Donato Cioli

Praziquantel: mechanisms of action, resistance and new derivatives for schistosomiasis.

Purpose of review Praziquantel (PZQ) is the only drug being used to treat human schistosomiasis on a large scale. This review focuses on current knowledge about the mechanisms of action of PZQ, prospects for PZQ resistance, possible future alternative drugs and on exhortations that control of schistosomiasis and other so-called neglected tropical diseases becomes more integrated. Recent findings Schistosome calcium ion (Ca2+) channels are the only moiety so far identified as the molecular target of PZQ, but the evidence remains indirect. In the presence of cytochalasin D worms survive high concentrations of PZQ and experiments with cytochalasin D also indicated that PZQ induced worm death and Ca2+ influx are not correlated. Despite PZQ being widely used, there is no clinically relevant evidence for resistance to date, but worryingly low-cure rates have been recorded in some studies in Africa. Artemisinins and the related 1,2,4-trioxolanes are new promising antischistosomal compounds, as are inhibitors of a schistosome-specific bifunctional enzyme, thioredoxin-glutathione reductase. Summary Use of PZQ will increase in the foreseeable future, whether given alone or coadministered with other anthelminthics in integrated control programmes. PZQ resistance remains a threat and its prevention requires adequate monitoring of current mass drug administration programmes and development of new schistosomicides.

Antischistosomal drugs: Past, present … and future?

The major antischistosomal drugs that have been or still are in use against infections with schistosomes are considered here together with some compounds that have not been in clinical use, but show interesting characteristics. Each individual compound presents aspects that may be enlightening about parasite biochemistry, parasite biology, and host-parasite relationships. Special attention is given to the mechanisms of action, an understanding of which is seen here as a major factor of progress in chemotherapy. Three compounds are currently in use, i.e., metrifonate, oxamniquine, and praziquantel, and all three are included in the World Health Organization list of essential drugs. They are analyzed in some detail, as each one presents advantages and disadvantages in antischistosomal therapy. The reported occurrence of drug-resistant schistosomes after treatment with oxamniquine and praziquantel suggests strict monitoring of such phenomena and encourages renewed efforts toward the development of multiple drugs against this human parasite.

Praziquantel: its use in control of schistosomiasis in sub-Saharan Africa and current research needs

Treatment with praziquantel (PZQ) has become virtually the sole basis of schistosomiasis control in sub-Saharan Africa and elsewhere, and the drug is reviewed here in the context of the increasing rate that it is being used for this purpose. Attention is drawn to our relative lack of knowledge about the mechanisms of action of PZQ at the molecular level, the need for more work to be done on schistosome isolates that have been collected recently from endemic areas rather than those maintained in laboratory conditions for long periods, and our reliance for experimental work mainly on Schistosoma mansoni, little work having been done on S. haematobium. There is no evidence that resistance to PZQ has been induced in African schistosomes as a result of its large-scale use on that continent to date, but there is also no assurance that PZQ and/or schistosomes are in any way unique and that resistant organisms will not be selected as a result of widespread drug usage. The failure of PZQ to produce complete cures in populations given a routine treatment should therefore solicit considerable concern. With few alternatives to PZQ currently available and/or on the horizon, methods to monitor drug-susceptibility in African schistosomes need to be devised and used to help ensure that this drug remains effective for as long a time as possible.

Chemotherapy of Schistosomiasis: An Update

No major changes have occurred during the past 20 years regarding the therapeutic tools available to the clinician for the treatment of schistosomiasis. If anything, the two drugs (oxamniquine and metrifonate) that are valuable alternatives to the drug of choice (praziquantel) have become more difficult to procure in some African countries. Here, Donato Cioli summarizes some of the most recent and interesting laboratory studies on potential antischistosomal compounds, and then reviews recent developments related to the mechanism of action of praziquantel and to the possible emergence of praziquantel-resistant schistosomes.

Schistosomiasis control: praziquantel forever?

Since no vaccine exists against schistosomiasis and the molluscs acting as intermediate hosts are not easy to attack, chemotherapy is the main approach for schistosomiasis control. Praziquantel is currently the only available antischistosomal drug and it is distributed mainly through mass administration programs to millions of people every year. A number of positive features make praziquantel an excellent drug, especially with regard to safety, efficacy, cost and ease of distribution. A major flaw is its lack of efficacy against the immature stages of the parasite. In view of its massive and repeated use on large numbers of individuals, the development of drug resistance is a much feared possibility. The mechanism of action of praziquantel is still unclear, a fact that does not favor the development of derivatives or alternatives. A large number of compounds have been tested as potential antischistosomal agents. Some of them are promising, but none so far represents a suitable substitute or adjunct to praziquantel. The research of new antischistosomal compounds is an imperative and urgent matter.

Drug resistance in schistosomes

Drug resistance in schistosomes is confined essentially to compounds of the hyconthone/oxamniquine family, since no documented case of resistance has so far been reported for the widely used drug praziquantel. The availability of strains of Schistosoma mansoni that are resistant to hyconthone and oxomniquine has permitted a detailed genetic and biochemical study of the mechanism of action of these compounds. Drugs must be activated by enzymatic esterification and this ultimately results in the production of an electrophilic moiety capable of alkylating DNA and other parasite macromolecules. As reviewed here by Donato Cioli, Livia Pica-Mattoccia and Sydney Archer, resistance is due to the loss of a drug-activating enzyme that is present in sensitive schistosomes and absent in resistant worms and in the mammalian hosts. Further study of this enzyme may yield valuable clues for drug design and for a basic understanding of parasite metabolism.

Genetic and Molecular Basis of Drug Resistance and Species-Specific Drug Action in Schistosome Parasites

Blood Fluke Resistance The larval stages of the blood fluke Schistosoma mansoni are disseminated via a replicative cycle in freshwater snails. When people come into contact with contaminated water, the larvae attach to and penetrate the skin. The resulting disease, bilharzia or schistosomiasis, afflicts approximately 67 million people in Africa and South America. Unfortunately, the parasite is showing resistance to one of the available therapeutic drugs, oxamniquine, which means that schistosome control relies on a single drug, praziquantel. Valentim et al. (p. 1385, published online 21 November) analyzed the genetic and molecular basis of resistance to oxamniquine through a combination of genetic linkage mapping, genome sequencing, functional genomics analysis, and x-ray crystallography. Mutations in a distinctive sulfotransferase are responsible for oxamniquine resistance in a human blood fluke. Oxamniquine resistance evolved in the human blood fluke (Schistosoma mansoni) in Brazil in the 1970s. We crossed parental parasites differing ~500-fold in drug response, determined drug sensitivity and marker segregation in clonally derived second-generation progeny, and identified a single quantitative trait locus (logarithm of odds = 31) on chromosome 6. A sulfotransferase was identified as the causative gene by using RNA interference knockdown and biochemical complementation assays, and we subsequently demonstrated independent origins of loss-of-function mutations in field-derived and laboratory-selected resistant parasites. These results demonstrate the utility of linkage mapping in a human helminth parasite, while crystallographic analyses of protein-drug interactions illuminate the mode of drug action and provide a framework for rational design of oxamniquine derivatives that kill both S. mansoni and S. haematobium, the two species responsible for >99% of schistosomiasis cases worldwide.

Will new antischistosomal drugs finally emerge

It has been often observed that the chemotherapeutic armamentarium against an important disease such as schistosomiasis consists of just one drug, praziquantel. Thus, development of drug resistance is an impending danger, with serious implications for the health protection of many millions of people. This rational and legitimate concern might now begin to be relieved by the recent proposal of a new class of compounds that could represent a novel source of drugs against schistosomiasis.

The morphology and reproductive status of female Schistosoma mansoni following separation from male worms.

Abstract Popiel I. , Cioli D. and Erasmus D. A. 1984. The morphology and reproductive status of female Schistosoma mansoni following separation from male worms. International Journal for Parasitology14: 183–190. Sexually mature females of Schistosoma mansoni were separated from their male partners and surgically transferred to Nile rats (Arvicanthis niloticus). Over a period of 35 days there was a significant decrease in size of these worms and regression of the reproductive system took place. Electron microscope observations of the vitelline gland and ovary provided details of and a time scale for the regressive changes which took the form of a cessation of cell differentiation and turnover, together with extensive cell death. Survival of cells within these organs was restricted to the undifferentiated cells and by day 35 the worms resembled immature females. It is concluded that regression of the female reproductive system was the result of discontinued male stimulation. The nature and implications of the obligatory relationship between male and female S. mansoni are discussed.

Schistosoma mansoni: Lack of correlation between praziquantel-induced intra-worm calcium influx and parasite death

The schistosomicidal activity of praziquantel (PZQ) is accompanied by a large influx of calcium into the worms, suggesting that this phenomenon could be the source of the observed muscular contraction, surface disruption and eventual death of the parasite. We have incubated live adult schistosomes in a medium containing radioactive calcium and we were able to confirm that PZQ does indeed stimulate calcium entry into the parasite. An even higher calcium uptake, however, occurred in schistosomes exposed to PZQ after pre-incubation with cytochalasin D, a condition that suppresses PZQ schistosomicidal effects and allows the complete survival of the parasites. The calcium blockers nicardipine and nifedipine also failed to prevent the calcium influx induced by PZQ. Similarly, a large calcium influx occurred in 28-day-old worms exposed to PZQ, in spite of the fact that these immature worms are largely insensitive to the schistosomicidal effects of the drug. Schistosomes incubated overnight with radioactive calcium and PZQ and then returned to normal medium, retained a calcium content higher than worms pre-incubated with cytochalasin D, but the difference could be a consequence--rather than a cause--of schistosomicidal effects. These results suggest that calcium accumulation by itself, at least as measured in whole parasites maintained in vitro, may not represent an exhaustive explanation for the schistosomicidal effects of PZQ.