PHYTO-LARIA ® A PROMISING HERBAL ANTIMALARIAL FROM GHANA THE HERBAL DIVISION OF PHYTO-RIKER PHARMACEUTICALS

1. PHYTO-LARIA®A PROMISING HERBALANTIMALARIAL FROM GHANA THE HERBAL DIVISION OF PHYTO-RIKER PHARMACEUTICALS Diane Winn

2. In Ghana, Artesunate has become the treatment of choice, but it has proven to be in short supply, it’s hard to obtain, prices are high, and several patients on Artesunate-Amodiaquin therapy have recently died.

3. The African continent abounds with other plants that reportedly have anti-malarial activity which could be further studied and exploited.

4. Herbal Products for Phyto-Riker have been developed by a team of individual scientists and collaborating institutions, building on the work of Dr. Oku Ampofo, a western trained Ghanaian physician who incorporated herbal medicines into his practice of western medicine for nearly 40 years.

5. The main plant that Dr. Ampofo recommended for the treatment of malaria was Cryptolepis sanguinolenta. The root is bright yellow when it is cut and the root is the main source of its anti-malarial activity.

6. Folklore indicates that Cryptolepis was used by the Fulanis for jaundice and hepatitis, in Zaire and Senegal for stomach and intestinal disorders, in the Congo for amoebiasis, and among various tribes in Ghana for fevers, infectious diseases, venereal diseases and especially for malaria.

7. Cryptolepis sanguinolenta

9. THE PLANT • Anecdotal evidence of efficacy of root and root bark decoction of a plant used by traditional medical practitioners to treat a number of diseases including malaria. • Name of plant Cryptolepis sanguinolenta a.k.a. Pergularia sanguinolenta or Cryptolepis triangularis. • Indigenous to Africa. • Local name is “Nibima”. • Grows wild as a thin-stemmed twining and scrambling shrub along the west coast of Africa.

10. WHAT IS KNOWN • A number of scientific studies on preparations of C. sanguinolenta available, indicating that the plant is: • Anti-plasmodial, i.e., works against the malaria parasite Plasmodium falciparum outside the body. • Anti-microbial, i.e., works against small or micro organisms (germs, bacteria); • Anti-hyperglycaemic, i.e., against diabetes.

11. The root decoction of Cryptolepis, a plant that is indigenous to Ghana, has been traditionally used for the treatment of malaria. The anti-malarial effect of the decoction has been studied by the Faculty of Pharmacy, Kwame Nkrumah University of Science and Technology in Kumasi and the Centre for Scientific Research into Plant Medicine.

12. The Noguchi Memorial Institute for Medical Research has carried out extensive studies on the safety and toxicity of the tea bag formulation. The faculty of Pharmacy of KNUST has standardized the tea bag formulation and Phyto-Riker manufactured it and put it on the market as PHYTO-LARIA®.

13. In a teabag formulation clinical trial conducted by Boye et al in 2000, Phyto-Laria® completely eliminated parasitaemia within3 to 5 days in over 90% of patients, with no observable side effects. Fever was reduced within the first 24 hours, thus obviating the need for a separate anti-pyretic medication.

14. This trial is important, in that: • there has been only one publication on clinical efficacy of the plant, in spite of many anecdotal claims of efficacy in treating malaria. • the results indicated that efficacy of Cryptolepis is comparable to that of chloroquine. • the Current evaluation is another one on clinical efficacy. • the study shows that there is no need for a separate anti-pyretic medication.

15. RESULTS: • an overall cure rate of 93.5%. • two cases of late recrudescence on Days 21 and 28 could be due to re- infection • values of parasite clearance time (82.3h) and fever clearance time (25.2h) comparable to those obtained in the reported clinical study when the Cryptolepis aqueous extract was compared with chloroquine, (80h and 36h respectively). • shorter fever clearance time when compared to chloroquine.

16. RESULTS: • Presenting symptoms with very high incidence (>90%) could be regarded as the ones characteristic of falciparum malaria. • These were • Bodyache - Chills • Fever - Headache • Weakness - Nausea • Of these, chills, fever, nausea and vomiting cleared rapidly and were completely resolved by Day 7 when the blood was cleared of parasites.

17. CONCLUSION: • Evaluated on evidence of fever clearance and disappearance of parasitaemia by Day 7, according to the modified WHO criteria, • PHYTO-LARIA® has been shown to be highly effective in the treatment of acute uncomplicated malaria.

18. Compliance was a bit of a problem because of the bitter taste of the tea. An encapsulated extract has now been developed that has overcome the bitter taste and the capsules willbe tested in double blind clinical trials to confirm the efficacy found in the teabag formulation.

19. The root extract comprises multiple active compounds, several of which are anti-malarial, would have syner- gistic activity and, unlike Artesunate, is predicted make parasite resistance to it evolve much more slowly. It could also be formulated in combination with other anti-malarial drugs to further delay the emergence of resistance.

20. Approval from the Ghanaian Food and Drugs Board has been granted to enable the Noguchi Institute to conduct dose-finding as well as efficacy studies on the capsule formulation. This latter study has received funding from theWHO Africa Regional Office.

21. A public–private partnership called “PHYTOSEARCH” has been formed to seek financial assistance to carry out further clinical trials and other relevant studies that will result in a scientifically developed indigenous herbal medicine for the treatment of malaria that will be internationally recognized.

22. Plans also includes cultivation of the plant on a large scaleas a raw material source and will thus provide employment for Ghanaian farmers.

23. NEXT STEPS FOR CRYPTOLEPIS THERAPY DEVELOPMENT:

24. 1. The dose finding study, funded by WHO Africa, is currently underway at the Noguchi Institute, using the capsule formulation, to determine the optimal dose. Pharmacokinetic activity may be a determining factor.

25. 2.A summary of what has been done to date, as part of an initial Investigator’s Brochure, will be prepared by the Director of Noguchi for an initial submission to WHO, as well as proposals and protocols for subsequent studies, with detailed budget figures and timelines attached.

26. 3. Additional studies to determine the best technique to yield the highest quality extract, and development of improved assays for standardizing the extract have to be done. Apart from Cryptolepine, other indoloquinoline alkaloids, which are isomers and dimers of cryptolepine, also have anti-malarial activity.

27. 4. The objective is to standardize the extract against the content of all the indoloquinoline alkaloids, for an improved standardization method. Toxicology studies will also have to be done to confirm the safety of the newly formulated product, as well as bioavailability and pharmacokinetic studies.

28. 5.It will be important to publish the results of the clinical trials and encourage multi-center trials to confirm the results. This would most likely involve randomized controlled trials of Cryptolepis versus the current first-line treatment for malaria in patients at the primary health care level with presumed uncomplicated malaria .

29. 6.Cost effectiveness will be a primary outcome measure of the trials, after which the Investigator’s Brochure will be completed and presented to WHO, along with an appeal to WHO to recognize and recommend the product for use on the African continent.

30. 7.We must begin to expand the cultivation of the plant by outgrower farming networks. Cryptolepis is a plant indigenous to Ghana and is a climber which grows better in the rainforest areas than on the plains. Growing in different areas must be compared, to ensure uniformity in quality of the final product.

31. 8.Work with agricultural partners for large scale growing of Cryptolepis. And, an efficient tracking system must be put in place to ensure consistency from “seed to capsule”

32. 9.It will be important to develop an alternative formulation for infants and young children, whether it is syrup, a suppository or a sub-lingual spray. It will then be important to conduct a dose finding study and a clinical trial to confirm its efficacy in infants and young children.

33. 10. The last step is to launch these products into the market, with marketing studies and an effective promotional and advertising campaign, including post marketing surveillance. We should also appeal to governments and to the NGO communities to make them available to those who are most vulnerable to malaria.

34. WHY THIS STUDY? • Only one publication on clinical efficacy of the plant, in spite of many anecdotal claims of efficacy in treating malaria. • Results indicated that efficacy of C. sanguinolenta is comparable to that of chloroquine. • Current evaluation is another one on clinical efficacy.

35. RATIONALE FOR THIS STUDY • Tea-bag formulation: to avoid preservation with chemicals including CHCl3. • Necessity of confirming the clinical efficacy of C. sanguinolenta in the new tea-bag formulation and in the dose prescribed. • Overall aim of the study: • to evaluate the clinical efficacy and safety of PHYTO-LARIA® as prescribed in the treatment of symptomatic uncomplicated malaria in semi-immune patients.

36. PATIENTS • 11 to 50 years old with clinical features of uncomplicated malaria, recruited from three outpatient clinic sites. • Patients with large number of parasites in the blood (between 1000 and 100,000 P. falciparum per 8000 white blood cells). • Exclusion criteria: • Patients with complicated malaria, (severe anaemia or cerebral malaria); • Pregnant and lactating women; • Patients who had taken therapeutic doses of chloroquine within the previous 14 days, or sulfadoxine/pyremethamine within 28 days. • Consent obtained from all participating patients.

37. TEST DRUG • PHYTO-LARIA® a teabag formulation of C. sanguinolenta root powder. • Each teabag contained 2.5g of the root powder, plus flavourings primarily to cover up the bitter taste. • Dose = one teabag three times a day, morning noon and night, for five days of treatment.

38. STUDY PLAN • Days of examination 0 - 7, 14, 21, 28. • Patients’ medical history: Day 0. • Days of treatment: days 1 – 5. • Physical examination for presenting symptoms: all days of examination. • Thick and thin blood films prepared and used to count the number of parasites. • Blood obtained for haematological indices and blood chemistry on days 0, 3, 7, 14, 21 and 28.

39. PRESENTING SYMPTOMS • Abdominal Pains; • Body ache; • Chills; • Diarrhoea; • Dizziness; • Fever;Hallucinations; • Headache; • Nausea; • Skin itching; • Vomiting; • Weakness.

40. PARAMETERS TO BE OBTAINED • Parasite clearance time; • Fever clearance time; • Recurrence within the 28 days follow up. • Treatment considered curative if all parasites cleared from the blood by Day 7 and no recurrence during the 28-day follow up period.

41. PATIENTS • 23 males and 21 females (44 patients) entered the study. • Mean age = 25.2 years, mean body weight = 60.1kg. • Thirty-one patients completed the study. • All patients in the study had symptoms of malaria and a significant number of parasites in the blood

42. RESULTS • Patients’ mean initial temperature was 38.430C. • Mean fever clearance time was 25.2 hours. • Mean parasite clearance time was 82.3 hours • More than 50% of patients were cleared of para-sites in their blood by the end of the third day. • All patients cleared of parasites by Day 7 and, except for two, remained so throughout the rest of the 28 days. • There were 2 cases of recurrence, one occurring on Day 21 and the other on Day 28, but they may have been re-infected.

43. RESULTS cont’d • Mean haemoglobin levels lower during treatment, compared to pre-treatment values, but started to rise by Day 14, approaching pre-treatment levels by Day 28. • Total WBC count dropped from the pre-treatment level and remained low throughout the 28-day study period although the post-treatment values were higher than the values during treatment. • Platelet count increased progressively with treatment, from a low pre-treatment value to upper normal values and began to decline after Day 14. • ESR, haematocrit and reticulocyte counts showed little change from the pre-treatment values with treatment.

44. RESULTS cont’d • Biochemical parameters not significantly modified following treatment: • Creatinine; • Urea were within the range considered normal. • Both total and direct bilirubin appeared elevated compared to pre-treatment values but the levels were all within the range considered normal. • No significant differences in the two aminotransferases measured (ASAT and ALAT), although the values were generally higher during and after treatment. • Level of total protein and glucose did not change significantly with treatment.

45. INFERENCE • Overall cure rate of 93.5%. • Two cases of late recrudescence on Days 21 and 28 could be due to re-infection as this was an out-patient study. • Values of parasite clearance time (82.3h) and fever clearance time (25.2h) comparable to those obtained in the reported clinical study when C. sanguinolenta aqueous extract was compared with chloroquine, (80h and 36h respectively). • Shorter fever clearance time for PHYTO-LARIA® compared to chloroquine. Therefore, more evidence of anti-pyretic effect reported for C. sanguinolenta provided.

46. INFERENCE • Evidence of chloroquine resistance in Ghana. • C. sanguinolenta has been shown to be effective against chloroquine-resistant strains of the parasite. • Therefore, although chloroquine resistance was not part of the study, the high cure rate reported suggests that PHYTO-LARIA® could be used for the treatment of malaria caused by chloroquine-resistant strain of P. falciparum.

47. CONCLUSION • Evaluated on evidence of fever clearance and disappearance of parasitaemia by Day 7, according to the modified WHO criteria, PHYTO-LARIA® has been shown to be highly effective in the treatment of acute uncomplicated malaria.