Safety and efficacy of the choline analogue SAR97276 for malaria treatment: results of two phase 2, open-label, multicenter trials in African patients

Chemo-proteomics in antimalarial target identification and engagement

Humans have lived in tenuous battle with malaria over millennia. Today, while much of the world is free of the disease, areas of South America, Asia, and Africa still wage this war with substantial impacts on their social and economic development. The threat of widespread resistance to all currently available antimalarial therapies continues to raise concern. Therefore, it is imperative that novel antimalarial chemotypes be developed to populate the pipeline going forward. Phenotypic screening has been responsible for the majority of the new chemotypes emerging in the past few decades. However, this can result in limited information on the molecular target of these compounds which may serve as an unknown variable complicating their progression into clinical development. Target identification and validation is a process that incorporates techniques from a range of different disciplines. Chemical biology and more specifically chemo-proteomics have been heavily utilized for this purpose. This review provides an in-depth summary of the application of chemo-proteomics in antimalarial development. Here we focus particularly on the methodology, practicalities, merits, and limitations of designing these experiments. Together this provides learnings on the future use of chemo-proteomics in antimalarial development.

Novel Therapeutics for Malaria

Malaria is a potentially fatal disease caused by protozoan parasites of the genus Plasmodium. It is responsible for significant morbidity and mortality in endemic countries of the tropical and subtropical world, particularly in Africa, Southeast Asia, and South America. It is estimated that 247 million malaria cases and 619,000 deaths occurred in 2021 alone. The World Health Organization's (WHO) global initiative aims to reduce the burden of disease but has been massively challenged by the emergence of parasitic strains resistant to traditional and emerging antimalarial therapy. Therefore, development of new antimalarial drugs with novel mechanisms of action that overcome resistance in a safe and efficacious manner is urgently needed. Based on the evolving understanding of the physiology of Plasmodium, identification of potential targets for drug intervention has been made in recent years, resulting in more than 10 unique potential anti-malaria drugs added to the pipeline for clinical development. This review article will focus on current therapies as well as novel targets and therapeutics against malaria.

Specific sub fractions from Terminalia mantaly (H. Perrier) extracts potently inhibit Plasmodium falciparum rings, merozoite egress and invasion

ETHNOPHARMACOLOGICAL RELEVANCE

Terminalia mantaly (H. Perrier) and Terminalia superba (Engl. & Diels) are sources of treatment for various diseases, including malaria and/or related symptoms in parts of Southwestern Cameroon. However, there is limited information on the extent of the antiplasmodial potential of their extracts.

AIM OF THE STUDY

The present study was designed to investigate the antiplasmodial potential of chromatographic sub fractions (SFs) from promising fractions of Terminalia mantaly (Tm) [Tmsb^wChl, the chloroform fraction from water extract of Tm, IC₅₀ (μg/mL) PfINDO: 0.56, Pf3D7: 1.12; SI > 357 (HEK/PfINDO) & 178 (HEK/Pf3D7)] and Terminalia superba (Ts) [Tsr^mEA, the ethyl acetate fraction from methanolic extract of Ts, IC₅₀ (μg/mL) PfINDO: 1.82, Pf3D7: 1.65; SI > 109 (HEK/PfINDO) & 121 (HEK/Pf3D7)] obtained from previous studies. The SFs were tested against Plasmodium falciparum 3D7 (Pf3D7-chloroquine sensitive) and INDO (PfINDO-chloroquine resistant) strains in culture. Also, the phytochemical profile of potent SFs was determined and finally, the inhibition of the asexual blood stages of Plasmodium falciparum by the SFs with the highest promise was assessed.

MATERIAL AND METHODS

Selected SFs were submitted to a second bio-guided fractionation using silica gel column chromatography. The partial phytochemical composition of potent antiplasmodial SFs was determined using gas chromatography coupled to mass spectrometry (GC-MS). The SYBR Green I-based fluorescence microtiter plate assay was used to monitor the growth of Plasmodium falciparum parasites in culture in the presence or absence of extracts. Microscopy and flow cytometry counting was used to assess the Plasmodium falciparum stage-specific inhibition and post-drug exposure growth suppression by highly potent extracts.

RESULTS

Twenty-one of the 39 SFs afforded from Tmsb^wChl showed activity (IC₅₀: 0.29-4.74 μg/mL) against both Pf3D7 and PfINDO strains. Of note, eight SFs namely, Tm25, Tm28-30, Tm34-36 and Tm38, exerted highly potent antiplasmodial activity (IC₅₀ < 1 μg/mL) with IC₅₀PfINDO: 0.41-0.84 μg/mL and IC₅₀Pf3D7: 0.29-0.68 μg/mL. They also displayed very high selectivity (50 < SI_PfINDO, SI_Pf3D7 > 344) on the two Plasmodial strains. On the other hand, 7 SFs (SFs Ts03, Ts04, Ts06, Ts09, Ts10, Ts12 and Ts13) from Tsr^mEA showed promising inhibitory potential against both parasite strains (IC₅₀: 2.01-5.14 μg/mL). Sub fraction Tm36 (IC₅₀PfINDO: 0.41 μg/mL, SI_PfINDO > 243; IC₅₀Pf3D7: 0.29 μg/mL, SI_Pf3D7 > 344) showed the highest promise. The GC-MS analysis of the 8 selected SFs led to the identification of 99 phytometabolites, with D-limonene (2), benzaldehyde (12), carvone (13), caryophyllene (35), hexadecanoic acid, methyl ester (74) and 9-octadecenoic acid, methyl ester (82) being the main constituents. Sub fractions Tm28, Tm29, Tm30, Tm36 and Tm38 inhibited all the three intraerythrocytic stages of P. falciparum, with strong potency against ring stage development, merozoite egress and invasion processes.

CONCLUSIONS

This study has identified highly potent antiplasmodial SFs from Terminalia mantaly with significant activity on the intraerythrocytic development of Plasmodium falciparum. These SFs qualify as promising sources of novel antiplasmodial lead compounds. Further purification and characterization studies are expected to unravel molecular targets in rings and merozoites.

Antimalarial drug candidates in phase I and II drug development: a scoping review

The emergence and spread of parasite resistance to currently available antimalarials has highlighted the importance of developing novel antimalarials. This scoping review provides an overview of antimalarial drug candidates undergoing phase I and II studies between 1 January 2016 and 28 April 2021. PubMed, Web of Science, Embase, clinical trial registries, and reference lists were searched for relevant studies. Information regarding antimalarial compound details, clinical trial characteristics, study population, and drug pharmacokinetics and pharmacodynamics (PK-PD) were extracted. A total of 50 studies were included, of which 24 had published their results and 26 were unpublished. New antimalarial compounds were evaluated as monotherapy (28 studies, 14 drug candidates) and combination therapy (9 studies, 10 candidates). Fourteen active compounds were identified in the current antimalarial drug development pipeline together with 11 compounds that are inactive, 6 due to insufficient efficacy. PK-PD data were available from 24 studies published as open-access articles. Four unpublished studies have made their results publicly available on clinical trial registries. The terminal elimination half-life of new antimalarial compounds ranged from 14.7 to 483 h. The log₁₀ parasite reduction ratio over 48 h and parasite clearance half-life for Plasmodium falciparum following a single-dose monotherapy were 1.55 to 4.1 and 3.4 to 9.4 h, respectively. The antimalarial drug development landscape has seen a number of novel compounds, with promising PK-PD properties, evaluated in phase I and II studies over the past 5 years. Timely public disclosure of PK-PD data is crucial for informative decision-making and drug development strategy.

Antiprotozoal agents: How have they changed over a decade?

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.

Histone deacetylase inhibitors with high in vitro activities against Plasmodium falciparum isolates collected from Gabonese children and adults

Histone deacetylase (HDAC) enzymes are targets for the development of antimalarial drugs with a different mode of action to established antimalarials. Broad-spectrum HDAC-inhibitors show high potency against Plasmodium falciparum, but displayed some toxicity towards human cells. Inhibitors of human HDAC6 are new drug candidates with supposed reduced toxicity to human cells and favorable activities against laboratory P. falciparum strains. We investigated the potency of 12 peptoid-based HDAC-inhibitors against asexual stages of P. falciparum clinical isolates. Parasites representing different genetic backgrounds were isolated from adults and children with uncomplicated malaria in Gabon. Clinical studies on (non-HDAC-inhibitors) antimalarials, moreover, found lower drug efficacy in children, mainly attributed to acquired immunity with age in endemic areas. Therefore, we compared the in vitro sensitivity profiles of adult- and child-derived isolates to antimalarials (HDAC and standard drugs). All HDAC-inhibitors showed 50% inhibitory concentrations at nanomolar ranges with higher activities than the FDA approved reference HDAC-inhibitor SAHA. We propose peptoid-based HDAC6-inhibitors to be lead structures for further development as antimalarial chemotherapeutics. Our results further suggest no differences in activity of the tested antimalarials between P. falciparum parasites isolated from children and adults.

Evaluation of amidoxime derivatives as prodrug candidates of potent bis-cationic antimalarials

Plasmodium falciparum is responsible for most of the cases of malaria and its resistance to established antimalarial drugs is a major issue. Thus, new chemotherapies are needed to fight the emerging multi-drug resistance of P. falciparum malaria, like choline analogues targeting plasmodial phospholipidic metabolism. Here we describe the synthesis of amidoxime derivatives as prodrug candidates of reverse-benzamidines and hybrid compounds able to mimic choline, as well as the design of a new series of asymmetrical bis-cationic compounds. Bioconversion studies were conducted on amidoximes in asymmetrical series and showed that amidoxime prodrug strategy could be applied on C-alkylamidine moieties, like benzamidines and that N-substituents did not alter the bioconversion of amidoximes. The antimalarial activity of the three series of compounds was evaluated in vitro against P. falciparum and in vivo against P. vinckei petteri in mice.