Les combinaisons thérapeutiques à base d’artémisinine (ou CTAs) sont une des clés de voûte des stratégies actuelles de lutte contre le paludisme : ces thérapies ont en effet joué un rôle important dans la réduction de l’impact du paludisme au cours de la dernière décennie. Cependant, ces progrès sont aujourd’hui compromis par l’émergence de parasites Plasmodium falciparum résistants aux dérivés de l’artémisinine (ART). Les premiers parasites résistants ont été détectés pour la première fois en 2008 dans l’ouest du Cambodge, puis dans plusieurs pays avoisinants d’Asie du Sud-Est. Le problème de la multirésistance aux antipaludiques s’est récemment aggravé au Cambodge : plusieurs études ont rapporté l’émergence de parasites résistants à la pipéraquine (PPQ), la dernière génération de molécule partenaire utilisée en combinaison avec la dihydroartémisinine, entraînant des taux alarmants d’échecs cliniques. Pour préserver l’efficacité de ces combinaisons, la surveillance et la compréhension de ces deux types de résistance sont cruciales afin d’éviter la dissémination de parasites multirésistants en dehors d’Asie du Sud-Est, et particulièrement en Afrique où les conséquences sanitaires seraient désastreuses. À cette fin, le développement de nouveaux outils est nécessaire pour étudier les mécanismes biologiques et moléculaires impliqués dans la résistance aux CTAs et pour surveiller la distribution géographique des parasites multirésistants. Dans la première partie de cette thèse, axée sur la résistance à l’artémisinine, nous présentons tout d’abord la découverte de mutations au sein du gène K13, marqueur moléculaire pour la résistance à l'ART. Puis nous confirmons leur rôle comme déterminant majeur de cette résistance. Enfin, nous analysons l’étendue de cette résistance au travers d'une cartographie mondiale des polymorphismes de K13. Dans la seconde partie de cette thèse, nous présentons nos travaux portant sur l’émergence de la résistance à la pipéraquine au Cambodge, en confirmant dans un premier temps que des parasites multirésistants à l’ART et à la PPQ circulent désormais dans le pays. Puis en détaillant la mise en point d’un nouveau test phénotypique pour la détection des parasites PPQ-résistants, le Piperaquine Survival Assay ou PSA. Pour finir, nous exposons la découverte de l’amplification du gène PfPM2 comme marqueur moléculaire pour la résistance à la PPQ. / Artemisinin-based combination therapies (ACTs) are one of the pillars of the current strategies implemented for fighting malaria. Over the last decade, ACTs have played a major role in decreasing malaria burden. However, this progress is being jeopardized by the emergence of artemisinin-resistant Plasmodium falciparum parasites. Artemisinin (ART) resistance was first detected in western Cambodia in 2008 and has since been observed in neighboring countries in Southeast Asia. The problem of antimalarial drug resistance has recently worsened in Cambodia, with reports of parasites resistant to piperaquine (PPQ), the latest generation of partner drug used in combination with dihydroartemisinin, leading to worrying rates of clinical treatment failure. The monitoring and the comprehension of both types of resistance are crucial to prevent the spread of multi-drug resistant parasites outside Southeast Asia, and particularly to Africa, where the public health consequences would be catastrophic. To this end, new tools are required for studies of the biological and molecular mechanisms underlying resistance to antimalarial drugs and for monitoring the geographic distribution of the resistant parasites.In the first section of this thesis, centered on artemisinin resistance, we first present the discovery of mutations within the K13 gene as a molecular marker for ART resistance. Then we confirm their role as a major determinant of such a resistance. Finally, we analyze the extent of ART resistance through a global mapping of K13 polymorphisms. In the second section, we present our work on the emergence of piperaquine resistance in Cambodia, by initially confirming that multiresistant parasites now circulate in the country. Then we detail the development of a new phenotypical test for the detection of PPQ-resistant parasites, the Piperaquine Survival Assay or PSA. Lastly, we report the discovery of the PfPM2 gene amplification as a candidate molecular marker for PPQ-resistance.

<p>This thesis deals with the development of analytical methods for the determination of new antimalarial drugs in biological fluids. The goal was to develop methods that facilitate clinical studies performed in the field, such as capillary blood sampling onto sampling paper.</p><p>Methods for the determination of atovaquone (ATQ) in plasma, whole blood and capillary blood applied onto sampling paper were developed and validated. </p><p>Automated solid-phase extraction (SPE) and liquid chromatography (LC) with UV absorbance detection was used to quantify ATQ. Venous blood contained higher levels of ATQ than capillary blood after a single dose of Malarone (ATQ + proguanil).</p><p>Ion-pairing LC was used to separate amodiaquine (AQ), chloroquine (CQ) and their metabolites on a CN-column. A method for quantification of AQ, CQ and their metabolites in capillary blood applied onto sampling paper was developed and validated. Perchloric acid and acetonitrile were used to facilitate the extraction of the analytes from the sampling paper. The liquid extract was further cleaned by SPE.</p><p>Methods for the determination of piperaquine (PQ) in plasma and whole blood using SPE and LC were developed and validated. Addition of trichloroacetic acid (TCA) to the samples prior to injection into the LC-system significantly enhanced the efficiency for the PQ peak. Serum and whole blood contained higher levels (about 300 nM) of PQ than plasma (about 200 nM) after a single oral dose of 340 mg PQ. This indicates that PQ may be taken up in the leucocytes and thrombocytes.</p>

This thesis deals with the development of analytical methods for the determination of new antimalarial drugs in biological fluids. The goal was to develop methods that facilitate clinical studies performed in the field, such as capillary blood sampling onto sampling paper. Methods for the determination of atovaquone (ATQ) in plasma, whole blood and capillary blood applied onto sampling paper were developed and validated. Automated solid-phase extraction (SPE) and liquid chromatography (LC) with UV absorbance detection was used to quantify ATQ. Venous blood contained higher levels of ATQ than capillary blood after a single dose of Malarone (ATQ + proguanil). Ion-pairing LC was used to separate amodiaquine (AQ), chloroquine (CQ) and their metabolites on a CN-column. A method for quantification of AQ, CQ and their metabolites in capillary blood applied onto sampling paper was developed and validated. Perchloric acid and acetonitrile were used to facilitate the extraction of the analytes from the sampling paper. The liquid extract was further cleaned by SPE. Methods for the determination of piperaquine (PQ) in plasma and whole blood using SPE and LC were developed and validated. Addition of trichloroacetic acid (TCA) to the samples prior to injection into the LC-system significantly enhanced the efficiency for the PQ peak. Serum and whole blood contained higher levels (about 300 nM) of PQ than plasma (about 200 nM) after a single oral dose of 340 mg PQ. This indicates that PQ may be taken up in the leucocytes and thrombocytes.

This thesis describes bioanalytical methods for drug determination in biological matrixes, with drugs in focus used against diseases largely affecting low-income countries. Solid-phase extraction is used for sample cleanup, and processed samples are analyzed by liquid chromatography. Developed bioanalytical methods are validated according to international guidelines. Eflornithine (DFMO) is a chiral drug, used for treating human African trypanosomiasis. A bioanalytical method for determination of DFMO enantiomers in plasma is presented. The enantiomers are detected by evaporative light-scattering detection. The method has been applied to determination of D-DFMO and L-DFMO in rats, after intravenous and oral administration of racemic DFMO. It is concluded that DFMO exhibits enantioselective absorption, with the more potent enantiomer L-DFMO being less favored. Sulfadoxine (SD) and sulfamethoxazole (SM) are sulfa-drugs used for malaria and pneumonia respectively. Two methods are described for simultaneous determination of SD and SM in capillary blood sampled on filter paper. The former method allows direct injection of extracts from dried blood spots (DBS), while for the latter method solid-phase extraction is added. Pre-analytical factors contributing to measurement uncertainty is also discussed, and it is concluded that it is of high importance that homogeneity in type of sampling paper and sampling volume is assured. Piperaquine (PQ) is an antimalarial, increasingly used in artemisinin combination therapy. A method for determination of piperaquine in DBS is presented. By using a monolithic LC column, a very short LC analysis of two minutes per sample is achieved. A method for simultaneous determination of three antiretroviral drugs i.e. lamivudine (3TC), zidovudine (AZT) and nevirapine (NVP), in DBS samples is described. The method is applied to drug determination in two subjects after receiving standard antiretroviral treatment. Conclusion is that the method is suitable for determination of 3TC and NVP, and to some extent for AZT.