharmacokinetic or other analyses, and methods to estimate efficacy at extended follow-up accounting for the sequential design and changes in cure status during extended follow-up. Methods We provided R functions that generalize the triangular design to impose a minimum sample size before allowing stopping for efficacy. For estimation of efficacy at a second, extended, follow-up time, the performance of a shrinkage estimator (SHE), a probability tree estimator (PTE) and the maximum likelihood estimator (MLE) for estimation was assessed by simulation. Results The SHE and PTE are viable approaches to estimate an extended follow-up although the SHE performed better than the PTE: the bias and root mean square error were lower and coverage probabilities higher. Conclusions Generalization of the triangular design is simple to implement for adaptations to meet requirements for pharmacokinetic analyses. Using the simple MLE approach to estimate efficacy at extended follow-up will lead to biased results, generally over-estimating treatment success. The SHE is recommended in trials of two or more treatments. The PTE is an acceptable alternative for one-arm trials or where use of the SHE is not possible due to computational complexity. Trial registration NCT01067443, February 2010. Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-1018-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Annabel Allison
- Lancaster University, Lancaster, LA1 4YW, UK. .,The University of Sheffield, Western Bank, Sheffield, S10 2TN, UK.
| | - Tansy Edwards
- MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Raymond Omollo
- Drugs for Neglected Diseases initiative (DNDi) Africa, Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya. .,Maseno University, Private Bag, Maseno, Kenya.
| | | | - Dominic Magirr
- Lancaster University, Lancaster, LA1 4YW, UK. .,Centre for Medical Statistics, Medical University of Vienna, Spitalgasse 23, Vienna, 1090, Austria.
| | - Neal D E Alexander
- MRC Tropical Epidemiology Group, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
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Shivahare R, Ali W, Vishwakarma P, Natu S, Puri SK, Gupta S. Leptin augments protective immune responses in murine macrophages and enhances potential of miltefosine against experimental visceral leishmaniasis. Acta Trop 2015; 150:35-41. [PMID: 26119043 DOI: 10.1016/j.actatropica.2015.06.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Revised: 06/19/2015] [Accepted: 06/22/2015] [Indexed: 10/23/2022]
Abstract
Adverse side effects and drug resistance issues are the two most important drawbacks which influence the widespread use of existing antileishmanial drugs. Use of immune stimulating agent with standard antileishmanial might be helpful to minimize the toxic effect of drug, shorten the dose regimen and delay the emergence of resistance. In the present study, we explored the in vitro immunomodulatory potential of an immunomodulator, leptin with lower concentration of standard drug, miltefosine. The level of Th1/Th2 cytokines, production of nitric oxide and reactive oxygen species and phagocytic activity was assessed by ELISA, Griess reaction and flow cytometric analysis, respectively. Leptin at a concentration of 15μg/mL showed heightened level of Th1 cytokines and nitric oxide generation from murine macrophages (J-774A.1 cells). Leptin (15μg/mL) also reduces the effective concentration of miltefosine by 2-folds from 7.5μM to 3.7μM. When given in conjunction with lower concentration of miltefosine (4μM), leptin (15μg/mL) significantly (***p<0.001) elevated the level of IL-12 (7.7 fold), TNF-α (8.1 fold) and nitric oxide (6.6 fold) along with markedly (***p<0.001) suppressed level of IL-10 and TGF-β when compared with untreated infected macrophages. Leptin plus miltefosine also induces the phagocytic ability (**p<0.01) of macrophages in comparison to leptin alone and miltefosine alone treated groups. These finding illustrate that leptin activates host macrophages to generate protective immune response for the successful elimination of Leishmania parasite at lower concentration of miltefosine and has potential for further exploration in experimental animal model of visceral leishmaniasis (VL).
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Monge-Maillo B, López-Vélez R. Miltefosine for visceral and cutaneous leishmaniasis: drug characteristics and evidence-based treatment recommendations. Clin Infect Dis 2015; 60:1398-404. [PMID: 25601455 DOI: 10.1093/cid/civ004] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 12/23/2014] [Indexed: 12/25/2022] Open
Abstract
Miltefosine is the only recognized oral agent with potential to treat leishmaniasis. Miltefosine had demonstrated very good cure rates for visceral leishmaniasis (VL) in India, Nepal, and Bangladesh, but high rates of clinical failures have been recently reported. Moderate efficacy has been observed for VL in East Africa, whereas data from Mediterranean countries and Latin America are scarce. Results have not been very promising for patients coinfected with VL and human immunodeficiency virus. However, miltefosine's long half-life and its oral administration could make it a good option for maintenance prophylaxis. Good evidence of efficacy has been documented in Old World cutaneous leishmaniasis (CL), and different cure rates among New World CL have been obtained depending on the geographical areas and species involved. Appropriate regimens for New World mucocutaneous leishmaniasis need to be established, although longer treatment duration seems to confer better results. Strategies to prevent the development and spread of miltefosine resistance are urgently needed.
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Affiliation(s)
- Begoña Monge-Maillo
- Tropical Medicine Centre, Infectious Diseases Department, Ramón y Cajal Hospital, Madrid, Spain
| | - Rogelio López-Vélez
- Tropical Medicine Centre, Infectious Diseases Department, Ramón y Cajal Hospital, Madrid, Spain
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Sánchez-Fernández EM, Gómez-Pérez V, García-Hernández R, García Fernández JM, Plata GB, Padrón JM, Ortiz Mellet C, Castanys S, Gamarro F. Antileishmanial activity of sp2-iminosugar derivatives. RSC Adv 2015. [DOI: 10.1039/c5ra02627j] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
sp2-iminosugar S-linked pseudoglycosides selectively inhibit growth of the intracellular form of Leishmania donovani.
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Affiliation(s)
| | - Verónica Gómez-Pérez
- Instituto de Parasitología y Biomedicina “López-Neyra”
- IPBLN-CSIC
- Parque Tecnológico de Ciencias de la Salud
- 18016-Granada
- Spain
| | - Raquel García-Hernández
- Instituto de Parasitología y Biomedicina “López-Neyra”
- IPBLN-CSIC
- Parque Tecnológico de Ciencias de la Salud
- 18016-Granada
- Spain
| | | | - Gabriela B. Plata
- BioLab
- Instituto Universitario de Bio-Orgánica “Antonio González”
- Centro de Investigaciones Biomédicas de Canarias
- Universidad de La Laguna
- La Laguna
| | - José M. Padrón
- BioLab
- Instituto Universitario de Bio-Orgánica “Antonio González”
- Centro de Investigaciones Biomédicas de Canarias
- Universidad de La Laguna
- La Laguna
| | - Carmen Ortiz Mellet
- Departamento de Química Orgánica
- Facultad de Química
- Universidad de Sevilla
- Spain
| | - Santiago Castanys
- Instituto de Parasitología y Biomedicina “López-Neyra”
- IPBLN-CSIC
- Parque Tecnológico de Ciencias de la Salud
- 18016-Granada
- Spain
| | - Francisco Gamarro
- Instituto de Parasitología y Biomedicina “López-Neyra”
- IPBLN-CSIC
- Parque Tecnológico de Ciencias de la Salud
- 18016-Granada
- Spain
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Machado-Silva A, Guimarães PPG, Tavares CAP, Sinisterra RD. New perspectives for leishmaniasis chemotherapy over current anti-leishmanial drugs: a patent landscape. Expert Opin Ther Pat 2014; 25:247-60. [PMID: 25530084 DOI: 10.1517/13543776.2014.993969] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Although leishmaniasis is estimated to cause the ninth largest disease burden among individual infectious diseases, it is still one of the most neglected diseases in terms of drug development. Current drugs are highly toxic, resistance is common and compliance of patients to treatment is low, as treatment is long and drug price is high. AREAS COVERED In this review, the authors carried out a patent landscape in search for new perspectives for leishmaniasis therapy. This search encompassed patent documents having priority date between 1994 and 2014. Selected compounds were compared to current anti-leishmanial drugs regarding efficacy and toxicity, when experimental data were available. EXPERT OPINION Most patents related to drugs for leishmaniasis have not been produced by the pharmaceutical industry but rather by public research institutes or by universities, and the majority of the inventions disclosed are still in preclinical phase. There is an urgent need to find new ways of funding research for leishmaniasis drugs, incentivizing product development partnerships and pushing forward innovation.
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Affiliation(s)
- Alice Machado-Silva
- Universidade Federal de Minas Gerais, Instituto de Ciências Exatas,Departamento de Química , Av. Antonio Carlos, 6627, Pampulha, CEP 31270-901, Belo Horizonte-MG , Brazil +55 31 3409 5778 ; +55 31 3409 5700 ;
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Abstract
INTRODUCTION Leishmaniasis broadly manifests as visceral leishmaniasis (VL), cutaneous leishmaniasis (CL) and mucocutaneous leishmaniasis. The treatment of leishmaniasis is challenging and the armamentarium of drugs is small, duration of treatment is long, and most drugs are toxic. AREAS COVERED A literature search on treatment of leishmaniasis was done on PubMed. Single dose of liposomal amphotericin B (L-AmB) and multidrug therapy (L-AmB + miltefosine, L-AmB + paromomycin (PM), or miltefosine + PM) are the treatment of choice for VL in the Indian subcontinent. A 17-day combination therapy of pentavalent antimonials (Sb(v)) and PM remains the treatment of choice for East African VL. L-AmB at a total dose of 18 - 21 mg/kg is the recommended regimen for VL in the Mediterranean region and South America. Treatment of CL should be decided by the severity of clinical lesions, etiological species and its potential to develop into mucosal leishmaniasis. EXPERT OPINION There is an urgent need to implement a single-dose L-AmB or combination therapy in the Indian subcontinent. Shorter and more acceptable regimens are needed for the treatment of post - kala-azar dermal leishmaniasis. Combination therapy with newer drugs needs to be tested in Africa. Due to the toxicity of systemic therapy, a trend toward local treatment for New World CL is preferred in patients without risk of mucosal disease.
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Affiliation(s)
- Shyam Sundar
- Banaras Hindu University, Institute of Medical Sciences, Department of Medicine , Varanasi , India +91 542 2369632 ;
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Abstract
Visceral leishmaniasis (VL), also known as Kala-Azar, is a disseminated protozoal infection caused principally by Leishmania donovani and Leishmania infantum (known as Leishmania chagasi in South America). The therapeutic options for VL are diverse and depend on different factors, such as the geographical area of the infection, development of resistance to habitual treatments, HIV co-infection, malnourishment and other concomitant infections. This article provides an exhaustive review of the literature regarding studies published on the treatment of VL, and gives therapeutic recommendations stratified according to their level of evidence, the species of Leishmania implicated and the geographical location of the infection.
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Affiliation(s)
- Begoña Monge-Maillo
- Tropical Medicine and Clinical Parasitology, Infectious Diseases Department, Ramón y Cajal Hospital, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Carretera de Colmenar Km 9,1, 28034, Madrid, Spain
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Mohapatra S. Drug resistance in leishmaniasis: Newer developments. Trop Parasitol 2014; 4:4-9. [PMID: 24754020 PMCID: PMC3992802 DOI: 10.4103/2229-5070.129142] [Citation(s) in RCA: 86] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Accepted: 03/20/2014] [Indexed: 11/06/2022] Open
Abstract
Leishmaniasis is a vector borne protozoan disease and it remains a major public health problem world-wide. Lack of an effective vaccine and vector control program makes the chemotherapy as the primary tool for leishmaniasis. Antimonials were used as the first line of treatment for many years. Emergence of resistance against this drug has become a major concern. Literatures and studies published on anti-leishmanial drug resistance, newer drug discovery for leishmanial resistance etc., in PubMed, Medline and Google search and reviewed thoroughly. Various newer drugs have been identified but, are in limited use because of high cost, toxicity, resistance etc., Recently, many newer mechanisms of drug resistance have been identified which may boost in future designing and development of drugs.
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Affiliation(s)
- Sarita Mohapatra
- Department of Microbiology, Vardhaman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
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Combination therapy with tamoxifen and amphotericin B in experimental cutaneous leishmaniasis. Antimicrob Agents Chemother 2014; 58:2608-13. [PMID: 24550333 DOI: 10.1128/aac.01315-13] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Leishmaniasis chemotherapy remains very challenging. The high cost of active drugs, along with the severity of their side effects and the increasing failure rate of the current therapeutic schemes, calls for the discovery of new active drugs and schemes of treatment. The use of combination therapy has gained much attention in recent years as a possible strategy for overcoming the various shortcomings in the present arsenal. We recently described the effectiveness of tamoxifen in murine models of leishmaniasis, and here, we investigated the interactions between tamoxifen and amphotericin B, one of the most potent drugs used in leishmaniasis treatment. The in vitro interactions were indifferent for the association of tamoxifen and amphotericin B. The association was also assayed in vivo in Leishmania amazonensis-infected BALB/c mice and was found to yield at least additive effects at low doses of both drugs.
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Safety and efficacy of single dose versus multiple doses of AmBisome for treatment of visceral leishmaniasis in eastern Africa: a randomised trial. PLoS Negl Trop Dis 2014; 8:e2613. [PMID: 24454970 PMCID: PMC3894173 DOI: 10.1371/journal.pntd.0002613] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2013] [Accepted: 11/18/2013] [Indexed: 11/19/2022] Open
Abstract
Background Anti-leishmanial drug regimens that include a single dose AmBisome® could be suitable for eastern African patients with symptomatic visceral leishmaniasis (VL) but the appropriate single dose is unknown. Methodology A multi-centre, open-label, non-inferiority, randomized controlled trial with an adaptive design, was conducted to compare the efficacy and safety of a single dose and multiple doses of AmBisome® for the treatment of VL in eastern Africa. The primary efficacy endpoint was definitive cure (DC) at 6 months. Symptomatic patients with parasitologically-confirmed, non-severe VL, received a single dose of AmBisome® 7.5 mg/kg body weight or multiple doses, 7 times 3 mg/kg on days 1–5, 14, and 21. If interim analyses, evaluated 30 days after the start of treatment following 40 or 80 patients, showed the single dose gave significantly poorer parasite clearance than multiple doses at the 5% significance level, the single dose was increased by 2·5 mg/kg. In a sub-set of patients, parasite clearance was measured by quantitative reverse transcriptase (qRT) PCR. Principal Findings The trial was terminated after the third interim analysis because of low efficacy of both regimens. Based on the intention-to-treat population, DC was 85% (95%CI 73–93%), 40% (95%CI 19–64%), and 58% (95%CI 41–73%) in patients treated with multiple doses (n = 63), and single doses of 7·5 (n = 21) or 10 mg/kg (n = 40), respectively. qRT-PCR suggested superior parasite clearance with multiple doses as early as day 3. Safety data accorded with the drug label. Conclusions The tested AmBisome® regimens would not be suitable for VL treatment across eastern Africa. An optimal single dose regimen was not identified. Trials Registration www.clinicaltrials.govNCT00832208 Visceral leishmaniasis is a potentially fatal disease which affects 0.2–0.4 million people every year, principally in South-East Asia, Latin America or Eastern Africa. Currently the safest drug in use is AmBisome®, which cures 90% of patients in India at 5 mg/kg, and is even more effective at higher doses (10 mg/kg) or in combination with miltefosine or paromomycin. These regimens have been shown to be equally cost-effective in India. However, the drug requires a cold chain for storage and reconstitution prior to injection. Although it is licensed for use in eastern Africa, in practice it is mainly used as a second-line treatment. A small study carried out in Kenya indicated that a higher dose is necessary in eastern Africa in contrast to Asia. This study aimed to determine the minimum single dose that is safe and effective for treatment of eastern African VL patients so as to be used in simplified treatment regimens. However, the tested regimens were found to be ineffective, and an optimal single dose that could potentially be used in simplified treatment regimens was not identified.
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Five-year retrospective Italian multicenter study of visceral leishmaniasis treatment. Antimicrob Agents Chemother 2013; 58:414-8. [PMID: 24189252 DOI: 10.1128/aac.00840-13] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The treatment of visceral leishmaniasis (VL) is poorly standardized in Italy in spite of the existing evidence. All consecutive patients with VL admitted at 15 Italian centers as inpatients or outpatients between January 2004 and December 2008 were retrospectively considered; outcome data at 1 year after treatment were obtained for all but 1 patient. Demographic characteristics, underlying diseases, diagnostic procedures, treatment regimens and outcomes, as well as side effects were recorded. A confirmed diagnosis of VL was reported for 166 patients: 120 (72.3%) immunocompetent, 21 (12.6%) patients with immune deficiencies other than HIV infection, and 25 (15.1%) coinfected with HIV. Liposomal amphotericin B (L-AmB) was the drug almost universally used for treatment, administered to 153 (92.2%) patients. Thirty-seven different regimens, including L-AmB were used. The mean doses were 29.4 ± 7.9 mg/kg in immunocompetent patients, 32.9 ± 8.6 mg/kg in patients with non-HIV-related immunodeficiencies, and 40.8 ± 6.7 mg/kg in HIV-infected patients (P < 0.001). The mean numbers of infusion days were 7.8 ± 3.1 in immunocompetent patients, 9.6 ± 3.9 in non-HIV-immunodeficient patients, and 12.0 ± 3.4 in HIV-infected patients (P < 0.001). Mild and reversible adverse events were observed in 12.2% of cases. Responsive patients were 154 (93.3%). Successes were 98.4% among immunocompetent patients, 90.5% among non-HIV-immunodeficient patients, and 72.0% among HIV-infected patients. Among predictors of primary response to treatment, HIV infection and age held independent associations in the final multivariate models, whereas the doses and duration of L-AmB treatment were not significantly associated. Longer treatments and higher doses of L-AmB were not able to significantly modify treatment outcomes either in the immunocompetent or in the immunocompromised population.
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Meheus F, Abuzaid AA, Baltussen R, Younis BM, Balasegaram M, Khalil EAG, Boelaert M, Musa AM. The economic burden of visceral leishmaniasis in Sudan: an assessment of provider and household costs. Am J Trop Med Hyg 2013; 89:1146-1153. [PMID: 24189368 PMCID: PMC3854893 DOI: 10.4269/ajtmh.12-0585] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Visceral leishmaniasis (VL) is a neglected parasitic disease that is fatal if left untreated and is endemic in eastern Sudan. We estimated the direct and indirect costs of treatment of VL from the perspective of the provider and the household at three public hospitals in Gedaref State. The median total cost for one VL episode was estimated to be US$450. Despite the free provision of VL drugs at public hospitals, households bore 53% of the total cost of VL with one episode of VL representing 40% of the annual household income. More than 75% of households incurred catastrophic out-of-pocket expenditures. The length of treatment of 30 days led to important costs for both health providers and households. Alternative treatment regimens that reduce the duration of treatment are urgently needed.
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Affiliation(s)
- Filip Meheus
- *Address correspondence to Filip Meheus, Health Economics Unit, School of Public Health and Family Medicine, University of Cape Town, Anzio Road, Observatory 7925, South Africa. E-mail:
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Ejazi SA, Ali N. Developments in diagnosis and treatment of visceral leishmaniasis during the last decade and future prospects. Expert Rev Anti Infect Ther 2013; 11:79-98. [PMID: 23428104 DOI: 10.1586/eri.12.148] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Human visceral leishmaniasis (VL) continues to be a life-threatening neglected tropical disease, with close to 200 million people at risk of infection globally. Epidemics and resurgence of VL are associated with negligence by the policy makers, economic decline and population movements. Control of the disease is hampered by the lack of proficient vaccination, rapid diagnosis in a field setting and severe side effects of current drug therapies. The diagnosis of VL relied largely on invasive techniques of detecting parasites in splenic and bone marrow aspirates. rK39 and PCR, despite problems related to varying sensitivities and specificities and field adaptability, respectively, are considered the best options for VL diagnosis today. No single therapy of VL currently offers satisfactory efficacy along with safety. The field of VL research only recently shifted toward actively identifying new drugs for safe and affordable treatment. Oral miltefosine and safe AmBisome along with better use of amphotericin B have been rapidly implemented in the last decade. A combination therapy will substantially reduce the required dose and duration of drug administration and reduce the chance of the development of resistance. In addition, identification of asymptomatic cases, vector control and treatment of post-kala-azar dermal leishmaniasis would allow new perspectives in VL control and management.
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Affiliation(s)
- Sarfaraz Ahmad Ejazi
- Infectious Diseases and Immunology Division, Indian Institute of Chemical Biology, 4 Raja S.C. Mullick Road, Kolkata 700032, India
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Macareo L, Lwin KM, Cheah PY, Yuentrakul P, Miller RS, Nosten F. Triangular test design to evaluate tinidazole in the prevention of Plasmodium vivax relapse. Malar J 2013; 12:173. [PMID: 23718705 PMCID: PMC3671156 DOI: 10.1186/1475-2875-12-173] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Accepted: 05/24/2013] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND There are very few drugs that prevent the relapse of Plasmodium vivax malaria in man. Tinidazole is a 5-nitroimidazole approved in the USA for the treatment of indications including amoebiasis and giardiasis. In the non-human primate relapsing Plasmodium cynomolgi/macaque malaria model, tinidazole cured one of six macaques studied with an apparent mild delay to relapse in the other five of 14-28 days compared to 11-12 days in controls. One study has demonstrated activity against P. vivax in man. Presented here are the results of a pilot phase II, randomized, open-label study conducted along the Thai-Myanmar border designed to evaluate the efficacy of tinidazole to prevent relapse of P. vivax when administered with chloroquine. METHODS This study utilized a modified triangular test sequential analysis which allows repeated statistical evaluation during the course of enrolment while maintaining a specified power and type 1 error and minimizing recruitment of subjects. Enrolment was to be halted when a pre-specified success/failure ratio was surpassed. The study was designed to have a 5% type 1 error and 90% power to show whether tinidazole would produce a relapse rate of less than 20% or greater than 45% through Day 63 of weekly follow-up after initiation of treatment and initial parasite clearance with 3 days of an oral weight based dosing of chloroquine and five days of 2 grams/day of tinidazole. RESULTS All subjects cleared their parasitaemia by Day 3. Six of the first seven subjects treated with tinidazole relapsed prior to Day 63 (average Day 48.3 (range 42-56)). This exceeded the upper boundary of the triangular test and enrolment to receive tinidazole was halted. A concurrent cohort of five subjects definitively treated with standard doses of primaquine and chloroquine (historically 100% effective) showed no episodes of recurrent P. vivax parasitaemia during the 63-day protocol specified follow-up period. CONCLUSIONS Tinidazole is ineffective in preventing relapse of P. vivax at the dose used. The macaque relapsing model appeared to correctly predict outcome in humans. Use of the modified triangular test allowed minimal enrolment and limited unnecessary exposure to the study drug and reduced costs. This adds weight to the ethical and economic advantages of this study design to evaluate similarly situated drugs. TRIAL REGISTRATION ClinicalTrials.gov NCT00811096.
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Affiliation(s)
- Louis Macareo
- Walter Reed Army Institute of Research, 503 Robert Grant Avenue, Silver Spring, MD 20910, USA
| | - Khin Maung Lwin
- Shoklo Malaria Research Unit, 68/30 Bantung Road, PO Box 46, Mae Sod 63110, Thailand
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Rd, Ratchathewi, Bangkok 10400, Thailand
| | - Phaik Yeong Cheah
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Rd, Ratchathewi, Bangkok 10400, Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, CCVTM, University of Oxford, Oxford OX3 7LJ, UK
| | - Prayoon Yuentrakul
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Rd, Ratchathewi, Bangkok 10400, Thailand
| | - R Scott Miller
- Walter Reed Army Institute of Research, 503 Robert Grant Avenue, Silver Spring, MD 20910, USA
| | - Francois Nosten
- Shoklo Malaria Research Unit, 68/30 Bantung Road, PO Box 46, Mae Sod 63110, Thailand
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Rd, Ratchathewi, Bangkok 10400, Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, CCVTM, University of Oxford, Oxford OX3 7LJ, UK
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Abstract
INTRODUCTION Leishmaniasis broadly manifests as visceral leishmaniasis (VL), cutaneous leishmaniasis (CL) and mucocutaneous leishmaniasis (MCL). The treatment of VL is challenging. The duration of treatment is long, and drugs are toxic thereby needing monitoring and hospitalization. AREAS COVERED Novel therapies such as single dose of liposomal amphotericin B (L-AmB) and multidrug therapy are important breakthrough for VL in the Indian subcontinent and have been recommended as the treatment of choice in this region. African Leishmania donovani is less susceptible to L-AmB, miltefosine and paromomycin as compared to the Indian strains, and the treatment of choice remains a 17-day combination therapy of pentavalent antimonials (SB(v)) and paromomycin. L-AmB at a total dose of 18 - 21 mg/kg is the recommended regimen in the Mediterranean region and South America. It is also the treatment of choice for HIV-VL coinfection. Treatment of CL should be decided by the clinical lesions, etiological species and its potential to develop into mucosal leishmaniasis. A literature search on treatment of leishmaniasis was done on PubMed and through Google. EXPERT OPINION There is an urgent need for exploratory studies with short course, highly efficient regimens such as single dose L-AmB or combination therapy for all the endemic regions of VL. Shorter and more acceptable regimens are needed for the treatment of post-kala-azar dermal leishmaniasis. Treatment of CL remains one of the neglected areas of leishmaniasis as data are scarce and drawn from uncontrolled studies.
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Affiliation(s)
- Shyam Sundar
- Banaras Hindu University, Institute of Medical Sciences, Department of Medicine, Varanasi 221 005, India.
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García-Hernández R, Manzano JI, Castanys S, Gamarro F. Leishmania donovani develops resistance to drug combinations. PLoS Negl Trop Dis 2012; 6:e1974. [PMID: 23285310 PMCID: PMC3527373 DOI: 10.1371/journal.pntd.0001974] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2012] [Accepted: 11/03/2012] [Indexed: 01/31/2023] Open
Abstract
Drug combinations for the treatment of leishmaniasis represent a promising and challenging chemotherapeutic strategy that has recently been implemented in different endemic areas. However, the vast majority of studies undertaken to date have ignored the potential risk that Leishmania parasites could develop resistance to the different drugs used in such combinations. As a result, this study was designed to elucidate the ability of Leishmania donovani to develop experimental resistance to anti-leishmanial drug combinations. The induction of resistance to amphotericin B/miltefosine, amphotericin B/paromomycin, amphotericin B/SbIII, miltefosine/paromomycin, and SbIII/paromomycin was determined using a step-wise adaptation process to increasing drug concentrations. Intracellular amastigotes resistant to these drug combinations were obtained from resistant L. donovani promastigote forms, and the thiol and ATP levels and the mitochondrial membrane potential of the resistant lines were analysed. Resistance to drug combinations was obtained after 10 weeks and remained in the intracellular amastigotes. Additionally, this resistance proved to be unstable. More importantly, we observed that promastigotes/amastigotes resistant to one drug combination showed a marked cross-resistant profile to other anti-leishmanial drugs. Additionally, the thiol levels increased in resistant lines that remained protected against the drug-induced loss of ATP and mitochondrial membrane potential. We have therefore demonstrated that different resistance patterns can be obtained in L. donovani depending upon the drug combinations used. Resistance to the combinations miltefosine/paromomycin and SbIII/paromomycin is easily obtained experimentally. These results have been validated in intracellular amastigotes, and have important relevance for ensuring the long-term efficacy of drug combinations. Leishmania is a protozoan parasite that infects human macrophages to produce the neglected tropical disease known as leishmaniasis. Chemotherapy is currently the only treatment option for leishmaniasis. First-line therapies include pentavalent antimonials, except in some regions in the Indian subcontinent, the liposomal formulation of amphotericin B, miltefosine and paromomycin. The WHO has recently recommended a combined therapy in order to extend the life expectancy of these compounds. However, resistance could be induced in Leishmania if this approach is not applied in a controlled and regulated way, thus resulting in a rapid loss of efficacy of not one but two therapeutic options. In light of this, we have designed relevant experimental studies in order to determine whether Leishmania parasites are able to develop resistance to the different potential anti-leishmanial drug combinations that will be used in the near future. The results obtained could help us to predict the success of drug combination therapy. Experimental resistance of Leishmania donovani promastigotes to drug combinations was obtained after 10 weeks and remained in the intracellular amastigotes. We therefore conclude that L. donovani can easily develop resistance to drug combinations mainly miltefosine/paromomycin and SbIII/paromomycin. These results have been validated in intracellular amastigotes and are of considerable interest for future prediction of the success of drug combination therapy.
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Affiliation(s)
- Raquel García-Hernández
- Instituto de Parasitología y Biomedicina “López-Neyra”, IPBLN-CSIC, Parque Tecnológico de Ciencias de la Salud, Granada, Spain
| | - José Ignacio Manzano
- Instituto de Parasitología y Biomedicina “López-Neyra”, IPBLN-CSIC, Parque Tecnológico de Ciencias de la Salud, Granada, Spain
| | - Santiago Castanys
- Instituto de Parasitología y Biomedicina “López-Neyra”, IPBLN-CSIC, Parque Tecnológico de Ciencias de la Salud, Granada, Spain
| | - Francisco Gamarro
- Instituto de Parasitología y Biomedicina “López-Neyra”, IPBLN-CSIC, Parque Tecnológico de Ciencias de la Salud, Granada, Spain
- * E-mail:
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Dorlo TPC, Balasegaram M, Beijnen JH, de Vries PJ. Miltefosine: a review of its pharmacology and therapeutic efficacy in the treatment of leishmaniasis. J Antimicrob Chemother 2012; 67:2576-97. [PMID: 22833634 DOI: 10.1093/jac/dks275] [Citation(s) in RCA: 487] [Impact Index Per Article: 40.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Miltefosine is an alkylphosphocholine drug with demonstrated activity against various parasite species and cancer cells as well as some pathogenic bacteria and fungi. For 10 years it has been licensed in India for the treatment of visceral leishmaniasis (VL), a fatal neglected parasitic disease. It is the first and still the only oral drug that can be used to treat VL and cutaneous leishmaniasis (CL). The standard 28 day miltefosine monotherapy regimen is well tolerated, except for mild gastrointestinal side effects, although its teratogenic potential severely hampers its general use in the clinic and roll-out in national elimination programmes. The pharmacokinetics of miltefosine are mainly characterized by its long residence time in the body, resulting in extensive drug accumulation during treatment and long elimination half-lives. At the moment, different combination therapy strategies encompassing miltefosine are being tested in multiple controlled clinical trials in various geographical areas of endemicity, both in South Asia and East Africa. We here review the most salient pre-clinical and clinical pharmacological aspects of miltefosine, its mechanism of action against Leishmania parasites and other pathogens, and provide a systematic overview of the efficacy and safety data from all clinical trials of miltefosine, either alone or in combination, in the treatment of VL and CL.
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Affiliation(s)
- Thomas P C Dorlo
- Center for Tropical Medicine and Travel Medicine, Division of Infectious Diseases, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
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Dorlo TPC, Balasegaram M, Lima MA, de Vries PJ, Beijnen JH, Huitema ADR. Translational pharmacokinetic modelling and simulation for the assessment of duration of contraceptive use after treatment with miltefosine. J Antimicrob Chemother 2012; 67:1996-2004. [DOI: 10.1093/jac/dks164] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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