ARTEMESININ AND RELATED COMPOUNDS page 662 page 663 These sesquiterpene lactones are derived from the

herb qing hao, a traditional Chinese remedy for malaria. The scientific name, conferred on the herb by Linnaeus, is Artemisia.4 Artemisinin, a poorly soluble chemical extract from Artemisia, is a fast-acting blood schizonticide effective in treating the acute attack of malaria (including chloroquine-resistant and cerebral malaria). Artesunate, a water-soluble derivative, and the synthetic analogues artemether and artether, have higher activity and are better absorbed. The compounds are concentrated in parasitised red cells. The mechanism of action is probably through inhibition of a parasite Ca+-dependent ATPase (Eckstein-Ludwig et al., 2003) and it is likely that the 'endoperoxide bridge' of this drug (see Fig. 53.2) has to be 'activated' in the presence of intracellular iron before it can exert its effects. These drugs are without effect on liver hypnozoites. Artemisinin can be given orally, intramuscularly or by suppository, artemether orally or intramuscularly, and artesunate intramuscularly or intravenously. They are rapidly absorbed and widely distributed, and are converted in the liver to the active metabolite dihydroartemisinin. The half-life of artemisinin is about 4 h, of artesunate 45 min and of artemether 4-11 h. There have been few unwanted effects reported to date. Transient heart block, decrease in blood neutrophil count and brief episodes of fever have been reported. In animal studies, artemisinin causes an unusual injury to some brain stem nuclei, particularly those involved in auditory function; however, there have been no reported incidences of neurotoxicity in humans. So far, resistance has not been a problem, but recent reports suggest that it is developing in some countries. In rodent studies, artemisinin potentiated the effects of mefloquine, primaquine and tetracycline, was additive with chloroquine and antagonised the sulfonamides and the folate antagonists. For this reason, artemisinin derivatives are frequently used in combination with other antimalarial drugs; for example, artemether is often given in combination with lumefantrine. In randomised trials, the qinghaosu compounds have cured attacks of malaria, including cerebral malaria, more rapidly and with fewer unwanted effects than other antimalarial agents. Artemisinin and derivatives are effective against multidrug-resistant P. falciparum in sub-Saharan Africa and, combined with mefloquine, against multidrug-resistant P. falciparum in South-east Asia. Antimalarial drugs Artemisinin derivatives are now widely used particularly in combination with other drugs such as lumefantrine. They are fast-acting blood schizonticidal agents that are effective against both P. falciparum and P. vivax. Artesunate is water soluble and can be given orally or by intravenous, intramuscular or rectal administration. Side effects are rare. Resistance is so far uncommon. Table 53-3. Drug targets of antimalarial drugs Parasite Target Chemical class Drugs organelle Cytosolic Inhibit or antagonise Diaminopyridines Pyrimethamine compartment folic acid Biguanides Proguanil metabolism Sulfones Dapsone Sulfonamides Sulphadoxine Mitochondrion Block electron Hydroxynapthoquinones Atovaquone, transport energy tafenoquine, pyridones production Apicoplast Block protein Tetracyclines and others Azithromycin, synthetic machinery doxycycline, clindamycin other antibiotics Digestive Inhibit the Quinolones Chloroquine, vacuole detoxification of amodiaquine, haem mefloquine, quinine Aryl amino alcohols Lumefantrine + Membranes ? Inhibition of Ca - Sesquiterpene lactones Artemisinin derivatives dependent ATPase After Fidock et al., 2004.

Artemisinin
Artemisinin has been used in China (where it is known as qinghao ) for centuries in the treatment of individuals with fever. The compound is a cyclic endoperoxide that, when activated by free or heme -bound iron, forms a carbon-centered free-radical compound (Fig. 35 -5). This free radical has the ability to alkylate many proteins as well as heme. The mech anism of specificity of the drug for plasmodia -infected erythrocytes is unknown two potential sources of specificity include artemisinin's requirement for heme for free radical formation and artemisinin's preferential accumulation in plasmodia. Administrat ion of artemisinin and its derivatives ( artesunate , artemether , artemotil , dihydroartemisinin ) is associated with a rapid decrease in the level of malaria parasites in the blood of an infected individual and rapid resolution of symptoms in patients with bl ood-stage malaria. Artemisinin is not effective as a prophylactic agent against malaria.

Figure 35 -5. Proposed mechanism of action of artemisinin. Artemisinin is a cyclic endoperoxide compound that forms a free radical after activation by iron (Fe). This free radical is able to alkylate macromolecules such as heme and proteins, resulting in the formation of artemisinin -heme adducts and artemisinin -protein adducts that are toxic to plasmodia. Because of widespread resistance to other antimalarial agents, first -line therapy for uncomplicated and complicated malaria in Sub -Saharan Africa involves a combination of artemisinin and a second antimalarial a gent. Although there has been evidence of in vitro resistance to artemisinin in field isolates of P. falciparum , clinical cases of resistant infection have not yet been reported. Because of concerns over the development of resistance and over the short half-life of artemisinin derivatives (from 1 to 11 hours), it is recommended that artemisinin compounds be coadministered with a second agent with a different mechanism of action and a longer half -life. Addition of the second agent will hopefully delay the de velopment of artemisinin resistance and prolong the therapeutic effect of the combination (see section on antimalarial drug resistance below). Artemisinin and its derivatives are generally well tolerated but can have neurotoxic and cardiotoxic adverse effe cts. In laboratory animals, artemisinin has been shown to cause P.637 brainstem neuropathy; although this potentially lethal effect has not been observed in humans, accumulating evidence suggests that artemisinins may indeed be associated with auditory imp airment and other neurotoxic effects. Hypoglycemia occurs less often than with quinine -based therapy. Safety data in pregnancy are lacking.

Table 491 Malarial Parasite Developmental Stages Targeted by Antimalarial Drugs

EFFECT OF DRUG ON PARASITE VIABILITY LIVER STAGES

GROUP DRUGS

BLOOD STAGES + + + + + + + + + +/ +/ +/ +

SPOROZOITE PRIMARY HYPNOZOITE ASEXUAL GAMETOCYTE

Artemisinins Chloroquine Mefloquine Quinine/Quinidine Pyrimethamine Sulfadoxine Tetracycline

Atovaquone/Proguanil

3 Primaquine + , no activity; +/, low to moderate activity; +, important activity.

Artemisinin and Derivatives History Artemisinin is a sesquiterpene lactone endoperoxide derived from qing hao (Artemisia annua), also called sweet wormwood or annual wormwood. The Chinese have ascribed medicinal value to this plant for >2000 years (White, 2008). As early as 340 A.D., Ge Hong prescribed tea made from qing hao as a remedy for fevers, and in 1596, Li Shizhen recommended it to relieve malarial symptoms. By 1972, Chinese scientists had identified the major antimalarial ingredient, qinghaosu, now known as artemisinin. Chemistry The structures of artemisinin and its three major semisynthetic derivatives in clinical use, dihydroartemisinin, artemether, and artesunate, are as follows:

The derivatives display improved potency and bioavailability and have largely replaced the use of artemisinin. Dihydroartemisinin is a reduced product, artesunate is the water-soluble hemisuccinate ester of dihydroartemisinin, and artemether is a lipophilic methyl ether. Extensive structure-activity studies have confirmed the requirement for an endoperoxide moiety for antimalarial activity. Mechanisms of Antimalarial Action and Resistance As a class, the artemisinins are very potent and fast-acting antimalarials, inducing more rapid parasite clearance and fever resolution than any other currently licensed antimalarial drug. They are particularly well suited for the treatment of severe P. falciparum malaria and are also effective against the asexual erythrocytic stages of P. vivax. Increasingly, the standard treatment of malaria employs artemisinin-based combination therapies (ACTs) to increase treatment efficacy and reduce selection pressure for the emergence of drug resistance. Artemisinins cause a significant reduction of the parasite burden, with a four-log10 reduction in the parasite population for each 48-hour cycle of intraerythrocytic invasion, replication, and egress. As such, only three to four cycles (6-8 days) of treatment are required to remove all the parasites from the blood (White, 2008). Additionally, artemisinins possess some gametocytocidal activity, leading to a decrease in malarial parasite transmission. ACTs have low toxicity and are considered safe for use in nonpregnant adults and children. Of concern, however, is the widespread distribution of counterfeit or clinically substandard drugs that contain small quantities of the artemisinin derivative, a practice that threatens the effective administration of ACTs. The mechanisms by which ACTs exert their antimalarial activity remain contentious (Golenser et al., 2006). Nevertheless, most studies concur that the activity of artemisinin and its potent derivatives results from reductive scission of the peroxide bridge by reduced heme-iron, which is produced inside the highly acidic

digestive vacuole (DV) of the parasite as it digests hemoglobin. In addition to the formation of potentially toxic heme-adducts, activated artemisinin (for which the site of action remains unclear) might in turn generate free radicals that alkylate and oxidize proteins and possibly lipids in parasitized erythrocytes (Eastman and Fidock, 2009). Artemisinins do not display significant clinical cross-resistance with other drugs. Indeed, sensitivity to artemisinins may even be increased in at least some strains of chloroquine-resistant parasites. Recent evidence has nonetheless suggested the emergence of P. falciparum isolates with an increased tolerance to artemisinins, manifesting as longer parasite clearance times (Dondorp et al., 2009). This has triggered significant efforts to elucidate the mechanistic basis of resistance and implement means to limit its spread. The World Health Organization (WHO) and most authorities strenuously recommend using artemisinins only in combination therapy, both to increase treatment efficacy and prevent the emergence of drug resistance. Absorption, Fate, and Excretion The semisynthetic artemisinins have been formulated for oral (dihydroartemisinin, artesunate, and artemether), intramuscular (artesunate and artemether), intravenous (artesunate), and rectal (artesunate) routes. Bioavailability after oral dosing typically is 30%. Although artemisinins rapidly achieve peak serum levels; intramuscular administration of the lipid-soluble artemether peaks in 2-6 hours, due to a depot effect at the injection site. Both artesunate and artemether have modest levels of plasma protein binding, ranging from 43% to 82%. These derivatives are extensively metabolized and converted to dihydroartemisinin, which has a plasma t1/2 of 1-2 hours (German and Aweeka, 2008). Rectal administration of artesunate has emerged as an important administration route, especially in tropical countries where it can be lifesaving. However, drug bioavailability via rectal administration is highly variable among individual patients (Medhi et al., 2009). With repeated dosing, artemisinin and artesunate induce their own CYP-mediated metabolism, primarily via CYPs 2B6 and 3A4. This may enhance clearance by up to 5-fold. Recent studies have found no clinically significant pharmacokinetic or toxic interactions between artemisinins and its partner drugs. Therapeutic Uses Given their rapid and potent activity against even multidrug-resistant parasites, the artemisinins are valuable for the treatment of severe P. falciparum malaria. Intravenous artesunate is more than comparable to a standard quinine regimen, likely possessing higher efficacy and a better safety profile in many patient populations (Rosenthal, 2008). The artemisinins generally are not used alone because of their limited ability to eradicate infection completely. In numerous studies in Africa, South America, and Asia, artemisinins have proven highly effective, when combined with other antimalarials, for the first-line treatment of malaria (Sinclair et al., 2009). Artemisinins should not be used for chemoprophylaxis because of their short t 1/2, which translates into high recrudescence rates. In the U.S., the Food and Drug Administration (FDA) has approved the use of artemether-lumefantrine for oral treatment of uncomplicated P. falciparum malaria. Although useful in treating presumptively chloroquine-resistant P. vivax, artemether-lumefantrine does not have a formal FDA-approved indication for this infection. Under an investigational new drug (IND) application, intravenous artesunate is now indicated for the treatment of severe malaria; this drug currently can be obtained through the Centers for Disease Control and Prevention (CDC) Drug Service or CDC Quarantine Stations. Toxicity and Contraindications The increasing usage of ACTs has focused attention on the safety profile of artemisinins, especially with regard to potential toxic effects in infants and during the first trimester of pregnancy. In pregnant rats and rabbits, artemisinins can cause increased embryo lethality or malformations early postconception. Preclinical toxicity studies have identified the brain (and brainstem), liver, bone marrow, and fetus as the principal target organs. In patients, the many neurological changes that accompany severe malaria confound the evaluation of drug neurotoxicity; however, no systematic neurological changes were attributable to treatment in patients >5 years of age. As in small animals, patients may develop dose-related and reversible decreases in reticulocyte and neutrophil counts and increases in transaminase levels in patients. About 1 in 3000 patients develops an allergic reaction. Studies of artemisinin treatment during the first trimester have found no evidence of adverse effects on fetal development (Eastman and Fidock, 2009). Nonetheless, out of general concern, it is recommended that ACTs not be used for the treatment of children 5 kg or during the first trimester of pregnancy. Act Partner Drugs

The short plasma t1/2 of artemisinin and its derivatives translates into substantial treatment failure rates when artemisinins are used as monotherapy. Combining an artemisinin derivative with a longer-lasting partner drug assures sustained antimalarial activity. Current ACT regimens that are well tolerated in adults and children 5 kg include artemether-lumefantrine, artesunate-mefloquine, artesunate-amodiaquine, artesunate-sulfoxadinepyrimethamine, and dihydroartemisinin-piperaquine. Artesunate-pyronaridine has also recently completed phase III clinical trials. Combination with mefloquine or sulfadoxine- pyrimethamine is discussed in a separate section. Properties of other partner drugs are discussed later. Lumefantrine shares structural similarities with the arylaminoalcohol drugs mefloquine and halofantrine (Figure 492) and is formulated with artemether (COARTEM). Figure 492.

Chemical structure of antimalarial quinolines and related compounds. This combination has proven to be highly effective for the treatment of uncomplicated malaria and is the most widely used first-line antimalarial across Africa. The pharmacokinetic properties of lumefantrine include a large apparent volume of distribution and a terminal elimination t 1/2 of 4-5 days. Human pharmacokinetic and pharmacodynamic studies correlate the risk of clinical failure (the likelihood to recrudesce) with plasma lumefantrine concentrations falling below 280 ng/mL. These findings, combined with a report of up to 15-fold variability in lumefantrine plasma concentrations in clinical trial volunteers, highlight the importance of appropriate dosing with lumefantrine-containing combinations (Checchi et al., 2006). Administration with a high-fat meal is recommended because it significantly increases absorption. Recently a sweetened dispersible formulation of artemether-lumefantrine (COARTEM Dispersible) has been approved for treatment of children. This formulation has comparable pharmacokinetics to crushed tablets and provides substantially improved ease of administration. Amodiaquine is a congener of chloroquine (Figure 492) that is no longer recommended in the U.S. for chemoprophylaxis of P. falciparum malaria because of its toxicity (hepatic and agranulocytosis). These adverse events, however, were generally associated with its prophylactic use. A meta-analysis of clinical studies found that therapeutic amodiaquine regimes, with a total dose of up to 35 mg/kg body weight administered over 3 days, were as well tolerated as chloroquine for the treatment of uncomplicated P. falciparum malaria (Olliaro and Mussano, 2003). One recent study reported an increased risk of neutropenia with amodiaquine therapy in HIV patients receiving antiretroviral therapy (Gasasira et al., 2008). In vivo, amodiaquine is rapidly converted by hepatic CYPs into monodesethyl-amodiaquine. This metabolite, which retains substantial antimalarial activity, has a plasma t1/2 of 9-18 days and reaches a peak concentration of ~500 nM 2 hours after oral administration. By contrast, amodiaquine has a t 1/2 of ~3 hours, attaining a peak concentration of ~25 nM within 30 minutes of oral administration (Eastman and Fidock, 2009). In vivo clearance rates of amodiaquine, however, display a variation between individuals that ranges from 78 to 943 mL/min/kg. Piperaquine, a potent and well-tolerated bisquinoline compound (Figure 492) structurally related to chloroquine, became the primary antimalarial in China during the 1970s and 1980s in response to increasing rates of chloroquine resistance. Piperaquine has a large volume of distribution and reduced rates of excretion after multiple doses. This lipophilic drug is rapidly absorbed, with a Tmax (time to reach the highest concentration) of 2 hours after a single dose. In clinical trials, the combination of piperaquine and dihydroartemisinin produced cure rates and cleared fever and parasites in a time frame similar to artesunate-mefloquine (Wells et al., 2009). Piperaquine has the longest plasma t1/2 (5 weeks) of all ACT partner drugs, suggesting that piperaquine-dihydroartemisinin might also be effective in reducing rates of reinfection following treatment. Pyronaridine, an antimalarial structurally related to amodiaquine (Figure 49 2), was developed by the Chinese in the 1970s. Pyronaridine is well tolerated and highly potent against both P. falciparum and P. vivax, causing fever to subside in 1-2 days and parasite clearance in 2-3 days. Clinical data from trials of artesunate-pyronaridine should soon be available (Wells et al., 2009).