HK40112908A - Treatment of severe and uncomplicated malaria - Google Patents

Description

Treatment of severe malaria and uncomplicated malaria

Cross-references to related applications

This application claims priority to Vietnam Application No. 1-2021-04540, filed on July 23, 2021, which is incorporated herein by reference in its entirety.

Government-supported statement

This invention was made with government support from the National Institutes of Health (NIH) grant number GM24417-40. Therefore, the U.S. government holds certain rights in the claimed invention.

Technical Field

This disclosure relates to methods for treating severe malaria and uncomplicated malaria; artemisinin isoforms; hydrophobic amines; spleen tyrosine kinase (Syk) inhibitors; single oral dosage forms; and packaging.

Background Technology

Malaria remains a serious health problem in most parts of the world today, with 228 million new cases and 405,000 deaths reported in 2018 (World Health Organization. World Malaria Report 2019. Geneva: World Health Organization; 2019. Pages 1-232). Although artemisinin combination therapy (ACT) continues to be successful in treating most Plasmodium falciparum malaria strains, new drug resistance mutations leading to delayed parasite clearance (DPC; persistent parasitemia 3 days after standard treatment) are now emerging (Conrad et al., Lancet Infect Dis19(10):e-338-351 (October 2019); Ouji et al., Parasite[I [internet]25:24 (April 20, 2018); Lu et al., N Engl J Med [Internet] 376(10):991-993 (2017); Pau et al., PLoS One 14(4):e0214667 (2019); and Thriemer et al., Antimicrob Agents Chemother [Internet] 58(12):7049LP-7055 (December 1, 2014)), suggesting that current measures to control parasite reproduction may soon be insufficient. Although artemisinin (the cornerstone of ACT) is fast-acting and effective, its efficacy is short-lived and requires accompaniment drugs to achieve longer-lasting activity (Nsanzabana, Top Med Infect Dis [Internet] 4(1):26 (February 2019); Li, Chapter 4, Pharmacokinetic and Pharmacodynamic Profiles of Rapid-and Slow-Acting Antimalarial Drugs. In: Kasenga BPE-FH, ed. Rijeka: IntechOpen (2019)). Unfortunately, resistance to such concomitant drugs is also increasing (Conrad et al. (2019), ibid.), and at the same time, triple combination therapy is being investigated to prevent DPC (Rosenthal, Lancet [Internet] 395(10233):1316-1317 (April 25, 2020); van der Pluijm et al., Lancet [Internet] 395(10233):1345-1360 (April 25, 2020); and Dini et al., Antimicrob Agents Chemother [Internet] 62(11):e01068-18 (November 1, 2018)). In most of these ACTs, the third component is an antimalarial drug that has become ineffective due to decreased potency (Conrad et al. (2019), ibid.). In conclusion, these observations demonstrate the urgent need for new methods to treat Plasmodium falciparum malaria using orthogonal interaction mechanisms.

In view of the above, one object of this disclosure is to provide a triple combination therapy for treating severe malaria and uncomplicated malaria. This object, along with other objects and advantages and inventive features, will become apparent from the detailed description provided herein.

Invention Overview

A method for treating severe malaria in subjects is provided. The method involves administering an artemisinin isoform, a hydrophobic amine, and a spleen tyrosine kinase (Syk) inhibitor to the subjects in an amount that effectively eliminates parasitemia within approximately 72 hours.

In the treatment of severe malaria, artemisinin isoforms can be selected from artemisinin, dihydroartemisinin, artesunate, and artemether. Hydrophobic amines used in the treatment of severe malaria can be selected from fluorenol, mefloquine, amodiaquine, combinations of sulfadoxine and pyrimethamine, piperaquine, chloroquine, and combinations of chlorpromazine and dapsone.

In treatments of severe malaria, Syk inhibitors compete with adenosine triphosphate (ATP) for binding to Syk, and preferably do so. Syk inhibitors may contain a diarylaniline core that interacts with the gatekeeper amino acid residue Thr315 in the ATP-binding pocket of BCR-ABL via hydrogen bonding and van der Waals interactions. Syk inhibitors may be selected from imatinib, imatinib mesylate, and nilotinib. Syk inhibitors can be Syk inhibitor II, Syk inhibitor IV, R406 (the active metabolite of fostamatinib), R788 (fotamatinib), P505-15 (PRT062607), MNS (3,4-methylenedioxy-β-nitrostyrene), R112, GS-9973 (entospletinib), levofloxacin, dasatinib, bosutinib, or panatinib.

Treatment for severe malaria may include administering approximately 40 mg/day of dihydroartemisinin, approximately 320 mg/day of piperaquine, and approximately 400 mg/day of imatinib to the subject.

A method for treating uncomplicated malaria in subjects is also provided. The method comprises administering to the subject an artemisinin isoform, a hydrophobic amine, and a Syk inhibitor in an amount that effectively eliminates parasitemia within approximately 72 hours, wherein when the artemisinin isoform is dihydroartemisinin and the hydrophobic amine is piperaquine, the Syk inhibitor is not imatinib or imatinib mesylate.

In the treatment of uncomplicated malaria, artemisinin isoforms can be selected from artemisinin, dihydroartemisinin, artesunate, and artemether. Hydrophobic amines in the treatment of uncomplicated malaria can be selected from fluorenol, mefloquine, amodiaquine, combinations of sulfadoxine and pyrimethamine, piperaquine, chloroquine, and combinations of chlorpromazine and dapsone.

In the treatment of uncomplicated malaria, a Syk inhibitor can competitively bind to Syk with ATP, and preferably does so. The Syk inhibitor may contain a bis(aryl) aniline core that interacts with the gate amino acid residue Thr315 in the ATP-binding pocket of BCR-ABL via hydrogen bonding and van der Waals interactions. The Syk inhibitor may be nilotinib. Syk inhibitors may be Syk inhibitor II, Syk inhibitor IV, R406 (tamatinib; the active metabolite of fantatinib), R788 (fotatinib), P505-15 (PRT062607), MNS (3,4-methylenedioxy-β-nitrostyrene), R112, GS-9973 (entotinib), levofloxacin, dasatinib, bosutinib, or panatinib.

Another method for treating uncomplicated malaria is also provided. This method involves administering approximately 40 mg/day of dihydroartemisinin, approximately 320 mg/day of piperaquine, and approximately 400 mg/day of imatinib to the subject.

A single oral formulation is also provided, comprising an effective therapeutic amount of artemisinin isoform, a hydrophobic amine, and a Syk inhibitor. The artemisinin isoform may be selected from artemisinin, dihydroartemisinin, artesunate, and artemether. The hydrophobic amine may be selected from fluorenol, mefloquine, amodiaquine, a combination of sulfadoxine and pyrimethamine, piperaquine, chloroquine, and a combination of chlorpromazine and dapsone. The Syk inhibitor may compete with ATP for binding to Syk, and preferably does so. The Syk inhibitor may contain a diarylaniline core that interacts with the gate amino acid residue Thr315 in the ATP-binding pocket of BCR-ABL via hydrogen bonding and van der Waals interactions. The Syk inhibitor may be selected from imatinib, imatinib mesylate, and nilotinib. Syk inhibitors can be Syk inhibitor II, Syk inhibitor IV, R406, R788, P505-15, 3,4-methylenedioxy-β-nitrostyrene, R112, GS-9973, levofloxacin, dasatinib, bosutinib, or panatinib. Single oral formulations may contain dihydroartemisinin, piperaquine, and imatinib, for example, approximately 40 mg of dihydroartemisinin, approximately 320 mg of piperaquine, and approximately 400 mg of imatinib.

A single oral formulation may comprise an artemisinin isoform, a hydrophobic amine, and a Syk inhibitor other than imatinib or imatinib mesylate. The artemisinin isoform may be selected from artemisinin, dihydroartemisinin, artesunate, and artemether. The hydrophobic amine may be selected from fluorenol, mefloquine, amodiaquine, a combination of sulfadoxine and pyrimethamine, piperaquine, chloroquine, and a combination of chlorpromazine and dapsone. The Syk inhibitor may compete with ATP for binding to Syk, and preferably does so. The Syk inhibitor may comprise a diarylaniline core that interacts with the gate amino acid residue Thr315 in the ATP-binding pocket of BCR-ABL via hydrogen bonding and van der Waals interactions. The Syk inhibitor may be nilotinib. Syk inhibitors can be Syk inhibitor II, Syk inhibitor IV, R406, R788, P505-15, 3,4-methylenedioxy-β-nitrostyrene, R112, GS-9973, levofloxacin, dasatinib, bosutinib, or panatinib. Single oral formulations may contain dihydroartemisinin, piperaquine, and a Syk inhibitor other than imatinib or imatinib mesylate, such as approximately 40 mg of dihydroartemisinin, approximately 320 mg of piperaquine, and approximately 400 mg of a Syk inhibitor other than imatinib or imatinib mesylate.

A medicine box is also provided. The medicine box contains multiple single oral dosage forms as described above and instructions for use for severe malaria, uncomplicated malaria, or both. The medicine box may contain two or three single oral dosage forms.

Brief description of the attached diagram

Figure 1A is a graph comparing the number of days versus the mean parasitemia (parasites/μL) of standard care (SOC; 40 mg dihydroartemisinin + 320 mg piperaquine phosphate; n = 8) and imatinib alone (400 mg; n = 7). Error bars are represented by SEM.

Figure 1B is a graph of days vs. parasitemia (parasites/μL), which shows the representative time course of parasitemia in participants who exhibited a transient increase in parasitemia during the imatinib monotherapy trial.

Figure 1C is a graph of days vs. parasitemia (parasites/μL), which shows a representative time course of parasitemia in participants who showed a monotonic reduction in parasitemia in the imatinib monotherapy trial.

Figure 1D is a plot of days vs. temperature (°C), showing the mean participant body temperature plotted for SOC and the imatinib-only cohort. Error bars are represented by SEM.

Figure 2A is a day vs. temperature (°C) plot, showing the daily body temperature of participants plotted for SOC (40 mg dihydroartemisinin + 320 mg piperaquine phosphate; n = 21) and SOC + imatinib (SOC + 400 mg imatinib; n = 20). Error bars are represented by SEM and * = p < 0.05, ** = p < 0.01, *** = p < 0.001, and **** = p < 0.0001.

Figure 2B is a bar chart of SOC and SOC + imatinib (Im + SOC) vs. duration of fever (days), showing the mean duration of fever in the two groups. Error bars are represented by SEM and * = p < 0.05, ** = p < 0.01, *** = p < 0.001, and **** = p < 0.0001.

Figure 2C is a bar chart of the percentage of patients with SOC and Im+SOC vs. patients, showing the percentage of participants exhibiting a second fever peak. Error bars are represented by SEM and * = p < 0.05, ** = p < 0.01, *** = p < 0.001, and **** = p < 0.0001.

Figure 2D is a graph of days vs. temperature (°C), showing the changes in individual body temperature over time for the SOC group (n=21).

Figure 2E is a graph of days vs. temperature (°C), showing the changes in body temperature over time for individuals in the Im+SOC group (n=20).

Figure 3A is a graph of the number of days for SOC and Im+SOC versus the mean parasitemia (parasites/μL). Error bars are represented by SEM and * = p < 0.05, ** = p < 0.01, *** = p < 0.001, and **** = p < 0.0001.

Figure 3B is a graph of days vs. percentage of patients with detectable parasitemia, showing the percentage of patients with detectable parasitemia on different days after the start of treatment. Error bars are represented by SEM and * = p < 0.05, ** = p < 0.01, *** = p < 0.001, and **** = p < 0.0001.

Figure 3C is a bar chart of SOC and Im+SOC vs. time (hours) to reach 50% of the initial parasitemia level, showing the average time for parasitemia to decrease to 50% of its initial level. Error bars are represented by SEM and * = p < 0.05, ** = p < 0.01, *** = p < 0.001, and **** = p < 0.0001.

Figure 3D is a graph of the number of days of SOC (initial parasitemia <10,000 parasites/μL and >10,000 parasites/μL) and Im+SOC (initial parasitemia <10,000 parasites/μL and >10,000 parasites/μL) vs. parasitemia remaining (%), showing the reduction in parasitemia as a function of time. Error bars are represented by SEM and * = p value < 0.05, ** = p value < 0.01, *** = p value < 0.001, and **** = p value < 0.0001.

Figure 3E is a graph of the number of days of SOC (initial parasitemia <10,000; n=9) vs. the percentage of parasitemia remaining.

Figure 3F is a graph of the number of days of Im+SOC (initial parasitemia <10,000; n=10) vs. the percentage of parasitemia remaining.

Figure 3G is a graph of the number of days of SOC (initial parasitemia > 10,000; n = 12) vs. the percentage of parasitemia remaining.

Figure 3H is a graph of the number of days of Im+SOC (initial parasitemia > 10,000; n = 10) vs. the percentage of parasitemia remaining.

Invention Details

Malaria in humans is caused by five single-celled eukaryotic parasites called Plasmodium. The main species causing malaria are Plasmodium falciparum and Plasmodium vivax. The parasites are transmitted to humans through mosquito bites, especially the bites of Anopheles mosquito.

The parasites grow and multiply in the liver. They then multiply exponentially in red blood cells. It is during this stage of the parasite's life cycle that the signs and symptoms of infection become apparent.

Malaria is generally classified as asymptomatic, uncomplicated, and complicated/severe. Patients with "asymptomatic malaria" have circulating parasites but show no symptoms. "Uncomplicated malaria" usually appears 7 to 10 days after being bitten by an infected mosquito. Symptoms are nonspecific and may include fever, chills, shivering, profuse sweating, headache, nausea, vomiting, diarrhea, and anemia. "Complicated/severe malaria" is usually caused by infection with *Plasmodium falciparum*, although it can also be caused by infection with *Plasmodium vivax* or *Plasmodium knowlesi*. It is accompanied by clinical and laboratory signs of severe anemia and severe organ dysfunction, including cerebral malaria (e.g., behavioral abnormalities, altered consciousness, seizures, coma, and other neurological abnormalities), pulmonary complications (e.g., edema and hyperventilation syndrome), hypoglycemia, and acute kidney injury. It is usually associated with hyperparasitemia (e.g., >5% infected red blood cells or >250,000 parasites/μl); and often leads to death (e.g., 3% in the case of >4% infected red blood cells).

In view of the above, a method for treating severe malaria in subjects is provided. The method comprises administering an artemisinin isoform, a hydrophobic amine, and a spleen tyrosine kinase (Syk) inhibitor to the subject in an amount that effectively eliminates parasitemia within approximately 72 hours. Parasitemia is eliminated within approximately 48 hours. The artemisinin isoform may be selected from artemisinin, dihydroartemisinin, artesunate, and artemether. The hydrophobic amine may be selected from fluorenol, mefloquine, amodiaquine, a combination of sulfadoxine and pyrimethamine, piperaquine, chloroquine, and a combination of chlorpromazine and dapsone. The Syk inhibitor may compete with adenosine triphosphate (ATP) for binding to Syk. The Syk inhibitor may contain a diaryl aniline core that interacts with the gatekeeper amino acid residue Thr315 in the ATP-binding pocket of BCR-ABL via hydrogen bonding and van der Waals interactions. The Syk inhibitor may be selected from imatinib, imatinib mesylate, and nilotinib. Syk inhibitors may be Syk inhibitor II, Syk inhibitor IV, R406 (tamatinib; the active metabolite of fantatinib), R788 (fotatinib), P505-15 (PRT062607), MNS (3,4-methylenedioxy-β-nitrostyrene), R112, GS-9973 (entotinib), piperazine, dasatinib, bosutinib, or panatinib. (i) A combination of artemisinin isoforms with hydrophobic amines and (ii) Syk inhibitors may have synergistic effects, and such synergistic effects are expected. The method may include administering approximately 40 mg/day of dihydroartemisinin, approximately 320 mg/day of piperaquine, and approximately 400 mg/day of imatinib to the subject.

Also in view of the above, a method for treating uncomplicated malaria in subjects, the method comprising administering to the subject an artemisinin isoform, a hydrophobic amine, and a Syk inhibitor in an amount that effectively eliminates parasitemia within approximately 72 hours (e.g., within approximately 48 hours), wherein when the artemisinin isoform is dihydroartemisinin and the hydrophobic amine is piperaquine, the Syk inhibitor is not imatinib or imatinib mesylate, thereby treating the subject for uncomplicated malaria. The artemisinin isoform may be selected from artemisinin, dihydroartemisinin, artesunate, and artemether. The hydrophobic amine may be selected from fluorenol, mefloquine, amodiaquine, a combination of sulfadoxine and pyrimethamine, piperaquine, chloroquine, and a combination of chlorpromazine and dapsone. The Syk inhibitor may compete with ATP for binding to Syk. The Syk inhibitor may contain a diarylaniline core that interacts with the gatekeeper amino acid residue Thr315 in the ATP-binding pocket of BCR-ABL via hydrogen bonding and van der Waals interactions. Syk inhibitors can be nilotinib. Syk inhibitors can be Syk inhibitor II, Syk inhibitor IV, R406 (tamatinib; the active metabolite of fantatinib), R788 (fantatinib), P505-15 (PRT062607), MNS (3,4-methylenedioxy-β-nitrostyrene), R112, GS-9973 (entotinib), levofloxacin, dasatinib, bosutinib, or panatinib.

Another method for treating uncomplicated malaria is also provided. This method involves administering approximately 40 mg/day of dihydroartemisinin, approximately 320 mg/day of piperaquine, and approximately 400 mg/day of imatinib to the subject.

"Administration" can be carried out by any suitable means as known in the art. Administration can be oral, for example, oral administration of a single oral dosage form as described below.

Artemisinin isoforms, hydrophobic amines, and Syk inhibitors (i.e., “active agents”) or compositions containing them may be administered via the same or different routes and/or at the same or different times. However, it is desirable that the active agents be administered via such routes and at such times to allow and even promote synergistic effects between the active agents.

The active agent is administered in a dose effective for treating parasitemia. The synergistic effect between the active agents allows for the administration of lower daily doses.

Artemisinin isoforms can be administered at any suitable daily dose, such as less than about 100 mg, for example, about 95 mg, about 90 mg, about 85 mg, about 80 mg, about 75 mg, about 70 mg, about 65 mg, about 60 mg, about 55 mg, about 50 mg, about 45 mg, about 40 mg, about 35 mg, about 30 mg, or about 25 mg. Artemisinin isoforms can also be administered daily at a dose of about 40 mg.

Hydrophobic amines can be administered at any suitable daily dose, such as less than about 1,000 mg, for example, about 950 mg, about 900 mg, about 850 mg, about 800 mg, about 750 mg, about 700 mg, about 650 mg, about 600 mg, about 550 mg, about 500 mg, about 450 mg, about 400 mg, about 350 mg, about 300 mg, or about 250 mg. Hydrophobic amines can also be administered daily at a dose of about 320 mg.

Syk inhibitors can be administered at any suitable daily dose, such as less than about 1,000 mg, for example, about 950 mg, about 900 mg, about 850 mg, about 800 mg, about 750 mg, about 700 mg, about 650 mg, about 600 mg, about 550 mg, about 500 mg, about 450 mg, about 400 mg, about 350 mg, about 300 mg, or about 250 mg. Syk inhibitors can also be administered daily at doses less than about 750 mg, about 700 mg, about 650 mg, about 600 mg, about 550 mg, about 500 mg, about 450 mg, about 400 mg, about 350 mg, about 300 mg, or about 250 mg. Syk inhibitors can also be administered daily at a dose of about 40 mg.

A single oral formulation is also available. This single oral formulation may contain an effective therapeutic amount of artemisinin isoform, a hydrophobic amine, and a Syk inhibitor. The artemisinin isoform may be selected from artemisinin, dihydroartemisinin, artesunate, and artemether. The hydrophobic amine may be selected from fluorenol, mefloquine, amodiaquine, a combination of sulfadoxine and pyrimethamine, piperaquine, chloroquine, and a combination of chlorpromazine and dapsone. The Syk inhibitor may compete with ATP for binding to Syk, and preferably does so. The Syk inhibitor may contain a diarylaniline core that interacts with the gate amino acid residue Thr315 in the ATP-binding pocket of BCR-ABL via hydrogen bonding and van der Waals interactions. The Syk inhibitor may be selected from imatinib, imatinib mesylate, and nilotinib. Syk inhibitors can be Syk inhibitor II, Syk inhibitor IV, R406, R788, P505-15, 3,4-methylenedioxy-β-nitrostyrene, R112, GS-9973, levofloxacin, dasatinib, bosutinib, or panatinib. Single oral formulations may contain dihydroartemisinin, piperaquine, and imatinib, for example, approximately 40 mg of dihydroartemisinin, approximately 320 mg of piperaquine, and approximately 400 mg of imatinib.

A single oral formulation may comprise an artemisinin isoform, a hydrophobic amine, and a Syk inhibitor other than imatinib or imatinib mesylate. The artemisinin isoform may be selected from artemisinin, dihydroartemisinin, artesunate, and artemether. The hydrophobic amine may be selected from fluorenol, mefloquine, amodiaquine, a combination of sulfadoxine and pyrimethamine, piperaquine, chloroquine, and a combination of chlorpromazine and dapsone. The Syk inhibitor may compete with ATP for binding to Syk, and preferably does so. The Syk inhibitor may comprise a diarylaniline core that interacts with the gate amino acid residue Thr315 in the ATP-binding pocket of BCR-ABL via hydrogen bonding and van der Waals interactions. The Syk inhibitor may be nilotinib. Syk inhibitors can be Syk inhibitor II, Syk inhibitor IV, R406, R788, P505-15, 3,4-methylenedioxy-β-nitrostyrene, R112, GS-9973, levofloxacin, dasatinib, bosutinib, or panatinib. Single oral formulations may contain dihydroartemisinin, piperaquine, and a Syk inhibitor other than imatinib or imatinib mesylate, such as approximately 40 mg of dihydroartemisinin, approximately 320 mg of piperaquine, and approximately 400 mg of a Syk inhibitor other than imatinib or imatinib mesylate.

A single oral dosage form may comprise pharmaceutically acceptable carriers or excipients as known in the art. Pharmaceutically acceptable carriers or excipients can be used to prepare pharmaceutical compositions that are generally safe, non-toxic, and not biologically or otherwise undesirable. Such carriers and excipients may include those acceptable for human and veterinary use.

A medicine box is also provided. The medicine box contains multiple, for example, at least two or three, such as two or three single oral dosage forms and instructions for use for severe malaria or uncomplicated malaria (or both).

Example

The following examples are provided to illustrate some aspects of this disclosure. These examples are not intended to limit the scope of the claimed invention.

Research drugs

Imatinib mesylate was purchased from TEVA Pharmaceuticals (Jerusalem, Israel) and administered to patients in two 200 mg tablets/dose, consistent with the usual dose of imatinib indicated for the treatment of chronic myeloid leukemia. CV-Artecan, the standard-of-care (SOC) for the treatment of Plasmodium falciparum malaria in Vietnam, was purchased from OPC Pharmaceuticals (Ho Chi Minh City, Vietnam) and administered to patients as a tablet containing 40 mg of dihydroartemisinin and 320 mg of piperaquine phosphate.

Research participants

Men aged 16 to 55 years with no comorbid Plasmodium falciparum infection who had not received antimalarial drugs in the previous 4 weeks were eligible for both trials: imatinib monotherapy and imatinib plus SOC (Im+SOC) triple combination therapy. Individuals who met the eligibility criteria and provided informed written consent were enrolled in the trials.

Research Plan

The Phase 1/2 Imatinib Monotherapy Trial was an open-label trial designed to determine the safety and tolerability of imatinib in adult male patients with uncomplicated Plasmodium falciparum malaria. Patients were randomly assigned to either the Standard of Care (SOC) control group (n=8), who received 40 mg of dihydroartemisinin plus 320 mg of piperaquine phosphate orally twice daily (12 hours apart) on day 1, followed by once daily for the next two days; or the imatinib monotherapy group (n=7), who received 400 mg of imatinib mesylate orally once daily with food and a full glass of water for five days.

Participants in the subsequent "Imatinib + SOC (Im+SOC) Triple Combination Therapy Trial" were also randomly assigned to one of two groups, the SOC group (n=21) or the Im+SOC group (n=20). The SOC group received the precise administration as described above, while the Im+SOC group received the administration as described above, except that each patient received 400 mg of imatinib mesylate orally once daily with food and a full glass of water for 3 days.

During both trials, patient body temperature and peripheral blood parasite levels were monitored on days 0, 1, 2, 3, 5, 7, 28, and 42 before, during, and after the trials. Common symptoms of Plasmodium falciparum malaria were also examined in patients, including fever, chills, headache, fatigue, anorexia, and mild diarrhea. Patients were immediately transferred to the State of the Occupation (SOC) if any participant was observed to exhibit an increase in parasitemia >150,000 parasites/μL or adverse symptoms exceeding those typically associated with malaria.

Both trials were approved by the Vietnam Ministry of Health and the Institutional Review Board at the Hue University of Medicine and Pharmacy. The trials were conducted in six communities in Huong Hoa District, Lia Region, Quang Tri Province, because of the high DPC levels in this region of Vietnam (Pau et al. (2019), ibid.; and Thriemer et al. (2014), ibid.). Both studies were registered online at ClinicalTrials(dot)gov (NCT02614404 and NCT03697668).

Randomization and masking

Both clinical trials were open-label, and therefore no blinding was performed on the attending physicians. However, participants were randomly assigned to their groups through alternating allocation based on admission date and time, and all participants, as well as the microscopists performing the quantitative parasitemia, were unaware of the treatment regimen.

result

The primary endpoints for both studies were safety and tolerability. Secondary endpoints were reduction of parasitemia in the imatinib monotherapy study and reduction of both parasitemia and fever in the Im+SOC study. Safety and tolerability were assessed at the protocol-specified time points, and adverse events were categorized as toxicities generally unrelated to Plasmodium falciparum malaria, including edema, rash, and severe diarrhea. The severity of any adverse event was suggested to be categorized as follows: i) mild – events requiring minimal or no treatment and not interfering with the participant's daily activities; ii) moderate – events causing minor inconvenience or concern and potentially interfering with the participant's daily functioning; iii) severe – events disrupting the participant's daily activities and potentially causing incapacitation or requiring medical intervention. The attribution of adverse events to imatinib was assessed using a 5-point scale: unrelated, unlikely to be related, possibly related, very likely related, and clearly related. The primary endpoint was met if no serious adverse events occurred in the imatinib treatment group and there was no significant increase or actual decrease in moderate adverse events.

Statistical analysis

A pooled ANOVA was performed to determine the effects of drug treatment on parasitemia and fever. Post-hoc multiple comparison tests were used to determine which time points were statistically significant. Two-tailed t-tests were used to determine statistically significant differences between independent group means. A p-value < 0.05 was assumed to be significant. Data from all participants receiving three doses of the treatment drug were included in the analysis. The SOC treatment cohort from each individual trial was analyzed separately. Unless otherwise stated, all error bars represent the standard error (SEM) of the mean.

result

To evaluate the safety, tolerability, and efficacy of imatinib in patients with Plasmodium falciparum malaria, an initial phase 1/2 clinical trial was conducted in which imatinib was administered as monotherapy to participants and compared to a parallel cohort treated with standard of care (SOC) in Vietnam. Although imatinib has a well-established safety record in long-term administration to patients with chronic myeloid leukemia (O’Brien et al., N Engl J Med 348(11):994-1004(2003); and Hochhaus et al., N Engl J Med[Internet]376(10):917-927(March 9, 2017)), it had not been administered to malaria patients prior to this study. Therefore, the primary endpoint of this trial was the safety and tolerability of imatinib in patients with Plasmodium falciparum malaria, and the secondary endpoint was the reduction of parasitemia.

Before the trial could begin, suitable locations with endemic malaria and delayed parasite clearance (DPC) needed to be identified. As mentioned in the introduction, DPC has shown an increasing trend in Southeast Asia, requiring patients to undergo treatment far beyond the usual three days (Pau et al. (2019), ibid.; and Thriemer et al. (2014), ibid.). Because any new treatment for malaria must demonstrate efficacy against these more refractory strains of Plasmodium falciparum, it was decided to conduct an initial clinical trial in Quang Tri province, Vietnam, where DPC was recorded by standard microscopy in 27.2% of patients (39.3% when parasitemia was measured by PCR), and genetic markers of artemisinin and piperaquine resistance (K13 C580Y and multiple copies of PfPM2) were identified in 1.2% of infected individuals (Pau et al. (2019), ibid.).

To evaluate the safety and tolerability of imatinib, participants (male, 18 to 54 years old; Table 1) with uncomplicated malaria and no comorbidities who had not taken antimalarial drugs during the previous month were randomly assigned to one of two treatment groups. After informed consent, participants received either three days of SOC treatment or five consecutive days of a single daily dose of 400 mg imatinib (the usual dose for treating patients with chronic myeloid leukemia), as described in the methods and Table 2. Changes in hematology, blood chemistry, fever, parasite levels, and adverse events were monitored in each patient during and after treatment. No adverse events were observed other than the expected symptoms of Plasmodium falciparum malaria, except for one case of mild abdominal pain that spontaneously resolved and recurred periodically in malaria patients receiving SOC. Analysis of blood parameters and body temperature also showed no evidence of drug-related toxicity. Because imatinib monotherapy demonstrated safety and good tolerability, this trial met its primary endpoint and provided motivation to test imatinib in combination with SOC.

Table 1: Baseline characteristics of participants

Table 2. Treatment regimens in the trial

To determine whether imatinib alone would demonstrate any efficacy indication, we simultaneously quantified parasitemia in the peripheral blood of each participant before, during, and after their treatment course. As shown in Figure 1A, a reduction in the number of parasitic cells per microliter of blood was observed in the imatinib treatment group. Although this reduction lagged behind a similar response in the SOC group, no statistically significant interaction was identified between the treatment group and parasitemia levels when performing principal factor analysis using pooled ANOVA (p = 0.7736). Conversely, a significant interaction was found between time and parasitemia levels (p = 0.0006).

Unlike the SOC group, two of the seven participants treated with imatinib alone experienced elevated parasitemia and therefore had to be transferred to the SOC (see representative time course in Figure 1B). In contrast, the other patients in the imatinib monotherapy group experienced irregular or steady declines in parasitemia (Figure 1C). Consistent with in vitro studies, these studies indicated that the efficacy of imatinib depends on the stage of the parasite life cycle during the first administration of imatinib (i.e., due to the fact that imatinib primarily blocks parasite egress at the end of the parasite life cycle (Kesely et al., PLoS One 11(10:e0164895(2016); Pantaleo et al., Blood[Internet]130(8):1031LP-1040(August 24, 2017); Kesely et al.). t al., PLoS One [Internet] 15(11):e0242372 (November 12, 2020)), anticipated the time-dependent efficacy of imatinib monotherapy and speculated that it was due to the stage of the parasite's life cycle at the start of treatment. Finally, although the combined ANOVA showed a significantly accelerated decrease in fever in the imatinib-treated group (Figure 1D) which did not reach statistical significance (p = 0.7029), we still chose to include the rate of fever reduction as a secondary endpoint in the triplet combination trial to determine whether imatinib could accelerate fever reduction.

Encouraged by the antimalarial activity of imatinib, we decided to compare the safety and efficacy of SOC alone (40 mg/day dihydroartemisinin + 320 mg/day piperaquine) with that of Im+SOC (400 mg/day imatinib + 40 mg/day dihydroartemisinin + 320 mg/day piperaquine). For this purpose, 41 adult male participants with uncomplicated malaria were recruited from the same region of Vietnam and randomly assigned to one of two groups receiving either SOC or Im+SOC for three consecutive days (Table 2). Evaluation of all adverse events showed that the triplet therapy was as safe as SOC, with no adverse events attributable to the increased imatinib. Therefore, the Im+SOC triplet therapy met the primary endpoints of safety and tolerability.

Although both groups entered the trial with similar fever levels (SOC vs Im+SOC: 39.6±0.1℃ vs 39.2±0.2℃; p = 0.0501, NS; Figure 2A), analyses of patient temperatures before, during, and after treatment showed that temperatures (i.e., a good measure of how well the patient felt) in the triplet combination returned to normal approximately 2 days faster than with SOC treatment (1.65±0.12 days vs. 3.57±0.26 days; p = 0.00002) (Figure 2B). Furthermore, while all participants treated with Im+SOC (Figures 2C and 2E) experienced a monotonic decrease in temperature, >30% of participants in the SOC group (Figures 2C and 2D) experienced a second rise in temperature during their follow-up period or at least one day of treatment (p = 0.0311). Consistent with these results, the attending physician noted that participants in the triple combination group frequently reported feeling better earlier compared to the SOC group. In summary, these data suggest that the Im+SOC treatment group met the secondary endpoint of faster fever resolution.

To assess whether the accelerated decrease in body temperature could be associated with a more rapid elimination of parasitemia, we next compared the number of parasites/μL in peripheral blood between the two treatment groups. Although there was no significant difference in the mean initial parasite concentration in peripheral blood between the SOC and Im+SOC groups (16,601 ± 2099 parasites/μL vs. 28,347 ± 15,467 parasites/μL; p = 0.2033), parasitemia decreased more rapidly in the triplet group than in the SOC group (Fig. 3A, Figs. A, B, C, D). Consequently, 18% of participants receiving Im+SOC did not show residual parasitemia 24 hours after ingestion of the initial dose (i.e., before receiving the second dose), while none of the SOC participants showed the absence of parasitemia at the same 24-hour time point (Fig. 4B). Furthermore, 88% of participants in the Im+SOC cohort were parasite-free by 48 hours after treatment initiation, and the majority of the remainder became parasite-free by day three. In contrast, only 14% of participants in the SOC group were parasite-free by the end of day two, while one-third of the participants remained measurably parasite-free after the full three-day treatment course (Figure 3B); thus confirming the established delayed parasite clearance in this region of Vietnam. (5) Therefore, the secondary endpoint of faster parasite clearance was met in the Im+SOC cohort.

Further review of the individual patient data in Figure 3 revealed a bimodal response to the triplet therapy, with individuals initially diagnosed with high levels of parasitemia (Figure H) responding more rapidly than those initially diagnosed with low levels of parasitemia (Figure F). Indeed, in the Im+SOC treatment group, all 10 patients presenting with >10,000 parasites/μL of blood experienced a rapid decline in parasitemia (>80% within 24 hours; Figure 3H). In contrast, no such trend was observed in the SOC treatment cohort, where patients presenting with high or low parasitemia at diagnosis showed similar responses (Figure 3, Figures D, E, G). Importantly, no participants in the triplet therapy group experienced relapse after completing three days of treatment (data collected 42 days after treatment initiation).

All patents, patent application publications, journal articles, textbooks, and other publications mentioned in this specification represent the technical skill of a person skilled in the art to which this disclosure pertains. All such publications are incorporated herein by reference to the extent that each individual publication is specifically and individually indicated to be incorporated by reference.

The invention described herein by way of example may be practiced in the absence of any element or limitation not specifically disclosed herein. Thus, for example, in each case herein, any one of the terms “comprising/including,” “substantially consisting of,” and “consisting of” may be replaced by any of the other two terms. Similarly, unless the context clearly specifies otherwise, a noun not modified by a quantifier includes one/more/a. Thus, for example, references to “method” include one or more types of methods and/or steps, which are described herein and/or will become apparent to those skilled in the art upon reading this disclosure.

The terms and expressions used are used as descriptive rather than restrictive terms. In this respect, if certain terms are defined under “Definitions” and otherwise defined, described, or discussed elsewhere in “Detailed Description of the Invention,” all such definitions, descriptions, and discussions are intended to be attributed to such terms. The use of such terms and expressions is also not intended to exclude any equivalents of the features shown and described or portions thereof. Furthermore, while subheadings such as “Definitions” are used in “Detailed Description of the Invention,” such use is for convenience of reference only and is not intended to limit any disclosure made in a section to that section; rather, any disclosure made under a subheading is intended to constitute the disclosure under that subheading and every other subheading.

It is recognized that various modifications are possible within the scope of the claimed invention. Therefore, it should be understood that although the invention has been specifically disclosed in the context of preferred embodiments and optional features, modifications and variations of the concepts disclosed herein can be made by those skilled in the art. Such modifications and variations are considered to be within the scope of the invention claimed herein.

The following implementation schemes are provided, and their numbers should not be interpreted as indicating a level of importance:

1. A method for treating severe malaria in a subject, the method comprising administering an artemisinin isoform, a hydrophobic amine, and a spleen tyrosine kinase (Syk) inhibitor to the subject in an amount that effectively eliminates parasitemia within approximately 72 hours, thereby treating the subject with severe malaria.

2. The method described in Implementation Scheme 1, wherein the artemisinin isoform is selected from artemisinin, dihydroartemisinin, artesunate, and artemether.

3. The method of claim 1 or 2, wherein the hydrophobic amine is selected from benzyl fluorene, mefloquine, amodiaquine, a combination of sulfadiazine and pyrimethamine, piperaquine, chloroquine, and a combination of chlorpromazine and dapsone.

4. The method described in implementation schemes 1, 2, or 3, wherein the Syk inhibitor competes with adenosine triphosphate (ATP) for binding to Syk.

5. The method of embodiment 4, wherein the Syk inhibitor comprises a bisaryl aniline core that interacts with the gate amino acid residue Thr315 in the ATP-binding pocket of BCR-ABL via hydrogen bonding and van der Waals interactions.

6. The method of Implementation Scheme 4, wherein the Syk inhibitor is selected from imatinib, imatinib mesylate, and nilotinib.

7. The method described in Implementation Scheme 1, 2 or 3, wherein the Syk inhibitor is Syk inhibitor II, Syk inhibitor IV, R406, R788, P505-15, 3,4-methylenedioxy-β-nitrostyrene, R112, GS-9973, levofloxacin, dasatinib, bosutinib or panatinib.

8. The method of implementation scheme 1, the method comprising administering to the subject approximately 40 mg/day of dihydroartemisinin, approximately 320 mg/day of piperaquine, and approximately 400 mg/day of imatinib.

9. A method for treating uncomplicated malaria in a subject, the method comprising administering to the subject an artemisinin isoform, a hydrophobic amine, and a spleen tyrosine kinase (Syk) inhibitor in an amount that effectively eliminates parasitemia within approximately 72 hours, wherein the artemisinin isoform is dihydroartemisinin and the hydrophobic amine is piperaquine, and the Syk inhibitor is not imatinib or imatinib mesylate, thereby treating the subject for uncomplicated malaria.

10. The method of embodiment 9, wherein the artemisinin isoform is selected from artemisinin, dihydroartemisinin, artesunate, and artemether.

11. The method of embodiment 9 or 10, wherein the hydrophobic amine is selected from benzyl fluorene, mefloquine, amodiaquine, a combination of sulfadoxine and pyrimethamine, piperaquine, chloroquine, and a combination of chlorpromazine and dapsone.

12. The method of embodiment 9, 10 or 11, wherein the Syk inhibitor competes with adenosine triphosphate (ATP) for binding to Syk.

13. The method of embodiment 12, wherein the Syk inhibitor comprises a bisaryl aniline core that interacts with the gate amino acid residue Thr315 in the ATP-binding pocket of BCR-ABL via hydrogen bonding and van der Waals interactions.

14. The method of implementation scheme 12, wherein the Syk inhibitor is nilotinib.

15. The method of embodiment 9, 10 or 11, wherein the Syk inhibitor is Syk inhibitor II, Syk inhibitor IV, R406, R788, P505-15, 3,4-methylenedioxy-β-nitrostyrene, R112, GS-9973, levofloxacin, dasatinib, bosutinib or panatinib.

16. A method for treating uncomplicated malaria in a subject, the method comprising administering to the subject about 40 mg/day of dihydroartemisinin, about 320 mg/day of piperaquine, and about 400 mg/day of imatinib, thereby treating the subject for uncomplicated malaria.

17. A single oral formulation containing an effective amount of artemisinin isoform, hydrophobic amine, and spleen tyrosine kinase (Syk) inhibitor for treating parasitemia.

18. The single oral dosage form described in Implementation Scheme 17, wherein the artemisinin isoform is selected from artemisinin, dihydroartemisinin, artesunate, and artemether.

19. The single oral dosage form of embodiment 17 or 18, wherein the hydrophobic amine is selected from benzyl fluorene, mefloquine, amodiaquine, a combination of sulfadoxine and pyrimethamine, piperaquine, chloroquine, and a combination of chlorpromazine and dapsone.

20. The single oral formulation of embodiment 17, 18 or 19, wherein the Syk inhibitor competes with adenosine triphosphate (ATP) for binding to Syk.

21. The single oral formulation of embodiment 20, wherein the Syk inhibitor comprises a bisaryl aniline core that interacts with the gate amino acid residue Thr315 in the ATP-binding pocket of BCR-ABL via hydrogen bonding and van der Waals interactions.

22. The single oral dosage form of embodiment 20, wherein the Syk inhibitor is selected from imatinib, imatinib mesylate, and nilotinib.

23. The single oral dosage form as described in embodiments 17, 18 or 19, wherein the Syk inhibitor is Syk inhibitor II, Syk inhibitor IV, R406, R788, P505-15, 3,4-methylenedioxy-β-nitrostyrene, R112, GS-9973, levofloxacin, dasatinib, bosutinib or panatinib.

24. The single oral dosage form described in Implementation Scheme 17, comprising dihydroartemisinin, piperaquine, and imatinib.

25. The single oral dosage form described in Implementation Scheme 24, comprising approximately 40 mg of dihydroartemisinin, approximately 320 mg of piperaquine, and approximately 400 mg of imatinib.

26. The single oral dosage form described in Implementation Scheme 17, comprising an artemisinin isoform, a hydrophobic amine, and a Syk inhibitor other than imatinib or imatinib mesylate.

27. The single oral dosage form described in Implementation Scheme 26, wherein the artemisinin isoform is selected from artemisinin, dihydroartemisinin, artesunate, and artemether.

28. The single oral dosage form of embodiment 26 or 27, wherein the hydrophobic amine is selected from benzyl fluorene, mefloquine, amodiaquine, a combination of sulfadoxine and pyrimethamine, piperaquine, chloroquine, and a combination of chlorpromazine and dapsone.

29. The single oral formulation of embodiment 26, 27 or 28, wherein the Syk inhibitor competes with ATP for binding to Syk.

30. The single oral formulation of embodiment 29, wherein the Syk inhibitor comprises a bisaryl aniline core that interacts with the gate amino acid residue Thr315 in the ATP-binding pocket of BCR-ABL via hydrogen bonding and van der Waals interactions.

31. The single oral dosage form as described in Implementation Scheme 29, wherein the Syk inhibitor is nilotinib.

32. The single oral dosage form as described in embodiments 26, 27 or 28, wherein the Syk inhibitor is Syk inhibitor II, Syk inhibitor IV, R406, R788, P505-15, 3,4-methylenedioxy-β-nitrostyrene, R112, GS-9973, levofloxacin, dasatinib, bosutinib or panatinib.

33. The single oral dosage form of embodiment 26, comprising dihydroartemisinin, piperaquine, and a Syk inhibitor other than imatinib or imatinib mesylate.

34. The single oral dosage form described in Implementation Scheme 33, comprising approximately 40 mg of dihydroartemisinin, approximately 320 mg of piperaquine, and approximately 400 mg of a Syk inhibitor other than imatinib or imatinib mesylate.

35. A medicine box comprising a single oral dosage form of any one of embodiments 17 to 25 and instructions for administration for severe malaria.

36. The medicine box described in Implementation Scheme 35, comprising two or three single oral dosage forms.

37. A medicine box comprising a single oral dosage form of any one of embodiments 26 to 34 and instructions for administration for uncomplicated malaria.

38. The medicine box described in Implementation Scheme 37, comprising at least two or three single oral dosage forms.

Claims (38)

1. A method for treating severe malaria in a subject, the method comprising administering an artemisinin isoform, a hydrophobic amine, and a spleen tyrosine kinase (Syk) inhibitor to the subject in an amount that effectively eliminates parasitemia within approximately 72 hours, thereby treating the subject with severe malaria. 2. The method of claim 1, wherein the artemisinin isoform is selected from artemisinin, dihydroartemisinin, artesunate, and artemether. 3. The method of claim 1, wherein the hydrophobic amine is selected from benzyl fluorene, mefloquine, amodiaquine, a combination of sulfadiazine and pyrimethamine, piperaquine, chloroquine, and a combination of chlorpromazine and dapsone. 4. The method of claim 1, 2 or 3, wherein the Syk inhibitor competes with adenosine triphosphate (ATP) for binding to Syk. 5. The method of claim 4, wherein the Syk inhibitor comprises a bisaryl aniline core that interacts with the gate amino acid residue Thr315 in the ATP-binding pocket of BCR-ABL via hydrogen bonding and van der Waals interactions. 6. The method of claim 4, wherein the Syk inhibitor is selected from imatinib, imatinib mesylate, and nilotinib. 7. The method of claim 1, 2 or 3, wherein the Syk inhibitor is Syk inhibitor II, Syk inhibitor IV, R406, R788, P505-15, 3,4-methylenedioxy-β-nitrostyrene, R112, GS-9973, levofloxacin, dasatinib, bosutinib or panatinib. 8. The method of claim 1, wherein the method comprises administering to the subject about 40 mg/day of dihydroartemisinin, about 320 mg/day of piperaquine, and about 400 mg/day of imatinib. 9. A method for treating uncomplicated malaria in a subject, the method comprising administering to the subject an artemisinin isoform, a hydrophobic amine, and a spleen tyrosine kinase (Syk) inhibitor in an amount that effectively eliminates parasitemia within approximately 72 hours, wherein the artemisinin isoform is dihydroartemisinin and the hydrophobic amine is piperaquine, and the Syk inhibitor is not imatinib or imatinib mesylate, thereby treating the subject for uncomplicated malaria. 10. The method of claim 9, wherein the artemisinin isoform is selected from artemisinin, dihydroartemisinin, artesunate, and artemether. 11. The method of claim 9 or 10, wherein the hydrophobic amine is selected from fluorenol, mefloquine, amodiaquine, a combination of sulfadiazine and pyrimethamine, piperaquine, chloroquine, and a combination of chlorpromazine and dapsone. 12. The method of claim 9, 10 or 11, wherein the Syk inhibitor competes with adenosine triphosphate (ATP) for binding to Syk. 13. The method of claim 12, wherein the Syk inhibitor comprises a bisaryl aniline core that interacts with the gate amino acid residue Thr315 in the ATP-binding pocket of BCR-ABL via hydrogen bonding and van der Waals interactions. 14. The method of claim 12, wherein the Syk inhibitor is nilotinib. 15. The method of claim 9, 10 or 11, wherein the Syk inhibitor is Syk inhibitor II, Syk inhibitor IV, R406, R788, P505-15, 3,4-methylenedioxy-β-nitrostyrene, R112, GS-9973, leucovorin, dasatinib, bosutinib or panatinib. 16. A method for treating uncomplicated malaria in a subject, the method comprising administering to the subject about 40 mg/day of dihydroartemisinin, about 320 mg/day of piperaquine, and about 400 mg/day of imatinib, thereby treating the subject for uncomplicated malaria. 17. A single oral formulation containing an effective amount of artemisinin isoform, hydrophobic amine, and spleen tyrosine kinase (Syk) inhibitor for treating parasitemia. 18. The single oral dosage form of claim 17, wherein the artemisinin isoform is selected from artemisinin, dihydroartemisinin, artesunate, and artemether. 19. The single oral dosage form of claim 17 or 18, wherein the hydrophobic amine is selected from fluorenol, mefloquine, amodiaquine, a combination of sulfadiazine and pyrimethamine, piperaquine, chloroquine, and a combination of chlorpromazine and dapsone. 20. The single oral formulation of claim 17, 18 or 19, wherein the Syk inhibitor competes with adenosine triphosphate (ATP) for binding to Syk. 21. The single oral formulation of claim 20, wherein the Syk inhibitor comprises a bisaryl aniline core that interacts with the gate amino acid residue Thr315 in the ATP-binding pocket of BCR-ABL via hydrogen bonding and van der Waals interactions. 22. The single oral dosage form of claim 20, wherein the Syk inhibitor is selected from imatinib, imatinib mesylate, and nilotinib. 23. The single oral dosage form according to claim 17, 18 or 19, wherein the Syk inhibitor is Syk inhibitor II, Syk inhibitor IV, R406, R788, P505-15, 3,4-methylenedioxy-β-nitrostyrene, R112, GS-9973, levofloxacin, dasatinib, bosutinib or panatinib. 24. The single oral dosage form of claim 17, comprising dihydroartemisinin, piperaquine, and imatinib. 25. The single oral dosage form of claim 24, comprising about 40 mg of dihydroartemisinin, about 320 mg of piperaquine and about 400 mg of imatinib. 26. The single oral dosage form of claim 17, comprising an artemisinin isoform, a hydrophobic amine, and a Syk inhibitor other than imatinib or imatinib mesylate. 27. The single oral dosage form of claim 26, wherein the artemisinin isoform is selected from artemisinin, dihydroartemisinin, artesunate, and artemether. 28. The single oral dosage form of claim 26 or 27, wherein the hydrophobic amine is selected from fluorenol, mefloquine, amodiaquine, a combination of sulfadiazine and pyrimethamine, piperaquine, chloroquine, and a combination of chlorpromazine and dapsone. 29. The single oral formulation of claim 26, 27 or 28, wherein the Syk inhibitor competes with ATP for binding to Syk. 30. The single oral formulation of claim 29, wherein the Syk inhibitor comprises a bisaryl aniline core that interacts with the gate amino acid residue Thr315 in the ATP-binding pocket of BCR-ABL via hydrogen bonding and van der Waals interactions. 31. The single oral dosage form of claim 29, wherein the Syk inhibitor is nilotinib. 32. The single oral dosage form according to claim 26, 27 or 28, wherein the Syk inhibitor is Syk inhibitor II, Syk inhibitor IV, R406, R788, P505-15, 3,4-methylenedioxy-β-nitrostyrene, R112, GS-9973, levofloxacin, dasatinib, bosutinib or panatinib. 33. The single oral dosage form of claim 26, comprising dihydroartemisinin, piperaquine, and a Syk inhibitor other than imatinib or imatinib mesylate. 34. The single oral dosage form of claim 33, comprising about 40 mg of dihydroartemisinin, about 320 mg of piperaquine, and about 400 mg of a Syk inhibitor other than imatinib or imatinib mesylate. 35. A medicine box comprising a single oral dosage form as described in claim 17 and instructions for administration for severe malaria. 36. The medicine box of claim 35, comprising two or three single oral dosage forms. 37. A medicine box comprising a single oral dosage form as described in claim 26 and instructions for administration for uncomplicated malaria. 38. The medicine box of claim 37, comprising at least two or three single oral dosage forms.