Download - Lecture 1 anti viral agents
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ANTIVIRAL DRUGS
Dr. Gyanendra Raj Joshi
PharmD, RPh
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Virus :Obligate parasite Virus particles (virions)
consist of following parts:
• Genetic material (DNA or RNA).
• Protein coat (capsid) that surrounds nucleic acid.
• Envelope (contains lipids and lipoproteins) that surrounds the capsid when virus is outside a cell.
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DNA Virus:Pox virus( small pox)Herpes virusAdeno virus
( conjunctivitis , sore throat)
Hepadna virus ( HBV)Papilloma virus ( warts )
RNA virusRubella virus ( German Measles)Rhabdo virus ( rabies)Picorna virus ( polio, meningitis,
cold , Hepatitis A)Arena virus (lassa fever)Flavi virus (yellow fever , HCV)Orthomyxo virus (Influenza)Paramyxo virus (mumps ,
measles)Corona virus (cold , SARS)
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Viral infections
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Mechanism of action Major drugs
Block viral penetration/ uncoating Amantadine, enfuvirtide, maraviroc
Inhibit viral DNA polymerase Acyclovir , foscarnet, ganciclovir
Inhibit RNA polymerase Foscarnet , ribavirin
Inhibit viral Reverse transcriptase Zidovudine, didanosine,zalcitabine , lamivudine, stavudine, neprapine , efavirenz
Inhibit viral aspartate protease Indinavir, ritonavir, saquinavir , nelfinavir
Inhibit viral neuraminidase Zanamivir, oseltamivir
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1. Anti Herpes agents
AcyclovirValacyclovirFamciclovirGanciclovir Foscarnet Penciclovir Cidofovir Idoxuridine
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3. Anti HBV Agents Adefovir
Entacavir
4. Anti-Influenza Virus Amantadine Rimantadine
5. Nonselective Antiviral Drugs RibavirinLamivudine AdefovirInterferons
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Anti Herpes Drugs Herpesviridae family- HSV-1, HSV-2, VZV, CMV
Mouth, face skin, esophagus , brain----HSV-1Genitals , rectum, skin , hands, meninges----HSV-2
Arrest DNA synthesis by inhibiting viral DNA polymerase .
Most of them prodrugs
Require Viral and Host cellular enzymes ( eg. Thymidine deoxyguanosine kinase ) to phosphorylate them into active triphosphate form
Common mechanism of resistance is alteration in viral enzymes
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Mechanism of action of Anti Herpes agents
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Acyclovir
• Synthetic analogue of guanosine • Valacyclovir is a prodrug
Acyclovir monophosphate is phosphorylated to triphosphate , gets incorporated into Viral DNA and inhibits replication.
HSV thymidine kinase DNA polymerase Chain terminationSuicide inactivationSpectrum: HSV-1, HSV-2, VZVNever totally cure
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• Advantage:– No hematotoxicity, no myelosupression– Treatment of herpes encephalitis
• Resistance :– Absence or partial production of TK– Altered TK specificity– Altered viral DNA polymerase
• Adverse effects :– PEG base topical effects– Oral- nausea , vomiting , diarrhoea and headache – Dose dependent renal impairment , crystallie nephropathy– Neurological – lethargy , confusion , tremors – Rash , itching and phlebitis at injection site
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Ganciclovir
• Similar to acyclovir • First phosphorylation viral specific, TK in HSV,
Phosphotransferase (UL97) in CMV• Triphosphate form inhibits viral DNA
polymerase and causes chain termination• HSV, VZV, CMV reitinitis in HIV patients • Dose limiting hematotoxicity, mucositis , fever,
rash , crystalluria• Seizures in overdose
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Foscarnet
Inorganic pyrophosphate analog inhibitory for herpes and HIV
• Not an antimetabolite• Interacts directly with Viral DNA polymerase
or HIV reverse transcriptase • Blocks binding site of pyrophosphate and
inhibits cleavage • IV
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• Nephrotoxicity• Hypocalcemia• Acute tubular necrosis• Crystalluria• CNS – tremor, irritabilty, seizure , halluccination, • Rash, fever,nausea, vomiting• Anemia, LFT,ECG• Avoid pentamidine iv• CMV retinitis • Ganciclovir resistant infections in AIDS
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Anti-influenza agents • Amantadine/ rimantadine
– Tricyclic amines– Low concentration inhibits replication– Rimantadine more active , also for Trypanosoma brucei– Inhibit attachment, penetration and viral uncoating– M2 protein inhibition– Potentiate acid pH induced changes in hemaggluttin during intracellular
transfer– Minor Dose related GIT and CNS effects – Atropine like – Livedo reticularis– Insomnia – Loss of appetite – Teratogenic
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Oseltamivir/zanamivir
– Absorbed rapidly and cleaved to active carboxylate
– Selective inhibitor of vial neuraminidase and leads to viral aggregation and reduced spread
– Nausea , abdominal discomfort—given with food– Nasal and throat irritation– Flu like – Influenza A and B
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Ribavirin
• Monophosphorylated form inhibits IMP dehydrogenase and as a result depletes intracellular nucleotide reserves.
• Triphosphate inhibits viral RNA polymerase and end capping of viral RNA
• Used as an adjunct to IFN in HCV infection• Management of respiratory syncytial virus • Lassa fever • Hematotoxic• Upper airway irritation• Teratogenic
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Anti hepatitis agents
• Adefovir dipivoxil– Acyclic phosphonate
nucleotide of adenosine monophosphate
– Adefovir diphosphate is competitive inhibitor of DNA polymerase and reverse transcriptase
– Chain terminator – Chronic HBV– Lamivudine resistant HBV
strains
– Reduced carnitine – Dose related
nephrotoxicity/tubular dysfunction
– Headache , abdominal discomfort, diarrhoea , asthenia
– Hepatotoxicity ,lymphoid toxicity
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Interferons
• Potent cytokines • Antiviral, immunomodulating and antiproliferative • Synthesised by host cells • Types – – α, β- all cells, stimulate MHC antigen– γ - T lymphocytes / NK cells
• Pegylated interferon• Inhibit protein synthesis , activate
endoribonuclease
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• Acute influenza like syndrome – fever , chills, headache, myalgia , arthralgia, nausea , vomiting and diarrhorea
• Tolerance• Dose limiting –
myleosuppression• Neurotoxicity- confusion• Hepatotoxicity
• Condyloma acuminata( genital warts )
• Chronic HCV, HBV• Kaposi Sarcoma in HIV• Multiple sclerosis
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Anti HIV Agents/Anti Retroviral Agents
i. Nucleoside Reverse Transcriptase Inhibitors (NRTIs)
Zidovudine (AZT)Didanosine (DDI)Emtricitabine (FTC)Lamivudine (3TC)Zalcitabine (ddC)Abacavir (ABC)
ii. Nucleotide Reverse Transcriptase Inhibitors (NtRTIs)
Tenofovir Disproxil Fumarate
iii. Non-nucleoside reverse Transcriptase Inhibitors ( NNRTIS)
Delavirdine Efavirenz Nevirapine Etravirine
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iv. Protease Inhibitors Amprenavir AtazanavirDarunavir Fosamprenavir Indinavir Lopinavir Ritonavir Nelfinavir SaquinavirTipranivir
v. Fusion Inhibitors:
EnfuviritideMaraviroc
vi. Integrase Inhibitor :
Raltegravir
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Reverse Transcriptase Inhibitors
• NRTIs :Inactive until phosphorylated by human cellular
kinases Used together with protease inhibitors
• NNRTIs:– Not prodrugs – No myelosupression– Efavirenz, nevirapine
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Side effects of NRTIs
• Zidovudine AZT– hematotoxicity– Headache , myalgia , myopathy , peripheral
neuropathy• Didanosine DDI– Pancreatitis– Peripheral neuropathy, hyperuricemia, liver
dysfunction
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• Zalcitabine DDC– Peripheral neuropathy– GI distress, pancreatitis, neutropenia, rash
• Stavudine D4T– Peripheral neuropathy– Myelosupression
• Lamivudine 3TC– GI effects and neutropenia
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• ADRs of Efavirenz (a NNRTI)– Not during pregnancy– Dizziness– Vivid dreams
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Protease inhibitors
• Aspartate protease (pol gene encoded) cleaves precursor polypeptides to form the proteins of mature virion core
• Selective to dipeptide structure of viral proteins
• Combined with NRTIs• Indinavir , ritonavir
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Adverse effects of PI
• Paresthesia• Diarrhoea• Nausea and vomiting• Hypertriglyceridemia• Hyperglycemia• Hypercholesterolemia
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Fusion inhibitors
Enfuvirtide :• Binds gp41 and inhibits
fusion of HIV to CD4+ cells
• injection site reactions (pain, hardening of skin, erythema, nodules, cysts, itch)
Maraviroc :• Blocks CCR5 on T cell
surface to prevent viral entry
• hepatotoxicityallergic reactions (systemic), skin rash, fever, abd. pain, muscle/joint pain, cough, URTI, sleep disturbances
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HIV treatment guidelines
• 99% cell kill • Need of Combination therapy• CD4 cell count (≥350/mm3)
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Highly Active Anti Retroviral therapy
Combinations :1) 2 NNRTI+ PIEfavirenz + nevirapine + atazanavir/ritonavirnevirapine + etravirine + lopinavir/ritonavir2) 2 NRTI+ PITenofovir + emtricitabine + ritonavirAbacavir + lamivudine + ritonavirZidovudine + lamivudine +ritonavir
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Combinations to avoid:• Didanosine+Zalcitabine• Stavudine + zidovudine
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HIV Postexposure Prophylaxis (PEP)
Contact with blood /fluid or blood transfusionSharp injury or needle stick of HIV infected
NRTIs for 28 days/ with triple therapy (dual NRTIs plus a boosted PI)
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Prevention of mother-to-child-transmission
• Start Zidovudine (AZT) from 28 weeks or as soon as possible thereafter, be provided with single-dose Nevirapine (NVP) when entering labour, and be given AZT+3TC for one week following delivery
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Quick Review of Antiviral Agents
• Anti herpetics• Anti influenza agents • Anti hepatitis viral infections • Anti retroviral drugs