Rational dispensing and use of artemether-lumefantrine during pregnancy in Dar es Salaam, Tanzania

Artemether–Lumefantrine (ALu) is widely used for uncomplicated malaria during the second and third trimester of pregnancy. Because of the suspected teratogenic effects of artemether during the first trimester, quinine is used in early pregnancy unless the risks outweigh the benefits. The aim of this study was to assess dispensing practice of ALu in private pharmacies and knowledge of pregnant women regarding the use of ALu. This was a prospective-descriptive study involving visits to 200 private retail pharmacies (using a mystery shopper) and interviewing pregnant women at the municipal public hospitals in Dar es Salaam, Tanzania. Among the drug dispensers, 60 (30%) were pharmacists, 71(35.5%) nurse assistants, 34 (17%) pharmaceutical technicians and 35 (17.5%) sales persons with no formal education on drug dispensing. Among the dispensers, 14.5% had high knowledge, 38.0% had medium knowledge and 47.5% had low knowledge on the use of ALu during pregnancy. About thirty three percent of the drug dispensers were willing to dispense ALu during the first trimester of pregnancy.  Sixty two percent of the drug dispensers indicated that ALu is the drug of choice for uncomplicated malaria after the first trimester of pregnancy. However, 36% indicated that ALu could not be used during pregnancy.  A total of 200 pregnant women were interviewed. Among them, 16.5% were aware that ALu should not be taken during the first trimester of pregnancy. Only 17% of pregnant women were given information on the importance of taking food when using ALu, but none of them was given information on the importance of fatty meals when using ALu. In conclusion, the results show that most drug dispensers have inadequate knowledge about good dispensing practice of ALu in pregnancy. There is therefore a need for continuing training of drug dispensers regarding antimalarial drugs use in pregnancy

Identification of GSK-3 as a potential therapeutic entry point for epilepsy

In view of the clinical need for new antiseizure drugs (ASDs) with novel modes of action, we used a zebrafish seizure model to screen the anticonvulsant activity of medicinal plants used by traditional healers in the Congo for the treatment of epilepsy, and identified a crude plant extract that inhibited pentylenetetrazol (PTZ)-induced seizures in zebrafish larvae. Zebrafish bioassay-guided fractionation of this anticonvulsant Fabaceae species, Indigofera arrecta, identified indirubin, a compound with known inhibitory activity of glycogen synthase kinase (GSK)-3, as the bioactive component. Indirubin, as well as the more potent and selective GSK-3 inhibitor 6-bromoindirubin-3'-oxime (BIO-acetoxime) were tested in zebrafish and rodent seizure assays. Both compounds revealed anticonvulsant activity in PTZ-treated zebrafish larvae, with electroencephalographic recordings revealing reduction of epileptiform discharges. Both indirubin and BIO-acetoxime also showed anticonvulsant activity in the pilocarpine rat model for limbic seizures and in the 6-Hz refractory seizure mouse model. Most interestingly, BIO-acetoxime also exhibited anticonvulsant actions in 6-Hz fully kindled mice. Our findings thus provide the first evidence for anticonvulsant activity of GSK-3 inhibition, thereby implicating GSK-3 as a potential therapeutic entry point for epilepsy. Our results also support the use of zebrafish bioassay-guided fractionation of antiepileptic medicinal plant extracts as an effective strategy for the discovery of new ASDs with novel mechanisms of action

Rational dispensing and use of artemether-lumefantrine during pregnancy in Dar es Salaam, Tanzania

Artemether–Lumefantrine (ALu) is widely used for uncomplicated malaria during the second and third trimester of pregnancy. Because of the suspected teratogenic effects of artemether during the first trimester, quinine is used in early pregnancy unless the risks outweigh the benefits. The aim of this study was to assess dispensing practice of ALu in private pharmacies and knowledge of pregnant women regarding the use of ALu. This was a prospective-descriptive study involving visits to 200 private retail pharmacies (using a mystery shopper) and interviewing pregnant women at the municipal public hospitals in Dar es Salaam, Tanzania. Among the drug dispensers, 60 (30%) were pharmacists, 71(35.5%) nurse assistants, 34 (17%) pharmaceutical technicians and 35 (17.5%) sales persons with no formal education on drug dispensing. Among the dispensers, 14.5% had high knowledge, 38.0% had medium knowledge and 47.5% had low knowledge on the use of ALu during pregnancy. About thirty three percent of the drug dispensers were willing to dispense ALu during the first trimester of pregnancy. Sixty two percent of the drug dispensers indicated that ALu is the drug of choice for uncomplicated malaria after the first trimester of pregnancy. However, 36% indicated that ALu could not be used during pregnancy. A total of 200 pregnant women were interviewed. Among them, 16.5% were aware that ALu should not be taken during the first trimester of pregnancy. Only 17% of pregnant women were given information on the importance of taking food when using ALu, but none of them was given information on the importance of fatty meals when using ALu. In conclusion, the results show that most drug dispensers have inadequate knowledge about good dispensing practice of ALu in pregnancy. There is therefore a need for continuing training of drug dispensers regarding antimalarial drugs use in pregnancy

Prevalence and Correlates of Asymptomatic Malaria and Anemia on First Antenatal Care Visit among Pregnant Women in Southeast, Tanzania

Asymptomatic malaria and anemia during pregnancy increase the risk of negative birth outcomes. This cross-sectional study investigated the prevalence and correlates of asymptomatic malaria and anemia during first antenatal care (ANC) visit among pregnant women in a rural district, Tanzania. HIV-uninfected pregnant women without symptoms of malaria (n = 819) attending their first ANC at Kibiti Health Centre were enrolled from February 2017 to February 2018. Asymptomatic malaria was detected by malaria rapid-diagnostic tests (mRDT) and real-time PCR. Hemoglobin concentration was determined by HemoCue Hemoglobin 201+. The study outcomes were the prevalence of asymptomatic malaria and anemia (Hemoglobin level <11 g/dL). The overall prevalence of asymptomatic malaria was 36.4% (95% CI: 33.1, 39.8). The monthly prevalence of asymptomatic malaria remained >25% throughout the year, and the highest prevalence (40%) was recorded during the rainy season. Asymptomatic malaria was significantly associated with primigravida, younger maternal age, and anemia. The prevalence of anemia was 68.5% (95% CI: 65.2, 71.6). Asymptomatic malaria, primigravida, younger maternal age and low Body Mass Index were significant predictors of low hemoglobin concentration. We report high prevalence of asymptomatic malaria and anemia among pregnant women on the first ANC visit. Screening of malaria and anemia during the first ANC visit is recommended for targeted interventions

Pregnancy Increases CYP3A Enzymes Activity as Measured by the 4β-Hydroxycholesterol/Cholesterol Ratio

Changes in cortisol and other hormones during pregnancy may alter CYP3A enzymes activity, but data from sub-Saharan Africa are sparse. We investigated the effect of pregnancy and CYP3A5 genotypes on CYP3A enzymes activity using the plasma 4β-hydroxycholesterol (4β-OHC)/cholesterol (Chol) ratio, a known endogenous biomarker. Tanzanian pregnant women (n = 110) and non-pregnant women (n = 59) controls were enrolled. Plasma 4β-OHC and Chol were determined in the second and third trimesters for pregnant women and once for non-pregnant women using gas chromatography–mass spectrometry. Genotyping for CYP3A5 (*3, *6, *7) was performed. Wilcoxon Signed-Rank Test and Mann–Whitney U test were used to compare the median 4β-OHC/Chol ratio between trimesters in pregnant women and between pregnant and non-pregnant women. Repeated-measure ANOVA was used to evaluate the effect of the CYP3A5 genotypes on the 4β-OHC/Chol ratio in pregnant women. No significant effect of the pregnancy status or the CYP3A5 genotype on the cholesterol level was observed. The plasma 4β-OHC/Chol ratio significantly increased by 7.3% from the second trimester to the third trimester (p = 0.02). Pregnant women had a significantly higher mean 4β-OHC/Chol ratio than non-pregnant women, (p CYP3A5 alleles (*3, *6 or *7) as compared to women with the CYP3A5*1/*1 genotypes (p = 0.002). Pregnancy increases CYP3A enzymes activity in a gestational-stage manner. The CYP3A5 genotype predicts CYP3A enzymes activity in the black Tanzanian population, but not during pregnancy-mediated CYP3A enzyme induction

In vitro accumulation and permeation of hypericin and lipophilic analogues in 2-D and 3-D cellular systems

Previous studies have shown that hypericin is an excellent diagnostic tool for the fluorescence detection of carcinoma in situ in the human bladder. The present work was performed to get a better insight into the mechanism of cellular uptake of hypericin (HYP) using RT-112 human papillary TCC cells of the bladder. Using lipophilic hypericin acid amide derivatives like hypericin acid hexylamide (AM6), hypericin acid octylamide (AM8) and hypericin acid dodecylamide (AM12), the effect of increased lipophilicity on the binding to serum proteins was investigated, as well as the cellular accumulation and permeation, both in 2-D and 3-D cell conditions. Density-gradient ultracentrifugation of the compounds pre-incubated with fetal bovine serum (FBS) showed that HYP and to a lesser extent AM6 predominantly bind to LDL, whereas AM8 and especially AM12 preferably associate with HDL. The cellular accumulation of the compounds did not significantly differ when LDL or AcLDL was supplemented to medium, and with all compounds the highest uptake could be observed in case of medium without supplements. Using medium without supplements it was further observed that the compounds with the highest lipophilicity accumulated substantially less in RT-112 cells. We further found a significant difference in the intracellular concentration of AM8 and AM12 when LDL or FBS was supplemented to MEM, but not in case of HYP and AM6. Of particular interest, AM8 and especially AM12 showed enhanced intraspheroidal permeation in the presence of FBS. It is believed that the relative stronger binding to HDL reduces the intracellular accumulation, as seen in the 2-D conditions, and therefore increases the probability of paracellular transport in a 3-D multicellular system by passive diffusion. In conclusion the data suggest that the amount of free hypericin or its lipophilic congener determines the extent of intracellular accumulation. This concentration is both determined and limited by binding to different lipoproteins present in the medium, and by the formation of stable homoaggregates. The findings further highlight AM8 and AM12 as compounds better tailored for paracellular transport than HYP itself and therefore as potentially very interesting diagnostic tools for TCC lesions in the bladder.status: publishe

Safety and Tolerability of Ivermectin and Albendazole Mass Drug Administration in Lymphatic Filariasis Endemic Communities of Tanzania: A Cohort Event Monitoring Study

Ivermectin and albendazole (IA) combination preventive chemotherapy to all at-risk populations is deployed to eliminate lymphatic filariasis. Although safety monitoring is imperative, data from Sub-Saharan Africa is scarce. We conducted a large-scale active safety surveillance of adverse events (AEs) following IA mass drug administration (MDA) to identify the type, incidence, and associated risk factors in Tanzania. After recording sociodemographic, clinical, and medical histories, 9640 eligible residents received single-dose IA combination preventive chemotherapy. Treatment-associated AEs were actively monitored through house-to-house visits on day 1, day 2, and day 7 of MDA. Events reported before and after MDA were cross-checked and verified to identify MDA-associated AEs. 9288 participants (96.3%) completed the seven-day safety follow-up, of whom 442 reported 719 MDA-associated AEs. The incidence of experiencing one or more type of MDA-associated AE was 4.8% (95% CI = 4.3–5.2%); this being significantly higher among those with Pre-MDA clinical events than those without (8.5% versus 4.1%, p < 0.001). AEs were mild (83.8%), moderate (15.9%), and severe (0.3%), and most resolved within 72 h. The incidence of experiencing one, two, ≥ three types of AEs were 2.8%, 1.3%, and 0.6%, respectively. The most common AEs were headache (1.23%), drowsiness (1.15%), fever (1.12%), and dizziness (1.06%). A chronic illness, or clinical manifestation of lymphatic filariasis, or being female or pre-existing clinical symptoms were independent significant predictors of AEs. IA combination preventive chemotherapy is safe and tolerable, and associated AEs are mild-to-moderate and transient, with few severe AEs. Safety monitoring during MDA campaigns in individuals with underlying clinical conditions is recommended for timely detection and management of AEs

Effect of pharmacogenetics on plasma lumefantrine pharmacokinetics and malaria treatment outcome in pregnant women

Abstract Background Pregnancy has considerable effects on the pharmacokinetic properties of drugs used to treat uncomplicated Plasmodium falciparum malaria. The role of pharmacogenetic variation on anti-malarial drug disposition and efficacy during pregnancy is not well investigated. The study aimed to examine the effect of pharmacogenetics on lumefantrine (LF) pharmacokinetics and treatment outcome in pregnant women. Methods Pregnant women with uncomplicated falciparum malaria were enrolled and treated with artemether-lumefantrine (ALu) at Mkuranga and Kisarawe district hospitals in Coast Region of Tanzania. Day-7 LF plasma concentration and genotyping forCYP2B6 (c.516G>T, c.983T>C), CYP3A4*1B, CYP3A5 (*3, *6, *7) and ABCB1 c.4036A4G were determined. Blood smear for parasite quantification by microscopy, and dried blood spot for parasite screening and genotyping using qPCR and nested PCR were collected at enrolment up to day 28 to differentiate between reinfection from recrudescence. Treatment response was recorded following the WHO protocol. Results In total, 92 pregnant women in their second and third trimester were included in the study and 424 samples were screened for presence of P. falciparum. Parasites were detected during the follow up period in 11 (12%) women between day 7 and 28 after treatment and PCR genotyping confirmed recrudescent infection in 7 (63.3%) women. The remaining four (36.4%) pregnant women had reinfection: one on day 14 and three on day 28. The overall PCR-corrected treatment failure rate was 9.0% (95% CI 4.4–17.4). Day 7 LF concentration was not significantly influenced by CYP2B6, CYP3A4*1B and ABCB1 c.4036A>G genotypes. Significant associations between CYP3A5 genotype and day 7 plasma LF concentrations was found, being higher in carriers of CYP3A5 defective variant alleles than CYP3A5*1/*1 genotype. No significant influence of CYP2B6, CYP3A5 and ABCB1 c.4036A>Genotypes on malaria treatment outcome were observed. However, CYP3A4*1B did affect malaria treatment outcome in pregnant women followed up for 28 days (P = 0.018). Conclusions Genetic variations in CYP3A4 and CYP3A5may influence LF pharmacokinetics and treatment outcome in pregnant women