huifang tang [email protected] anti-parasitic drugs ( 抗寄生虫药 )

huifang Tang [email protected]

Anti-parasitic drugs( 抗寄生虫药 )

Anti-parasitic drugsAnti-parasitic drugs

1. Anti-malarial drugs( 抗疟药 )2. Anti-schistosomiasis and

anti-filariasis drugs( 抗血吸虫病和抗丝虫病药 )

3. Anti-amebiasis and anti-trichomoniasis drugs( 抗阿米巴病和抗滴虫病药 )

4. Anthelmintic drugs( 抗肠蠕虫药 )

Part1 1. Anti-malarial drugs( 抗疟药 )

Part1 Antimalarial drugs Antimalarial drugs (( 抗疟药抗疟药 ))

•The The malarial parasite(Plasmodium)(malarial parasite(Plasmodium)( 疟疟原虫原虫 )), is a very small, single-cell blood , is a very small, single-cell blood organism. organism. •It lives as a parasite in other It lives as a parasite in other organisms, namely organisms, namely man and mosquitoman and mosquito. .

•The parasite is the cause of the The parasite is the cause of the tropical (tropical ( 热带热带 )disease )disease malariamalaria(( 疟疾疟疾 ).).

Anti-malarial drugs ( 抗疟药 )

1. Biology of malarial parasite: (1)Classification of malaria: Human malaria is caused by 4 species of

malarial parasite(plasmodium, 疟原虫 ), include:

P. falciparum( 恶性疟原虫 ), P. vivax( 间日疟原虫 ), P. malariae( 三日疟原虫 ), P. ovale( 卵形疟原虫 ). Common malaria in our country are

subtertian malaria( 恶性疟 ) and tertian malaria( 间日疟 ).

The conditions of tertian malaria are milder, therefore, it is called benign malaria( 良性疟 ) too.

Anti-malarial drugsAnti-malarial drugs

Parasite Life CycleParasite Life Cycle

Anti-malarial Anti-malarial drugsdrugs

1.1. Tissue schizonticides Tissue schizonticides 组织裂殖体杀灭剂组织裂殖体杀灭剂eliminate developing or dormant liver forms(eliminate developing or dormant liver forms( 红外期裂殖红外期裂殖

体体 ););

---For control the ---For control the prevention(prevention( 预防预防 ) and relapse ) and relapse (( 复发复发 ))

2.2. Blood schizonticides Blood schizonticides 血裂殖体杀灭剂血裂殖体杀灭剂

act on erythrocytic parasites(act on erythrocytic parasites( 红内期裂殖体红内期裂殖体 ););

---For control the ---For control the symptom (symptom ( 症状症状 ))

3. Gametocides3. Gametocides 杀配子药杀配子药 kill sexual stages and kill sexual stages and prevent transmission to mosquitoes.prevent transmission to mosquitoes.

---For control the ---For control the communication(communication( 传播传播 ))

AntimalarialAntimalarial drugsdrugs -- DrugDrug ClassificationClassification


(2)Life cycle of malarial parasite:

Although malaria can be transmitted by transfusion of infected blood, human beings are infected more commonly by sporozoites( 子孢子 ) injected by the bite of infected female mosquitoes.

①Asexual propagated stage in human body;

②Sexual propagated stage in female mosquitoes.


①Asexual propagated stage in human body: ▲Exo-erythrocytic stage: There are two types of sporozoites of tertian malaria( 间日疟 ), that is: Tackysporozoite( 速发型子孢子 ), and Bradysporozoite( 迟发型子孢子 ). The tackysporozoites leave the circula-tion and localized in liver cells, then they rapidly transform, multiply and develop into schizonts( 裂殖体 ) and merozoites( 裂殖子 ). There are no symptoms in this stage.


The bradysporozoites enter liver cells, then go into hypnozoite( 休眠期 ), they become to dormancytes( 休眠子 ), which is the source of tertian malaria relapse.

Pyrimethamine( 乙胺嘧啶 ) can kill tacky-sporozoites in the exo-erythrocytic stage.

Primaquine( 伯氨喹 ) can kill bradyspor-ozoites to radically treat tertian malaria ( 间日疟 ), and prevent tertian malaria relapse.


▲Erythrocytic stage: The schizonts( 裂殖体 ) then rupture, each releasing thousands of merozoites ( 裂殖子 ), then enter the circulation and invade erythrocytes, initiate the eryth-rocytic stage, and transform trophozoite ( 滋养体 ) and schizonts, then release many merozoites. There are a lot of symptoms in this stage. Chloroquine( 氯喹 ), Quinine( 奎宁 ), and Artemisinin( 青蒿素 ) are effective to this stage, they can control the symptoms, and prevent attack of malaria.


②Sexual propagated stage in female mosquitoes: Some erythrocytic malarial parasites differentiate into sexual forms known as gametocytes( 配子体 ). The ♂ and ♀ gametocytes in the gut of the mosquito combine to thezygote( 合子 ), which develops in the gut wall to infective sporozoites( 子孢子 ), which invades salivary gland, become the source of infection. Pyrimethamine can inhibit the development of ♂ and ♀ gametocytes in mosquito to control transmission of malaria. Primaquine can kill various gametocytes of subtertian and tertian malaria.


ChloroquineChloroquine( 氯喹 )

•Chloroquine is a synthetic 4-aminoquinoline derivate


1. Antimalarial effects: 1. Antimalarial effects: erythrocytic stage•Rapid schizonticidal(Rapid schizonticidal( 裂殖体杀灭剂裂殖体杀灭剂 )activity )activity against all infections of malaria species . against all infections of malaria species . •gametocytocidal(gametocytocidal( 杀配子体杀配子体 )against P. vivax, )against P. vivax, P. malariae and P. ovale as well as immature P. malariae and P. ovale as well as immature gametocytes (stages 1-3) of P. falciparum.gametocytes (stages 1-3) of P. falciparum. •The effects are fast and lasting. The effects are fast and lasting. •The symptoms will vanish after oral The symptoms will vanish after oral administration of chloroquine in 24~48 h, blood administration of chloroquine in 24~48 h, blood malarial parasites disappear in 48 ~72 h, the malarial parasites disappear in 48 ~72 h, the recurrence rate in one month is low. recurrence rate in one month is low.

Pharmacological effectsPharmacological effects

Anti-malarial Anti-malarial drugsdrugsChloroquiChloroqui

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2. Immune inhibition2. Immune inhibition•Treatment of rheumatoid Treatment of rheumatoid arthritis, lupus erythematosus arthritis, lupus erythematosus

3. Extraintestinal amebiasis3. Extraintestinal amebiasis•Amoeba trophozoite amebic Amoeba trophozoite amebic liver abscessliver abscess


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•Accumulation in erythrocyte→PH↑ → Accumulation in erythrocyte→PH↑ → malarial pigment sythesis↓malarial pigment sythesis↓•Haemoglobin-quinolineHaemoglobin-quinoline 喹啉喹啉 compound → haemoglobin accumulate compound → haemoglobin accumulate in plasmodium ↑in plasmodium ↑•Insert in the double stranded DNA Insert in the double stranded DNA helix → DNA replication and RNA helix → DNA replication and RNA transcription ↓transcription ↓


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ADME of ADME of chloroquine:chloroquine:

well absorbed after oral well absorbed after oral administration;administration; TTmaxmax = 3 = 3 ~~ 5 hr, t5 hr, t½½> 1 week;> 1 week; Widely distributed, the Widely distributed, the concentration in liver, lung, and concentration in liver, lung, and kidney is higher 200 ~ 700 times kidney is higher 200 ~ 700 times than blood;than blood; The concentration in erythrocyte The concentration in erythrocyte is higher 20 ~ 30 times than plasma; is higher 20 ~ 30 times than plasma; the concentration in infected the concentration in infected erythrocyte by malarial parasite is erythrocyte by malarial parasite is higher 25 times than normal higher 25 times than normal erythrocyte.erythrocyte.


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①Malaria: ▲to control the symptoms of benign malaria( 良性疟 ); ▲to cure subtertian malaria( 恶性疟 ); ▲symptomatic prevention in epidemic area( 疫区的症状性预防 ). ②Amebiasis( 阿米巴病 ): It can kill amebic trophozoite( 滋养体 ), to treat systemic amebiasis( 肠外阿米巴病 ), such as amebic hepatitis( 阿米巴肝炎 ) and amebic hepatic abscess( 阿米巴肝脓肿 ).

③Immune disease( 免疫性疾病 ).


Clinical uses:

ChloroquiChloroquinene

Adverse reaction

Rare at the usual antimalarial dosageRare at the usual antimalarial dosage

Pruritus (Pruritus ( 搔痒症搔痒症 ) common among dark-) common among dark-skinned people.skinned people.

Transient headaches, nausea, vomiting, Transient headaches, nausea, vomiting, gastrointestinal symptoms and "blurred gastrointestinal symptoms and "blurred vision“.vision“.

Others: aplastic blood and neurological Others: aplastic blood and neurological disorders, such as polyneuritisdisorders, such as polyneuritis 多发性神经多发性神经炎炎 , ototoxicity, seizures and , ototoxicity, seizures and neuromyopathy.neuromyopathy.


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1.1.Quinine Quinine 奎宁奎宁2.2.MefloquineMefloquine 甲氟喹甲氟喹3.3.Pyronaridine Pyronaridine 咯萘啶咯萘啶4.4.ArtemisininArtemisinin 青蒿素青蒿素5.5.Artemether and artesunate Artemether and artesunate 蒿甲醚和青蒿琥酯蒿甲醚和青蒿琥酯

OtherOther angentsangents killkill erythrocyticerythrocytic parasitesparasites


Quinine( 奎宁 )

Quinine is the chief alkaloid of cincho-na( 金鸡纳 ), the bark of the South Ameri-

can cinchona tree.(1)Anti-malarial action and clinical uses: Quinine acts primarily as a blood schi-zontocide( 杀裂殖体药 ) to control the clini-cal symptoms; It is a gametocide for gametocytes( 配子体 ) of P. vivax( 间日疟原虫 ) & P. malariae( 三日疟原虫 ) also, but not effective for game-tocytes of P. falciparum( 恶性疟原虫 ).

Anti-malarial Anti-malarial drugsdrugsquiniquini

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Quinine is more toxic and less effective than chloroquine. but, it is especially valuable to treat: ①chloroquine-resistant and multidrug-resistant subtertian malaria( 耐氯喹和多药耐受的恶性疟 ), ②severe cerebral malaria( 严重的脑型疟 ).

(2)Adverse reaction: more. ①Cinchonism( 金鸡纳反应 ): ringing in the ears( 耳鸣 ), headache, nausea, disturbed vision, etc.


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②Myocardial depression( 心肌抑制作用 ): to reduce myocardial contractility, and slow down conduction and prolong refra-ctory period, but weaker than quinidine ( 奎尼丁 , dextrogyre of quinine).

③Stimulating womb( 兴奋子宫 ): can induce abortion, not to be take by pregnant woman.

④Idiosyncrasy( 特异质反应 ): acute hemolytic reaction.


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Mefloquine( 甲氟喹 )

(1)Anti-malarial action:　 It is an efficient schizontocide in ery-throcytic stage, effective to chloroquine-resistant subtertian malaria. (2)Clinical uses: ①to treat chloroquine-resistant subter-tian malaria. ②to prevent and control the symptoms of benign malaria, once/two week. (3)Adverse reaction: GI reaction, nervous and pschic reaction.

Anti-malarial Anti-malarial drugsdrugsmefloquimefloqui

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Artemisinin(Qinghaosu, 青蒿素 )

(1)Anti-malarial action:　 It is a highly efficient malariacide of schizonts in erythrocytic stage.

The effects are faster than that of chloroquine, and effective to chloroquine-resistant subtertian malaria, especially effective to cerebral malaria.

(2)Clinical uses: to treat chloroquine-resistant subter-tian malaria, and to treat benign malaria also. but its recurrence rate is high.

(3)Adverse reaction: less, GI reaction, occasionally serum GPT .


Primaquine ( 伯氨喹 )

(1)Anti-malarial action: can kill dormancytes( 休眠子 ) of tertian malaria and various gametocytes( 配子体 ) of subtertian malaria. Owing to elimination fast, the effects are not lasting.

Pharmacological effectsHighly active against the gametocytes 配子体 of all malaria species →dissemination ↓

Active against hypnozoites 迟发型子孢子 of the relapsing malarial parasites

The only drug currently used for the treatment of relapsing malaria

Anti-malarial Anti-malarial drugsdrugsprimaquiprimaqui

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AntimalarialAntimalarial drugsdrugs -- PrimaquinePrimaquineAnti-malarial Anti-malarial

drugsdrugs

(2)Mechanism of actions

Inhibition of coenzyme Q Inhibition of reduction of NADP

(3)Clinical uses: ①use it with chloroquine to

radically treat benign malaria( 良性疟 );

②to prevent transmission of subterti-an malaria( 恶性疟 ).

primaquiprimaquinene

(3)Adverse reaction:

Its toxicity is large

nervous system :Transient dizziness , nausea, vomiting, gastrointestinal symptoms

blood system:Acute hemolytic anemia( 急性溶血性贫血 ), methemoglobinemia 高铁血红蛋白血症

primaquiprimaquinene


Pyrimethamine( 乙胺嘧啶 )

(1)Anti-malarial action:

①It can kill schizonts( 裂殖体 ) of subter-tian malarial parasites and benign mala-rial parasites in exoerythrocytic stage;

②It can also kill immature schizonts of erythrocytic stage;

③It can not kill gametocytes( 配子体 ), but can inhibit development of sporop-hytes( 孢子体 ) in mosquito.

Mechanism of actions

Dihydrofolate reductase inhibitor

Anti-malarial Anti-malarial drugsdrugsprimethamiprimethami

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(2)Clinical uses:　 It is mainly used to prevent malaria, the first chosen drug for malarial prevention.

(3)Adverse reaction: Folate metabolism disturbtance Its toxicity is less. But long-term and larger dose admi-nistration, it can cause megaloblastic anemia( 巨红细胞贫血 ).

This adverse reaction can be treated by formyl tetrahydrofolic acid( 甲酰四氢叶酸 ).

In addition, once large dose can cause acute intoxication.

Anti-malarial Anti-malarial drugsdrugsprimethamiprimethami

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3. Summarization:(1)Selection of antimalarial drugs:①Symptom control: Chloroquine;②Cerebral malaria: Artemisinin, im. Quinine dihydrochloride, iv gtt( 静脉滴注 ); ③Chloroquine-resistant subtertian malaria: Artemisinin, Quinine, Mefloquine; ④Resting stage: Pyrimethamine + Primaquine;⑤Prevent transmission: Pyrimethamine. (2)Combined administration: Chloroquine + Primaquine; Pyrimethamine + Primaquine( 防止复发 ).


Atovaquone( 阿托伐醌 ) Atovaquone, a hydroxynaphthoquinone , was initially d

eveloped as an antimalarial agent Atovaquone has also been approved by the FDA for the t

reatment of mild to moderate P jiroveci pneumonia. Malarone, a fixed combination of atovaquone (250 mg)

and proguanil (100 mg) highly effective for both the treatment and chemoprophylaxis of falcip

arum malaria （恶性疟疾） , and it is now approved for both indications in the USA.

For chemoprophylaxis, Malarone must be taken daily. It has an advantage over mefloquine and doxycycline in requiring shorter periods of treatment before and after the period at risk for malaria transmission, but it is more expensive than the other agents. It should be taken with food.

氯喹

奎宁

氯胍

伯氨喹

甲氟喹

奎尼丁

多西环素

青蒿素

阿莫地喹

苯芴醇

卤泛曲林

阿托伐醌 / 氯胍( 马拉隆 )

磺胺多辛 - 乙胺嘧啶

Part2 Anti-schistosomiasis drugs(( 抗血吸虫药抗血吸虫药 ))

Schistosomiasis( 血吸虫病 ) is caused by Schistosoma( 血吸虫 , 裂体吸虫 ) infection.

There are five kinds of Schistosoma caused Schistosomiasis of human:

S. japonia( 日本血吸虫 ), S. heamatobium ( 埃及血吸虫 ), S. mansoni( 曼索血吸虫 ), S. intercalatum( 间插血吸虫 ) and S. mekongi ( 湄公血吸虫 ).

In our country, the schistosomiasis is caused mainly by S. japonia.

肝硬化主征肝硬化主征

巨脾巨脾

腹水腹水

门脉高压门脉高压

In the past, the drug treated schisto-somiasis was PAT( 酒石酸锑钾 , potassium antimony tartrate), its course of treat-ment was longer, the toxicity larger, need iv administration, and the ADRs were severe.

Since 1970’, praziquantel( 吡喹酮 ) had be discovered, because its ADRs is less, praziquantel became the main drug to treat schistosomiasis.

Anti-schistosomiasis Anti-schistosomiasis drugsdrugs

Praziquantel( 吡喹酮 )(1)Anti-parasite effects: It is a highly effective and broad spectrum anti-parasite drug. It can kill schistosoma( 血吸虫 ) directly; and it can kill other trematde( 吸虫 ) too, e.g. clonorchis sinensis( 华支睾吸虫 , 即“肝吸虫” ), lung fluke( 肺吸虫 ), fasciolopsis( 布氏姜片虫 , 即“肠吸虫” ); certain intestinal parasites(e.g. tapeworm( 绦虫 ). Mechanism of anti-schistosoma effects: It can increase the membrane permeability to certain monovalent and divalent cation, particularly Ca2+, to cause schistosoma muscular contraction and spastic paralysis.

Anti-schistosomiasis Anti-schistosomiasis drugsdrugspraziquantpraziquant

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(2)Clinical uses:①Schistosomiasis( 血吸虫病 ): It is effective to both acute & chronic schistosomiasis. To acute schistosomiasis: It is to bring down the fever, and alleviate the systematic symptoms fast, the late results reach 90%; To chronic schistosomiasis: The curative effect is well too, only 1 ～ 2 days of course of treatment, the late results reach 90% too. To the later period patients with cardiac and hepatic complication: can accept the course of treatment smoothly.


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②Clonorchiasis( 华枝睾吸虫病 ): It is the first-chosen drug.③Other trematode( 其他吸虫 ): Used to treat paragonimiasis( 肺吸虫病 ) and fasciolopsiasis( 姜片虫病 ). It is the first-chosen drug.④Taeniasis( 绦虫病 ): Including imago( 成虫 ) & larva( 幼虫 ) of various tapeworm( 绦虫 ) infective disease, such as cysticercisis( 囊虫症——猪囊虫尾蚴病 ) and hydatidosis( 包虫病——由细粒棘球绦虫的幼虫引起 ). It is the first-chosen drug too.


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(3)Adverse reaction less and lighter (than potassium anti-mony tartrate, 酒石酸锑钾 ). After oral administration, it can cause abdominal pain, nausea, dizziness, and headache in short-term.


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C. anti-filariasis drugs ( 抗丝虫病药 )

下肢象皮肿

阴囊象皮肿

Anti-filariasis Anti-filariasis drugsdrugs

Diethylcarbamazine Diethylcarbamazine 乙乙胺嗪胺嗪

Pharmacology actionPharmacology action

Diethylcarbamazine Diethylcarbamazine immobilizes microfilariae(immobilizes microfilariae( 微丝微丝蚴蚴 )and alters their surface )and alters their surface structure, displacing them from structure, displacing them from tissues and making them more tissues and making them more susceptible to destruction by susceptible to destruction by host defense mechanisms. host defense mechanisms.

The mode of action against The mode of action against adult worms is unknown.adult worms is unknown.


DiethylcarbamazineDiethylcarbamazineAdverse effectsAdverse effects

Generally mild and transientGenerally mild and transient

Include headache, malaise, Include headache, malaise, anorexia, weakness, nausea, anorexia, weakness, nausea, vomiting, and dizziness.vomiting, and dizziness.


huifang tang [email protected] anti-parasitic drugs ( 抗寄生虫药 )

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