|Systematic (IUPAC) name|
|Half-life||6 to 8 days and 31 days |
|Mol. mass||407.568 g/mol|
|(what is this?)|
Miltefosine (INN, trade names Impavido and Miltex) is a phospholipid drug. Chemically, it is a derivative of alkylphosphocholine compounds discovered in the early 1980s. It was developed in the late 1980s as an anticancer drug by German scientists Hansjörg Eibl and Clemens Unger. Simultaneously, but independently, it was found that the drug could kill Leishmania parasites, and since the mid-1990s, successful clinical trials were conducted. The drug became the first (and still the only prescribed) oral drug in the treatment of leishmaniasis. It is now known to be a broad-spectrum antimicrobial drug, active against pathogenic bacteria and fungi, as well as human trematode Schistosoma mansoni and its vector host, the snail Biomphalaria alexandrina. It can be administered orally and topically.
On 19 March 2014, the US Food and Drug Administration approved miltefosine for any form of leishmaniasis, specifically for patients of 12 years of age and older, and became the first approved drug for cutaneous or mucosal leishmaniasis.
In 2013, the US Centers for Disease Control and Prevention recommended miltefosin as the only and first line therapy for granulomatous amoebic encephalitis and primary amoebic meningoencephalitis, two fatal protozoal diseases. For the first time in history, in 2013, two children survived and recovered from primary amoebic meningoencephalitis after treatment with miltefosin.
Miltefosine is used for the treatment of visceral and cutaneous leishmaniasis, and is undergoing clinical trials for this use in several other countries, such as Brazil, Guatemala. and the United States. Several medical agents have some efficacy against visceral or cutaneous leishmaniasis, however a 2005 survey concluded that miltefosine is the only effective oral treatment for both forms of leishmaniasis. It was used successfully in some cases of the very rare, but highly lethal, brain infection by the amoeba, Naegleria fowleri, acquired through water entering the nose during a plunge in contaminated water.
Miltefosine is being made available in the United States through the CDC for emergency use under an expanded access IND protocol for treatment of free-living amoeba (FLA) infections: Primary amoebic meningoencephalitis caused by Naegleria fowleri and granulomatous amoebic encephalitis caused by Balamuthia mandrillaris, and Acanthamoeba species.
The main side effects reported with miltefosine treatment are nausea and vomiting, which occur in 60% of patients. Adverse effect is more severe in women and young children. The overall effects are quite mild and easily reversed. It is embryotoxic and fetotoxic in rats and rabbits, and teratogenic in rats but not in rabbits. It is therefore contraindicated for use during pregnancy, and contraception is required beyond the end of treatment in women of child-bearing age.
Phospholipid group alkylphosphocholine were known since the early 1980s, particularly in terms of their binding affinity with cobra venom. In 1987 the phospholipids were found to be potent toxins on leukemic cell culture. Initial in vivo investigation on the antineoplastic activity showed positive result, but then only at high dosage and at high toxicity. At the same time in Germany, Hansjörg Eibl, at the Max Planck Institute for Biophysical Chemistry, and Clemens Unger, at the University of Göttingen, demonstrated that the antineoplastic activity of the phospholipid analogue miltefosine (at the time known as hexadecylphosphocholine) was indeed tumour-specific. It was highly effective against methylnitrosourea-induced mammary carcinoma, but less so on transplantable mammary carcinomas and autochthonous benzo(a)pyrene-induced sarcomas, and relatively inactive on Walker 256 carcinosarcoma and autochthonous acetoxymethylmethylnitrosamine-induced colonic tumors of rats. It was subsequently found that miltefosine was structurally unique among lipids having anticancer property in that it lacks the glycerol group, is highly selective on cell types and acts through different mechanism.
In the same year as the discovery of the acticancer property, miltefosine was reported by S. L. Croft and his team at the London School of Hygiene and Tropical Medicine as having antileishmanial effect as well. The compound was effective against Leishmania donovani amastigotes in cultured mouse peritoneal macrophages at a dose of 12.8 mg/kg/day in a five-day course. However, priority was given to the development of the compound for cutaneous metastases of breast cancer. In 1992 a new research was reported in which the compound was highly effective in mouse against different life cycle stages of different Leishmania species, and in fact, more potent than the conventional sodium stibogluconate therapy by a factor of more than 600. Results of the first clinical trial in humans were reported from Indian patients with chronic leishmaniasis with high degree of success and safety. This promising development promulgated a unique public–private partnership collaboration between ASTA Medica (later Zentaris GmbH), the WHO Special Programme for Research and Training in Tropical Diseases, and the Government of India. Eventually, several successful Phase II and III trials led to the approval of miltefosine in 2002 as the first and only oral drug for leishmaniasis.
Antiprotozoal and antifungal activities
Miltefosine is being investigated by researchers interested in finding treatments for infections which have become resistant to existing drugs. Animal and in vitro studies suggest it may have broad anti-protozoal and anti-fungal properties:
- Animal studies suggest miltefosine may also be effective against Trypanosoma cruzi, the parasite responsible for Chagas' disease.
- Several studies have found the drug to be effective against Cryptococcus neoformans, Candida, Aspergillus and Fusarium.
- A 2006 in vitro study found that miltefosine is effective against metronidazole-resistant variants of Trichomonas vaginalis, a sexually transmitted protozoal disease.
- Hexadecyltrimethylammonium bromide, a compound structurally similar to miltefosine, was demonstrated in 2007 to exhibit potent in vitro activity against Plasmodium falciparum.
- An in vitro test in 2006 showed that miltefosine is effective gainst amoebic pathogens, Naegleria fowleri, Balamuthia mandrillaris, and Acanthamoeba species. However, later studies showed that it is not as potent as other drugs, such as chlorpromazine and diminazene aceturate (Berenil®). In 2014 it was reported that treatment of Acanthamoeba encephalitis in a 63-year-old male was not cured by miltefosine, or sulfadiazine, fluconazole, flucytosine, and azithromycin.
- In 2013, there were reports of failure of miltefosine in the treatment of leishmaniasis. Although drug resistance was suspected, studies in 2014 reported that miltefosine is not so effective in children, most probably related to a lack of drug exposure in children. Moverover, males appeared to have a higher probability of relapse as well.
Miltefosine targets HIV infected macrophages, which play a role in vivo as long-lived HIV-1 reservoirs. The HIV protein Tat activates pro-survival PI3K/Akt pathway in primary human macrophages. Miltefosine acts by inhibiting the PI3K/Akt pathway, thus removing the infected macrophages from circulation, without affecting healthy cells. It significantly reduces replication of HIV-1 in cocultures of human dendritic cells (DCs) and CD4(+) T cells, which is due to a rapid secretion of soluble factors and is associated with induction of type-I interferon (IFN) in the human cells.
- Dorlo, T. P. C.; Balasegaram, M.; Beijnen, J. H.; de Vries, P. J. (2012). "Miltefosine: a review of its pharmacology and therapeutic efficacy in the treatment of leishmaniasis". Journal of Antimicrobial Chemotherapy 67 (11): 2576–2597. doi:10.1093/jac/dks275. PMID 22833634.
- Eibl, H; Unger, C (1990). "Hexadecylphosphocholine: a new and selective antitumor drug.". Cancer Treatment Reviews 17 (2-3): 233–42. doi:10.1016/0305-7372(90)90053-i. PMID 2272038.
- Almeida Pachioni, JD; Magalhães, JG; Cardoso Lima, EJ; Moura Bueno, LD; Barbosa, JF; Malta de Sá, M; Rangel-Yagui, CO (2013). "Alkylphospholipids - a promising class of chemotherapeutic agents with a broad pharmacological spectrum.". Journal of Pharmacy & Pharmaceutical sciences : a publication of the Canadian Society for Pharmaceutical Sciences, Societe canadienne des sciences pharmaceutiques 16 (5): 742–59. PMID 24393556.
- Eissa, Maha M; El Bardicy, Samia; Tadros, Menerva (2011). "Bioactivity of miltefosine against aquatic stages of Schistosoma mansoni, Schistosoma haematobium and their snail hosts, supported by scanning electron microscopy". Parasites & Vectors 4 (1): 73. doi:10.1186/1756-3305-4-73. PMC 3114006. PMID 21569375.
- Yao, Stephanie (19 March 2014). "FDA approves Impavido to treat tropical disease leishmaniasis". FDA NEWS RELEASE. U.S. Food and Drug Administration. Retrieved 30 August 2014.
- Cope, Jennifer R (2013). "Investigational drug available directly from CDC for the treatment of infections with free-living amebae.". MMWR. Morbidity and mortality weekly report 62 (33): 666. PMID 23965830.
- CDC (2014). "Naegleria fowleri - Primary Amebic Meningoencephalitis (PAM)". Centers for Disease Control and Prevention. Retrieved 29 August 2014.
- Gholipour, Bahar (14 August 2013). "Brain-Eating Amoeba: How One Girl Survived". livescience. Retrieved 29 August 2014.
- Chugh P, Bradel-Tretheway B, Monteiro-Filho CM, et al. (2008). "Akt inhibitors as an HIV-1 infected macrophage-specific anti-viral therapy". Retrovirology 5 (1): 11. doi:10.1186/1742-4690-5-11. PMC 2265748. PMID 18237430.
- "Parasitic Drug Shows HIV-Fighting Promise". AIDSmeds.com. 2008-02-01. Retrieved 2008-02-02.
- Cristina, Márcia; Pedrosa, Robert (September 2005). "Hospital de Doenças Tropicais testa droga contra calazar". Sapiência (in Portuguese) (Fundação de Amparo à Pesquisa do Estado do Piauí). Archived from the original on 2006-08-22. Retrieved 2006-09-01.
- Soto J, Berman J; Berman (2006). "Treatment of New World cutaneous leishmaniasis with miltefosine". Trans R Soc Trop Med Hyg 100: S34–40. doi:10.1016/j.trstmh.2006.02.022. PMID 16930649.
- Berman, J. (2005). "Clinical status of agents being developed for leishmaniasis". Expert Opinion on Investigational Drugs 14 (11): 1337–1346. doi:10.1517/135437188.8.131.527. PMID 16255674.
- S.D. Seth (2008). "Drug therapy of leishmaniasis". In S.D. Seth. Textbook of Pharmacology. Elsevier India. p. 31. ISBN 9788131211588.
- Sindermann, H.; Engel, J. (2006). "Development of miltefosine as an oral treatment for leishmaniasis". Transactions of the Royal Society of Tropical Medicine and Hygiene 100 (Suppl 1): S17–S20. doi:10.1016/j.trstmh.2006.02.010. PMID 16730362.
- Teshima, K; Ikeda, K; Hamaguchi, K; Hayashi, K (1983). "Bindings of cobra venom phospholipases A2 to micelles of n-hexadecylphosphorylcholine.". Journal of Biochemistry 94 (1): 223–32. PMID 6619110.
- Fleer, EA; Unger, C; Kim, DJ; Eibl, H (1987). "Metabolism of ether phospholipids and analogs in neoplastic cells.". Lipids 22 (11): 856–61. doi:10.1007/bf02535544. PMID 3444378.
- Berger, MR; Petru, E; Schmähl, D (1987). "Therapeutic ratio of mono or combination bacterial lipopolysaccharide therapy in methylnitrosourea-induced rat mammary carcinoma.". Journal of Cancer Research and Clinical Oncology 113 (5): 437–45. doi:10.1007/bf00390037. PMID 3624299.
- Muschiol, C; Berger, MR; Schuler, B; Scherf, HR; Garzon, FT; Zeller, WJ; Unger, C; Eibl, HJ; Schmähl, D (1987). "Alkyl phosphocholines: toxicity and anticancer properties.". Lipids 22 (11): 930–4. doi:10.1007/bf02535558. PMID 3444388.
- Berger, MR; Muschiol, C; Schmähl, D; Eibl, HJ (1987). "New cytostatics with experimentally different toxic profiles". Cancer treatment Reviews 14 (3–4): 307–17. doi:10.1016/0305-7372(87)90023-5. PMID 3440252.
- Hilgard, P; Stekar, J; Voegeli, R; Engel, J; Schumacher, W; Eibl, H; Unger, C; Berger, MR (1988). "Characterization of the antitumor activity of hexadecylphosphocholine (D 18506).". European Journal of Cancer & Clinical Oncology 24 (9): 1457–61. doi:10.1016/0277-5379(88)90336-7. PMID 3141197.
- Croft, S.L.; Neal, R.A.; Pendergast, W.; Chan, J.H. (1987). "The activity of alkyl phosphorylcholines and related derivatives against Leishmania donovani". Biochemical Pharmacology 36 (16): 2633–2636. doi:10.1016/0006-2952(87)90543-0. PMID 3606662.
- Kuhlencord, A; Maniera, T; Eibl, H; Unger, C (1992). "Hexadecylphosphocholine: oral treatment of visceral leishmaniasis in mice.". Antimicrobial Agents and Chemotherapy 36 (8): 1630–1634. doi:10.1128/AAC.36.8.1630. PMC 192021. PMID 1329624.
- Sundar, Shyam; Rosenkaimer, Frank; Makharia, Manoj K; Goyal, Ashish K; Mandal, Ashim K; Voss, Andreas; Hilgard, Peter; Murray, Henry W (1998). "Trial of oral miltefosine for visceral leishmaniasis". The Lancet 352 (9143): 1821–1823. doi:10.1016/S0140-6736(98)04367-0. PMID 9851383.
- Saraiva V, Gibaldi D, Previato J, Mendonça-Previato L, Bozza M, Freire-De-Lima C, Heise N; Gibaldi; Previato; Mendonça-Previato; Bozza; Freire-De-Lima; Heise (2002). "Proinflammatory and cytotoxic effects of hexadecylphosphocholine (miltefosine) against drug-resistant strains of Trypanosoma cruzi". Antimicrob Agents Chemother 46 (11): 3472–7. doi:10.1128/AAC.46.11.3472-3477.2002. PMC 128733. PMID 12384352.
- Widmer F, Wright L, Obando D, Handke R, Ganendren R, Ellis D, Sorrell T; Wright; Obando; Handke; Ganendren; Ellis; Sorrell (2006). "Hexadecylphosphocholine (miltefosine) has broad-spectrum fungicidal activity and is efficacious in a mouse model of cryptococcosis". Antimicrob Agents Chemother 50 (2): 414–21. doi:10.1128/AAC.50.2.414-421.2006. PMC 1366877. PMID 16436691.
- Blaha C, Duchêne M, Aspöck H, Walochnik J; Duchêne; Aspöck; Walochnik (2006). "In vitro activity of hexadecylphosphocholine (miltefosine) against metronidazole-resistant and -susceptible strains of Trichomonas vaginalis". J. Antimicrob. Chemother. 57 (2): 273–8. doi:10.1093/jac/dki417. PMID 16344287.
- Choubey V, Maity P, Guha M et al. (2007). "Inhibition of Plasmodium falciparum choline kinase by hexadecyltrimethylammonium bromide: a possible antimalarial mechanism". Antimicrob. Agents Chemother. 51 (2): 696–706. doi:10.1128/AAC.00919-06. PMC 1797733. PMID 17145794.
- Schuster, FL; Guglielmo, BJ; Visvesvara, GS (2006). "In-vitro activity of miltefosine and voriconazole on clinical isolates of free-living amebas: Balamuthia mandrillaris, Acanthamoeba spp., and Naegleria fowleri". The Journal of Eukaryotic Microbiology 53 (2): 121–6. doi:10.1111/j.1550-7408.2005.00082.x. PMID 16579814.
- Kim, J.-H.; Jung, S.-Y.; Lee, Y.-J.; Song, K.-J.; Kwon, D.; Kim, K.; Park, S.; Im, K.-I.; Shin, H.-J. (2008). "Effect of therapeutic chemical agents in vitro and on experimental meningoencephalitis due to Naegleria fowleri". Antimicrobial Agents and Chemotherapy 52 (11): 4010–4016. doi:10.1128/AAC.00197-08. PMC 2573150. PMID 18765686.
- Ahmad, Arine F.; Heaselgrave, Wayne; Andrew, Peter W.; Kilvington, Simon (2013). "The in vitro efficacy of antimicrobial agents against the pathogenic free-living amoeba Balamuthia mandrillaris". Journal of Eukaryotic Microbiology 60 (5): 539–543. doi:10.1111/jeu.12062. PMID 23869955.
- Swiatlo, E; Henderson, H; Zamora, A (2014). "Acanthamoeba encephalitis: A Case Report and Review of Therapy". Surgical Neurology International 5 (1): 68. doi:10.4103/2152-7806.132239. PMC 4078452. PMID 24991471.
- Rijal, S.; Ostyn, B.; Uranw, S.; Rai, K.; Bhattarai, N. R.; Dorlo, T. P. C.; Beijnen, J. H.; Vanaerschot, M.; Decuypere, S.; Dhakal, S. S.; Das, M. L.; Karki, P.; Singh, R.; Boelaert, M.; Dujardin, J.-C. (2013). "Increasing failure of miltefosine in the treatment of Kala-azar in Nepal and the potential role of parasite drug resistance, reinfection, or noncompliance". Clinical Infectious Diseases 56 (11): 1530–1538. doi:10.1093/cid/cit102. PMID 23425958.
- Rai, K.; Cuypers, B.; Bhattarai, N. R.; Uranw, S.; Berg, M.; Ostyn, B.; Dujardin, J.-C.; Rijal, S.; Vanaerschot, M. (2013). "Relapse after treatment with miltefosine for visceral leishmaniasis is associated with increased infectivity of the infecting Leishmania donovani strain". MBio 4 (5): e00611–13–e00611–13. doi:10.1128/mBio.00611-13. PMC 3791894. PMID 24105765.
- Dorlo, T. P. C.; Rijal, S.; Ostyn, B.; de Vries, P. J.; Singh, R.; Bhattarai, N.; Uranw, S.; Dujardin, J.-C.; Boelaert, M.; Beijnen, J. H.; Huitema, A. D. R. (2014). "Failure of miltefosine in visceral leishmaniasis is associated with low drug exposure". Journal of Infectious Diseases 210 (1): 146–153. doi:10.1093/infdis/jiu039. PMID 24443541.
- Ostyn, Bart; Hasker, Epco; Dorlo, Thomas P. C.; Rijal, Suman; Sundar, Shyam; Dujardin, Jean-Claude; Boelaert, Marleen; Ng, Lisa FP. (2014). "Failure of miltefosine treatment for visceral leishmaniasis in children and men in South-East Asia". PLoS ONE 9 (6): e100220. doi:10.1371/journal.pone.0100220. PMC 4062493. PMID 24941345.
- Garg, Ravendra; Tremblay, Michel J. (2012). "Miltefosine represses HIV-1 replication in human dendritic cell/T-cell cocultures partially by inducing secretion of type-I interferon". Virology 432 (2): 271–276. doi:10.1016/j.virol.2012.05.032. PMID 22704066.