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BACKGROUND: Chloroquine is effective against the asexual blood stage of Plasmodium vivax. A high proportion of children are underdosed with the drug, but there are no studies comparing chloroquine exposure in adults and children aged 8-11 years old. The present study intends to compare these populations using the area under the curve (AUC) derived from the plasma concentration-time profile in patients with P. vivax. METHODS: A prospective study of cases was performed on male children (aged 9-11 years) and adults with vivax malaria. Blood samples were collected after several days of treatment. Chloroquine was measured by high-performance liquid chromatography. A non-compartmental pharmacokinetic model was used to calculate the pharmacokinetic parameters of the drug. RESULTS: A total of 20 children and 25 adults were included in the study. Plasma concentrations of chloroquine in older children ranged from 67 to 1112 ng/ml, and in adults the value ranged from 74 to 1147 ng/ml. The AUC to the last measurable concentration and to infinite was significantly lower in children than in adults, indicating a lower exposure to the drug. CONCLUSION: These data demonstrate lower exposure to chloroquine in children, which corroborates the importance of optimising the doses of chloroquine in the study age band to ensure adequate exposure to the drug.
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Antimaláricos , Malária Vivax , Malária , Adulto , Antimaláricos/farmacologia , Antimaláricos/uso terapêutico , Criança , Cloroquina/uso terapêutico , Resistência a Medicamentos , Humanos , Malária/tratamento farmacológico , Malária Vivax/tratamento farmacológico , Masculino , Plasmodium vivax , Estudos ProspectivosRESUMO
BACKGROUND: Activation of hypnozoites of vivax malaria causes multiple clinical relapses, which contribute to the Plasmodium vivax burden and continuing transmission. Artemisinin-based combination therapy (ACT) is effective against blood-stage P. vivax but requires co-administration with primaquine to achieve radical cure. The therapeutic efficacy of primaquine depends on the generation of a therapeutically active metabolite via cytochrome P450 2D6 (CYP2D6). Impaired CYP2D6 metabolism has been associated with primaquine treatment failure. This study investigated the association between impaired CYP2D6 genotypes, drug-exposure to the long-acting ACT component (schizonticidal drugs) and tolerance and efficacy. METHODS: Adult patients with acute vivax malaria were enrolled in a recently completed trial and treated with artesunate-mefloquine, chloroquine or artemether-lumefantrine. All received concomitant primaquine (0.5 mg/kg/day for 7-9 days). The association between efficacy and safety and drug exposure was explored using area-under-the-curve (AUC) and half-life (t1/2) estimates obtained by non-compartmental analysis of the long half-life drugs. Parasite recurrences by day 63 were categorized as related relapses or re-infections/unrelated hypnozoite activation by genotyping three microsatellite loci and two polymorphic loci of merozoite surface antigen-1. The CYP2D6 genotype was identified with Taqman assays by real-time PCR to 9 polymorphisms (8 SNPs and one deletion). Impaired CYP2D6 activity was inferred using the Activity Score System. RESULTS: Most recurrences in the ASMQ (67%), CQ (80%) and AL (85%) groups were considered related relapses. Eight of nine (88.9%) of the patients with impaired CYP2D6 activity relapsed with related parasite compared to 18/25 (72%) with normal activity (RR = 1.23, 0.88; 1.72, p = 0.40). There were no associations between the measured PK parameters and recurrence. Patients with longer chloroquine half-lives had more pruritus (RR = 1.09, 1.03; 1.14, p = 0.001). Higher CQ AUCs were associated with reduced falls in haemoglobin by day 14 (Coef - 0.02, - 0.005; - 0.03, p = 0.01). All regimens were well tolerated. CONCLUSION: Genotyping of P. vivax showed that activation of related (homologous) hypnozoites was the most frequent cause of recurrence. The high proportion of the impaired CYP2D6 activity among patients with recurrent infections suggests that slow primaquine metabolism might influence related relapse rates in Brazil among patients receiving primaquine for radical cure, although confirmatory studies are needed. There was no association between drug exposure of the long-acting ACT component (schizonticidal drugs) and risk of related relapse. ACT was well tolerated. These results provide further re-assurance about the safety and efficacy of ACT when combined with short course primaquine to treat uncomplicated malaria vivax in Brazil. Trial registration RBR-79s56s ( http://www.ensaiosclinicos.gov.br/rg/RBR-79s56s/ ).
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Antimaláricos/farmacologia , Artemisininas/farmacologia , Cloroquina/farmacologia , Primaquina/farmacologia , Adulto , Idoso , Antimaláricos/farmacocinética , Artemisininas/farmacocinética , Brasil , Cloroquina/farmacocinética , Combinação de Medicamentos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Primaquina/farmacocinética , Adulto JovemRESUMO
ETHNOPHARMACOLOGICAL RELEVANCE: Aspidosperma excelsum Benth. (Apocynaceae), a native tree in the Brazilian Amazonia, is traditionally used to treat various diseases, including malaria. AIM OF STUDY: To investigate the chemical constitution, antiplasmodial activity and cytotoxicity of samples obtained from A. excelsum trunk bark by different procedures aiming to evaluate their potential as an antimalarial phytomedicine. MATERIALS AND METHODS: A hydroethanolic extract and alkaloid extracts were prepared and assayed for antiplasmodial activity and cytotoxicity against chloroquine-resistant Plasmodium falciparum (W2 strain) and HepG2 cells, respectively. Taking into account the known occurrence and antimalarial activity of Aspidosperma monoterpene indole alkaloids (MIA), acid-base extractions were carried out and the fractions were assayed for antiplasmodial activity and cytotoxicity. All the samples were analysed by hyphenated chromatographic techniques, such as UPLC-DAD-ESI-MS/MS and HRMS (HPLC-MS MicroTOF), comparing their chemical composition to the literature data. RESULTS: The hydroethanolic extract disclosed a moderate in vitro activity against chloroquine-resistant Plasmodium falciparum (W2 strain) with IC50 23.68 ± 3.08 µg/mL), low cytotoxicity to HepG2 cells (> 250 µg/mL) and good SI (> 10.56). A total of 20 known monoterpene indole alkaloids were identified, seven of which are here firstly described for A. excelsum. Known highly active alkaloids, namely demethylaspidospermine, aspidocarpine, and ochrolifuanine are present in active alkaloid fractions and might contribute to their observed antiplasmodial effect. An alkaloid fraction (Ae-Alk2), obtained directly from trunk bark by extraction with dil. aqueous HCl, pointed out for its activity (IC50 8.75±2.26 µg/mL, CC50 185.14±1.97 µg/mL, SI 21.16) and should be highlighted as the most promising out of the assayed samples. CONCLUSION: The present results represent a preliminary support to the alleged antimalarial use of A. excelsum trunk bark and allowed to highlight alkaloid fractions as promising phytomedicines.
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Antimaláricos/farmacologia , Aspidosperma , Alcaloides Indólicos/farmacologia , Plasmodium falciparum/efeitos dos fármacos , Antimaláricos/análise , Brasil , Cloroquina , Cromatografia Líquida , Resistência Microbiana a Medicamentos , Eritrócitos/microbiologia , Células Hep G2 , Humanos , Alcaloides Indólicos/análise , Medicina Tradicional , Casca de Planta , Espectrometria de Massas em TandemRESUMO
BACKGROUND: Several species of Aspidosperma plants are referred to as remedies for the treatment of malaria, especially Aspidosperma nitidum. Aspidosperma pyrifolium, also a medicinal plant, is used as a natural anti-inflammatory. Its fractionated extracts were assayed in vitro for activity against malaria parasites and for cytotoxicity. METHODS: Aspidosperma pyrifolium activity was evaluated against Plasmodium falciparum using extracts in vitro. Toxicity towards human hepatoma cells, monkey kidney cells or human monocytes freshly isolated from peripheral blood was also assessed. Anti-malarial activity of selected extracts and fractions that presented in vitro activity were tested in mice with a Plasmodium berghei blood-induced infection. RESULTS: The crude stem bark extract and the alkaloid-rich and ethyl acetate fractions from stem extract showed in vitro activity. None of the crude extracts or fractions was cytotoxic to normal monkey kidney and to a human hepatoma cell lines, or human peripheral blood mononuclear cells; the MDL50 values of all the crude bark extracts and fractions were similar or better when tested on normal cells, with the exception of organic and alkaloidic-rich fractions from stem extract. Two extracts and two fractions tested in vivo caused a significant reduction of P. berghei parasitaemia in experimentally infected mice. CONCLUSION: Considering the high therapeutic index of the alkaloidic-rich fraction from stem extract of A. pyrifolium, it makes the species a candidate for further investigation aiming to produce a new anti-malarial, especially considering that the active extract has no toxicity, i.e., no mutagenic effects in the genototoxicity assays, and that it has an in vivo anti-malarial effect. In its UPLC-HRMS analysis this fraction was shown to have two major components compatible with the bisindole alkaloid Leucoridine B, and a novel compound, which is likely to be responsible for the activity against malaria parasites demonstrated in in vitro tests.
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Antimaláricos/farmacologia , Aspidosperma/química , Extratos Vegetais/farmacologia , Plantas Medicinais/química , Plasmodium falciparum/efeitos dos fármacos , Animais , Antimaláricos/administração & dosagem , Antimaláricos/isolamento & purificação , Antimaláricos/toxicidade , Brasil , Sobrevivência Celular/efeitos dos fármacos , Células Cultivadas , Modelos Animais de Doenças , Feminino , Haplorrinos , Humanos , Malária/terapia , Camundongos , Carga Parasitária , Parasitemia , Extratos Vegetais/administração & dosagem , Extratos Vegetais/isolamento & purificação , Extratos Vegetais/toxicidade , Plasmodium berghei/isolamento & purificação , Resultado do TratamentoRESUMO
BACKGROUND: In this article we present the plants used for the treatment of malaria and associated symptoms in Santa Isabel do Rio Negro in the Brazilian Amazon. The region has important biological and cultural diversities including more than twenty indigenous ethnic groups and a strong history in traditional medicine. OBJECTIVE: The aims of this study are to survey information in the Baniwa, Baré, Desana, Piratapuia, Tariana, Tukano, Tuyuca and Yanomami ethnic communities and among caboclos (mixed-ethnicity) on (a) plant species used for the treatment of malaria and associated symptoms, (b) dosage forms and (c) distribution of these anti-malarial plants in the Amazon. METHODS: Information was obtained through classical ethnobotanical and ethnopharmacological methods from interviews with 146 informants in Santa Isabel municipality on the upper Negro River, Brazil. RESULTS: Fifty-five mainly native neotropical plant species from 34 families were in use. The detailed uses of these plants were documented. The result was 187 records (64.5%) of plants for the specific treatment of malaria, 51 records (17.6%) of plants used in the treatment of liver problems and 29 records (10.0%) of plants used in the control of fevers associated with malaria. Other uses described were blood fortification ('dar sangue'), headache and prophylaxis. Most of the therapeutic preparations were decoctions and infusions based on stem bark, root bark and leaves. These were administered by mouth. In some cases, remedies were prepared with up to three different plant species. Also, plants were used together with other ingredients such as insects, mammals, gunpowder and milk. CONCLUSION: This is the first study on the anti-malarial plants from this region of the Amazon. Aspidosperma spp. and Ampelozizyphus amazonicus Ducke were the most cited species in the communities surveyed. These species have experimental proof supporting their anti-malarial efficacy. The dosage of the therapeutic preparations depends on the kind of plant, quantity of plant material available, the patient's age (children and adults) and the local expert. The treatment time varies from a single dose to up to several weeks. Most anti-malarial plants are domesticated or grow spontaneously. They are grown in home gardens, open areas near the communities, clearings and secondary forests, and wild species grow in areas of seasonally flooded wetlands and terra firme ('solid ground') forest, in some cases in locations that are hard to access. Traditional knowledge of plants was found to be falling into disuse presumably as a consequence of the local official health services that treat malaria in the communities using commercial drugs. Despite this, some species are used in the prevention of this disease and also in the recovery after using conventional anti-malarial drugs.
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Antimaláricos/uso terapêutico , Etnobotânica/métodos , Indígenas Sul-Americanos/etnologia , Malária/etnologia , Plantas Medicinais , Rios , Ampelopsis , Antimaláricos/isolamento & purificação , Aspidosperma , Brasil/etnologia , Feminino , Humanos , Malária/tratamento farmacológico , Masculino , Inquéritos e QuestionáriosRESUMO
Classical pharmacology has been the basis for the discovery of new chemical entities with therapeutic effects for decades. In natural product research, compounds are generally tested in vivo only after full in vitro characterization. However drug screening using this methodology is expensive, time-consuming and very often inefficient. Reverse pharmacology, also called bedside-to-bench, is a research approach based on the traditional knowledge and relates to reversing the classical laboratory to clinic pathway to a clinic to laboratory practice. It is a trans-disciplinary approach focused on traditional knowledge, experimental observations and clinical experiences. This paper is an overview of the reverse pharmacology approach applied to the decoction of Argemone mexicana, used as an antimalarial traditional medicine in Mali. A. mexicana appeared as the most effective traditional medicine for the treatment of uncomplicated falciparum malaria in Mali, and the clinical efficacy of the decoction was comparable to artesunate-amodiaquine as previously published. Four stages of the reverse pharmacology process will be described here with a special emphasis on the results for stage 4. Briefly, allocryptopine, protopine and berberine were isolated through bioguided fractionation, and had their identity confirmed by spectroscopic analysis. The three alkaloids showed antiparasitic activity in vitro, of which allocryptopine and protopine were selective towards Plasmodium falciparum. Furthermore, the amount of the three active alkaloids in the decoction was determined by quantitative NMR, and preliminary in vivo assays were conducted. On the basis of these results, the reverse pharmacology approach is discussed and further pharmacokinetic studies appear to be necessary in order to determine whether these alkaloids can be considered as phytochemical markers for quality control and standardization of an improved traditional medicine made with this plant.
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Anti-malarial resistance in Plasmodium falciparum remains an obstacle for malaria control. Resistance-associated genes were analysed in Brazilian samples over four decades to evaluate the impact of different treatment regimens on the parasite genetic profile. Methods: Samples were collected on filter paper from patients infected in the Amazon region from 1984 to 2011.DNA was extracted with Chelex® 100 and monoinfection confirmed by PCR. SNPs in the pfcrt, pfmdr1, pfdhfr and pfdhpsgenes were assessed by PCR-RFLP. The pfmdr1 copy number was estimated using real time quantitative PCR with SYBR®Green. Parasite response was assessed ex vivo with seven concentrations of each anti-malarial. Patients were treatedaccording to Brazilian guidelines: quinine plus tetracycline or mefloquine in period 1 and ACT in period 2...
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Humanos , Plasmodium falciparum , Plasmodium falciparum/crescimento & desenvolvimento , Plasmodium falciparum/genéticaRESUMO
OBJECTIVES: Chloroquine (CQ), after 67 years of use in Haiti, is still part of the official treatment policy for malaria. Several countries around the world have used CQ in the past due to its low incidence of adverse events, therapeutic efficacy, and affordability, but were forced to switch treatment policy due to the development of widespread CQ resistance. The purpose of this paper was to compile literature on malaria treatment policies and antimalarial drug efficacy in Haiti over 67-year period. METHODS: A systematic review of PubMed, Web of Science, and the Armed Forces Pest Management Board, was conducted to find pertinent documents on national malaria treatment policies and antimalarial drug efficacy studies in Haiti between 1955 and 2012. A total of 329 citations and abstracts were reviewed independently by two researchers, of which thirty three met the final inclusion criteria of studies occurring in Haiti between 1955 and 2012 which specifically discuss malaria treatment policies and drug efficacy. RESULTS: Results suggest that CQ has been the predominant antimalarial drug in use from 1955 to 2012. In 2010 single dose primaquine (PQ) was added to the national treatment policy, however it is not clear whether this new policy has been put into practice. CONCLUSIONS: Although no widespread CQ resistance has been reported, some studies have detected low levels of CQ resistance. Increased surveillance and monitoring for CQ resistance should be implemented in Haiti.
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Since emergence of chloroquine-resistant Plasmodium falciparum and reports of parasite resistance to alternative drugs, there has been renewed interest in the antimalarial activity of acridines and their congeners, the acridinones. This article presents literature compilation of natural acridinone alkaloids and synthetic 9-substituted acridines, acridinediones, haloalcoxyacridinones and 10-N-substituted acridinones with antimalarial activity. The review also provides an outlook to antimalarial modes of action of some described compounds.
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Acanthospermum australe (Loefl.) O. Kuntze, conhecido popularmente no Brasil como carrapichinho pertence à família Asteraceae e é utilizado na medicina popular como hepatoprotetora, diaforética, antiblenorrágica, antimalárica, entre outras funções. O objetivo do presente trabalho foi estudar a espécie sob o aspecto botânico, químico e farmacológico. Assim, folhas e caules foram analisados macro e microscopicamente, contribuindo no auxílio da diagnose da espécie. Os órgãos em estudo foram submetidos a ensaios preliminares para a pesquisa dos principais grupos de princípios ativos provenientes do metabolismo secundário dos vegetais. Diferentes extratos foram obtidos por percolação e por decocção, sendo alguns deseus componentes isolados por CCD preparativa e identificadas por CG/EM. O óleoessencial do vegetal, coletado em diferentes épocas do ano e variados estágios de desenvolvimento, foi obtido em aparelho de Clevenger modificado, sendo que sua composição também foi analisada por CG/EM. O extrato clorofórmico e o extrato hidroetanólico liofilizado (EHL) foram avaliados quanto à atividade antimalárica e antileishmania. Com o EHL foi realizado também ensaio de atividade antiúlcera em ratos Wistar Hannover fêmeas e atividade antimicrobiana em bactérias e fungos. A espécie em estudo, nas condições deste trabalho, apresentou flavonóides, taninos, saponinas, óleo essencial e mucilagens. O extrato clorofórmico e hidroetanólico liofilizado, nas concentrações de 100 µg/mL, provocaram 100% de morte dos protozoários de Plasmodium chabaudi AJ, porém ambos não apresentaram atividade em promastigotas de Leishmania (L.) chagasi nesta concentração. O EHL na concentração de 10 mg/mL demonstrou significativa atividade antifúngica contra o Aspergillus niger, não apresentando nenhuma atividade para Staphylococcus aureus, Pseudomonas aeruginosa, Escherichia coli e Candida albicans. O mesmo extrato, na concentração de 400 mg/kg, administrada por via oral, mostrou-se com atividade antiúlcera aguda significativa, reduzindo a Área Total de Lesão (ATL) em 49,13% em relação ao controle. O óleo essencial, nas condições do experimento, apresentou diferenças qualitativas e quantitativas quando comparado a estudos já realizados, sendo constituído em sua maioria por sesquiterpenos dos grupos cadinano (α-cadinol e δ-cadineno), cariofilano (ß-cariofileno) e, principalmente, germacrano (globulol). As análises permitiram concluir ainda que o isômero do espatulenol é o componente exclusivo e majoritário do óleo essencial de caule e o isômero do globulol, o componente presente em maior quantidade no óleo quando o vegetal encontra-se em fase de floração
Acanthospermum australe (Loefl.) O. Kuntze, known popularly in Brazil as carrapichinho belongs to the family Asteraceae and it is used in the tradicional medicine as hepatic protector, diaforetic, blenorragic activity, antimalarial activity among others. The objective of the present work was to study this species under the aspect botanical, chemical and pharmacological. Thus, leaves and stems were analyzed macro and microscopic contributing in the aid of the diagnosis of species.The aerial parts in study were submitted to preliminary phytochemical screening for the research of the main groups of secondary metabolites of plants. Difterent extracts were obtained by percolation and for decoction being some of their components, isolated for TLC preparative and identified for GC/MS. The essential oil of the plants, collected at different seasons of the year and different development stadiums, it was obtained in a Clevenger apparatus, and it composition, was also analyzed by GC/MS. The chloroformic extract and liofilized hidroethanolic extract (LHE) were assayed for the antimalarial and antileishmania activities. Using LHE it was also assayed for the anti ulcer activity in mice Wistar Hannover females and antimicrobial activity in bacteria and fungi. The species in study, in conditions of this work, presented flavonoids, tannins, saponnins, essential oil and mucilages. The chloroformic extract and LHE in the concentrations of 100 µg/mL caused 100% of death in the blood forms of Plasmodium chabaudi AJ, however none of them presented activity in blood forms of Leishmania (L.) chagasi in this concentration. LHE in the concentration of 10 mg/mL presented significant antifungal activity against the Aspergillus niger, and no activity against Staphy/ococcus aureus, Pseudomonas aeruginosa, Escherichia coli and Candida albicans. The same extract, in the concentration of 400 mg/kg, administered orally, presented significant antiulcerogenic activity, reducing the Total Area of Lesion (TAL) in 49,13% in relation to the control. The essential oil, in the conditions of the experiment, presented qualitative and quantitative difterences when compared to previous studies and constituted in its majority by sesquiterpenes of the cadinano groups (α-cadinol and δ-cadinene), caryophyllano (ß-caryophyllene) and mainly, germacrano (globulol). The analyses still permit to conclude that the isomer of the spathulenol is the exclusive and mayor component of the essential oil in the stem. Isomer of the globulol is the representative present in mayor amount in the oil when the plant is in flower stadium