Pharmacokinetic studies of antimalarials: recent developments

Updated pharmacokinetic considerations for the use of antimalarial drugs in pregnant women

INTRODUCTION

The association between pregnancy and altered drug pharmacokinetic (PK) properties is acknowledged, as is its impact on drug plasma concentrations and thus therapeutic efficacy. However, there have been few robust PK studies of antimalarial use in pregnancy. Given that inadequate dosing for prevention or treatment of malaria in pregnancy can result in negative maternal/infant outcomes, along with the potential to select for parasite drug resistance, it is imperative that reliable pregnancy-specific dosing recommendations are established.

AREAS COVERED

PK studies of antimalarial drugs in pregnancy. The present review summarizes the efficacy and PK properties of WHO-recommended therapies used in pregnancy, with a focus on PK studies published since 2014.

EXPERT OPINION

Changes in antimalarial drug disposition in pregnancy are well described, yet pregnant women continue to receive treatment regimens optimized for non-pregnant adults. Contemporary in silico modeling has recently identified a series of alternative dosing regimens that are predicted to provide optimal therapeutic efficacy for pregnant women.

A Microbial Transformation Model for Simulating Mammal Metabolism of Artemisinin

Artemisinin (ART) is a highly effective antimalarial agent isolated from the traditional Chinese herb Qinghao. Metabolism of ART and its derivatives in the body is one of the most pressing issues for pharmaceutical scientists. Herein, an efficient in vitro microorganism model for simulation of metabolism of ART in vivo was developed employing Cunninghamella elegans. Metabolites in the microbial transformation system and plasma of mice pre-administrated ART orally were analyzed by ultra-performance liquid chromatography (UPLC)-electrospray ionization (ESI)-quadrupole time-of-flight (Q-TOF)-mass spectrometry (MS^E) combined with UNIFI software. Thirty-two metabolites were identified in vitro and 23 were identified in vivo. After comparison, 16 products were found to be common to both models including monohydroxylated ART, dihydroxylated ART, deoxyartemisinin, hydroxylated deoxyartemisinin, hydroxylated dihydroartemisinin (DHA), and hydroxylated deoxy-DHA. These results revealed that C. elegans CICC 40250 functioned as an appropriate model to mimic ART metabolism in vivo. Moreover, an overall description of metabolites of ART from C. elegans CICC 40250 has been provided. Notably, DHA was detected and identified as a metabolite of ART in mouse plasma for the first time.

Strong correlation of lumefantrine concentrations in capillary and venous plasma from malaria patients

Background

Lumefantrine is a long-acting antimalarial drug with an elimination half-life of over 3 days and protein binding of 99 percent. Correlation of lumefantrine concentrations from capillary plasma via fingerprick (C_c) versus venous plasma (C_v) remains to be defined.

Methods

Venous and capillary plasma samples were collected simultaneously from children, pregnant women, and non-pregnant adults at 2, 24, 120hr post last dose of a standard 3-day artemether-lumefantrine regimen they received for uncomplicated malaria. Some of the enrolled children and pregnant women were also HIV-infected. Samples were analyzed via liquid chromatography tandem mass spectrometry. Linear regression analysis was performed using the program Stata® SE12.1.

Results

In children, the linear regression equations for C_c vs C_v at 2, 24, and 120hr (day 7) post dose are [C_c] = 1.05*[C_v]+95.0 (n = 142, R² = 0.977), [C_c] = 0.995*[C_v]+56.7 (n = 147, R² = 0.990) and [C_c] = 0.958*[C_v]+18.6 (n = 139, R² = 0.994), respectively. For pregnant women, the equations are [C_c] = 1.04*[C_v]+68.1 (n = 43, R² = 0.990), [C_c] = 0.997*[C_v]+37.3 (n = 43, R² = 0.993) and [C_c] = 0.941*[C_v]+11.1 (n = 41, R² = 0.941), respectively. For non-pregnant adults, the equations are [C_c] = 1.05*[C_v]-117 (n = 32, R² = 0.958), [C_c] = 0.962*[C_v]+9.21 (n = 32, R² = 0.964) and [C_c] = 1.04*[C_v]-40.1 (n = 32, R² = 0.988), respectively. In summary, a linear relationship with a slope of ~1 was found for capillary and venous lumefantrine levels in children, pregnant women and non-pregnant adults at 2hr, 24hr and 120hr post last dose, representing absorption, distribution, and elimination phases.

Conclusions

Capillary and venous plasma concentration of lumefantrine can be used interchangeably at 1:1 ratio. Capillary sampling method via finger prick is a suitable alternative for sample collection in clinical studies.

The influence of pregnancy on the pharmacokinetic properties of artemisinin combination therapy (ACT): a systematic review

Background

Pregnancy has been reported to alter the pharmacokinetic properties of anti-malarial drugs, including the different components of artemisinin-based combination therapy (ACT). However, small sample sizes make it difficult to draw strong conclusions based on individual pharmacokinetic studies. The aim of this review is to summarize the evidence of the influence of pregnancy on the pharmacokinetic properties of different artemisinin-based combinations.

Methods

A PROSPERO-registered systematic review to identify clinical trials that investigated the influence of pregnancy on the pharmacokinetic properties of different forms of ACT was conducted, following PRISMA guidelines. Without language restrictions, Medline/PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, LILACS, Biosis Previews and the African Index Medicus were searched for studies published up to November 2015. The following components of ACT that are currently recommend by the World Health Organization as first-line treatment of malaria in pregnancy were reviewed: artemisinin, artesunate, dihydroartemisinin, lumefantrine, amodiaquine, mefloquine, sulfadoxine, pyrimethamine, piperaquine, atovaquone and proguanil.

Results

The literature search identified 121 reports, 27 original studies were included. 829 pregnant women were included in the analysis. Comparison of the available studies showed lower maximum concentrations (C_max) and exposure (AUC) of dihydroartemisinin, the active metabolite of all artemisinin derivatives, after oral administration of artemether, artesunate and dihydroartemisinin in pregnant women. Low day 7 concentrations were commonly seen in lumefantrine studies, indicating a low exposure and possibly reduced efficacy. The influence of pregnancy on amodiaquine and piperaquine seemed not to be clinically relevant. Sulfadoxine plasma concentration was significantly reduced and clearance rates were higher in pregnancy, while pyrimethamine and mefloquine need more research as no general conclusion can be drawn based on the available evidence. For atovaquone, the available data showed a lower maximum concentration and exposure. Finally, the maximum concentration of cycloguanil, the active metabolite of proguanil, was significantly lower, possibly compromising the efficacy.

Conclusion

These findings suggest that reassessment of the dose of the artemisinin derivate and some components of ACT are necessary to ensure the highest possible efficacy of malaria treatment in pregnant women. However, for most components of ACT, data were insufficient and extensive research with larger sample sizes will be necessary to identify the exact influences of pregnancy on the pharmacokinetic properties of different artemisinin-based combinations. In addition, different clinical studies used diverse study designs with various reported relevant outcomes. Future pharmacokinetic studies could benefit from more uniform designs, in order to increase quality, robustness and effectiveness.

Study registration: CRD42015023756 (PROSPERO)

Electronic supplementary material

The online version of this article (doi:10.1186/s12936-016-1160-6) contains supplementary material, which is available to authorized users.