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Ndayisaba G, Yeka A, Asante KP, Grobusch MP, Karita E, Mugerwa H, Asiimwe S, Oduro A, Fofana B, Doumbia S, Jain JP, Barsainya S, Kullak-Ublick GA, Su G, Schmitt EK, Csermak K, Gandhi P, Hughes D. Hepatic safety and tolerability of cipargamin ( KAE609), in adult patients with Plasmodium falciparum malaria: a randomized, phase II, controlled, dose-escalation trial in sub-Saharan Africa. Malar J 2021; 20:478. [PMID: 34930267 PMCID: PMC8686384 DOI: 10.1186/s12936-021-04009-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 12/04/2021] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND The novel anti-malarial cipargamin (KAE609) has potent, rapid activity against Plasmodium falciparum. Transient asymptomatic liver function test elevations were previously observed in cipargamin-treated subjects in two trials: one in malaria patients in Asia and one in volunteers with experimentally induced malaria. In this study, the hepatic safety of cipargamin given as single doses of 10 to 150 mg and 10 to 50 mg once daily for 3 days was assessed. Efficacy results, frequency of treatment-emerging mutations in the atp4 gene and pharmacokinetics have been published elsewhere. Further, the R561H mutation in the k13 gene, which confers artemisinin-resistance, was associated with delayed parasite clearance following treatment with artemether-lumefantrine in Rwanda in this study. This was also the first study with cipargamin to be conducted in patients in sub-Saharan Africa. METHODS This was a Phase II, multicentre, randomized, open-label, dose-escalation trial in adults with uncomplicated falciparum malaria in five sub-Saharan countries, using artemether-lumefantrine as control. The primary endpoint was ≥ 2 Common Terminology Criteria for Adverse Events (CTCAE) Grade increase from baseline in alanine aminotransferase (ALT) or aspartate transaminase (AST) during the 4-week trial. RESULTS Overall, 2/135 patients treated with cipargamin had ≥ 2 CTCAE Grade increases from baseline in ALT or AST compared to 2/51 artemether-lumefantrine patients, with no significant difference between any cipargamin treatment group and the control group. Cipargamin exposure was comparable to or higher than those in previous studies. Hepatic adverse events and general safety and tolerability were similar for all cipargamin doses and artemether-lumefantrine. Cipargamin was well tolerated with no safety concerns. CONCLUSIONS This active-controlled, dose escalation study was a detailed assessment of the hepatic safety of cipargamin, across a wide range of doses, in patients with uncomplicated falciparum malaria. Comparison with previous cipargamin trials requires caution as no clear conclusion can be drawn as to whether hepatic safety and potential immunity to malaria would differ with ethnicity, patient age and or geography. Previous concerns regarding hepatic safety may have been confounded by factors including malaria itself, whether natural or experimental infection, and should not limit the further development of cipargamin. Trial registration ClinicalTrials.gov number: NCT03334747 (7 Nov 2017), other study ID CKAE609A2202.
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Affiliation(s)
| | - Adoke Yeka
- Infectious Diseases Research Collaboration, Masafu, Uganda
| | - Kwaku Poku Asante
- Kintampo Health Research Centre, Kintampo North Municipality, Kintampo, Ghana
| | - Martin P Grobusch
- Centre de Recherches Médicales en Lambaréné, Lambaréné, Gabon
- Amsterdam University Medical Centers, Amsterdam, The Netherlands
- University of Tübingen, Tübingen, Germany
| | | | | | - Stephen Asiimwe
- Kabwohe Clinical Research Centre and Mbarara University of Science and Technology, Mbarara, Uganda
| | | | | | | | - Jay Prakash Jain
- Novartis Institutes for BioMedical Research, Emeryville, CA, USA
| | | | - Gerd A Kullak-Ublick
- Novartis Pharma AG, Novartis Campus, 4056, Basel, Switzerland
- University Hospital Zürich and University of Zürich, Zürich, Switzerland
| | - Guoqin Su
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | | | - Katalin Csermak
- Novartis Pharma AG, Novartis Campus, 4056, Basel, Switzerland
| | - Preetam Gandhi
- Novartis Pharma AG, Novartis Campus, 4056, Basel, Switzerland.
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Kreutzfeld O, Rasmussen SA, Ramanathan AA, Tumwebaze PK, Byaruhanga O, Katairo T, Asua V, Okitwi M, Orena S, Legac J, Conrad MD, Nsobya SL, Aydemir O, Bailey J, Duffey M, Bayles BR, Vaidya AB, Cooper RA, Rosenthal PJ. Associations between Varied Susceptibilities to PfATP4 Inhibitors and Genotypes in Ugandan Plasmodium falciparum Isolates. Antimicrob Agents Chemother 2021; 65:e0077121. [PMID: 34339273 PMCID: PMC8448140 DOI: 10.1128/aac.00771-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 07/22/2021] [Indexed: 11/20/2022] Open
Abstract
Among novel compounds under recent investigation as potential new antimalarial drugs are three independently developed inhibitors of the Plasmodium falciparum P-type ATPase (PfATP4): KAE609 (cipargamin), PA92, and SJ733. We assessed ex vivo susceptibilities to these compounds of 374 fresh P. falciparum isolates collected in Tororo and Busia districts, Uganda, from 2016 to 2019. Median IC50s were 65 nM for SJ733, 9.1 nM for PA92, and 0.5 nM for KAE609. Sequencing of pfatp4 for 218 of these isolates demonstrated many nonsynonymous single nucleotide polymorphisms; the most frequent mutations were G1128R (69% of isolates mixed or mutant), Q1081K/R (68%), G223S (25%), N1045K (16%), and D1116G/N/Y (16%). The G223S mutation was associated with decreased susceptibility to SJ733, PA92, and KAE609. The D1116G/N/Y mutations were associated with decreased susceptibility to SJ733, and the presence of mutations at both codons 223 and 1116 was associated with decreased susceptibility to PA92 and SJ733. In all of these cases, absolute differences in susceptibilities of wild-type (WT) and mutant parasites were modest. Analysis of clones separated from mixed field isolates consistently identified mutant clones as less susceptible than WT. Analysis of isolates from other sites demonstrated the presence of the G223S and D1116G/N/Y mutations across Uganda. Our results indicate that malaria parasites circulating in Uganda have a number of polymorphisms in PfATP4 and that modestly decreased susceptibility to PfATP4 inhibitors is associated with some mutations now present in Ugandan parasites.
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Affiliation(s)
- Oriana Kreutzfeld
- Department of Medicine, University of California, San Francisco, California, USA
| | | | - Aarti A. Ramanathan
- Center for Molecular Parasitology, Department of Microbiology and Immunology, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | | | | | - Thomas Katairo
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Victor Asua
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Martin Okitwi
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Stephen Orena
- Infectious Diseases Research Collaboration, Kampala, Uganda
| | - Jennifer Legac
- Department of Medicine, University of California, San Francisco, California, USA
| | - Melissa D. Conrad
- Department of Medicine, University of California, San Francisco, California, USA
| | | | | | | | | | - Brett R. Bayles
- Dominican University of California, San Rafael, California, USA
| | - Akhil B. Vaidya
- Center for Molecular Parasitology, Department of Microbiology and Immunology, Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | | | - Philip J. Rosenthal
- Department of Medicine, University of California, San Francisco, California, USA
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Schmitt EK, Ndayisaba G, Yeka A, Asante KP, Grobusch MP, Karita E, Mugerwa H, Asiimwe S, Oduro A, Fofana B, Doumbia S, Su G, Csermak Renner K, Venishetty VK, Sayyed S, Straimer J, Demin I, Barsainya S, Boulton C, Gandhi P. Efficacy of cipargamin ( KAE609) in a randomized, Phase II dose-escalation study in adults in sub-Saharan Africa with uncomplicated Plasmodium falciparum malaria. Clin Infect Dis 2021; 74:1831-1839. [PMID: 34410358 PMCID: PMC9155642 DOI: 10.1093/cid/ciab716] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Indexed: 12/02/2022] Open
Abstract
Background Cipargamin (KAE609) is a potent antimalarial in a phase II trial. Here we report efficacy, pharmacokinetics, and resistance marker analysis across a range of cipargamin doses. These were secondary endpoints from a study primarily conducted to assess the hepatic safety of cipargamin (hepatic safety data are reported elsewhere). Methods This phase II, multicenter, randomized, open-label, dose-escalation trial was conducted in sub-Saharan Africa in adults with uncomplicated Plasmodium falciparum malaria. Cipargamin monotherapy was given as single doses up to 150 mg or up to 50 mg once daily for 3 days, with artemether-lumefantrine as control. Key efficacy endpoints were parasite clearance time (PCT), and polymerase chain reaction (PCR)–corrected and uncorrected adequate clinical and parasitological response (ACPR) at 14 and 28 days. Pharmacokinetics and molecular markers of drug resistance were also assessed. Results All single or multiple cipargamin doses ≥50 mg were associated with rapid parasite clearance, with median PCT of 8 hours versus 24 hours for artemether-lumefantrine. PCR-corrected ACPR at 14 and 28 days was >75% and 65%, respectively, for each cipargamin dose. A treatment-emerging mutation in the Pfatp4 gene, G358S, was detected in 65% of treatment failures. Pharmacokinetic parameters were consistent with previous data, and approximately dose proportional. Conclusions Cipargamin, at single doses of 50 to 150 mg, was associated with very rapid parasite clearance, PCR-corrected ACPR at 28 days of >65% in adults with uncomplicated P. falciparum malaria, and recrudescent parasites frequently harbored a treatment-emerging mutation. Cipargamin will be further developed with a suitable combination partner. Clinical Trials Registration ClinicalTrials.gov (NCT03334747).
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Affiliation(s)
| | | | - Adoke Yeka
- Infectious Diseases Research Collaboration, Busia, Uganda
| | | | - Martin P Grobusch
- Centre de Recherches Médicales en Lambaréné, Lambaréné, Gabon, Amsterdam University Medical Centers, Amsterdam, The Netherlands.,University of Tübingen, Tübingen, Germany
| | | | | | - Stephen Asiimwe
- Kabwohe Clinical Research Center and Mbarara University of Science and Technology, Mbarara, Uganda
| | | | | | | | - Guoqin Su
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
| | | | | | | | - Judith Straimer
- Novartis Institutes for BioMedical Research, Emeryville, California, USA
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Bouwman SA, Zoleko-Manego R, Renner KC, Schmitt EK, Mombo-Ngoma G, Grobusch MP. The early preclinical and clinical development of cipargamin ( KAE609), a novel antimalarial compound. Travel Med Infect Dis 2020; 36:101765. [PMID: 32561392 DOI: 10.1016/j.tmaid.2020.101765] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 05/29/2020] [Accepted: 05/30/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cipargamin (KAE609) is a novel spiroindolone class drug for the treatment of malaria, currently undergoing phase 2 clinical development. This review provides an overview and interpretation of the pre-clinical and clinical data of this possible next-generation antimalarial drug published to date. METHODS We systematically searched the literature for studies on the preclinical and clinical development of cipargamin. PubMed and Google Scholar databases were searched using the terms 'cipargamin', 'KAE609' or 'NITD609' in the English language; one additional article was identified during revision. Nineteen of these in total 43 papers identified reported original studies; 13 of those articles were on pre-clinical studies and 6 reported clinical trials. RESULTS A total of 20 studies addressing its preclinical and clinical development have been published on this compound at the time of writing. Cipargamin acts on the PfATP4, which is a P-type Na + ATPase disrupting the Na + homeostasis in the parasite. Cipargamin is a very fast-acting antimalarial, it is active against all intra-erythrocytic stages of the malaria parasite and exerts gametocytocidal activity, with transmission-blocking potential. It is currently undergoing phase 2 clinical trial to assess safety and efficacy, with a special focus on hepatic safety. CONCLUSION In the search for novel antimalarial drugs, cipargamin exhibits promising properties, exerting activity against multiple intra-erythrocytic stages of plasmodia, including gametocytes. It exhibits a favourable pharmacokinetic profile, possibly allowing for single-dose treatment with a suitable combination partner. According to the clinical results of the first studies in Asian malaria patients, a possible safety concern is hepatotoxicity.
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Affiliation(s)
- Suzan Am Bouwman
- Center for Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Amsterdam University Medical Centers, Location AMC, Amsterdam Infection & Immunity, Amsterdam Public Health, University of Amsterdam, Meibergdreef 9, 1100 DD, Amsterdam, the Netherlands; Centre de Recherches Médicales de Lambaréné (CERMEL), Lambaréné, Gabon
| | - Rella Zoleko-Manego
- Centre de Recherches Médicales de Lambaréné (CERMEL), Lambaréné, Gabon; Institute of Tropical Medicine, University of Tübingen, Tübingen, Germany; Department of Tropical Medicine, Bernhard Nocht Institute for Tropical Medicine & I. Department of Medicine University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Esther K Schmitt
- Novartis Pharma AG, Global Health Development Unit, Basel, Switzerland
| | - Ghyslain Mombo-Ngoma
- Centre de Recherches Médicales de Lambaréné (CERMEL), Lambaréné, Gabon; Institute of Tropical Medicine, University of Tübingen, Tübingen, Germany; Department of Tropical Medicine, Bernhard Nocht Institute for Tropical Medicine & I. Department of Medicine University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin P Grobusch
- Center for Tropical Medicine and Travel Medicine, Department of Infectious Diseases, Division of Internal Medicine, Amsterdam University Medical Centers, Location AMC, Amsterdam Infection & Immunity, Amsterdam Public Health, University of Amsterdam, Meibergdreef 9, 1100 DD, Amsterdam, the Netherlands; Centre de Recherches Médicales de Lambaréné (CERMEL), Lambaréné, Gabon; Institute of Tropical Medicine, University of Tübingen, Tübingen, Germany.
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Dennis ASM, Lehane AM, Ridgway MC, Holleran JP, Kirk K. Cell Swelling Induced by the Antimalarial KAE609 (Cipargamin) and Other PfATP4-Associated Antimalarials. Antimicrob Agents Chemother 2018; 62:e00087-18. [PMID: 29555632 DOI: 10.1128/AAC.00087-18] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 02/18/2018] [Indexed: 12/15/2022] Open
Abstract
For an increasing number of antimalarial agents identified in high-throughput phenotypic screens, there is evidence that they target PfATP4, a putative Na+ efflux transporter on the plasma membrane of the human malaria parasite Plasmodium falciparum For several such "PfATP4-associated" compounds, it has been noted that their addition to parasitized erythrocytes results in cell swelling. Here we show that six structurally diverse PfATP4-associated compounds, including the clinical candidate KAE609 (cipargamin), induce swelling of both isolated blood-stage parasites and intact parasitized erythrocytes. The swelling of isolated parasites is dependent on the presence of Na+ in the external environment and may be attributed to the osmotic consequences of Na+ uptake. The swelling of the parasitized erythrocyte results in an increase in its osmotic fragility. Countering cell swelling by increasing the osmolarity of the extracellular medium reduces the antiplasmodial efficacy of PfATP4-associated compounds, consistent with cell swelling playing a role in the antimalarial activity of this class of compounds.
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Abstract
INTRODUCTION Despite increased international efforts for control and ultimate elimination, malaria remains a major health problem. Currently, artemisinin-based combination therapies are the treatment of choice for uncomplicated malaria exhibiting high efficacy in clinical trial settings in sub-Saharan Africa. However, their administration over a three-day period is associated with important problems of treatment adherence resulting in markedly reduced effectiveness of currently recommended antimalarials under real world settings. AREAS COVERED Antimalarial drug candidates and antimalarial drug combinations currently under advanced clinical development for the indication as single dose antimalarial therapy. Expert commentary: Several new drug candidates and combinations are currently undergoing pivotal proof-of-concept studies or clinical development programmes. The development of a single dose combination therapy would constitute a breakthrough in the control of malaria. Such an innovative treatment approach would simultaneously close the effectiveness gap of current three-day therapies and revolutionize population based interventions in the context of malaria elimination campaigns.
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Affiliation(s)
- Johannes Mischlinger
- a Centre de Recherches Médicales de Lambaréné , Lambaréné , Gabon.,b Institut für Tropenmedizin , Universität Tübingen , Tübingen , Germany
| | - Selidji T Agnandji
- a Centre de Recherches Médicales de Lambaréné , Lambaréné , Gabon.,b Institut für Tropenmedizin , Universität Tübingen , Tübingen , Germany
| | - Michael Ramharter
- a Centre de Recherches Médicales de Lambaréné , Lambaréné , Gabon.,b Institut für Tropenmedizin , Universität Tübingen , Tübingen , Germany.,c Department of Medicine I, Division of Infectious Diseases and Tropical Medicine , Medical University of Vienna , Vienna , Austria
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Abstract
Malaria is caused by the Plasmodium parasite and is a major health problem leading to many deaths worldwide. Lack of a vaccine and increasing drug resistance highlights the need for new antimalarial drugs with novel targets. Antiplasmodial activity of spiroindolones was discovered through whole-cell, phenotypic screening methods. Optimization of the lead spiroindolone improved both potency and pharmacokinetic properties leading to drug candidate NITD609 which has produced encouraging results in clinical trials. Spiroindolones inhibit PfATP4, a P-type Na(+)-ATPase in the plasma membrane of the parasite, causing a fatal disruption of its sodium homeostasis. Other diverse compounds from the Malaria Box appear to target PfATP4 warranting further research into its structure and binding with NITD609 and other potential antimalarial drugs.
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Zhang R, Suwanarusk R, Malleret B, Cooke BM, Nosten F, Lau YL, Dao M, Lim CT, Renia L, Tan KSW, Russell B. A Basis for Rapid Clearance of Circulating Ring-Stage Malaria Parasites by the Spiroindolone KAE609. J Infect Dis 2015; 213:100-4. [PMID: 26136472 PMCID: PMC4676544 DOI: 10.1093/infdis/jiv358] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 06/21/2015] [Indexed: 11/30/2022] Open
Abstract
Recent clinical trials revealed a surprisingly rapid clearance of red blood cells (RBCs) infected with malaria parasites by the spiroindolone KAE609. Here, we show that ring-stage parasite–infected RBCs exposed to KAE609 become spherical and rigid, probably through osmotic dysregulation consequent to the disruption of the parasite's sodium efflux pump (adenosine triphosphate 4). We also show that this peculiar drug effect is likely to cause accelerated splenic clearance of the rheologically impaired Plasmodium vivax– and Plasmodium falciparum–infected RBCs.
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Affiliation(s)
- Rou Zhang
- Department of Microbiology, Yong Loo Lin School of Medicine
| | - Rossarin Suwanarusk
- Singapore Immunology Network (SIgN), Agency for Science Technology and Research (A*STAR), Biopolis
| | - Benoit Malleret
- Department of Microbiology, Yong Loo Lin School of Medicine Singapore Immunology Network (SIgN), Agency for Science Technology and Research (A*STAR), Biopolis
| | - Brian M Cooke
- Department of Microbiology, Monash University, Melbourne, Victoria, Australia
| | - Francois Nosten
- Shoklo Malaria Research Unit, Mae Sot, Tak Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, University of Oxford, United Kingdom
| | - Yee-Ling Lau
- Department of Parasitology, Faculty of Medicine, University of Malaya, Kuala Lumpur
| | - Ming Dao
- Department of Materials Science and Engineering, Massachusetts Institute of Technology, Cambridge
| | - Chwee Teck Lim
- Biomedical Engineering, National University of Singapore
| | - Laurent Renia
- Singapore Immunology Network (SIgN), Agency for Science Technology and Research (A*STAR), Biopolis
| | | | - Bruce Russell
- Department of Microbiology, Yong Loo Lin School of Medicine
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Abstract
INTRODUCTION Malaria is a major health problem in endemic countries and chemotherapy remains the most important tool in combating it. Treatment options are limited and essentially rely on a single drug class - the artemisinins. Efforts are ongoing to restrict the evolving threat of artemisinin resistance but declining sensitivity has been reported. Fueled by the ambitious aim of malaria eradication, novel antimalarial compounds, with improved properties, are now in the progressive phase of drug development. AREAS COVERED Herein, the authors describe antimalarial compounds currently in Phase II clinical development and present the results of these investigations. EXPERT OPINION Thanks to recent efforts, a number of promising antimalarial compounds are now in the pipeline. First safety data have been generated for all of these candidates, although their efficacy as antimalarials is still unclear for most of them. Of particular note are KAE609, KAF156 and DSM265, which are of chemical scaffolds new to malaria chemotherapy and would truly diversify antimalarial options. Apart from SAR97276, which also has a novel chemical scaffold that has had its development stopped, all other compounds in the pipeline belong to already known substance classes, which have been chemically modified. At this moment in time, there is not one standout compound that will revolutionize malaria treatment but several compounds that will add to its control in the future.
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Affiliation(s)
- Jana Held
- Institut für Tropenmedizin, Eberhard Karls Universität , Wilhelmstraße 27, D-72074 Tübingen , Germany +49 7071 29 85569 ; +49 7071 295189 ;
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