Inhibitory mechanism by polysialic acid for lamina-specific branch formation of thalamocortical axons

During development, thalamocortical axons form arbors primarily in layer 4 of the neocortex. This lamina-specific branch formation was studied in cultures of rat thalamic explants grown next to chemically fixed cortical slices. After a week in vitro, thalamic axons formed branches specifically in the target layer of fixed cortical slices, regardless of the orientation of the ingrowth. This in vitro system permits a direct assessment of contributions of membrane-associated molecules to thalamic axon branch formation. To this end, the present study uses three enzymatic perturbations: chondroitinase, phosphatidylinositol phospholipase C, or the polysialic acid (PSA)-specific endoneuraminidase (endo N). With endo N pretreatment of cortex, the number of branch points was increased significantly, whereas branch tip length was decreased. In addition, the localization of branch points to the target layer was weakened considerably. These features of branch formation were not altered by the other two enzymatic treatments, except that branch tips were shortened by chondroitinase treatment to the same extent as in endo N treatment. These results suggest that membrane-bound components are involved in lamina-specific branch formation of thalamocortical axons, and in particular that PSA moieties contribute to laminar specificity by inhibiting branch emergence in inappropriate layers.

The anti-influenza virus agent 4-GU-DANA (zanamivir) inhibits cell fusion mediated by human parainfluenza virus and influenza virus HA

4-GU-DANA (zanamivir) (as well as DANA and 4-AM-DANA) was found to inhibit the neuraminidase activity of human parainfluenza virus type 3 (HPF3). The viral neuraminidase activity is attributable to hemagglutinin-neuraminidase (HN), an envelope protein essential for viral attachment and for fusion mediated by the other envelope protein, F. While there is no evidence that HN's neuraminidase activity is essential for receptor binding and syncytium formation, we found that 4-GU-DANA prevented hemadsorption and fusion of persistently infected cells with uninfected cells. In plaque assays, 4-GU-DANA reduced the number (but not the area) of plaques if present only during the adsorption period and reduced plaque area (but not number) if added only after the 90-min adsorption period. 4-GU-DANA also reduced the area of plaques formed by a neuraminidase-deficient variant, confirming that its interference with cell-cell fusion is unrelated to inhibition of neuraminidase activity. The order-of-magnitude lower 50% inhibitory concentrations of 4-GU-DANA (and also DANA and 4-AM-DANA) for plaque area reduction and for inhibition in the fusion assay than for reducing plaque number or blocking hemadsorption indicate the particular efficacy of these sialic acid analogs in interfering with cell-cell fusion. In cell lines expressing influenza virus hemagglutinin (HA) as the only viral protein, we found that 4-GU-DANA had no effect on hemadsorption but did inhibit HA2b-red blood cell fusion, as judged by both lipid mixing and content mixing. Thus, 4-GU-DANA can interfere with both influenza virus- and HPF3-mediated fusion. The results indicate that (i) in HPF3, 4-GU-DANA and its analogs have an affinity not only for the neuraminidase active site of HN but also for sites important for receptor binding and cell fusion and (ii) sialic acid-based inhibitors of influenza virus neuraminidase can also exert a direct, negative effect on the fusogenic function of the other envelope protein, HA.

Zanamivir. No noticeable progress against influenza

* Zanamivir (Relenza((R)), Glaxo Wellcome) an antiviral drug, is marketed for treatment of influenza during outbreaks.* The clinical file consists mainly of three doubleblind, placebo-controlled trials.* When administered to patients with symptoms of influenza, at an inhaled dose of 10 mg twice daily, zanamivir has no clear benefit, or very limited benefit (hastening clinical recovery by 0.7 to 1.5 days) provided treatment is started within 30 hours of symptom onset. Zanamivir seems to act on influenza virus types A and B. No reliable data are available on the effect of zanamivir on overall intensity of symptoms during episodes or on time required to resume normal activities. The value of zanamivir for preventing complications in people at risk remains to be demonstrated.* Zanamivir has not been compared with another antiviral drug, amantadine, which has been available for nearly 30 years for the same indication. The two drugs have similar efficacy regarding time to recovery. Amantadine acts only on influenza virus type A.* In clinical trials, incidence of adverse events was not significantly higher with zanamivir than with placebo, but some patients with asthma and chronic obstructive airways disease experienced bronchospasm following zanamivir administration. Amantadine, which has been in use for about 30 years, has a relatively good safety profile.* Zanamivir is a costly preparation.

Polysialic acid regulates chain formation by migrating olfactory interneuron precursors

Olfactory interneuron precursors in the rostral migration stream migrate in chains and through long distances to the olfactory bulb. The migration is inhibited when polysialic acid moiety of NCAM is removed. How polysialic acid regulates chain migration has remained unknown. Previous studies in other systems have indicated the polysialic acid as a negative regulator of cell-cell interactions. Thus, polysialic acid may prevent cells in chains from interacting too tightly. To test this hypothesis and examine how polysialic acid regulates chain migration, the effect of polysialic acid depletion was evaluated in vitro and in vivo. Surprisingly, removal of polysialic acid often resulted in the dispersion of chains into single cells in both subventricular zone cultures and in adult mice where chain migration was observed. These results indicate that polysialic acid plays an important role in the formation of chains by olfactory interneuron precursors.

Synthesis and antitumor activities of novel 5-deazaflavin-sialic acid conjugate molecules

6-Nitro-5-deazaflavin derivatives bearing O-(methyl 5-acetamido-4,7,8,9-tetra-O-acetyl-3,5-dideoxy-D-glycero-alpha- and beta-D-galacto-non-2-ulopyranosylonate)alkyl group (sialosylalkyl group) at N(3) or N(10) and 8-amino-5-deazaflavin substituted with the sialosylalkyl group at the amino group were synthesized and their physicochemical properties as well as antitumor effects on KB and L1210 cells have been investigated. The configurations of the glycosides were determined by 1H NMR and rate of hydrolysis of the glycosidic bond. It has been found that these conjugate molecules show significant antitumor activities. Combination of an 8-amino-5-deazaflavin with the sialosylalkyl group have been found to give rise to significant increase in antitumor activities of the compound. Antitumor effects of 6-nitro-5-deazaflavin-sialic acid conjugate molecules were similar or rather weak in comparison with those of the 6-nitro-5-deazaflavin derivatives without sialosylalkyl group.

Inhibition of in vitro fertilization of mouse gametes by sulfated sialic acid polymers

The effect of sialic acid (N-acetyl neuraminic acid), sialic acid dimer, sialic acid polymers (colominic acid) and sulfated colominic acid on the activity of hyaluronidase, on the dispersion of cumulus cells by mouse sperm and on in vitro mouse fertilization (sperm penetration of zona pellucida) were evaluated. Bovine testicular hyaluronidase activity was significantly inhibited by colominic acid and sulfated colominic acid, but not by sialic acid and its dimer. The dispersion of cumulus cells from eggs by mouse sperm was also inhibited by colominic acid and sulfated colominic acid. In vitro fertilization of mouse gametes was inhibited by sulfated colominic acid. The IC50 value of sulfated colominic acid-induced inhibition of fertilization was 0.3 mg/ml (ca. 0.9 mM). The value changed from 0.9 mM for cumulus-surrounded egg to 1.5 mM for cumulus free-egg. On the other hand, colominic acid showed little or no inhibitory effect on mouse in vitro fertilization at 0.5 mg/ml (ca. 1.6 mM). This antifertility activity by sulfated colominic acid did not appear to be due to an effect on sperm motility or on the oocytes. These results suggest that (1) the cumulus cells surrounding the eggs were dispersed by sperm hyaluronidase, (2) hyaluronidase was inhibited by colominic acid and by sulfated colominic acid, (3) sulfated colominic acid inhibits sperm penetration of zona pellucida by the inhibition of hyaluronidase and/or some enzymes required for mouse gametes fertilization.

Influenza A viruses lacking sialidase activity can undergo multiple cycles of replication in cell culture, eggs, or mice

Influenza A viruses possess both hemagglutinin (HA), which is responsible for binding to the terminal sialic acid of sialyloligosaccharides on the cell surface, and neuraminidase (NA), which contains sialidase activity that removes sialic acid from sialyloligosaccharides. Interplay between HA receptor-binding and NA receptor-destroying sialidase activity appears to be important for replication of the virus. Previous studies by others have shown that influenza A viruses lacking sialidase activity can undergo multiple cycles of replication if sialidase activity is provided exogenously. To investigate the sialidase requirement of influenza viruses further, we generated a series of sialidase-deficient mutants. Although their growth was less efficient than that of the parental NA-dependent virus, these viruses underwent multiple cycles of replication in cell culture, eggs, and mice. To understand the molecular basis of this viral growth adaptation in the absence of sialidase activity, we investigated changes in the HA receptor-binding affinity of the sialidase-deficient mutants. The results show that mutations around the HA receptor-binding pocket reduce the virus's affinity for cellular receptors, compensating for the loss of sialidase. Thus, sialidase activity is not absolutely required in the influenza A virus life cycle but appears to be necessary for efficient virus replication.

Development of a sensitive chemiluminescent neuraminidase assay for the determination of influenza virus susceptibility to zanamivir

Determination of the sensitivity of influenza viruses to neuraminidase (NA) inhibitors is presently based on assays of NA function because, unlike available cell culture methods, the results of such assays are predictive of susceptibility in vivo. At present the most widely used substrate in assays of NA function is the fluorogenic reagent 2'-O-(4-methylumbelliferyl)-N-acetylneuraminic acid (MUN). A rapid assay with improved sensitivity is required because a proportion of clinical isolates has insufficient NA to be detectable in the current fluorogenic assay, and because some mutations associated with resistance to NA inhibitors reduce the activity of the enzyme. A chemiluminescence-based assay of NA activity has been developed that uses a 1,2-dioxetane derivative of sialic acid (NA-STAR) as the substrate. When compared with the fluorogenic assay, use of the NA-STAR substrate results in a 67-fold reduction in the limit of detection of the NA assay, from 200 pM (11 fmol) NA to 3 pM (0.16 fmol) NA. A panel of isolates from phase 2 clinical studies of zanamivir, which were undetectable in the fluorogenic assay, was tested for activity using the NA-STAR substrate. Of these 12 isolates with undetectable NA activity, 10 (83%) were found to have detectable NA activity using the NA-STAR substrate. A comparison of sensitivity to zanamivir of a panel of influenza A and B viruses using the two NA assay methods has been performed. IC(50) values for zanamivir using the NA-STAR were in the range 1.0-7.5 nM and those for the fluorogenic assay in the range 1. 0-5.7 nM (n = 6). The NA-STAR assay is a highly sensitive, rapid assay of influenza virus NA activity that is applicable to monitoring the susceptibility of influenza virus clinical isolates to NA inhibitors.

Sialic acid and crystal binding

BACKGROUND

We studied the role of cell surface sialic acid in the adherence of calcium oxalate monohydrate (COM) crystals to Madin-Darby canine kidney (MDCK) cells.

METHODS

Studies were performed with undifferentiated (crystal-binding) cells in subconfluent cultures and maturated (noncrystal-binding) cells in confluent cultures. Lectins were used to study the emergence and abundance of oligosaccharides at the cell surface during epithelial development. The effect of neuraminidase treatment on crystal binding was studied with [14C]COM crystals, and the enzyme-induced release of cell surface-associated sialic acid molecules was monitored by labeling the cells metabolically with [3H]glucosamine.

RESULTS

Binding studies with lectins derived from Maackia Amurensis II (MALII) and Sambucus Nigra (SNA) demonstrated that the cells expressed terminal sialic acids attached to penultimate galactose through alpha 2,3 and alpha 2,6 bonds at different stages of epithelial development. Neuraminidase treatment strongly reduced the affinity of the cell surface for COM crystals in subconfluent cultures. Nevertheless, neuraminidase cleaved more sialic acids from cells in confluent cultures than from those in subconfluent cultures. Peanut agglutinin (PNA), which binds only to sialylated terminal galactose units, adhered to developing but not to maturated cells, unless the latter were pretreated with neuraminidase. Both results indicate that the surface of maturated MDCK cells is more heavily sialylated than that of undifferentiated cells. Free sialic acid molecules showed little or no affinity for COM crystals and did not affect the adherence of the crystals to undifferentiated cells.

CONCLUSIONS

There are at least two models that may explain these results. First, sialic acids are presented at the surface of immature cells in an orientation that specifically matches crystal surface characteristics favoring crystal-cell interactions. Second, sialic acid molecules are not directly associated with the crystals, but may be involved in the exposure of another crystal binding molecule at the cell surface.

Sialosylcholesterol induces reorganization of astrocyte filament network

Sialosylcholesterol induces the differentiation of astrocytes with respect to their morphological appearance (Kato et al., Brain Res. 438 (1988) 277-285; Ito et al., 481 (1989) 335-343), while in a cell-free condition it depolymerizes the astrocyte cellular filaments, the glia filaments and microfilaments (Ito et al., J. Neurochem. 61 (1993) 80-84). To solve this paradox, we examined hetero-interaction between the glia filaments and microfilaments in the presence of sialosylcholesterol. Each filament was prepared in a depolymerized form in low ionic strength, and was adjusted to physiological ionic strength to prevent from repolymerization by sialosylcholesterol. When the two filament preparations in this form were mixed, repolymerization took place in spite of the presence of sialosylcholesterol. The filament formed in the mixture was found almost exclusively composed of vimentin and actin, the major component of the glia filaments and microfilaments preparation, respectively. An excess amount of vimentin over actin in the precipitate implicated that the main mechanism for the hetero-polymerization was the enhancement of vimentin polymerization by actin. To support this view, pre-polymerization of the microfilaments before mixing with the depolymerized glia filaments resulted in a marked decrease in polymerization of the glia filaments. A similar hetero-interaction was found between the purified vimentin and actin. When polymerized vimentin and actin were directly depolymerized by sialosylcholesterol and mixed, polymer formation was demonstrated between these two proteins. Electronmicroscopy indicated direct interaction of the actin filament with the vimentin filament. The results indicate that sialosylcholesterol induces reorganization of the cellular filament network, such as disorganization of vimentin and actin filaments, and provokes their hetero-interaction to form the hetero-filament. Hence, this may be one of the key mechanisms for the induction of cellular differentiation by sialocylcholesterol.

Synthesis of a polymeric 4-N-linked sialoside which inhibits influenza virus hemagglutinin

A multiple sialic acid-bearing polymer 7 has been made in which a novel 4-N-substituted sialoside 5 has been coupled to polyacrylamide. The conjugate 7 has been found to inhibit the agglutination of influenza virus to red blood cells with HAI inhibition constants of around 10(-6) M, based on the sialic acid concentration.

[Critical review of anti-influenza drugs]

Neuraminidase inhibitors such as zanamivir and oseltamivir belong to a new class of antiviral drugs for the treatment and prevention of influenza. As yet however, the therapeutic efficacy of these drugs (shortening of recovery time by approximately one day) has only been demonstrated in healthy adults affected by influenza A, but not in risk groups and in influenza B disease, whereas studies of prophylactic efficacy are still going on. Neither do these drugs impact on viral spread, a public health risk against which the economic advantages of early work resumption have to be weighed. Since flu symptoms can be caused by other germs than the influenza A or B virus, caution in prescribing these drugs seems warranted, also to prevent the development of drug resistance. In addition, when designing therapeutic efficacy trials in risk groups, selecting the rate of secondary complications and death may be more adequate as clinical endpoint than (economically important) duration of illness.

Zanamivir susceptibility monitoring and characterization of influenza virus clinical isolates obtained during phase II clinical efficacy studies

Zanamivir is a highly selective neuraminidase (NA) inhibitor with demonstrated clinical efficacy against influenza A and B virus infections. In phase II clinical efficacy trials (NAIB2005 and NAIB2008), virological substudies showed mean reductions in virus shedding after 24 h of treatment of 1.5 to 2.0 log(10) 50% tissue culture infective doses compared to a placebo, with no reemergence of virus after the completion of therapy. Paired isolates (n = 41) obtained before and during therapy with zanamivir demonstrated no shifts in susceptibility to zanamivir when measured by NA assays, although for a few isolates NA activity was too low to evaluate. In plaque reduction assays in MDCK cells, the susceptibility of isolates to zanamivir was extremely variable even at baseline and did not correlate with the speed of resolution of virus shedding. Isolates with apparent limited susceptibility to zanamivir by plaque reduction proved highly susceptible in vivo in the ferret model. Further sequence analysis of paired isolates revealed no changes in the hemagglutinin and NA genes in the majority of isolates. The few changes observed were all natural variants. No amino acid changes that had previously been identified in vitro as being involved with reduced susceptibility to zanamivir were observed. These studies highlighted problems associated with monitoring susceptibility to NA inhibitors in the clinic, in that no reliable cell-based assay is available. At present the NA assay is the best available predictor of susceptibility to NA inhibitors in vivo, as measured in the validated ferret model of infection.

[Influenza: from vaccine prevention to antiviral therapy]

Influenza is a highly infectious disease responsible for dangerous epidemics, especially in patients at high risk. The vaccine exerts a valuable protective effect estimated up to 70% and is still considered as the key-approach against influenza. Antiviral agents of the first generation (amantadine, rimantadine, ribavirine) have limited use because of poor tolerance and occurrence of resistance. Zanamivir or Relenza, marketed by Glaxo Wellcome, is a new virostatic drug acting as a neuraminidase inhibitor. It prevents the release of new viruses and so stop the propagation of the infection. It must be taken orally by inhalation within 48 hours after the onset of symptoms. The treatment lasts 5 days (10 mg twice daily). Its efficacy has been demonstrated in controlled clinical trials, and its tolerance is generally excellent. However, caution is recommended in patients with asthma and chronic bronchitis because of the potential risk of bronchoconstriction. No resistance has been detected until now. Zanamivir is active on all strains of influenza A and B viruses.

In vitro selection and characterisation of influenza B/Beijing/1/87 isolates with altered susceptibility to zanamivir

We describe the in vitro selection and characterisation of virus derived from B/Beijing/1/87 passaged in the presence of zanamivir. During zanamivir passage, the phenotype of virus isolates was either drug dependent or drug resistant in plaque reduction assays. The susceptibility of the neuraminidase of the drug-dependent isolates was unchanged from that of the wild-type enzyme. The drug-dependent isolates contained two mutations in the viral haemagglutinin: V90A, close to the proposed secondary sialic acid-binding site, and L240Q, close to the primary sialic acid-binding site. Virus isolates that were drug resistant contained the same mutations in the haemagglutinin but also contained the mutation E116G in the neuraminidase. For the drug-dependent viruses, zanamivir susceptibility could not be measured because plaque numbers increased with increasing drug concentration. The in vitro zanamivir susceptibility of drug-resistant viruses was lower than that of the wild-type virus by a factor of 275- to >2532-fold. Neuraminidase containing the E116G mutation has a 33-fold lower affinity for zanamivir than the wild-type enzyme. The finding that the same haemagglutinin mutations are found in both drug-dependent and drug-resistant viruses confirms that the same changes to the receptor binding function can contribute to both phenotypes. This observation demonstrates the interplay between the influenza virus haemagglutinin and neuraminidase in escape from zanamivir inhibition in vitro.

Zanamivir (Relenza )--a new treatment for influenza

Deaths from influenza are recorded every year in the UK and flu epidemics raise concerns for the safety of the young, the elderly and other vulnerable groups in the community. Not surprisingly, the launch of zanamavir (Relenza) by Glaxo Welcome (Middlesex, UK) has received much attention in the medical media and lay press. Just who should receive this treatment and under what conditions it should be given remains to be confirmed in practice.

Randomized, placebo-controlled studies of inhaled zanamivir in the treatment of influenza A and B: pooled efficacy analysis

Zanamivir, a potent, highly selective inhibitor of influenza virus A and B neuraminidase, has been evaluated in seven, similarly designed, placebo-controlled studies of the treatment of influenza. Patients with typical influenza symptoms were recruited when influenza was known to be circulating in the community. Six of these studies included a zanamivir 10 mg inhaled bd (for 5 days) treatment arm, the dose regimen submitted to regulatory agencies. Pooled analyses were conducted to evaluate efficacy more precisely in terms of the alleviation of symptoms in population subgroups and for secondary endpoints. Median time to alleviation of symptoms, the primary endpoint, was reduced from 6.0 days in the placebo group (n = 1,102) to 5.0 days in the zanamivir group (n = 1,133), P< 0.001. In febrile, laboratory-confirmed, influenza-positive (IP) patients, time to alleviation was reduced from 6.5 days to 5.0 days, a treatment benefit of 1.5 days (P < 0.001). A larger treatment benefit (3 days) was seen in IP patients who had severe symptoms at entry (n = 474, P < 0.001), compared with 1 day in patients whose symptoms were not severe (n = 1,098, P< 0.001). Similarly, a 3 day treatment benefit (P = 0.003) was observed in IP patients aged >50 years (n = 263), compared with 1 day (P < 0.001) in patients aged <50 years. In 'high-risk' IP patients (recruited into all treatment studies), there was a treatment benefit of 2.5 days (n = 305, P = 0.006). Pooled analyses of secondary endpoints showed statistically significant reductions in antibiotic use, time to return to normal activities and use of relief medication. In addition, reductions in symptom scores were apparent shortly after commencing zanamivir treatment. By the evening of the second day of treatment, the median total symptom score had fallen by 44% in zanamivir recipients compared with 33% in placebo recipients (P < 0.001). These results highlight the groups likely to show greatest benefit from zanamivir treatment, and confirm the clinical relevance of the treatment benefit.

An analysis of the role of neuraminidase in the receptor-binding activity of influenza B virus: the inhibitory effect of Zanamivir on haemadsorption

We analysed the role of neuraminidase (NA) on haemadsorption by the haemagglutinin (HA) protein of influenza B virus. The influenza B virus mutant ts-7 has a temperature-sensitive mutation in the NA protein. At high temperature, cells infected with this virus did not exhibit haemadsorption activity, but the addition of bacterial neuraminidase (bNA) restored haemadsorption activity. COS cells transfected with HA cDNAs of B/Kanagawa/73 or B/Lee/40 virus showed no evidence of haemadsorption. However, with the addition of bNA or co- transfection with NA cDNA of the B/Lee/40 virus, haemadsorption was observed. Experiments with point-mutated HA cDNAs of B/Lee/40 virus showed that two N-acetyl glycosylation sites at amino acid residues 160 and 217 were responsible for the inability of the HA protein to adsorb to erythrocytes. These results indicated that haemadsorption by the HA protein of influenza B virus required the involvement of NA. Because the NA inhibitor Zanamivir was reported not to penetrate cells, we investigated the action of this inhibitor and found that Zanamivir inhibited haemadsorption on MDCK cells infected with B/Kanagawa/73 or B/Lee/40 virus. After removing Zanamivir by washing, the addition of bNA restored the haemadsorption activity on the infected cells. Scanning electron microscopy indicated that at 0.4 microM Zanamivir, HA protein did not adsorb to erythrocytes but retained the ability to aggregate virions. However, at 4 microM Zanamivir, distinct virion formation could not be observed.

Genetic analysis reveals that both haemagglutinin and neuraminidase determine the sensitivity of naturally occurring avian influenza viruses to zanamivir in vitro

The basis of differential sensitivity of replication of influenza viruses to the neuraminidase-specific inhibitor zanamivir was examined using four avian influenza viruses and reassortants produced between them. IC(50) values for inhibition of neuraminidase activity by zanamivir were similar for each of the four viruses, whereas the haemagglutinating activity of each of the viruses was relatively insensitive to zanamivir. However, the four viruses showed distinct zanamivir-sensitivity profiles in tissue culture. Analysis of the reassortant viruses showed that sensitivity was determined by the haemagglutinin gene (segment 4) and the neuraminidase gene (segment 6) and was independent of the remaining six RNA segments. Decreased sensitivity to zanamivir was associated with possession of a haemagglutinin that is released from cells with decreased dependence on neuraminidase and with possession of a neuraminidase that has a short stalk region.

Zanamivir: a review of clinical safety

Preclinical and clinical studies have clearly demonstrated that zanamivir, a potent and highly selective inhibitor of the influenza A and B virus neuraminidase, has an impressive safety profile. This report describes the safety and tolerability findings from the clinical studies completed up to the 17 July 1998 involving over 6000 adult and adolescent patients from North America, Europe and the Southern Hemisphere. Serious adverse events from an ongoing Japanese clinical programme are also reported. Zanamivir was administered in various dose forms and frequencies and was found to have a comparable safety profile with placebo when given for both the treatment and prophylaxis of influenza-like illness. These findings were independent of age and underlying medical condition. 4152 patients received zanamivir and the most commonly reported adverse events were consistent with the signs and symptoms of influenza-like illness. Most of the adverse events were mild and did not result in patient withdrawal from the studies. Less than 1% of zanamivir and placebo recipients reported a serious adverse event. In addition, 490 healthy volunteers received zanamivir in clinical pharmacology studies. It was well tolerated and the incidence of adverse events was similar in zanamivir and placebo recipients. In addition, no clinically significant laboratory abnormalities were detected. Results from in vitro and in vivo animal studies suggest that zanamivir has low acute toxicity and no significant systemic toxicity or respiratory tract irritancy at plasma exposures more than 100-fold higher than those anticipated following clinical use. Neither genotoxic nor reproductive types of toxicity have been observed in toxicology studies at doses equal to 17 to 197 times the current therapeutic dose (20 mg/day). The characteristics of the molecule and the low systemic exposure indicate a very low potential for drug interactions with the inhaled route. Furthermore, repeated 600mg intravenous doses were well tolerated in healthy volunteers. The observed safety profile of zanamivir compares favourably with currently available agents with anti-influenza virus activity, such as rimantadine and amantadine, as well as GS4104, a neuraminidase inhibitor currently in phase III development. This may be attributed to the low systemic bioavailability of zanamivir, which is given by oral inhalation, direct to the primary site of viral replication. The potential advantages of this include a reduced risk of drug-drug interactions, other nontarget organ toxicities (e.g. brain) and drug clearance issues from both kidney and liver. Therefore, the safety profile of zanamivir supports its use in the management of influenza.