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Alonso-Vega C, Urbina JA, Sanz S, Pinazo MJ, Pinto JJ, Gonzalez VR, Rojas G, Ortiz L, Garcia W, Lozano D, Soy D, Maldonado RA, Nagarkatti R, Debrabant A, Schijman A, Thomas MC, López MC, Michael K, Ribeiro I, Gascon J, Torrico F, Almeida IC. New chemotherapy regimens and biomarkers for Chagas disease: the rationale and design of the TESEO study, an open-label, randomised, prospective, phase-2 clinical trial in the Plurinational State of Bolivia. BMJ Open 2021; 11:e052897. [PMID: 34972765 PMCID: PMC8720984 DOI: 10.1136/bmjopen-2021-052897] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Chagas disease (CD) affects ~7 million people worldwide. Benznidazole (BZN) and nifurtimox (NFX) are the only approved drugs for CD chemotherapy. Although both drugs are highly effective in acute and paediatric infections, their efficacy in adults with chronic CD (CCD) is lower and variable. Moreover, the high incidence of adverse events (AEs) with both drugs has hampered their widespread use. Trials in CCD adults showed that quantitative PCR (qPCR) assays remain negative for 12 months after standard-of-care (SoC) BZN treatment in ~80% patients. BZN pharmacokinetic data and the nonsynchronous nature of the proliferative mammal-dwelling parasite stage suggested that a lower BZN/NFX dosing frequency, combined with standard or extended treatment duration, might have the same or better efficacy than either drug SoC, with fewer AEs. METHODS AND ANALYSIS New ThErapies and Biomarkers for ChagaS infEctiOn (TESEO) is an open-label, randomised, prospective, phase-2 clinical trial, with six treatment arms (75 patients/arm, 450 patients). Primary objectives are to compare the safety and efficacy of two new proposed chemotherapy regimens of BZN and NFX in adults with CCD with the current SoC for BZN and NFX, evaluated by qPCR and biomarkers for 36 months posttreatment and correlated with CD conventional serology. Recruitment of patients was initiated on 18 December 2019 and on 20 May 2021, 450 patients (study goal) were randomised among the six treatment arms. The treatment phase was finalised on 18 August 2021. Secondary objectives include evaluation of population pharmacokinetics of both drugs in all treatment arms, the incidence of AEs, and parasite genotyping. ETHICS AND DISSEMINATION The TESEO study was approved by the National Institutes of Health (NIH), U.S. Food and Drug Administration (FDA), federal regulatory agency of the Plurinational State of Bolivia and the Ethics Committees of the participating institutions. The results will be disseminated via publications in peer-reviewed journals, conferences and reports to the NIH, FDA and participating institutions. TRIAL REGISTRATION NUMBER NCT03981523.
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Affiliation(s)
| | - Julio A Urbina
- Center for Biochemistry and Biophysics, Venezuelan Institute for Scientific Research (IVIC), Caracas, Distrito Capital, Venezuela, Bolivarian Republic of
| | - Sergi Sanz
- Biostatistics and Data Management Unit, Barcelona Institute for Global Health, Barcelona, Spain
- Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Madrid, Spain
- Department of Basic Clinical Practice, Universitat de Barcelona, Barcelona, Spain
| | - María-Jesús Pinazo
- Barcelona Institute for Global Health (ISGLOBAL), Barcelona, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain
| | - Jimy José Pinto
- Fundación Ciencia y Estudios Aplicados para el Desarrollo en Salud y Medio Ambiente (CEADES), Cochabamba, Bolivia, Plurinational State of
| | - Virginia R Gonzalez
- Department of Biological Sciences, The University of Texas at El Paso, El Paso, Texas, USA
| | - Gimena Rojas
- Fundación Ciencia y Estudios Aplicados para el Desarrollo en Salud y Medio Ambiente (CEADES), Cochabamba, Bolivia, Plurinational State of
| | - Lourdes Ortiz
- Fundación Ciencia y Estudios Aplicados para el Desarrollo en Salud y Medio Ambiente (CEADES), Tarija, Bolivia, Plurinational State of
- Universidad Autónoma Juan Misael Saracho, Tarija, Bolivia, Plurinational State of
| | - Wilson Garcia
- Centro Plataforma Chagas Sucre, Fundación Ciencia y Estudios Aplicados para el Desarrollo en Salud y Medio Ambiente (CEADES), Sucre, Bolivia, Plurinational State of
- Programa Departamental de Chagas Chuquisaca, Servicio Departamental de Salud de Chuquisaca, Chuquisaca, Bolivia, Plurinational State of
| | - Daniel Lozano
- Fundación Ciencia y Estudios Aplicados para el Desarrollo en Salud y Medio Ambiente (CEADES), Cochabamba, Bolivia, Plurinational State of
| | - Dolors Soy
- Pharmacy Service, Division of Medicines, Hospital Clinic de Barcelona, Barcelona, Spain
- Institut de Investigació Biomèdica Agustí Pi i Sunyer (IDIBAPS), Universitat de Barcelona, Barcelona, Spain
| | - Rosa A Maldonado
- Department of Biological Sciences, The University of Texas at El Paso, El Paso, Texas, USA
| | - Rana Nagarkatti
- Division of Emerging and Transfusion Transmitted Diseases, Center for Biologics Evaluation and Research, U.S. Food and Drug Administration (FDA), Silver Spring, Maryland, USA
| | - Alain Debrabant
- Division of Emerging and Transfusion Transmitted Diseases, Center for Biologics Evaluation and Research, U.S. Food and Drug Administration (FDA), Silver Spring, Maryland, USA
| | - Alejandro Schijman
- Laboratorio de Biología Molecular de la Enfermedad de Chagas, Instituto de Investigaciones en Ingeniería Genética y Biología Molecular, Buenos Aires, Argentina
- National Scientific and Technical Research Council (CONICET), Buenos Aires, Argentina
| | - M Carmen Thomas
- Consejo Superior de Investigaciones Científicas, Instituto de Parasitología y Biomedicina López-Neyra, Granada, Spain
| | - Manuel Carlos López
- Consejo Superior de Investigaciones Científicas, Instituto de Parasitología y Biomedicina López-Neyra, Granada, Spain
| | - Katja Michael
- Department of Chemistry and Biochemistry, The University of Texas at El Paso, El Paso, Texas, USA
| | - Isabela Ribeiro
- Dynamic Portfolio Unit, Drugs for Neglected Diseases initiative, Geneva, Switzerland
| | - Joaquim Gascon
- Barcelona Institute for Global Health (ISGLOBAL), Barcelona, Spain
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Madrid, Spain
| | - Faustino Torrico
- Fundación Ciencia y Estudios Aplicados para el Desarrollo en Salud y Medio Ambiente (CEADES), Cochabamba, Bolivia, Plurinational State of
| | - Igor C Almeida
- Department of Biological Sciences, The University of Texas at El Paso, El Paso, Texas, USA
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Miranda-Arboleda AF, Zaidel EJ, Marcus R, Pinazo MJ, Echeverría LE, Saldarriaga C, Sosa Liprandi Á, Baranchuk A. Roadblocks in Chagas disease care in endemic and nonendemic countries: Argentina, Colombia, Spain, and the United States. The NET-Heart project. PLoS Negl Trop Dis 2021; 15:e0009954. [PMID: 34968402 PMCID: PMC8717966 DOI: 10.1371/journal.pntd.0009954] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Background Chagas disease (CD) is endemic in Latin America; however, its spread to nontropical areas has raised global interest in this condition. Barriers in access to early diagnosis and treatment of both acute and chronic infection and their complications have led to an increasing disease burden outside of Latin America. Our goal was to identify those barriers and to perform an additional analysis of them based on the Inter American Society of Cardiology (SIAC) and the World Heart Federation (WHF) Chagas Roadmap, at a country level in Argentina, Colombia, Spain, and the United States, which serve as representatives of endemic and nonendemic countries. Methodology and principal findings This is a nonsystematic review of articles published in indexed journals from 1955 to 2021 and of gray literature (local health organizations guidelines, local policies, blogs, and media). We classified barriers to access care as (i) existing difficulties limiting healthcare access; (ii) lack of awareness about CD and its complications; (iii) poor transmission control (vectorial and nonvectorial); (iv) scarce availability of antitrypanosomal drugs; and (v) cultural beliefs and stigma. Region-specific barriers may limit the implementation of roadmaps and require the application of tailored strategies to improve access to appropriate care. Conclusions Multiple barriers negatively impact the prognosis of CD. Identification of these roadblocks both nationally and globally is important to guide development of appropriate policies and public health programs to reduce the global burden of this disease. Chagas disease (CD) has been described as an epidemic in Latin America, but its geographical influence is global. One of the biggest challenges in providing care for patients with CD is to improve access to early diagnosis and treatment in order to avoid chronic cardiovascular and gastrointestinal complications. However, different roadblocks interfere with the optimal care of these patients, which facilitates disease progression. While some barriers to care are global in scope, there are additionally national and even local obstacles for patients with CD. Appropriate delineation of these barriers will allow for the development of targeted interventions to improve the outlook for CD patients in both endemic and nonendemic countries alike.
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Affiliation(s)
- Andrés F. Miranda-Arboleda
- Cardiology Department, Pablo Tobón Uribe Hospital, Medellín, Colombia
- Division of Cardiology, Kingston Health Science Centre, Queen’s University, Kingston, Ontario, Canada
| | - Ezequiel José Zaidel
- Cardiology Department, Sanatorio Güemes, and School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
- * E-mail:
| | - Rachel Marcus
- LASOCHA, Washington, DC, United States of America
- Medstar Union Memorial Hospital, Baltimore, Maryland, United States of America
| | | | | | - Clara Saldarriaga
- Cardiology Service, Clínica CardioVID, Universidad de Antioquia, Medellín, Colombia
| | - Álvaro Sosa Liprandi
- Cardiology Department, Sanatorio Güemes, and School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | - Adrián Baranchuk
- Division of Cardiology, Kingston Health Science Centre, Queen’s University, Kingston, Ontario, Canada
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Martinez-Peinado N, Cortes-Serra N, Sherman J, Rodriguez A, Bustamante JM, Gascon J, Pinazo MJ, Alonso-Padilla J. Identification of Trypanosoma cruzi Growth Inhibitors with Activity In Vivo within a Collection of Licensed Drugs. Microorganisms 2021; 9:microorganisms9020406. [PMID: 33669310 PMCID: PMC7920067 DOI: 10.3390/microorganisms9020406] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 02/08/2021] [Accepted: 02/13/2021] [Indexed: 11/17/2022] Open
Abstract
Chagas disease, caused by the parasite Trypanosoma cruzi (T. cruzi), affects more than six million people worldwide, with its greatest burden in Latin America. Available treatments present frequent toxicity and variable efficacy at the chronic phase of the infection, when the disease is usually diagnosed. Hence, development of new therapeutic strategies is urgent. Repositioning of licensed drugs stands as an attractive fast-track low-cost approach for the identification of safer and more effective chemotherapies. With this purpose we screened 32 licensed drugs for different indications against T. cruzi. We used a primary in vitro assay of Vero cells infection by T. cruzi. Five drugs showed potent activity rates against it (IC50 < 4 µmol L−1), which were also specific (selectivity index >15) with respect to host cells. T. cruzi inhibitory activity of four of them was confirmed by a secondary anti-parasitic assay based on NIH-3T3 cells. Then, we assessed toxicity to human HepG2 cells and anti-amastigote specific activity of those drugs progressed. Ultimately, atovaquone-proguanil, miltefosine, and verapamil were tested in a mouse model of acute T. cruzi infection. Miltefosine performance in vitro and in vivo encourages further investigating its use against T. cruzi.
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Affiliation(s)
- Nieves Martinez-Peinado
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic—University of Barcelona, 08036 Barcelona, Spain; (N.M.-P.); (N.C.-S.); (J.G.)
| | - Nuria Cortes-Serra
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic—University of Barcelona, 08036 Barcelona, Spain; (N.M.-P.); (N.C.-S.); (J.G.)
| | - Julian Sherman
- Department of Microbiology, New York University School of Medicine, New York, NY 10010, USA; (J.S.); (A.R.)
| | - Ana Rodriguez
- Department of Microbiology, New York University School of Medicine, New York, NY 10010, USA; (J.S.); (A.R.)
| | - Juan M. Bustamante
- Center for Tropical and Emerging Global Diseases, University of Georgia, Athens, GA 30602, USA;
| | - Joaquim Gascon
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic—University of Barcelona, 08036 Barcelona, Spain; (N.M.-P.); (N.C.-S.); (J.G.)
| | - Maria-Jesus Pinazo
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic—University of Barcelona, 08036 Barcelona, Spain; (N.M.-P.); (N.C.-S.); (J.G.)
- Correspondence: (M.-J.P.); (J.A.-P.); Tel.: +1-0034-932275400 (ext. 1802) (M.-J.P.); +1-0034-932275400 (ext. 4569) (J.A.-P.)
| | - Julio Alonso-Padilla
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic—University of Barcelona, 08036 Barcelona, Spain; (N.M.-P.); (N.C.-S.); (J.G.)
- Correspondence: (M.-J.P.); (J.A.-P.); Tel.: +1-0034-932275400 (ext. 1802) (M.-J.P.); +1-0034-932275400 (ext. 4569) (J.A.-P.)
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Martínez-Peinado N, Cortes-Serra N, Losada-Galvan I, Alonso-Vega C, Urbina JA, Rodríguez A, VandeBerg JL, Pinazo MJ, Gascon J, Alonso-Padilla J. Emerging agents for the treatment of Chagas disease: what is in the preclinical and clinical development pipeline? Expert Opin Investig Drugs 2020; 29:947-959. [PMID: 32635780 DOI: 10.1080/13543784.2020.1793955] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Chagas disease treatment relies on the lengthy administration of benznidazole and/or nifurtimox, which have frequent toxicity associated. The disease, caused by the parasite Trypanosoma cruzi, is mostly diagnosed at its chronic phase when life-threatening symptomatology manifest in approximately 30% of those infected. Considering that both available drugs have variable efficacy by then, and there are over 6 million people infected, there is a pressing need to find safer, more efficacious drugs. AREAS COVERED We provide an updated view of the path to achieve the aforementioned goal. From state-of-the-art in vitro and in vivo assays based on genetically engineered parasites that have allowed high throughput screenings of large chemical collections, to the unfulfilled requirement of having treatment-response biomarkers for the clinical evaluation of drugs. In between, we describe the most promising pre-clinical hits and the landscape of clinical trials with new drugs or new regimens of existing ones. Moreover, the use of monkey models to reduce the pre-clinical to clinical attrition rate is discussed. EXPERT OPINION In addition to the necessary research on new drugs and much awaited biomarkers of treatment efficacy, a key step will be to generalize access to diagnosis and treatment and maximize efforts to impede transmission.
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Affiliation(s)
- Nieves Martínez-Peinado
- Hospital Clínic - University of Barcelona, Barcelona Institute for Global Health (ISGlobal) , Barcelona, Spain
| | - Nuria Cortes-Serra
- Hospital Clínic - University of Barcelona, Barcelona Institute for Global Health (ISGlobal) , Barcelona, Spain
| | - Irene Losada-Galvan
- Hospital Clínic - University of Barcelona, Barcelona Institute for Global Health (ISGlobal) , Barcelona, Spain
| | - Cristina Alonso-Vega
- Hospital Clínic - University of Barcelona, Barcelona Institute for Global Health (ISGlobal) , Barcelona, Spain
| | - Julio A Urbina
- Venezuelan Institute for Scientific Research , Caracas, Venezuela
| | - Ana Rodríguez
- Department of Microbiology, New York University School of Medicine , New York, NY, USA
| | - John L VandeBerg
- Department of Human Genetics, South Texas Diabetes and Obesity Institute, and Center for Vector-Borne Diseases, The University of Texas Rio Grande Valley , Brownsville/Harlingen/Edinburg, TX, USA
| | - Maria-Jesus Pinazo
- Hospital Clínic - University of Barcelona, Barcelona Institute for Global Health (ISGlobal) , Barcelona, Spain
| | - Joaquim Gascon
- Hospital Clínic - University of Barcelona, Barcelona Institute for Global Health (ISGlobal) , Barcelona, Spain
| | - Julio Alonso-Padilla
- Hospital Clínic - University of Barcelona, Barcelona Institute for Global Health (ISGlobal) , Barcelona, Spain
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