1
|
Sanford LM, Keiser P, Fujii N, Woods H, Zhang C, Xu Z, Mahajani NS, Cortés JG, Plescia CB, Knipp G, Stahelin RV, Davey R, Davisson VJ. Evaluation of potency and metabolic stability of diphyllin-derived Vacuolar-ATPase inhibitors. Eur J Med Chem 2024; 275:116537. [PMID: 38875806 PMCID: PMC11236507 DOI: 10.1016/j.ejmech.2024.116537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 05/16/2024] [Accepted: 05/26/2024] [Indexed: 06/16/2024]
Abstract
Diphyllin is a naturally occurring lignan comprised of an aryl naphthalene lactone scaffold that demonstrates beneficial biological activities in disease models of cancer, obesity, and viral infection. A target of diphyllin and naturally occurring derivatives is the vacuolar ATPase (V-ATPase) complex. Although diphyllin-related natural products are active with in vitro models for viral entry, the potencies and unknown pharmacokinetic properties limit well-designed in vivo evaluations. Previous studies demonstrated that diphyllin derivatives have the utility of blocking the Ebola virus cell entry pathway. However, diphyllin shows limited potency and poor oral bioavailability in mice. An avenue to improve the potency was used in a new library of synthetic derivatives of diphyllin. Diphyllin derivatives exploiting ether linkages at the 4-position with one-to-three carbon spacers to an oxygen or nitrogen atom provided compounds with EC50 values ranging from 7 to 600 nM potency and selectivity up to >500 against Ebola virus in infection assays. These relative potencies are reflected in the Ebola virus infection of primary macrophages, a cell type involved in early pathogenesis. A target engagement study reveals that reducing the ATPV0a2 protein expression enhanced the potency of diphyllin derivatives to block EBOV entry, consistent with effects on the endosomal V-ATPase function. Despite the substantial enhancement of antiviral potencies, limitations were identified, including rapid clearance predicted by in vitro microsome stability assays. However, compounds with similar or improved half-lives relative to diphyllin demonstrated improved pharmacokinetic profiles in vivo. Importantly, these derivatives displayed suitable plasma levels using oral administration, establishing the feasibility of in vivo antiviral testing.
Collapse
Affiliation(s)
- Laura M Sanford
- Borch Department of Medicinal Chemistry and Molecular Pharmacology, Purdue University, West Lafayette, IN, 47907, United States
| | - Patrick Keiser
- Department of Microbiology, National Emerging Infectious Diseases Laboratories, Boston University, Boston, MA, 02118, United States
| | - Naoaki Fujii
- Borch Department of Medicinal Chemistry and Molecular Pharmacology, Purdue University, West Lafayette, IN, 47907, United States
| | - Hannah Woods
- Borch Department of Medicinal Chemistry and Molecular Pharmacology, Purdue University, West Lafayette, IN, 47907, United States
| | - Charlie Zhang
- Borch Department of Medicinal Chemistry and Molecular Pharmacology, Purdue University, West Lafayette, IN, 47907, United States; Department of Industrial and Molecular Pharmaceutics, Purdue University, West Lafayette, IN, 47907, United States
| | - Zhuangyan Xu
- Department of Industrial and Molecular Pharmaceutics, Purdue University, West Lafayette, IN, 47907, United States
| | - Nivedita S Mahajani
- Borch Department of Medicinal Chemistry and Molecular Pharmacology, Purdue University, West Lafayette, IN, 47907, United States
| | - Julián González Cortés
- Borch Department of Medicinal Chemistry and Molecular Pharmacology, Purdue University, West Lafayette, IN, 47907, United States
| | - Caroline B Plescia
- Borch Department of Medicinal Chemistry and Molecular Pharmacology, Purdue University, West Lafayette, IN, 47907, United States
| | - Gregory Knipp
- Department of Industrial and Molecular Pharmaceutics, Purdue University, West Lafayette, IN, 47907, United States
| | - Robert V Stahelin
- Borch Department of Medicinal Chemistry and Molecular Pharmacology, Purdue University, West Lafayette, IN, 47907, United States
| | - Robert Davey
- Department of Microbiology, National Emerging Infectious Diseases Laboratories, Boston University, Boston, MA, 02118, United States
| | - Vincent Jo Davisson
- Borch Department of Medicinal Chemistry and Molecular Pharmacology, Purdue University, West Lafayette, IN, 47907, United States.
| |
Collapse
|
2
|
Claas AM, Lee M, Huang PH, Knutson CG, Bullara D, Schoeberl B, Gaudet S. Viral Kinetics Model of SARS-CoV-2 Infection Informs Drug Discovery, Clinical Dose, and Regimen Selection. Clin Pharmacol Ther 2024; 116:757-769. [PMID: 38676291 DOI: 10.1002/cpt.3267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 03/18/2024] [Indexed: 04/28/2024]
Abstract
Quantitative systems pharmacology (QSP) has been an important tool to project safety and efficacy of novel or repurposed therapies for the SARS-CoV-2 virus. Here, we present a QSP modeling framework to predict response to antiviral therapeutics with three mechanisms of action (MoA): cell entry inhibitors, anti-replicatives, and neutralizing biologics. We parameterized three distinct model structures describing virus-host interaction by fitting to published viral kinetics data of untreated COVID-19 patients. The models were used to test theoretical behaviors and map therapeutic design criteria of the different MoAs, identifying the most rapid and robust antiviral activity from neutralizing biologic and anti-replicative MoAs. We found good agreement between model predictions and clinical viral load reduction observed with anti-replicative nirmatrelvir/ritonavir (Paxlovid®) and neutralizing biologics bamlanivimab and casirivimab/imdevimab (REGEN-COV®), building confidence in the modeling framework to inform a dose selection. Finally, the model was applied to predict antiviral response with ensovibep, a novel DARPin therapeutic designed as a neutralizing biologic. We developed a new in silico measure of antiviral activity, area under the curve (AUC) of free spike protein concentration, as a metric with larger dynamic range than viral load reduction. By benchmarking to bamlanivimab predictions, we justified dose levels of 75, 225, and 600 mg ensovibep to be administered intravenously in a Phase 2 clinical investigation. Upon trial completion, we found model predictions to be in good agreement with the observed patient data. These results demonstrate the utility of this modeling framework to guide the development of novel antiviral therapeutics.
Collapse
Affiliation(s)
- Allison M Claas
- Biomedical Research, Novartis, Cambridge, Massachusetts, USA
| | - Meelim Lee
- Biomedical Research, Novartis, Cambridge, Massachusetts, USA
| | - Pai-Hsi Huang
- Biomedical Research, Novartis, East Hanover, New Jersey, USA
| | | | | | | | - Suzanne Gaudet
- Biomedical Research, Novartis, Cambridge, Massachusetts, USA
| |
Collapse
|
3
|
Akamatsu H, Kohno Y, Hashizume J, Nakagawa H, Kodama Y, Kawano H, Maemura K, Ohyama K. Effect of rifampicin administration on CYP induction in a dermatomyositis patient with vasospastic angina attributable to nilmatrelvir/ritonavir-induced blood tacrolimus elevation: A case report. J Infect Chemother 2024; 30:928-933. [PMID: 38360184 DOI: 10.1016/j.jiac.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 01/31/2024] [Accepted: 02/04/2024] [Indexed: 02/17/2024]
Abstract
Ritonavir (RTV), which is used in combination with nilmatrelvir (NMV) to treat coronavirus disease 2019 (COVID-19), inhibits cytochrome P450 (CYP) 3A, thereby increasing blood tacrolimus (TAC) levels through a drug-drug interaction (DDI). We experienced a case in which a DDI between the two drugs led to markedly increased blood TAC levels, resulting in vasospastic angina (VSA) and acute kidney injury (AKI). Rifampicin (RFP) was administered to induce CYP3A and promote TAC metabolism. A 60-year-old man with dermatomyositis who was taking 3 mg/day TAC contracted COVID-19. The patient started oral NMV/RTV therapy, and he was admitted to the hospital after 4 days because of chest pain and AKI. On day 5, his blood TAC level increased markedly to 119.8 ng/mL. RFP 600 mg was administered once daily for 3 days, and his blood TAC level decreased to the therapeutic range of 9.6 ng/mL on day 9, leading to AKI improvement. Transient complete atrioventricular block and nonsustained ventricular tachycardia were present during chest pain. In the coronary spasm provocation test, complete occlusion was observed in the right coronary artery, leading to a diagnosis of VSA. VSA and AKI are possible side effects of high blood TAC levels caused by DDI, and attention should be paid to cardiovascular side effects such as VSA and AKI associated with increased blood levels of TAC when it is used together with NMV/RTV. When blood levels of TAC increase, oral RFP can rapidly decrease TAC blood levels and potentially reduce its toxicity.
Collapse
Affiliation(s)
- Hayato Akamatsu
- Department of Hospital Pharmacy, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Yusuke Kohno
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Junya Hashizume
- Department of Hospital Pharmacy, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan; Department of Medical Safety, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Hiroo Nakagawa
- Department of Hospital Pharmacy, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Yukinobu Kodama
- Department of Hospital Pharmacy, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Hiroaki Kawano
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Koji Maemura
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Kaname Ohyama
- Department of Hospital Pharmacy, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| |
Collapse
|
4
|
Allerton CN, Arcari JT, Aschenbrenner LM, Avery M, Bechle BM, Behzadi MA, Boras B, Buzon LM, Cardin RD, Catlin NR, Carlo AA, Coffman KJ, Dantonio A, Di L, Eng H, Farley KA, Ferre RA, Gernhardt SS, Gibson SA, Greasley SE, Greenfield SR, Hurst BL, Kalgutkar AS, Kimoto E, Lanyon LF, Lovett GH, Lian Y, Liu W, Martínez Alsina LA, Noell S, Obach RS, Owen DR, Patel NC, Rai DK, Reese MR, Rothan HA, Sakata S, Sammons MF, Sathish JG, Sharma R, Steppan CM, Tuttle JB, Verhoest PR, Wei L, Yang Q, Yurgelonis I, Zhu Y. A Second-Generation Oral SARS-CoV-2 Main Protease Inhibitor Clinical Candidate for the Treatment of COVID-19. J Med Chem 2024; 67:13550-13571. [PMID: 38687966 PMCID: PMC11345836 DOI: 10.1021/acs.jmedchem.3c02469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 03/13/2024] [Accepted: 04/22/2024] [Indexed: 05/02/2024]
Abstract
Despite the record-breaking discovery, development and approval of vaccines and antiviral therapeutics such as Paxlovid, coronavirus disease 2019 (COVID-19) remained the fourth leading cause of death in the world and third highest in the United States in 2022. Here, we report the discovery and characterization of PF-07817883, a second-generation, orally bioavailable, SARS-CoV-2 main protease inhibitor with improved metabolic stability versus nirmatrelvir, the antiviral component of the ritonavir-boosted therapy Paxlovid. We demonstrate the in vitro pan-human coronavirus antiviral activity and off-target selectivity profile of PF-07817883. PF-07817883 also demonstrated oral efficacy in a mouse-adapted SARS-CoV-2 model at plasma concentrations equivalent to nirmatrelvir. The preclinical in vivo pharmacokinetics and metabolism studies in human matrices are suggestive of improved oral pharmacokinetics for PF-07817883 in humans, relative to nirmatrelvir. In vitro inhibition/induction studies against major human drug metabolizing enzymes/transporters suggest a low potential for perpetrator drug-drug interactions upon single-agent use of PF-07817883.
Collapse
Affiliation(s)
| | - Joel T. Arcari
- Pfizer
Research & Development, Groton, Connecticut 06340, United States
| | | | - Melissa Avery
- Pfizer
Research & Development, Groton, Connecticut 06340, United States
| | - Bruce M. Bechle
- Pfizer
Research & Development, Groton, Connecticut 06340, United States
| | | | - Britton Boras
- Pfizer
Research & Development, La
Jolla, California 92121, United States
| | - Leanne M. Buzon
- Pfizer
Research & Development, Groton, Connecticut 06340, United States
| | - Rhonda D. Cardin
- Pfizer
Research & Development, Pearl
River, New York 10965, United States
| | - Natasha R. Catlin
- Pfizer
Research & Development, Groton, Connecticut 06340, United States
| | - Anthony A. Carlo
- Pfizer
Research & Development, Groton, Connecticut 06340, United States
| | - Karen J. Coffman
- Pfizer
Research & Development, Groton, Connecticut 06340, United States
| | - Alyssa Dantonio
- Pfizer
Research & Development, Groton, Connecticut 06340, United States
| | - Li Di
- Pfizer
Research & Development, Groton, Connecticut 06340, United States
| | - Heather Eng
- Pfizer
Research & Development, Groton, Connecticut 06340, United States
| | | | - Rose Ann Ferre
- Pfizer
Research & Development, La
Jolla, California 92121, United States
| | | | - Scott A. Gibson
- Institute
for Antiviral Research, Department of Animal, Dairy, and Veterinary
Sciences, Utah State University, Logan, Utah 84322, United States
| | | | | | - Brett L. Hurst
- Institute
for Antiviral Research, Department of Animal, Dairy, and Veterinary
Sciences, Utah State University, Logan, Utah 84322, United States
| | - Amit S. Kalgutkar
- Pfizer
Research & Development, Cambridge, Massachusetts 02139, United States
| | - Emi Kimoto
- Pfizer
Research & Development, Groton, Connecticut 06340, United States
| | | | - Gabrielle H. Lovett
- Pfizer
Research & Development, Cambridge, Massachusetts 02139, United States
| | - Yajing Lian
- Pfizer
Research & Development, Groton, Connecticut 06340, United States
| | - Wei Liu
- Pfizer
Research & Development, La
Jolla, California 92121, United States
| | | | - Stephen Noell
- Pfizer
Research & Development, Groton, Connecticut 06340, United States
| | - R. Scott Obach
- Pfizer
Research & Development, Groton, Connecticut 06340, United States
| | - Dafydd R. Owen
- Pfizer
Research & Development, Cambridge, Massachusetts 02139, United States
| | - Nandini C. Patel
- Pfizer
Research & Development, Cambridge, Massachusetts 02139, United States
| | - Devendra K. Rai
- Pfizer
Research & Development, Groton, Connecticut 06340, United States
| | - Matthew R. Reese
- Pfizer
Research & Development, Groton, Connecticut 06340, United States
| | - Hussin A. Rothan
- Pfizer
Research & Development, Pearl
River, New York 10965, United States
| | - Sylvie Sakata
- Pfizer
Research & Development, La
Jolla, California 92121, United States
| | - Matthew F. Sammons
- Pfizer
Research & Development, Cambridge, Massachusetts 02139, United States
| | - Jean G. Sathish
- Pfizer
Research & Development, Pearl
River, New York 10965, United States
| | - Raman Sharma
- Pfizer
Research & Development, Groton, Connecticut 06340, United States
| | - Claire M. Steppan
- Pfizer
Research & Development, Groton, Connecticut 06340, United States
| | - Jamison B. Tuttle
- Pfizer
Research & Development, Cambridge, Massachusetts 02139, United States
| | - Patrick R. Verhoest
- Pfizer
Research & Development, Cambridge, Massachusetts 02139, United States
| | - Liuqing Wei
- Pfizer
Research & Development, Groton, Connecticut 06340, United States
| | - Qingyi Yang
- Pfizer
Research & Development, Cambridge, Massachusetts 02139, United States
| | - Irina Yurgelonis
- Pfizer
Research & Development, Pearl
River, New York 10965, United States
| | - Yuao Zhu
- Pfizer
Research & Development, Pearl
River, New York 10965, United States
| |
Collapse
|
5
|
Lee WH, Kung YY, Sun CK, Chang CH, Peng WY, Lin LC, Hsu CH, Yang MH, Tsai TH. The anti-COVID-19 drug nirmatrelvir crosses the blood‒brain barrier and exhibits herb-drug pharmacokinetic interactions with Scutellaria baicalensis formulations. Heliyon 2024; 10:e34820. [PMID: 39170551 PMCID: PMC11336326 DOI: 10.1016/j.heliyon.2024.e34820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Revised: 06/28/2024] [Accepted: 07/17/2024] [Indexed: 08/23/2024] Open
Abstract
Aim of the study Our hypothesis is that nirmatrelvir can penetrate the blood‒brain barrier and reach effective concentrations in the brain. Furthermore, herbal formulations can help maintain nirmatrelvir levels in the body, suggesting potential interactions between these medications. Materials and methods To investigate this hypothesis, an animal model combining multisite microdialysis, ultrahigh-performance liquid chromatography and tandem mass spectrometry (UHPLC-MS/MS) methods was developed to monitor nirmatrelvir levels in the blood and brain of rats. Results The pharmacokinetic results showed that the area under the curve (AUC) of nirmatrelvir in the blood and brain was 798.3 ± 58.56 and 187.2 ± 23.46 min μg/mL, respectively, after the administration of nirmatrelvir alone (15 mg/kg, iv). When the Scutellaria baicalensis formulations were administered for five consecutive days prior to drug administration, the AUC of nirmatrelvir in the blood increased. Conclusions These results provide constructive preclinical information that the concentrations of nirmatrelvir in the blood and brain were greater than the effective concentration (EC90) for more than 6 h, and the Scutellaria baicalensis formulations had synergistic pharmacokinetic effects by increasing the concentration of nirmatrelvir in the blood.
Collapse
Affiliation(s)
- Wan-Hsin Lee
- Institute of Traditional Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yen-Ying Kung
- Institute of Traditional Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Center for Traditional Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Chung-Kai Sun
- Institute of Traditional Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chun-Hao Chang
- Institute of Traditional Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wen-Ya Peng
- Institute of Traditional Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Lie-Chwen Lin
- National Research Institute of Chinese Medicine, Ministry of Health and Welfare, Taipei, Taiwan
| | - Chung-Hua Hsu
- Institute of Traditional Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Branch of Linsen Chinese and Kunming, Taipei City Hospital, Taipei, Taiwan
| | - Muh-Hwa Yang
- Institute of Clinical Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Tung-Hu Tsai
- Institute of Traditional Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Graduate Institute of Acupuncture Science, China Medical University, Taichung, 404, Taiwan
- School of Pharmacy, Kaohsiung Medical University, Kaohsiung, 807, Taiwan
- Graduate Institute of Law and Interdisciplinary Studies, College of Law, National Chengchi University, Taipei, 116, Taiwan
| |
Collapse
|
6
|
Di Lenarda A, Ferri N, Lanzafame M, Montuori EA, Pacelli L. Cardiovascular Drug Interactions with Nirmatrelvir/Ritonavir for COVID-19: Considerations for Daily Practice. Eur Cardiol 2024; 19:e15. [PMID: 39220617 PMCID: PMC11363061 DOI: 10.15420/ecr.2024.04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 04/03/2024] [Indexed: 09/04/2024] Open
Abstract
Cardiovascular disease is associated with progression to severe COVID-19 and patients with the condition are among those in whom early antiviral therapy should be warranted. The combination of nirmatrelvir/ritonavir (Paxlovid®) has been approved for clinical use by the Food and Drug Administration and European Medicines Agency. Because patients with cardiovascular disease are often on polypharmacy, physicians need to be aware of potential drug-drug interactions (DDIs) when treating COVID-19 with nirmatrelvir/ritonavir. Guidance is given for avoiding DDIs, emphasising that preventing and managing potential DDIs with nirmatrelvir/ritonavir requires thorough assessment and knowledge. The present review summarises the clinical pharmacology of nirmatrelvir/ritonavir and provides details on potential DDIs with a focus on daily practice in patients with cardiovascular disease. Particular attention is needed for drugs that are predominantly metabolised by cytochrome P450 3A4, are substrates of P-glycoprotein and have a narrow therapeutic index. Proper management of potential DDIs must balance the benefit of nirmatrelvir/ ritonavir to prevent severe disease with the risk of serious adverse events.
Collapse
Affiliation(s)
- Andrea Di Lenarda
- Cardiovascular Center, Territory Specialist Department, Azienda Sanitaria Universitaria Giuliano Isontina – ASUGITrieste, Italy
| | - Nicola Ferri
- Department of Medicine, University of PadovaPadua, Italy
- Veneto Institute of Molecular Medicine (VIMM)Padua, Italy
| | | | | | | |
Collapse
|
7
|
Yang P, Liu W, Ying Y, Zhao L, Xiong X, Zhang X, Cheng Y, Zhou C, Zhang Y, Li X, Xu J, Yang L, Zhao R. Population pharmacokinetics of nirmatrelvir in Chinese patients with COVID-19: Therapeutic drug monitoring and dosing regimen selection in clinical practice. Int J Antimicrob Agents 2024; 64:107199. [PMID: 38795931 DOI: 10.1016/j.ijantimicag.2024.107199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 04/21/2024] [Accepted: 05/04/2024] [Indexed: 05/28/2024]
Abstract
OBJECTIVES To establish a population pharmacokinetics (PopPK) model of nirmatrelvir in Chinese COVID-19 patients and provide reference for refining the dosing strategy of nirmatrelvir in patients confirmed to be infected with SARS-CoV-2. METHODS A total of 80 blood samples were obtained from 35 mild to moderate COVID-19 patients who were orally administered nirmatrelvir/ritonavir tablets. The PopPK model of nirmatrelvir was developed using a nonlinear mixed effects modelling approach. The stability and prediction of the final model were assessed through a combination of goodness-of-fit and bootstrap method. The exposure of nirmatrelvir across various clinical scenarios was simulated using Monte Carlo simulations. RESULTS The pharmacokinetics of nirmatrelvir was well characterised by a one-compartment model with first-order absorption, and with creatinine clearance (Ccr) as the significant covariate. Typical population parameter estimates of apparent clearance and distribution volume for a patient with a Ccr of 95.5 mL·min-1were 3.45 L·h-1 and 48.71 L, respectively. The bootstrap and visual predictive check procedures demonstrated satisfactory predictive performance and robustness of the final model. CONCLUSION The final model was capable of offering an early prediction of drug concentration ranges for different nirmatrelvir dosing regimens and optimise the dose regimen of nirmatrelvir in individuals with confirmed SARS-CoV-2 infection.
Collapse
Affiliation(s)
- Ping Yang
- Department of Pharmacy, Peking University Third Hospital, Beijing, China; Therapeutic Drug Monitoring and Clinical Toxicology Center of Peking University, Beijing, China
| | - Wei Liu
- Department of Pharmacy, Peking University Third Hospital, Beijing, China; Therapeutic Drug Monitoring and Clinical Toxicology Center of Peking University, Beijing, China
| | - Yingqiu Ying
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - Libo Zhao
- Department of Pharmacy, Peking University Third Hospital, Beijing, China; Therapeutic Drug Monitoring and Clinical Toxicology Center of Peking University, Beijing, China
| | - Xin Xiong
- Department of Pharmacy, Peking University Third Hospital, Beijing, China; Therapeutic Drug Monitoring and Clinical Toxicology Center of Peking University, Beijing, China
| | - Xianhua Zhang
- Department of Pharmacy, Peking University Third Hospital, Beijing, China; Therapeutic Drug Monitoring and Clinical Toxicology Center of Peking University, Beijing, China
| | - Yinchu Cheng
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
| | - Congya Zhou
- Department of Pharmacy, Peking University Third Hospital, Beijing, China; Therapeutic Drug Monitoring and Clinical Toxicology Center of Peking University, Beijing, China
| | - Yuanyuan Zhang
- Department of Pharmacy, Peking University Third Hospital, Beijing, China; Therapeutic Drug Monitoring and Clinical Toxicology Center of Peking University, Beijing, China
| | - Xiaona Li
- Department of Pharmacy, Peking University Third Hospital, Beijing, China; Therapeutic Drug Monitoring and Clinical Toxicology Center of Peking University, Beijing, China
| | - Jiamin Xu
- Department of Pharmacy, Peking University Third Hospital, Beijing, China; Therapeutic Drug Monitoring and Clinical Toxicology Center of Peking University, Beijing, China
| | - Li Yang
- Department of Pharmacy, Peking University Third Hospital, Beijing, China; Therapeutic Drug Monitoring and Clinical Toxicology Center of Peking University, Beijing, China.
| | - Rongsheng Zhao
- Department of Pharmacy, Peking University Third Hospital, Beijing, China; Therapeutic Drug Monitoring and Clinical Toxicology Center of Peking University, Beijing, China.
| |
Collapse
|
8
|
Zeng L, Chen R, Jiang X, Li F, Zhu Z, Jiao Z, Ling Y, Zhang L. Population pharmacokinetics and pharmacodynamics of nirmatrelvir in Chinese patients with COVID-19. Fundam Clin Pharmacol 2024; 38:767-779. [PMID: 38342488 DOI: 10.1111/fcp.12989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 12/17/2023] [Accepted: 01/14/2024] [Indexed: 02/13/2024]
Abstract
BACKGROUND The pharmacokinetic (PK) and pharmacodynamic (PD) characteristics of nirmatrelvir (NMV) are unknown in Chinese patients with COVID-19. OBJECTIVES To understand the PK, as well as PK-PD characteristics of NMV for optimizing the dose in Chinese patients with COVID-19. METHODS We enrolled 141 participants who received NMV 300 mg/ritonavir (RTV) 100 mg b.i.d. for 5 days. The NMV concentrations were analyzed using 251 blood samples. PK/PD of NMV was investigated in these COVID-19 patients using a nonlinear mixed-effects model. RESULTS The patients had a mean age of 82 years (range, 34-97). The absorption rate constant and apparent clearance of NMV in this Chinese cohort were 0.253 h-1 and 6.83 L/h, respectively, similar to Caucasian patients. No covariates affected NMV clearance. Predicted peak (Cmax) and trough concentration (Cmin) under 300 mg NMV/100 mg RTV b.i.d. were 4004 and 1498 ng/mL, respectively. Although higher AUC and Cmin were weakly associated with a slight increase in the number of cycle threshold (CT) of viral genes, no significant correlation was found, indicating a weak relationship between drug exposure and efficacy (CT). CONCLUSIONS In all, our findings suggest no ethnic PK differences, a weak and clinically insignificant relationship between drug exposure and efficacy, suitable dosage for Chinese patients (including the elderly) based on PK parameters, and the need for further studies to determine optimal regimens for high-risk patients due to inter-individual variability.
Collapse
Affiliation(s)
- Liyan Zeng
- Department of Clinical Research Center, Shanghai Public Health Clinical Center, Fudan University, Shanghai, China
| | - Rui Chen
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Xuhua Jiang
- Department of Clinical Research Center, Shanghai Public Health Clinical Center, Fudan University, Shanghai, China
| | - Feng Li
- Department of Clinical Research Center, Shanghai Public Health Clinical Center, Fudan University, Shanghai, China
| | - Zhaoqin Zhu
- Department of Clinical Research Center, Shanghai Public Health Clinical Center, Fudan University, Shanghai, China
| | - Zheng Jiao
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yun Ling
- Department of Clinical Research Center, Shanghai Public Health Clinical Center, Fudan University, Shanghai, China
| | - Lijun Zhang
- Department of Clinical Research Center, Shanghai Public Health Clinical Center, Fudan University, Shanghai, China
| |
Collapse
|
9
|
Wu YE, Zheng YY, Li QY, Yao BF, Cao J, Liu HX, Hao GX, van den Anker J, Zheng Y, Zhao W. Model-informed drug development in pediatric, pregnancy and geriatric drug development: States of the art and future. Adv Drug Deliv Rev 2024; 211:115364. [PMID: 38936664 DOI: 10.1016/j.addr.2024.115364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 06/09/2024] [Accepted: 06/19/2024] [Indexed: 06/29/2024]
Abstract
The challenges of drug development in pediatric, pregnant and geriatric populations are a worldwide concern shared by regulatory authorities, pharmaceutical companies, and healthcare professionals. Model-informed drug development (MIDD) can integrate and quantify real-world data of physiology, pharmacology, and disease processes by using modeling and simulation techniques to facilitate decision-making in drug development. In this article, we reviewed current MIDD policy updates, reflected on the integrity of physiological data used for MIDD and the effects of physiological changes on the drug PK, as well as summarized current MIDD strategies and applications, so as to present the state of the art of MIDD in pediatric, pregnant and geriatric populations. Some considerations are put forth for the future improvements of MIDD including refining regulatory considerations, improving the integrity of physiological data, applying the emerging technologies, and exploring the application of MIDD in new therapies like gene therapies for special populations.
Collapse
Affiliation(s)
- Yue-E Wu
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Yuan-Yuan Zheng
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Qiu-Yue Li
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Bu-Fan Yao
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Jing Cao
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Hui-Xin Liu
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Guo-Xiang Hao
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - John van den Anker
- Division of Clinical Pharmacology, Children's National Medical Center, Washington, DC, USA; Departments of Pediatrics, Pharmacology & Physiology, George Washington University, School of Medicine and Health Sciences, Washington, DC, USA; Department of Paediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel, Basel, Switzerland
| | - Yi Zheng
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Wei Zhao
- Department of Clinical Pharmacy, Institute of Clinical Pharmacology, Key Laboratory of Chemical Biology (Ministry of Education), NMPA Key Laboratory for Clinical Research and Evaluation of Innovative Drug, School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, China.
| |
Collapse
|
10
|
Xu X, Zhang H, Liu L, Fu Q, Wu C, Lin X, Tang K, Wang C, Chen P. Pharmacokinetics of nirmatrelvir/ritonavir and the drug-drug interaction with calcineurin inhibitor in renal transplant recipients. Eur J Clin Pharmacol 2024; 80:1219-1227. [PMID: 38691139 DOI: 10.1007/s00228-024-03691-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Accepted: 04/15/2024] [Indexed: 05/03/2024]
Abstract
OBJECTIVES To describe the pharmacokinetic (PK) characteristics of nirmatrelvir/ritonavir in renal transplant recipients and explore the potential factors that related to the PK variance of nirmatrelvir/ritonavir and its interaction with calcineurin inhibitor (CNI). METHODS Renal transplant recipients treated with CNI and nirmatrelvir/ritonavir were prospectively enrolled. Steady-state plasma concentrations of nirmatrelvir/ritonavir were determined by high-performance liquid chromatography-tandem mass spectrometry, and the PK parameters were calculated using non-compartmental analysis. Spearman correlation analysis was used for exploring influencing factors. RESULTS A total of eight recipients were enrolled; for nirmatrelvir and ritonavir, AUC/dose was 0.24179 ± 0.14495 and 0.06196 ± 0.03767 μg·h·mL-1·mg-1. Red blood cell (RBC), hematocrit (Ht), hemoglobins (Hb), and creatinine clearance (Ccr) were negatively correlated with AUC/dose of nirmatrelvir, while Ccr, CYP3A5 genotype, and CYP3A4 genotype were related to the AUC/dose of ritonavir. Ccr was negatively correlated with the C0/dose of tacrolimus (TAC) after termination of nirmatrelvir/ritonavir (rs = -0.943, p = 0.008). CONCLUSIONS The PK characteristics of nirmatrelvir/ritonavir vary greatly among renal transplant recipients. Factors including Ccr and CYP3A5 genotype were related to the in vivo exposure of nirmatrelvir/ritonavir. During the whole process before and after nirmatrelvir/ritonavir therapy, it is recommended to adjust the CNI basing on renal function to avoid CNI toxicity exposure.
Collapse
Affiliation(s)
- Xueyin Xu
- Department of Pharmacy, the First Affiliated Hospital, Sun Yat-sen University, No. 58, Zhong Shan Er Lu, Guangzhou, China
- Institute of Clinical Pharmacology, Sun Yat-sen University, Guangzhou, China
| | - Huanxi Zhang
- Organ Transplant Center, the First Affiliated Hospital, Sun Yat-sen University, No. 58, Zhong Shan Er Lu, Guangzhou, China
| | - Longshan Liu
- Organ Transplant Center, the First Affiliated Hospital, Sun Yat-sen University, No. 58, Zhong Shan Er Lu, Guangzhou, China
| | - Qian Fu
- Organ Transplant Center, the First Affiliated Hospital, Sun Yat-sen University, No. 58, Zhong Shan Er Lu, Guangzhou, China
| | - Chenglin Wu
- Organ Transplant Center, the First Affiliated Hospital, Sun Yat-sen University, No. 58, Zhong Shan Er Lu, Guangzhou, China
| | - Xiaobin Lin
- Department of Pharmacy, the First Affiliated Hospital, Sun Yat-sen University, No. 58, Zhong Shan Er Lu, Guangzhou, China
| | - Kejing Tang
- Department of Pharmacy, the First Affiliated Hospital, Sun Yat-sen University, No. 58, Zhong Shan Er Lu, Guangzhou, China
| | - Changxi Wang
- Organ Transplant Center, the First Affiliated Hospital, Sun Yat-sen University, No. 58, Zhong Shan Er Lu, Guangzhou, China.
| | - Pan Chen
- Department of Pharmacy, the First Affiliated Hospital, Sun Yat-sen University, No. 58, Zhong Shan Er Lu, Guangzhou, China.
| |
Collapse
|
11
|
Zagórska A, Czopek A, Fryc M, Jończyk J. Inhibitors of SARS-CoV-2 Main Protease (Mpro) as Anti-Coronavirus Agents. Biomolecules 2024; 14:797. [PMID: 39062511 PMCID: PMC11275247 DOI: 10.3390/biom14070797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Revised: 07/01/2024] [Accepted: 07/03/2024] [Indexed: 07/28/2024] Open
Abstract
The main protease (Mpro) of SARS-CoV-2 is an essential enzyme that plays a critical part in the virus's life cycle, making it a significant target for developing antiviral drugs. The inhibition of SARS-CoV-2 Mpro has emerged as a promising approach for developing therapeutic agents to treat COVID-19. This review explores the structure of the Mpro protein and analyzes the progress made in understanding protein-ligand interactions of Mpro inhibitors. It focuses on binding kinetics, origin, and the chemical structure of these inhibitors. The review provides an in-depth analysis of recent clinical trials involving covalent and non-covalent inhibitors and emerging dual inhibitors targeting SARS-CoV-2 Mpro. By integrating findings from the literature and ongoing clinical trials, this review captures the current state of research into Mpro inhibitors, offering a comprehensive understanding of challenges and directions in their future development as anti-coronavirus agents. This information provides new insights and inspiration for medicinal chemists, paving the way for developing more effective Mpro inhibitors as novel COVID-19 therapies.
Collapse
Affiliation(s)
- Agnieszka Zagórska
- Department of Medicinal Chemistry, Jagiellonian University Medical College, Medyczna 9, 30-688 Kraków, Poland; (A.C.); (M.F.); (J.J.)
| | | | | | | |
Collapse
|
12
|
Hershan AA. Pathogenesis of COVID19 and the applications of US FDA-approved repurposed antiviral drugs to combat SARS-CoV-2 in Saudi Arabia: A recent update by review of literature. Saudi J Biol Sci 2024; 31:104023. [PMID: 38799719 PMCID: PMC11127266 DOI: 10.1016/j.sjbs.2024.104023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Revised: 05/05/2024] [Accepted: 05/10/2024] [Indexed: 05/29/2024] Open
Abstract
Still, there is no cure for the highly contagious severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-caused coronavirus disease 2019 (COVID19). The COVID19 pandemic caused health emergencies which resulted in enormous medical and financial consequences worldwide including Saudi Arabia. Saudi Arabia is the largest Arab country of the Middle East. The urban setting of Saudi Arabia makes it vulnerable towards SARS-CoV-2 (SCV-2). Religious areas of this country are visited by millions of pilgrims every year for the Umrah and Hajj pilgrimage, which contributes to the potential COVID19 epidemic risk. COVID19 throws various challenges to healthcare professionals to choose the right drugs or therapy in clinical settings because of the lack of availability of newer drugs. Current drug development and discovery is an expensive, complex, and long process, which involves a high failure rate in clinical trials. While repurposing of United States Food and Drug Administration (US FDA)-approved antiviral drugs offers numerous benefits including complete pharmacokinetic and safety profiles, which significantly shorten drug development cycles and reduce costs. A range of repurposed US FDA-approved antiviral drugs including ribavirin, lopinavir/ritonavir combination, oseltamivir, darunavir, remdesivir, nirmatrelvir/ritonavir combination, and molnupiravir showed encouraging results in clinical trials in COVID19 treatment. In this article, several COVID19-related discussions have been provided including emerging variants of concern of, COVID19 pathogenesis, COVID19 pandemic scenario in Saudi Arabia, drug repurposing strategies against SCV-2, as well as repurposing of US FDA-approved antiviral drugs that might be considered to combat SCV-2 in Saudi Arabia. Moreover, drug repurposing in the context of COVID19 management along with its limitations and future perspectives have been summarized.
Collapse
Affiliation(s)
- Almonther Abdullah Hershan
- The University of Jeddah, College of Medicine, Department of Medical microbiology and parasitology, Jeddah, Saudi Arabia
| |
Collapse
|
13
|
Esmaeili S, Owens K, Wagoner J, Polyak SJ, White JM, Schiffer JT. A unifying model to explain frequent SARS-CoV-2 rebound after nirmatrelvir treatment and limited prophylactic efficacy. Nat Commun 2024; 15:5478. [PMID: 38942778 PMCID: PMC11213957 DOI: 10.1038/s41467-024-49458-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 06/04/2024] [Indexed: 06/30/2024] Open
Abstract
In a pivotal trial (EPIC-HR), a 5-day course of oral ritonavir-boosted nirmatrelvir, given early during symptomatic SARS-CoV-2 infection (within three days of symptoms onset), decreased hospitalization and death by 89.1% and nasal viral load by 0.87 log relative to placebo in high-risk individuals. Yet, nirmatrelvir/ritonavir failed as post-exposure prophylaxis in a trial, and frequent viral rebound has been observed in subsequent cohorts. We develop a mathematical model capturing viral-immune dynamics and nirmatrelvir pharmacokinetics that recapitulates viral loads from this and another clinical trial (PLATCOV). Our results suggest that nirmatrelvir's in vivo potency is significantly lower than in vitro assays predict. According to our model, a maximally potent agent would reduce the viral load by approximately 3.5 logs relative to placebo at 5 days. The model identifies that earlier initiation and shorter treatment duration are key predictors of post-treatment rebound. Extension of treatment to 10 days for Omicron variant infection in vaccinated individuals, rather than increasing dose or dosing frequency, is predicted to lower the incidence of viral rebound significantly.
Collapse
Affiliation(s)
- Shadisadat Esmaeili
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA.
| | - Katherine Owens
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
| | - Jessica Wagoner
- Department of Laboratory Medicine & Pathology, University of Washington, Seattle, WA, USA
| | - Stephen J Polyak
- Department of Laboratory Medicine & Pathology, University of Washington, Seattle, WA, USA
| | - Judith M White
- Department of Cell Biology, University of Virginia, Charlottesville, VA, USA
| | - Joshua T Schiffer
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, WA, USA
- Department of Medicine, University of Washington, Seattle, WA, USA
| |
Collapse
|
14
|
Focosi D, Franchini M, Maggi F, Shoham S. COVID-19 therapeutics. Clin Microbiol Rev 2024; 37:e0011923. [PMID: 38771027 PMCID: PMC11237566 DOI: 10.1128/cmr.00119-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024] Open
Abstract
SUMMARYSince the emergence of COVID-19 in 2020, an unprecedented range of therapeutic options has been studied and deployed. Healthcare providers have multiple treatment approaches to choose from, but efficacy of those approaches often remains controversial or compromised by viral evolution. Uncertainties still persist regarding the best therapies for high-risk patients, and the drug pipeline is suffering fatigue and shortage of funding. In this article, we review the antiviral activity, mechanism of action, pharmacokinetics, and safety of COVID-19 antiviral therapies. Additionally, we summarize the evidence from randomized controlled trials on efficacy and safety of the various COVID-19 antivirals and discuss unmet needs which should be addressed.
Collapse
Affiliation(s)
- Daniele Focosi
- North-Western Tuscany Blood Bank, Pisa University Hospital, Pisa, Italy
| | - Massimo Franchini
- Division of Hematology and Transfusion Medicine, Carlo Poma Hospital, Mantua, Italy
| | - Fabrizio Maggi
- National Institute for Infectious Diseases "Lazzaro Spallanzani" IRCCS, Rome, Italy
| | - Shmuel Shoham
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| |
Collapse
|
15
|
Fernández-de-las-Peñas C, Franco-Moreno A, Ruiz-Ruigómez M, Arrieta-Ortubay E, Ryan-Murua P, Lumbreras-Bermejo C, del-Valle-Loarte P, Pellicer-Valero OJ, Giordano R, Arendt-Nielsen L, Martín-Garrido I, Torres-Macho J. Is Antiviral Treatment with Remdesivir at the Acute Phase of SARS-CoV-2 Infection Effective for Decreasing the Risk of Long-Lasting Post-COVID Symptoms? Viruses 2024; 16:947. [PMID: 38932239 PMCID: PMC11209434 DOI: 10.3390/v16060947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Revised: 06/08/2024] [Accepted: 06/09/2024] [Indexed: 06/28/2024] Open
Abstract
The aim of this study was to investigate the effects of administrating Remdesivir at the acute COVID-19 phase on developing post-COVID symptoms in previously hospitalized COVID-19 survivors by controlling factors such as age, sex, body mass index, and vaccination status. A case-control study was performed. Hospitalized COVID-19 survivors who had received intravenous Remdesivir during the acute phase (n = 216) were matched by age, sex, body mass index, and vaccination status with survivors who did not receive antiviral treatment (n = 216). Participants were asked to self-report the presence of any post-COVID symptom (defined as a symptom that started no later than three months after infection) and whether the symptom persisted at the time of study (mean: 18.4, SD: 0.8 months). Anxiety levels (HADS-A), depressive symptoms (HADS-D), sleep quality (PSQI), and severity/disability (FIC) were also compared. The multivariate analysis revealed that administration of Remdesivir at the acute COVID-19 phase was a protective factor for long-term COVID development (OR0.401, 95%CI 0.256-0.628) and specifically for the following post-COVID symptoms: fatigue (OR0.399, 95%CI 0.270-0.590), pain (OR0.368, 95% CI 0.248-0.548), dyspnea at rest (OR0.580, 95%CI 0.361-0.933), concentration loss (OR0.368, 95%CI 0.151-0.901), memory loss (OR0.399, 95%CI 0.270-0.590), hair loss (OR0.103, 95%CI 0.052-0.207), and skin rashes (OR0.037, 95%CI 0.005-0.278). This study supports the potential protective role of intravenous administration of Remdesivir during the COVID-19 acute phase for long-lasting post-COVID symptoms in previously hospitalized COVID-19 survivors.
Collapse
Affiliation(s)
- César Fernández-de-las-Peñas
- Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation, Universidad Rey Juan Carlos, 28922 Madrid, Spain
- Center for Neuroplasticity and Pain (CNAP), Sensory-Motor Interaction (SMI), Department of Health Science and Technology, Faculty of Medicine, Aalborg University, DK 9220 Aalborg, Denmark; (R.G.); (L.A.-N.)
| | - Anabel Franco-Moreno
- Department of Internal Medicine, Hospital Universitario Infanta Leonor-Virgen de la Torre, 28031 Madrid, Spain; (A.F.-M.); (P.R.-M.); (J.T.-M.)
| | - María Ruiz-Ruigómez
- Department of Internal Medicine, Hospital Universitario Doce de Octubre, 28041 Madrid, Spain; (M.R.-R.); (E.A.-O.); (C.L.-B.)
| | - Estibaliz Arrieta-Ortubay
- Department of Internal Medicine, Hospital Universitario Doce de Octubre, 28041 Madrid, Spain; (M.R.-R.); (E.A.-O.); (C.L.-B.)
| | - Pablo Ryan-Murua
- Department of Internal Medicine, Hospital Universitario Infanta Leonor-Virgen de la Torre, 28031 Madrid, Spain; (A.F.-M.); (P.R.-M.); (J.T.-M.)
- CIBER de Enfermedades Infecciosas (CIBERINFEC), Instituto de Investigación Carlos III (ISCIIII), 28220 Madrid, Spain
| | - Carlos Lumbreras-Bermejo
- Department of Internal Medicine, Hospital Universitario Doce de Octubre, 28041 Madrid, Spain; (M.R.-R.); (E.A.-O.); (C.L.-B.)
| | - Pablo del-Valle-Loarte
- Department of Internal Medicine, Hospital Universitario Severo Ochoa, 28911 Madrid, Spain;
| | - Oscar J. Pellicer-Valero
- Image Processing Laboratory (IPL), Universitat de València, Parc Científic, Paterna, 46980 València, Spain;
| | - Rocco Giordano
- Center for Neuroplasticity and Pain (CNAP), Sensory-Motor Interaction (SMI), Department of Health Science and Technology, Faculty of Medicine, Aalborg University, DK 9220 Aalborg, Denmark; (R.G.); (L.A.-N.)
- Department of Oral and Maxillofacial Surgery, Aalborg University Hospital, DK 9100 Aalborg, Denmark
| | - Lars Arendt-Nielsen
- Center for Neuroplasticity and Pain (CNAP), Sensory-Motor Interaction (SMI), Department of Health Science and Technology, Faculty of Medicine, Aalborg University, DK 9220 Aalborg, Denmark; (R.G.); (L.A.-N.)
- Department of Gastroenterology & Hepatology, Mech-Sense, Clinical Institute, Aalborg University Hospital, DK 9100 Aalborg, Denmark
- Steno Diabetes Center North Denmark, Clinical Institute, Aalborg University Hospital, DK 9100 Aalborg, Denmark
| | | | - Juan Torres-Macho
- Department of Internal Medicine, Hospital Universitario Infanta Leonor-Virgen de la Torre, 28031 Madrid, Spain; (A.F.-M.); (P.R.-M.); (J.T.-M.)
- Department of Medicine, School of Medicine, Universidad Complutense de Madrid, 28040 Madrid, Spain
| |
Collapse
|
16
|
Esmaeili S, Owens K, Wagoner J, Polyak SJ, White JM, Schiffer JT. A unifying model to explain high nirmatrelvir therapeutic efficacy against SARS-CoV-2, despite low post-exposure prophylaxis efficacy and frequent viral rebound. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2023.08.23.23294505. [PMID: 38352583 PMCID: PMC10862980 DOI: 10.1101/2023.08.23.23294505] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 03/03/2024]
Abstract
In a pivotal trial (EPIC-HR), a 5-day course of oral ritonavir-boosted nirmatrelvir, given early during symptomatic SARS-CoV-2 infection (within three days of symptoms onset), decreased hospitalization and death by 89.1% and nasal viral load by 0.87 log relative to placebo in high-risk individuals. Yet, nirmatrelvir/ritonavir failed as post-exposure prophylaxis in a trial, and frequent viral rebound has been observed in subsequent cohorts. We developed a mathematical model capturing viral-immune dynamics and nirmatrelvir pharmacokinetics that recapitulated viral loads from this and another clinical trial (PLATCOV). Our results suggest that nirmatrelvir's in vivo potency is significantly lower than in vitro assays predict. According to our model, a maximally potent agent would reduce the viral load by approximately 3.5 logs relative to placebo at 5 days. The model identifies that earlier initiation and shorter treatment duration are key predictors of post-treatment rebound. Extension of treatment to 10 days for Omicron variant infection in vaccinated individuals, rather than increasing dose or dosing frequency, is predicted to lower the incidence of viral rebound significantly.
Collapse
Affiliation(s)
- Shadisadat Esmaeili
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center; Seattle, WA, USA
| | - Katherine Owens
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center; Seattle, WA, USA
| | - Jessica Wagoner
- Department of Medicine, University of Washington; Seattle, WA, USA
| | | | - Judith M. White
- Department of Cell Biology, University of Virginia; Charlottesville, VA, USA
| | - Joshua T. Schiffer
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center; Seattle, WA, USA
- Department of Medicine, University of Washington; Seattle, WA, USA
| |
Collapse
|
17
|
Ng TM, Wang Z, Chan ECY. Physiologically-based pharmacokinetic modelling guided dose evaluations of nirmatrelvir/ritonavir in renal impairment for the management of COVID-19. Br J Clin Pharmacol 2024. [PMID: 38616514 DOI: 10.1111/bcp.16074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 03/06/2024] [Accepted: 03/21/2024] [Indexed: 04/16/2024] Open
Abstract
We aimed to address factors contributing to the pharmacokinetic changes of nirmatrelvir/ritonavir in renal impaired (RI) patients and recommend dosing adjustment via a physiologically-based pharmacokinetic (PBPK) modelling approach. A PBPK model of nirmatrelvir/ritonavir was developed via Simcyp® Simulator. Sensitivity analysis of the influence of hepatic CYP3A4 intrinsic clearance and abundance, as well as hepatic non-CYP3A4 metabolism (other human liver microsomes [HLM] CLint) was performed to evaluate the effects of RI on oral clearance of nirmatrelvir. Other HLM CLint, the most sensitive parameter, was adjusted, and the simulated plasma concentration profiles of nirmatrelvir in severe RI subjects were within the therapeutic index of 292-10 000 ng/mL for dosing regimens of loading doses of 300/100 mg followed by 150/100 mg or 75/100 mg twice daily of nirmatrelvir/ritonavir. Considering that nirmatrelvir is available as a 150 mg tablet, we recommend 300/100 mg followed by 150/100 mg twice daily as the dosing regimen to be investigated in severe RI.
Collapse
Affiliation(s)
- Tat Ming Ng
- Department of Pharmacy and Pharmaceutical Sciences, Faculty of Science, National University of Singapore, Singapore, Singapore
- Division of Pharmacy, Tan Tock Seng Hospital, Novena, Singapore
| | - Ziteng Wang
- Department of Pharmacy and Pharmaceutical Sciences, Faculty of Science, National University of Singapore, Singapore, Singapore
| | - Eric Chun Yong Chan
- Department of Pharmacy and Pharmaceutical Sciences, Faculty of Science, National University of Singapore, Singapore, Singapore
| |
Collapse
|
18
|
Liu W, Yang P, Yang P, Yang L, Jing H, Zhao L, Zhao R. Clinical characteristics and pharmacokinetics of PAXLOVID in COVID-19 patients with hematological tumor. MEDICAL REVIEW (2021) 2024; 4:169-171. [PMID: 38680682 PMCID: PMC11046570 DOI: 10.1515/mr-2023-0068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 02/06/2024] [Indexed: 05/01/2024]
Affiliation(s)
- Wei Liu
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
- Therapeutic Drug Monitoring and Clinical Toxicology Center of Peking University, Beijing, China
- NMPA Key Laboratory for Research and Evaluation of Generic Drugs, Beijing, China
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
| | - Ping Yang
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
- Therapeutic Drug Monitoring and Clinical Toxicology Center of Peking University, Beijing, China
- NMPA Key Laboratory for Research and Evaluation of Generic Drugs, Beijing, China
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
| | - Ping Yang
- Department of Hematology, Peking University Third Hospital, Beijing, China
| | - Li Yang
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
- Therapeutic Drug Monitoring and Clinical Toxicology Center of Peking University, Beijing, China
- NMPA Key Laboratory for Research and Evaluation of Generic Drugs, Beijing, China
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
| | - Hongmei Jing
- Department of Hematology, Peking University Third Hospital, Beijing, China
| | - Libo Zhao
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
- Therapeutic Drug Monitoring and Clinical Toxicology Center of Peking University, Beijing, China
- NMPA Key Laboratory for Research and Evaluation of Generic Drugs, Beijing, China
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
| | - Rongsheng Zhao
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
- Therapeutic Drug Monitoring and Clinical Toxicology Center of Peking University, Beijing, China
- NMPA Key Laboratory for Research and Evaluation of Generic Drugs, Beijing, China
- Institute for Drug Evaluation, Peking University Health Science Center, Beijing, China
| |
Collapse
|
19
|
Chen C, Li R, Xing S, Cao L, Qu Y, Lv Q, Li X, Chen Z. Nirmatrelvir and ritonavir combination against COVID-19 caused by omicron BA.2.2 in the elderly: A single-center large observational study. Immun Inflamm Dis 2024; 12:e1232. [PMID: 38578027 PMCID: PMC10996376 DOI: 10.1002/iid3.1232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 02/03/2024] [Accepted: 03/14/2024] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND Since coronavirus 2019 (COVID-19) swept the world, a variety of novel therapeutic and prevention strategies have been developed, among which nirmatrelvir-ritonavir is highly recommended. We intended to assess the effectiveness and safety of nirmatrelvir-ritonavir in the elderly mild-to-moderate COVID-19 population caused by the omicron BA.2.2 variant in real-world settings. METHODS An observational study was conducted retrospectively to review the outcomes of mild-to-moderate COVID-19 patients admitted between April 26 and June 30, 2022. Patients' baseline characteristics were collected and assessed. Participants in the intervention group were administered nirmatrelvir-ritonavir in addition to standard care, whereas those in the control group only received standard care. The primary outcome was the duration between the initial positive reverse-transcription polymerase chain reaction (RT-PCR) test and the subsequent conversion to a negative result. RESULTS The analysis included 324 patients who were administered nirmatrelvir-ritonavir and an equal number of control patients. The patient characteristics in both groups were evenly matched. The average duration from the initial positive RT-PCR to negative conversion was similar in both groups (16.2 ± 5.0 vs. 16.1 ± 6.3 days, p = .83). Control patients exhibited slower conversion in comparison to patients who received nirmatrelvir-ritonavir treatment within 10 days of symptom onset. CONCLUSIONS These findings suggest that administering nirmatrelvir-ritonavir within 10 days of symptom onset could potentially reduce the time it takes for SARS-CoV-2-infected patients to negative RT-PCR results, thereby expanding the current usage guidelines for nirmatrelvir-ritonavir.
Collapse
Affiliation(s)
- Can Chen
- Department of Pharmacy, Zhongshan HospitalFudan UniversityShanghaiChina
| | - Ranyi Li
- Department of Pharmacy, Zhongshan HospitalFudan UniversityShanghaiChina
| | - Shuliang Xing
- Science and Education OfficeShanghai Geriatric Medical CenterShanghaiChina
| | - Lei Cao
- Medical Administration Office, Zhongshan HospitalFudan UniversityShanghaiChina
| | - Yue Qu
- Department of Infectious DiseasesThe Alfred Hospital and Monash UniversityClaytonAustralia
| | - Qianzhou Lv
- Department of Pharmacy, Zhongshan HospitalFudan UniversityShanghaiChina
| | - Xiaoyu Li
- Department of Pharmacy, Zhongshan HospitalFudan UniversityShanghaiChina
| | - Zhangzhang Chen
- Department of Pharmacy, Zhongshan HospitalFudan UniversityShanghaiChina
| |
Collapse
|
20
|
Westberg M, Su Y, Zou X, Huang P, Rustagi A, Garhyan J, Patel PB, Fernandez D, Wu Y, Hao C, Lo CW, Karim M, Ning L, Beck A, Saenkham-Huntsinger P, Tat V, Drelich A, Peng BH, Einav S, Tseng CTK, Blish C, Lin MZ. An orally bioavailable SARS-CoV-2 main protease inhibitor exhibits improved affinity and reduced sensitivity to mutations. Sci Transl Med 2024; 16:eadi0979. [PMID: 38478629 PMCID: PMC11193659 DOI: 10.1126/scitranslmed.adi0979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 02/21/2024] [Indexed: 05/09/2024]
Abstract
Inhibitors of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) main protease (Mpro) such as nirmatrelvir (NTV) and ensitrelvir (ETV) have proven effective in reducing the severity of COVID-19, but the presence of resistance-conferring mutations in sequenced viral genomes raises concerns about future drug resistance. Second-generation oral drugs that retain function against these mutants are thus urgently needed. We hypothesized that the covalent hepatitis C virus protease inhibitor boceprevir (BPV) could serve as the basis for orally bioavailable drugs that inhibit SARS-CoV-2 Mpro more efficiently than existing drugs. Performing structure-guided modifications of BPV, we developed a picomolar-affinity inhibitor, ML2006a4, with antiviral activity, oral pharmacokinetics, and therapeutic efficacy similar or superior to those of NTV. A crucial feature of ML2006a4 is a derivatization of the ketoamide reactive group that improves cell permeability and oral bioavailability. Last, ML2006a4 was found to be less sensitive to several mutations that cause resistance to NTV or ETV and occur in the natural SARS-CoV-2 population. Thus, anticipatory design can preemptively address potential resistance mechanisms to expand future treatment options against coronavirus variants.
Collapse
Affiliation(s)
- Michael Westberg
- Department of Neurobiology, Stanford University; Stanford, CA 94305, USA
- Department of Chemistry, Aarhus University; 8000 Aarhus C, Denmark
- Interdisciplinary Nanoscience Center (iNANO), Aarhus University; 8000 Aarhus C, Denmark
| | - Yichi Su
- Department of Neurobiology, Stanford University; Stanford, CA 94305, USA
- Institute for Translational Brain Research, State Key Laboratory of Medical Neurobiology, MOE Frontiers Center for Brain Science, Fudan University, Shanghai, 200032, China
| | - Xinzhi Zou
- Department of Bioengineering, Stanford University; Stanford, CA 94305, USA
| | - Pinghan Huang
- Department of Microbiology and Immunology, The University of Texas Medical Branch; Galveston, TX 77555, USA
| | - Arjun Rustagi
- Department of Medicine, Stanford University; Stanford, CA 94305, USA
| | - Jaishree Garhyan
- Stanford In Vitro Biosafety Level 3 Service Center, Stanford University; Stanford, CA 94305, USA
| | - Puja Bhavesh Patel
- Stanford In Vitro Biosafety Level 3 Service Center, Stanford University; Stanford, CA 94305, USA
| | - Daniel Fernandez
- Program in Chemistry, Engineering, and Medicine for Human Health (ChEM-H), Stanford University; Stanford, CA 94305, USA
- Sarafan ChEM-H, Macromolecular Structure Knowledge Center, Stanford University; Stanford, CA 94305, USA
| | - Yan Wu
- Department of Bioengineering, Stanford University; Stanford, CA 94305, USA
| | - Chenzhou Hao
- Department of Neurobiology, Stanford University; Stanford, CA 94305, USA
| | - Chieh-Wen Lo
- Department of Medicine, Stanford University; Stanford, CA 94305, USA
| | - Marwah Karim
- Department of Medicine, Stanford University; Stanford, CA 94305, USA
| | - Lin Ning
- Department of Neurobiology, Stanford University; Stanford, CA 94305, USA
| | - Aimee Beck
- Department of Medicine, Stanford University; Stanford, CA 94305, USA
| | | | - Vivian Tat
- Department of Pathology, The University of Texas Medical Branch; Galveston, TX 77555, USA
| | - Aleksandra Drelich
- Department of Microbiology and Immunology, The University of Texas Medical Branch; Galveston, TX 77555, USA
| | - Bi-Hung Peng
- Department of Neuroscience, Cell Biology, and Anatomy, The University of Texas Medical Branch; Galveston, TX 77555, USA
| | - Shirit Einav
- Department of Medicine, Stanford University; Stanford, CA 94305, USA
- Department of Microbiology and Immunology, Stanford University; Stanford, CA 94305, USA
- Chan Zuckerberg Biohub; San Francisco, CA 94158, USA
| | - Chien-Te K. Tseng
- Department of Microbiology and Immunology, The University of Texas Medical Branch; Galveston, TX 77555, USA
- Department of Pathology, The University of Texas Medical Branch; Galveston, TX 77555, USA
- Department of Neuroscience, Cell Biology, and Anatomy, The University of Texas Medical Branch; Galveston, TX 77555, USA
| | - Catherine Blish
- Department of Medicine, Stanford University; Stanford, CA 94305, USA
- Chan Zuckerberg Biohub; San Francisco, CA 94158, USA
| | - Michael Z. Lin
- Department of Neurobiology, Stanford University; Stanford, CA 94305, USA
- Department of Bioengineering, Stanford University; Stanford, CA 94305, USA
- Department of Chemical and Systems Biology, Stanford University; Stanford, CA 94305, USA
| |
Collapse
|
21
|
Singh RSP, LaBadie RR, Toussi SS, Shi H, Berg JK, Neutel JM, Aggarwal S. Effect of Hepatic Impairment on the Pharmacokinetics of Nirmatrelvir/Ritonavir, the First Oral Protease Inhibitor for the Treatment of COVID-19. J Clin Pharmacol 2024; 64:145-154. [PMID: 37751891 DOI: 10.1002/jcph.2353] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 09/22/2023] [Indexed: 09/28/2023]
Abstract
Nirmatrelvir, a novel, potent, orally bioavailable severe acute respiratory syndrome coronavirus 2 main protease inhibitor, coadministered with ritonavir for pharmacokinetic (PK) enhancement is licensed for the treatment of mild to moderate COVID-19 in individuals at increased risk of progression to severe disease. Cytochrome P450 3A4 is the primary metabolic enzyme responsible for nirmatrelvir metabolism; however, when cytochrome P450 3A4 is inhibited by ritonavir, nirmatrelvir is primarily excreted, unchanged, in urine. Because of intended use of nirmatrelvir among individuals with hepatic impairment, this Phase 1 study (NCT05005312) evaluated the effects of hepatic impairment on nirmatrelvir PK parameters to assess the potential need for any dose adjustments in this population. Participants with normal hepatic function or moderate hepatic impairment (n = 8 each) were administered a single 100-mg nirmatrelvir dose, with 100 mg of ritonavir administered 12 hours before, together with, and 12 and 24 hours after nirmatrelvir. Nirmatrelvir median plasma concentrations and systemic exposure measured by area under the plasma concentration-time curve from time zero extrapolated to infinite time and maximum observed plasma concentration values were comparable in both groups. Nirmatrelvir/ritonavir had an acceptable safety profile in both groups, and no clinically significant changes in laboratory measurements, vital signs, or electrocardiogram assessments were observed. Based on these results, no dose adjustment is deemed necessary in patients with moderate hepatic impairment and, by extension, in patients with mild hepatic impairment.
Collapse
Affiliation(s)
| | | | - Sima S Toussi
- Worldwide Research, Development and Medical, Pfizer Inc, Pearl River, NY, USA
| | - Haihong Shi
- Global Product Development, Pfizer Inc, Groton, CT, USA
| | | | | | - Sudeepta Aggarwal
- Worldwide Research, Development and Medical, Pfizer Inc, Cambridge, MA, USA
| |
Collapse
|
22
|
An Z, Bu C, Shi D, Chen Q, Zhang B, Wang Q, Jin L, Chi L. Structurally defined heparin octasaccharide domain for binding to SARS-CoV-2 Omicron BA.4/BA.5/BA.5.2 spike protein RBD. Int J Biol Macromol 2024; 259:129032. [PMID: 38159696 DOI: 10.1016/j.ijbiomac.2023.129032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 11/15/2023] [Accepted: 11/30/2023] [Indexed: 01/03/2024]
Abstract
Heparin, a bio-molecule with the highest negative charge density, is pharmaceutically important to prevent SARS-CoV-2 infection due to its strong competitive binding to spike protein compared with cellular heparan sulfate, which was confirmed as a co-receptor for virus-host cell interaction. Hence, the refined structural characterization of heparin targeting viral protein-HS interaction was significant for developing antiviral pharmaceuticals. In our study, heparin oligomers (dp ≥ 4) were prepared using heparinase I. The affinity oligosaccharides binding to Omicron spike protein RBD were separated by affinity chromatography and size exclusion chromatography. HILIC-ESI-FTMS was used for chain mapping analysis. The basic building blocks were analyzed and the binding domain sequence was produced by Seq-GAG software and further measured by SAX chromatography. As results, heparin octasaccharide was found with significantly higher binding ability than hexasaccharide and tetrasaccharide, and the octasaccharide [ΔUA-GlcNS6S-GlcA-GlcNS6S-IdoA2S-GlcNS6S-IdoA2S-GlcNS6S] with 12 sulfate groups showed high binding to RBD. The mechanism of this structurally well-defined octasaccharide binding to RBD was further investigated by molecular docking. The affinity energy of optimal pose was -6.8 kcal/mol and the basic amino acid residues in RBD sequence (Arg403, Arg452, Arg493 and His505) were identified as the major contribution factor to interacting with sulfate/carboxyl groups on saccharide chain. Our study demonstrated that heparin oligosaccharide with well-defined structure could be potentially developed as anti-SARS-CoV-2 drugs.
Collapse
Affiliation(s)
- Zizhe An
- National Glycoengineering Research Center, Shandong University, No. 72, Binhai Road, Qingdao, Shandong Province 266237, China
| | - Changkai Bu
- National Glycoengineering Research Center, Shandong University, No. 72, Binhai Road, Qingdao, Shandong Province 266237, China
| | - Deling Shi
- National Glycoengineering Research Center, Shandong University, No. 72, Binhai Road, Qingdao, Shandong Province 266237, China
| | - Qingqing Chen
- National Glycoengineering Research Center, Shandong University, No. 72, Binhai Road, Qingdao, Shandong Province 266237, China
| | - Bin Zhang
- National Glycoengineering Research Center, Shandong University, No. 72, Binhai Road, Qingdao, Shandong Province 266237, China
| | - Qingchi Wang
- National Glycoengineering Research Center, Shandong University, No. 72, Binhai Road, Qingdao, Shandong Province 266237, China
| | - Lan Jin
- National Glycoengineering Research Center, Shandong University, No. 72, Binhai Road, Qingdao, Shandong Province 266237, China.
| | - Lianli Chi
- National Glycoengineering Research Center, Shandong University, No. 72, Binhai Road, Qingdao, Shandong Province 266237, China.
| |
Collapse
|
23
|
Fernández-de-Las-Peñas C, Torres-Macho J, Catahay JA, Macasaet R, Velasco JV, Macapagal S, Caldararo M, Henry BM, Lippi G, Franco-Moreno A, Notarte KI. Is antiviral treatment at the acute phase of COVID-19 effective for decreasing the risk of long-COVID? A systematic review. Infection 2024; 52:43-58. [PMID: 38113020 DOI: 10.1007/s15010-023-02154-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 12/04/2023] [Indexed: 12/21/2023]
Abstract
PURPOSE Preliminary evidence suggests a potential effect of antiviral medication used during the acute COVID-19 phase for preventing long-COVID. This review investigates if having received pharmacological treatment during acute SARS-CoV-2 infection may reduce the risk of long-COVID. METHODS MEDLINE, CINAHL, PubMed, EMBASE, Web of Science databases, as well as medRxiv/bioRxiv preprint servers were searched up to July 15th, 2023. Articles comparing the presence of long-COVID symptoms between individuals who received or not a specific medication, particularly antivirals, during the acute phase of SARS-CoV-2 infection were included. Methodological quality was assessed using the Newcastle-Ottawa Scale or Cochrane's Risk of Bias (Rob) tool. RESULTS From 517 studies identified, 6 peer-reviewed studies and one preprint met all inclusion criteria. The sample included 2683 (n = 4) hospitalized COVID-19 survivors and 307,409 (n = 3) non-hospitalized patients. The methodological quality was high in 71% of studies (n = 5/7). Two studies investigating the effects of Nirmaltrevir/Ritonavir and three studies the effect of Remdesivir reported conflicting results on effectiveness for preventing long-COVID. Three studies investigating the effects of other medication such as Dexamethasone (n = 2) or Metformin (n = 1) found positive results of these medications for preventing long-COVID. CONCLUSION Available evidence about the effect of medication treatment with antivirals during acute COVID-19 and reduced risk of developing long-COVID is conflicting. Heterogeneous evidence suggests that Remdesivir or Nirmaltrevir/Ritonavir could have a potential protective effect for long-COVID. A limited number of studies demonstrated a potential benefit of other medications such as Dexamethasone or Metformin, but more studies are needed.
Collapse
Affiliation(s)
- César Fernández-de-Las-Peñas
- Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation, Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos (URJC), Universidad Rey Juan Carlos, Avenida de Atenas S/N, 28922, Alcorcón, Madrid, Spain.
| | - Juan Torres-Macho
- Department of Internal Medicine, Hospital Universitario Infanta Leonor-Virgen de La Torre, Madrid, Spain
- Department of Medicine, School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | | | - Raymart Macasaet
- Department of Medicine, Monmouth Medical Center, Long Branch, NJ, USA
| | | | - Sharina Macapagal
- Department of Medicine, John A. Burns School of Medicine, University of Hawaii, Honolulu, USA
| | - Mario Caldararo
- Department of Medicine, Saint Peter's University Hospital, New Brunswick, NJ, USA
| | - Brandon Michael Henry
- Clinical Laboratory, Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, Department of Neuroscience, Biomedicine and Movement, University of Verona, Verona, Italy
| | - Ana Franco-Moreno
- Department of Internal Medicine, Hospital Universitario Infanta Leonor-Virgen de La Torre, Madrid, Spain
| | - Kin Israel Notarte
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
24
|
Sun CK, Lee WH, Yang MH, Tsai TH. Pharmacokinetic analysis of placental transfer of ritonavir as a component of paxlovid using microdialysis in pregnant rats. Heliyon 2024; 10:e24333. [PMID: 38293424 PMCID: PMC10826739 DOI: 10.1016/j.heliyon.2024.e24333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 01/05/2024] [Accepted: 01/07/2024] [Indexed: 02/01/2024] Open
Abstract
Background Ritonavir is one of the most potent CYP3A4 inhibitor currently on the market, and is often used together with other antiviral drugs to increase their bioavailability and efficacy. Paxlovid, consisting of nirmatrelvir and ritonavir, was approved for the treatment of COVID-19. As previous studies regarding the use of ritonavir during pregnancy were limited to ex-vivo experiments and systemic safety data, to fully explore the detailed pharmacokinetics of ritonavir in pregnant rats' blood and conceptus, an analytical method consisted of multi-microdialysis coupled with UHPLC-MS/MS were developed to analyze the pharmacokinetics of ritonavir, both as a component of Paxlovid and by itself. 17 days pregnant female Sprague-Dawley rats were randomly split into three experimental group: normal dosage of ritonavir alone (7 mg kg-1), normal dosage of Paxlovid (ritonavir 7 mg kg-1 + nirmatrelvir 15 mg kg-1), and 3× dosage of ritonavir (21 mg kg-1). Results 3× dosage of ritonavir produced a more than 3× increase in rats' blood and placenta. Transfer rate of ritonavir to the placenta, amniotic fluid, and fetus were determined to be 20.7%, 13.8%, and 4.7% respectively. Concentration of ritonavir in the placenta, amniotic fluid, and fetus did not significantly go down after 8 h. Significance Overall, ritonavir's metabolism was not influenced by the presence of nirmatrelvir in pregnant rats. A 3× increase in dosage produced a concentration of roughly 4×, most likely a result of ritonavir's auto-inhibition effect on cytochrome P450 proteins. Accumulation of ritonavir is possible in placenta, amniotic fluid, and fetus.
Collapse
Affiliation(s)
- Chung-Kai Sun
- Institute of Traditional Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
| | - Wan-Hsin Lee
- Institute of Traditional Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
| | - Muh-Hwa Yang
- Institute of Clinical Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
| | - Tung-Hu Tsai
- Institute of Traditional Medicine, College of Medicine, National Yang Ming Chiao Tung University, Taipei 112, Taiwan
- Graduate Institute of Acupuncture Science, China Medical University, Taichung 404, Taiwan
- Department of Chemistry, National Sun Yat-Sen University, Kaohsiung 804, Taiwan
- School of Pharmacy, Kaohsiung Medical University, Kaohsiung 807, Taiwan
| |
Collapse
|
25
|
Zhang H, Zhou J, Chen H, Mao J, Tang Y, Yan W, Zhang T, Li C, Chen S, Li G, Zhang G, Ding Y, Liu L. Phase I study, and dosing regimen selection for a pivotal COVID-19 trial of GST-HG171. Antimicrob Agents Chemother 2024; 68:e0111523. [PMID: 38099673 PMCID: PMC10777829 DOI: 10.1128/aac.01115-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 10/28/2023] [Indexed: 01/11/2024] Open
Abstract
This study is aimed to evaluate the safety, tolerability, and pharmacokinetics (PK), as well as to select an appropriate dosing regimen for the pivotal clinical trial of GST-HG171, an orally bioavailable, potent, and selective 3CL protease inhibitor by a randomized, double-blind, and placebo-controlled phase I trial in healthy subjects. We conducted a Ph1 study involving 78 healthy subjects to assess the safety, tolerability, and PK of single ascending doses (150-900 mg) as well as multiple ascending doses (MADs) (150 and 300 mg) of GST-HG171. Additionally, we examined the food effect and drug-drug interaction of GST-HG171 in combination with ritonavir through a MAD regimen of GST-HG171/ritonavir (BID or TID) for 5 days. Throughout the course of these studies, no serious AEs or deaths occurred, and no AEs necessitated study discontinuation. We observed that food had no significant impact on the exposure of GST-HG171. However, the presence of ritonavir substantially increased the exposure of GST-HG171, which facilitated the selection of the GST-HG171/ritonavir dose and regimen (150/100 mg BID) for subsequent phase II/III trials. The selected dose regimen was achieved through concentrations continuously at 6.2-9.9-fold above the levels required for protein-binding adjusted 50% inhibition (IC50) of viral replication in vitro. The combination of 150 mg GST-HG171/100 mg ritonavir demonstrated favorable safety and tolerability profiles. The PK data obtained from GST-HG171/ritonavir administration guided the selection of appropriate dose for a pivotal phase II/III trial currently in progress. (This study has been registered at ClinicalTrials.gov under identifier NCT05668897).
Collapse
Affiliation(s)
- Hong Zhang
- 1 Phase I Clinical Research Center, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Jing Zhou
- 1 Phase I Clinical Research Center, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Hong Chen
- 1 Phase I Clinical Research Center, The First Hospital of Jilin University, Changchun, Jilin, China
| | - John Mao
- Fujian Akeylink Biotechnology Co., Ltd., Fuzhou, Fujian, China
| | - Yanan Tang
- Fujian Akeylink Biotechnology Co., Ltd., Fuzhou, Fujian, China
| | - Wenhao Yan
- Fujian Akeylink Biotechnology Co., Ltd., Fuzhou, Fujian, China
| | - Tianxiang Zhang
- Fujian Akeylink Biotechnology Co., Ltd., Fuzhou, Fujian, China
| | - Chuanjing Li
- Fujian Akeylink Biotechnology Co., Ltd., Fuzhou, Fujian, China
| | - Shikui Chen
- Fujian Cosunter Pharmaceutical Co., Ltd., Fuzhou, Fujian, China
| | - Guoping Li
- Fujian Cosunter Pharmaceutical Co., Ltd., Fuzhou, Fujian, China
| | - George Zhang
- Fujian Akeylink Biotechnology Co., Ltd., Fuzhou, Fujian, China
| | - Yanhua Ding
- 1 Phase I Clinical Research Center, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Li Liu
- Department of Pediatrics, The First Hospital of Jilin University, Changchun, Jilin, China
| |
Collapse
|
26
|
Box HJ, Sharp J, Pennington SH, Kijak E, Tatham L, Caygill CH, Lopeman RC, Jeffreys LN, Herriott J, Neary M, Valentijn A, Pertinez H, Curley P, Arshad U, Rajoli RKR, Jochmans D, Vangeel L, Neyts J, Chatelain E, Escudié F, Scandale I, Rannard S, Stewart JP, Biagini GA, Owen A. Lack of antiviral activity of probenecid in vitro and in Syrian golden hamsters. J Antimicrob Chemother 2024; 79:172-178. [PMID: 37995258 PMCID: PMC10761260 DOI: 10.1093/jac/dkad362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 11/08/2023] [Indexed: 11/25/2023] Open
Abstract
OBJECTIVES Antiviral interventions are required to complement vaccination programmes and reduce the global burden of COVID-19. Prior to initiation of large-scale clinical trials, robust preclinical data to support candidate plausibility are required. This work sought to further investigate the putative antiviral activity of probenecid against SARS-CoV-2. METHODS Vero E6 cells were preincubated with probenecid, or control media for 2 h before infection (SARS-CoV-2/Human/Liverpool/REMRQ0001/2020). Probenecid or control media was reapplied, plates reincubated and cytopathic activity quantified by spectrophotometry after 48 h. In vitro human airway epithelial cell (HAEC) assays were performed for probenecid against SARS-CoV-2-VoC-B.1.1.7 (hCoV-19/Belgium/rega-12211513/2020; EPI_ISL_791333, 2020-12-21) using an optimized cell model for antiviral testing. Syrian golden hamsters were intranasally inoculated (SARS-CoV-2 Delta B.1.617.2) 24 h prior to treatment with probenecid or vehicle for four twice-daily doses. RESULTS No observable antiviral activity for probenecid was evident in Vero E6 or HAEC assays. No reduction in total or subgenomic RNA was observed in terminal lung samples (P > 0.05) from hamsters. Body weight of uninfected hamsters remained stable whereas both probenecid- and vehicle-treated infected hamsters lost body weight (P > 0.5). CONCLUSIONS These data do not support probenecid as a SARS-CoV-2 antiviral drug.
Collapse
Affiliation(s)
- Helen J Box
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool L7 3NY, UK
- Centre of Excellence in Long-acting Therapeutics (CELT), University of Liverpool, Liverpool L7 3NY, UK
| | - Joanne Sharp
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool L7 3NY, UK
- Centre of Excellence in Long-acting Therapeutics (CELT), University of Liverpool, Liverpool L7 3NY, UK
| | - Shaun H Pennington
- Centre for Drugs and Diagnostics, Department of Tropical Disease Biology, Liverpool School of Tropical Medicine, Liverpool L3 5QA, UK
| | - Edyta Kijak
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool L7 3NY, UK
- Centre of Excellence in Long-acting Therapeutics (CELT), University of Liverpool, Liverpool L7 3NY, UK
| | - Lee Tatham
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool L7 3NY, UK
- Centre of Excellence in Long-acting Therapeutics (CELT), University of Liverpool, Liverpool L7 3NY, UK
| | - Claire H Caygill
- Centre for Drugs and Diagnostics, Department of Tropical Disease Biology, Liverpool School of Tropical Medicine, Liverpool L3 5QA, UK
| | - Rose C Lopeman
- Centre for Drugs and Diagnostics, Department of Tropical Disease Biology, Liverpool School of Tropical Medicine, Liverpool L3 5QA, UK
| | - Laura N Jeffreys
- Centre for Drugs and Diagnostics, Department of Tropical Disease Biology, Liverpool School of Tropical Medicine, Liverpool L3 5QA, UK
| | - Joanne Herriott
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool L7 3NY, UK
- Centre of Excellence in Long-acting Therapeutics (CELT), University of Liverpool, Liverpool L7 3NY, UK
| | - Megan Neary
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool L7 3NY, UK
- Centre of Excellence in Long-acting Therapeutics (CELT), University of Liverpool, Liverpool L7 3NY, UK
| | - Anthony Valentijn
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool L7 3NY, UK
- Centre of Excellence in Long-acting Therapeutics (CELT), University of Liverpool, Liverpool L7 3NY, UK
| | - Henry Pertinez
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool L7 3NY, UK
- Centre of Excellence in Long-acting Therapeutics (CELT), University of Liverpool, Liverpool L7 3NY, UK
| | - Paul Curley
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool L7 3NY, UK
- Centre of Excellence in Long-acting Therapeutics (CELT), University of Liverpool, Liverpool L7 3NY, UK
| | - Usman Arshad
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool L7 3NY, UK
- Centre of Excellence in Long-acting Therapeutics (CELT), University of Liverpool, Liverpool L7 3NY, UK
| | - Rajith K R Rajoli
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool L7 3NY, UK
- Centre of Excellence in Long-acting Therapeutics (CELT), University of Liverpool, Liverpool L7 3NY, UK
| | - Dirk Jochmans
- KU Leuven, Department of Microbiology, Immunology and Transplantation, Rega Institute, Laboratory of Virology and Chemotherapy, 3000, Leuven, Belgium and the Global Virus Network (GVN), Baltimore, MD, USA
| | - Laura Vangeel
- KU Leuven, Department of Microbiology, Immunology and Transplantation, Rega Institute, Laboratory of Virology and Chemotherapy, 3000, Leuven, Belgium and the Global Virus Network (GVN), Baltimore, MD, USA
| | - Johan Neyts
- KU Leuven, Department of Microbiology, Immunology and Transplantation, Rega Institute, Laboratory of Virology and Chemotherapy, 3000, Leuven, Belgium and the Global Virus Network (GVN), Baltimore, MD, USA
| | - Eric Chatelain
- Drugs for Neglected Diseases initiative (DNDi), Research and Development, 1202, Geneva, Switzerland
| | - Fanny Escudié
- Drugs for Neglected Diseases initiative (DNDi), Research and Development, 1202, Geneva, Switzerland
| | - Ivan Scandale
- Drugs for Neglected Diseases initiative (DNDi), Research and Development, 1202, Geneva, Switzerland
| | - Steve Rannard
- Centre of Excellence in Long-acting Therapeutics (CELT), University of Liverpool, Liverpool L7 3NY, UK
- Department of Chemistry, University of Liverpool,Liverpool L7 3NY, UK
| | - James P Stewart
- Department of Infection Biology & Microbiomes, Institute of Infection, Veterinary and Ecological Sciences, University of Liverpool, Liverpool, UK
| | - Giancarlo A Biagini
- Centre for Drugs and Diagnostics, Department of Tropical Disease Biology, Liverpool School of Tropical Medicine, Liverpool L3 5QA, UK
| | - Andrew Owen
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool L7 3NY, UK
- Centre of Excellence in Long-acting Therapeutics (CELT), University of Liverpool, Liverpool L7 3NY, UK
| |
Collapse
|
27
|
Gerhart J, Cox DS, Singh RSP, Chan PLS, Rao R, Allen R, Shi H, Masters JC, Damle B. A Comprehensive Review of the Clinical Pharmacokinetics, Pharmacodynamics, and Drug Interactions of Nirmatrelvir/Ritonavir. Clin Pharmacokinet 2024; 63:27-42. [PMID: 38177893 PMCID: PMC10786959 DOI: 10.1007/s40262-023-01339-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2023] [Indexed: 01/06/2024]
Abstract
Nirmatrelvir is a potent and selective inhibitor of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) main protease that is used as an oral antiviral coronavirus disease 2019 (COVID-19) treatment. To sustain unbound systemic trough concentrations above the antiviral in vitro 90% effective concentration value (EC90), nirmatrelvir is coadministered with 100 mg of ritonavir, a pharmacokinetic enhancer. Ritonavir inhibits nirmatrelvir's cytochrome P450 (CYP) 3A4-mediated metabolism which results in renal elimination becoming the primary route of nirmatrelvir elimination when dosed concomitantly. Nirmatrelvir exhibits absorption-limited nonlinear pharmacokinetics. When coadministered with ritonavir in patients with mild-to-moderate COVID-19, nirmatrelvir reaches a maximum concentration of 3.43 µg/mL (11.7× EC90) in approximately 3 h on day 5 of dosing, with a geometric mean day 5 trough concentration of 1.57 µg/mL (5.4× EC90). Drug interactions with nirmatrelvir/ritonavir (PAXLOVIDTM) are primarily attributed to ritonavir-mediated CYP3A4 inhibition, and to a lesser extent CYP2D6 and P-glycoprotein inhibition. Population pharmacokinetics and quantitative systems pharmacology modeling support twice daily dosing of 300 mg/100 mg nirmatrelvir/ritonavir for 5 days, with a reduced 150 mg/100 mg dose for patients with moderate renal impairment. Rapid clinical development of nirmatrelvir/ritonavir in response to the emerging COVID-19 pandemic was enabled by innovations in clinical pharmacology research, including an adaptive phase 1 trial design allowing direct to pivotal phase 3 development, fluorine nuclear magnetic resonance spectroscopy to delineate absorption, distribution, metabolism, and excretion profiles, and innovative applications of model-informed drug development to accelerate development.
Collapse
Affiliation(s)
- Jacqueline Gerhart
- Pfizer Inc, Research and Development, 500 Arcola Road, Collegeville, PA, 19424, USA.
| | - Donna S Cox
- Pfizer Inc, Research and Development, 500 Arcola Road, Collegeville, PA, 19424, USA
| | | | | | - Rohit Rao
- Pfizer Inc, Research and Development, Cambridge, MA, USA
| | - Richard Allen
- Pfizer Inc, Research and Development, Cambridge, MA, USA
| | - Haihong Shi
- Pfizer Inc, Research and Development, Groton, CT, USA
| | | | - Bharat Damle
- Pfizer Inc, Research and Development, New York, NY, USA
| |
Collapse
|
28
|
Wan K, Kavetska O, Damle B, Shi H, Cox DS, Oladoyinbo O, Chan P, Singh RSP, Craft S, Berthier E, Corrigan B. Patient Centric Microsampling to Support Paxlovid Clinical Development: Bridging and Implementation. Clin Pharmacol Ther 2024; 115:42-51. [PMID: 37597239 DOI: 10.1002/cpt.3025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 08/07/2023] [Indexed: 08/21/2023]
Abstract
Nirmatrelvir is a potent and selective severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) main protease inhibitor. Nirmatrelvir co-packaged with ritonavir (as PAXLOVID) received US Food and Drug Administration (FDA) Emergency Use Authorization (EUA) on December 22, 2021, as an oral treatment for coronavirus disease 2019 (COVID-19) and subsequent new drug application approval on May 25, 2023. Pharmacokinetic (PK) capillary blood sampling at-home using Tasso-M20 micro-volumetric sampling device was implemented in the program, including three phase II/III outpatient and several clinical pharmacology studies supporting the EUA. The at-home sampling complemented venous blood sampling procedures to enrich the PK dataset, to decrease the need for patients' site visit for PK sampling, and to allow different sampling approaches for flexibility and convenience. To demonstrate concordance/equivalence, bridging between venous plasma and Tasso dried blood results was conducted by comparing concentrations and derived PK parameters from both sampling approaches. In addition, a two-compartment population PK model was utilized to bridge the plasma and Tasso data by estimating the PK parameters using blood-to-plasma ratio as a slope parameter. Operational challenges were successfully managed to implement at-home PK sampling in global phase II/III trials. Sample quality was generally very good with less than 3% samples deemed as "not usable" from over 800 samples collected in all the studies. Experience gained from sites and patients will guide future broader implementations.
Collapse
|
29
|
Nguyen NV, Kim L, Collins LF, Ofotokun I, Fernandes A, Yeh S, Shantha J. Retinopathy Associated With Ritonavir Treatment for HIV Infection: A Case Series Reappraisal in the COVID-19 Era. JOURNAL OF VITREORETINAL DISEASES 2024; 8:111-116. [PMID: 38223770 PMCID: PMC10786071 DOI: 10.1177/24741264231203806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2024]
Abstract
Purpose: To report 3 cases of retinopathy secondary to ritonavir use in the treatment of HIV. Methods: A retrospective review of patient records was performed for data including ophthalmic examination findings, demographic and HIV clinical characteristics, and progression of maculopathy disease. The review identified 3 patients with a history of HIV treated with antiretroviral therapy including ritonavir who had been evaluated for bilateral vision loss in both eyes. Results: A fundus examination of each patient revealed characteristic macular atrophy, and optical coherence tomography demonstrated corresponding central outer retinal atrophy. Uveitis workup results were unremarkable. Given the characteristics of macular atrophy, history of ritonavir use, and the absence of intraocular inflammation, all 3 patients were diagnosed with bilateral ritonavir-associated retinopathy. Each patients' vision continued to deteriorate, even after the cessation of ritonavir. Conclusions: Ritonavir toxicity should be considered in the differential diagnosis of retinopathy among patients with an exposure history.
Collapse
Affiliation(s)
- Nam V. Nguyen
- Truhlsen Eye Institute, University of Nebraska Medical Center, Omaha, NE, USA
- College of Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Lucas Kim
- Truhlsen Eye Institute, University of Nebraska Medical Center, Omaha, NE, USA
| | - Lauren F. Collins
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
- Grady Healthcare System, Ponce de Leon Center, Atlanta, GA, USA
| | - Igho Ofotokun
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
- Grady Healthcare System, Ponce de Leon Center, Atlanta, GA, USA
| | - Alcides Fernandes
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Steven Yeh
- Truhlsen Eye Institute, University of Nebraska Medical Center, Omaha, NE, USA
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, GA, USA
| | - Jessica Shantha
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, GA, USA
- Francis I. Proctor Foundation, University of California San Francisco, San Francisco, CA, USA
| |
Collapse
|
30
|
Arman BY, Brun J, Hill ML, Zitzmann N, von Delft A. An Update on SARS-CoV-2 Clinical Trial Results-What We Can Learn for the Next Pandemic. Int J Mol Sci 2023; 25:354. [PMID: 38203525 PMCID: PMC10779148 DOI: 10.3390/ijms25010354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 12/21/2023] [Accepted: 12/24/2023] [Indexed: 01/12/2024] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has claimed over 7 million lives worldwide, providing a stark reminder of the importance of pandemic preparedness. Due to the lack of approved antiviral drugs effective against coronaviruses at the start of the pandemic, the world largely relied on repurposed efforts. Here, we summarise results from randomised controlled trials to date, as well as selected in vitro data of directly acting antivirals, host-targeting antivirals, and immunomodulatory drugs. Overall, repurposing efforts evaluating directly acting antivirals targeting other viral families were largely unsuccessful, whereas several immunomodulatory drugs led to clinical improvement in hospitalised patients with severe disease. In addition, accelerated drug discovery efforts during the pandemic progressed to multiple novel directly acting antivirals with clinical efficacy, including small molecule inhibitors and monoclonal antibodies. We argue that large-scale investment is required to prepare for future pandemics; both to develop an arsenal of broad-spectrum antivirals beyond coronaviruses and build worldwide clinical trial networks that can be rapidly utilised.
Collapse
Affiliation(s)
- Benediktus Yohan Arman
- Antiviral Drug Discovery Unit, Oxford Glycobiology Institute, Department of Biochemistry, University of Oxford, Oxford OX1 3QU, UK; (J.B.); (N.Z.)
- Kavli Institute for Nanoscience Discovery, University of Oxford, Oxford OX1 3QU, UK
| | - Juliane Brun
- Antiviral Drug Discovery Unit, Oxford Glycobiology Institute, Department of Biochemistry, University of Oxford, Oxford OX1 3QU, UK; (J.B.); (N.Z.)
- Kavli Institute for Nanoscience Discovery, University of Oxford, Oxford OX1 3QU, UK
| | - Michelle L. Hill
- Sir William Dunn School of Pathology, University of Oxford, Oxford OX1 3RE, UK;
| | - Nicole Zitzmann
- Antiviral Drug Discovery Unit, Oxford Glycobiology Institute, Department of Biochemistry, University of Oxford, Oxford OX1 3QU, UK; (J.B.); (N.Z.)
- Kavli Institute for Nanoscience Discovery, University of Oxford, Oxford OX1 3QU, UK
| | - Annette von Delft
- Kavli Institute for Nanoscience Discovery, University of Oxford, Oxford OX1 3QU, UK
- Centre for Medicine Discovery, Nuffield Department of Medicine, University of Oxford, Oxford OX3 7BN, UK
| |
Collapse
|
31
|
Yang XM, Yang Y, Yao BF, Ye PP, Xu Y, Peng SP, Yang YM, Shu P, Li PJ, Li S, Hu HL, Li Q, Song LL, Chen KG, Zhou HY, Zhang YH, Zhao FR, Tang BH, Zhang W, Zhang XF, Fu SM, Hao GX, Zheng Y, Shen JS, Xu YC, Jiang XR, Zhang LK, Tang RH, Zhao W. A first-in-human phase 1 study of simnotrelvir, a 3CL-like protease inhibitor for treatment of COVID-19, in healthy adult subjects. Eur J Pharm Sci 2023; 191:106598. [PMID: 37783378 DOI: 10.1016/j.ejps.2023.106598] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 09/22/2023] [Accepted: 09/25/2023] [Indexed: 10/04/2023]
Abstract
Safe and efficacious antiviral therapeutics are in urgent need for the treatment of coronavirus disease 2019. Simnotrelvir is a selective 3C-like protease inhibitor that can effectively inhibit severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). We evaluated the safety, tolerability, and pharmacokinetics of dose escalations of simnotrelvir alone or with ritonavir (simnotrelvir or simnotrelvir/ritonavir) in healthy subjects, as well as the food effect (ClinicalTrials.gov Identifier: NCT05339646). The overall incidence of adverse events (AEs) was 22.2% (17/72) and 6.3% (1/16) in intervention and placebo groups, respectively. The simnotrelvir apparent clearance was 135-369 L/h with simnotrelvir alone, and decreased significantly to 19.5-29.8 L/h with simnotrelvir/ritonavir. The simnotrelvir exposure increased in an approximately dose-proportional manner between 250 and 750 mg when co-administered with ritonavir. After consecutive twice daily dosing of simnotrelvir/ritonavir, simnotrelvir had a low accumulation index ranging from 1.39 to 1.51. The area under the curve of simnotrelvir increased 44.0 % and 47.3 % respectively, after high fat and normal diet compared with fasted status. In conclusion, simnotrelvir has adequate safety and tolerability. Its pharmacokinetics indicated a trough concentration above the level required for 90 % inhibition of SARS-CoV-2 in vitro at 750 mg/100 mg simnotrelvir/ritonavir twice daily under fasted condition, supporting further development using this dosage as the clinically recommended dose regimen.
Collapse
Affiliation(s)
- Xin-Mei Yang
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, PR China
| | - Yang Yang
- Jiangsu Simcere Pharmaceutical Co., Ltd, Nanjing, PR China
| | - Bu-Fan Yao
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, PR China
| | - Pan-Pan Ye
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, PR China
| | - Yan Xu
- Simcere of America, Cambridge, MA, USA
| | - Shao-Ping Peng
- Jiangsu Simcere Pharmaceutical Co., Ltd, Nanjing, PR China
| | - Yu-Mei Yang
- Jiangsu Simcere Pharmaceutical Co., Ltd, Nanjing, PR China
| | - Pan Shu
- Jiangsu Simcere Pharmaceutical Co., Ltd, Nanjing, PR China
| | - Pei-Jin Li
- Jiangsu Simcere Pharmaceutical Co., Ltd, Nanjing, PR China
| | - Shan Li
- Jiangsu Simcere Pharmaceutical Co., Ltd, Nanjing, PR China
| | - Hong-Lin Hu
- Jiangsu Simcere Pharmaceutical Co., Ltd, Nanjing, PR China
| | - Qian Li
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, PR China
| | - Lin-Lin Song
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, PR China
| | - Ke-Guang Chen
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, PR China
| | - Hai-Yan Zhou
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, PR China
| | - Ye-Hui Zhang
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, PR China
| | - Fu-Rong Zhao
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, PR China
| | - Bo-Hao Tang
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, PR China
| | - Wei Zhang
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, PR China
| | - Xin-Fang Zhang
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, PR China
| | - Shu-Meng Fu
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, PR China
| | - Guo-Xiang Hao
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, PR China
| | - Yi Zheng
- Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, PR China
| | - Jing-Shan Shen
- Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, PR China
| | - Ye-Chun Xu
- Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, PR China
| | - Xiang-Rui Jiang
- Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, PR China
| | - Lei-Ke Zhang
- State Key Laboratory of Virology, Wuhan Institute of Virology, Center for Biosafety Mega-Science, Chinese Academy of Sciences, Wuhan, PR China
| | - Ren-Hong Tang
- Jiangsu Simcere Pharmaceutical Co., Ltd, Nanjing, PR China
| | - Wei Zhao
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, PR China; Department of Clinical Pharmacy, Key Laboratory of Chemical Biology (Ministry of Education), School of Pharmaceutical Sciences, Cheeloo College of Medicine, Shandong University, Jinan, PR China.
| |
Collapse
|
32
|
Cohen MS, Brown ER. Rebound of COVID-19 With Nirmatrelvir-Ritonavir Antiviral Therapy. Ann Intern Med 2023; 176:1672-1673. [PMID: 37956432 PMCID: PMC10644264 DOI: 10.7326/m23-2887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2023] Open
Abstract
In their article, Edelstein and colleagues provide the results of an observational study of virologic response in patients who received treatment with nirmatrelvir–ritonavir (N-R) versus those who received no COVID-19 therapy. The editorialists discuss the findings and emphasize the need for further consideration of the dosage, timing, and duration of treatment to inform optimal use of N-R.
Collapse
Affiliation(s)
- Myron S Cohen
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Elizabeth R Brown
- University of Washington, Fred Hutchinson Cancer Center, Seattle, Washington
| |
Collapse
|
33
|
Chan PLS, Singh RSP, Cox DS, Shi H, Damle B, Nicholas T. Dosing recommendation of nirmatrelvir/ritonavir using an integrated population pharmacokinetic analysis. CPT Pharmacometrics Syst Pharmacol 2023; 12:1897-1910. [PMID: 37803876 PMCID: PMC10725264 DOI: 10.1002/psp4.13039] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 08/11/2023] [Indexed: 10/08/2023] Open
Abstract
Protease inhibitor nirmatrelvir coadministered with ritonavir as a pharmacokinetic enhancer (PAXLOVID™; Pfizer Inc) became the first orally bioavailable antiviral agent granted Emergency Use Authorization in the United States in patients ≥12 years old with mild to moderate coronavirus disease 2019 (COVID-19). This population pharmacokinetic analysis used pooled plasma nirmatrelvir concentrations from eight completed phase I and II/III studies to characterize nirmatrelvir pharmacokinetics when coadministered with ritonavir in adults with/without COVID-19. Influence of covariates (e.g., formulation, dose, COVID-19) was examined using a stepwise forward selection (α = 0.05) and backward elimination (α = 0.001) approach. Simulations with 5000 subjects for each age and weight group and renal function category were performed to support dosing recommendations of nirmatrelvir/ritonavir for adults with COVID-19 and guide dose adjustments for specific patient populations (e.g., renal insufficiency, pediatrics). The final model was a two-compartment model with first-order absorption, including allometric scaling of body weight and dose-dependent absorption (power function on relative bioavailability). Nirmatrelvir clearance (CL) increased proportionally to body surface area-normalized creatinine CL (nCLCR) up to 70 ml/min/1.73 m2 and was independent of nCLCR above the breakpoint. Significant covariates included carbamazepine or itraconazole coadministration as markers for drug interactions, COVID-19 on CL, formulation on relative bioavailability, and age on central volume of distribution. Simulation results support current dosing recommendations of nirmatrelvir/ritonavir 300/100 mg twice daily (b.i.d.) in adults with normal renal function or mild impairment and pediatrics (12 to <18 years) weighing ≥40 kg and nirmatrelvir/ritonavir 150/100 mg b.i.d. in adults with moderate renal impairment.
Collapse
Affiliation(s)
- Phylinda L. S. Chan
- Worldwide Research, Development and MedicalPfizer R&D UK Ltd.Sandwich, KentUK
| | | | - Donna S. Cox
- Worldwide Research, Development and MedicalPfizer Inc.CollegevillePennsylvaniaUSA
| | - Haihong Shi
- Worldwide Research, Development and MedicalPfizer Inc.GrotonConnecticutUSA
| | - Bharat Damle
- Worldwide Research, Development and MedicalPfizer Inc.New YorkNew YorkUSA
| | - Timothy Nicholas
- Worldwide Research, Development and MedicalPfizer Inc.GrotonConnecticutUSA
| |
Collapse
|
34
|
Reis S, Metzendorf MI, Kuehn R, Popp M, Gagyor I, Kranke P, Meybohm P, Skoetz N, Weibel S. Nirmatrelvir combined with ritonavir for preventing and treating COVID-19. Cochrane Database Syst Rev 2023; 11:CD015395. [PMID: 38032024 PMCID: PMC10688265 DOI: 10.1002/14651858.cd015395.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
BACKGROUND Oral nirmatrelvir/ritonavir (Paxlovid) aims to avoid severe COVID-19 in asymptomatic people or those with mild symptoms, thereby decreasing hospitalization and death. It remains to be evaluated for which indications and patient populations the drug is suitable. OBJECTIVES To assess the efficacy and safety of nirmatrelvir/ritonavir plus standard of care (SoC) compared to SoC with or without placebo, or any other intervention for treating COVID-19 or preventing SARS-CoV-2 infection. To explore equity aspects in subgroup analyses. To keep up to date with the evolving evidence base using a living systematic review (LSR) approach and make new relevant studies available to readers in-between publication of review updates. SEARCH METHODS We searched the Cochrane COVID-19 Study Register, Scopus, and World Health Organization COVID-19 Research Database, identifying completed and ongoing studies without language restrictions and incorporating studies up to 15 May 2023. This is a LSR. We conduct update searches every two months and make them publicly available on the open science framework (OSF) platform. SELECTION CRITERIA We included randomized controlled trials (RCTs) comparing nirmatrelvir/ritonavir plus SoC to SoC with or without placebo, or any other intervention for treatment of people with confirmed COVID-19 diagnosis, irrespective of disease severity or treatment setting, and for prevention of SARS-CoV-2 infection. We screened all studies for research integrity. Studies were ineligible if they had been retracted, or if they were not prospectively registered including appropriate ethics approval. DATA COLLECTION AND ANALYSIS We followed standard Cochrane methodology and used the Cochrane RoB 2 tool. We rated the certainty of evidence using the GRADE approach for the following outcomes: 1. to treat outpatients with mild COVID-19; 2. to treat inpatients with moderate to severe COVID-19: mortality, clinical worsening or improvement, quality of life, (serious) adverse events, and viral clearance; 3. to prevent SARS-CoV-2 infection in postexposure prophylaxis (PEP); and 4. pre-exposure prophylaxis (PrEP) scenarios: SARS-CoV-2 infection, development of COVID-19 symptoms, mortality, admission to hospital, quality of life, and (serious) adverse events. We explored inequity by subgroup analysis for elderly people, socially-disadvantaged people with comorbidities, populations from low-income countries and low- to middle-income countries, and people from different ethnic and racial backgrounds. MAIN RESULTS As of 15 May 2023, we included two RCTs with 2510 participants with mild and mild to moderate symptomatic COVID-19 in outpatient and inpatient settings comparing nirmatrelvir/ritonavir plus SoC to SoC with or without placebo. All trial participants were without previous confirmed SARS-CoV-2 infection and at high risk for progression to severe disease. Randomization coincided with the Delta wave for outpatients and Omicron wave for inpatients. Outpatient trial participants and 73% of inpatients were unvaccinated. Symptom onset in outpatients was no more than five days before randomisation and prior or concomitant therapies including medications highly dependent on CYP3A4 were not allowed. We excluded two studies due to concerns with research integrity. We identified 13 ongoing studies. Three studies are currently awaiting classification. Nirmatrelvir/ritonavir for treating people with asymptomatic or mild COVID-19 in outpatient settings Nirmatrelvir/ritonavir plus SoC compared to SoC plus placebo may reduce all-cause mortality at 28 days (risk ratio (RR) 0.04, 95% confidence interval (CI) 0.00 to 0.68; 1 study, 2224 participants; low-certainty evidence) and admission to hospital or death within 28 days (RR 0.13, 95% CI 0.07 to 0.27; 1 study, 2224 participants; low-certainty evidence). Nirmatrelvir/ritonavir plus SoC may reduce serious adverse events during the study period compared to SoC plus placebo (RR 0.24, 95% CI 0.15 to 0.41; 1 study, 2224 participants; low-certainty evidence). Nirmatrelvir/ritonavir plus SoC probably has little or no effect on treatment-emergent adverse events (RR 0.95, 95% CI 0.82 to 1.10; 1 study, 2224 participants; moderate-certainty evidence), and probably increases treatment-related adverse events such as dysgeusia and diarrhoea during the study period compared to SoC plus placebo (RR 2.06, 95% CI 1.44 to 2.95; 1 study, 2224 participants; moderate-certainty evidence). Nirmatrelvir/ritonavir plus SoC probably decreases discontinuation of study drug due to adverse events compared to SoC plus placebo (RR 0.49, 95% CI 0.30 to 0.80; 1 study, 2224 participants; moderate-certainty evidence). No studies reported improvement of clinical status, quality of life, or viral clearance. Nirmatrelvir/ritonavir for treating people with moderate to severe COVID-19 in inpatient settings We are uncertain whether nirmatrelvir/ritonavir plus SoC compared to SoC reduces all-cause mortality at 28 days (RR 0.63, 95% CI 0.21 to 1.86; 1 study, 264 participants; very low-certainty evidence), or increases viral clearance at seven days (RR 1.06, 95% CI 0.71 to 1.58; 1 study, 264 participants; very low-certainty evidence) and 14 days (RR 1.05, 95% CI 0.92 to 1.20; 1 study, 264 participants; very low-certainty evidence). No studies reported improvement or worsening of clinical status and quality of life. We did not include data for safety outcomes due to insufficient and inconsistent information. Subgroup analyses for equity For outpatients, the outcome 'admission to hospital or death' was investigated for equity regarding age (less than 65 years versus 65 years or greater) and ethnicity. There were no subgroup differences for age or ethnicity. For inpatients, the outcome 'all-cause mortality' was investigated for equity regarding age (65 years or less versus greater than 65 years). There was no difference between subgroups of age. No further equity-related subgroups were reported, and no subgroups were reported for other outcomes. Nirmatrelvir/ritonavir for preventing SARS-CoV-2 infection (PrEP and PEP) No studies available. AUTHORS' CONCLUSIONS Low-certainty evidence suggests nirmatrelvir/ritonavir reduces the risk of all-cause mortality and hospital admission or death in high-risk, unvaccinated COVID-19 outpatients infected with the Delta variant of SARS-CoV-2. There is low- to moderate-certainty evidence of the safety of nirmatrelvir/ritonavir. Very low-certainty evidence exists regarding the effects of nirmatrelvir/ritonavir on all-cause mortality and viral clearance in mildly to moderately affected, mostly unvaccinated COVID-19 inpatients infected with the Omicron variant of SARS-CoV-2. Insufficient and inconsistent information prevents the assessment of safety outcomes. No reliable differences in effect size and direction were found regarding equity aspects. There is no available evidence supporting the use of nirmatrelvir/ritonavir for preventing SARS-CoV-2 infection. We are continually updating our search and making search results available on the OSF platform.
Collapse
Affiliation(s)
- Stefanie Reis
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Maria-Inti Metzendorf
- Cochrane Metabolic and Endocrine Disorders Group, Institute of General Practice, Medical Faculty of the Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Rebecca Kuehn
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Maria Popp
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Ildiko Gagyor
- Department of General Practice, University Hospital Würzburg, Würzburg, Germany
| | - Peter Kranke
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Nicole Skoetz
- Cochrane Haematology, Department of Internal Medicine, Faculty of Medicine and University Hospital Cologne, Center for Integrated Oncology, University of Cologne, Cologne, Germany
| | - Stephanie Weibel
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Würzburg, Würzburg, Germany
| |
Collapse
|
35
|
Abdallah IA, Hammad SF, Bedair A, Mansour FR. Homogeneous liquid-liquid microextraction coupled with HPLC/DAD for determination of nirmatrelvir and ritonavir as COVID-19 combination therapy in human plasma. BMC Chem 2023; 17:166. [PMID: 38001530 PMCID: PMC10675862 DOI: 10.1186/s13065-023-01080-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 11/08/2023] [Indexed: 11/26/2023] Open
Abstract
The study reports the development of a high-performance liquid chromatography/diode array detection method to measure the levels of nirmatrelvir and ritonavir in human plasma. These two antiviral medications are used for the treatment of COVID-19 and are marketed as Paxlovid®. The method employed sugaring-out induced homogeneous liquid-liquid microextraction to improve sensitivity. Optimization of the method was performed using the one variable at a time approach by adjusting several factors such as type of sugar, extractant, amount of sugar, volume of extractant, and pH of the aqueous sample to achieve the highest efficiency. The developed method was validated according to the Food and Drug Administration guidelines and demonstrated good linearity, accuracy, and precision. The range of linearity was from 1000 to 20,000 ng/mL for nirmatrelvir and 200 to 20,000 ng/mL for ritonavir with correlation coefficient values of 0.998 and 0.996, respectively. Selectivity studies revealed that no others peaks appeared in the retention times of the studied drugs. The stability of nirmatrelvir and ritonavir were also investigated through short term and three cycles of freeze-thaw, and both drugs were found stable. This analytical method could be useful for monitoring drug concentrations in patients undergoing treatment with these medications for COVID-19. In this work, for the first time, SULLME was used for the sensitive determination of nirmatrelvir and ritonavir in biological fluids. The developed method was able to determine both drugs in therapeutic levels with no need to sophisticated techniques like LC-MS. In addition to that, SULLME is considered a simple and green sample preparation in comparison with conventional sample preparation methods.
Collapse
Affiliation(s)
- Inas A Abdallah
- Department of Analytical Chemistry, Faculty of Pharmacy, University of Sadat City, Sadat City, 32897, Monufia, Egypt
| | - Sherin F Hammad
- Department of Pharmaceutical Analytical Chemistry, Faculty of Pharmacy, Tanta University, Elgeish Street, The Medical Campus of Tanta University, Tanta, 31111, Egypt
| | - Alaa Bedair
- Department of Analytical Chemistry, Faculty of Pharmacy, University of Sadat City, Sadat City, 32897, Monufia, Egypt
| | - Fotouh R Mansour
- Department of Pharmaceutical Analytical Chemistry, Faculty of Pharmacy, Tanta University, Elgeish Street, The Medical Campus of Tanta University, Tanta, 31111, Egypt.
| |
Collapse
|
36
|
Kushwaha ND, Mohan J, Kushwaha B, Ghazi T, Nwabuife JC, Koorbanally N, Chuturgoon AA. A comprehensive review on the global efforts on vaccines and repurposed drugs for combating COVID-19. Eur J Med Chem 2023; 260:115719. [PMID: 37597435 DOI: 10.1016/j.ejmech.2023.115719] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 07/31/2023] [Accepted: 08/09/2023] [Indexed: 08/21/2023]
Abstract
The recently discovered coronavirus, known as SARS-CoV-2, is a highly contagious and potentially lethal viral infection that was declared a pandemic by the World Health Organization on March 11, 2020. Since the beginning of the pandemic, an unprecedented number of COVID-19 vaccine candidates have been investigated for their potential to manage the pandemic. Herein, we reviewed vaccine development and the associated research effort, both traditional and forward-looking, to demonstrate the advantages and disadvantages of their technology, in addition to their efficacy limitations against mutant SARS-CoV-2. Moreover, we report repurposed drug discovery, which mainly focuses on virus-based and host-based targets, as well as their inhibitors. SARS-CoV-2 targets include the main protease (Mpro), and RNA-dependent RNA-polymerase (RdRp), which are the most well-studied and conserved across coronaviruses, enabling the development of broad-spectrum inhibitors of these enzymes.
Collapse
Affiliation(s)
- Narva Deshwar Kushwaha
- Discipline of Medical Biochemistry, School of Laboratory Medicine and Medical Science, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa; Department of Pharmaceutical Sciences, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, MI, 48201, USA.
| | - Jivanka Mohan
- Discipline of Medical Biochemistry, School of Laboratory Medicine and Medical Science, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Babita Kushwaha
- Discipline of Medical Biochemistry, School of Laboratory Medicine and Medical Science, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Terisha Ghazi
- Discipline of Medical Biochemistry, School of Laboratory Medicine and Medical Science, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Joshua C Nwabuife
- Discipline of Pharmaceutical Sciences, College of Health Sciences, University of KwaZulu-Natal, Durban, 4000, South Africa
| | - Neil Koorbanally
- School of Chemistry, College of Agriculture, Engineering and Science, University of KwaZulu-Natal, Durban, 4000, South Africa
| | - Anil A Chuturgoon
- Discipline of Medical Biochemistry, School of Laboratory Medicine and Medical Science, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa.
| |
Collapse
|
37
|
Iwamoto M, Duncan KE, Wickremasingha PK, Zhao T, Liberti MV, Lemoine L, Decaesteker T, Rottey S, Maas BM, Gillespie G, Stoch SA. Assessment of pharmacokinetics, safety, and tolerability following twice-daily administration of molnupiravir for 10 days in healthy participants. Clin Transl Sci 2023; 16:1947-1956. [PMID: 37526305 PMCID: PMC10582664 DOI: 10.1111/cts.13602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 06/30/2023] [Accepted: 07/13/2023] [Indexed: 08/02/2023] Open
Abstract
Molnupiravir is an orally administered, small-molecule ribonucleoside prodrug of β-D-N4-hydroxycytidine (NHC) that has demonstrated potent, broad-spectrum preclinical activity against RNA viruses and has a high barrier to the development of resistance. A double-blind, placebo-controlled, phase I trial was conducted to evaluate the pharmacokinetics (PKs), safety, and tolerability of 10.5-day administration of multiple doses of molnupiravir and its metabolites in healthy, adult participants. Participants were randomly assigned (3:1) to receive molnupiravir (400 mg [n = 6], 600 mg [n = 6], and 800 mg [n = 12]) or matching placebo (n = 8) every 12 h (q12h) for 10.5 days. Blood was collected to evaluate the PKs of NHC in plasma and of its active metabolite, NHC-triphosphate (NHC-TP), in peripheral blood mononuclear cells (PBMCs). Molnupiravir was generally well-tolerated. All adverse events were mild or moderate in severity and none led to treatment discontinuation. No clinically meaningful dose-related safety findings were observed. Mean time to maximal concentration was ~1.50 to 1.98 h for plasma NHC and ~4.00 to 8.06 h for PBMC NHC-TP. Accumulation was minimal (<1.2) for NHC and ~2- to 2.5-fold for NHC-TP. Plasma NHC PKs was generally dose proportional, and PBMC NHC-TP PKs was less than dose proportional over the dose range studied. NHC and NHC-TP PK support twice-daily administration. Overall, molnupiravir administered at up to 800 mg q12h for 10.5 days was generally well-tolerated in healthy participants with dose-linear PKs, supporting the evaluation of longer molnupiravir dosing up to 10 days in future clinical trials.
Collapse
Affiliation(s)
| | | | | | - Tian Zhao
- Merck & Co., Inc.RahwayNew JerseyUSA
| | | | | | | | | | | | | | | |
Collapse
|
38
|
Zhuang W, Xu J, Wu Y, Yang J, Lin X, Liao Y, Wan J, Weng L, Lin W. Post-marketing safety concerns with nirmatrelvir: A disproportionality analysis of spontaneous reports submitted to the FDA Adverse Event Reporting System. Br J Clin Pharmacol 2023; 89:2830-2842. [PMID: 37170890 DOI: 10.1111/bcp.15783] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 04/15/2023] [Accepted: 05/04/2023] [Indexed: 05/13/2023] Open
Abstract
AIMS Nirmatrelvir is an antiviral drug with a novel mechanism of action, targeting the 3-CL protease, and is used in the treatment of COVID-19. However, the potential side effects have not yet been fully studied. The aim of this study was to identify potential safety signals of nirmatrelvir by analysing post-marketing safety data based on the largest publicly available worldwide pharmacovigilance database. METHODS We analysed nirmatrelvir adverse events to identify and characterize relevant safety signals based on the FDA Adverse Event Reporting System database in 2022. The case/non-case approach was used to estimate the reporting odds ratio (ROR) and information component (IC) with relevant confidence intervals (95% CI) for adverse events (AEs) that numbered 4 or more. RESULTS A total of 26 846 cases were included. Disease recurrence (ROR [95% CI] = 413.2 [395.6-431.59]), dysgeusia (ROR [95% CI] = 110.84 [106.04-115.85]), anosmia (ROR [95% CI] = 15.21 [12.76-18.11]), ageusia (ROR [95% CI] = 9.80 [8.50-11.3]) and urticaria (ROR [95% CI] = 1.91 [1.69-2.17]) were the main safety signals. In addition, abdominal pain upper and skin toxicity were two specific safety signals of nirmatrelvir. In the pregnant population, there was a significant increased ROR for life-threatening conditions (ROR [95% CI] = 8.00 [1.77-36.20]). CONCLUSIONS Our study identified that the main and specific safety signals of nirmatrelvir were disease recurrence, dysgeusia, abdominal pain upper and skin toxicity. Clinicians and pharmacists should be vigilant of these AEs, although differentiating between COVID-19 symptoms and AEs can be challenging. Notably, a potential safety concern of nirmatrelvir should be a warning based on a small number of events in the pregnant population. However, the available data are insufficient, and further continued pharmacovigilance and surveillance is needed to fully understand this issue.
Collapse
Affiliation(s)
- Wei Zhuang
- Department of Pharmacy, Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, China
| | - Jiabing Xu
- School of Pharmaceutical, Fujian University of Traditional Chinese Medicine, Fuzhou, China
| | - Ye Wu
- Department of Ultrasound, The First Affiliated Hospital of Xiamen University, Xiamen, China
| | - Jianhui Yang
- Department of Pharmacy, Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, China
| | - Xiuxian Lin
- Department of Pharmacy, Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, China
| | - Yufang Liao
- Department of Pharmacy, Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, China
| | - Jun Wan
- Department of Pharmacy, Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, China
| | - Lizhu Weng
- Department of Pharmacy, Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, China
| | - Wanlong Lin
- Department of Pharmacy, Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, China
| |
Collapse
|
39
|
Cox DS, Van Eyck L, Pawlak S, Beckerman B, Linn C, Ginman K, Thay Cha Y, LaBadie RR, Shi H, Damle B. Effects of itraconazole and carbamazepine on the pharmacokinetics of nirmatrelvir/ritonavir in healthy adults. Br J Clin Pharmacol 2023; 89:2867-2876. [PMID: 37184075 DOI: 10.1111/bcp.15788] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 05/03/2023] [Accepted: 05/04/2023] [Indexed: 05/16/2023] Open
Abstract
AIMS The objective of this study was to evaluate the effects of a strong cytochrome P450 family (CYP) 3A4 inhibitor (itraconazole) and inducer (carbamazepine) on the pharmacokinetics and safety of nirmatrelvir/ritonavir. METHODS Pharmacokinetics were measured in two phase 1, open-label, fixed-sequence studies in healthy adults. During Period 1, oral nirmatrelvir/ritonavir 300 mg/100 mg twice daily was administered alone; during Period 2, it was administered with itraconazole or carbamazepine. Nirmatrelvir/ritonavir was administered as repeated doses or one dose in the itraconazole and carbamazepine studies, respectively. Nirmatrelvir and ritonavir plasma concentrations and adverse event (AE) rates in both periods were analysed. RESULTS Each study included 12 participants. Following administration of nirmatrelvir/ritonavir with itraconazole (Test) or alone (Reference), test/reference ratios of the adjusted geometric means (90% CIs) for nirmatrelvir AUCtau and Cmax were 138.82% (129.25%, 149.11%) and 118.57% (112.50%, 124.97%), respectively. After administration of nirmatrelvir/ritonavir with carbamazepine (Test) or alone (Reference), test/reference ratios (90% CIs) of the adjusted geometric means for nirmatrelvir AUCinf and Cmax were 44.50% (33.77%, 58.65%) and 56.82% (47.04%, 68.62%), respectively. Nirmatrelvir/ritonavir was generally safe when administered with or without itraconazole or carbamazepine. No serious or severe AEs were reported. CONCLUSIONS Coadministration of a strong CYP3A4 inhibitor with a strong CYP3A inhibitor used for pharmacokinetic enhancement (i.e., ritonavir) resulted in small increases in plasma nirmatrelvir exposure, whereas coadministration of a strong inducer substantially decreased systemic nirmatrelvir and ritonavir exposures suggesting a contraindication in the label with CYP3A4 strong inducers. Administration of nirmatrelvir/ritonavir alone or with itraconazole or carbamazepine was generally safe.
Collapse
Affiliation(s)
- Donna S Cox
- Global Product Development, Pfizer Inc., Collegeville, Pennsylvania, USA
| | - Lien Van Eyck
- Clinical Research Unit, Pfizer Inc., Brussels, Belgium
| | - Sylvester Pawlak
- Clinical Research Unit, Pfizer Inc., New Haven, Connecticut, USA
| | - Bruce Beckerman
- Clinical Development and Operations, Pfizer Inc., New York, New York, USA
| | - Carlos Linn
- Global Product Development, Pfizer Inc., Taipei, Taiwan
| | - Katherine Ginman
- Global Product Development, Pfizer Inc., Groton, Connecticut, USA
| | - Youliny Thay Cha
- Global Product Development, Pfizer Inc., Groton, Connecticut, USA
| | - Robert R LaBadie
- Global Product Development, Pfizer Inc., Groton, Connecticut, USA
| | - Haihong Shi
- Global Product Development, Pfizer Inc., Groton, Connecticut, USA
| | - Bharat Damle
- Global Product Development, Pfizer Inc., New York, New York, USA
| |
Collapse
|
40
|
Cox RM, Lieber CM, Wolf JD, Karimi A, Lieberman NAP, Sticher ZM, Roychoudhury P, Andrews MK, Krueger RE, Natchus MG, Painter GR, Kolykhalov AA, Greninger AL, Plemper RK. Comparing molnupiravir and nirmatrelvir/ritonavir efficacy and the effects on SARS-CoV-2 transmission in animal models. Nat Commun 2023; 14:4731. [PMID: 37550333 PMCID: PMC10406822 DOI: 10.1038/s41467-023-40556-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 08/01/2023] [Indexed: 08/09/2023] Open
Abstract
Therapeutic options against SARS-CoV-2 are underutilized. Two oral drugs, molnupiravir and paxlovid (nirmatrelvir/ritonavir), have received emergency use authorization. Initial trials suggested greater efficacy of paxlovid, but recent studies indicated comparable potency in older adults. Here, we compare both drugs in two animal models; the Roborovski dwarf hamster model for severe COVID-19-like lung infection and the ferret SARS-CoV-2 transmission model. Dwarf hamsters treated with either drug survive VOC omicron infection with equivalent lung titer reduction. Viral RNA copies in the upper respiratory tract of female ferrets receiving 1.25 mg/kg molnupiravir twice-daily are not significantly reduced, but infectious titers are lowered by >2 log orders and direct-contact transmission is stopped. Female ferrets dosed with 20 or 100 mg/kg nirmatrelvir/ritonavir twice-daily show 1-2 log order reduction of viral RNA copies and infectious titers, which correlates with low nirmatrelvir exposure in nasal turbinates. Virus replication resurges towards nirmatrelvir/ritonavir treatment end and virus transmits efficiently (20 mg/kg group) or partially (100 mg/kg group). Prophylactic treatment with 20 mg/kg nirmatrelvir/ritonavir does not prevent spread from infected ferrets, but prophylactic 5 mg/kg molnupiravir or 100 mg/kg nirmatrelvir/ritonavir block productive transmission. These data confirm reports of similar efficacy in older adults and inform on possible epidemiologic benefit of antiviral treatment.
Collapse
Affiliation(s)
- Robert M Cox
- Center for Translational Antiviral Research, Georgia State University Institute for Biomedical Sciences, Atlanta, GA, 30303, USA
| | - Carolin M Lieber
- Center for Translational Antiviral Research, Georgia State University Institute for Biomedical Sciences, Atlanta, GA, 30303, USA
| | - Josef D Wolf
- Center for Translational Antiviral Research, Georgia State University Institute for Biomedical Sciences, Atlanta, GA, 30303, USA
| | - Amirhossein Karimi
- Center for Translational Antiviral Research, Georgia State University Institute for Biomedical Sciences, Atlanta, GA, 30303, USA
| | - Nicole A P Lieberman
- Virology Division, Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, 98185, USA
| | - Zachary M Sticher
- Emory Institute for Drug Development, Emory University, Atlanta, GA, USA
| | - Pavitra Roychoudhury
- Virology Division, Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, 98185, USA
| | - Meghan K Andrews
- Emory Institute for Drug Development, Emory University, Atlanta, GA, USA
| | - Rebecca E Krueger
- Emory Institute for Drug Development, Emory University, Atlanta, GA, USA
| | - Michael G Natchus
- Emory Institute for Drug Development, Emory University, Atlanta, GA, USA
| | - George R Painter
- Emory Institute for Drug Development, Emory University, Atlanta, GA, USA
- Department of Pharmacology, Emory University, Atlanta, GA, 30322, USA
| | | | - Alexander L Greninger
- Virology Division, Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, 98185, USA
| | - Richard K Plemper
- Center for Translational Antiviral Research, Georgia State University Institute for Biomedical Sciences, Atlanta, GA, 30303, USA.
| |
Collapse
|
41
|
Sagawa K, Lin J, Jaini R, Di L. Physiologically-Based Pharmacokinetic Modeling of PAXLOVID™ with First-Order Absorption Kinetics. Pharm Res 2023; 40:1927-1938. [PMID: 37231296 PMCID: PMC10212229 DOI: 10.1007/s11095-023-03538-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 05/15/2023] [Indexed: 05/27/2023]
Abstract
PURPOSE PAXLOVID™ is nirmatrelvir tablets co-packaged with ritonavir tablets. Ritonavir is used as a pharmacokinetics (PK) enhancer to reduce metabolism and increase exposure of nirmatrelvir. This is the first disclosure of Paxlovid physiologically-based pharmacokinetic (PBPK) model. METHODS Nirmatrelvir PBPK model with first-order absorption kinetics was developed using in vitro, preclinical, and clinical data of nirmatrelvir in the presence and absence of ritonavir. Clearance and volume of distribution were derived from nirmatrelvir PK obtained using a spray-dried dispersion (SDD) formulation where it is considered to be dosed as an oral solution, and absorption is near complete. The fraction of nirmatrelvir metabolized by CYP3A was estimated based on in vitro and clinical ritonavir drug-drug interaction (DDI) data. First-order absorption parameters were established for both SDD and tablet formulation using clinical data. Nirmatrelvir PBPK model was verified with both single and multiple dose human PK data, as well as DDI studies. Simcyp® first-order ritonavir compound file was also verified with additional clinical data. RESULTS The nirmatrelvir PBPK model described the observed PK profiles of nirmatrelvir well with predicted AUC and Cmax values within ± 20% of the observed. The ritonavir model performed well resulting in predicted values within twofold of observed. CONCLUSIONS Paxlovid PBPK model developed in this study can be applied to predict PK changes in special populations, as well as model the effect of victim and perpetrator DDI. PBPK modeling continues to play a critical role in accelerating drug discovery and development of potential treatments for devastating diseases such as COVID-19. NCT05263895, NCT05129475, NCT05032950 and NCT05064800.
Collapse
Affiliation(s)
- Kazuko Sagawa
- Pharmaceutical Science, Pfizer Worldwide Research and Development, 445 Eastern Point Road, Groton, CT, 06340, USA
| | - Jian Lin
- Pharmacokinetics, Dynamics and Metabolism, Pfizer Worldwide Research and Development, 445 Eastern Point Road, Groton, CT, 06340, USA
| | - Rohit Jaini
- Pharmaceutical Science, Pfizer Worldwide Research and Development, 445 Eastern Point Road, Groton, CT, 06340, USA
- Pharmaceutical Science, Pfizer Worldwide Research and Development, 1 Portland Street, Cambridge, MA, 02139, USA
| | - Li Di
- Pharmacokinetics, Dynamics and Metabolism, Pfizer Worldwide Research and Development, 445 Eastern Point Road, Groton, CT, 06340, USA.
| |
Collapse
|
42
|
Navitha Reddy G, Jogvanshi A, Naikwadi S, Sonti R. Nirmatrelvir and ritonavir combination: an antiviral therapy for COVID-19. Expert Rev Anti Infect Ther 2023; 21:943-955. [PMID: 37525997 DOI: 10.1080/14787210.2023.2241638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 07/24/2023] [Indexed: 08/02/2023]
Abstract
INTRODUCTION The emergence of the Omicron SARS-CoV-2 variant of concern in late November 2021 presaged yet another stage of the COVID-19 pandemic. Paxlovid, a co-packaged dosage form of two antiviral drugs (nirmatrelvir and ritonavir) developed by Pfizer, received its first FDA Emergency Use Authorization (EUA) and conditional marketing by European Medical Agency in patients at high risk of developing severe COVID-19. AREAS COVERED We reviewed the timeline of the drug nirmatrelvir from its discovery to authorization by FDA. After 1 year of its authorization, numerous studies and reports on paxlovid's use and post-use consequences are available. This review summarizes the complete journey of paxlovid from its development, preclinical studies, clinical trials, regulatory approvals, ongoing clinical trials, and safety measures, followed by discussions on recent updates on drug-drug interactions, adverse effects, and relapse of COVID-19. EXPERT OPINION Paxlovid, a new oral antiviral therapy for COVID-19, has shown promising results in clinical trials and has the potential to be effective against the pandemic, particularly for individuals at high risk of severe illness. Comorbidity usage and pharmacovigilance will play a significant stake in the future of paxlovid development. Second-generation Mpro inhibitors play an important role in the upcoming problems associated with COVID-19.
Collapse
Affiliation(s)
- Gangireddy Navitha Reddy
- Department of Pharmaceutical Analysis, National Institute of Pharmaceutical Education and Research (NIPER), Hyderabad, Telangana, India
| | - Akanksha Jogvanshi
- Department of Pharmaceutical Analysis, National Institute of Pharmaceutical Education and Research (NIPER), Hyderabad, Telangana, India
| | - Sana Naikwadi
- Department of Pharmaceutical Analysis, National Institute of Pharmaceutical Education and Research (NIPER), Hyderabad, Telangana, India
| | - Rajesh Sonti
- Department of Pharmaceutical Analysis, National Institute of Pharmaceutical Education and Research (NIPER), Hyderabad, Telangana, India
| |
Collapse
|
43
|
von Delft A, Hall MD, Kwong AD, Purcell LA, Saikatendu KS, Schmitz U, Tallarico JA, Lee AA. Accelerating antiviral drug discovery: lessons from COVID-19. Nat Rev Drug Discov 2023; 22:585-603. [PMID: 37173515 PMCID: PMC10176316 DOI: 10.1038/s41573-023-00692-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2023] [Indexed: 05/15/2023]
Abstract
During the coronavirus disease 2019 (COVID-19) pandemic, a wave of rapid and collaborative drug discovery efforts took place in academia and industry, culminating in several therapeutics being discovered, approved and deployed in a 2-year time frame. This article summarizes the collective experience of several pharmaceutical companies and academic collaborations that were active in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antiviral discovery. We outline our opinions and experiences on key stages in the small-molecule drug discovery process: target selection, medicinal chemistry, antiviral assays, animal efficacy and attempts to pre-empt resistance. We propose strategies that could accelerate future efforts and argue that a key bottleneck is the lack of quality chemical probes around understudied viral targets, which would serve as a starting point for drug discovery. Considering the small size of the viral proteome, comprehensively building an arsenal of probes for proteins in viruses of pandemic concern is a worthwhile and tractable challenge for the community.
Collapse
Affiliation(s)
- Annette von Delft
- Centre for Medicines Discovery, Nuffield Department of Medicine, University of Oxford, Oxford, UK.
- Oxford Biomedical Research Centre, National Institute for Health Research, University of Oxford, Oxford, UK.
| | - Matthew D Hall
- National Center for Advancing Translational Sciences, National Institutes of Health, Rockville, MD, USA
| | | | | | | | | | | | - Alpha A Lee
- PostEra, Inc., Cambridge, MA, USA.
- Cavendish Laboratory, University of Cambridge, Cambridge, UK.
| |
Collapse
|
44
|
Pagliano P, Spera A, Sellitto C, Scarpati G, Folliero V, Piazza O, Franci G, Conti V, Ascione T. Preclinical discovery and development of nirmatrelvir/ritonavir combinational therapy for the treatment of COVID-19 and the lessons learned from SARS-COV-2 variants. Expert Opin Drug Discov 2023; 18:1301-1311. [PMID: 37614103 DOI: 10.1080/17460441.2023.2248879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 08/14/2023] [Indexed: 08/25/2023]
Abstract
INTRODUCTION Nirmatrelvir/ritonavir (Paxlovid®) represent an oral antiviral therapy approved for the treatment of COVID-19. Extensive in vitro and in vivo studies have reported the promising activity of nirmatrelvir/ritonavir against numerous emerging viruses. This combination consists of nirmatrelvir, a protease reversible inhibitor of coronavirus 3CLpro mainly metabolized by cytochrome P450 (CYP)3A4, and ritonavir, an inhibitor of the CYP3A isoforms that enhances the efficacy of nirmatrelvir by fixing its suboptimal pharmacokinetic properties. AREAS COVERED This review comprehensively examines the efficacy of nirmatrelvir/ritonavir through rigorous analysis of in vitro and in vivo studies. Moreover, it thoroughly assesses its safety, tolerability, pharmacokinetics, and antiviral efficacy against SARS-COV-2 infection, based on the main pre-authorization randomized controlled trials. EXPERT OPINION Nirmatrelvir/ritonavir has a good tolerability profile. Its administration during the early stages of mild-to-moderate COVID-19 holds potential benefits, as it can help prevent the onset of an aberrant immune response that could lead to pulmonary and extra-pulmonary complications. However, its drug - drug interactions can be a factor limiting its use, at least in populations on some chronic therapies, along with the risk of infection relapse after treatment.
Collapse
Affiliation(s)
- Pasquale Pagliano
- Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana", Unit of Infectious Diseases, University of Salerno, Baronissi, Italy
| | - Annamaria Spera
- Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana", Unit of Infectious Diseases, University of Salerno, Baronissi, Italy
| | - Carmine Sellitto
- Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana", Unit of Pharmacology, University of Salerno, Baronissi, Italy
| | - Giuliana Scarpati
- Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana", Unit of Anesthesiology, University of Salerno, Baronissi, Italy
| | - Veronica Folliero
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", Unit of Microbiology, University of Salerno, Baronissi, Italy
| | - Ornella Piazza
- Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana", Unit of Anesthesiology, University of Salerno, Baronissi, Italy
| | - Gianluigi Franci
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana", Unit of Microbiology, University of Salerno, Baronissi, Italy
| | - Valeria Conti
- Department of Medicine, Surgery and Dentistry, "Scuola Medica Salernitana", Unit of Pharmacology, University of Salerno, Baronissi, Italy
| | - Tiziana Ascione
- Department of Medicine, Service of Infectious Diseases, Cardarelli Hospital, Naples, Italy
| |
Collapse
|
45
|
Lu J, Cai H, Hao Y, Lin Z, Liu S, Zhan Y, Ding L, Huang M, Li Z, Xu L, Yan X, Yang L, Zhang H, Zhang W, Zhao L, Zhao J, Wang T, Gu L. Nirmatrelvir/Ritonavir for hemodialysis patients with COVID-19. Front Pharmacol 2023; 14:1161897. [PMID: 37251313 PMCID: PMC10213535 DOI: 10.3389/fphar.2023.1161897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 05/02/2023] [Indexed: 05/31/2023] Open
Abstract
Background: Hemodialysis patients have a high risk of severe/critical COVID-19 and related high mortality, but nirmatrelvir/ritonavir is not recommended for hemodialysis patients with COVID-19 infection because of lack of evidence of safety. Objectives: Our study aims to evaluate the minimum plasma concentration (Cmin) of nirmatrelvir and its safety of different doses of nirmatrelvir/ritonavir in hemodialysis patients with mild COVID-19. Method: This was a prospective, two step, nonrandomized, open-label study. Participants were treated with nirmatrelvir 150 mg or 300 mg once a day (another 75 mg or 150 mg supplied after hemodialysis) and ritonavir 100 mg twice daily for 5 days, respectively. The primary outcome was the safety of nirmatrelvir/ritonavir, including the Cmin of nirmatrelvir and the number of adverse events (AE). The secondary outcome was the time of viral elimination in hemodialysis patients. Results: Adverse events were happened in 3 and 7 participants in the step 1 and step 2 group, respectively (p = 0.025). Among them, 2 and 6 participants were identified as drug-related adverse events (p = 0.054). No SAE or liver function damage happened. The Cmin of nirmatrelvir in step 1 and step 2 group were 5,294.65 ± 2,370.59 ng/mL and 7,675.67 ± 2,745.22 ng/mL (p = 0.125). The Cmin of the control group was 2,274.10 ± 1,347.25 ng/mL (p = 0.001 compared to step 2 and p = 0.059 compared to step 1). Compared to hemodialysis patients without nirmatrelvir/ritonavir, there were no statistical differences in overall viral elimination time (p = 0.232). Conclusion: In our study, two doses of nirmatrelvir/ritonavir appeared to be excessive for hemodialysis patients. Although all of the patients tolerated 5-day administration, nearly half of the patients experienced drug-related adverse events. In addition, the medication group did not show a significant advantage in the time of viral elimination.
Collapse
Affiliation(s)
- Jiayue Lu
- Department of Nephrology, Molecular Cell Lab for Kidney Disease, Shanghai Peritoneal Dialysis Research Center, Renji Hospital, Uremia Diagnosis and Treatment Center, Shanghai Jiaotong University, School of Medicine, Shanghai, China
| | - Hong Cai
- Department of Nephrology, Molecular Cell Lab for Kidney Disease, Shanghai Peritoneal Dialysis Research Center, Renji Hospital, Uremia Diagnosis and Treatment Center, Shanghai Jiaotong University, School of Medicine, Shanghai, China
| | - Yujun Hao
- State Key Laboratory of Oncogenes and Related Genes, Shanghai Cancer Institute, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhang Lin
- State Key Laboratory of Oncogenes and Related Genes, Shanghai Cancer Institute, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shang Liu
- Department of Nephrology, Molecular Cell Lab for Kidney Disease, Shanghai Peritoneal Dialysis Research Center, Renji Hospital, Uremia Diagnosis and Treatment Center, Shanghai Jiaotong University, School of Medicine, Shanghai, China
| | - Yaping Zhan
- Department of Nephrology, Molecular Cell Lab for Kidney Disease, Shanghai Peritoneal Dialysis Research Center, Renji Hospital, Uremia Diagnosis and Treatment Center, Shanghai Jiaotong University, School of Medicine, Shanghai, China
| | - Li Ding
- Department of Nephrology, Molecular Cell Lab for Kidney Disease, Shanghai Peritoneal Dialysis Research Center, Renji Hospital, Uremia Diagnosis and Treatment Center, Shanghai Jiaotong University, School of Medicine, Shanghai, China
| | - Meilan Huang
- Department of Gastroenterology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Zhenyuan Li
- Department of Nephrology, Molecular Cell Lab for Kidney Disease, Shanghai Peritoneal Dialysis Research Center, Renji Hospital, Uremia Diagnosis and Treatment Center, Shanghai Jiaotong University, School of Medicine, Shanghai, China
| | - Lan Xu
- Department of Hematology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Xiujuan Yan
- Department of Gastroenterology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Li Yang
- Department of Gastroenterology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - He Zhang
- Department of Nephrology, Molecular Cell Lab for Kidney Disease, Shanghai Peritoneal Dialysis Research Center, Renji Hospital, Uremia Diagnosis and Treatment Center, Shanghai Jiaotong University, School of Medicine, Shanghai, China
| | - Wei Zhang
- Department of Gastroenterology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Li Zhao
- Department of Gastroenterology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Junli Zhao
- Department of Nephrology, Zhoupu Hospital, Shanghai University of Medicine and Health Sciences, Shanghai, China
| | - Ting Wang
- Department of Hematology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Leyi Gu
- Department of Nephrology, Molecular Cell Lab for Kidney Disease, Shanghai Peritoneal Dialysis Research Center, Renji Hospital, Uremia Diagnosis and Treatment Center, Shanghai Jiaotong University, School of Medicine, Shanghai, China
| |
Collapse
|
46
|
Saramago LC, Santana MV, Gomes BF, Dantas RF, Senger MR, Oliveira Borges PH, Ferreira VNDS, dos Santos Rosa A, Tucci AR, Dias Miranda M, Lukacik P, Strain-Damerell C, Owen CD, Walsh MA, Ferreira SB, Silva-Junior FP. AI-Driven Discovery of SARS-CoV-2 Main Protease Fragment-like Inhibitors with Antiviral Activity In Vitro. J Chem Inf Model 2023; 63:2866-2880. [PMID: 37058135 PMCID: PMC10124747 DOI: 10.1021/acs.jcim.3c00409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Indexed: 04/15/2023]
Abstract
SARS-CoV-2 is the causative agent of COVID-19 and is responsible for the current global pandemic. The viral genome contains 5 major open reading frames of which the largest ORF1ab codes for two polyproteins, pp1ab and pp1a, which are subsequently cleaved into 16 nonstructural proteins (nsp) by two viral cysteine proteases encoded within the polyproteins. The main protease (Mpro, nsp5) cleaves the majority of the nsp's, making it essential for viral replication and has been successfully targeted for the development of antivirals. The first oral Mpro inhibitor, nirmatrelvir, was approved for treatment of COVID-19 in late December 2021 in combination with ritonavir as Paxlovid. Increasing the arsenal of antivirals and development of protease inhibitors and other antivirals with a varied mode of action remains a priority to reduce the likelihood for resistance emerging. Here, we report results from an artificial intelligence-driven approach followed by in vitro validation, allowing the identification of five fragment-like Mpro inhibitors with IC50 values ranging from 1.5 to 241 μM. The three most potent molecules (compounds 818, 737, and 183) were tested against SARS-CoV-2 by in vitro replication in Vero E6 and Calu-3 cells. Compound 818 was active in both cell models with an EC50 value comparable to its measured IC50 value. On the other hand, compounds 737 and 183 were only active in Calu-3, a preclinical model of respiratory cells, showing selective indexes twice as high as those for compound 818. We also show that our in silico methodology was successful in identifying both reversible and covalent inhibitors. For instance, compound 818 is a reversible chloromethylamide analogue of 8-methyl-γ-carboline, while compound 737 is an N-pyridyl-isatin that covalently inhibits Mpro. Given the small molecular weights of these fragments, their high binding efficiency in vitro and efficacy in blocking viral replication, these compounds represent good starting points for the development of potent lead molecules targeting the Mpro of SARS-CoV-2.
Collapse
Affiliation(s)
- Luiz Carlos Saramago
- LaBECFar-Laboratório de Bioquímica
Experimental e Computacional de Fármacos, Instituto Oswaldo Cruz,
Fundação Oswaldo Cruz, 21040-900 Rio de
Janeiro, Brazil
| | - Marcos V. Santana
- LaBECFar-Laboratório de Bioquímica
Experimental e Computacional de Fármacos, Instituto Oswaldo Cruz,
Fundação Oswaldo Cruz, 21040-900 Rio de
Janeiro, Brazil
| | - Bárbara Figueira Gomes
- LaBECFar-Laboratório de Bioquímica
Experimental e Computacional de Fármacos, Instituto Oswaldo Cruz,
Fundação Oswaldo Cruz, 21040-900 Rio de
Janeiro, Brazil
| | - Rafael Ferreira Dantas
- LaBECFar-Laboratório de Bioquímica
Experimental e Computacional de Fármacos, Instituto Oswaldo Cruz,
Fundação Oswaldo Cruz, 21040-900 Rio de
Janeiro, Brazil
| | - Mario R. Senger
- LaBECFar-Laboratório de Bioquímica
Experimental e Computacional de Fármacos, Instituto Oswaldo Cruz,
Fundação Oswaldo Cruz, 21040-900 Rio de
Janeiro, Brazil
| | - Pedro Henrique Oliveira Borges
- LaBECFar-Laboratório de Bioquímica
Experimental e Computacional de Fármacos, Instituto Oswaldo Cruz,
Fundação Oswaldo Cruz, 21040-900 Rio de
Janeiro, Brazil
- LaSOPB-Laboratório de Síntese
Orgânica e Prospecção Biológica, Instituto de Química,
Universidade Federal do Rio de Janeiro, 21040-900 Rio de
Janeiro, Brazil
| | - Vivian Neuza dos Santos Ferreira
- LMMV-Laboratório de Morfologia e
Morfogênese Viral (LMMV), Instituto Oswaldo Cruz,
Fundação Oswaldo Cruz, 21040-900 Rio de
Janeiro, Brazil
| | - Alice dos Santos Rosa
- LMMV-Laboratório de Morfologia e
Morfogênese Viral (LMMV), Instituto Oswaldo Cruz,
Fundação Oswaldo Cruz, 21040-900 Rio de
Janeiro, Brazil
| | - Amanda Resende Tucci
- LMMV-Laboratório de Morfologia e
Morfogênese Viral (LMMV), Instituto Oswaldo Cruz,
Fundação Oswaldo Cruz, 21040-900 Rio de
Janeiro, Brazil
| | - Milene Dias Miranda
- LMMV-Laboratório de Morfologia e
Morfogênese Viral (LMMV), Instituto Oswaldo Cruz,
Fundação Oswaldo Cruz, 21040-900 Rio de
Janeiro, Brazil
| | - Petra Lukacik
- Diamond Light Source, Harwell Science and
Innovation Campus, OX11 0DE Didcot, U.K.
- Research Complex at Harwell, Harwell
Science & Innovation Campus, OX11 0FA Didcot,
U.K.
| | - Claire Strain-Damerell
- Diamond Light Source, Harwell Science and
Innovation Campus, OX11 0DE Didcot, U.K.
- Research Complex at Harwell, Harwell
Science & Innovation Campus, OX11 0FA Didcot,
U.K.
| | - C. David Owen
- Diamond Light Source, Harwell Science and
Innovation Campus, OX11 0DE Didcot, U.K.
- Research Complex at Harwell, Harwell
Science & Innovation Campus, OX11 0FA Didcot,
U.K.
| | - Martin Austin Walsh
- Diamond Light Source, Harwell Science and
Innovation Campus, OX11 0DE Didcot, U.K.
- Research Complex at Harwell, Harwell
Science & Innovation Campus, OX11 0FA Didcot,
U.K.
| | - Sabrina Baptista Ferreira
- LaSOPB-Laboratório de Síntese
Orgânica e Prospecção Biológica, Instituto de Química,
Universidade Federal do Rio de Janeiro, 21040-900 Rio de
Janeiro, Brazil
| | - Floriano Paes Silva-Junior
- LaBECFar-Laboratório de Bioquímica
Experimental e Computacional de Fármacos, Instituto Oswaldo Cruz,
Fundação Oswaldo Cruz, 21040-900 Rio de
Janeiro, Brazil
| |
Collapse
|
47
|
Ceja-Gálvez HR, Renteria-Flores FI, Nicoletti F, Hernández-Bello J, Macedo-Ojeda G, Muñoz-Valle JF. Severe COVID-19: Drugs and Clinical Trials. J Clin Med 2023; 12:jcm12082893. [PMID: 37109231 PMCID: PMC10142549 DOI: 10.3390/jcm12082893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 04/08/2023] [Accepted: 04/14/2023] [Indexed: 04/29/2023] Open
Abstract
By January of 2023, the COVID-19 pandemic had led to a reported total of 6,700,883 deaths and 662,631,114 cases worldwide. To date, there have been no effective therapies or standardized treatment schemes for this disease; therefore, the search for effective prophylactic and therapeutic strategies is a primary goal that must be addressed. This review aims to provide an analysis of the most efficient and promising therapies and drugs for the prevention and treatment of severe COVID-19, comparing their degree of success, scope, and limitations, with the aim of providing support to health professionals in choosing the best pharmacological approach. An investigation of the most promising and effective treatments against COVID-19 that are currently available was carried out by employing search terms including "Convalescent plasma therapy in COVID-19" or "Viral polymerase inhibitors" and "COVID-19" in the Clinicaltrials.gov and PubMed databases. From the current perspective and with the information available from the various clinical trials assessing the efficacy of different therapeutic options, we conclude that it is necessary to standardize certain variables-such as the viral clearance time, biomarkers associated with severity, hospital stay, requirement of invasive mechanical ventilation, and mortality rate-in order to facilitate verification of the efficacy of such treatments and to better assess the repeatability of the most effective and promising results.
Collapse
Affiliation(s)
- Hazael Ramiro Ceja-Gálvez
- Institute of Research in Biomedical Sciences, University Center of Health Sciences (CUCS), University of Guadalajara, Guadalajara 44340, Jalisco, Mexico
| | - Francisco Israel Renteria-Flores
- Institute of Research in Biomedical Sciences, University Center of Health Sciences (CUCS), University of Guadalajara, Guadalajara 44340, Jalisco, Mexico
| | - Ferdinando Nicoletti
- Department of Biomedical and Biotechnological Sciences, University of Catania, 95123 Catania, Italy
| | - Jorge Hernández-Bello
- Institute of Research in Biomedical Sciences, University Center of Health Sciences (CUCS), University of Guadalajara, Guadalajara 44340, Jalisco, Mexico
| | - Gabriela Macedo-Ojeda
- Institute of Research in Biomedical Sciences, University Center of Health Sciences (CUCS), University of Guadalajara, Guadalajara 44340, Jalisco, Mexico
| | - José Francisco Muñoz-Valle
- Institute of Research in Biomedical Sciences, University Center of Health Sciences (CUCS), University of Guadalajara, Guadalajara 44340, Jalisco, Mexico
| |
Collapse
|
48
|
Rao R, Musante CJ, Allen R. A quantitative systems pharmacology model of the pathophysiology and treatment of COVID-19 predicts optimal timing of pharmacological interventions. NPJ Syst Biol Appl 2023; 9:13. [PMID: 37059734 PMCID: PMC10102696 DOI: 10.1038/s41540-023-00269-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 02/09/2023] [Indexed: 04/16/2023] Open
Abstract
A quantitative systems pharmacology (QSP) model of the pathogenesis and treatment of SARS-CoV-2 infection can streamline and accelerate the development of novel medicines to treat COVID-19. Simulation of clinical trials allows in silico exploration of the uncertainties of clinical trial design and can rapidly inform their protocols. We previously published a preliminary model of the immune response to SARS-CoV-2 infection. To further our understanding of COVID-19 and treatment, we significantly updated the model by matching a curated dataset spanning viral load and immune responses in plasma and lung. We identified a population of parameter sets to generate heterogeneity in pathophysiology and treatment and tested this model against published reports from interventional SARS-CoV-2 targeting mAb and antiviral trials. Upon generation and selection of a virtual population, we match both the placebo and treated responses in viral load in these trials. We extended the model to predict the rate of hospitalization or death within a population. Via comparison of the in silico predictions with clinical data, we hypothesize that the immune response to virus is log-linear over a wide range of viral load. To validate this approach, we show the model matches a published subgroup analysis, sorted by baseline viral load, of patients treated with neutralizing Abs. By simulating intervention at different time points post infection, the model predicts efficacy is not sensitive to interventions within five days of symptom onset, but efficacy is dramatically reduced if more than five days pass post symptom onset prior to treatment.
Collapse
Affiliation(s)
- Rohit Rao
- Early Clinical Development, Pfizer Worldwide Research, Development and Medical, Cambridge, MA, USA.
| | - Cynthia J Musante
- Early Clinical Development, Pfizer Worldwide Research, Development and Medical, Cambridge, MA, USA
| | - Richard Allen
- Early Clinical Development, Pfizer Worldwide Research, Development and Medical, Cambridge, MA, USA
| |
Collapse
|
49
|
Westra N, Touw D, Lub-de Hooge M, Kosterink J, Oude Munnink T. Pharmacokinetic Boosting of Kinase Inhibitors. Pharmaceutics 2023; 15:pharmaceutics15041149. [PMID: 37111635 PMCID: PMC10146729 DOI: 10.3390/pharmaceutics15041149] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 03/21/2023] [Accepted: 04/03/2023] [Indexed: 04/08/2023] Open
Abstract
(1) Introduction: Pharmacokinetic boosting of kinase inhibitors can be a strategy to enhance drug exposure and to reduce dose and associated treatment costs. Most kinase inhibitors are predominantly metabolized by CYP3A4, enabling boosting using CYP3A4 inhibition. Kinase inhibitors with food enhanced absorption can be boosted using food optimized intake schedules. The aim of this narrative review is to provide answers to the following questions: Which different boosting strategies can be useful in boosting kinase inhibitors? Which kinase inhibitors are potential candidates for either CYP3A4 or food boosting? Which clinical studies on CYP3A4 or food boosting have been published or are ongoing? (2) Methods: PubMed was searched for boosting studies of kinase inhibitors. (3) Results/Discussion: This review describes 13 studies on exposure boosting of kinase inhibitors. Boosting strategies included cobicistat, ritonavir, itraconazole, ketoconazole, posaconazole, grapefruit juice and food. Clinical trial design for conducting pharmacokinetic boosting trials and risk management is discussed. (4) Conclusion: Pharmacokinetic boosting of kinase inhibitors is a promising, rapidly evolving and already partly proven strategy to increase drug exposure and to potentially reduce treatment costs. Therapeutic drug monitoring can be of added value in guiding boosted regimens.
Collapse
Affiliation(s)
- Niels Westra
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands
| | - Daan Touw
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands
- Pharmaceutical Analysis, Groningen Research Institute of Pharmacy, University of Groningen, 9713 AV Groningen, The Netherlands
| | - Marjolijn Lub-de Hooge
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands
| | - Jos Kosterink
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands
- PharmacoTherapy, Epidemiology & Economics, Groningen Research Institute of Pharmacy, University of Groningen, 9713 AV Groningen, The Netherlands
| | - Thijs Oude Munnink
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands
| |
Collapse
|
50
|
Mutoh Y, Umemura T, Nishikawa T, Kondo K, Nishina Y, Soejima K, Noguchi Y, Bando T, Ota S, Shimahara T, Hirota S, Hagimoto S, Takei R, Fukihara J, Sasano H, Yamano Y, Yokoyama T, Kataoka K, Matsuda T, Kimura T, Ichihara T, Kondoh Y. Real-World Experience of the Comparative Effectiveness and Safety of Molnupiravir and Nirmatrelvir/Ritonavir in High-Risk Patients with COVID-19 in a Community Setting. Viruses 2023; 15:v15030811. [PMID: 36992519 PMCID: PMC10054616 DOI: 10.3390/v15030811] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 03/21/2023] [Accepted: 03/21/2023] [Indexed: 03/31/2023] Open
Abstract
Molnupiravir (MOV) and nirmatrelvir/ritonavir (NMV/r) are efficacious oral antiviral agents for patients with the 2019 coronavirus (COVID-19). However, little is known about their effectiveness in older adults and those at high risk of disease progression. This retrospective single-center observational study assessed and compared the outcomes of COVID-19 treated with MOV and NMV/r in a real-world community setting. We included patients with confirmed COVID-19 combined with one or more risk factors for disease progression from June to October 2022. Of 283 patients, 79.9% received MOV and 20.1% NMV/r. The mean patient age was 71.7 years, 56.5% were men, and 71.7% had received ≥3 doses of vaccine. COVID-19-related hospitalization (2.8% and 3.5%, respectively; p = 0.978) or death (0.4% and 3.5%, respectively; p = 0.104) did not differ significantly between the MOV and NMV/r groups. The incidence of adverse events was 2.7% and 5.3%, and the incidence of treatment discontinuation was 2.7% and 5.3% in the MOV and NMV/r groups, respectively. The real-world effectiveness of MOV and NMV/r was similar among older adults and those at high risk of disease progression. The incidence of hospitalization or death was low.
Collapse
Affiliation(s)
- Yoshikazu Mutoh
- Department of Infectious Diseases, Tosei General Hospital, Seto 489-8642, Japan
| | - Takumi Umemura
- Department of Infection Control Team, Tosei General Hospital, Seto 489-8642, Japan
| | - Takeshi Nishikawa
- Department of Infectious Diseases, Tosei General Hospital, Seto 489-8642, Japan
| | - Kaho Kondo
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto 489-8642, Japan
| | - Yuta Nishina
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto 489-8642, Japan
| | - Kazuaki Soejima
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto 489-8642, Japan
| | - Yoichiro Noguchi
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto 489-8642, Japan
| | - Tomohiro Bando
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto 489-8642, Japan
| | - Sho Ota
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto 489-8642, Japan
| | - Tatsuki Shimahara
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto 489-8642, Japan
| | - Shuko Hirota
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto 489-8642, Japan
| | - Satoshi Hagimoto
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto 489-8642, Japan
| | - Reoto Takei
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto 489-8642, Japan
| | - Jun Fukihara
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto 489-8642, Japan
| | - Hajime Sasano
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto 489-8642, Japan
| | - Yasuhiko Yamano
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto 489-8642, Japan
| | - Toshiki Yokoyama
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto 489-8642, Japan
| | - Kensuke Kataoka
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto 489-8642, Japan
| | - Toshiaki Matsuda
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto 489-8642, Japan
| | - Tomoki Kimura
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto 489-8642, Japan
| | - Toshihiko Ichihara
- Department of Infectious Diseases, Tosei General Hospital, Seto 489-8642, Japan
- Department of Infection Control Team, Tosei General Hospital, Seto 489-8642, Japan
| | - Yasuhiro Kondoh
- Department of Respiratory Medicine and Allergy, Tosei General Hospital, Seto 489-8642, Japan
| |
Collapse
|