artemisinin
/ qinghaosu(a
molecule with a pharmacophoric peroxide bond in a unique 1,2,4-trioxane
heterocycle) : is a compound based on qinghaosu, or sweet wormwood. 1st
isolated in 1965 by Chinese military researchers while seeking a new antimalarial
treatment for Vietnamese troops fighting American forces, it cut the death
rate by 97% in a malaria epidemic in Viet Nam in the early 1990's. It is
rapidly replacing quinine derivatives and later drugs against which the
disease has evolved into resistant strains. To protect artemisinin from
the same fate, it will be given as part of multidrug cocktails. Unicef,
the United Nations Children's Fund, which procures drugs for the world's
poorest countries, opposed its use during an Ethiopian epidemic in 2003,
saying that there was too little supply and that switching drugs in mid-outbreak
would cause confusion. Until recently, big donors like the United States
and Britain had opposed its use on a wide scale, saying it was too
expensive, had not been tested enough on children and was not needed in
areas where other malaria drugs still worked. In 2004 the new Global Fund
for AIDS, Tuberculosis and Malaria has given 11 countries grants to buy
artemisinin and has instructed 34 others to drop requests for 2 older drugs
-- chloroquine and sulfadoxine-pyrimethamine -- and switch to the new one.
The price of artemisinin cocktails has fallen from $2 per treatment to
< 90 cents as more companies in China, India and Viet Nam have begun
making them (older drugs cost only 20 cents)
Pharmacodynamics : intraparasitic heme
of infected erythrocytes irreversible catalyzes cleavage of the endoperoxide
bridge. This is followed by intramolecular rearrangement to produce carbon-centered
radicals that covalently modify (alkylation) and damage haem and proteins.
Further artemisins interfere with the function of the sarcoplasmic-endoplasmic
reticulum ATPase PfATP6 that generates energy in the malaria parasite.
Semi-synthetic derivatives :
dihydroartemisin (DHA)
dihydroartemisinin with napthoquine and trimethoprim (DNP)
b-artemether
(Artenam®; co-artemether / CGP 56697 / A-L in combination
with lumefantrine (Coartem® (sold
by Novartis to poor countries for 10 cents less than it costs to make),
Riamet® (sold to European travelers for about $20))
In some parts of Southeast Asia they are the only effective treatment for
acute malaria. Notably, there is no evidence of drug resistance to any
member of the artemisinin family of drugs. As a drug class, the artemisinins
suffer from chemical (semi-synthetic availability, purity and cost), biopharmaceutical
(poor bioavailability and limiting pharmacokinetics : they remain in the
bloodstream for only a short time so have to be taken frequently) and treatment
(non-compliance with long treatment regimens and recrudescence) issues
that limit their therapeutic potential
although total synthesis of artemisinin is difficult and costly, the semi-synthesis
of artemisinin or any derivative from microbially sourced artemisinic acid,
its immediate precursor, could be a cost-effective, environmentally friendly,
high-quality and reliable source of artemisinin. Saccharomyces cerevisiae
has been engineered to produce high titres (up to 100 mg/l) of artemisinic
acid using an engineered mevalonate pathway, amorphadiene synthase, and
a novel cytochrome P450 monooxygenase (CYP71AV1) from A. annua that
performs a 3-step oxidation of amorpha-4,11-diene to artemisinic acid.
The synthesized artemisinic acid is transported out and retained on the
outside of the engineered yeast, meaning that a simple and inexpensive
purification process can be used to obtain the desired product. Although
the engineered yeast is already capable of producing artemisinic acid at
a significantly higher specific productivity than A. annua, yield
optimization and industrial scale-up will be required to raise artemisinic
acid production to a level high enough to reduce artemisinin combination
therapies to significantly below their current pricesref.
RBx-11160, is a synthetic, slightly altered
version of artemisinin. It only needs to be taken for around 3 days, and
its simple structure means it should be at least 5 times cheaper to produce.
Better solubility means the drug can be given orally or injected intravenously.
Added stability means that less of the compound is broken down as it travels
to the blood plasma, where the parasite lives. The new version is also
more potent. When infected mice are given the drug, 95-100% of parasites
disappear within four days. Conventional artemisinin drugs take a week
to clear 95% of parasites. The drug entered preliminary human safety trials
in Britain in July 2004. If the drug works well in people, it would probably
be given in combination with a second drug, which would kill any parasites
missed by RBx-11160ref.
chloroquine (Aralen® in
combination with primaquine; once called Resochin®)
phosphate, diphosphate or sulfate.
hydroxychloroquine (Plaquenil®)
amodiaquine (Basoquin®,
CAM-AQ1®, Camoquin®, Camoquinal®,
Flavoquin®, Fluroquine®, Miaquin®,
SN-10,751®; Camoprima Infatabs® in combination
with primaquine)
pyronaridine, a hydroxyanilino-benzonaphthyridine
synthesized in China in 1970, which has been used for the treatment of
P.
vivax and P. falciparum for more than 20 years and has been
shown to be effective in the treatment of falciparum malaria in children
in Cameroon. It has more gastrointestinal side effects than chloroquine.
There are insufficient data at present to recommend the use of pyronaridine
for the treatment of malaria in non-immune travellers.
bisquinoline
piperaquine phosphate is an orally active
bisquinoline discovered in the early 1960s and developed for clinical use
in China in 1973. In vitro testing in several laboratories has shown that
piperaquine approximates chloroquine’s effects against sensitive parasites
and is significantly more effective than chloroquine in treating resistant
P. falciparum. In China, Vietnam and Cambodia, piperaquine is now available
as a fixed combination with
clioquinol / iodochlorhydroxyquin (nowadays
used only as Zn chelator)
4-quinoline-methanols
mefloquine chlorhydrate (Falcitab®,
Lariam®) was isolated at the Walter Reed Army Institute
of Research in 1963 for American troops in the Vietnamese conflict. In
combination with pyrimethamine-sulfadoxine
in Fansimef®
Side effects : acute psychiatric syndrome
(=> suicide)
and post-malaria
neurological syndrome (PMNS).
The Pentagon is studying 21 suicides committed in Iraq and Kuwait during
Operation Iraqi Freedom (plus 5 more deaths in Iraq as possible suicides,
and six deaths among soldiers in Iraq who killed themselves after returning
to the United States). 4 of the 21 soldiers who committed suicide in Iraq
or Kuwait came from units that took Lariam and 1 tested positive for Lariam
in the blood
antimetabolites
protozoal dihydropteroate synthetase
sulfones
dapsone / 4,4'-diaminodiphenylsulfone (Lapdap®
in combination with chlorproguanil)
sulfonamides
sulfadiazine
sulfadoxine
protozoal DHF reductase (at concentrations far lower than those
required to produce comparable inhibition of the mammalian enzymes) (antifols)
work poorly against P. vivax
2,4-diaminopyrimidines
pyrimethamine (Daraprim®).
In combination with sulfadoxine in Fansidar®,
in combination with dapsone in Maloprim®)
lumefantrine / benflumetol (a fluorene
derivative) (co-artemether / CGP 56697 / A-L (Coartem®,
Riamet®) in combination with artemether)
proguanil / chloroguanide
(Paludrine®) chlorhydrate => cycloguanil; usually
administered in combination with atovaquone
(Malarone®)
chlorproguanil (Lapudrine®;
Lapdap® in combination with dapsone)
trypanothione reductase
melarsoprol / Mel B (Arsobal®)
: binding to trypanothione (a glutathione analog) results in formation
of melarsen oxide-trypanothione adduct (Mel T), a compound that
is a potent competitive inhibitor of trypanothione reductase, thus affecting
defenses against oxidative stress.
ornithine decarboxylase (ODC)
eflornithine / a-difluoromethylornithine
(DFMO) hydrochloride (Ornidyl®, Vaniga®)
: also used to treat unwanted facial hair (UFH) in females.
suramin sodium (Germanin® /
Bayer 205®) is a polysulfonated derivative of urea and has
been widely used both to treat trypanosome infections and as a chemotherapeutic
drug. Suramin has been shown to inhibit growth factor signaling pathways
and inhibits death receptor-induced apoptosis in hepatoma and lymphoma
cells in vitro and fulminant apoptotic liver damage in mice. It
also inhibits the proapoptotic effect of chemotherapeutic drugsref
pentamidine isethionate or methylate
(Pentacarinate®, Pentam® or NebuPent®)
stilbamidine
dibromo propamidine isethiaote (Brolene®)
diminazine (Berenil®)
cell membrane stability
polyene macrolides
amphotericin
B
(AmB) deoxycholate (DAMB) (Amphocil®,
Amphocin®, Fungilin®, Fungizone®,
Intralipid®) : parenteral administration of amphotericin
B (AMB), a polyene antibiotic with strong antifungal activity, remains
the therapy of choice for systemic mycoses. It is highly hydrophobic and
is commonly administrated as desoxycholate amphotericin (DAMB), a detergent
micelle complex. AMB binds preferentially to ergosterol in fungal plasma
membranes, although it also interacts with animal cell sterols such as
cholesterol, which accounts for known toxicityref1,
ref2.
DAMB therapy is associated with nephrotoxicity, central nervous system
and liver damage, and side effects such as nausea and feverref1,
ref2,
ref3.
AMB, with its inherent low solubility in water and many organic solvents,
shows relatively poor bioavailabilityref1,
ref2.
In order to increase the therapeutic index of AMB and reduce its associated
toxicity, new lipid-based formulations have been developedref1,
ref2,
ref3.
These drug delivery systems, such as liposomal formulations, lipid complexes,
lipid emulsions, and colloidal dispersions, have been introduced into clinical
practice. But their use remains limited by cost, stability, and toxicityref1,
ref2,
ref3,
ref4,
ref5,
ref6.
Despite the improvement in therapeutic index for liposomal AMB formulations,
the overall prognosis for patients with severe candidemia remains poor
due to the inadequacy of treatments. The development of new, effective
antifungal delivery systems for acute and prophylactic application remains
an important objective. AMB is not significantly absorbed across the gastrointestinal
tract in either detergent-solubilized form or in liposomal preparationsref.
amphotericin B lipid complex (ABLC) (Abelcet®)
amphotericin B colloidal dispersion (ABCD) (Amphotec®)
liposomal amphotericin B (LAMB) (AmBisome®,
Fujisawa Healthcare, Inc.)
cochleates containing amphotericin B (CAMB)are
a novel lipid-based delivery vehicle that have an advantage over existing
formulations due to the stability of cochleates and their resistance to
degradation in the gastrointestinal tract. Thus, cochleate preparations
have the potential to delivery AMB orally. Cochleates are stable phospholipid-calcium
precipitates comprised mainly of phosphatidylserine. They have a defined
multilayered structure consisting of a continuous, solid, lipid bilayer
sheet rolled up in a spiral, with no internal aqueous space. Papahadjopoulos
et al. first described cochleates in 1975 as an intermediate in the preparation
of large unilamellar vesiclesref.
Cochleates have been used to deliver protein, peptide, and DNA for vaccine
and gene therapy applications and have been used recently as a drug delivery
systemref.
CAMB have been shown to be highly protective in a mouse candidiasis model
following parenteral administration. Because of the hydrophobic nature
of AMB molecules, it was hypothesized that AMB would be localized in the
unique, rigid lipid bilayers of the cochleates. This unique association
should provide protection for AMB from degradation when exposed to harsh
environmental conditions or enzymes. CAMB should be an ideal system to
deliver amphotericin B orally. Initial biodistribution studies of CAMB
administered orally in a mouse model showed that cochleates delivered therapeutic
levels of AMB to target organsref
protein synthesis
tetracyclines,
azithromycin
and clindamycin
also have antiplasmodial activity, although in general their action is
slow for malaria treatment (as opposed to prophylaxis); they are recommended
only in combination with other antimalarial drugs
caspofungin acetate (Cancidase®,
MK-0991®) is a semisynthetic lipopeptide derivative of pneumocandin
B0 that inhibits (1,3)b-glucan synthase,
preventing formation of b(1,3)-D-glucans
in the fungal cell wall
micafungin / FK463
... cell membrane stability
polyene macrolides : bind to ergosterol (affinity
is greater than for cholesterol) and create pores or channels.
tetraenes
nystatin
(Mycostatin®, Nilstat®) active against Candida
methylpartricin / mepartricin : a methyl ester of partricin, used
chiefly in the treatment of vaginal and cutaneous candidiasis, applied
topically.
azoles inhibit sterol 14-a-demethylase,
a microsomal cytochrome P450-dependent enzyme system necessary for synthesis
of ergosterol from lanosterol. Accumulation of 14-a-methylsterols
lead to disruption of close packing of acyl chains of phospholipids, impairing
the functions of membrane-bound enzymes.
imidazoles
bifonazole (Azolmen®, Bifazol®,
Micospor®)
butoconazole nitrate (Femstat 3®)
clotrimazole (Antimicotico Same®,
Canesten®, Lotremin®, Lotrimin®,
Mycelex®, Gynelotrimin®, Gyno-canesten®,
Mycelex-G®; Meclon®, Meclon 100®
in combination with
metronidazole)
econazole (Ganazolo®, Ifenec-Derm®,
Ifenec-Ginec.®, Micos®, Pevaryl®,
Pevaryl Gel®; Pevisone® in combination with
triamcinolone)
itraconazole (Sporanox®,
Sporonox®, Triasporin®) : dilute in water,
make oral cavity washings and then swallow
terconazole (Terazol®)
'second-generation' triazoles
posaconazole / SCH 56592 (Noxafil®)
ravuconazole
voriconazole / UK-109,496 (Vfend®)
allylamines and other nonazole ergosterol biosynthesis inhibitors
: fungal squalene epoxidase inhibitors
amorolfine (Loceryl®)
butenafine hydrochloride (Mentax®)
naftifine hydrochloride (Exoderil®,
Naftin®, Suadian®) inhibits squalene-2,3-epoxidase
and so fungal biosynthesis of ergosterol
terbinafine (Lamisil®)
praziquantel (Azinox®,
Biltricide®, Cesol®, Distocide®,
Pikiton®) : a pyrazinoisoquinoline that alters membrane
permeability
myriocin / thermozymocidin / ISP-I from from
Myriococcum
albomyces is a serine palmitoyltransferase inhibitor. Inhibition of
ceramide synthesis leads to a rapid and specific reduction in the rate
of transport of glycosylphosphatidylinositol (GPI)-anchored proteins to
the Golgi apparatus without affecting transport of soluble or transmembrane
proteins. Inhibition of ceramide biosynthesis also quickly blocks remodelling
of GPI anchors to their ceramide-containing
griseofulvin
(Fulcin®, Fulvicin P/G®, Grisactin®,
Grifulvin V®, Grisovin®, Likuden®)
inhibits microtubule formation in mitotic spindle by binding to tubulin
and MAPs. It may acts as a photosensitizer.
tunicamicin inhibits the reaction between dolichol-P and UDP-GlcNAc,
preventing all O-glycosylations.
... unknown
hydroxypyridone
ciclopiroxolamine (ciclopirox olamine)
(systemic : Loprox®; topical : Dafnegin®,
Penloc®; Batrafen) has a high affinity for trivalent metal
cations. Ciclopirox olamine can be used to synchronize mammalian cells,
but its mechanism of action is not understood well. The targets of ciclopirox
olamine in S. cerevisiae appear to include multiple proteins that participate
in various components of cellular metabolism, including DNA replication,
DNA repair, and cellular transport. Three genes were cloned: a Fe/Cu reductase
(FRE1/COS107), an oxidative stress response gene (YAP1/COS110), and a gene
involved in signal transduction (YBR203W/COS111)ref.
thiocarbamates
tolciclate (Tolmicen®)
tolnaftate (Aftate®, Tinactin®, Tinaderm®,
...)
haloprogin (Halotex®)
undecylenic acid (Caldesene®,
Cruex®, Desenex®, Dr Scholl's®,
Egomycol®, Mycota®)
zinc undecenoate (Tineafax®)
benzoic acid (6%) and salicylic acid (3%) (Whitfield's ointment)
chlordantoin : an antifungal agent effective
against various fungi, including Candida albicans; used topically
in the treatment of fungal infections of the vulvovaginal region and of
the skin
Anti-helminticor
dewormers (including helminthicides / helminthagogues and nematicides)
praziquantel (Biltricide® or Distocide®)
a pyrazinoisoquinoline that increases membrane permeability of calcium
and has a selective effect on the tegument of trematodes
clorsulon is a selective antagonist of fluke phosphoglycerate kinase
and mutase
GABA-R
agonist on nematode muscles => causes flaccid paralysis.
piperazine citrate (Multifuge®)
piperazine derivatives
diethylcarbamazine
(DEC) citrate (Filaribits®, Hetrazan®)
blocks host, and possibly parasite, enzymes involved in arachidonic acid
metabolism, and enhances the innate, nonspecific immune system.
paralysis of pharyngeal pumping
HC110R blockers
cyclooctadepsipeptides
PF1022A, the first anthelmintically active
member, is a natural compound from the fungus Mycelia sterilia that
belongs to the microflora of the leaves of the Camellia japonica.
PF1022A contains 4 N-methyl-L-leucines, 2 D-lactic
acids and 2-D-phenyllactic acids arranged as a cyclic
octadepsipeptide with an alternating L-D-L-configuration
emodepside is a semisynthetic derivative of PF1022A with a morpholine
ring at each of the 2 D-phenyllactic acids in para
position
22,23-dihydroavermectin B1a / ivermectin
(Eqvalan®, Furexel®,
Ivomec®, Mectizan®
or Stromectol®) is an agonist of GABAA receptors
found in the muscle and nerve cells of invertebrates and doesn't cross
the BBB.
levamisole (LMS)
/ (--)-2,3,5,6-tetrahydro-6-phenylimidazo[2,1-b]thiazole
(Decaris®, Levasol®, Tramisole®,
Ripercol®, Ergamisol®) is also an immunomodulator
pyrethroids are used in insecticide treated
net (ITN) and in "zampirone" spirals (from the inventor's name Zampironi)
permethrin
(Acticin®, Ambush®, Elimite®,
Imperator/Peripel® (EC : 200-500 mg/m2), Nix®,
Pounce®), a synthetic derivative of
pyrethrins
alphacyano pyrethroids : more reported side effects than permethrin,
but far more active, can be used at lower doses and last longer than permethrin.
alphacypermethrin
(Alphacypermethrin TG®, Alphacypermethrin
95% TG®, Alphaguard 10 EC®,
Alphaguard TG®, Bitin®,
Fendona® (SC : 20-40 mg/m2),
Prabal 100®, Renegade®)
is a racemic mixture of 2 isomers (1Rcis S and 1Scis
R isomers) out of the 8 cypermethrin isomers. It is 2-3 times more active
than cypermethrin under field conditions. It is effective on a wide range
of insects in a variety of crops at dosage of 7-30g a.i./ha. Alphacypermethrin
has contact and stomach action and can be used on cereals, cotton, fruits,
vegetables, flower crops, oilseeds, sugar beet, tea, tobacco, vines, etc.
for the control of a variety of insects.
etofenprox (Vectron® (EW : 200 mg/m2))
is completely different from the pyrethroids. Activity similar to permethrin,
but far less toxic than any of the pyrethoids.
flumethrin (Bayticol & Drastic Deadline®) 1%
S.C.
zetacypermethrin (Fury 10EW®)
piperonyl butoxide
bioresmethrin
esfenvalerate (Sumi-alpha®)
fenvalerate
remethrin
Formulations :
suspension concentrate (SC) : active ingredient is in the form of
crystalline particles mixed with solvents. Because the active ingredient
is in particles, it is less easily absorbed by net fibers or by the skin
- this means that the insecticide is not only more readily available to
kill mosquitoes, but is less toxic to people.
capsule suspension (CS) : microencapsulated formulation. The active
ingredient is encased in microscopic plastic capsules suspended in water.
Capsule suspension formulation are more pleasant to handle than emulsifiable
concentrates, have almost no smell and remain effective for a longer period
of time - they are however usually more expensive.
emulsifiable concentrate (EC) : insecticide is mixed with a solvent
to give a clear solution that turns milky when mixed with water. Because
the solvent allows the insecticide to more easily penetrate the skin they
can be significantly more toxic. Many agricultural pesticides are EC. Except
for permethrin, EC formulations of the others should not be used for treating
nets.
emulsion in water (EW) : the active ingredient is dissolved in a
synthetic oil mixed with water so the insecticide is in fine oil phase
droplets suspended in water. The synthetic oil helps the active ingredient
to adhere to the net fibers. It also masks the smell and irritancy of the
active ingredient.
wettable powder (WP) : the pesticide is mixed with a carrier plus
a wetting agent. Commonly used for indoor spraying (e.g. ICON), but flakes
off too easily when applied to a net. Only deltamethrin is effective in
WP formulations - but because the other formulations are so much better,
this should only be used in an emergency.
methyl bromide (MBr) : chloropicrin
(CCl3NO2), a powerful stimulator of lacrimation,
is added to fumigants as a warning of methyl bromide exposure. Side
effects : prostate
adenocarcinoma.
D-D (a mixture of 1,3-dichloropropene and 1,2-dichloropropane)