Evaluating drug resistance in visceral leishmaniasis: the challenges.

For decades antimonials were the drugs of choice for the treatment of visceral leishmaniasis (VL), but the recent emergence of resistance has made them redundant as first-line therapy in the endemic VL region in the Indian subcontinent. The application of other drugs has been limited due to adverse effects, perceived high cost, need for parenteral administration and increasing rate of treatment failures. Liposomal amphotericin B (AmB) and miltefosine (MIL) have been positioned as the effective first-line treatments; however, the number of monotherapy MIL-failures has increased after a decade of use. Since no validated molecular resistance markers are yet available, monitoring and surveillance of changes in drug sensitivity and resistance still depends on standard phenotypic in vitro promastigote or amastigote susceptibility assays. Clinical isolates displaying defined MIL- or AmB-resistance are still fairly scarce and fundamental and applied research on resistance mechanisms and dynamics remains largely dependent on laboratory-generated drug resistant strains. This review addresses the various challenges associated with drug susceptibility and -resistance monitoring in VL, with particular emphasis on the choice of strains, susceptibility model selection and standardization of procedures with specific read-out parameters and well-defined threshold criteria. The latter are essential to support surveillance systems and safeguard the limited number of currently available antileishmanial drugs.

Preclinical safety and tolerability of a repeatedly administered human leishmaniasis DNA vaccine.

The leishmaniases are a complex of vector-borne diseases caused by protozoan parasites of the genus Leishmania. LEISHDNAVAX is a multi-antigen, T-cell epitope-enriched DNA vaccine candidate against human leishmaniasis. The vaccine candidate has been proven immunogenic and showed prophylactic efficacy in preclinical studies. Here, we describe the safety testing of LEISHDNAVAX in naive mice and rats, complemented by the demonstration of tolerability in Leishmania-infected mice. Biodistribution and persistence were examined following single and repeated intradermal (i.d.) administration to rats. DNA vectors were distributed systemically but did not accumulate upon repeated injections. Although vector DNA was cleared from most other tissues within 60 days after the last injection, it persisted in skin at the site of injection and in draining lymph nodes. Evaluation of single-dose and repeated-dose toxicity of the vaccine candidate after i.d. administration to naive, non-infected mice did not reveal any safety concerns. LEISHDNAVAX was also well tolerated in Leishmania-infected mice. Taken together, our results substantiate a favorable safety profile of LEISHDNAVAX in both naive and infected animals and thus, support the initiation of clinical trials for both preventive and therapeutic applications of the vaccine.

Leishmaniasis chemotherapy--challenges and opportunities.

Although there have been significant advances in the treatment of visceral leishmaniasis (VL), there remain challenges to ensure that treatments effective in India are also effective in other regions of the world and to identify treatment for post kala-azar dermal leishmaniasis as well as the opportunity to develop a safe oral short-course treatment. At the same time, there have been few advances for the treatment of simple or complex forms of cutaneous leishmaniasis (CL), other than topical paromomycin formulations. The main challenge for CL is to ensure that this disease is on the research and development agenda, so that new drugs are evaluated or compounds are screened in appropriate models, and that the standardization of quality of clinical trials is guaranteed. Problems also remain in the treatment of HIV/leishmaniasis co-infected patients. We are some way from having the ideal treatments for VL and CL and drug research and development for these diseases must remain focused.

Kinetoplastida: new therapeutic strategies.

New formulations and therapeutic switching of the established drugs, amphotericin B and paromomycin, together with the discovery of miltefosine, have significantly improved the opportunities for treatment of visceral leishmaniasis (VL) chemotherapy. However, for human African trypanosomiasis (HAT), Chagas disease and cutaneous leishmaniases there has been limited progress. For HAT, a novel diamidine, parfuramidine, is in phase III clinical trial for early-stage disease, but for the treatment of late-stage disease there are no new drugs and combinations of eflornithine with melarsoprol or nifurtimox have been the focus of clinical studies. For Chagas disease, different classes of compounds that have validated biochemical targets, sterol biosynthesis methylases and cysteine proteases, are in various stages of development. The genome sequences that are now available for the pathogens that cause the leishmaniases and trypanosomiases, and new methods for rapid validation of targets, are part of the solution to discover new drugs. The integration of medicinal chemistry, pharmacokinetics, project planning and interaction with the pharma/biotech sector are essential if progress is to be made. Although there are financial constraints, the appearance of new funding sources and not-for-profit product development partnerships offers hope for drug development.

Antimalarial efficacy and drug interactions of the novel semi-synthetic endoperoxide artemisone in vitro and in vivo.

OBJECTIVES: The in vitro and in vivo efficacy and drug-drug interactions of the novel semi-synthetic endoperoxide artemisone with standard antimalarials were investigated in order to provide the basis for the selection of the best partner drug. METHODS: Antimalarial activity and drug interactions were evaluated in vitro against Plasmodium falciparum by the incorporation of [(3)H]hypoxanthine. In vivo efficacy and drug interactions were assessed using the standard 4-day Peters' test. RESULTS: Artemisone was 10 times more potent than artesunate in vitro against a panel of 12 P. falciparum strains, independent of their susceptibility profile to antimalarial drugs, and consistently 4 to 10 times more potent than artesunate in rodent models against drug-susceptible and primaquine- or sulfadoxine/pyrimethamine-resistant Plasmodium berghei lines and chloroquine- or artemisinin-resistant lines of Plasmodium yoelii. Slight antagonistic trends were found between artemisone and chloroquine, amodiaquine, tafenoquine, atovaquone or pyrimethamine and additive to slight synergistic trends with artemisone and mefloquine, lumefantrine or quinine. Various degrees of synergy were observed in vivo between artemisone and mefloquine, chloroquine or clindamycin. CONCLUSIONS: These results confirm the increased efficacy of artemisone over artesunate against multidrug-resistant P. falciparum and provide the basis for the selection of potential partner drugs for future deployment in areas of multidrug-resistant malaria. Artemisone represents an important addition to the repertoire of artemisinin combination therapies currently in use, as it has enhanced antimalarial activity, improved bioavailability and stability over current endoperoxides.

Miltefosine (Impavido): the first oral treatment against leishmaniasis.

Miltefosine is a novel antileishmanial drug that has significant selectivity in both in vitro and in vivo models. Clinical efficacy was demonstrated for the treatment of visceral leishmaniasis with the advantage of oral administration over the currently recommended antileishmanial drugs that require parenteral administration. Miltefosine produces high cure rates also in patients resistant to the standard antimonial therapy.

Screening of plant extracts for antiprotozoal and cytotoxic activities.

Methanolic and aqueous extracts derived from 43 plant species, selected either from ethnobotanical or chemotaxonomical data, were screened for their antiprotozoal activity against Leishmania donovani and Trypanosoma brucei brucei. The cytotoxic activity against KB cells was also determined. Eight extracts had IC50 values of less than 10 microg/ml against Leishmania donovani. The most active was Triclisia patens with an IC50 value of 1.5 microg/ml against Leishmania donovani. Annona purpurea and Alstonia macrophylla had IC50 values below 10 microg/ml against Trypanosoma brucei brucei. Annona purpurea was the most cytotoxic against KB cells.

Natural products as antiparasitic drugs.

Natural products are not only the basis for traditional or ethnic medicine. Only recently, they have provided highly successful new drugs such as Artemisinin. Furthermore, screening natural products found in all sorts of environments such as the deep sea, rain forests and hot springs, and produced by all sorts of organisms ranging from bacteria, fungi and plants to protozoa, sponges and invertebrates, is a highly competitive field where all of the major pharmaceutical companies are encountered. Already, many new natural product groups have revealed antiparasitic properties of surprising efficacy and selectivity, as will be shown in this review for plant-derived alkaloids, terpenes and phenolics. Many novel lead structures, however, have severe chemico-physical drawbacks such as poor solubility. Here, innovative drug formulations and carrier systems might help, as discussed by the authors in another article of this series.

Formulation and biopharmaceutical issues in the development of drug delivery systems for antiparasitic drugs.

The development of really new antiparasitic drugs to market level is a very rare event. A large number of lead structures have already been screened and discarded, the market is large but poor, and the administrative barriers are increasingly high and costly. Novel antiparasitics must not only be better, they must also be substantially safer than the existing repertoire. There are two major aspects to drug development. One is the strategy of pathogen-specific biochemical intervention, the other the strategy of optimal formulation and application. This review focuses on the latter. In finding and adapting innovative and "intelligent", i.e. parasite- and disease-specific formulations and delivery systems, established but deficient drugs might be optimised, enhancing their efficiency and reducing negative side effects at relatively low cost. Further, many promising new ideas are severely hampered by the low water solubility of the antiparasitic drug. Here as well, some of the innovative drug formulation and delivery systems discussed below might offer highly efficient, while technologically simple, solutions.

Formulation of amphotericin B as nanosuspension for oral administration.

Amphotherin B was formulated in a nanosuspension as a new oral drug delivery system for the treatment of experimental visceral leishmaniasis. Amphotericin B (AmB) nanosuspensions were produced by high pressure homogenisation obtaining particles with a PCS diameter of 528 nm. Environmental stability was determined in artificial gastrointestinal fluids at different pH and electrolyte concentrations. In vivo efficacy was determined in a mouse model of visceral leishmaniasis. Following oral administration (5 mg kg(-1)), micronised amphotericin B did not show any curative effect. However, administrations of amphotericin B nanosuspension, reduced liver parasite load by 28.6% compared to untreated controls.

Recent advances in research and control of malaria, leishmaniasis, trypanosomiasis and schistosomiasis.

In the Eastern Mediterranean Region of the World Health Organization (WHO), malaria, schistosomiasis, leishmaniasis and trypanosomiasis are the parasitic diseases of major importance. Our review focuses on recent advances in the control and treatment of these diseases with particular reference to diagnosis, chemotherapy, vaccines, vector and environmental control. The Roll Back Malaria Programme, for example, emphasizes the use of insecticide treated bednets in Africa and targets a 30-fold increase in treated bednet use by 2007. Increasing risk factors for leishmaniasis include urbanization, extended agricultural projects and civil unrest and the increase in patients with Leishmania infantum and HIV co-infection in the Region may signal a new threat. In the past 20 years, human African trypanosomiasis has resurged in sub-Saharan Africa; within the Region it has become more common in the southern Sudan where anthroponotic and zoonotic sub-species infections overlap. Schistosomiasis in the Region is caused by either Schistosoma haematobium or S. mansoni and large-scale control efforts include providing regular treatment to at-risk groups and supporting drug delivery through schools.

Recent advances in research and control of malaria, leishmaniasis, trypanosomiasis and schistosomiasis

In the Eastern Mediterranean Region of the World Health Organization [WHO], malaria, schistosomiasis, leishmaniasis and trypanosomiasis are the parasitic diseases of major importance. Our review focuses on recent advances in the control and treatment of these diseases with particular reference to diagnosis, chemotherapy, vaccines, vector and environmental control. The Roll Back Malaria Programme, for example, emphasizes the use of insecticide treated bednets in Africa and targets a 30-fold increase in treated bednet use by 2007. Increasing risk factors for leishmaniasis include urbanization, extended agricultural projects and civil unrest and the increase in patients with Leishmania infantum and HIV co-infection in the Region may signal a new threat. In the past 20 years, human African trypanosomiasis has resurged in sub-Saharan Africa; within the Region it has become more common in the southern Sudan where anthroponotic and zoonotic sub-species infections overlap. Schistosomiasis in the Region is caused by either Schistosoma haematobium or S. mansoni and large-scale control efforts include providing regular treatment to at-risk groups and supporting drug delivery through schools

N-(2-hydroxypropyl)methacrylamide (HPMA) copolymers for targeted delivery of 8-aminoquinoline antileishmanial drugs.

A challenge to successful chemotherapy of visceral leishmaniasis is the dose-limiting toxicity of antileishmanial agents. One approach to increase the efficacy and reduce the toxicity of these agents is to direct the drug to the phagolysosomes of the reticuloendothelial system (RES) where the leishmanial parasites reside. In this work a series of N-(2-hydroxypropyl)methacrylamide (HPMA) copolymer-antileishmanial drug conjugates containing lysosomally degradable side chains and with or without sugar targeting moieties were synthesized, characterized and investigated for their in vivo efficacy in mice infected with Leishmania. An 8-aminoquinoline analog, namely 8-[(4-amino-1-methylbutyl)amino]-5-[3,4-dichlorophenoxy]-6-methoxy-4-methylquinoline (NPC1161) was used as a model antileishmanial agent. At 5 mg/kg body weight drug equivalent dose, all HPMA copolymer-drug conjugates which contained lysosomally degradable side chains showed significant in vivo antileishmanial activity (>99% inhibition), comparable to the activity of the free drug. At 2 mg dose, the same conjugates were significantly more effective (84-90% inhibition) than the free drug (67% inhibition). These results indicate the potential of lysosomotropic HPMA copolymers for the targeted delivery of antileishmanial compounds in the treatment of visceral leishmaniasis.

In vitro antiprotozoal activity of extract and compounds from the stem bark of Combretum molle.

The antiprotozoal activity of the Ethiopian medicinal plant Combretum molle (R. Br. ex G. Don.) Engl & Diels (Combretaceae) was evaluated by in vitro testing against Plasmodium falciparum, Trypanosoma brucei rhodesiense, Trypanosoma cruzi and Leishmania donovani. The acetone fraction of the stem bark of this plant prepared by soxhlet extraction was inactive against the intracellular amastigotes of L. donovani and T. cruzi in murine peritoneal macrophages but showed significant activity against extracellular T. b. rhodesiense blood stream form trypomastigotes and trophozoites of P. falciparum with IC(50) values of 2.19 and 8.17 microg/mL, respectively. Phytochemical examination of the bioactive fraction resulted in the isolation of two tannins and two oleanane-type pentacyclic triterpene glycosides. One of the tannins was identified as the ellagitannin, punicalagin, whilst the structure of the other (CM-A) has not yet been fully elucidated. The saponins that were characterized as arjunglucoside (also called 4-epi-sericoside) and sericoside displayed no activity against any of the four species of protozoa tested. On the other hand, punicalagin and CM-A had IC(50) values of 1.75 and 1.50 microM, respectively, against T. b. rhodesiense and were relatively less toxic to KB cells (cytotoxic/antiprotozoal ratios of 70 and 48, respectively). The tannins also showed intermediate activity against P. falciparum, although their selectivity against these parasites was less favourable than the above. It appears that our findings are the first report of hydrolysable tannins exhibiting antitrypanosomal and antiplasmodial activities.

Monitoring drug resistance in leishmaniasis.

There are many factors that can influence the efficacy of drugs in the treatment of leishmaniasis. These include both an intrinsic variation in the sensitivity of Leishmania species, described for pentavalent antimonials, paromomycin, azoles and other drugs that have reached clinical trials, as well as acquired drug resistance to antimonials. Acquired resistance has been studied in the laboratory for several decades but it is only recently that clinical resistance in L. donovani field isolates has been demonstrated. The monitoring of resistance is problematic due to a reliance on the amastigote-macrophage culture assay to adequately correlate clinical and in vitro resistance and a lack of knowledge about the molecular and biochemical mechanisms of resistance to antileishmanial drugs.

Antiprotozoal and cytotoxicity evaluation of sulfonamide and urea analogues of quinacrine.

Sulfonamide and urea derivatives of quinacrine with varying methylene spacer lengths were synthesised and tested for inhibition of trypanothione reductase (TryR) and for activity in vitro against strains of the parasitic protozoa Trypanosoma, Leishmania, and Plasmodium. These derivatives are superior inhibitors of TryR relative to quinacrine with the best compound being 40 times more potent. Urea derivatives generally displayed good in vitro activity against all parasites.

Synthesis and evaluation of cryptolepine analogues for their potential as new antimalarial agents.

The indoloquinoline alkaloid cryptolepine 1 has potent in vitro antiplasmodial activity, but it is also a DNA intercalator with cytotoxic properties. We have shown that the antiplasmodial mechanism of 1 is likely to be due, at least in part, to a chloroquine-like action that does not depend on intercalation into DNA. A number of substituted analogues of 1 have been prepared that have potent activities against both chloroquine-sensitive and chloroquine-resistant strains of Plasmodium falciparum and also have in common with chloroquine the inhibition of beta-hematin formation in a cell-free system. Several compounds also displayed activity against Plasmodium berghei in mice, the most potent being 2,7-dibromocryptolepine 8, which suppressed parasitemia by 89% as compared to untreated infected controls at a dose of 12.5 mg kg(-1) day(-1) ip. No correlation was observed between in vitro cytotoxicity and the effect of compounds on the melting point of DNA (DeltaT(m) value) or toxicity in the mouse-malaria model.

QSAR study on the contribution of log P and E(s) to the in vitro antiprotozoal activity of glutathione derivatives.

A series of N-S-blocked glutathione monoester and diester derivatives based on N-benzyloxycarbonyl-S-(2,4-dinitrophenyl)glutathione were evaluated for activity against the pathogenic parasites Trypanosoma brucei brucei, Trypanosoma cruzi, and Leishmania donovani in vitro.Only monoesters 7-9 with a log P value of >2.7 were active inhibitors of T.b. brucei bloodstream form trypomastigotes. Diester compounds 10-15 and 17-27 in most cases were better inhibitors of T.b. brucei than monoester compounds, and some displayed high activity against T. cruzi 14 and L. donovani 17, 19, 29. Compounds 14, 24, and 25 were the most active compounds identified against T.b. brucei having ED(50) values of <0.4 microM. Analysis of the inhibition data (ED(50)) vs calculated log P and E(s) values provided evidence to support membrane penetration and steric factors as the key component in the activity of these compounds. The optimum values for log P and E(s) determined were 5.8 and -0.70, respectively. A QSAR equation relating log(1/ED(50)) vs log P and E(s) was determined and interpreted within the proposed mechanism of activity for these compounds.

Design, synthesis, and biological evaluation of a series of simple and novel potential antimalarial compounds.

A series of compounds bearing an endocyclic -N-O- moiety with potential antimalarial activity based on simple derivatives of the tropolone purpurogallin was prepared by means of a hetero Diels-Alder reaction using nitrosobenzene as a dienophile. The rationale behind the design of these compounds is presented, together with the synthetic route to derivatives bearing aromatic and aliphatic esters of the C4'-position hydroxyl group of the purpurogallin framework, as well as biological data obtained from in vitro assays against Plasmodium falciparum and Trypanosoma cruzi. Several of the new compounds have activities in the 3-9 microM range, and provide leads for the development of a novel class of antiparasitic drugs with improved biological and pharmacological properties.

Activities of hexadecylphosphocholine (miltefosine), AmBisome, and sodium stibogluconate (Pentostam) against Leishmania donovani in immunodeficient scid mice.

In both scid and BALB/c mouse-Leishmania donovani models, hexadecyphosphocholine (miltefosine) and AmBisome had similar levels of activity. In contrast, sodium stibogluconate (Pentostam) was significantly less active against L. donovani in scid mice than in BALB/c mice. The in vitro anti-leishmanial activity of miltefosine was similar in peritoneal macrophages derived from both scid and BALB/c mice, whereas Pentostam and AmBisome were significantly more active in the latter.