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Pamaquine Naphthoate As a Prophylactic for Malarial Infections

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Pamaquine Naphthoate As a Prophylactic for Malarial Infections PAMAQUINE NAPHTHOATE AS A PROPHYLACTIC FOR MALARIAL INFECTIONS Harry A. Feldman, … , Franklin D. Murphy, Robert B. Watson J Clin Invest. 1947;26(1):77-86. https://doi.org/10.1172/JCI101792. Research Article Find the latest version: https://jci.me/101792/pdf PAMAQUINE NAPHTHOATE AS A PROPHYLACTIC FOR MALARIAL INFECTIONS 1 By HARRY A. FELDMAN,2 HENRY PACKER,- FRANKLIN D. MURPHY,4 AND ROBERT B. WATSON5 (From the Department of Preventive Medicine, University of Tennessee College of Medicine, Memphis, and The Health and Safety Division of the Tennessee Valley Authority) (Received for publication August 5, 1946) Plasmoquine, 6-methoxy-8- ( 1-methyl-4-diethyl- form of 20-mgm. tablets. A second lot came as powder, amino)butyl-aminoquinoline, has been assigned the and was capsulated locally. Both drug lots had such similar assays that they may be considered identical. name "Pamaquine" by the United States Pharma- (b) Plasma concentrations. The plasma concentra- copea XII, and will be so referred to in this pres- tion of pamaquine was usually determined daily by means entation. This anti-malarial has been so fre- of a macrocolorimetric method (3) devised by Brodie quently discussed in the literature that a detailed et al.6 review of its history will not be included here. (c) Subjects. Thirty-six white and colored males and females, who were relatively normal except for central Reference will be made only to those papers which nervous system syphilis, were employed in these experi- bear directly upon the subject of this report. ments. Their ages ranged from 14 to 60 years. Each re- In 1931, James et al (1, 2) conducted a series ceived complete physical, hematological, and blood chem- of experiments which showed that pamaquine in istry examinations, urinalysis, x-rays of the chest, and 80 on a 1-1-6 regime electrocardiographic studies prior to the institution of doses of mgm. per day (that treatment. Subsequently, these tests (except for the is, administered on the day before, the day of, and roentgenograms) were performed daily until experience for 6 days after inoculation with sporozoites) acted indicated that with the exceptions of determinations of as a true causal prophylactic for both vivax and methemoglobin, plasma bilirubin, hematocrit indices, and falciparum inoculations (Roumanian strain). leukocyte counts, such extensive tests were unnecessary, in Table I. It will be and they were discontinued as routine procedures. This work is summarized (d) Methemoglobin. Methemoglobin formation is noted that the number of subjects tested was small. known to occur regularly during pamaquine administra- In view of this fact, and because of the importance tion. Since this may be a factor in the serious toxic re- of the results obtained, it is surprising that de- actions ascribed to the drug, it was considered necessary spite the reputation for toxicity which the drug had to determine its concentration daily. These determina- it was not explored further until a de- tions were performed by means of a simple procedure de- acquired, vised by Wendel (4). The test utilizes a photoelectric cision was made by the Panel on Clinical Testing colorimeter, and requires only small amounts of blood. of Anti-malarials of the Committee on Medical (e) Parasitological methods. Inoculations were gen- Research to reevaluate this drug. This project erally performed on the second day of treatment, although was assigned the task of repeating and expanding exceptions to this rule will be noted in the tabulated data. the study of James during the summer of 1944. Laboratory-bred Anopheles quadrimaculatus, infected by feeding on patients with either P. vivax (McCoy) or P. The information obtained to date forms the basis falciparum (Costa) parasites, were allowed to inoculate of this report. by feeding. The mosquitoes were then killed, dissected, MATERIALS AND METHODS and the sporozoite content of their salivary glands esti- mated by a scale of pluses ranging from 1 (minimal) to 4 (a) Drug. Pamaquine naphthoate was the compound (maximal). Although in obvious excess, a goal of 16 employed throughout this study. Approximately 45 per pluses was sought for each infection. When necessary tent of this salt is considered to be active base. Conse- (and available) additional mosquitoes were fed on the quently, dividing our doses by 2 yields a figure for com- same subject if the initial inoculum was less than 12 pluses. parison with doses generally referred to in the literature. Ordinarily, P. vivax was reserved for whites and P. The original lot of drug employed was supplied in the falciparum for negroes. However, it was sometimes nec- essary to use P. falciparum in whites, but no mishaps 1 Work done under contract with the Office of Scientific Research and Development. occurred. 2 Lieutenant Colonel, M.C., A.U.S. 6 Dr. William B. Wendel, formerly of the Department 8Associate Professor of Preventive Medicine. of Biochemistry of the University of Tennessee College 4 Captain, M.C., A.U.S. of Medicine, supervised all of our plasma level deter- Sf Principal Malariologist, T.V.A. minations. 77 78 H. A. FELDMAN, H. PACKER, F. D. MURPHY, AND R. B. WATSON TABLE I* Pamaquine as a true causal prophyladtic (Summary of the experiments of Col. James) Duration of administration Protection afforded (i.e., no evidence malaria) Group Number of Doses** s after day Immediate Late Ttaotal Daysof biting (up to 30 days) (followed up to 3 years) grams days no. per cent | #. per cent P. viwax I Not given 0.08 | 8 | 6 All 100 All 100 (0.08 first 3 days, 0.06 last 5 days) II 10 0.06 7 5 10 100 5 50 III 5 0.04 10 8 5 100 Not tested IV 2 0.04 7 5 1 50 Not reported V 4 0.04 5 3 2 50 Not reported VI 5 0.04 4 2 1 20 Not reported VII 3 0.08 evening before infection 2 67 0 0 (Roumanian strain) 0.08 at time of infection (no other doses) I P. fakiparum I Not given 0.08 | 8 6 All 100 All 100 (0.08 first 3 days, 0.06 last 5 days) VIII 5 0.08 6 4 5 100 5 100 (Roumanian strain) * From a summary prepared by Dr. Thomas C. Butler for the Board for the Coordination of Malarial Studies. ** Presumed to be base, and thus equivalent to about 45 per cent of the naphthoate. Each patient had a pretreatment negative thick film and in order of increasing drug dosage. This is examination for malaria parasites. Similar smears were not the chronological order of experimentation, examined daily from the seventh postinoculation day un- til discharge from the hospital. All negatives were fol- but probably represents a more rational approach lowed for at least 30 days in the hospital, and at intervals for the reader. thereafter, depending upon the location of the individual's (a) Experiments with P. vivax (McCoy). The home or place of custodial hospitalization. Prior to the trials with P. vivax (McCoy) are summarized in employment of penicillin for the treatment of the patients' Table II. Two patients who received 160 mgm. neuro-syphilis, 3 subjects received trophozoite inocula- a tions after 31 to 34 days of negative observation. The of pamaquine naphthoate day for the second to malarial course of each of these was perfectly normal. sixth postinoculation days had prepatent periods Although it had been shown that penicillin had no of 15 and 19 days. Although slightly longer than effect upon malaria trophozoites (5, 6), no infornation usual, these periods are not significantly different was available concerning its action on sporozoite or from those normally encountered. This experi- "exoerythrocytic" forms. Consequently, 2 patients were given, in divided doses, 240,000 units of penicillin on each ment was designed to test the thesis that pamaquine of 10 days. On the second day, one patient was inocu- acted against other than sporozoite and tropho- lated by mosquitoes with sporozoites of P. zivax (Mc- zoite forms. The results in these 2 patients do not Coy), and the other with P. falciparum (Costa). Both indicate that such, at least, is the sole case. developed malarial infections within normal prepatent In order to determine whether the activity of periods, and so it was felt that the subsequent expression a of infections in our experimental subjects was not in- pamaquine depended upon slowly excreted deg- fluenced by intensive penicillin therapy received during radation product, 180 mgm. were administered the early prepatent phase. daily for 8 days to 1 patient. Inoculation was ac- complished on the ninth day, and 12 days later RESULTS he developed a demonstrable parasitemia. In this The results of the experiments will be presented instance, at least, the hypothesis appears to have in relation to each of the parasite species employed, bern unfounded. PAMAQUINE NAPHTHOATE FOR MALARIA PROPHYLAXIS 79 Another patient, receiving 180 mgm. of pama- the day of, and for 5 days following inoculation. quine naphthoate a day, was inoculated on the The former developed malaria on the fourteenth, second of the 2 days in which he received this dose. and the latter on the sixteenth day. In view of The appearance of an acute hemolytic anemia then other similar experiments (vide infra) these dos- necessitated drug withdrawal; parasitemia was ages appear to have been indaequate. evident on the eleventh postinoculation day. Another patient was given 160 mgm. of pama- One patient was given 160 mgm. of drug on the quine naphthoate daily on the same schedule as day before, the day of, and for 2 days following the 2 patients just described. After 34 negative inoculation. The development of severe abdominal days he received an intravenous inoculation of P.
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