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Zhang CX, Conrad TM, Hermann D, Gordon MA, Houpt E, Iroh Tam P, Jere KC, Nedi W, Operario DJ, Phulusa J, Quinnan GV, Sawyer LA, Barrett LK, Thole H, Toto N, Van Voorhis WC, Arnold SLM. Clofazimine pharmacokinetics in HIV-infected adults with diarrhea: Implications of diarrheal disease on absorption of orally administered therapeutics. CPT Pharmacometrics Syst Pharmacol 2024; 13:410-423. [PMID: 38164114 PMCID: PMC10941540 DOI: 10.1002/psp4.13092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 11/05/2023] [Accepted: 11/20/2023] [Indexed: 01/03/2024] Open
Abstract
Oral drug absorption kinetics are usually established in populations with a properly functioning gastrointestinal tract. However, many diseases and therapeutics can alter gastrointestinal physiology and cause diarrhea. The extent of diarrhea-associated impact on drug pharmacokinetics has not been quantitatively described. To address this knowledge gap, we used a population pharmacokinetic modeling approach with data collected in a phase IIa study of matched human immunodeficiency virus (HIV)-infected adults with/without cryptosporidiosis and diarrhea to examine diarrhea-associated impact on oral clofazimine pharmacokinetics. A population pharmacokinetic model was developed with 428 plasma samples from 23 HIV-infected adults with/without Cryptosporidium infection using nonlinear mixed-effects modeling. Covariates describing cryptosporidiosis-associated diarrhea severity (e.g., number of diarrhea episodes, diarrhea grade) or HIV infection (e.g., viral load, CD4+ T cell count) were evaluated. A two-compartment model with lag time and first-order absorption and elimination best fit the data. Maximum diarrhea grade over the study duration was found to be associated with a more than sixfold reduction in clofazimine bioavailability. Apparent clofazimine clearance, intercompartmental clearance, central volume of distribution, and peripheral volume of distribution were 3.71 L/h, 18.2 L/h (interindividual variability [IIV] 45.0%), 473 L (IIV 3.46%), and 3434 L, respectively. The absorption rate constant was 0.625 h-1 (IIV 149%) and absorption lag time was 1.83 h. In conclusion, the maximum diarrhea grade observed for the duration of oral clofazimine administration was associated with a significant reduction in clofazimine bioavailability. Our results highlight the importance of studying disease impacts on oral therapeutic pharmacokinetics to inform dose optimization and maximize the chance of treatment success.
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Affiliation(s)
- Cindy X. Zhang
- Department of PharmaceuticsUniversity of WashingtonSeattleWashingtonUSA
| | - Thomas M. Conrad
- EmmesRockvilleMarylandUSA
- Present address:
AstraZenecaRockvilleMDUSA
| | | | - Melita A. Gordon
- Paediatrics and Child Health Research GroupMalawi‐Liverpool Wellcome Trust Clinical Research ProgrammeBlantyreMalawi
- Institute of Infection and Global HealthUniversity of LiverpoolLiverpoolUK
| | - Eric Houpt
- Division of Infectious Diseases and International HealthUniversity of VirginiaCharlottesvilleVirginiaUSA
| | - Pui‐Ying Iroh Tam
- Paediatrics and Child Health Research GroupMalawi‐Liverpool Wellcome Trust Clinical Research ProgrammeBlantyreMalawi
- Liverpool School of Tropical MedicineLiverpoolUK
| | - Khuzwayo C. Jere
- Paediatrics and Child Health Research GroupMalawi‐Liverpool Wellcome Trust Clinical Research ProgrammeBlantyreMalawi
- Institute of Infection and Global HealthUniversity of LiverpoolLiverpoolUK
| | - Wilfred Nedi
- Paediatrics and Child Health Research GroupMalawi‐Liverpool Wellcome Trust Clinical Research ProgrammeBlantyreMalawi
| | - Darwin J. Operario
- Division of Infectious Diseases and International HealthUniversity of VirginiaCharlottesvilleVirginiaUSA
- Present address:
World Health OrganizationSuvaCentralFiji
| | - Jacob Phulusa
- Paediatrics and Child Health Research GroupMalawi‐Liverpool Wellcome Trust Clinical Research ProgrammeBlantyreMalawi
| | | | | | - Lynn K. Barrett
- Center for Emerging and Re‐emerging Infectious DiseasesUniversity of WashingtonSeattleWashingtonUSA
| | - Herbert Thole
- Paediatrics and Child Health Research GroupMalawi‐Liverpool Wellcome Trust Clinical Research ProgrammeBlantyreMalawi
| | - Neema Toto
- Liverpool School of Tropical MedicineLiverpoolUK
| | - Wesley C. Van Voorhis
- Center for Emerging and Re‐emerging Infectious DiseasesUniversity of WashingtonSeattleWashingtonUSA
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Yarlett N, Morada M, Schaefer DA, Ackman K, Carranza E, Baptista RDP, Riggs MW, Kissinger JC. Genomic and virulence analysis of in vitro cultured Cryptosporidium parvum. PLoS Pathog 2024; 20:e1011992. [PMID: 38416794 PMCID: PMC10927135 DOI: 10.1371/journal.ppat.1011992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 03/11/2024] [Accepted: 01/22/2024] [Indexed: 03/01/2024] Open
Abstract
Recent advances in the in vitro cultivation of Cryptosporidium parvum using hollow fiber bioreactor technology (HFB) have permitted continuous growth of parasites that complete all life cycle stages. The method provides access to all stages of the parasite and provides a method for non-animal production of oocysts for use in clinical trials. Here we examined the effect of long-term (>20 months) in vitro culture on virulence-factors, genome conservation, and in vivo pathogenicity of the host by in vitro cultured parasites. We find low-level sequence variation that is consistent with that observed in calf-passaged parasites. Further using a calf model infection, oocysts obtained from the HFB caused diarrhea of the same volume, duration and oocyst shedding intensity as in vivo passaged parasites.
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Affiliation(s)
- Nigel Yarlett
- Department of Chemistry and Physical Sciences, Pace University, New York, New York, United States of America
- Haskins Laboratories, Pace University, New York, New York, United States of America
| | - Mary Morada
- Haskins Laboratories, Pace University, New York, New York, United States of America
| | - Deborah A. Schaefer
- School of Animal and Comparative Biomedical Sciences, University of Arizona, Tucson, Arizona, United States of America
| | - Kevin Ackman
- School of Animal and Comparative Biomedical Sciences, University of Arizona, Tucson, Arizona, United States of America
| | - Elizabeth Carranza
- School of Animal and Comparative Biomedical Sciences, University of Arizona, Tucson, Arizona, United States of America
| | - Rodrigo de Paula Baptista
- Center for Tropical and Emerging Global Diseases, University of Georgia, Athens, Georgia, United States of America
- Institute of Bioinformatics, University of Georgia, Athens, Georgia, United States of America
| | - Michael W. Riggs
- School of Animal and Comparative Biomedical Sciences, University of Arizona, Tucson, Arizona, United States of America
| | - Jessica C. Kissinger
- Center for Tropical and Emerging Global Diseases, University of Georgia, Athens, Georgia, United States of America
- Institute of Bioinformatics, University of Georgia, Athens, Georgia, United States of America
- Department of Genetics, University of Georgia, Athens, Georgia, United States of America
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Lee S, Love MS, Modukuri R, Chatterjee AK, Huerta L, Lawson AP, McNamara CW, Mead JR, Hedstrom L, Cuny GD. Structure-activity relationship of BMS906024 derivatives for Cryptosporidium parvum growth inhibition. Bioorg Med Chem Lett 2023; 90:129328. [PMID: 37196868 PMCID: PMC10290938 DOI: 10.1016/j.bmcl.2023.129328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 04/28/2023] [Accepted: 05/10/2023] [Indexed: 05/19/2023]
Abstract
BMS906024, a γ-secretase inhibitor that blocks Notch signaling, was previously shown to inhibit Cryptosporidium parvum growth in vitro. A structure-activity relationship (SAR) analysis of BMS906024 reported herein demonstrates the importance of the stereochemistry of the C-3 benzodiazepine and the succinyl β-substituent. However, concomitant removal of the succinyl α-substituent and switching the primary amide with secondary amides was tolerated. For example, 32 (SH287) inhibited C. parvum growth in HCT-8 host cells with an EC50 = 6.4 nM and an EC90 = 16 nM; however, blocking C. parvum growth with BMS906024 derivatives was correlative with inhibition of Notch signaling, highlighting that additional SAR analysis will be needed to separate these two activities.
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Affiliation(s)
- Seungheon Lee
- Department of Pharmacological and Pharmaceutical Sciences, University of Houston, Health Building 2, Houston, TX 77204, USA
| | - Melissa S Love
- Calibr, a Division of The Scripps Research Institute, La Jolla, CA, 92037, USA
| | - Ramkumar Modukuri
- Calibr, a Division of The Scripps Research Institute, La Jolla, CA, 92037, USA
| | - Arnab K Chatterjee
- Calibr, a Division of The Scripps Research Institute, La Jolla, CA, 92037, USA
| | - Lauren Huerta
- Calibr, a Division of The Scripps Research Institute, La Jolla, CA, 92037, USA
| | - Ann P Lawson
- Department of Biology, Brandeis University, 415 South St., Waltham, MA 02454, USA
| | - Case W McNamara
- Calibr, a Division of The Scripps Research Institute, La Jolla, CA, 92037, USA
| | - Jan R Mead
- Atlanta VA Medical Center and Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA
| | - Lizbeth Hedstrom
- Department of Biology, Brandeis University, 415 South St., Waltham, MA 02454, USA; Department of Chemistry, Brandeis University, 415 South St., Waltham, MA 02454, USA
| | - Gregory D Cuny
- Department of Pharmacological and Pharmaceutical Sciences, University of Houston, Health Building 2, Houston, TX 77204, USA.
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Stadler JAM, Maartens G, Meintjes G, Wasserman S. Clofazimine for the treatment of tuberculosis. Front Pharmacol 2023; 14:1100488. [PMID: 36817137 PMCID: PMC9932205 DOI: 10.3389/fphar.2023.1100488] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 01/19/2023] [Indexed: 02/05/2023] Open
Abstract
Shorter (6-9 months), fully oral regimens containing new and repurposed drugs are now the first-choice option for the treatment of drug-resistant tuberculosis (DR-TB). Clofazimine, long used in the treatment of leprosy, is one such repurposed drug that has become a cornerstone of DR-TB treatment and ongoing trials are exploring novel, shorter clofazimine-containing regimens for drug-resistant as well as drug-susceptible tuberculosis. Clofazimine's repurposing was informed by evidence of potent activity against DR-TB strains in vitro and in mice and a treatment-shortening effect in DR-TB patients as part of a multidrug regimen. Clofazimine entered clinical use in the 1950s without the rigorous safety and pharmacokinetic evaluation which is part of modern drug development and current dosing is not evidence-based. Recent studies have begun to characterize clofazimine's exposure-response relationship for safety and efficacy in populations with TB. Despite being better tolerated than some other second-line TB drugs, the extent and impact of adverse effects including skin discolouration and cardiotoxicity are not well understood and together with emergent resistance, may undermine clofazimine use in DR-TB programmes. Furthermore, clofazimine's precise mechanism of action is not well established, as is the genetic basis of clofazimine resistance. In this narrative review, we present an overview of the evidence base underpinning the use and limitations of clofazimine as an antituberculosis drug and discuss advances in the understanding of clofazimine pharmacokinetics, toxicity, and resistance. The unusual pharmacokinetic properties of clofazimine and how these relate to its putative mechanism of action, antituberculosis activity, dosing considerations and adverse effects are highlighted. Finally, we discuss the development of novel riminophenazine analogues as antituberculosis drugs.
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Affiliation(s)
- Jacob A. M. Stadler
- Department of Medicine, University of Cape Town, Cape Town, South Africa,Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa,*Correspondence: Jacob A. M. Stadler,
| | - Gary Maartens
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa,Department of Medicine, Division of Clinical Pharmacology, University of Cape Town, Cape Town, South Africa
| | - Graeme Meintjes
- Department of Medicine, University of Cape Town, Cape Town, South Africa,Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Sean Wasserman
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa,Division of Infectious Diseases and HIV Medicine, Department of Medicine, University of Cape Town, Cape Town, South Africa
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Caravedo MA, White AC. Treatment of cryptosporidiosis: nitazoxanide yes, but we can do better. Expert Rev Anti Infect Ther 2023; 21:167-173. [PMID: 36533398 DOI: 10.1080/14787210.2023.2160704] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Cryptosporidiosis was initially recognized as an important cause of diarrhea in AIDS patients. It has been underdiagnosed in other populations. Recent studies have highlighted the importance of Cryptosporidium as a cause of diarrhea and malnutrition in young children in resource-poor countries and an emerging pathogen in organ-transplant recipients. AREAS COVERED Nitazoxanide is FDA approved for treatment of cryptosporidiosis in immunocompetent people. However, it is less effective in HIV and transplant patients and malnourished children. In transplant recipients, there is emerging data on antiparasitic combinations for cryptosporidiosis, including combinations of nitazoxanide, azithromycin, and in one case rifaximin. High-throughput phenotypic screens have identified some potential treatments. Among them, clofazimine was no better than placebo in a trial in AIDS patients. There have also been efforts to develop drug versus specific parasite targets. However, in part due to safety issues, none of these compounds have advanced into clinical trials. EXPERT OPINION Development of new and more efficacious therapies for cryptosporidium is imperative. Current approve therapy is far from optimal and lacks efficacy in high-risk populations, such as, patients living with HIV. Additionally, there is limited data on patients with other types of immunosuppression (Transplanted, autoimmune conditions, etc).
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Affiliation(s)
- Maria A Caravedo
- Infectious Disease Division Department of Internal Medicine University of Texas Medical Branch, Galveston, Texas, USA
| | - A Clinton White
- Infectious Disease Division Department of Internal Medicine University of Texas Medical Branch, Galveston, Texas, USA
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The Marine Compound Tartrolon E Targets the Asexual and Early Sexual Stages of Cryptosporidium parvum. Microorganisms 2022; 10:microorganisms10112260. [PMID: 36422330 PMCID: PMC9693555 DOI: 10.3390/microorganisms10112260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 11/08/2022] [Accepted: 11/10/2022] [Indexed: 11/16/2022] Open
Abstract
New therapeutic agents for cryptosporidiosis are a critical medical need. The marine organic compound, tartrolon E (trtE), is highly effective against multiple apicomplexan parasites, including Cryptosporidium. Understanding the mechanism of action of trtE is required to advance in the drug development pipeline. Here, we validate using Nluc C. parvum parasites for the study of trtE and pinpoint the life stage targeted by trtE. Results show that trtE kills Nluc and wild type C. parvum with equal efficiency, confirming the use of the Nluc C. parvum to study this compound. Results revealed that trtE kills the parasite within an hour of treatment and while the compound has no effect on viability of sporozoites, trtE does inhibit establishment of infection. Targeting treatment at particular life cycle stages demonstrated that trtE is effective against asexual of the parasite but has reduced efficacy against mature sexual stages. Gene expression analysis shows that trtE inhibits the early sexual stage of the parasite. Results from these studies will aid the development of trtE as a therapeutic for cryptosporidiosis.
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