Efficacy of ganciclovir in combination with other antimicrobial agents against cytomegalovirus in vitro and in vivo

Therapeutic Drug Monitoring of Ganciclovir: Where Are We?

BACKGROUND

Ganciclovir is the mainstay of therapy for the prophylaxis and treatment of Cytomegalovirus. However, therapy with this antiviral agent is hindered by side effects such as myelosuppression, which often leads to therapy cessation. Underdosing, as an attempt to prevent side effects, can lead to drug resistance and therapy failure. Therapeutic drug monitoring (TDM) has been used to overcome these problems. The purpose of this narrative review was to give an overview of ganciclovir TDM, available assays, population pharmacokinetic models, and discuss the current knowledge gaps.

METHODS

For this narrative review, a nonsystematic literature search was performed on the PubMed database in April 2021. The following search terms were used: ganciclovir, valganciclovir, pharmacokinetics, pharmacodynamics, population pharmacokinetics, therapeutic drug monitoring, bioassay, liquid chromatography coupled with tandem mass spectrometry, liquid chromatography, chromatography, spectrophotometry, and toxicity. In addition, the reference lists of the included articles were screened.

RESULTS

The most common bioanalysis method identified was liquid chromatography coupled with tandem mass spectrometry. There are different models presenting ganciclovir IC50; however, establishing a pharmacokinetic/pharmacodynamic target for ganciclovir based on preclinical data is difficult because there are no studies combining dynamic drug exposure in relation to inhibition of viral replication. The data on ganciclovir TDM show large interindividual variability, indicating that TDM may play a role in modifying the dose to reduce toxicity and prevent treatment failure related to low concentrations. The main hurdle for implementing TDM is the lack of robust data to define a therapeutic window.

CONCLUSIONS

Although the pharmacokinetics (PK) involved is relatively well-described, both the pharmacodynamics (PD) and pharmacokinetic/pharmacodynamic relationship are not. This is because the studies conducted to date have mainly focused on estimating ganciclovir exposure, and owing to the limited therapeutic options for CMV infections, future studies on ganciclovir are warranted.

Investigational hemagglutinin-targeted influenza virus inhibitors

INTRODUCTION

Seasonal influenza and pandemic outbreaks typically result in high mortality and morbidity associated with severe economic burdens. Vaccines and anti-influenza drugs have made great contributions to control the infection. However, antigenic drifts and shifts allow influenza viruses to easily escape immune neutralization and antiviral drug activity. Hemagglutinin (HA)is an important envelope protein for the entry of influenza viruses into host cells, thus, HA-targeted agents may be potential anti-influenza drugs. Areas covered: In this review, we describe arbidol, a unique licensed drug targeting HA; discuss and summarize HA-targeted anti-influenza agents been tested before or being tested currently in clinical trials, including monoclonal antibodies, small molecule inhibitors, proteins and peptides. Other small molecule inhibitors are also briefly introduced. Expert opinion: Exploring new clinical applications for existing drugs can provide additional anti-influenza candidates with promising safety and bioavailability, and largely shortened time and costs. To enhance therapeutic efficacy and avoid drug-resistance, combination therapy involving in HA-targeted anti-influenza agent is reasonable and attractive. For drug discovery, it is helpful to keep an eye on the development of methodology in organic synthesis and probe into the co-crystal structure of HA in complex with small molecule.

The role of ganciclovir for the management of cytomegalovirus retinitis in HIV patients: Pharmacological review and update on new developments

OBJECTIVE

To review the pharmacology and pharmacokinetics of intravenous, oral and intraocular ganciclovir, and to discuss the role of these various formulations in the management of cytomegalovirus (CMV) retinitis in AIDS patients.

DATA SOURCES

A MEDLINE search (1987 through November 1995) of English-language literature using the main medical subject headings 'ganciclovir' and 'cytomegalovirus', and the subheading 'acquired immunodeficiency syndrome'. Relevant articles were also selected from references of identified articles. Abstracts from recent medical conferences of infectious diseases, pharmacology and human immunodeficiency virus were screened for additional data.

STUDY SELECTION AND DATA EXTRACTION

All articles and abstracts discussing the use of ganciclovir for the management or prophylaxis of CMV retinitis in AIDS patients were considered for inclusion. Pertinent information, as judged by the authors, was selected and synthesized for discussion.

DATA SYNTHESIS

Ganciclovir has demonstrated virustatic activity against CMV, and is often administered 5 mg/kg intravenously every 12 h as first-line therapy for CMV retinitis. Intravenous maintenance therapy at 5 mg/kg daily is usually effective at delaying retinitis progression for approximately 60 to 70 days. Neutropenia and thrombocytopenia are observed frequently, often necessitating interruption or discontinuation of therapy. Local drug administration may delay disease progression even further, and may be considered for patients who are intolerant to or failing intravenous therapy. However, systemic ganciclovir should be encouraged to reduce the risk of developing contralateral eye or end-organ CMV disease. Oral ganciclovir at 1 g tid is almost as effective as intravenous ganciclovir 5 mg/kg/day in delaying retinitis progression and is associated with fewer line-related complications. Absorption, drug interactions, cost and compliance should also be considered.

CONCLUSIONS

Until recently, ganciclovir was available only for intravenous use. Recent developments allow for intraocular and oral administration of this agent. A clear understanding of the advantages and disadvantages of these new formulations is required in order to select the most appropriate product for managing CMV retinitis in AIDS patients.

Management of drug interactions in patients with HIV

OBJECTIVE

To provide a complication of relevant information on drug interactions to assist healthcare practitioners in managing complex HIV-related pharmacotherapy.

DATA SOURCES

Information was retrieved via a MEDLINE search (January 1966-December 1996) using MeSH headings "human immunodeficiency virus," "drug interactions," and names of medications commonly prescribed for the management of HIV infection and related opportunistic infections. Abstracts of international and national conferences, review articles, textbooks, and references of all articles were also searched.

STUDY SELECTION AND DATA EXTRACTION

All literature on pharmacokinetic or pharmacodynamic interactions was considered for inclusion. Pertinent information, as assessed by the authors, was selected and summarized for discussion.

DATA SYNTHESIS

Drug disposition and/or pharmacologic effect may be affected either by HIV-related physiologic changes or by the presence of concomitant drug therapy. Modifications in drug selection, dosage, dosing regimen, or route of administration may be needed to avoid or manage drug-disease, drug-drug, or drug-food interactions. Management options may depend on the mechanism and the clinical significance of the interaction, the availability of therapeutic alternatives, patient convenience, and cost restrictions. In the absence of specific data, consideration of pharmacokinetic and pharmacodynamic characteristics to assist practitioners in predicting the likelihood of possible interactions was included.

RESULTS

A comprehensive table of clinically significant drug interactions is provided. Drug interaction principles and practical management strategies are also discussed.

CONCLUSIONS

The potential for drug interactions is extremely common, given the increasing complexity of managing patients infected with HIV. To avoid compromising therapeutic efficacy or increasing drug toxicity, practitioners need to be aware of potential interactions and are encouraged to use a systematic approach when managing patient drug therapy.

Treatment of murine cytomegalovirus salivary-gland infection by combined therapy with ganciclovir and thymic humoral factor gamma 2

An optimal therapeutic regimen against primary CMV salivary-gland infection has not yet been developed. We used a murine CMV (MCMV) model system to assess the ability of combined thymic humoral factor THF-gamma 2 immunotherapy and ganciclovir (GCV) antiviral chemotherapy to eliminate detectable viral DNA from salivary glands of infected animals. Mice in different experimental groups were inoculated intraperitoneally with MCMV, treated, and then sacrificed either 2 weeks or 3 months later. To amplify and detect MCMV DNA in infected salivary-gland tissue, we developed a sensitive polymerase chain reaction (PCR) using a glycoprotein B gene primer pair that amplifies a 356 bp segment. During the acute phase of the infection, the detection of high titers of infectious virus in the salivary glands correlated with a strong PCR amplification signal. Although active virions could not be recovered from untreated animals 3 months after viral inoculation, the PCR assay detected a latent MCMV genome. Treatment with either GCV alone or THF-gamma 2 alone had little or no effect on the presence of MCMV DNA. By contrast, combined treatment with THF-gamma 2 and GCV significantly reduced the amount of salivary-gland MCMV DNA to below the limit of PCR detection. The results presented here, and experimental data from previous MCMV research in our laboratories, imply that elimination of the virus from the salivary glands could be due in part to THF-gamma 2 restoration of the various MCMV-suppressed, cell mediated immune-responses. Combining THF-gamma 2 immunotherapy and GCV antiviral chemotherapy may be an important step toward an effective therapeutic regimen that has the potential to prevent the establishment of viral latency ensuing from primary MCMV salivary-gland infection.

Efficacy of AZT therapy in reducing p24 antigen burden in a modified SCID mouse model of HIV infection

A modified severe combined immunodeficient (SCID) mouse model of HIV infection which utilized multiple reconstitutions with human lymphocytes and a large inoculum of HIV was investigated. This mouse model yielded splenic HIV p24 antigen concentrations detectable by standard clinical means. The concentration of p24 exceeded 600 pg/g of spleen through 4 weeks postinfection. A 1-week course of AZT therapy initiated after infection produced a dose responsive reduction in p24 antigen burden. Up to a 95% reduction in p24 antigen burden was observed following AZT therapy at 50 mg/kg/day, while AZT therapy at 5 and 0.5 mg/kg/day produced 52 and 18% reductions. In vitro and pharmacokinetic evaluations correlated potency and tissue concentrations of AZT with treatment efficacy. Active HIV replication in the SCID mice was suggested by both the recovery of viable virus from SCID spleens, and by the efficacy of a brief course of AZT therapy. This SCID mouse model of HIV infection was more quantitative than previous mouse models that utilize PCR-based techniques for detection of HIV. The high HIV burden in this SCID mouse model allowed reductions in p24 concentration to be monitored in response to AZT therapy. A dose response to AZT therapy was demonstrated, even when the first dose was administered after infection. This result suggests greater sensitivity than in previous models in which pretreatment with AZT was required to produce a protective response. This SCID mouse model may be useful for determining efficacy of experimental HIV therapeutics prior to clinical use. An effective animal model could result in a reduction in cost and more rapid development of effective HIV therapeutics.

Efficacy of ganciclovir in combination with zidovudine against cytomegalovirus in vitro and in vivo

In cultured MRC-5 cells, ganciclovir (GCV) alone had good activity against both the established AD169 strain (IC50 8 and 9 microM) and a clinical isolate (IC50 14 microM) of human cytomegalovirus (CMV), while 3'-azido-3'-deoxythymidine (AZT) was relatively inactive [IC50 508 and > 800 (AD169 strain); > 800 microM (clinical isolate)]. When reductions in plaques were compared against reductions in the cellular metabolism of MTT at all GCV and AZT combination concentrations using an improved 3-dimensional linear regression analysis, AZT had an additive effect on the antiviral activity of GCV against the AD169 strain and potentiated the antiviral activity of GCV against the clinical isolate. Calculations showed that, in the presence of 50 microM AZT, the anti-CMV activity of GCV was unchanged for the AD169 strain, whereas the activity of GCV was increased approximately 5-10-fold for the clinical isolate. An increase in GCV efficacy for the AD169 strain first became apparent at 100 microM AZT with an approximately 3-fold increase in activity. In Swiss-Webster mice, the anti-CMV activity of GCV against murine CMV was unaffected when administered in combination with AZT. GCV given alone subcutaneously had an ED50 of 6 mg/kg which was unaffected by daily intraperitoneal doses of 320 mg/kg AZT. These results suggest that AZT will not adversely affect the efficacy of GCV against CMV in HIV-positive, non-neutropenic patients.