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Antillon M, Huang CI, Sutherland SA, Crump RE, Bessell PR, Shaw APM, Tirados I, Picado A, Biéler S, Brown PE, Solano P, Mbainda S, Darnas J, Wang-Steverding X, Crowley EH, Peka M, Tediosi F, Rock KS. Health economic evaluation of strategies to eliminate gambiense human African trypanosomiasis in the Mandoul disease focus of Chad. PLoS Negl Trop Dis 2023; 17:e0011396. [PMID: 37498938 PMCID: PMC10409297 DOI: 10.1371/journal.pntd.0011396] [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: 07/28/2022] [Revised: 08/08/2023] [Accepted: 05/22/2023] [Indexed: 07/29/2023] Open
Abstract
Human African trypanosomiasis, caused by the gambiense subspecies of Trypanosoma brucei (gHAT), is a deadly parasitic disease transmitted by tsetse. Partners worldwide have stepped up efforts to eliminate the disease, and the Chadian government has focused on the previously high-prevalence setting of Mandoul. In this study, we evaluate the economic efficiency of the intensified strategy that was put in place in 2014 aimed at interrupting the transmission of gHAT, and we make recommendations on the best way forward based on both epidemiological projections and cost-effectiveness. In our analysis, we use a dynamic transmission model fit to epidemiological data from Mandoul to evaluate the cost-effectiveness of combinations of active screening, improved passive screening (defined as an expansion of the number of health posts capable of screening for gHAT), and vector control activities (the deployment of Tiny Targets to control the tsetse vector). For cost-effectiveness analyses, our primary outcome is disease burden, denominated in disability-adjusted life-years (DALYs), and costs, denominated in 2020 US$. Although active and passive screening have enabled more rapid diagnosis and accessible treatment in Mandoul, the addition of vector control provided good value-for-money (at less than $750/DALY averted) which substantially increased the probability of reaching the 2030 elimination target for gHAT as set by the World Health Organization. Our transmission modelling and economic evaluation suggest that the gains that have been made could be maintained by passive screening. Our analysis speaks to comparative efficiency, and it does not take into account all possible considerations; for instance, any cessation of ongoing active screening should first consider that substantial surveillance activities will be critical to verify the elimination of transmission and to protect against the possible importation of infection from neighbouring endemic foci.
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Affiliation(s)
- Marina Antillon
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Ching-I Huang
- Zeeman Institute for Systems Biology and Infectious Disease Epidemiology Research, The University of Warwick, Coventry, United Kingdom
- Mathematics Institute, The University of Warwick, Coventry, United Kingdom
| | - Samuel A. Sutherland
- Zeeman Institute for Systems Biology and Infectious Disease Epidemiology Research, The University of Warwick, Coventry, United Kingdom
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Ronald E. Crump
- Zeeman Institute for Systems Biology and Infectious Disease Epidemiology Research, The University of Warwick, Coventry, United Kingdom
- Mathematics Institute, The University of Warwick, Coventry, United Kingdom
| | | | - Alexandra P. M. Shaw
- Infection Medicine, Deanery of Biomedical Sciences, College of Medicine and Veterinary Medicine, The University of Edinburgh, Edinburgh, United Kingdom
- AP Consultants, Walworth Enterprise Centre, Andover, United Kingdom
| | - Iñaki Tirados
- Department of Vector Biology, Liverpool School of Tropical Medicine, United Kingdom
| | - Albert Picado
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
| | - Sylvain Biéler
- Foundation for Innovative New Diagnostics (FIND), Geneva, Switzerland
| | - Paul E. Brown
- Zeeman Institute for Systems Biology and Infectious Disease Epidemiology Research, The University of Warwick, Coventry, United Kingdom
- Mathematics Institute, The University of Warwick, Coventry, United Kingdom
| | - Philippe Solano
- Institut de Recherche pour le Développement, UMR INTERTRYP IRD-CIRAD, Université de Montpellier, Montpellier, France
| | - Severin Mbainda
- Programme National de Lutte contre la Trypanosomiase Humaine Africaine (PNLTHA), Moundou, Chad
| | - Justin Darnas
- Programme National de Lutte contre la Trypanosomiase Humaine Africaine (PNLTHA), Moundou, Chad
| | - Xia Wang-Steverding
- Zeeman Institute for Systems Biology and Infectious Disease Epidemiology Research, The University of Warwick, Coventry, United Kingdom
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Emily H. Crowley
- Zeeman Institute for Systems Biology and Infectious Disease Epidemiology Research, The University of Warwick, Coventry, United Kingdom
- Mathematics Institute, The University of Warwick, Coventry, United Kingdom
| | - Mallaye Peka
- Programme National de Lutte contre la Trypanosomiase Humaine Africaine (PNLTHA), Moundou, Chad
| | - Fabrizio Tediosi
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Kat S. Rock
- Zeeman Institute for Systems Biology and Infectious Disease Epidemiology Research, The University of Warwick, Coventry, United Kingdom
- Mathematics Institute, The University of Warwick, Coventry, United Kingdom
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García-Estrada C, Pérez-Pertejo Y, Domínguez-Asenjo B, Holanda VN, Murugesan S, Martínez-Valladares M, Balaña-Fouce R, Reguera RM. Further Investigations of Nitroheterocyclic Compounds as Potential Antikinetoplastid Drug Candidates. Biomolecules 2023; 13:biom13040637. [PMID: 37189384 DOI: 10.3390/biom13040637] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 03/28/2023] [Accepted: 03/30/2023] [Indexed: 04/05/2023] Open
Abstract
Due to the lack of specific vaccines, management of the trypanosomatid-caused neglected tropical diseases (sleeping sickness, Chagas disease and leishmaniasis) relies exclusively on pharmacological treatments. Current drugs against them are scarce, old and exhibit disadvantages, such as adverse effects, parenteral administration, chemical instability and high costs which are often unaffordable for endemic low-income countries. Discoveries of new pharmacological entities for the treatment of these diseases are scarce, since most of the big pharmaceutical companies find this market unattractive. In order to fill the pipeline of compounds and replace existing ones, highly translatable drug screening platforms have been developed in the last two decades. Thousands of molecules have been tested, including nitroheterocyclic compounds, such as benznidazole and nifurtimox, which had already provided potent and effective effects against Chagas disease. More recently, fexinidazole has been added as a new drug against African trypanosomiasis. Despite the success of nitroheterocycles, they had been discarded from drug discovery campaigns due to their mutagenic potential, but now they represent a promising source of inspiration for oral drugs that can replace those currently on the market. The examples provided by the trypanocidal activity of fexinidazole and the promising efficacy of the derivative DNDi-0690 against leishmaniasis seem to open a new window of opportunity for these compounds that were discovered in the 1960s. In this review, we show the current uses of nitroheterocycles and the novel derived molecules that are being synthesized against these neglected diseases.
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Affiliation(s)
- Carlos García-Estrada
- Departamento de Ciencias Biomédicas, Facultad de Veterinaria, Universidad de León, Campus de Vegazana s/n, 24071 León, Spain
| | - Yolanda Pérez-Pertejo
- Departamento de Ciencias Biomédicas, Facultad de Veterinaria, Universidad de León, Campus de Vegazana s/n, 24071 León, Spain
| | - Bárbara Domínguez-Asenjo
- Departamento de Ciencias Biomédicas, Facultad de Veterinaria, Universidad de León, Campus de Vegazana s/n, 24071 León, Spain
| | - Vanderlan Nogueira Holanda
- Departamento de Ciencias Biomédicas, Facultad de Veterinaria, Universidad de León, Campus de Vegazana s/n, 24071 León, Spain
| | - Sankaranarayanan Murugesan
- Medicinal Chemistry Research Laboratory, Department of Pharmacy, Birla Institute of Technology and Science Pilani, Pilani Campus, Pilani 333031, India
| | - María Martínez-Valladares
- Instituto de Ganadería de Montaña (IGM), Consejo Superior de Investigaciones Científicas-Universidad de León, Carretera León-Vega de Infanzones, Vega de Infanzones, 24346 León, Spain
- Departamento de Sanidad Animal, Facultad de Veterinaria, Universidad de León, Campus de Vegazana s/n, 24071 León, Spain
| | - Rafael Balaña-Fouce
- Departamento de Ciencias Biomédicas, Facultad de Veterinaria, Universidad de León, Campus de Vegazana s/n, 24071 León, Spain
| | - Rosa M. Reguera
- Departamento de Ciencias Biomédicas, Facultad de Veterinaria, Universidad de León, Campus de Vegazana s/n, 24071 León, Spain
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Betu Kumeso VK, Kalonji WM, Rembry S, Valverde Mordt O, Ngolo Tete D, Prêtre A, Delhomme S, Ilunga Wa Kyhi M, Camara M, Catusse J, Schneitter S, Nusbaumer M, Mwamba Miaka E, Mahenzi Mbembo H, Makaya Mayawula J, Layba Camara M, Akwaso Massa F, Kaninda Badibabi L, Kasongo Bonama A, Kavunga Lukula P, Mutanda Kalonji S, Mariero Philemon P, Mokilifi Nganyonyi R, Embana Mankiara H, Asuka Akongo Nguba A, Kobo Muanza V, Mulenge Nasandhel E, Fifi Nzeza Bambuwu A, Scherrer B, Strub-Wourgaft N, Tarral A. Efficacy and safety of acoziborole in patients with human African trypanosomiasis caused by Trypanosoma brucei gambiense: a multicentre, open-label, single-arm, phase 2/3 trial. THE LANCET. INFECTIOUS DISEASES 2023; 23:463-470. [PMID: 36460027 PMCID: PMC10033454 DOI: 10.1016/s1473-3099(22)00660-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 09/28/2022] [Accepted: 09/29/2022] [Indexed: 12/05/2022]
Abstract
BACKGROUND Human African trypanosomiasis caused by Trypanosoma brucei gambiense (gambiense HAT) in patients with late-stage disease requires hospital admission to receive nifurtimox-eflornithine combination therapy (NECT). Fexinidazole, the latest treatment that has been recommended by WHO, also requires systematic admission to hospital, which is problematic in areas with few health-care resources. We aim to assess the safety and efficacy of acoziborole in adult and adolescent patients with gambiense HAT. METHODS This multicentre, prospective, open-label, single-arm, phase 2/3 study recruited patients aged 15 years or older with confirmed gambiense HAT infection from ten hospitals in the Democratic Republic of the Congo and Guinea. Inclusion criteria included a Karnofsky score greater than 50, ability to swallow tablets, a permanent address or traceability, ability to comply with follow-up visits and study requirements, and agreement to hospital admission during treatment. Oral acoziborole was administered as a single 960 mg dose (3 × 320 mg tablets) to fasted patients. Patients were observed in hospital until day 15 after treatment administration then for 18 months as outpatients with visits at 3, 6, 12, and 18 months. The primary efficacy endpoint was the success rate of acoziborole treatment at 18 months in patients with late-stage gambiense HAT (modified intention-to-treat [mITT] population), based on modified WHO criteria. A complementary post-hoc analysis comparing the 18-month success rates for acoziborole and NECT (using historical data) was performed. This study is registered at ClinicalTrials.gov, NCT03087955. FINDINGS Between Oct 11, 2016, and March 25, 2019, 260 patients were screened, of whom 52 were ineligible and 208 were enrolled (167 with late-stage and 41 with early-stage or intermediate-stage gambiense HAT; primary efficacy analysis set). All 41 (100%) patients with early-stage or intermediate-stage and 160 (96%) of 167 with late-stage disease completed the last 18-month follow-up visit. The mean age of participants was 34·0 years (SD 12·4), including 117 (56%) men and 91 (44%) women. Treatment success rate at 18 months was 95·2% (95% CI 91·2-97·7) reached in 159 of 167 patients with late-stage gambiense HAT (mITT population) and 98·1% (95·1-99·5) reached in 159 of 162 patients (evaluable population). Overall, 155 (75%) of 208 patients had 600 treatment-emergent adverse events. A total of 38 drug-related treatment-emergent adverse events occurred in 29 (14%) patients; all were mild or moderate and most common were pyrexia and asthenia. Four deaths occurred during the study; none were considered treatment related. The post-hoc analysis showed similar results to the estimated historical success rate for NECT of 94%. INTERPRETATION Given the high efficacy and favourable safety profile, acoziborole holds promise in the efforts to reach the WHO goal of interrupting HAT transmission by 2030. FUNDING Bill & Melinda Gates Foundation, UK Aid, Federal Ministry of Education and Research, Swiss Agency for Development and Cooperation, Médecins Sans Frontières, Dutch Ministry of Foreign Affairs, Norwegian Agency for Development Cooperation, Norwegian Ministry of Foreign Affairs, the Stavros Niarchos Foundation, Spanish Agency for International Development Cooperation, and the Banco Bilbao Vizcaya Argentaria Foundation. TRANSLATION For the French translation of the abstract see Supplementary Materials section.
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Affiliation(s)
| | | | - Sandra Rembry
- Drugs for Neglected Diseases initiative, Geneva, Switzerland
| | | | - Digas Ngolo Tete
- Drugs for Neglected Diseases initiative, Kinshasa, Democratic Republic of the Congo
| | - Adeline Prêtre
- Drugs for Neglected Diseases initiative, Geneva, Switzerland
| | - Sophie Delhomme
- Drugs for Neglected Diseases initiative, Geneva, Switzerland
| | | | - Mamadou Camara
- Programme National de Lutte contre la Trypanosomiase Humaine Africaine, Conakry, Guinea
| | - Julie Catusse
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland; University of Basel, Basel, Switzerland
| | - Stefan Schneitter
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland; University of Basel, Basel, Switzerland
| | - Morgane Nusbaumer
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland; University of Basel, Basel, Switzerland
| | - Erick Mwamba Miaka
- Programme National de Lutte contre la Trypanosomiase Humaine Africaine, Kinshasa, Democratic Republic of the Congo
| | | | | | | | | | | | | | | | - Sylvain Mutanda Kalonji
- Drugs for Neglected Diseases initiative, Kinshasa, Democratic Republic of the Congo; Ngandajika Hospital, Kasaï Oriental, Democratic Republic of the Congo
| | | | - Ricardo Mokilifi Nganyonyi
- Kwamouth Hospital, Kwamouth, Democratic Republic of the Congo; Bolobo Hospital, Bolobo, Democratic Republic of the Congo
| | | | | | | | | | | | - Bruno Scherrer
- Bruno Scherrer Conseil, Saint Arnoult en Yvelines, France
| | | | - Antoine Tarral
- Drugs for Neglected Diseases initiative, Geneva, Switzerland.
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Determination of the Optimal Single Dose Treatment for Acoziborole, a Novel Drug for the Treatment of Human African Trypanosomiasis: First-in-Human Study. Clin Pharmacokinet 2023; 62:481-491. [PMID: 36763327 PMCID: PMC10042906 DOI: 10.1007/s40262-023-01216-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND AND OBJECTIVES Acoziborole is a novel boron-containing candidate developed as an oral drug for the treatment of human African trypanosomiasis (HAT). Results from preclinical studies allowed progression to Phase 1 trials. We aimed to determine the best dose regimen for all stages of HAT. METHODS Acoziborole was assessed in 128 healthy adult males of sub-Saharan African origin living in France. The study included a single oral administration of a 20- to 1200-mg dose in a randomised double-blind study in cohorts of 8 (6 active, 2 placebo) to assess safety, tolerability, and pharmacokinetics. In three additional open cohorts of 6 participants, the effect of activated charcoal was evaluated, bioequivalence of capsules versus tablets was assessed, and safety in the 960-mg tablet cohorts was monitored. RESULTS Acoziborole was well tolerated at all doses tested; no dose-related adverse events were observed. The drug appeared rapidly in plasma (at 1 h), reached tmax between 24 and 72 h, and remained stable for up to 96 h, after which a slow decrease was quantifiable until 14 weeks after dosing. Charcoal had little impact on the enterohepatic recirculation effect, except for the 20-mg dose. Bioequivalence between capsule and tablet formulations was demonstrated. The therapeutic single dose for administration under fasted conditions was fixed to 960 mg. The maximum administered dose was 1200 mg. CONCLUSIONS This study showed that acoziborole could be safely assessed in patients as a potential single-dose oral cure for both stages of gambiense HAT. TRIAL REGISTRATION The study was registered with ClinicalTrials.gov: NCT01533961.
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Kande Betu Kumesu V, Mutombo Kalonji W, Bardonneau C, Valverde Mordt O, Ngolo Tete D, Blesson S, Simon F, Delhomme S, Bernhard S, Nganzobo Ngima P, Mahenzi Mbembo H, Fina Lubaki JP, Lumeya Vuvu S, Kuziena Mindele W, Ilunga Wa Kyhi M, Mandula Mokenge G, Kaninda Badibabi L, Kasongo Bonama A, Kavunga Lukula P, Lumbala C, Scherrer B, Strub-Wourgaft N, Tarral A. Safety and efficacy of oral fexinidazole in children with gambiense human African trypanosomiasis: a multicentre, single-arm, open-label, phase 2–3 trial. THE LANCET GLOBAL HEALTH 2022; 10:e1665-e1674. [PMID: 36179736 PMCID: PMC9554014 DOI: 10.1016/s2214-109x(22)00338-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 06/22/2022] [Accepted: 07/28/2022] [Indexed: 11/24/2022] Open
Abstract
Background Fexinidazole has been reported as an effective oral monotherapy against non-severe gambiense human African trypanosomiasis in a recent trial in adults. We aimed to assess the safety and efficacy of fexinidazole in children across all disease stages of gambiense human African trypanosomiasis. Methods We did a multicentre, single-arm, open-label, phase 2–3 trial at eight district hospitals in the Democratic Republic of the Congo. We recruited children with a Karnofsky score of more than 50, those aged 6 years to younger than 15 years, weighing 20 kg or more, and with confirmed gambiense human African trypanosomiasis (any stage). Children weighing 20 kg or more and less than 35 kg received oral fexinidazole of 1200 mg (two × 600 mg tablets) once per day for 4 days (days 1–4) followed by 600 mg (one × 600 mg tablet) once per day for 6 days (days 5–10). Children weighing 35 kg or more received oral fexinidazole of 1800 mg (three × 600 mg tablets) once per day for 4 days (days 1–4), followed by 1200 mg (two × 600 mg tablets) once per day for 6 days (days 5–10). The primary endpoint was fexinidazole treatment success rate 12 months after end of treatment. A rate greater than 80% was deemed acceptable and a target value of 92% was aimed for. Safety was assessed through routine monitoring. This study is completed and registered with ClinicalTrials.gov, number NCT02184689. Findings Between May 3, 2014, and Nov 22, 2016, we screened a total of 130 paediatric patients, of whom 125 (96%) received at least one dose of fexinidazole. All 125 patients (69 [55%] patients with stage 1, 19 [15%] with early stage 2, and 37 [30%] with late stage 2 gambiense human African trypanosomiasis) completed the 10-day treatment. Treatment success rate at 12 months was 97·6% (95% CI 93·1–99·5; 122 of 125 patients). The primary endpoint was met and the targeted value of 92% was exceeded. Treatment success at 12 months was elevated across all disease stages: 98·6% (95% CI 92·2–99·9; 68 of 69 patients) in stage 1, 94·7% (74·0–99·9; 18 of 19 patients) in early stage 2, and 97·3% (85·8–99·9; 36 of 37 patients) in late stage 2 gambiense human African trypanosomiasis. No new safety issues were observed beyond those found in adult trials. Overall, 116 (93%) of 125 patients reported 586 treatment-emergent adverse events, mainly mild or moderate. The most frequently reported treatment-emergent adverse events of interest during hospital admission were vomiting (86 [69%] of 125) and headache (41 [33%]). Seven (6%) of 125 patients had severe malaria, which was often accompanied by anaemia that was unrelated to fexinidazole. One patient died following dyspnoea and injury due to traumatic aggression 172 days after end of treatment, which was considered unrelated to fexinidazole or gambiense human African trypanosomiasis. Interpretation Oral fexinidazole is a safe and effective first-line treatment option across all gambiense human African trypanosomiasis disease stages in paediatric patients. Funding Through the Drugs for Neglected Diseases initiative: the Bill & Melinda Gates Foundation (USA), the Republic and Canton of Geneva (Switzerland), the Dutch Ministry of Foreign Affairs (Netherlands), the Norwegian Agency for Development Cooperation (Norway), the Federal Ministry of Education and Research through KfW (Germany), the Brian Mercer Charitable Trust (UK), and other private foundations and individuals from the human African trypanosomiasis campaign. Translation For the French translation of the abstract see Supplementary Materials section.
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Kasozi KI, MacLeod ET, Ntulume I, Welburn SC. An Update on African Trypanocide Pharmaceutics and Resistance. Front Vet Sci 2022; 9:828111. [PMID: 35356785 PMCID: PMC8959112 DOI: 10.3389/fvets.2022.828111] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 01/12/2022] [Indexed: 12/22/2022] Open
Abstract
African trypanosomiasis is associated with Trypanosoma evansi, T. vivax, T. congolense, and T. brucei pathogens in African animal trypanosomiasis (AAT) while T. b gambiense and T. b rhodesiense are responsible for chronic and acute human African trypanosomiasis (HAT), respectively. Suramin sodium suppresses ATP generation during the glycolytic pathway and is ineffective against T. vivax and T. congolense infections. Resistance to suramin is associated with pathogen altered transport proteins. Melarsoprol binds irreversibly with pyruvate kinase protein sulfhydryl groups and neutralizes enzymes which interrupts the trypanosome ATP generation. Melarsoprol resistance is associated with the adenine-adenosine transporter, P2, due to point mutations within this transporter. Eflornithine is used in combination with nifurtimox. Resistance to eflornithine is caused by the deletion or mutation of TbAAT6 gene which encodes the transmembrane amino acid transporter that delivers eflornithine into the cell, thus loss of transporter protein results in eflornithine resistance. Nifurtimox alone is regarded as a poor trypanocide, however, it is effective in melarsoprol-resistant gHAT patients. Resistance is associated with loss of a single copy of the genes encoding for nitroreductase enzymes. Fexinidazole is recommended for first-stage and non-severe second-stage illnesses in gHAT and resistance is associated with trypanosome bacterial nitroreductases which reduce fexinidazole. In AAT, quinapyramine sulfate interferes with DNA synthesis and suppression of cytoplasmic ribosomal activity in the mitochondria. Quinapyramine sulfate resistance is due to variations in the potential of the parasite's mitochondrial membrane. Pentamidines create cross-links between two adenines at 4–5 pairs apart in adenine-thymine-rich portions of Trypanosoma DNA. It also suppresses type II topoisomerase in the mitochondria of Trypanosoma parasites. Pentamidine resistance is due to loss of mitochondria transport proteins P2 and HAPT1. Diamidines are most effective against Trypanosome brucei group and act via the P2/TbAT1 transporters. Diminazene aceturate resistance is due to mutations that alter the activity of P2, TeDR40 (T. b. evansi). Isometamidium chloride is primarily employed in the early stages of trypanosomiasis and resistance is associated with diminazene resistance. Phenanthridine (homidium bromide, also known as ethidium bromide) acts by a breakdown of the kinetoplast network and homidium resistance is comparable to isometamidium. In humans, the development of resistance and adverse side effects against monotherapies has led to the adoption of nifurtimox-eflornithine combination therapy. Current efforts to develop new prodrug combinations of nifurtimox and eflornithine and nitroimidazole fexinidazole as well as benzoxaborole SCYX-7158 (AN5568) for HAT are in progress while little comparable progress has been done for the development of novel therapies to address trypanocide resistance in AAT.
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Affiliation(s)
- Keneth Iceland Kasozi
- Infection Medicine, Deanery of Biomedical Sciences, College of Medicine and Veterinary Medicine, The University of Edinburgh, Edinburgh, United Kingdom
- School of Medicine, Kabale University, Kabale, Uganda
- *Correspondence: Keneth Iceland Kasozi ;
| | - Ewan Thomas MacLeod
- Infection Medicine, Deanery of Biomedical Sciences, College of Medicine and Veterinary Medicine, The University of Edinburgh, Edinburgh, United Kingdom
| | - Ibrahim Ntulume
- School of Biosecurity Biotechnical and Laboratory Sciences, College of Medicine and Veterinary Medicine, Makerere University, Kampala, Uganda
| | - Susan Christina Welburn
- Infection Medicine, Deanery of Biomedical Sciences, College of Medicine and Veterinary Medicine, The University of Edinburgh, Edinburgh, United Kingdom
- Zhejiang University-University of Edinburgh Joint Institute, Zhejiang University, Hangzhou, China
- Susan Christina Welburn
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Lutje V, Probyn K, Seixas J, Bergman H, Villanueva G. Chemotherapy for second-stage human African trypanosomiasis: drugs in use. Cochrane Database Syst Rev 2021; 12:CD015374. [PMID: 34882307 PMCID: PMC8656462 DOI: 10.1002/14651858.cd015374] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Human African trypanosomiasis, or sleeping sickness, is a severe disease affecting people in the poorest parts of Africa. It is usually fatal without treatment. Conventional treatments require days of intravenous infusion, but a recently developed drug, fexinidazole, can be given orally. Another oral drug candidate, acoziborole, is undergoing clinical development and will be considered in subsequent editions. OBJECTIVES: To evaluate the effectiveness and safety of currently used drugs for treating second-stage Trypanosoma brucei gambiense trypanosomiasis (gambiense human African trypanosomiasis, g-HAT). SEARCH METHODS On 14 May 2021, we searched the Cochrane Infectious Diseases Group Specialized Register, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, Latin American and Caribbean Health Science Information database, BIOSIS, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform. We also searched reference lists of included studies, contacted researchers working in the field, and contacted relevant organizations. SELECTION CRITERIA Eligible studies were randomized controlled trials that included adults and children with second-stage g-HAT, treated with anti-trypanosomal drugs currently in use. DATA COLLECTION AND ANALYSIS Two review authors extracted data and assessed risk of bias; a third review author acted as an arbitrator if needed. The included trial only reported dichotomous outcomes, which we presented as risk ratio (RR) or risk difference (RD) with 95% confidence intervals (CI). MAIN RESULTS: We included one trial comparing fexinidazole to nifurtimox combined with eflornithine (NECT). This trial was conducted between October 2012 and November 2016 in the Democratic Republic of the Congo and the Central African Republic, and included 394 participants. The study reported on efficacy and safety, with up to 24 months' follow-up. We judged the study to be at low risk of bias in all domains except blinding; as the route of administration and dosing regimens differed between treatment groups, participants and personnel were not blinded, resulting in a high risk of performance bias. Mortality with fexinidazole may be higher at 24 months compared to NECT. There were 9/264 deaths in the fexinidazole group and 2/130 deaths in the NECT group (RR 2.22, 95% CI 0.49 to 10.11; 394 participants; low-certainty evidence). None of the deaths were related to treatment. Fexinidazole likely results in an increase in the number of people relapsing during follow-up, with 14 participants in the fexinidazole group (14/264) and none in the NECT group (0/130) relapsing at 24 months (RD 0.05, 95% CI 0.02 to 0.08; 394 participants; moderate-certainty evidence). We are uncertain whether there is any difference between the drugs regarding the incidence of serious adverse events at 24 months. (31/264 with fexinidazole and 13/130 with NECT group at 24 months). Adverse events were common with both drugs (247/264 with fexinidazole versus 121/130 with NECT), with no difference between groups (RR 1.01, 95% CI 0.95 to 1.06; 394 participants; moderate-certainty evidence). AUTHORS' CONCLUSIONS: Oral treatment with fexinidazole is much easier to administer than conventional treatment, but deaths and relapse appear to be more common. However, the advantages or an oral option are considerable, in terms of convenience, avoiding hospitalisation and multiple intravenous infusions, thus increasing adherence.
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Affiliation(s)
- Vittoria Lutje
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Jorge Seixas
- Institute of Hygiene and Tropical Medicine and Global Health and Tropical Medicine R&D Center, NOVA University, Lisbon, Portugal
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Kuemmerle A, Schmid C, Bernhard S, Kande V, Mutombo W, Ilunga M, Lumpungu I, Mutanda S, Nganzobo P, Tete DN, Kisala M, Burri C, Blesson S, Valverde Mordt O. Effectiveness of Nifurtimox Eflornithine Combination Therapy (NECT) in T. b. gambiense second stage sleeping sickness patients in the Democratic Republic of Congo: Report from a field study. PLoS Negl Trop Dis 2021; 15:e0009903. [PMID: 34748572 PMCID: PMC8601604 DOI: 10.1371/journal.pntd.0009903] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 11/18/2021] [Accepted: 10/12/2021] [Indexed: 11/19/2022] Open
Abstract
Background Nifurtimox-eflornithine combination therapy (NECT) for the treatment of second stage gambiense human African trypanosomiasis (HAT) was added to the World Health Organization’s Essential Medicines List in 2009 after demonstration of its non-inferior efficacy compared to eflornithine therapy. A study of NECT use in the field showed acceptable safety and high efficacy until hospital discharge in a wide population, including children, pregnant and breastfeeding women, and patients with a HAT treatment history. We present here the effectiveness results after the 24-month follow-up visit. Methodology/Principal findings In a multicenter, open label, single arm phase IIIb study, second stage gambiense HAT patients were treated with NECT in the Democratic Republic of Congo. Clinical cure was defined 24 months after treatment as survival without clinical and/or parasitological signs of HAT. Of the 629 included patients, 619 (98.4%) were discharged alive after treatment and were examined for the presence of trypanosomes, white blood cell count in cerebro-spinal fluid, and disease symptoms. The clinical cure rate of 94.1% was comparable for all subpopulations analyzed at the 24-month follow-up visit. Self-reported adverse events during follow-up were few and concerned mainly nervous system disorders, infections, and gastro-intestinal disorders. Overall, 28 patients (4.3%) died during the course of the trial. The death of 16 of the 18 patients who died during the follow-up period was assessed as unlikely or not related to NECT. Within 24 months, eight patients (1.3%) relapsed and received rescue treatment. Sixteen patients were completely lost to follow-up. Conclusions/Significance NECT treatment administered under field conditions was effective and sufficiently well tolerated, no major concern arose for children or pregnant or breastfeeding women. Patients with a previous HAT treatment history had the same response as those who were naïve. In conclusion, NECT was confirmed as effective and appropriate for use in a broad population, including vulnerable subpopulations. Trial registration The trial is registered at ClinicalTrials.gov, number NCT00906880. The advanced stage of the neglected tropical disease human African trypanosomiasis was, until relatively recently, treated with an old toxic arsenical drug and there was little investment in an improved treatment option. Eflornithine alone was efficacious, but difficult to administer as it required four two-hour infusions a day for 14 days. Nifurtimox-eflornithine combination therapy (NECT) was developed as a simplified and easier to use treatment and was shown to be effective and sufficiently well tolerated in a randomized clinical trial. The present study was conducted to assess the overall effectiveness, including the feasibility of implementation of NECT under field conditions in a wider population than in the randomized clinical trial. We found that NECT can be implemented under field conditions and in remote areas, with the necessary logistical support and staff training for treatment administration. Adverse events, although very frequent, were considered acceptable given the severity of the disease. Less than 10% of patients showed severe adverse events. Over 24 months, the case fatality rate was 4.5% and relapses were rare (1.3%). The effectiveness of NECT was confirmed in a broad spectrum of second stage gambiense HAT patients, including children, pregnant and breastfeeding women, and patients who had been previously treated for HAT.
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Affiliation(s)
- Andrea Kuemmerle
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Caecilia Schmid
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Sonja Bernhard
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Victor Kande
- Programme National de Lutte contre la Trypanosomiase Humaine Africaine (PNLTHA), Kinshasa, Democratic Republic of the Congo
| | - Wilfried Mutombo
- Programme National de Lutte contre la Trypanosomiase Humaine Africaine (PNLTHA), Kinshasa, Democratic Republic of the Congo
- Drugs for Neglected Diseases initiative, Geneva, Switzerland
| | - Medard Ilunga
- Programme National de Lutte contre la Trypanosomiase Humaine Africaine (PNLTHA), Kinshasa, Democratic Republic of the Congo
| | - Ismael Lumpungu
- Programme National de Lutte contre la Trypanosomiase Humaine Africaine (PNLTHA), Kinshasa, Democratic Republic of the Congo
| | - Sylvain Mutanda
- Programme National de Lutte contre la Trypanosomiase Humaine Africaine (PNLTHA), Kinshasa, Democratic Republic of the Congo
| | - Pathou Nganzobo
- Programme National de Lutte contre la Trypanosomiase Humaine Africaine (PNLTHA), Kinshasa, Democratic Republic of the Congo
| | - Digas Ngolo Tete
- Programme National de Lutte contre la Trypanosomiase Humaine Africaine (PNLTHA), Kinshasa, Democratic Republic of the Congo
- Drugs for Neglected Diseases initiative, Geneva, Switzerland
| | - Mays Kisala
- Bureau Diocesain d’Oeuvres Médicales (BDOM), Kikwit, Democratic Republic of the Congo
| | - Christian Burri
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
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Hidalgo J, Ortiz JF, Fabara SP, Eissa-Garcés A, Reddy D, Collins KD, Tirupathi R. Efficacy and Toxicity of Fexinidazole and Nifurtimox Plus Eflornithine in the Treatment of African Trypanosomiasis: A Systematic Review. Cureus 2021; 13:e16881. [PMID: 34513456 PMCID: PMC8411996 DOI: 10.7759/cureus.16881] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2021] [Indexed: 11/29/2022] Open
Abstract
Human African trypanosomiasis (HAT), or sleeping sickness disease, is an infection caused mainly by Trypanosoma brucei gambiense-human African trypanosomiasis (g-HAT) and is transmitted by tsetse flies. The disease goes through two stages: hemolymphatic and meningo-encephalic phases. The treatment for the second stage has changed from melarsoprol or eflornithine to nifurtimox-eflornithine combination therapy (NECT) and fexinidazole. We aimed to systematically review the literature on the efficacy and toxicity of fexinidazole and NECT. We used PubMed advanced strategy and Google Scholar databases, including clinical trials and observational studies on humans in the last 20 years in the English literature. Applying the inclusion/exclusion criteria, we reviewed eight studies. We used Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) and Meta-analysis of Observational Studies in Epidemiology (MOOSE) protocol. For assessing bias, we used the Cochrane Collaboration’s tool for risk assessment of the clinical trials and the Robins-I tool for the observational studies. Overall, the clinical trials showed that NECT was non-inferior to eflornithine. The proportion of patients discharged alive is higher in patients treated with NECT vs. patients treated with eflornithine. Gastrointestinal complaints are a common side effect of NECT therapy, while fearful but relatively rare convulsions can also occur. The main limitation among the studies of NECT was the lack of blinding because most of them were open-label. Fexinidazole, the new oral medication showed is effective and safe for the treatment of g-HAT infection. Because of their convenience, fexinidazole is preferred over NECT therapy, oral vs. IV infusion in the first and second stages of the disease. Compared to older therapies, fexinidazole and NECT are more effective and safer than eflornithine and melarsoprol monotherapy.
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Affiliation(s)
- Jessica Hidalgo
- Internal Medicine, San Francisco de Quito University, Quito, ECU
| | | | - Stephanie P Fabara
- Internal Medicine, Santiago de Guayaquil Catholic University, Guayaquil, ECU
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10
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Kande Betu Ku Mesu V, Mutombo Kalonji W, Bardonneau C, Valverde Mordt O, Ngolo Tete D, Blesson S, Simon F, Delhomme S, Bernhard S, Mahenzi Mbembo H, Mpia Moke C, Lumeya Vuvu S, Mudji E'kitiak J, Akwaso Masa F, Mukendi Ilunga M, Mpoyi Muamba Nzambi D, Mayala Malu T, Kapongo Tshilumbwa S, Botalema Bolengi F, Nkieri Matsho M, Lumbala C, Scherrer B, Strub-Wourgaft N, Tarral A. Oral fexinidazole for stage 1 or early stage 2 African Trypanosoma brucei gambiense trypanosomiasis: a prospective, multicentre, open-label, cohort study. Lancet Glob Health 2021; 9:e999-e1008. [PMID: 34143998 PMCID: PMC8220131 DOI: 10.1016/s2214-109x(21)00208-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 03/01/2021] [Accepted: 04/09/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Staging and treatment of human African trypanosomiasis caused by Trypanosoma brucei gambiense (g-HAT) required lumbar puncture to assess cerebrospinal fluid (CSF) and intravenous drugs that cross the blood-brain barrier for late-stage infection. These procedures are inconvenient in rural health systems of disease-endemic countries. A pivotal study established fexinidazole as the first oral monotherapy to be effective against non-severe stage 2 g-HAT. We aimed to assess the safety and efficacy of fexinidazole in early g-HAT. METHODS In this prospective, multicentre, open-label, single-arm cohort study, patients with stage 1 or early stage 2 g-HAT were recruited from eight treatment centres in the Democratic Republic of the Congo. Primary inclusion criteria included being older than 15 years, being able to ingest at least one complete meal per day (or at least one sachet of Plumpy'Nut®), a Karnofsky score higher than 50, evidence of trypanosomes in the blood or lymph but no evidence of trypanosomes in the CSF, willingness to be admitted to hospital to receive treatment, having a permanent address, and being able to comply with the follow-up visit schedule. Exclusion criteria included severe malnutrition, inability to take medication orally, pregnant or breastfeeding women, any clinically important medical condition that could jeopardise patient safety or participation in the study, severely deteriorated general status, any contraindication to imidazole drugs, HAT treatment in the past 2 years, previous enrolment in the study or previous intake of fexinidazole, abnormalities on electrocardiogram that did not return to normal in pretreatment repeated assessments or were considered clinically important, QT interval corrected using Fridericia's formula of at least 450 ms, and patients not tested for malaria or not having received appropriate treatment for malaria or for soil-transmitted helminthiasis. Patients were classified into stage 1 or early stage 2 g-HAT groups following evidence of trypanosomes in the blood, lymph, and absence in CSF, and using white-blood-cell count in CSF. Patients received 1800 mg fexinidazole once per day on days 1-4 then 1200 mg fexinidazole on days 5-10. Patients were observed for approximately 19 months in total. Study participants were followed up on day 5 and day 8 during treatment, at end of treatment on day 11, at end of hospitalisation on days 11-18, at week 9 for a subset of patients, and after 6 months, 12 months, and 18 months. The primary endpoint was treatment success at 12 months. Safety was assessed through routine monitoring. Analyses were done in the intention-to-treat population. The acceptable success rate was defined as treatment efficacy in more than 80% of patients. This study is completed and registered with ClinicalTrials.gov (NCT02169557). FINDINGS Patients were enrolled between April 30, 2014, and April 25, 2017. 238 patients were recruited: 195 (82%) patients with stage 1 g-HAT and 43 (18%) with early stage 2 g-HAT. 189 (97%) of 195 patients with stage 1 g-HAT and 41 (95%) of 43 patients with early stage 2 g-HAT were finally included and completed the 10 day treatment period. Three patients with stage 1 g-HAT died after the 10 day treatment period and before the 12 month primary follow-up visit, considered as treatment failure and were withdrawn from the study. Treatment was effective at 12 months for 227 (99%) of 230 patients (95% CI 96·2-99·7): 186 (98%) of 189 patients (95·4-99·7) with stage 1 and 41 (100%) of 41 patients (91·4-100·0) with early stage 2, indicating that the primary study endpoint was met. No new safety issues were observed. The most frequent adverse events were headache and vomiting. In total, 214 (93%) of 230 patients had treatment-emergent adverse events, mainly common-terminology criteria for adverse events grades 1 to 3. None led to treatment discontinuation. INTERPRETATION Fexinidazole is a valuable first-line treatment option in the early stages of g-HAT. FUNDING Through the Drugs for Neglected Diseases initiative: the Bill & Melinda Gates Foundation, the Republic and Canton of Geneva (Switzerland), the Dutch Ministry of Foreign Affairs (also known as DGIS; Netherlands), the Norwegian Agency for Development Cooperation (also known as Norad; Norway), the Federal Ministry of Education and Research (also known as BMBF) through KfW (Germany), the Brian Mercer Charitable Trust (UK), and other private foundations and individuals from the HAT campaign. TRANSLATION For the French translation of the abstract see Supplementary Materials section.
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Affiliation(s)
| | - Wilfried Mutombo Kalonji
- National HAT Control Programme, Programme National de Lutte contre la Trypanosomiase Humaine Africaine, Kinshasa, Democratic Republic of the Congo
| | | | | | - Digas Ngolo Tete
- Drugs for Neglected Diseases initiative, Kinshasa, Democratic Republic of the Congo
| | | | - François Simon
- Drugs for Neglected Diseases Initiative, Geneva, Switzerland
| | - Sophie Delhomme
- Drugs for Neglected Diseases Initiative, Geneva, Switzerland
| | - Sonja Bernhard
- Swiss Tropical and Public Health Institute, Basel, Switzerland
| | | | | | | | | | - Felix Akwaso Masa
- Masi Manimba Hospital, Kwilu Province, Democratic Republic of the Congo
| | - Melchias Mukendi Ilunga
- Dipumba Hospital (MIBA), Mbuji Mayi, Kasaï Oriental Province, Democratic Republic of the Congo
| | | | - Tim Mayala Malu
- Mushie Hospital, Maï Ndombe Province, Democratic Republic of the Congo
| | | | | | | | - Crispin Lumbala
- National HAT Control Programme, Programme National de Lutte contre la Trypanosomiase Humaine Africaine, Kinshasa, Democratic Republic of the Congo
| | - Bruno Scherrer
- Bruno Scherrer Conseil, Saint Arnoult en Yvelines, France
| | | | - Antoine Tarral
- Drugs for Neglected Diseases Initiative, Geneva, Switzerland.
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11
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Adeyemi OS, Molefe-Nyembe NI, Eseola AO, Plass W, Shittu OK, Yunusa IO, Atolani O, Evbuomwan IO, Awakan OJ, Suganuma K, Kato K. New Series of Imidazoles Showed Promising Growth Inhibitory and Curative Potential Against Trypanosoma Infection. THE YALE JOURNAL OF BIOLOGY AND MEDICINE 2021; 94:199-207. [PMID: 34211341 PMCID: PMC8223535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The Trypanosoma spp. cause animal and human trypanosomiasis characterized with appreciable health and economic burden mostly in developing nations. There is currently no effective therapy for this parasitic disease, due to poor drug efficacy, drug resistance, and unwanted toxicity, etc. Therefore, new anti-Trypanosoma agents are urgently needed. This study explored new series of imidazoles for anti-Trypanosoma properties in vitro and in vivo. The imidazoles showed moderate to strong and specific action against growth of T. congolense. For example, the efficacy of the imidazole compounds to restrict Trypanosoma growth in vitro was ≥ 12-fold specific towards T. congolense relative to the mammalian cells. Additionally, the in vivo study revealed that the imidazoles exhibited promising anti-Trypanosoma efficacy corroborating the in vitro anti-parasite capacity. In particular, three imidazole compounds (C1, C6, and C8) not only cleared the systemic parasite burden but cured infected rats after no death was recorded. On the other hand, the remaining five imidazole compounds (C2, C3, C4, C5, and C7) drastically reduced the systemic parasite load while extending survival time of the infected rats by 14 days as compared with control. Untreated control died 3 days post-infection, while the rats treated with diminazene aceturate were cured comparable to the results obtained for C1, C6, and C8. In conclusion, this is the first study demonstrating the potential of these new series of imidazoles to clear the systemic parasite burden in infected rats. Furthermore, a high selectivity index of imidazoles towards T. congolensein vitro and the oral LD50 in rats support anti-parasite specific action. Together, findings support the anti-parasitic prospects of the new series of imidazole derivatives.
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Affiliation(s)
- Oluyomi Stephen Adeyemi
- SDG 03 Group – Good Health & Well-being, Landmark
University, Omu-Aran, Kwara State, Nigeria,Department of Biochemistry, Medicinal Biochemistry and
Toxicology Laboratory, Landmark University, Omu-Aran, Nigeria,To whom all correspondence should be addressed:
Oluyomi Stephen Adeyemi, Department of Biochemistry, Medicinal Biochemistry and
Toxicology Laboratory, Landmark University, PMB 1001, Ipetu Road,
Omu-Aran-251101, Nigeria; ; ORCID iD:
https://orcid.org/0000-0001-9342-8505
| | | | - Abiodun Omokehinde Eseola
- Department of Chemical Sciences, Redeemer’s University,
Ede, Nigeria,Institute of Inorganic and Analytical Chemistry,
Friedrich-Schiller-Universität Jena, Jena, Germany
| | - Winfried Plass
- Institute of Inorganic and Analytical Chemistry,
Friedrich-Schiller-Universität Jena, Jena, Germany
| | - Oluwatosin Kudirat Shittu
- Tropical Disease Research Unit, Department of
Biochemistry, Federal University of Technology, Minna, Nigeria
| | - Ibrahim Olatunji Yunusa
- Tropical Disease Research Unit, Department of
Biochemistry, Federal University of Technology, Minna, Nigeria
| | | | - Ikponmwosa Owen Evbuomwan
- Cellular Parasitology Laboratory, Department of
Microbiology, Landmark University, Omu-Aran, Nigeria
| | - Oluwakemi J. Awakan
- SDG 03 Group – Good Health & Well-being, Landmark
University, Omu-Aran, Kwara State, Nigeria,Department of Biochemistry, Medicinal Biochemistry and
Toxicology Laboratory, Landmark University, Omu-Aran, Nigeria
| | - Keisuke Suganuma
- National Research Center for Protozoan Diseases,
Obihiro University of Agriculture and Veterinary Medicine, Inada-cho, Obihiro,
Hokkaido, Japan
| | - Kentaro Kato
- Laboratory of Sustainable Animal Environment, Graduate
School of Agricultural Science, Tohoku University, Naruko-onsen, Osaki, Miyagi,
Japan
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12
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Hayashida K, Nambala P, Reet NV, Büscher P, Kawai N, Mutengo MM, Musaya J, Namangala B, Sugimoto C, Yamagishi J. Development of a bio-inkjet printed LAMP test kit for detecting human African trypanosomiasis. PLoS Negl Trop Dis 2020; 14:e0008753. [PMID: 33091922 PMCID: PMC7608988 DOI: 10.1371/journal.pntd.0008753] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 11/03/2020] [Accepted: 08/28/2020] [Indexed: 12/19/2022] Open
Abstract
Human African trypanosomiasis (HAT) is one of the neglected tropical diseases in sub-Saharan Africa. Early diagnosis and treatment prior to disease progression are crucial for the survival of HAT patients. We had previously established a loop-mediated isothermal amplification (LAMP) method for HAT diagnosis in which the reagents were dried for field-use purposes. In this study, we used a semi-automated process to produce the test tubes using a bio-inkjet printer to achieve an accurate production. The performance of the inkjet printer-produced dried LAMP test (CZC-LAMP) was found to be stable after storage for up to 180 days at 30 °C. The diagnostic accuracy of CZC-LAMP HAT was evaluated using DNA samples that were extracted from 116 Trypanosoma brucei gambiense patients and 66 T. b. rhodesiense patients. The sensitivity was 72% for T. b. gambiense (95%CI: 63%-80%) and 80% for T. b. rhodesiense (95%CI: 69%-89%). The specificity determined using DNA from 116 endemic control DNA samples was 95% (95%CI: 89%-98%). The performance of the CZC-LAMP HAT and CZC-LAMP rHAT were also evaluated using 14 crude blood lysate samples obtained from T. b. rhodesiense patients and endemic control samples collected from Rumphi District in Malawi. The sensitivity and specificity were both 100% (95%CI: 77%-100%). As the developed CZC-LAMP test does not require a cold chain or a sophisticated laboratory, it holds promise for use as a routine simple molecular tool for point-of-care HAT diagnosis in endemic areas.
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Affiliation(s)
- Kyoko Hayashida
- Division of Collaboration and Education, Research Center for Zoonosis Control (CZC), Hokkaido University, Sapporo, Japan
- International Collaboration Unit, Research Center for Zoonosis Control, Hokkaido University, Sapporo, Japan
| | - Peter Nambala
- Department of Pathology, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Nick Van Reet
- Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerpen, Belgium
| | - Philippe Büscher
- Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerpen, Belgium
| | - Naoko Kawai
- Division of Collaboration and Education, Research Center for Zoonosis Control (CZC), Hokkaido University, Sapporo, Japan
| | - Mable Mwale Mutengo
- Institute of Basic and Biomedical Sciences, Levy Mwanawasa Medical University, Lusaka, Zambia
| | - Janelisa Musaya
- Department of Pathology, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Boniface Namangala
- Department of Paraclinical Studies, School of Veterinary Medicine, University of Zambia, Lusaka, Zambia
| | - Chihiro Sugimoto
- Division of Collaboration and Education, Research Center for Zoonosis Control (CZC), Hokkaido University, Sapporo, Japan
| | - Junya Yamagishi
- Division of Collaboration and Education, Research Center for Zoonosis Control (CZC), Hokkaido University, Sapporo, Japan
- International Collaboration Unit, Research Center for Zoonosis Control, Hokkaido University, Sapporo, Japan
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13
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Kuemmerle A, Schmid C, Kande V, Mutombo W, Ilunga M, Lumpungu I, Mutanda S, Nganzobo P, Ngolo D, Kisala M, Valverde Mordt O. Prescription of concomitant medications in patients treated with Nifurtimox Eflornithine Combination Therapy (NECT) for T.b. gambiense second stage sleeping sickness in the Democratic Republic of the Congo. PLoS Negl Trop Dis 2020; 14:e0008028. [PMID: 31986140 PMCID: PMC7004379 DOI: 10.1371/journal.pntd.0008028] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 02/06/2020] [Accepted: 01/03/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Nifurtimox eflornithine combination therapy (NECT) to treat human African trypanosomiasis (HAT), commonly called sleeping sickness, was added to the World Health Organisation's (WHO) Essential Medicines List in 2009 and to the Paediatric List in 2012. NECT was further tested and documented in a phase IIIb clinical trial in the Democratic Republic of Congo (DRC) assessing the safety, effectiveness, and feasibility of implementation under field conditions (NECT-FIELD study). This trial brought a unique possibility to examine concomitant drug management. METHODOLOGY/PRINCIPAL FINDINGS This is a secondary analysis of the NECT-FIELD study where 629 second stage gambiense HAT patients were treated with NECT, including children and pregnant and breastfeeding women in six general reference hospitals located in two provinces. Concomitant drugs were prescribed by the local investigators as needed. Patients underwent daily evaluations, including vital signs, physical examination, and adverse event monitoring. Concomitant medication was documented from admission to discharge. Patients' clinical profiles on admission and safety profile during specific HAT treatment were similar to previously published reports. Prescribed concomitant medications administered during the hospitalization period, before, during, and immediately after NECT treatment, were mainly analgesics/antipyretics, anthelmintics, antimalarials, antiemetics, and sedatives. Use of antibiotics was reasonable and antibiotics were often prescribed to treat cellulitis and respiratory tract infections. Prevention and treatment of neurological conditions such as convulsions, loss of consciousness, and coma was used in approximately 5% of patients. CONCLUSIONS/SIGNIFICANCE The prescription of concomitant treatments was coherent with the clinical and safety profile of the patients. However, some prescription habits would need to be adapted in the future to the evolving available pharmacopoeia. A list of minimal essential medication that should be available at no cost to patients in treatment wards is proposed to help the different actors to plan, manage, and adequately fund drug supplies for advanced HAT infected patients. TRIAL REGISTRATION NUMBER The initial study was registered at ClinicalTrials.gov, number NCT00906880.
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Affiliation(s)
- Andrea Kuemmerle
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Caecilia Schmid
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Victor Kande
- Programme National de Lutte contre la Trypanosomiase Humaine Africaine, Democratic Republic of the Congo
| | - Wilfried Mutombo
- Programme National de Lutte contre la Trypanosomiase Humaine Africaine, Democratic Republic of the Congo
- DNDi, Geneva, Switzerland
| | - Medard Ilunga
- Programme National de Lutte contre la Trypanosomiase Humaine Africaine, Democratic Republic of the Congo
| | - Ismael Lumpungu
- Programme National de Lutte contre la Trypanosomiase Humaine Africaine, Democratic Republic of the Congo
| | - Sylvain Mutanda
- Programme National de Lutte contre la Trypanosomiase Humaine Africaine, Democratic Republic of the Congo
| | - Pathou Nganzobo
- Programme National de Lutte contre la Trypanosomiase Humaine Africaine, Democratic Republic of the Congo
| | - Digas Ngolo
- Programme National de Lutte contre la Trypanosomiase Humaine Africaine, Democratic Republic of the Congo
- DNDi, Geneva, Switzerland
| | - Mays Kisala
- Bureau Diocesain d’Oeuvres Medicales, Kikwit, Democratic Republic of the Congo
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14
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Andrade CH, Neves BJ, Melo-Filho CC, Rodrigues J, Silva DC, Braga RC, Cravo PVL. In Silico Chemogenomics Drug Repositioning Strategies for Neglected Tropical Diseases. Curr Med Chem 2019. [DOI: 10.2174/0929867325666180309114824] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Only ~1% of all drug candidates against Neglected Tropical Diseases (NTDs)
have reached clinical trials in the last decades, underscoring the need for new, safe and effective
treatments. In such context, drug repositioning, which allows finding novel indications
for approved drugs whose pharmacokinetic and safety profiles are already known,
emerging as a promising strategy for tackling NTDs. Chemogenomics is a direct descendent
of the typical drug discovery process that involves the systematic screening of chemical
compounds against drug targets in high-throughput screening (HTS) efforts, for the identification
of lead compounds. However, different to the one-drug-one-target paradigm, chemogenomics
attempts to identify all potential ligands for all possible targets and diseases. In
this review, we summarize current methodological development efforts in drug repositioning
that use state-of-the-art computational ligand- and structure-based chemogenomics approaches.
Furthermore, we highlighted the recent progress in computational drug repositioning
for some NTDs, based on curation and modeling of genomic, biological, and chemical data.
Additionally, we also present in-house and other successful examples and suggest possible solutions
to existing pitfalls.
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Affiliation(s)
- Carolina Horta Andrade
- LabMol - Laboratory for Molecular Modeling and Drug Design, Faculty of Pharmacy, Federal University of Goias, Goiania, GO, 74605-170, Brazil
| | - Bruno Junior Neves
- LabMol - Laboratory for Molecular Modeling and Drug Design, Faculty of Pharmacy, Federal University of Goias, Goiania, GO, 74605-170, Brazil
| | - Cleber Camilo Melo-Filho
- LabMol - Laboratory for Molecular Modeling and Drug Design, Faculty of Pharmacy, Federal University of Goias, Goiania, GO, 74605-170, Brazil
| | - Juliana Rodrigues
- LabMol - Laboratory for Molecular Modeling and Drug Design, Faculty of Pharmacy, Federal University of Goias, Goiania, GO, 74605-170, Brazil
| | - Diego Cabral Silva
- LabMol - Laboratory for Molecular Modeling and Drug Design, Faculty of Pharmacy, Federal University of Goias, Goiania, GO, 74605-170, Brazil
| | - Rodolpho Campos Braga
- LabMol - Laboratory for Molecular Modeling and Drug Design, Faculty of Pharmacy, Federal University of Goias, Goiania, GO, 74605-170, Brazil
| | - Pedro Vitor Lemos Cravo
- Laboratory of Cheminformatics, Centro Universitario de Anapolis (UniEVANGELICA), Anapolis, GO, 75083-515, Brazil
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GNS HS, GR S, Murahari M, Krishnamurthy M. An update on Drug Repurposing: Re-written saga of the drug’s fate. Biomed Pharmacother 2019; 110:700-716. [DOI: 10.1016/j.biopha.2018.11.127] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2018] [Revised: 11/16/2018] [Accepted: 11/27/2018] [Indexed: 12/20/2022] Open
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Boitel E, Desoubeaux G. Antiparasitic treatments in pregnant women: Update and recommendations. Med Mal Infect 2018; 50:3-15. [PMID: 30361033 DOI: 10.1016/j.medmal.2018.09.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 09/20/2018] [Indexed: 11/25/2022]
Abstract
Parasitoses are a major cause of morbidity and mortality worldwide, especially in resource-poor countries where the prevalence of such infections is very high. Their consequences for pregnant women are a public health issue. It is very challenging to successfully control parasitic infections with the dedicated drugs, while protecting the fetus from the harmful effects of these medications. However, in both temperate and tropical regions, true antiparasitic innovations are rare, and the therapeutic armamentarium remains limited. Scientific data is incomplete as only a few clinical studies have included pregnant women so far. Therefore, physicians have to learn how to thoroughly handle the antiparasitic molecules available. They also need to know the embryo- and fetotoxic effects of each of them. Medical practices must be adapted to the trimester of pregnancy.
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Affiliation(s)
- E Boitel
- Service de parasitologie, mycologie, médecine tropicale, CHU de Tours, 37044 Tours, France
| | - G Desoubeaux
- Service de parasitologie, mycologie, médecine tropicale, CHU de Tours, 37044 Tours, France.
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Repurposing Strategy of Atorvastatin against Trypanosoma cruzi: In Vitro Monotherapy and Combined Therapy with Benznidazole Exhibit Synergistic Trypanocidal Activity. Antimicrob Agents Chemother 2018; 62:AAC.00979-18. [PMID: 29987140 DOI: 10.1128/aac.00979-18] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 06/22/2018] [Indexed: 01/22/2023] Open
Abstract
Statins are inhibitors of cholesterol synthesis, but other biological properties, such as antimicrobial effects, have also been assigned to them, leading to their designation as pleiotropic agents. Our goal was to investigate the activity and selectivity of atorvastatin (AVA) against Trypanosoma cruzi by using in vitro models, aiming for more effective and safer therapeutic options through drug repurposing proposals for monotherapy and therapy in combination with benznidazole (BZ). Phenotypic screening was performed with different strains (Tulahuen [discrete typing unit {DTU} VI] and Y [DTU II]) and forms (intracellular forms, bloodstream trypomastigotes, and tissue-derived trypomastigotes) of the parasite. On assay of the Tulahuen strain, AVA was more active against intracellular amastigotes (selectivity index [SI] = 3). Also, against a parasite of another DTU (Y strain), this statin was more active (2.1-fold) and selective (2.4-fold) against bloodstream trypomastigotes (SI = 51) than against the intracellular forms (SI = 20). A cytomorphological approach using phalloidin-rhodamine permitted us to verify that AVA did not induced cell density reduction and that cardiac cells (CC) maintained their typical cytoarchitecture. Combinatory approaches using fixed-ratio methods showed that AVA and BZ gave synergistic interactions against both trypomastigotes and intracellular forms (mean sums of fractional inhibitory concentration indexes [∑FICIs] of 0.46 ± 0.12 and 0.48 ± 0.03, respectively). Thus, the repurposing strategy for AVA, especially in combination with BZ, which leads to a synergistic effect, is encouraging for future studies to identify novel therapeutic protocols for Chagas disease treatment.
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Filardy AA, Guimarães-Pinto K, Nunes MP, Zukeram K, Fliess L, Pereira L, Oliveira Nascimento D, Conde L, Morrot A. Human Kinetoplastid Protozoan Infections: Where Are We Going Next? Front Immunol 2018; 9:1493. [PMID: 30090098 PMCID: PMC6069677 DOI: 10.3389/fimmu.2018.01493] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 06/15/2018] [Indexed: 01/19/2023] Open
Abstract
Kinetoplastida trypanosomatidae microorganisms are protozoan parasites exhibiting a developmental stage in the gut of insect vectors and tissues of vertebrate hosts. During the vertebrate infective stages, these parasites alter the differential expression of virulence genes, modifying their biological and antigenic properties in order to subvert the host protective immune responses and establish a persistent infection. One of the hallmarks of kinetoplastid parasites is their evasion mechanisms from host immunity, leading to disease chronification. The diseases caused by kinetoplastid parasites are neglected by the global expenditures in research and development, affecting millions of individuals in the low and middle-income countries located mainly in the tropical and subtropical regions. However, investments made by public and private initiatives have over the past decade leveraged important lines of intervention that if well-integrated to health care programs will likely accelerate disease control initiatives. This review summarizes recent advances in public health care principles, including new drug discoveries and their rational use with chemotherapeutic vaccines, and the implementation of control efforts to spatially mapping the kinetoplastid infections through monitoring of infected individuals in epidemic areas. These approaches should bring us the means to track genetic variation of parasites and drug resistance, integrating this knowledge into effective stewardship programs to prevent vector-borne kinetoplastid infections in areas at risk of disease spreading.
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Affiliation(s)
- Alessandra Almeida Filardy
- Department of Immunology, Paulo de Góes Microbiology Institute, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Kamila Guimarães-Pinto
- Department of Immunology, Paulo de Góes Microbiology Institute, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marise Pinheiro Nunes
- Immunoparasitology Laboratory, Oswaldo Cruz Foundation, Oswaldo Cruz Institute, FIOCRUZ, Rio de Janeiro, Brazil
| | - Ketiuce Zukeram
- Department of Immunology, Paulo de Góes Microbiology Institute, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Lara Fliess
- Department of Immunology, Paulo de Góes Microbiology Institute, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Ludimila Pereira
- Department of Immunology, Paulo de Góes Microbiology Institute, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Danielle Oliveira Nascimento
- Department of Immunology, Paulo de Góes Microbiology Institute, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Luciana Conde
- Department of Immunology, Paulo de Góes Microbiology Institute, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Alexandre Morrot
- Immunoparasitology Laboratory, Oswaldo Cruz Foundation, Oswaldo Cruz Institute, FIOCRUZ, Rio de Janeiro, Brazil.,Tuberculosis Research Center, Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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Kansiime F, Adibaku S, Wamboga C, Idi F, Kato CD, Yamuah L, Vaillant M, Kioy D, Olliaro P, Matovu E. A multicentre, randomised, non-inferiority clinical trial comparing a nifurtimox-eflornithine combination to standard eflornithine monotherapy for late stage Trypanosoma brucei gambiense human African trypanosomiasis in Uganda. Parasit Vectors 2018; 11:105. [PMID: 29471865 PMCID: PMC5824494 DOI: 10.1186/s13071-018-2634-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 01/10/2018] [Indexed: 01/29/2023] Open
Abstract
Background While the combination of nifurtimox and eflornithine (NECT) is currently recommended for the treatment of the late stage human African trypansomiasis (HAT), single-agent eflornithine was still the treatment of choice when this trial commenced. This study intended to provide supportive evidence to complement previous trials. Methods A multi-centre randomised, open-label, non-inferiority trial was carried out in the Trypanosoma brucei gambiense endemic districts of North-Western Uganda to compare the efficacy and safety of NECT (200 mg/kg eflornithine infusions every 12 h for 7 days and 8 hourly oral nifurtimox at 5 mg/kg for 10 days) to the standard eflornithine regimen (6 hourly at 100 mg/kg for 14 days). The primary endpoint was the cure rate, determined as the proportion of patients alive and without laboratory signs of infection at 18 months post-treatment, with no demonstrated trypanosomes in the cerebrospinal fluid (CSF), blood or lymph node aspirates, and CSF white blood cell count < 20 /μl. The non-inferiority margin was set at 10%. Results One hundred and nine patients were enrolled; all contributed to the intent-to-treat (ITT), modified intent-to-treat (mITT) and safety populations, while 105 constituted the per-protocol population (PP). The cure rate was 90.9% for NECT and 88.9% for eflornithine in the ITT and mITT populations; the same was 90.6 and 88.5%, respectively in the PP population. Non-inferiority was demonstrated for NECT in all populations: differences in cure rates were 0.02 (95% CI: -0.07–0.11) and 0.02 (95% CI: -0.08–0.12) respectively. Two patients died while on treatment (1 in each arm), and 3 more during follow-up in the NECT arm. No difference was found between the two arms for the secondary efficacy and safety parameters. A meta-analysis involving several studies demonstrated non-inferiority of NECT to eflornithine monotherapy. Conclusions These results confirm findings of earlier trials and support implementation of NECT as first-line treatment for late stage T. b. gambiense HAT. The overall risk difference for cure between NECT and eflornithine between this and two previous randomised controlled trials is 0.03 (95% CI: -0.02–0.08). The NECT regimen is simpler, safer, shorter and less expensive than single-agent DFMO. Trial registration ISRCTN ISRCTN03148609 (registered 18 April 2008). Electronic supplementary material The online version of this article (10.1186/s13071-018-2634-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Freddie Kansiime
- Busitema University Faculty of Health Sciences, Box 1460, Mbale, Uganda
| | | | | | | | - Charles Drago Kato
- College of Veterinary Medicine, Animal Resources & Bio-security, Makerere University, P.O. Box 7062, Kampala, Uganda
| | - Lawrence Yamuah
- Armauer Hansen Research Institute, Box 1005, Addis Ababa, Ethiopia
| | - Michel Vaillant
- Competence Centre in Methodology and Statistics, Luxembourg Institute of Health, 1ab Rue Edison, Strassen, L-1445, Grand Duchy of Luxembourg
| | - Deborah Kioy
- Geneva Foundation for Medical Education and Research, 150, route de Ferney, 1211, Geneva 2, Switzerland
| | - Piero Olliaro
- UNICEF/UNDP/World Bank/WHO Special Programme for Research & Training in Tropical Diseases (TDR), Geneva, Switzerland
| | - Enock Matovu
- College of Veterinary Medicine, Animal Resources & Bio-security, Makerere University, P.O. Box 7062, Kampala, Uganda.
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Mesu VKBK, Kalonji WM, Bardonneau C, Mordt OV, Blesson S, Simon F, Delhomme S, Bernhard S, Kuziena W, Lubaki JPF, Vuvu SL, Ngima PN, Mbembo HM, Ilunga M, Bonama AK, Heradi JA, Solomo JLL, Mandula G, Badibabi LK, Dama FR, Lukula PK, Tete DN, Lumbala C, Scherrer B, Strub-Wourgaft N, Tarral A. Oral fexinidazole for late-stage African Trypanosoma brucei gambiense trypanosomiasis: a pivotal multicentre, randomised, non-inferiority trial. Lancet 2018; 391:144-154. [PMID: 29113731 DOI: 10.1016/s0140-6736(17)32758-7] [Citation(s) in RCA: 161] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 10/12/2017] [Accepted: 10/13/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Few therapeutic options are available to treat the late-stage of human African trypanosomiasis, a neglected tropical disease, caused by Trypanosoma brucei gambiense (g-HAT). The firstline treatment is a combination therapy of oral nifurtimox and intravenous eflornithine that needs to be administered in a hospital setting by trained personnel, which is not optimal given that patients often live in remote areas with few health resources. Therefore, we aimed to assess the safety and efficacy of an oral regimen of fexinidazole (a 2-substituted 5-nitroimidazole with proven trypanocidal activity) versus nifurtimox eflornithine combination therapy in patients with late-stage g-HAT. METHODS In this randomised, phase 2/3, open-label, non-inferiority trial, we recruited patients aged 15 years and older with late-stage g-HAT from g-HAT treatment centres in the Democratic Republic of the Congo (n=9) and the Central African Republic (n=1). Patients were randomly assigned (2:1) to receive either fexinidazole or nifurtimox eflornithine combination therapy according to a predefined randomisation list (block size six). The funder, data management personnel, and study statisticians were masked to treatment. Oral fexinidazole was given once a day (days 1-4: 1800 mg, days 5-10: 1200 mg). Oral nifurtimox was given three times a day (days 1-10: 15 mg/kg per day) with eflornithine twice a day as 2 h infusions (days 1-7: 400 mg/kg per day). The primary endpoint was success at 18 months (ie, deemed as patients being alive, having no evidence of trypanosomes in any body fluid, not requiring rescue medication, and having a cerebrospinal fluid white blood cell count ≤20 cells per μL). Safety was assessed through routine monitoring. Primary efficacy analysis was done in the modified intention-to-treat population and safety analyses in the intention-to-treat population. The acceptable margin for the difference in success rates was defined as 13%. This study has been completed and is registered with ClinicalTrials.gov, number NCT01685827. FINDINGS Between October, 2012, and November, 2016, 419 patients were pre-screened. Of the 409 eligible patients, 14 were not included because they did not meet all inclusion criteria (n=12) or for another reason (n=2). Therefore, 394 patients were randomly assigned, 264 to receive fexinidazole and 130 to receive nifurtimox eflornithine combination therapy. Success at 18 months was recorded in 239 (91%) patients given fexinidazole and 124 (98%) patients given nifurtimox eflornithine combination therapy, within the margin of acceptable difference of -6·4% (97·06% CI -11·2 to -1·6; p=0·0029). We noted no difference in the proportion of patients who experienced treatment-related adverse events (215 [81%] in the fexinidazole group vs 102 [79%] in the nifurtimox eflornithine combination therapy group). Treatment discontinuations were unrelated to treatment (n=2 [1%] in the fexinidazole group). Temporary nifurtimox eflornithine combination therapy interruption occurred in three (2%) patients. 11 patients died during the study (nine [3%] in the fexinidazole group vs two [2%] in the nifurtimox eflornithine combination therapy group). INTERPRETATION Our findings show that oral fexinidazole is effective and safe for the treatment of T b gambiense infection compared with nifurtimox eflornithine combination therapy in late-stage HAT patients. Fexinidazole could be a key asset in the elimination of this fatal neglected disease. FUNDING Drugs for Neglected Diseases initiative.
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Affiliation(s)
| | - Wilfried Mutombo Kalonji
- National HAT Control Programme (Programme National de Lutte contre la Trypanosomiase Humaine Africaine [PNLTHA]), Geneva, Switzerland
| | | | | | - Séverine Blesson
- Drugs for Neglected Diseases initiative (DNDi), Geneva, Switzerland
| | - François Simon
- Drugs for Neglected Diseases initiative (DNDi), Geneva, Switzerland
| | - Sophie Delhomme
- Drugs for Neglected Diseases initiative (DNDi), Geneva, Switzerland
| | - Sonja Bernhard
- Swiss TPH, Basel, Switzerland; University of Basel, Basel, Petersplatz 1, PO Box, CH-4001 Basel, Switzerland
| | - Willy Kuziena
- Masi Manimba Hospital, Province Kwilu, Democratic Republic of the Congo
| | | | | | | | | | - Médard Ilunga
- Dipumba Hospital (MIBA), Mbuji Mayi, Province Kasaï Oriental, Democratic Republic of the Congo
| | | | | | | | - Guylain Mandula
- Mushie Hospital, Province Maï Ndombe, Democratic Republic of the Congo
| | | | | | | | - Digas Ngolo Tete
- Drugs for Neglected Diseases initiative (DNDi), Kinshasa, Democratic Republic of the Congo
| | - Crispin Lumbala
- Drugs for Neglected Diseases initiative (DNDi), Kinshasa, Democratic Republic of the Congo
| | - Bruno Scherrer
- Bruno Scherrer Conseil, Saint Arnoult en Yvelines, France
| | | | - Antoine Tarral
- Drugs for Neglected Diseases initiative (DNDi), Geneva, Switzerland.
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Büscher P, Cecchi G, Jamonneau V, Priotto G. Human African trypanosomiasis. Lancet 2017; 390:2397-2409. [PMID: 28673422 DOI: 10.1016/s0140-6736(17)31510-6] [Citation(s) in RCA: 430] [Impact Index Per Article: 61.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 03/20/2017] [Accepted: 04/28/2017] [Indexed: 10/19/2022]
Abstract
Human African trypanosomiasis (sleeping sickness) is a parasitic infection that almost invariably progresses to death unless treated. Human African trypanosomiasis caused devastating epidemics during the 20th century. Thanks to sustained and coordinated efforts over the past 15 years, the number of reported cases has fallen to an historically low level. Fewer than 3000 cases were reported in 2015, and the disease is targeted for elimination by WHO. Despite these recent successes, the disease is still endemic in parts of sub-Saharan Africa, where it is a considerable burden on rural communities, most notably in central Africa. Since patients are also reported from non-endemic countries, human African trypanosomiasis should be considered in differential diagnosis for travellers, tourists, migrants, and expatriates who have visited or lived in endemic areas. In the absence of a vaccine, disease control relies on case detection and treatment, and vector control. Available drugs are suboptimal, but ongoing clinical trials provide hope for safer and simpler treatments.
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Affiliation(s)
- Philippe Büscher
- Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerp, Belgium.
| | - Giuliano Cecchi
- Food and Agriculture Organization of the United Nations, Sub-regional Office for Eastern Africa, Addis Ababa, Ethiopia
| | - Vincent Jamonneau
- UMR INTERTRYP, Institut de Recherche pour le Développement, Montpellier, France
| | - Gerardo Priotto
- World Health Organization, Control of Neglected Tropical Diseases, Innovative and Intensified Disease Management, Geneva, Switzerland
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Drug repurposing strategy against Trypanosoma cruzi infection: In vitro and in vivo assessment of the activity of metronidazole in mono- and combined therapy. Biochem Pharmacol 2017; 145:46-53. [PMID: 28870526 DOI: 10.1016/j.bcp.2017.08.025] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Accepted: 08/31/2017] [Indexed: 11/24/2022]
Abstract
Metronidazole (Mtz) is a commercial broad-spectrum nitroimidazolic derivative with relevant antimicrobial activity and relative safety profile. Therefore, it is fair to consider Mtz a candidate for drug repurposing for other neglected conditions such as Chagas disease (CD), a parasitic pathology caused by Trypanosoma cruzi. CD is treated only with benznidazole (Bz) and nifurtimox, both introduced in clinics decades ago despite important limitations, including low efficacy on the later disease stage (chronic form) and severe side effects. New cheap and fast alternative treatments for CD are needed, thus the repurposing of Mtz was assessed in vitro and in vivo in mono- and combined therapy. In vitro assays demonstrated EC50>200µM for Mtz, while for Bz the values ranged from 2.51µM (intracellular forms) to 11.5µM (bloodstream trypomastigotes). When both drugs were combined in fixed-ratio proportions, Mtz promoted Bz potency (lower EC50 values). In vivo toxicity assays for Mtz in mice showed no adverse effects neither histopathological alterations up to 2000mg/kg. Regarding experimental T. cruzi infection, Bz 100mg/kg suppressed parasitemia while Mtz (up to 1000mg/kg) in monotherapy did not, but prolonged animal survival at 250 and 500 regimen doses. The combination of both drugs (Bz 10+Mtz 250) prevented mortality (70%) besides protected against electric cardiac alterations triggered by the parasite infection. Although not able to reduce parasite load, the combination therapy prevented animal mortality; this was possibly due to a protection of the electric cardiac physiology that is normally altered in experimental infection of T. cruzi. It also suggested that the interaction with Mtz could have improved the pharmacokinetics of Bz. Our study emphasizes the importance of drug repurposing and combined therapy for CD to contribute to alternative therapies for this neglected and silent pathology.
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Marsiccobetre S, Rodríguez-Acosta A, Lang F, Figarella K, Uzcátegui NL. Aquaglyceroporins Are the Entry Pathway of Boric Acid in Trypanosoma brucei. BIOCHIMICA ET BIOPHYSICA ACTA-BIOMEMBRANES 2017; 1859:679-685. [PMID: 28087364 DOI: 10.1016/j.bbamem.2017.01.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 01/03/2017] [Accepted: 01/07/2017] [Indexed: 11/17/2022]
Abstract
The boron element possesses a range of different effects on living beings. It is essential to beneficial at low concentrations, but toxic at excessive concentrations. Recently, some boron-based compounds have been identified as promising molecules against Trypanosoma brucei, the causative agent of sleeping sickness. However, until now, the boron metabolism and its access route into the parasite remained elusive. The present study addressed the permeability of T. brucei aquaglyceroporins (TbAQPs) for boric acid, the main natural boron species. To this end, the three TbAQPs were expressed in Saccharomyces cerevisiae and Xenopus laevis oocytes. Our findings in both expression systems showed that all three TbAQPs are permeable for boric acid. Especially TbAQP2 is highly permeable for this compound, displaying one of the highest conductances reported for a solute in these channels. Additionally, T. brucei aquaglyceroporin activities were sensitive to pH. Taken together, these results establish that TbAQPs are channels for boric acid and are highly efficient entry pathways for boron into the parasite. Our findings stress the importance of studying the physiological functions of boron and their derivatives in T. brucei, as well as the pharmacological implications of their uptake by trypanosome aquaglyceroporins.
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Affiliation(s)
- Sabrina Marsiccobetre
- Laboratory of Immunochemistry and Ultrastructure, Institute of Anatomy, Central University of Venezuela, Caracas, Venezuela
| | - Alexis Rodríguez-Acosta
- Laboratory of Immunochemistry and Ultrastructure, Institute of Anatomy, Central University of Venezuela, Caracas, Venezuela
| | - Florian Lang
- Department of Physiology I, University of Tubingen, Tubingen, Germany
| | - Katherine Figarella
- Laboratory of Immunochemistry and Ultrastructure, Institute of Anatomy, Central University of Venezuela, Caracas, Venezuela.
| | - Néstor L Uzcátegui
- Laboratory of Immunochemistry and Ultrastructure, Institute of Anatomy, Central University of Venezuela, Caracas, Venezuela; Department of Physiology I, University of Tubingen, Tubingen, Germany.
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Hotez PJ, Pecoul B, Rijal S, Boehme C, Aksoy S, Malecela M, Tapia-Conyer R, Reeder JC. Eliminating the Neglected Tropical Diseases: Translational Science and New Technologies. PLoS Negl Trop Dis 2016; 10:e0003895. [PMID: 26934395 PMCID: PMC4774924 DOI: 10.1371/journal.pntd.0003895] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Today, the World Health Organization recognizes 17 major parasitic and related infections as the neglected tropical diseases (NTDs). Despite recent gains in the understanding of the nature and prevalence of NTDs, as well as successes in recent scaled-up preventive chemotherapy strategies and other health interventions, the NTDs continue to rank among the world’s greatest global health problems. For virtually all of the NTDs (including those slated for elimination under the auspices of a 2012 London Declaration for NTDs and a 2013 World Health Assembly resolution [WHA 66.12]), additional control mechanisms and tools are needed, including new NTD drugs, vaccines, diagnostics, and vector control agents and strategies. Elimination will not be possible without these new tools. Here we summarize some of the key challenges in translational science to develop and introduce these new technologies in order to ensure success in global NTD elimination efforts.
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Affiliation(s)
- Peter J Hotez
- Sabin Vaccine Institute and Texas Children's Hospital Center for Vaccine Development, National School of Tropical Medicine, Baylor College of Medicine, Houston, Texas, United States of America
| | - Bernard Pecoul
- Drugs for Neglected Diseases Initiative (DNDi), Geneva, Switzerland
| | - Suman Rijal
- Drugs for Neglected Diseases Initiative (DNDi), Delhi, India
| | - Catharina Boehme
- Foundation for Innovative new Diagnostics (FIND), Geneva, Switzerland
| | - Serap Aksoy
- Yale School of Public Health, Department of Epidemiology of Microbial Diseases, New Haven, Connecticut, United States of America
| | | | | | - John C Reeder
- UNICEF/UNDP/ World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR), Geneva, Switzerland
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Tarral A, Blesson S, Mordt OV, Torreele E, Sassella D, Bray MA, Hovsepian L, Evène E, Gualano V, Felices M, Strub-Wourgaft N. Determination of an optimal dosing regimen for fexinidazole, a novel oral drug for the treatment of human African trypanosomiasis: first-in-human studies. Clin Pharmacokinet 2015; 53:565-80. [PMID: 24535888 PMCID: PMC4037587 DOI: 10.1007/s40262-014-0136-3] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Background and Objectives Fexinidazole is a 5-nitroimidazole recently included in a clinical efficacy trial as an oral drug for the treatment of human African trypanosomiasis (HAT). Preclinical studies showed it acts as a pharmacologically active pro-drug with two key active metabolites: sulfoxide and sulfone (the most active metabolite). The present studies aimed to determine the best dose regimen for the treatment of stage 2 sleeping sickness patients, which could eventually also treat stage 1 patients. Methods Fexinidazole was assessed in 154 healthy adult male subjects of sub-Saharan African origin. Three initial first-in-human studies and two additional studies assessed a single ascending dose and multiple ascending doses (both under fasted conditions), tablet versus suspension formulation and food effect (fasted vs. high-fat meal and field-adapted food), and multiple ascending doses with a loading dose regimen under fed conditions. Results Fexinidazole was well-tolerated in a single dose from 100 to 3,600 mg, with quick absorption of the parent drug and rapid metabolism into sulfoxide [time to maximum concentration (tmax) 2–5 h] and sulfone (tmax 18–24 h). The tablet formulation was approximately 25 % less bioavailable than the suspension, and food intake increased drug absorption and plasma concentrations of fexinidazole and its two metabolites by approximately 200 %. Fourteen-day multiple ascending dosing administered up to 3,600 mg/day in fasted conditions showed that fexinidazole was generally well-tolerated (mild to moderate, spontaneously reversible drug-related adverse events). Following the high-fat food effect finding, another study was conducted to evaluate the impact of a low-fat regimen closer to that of the target population, showing that the type of meal does not influence fexinidazole absorption. The last study showed that a loading dose of 1,800 mg/day for 4 days followed by a 1,200 mg/day regimen for 6 days with a normal meal provided the desired exposure of fexinidazole and its metabolites, particularly sulfone, with good tolerability. Based on preclinical evidence from a chronic infection mouse model, systemic drug concentrations obtained are expected to be clinically effective in stage 2 HAT. Conclusions These studies show that fexinidazole can be safely assessed in patients as a potential oral cure for both stages of HAT. Electronic supplementary material The online version of this article (doi:10.1007/s40262-014-0136-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Antoine Tarral
- Drugs for Neglected Diseases Initiative (DNDi), 15 Chemin Louis-Dunant, 1202, Geneva, Switzerland,
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Padberg S. Anti-infective Agents. DRUGS DURING PREGNANCY AND LACTATION 2015. [PMCID: PMC7150338 DOI: 10.1016/b978-0-12-408078-2.00007-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 10/29/2022]
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Sudarshi D, Lawrence S, Pickrell WO, Eligar V, Walters R, Quaderi S, Walker A, Capewell P, Clucas C, Vincent A, Checchi F, MacLeod A, Brown M. Human African trypanosomiasis presenting at least 29 years after infection--what can this teach us about the pathogenesis and control of this neglected tropical disease? PLoS Negl Trop Dis 2014; 8:e3349. [PMID: 25522322 PMCID: PMC4270486 DOI: 10.1371/journal.pntd.0003349] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Affiliation(s)
- Darshan Sudarshi
- Hospital for Tropical Diseases, University College London Hospital, London, United Kingdom
| | - Sarah Lawrence
- Hospital for Tropical Diseases, University College London Hospital, London, United Kingdom
| | | | - Vinay Eligar
- Princess of Wales Hospital, Bridgend Hospital, Wales, United Kingdom
| | - Richard Walters
- Morriston Hospital, Swansea, Wales, United Kingdom
- Princess of Wales Hospital, Bridgend Hospital, Wales, United Kingdom
| | - Shumonta Quaderi
- Hospital for Tropical Diseases, University College London Hospital, London, United Kingdom
| | - Alice Walker
- Hospital for Tropical Diseases, University College London Hospital, London, United Kingdom
| | - Paul Capewell
- Institute of Biodiversity, Animal Health and Comparative Medicine, University of Glasgow, Glasgow, United Kingdom
| | - Caroline Clucas
- Institute of Biodiversity, Animal Health and Comparative Medicine, University of Glasgow, Glasgow, United Kingdom
| | - Angela Vincent
- Nuffield Dept of Clinical Neurology, University of Oxford, Oxford, United Kingdom
| | - Francesco Checchi
- Faculty of Infectious & Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Annette MacLeod
- Institute of Biodiversity, Animal Health and Comparative Medicine, University of Glasgow, Glasgow, United Kingdom
| | - Michael Brown
- Hospital for Tropical Diseases, University College London Hospital, London, United Kingdom
- Faculty of Infectious & Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom
- * E-mail:
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Eperon G, Balasegaram M, Potet J, Mowbray C, Valverde O, Chappuis F. Treatment options for second-stage gambiense human African trypanosomiasis. Expert Rev Anti Infect Ther 2014; 12:1407-17. [PMID: 25204360 PMCID: PMC4743611 DOI: 10.1586/14787210.2014.959496] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Treatment of second-stage gambiense human African trypanosomiasis relied on toxic arsenic-based derivatives for over 50 years. The availability and subsequent use of eflornithine, initially in monotherapy and more recently in combination with nifurtimox (NECT), has drastically improved the prognosis of treated patients. However, NECT logistic and nursing requirements remain obstacles to its deployment and use in peripheral health structures in rural sub-Saharan Africa. Two oral compounds, fexinidazole and SCYX-7158, are currently in clinical development. The main scope of this article is to discuss the potential impact of new oral therapies to improve diagnosis-treatment algorithms and patients' access to treatment, and to contribute to reach the objectives of the recently launched gambiense human African trypanosomiasis elimination program.
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Affiliation(s)
| | | | - Julien Potet
- Geneva University Hospitals,
Geneva, Switzerland
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Mitashi P, Hasker E, Mbo F, Van Geertruyden JP, Kaswa M, Lumbala C, Boelaert M, Lutumba P. Integration of diagnosis and treatment of sleeping sickness in primary healthcare facilities in the Democratic Republic of the Congo. Trop Med Int Health 2014; 20:98-105. [PMID: 25329353 DOI: 10.1111/tmi.12404] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Control of human African trypanosomiasis (HAT) in the Democratic Republic of Congo (DRC) has always been a vertical programme, although attempts at integration in general health services were made in recent years. Now that HAT prevalence is declining, the integration question becomes even more crucial. We studied the level of attainment of integration of HAT case detection and management in primary care centres in two high-prevalence districts in the province of Bandundu, DRC. METHODS We visited all 43 first-line health centres of Mushie and Kwamouth districts, conducted structured interviews and inspected facilities using a standardised checklist. We focused on: availability of well trained staff - besides HAT, we also tested for knowledge on tuberculosis; availability of equipment, consumables and supplies; and utilisation of the services. RESULTS All health centres were operating but most were poorly equipped, and attendance rates were very low. We observed a median of 14 outpatient consultations per facility (IQR 8-21) in the week prior to our visit, that is two patients per day. The staff had good knowledge on presenting symptoms, diagnosis and treatment of both HAT and tuberculosis. Nine centres were accredited by the national programme as HAT diagnosis and treatment centres, but the most sensitive diagnostic confirmation test, the mini-anion exchange centrifugation technique (mAECT), was not present in any. Although all nine were performing the CATT screening test, only two had the required cold chain in working order. CONCLUSION In these high-prevalence districts in DRC, staff is well-acquainted with HAT but lack the tools required for an adequate diagnostic procedure. Attendance rates of these primary care centres are extremely low, making timely recognition of a resurgence of HAT unlikely in the current state of affairs.
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Affiliation(s)
- P Mitashi
- Institute of Tropical Medicine, Antwerpen, Belgium; Faculty of Medicine, Kinshasa University, Kinshasa, Democratic Republic of the Congo; Institut National de Recherche Biomédicale, Kinshasa, Democratic Republic of Congo; International Health, Antwerp University, Antwerpen, Belgium
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Abstract
BACKGROUND Human African trypanosomiasis, or sleeping sickness, is a painful and protracted disease affecting people in the poorest parts of Africa and is fatal without treatment. Few drugs are currently available for second-stage sleeping sickness, with considerable adverse events and variable efficacy. OBJECTIVES To evaluate the effectiveness and safety of drugs for treating second-stage human African trypanosomiasis. SEARCH METHODS We searched the Cochrane Infectious Diseases Group Specialized Register (January 2013), CENTRAL (The Cochrane Library Issue 12 2012) , MEDLINE (1966 to January 2013), EMBASE (1974 to January 2013), LILACS (1982 to January 2013 ), BIOSIS (1926-January 2013), mRCT (January 2013) and reference lists. We contacted researchers working in the field and organizations. SELECTION CRITERIA Randomized and quasi-randomized controlled trials including adults and children with second-stage HAT, treated with anti-trypanosomal drugs. DATA COLLECTION AND ANALYSIS Two authors (VL and AK) extracted data and assessed methodological quality; a third author (JS) acted as an arbitrator. Included trials only reported dichotomous outcomes, and we present these as risk ratio (RR) with 95% confidence intervals (CI). MAIN RESULTS Nine trials with 2577 participants, all with Trypansoma brucei gambiense HAT, were included. Seven trials tested currently available drugs: melarsoprol, eflornithine, nifurtimox, alone or in combination; one trial tested pentamidine, and one trial assessed the addition of prednisolone to melarsoprol. The frequency of death and number of adverse events were similar between patients treated with fixed 10-day regimens of melarsoprol or 26-days regimens. Melarsoprol monotherapy gave fewer relapses than pentamidine or nifurtimox, but resulted in more adverse events.Later trials evaluate nifurtimox combined with eflornithine (NECT), showing this gives few relapses and is well tolerated. It also has practical advantages in reducing the frequency and number of eflornithine slow infusions to twice a day, thus easing the burden on health personnel and patients. AUTHORS' CONCLUSIONS Choice of therapy for second stage Gambiense HAT will continue to be determined by what is locally available, but eflornithine and NECT are likely to replace melarsoprol, with careful parasite resistance monitoring. We need research on reducing adverse effects of currently used drugs, testing different regimens, and experimental and clinical studies of new compounds, effective for both stages of the disease.
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Affiliation(s)
- Vittoria Lutje
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK.
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