Orientador: Prof. Dr. Fabio Furlan Ferreira / Tese (doutorado) - Universidade Federal do ABC, Programa de Pós-Graduação em Nanociências e Materiais Avançados, 2017. / A malária, apesar de ser uma doença tratável, ainda continua causando um grande número de mortes, principalmente no continente africano, sendo considerada uma das doenças parasitárias mais prevalecentes no mundo. A recomendação da organização mundial da saúde (OMS) para o tratamento da malária consiste na utilização de terapia combinada de artemisinina (artemisinin combined therapy - ACT). A ACT visa combinar a artemisinina ou um derivado com outro fármaco antimalárico que tenha um maior tempo de meia-vida e, assim, tornar o tratamento mais eficaz e evitar o aparecimento de resistência dos parasitas aos antimaláricos. O MEFAS é um novo sal híbrido derivado do artesunato e da mefloquina ¿ dois compostos antimaláricos ¿ que apresenta dois mecanismos de ação diferentes e promissoras características que viabiliza a sua utilização no tratamento da malária. Neste contexto, foi realizado um estudo estrutural do MEFAS em estado sólido e foi proposta uma síntese mecanoquímica para sua obtenção. Com o uso da difração de raios X por policristais (DRXP) foi verificado que uma das amostras de MEFAS estudadas, apresenta uma fase amorfa. A estabilidade química do MEFAS também foi estudada, visto que fases amorfas tendem a ser instáveis; os resultados mostraram que o MEFAS se degradou após dezoito meses de armazenamento, formando a diidroartemisinina (DHA). Isto foi evidenciado com o uso das técnicas de espectroscopia vibracional na região do infravermelho por transformada de Fourier (FTIR), ressonância magnética nuclear de estado sólido (RMN) e também pelos dados de DRXP e método de Rietveld. A estabilidade química do MEFAS em solventes orgânicos também foi estudada. Para os solventes testados, o MEFAS demonstrou ser estável quimicamente apenas em éter etílico. Por fim, uma rota de síntese via mecanoquímica é proposta para a obtenção do MEFAS, com a possibilidade de utilização de pequenas quantidades de solventes. Essa é uma boa estratégia, pois é uma rota de síntese mais rápida, comparada com a obtenção do MEFAS via reação química em solução, e ainda é uma síntese considerada "química verde", ou seja, um método sustentável. Os resultados obtidos pelas técnicas de FTIR e RMN indicaram que a síntese mecanoquímica foi promissora na formação do MEFAS, sendo que após quinze minutos de moagem foi obtido o sal hibrido desejado. / Malaria, despite being a treatable disease, still continues to cause a large number of deaths, especially on the African continent, and is considered one of the most prevalent parasitic diseases in the world. The recommendation of the World Health Organization (WHO) for the treatment of malaria is the use of artemisinin combination therapy ¿ ACT. ACT aims to combine artemisinin or derivative with another antimalarial drug that has a longer half-life and thus make treatment more effective and prevent the emergence of parasite resistance to antimalarials. The MEFAS, a new hybrid salt derived from artesunate and mefloquine ¿ two antimalarials compounds ¿ has two different mechanisms of action and presents promising characteristics that make its use feasible in the treatment of malaria. In this context, a structural study of MEFAS in solid state was performed and a mechanochemical synthesis was proposed to obtain this hybrid salt. With the use of X-ray powder diffraction data (XRPD) it was verified that the MEFAS is in the amorphous form. The chemical stability of MEFAS has also been studied, since that the amorphous phases tend to be unstable; the results showed that MEFAS degraded after eighteen months of storage. When degradation of this hybrid salt occurs, dihydroartemisinin (DHA) is formed. This was evidenced by Fourier transform infrared (FTIR) spectroscopy, nuclear magnetic resonance (NMR) as well as by the Rietveld method with X-ray powder diffraction data. Finally, a route of synthesis via mechanochemistry is proposed to obtain the MEFAS, with the possibility of using catalytic amounts of solvents. This is a good strategy and is still a synthesis considered "green chemistry", that is, a more ecologically correct method. The results obtained by FTIR and NMR techniques indicated that the mechanochemical synthesis was promising in the formation of MEFAS, after fifteen minutes of milling the desired hybrid salt was obtained.

A modernização dos equipamentos de granulação por via úmida permitiu o desenvolvimento de diversas técnicas a partir do método tradicional. Dentre as técnicas desenvolvidas, a granulação por solidificação de materiais fundidos (GSMF) elimina o uso de solventes e diminui o tempo de processo. O presente trabalho teve por objetivo estudar o processo de granulação por solidificação de materiais fundidos usando um misturador/granulador do tipo high-shear (HSMG) e avaliar a influência das variáveis do processo nas características farmacotécnicas dos granulados e comprimidos obtidos. O artesunato foi escolhido para realização do estudo de granulação devido ao seu alto grau de cristalinidade e instabilidade química. Foi realizado um estudo de compatibilidade fármaco-excipiente usando técnicas de DSC, FTIR associada a técnicas estatísticas multivariadas (PCA e HCA) e cromatografia líquida de alta eficiência. Os parâmetros de HSMG estudados foram o tipo de diluente, a quantidade de PEG 6000 adicionada, o tempo de massificação, a velocidade do misturador e a velocidade do chopper, usando um planejamento experimental fatorial fracionário 25-1. Os granulados obtidos foram avaliados quanto a densidade, propriedades de fluxo e distribuição granulométrica. Os granulados de manitol apresentaram teor de umidade <1% e span de 1,690. Aqueles com lactose apresentaram teor de umidade > 2% e span de 2,814. A velocidade do misturador e do chopper não apresentaram efeitos significativos nas características dos granulados. O manitol foi escolhido como diluente para o artesunato que foi granulado com misturador a 100 rpm e chopper em 1000 rpm seguindo planejamento experimental fatorial completo 32 em duplicata para estudar variáveis de formulação: a razão artesunato/manitol e a quantidade de PEG 6000 adicionada. A quantidade PEG 6000 adicionada aos granulados contribuiu para o aumento da densidade (aparente e compactada) e do tamanho de partícula, e também para a diminuição da friabilidade, da formação de finos e do span. O perfil compressional dos granulados foi determinado graficamente através das curvas força-tempo e força-deslocamento. O tempo de desintegração dos comprimidos obtidos aumentou com a quantidade de artesunato na formulação enquanto a dureza diminuiu. O PEG 6000 aumentou a resistência mecânica e diminuiu o tempo de desintegração. Foram adicionados 2% de croscarmelose às amostras duplicadas e foi observado uma diminuição do tempo de desintegração dos comprimidos obtidos em 70% e o processo de compressão ficou mais uniforme sem alterar outras características do comprimido como resistência mecânica, trabalho útil, trabalho elástico e plasticidade da formulação. / The modernization of the equipment for wet granulation has enabled the development of different techniques from the traditional method. Among the techniques developed, hot - melt granulation eliminates the use of solvents and reduces the process time. The present work aimed to study the process of granulation by solidification of molten materials using a high-shear mixer/granulator (HSMG) and evaluate the influence of process parameters on particle size distribution, flowability and tableting characteristics of material produced. The artesunate was chosen to carry out the granulation study due to its high degree of crystallinity and chemical instability. A drug-excipient compatibility study was performed by DSC, FTIR combined with multivariate statistical techniques (PCA and HCA) and high performance liquid chromatography. The HSMG parameters investigated were the type of diluent, the amount of PEG 6000 added, massification time, the mixer speed and chopper speed, using a fractional factorial experimental design 25-1. Density, flow properties and particle size distribution of the granules were evaluated. The granular mannitol showed moisture content < 1% and span of 1.690. Granular lactose showed moisture content > 2% and span of 2.814. The mixer and chopper speed did not show significant effects on granule characteristics. Mannitol was chosen as more suitable diluent for artesunate. HSMG was carried out with the mixer speed 100 rpm and chopper speed 1000 rpm according to a full factorial experimental design 32 in duplicate to study formulation variables: artesunate/mannitol proportion and the amount of PEG 6000 added. The amount of PEG 6000 added contributed to increase the granules density (bulk and tapped), mean particle size and also to reduce friability, formation of fine particles and span. The granules compressional profile was determined graphically through force-time and force-displacement plots showing differences in work of compaction, compression and elastic recovery. The disintegration time of tablets obtained increased with the amount of artesunate in formulation while the tensile strength decreased. The amount of PEG 6000 increased hardness and decreased disintegration time. To the duplicate samples were added 2% of croscarmellose and a decrease of 70% in disintegration time of tablets was noted and also compression process become more uniform without changing other tablet features as mechanical resistance, compaction, elastic recovery and formulation plasticity.

Submitted by Renata Lopes (renatasil82@gmail.com) on 2017-05-08T17:25:12Z No. of bitstreams: 1 elgteelminborgesdepaula.pdf: 3070841 bytes, checksum: 4405f18ee4db96eba54abf3c61692232 (MD5) / Approved for entry into archive by Adriana Oliveira (adriana.oliveira@ufjf.edu.br) on 2017-05-17T14:03:07Z (GMT) No. of bitstreams: 1 elgteelminborgesdepaula.pdf: 3070841 bytes, checksum: 4405f18ee4db96eba54abf3c61692232 (MD5) / Made available in DSpace on 2017-05-17T14:03:07Z (GMT). No. of bitstreams: 1 elgteelminborgesdepaula.pdf: 3070841 bytes, checksum: 4405f18ee4db96eba54abf3c61692232 (MD5) Previous issue date: 2013-08-08 / FAPEMIG - Fundação de Amparo à Pesquisa do Estado de Minas Gerais / Este trabalho compreende um estudo de sistemas supramoleculares estabilizados por interações não covalentes, formados entre substâncias utilizadas no tratamento de doenças negligenciadas, como as leishmanioses e a malária, com β-ciclodextrina (βCD). Investigou-se a associação do antileishmanico Isotionato de Pentamidina (PNT), do antimalárico Artesunato (AS) e do potencial antimalárico 1-(7-cloroquin-4-il)-tiossemicarbazida (CQT) com βCD. Os compostos envolvendo βCD e PNT foram obtidos pelo método de liofilização, ao passo que os compostos envolvendo AS e CQT foram obtidos por secagem por nebulização. Os compostos foram caracterizados por técnicas no estado sólido por espectroscopia vibracional da região do infravermelho (IV), análise térmica (TG/DTA) e microscopia eletrônica de varredura (MEV). Em solução, utilizou-se espectrometria de massas com ionização por eletrospray (IES-EM), ressonância magnética nuclear uni e bidimensional (1H e ROESY) e titulação calorimétrica isotérmica (ITC) (apenas o sistema envolvendo PNT). Além disso, os compostos tiveram sua atividade biológica investigada. Combinando técnicas termodinâmicas e estruturais como ITC, IES-EM e RMN, o processo de inclusão e os parâmetros termodinâmicos foram identificados. Os dados experimentais obtidos por ITC e IES-EM sugerem a formação simultânea de diferentes complexos supramoleculares em solução. Além disso, os dados de RMN sugerem uma inclusão profunda de PNT na cavidade de βCD. Os testes biológicos realizados in vivo, evidenciaram a atividade por via oral do composto de inclusão estudado (βCD:PNT)1:1, em relação ao fármaco livre, o qual é inativo. Tais resultados foram promissores no que se refere à investigação de uma alternativa terapêutica para o tratamento da Leishmaniose. Para o sistema formado entre AS e βCD, as caracterizações indicaram a formação de um sistema supramolecular envolvendo as duas espécies. Experimentos do tipo DOSY, indicaram o mesmo coeficiente de difusão para fármaco e macromolécula, evidenciando assim que os precursores evoluem juntos. Para CQT, verificou-se que o composto de inclusão (βCD:CQT) não foi formado. Deste modo, preparou-se o composto (αCD:CQT)1:1, o qual foi devidamente caracterizado. Os resultados obtidos por ROESY indicaram interações entre os hidrogênios benzênicos, H5, H6 e H8, com os hidrogênios H-3 e H-5 situados na cavidade da molécula hospedeira, envidenciando a formação do composto de inclusão com αCD. Os ensaios biológicos para os antimaláricos AS e CQT foram realizados in vivo. A toxicidade aguda do composto de inclusão (βCD:AS)1:1 não apresentou toxicidade aos camundongos após 5 dias de administração. Adicionalmente, realizou-se ensaios para avaliar a atividade citotóxica de AS, (βCD:AS)1:1 e CQT. Os resultados indicaram que as moléculas não apresentaram toxicidade in vitro para células renais e hepáticas. A atividade in vivo de CQT foi testada contra P. berghei, constatando-se o potencial antimalárico foi ativo no quinto e sétimo dias, reduzindo aproximadamente 66 % da parasitemia. / This work includes a study of supramolecular systems stabilized by non-covalent interactions, formed between the substances used in the treatment of neglected diseases such leishmaniasis and malaria, with β-cyclodextrin (βCD). We investigated the association of antileishmanial pentamidine isethionate (PNT), the antimalarial artesunate (AS) and potential antimalarial 1,7-chloroquinolinyl-thiosemicarbazide (CQT) with βCD. The compounds involving PNT were obtained by lyophilization, while compounds involving AS and CQT were obtained by spray drying. The compounds were characterized by standard solid state methods such as vibrational spectroscopy in the infrared regiond (IR), thermal analysis (TG/DTA) and scanning electron microscopy (SEM). In solution, we used mass spectrometry with electrospray ionization (ESI-MS), nuclear magnetic resonance (1H and ROESY) and isothermal titration calorimetry (ITC) (only the system involving PNT). Furthermore, the compounds have biological activity investigated. Combining thermodynamic and structural techniques such as ITC, ESI-MS and NMR, the inclusion process and the thermodynamic parameters were identified. The experimental data obtained by ESI-MS and ITC suggest the simultaneous formation of different supramolecular complexes in solution. Also, NMR data suggest a deep inclusion of PNT in βCD cavity. The biological tests performed in vivo showed the oral activity of inclusion compound studied (βCD:PNT)1:1, compared to free drug which is inactive. These results are promising with regard to the investigation of alternative therapeutic alternatives for leishmaniasis treatment. For the system formed between AS e βCD the characterizations indicated the formation of a supramolecular system involving two species. DOSY experiments indicated the same diffusion coefficient for the drug and the macromolecule, showing the formation of inclusion compound (βCD:AS)1:1. It was verified that (βCD:CQT) inclusion compound was not formed. Thus the compound (αCD:CQT)1:1 was prepared, which was properly characterized. The ROESY results indicated interactions between the aromatic hydrogens, H5, H6 and H8 with H-3 and H-5 located in the cavity of host molecule, showing the formation of inclusion compound with αCD. The biological tests for antimalarials AS and CQT were performed in vivo. Acute toxicity of the inclusion compound (βCD:AS)1:1 showed no toxicity to mice after 5 days of administration. Additionally, tests were conducted to evaluate the cytotoxic activity of AS, (βCD:AS)1:1 and CQT. The results indicated that the molecules showed no toxicity in vitro in renal and hepatic cells. The in vivo activity of CQT was tested against P. Berghei, noting the potential antimalarial was active in the fifth and seventh days, reducing approximately 66% parasitemia.

Malaria is the most important parasitic disease in man and it kills approximately 2,000 people each day. Pregnant women are especially vulnerable to malaria with increased incidence and mortality rates. There are indications that pregnancy alters the pharmacokinetic properties of many antimalarial drugs. This is worrisome as lower drug exposures might result in lowered efficacy and lower drug exposures can also accelerate the development and spread of resistant parasites. The aim of this research was to study the pharmacokinetics and pharmacodynamics of the most commonly used drugs for the treatment of uncomplicated Plasmodium falciparum malaria during the second and third trimester of pregnancy using a pharmacometric approach. This thesis presents a number of important findings that increase the current knowledge of antimalarial drug pharmacology and that may have an impact in terms of drug efficacy and resistance. (1) Lower lumefantrine plasma concentrations at day 7 were evident in pregnant women compared to that in non-pregnant patients. Subsequent in-silico simulations with the final pharmacokinetic-pharmacodynamic lumefantrine/desbutyl-lumefantrine model showed a decreased treatment failure rate after a proposed extended artemether-lumefantrine treatment. (2) Dihydroartemisinin exposure (after intravenous and oral administration of artesunate) was lower during pregnancy compared to that in women 3 months post-partum (same women without malaria). Consecutive in-silico simulations with the final model showed that the underexposure of dihydroartemisinin during pregnancy could be compensated by a 25% dose increase. (3) Artemether/dihydroartemisinin exposure in pregnant women was also lower compared to literature values in non-pregnant patients. This further supports the urgent need for a study in pregnant women with a non-pregnant control group. (4) Quinine pharmacokinetics was not affected by pregnancy trimester within the study population and a study with a non-pregnant control group is needed to evaluate the absolute effects of pregnancy. (5) Finally, a data-dependent power calculation methodology using the log likelihood ratio test was successfully used for sample size calculations of mixed pharmacokinetic study designs (i.e. sparsely and densely sampled patients). Such sample size calculations can contribute to a better design of future pharmacokinetic studies. In conclusion, this thesis showed lower exposures for drugs used to treat uncomplicated Plasmodium falciparum malaria during the second and third trimester of pregnancy. More pharmacokinetic studies in pregnant women with a non-pregnant control group are urgently needed to confirm the current findings and to enable an evidence-based dose optimisation. The data-dependent power calculation methodology using the log likelihood ratio test can contribute to an effective design of these future pharmacokinetic studies.

Introduction: Antimalarial resistance, particularly artemisinin resistance, is a major threat to P. falciparum malaria elimination efforts worldwide. Urgent intervention is required to tackle artemisinin resistance but field data on which to base planning of strategies are limited. The aims were to collect available field data and develop population level mathematical models of P. falciparum malaria treatment and artemisinin resistance in order to determine the optimal strategies for elimination of artemisinin resistant malaria in Cambodia and treatment of pre-hospital and severe malaria in Cambodia and Bangladesh. Methods: Malaria incidence and parasite clearance data from Cambodia and Bangladesh were collected and analysed and modelling parameters derived. Population dynamic mathematical models of P. falciparum malaria were produced. Results: The modelling demonstrated that elimination of artemisinin resistant P. falciparum malaria would be achievable in Cambodia in the context of artemisinin resistance using high coverages with ACT treatment, ideally combined with LLITNs and adjunctive single dose primaquine. Sustained efforts would be necessary to achieve elimination and effective surveillance is essential, both to identify the baseline malaria burden and to monitor parasite prevalence as interventions are implemented. A modelled policy change to rectal and intravenous artesunate in the context of pre-existing artemisinin resistance would not compromise the efficacy of ACT for malaria elimination. Conclusions: By being developed rapidly in response to specific questions the models presented here are helping to inform planning efforts to combat artemisinin resistance. As further field data become available, their planned on-going development will produce increasingly realistic and informative models which can be expected to play a central role in planning efforts for years to come.

Malaria affects about forty percent of the world’s population. Annually more than 1.5 million fatalities due to malaria occur and parasite resistance to existing antimalarial drugs such as mefloquine has already reached disturbingly high levels in South-East Asia and on the African continent. Consequently, there is a dire need for new drugs or formulations in the prophylaxis and treatment of malaria. Artesunate, an artemisinin derivative, represents a new category of antimalarials that is effective against drug-resistant Plasmodium falciparum strains and is of significance in the current antimalarial campaign. As formulating an ACT double fixed-dose combination is technically difficult, it is essential that fixed-dose combinations are shown to have satisfactory ingredient compatibility, stability, and dissolution rates similar to the separate oral dosage forms. Since the general deployment of a combination of artesunate and mefloquine in 1994, the cure rate increased again to almost 100% from 1998 onwards, and there has been a sustained decline in the incidence of Plasmodium falciparum malaria in the experimental studies (Nosten et al., 2000:297; WHO, 2010:17). However, the successful formulation of a solid oral dosage form and fixed dosage combination of artesunate and mefloquine remains both a market opportunity and a challenge. Artesunate and mefloquine both exhibited poor flow properties. Furthermore, different elimination half-lives, treatment dosages as well as solubility properties of artesunate and mefloquine required different formulation approaches. To substantiate the FDA’s pharmaceutical quality by design concept, the double fixed-dose combination of artesunate and mefloquine required strict preliminary formulation considerations regarding compatibility between excipients and between the APIs. Materials and process methods were only considered if theoretically and experimentally proved safe. Infrared absorption spectroscopy (IR) and X-ray powder diffraction (XRPD) data proved compatibility between ingredients and stability during the complete manufacturing process by a peak by peak correlation. Scanning Electron Micrographs (SEM) provided explanations for the inferior flow properties exhibited by the investigated APIs. Particle size analysis and SEM micrographs confirmed that the larger, rounder and more consistently sized particles of the granulated APIs contributed to improved flow under the specified testing conditions. A compressible mixture containing 615 mg of the APIs in accordance with the WHO recommendation of 25 mg/kg of mefloquine taken in two or three divided dosages, and 4 mg/kg/day for 3 days of artesunate for uncomplicated falciparum malaria was developed. Mini-tablets of artesunate and mefloquine were compressed separately and successfully with the required therapeutic dosages and complied with pharmacopoeial standards. Preformulation studies eventually led to a formula for a double fixed-dose combination and with the specific aim of delaying the release of artesunate due to its short half-life. A factorial design revealed the predominant factors contributing to the successful wet granulation of artesunate and mefloquine. A fractional factorial design identified the optimum factors and factor levels. The application of the granulation fluid (20% w/w) proved to be sufficient by a spraying method for both artesunate and mefloquine. A compatible acrylic polymer and coating agent for artesunate, Eudragit® L100 was employed to delay the release of approximately half of the artesunate dose from the double fixed-dose combination tablet until a pH of 6.8. A compressible mixture was identified and formulated to contain 200 mg of artesunate and 415 mg of mefloquine per tablet. The physical properties of the tablets complied with BP standards. An HPLC method from available literature was adapted and validated for analytical procedures. Dissolution studies according to a USP method were conducted to verify and quantify the release of the APIs in the double fixed-dose combination. The initial dissolution rate (DRi) of artesunate and mefloquine in the acidic dissolution medium was rapid as required. The enteric coated fraction of the artesunate exhibited no release in an acidic environment after 2 hours, but rapid release in a medium with a pH of 6.8. The structure of the granulated particles of mefloquine may have contributed to its first order release profile in the dissolution mediums. A linear correlation was present between the rate of mefloquine release and the percentage of mefloquine dissolved (R2 = 0.9484). Additionally, a linear relationship was found between the logarithm of the percentage mefloquine remaining against time (R2 = 0.9908). First order drug release is the dominant release profile found in the pharmaceutical industry today and is coherent with the kinetics of release obtained for mefloquine. A concept pre-clinical phase, double fixed-dose combination solid oral dosage form for artesunate and mefloquine was developed. The double fixed-dose combination was designed in accordance with the WHO’s recommendation for an oral dosage regimen of artesunate and mefloquine for the treatment of uncomplicated falciparum malaria. The specifications of the double fixed-dose combination were developed in close accordance with the FDA’s quality by design concept and WHO recommendations. An HPLC analytical procedure was developed to verify the presence of artesunate and mefloquine. The dissolution profiles of artesunate and mefloquine were investigated during the dissolution studies. / PhD (Pharmaceutics), North-West University, Potchefstroom Campus, 2014

Introduction: Emergence of resistance to artemisinin-based combination therapy (ACT) is a major threat to combat Plasmodium falciparum malaria. Regular therapeutic studies to monitor treatment efficacy is essential, and genotyping of molecular makers is useful for mapping development and spread of resistance. Aims: The study aims are to assess efficacy of artesunate-amodiquine (ASAQ) and prevalence of molecular markers of drug resistance in Zanzibar in 2017. Methods: Treatment efficacy of the clinical trial conducted in 2017 was compared with efficacies in 2002 and 2005. A total of 142 samples were genotyped for single nucleotide polymorphisms (SNPs) in the P. falciparum chloroquine resistance transporter gene (pfcrt) gene, the P. falciparum multi drug resistance 1 (pfmdr1) gene, and in the P. falciparum Kelch 13 (PfK13) propeller region. Prevalence of SNPs were assessed during the period 2002-2017. Results: Cure rate was 100% in 2017, compared to 94% and 96%, in 2002-2003 and 2005, respectively. Day 3 fever clearance rate were also high 93% (2002-3), 99% (2005) and 98% (2017) in all studies. Prevalence of pfcrt 76T, pfmdr1 86Y, 184Y and 1246Y and pfmdr1 (86Y, 184Y and 1246Y) YYY haplotypes were significantly decreased between 2002-3 and 2017 (p &lt; 0.001). No SNP in the PfK13 gene related to artemisinin resistance was identified. Conclusion: Efficacy of ASAQ remains high after fourteen years as first-line treatment, despite the wide-scale use of ASAQ, and there is no evidence of selection of resistance markers in Zanzibar. Continuous monitoring of drug efficacy and resistance markers is recommended. / <p>This master thesis is a collaboration project between Institutionen för kvinnors och barns hälsa, Department of Women's and Children's Health, Uppsala Universtiy and Anders Björkman group, Department of Microbiology, Tumor and Cell Biology (MTC), C1, Karolinska Institutet. Laboratory examinations were mainly conducted at MTC house, Karolinska Institutet.</p>

Malaria affects about forty percent of the world’s population. Annually more than 1.5 million fatalities due to malaria occur and parasite resistance to existing antimalarial drugs such as mefloquine has already reached disturbingly high levels in South-East Asia and on the African continent. Consequently, there is a dire need for new drugs or formulations in the prophylaxis and treatment of malaria. Artesunate, an artemisinin derivative, represents a new category of antimalarials that is effective against drug-resistant Plasmodium falciparum strains and is of significance in the current antimalarial campaign. As formulating an ACT double fixed-dose combination is technically difficult, it is essential that fixed-dose combinations are shown to have satisfactory ingredient compatibility, stability, and dissolution rates similar to the separate oral dosage forms. Since the general deployment of a combination of artesunate and mefloquine in 1994, the cure rate increased again to almost 100% from 1998 onwards, and there has been a sustained decline in the incidence of Plasmodium falciparum malaria in the experimental studies (Nosten et al., 2000:297; WHO, 2010:17). However, the successful formulation of a solid oral dosage form and fixed dosage combination of artesunate and mefloquine remains both a market opportunity and a challenge. Artesunate and mefloquine both exhibited poor flow properties. Furthermore, different elimination half-lives, treatment dosages as well as solubility properties of artesunate and mefloquine required different formulation approaches. To substantiate the FDA’s pharmaceutical quality by design concept, the double fixed-dose combination of artesunate and mefloquine required strict preliminary formulation considerations regarding compatibility between excipients and between the APIs. Materials and process methods were only considered if theoretically and experimentally proved safe. Infrared absorption spectroscopy (IR) and X-ray powder diffraction (XRPD) data proved compatibility between ingredients and stability during the complete manufacturing process by a peak by peak correlation. Scanning Electron Micrographs (SEM) provided explanations for the inferior flow properties exhibited by the investigated APIs. Particle size analysis and SEM micrographs confirmed that the larger, rounder and more consistently sized particles of the granulated APIs contributed to improved flow under the specified testing conditions. A compressible mixture containing 615 mg of the APIs in accordance with the WHO recommendation of 25 mg/kg of mefloquine taken in two or three divided dosages, and 4 mg/kg/day for 3 days of artesunate for uncomplicated falciparum malaria was developed. Mini-tablets of artesunate and mefloquine were compressed separately and successfully with the required therapeutic dosages and complied with pharmacopoeial standards. Preformulation studies eventually led to a formula for a double fixed-dose combination and with the specific aim of delaying the release of artesunate due to its short half-life. A factorial design revealed the predominant factors contributing to the successful wet granulation of artesunate and mefloquine. A fractional factorial design identified the optimum factors and factor levels. The application of the granulation fluid (20% w/w) proved to be sufficient by a spraying method for both artesunate and mefloquine. A compatible acrylic polymer and coating agent for artesunate, Eudragit® L100 was employed to delay the release of approximately half of the artesunate dose from the double fixed-dose combination tablet until a pH of 6.8. A compressible mixture was identified and formulated to contain 200 mg of artesunate and 415 mg of mefloquine per tablet. The physical properties of the tablets complied with BP standards. An HPLC method from available literature was adapted and validated for analytical procedures. Dissolution studies according to a USP method were conducted to verify and quantify the release of the APIs in the double fixed-dose combination. The initial dissolution rate (DRi) of artesunate and mefloquine in the acidic dissolution medium was rapid as required. The enteric coated fraction of the artesunate exhibited no release in an acidic environment after 2 hours, but rapid release in a medium with a pH of 6.8. The structure of the granulated particles of mefloquine may have contributed to its first order release profile in the dissolution mediums. A linear correlation was present between the rate of mefloquine release and the percentage of mefloquine dissolved (R2 = 0.9484). Additionally, a linear relationship was found between the logarithm of the percentage mefloquine remaining against time (R2 = 0.9908). First order drug release is the dominant release profile found in the pharmaceutical industry today and is coherent with the kinetics of release obtained for mefloquine. A concept pre-clinical phase, double fixed-dose combination solid oral dosage form for artesunate and mefloquine was developed. The double fixed-dose combination was designed in accordance with the WHO’s recommendation for an oral dosage regimen of artesunate and mefloquine for the treatment of uncomplicated falciparum malaria. The specifications of the double fixed-dose combination were developed in close accordance with the FDA’s quality by design concept and WHO recommendations. An HPLC analytical procedure was developed to verify the presence of artesunate and mefloquine. The dissolution profiles of artesunate and mefloquine were investigated during the dissolution studies. / PhD (Pharmaceutics), North-West University, Potchefstroom Campus, 2014

Malaria is a life–threatening disease caused by Plasmodium spp and causes over one million deaths annually. The complex life cycle of the malaria parasite offers several points of attack for the antimalarial drugs. The rapid spread of resistance against antimalarial drugs, especially chloroquine and pyrimethamine–sulphadoxine, emphasises the need for new alternatives or modification of existing drugs. Artemisinin–based combination therapies (ACT’s) with different targets prevent or delay the development of drug resistance and therefore have been adopted as first–line therapy by all endemic countries. Proguanil–dapsone, an antifolate combination is more active than pyrimethamine–sulphadoxine and is being considered as an alternative to pyrimethamine–sulphadoxine. Artesunate–proguanil–dapsone is a new ACT that has wellmatched pharmacokinetics and is relatively rapidly eliminated; therefore there is a reduced risk of exposure to any single compound and potentially a decreasing risk of resistance. A few studies have been done on a triple fixed–dose combination therapy for malaria treatment and such a combination for artesunate, proguanil and dapsone are not currently investigated, manufactured or distributed. The aim of this study was to develop a triple fixed–dose combination for artesunate, proguanil and dapsone. The formulation was developed in three phases; basic formulation development, employing factorial design to obtain two possible optimised formulations and evaluating the optimised formulations. During the formulation development the most suitable manufacturing procedure and excipients were selected. A full 24 factorial design (four factors at two levels) was used to obtain the optimised formulations. As end–points to identify the optimised formulations, weight variation, friability, crushing strength and disintegration of the tablets, were used. Statistical analysis (one way ANOVA) was used to identify optimal formulations. To identify any interaction between the active pharmaceutical ingredients (API’s) and the API’s and excipients, differential scanning calorimetry was done. Flow properties of the powder mixtures (of the optimised formulations) were characterised by means of angle of repose; critical orifice diameter (COD); bulk density and tapped density; and flow rate. Tablets of the two optimised powder formulations were compressed. The tablets were evaluated and characterised in terms of weight variation, friability, crushing strength, disintegration and dissolution behaviour. Initial formulation development indicated that wet granulation was the most suitable manufacturing method. The results from the factorial design indicated that different amounts (% w/w) of the lubricant and binder as well as two different fillers influenced the weight variation, crushing strength and disintegration statistically significant. Two formulations containing two different fillers (microcrystalline cellulose or Avicel® PH 101, and lactose or Granulac® 200) were found to be within specifications and ideal for manufacturing. Tablets prepared from the FA formulation (formulation containing Avicel® PH 101) complied with the standards and guidelines for weight variation, friability, crushing strength and disintegration as set by the British Pharmacopoeia (BP). Tablets had an average crushing strength of 121.56 ± 0.022 N. Tablets disintegrated within 52.00 seconds and a maximum weight loss of 0.68% occurred during the friability test. Weight variation of the tablets prepared from the FG formulation (formulation containing Granulac® 200) complied with the standards. Average crushing strength was 91.99 ± 6.008 N and the tablets disintegrated within 140.00 seconds. Percentage friability (1.024%) did not comply with the guideline of a percentage friability of less than 1%, however, no cracked or broken tablets were seen. Dissolution showed that 98, 93 and 94% of artesunate, proguanil and dapsone were respectively released (of the label value) within 15 minutes for the FA formulations. Release of artesunate, proguanil and dapsone for the FG formulation was 62, 85 and 92% for the same time period. The release of the three API’s (the FG formulation) increased to 78, 89 and 92%, respectively, after 45 minutes. / Thesis (M.Sc. (Pharmaceutics))--North-West University, Potchefstroom Campus, 2012.

Malaria is a life–threatening disease caused by Plasmodium spp and causes over one million deaths annually. The complex life cycle of the malaria parasite offers several points of attack for the antimalarial drugs. The rapid spread of resistance against antimalarial drugs, especially chloroquine and pyrimethamine–sulphadoxine, emphasises the need for new alternatives or modification of existing drugs. Artemisinin–based combination therapies (ACT’s) with different targets prevent or delay the development of drug resistance and therefore have been adopted as first–line therapy by all endemic countries. Proguanil–dapsone, an antifolate combination is more active than pyrimethamine–sulphadoxine and is being considered as an alternative to pyrimethamine–sulphadoxine. Artesunate–proguanil–dapsone is a new ACT that has wellmatched pharmacokinetics and is relatively rapidly eliminated; therefore there is a reduced risk of exposure to any single compound and potentially a decreasing risk of resistance. A few studies have been done on a triple fixed–dose combination therapy for malaria treatment and such a combination for artesunate, proguanil and dapsone are not currently investigated, manufactured or distributed. The aim of this study was to develop a triple fixed–dose combination for artesunate, proguanil and dapsone. The formulation was developed in three phases; basic formulation development, employing factorial design to obtain two possible optimised formulations and evaluating the optimised formulations. During the formulation development the most suitable manufacturing procedure and excipients were selected. A full 24 factorial design (four factors at two levels) was used to obtain the optimised formulations. As end–points to identify the optimised formulations, weight variation, friability, crushing strength and disintegration of the tablets, were used. Statistical analysis (one way ANOVA) was used to identify optimal formulations. To identify any interaction between the active pharmaceutical ingredients (API’s) and the API’s and excipients, differential scanning calorimetry was done. Flow properties of the powder mixtures (of the optimised formulations) were characterised by means of angle of repose; critical orifice diameter (COD); bulk density and tapped density; and flow rate. Tablets of the two optimised powder formulations were compressed. The tablets were evaluated and characterised in terms of weight variation, friability, crushing strength, disintegration and dissolution behaviour. Initial formulation development indicated that wet granulation was the most suitable manufacturing method. The results from the factorial design indicated that different amounts (% w/w) of the lubricant and binder as well as two different fillers influenced the weight variation, crushing strength and disintegration statistically significant. Two formulations containing two different fillers (microcrystalline cellulose or Avicel® PH 101, and lactose or Granulac® 200) were found to be within specifications and ideal for manufacturing. Tablets prepared from the FA formulation (formulation containing Avicel® PH 101) complied with the standards and guidelines for weight variation, friability, crushing strength and disintegration as set by the British Pharmacopoeia (BP). Tablets had an average crushing strength of 121.56 ± 0.022 N. Tablets disintegrated within 52.00 seconds and a maximum weight loss of 0.68% occurred during the friability test. Weight variation of the tablets prepared from the FG formulation (formulation containing Granulac® 200) complied with the standards. Average crushing strength was 91.99 ± 6.008 N and the tablets disintegrated within 140.00 seconds. Percentage friability (1.024%) did not comply with the guideline of a percentage friability of less than 1%, however, no cracked or broken tablets were seen. Dissolution showed that 98, 93 and 94% of artesunate, proguanil and dapsone were respectively released (of the label value) within 15 minutes for the FA formulations. Release of artesunate, proguanil and dapsone for the FG formulation was 62, 85 and 92% for the same time period. The release of the three API’s (the FG formulation) increased to 78, 89 and 92%, respectively, after 45 minutes. / Thesis (M.Sc. (Pharmaceutics))--North-West University, Potchefstroom Campus, 2012.