Background
Methodology
Controlling malaria: artemisinin combination therapy as first-line treatment
Active ingredients (adult dose) | Partnership | Phase/status | Product name(s) | Comments | Chemical structure in Figure1 | References |
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Artemether (20 mg), lumefantrine (120 mg) x 4 b.i.d | Novartis, MMV | Launched 2008 | Coartem®; Coartem®-Dispersible | Coartem was launched in 2001. Coartem Dispersible is a specific paediatric formulation with a sweet-tasting flavour. It is given twice per day for three days. Coartem Dispersible decreases gametocytes by 6–8- fold compared to sulphadoxine/pyrimethamine and chloroquine. Approved by Swissmedic in Dec 2008, it received WHO prequalification in Feb 2009. Four dose strengths are registered in 83 countries. In Apr 2009, Novartis received approval from the US-FDA for Coartem, including a ‘Priority Review Voucher’ (PRV). | a), f) | |
Artesunate (100 mg), amodiaquine (270 mg) x 2 q.d. | Sanofi, DNDi (MMV) | Prequalified 2008 | Coarsucam®; ASAQ-Winthrop® | Marketed as Coarsucam in the private market and ASAQ-Winthrop in the public markets. Given once per day for three days. Originally registered in Morocco, it is now approved in 31 countries (including 25 in Africa) and prequalified in 2008 by WHO, but so far has not been submitted to a Stringent Regulatory Authority. Stability data now available for three years in Zone IVb (30°C and 75% relative humidity), compared to two years for other ACT. | b), g) | |
Dihydroartemisinin (40 mg), piperaquine (320 mg) x 3 q.d. | sigma-tau, MMV, Chongqing Holley Holding | Approved | Eurartesim®; Artekin®; Duo-Cotecxin® | Available as Duo-Cotexcin since 2005 (approved by Sino-FDA), uses the active metabolite of artemisinin, dihydroartemisinin. Given once per day for three days. Two pivotal clinical trials led to approval by the EMA in 2011. Prequalification expected 2012. Shows superiority to artemether-lumefantrine in post-treatment protection until day 63. | c), d) | |
Pyronaridine (180 mg), artesunate (60 mg) | Shin Poong, MMV | Pre-registration | Pyramax® | Approved by the Korean K-FDA, and by the EMA, article 58 in Feb 2012. Prequalified by WHO. Given once per day for three days. Four pivotal clinical studies were performed 2007–2009, with the first regulatory studies on an ACT in both Plasmodium falciparum and Plasmodium vivax malaria. Shows superiority to artemether-lumefantrine in post-treatment protection until day 42. | g), b) | |
Mefloquine, (200 mg), artesunate (100 mg), x2 qd | Farmanguinhos, DNDi, (Cipla Ltd, MMV), Mepha Ltd | Launched (Brazil) 2008; Launched (Portugal) 2003 | ASMQ; Artequin | A fixed-dose combination from Farmanguinhos (Brazil)/DNDi was registered in Brazil in 2008. Given once per day over three days. Use outside Brazil should be accelerated by production by Cipla (India), and Indian registration in 2012. Prequalified by WHO in September 2012. Fixed-dose combination called artequin granules (50 mg artesunate/125 mg mefloquine), originally registered in Portugal (2003) and now sold in Africa in commercial markets. | e), b) | |
Artemisinin (125 mg), naphthoquine (50 mg) x 8 tablets | Chinese Academy of Military Medical Sciences, Kunming Pharma Corp | Launched (China) | ARCO® | Combination of poorly bio-available artemisinin with naphthoquine. Given either as a single dose or split twice within the same day. Clinical studies are not GCP compliant, and report on a limited number of patients. Very little preclinical data available for review. Registered and promoted in more than 10 countries. | a), h) |
Artemether lumefantrine | Artesunate amodiaquine | Dihydroartemisinin piperaquine | Pyronaridine artesunate | Artesunate mefloquine | Artemisinin naphthoquine | |
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Partner
| Novartis, MMV | Sanofi, DNDi, (MMV) | sigma-tau, Pfizer, MMV | Shin Poong, MMV | Farmanguinhos/DNDi, Cipla; Mepha | AMMS, Kunming Pharma Corp |
Trade name
| Coartem®; Coartem-® Dispersible | Coarsucam®; ASAQ-Winthrop® | Eurartesim® | Pyramax® | ASMQ | ARCO® |
Approval Date
| 1Q'01/1Q'09 Swiss-Medic | 2Q'07 Morrocco Prequalified 4Q’08 | 4Q'11 EMA | 1Q'12 EMA and Prequalification | 2Q'08 Brazil Prequalification anticipated | 2005 China |
Stringent Approval
| Yes: CH, US-FDA, WHO Prequalified | No: Morocco, WHO Prequalified | EMA Submitted; approved by the CHMP in Jun 2011, and EU in Oct 2011 | EMA Submitted. Approved by the Korean FDA in Aug 2011; approved by EMA in Feb 2012 | Farmanguinhos/DNDi No: Brazil, WHO Prequalification submitted; Mepha product approved in West Africa and Portugal | No: Sino-FDA for the moment |
Formulation
| Tablet (adult), dispersible flavoured tablets (child) | Dispersible tablets for all ages | Tablet (adult, child), dispersible formulation for children (submission in 2014) | Tablet (adult), sachet with granules (child), (submission in 2014) | Tablet (adult, child) | Tablet (adult, child) |
Key Strengths
| 350 million treatments to date. Paediatric formulation is dispersible and flavoured | First line therapy in francophone Africa. Three-year shelf life. Once per day, three days. Paediatric dose. | Once per day, three-day treatment course. Long terminal half-life of piperaquine. Strong post-treatment protection of 42 days | Once per day, three-day treatment. Granulated paediatric formulation with taste-masking. Best preclinical and clinical data against Plasmodium vivax. | Once a day, three-day treatment. Strong post-treatment prophylaxis. Active against chloroquine resistant P. vivax. | Single dose treatment, may be split over two days. |
Key Weakness
| Twice per day | Amodiaquine resistance in some countries. GI adverse events | Previous concerns on stability, but data now support two years under Zone IVb conditions | Tablets can only be given to patients >20 kg. Limited repeat dose data. Currently only recommended for a single treatment | Psychiatric and GI adverse events. Mefloquine-resistant strains exist. Concern over use where mefloquine prophylaxis is recommended. Currently relatively expensive ($2.50) | No GCP clinical studies or safety data. Insufficient information on ARCO for children. No stringent regulatory approval |
Market size & strength 2010
| First line treatment in 35 countries. 82 million treatments (37 million Coartem-® Dispersible) per year. Estimated 21 million are generic artemether/lumefantrine. | 45 million (fixed-dose combinations). First line treatment in 17 countries (West Africa) | Two million treatments per year. Registered in 30% of African countries. First line therapy in Cambodia, on treatment guidelines in six countries | Not launched yet. Should be medicine of choice in Asia/Pacific dual-infection areas. | Still relatively small (200,000 treatments). An Indian approval would significantly change this. | Registered in more than 10 countries. Treats one million patients per year. |
Stability
| 24 months | 36 months | 24 months | 24+ months | 36 months (Brazil) | Unknown |
Public sector pricing (USD) | $0.74 weighted average (from $0.37-$1.41 depending on weight) | $0.60 weighted average (from $0.30-$1.50 depending on weight) | Estimated $0.90-$1.10 weighted average (from $0.50-$1.50 depending on weight). Final price may be higher due to DHA prices | $1.10 weighted average (from $0.34-$2.12, lowest to highest weight band). Final price may be higher due to artesunate prices | Currently at $2.50 per adult. New mefloquine synthesis should make the price similar to other ACT | Not sold in the public sector. |
New treatments for severe malaria
Active ingredients | Partners | Phase/status | Comments | References | |
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Intra-rectal artesunate | UNICEF-UNDP-World Bank-WHO Special Programme for research and training in Tropical Diseases (WHO-TDR) | Pre-registration | Intra-rectal artesunate improves outcomes in sub-group in retrospective analyses: patients >6 hours from hospital, and <6 years old. No manufacturing or distribution partner has been defined. | ||
Sevuparin sodium (DF-02) | Dilafor AB | Phase IIa | Heparin analogue with a low anticoagulant activity. Phase I data were reported in Oct 2009 with doses as high as 420 mg. A Phase II study started in 2011 | [68] | |
Artesunate for injection | Guilin Pharmaceutical | WHO prequalified 2010 | Artesunate for injection has been produced since 1987. In 2010, Guilin gained WHO prequalification (with support from MMV). The clinical data in both the Aquamat and Seaquamat studies used Guilin material. Current price is $1.40 per 60 mg vial, over 2 500 000 vials sold in 2011 | [69] | |
ARH1 (150 mg/ml artemether) | Lincoln Pharmaceuticals | Launched (India) 2011 | ARH1, an injectable formulation of arteether (ethyl ether derivative of artemisinin). It is oil soluble, has a long elimination half-life (greater than 20 hours), and is more stable than other artemisinin compounds: launched in India in Jun 2011. | [70] | |
SAR97276 (albitiazolium bromide) | Sanofi/CNRS | Phase II | Bisthiazolium choline uptake inhibitor, not orally bio-available. Being developed as an intramuscular injection for severe malaria. Initial Phase II data showed relatively poor efficacy in uncomplicated malaria, and may require a higher dose. Medicine could have the advantage of being shipped in pre-filled syringes, making delivery simpler. | [71] NCT00739206 | |
Artemether | Eastland Medical, Star Medical, Protopharma Ltd | Phase III | ArTiMist™ (sublingual mouth spray) | An artemether sublingual mouth spray. A Phase II study was conducted to compare the efficacy of ArTiMist™ and intravenous quinine in children infected with severe malaria, or uncomplicated malaria and gastro-intestinal complications (NCT01047436). The difficulty is to make sure this product does not break WHO’s call for the withdrawal of artemisinin monotherapy in uncomplicated malaria. | NCT01047436 NCT01258049 |
E6446 (TLR9 antagonist) | Eisai Co Ltd | Preclinical | Toll-like receptor antagonists. TLR 9 antagonism has been suggested to suppress cerebral vascular lesions and leakage of vascular contents. The difficulties in interpreting the murine data mean additional proof of mechanism in humans will be needed before starting a severe malaria trial. |
Active ingredients | Partnership | Product name(s) | Phase | Comments | References |
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Azithromycin 250 mg, chloroquine 155 mg | Pfizer, MMV, London School of Hygiene and Tropical Medicine | AZCQ | Phase III | Azithromycin is a macrolide requiring 2000 mg/day to be effective as monotherapy but shows clinical synergy with chloroquine even where chloroquine resistance is as high as 50%. Entered Phase III for intermittent preventive treatment of Plasmodium falciparum malaria in pregnancy (IPTp) in Oct 2010. The primary outcome is a reduction in the number of subjects with suboptimal pregnancy outcome, and results should be available in 2014. | |
Trimethoprim/sulphamethoxazole | Studies by Institute of Tropical Medicine, Antwerp in Zambia and UCSF in Uganda | Co-trimoxazole | Phase III for malaria | An antibacterial with activity against malaria. Early data in children showed similar efficacy to amodiaquine artesunate. A Phase III study comparing against SP and DHA-piperaquine is expected to be completed in Jul 2014. A Phase III study with 1,714 subjects in Zambia is testing its effectiveness as prophylaxis to prevent malaria in pregnancy, expected to be completed in Nov 2011 | |
Rbx11160/OZ277 150 mg, piperaquine phosphate 750 mg | MMV, Ranbaxy | Arterolane maleate + piperaquine phosphate | Phase III | First generation synthetic peroxide (trioxalane), given as one tablet per day for three days. Arterolane as a monotheraphy drug showed lower efficacy than artesunate with seven days of dosing. A Phase III trial in India, Bangladesh and Thailand is now underway. The medicine was approved in India in early 2012. | |
OZ439 | MMV, (University of Nebraska, Monash University and Swiss TPHI) | Phase IIa (monotherapy) | Next-generation synthetic peroxide. Phase I showed OZ439 was safe at doses up to 1,600 mg as a single dose, and gives plasma concentrations with anti-parasite activity up to 72 hours. A Phase IIa study in P. falciparum and P. vivax patients was completed in mid-2012. | [84] NCT01383096 NCT00928083 | |
SSR97193, artesunate | Sanofi | Ferroquine | Phase IIa | 4-aminoquinoline active in vitro against multidrug resistant P. falciparum. Phase II studies showed that it is active in combination with artesunate in African adults and children. Project was put on hold, presumably because of insufficient product differentiation. | |
Fosmidomycin, clindamycin | Jomaa Pharma Ltd | Fosclin | Phase IIa | Fosmidomycin is a DOXP inhibitor, used in combination with the antibiotic clindamycin. A study in children showed good tolerability and 94% efficacy. A further Phase II was completed in Sept 2011. | |
Methylene blue, chloroquine | Ruprecht-Karls-Universität, Heidelberg, DSM | Phase II | Methylene blue was originally suggested by Paul Ehrlich. The combination MB-CQ is safe in adults and children with or without G6PD deficiency. Local acceptability studies imply discolouration of urine is not seen as a major issue. | ||
NITD609 | Novartis, MMV | Phase IIa (monotherapy) | Spiroindolone suppresses protein synthesis in the parasite, working through PfATP4. NITD609 has the pharmacokinetic properties compatible with once-daily oral dosing for the potential treatment of falciparum and vivax malaria. A Phase IIa trial started in December 2011. | ||
Actelion antimalarial | Actelion | Phase I | A compound of undisclosed structure with similar parasite reduction rates as chloroquine. Completed Phase I in summer 2012 | ||
GNF156 | Genome Foundation of Novartis, MMV | Preclinical | An imidazolopiperazine active against blood, liver and gametocytes, with stages of Plasmodium, and active in murine models. Preclinical safety studies started in the first quarter of 2011, and Phase I early in 2012. | ||
Oxaboroles | Anacor, MMV | Preclinical | A new class of oxaboroles. Highly potent against P. falciparum parasites, and curative in animal models. Has a good safety profile and excellent drug-like properties, and low cost-of-goods. | ||
DSM265 | University of Texas Southwestern, MMV, University of Washington, Monash University | Preclinical | A dihydroorotate dehydrogenase (DHODH) inhibitor. In June 2010, a compound was chosen from the inhibitor series for full preclinical development. First in human studies are planned for early 2013. | ||
MK4815 | Merck, MMV | Preclinical | A cell-based inhibitor that has demonstrated potency against P. falciparum malaria when tested in vivo. Its mechanism of action appears to involve the mitochondrial electron transport chain of the parasite, and when administered, concentrates in infected erythrocytes. Due to safety issues, the molecule is still in preclinical evaluation. | ||
P218 | BIOTEC, Monash University, LSHTM, MMV | Preclinical | A dihydrofolate reductase inhibitor binds with high affinity to the wild-type and resistant DHFR enzymes and has an excellent ADME-PK profile. Currently in preclinical development, although there are concerns about the impact of pre-existing DHFR mutant stains of parasite. | ||
Genz668764 | Genzyme Corp (Sanofi), MMV | Preclinical | An aminoindole, with activity against both P. falciparum and P. knowlesi. This family has the advantage that it has been impossible so far to produce resistant mutant strains of parasite. Preclinical evaluation started in early 2011. | [106] | |
RKA 182 | Liverpool School of Tropical Medicine, Liverpool University | Preclinical | Lead compound from a series of tetraoxanes with rapid anti-parasitic activity. Has shown anti-malarial activity against a range of multi-drug resistant isolates. Its half-life is intermediate between OZ277 and OZ439. Next-generation compounds are currently being tested. | ||
BCX4945 | Albert Einstein College of Medicine, Biocryst Pharmaceuticals, | On Hold | Parasites cultured in human erythrocytes can be killed rapidly by this purine nucleoside phosphorylase (PNP) (immucillin-H). Purine salvage pathways in the mouse suggest a mechanism for lack of in vivo activity, and that these compounds will have to be tested directly in human challenge models. | ||
CDRI 99/411 | Ipca, CDRI | On Hold | A trioxane anti-malarial candidate, shown initially to be safe in pre-clinical studies. An IND was approved in March 2010 in India, but no further progress has been reported. | [111] | |
AQ-13 | Immtech | On hold | AQ-13 is another 4-aminoquinoline, active against chloroquine-resistant P. falciparum infection. A Phase I study with 126 individuals was successfully completed in 2005, but no further development was reported. The compound has no significant advantages over other 4-aminoquinolines. | ||
N-tertiary-butyl isoquine | Liverpool School of Tropical Medicine, GSK, MMV | On hold | N-tert-butyl isoquine was developed as a safer alternative to amodiaquine. In May 2008, a single-blinded, placebo-controlled, randomized Phase I trial was initiated in healthy volunteers. The trial was stopped later in 2008 as a result of adverse events, at the highest dose. Experiments are ongoing to recalculate the estimated human effective dose. | ||
SAR116242/PA1103 | Palumed, MMV | On hold | A fusion compound containing a trioxane ring and a 4-aminoquinoline group. It entered preclinical development in 2007, but has not progressed into human studies. | [118] | |
Artemisone | Hong Kong University of Science and Technology, (MMV, Bayer) | Artemefone (semisynthetic artemisinin derivative) | On hold | In preclinical studies, artemisone, a new artemisinin derivative proposed to have enhanced safety over artesunate. Currently being discussed as an option for treating artemisinin-resistant malaria, although clinical trials have not started, and a commercial partner is still being sought. |