Artemisinin (pronounced
/ɑrtɨˈmɪsɨnɨn/) is a
drug used to treat multi-drug resistant strains of
falciparum
malaria. The compound (a
sesquiterpene lactone) is isolated from the plant
Artemisia annua. Not all plants of this species
contain artemisinin. Apparently it is only produced when the
plant is subjected to certain conditions, most likely
biotic or
abiotic stress. It can be synthesized from
artemisinic acid.[1]
Politics
For many years, access to the purified drug and the plant
it was extracted from were restricted by the Chinese
government. It was not until the late 1970s and early 80s
that news of the discovery reached scientists outside China.
The World Health Organisation (WHO) tried to contact Chinese
scientists and officials to find out more, but drew a blank.
Dr Ying Lee, one of the scientists involved in the research
into Artemisinin, said the Chinese distrusted the West. The
Chinese suspected the West just wanted to exploit the drug
and sell it around the world slightly altered and
repatented. The fact that there were several Americans on
the WHO's steering board on malaria and that some were from
the military did not help clear the distrust. It can be
noted Americans had just invested a lot into
Mefloquine, a synthetic version of
Chloroquine.
Currently, artemisinin is widely used in China and
Southeast Asia for treatment of malaria. The World Health
Organization is pressuring manufacturers to stop making the
pure drug, saying it would be a loss if the parasites would
build up resistance for the only known drug the parasites
have not developed resistance to.[5].
In vitro experiments have been able to generate a
resistant strain of the parasite and resistant strains have
been found from field samples.
Because artemisinin itself has physical properties such
as poor
bioavailability that limit its effectiveness,
semi-synthetic
derivatives of artemisinin, including
artemether and
artesunate, have been developed. However, their activity
is not long lasting, with significant decreases in
effectiveness after one to two hours. To counter this
drawback, artemisinin is given alongside
lumefantrine (also known as benflumetol) to treat
uncomplicated falciparum malaria. Lumefantrine has a
half-life of about 3 to 6 days. Such a treatment is called
ACT (artemisinin-based
combination therapy); other examples are
artemether-lumefantrine, artesunate-mefloquine,
artesunate-amodiaquine,
and artesunate-sulfadoxine/pyrimethamine.
Recent trials have shown that ACT is more than 90%
effective, with a recovery of malaria after three days,
especially for the
chloroquine-resistant
Plasmodium falciparum.
The
World Health Organisation has recommended that a switch
to ACT should be made in all countries where the malaria
parasite has developed resistance to
chloroquine. Artemisinin and its derivatives are now
standard components of malaria treatment in China, Vietnam,
and some other countries in Asia and Africa, where they have
proved to be safe and effective anti-malarial drugs. They
have minimal adverse side effects. Currently, artemisinin is
not widely available in the United States or Canada, but is
easy to find in Africa and Asia. There have been some
concerns about the quality of some products on offer in
Africa,[6]
where so called 'Artemisinin Combination Treatments' are
sold, having cheaper ineffective substitutes in place of
Artemisinin, the most expensive ingredient.
To counter the present shortage in leaves of
Artemisia annua, researchers have been searching for
a way to develop artemisinin artificially in the laboratory.
A recent paper in Nature[7]
presented a genetically engineered yeast that can synthesize
a precursor called artemisinic acid which can be chemically
converted to Artemisinin. The compound called
OZ-277 (also known as RBx11160), developed by
Jonathan Vennerstrom at the
University of Nebraska, has proved to be even more
effective than the natural product in test-tube trials. A
six month trial of the drug on human subjects in Thailand
was started in January 2005. There are also plans to have
the plant grow in other areas of the world outside Vietnam
and China (Kenya, Tanzania, Madagascar).
Analogues
There are a number of derivatives and
analogues within the artemisinin family:
-
Artesunate (water-soluble: for oral, rectal,
intramuscular, or intravenous use)
-
Artemether (lipid-soluble: for oral, rectal or
intramuscular use)
-
Arteether
-
Dihydroartemisinin
-
Artelinic acid
-
Artenimol
-
Artemotil
Cancer treatment
Artemisinin is under early research and testing for
treatment of
cancer, primarily by researchers at the University of
Washington.[8]
[9]
Artemisinin has a
peroxide
lactone group in its structure. It is thought that when
the peroxide comes into contact with high iron
concentrations (common in cancerous cells), the molecule
becomes unstable and releases
reactive oxygen species. It has been shown to reduce
angiogenesis and the expression of
vascular endothelial growth factor in some tissue
cultures.
Mechanism of action
The specific
mechanism of action of artemisinin is not well
understood, and there is ongoing research directed at
elucidating it. When the parasite that causes malaria
infects a red blood cell, it consumes hemoglobin and
liberates free
heme, an iron-porphyrin complex. The iron reduces the
peroxide bond in artemisinin generating high-valent iron-oxo
species, resulting in a cascade of reactions that produce
reactive oxygen
radicals which damage the parasite leading to its death.[10]
Numerous studies have investigated the type of damage
that these oxygen radicals may induce. For example, Pandey
et al. have observed inhibition of digestive vacuole
cysteine protease activity of malarial parasite by
artemisinin.[11]
These observations were further confirmed by ex vivo
experiments showing accumulation of hemoglobin in the
parasites treated with artemisinin, suggesting inhibition of
hemoglobin degradation. They found artemisinin to be a
potent inhibitor of hemozoin formation activity of malaria
parasite.
A 2005 study investigating the mode of action of
artemisinin using a yeast model demonstrated that the drug
acts on the electron transport chain, generates local
reactive oxygen species, and causes the depolarization of
the mitochondrial membrane.[12]
Artemisinins have also been shown to
inhibit PfATP6, a
SERCA-type
enzyme (calcium transporter) and artemisinin has been
shown to compete with
thapsigargin for SERCA binding, though artemesinin is
much less toxic to mammalian cells. These experiments
however, have only been conducted in a recombinant system (Xenopus
oocytes), and it remains to be verified within P.
falciparum parasites. Resistance to artemisinin is
conferred by a single mutation in the calcium transporter
(PfATP6). This mutation has been studied in the laboratory
but recently a study from French Guiana in field isolates of
malaria parasites has identified a different mutation in the
calcium transporter (PfATP6) that is associated with
resistance to artemether, lending support to the idea that
PfATP6 is the target for artemisinins.[13]
Dosing
The WHO approved adult dose of co-artemether (artemether-lumofantrine)
for malaria is 4 tablets at 0, 8, 24, 36, 48 and 60 hours
(six doses).[14][15]
This has been proven to be superior to regimens based on
amodiaquine.[16]
Artemesinin is not soluble in water and therefore
Artemisia annua tea was postulated not to contain
pharmacologically significant amounts of artemesinin.[17].
However, this conclusion was rebuked by several experts who
stated that hot water (85oC), and not boiling
water, should be used to prepare the tea. Although Artemisia
tea is not recommended as a substitute for the ACT (artemisinin
combination therapies) more clinical studies on artemisia
tea preparation have been suggested.[18] The artemesinins are not used for malaria prophylaxis
(prevention) because of the extremely short activity of the
drug. To be effective, it would have to be administered
multiple times each day.
Synthesis
In 2006 a team from Berkeley published an article
claiming that they had engineered
Saccharomyces cerevisiae microbes that can produce
the precursor artemisinic acid. The synthesized artemisinic
acid can then be transported out, purified and turned into a
drug that they claim will cost roughly 0.25 cents per dose.
Details of the formation of artemisinic acid involves a
mevalonate pathway, expression of amorphadiene synthase, a
novel cytochrome P450 monooxygenase (CYP71AV1) and its redox
partner from A. annua. A three-step oxidation of
amorpha-4,11-diene gives the resulting artemisinic acid.[19]
Amyris Biotechnologies is collaborating with
UC Berkeley and the
Institute for One World Health to further develop this
technology.[20]
Using seed supplied by Action for Natural Medicine
(ANAMED), the World Agroforestry Centre (ICRAF) has
developed a hybrid, dubbed A3, which can grow to a height of
3 m and which produces 20 times more artemisinin than wild
varieties. In northwestern Mozambique, ICRAF is working
together with a medical organisation, Médecins sans
frontières (MSF), ANAMED and the Ministry of Agriculture and
Rural Development to train farmers on how to grow the shrub
from cuttings, and to harvest and dry the leaves to make
artemisia tea. Cultivation of this crop may well prove a
valuable niche market for Africa, given the strong demand
for the plant from pharmaceutical laboratories.
The biosynthesis of artemisinin is expected to involve
the mevalonate pathway (MVA) and the cyclization of FDP (farnesyl
diphosphate). Although it is not clear whether the DXP (deoxyxylulose
phosphate)pathway can also contribut 5-carbon precurosrs
(IPP or/and DMAPP), as occurs in other sesquiterpene
biosynthetic system. The routes from artemisinic alcohol to
artemisinin remain controversial and they differ mainly in
when the reduction step takes place. Both routes suggested
dihydroartemisinic acid as the final precursor to
artemisinin. Dihydroartemisinic acid then undergoes
photoxidation to produce dihydroartemisinic acid
hydroperoxide. Ring expansion by the cleavage of
hydroeroxide and a second oxygen-mediated hydroperoxidation
furnish the biosynthesis of artemisinin.
The total synthesis of Artemisinin can also be performed
using basic organic reagents. In 1982, G. Schmid and W.
Hofheinz published a paper showing the complete synthesis of
artemisinin. Their starting material was (-)-Isopulegol (2)
which as converted to
methoxymethyl ether (3). The ether was hydroborated and
then underwent oxidative workup to give (4). The primary
hydroxyl group was then benzylated and the methoxymethyl
ether was cleaved resulting in (5) which would be oxidized
to (6). Next, the compound was protonated and treated with
(E)-(3-iodo-1-methyl-1-propenyl)-trimethylsilane to give
(7). This resulting ketone was reacted with lithium methoxy(trimethylsily)methylide
to obtain two diastereomeric alcohols, (8a) and (8b). 8a was
then debenzylated using (Li, NH3) to give lactone (9). The
vinylsilane was then oxidized to ketone (10). The ketone was
then reacted with fluoride ion that caused it to undergo
desilylation, enol ether formation and carboxylic acid
formation to give (11). An introduction of a hydroperoxide
function at C(3) of 11 gives rise to (12). Finally, this
underwent photooxygenation and then treated with acid to
produce artemisinin.[21]
References
-
Acton, N. &
Roth, R.J. On the conversion of dihydroartemisinic
acid into artemisinin. J. Org. Chem. 57,
3610-3614 (1992)
-
ChinaVitae: Tu Youyou
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Panyu Tiger
-
ycwb.com
-
"WHO
ultimatum on artemisinin monotherapy is showing
results".
British Medical Journal. Retrieved on
2008-11-14.
-
BBC news
-
Ro DK and
Paradise EM et al. Production of the antimalarial
drug precursor artemisinic acid in engineered yeast.
Nature. (2006) 440: 940-943.
-
University of Washington: News
-
University of Washington: Artemisinin
-
Cumming,
Jared N.; Ploypradith, Poonsakdi; Posner, Gary H..
Antimalarial activity of artemisinin (qinghaosu) and
related trioxanes: mechanism(s) of action. Advances
in Pharmacology (San Diego) (1997), 37 253-297.
-
Pandey et al
-
Li et
al., PLOS Genetics, September 2005, Volume 1,
Issue 3
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A.-C.
Uhlemann et al. Nature Struct. Mol. Biol.
12, 628-629;2005
-
Vugt MV, Wilairatana P, Gemperli B, et al.
(1999). "Efficacy of six doses of
artemether-lumefantrine (benflumetol) in multidrug-resistant
Plasmodium falciparum malaria". Am J Trop Med Hyg
60 (6): 936–42.
PMID 10403324.
-
Lefevre G, Looareesuwan S, Treeprasertsuk S, et
al. (2001). "A clinical and pharmacokinetic
trial of six doses of artemether-lumefantrine for
multidrug-resistant Plasmodium falciparum
malaria in Thailand". Am J Trop Med Hyg 64
(5–6): 247–56.
PMID 11463111.
-
Mutabingwa TK, Anthony D, Heller A, et al.
(2005). "Amodiaquine alone,
amodiaquine+sulfadoxine-pyrimethamine,
amodiaquine+artesunate, and artemether-lumefantrine
for outpatient treatment of malaria in Tanzanian
children: a four-arm randomised effectiveness
trial". Lancet 365 (9469): 1474–80.
doi:10.1016/S0140-6736(05)66417-3.
PMID 15850631.
-
Jansen FH (2006). "The herbal tea approach for
artemesinin as a therapy for malaria?". Trans R
Soc Trop Med Hyg 100 (3): 285–6.
doi:10.1016/j.trstmh.2005.08.004.
-
Bioline
-
Richmond
Sarpong, Jay D. Keasling. "Production of the
antimalarial drug precursor artemisinic acid in
engineered yeast" Nature 440, 940-943 (13 April
2006)
-
Amyris Biotechnologies
-
G. Schmid,
W. Hofheinz. "Total Synthesis of qinghaosu" J. Am.
Chem. Soc.; 1983; 105 (3); 624-625
External links
-
History, Aetiology, Pathophysiology, Clinical Features,
Diagnosis, Treatment, Complications And Control Of
Malaria: Artemisinin Derivatives
-
Design and synthesis of antimalarial endoperoxides
-
Clinical trials of artemether-lumefantrine
-
Malaria, Science, and Social Responsibility: Nonprofit
drug-development partnership seeks to cure the ills of
developing nations
-
Research on the use of Artemisinin for cancer treatment
-
Artemisia Annua L.: the Hope Against Malaria and Cancer
-
Artemisinin - Researchers blend folk treatment, high
tech for promising anti-cancer compound
-
BBC Horizon documentary about artemisinin
-
Artemisinin: From Malaria to Cancer Treatment, by Robert
Jay Rowen, MD Editor-in-Chief, Second Opinion
-
Artemisia Annua, by Memorial-Sloan Kettering Cancer
Center
-
Use of Artemisinin for Cancer Treatment and Bacterial
Infection, Henry Lai, Ph.D., University of Washington
(streaming video, Spring 2005)
-
WHO calls for an immediate halt to provision of
single-drug artemisinin malaria pills: New malaria
treatment guidelines issued by WHO
Reprinted from
Wikipedia