Pharmacogenetic tools for malaria and TB in the Developing World

Pharmacogenetics and rational drug use around the world

The WHO embraces evidence-based medicine to formulate an essential medicines list (EML) considering disease prevalence, drug efficacy, drug safety and cost-effectiveness. The EML is used by developing countries to build a national formulary. As pharmacogenetics in developed countries evolves, the Pharmacogenetics for Every Nation Initiative (PGENI) convened with representatives from China, Mexico, Ghana and South Africa in August 2009 to evaluate the use of human pharmacogenetics to enhance global drug use policy. The diseases causing mortality, the lack of integration of pharmacovigilance at the national formulary level, the pharmacogenetics research agenda and pharmacogenetics clinician education did not differ greatly among the countries. While there are many unanswered questions, systematically incorporating pharmacogenetics at the national formulary level promises to improve global drug use.

The pharmacogenetics of antimalaria artemisinin combination therapy

INTRODUCTION

Plasmodium falciparum malaria is one of the world's most lethal infectious diseases, commanding millions of drug administrations per year. The pharmacogenetics of these drugs is poorly known, although its application can be pivotal for the optimized management of this disease.

AREAS COVERED

The main components of artemisinin combination therapy (ACT), the worldwide main antimalarial strategy, are metabolized by the polymorphic CYP3A4 (mefloquine, artemether, lumefantrine), CYP2C8 (amodiaquine), CYP2A6 (artesunate) and CYP1A1/2 (amodiaquine/desethylamodiaquine), with dihydroartemisinin being acted by Phase II UDP-glucuronosyltransferases. The worldwide adoption of ACT is leading to a large number of antimalarial treatments. Simultaneously, the feared development of parasite drug resistance might drive dosing increases. In these scenarios of increased drug exposure, pharmacogenetics can be a key tool supporting evidence-based medicine aiming for the longest possible useful lifespan of this important chemotherapy.

EXPERT OPINION

Translation in this moment is not operationally possible at an individual level, but large population studies are achievable for: i) the development of robust pharmacogenetics markers; and ii) the parallel development of a pharmacogenetic cartography of malaria settings. Advances in the understanding of antimalarial pharmacogenetics are urgent in order to protect the exposed populations, enhance the effectiveness of ACT and, consequently, contributing for the long aimed elimination of the disease.

The antimalarial drug quinine disrupts Tat2p-mediated tryptophan transport and causes tryptophan starvation

Quinine is a major drug of choice for the treatment of malaria. However, the primary mode of quinine action is unclear, and its efficacy is marred by adverse reactions among patients. To help address these issues, a genome-wide screen for quinine sensitivity was carried out using the yeast deletion strain collection. Quinine-sensitive mutants identified in the screen included several that were defective for tryptophan biosynthesis (trp strains). This sensitivity was confirmed in independent assays and was suppressible with exogenous Trp, suggesting that quinine caused Trp starvation. Accordingly, quinine was found to inhibit [(3)H]Trp uptake by cells, and the quinine sensitivity of a trp1Delta mutant could be rescued by overexpression of Trp permeases, encoded by TAT1 and TAT2. The site of quinine action was identified specifically as the high affinity Trp/Tyr permease, Tat2p, with which quinine associated in a Trp-suppressible manner. A resultant action also on Tyr levels was reflected by the Tyr-suppressible quinine hypersensitivity of an aro7Delta deletion strain, which is auxotrophic for Tyr (and Phe). The present genome-wide dataset provides an important resource for discovering modes of quinine toxicity. That potential was validated with our demonstration that Trp and Tyr uptake via Tat2p is a major target of cellular quinine toxicity. The results also suggest that dietary tryptophan supplements could help to avert the toxic effects of quinine.