Increased primaquine total dose prevents Plasmodium vivax relapses in patients with impaired CYP2D6 activity: report of three cases.

BACKGROUND: The relapsing nature of Plasmodium vivax infection is a major barrier to its control and elimination. Factors such as adequate dosing, adherence, drug quality, and pharmacogenetics can impact the effectiveness of radical cure of P. vivax and need to be adequately evaluated. CYP2D6 pathway mediates the activation of primaquine (primaquine) into an active metabolite(s) in hepatocytes, and impaired activity has been linked to a higher risk of relapse. CASES PRESENTATION: Three patients diagnosed with P. vivax malaria presented repeated relapses after being initially treated with chloroquine (25 mg/kg) and primaquine (3.5 mg/kg in 14 days) at a non-endemic travel clinic. Recurring episodes were subsequently treated with a higher dose of primaquine (7 mg/kg in 14 days), which prevented further relapses in two patients. However, one patient still presented two episodes after a higher primaquine dose and was prescribed 300 mg of chloroquine weekly to prevent further episodes. Impaired CYP2D6 function was observed in all of them. CONCLUSION: Lack of response to primaquine was associated with impaired CYP2D6 activity in three patients presenting multiple relapses followed in a non-endemic setting. Higher primaquine dosage was safe and effectively prevented relapses in two patients and should be further investigated as an option in Latin America. It is crucial to investigate the factors associated with unsuccessful radical cures and alternative therapeutic options.

Novel Insights into Plasmodium vivax Therapeutic Failure: CYP2D6 Activity and Time of Exposure to Malaria Modulate the Risk of Recurrence.

Plasmodium vivax relapse is one of the major causes of sustained global malaria transmission. Primaquine (PQ) is the only commercial drug available to prevent relapses, and its efficacy is dependent on metabolic activation by cytochrome P450 2D6 (CYP2D6). Impaired CYP2D6 function, caused by allelic polymorphisms, leads to the therapeutic failure of PQ as a radical cure for P. vivax malaria. Here, we hypothesized that the host immune response to malaria parasites modulates susceptibility to P. vivax recurrences in association with CYP2D6 activity. We performed a 10-year retrospective study by genotyping CYP2D6 polymorphisms in 261 malaria-exposed individuals from the Brazilian Amazon. The immune responses against a panel of P. vivax blood-stage antigens were evaluated by serological assays. We confirmed our previous findings, which indicated an association between impaired CYP2D6 activity and a higher risk of multiple episodes of P. vivax recurrence (risk ratio, 1.75; 95% confidence interval [CI], 1.2 to 2.6; P = 0.0035). An important finding was a reduction of 3% in the risk of recurrence (risk ratio, 0.97; 95% CI, 0.96 to 0.98; P < 0.0001) per year of malaria exposure, which was observed for individuals with both reduced and normal CYP2D6 activity. Accordingly, subjects with long-term malaria exposure and persistent antibody responses to various antigens showed fewer episodes of malaria recurrence. Our findings have direct implications for malaria control, since it was shown that nonimmune individuals who do not respond adequately to treatment due to reduced CYP2D6 activity may present a significant challenge for sustainable progress toward P. vivax malaria elimination.

Pharmacokinetics/pharmacodynamics of chloroquine and artemisinin-based combination therapy with primaquine.

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/ ).

Correction: Variation in Human Cytochrome P-450 Drug-Metabolism Genes: A Gateway to the Understanding of Plasmodium vivax Relapses.

[This corrects the article DOI: 10.1371/journal.pone.0160172.].

Variation in Human Cytochrome P-450 Drug-Metabolism Genes: A Gateway to the Understanding of Plasmodium vivax Relapses.

Although Plasmodium vivax relapses are classically associated with hypnozoite activation, it has been proposed that a proportion of these cases are due to primaquine (PQ) treatment failure caused by polymorphisms in cytochrome P-450 2D6 (CYP2D6). Here, we present evidence that CYP2D6 polymorphisms are implicated in PQ failure, which was reinforced by findings in genetically similar parasites, and may explain a number of vivax relapses. Using a computational approach, these polymorphisms were predicted to affect the activity of CYP2D6 through changes in the structural stability that could lead to disruption of the PQ-enzyme interactions. Furthermore, because PQ is co-administered with chloroquine (CQ), we investigated whether CQ-impaired metabolism by cytochrome P-450 2C8 (CYP2C8) could also contribute to vivax recurrences. Our results show that CYP2C8-mutated patients frequently relapsed early (<42 days) and had a higher proportion of genetically similar parasites, suggesting the possibility of recrudescence due to CQ therapeutic failure. These results highlight the importance of pharmacogenetic studies as a tool to monitor the efficacy of antimalarial therapy.

Recorrências na malária por Plasmodium vivax: variabilidade na enzima do complexo citocromo P450 2D6 (CYP2D6) e sua influência na falha terapêutica por primaquina

Plasmodium vivax representa um grande desafio para a eliminação da malária devido à sua capacidade de causar infecções recorrentes, a partir da reativação de parasitos latentes no fígado, os hipnozoítos. A primaquina (PQ) é o único medicamento antimalárico aprovado com efeito hipnozoiticida e sua eficácia depende da ativação metabólica pela enzima do complexo citocromo P450 2D6 (CYP2D6). Estudos recentes sugerem que a função reduzida de CYP2D6, causada por polimorfismos na enzima, leva à falha terapêutica da PQ, comumente administrada com a cloroquina, no tratamento para cura radical da malária por P. vivax. Aqui, analisamos as implicações da variabilidade genética do gene CYP2D6 nas falhas terapêuticas por PQ na comunidade de Rio Pardo, área de transmissão instável de malária no estado do Amazonas. Na área de estudo, as recorrências de P. vivax foram responsáveis por aproximadamente 18% dos casos clínicos relatados anualmente (2003 e 2013). A prevalência de indivíduos com atividade reduzida de CYP2D6 (fenótipos gPM, gIM e gNM-S) foi de 25,4% (64/252 indivíduos). Para avaliar a associação entre CYP2D6 e o número de recorrências na malária por P. vivax, um modelo de Regressão Binomial Negativo foi ajustado para local e tempo de residência na área endêmica de malária. Um achado importante foi que indivíduos com níveis reduzidos de atividade de CYP2D6 apresentaram o dobro do risco de recorrência em comparação a indivíduos com enzima funcional (gNM-S e gUM) (Razão de risco = 1,75, IC 95% 1,2 ­ 2,6; P = 0,003). O risco de recorrência também foi maior para indivíduos que vivem em áreas ribeirinhas, às margens do rio que atravessa a comunidade (Razão de risco = 2,68, IC 95% 1,9-2,8; P < 0,0001). No entanto, indivíduos que viviam por mais tempo na região amazônica apresentaram um menor risco de recorrência da infecção por P. vivax (Razão de risco 0,97, IC 95% 0,96 ­ 0,98; P < 0,0001). Quando analisado a influência da atividade reduzida da enzima no tempo de recorrência, o fenótipo de CYP2D6 não influenciou o intervalo entre o episódio inicial e a recorrência (P = 0,357, Teste de Log-rank). Em conjunto, nossos achados têm implicações diretas para o controle da malária, uma vez que foi demonstrado que 25% dos indivíduos, em área de transmissão instável de malária, podem não responder adequadamente ao tratamento com PQ-CQ devido à redução da atividade de CYP2D6. Além disso, sugerimos que: a resposta imune individual e a exposição à transmissão da malária modulam e influenciam a susceptibilidade a recorrências por P. vivax, em pacientes com atividade reduzida da enzima. Essa associação pode ser válida como resultado para a otimização do uso de antimaláricos, sugerindo a terapia individualizada, com ajuste da dosagem de PQ e acompanhamento do paciente, como alternativa eficaz para o controle e eliminação dos hipnozoítos de P. vivax.