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Antimicrobial Agents and Chemotherapy, July 2004, p. 2624-2632, Vol. 48, No. 7
0066-4804/04/$08.00+0 DOI: 10.1128/AAC.48.7.2624-2632.2004
Divisions of Experimental Therapeutics,1 Neurosciences, Walter Reed Army Institute of Research, Silver Spring, Maryland 209102
Received 16 September 2003/ Returned for modification 25 November 2003/ Accepted 3 March 2004
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Adverse central nervous system (CNS) events have been associated with mefloquine use. Severe CNS events requiring hospitalization (e.g., seizures and hallucinations) occur in 1:10,000 patients taking mefloquine for chemoprophylaxis (22). However, milder CNS events (e.g., dizziness, headache, insomnia, and vivid dreams) are more frequently observed, occurring in up to 25% of patients (22). The rate of adverse neurological events associated with mefloquine is higher than for Malarone (20), and subjects receiving mefloquine in clinical trials are more likely to withdraw from the trial than those receiving placebo (8). The higher incidence of adverse events observed when the drug is used at the higher doses needed for malaria treatment (22, 23) implies a dose effect. There is no accepted biochemical basis for the neurotoxicity of the drug; however, we recently showed that mefloquine severely disrupts calcium homeostasis in rat neurons in vitro at concentrations in excess of 20 µM, an effect closely related to the acute neurotoxicity of the drug in terms of dose effect and kinetics (10). Peak plasma levels of mefloquine are 3.8 and 2.1 to 23 µM after prophylaxis and treatment, respectively (16, 25). However, the drug crosses the blood-brain barrier and accumulates as much as 30-fold in the central nervous system and mefloquine brain concentrations as high as 50 µM have been reported in human postmortem cases (14, 21). Mefloquine brain concentrations as high as 90 µM have been reported in rats given a therapy-equivalent dose rate, with concentrations in subcompartments in the brain exceeding 100 µM (2). Since it has long been known that a prolonged disruption of neuronal calcium homeostasis may lead to neuronal cell death and injury (6, 13), it is reasonable to suppose that such events may contribute to the clinical neuropathy of the drug.
Mefloquine remains a useful antimalarial drug for many patients who are able to tolerate the drug or are unable or unwilling to take doxycycline or Malarone. However, the neurotoxicity associated with mefloquine is such that some have questioned its clinical utility as a prophylactic drug (7). There are several approaches to the amelioration of this problem, including (i) administration of neuroprotective drugs such as physostigmine (26), (ii) reformulation of mefloquine as a pure isomer (24), and (iii) reengineering of the mefloquine molecule to yield derivatives that are less neurotoxic but retain their antimalarial activity. Bhattacharjee and Karle (3) earlier showed that the in vivo potency of 4-quinolinecarbinolamines was correlated with key stereoelectronic features, including electrostatic potential and lipophilicity. However, the issues of neurotoxicity and drug resistance were not addressed. In the present report, we show that the antimalarial potential of 4-quinolinecarbinolamines may be limited by their neurotoxicity and cross-resistance of mefloquine-resistant parasites. We also describe the generation of a reliable function-based three-dimensional (3D) quantitative structure activity relationship (QSAR) pharmacophore model for neurotoxicity of this class of compounds which may be useful for selecting new quinoline analog candidates devoid of such toxicity.
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TABLE 1. Molecular structures, neurotoxicity, and in vitro and in vivo antimalarial activity of 4-quinolinecarbinolamines analogs
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FIG. 1. Core structure of the 4-quinolinecarbinolamines. Substituents at positions R1, R2, and R3 for each analog are listed in Table 1.
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Antimalarial activity. The susceptibility of different malaria strains to the mefloquine analogs was determined using the tritiated hypoxanthine incorporation assay of Desjardins et al. (9), as modified by Milhous et al. (17), except that the drug exposure period was 48 h. IC50s of the drugs were determined using a nonlinear logistic dose response program. The P. falciparum clones used were W2, D6, and TM91C235 (19). W2 is a mefloquine-sensitive strain resistant to chloroquine and pyrimethamine. Strains D6 and TM91C235 are both resistant to mefloquine. TM91C235 is a strain from Southeast Asia that is highly resistant to mefloquine and a number of other antimalarials. Therapeutic indices were calculated using the following formula: neurotoxicity of drug (IC50 in micromoles)/antimalarial activity of drug (IC50 in micromoles). From these data, therapeutic indices relative to mefloquine were calculated using the following formula: therapeutic index of drug/therapeutic index of mefloquine. In vivo efficacy data are expressed as a mefloquine index (MfI). These values were determined using the Plasmodium berghei mouse model with a single subcutaneous dose at 640 mg/kg of body weight as the highest dose (29). MfI is defined as the ratio of the molar 50% curative dose of mefloquine to the 50% curative dose of the test compound. The 50% curative dose is that which cures 50% of test animals. These values are considered approximate because of the relatively few animals used in testing (5 mice/dose; six dosing levels).
Confocal microscopy. The effects of some of the analogs on neuronal calcium homeostasis were investigated as previously described (10, 15). The neurons were loaded with the calcium-sensitive dye Fluo 3-AM (5 µM for 1 h), rinsed, and returned to an incubator for 15 min prior to the imaging experiment. Changes in neuronal calcium homeostasis were monitored using a Bio-Rad Radiance 2000 confocal imaging system. Changes in cytoplasmic calcium were recorded as fluctuations in the emitted fluorescence of Fluo-3-complexed calcium at 530 nm (excitation was 488 nM). Sequential image scans of fields containing 5 to 25 neurons were used to construct temporal profiles of the effects of the different analogs. Scans were made at 10-s intervals. To compare the fluorescence levels in different neurons (which were often in slightly different focal planes) on different days, readings at each time point were normalized to the first value measured for each neuron. Drugs (at concentrations of 100 µM or 4x the drug's IC50 in 1% DMSO) were added after four scans, and their effects on calcium homeostasis were monitored for 6 min. Each drug was tested at least in triplicate. After subtraction of baseline values (1% DMSO control), the effects of the drugs are expressed as the percentage of increase in Fluo-3 fluorescence over time. For the chloroquine experiments, the drug was prepared in Locke's buffer, which was also used as the baseline control.
Generation of a neurotoxicity pharmacophore. The 3D neurotoxicity pharmacophore model was developed using the HypoGen algorithm of the CATALYST methodology (1). Structures of the 4-quiniolinecarbinolamines were imported into CATALYST to create a training set, and energy was minimized to the closest local minimum with the generalized CHARMM-like force field as implemented in the program. The CATALYST model treats molecular structures as templates comprised of chemical functions localized in space that will bind effectively with complementary functions on the respective binding proteins. The most relevant chemical features are extracted from a small set of compounds that cover a broad range of activity (28). Molecular flexibility is taken into account by considering each compound as an ensemble of conformers representing different accessible areas in 3D space. The "best searching procedure" was applied to select representative conformers within 10 kcal/mol of the global minimum (12). CATALYST allows the use of structure and activity data for a set of lead compounds to create a hypothesis characterizing the activity of the lead set. HypoGen generates 10 hypotheses for the training set with various costs. The hypotheses are described by a set of functional features such as hydrophobicity, hydrogen bond donor, hydrogen bond acceptor, and positively and negatively ionizable sites distributed over a 3D space. The hydrogen bonding features are vectors, whereas all other functions are points. The statistical relevance of the obtained hypothesis is assessed on the basis of their cost relative to the null hypothesis and their correlation coefficient. The difference between the fixed and null costs in the present study was found to be 68 bits, and the cost range between the first and the 10th hypotheses is about 8 bits. Therefore, it can be expected that for all these hypotheses there is a 75 to 90% chance of representing a true correlation of the data. The validation of statistical significance of a hypothesis is based on Fischer's randomization test as implemented in CATALYST (1). However, the main goal of performing this type of validation is to check whether there is a strong correlation between the chemical structures and biological activity.
Prediction of neurotoxicity of test set members. The neurotoxicity pharmacophore was converted into a 3D-shape-based template. This template was used to predict the neurotoxicity of a test set of compounds including four 4-quinolinecarbinolamines, amodiaquine, chloroquine, halofantrine and quinine. The IC50s of the compounds were estimated by fast-fitting their 3D structures to the template. The analogs were predicted to be neurotoxic when their estimated IC50s were less than 300 µM. This criterion was based on a toxicity threshold of 100 µM (the maximum level to which mefloquine accumulates across the blood-brain barrier) multiplied threefold to account for the error inherent in the pharmacophore model. These criteria are conservative, because we have assumed that mefloquine analogs may accumulate in the CNS to the same degree as mefloquine and that estimates of neurotoxicity will be lower by a factor of three in every case. The actual IC50s of the test set members were then determined as described above.
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Effects of quinolines on neuronal calcium homeostasis. The effects of a number of different quinolines at a concentration of 100 µM on neuronal calcium homeostasis were investigated using confocal microscopy. Treatment of neurons with mefloquine, WR006006, WR007930, halofantrine, and amodiaquine but not with chloroquine increased cytoplasmic calcium concentrations (Fig. 2, 3, and 4). This effect was much more pronounced with the 4-quinolinecarbinolamines (Fig. 2). Halofantrine induced a transient increase in cytosolic calcium concentrations (Fig. 2). This effect was similar in duration and magnitude to that observed at lower mefloquine concentrations (data not shown). At concentrations approximately four times higher than their IC50s, chloroquine and amodiaquine treatment induced a sharp initial increase in intracellular calcium concentration followed by a sharp decline relative to baseline values (Fig. 3 and 4). The effects of chloroquine and amodiaquine were qualitatively different from that of mefloquine at an equivalent concentration (100 µM), as the latter drug induces a more sustained elevation in cytoplasmic calcium concentrations (Fig. 3 and 4).
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FIG. 2. Effects of 4-quinolinecarbinolamines and halofantrine on neuronal calcium homeostasis. Drugs were added after 30 s as indicated by the arrow, and their effects on neuronal cytoplasmic calcium levels were monitored using confocal microscopy. Data are expressed as the percentages of change (± standard errors of the means [SEM]) in Fluo 3-AM (F530) fluorescence after subtraction of appropriate baseline values (1% DMSO). Mefloquine, WR006006, and WR007930 at concentrations of 100 µM induced sustained elevations in cytoplasmic calcium levels. Halofantrine (100 µM) exhibited a more modest and transient increase in cytoplasmic calcium levels. The concentration of mefloquine used is four times higher than the compound's IC50 against embryonic rat neurons and represents the maximum level of accumulation of the drug in the brain after transport across the blood-brain barrier.
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FIG. 3. Effect of amodiaquine on neuronal calcium homeostasis. Drugs were added after 30 s as indicated by the arrow, and their effects on neuronal cytoplasmic calcium levels were monitored using confocal microscopy. Data are expressed as the percentages of change (± SEM) in Fluo 3-AM (F530) fluorescence after subtraction of appropriate baseline values (1% DMSO). Amodiaquine at a concentration of 100 µM (AMQ100) induced a more modest and transient increase in the cytoplasmic calcium concentration than mefloquine (MEF100). At a concentration (1,600 µM [AMQ1600]) equivalent to that used for mefloquine, amodiaquine also induced a sharp, albeit brief, increase in the cytoplasmic calcium concentration that was followed by a decline below the baseline level.
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FIG. 4. Effect of chloroquine on neuronal calcium homeostasis. Drugs were added after 30 s as indicated by the arrow, and their effects on neuronal cytoplasmic calcium levels were monitored using confocal microscopy. Data are expressed as the percentages of change (± SEM) in Fluo 3-AM (F530) fluorescence after subtraction of appropriate baseline values (1% DMSO for mefloquine and Locke's buffer for chloroquine). In comparison to mefloquine (100 µM [MEF100]), chloroquine (100 µM [CHQ100]) did not alter calcium homeostasis. At concentrations (2,400 µM [CHQ2400]) equivalent to that used for mefloquine, chloroquine induced a sharp but brief increase in the cytoplasmic calcium concentration that was followed by a decline below the baseline level.
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FIG. 5. Neurotoxicity pharmacophore for 4-quinolinecarbinolamines: The pharmacophore for the neurotoxicity of 4-quinolinecarbinolamines is depicted. The key functional features required for neurotoxicity include (i) one lipid type H-bond acceptor function (shown in green with a direction vector), (ii) one ring aromatic function (shown in light magenta), and (iii) one aliphatic hydrophobic function (shown as a blue sphere).
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FIG. 6. Correlation (r = 0.86; P < 0.0001 [Pearson correlation]) of experimental and estimated neurotoxicity (IC50) data for the training set.
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FIG. 7. Mapping of the pharmacophore on two known neurotoxic compounds, mefloquine (A) and WR006006 (B), showing how all the features of the pharmacophore map onto them.
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FIG. 8. Mapping of the pharmacophore on two nonneurotoxic compounds, amodiaquine (A) and chloroquine (B), showing how not all of the features of the pharmacophore map onto them.
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TABLE 2. Actual and predicted neurotoxicity of test set compounds
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The utility of a mefloquine replacement drug could also be improved if the relative dose rate could be reduced. This might be possible if a mefloquine analog were at worst equivalent to mefloquine in terms of neurotoxicity but exhibited a greater relative therapeutic index against mefloquine-resistant strains of malaria. Selection of a particular relative therapeutic index as a threshold is necessarily problematic, because the reduction of dose that would be possible and the degree to which CNS accumulation would be consequently reduced are difficult to predict. Therefore, an empirically derived benchmark is probably the most appropriate. Halofantrine is a conventional quinoline antimalarial that displays some cross-resistance to mefloquine both in vitro (high relative IC50s against D6 and TM91C235; Table 1) and in vivo (5). Halofantrine was the only one of the conventional antimalarials to exhibit neurotoxicity in the same concentration range as the 4-quinolinecarbinolamines, with some mechanistic attributes in common.
Therefore, we propose that the threshold therapeutic index relative to mefloquine should be approximately 30 against TM91C235, the same as that of halofantrine. On this basis, the 4-quinolinecarbinolamines tested here do not exhibit sufficient selective antimalarial activity.
However, this does not mean that other quinolines would not be suitable replacement drugs (11, 27). Three of the conventional antimalarial antimalarials tested here were much less neurotoxic than mefloquine and exhibited qualitatively different mechanisms of action against neurons. Further, not all quinoline antimalarials exhibit the same inherent cross-resistance to mefloquine as halofantrine and the 4-quinolinecarbinolamines (Table 1). Therefore, there are reasonable grounds to propose that there may be other, as-yet-undiscovered quinolines that exhibit much greater selective toxicity than those tested here. One might be able to identify such compounds by developing a reliable 3D pharmacophore and using it for virtual screening of compound databases, since these techniques not only enable predictions of the biological activity of unknown compounds but also provide a basis for custom-designed synthesis of compounds with optimum efficacy that have both the necessary chemical functions and the requisite stereoelectronic properties (4). As a first step in the development of such an in silico screening method for quinoline antimalarials, we have developed a pharmacophore on the basis of the neurotoxicity data for the 4-quinolinecarbinolamines.
The crucial molecular features that appear to correlate with the neurotoxic properties of the 4-quinolinecarbinolamines include (i) one hydrogen bond acceptor (lipid) function, (ii) one aliphatic hydrophobic function, and (iii) a ring aromatic function at specific geometric locations distributed over the 3D space of the molecule. When the pharmacophore was employed as a qualitative in silico screening tool, we observed that the approach was able to correctly predict whether a series of quinolines were neurotoxic (or not) on the basis of the mapping of their 3D structures to the pharmacophore (Table 2 and Fig. 7 and 8). These preliminary data suggest that the approach has merit. The next step in the process is obviously to develop an appropriate pharmacophore on the basis of the antimalarial activity of quinolines. This approach is presently under investigation in our laboratory.
This project was funded through a grant from the U.S. Military Infectious Diseases Research Program.
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