Developmental Toxicity Study for the Antimalarial Drug Combination Cabamiquine‐Pyronaridine Using a Translational Approach

BACKGROUND: The safety of pharmacological treatments during pregnancy is a significant concern, as many medications lack comprehensive reproductive safety data. This creates gaps in therapeutic options for pregnant women, particularly malaria, which poses serious risks to maternal and fetal health. Additionally, there is an urgent need to develop combination therapies for which reproductive safety data are currently unavailable, further complicating treatment options for this vulnerable population. The combination of cabamiquine and pyronaridine emerges as a promising solution; however, since no reproductive safety data exist for this combination, comprehensive evaluations are essential to ensure maternal and fetal well-being. MATERIALS AND METHODS: The cabamiquine-pyronaridine combination was evaluated using an in vivo embryo-fetal development (EFD) toxicity study in rats and a Zebrafish Embryo Developmental Toxicity Assay (ZEDTA), following regulatory frameworks. Zebrafish developmental toxicity data were further integrated using pharmacokinetic and toxicokinetic modeling to assess safety margins and predict potential toxicity at anticipated clinical study doses and exposures. RESULTS: Combined administration of cabamiquine and pyronaridine showed no significant impact on prenatal outcomes. Both compounds exhibited dose-proportional increases in maternal systemic exposure, with no fetal mortality or adverse findings. No adverse effects on embryo-fetal development were observed at the previously defined monotherapy NOAEL doses, indicating the absence of adverse drug-drug interactions. Safety assessments at higher doses in the ZEDTA revealed no toxicity effects at ongoing clinical study doses. Pharmacokinetics and toxicokinetics modeling do not suggest the potential of cabamiquine and pyronaridine to cause toxicity at the forecast clinical study doses and anticipated exposures. DISCUSSION: The combined findings from the rat EFD study, ZEDTA, and model-based pharmacokinetic and toxicokinetic analyses consistently demonstrated the absence of developmental toxicity and adverse drug-drug interactions across multiple complementary approaches. These data provide confidence that the combination is unlikely to pose developmental safety concerns at clinically relevant exposures. CONCLUSION: These findings support the clinical development of the cabamiquine-pyronaridine combination for women of childbearing potential and provide a foundation for future clinical evaluation during pregnancy.