Parasitol Res (2008) 102:537–540

DOI 10.1007/s00436-007-0801-7

SHORT COMMUNICATION

Artemether and tribendimidine lack activity in experimental

treatment of Paragonimus westermani in the dog
Jian Xue & Jürg Utzinger & Yong-Nian Zhang &
Marcel Tanner & Jennifer Keiser & Shu-Hua Xiao

Received: 29 October 2007 / Accepted: 31 October 2007 / Published online: 8 December 2007
# Springer-Verlag 2007

Abstract Artemether and tribendimidine are active against
several trematode species, but no data are available
regarding the lung fluke Paragonimus westermani. We
infected six dogs with 100 P. westermani metacercariae
each. At day 103 post-infection, four dogs were treated
orally for 3 days with either artemether (total dose, 66.7 and
75 mg/kg) or tribendimidine (total dose, 100 mg/kg). The
remaining dogs were left untreated and served as control.
Sixteen days after the final dosing, dogs were killed, and
P. westermani flukes were recovered from the lungs and
counted. Neither artemether nor tribendimidine showed
activity against P. westermani at this dose regimen in dogs.
J. Xue : Y.-N. Zhang : S.-H. Xiao (*)
National Institute of Parasitic Diseases,
Chinese Center for Disease Control and Prevention,
Shanghai 200025, People’s Republic of China
e-mail: shxiao1@yahoo.com
J. Xue
e-mail: xuejian74@yahoo.com.cn
Y.-N. Zhang
e-mail: zhangyongn@yahoo.com.cn
J. Utzinger : M. Tanner
Department of Public Health and Epidemiology,
Swiss Tropical Institute,
P.O. Box, 4002 Basel, Switzerland
J. Utzinger
e-mail: juerg.utzinger@unibas.ch
M. Tanner
e-mail: marcel.tanner@unibas.ch
J. Keiser
Department of Medical Parasitology and Infection Biology,
Swiss Tropical Institute,
P.O. Box, 4002 Basel, Switzerland
e-mail: jennifer.keiser@unibas.ch
Keywords Artemether . Tribendimidine . Food-borne
trematodiasis . Paragonimus westermani . In vivo study . Dog
Introduction
Artemisinin and its semisynthetic derivatives (e.g., artemether
and artesunate) possess outstanding antimalarial properties,
and hence, these compounds are increasingly recommended
as first-line treatment against malaria, particularly as
artemisinin-based combination therapies (Ashley and White
2005; Mutabingwa 2005; O’Neill 2005; Haynes 2006). The
artemisinins also exhibit in vitro and in vivo activity against
schistosomes (the causative agent of human schistosomia-
sis) with the highest activities confined to the juvenile
stages of the parasites (Xiao et al. 2002; Utzinger et al.
2007). Recently, laboratory investigations with artemether
and artesunate have been extended from schistosomes to
other trematodes. It was found that the intestinal fluke
Echinostoma caproni harbored in the mouse (Keiser et al.
2006a), and the two liver flukes Clonorchis sinensis and
Fasciola hepatica in the rat were highly susceptible to single
oral doses of artemether and artesunate (Keiser et al. 2006b,
d). A somewhat lower, but still statistically significant, worm
burden reduction has been observed against the liver fluke
Opisthorchis viverrini in the hamster (Keiser et al. 2006d).
Tribendimidine is active against various nematodes in
dogs and different rodent models and cestodes in chicken.
Clinical trials showed that single oral tribendimidine is safe
and as efficacious as albendazole in treating soil-transmitted
helminth infections, particularly Ascaris lumbricoides and
the hookworms (Ancylostoma duodenale and Necator amer-
icanus). Hence, tribendimidine has been approved by the
Chinese Food and Drug Administration (Xiao et al. 2005)
and recent phase 4 clinical testing, involving 899 children
538 Parasitol Res (2008) 102:537–540

and 1,292 adults, confirmed that tribendimidine is safe and Fecal samples from treated dogs were collected 12 days
efficacious in treating A. lumbricoides and hookworm after the final dosing and examined for the presence of
infections (Xiao et al. 2007; Zhang et al. 2007). We have P. westermani eggs. Four days later, all dogs were killed, their
documented in vivo activity of tribendimidine against dif- lungs removed and carefully examined for P. westermani.
ferent trematodes, namely E. caproni in the mouse (Keiser The number of worms was counted for each animal. The
et al. 2006c), C. sinensis in the rat, and O. viverrini in the effect of the drug was evaluated by comparing the number of
hamster (Keiser et al. 2007). trematodes recovered from treated compared to untreated
No data are currently available regarding in vivo activity control animals.
of artemisinin derivatives and tribendimidine against the
lung fluke Paragonimus westermani. To fill this gap, we
administered high doses of artemether and tribendimidine Results
to P. westermani-infected dogs.
No adverse events were observed after administration of
artemether or tribendimidine to dogs infected with P. west-
Materials and methods ermani. Twelve days after the final dosing, P. westermani eggs
were still present in the feces of all treated dogs. Dog 3,
Host, parasite and infection administered 100 mg tribendimidine twice daily for three
consecutive days, died 16 days after the final dosing, which
Six hybrid dogs, weighing 5.5–19 kg, were kept at the animal prompted us to kill the remaining dogs for recovery of
facilities of the National Institute of Parasitic Diseases, Chinese P. westermani to assess in vivo drug activity.
Center for Disease Control and Prevention (Shanghai, China). Table 1 shows the number of worms recovered from the
Dogs had free access to water and were fed commercial dog diet. lungs of the different animals. From the two control dogs,
P. westermani metacercariae were isolated from crabs 22 and 54 P. westermani worms were recovered (mean=
collected from Yongjia county, Zhejiang province, China. 38). One dog in each of the two treatment groups harbored
Dogs were infected intraperitoneally with 100 P. westermani more worms than the lower worm count in the untreated
metacercariae each. Fecal samples from dogs were monitored dog (tribendimidine, 24 worms; artemether, 46 worms vs
longitudinally for the presence of P. westermani eggs. control, 22 worms). While the mean worm burden in the
dogs treated with tribendimidine (31 worms) was slightly
Drugs and treatment lower than in the control animals, a considerably higher
mean worm burden was found in dogs treated with
Artemether capsules (100 mg per capsule) were purchased artemether (59 worms).
from Kunming Pharmaceutical Corporation (Kunming, Visual inspection revealed similar pathological altera-
China; lot no. 20040416). Tribendimidine enteric-coated tions of lungs of P. westermani-infected dogs treated with
tablets (100 or 200 mg per tablet) were obtained from either artemether or tribendimidine or left untreated.
Shandong Xinhua Pharmaceutical Company Limited (Zibo, Moreover, the size of the worm cysts, the color of the cyst
China; lot no. 0509216). fluid, and worm motor activity were similar among
Drug administration commenced 103 days post-infection P. westermani recovered from treated animals when
when P. westermani eggs were present in the feces of all compared to untreated control dogs.
dogs. Drugs were wrapped in well-cooked pieces of pork,
which could easily be swallowed by the dogs. Dog 1 Table 1 Effect of artemether and tribendimidine against adult Para-
gonimus westermani in dogs
(weight, 9 kg) and dog 2 (weight, 8 kg) were administered a
single 100-mg artemether capsule twice daily for three Dog Weight Treatment Total Worm Mean
consecutive days. The total dose of artemether was no. (kg) dose count worm
therefore 66.7 and 75 mg/kg, respectively. Dogs 3 and 4, (mg/kg) burden
weighing 6 and 12 kg, were treated with a single 100 and
1 9 Artemetherb 66.7 72 59
200 mg tribendimidine enteric-coated tablet twice daily for 2 8 Artemetherb 75 46
three consecutive days, respectively. The total dose of 3a 6 Tribendimidinec 100 24 31
tribendimidine was therefore 100 mg/kg. 4 12 Tribendimidinec 100 38
5 5.5 Control – 22 38
Control animals and appraisal of drug efficacy 6 19 Control – 54
a
Dog 3 died 16 days after the final dosing
Dogs 5 and 6, weighing 5.5 and 19 kg, remained untreated, b
Capsule
c
and hence, served as control. Enteric-coated tablet
Parasitol Res (2008) 102:537–540
Discussion
An estimated 293 million people are at risk of para-
gonimiasis throughout Asia and in parts of West Africa, and
some 20 million individuals are infected (Walker and Zunt
2005; Keiser and Utzinger 2007b). An infection occurs
through the consumption of raw or undercooked freshwater
crab or crayfish. Domesticated cats, dogs, or pigs often also
harbor the fluke causing significant economic losses in
livestock industry and an elevated risk for disease trans-
mission (Wang et al. 2006).
In recent reviews focusing on the in vivo activities of
the artemisinins against major trematodes, the paucity of
data regarding Paragonimus spp. has been noted (Keiser
and Utzinger 2007a, b). Since the advent of praziquantel
and triclabendazole 20–30 years ago, discovery and
development research on new drugs against paragonimiasis
has been neglected (Keiser and Utzinger 2007a). Thus far,
in vivo activity of tribendimidine against Paragonimus spp.
had not been investigated. To fill these gaps, we orally
administered high doses of artemether (66.7–75 mg/kg) and
tribendimidine (100 mg/kg) over a 3-day treatment course
to dogs experimentally infected with P. westermani. In
previous studies, lower doses of artemether administered
orally in a 3-day course (25–35 mg/kg) or multiple 10- to 15-
mg/kg doses administered at 7-day intervals to dogs
infected with either juvenile or adult Schistosoma japoni-
cum resulted in significant worm burden reductions (Le et
al. 1982; Xiao et al. 2000). With regard to tribendimidine,
we employed an eightfold higher dose than the single dose
of 12 mg/kg used before in treating Ancylostoma caninum-
infected dogs (Xiao et al. 2005).
Our results indicate that artemether and tribendimidine
lack activity against adult P. westermani at the dose
regimens investigated. Twelve days after the final dosing,
eggs of P. westermani were still present in feces from
treated dogs. Lungs removed from treated and untreated
control dogs 16 days after the final dosing showed similar
pathological features. No differences were observed regard-
ing the number of worms, size of worm cysts, the color of
the cyst fluid, and worm motor activity in dogs treated with
either drug or left untreated.
It is interesting to juxtapose our findings to previous
investigations that assessed the effect of oral artemether in
different trematode-rodent models. Activity has been found
against schistosomes that are located in the blood vessels
(Utzinger et al. 2007) and against C. sinensis, F. hepatica,
and O. viverrini that are located in the bile duct (Keiser et
al. 2006a, b, d). As P. westermani is located in the lung
tissues and is surrounded by a cyst, it might be speculated
that the parasite lacks susceptibility to artemether or the
drug fails to reach the parasite. However, it has been
demonstrated that artemether is distributed moderately to
539
the lungs of rats (Jiang et al. 1989). Furthermore, artesunate
was highly active against Echinococcus multilocularis
metacestodes in vitro (A. Hemphill, personal communica-
tion). Hence, new research is needed to better understand
why artemether lacks activity against P. westermani
harbored in dogs. Administration of tribendimidine to
rodents infected with the aforementioned trematodes found
in vivo activities against C. sinensis and O. viverrini, but
there was no apparent effect against S. mansoni and
F. hepatica (Keiser et al. 2007).
Concluding, both artmether and tribendimidine lack in
vivo activity against P. westermani. Praziquantel, therefore,
remains the drug of choice against this lung fluke, and
triclabendazole might serve as an alternative should resistance
emerge for the former drug (Keiser and Utzinger 2007b).
There is still a pressing need to develop novel trematocidal
drugs as long as praziquantel and triclabendazole remain
effective.
Acknowledgements This study received financial support from
National Institute of Parasitic Diseases, Chinese Center for Disease
Control and Prevention. J. Utzinger (project no. PPOOB-102883) and
J. Keiser (project no. PPOOA-114941) are grateful to the Swiss
National Science Foundation for personal career development grants.
References
Ashley EA, White NJ (2005) Artemisinin-based combinations. Curr
Opin Infect Dis 18:531–536
Haynes RK (2006) From artemisinin to new artemisinin antimalarials:
biosynthesis, extraction, old and new derivatives, stereochemistry
and medicinal chemistry requirements. Curr Top Med Chem
6:509–537
Jiang JR, Zou CD, Shu HL, Zeng YL (1989) Assessment of
absorption and distribution of artemether in rats using a thin
layer chromatography scanning technique. Acta Pharmacol Sin
10:431–434 (in Chinese)
Keiser J, Utzinger J (2007a) Advances in the discovery and
development of novel trematocidal drugs. Expert Opin Drug
Discov 2(Suppl 1):S9–S23
Keiser J, Utzinger J (2007b) Food-borne trematodiasis: current
chemotherapy and advances with artemisinins and synthetic
trioxolanes. Trends Parasitol 23:555–562
Keiser J, Brun R, Fried B, Utzinger J (2006a) Trematocidal activity of
praziquantel and artemisinin derivatives: in vitro and in vivo
investigations with adult Echinostoma caproni. Antimicrob
Agents Chemother 50:803–805
Keiser J, Xiao SH, Tanner M, Utzinger J (2006b) Artesunate and
artemether are effective fasciolicides in the rat model and in vitro.
J Antimicrob Chemother 57:1139–1145
Keiser J, Xiao SH, Utzinger J (2006c) Effect of tribendimidine on
adult Echinostoma caproni harbored in mice, including scanning
electron microscopic observations. J Parasitol 92:858–862
Keiser J, Xiao SH, Xue J, Chan ZS, Odermatt P, Tesana S, Tanner M,
Utzinger J (2006d) Effect of artesunate and artemether against
Clonorchis sinensis and Opisthorchis viverrini in rodent models.
Int J Antimicrob Agents 28:370–373
Keiser J, Xiao SH, Chollet J, Tanner M, Utzinger J (2007) Evaluation
of the in vivo activity of tribendimidine against Schistosoma
540
mansoni, Fasciola hepatica, Clonorchis sinensis, and Opis-
thorchis viverrini. Antimicrob Agents Chemother 51:1096–1098
Le WJ, You JQ, Yang YQ, Mei JY, Guo HF, Yang HZ, Zang CW
(1982) Studies on the efficacy of artemether in experimental
schistosomiasis. Acta Pharmaceut Sin 17:187–193 (in Chinese)
Mutabingwa TK (2005) Artemisinin-based combination therapies
(ACTs): best hope for malaria treatment but inaccessible to the
needy! Acta Trop 95:305–315
O’Neill PM (2005) The therapeutic potential of semi-synthetic
artemisinin and synthetic endoperoxide antimalarial agents.
Expert Opin Investig Drugs 14:1117–1128
Utzinger J, Xiao SH, Tanner M, Keiser J (2007) Artemisinins for
schistosomiasis and beyond. Curr Opin Investig Drugs 8:105–116
Walker MD, Zunt JR (2005) Neuroparasitic infections: cestodes,
trematodes, and protozoans. Semin Neurol 25:262–277
Wang CR, Qiu JH, Zhao JP, Xu LM, Yu WC, Zhu XQ (2006)
Prevalence of helminthes in adult dogs in Heilongjiang Province,
the People’s Republic of China. Parasitol Res 99:627–630
Parasitol Res (2008) 102:537–540
Xiao SH, Booth M, Tanner M (2000) The prophylactic effects of
artemether against Schistosoma japonicum infections. Parasitol
Today 16:122–126
Xiao SH, Tanner M, N’Goran EK, Utzinger J, Chollet J, Bergquist R,
Chen MG, Zheng J (2002) Recent investigations of artemether, a
novel agent for the prevention of schistosomiasis japonica,
mansoni and haematobia. Acta Trop 82:175–181
Xiao SH, Wu HM, Tanner M, Utzinger J, Wang C (2005)
Tribendimidine: a promising, safe and broad-spectrum anthel-
mintic agent from China. Acta Trop 94:1–14
Xiao SH, Wu ZX, Zhang JH, Wang SQ, Wang SH, Qiu DC, Wang C
(2007) Clinical observation on 899 children infected with intestinal
nematodes and treated with tribendimidine enteric coated tablets.
Chin J Parasitol Parasit Dis 25:372–375 (in Chinese)
Zhang JH, Xiao SH, Wu ZX, Wang C (2007) Efficacy of
tribendimidine enteric coated tablet in treatment of 1292 adult
patients with intestinal mematode infection—a phase IV clinical
trial. Chin J Parasitol Parasit Dis 25:(in press, in Chinese)