Activity of a combination of three cinchona bark alkaloids against Plasmodium falciparum in vitro

In vitro studies with quinine, quinidine, cinchonine, and cinchonidine showed that despite a similarity of chemical structure, the effectiveness of these cinchona bark alkaloids against several culture lines of Plasmodium falciparum varied widely. Depending on the strain tested, quinidine and cinchonine were 1 to 10 and 1 to 5 times, respectively, more active than quinine. A combination made of equal parts of quinine, quinidine, and cinchonine was found to have several interesting features; it had activity similar to that of quinine against quinine-susceptible strains but was found to be 2 to 10 times more effective against strains resistant to quinine and had a more consistent effect than any of the alkaloids used singly. The potentiation was found to depend mainly on the presence of cinchonine in the mixtures studied. Synergism was also confirmed in a study of 25 P. falciparum strains isolated from Thai patients. Combinations of cinchona bark alkaloids could thus be of interest in areas where P. falciparum is becoming less susceptible to quinine.