Primum non nocere - Are chloroquine and hydroxychloroquine safe prophylactic/treatment options for SARS-CoV-2 (covid-19)?

ABSTRACT Chloroquine (CQ) and its analog hydroxychloroquine (HCQ) were recently included in several clinical trials as potential prophylactic and therapeutic options for SARS-COV-2 infection/covid-19. However, drug effectiveness in preventing, treating, or slowing the progression of the disease is still unknown. Despite some initial promising in vitro results, rigorous pre-clinical animal studies and randomized clinical trials have not been performed yet. On the other hand, while the potential effectiveness of CQ/HCQ is, at best, hypothetical, their side effects are factual and most worrisome, particularly when considering vulnerable groups of patients being treated with these drugs. in this comment, we briefly explain the possible mechanisms of action of CQ/HCQ for treating other diseases, possible actions against covid-19, and their potent side effects, in order to reinforce the necessity of evaluating the benefit-risk balance when widely prescribing these drugs for SARS-COV-2 infection/covid-19. We conclude by strongly recommending against their indiscriminate use.

A newly validated high-performance liquid chromatography method with diode array ultraviolet detection for analysis of the antimalarial drug primaquine in the blood plasma

Abstract INTRODUCTION: Primaquine (PQ) diphosphate is an 8-aminoquinoline antimalarial drug with unique therapeutic properties. It is the only drug that prevents relapses of Plasmodium vivax or Plasmodium ovale infections. In this study, a fast, sensitive, cost-effective, and robust method for the extraction and high-performance liquid chromatography with diode array ultraviolet detection (HPLC-DAD-UV ) analysis of PQ in the blood plasma was developed and validated. METHODS: After plasma protein precipitation, PQ was obtained by liquid-liquid extraction and analyzed by HPLC-DAD-UV with a modified-silica cyanopropyl column (250mm × 4.6mm i.d. × 5μm) as the stationary phase and a mixture of acetonitrile and 10mM ammonium acetate buffer (pH = 3.80) (45:55) as the mobile phase. The flow rate was 1.0mL·min-1, the oven temperature was 50OC, and absorbance was measured at 264nm. The method was validated for linearity, intra-day and inter-day precision, accuracy, recovery, and robustness. The detection (LOD) and quantification (LOQ) limits were 1.0 and 3.5ng·mL-1, respectively. The method was used to analyze the plasma of female DBA-2 mice treated with 20mg.kg-1 (oral) PQ diphosphate. RESULTS: By combining a simple, low-cost extraction procedure with a sensitive, precise, accurate, and robust method, it was possible to analyze PQ in small volumes of plasma. The new method presents lower LOD and LOQ limits and requires a shorter analysis time and smaller plasma volumes than those of previously reported HPLC methods with DAD-UV detection. CONCLUSIONS: The new validated method is suitable for kinetic studies of PQ in small rodents, including mouse models for the study of malaria.

Distribution of C14-labelled arteether in kidneys and livers of experimental mice after intramuscular injection.

To study the distribution and localization of oil-soluble arteether in experimental mice, we injected C14-labelled arteether (20 microCi/kg body weight) intramuscularly and measured radioactivity in the blood, kidney, and liver. The labelled arteether distributed and localized more to the kidney (819,180.4 +/- 34,134 dpm/cm3) than the liver (288,628.9 +/- 54,954 dpm/cm3) 4 hours post-injection. The main localization of labelled arteether was in the kidney cortex rather than the medulla (p < 0.05). However, the distribution of radioactivity was homogeneous in the liver. The terminal half-life of labelled arteether in the blood was 1.8 hours. The blood:kidney:liver ratio was 1:5:2. These findings show that labelled arteether was distributed quickly and localized in the cytoplasmic cortex of the kidney and homogeneously in the liver.

Interactions between antiplasmodial 3,6-diamino-1'-dimethyl-9-anilinoacridine and hematin and concanamycin A.

Antiplasmodial 9-anilinoacridine derivatives exert their effects either by inhibiting DNA topoisomerase (topo) II or by interfering with heme crystallization within the parasite acidic food vacuole. Previous studies have shown that analogs of 9-anilinoacridine containing 3,6-diamino substitutions (in the acridine ring) inhibit Plasmodium falciparum DNA topo II in situ, whereas those with a 3,6-diCl substitution act by inhibiting beta-hematin formation, a property also seen with 3,6-diamino-1'-dimethyl-9-anilinoacridine (DDAA). To understand this seemingly anomalous property of DDAA, studies of its interaction with hematin and localization within the parasite food vacuole were undertaken. A weak interaction with hematin was demonstrated spectroscopically. Antagonism of DDAA inhibition of Plasmodium falciparum growth in culture by concanamycin A, a macrolide antibiotic inhibitor of vacuolar H(+)-ATPase derived from Streptomyces sp, was equivocal.

Antimaláricos potenciais: pró-fármacos poliméricos e formas de liberação controlada de artemisinina / Potential antimalarial agents: polymer prodrugs and controlled release formulations of artemisinin

A malária ainda constitui grave problema de saúde pública, estando presente principalmente em países em desenvolvimento. Acredita-se que 40% da população mundial vivam em áreas endêmicas para esta parasitose. No Brasil, cerca de 600 mil novos casos aparecem a cada ano, merecendo realce a Amazônia, que corresponde a 99% dos casos brasileiros. Dentre os agentes etiológicos, o Plasmodium falciparum suscita atenção especial, pois é o responsável pela malária grave. A artemisinina é agente antimalárico cujo emprego encontra-se principalmente para cepas resistentes. Embora este fármaco seja o único antimalárico cuja resistência dos plasmódios não possui relevância clínica, problemas de solubilidade comprometem sua eficácia clínica e fazem com que seja utilizado sempre em associação a antimaláricos com maior meia-vida plasmática. Com o objetivo de aumentar a biodisponibilidade do antimalárico, conferindo-lhe maior hidrossolubilidade e ante ao emprego de quitosana como transportador com vistas, entre outros, a esse objetivo, planejaram-se pró-fármacos de quitosanas modificadas e artemisinina. Inicialmente, obtiveram-se quatro derivados hidrofílicos da quitosana: N-carboxibutilquitosana, N-carboximetilquitosana, N,O-carboximetilquitosana e N-succinilquitosana. A artemisinina foi empregada na forma reduzida, a diidroartemisinina, sintetizada a partir do fármaco na presença de boroidreto de sódio em várias proporções relativas ao fármaco. Procedeu-se, então, à condensação entre a diidroartemisinina e os derivados hidrofílicos obtidos por meio de quatro métodos distintos. Prepararam-se, também, microesferas para incorporar e ligar covalentemente a diidroartemisinina à quitosana O fármaco flurbiprofeno foi utilizado como fármaco lipofílico modelo de reação. Os resultados obtidos indicam a formação de microesferas de pró-fármaco de quitosana com artemisinina, utilizando genipina como reticulante, empregando-se emulsão múltipla O/AIO juntamente com as microesferas...

El citocromo P-450 y la respuesta terapéutica a los antimaláricos / Cytochrome P-450 and the response to antimalarial drugs

OBJETIVOS: Evaluar la relación entre los factores genéticos y fenotípicos del sistema enzimático del citocromo P-450 y la respuesta terapéutica antimalárica a la cloroquina, la amodiaquina, la mefloquina y el proguanil, así como determinar la influencia de algunos factores biológicos y sociales del hospedero en el comportamiento de este complejo enzimático. MÉTODOS: Revisión sistemática de las bases de literatura biomédica PubMed, Excerpta Medica, LILACS y SciELO mediante descriptores en español e inglés. Se usaron los siguientes descriptores: "CYP-450" y "citocromo P-450" y sus combinaciones con "proguanil" (y lo mismo con "mefloquina", "cloroquina" y "amodiaquina"), "farmacocinética de proguanil" (y lo mismo con "mefloquina", "cloroquina" y "amodiaquina"), "resistencia a proguanil" (y lo mismo con "mefloquina", "cloroquina" y "amodiaquina"), "metabolismo", "farmacogenética", "enfermedad", "inflamación", "infección", "enfermedad hepática", "malaria", "nutrición" y "desnutrición". Estos mismos términos se usaron en inglés. La búsqueda se limitó a los artículos publicados en español, inglés y portugués hasta el 30 de junio de 2005 y a cuatro medicamentos antimaláricos: amodiaquina, cloroquina, mefloquina y proguanil. RESULTADOS: Algunos factores genéticos del citocromo P-450 humano (principalmente su polimorfismo), así como otros de tipo biológico y social (la propia presencia de enfermedad, inflamación o infección, la administración de medicamentos antimaláricos y su combinación, y el estado nutricional del paciente), influyen en la actividad de ese complejo enzimático. Solo en la última década se ha abordado el estudio de las bases genéticas de los citocromos y se han podido dilucidar los mecanismos de algunas interacciones entre fármacos y del metabolismo de estos, lo que ha permitido caracterizar el proceso de biotransformación de la amodiaquina y de la cloroquina. Se espera que nuevas investigaciones permitan responder a las interrogantes que aún subsisten, entre ellas cuál es la ruta metabólica de otros medicamentos antimaláricos, la distribución en la población de los alelos de las enzimas que participan en su metabolismo, y la contribución de tales mutaciones al fracaso terapéutico, y predecir la respuesta a los tratamientos antimaláricos...

Dissolução de formas farmacêuticas sólidas contendo antimaláricos e desenvolvimento de comprimidos de primaquina de liberação convencional / Dissolution of solid pharmaceutical forms contend antimalarial and development of tablets of primaquine of conventional liberation

O presente trabalho teve como objetivos, a avaliação das características físico-químicas e parâmetros de dissolução de especialidades farmacêuticas contendo sulfato de quinino, difosfato de cloroquina e fosfato de primaquina disponíveis para o tratamento da malária no Brasil, e o desenvolvimento de formulações de comprimidos de fosfato de primaquina de liberação convencional, considerando-se os requisitos de eficácia, segurança e qualidade assegurada. Comprimidos de sulfato de quinino, difosfato de cloroquina e fosfato de primaquina utilizados no tratamento de malária no Brasil, foram submetidos aos ensaios de peso médio, dureza, friabilidade, teste e perfil de dissolução e ensaios termoanalíticos...

Malaria: infección subclínica entre escolares en la comunidad de Palacios, la Mosquitia / Malaria: subclinical infection among school children in Palacios, Mosquito Coast

Basados en la detección pasiva de casos de malaria en aproximadamente un tercio de los pacientes febriles atendidos en el Centro de Salud de los Palacios, La Mosquitia, en un período de 17 semanas, se propuso realizar una búsqueda activa entre escolares con el objetivo de detectar infecciones subclínicas. Se explicó el propósito del estudio al personal de la Escuela Marco Aurelio Soto y a varios padres de familia. Durante dos días de trabajo, se entrevistaron y se examinaron los niños que asistieron a clases. Se tomó muestra de sangre por pinchazo del dedo para gota gruesa. Se estudiaron 146 niños, 75 (51.4 por ciento) del sexo masculino, distribuidos en proporción similar en los grupos etáreos de 5-9 años y 10-15 años. Ninguno de los niños informó estar enfermo y todos estaban afebriles al momento de examinarlos. Se detectó esplenomegalia leve en 21 casos (14.4 por ciento). Se demostró plasmodium vivax en dos niños para una prevalencia del 1.4 por ciento (IC 95 por ciento 0.2-4.9). Los resultados indican que en esta región del pais la intensidad de transmisión de la malaria es suficiente para producir infecciones subclínicas. Debido a que las actividades de control y prevención están dirigidas a casos febriles, las infecciones subclínicas contribuyen a mantener la transmisión

Malária grave / Severe malaria

A malária é uma doença parasitária de profundo impacto sanitário mundial, acometendo importante fração da humanidade. Por seu alcance, se faz necessário o conhecimento adequado de suas manifestações clínicas e da terapêutica, para otimização da conduta. Neste âmbito, o presente artigo destina-se à discussão da forma grave da malária, com ênfase no quadro clínico e no tratamento

Pharmacokinetics of proguanil in malaria patients treated with proguanil plus atovaquone.

Clinical studies have shown atovaquone (ATQ), a new blood schizontocidal drug, in combination with proguanil (PROG) to be very effective in the treatment of acute multidrug-resistant falciparum malaria. The multiple dose pharmacokinetics of PROG were determined in Thai patients with acute falciparum malaria given PROG alone (200 mg PROG twice a day for 3 days, n = 4) and concurrently PROG and ATQ (200 mg PROG and 500 mg ATQ twice a day for 3 days, n = 12). There were no statistical differences (p > 0.05) in the area under the plasma drug concentration-time curve (AUC), apparent oral clearance (CL/F) and elimination half-life (t1/2) of PROG between patients given PROG alone and PROG/ ATQ. The median (range) kinetic values of PROG in patients given PROG alone and PROG/ATQ were respectively: CL/F = 1.25 l/h/kg (0.99-1.45) and 0.95 (0.73-1.32) l/h/kg, and t1/2 = 14.2 hours (9.3-16.8) and 13.6 hours (9.1-17.6). The CL/F and t1/2 of PROG in the Thai patients treated with the 2 treatment regimens were also comparable to values reported in healthy Thai volunteers given a standard prophylactic dose (200 mg PROG). The results of this preliminary study suggest that ATQ is unlikely to affect the pharmacokinetics of PROG to a clinically important extent at an ATQ dosage of 500 mg twice a day for 3 days in malaria infected patients.

A symposium on containment of mefloquine-resistant falciparum malaria in Southeast Asia with special reference to border malaria.

Important questions related to the factors responsible for and contributing to the origin and spread of multi-drug resistant falciparum malaria at the Thai-Cambodian and Thai-Myanmar border areas are discussed, including the current geographical distribution of multi-drug resistance and the prevention and control of this phenomenon. Specific recommendations are made on epidemiological surveillance, drug deployment, vector control, and the problem of migration which plays a major role in the dissemination of resistant parasite populations. The recent advent of mefloquine resistance of P. falciparum in Thailand may serve as fair warning in the absence of stern measures for preventing the occurrence of resistance to the next and currently last line of antimalaria drugs, especially those with a long half-life, in areas with intensive, uncontrolled malaria transmission, such as tropical Africa.

Pharmacology of absorption and distribution: optimal use of antimalarial drugs in the treatment of severe falciparum malaria in Kenya

Since 1989; a project at the KEMRI CRC Unit at Kilifi has focused on the design of appropriate and praticable regimens for the treatment of severe falciparum malaria. Initially; there was no data describing the absorption; distribution and elimination of quinine in Kenyan children; who constitute the great majority of patients. Pharmacokinetic studies were conducted to define these variables; which formed the basis for the design of appropriate and praticable treatment regimens. Even with optimal clinical management; the majority is high in cases of severe malaria treated with quinine at Kilifi. Alternative drugs have been studied in a search for a therapeutic regimen which will further reduce mortality

Inhibition of tolbutamide metabolism by antimalarial drugs.

The effects of mefloquine (MQ), the combination of MQ with sulfadoxine-pyrimethamine (MSP), sulfadoxine (S), pyrimethamine (P) quinine (Q) and quinidine (Qd) on in vitro hepatic metabolism has been studied using tolbutamide as a substrate. The hydroxylation of tolbutamide was determined in the presence of variable concentrations of each compound. Tolbutamide hydroxylase activity in control microsomes was 0.20 +/- 0.13 nmole/min/mg microsomal protein at a substrate concentration of 150 microM. All compounds studied inhibited tolbutamide metabolism as shown by a decrease in 4-hydroxytolbutamide formation. The order of potency of the inhibitors was MSP greater than S greater than MQ greater than Q greater than Qd greater than P. MQ, MSP, S, Q, and Qd were examined in detail for the type of inhibition. MQ and Qd were non-competitive inhibitors, whereas MSP and S were competitive inhibitors and Q was an uncompetitive inhibitor of tolbutamide 4-hydroxylation. These data provide more information on the inhibitory potential of some antimalarial drugs on microsomal enzymes in human liver. S has been shown to be a potent inhibitor in vitro and this finding possibly explains the longer T 1/2 and MRT of MQ when co-administered with S in healthy volunteers. Further studies in man should be attempted in order to understand the clinical relevance of the inhibitory potential of the antimalarial drugs.