Artemether resistance in vitro is linked to mutations in PfATP6 that also interact with mutations in PfMDR1 in travellers returning with Plasmodium falciparum infections

Identifying associations between genotypes of Plasmodium falciparum and artemisinin resistance, however it may be defined, is of paramount importance. Attempts to demonstrate clear-cut associations between genotype and phenotype are challenged by variable definitions of clinical treatment failure [1], dormancy in immature parasites that do not show increased in vitro resistance to artemisinins but recrudesce after exposure to high drug concentrations [2‐4], and the absence of interpretive breakpoints that demarcate susceptibility and resistance to artemisinins.

Several years ago, PfATP6 was hypothesized to be, a SERCA-type calcium pump of the parasite that was a potential target for artemisinins [5]. One implication of this hypothesis was that mutations in PfATP6 might influence susceptibility to artemisinins [6]. Decreased in vitro sensitivity to artemisinins was later associated with mutations in pfatp6 (particularly coding for an S769N substitution) in some geographically and temporally dispersed observations [7‐9]. However, there are reports (reviewed in [10]) that do not associate other SNPs in pfatp6 with decreased susceptibility to artemisinins, perhaps because the detection of these associations may be confounded by the intrinsic polymorphic tendency of this sequence [8, 11, 12] or lack of detailed phenotypic characterizations. Alternative mechanisms of action and resistance have also been examined for artemisinins (reviewed in [10, 13, 14]), with these hypotheses having different implications for monitoring of resistance and new drug development programmes. Consequently, any evidence obtained from patient isolates that can clarify relationships between parasite genotypes and artemisinin sensitivity will be useful, particularly as in vitro models may not be able to replicate phenotypes of resistance to artemisinins observed in clinical isolates.

Increased copy number for pfmdr1 is associated in many geographic areas with elevations in IC₅₀ values to arylaminoalcohols (mefloquine and lumefantrine) and artemisinins. These observations were first made in laboratory models of drug resistance and confirmed in isolates from patients in Southeast Asia [15‐18]. Increased pfmdr1 copy number is established as a clinically relevant determinant of treatment failure with mefloquine even when given with artesunate [17, 19]. Laboratory in vitro and in vivo models have confirmed the causal link between pfmdr1 copy number and multidrug resistance [20, 21]. Amino acid substitutions in pfmdr1 may also modulate drug susceptibility in clinical isolates [22, 23].

Mechanisms of artemisinin resistance were studied in travellers returning to Southern Ontario with a presumptive diagnosis of P. falciparum infection who had blood specimens submitted to the Toronto Public Health Laboratory for confirmation of diagnosis. As part of a study to validate in vitro susceptibility testing for P. falciparum, parasites were introduced into cultures and their drug sensitivity profiles assessed. An early case report from these efforts suggested that some parasites manifest in vitro resistance to the artemisinin class of anti-malarials [24], and that this phenotype could be linked to polymorphisms in pfatp6, and pfmdr1 copy number. This report expands those preliminary findings and provides results from approximately three times the number of isolates originally examined. Here, the hypothesis that particular mutations in pfatp6 are associated with elevations in IC₅₀ values to some artemisinins is tested, and the potential contribution of mutations in pfmdr1 to this resistance phenotype is examined.

Twenty-eight parasites were cultured from travellers returning with clinical symptoms of malaria between April 2008 and January 2011. Of these 28 patients, only three had taken any form of prophylaxis. Presenting parasitaemia from these patients ranged from <0.1% - 28%, with most (25/28) infections acquired in sub-Saharan Africa. All patient information, demographic details, symptoms, parasitaemia, results of individual drug sensitivity assays and mutations determined for each isolate are presented in Additional file 2. Results for IC₅₀ values are normally distributed for all artemisinins (p > 0.1). There was no effect on IC₅₀ values of presenting parasitaemia or assay method (in vitro versus ex vivo; p > 0.05 for each artemisinin tested).

This report confirms that increased IC₅₀ values to artemether are linked to the pfatp6 A623E/S769N haplotype. There are several reasons why this association may be of interest to those studying mechanisms of drug action and resistance in malaria. Parasites with this pfatp6 haplotype have originated from dispersed countries in sub-Saharan Africa (Additional file 2). Most have presented without obvious drug selection pressure applied by the traveller, so that it is likely these mutations are present at source. Selection for these polymorphisms may therefore be taking place in the countries of origin for these parasites, by the rapid scale up of anti-malarial treatment programmes being implemented in recent years, and now at about 300 million doses of artemisinin combination therapies disbursed in a year [33, 34].

These findings have implications for epidemiological studies monitoring drug resistance to artemisinins. In PfATP6, A623E and S769N substitutions have been reported individually as being associated with elevated IC₅₀ values to artesunate and artemether respectively [7, 35]. Each of these polymorphisms has also been associated with other amino acid substitutions in PfATP6, but not hitherto with each other (reviewed in [10]). Combinations of mutations in PfATP6 may result in more obvious effects on IC₅₀ values, with the haplotype observed in these studies emerging as being an important one. Despite the highly polymorphic nature of PfATP6 [8, 12], the independent linkage between artemether and mutations described here confirms previous observations from French Guiana that these mutations are worth monitoring in future epidemiological studies of artemisinin resistance [7]. Other reported mutations may also prove epidemiologically useful once the intrinsic variability of PfATP6 sequence can be distinguished from those that have relevance to artemisinin sensitivity, as discussed in detail elsewhere [12].

The magnitude of elevation in IC₅₀ values for artemether in PfATP6 mutant-bearing parasites is approximately two-fold (Figure 1 and Results). This difference is larger than between parasites carrying the L263E mutation in PfATP6 when compared with control parasites (23%), for artemisinin and DHA [36]. Interestingly, increases in IC₅₀ values for L263E mutants did not apply to all the artemisinins examined (for example, artesunate) and this also is the case in this study, where artemether is the derivative predominantly affected by these mutations in PfATP6 (Figures 1 and 2). Mutations in PfATP6 identified in isolates taken from patients (in contrast to L263E) may not fall within protein areas of obvious functional significance for SERCA type activity that have been identified in mutagenesis studies over several decades in many organisms, and by more recent solutions of crystal structures [37‐39]. They are located in less highly conserved regions, so this may reflect ignorance of structure-function relationships in polymorphic plasmodial proteins that contain low complexity ‘inserts’, as suggested almost two decades ago [40]. These studies also illustrate some difficulties in developing laboratory models of drug resistance with transgenic parasites because resistance phenotypes may be difficult to identify in some contexts. For example, resistance observed with K76T pfcrt for chloroquine, may depend on genetic context [41]. Part of this genetic context includes the pfmdr1 gene, which itself can modulate in vitro sensitivity to a variety of unrelated drug classes (reviewed in [42]).

Duplication in pfmdr1 has emerged as being perhaps surprisingly common in these returning travellers. Previous reports from African countries have only demonstrated sporadic instances of pfmdr1 gene duplication. Duplications can arise within the host after drug treatment as well as being selectable in vitro ([20, 43, 44] suggesting that the potential for this genetic event to occur is high. This is borne out by the correspondingly high prevalence of pfmdr1 duplications in parasites in countries that have used arylaminoalcohols such as mefloquine as part of their anti-malarial treatment regimens (e.g.[17]) as well as the ease for selection of increased copy number in African parasites [45].

There may be a strong association between duplications in pfmdr1 and mutations in pfatp6 that influence the IC₅₀ values for artemether (and artesunate), because even in a relatively small subset of parasites, there is a highly significant link between mutations in both transporter genes and IC₅₀ values. This association is not apparent with pfmdr1 duplications alone in this relatively small dataset, although it has been noted before in larger studies of field isolates in different regions of the world (e.g.[17]), and also in laboratory models [21, 46‐48].

Several studies have reported on mutations in pfatp6 and pfmdr1 gene duplications or polymorphisms as part of epidemiological monitoring for drug resistance, including for resistance to artemisinins. Interestingly, some studies may only be able to provide useful information when parasites are cultured for the short term ex vivo because of mixed populations of parasites with and without mutations in pfatp6 and associated fitness costs of mutations. These can result in disappearance of pfatp6 mutations after adaptation to continuous culture, as carefully documented previously [9]. Artemisinin or artesunate IC₅₀ values are almost double in field isolates from Southeast Asia with gene duplications, whereas in these studies there is no significant change in IC₅₀ values to DHA [17, 49, 50]. Mutations in the 3’ sequence of pfmdr1 (with D1246Y being a good example) increase sensitivity to artemisinin [51‐53], whereas they may affect artesunate in the opposite way, by decreasing sensitivity in field isolates [17]. One of the strongest associations is between the N86Y substitution and increased sensitivity to artemisinin and DHA in this analysis. This finding is consistent with previous reports that this mutation in pfmdr1 may modulate the effects of artemisinins.

PfMDR1 is localized to the food vacuole of parasites, and studies after heterologous expression suggest that SNPs alter substrate specificity for aminoquinolines and arylaminoalcohols [54] with the suggestion that drugs are removed from the cytoplasm into the food vacuole (reviewed in [55]). Mutations in PfMDR1 may alter IC₅₀ values to artemisinins by modulating their removal (to the food vacuole) away from their proposed target (PfATP6 localised in the ER). A simple hypothesis that highlights the importance of interactions between PfATP6 and PfMDR1 in modulating artemisinin sensitivity is that resistant parasites carrying mutations in PfATP6 can become sensitive if SNPs in PfMDR1 decrease delivery of artemisinins to the food vacuole. This suggestion is consistent with results from modelling suggesting that mutations in PfATP6 are unlikely to differentially affect interactions with different artemisinins and PfATP6, whereas PfMDR1 mutations may have variable effects on transport of artemisinins.

These insights into the biology of drug resistance mechanisms have developed from an analysis that combines results from field isolates with contributions from molecular studies including modelling. Studies of returning travellers as ‘sentinels’ for drug resistance may be particularly useful, as previously pfmdr1 gene duplication in Africa was first recorded in a returning traveller [56]. For epidemiological purposes, monitoring for mutations in both transporter genes (pfatp6 and pfmdr1) should be carried out and related to in vitro sensitivity profiles of the clinically relevant artemisinin derivatives.