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Miyazaki T, Hosogaya N, Fukushige Y, Takemori S, Morimoto S, Yamamoto H, Hori M, Ozawa Y, Shiko Y, Inaba Y, Kurokawa T, Hanaoka H, Iwanami S, Kim K, Iwami S, Watashi K, Miyazawa K, Umeyama T, Yamagoe S, Miyazaki Y, Wakita T, Sumiyoshi M, Hirayama T, Izumikawa K, Yanagihara K, Mukae H, Kawasuji H, Yamamoto Y, Tarumoto N, Ishii H, Ohno H, Yatera K, Kakeya H, Kichikawa Y, Kato Y, Matsumoto T, Saito M, Yotsuyanagi H, Kohno S. A Multicenter Randomized Controlled Trial To Evaluate the Efficacy and Safety of Nelfinavir in Patients with Mild COVID-19. Microbiol Spectr 2023; 11:e0431122. [PMID: 37140398 PMCID: PMC10269734 DOI: 10.1128/spectrum.04311-22] [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: 10/27/2022] [Accepted: 04/11/2023] [Indexed: 05/05/2023] Open
Abstract
Nelfinavir, an orally administered inhibitor of human immunodeficiency virus protease, inhibits the replication of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in vitro. We conducted a randomized controlled trial to evaluate the clinical efficacy and safety of nelfinavir in patients with SARS-CoV-2 infection. We included unvaccinated asymptomatic or mildly symptomatic adult patients who tested positive for SARS-CoV-2 infection within 3 days before enrollment. The patients were randomly assigned (1:1) to receive oral nelfinavir (750 mg; thrice daily for 14 days) combined with standard-of-care or standard-of-care alone. The primary endpoint was the time to viral clearance, confirmed using quantitative reverse-transcription PCR by assessors blinded to the assigned treatment. A total of 123 patients (63 in the nelfinavir group and 60 in the control group) were included. The median time to viral clearance was 8.0 (95% confidence interval [CI], 7.0 to 12.0) days in the nelfinavir group and 8.0 (95% CI, 7.0 to 10.0) days in the control group, with no significant difference between the treatment groups (hazard ratio, 0.815; 95% CI, 0.563 to 1.182; P = 0.1870). Adverse events were reported in 47 (74.6%) and 20 (33.3%) patients in the nelfinavir and control groups, respectively. The most common adverse event in the nelfinavir group was diarrhea (49.2%). Nelfinavir did not reduce the time to viral clearance in this setting. Our findings indicate that nelfinavir should not be recommended in asymptomatic or mildly symptomatic patients infected with SARS-CoV-2. The study is registered with the Japan Registry of Clinical Trials (jRCT2071200023). IMPORTANCE The anti-HIV drug nelfinavir suppresses the replication of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in vitro. However, its efficacy in patients with COVID-19 has not been studied. We conducted a multicenter, randomized controlled trial to evaluate the efficacy and safety of orally administered nelfinavir in patients with asymptomatic or mildly symptomatic COVID-19. Compared to standard-of-care alone, nelfinavir (750 mg, thrice daily) did not reduce the time to viral clearance, viral load, or the time to resolution of symptoms. More patients had adverse events in the nelfinavir group than in the control group (74.6% [47/63 patients] versus 33.3% [20/60 patients]). Our clinical study provides evidence that nelfinavir, despite its antiviral effects on SARS-CoV-2 in vitro, should not be recommended for the treatment of patients with COVID-19 having no or mild symptoms.
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Affiliation(s)
- Taiga Miyazaki
- Division of Respirology, Rheumatology, Infectious Diseases, and Neurology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
- Nagasaki University, Nagasaki, Japan
| | - Naoki Hosogaya
- Clinical Research Center, Nagasaki University Hospital, Nagasaki, Japan
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Yuri Fukushige
- Clinical Research Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Sachiko Takemori
- Clinical Research Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Shinpei Morimoto
- Clinical Research Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Hiroshi Yamamoto
- Clinical Research Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Makoto Hori
- Division of Clinical Research Center, Chiba University Hospital, Chiba, Japan
| | - Yoshihito Ozawa
- Division of Clinical Research Center, Chiba University Hospital, Chiba, Japan
| | - Yuki Shiko
- Division of Clinical Research Center, Chiba University Hospital, Chiba, Japan
| | - Yosuke Inaba
- Division of Clinical Research Center, Chiba University Hospital, Chiba, Japan
| | - Tomoya Kurokawa
- Division of Clinical Research Center, Chiba University Hospital, Chiba, Japan
| | - Hideki Hanaoka
- Division of Clinical Research Center, Chiba University Hospital, Chiba, Japan
| | - Shoya Iwanami
- interdisciplinary Biology Laboratory (iBLab), Division of Biological Sciences, Graduate School of Science, Nagoya University, Aichi, Japan
| | - Kwangsu Kim
- interdisciplinary Biology Laboratory (iBLab), Division of Biological Sciences, Graduate School of Science, Nagoya University, Aichi, Japan
| | - Shingo Iwami
- interdisciplinary Biology Laboratory (iBLab), Division of Biological Sciences, Graduate School of Science, Nagoya University, Aichi, Japan
| | - Koichi Watashi
- Research Center for Drug and Vaccine Development, National Institute of Infectious Diseases, Tokyo, Japan
| | - Ken Miyazawa
- Department of Fungal Infection, National Institute of Infectious Diseases, Tokyo, Japan
| | - Takashi Umeyama
- Department of Fungal Infection, National Institute of Infectious Diseases, Tokyo, Japan
| | - Satoshi Yamagoe
- Section of Infectious Resource Coordination, Department of Research Resource, Center of Clinical Sciences, National Center for Global Health and Medicine, Tokyo, Japan
| | - Yoshitsugu Miyazaki
- Department of Fungal Infection, National Institute of Infectious Diseases, Tokyo, Japan
| | - Takaji Wakita
- National Institute of Infectious Diseases, Tokyo, Japan
| | - Makoto Sumiyoshi
- Division of Respirology, Rheumatology, Infectious Diseases, and Neurology, Department of Internal Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Tatsuro Hirayama
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
- Department of Pharmacotherapeutics, Nagasaki University Graduate School of Biomedical Science, Nagasaki, Japan
| | - Koichi Izumikawa
- Infection Control and Education Center, Nagasaki University Hospital, Nagasaki, Japan
| | - Katsunori Yanagihara
- Department of Laboratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Hiroshi Mukae
- Department of Respiratory Medicine, Nagasaki University Hospital, Nagasaki, Japan
| | - Hitoshi Kawasuji
- Department of Infectious Disease, Toyama University Hospital, Toyama, Japan
| | - Yoshihiro Yamamoto
- Department of Infectious Disease, Toyama University Hospital, Toyama, Japan
| | - Norihito Tarumoto
- Department of Infectious Disease and Infection Control, Saitama Medical University Hospital, Saitama, Japan
| | - Hiroshi Ishii
- Department of Respiratory Medicine, Fukuoka University Chikushi Hospital, Fukuoka, Japan
| | - Hideaki Ohno
- Department of Infectious Disease and Infection Control, Saitama Medical Center, Saitama, Japan
| | - Kazuhiro Yatera
- Department of Respiratory Medicine, Hospital of the University of Occupational and Environmental Health, Japan, Fukuoka, Japan
| | - Hiroshi Kakeya
- Department of Infection Control Science, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | | | - Yasuyuki Kato
- Department of Infectious Diseases, International University of Health and Welfare Narita Hospital, Chiba, Japan
| | - Tetsuya Matsumoto
- Department of Infectious Diseases, International University of Health and Welfare Narita Hospital, Chiba, Japan
| | - Makoto Saito
- Department of Infectious Diseases and Applied Immunology, IMSUT Hospital of The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
| | - Hiroshi Yotsuyanagi
- Department of Infectious Diseases and Applied Immunology, IMSUT Hospital of The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
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Xu Z, Shi D, Han JB, Ling Y, Jiang X, Lu X, Li C, Gong L, Ge G, Zhang Y, Zang Y, Song TZ, Feng XL, Tian RR, Ji J, Zhu M, Wu N, Wu C, Wang Z, Xu Y, Peng C, Zheng M, Yang J, Du F, Wu J, Wang P, Shen J, Zhang J, Zheng YT, Yao H, Zhu W. Preventive and therapeutic benefits of nelfinavir in rhesus macaques and human beings infected with SARS-CoV-2. Signal Transduct Target Ther 2023; 8:169. [PMID: 37095086 PMCID: PMC10123561 DOI: 10.1038/s41392-023-01429-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 03/08/2023] [Accepted: 04/04/2023] [Indexed: 04/26/2023] Open
Abstract
Effective drugs with broad spectrum safety profile to all people are highly expected to combat COVID-19 caused by SARS-CoV-2. Here we report that nelfinavir, an FDA approved drug for the treatment of HIV infection, is effective against SARS-CoV-2 and COVID-19. Preincubation of nelfinavir could inhibit the activity of the main protease of the SARS-CoV-2 (IC50 = 8.26 μM), while its antiviral activity in Vero E6 cells against a clinical isolate of SARS-CoV-2 was determined to be 2.93 μM (EC50). In comparison with vehicle-treated animals, rhesus macaque prophylactically treated with nelfinavir had significantly lower temperature and significantly reduced virus loads in the nasal and anal swabs of the animals. At necropsy, nelfinavir-treated animals had a significant reduction of the viral replication in the lungs by nearly three orders of magnitude. A prospective clinic study with 37 enrolled treatment-naive patients at Shanghai Public Health Clinical Center, which were randomized (1:1) to nelfinavir and control groups, showed that the nelfinavir treatment could shorten the duration of viral shedding by 5.5 days (9.0 vs. 14.5 days, P = 0.055) and the duration of fever time by 3.8 days (2.8 vs. 6.6 days, P = 0.014) in mild/moderate COVID-19 patients. The antiviral efficiency and clinical benefits in rhesus macaque model and in COVID-19 patients, together with its well-established good safety profile in almost all ages and during pregnancy, indicated that nelfinavir is a highly promising medication with the potential of preventative effect for the treatment of COVID-19.
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Affiliation(s)
- Zhijian Xu
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, 201203, China
- Drug Discovery and Design Center, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, 201203, China
- School of Pharmacy, University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Danrong Shi
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, China
| | - Jian-Bao Han
- Kunming National High-level Biosafety Research Center for Non-human Primates, Center for Biosafety Mega-Science, Kunming Institute of Zoology, Chinese Academy of Sciences, Kunming, Yunnan, 650107, China
| | - Yun Ling
- Department of Infectious Disease, Shanghai Public Health Clinical Center, Fudan University, Shanghai, 201508, China
| | - Xiangrui Jiang
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, 201203, China
- School of Pharmacy, University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Xiangyun Lu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, China
| | - Chuan Li
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, 201203, China
- School of Pharmacy, University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Likun Gong
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, 201203, China
- School of Pharmacy, University of Chinese Academy of Sciences, Beijing, 100049, China
- Center for Drug Safety Evaluation and Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, 201203, China
| | - Guangbo Ge
- Shanghai Frontiers Science Center of TCM Chemical Biology, Institute of Interdisciplinary Integrative Medicine Research, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
| | - Yani Zhang
- Shanghai Frontiers Science Center of TCM Chemical Biology, Institute of Interdisciplinary Integrative Medicine Research, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
| | - Yi Zang
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, 201203, China
- School of Pharmacy, University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Tian-Zhang Song
- Kunming National High-level Biosafety Research Center for Non-human Primates, Center for Biosafety Mega-Science, Kunming Institute of Zoology, Chinese Academy of Sciences, Kunming, Yunnan, 650107, China
- Key Laboratory of Animal Models and Human Disease Mechanisms of the Chinese Academy of Sciences, KIZ-CUHK Joint Laboratory of Bioresources and Molecular Research in Common Diseases, Kunming Institute of Zoology, Chinese Academy of Sciences, Kunming, Yunnan, 650223, China
| | - Xiao-Li Feng
- Kunming National High-level Biosafety Research Center for Non-human Primates, Center for Biosafety Mega-Science, Kunming Institute of Zoology, Chinese Academy of Sciences, Kunming, Yunnan, 650107, China
| | - Ren-Rong Tian
- Kunming National High-level Biosafety Research Center for Non-human Primates, Center for Biosafety Mega-Science, Kunming Institute of Zoology, Chinese Academy of Sciences, Kunming, Yunnan, 650107, China
- Key Laboratory of Animal Models and Human Disease Mechanisms of the Chinese Academy of Sciences, KIZ-CUHK Joint Laboratory of Bioresources and Molecular Research in Common Diseases, Kunming Institute of Zoology, Chinese Academy of Sciences, Kunming, Yunnan, 650223, China
| | - Jia Ji
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, China
| | - Miaojin Zhu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, China
| | - Nanping Wu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, China
| | - Chunhui Wu
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, 201203, China
- School of Pharmacy, University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Zhen Wang
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, 201203, China
- School of Pharmacy, University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Yechun Xu
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, 201203, China
- Drug Discovery and Design Center, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, 201203, China
- School of Pharmacy, University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Cheng Peng
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, 201203, China
- Drug Discovery and Design Center, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, 201203, China
- School of Pharmacy, University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Min Zheng
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, China
| | - Junling Yang
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, 201203, China
- School of Pharmacy, University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Feifei Du
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, 201203, China
- School of Pharmacy, University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Junliang Wu
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, 201203, China
- School of Pharmacy, University of Chinese Academy of Sciences, Beijing, 100049, China
- Center for Drug Safety Evaluation and Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, 201203, China
| | - Peipei Wang
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, 201203, China
- School of Pharmacy, University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Jingshan Shen
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, 201203, China.
- School of Pharmacy, University of Chinese Academy of Sciences, Beijing, 100049, China.
| | - Jianliang Zhang
- Department of Infectious Disease, Shanghai Public Health Clinical Center, Fudan University, Shanghai, 201508, China.
| | - Yong-Tang Zheng
- Kunming National High-level Biosafety Research Center for Non-human Primates, Center for Biosafety Mega-Science, Kunming Institute of Zoology, Chinese Academy of Sciences, Kunming, Yunnan, 650107, China.
- Key Laboratory of Animal Models and Human Disease Mechanisms of the Chinese Academy of Sciences, KIZ-CUHK Joint Laboratory of Bioresources and Molecular Research in Common Diseases, Kunming Institute of Zoology, Chinese Academy of Sciences, Kunming, Yunnan, 650223, China.
| | - Hangping Yao
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, China.
- Jinan Microecological Biomedicine Shandong Laboratory, Jinan, 250117, China.
| | - Weiliang Zhu
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, 201203, China.
- Drug Discovery and Design Center, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, 201203, China.
- School of Pharmacy, University of Chinese Academy of Sciences, Beijing, 100049, China.
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Zhu D, Taguchi-Nakamura H, Goto M, Odawara T, Nakamura T, Yamada H, Kotaki H, Sugiura W, Iwamoto A, Kitamura Y. Influence of Single-Nucleotide Polymorphisms in the Multidrug Resistance-1 Gene on the Cellular Export of Nelfinavir and Its Clinical Implication for Highly Active Antiretroviral Therapy. Antivir Ther 2004. [DOI: 10.1177/135965350400900610] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Protease inhibitors (PIs) such as nelfinavir (NFV) suppress HIV replication. PIs are substrates of P-glycoprotein (P-gp), the product of the multidrug-resistance-1 ( MDR1) gene. Three single-nucleotide polymorphisms (SNPs) are present in exons of the MDR1 gene: MDR1 1236, MDR1 2677 and MDR1 3435. We speculated that these genetic polymorphisms affected PI concentration in the cell. To verify this hypothesis, we first genotyped these SNPs in 79 Japanese patients by the SNaPshot method and found incomplete linkage disequilibrium between the SNPs. Because the SNP at MDR1 3435 has been reported to be associated with P-gp expression, we evaluated the effect of that SNP on the export of NFV from HIV-positive patients’ lymphoblastoid cell lines by measuring time-dependent decrease in the amount of intracellular NFV by high-performance liquid chromatography. We found the intracellular concentration of NFV in lymphoblastoid cell lines (LCLs) with the homozygous T/T genotype at MDR1 3435 were higher than that with C/C genotype with statistical significance. This suggests that the activity of P-gp in patients’ LCL cells with the MDR1 3435 T/T genotype was lower. In a retrospective study we evaluated the effect of the SNPs on CD4 cell count recovery in response to antiretroviral treatment with PIs, and obtained statistically significant evidence that suggested marginal association of the SNP at MDR1 1236 but not at MDR1 2677 or MDR1 3435. As in vitro results were not consistent with the clinical evaluation, clinical importance of MDR1 genotyping for antiretroviral therapy remains to be investigated in a larger, case-controlled study.
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Affiliation(s)
- Dayong Zhu
- Division of Infectious Diseases, Advanced Clinical Research Centre, Institute of Medical Science, University of Tokyo, Tokyo, Japan
| | - Hitomi Taguchi-Nakamura
- Division of Infectious Diseases, Advanced Clinical Research Centre, Institute of Medical Science, University of Tokyo, Tokyo, Japan
| | - Mieko Goto
- Division of Infectious Diseases, Advanced Clinical Research Centre, Institute of Medical Science, University of Tokyo, Tokyo, Japan
| | - Takashi Odawara
- Department of Infectious Diseases and Applied Immunology, Institute of Medical Science, University of Tokyo, Tokyo, Japan
| | - Tetsuya Nakamura
- Department of Infectious Diseases and Applied Immunology, Institute of Medical Science, University of Tokyo, Tokyo, Japan
| | - Harumi Yamada
- Department of Pharmacy, Research Hospital, Institute of Medical Science, University of Tokyo, Tokyo, Japan
| | - Hajime Kotaki
- Department of Pharmacy, Research Hospital, Institute of Medical Science, University of Tokyo, Tokyo, Japan
| | | | - Aikichi Iwamoto
- Division of Infectious Diseases, Advanced Clinical Research Centre, Institute of Medical Science, University of Tokyo, Tokyo, Japan
- Department of Infectious Diseases and Applied Immunology, Institute of Medical Science, University of Tokyo, Tokyo, Japan
| | - Yoshihiro Kitamura
- Division of Infectious Diseases, Advanced Clinical Research Centre, Institute of Medical Science, University of Tokyo, Tokyo, Japan
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