Cardiac effects of antimalarial treatment with halofantrine

Chemotherapy of drug-resistant malaria

OBJECTIVE

To review the impact of drug-resistant malaria on current management of plasmodial infections.

DATA SOURCES

A MEDLINE search of the English-language medical literature from 1985 to 1995; bibliographies of selected papers; international malaria advisory experts.

DATA SYNTHESIS

Combinations of artemisinin derivatives and mefloquine or atovaquone plus proguanil appear to be the most active drug regimens against multidrug-resistant falciparum malaria from Southeast Asia. The optimal therapy for chloroquine-resistant Plasmodium vivax is unknown, but recent data indicate that halofantrine or chloroquine plus high doses of primaquine are efficacious.

CONCLUSIONS

The incidence of drug-resistant malaria continues to increase at a rate that exceeds new drug development. Ultimately the control of malaria will require more creative approaches than just the development of additional inhibitory drugs. These might include the identification of biochemical pathways unique to the parasite (such as drug efflux and heme polymerization), making it possible to design new classes of antimalarial agents that are selectively toxic to the parasite; methods to block parasite development in the mosquito vector; and multistage vaccines against asexual and sexual stages to block both the pathophysiology and the transmission of disease.

Pharmacokinetics of quinine in chronic liver disease

The pharmacokinetics of quinine were investigated in a) six healthy male Thai subjects, and b) nine male Thai patients with a moderate degree of chronic liver disease, after a single oral dose of 600 mg quinine sulphate. tmax and t1/2.2 were significantly prolonged in patients (median [range] tmax 2 [1-5] vs 1.6 [0.8-2] h; t1/2,z 23.4 [17.4-41.7] vs 9.7 [7.8-17.2] h), and Vz/F was significantly larger (median [range] 4.21 [2.33-15.87] vs 2.78 [1.49-3.38] 1 kg-1). Median (range) concentration of the plasma unbound Qn fraction collected from the patients at 4 h after drug administration was 17 (8.4-17.8)% of total drug concentration.

An investigation of the interaction between halofantrine, CYP2D6 and CYP3A4: studies with human liver microsomes and heterologous enzyme expression systems

1. We have assessed the interaction of the antimalarial halofantrine with cytochrome P450 (CYP) enzymes in vitro, with the use of microsomes from human liver and recombinant cell lines. 2. Rac-halofantrine was a potent inhibitor (IC50 = 1.06 microM, Ki = 4.3 microM) of the 1-hydroxylation of bufuralol, a marker for CYP2D6 activity. Of a group of structurally related antimalarials tested, only quinidine (IC50 = 0.04 microM) was more potent. 3. Microsomes prepared from recombinant CYP2D6 and CYP3A4 cell lines were shown to catalyse halofantrine N-debutylation. 4. The metabolism of halofantrine to its N-desbutyl metabolite by human liver microsomes showed no correlation with CYP2D6 genotypic or phenotypic status and there was no consistent inhibition by quinidine. 5. The rate of halofantrine metabolism showed a significant correlation with both CYP3A4 protein levels (r = 0.88, P = 0.01) and the rate of felodipine metabolism (r = 0.86, P = 0.013), a marker substrate for CYP3A4 activity. Inhibition studies showed that ketoconazole is a potent inhibitor of halofantrine metabolism (IC50 = 1.57 microM). 6. In conclusion, we have demonstrated that halofantrine is a potent inhibitor of CYP2D6 in vitro and can also be metabolised by the enzyme. However, in human liver microsomes it appears to be metabolised largely by CYP3A4.

Artesunate versus artemether in combination with mefloquine for the treatment of multidrug-resistant falciparum malaria

To compare the therapeutic efficacy of oral artesunate and artemether in combination with mefloquine for the treatment of multidrug resistant malaria, a trial was conducted in 540 adults and children on the Thai-Myanmar border. Three regimens were compared: artesunate (4 mg/kg/d for 3 d), artemether (4 mg/kg/d for 3 d), both in combination with mefloquine (25 mg/kg), and a single dose of mefloquine (25 mg/kg). The artesunate and artemether regimens gave very similar clinical and parasitological responses, and were both very well tolerated. There was no significant adverse effect attributable to the artemisinin derivatives. Fever and parasite clearance times with mefloquine alone were significantly longer (P < 0.001). After adjusting for reinfections the failure rates were 13.9% for the artesunate combination, 12.3% for the artemether combination and 49.2% for mefloquine alone (P < 0.0001; relative risk 3.8 [95% confidence interval 2.6-5.4]). Mefloquine should no longer be used alone for the treatment of multidrug resistant falciparum malaria in this area. Three-day combination regimens with artesunate or artemether are well tolerated and more effective.

Effect of halofantrine and its desbutyl metabolite on lymphocyte proliferation dynamics

Halofantrine hydrochloride (HF), one of the latest antimalarial agents currently undergoing clinical trials, and its active metabolite, N-desbutylhalofantrine (DHF), were examined for their effects on human and rat lymphocytes. HF has a biphasic concentration-dependent effect on phytohemagglutinin stimulated proliferation of human lymphocytes. Concentrations lower than 2.25 microM enhance, while higher concentrations inhibit proliferation. The IC50 values were 9.4 microM for HF, 4.5 microM for DHF and 14.7 microM for chloroquine. In human lymphocytes, enhanced proliferation was not detected for DHF unlike for HF. Combined achievable plasma concentrations of HF and DHF may sometimes be in the range where reduced lymphocyte proliferation occurs in vitro when based on simple additive dynamics. It remains to be confirmed if malarial treatment with HF leads to reduced T-cell responsiveness to antigenic challenges since HF and DHF persist for several days.

Chemotherapy and prevention of drug-resistant malaria

Drug-resistant falciparum and vivax malaria will continue to be an increasing problem. The incidence of drug-resistant malaria has been increasing at a rate that exceeds new drug development. Plasmodium falciparum has rapidly developed resistance to new synthetic antimalarials, including mefloquine and halofantrine. P. vivax malaria resistant to chloroquine and primaquine is now widespread in parts of Oceania; the optimal therapy for this infection is unknown. At present, a combination of qinghaosu derivatives and mefloquine appears to be the most active drug regimen against multidrug-resistant falciparum malaria from Southeast Asia. However, qinghaosu compounds are not yet licensed and widely available. The capacity of P. falciparum to rapidly develop drug resistance and the growing evidence that other plasmodia can evolve resistance suggests that within the next 10 years, we face the real prospect of untreatable malaria. Ultimately, control of malaria may require more creative approaches than additional inhibitory drugs. These might include: the identification of biochemical pathways unique to the parasite (such as drug efflux and heme polymerase), making it possible to design new classes of antimalarial agents that are selectively toxic to the parasite; methods to block parasite development in the mosquito vector; and multistage vaccines against both asexual and sexual stages in order to block both the pathophysiology and transmission of disease.

Cardiac complications of halofantrine: a prospective study of 20 patients

Halofantrine, increasingly used for treatment of Plasmodium falciparum malaria, is a normally well-tolerated amino-alcohol with very few side-effects, but torsades de pointes ventricular tachycardia due to halofantrine has been reported in a few patients with a congenital long QT interval (Romano-Ward syndrome). We performed a prospective study of the cardiac effect of halofantrine in 20 patients with 48 h ambulatory electrocardiographic (ECG) monitoring; the halofantrine levels in their serum were also determined. Minimal ECG changes were noted, with lengthening of the QT interval without clinical symptoms. This effect was dose-dependent and can be very severe in cases of pre-existing cardiopathy; it also occurs in patients without any pre-existing cardiopathy. In order to reduce the likelihood of such incidents, which are admittedly rare, we suggest performing electrocardiography on all patients before initiating treatment with halofantrine.

New solid-phase extraction for an improved high-performance liquid chromatographic procedure for the quantitation of halofantrine and monodesbutylhalofantrine in blood or plasma

A rapid, accurate, and sensitive high-performance liquid chromatographic (HPLC) method, with fluorimetric detection, for the simultaneous measurement of halofantrine and desbutylhalofantrine in human plasma or whole blood is described. Sample preparation involved protein precipitation, followed by an efficient solid-phase extraction on a C8 cartridge. Analytes were isolated from 1 ml of the biological fluids and recovered by a 2% acetic acid in ethyl acetate solution. Chromatographic separation was carried out on a LiChrospher 60 RP select B, C8 bonded phase (5 microns particle size, 25 cm x 4 mm I.D.) using a mobile phase of water-acetonitrile (35:65, v/v) containing triethylamine (1%) and adjusted to pH 4 with orthophosphoric acid. The total run time was 14 min. Relative standard deviations of the intra-and inter-assay precisions were less than 5.9%. Assumption of linearity was investigated by studying the y-residuals and by ANOVA (analysis of variance). Because of the wide range of calibration (0.1 to 2.0 microgram/ml) variances were non-homogeneous (Hartley's test) and the weighted regression line was computed in order to allow pharmacokinetic studies. Accuracy was tested using a t-statistic. Limits of decision, detection and quantification were realized from an analysis of the blanks. Application of the method to clinical specimens was demonstrated.

Drug-resistant malaria in children and in travelers

Malaria remains a significant cause of childhood morbidity and mortality worldwide. Drug resistance in Plasmodium falciparum has become widespread in the past 30 years, and in some parts of the world multidrug resistance is common. Chloroquine resistance in Plasmodium vivax has recently been recognized in Indonesia. The mechanisms of drug resistance have been defined for the antifolate antimalarial agents but remain incompletely understood for the quinolines. Judicious use of antimalarial compounds will be essential to prevent the emergence and spread of further drug resistance. The history, geographic distribution, and mechanisms of drug resistance are reviewed, together with current recommendations regarding prophylaxis and therapy.

The antimalarial drug halofantrine is bound mainly to low and high density lipoproteins in human serum

1. The major serum proteins which bind halofantrine were identified by size exclusion chromatography. In addition, the binding affinity of halofantrine to human erythrocytes and serum proteins was measured by an erythrocyte partitioning technique. The influence of serum-drug binding on the distribution of halofantrine in whole blood was estimated by simulating several disease-related changes in the levels of the most important binding proteins. 2. The chromatographic resolution of serum preincubated with halofantrine allowed a quantitative analysis of binding to low density lipoproteins, high density lipoproteins, alpha 1-acid glycoprotein and albumin using the erythrocyte partitioning technique. Very low density lipoproteins did not bind halofantrine to a significant extent. 3. In whole blood halofantrine is bound to serum proteins (83%) and to erythrocytes (17%). Low density lipoproteins (affinity constant nKP = 44.4 l g-1) and high density lipoproteins (nKP = 14.4 l g-1) were the most important binding proteins in serum. alpha 1-acid glycoprotein (nKP = 4.39 l g-1) and albumin (nKP = 0.27 l g-1) had relatively low binding affinities. 4. The concentration of serum proteins influences both the fraction of unbound drug and the fraction of drug associated with the erythrocytes. Changes in serum protein concentrations often encountered in malaria are likely to increase both the unbound fraction and the fraction bound to the erythrocytes.

Pharmacokinetics of an extended-dose halofantrine regimen in patients with malaria and in healthy volunteers

The pharmacokinetics and tolerance of a 4.5 gm 7-day halofantrine loading dose regimen were evaluated in 10 Thai patients with malaria and in 10 noninfected volunteers. Halofantrine peak plasma concentrations and bioavailability on the first day of treatment were significantly lower in patients with malaria than in healthy volunteers. Halofantrine elimination half-life was significantly shorter in patients with malaria than healthy control subjects (9.5 versus 15.8 days). These data show a distinct effect of acute malaria on the absorption and elimination of the drug. In addition, marked intersubject and intrasubject variability in peak and trough halofantrine levels was observed, indicating variable drug absorption. This dosing regimen was effective and well tolerated, with mild transient diarrhea during the first few days of treatment in both groups. To produce consistently effective drug levels, the currently recommended dosing regimens may be suboptimal. Slow halofantrine elimination raises concern for induction of parasite resistance when the drug is used in endemic areas of the world.

Halofantrine pharmacokinetics in Kenyan children with non-severe and severe malaria

1. Kenyan children with uncomplicated malaria given oral halofantrine (HF; non-micronised suspension; 8 mg base kg-1 body weight 6 hourly for three doses) showed wide variation in the disposition of HF and desbutylhalofantrine (HFm). 2. Eight Kenyan children with severe (prostrate) falciparum malaria who were receiving intravenous quinine, were given the same HF regimen by nasogastric tube. One patient had undetectable HF and two had undetectable HFm at all times after drug administration. 3. The mean AUC(0,24 h) of HF in prostrate children was half (7.54 compared with 13.10 micrograms ml-1 h) (P = 0.06), and that for HFm one-third (0.84 compared with 2.51 micrograms ml-1 h) (P < 0.05) of the value in children with uncomplicated malaria. 4. Oral HF may be appropriate for some cases of uncomplicated falciparum malaria in Africa, but in patients with severe malaria, the bioavailability of HF and HFm may be inadequate.

Specific inhibition of cyclic AMP-dependent protein kinase by the antimalarial halofantrine and by related phenanthrenes

The phenanthrenemethanol antimalarial halofantrine is a potent inhibitor of bovine heart and rat liver cyclic AMP-dependent protein kinase catalytic subunit (cAK) (IC50 values 2.1 microM and 0.6 microM, respectively). The inhibition of rat liver cAK by halofantrine is non-competitive with respect to both ATP and to the synthetic peptide substrate employed (LRRASLG). Halofantrine is a poor inhibitor of calmodulin-dependent myosin light chain kinase (MLCK) and wheat embryo Ca(2+)-dependent protein kinase (CDPK) and does not inhibit rat brain Ca(2+)- and phospholipid-dependent protein kinase C (PKC). In contrast, the acridine-based antimalarial quinacrine and a variety of quinoline-based antimalarials are very poor inhibitors of cAK, the best inhibitor being chloroquine (IC50 for bovine heart cAK, 80 microM). Quinacrine and the quinoline-based antimalarials variously inhibit CDPK, PKC and MLCK albeit at relatively high concentrations (about 1 to 4 x 10(-4) M), the best inhibitors found being primaquine, pentaquine and mefloquine (IC50 values for MLCK 49, 103 and 33 microM, respectively). A number of phenanthrene derivatives having a 9-hydroxy or 9-keto substituent, namely phenanthrenequinone, 6(5H)-phenanthridinone and 9-phenanthrol are potent inhibitors of bovine heart cAK (IC50 values 8, 10 and 10 microM, respectively) and of MLCK (IC50 values 6, 53 and 10 microM, respectively). The selective, high affinity interaction of halofantrine with cAK may contribute to biological effects in vivo of this clinically-employed antimalarial compound.

Provocation of ventricular tachycardia by antimalarial drug halofantrine in congenital long QT syndrome

This report deals with two patients who suffered sustained episodes of torsade de pointes ventricular tachycardia while using the novel antimalarial drug halofantrine. Both patients had congenital long QT syndrome, and their QT interval was further prolonged at the time of the event. This first electrocardiographic documentation of ventricular arrhythmias together with halofantrine's known prolonging effect on the QT interval demonstrates that the drug has the potential to induce life-threatening arrhythmias.

Artemisinin: large community studies

Prospective randomized trials with oral artemisinin derivatives have been conducted in over 1000 patients to determine the optimum treatment of multi-drug resistant falciparum malaria on the Thai-Burmese border. These drugs have proved valuable in 3 settings. (i) Primary treatment of uncomplicated malaria in combination with mefloquine, when they accelerate the rate of recovery, eliminate the risk of dangerous early failures, and if given for 3 d or more improve overall cure rates; (ii) treatment of recrudescent infections, which otherwise have a high failure rate; and (iii) oral treatment of patients with high parasitaemias (> or = 4%) but no clinical evidence of severity (a group who would usually receive parenteral quinine). The parenteral formulation of artemether is absorbed if given rectally, and this may offer a practical alternative method of treating severe malaria in rural areas.

Pharmacokinetics, efficacy and toxicity of parenteral halofantrine in uncomplicated malaria

1 The pharmacokinetics, efficacy and toxicity of a new parenteral formulation of halofantrine hydrochloride were evaluated in 12 adults with acute uncomplicated falciparum malaria and nine adults who attended in convalescence. 2 Intravenous halofantrine (1 mg kg(-1) infused in 1 h) was given every 8 h for a total of three doses in the acute study. Halofantrine cleared parasitaemia rapidly in all but one patient, with a mean (s.d.) parasite clearance time of 71 (29) h. Convalescent patients received a single infusion (1 mg kg(-1) in 1 h). 3 An open two-compartment model with the following parameters described the pharmacokinetics of halofantrine in acute malaria (mean (s.d)): V1 = 0.36 (0.18) l kg(-1); CL = 0.355 (0.18) l h(-1) kg(-1); t1/2alpha = 0.19 (0.12) h; t1/2beta = 14.4 (7.5) h. 4 Intravenous halofantrine in acute malaria produced significant prolongations of the QT and QTc intervals (mean (s.d.)) of 20 (15%) and 8.2 (5.6)%, respectively (P < 0.001) after the third dose, but no clinically significant cardiotoxcity. Eight patients experienced mild to moderate thrombophlebitis at the halofantrine infusion site which had resolved in six by the time of follow-up. In the single treatment failure who received oral quinine, there was a large rise in plasma halofantrine concentration but this did not result in detectable toxicity. 5 These data provide the basis for the design of improved dosing regimens for the use of parenteral halofantrine in malaria.

Halofantrine--an alternative treatment for malaria

Halofantrine (Halfan – SKB) is a new phenanthrene antimalarial introduced last year for the oral treatment of patients with falciparum and vivax malaria. The data sheet states that it is especially useful for the treatment of patients “likely to be infected with chloroquine or multi-drug-resistant strains of malaria”. We have previously discussed drug treatments for choroquine-resistant malaria.1 Where does halofantrine fit in?

Halofantrine versus mefloquine in treatment of multidrug-resistant falciparum malaria

The continuing spread of multidrug resistance in Plasmodium falciparum malaria makes the search for alternative treatments ever more urgent. We have investigated the relative efficacy of halofantrine and mefloquine in two paired randomised trials on the Thai-Burmese border, a multidrug-resistant area. In the first trial, 198 patients with acute uncomplicated falciparum malaria were randomly assigned either the standard halofantrine regimen (24 mg/kg) or mefloquine (25 mg/kg). The cumulative failure rates by day 28 were 35% with halofantrine and 10% with mefloquine (p = 0.0002). In the second study of 437 patients, a higher dose of halofantrine (8 mg/kg every 8 h for 3 days = 72 mg/kg) was both more effective and better tolerated than mefloquine 25 mg/kg; the failure rates were 3% and 8% (p = 0.03), respectively, or 1% vs 6% after adjustment for possible reinfections (p = 0.009). The rate of failure was higher after retreatment than after primary treatment in all study groups. Halofantrine 72 mg/kg was especially effective in the retreatment of these recrudescent infections; the failure rate was 44% with mefloquine and 15% with high-dose halofantrine (relative risk 3.0 [95% CI 1.2-7.3], p = 0.008). Thus, high-dose halofantrine is better tolerated and more effective than mefloquine for the treatment of uncomplicated falciparum malaria in this area. However, evidence of possible cardiotoxicity will need to be investigated fully before a role can be established for halofantrine in the treatment of multidrug-resistant malaria.