Viruses Obligate intracellular parasites Replication depends primarily on synthetic processes of the host cell

Viral Replication Steps 1. 2. 3. 4. 5. 6. 7. 8. Attachment of the virus to the host cell Entry of the virus through the host cell membrane Uncoating of viral nucleic acid Synthesis of early regulatory proteins Synthesis of RNA or DNA Synthesis of late, structural proteins Assembly (maturation) of viral particles Release from the cell

Antiviral agents can potentially target any of these steps

ANTIVIRAL AGENTS

ANTIVIRAL AGENTS Progress in antiviral chemotherapy began in the early 1950s, when the search for anticancer drugs generated several new compounds capable of inhibiting viral DNA synthesis. First-generation antiviral agents: (poor specificity that rendered them too toxic for systemic use, but effective when used topically for treatment of herpes keratitis) o 5-iododeoxyuridine o Trifluorothymidine To be EFFECTIVE, antiviral agents must: o block viral entry/exit from the host cell o be active inside host cell To be IDEAL, antiviral agents must be: o selective (no damage to host cell) o reduce symptom w/o affecting immune response NEED for agents vs. viruses o o o Vaccine not available Multiple serotypes ( e.g. rhinoviruses) Constantly changing (e.g. influenza, HIV)

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SY 2011-2012

Subject: Pharmacology Topic: Antiviral Agents Lecturer: Dr. Deo Panganiban Date of Lecture: Sept 16, 2011 Transcriptionists: Neneng Balentong Pages: 14

Possible Site/s of Antiviral Action o Attachment to host cells (gamma globulin) Uncoating (Amantadine) Synthesis of viral mRNA (Interferons) Translation of mRNA (Interferons) Replication of viral RNA or DNA (Nucleoside Analogues) Maturation of new virus proteins (Protease Inhibitors) Release

o o o o

o Major Sites of Antiviral drug action:

Note: Interferon-alfa are speculated to have multiple sites of action Pathogenic Viruses o DNA Viruses- poxvirus, herpes virus, adenovirus, papilloma virus *enter host cell nucleus and direct the generation of new viruses o RNA Viruses- orthomyxovirus, rubella, rhabdovirus, picornavirus, retrovirus, arenavirus, hepadnavirus, arbovirus *does not involve host cell nucleus o RNA Retroviruses: AIDS virus T-cell leukemia virus

*contain an enzyme, reverse transcriptase, which makes a DNA copy of the viral RNA. This DNA copy is integrated into the host cell genome and directs the generation of new virus particles.

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GENERAL ACTIONS OF ANTIVIRAL DRUGS

A. Inhibition of transcription of the viral genome 1. DNA polymerase inhibitors * Acyclovir, Valacyclovir, Famciclovir 2. Antiretroviral agents *NRTI- AZT (NRTI= Nucleoside Reverse Transcriptase Inhibitor; AZT= Zidovudine) *NNRTI-Nevirapine (NNRTI=Nonnucleoside Reverse Transcriptase Inhibitor) B. Inhibition of post-translational events 1. Protease Inhibitors *Saquinavir C. Inhibition of attachment to or penetration of host cells *Amantadine D. Immunomodulators 1. Interferons

Viruses responsive to Antiviral Agents Herpes simplex - Acyclovir Varicella-Zoster - Acyclovir Cytomegalovirus - Gancyclovir, Foscarnet AIDS - AZT, 3TC, Protease inhibitors combination (AZT= Zidovudine; 3TC= Lamivudine) Respiratory Syncythial Virus - Ribavirin Influenza Amantadine

NUCLEOSIDE ANALOGS Nucleoside Analogs Synthetic compounds that resemble nucleosides but have an incomplete or abnormal deoxyribose/ribose group Phosphorylated to the tri-phosphate form within the infected cells---compete with normal nucleotides for incorporation into viral DNA or RNA >>>irreversible inhibition of viral polymerase and chain termination

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Chemical structures of some antiviral nucleoside and nucleotide analogs

AGENTS AGAINST HSV & VZV 3 Oral nucleoside analogs for treatment of HSV (Herpes simplex virus) and VZV (Varicella-zoster virus) infections: o o o Acyclovir Valacyclovir Famciclovir

They have similar mechanism of action and similar indications for clinical use All are well tolerated

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ACYCLOVIR Acyclic guanosine derivative High specificity for herpes simplex virus (HSV-1 and HSV-2) and varicella-zoster viruses

Acyclovir requires three phosphorylation steps for activation. 1. It is converted first to the monophosphate derivative by the virus-specified thymidine kinase 2. Then it is converted to di- and triphosphate compounds by host cell enzymes (Cellular GMP kinase and Cellular phosphatase)

Mechanism of Action of Anti-herpes agents

Acyclovir requires viral kinase for initial phosphorylation. It is selectively activated, and the active metabolite accumulates, only in the infected cell. Acyclovir triphosphate inhibits viral DNA synthesis by two mechanisms: a.) competition with deoxyGTP for the viral DNA polymerase, resulting in binding to the DNA template as an irreversible complex; and b.) chain termination following incorporation into the viral DNA. Resistance in HSV Absence or partial production of viral thymidine kinase Altered thymidine kinase substrate specificity Altered viral DNA polymerase Clinically resistant infections have been reported in immunocompromised hosts

Pharmacokinetics Oral, intravenous, topical administration

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Oral bioavailability- 20-30%, unaffected by food Well distributed; CSF concentration is 50% of serum level Half- life: 3-4 hrs - normal renal function 20 hrs - anuric patients

Excreted primarily by glomerular filtration and tubular secretion

Adverse Effects Generally well tolerated Principal dose-limiting toxicities: renal insufficiency IV infusion: o o Reversible renal dysfunction (d/t crystalline nephropathy) Rare CNS side effects (tremors, delirium, seizures) Uncommon with adequate hydration and avoidance of rapid transfusion

ANTIRETROVIRALS A. Nucleoside and Nucleotide Reverse Transcriptase Inhibitors (NRTIs) MOA: Competitive inhibition of HIV-1 reverse transcriptase (RNA-dependent DNA polymerase) Incorporated into growing viral DNA chain to cause termination

Each requires intracytoplasmic activation via phosphorylation by cellular enzymes to the triphosphate form. Most have activity against HIV-2 as well as HIV-1. May be associated with mitochondrial toxicity o probably due to inhibition of mitochondrial DNA polymerase gamma resulting to: increased risk of lactic acidosis with hepatic steatosis may be fatal disorders of lipid metabolism NRTI treatment should be suspended in the setting of: o rapidly rising aminotransferase levels o progressive hepatomegaly o metabolic acidosis of unknown cause

Chemical structures of some antiviral nucleoside and nucleotide analogs : Anti- HIV NRTI agents

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Life Cycle of HIV

Binding of viral glycoproteins to host CD4 and chemokine receptors precedes fusion and entry into the cell. After uncoating, reverse transcription copies the single-stranded HIV RNA genome into double-stranded DNA, which is integrated into the host cell genome. Gene transcription by host cell enzymes produces mRNA, which is translated into proteins that assemble into immature noninfectious virions that bud from the host cell membrane. Maturation into fully infectious virions is through proteolytic cleavage. ZIDOVUDINE (AZT) a.k.a Azidothymidine Analogue of deoxythymidine First antiretroviral agent to be approved Well studied

Pharmacokinetics Well absorbed from the gut Distributed to most body tissues and fluids (including CSF, where drug levels are 60-65% of those in serum) Average serum half-life= 1 hr Intracellular half-life of the phosphorylated compound= 3-7 hours Eliminated by renal excretion following glucoronidation in the liver Metabolized to inactive glucuronide 20% active form excreted in the urine Clearance is reduced by 50% in uremic patients, and toxicity may increase in patients with advanced hepatic insufficiency

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Adverse Effects Most common: myelosuppression resulting in macrocytic anemia (1-4%) or neutropenia (2-8%) GIT intolerance headache insomnia thrombocytopenia hyperpigmentation of nails myopathy Less frequent Occur but resolve on therapy

Resistance High level zidovudine resistance is generally seen in strains with three or more of the five most common mutations: o M41L o D67N o K70R o T215F o K219Q

Drug Interactions Increased AZT with concomitant use of: Probenecid Phenytoin Fluconazole Valproic acid Lamivudine * inhibition of first-pass metabolism *decreased clearance AZT may decrease phenytoin levels. Hematologic toxicity may be increased when given with other myelosuppressants like ganciclovir and cytotoxic agents

B. Non- Nucleoside Reverse Transcriptase Inhibitors (NNRTIs) MOA: Binds directly to the enzymes (HIV-1 reverse transcriptase) active site blocking RNA- and DNAdependent DNA polymerase activity Unlike NRTI agents, NNRTIs neither compete with nucleoside triphosphates nor require phosphorylation to be active

Resistance: Occurs rapidly with monotherapy and can be due to single mutation. K103N Confer resistance across the entire class Y181C of NNRTIs

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NEVIRAPINE >90% bioavailability Not food-dependent Highly lipophilic

Pharmacokinetics 60% protein-bound Serum half-life: 25-30 hours Extensively metabolized by CP450 (according to doc Deos lecture), but CYP3A (according to the book) isoform to hydroxylated metabolites and then excreted. Excreted mainly in the urine

Adverse Effects Severe, life threatening skin rashes o o Stevens-Johnson toxic epidermal necrolysis

Hepatotoxicity o occur more frequently in those with higher pre- therapy CD4 cell counts, in women, and in patients with Hepatitis B or C co-infection

Fulminant hepatitis- rare Fever, nausea, headache, somnolence

Drug Interactions According to doc Deos lecture: *hepatic induction of Nevirapine may decrease level of saquinavir, ritonavir, oral contraceptives, and itself RMP may decrease level of Nevirapine *hepatic enzyme inhibition- cimetidine, macrolides may increase level of Nevirapine From Katzung: Moderate inducer of CYP3A metabolism, resulting in decreased levels of: o Amprenavir o Indinavir o Lopinavir o Saquinavir o Efavirenz o Methadone Decrase levels of Nevirapine- drugs that induce the CYP3A system o Tipranavir o Rifampin o Rifabutin o St. Johns wort Increase levels of Nevirapine- drugs that inhibit CYP3A activity o Fluconazole o Clarithromycin o Ketoconazole

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C. Protease Inhibitors Protease- responsible for cleaving Gag and Gag-Pol gene products to produce final structural proteins of the mature virion core. MOA: Inhibit cleavage of the translated protein (Gag and Gag-Pol polyproteins) into functional and structural proteins production of immature and non-infectious viral particles block viral maturation therefore active in both acutely and chronically infected cells

1. SAQUINAVIR Hard gel capsule (original formulation), has poor bioavailability (4%), and should be taken within 2 hrs after a fatty meal (better absorbed) Soft gel capsule (newer formulation) 3x better absorption, increased when taken with food Pharmacokinetics 98% protein-bound large volume of distribution CSF penetration is negligible Elimination half-life: 12 hours extensive first-pass metabolism excreted mainly in the feces

Drug Interaction Saquinavir increased by ritonavir (combination leads to higher and more efficacious levels of Saquinavir) Ketoconazole, clarithromycin, grapefruit juice may also increase Saquinavir level ***A decreased dose of saquinavir is recommended when co-administered with nelfinavir. Increased saquinavir levels when co-administered with omeprazole necessitate close monitoring for toxicities. Digoxin levels may increase if co-administered with saquinavir and should therefore be monitored. Liver function tests should be monitored if saquinavir is co-administered with delavirdine or rifampin. There is no evidence of human teratogenicity from saquinavir; there is short-term safety data. Rifampicin, phenobarbital, phenytoin, dexamethasone, and carbamazepine may decrease levels of Saquinavir

Adverse Effects GIT discomfort o Nausea o Diarrhea o Abdominal discomfort o Dyspepsia Rhinitis

More common with Saquinavir-S (soft-gel)

2. RITONAVIR Inhibitor of HIV-1 and HIV-2 proteases

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Pharmacokinetics High bioavailability (75%), increased when given with food Metabolism to an active metabolite occurs via CYP3A and CYP2D6 isoforms Use with caution in patients with impaired hepatic function Excreted mainly in the feces

Adverse Effects GIT disturbances Paresthesias (circumoral and peripheral) elevated serum aminotransferase levels altered taste hypertriglyceridemia nausea Occur during first few weeks of therapy vomiting abdominal pain

Slow dose escalation is recommended to decrease the dose-limiting side effects Drug Interaction Potent inhibitor of CYP3A Therapeutic levels of digoxin and theophylline should be monitored when co-administered with Ritonavir because it can increase their concentrations ENTRY INHIBITORS Fusion inhibitors that blocks the entry into the cell, they are a new class of antiretroviral agents. ENFUVIRTIDE (formerly called T-20) o o Synthetic 36-amino-acid peptide Binds to the gp41 subunit of the viral envelope glycoprotein, preventing the conformational changes required for the fusion of the viral and cellular membranes Administered subcutaneously

MARAVIROC VICRIVIROC INTEGRASE INHIBITOR

RALTEGRAVIR ELVITEGRAVIR
NOTE: Combination of multiple agents is recommended for HIV-infected individuals to: - increase potency - delay emergence of resistance o o o ELVUCITABINE (NRTI) VICRIVIROC (ENTRY INHIBITOR) ELVITEGRAVIR (INTEGRASE INHIBITOR)

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ANTICYTOMEGALOVIRUS CMV infections occur primarily in the setting of advanced immunosupression and are typically due to reactivation of latent infection. GANCICLOVIR VALGANCICLOVIR FOSCARNET CIDOFOVIR

ANTIHEPATITIS ANTIHEPATITIS B o o Interferon alfa-2b Pegylated Interferon alfa-2b

ANTIHEPATITIS

ANTIHEPATITIS C o o o o Interferon alfa-2b Pegylated Interferon alfa-2a Pegylated Interferon alfa-2b Interferon alfacon-1

INTERFERONS Function: -enhance specific T-cell mediated immune response Direct antiviral effect: o o o degradation of viral mRNA inhibition of protein synthesis prevents infection of new cells ANTI- INFLUENZA AGENTS

ANTI-INFLUENZA AGENTS AMANTADINE RIMANTADINE OSELTAMIVIR ZANAMIVIR

Amantadine HCl Targets early stages of viral infection Approved by FDA in 1976 to treat influenza A (not influenza B)

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MOA: Inhibits the un-coating of the viral genome Specifically targets a protein called M2 (an ion channel) Inactive against influenza B, which lacks M2

Pharmacokinetics Well absorbed orally; crosses BBB 90% excreted unchanged ; no reports of metabolic products

Adverse effects Low toxicity at therapeutic levels some GIT (nausea/vomiting) CNS side effect (nervousness, light headedness, scary hallucinations)

Rimantadine HCl Approved by FDA in 1994 to treat influenza A (not influenza B)

Mechanism / Pharmacokinetics Similar to amantadine (same target: M2 ion channel protein)

Adverse effects Fewer CNS effects than amantadine (i.e., better hallucinations) IMMUNOGLOBULIN THERAPY

Immunoglobulin Therapy Normal Immune globulin: o Pooled product from serum of normal donors; contain low titers of antibody to a wide range of human viruses

Prophylaxis vs: o o o Hepatitis A Parvovirus Enterovirus (neonates)

Hyper-immune globulin serum of selected individuals with high titers of antibody to a particular disease

Examples: o o o Zoster immune globulin Human Rabies Immunoglobulin Hepatitis B Immune globulin

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VIRAL VACCINES VIRAL VACCINES Vaccination- most cost-effective method of prevention of serious viral infections a. killed-virus vaccine(Influenza, Rabies) b. attenuated live-virus vaccine(MMR) FUTURE?? GENETIC MANIPULATION

----------------------------------------------------------- End Of Transcription --------------------------------------------------------This tranx is based on Doc Deos ppt, lecture and some notes from the book. Remember that transcriptions are not a substitute to your books. Please read Katzung, kasi maraming hindi nadiscuss si Doc Deo na nasa book and minsan contradicting ung sinasabi nya sa discussion sa book. Happy Aral Batch 2014!!

The beginning of wisdom is to work to acquire it. At the cost of all you possess, strive to gain insight. -Proverbs 4:7

Nothing splendid has ever been achieved except by those who dare to believe that something inside them was superior to circumstance.

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