InTechOpen uses cookies to offer you the best online experience. By continuing to use our site, you agree to our Privacy Policy.

Medicine » Infectious Diseases » "An Overview of Tropical Diseases", book edited by Amidou Samie, ISBN 978-953-51-2224-1, Published: December 2, 2015 under CC BY 3.0 license. © The Author(s).

Chapter 3

Recent Advances in Antimalarial Drug Discovery — Challenges and Opportunities

By Chiranjeev Sharma and Satish Kumar Awasthi
DOI: 10.5772/61191

Article top

Recent Advances in Antimalarial Drug Discovery — Challenges and Opportunities

Chiranjeev Sharma1 and Satish Kumar Awasthi1

1. Introduction

1.1. History

The chronicle of malaria predating humanity is as ancient as mankind.[1] Malaria continues to be a persistent menace wreaking havoc especially in tropical and subtropical regions despite tremendous efforts toward its control and eradication. The unavailability of the vaccine and the emergence of resistance in the parasite against nearly all existing antimalarial drugs have attracted attention of researchers to modify the existing antimalarial drugs with improved efficacy over older therapies and identify new compounds as appropriate clinical candidate. Mortality from malaria is increasing at an alarming rate despite various renewed efforts and eradication campaigns[2] because the parasites (Plasmodium strains) responsible for the majority of fatal infections have become resistant to the existing drugs. Malaria is also the cause of poverty and a major hindrance to economic development, especially in sub-Saharan countries.[3] Mostly, malaria is spread due to local transmission through female anopheles mosquitoes. Occasionally, it can also be transmitted by exposure to infected blood products (transfusion malaria) and also through congenital transmission. The major species of Plasmodium strains that infect humans are P. falciparum, P. vivax, P. ovale, P. malariae, and P. knowlesi. Among these, P. falciparum causes the most severe form of infection, which could be fatal.

The original picture of the parasitic existence and passage of malaria through historic times remains blurred. It is uncertain whether the human population settlements preceded the arrival of malaria within them.[3] The versions may vary from tentative to widely accepted or even controversial based on the general scientific evidence. However, the effect of malaria wreaking havoc to the human species is prominent, clear, and unmistakable. There was no specific treatment for malaria until the 17th century.[4] The discovery of quinine from the bark of Cinchona calisaya began effective treatment of malaria. Further, the synthesis of chloroquine by Hans Andersag in 1934 introduced a cheap antimalarial drug and a substitute for quinine.[5] Until the widespread resistance in 1960, quinoline-related antimalarial drugs played an important role in the treatment of malaria. Fortunately, in 1972, the Chinese discovered artemisinin from sweet wormwood plant Artemisia annua.[6] Artemisinin along with its derivatives artemether, arteether (artemotil), and artesunate are the main treatment for malaria that is resistant to conventional therapies.

Recent advances in the molecular genetics and biochemical technologies available for the investigation of malaria parasites within the last half century have enabled us to gain a unique perspective on the human health and health services in relation to malaria.[7]

1.2. Life cycle of malaria parasite

The life cycle of malaria parasites is very complex. It is completed inside two hosts, including the humans (asexual) and the mosquitoes (sexual) (Figure 1).[8, 9] Malaria infection begins when an infected female anopheles mosquito feeding on human blood bites and injects sporozoites into the bloodstream. The parasites then quickly reach liver to form merozoites by asexual multiplication. Subsequently, merozoites exit liver with the rupture of hepatic tissues and enter the bloodstream where they invade and disintegrate red blood cells. Some merozoites transform into gametocytes, which are then circulated in the bloodstream. When the second mosquito bites an infected human, it gets infected and intakes gametocytes. The sexual transformation of gametocytes into ookinetes and ookinetes into oocyst takes place inside the midgut of mosquito. Finally, sporozoites are developed from oocysts, which eventually burst, releasing sporozoites into the salivary gland. Continued infection in humans and mosquitoes alternatively propagates and spreads malaria.


Figure 1.

Life cycle of malaria parasite.[9]

A comparative study with human and rodent parasites revealed the activities of current antimalarial drugs on the life cycle stages of plasmodium.[10] 8-Aminoquinolones are known to be active for liver stage. The most currently available antimalarial drugs primarily target the human blood cell stage. In addition to the asexual blood stage, some drugs (viz., pyronaridine and atovaquone) can also target both liver and sexual stage. Further, new stable synthetic endoperoxides can inhibit gamete formation and gametocyte maturation.[10] Furthermore, it is important to profile the currently available drugs for specific stage in parasite’s life cycle to combat malaria by eradication and circumventing resistance.

1.3. Status quo

WHO has recommended artemisinin combination therapy (ACT) for the treatment of malaria.[11] Since 2006, artemisinin-based combination therapies remain as the first-line treatment for P. falciparum malaria replacing chloroquine and sulfadoxine/pyrimethamine. Combined with other drugs, its derivatives, such as artesunate and artemether, can clear symptoms of malaria in three days. However, a rise in demand has led to a shortage of artemisinin. Artemisinin-based drugs are also more expensive than conventional treatments, in part because large doses are required. Further, with recent reports on the emergence of resistance to artemisinin,[12] it can be foreseen that in the near future, new armamentarium will be required to fight against malaria. Thus, to overcome this problem, there is an urgent need to identify new chemotypes or reexamining old molecules to transform them into an appropriate clinical candidate.

2. Drug resistance

The greatest challenge to malaria control and eradication is the emergence of malaria parasites that are resistant to antimalarial drugs.[13] The reemergence of malaria from the areas where it was eradicated and spread of malaria to new areas is a major threat. The World Health Organization defined antimalarial drug resistance as the “ability of a parasite strain to survive and/or multiply despite the administration and absorption of a drug given in doses equal to or higher than those usually recommended but within tolerance of the subject.”[14] It was modified later to specify that the drug in question must “gain access to the parasite or the infected red blood cell for the duration of the time necessary for its normal action.”[15] Antimalarial drug resistance occurs through spontaneous mutations that reduces the sensitivity to a given class of drug(s).[16] Only a single point mutation is sufficient to confer resistance to some drugs, while multiple mutations appear to be required for others.

Sl. no Drug class Drug Resistance Mechanism of action
1.4-AminoquinolineChloroquineSince 1945Inhibition of hemozoin formation
3.PiperaquineSince 1980s
5.Aryl-amino alcoholQuinineYesUnknown
6.MefloquineSince 1985
8.AntifolatesPyrimethamineSince 1967Inhibition of DHFR
10.ProguanilSince 2000
12.NapthoquinoneAtovaquoneSince 2000Inhibition cytochrome
13.AntibioticDoxycyclineNoInhibition of protein synthesis and apicoplast
15.ArtemisininArtesunateYesFree radical mechanism
Heme alkylation
16.ArtemetherSince 2001

Table 1.

Status of resistance in antimalarial drugs.

The malaria parasite has developed some level of resistance against nearly all previous generation antimalarial drugs (Table 1). Recent research has confirmed evidence of artemisinin resistance.[10] Although it is under investigation, immediate actions are needed to restrict resistance to artemisinin from spreading to new areas. It is high time that we should fight this overwhelming menace with improved tools to aim at controlling the mosquito vector and develop new armaments; otherwise, the future looks bleak and grim.

3. Mechanism of action

The mechanism of action of antimalarial drugs is based on the extensive studies of selected drugs. Most drugs available for the treatment were discovered based on the serendipitous identification of active compounds (natural, synthetic, and semisynthetic).[17] The progress in the understanding of the biochemistry of malarial parasite has shed light on the mechanism of action of new as well as older drugs.

It is believed that artemisinin and related drugs are transported to the food vacuole of the parasite, where they generate free radicals upon interaction with Fe(II)-heme. These free radical’s interaction with heme generates oxidative stress and kills the parasite.[18] The mechanism of action of quinoline and related drugs is also well established.[19] It is shown that the drugs enter the RBC and inhabit the digestive vacuole of parasite by simple diffusion. The subsequent inhibition of hemozoin biocrystallization leads to the aggregation and accumulation of cytotoxic heme in food vacuoles resulting in parasite’s death. The commercially available quinolone antimalarials target the gyrase and inhibit DNA replication. It results in the delayed death of treated parasites by formation of abnormal apicoplasts.[20]

Based on the mechanism of action, different groups of antimalarials can be classified as follows:

  • Artemisinin: binds heme iron and generates oxygen radicals

  • Antifolate: inhibits DNA synthesis

  • Atovaquone: collapses mitrochondrial membrane potential

  • Quinoline: inhibits heme crystallization

  • Antibacterial: ribosome and DNA gyrase inhibition

4. Toxicity of the antimalarial drugs

The most important determinant of drug use and its effectiveness is the patient compliance. The toxicity of the drug must be balanced with the efficacy of the drug and the risk from malaria, i.e., the drug should cause less harm than the disease itself. The doses given to the patients should be taken into account in determining the treatment of malaria. The assessment of the tolerability of many antimalarial drugs is ongoing, but evaluating adverse drug reactions, events, side effects, and drug-related toxicity is difficult due to the unavailability of good techniques to measure the side effects.[21]

The most promising naturally occurring sesquiterpene lactone drug and its derivatives (artemether, arteether, and sodium artesunate) did not show any serious side effects. However, insufficient clinical trials to detect the toxicity stopped us from declaring artemisinin 100% safe. However, they have excellent safety profile and remarkable efficacy. The current knowledge obtained from the laboratory and clinical study is that the long-term availability of artemisinins may cause toxicity (rarely produce neurotoxicity and allergic reactions).[22] The short-term peak concentrations followed by rapid elimination of artemisinins after oral intake is relatively safe compared to administration by intramuscular injection. Evidently, the majority of animal experiments showed considerable toxicities in contrast to human studies.

Chloroquine, considered being a safe drug even at higher doses, also causes mild side effects such as reversible effect on optical accommodation, which can potentially affect eyesight. It also binds irreversibly to melanin. Hence, the patients with rheumatoid arthritis treated with the long-term use of high dose chloroquine suffer from accumulation of chloroquine in retinal melanin. Some reports also suggest that chloroquine administered to patients with light intolerant disease can aggravate psoriasis.[22] Proguanil is also assumed to be safe at a dose of 200 mg a day. However, for doses higher than 200 mg, there are reports of reversible alopecia and aphthous ulceration, nausea, and gastric irritation.[23] These side effects are common with other antimalarial agents as well. The combination of chloroquine with proguanil has good tolerability. However, gastrointestinal upset and mouth ulcers are still observed. Sulfadoxine/pyrimethamine is also well tolerated, but it is no longer used because it causes Stevens–Johnson syndrome and toxic epidermal necrolysis. Mefloquine is another valuable drug for the treatment of malaria. Despite good tolerability to most patients, dose-related serious neuropsychiatric toxicity can occur. Cardiovascular or CNS toxicity is rare for quinine but hypoglycemia may occur. Further, due to its potential for cardiotoxicity, halofantrine is unsuitable for widespread use. Mepacrine, sulfonamides, dapsone, and amodiaquine are also withdrawn from the use because of the high frequency of adverse side effects.[24]

5. Malaria vaccine

Malaria vaccine development is a challenging and difficult task because of the antigenic complexity and the complex life cycle of malaria parasite. Research on the development of malaria vaccine is of prime importance because such a discovery can prevent millions of deaths worldwide. The currently available tools are insufficient for malaria eradication. Malaria vaccine could be a transformative tool to help in reduced transmission and future eradication. Extensive research has been carried out in the last two decades, and several vaccines have reached clinical trials, but there is none in the clinical practice due to insufficient immunogenicity. Although parasite vaccines are in development, there is no FDA-approved vaccine for organisms more complex than viruses and bacteria.[25]

5.1. Scientific challenges

The significant hurdle in the development of malaria vaccine is insufficient knowledge about the malaria parasite. Understanding the structure and antigenic variation of parasite population requires lengthy, tedious, and difficult lab and field studies. Antigenic variation and parasite polymorphism also create a major scientific barrier. Unfortunately, in nature, there are not many good examples of immunity to malaria, and many vaccine development programs are based only on naturally acquired immunity. Since the mechanism of immune protection is still unknown, it is difficult to comprehend why certain people are protected while others are not. Inadequate animal models and lack of clarity in the definition of desired outcomes create confusion in choosing the best approach to develop a malaria vaccine. Even in particular animal model systems with defined outcomes, there is always uncertainty in translating the success of protection in the model systems with success in humans.[26]

The malaria vaccine development includes recombinant proteins, gene-based (DNA or viral vector) vaccines, attenuated whole organisms, peptides, and prime-boost strategy, which involves a combination of different antigen delivery systems encoding the same epitopes or antigen using various adjuvants. Reports dating back to 1960s[26] demonstrated species-specific and strain cross-reactive protection on immunization with radiation-attenuated sporozoites in primate and experimental rodent models. Studies showed optimistic levels of protective immunity. However, the volunteers immunized against multiple strains of P. falciparum malaria were not protected against P. vivax. The target antigens were identified from the sera cells of experimental hosts immunized with attenuated sporozoite vaccine and protected volunteers. Circumsporozoite protein, the first cloned and sequenced malaria parasite in P. knowlesi and P. falciparum, is also the first antigen identified by serological screening. It plays an important role in protection. When the sporozoite was irradiated in the rodent models, antibody and cells showed different roles in malaria species and different strains. Although multifaceted cellular responses are observed, the basic mechanism of immunity is believed to target the intracellular hepatic exoerythrocytic forms by the production of interferon. The antibody eliminates most of the infectious sporozoite inoculum, when the vaccines prove a multipronged approach. The cellular responses target the rest of the intracellular exoerythrocytic forms by direct cytotoxicity or inhibitory cytokines.

The understanding of the research related to vaccine development is greatly benefitted by the lessons learned from discontinued and inactive projects. Recent findings allow us to be optimistic about the possibility of an effective malaria vaccine. Several malaria vaccine candidates have entered field trials. It is now possible to impact the host–parasite relationship using different platforms through vaccine-induced immune responses to multiple antigenic targets. The field has grown rapidly over the last two decades from the first clinical trials to the successful conduct of large-scale field studies, and substantial progress has been made in evaluating many antigens. Despite the daunting task, researchers have produced surprising progress in several areas. The malaria vaccination program has progressed to an assessment and clinical evaluation of RTS,S/AS01E in phase 3 trial.[27] The first malaria vaccine may be considered for licensure in the coming years. Further, there is a possibility of developing more efficacious second-generation vaccines. Researchers are now better equipped to establish clear product profiles. The lessons learned in terms of safety, immunogenicity, efficacy, and trial methodology from malaria vaccine research is summarized in Table 2.

Parameters Remarks
Safety ⋅ It is often lower in semi-immune populations living in endemic areas than in naïve populations
⋅ Reactogenicity in young children has not been worse than in adult populations
Immunogenicity ⋅ DNA alone is poorly immunogenic
⋅ Little clinically significant interference is observed between vaccine antigens and the malarial antigen
Efficacy ⋅ Only RTS,S-based vaccines proved to be effective to reduce morbidity in endemic areas
⋅ Highly polymorphic blood-stage antigens have tended to lead to allele-specific efficacy, but poor efficacy against the population of circulating strains
Methodology ⋅ In vitro studies and animal studies does not correlate well
⋅ For testing of new malaria vaccines, ethical and methodological issues may arise
⋅ There is a need to make formal trial design for phase trials and sample size calculations. Epidemiological studies are required to assess the effectiveness of mosquito antigen vaccines in sexual stage

Table 2.

Lessons from two decades of malaria vaccine development research.

6. Antimalarial drugs

Malaria, existing in over 100 countries, is one of the deadliest infectious diseases and major health problem worldwide. Antimalarial drugs are designed to cure malaria, many of which are in market.[28] From the 17th century onward quinine had been the drug of choice for the treatment of malaria. Later on, medication therapies heavily relied on chloroquine, primaquine, mefloquine, etc.4 These drugs especially chloroquine have saved more lives than any other drugs in history. Recently, artemisinin and its derivatives have emerged as a new generation of antimalarials (Figure 2).


Figure 2.

Antimalarial drugs.

There is a critical need to develop newer synthetic and more effective drugs that could address the issues associated with the existing and traditional drug therapies. The availability of artemisinin also causes supply constraints because artemisinin and its derivatives constitute an active ingredient of many combination therapy dugs. For example, Coartem contains a fixed combination of artemether and lumefantrine. In 2012, Ranbaxy also launched a new synthetic peroxide antimalarial drug SynriamTM in the market in line with the recommendations of the WHO. It is a fixed dose combination of arterolane maleate and piperaquine phosphate. The chemical structures are shown below.

Research groups across the world are united in the efforts to discover new chemicals for the treatment of malaria. Attempts to modify the established drugs are also ongoing. Long-term hopes are resting on the modification of the synthetic artemisinin-based drugs containing endoperoxide rings. The following sections will mainly focus on the development of peroxidic antimalarial agents.

6.1. Natural products

Natural products continue to make an immense contribution to malaria chemotherapy. The discovery of quinine and artemisinin proves that nature is a rich source of lead compounds that can provide cure and medicine for malaria. Nature has been extremely generous when it comes to search of new molecular scaffolds for good malarial activity. These scaffolds later serve as template for the development of structurally diverse analogues with more potent activity.[29] For example, quinine a bitter-tasting alkaloid, is one of the earliest natural compounds that helped man in the fight against malaria. It was isolated from the Cinchona bark. Later, it also served as a template for the synthesis of more potent and structurally simpler analogues such as chloroquine, primaquine, mepacrine, and mefloquine (Figure 2). Artemisinin extracted from Artemesia annua is another example whose diverse pharmacological potential has attracted the researchers worldwide. Artemisinin also gave rise to the development of dihydroxyartemisinin, artemether, arteether and artesunate. Thus, natural products such as quinine and artemisinin have demonstrated the enormous potential of nature in providing lead compounds, which can be further manipulated structurally for the development of more effective antimalarial agents. Many more natural products possessing various chemical structures, such as alkaloids, steroids, chalcones, terpenes, flavonoids, peptides, quinones, xanthones, coumarines, naphthopyrones, polyketides, phenols, lignans, chromenes, etc., have been tested as antimalarial drugs.[30, 33]

6.2. Semisynthetic drugs

The success of the most potent antimalarial drugs, quinine and artemisinin, has brought some optimism. Due to the widespread emergence of drug-resistant chloroquine, primaquine, mepacrine, and mefloquine (Figure 2) were developed. Despite the remarkable antimalarial activity, artemisinin suffers from limited availability, low solubility, high cost, metabolic stability, short half-life, poor bioavailability, and chemical stability. Thus, there is a need for new compounds more active than the parent artemisinin. To circumvent some of these problems, semisynthetic analogs were prepared. The reduction of artemisinin yields dihydroartemisinin, and the lactol group can be further converted to its ether (artemether, arteether, and artelinic acid) and ester (sodium artesunate) derivatives.[34]

6.3. Synthetic drugs

Artemisinin, a sesquiterpene endoperoxide, has established the role of peroxide ring for potential antimalarial activity. However, the naturally isolated artemisinin is available in short supply and expensive to synthesize. As a consequence, extensive research directed towards the discovery of peroxidic antimalarials inspired researchers to explore structurally simple peroxides. Trioxanes, tetraoxanes, and their hybrids were consequently identified as promising candidates for the development of next generation antimalarial drugs.

6.3.1. Various synthetic procedures for the synthesis of trioxanes

Trioxanes can be synthesized from inexpensive starting materials, and their scale-up preparations are feasible. Most methods reported for the synthesis of trioxanes starts with the reaction of singlet oxygen with carbonyls in the presence of Lewis acids. Then acid-catalyzed cyclization of hydroxyperoxides with olefins and reaction of α-peroxy aldehydes with carbonyl compound yields trioxanes in good yields. Many synthetic strategies were developed for the synthesis 1,2,4-trioxanes, which are described below. Photooxygenation method

Starting from commercially available cyclohexanediones, tricyclic 1,2,4-trioxanes can be synthesized by following simple method. Briefly, photooxygenation of the electron-rich allylic alcohols 1 using singlet oxygen gives β-hydroxyperoxide 2. Further, β-hydroxyperoxide 2 was condensed with 1,4-cyclohexadiene followed by Lewis acid-mediated cyclization to give keto-trioxane 3. Amino functionalized trioxanes 4 were also synthesized on reductive amination with various amines in the presence of sodium triacetoxy borohydride (Scheme 1).[35]


Sheme 1.

Photooxygenation method for trioxane synthesis.

In another synthetic procedure, the geranyl acetate was transformed into aldehyde acetate 5, which is converted into allylic alcohol 6. Photooxygenation of 6 followed by subsequent acid catalyzed condensation of β-hydroxyhydroperoxides 7 with various ketones resulted in the formation of new 1,2,4-trioxanes 8 (Scheme 2).[36] The hydroxyl functionalized side chains can be further manipulated for the synthesize of a diverse library of compounds.


Sheme 2.

Synthesis of Geraniol derived 1,2,4-trioxanes. Epoxidation method

The epoxidation of N-Boc piperidone 9 gives N-Boc spirooxirane 10. Dispiro N-Boc-protected 1,2,4-trioxane can then be synthesized by MoO2(acac)2 catalyzed perhydrolysis of N-Boc spirooxirane 10, as shown in Scheme 3.[37] Subsequent condensation of the resulting β-hydroperoxy alcohol 11 with 2-adamantanone gives N-Boc 1,2,4-trioxane 12, which can be converted into the amine 1,2,4-trioxane hydrochloride salt 13. Further, alkylation may result in a diversified sulfonamide trioxane derivatives 14.


Sheme 3.

Trioxane synthesis using epoxidation method. Catalytic enantioselective synthesis

Trioxanes can also be synthesized by catalytic enantioselective synthesis. Para-cresol 15 is converted into p-peroxyquinols 16. The desymmetrization of p-peroxyquinols 16 occurs via an acetalization/oxa-Michael cascade reaction (Scheme 4).[38] The reaction proceeds via a dynamic kinetic resolution of a peroxyhemiacetal intermediate. Various derivatized trioxanes 17 can be easily obtained by this method. The use of chiral Brønsted acid catalyst TRIP 18 gave a single diastereomer trioxane 17 in 86% ee, while using bis-(2,4,6-triisopropylphenyl)spirobiindane phosphoric acid 19 gave 96% ee. The use of thiourea 20 as cocatalyst helped to restore the reactivity even at lower catalyst loading.


Sheme 4.

Enantioselective synthesis of trioxanes. Solid phase synthesis

The solid support synthesis of 1,2,4-trioxanes also needs light mediated oxygenation on polystyrene polymer support. Wang and Rink amide resins can be used as linkers. The reaction of resin-bound p-carboxybenzaldehydes 21 with excess of ionone derivatives 22 gave immobilized dienones 23 in the presence of LiOH in DME (Scheme 5).[39] Resin-bound trioxane 24 was obtained upon irradiation of compound 23 with UV light (354 nm) in toluene yielded. After cleavage from the solid support, the formation of 25 was confirmed by 13C NMR. Peaks at 82.4 and 94.4 ppm corresponded to the peroxy-bearing carbon and peroxyketal carbon of the trioxane ring system.


Sheme 5.

Solid phase trioxane synthesis.

6.3.2. Various synthetic procedures for the synthesis of tetraoxanes

The chemical modification of artemisinin retaining the crucial endoperoxide ring has resulted in yet another simplified structure known as 1,2,4,5-tetraoxane. Tetraoxanes show significantly higher stability and exhibit even higher activity than natural peroxidic drugs for curing malaria infections. In 1899, Baeyer and Villiger reported the synthesis of the first dimeric acetone peroxide upon treatment of acetone and Caro’s acid in ether. Since then, the field has moved ahead significantly and newer synthetic routes and efficient methodologies were developed. The synthesis can be carried out by several methods as described below. Peroxidation method

The most commonly and widely used method for tetraoxane synthesis is known as peroxidation method. In this method, acid-catalyzed cyclocondensation of ketones or aldehydes gives the gem-dihydroperoxide as an important active intermediate. Generally, the acid-catalyzed addition of hydrogen peroxide to carbonyl compound 26 produce gem-dihydroperoxide 27, which on subsequent cyclocondensation in the presence of strong acid such as sulfuric acid, perchloric acid, or methanesulfuric acid yield more stable symmetrical tetraoxane 28 along with side product hexaoxane 29, as shown in Scheme 6. It is also known that the trimeric cyclic peroxide by-product hexaoxonane is formed in the presence of excess hydrogen peroxide. Dimethyl sulfide and potassium iodide can be used for the removal of hydroperoxide-related impurities. Hexaoxonanes could be removed by washing the reaction mixture with cold methanol. [40]


Sheme 6.

Acid catalyzed synthesis of tetraoxanes and hexaoxonanes.

In our lab, we also attempted the synthesis of a new series of tetraoxane by incorporating nitrogen within the cyclohexyl ring. [41] Methyl 2-(4-oxopiperidin-1-yl)acetate 30 on reaction with gem-dihydroperoxide 27 may give very small amount of tetraoxane 31 and trimer 29, as shown in Scheme 7. We characterized hexaoxonane 29 as a main side product by spectroscopy and x-ray crystallography.


Sheme 7.

Synthesis of piperidinetetraoxane One pot synthesis

Iskara et al.[42] developed the first one-pot synthesis of tetraoxane. Simple carbonyl compounds 32 in the presence of 30% H2O2, 0.1% MTO, and fluorous alcohols (TFE and HFIP) selectively gives tetraoxanes 33 (Scheme 8). Fluorous solvents TFE and HFIP activate both H2O2 and MTO for oxidation reactions. The one-pot synthesis of mixed tetraoxanes begins with the oxidation of the most reactive carbonyl compound, and then less oxidizable carbonyl compound is added in the presence of acid. In this reaction, no trimeric product is formed.


Sheme 8.

One pot tetraoxane synthesis. Ozonolysis method

The most prolific strategy for the synthesis of tetraoxanes is the ozonolysis of suitable olefins and oximes. This method has dual advantage over others: (1) the absence of hexaoxonane (a usual by-product), which is very common in acid catalyzed reactions, and (2) it is useful for the synthesis of aromatic tetraoxanes, which could not be obtained by other methods. In the 1970s, Keul et al. reported the synthesis of dimeric adamantine peroxide 35 by ozonization of methyleneadamantane 34 in pentane at –78°C. The ozonolysis of valerophenone oxime o-methyl ether 36 produces carbonyl oxide 38 via an intermediate ozonoid 37 to give the crystalline dimeric valerophenone peroxides 39 in the absence of carbonyl compounds or protic solvents.[43]


Sheme 9.

Tetraoxane synthesis by ozonolysis method.

7. Prodrug and combination therapies

The search of newer drugs and the enhancement of antimalarial activity of the existing ones have led to the development of prodrug and combination therapy approaches. It presents a good platform for the usage of readily available drugs in combination with other effective drugs. The potential of drug hybrids, prodrugs, and combination therapy as new approaches are immense.[44]

Tetraoxaquine 40 contain two covalently linked pharmacophores, i.e., a tetraoxane (a radical donor) and an aminoquinoline (interferes with hematin polymerization).[45] Moreover, trioxaquine 41 contains covalently attached trioxane to a 4-aminoquinoline moiety.[46] The chimeric drug penetrates (enabled by aminoquinoline) into infected erythrocyte and targets the free heme. The hemoglobin digestion of the schizonts within infected red blood cells liberates free heme, which is alkylated by the peroxidic part. Trioxaferroquine 42 consists of a trioxane, a substituted quinoline, and an iron (II) species within a single structure.[47]

These new chimeric molecules containing two covalently attached moieties can be expected to possess synergistic therapeutic value, reduce resistance, and toxicity. These strategies offer a rational drug design approach for the development of next generation drug candidates. Notwithstanding few selected examples, which are discussed in this section, it explains the concept and potential applications.


8. Conclusion and future prospect

The development of new drugs for malaria presents a challenging situation. Lack of alternatives and increasing ineffectiveness of the existing drugs are the main reasons for increased mortality. Traditional medicines have provided few drugs, but to combat malaria, new drugs are urgently needed. These new drugs must ideally possess minimal toxicity, rapid efficacy, and low cost. However, there is consensus among scientific community that drug combinations may create optimal control of malaria because the combination therapies are believed to be additive in potency, provide synergistic activity, and is more advantageous than monotherapies. Unfortunately, these requirements are not met by any combination at the current window of time. Besides all the challenges, failures, and setbacks, the global importance of fighting malaria is recognized. Dedicated efforts and academic engagement to discover, develop, and deliver new, effective, and affordable antimalarials have thus increased dramatically. Natural products, semisynthetic drugs, and synthetic compounds offer vast opportunity for the drug development process. Further, assessment and clinical evaluation of RTS,S/AS01E for malaria vaccination offers hope that we may soon expect some good news. Malaria drug discovery is undoubtedly challenging, but scientists are optimistic as they also have got various opportunities too. The status quo seems balanced. However, we believe that we have to provoke the status quo to gain the upper hand in the battle against this tropical scourge.


CS is thankful to UGC, New Delhi, for SRF. SKA acknowledges the financial support from the University of Delhi, Delhi-110007, India.


1 - Poinar G. Plasmodium dominicana n. sp. (Plasmodiidae: Haemospororida) from Tertiary Dominican amber. Systematic Parasitology 2005; 61(1), 47–52
2 - World Malaria Report 2014, (accessed 21.03.2015).
3 - Eve WE, Basu S, Hanson K. Is malaria a disease of poverty? A review of the literature. Tropical Medicine and International Health 2005; 10(10), 1047–1059.
4 - Greenwood D. Conflicts of interest: the genesis of synthetic antimalarial agents in peace and war. Journal of Antimicrobial Chemotherapy 1995; 36(5), 857–872.
5 - Krafts K, Hempelmann E, Skorska-Stania A. From methylene blue to chloroquine: a brief review of the development of an antimalarial therapy. Parasitology Research 2012; 111(1), 1–6.
6 - Kayman DL. Qinghaosu (artemisinin): an antimalarial drug from China. Science 1985; 228(4703), 1049–1055.
7 - Neafsey DE, et al. Highly evolvable malaria vectors: the genomes of 16 Anopheles mosquitoes. Science 2015; 347(6217), 1258522.
8 - Chang HH, Hartl DL. Recurrent bottlenecks in the malaria life cycle obscure signals of positive selection. Parasitology 2015; 142(S1): S98–S107.
9 - Neupane CS, Awasthi SK. In: Synthetic Quinolones: Emerging Antimalarial Agents. A. Pandey (eds.), Antibacterial activity in natural and synthetic compounds. 2013,443-459.
10 - Delves M, Plouffe D, Scheurer C, Meister S, Wittlin S, Winzeler EA, Sinden RE, Leroy D. The activities of current antimalarial drugs on the life cycle stages of plasmodium: a comparative study with human and rodent parasites. PLOS Medicine 2012; 9(2): e1001169/1–e1001169/14.
11 - World Health Organization. Guidelines for the Treatment of Malaria. Second edition. March 2010.
12 - Carter TE, Boulter A, Existe A, Romain JR, St. Victor JY, Mulligan CJ, Okech BA. Artemisinin resistance-associated polymorphisms at the K13-propeller locus are absent in Plasmodium falciparum isolates from Haiti. American Journal of Tropical Medicine and Hygiene 2015; 92(3), 552–554.
13 - Hyde JE. Drug-resistant malaria—an insight. FEBS Journal 2007; 274(18), 4688–4698.
14 - Peters W. History and current status of drug resistance. In: Peters W, Richards WHG. (eds.), Antimalarial Drugs. Handbook of Experimental Pharmacology. 1984, pp. 423–445.
15 - World Health Organization. Guidelines for the Treatment of Malaria. 2006.
16 - White NJ. Antimalarial drug resistance. Journal of Clinical Investigation 2004; 113(8), 1084–1092.
17 - Schlesinger PH, Krogstad DJ, Herwaldt BL. Antimalarial agents: mechanism of action. Antimicrobial Agents and Chemotherapy 1988; 32(6), 793–798.
18 - Meshnick SR. Artemisinin: mechanisms of action, resistance and toxicity. International Journal for Parasitology 2002; 32(13), 1655–1660.
19 - Bray PG, Ward SA, O’Neill PM. Quinolines and artemisinin: chemistry, biology and history. Current Topics in Microbiology and Immunology 2005; 295, 3–38.
20 - Biagini GA, et al. Generation of quinolone antimalarials targeting the Plasmodium falciparum mitochondrial respiratory chain for the treatment and prophylaxis of malaria. Proceedings of the National Academy of Sciences of the United States of America 2012; 109(21), 8298–8303.
21 - Peto TE. Toxicity of antimalarial drugs. Journal of the Royal Society of Medicine 1989; 82(17), 30–33.
22 - Wesche Dl, DeCoster MA, Tortella FC, Brewer TG. Neurotoxicity of artemisinin analogs in vitro. Antimicrobial Agents and Chemotherapy 1994; 38(8), 1813–1819.
23 - Davidson NM. Mouth ulceration associated with proguanil. Lancet 1986; 327(8477), 384.
24 - Taylor WBJ, White NJ. Antimalarial drug toxicity: a review. Drug Safety 2004; 27(1), 25–61.
25 - Schwartz L, Brown GV, Genton B, Moorthy VS. A review of malaria vaccine clinical projects based on the WHO rainbow table. Malaria Journal 2012; 11, 11.
26 - Graves PM, Levine MM. Battling Malaria: Strengthening the U.S. Military Malaria Vaccine Program. 2006, pp. 26–33.
27 - Olotu A, et al. Four-year efficacy of RTS,S/AS01E and its interaction with malaria exposure. New England Journal of Medicine 2013; 368(12), 1111–1120.
28 - Crowther GJ, et al. Identification of inhibitors for putative malaria drug targets among novel antimalarial compounds. Molecular and Biochemical Parasitology 2011; 175(1), 21–29.
29 - Guantai E, Chibale K. How can natural products serve as a viable source of lead compounds for the development of new/novel anti-malarials? Malaria Journal 2011, 10(Suppl 1):S2.
30 - Department of International Development. Medicines For Malaria Venture (MMV) 2005–2010. MMV in natural products: harnessing the power of nature in malaria drug discovery. 2009, (accessed 21.03.2015)
31 - Nogueira CR, Lopes LMX. Antiplasmodial natural products. Molecules 2011; 16, 2146–2190.
32 - Agarwal D, Sharma M, Dixit SK, Dutta RK, Singh AK, Gupta RD, Awasthi SK. In vitro synergistic effect of fluoroquinolone analogs in combination with artemisinin against Plasmodium falciparum; their antiplasmodial action in rodent malaria model. Malaria Journal 2015; 14(1), 48.
33 - Dixit SK, Yadav N, Kumar S, Good L, Awasthi SK. Synthesis and antibacterial activity of fluoroquinoone analogs. Medicinal Chemistry Research 2014; 23(12), 5237–5249.
34 - Yadav N, Sharma C, Awasthi SK. Diversifications in the synthesis of antimalarial trioxane and tetraxoane analogs. RSC Advances 2014; 4, 5469–5498.
35 - Singh C, Malik H, Puri SK. Orally active 1,2,4-trioxanes: synthesis and antimalarial assessment of a new series of 9-functionalized 3-(1-arylvinyl)-1,2,5-trioxaspiro[5.5]undecanes against multi-drug-resistant Plasmodium yoelii nigeriensis in mice. Journal of Medicinal Chemistry 2006; 49(9), 2794–2803.
36 - Singh C, Gupta N, Puri SK. Geraniol-derived 1,2,4-trioxanes with potent in-vivo antimalarial activity. Bioorganic and Medicinal Chemistry Letters 2003; 13(20), 3447–3450.
37 - Sabbani S, Stocks PA, Ellis GL, Davies J, Hedenstrom E, Ward SA, O’Neill PM. Piperidine dispiro-1,2,4-trioxane analogues. Bioorganic and Medicinal Chemistry Letters 2008; 18(21), 5804–5808.
38 - Rubush DM, Morges MA, Rose BJ, Thamm DH, Rovis T. An asymmetric synthesis of 1,2,4-trioxane anticancer agents via desymmetrization of peroxyquinols through a Brønsted acid catalysis cascade. Journal of American Chemical Society 2012; 134(33), 13554−13557.
39 - La-Venia A, Mata EG, Mischne MP. Photoinduced oxygen capture on immobilized dienone systems. First solid-phase synthesis of trioxane scaffolds. Journal of Combinatorial Chemistry 2008; 10(4), 504–506.
40 - Kumar N, Singh R, Rawat DS. Tetraoxanes: synthetic and medicinal chemistry perspective. Medicinal Research Reviews 2012; 32(3), 581–610.
41 - Neupane CS, Awasthi SK. Unique trifurcated hydrogen bonding in a pseudopolymorph of tricyclohexane triperoxide (TCTP) and its thermal studies. Tetrahedron letters 2012; 53(45), 6067–6070.
42 - Iskra J, Bonnet-Delpon D, Begue, JP. One-pot synthesis of non-symmetric tetraoxanes with the H2O2/MTO/fluorous alcohol system. Tetrahedron Letters 2003; 44(33), 6309–6312.
43 - Ito Y, Konishi M, Matsuura T. Thermal and photosensitized decomposition of dimeric valerophenone peroxide formed by ozonation of valerophenone oxime ether. Photochemistry and Photobiology 1979; 30(1), 53–57.
44 - Gutema GB, Hailu GS, Kidanemariam ZA, Hishe HZ. Combination therapy and its implication on clinical efficacy of artemisinins—review. International Journal of Pharmaceutical Sciences and Research 2011; 2(8), 1914–1921.
45 - Opsenica I, Opsenica D, Lanteri CA, Anova L, Milhous WK, Smith KS, Solaja BA. New chimeric antimalarials with 4-aminoquinoline moiety linked to a tetraoxane skeleton. Journal of Medicinal Chemistry 2008; 51(19), 6216–6219.
46 - Odile DC, Francoise BV, Anne R, Bernard M. Preparation and antimalarial activities of “trioxaquines,” new modular molecules with a trioxane skeleton linked to a 4-aminoquinoline. ChemBioChem 2000; 1(4), 281–283.
47 - Francois B, Frederic C, Laure V, Jacques B, Bernard M, Anne R. Trioxaferroquines as new hybrid antimalarial drugs. Journal of Medicinal Chemistry 2010; 53(10), 4103–4109.