Population pharmacokinetics and pharmacodynamics of pyronaridine

Pyronaridine/Artesunate (PA) 3:1 fixed dose combination is a novel artemisinin-based combination therapy (ACT) in development for the treatment of acute uncomplicated Plasmodium falciparum or Plasmodium vivax malaria. An understanding of both pharmacokinetics and pharmacodynamics of pyronaridine is of importance in order to achieve optimal therapeutic outcome.

In this thesis, population pharmacokinetic models for pyronaridine in healthy subjects, and adult and pediatric malaria patients were developed. Pyronaridine pharmacokinetics in both adult and pediatric populations were best described by a two compartment model with first order absorption and elimination from the central compartment. A presence of malaria infection and body weight were the significant covariates that explained pyronaridine pharmacokinetic variability in the adult population. For the pediatric population, age was the only significant covariate that explained pyronaridine pharmacokinetic variability.

Monte Carlo simulations were also performed to address differences in pyronaridine exposures among these populations and to explore the exposures of pyronaridine among recommended dosage regimens for pediatric and adult malaria patients. Healthy adults had a higher exposure to pyronaridine as compared to adult malaria patients. For the pediatric population, younger children had a higher exposure to pyronaridine as compared to older children. The overall range of pyronaridine exposures among dosing groups for adult and pediatric malaria patients were relatively similar.

The cut-off values of pyronaridine pharmacokinetic parameters associated with successful treatment outcome were also determined by means of receiver operating characteristic (ROC) curve. These cut-off values can be used to optimize the outcome of malaria treatment. Additionally, Cox proportional hazard model was conducted to determine the relationship between several covariates and time to the occurrence of re-infection or recrudescence. The models showed that as the levels of predicted pyronaridine concentrations on day 7 increased, the risks of acquiring re-infection or recrudescence decreased.

Finally, pharmacokinetic drug-drug interaction of pyronaridine and ritonavir was assessed based on the overlap pathway for metabolism of both drugs and the high rates of HIV and malaria co-infection. There was an effect of ritonavir on pyronaridine pharmacokinetics. However, the results were not considered clinically relevant. An increase in ritonavir exposure was observed in the presence of fixed dose PA.