Recent reports of increased tolerance to artemisinin derivatives-the last widely effective class of antimalarials -bolster the medical need for new treatments. The spirotetrahydro-β-carbolines, or spiroindolones, are a new class of fast-acting and potent schizonticidal drugs displaying low nanomolar potency against Plasmodium falciparum and Plasmodium vivax clinical isolates. Spiroindolones rapidly diminish protein synthesis in P. falciparum, an effect that is ablated in parasites bearing non-synonymous mutations in the gene encoding the P-type cation-transporter ATPase4 (PfATP4). The optimized spiroindolone NITD609 shows an acceptable safety profile and pharmacokinetic properties compatible with once-daily oral dosing; and demonstrates singledose efficacy in a rodent malaria model. Collectively, these data demonstrate that NITD609 possesses a pharmacological profile suitable for a new drug candidate for the treatment of malaria.Globally, 3.3 billion people are exposed to malaria, a devastating disease that causes over 800,000 deaths each year and kills more under five-year-olds than any other infectious agent (1). Fifty years ago, malaria had been eliminated from many areas of the world through effective antimalarial drug treatments, vector control interventions and disease prevention # Corresponding authors (Winzeler@scripps.edu and Thierry.diagana@novartis.com). * These authors equally contributed to this work One-sentence summary We describe the pharmacological profile of a new antimalarial drug candidate-the spiroindolone NITD609-which through a novel mechanism of action rapidly clears a Plasmodium infection upon administration of a single oral dose in a malaria mouse model. NIH Public Access Author ManuscriptScience. Author manuscript; available in PMC 2011 September 3. (2). However, the global spread of drug resistance resulted, by the 1980s, in a substantial increase in disease incidence and mortality. Today, some encouraging epidemiological data suggest that the introduction of new drugs (notably the artemisinin-based combination therapies or ACTs) may have reversed that trend (3). Derivatives of the endoperoxide artemisinin constitute the only antimalarial drugs that remain effective in all malariaendemic regions, but recent reports suggest that decades of continuous use as monotherapies might have fostered the emergence of resistance (4-6). This realization has triggered a concerted search for new drugs that could be deployed if artemisinin resistance were to spread.Many of the therapies currently in development utilize known antimalarial pharmacophores (e.g. aminoquinolines and/or peroxides) chemically modified to overcome the liabilities of their predecessors (7). While these compounds may prove to be important in the treatment of malaria, it would be preferable to discover novel chemotypes with a distinct mechanism of action (8). However, despite significant advances in our understanding of Plasmodium genome biology, the identification and validation of new drug targets has proven challengi...

SummaryAchieving the goal of malaria elimination will depend on targeting Plasmodium pathways essential across all life stages. Here, we identify a lipid kinase, phosphatidylinositol 4-kinase (PI4K), as the target of imidazopyrazines, a novel antimalarial compound class that inhibits the intracellular development of multiple Plasmodium species at each stage of infection in the vertebrate host. Imidazopyrazines demonstrate potent preventive, therapeutic, and transmission-blocking activity in rodent malaria models, are active against blood-stage field isolates of the major human pathogens, P. falciparum and P. vivax, and inhibit liver stage hypnozoites in the simian parasite P. cynomolgi. We show that imidazopyrazines exert their effect through inhibitory interaction with the ATP-binding pocket of PI4K, altering the intracellular distribution of phosphatidylinositol 4-phosphate. Collectively, our data define PI4K as a key Plasmodium vulnerability, opening up new avenues of target-based discovery to identify drugs with an ideal activity profile for the prevention, treatment and elimination of malaria.

SummaryThe malaria parasite Plasmodium falciparum establishes in the host erythrocyte plasma membrane new permeability pathways that mediate nutrient uptake into the infected cell. These pathways simultaneously allow Na+ influx, causing [Na+] in the infected erythrocyte cytosol to increase to high levels. The intraerythrocytic parasite itself maintains a low cytosolic [Na+] via unknown mechanisms. Here we present evidence that the intraerythrocytic parasite actively extrudes Na+ against an inward gradient via PfATP4, a parasite plasma membrane protein with sequence similarities to Na+-ATPases of lower eukaryotes. Mutations in PfATP4 confer resistance to a potent class of antimalarials, the spiroindolones. Consistent with this, the spiroindolones cause a profound disruption in parasite Na+ homeostasis, which is attenuated in parasites bearing resistance-conferring mutations in PfATP4. The mutant parasites also show some impairment of Na+ regulation. Taken together, our results are consistent with PfATP4 being a Na+ efflux ATPase and a target of the spiroindolones.

The antiplasmodial activity of a series of spirotetrahydro beta-carbolines is described. Racemic spiroazepineindole (1) was identified from a phenotypic screen on wild type Plasmodium falciparum with an in vitro IC(50) of 90 nM. Structure-activity relationships for the optimization of 1 to compound 20a (IC(50) = 0.2 nM) including the identification of the active 1R,3S enantiomer and elimination of metabolic liabilities is presented. Improvement of the pharmacokinetic profile of the series translated to exceptional oral efficacy in the P. berghei infected malaria mouse model where full cure was achieved in four of five mice with three daily doses of 30 mg/kg.

A molecular understanding of drug resistance mechanisms enables surveillance of the effectiveness of new antimicrobial therapies during development and deployment in the field. We used conventional drug resistance selection as well as a regime of limiting dilution at early stages of drug treatment to probe two antimalarial imidazolopiperazines, KAF156 and GNF179. The latter approach permits isolation of low-fitness mutants that might otherwise be out-competed during selection. Whole-genome sequencing of 24 independently-derived resistant P. falciparum clones revealed four parasites with mutations in the known cyclic amine resistance locus (pfcarl), and a further 20 with mutations in two previously unreported P. falciparum drug resistance genes, an acetyl-CoA transporter (pfact) and a UDP-galactose transporter (pfugt). Mutations were validated both in vitro by CRISPR editing in P. falciparum, and in vivo by evolution of resistant P. berghei mutants. Both PfACT and PfUGT were localized to the endoplasmic reticulum by fluorescence microscopy. As mutations in pfact and pfugt conveyed resistance against additional unrelated chemical scaffolds, these genes are likely to be involved in broad mechanisms of antimalarial drug resistance.