PfK13-associated Artemisinin Resistance Slows Drug Activation and Enhances Antioxidant Defence, Which Can Be Overcome with Sulforaphane

Artemisinin resistance is globally prevalent, including in Africa, raising concerns and highlighting the need to better understand the cellular mechanisms behind this resistance. In Plasmodium falciparum , artemisinin resistance is primarily attributed to mutations in the PfKelch13 (PfK13) gene. In this study, we performed proteomic analysis on a range of sensitive and artemisinin-resistant parasites (both laboratory-generated and field isolates), revealing specific dysregulation of PfK13 protein abundance. Reduced PfK13 levels were linked to impaired hemoglobin digestion, decreased free heme levels, and consequently, decreased artemisinin activation. Artemisinin resistant parasites also exhibited elevated thiol levels, indicating a more reduced cellular state. Targeting the parasite redox capacity with sulforaphane potentiated artemisinin activity in vitro and in an in vivo rodent Plasmodium berghei model, offering a potential strategy to overcome resistance. Our findings provide critical insights into the molecular mechanisms of artemisinin resistance and suggest novel therapeutic interventions to restore drug sensitivity. One Sentence Summary: PfK13 mutations drive artemisinin resistance in Plasmodium parasites by enhancing antioxidant defences, which can be targeted by redox modulators such as sulforaphane. ### Competing Interest Statement The authors have declared no competing interest. National Health and Medical Research Council, https://ror.org/011kf5r70, APP1148700, APP1185354 Australian Research Council, https://ror.org/05mmh0f86, FT220100564