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Mane V, Mehta R, Alvarez N, Sharma V, Park S, Fox A, DeCarlo C, Yang X, Perlin DS, Powell RLR. In vivo antiviral efficacy of LCTG-002, a pooled, purified human milk secretory IgA product, against SARS-CoV-2 in a murine model of COVID-19. Hum Vaccin Immunother 2024; 20:2303226. [PMID: 38251677 PMCID: PMC10807469 DOI: 10.1080/21645515.2024.2303226] [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: 09/25/2023] [Accepted: 01/05/2024] [Indexed: 01/23/2024] Open
Abstract
Immunoglobulin A (IgA) is the most abundant antibody (Ab) in human mucosae, with secretory form (sIgA) being dominant and uniquely stable. sIgA is challenging to produce recombinantly but is naturally found in human milk, which could be considered a global resource for this biologic, justifying its development as a mucosal therapeutic. Presently, SARS-CoV-2 was utilized as a model mucosal pathogen, and methods were developed to efficiently extract human milk sIgA from donors who were naïve to SARS-CoV-2 or had recovered from infection that elicited high-titer anti-SARS-CoV-2 Spike sIgA in their milk (pooled to make LCTG-002). Mass spectrometry determined that proteins with a relative abundance of 1% or greater were all associated with sIgA. Western blot demonstrated that all batches consisted predominantly of sIgA. Compared to control IgA, LCTG-002 demonstrated significantly higher Spike binding (mean endpoint of 0.87 versus 5.87). LCTG-002 was capable of blocking the Spike receptor-binding domain - angiotensin-converting enzyme 2 (ACE2) interaction with significantly greater potency compared to control (mean LCTG-002 IC50 154ug/mL versus 50% inhibition not achieved for control), and exhibited significant neutralization activity against Spike-pseudotyped virus infection (mean LCTG-002 IC50 49.8ug/mL versus 114.5ug/mL for control). LCTG-002 was tested for its capacity to reduce viral lung burden in K18+hACE2 transgenic mice inoculated with SARS-CoV-2. LCTG-002 significantly reduced SARS-CoV-2 titers compared to control when administered at 0.25 mg/day or 1 mg/day, with a maximum TCID50 reduction of 4.9 logs. This innovative study demonstrates that LCTG-002 is highly pure and efficacious in vivo, supporting further development of milk-derived, polyclonal sIgA therapeutics.
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Affiliation(s)
- Viraj Mane
- Lactiga US, Inc. 675 US-1, North Brunswick, NJ, USA
| | - Rikin Mehta
- Lactiga US, Inc. 675 US-1, North Brunswick, NJ, USA
| | - Nadine Alvarez
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ, USA
| | - Vijeta Sharma
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ, USA
| | - Steven Park
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ, USA
| | - Alisa Fox
- Icahn School of Medicine at Mount Sinai, Department of Medicine, Division of Infectious Diseases, New York, NY, USA
| | - Claire DeCarlo
- Icahn School of Medicine at Mount Sinai, Department of Medicine, Division of Infectious Diseases, New York, NY, USA
| | - Xiaoqi Yang
- Icahn School of Medicine at Mount Sinai, Department of Medicine, Division of Infectious Diseases, New York, NY, USA
| | - David S. Perlin
- Center for Discovery and Innovation, Hackensack Meridian Health, Nutley, NJ, USA
| | - Rebecca L. R. Powell
- Icahn School of Medicine at Mount Sinai, Department of Medicine, Division of Infectious Diseases, New York, NY, USA
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Zhang Z, Zhou L, Liu Q, Zheng Y, Tan X, Huang Z, Guo M, Wang X, Chen X, Liang S, Li W, Song K, Yan K, Li J, Li Q, Zhang Y, Yang S, Cai Z, Dai M, Xian Q, Shi ZL, Xu K, Lan K, Chen Y. The lethal K18-hACE2 knock-in mouse model mimicking the severe pneumonia of COVID-19 is practicable for antiviral development. Emerg Microbes Infect 2024; 13:2353302. [PMID: 38753462 PMCID: PMC11132709 DOI: 10.1080/22221751.2024.2353302] [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: 01/09/2024] [Accepted: 05/03/2024] [Indexed: 05/18/2024]
Abstract
Animal models of COVID-19 facilitate the development of vaccines and antivirals against SARS-CoV-2. The efficacy of antivirals or vaccines may differ in different animal models with varied degrees of disease. Here, we introduce a mouse model expressing human angiotensin-converting enzyme 2 (ACE2). In this model, ACE2 with the human cytokeratin 18 promoter was knocked into the Hipp11 locus of C57BL/6J mouse by CRISPR - Cas9 (K18-hACE2 KI). Upon intranasal inoculation with high (3 × 105 PFU) or low (2.5 × 102 PFU) dose of SARS-CoV-2 wildtype (WT), Delta, Omicron BA.1, or Omicron BA.2 variants, all mice showed obvious infection symptoms, including weight loss, high viral loads in the lung, and interstitial pneumonia. 100% lethality was observed in K18-hACE2 KI mice infected by variants with a delay of endpoint for Delta and BA.1, and a significantly attenuated pathogenicity was observed for BA.2. The pneumonia of infected mice was accompanied by the infiltration of neutrophils and pulmonary fibrosis in the lung. Compared with K18-hACE2 Tg mice and HFH4-hACE2 Tg mice, K18-hACE2 KI mice are more susceptible to SARS-CoV-2. In the antivirals test, REGN10933 and Remdesivir had limited antiviral efficacies in K18-hACE2 KI mice upon the challenge of SARS-CoV-2 infections, while Nirmatrelvir, monoclonal antibody 4G4, and mRNA vaccines potently protected the mice from death. Our results suggest that the K18-hACE2 KI mouse model is lethal and stable for SARS-CoV-2 infection, and is practicable and stringent to antiviral development.
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Affiliation(s)
- Zhen Zhang
- State Key Laboratory of Virology, Modern Virology Research Center and RNA Institute, College of Life Sciences and Frontier Science Center for Immunology and Metabolism, Wuhan University, Wuhan, People’s Republic of China
- Institute for Vaccine Research, Animal Bio-Safety Level III Laboratory / Center for Animal Experiment, Wuhan University School of Medicine, Wuhan, People’s Republic of China
| | - Li Zhou
- State Key Laboratory of Virology, Modern Virology Research Center and RNA Institute, College of Life Sciences and Frontier Science Center for Immunology and Metabolism, Wuhan University, Wuhan, People’s Republic of China
- Institute for Vaccine Research, Animal Bio-Safety Level III Laboratory / Center for Animal Experiment, Wuhan University School of Medicine, Wuhan, People’s Republic of China
| | - Qianyun Liu
- State Key Laboratory of Virology, Modern Virology Research Center and RNA Institute, College of Life Sciences and Frontier Science Center for Immunology and Metabolism, Wuhan University, Wuhan, People’s Republic of China
| | - Yucheng Zheng
- State Key Laboratory of Virology, Modern Virology Research Center and RNA Institute, College of Life Sciences and Frontier Science Center for Immunology and Metabolism, Wuhan University, Wuhan, People’s Republic of China
| | - Xue Tan
- State Key Laboratory of Virology, Modern Virology Research Center and RNA Institute, College of Life Sciences and Frontier Science Center for Immunology and Metabolism, Wuhan University, Wuhan, People’s Republic of China
| | - Zhixiang Huang
- State Key Laboratory of Virology, Modern Virology Research Center and RNA Institute, College of Life Sciences and Frontier Science Center for Immunology and Metabolism, Wuhan University, Wuhan, People’s Republic of China
- Institute for Vaccine Research, Animal Bio-Safety Level III Laboratory / Center for Animal Experiment, Wuhan University School of Medicine, Wuhan, People’s Republic of China
| | - Ming Guo
- State Key Laboratory of Virology, Modern Virology Research Center and RNA Institute, College of Life Sciences and Frontier Science Center for Immunology and Metabolism, Wuhan University, Wuhan, People’s Republic of China
| | - Xin Wang
- State Key Laboratory of Virology, Modern Virology Research Center and RNA Institute, College of Life Sciences and Frontier Science Center for Immunology and Metabolism, Wuhan University, Wuhan, People’s Republic of China
| | - Xianying Chen
- State Key Laboratory of Virology, Modern Virology Research Center and RNA Institute, College of Life Sciences and Frontier Science Center for Immunology and Metabolism, Wuhan University, Wuhan, People’s Republic of China
| | - Simeng Liang
- State Key Laboratory of Virology, Modern Virology Research Center and RNA Institute, College of Life Sciences and Frontier Science Center for Immunology and Metabolism, Wuhan University, Wuhan, People’s Republic of China
| | - Wenkang Li
- State Key Laboratory of Virology, Modern Virology Research Center and RNA Institute, College of Life Sciences and Frontier Science Center for Immunology and Metabolism, Wuhan University, Wuhan, People’s Republic of China
| | - Kun Song
- State Key Laboratory of Virology, Modern Virology Research Center and RNA Institute, College of Life Sciences and Frontier Science Center for Immunology and Metabolism, Wuhan University, Wuhan, People’s Republic of China
| | - Kun Yan
- State Key Laboratory of Virology, Modern Virology Research Center and RNA Institute, College of Life Sciences and Frontier Science Center for Immunology and Metabolism, Wuhan University, Wuhan, People’s Republic of China
| | - Jiali Li
- State Key Laboratory of Virology, Modern Virology Research Center and RNA Institute, College of Life Sciences and Frontier Science Center for Immunology and Metabolism, Wuhan University, Wuhan, People’s Republic of China
| | - Qiaohong Li
- State Key Laboratory of Virology, Modern Virology Research Center and RNA Institute, College of Life Sciences and Frontier Science Center for Immunology and Metabolism, Wuhan University, Wuhan, People’s Republic of China
- Institute for Vaccine Research, Animal Bio-Safety Level III Laboratory / Center for Animal Experiment, Wuhan University School of Medicine, Wuhan, People’s Republic of China
| | - Yuzhen Zhang
- State Key Laboratory of Virology, Modern Virology Research Center and RNA Institute, College of Life Sciences and Frontier Science Center for Immunology and Metabolism, Wuhan University, Wuhan, People’s Republic of China
- Institute for Vaccine Research, Animal Bio-Safety Level III Laboratory / Center for Animal Experiment, Wuhan University School of Medicine, Wuhan, People’s Republic of China
| | - Shimin Yang
- State Key Laboratory of Virology, Modern Virology Research Center and RNA Institute, College of Life Sciences and Frontier Science Center for Immunology and Metabolism, Wuhan University, Wuhan, People’s Republic of China
| | - Zeng Cai
- State Key Laboratory of Virology, Modern Virology Research Center and RNA Institute, College of Life Sciences and Frontier Science Center for Immunology and Metabolism, Wuhan University, Wuhan, People’s Republic of China
- Institute for Vaccine Research, Animal Bio-Safety Level III Laboratory / Center for Animal Experiment, Wuhan University School of Medicine, Wuhan, People’s Republic of China
| | - Ming Dai
- Institute for Vaccine Research, Animal Bio-Safety Level III Laboratory / Center for Animal Experiment, Wuhan University School of Medicine, Wuhan, People’s Republic of China
| | - Qiaoyang Xian
- Institute for Vaccine Research, Animal Bio-Safety Level III Laboratory / Center for Animal Experiment, Wuhan University School of Medicine, Wuhan, People’s Republic of China
| | - Zheng-Li Shi
- CAS Key Laboratory of Special Pathogens, Wuhan Institute of Virology, Chinese Academy of Sciences, Wuhan, People’s Republic of China
| | - Ke Xu
- State Key Laboratory of Virology, Modern Virology Research Center and RNA Institute, College of Life Sciences and Frontier Science Center for Immunology and Metabolism, Wuhan University, Wuhan, People’s Republic of China
- Institute for Vaccine Research, Animal Bio-Safety Level III Laboratory / Center for Animal Experiment, Wuhan University School of Medicine, Wuhan, People’s Republic of China
| | - Ke Lan
- State Key Laboratory of Virology, Modern Virology Research Center and RNA Institute, College of Life Sciences and Frontier Science Center for Immunology and Metabolism, Wuhan University, Wuhan, People’s Republic of China
- Institute for Vaccine Research, Animal Bio-Safety Level III Laboratory / Center for Animal Experiment, Wuhan University School of Medicine, Wuhan, People’s Republic of China
| | - Yu Chen
- State Key Laboratory of Virology, Modern Virology Research Center and RNA Institute, College of Life Sciences and Frontier Science Center for Immunology and Metabolism, Wuhan University, Wuhan, People’s Republic of China
- Institute for Vaccine Research, Animal Bio-Safety Level III Laboratory / Center for Animal Experiment, Wuhan University School of Medicine, Wuhan, People’s Republic of China
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Zheng HY, Song TZ, Zheng YT. Immunobiology of COVID-19: Mechanistic and therapeutic insights from animal models. Zool Res 2024; 45:747-766. [PMID: 38894519 PMCID: PMC11298684 DOI: 10.24272/j.issn.2095-8137.2024.062] [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: 02/23/2024] [Accepted: 04/22/2024] [Indexed: 06/21/2024] Open
Abstract
The distribution of the immune system throughout the body complicates in vitro assessments of coronavirus disease 2019 (COVID-19) immunobiology, often resulting in a lack of reproducibility when extrapolated to the whole organism. Consequently, developing animal models is imperative for a comprehensive understanding of the pathology and immunology of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. This review summarizes current progress related to COVID-19 animal models, including non-human primates (NHPs), mice, and hamsters, with a focus on their roles in exploring the mechanisms of immunopathology, immune protection, and long-term effects of SARS-CoV-2 infection, as well as their application in immunoprevention and immunotherapy of SARS-CoV-2 infection. Differences among these animal models and their specific applications are also highlighted, as no single model can fully encapsulate all aspects of COVID-19. To effectively address the challenges posed by COVID-19, it is essential to select appropriate animal models that can accurately replicate both fatal and non-fatal infections with varying courses and severities. Optimizing animal model libraries and associated research tools is key to resolving the global COVID-19 pandemic, serving as a robust resource for future emerging infectious diseases.
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Affiliation(s)
- Hong-Yi Zheng
- State Key Laboratory of Genetic Evolution & Animal Models, KIZ-CUHK Joint Laboratory of Bioresources and Molecular Research in Common Diseases, Center for Biosafety Mega-Science, Kunming Institute of Zoology, Chinese Academy of Sciences, Kunming, Yunnan 650223, China
| | - Tian-Zhang Song
- State Key Laboratory of Genetic Evolution & Animal Models, KIZ-CUHK Joint Laboratory of Bioresources and Molecular Research in Common Diseases, Center for Biosafety Mega-Science, Kunming Institute of Zoology, Chinese Academy of Sciences, Kunming, Yunnan 650223, China
| | - Yong-Tang Zheng
- State Key Laboratory of Genetic Evolution & Animal Models, KIZ-CUHK Joint Laboratory of Bioresources and Molecular Research in Common Diseases, Center for Biosafety Mega-Science, Kunming Institute of Zoology, Chinese Academy of Sciences, Kunming, Yunnan 650223, China
- National Resource Center for Non-Human Primates, National Research Facility for Phenotypic & Genetic Analysis of Model Animals (Primate Facility), Kunming Institute of Zoology, Chinese Academy of Sciences, Kunming, Yunnan 650107, China. E-mail:
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4
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Alvarez N, Adam GC, Howe JA, Sharma V, Zimmerman MD, Dolgov E, Rasheed R, Nizar F, Sahay K, Nelson AM, Park S, Zhou X, Burlein C, Fay JF, Iwamoto DV, Bahnck-Teets CM, Getty KL, Lin Goh S, Salhab I, Smith K, Boyce CW, Cabalu TD, Murgolo N, Fox NG, Mayhood TW, Shurtleff VW, Layton ME, Parish CA, McCauley JA, Olsen DB, Perlin DS. Novel Pan-Coronavirus 3CL Protease Inhibitor MK-7845: Biological and Pharmacological Profiling. Viruses 2024; 16:1158. [PMID: 39066320 PMCID: PMC11281459 DOI: 10.3390/v16071158] [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: 06/17/2024] [Revised: 07/09/2024] [Accepted: 07/11/2024] [Indexed: 07/28/2024] Open
Abstract
Severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) continues to be a global threat due to its ability to evolve and generate new subvariants, leading to new waves of infection. Additionally, other coronaviruses like Middle East respiratory syndrome coronavirus (MERS-CoV, formerly known as hCoV-EMC), which first emerged in 2012, persist and continue to present a threat of severe illness to humans. The continued identification of novel coronaviruses, coupled with the potential for genetic recombination between different strains, raises the possibility of new coronavirus clades of global concern emerging. As a result, there is a pressing need for pan-CoV therapeutic drugs and vaccines. After the extensive optimization of an HCV protease inhibitor screening hit, a novel 3CLPro inhibitor (MK-7845) was discovered and subsequently profiled. MK-7845 exhibited nanomolar in vitro potency with broad spectrum activity against a panel of clinical SARS-CoV-2 subvariants and MERS-CoV. Furthermore, when administered orally, MK-7845 demonstrated a notable reduction in viral burdens by >6 log orders in the lungs of transgenic mice infected with SARS-CoV-2 (K18-hACE2 mice) and MERS-CoV (K18-hDDP4 mice).
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Affiliation(s)
- Nadine Alvarez
- Center for Discovery and Innovation, Hackensack Meridian Health, 111 Ideation Way, Nutley, NJ 07110, USA (D.S.P.)
| | | | | | - Vijeta Sharma
- Center for Discovery and Innovation, Hackensack Meridian Health, 111 Ideation Way, Nutley, NJ 07110, USA (D.S.P.)
| | - Matthew D. Zimmerman
- Center for Discovery and Innovation, Hackensack Meridian Health, 111 Ideation Way, Nutley, NJ 07110, USA (D.S.P.)
| | - Enriko Dolgov
- Center for Discovery and Innovation, Hackensack Meridian Health, 111 Ideation Way, Nutley, NJ 07110, USA (D.S.P.)
| | - Risha Rasheed
- Center for Discovery and Innovation, Hackensack Meridian Health, 111 Ideation Way, Nutley, NJ 07110, USA (D.S.P.)
| | - Fatima Nizar
- Center for Discovery and Innovation, Hackensack Meridian Health, 111 Ideation Way, Nutley, NJ 07110, USA (D.S.P.)
| | - Khushboo Sahay
- Center for Discovery and Innovation, Hackensack Meridian Health, 111 Ideation Way, Nutley, NJ 07110, USA (D.S.P.)
| | - Andrew M. Nelson
- Center for Discovery and Innovation, Hackensack Meridian Health, 111 Ideation Way, Nutley, NJ 07110, USA (D.S.P.)
| | - Steven Park
- Center for Discovery and Innovation, Hackensack Meridian Health, 111 Ideation Way, Nutley, NJ 07110, USA (D.S.P.)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - David S. Perlin
- Center for Discovery and Innovation, Hackensack Meridian Health, 111 Ideation Way, Nutley, NJ 07110, USA (D.S.P.)
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5
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Choi MH, Wan EYF, Wong ICK, Chan EWY, Chu WM, Tam AR, Yuen KY, Hung IFN. Comparative effectiveness of combination therapy with nirmatrelvir-ritonavir and remdesivir versus monotherapy with remdesivir or nirmatrelvir-ritonavir in patients hospitalised with COVID-19: a target trial emulation study. THE LANCET. INFECTIOUS DISEASES 2024:S1473-3099(24)00353-0. [PMID: 39025098 DOI: 10.1016/s1473-3099(24)00353-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 05/20/2024] [Accepted: 05/21/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND Remdesivir (Veklury, Gilead Sciences, Foster City, CA, USA) and nirmatrelvir-ritonavir (Paxlovid, Pfizer, New York, NY, USA) were reported to improve the outcome of patients with mild-to-moderate COVID-19 symptoms. Preclinical data suggest that nirmatrelvir-ritonavir might be more effective than remdesivir alone or in combination with nirmatrelvir-ritonavir for people at high risk of severe COVID-19. We aimed to assess the safety and effectiveness of combining remdesivir and nirmatrelvir-ritonavir compared with using each drug alone for adults hospitalised with COVID-19. METHODS In this target trial emulation study, we used electronic health records of patients aged 18 years or older who received either combination treatment of nirmatrelvir-ritonavir and remdesivir or monotherapy of either drug between March 16 and Dec 31, 2022, within 5 days of hospitalisation for COVID-19 in Hong Kong. Inverse probability of treatment weighting was applied to balance baseline patient characteristics across the treatment groups. The primary outcome was all-cause mortality. Cox proportional hazards regression adjusting weighting was used to compare the risk of all-cause mortality, intensive care unit (ICU) admission, or ventilatory support for 90 days of follow-up between groups. FINDINGS Between March 16 and Dec 31, 2022, 18 196 participants were identified from electronic health records and assigned to receive remdesivir (n=4232), nirmatrelvir-ritonavir (n=13 656), or nirmatrelvir-ritonavir and remdesivir (n=308). By applying an inverse probability of treatment weighting, a weighted sample composed of 18 410 recipients of nirmatrelvir-ritonavir and remdesivir combination treatment, 18 178 recipients of remdesivir monotherapy, and 18 287 recipients of nirmatrelvir-ritonavir monotherapy was obtained. After a median follow-up of 84 days (IQR 45-90), risk of mortality was lower in patients who received nirmatrelvir-ritonavir monotherapy (hazard ratio [HR] 0·18 [95% CI 0·15 to 0·20]; absolute risk reduction [ARR] -16·33% [95% CI -16·98 to -15·68]) or remdesivir and nirmatrelvir-ritonavir combination therapy (HR 0·66 [95% CI 0·49 to 0·89]; ARR -6·52% [95% CI -7·29 to -5·74]) than in patients who received remdesivir monotherapy. Similar results were observed for ICU admission or ventilatory support (nirmatrelvir-ritonavir monotherapy: HR 0·09 [95% CI 0·07 to 0·11]; ARR -10·04% [95% CI -10·53 to -9·56]; combination therapy: HR 0·68 [95% CI 0·42 to 1·12]; ARR -3·24% [95% CI -3·84 to -2·64]). Compared with combination therapy, nirmatrelvir-ritonavir monotherapy was associated with lower risk of mortality (HR 0·27 [95% CI 0·20 to 0·37]; ARR -9·81% [95% CI -10·39 to -9·24]) and ICU admission or ventilatory support (HR 0·13 [95% CI 0·08 to 0·22]; ARR -6·80% [95% CI -7·22 to -6·39]). INTERPRETATION Our study highlighted the potential for reduced risk of mortality, ICU admission, or the need for ventilatory support in patients hospitalised with COVID-19 treated with nirmatrelvir-ritonavir as a monotherapy compared with treatment regimens based on nirmatrelvir-ritonavir and remdesivir combination therapy or remdesivir monotherapy. Further randomised controlled trials are needed to support the validity of the current results. FUNDING The Health and Medical Research Fund Commissioned Research on COVID-19. TRANSLATION For the Chinese translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Ming Hong Choi
- Division of Infectious Diseases, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Eric Yuk Fai Wan
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China; Laboratory of Data Discovery for Health (D24H), Hong Kong Science and Technology Park, Hong Kong Special Administrative Region, China; Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Ian Chi Kei Wong
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China; Laboratory of Data Discovery for Health (D24H), Hong Kong Science and Technology Park, Hong Kong Special Administrative Region, China; Aston Pharmacy School, Aston University, Birmingham, UK; School of Pharmacy, Medical Sciences Division, Macau University of Science and Technology, Macau Special Administrative Region, China
| | - Esther Wai Yin Chan
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China; Laboratory of Data Discovery for Health (D24H), Hong Kong Science and Technology Park, Hong Kong Special Administrative Region, China; Department of Pharmacy, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China; Shenzhen Institute of Research and Innovation, The University of Hong Kong, Shenzhen, China
| | - Wing Ming Chu
- Division of Infectious Diseases, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Anthony Raymond Tam
- Division of Infectious Diseases, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Kwok Yung Yuen
- State Key Laboratory of Emerging Infectious Diseases, Carol Yu Centre for Infection, Department of Microbiology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Ivan Fan Ngai Hung
- Division of Infectious Diseases, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong Special Administrative Region, China.
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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.
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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
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7
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Sakander N, Ahmed A, Bhardwaj M, Kumari D, Nandi U, Mukherjee D. A path from synthesis to emergency use authorization of molnupiravir as a COVID-19 therapy. Bioorg Chem 2024; 147:107379. [PMID: 38643567 DOI: 10.1016/j.bioorg.2024.107379] [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: 12/26/2023] [Revised: 04/04/2024] [Accepted: 04/14/2024] [Indexed: 04/23/2024]
Abstract
Coronaviruses are a group of enveloped viruses with non-segmented, single-stranded, and positive-sense RNA genomes. It belongs to the 'Coronaviridae family', responsible for various diseases, including the common cold, SARS, and MERS. The COVID-19 pandemic, which began in March 2020, has affected 209 countries, infected over a million people, and claimed over 50,000 lives. Significant efforts have been made by repurposing several approved drugs including antiviral, to combat the COVID-19 pandemic. Molnupiravir is found to be the first orally acting efficacious drug to treat COVID-19 cases. It was approved for medical use in the UK in November 2021 and other countries, including USFDA, which granted approval an emergency use authorization (EUA) for treating adults with mild to moderate COVID-19 patients. Considering the importance of molnupiravir, the present review deals with its various synthetic strategies, pharmacokinetics, bio-efficacy, toxicity, and safety profiles. The comprehensive information along with critical analysis will be very handy for a wide range of audience including medicinal chemists in the arena of antiviral drug discovery especially anti-viral drugs against any variant of COVID-19.
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Affiliation(s)
- Norein Sakander
- Natural Product and Medicinal Chemistry Division, CSIR-Indian Institute of Integrative Medicine, Jammu 180001, India; Academy of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, India
| | - Ajaz Ahmed
- Natural Product and Medicinal Chemistry Division, CSIR-Indian Institute of Integrative Medicine, Jammu 180001, India; Academy of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, India; Department of Chemistry and Biochemistry, University of California, Los Angeles, CA, 90095, USA
| | - Mahir Bhardwaj
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, India; Pharmacology Division, CSIR-Indian Institute of Integrative Medicine, Jammu 180001, India
| | - Diksha Kumari
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, India; Infectious Diseases Division, CSIR-Indian Institute of Integrative Medicine, Jammu 180001, India
| | - Utpal Nandi
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, India; Pharmacology Division, CSIR-Indian Institute of Integrative Medicine, Jammu 180001, India
| | - Debaraj Mukherjee
- Academy of Scientific and Innovative Research (AcSIR), Ghaziabad 201002, India; Department of Chemical Sciences, Bose Institute, EN 80, Sector V, Bidhan Nagar, Kolkata 700091, WB, India.
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8
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Kinsella PM, Moso MA, Morrissey CO, Dendle C, Guy S, Bond K, Sasadeusz J, Slavin MA. Antiviral therapies for the management of persistent coronavirus disease 2019 in immunocompromised hosts: A narrative review. Transpl Infect Dis 2024; 26:e14301. [PMID: 38809102 DOI: 10.1111/tid.14301] [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: 12/10/2023] [Revised: 04/11/2024] [Accepted: 05/08/2024] [Indexed: 05/30/2024]
Abstract
Antiviral agents with activity against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have played a critical role in disease management; however, little is known regarding the efficacy of these medications in the treatment of SARS-CoV-2 infection in immunocompromised patients, particularly in the management of persistent SARS-CoV-2 positivity. This narrative review discusses the management of persistent coronavirus disease 2019 in immunocompromised hosts, with a focus on antiviral therapies. We identified 84 cases from the literature describing a variety of approaches, including prolonged antiviral therapy (n = 11), combination antivirals (n = 13), and mixed therapy with antiviral and antibody treatments (n = 60). A high proportion had an underlying haematologic malignancy (n = 67, 80%), and were in receipt of anti-CD20 agents (n = 51, 60%). Success was reported in 70 cases (83%) which varied according to the therapy type. Combination therapies with antivirals may be an effective approach for individuals with persistent SARS-CoV-2 positivity, particularly those that incorporate treatments aimed at increasing neutralizing antibody levels. Any novel approaches taken to this difficult management dilemma should be mindful of the emergence of antiviral resistance.
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Affiliation(s)
- Paul M Kinsella
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia
- Department of Infectious Diseases, University of Melbourne at the Doherty Institute of Infection and Immunity, Melbourne, Australia
| | - Michael A Moso
- Department of Infectious Diseases, University of Melbourne at the Doherty Institute of Infection and Immunity, Melbourne, Australia
- Victorian Infectious Diseases Service, Royal Melbourne Hospital at the Doherty Institute of Infection and Immunity, Melbourne, Australia
| | | | - Claire Dendle
- Monash Infectious Diseases, Monash Health, Melbourne, Australia
- School of Clinical Sciences, Monash University, Melbourne, Australia
| | - Stephen Guy
- Department of Infectious Diseases, Eastern Health, Melbourne, Australia
- Eastern Health Clinical School, Monash University, Melbourne, Australia
| | - Katherine Bond
- Department of Microbiology, Royal Melbourne Hospital, Melbourne, Australia
- Victorian Infectious Diseases Reference Laboratory (VIDRL) at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
- Department of Microbiology and Immunology, University of Melbourne at the Doherty Institute of Infection and Immunity, Melbourne, Australia
| | - Joseph Sasadeusz
- Department of Infectious Diseases, University of Melbourne at the Doherty Institute of Infection and Immunity, Melbourne, Australia
- Victorian Infectious Diseases Service, Royal Melbourne Hospital at the Doherty Institute of Infection and Immunity, Melbourne, Australia
| | - Monica A Slavin
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Australia
- Victorian Infectious Diseases Service, Royal Melbourne Hospital at the Doherty Institute of Infection and Immunity, Melbourne, Australia
- Sir Peter MacCallum Department of Oncology, Peter MacCallum Cancer Centre, Melbourne, Australia
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9
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Orth HM, Flasshove C, Berger M, Hattenhauer T, Biederbick KD, Mispelbaum R, Klein U, Stemler J, Fisahn M, Doleschall AD, Baermann BN, Koenigshausen E, Tselikmann O, Killer A, de Angelis C, Gliga S, Stegbauer J, Spuck N, Silling G, Rockstroh JK, Strassburg CP, Brossart P, Panse JP, Jensen BEO, Luedde T, Boesecke C, Heine A, Cornely OA, Monin MB. Early combination therapy of COVID-19 in high-risk patients. Infection 2024; 52:877-889. [PMID: 38017344 PMCID: PMC11142969 DOI: 10.1007/s15010-023-02125-5] [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: 08/13/2023] [Accepted: 10/24/2023] [Indexed: 11/30/2023]
Abstract
PURPOSE Prolonged shedding of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has been observed in immunocompromised hosts. Early monotherapy with direct-acting antivirals or monoclonal antibodies, as recommended by the international guidelines, does not prevent this with certainty. Dual therapies may therefore have a synergistic effect. METHODS This retrospective, multicentre study compared treatment strategies for corona virus disease-19 (COVID-19) with combinations of nirmatrelvir/ritonavir, remdesivir, molnupiravir, and/ or mABs during the Omicron surge. Co-primary endpoints were prolonged viral shedding (≥ 106 copies/ml at day 21 after treatment initiation) and days with SARS-CoV-2 viral load ≥ 106 copies/ml. Therapeutic strategies and risk groups were compared using odds ratios and Fisher's tests or Kaplan-Meier analysis and long-rank tests. Multivariable regression analysis was performed. RESULTS 144 patients were included with a median duration of SARS-CoV-2 viral load ≥ 106 copies/ml of 8.0 days (IQR 6.0-15.3). Underlying haematological malignancies (HM) (p = 0.03) and treatment initiation later than five days after diagnosis (p < 0.01) were significantly associated with longer viral shedding. Prolonged viral shedding was observed in 14.6% (n = 21/144), particularly in patients with underlying HM (OR 3.5; 95% CI 1.2-9.9; p = 0.02). Clinical courses of COVID-19 were mild to moderate with only few adverse effects potentially related to combination treatment. CONCLUSION Early combination treatment of COVID-19 effectively prevented prolonged viral shedding in 85.6% of cases. Considering the rapid viral clearance rates and low toxicity, individualized dual therapy approaches may be beneficial in high-risk patients.
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Affiliation(s)
- Hans Martin Orth
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf, (ABCD), Aachen, Germany
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Charlotte Flasshove
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf, (ABCD), Aachen, Germany
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Moritz Berger
- Institute for Medical Biometry, Informatics and Epidemiology, Bonn University Hospital, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Tessa Hattenhauer
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf, (ABCD), Aachen, Germany
- Department of Oncology, Hematology, Rheumatology and Immune-Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Kaja D Biederbick
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf, (ABCD), Aachen, Germany
- Department of Oncology, Hematology, Rheumatology and Immune-Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Rebekka Mispelbaum
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf, (ABCD), Aachen, Germany
- Department of Oncology, Hematology, Rheumatology and Immune-Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Uwe Klein
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf, (ABCD), Aachen, Germany
- Department of Oncology, Hematology, Rheumatology and Immune-Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Jannik Stemler
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf, (ABCD), Aachen, Germany
- Department I of Internal Medicine, European Diamond Excellence Centre for Medical Mycology (ECMM), University of Cologne, Faculty of Medicine, and University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
- Institute of Translational Research, Cologne Excellence Cluster On Cellular Stress Responses, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
- German Centre for Infection Research (DZIF), Partner-Site Cologne-Bonn, Kerpener Str. 62, 50937, Cologne, Germany
| | - Matthis Fisahn
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf, (ABCD), Aachen, Germany
- Department I of Internal Medicine, European Diamond Excellence Centre for Medical Mycology (ECMM), University of Cologne, Faculty of Medicine, and University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
- Institute of Translational Research, Cologne Excellence Cluster On Cellular Stress Responses, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
- German Centre for Infection Research (DZIF), Partner-Site Cologne-Bonn, Kerpener Str. 62, 50937, Cologne, Germany
| | - Anna D Doleschall
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf, (ABCD), Aachen, Germany
- Department of Oncology, Hematology, Hemostaseology and Stem Cell Transplantation, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Ben-Niklas Baermann
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf, (ABCD), Aachen, Germany
- Department of Hematology, Oncology, and Clinical Immunology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Eva Koenigshausen
- Department of Nephrology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Olga Tselikmann
- Department of Nephrology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Alexander Killer
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf, (ABCD), Aachen, Germany
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Clara de Angelis
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf, (ABCD), Aachen, Germany
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Smaranda Gliga
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf, (ABCD), Aachen, Germany
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Johannes Stegbauer
- Department of Nephrology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Nikolai Spuck
- Institute for Medical Biometry, Informatics and Epidemiology, Bonn University Hospital, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Gerda Silling
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf, (ABCD), Aachen, Germany
- Department of Oncology, Hematology, Hemostaseology and Stem Cell Transplantation, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Jürgen K Rockstroh
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf, (ABCD), Aachen, Germany
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
- German Centre for Infection Research (DZIF), Partner-Site Cologne-Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Christian P Strassburg
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf, (ABCD), Aachen, Germany
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Peter Brossart
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf, (ABCD), Aachen, Germany
- Department of Oncology, Hematology, Rheumatology and Immune-Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Jens P Panse
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf, (ABCD), Aachen, Germany
- Department of Oncology, Hematology, Hemostaseology and Stem Cell Transplantation, University Hospital RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Björn-Erik Ole Jensen
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf, (ABCD), Aachen, Germany
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Tom Luedde
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf, (ABCD), Aachen, Germany
- Department of Gastroenterology, Hepatology and Infectious Diseases, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany
| | - Christoph Boesecke
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf, (ABCD), Aachen, Germany
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
- German Centre for Infection Research (DZIF), Partner-Site Cologne-Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Annkristin Heine
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf, (ABCD), Aachen, Germany
- Department of Oncology, Hematology, Rheumatology and Immune-Oncology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Oliver A Cornely
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf, (ABCD), Aachen, Germany
- Department I of Internal Medicine, European Diamond Excellence Centre for Medical Mycology (ECMM), University of Cologne, Faculty of Medicine, and University Hospital of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
- Institute of Translational Research, Cologne Excellence Cluster On Cellular Stress Responses, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
- German Centre for Infection Research (DZIF), Partner-Site Cologne-Bonn, Kerpener Str. 62, 50937, Cologne, Germany
| | - Malte B Monin
- Centre for Integrated Oncology (CIO), Aachen, Bonn, Cologne, Düsseldorf, (ABCD), Aachen, Germany.
- Department of Internal Medicine I, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
- German Centre for Infection Research (DZIF), Partner-Site Cologne-Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
- Johanniter-Kliniken Bonn GmbH, Johanniter-Krankenhaus Bonn, Bonn, Germany.
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10
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Petit PR, Touret F, Driouich JS, Cochin M, Luciani L, Bernadin O, Laprie C, Piorkowski G, Fraisse L, Sjö P, Mowbray CE, Escudié F, Scandale I, Chatelain E, de Lamballerie X, Solas C, Nougairède A. Further preclinical characterization of molnupiravir against SARS-CoV-2: Antiviral activity determinants and viral genome alteration patterns. Heliyon 2024; 10:e30862. [PMID: 38803975 PMCID: PMC11128822 DOI: 10.1016/j.heliyon.2024.e30862] [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: 01/09/2024] [Revised: 04/12/2024] [Accepted: 05/07/2024] [Indexed: 05/29/2024] Open
Abstract
The SARS-CoV-2 pandemic has highlighted the need for broad-spectrum antiviral drugs to respond promptly to viral emergence. We conducted a preclinical study of molnupiravir (MOV) against SARS-CoV-2 to fully characterise its antiviral properties and mode of action. The antiviral activity of different concentrations of MOV was evaluated ex vivo on human airway epithelium (HAE) and in vivo in a hamster model at three escalating doses (150, 300 and 400 mg/kg/day) according to three different regimens (preventive, pre-emptive and curative). We assessed viral loads and infectious titres at the apical pole of HAE and in hamster lungs, and MOV trough concentration in plasma and lungs. To explore the mode of action of the MOV, the entire genomes of the collected viruses were deep-sequenced. MOV effectively reduced viral titres in HAE and in the lungs of treated animals. Early treatment after infection was a key factor in efficacy, probably associated with high lung concentrations of MOV, suggesting good accumulation in the lung. MOV induced genomic alteration in viral genomes with an increase in the number of minority variants, and predominant G to A transitions. The observed reduction in viral replication and its mechanism of action leading to lethal mutagenesis, supported by clinical trials showing antiviral action in humans, provide a convincing basis for further research as an additional means in the fight against COVID-19 and other RNA viruses.
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Affiliation(s)
- Paul-Rémi Petit
- Unité des Virus Émergents (UVE: Aix-Marseille Univ, Università di Corsica, IRD 190, Inserm 1207, IRBA), France
| | - Franck Touret
- Unité des Virus Émergents (UVE: Aix-Marseille Univ, Università di Corsica, IRD 190, Inserm 1207, IRBA), France
| | - Jean-Sélim Driouich
- Unité des Virus Émergents (UVE: Aix-Marseille Univ, Università di Corsica, IRD 190, Inserm 1207, IRBA), France
| | - Maxime Cochin
- Unité des Virus Émergents (UVE: Aix-Marseille Univ, Università di Corsica, IRD 190, Inserm 1207, IRBA), France
| | - Léa Luciani
- Unité des Virus Émergents (UVE: Aix-Marseille Univ, Università di Corsica, IRD 190, Inserm 1207, IRBA), France
| | - Ornéllie Bernadin
- Unité des Virus Émergents (UVE: Aix-Marseille Univ, Università di Corsica, IRD 190, Inserm 1207, IRBA), France
| | | | - Géraldine Piorkowski
- Unité des Virus Émergents (UVE: Aix-Marseille Univ, Università di Corsica, IRD 190, Inserm 1207, IRBA), France
| | - Laurent Fraisse
- Drugs for Neglected Diseases Initiative, Geneva, Switzerland
| | - Peter Sjö
- Drugs for Neglected Diseases Initiative, Geneva, Switzerland
| | | | - Fanny Escudié
- Drugs for Neglected Diseases Initiative, Geneva, Switzerland
| | - Ivan Scandale
- Drugs for Neglected Diseases Initiative, Geneva, Switzerland
| | - Eric Chatelain
- Drugs for Neglected Diseases Initiative, Geneva, Switzerland
| | - Xavier de Lamballerie
- Unité des Virus Émergents (UVE: Aix-Marseille Univ, Università di Corsica, IRD 190, Inserm 1207, IRBA), France
| | - Caroline Solas
- Unité des Virus Émergents (UVE: Aix-Marseille Univ, Università di Corsica, IRD 190, Inserm 1207, IRBA), France
- Laboratoire de Pharmacocinétique et Toxicologie, Hôpital La Timone, APHM, Marseille, France
| | - Antoine Nougairède
- Unité des Virus Émergents (UVE: Aix-Marseille Univ, Università di Corsica, IRD 190, Inserm 1207, IRBA), France
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11
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Do TND, Abdelnabi R, Boda B, Constant S, Neyts J, Jochmans D. The triple combination of Remdesivir (GS-441524), Molnupiravir and Ribavirin is highly efficient in inhibiting coronavirus replication in human nasal airway epithelial cell cultures and in a hamster infection model. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.05.14.594200. [PMID: 38798406 PMCID: PMC11118304 DOI: 10.1101/2024.05.14.594200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2024]
Abstract
The use of fixed dose-combinations of antivirals with different mechanisms of action has proven a key in the successful treatment of infections with HIV and HCV. For the treatment of infections with SARS-CoV-2 and possible future epi-/pandemic coronaviruses, it will be important to explore the efficacy of combinations of different drugs, in particular to avoid resistance development, such as in patients with immunodeficiencies. As a first effort, we studied the antiviral potency of combinations of antivirals. To that end, we made use of primary human airway epithelial cell (HAEC) cultures grown at the air-liquid interface that were infected with the beta coronavirus OC43. We found that the triple combination of GS-441524 (parent nucleoside of remdesivir), molnupiravir, and ribavirin resulted in a more pronounced antiviral efficacy than what could be expected from a purely additive antiviral effect. The potency of this triple combination was next tested in SARS-CoV-2 infected hamsters. To that end, for each of the drugs, intentionally suboptimal or even ineffective doses were selected. Yet, in the lungs of all hamsters that received triple prophylactic therapy with suboptimal/inactive doses of GS-441524, molnupiravir, and ribavirin, no infectious virus was detectable. Our finding indicate that co-administration of approved drugs for the treatment of coronavirus infections should be further explored but also against other families of viruses with epidemic and pandemic potential for which no effective antiviral treatment is available.
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Affiliation(s)
- Thuc Nguyen Dan Do
- KU Leuven, Department of Microbiology, Immunology and Transplantation, Rega Institute, Laboratory of Virology and Chemotherapy, 3000 Leuven, Belgium
| | - Rana Abdelnabi
- KU Leuven, Department of Microbiology, Immunology and Transplantation, Rega Institute, Laboratory of Virology and Chemotherapy, 3000 Leuven, Belgium
- The VirusBank Platform, Gaston Geenslaan, B-3000 Leuven, Belgium
| | - Bernadett Boda
- Epithelix Sàrl, 18 Chemin des Aulx, Plan-les-Ouates, CH-1228, Geneva, Switzerland
| | - Samuel Constant
- Epithelix Sàrl, 18 Chemin des Aulx, Plan-les-Ouates, CH-1228, Geneva, Switzerland
| | - Johan Neyts
- KU Leuven, Department of Microbiology, Immunology and Transplantation, Rega Institute, Laboratory of Virology and Chemotherapy, 3000 Leuven, Belgium
- The VirusBank Platform, Gaston Geenslaan, B-3000 Leuven, Belgium
| | - Dirk Jochmans
- KU Leuven, Department of Microbiology, Immunology and Transplantation, Rega Institute, Laboratory of Virology and Chemotherapy, 3000 Leuven, Belgium
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12
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Moon C, Porges E, Roberts A, Bacon J. A combination of nirmatrelvir and ombitasvir boosts inhibition of SARS-CoV-2 replication. Antiviral Res 2024; 225:105859. [PMID: 38492891 DOI: 10.1016/j.antiviral.2024.105859] [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: 12/18/2023] [Revised: 03/05/2024] [Accepted: 03/06/2024] [Indexed: 03/18/2024]
Abstract
Antiviral therapeutics are highly effective countermeasures for the treatment of coronavirus disease 2019 (COVID-19). However, development of resistance to antivirals undermines their effectiveness. Combining multiple antivirals during patient treatment has the potential to overcome the evolutionary selective pressure towards antiviral resistance, as well as provide a more robust and efficacious treatment option. The current evidence for effective antiviral combinations to inhibit severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) replication is limited. Here, we demonstrate a combination of nirmatrelvir with ombitasvir, to jointly bring about potent inhibition of SARS-CoV-2 replication. We developed an in vitro 384- well plate cytopathic effect assay for the evaluation of antiviral combinations against Calu-3 cells infected with SARS-CoV-2 and found, that a combination of ombitasvir and nirmatrelvir was synergistic; thereby decreasing the nirmatrelvir IC50 by approx. 16-fold. The increased potency of the nirmatrelvir-ombitasvir combination, over nirmatrelvir alone afforded a greater than 3 log10 reduction in viral titre, which is sufficient to fully prevent the detection of progeny SARS-CoV-2 viral particles at 48 h post infection. The mechanism of this potentiated effect was shown to be, in-part, due to joint inhibition of the 3-chymotrypsin-like protease via a positive allosteric modulation mechanism.
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Affiliation(s)
- Christopher Moon
- Discovery Group, UK Health Security Agency, Porton Down, Salisbury, SP4 0JG, UK.
| | - Eleanor Porges
- Discovery Group, UK Health Security Agency, Porton Down, Salisbury, SP4 0JG, UK
| | - Adam Roberts
- Discovery Group, UK Health Security Agency, Porton Down, Salisbury, SP4 0JG, UK
| | - Joanna Bacon
- Discovery Group, UK Health Security Agency, Porton Down, Salisbury, SP4 0JG, UK
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13
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Ullah I, Escudie F, Scandale I, Gilani Z, Gendron-Lepage G, Gaudette F, Mowbray C, Fraisse L, Bazin R, Finzi A, Mothes W, Kumar P, Chatelain E, Uchil PD. Bioluminescence imaging reveals enhanced SARS-CoV-2 clearance in mice with combinatorial regimens. iScience 2024; 27:109049. [PMID: 38361624 PMCID: PMC10867665 DOI: 10.1016/j.isci.2024.109049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 11/21/2023] [Accepted: 01/23/2024] [Indexed: 02/17/2024] Open
Abstract
Direct acting antivirals (DAAs) represent critical tools for combating severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants of concern (VOCs) that have escaped vaccine-elicited spike-based immunity and future coronaviruses with pandemic potential. Here, we used bioluminescence imaging to evaluate therapeutic efficacy of DAAs that target SARS-CoV-2 RNA-dependent RNA polymerase (favipiravir, molnupiravir) or main protease (nirmatrelvir) against Delta or Omicron VOCs in K18-hACE2 mice. Nirmatrelvir displayed the best efficacy followed by molnupiravir and favipiravir in suppressing viral loads in the lung. Unlike neutralizing antibody treatment, DAA monotherapy regimens did not eradicate SARS-CoV-2 in mice, but combining molnupiravir with nirmatrelvir exhibited superior additive efficacy and led to virus clearance. Furthermore, combining molnupiravir with caspase-1/4 inhibitor mitigated inflammation and lung pathology whereas combining molnupiravir with COVID-19 convalescent plasma demonstrated synergy, rapid virus clearance, and 100% survival. Thus, our study provides insights into in vivo treatment efficacies of DAAs and other effective combinations to bolster COVID-19 therapeutic arsenal.
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Affiliation(s)
- Irfan Ullah
- Department of Internal Medicine, Section of Infectious Diseases, Yale University School of Medicine, New Haven, CT 06520, USA
| | - Fanny Escudie
- Drugs for Neglected Diseases Initiative, Geneva, Switzerland
| | - Ivan Scandale
- Drugs for Neglected Diseases Initiative, Geneva, Switzerland
| | - Zoela Gilani
- Department of Microbial Pathogenesis, Yale University School of Medicine, New Haven, CT 06510, USA
| | | | - Fleur Gaudette
- Centre de Recherche du CHUM, Montréal, QC H2X0A9, Canada
| | - Charles Mowbray
- Drugs for Neglected Diseases Initiative, Geneva, Switzerland
| | - Laurent Fraisse
- Drugs for Neglected Diseases Initiative, Geneva, Switzerland
| | - Renée Bazin
- Hema-Quebec, Affaires Médicales et Innovation, Québec, QC G1V 5C3, Canada
| | - Andrés Finzi
- Centre de Recherche du CHUM, Montréal, QC H2X0A9, Canada
- Departement de Microbiologie, Infectiologie et Immunologie, Université de Montréal, Montréal, QC H2X0A9, Canada
| | - Walther Mothes
- Department of Microbial Pathogenesis, Yale University School of Medicine, New Haven, CT 06510, USA
| | - Priti Kumar
- Department of Internal Medicine, Section of Infectious Diseases, Yale University School of Medicine, New Haven, CT 06520, USA
| | - Eric Chatelain
- Drugs for Neglected Diseases Initiative, Geneva, Switzerland
| | - Pradeep D Uchil
- Department of Microbial Pathogenesis, Yale University School of Medicine, New Haven, CT 06510, USA
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14
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Cianfarini C, Hassler L, Wysocki J, Hassan A, Nicolaescu V, Elli D, Gula H, Ibrahim AM, Randall G, Henkin J, Batlle D. Soluble Angiotensin-Converting Enzyme 2 Protein Improves Survival and Lowers Viral Titers in Lethal Mouse Model of Severe Acute Respiratory Syndrome Coronavirus Type 2 Infection with the Delta Variant. Cells 2024; 13:203. [PMID: 38334597 PMCID: PMC10854654 DOI: 10.3390/cells13030203] [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: 12/22/2023] [Revised: 01/19/2024] [Accepted: 01/20/2024] [Indexed: 02/10/2024] Open
Abstract
Severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) utilizes angiotensin-converting enzyme 2 (ACE2) as its main receptor for cell entry. We bioengineered a soluble ACE2 protein termed ACE2 618-DDC-ABD that has increased binding to SARS-CoV-2 and prolonged duration of action. Here, we investigated the protective effect of this protein when administered intranasally to k18-hACE2 mice infected with the aggressive SARS-CoV-2 Delta variant. k18-hACE2 mice were infected with the SARS-CoV-2 Delta variant by inoculation of a lethal dose (2 × 104 PFU). ACE2 618-DDC-ABD (10 mg/kg) or PBS was administered intranasally six hours prior and 24 and 48 h post-viral inoculation. All animals in the PBS control group succumbed to the disease on day seven post-infection (0% survival), whereas, in contrast, there was only one casualty in the group that received ACE2 618-DDC-ABD (90% survival). Mice in the ACE2 618-DDC-ABD group had minimal disease as assessed using a clinical score and stable weight, and both brain and lung viral titers were markedly reduced. These findings demonstrate the efficacy of a bioengineered soluble ACE2 decoy with an extended duration of action in protecting against the aggressive Delta SARS-CoV-2 variant. Together with previous work, these findings underline the universal protective potential against current and future emerging SARS-CoV-2 variants.
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Affiliation(s)
- Cosimo Cianfarini
- Division of Nephrology/Hypertension, Department of Medicine, Feinberg School of Medicine, Northwestern University, 710 North Fairbanks Court, Chicago, IL 60611, USA
- Charité Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Luise Hassler
- Division of Nephrology/Hypertension, Department of Medicine, Feinberg School of Medicine, Northwestern University, 710 North Fairbanks Court, Chicago, IL 60611, USA
| | - Jan Wysocki
- Division of Nephrology/Hypertension, Department of Medicine, Feinberg School of Medicine, Northwestern University, 710 North Fairbanks Court, Chicago, IL 60611, USA
| | - Abdelsabour Hassan
- Division of Nephrology/Hypertension, Department of Medicine, Feinberg School of Medicine, Northwestern University, 710 North Fairbanks Court, Chicago, IL 60611, USA
| | - Vlad Nicolaescu
- Howard Taylor Ricketts Laboratory, Department of Microbiology, The University of Chicago, Lemont, IL 60637, USA
| | - Derek Elli
- Howard Taylor Ricketts Laboratory, Department of Microbiology, The University of Chicago, Lemont, IL 60637, USA
| | - Haley Gula
- Howard Taylor Ricketts Laboratory, Department of Microbiology, The University of Chicago, Lemont, IL 60637, USA
| | - Amany M. Ibrahim
- Howard Taylor Ricketts Laboratory, Department of Microbiology, The University of Chicago, Lemont, IL 60637, USA
| | - Glenn Randall
- Howard Taylor Ricketts Laboratory, Department of Microbiology, The University of Chicago, Lemont, IL 60637, USA
| | - Jack Henkin
- Center for Developmental Therapeutics, Northwestern University, Evanston, IL 60208, USA
| | - Daniel Batlle
- Division of Nephrology/Hypertension, Department of Medicine, Feinberg School of Medicine, Northwestern University, 710 North Fairbanks Court, Chicago, IL 60611, USA
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15
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Fiaschi L, Biba C, Varasi I, Bartolini N, Paletti C, Giammarino F, Saladini F, Zazzi M, Vicenti I. In Vitro Combinatorial Activity of Direct Acting Antivirals and Monoclonal Antibodies against the Ancestral B.1 and BQ.1.1 SARS-CoV-2 Viral Variants. Viruses 2024; 16:168. [PMID: 38399944 PMCID: PMC10892871 DOI: 10.3390/v16020168] [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: 01/04/2024] [Revised: 01/19/2024] [Accepted: 01/20/2024] [Indexed: 02/25/2024] Open
Abstract
Combination antiviral therapy may be helpful in the treatment of SARS-CoV-2 infection; however, no clinical trial data are available, and combined use of direct-acting antivirals (DAA) and monoclonal antibodies (mAb) has been reported only anecdotally. To assess the cooperative effects of dual drug combinations in vitro, we used a VERO E6 cell-based in vitro system with the ancestral B.1 or the highly divergent BQ.1.1 virus to test pairwise combinations of the licensed DAA, including nirmatrelvir (NRM), remdesivir (RDV) and the active metabolite of molnupiravir (EIDD-1931) as well the combination of RDV with four licensed mAbs (sotrovimab, bebtelovimab, cilgavimab, tixagevimab; tested only with the susceptible B.1 virus). According to SynergyFinder 3.0 summary and weighted scores, all the combinations had an additive effect. Within DAA/DAA combinations, paired scores with the B.1 and BQ.1.1 variants were comparable. In the post hoc analysis weighting synergy by concentrations, several cases of highly synergistic scores were detected at specific drug concentrations, both for DAA/DAA and for RDV/mAb combinations. This was supported by in vitro confirmation experiments showing a more than a linear shift of a drug-effective concentration (IC50) at increasing concentrations of the companion drug, although the effect was prominent with DAA/DAA combinations and minimal or null with RDV/mAb combinations. These results support the cooperative effects of dual drug combinations in vitro, which should be further investigated in animal models before introduction into the clinic.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Ilaria Vicenti
- Department of Medical Biotechnologies, University of Siena, 53100 Siena, Italy; (L.F.); (C.B.); (I.V.); (N.B.); (C.P.); (F.G.); (F.S.); (M.Z.)
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16
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Mao L, Shaabani N, Zhang X, Jin C, Xu W, Argent C, Kushnareva Y, Powers C, Stegman K, Liu J, Xie H, Xu C, Bao Y, Xu L, Zhang Y, Yang H, Qian S, Hu Y, Shao J, Zhang C, Li T, Li Y, Liu N, Lin Z, Wang S, Wang C, Shen W, Lin Y, Shu D, Zhu Z, Kotoi O, Kerwin L, Han Q, Chumakova L, Teijaro J, Royal M, Brunswick M, Allen R, Ji H, Lu H, Xu X. Olgotrelvir, a dual inhibitor of SARS-CoV-2 M pro and cathepsin L, as a standalone antiviral oral intervention candidate for COVID-19. MED 2024; 5:42-61.e23. [PMID: 38181791 DOI: 10.1016/j.medj.2023.12.004] [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: 06/08/2023] [Revised: 08/18/2023] [Accepted: 12/03/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND Oral antiviral drugs with improved antiviral potency and safety are needed to address current challenges in clinical practice for treatment of COVID-19, including the risks of rebound, drug-drug interactions, and emerging resistance. METHODS Olgotrelvir (STI-1558) is designed as a next-generation antiviral targeting the SARS-CoV-2 main protease (Mpro), an essential enzyme for SARS-CoV-2 replication, and human cathepsin L (CTSL), a key enzyme for SARS-CoV-2 entry into host cells. FINDINGS Olgotrelvir is a highly bioavailable oral prodrug that is converted in plasma to its active form, AC1115. The dual mechanism of action of olgotrelvir and AC1115 was confirmed by enzyme activity inhibition assays and co-crystal structures of AC1115 with SARS-CoV-2 Mpro and human CTSL. AC1115 displayed antiviral activity by inhibiting replication of all tested SARS-CoV-2 variants in cell culture systems. Olgotrelvir also inhibited viral entry into cells using SARS-CoV-2 Spike-mediated pseudotypes by inhibition of host CTSL. In the K18-hACE2 transgenic mouse model of SARS-CoV-2-mediated disease, olgotrelvir significantly reduced the virus load in the lungs, prevented body weight loss, and reduced cytokine release and lung pathologies. Olgotrelvir demonstrated potent activity against the nirmatrelvir-resistant Mpro E166 mutants. Olgotrelvir showed enhanced oral bioavailability in animal models and in humans with significant plasma exposure without ritonavir. In phase I studies (ClinicalTrials.gov: NCT05364840 and NCT05523739), olgotrelvir demonstrated a favorable safety profile and antiviral activity. CONCLUSIONS Olgotrelvir is an oral inhibitor targeting Mpro and CTSL with high antiviral activity and plasma exposure and is a standalone treatment candidate for COVID-19. FUNDING Funded by Sorrento Therapeutics.
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Affiliation(s)
- Long Mao
- ACEA Therapeutics, Inc., San Diego, CA 92121, USA
| | | | - Xiaoying Zhang
- ACEA Pharmaceutical Co., Ltd., Hangzhou, Zhejiang, P.R. China
| | - Can Jin
- ACEA Therapeutics, Inc., San Diego, CA 92121, USA
| | - Wanhong Xu
- ACEA Pharmaceutical Co., Ltd., Hangzhou, Zhejiang, P.R. China
| | | | | | - Colin Powers
- Sorrento Therapeutics, Inc., San Diego, CA 92121, USA
| | - Karen Stegman
- Sorrento Therapeutics, Inc., San Diego, CA 92121, USA
| | - Jia Liu
- ACEA Therapeutics, Inc., San Diego, CA 92121, USA
| | - Hui Xie
- Sorrento Therapeutics, Inc., San Diego, CA 92121, USA
| | - Changxu Xu
- ACEA Pharmaceutical Co., Ltd., Hangzhou, Zhejiang, P.R. China
| | - Yimei Bao
- ACEA Pharmaceutical Co., Ltd., Hangzhou, Zhejiang, P.R. China
| | - Lijun Xu
- ACEA Pharmaceutical Co., Ltd., Hangzhou, Zhejiang, P.R. China
| | - Yuren Zhang
- ACEA Pharmaceutical Co., Ltd., Hangzhou, Zhejiang, P.R. China
| | - Haigang Yang
- ACEA Pharmaceutical Co., Ltd., Hangzhou, Zhejiang, P.R. China
| | - Shengdian Qian
- ACEA Pharmaceutical Co., Ltd., Hangzhou, Zhejiang, P.R. China
| | - Yong Hu
- ACEA Pharmaceutical Co., Ltd., Hangzhou, Zhejiang, P.R. China
| | - Jianping Shao
- ACEA Pharmaceutical Co., Ltd., Hangzhou, Zhejiang, P.R. China
| | - Can Zhang
- ACEA Pharmaceutical Co., Ltd., Hangzhou, Zhejiang, P.R. China
| | - Tingting Li
- ACEA Pharmaceutical Co., Ltd., Hangzhou, Zhejiang, P.R. China
| | - Yi Li
- ACEA Pharmaceutical Co., Ltd., Hangzhou, Zhejiang, P.R. China
| | - Na Liu
- ACEA Pharmaceutical Co., Ltd., Hangzhou, Zhejiang, P.R. China
| | - Zhenhao Lin
- ACEA Pharmaceutical Co., Ltd., Hangzhou, Zhejiang, P.R. China
| | - Shanbo Wang
- ACEA Pharmaceutical Co., Ltd., Hangzhou, Zhejiang, P.R. China
| | - Chao Wang
- ACEA Pharmaceutical Co., Ltd., Hangzhou, Zhejiang, P.R. China
| | - Wei Shen
- ACEA Pharmaceutical Co., Ltd., Hangzhou, Zhejiang, P.R. China
| | - Yuanlong Lin
- Shenzhen Third People's Hospital, SUSTech, Shenzhen, P.R. China
| | - Dan Shu
- Shenzhen Third People's Hospital, SUSTech, Shenzhen, P.R. China
| | - Zhenhong Zhu
- ACEA Therapeutics, Inc., San Diego, CA 92121, USA
| | - Olivia Kotoi
- ACEA Therapeutics, Inc., San Diego, CA 92121, USA
| | - Lisa Kerwin
- Sorrento Therapeutics, Inc., San Diego, CA 92121, USA
| | - Qing Han
- Structure Based Design, Inc., San Diego, CA 92121, USA
| | | | - John Teijaro
- Department of Immunology and Microbial Science, The Scripps Research Institute, La Jolla, CA 92037, USA
| | - Mike Royal
- Sorrento Therapeutics, Inc., San Diego, CA 92121, USA
| | | | - Robert Allen
- Sorrento Therapeutics, Inc., San Diego, CA 92121, USA
| | - Henry Ji
- Sorrento Therapeutics, Inc., San Diego, CA 92121, USA
| | - Hongzhou Lu
- Shenzhen Third People's Hospital, SUSTech, Shenzhen, P.R. China.
| | - Xiao Xu
- ACEA Therapeutics, Inc., San Diego, CA 92121, USA.
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17
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Focosi D, Maggi F, D'Abramo A, Nicastri E, Sullivan DJ. Antiviral combination therapies for persistent COVID-19 in immunocompromised patients. Int J Infect Dis 2023; 137:55-59. [PMID: 37778409 DOI: 10.1016/j.ijid.2023.09.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 09/22/2023] [Accepted: 09/26/2023] [Indexed: 10/03/2023] Open
Abstract
OBJECTIVES After the third year of the COVID-19 pandemic, most of the severe COVID-19 burden falls upon immunocompromised patients who cannot mount an endogenous immune response after both vaccination and/or natural infection. They also experience persistent SARS-CoV-2 infection with high viral loads often unsuccessfully managed by the standard antiviral monotherapy regimen initially validated for treatment of COVID-19 immunocompetent patients, only. The off-label prescription of such monotherapy regimens in immunocompromised patients is likely to drive the emergence of treatment-related immune escape, relapses, excess morbidity, and mortality from both COVID-19 and delayed treatment of the underlying disorders. A possible treatment approach to mitigate such consequence is based on combined antiviral therapies. METHODS We searched PubMed for case reports, case series and clinical trials reporting the usage of combined antiviral therapies for COVID-19. RESULTS In this narrative review, we show that combinations of either small molecule antivirals or small molecule antiviral plus passive immunotherapies are safe and effective in small cohorts reported so far. CONCLUSION Considering the progressive loss of efficacy of all authorized anti-spike monoclonal antibodies, promising regimen options are reserved to combinations of small molecule antivirals and COVID-19 convalescent plasma from vaccinated donors.
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Affiliation(s)
- Daniele Focosi
- North-Western Tuscany Blood Bank, Pisa University Hospital, Pisa, Italy.
| | - Fabrizio Maggi
- National Institute for Infectious Diseases "Lazzaro Spallanzani" IRCCS, Rome, Italy
| | - Alessandra D'Abramo
- National Institute for Infectious Diseases "Lazzaro Spallanzani" IRCCS, Rome, Italy
| | - Emanuele Nicastri
- National Institute for Infectious Diseases "Lazzaro Spallanzani" IRCCS, Rome, Italy
| | - David J Sullivan
- Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
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18
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Condor Capcha JM, Kamiar A, Robleto E, Saad AG, Cui T, Wong A, Villano J, Zhong W, Pekosz A, Medina E, Cai R, Sha W, Ranek MJ, Webster KA, Schally AV, Jackson RM, Shehadeh LA. Growth hormone-releasing hormone receptor antagonist MIA-602 attenuates cardiopulmonary injury induced by BSL-2 rVSV-SARS-CoV-2 in hACE2 mice. Proc Natl Acad Sci U S A 2023; 120:e2308342120. [PMID: 37983492 PMCID: PMC10691341 DOI: 10.1073/pnas.2308342120] [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: 05/25/2023] [Accepted: 09/07/2023] [Indexed: 11/22/2023] Open
Abstract
COVID-19 pneumonia causes acute lung injury and acute respiratory distress syndrome (ALI/ARDS) characterized by early pulmonary endothelial and epithelial injuries with altered pulmonary diffusing capacity and obstructive or restrictive physiology. Growth hormone-releasing hormone receptor (GHRH-R) is expressed in the lung and heart. GHRH-R antagonist, MIA-602, has been reported to modulate immune responses to bleomycin lung injury and inflammation in granulomatous sarcoidosis. We hypothesized that MIA-602 would attenuate rVSV-SARS-CoV-2-induced pulmonary dysfunction and heart injury in a BSL-2 mouse model. Male and female K18-hACE2tg mice were inoculated with SARS-CoV-2/USA-WA1/2020, BSL-2-compliant recombinant VSV-eGFP-SARS-CoV-2-Spike (rVSV-SARS-CoV-2), or PBS, and lung viral load, weight loss, histopathology, and gene expression were compared. K18-hACE2tg mice infected with rVSV-SARS-CoV-2 were treated daily with subcutaneous MIA-602 or vehicle and conscious, unrestrained plethysmography performed on days 0, 3, and 5 (n = 7 to 8). Five days after infection mice were killed, and blood and tissues collected for histopathology and protein/gene expression. Both native SARS-CoV-2 and rVSV-SARS-CoV-2 presented similar patterns of weight loss, infectivity (~60%), and histopathologic changes. Daily treatment with MIA-602 conferred weight recovery, reduced lung perivascular inflammation/pneumonia, and decreased lung/heart ICAM-1 expression compared to vehicle. MIA-602 rescued altered respiratory rate, increased expiratory parameters (Te, PEF, EEP), and normalized airflow parameters (Penh and Rpef) compared to vehicle, consistent with decreased airway inflammation. RNASeq followed by protein analysis revealed heightened levels of inflammation and end-stage necroptosis markers, including ZBP1 and pMLKL induced by rVSV-SARS-CoV-2, that were normalized by MIA-602 treatment, consistent with an anti-inflammatory and pro-survival mechanism of action in this preclinical model of COVID-19 pneumonia.
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Affiliation(s)
- Jose M. Condor Capcha
- Department of Medicine, Division of Cardiology, University of Miami Leonard M. Miller School of Medicine, Miami, FL33136
- Interdisciplinary Stem Cell Institute, University of Miami Leonard M. Miller School of Medicine, Miami, FL33136
| | - Ali Kamiar
- Department of Medicine, Division of Cardiology, University of Miami Leonard M. Miller School of Medicine, Miami, FL33136
- Interdisciplinary Stem Cell Institute, University of Miami Leonard M. Miller School of Medicine, Miami, FL33136
| | - Emely Robleto
- Department of Medicine, Division of Cardiology, University of Miami Leonard M. Miller School of Medicine, Miami, FL33136
- Interdisciplinary Stem Cell Institute, University of Miami Leonard M. Miller School of Medicine, Miami, FL33136
| | - Ali G. Saad
- Department of Pathology, University of Miami Leonard M. Miller School of Medicine, Miami, FL33136
| | - Tengjiao Cui
- Research Service, Miami Veterans Affairs Health System (VAHS), Miami, FL33125
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Miami Miller School of Medicine, Miami, FL33101
| | - Amanda Wong
- Department of Molecular and Comparative Pathobiology, Johns Hopkins University, Baltimore, MD21205
| | - Jason Villano
- Department of Molecular and Comparative Pathobiology, Johns Hopkins University, Baltimore, MD21205
| | - William Zhong
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University, Baltimore, MD21205
| | - Andrew Pekosz
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins University, Baltimore, MD21205
| | - Edgar Medina
- Qualityminds Gesellschaft mit beschränkter Haftung (GmbH), Munchen, Munich81549, Germany
| | - Renzhi Cai
- Interdisciplinary Stem Cell Institute, University of Miami Leonard M. Miller School of Medicine, Miami, FL33136
- Research Service, Miami Veterans Affairs Health System (VAHS), Miami, FL33125
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Miami Miller School of Medicine, Miami, FL33101
| | - Wei Sha
- Research Service, Miami Veterans Affairs Health System (VAHS), Miami, FL33125
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Miami Miller School of Medicine, Miami, FL33101
| | - Mark J. Ranek
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD21205
- Department of Pharmacology and Molecular Sciences, Johns Hopkins University, Baltimore, MD21205
| | - Keith A. Webster
- Integene International Holdings, Miami, FL33179
- Baylor College of Medicine, Houston, TX77030
| | - Andrew V. Schally
- Interdisciplinary Stem Cell Institute, University of Miami Leonard M. Miller School of Medicine, Miami, FL33136
- Research Service, Miami Veterans Affairs Health System (VAHS), Miami, FL33125
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Miami Miller School of Medicine, Miami, FL33101
| | - Robert M. Jackson
- Research Service, Miami Veterans Affairs Health System (VAHS), Miami, FL33125
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Miami Miller School of Medicine, Miami, FL33101
| | - Lina A. Shehadeh
- Department of Medicine, Division of Cardiology, University of Miami Leonard M. Miller School of Medicine, Miami, FL33136
- Interdisciplinary Stem Cell Institute, University of Miami Leonard M. Miller School of Medicine, Miami, FL33136
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19
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Rasmussen HB, Hansen PR. Molnupiravir Revisited-Critical Assessment of Studies in Animal Models of COVID-19. Viruses 2023; 15:2151. [PMID: 38005828 PMCID: PMC10675540 DOI: 10.3390/v15112151] [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: 08/31/2023] [Revised: 10/10/2023] [Accepted: 10/16/2023] [Indexed: 11/26/2023] Open
Abstract
Molnupiravir, a prodrug known for its broad antiviral activity, has demonstrated efficacy in animal models of COVID-19, prompting clinical trials, in which initial results indicated a significant effect against the disease. However, subsequent clinical studies did not confirm these findings, leading to the refusal of molnupiravir for permanent market authorization in many countries. This report critically assessed 22 studies published in 18 reports that investigated the efficacy of molnupiravir in animal models of COVID-19, with the purpose of determining how well the design of these models informed human studies. We found that the administered doses of molnupiravir in most studies involving animal COVID-19 models were disproportionately higher than the dose recommended for human use. Specifically, when adjusted for body surface area, over half of the doses of molnupiravir used in the animal studies exceeded twice the human dose. Direct comparison of reported drug exposure across species after oral administration of molnupiravir indicated that the antiviral efficacy of the dose recommended for human use was underestimated in some animal models and overestimated in others. Frequently, molnupiravir was given prophylactically or shortly after SARS-CoV-2 inoculation in these models, in contrast to clinical trials where such timing is not consistently achieved. Furthermore, the recommended five-day treatment duration for humans was exceeded in several animal studies. Collectively, we suggest that design elements in the animal studies under examination contributed to a preference favoring molnupiravir, and thus inflated expectations for its efficacy against COVID-19. Addressing these elements may offer strategies to enhance the clinical efficacy of molnupiravir for the treatment of COVID-19. Such strategies include dose increment, early treatment initiation, administration by inhalation, and use of the drug in antiviral combination therapy.
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Affiliation(s)
- Henrik Berg Rasmussen
- Institute of Biological Psychiatry, Mental Health Centre Sct. Hans, 4000 Roskilde, Denmark
- Department of Science and Environment, Roskilde University, 4000 Roskilde, Denmark
| | - Peter Riis Hansen
- Department of Cardiology, Herlev and Gentofte Hospital, Copenhagen University Hospital, 2900 Hellerup, Denmark;
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, 2200 Copenhagen, Denmark
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20
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Zibat A, Zhang X, Dickmanns A, Stegmann KM, Dobbelstein AW, Alachram H, Soliwoda R, Salinas G, Groß U, Görlich D, Kschischo M, Wollnik B, Dobbelstein M. N4-hydroxycytidine, the active compound of Molnupiravir, promotes SARS-CoV-2 mutagenesis and escape from a neutralizing nanobody. iScience 2023; 26:107786. [PMID: 37731621 PMCID: PMC10507161 DOI: 10.1016/j.isci.2023.107786] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 07/27/2023] [Accepted: 08/28/2023] [Indexed: 09/22/2023] Open
Abstract
N4-hydroxycytidine (NHC), the active compound of the drug Molnupiravir, is incorporated into SARS-CoV-2 RNA, causing false base pairing. The desired result is an "error catastrophe," but this bears the risk of mutated virus progeny. To address this experimentally, we propagated the initial SARS-CoV-2 strain in the presence of NHC. Deep sequencing revealed numerous NHC-induced mutations and host-cell-adapted virus variants. The presence of the neutralizing nanobody Re5D06 selected for immune escape mutations, in particular p.E484K and p.F490S, which are key mutations of the Beta/Gamma and Omicron-XBB strains, respectively. With NHC treatment, nanobody resistance occurred two passages earlier than without. Thus, within the limitations of this purely in vitro study, we conclude that the combined action of Molnupiravir and a spike-neutralizing antagonist leads to the rapid emergence of escape mutants. We propose caution use and supervision when using Molnupiravir, especially when patients are still at risk of spreading virus.
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Affiliation(s)
- Arne Zibat
- Department of Human Genetics, University Medical Center Göttingen, 37073 Göttingen, Germany
| | - Xiaoxiao Zhang
- Department of Mathematics and Technology, University of Applied Sciences Koblenz, 53424 Remagen, Germany
- Department of Informatics, Technical University of Munich, 81675 Munich, Germany
| | - Antje Dickmanns
- Department of Molecular Oncology, Göttingen Center of Molecular Biosciences (GZMB), University Medical Center Göttingen, 37077 Göttingen, Germany
| | - Kim M. Stegmann
- Department of Molecular Oncology, Göttingen Center of Molecular Biosciences (GZMB), University Medical Center Göttingen, 37077 Göttingen, Germany
| | | | - Halima Alachram
- Department of Human Genetics, University Medical Center Göttingen, 37073 Göttingen, Germany
| | - Rebecca Soliwoda
- Department of Molecular Oncology, Göttingen Center of Molecular Biosciences (GZMB), University Medical Center Göttingen, 37077 Göttingen, Germany
| | - Gabriela Salinas
- NGS Integrative Genomics Core Unit, Department of Human Genetics, University Medical Center Göttingen, 37077 Göttingen, Germany
| | - Uwe Groß
- Department of Medical Microbiology and Virology, University Medical Center Göttingen, 37075 Göttingen, Germany
| | - Dirk Görlich
- Max Planck Institute for Multidisciplinary Sciences, 37077 Göttingen, Germany
| | - Maik Kschischo
- Department of Mathematics and Technology, University of Applied Sciences Koblenz, 53424 Remagen, Germany
| | - Bernd Wollnik
- Department of Human Genetics, University Medical Center Göttingen, 37073 Göttingen, Germany
- Cluster of Excellence "Multiscale Bioimaging: from Molecular Machines to Networks of Excitable Cells" (MBExC), University of Göttingen, 37075 Göttingen, Germany
| | - Matthias Dobbelstein
- Department of Molecular Oncology, Göttingen Center of Molecular Biosciences (GZMB), University Medical Center Göttingen, 37077 Göttingen, Germany
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21
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Zhang Y, Sun Y, Xie Y, Shang W, Wang Z, Jiang H, Shen J, Xiao G, Zhang L. A viral RNA-dependent RNA polymerase inhibitor VV116 broadly inhibits human coronaviruses and has synergistic potency with 3CLpro inhibitor nirmatrelvir. Signal Transduct Target Ther 2023; 8:360. [PMID: 37735468 PMCID: PMC10514301 DOI: 10.1038/s41392-023-01587-1] [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: 02/25/2023] [Revised: 06/28/2023] [Accepted: 08/03/2023] [Indexed: 09/23/2023] Open
Abstract
During the ongoing pandemic, providing treatment consisting of effective, low-cost oral antiviral drugs at an early stage of SARS-CoV-2 infection has been a priority for controlling COVID-19. Although Paxlovid and molnupiravir have received emergency approval from the FDA, some side effect concerns have emerged, and the possible oral agents are still limited, resulting in optimized drug development becoming an urgent requirement. An oral remdesivir derivative, VV116, has been reported to have promising antiviral effects against SARS-CoV-2 and positive therapeutic outcomes in clinical trials. However, whether VV116 has broad-spectrum anti-coronavirus activity and potential synergy with other drugs is not clear. Here, we uncovered the broad-spectrum antiviral potency of VV116 against SARS-CoV-2 variants of concern (VOCs), HCoV-OC43, and HCoV-229E in various cell lines. In vitro drug combination screening targeted RdRp and proteinase, highlighting the synergistic effect of VV116 and nirmatrelvir on HCoV-OC43 and SARS-CoV-2. When co-administrated with ritonavir, the combination of VV116 and nirmatrelvir showed significantly enhanced antiviral potency with noninteracting pharmacokinetic properties in mice. Our findings will facilitate clinical treatment with VV116 or VV116+nirmatrelvir combination to fight coronavirus infection.
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Affiliation(s)
- Yumin Zhang
- State Key Laboratory of Virology, Wuhan Institute of Virology, Center for Biosafety Mega-Science, Chinese Academy of Sciences, 430071, Wuhan, China
| | - Yuan Sun
- State Key Laboratory of Virology, Wuhan Institute of Virology, Center for Biosafety Mega-Science, Chinese Academy of Sciences, 430071, Wuhan, China
- University of Chinese Academy of Sciences, 100049, Beijing, China
| | | | - Weijuan Shang
- State Key Laboratory of Virology, Wuhan Institute of Virology, Center for Biosafety Mega-Science, Chinese Academy of Sciences, 430071, Wuhan, China
| | - Zhen Wang
- Lingang Laboratory, 200031, Shanghai, China
| | - Hualiang Jiang
- Lingang Laboratory, 200031, Shanghai, China
- Shanghai Institute of Materia Medica, Chinese Academy of Sciences, 201203, Shanghai, China
| | - Jingshan Shen
- University of Chinese Academy of Sciences, 100049, Beijing, China.
- Shanghai Institute of Materia Medica, Chinese Academy of Sciences, 201203, Shanghai, China.
| | - Gengfu Xiao
- State Key Laboratory of Virology, Wuhan Institute of Virology, Center for Biosafety Mega-Science, Chinese Academy of Sciences, 430071, Wuhan, China.
- University of Chinese Academy of Sciences, 100049, Beijing, China.
| | - Leike Zhang
- State Key Laboratory of Virology, Wuhan Institute of Virology, Center for Biosafety Mega-Science, Chinese Academy of Sciences, 430071, Wuhan, China.
- University of Chinese Academy of Sciences, 100049, Beijing, China.
- Hubei Jiangxia Laboratory, 430200, Wuhan, China.
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22
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Rzymski P, Pokorska-Śpiewak M, Jackowska T, Kuchar E, Nitsch-Osuch A, Pawłowska M, Babicki M, Jaroszewicz J, Szenborn L, Wysocki J, Flisiak R. Key Considerations during the Transition from the Acute Phase of the COVID-19 Pandemic: A Narrative Review. Vaccines (Basel) 2023; 11:1502. [PMID: 37766178 PMCID: PMC10537111 DOI: 10.3390/vaccines11091502] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 09/12/2023] [Accepted: 09/15/2023] [Indexed: 09/29/2023] Open
Abstract
The COVID-19 pandemic has been met with an unprecedented response from the scientific community, leading to the development, investigation, and authorization of vaccines and antivirals, ultimately reducing the impact of SARS-CoV-2 on global public health. However, SARS-CoV-2 is far from being eradicated, continues to evolve, and causes substantial health and economic burdens. In this narrative review, we posit essential points on SARS-CoV-2 and its responsible management during the transition from the acute phase of the COVID-19 pandemic. As discussed, despite Omicron (sub)variant(s) causing clinically milder infections, SARS-CoV-2 is far from being a negligible pathogen. It requires continued genomic surveillance, particularly if one considers that its future (sub)lineages do not necessarily have to be milder. Antivirals and vaccines remain the essential elements in COVID-19 management. However, the former could benefit from further development and improvements in dosing, while the seasonal administration of the latter requires simplification to increase interest and tackle vaccine hesitancy. It is also essential to ensure the accessibility of COVID-19 pharmaceuticals and vaccines in low-income countries and improve the understanding of their use in the context of the long-term goals of SARS-CoV-2 management. Regardless of location, the primary role of COVID-19 awareness and education must be played by healthcare workers, who directly communicate with patients and serve as role models for healthy behaviors.
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Affiliation(s)
- Piotr Rzymski
- Department of Environmental Medicine, Poznan University of Medical Sciences, 60-806 Poznań, Poland
| | - Maria Pokorska-Śpiewak
- Department of Children’s Infectious Diseases, Medical University of Warsaw, 02-091 Warsaw, Poland;
| | - Teresa Jackowska
- Department of Pediatrics, Centre for Postgraduate Medical Education, 01-813 Warsaw, Poland;
| | - Ernest Kuchar
- Department of Pediatrics with Clinical Assessment Unit, Medical University of Warsaw, 02-091 Warsaw, Poland;
| | - Aneta Nitsch-Osuch
- Department of Social Medicine and Public Health, Medical University of Warsaw, 02-007 Warsaw, Poland;
| | - Małgorzata Pawłowska
- Department of Infectious Diseases and Hepatology, Faculty of Medicine, Collegium Medicum, Nicolaus Copernicus University, 85-067 Bydgoszcz, Poland;
| | - Mateusz Babicki
- Department of Family Medicine, Wroclaw Medical University, 51-141 Wroclaw, Poland;
| | - Jerzy Jaroszewicz
- Department of Infectious Diseases and Hepatology, Medical University of Silesia, 41-902 Bytom, Poland;
| | - Leszek Szenborn
- Department of Pediatric Infectious Diseases, Wrocław Medical University, 50-367 Wroclaw, Poland;
| | - Jacek Wysocki
- Department of Preventive Medicine, Poznan University of Medical Sciences, 61-701 Poznań, Poland;
| | - Robert Flisiak
- Department of Infectious Diseases and Hepatology, Medical University of Białystok, 15-089 Bialystok, Poland;
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23
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Do MH, Li H, Cho SY, Oh S, Jeong JH, Song MS, Jeong JM. Animal efficacy study of a plant extract complex (BEN815) as a potential treatment for COVID-19. PLoS One 2023; 18:e0291537. [PMID: 37708114 PMCID: PMC10501575 DOI: 10.1371/journal.pone.0291537] [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: 01/19/2023] [Accepted: 08/22/2023] [Indexed: 09/16/2023] Open
Abstract
In a short time, several types of injectable and oral therapeutics have been developed and used to effectively manage patients with coronavirus disease 2019 (COVID-19). BEN815 is an improved mixture of three extracts (Psidium guajava, Camellia sinensis, and Rosa hybrida) recognized by the Ministry of Food and Drug Safety of Korea as a health food ingredient that alleviates allergic rhinitis. The current animal efficacy study was performed to assess its probability of improving COVID-19 symptoms. BEN815 treatment significantly increased the survival of K18-hACE2 transgenic mice and reduced viral titers in the lungs at 5 days post infection (DPI). Furthermore, the lungs of the treated mice showed mild tissue damage at 5 DPI and nearly complete recovery from COVID-19 at 14 DPI. BEN815 appears to be an effective and minimally toxic anti-SARS-CoV-2 agent in mice and has potential for clinical applications.
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Affiliation(s)
- Moon Ho Do
- Biotechnology Research Center, Ben’s Lab Co., Ltd., Anyang-si, Gyeonggi-do, Republic of Korea
| | - Hua Li
- Biotechnology Research Center, Ben’s Lab Co., Ltd., Anyang-si, Gyeonggi-do, Republic of Korea
| | - Su Yeon Cho
- Biotechnology Research Center, Ben’s Lab Co., Ltd., Anyang-si, Gyeonggi-do, Republic of Korea
| | - Subin Oh
- Biotechnology Research Center, Ben’s Lab Co., Ltd., Anyang-si, Gyeonggi-do, Republic of Korea
| | - Ju Hwan Jeong
- Department of Microbiology, Chungbuk National University College of Medicine and Medical Research Institute, Cheongju-si, Chungcheongbuk-do, Republic of Korea
| | - Min-Suk Song
- Department of Microbiology, Chungbuk National University College of Medicine and Medical Research Institute, Cheongju-si, Chungcheongbuk-do, Republic of Korea
| | - Jong-Moon Jeong
- Biotechnology Research Center, Ben’s Lab Co., Ltd., Anyang-si, Gyeonggi-do, Republic of Korea
- Department of Bioscience, The University of Suwon, Hwasung-si, Gyeonggi-do, Republic of Korea
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24
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Valipour M, Irannejad H, Keyvani H. An Overview on Anti-COVID-19 Drug Achievements and Challenges Ahead. ACS Pharmacol Transl Sci 2023; 6:1248-1265. [PMID: 37705590 PMCID: PMC10496143 DOI: 10.1021/acsptsci.3c00121] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Indexed: 09/15/2023]
Abstract
The appearance of several coronavirus pandemics/epidemics during the last two decades (SARS-CoV-1 in 2002, MERS-CoV in 2012, and SARS-CoV-2 in 2019) indicates that humanity will face increasing challenges from coronaviruses in the future. The emergence of new strains with similar transmission characteristics as SARS-CoV-2 and mortality rates similar to SARS-CoV-1 (∼10% mortality) or MERS-CoV (∼35% mortality) in the future is a terrifying possibility. Therefore, getting enough preparations to face such risks is an inevitable necessity. The present study aims to review the drug achievements and challenges in the fight against SARS-CoV-2 with a combined perspective derived from pharmacology, pharmacotherapy, and medicinal chemistry insights. Appreciating all the efforts made during the past few years, there is strong evidence that the desired results have not yet been achieved and research in this area should still be pursued seriously. By expressing some pessimistic possibilities and concluding that the drug discovery and pharmacotherapy of COVID-19 have not been successful so far, this short essay tries to draw the attention of responsible authorities to be more prepared against future coronavirus epidemics/pandemics.
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Affiliation(s)
- Mehdi Valipour
- Razi
Drug Research Center, Iran University of
Medical Sciences, Tehran 1134845764, Iran
| | - Hamid Irannejad
- Department
of Medicinal Chemistry, Faculty of Pharmacy, Mazandaran University of Medical Sciences, Sari 48157-33971, Iran
| | - Hossein Keyvani
- Department
of Virology, School of Medicine, Iran University
of Medical Sciences, Tehran 1134845764, Iran
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25
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Yan D, Yan B. Viral target and metabolism-based rationale for combined use of recently authorized small molecule COVID-19 medicines: Molnupiravir, nirmatrelvir, and remdesivir. Fundam Clin Pharmacol 2023; 37:726-738. [PMID: 36931725 PMCID: PMC10505250 DOI: 10.1111/fcp.12889] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 02/12/2023] [Accepted: 02/27/2023] [Indexed: 03/19/2023]
Abstract
The COVID-19 pandemic remains a major health concern worldwide, and SARS-CoV-2 is continuously evolving. There is an urgent need to identify new antiviral drugs and develop novel therapeutic strategies. Combined use of newly authorized COVID-19 medicines including molnupiravir, nirmatrelvir, and remdesivir has been actively pursued. Mechanistically, nirmatrelvir inhibits SARS-CoV-2 replication by targeting the viral main protease (Mpro ), a critical enzyme in the processing of the immediately translated coronavirus polyproteins for viral replication. Molnupiravir and remdesivir, on the other hand, inhibit SARS-CoV-2 replication by targeting RNA-dependent RNA-polymerase (RdRp), which is directly responsible for genome replication and production of subgenomic RNAs. Molnupiravir targets RdRp and induces severe viral RNA mutations (genome), commonly referred to as error catastrophe. Remdesivir, in contrast, targets RdRp and causes chain termination and arrests RNA synthesis of the viral genome. In addition, all three medicines undergo extensive metabolism with strong therapeutic significance. Molnupiravir is hydrolytically activated by carboxylesterase-2 (CES2), nirmatrelvir is inactivated by cytochrome P450-based oxidation (e.g., CYP3A4), and remdesivir is hydrolytically activated by CES1 but covalently inhibits CES2. Additionally, remdesivir and nirmatrelvir are oxidized by the same CYP enzymes. The distinct mechanisms of action provide strong rationale for their combined use. On the other hand, these drugs undergo extensive metabolism that determines their therapeutic potential. This review discusses how metabolism pathways and enzymes involved should be carefully considered during their combined use for therapeutic synergy.
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Affiliation(s)
- Daisy Yan
- Department of Dermatology, Boston University School of Medicine 609 Albany Street Boston, MA 02118
| | - Bingfang Yan
- Division of Pharmaceutical Sciences, James L. Winkle College of Pharmacy, University of Cincinnati, Cincinnati, OH 45229
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26
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Ewart G, Bobardt M, Bentzen BH, Yan Y, Thomson A, Klumpp K, Becker S, Rosenkilde MM, Miller M, Gallay P. Post-infection treatment with the E protein inhibitor BIT225 reduces disease severity and increases survival of K18-hACE2 transgenic mice infected with a lethal dose of SARS-CoV-2. PLoS Pathog 2023; 19:e1011328. [PMID: 37549173 PMCID: PMC10434922 DOI: 10.1371/journal.ppat.1011328] [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: 03/30/2023] [Revised: 08/17/2023] [Accepted: 07/06/2023] [Indexed: 08/09/2023] Open
Abstract
The Coronavirus envelope (E) protein is a small structural protein with ion channel activity that plays an important role in virus assembly, budding, immunopathogenesis and disease severity. The viroporin E is also located in Golgi and ER membranes of infected cells and is associated with inflammasome activation and immune dysregulation. Here we evaluated in vitro antiviral activity, mechanism of action and in vivo efficacy of BIT225 for the treatment of SARS-CoV-2 infection. BIT225 showed broad-spectrum direct-acting antiviral activity against SARS-CoV-2 in Calu3 and Vero cells with similar potency across 6 different virus strains. BIT225 inhibited ion channel activity of E protein but did not inhibit endogenous currents or calcium-induced ion channel activity of TMEM16A in Xenopus oocytes. BIT225 administered by oral gavage for 12 days starting 12 hours before infection completely prevented body weight loss and mortality in SARS-CoV-2 infected K18 mice (100% survival, n = 12), while all vehicle-dosed animals reached a mortality endpoint by Day 9 across two studies (n = 12). When treatment started at 24 hours after infection, body weight loss, and mortality were also prevented (100% survival, n = 5), while 4 of 5 mice maintained and increased body weight and survived when treatment started 48 hours after infection. Treatment efficacy was dependent on BIT225 dose and was associated with significant reductions in lung viral load (3.5 log10), virus titer (4000 pfu/ml) and lung and serum cytokine levels. These results validate viroporin E as a viable antiviral target and support the clinical study of BIT225 for treatment and prophylaxis of SARS-CoV-2 infection.
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Affiliation(s)
- Gary Ewart
- Biotron Limited, North Ryde, New South Wales, Australia
| | - Michael Bobardt
- The Scripps Institute, Immunology and Microbiology, La Jolla, California, United States of America
| | - Bo Hjorth Bentzen
- University of Copenhagen, Department of Biomedical Sciences, Copenhagen, Denmark
| | - Yannan Yan
- University of Copenhagen, Department of Biomedical Sciences, Copenhagen, Denmark
| | | | - Klaus Klumpp
- Biotron Limited, North Ryde, New South Wales, Australia
| | | | - Mette M. Rosenkilde
- University of Copenhagen, Department of Biomedical Sciences, Copenhagen, Denmark
| | | | - Philippe Gallay
- The Scripps Institute, Immunology and Microbiology, La Jolla, California, United States of America
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27
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Gidari A, Sabbatini S, Schiaroli E, Bastianelli S, Pierucci S, Busti C, Saraca LM, Capogrossi L, Pasticci MB, Francisci D. Synergistic Activity of Remdesivir-Nirmatrelvir Combination on a SARS-CoV-2 In Vitro Model and a Case Report. Viruses 2023; 15:1577. [PMID: 37515263 PMCID: PMC10385213 DOI: 10.3390/v15071577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 07/10/2023] [Accepted: 07/17/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND This study aims to investigate the activity of the remdesivir-nirmatrelvir combination against Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) and to report a case of Coronavirus Disease 2019 (COVID-19) cured with this combination. METHODS A Vero E6 cell-based infection assay was used to investigate the in vitro activity of the remdesivir-nirmatrelvir combination. The SARS-CoV-2 strains tested were 20A.EU1, BA.1 and BA.5. After incubation, a viability assay was performed. The supernatants were collected and used for viral titration. The Highest Single Agent (HSA) reference model was calculated. An HSA score >10 is considered synergic. RESULTS Remdesivir and nirmatrelvir showed synergistic activity at 48 and 72 h, with an HSA score of 52.8 and 28.6, respectively (p < 0.0001). These data were confirmed by performing supernatant titration and against the omicron variants: the combination reduced the viral titer better than the more active compound alone. An immunocompromised patient with prolonged and critical COVID-19 was successfully treated with remdesivir, nirmatrelvir/ritonavir, tixagevimab/cilgavimab and dexamethasone, with an excellent clinical-radiological response. However, she required further off-label prolonged therapy with nirmatrelvir/ritonavir until she tested negative. CONCLUSIONS Remdesivir-nirmatrelvir combination has synergic activity in vitro. This combination may have a role in immunosuppressed patients with severe COVID-19 and prolonged viral shedding.
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Affiliation(s)
- Anna Gidari
- Department of Medicine and Surgery, Clinic of Infectious Diseases, "Santa Maria della Misericordia" Hospital, University of Perugia, 06123 Perugia, Italy
- Clinic of Infectious Diseases, "Santa Maria" Hospital, Terni, 05100 Terni, Italy
| | - Samuele Sabbatini
- Department of Medicine and Surgery, Medical Microbiology Section, University of Perugia, 06123 Perugia, Italy
| | - Elisabetta Schiaroli
- Department of Medicine and Surgery, Clinic of Infectious Diseases, "Santa Maria della Misericordia" Hospital, University of Perugia, 06123 Perugia, Italy
| | - Sabrina Bastianelli
- Department of Medicine and Surgery, Clinic of Infectious Diseases, "Santa Maria della Misericordia" Hospital, University of Perugia, 06123 Perugia, Italy
| | - Sara Pierucci
- Department of Medicine and Surgery, Clinic of Infectious Diseases, "Santa Maria della Misericordia" Hospital, University of Perugia, 06123 Perugia, Italy
| | - Chiara Busti
- Department of Medicine and Surgery, Clinic of Infectious Diseases, "Santa Maria della Misericordia" Hospital, University of Perugia, 06123 Perugia, Italy
| | - Lavinia Maria Saraca
- Clinic of Infectious Diseases, "Santa Maria" Hospital, Terni, 05100 Terni, Italy
| | - Luca Capogrossi
- Department of Medicine and Surgery, Clinic of Infectious Diseases, "Santa Maria della Misericordia" Hospital, University of Perugia, 06123 Perugia, Italy
| | - Maria Bruna Pasticci
- Department of Medicine and Surgery, Clinic of Infectious Diseases, "Santa Maria della Misericordia" Hospital, University of Perugia, 06123 Perugia, Italy
- Clinic of Infectious Diseases, "Santa Maria" Hospital, Terni, 05100 Terni, Italy
| | - Daniela Francisci
- Department of Medicine and Surgery, Clinic of Infectious Diseases, "Santa Maria della Misericordia" Hospital, University of Perugia, 06123 Perugia, Italy
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28
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Jeong JH, Choi JH, Kim BK, Min SC, Chokkakula S, Oh S, Park JH, Shim SM, Kim EG, Choi YK, Lee JY, Baek YH, Song MS. Evaluating Z-FA-FMK, a host cathepsin L protease inhibitor, as a potent and broad-spectrum antiviral therapy against SARS-CoV-2 and related coronaviruses. Antiviral Res 2023; 216:105669. [PMID: 37437781 DOI: 10.1016/j.antiviral.2023.105669] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 06/22/2023] [Accepted: 07/08/2023] [Indexed: 07/14/2023]
Abstract
Even though the World Health Organization announced the end of the COVID-19 pandemic as a global public health emergency on May 5, 2023, SARS-CoV-2 continues to pose a significant health threat worldwide, resulting in substantial numbers of infections and fatalities. This study investigated the antiviral potential of Z-FA-FMK (FMK), a novel host cathepsin L protease inhibitor, against SARS-CoV-2 infection using both in vitro and in vivo models. In vitro assessments of FMK against a diverse set of SARS-CoV-2 strains, including the Wuhan-like strain and nine variants, demonstrated potent inhibition with EC50 values ranging from 0.55 to 2.41 μM, showcasing similar or superior efficacy compared to FDA-approved antivirals nirmatrelvir (NTV) and molnupiravir (MPV). In vivo experiments using orally administered FMK (25 mg/kg) in SARS-CoV-2-infected K18 hACE2 transgenic mice revealed improved survival rates of 60% and accelerated recovery compared to NTV and MPV treatments. Additionally, FMK displayed a longer half-life (17.26 ± 8.89 h) than NTV and MPV in the mouse model. Due to its host-targeting mechanism, FMK offers potential advantages such as reduced drug resistance and broad-spectrum antiviral activity against multiple coronaviruses. These findings indicate that FMK may serve as a promising candidate for further clinical evaluation in the fight against SARS-CoV-2.
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Affiliation(s)
- Ju Hwan Jeong
- Department of Microbiology, Chungbuk National University College of Medicine and Medical Research Institute, Cheongju, Chungbuk, 28644, Republic of Korea
| | - Jang-Hoon Choi
- Division of Acute Viral Disease, Center for Emerging Virus Research, National Institute of Infectious Diseases, Korea National Institute of Health, Cheongju, 28159, Republic of Korea
| | - Beom Kyu Kim
- Department of Microbiology, Chungbuk National University College of Medicine and Medical Research Institute, Cheongju, Chungbuk, 28644, Republic of Korea
| | - Seong Cheol Min
- Department of Microbiology, Chungbuk National University College of Medicine and Medical Research Institute, Cheongju, Chungbuk, 28644, Republic of Korea
| | - Santosh Chokkakula
- Department of Microbiology, Chungbuk National University College of Medicine and Medical Research Institute, Cheongju, Chungbuk, 28644, Republic of Korea
| | - Sol Oh
- Department of Microbiology, Chungbuk National University College of Medicine and Medical Research Institute, Cheongju, Chungbuk, 28644, Republic of Korea
| | - Ji-Hyun Park
- Department of Microbiology, Chungbuk National University College of Medicine and Medical Research Institute, Cheongju, Chungbuk, 28644, Republic of Korea
| | - Sang-Mu Shim
- Division of Acute Viral Disease, Center for Emerging Virus Research, National Institute of Infectious Diseases, Korea National Institute of Health, Cheongju, 28159, Republic of Korea
| | - Eung-Gook Kim
- Department of Biochemistry, Chungbuk National University College of Medicine and Medical Research Institute, Cheongju, Chungbuk, 28644, Republic of Korea
| | - Young Ki Choi
- Department of Microbiology, Chungbuk National University College of Medicine and Medical Research Institute, Cheongju, Chungbuk, 28644, Republic of Korea; Center for Study of Emerging and Re-emerging Viruses, Korea Virus Research Institute, Institute for Basic Science (IBS), Daejeon, 34126, Republic of Korea
| | - Joo-Yeon Lee
- Center for Emerging Virus Research, Korea National Institute of Health, Korea Disease Control and Prevention Agency, Cheongju-si, Republic of Korea.
| | - Yun Hee Baek
- Department of Microbiology, Chungbuk National University College of Medicine and Medical Research Institute, Cheongju, Chungbuk, 28644, Republic of Korea.
| | - Min-Suk Song
- Department of Microbiology, Chungbuk National University College of Medicine and Medical Research Institute, Cheongju, Chungbuk, 28644, Republic of Korea.
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29
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Ivachtchenko AV, Ivashchenko AA, Shkil DO, Ivashchenko IA. Aprotinin-Drug against Respiratory Diseases. Int J Mol Sci 2023; 24:11173. [PMID: 37446350 DOI: 10.3390/ijms241311173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 06/28/2023] [Accepted: 07/03/2023] [Indexed: 07/15/2023] Open
Abstract
Aprotinin (APR) was discovered in 1930. APR is an effective pan-protease inhibitor, a typical "magic shotgun". Until 2007, APR was widely used as an antithrombotic and anti-inflammatory drug in cardiac and noncardiac surgeries for reduction of bleeding and thus limiting the need for blood transfusion. The ability of APR to inhibit proteolytic activation of some viruses leads to its use as an antiviral drug for the prevention and treatment of acute respiratory virus infections. However, due to incompetent interpretation of several clinical trials followed by incredible controversy in the literature, the usage of APR was nearly stopped for a decade worldwide. In 2015-2020, after re-analysis of these clinical trials' data the restrictions in APR usage were lifted worldwide. This review discusses antiviral mechanisms of APR action and summarizes current knowledge and prospective regarding the use of APR treatment for diseases caused by RNA-containing viruses, including influenza and SARS-CoV-2 viruses, or as a part of combination antiviral treatment.
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Affiliation(s)
- Alexandre V Ivachtchenko
- ChemDiv Inc., San Diego, CA 92130, USA
- ASAVI LLC, 1835 East Hallandale Blvd #442, Hallandale Beach, FL 33009, USA
| | | | - Dmitrii O Shkil
- ASAVI LLC, 1835 East Hallandale Blvd #442, Hallandale Beach, FL 33009, USA
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30
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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.
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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
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31
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Bajaj T, Wehri E, Suryawanshi RK, King E, Pardeshi KS, Behrouzi K, Khodabakhshi Z, Schulze-Gahmen U, Kumar GR, Mofrad MRK, Nomura DK, Ott M, Schaletzky J, Murthy N. Mercapto-pyrimidines are reversible covalent inhibitors of the papain-like protease (PLpro) and inhibit SARS-CoV-2 (SCoV-2) replication. RSC Adv 2023; 13:17667-17677. [PMID: 37312993 PMCID: PMC10259201 DOI: 10.1039/d3ra01915b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 06/01/2023] [Indexed: 06/15/2023] Open
Abstract
The papain-like protease (PLpro) plays a critical role in SARS-CoV-2 (SCoV-2) pathogenesis and is essential for viral replication and for allowing the virus to evade the host immune response. Inhibitors of PLpro have great therapeutic potential, however, developing them has been challenging due to PLpro's restricted substrate binding pocket. In this report, we screened a 115 000-compound library for PLpro inhibitors and identified a new pharmacophore, based on a mercapto-pyrimidine fragment that is a reversible covalent inhibitor (RCI) of PLpro and inhibits viral replication in cells. Compound 5 had an IC50 of 5.1 μM for PLpro inhibition and hit optimization yielded a derivative with increased potency (IC50 0.85 μM, 6-fold higher). Activity based profiling of compound 5 demonstrated that it reacts with PLpro cysteines. We show here that compound 5 represents a new class of RCIs, which undergo an addition elimination reaction with cysteines in their target proteins. We further show that their reversibility is catalyzed by exogenous thiols and is dependent on the size of the incoming thiol. In contrast, traditional RCIs are all based upon the Michael addition reaction mechanism and their reversibility is base-catalyzed. We identify a new class of RCIs that introduces a more reactive warhead with a pronounced selectivity profile based on thiol ligand size. This could allow the expansion of RCI modality use towards a larger group of proteins important for human disease.
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Affiliation(s)
- Teena Bajaj
- Graduate Program of Comparative Biochemistry, University of California Berkeley CA USA
| | - Eddie Wehri
- The Henry Wheeler Center of Emerging and Neglected Diseases 344 Li Ka Shing Berkeley CA USA
| | | | - Elizabeth King
- Chemical Biology Graduate Program, University of California Berkeley CA USA
| | | | - Kamyar Behrouzi
- Department of Mechanical Engineering, University of California Berkeley CA USA
| | | | | | - G Renuka Kumar
- Gladstone Institute of Virology Gladstone Institutes San Francisco CA USA
| | | | - Daniel K Nomura
- Department of Chemistry, University of California Berkeley CA USA
| | - Melanie Ott
- Gladstone Institute of Virology Gladstone Institutes San Francisco CA USA
- Department of Medicine, University of California San Francisco CA USA
- Chan Zuckerberg Biohub San Francisco CA USA
| | - Julia Schaletzky
- The Henry Wheeler Center of Emerging and Neglected Diseases 344 Li Ka Shing Berkeley CA USA
| | - Niren Murthy
- Department of Bioengineering, University of California Berkeley CA USA
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32
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Ullah I, Escudie F, Scandale I, Gilani Z, Gendron-Lepage G, Gaudette F, Mowbray C, Fraisse L, Bazin R, Finzi A, Mothes W, Kumar P, Chatelain E, Uchil PD. Combinatorial Regimens Augment Drug Monotherapy for SARS-CoV-2 Clearance in Mice. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.05.31.543159. [PMID: 37398307 PMCID: PMC10312581 DOI: 10.1101/2023.05.31.543159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
Direct acting antivirals (DAAs) represent critical tools for combating SARS-CoV-2 variants of concern (VOCs) that evolve to escape spike-based immunity and future coronaviruses with pandemic potential. Here, we used bioluminescence imaging to evaluate therapeutic efficacy of DAAs that target SARS-CoV-2 RNA-dependent RNA polymerase (favipiravir, molnupiravir) or Main protease (nirmatrelvir) against Delta or Omicron VOCs in K18-hACE2 mice. Nirmatrelvir displayed the best efficacy followed by molnupiravir and favipiravir in suppressing viral loads in the lung. Unlike neutralizing antibody treatment, DAA monotherapy did not eliminate SARS-CoV-2 in mice. However, targeting two viral enzymes by combining molnupiravir with nirmatrelvir resulted in superior efficacy and virus clearance. Furthermore, combining molnupiravir with Caspase-1/4 inhibitor mitigated inflammation and lung pathology whereas combining molnupiravir with COVID-19 convalescent plasma yielded rapid virus clearance and 100% survival. Thus, our study provides insights into treatment efficacies of DAAs and other effective combinations to bolster COVID-19 therapeutic arsenal.
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33
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Markov PV, Ghafari M, Beer M, Lythgoe K, Simmonds P, Stilianakis NI, Katzourakis A. The evolution of SARS-CoV-2. Nat Rev Microbiol 2023; 21:361-379. [PMID: 37020110 DOI: 10.1038/s41579-023-00878-2] [Citation(s) in RCA: 265] [Impact Index Per Article: 265.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2023] [Indexed: 04/07/2023]
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused millions of deaths and substantial morbidity worldwide. Intense scientific effort to understand the biology of SARS-CoV-2 has resulted in daunting numbers of genomic sequences. We witnessed evolutionary events that could mostly be inferred indirectly before, such as the emergence of variants with distinct phenotypes, for example transmissibility, severity and immune evasion. This Review explores the mechanisms that generate genetic variation in SARS-CoV-2, underlying the within-host and population-level processes that underpin these events. We examine the selective forces that likely drove the evolution of higher transmissibility and, in some cases, higher severity during the first year of the pandemic and the role of antigenic evolution during the second and third years, together with the implications of immune escape and reinfections, and the increasing evidence for and potential relevance of recombination. In order to understand how major lineages, such as variants of concern (VOCs), are generated, we contrast the evidence for the chronic infection model underlying the emergence of VOCs with the possibility of an animal reservoir playing a role in SARS-CoV-2 evolution, and conclude that the former is more likely. We evaluate uncertainties and outline scenarios for the possible future evolutionary trajectories of SARS-CoV-2.
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Affiliation(s)
- Peter V Markov
- European Commission, Joint Research Centre (JRC), Ispra, Italy.
- London School of Hygiene & Tropical Medicine, University of London, London, UK.
| | - Mahan Ghafari
- Big Data Institute, University of Oxford, Oxford, UK
| | - Martin Beer
- Institute of Diagnostic Virology, Friedrich-Loeffler-Institut, Insel Riems, Germany
| | | | - Peter Simmonds
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Nikolaos I Stilianakis
- European Commission, Joint Research Centre (JRC), Ispra, Italy
- Department of Biometry and Epidemiology, University of Erlangen-Nuremberg, Erlangen, Germany
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34
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Kim KH, Kang G, Woo WS, Sohn MY, Son HJ, Kwon MG, Kim JO, Park CI. Impact of Red Sea Bream Iridovirus Infection on Rock Bream (Oplegnathus fasciatus) and Other Fish Species: A Study of Horizontal Transmission. Animals (Basel) 2023; 13:ani13071210. [PMID: 37048466 PMCID: PMC10093424 DOI: 10.3390/ani13071210] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 03/29/2023] [Accepted: 03/30/2023] [Indexed: 04/03/2023] Open
Abstract
Red sea bream iridovirus (RSIV) causes significant economic losses in aquaculture. Here, we analyzed the pathogenicity, viral shedding, and transmission dynamics of RSIV in rock bream (Oplegnathus fasciatus) by employing immersion infection and cohabitation challenge models. Rock bream challenged by immersion exposure exhibited 100% mortality within 35 days post RSIV exposure, indicating that the viral shedding in seawater peaked after mortality. At 25 °C, a positive correlation between the viral loads within infected rock bream and virus shedding into the seawater was observed. Specific RSIV lesions were observed in the spleen and kidney of the infected rock bream, and the viral load in the spleen had the highest correlation with the histopathological grade. A cohabitation challenge mimicking the natural transmission conditions was performed to assess the virus transmission and determine the pathogenicity and viral load. The RSIV-infected rock breams (donors) were cohabited with uninfected rock bream, red sea bream (Pagrus major), and flathead grey mullet (Mugil cephalus) (recipients) at both 25 °C and 15 °C. In the cohabitation challenge group maintained at 15 °C, no mortality was observed across all experimental groups. However, RSIV was detected in both seawater and the recipient fish. Our results provide preliminary data for further epidemiological analyses and aid in the development of preventive measures and management of RSIVD in aquaculture.
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35
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Rosenke K, Lewis MC, Feldmann F, Bohrnsen E, Schwarz B, Okumura A, Bohler WF, Callison J, Shaia C, Bosio CM, Lovaglio J, Saturday G, Jarvis MA, Feldmann H. Combined molnupiravir-nirmatrelvir treatment improves the inhibitory effect on SARS-CoV-2 in macaques. JCI Insight 2023; 8:166485. [PMID: 36574296 PMCID: PMC9977490 DOI: 10.1172/jci.insight.166485] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 12/21/2022] [Indexed: 12/28/2022] Open
Abstract
The periodic emergence of SARS-CoV-2 variants of concern (VOCs) with unpredictable clinical severity and ability to escape preexisting immunity emphasizes the continued need for antiviral interventions. Two small molecule inhibitors, molnupiravir (MK-4482), a nucleoside analog, and nirmatrelvir (PF-07321332), a 3C-like protease inhibitor, have recently been approved as monotherapy for use in high-risk patients with COVID-19. As preclinical data are only available for rodent and ferret models, here we assessed the efficacy of MK-4482 and PF-07321332 alone and in combination against infection with the SARS-CoV-2 Delta VOC in the rhesus macaque COVID-19 model. Macaques were infected with the SARS-CoV-2 Delta variant and treated with vehicle, MK-4482, PF-07321332, or a combination of MK-4482 and PF-07321332. Clinical exams were performed at 1, 2, and 4 days postinfection to assess disease and virological parameters. Notably, use of MK-4482 and PF-07321332 in combination improved the individual inhibitory effect of both drugs, resulting in milder disease progression, stronger reduction of virus shedding from mucosal tissues of the upper respiratory tract, stronger reduction of viral replication in the lower respiratory tract, and reduced lung pathology. Our data strongly indicate superiority of combined MK-4482 and PF-07321332 treatment of SARS-CoV-2 infections as demonstrated in the closest COVID-19 surrogate model of human infection.
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Affiliation(s)
| | | | | | - Eric Bohrnsen
- Laboratory of Bacteriology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, NIH, Hamilton, Montana, USA
| | - Benjamin Schwarz
- Laboratory of Bacteriology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, NIH, Hamilton, Montana, USA
| | | | | | | | | | - Catharine M Bosio
- Laboratory of Bacteriology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases, NIH, Hamilton, Montana, USA
| | | | | | - Michael A Jarvis
- Laboratory of Virology.,University of Plymouth, Plymouth, Devon, United Kingdom.,The Vaccine Group Ltd, Plymouth, Devon, United Kingdom
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36
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Molnupiravir: A Versatile Prodrug against SARS-CoV-2 Variants. Metabolites 2023; 13:metabo13020309. [PMID: 36837928 PMCID: PMC9962121 DOI: 10.3390/metabo13020309] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 02/06/2023] [Accepted: 02/14/2023] [Indexed: 02/22/2023] Open
Abstract
The nucleoside analog β-D-N4-hydroxycytidine is the active metabolite of the prodrug molnupiravir and is accepted as an efficient drug against COVID-19. Molnupiravir targets the RNA-dependent RNA polymerase (RdRp) enzyme, which is responsible for replicating the viral genome during the replication process of certain types of viruses. It works by disrupting the normal function of the RdRp enzyme, causing it to make mistakes during the replication of the viral genome. These mistakes can prevent the viral RNA from being transcribed, converted into a complementary DNA template, translated, or converted into a functional protein. By disrupting these crucial steps in the viral replication process, molnupiravir can effectively inhibit the replication of the virus and reduce its ability to cause disease. This review article sheds light on the impact of molnupiravir and its metabolite on SARS-CoV-2 variants of concern, such as delta, omicron, and hybrid/recombinant variants. The detailed mechanism and molecular interactions using molecular docking and dynamics have also been covered. The safety and tolerability of molnupiravir in patients with comorbidities have also been emphasized.
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37
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Johnson DM, Brasel T, Massey S, Garron T, Grimes M, Smith J, Torres M, Wallace S, Villasante-Tezanos A, Beasley DW, Comer JE. Evaluation of molnupiravir (EIDD-2801) efficacy against SARS-CoV-2 in the rhesus macaque model. Antiviral Res 2023; 209:105492. [PMID: 36535309 PMCID: PMC9756747 DOI: 10.1016/j.antiviral.2022.105492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 12/08/2022] [Accepted: 12/11/2022] [Indexed: 12/23/2022]
Abstract
Molnupiravir (EIDD-2801) is a prodrug of a ribonucleoside analogue that is currently being used under a US FDA emergency use authorization for the treatment of mild to moderate COVID-19. We evaluated molnupiravir for efficacy as an oral treatment in the rhesus macaque model of SARS-CoV-2 infection. Twenty non-human primates (NHPs) were challenged with SARS-CoV-2 and treated with 75 mg/kg (n = 8) or 250 mg/kg (n = 8) of molnupiravir twice daily by oral gavage for 7 days. The NHPs were observed for 14 days post-challenge and monitored for clinical signs of disease. After challenge, all groups showed a trend toward increased respiration rates. Treatment with molnupiravir significantly reduced viral RNA levels in bronchoalveolar lavage (BAL) samples at Days 7 and 10. Considering the mild to moderate nature of SARS-CoV-2 infection in the rhesus macaque model, this study highlights the importance of monitoring the viral load in the lung as an indicator of pharmaceutical efficacy for COVID-19 treatments. Additionally, this study provides evidence of the efficacy of molnupiravir which supplements the current ongoing clinical trials of this drug.
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Affiliation(s)
- Dylan M Johnson
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, TX, USA
| | - Trevor Brasel
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, TX, USA; Office of Regulated Nonclinical Studies, University of Texas Medical Branch, Galveston, TX, USA
| | - Shane Massey
- Office of Regulated Nonclinical Studies, University of Texas Medical Branch, Galveston, TX, USA
| | - Tania Garron
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, TX, USA
| | - Michael Grimes
- Office of Regulated Nonclinical Studies, University of Texas Medical Branch, Galveston, TX, USA
| | - Jeanon Smith
- Office of Regulated Nonclinical Studies, University of Texas Medical Branch, Galveston, TX, USA
| | - Maricela Torres
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, TX, USA
| | | | | | - David W Beasley
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, TX, USA; Office of Regulated Nonclinical Studies, University of Texas Medical Branch, Galveston, TX, USA
| | - Jason E Comer
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, TX, USA; Office of Regulated Nonclinical Studies, University of Texas Medical Branch, Galveston, TX, USA.
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38
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Jeon J, Chin B. Treatment Options for Patients With Mild-to-Moderate Coronavirus Disease 2019 in Korea. J Korean Med Sci 2022; 37:e352. [PMID: 36513054 PMCID: PMC9745683 DOI: 10.3346/jkms.2022.37.e352] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 12/04/2022] [Indexed: 12/13/2022] Open
Abstract
The coronavirus disease 2019 (COVID-19) continues to threaten public health in Korea although several surges have passed in the past 3 years since 2019. Although patients with mild-to-moderate COVID-19 can usually recover at home, antiviral therapy to prevent disease progression and hospitalization is beneficial for those at high risk of progressing to severe COVID-19. The purpose of this article was to review how antivirals have been rolled out for the treatment of COVID-19 and how domestic and international guidelines for their use have evolved. Several evidence-based treatment guidelines have been developed in Korea, including those derived from domestic studies. Although many different antiviral agents were nominated as promising therapeutics at the onset of the pandemic, most failed to show efficacy in clinical trials. Currently, three types of antiviral agents-nirmatrelvir-ritonavir, molnupiravir, and remdesivir-are available in Korea to treat severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Each antiviral has its advantages and disadvantages. For most individuals, nirmatrelvir/ritonavir is preferred because of its high efficacy and convenience of administration. When serious drug interactions occur or are expected with nirmatrelvir/ritonavir administration, 3 days of remdesivir treatment is shown to be a reasonable alternative. Molnupiravir may be prescribed with caution only if no other therapeutic options are available or acceptable.
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Affiliation(s)
- Jaehyun Jeon
- Research Institute for Public Healthcare, National Medical Center, Seoul, Korea
- Department of Infectious Diseases, Clinical Infectious Disease Research Center, National Medical Center, Seoul, Korea.
| | - BumSik Chin
- Division of Infectious Diseases, Department of Internal Medicine, National Medical Center, Seoul, Korea
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39
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Ceramella J, Iacopetta D, Sinicropi MS, Andreu I, Mariconda A, Saturnino C, Giuzio F, Longo P, Aquaro S, Catalano A. Drugs for COVID-19: An Update. Molecules 2022; 27:molecules27238562. [PMID: 36500655 PMCID: PMC9740261 DOI: 10.3390/molecules27238562] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 11/30/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022] Open
Abstract
The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was the seventh known human coronavirus, and it was identified in Wuhan, Hubei province, China, in 2020. It caused the highly contagious disease called coronavirus disease 2019 (COVID-19), declared a global pandemic by the World Health Organization (WHO) on 11 March 2020. A great number of studies in the search of new therapies and vaccines have been carried out in these three long years, producing a series of successes; however, the need for more effective vaccines, therapies and other solutions is still being pursued. This review represents a tracking shot of the current pharmacological therapies used for the treatment of COVID-19.
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Affiliation(s)
- Jessica Ceramella
- Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Arcavacata di Rende, 87036 Rende, Italy
| | - Domenico Iacopetta
- Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Arcavacata di Rende, 87036 Rende, Italy
| | - Maria Stefania Sinicropi
- Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Arcavacata di Rende, 87036 Rende, Italy
- Correspondence: (M.S.S.); (C.S.)
| | - Inmaculada Andreu
- Departamento de Química, Universitat Politècnica de València, Camino de Vera s/n, 46022 Valencia, Spain
- Unidad Mixta de Investigación UPV-IIS La Fe, Hospital Universitari i Politècnic La Fe, Avenida de Fernando Abril Martorell 106, 46026 Valencia, Spain
| | | | - Carmela Saturnino
- Department of Science, University of Basilicata, 85100 Potenza, Italy
- Correspondence: (M.S.S.); (C.S.)
| | - Federica Giuzio
- Department of Science, University of Basilicata, 85100 Potenza, Italy
| | - Pasquale Longo
- Department of Chemistry and Biology, University of Salerno, Via Giovanni Paolo II, 132, 84084 Fisciano, Italy
| | - Stefano Aquaro
- Department of Pharmacy, Health and Nutritional Sciences, University of Calabria, Arcavacata di Rende, 87036 Rende, Italy
| | - Alessia Catalano
- Department of Pharmacy-Drug Sciences, University of Bari “Aldo Moro”, 70126 Bari, Italy
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40
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Viral proteases as therapeutic targets. Mol Aspects Med 2022; 88:101159. [PMID: 36459838 PMCID: PMC9706241 DOI: 10.1016/j.mam.2022.101159] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 11/21/2022] [Accepted: 11/23/2022] [Indexed: 11/30/2022]
Abstract
Some medically important viruses-including retroviruses, flaviviruses, coronaviruses, and herpesviruses-code for a protease, which is indispensable for viral maturation and pathogenesis. Viral protease inhibitors have become an important class of antiviral drugs. Development of the first-in-class viral protease inhibitor saquinavir, which targets HIV protease, started a new era in the treatment of chronic viral diseases. Combining several drugs that target different steps of the viral life cycle enables use of lower doses of individual drugs (and thereby reduction of potential side effects, which frequently occur during long term therapy) and reduces drug-resistance development. Currently, several HIV and HCV protease inhibitors are routinely used in clinical practice. In addition, a drug including an inhibitor of SARS-CoV-2 main protease, nirmatrelvir (co-administered with a pharmacokinetic booster ritonavir as Paxlovid®), was recently authorized for emergency use. This review summarizes the basic features of the proteases of human immunodeficiency virus (HIV), hepatitis C virus (HCV), and SARS-CoV-2 and discusses the properties of their inhibitors in clinical use, as well as development of compounds in the pipeline.
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