A new in vitro checkerboard-parasite reduction ratio interaction assay for early de-risk of clinical development of antimalarial combinations

The development and spread of drug resistant phenotypes substantially threaten malaria control efforts. Combination therapies have the potential to minimize the risk of resistance development but require intensive preclinical studies to determine optimal combination and dosing regimens. To support the selection of new combinations, we developed a novel in vitro-in silico combination approach to help identify the pharmacodynamic interactions of the two antimalarial drugs which can be plugged into a pharmacokinetic/pharmacodynamic model built with human monotherapies parasitological data to predict the parasitological endpoints of the combination. This allows to optimally select drug combinations and doses for the clinical development of antimalarials. With this assay, we successfully predicted the endpoints of two phase 2 clinical trials in patients with the artefenomel - piperaquine and artefenomel - ferroquine drug combinations. Besides, the predictive performance of our novel in vitro model was equivalent to the humanized mouse model outcome. Lastly, our more granular in vitro combination assay provided additional insights into the pharmacodynamic drug interactions compared to the in vivo systems, e.g. a concentration-dependent change in the Emax and the EC50 values of piperaquine or artefenomel or a directional reduction of the EC50 of ferroquine by artefenomel and a directional reduction of Emax of ferroquine by artefenomel. Overall, this novel in vitro-in silico-based technology will significantly improve and streamline the economic development of new drug combinations in malaria and potentially also in other therapeutic areas.