Safety, efficacy and population pharmacokinetics of fixed-dose combination of artesunate-mefloquine in the treatment of acute uncomplicated Plasmodium falciparum malaria in India

BACKGROUND & OBJECTIVES

India has switched over to artemisinin-based combination therapy (ACT) for the treatment of acute uncomplicated Plasmodium falciparum malaria and the ACT used in the national programme is artesunate + sulphadoxine-pyrimethamine. Since the efficacy of ACT is dependent also on the partner drug, there is a need to evaluate and deploy multiple ACTs.

METHODS

This multicentre, single-arm, open-label clinical trial was carried out to assess the efficacy, safety and population pharmacokinetics of a fixed dose combination (FDC) artesunate mefloquine (ASMQ) in P. falciparum infected, Indian adults at Panjim, Goa, and Mangalore, Karnataka between December 2007 and November 2008.

RESULTS

A total of 77 patients (males 74) were screened and enrolled: 42 at Goa and 35 at Mangalore with a median age of 25 yr (range 18-55 yr). One patient failed in treatment on D53, a PCR proven new infection, seven developed recurrent vivax parasitaemia and 11 did not have a parasitological endpoint. By per protocol analysis, the D63 cure rate was 58/59 (98.3; 95% C.I. 90.9-99.9%), and 58/58, with PCR correction. ASMQ was well-tolerated and no serious adverse events were reported.

INTERPRETATION & CONCLUSION

The study showed that the ASMQ FDC was efficacious and well-tolerated for the treatment of acute, uncomplicated P. falciparum malaria in highly endemic, chloroquine resistant areas of Goa and Mangalore. It is a viable option for India.

Effect of artesunate and mefloquine in combination on the Fridericia corrected QT intervals in Plasmodium falciparum infected adults from Thailand

OBJECTIVE

To ascertain whether mefloquine (MQ) produces electrocardiogram (ECG) changes that could be a risk for Torsades de Pointe (TdP), a potentially malignant, ventricular tachyarrhythmia.

METHODS

We measured the Fridericia corrected QT (QTcF) intervals on 12 lead ECGs on days (D) 0, 3, 7 in Plasmodium falciparum infected adults, treated with oral artesunate (AS) and MQ as a new fixed dose (n = 25) combination or loose tablets (n = 25) over 3 days. Target total doses were 12 mg/kg of AS and 24-25 mg/kg of MQ. MQ concentrations ([MQ]) were measured by HPLC.

RESULTS

All ECG intervals were similar between drug arms and were combined for analysis. Mean QTcF values were 389 (D0), 407 (D3) and 399 (D7) ms (Ps < 0.003 vs. D0); corresponding heart rates and [MQ]s were 83, 67 and 73 beats/minute (Ps ≤ 0.0003 vs. D0) and 0, 3095 and 1721 ng/ml. One male patient (loose arm) had a D3 QTcF 504 ms (D0 406 ms, D7 433 ms). In the modelling of QTcF and JTcF from D0 to D7, significant effects were observed individually for [MQ], temperature and heart rate (HR). The MQ AUC(0-∞) was not a significant factor. Using a manual descending, model building approach to select variables, the HR was the only significant variable (P = 0.001) over time in the model that best explained the changes in the QTcF and JTcF intervals.

CONCLUSIONS

In this small group of patients, slowing heart rates due to malaria resolution best explained the observed increases in the QTcF intervals.

Fluoronaphthyridines and -quinolones as antibacterial agents. 5. Synthesis and antimicrobial activity of chiral 1-tert-butyl-6-fluoro-7-substituted-naphthyridones

A series of novel 7-substituted-1-tert-butyl-6-fluoronaphthyridone-3- carboxylic acids has been prepared. These derivatives are characterized by chiral aminopyrrolidine substituents at the 7 position. In this paper we report the full details of the asymmetric synthesis of this series of compounds. Structure-activity relationship studies indicate that the absolute stereochemistry at the asymmetric centers of the pyrrolidine ring is critical for maintaining good activity. Compounds 60 and 61 (3-amino-4-methylpyrrolidine enantiomers) were selected for preclinical evaluation.

Fluoronaphthyridines and -quinolones as antibacterial agents. 3. Synthesis and structure-activity relationships of new 1-(1,1-dimethyl-2-fluoroethyl), 1-[1-methyl-1-(fluoromethyl)-2-fluoroethyl], and 1-[1,1-(difluoromethyl)-2-fluoroethyl] substituted derivatives

A series of novel N-1-(mono-,-(di- and -(trifluoro-tert-butyl)quinolones and -naphthyridines has been prepared. Structure-activity relationship (SAR) studies indicated that the in vitro antibacterial potency was the following order: 1-(1,1-dimethyl-2-fluoroethyl) greater than 1-[1-methyl-1-(fluoromethyl)-2-fluoroethyl] greater than 1-[1,1-(difluoromethyl)-2-fluoroethyl] substituents. In the quinolone series the monofluoro-tert-butyl derivatives were found to possess better in vitro antibacterial activity than the nonfluorinated-tert-butyl equivalents. In vivo PD50 values of the 1-fluoro-tert-butyl-substituted derivatives reflect pharmacokinetic behavior and incomplete oral absorption.

Fluoronaphthyridines and quinolones as antibacterial agents. 2. Synthesis and structure-activity relationships of new 1-tert-butyl 7-substituted derivatives

A number of 7-substituted-1-tert-butyl-6-fluoroquinolone-3-carboxylic acids and 7-substituted-1-tert-butyl-6-fluoro-1,8-naphthyridine-3-carboxylic acids have been prepared and tested for antibacterial activities. Among those the 7-aminopyrrolidinyl 20b and the 7-diazabicyclo naphthyridine 18b are the most potent compounds in vitro and in vivo. Physicochemical data and acute toxicity are also discussed. Compound 18b, BMY 40062, exhibits the most favorable overall properties, considering in vitro and in vivo microbiological activity, its low toxicity, and pharmacokinetic profile, and was selected for clinical evaluation.

Determination of sub-nanogram amounts of dihydroergotamine in plasma and urine using liquid chromatography and fluorimetric detection with off-line and on-line solid-phase drug enrichment

A highly sensitive and selective high-performance liquid chromatographic method, involving sample pre-treatment, column switching and fluorimetric detection, is described for the determination of dihydroergotamine in plasma and urine samples. The pre-chromatographic sample treatment consists of extraction by means of an Extrelut column for plasma samples, and pre-separation with enrichment steps on a Sep-Pak column for urine samples. The samples are then injected onto a pre-separation column (Aquapore), and the fraction containing dihydroergotamine are automatically diverted onto an analytical column (ODS reversed phase). An acetonitrile-ammonium carbamate gradient is used as the mobile phase. High recovery of dihydroergotamine from both plasma (87%) and urine (100%) and a detection limit as low as 100 pg/ml were achieved, with a linear response up to 5 ng/ml. The assay demonstrated a high degree of selectivity with regard to the extensive metabolism of dihydroergotamine especially to the main metabolite 8'-hydroxydihydroergotamine. The assay was successfully applied for more than one year to the determination of plasma and urine concentrations of dihydroergotamine after parenteral administration.

Effect of the binding of isradipine and darodipine to different plasma proteins on their transfer through the rat blood-brain barrier. Drug binding to lipoproteins does not limit the transfer of drug

Brain extraction of two calcium channel antagonists, isradipine (PN 200-110) and darodipine (PY 108-068) was investigated using the carotid injection technique in rats. An inhibitor effect of binding to plasma proteins on the brain extraction was also investigated. Equilibrium dialysis at 37 degrees C showed that both drugs were highly bound to human serum proteins, including albumin, alpha-1 acid glycoprotein and lipoproteins. The free dialyzable drug fraction was inversely related to the protein concentration. The brain extraction of the drugs in the presence of either albumin or alpha-1 acid glycoprotein was inversely related to the protein concentrations in the presence of either albumin or alpha-1 acid glycoprotein, but it was higher than expected from the in vitro measurement of the dialyzable fraction. Despite a significant degree of binding to lipoproteins, no significant reduction in the brain extraction of the drugs was observed, regardless of the class or the concentration of lipoproteins. These data indicate that the amount of circulating darodipine or isradipine available for entry in a peripheral tissue such as brain exceeds the dialyzable fraction of drug. However, the in vivo exchangeable drug fraction still parallels the dialyzable fraction, except if the drug is lipoprotein bound.

Binding of (+)-PN 200-110 to rat pituitaries and to normal and adenomatous human pituitaries

Endocrine cells possess voltage-sensitive Ca2+ channels involved in the modulation of hormonal secretion. Using the dihydropyridine, (+)-PN 200-110, we have investigated the binding characteristics of this ligand to pituitary membrane Ca2+ channels from normal rat, normal and adenomatous human pituitaries. [3H]PN 200-110 binds specifically to rat pituitary membranes to one class of sites (Kd = 0.41 +/- 0.10 mM; Bmax = 39 +/- 1.3 fmol/mg protein). At 37 degrees C, equilibrium is reached in 45 min and half-life of the binding is 13 min. No significant changes were observed for either the Kd or Bmax values between normal rat and human pituitaries or between the different types of adenomas (GH- and PRL-secreting and non-secreting). As the secretory activity of the pituitary adenomas, involving Ca2+ mobilization, varies from one adenoma to another, our results could indicate that, if there is a modified regulation of Ca2+ entry in the adenomas, it may not be related to a varying number of calcium channels, at least the channels labeled by the dihydropyridine (+)-PN 200-110.

Species differences in metabolism of ketotifen in rat, rabbit and man: demonstration of similar pathways in vivo and in cultured hepatocytes

In vitro drug metabolism by cultured rat, rabbit and human adult hepatocytes has been studied, using ketotifen (ZADITEN) as a model substrate because it is biotransformed in vivo by various metabolic pathways in man and animals. The major in vivo pathways were demonstrated in vitro, namely oxidation in rat hepatocytes, oxidation, glucuronidation and sulfation in rabbit hepatocytes, reduction and glucuronidation in human hepatocytes. Human hepatocytes were the most stable in culture, displaying ketotifen biotransformation for at least one week. These results clearly demonstrated that cultured hepatocytes retain their in vivo specific drug metabolizing activities, including inter-species polymorphism, for a few days. Therefore, pure hepatocyte cultures represent a useful system suitable for drug metabolism studies.

Impaired regulation of beta 2-adrenergic receptor density in mononuclear cells during chronic renal failure

Previous investigations have suggested that beta-adrenoceptor-mediated responses were decreased in uremia. To evaluate this phenomenon further, beta 2-receptor density in mononuclear cells, plasma catecholamines and plasma parathyroid hormone were studied in two groups of normotensive patients: group U, twenty-five chronic uremic patients with end-stage renal failure; group C, twenty-eight control subjects. Each group was divided into three age and sex-matched subgroups. Beta 2-receptor density was determined using (-)125 iodocyanopindolol. Despite a significant increase in plasma epinephrine in the group of uremic patients, there was a significant increase in beta 2-adrenoceptor density. On the other hand the uremic state did not influence (-)125 iodocyanopindolol binding affinity and plasma norepinephrine. Parathyroid hormone, as expected, was significantly elevated in all the uremic subgroups. It can be concluded that the uremic state is associated with an unexpected upregulation of beta 2-receptor density in mononuclear cells. The role of an endogenous beta-blocking substance is suggested.

Pharmacokinetics of guanfacine in patients with impaired renal function and in some elderly patients

The effects of renal impairment and age on the pharmacokinetics of guanfacine were evaluated. In normal subjects, guanfacine was found to be rapidly and completely absorbed, with an absolute bioavailability close to 100% and therefore no evidence of a noticeable first-pass effect. Its kinetics were best described by a 2-compartment model, with an elimination half-life of the beta phase of 17 hours. The major route of excretion was in the urine, with urinary excretion of 80% of a given dose within 4 days. Linearity of dose and thus predictability of blood levels were observed for single doses and at steady state. Although cumulative urinary excretion and renal clearance of unchanged guanfacine were reduced in patients with renal insufficiency, total clearances, serum levels, elimination rates constants and elimination half-lives differed very slightly, or at most by a factor of 1.5 to 2 between patients with normal and severely impaired renal function. Age-related decreases in urinary excretion and renal clearance of guanfacine were observed in 6 elderly patients and were accompanied by an increased proportion of metabolites to parent drug, confirming the significant nonrenal clearance of the drug. Based on pharmacokinetic studies in these target groups and on the dual renal and nonrenal clearance of guanfacine, the drug may, most probably, be administered to elderly patients and patients with renal insufficiency without dosage adjustment.

Nicardipine: pharmacokinetics and effects on carotid and brachial blood flows in normal volunteers

The effects of nicardipine, 20 mg, three times daily, nicardipine slow release, 30 mg, twice daily and a placebo on brachial and carotid arteries diameters and flows have been investigated by the pulsed Doppler technique during a single blind and cross-over study performed in six healthy volunteers. Simultaneously, nicardipine plasma levels and relative bioavailability were determined. Nicardipine significantly increased brachial and carotid arteries diameters (by 16 and 10% respectively) and flows (by 60 and 35% respectively). These effects peaked after 4 h and lasted no longer than 6 h. Forearm vascular resistance was significantly decreased. Hence nicardipine dilated both large and small arteries. Nicardipine slow release elicited the same effects on brachial and carotid arteries diameters and flows as nicardipine. These effects peaked at 6 h and lasted up to 10 h. Although the profiles of the pharmacodynamic effects and of the kinetics of nicardipine were almost parallel in each individual after administration of both nicardipine formulations, there was no correlation between the nicardipine plasma relative bioavailability and its effects on brachial and carotid arteries blood flows when considering all subjects together.

[Pharmacokinetics: a contribution in clinical geriatric pharmacology?]

Clinical pharmacology in elderly patients and its therapeutic implications come up against the difficulty to consider independently the factor age from the other factors, influencing the kinetics in this population. The knowledge of pharmacokinetics give essential informations for the development of new pharmaceutical forms, adjustment of dosage regimen and recommendations for drug intake in order to minimize the variations in bioavailability and to improve compliance. In regard of results, obtained in such studies, individualized treatment in function of age could possibly be considered. These different aspects are illustrated by recent studies on dihydroergotoxine, a geriatric drug for which improvements in therapy, based on new kinetic informations and the development of new galenical forms, can be expected. Though pharmacokinetics is a useful tool in clinical pharmacology in elderly patients, more informations of the influence of age on the physiology and biochemistry are needed to better explain the difference of response of this population to drug treatment.

Metabolism of ketotifen by human liver microsomes. In vitro characterization of a tertiary amine glucuronidation

Biotransformation of ketotifen was investigated in vitro using human liver microsomes. Three of the four metabolic pathways observed in vivo in man were exhibited under the conditions of incubation, namely demethylation, N-oxidation, and N-glucuronidation, the absent route being the ketoreduction, which probably has a cytosolic localization. The kinetic parameters of the N-glucuronidation (KM for ketotifen and UDPGA and Vmax) were determined with native and detergent-treated microsomes. Treatment by Triton X-100 increased by about 3-fold the conjugation reaction. No sex difference was observed and N-glucuronidation did not seem to be inhibited either by bilirubin or by 4-nitrophenol. Thus, human liver microsomes are a useful and suitable in vitro model for studying metabolic routes, specific for man, as in the case of ketotifen. Obviously, the results obtained can only reflect partially the multiplicity of in vivo events and interpretation has to be complemented by investigations with other models.

Interaction of dihydroergotamine and triacetyloleandomycin in the minipig

The kinetics of unchanged DHE and of the sum of parent drug and metabolites under the effect of acute TO exposure were investigated by comparing the areas under the plasma concentration-time curves after oral, intravenous and hepatoportal administration in minipigs. While TO (500 mg p.o. 15 min. before DHE) caused only a slight increase of plasma levels of parent drug or the sum of parent drug and metabolites after an intravenous dose of 1 mg DHE, there was an important and significant increase of the 0-24 hrs AUC's after administration of (10 mg) oral or (1 mg) hepatoportal DHE. This finding strongly suggests that the interaction TO and DHE occurs at the hepatic site. However, under these experimental conditions, the metabolism of DHE does not seem to be modified by TO administration, an indication that the mechanism of the interaction with TO could be an inhibition of the biliary excretion of DHE and DHE metabolites and/or a release of DHE and metabolites from hepatic binding sites.

Quantification of ketotifen and its metabolites in human plasma by gas chromatography mass spectrometry

Gas chromatography mass spectrometry with selected ion monitoring has been used to develop a method for the quantification of ketotifen and its demethylated, 10-hydroxy and 10-hydroxy demethylated metabolites in human plasma. The minimum detectable concentrations for ketotifen and its demethylated metabolites were 50 pg ml-1 and 300 pg ml-1 for the 10-hydroxy metabolite. The methodology has been applied in studies of the kinetics of the drug in man, and plasma levels of the unchanged drugs and its metabolites in free and conjugated form are reported.

Estimation of the absolute oral bioavailability of pindolol by two analytical methods

The absolute oral bioavailability of pindolol has been estimated by two analytical methods, fluorimetry and GLC-ECD. The study was carried out in six healthy subjects who received either i.v. or oral pindolol in random order. The results obtained by both methods were similar and confirm the high bioavailability (about 75%) of pindolol. The present findings are compared with previous publications and emphasize the importance of undertaking bioavailability studies in the same subjects.

Pharmacokinetic aspects of guanfacine withdrawal syndrome in a hypertensive patient with chronic renal failure

The unusual observation of a withdrawal syndrome due to guanfacine in a hypertensive patient with chronic renal failure led to a study of the kinetics of the drug in this patient. The principal pharmacokinetic parameters of guanfacine were greatly altered, with extended biotransformation and a decrease in the half-life compared to the values observed in other cases of severe renal insufficiency. Associated treatment with phenobarbital had had a considerable effect, as shown by the results of a further kinetic study 2 months after withdrawal of the phenobarbital. The findings then were in good agreement with reference values which strongly suggests a consequence of the enzyme inducing effect of phenobarbital. Advice about the dosage regimen in such cases is given.

Determination of 3-hydroxy-guanfacine in biological fluids by electron-capture gas-liquid chromatography

An electron-capture gas-liquid chromatographic method was developed for measuring 3-hydroxy-guanfacine, the main metabolite of guanfacine in human plasma and urine. After extraction, the metabolite was derivatized by condensing the amidino group with hexafluoroacetylacetone and by methylating the NH and OH groups with methyl iodide. The obtained derivative possessed good bioanalytical gas chromatographic properties, using a capillary column. The O-glucuronide was measured after enzymatic hydrolysis. Unchanged guanfacine could be determined in urine together with its 3-hydroxy metabolite by this method.

Biotransformation of drugs during aging

Wherever the age of an individual can, of course, be precisely indicated, the individual physiological state of every aged person varies greatly and therefore the resultant implications considering absorption, distribution, metabolism and excretion. In animals aging has been described as a factor of modification of metabolism. In the elderly the oxidative enzyme activity appears diminished but coupled to a decreased liver mass and liver blood flow. Examples of decreased conjugation for paracetamol and indomethacin are known. Acetylation does not seem to be influenced. The net effect of aging appears quite frequently an increase in the blood level of unchanged drug. However, drug metabolism cannot be considered independently from the other factors calling for an individualized treatment of the elderly.

Pindolol: disposition and metabolism in rhesus monkeys after chronic treatment

1. The absorption, distribution, excretion and metabolism of pindolol were studied in rhesus monkeys after a single oral dose of 2.5 mg/kg or 25 mg/kg and after a chronic treatment of 5 years at the same daily dosage. 2. The pharmacokinetic parameters were the same for animals which received pindolol for the first time, and animals which underwent the 5 years' chronic treatment. An elimination half-life of 1.5 to 1.9 h was estimated in plasma for unchanged pindolol. 3. The distribution pattern of unchanged pindolol determined fluorimetrically, as well as total 14C in the tissues, following administration of [14C]pindolol showed no difference between a single dose and 5 years of chronic treatment. No accumulation of pindolol or metabolites was detected in the tissues of chronically treated animals. A mean elimination half-life of 10h was evaluated in 21 organs. 4. Acutely dosed and chronically treated rhesus monkeys showed the same metabolic pattern in urine. There was no evidence for induction or inhibition of the metabolism of pindolol.

Determination of pindolol in biological fluids by electron-capture GLC

An electron-capture GLC method was developed for measuring pindolol in human plasma and urine. The unchanged drug was extracted with benzene from alkalinized plasma or urine using propranolol as the internal standard. Both compounds subsequently were back-extracted into 0.1 M HCl and then into benzene. After evaporation of the organic phase, the compounds were derivatized with trifluoroacetylimidazole to form the trifluoroacetyl ester of pindolol and propranolol. These derivatives then were analyzed by electron-capture GLC. The method allowed the measurement of concentrations as low as 1 ng of pindolol/ml of plasma and was applied successfully to determinations of plasma levels in humans after oral administraton of a single 10-mg dose of pindolol.

Pharmacokinetics and metabolism of guanfacine in man: a review

1 The fate of guanfacine has been investigated extensively in animals.

2 Pharmacokinetics and metabolism of [¹⁴C]-guanfacine were studied in fourteen subjects given 3 mg orally (seven subjects) and 2.3 mg intravenously. Plasma levels and urinary excretion of radioactivity were measured by liquid scintillation counting. Parent drug was determined by gas chromatography-mass spectrometry. The analytical results were submitted to pharmacokinetic evaluation using the SAAM 26 programme. Metabolites in urine were identified by high pressure liquid chromatography.

3 Guanfacine was rapidly and completely absorbed. Its absolute bioavailability was close to 100%, no evidence of any first-pass effect being found.

4 Its distribution was characterized by low blood levels, low plasma protein binding and a relatively high affinity to the tissues (V_d of 300 l).

5 The elimination half-life of the β-phase was 17 hours. The major route of excretion (80% of the dose) was in the urine. About 1/3 to 1/4 of the total clearance of 11 l/h was renal.

6 The principal metabolite was the 3-hydroxy-derivative of guanfacine conjugated as either O-glucuronide or O-sulphate. The important fraction (30%) of parent drug found in the urine demonstrates a rather moderate biotransformation of guanfacine in man.

7 The results of an additional study after multiple dosing showed that the measured steady-state plasma levels were in agreement with the values predicted from a single dose experiment and proportional to the daily dosage.