Quinacrine, a PLA2 inhibitor, alleviates LPS-induced acute kidney injury in rats: Involvement of TLR4/NF-κB/TNF α-mediated signaling

Acute Kidney Injury (AKI) is a major factor in sepsis-related mortality and may occur due to lipopolysaccharide (LPS), an endotoxin produced by gram-negative bacteria that triggers a systemic acute inflammatory response. Quinacrine's (QC) renoprotective properties in sepsis and the underlying mechanism, however, are still not fully understood. This study was done to investigate the anti-inflammatory, antioxidative, and anti-apoptotic effects of QC, a phospholipase A2 (PLA2) inhibitor, against LPS-induced AKI. Rats were randomly divided into five groups: control group, QC30 group, LPS group, LPS+QC 10 group, and LPS+QC 30 group. The rats were administered intraperitoneally QC (10 and 30 mg/kg) for 3 days (once a day) prior to injection of LPS (3 mg/kg). Six hours after the LPS injection, the histopathological changes, oxidative stress, inflammation, and apoptosis in the collected kidney tissues were detected by hematoxylin and eosin staining, enzyme-linked immunosorbent assay (ELISA), real-time PCR (RT-PCR), and immunohistochemistry staining, respectively. QC pretreatment could successfully attenuate LPS-induced AKI, as evidenced by a decrease in tissue histopathological injury. Meanwhile, QC alleviated LPS-induced kidney oxidative stress; it reduced MDA levels and increased levels of SOD, CAT, GPX, and GSH. LPS-induced elevations in kidney TLR4, NF-κB, TNF-α, IL-1β, IL-6, PLA2, caspase 3, and Bax contents were significantly attenuated in QC-treated groups. Our findings revealed a significant effect of QC: protecting against LPS-induced AKI through inhibition of PLA2 and decreasing inflammation, oxidative stress, and apoptosis. To treat LPS-induced AKI, QC may be an effective substance with an excellent protection profile.

Treatment strategies for nitroimidazole-refractory giardiasis: a systematic review

RATIONALE FOR REVIEW

Giardiasis is one of the most common human protozoal infections worldwide. First-line therapy of giardiasis includes nitroimidazole antibiotics. However, treatment failure with nitroimidazoles is increasingly reported, with up to 45% of patients not responding to initial treatment. There is no clear consensus on the approach to the management of nitroimidazole-refractory giardiasis. This systematic review aims to summarize the literature on pharmacotherapy for nitroimidazole-refractory giardiasis.

METHODS

We conducted a systematic review of the literature to determine the optimal management strategies for nitroimidazole-refractory giardiasis. We searched Pubmed/MEDLINE, Embase and Cochrane library using the following search terms 'Giardia' AND 'treatment failure' OR 'refractory giardia' OR 'resistant giardia' with date limits of 1 January 1970 to 30 June 2021. We included all reports on humans, which described clinical outcomes of individuals with treatment refractory giardiasis, including case series and case reports. A descriptive synthesis of the data was conducted with pooling of data for interventions.

KEY FINDINGS

Included in this review were five prospective studies, three retrospective studies, seven case series and nine case reports. Across these reports, a wide heterogeneity of treatment regimens was employed, including retreatment with an alternative nitroimidazole, combination therapy with a nitroimidazole and another agent and monotherapy with non-nitroimidazole regimens, including quinacrine, paromomycin and nitazoxanide. Retreatment with a nitroimidazole was not an effective therapy for refractory giardiasis. However, treatment with a nitroimidazole in combination with albendazole had a cure rate of 66.9%. In the included studies, quinacrine monotherapy was administered to a total of 179 patients, with a clinical cure rate of 88.8%. Overall, quinacrine was fairly well tolerated.

CONCLUSIONS

Reports on the treatment of nitroimidazole-refractory giardiasis demonstrate a heterogeneous approach to treatment. Of these, quinacrine appeared to be highly effective, though more data on its safety are needed.

Antimalarial lichenoid tissue reactions in patients with pre-existing lupus erythematosus

Recently a number of cases of drug induction or exacerbation of lupus erythematosus (LE) specific skin disease have been described in the literature. Many of the responsible medications are also known for their ability to induce a lichenoid tissue reaction. Aminoquinoline antimalarials are currently the first line of therapy in cutaneous LE specific skin disease. Lichenoid tissue reactions are among the most common cutaneous side effects of aminoquinolone antimalarials. We report three cases of aminoquinolone antimalarial induced or exacerbated LE specific skin disease. We also review the pathophysiology of LE specific skin disease and propose a mechanism by which induction of the lichenoid tissue reaction may result in Koebnerization of LE specific skin lesions.

Inhibition of spawning in zebrafish (Danio rerio): Adverse outcome pathways of quinacrine and ethinylestradiol

This study determined the effects of the estrogen receptor agonist ethinylestradiol (EE2) and the phospholipase A2 inhibitor quinacrine (QUIN) on the pathways controlling follicular development, steroidogenesis, oocyte maturation, ovulation and spawning success in adult zebrafish. Both EE2 and QUIN inhibited spawning but did so through different mechanisms. EE2 affected follicular development (reduced ovarian size and reduction in the proportion of cortical alveolus, vitellogenic and mature follicle stages), steroidogenesis (reduced expression of aromatase), maturation (reduced luteinizing hormone receptor expression) and ovulation (reduced expression of cytosolic phospholipase A2 and the nuclear progesterone receptor). Although EE2 alters the proportion of follicle stages within the ovary, the downregulation of gene expression as a consequence of EE2 exposure was primarily due to a decline in expression of the genes of interest in vitellogenic and mature ovarian follicles. QUIN targeted ovulation via a reduction of the steroid 17α,20β dihydroxy-4-prenen-3-one (17α,20β-P) and decreased expression of the prostaglandin metabolizing enzyme cyclooxygenase 2. This study demonstrates the usefulness in defining the impacts of toxicants at the molecular and cellular, organ and whole organism level and how connections between these impacts can be used to describe the adverse outcome pathways (AOPs) that mediate toxicant action. Histological analysis and gene expression were effective tools in defining the AOPs of QUIN and EE2 while the measurement of reproductive hormones level did not provide much valuable information regarding the toxicant's mode of action.

A nonsurgical permanent contraception stakeholder advisory committee: FHI 360's experience

As part of its research program on nonsurgical permanent contraception, FHI 360, a nonprofit human development organization, created a stakeholder advisory committee to help address the controversy surrounding quinacrine. This committee contributed to FHI 360's research agenda, liaised with other stakeholders and provided input on key decisions. This report summarizes the process for establishing the committee, delineates the successes and challenges that arose and specifies recommendations for other organizations considering stakeholder collaboration.

Pigmented oral mucosa due to quinacrine

We describe the case of a 50-year-old woman with asymptomatic, irregularly outlined macule, dark in color on the hard palate. Antecedents include antimalarial medication for lupus erythematous subacute. After a histopathological study, differential diagnoses are presented.

[Quinacrine in the treatment of cutaneous lupus erythematosus: practical aspects and a case series]

Hydroxychloroquine and chloroquine are antimalarials used as first-line treatment of cutaneous lupus. Quinacrine is not often employed by Spanish physicians due to a lack of information about its use and the fact that it is not marketed in Spain. It is effective in monotherapy or in combination therapy with other antimalarials. One of the advantages of quinacrine over chloroquine and hydroxychloroquine is that it does not appear to cause retinal toxicity. Quinacrine is used as second-line therapy in patients with pre-existing eye problems that contraindicate treatment with chloroquine or hydroxychloroquine (after evaluation of which drug has the better risk-benefit relationship), and in combination therapy with other antimalarials inpatients with resistance or only a partial response to chloroquine or hydroxychloroquine. We report 8 cases of patients with cutaneous lupus who received treatment with quinacrine in monotherapy or in combination with others antimalarials. Lesions resolved in 5 patients and improved in 3. Therapy had to be withdrawn in 1 patient due to an exacerbation of his psoriasis.

Randomized clinical study of five days apostrophe therapy with mebendazole compared to quinacrine in the treatment of symptomatic giardiasis in children

AIM: To compare the efficacy and safety of five days apostrophe therapy of mebendazole (MBZ) versus quinacrine (QC) on human giardiasis in children.

METHODS: A clinical trial was carried out in paediatric patients (aged 5-15 years) with confirmed symptomatic G. duodenalis mono-infection. Patients were randomly assigned to receive either MBZ [200 mg taken three times per day (TID) (n = 61)] or QC [2 mg/kg bodyweight tid (n = 61)], both for five days. Follow-up faecal samples were obtained at 3, 5 and 7 d after the end of the treatment.

RESULTS: Although the frequency of cure was higher for QC (83.6%) than for MBZ (78.7%), the difference was not statistically significant (P > 0.05). Adverse events were reported more in the QC group (P < 0.05), all of them transient and self-limiting.

CONCLUSION: Despite final cure rates ocurring lower than expected, the overall results of this study reconfirmed the efficacy of MBZ in giardiasis and also indicate that, although comparable to QC, at least in this setting the 5 d course of MBZ did not appear to improve the cure rates in this intestinal parasitic infection.

Rhabdomyolysis associated with quinacrine therapy in a patient with chronic cutaneous lupus erythematosus

We describe a patient who developed rhabdomyolysis 6 weeks after starting combination therapy with hydroxychloroquine and quinacrine for the treatment of chronic cutaneous lupus erythematosus (CCLE). Myopathy due to 4-aminoquinolone antimalarials has been well documented. It is plausible that quinacrine may induce muscle injury in a manner similar to other antimalarials but, to our knowledge, rhabdomyolysis associated with antimalarial therapy has not been reported.

Compassionate use of quinacrine in Creutzfeldt–Jakob disease fails to show significant effects

Quinacrine has been reported as an antiprion agent and proposed as an immediately applicable treatment for Creutzfeldt–Jakob disease (CJD). The authors report the results of an open compassionate procedure to which 32 CJD patients had access. In some genotypic subgroups, a slight but nonsignificant increase in survival was observed, likely due to biased inclusion of long-term surviving patients. There was no pathologic evidence of a beneficial effect of quinacrine treatment.

Oral mucosal pigmentation secondary to treatment with mepacrine, with sparing of the denture bearing area

We report a case of oral mucosal pigmentation secondary treatment with mepacrine, with sparing of the denture bearing area. To our knowledge this phenomenon has not been reported since the association between antimalarial therapy and mucosal pigmentation was first described.

The acceptability, efficacy and safety of quinacrine non-surgical sterilization (QS), tubectomy and vasectomy in 5 provinces in the Red River Delta, Vietnam: a follow-up of 15,190 cases

OBJECTIVES

To compare the safety, efficacy and acceptability of quinacrine sterilization (QS), tubectomy and vasectomy in Vietnam.

METHODS

This study was initiated in January 1998 and completed in February 2000. A sample of 9 districts in 5 provinces, where the prevalence of QS was known to be high, was selected. Every person sterilized in these 9 districts between January 1, 1988 and March 31, 1998 was identified and systematically interviewed by family planning clinicians who had received special training for this project.

RESULTS

A total of 15,982 sterilization users were identified and 15,190 were interviewed and examined, including a gynecologic exam, if needed: a follow-up rate of 95%. Of those interviewed, 9,753 used tubectomy, 3,734 used QS and 1,703 used vasectomy. All three methods were found to be safe, although morbidity associated with tubectomy was more serious than with QS or vasectomy. No deaths were reported. After more than 5 years of follow-up, tubectomy had the lowest failure rate: 1.0%, followed by 4.1% with vasectomy. A pregnancy rate of 13.2% was reported with quinacrine, although only a small fraction of these failures were confirmed. A strong preference for QS was found.

CONCLUSION

QS has an important role to play in sterilization services in Vietnam.

Bull's-eye maculopathy associated with quinacrine therapy for malaria

PURPOSE

To report a side effect of quinacrine therapy for malaria.

DESIGN

Case report.

METHODS

Review of clinical chart and photographs.

SETTING

Private retina practice.

RESULTS

A patient developed a bilaterally symmetric bull's-eye maculopathy 45 years after taking quinacrine for 18 months as prophylaxis against malaria. Progression of the clinical picture was documented over 15 years of follow-up. The clinical picture was identical to that of chloroquine and hydroxychloroquine maculopathy.

CONCLUSIONS

Low dosages of quinacrine used for malaria prophylaxis can be associated with a delayed, severe maculopathy indistinguishable from chloroquine maculopathy in certain patients.

Quinacrine nonsurgical female sterilization in Baroda, India: 23 years of follow-up of 84 women

OBJECTIVES

Evaluate the long-term effectiveness and safety of transcervical insertion of quinacrine hydrochloride pellets for nonsurgical female sterilization (QS).

METHODS

During the period June 1979 through January 1980, 84 women were admitted to a study at the Baroda Medical College and Hospital, Baroda, India. Our protocol called for three transcervical insertions of 252 mg of quinacrine hydrochloride to be deposited in the uterus of each patient. Follow-up was scheduled at 6, 12 and 48 months after the last administration.

RESULTS

These women were 25 to 39 years of age at the time of the QS procedure and now, 23 years later, have completed their reproductive years. There were 4 pregnancies subsequent to the completion of QS, all prior to their 4-year follow-up. Thus, the life-time failure rate for these women was 3.7%. Complaints were minor, especially when compared to surgical sterilization. There were no long-term effects suspected of being attributable to QS.

CONCLUSIONS

QS appears to be a reasonably effective method that is much safer than surgical sterilization.

Quinacrine sterilization (QS) among high-risk women: a study of 134 cases

OBJECTIVE

To determine if quinacrine sterilization (QS) is safe and effective in women at high risk for surgery.

METHODS

A trial was initiated at the Government Medical College in Patiala, India, in December 1993. Patient intake was terminated in July 1999 and the cut-off date for this analysis was March 31, 2003. Using a modified IUD inserter, seven 252 mg quinacrine pellets with 50 mg of diclofenac were transcervically inserted into the uterus. DMPA 150 mg was administered IM at the time of the first insertion as a back-up contraceptive. This same combination was inserted a month later. A total of 134 women underwent QS. Of these, 92 were considered to be at high risk for surgery, 27 were afraid of surgery or voluntarily opted for QS, and 15 had had failed surgical sterilization or surgery was found not to be technically feasible. Follow-up was scheduled for 1, 3, 6 and 12 months, and then annually after the second insertion or whenever side effects or complications were experienced.

RESULTS

Mean follow-up was 7.2 years. No pregnancies or serious complications were experienced.

CONCLUSION

QS is a safe and effective option for women at high risk of surgical complications.

The rate of ectopic pregnancy for 24,589 quinacrine sterilization (QS) users compared to users of other methods and no method in 4 provinces in Vietnam, 1994-1996

OBJECTIVE

To determine the rates of ectopic pregnancy with the use of quinacrine sterilization (QS) compared to other methods and no method (non-users).

METHODS

Four provinces were selected for their above average numbers of women who had undergone QS: Nam Dinh, Nam Ha, Hai Duong and Hung Yen. Case histories related to surgical treatment of all ectopic pregnancies in these 4 provinces from 1994 through 1996 were collected from all hospitals by researchers from the Ministry of Health in June 1997. Using a questionnaire designed for this study, 120 physicians interviewed every woman in her home who had had an ectopic pregnancy during this period. If deceased, a family member was consulted. All interviews were completed in September 1998. The numbers of users of each method and nonusers were calculated from service statistics and demographic data.

RESULTS

Based on 2,551,355 woman-years of exposure, the rate of ectopic pregnancy among users per 1000 woman-years was calculated to be: 0.26 with QS; 0.42 with surgical sterilization (TL) and IUD; 0.45 with the Pill; 0.50 with condoms; 0.78 relying on withdrawal; and 1.18 among non-users.

CONCLUSION

Ectopic pregnancy rates for QS, TL, IUD and the Pill were similar and much lower than the rate for non-users of contraception.

10-year follow-up of women who elected quinacrine sterilization (QS) in Wonosobo, Central Java, Indonesia

OBJECTIVES

To evaluate the safety and efficacy of quinacrine sterilization (QS) in Indonesia.

METHODS

During the period, August 1992 to October 1993, 200 women who had requested surgical sterilization volunteered for QS at the Wonosobo Regency Hospital, Central Java Province, Indonesia. The protocol called for transcervical insertion of 252 mg of quinacrine in the form of 7 cylindrical pellets and 55.5 mg of ibuprofen with a CuT-IUD (Kimia Farma) inserter during the proliferative phase of the menstrual cycle. A second procedure was done 4 weeks later. The technique used is essentially the same as inserting a CuT-IUD. Follow-up was scheduled at 6, 12, 24 and 48 months after the last insertion. In March 2003 additional monitoring was completed.

RESULTS

The 10-year cumulative pregnancy rate was 4.3 per 100 women with a follow-up rate of 93%. No pregnancies had occurred among these women since the 4-year follow-up. No long-term side effects or complications were reported.

CONCLUSIONS

After 10 years of use, QS was found to be safe and reasonably effective.

A comparison of quinacrine sterilization (QS) and surgical sterilization (TL) in 600 women in Guizhou Province, China

OBJECTIVES

Compare the safety and efficacy of quinacrine sterilization (QS) and surgical sterilization, also known as tubal ligation (TL).

METHODS

300 women accepted QS in Guiyang, China during the period from July 1995 to September 1997. Each patient was scheduled for follow-up at 3, 6, 12 and 24 months. In March 1998, a comparison group of 300 women electing TL during the same time period was systematically chosen. Researchers visited the village of every woman and conducted a structured interview. Each candidate was given a general health and pelvic exam at a clinic in her village. All interviews and exams were completed in August 1998.

RESULTS

Of the 289 QS patients interviewed (a follow-up rate of 96.3%), 265 had had 2 insertions. There were 3 pregnancy failures for a cumulative life table failure rate of 1.2 per 100 women at 24 months. The 299 TL patients (a follow-up rate of 99.7%) had a similar rate of 0.7. There were no life-threatening side effects or deaths in either groups. QS was less disruptive, more easily tolerated, required fewer resources and was viewed more favorably than TL by women and their spouses.

CONCLUSIONS

Both methods were found safe and very effective. However, QS was considered to be more acceptable than TL.

Quinacrine sterilization (QS): the ethical issues

QS has generated debates that are ultimately grounded in various principles, norms, and values. Through a careful analysis of opposing arguments, this paper focuses on two ethical principles claimed by both sides, namely: respect for life and beneficence. Though issues surrounding QS are complex, from the common ground of these two principles, this paper proposes a course of action that addresses many of the concerns from both points of view.

Quinacrine sterilization (QS) in Costa Rica: 694 cases

OBJECTIVES

To evaluate the safety, efficacy and acceptability of quinacrine sterilization (QS) in Costa Rica.

METHODS

From 1989 though August 1993, 694 women volunteered for QS in my private practice. All were referred by a family planning clinic or a local hospital obstetric service. The protocol used involved the transcervical insertion of 216 mg of quinacrine hydrochloride in the form of 6 pellets. A second dose was given 4 weeks later. All insertions were done in the first 14 days of the menstrual cycle. The procedure was similar to the CuT IUD placement. Temporary contraception was recommended for 3 months after the last insertion. The cut-off date for this analysis was April 1994.

RESULTS

With 7 months to 5 years of follow-up, the gross pregnancy rate was 2.5%. Side effects were relatively minor, none requiring hospitalization.

CONCLUSION

QS was found to be safe, effective and acceptable.

[Therapeutics for prion diseases]

Recent outbreaks of acquired forms of human prion diseases in younger people are promoting the development of prophylaxis and therapeutics. One possible target for therapeutic interventions is to inhibit the biosynthesis and accumulation of an abnormal isoform of prion protein, which is supposed to be a pathogen itself. Here, our current in-vitro and in-vivo data on anti-prion chemicals with amyloid binding capacity, represented by pentosan polysulfate and thioflavin-related chemicals, are presented, and structural aspects on the interaction between prion protein molecules and anti-prion chemicals including quinacrine are discussed. The current status of clinical trials using quinacrine or pentosan polysulfate is also reviewed. Finally, key structure(s) in the prion protein molecules, important to inhibit the conversion into abnormal prion protein molecules, are discussed in terms of pharmacology, and possibility of the in-silico rational drug design is also referred. Exploitation of anti-prion drugs should facilitate to solve the enigma of "prion" which can be the only creature against the central dogma, in addition to its contributing to the people with the illness or the people in high risks.

Quinacrine sterilization (QS) experience in the Philippines: a preliminary report

OBJECTIVE

The first clinical trial of Quinacrine Sterilization (QS) in the Philippines was undertaken in Cebu City on January 10, 2000, to evaluate the acceptability, safety, effectiveness and side effects of this technology. We intend to recruit 500 patients to utilize this technique for limiting family size. For the purposes of this report, our cut-off date is April 11, 2003.

METHODS

Over more than two years, QS was performed on 36 volunteer patients. After careful explanation of the procedure and given the opportunity to ask questions, they had signed an informed consent. The trial involved transcervical insertion of 252 mg quinacrine in the form of pellets, and placed at the tip of the uterine fundus on two occasions, a month apart. Condoms were routinely provided to all patients except those on oral contraceptive pills and DMPA after the first insertion to be used for six weeks after the second one. As the numbers are small, no statistical evaluation was called for.

RESULTS

The accumulated experience was 515 woman-months. There were no pregnancies, neither ectopic nor intrauterine: Adverse events (AE) were mild. Some patients complained of a yellow discharge and itching. Fifty percent experienced mild abdominal discomfort which was easily managed with mefenamic acid.

CONCLUSIONS

Although this is a small study, we believe that QS is both safe and effective and we are strongly encouraged to continue to offer this nonsurgical sterilization method to our patients.

8-year follow-up in a randomized trial of one vs two transcervical insertions of quinacrine pellets for sterilization in Indonesia

OBJECTIVE

To evaluate the efficacy of one vs two insertions of quinacrine and the long-term safety of quinacrine sterilization (QS) 8 years after the procedure in Indonesia.

METHODS

Between March 1993 and September 1995, a randomized trial was conducted in 6 academic centers in Indonesia. In February 2003, a follow-up study was undertaken in Bandung, one of those centers. This survey required a home visit of each woman. A questionnaire was designed to elicit information regarding current general health status, method failure, pregnancy outcomes and other contraceptive methods now used by women who experienced failures. Among the 70 patients receiving a single insertion of quinacrine pellets, 14.3% had become pregnant. There were no pregnancies among the 30 who received 2 insertions. All the women were found to be in good health. No long-term side effects or complications were identified.

CONCLUSION

The two-insertion protocol is unmistakably superior to the single insertion. This study provides further evidence that QS is a safe contraceptive method.

An FDA phase I clinical trial of quinacrine sterilization (QS)

OBJECTIVE

To review the significance of a United States Food and Drug Administration (FDA) approved Phase I clinical trial of a new use for an old drug, quinacrine. To discover whether ultrasound may have utility in quinacrine sterilization (QS).

METHOD

This clinical trial began on 16 September 2000 at the Women's and Children's Hospital of Buffalo (WCHOB) in Buffalo, New York. Ten patients volunteered to have QS. These subjects were carefully followed with regularly scheduled examinations, including extensive laboratory blood tests. In addition, each patient had a trans-abdominal ultrasound examination six weeks or later past the date of the second insertion of quinacrine. The trial was completed on 30 April 2003.

RESULTS

Laboratory results fell within normal limits, thus providing additional evidence to affirm the lack of toxic effects of QS. With ultrasound, we were able to see scars in both oviducts on all of our patients. One patient with a small scar as seen on ultrasound became pregnant.

CONCLUSION

QS was found to be safe and effective. Ultrasound holds the promise of reducing the failure rate.

Quinacrine female nonsurgical sterilization (QS): endometrial assessment by vaginal ultrasonography in 128 women

OBJECTIVE

Investigate effectiveness, safety and endometrial pattern after QS.

METHOD

This study began in March 1999 and ended March 18, 2003; 128 women received transcervical insertions of quinacrine. Follow-up visits with ultrasound were scheduled at 1, 3, 6, 12-month intervals.

RESULTS

Two pregnancies occurred, one at 25 months, the other at 37. Adverse events (AE) were: yellow vaginal discharge, headache, mild abdominal pain, vaginal pruritus, nausea and transient decrease in endometrial thickness. One patient had allergic reaction. A third insertion was done in case of vaginal bleeding (16.4%). One year after QS 10% still had amenorrhea, which may be the result of the fact that 73% of our patients had received DMPH. Once inside the uterus, the dissolved quinacrine could be seen within seconds, via ultrasound as a "Lake of Quinacrine" which stays for up to two hours. Frequently, a transverse vaginal ultrasonographic view of the uterine cavity showed plug-like echogenic points at the cornua.

CONCLUSION

Quinacrine sterilization is safe and effective. The echogenic points need to be more thoroughly studied in order to affirm whether ultrasonography may identify the blockage of the tubes. Since early pregnancy is due to imperfect tubal closure, the use of ultrasound may prevent failure. However, pregnancy due to later recanalization cannot be avoided.

Quinacrine sterilization (QS) in Syria: a preliminary report on 297 cases

OBJECTIVES

To evaluate the safety, efficacy and acceptability of quinacrine sterilization (QS) in Syria.

METHODS

From July 2001 to December 2002, 297 women who requested permanent sterilization volunteered for QS either in my private practice or my local family planning center in Aleppo, Syria. The standard protocol was used: 252 mg of quinacrine in the form of 7 pellets are deposited at the uterine fundus with a modified CuT IUD inserter during the proliferative phase of the menstrual cycle. This procedure is repeated 4 weeks later. DMPA was injected at the time of the first insertion for temporary contraception. Every sterilized woman has had a monthly checkup visit until the cut-off date for this report, including a beta HCG pregnancy test. All procedures were performed by the author. The cut-off date for this report was June 11, 2003.

RESULTS

The single pregnancy was ectopic. Four women (1.3%) complained of severe pain. Moderate pain was experienced by 13.1% while the remaining women felt mild pain, all easily treated. The remaining side effects were minor and also easily treated. Oligomenorrhea and amenorrhea affected 29% of the women and lasted for several months. Immediate side effects are similar to reports from other researchers.

CONCLUSIONS

Results thus far regarding efficacy are encouraging. QS has proven to be acceptable.

25 years of quinacrine sterilization experience in Chile: review of 2,592 cases

OBJECTIVES

To assess short-term side effects, long-term risks and efficacy of quinacrine sterilization (QS) in Chile.

METHODS

Review experience of 2,592 cases sterilized with 2 or 3 transcervical insertions of 252 mg quinacrine as pellets since 1977; review the Chilean pre-clinical experience and epidemiological studies on cervical, endometrial and other cancers.

RESULTS

Among 2,592 women who underwent QS, the total number of pregnancies was 119 (4.6%); 59 (49.5%) were carried to term with no birth defects related to QS. Nine cases were ectopic pregnancies. The ectopic pregnancy risk per 1,000 woman-years was 0.41, similar to that for surgical sterilization. The cumulative life-table pregnancy rates per 100 women at 10 years varied from 5.2 to 6.9. Mild and transient side effects were reported in 13.5% of quinacrine intrauterine insertions and pelvic inflammatory disease was diagnosed in 4 cases (0.15%). Long-term follow-up of quinacrine-sterilized patients shows no increased risk of cervical, endometrial or other cancer.

CONCLUSIONS

QS efficacy at 10 years is comparable to widely accepted tubal clip and single point bipolar electrocoagulation laparoscopic procedures. QS has a low risk of serious, immediate side effects. No long-term risks have been identified after 25 years of use.

Quinacrine-induced psychiatric disturbances in a child with common variable immunodeficiency and chronic giardiasis

Psychiatric disorders due to quinacrine for antiparasitic therapy represent an infrequent, but serious, complication. The remarkable course of a 12-year-old boy with common variable immunodeficiency who developed severe psychiatric reactions following quinacrine therapy for his resistant chronic giardiasis is presented. The broad clinical spectrum of quinacrine-associated neuropsychiatric disturbances has been emphasized for the clinicians.

[Prospects of the therapeutic approaches to Creutzfeldt-Jakob disease: a clinical trial of antimalarial, quinacrine]

Prion diseases are lethal transmissible neurodegenerative illnesses that affect humans and many other animals. Since the accumulation of the pathogenic form of prion protein is a pivotal event in prion diseases, most of the therapeutic strategies are designed to prevent the conformational change of normal prion protein to that of the pathogenic form or to remove the accumulated prion protein. Quinacrine is one of the compounds that can inhibit the accumulation of pathogenic prion protein in cultured neuroblastoma cells. Here we report the results of clinical trials of quinacrine administration to the patients of Creutzfeldt-Jakob disease. In some patients, response to visual and auditory stimulations improved transiently. Lemon-yellow discolorization of skin and liver dysfunction were common side effects by quinacrine.

Randomized trial of one versus two transcervical insertions of quinacrine pellets for sterilization

OBJECTIVE

To determine the relative effectiveness of single vs. two transcervical monthly insertions of 252 mg of quinacrine for female sterilization.

DESIGN

Controlled clinical study.

SETTING

Family planning clinics of 6 academic centers.

PATIENT(S)

Sexually active reproductive-age women requesting sterilization.

INTERVENTION(S)

At each of six centers 70 and 30 women were randomly assigned to receive either one or two, respectively, monthly transcervical insertions to the fundus of 252 mg of quinacrine and 75 mg of diclofenac as pellets and they were followed for 1 year.

MAIN OUTCOME MEASURE(S)

Complications, side effects, and pregnancy failures.

RESULT(S)

There were no serious complications and side effects were transient and easily treated. There were 31 (7.4%) pregnancy failures in the single insertions group and 2 (1.1%) in the two insertions group, but with marked center variation.

CONCLUSION(S)

Quinacrine sterilization using two monthly insertions of 252 mg of quinacrine appears safe and reasonably effective.

The effect of chloroquine, quinacrine, and metronidazole on both soybean plants and soil microbiota

Chloroquine, quinacrine, and metronidazole are used extensively for therapeutic purposes. Substantial quantities of these compounds end up in the environment. The potential effect of these compounds on soybean and on the protozoa in soil was assessed. The growth of soybean plants was affected by increasing concentrations of the chloroquine, metronidazole, and quinacrine dihydrochloride. The plants were particularly sensitive to low concentrations of metronidazole. The number of bacteria and protozoa in soil was either unchanged or increased in the presence of chloroquine and quinacrine. However, in the presence of only 0.5 mg metronidazole g(-1) soil, the density of protozoa in the rhizosphere was reduced by a 10-fold.

Current treatment of cutaneous lupus erythematosus

Cutaneous lupus erythematosus has a variety of clinical presentations, but treatment is similar for the different forms. The antimalarials remain the cornerstone of treatment because of their effectiveness and safety. Optimal use of the antimalarials as well as alternative therapy options are discussed.

Antimalarials

Antimalarial medications have become the parenteral drugs of choice for treating the cutaneous manifestations of lupus erythematosus. The immune-modulating activity of these agents makes them useful in a variety of other dermatoses. With prudent dosage and monitoring, these agents can be used safely and effectively in the treatment and management of dermatologic disease.

Long-term follow-up after quinacrine sterilization in Vietnam. Part II: interim safety analysis

OBJECTIVE

To determine the long-term safety of nonsurgical sterilization with quinacrine.

DESIGN

Observational cohort study.

SETTING

Rural provinces in northern Vietnam.

PATIENT(S)

Two thousand eight hundred forty women who had had quinacrine insertions and an age-matched comparison group of 1,658 women who had an intrauterine device (IUD) insertion between 1989 and 1993.

METHOD(S)

Interviews in 1994, 1995, and 1996 and review of available medical records. This is a planned interim analysis.

MAIN OUTCOME MEASURE(S)

Ectopic pregnancies and the occurrence of other adverse health events.

RESULT(S)

Over 90% of women were interviewed at least once. Despite matching on age, the groups differed on baseline parity. The ectopic pregnancy rates were similar after either one or two insertions and were similar to the rate of ectopic pregnancies after surgical sterilization in the United States. The quinacrine group reported more gynecologic health problems than the IUD group. However, after correcting for information bias, there was no dose-response effect between the one- and two-insertion quinacrine groups, suggesting the possibility of recall bias or differing baseline health status.

CONCLUSION(S)

Ectopic pregnancies do not appear to be increased compared with U.S. surgical sterilization rates. The data on other adverse events are more difficult to interpret.

Quinacrine sterilization: experience among women at high risk for surgery

A non-surgical method of female sterilization is needed because many women are at high risk of complications with standard surgical methods, especially in developing countries. Also, some women who desire sterilization refuse it for fear of surgery. To meet these special needs, we initiated a trial of quinacrine sterilization (QS), a non-surgical method involving transcervical insertion of 252 mg quinacrine as pellets by a modified IUD inserter. Diclofenac (50 mg) was inserted with the quinacrine pellets. This insertion was repeated a month later and a 150-mg injection of depo medroxyprogesterone was administered at the time of the first insertion. One hundred and thirty-four women of reproductive age entered the trial. Of these, 92 were considered to be at high risk for surgery, 27 had refused surgery, and 15 had had failed surgical sterilization. Mean follow-up was 3.46 years. No pregnancies or serious complications were experienced. The main side-effect was menstrual irregularity, due probably to the depo medroxyprogesterone injection. QS is a suitable option for women at high risk of surgical complications.

Oral mucosal hyperpigmentation secondary to antimalarial drug therapy

A case of oral mucosal hyperpigmentation resulting from antimalarial drug therapy is presented. The patient reported a history of long-term quinacrine therapy and exhibited diffuse blue-gray pigmentation of the nail beds and the skin of the nasal ala. Microscopic examination of the involved mucosa showed macrophages, containing both melanin and ferric iron, scattered within the connective tissue adjacent to the epithelium. The clinical, historical, and microscopic features of antimalarial-induced pigmentation are discussed. Other causes of diffuse or multifocal oral pigmentation are also addressed.

The benefit of combining hydroxychloroquine with quinacrine in the treatment of SLE patients

BACKGROUND

Although the benefit of antimalarials in the treatment of cutaneous LE is well established, the effect of combined hydroxychloroquine and quinacrine treatment in systemic lupus erythematosus with major organ involvement remains underappreciated.

PATIENTS

Six active SLE patients (SLEDAI score > 5 points), with a mean duration of illness 9.1 yr (range 2-17 yr) were started on quinacrine (100 mg/d) following failure to achieve clinical remission on a therapeutic regimen which included a maintenance dose of hydroxychloroquine (400 mg/d) together with prednisone (either 10-20 mg/d or higher daily doses of this agent for short periods) and azathioprine (150 mg/d) or methotrexate (7.5 mg/week).

OUTCOME

In 5/6 of the patients the addition of quinacrine to the previous treatment resulted in complete remission (SLEDAI 0-2 points), which persisted over the follow-up period [mean +/- 2.2 yr (range 0.5-3.5)]. During this period hydroxychloroquine and azathioprine were reduced to 200 mg/d and 100 mg/d respectively, whereas prednisone was modified as follows: in 2 patients daily administration was discontinued; in one the dose was reduced to 2.5 mg/d (from that of > or = 20 mg/d); in 2 others the previous need for an intermittent course was avoided. However, in one out of the six patients the addition for 3 months of quinacrine to the therapeutic protocol did not result in clinical improvement and was therefore discontinued.

CONCLUSIONS

The promising results of this preliminary investigation encourages the combined use of the two antimalarial drugs in appropriate candidates. This modality may induce remission, seems to be safe and possesses a steroid sparing effect.

Quinacrine dihydrochloride, the non-surgical female sterilant induces dicentrics, rings, and marker chromosomes in human peripheral blood lymphocytes treated in vitro: a preliminary report

During the last decade, quinacrine dihydrochloride (QDH) has been promoted for clinical trials as a much needed non-surgical female sterilant, largely in the Third World. Recently, however, these human trials have come under severe criticism due to lack of adequate evidence of biological safety of QDH, particularly of its genotoxicity in mammalian systems. In the present study, the cytogenetic analysis of QDH-treated human lymphocytes, grown as whole blood cultures in vitro, surprisingly showed a wide range of chromosomal aberrations. At a concentration of 3.0 and 6.0 microg/ml in culture, QDH was cytotoxic, as shown by the very few analyzable metaphases that could be observed. G(0) lymphocytes, treated with 0. 6 microg/ml QDH, exhibited chromosome aberrations including dicentrics, ring configurations, translocations, inversions, and marker chromosomes. Near haploid, polyploid, and endoreduplicated cells were also observed. All the rings appeared to be formed as a result of telomere fusion/association. Twenty percent of the dicentrics observed also indicated telomere fusion/association in the D and G groups of chromosomes. Overall, a frequent involvement of chromosomes 1, 2, and 3 in both unstable and stable chromosome rearrangements was also observed. Exposure of 72-h cultures to 0.45 microg/ml QDH at 69 h resulted in an accumulation of C-metaphases, suggesting that probably QDH behaves as a mitotic spindle inhibitor. The G(2) lymphocytes from two donors exposed to 0.6, 1.5 or 3.0 microg/ml of QDH showed no increase in chromatid aberrations in two donors. However, QDH at 0.6 microg/ml increased the frequency of micronucleated binucleate cells. No increase in sister chromatid exchanges was observed at this concentration. Though preliminary, these observations demonstrate the chromosome damaging ability of QDH in human lymphocytes treated in vitro. Surprisingly, like ionizing radiation, QDH acted by an S-phase-independent mechanism, unlike most of the chemical mutagens. These results warrant detailed investigations on the cytogenetic effects of QDH in vitro, as well as among women exposed to this agent during clinical trials for non-surgical sterilization. The interesting cytogenetic profile of QDH deserves to be pursued and the underlying mechanisms, in particular, the DNA topoisomerase II inhibitory effect, if any, needs to be elucidated.

[Combination of antimalarial drugs mepacrine and chloroquine in therapy refractory cutaneous lupus erythematosus]

Antimalarials represent the first line in treatment of cutaneous lupus erythematosus (LE). However, some patients show no improvement on monotherapy with chloroquine or hydroxychloroquine. A 30-year-old female patient had treatment-resistant cutaneous LE exhibiting features of both LE tumidus and subacute cutaneous LE. Previously, the patient had been unsuccessfully treated with chloroquine, hydroxychloroquine, dapsone, and azathioprine, each in combination with variable doses of prednisolone. However, the LE lesions increased during these therapeutic regimens. A combination of chloroquine and mepacrine therapy led to improvement and then total clearing after 4 months of treatment.

Quinacrine sterilization: an assessment of risks for ectopic pregnancy, birth defects and cancer

Quinacrine sterilization (QS) involves transcervical insertion of quinacrine pellets using a modified Copper TIUD inserter. Pellets are placed at the fundus in the proliferative phase of the menstrual cycle. Efficacy is presently estimated at 1 pregnancy failure per 100 women at 2 years. Early complications are lower for QS than surgical sterilization and this is also true for risk of ectopic pregnancy with newer insertion protocols. The risk of birth defects is very low, when estimated from a model with reasonable assumptions for probability of insertion in a pregnant uterus or within 30 days of conception, probability of such exposed pregnancy being carried to term, and probability of quinacrine exposure to the fetus causing a birth defect. Although quinacrine is a mutagen it is unlikely to be a carcinogen. Concentrations of quinacrine in the uterus after transcervical insertion are higher than for oral administration for only a matter of a few hours, although this brief exposure is adequate to cause injury to the tubal epithelium, leading to inflammation and an occluding scar. Oral administration of quinacrine is accepted as non-carcinogenic. Each site of use of QS must make its own risk/benefit assessment. The benefits of any contraceptive that can raise contraceptive prevalence is greatest for developing countries.