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Falciparum malaria is a major parasitic disease causing widespread morbidity and mortality globally. Artemisinin derivatives---the most effective and widely-used antimalarials that have helped reduce the burden of malaria by 60% in some areas over the past decade---have recently been found to induce growth retardation of blood-stage Plasmodium falciparum when applied at clinically relevant concentrations. To date, no model has been designed to quantify the growth retardation effect and to predict the influence of this property on in vivo parasite killing. Here we introduce a mechanistic model of parasite growth from the ring to trophozoite stage of the parasite's life cycle, and by modelling the level of staining with an RNA-binding dye, we demonstrate that the model is able to reproduce fluorescence distribution data from in vitro experiments using the laboratory 3D7 strain. We quantify the dependence of growth retardation on drug concentration and demonstrate the model's utility as a platform to propose experimentally-testable mechanisms of growth retardation. Furthermore we illustrate that a drug-induced delay in growth may significantly influence in vivo parasite dynamics, demonstrating the importance of considering growth retardation in the design of optimal artemisinin-based dosing regimens., Comment: 44 pages, 20 figures (including 8 supplementary figures), 8 tables (including 6 supplementary tables)

Artemisinin resistance constitutes a major threat to the continued success of control programs for malaria. With alternative antimalarial drugs not yet available, improving our understanding of how artemisinin-based drugs act and how resistance manifests is essential to enable optimisation of dosing regimens in order to prolong the lifespan of current first-line treatment options. Here, through introduction of a novel model of the dynamics of the parasites' response to drug, we explore how artemisinin-based therapies may be adjusted to maintain efficacy and how artemisinin resistance may manifest and be overcome. We introduce a dynamic mathematical model, extending on the traditional pharmacokinetic-pharmacodynamic framework, to capture the time-dependent development of a stress response in parasites. We fit the model to in vitro data and establish that the parasites' stress response explains the recently identified complex interplay between drug concentration, exposure time and parasite viability. Our model demonstrates that the previously reported hypersensitivity of early ring stage parasites of the 3D7 strain to dihydroartemisinin (DHA) is primarily due to the rapid development of stress, rather than any change in the maximum achievable killing rate. Of direct clinical relevance, we demonstrate that the complex temporal features of artemisinin action observed in vitro have a significant impact on predictions of in vivo parasite clearance using PK-PD models. Given the important role that such models play in the design and evaluation of clinical trials for alternative drug dosing regimens, our model contributes an enhanced predictive platform for the continued efforts to minimise the burden of malaria., Comment: 24 Pages, 9 figures, 2 tables