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Zorc B, Perković I, Pavić K, Rajić Z, Beus M. Primaquine derivatives: Modifications of the terminal amino group. Eur J Med Chem 2019; 182:111640. [PMID: 31472472 PMCID: PMC7126120 DOI: 10.1016/j.ejmech.2019.111640] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 08/21/2019] [Accepted: 08/21/2019] [Indexed: 02/07/2023]
Abstract
Numerous modifications of the well-known antimalarial drug primaquine, both at the quinoline ring and at the primary amino group, have been reported, mostly to obtain antimalarial agents with improved bioavailability, reduced toxicity and/or prolonged activity. Modifications of the terminal amino group were made with the main idea to prevent the metabolic pathway leading to inactive and toxic carboxyprimaquine (follow-on strategy), but also to get compounds with different activity (repurposing strategy). The modifications undertaken until 2009 were included in a review published in the same year. The present review covers various classes of primaquine N-derivatives with diverse biological profiles, prepared in the last decade by our research group as well as the others. We have summarized the synthetic procedures applied for their preparation and discussed the main biological results. Several hits for the development of novel antiplasmodial, anticancer, antimycobacterial and antibiofilm agents were identified.
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Affiliation(s)
- Branka Zorc
- University of Zagreb Faculty of Pharmacy and Biochemistry, Department of Medicinal Chemistry, A. Kovačića 1, HR-10 000, Zagreb, Croatia.
| | - Ivana Perković
- University of Zagreb Faculty of Pharmacy and Biochemistry, Department of Medicinal Chemistry, A. Kovačića 1, HR-10 000, Zagreb, Croatia
| | - Kristina Pavić
- University of Zagreb Faculty of Pharmacy and Biochemistry, Department of Medicinal Chemistry, A. Kovačića 1, HR-10 000, Zagreb, Croatia
| | - Zrinka Rajić
- University of Zagreb Faculty of Pharmacy and Biochemistry, Department of Medicinal Chemistry, A. Kovačića 1, HR-10 000, Zagreb, Croatia
| | - Maja Beus
- University of Zagreb Faculty of Pharmacy and Biochemistry, Department of Medicinal Chemistry, A. Kovačića 1, HR-10 000, Zagreb, Croatia
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52
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Plewes K, Leopold SJ, Kingston HWF, Dondorp AM. Malaria: What's New in the Management of Malaria? Infect Dis Clin North Am 2019; 33:39-60. [PMID: 30712767 DOI: 10.1016/j.idc.2018.10.002] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The global burden of malaria remains high, with 216 million cases causing 445,000 deaths in 2016 despite first-line treatment with artemisinin-based combination therapy. Decreasing transmission in Africa shifts the risk for severe malaria to older age groups as premunition wanes. Prompt diagnosis and treatment with intravenous artesunate in addition to appropriate supportive management are critical to reduce deaths from severe malaria. Effective individual management is challenging in settings with limited resources for higher-level care. Adjunctive therapies targeting the underlying pathophysiological pathways have the potential to reduce mortality. Resistance to artemisinin derivatives and their partner drugs threaten malaria management and control.
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Affiliation(s)
- Katherine Plewes
- Malaria Department, Mahidol Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, 3/F 60th, Anniversary Chalermprakiat Building, 420/6 Rajvithi Road, Bangkok 10400, Thailand; Department of Medicine, University of British Columbia, Vancouver General Hospital, 452D Heather Pavilion East, 2733 Heather Street, Vancouver, British Columbia V5Z 3J5, Canada
| | - Stije J Leopold
- Malaria Department, Mahidol Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, 3/F 60th, Anniversary Chalermprakiat Building, 420/6 Rajvithi Road, Bangkok 10400, Thailand
| | - Hugh W F Kingston
- Nuffield Department of Clinical Medicine, University of Oxford, Old Road Campus, Headington, Oxford OX3 7BN, UK; Malaria Department, Mahidol Oxford Research Unit, Faculty of Tropical Medicine, Mahidol University, 3/F 60th, Anniversary Chalermprakiat Building, 420/6 Rajvithi Road, Bangkok 10400, Thailand
| | - Arjen M Dondorp
- Nuffield Department of Clinical Medicine, University of Oxford, Old Road Campus, Headington, Oxford OX3 7BN, UK; Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, 3/F 60th, Anniversary Chalermprakiat Building, 420/6 Rajvithi Road, Bangkok 10400, Thailand.
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Abstract
Abstract
Primaquine (PQ) has long been recognized as the only effective drug in the treatment of hepatic stage malaria. However, severe toxicity limits its therapeutical application. Combining PQ with chloroquine (CQ) has been reported as enhancing the former’s efficacy, while simultaneously reducing its toxicity. In this study, the optimal conditions for encapsulating PQ-CQ in liposome, including incubation time, temperature and drug to lipid ratio, were identified. Furthermore, the effect of the loading combination of these two drugs on liposomal characteristics and the drug released from liposome was evaluated. Liposome is composed of HSPC, cholesterol and DSPE-mPEG2000 at a molar ratio of 55:40:5 and the drugs were loaded by means of the transmembrane pH gradient method. The particle size, ζ-potential and drug encapsulation efficiency were subsequently evaluated. The results showed that all liposome was produced with a similar particle size and ζ -potential. PQ and CQ could be optimally loaded into liposome by incubating the mixtures at 60°C for 20 minutes at a respective drug to lipid ratio of 1:3 for PQ and CQ. However, compared to single drug loading, dual-loading of PQ+CQ into liposome resulted in lower drug encapsulation and slower drug release. In conclusion, PQ and CQ can be jointly loaded into liposome with differing profiles of encapsulation and drug release.
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54
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Val F, Costa FT, King L, Brito-Sousa JD, Bassat Q, Monteiro WM, Siqueira AM, Luzzatto L, Lacerda MV. Tafenoquine for the prophylaxis, treatment and elimination of malaria: eagerness must meet prudence. Future Microbiol 2019; 14:1261-1279. [PMID: 31596137 DOI: 10.2217/fmb-2019-0202] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Malaria puts more than 3 billion people at risk of infection and causes high morbidity and mortality. Plasmodium vivax forms hypnozoites, which may initiate recurrences, even in the absence of reinfection or superinfection. Until recently, the only drug available for eliminating hypnozoites was primaquine (PQ), which, given its short half-life, requires a relatively long course of treatment. Tafenoquine (TQ) is a PQ analog with a longer half-life. This enables radical cure of malaria with a single dose and overcomes adherence issues associated with PQ, thereby increasing effectiveness in real-life settings. Clinical studies have provided sound evidence for TQ's safety and efficacy against malaria, which recently led to its approval by the US FDA. Here, we review aspects of TQ, including how to avoid hemolytic anemia in G6PD deficient patients. We believe that TQ promises to be a major advance toward malaria elimination.
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Affiliation(s)
- Fernando Val
- Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus, Amazonas, 69040-000, Brazil
| | - Fabio Tm Costa
- Universidade Estadual de Campinas (UNICAMP), Campinas, São Paulo, 13083-970, Brazil
| | - Liam King
- The Scripps Research Institute, La Jolla, CA 92037, USA
| | - Jose D Brito-Sousa
- Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus, Amazonas, 69040-000, Brazil.,Escola Superior de Ciências da Saúde,Universidade do Estado do Amazonas, Manaus, Amazonas, 69065-001, Brazil
| | - Quique Bassat
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, 08036, Spain.,Centro de Investigação em Saúde de Manhiça (CISM), Distrito da Manhiça, CP 1929, Maputo, Mozambique.,ICREA, Pg. Lluís Companys 23, Barcelona, 08010, Spain.,Pediatric Infectious Diseases Unit, Pediatrics Department, Hospital Sant Joan de Déu (University of Barcelona), Barcelona, 08950, Spain
| | - Wuelton M Monteiro
- Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus, Amazonas, 69040-000, Brazil.,Escola Superior de Ciências da Saúde,Universidade do Estado do Amazonas, Manaus, Amazonas, 69065-001, Brazil
| | - André M Siqueira
- Instituto Nacional de Infectologia Evandro Chagas, Fundação Oswaldo Cruz, Rio de Janeiro, Rio de Janeiro, 21040-360, Brazil
| | - Lucio Luzzatto
- Department of Hematology & Blood Transfusion, Muhimbili University of Health & Allied Sciences, Dar-es-Salaam, Tanzania
| | - Marcus Vg Lacerda
- Fundação de Medicina Tropical Doutor Heitor Vieira Dourado, Manaus, Amazonas, 69040-000, Brazil.,Instituto Leônidas e Maria Deane, FIOCRUZ-AM, Manaus, Amazonas, 69057-070, Brazil
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55
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Markus MB. Killing of Plasmodium vivax by Primaquine and Tafenoquine. Trends Parasitol 2019; 35:857-859. [PMID: 31522991 DOI: 10.1016/j.pt.2019.08.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 08/30/2019] [Indexed: 10/26/2022]
Abstract
Primaquine administration results in H2O2 accumulation in bone marrow, where gametocytes and asexual parasites are therefore killed. This finding, by Camarda et al., supports the theory that the nonperipheral blood origin of recurrent Plasmodium vivax malaria is both hypnozoites (relapse source) and merozoites (recrudescence source), not hypnozoites only.
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Affiliation(s)
- Miles B Markus
- School of Animal, Plant, and Environmental Sciences, Faculty of Science, University of Witwatersrand, Johannesburg, South Africa; Wits Research Institute for Malaria, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.
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56
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Smilkstein MJ, Pou S, Krollenbrock A, Bleyle LA, Dodean RA, Frueh L, Hinrichs DJ, Li Y, Martinson T, Munar MY, Winter RW, Bruzual I, Whiteside S, Nilsen A, Koop DR, Kelly JX, Kappe SHI, Wilder BK, Riscoe MK. ELQ-331 as a prototype for extremely durable chemoprotection against malaria. Malar J 2019; 18:291. [PMID: 31455339 PMCID: PMC6712883 DOI: 10.1186/s12936-019-2921-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 08/17/2019] [Indexed: 12/02/2022] Open
Abstract
Background The potential benefits of long-acting injectable chemoprotection (LAI-C) against malaria have been recently recognized, prompting a call for suitable candidate drugs to help meet this need. On the basis of its known pharmacodynamic and pharmacokinetic profiles after oral dosing, ELQ-331, a prodrug of the parasite mitochondrial electron transport inhibitor ELQ-300, was selected for study of pharmacokinetics and efficacy as LAI-C in mice. Methods Four trials were conducted in which mice were injected with a single intramuscular dose of ELQ-331 or other ELQ-300 prodrugs in sesame oil with 1.2% benzyl alcohol; the ELQ-300 content of the doses ranged from 2.5 to 30 mg/kg. Initial blood stage challenges with Plasmodium yoelii were used to establish the model, but the definitive study measure of efficacy was outcome after sporozoite challenge with a luciferase-expressing P. yoelii, assessed by whole-body live animal imaging. Snapshot determinations of plasma ELQ-300 concentration ([ELQ-300]) were made after all prodrug injections; after the highest dose of ELQ-331 (equivalent to 30 mg/kg ELQ-300), both [ELQ-331] and [ELQ-300] were measured at a series of timepoints from 6 h to 5½ months after injection. Results A single intramuscular injection of ELQ-331 outperformed four other ELQ-300 prodrugs and, at a dose equivalent to 30 mg/kg ELQ-300, protected mice against challenge with P. yoelii sporozoites for at least 4½ months. Pharmacokinetic evaluation revealed rapid and essentially complete conversion of ELQ-331 to ELQ-300, a rapidly achieved (< 6 h) and sustained (4–5 months) effective plasma ELQ-300 concentration, maximum ELQ-300 concentrations far below the estimated threshold for toxicity, and a distinctive ELQ-300 concentration versus time profile. Pharmacokinetic modeling indicates a high-capacity, slow-exchange tissue compartment which serves to accumulate and then slowly redistribute ELQ-300 into blood, and this property facilitates an extremely long period during which ELQ-300 concentration is sustained above a minimum fully-protective threshold (60–80 nM). Conclusions Extrapolation of these results to humans predicts that ELQ-331 should be capable of meeting and far-exceeding currently published duration-of-effect goals for anti-malarial LAI-C. Furthermore, the distinctive pharmacokinetic profile of ELQ-300 after treatment with ELQ-331 may facilitate durable protection and enable protection for far longer than 3 months. These findings suggest that ELQ-331 warrants consideration as a leading prototype for LAI-C.
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Affiliation(s)
- Martin J Smilkstein
- VA Portland Health Care System Research and Development Service, 3710 SW US Veterans Hospital Road, RD-33, Portland, OR, 97239, USA.
| | - Sovitj Pou
- VA Portland Health Care System Research and Development Service, 3710 SW US Veterans Hospital Road, RD-33, Portland, OR, 97239, USA
| | - Alina Krollenbrock
- Department of Physiology and Pharmacology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
| | - Lisa A Bleyle
- Bioanalytical Shared Resource Core Pharmacokinetics, Department of Physiology and Pharmacology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, L334, Portland, OR, 97239, USA
| | - Rozalia A Dodean
- VA Portland Health Care System Research and Development Service, 3710 SW US Veterans Hospital Road, RD-33, Portland, OR, 97239, USA.,Department of Chemistry, Portland State University, PO Box 751, Portland, OR, 97207, USA
| | - Lisa Frueh
- VA Portland Health Care System Research and Development Service, 3710 SW US Veterans Hospital Road, RD-33, Portland, OR, 97239, USA
| | - David J Hinrichs
- VA Portland Health Care System Research and Development Service, 3710 SW US Veterans Hospital Road, RD-33, Portland, OR, 97239, USA
| | - Yuexin Li
- VA Portland Health Care System Research and Development Service, 3710 SW US Veterans Hospital Road, RD-33, Portland, OR, 97239, USA
| | - Thomas Martinson
- Vaccine & Gene Therapy Institute (VGTI), Oregon Health and Science University (West Campus), 505 NW 185th Avenue, #1, Beaverton, OR, 97006, USA
| | - Myrna Y Munar
- Oregon State University/Oregon Health and Science University College of Pharmacy, 2730 SW Moody Avenue, CL5CP, Portland, OR, 97201, USA
| | - Rolf W Winter
- VA Portland Health Care System Research and Development Service, 3710 SW US Veterans Hospital Road, RD-33, Portland, OR, 97239, USA.,Department of Chemistry, Portland State University, PO Box 751, Portland, OR, 97207, USA
| | - Igor Bruzual
- VA Portland Health Care System Research and Development Service, 3710 SW US Veterans Hospital Road, RD-33, Portland, OR, 97239, USA
| | - Samantha Whiteside
- Center for Global Infectious Disease Research, Seattle Children's Research Institute, 307 Westlake Ave N., Suite 500, Seattle, WA, USA
| | - Aaron Nilsen
- VA Portland Health Care System Research and Development Service, 3710 SW US Veterans Hospital Road, RD-33, Portland, OR, 97239, USA
| | - Dennis R Koop
- Bioanalytical Shared Resource Core Pharmacokinetics, Department of Physiology and Pharmacology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, L334, Portland, OR, 97239, USA
| | - Jane X Kelly
- VA Portland Health Care System Research and Development Service, 3710 SW US Veterans Hospital Road, RD-33, Portland, OR, 97239, USA.,Department of Chemistry, Portland State University, PO Box 751, Portland, OR, 97207, USA
| | - Stefan H I Kappe
- Center for Global Infectious Disease Research, Seattle Children's Research Institute, 307 Westlake Ave N., Suite 500, Seattle, WA, USA
| | - Brandon K Wilder
- Vaccine & Gene Therapy Institute (VGTI), Oregon Health and Science University (West Campus), 505 NW 185th Avenue, #1, Beaverton, OR, 97006, USA
| | - Michael K Riscoe
- VA Portland Health Care System Research and Development Service, 3710 SW US Veterans Hospital Road, RD-33, Portland, OR, 97239, USA.,Department of Molecular Microbiology and Immunology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Portland, OR, 97239, USA
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Abstract
The technical genesis and practice of 8-aminoquinoline therapy of latent malaria offer singular scientific, clinical, and public health insights. The 8-aminoquinolines brought revolutionary scientific discoveries, dogmatic practices, benign neglect, and, finally, enduring promise against endemic malaria. The clinical use of plasmochin-the first rationally synthesized blood schizontocide and the first gametocytocide, tissue schizontocide, and hypnozoitocide of any kind-commenced in 1926. Plasmochin became known to sometimes provoke fatal hemolytic crises. World War II delivered a newer 8-aminoquinoline, primaquine, and the discovery of glucose-6-phosphate dehydrogenase (G6PD) deficiency as the basis of its hemolytic toxicity came in 1956. Primaquine nonetheless became the sole therapeutic option against latent malaria. After 40 years of fitful development, in 2018 the U.S. Food and Drug Administration registered the 8-aminoquinoline called tafenoquine for the prevention of all malarias and the treatment of those that relapse. Tafenoquine also cannot be used in G6PD-unknown or -deficient patients. The hemolytic toxicity of the 8-aminoquinolines impedes their great potential, but this problem has not been a research priority. This review explores the complex technical dimensions of the history of 8-aminoquinolines. The therapeutic principles thus examined may be leveraged in improved practice and in understanding the bright prospect of discovery of newer drugs that cannot harm G6PD-deficient patients.
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58
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Mayence A, Vanden Eynde JJ. Tafenoquine: A 2018 Novel FDA-Approved Prodrug for the Radical Cure of Plasmodium vivax Malaria and Prophylaxis of Malaria. Pharmaceuticals (Basel) 2019; 12:ph12030115. [PMID: 31366060 PMCID: PMC6789594 DOI: 10.3390/ph12030115] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 07/25/2019] [Accepted: 07/27/2019] [Indexed: 12/18/2022] Open
Abstract
Tafenoquine (an 8-aminoquinoline) was approved by the Food and Drug Administration (FDA) in 2018 for the radical cure of Plasmodium vivax malaria and preventive action against malaria. Despite the fact that the mechanism of action of the drug remains unclear, all studies indicated that a metabolite is responsible for its efficacy. Routes for the preparation of the drug are described.
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Affiliation(s)
- Annie Mayence
- Haute Ecole Provinciale de Hainaut-Condorcet, 7330 Saint-Ghislain, Belgium
| | - Jean Jacques Vanden Eynde
- Formerly head of the Department of Organic Chemistry (FS), University of Mons-UMONS, 7000 Mons, Belgium.
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59
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Camarda G, Jirawatcharadech P, Priestley RS, Saif A, March S, Wong MHL, Leung S, Miller AB, Baker DA, Alano P, Paine MJI, Bhatia SN, O'Neill PM, Ward SA, Biagini GA. Antimalarial activity of primaquine operates via a two-step biochemical relay. Nat Commun 2019; 10:3226. [PMID: 31324806 PMCID: PMC6642103 DOI: 10.1038/s41467-019-11239-0] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Accepted: 07/02/2019] [Indexed: 12/29/2022] Open
Abstract
Primaquine (PQ) is an essential antimalarial drug but despite being developed over 70 years ago, its mode of action is unclear. Here, we demonstrate that hydroxylated-PQ metabolites (OH-PQm) are responsible for efficacy against liver and sexual transmission stages of Plasmodium falciparum. The antimalarial activity of PQ against liver stages depends on host CYP2D6 status, whilst OH-PQm display direct, CYP2D6-independent, activity. PQ requires hepatic metabolism to exert activity against gametocyte stages. OH-PQm exert modest antimalarial efficacy against parasite gametocytes; however, potency is enhanced ca.1000 fold in the presence of cytochrome P450 NADPH:oxidoreductase (CPR) from the liver and bone marrow. Enhancement of OH-PQm efficacy is due to the direct reduction of quinoneimine metabolites by CPR with the concomitant and excessive generation of H2O2, leading to parasite killing. This detailed understanding of the mechanism paves the way to rationally re-designed 8-aminoquinolines with improved pharmacological profiles. Primaquine (PQ) is a widely used anti-malaria drug, but its mechanism of action is unclear. Here, Camarda et al. show that PQ’s activity against liver and sexual Plasmodium stages depends on generation of hydroxylated-PQ metabolites (OH-PQm), which, undergoing further reactions, results in production of H2O2.
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Affiliation(s)
- Grazia Camarda
- Centre for Drugs and Diagnostics Research, Tropical Disease Biology Department, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
| | - Piyaporn Jirawatcharadech
- Centre for Drugs and Diagnostics Research, Tropical Disease Biology Department, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
| | - Richard S Priestley
- Centre for Drugs and Diagnostics Research, Tropical Disease Biology Department, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK.,ARUK Oxford Drug Discovery Institute, University of Oxford, Oxford, OX3 7FZ, UK
| | - Ahmed Saif
- Centre for Drugs and Diagnostics Research, Tropical Disease Biology Department, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK.,Clinical Laboratory sciences Department, College of Applied Medical Sciences, Najran University, Najran, 61441, Saudi Arabia
| | - Sandra March
- Health Sciences and Technology/Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
| | - Michael H L Wong
- Department of Chemistry, University of Liverpool, Liverpool, L69 7ZD, UK
| | - Suet Leung
- Department of Chemistry, University of Liverpool, Liverpool, L69 7ZD, UK
| | - Alex B Miller
- Health Sciences and Technology/Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
| | - David A Baker
- Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Pietro Alano
- Dipartimento di Malattie Infettive, Istituto Superiore di Sanità, Rome, 00161, Italy
| | - Mark J I Paine
- Vector Biology Department, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
| | - Sangeeta N Bhatia
- Health Sciences and Technology/Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, 02139, USA
| | - Paul M O'Neill
- Department of Chemistry, University of Liverpool, Liverpool, L69 7ZD, UK
| | - Stephen A Ward
- Centre for Drugs and Diagnostics Research, Tropical Disease Biology Department, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK
| | - Giancarlo A Biagini
- Centre for Drugs and Diagnostics Research, Tropical Disease Biology Department, Liverpool School of Tropical Medicine, Liverpool, L3 5QA, UK.
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60
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Antimalarial Drugs for Malaria Elimination. Methods Mol Biol 2019. [PMID: 31267500 DOI: 10.1007/978-1-4939-9550-9_11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
Abstract
The diversity of Anopheles species and the environmental issues posed by the large-scale use of insecticides make it unlikely that malaria elimination will be achieved by fighting mosquitoes only. Malaria elimination necessitates targeting the parasite itself. For this, in the absence of efficient vaccines against the disease, antimalarial drugs remain the primary tool. We present here the limitations of currently available antimalarials and the different implementation strategies of these drugs, which ultimately depends on the epidemiological context of the disease.
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Raman J, Allen E, Workman L, Mabuza A, Swanepoel H, Malatje G, Frean J, Wiesner L, Barnes KI. Safety and tolerability of single low-dose primaquine in a low-intensity transmission area in South Africa: an open-label, randomized controlled trial. Malar J 2019; 18:209. [PMID: 31234865 PMCID: PMC6592007 DOI: 10.1186/s12936-019-2841-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 06/17/2019] [Indexed: 12/13/2022] Open
Abstract
Background To reduce onward falciparum malaria transmission, the World Health Organization recommends adding single low-dose (SLD) primaquine to artemisinin-based combination treatment in low transmission areas. However, uptake of this recommendation has been relatively slow given concerns about whether individual risks justify potential community benefit. This study was undertaken to generate comprehensive local data on the risk–benefit profile of SLD primaquine deployment in a pre-elimination area in South Africa. Methods This randomized, controlled open-label trial investigated adding a single low primaquine dose on day 3 to standard artemether–lumefantrine treatment for uncomplicated falciparum malaria. Efficacy, safety and tolerability of artemether–lumefantrine and primaquine treatment were assessed on days 3, 7, 14, 28 and 42. Lumefantrine concentrations were assayed from dried blood spot samples collected on day 7. Results Of 217 patients screened, 166 were enrolled with 140 randomized on day 3, 70 to each study arm (primaquine and no primaquine). No gametocytes were detected by either microscopy or PCR in any of the follow-up samples collected after randomization on day 3, precluding assessment of primaquine efficacy. Prevalence of the CYP2D6*4, CYP2D6*10 and CYP2D6*17 mutant alleles was low with allelic frequencies of 0.02, 0.11 and 0.16, respectively; none had the CYP2D6*4/*4 variant associated with null activity. Among 172 RDT-positive patients G6PD-genotyped, 24 (14%) carried the G6PD deficient (A−) variant. Median haemoglobin concentrations were similar between treatment arms throughout follow-up. A third of participants had a haemoglobin drop > 2 g/dL; this was not associated with primaquine treatment but may be associated with G6PD genotype [52.9% (9/17) with A− genotype vs. 31% (36/116) with other genotypes (p = 0.075)]. Day 7 lumefantrine concentrations and the number and nature of adverse events were similar between study arms; only one serious adverse event occurred (renal impairment in the no primaquine arm). The artemether–lumefantrine PCR-corrected adequate clinical and parasitological response rate was 100%, with only one re-infection found among the 128 patients who completed 42-day follow-up. Conclusions Safety, tolerability, CYP2D6 and G6PD variant data from this study support the deployment of the WHO-recommended SLD primaquine without G6PD testing to advance malaria elimination in South African districts with low-intensity residual transmission. Trial registration Pan African Clinical Trial Registry, PACTR201611001859416. Registered 11 November 2016, https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=1859
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Affiliation(s)
- Jaishree Raman
- Parasitology Reference Laboratory, National Institute for Communicable Diseases, A Division of the National Health Laboratory Services, Johannesburg, South Africa.,Wits Research Institute for Malaria, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.,UCT/MRC Collaborating Centre for Optimising Antimalarial Therapy, University of Cape Town, Cape Town, South Africa
| | - Elizabeth Allen
- UCT/MRC Collaborating Centre for Optimising Antimalarial Therapy, University of Cape Town, Cape Town, South Africa.,Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Lesley Workman
- UCT/MRC Collaborating Centre for Optimising Antimalarial Therapy, University of Cape Town, Cape Town, South Africa.,Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Aaron Mabuza
- UCT/MRC Collaborating Centre for Optimising Antimalarial Therapy, University of Cape Town, Cape Town, South Africa.,Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa.,Mpumalanga Provincial Malaria Elimination Programme, Mpumalanga, South Africa
| | - Hendrik Swanepoel
- UP Institute for Sustainable Malaria Control and MRC Collaborating Centre for Malaria Research, University of Pretoria, Pretoria, South Africa
| | - Gillian Malatje
- Mpumalanga Provincial Malaria Elimination Programme, Mpumalanga, South Africa
| | - John Frean
- Parasitology Reference Laboratory, National Institute for Communicable Diseases, A Division of the National Health Laboratory Services, Johannesburg, South Africa.,Wits Research Institute for Malaria, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Lubbe Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Karen I Barnes
- UCT/MRC Collaborating Centre for Optimising Antimalarial Therapy, University of Cape Town, Cape Town, South Africa. .,Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa.
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Monitoring the Efficacy of Chloroquine-Primaquine Therapy for Uncomplicated Plasmodium vivax Malaria in the Main Transmission Hot Spot of Brazil. Antimicrob Agents Chemother 2019; 63:AAC.01965-18. [PMID: 30782991 DOI: 10.1128/aac.01965-18] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 02/10/2019] [Indexed: 12/15/2022] Open
Abstract
Emerging Plasmodium vivax resistance to chloroquine (CQ) may undermine malaria elimination efforts in South America. CQ-resistant P. vivax has been found in the major port city of Manaus but not in the main malaria hot spots across the Amazon Basin of Brazil, where CQ is routinely coadministered with primaquine (PQ) for radical cure of vivax malaria. Here we randomly assigned 204 uncomplicated vivax malaria patients from Juruá Valley, northwestern Brazil, to receive either sequential (arm 1) or concomitant (arm 2) CQ-PQ treatment. Because PQ may synergize the blood schizontocidal effect of CQ and mask low-level CQ resistance, we monitored CQ-only efficacy in arm 1 subjects, who had PQ administered only at the end of the 28-day follow-up. We found adequate clinical and parasitological responses in all subjects assigned to arm 2. However, 2.2% of arm 1 patients had microscopy-detected parasite recrudescences at day 28. When PCR-detected parasitemias at day 28 were considered, response rates decreased to 92.1% and 98.8% in arms 1 and 2, respectively. Therapeutic CQ levels were documented in 6 of 8 recurrences, consistent with true CQ resistance in vivo In contrast, ex vivo assays provided no evidence of CQ resistance in 49 local P. vivax isolates analyzed. CQ-PQ coadministration was not found to potentiate the antirelapse efficacy of PQ over 180 days of surveillance; however, we suggest that larger studies are needed to examine whether and how CQ-PQ interactions, e.g., CQ-mediated inhibition of PQ metabolism, modulate radical cure efficacy in different P. vivax-infected populations. (This study has been registered at ClinicalTrials.gov under identifier NCT02691910.).
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Pharmacogenomics in Papua New Guineans: unique profiles and implications for enhancing drug efficacy while improving drug safety. Pharmacogenet Genomics 2019; 28:153-164. [PMID: 29768302 DOI: 10.1097/fpc.0000000000000335] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Papua New Guinea (PNG) can be roughly divided into highland, coastal and island peoples with significant mitochondrial DNA differentiation reflecting early and recent distinct migrations from Africa and East Asia, respectively. Infectious diseases such as tuberculosis, malaria and HIV severely impact on the health of its peoples for which drug therapy is the major treatment and pharmacogenetics has clinical relevance for many of these drugs. Although there is generally little information about known single nucleotide polymorphisms in the population, in some instances, their frequencies have been shown to be higher than anywhere worldwide. For example, CYP2B6*6 is over 50%, and CYP2C19*2 and *3 are over 40 and 25%, respectively. Conversely, CYP2A6*9, 2B6*2, *3, *4 and *18, and 2C8*3 appear to be much lower than in Whites. CYP2D6 known variants are unclear, and for phase II enzymes, only UGT2B7 and UGT1A9 data are available, with variant frequencies either slightly lower than or similar to Whites. Although almost all PNG people tested are rapid acetylators, but which variant(s) define this phenotype is not known. For HLA-B*13:01, HLA-B*35:05 and HLA-C*04:01, the frequencies show some regioselectivity, but the clinical implications with respect to adverse drug reactions are not known. There are minimal phenotype data for the CYPs and nothing is known about drug transporter or receptor genetics. Determination of genetic variants that are rare in Whites or Asians but common in PNG people is a topic of both scientific and clinical importance, and further research needs to be carried out. Optimizing the safety and efficacy of infectious disease drug therapy through pharmacogenetic studies that have translation potential is a priority.
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Appiah-Opong R, Tuffour I, Ofori-Attah E, Aning A, Atchoglo P, Danso EA, Ahedor B, Adjei S, Nyarko AK. In Vivo Modulation of Rat Liver Microsomal Cytochrome P450 Activity by Antimalarial, Anti-HIV, and Antituberculosis Plant Medicines. J Evid Based Integr Med 2019; 23:2515690X18810001. [PMID: 30392393 PMCID: PMC6238197 DOI: 10.1177/2515690x18810001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Drug interactions are key reasons for adverse drug reactions and attrition from market. Major infectious diseases causing morbidity/mortality in Ghana are malaria, tuberculosis, and HIV/AIDS. In this study, plant medicines commonly used to treat/manage these diseases in Ghana were investigated for their potential to modulate rat cytochrome P450 enzyme activities. Fluorescence and high-performance liquid chromatography-based assays were used to assess effects of antimalarial plant medicines, Fever (FEV), Mal-TF (MAL), and Kantinka terric (KT); anti-TB medicines, Chestico (CHES), CA + ST Pains + HWNT (TF), and Kantinka herbatic (KHB); and anti-HIV/AIDS medicines, Wabco (WAB), AD + T/AD (LIV) and Kantinka BA (KBA) on rat liver microsomal cytochrome P450 enzyme activities. Effects of medicines on rat biochemical and hematological parameters were also assessed. Generally, the medicines altered microsomal CYP1A1/1A2, CYP2B1/2B2, CYP2C9, and CYP2D6 activities. Only KBA elicited an increase (80%) in CYP1A1/1A2 activity. FEV, MAL, CHES, WAB, and LIV strongly inhibited the enzyme activity. All the medicines significantly inhibited CYP2C9 (24%-80%) activity. CYP2D6 activity increased after treatment with MAL, KBA, LIV, and TF. Also, MAL, WAB, LIV, KHB, and CHES increased CYP2B1/2B2 activity, while KT decrease the activity. Generally, the medicines altered liver function in the rats. Cholesterol levels declined after KBA treatment only. White and red blood cell counts, hemoglobin and hematocrit levels were significantly reduced in KT- and KBA-treated rats. Our results suggest that use of the medicines could have implications for drug interactions and safety, particularly if the medicines are administered over prolonged periods. Further investigations are imperative to establish clinical relevance of these results.
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Effects of MAO-A and CYP450 on primaquine metabolism in healthy volunteers. Parasitol Res 2019; 118:1011-1018. [PMID: 30706164 DOI: 10.1007/s00436-019-06210-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 01/10/2019] [Indexed: 02/07/2023]
Abstract
Eliminating the Plasmodium vivax malaria parasite infection remains challenging. One of the main problems is its capacity to form hypnozoites that potentially lead to recurrent infections. At present, primaquine is the only drug used for the management of hypnozoites. However, the effects of primaquine may differ from one individual to another. The aim of this work is to determine new measures to reduce P. vivax recurrence, through primaquine metabolism and host genetics. A genetic study of MAO-A, CYP2D6, CYP1A2 and CYP2C19 and their roles in primaquine metabolism was undertaken of healthy volunteers (n = 53). The elimination rate constant (Ke) and the metabolite-to-parent drug concentration ratio (Cm/Cp) were obtained to assess primaquine metabolism. Allelic and genotypic analysis showed that polymorphisms MAO-A (rs6323, 891G>T), CYP2D6 (rs1065852, 100C>T) and CYP2C19 (rs4244285, 19154G>A) significantly influenced primaquine metabolism. CYP1A2 (rs762551, -163C>A) did not influence primaquine metabolism. In haplotypic analysis, significant differences in Ke (p = 0.00) and Cm/Cp (p = 0.05) were observed between individuals with polymorphisms, GG-MAO-A (891G>T), CT-CYP2D6 (100C>T) and GG-CYP2C19 (19154G>A), and individuals with polymorphisms, TT-MAO-A (891G>T), TT-CYP2D6 (100C>T) and AA-CYP2C19 (19154G>A), as well as polymorphisms, GG-MAO-A (891G>T), TT-CYP2D6 (100C>T) and GA-CYP2C19 (19154G>A). Thus, individuals with CYP2D6 polymorphisms had slower primaquine metabolism activity. The potential significance of genetic roles in primaquine metabolism and exploration of these might help to further optimise the management of P. vivax infection.
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Fasinu PS, Nanayakkara NPD, Wang YH, Chaurasiya ND, Herath HMB, McChesney JD, Avula B, Khan I, Tekwani BL, Walker LA. Formation primaquine-5,6-orthoquinone, the putative active and toxic metabolite of primaquine via direct oxidation in human erythrocytes. Malar J 2019; 18:30. [PMID: 30700282 PMCID: PMC6352325 DOI: 10.1186/s12936-019-2658-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Accepted: 01/17/2019] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The activity and haemolytic toxicity associated with primaquine has been linked to its reactive metabolites. The reactive metabolites are thought to be primarily formed through the action of cytochrome P450-mediated pathways. Human erythrocytes generally are not considered a significant contributor to drug biotransformation. As erythrocytes are the target of primaquine toxicity, the ability of erythrocytes to mediate the formation of reactive oxidative primaquine metabolites in the absence of hepatic enzymes, was evaluated. METHODS Primaquine and its enantiomers were incubated separately with human red blood cells and haemoglobin. Post-incubation analysis was performed with UPLC-MS/MS to identify products of biotransformation. RESULTS The major metabolite detected was identified as primaquine-5,6-orthoquinone, reflecting the pathway yielding putative active and haematotoxic metabolites of primaquine, which was formed by oxidative demethylation of 5-hydroxyprimaquine. Incubation of primaquine with haemoglobin in a cell-free system yielded similar results. It appears that the observed biotransformation is due to non-enzymatic processes, perhaps due to reactive oxygen species (ROS) present in erythrocytes or in the haemoglobin incubates. CONCLUSION This study presents new evidence that primaquine-5,6-orthoquinone, the metabolite of primaquine reflecting the oxidative biotransformation pathway, is generated in erythrocytes, probably by non-enzymatic means, and may not require transport from the liver or other tissues.
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Affiliation(s)
- Pius S Fasinu
- The National Center for Natural Products Research, The University of Mississippi, University, MS, 38677, USA. .,Department of Pharmaceutical Sciences, Campbell University, Buies Creek, NC, 27501, USA.
| | - N P Dhammika Nanayakkara
- The National Center for Natural Products Research, The University of Mississippi, University, MS, 38677, USA
| | - Yan-Hong Wang
- The National Center for Natural Products Research, The University of Mississippi, University, MS, 38677, USA
| | - Narayan D Chaurasiya
- The National Center for Natural Products Research, The University of Mississippi, University, MS, 38677, USA
| | - H M Bandara Herath
- The National Center for Natural Products Research, The University of Mississippi, University, MS, 38677, USA
| | | | - Bharathi Avula
- The National Center for Natural Products Research, The University of Mississippi, University, MS, 38677, USA
| | - Ikhlas Khan
- The National Center for Natural Products Research, The University of Mississippi, University, MS, 38677, USA.,Department of BioMolecular Sciences, School of Pharmacy, The University of Mississippi, University, MS, 38677, USA
| | - Babu L Tekwani
- The National Center for Natural Products Research, The University of Mississippi, University, MS, 38677, USA.,Department of Infectious Diseases, Southern Research Institute, Birmingham, AL, USA
| | - Larry A Walker
- The National Center for Natural Products Research, The University of Mississippi, University, MS, 38677, USA. .,Department of BioMolecular Sciences, School of Pharmacy, The University of Mississippi, University, MS, 38677, USA.
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Leven M, Held J, Duffy S, Alves Avelar LA, Meister S, Delves M, Plouffe D, Kuna K, Tschan S, Avery VM, Winzeler EA, Mordmüller B, Kurz T. 8-Aminoquinolines with an Aminoxyalkyl Side Chain Exert in vitro Dual-Stage Antiplasmodial Activity. ChemMedChem 2019; 14:501-511. [PMID: 30605243 DOI: 10.1002/cmdc.201800691] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 12/13/2018] [Indexed: 12/29/2022]
Abstract
A series of novel 8-aminoquinolines (8-AQs) with an aminoxyalkyl side chain were synthesized and evaluated for in vitro antiplasmodial properties against asexual blood stages, liver stages, and sexual stages of Plasmodium falciparum. 8-AQs bearing 2-alkoxy and 5-phenoxy substituents on the quinoline ring system were found to be the most promising compounds under study, exhibiting potent blood schizontocidal and moderate tissue schizontocidal in vitro activity.
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Affiliation(s)
- Michael Leven
- Institut für Pharmazeutische und Medizinische Chemie, Heinrich-Heine-Universität Düsseldorf, Universitätsstrasse 1, 40225, Düsseldorf, Germany
| | - Jana Held
- Institut für Tropenmedizin, Eberhard Karls Universität Tübingen, Wilhelmstrasse 27, 72074, Tübingen, Germany
| | - Sandra Duffy
- Eskitis Institute for Drug Discovery, Griffith University, Brisbane Innovation Park Campus, Nathan, QLD, 4111, Australia
| | - Leandro A Alves Avelar
- Institut für Pharmazeutische und Medizinische Chemie, Heinrich-Heine-Universität Düsseldorf, Universitätsstrasse 1, 40225, Düsseldorf, Germany
| | - Stephan Meister
- Department of Pediatrics, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, 92037, USA
| | - Michael Delves
- Department of Life Sciences, Imperial College London, London, SW7 2AZ, UK
| | - David Plouffe
- Genomics Institute of the Novartis Research Foundation Department, Novartis, 10675 John Jay Hopkins Drive, San Diego, CA, 92121, USA
| | - Krystina Kuna
- Institut für Pharmazeutische und Medizinische Chemie, Heinrich-Heine-Universität Düsseldorf, Universitätsstrasse 1, 40225, Düsseldorf, Germany
| | - Serena Tschan
- Institut für Tropenmedizin, Eberhard Karls Universität Tübingen, Wilhelmstrasse 27, 72074, Tübingen, Germany
| | - Vicky M Avery
- Eskitis Institute for Drug Discovery, Griffith University, Brisbane Innovation Park Campus, Nathan, QLD, 4111, Australia
| | - Elizabeth A Winzeler
- Department of Pediatrics, University of California San Diego, 9500 Gilman Drive, La Jolla, CA, 92037, USA
| | - Benjamin Mordmüller
- Institut für Tropenmedizin, Eberhard Karls Universität Tübingen, Wilhelmstrasse 27, 72074, Tübingen, Germany
| | - Thomas Kurz
- Institut für Pharmazeutische und Medizinische Chemie, Heinrich-Heine-Universität Düsseldorf, Universitätsstrasse 1, 40225, Düsseldorf, Germany
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68
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Ferreira MU, Castro MC. Malaria Situation in Latin America and the Caribbean: Residual and Resurgent Transmission and Challenges for Control and Elimination. Methods Mol Biol 2019; 2013:57-70. [PMID: 31267493 DOI: 10.1007/978-1-4939-9550-9_4] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Despite recent progress toward malaria elimination in Latin America and the Caribbean, with an overall 62% decrease in incidence between 2000 and 2015, malaria remains endemic to 21 countries and territories in the region, where 120 million people are exposed to some risk of infection. Here we review recent epidemiologic trends, highlight current challenges, and briefly discuss the relative role of traditional and novel strategies for better malaria control and elimination across the continent.
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Affiliation(s)
- Marcelo U Ferreira
- Department of Parasitology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, SP, Brazil.
| | - Marcia C Castro
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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69
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Critical examination of approaches exploited to assess the effectiveness of transmission-blocking drugs for malaria. Future Med Chem 2018; 10:2619-2639. [PMID: 30499742 DOI: 10.4155/fmc-2018-0169] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
In the absence of clinically proven vaccines and emerging resistance to common antimalarials and insecticides, the onus of interrupting the life cycle of Plasmodium falciparum, is upon the transmission-blocking drugs. Current transmission-blocking drug primaquine finds its use restricted because of associated hemolytic toxicity issues in Glucose-6-Phosphate-Dehydrogenase deficient individuals. This article provides an extensive review of the assays used by the investigators to evaluate the transmission-blocking activity of drugs. Furthermore, limitations in existing transmission-blocking assessment approaches/studies are also covered in detail. This review is expected to help in the identification of lacunae in current understanding of transmission-blocking strategies, which are hindering our efforts to develop sustainable and effective transmission-blocking interventions.
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70
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Puaprasert K, Chu C, Saralamba N, Day NPJ, Nosten F, White NJ, Dondorp AM, Imwong M. Real time PCR detection of common CYP2D6 genetic variants and its application in a Karen population study. Malar J 2018; 17:427. [PMID: 30442143 PMCID: PMC6238304 DOI: 10.1186/s12936-018-2579-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 11/09/2018] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Plasmodium vivax malaria is characterized by relapses arising from the hypnozoite stages in the liver. The only currently registered drug for radical treatment to prevent relapse is primaquine. Primaquine, a prodrug, requires metabolism through the liver cytochrome CYP2D6 isoenzyme to its active metabolite. Mutations in the CYP2D6 gene may thus affect primaquine efficacy. A SNPs genotyping technique was developed to characterize the CYP2D6 genetic variants and tested this in the patients with Plasmodium vivax infection collected in a Karen population on the Thailand-Myanmar border, where P. vivax malaria is endemic. METHODS Direct sequencing of PCR-reamplified products (DSP) was used to uncover exonic CYP2D6 sequence variations. Subsequently, an allele-specific oligonucleotide probe real-time SNPs genotyping (ASO) assay was developed for rapid detection of the four clinically relevant CYP2D6 variants occurring in this population. These two in-house developed assays were used to genotype CYP2D6 mutations in blood samples obtained from 70 Karen adults. RESULTS Results showed a high degree of concordance between the DSP and ASO methods. Six CYP2D6 point mutations were identified within the Karen population: C100T, C1039T, G1661C, G1846A, C2850T and G4180C, at frequencies of 0.43, 0.43, 0.76, 0.02, 0.32 and 0.76, respectively. The CYP2D6*2, *4, *5, *10 and *36 allelic frequencies were 0.33, 0.02, 0.03, 0.40 and 0.01, respectively. Alleles conferring an intermediate CYP2D6 metabolizer phenotype comprised 46% of the total number of alleles. CONCLUSION The newly developed ASO assay is a reliable and rapid tool for large-scale CYP2D6 genotyping. The high frequency of the CYP2D6*10 allele in the Karen population warrants further assessment of its association with the radical curative efficacy of primaquine.
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Affiliation(s)
- Kanokpich Puaprasert
- Department of Molecular Tropical Medicine and Genetics, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Cindy Chu
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Naowarat Saralamba
- Department of Molecular Tropical Medicine and Genetics, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - 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, UK
| | - Francois Nosten
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - 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, UK
| | - Arjen M Dondorp
- 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, UK
| | - Mallika Imwong
- Department of Molecular Tropical Medicine and Genetics, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
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Avula B, Tekwani BL, Chaurasiya ND, Fasinu P, Dhammika Nanayakkara NP, Bhandara Herath HMT, Wang YH, Bae JY, Khan SI, Elsohly MA, McChesney JD, Zimmerman PA, Khan IA, Walker LA. Metabolism of primaquine in normal human volunteers: investigation of phase I and phase II metabolites from plasma and urine using ultra-high performance liquid chromatography-quadrupole time-of-flight mass spectrometry. Malar J 2018; 17:294. [PMID: 30103751 PMCID: PMC6090659 DOI: 10.1186/s12936-018-2433-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Accepted: 07/30/2018] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Primaquine (PQ), an 8-aminoquinoline, is the only drug approved by the United States Food and Drug Administration for radical cure and prevention of relapse in Plasmodium vivax infections. Knowledge of the metabolism of PQ is critical for understanding the therapeutic efficacy and hemolytic toxicity of this drug. Recent in vitro studies with primary human hepatocytes have been useful for developing the ultra high-performance liquid chromatography coupled with high-resolution mass spectrometric (UHPLC-QToF-MS) methods for simultaneous determination of PQ and its metabolites generated through phase I and phase II pathways for drug metabolism. METHODS These methods were further optimized and applied for phenotyping PQ metabolites from plasma and urine from healthy human volunteers treated with single 45 mg dose of PQ. Identity of the metabolites was predicted by MetaboLynx using LC-MS/MS fragmentation patterns. Selected metabolites were confirmed with appropriate standards. RESULTS Besides PQ and carboxy PQ (cPQ), the major plasma metabolite, thirty-four additional metabolites were identified in human plasma and urine. Based on these metabolites, PQ is viewed as metabolized in humans via three pathways. Pathway 1 involves direct glucuronide/glucose/carbamate/acetate conjugation of PQ. Pathway 2 involves hydroxylation (likely cytochrome P450-mediated) at different positions on the quinoline ring, with mono-, di-, or even tri-hydroxylations possible, and subsequent glucuronide conjugation of the hydroxylated metabolites. Pathway 3 involves the monoamine oxidase catalyzed oxidative deamination of PQ resulting in formation of PQ-aldehyde, PQ alcohol and cPQ, which are further metabolized through additional phase I hydroxylations and/or phase II glucuronide conjugations. CONCLUSION This approach and these findings augment our understanding and provide comprehensive view of pathways for PQ metabolism in humans. These will advance the clinical studies of PQ metabolism in different populations for different therapeutic regimens and an understanding of the role these play in PQ efficacy and safety outcomes, and their possible relation to metabolizing enzyme polymorphisms.
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Affiliation(s)
- Bharathi Avula
- National Center for Natural Products Research, School of Pharmacy, The University of Mississippi, University, MS, 38677, USA
| | - Babu L Tekwani
- National Center for Natural Products Research, School of Pharmacy, The University of Mississippi, University, MS, 38677, USA.
| | - Narayan D Chaurasiya
- National Center for Natural Products Research, School of Pharmacy, The University of Mississippi, University, MS, 38677, USA
| | - Pius Fasinu
- National Center for Natural Products Research, School of Pharmacy, The University of Mississippi, University, MS, 38677, USA
| | - N P Dhammika Nanayakkara
- National Center for Natural Products Research, School of Pharmacy, The University of Mississippi, University, MS, 38677, USA
| | - H M T Bhandara Herath
- National Center for Natural Products Research, School of Pharmacy, The University of Mississippi, University, MS, 38677, USA
| | - Yan-Hong Wang
- National Center for Natural Products Research, School of Pharmacy, The University of Mississippi, University, MS, 38677, USA
| | - Ji-Yeong Bae
- National Center for Natural Products Research, School of Pharmacy, The University of Mississippi, University, MS, 38677, USA
| | - Shabana I Khan
- National Center for Natural Products Research, School of Pharmacy, The University of Mississippi, University, MS, 38677, USA
| | - Mahmoud A Elsohly
- National Center for Natural Products Research, School of Pharmacy, The University of Mississippi, University, MS, 38677, USA
| | | | - Peter A Zimmerman
- Center for Global Health & Diseases, Case Western Reserve University Cleveland, Ohio, 44106, USA
| | - Ikhlas A Khan
- National Center for Natural Products Research, School of Pharmacy, The University of Mississippi, University, MS, 38677, USA
| | - Larry A Walker
- National Center for Natural Products Research, School of Pharmacy, The University of Mississippi, University, MS, 38677, USA
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Baird JK, Louisa M, Noviyanti R, Ekawati L, Elyazar I, Subekti D, Chand K, Gayatri A, Instiaty, Soebianto S, Crenna-Darusallam C, Djoko D, Hasto BD, Meriyenes D, Wesche D, Nelwan EJ, Sutanto I, Sudoyo H, Setiabudy R. Association of Impaired Cytochrome P450 2D6 Activity Genotype and Phenotype With Therapeutic Efficacy of Primaquine Treatment for Latent Plasmodium vivax Malaria. JAMA Netw Open 2018; 1:e181449. [PMID: 30646129 PMCID: PMC6324265 DOI: 10.1001/jamanetworkopen.2018.1449] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
IMPORTANCE Latent hepatic Plasmodium vivax hypnozoites provoke repeated clinical attacks called relapses. Only primaquine phosphate kills hypnozoites, and its therapeutic activity may depend on naturally polymorphic cytochrome P450 2D6 isotype (CYP2D6) activity. OBJECTIVE To examine the association of impaired CYP2D6 genotypes and CYP2D6 metabolic phenotypes with therapeutic failure of directly observed high-dose primaquine treatment for P vivax malaria relapse. DESIGN, SETTING, AND PARTICIPANTS Nested case-control study of patients who, in July 2014, completed a randomized clinical trial of directly observed primaquine treatment for radical cure of acute P vivax malaria in an area of Indonesia where reinfection during 1 year of posttreatment follow-up was improbable. A total of 177 of 180 patients with P vivax malaria completed the clinical trial of primaquine treatment to prevent relapse; 151 were eligible for recruitment as controls. After screening, 59 potential control individuals (no relapse) and 26 potential case patients (relapse) were considered, and 36 controls and 21 cases were enrolled. EXPOSURES Cases and controls were exposed to P vivax malaria and primaquine therapy but had variable exposure to the enzymatic activity of CYP2D6, classified as impaired by a genotype-determined qualitative phenotype (poor or intermediate), genotype-determined activity score less than 1.5, or a log of the 24-hour pooled urine dextromethorphan-dextrorphan metabolic ratio greater than -1.0. MAIN OUTCOMES AND MEASURES Unadjusted odds ratios (ORs) of relapse with impaired CYP2D6 metabolism determined by genotype or measured by urinary dextromethorphan-dextrorphan metabolic ratio. RESULTS Among the 21 cases (mean [SD] age, 30.5 [6.3] years; all male) and 36 controls (mean [SD] age, 29.0 [3.6] years; all male), 6 CYP2D6 alleles (*1, *2, *4, *5, *10, and *41) occurred as 12 distinct genotypes, with model activity scores ranging from 0.0 to 2.0. Among 32 patients with genotypic activity scores of 1.0 or less, 18 had experienced relapse, whereas among the 25 with scores higher than 1.0, 3 had experienced relapse (OR, 9.4; 95% CI, 2.1-57.0; P = .001). When the log of the metabolic ratio of dextromethorphan-dextrorphan was -1.0 or less, only 1 of 18 patients experienced relapse, whereas above that threshold (consistent with low metabolic activity), 20 of 39 patients experienced relapse (OR, 18; 95% CI, 2.2-148.0; P = .007). CONCLUSIONS AND RELEVANCE Genotype-determined and directly measured impaired levels of CYP2D6 activity were associated with elevated risk of therapeutic failure. These findings suggest a natural variability in CYP2D6-dependent metabolism of primaquine as a key determinant of therapeutic efficacy against latent P vivax malaria.
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Affiliation(s)
- J. Kevin Baird
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Eijkman-Oxford Clinical Research Unit, Eijkman Institute of Molecular Biology, Central Jakarta, Indonesia
| | - Melva Louisa
- Department of Pharmacology, Faculty of Medicine Universitas Indonesia, Jalan Salemba Raya No. 6, Central Jakarta, Indonesia
| | - Rintis Noviyanti
- Eijkman Institute of Molecular Biology, Central Jakarta, Indonesia
| | - Lenny Ekawati
- Eijkman-Oxford Clinical Research Unit, Eijkman Institute of Molecular Biology, Central Jakarta, Indonesia
| | - Iqbal Elyazar
- Eijkman-Oxford Clinical Research Unit, Eijkman Institute of Molecular Biology, Central Jakarta, Indonesia
| | - Decy Subekti
- Eijkman-Oxford Clinical Research Unit, Eijkman Institute of Molecular Biology, Central Jakarta, Indonesia
| | - Krisin Chand
- Eijkman-Oxford Clinical Research Unit, Eijkman Institute of Molecular Biology, Central Jakarta, Indonesia
| | - Anggi Gayatri
- Department of Pharmacology, Faculty of Medicine Universitas Indonesia, Jalan Salemba Raya No. 6, Central Jakarta, Indonesia
| | - Instiaty
- Department of Pharmacology, Faculty of Medicine Universitas Indonesia, Jalan Salemba Raya No. 6, Central Jakarta, Indonesia
| | - Saraswati Soebianto
- Eijkman-Oxford Clinical Research Unit, Eijkman Institute of Molecular Biology, Central Jakarta, Indonesia
| | | | - Dwi Djoko
- Army Health Command, East Jakarta, Indonesia
| | | | | | - David Wesche
- Certara Strategic Consulting, Princeton, New Jersey
| | - Erni J. Nelwan
- Division of Tropical Infectious Diseases, Faculty of Medicine, Universitas Indonesia, Central Jakarta, Indonesia
| | - Inge Sutanto
- Department of Parasitology, Faculty of Medicine, Universitas Indonesia, Central Jakarta, Indonesia
| | - Herawati Sudoyo
- Eijkman Institute of Molecular Biology, Central Jakarta, Indonesia
| | - Rianto Setiabudy
- Department of Pharmacology, Faculty of Medicine Universitas Indonesia, Jalan Salemba Raya No. 6, Central Jakarta, Indonesia
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Abstract
Following unsuccessful eradication attempts there was a resurgence of malaria towards the end of the 20th century. Renewed control efforts using a range of improved tools, such as long-lasting insecticide-treated bednets and artemisinin-based combination therapies, have more than halved the global burden of disease, but it remains high with 445 000 deaths and more than 200 million cases in 2016. Pitfalls in individual patient management are delayed diagnosis and overzealous fluid resuscitation in severe malaria. Even in the absence of drug resistance, parasite recurrence can occur, owing to high parasite densities, low host immunity, or suboptimal drug concentrations. Malaria elimination is firmly back as a mainstream policy but resistance to the artemisinin derivatives, their partner drugs, and insecticides present major challenges. Vaccine development continues on several fronts but none of the candidates developed to date have been shown to provide long-lasting benefits at a population level. Increased resources and unprecedented levels of regional cooperation and societal commitment will be needed if further substantial inroads into the malaria burden are to be made.
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Affiliation(s)
- Elizabeth A Ashley
- Myanmar-Oxford Clinical Research Unit, Yangon, Myanmar; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Aung Pyae Phyo
- Shoklo Malaria Research Unit, Mae Sot, Thailand; Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Charles J Woodrow
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK; Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
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74
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Characterization of the Preclinical Pharmacology of the New 2-Aminomethylphenol, JPC-3210, for Malaria Treatment and Prevention. Antimicrob Agents Chemother 2018; 62:AAC.01335-17. [PMID: 29311093 DOI: 10.1128/aac.01335-17] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 01/05/2018] [Indexed: 12/15/2022] Open
Abstract
The new 2-aminomethylphenol, JPC-3210, has potent in vitro antimalarial activity against multidrug-resistant Plasmodium falciparum lines, low cytotoxicity, and high in vivo efficacy against murine malaria. Here we report on the pharmacokinetics of JPC-3210 in mice and monkeys and the results of in vitro screening assays, including the inhibition of cytochrome P450 (CYP450) isozymes. In mice, JPC-3210 was rapidly absorbed and had an extensive tissue distribution, with a brain tissue-to-plasma concentration ratio of about 5.4. JPC-3210 had a lengthy plasma elimination half-life of about 4.5 days in mice and 11.8 days in monkeys. JPC-3210 exhibited linear single-oral-dose pharmacokinetics across the dose range of 5 to 40 mg/kg of body weight with high oral bioavailability (∼86%) in mice. Systemic blood exposure of JPC-3210 was 16.6% higher in P. berghei-infected mice than in healthy mice. In vitro studies with mice and human hepatocytes revealed little metabolism and the high metabolic stability of JPC-3210. The abundance of human metabolites from oxidation and glucuronidation was 2.0% and 2.5%, respectively. CYP450 studies in human liver microsomes showed JPC-3210 to be an inhibitor of CYP2D6 and, to a lesser extent, CYP3A4 isozymes, suggesting the possibility of a metabolic drug-drug interaction with drugs that are metabolized by these isozymes. In vitro studies showed that JPC-3210 is highly protein bound to human plasma (97%). These desirable pharmacological findings of a lengthy blood elimination half-life, high oral bioavailability, and low metabolism as well as high in vivo potency have led the Medicines for Malaria Venture to select JPC-3210 (MMV892646) for further advanced preclinical development.
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75
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Understanding human genetic factors influencing primaquine safety and efficacy to guide primaquine roll-out in a pre-elimination setting in southern Africa. Malar J 2018; 17:120. [PMID: 29558929 PMCID: PMC5859786 DOI: 10.1186/s12936-018-2271-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 03/13/2018] [Indexed: 12/27/2022] Open
Abstract
Background Primaquine (PQ) is recommended as an addition to standard malaria treatments in pre-elimination settings due to its pronounced activity against mature Plasmodium falciparum gametocytes, the parasite stage responsible for onward transmission to mosquitoes. However, PQ may trigger haemolysis in glucose-6-phosphate dehydrogenase (G6PD)-deficient individuals. Additional human genetic factors, including polymorphisms in the human cytochrome P450 2D6 (CYP2D6) complex, may negatively influence the efficacy of PQ. This study assessed the prevalence of G6PD deficiency and two important CYP2D6 variants in representative pre-elimination settings in South Africa, to inform malaria elimination strategies. Methods Volunteers (n = 248) attending six primary health care facilities in a malaria-endemic region of South Africa were enrolled between October and November 2015. G6PD status was determined phenotypically, using a CareStart™ G6PD rapid diagnostic test (RDT), and genotypically for two common African G6PD variants, namely A+ (A376G) and A− (G202A, A542T, G680T & T968C) by PCR, restriction fragment length polymorphisms (RFLP) and DNA sequencing. CYP2D6*4 and CYP2D6*17 variants were determined with PCR and RFLP. Results A prevalence of 13% (33/248) G6PD deficiency was observed in the cohort by G6PD RDT whilst by genotypic assessment, 32% (79/248) were A+ and 3.2% were A−, respectively. Among the male participants, 11% (6/55) were G6PD A− hemizygous; among females 1% (2/193) were G6PD A− homozygous and 16% (32/193) G6PD A− heterozygous. The strength of agreement between phenotyping and genotyping result was fair (Cohens Kappa κ = 0.310). The negative predictive value for the G6PD RDT for detecting hemizygous, homozygous and heterozygous individuals was 0.88 (95% CI 0.85–0.91), compared to the more sensitive genotyping. The CYP2D6*4 allele frequencies for CYP2D6*4 (inferred poor metabolizer phenotype) and CYP2D6*17 (inferred intermediate metabolizer phenotype) were 3.2 and 19.5%, respectively. Conclusions Phenotypic and genotypic analyses both detected low prevalence of G6PD deficiency and the CYP2D6*4 variants. These findings, combined with increasing data confirming safety of single low-dose PQ in individuals with African variants of G6PD deficiency, supports the deployment of single low-dose PQ as a gametocytocidal drug. PQ would pose minimal risks to the study populations and could be a useful elimination strategy in the study area.
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76
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Relapsing Malaria: A Case Report of Primaquine Resistance. Case Rep Infect Dis 2018; 2018:9720823. [PMID: 29713556 PMCID: PMC5866905 DOI: 10.1155/2018/9720823] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 02/22/2018] [Indexed: 11/18/2022] Open
Abstract
Primaquine (an 8-aminoquinoline malarial therapy) is the only FDA-approved therapy to treat the hypnozoite stage of P. vivax. We think of relapse occurring because of parasitic resistance or poor compliance secondary to drug toxicities. However, in patients with repeated treatment failure, we must consider CYP-450 mutations affecting drug metabolism as an important cause of relapse. A 47-year-old man who travelled to a jungle in Venezuela was diagnosed with P. falciparum and P. vivax in July 2015. He was treated with seven rounds of primaquine-based therapy in the following year, all resulted in relapse without further exposure to endemic areas. On his eighth presentation, he was found to have CYP-4502D6 mutation that affected the metabolism and activation of primaquine. Thereafter, he was treated without relapse. Primaquine efficacy depends on many factors. Understanding the mechanism responsible for malaria relapse is paramount for successful treatment and reduction in morbidity and mortality. This case illustrates the importance of considering cytochrome mutations that affect drug efficacy in cases of relapsing malaria.
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77
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Brasil LW, Rodrigues-Soares F, Santoro AB, Almeida ACG, Kühn A, Ramasawmy R, Lacerda MVG, Monteiro WM, Suarez-Kurtz G. CYP2D6 activity and the risk of recurrence of Plasmodium vivax malaria in the Brazilian Amazon: a prospective cohort study. Malar J 2018; 17:57. [PMID: 29390987 PMCID: PMC5795836 DOI: 10.1186/s12936-017-2139-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 12/09/2017] [Indexed: 11/11/2022] Open
Abstract
Background CYP2D6 pathway mediates the activation of primaquine into active metabolite(s) in hepatocytes. CYP2D6 is highly polymorphic, encoding CYP2D6 isoforms with normal, reduced, null or increased activity. It is hypothesized that Plasmodium vivax malaria patients with defective CYP2D6 function would be at increased risk for primaquine failure to prevent recurrence. The aim of this study was to investigate the association of CYP2D6 polymorphisms and inferred CYP2D6 phenotypes with malaria recurrence in patients from the Western Brazilian Amazon, following chloroquine/primaquine combined therapy. Methods The prospective cohort consisted of P. vivax malaria patients who were followed for 6 months after completion of the chloroquine/primaquine therapy. Recurrence was defined as one or more malaria episodes, 28–180 days after the initial episode. Genotyping for nine CYP2D6 SNPs and copy number variation was performed using TaqMan assays in a Fast 7500 Real-Time System. CYP2D6 star alleles (haplotypes), diplotypes and CYP2D6 phenotypes were inferred, and the activity score system was used to define the functionality of the CYP2D6 diplotypes. CYP2D6 activity scores (AS) were dichotomized at ≤ 1 (gPM, gIM and gNM-S phenotypes) and ≥ 1.5 (gNM-F and gUM phenotypes). Results Genotyping was successfully performed in 190 patients (44 with recurrence and 146 without recurrences). Recurrence incidence was higher in individuals presenting reduced activity CYP2D6 phenotypes (adjusted relative risk = 1.89, 95% CI 1.01–3.70; p = 0.049). Attributable risk and population attributable fraction were 11.5 and 9.9%, respectively. The time elapsed from the first P. vivax malaria episode until the recurrence did not differ between patients with AS of ≤ 1 versus ≥ 1.5 (p = 0.917). Conclusions The results suggest that CYP2D6 polymorphisms are associated with increased risk of recurrence of vivax malaria, following chloroquine–primaquine combined therapy. This association is interpreted as the result of reduced conversion of primaquine into its active metabolites in patients with reduced CYP2D6 enzymatic activity.
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Affiliation(s)
- Larissa W Brasil
- Diretoria de Ensino e Pesquisa, Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, AM, Brazil.,Programa de Pós-Graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, AM, Brazil
| | - Fernanda Rodrigues-Soares
- Programa de Pós-Graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, AM, Brazil
| | - Ana B Santoro
- Coordenação de Pesquisa, Instituto Nacional de Câncer, Rio de Janeiro, RJ, 20231-050, Brazil
| | - Anne C G Almeida
- Diretoria de Ensino e Pesquisa, Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, AM, Brazil.,Programa de Pós-Graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, AM, Brazil
| | - Andrea Kühn
- Diretoria de Ensino e Pesquisa, Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, AM, Brazil
| | - Rajendranath Ramasawmy
- Diretoria de Ensino e Pesquisa, Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, AM, Brazil.,Programa de Pós-Graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, AM, Brazil.,Faculdade de Medicina, Universidade Nilton Lins, Manaus, AM, Brazil
| | - Marcus V G Lacerda
- Diretoria de Ensino e Pesquisa, Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, AM, Brazil.,Programa de Pós-Graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, AM, Brazil.,Instituto Leônidas & Maria Deane, Fiocruz, Manaus, AM, Brazil
| | - Wuelton M Monteiro
- Diretoria de Ensino e Pesquisa, Fundação de Medicina Tropical Dr. Heitor Vieira Dourado, Manaus, AM, Brazil.,Programa de Pós-Graduação em Medicina Tropical, Universidade do Estado do Amazonas, Manaus, AM, Brazil.,Faculdade de Medicina, Universidade Nilton Lins, Manaus, AM, Brazil
| | - Guilherme Suarez-Kurtz
- Coordenação de Pesquisa, Instituto Nacional de Câncer, Rio de Janeiro, RJ, 20231-050, Brazil.
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78
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Baird JK. Tafenoquine for travelers' malaria: evidence, rationale and recommendations. J Travel Med 2018; 25:5150129. [PMID: 30380095 PMCID: PMC6243017 DOI: 10.1093/jtm/tay110] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 10/17/2018] [Accepted: 10/30/2018] [Indexed: 01/01/2023]
Abstract
Background Endemic malaria occurring across much of the globe threatens millions of exposed travelers. While unknown numbers of them suffer acute attacks while traveling, each year thousands return from travel and become stricken in the weeks and months following exposure. This represents perhaps the most serious, prevalent and complex problem faced by providers of travel medicine services. Since before World War II, travel medicine practice has relied on synthetic suppressive blood schizontocidal drugs to prevent malaria during exposure, and has applied primaquine for presumptive anti-relapse therapy (post-travel or post-diagnosis of Plasmodium vivax) since 1952. In 2018, the US Food and Drug Administration approved the uses of a new hepatic schizontocidal and hypnozoitocidal 8-aminoquinoline called tafenoquine for the respective prevention of all malarias and for the treatment of those that relapse (P. vivax and Plasmodium ovale). Methods The evidence and rationale for tafenoquine for the prevention and treatment of malaria was gathered by means of a standard search of the medical literature along with the package inserts for the tafenoquine products Arakoda™ and Krintafel™ for the prevention of all malarias and the treatment of relapsing malarias, respectively. Results The development of tafenoquine-an endeavor of 40 years-at last brings two powerful advantages to travel medicine practice against the malaria threat: (i) a weekly regimen of causal prophylaxis; and (ii) a single-dose radical cure for patients infected by vivax or ovale malarias. Conclusions Although broad clinical experience remains to be gathered, tafenoquine appears to promise more practical and effective prevention and treatment of malaria. Tafenoquine thus applied includes important biological and clinical complexities explained in this review, with particular regard to the problem of hemolytic toxicity in G6PD-deficient patients.
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Affiliation(s)
- J Kevin Baird
- Eijkman-Oxford Clinical Research Unit, Eijkman Institute of Molecular Biology, Jakarta 10430, Indonesia; and Nuffield Department of Medicine, the Centre for Tropical Medicine and Global Health, University of Oxford, UK
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79
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Abstract
Controlled human malaria infection (CHMI) entails deliberate infection with malaria parasites either by mosquito bite or by direct injection of sporozoites or parasitized erythrocytes. When required, the resulting blood-stage infection is curtailed by the administration of antimalarial drugs. Inducing a malaria infection via inoculation with infected blood was first used as a treatment (malariotherapy) for neurosyphilis in Europe and the United States in the early 1900s. More recently, CHMI has been applied to the fields of malaria vaccine and drug development, where it is used to evaluate products in well-controlled early-phase proof-of-concept clinical studies, thus facilitating progression of only the most promising candidates for further evaluation in areas where malaria is endemic. Controlled infections have also been used to immunize against malaria infection. Historically, CHMI studies have been restricted by the need for access to insectaries housing infected mosquitoes or suitable malaria-infected individuals. Evaluation of vaccine and drug candidates has been constrained in these studies by the availability of a limited number of Plasmodium falciparum isolates. Recent advances have included cryopreservation of sporozoites, the manufacture of well-characterized and genetically distinct cultured malaria cell banks for blood-stage infection, and the availability of Plasmodium vivax-specific reagents. These advances will help to accelerate malaria vaccine and drug development by making the reagents for CHMI more widely accessible and also enabling a more rigorous evaluation with multiple parasite strains and species. Here we discuss the different applications of CHMI, recent advances in the use of CHMI, and ongoing challenges for consideration.
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80
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Milner EE, Berman J, Caridha D, Dickson SP, Hickman M, Lee PJ, Marcsisin SR, Read LT, Roncal N, Vesely BA, Xie LH, Zhang J, Zhang P, Li Q. Cytochrome P450 2D-mediated metabolism is not necessary for tafenoquine and primaquine to eradicate the erythrocytic stages of Plasmodium berghei. Malar J 2016; 15:588. [PMID: 27923405 PMCID: PMC5142148 DOI: 10.1186/s12936-016-1632-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 11/22/2016] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Due to the ability of the 8-aminoquinolines (8AQs) to kill different stages of the malaria parasite, primaquine (PQ) and tafenoquine (TQ) are vital for causal prophylaxis and the eradication of erythrocytic Plasmodium sp. parasites. Recognizing the potential role of cytochrome (CYP) 450 2D6 in the metabolism and subsequent hepatic efficacy of 8-aminoquinolines, studies were designed to explore whether CYP2D-mediated metabolism was related to the ability of single-dose PQ and TQ to eliminate the asexual and sexual erythrocytic stages of Plasmodium berghei. METHODS An IV P. berghei sporozoite murine challenge model was utilized to directly compare causal prophylactic and erythrocytic activity (asexual and sexual parasite stages) dose-response relationships in C57BL/6 wild-type (WT) mice and subsequently compare the erythrocytic activity of PQ and TQ in WT and CYP2D knock-out (KO) mice. RESULTS Single-dose administration of either 25 mg/kg TQ or 40 mg/kg PQ eradicated the erythrocytic stages (asexual and sexual) of P. berghei in C57BL WT and CYP2D KO mice. In WT animals, the apparent elimination of hepatic infections occurs at lower doses of PQ than are required to eliminate erythrocytic infections. In contrast, the minimally effective dose of TQ needed to achieve causal prophylaxis and to eradicate erythrocytic parasites was analogous. CONCLUSION The genetic deletion of the CYP2D cluster does not affect the ability of PQ or TQ to eradicate the blood stages (asexual and sexual) of P. berghei after single-dose administration.
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Affiliation(s)
- Erin E Milner
- Walter Reed Army Institute of Research (WRAIR), Silver Spring, MD, USA.
| | - Jonathan Berman
- Walter Reed Army Institute of Research (WRAIR), Silver Spring, MD, USA
| | - Diana Caridha
- Walter Reed Army Institute of Research (WRAIR), Silver Spring, MD, USA
| | - Samuel P Dickson
- United States Army Medical Materiel Development Authority (USAMMDA), Ft Detrick, Frederick, MD, USA
| | - Mark Hickman
- Walter Reed Army Institute of Research (WRAIR), Silver Spring, MD, USA
| | - Patricia J Lee
- Walter Reed Army Institute of Research (WRAIR), Silver Spring, MD, USA
| | - Sean R Marcsisin
- Walter Reed Army Institute of Research (WRAIR), Silver Spring, MD, USA
| | - Lisa T Read
- United States Army Medical Materiel Development Authority (USAMMDA), Ft Detrick, Frederick, MD, USA
| | - Norma Roncal
- Walter Reed Army Institute of Research (WRAIR), Silver Spring, MD, USA
| | - Brian A Vesely
- Walter Reed Army Institute of Research (WRAIR), Silver Spring, MD, USA
| | - Lisa H Xie
- Walter Reed Army Institute of Research (WRAIR), Silver Spring, MD, USA
| | - Jing Zhang
- Walter Reed Army Institute of Research (WRAIR), Silver Spring, MD, USA
| | - Ping Zhang
- Walter Reed Army Institute of Research (WRAIR), Silver Spring, MD, USA
| | - Qigui Li
- Walter Reed Army Institute of Research (WRAIR), Silver Spring, MD, USA
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81
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Jin X, Potter B, Luong TL, Nelson J, Vuong C, Potter C, Xie L, Zhang J, Zhang P, Sousa J, Li Q, Pybus BS, Kreishman-Deitrick M, Hickman M, Smith PL, Paris R, Reichard G, Marcsisin SR. Pre-clinical evaluation of CYP 2D6 dependent drug-drug interactions between primaquine and SSRI/SNRI antidepressants. Malar J 2016; 15:280. [PMID: 27188854 PMCID: PMC4869338 DOI: 10.1186/s12936-016-1329-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Accepted: 05/05/2016] [Indexed: 12/21/2022] Open
Abstract
Background The liver-stage anti-malarial activity of primaquine and other 8-aminoquinoline molecules has been linked to bio-activation through CYP 2D6 metabolism. Factors such as CYP 2D6 poor metabolizer status and/or co-administration of drugs that inhibit/interact with CYP 2D6 could alter the pharmacological properties of primaquine. Methods In the present study, the inhibitory potential of the selective serotonin reuptake inhibitor (SSRI) and serotonin norepinephrine reuptake inhibitor (SNRI) classes of antidepressants for CYP 2D6-mediated primaquine metabolism was assessed using in vitro drug metabolism and in vivo pharmacological assays. Results The SSRI/SNRI classes of drug displayed a range of inhibitory activities on CYP 2D6-mediated metabolism of primaquine in vitro (IC50 1–94 μM). Fluoxetine and paroxetine were the most potent inhibitors (IC50 ~1 µM) of CYP 2D6-mediated primaquine metabolism, while desvenlafaxine was the least potent (IC50 ~94 µM). The most potent CYP 2D6 inhibitor, fluoxetine, was chosen to investigate the potential pharmacological consequences of co-administration with primaquine in vivo. The pharmacokinetics of a CYP 2D6-dependent primaquine metabolite were altered upon co-administration with fluoxetine. Additionally, in a mouse malaria model, co-administration of fluoxetine with primaquine reduced primaquine anti-malarial efficacy. Conclusions These results are the first from controlled pre-clinical experiments that indicate that primaquine pharmacological properties can be modulated upon co-incubation/administration with drugs that are known to interact with CYP 2D6. These results highlight the potential for CYP 2D6-mediated drug–drug interactions with primaquine and indicate that the SSRI/SNRI antidepressants could be used as probe molecules to address the primaquine-CYP 2D6 DDI link in clinical studies. Additionally, CYP 2D6-mediated drug–drug interactions can be considered when examining the possible causes of human primaquine therapy failures. Electronic supplementary material The online version of this article (doi:10.1186/s12936-016-1329-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Xiannu Jin
- Military Malaria Research Program, Experimental Therapeutics Branch, Walter Reed Army Institute of Research, 503 Robert Grant Ave, Silver Spring, MD, 20910, USA
| | - Brittney Potter
- Military Malaria Research Program, Experimental Therapeutics Branch, Walter Reed Army Institute of Research, 503 Robert Grant Ave, Silver Spring, MD, 20910, USA
| | - Thu-Lan Luong
- Military Malaria Research Program, Experimental Therapeutics Branch, Walter Reed Army Institute of Research, 503 Robert Grant Ave, Silver Spring, MD, 20910, USA
| | - Jennifer Nelson
- Military Malaria Research Program, Experimental Therapeutics Branch, Walter Reed Army Institute of Research, 503 Robert Grant Ave, Silver Spring, MD, 20910, USA
| | - Chau Vuong
- Military Malaria Research Program, Experimental Therapeutics Branch, Walter Reed Army Institute of Research, 503 Robert Grant Ave, Silver Spring, MD, 20910, USA
| | - Corttney Potter
- Military Malaria Research Program, Experimental Therapeutics Branch, Walter Reed Army Institute of Research, 503 Robert Grant Ave, Silver Spring, MD, 20910, USA
| | - Lisa Xie
- Military Malaria Research Program, Experimental Therapeutics Branch, Walter Reed Army Institute of Research, 503 Robert Grant Ave, Silver Spring, MD, 20910, USA
| | - Jing Zhang
- Military Malaria Research Program, Experimental Therapeutics Branch, Walter Reed Army Institute of Research, 503 Robert Grant Ave, Silver Spring, MD, 20910, USA
| | - Ping Zhang
- Military Malaria Research Program, Experimental Therapeutics Branch, Walter Reed Army Institute of Research, 503 Robert Grant Ave, Silver Spring, MD, 20910, USA
| | - Jason Sousa
- Military Malaria Research Program, Experimental Therapeutics Branch, Walter Reed Army Institute of Research, 503 Robert Grant Ave, Silver Spring, MD, 20910, USA
| | - Qigui Li
- Military Malaria Research Program, Experimental Therapeutics Branch, Walter Reed Army Institute of Research, 503 Robert Grant Ave, Silver Spring, MD, 20910, USA
| | - Brandon S Pybus
- Military Malaria Research Program, Experimental Therapeutics Branch, Walter Reed Army Institute of Research, 503 Robert Grant Ave, Silver Spring, MD, 20910, USA
| | - Mara Kreishman-Deitrick
- Military Malaria Research Program, Experimental Therapeutics Branch, Walter Reed Army Institute of Research, 503 Robert Grant Ave, Silver Spring, MD, 20910, USA
| | - Mark Hickman
- Military Malaria Research Program, Experimental Therapeutics Branch, Walter Reed Army Institute of Research, 503 Robert Grant Ave, Silver Spring, MD, 20910, USA
| | - Philip L Smith
- Military Malaria Research Program, Experimental Therapeutics Branch, Walter Reed Army Institute of Research, 503 Robert Grant Ave, Silver Spring, MD, 20910, USA
| | - Robert Paris
- Military Malaria Research Program, Experimental Therapeutics Branch, Walter Reed Army Institute of Research, 503 Robert Grant Ave, Silver Spring, MD, 20910, USA
| | - Gregory Reichard
- Military Malaria Research Program, Experimental Therapeutics Branch, Walter Reed Army Institute of Research, 503 Robert Grant Ave, Silver Spring, MD, 20910, USA
| | - Sean R Marcsisin
- Military Malaria Research Program, Experimental Therapeutics Branch, Walter Reed Army Institute of Research, 503 Robert Grant Ave, Silver Spring, MD, 20910, USA.
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