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Drugs Used Against Malaria


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Drugs Used Against Malaria

- Malaria is a vicious disease which accounts for annual 1.5 – 2.5 million deaths, worldwide, mostly children < 5 yo.

- ~40% of the world population live in areas with the risk of malaria

- About 273 million malaria cases were reported in 1998 and the worldwide average annual infection with malaria is 300 – 500 million

- Despite the initial success of the World Health Organization to eradicate global malaria during the 1950& 1960’s, the estimated number of new infections has now reached their original levels.

- Malaria is not as common in the US as other protozoan infections, e.g., coccidiosis in chickens & trichomonal vaginitis in humans, which cause more serious problems.

- International travel has caused increased awareness of the prevention & treatment of malaria & other protozoan infections.

- During the Vietnam War, several thousand cases of malaria (mainly of returning servicemen) were reported in the US.


Factors contribute to persistence of malaria:

1. Lack of effective malaria vaccine.

2. The emerging parasite resistance to the current drugs as chloroquine & mefloquine.

3. Increased mosquito resistance to inexpensive insecticides.

4. Little pharmaceutical industry interest in developing new antimalarial drugs since the

risks are significant while the expected investment returns are low.





Types of Malaria (4 Types):

1. Plasmodium vivax – (Benign Tertian Malaria)

- causes ~40% of cases

- Clinical symptoms recur every 48 hours

- Not many merozoites are produced but many of them reenter new liver cells to form secondary schizonts, which can cause relapse for several years.

2. P. falciparum(Malignant Tertian, Subtertian)



- cause ~50% of malaria cases

- The most dangerous & lethal malaria parasite, which causes cerebral malaria

- No secondary schizont.

- Can damage up to 65% of erythrocytes in some cases

3. P. malaria (Quartan Malaria)

- Similar to P. vivax, relapse can occur for decades

4- P. ovale (Mild Tertian Malaria)

- Least common

- Similar to P. vivax and P. malaria.

- Long-lasting secondary schizont stage
- Malaria protozoa are very specific & biochemically-dependent on host & vector.

- Malaria need host erythrocytes to replicate their own DNA & RNA.

- Protozoa can synthesize their own pyrimidines (cytosine, uracil, thymine) & some amino acids.

- Malaria protozoa cannot synthesize their own:

- purines (adenine & guanidine)

- phosphate & pentoses for DNA & RNA synthesis

- cholesterol & fatty acids (for cell membrane & glyceride synthesis)
- hence they must obtain them from host’s erythrocytes.

- They digest host’s hemoglobin and plasma

- Malaria synthesize folic acid, hence sulfonamides, which block folic acid synthesis, can also block malaria growth.

- ~75% of infected erythrocyte’s hemoglobin is digested by malaria haemozoin (protease?)



Early Antimalarial Drugs


I. Quinoline & Analogues


- Cinchona alkaloids: with unique quinuclidine moiety,

- 7-chloro-4-aminoquinoline: chloroquine,

- 8-aminoquinolines: primaquine,

- Quinoline methanol: mefloquine.


II- 9-Aminoacridines : Quinacrine
Quinoline and Analogues

- Mechanism of Action –Generally, aminoquinolines intercalate into plasmodial DNA to direct inhibition of protein synthesis.

1. Binding of chlororquine to ferriprotoporphyrin IX (FPIX), which can cause erythrocytes & malaria protozoan cells to lyse.

2. Trapping of chlororquine in the malaria lysosome increases pH, which inactivates hemoglobin-digesting enzymes.

- This will disrupt the pH-sensitive proteolytic enzymes & inactivate the lysosomal proton pump.

Mechanism of Resistance to Quinolines:

- Several chlororquine& other quinolines resistant strains of P. falciparum & P. vivax are reported without change in the uptake rate.


- These resistant strains contain increased amounts of a membrane protein that pump drugs out of the protozoa.

- This protein is similar to the P-glycoprotein that cause multidrug resistance in cancer cells.

- High doses of verapamil can reverse malaria resistance by blocking the P- glycoprotein pump, but this can cause arrhythmias. The natural product tetrandrine also can reverse malaria resistance by blocking the P-glycoprotein

pump.


- Resistant strains rapidly metabolize quinolines due to increased activity of cytochrome P-450 enzyme

- The natural product tetrandrine (from the Chinese herb Stephania tetrandra) also

can also reverse malaria resistance by blocking the P-glycoprotein pump.



Cinchona Alkaloids

- Bark of Cinchona ledgeriana, C. pubescens & C. calisaya, family Rubiaceae.

- The oldest antimalarial remedy

- Afforded several antimalarial quinoline alkaloids:

- Quinine: 5%

- Quinidine: 0.1%

- Cinchonine: 0.3%,

- Cinchonidine: 0.4%

- other minor alkaloids:

- Rubane


- 9-epi-quinine

- 9-epi-quinidine.



Cinchona Alkaloids

- changes in stereochemistry at C8 and C9 has significant effect on action



Pharmacokinetics of Cinchona Alkaloids

- Cinchona alkaloids are absorbed quickly & completely after oral administration (1-4 hr).

- Blood levels fall off quickly after administration stops.

- A single quinine dose is disposed in 24 hr.

- They are metabolized mainly by oxidative liver enzymes, mainly hydroxylate position 2’of the quinoline ring.

- The resulting metabolites are much less toxic and active and rapidly excreted in urine



Toxicity of Cinchona Alkaloids

- cinchonism: hypersensitivity to cinchona alkaloids—allergic skin reactions, tinnitus, deafness, vertigo & slight mental depression.


Routes of Administration

- Oral, i.v. & i.m. injections

- Quinetum: extract with large amount of quinine.

- Cinchona fibrifuge: alkaloids remaining after quinine removal.

- Totaquine: 7-12% anhydrous crystallizable alkaloids.

- The usual dose is 600 mg/day.



Quinine & its Diastereoisomer Quinidine:

- Isolated from Cinchona bark are effective schizonticidal agents, active against all

plasmodium species including Plasmodium falciparum, P. vivax, P. ovale & P. malaria.

- Quinine is slightly water soluble (1:1500), but soluble in alcohol & chloroform.

- It is dibasic, forming salts with acids (acid or bisalts), when both nitrogens are involved.

- Neutral quinine salts are formed by the nitrogen of quinuclidine moiety.

- Quinine sulfate is the most common salt, prepared by adding dilute sulfuric acid to the free base or the crude extract.

7-Chloro-4-Aminioquilolines



Pharmacokinetics of 7-Chloro-4-Aminoquinolines

- Chloroquine is readily absorbed from GIT, unlike amodiaquine.

- Peak plasma concentration is reached within 3 hr, falling off quickly after stop of administration.

- Half-life (t1/2) of chloroquine is 3 days from a single dose, & one week or more after 2-weeks daily doses.

- Mostly excreted unmetabolized in urine.

Toxicity:

- Quite low: nausea, vomiting anorexia, diarrhea, headache, dizziness, pruritus, urticaria.

- Long term, high doses: adverse effects on eyes.

Other Uses of 4-Aminoquinolines:

- Chlororquine& hydroxychlororquine are particularly useful against extra-intestinal

amebiasis & chronic discoid lupus erythematosus.

- Apparently, by suppression of antigens that may induce hypersensitivity reactions, which cause symptoms to develop.

- Their use in systemic lupus erythematosus & rheumatoid arthritis is questionable.

- A minimum of 4-5 weeks use is required for adequate response to collagen diseases.



Routes of Administration

- Orally as salts in tablet forms. If nausea

occurred, i.m. injection can be administered.

- To protect drugs from high humidity of tropical climate, usually tablets are coated with granules of cetyl & stearyl alcohols.

- Combined with chloroguanide or pyrimethamine for broader activity spectrum.

Chloroquine:

- Slightly soluble in water, soluble in organic solvents.

- Chloroquine phosphate (Resochin) is freely soluble in water.

Hydroxychloroquine Sulfate:

- Freely water soluble, producing a solution of pH 4.5.

- More preferred than chloroquine in treatment of collagen diseases because of its

lower toxicity.



Amodiaquine HCl:

- Slightly alcohol soluble but freely water soluble.

- The price is much higher than chloroquine because its synthesis is more expensive.

- 3-4 Times more active than quinine in suppressing P. falciparium& P. vivax infections,

but no curative activity except against P. falciparium.



Pharmacokinetics of 8-Aminoquinolines

- Rapidly absorbed from GIT, ~90% absorption within 2 hr after oral administration, peak plasma concentration within 2 hr.

- Rapidly metabolized (~99%) & urine-excreted, only 1% eliminated unchanged.

- Apparently, activity & toxicity are attributed to these metabolites.



Mechanism of Action:

- Not known yet.

- Primaquine affects the mitochondria of exoerythrocytic forms of avian forms of P.

falciparium but not affect DNA transcription or replication.

Toxicity:

- Mainly: CNS & blood toxicity.

- Occasionally anorexia, vomiting & cyanosis.

- Hemolyic anemia, leukopenia & methemoglobinemia.

- Genetic deficiency of G6PD weakens erytherocytes, making them more

susceptible for damage by 8-aminoquinolines.

- Hence, patient must be tested for G6PD deficiency before prescription of these

drugs.


- Toxicity increased by quinacrine, hence they should not be used concomitantly.

Routes of Administration & Uses:

- Orally, in tablet form, to prevent relapses caused by exoerythrocytic malaria forms.

- Primaquine is usually used as HCL or phosphate salts.

- Pamaquine is used as the methylene-bis-hydroxy-naphthoate (or pamoate) since this salt is of low solubility, which delay absorption, maintaining longer & uniform plasma level.



Primaquine Phosphate:

- Orange red crystals, water soluble.

- Best tolerated 8-aminoquinoline.

- Exoerythrocytic schizontocide, 4-6 times more active than pamaquine, with 1/2

toxicity.

- When 15 mg base/day used for 14 days, radical cure is achieved in most P. vivax

infections.

- For very resistant strains of P. vivax, 45 mg primaquine base once a week for 8

weeks, simultaneously with 300 mg chloroquine, are successfully used, with reduced

hemolytic toxicity of primaquine.



4-Quinolinemethanols

Mefloquine

- Approved by FDA in 1989.

- Drug of choice for malaria prophylaxis,

- 250 mg/week starting one week before entry to an endemic area & continue 4 weeks after departure

- Mefloquine has t1/2 10-24 days

- Effective in curing multidrug-resistant P. falciparium (1250 mg, single dose).

- Acts by interference with the transport of hemoglobin products from the host to the

parasite’s food vacuoles.

- Resistance to mefloquine has been reported.
9-Aminoacridines

- e.g., Quinacrine (mepacrine, Atabrine)

- rarely used now, widely used during the 1940’s

- Sparingly water-soluble, alcohol and organic solvents-insoluble

- Dihydrochloride salt should not be stored due to instability



Toxicity:

- CNS, headache, epileptiform convulsions, transient psychoses, nausea & vomiting.

- Hematopoietic disturbance, e.g., aplastic anemia.

- Skin reactions, hepatitis, death from exofoliative dermatitis.



Uses of Quinacrine:

- Erythrocytic schizontocide in all human malaria types. Moderately effective as gametocytocide in P. vivax& P. malaria.



Other Uses:

1. Alternative to quinine in black water fever.

2. Curative agent in giardiasis (caused by Giardia lamblia), intestinal cestodes, e.g., Taenia saginata (beef tapeworm) & T. solium (pork tapeworm) & Hymenolepis nana (dwarf tapeworm).

3. Treatment of light-sensitive dermatoses, e.g., discoid lupus erythematoses.





Tetrahydrofolate Synthesis Inhibitors:

- Malaria & mammalian dihydrofolate reductase (DHFR) are structurally different, hence, malaria DHFR is 2000 more sensitive to antimalarial sulfonamides.

- Usually reserved for resistant malaria strains to quinolines.

- Slow onset of action, given in combination with quinolines for acute attacks.



- Inhibition of C-1 donors will inhibit parasite’s essential biosynthetic pathways, especially the conversion of uridine to thymidine, which is needed for DNA synthesis.



Diaminopyrimidines:

- Discovered in 1940’s after observing the competitive inhibition of 2,4-diaminopyrimidines to FA utilization by Lactobacillus casei.

- 2,4-Diamino-5-phenoxypyrimidines show highest activity.



Maximum activity can be obtained by:

1. Presence of electron-donating groups at C-6 position of pyrimidines.

2. Chlorine atom present in para position of the phenyl ring .

- This is best represented in pyrimethamine.



Pyrimethamine (Daraprim):

- Effective erythrocytic & exoerythrocytic schizontocide against all human malaria types.

- Compete with pteridine moiety of FA, inhibiting utilization of folate by inhibiting

FH2-reductase.

- Absorbed slowly & completely from GIT, excreted metabolized in urine.

- A single weekly dose of 25 mg is enough for suppression.

- Relatively non-toxic but high doses may suppress cell growth by inhibiting FA activity.

Trimethoprim:

- 2,4-Diamino-5-(3,4,5-tri-methoxybenzyl) pyrimidine

- Marketed separate or in combination with sulfonamide (Bactrim, Septra, Septrin, etc.) as antibacterial agent.

- Mixed effectiveness for human malaria as it is not selective for protozoan FH2-reductase as pyrimethamine, hence usually used in combination with other antimalarial drugs.

- Has much shorter life-time (~24 hr), compared to pyrimethamine, which limited its use for malaria.

Biguanides& Dihydrotriazines:

- Biguanides are prodrugs that metabolically activated by liver microsomal enzymes

to the active metabolites, the dihydrotriazines, e.g., proguanil to cycloguanil.

- Dihydrotriazines (except cycloguanil pamoate) are metabolized quickly, which limits their use in humans.

- Cycloguanil pamoate is formulated as a depot i.m. injection to provide several months of antimalarial protection

SAR:

- para-Substituted halogen is essential for activity.

- If Br replaced Cl in proguanil, it is still very effective.

- Another Cl at position 3 of the proguanil phenyl ring enhances the activity, but also increases the toxicity.

Pharmacokinetics :

- Biguanides absorbed relatively quickly from GIT & concentrate in the liver, lung,

spleen & kidneys, but not cross the blood-brain barrier.

Toxicity:

- Mild, includes GI disturbances if taken on an empty stomach.

- Excessive doses (> 1g) may cause renal disorders,

e.g., hematuria & albuminuria.



Chloroguanide HCl (Paludrine):

- White crystalline powder, soluble in water & alcohol, stable in air but darken on exposure to light.


Cycloguanil Pamoate (Camolar):

- Acts on the formation of FH4, hence inhibiting the parasite’s DNA synthesis.

- Used for protection against all malaria types.

- Resistance develop quickly, which doesn’t improve by using combination of antimalarial drugs.



Toxicity:

- Injection site can be painful.


Sulfonamides:

- Competitively block the incorporation of PABA into the malaria protozoa FAH2.

- The azo dye Prontosil (prodrug of sulfanilamide) was first found active against malaria in 1930’s.

- Effective against erythrocytic stage, used in drug-resistant malaria strains.

- Active against P. falciparum, less active against P. vivax. P. malariae, or P. ovale.

- Medium or long-acting sulfonamides are used for malaria.

- More effective in combination with pyrimethamine or trimethoprim.

Antimalarial sulfonamides include:





Sulfones:

- Dapsone (4,4’-diaminodiphenyl-Sulfone), R= H, has been known for its antimalarial & anti-leprosy activity.



- Dapsone (DDS) considered an inferior antimalrial drug until its effective chemoprophylactic activity against chloroquine-resistant P. falciparium was discovered in Southeast Asia.

- The derivative N,N’-diacetyldapsone (DADDS, R = CH3CO) shows more prolonged activity & low toxicity, compared to dapsone.

- DADDS long-acting depot in combination with cycloguanil proved useful.




Phenanthrenes:

- Halofantrine



- Synthetic blood schizontocide drug.

- Mechanism: Unknown

- Cross resistance with mefloquine in P. falciparum infections.


- From the ancient Chinese herbal remedy: Sweet Annie: The above ground parts of

Artemisia annua, family Asteraceae, artemisinin, a prototype of a new class of

antimalarial was discovered.


Endoperoxides:

- Artemisinin (quinghaosu) & its semisynthetic derivatives artemether, arteether, artesunate, dihydroartemisinin, artelinate, & arteflene.

- Useful in high-risk malaria patients, including cerebral malaria.

- The endoperoxide moiety is necessary for anti-malarial activity, since analogs which lack this group are inactive.



Mechanism of Action:

- Since the parasite is rich in iron & heme, which catalyze the reductive cleavage of the

endoperoxide bridge, generating free radicals & other electrophilic intermediates, which act as alkylating agents for specific malaria proteins.

Toxicity:

- Very rare, some neurotoxicity in multidose study.



Study questions for next section: Antifungal Drugs

1. What are the difference between fungal & mammalian cell membranes?

2. Why azoles & allylamines are effective antifungal agents? How they selectively target fungal cells?

3. Why oral bioavailability of azoles is pH-dependent?

4. What are the antifungal drugs which ranked among the top 200 top drugs in terms of sale?
Anti-Fungals 1

Unlike plants & mammals, fungi contain no chlorophyll & their cell wall contains the polysaccharide chitin

(polymer of N-acetyl-glucosamine, NAG).

Dermatophytes obtain their nutrients by attacking the cross-linking structural protein keratin, which other

fungi cannot use as a food source.

Fungal infections are difficult to treat because:

1- Infections usually occur in poor vascularized areas, e.g., nails, hair, superficial skins.

2- Fungi grow relatively slow, hence it is difficult to target their cell division.

3- Most antifungal drugs are poorly water soluble.

Water solubility creates many problems.

During the past 20 years the incidence of systemic mycoses have sharply risen especially among

immunocompromised patients, e.g., organ & bone marrow transplant recipients, AIDS patients & patients

under chemotherapy regimen.

Antifungal Agents

Azoles – Ergosterol biosynthesis & biochemical targets of antifungal chemotherapy.

Ergosterol is a main component in fungal cell wall. Azoles inhibit ergosterol biosynthesis by targeting

cytochrome P450 enzymes, e.g., lanosterol 14a-demethylase. Lanosterol 14a-demethylase is a key enzyme

for ergosterols & cholesterol biosynthesis in fungi & mammals, respectively. Azoles also inhibit

cytochrome P450 oxidase , a significant enzyme in mammalian steroid biosynthesis. The 1,2,4-triazoles

are less toxic than imidazoles because of their lower affinity to mammalian cytochrome P450 enzymes.

Imidazoles - Fungicidal at high (mmolar) concentrations, causing damage of fungal cell

membrane & loss of essential cellular constituents, e.g., K+ & amino acids. Fungistatic at low

concentrations (nanomolar), causing inhibition of membrane-bound enzymes. The amidine N is believed to

bind the heme iron of enzyme-bound cytochrome P450, inhibiting activation of molecular oxygen &

preventing oxidation of steroid substrates.

Topical & Systemic – Ketoconazole - Only miconazole & ketoconazole are formulated

for systemic use. Broad spectrum systemic oral antifungal agent. Oral bioavailability of ketokonazole

depends on acidic pH for dissolution & absorption. Hence, antiacids, anticholinergic & H2-histamine

antagonists inhibit gastric secretion & interfere with the drug’s absorption. Inhibits cytochrome P450

enzymes (including lanosterol 14a-demethylase) in fungi & humans, which results in:

1- Inhibition of cholesterol biosynthesis: lowering the levels of testosterone & corticosterone

levels in humans.

2- Many possible drug-drug interactions, e.g., cyclosporine, phenytoin, terfenadine metabolism

will be inhibited & hence their plasma level will be increased. Inhibits cytochrome P450 enzymes

(including lanosterol 14a-demethylase) in fungi & humans, which results in:

a- Inhibition of cholesterol biosynthesis: lowering the levels of testosterone &

corticosterone levels in humans.

b- Many possible drug-drug interactions, e.g., cyclosporine, phenytoin, terfenadine

metabolism will be inhibited & hence their plasma level will be increased.

c- Enhances responses to sulfonyl urea hypoglycemic & coumarin anticoagulant drugs.

Ketoconazole activity is antagonized by amphotericin B.

Ketoconazole is used for systemic mycoses infections. The trans isomers (2R, 4R & 2S, 4S) are less active.

Imidazoles

Clotrimazole - Broad spectrum drug against tinea (e.g., T. pedis, T. cruris, T. versicolor) & candidiasis

infections. Used systemically as 100 & 500 mg tablets for vulvo-vaginal candidiasis.

Miconazole Nitrate - The free base is solubilized with ethylene glycol & castor oil & used as i.m. injection

for systemic mycoses, e.g., candidiasis, cryptococcosis, petriellidiosis, etc. Vaginal creams & suppositories

are also available for vaginal candidiasis.

Sulconazole Nitrate – Used for athlete’s foot, jock itch & ringworm.

Tioconazole - The best choice of azoles in cases of Torulopsis glabrata infections.



Triazoles

Terconazole - Exclusively used for the control of vulvo-vaginal moniliasis caused by Candida albicans &

other Candida species.

Itraconazole - Similar to ketoconazole, requires acidic environment for optimum solubilization & oral

absorption, hence antiacids, anticholinergic & H2-histamine antagonists interfere with the drug’s

absorption. Food greatly enhances itraconazole bioavailability, nearly to double. Unlike ketoconazole, it is

not hepatotoxic, doesn’t induce adrenal or testicular suppression, in therapeutic doses. It inhibits

cytochrome P450 oxidase, which metabolizes xenobiotics & antihistaminic drugs terfenadine & astemizole.



Bis-triazole

Fluconazole - usable orally & intravenously (2 mg/ in 1 ml isotonic NaCl or dextrose solution). Oral tablets

or suspension have excellent bioavailability, which does not affect by gastric pH or food. Doesn’t

interfere with corticosteroid or androgen biosynthesis in therapeutic doses. Used for treatment &

prophylaxis of disseminated & deep organ,e.g., oropharyngeal & esophageal candidiasis. Because it

penetrates cerebrospinal fluid, it is the drug of choice for cryptococcal & coccidioidal meningitis.



Allylamines & Others

Interfere with early stages of ergosterol biosynthesis by inhibiting epoxidation of squalene, catalyzed by

squalene epoxidase in fungi, which leads to accumulation of squalene, which damage the fungal cell

membrane. This effect is minimal on mammalian cells, hence no significant inhibition for mammalian

cholesterol biosynthesis.

Naftifine - for ringworm, jock itch & athlete’s foot. Used also for tinea infections. Also show some

potential against tinea barbae (ringworm of the beard), T. capitis (scalp ringworm) & T. versicolor (sun

fungus).


Terbenafine - Used as 1% cream against the same fungi as naftifine & considered more potent.

Tolnaftate - Not an allylamine, it is a thioester of b-naphthol, but acts by inhibiting squalene epoxidase.

Fungicidal against dermatophytes, e.g. Tricophyton, Microsporum & Epidermophyton species.

Antifungal Drugs in Top 200

Three antifungal drugs in the top 200 drugs in terms of sale:

1- Fluconazole (Diflucan)

2- Terbinafine (Lamisil)

3- Itraconazole (Sporanox)



Lecture 3

Anti-Fungals 2

Fatty Acids

All fatty acids have fungicidal activity. High molecular weight fatty acids and their salts have the advantage

of low volatility, hence appropriate for topical preparations.

Propionic acid & Zinc Propionate

Na & Zinc Caprylate - Natural product in coconut & palm oils. Na Caprylate is cream granules, soluble in

water and used topically for superficial Candida, Microsporum, Tricophyton & Epidermophyton.

Undecylenic Acid - Obtained by destructive distillation of castor oil.

Triacetin - Fungicidal effect is due to enzymatic hydrolysis by skin esterase to acetic acid. The rate of

acetic acid formation is self-limiting due to inactivation of esterase at pH of 4.

Phenols & Related Compounds

Phenols appear to interfere with cell membrane integrity & function in susceptible fungi.

Salicylic Acid

Haloprogin

Ciclopirox Olamine - It is the primary choice for T. corporis, T. cruris, T. pedis & T. versicolor. It is the

secondary agent for onychomycoses (nails ringworm).

Clioquinol - Also used as 3% ointment for T. vaginitis vaginal infections.

Nucleoside Analogs

Flucytosine - Flucytosine is not active or cytotoxic, but acts as a pro-drug, which is activated by fungal

cytosine deaminase to 5-fluorouracil (5-FU), which is cytotoxic & used in cancer chemotherapy.

5-FU is then converted to 5-fluorodeoxyuridine, which is thymidylate synthease inhibitor, interferes with

protein & RNA synthesis in fungi. Human cells do not contain cytosine deaminase, hence fluctosine is

selective to fungi.



Polyene Antifungal Antibiotics

Polyenes are either 26-membered ring, with tetraene system, e.g., natamycin or 38-membered ring, with

hexaene system, e.g., nystatin or heptaene, e.g., amphotericin B. Ployenes are active against many

pathogenic yeasts, molds & dermatophytes. They are also active against some protozoa, e.g., Leishmania.

Totally inactive against bacteria, rickettsia & viruses.

Mechanism of Action: Polyenes have affinity for sterol-containing membranes, insert into & disrupting

membrane functions, causing them to become leaky and cell dies from losing the essential constituents,

e.g., K+ & small organic molecules. The 26-membered ring polyenes, e.g. natamycin, cause K+ leakage &

cell lysis at low or high concentration, unlike the 38-membered ring polyenes, which cause K+ leakage at

low, fungistatic concentrations & cell lysis at high fungicidal concentrations.

Nystatine - indicated for local & GI monilial infections of Candida species. Indicated with tetracycline

therapy, to prevent monilial overgrowth caused by destruction of intestinal microbial flora.

Amphotericin B - Never indicated for intramuscular injection. Intravenous parenteral form is aqueous

colloidal dispersion, stabilized with Na deoxycholate. Formulations with liposomal encapsulation & lipid

complexes have dramatically decreased its toxicity. Amphotericin B will complex more easily with lipid

vehicle, it will also be more concentrated in lymphatic system, spleen, liver & lung, where invading fungi

tend to locate. Amphotericin B is parenterally used for serious, life-threatening fungal infections, e.g.,

disseminated coccidioidomycoses, histplasmosis, sporotrichosis, blastomycoses, cryptococcosis,

aspergillosis & mucormycoses. Nephrotoxicity occur in 80% of patients.

Natamycin - Used as 5% ophthalmic suspension for fungal conjunctivitis, blepharitis & keratitis.



Cell Mitosis Inhibitors

Griseofulvin - Used orally for refractory ringworm infections in nails, hair & feet caused by various

dermatophytes, e.g., Tricophyton & Epidermophyton. After oral absorption, griseofulvin is carried by the

systemic circulation to the skin, fingernails, hair, where it concentrates in keratin precursor cells, which

gradually exfoliate & replaced by new tissue. Its fungistatic action prevents further infections. It ultimately

incorporated into fungal keratin, which cannot then support fungal growth. Because the old tissue may

support fungal growth, treatment must continue until all of the infected tissue exfoliated. Hence, therapy

must continue for several months in slow growing tissues. Griseofulvin also acts by binding to the protein

tubulin, which interferes with the function of the mitotic spindle & thereby inhibits cell division. It also

interferes directly with DNA replication. Oral bioavailability is greatly enhanced by particle size reduction

(micro or ultramicro size forms) and by administration with fatty meals.

Protozoal Diseases

Amebiasis - E. histolytica. HIV infection, pregnancy, protein malnutrition or high carbohydrate intake may

encourage susceptibilty to amebiasis.



Giardiasis - Cause of water-borne diarrhea in The US, especially in campers who drink from contaminated

streams. It also spread between family members, children in day cares & dogs & their masters.



Trichomoniasis - Trichomonas vaginalis, exists only in trophozoite forms.

Drug Therapy For Protozoal Infections

Metronidazole - Initially used for T. vaginitis, Shows effective oral activity against both acute & carrier

states of amebiasis & giardiasis, & against anaerobic bacterial infections including Clostridium difficile.

Used for serious infections as septicemia, pneumonia, peritonitis, meningitis, etc. Used as alternative

therapy for Helicobacter pylori infections. Mechanism: Metronidazole acts as a prodrug. Anerobic

microbial reduction of the 5-nitro group in the drug results many reactive intermediates, e.g., nitroxide,

hydroxylamine, nitroso, & amine derivatives & superoxide radical anions, which covalently bind to

microorganism’s DNA. Side Effects: disulfiram-like effect if taken with alcohol. It is reported to be

carcinogenic in mice, possibly due to the metabolite acetamide, hence, it should not be used during

pregnancy’s first trimester.

Diloxanide Furoate - Hydrolysis of the ester is essential for activity. Used for treatment of asymptomatic

amebiasis, but not effective individually for extraintestinal forms. Hydroxyquinoline - The antibacterial &

antifungal activity of oxine is attributed to its ability to chelate metal ions. Used for acute & chronic

amebiasis. High incidience of causing topic neuropathy prohibited its use.

Emetine & Dehydroemetine

Direct amebecidal activity against all forms of E. histolytica. Inhibit protozoal & mammalian protein

synthesis by preventing protein elongation. High concentration in liver after i.m. injection provide high

effectiveness against hepatic abscess. Dehydroemetine (Mebadin), shows lower cardiac toxicity. Used also

for fascioliasis

Drug Therapy of Leishmaniasis

Sodium Stibogluconate - Pentavalent antimonial compound, first choice for leishmaniasis (along with

meglumine antimonite. Also used for treatment of schistosomiasis. Acts by inhibiting 86-94% of protozoal

glucose catabolism (glycolytic enzymes, e.g., phosphofructokinase), inhibiting ATP/GTP formation. Low

therapeutic index, careful blood level monitoring should be implemented to avoid heavy metal poisoning.

Pneumocytosis & Toxoplasmosis

Pneumocystis - The disease becomes active only in AIDS patients (80% contract this disease, 50%

recurrence rate) & immunocompromised patients, hence it is considered OI, causing severe pneumonia.



Toxoplasmosis - It is one of the prevalent AIDS-associated infections.

Dapsone + Trimethoprim

Sulfamethoxyazole-Trimethoprim - Used for prophylaxis & treatment of pneumocytosis & toxoplasmosis

in AIDS patients.

Pentamidine Isethionate - Administered for pneumocytosis as: injection: deep i.m. or slow i.v. Aerosol: for

inhalation in high risk AIDS patients who have previous history of pneumocytosis or low peripheral CD4

lymphocyte count. Pentamidine is also used for treatment & prophylaxis of African trypanosomiasis & in

treating visceral leishmaniasis.

Atovaquone - This structure similarity suggests that atovaquone is an ubiquinone 6 antimetabolite,

inhibiting mitochondrial respiratory chain. Atovaquone is recommended as alternative for cotrimazole in

AIDS patients with pneumocytosis. It is also effective against Toxoplasma gindii. High fat diet increase

atovaquone GI absorption. Significant stereospecificity: the trans isomer is much more active than the cis

isomer.


Trypanosomiasis

Trypanosomiasis (Chaga’s Disease and African Sleeping Sickness) - The sole energy source of the

protozoan is glycolysis, which explains the reason of hypoglycemia seen in infected individuals.

Eflornithine - Amino acid derivative, enzyme-activated inhibitor of ornithine decarboxylase (OD). OD is a

pyridoxal phosphate-requiring enzyme, which catalyze the rate-limiting step in biosynthesis of polyamines.

Polyamines are essential for DNA synthesis & cell proliferation in microorganisms & animal tissue. Used

for treating meningoencephalitis stage of T. brucii gambiense infections. Only (-)-isomer,

stereochemically-related to L-ornithine is active. CSF penetration facilitated by meninges.

Nifurtimox - The only effective drug against acute & chronic T. cruzi infections (SA trypanosomiasis).

Benznidazole - A nitroimidazole derivative used for Chagas’ disease. Adverse effects: peripheral

neuropathy, bone marrow depression & allergic-like reactions.

Melarsoprol - DOC for the latter stages of both African trypanosomiasis forms. Effectively penetrates CNS,

hence effective against both T. gambiense & T. rhodesiense mengioencephalititis. Bonding of As with S

decrease toxicity to host, improve drug distrubution & chemical stability.

Dimercaprol - Effective topical & systemic antidote for arsenic, antimony, mercury, gold & lead poisoning.

Used to treat As & Sb overdose & accidental ingestion. Heavy metals react with SH groups in proteins,

BAL compete effectively with such proteins for the metal by reversible forming metal ring complex.

Suramin Sodium – DOC for non-CNS associated African trypanosomiasis. Effective long-term

prophylactic agent, up to 3 months after a single i.v. injection. Mechanism: It also inhibits dihydrofolate

reductase & thymidine kinase. Inhibits protozoal glycolytic enzymes, blocking its energy sources.

Helminth Infections

Nematodes

1- Ascariasis

2- Hookworm

3- Pinworm

4- Whipworm - Trichuriasis

5- Trichinosis - Trichina Infection

6- Filariasis

Cestodes

1- Taenia saginata - Beef Tapeworm

2- Taenia solium - Pork Tapeworm, Bladder Worm

3- Hymenolepis nana - Dwarf Tapeworm

Trematodes

Schistosomiasis - Blood Flukes



Drug Therapy for Helminth Infection

Benzimidazoles

a- Inhibit helminths fumarate reductase, an enzyme which is essential for oxidation of NADH to

NAD, which uncouples worm’s oxidative phosphorylation & ATP production.

b- Binds the worm’s protein tubulin, preventing its polymerization to microtubules. Microtubule

capped from one end & continues to dissociate from the other end, resulting in the loss microtubule length.

This effect is minimal on mammals

Side Effects: Teratogenic in experimental animals, should never been used in the first trimester of

pregnancy.

Thiabendazole - Causes Steven-Johnson syndrome, crystalluria & potential hepatotoxic. Used for

enterobiasis, strongyloidiasis (threadworm), ascariasis, uncinariasis (hookworm infection), trichuriasis

(whipworm). Also used as drug of choice for cutaneous larva migrans (creeping eruption) & invasive phase

of trichinosis. Used now mainly for veterinary medicine due to its hepatotoxicity to humans.

Mebendazole - Broad-spectrum, against nematodes: whipworm, pinworm, roundworm, hookworm.

Irreversibly blocks glucose uptake in helminths, depleting parasite’s glycogen.

Albendazole - Nematodes: single-dose treatment for ascariasis, New & Old World’s hookworms &

trichuriasis.Multiple dose to eradicate pinworm, threadworm, capillariasis, clonorchiasis & hydatid disease.

Piperazine Citrate - Used for pinworm (oxyuris) & roundworm (ascaris) infections. Mechanism: Blocks the

worm response to acetylcholine, causing a flaccid paralysis of the worm, which then dislodged & expelled

in the feces.

Diethylcarbamazine Citrate - MOA - Inhibition of microtubule polymerization & disruption of performed

microtubule. Interference with arachadonic acid metabolism, suggested by the antiinflammatory activity of

the drug, blocking cyclooxygenase & leukotriene A4 synthase. Side effects: Generally mild, but under

some high load of microfilarial infection, the presence of dead microfilaria may trigger severe anaphylactic

reaction, known as the Mazzotti reaction. This includes: intense pruritus & ocular complications.

Ivermectin - wide variety of nematodes & arthropods: endo & ectoparasites in domestic animals. Also

effective for the treatment of onchocerciasis (river blindness) in human. It also destroys & inhibits the

release of the microfilariae, the immature form of the nematode that creates the skin & tissue nodules,

which can lead to blindness. MOA - Blocks interneuron-motor neuron transmission in nematodes by

stimulating the release of the inhibitory neurotransmitter g-aminobutyric acid (GABA).

Pyrantel Pamoate - Particularly useful for pinworms (oxyuris) & roundworms (ascaris). Its action

antagonizes the action of piperazine, hence they should not be used together.

Niclosamide - Used as a potent taeniacide, causing rapid disintegration of worm segments & the scolex.

Saline purge 1-2 hours after ingestion is indicated to remove damaged segments and to prevent possible

cysticercosis (release of live ova) in Taenia solium. The drug’s penetration into various cestodes is

facilitated by host’s digestive juices, since very little of the drug is absorbed by worms, in vitro.

Bithionol - has been removed from the market after several reports of contact photodermatitis.

Drug of choice for the liver fluke infection Fasciola hepatica & the lung fluke Paragonimus westermani.

Oxamniquine - Antischistosomal agent for S. mansoni (intestinal schistosomiasis). Acts by inhibiting the

worm’s DNA, RNA, & protein synthesis.

Praziquantel - Broad-spectrum drug effective against trematodes (flukes). DOC in schistosomiasis.

Effective also for: fasciolopsiasis (intestinal fluke), clonorchiasis (Chinese liver fluke), fascioliasis (sheep

liver fluke) & paragonimiasis (lung fluke). Acts by increasing cell membrane permeability of susceptible

worms, resulting in its loss of extracellular Ca, massive contractions & paralysis.

Anti-Mycobacterials

Drugs used to treat tuberculosis (M. tuberculosis), leprosy (M. leprae), & M. avium infections are grouped

together because they have similar therapeutic problems:

--prolonged therapeutic use with drug toxicity & microbial resistance.



M. tuberculosis contains a fatty waxy layer in its cell wall (mainly mycolic acid), that greatly increases its

resistance to environmental fluctuations In the lab, stain must be associated with heat to penetrate this

barrier. Once stained, the organism is able to resist decolorization, even when subjected to a 5% acidulated

alcohol solution. Hence, it is named acid-resistant or acid-fast.

HIV has increased the TB incidence by causing immuno-suppression, which enables latent infection to

clinically progress. Being airborne-transmitted, TB became uniquely serious as it now may spread to adults

& children who are not at AIDS risk. The coincidence of TB & AIDS epidemic resulted in drug-resistant

isolates of M. tuberculosis, which necessitates the search for new anti-TB drugs Combination therapy,

using 2 or more anti-TB drugs is well documented to reduce the emergence of resistant M. tube. strains

Leprosy is spread by multiple skin contacts & droplets from the upper respiratory tracts. Incubation period

is 3-6 years, making its identification very difficult.

M. avium & M. intracellularae (MAC) are an opportunistic infection tremendously disseminates in AIDS

& immunocompromised patients, causing high morbidity & mortality rates.

In 1982, 27 cases of M. cheloni were identified in patients undergoing hemodialysis in a Louisiana hospital.

The source was found to be the water used in processing the dialyzers.



First-Line Anti-Mycobacterial Drugs

Isoniazid - Preparation: Heating isonicotinic acid or its ethyl ester with anhydrous hydrazine. Mechanism:

Inhibits the synthesis of mycolic acids, high molecular weight branched b-hydroxy fatty acids, essential for

mycobacterial cell wall synthesis. Toxicity: Low, although used for long term, mainly peripheral neuritis

(which is prevented by pyridoxine coadministration), GI disturbances & hepatotoxicity. Hepatitis occurs in

2% in ages >50, & rarely occurs in ages <35.

Pyrazinamide - Inactive against metabolically inactive Mycobacterium, it is not used for long-term therapy.

Potential hepatotoxicity also prohibits its long-term use. Mechanism: Not well known, despite it is related

to INH, it does not inhibit mycobacterial mycolic acid biosynthesis. Pyrazinamide & its metabolites

interfere with uric acid excretion, hence it should be used with caution in patients with gout or

hyperuricemia.

Ethambutol - The (+)-enantiomer is 16-times as active as the meso form. Effective against INH or

streptomycin-resistant TB. But active only against dividing mycobacteria, no effect on encapsulated or

non-proliferating forms. Mechanism: Inhibition of the incorporation of mycolic acids in bacterial cell wall,

or RNA synthesis.

Rifamycins - Mechanism: Selective binding to the b-subunit of bacterial DNA-dependent RNA

polymerase, preventing chain initiation. No inhibitory activity on mammalian enzymes. Inhibit virus

replication by prevention of specific polypeptide conversion.

Rifmapin - interferes with liver function, should not be used with other potential hepatotoxic drugs nor used

in patients with impaired hepatic function, e.g., alcoholism. Rifampin induces hepatic cytochrome P450

oxygenases, which may potentiate the actions of drugs which are metabolized by this enzyme, e.g.,

barbiturates, anti-coagulants, benzodiazepines, oral hypoglycemics, theophylline, phenytoin. Rifampin

should be administered on an empty stomach as food markedly impairs its oral absorption.

Rifabutin - approved in 1992 for treatment & prophylaxis of disseminated MAC &

other atypical mycobacterial infections in AIDS patients. It considered inferior to rifampin for the shortterm

therapy of TB, because of its very low plasma concentrations.

Streptomycin - The undesirable side effects, especially nephrotoxicity & ototoxicity

restrict its systemic use for serious infections that are resistant to other drugs. Mechanism: Targets the

bacterial ribosome subunit 30S, which inhibits the initiation of protein synthesis & interferes with the

fidelity of translation of genetic message.



Second-Line Anti-Mycobacterial Drugs

Kanamycin

Capreomycin - Potentially toxic: damage the 8th cranial nerve & renal toxic

Ethionamide - weak in vitro bacteriostatic, but effective in vivo activity due to its high lipophilic nature.

Due to its low potency, the maximum tolerated dose of ehionamide is usually used.

Aminosalicylic Acid (PAS) - Mechanism of action is similar to sulfonamides: inhibits the incorporation of



p-aminobenzoic acid (PABA) into the dihydrofolic acid molecule catalyzed by the enzyme dihydrofolate

synthetase. Toxicity: GI irritation, hence it is formulated as a Ca salt or phenyl ester & used with an

antacids, e.g., Al(OH)3 or with anion exchange resin (Rezi-PAS).

Cycloserine - L-Isomer has a similar antibiotic activity. Mechanism: Prevents the synthesis of cross-linking

peptide during the bacterial cell wall formation. It is only recommended for patients who fail to respond to

other drugs or seem to be infected by resistant strains.



Drugs Treating M. leprae

Dapsone - Preparation: Benzene is condensed with H2SO4 to yield phenyl sulfone [(C6H5)2SO2], which

then nitrated & reduced by tin/HCl. The antibacterial activity & mechanism of action are similar to those of

sulfonamides. Synergistic with trimethoprim in treating Pneumocystis carinii pneumonia. Toxicity:

Hemolytic anemia in glucose-6-phosphate dehydrogenase deficient persons.

Clofazimine - Has antiinflammatory & immunomodulatory activities, which help in controlling neuritic



complications & erythema nodosum leprosum reactions associated with lepromatous leprosy.


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