Antimalarial Drug Resistance

Jeanne Rini Poespoprodjo

Management of Malaria Training –
Timika, 25-28 March 2019
 Concept
• Parasites exposure to sub-therapeutic level of
antimalarial drug in the blood.

White, N.J, 2004; J Clin Invest 113, 1084-1092

 Uninterupted Infections

• Each infections can consist of 2-3 asexual

cycles, each cycle takes 48 hours (2 days)

Day 0 1 2 3 4 5 6 7-20 days

Infected Gametocytes
 Parasite Multiplication Rate
• Median number of viable merozoites liberated
by rupturing schizonts

• Efficiency > 50% in non immune patient: PMR

about 10 per asexual cycle
 Parasite Reduction Ratio
Antimalarial drug with Parasite Reduction Ratio
(PRR): 10-1 to 10-4 per cycle

Example:
Total number of P. falciparum parasites in the
body: 1012
Treated with antimalarial drug with PRR 10-4:
1,000,000,000,000 parasite biomass will be
reduced 99% in 48 hours
 Parasite Multiplication Rate
(PMR):
Jumlah merozoite yang viabel
yang diproduksi oleh Schizont

Parasite Reduction Ratio (PRR):

Laju kecepatan obat antimalaria
mengurangi jumlah parasit
dalam satu siklus aseksual

White, N.J, 2004; J Clin Invest 113, 1084-1092

Time Required to Clear Parasites

Adult with 2% parasitaemia: total number of parasites 1012

Dose Response Curve

White, N.J, 2004; J Clin Invest 113, 1084-1092

Increasing drug resistance: shift to the right

Slowly Eliminated Antimalarial Drug
Drug Concentration
• A: Artesunate
• Q: Quinine
• P: Pyrimethamine
• C: Chloroquine
• M: Mefloquine
De Novo Selection in High
Transmission Areas

White, N.J, 2004; J Clin Invest 113, 1084-1092

 De Novo Selection of Resistance
• Genetic mutations of the parasites
• Exposure of large numbers of parasites with
sub therapeutic antimalarial drug
concentration
 Probability of selection of de novo
antimalarial drug resistance

• Resistance mechanism frequency

• Fitness cost of the parasites with resistance
mechanism
• The number of parasites in the human host
exposed to the drug
• The concentration of the drug
(pharmacokinetic)
• Pharmacodynamics of the drug
• The degree of resistance (the shift of the
concentration effect relationship)
• The level of host defense
• The simultaneous presence of other
antimalarial drug that will still kill the parasites
if it develops resistance to other drug
De Novo Selection of Resistance
Presence of Antimalarial
Parasites + Drug

Non Immune:
symptomatic
Drug
High
Concentration
Parasitaemia

Immune:
Symptomatic Parasite
with higher Reduction
parasitaemia Ratio
De Novo Selection of Resistance
High
Parasitaemia
Some Parasite
Resistance
mutation

Inadequate Slow drug

Low Parasite
drug elimination:
Reduction
concentration Long duration
Ratio
of exposure
 Spread of Resistance

Ineffective
High
parasite
Parasitaemia
killing drug

Mutant
Parasites
Multiplicate
Gametocytes

Transmission
Why Parasite Develop Resistance?
• Poor treatment practices
• Inadequate patient adherence to prescribed
antimalarial regimens
• Widespread availability of oral artemisinin-
based monotherapies and substandard forms
of the drug
 Chloroquine and Sulfadoxine-
pyrimethamine Resistant Parasites
 Pf: CQ and SP efficacy in Indonesia, 1998-2003
Riau, 2003
CQ 27% ACR
Armopa Region, 1999
SP 88% ACR
Minahasa, 2003 CQ 30% ACR
CQ 28% ACR SP 37% ACR
Bangka, 2003 SP 41% ACR
SP 89% ACR

Nias Island, 1998

SP 17% ACR

Padang Cermin, 2003

Jayapura District, 1999
CQ 19% ACR
Alor Island, 2003 CQ 17% ACR
SP 79% ACR
CQ 31% ACR SP 79% ACR
SP 92% ACR CQ+SP 62% ACR
Puworejo, 2003
SP 87% ACR

Source: MoH, Republic of Indonesia

Multi-drug resistance in P. falciparum
and P. vivax
 Papua is the Epicentre of Chloroquine-Resistant P. vivax

1999
Red stars = >10% recurrence (and greater than 5 absolute failures) by day 28 with or without chloroquine levels; orange
diamonds = <10% recurrence (or less than 5 absolute failures) by day 28, with chloroquine levels; yellow circles = <10%
recurrence (or less than 5 absolute failures) by day 28, without chloroquine levels.
 Papua is the Epicentre of Chloroquine-Resistant P. vivax

2009
Red stars = >10% recurrence (and greater than 5 absolute failures) by day 28 with or without chloroquine levels; orange
diamonds = <10% recurrence (or less than 5 absolute failures) by day 28, with chloroquine levels; yellow circles = <10%
recurrence (or less than 5 absolute failures) by day 28, without chloroquine levels.
P. vivax causes severe and fatal disease,
especially in infants
Severe Anaemia is Particularly Common

11
10
9
8
7

0 5 10 15 20 25 30 35 40
Age (years)
Negative (95% CI) P. vivax (95% CI) P. falciparum (95% CI) Mixed (95% CI)
The Artemisinin Combination Therapy –
Dihydroartemisinin-Piperaquine – was better than
all other Drugs for both P. falciparum and P. vivax in
Randomised Trials
In 2005, 60% of People Sought Malaria
Treatment in Informal Sector

Fever
Prevention of Resistance
 Aim of ACT
Improved antimalarial activity
Reduction in gametocyte carriage
Mutual protection from the emergence of resistance

TOTAL PARASITES The ACT rationale Parasite Reduction Ratio of

1012
m Artemisinin Derivatives
1010 Drug level
Detection limit 104  99.99% reduction over
108
n 48 hours
106 x
A
104 y

102
Goal: To reduce the residual
B B1
0
parasite biomass exposed to the
0 1 2 3 4 partner drug to as low as
WEEKS
possible (small triangle B).
 Why 3 day ACT?
• Improved antimalarial activity
• Reduction in gametocyte
3 day Artesunate and Mefloquine carriage
• Mutual protection from the
emergence of resistance

Nosten, F et al. Am J Trop Med Hyg. 2007;77(suppl 6):181-92

 3 Day ACT covers 2 asexual cycles

Each infections can consist of 2-3 asexual cycles,

each cycle takes 48 hours (2 days)

Day 0 1 2 3 4 5 6 7-20 days

Infected Gametocytes
Number of parasites remaining after artesunate therapy
for removal by the partner drug (starting from 1%
parasitaemia = 40,000 µl-1 = Total 1012 parasites)

Number of days of Total Parasites Blood Smear

Artesunate Remaining µL -1
Administered
1day 10 9 400
2 day 10 7 4
3 day 10 5 Negative

1 day ACT is 10,000 fold more likely to harbour a resistant

isolate compared to a three day ACT (for an equivalent
compound)

Potency of artemisinin is considerably less

Artesunate and DHA > Artemether > Artemisinin
Dihydroartemisinin-Piperaquine

• Dihydroartemisinin:
– short half life (30 minutes) and high PRR (10-4)

• Piperaquine:
– long half life (28 days) and low PRR (10-1-10-2)

Timika,2
015
• ACPR day 42 (PCR Corrected)
– P. falciparum : 100% (95%CI, 90.1-100) – 35/35
– P. vivax : 91.7% (95%CI, 64.6-98.5) – 11/12
• Day 3 positive proportion: 0%
New Eng J Med 371;5 31 July 2014

Artemisinin Resistance
Parasite clearance half life > 5 hours
with some Pf isolates has Kelch13 polymorphism

Prolonged Parasite Clearance Time

Median Parasite clearance half lives: 1.9 – 7 hours
The stages of P. falciparum:
Fig 1 Normal red cell

Figs. 2-18: Trophozoites (among these,

Figs. 2-10 correspond to ring-stage
trophozoites)

Figs. 19-26: Schizonts (Fig. 26 is a

ruptured schizont);

Figs. 27, 28: Mature macrogametocytes

(female)

Figs. 29, 30: Mature microgametocytes

(male
Artemisinin resistance against
the ring stage only (2-10):
Partial Resistance
Artemisinin Resistance: definition
• suspected artemisinin resistance:
– high prevalence of the delayed parasite clearance
phenotype, OR
– high prevalence of K13 mutants

• confirmed artemisinin resistance: delayed

parasite clearance AND K13 resistance-
associated mutations in a single patient

WHO, 2015
 Figure 2. Therapeutic efficacy studies of Artemisinin Combination Therapy in Indonesia (2005-2010) and proposed sentinel sites

AAQ for Pf malaria (2005)

DHP for Pf and Pv malaria (2010)
(2010)
AL for Pf malaria (2007) DHP for Pf malaria (2010)

DHP vs AN for Pf and Pv malaria (2007)

AAQ for Pf malaria (2005)

DHP vs AAQ for Pf and Pv malaria (2005)

Notes on the boxes:
DHP vs AL for Pf and Pv malaria (2005)
· solid margins: published randomized clinical
trials
AAQ vs SP for Pf malaria (2005)
· dashed margins: published efficacy studies
· shades: unpublished efficacy studies!
AL for Pf malaria (2004)
Proposed sentinel sites
AAQ for Pf malaria (2005)
DHP=dihydroartemisinin-piperaquine; AAQ=artesunate-
!
amodiaquine; AL=artemether-lumefantrine;
AN=artemisinin-naphtoquine; SP=sulphadoxine-
pyrimethamine; Pf=P. falciparum; Pv=P. vivax

! Randomized Trials: 5 19!

Non Comparative studies: 7

 P. falciparum Infections
!
In vivo ACT efficacy studies for P. falciparum malaria (2005-2010)

DHP ACPR 98.3% AAQ ACPR 89% (2005)

and 98.6% (2010)
DHP ACPR 98.3%
AL ACPR 100% (2007) and 98.6% (2010)

DHP ACPR 96.3%

AN ACPR 93.7% (2007)

AAQ clearance time 40.5 hrs

(2005)

DHP ACPR 95.2%

AAQ ACPR 84% (2005)

DHP ACPR 95.9%

AAQ ACPR 80.8% (2005) AL ACPR 95.3% (2005)
!
! AL ACPR 100% (2004)
!
! AAQ ACPR 98% (12% still
! parasitaemia on day 3) (2005)
!
 P. vivax infections
In vivo ACT efficacy studies for P. vivax malaria (2005-2010)!

DHP ACPR 91.7% (2010)

DHP ACPR 91.7% (2010)

DHP ACPR: 96.3%

AN ACPR 93.7%
(2007)

DHP ACPR 84%

AAQ ACPR 52% (2005)

DHP ACPR 86%

AL ACPR 43% (2005)
 Monitoring the efficacy of
dihydroartemisinin-piperaquine (DHP) for
the treatment of uncomplicated Falciparum
and Vivax malaria
After 9 years of deployment

Timika Site
Papua - Indonesia
 Introduction
• Monitoring and evaluation of DHP efficacy
after 9 years of deployment in Timika, Papua,
Indonesia
• Site: Community Health Centre Timika
• Sample size: Total of 200
– P. falciparum : 100
– P. vivax : 100
 Objectives
• Clinical and parasitological evaluation on day
42 following treatment with DHP
• Evaluation of the proportion of parasitemia on
day 3 of treatment with DHP (delayed parasite
clearance): early sign of possible artemisinin
resistance
• Evaluation of adverse reactions or adverse
effect
 DHP Dosing
National Guidelines (2013)
Dihydroartemisinin-piperaquine (40 mg dihydroartemisinin and 320 mg piperaquine):
2.25 and 18 mg/kg per dose of dihydroartemisinin and piperaquine, once daily for 3
days.
Day 28 in Pv malaria: Primaquine 0.5 mg/kgBW once daily for 14 days
 Study Profile – Timika Site
March 2015- March 2016
979 malaria cases 306 Screened
• Pf 482
• Pv 451
261 Eligible
• Mix PfPv 26

130 Enrolled

61 P. falciparum 69 P. vivax

3 WoC 2 WoC
11 LFU 6 LFU
4 others 4 others

43 Completed Follow up 57 Completed Follow up

Patient’s Characteristic at baseline
P. falciparum P. vivax
 Results
Per Protocol Analysis
• ACPR day 42:
– P. falciparum : 95.3% (95%CI, 84.2-99.4) – 41/43
– P. vivax : 96.5% (95%CI, 87.9-99.6) – 55/57
• ACPR day 42 (PCR Corrected)
– P. falciparum : 97.6% (95%CI, 87.4-99.9) – 42/43
– P. vivax : 100% (95%CI, 93.5-100) – 57/57
• Day 3 positive proportion: 0%
• Late parasitological failure (PCR corrected): 1
Pf case with similar genotype at day 35
 Summary
• DHP is still effective for the treatment of
falciparum dan vivax malaria
• No evidence of possible artemisinin resistance
Terimakasih
 Acknowledgements
Timika Research Facility Eijkman Institute
Enny Kenangalem Universitas Gadjah Mada Rintis Noviyanti
Frans Thio Yati Soenarto Leily Trianty
Daniel Lampah Yodi Mahendradhata Din Syafruddin
Ferryanto Chalfein Ratni Indrawanti
Pemda Kab Mimika
Prayoga
Maurits Okoseray
Frans Wabisar
Erens Meokbun
Natalia
Munik Indonesian MOH
Menzies
Asik Surya
Nicholas Anstey
LPMAK Minerva Theodora
Ric Price
Firdy Permana Iriani Samad
Jutta Marfurt
Yusuf Nugroho

WHO
Anand Joshi
Dewi REGISTRATION FORM
12th International Training Course
on Management of Malaria
15 - 19 September, 2014