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Frézard, F.;  Aguiar, M.M.G.;  Ferreira, L.A.M.;  Ramos, G.S.;  Santos, T.T.;  Borges, G.S.M.;  Vallejos, V.M.R.;  Morais, H.L.O.D. Liposomal Amphotericin B for Treatment of Leishmaniasis. Encyclopedia. Available online: https://encyclopedia.pub/entry/39689 (accessed on 17 November 2024).
Frézard F,  Aguiar MMG,  Ferreira LAM,  Ramos GS,  Santos TT,  Borges GSM, et al. Liposomal Amphotericin B for Treatment of Leishmaniasis. Encyclopedia. Available at: https://encyclopedia.pub/entry/39689. Accessed November 17, 2024.
Frézard, Frédéric, Marta M. G. Aguiar, Lucas A. M. Ferreira, Guilherme S. Ramos, Thais T. Santos, Gabriel S. M. Borges, Virgínia M. R. Vallejos, Helane L. O. De Morais. "Liposomal Amphotericin B for Treatment of Leishmaniasis" Encyclopedia, https://encyclopedia.pub/entry/39689 (accessed November 17, 2024).
Frézard, F.,  Aguiar, M.M.G.,  Ferreira, L.A.M.,  Ramos, G.S.,  Santos, T.T.,  Borges, G.S.M.,  Vallejos, V.M.R., & Morais, H.L.O.D. (2023, January 03). Liposomal Amphotericin B for Treatment of Leishmaniasis. In Encyclopedia. https://encyclopedia.pub/entry/39689
Frézard, Frédéric, et al. "Liposomal Amphotericin B for Treatment of Leishmaniasis." Encyclopedia. Web. 03 January, 2023.
Liposomal Amphotericin B for Treatment of Leishmaniasis
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This entry is adapted from the peer-reviewed paper 10.3390/pharmaceutics15010099

The liposomal amphotericin B (AmB) formulation, AmBisome®, still represents the best therapeutic option for cutaneous and visceral leishmaniasis. However, the need for parenteral administration, its side effects and high cost significantly limit its use in developing countries. The recent advances in the development of topical and oral formulations of liposomal AmB are presented, in addition to the current knowledge on the physicochemical and pharmacological features of AmB.

liposomes amphotericin B leishmaniasis oral route topical route

1. Introduction

Leishmaniasis, a group of diseases caused by Leishmania spp. and transmitted by the bites of female phlebotomine sandflies, is among the top ten neglected tropical diseases worldwide. Distinct species of Leishmania cause different clinical manifestations, including cutaneous leishmaniasis (CL), mucocutaneous (MCL) and visceral leishmaniasis (VL). VL is principally caused by L. donovani in Asia and Africa and by L. infantum in the Mediterranean Basin, the Middle East, central Asia and South and Central America. In contrast, CL is caused by L. major, L. tropica and L. aethiopica in the Old World and L. amazonensis, L. mexicana, L. braziliensis and L. guyanensis in the New World. Risk factors for progression of VL and increased spread in all transmission settings include malnutrition, genetic factors, population movement, other infectious diseases and immune suppression, notably HIV infection. The epidemiology of CL in the Americas is very complex, with variations in transmission cycles, reservoir hosts, sandfly vectors, clinical manifestations and response to therapy, and multiple circulating Leishmania species in the same geographical area [1][2][3][4][5]. In 2020, more than 90% of the VL cases reported to WHO were in Brazil, Ethiopia, Eritrea, India, Iraq, Kenya, Nepal, Somalia, South Sudan and Sudan, and of the 10 countries with the highest number of cases of CL, 4 are in the Americas: Brazil, Colombia, Nicaragua and Peru. There are more than 12 million infected people, 0.9 to 1.6 million new cases and between 20,000 and 30,000 deaths each year, and 350 million people at risk of infection [1][4].
The treatment of leishmaniasis depends on several factors, including type of disease, concomitant pathologies, parasite species and geographic location [6]. Leishmaniasis is a treatable and curable disease, which requires an immunocompetent system due to parasite multiplication inside the macrophages and the dependence of parasite clearance on the activation status of the host cell. Thus, the risk of relapse exists if immunosuppression occurs. Antimonials, amphotericin B (AmB), pentamidine isethionate and miltefosine constitute the therapeutic arsenal available for systemic treatment of leishmaniasis [7]. Pentavalent antimonials are the oldest drugs available and are still considered first-line treatments against most forms of leishmaniasis in several developing countries [7]. However, their adverse effects—cardiotoxicity, particularly evident in HIV–VL co-infection; renal failure; and pancreatitis—represent limitations of this treatment modality [5][8]. In addition to drug toxicity, a major challenge in the treatment of leishmaniasis is that traditional antileishmanial drugs face specific difficulties penetrating inside the macrophages to reach parasites.
Among the lipid formulations of AmB, liposomal AmB, called AmBisome®, has a lower incidence of adverse reactions, notably nephrotoxicity and infusion-related reactions. Now, AmBisome® is recommended as a first-line drug in VL patients in endemic areas, such as India, as well as in the Americas [7][9][10]. However, the widespread use of AmBisome® and its generics remains limited by their low stability at temperatures higher than 25 °C and the need for parenteral administration [11][12][13]. Furthermore, AmBisome® showed moderate efficacies in New World CL, with a cure rate lower than 80% [14][15][16]. Thus, efforts have been devoted to improving the efficacy of liposomal AmB against CL and achieving topically and orally active liposomal formulations.

2. Physicochemical Characteristics, Mechanisms of Action and Toxicity of AmB

2.1. AmB Physicochemical Characteristics

AmB has a complex chemical structure composed of a hydrophilic polyhydroxyl chain, a lipophilic polyene hydrocarbon chain and a mycosamine moiety containing a free amino group [17][18].
AmB is an amphoteric molecule that presents two ionizable groups: a carboxyl (that can be negatively ionized, pKa = 3.72) and an amine (that can be positively ionized, pKa = 8.12) [19]. When just one group is ionized (pH values below 2 or above 10), AmB is soluble in aqueous media (0.1 mg/mL), but when both groups are ionized (pH values between 6 and 7), AmB exhibits a very low solubility. Regarding organic solvents, AmB is known to be soluble in polar solvents, such as dimethylsulfoxide (DMSO) (30–40 mg/mL) and dimethylformamide (DMF) (2–4 mg/mL) [20].
In water at neutral pH values (around 7.4), AmB dimers are formed by apposition of the hydrophobic moieties of the two monomers, above the AmB critical aggregate concentration (0.001 mg/mL) [21]. AmB dimers continue to self-associate as AmB concentration is increased in a specific medium and/or temperature is increased, forming structures that are known as aggregates.
The AmB monomer was observed after dilution of AmB in water at extreme pH values (below 2 or above 10); dilution in organic solvents, such as DMSO and DMF; or immobilization in drug delivery systems, such as cyclodextrins [22] and nanoemulsions [23]. Regarding AmB oligomers (dimers), those were reported in deoxycholate micelles (commercial product, Fungizone®). Regarding higher-order aggregates, they can be obtained when deoxycholate AmB is heated at 70 °C for 20 min or at concentrations above 0.001 mg/mL in an aqueous medium [24][25].
It is possible to distinguish monomeric, oligomeric and aggregated forms of AmB through different physicochemical techniques, such as ultraviolet/visible (UV/Vis) electronic absorption, circular dichroism (CD), fluorescence spectroscopies, powder X-ray diffraction (PXRD), differential scanning calorimetry (DSC) and average size measurements.

2.1.1. UV/Vis Electronic Absorption

The electronic absorption spectrum of AmB is highly sensitive to the state of aggregation of the molecule. Monomeric AmB presents absorption peaks at 363–365, 383–384 and 406–409 nm. When AmB begins to aggregate through hydrophobic interactions, forming oligomers, a very strong absorption peak is detected at 328–340 nm. When oligomers are heated, forming super-aggregates, this peak suffers a hypsochromic shift, which is detected at 322 nm [22][24].

2.1.2. Circular Dichroism

CD is a technique that involves the application of circularly polarized light through a sample and the measurement of the absorption difference between right- and left-handed polarized lights [26]. Monomeric AmB presents a spectrum of very low intensity. On the contrary, oligomers present two maxima at 330 and 350 nm, with a dichroic couplet centered at 340 nm. Regarding aggregates, they present the same maxima wavelength when formed through the increase in concentration. Nonetheless, when aggregates are formed through heating, there is a blue shift (close to what is seen in the UV/Vis absorption spectrum), with two maxima at 320 and 340 nm and a dichroic couplet signal centered at 330 nm [24][27][28][29]. The higher the extent of AmB aggregation, the higher the CD intensity.

2.1.3. Fluorescence Techniques

Analyses of steady-state and time-resolved fluorescence, fluorescence anisotropy and fluorescence correlation spectroscopy of AmB (autofluorescence) in different solutions [30][31][32] revealed the formation of dimeric and aggregated species of the drug, even in alkaline solution at pH 12. The fact that these self-associated species appeared when drug molecules were electrically charged (at pH 12) also implied an antiparallel orientation of neighboring molecules in the structures [31].

2.1.4. Dynamic Light Scattering for Particle Size Analysis

As expected, the higher the aggregation, the higher the size of the AmB nanoassembly. While an AmB monomer has an average size of 1 nm, oligomers have a size around 40 nm and aggregates around 300 nm [22][33].

2.1.5. DSC and PXRD for Crystallinity Analysis

AmB can be present in the amorphous phase as a monomer or oligomers. Nonetheless, if AmB is in aggregated forms, it has some degree of crystallinity that can be detected by techniques such as DSC and PXRD [22].

2.2. AmB Mechanism of Action

The most prominent mechanism of action of AmB involves its binding to ergosterol, the main component of fungal or parasitic cell membranes. AmB tetramers and octamers arrange themselves in cylindric-like structures, with the hydrophobic part of AmB molecules interacting with ergosterol in the lipid bilayer, resulting in multimeric transmembrane pores. The positively charged amino group of AmB is required for its activity, as well as the polyene subunit [9][32][34][35].
The formation of pores allows the extravasation of electrolytes (such as K+, NH4+ and H2PO4−) from the intracellular environment, in addition to carbohydrates and proteins [17]. Moreover, there is a subsequent influx of protons into the pathogenic cell that causes acidification of the intracellular medium, with precipitation in the cytoplasm and, eventually, cell death [9][36].
It has also been proposed that AmB may adsorb or sequester ergosterol on the membrane surface, destabilizing the phospholipid bilayer and impairing fundamental cellular processes [12][37]. Moreover, AmB can induce oxidative stress, either directly producing or causing intracellular accumulation of reactive oxygen species (ROS) and reactive nitrogen species [38][39]. The oxidation of unsaturated fatty acids of the cell membrane leads to a change in the integrity of the membrane that becomes susceptible to the osmotic shock derived from the formation of transmembrane channels [25].
The supramolecular organization of AmB also exerts influence on its mechanism of action. Data from in vitro assays indicated that AmB activity was higher for the monomeric form and lower for the aggregates, while an intermediate activity was observed for the oligomers. The reason for that can be related to several factors. It was found that aggregated AmB produced less ROS [22][40]. Moreover, the smaller size of monomeric AmB may result in a higher drug penetration, compared to the larger oligomeric and aggregated forms [22][40].

2.3. AmB Mechanism of Toxicity

Besides being toxic to fungal and Leishmania cells, AmB can be toxic to human tissues. AmB toxicity is related to its binding to cholesterol, oxidation of cell membranes and production of ROS. Nephrotoxicity represents an AmB major side effect, with AmB supramolecular organization influencing this effect.
It is well known that the size of the drug molecules and their supramolecular species interfere in their biodistribution. It has been demonstrated that while particles with an average diameter larger than 20 nm did not accumulate significantly in the kidneys, those with less than 5 nm were effectively retained therein [41]. One third of AmB total clearance is renal [9]; therefore, nephrotoxicity occurs when AmB passes through the kidneys to be eliminated in urine. As monomeric AmB has a very small size (around 1 nm), it is preferentially eliminated in the urine. On the contrary, as AmB aggregates have a higher average size (>300 nm), they tend to accumulate more in the liver and spleen and are less nephrotoxic [22][33].
Moreover, the interaction of AmB oligomers with cholesterol was found to favor the formation of AmB tetramers and octamers, leading to cell death. In contrast, AmB monomers’ interaction with cholesterol did not lead to oligomer formation. In that sense, it was documented that AmB monomers were safer than AmB oligomers in vivo [42]. From this data, it has been suggested that AmB monomers might be a safer option compared to oligomers [12][36].
Finally, AmB aggregates may act as AmB reservoirs, releasing monomers over time. Therefore, they can be seen as a more specific option than AmB oligomers, with a similar safety profile compared to the monomers [43][44]. Some studies have also stressed that AmB aggregates may be even more specific and safer than AmB monomers [22][45].

3. Topical Liposomal Formulations of AmB

3.1. Topical Delivery

Topical treatments are especially attractive for uncomplicated CL cases, offering significant advantages over systemic therapy, including easier administration, fewer adverse effects and cost-effectiveness. Despite being a very attractive route of administration, the topical route represents a challenge for many drugs. The outermost layer, the epidermis, is composed of two main layers: stratum corneum (SC) and viable epidermis. The SC, composed of corneocytes embedded in a lipid matrix, represents the main physical barrier of the skin, protecting the inner layers from the external environment. The viable epidermis is composed mainly of keratinocytes, melanocytes, Merkel cells and Langerhans cells. Adjacent to the epidermis is the dermis, which performs important functions of nutrition and support. The innermost layer of the skin, the hypodermis, is a fat layer providing mechanical support and thermal insulation [46][47][48].
After topical application, drugs can permeate through the skin by three different pathways: (i) appendageal or transfollicular, allowing the direct transport of substances via hair follicles and glandular ducts; (ii) intercellular or paracellular pathway, in which the drug diffuses between the cells, passing through the lipid matrix; and (iii) the intracellular or transcellular pathway, in which the drug passes inside the skin cells and through the lipid matrix [48][49][50]. It is assumed that a combination of these three pathways can contribute to the skin penetration of all substances, but the preferred route depends on their physicochemical characteristics [51].
In CL treatment, the goal of a topical formulation would be to target the infected macrophages located in the dermis [52]. An important aspect of CL is that the patient’s skin is not always intact, as, with the evolution of the disease, the SC is usually damaged. In CL, a papule initially forms at the inoculation site, which usually evolves into ulcerated lesions. In this process, there is a loss of the epidermis and part of the dermis as a result of the local inflammatory response [53]. Although this loss of SC initially facilitates the entry of drugs through the skin, re-epithelialization and wound healing during treatment, along with the production of collagen and metalloproteases of the extracellular matrix, may represent an additional challenge for topical treatment [54]. Thus, it is desired that the formulation works in all possible situations: intact, partially or completely damaged skin [55].
To ensure efficient penetration of a substance through the intact skin, it has been proposed that it must have some characteristics, such as a melting point of less than 200 °C, low molecular weight (less than 500 Da) and log p value between 1–3 [50]. The ability of the molecule to form hydrogen bonds and its degrees of ionization also need to be considered [47]. Other factors related to the individual, as well as the environment, can also impact skin permeation, such as age, hormonal balance, sebum production, skin hydration and pH gradient [48].
AmB has unfavorable physicochemical characteristics for topical administration, such as high molecular weight (~924 Da), amphoteric nature, low aqueous solubility at physiological pH and tendency to self-aggregation [52][54][56][57]. Its poor permeability across biological barriers severely limits its effectiveness, as reported by López and colleagues [57] in a clinical trial (NCT01845727) using a cream containing 3% AmB (Anfoleish®). Although safe, this formulation showed low efficacy in patients with CL, which was attributed to the low transdermal permeation confirmed by the absence of AmB in patients’ plasma [57].
Thus, alternative formulations capable of promoting the topical delivery of AmB are needed. To improve the dermal penetration of drugs and topical therapy, different strategies can be used, such as passive methods (chemical permeation enhancers, for example), physical methods and nanocarriers. The nanocarriers offer a gentler alternative to facilitate drug permeation, being the least damaging one and capable of increasing the drug residence time in the skin [51]. In this sense, recent studies have investigated the use of different types of nanosystems to improve AmB skin permeation, including liposomes, lipid nanoparticles and polymeric carriers [58][59][60][61][62][63][64].

3.2. AmB Delivery: Liposomes for Topical Management of CL

Liposomes were the first lipid nanocarriers investigated and marketed to enhance drug penetration into the skin for dermatological and cosmetic applications. The skin delivery of active substances by liposomes is highly affected by their lipid constituents, particle size, surface charge and lamellarity [56]. Over the past three decades, significant progress has been achieved in the design of more deformable vesicles, in particular niosomes, transfersomes and ethosomes, allowing delivery of drugs deeper into/through the skin [46][51].
Jaafari et al. [64] have investigated liposomes loaded with AmB at different concentrations: 0.1, 0.2 and 0.4% (Lip-AmB). An in vitro permeation study using intact mice skin showed that increasing the AmB concentration in the formulation resulted in a greater amount of AmB permeating the skin. In vivo studies on BALB/c mice infected by L. major showed that the efficacy of Lip-AmB 0.4% was greater compared to the other groups (Lip-AmB 0.1 and 0.2%, empty liposomes or PBS). According to the authors, the presence of skin permeation enhancers in liposomes could contribute to these positive results: significant reduction in lesion size and almost complete elimination of parasites in the skin and spleen [64][65]. The results led to development of topical Lip-AmB (0.4%) (Sina Ampholeish®) [66].
Other interesting studies in AmB topical delivery have explored the potential of ultra-deformable liposomes (AmB-UDL), using Tween 80®, sodium cholate or sodium deoxycholate as an edge activator. Perez et al. [67] noticed that the insertion of AmB reduced vesicle deformability. This finding is in line with other reports in the literature and can be explained by the interaction of AmB with the lipids and edge activators, reducing their mobility [52][67][68][69]. As shown by the authors, the increase in AmB content, in addition to reducing the deformability, modified the absorption spectrum, suggesting AmB self-association in liposome bilayers. An interesting observation was that increasing the surfactant concentration could circumvent this event, keeping AmB in the monomeric form [67]. This probably explains the improved in vitro skin penetration of AmB from this formulation, in comparison to the AmBisome®. Carvalheiro et al. [68] conducted studies evaluating liposomes of similar composition, confirming that ultra-deformable liposomes promoted increased drug penetration into the skin. In addition, Peralta et al. [52] also showed that this type of liposome provided better drug penetration into/through human skin than conventional ones. The studies presented above showed improvement in AmB’s topical delivery. However, in vivo proof of concept was not performed. For a more complete view, studies on experimental models of CL are described below.
Fernández-García et al. [60] developed another AmB formulation in ultradeformable vesicles (AmB-TF) and evaluated in vitro the drug permeation across intact mice skin. Although there was no significant difference in permeation between the AmB-TF and AmB-DMSO solutions, the permeation flux from AmB-TF was about five times higher than that described previously for other liposomal formulations, including transferosomes loaded with AmB. The in vivo skin pharmacokinetic of AmB-TF was also assessed after topical administration in mice and showed permeation and accumulation of AmB in the dermis at therapeutic concentrations relevant for the treatment of leishmaniasis. In line with these findings, the topical application of AmB-TF in mice experimentally infected by L. amazonensis over 10 days resulted in almost complete elimination of the parasite burden in the lesion, which was similar to that observed after intralesionally administered Glucantime®. Regarding the effect on the lesion size, the efficacy of intralesional Glucantime® was greater than that of AmB-TF. However, the overall data suggested that increasing treatment time or twice-daily application of topical AmB-TF could lead to complete lesion healing.
In addition to using ultradeformable vesicles, some authors used another strategy: the drug combination. Mostafavi et al. [58] evaluated niosomes co-encapsulating AmB and Glucantime® (AmB-Glucantime® niosomes), composed by Span 40 and Tween 40, whereas Dar et al. [59] investigated ultradeformable liposomes co-loaded with AmB and miltefosine (AmB-MTF liposomes), composed by PC and Tween 80. Despite the large particle size of the niosomes co-encapsulating AmB and Glucantime® (9.5 μm), the topical treatment of BALB/c mice infected with L. major (twice daily for 30 days) promoted reduction in the lesion in comparison to placebo and intramuscular Glucantime® [59]. On the contrary, the topical treatment with AmB-MTF liposomes developed by Dar et al. [59] resulted in complete lesion resolution in mice infected with L. mexicana after twice daily treatment for 4 weeks. In agreement, the lesion parasite burden had a significant reduction for AmB-MTF liposomes when compared to the other groups—untreated, treated with plain AmB-gel or treated with ultradeformable liposome gel containing only AmB [59]. These results confirmed the benefit of drug combination due to a possible synergistic effect in CL treatment.
Although there are few clinical trials investigating AmB topical formulations, Khamesipour et al. [70] investigated the activity of liposomal AmB (0.4%) (SinaAmpholeish®) developed by Jaafari et al. [64], which had already shown safety in a Phase I clinical trial [71]. The pilot study compared three treatment groups in patients with CL caused by L. major: (i) topical liposomal AmB (0.4%) alone twice daily for 28 days; (ii) topical liposomal AmB (0.4%) in combination with daily intramuscular Glucantime®; (iii) weekly intralesional Glucantime® plus biweekly cryotherapy (the standard treatment in the Islamic Republic of Iran). Complete cure was 92%, 95% and 48.5% of patients who received combination treatment (liposomal AmB 0.4% plus Glucantime®), topical liposomal AmB only and standard treatment alone (Glucantime® plus cryotherapy), respectively.
In turn, Horev et al. [72] performed a randomized, double-blind, placebo-controlled trial to investigate the efficacy of liposomal AmB 0.4% gel in L. major-infected patients treated twice daily for 56 days. Different parameters were evaluated, such as lesion diameter, ulceration and healing. At the end of treatment, the results were similar between the liposomal AmB gel-treated and control groups. The authors suggested that a longer treatment duration may be necessary to improve efficacy because clinical improvement, including negative PCR test, was more clearly observed after 56 days rather than earlier.
In the literature there are many reports about the ideal characteristics of the liposome carrier for topical application. However, the effects of the AmB aggregation state on the skin drug penetration and the formulation efficacy are still poorly explored. AmB insertion in lipid vesicles is a complex process because it can adopt different aggregation forms, depending on the AmB concentration, vesicle composition and preparation method [73]. Additionally, the development of new skin models, providing more realistic conditions, is an important point to increase the chance of bringing topical formulations from the bench to the market [48]. In this sense, it is worth noting that all studies presented here performed skin permeation tests on intact skin. This is an important limitation because, under pathological conditions like CL, considerable skin damage usually occurs, altering skin architecture and permeability [55].

4. Oral Liposomal Formulations of AmB

The oral route is usually preferred for drug administration. Oral treatments often result in lower drug toxicity in comparison to the parenteral ones and improved patient compliance. This is especially important for neglected tropical diseases, such as leishmaniasis, which affect mainly poor people, who live in remote areas and have limited access to health centers.
However, AmB is a class IV drug, according to the BCS classification system, exhibiting low solubility in neutral pH and low membrane permeability, with expected low oral bioavailability.
Indeed, several physicochemical factors contribute to the low oral bioavailability of AmB from the existing commercial formulations, including AmBisome®. These factors comprise the high molecular weight of the AmB molecule, its low solubility in both aqueous and lipidic environments and tendency to self-associate, and its instability at the low pH found in the stomach [74].
This context has stimulated the search for strategies to improve the oral delivery of AmB, with few successful cases [34][74][75][76]. The following drug carriers have shown improvement of AmB bioavailability or efficacy by the oral route: polymeric nanoparticles [77][78], polymer lipid hybrid nanoparticles [79], solid lipid nanoparticles [80], chitosan-coated nanostructured lipid carriers [81], cubosomes [82], emulsions [83][84], cochleates [85][86][87][88] and liposomes [89].
In a recent review, Wasan et al. [75] reported currently investigated AmB formulations for the treatment of parasitic infections, with an emphasis on two oral lipid formulations that have reached clinical trials. First, a self-emulsifying lipid-based formulation (iCo-019), consisting of a mixture of mono- and di-glycerides, in addition to D-alpha-tocopheryl poly(ethylene glycol) succinate, which completed two human Phase I trials. Second, an encochleated AmB deoxycholate formulation under Phase II trials to determine its efficacy for cryptococcal meningitis. Interestingly, a low aggregation state of AmB was claimed for both types of formulations [75][86]. Moreover, the safety, tolerability and pharmacokinetics data of iCo-19 following single doses to healthy humans supported long-lasting systemic drug exposure, with no evidence of gastrointestinal, hepatic or renal toxicities associated with AmB [90]. A similar safety profile has been reported in humans for the encochleated AmB deoxycholate formulation [88]. This first set of clinical data highlights the great potential of these lipid AmB formulations for the oral treatment of leishmaniasis.
Ramos et al. [89] reported for the first time an orally active liposomal AmB formulation. The nanoformulation contained the same lipids as AmBisome®, but also included 4.7 mol% DSPE-PEG2000. Characterization of the drug aggregation state by CD suggested lower aggregation of AmB in the PEGylated formulation, when compared to AmBisome®. This feature is likely critical, as the liposomal AmB formulation seems to share the low drug aggregation state with oral AmB formulations under clinical trials. The new liposomal AmB formulation exhibited much faster drug release than AmBisome®, in agreement with the lower extent of drug aggregation. The PEGylated formulation also showed greater stability in simulated gastric fluid, when compared to the non-PEGylated formulation, regarding particle size distribution and AmB aggregation state. Importantly, the PEGylated liposomal AmB formulation exhibited therapeutic efficacy by the oral route in the murine model of CL, promoting significant inhibition in the lesion size growth and reduction in the parasite load in the lesion, when compared to the saline-treated control. This effect was achieved at a relatively low dose of AmB (5 mg/kg) given on alternate days. The reduced renal toxicity of oral treatment with PEGylated liposomal formulation was also supported by the absence of change in the plasma level of urea, in contrast to AmBisome® given parenterally at the same dosage. Considering the low aggregation state of AmB in the oral liposomal formulation and the significant drug release, one can expect an effective intestinal absorption of AmB under the free form. In this context, a sustained drug release from the liposomal formulation in the intestine may result in a long-lasting drug plasma level and may explain the reduced toxicity, as proposed previously for iCo-019 [90].
The benefit of liposome PEGylation for oral drug delivery is consistent with previous reports in the literature for other drugs, including peptides, proteins and lipophilic substances [91]. The oral efficacy of PEGylated liposomal AmB formulation may be attributed to several factors, including: (i) the prevention of liposome aggregation in an acidic environment, (ii) the protection of liposomes from the action of bile, (iii) the protection of AmB from acidic degradation, and (iv) the low state of AmB aggregation, leading to more effective intestinal drug absorption. Further studies are needed to identify the factors that most contribute to improved oral drug efficacy and further optimize liposomal formulations for the delivery of AmB by the oral route.

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Frédéric Frézard
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Lucas A. M. Ferreira
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Guilherme S. Ramos
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Thais T. Santos
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Gabriel S. M. Borges
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Virgínia M. R. Vallejos
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Helane L. O. De Morais
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