Mechanism of chloroquine resistance in malaria

The relationship of physico-chemical properties and structure to the differential antiplasmodial activity of the cinchona alkaloids

Background

The 8-amino and 9-hydroxy substituents of antimalarial cinchona alkaloids have the erythro orientation while their inactive 9-epimers are threo. From the X-ray structures a 90° difference in torsion angle between the N1-H1 and C9-O12 bonds in the two series is believed to be important. In order to kill the malaria parasite, alkaloids must cross the erythrocyte and parasite membranes to accumulate in the acid digestive vacuole where they prevent detoxication of haematin produced during haemoglobin breakdown.

Methods

Ionization constants, octanol/water distribution and haematin interaction are examined for eight alkaloids to explain the influence of small structural differences on activity.

Results

Erythro isomers have a high distribution ratio of 55:1 from plasma to the erythrocyte membrane, while for the more basic threo epimers this is only 4.5:1. This gives an increased transfer rate of the erythro drugs into the erythrocyte and thence into the parasite vacuole where their favourable conformation allows interaction with haematin, inhibiting its dimerization strongly (90 ± 7%) and thereby killing the parasite. The threo compounds not only enter more slowly but are then severely restricted from binding to haematin by the gauche alignment of their N1-H1 and C9-O12 bonds. Confirmatory molecular models allowed measurement of angles and bond lengths and computation of the electronic spectrum of a quinine-haematin complex.

Conclusion

Differences in the antiplasmodial activity of the erythro and threo cinchona alkaloids may therefore be attributed to the cumulative effects of lipid/aqueous distribution ratio and drug-haematin interaction. Possible insights into the mechanism of chloroquine-resistance are discussed.

Metalloantimalarials: targeting of P. falciparum strains with novel iron(III) and gallium(III) complexes of an amine phenol ligand

Emergence of chloroquine (CQ)-resistant Plasmodium falciparum strains necessitates discovery of potent and inexpensive antimalarial drugs. The high cost of new drugs negatively impacts their access and distribution in the regions of the world with scarce economic resources. While exploring structure-activity relationships, using gallium(III) as a surrogate marker for iron(III), we found cationic, and moderately hydrophobic, compounds, [[1,12-bis(2-hydroxy-3-ethyl-benzyl)-1,5,8,12-tetraazadodecane]metal(III)](+) (metal = Fe(III) and Ga(III); [Fe-3-Eadd](+), 3; [Ga-3-Eadd](+), 4), that possessed antimalarial activity. Crystal structure analyses revealed octahedral geometry for these complexes. The RP-HPLC analysis, after incubation in PBS or HEPES buffer (pH 7.4) at 37 degrees C for 3 days, detected only parental compounds thereby providing evidence for stability under physiological conditions. Both 3 and 4 demonstrated promising half-maximum inhibitory concentration (IC(50)) values of approximately 80 and 86 nM in the CQ-sensitive HB-3 line, respectively. However, both 3 and 4 were found to possess elevated IC(50) values of 2.5 and 0.8 microM, respectively, in the CQ-resistant Dd2 line, thus displaying preferential cytotoxicity toward the CQ-sensitive HB3 line. In cultured parasites, 3 and 4 targeted hemozoin formation. Thus, these compounds acted similarly to chloroquine with regard to action and resistance, despite the lack of structural similarity to quinolines. Finally, similarity in coordination chemistry, stability, and antimalarial cytotoxicity profiles indicated that gallium(III) ion can serve as a template for iron(III) in structure elucidation of active molecules in solution.

Altered binding of chloroquine to ferriprotoporphyrin IX is the basis for chloroquine resistance

The antimalarial specificity of chloroquine (CQ) stems from the saturable uptake of the drug into malaria parasites. Strains of Plasmodium falciparum that are resistant to CQ have evolved a mechanism to reduce the saturable uptake of CQ and several biochemical models have been proposed to explain this. These include an efflux process analogous to multi-drug resistance (MDR) in cancer cells, reduced proton trapping due to elevated vacuolar pH, reduced binding to an intracellular receptor and reduced activity of a permease or drug importer. Here, we attempt to reconcile many of the apparently conflicting data used to support these models. Previous data are analysed in the context of our own model in which CQ uptake is determined by access of the drug to ferriprotoporphyrin IX (FPIX), the intracellular receptor. Copyright 1999 Harcourt Publishers Ltd.

In vitro antimalarial activity of a new organometallic analog, ferrocene-chloroquine

The in vitro activities of new organometallic chloroquine analogs, based on 4-amino-quinoleine compounds bound to a molecule of ferrocene, were evaluated against chloroquine-susceptible, chloroquine-intermediate, and chloroquine-resistant, culture-adapted Plasmodium falciparum lineages by a proliferation test. One of the ferrocene analogs totally restored the activity of chloroquine against chloroquine-resistant parasites. This compound, associated with tartaric acid for better solubility, was highly effective. The role of the ferrocene in reversing chloroquine resistance is discussed, as is its potential use for human therapy.

The mechanisms of action of antiprotozoal and anthelmintic drugs in man

The mechanisms of action of antiprotozoal and anthelmintic drugs are reviewed according to: (1) drugs interfering with metabolic processes; (2) drugs interfering with reproduction and larval physiology; and (3) drugs interfering with neuromuscular physiology of parasites.

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.

Uptake and efflux of chloroquine by chloroquine-resistant Plasmodium falciparum clones recently isolated in Africa

In recently isolated African Plasmodium falciparum clones, the intracellular chloroquine concentration at steady-state, under standard culture conditions, could not differentiate chloroquine-sensitive from resistant parasites. However, under an atmosphere of air the chloroquine-resistant P. falciparum clones released pre-accumulated [3H]chloroquine more rapidly than sensitive clones. The very fast efflux of the pre-accumulated drug from chloroquine-resistant (CQR) parasites resulted in a differential in the drug retained by resistant and sensitive parasites. The chloroquine-sensitive parasites retained 2-3 times more chloroquine than resistant parasites. The steady-state uptake of [3H]chloroquine appeared to be enhanced by verapamil and desipramine in the chloroquine-resistant clones, while the opposite was observed with sensitive clones. This confirmed the suggestion that verapamil inhibits the rapid efflux in CQR parasites resulting in a readily detectable increase in chloroquine accumulation. These observations indicate that the biochemical phenotypes of African chloroquine-resistant P. falciparum are similar to those reported from S.E. Asia and Latin America and are consistent with a common molecular basis for the phenomenon.

The mode of action and the mechanism of resistance to antimalarial drugs

The mechanism of action of the antifolate and quinoline antimalarials has been investigated over the last few decades, and recent advances should aid the development of new drugs to combat the increasingly refractile parasite. The molecular description of resistance to the antifolates has been well characterised and is due to structural changes in the target enzymes, but the factors involved in the parasite's ability to circumvent the action of the quinoline antimalarials have yet to be fully elucidated. This review discusses the mode of action of these drugs and the means used by the parasite to defeat our therapeutic ingenuity.

Relationship of global chloroquine transport and reversal of resistance in Plasmodium falciparum

Control of falciparum malaria has become almost impossible in many areas due to the development of resistance to chloroquine and other antimalarial drugs. Verapamil and a number of unrelated compounds which chemosensitise multi-drug resistant cancer cells also enhance chloroquine susceptibility in Plasmodium falciparum. Chloroquine is accumulated to lower levels in resistant plasmodia, hence the reversal of chloroquine resistance has been attributed to the ability of chemosensitising agents to increase the amount of chloroquine accumulated by the resistant parasite. We have conducted a detailed examination of the effect of verapamil on chloroquine sensitivity and its relationship to chloroquine accumulation. The ability of verapamil to increase steady-state chloroquine accumulation was found to be totally insufficient to explain the increase in chloroquine sensitivity caused by the drug. In contrast, when chloroquine accumulation was increased by raising the pH gradient, the corresponding shifts in sensitivity to chloroquine could be accurately predicted. These results were confirmed with other classes of chemosensitisers and we conclude that an alternative mechanistic explanation is required to completely explain the reversal of chloroquine resistance in P. falciparum.

Malaria chemotherapy: resistance to quinoline containing drugs in Plasmodium falciparum

Resistance to quinoline containing drugs, particularly chloroquine (CQ), is a major impediment to the successful chemotherapy and prophylaxis of malaria. CQ-resistant parasites fail to accumulate as much drug as their sensitive counterparts and two major hypotheses have been proposed to account for this phenomenon. CQ-resistant parasites are thought to maintain lower intracellular drug levels by means of an active efflux system, similar to that found in multi-drug resistant cancer cells, despite major differences in both the genetic and biochemical manifestations of drug resistance in the two cell types. Alternatively, CQ-resistance could be linked to a defective CQ uptake mechanism, possibly an impaired acidification process in the food vacuole of the resistant parasite. These two theories are discussed in detail in the following review. The potential of pharmacological intervention to override these resistance mechanisms is also discussed.

Drug response and genetic characterization of Plasmodium falciparum clones recently isolated from a Sudanese village

We have isolated 20 clones of Plasmodium falciparum from isolates from patients attending a village clinic in Sudan during 10 d in October-November 1989. The clones were genetically diverse, having highly variable molecular karyotypes and a wide range of drug responses. Chloroquine-sensitive (50% inhibitory concentration [IC50] in the 4-15 nM range) and chloroquine-resistant clones (IC50 in the 40-95 nM range) co-existed in the population, but no obvious amplification of the P-glycoprotein homologue gene, Pgh1 (previously known as the multi-drug resistance gene, mdr1) marked the chloroquine-resistant clones. Chloroquine resistance was reversible by verapamil in these clones, although they varied in their susceptibility to verapamil alone. These observations indicate that the biochemical characteristics of the Sudanese chloroquine-resistant P. falciparum are similar to those reported from south-east Asian and Latin American isolates, which is consistent with there being a similar molecular basis for this phenomenon.

Molecular modelling of malaria calmodulin suggests that it is not a suitable target for novel antimalarials

The recent cloning and sequencing of many calmodulin genes permits alignment of DNA and protein sequences, as well as structural comparison based on homology modelling. The crystal structure of calmodulin places the four Ca(2+)-binding domains in a dumbbell-like configuration, with a large hydrophobic cleft in each half of the molecule. Calmodulin from Plasmodium falciparum has a high level of sequence identity (89%) with its mammalian counterpart. However, a lower degree of sequence conservation is observed among calmodulins from other lower eukaryotes. Potentially important differences in calmodulin sequences involve amino acids with side-chains forming the hydrophobic clefts as well as in the central helix; these differences could alter interactions with small hydrophobic molecules such as chloroquine and with enzymes modulated by calmodulin. Our modelling studies suggest that neither of the antimalarials examined (chloroquine and quinine) bind tightly to calmodulin. We conclude that the differences between host and parasite calmodulins are insufficient to merit this protein being chosen as a realistic target for antimalarial drug design. By contrast, our sequence comparisons reveal that the fungal calmodulins are significantly divergent from those of higher eukaryotes suggesting that at least in these species, calmodulin might be a target for novel antimycotic drugs.

Epidemiological evidence for an association between chloroquine resistance of Plasmodium falciparum and its immunological properties

The appearance of chloroquine-resistant genotypes o f Plasmodium falciparum has thwarted the goal of global eradication of malaria. Although much effort has been put into understanding the molecular mechanisms of chloroquine resistance, many questions about its distribution remain open: Why, some 30 years after the emergence o f chloroquine resistance, have resistant genotypes not taken over the population? Why have many parasites remained sensitive? Why, after its first appearance in Africa, has chloroquine resistance spread so rapidly through sub-Saharan Africa? In this paper Jacob Koella reviews epidemiological data that suggest that an answer to these questions may involve an association between chloroquine resistance and immunological properties o f malaria parasites.

A study of chloroquine and desethylchloroquine plasma levels in patients infected with sensitive and resistant malaria parasites

This study was carried out on 63 patients in the town of Gadaref in eastern Sudan; each patient was given the standard therapeutic dose of chloroquine (CQ). Plasma levels of chloroquine and its major metabolite desethylchloroquine (DCQ) were measured by means of a high-performance liquid chromatographic method (HPLC) in patients infected with sensitive (sensitive group) and resistant (resistant groups) strains of Plasmodium falciparum. The ratios of chloroquine to desethylchloroquine (CQ/DCQ) in different groups were calculated and the results obtained were compared and correlated with the degree of parasitaemia. The statistical analysis of the results showed that the plasma content of CQ and the CQ/DCQ ratio in the majority of the patients fall within the normal mode of distribution. A small group of patients showed a deviation from the normal mode by having a rather high CQ plasma level and a high ratio of CQ/DCQ. The mean plasma levels of CQ and the CQ/DCQ ratio in the sensitive group was found to be higher than that in the resistant groups. However, these differences were found to be not significant. Correlation tests showed that the levels of CQ and the CQ/DCQ ratios increase with the increase of the degree of parasitaemia in the sensitive group but decrease with the increase of parasitaemia in resistant groups.

Simulation of kinetic data on the influx and efflux of chloroquine by erythrocytes infected with Plasmodium falciparum. Evidence for a drug-importer in chloroquine-sensitive strains

Literature data on influx and efflux kinetics of chloroquine (CQ) with erythrocytes infected with the malaria parasite Plasmodium falciparum were simulated using a four-compartment model with first-order exchange between the compartments. The four compartments represent (1) the buffer surrounding the infected erythrocyte; (2) the cytosol of the host erythrocyte; (3) the parasite cytosol; and (4) the food vacuole. Simulations showed that basal membrane transport of CQ, estimated from data on influx of CQ into uninfected red cells, largely accounts for uptake and release of CQ by erythrocytes infected with two different CQ-resistant (CQ-R) parasite strains. In contrast, the rate of uptake of CQ by erythrocytes infected with a CQ-sensitive (CQ-S) strain is substantially higher than predicted by uptake with membrane transfer by basal diffusion of CQ. Simulations also indicate that the difference in kinetics of CQ uptake by erythrocytes infected with the CQ-S and CQ-R strains can be explained by a net increase in the inward permeability coefficient at the host erythrocyte membrane, the composite membrane surrounding the parasite or the food vacuole membrane. The results are consistent with the presence of a drug-importer for CQ in erythrocytes infected with sensitive strains, which is absent in those infected with resistant strains. They are not consistent with the hypothesis that CQ resistance is attributable to a drug-exporter in resistant cells which is lacking in sensitive cells.

In vitro and in vivo potentiation of chloroquine against malaria parasites by an enantiomer of amlodipine

A combination of chloroquine and amlodipine, a derivative of 1,4-dihydropyridine calcium channel blocker, was tested against Plasmodium falciparum in vitro and P. yoelii in mice. The dextrorotary enantiomer of amlodipine, practically devoid of calcium channel blocking action, increased chloroquine accumulation inside the infected mouse erythrocytes and potentiated chloroquine action against the resistant strains of P. falciparum in vitro and P. yoelii in mice. Unlike the racemate, the dextrorotary amlodipine was not toxic to the host animal, even at the highest dose of 250 mg/kg. No potentiating effect was noted in the chloroquine-susceptible strains of P. falciparum. The results of this study indicate that chloroquine potentiation of amlodipine is probably independent of calcium channels and that a combination therapy of the dextrorotary enantiomer of amlodipine and chloroquine might be a potentially useful therapeutic strategy against chloroquine-resistant falciparum malaria.

A P-glycoprotein homologue of Plasmodium falciparum is localized on the digestive vacuole

Resistance to chloroquine in Plasmodium falciparum bears a striking similarity to the multi-drug resistance (MDR) phenotype of mammalian tumor cells which is mediated by overexpression of P-glycoprotein. We show here that the P. falciparum homologue of the P-glycoprotein (Pgh1) is a 160,000-D protein that is expressed throughout the asexual erythrocytic life cycle of the parasite. Quantitative immunoblotting analysis has shown that the protein is expressed at approximately equal levels in chloroquine resistant and sensitive isolates suggesting that overexpression of Pgh1 is not essential for chloroquine resistance. The chloroquine-resistant cloned line FAC8 however, does express approximately threefold more Pgh1 protein than other isolates which is most likely because of the increased pfmdr1 gene copy number present in this isolate. Immunofluorescence and immunoelectron microscopy has demonstrated that Pgh1 is localized on the membrane of the digestive vacuole of mature parasites. This subcellular localization suggests that Pgh1 may modulate intracellular chloroquine concentrations and has important implications for the normal physiological function of this protein.

Plasmodium falciparum: in vitro drug interaction between chloroquine and enantiomers of amlodipine

Both enantiomers of amlodipine, whose calcium antagonist action resides almost exclusively in the R(-) enantiomer, reversed chloroquine resistance in Plasmodium falciparum in vitro. R(-) enantiomer was slightly more effective than the S(+) enantiomer in potentiating chloroquine action against chloroquine-resistant strains of parasites. No potentiating effect was observed in chloroquine-sensitive parasites. Both enantiomers entered rapidly into parasitized erythrocytes to the same extent. Reversal of chloroquine resistance by the enantiomers of amlodipine was related to dose-dependent increase in the accumulation of chloroquine inside the erythrocytes parasitized by resistant parasites. These results suggest that the potentiating effect on chloroquine is independent of calcium metabolism of malaria parasites.

The P-glycoprotein homologues of Plasmodium falciparum: Are they involved in chloroquine resistance?

Chloroquine has been the mainstay of antimalarial chemotherapy but the rapid spread of resistance to this important drug has now compromised its efficacy. The mechanism of chloroquine resistance has not been known but recent evidence from Plasmodium falciparum, the causative agent of the most severe form of human malaria, suggested similarities to the multidrug resistance phenotype (MDR) of mammalian tumour cells which is mediated by a protein molecule termed P-glycoprotein. Two mdr genes (pfmdr1 and pfmdr2) encoding P-glycoprotein homologues have been identified in P. falciparum and one of these (pfmdr1) has several alleles that have been linked to the chloroquine resistance phenotype. In contrast analysis of a genetic cross between chloroquine-resistant and -sensitive P. falciparum has suggested that the genes encoding the known P-glycoprotein homologues are not linked. This review outlines the similarities of the chloroquine resistance phenotype with the MDR phenotype of mammalian tumour cells and explores the possible role of the pfmdr genes.

Molecular genetics of drug resistance in Plasmodium faiciparum malaria

Resistance to dihydro folate reductase inhibitors and resistance to chloroquine have been mapped to single genetic loci in Plasmodium falciparum. Specific point mutations in the dihydro folate reductase gene confer different degrees of resistance to two dihydro folate inhibitors, cycloguanil and pyrimethamine, depending on the positions of the mutations and the residues involved. The chloroquine resistance locus has been mapped to a 400 kilobase (kb) segment of chromosome 7 in a P. falciparum cross. Identification and characterization of genes within this segment should lead to an understanding of the rapid drug efflux mechanism responsible for chloroquine resistance.

Uptake of chloroquine by human erythrocytes

Analysis of studies of the pH dependence of the kinetics of chloroquine (CQ) uptake by human erythrocytes indicates that the unionised CQ species is the major membrane permeant at physiological pH even though the concentration of this species as a fraction of the total CQ concentration in solution is extremely small (0.01% at pH 7.4). CQ concentration-dependence studies and studies performed in the presence of various substrates and inhibitors of erythrocyte membrane transport failed to provide evidence of saturation or inhibition of CQ transport, which suggests that the likely mechanism of CQ transport across human erythrocyte membranes is by passive diffusion. Results of equilibrium binding studies of CQ to intact and lysed human erythrocytes indicated that the mechanism of CQ accumulation in intact human erythrocytes appears to be by a combination of ion trapping (a consequence of the basic nature of the drug and the pH gradient across the human erythrocyte membrane) and binding of CQ to cell components.

The prevention of antimalarial drug resistance

The deployment of antiprotozoal drugs on a large scale for prophylaxis or monotherapy inevitably results in the selection of drug-resistance. The use of appropriately selected drug combinations may impede this process. Point mutations underlie resistance to dihydrofolate reductase inhibitors such as pyrimethamine. Potentiating combinations of such compounds with sulfonamides or sulfones have effectively delayed resistance to them. The use of triple combinations may be of value in protecting such compounds as chloroquine and mefloquine, resistance to which is associated in some cases with gene amplification. It is essential to seek partner compounds for any new antimalarials, e.g. artemisinin. Past experience with existing compounds is discussed and the need to make use of all available means of interrupting malaria transmission is stressed, rather than depending entirely on drugs.