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Zhang J, Li Y, Wan J, Zhang M, Li C, Lin J. Artesunate: A review of its therapeutic insights in respiratory diseases. Phytomedicine 2022; 104:154259. [PMID: 35849970 DOI: 10.1016/j.phymed.2022.154259] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 05/31/2022] [Accepted: 06/07/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Artesunate, as a semi-synthetic artemisinin derivative of sesquiterpene lactone, is widely used in clinical antimalarial treatment due to its endoperoxide group. Recent studies have found that artesunate may have multiple pharmacological effects, indicating its significant therapeutic potential in multiple respiratory diseases. PURPOSE This review aims to summarize proven and potential therapeutic effects of artesunate in common respiratory disorders. STUDY DESIGN This review summarizes the pharmacological properties of artesunate and then interprets the function of artesunate in various respiratory diseases in detail, such as bronchial asthma, chronic obstructive pulmonary disease, lung injury, lung cancer, pulmonary fibrosis, coronavirus disease 2019, etc., on different target cells and receptors according to completed and ongoing in silico, in vitro, and in vivo studies (including clinical trials). METHODS Literature was searched in electronic databases, including Pubmed, Web of Science and CNKI with the primary keywords of 'artesunate', 'pharmacology', 'pharmacokinetics', 'respiratory disorders', 'lung', 'pulmonary', and secondary search terms of 'Artemisia annua L.', 'artemisinin', 'asthma', 'chronic obstructive lung disease', 'lung injury', 'lung cancer', 'pulmonary fibrosis', 'COVID-19' and 'virus' in English and Chinese. All experiments were included. Reviews and irrelevant studies to the therapeutic effects of artesunate on respiratory diseases were excluded. Information was sort out according to study design, subject, intervention, and outcome. RESULTS Artesunate is promising to treat multiple common respiratory disorders via various mechanisms, such as anti-inflammation, anti-oxidative stress, anti-hyperresponsiveness, anti-proliferation, airway remodeling reverse, induction of cell death, cell cycle arrest, etc. CONCLUSION: Artesunate has great potential to treat various respiratory diseases.
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Affiliation(s)
- Jingyuan Zhang
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing 100-730, China; Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing 100-029, China
| | - Yun Li
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing 100-029, China; Beijing University of Chinese Medicine, Beijing 100-029, China
| | - Jingxuan Wan
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing 100-730, China; Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing 100-029, China
| | - Mengyuan Zhang
- Graduate School of Peking Union Medical College, Chinese Academy of Medical Sciences/Peking Union Medical College, Beijing 100-730, China; Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing 100-029, China
| | - Chunxiao Li
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing 100-029, China; Peking University China‑Japan Friendship School of Clinical Medicine, Beijing 100-029, China
| | - Jiangtao Lin
- Department of Pulmonary and Critical Care Medicine, Center of Respiratory Medicine, China-Japan Friendship Hospital, Beijing 100-029, China.
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Abstract
OBJECTIVE Dihydroartemisinin-Piperaquine (DHP) combination is the first-line treatment for uncomplicated malaria in Indonesia and has been used since 2010. This study was conducted to determine the efficacy of DHP combination for uncomplicated malaria treatment in a community-based evaluation. METHODS Recruitment was done by active or passive case detection. All uncomplicated malaria patients were treated with DHP once a day, for 3 days, administered orally (as is done in primary health care). Patients were followed up until day 28 post-treatment. The primary end point was a 28-day cure rate. RESULTS In this study, 484 subjects were screened through active and passive cases detection. A total of 45 subjects infected by P. vivax and 2 subjects infected by P. falciparum agreed to participate through written informed consent. There was no difference between clinical malaria and asymptomatic malaria in all analyzed characteristics. One patient had a D3 parasite density greater than 25% D0, although no parasites were found on the following day (D4). This study found 46 patients (97.9%) who had adequate clinical and parasitological responses. No adverse event was reported during the follow up of this study. CONCLUSION DHP was effective, safe, and well tolerated in the treatment of uncomplicated malaria at primary health care.
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Affiliation(s)
- Lambok Siahaan
- Universitas Sumatera Utara Medical Faculty, Department of Parasitology, Sumatera Utara, Indonesia
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Sacramento CQ, Fintelman-Rodrigues N, Dias SSG, Temerozo JR, Da Silva ADPD, da Silva CS, Blanco C, Ferreira AC, Mattos M, Soares VC, Pereira-Dutra F, Miranda MD, Barreto-Vieira DF, da Silva MAN, Santos SS, Torres M, Chaves OA, Rajoli RKR, Paccanaro A, Owen A, Bou-Habib DC, Bozza PT, Souza TML. Unlike Chloroquine, Mefloquine Inhibits SARS-CoV-2 Infection in Physiologically Relevant Cells. Viruses 2022; 14:v14020374. [PMID: 35215969 PMCID: PMC8874959 DOI: 10.3390/v14020374] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 01/25/2022] [Accepted: 02/03/2022] [Indexed: 11/17/2022] Open
Abstract
Despite the development of specific therapies against severe acute respiratory coronavirus 2 (SARS-CoV-2), the continuous investigation of the mechanism of action of clinically approved drugs could provide new information on the druggable steps of virus-host interaction. For example, chloroquine (CQ)/hydroxychloroquine (HCQ) lacks in vitro activity against SARS-CoV-2 in TMPRSS2-expressing cells, such as human pneumocyte cell line Calu-3, and likewise, failed to show clinical benefit in the Solidarity and Recovery clinical trials. Another antimalarial drug, mefloquine, which is not a 4-aminoquinoline like CQ/HCQ, has emerged as a potential anti-SARS-CoV-2 antiviral in vitro and has also been previously repurposed for respiratory diseases. Here, we investigated the anti-SARS-CoV-2 mechanism of action of mefloquine in cells relevant for the physiopathology of COVID-19, such as Calu-3 cells (that recapitulate type II pneumocytes) and monocytes. Molecular pathways modulated by mefloquine were assessed by differential expression analysis, and confirmed by biological assays. A PBPK model was developed to assess mefloquine's optimal doses for achieving therapeutic concentrations. Mefloquine inhibited SARS-CoV-2 replication in Calu-3, with an EC50 of 1.2 µM and EC90 of 5.3 µM. It reduced SARS-CoV-2 RNA levels in monocytes and prevented virus-induced enhancement of IL-6 and TNF-α. Mefloquine reduced SARS-CoV-2 entry and synergized with Remdesivir. Mefloquine's pharmacological parameters are consistent with its plasma exposure in humans and its tissue-to-plasma predicted coefficient points suggesting that mefloquine may accumulate in the lungs. Altogether, our data indicate that mefloquine's chemical structure could represent an orally available host-acting agent to inhibit virus entry.
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Affiliation(s)
- Carolina Q. Sacramento
- Laboratório de Imunofarmacologia, Oswaldo Cruz Institute, Fundação Oswaldo Cruz (Fiocruz), Rio de Janeiro 21040-360, RJ, Brazil; (N.F.-R.); (S.S.G.D.); (A.d.P.D.D.S.); (C.S.d.S.); (C.B.); (A.C.F.); (M.M.); (V.C.S.); (F.P.-D.); (O.A.C.); (P.T.B.)
- National Institute for Science and Technology on Innovation in Diseases of Neglected Populations (INCT/IDPN), Center for Technological Development in Health (CDTS), Fiocruz, Rio de Janeiro 21040-360, RJ, Brazil
- Correspondence: (C.Q.S.); (T.M.L.S.); Tel.: +55-21-2562-1311 (T.M.L.S.)
| | - Natalia Fintelman-Rodrigues
- Laboratório de Imunofarmacologia, Oswaldo Cruz Institute, Fundação Oswaldo Cruz (Fiocruz), Rio de Janeiro 21040-360, RJ, Brazil; (N.F.-R.); (S.S.G.D.); (A.d.P.D.D.S.); (C.S.d.S.); (C.B.); (A.C.F.); (M.M.); (V.C.S.); (F.P.-D.); (O.A.C.); (P.T.B.)
- National Institute for Science and Technology on Innovation in Diseases of Neglected Populations (INCT/IDPN), Center for Technological Development in Health (CDTS), Fiocruz, Rio de Janeiro 21040-360, RJ, Brazil
| | - Suelen S. G. Dias
- Laboratório de Imunofarmacologia, Oswaldo Cruz Institute, Fundação Oswaldo Cruz (Fiocruz), Rio de Janeiro 21040-360, RJ, Brazil; (N.F.-R.); (S.S.G.D.); (A.d.P.D.D.S.); (C.S.d.S.); (C.B.); (A.C.F.); (M.M.); (V.C.S.); (F.P.-D.); (O.A.C.); (P.T.B.)
| | - Jairo R. Temerozo
- National Institute for Science and Technology on Neuroimmunomodulation (INCT/NIM), Oswaldo Cruz Institute, Fiocruz, Rio de Janeiro 21040-360, RJ, Brazil; (J.R.T.); (D.C.B.-H.)
- Laboratory on Thymus Research, Oswaldo Cruz Institute, Fiocruz, Rio de Janeiro 21040-360, RJ, Brazil
| | - Aline de Paula D. Da Silva
- Laboratório de Imunofarmacologia, Oswaldo Cruz Institute, Fundação Oswaldo Cruz (Fiocruz), Rio de Janeiro 21040-360, RJ, Brazil; (N.F.-R.); (S.S.G.D.); (A.d.P.D.D.S.); (C.S.d.S.); (C.B.); (A.C.F.); (M.M.); (V.C.S.); (F.P.-D.); (O.A.C.); (P.T.B.)
- National Institute for Science and Technology on Innovation in Diseases of Neglected Populations (INCT/IDPN), Center for Technological Development in Health (CDTS), Fiocruz, Rio de Janeiro 21040-360, RJ, Brazil
| | - Carine S. da Silva
- Laboratório de Imunofarmacologia, Oswaldo Cruz Institute, Fundação Oswaldo Cruz (Fiocruz), Rio de Janeiro 21040-360, RJ, Brazil; (N.F.-R.); (S.S.G.D.); (A.d.P.D.D.S.); (C.S.d.S.); (C.B.); (A.C.F.); (M.M.); (V.C.S.); (F.P.-D.); (O.A.C.); (P.T.B.)
- National Institute for Science and Technology on Innovation in Diseases of Neglected Populations (INCT/IDPN), Center for Technological Development in Health (CDTS), Fiocruz, Rio de Janeiro 21040-360, RJ, Brazil
| | - Camilla Blanco
- Laboratório de Imunofarmacologia, Oswaldo Cruz Institute, Fundação Oswaldo Cruz (Fiocruz), Rio de Janeiro 21040-360, RJ, Brazil; (N.F.-R.); (S.S.G.D.); (A.d.P.D.D.S.); (C.S.d.S.); (C.B.); (A.C.F.); (M.M.); (V.C.S.); (F.P.-D.); (O.A.C.); (P.T.B.)
- National Institute for Science and Technology on Innovation in Diseases of Neglected Populations (INCT/IDPN), Center for Technological Development in Health (CDTS), Fiocruz, Rio de Janeiro 21040-360, RJ, Brazil
| | - André C. Ferreira
- Laboratório de Imunofarmacologia, Oswaldo Cruz Institute, Fundação Oswaldo Cruz (Fiocruz), Rio de Janeiro 21040-360, RJ, Brazil; (N.F.-R.); (S.S.G.D.); (A.d.P.D.D.S.); (C.S.d.S.); (C.B.); (A.C.F.); (M.M.); (V.C.S.); (F.P.-D.); (O.A.C.); (P.T.B.)
- National Institute for Science and Technology on Innovation in Diseases of Neglected Populations (INCT/IDPN), Center for Technological Development in Health (CDTS), Fiocruz, Rio de Janeiro 21040-360, RJ, Brazil
- Laboratório de Pesquisas Pré-Clínicas, Departamento de Ciências Biológicas, Universidade Iguaçu, Nova Iguaçu 26260-045, RJ, Brazil
| | - Mayara Mattos
- Laboratório de Imunofarmacologia, Oswaldo Cruz Institute, Fundação Oswaldo Cruz (Fiocruz), Rio de Janeiro 21040-360, RJ, Brazil; (N.F.-R.); (S.S.G.D.); (A.d.P.D.D.S.); (C.S.d.S.); (C.B.); (A.C.F.); (M.M.); (V.C.S.); (F.P.-D.); (O.A.C.); (P.T.B.)
- National Institute for Science and Technology on Innovation in Diseases of Neglected Populations (INCT/IDPN), Center for Technological Development in Health (CDTS), Fiocruz, Rio de Janeiro 21040-360, RJ, Brazil
| | - Vinicius C. Soares
- Laboratório de Imunofarmacologia, Oswaldo Cruz Institute, Fundação Oswaldo Cruz (Fiocruz), Rio de Janeiro 21040-360, RJ, Brazil; (N.F.-R.); (S.S.G.D.); (A.d.P.D.D.S.); (C.S.d.S.); (C.B.); (A.C.F.); (M.M.); (V.C.S.); (F.P.-D.); (O.A.C.); (P.T.B.)
- Program of Immunology and Inflammation, Federal University of Rio de Janeiro (UFRJ), Rio de Janeiro 21941-617, RJ, Brazil
| | - Filipe Pereira-Dutra
- Laboratório de Imunofarmacologia, Oswaldo Cruz Institute, Fundação Oswaldo Cruz (Fiocruz), Rio de Janeiro 21040-360, RJ, Brazil; (N.F.-R.); (S.S.G.D.); (A.d.P.D.D.S.); (C.S.d.S.); (C.B.); (A.C.F.); (M.M.); (V.C.S.); (F.P.-D.); (O.A.C.); (P.T.B.)
| | - Milene Dias Miranda
- Laboratório de Vírus Respiratório e do Sarampo, Oswaldo Cruz Institute, Fiocruz, Rio de Janeiro 21040-360, RJ, Brazil;
| | - Debora F. Barreto-Vieira
- Laboratório de Morfologia e Morfogênese Viral, Oswaldo Cruz Institute, Fiocruz, Rio de Janeiro 21040-360, RJ, Brazil; (D.F.B.-V.); (M.A.N.d.S.)
| | - Marcos Alexandre N. da Silva
- Laboratório de Morfologia e Morfogênese Viral, Oswaldo Cruz Institute, Fiocruz, Rio de Janeiro 21040-360, RJ, Brazil; (D.F.B.-V.); (M.A.N.d.S.)
| | - Suzana S. Santos
- School of Applied Mathematics, Fundação Getulio Vargas, Rio de Janeiro 22250-900, RJ, Brazil; (S.S.S.); (M.T.); (A.P.)
| | - Mateo Torres
- School of Applied Mathematics, Fundação Getulio Vargas, Rio de Janeiro 22250-900, RJ, Brazil; (S.S.S.); (M.T.); (A.P.)
| | - Otávio Augusto Chaves
- Laboratório de Imunofarmacologia, Oswaldo Cruz Institute, Fundação Oswaldo Cruz (Fiocruz), Rio de Janeiro 21040-360, RJ, Brazil; (N.F.-R.); (S.S.G.D.); (A.d.P.D.D.S.); (C.S.d.S.); (C.B.); (A.C.F.); (M.M.); (V.C.S.); (F.P.-D.); (O.A.C.); (P.T.B.)
- National Institute for Science and Technology on Innovation in Diseases of Neglected Populations (INCT/IDPN), Center for Technological Development in Health (CDTS), Fiocruz, Rio de Janeiro 21040-360, RJ, Brazil
| | - Rajith K. R. Rajoli
- Centre of Excellence in Long Acting Therapeutics (CELT), Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool L1 8JX, UK; (R.K.R.R.); (A.O.)
| | - Alberto Paccanaro
- School of Applied Mathematics, Fundação Getulio Vargas, Rio de Janeiro 22250-900, RJ, Brazil; (S.S.S.); (M.T.); (A.P.)
- Department of Computer Science, Royal Holloway, University of London, Egham WC1E 7HU, UK
| | - Andrew Owen
- Centre of Excellence in Long Acting Therapeutics (CELT), Department of Pharmacology and Therapeutics, University of Liverpool, Liverpool L1 8JX, UK; (R.K.R.R.); (A.O.)
| | - Dumith Chequer Bou-Habib
- National Institute for Science and Technology on Neuroimmunomodulation (INCT/NIM), Oswaldo Cruz Institute, Fiocruz, Rio de Janeiro 21040-360, RJ, Brazil; (J.R.T.); (D.C.B.-H.)
- Laboratory on Thymus Research, Oswaldo Cruz Institute, Fiocruz, Rio de Janeiro 21040-360, RJ, Brazil
| | - Patrícia T. Bozza
- Laboratório de Imunofarmacologia, Oswaldo Cruz Institute, Fundação Oswaldo Cruz (Fiocruz), Rio de Janeiro 21040-360, RJ, Brazil; (N.F.-R.); (S.S.G.D.); (A.d.P.D.D.S.); (C.S.d.S.); (C.B.); (A.C.F.); (M.M.); (V.C.S.); (F.P.-D.); (O.A.C.); (P.T.B.)
| | - Thiago Moreno L. Souza
- Laboratório de Imunofarmacologia, Oswaldo Cruz Institute, Fundação Oswaldo Cruz (Fiocruz), Rio de Janeiro 21040-360, RJ, Brazil; (N.F.-R.); (S.S.G.D.); (A.d.P.D.D.S.); (C.S.d.S.); (C.B.); (A.C.F.); (M.M.); (V.C.S.); (F.P.-D.); (O.A.C.); (P.T.B.)
- National Institute for Science and Technology on Innovation in Diseases of Neglected Populations (INCT/IDPN), Center for Technological Development in Health (CDTS), Fiocruz, Rio de Janeiro 21040-360, RJ, Brazil
- Correspondence: (C.Q.S.); (T.M.L.S.); Tel.: +55-21-2562-1311 (T.M.L.S.)
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Pernaute-Lau L, Camara M, Nóbrega de Sousa T, Morris U, Ferreira MU, Gil JP. An update on pharmacogenetic factors influencing the metabolism and toxicity of artemisinin-based combination therapy in the treatment of malaria. Expert Opin Drug Metab Toxicol 2022; 18:39-59. [PMID: 35285373 DOI: 10.1080/17425255.2022.2049235] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Artemisinin-based combination therapies (ACTs) are recommended first-line antimalarials for uncomplicated Plasmodium falciparum malaria. Pharmacokinetic/pharmacodynamic variation associated with ACT drugs and their effect is documented. It is accepted to an extent that inter-individual variation is genetically driven, and should be explored for optimized antimalarial use. AREAS COVERED We provide an update on the pharmacogenetics of ACT antimalarial disposition. Beyond presently used antimalarials, we also refer to information available for the most notable next-generation drugs under development. The bibliographic approach was based on multiple Boolean searches on PubMed covering all recent publications since our previous review. EXPERT OPINION The last 10 years have witnessed an increase in our knowledge of ACT pharmacogenetics, including the first clear examples of its contribution as an exacerbating factor for drug-drug interactions. This knowledge gap is still large and is likely to widen as a new wave of antimalarial drug is looming, with few studies addressing their pharmacogenetics. Clinically useful pharmacogenetic markers are still not available, in particular, from an individual precision medicine perspective. A better understanding of the genetic makeup of target populations can be valuable for aiding decisions on mass drug administration implementation concerning region-specific antimalarial drug and dosage options.
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Affiliation(s)
- Leyre Pernaute-Lau
- Department of Microbiology, Tumor and Cell biology, Karolinska Institutet, Solna, Sweden.,Faculty of Sciences, BioISI - Biosystems & Integrative Sciences Institute, University of Lisbon, Lisbon, 1749-016, Portugal
| | - Mahamadou Camara
- Department of Epidemiology of Parasitic Diseases, Faculty of Pharmacy, Malaria Research and Training Center, University of Science, Techniques and Technologies of Bamako, Bamako, Mali
| | - Taís Nóbrega de Sousa
- Molecular Biology and Malaria Immunology Research Group, Instituto René Rachou, Fundação Oswaldo Cruz (FIOCRUZ), Belo Horizonte, Brasil
| | - Ulrika Morris
- Department of Microbiology, Tumor and Cell biology, Karolinska Institutet, Solna, Sweden
| | - Marcelo Urbano Ferreira
- Faculty of Sciences, BioISI - Biosystems & Integrative Sciences Institute, University of Lisbon, Lisbon, 1749-016, Portugal.,Department of Parasitology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
| | - José Pedro Gil
- Department of Microbiology, Tumor and Cell biology, Karolinska Institutet, Solna, Sweden.,Faculty of Sciences, BioISI - Biosystems & Integrative Sciences Institute, University of Lisbon, Lisbon, 1749-016, Portugal.,Global Health and Tropical Medicine, Institute of Hygiene and Tropical Medicine, Nova University of Lisbon, Portugal
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Hu Y, Coates A. Mefloquine enhances the activity of colistin against antibiotic-resistant Enterobacterales in vitro and in an in vivo animal study. Int J Antimicrob Agents 2021; 57:106309. [PMID: 33609719 DOI: 10.1016/j.ijantimicag.2021.106309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 02/10/2021] [Accepted: 02/14/2021] [Indexed: 11/16/2022]
Abstract
Infections caused by carbapenem-resistant Enterobacterales are difficult to treat. Colistin is the last-resort drug for the treatment of these infections, however colistin resistance has emerged in animals and humans. This study investigated the in vitro efficacy of mefloquine in combination with colistin against 114 antibiotic-resistant Enterobacterales isolates including NDM-1, extended-spectrum β-lactamase (ESBL) and mcr-1 containing strains from a broad range of origins. The effect of the mefloquine and colistin combination was examined in vitro by chequerboard method and time-kill analysis and in vivo in a murine peritoneal infection model. The fractional inhibitory concentration index (FICI) of the combination indicated that synergy was detected for all NDM-1 and mcr-1 containing strains, 87.5% of ESBL producing Escherichia coli and 97.9% of ESBL producing Klebsiella pneumoniae strains. Time-kill curves demonstrated significant synergistic activity with low concentrations of colistin that were boosted by mefloquine. The combination showed enhanced activity against infection with NDM-1- or mcr-1 containing Enterobacteriaceae in mice at 4 h and 6 h after treatment. These findings suggest that the combination of mefloquine and colistin has the potential for rejuvenating the activity of colistin against multidrug-resistant Enterobacterales.
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Affiliation(s)
- Yanmin Hu
- Institute for Infection and Immunity, St George's, University of London, London, UK.
| | - Anthony Coates
- Institute for Infection and Immunity, St George's, University of London, London, UK; Helperby Therapeutics Group plc, London, UK
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Arshad U, Pertinez H, Box H, Tatham L, Rajoli RKR, Curley P, Neary M, Sharp J, Liptrott NJ, Valentijn A, David C, Rannard SP, O’Neill PM, Aljayyoussi G, Pennington SH, Ward SA, Hill A, Back DJ, Khoo SH, Bray PG, Biagini GA, Owen A. Prioritization of Anti-SARS-Cov-2 Drug Repurposing Opportunities Based on Plasma and Target Site Concentrations Derived from their Established Human Pharmacokinetics. Clin Pharmacol Ther 2020; 108:775-790. [PMID: 32438446 PMCID: PMC7280633 DOI: 10.1002/cpt.1909] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 05/18/2020] [Indexed: 12/13/2022]
Abstract
There is a rapidly expanding literature on the in vitro antiviral activity of drugs that may be repurposed for therapy or chemoprophylaxis against severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2). However, this has not been accompanied by a comprehensive evaluation of the target plasma and lung concentrations of these drugs following approved dosing in humans. Accordingly, concentration 90% (EC90 ) values recalculated from in vitro anti-SARS-CoV-2 activity data was expressed as a ratio to the achievable maximum plasma concentration (Cmax ) at an approved dose in humans (Cmax /EC90 ratio). Only 14 of the 56 analyzed drugs achieved a Cmax /EC90 ratio above 1. A more in-depth assessment demonstrated that only nitazoxanide, nelfinavir, tipranavir (ritonavir-boosted), and sulfadoxine achieved plasma concentrations above their reported anti-SARS-CoV-2 activity across their entire approved dosing interval. An unbound lung to plasma tissue partition coefficient (Kp Ulung ) was also simulated to derive a lung Cmax /half-maximal effective concentration (EC50 ) as a better indicator of potential human efficacy. Hydroxychloroquine, chloroquine, mefloquine, atazanavir (ritonavir-boosted), tipranavir (ritonavir-boosted), ivermectin, azithromycin, and lopinavir (ritonavir-boosted) were all predicted to achieve lung concentrations over 10-fold higher than their reported EC50 . Nitazoxanide and sulfadoxine also exceeded their reported EC50 by 7.8-fold and 1.5-fold in lung, respectively. This analysis may be used to select potential candidates for further clinical testing, while deprioritizing compounds unlikely to attain target concentrations for antiviral activity. Future studies should focus on EC90 values and discuss findings in the context of achievable exposures in humans, especially within target compartments, such as the lungs, in order to maximize the potential for success of proposed human clinical trials.
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Affiliation(s)
- Usman Arshad
- Department of Molecular and Clinical PharmacologyMaterials Innovation FactoryUniversity of LiverpoolLiverpoolUK
| | - Henry Pertinez
- Department of Molecular and Clinical PharmacologyMaterials Innovation FactoryUniversity of LiverpoolLiverpoolUK
| | - Helen Box
- Department of Molecular and Clinical PharmacologyMaterials Innovation FactoryUniversity of LiverpoolLiverpoolUK
| | - Lee Tatham
- Department of Molecular and Clinical PharmacologyMaterials Innovation FactoryUniversity of LiverpoolLiverpoolUK
| | - Rajith K. R. Rajoli
- Department of Molecular and Clinical PharmacologyMaterials Innovation FactoryUniversity of LiverpoolLiverpoolUK
| | - Paul Curley
- Department of Molecular and Clinical PharmacologyMaterials Innovation FactoryUniversity of LiverpoolLiverpoolUK
| | - Megan Neary
- Department of Molecular and Clinical PharmacologyMaterials Innovation FactoryUniversity of LiverpoolLiverpoolUK
| | - Joanne Sharp
- Department of Molecular and Clinical PharmacologyMaterials Innovation FactoryUniversity of LiverpoolLiverpoolUK
| | - Neill J. Liptrott
- Department of Molecular and Clinical PharmacologyMaterials Innovation FactoryUniversity of LiverpoolLiverpoolUK
| | - Anthony Valentijn
- Department of Molecular and Clinical PharmacologyMaterials Innovation FactoryUniversity of LiverpoolLiverpoolUK
| | - Christopher David
- Department of Molecular and Clinical PharmacologyMaterials Innovation FactoryUniversity of LiverpoolLiverpoolUK
| | | | | | - Ghaith Aljayyoussi
- Department of Tropical Disease BiologyLiverpool School of Tropical MedicineCentre for Drugs and DiagnosticsLiverpoolUK
| | - Shaun H. Pennington
- Department of Tropical Disease BiologyLiverpool School of Tropical MedicineCentre for Drugs and DiagnosticsLiverpoolUK
| | - Stephen A. Ward
- Department of Tropical Disease BiologyLiverpool School of Tropical MedicineCentre for Drugs and DiagnosticsLiverpoolUK
| | - Andrew Hill
- Department of Molecular and Clinical PharmacologyMaterials Innovation FactoryUniversity of LiverpoolLiverpoolUK
| | - David J. Back
- Department of Molecular and Clinical PharmacologyMaterials Innovation FactoryUniversity of LiverpoolLiverpoolUK
| | - Saye H. Khoo
- Department of Molecular and Clinical PharmacologyMaterials Innovation FactoryUniversity of LiverpoolLiverpoolUK
| | | | - Giancarlo A. Biagini
- Department of Tropical Disease BiologyLiverpool School of Tropical MedicineCentre for Drugs and DiagnosticsLiverpoolUK
| | - Andrew Owen
- Department of Molecular and Clinical PharmacologyMaterials Innovation FactoryUniversity of LiverpoolLiverpoolUK
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Chan XHS, Win YN, Haeusler IL, Tan JY, Loganathan S, Saralamba S, Chan SKS, Ashley EA, Barnes KI, Baiden R, Bassi PU, Djimde A, Dorsey G, Duparc S, Hanboonkunupakarn B, ter Kuile FO, Lacerda MVG, Nasa A, Nosten FH, Onyeji CO, Pukrittayakamee S, Siqueira AM, Tarning J, Taylor WRJ, Valentini G, van Vugt M, Wesche D, Day NPJ, Huang CLH, Brugada J, Price RN, White NJ. Factors affecting the electrocardiographic QT interval in malaria: A systematic review and meta-analysis of individual patient data. PLoS Med 2020; 17:e1003040. [PMID: 32134952 PMCID: PMC7058280 DOI: 10.1371/journal.pmed.1003040] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 02/05/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Electrocardiographic QT interval prolongation is the most widely used risk marker for ventricular arrhythmia potential and thus an important component of drug cardiotoxicity assessments. Several antimalarial medicines are associated with QT interval prolongation. However, interpretation of electrocardiographic changes is confounded by the coincidence of peak antimalarial drug concentrations with recovery from malaria. We therefore reviewed all available data to characterise the effects of malaria disease and demographic factors on the QT interval in order to improve assessment of electrocardiographic changes in the treatment and prevention of malaria. METHODS AND FINDINGS We conducted a systematic review and meta-analysis of individual patient data. We searched clinical bibliographic databases (last on August 21, 2017) for studies of the quinoline and structurally related antimalarials for malaria-related indications in human participants in which electrocardiograms were systematically recorded. Unpublished studies were identified by the World Health Organization (WHO) Evidence Review Group (ERG) on the Cardiotoxicity of Antimalarials. Risk of bias was assessed using the Pharmacoepidemiological Research on Outcomes of Therapeutics by a European Consortium (PROTECT) checklist for adverse drug events. Bayesian hierarchical multivariable regression with generalised additive models was used to investigate the effects of malaria and demographic factors on the pretreatment QT interval. The meta-analysis included 10,452 individuals (9,778 malaria patients, including 343 with severe disease, and 674 healthy participants) from 43 studies. 7,170 (68.6%) had fever (body temperature ≥ 37.5°C), and none developed ventricular arrhythmia after antimalarial treatment. Compared to healthy participants, patients with uncomplicated falciparum malaria had shorter QT intervals (-61.77 milliseconds; 95% credible interval [CI]: -80.71 to -42.83) and increased sensitivity of the QT interval to heart rate changes. These effects were greater in severe malaria (-110.89 milliseconds; 95% CI: -140.38 to -81.25). Body temperature was associated independently with clinically significant QT shortening of 2.80 milliseconds (95% CI: -3.17 to -2.42) per 1°C increase. Study limitations include that it was not possible to assess the effect of other factors that may affect the QT interval but are not consistently collected in malaria clinical trials. CONCLUSIONS Adjustment for malaria and fever-recovery-related QT lengthening is necessary to avoid misattributing malaria-disease-related QT changes to antimalarial drug effects. This would improve risk assessments of antimalarial-related cardiotoxicity in clinical research and practice. Similar adjustments may be indicated for other febrile illnesses for which QT-interval-prolonging medications are important therapeutic options.
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Affiliation(s)
- Xin Hui S. Chan
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Yan Naung Win
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Health and Diseases Control Unit, Naypyidaw, Myanmar
| | - Ilsa L. Haeusler
- WorldWide Antimalarial Research Network, Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Jireh Y. Tan
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Shanghavie Loganathan
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Christ Church College, University of Oxford, Oxford, United Kingdom
| | - Sompob Saralamba
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Shu Kiat S. Chan
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Singapore Armed Forces Medical Corps, Singapore
| | - Elizabeth A. Ashley
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Lao PDR
| | - Karen I. Barnes
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- WorldWide Antimalarial Resistance Network, Cape Town, South Africa
| | | | - Peter U. Bassi
- Department of Internal Medicine, Faculty of Clinical Sciences, College of Health Sciences, University of Abuja, Abuja, Nigeria
| | - Abdoulaye Djimde
- Malaria Research and Training Center, Department of Epidemiology of Parasitic Diseases, Faculty of Pharmacy, University of Science Techniques and Technologies of Bamako, Bamako, Mali
| | - Grant Dorsey
- Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
| | | | - Borimas Hanboonkunupakarn
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Feiko O. ter Kuile
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Marcus V. G. Lacerda
- Fundação de Medicina Tropical Dr Heitor Vieira Dourado, Manaus, Brazil
- Instituto Leônidas e Maria Deane (FIOCRUZ-Amazonas), Fundação Oswaldo Cruz, Manaus, Brazil
| | - Amit Nasa
- Sun Pharmaceutical Industries Ltd, Gurgaon, Haryana, India
| | - François H. Nosten
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | | | - Sasithon Pukrittayakamee
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- The Royal Society of Thailand, Dusit, Bangkok, Thailand
| | - André M. Siqueira
- Fundação de Medicina Tropical Dr Heitor Vieira Dourado, Manaus, Brazil
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Brazil
| | - Joel Tarning
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- WorldWide Antimalarial Research Network, Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Walter R. J. Taylor
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | | | - Michèle van Vugt
- Amsterdam University Medical Centers, Location Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - David Wesche
- Certara, Princeton, New Jersey, United States of America
| | - Nicholas P. J. Day
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | | | - Josep Brugada
- Cardiovascular Institute, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Ric N. Price
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - Nicholas J. White
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
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Antoszczak M, Markowska A, Markowska J, Huczyński A. Old wine in new bottles: Drug repurposing in oncology. Eur J Pharmacol 2020; 866:172784. [DOI: 10.1016/j.ejphar.2019.172784] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 11/05/2019] [Accepted: 11/07/2019] [Indexed: 02/07/2023]
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Kouakou YI, Tod M, Leboucher G, Lavoignat A, Bonnot G, Bienvenu AL, Picot S. Systematic review of artesunate pharmacokinetics: Implication for treatment of resistant malaria. Int J Infect Dis 2019; 89:30-44. [PMID: 31491558 DOI: 10.1016/j.ijid.2019.08.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 08/23/2019] [Accepted: 08/28/2019] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Artesunate (ART) is an artemisinin derivative used as monotherapy for the treatment of severe malaria and in combination with a partner drug for non-severe malaria. Resistance of malaria parasites to artemisinins have emerged in Southeast Asia. Adjustment of drug regimen may be an option to prevent therapeutic failures considering the relative favourable safety profile of ART high doses. METHODS For that purpose, a systematic review was done using PubMed, Scopus and Web of Science databases. All studies on ART and DHA pharmacokinetic post-administration of artesunate in human patients or volunteers were included. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist 2009 was used. FINDINGS Fifty studies exploring oral, intravenous, rectal, and intramuscular route (1470 persons, volunteers and patients) were included. Correlations between artesunate doses and Cmax or AUC0-∞ of dihydroartemisinin (DHA) and DHA+ART were evaluated. This correlation was good (R2>0.9) using intravenous (IV) route. DHA and ART+DHA average concentrations (Cav) were well above estimated in vivo half-maximal effective concentration (EC50) for intravenous route, but this was not the case for oral route. INTERPRETATION The favorable Cav/EC50 ratio for IV route provides evidence that IV ART will remain efficient even in the case of increased resistance level, whereas for the oral route, a two-fold increase in EC50 may lead to therapeutic failures, thus providing a rationale for oral dose escalation. Considering the inter-individual variability of ART pharmacokinetic, Therapeutic Drug Monitoring through antimalarial stewardship activities is needed to optimize drug exposure and avoid resistance development.
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Hanboonkunupakarn B, van der Pluijm RW, Hoglund R, Pukrittayakamee S, Winterberg M, Mukaka M, Waithira N, Chotivanich K, Singhasivanon P, White NJ, Dondorp AM, Tarning J, Jittamala P. Sequential Open-Label Study of the Safety, Tolerability, and Pharmacokinetic Interactions between Dihydroartemisinin-Piperaquine and Mefloquine in Healthy Thai Adults. Antimicrob Agents Chemother 2019; 63:e00060-19. [PMID: 31182525 DOI: 10.1128/AAC.00060-19] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 05/25/2019] [Indexed: 11/26/2022] Open
Abstract
Artemisinin-based combination therapies (ACTs) have contributed substantially to the global decline in Plasmodium falciparum morbidity and mortality, but resistance to artemisinins and their partner drugs is increasing in Southeast Asia, threatening malaria control. New antimalarial compounds will not be generally available soon. Artemisinin-based combination therapies (ACTs) have contributed substantially to the global decline in Plasmodium falciparum morbidity and mortality, but resistance to artemisinins and their partner drugs is increasing in Southeast Asia, threatening malaria control. New antimalarial compounds will not be generally available soon. Combining three existing antimalarials in the form of triple ACTs, including dihydroartemisinin (DHA)-piperaquine + mefloquine, is a potential treatment option for multidrug-resistant Plasmodium falciparum malaria. In a sequential open-label study, healthy Thai volunteers were treated with DHA-piperaquine (120 to 960 mg), mefloquine (500 mg), and DHA-piperaquine + mefloquine (120 to 960 mg + 500 mg), and serial symptom questionnaires, biochemistry, full blood counts, pharmacokinetic profiles, and electrocardiographic measurements were performed. Fifteen healthy subjects were enrolled. There was no difference in the incidence or severity of adverse events between the three treatment arms. The slight prolongation in QTc (QT interval corrected for heart rate) associated with DHA-piperaquine administration did not increase after administration of DHA-piperaquine + mefloquine. The addition of mefloquine had no significant effect on the pharmacokinetic properties of piperaquine. However, coadministration of mefloquine significantly reduced the exposures to dihydroartemisinin for area under the concentration-time curve (−22.6%; 90% confidence interval [CI], −33.1, −10.4; P = 0.0039) and maximum concentration of drug in serum (−29.0%; 90% CI, −40.6, −15.1; P = 0.0079). Mefloquine can be added safely to dihydroartemisinin-piperaquine in malaria treatment. (This study has been registered at ClinicalTrials.gov under identifier NCT02324738.)
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Guidi M, Mercier T, Aouri M, Decosterd LA, Csajka C, Ogutu B, Carn G, Kiechel JR. Population pharmacokinetics and pharmacodynamics of the artesunate-mefloquine fixed dose combination for the treatment of uncomplicated falciparum malaria in African children. Malar J 2019; 18:139. [PMID: 30999915 PMCID: PMC6471806 DOI: 10.1186/s12936-019-2754-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 03/29/2019] [Indexed: 12/02/2022] Open
Abstract
Background The World Health Organization (WHO) recommends combinations of an artemisinin derivative plus an anti-malarial drug of longer half-life as treatment options for uncomplicated Plasmodium falciparum infections. In Africa, artesunate–mefloquine (ASMQ) is an infrequently used artemisinin-based combination therapy (ACT) because of perceived poor tolerance to mefloquine. However, the WHO has recommended reconsideration of the use of ASMQ in Africa. In this large clinical study, the pharmacokinetics (PK) of a fixed dose combination of ASMQ was investigated in an African paediatric population to support dosing recommendations used in Southeast Asia and South America. Methods Among the 472 paediatric patients aged 6–59 months from six African centres included in the large clinical trial, a subset of 50 Kenyan children underwent intensive sampling to develop AS, its metabolite dihydroartemisinin (DHA) and MQ PK models. The final MQ PK model was validated using sparse data collected in the remaining participants (NONMEM®). The doses were one or two tablets containing 25/55 mg AS/MQ administered once a day for 3 days according to patients’ age. A sensitive LC–MS/MS method was used to quantify AS, DHA and MQ concentrations in plasma. An attempt was made to investigate the relationship between the absence/presence of malaria recrudescence and MQ area under the curve (AUC) using logistic regression. Results AS/DHA concentration–time profiles were best described using a one-compartment model for both compounds with irreversible AS conversion into DHA. AS/DHA PK were characterized by a significant degree of variability. Body weight affected DHA PK parameters. MQ PK was characterized by a two-compartment model and a large degree of variability. Allometric scaling of MQ clearances and volumes of distribution was used to depict the relationship between MQ PK and body weight. No association was found between the model predicted AUC and appearance of recrudescence. Conclusions The population pharmacokinetic models developed for both AS/DHA and MQ showed a large variability in drug exposure in the investigated African paediatric population. The largest contributor to this variability was body weight, which is accommodated for by the ASMQ fixed dose combination (FDC) dosing recommendation. Besides body weight considerations, there is no indication that the dosage should be modified in children with malaria compared to adults. Trial registration Pan African Clinical Trials Registry PACTR201202000278282 registration date 2011/02/16 Electronic supplementary material The online version of this article (10.1186/s12936-019-2754-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Monia Guidi
- School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland.,Laboratory and Service of Clinical Pharmacology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Thomas Mercier
- Laboratory and Service of Clinical Pharmacology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Manel Aouri
- Laboratory and Service of Clinical Pharmacology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Laurent A Decosterd
- Laboratory and Service of Clinical Pharmacology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Chantal Csajka
- School of Pharmaceutical Sciences, University of Geneva, University of Lausanne, Geneva, Switzerland.,Laboratory and Service of Clinical Pharmacology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | | | - Gwénaëlle Carn
- Drugs for Neglected Diseases initiative, Geneva, Switzerland
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Sugiarto SR, Davis TME, Salman S. Pharmacokinetic considerations for use of artemisinin-based combination therapies against falciparum malaria in different ethnic populations. Expert Opin Drug Metab Toxicol 2017; 13:1115-1133. [PMID: 29027504 DOI: 10.1080/17425255.2017.1391212] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Artemisinin-based combination therapy (ACT) is used extensively as first-line treatment for uncomplicated falciparum malaria. There has been no rigorous assessment of the potential for racial/ethnic differences in the pharmacokinetic properties of ACTs that might influence their efficacy. Areas covered: A comprehensive literature search was performed that identified 72 publications in which the geographical origin of the patients could be ascertained and the key pharmacokinetic parameters maximum drug concentration (Cmax), area under the plasma concentration-time curve (AUC) and elimination half-life (t½β) were available for one or more of the five WHO-recommended ACTs (artemether-lumefantrine, artesunate-amodiaquine, artesunate-mefloquine, dihydroartemisinin-piperaquine and artesunate-sulfadoxine-pyrimethamine). Comparisons of each of the three pharmacokinetic parameters of interest were made by drug (artemisinin derivative and long half-life partner), race/ethnicity (African, Asian, Caucasian, Melanesian, South American) and patient categories based on age and pregnancy status. Expert opinion: The review identified no evidence of a clinically significant influence of race/ethnicity on the pharmacokinetic properties of the nine component drugs in the five ACTs currently recommended by WHO for first-line treatment of uncomplicated falciparum malaria. This provides reassurance for health workers in malaria-endemic regions that ACTs can be given in recommended doses with the expectation of adequate blood concentrations regardless of race/ethnicity.
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Affiliation(s)
- Sri Riyati Sugiarto
- a Medical School , University of Western Australia, Fremantle Hospital , Fremantle , Australia
| | - Timothy M E Davis
- a Medical School , University of Western Australia, Fremantle Hospital , Fremantle , Australia
| | - Sam Salman
- a Medical School , University of Western Australia, Fremantle Hospital , Fremantle , Australia
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Zhang L, Chen F, Zhang Z, Chen Y, Wang J. Synthesis and biological evaluation of a novel artesunate–podophyllotoxin conjugate as anticancer agent. Bioorg Med Chem Lett 2016; 26:38-42. [DOI: 10.1016/j.bmcl.2015.11.042] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Revised: 08/17/2015] [Accepted: 11/13/2015] [Indexed: 12/11/2022]
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Ogutu B, Juma E, Obonyo C, Jullien V, Carn G, Vaillant M, Taylor WRJ, Kiechel JR. Fixed dose artesunate amodiaquine - a phase IIb, randomized comparative trial with non-fixed artesunate amodiaquine. Malar J 2014; 13:498. [PMID: 25515698 PMCID: PMC4302156 DOI: 10.1186/1475-2875-13-498] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Accepted: 12/06/2014] [Indexed: 12/03/2022] Open
Abstract
Background Pharmacokinetic (PK) and pharmacodynamic (PD) data are limited for artesunate (AS) and amodiaquine (AQ) in uncomplicated Plasmodium falciparum. Methods From 2007-8, 54 P. falciparum-infected, Kenyan adults were assigned randomly fixed dose (FD) ASAQ (n = 26) or non-fixed (NF) ASAQ (n = 28). Total doses were 600 mg AS (both arms) + 1,620 mg (FD) or 1,836 mg (NF)AQ. Follow-up extended over 28 days. PK data were collected for AS, dihydroartemisinin (DHA), AS + DHA combined as DHA equivalents (DHAeq), AQ, desethylamodiaquine (DAQ),and their relationships assessed against the PD collected data consisting of parasitological efficacy, adverse events (AEs), and the Bazett’s corrected QTinterval (QTcB). Results Mean AUC 0-72 of dihydroartemisinin equivalents (DHAeq) when administered as a fixed dose (FD) compared to NF dose were similar: 24.2 ±4.6 vs 26.4±6.9 µmol*h/L (p = 0.68) Parasite clearance rates were also similar after 24 hrs: 17/25 (68%) vs 18/28(64.3%) (p = 0.86),as well as at 48 hrs: 25/8 (100%)vs 26 (92.9%)/28 (p = 0.49). Mean FD vs NF DAQ AUC0-28 were 27.6±3.19 vs 32.7±5.53 mg*h/L (p = 0.0005). Two PCR-proven new infections occurred on Day (D) 28 for estimated, in vivo, DAQ minimum inhibitory concentrations of 15.2 and 27.5 ng/mL. Combining the FD and NF arms, the mean QTcB at D2+4 hrs increased significantly (p = 0.0059) vs baseline: 420 vs410 ms (∆ = 9.02 (95% confidence interval 2.72-15.31 ms), explained by falling heart rates, increasing DAQ concentrations and female sex in a general linear mixed effects model. Ten of 108 (9.26%) AEs (5/arm) reported by 37/54 (68.5%) patients were possibly or probably drug related. Severe, asymptomatic neutropaenia developed in 2/47 (4.25%) patients on D28: 574/µL (vsD0: 5,075/µL), and 777/µL (vsD0: 3,778/µL). Conclusions Tolerability of both formulations was good. For QTcB, a parameter for ECG modifications, increases were modest and due to rising DAQ concentrations and falling heart rates as malaria resolved. Rapid parasite clearance rates and no resistant infections suggest effective pharmacokinetics of both formulations. Electronic supplementary material The online version of this article (doi:10.1186/1475-2875-13-498) contains supplementary material, which is available to authorized users.
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Reuter SE, Upton RN, Evans AM, Navaratnam V, Olliaro PL. Population pharmacokinetics of orally administered mefloquine in healthy volunteers and patients with uncomplicated Plasmodium falciparum malaria. J Antimicrob Chemother 2014; 70:868-76. [PMID: 25377567 DOI: 10.1093/jac/dku430] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The determination of dosing regimens for the treatment of malaria is largely empirical and thus a better understanding of the pharmacokinetic/pharmacodynamic properties of antimalarial agents is required to assess the adequacy of current treatment regimens and identify sources of suboptimal dosing that could select for drug-resistant parasites. Mefloquine is a widely used antimalarial, commonly given in combination with artesunate. PATIENTS AND METHODS Mefloquine pharmacokinetics was assessed in 24 healthy adults and 43 patients with Plasmodium falciparum malaria administered mefloquine in combination with artesunate. Population pharmacokinetic modelling was conducted using NONMEM. RESULTS A two-compartment model with a single transit compartment and first-order elimination from the central compartment most adequately described mefloquine concentration-time data. The model incorporated population parameter variability for clearance (CL/F), central volume of distribution (VC/F) and absorption rate constant (KA) and identified, in addition to body weight, malaria infection as a covariate for VC/F (but not CL/F). Monte Carlo simulations predict that falciparum malaria infection is associated with a shorter elimination half-life (407 versus 566 h) and T>MIC (766 versus 893 h). CONCLUSIONS This is the first known population pharmacokinetic study to show falciparum malaria to influence mefloquine disposition. Protein binding, anaemia and other factors may contribute to differences between healthy individuals and patients. As VC/F is related to the earlier portion of the concentration-time profiles, which occurs during acute malaria, and CL/F is more related to the terminal phase during convalescence after treatment, this may explain why malaria was found to be a covariate for VC/F but not CL/F.
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Affiliation(s)
- Stephanie E Reuter
- School of Pharmacy & Medical Sciences, University of South Australia, Adelaide, SA, Australia Sansom Institute for Health Research, University of South Australia, Adelaide, SA, Australia
| | - Richard N Upton
- School of Pharmacy & Medical Sciences, University of South Australia, Adelaide, SA, Australia Sansom Institute for Health Research, University of South Australia, Adelaide, SA, Australia
| | - Allan M Evans
- School of Pharmacy & Medical Sciences, University of South Australia, Adelaide, SA, Australia Sansom Institute for Health Research, University of South Australia, Adelaide, SA, Australia
| | - Visweswaran Navaratnam
- Centre for Drug Research, Universiti Sains Malaysia, Penang, Malaysia Postgraduate, Research and Strategic Development, Taylor's University, Selangor, Malaysia
| | - Piero L Olliaro
- UNICEF/UNDP/World Bank/WHO Special Programme for Research & Training in Tropical Diseases (TDR), Geneva, Switzerland Centre for Tropical Medicine and Vaccinology, Nuffield Department of Medicine, University of Oxford, Churchill Hospital, Oxford, UK
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Zongo I, Somé FA, Somda SAM, Parikh S, Rouamba N, Rosenthal PJ, Tarning J, Lindegardh N, Nosten F, Ouédraogo JB. Efficacy and day 7 plasma piperaquine concentrations in African children treated for uncomplicated malaria with dihydroartemisinin-piperaquine. PLoS One 2014; 9:e103200. [PMID: 25133389 PMCID: PMC4136730 DOI: 10.1371/journal.pone.0103200] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2013] [Accepted: 06/24/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND One promising new Artemisinin-based combination therapies (ACTs) is dihydroartemisinin-piperaquine (DHA-PQ). However, the pharmacokinetics of piperaquine and the relationship between drug levels and clinical efficacy are incompletely characterized, particularly in children. METHODS We performed a single-arm open-label trial in Bobo-Dioulasso, Burkina Faso. A total of 379 participants aged 6 months or more with uncomplicated falciparum malaria were enrolled. Each participant received daily dose of DHA-PQ for three days and followed for 42 days. Parasitological efficacy was analyzed, considering rates of recrudescence and overall recurrence. PK was an exploratory endpoint and a priori, no sample size had been determined. Day 7 capillary and venous plasma concentrations of piperaquine were measured in children aged 2-10 years. RESULTS Of the 379 participants, 365 (96.3%) completed 42 days of follow-up. The median daily dose of PQ was 18.5 mg/kg [6.5-24]. Treatment with DHA-PQ was well tolerated with fever and parasitemia resolution within 48 hours in nearly all children. Recurrent malaria within 42 days of follow-up occurred in 31.3% (10/34) of children less than 2 years old, 16.0% (16/106) of those aged 2-5 years, 9.4% (15/160) of those aged 5-10 years, and none (0/68) of those over 10 years old. After genotyping, 3 of 41 recurrent episodes were recrudescence. An exploratory analysis shows that children with successful treatment outcomes had significantly higher median plasma concentrations of PQ compared to those with recurrent malaria within 42 days after therapy, considering either capillary samples (68 ng/ml [50-85] compared to 48 ng/ml [36-55], p<0.001) or venous samples (42 ng/ml [29-59] compared to 25 ng/ml [19-44], p<0.001). CONCLUSION DHA-PQ was effective for uncomplicated P. falciparum malaria treatment and offers an alternative to other ACTs. Recurrent malaria was mainly due to new infections after treatment and was correlated with low day 7 PQ concentration in the youngest patients. TRIAL REGISTRATION Controlled-Trials.com ISRCTN59761234.
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Affiliation(s)
- Issaka Zongo
- Direction Régionale de l'Ouest, Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso
| | - Fabrice A. Somé
- Direction Régionale de l'Ouest, Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso
| | - Serge A. M. Somda
- Non Transmissible disease department, Centre Muraz Bobo-Dioulasso, Bobo-Dioulasso, Burkina Faso
| | - Sunil Parikh
- Department of Medicine, Yale University School of Public Health, New Haven, Connecticut, United States of America
| | - Noel Rouamba
- Direction Régionale de l'Ouest, Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso
| | - Philip J. Rosenthal
- Department of Medicine, University of California San Francisco, San Francisco, California, United States of America
| | - Joel Tarning
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Niklas Lindegardh
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - François Nosten
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Jean Bosco Ouédraogo
- Direction Régionale de l'Ouest, Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso
- Non Transmissible disease department, Centre Muraz Bobo-Dioulasso, Bobo-Dioulasso, Burkina Faso
- * E-mail:
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Jullien V, Valecha N, Srivastava B, Sharma B, Kiechel JR. Population pharmacokinetics of mefloquine, administered as a fixed-dose combination of artesunate-mefloquine in Indian patients for the treatment of acute uncomplicated Plasmodium falciparum malaria. Malar J 2014; 13:187. [PMID: 24886117 PMCID: PMC4046089 DOI: 10.1186/1475-2875-13-187] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Accepted: 04/27/2014] [Indexed: 11/10/2022] Open
Abstract
Background Fixed-dose combinations of artemisinin combination therapy are strongly recommended to facilitate drug administration and compliance. New fixed-dose combinations must nevertheless be evaluated in relevant populations in terms of efficacy and pharmacokinetics. Methods A single-arm, open-label, clinical trial was performed in Indian patients with acute uncomplicated Plasmodium falciparum malaria to investigate the efficacy and the pharmacokinetics of mefloquine when combined with artesunate in a fixed-dose combination (400/200 mg of mefloquine base/artesunate). The pharmacokinetic analysis was performed using a population approach. Results Seventy-seven patients were included in the study. Mefloquine pharmacokinetics obeys a two-compartment model with first-order absorption and elimination. Mean parameter estimates (% inter-individual variability) were as follows: 0.16 h-1 (75%) for the absorption rate constant, 1.13 L/h (30%) for the apparent plasma clearance, 271 L (21%) for the apparent central distribution volume, 344 L (54%) for the apparent peripheral distribution volume, and 1.43 L/h for the apparent distribution clearance. These values were consistent with the pharmacokinetic results described in Thai patients. No significant covariate was found for clearance. Body weight explained the inter-individual variability of the apparent central and peripheral distribution volumes. The PCR-adjusted efficacy of the treatment was 100%. Conclusions The lack of significant covariate explaining the inter-individual variability of mefloquine clearance, combined with the excellent efficacy, supports the use of the standard 200/400 mg of artesunate-mefloquine fixed-dose combination in Indian patients with uncomplicated P. falciparum malaria. Trial Registration Clinical Trial Registration: ISRCTN70618692
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Affiliation(s)
| | | | | | | | - Jean-René Kiechel
- Drugs for Neglected Diseases initiative, 15 chemin Louis-Dunant, 1202 Geneva, Switzerland.
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19
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Johnston GL, Gething PW, Hay SI, Smith DL, Fidock DA. Modeling within-host effects of drugs on Plasmodium falciparum transmission and prospects for malaria elimination. PLoS Comput Biol 2014; 10:e1003434. [PMID: 24465196 PMCID: PMC3900379 DOI: 10.1371/journal.pcbi.1003434] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Accepted: 11/25/2013] [Indexed: 01/05/2023] Open
Abstract
Achieving a theoretical foundation for malaria elimination will require a detailed understanding of the quantitative relationships between patient treatment-seeking behavior, treatment coverage, and the effects of curative therapies that also block Plasmodium parasite transmission to mosquito vectors. Here, we report a mechanistic, within-host mathematical model that uses pharmacokinetic (PK) and pharmacodynamic (PD) data to simulate the effects of artemisinin-based combination therapies (ACTs) on Plasmodium falciparum transmission. To contextualize this model, we created a set of global maps of the fold reductions that would be necessary to reduce the malaria RC (i.e. its basic reproductive number under control) to below 1 and thus interrupt transmission. This modeling was applied to low-transmission settings, defined as having a R0<10 based on 2010 data. Our modeling predicts that treating 93–98% of symptomatic infections with an ACT within five days of fever onset would interrupt malaria transmission for ∼91% of the at-risk population of Southeast Asia and ∼74% of the global at-risk population, and lead these populations towards malaria elimination. This level of treatment coverage corresponds to an estimated 81–85% of all infected individuals in these settings. At this coverage level with ACTs, the addition of the gametocytocidal agent primaquine affords no major gains in transmission reduction. Indeed, we estimate that it would require switching ∼180 people from ACTs to ACTs plus primaquine to achieve the same transmission reduction as switching a single individual from untreated to treated with ACTs. Our model thus predicts that the addition of gametocytocidal drugs to treatment regimens provides very small population-wide benefits and that the focus of control efforts in Southeast Asia should be on increasing prompt ACT coverage. Prospects for elimination in much of Sub-Saharan Africa appear far less favorable currently, due to high rates of infection and less frequent and less rapid treatment. We utilize a within-host mathematical model of malaria transmission to predict the effects of antimalarial treatment across the globe. We predict that areas containing 91% of the at-risk population of Southeast Asia can achieve elimination if at least 93–98% of symptomatic individuals are promptly treated with effective artemisinin-based combination therapies (ACTs), based on assessments of treatment and transmission levels as of 2010. The benefit of attaining this level of coverage far outperforms that of adding additional gametocyte-specific transmission-blocking drugs to current ACTs. We advocate for elimination programs in Southeast Asia to focus on maximizing ACT coverage.
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Affiliation(s)
- Geoffrey L. Johnston
- Department of Microbiology and Immunology, Columbia University College of Physicians and Surgeons, New York, New York, United States of America
- School of International and Public Affairs, Columbia University, New York, New York, United States of America
- Bloomberg School of Public Health, John Hopkins University, Baltimore, Maryland, United States of America
| | - Peter W. Gething
- Spatial Ecology and Epidemiology Group, Department of Zoology, University of Oxford, Oxford, United Kingdom
| | - Simon I. Hay
- Spatial Ecology and Epidemiology Group, Department of Zoology, University of Oxford, Oxford, United Kingdom
| | - David L. Smith
- Bloomberg School of Public Health, John Hopkins University, Baltimore, Maryland, United States of America
- * E-mail: (DLS); (DAF)
| | - David A. Fidock
- Department of Microbiology and Immunology, Columbia University College of Physicians and Surgeons, New York, New York, United States of America
- Division of Infectious Diseases, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, United States of America
- * E-mail: (DLS); (DAF)
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20
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Wells S, Diap G, Kiechel JR. The story of artesunate-mefloquine (ASMQ), innovative partnerships in drug development: case study. Malar J 2013; 12:68. [PMID: 23433060 PMCID: PMC3640935 DOI: 10.1186/1475-2875-12-68] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Accepted: 01/17/2013] [Indexed: 11/21/2022] Open
Abstract
Background The Drugs for Neglected Diseases initiative (DNDi) is a not-for profit organization committed to providing affordable medicines and access to treatments in resource-poor settings. Traditionally drug development has happened “in house” within pharmaceutical companies, with research and development costs ultimately recuperated through drug sales. The development of drugs for the treatment of neglected tropical diseases requires a completely different model that goes beyond the scope of market-driven research and development. Artesunate and mefloquine are well-established drugs for the treatment of uncomplicated malaria, with a strong safety record based on many years of field-based studies and use. The administration of such artemisinin-based combination therapy in a fixed-dose combination is expected to improve patient compliance and to reduce the risk of emerging drug resistance. Case description DNDi developed an innovative approach to drug development, reliant on strong collaborations with a wide range of partners from the commercial world, academia, government institutions and NGOs, each of which had a specific role to play in the development of a fixed dose combination of artesunate and mefloquine. Discussion and evaluation DNDi undertook the development of a fixed-dose combination of artesunate with mefloquine. Partnerships were formed across five continents, addressing formulation, control and production through to clinical trials and product registration, resulting in a safe and efficacious fixed dose combination treatment which is now available to treat patients in resource-poor settings. The south-south technology transfer of production from Farmanguinhos/Fiocruz in Brazil to Cipla Ltd in India was the first of its kind. Of additional benefit was the increased capacity within the knowledge base and infrastructure in developing countries. Conclusions This collaborative approach to drug development involving international partnerships and independent funding mechanisms is a powerful new way to develop drugs for tropical diseases.
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Affiliation(s)
- Susan Wells
- Drugs for Neglected Diseases initiative, Geneva, Switzerland
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Duparc S, Borghini-Fuhrer I, Craft CJ, Arbe-Barnes S, Miller RM, Shin CS, Fleckenstein L. Safety and efficacy of pyronaridine-artesunate in uncomplicated acute malaria: an integrated analysis of individual patient data from six randomized clinical trials. Malar J 2013; 12:70. [PMID: 23433102 PMCID: PMC3598551 DOI: 10.1186/1475-2875-12-70] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2012] [Accepted: 02/18/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pyronaridine-artesunate (PA) is indicated for the treatment of acute uncomplicated Plasmodium falciparum and Plasmodium vivax malaria. METHODS Individual patient data on safety outcomes were integrated from six randomized clinical trials conducted in Africa and Asia in patients with microscopically confirmed P. falciparum (five studies) or P. vivax (one study) malaria. Efficacy against P. falciparum was evaluated across three Phase III clinical trials. RESULTS The safety population included 2,815 patients randomized to PA, 1,254 to comparators: mefloquine + artesunate (MQ + AS), artemether-lumefantrine (AL), or chloroquine. All treatments were generally well tolerated. Adverse events occurred in 57.2% (1,611/2,815) of patients with PA versus 51.5% (646/1,254) for comparators, most commonly (PA; comparators): headache (10.6%; 9.9%), cough (5.9%; 5.6%) and anaemia (4.5%; 2.9%). Serious averse events were uncommon for all treatments (0-0.7%). Transient increases in alanine aminotransferase and aspartate aminotransferase were observed with PA but did not lead to any clinical sequelae. For P. falciparum malaria, day-28 PCR-corrected adequate clinical and parasitological response with PA was 93.6% ([1,921/2,052] 95% CI 92.6, 94.7) in the intent-to-treat population and 98.5% ([1,852/1,880] 95% CI 98.0, 99.1) in the per-protocol population. Median parasite clearance time was 24.1 h with PA, 31.9 h with MQ + AS, and 24.0 h with AL. Median fever clearance time was 15.5 h with PA, 15.8 h with MQ + AS, and 14.0 h with AL. By day 42, P. falciparum gametocytes had declined to near zero for all treatments. CONCLUSIONS Pyronaridine-artesunate was well tolerated with no safety concerns with the exception of mostly mild transient rises in transaminases. Efficacy was high and met the requirements for use as first-line therapy. Pyronaridine-artesunate should be considered for inclusion in malaria treatment programmes. TRIAL REGISTRATION Clinicaltrials.gov: NCT00331136; NCT00403260; NCT00422084; NCT00440999; NCT00541385; NCT01594931.
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Affiliation(s)
- Stephan Duparc
- Medicines for Malaria Venture (MMV), International Center Cointrin, Route de Pré-Bois 20, PO Box 1826, CH-1215, Geneva 15, Switzerland.
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22
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Santelli AC, Ribeiro I, Daher A, Boulos M, Marchesini PB, dos Santos RLC, Lucena MBF, Magalhães I, Leon AP, Junger W, Ladislau JLB. Effect of artesunate-mefloquine fixed-dose combination in malaria transmission in Amazon basin communities. Malar J 2012; 11:286. [PMID: 22905900 PMCID: PMC3472241 DOI: 10.1186/1475-2875-11-286] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Accepted: 07/31/2012] [Indexed: 11/10/2022] Open
Abstract
Background Studies in South-East Asia have suggested that early diagnosis and treatment with artesunate (AS) and mefloquine (MQ) combination therapy may reduce the transmission of Plasmodium falciparum malaria and the progression of MQ resistance. Methods The effectiveness of a fixed-dose combination of AS and MQ (ASMQ) in reducing malaria transmission was tested in isolated communities of the Juruá valley in the Amazon region. Priority municipalities within the Brazilian Legal Amazon area were selected according to pre-specified criteria. Routine national malaria control programmatic procedures were followed. Existing health structures were reinforced and health care workers were trained to treat with ASMQ all confirmed falciparum malaria cases that match inclusion criteria. A local pharmacovigilance structure was implemented. Incidence of malaria and hospitalizations were recorded two years before, during, and after the fixed-dose ASMQ intervention. In total, between July 2006 and December 2008, 23,845 patients received ASMQ. Two statistical modelling approaches were applied to monthly time series of P. falciparum malaria incidence rates, P. falciparum/Plasmodium vivax infection ratio, and malaria hospital admissions rates. All the time series ranged from January 2004 to December 2008, whilst the intervention period span from July 2006 to December 2008. Results The ASMQ intervention had a highly significant impact on the mean level of each time series, adjusted for trend and season, of 0.34 (95%CI 0.20 – 0.58) for the P. falciparum malaria incidence rates, 0.67 (95%CI 0.50 – 0.89) for the P. falciparum/P. vivax infection ratio, and 0.53 (95%CI 0.41 – 0.69) for the hospital admission rates. There was also a significant change in the seasonal (or monthly) pattern of the time series before and after intervention, with the elimination of the malaria seasonal peak in the rainy months of the years following the introduction of ASMQ. No serious adverse events relating to the use of fixed-dose ASMQ were reported. Conclusions In the remote region of the Juruá valley, the early detection of malaria by health care workers and treatment with fixed-dose ASMQ was feasible and efficacious, and significantly reduced the incidence and morbidity of P. falciparum malaria.
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Affiliation(s)
- Ana C Santelli
- Programa Nacional de Controle da Malária, Secretaria de Vigilância emSaúde, Ministério da Saúde, Brazil
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Morris CA, Duparc S, Borghini-Fuhrer I, Jung D, Shin CS, Fleckenstein L. Review of the clinical pharmacokinetics of artesunate and its active metabolite dihydroartemisinin following intravenous, intramuscular, oral or rectal administration. Malar J 2011; 10:263. [PMID: 21914160 PMCID: PMC3180444 DOI: 10.1186/1475-2875-10-263] [Citation(s) in RCA: 140] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2011] [Accepted: 09/13/2011] [Indexed: 11/10/2022] Open
Abstract
Artesunate (AS) is a clinically versatile artemisinin derivative utilized for the treatment of mild to severe malaria infection. Given the therapeutic significance of AS and the necessity of appropriate AS dosing, substantial research has been performed investigating the pharmacokinetics of AS and its active metabolite dihydroartemisinin (DHA). In this article, a comprehensive review is presented of AS clinical pharmacokinetics following administration of AS by the intravenous (IV), intramuscular (IM), oral or rectal routes. Intravenous AS is associated with high initial AS concentrations which subsequently decline rapidly, with typical AS half-life estimates of less than 15 minutes. AS clearance and volume estimates average 2 - 3 L/kg/hr and 0.1 - 0.3 L/kg, respectively. DHA concentrations peak within 25 minutes post-dose, and DHA is eliminated with a half-life of 30 - 60 minutes. DHA clearance and volume average between 0.5 - 1.5 L/kg/hr and 0.5 - 1.0 L/kg, respectively. Compared to IV administration, IM administration produces lower peaks, longer half-life values, and higher volumes of distribution for AS, as well as delayed peaks for DHA; other parameters are generally similar due to the high bioavailability, assessed by exposure to DHA, associated with IM AS administration (> 86%). Similarly high bioavailability of DHA (> 80%) is associated with oral administration. Following oral AS, peak AS concentrations (Cmax) are achieved within one hour, and AS is eliminated with a half-life of 20 - 45 minutes. DHA Cmax values are observed within two hours post-dose; DHA half-life values average 0.5 - 1.5 hours. AUC values reported for AS are often substantially lower than those reported for DHA following oral AS administration. Rectal AS administration yields pharmacokinetic results similar to those obtained from oral administration, with the exceptions of delayed AS Cmax and longer AS half-life. Drug interaction studies conducted with oral AS suggest that AS does not appreciably alter the pharmacokinetics of atovaquone/proguanil, chlorproguanil/dapsone, or sulphadoxine/pyrimethamine, and mefloquine and pyronaridine do not alter the pharmacokinetics of DHA. Finally, there is evidence suggesting that the pharmacokinetics of AS and/or DHA following AS administration may be altered by pregnancy and by acute malaria infection, but further investigation would be required to define those alterations precisely.
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Affiliation(s)
- Carrie A Morris
- Pharmaceutical Sciences and Experimental Therapeutics, University of Iowa College of Pharmacy, 115 South Grand Avenue, Iowa City, IA 52242, USA
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Abstract
INTRODUCTION Plasmodium falciparum malaria is one of the world's most lethal infectious diseases, commanding millions of drug administrations per year. The pharmacogenetics of these drugs is poorly known, although its application can be pivotal for the optimized management of this disease. AREAS COVERED The main components of artemisinin combination therapy (ACT), the worldwide main antimalarial strategy, are metabolized by the polymorphic CYP3A4 (mefloquine, artemether, lumefantrine), CYP2C8 (amodiaquine), CYP2A6 (artesunate) and CYP1A1/2 (amodiaquine/desethylamodiaquine), with dihydroartemisinin being acted by Phase II UDP-glucuronosyltransferases. The worldwide adoption of ACT is leading to a large number of antimalarial treatments. Simultaneously, the feared development of parasite drug resistance might drive dosing increases. In these scenarios of increased drug exposure, pharmacogenetics can be a key tool supporting evidence-based medicine aiming for the longest possible useful lifespan of this important chemotherapy. EXPERT OPINION Translation in this moment is not operationally possible at an individual level, but large population studies are achievable for: i) the development of robust pharmacogenetics markers; and ii) the parallel development of a pharmacogenetic cartography of malaria settings. Advances in the understanding of antimalarial pharmacogenetics are urgent in order to protect the exposed populations, enhance the effectiveness of ACT and, consequently, contributing for the long aimed elimination of the disease.
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Affiliation(s)
- Rita Piedade
- Karolinska Institute, Division of Pharmacogenetics, Department of Physiology and Pharmacology, Stockholm, Sweden
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Krudsood S, Looareesuwan S, Wilairatama P, Leowattana W, Tangpukdee N, Chalermrut K, Ramanathan S, Navaratnam V, Olliaro P, Vaillant M, Kiechel JR, Taylor WRJ. Effect of artesunate and mefloquine in combination on the Fridericia corrected QT intervals in Plasmodium falciparum infected adults from Thailand. Trop Med Int Health 2011; 16:458-65. [PMID: 21219551 DOI: 10.1111/j.1365-3156.2010.02714.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To ascertain whether mefloquine (MQ) produces electrocardiogram (ECG) changes that could be a risk for Torsades de Pointe (TdP), a potentially malignant, ventricular tachyarrhythmia. METHODS We measured the Fridericia corrected QT (QTcF) intervals on 12 lead ECGs on days (D) 0, 3, 7 in Plasmodium falciparum infected adults, treated with oral artesunate (AS) and MQ as a new fixed dose (n = 25) combination or loose tablets (n = 25) over 3 days. Target total doses were 12 mg/kg of AS and 24-25 mg/kg of MQ. MQ concentrations ([MQ]) were measured by HPLC. RESULTS All ECG intervals were similar between drug arms and were combined for analysis. Mean QTcF values were 389 (D0), 407 (D3) and 399 (D7) ms (Ps < 0.003 vs. D0); corresponding heart rates and [MQ]s were 83, 67 and 73 beats/minute (Ps ≤ 0.0003 vs. D0) and 0, 3095 and 1721 ng/ml. One male patient (loose arm) had a D3 QTcF 504 ms (D0 406 ms, D7 433 ms). In the modelling of QTcF and JTcF from D0 to D7, significant effects were observed individually for [MQ], temperature and heart rate (HR). The MQ AUC(0-∞) was not a significant factor. Using a manual descending, model building approach to select variables, the HR was the only significant variable (P = 0.001) over time in the model that best explained the changes in the QTcF and JTcF intervals. CONCLUSIONS In this small group of patients, slowing heart rates due to malaria resolution best explained the observed increases in the QTcF intervals.
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Affiliation(s)
- S Krudsood
- Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
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