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      Acarbose presents in vitro and in vivo antileishmanial activity against Leishmania infantum and is a promising therapeutic candidate against visceral leishmaniasis

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          Abstract

          Treatment against visceral leishmaniasis (VL) is mainly hampered by drug toxicity, long treatment regimens and/or high costs. Thus, the identification of novel and low-cost antileishmanial agents is urgent. Acarbose (ACA) is a specific inhibitor of glucosidase-like proteins, which has been used for treating diabetes. In the present study, we show that this molecule also presents in vitro and in vivo specific antileishmanial activity against Leishmania infantum. Results showed an in vitro direct action against L. infantum promastigotes and amastigotes, and low toxicity to mammalian cells. In addition, in vivo experiments performed using free ACA or incorporated in a Pluronic ® F127-based polymeric micelle system called ACA/Mic proved effective for the treatment of L. infantum-infected BALB/c mice. Treated animals presented significant reductions in the parasite load in their spleens, livers, bone marrows and draining lymph nodes when compared to the controls, as well as the development of antileishmanial Th1-type humoral and cellular responses based on high levels of IFN-γ, IL-12, TNF-α, GM-CSF, nitrite and IgG2a isotype antibodies. In addition, ACA or ACA-treated animals suffered from low organ toxicity. Treatment with ACA/Mic outperformed treatments using either Miltefosine or free ACA based on parasitological and immunological evaluations performed one and 15 days post-therapy. In conclusion, data suggest that the ACA/Mic is a potential therapeutic agent against L. infantum and merits further consideration for VL treatment.

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          Leishmaniasis

          Leishmaniasis is a poverty-related disease with two main clinical forms: visceral leishmaniasis and cutaneous leishmaniasis. An estimated 0·7-1 million new cases of leishmaniasis per year are reported from nearly 100 endemic countries. The number of reported visceral leishmaniasis cases has decreased substantially in the past decade as a result of better access to diagnosis and treatment and more intense vector control within an elimination initiative in Asia, although natural cycles in transmission intensity might play a role. In east Africa however, the case numbers of this fatal disease continue to be sustained. Increased conflict in endemic areas of cutaneous leishmaniasis and forced displacement has resulted in a surge in these endemic areas as well as clinics across the world. WHO lists leishmaniasis as one of the neglected tropical diseases for which the development of new treatments is a priority. Major evidence gaps remain, and new tools are needed before leishmaniasis can be definitively controlled.
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            Increasing failure of miltefosine in the treatment of Kala-azar in Nepal and the potential role of parasite drug resistance, reinfection, or noncompliance.

            Miltefosine (MIL), the only oral drug for visceral leishmaniasis (VL), is currently the first-line therapy in the VL elimination program of the Indian subcontinent. Given the paucity of anti-VL drugs and the looming threat of resistance, there is an obvious need for close monitoring of clinical efficacy of MIL. In a cohort study of 120 VL patients treated with MIL in Nepal, we monitored the clinical outcomes up to 12 months after completion of therapy and explored the potential role of drug compliance, parasite drug resistance, and reinfection. The initial cure rate was 95.8% (95% confidence interval [CI], 92.2-99.4) and the relapse rate at 6 and 12 months was 10.8% (95% CI, 5.2-16.4) and 20.0% (95% CI, 12.8-27.2) , respectively. No significant clinical risk factors of relapse apart from age <12 years were found. Parasite fingerprints of pretreatment and relapse bone marrow isolates within 8 patients were similar, suggesting that clinical relapses were not due to reinfection with a new strain. The mean promastigote MIL susceptibility (50% inhibitory concentration) of isolates from definite cures was similar to that of relapses. Although more tolerant strains were observed, parasite resistance, as currently measured, is thus not likely involved in MIL treatment failure. Moreover, MIL blood levels at the end of treatment were similar in cured and relapsed patients. Relapse in one-fifth of the MIL-treated patients observed in our study is an alarming signal for the VL elimination campaign, urging for further review and cohort monitoring.
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              Efficacy of miltefosine in the treatment of visceral leishmaniasis in India after a decade of use.

              Miltefosine is the only oral drug available for treatment of Indian visceral leishmaniasis (VL), which was shown to have an efficacy of 94% in a phase III trial in the Indian subcontinent. Its unrestricted use has raised concern about its continued effectiveness. This study evaluates the efficacy and safety of miltefosine for the treatment of VL after a decade of use in India. An open-label, noncomparative study was performed in which 567 patients received oral miltefosine (50 mg for patients weighing <25 kg, 100 mg in divided doses for those weighing ≥25 kg, and 2.5 mg per kg for those aged <12 years, daily for 28 days) in a directly observed manner. Patients were followed up for 6 months to see the response to therapy. At the end of treatment the initial cure rate was 97.5% (intention to treat), and 6 months after the end of treatment the final cure rate was 90.3%. The overall death rate was 0.9% (5 of 567), and 2 deaths were related to drug toxicity. Gastrointestinal intolerance was frequent (64.5%). The drug was interrupted in 9 patients (1.5%) because of drug-associated adverse events. As compared to the phase III trial that led to registration of the drug a decade ago, there is a substantial increase in the failure rate of oral miltefosine for treatment of VL in India.
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                Author and article information

                Contributors
                eduardoferrazcoelho@yahoo.com.br
                Journal
                Med Microbiol Immunol
                Med Microbiol Immunol
                Medical Microbiology and Immunology
                Springer Berlin Heidelberg (Berlin/Heidelberg )
                0300-8584
                1432-1831
                18 April 2021
                : 1-15
                Affiliations
                [1 ]GRID grid.8430.f, ISNI 0000 0001 2181 4888, Laboratório de Pesquisa do Programa de Pós-Graduação em Ciências da Saúde: Infectologia e Medicina Tropical, Faculdade de Medicina, , Universidade Federal de Minas Gerais, ; Avenida Prof. Alfredo Balena, 190, 30.130-100, Belo Horizonte, Minas Gerais Brazil
                [2 ]GRID grid.411198.4, ISNI 0000 0001 2170 9332, Departamento de Parasitologia, Microbiologia e Imunologia, Instituto de Ciências Biológicas, , Universidade Federal de Juiz de Fora, ; Juiz de Fora, Minas Gerais Brazil
                [3 ]GRID grid.411213.4, ISNI 0000 0004 0488 4317, Laboratório de Imunopatologia, Núcleo de Pesquisas em Ciências Biológicas/NUPEB, Departamento de Ciências Biológicas, Insituto de Ciências Exatas e Biológicas, , Universidade Federal de Ouro Preto, ; Ouro Preto, Minas Gerais Brazil
                [4 ]GRID grid.123047.3, ISNI 0000000103590315, Neisseria Research Group, Molecular Microbiology, School of Clinical and Experimental Sciences, , University of Southampton Faculty of Medicine, Southampton General Hospital, ; Southampton, SO16 6YD England
                [5 ]GRID grid.8430.f, ISNI 0000 0001 2181 4888, Departamento de Patologia Clínica, , COLTEC, Universidade Federal de Minas Gerais, ; Belo Horizonte, Minas Gerais Brazil
                [6 ]GRID grid.441990.1, ISNI 0000 0001 2226 7599, Universidad Católica de Santa María, ; Urb. San José S/N, Umacollo, Arequipa, Peru
                Author notes

                Edited by: Christian Bogdan.

                Author information
                http://orcid.org/0000-0002-6681-9014
                Article
                707
                10.1007/s00430-021-00707-4
                8053370
                fb62cedc-5e79-485c-859a-53ef139a3991
                © The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature 2021

                This article is made available via the PMC Open Access Subset for unrestricted research re-use and secondary analysis in any form or by any means with acknowledgement of the original source. These permissions are granted for the duration of the World Health Organization (WHO) declaration of COVID-19 as a global pandemic.

                History
                : 16 September 2020
                : 3 April 2021
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/501100009187, Medical Research Foundation;
                Award ID: MR/R005850/1
                Award Recipient :
                Funded by: FundRef http://dx.doi.org/10.13039/501100003593, Conselho Nacional de Desenvolvimento Científico e Tecnológico;
                Award ID: APQ-408675/2018-7
                Award Recipient :
                Categories
                Original Investigation

                Microbiology & Virology
                treatment,drug repositioning,acarbose,visceral leishmaniasis,miltefosine,leishmania infantum

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