A Research Report Submitted to the School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, in partial fulfilment of the requirements for the Degree of Master of Science in Medicine in Tropical Diseases (Epidemiology and Biostatistics Option). Johannesburg, January 2001 / Background: increasing spread of drug resistance among Plasmodium falciparum poses a serious threat to malaria treatment. The situation is complicated not only because new drugs are expensive and slow in development but also because they must be effective, preferably have a novel method of action, with an acceptable level of adverse effects, and be deployed in such a way as to prolong their use. / IT2018

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Malaria is an infectious disease caused by various forms of the Plasmodium parasite. It is responsible for thousands of deaths yearly with 90 % of those deaths being in sub-Saharan Africa, thus making it a disease of global importance. The global burden of malaria is worsened by resistance to current treatment, a lack in funding and limited research outputs. More alternative ways of treatment must be explored and may include the co-formulation of antimalarial drug substances as well as alternative ways of drug delivery. Antifolates are drugs which interfere with an organism’s folate metabolism by inhibiting dihydropteroate synthase (DHPS) or dihydrofolate reductase (DHFR). Dapsone is a synthetic sulfone which has a mechanism of action that is very similar to that of sulphonamides. The mechanism of action is characterised by the inhibition of folic acid synthesis through the inhibition of dihydropteroate synthase (DHPS). Another antifolate drug, proguanil, is the prodrug of cycloguanil. Its mechanism involves the inhibition of dihydrofolate reductase (DHFR), thus inhibiting the malaria parasite to metabolise folates and therefore stunting its growth. Unfortunately, dapsone has a serious side-effect in people with a deficiency of the enzyme glucose-6-phosphate dehydrogenase (G6PD) causing oxidative stress on the red blood cells leading to the rupturing of these cells. The main objective of this study was to formulate and characterise TMC-TPP microparticles loaded with the effective but toxic drug combination of dapsone and proguanil and to determine if these drug-containing microparticles had in vivo efficacy against malaria. N-trimethyl chitosan chloride (TMC), a partially quaternised chitosan derivative, shows good water solubility across a wide pH range thus having mucoadhesive properties and excellent absorption enhancing effects even at neutral pH. A faster, more efficient microwave irradiation method was developed as an alternative to the conventional synthesising method of TMC. TMC with the same degree of quaternisation (DQ), ± 60 %, was obtained in a quarter of the reaction time (30 min) by using the newly developed method. The TMC synthesised with the microwave irradiation method also exhibited less degradation of the polymer structure, thus limiting the chance for the formation of any unwanted by-products (Omethylation, N,N-dimethylation and N-monomethylation). The formation of complexes by ionotropic gelation between TMC and oppositely charged macromolecules, such as tripolyphosphate (TPP), has been utilised to prepare microparticles which are a suitable drug delivery system for the dapsone-proguanil combination. Both these drugs were successfully entrapped. These particles were characterised and the in vivo efficacy against the malaria parasites was determined. The microparticles with both the drugs, separately and in combination, displayed similar or better in vivo efficacy when compared to the drugs without the TMC microparticles. An in vitro dissolution study was also performed by subjecting the dapsone and proguanil TMC formulations to 0.1N HCl dissolution medium. Samples were withdrawn after predetermined time points and the drug concentration was determined with HPLC. It was found that the TMC microparticles resulted in a sustained release profile since only 73.00 ± 1.70 % (dapsone) and 55.00 ± 1.90 % (proguanil) was released after 150 minutes. The in vivo bioavailability of the dapsone and proguanil TMC formulations was evaluated in mice by collecting blood samples at predetermined time points and analysing the samples with a sensitive and accurate LC-MS/MS method. The in vivo bioavailability of the dapsone TMC formulation relative to the normal dapsone formulation was found to be 244 % and 123 % for the proguanil TMC formulation relative to the normal proguanil formulation. These TMC-TPP microparticles formulations showed better in vivo efficacy and bioavailability when compared to the normal formulation. Together with the sustained release, these formulations may be a promising cheaper and more effective treatment against malaria. / PhD (Pharmaceutics), North-West University, Potchefstroom Campus, 2015

Malaria is an infectious disease caused by various forms of the Plasmodium parasite. It is responsible for thousands of deaths yearly with 90 % of those deaths being in sub-Saharan Africa, thus making it a disease of global importance. The global burden of malaria is worsened by resistance to current treatment, a lack in funding and limited research outputs. More alternative ways of treatment must be explored and may include the co-formulation of antimalarial drug substances as well as alternative ways of drug delivery. Antifolates are drugs which interfere with an organism’s folate metabolism by inhibiting dihydropteroate synthase (DHPS) or dihydrofolate reductase (DHFR). Dapsone is a synthetic sulfone which has a mechanism of action that is very similar to that of sulphonamides. The mechanism of action is characterised by the inhibition of folic acid synthesis through the inhibition of dihydropteroate synthase (DHPS). Another antifolate drug, proguanil, is the prodrug of cycloguanil. Its mechanism involves the inhibition of dihydrofolate reductase (DHFR), thus inhibiting the malaria parasite to metabolise folates and therefore stunting its growth. Unfortunately, dapsone has a serious side-effect in people with a deficiency of the enzyme glucose-6-phosphate dehydrogenase (G6PD) causing oxidative stress on the red blood cells leading to the rupturing of these cells. The main objective of this study was to formulate and characterise TMC-TPP microparticles loaded with the effective but toxic drug combination of dapsone and proguanil and to determine if these drug-containing microparticles had in vivo efficacy against malaria. N-trimethyl chitosan chloride (TMC), a partially quaternised chitosan derivative, shows good water solubility across a wide pH range thus having mucoadhesive properties and excellent absorption enhancing effects even at neutral pH. A faster, more efficient microwave irradiation method was developed as an alternative to the conventional synthesising method of TMC. TMC with the same degree of quaternisation (DQ), ± 60 %, was obtained in a quarter of the reaction time (30 min) by using the newly developed method. The TMC synthesised with the microwave irradiation method also exhibited less degradation of the polymer structure, thus limiting the chance for the formation of any unwanted by-products (Omethylation, N,N-dimethylation and N-monomethylation). The formation of complexes by ionotropic gelation between TMC and oppositely charged macromolecules, such as tripolyphosphate (TPP), has been utilised to prepare microparticles which are a suitable drug delivery system for the dapsone-proguanil combination. Both these drugs were successfully entrapped. These particles were characterised and the in vivo efficacy against the malaria parasites was determined. The microparticles with both the drugs, separately and in combination, displayed similar or better in vivo efficacy when compared to the drugs without the TMC microparticles. An in vitro dissolution study was also performed by subjecting the dapsone and proguanil TMC formulations to 0.1N HCl dissolution medium. Samples were withdrawn after predetermined time points and the drug concentration was determined with HPLC. It was found that the TMC microparticles resulted in a sustained release profile since only 73.00 ± 1.70 % (dapsone) and 55.00 ± 1.90 % (proguanil) was released after 150 minutes. The in vivo bioavailability of the dapsone and proguanil TMC formulations was evaluated in mice by collecting blood samples at predetermined time points and analysing the samples with a sensitive and accurate LC-MS/MS method. The in vivo bioavailability of the dapsone TMC formulation relative to the normal dapsone formulation was found to be 244 % and 123 % for the proguanil TMC formulation relative to the normal proguanil formulation. These TMC-TPP microparticles formulations showed better in vivo efficacy and bioavailability when compared to the normal formulation. Together with the sustained release, these formulations may be a promising cheaper and more effective treatment against malaria. / PhD (Pharmaceutics), North-West University, Potchefstroom Campus, 2015

L'apparition récurrente de Plasmodium falciparum résistant aux antipaludiques est un obstacle majeur au contrôle du paludisme. Introduite en 2000, une nouvelle association très bien tolérée, l'atovaquone-proguanil est rapidement devenue le traitement de choix des accès palustres simples dans certains hôpitaux français. Ce travail de recherche avait pour objectif d'approfondir les connaissances sur la résistance à cette association. Nous n'avons détecté aucune résistance naturelle à l'atovaquone-proguanil en Afrique de l'Ouest et dans l'Océan Indien parmi 477 isolats. La majorité des rechutes précoces sont liées à une malabsorption des principes actifs alors que les échecs tardifs sont liés à la présence de parasites hautement résistants in vitro présentant, au moment de la rechute, une mutation au niveau du codon 268 du cytochrome b (Y268S ou Y268C) sans augmentation du nombre de copies de ce gène, évalué par PCR en temps réel à 16 ± 9 copies par parasite. Le séquençage du génome mitochondrial et l'analyse de marqueurs microsatellites chromosomiques des parasites isolés avant et après la rechute parasitaire montrent que la mutation associée à cette résistance est apparue indépendamment chez chacun des six patients en échec étudiés. L'atovaquone-proguanil est efficace pour le traitement des voyageurs avec moins de 0,1% de résistance. Le risque actuel de dispersion des résistances est négligeable puisqu'elles émergent chez des patients traités hors de zone de transmission. Par contre, si cette association devait être déployée en zone d'endémie, il serait indispensable de la combiner avec d'autres molécules.

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.