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http://en.wikipedia.org/wiki/Artemisinin
Artemisinin
From Wikipedia, the free encyclopedia
Artemisinin /rtmsnn/, also known as Qinghaosu (Chinese: ), and its derivatives are a group of
drugs that possess the most rapid action of all current drugs against Plasmodium falciparum malaria.[1]
Treatments containing an artemisinin derivative (artemisinin-combination therapies, ACTs) are now standard
treatment worldwide for P. falciparum malaria. Artemisinin is isolated from the plant Artemisia annua, sweet
wormwood, a herb employed in Chinese traditional medicine. It can now also be produced using genetically
engineered yeast.
Artemisinin
Chemically, artemisinin is a sesquiterpene lactone containing an unusual peroxide bridge. This peroxide is
believed to be responsible for the drug's mechanism of action. Few other natural compounds with such a
peroxide bridge are known.[2]
Use of the drug by itself as a monotherapy is explicitly discouraged by the World Health Organization, as
there have been signs that malarial parasites are developing resistance to the drug. Therapies that combine
artemisinin with some other antimalarial drug are the preferred treatment for malaria and are both effective
and well tolerated in patients. The drug is also increasingly being used in Plasmodium vivax malaria,[3] as well
as being a topic of research in cancer treatment.
Clinical data
Contents
Legal status
Routes
Oral
Identifiers
1 History
1.1 Etymology
1.2 Discovery
2 Artemisinin derivatives
3 Indications
3.1 Uncomplicated malaria
3.2 Severe malaria
3.3 Cancer treatment
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CAS number
63968-64-9
ATC code
P01BE01
PubChem
CID 68827
ChemSpider
62060
UNII
9RMU91N5K2
KEGG
D02481
ChEBI
CHEBI:223316
2014/11/05 09:26 PM
http://en.wikipedia.org/wiki/Artemisinin
ChEMBL
CHEMBL77
Synonyms
Artemisinine, Qinghaosu
5 Adverse effects
Chemical data
6 Mechanism of action
Formula
C15H22O5
7 Dosing
Mol. mass
282.332 g/mol
SMILES
9 Synthesis
InChI
Physical data
Density
Melt. point
152157 C (306315 F)
10 References
11 External links
History
Etymology
Artemisinin is an antimalarial lactone derived from qing hao (Artemisia annua or sweet wormwood). The medicinal value of this plant has been known to
the Chinese for at least 2,000 years. In 1596, Li Shizhen recommended tea made from qing hao specifically to treat malaria symptoms in his "Compendium of
Materia Medica". The genus name is derived from the Greek goddess Artemis and, more specifically, may have been named after Queen Artemisia II of Caria, a
botanist and medical researcher in the fourth century bce.[4]
Discovery
Artemisia annua (A. annua) is a common herb found in many parts of the world, and has been used by Chinese herbalists for more than two thousand years in
the treatment of malaria. The earliest record dates back to 200 BC, in the "Fifty-two Prescriptions" unearthed from the Mawangdui Han Dynasty tombs.[5] Its
antimalarial application was first described, in Zhouhou Beiji Fang ("The Handbook of Prescriptions for Emergencies", Chinese: ), edited in the
middle of the fourth century by Ge Hong; in that book, 43 malaria treatment methods were recorded.[6] Images of the original scientific papers that record the
history of the discovery, have been available online since 2006.[7]
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In 1967, a plant screening research program, under the name Project 523, was set up by the Chinese army to find an adequate
treatment for malaria; the program and early clinical work were ordered of Chairman Mao Zedong at the request of North
Vietnamese leaders to provide assistance for their malaria-ridden army.[8] In the course of this research, Tu Youyou
discovered artemisinin in the leaves of Artemisia annua (annual wormwood; 1972).[9] The drug is named Qinghaosu (Chinese:
) in Chinese. It was one of many candidates tested as possible treatments for malaria by Chinese scientists, from a list of nearly
5000 traditional Chinese medicines. Tu Youyou also discovered that a low-temperature extraction process could be used to isolate
an effective antimalarial substance from the plant; Tu says she was influenced by a traditional Chinese herbal medicine source
saying that this herb should be steeped in cold water.[10] The extracted substance, once subject to purification, proved to be a usable
antimalarial drug.[11] A 2012 review reported that artemisinin-based therapies were the most effective drugs for treatment of malaria
at that time;[12] it was also reported to clear malaria parasites from patients' bodies faster than other drugs. In addition to artemisinin,
Project 523 developed a number of products that can be used in combination with artemisinin, including lumefantrine, piperaquine,
and pyronaridine.[9]
http://en.wikipedia.org/wiki/Artemisinin
Artemisia annua
For many years after the discovery, access to the purified drug and the plant from which it was extracted were restricted by the
Chinese government. It was not until the Chinese economic reform in the late 1970s and early 1980s that news of the discovery reached scientists outside China
via results published in the Chinese Medical Journal (in 1979).[13] Ying Lee, one of the scientists involved in the research into artemisinin, said the Chinese had
distrusted the West at the time. The research was met with skepticism at first, partly because the chemical structure of artemisinin, particularly the peroxide
portion, appeared to be too unstable to be a viable drug.[2]
In the late 1990s, Novartis bought a new Chinese patent for a combination treatment with artemether and lumefantrine, providing the first artemisinin-based
combination therapies (ACTs) (Coartem) at reduced prices to the World Health Organisation.[14] In 2006, after artemisinin had become the treatment of choice
for malaria, the WHO called for an immediate halt to single-drug artemisinin preparations in favor of combinations of artemisinin with another malaria drug, to
reduce the risk of parasites developing resistance.[15]
In 2011, Tu Youyou was awarded the prestigious Lasker-DeBakey Clinical Medical Research Award for her role in the discovery and development of
artemisinin.[9][16] The New York Times notes that the discovery of artemisinin is under consideration for a future Nobel Prize in Physiology or Medicine.[17]
Artemisinin derivatives
Because artemisinin itself has physical properties such as poor bioavailability that limit its effectiveness, semisynthetic derivatives of artemisinin have been
developed. These include:
Artesunate (water-soluble: for oral, rectal, intramuscular, or intravenous use)
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Indications
Uncomplicated malaria
Artemisinins can be used alone, but this leads to a high rate of recrudescence (return of parasites) and other drugs are required to clear the body of all parasites
and prevent recurrence. The World Health Organization (WHO) is pressuring manufacturers to stop making the uncompounded drug available to the medical
community at large, aware of the catastrophe that would result if the malaria parasite developed resistance to artemisinins.[21]
The WHO has recommended artemisinin combination therapies (ACT) be the first-line therapy for P. falciparum malaria worldwide.[22] Combinations are
effective because the artemisinin component kills the majority of parasites at the start of the treatment, while the more slowly eliminated partner drug clears the
remaining parasites.[23]
Several fixed-dose ACTs are now available containing an artemisinin component and a partner drug which has a long half-life, such as mefloquine (ASMQ[24]),
lumefantrine (Coartem), amodiaquine (ASAQ), piperaquine (Duo-Cotecxin), and pyronaridine (Pyramax). Increasingly, these combinations are being made to
GMP standard. A separate issue concerns the quality of some artemisinin-containing products being sold in Africa and Southeast Asia.[25][26]
Artemisinins are not used for malaria prophylaxis (prevention) because of the extremely short activity (half-life) of the drug. To be effective, it would have to be
administered multiple times each day.
Severe malaria
Artesunate administered by intravenous or intramuscular injection has proven superior to quinine in large, randomised controlled trials in both adults [27] and
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children.[28] Combining all trials comparing these two drugs, artesunate is associated with a mortality rate that is approximately 30% lower than that of
quinine.[28] Reasons for this difference include reduced incidence of hypoglycaemia, easier administration and more rapid action against circulating and
sequestered parasites. Artesunate is now recommended by the WHO for treatment of all cases of severe malaria.
Cancer treatment
Artemisinin is undergoing early research and testing for the treatment of cancer.[29] Artemisinin has anticancer effects in experimental models of hepatocellular
carcinoma.[30] Artemisinin has a peroxide lactone group in its structure, and 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. Recent pharmacological evidence demonstrates the artemisinin derivative dihydroartemisinin
targets human metastatic melanoma cells in vitro with induction of phorbol-12-myristate-13-acetate-induced protein 1 dependent mitochondrial apoptosis that
occurs downstream of iron-dependent generation of cytotoxic oxidative stress.[31]
Helminth parasites
Serendipitous discovery was made in China while searching for novel anthelmintics for schistosomiasis. Artemisinin was effective against schistosomes, the
human blood flukes, which are the second-most prevalent parasitic infections, after malaria. Artemisinin and its derivatives are all potent anthelmintics.[32]
Artemisinins were later found to possess a broad spectrum of activity against a wide range of trematodes, including Schistosoma japonicum, S. mansoni, S.
haematobium, Clonorchis sinensis, Fasciola hepatica, and Opisthorchis viverrini. Clinical trials were also successfully conducted in Africa among patients with
schistosomiasis.[33] A randomized, double-blind, placebo-controlled trial also revealed the efficacy against schistosome infection in Cte d'Ivoire[34] and
China.[35]
Resistance
Clinical evidence for artemisinin resistance in southeast Asia was first reported in 2008,[36] and was subsequently confirmed by a detailed study from western
Cambodia.[37] Resistance in neighbouring Thailand was reported in 2012,[38] and in Northern Cambodia, Vietnam and Eastern Myanmar in 2014.[39][40]
Emerging resistance was reported in Southern Laos, central Myanmar and North-Eastern Cambodia in 2014.[39][40] The parasite's kelch gene on chromosome 13
appears to be a reliable molecular marker for clinical resistance in southeast Asia.[41]
In April 2011, the WHO stated that resistance to the most effective antimalarial drug, artemisinin, could unravel national (India) malaria control programs, which
have achieved significant progress in the last decade. WHO advocates the rational use of antimalarial drugs and acknowledges the crucial role of community
health workers in reducing malaria in the region.[42]
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Adverse effects
Artemisinins are generally well tolerated at the doses used to treat malaria.[43] The side effects from the artemisinin class of medications are similar to the
symptoms of malaria: nausea, vomiting, anorexia, and dizziness. Mild blood abnormalities have also been noted. A rare but serious adverse effect is allergic
reaction.[43][44] One case of significant liver inflammation has been reported in association with prolonged use of a relatively high-dose of artemisinin for an
unclear reason (the patient did not have malaria).[45] The drugs used in combination therapies can contribute to the adverse effects experienced by those
undergoing treatment. Adverse effects in patients with acute P. falciparum malaria treated with artemisinin derivatives tend to be higher.[46]
Mechanism of action
Most artemisinins used today are prodrugs of the biologically active metabolite dihydroartemisinin, which is active during the stage when the parasite is located
inside red blood cells. Although there is no consensus regarding the mechanism through which artemisinin derivatives kill the parasites,[47] several lines of
evidence indicate that artemisinins exert their antimalarial action by radical formation that depends on their endoperoxide bridge. When the parasite that causes
malaria infects a red blood cell, it consumes hemoglobin within its digestive vacuole, a process that generates oxidative stress.[48] In one theory of the mechanism
of action the iron of the heme directly reduces the peroxide bond in artemisinin, generating high-valent iron-oxo species and resulting in a cascade of reactions
that produce reactive oxygen radicals which damages the parasite and lead to its death.[49] However, the likelihood of this mechanism has been debated.[50] A
more recently described alternative is that artemisinins disrupt cellular redox cycling.[51] Artesunate has been shown to potently inhibit the essential Plasmodium
falciparum exported protein 1 (EXP1), a membrane glutathione S-transferase.[52]
Numerous studies have investigated the type of damage oxygen radicals may induce. For example, Pandey et al. have observed inhibition of digestive vacuole
cysteine protease activity of malarial parasites by artemisinin.[53] These observations were supported by ex vivo experiments showing accumulation of
hemoglobin in the parasites treated with artemisinin and inhibition of hemozoin formation by malaria parasites, although this inhibition was not seen in an in vitro
B-hematin inhibition assay.[54] Electron microscopic evidence linking artemisinin action to the parasite's digestive vacuole has been obtained showing that the
digestive vacuole membrane suffers damage soon after parasites are exposed to artemisinin.[55] This would also be consistent with data showing that the digestive
vacuole is already established by the mid-ring stage of the parasite's blood cycle,[56] a stage that is sensitive to artemisinins but not other antimalarials. However,
fluorescently tagged artemisinin was seen in the Golgi, ER and mitochondria, rather than the digestive vacuole, suggesting that the vacuolar damage may be a
downstream effect, and also that tiny ring stages (containing minimal digested material) are highly susceptible to artemisinins.[57][58][59]
Other suggested targets include the mitochondrial electron transport chain [60] and the parasite's SERCA pump (PfATP6/PfSERCA);[61] neither theory has
gained widespread acceptance.
Dosing
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Artemisinin derivatives have half-lives of the order of an hour, and therefore require at least daily dosing over several days. For example, the WHO-approved
adult dose of co-artemether (artemether-lumefantrine) is 4 tablets at 0, 8, 24, 36, 48 and 60 hours (six doses).[62][63]
Artemisinin is not soluble in water, therefore Artemisia annua tea was postulated not to contain pharmacologically significant amounts of artemesinin.[64]
However, this conclusion was rebuked by several experts who stated that hot water (85 C), 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 its tea preparation have been
suggested.[65]
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availability for ACTs treatment. In August 2014, Sanofi announced the release of the first batch of semisynthetic artemisinin. 1.7 million doses of Sanofi's
ArteSunate AmodiaQuine Winthrop (ASAQ Winthrop), a fixed-dose artemisinin-based combination therapy will be shipped to half a dozen African countries
over the next few months.[72]
Synthesis
Biosynthesis in A. annua
The biosynthesis of artemisinin is believed to involve the mevalonate pathway (MVA) and the cyclization of farnesyl diphosphate (FDP). It is not clear whether
the non-mevalonate pathway pathway can also contribute 5-carbon precursors (IPP or/and DMAPP), as occurs in other sesquiterpene biosynthetic systems. 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 photo-oxidation to produce dihydroartemisinic acid
hydroperoxide. Ring expansion by the cleavage of hydroperoxide and a second oxygen-mediated hydroperoxidation finish the biosynthesis of artemisinin.
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Chemical synthesis
The total synthesis of the sesquiterpene lactone, artemisinin (quinghaosu) has been performed from available organic starting materials, using basic organic
reagents, many times. The first two total syntheses were a "remarkable... stereoselective synthesis" by Schmid and Hofheinz at Hoffmann-La Roche in Basel
starting from ()-isopulegol (13 steps, 5% overall yield) and a concurrent synthesis by Zhou and coworkers at the Shanghai Institute of Organic Chemistry from
R-(+)-citronellal (20 steps, 0.3% overall yield).[73] Key steps of the Schmid-Hofheinz approach included an initial Ohrloff stereoselective
hydroboration/oxidation to establish the "off-ring" methyl stereocenter on the propene side chain; two sequential lithium-reagent mediated alkylations that
introduced all needed carbon atoms and that were, together highly diasteroselective; and further reduction, oxidation, and desilylation steps performed on this
mono-carbocyclic intermediate, including a final singlet oxygen-utilizing photooxygenation and ene reaction, which, after acidic workup closed the three
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remaining oxacyclic rings of the desired product, artemisinin, in a single step.[73][74] (In essence, the final oxidative ring closing operation in these syntheses
accomplishes the closing three biosynthetic steps shown above.)
A wide variety of further routes continue to be explored, from early days until today, including total synthesis routes from R-(+)-pulegone, isomenthene,[73] and
even 2-cyclohexen-1-one,[75] as well as routes better described as partial or semisyntheses from a more plentiful biosynthetic precursor, artemisinic acidin the
latter case, including some very short and very high yielding biomimetic synthesis examples (of Roth and Acton, and Haynes et al., e.g., 3 steps, 30% yield),
which again feature the singlet oxygen ene chemsitry.[73][76][77]
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External links
History, Aetiology, Pathophysiology, Clinical Features, Diagnosis, Treatment, Complications And Control Of
Malaria: Artemisinin Derivatives (http://www.malariasite.com/malaria/artemisinin.htm)
Design and synthesis of antimalarial endoperoxides (http://www.organic-chemistry.org/Highlights
Look up artemisinin in
Wiktionary, the free
dictionary.
/2004/25OctoberA.shtm)
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