Collateral hypersensitivity between ZY19489 and piperaquine neutralizes PfCRT-mediated drug efflux and Plasmodium falciparum resistance

Collateral hypersensitivity between ZY19489 and piperaquine neutralizes PfCRT-mediated drug efflux and Plasmodium falciparum resistance | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Collateral hypersensitivity between ZY19489 and piperaquine neutralizes PfCRT-mediated drug efflux and Plasmodium falciparum resistance David Fidock, John Okombo, Tolla Ndiaye, Tarrick Qahash, Igor Moura, and 24 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7697517/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted You are reading this latest preprint version Abstract New antimalarial drugs are essential to combat the current emergence and spread of Plasmodium falciparum parasite resistance to first-line artemisinin-based combination therapies. Here, we identify a mechanism of parasite resistance to ZY19489, a triaminopyrimidine currently in a Phase IIb clinical trial. Low-grade resistance was mediated by a novel mutation in the P. falciparum chloroquine resistance transporter PfCRT, which caused a major reduction in asexual blood stage parasite growth rates and a substantial fitness cost. Parasites resistant to ZY19489 lost their chloroquine resistance status and became hypersusceptible to the artemisinin-based combination partner drug piperaquine. All three agents were shown to interfere with parasite-mediated catabolism of host hemoglobin. Uptake studies in PfCRT-containing proteoliposomes provide evidence that ZY19489 can block mutant PfCRT-mediated efflux of piperaquine and chloroquine, creating a scenario of an evolutionary trap whereby resistance to ZY19489 blocks PfCRT efflux-mediated resistance and restores susceptibility to piperaquine and chloroquine. Metabolomic studies revealed that ZY19489 significantly reduces intracellular levels of short hemoglobin-derived peptides (a natural substrate of PfCRT) and leads to higher accumulation of pyrimidine deoxynucleotides. Our data present a marker for tracking the evolution of clinical resistance to ZY19489 and a rationale for pairing this with piperaquine to generate a novel resistance-refractory combination. Biological sciences/Microbiology/Parasitology/Parasite biology Biological sciences/Chemical biology/Mechanism of action Full Text Additional Declarations There is NO Competing Interest. Supplementary Files OkomboZY19489SupplementaryMaterial.docx Supplementary Figures and Tables Cite Share Download PDF Status: Under Review Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7697517","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":526461761,"identity":"63a51331-1579-4d0f-97a2-5a34b640b377","order_by":0,"name":"David 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PfCRT-mediated drug efflux and Plasmodium falciparum resistance","fulltext":[],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":true,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":true,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"nature-portfolio","isNatureJournal":true,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"","title":"Nature Portfolio","twitterHandle":"","acdcEnabled":false,"dfaEnabled":false,"editorialSystem":"ejp","reportingPortfolio":"","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7697517/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7697517/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"New antimalarial drugs are essential to combat the current emergence and spread of Plasmodium falciparum parasite resistance to first-line artemisinin-based combination therapies. Here, we identify a mechanism of parasite resistance to ZY19489, a triaminopyrimidine currently in a Phase IIb clinical trial. Low-grade resistance was mediated by a novel mutation in the P. falciparum chloroquine resistance transporter PfCRT, which caused a major reduction in asexual blood stage parasite growth rates and a substantial fitness cost. Parasites resistant to ZY19489 lost their chloroquine resistance status and became hypersusceptible to the artemisinin-based combination partner drug piperaquine. All three agents were shown to interfere with parasite-mediated catabolism of host hemoglobin. Uptake studies in PfCRT-containing proteoliposomes provide evidence that ZY19489 can block mutant PfCRT-mediated efflux of piperaquine and chloroquine, creating a scenario of an evolutionary trap whereby resistance to ZY19489 blocks PfCRT efflux-mediated resistance and restores susceptibility to piperaquine and chloroquine. Metabolomic studies revealed that ZY19489 significantly reduces intracellular levels of short hemoglobin-derived peptides (a natural substrate of PfCRT) and leads to higher accumulation of pyrimidine deoxynucleotides. Our data present a marker for tracking the evolution of clinical resistance to ZY19489 and a rationale for pairing this with piperaquine to generate a novel resistance-refractory combination.","manuscriptTitle":"Collateral hypersensitivity between ZY19489 and piperaquine neutralizes PfCRT-mediated drug efflux and Plasmodium falciparum resistance","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-09 02:50:42","doi":"10.21203/rs.3.rs-7697517/v1","editorialEvents":[],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"nature-communications","isNatureJournal":true,"hasQc":false,"allowDirectSubmit":false,"externalIdentity":"NCOMMS","sideBox":"Learn more about [Nature Communications](http://www.nature.com/ncomms/)","snPcode":"","submissionUrl":"https://mts-ncomms.nature.com/","title":"Nature Communications","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"ejp","reportingPortfolio":"Nature Communications","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"eb070d48-8d6b-448e-a878-614dbda6fdb6","owner":[],"postedDate":"October 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":55955574,"name":"Biological sciences/Microbiology/Parasitology/Parasite biology"},{"id":55955575,"name":"Biological sciences/Chemical biology/Mechanism of action"}],"tags":[],"updatedAt":"2026-03-03T12:42:40+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-09 02:50:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7697517","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7697517","identity":"rs-7697517","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}