Synergistic antimalarial activity of pyrimethamine and sulfadoxine against Plasmodium falciparum in vitro.

Two strains of Plasmodium falciparum were tested in vitro for sensitivity to the dihydrofolate reductase inhibitor pyrimethamine, the p-aminobenzoic acid (PABA) analogue sulfadoxine, and combinations of both drugs. One strain was sensitive and one resistant to pyrimethamine in vitro. Parasites cultured in medium containing neither folic acid nor PABA were inhibited by 10(-6) M sulfadoxine, a concentration well below that achievable after therapeutic dosage. Folic acid added to this medium at a physiological concentration of 0.01 mg/liter caused a 1,000-fold reduction in sulfadoxine activity; a 100-fold higher concentration of folic acid caused a 10-fold reduction in pyrimethamine activity. Sulfadoxine in a concentration of 10(-7) M was able to potentiate pyrimethamine activity in PABA-free medium with no added folic acid or with 0.01 mg folic acid/liter. These data indicate that P. falciparum can utilize exogenous folic acid, and suggest that sulfadoxine may potentiate pyrimethamine activity by simultaneous inhibition of dihydrofolate reductase.