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In vitro additive interaction between ketoconazole and antimony against intramacrophage Leishmania (Leishmania) amazonensis amastigotes

  • Débora Cristina de Oliveira Nunes,

    Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Validation, Writing – original draft, Writing – review & editing

    Affiliations Instituto de Genética e Bioquímica, Universidade Federal de Uberlândia, Uberlândia, Minas Gerais, Brazil, Instituto Nacional de Ciência e Tecnologia em Nano-Biofarmacêutica (N-Biofar), Belo Horizonte, Minas Gerais, Brazil

  • Luiz Borges Bispo-da-Silva,

    Roles Conceptualization, Formal analysis, Methodology, Writing – original draft, Writing – review & editing

    Affiliation Área de Ciências Fisiológicas, Instituto de Ciências Biomédicas, Universidade Federal de Uberlândia, Uberlândia, Minas Gerais, Brazil

  • Danielle Reis Napolitano,

    Roles Investigation, Methodology, Validation, Writing – review & editing

    Affiliations Instituto Nacional de Ciência e Tecnologia em Nano-Biofarmacêutica (N-Biofar), Belo Horizonte, Minas Gerais, Brazil, Área de Ciências Fisiológicas, Instituto de Ciências Biomédicas, Universidade Federal de Uberlândia, Uberlândia, Minas Gerais, Brazil

  • Mônica Soares Costa,

    Roles Investigation, Validation, Writing – review & editing

    Affiliation Instituto de Genética e Bioquímica, Universidade Federal de Uberlândia, Uberlândia, Minas Gerais, Brazil

  • Márcia Moura Nunes Rocha Figueira,

    Roles Investigation, Validation, Writing – review & editing

    Affiliation Instituto de Genética e Bioquímica, Universidade Federal de Uberlândia, Uberlândia, Minas Gerais, Brazil

  • Renata Santos Rodrigues,

    Roles Funding acquisition, Resources, Writing – review & editing

    Affiliations Instituto de Genética e Bioquímica, Universidade Federal de Uberlândia, Uberlândia, Minas Gerais, Brazil, Instituto Nacional de Ciência e Tecnologia em Nano-Biofarmacêutica (N-Biofar), Belo Horizonte, Minas Gerais, Brazil

  • Veridiana de Melo Rodrigues,

    Roles Funding acquisition, Resources, Writing – review & editing

    Affiliations Instituto de Genética e Bioquímica, Universidade Federal de Uberlândia, Uberlândia, Minas Gerais, Brazil, Instituto Nacional de Ciência e Tecnologia em Nano-Biofarmacêutica (N-Biofar), Belo Horizonte, Minas Gerais, Brazil

  • Kelly Aparecida Geraldo Yoneyama

    Roles Conceptualization, Funding acquisition, Methodology, Project administration, Resources, Writing – original draft, Writing – review & editing

    kelly.tudini@ufu.br

    Affiliation Instituto de Genética e Bioquímica, Universidade Federal de Uberlândia, Uberlândia, Minas Gerais, Brazil

In vitro additive interaction between ketoconazole and antimony against intramacrophage Leishmania (Leishmania) amazonensis amastigotes

  • Débora Cristina de Oliveira Nunes, 
  • Luiz Borges Bispo-da-Silva, 
  • Danielle Reis Napolitano, 
  • Mônica Soares Costa, 
  • Márcia Moura Nunes Rocha Figueira, 
  • Renata Santos Rodrigues, 
  • Veridiana de Melo Rodrigues, 
  • Kelly Aparecida Geraldo Yoneyama
PLOS
x

Abstract

Leishmaniasis is a group of diseases caused by protozoa of Leishmania genus. The currently available treatments for this disease are expensive, present high toxicity and are associated to difficulties of healing and parasite resistance. Therefore, the development of strategies for leishmaniasis treatment is indispensable and includes reposition of existing drugs, as well as drug combination therapy. The aim of this study was to assess the nature of ketoconazole and antimony association on the cytotoxic effect against Leishmania (Leishmania) amazonensis amastigotes. The calculated mean sum of fractional 50% inhibitory concentration (ΣFIC50) was 2.54 and 1.43 for free and intracellular amastigotes, respectively, values that suggest an additive interaction between ketoconazole and antimony concerning to Leishmania toxicity only in the intramacrophage parasite form. Despite the clinical efficacy of ketoconazole-antimony combination has been shown in the literature, our study is the first to describe the nature of ketoconazole-antimony interaction against L. (L.) amazonensis amastigotes. Moreover, our results point out the need for future in vivo studies to confirm the nature of ketoconazole-antimony interaction and also to determine possible effective dosage regimens related to ketoconazole administration in association with the optimal lower dose of antimony.

Introduction

Parasitic protozoan diseases are commonly found in the poorest countries of the world and constitute one of the most widely spread human health problem [1]. These diseases are still neglected and unfortunately have received little attention from the pharmaceutical industry and scientific funding agencies [2]. Despite several therapeutic options are available to treat different forms of leishmaniasis, the current chemotherapy of cutaneous leishmaniasis usually relies on antimony-based drugs. However, these drugs produce many side effects and their toxicity associated to the drug-resistant strains have limited therapeutic uses of antimony-based agents [3].

Nowadays, the repositioning of agents already used clinically for other purposes represents an important therapeutic strategy to treat leishmaniasis. In this way, azole compounds, known to inhibit fungal sterol biosynthesis, have been an option described in the literature [4]. Another therapeutic strategy is the combination of drugs with different mechanisms of action. This approach has many therapeutic advantages, such as: increased therapeutic efficacy; decreased toxicity due to reduction in the effective dose; reduced development of drug resistance; and selective synergism against parasite target versus host [3,5,6]. In this respect, the association of antimony-based agents with ketoconazole has been successfully used in human against old world leishmaniasis [7]; however, nothing is known about the pharmacological nature of this association, as well as of its efficacy on new world Leishmania species, such as L. (L.) amazonensis. Therefore, in the present study we aimed at investigating the in vitro antiparasitic efficacy and the pharmacological nature of antimony associated to ketoconazole against L. (L.) amazonensis amastigotes.

Materials and methods

Chemicals

Dimethylsulfoxide (DMSO), Giemsa stain modified solution, 4-(2-hydroxyethyl)-1- piperazineethanesulfonic acid (HEPES), ketoconazole, 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide (MTT), potassium antimonyl tartrate trihydrate, RPMI 1640 medium, sodium dodecyl sulphate (SDS), penicillin and streptomycin were purchased from Sigma Chemical Co. (St Louis, USA). Heat-inactivated fetal bovine serum (FBS) (Cultilab, Brazil), Schneider’s insect medium (LGC Biotecnologia, Brazil). All other reagents were analytical grade or superior. Ketoconazole was dissolved in a 1 M stock of dimethyl sulfoxide (DMSO) and stored at -20°C. For experiments, new dilutions were prepared in culture medium to ensure that the DMSO concentration in culture medium did not exceed 0.1%.

Animals

The experiments were performed using female BALB/c mice supplied by the animal facility of the Federal University of Uberlândia (CBEA/UFU). The animals were housed in a room at 25°C with 12 h light/dark cycles and were provided free access to water and standard chow ad libitum. All the protocols used were reviewed and approved by the Ethics Committee on Animal Use of the Federal University of Uberlândia (CEUA/UFU; process n° 36/2013).

Parasites—Promastigote and free amastigote

Leishmania (Leishmania) amazonensis (IFLA/BR/67/PH8 strain) promastigotes were cultured in Schneider’s insect medium, pH 7.0, supplemented with 10% FBS, penicillin (100 UI.mL−1) and streptomycin (100 μg.mL−1) at 23 ± 0.5°C. Promastigotes used in all experiments were isolated from the stationary growth phase.

Free amastigotes were obtained from footpad of BALB/c mice (6–8 weeks old) previously infected with promastigote forms (1×107 cells/footpad) for 5 to 6 weeks [8]. These parasites were cultured in complete Schneider’s insect medium, at 32 ± 0.5°C, ensuring that these parasites remained as axenic amastigote forms [9], and used within two days.

Murine macrophage culture

Murine macrophage cell line RAW264.7 was obtained from Rio de Janeiro Bank Cell and cultured in RPMI 1640 medium, supplemented with 5% FBS, penicillin (100 UI.mL−1), streptomycin (100 μg.mL−1) in 75-cm2 flasks. All cell cultures were done at 37°C in humidified air with 5% CO2.

Viability—Macrophage and free amastigote assays

Viability assays in presence of drugs (antimony and/or ketoconazole) were carried on free amastigote forms and murine macrophages cell line RAW264.7, by colorimetric method based on mitochondrial oxidation of MTT reagent (5 mg.mL−1, 100 μg/well) [10]. Free amastigotes (5x105 cells/well) and macrophages (2x105 cells/well) were incubated with its respective medium alone (control) or containing ketoconazole (10−10 to 10−3 M) or antimony (10−12 to 10−3 M) for 48 hours. The 50% inhibitory concentration (IC50) of drugs on cell viability were then determined in each individual experiment considering control values as 100% of viability. This assay was carried out in triplicate and three independent experiments were performed. Cytotoxicity in RAW macrophages and activity against free amastigotes for ketoconazole and antimony were compared using the selectivity index (SI; ratio: IC50 RAW macrophage/ IC50 parasite).

Infectivity—Intracellular amastigote assay

Macrophages (4×105) were placed in 24-well plates containing 13-mm diameter glass coverslips. Then, macrophages were infected with L. (L.) amazonensis free amastigotes isolated immediately before their use at 2:1 ratio (free amastigotes/macrophage). After 1h30, plates were washed with PBS to remove non-internalized amastigotes and RPMI medium alone (control) or containing drugs (13.125 to 420 μM for ketoconazole and 0.156 to 5 μM for antimony, both double serial dilutions) were added. Experiments were conducted at 37°C in a 5% CO2 humidified incubator for 48 h. Cells on coverslips were fixed and stained with Giemsa stain modified solution for evaluation of the infection index. Infectivity index was defined as the average number of intracellular amastigotes in infected macrophages multiplied by percentage of infected macrophage; 100 cells per coverslip were blind counted. The IC50 values of drugs on the infectivity were then determined in each individual experiment considering control values as 100% of infectivity. This assay was carried out in triplicate and two independent experiments were performed.

Isobologram

The interaction between ketoconazole and antimony was in vitro evaluated by using the modified isobologram method according to [5, 11], with modification. Briefly, to construct an isobologram and determine the type of interaction between drugs, the prerequisite is to know the potency and a form of dose-effect curve of each drug alone. The IC50 values obtained in the experiments described in ‘Viability—macrophage and free amastigote assays’ and ‘Infectivity—Intracellular amastigote assay’ subsections were used to determine the maximum concentration of each drug in the combination assay ensuring that IC50 was in the midpoint of curves, except for the intracellular amastigote assay; in this case, the IC50 falls on the third point (from the maximum concentration used), that was not the midpoint, since highest concentrations of both drugs necessary to complete the curves were toxic for macrophages. The highest concentration of the solutions were prepared in proportions of 5:0, 4:1, 3:2, 2:3, 1:4 and 0:5 of ketoconazole and antimony, which were serially diluted to the ninth or sixth well of microplate for free amastigote or intracellular amastigote assays, respectively; this assay was carried out in duplicate (infectivity assay) or triplicate (viability assay) and two independent experiments were performed. Assays of combinations in each ratio allowed getting concentration-effect curves and therefore the IC50 for each combination ratio in relation to ketoconazole and antimony. Then, fractional inhibitory concentrations (FICs) at the IC50 level (FIC50) were calculated for both drugs, as follows: FIC50 = IC50 drugs in combination/IC50 drug alone. FIC50s of each drug ratio (i.e, 4:1, 3:2, 2:3 and 1:4) were used to build isobolograms. It is important to mention that isobolograms constructed using FIC values are also known as normalized isobolograms [6]. Moreover, the sum of the FIC50s for each ratio, also referred as combination index [6], was determined (ΣFIC50s = FIC50 ketoconazole + FIC50 antimony), and an overall mean of ΣFIC50s (ΣFIC50) was calculated. Finally, the average of the ΣFIC50 was used to classify the nature of interaction: ‘Synergy’ defined as mean ΣFIC ≤ 0.5; ‘Indifference/Additive’ as mean ΣFIC > 0.5 and ≤ 2; and ‘Antagonism’ as mean ΣFIC > 2 [12].

Statistical analysis

In the experiments, the 50% viability/infectivity inhibition values (IC50) were estimated by fitting the concentration-response data to the four parameter logistic equation through nonlinear regression analysis, according to the following equation: as follows: Y = Bottom + (Top-Bottom)/(1+10^((LogEC50-X)*HillSlope)) [13]. Moreover, IC50, FIC50, ΣFIC50s and ΣFIC50 were calculated for each individual experiment using GraphPad Prism 5.0 (GraphPad Software Inc., San Diego, USA), and results were expressed as the mean and standard error of at least two independent experiments.

Results

In vitro susceptibility of amastigotes and macrophages to individual drugs

Both drugs caused a concentration-dependent inhibition on amastigote viability after 48 hours of incubation presenting IC50 values of 105.5 μM for ketoconazole and 2.5 μM for antimony (Fig 1A). Concentration-dependent inhibition on macrophages cell line RAW viability was also observed (Fig 1B). Ketoconazole was much less toxic to macrophage than antimony (Fig 1B; IC50 = 436.5 vs. 7.3 μM; ketoconazole vs. antimony) presenting selectivity index of approximately 4.1 and 2.9 for ketoconazole and antimony, respectively. Both drugs also inhibited intracellular amastigotes in a concentration-dependent way, presenting IC50 of 75 and 1.5 μM for ketoconazole and antimony, respectively (Fig 1C).

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Fig 1. Cytotoxic effects of isolated drugs (ketoconazole and antimony) on free amastigotes, murine macrophages cell line RAW264.7 and intracellular amastigotes.

Concentration-effect curves to ketoconazole (white points) and antimony (black points) against L. (L.) amazonensis free amastigotes (A), murine macrophages (B) or intracellular amastigotes (C). Data represent mean ± SEM of two to three independent experiments performed in triplicate.

https://doi.org/10.1371/journal.pone.0180530.g001

Effect of ketoconazole and antimony combination on amastigotes and isobologram

This experimental approach allowed the determination of FIC50 values for each combination. Overall mean of ΣFIC50 for free amastigotes assay ranged from 2.01 to 2.99 and the ΣFIC50 was 2.54 ± 1.7. For intracellular amastigotes, the overall mean of ΣFIC50 ranged from 1.07 to 1.60 and the ΣFIC50 was 1.43 ± 0.38. The IC50, FIC50, ΣFIC50 and ΣFIC50 values are given in Table 1 and the corresponding isobolograms are shown in Fig 2A and 2B. The sigmoidal concentration-effect curves for each combination are present in Fig 2C and 2D.

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Table 1. IC50, FIC50 and ΣFIC50 of antimony-ketoconazole combination against L. (L.) amazonensis free and intracellular amastigotes.

https://doi.org/10.1371/journal.pone.0180530.t001

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Fig 2. Ketoconazole and antimony combination on L. (L.) amazonensis amastigotes.

Isobologram representing in vitro ketoconazole-antimony interaction against L. (L.) amazonensis free (A) or intracellular (B) amastigotes by a fixed-ratio method based on the IC50. Dashed line represents an ideal theoretical line for the additive effect; the ΣFIC50 for all interactions tested is also shown. Concentration-effect curves concerning the inhibition of L. (L.) amazonensis free (C) and intracellular (D) amastigotes by different combinations of antimony (black points) and ketoconazole (white points). Data represent mean ± SEM of two independent experiments performed in triplicate.

https://doi.org/10.1371/journal.pone.0180530.g002

Discussion

Ketoconazole- and antimony-induced Leishmania toxicity appears to be related to the inhibitory effects of these drugs on different parasite metabolic pathways [4, 14]. Therefore, in the present study we tested the hypothesis that the combination of ketoconazole with antimony could improve the antileishmanial effect of these agents. It has been shown that Sb5+ should be reduced by the host cells to Sb3+, the active form against parasites [15, 16]. Thus, since both intramacrophage or free parasites were analyzed, and to avoid biases due to variability in macrophage drug conversion, antimonyl tartrate (Sb3+) was used instead meglumine antimoniate (Sb5+). Despite ketoconazole was less potent than antimony in inducing L. (L.) amazonensis free (ca. 40 times) and intracellular (ca. 50 times) amastigotes death in vitro, ketoconazole was much less toxic to macrophages than antimony. These data strongly suggest that this azole compound may be used against parasite-infected macrophages ensuring safety and efficacy.

Previous clinical trials studies showed the efficacy of ketoconazole alone in several Leishmania species around the world [17, 18, 19, 20], and the literature also pointed out that ketoconazole efficacy is comparable to those of antimonial based drugs [21, 22, 23]. However, to our knowledge, only one study focused on the combined therapy of ketoconazole and antimony. In that study it was observed that sodium stibogluconate (SSG) combined with ketoconazole was more effective than SSG alone to treat human cutaneous leishmaniotic lesions [7]. It is important to mention that the clinical study cited above was conducted in an Asian country where the common etiologic agents for cutaneous leishmaniasis are L. major, L. tropica, and L. aethiopica; however, in our study we focused on L. (L.) amazonensis, one of the typical species related to the disease in the America continent [1].

FIC is a widespread index used to study drug interactions and many critical values have been arbitrarily used to define the nature of drug combination [6, 24, 25, 26, 27]. The additivity range of 0.5 to 4.0 has been recommended by some expertise in the field [26] and employed in several studies concerning the interactions of antileishmanial drugs [11, 28, 29, 30]. However, based on the absence of in vitro-in vivo correlation studies, concerns about the validity of this arbitrarily chosen FIC were raised, and a more symmetrical additivity range of 0.5 to 2.0 was suggested [12]. In the present study, two different experimental conditions were perforned, including the amastigote-macrophage model, the gold standard assay for determining the intrinsic drug susceptibility of intracellular amastigotes [31]. According to the more symmetrical additivity range mentioned above, the ΣFIC (1.42) observed in our study indicate an additive nature to ketoconazole-antimony combination against intramacrophage amastigote. Moreover, the ketoconazole-antimony combination resulted in ΣFICmin and ΣFICmax of 1.07 and 1.60, respectively, values that are within the range observed in self-drug additive combination studies [12]. On the other hand, the ΣFIC (2.54) for free amastigotes suggests an antagonic interaction between ketoconazole and antimony. Despite we have no explanation for this discrepancy these results suggest altogether that the intracellular environment alter the nature of the interaction between ketoconazole and antimony against L. (L.) amazonensis. It is noteworthy that although experiments carried out with promastigotes or axenic amastigotes are easier to perform, to use intracellular amastigotes is clinically more relevant once this parasite form bears a closer similarity to the in vivo situation and correlate better with the treatment outcome [32, 33]. The use of lower doses of antimony associated with ketoconazole has the advantage of reducing side effects and limits the development of resistant strains, an emerging worldwide therapeutic problem. Therefore, considering the toxicity of antimony, its indifferent interaction with ketoconazole against intramacrophage amastigote could be useful and should be confirmed in vivo.

Moreover, cutaneous lesion may become susceptible to colonization with a number of microorganisms, such as pathogenic or opportunistic fungi that could cause secondary infections [34]. Hence, beyond the suggestion (based on our in vitro data) that direct effects of the ketoconazole in combination with antimony on Leishmania death could occur in vivo, ketoconazole could also improve the leishmaniotic lesion due to its action on fungi.

It is important to mention that we analyzed the interaction just in relation to IC50 level, since we obtained inhibition percentages nearby but less than 100% for some combination within the dilution range used; this fact preclude the determination of all the FIC90 necessary for the data analysis. In attempt to reach 100% of inhibition we increased the ketoconazole concentration, however, in this condition the drug precipitated. It is important to mention that analyzing data using only IC50 level do not invalidate our results and interpretations, since the evaluation of FIC at IC90 levels serve only as rebuttal [35, 36].

In conclusion, although the clinical efficacy of ketoconazole-antimony combination has been shown in the literature, our study is the first to describe the nature of ketoconazole-antimony interaction against L. (L.) amazonensis both in free and intracellular amastigotes. The additive interaction of ketoconazole-antimony combination in the intramacrophage parasite form points out that future in vivo experiment should be conducted to confirm this interaction and also to determine possible effective dosage regimens related to ketoconazole administration in association with the optimal lower dose of antimony.

Acknowledgments

We thank Prof. Fábio de Oliveira (Laboratório de Biologia Molecular e Celular—ICBIM/UFU) for gently gift macrophage cell line and providing laboratory facilities.

References

  1. 1. Elmahallawy EK, Martínez AS, Rodriguez-Granger J, Hoyos-Mallecot Y, Agil A, Mari JMN et al. Diagnosis of leishmaniasis. J Infect Dev Ctries. 2014; 8, 8: 961–972. pmid:25116660
  2. 2. Chaudhary K, Ross D. Protozoan genomics for drug discovery. Nat Biotechnol. 2005; 23: 1089–1091. pmid:16151400
  3. 3. Haldar AK, Sen P, Roy S. Use of antimony in the treatment of leishmaniasis: current status and future directions. Mol Biol Int. 2011; 2011: 1–23.
  4. 4. Lepesheva GI, Waterman MR. Sterol 14alpha-demethylase (CYP51) as a therapeutic target for human Trypanosomiasis and Leishmaniasis. Curr Top Med Chem. 2011; 11: 2060–2071. pmid:21619513
  5. 5. Fivelman QL, Adagu IS, Warhurst DC. Modified fixed-ratio isobologram method for studying in vitro interactions between Atovaquone and Proguanil or Dihydroartemisinin against drug-resistant strains of Plasmodium falciparum. Antimicrob Agents Chemother. 2004; 48, 11: 4097–4102. pmid:15504827
  6. 6. Chou T. Theoretical basis, experimental design, and computerized simulation of synergism and antagonism in drug combination studies. Pharmacol Rev. 2006; 58: 621–681. pmid:16968952
  7. 7. El-Sayed M, Anwar AE. Intralesional sodium stibogluconate alone or its combination with either intramuscular sodium stibogluconate or oral ketoconazole in the treatment of localized cutaneous leishmaniasis: a comparative study. J Eur Acad Dermatol Venereol. 2010; 24: 335–340. pmid:19744259
  8. 8. Nunes DCO, Figueira MNRF, Lopes DS, de Souza DLN, Izidoro LF, Ferro EA, et al. BnSP-7 toxin, a basic phospholipase A2 from Bothrops pauloensis snake venom, interferes with proliferation, ultrastructure and infectivity of Leishmania (Leishmania) amazonensis. Parasitol. 2013; 140, 7: 844–854.
  9. 9. Gupta N, Goyal N, Rastogi AK. In vitro cultivation and characterization of axenic amastigotes of Leishmania. Trends Parasitol. 2001; 17, 3: 150–153. pmid:11286801
  10. 10. Mosmann TJ. Rapid colorimetric assay for cellular growth and survival: application to proliferation and cytotoxicity assays. Immunol Methods. 1983; 65: 55–63.
  11. 11. Mesquita JT, Tempone AG, Reimão JQ. Combination therapy with Nitazoxanide and Amphotericin B, Glucantime®, Miltefosine and Sitamaquine against Leishmania (Leishmania) infantum intracellular amastigotes. Acta Trop.2014; 130: 112–116. pmid:24239532
  12. 12. Meletiadis J, Pournaras S, Roilides E, Walsh TJ. Defining fractional inhibitory concentration index cutoffs for additive interactions based on self-drug additive combinations, Monte Carlo simulation analysis, and in vitro-in vivo correlation data for antifungal drug combinations against Aspergillus fumigates. Antimicrob A Chemoter. 2010; 54 (2): 602–609.
  13. 13. Zhang G, Cvijic ME. Screening and characterization of G-protein-coupled receptor ligands for drug discovery. In: Seethala R, Zhang . Handbook of drug screening. New York. USA: Informa Healthcare; 2009, chapter 6, pp. 142.
  14. 14. Souza W, Rodrigues JCF. Sterol biosynthesis pathway as target for anti-trypanosomatid drugs. Interdiscip Perspect Infect Dis. 2009; 2009: 1–19.
  15. 15. Goodwin LG, Page JE. A study of the excretion of organic antimonials using a polarographic procedure. Biochem J. 1943; 37,198–209. pmid:16747617
  16. 16. Hansen C, Hansen EW, Hansen HR, Gammelgaard B, Stürup S. Reduction of Sb(V) in a human macrophage cell line measured by HPLC-ICP-MS. Biol Trace Elem Res. 2011; 144: 234–243. pmid:21618006
  17. 17. Urcuyo FG, Zaias N. Oral ketoconazole in the treatment of leishmaniasis. Pharmacol Ther. 1982; 21: 414–416.
  18. 18. Jolliffe DS. Cutaneous leishmaniasis from Belize—treatment with ketoconazole. Clin Exp Dermatol. 1986; 11: 62–68. pmid:3708895
  19. 19. Alsaleh QA, Dvorak R, Nanda A. Ketoconazole in the treatment of cutaneous leishmaniasis in Kuwait. Int J Dermatol. 1995; 34,7: 495–497. pmid:7591417
  20. 20. Boecken G, Sunderkotter C, Bogdan C, Weitzel T, Fischer M, Muller A, et al. Diagnosis and therapy of cutaneous and mucocutaneous Leishmaniasis in Germany. J Dtsch Dermatol Ges. 2011; 9, 8: 1–51.
  21. 21. Saenz RE, Paz H, Berman JD. Efficacy of ketoconazole against Leishmania braziliensis panamensis cutaneous leishmaniasis. Am J Med. 1990; 89: 147–155. pmid:2166429
  22. 22. Navin TR, Arana BA, Arana FE, Berman JD, Chajón JF. Placebo-controlled clinical trial of sodium stibugluconate (Pentostam) versus ketoconazole for treating cutaneous leishmaniasis in Guatemala. J Infect Dis. 1992; 165: 528–534. pmid:1311351
  23. 23. Salmanpour R, Handjani F, Nouhpisheh MK. Comparative study of the efficacy of oral ketoconazole with intra-lesional meglumine antimoniate (Glucantime) for the treatment of cutaneous leishmaniasis. J Dermatolog Treat. 2001; 12: 159–162. pmid:12243707
  24. 24. Berenbaum MC. A method for testing for synergy with any number of agents. J Infec Dis. 1978; 137 (2): 122–130.
  25. 25. Hall MJ, Middleton RF, Westmacott D. The fractional inhibitory concentration (FIC) index as a measure of sinergy. J Antimicrob Chemother. 1983; 11:427–433. pmid:6874629
  26. 26. Dorsthrst DTA, Verweij PE, Meis JFGM, Punt NC, Mouton JW. Comparison of fractional inhibitory concentration index with response surface modeling for characterization of in vitro interaction of antifungals against itraconazole-susceptible and resistant Aspergillus fumigates isolates. Antimicrob A Chemoter. 2002; 46 (2): 702–707.
  27. 27. Odds FC. Synergy, antagonism, and what the chequerboard puts between them. J Antimicrob Chemother. 2003; 52: 1. pmid:12805255
  28. 28. Seifert K, Munday J, Syeda T, Croft SL. In vitro interactions between sitamaquine and amphotericin B, sodium stibugluconate, miltefosine paramomycin and pentamidine against Leishmania donovani. J Antimicrob Chemother. 2011; 66: 850–854. pmid:21393188
  29. 29. Shakya N, Sane SA, Vishwakarma P, Bajpai P, Gupta S. Improved treatment of visceral leishmaniasis (kala-azar) by using combinatios of ketoconazole, miltefosine with an immunomodulator—Pricoliv. Acta Trop. 2011; 119: 188–193. pmid:21679679
  30. 30. Morais-Teixeira E, Gallupo MK, Rodrigues LF, Romanha AJ, Rabello A. In vitro interaction between paramomycin sulphate and four drugs with leishmanicidal activity against three New World Leishmania species. J Antimicrob Chemother. 2014; 69: 150–154. pmid:23970484
  31. 31. Maes L, Cos P, Croft S. The relevance of susceptibility tests, breakpoints and markers. In: Ponte-Sucre A, Diaz E, Padŕon-Nieves M, editors. Drug resistance in Leishmania parasites. Vienna, Austria: Springer; 2013. pp. 407–429.
  32. 32. Callahan HI, Portal AC, Devereaux R, Grogl M. An axenic amastigote system for drug screening. Antim A Chemoter. 1997, 41 (4): 818–822.
  33. 33. Le Bras J, Secor WE. Susceptibility test methods: parasites. In: Versalovic J, Karroll KC, Funke G, Jorgensen JH, Landry ML, Warnock DW, editors. Manual of clinical microbiology. Washington, USA: ASM Press; 2011. pp.2113–2117.
  34. 34. Fontes CO, Carvalho MAR, Nicoli JR, Hamdan JS, Mayrink W, Genaro O, et al. Identification and antimicrobial susceptibility of micro-organisms recovered from cutaneous lesions of human American tegumentar leishmaniasis in Minas Gerais, Brazil. J Med Microbiol. 2005; 54: 1071–1076. pmid:16192439
  35. 35. Pandharkar T, Zhu X, Mathur R, Jiang J, Schmittgen TD, Shaha C, Werbovetz KA. Studies on the antileishmanial mechanism of action of the Arylimidamine DB766: azole interactions and role of CYP5122A1. Antimicrob Agents Chemother. 2014; 58, 8: 4682–4689. pmid:24890590
  36. 36. Trinconi CT, Reimão JQ, Yokoyama-Yasunaka JKU, Miguel DC, Uliana SRB. Combination therapy with Tamoxifen and Amphotericin B in experimental cutaneous leishmaniasis. Antimicrob Agents Chemother. 2014; 58, 5: 2608–2613. pmid:24550333