Antiviral Drugs

 Antiviral agents are drugs that treat or control virus infections. Unlike antibacterial drugs, which may cover a wide range of pathogens, antiviral agents tend to be narrow in spectrum, and have limited efficacy. As a class, the antiviral drugs are not curative, and must be used either prophylactically or early in the development of an infection

Strateges for Antiviral Therapy Any stage of viral replication can be a target for antiviral drugs. The only requirements are:
The stage targeted is essential for virus replication. The therapeutic agent is active against the virus while having "acceptable toxicity" to the host organism.
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Stages in Virus Replication: Possible Targets for Chemotherapeutic Agents Adsorption Entry Uncoating Transcription Translation Assembly Release
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Classification of Antivirals

Anti-virals effective against influenza virus Antivirals effective against herpes virus Broad spectrum anti-viral agents Anti-virals effective against HIV virus

1. Antiviral Agents Effective Against

Influenza Viruses
A) Agents Effective Against Influenza Virus Type A Adamantane Derivatives
i. Amantadine HCl (Adamine) ii. Rimantadine HCl (Flumadine)
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NH2.HCl

H3C

NH2 .HCl

1-Adamantanamine Hydrochloride

E-Methyl-1-adamantanemethylamine hydrochloride

Mechanism of Action
The two drugs inhibit the early stages of viral replication i.e. blocking virus particle

penetration, and uncoating of the viral genome and the transfer of nucleic acid into the host cells.

 The clinical usefulness of amantadine and rimantadine is limited to the prevention and treatment of influenza A virus infections. Amantadine is excreted by the kidneys unchanged via glomerular filtration and tubular secretion while

rimantadine is metabolized by the liver (75%) and is also excreted by the kidneys. Rimantadine also has a longer duration of action and a lesser CNS side effects.
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B) Agents Effective against Virus Influenza Types A and B

Neuraminidase Inhibitors (Sialic Acid Analogs)
Zanamivir and Oseltamivir

HO HO H3CCONH HN

OH H O COOH

O
3 4 5

COOC 2H 5

HN
NH2

N H

NH 2 . H 3PO 4
Oseltamivir
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Zanamivir

Mechanism of Action Influenza viruses are surrounded by a protein coat and a lipid envelope. Embedded in the lipid membrane there are two surface glycoproteins: Hemaglutinin (HA) is an enzyme important for binding viruses to target cell receptors having a terminal sialic acid residues.

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Neuraminidase (NA) an enzyme involved in various activation of influenza viruses. NA is found in both influenza A and B and is thought to be involved in catalytically cleaving glycosidic bonds between terminal sialic acid residues of the receptors on the host cell membranes and an adjacent sugar moieties of viral HAs. The cleavage of sialic acid bonds facilitates the spread of viruses and as a result increases the infectiveness or pathogencity of the virus. NA also play a role in preventing viral inactivation by respiratory mucus. NA-inhibitors interfere with the spread of the infection by blocking the cleavage of glycosidic bonds between sialic acids and HAs.
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 The

neuraminidase

inhibitors,

zanamivir

and

oseltamivir, are chemically related drugs that have activity against both influenza A and B viruses. Zanamivir is an orally inhaled powdered drug that is approved for treatment of influenza infections. It can also be given via intraperitoneal or IV routes but it is inactive when given orally.

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 Oseltamivir is an ethyl ester prodrug requiring ester hydrolysis for conversion to the active form, oseltamivir carboxylate. Oseltamivir is an orally administered capsule or oral suspension that is approved for treatment of influenza A and B viruses. It is also approved for chemoprophylaxis of influenza A and B nfections.

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2. Antiviral Agents Effective Against Herpes

Viruses The family of herpes viruses (herpesviridae) includes:
Herpes simplex types 1 and 2 (HSV-1, HSV-2), Varicella Zoster virus (VZV), Epstein Bar virus (EBV) and Cytomegalovirus virus (CMV).
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Agents Effective Against HSV1 and 2, VZV and EBV Drugs in this class are Nucleoside analogues with a sugar modification. They resemble natural nucleotides, but have an incomplete ribose group. They act as DNA polymerase inhibitors.

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I. Acyclovir and Valacyclovir

Acyclovir has a nucleoside like structure and contains the same nucleic acid base as 2-deoxyguanosine, but lacks the complete sugar ring. In virally infected cells, it is phosphorylated in three stages to form a triphosphate which is the active agent, and so acyclovir it self is a prodrug. It is used for the treatment and suppression of genital herpes infection.
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Mechanism of Action
They are phosphorylated to the monophosphate by viral thymidine kinase and then to the di- then tri-phosphate by a host cell thymidylate kinases. Acyclovir triphosphate prevents DNA replication in two ways: First, by competitive inhibition of viral DNA Polymerase. Second, DNA polymerase can catalyse the attachment of the acyclovir nucleotide to the growing DNA chain. Such incorporation will lead to the termination of the growing viral DNA chain. Chain termination occurs because the drug triphosphate lacks the 3-hydroxy group of cyclic sugar.
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Selectivity of Action
What is to stop acyclovir triphosphate from inhibiting DNApolymerase in normal, uninfected cells?
The answer lies in the fact that acyclovir is only converted to the active triphosphate in virally infected cells. Because, o Viral thymidine kinase phosphorylates the drug over 100 times faster than host cells thymidine kinases (differential toxicity). o There is a selective uptake of acyclovir by infected cells. o In addition, acyclovir triphosphate competitively inhibits viral DNA
polymerases (~ 50 fold selective action), and to a much smaller extent of cellular DNA polymerases.
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 The oral bioavailability of acyclovir is quite low ( 15-30 %) and to overcome this, various prodrugs were developed to decrease water solubility. Valacyclovir is a l-valine ester of acyclovir that is well absorbed. Its bioavailability is 2-5% greater than acyclovir. So low dose is possible at less frequent intervals.  Desciclovir (6-deoxyacyclovir) is a prodrug of acyclovir which lacks the carbonyl group at position 6 of the purine ring and is more water soluble. Metabolism by cellular xanthine oxidase oxidizes desciclovir at the 6-position to give acyclovir.
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iii. Famiciclovir (Famvir)

O HN H2N CH3-CO-O CH3-CO-O N N N 1. Esterase 2. Oxidase H2N HO HO HN N O N N

Famciclovir

Panciclovir
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 Famiciclovir is the prodrug of penciclovir which is the active form and a guanosine analogue. It has a very high bioavailability of 77%. It is converted into penciclovir by a two step process. The first step occurs in the gut and the second step in the liver It acts as an inhibitor of viral DNA polymerase and also as a chain terminator.
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Other Drugs Used as Topical Applications for Herpes

Tifluridine ( 2'-deoxy-5-(trifluoromethyl) uridine ) and Idoxuridine ( 2'-deoxy-5-iodouridine ) These are pyrimidine analogs with base modification They are phosphorylated equally well by viral and cellular thymidine kinase, and so there is less selectivity for virally infected cells. These drugs have more toxic side effects. As a result, they are only suitable for topical use.
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O HN O O HO HO N R

Trifluridine Idoxuridine

(R = CF3) (R = I)

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B) Agents Effective Against Cytomegalovirus (CMV)

Ganciclovir Ganciclovir is a deoxyguanosine analog that differs from acyclovir in having an additional hydroxy methyl group on the acyclic side chain. It is the preferred drug for treating (CMV) infections in patients with acquired immune deficiency syndrome (AIDS) or other immunodeficiencies.
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 It has very poor oral bioavailability (3 percent), and, therefore, mostly given intravenously.

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Mechanism of Action It is an acyclic guanine nucleoside analogue and is activated to the nucleoside triphosphate that incorporates into new viral DNA and inhibits DNA polymerase. Thymidine kinase is deficient in CMV, this is why acyclovir has no activity against CMV.

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 CMV may phosphorylate this drug by using UL97- gene product: a different kinase. Selectivity is achieved because the viral DNA polymerase has 30 times greater affinity for ganciclovir than the host enzyme.

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ii. Foscarnet It is trisodium phosphonoformate It is the second drug used in the treatment of CMV infections, particularly CMV retinitis, in immuno- compromised patients. O
P O O
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3 Na COO

Mechanism of action
It is an inorganic pyrophosphate analog that works by reversibly blocking the pyrophosphate binding site on viral DNA polymerase, thereby terminating chain elongation. Unlike nucleoside analogs, foscarnet does not need to be activated by cellular or viral kinases.
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Broad spectrum Anriviral agent

1. Interferons
Interferons are a family of cytokines with broad spectrum antiviral and potential anticancer activity. There are three main types of interferons, alpha, beta, and gamma interferons which differ both structurally and antigenically. Interferon consists of small proteins with molecular weights ranging from 20,000 to 160,000. They are released from eukaryotic cell types in response to virus infection, and other biological inducers.
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 The important role played by interferons as a defense mechanism is supported by three types of experimental and clinical observations:

For many viral infections, a strong correlation has been established between interferon production

and natural recovery. Inhibition of interferon production or action enhances the severity of infection. Treatment with interferon protects against infection36

Mechanism of Action of Interferon

Increased expression of Class I and Class II MHC (major histocompatibility complex) glycoproteins, thereby facilitating the recognition of viral antigens by the immune system. Immunoregulatory effects - activation of cells with the ability to destroy virus-infected targets; these include NK cells and macrophages.
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Interferon Inducers
These are chemical compounds that induce the production and release of interferon in humans. Among interferon inducers are:
Statolon A double-stranded RNA produced in Penicillium stoloniferum culture. Ampligen A polynucleotide derivative that was found to have in-vitro anti-HIV activity and acts also as immunomodulator.

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Clinical Application
Recombinant alpha and beta interferons are now available and have been used for the treatment of
Chronic hepatitis C (plus ribavirin) and chronic hepatitis B. Influenza, herpes zoster and herpes genitalis, Common cold infections and cancers such as breast cancer and lung carcinoma.
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Disadvantage of Interferon Treatment

GIT problems. CNS side effects. Hypotension, anorexia and weight loss.

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2. Ribavirin (Virazole)
Ribavirin (1 -D-Ribofuranosyl-1H-1,2,4triazole-3-carboxamide) Ribavirin is a synthetic triazole nucleoside in which both the base and the D-ribose sugar are necessary for antiviral activity

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O H2 N N N N O HO HO OH

The drug is administered as a small-particle aerosol (particle diameter, 1 to 3 m) so that it can reach the lower respiratory tract for the treatment of respiratory syncytial viruses.
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Mechanism of action
The antiviral mechanism of action of ribavirin is not fully defined but relates to the ability of cells to take up ribavirin and to form active triphosphate derivatives. Intracellular phosphorylation to the mono-, di-, and triphosphate derivatives is mediated by host cell enzymes. Ribavirin monophosphate inhibits inosine monophosphate dehydrogenase which is involved in the synthesis of guanosine monophosphate and the triphosphate is an inhibitor of viral RNA polymerase. It was the first synthetic, non-interferon inducing broad spectrum antiviral nucleoside, and can inhibit both RNA- and DNA-viruses, by a variety of mechanisms, although it is only licensed for hepatitis C and respiratory syncytial virus.
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ANTI-HIV AGENTS
Potential anti-HIV agents can be grouped into three groups based on the phase of their interference with the virus replication cycle.
Pre-transcription inhibitors are those agents capable of blocking viral entry into the host cell.
 This class includes inhibitors of gp120 binding to CD4 (viral adsorption inhibitors), inhibitors of gp120 binding to coreceptors, and inhibitors of viral fusion and viral un-coating.
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Transcription inhibitors- inhibit reverse transcriptase. Post-transcription inhibitors are

 Agents that inhibit viral DNA integration into the host cell genome (integrase inhibitors) and Agents that interfere with virus maturation by blocking the crucial step of producing viral functional proteins from the poly-protein precursor (protease inhibitors or viral maturation inhibitors).

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 Most anti-HIV drugs currently approved for clinical use fall into the categories of reverse transcriptase and protease inhibitors. The reverse transcriptase inhibitors are further subclassified into two sub-classes, the nucleoside reverse transcriptase inhibitors (NRTIs) and the non-nucleoside (NNRTIs).
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reverse

transcriptase

inhibitors

 The most challenging problem associated with HIV therapy is the development of drug resistance. The combination therapy approach has been broadly practiced in HIV treatment as a strategy to avoid such problem.

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 Current efforts to develop new anti-HIV drugs are

now directed more toward developing inhibitors for other steps in the virus life cycle, such as
 viral entry into the T-cell,  its integration with the host DNA, or  its assembly into daughter particles.

These proposed sites of intervention may provide

additional options to maintain long-term suppression of the virus replication.

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Inhibitors of Viral Entry

1. HIV Vaccines The most ideal approach to inhibit HIV binding to the T-cells is to develop a vaccine that can neutralize the virus in circulation. Several attempts to develop antibodies to HIV as blocker for the viral binding to prevent infection have been reported.
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2. Viral Adsorption Inhibitors

The recognition of the role of viral gp120 and gp41 glycoproteins in the processes of HIV binding and fusion with the T-cell surface flagged these sites as an attractive molecular target for intervention. In principle, agents affecting any of the viral entry events would be effective as inhibitors of HIV-1 replication.
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 Targets of viral entry inhibition and fusion include the process of gp120 binding to CD4 receptors and other co-receptors (CCR5, CXCR4) on the T- cell membrane.

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A. Soluble CD4 Peptide Fragments

Soluble forms of CD4 (sCD4) were isolated and evaluated for clinical efficacy to suppress HIV infection but the result was disappointing. Recent efforts to use soluble CD4 forms have focused on CD4 conjugation product of the CD4 soluble receptors with the constant regions (both heavy and light chains) of the human IgG2 was found to be more effective than the soluble CD4 alone in blocking HIV transmission in the scidhu- PBL mouse model
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B. Inhibitors of Gp120 Binding to the T-cell Co-receptors

CXCR4 and CCR5 are Gp120 Co-receptors which are found on T-cell membrane surface The most interesting member of Gp120-CXCR4 Binding Inhibitor is the compound bi-cyclam (AMD3100)

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3. Inhibitors of Viral Fusion

The fusion of the virus envelope with the T-cell membrane commences after the binding of gp120 to the co-receptors CXCR4 and CCR5. This binding triggers a spring-loaded action of the glycoprotein gp41, which is normally covered by the larger gp120. The gp41 anchors itself to the T-cell membrane through the hairpin structures HR1 and HR2
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ENFUVIRTIDE Is an oligo-peptide consisting of 36 amino acids.

It is a synthetic peptide that mimics an HR2 fragment of gp41, blocking the formation of a six-helix bundle structure that is critical in the fusion of the HIV-1 virion to a CD4-positive Tlymphocyte. It is used in combination with other antietrovirals and works against a variety of HIV-1 variants, but it is not active against HIV-2 the drug is administered twice daily as a subcutaneous injection.

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Inhibitors of HIV Reverse Transcription

The enzyme reverse transcriptase catalyzes the synthesis of DNA from RNA by simultaneous binding of both the nucleotide and RNA at its catalytic active site. Inhibitors of HIV transcriptase act by impeding the nucleotide binding to the active site. The inhibition is achieved by two distinct mechanisms, either competitively
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 The competitive inhibitors are natural nucleoside analogs or have nucleoside-like structures, and hence are called

Nucleoside Reverse-transcriptase Inhibitors (NRTIs). The nucleoside inhibitors are further classified into purine and pyrimidine nucleoside inhibitors based on the nucleic acid base existing in the molecule. On the other hand, the non-competitive inhibitors are not structurally related to the natural nucleotides and are referred to as allosteric inhibitors or more commonly as Non Nucloeside Reverse Transcriptase Inhibitors (NNRTIs).
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A. Nucleoside Reverse Transcriptase Inhibitors (NRTls)

Act as reversible, competitive inhibitors for the HIV RT. Members of this class, being nucleoside in nature (i.e., contain only the base and the sugar), require intracellular activation to the nucleoside nucleotide). They cause chain termination by irreversibly 58 binding to the newly growing portion of viral tri-phosphate form (the

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 Second generation NRTIs are also already finish phase III clinical trails.

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B. Non-nucleoside Reverse Transcriptase Inhibitors (NNRTIs)

NNRTIs target the allosteric non-substrate binding sites. Members of this class are described as noncompetitive, reversible inhibitors. The dissimilarity of their chemical structures to the natural substrate implies different
61 binding sites, hence the classification as

 Unlike NRTIs, members of this class are highly specific to HIV-1 RT without affecting the host DNA polymerases, which explains the low toxicity and side effects of these drugs. Only three drugs belonging to the NNRTI class have been approved for clinical use: nevirapine, delavirdine, and efavirenz
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 The third-generation NNRTI emivirine (MK442,) is in Phase III clinical trial.

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HIV Protease Inhibitors (PI)

HIV protease is a proteolytic enzyme responsible for cleaving the large poly-protein precursor into biologically active protein products. HIV protease cleaves this poly-protein precursor during or shortly after viral budding to produce the mature virion. Therefore, inhibition of this post-translational step leads 65 to total arrest of viral maturation, thereby

 Three different approaches have been taken in the design of protease inhibitors. Based on the transition-state mimetic approach Based on disrupting the enzyme's two fold rotational C2-symmetry axis by forming specific hydrogen bonds and hydrophobic interactions with the amino acid residues involved in stabilizing the dimmer. Developing inhibitors with fewer peptide
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characteristics.

 Accordingly, HIV protease inhibitors are classified as peptide inhibitors (first

generation) and non-peptide inhibitors (second generation).

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First generation PIs

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Newer protease inhibitors

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