Optimization of an adenovirus-vectored zoster vaccine production process with chemically defined medium and a perfusion system

OBJECTIVES

Cells grown in chemically defined medium are sensitive to shear force, potentially resulting in decreased cell growth. We optimized the perfusion process for HEK293 cell-based recombinant adenovirus-vectored zoster vaccine (Ad-HER) production with chemically defined medium.

METHODS

We first studied the pseudo-continuous strategies in shake flasks as a mimic of the bioreactor equipped with perfusion systems. Using design of experiment (DoE) in shake flasks, we obtained the regression models between Ad-HER titer/virus input-output ratio and three production process parameters: time of infection (TOI), multiplicity of infection (MOI), and virus production pH (pH). We then confirmed the effect of Pluronic F68 (PF-68) at 3.0 g/L on HEK293 cell growth and Ad-HER production in shake flasks and a 2 L benchtop bioreactor.

RESULTS

The optimized process was scale-up to a 2 L benchtop bioreactor with the PATFP perfusion system, which yielded cell density of 7.4 × 10⁶ cells/mL and Ad-HER titer of 9.8 × 10⁹ IFU/mL at 2 dpi, comparable to the bioreactor with a ATF2 system.

CONCLUSION

This optimization strategy could be used to develop a robust process with stable cell culture performance and adenovirus titer. Increasing PF-68 concentration in chemically defined medium could protect cells from shear stress generated by perfusion system.

Association Between the Risk for Cardiovascular Events and Antiviral Treatment for Herpes Zoster

BACKGROUND

Cardiovascular risk increases following herpes zoster. We investigated whether treatment with antiviral agents, steroids, and common cardiovascular medications was associated with the risk of postherpetic cardiovascular events.

METHODS

This was a nationwide population-based, retrospective, cohort study using the National Health Insurance Service health claims data in Korea. We included patients with a first-ever diagnosis of herpes zoster in 2003-2014 and no prior cardiovascular event. The primary outcome was the occurrence of composites of myocardial infarction (International Statistical Classification of Diseases, Tenth Revision, code I21) and stroke (codes I60-I63) since the herpes zoster. We analyzed the exposure (intravenous or oral administration) to antiviral agents, steroids, antithrombotics, and statins within ±7 days from the index date of herpes zoster diagnosis. Follow-up was performed until occurrence of the primary outcome, death, or 31 December 2015, whichever came first.

RESULTS

Of 84 993 patients with herpes zoster, the proportions of patients who received the treatment with antiviral agents, steroids, antithrombotics, and statins were 90.5%, 48.0%, 9.1%, and 7.9%, respectively. During the mean (standard deviation) follow-up period of 5.4 (3.1) years, 1523 patients experienced the primary outcome. Multivariate Cox regression analysis demonstrated that treatment with antiviral agents (adjusted hazard ratio, 0.82; 95% confidence interval, .71-.95) and statins (0.71; .59-.85) were significantly associated with the lower risk of primary outcome. Use of antithrombotics and steroids were not associated with the risk.

CONCLUSIONS

After herpes zoster, treatment with antiviral agents was significantly associated with lower risk of cardiovascular events. We need more information on the cardiovascular protective role of herpes zoster treatments.

Low willingness to vaccinate against herpes zoster in a Chinese metropolis

BACKGROUND

Herpes zoster vaccine (HZV) has been available in China's mainland since June 2020. This study estimated willingness to receive HZV to characterize factors that may influence vaccination willingness.

METHODS

We conducted a face-to-face questionnaire survey in adults aged 50-69 years in 13 communities in Shanghai in late 2020. We explored the relationship between vaccination willingness and independent factors including demographic factors, medical history, knowledge of herpes zoster and HZV, and vaccine hesitancy. Outcomes included participants' willingness to vaccinate themselves, their partners, and their parents, under both the current payment scenario (self-payment) and a hypothetical scenario (payment by basic medical insurance).

RESULTS

A total of 1672 respondents aged 50-69 years were included in this study. The proportion of respondents willing to get vaccinated was 16.57% for themselves, 13.88% for their partners, and 8.49% for their parents. If the vaccine was covered under insurance, these numbers increased to 72.25%, 62.50%, and 29.96%, respectively. Younger age, female gender, higher income, higher educational level, local residents, and lower vaccine hesitancy were associated with increased willingness to vaccinate. Knowledge of herpes zoster and HZV positively influenced the willingness in the hypothetical payment scenario.

CONCLUSION

We determined a very low willingness to vaccinate HZV in adults aged 50-69 years in a Chinese metropolis. Decreasing costs is important to increase coverage. Additionally, strengthening advocacy and health promotion for the vaccine will be particularly important, especially for groups with certain underlying diseases.

Treatment Patterns and Medication Use in Patients with Postherpetic Neuralgia

BACKGROUND

Postherpetic neuralgia (PHN) is a chronic, painful condition characterized by persistent pain following resolution of a herpes zoster (HZ) infection. Epidemiologic data demonstrate that the risks for HZ infections and the development of PHN increase with age.

OBJECTIVE

To characterize prescribing patterns, health care utilization, and treatment costs for adults with PHN based on real-world data.

METHODS

This study analyzed medical and pharmacy claims from 2010 to 2014 in the MarketScan Commercial and Medicare Supplemental databases. PHN patients were identified based on criteria from a published algorithm. PHN treatment patterns were analyzed by age and reported descriptively for patients aged < 65 or ≥ 65 years. Excess incremental health care costs were calculated for PHN patients by comparing expenditures for a cohort of PHN patients to expenditures of a propensity score-matched control group of patients with HZ alone.

RESULTS

Approximately 0.4% of patients aged < 65 years were diagnosed with HZ versus 1.3% of patients aged ≥ 65 years; approximately 15.3% of HZ patients aged < 65 years and 26.4% of patients aged ≥ 65 years were diagnosed with PHN. Overall, opioids remained the most frequently prescribed initial treatment. Approximately 21.6% of PHN patients received an opioid as an initial treatment for PHN, 15.1% received gabapentin; 8.9% received a prescription nonsteroidal anti-inflammatory drug (NSAID); 8.3% received a lidocaine patch; 3.3% received pregabalin; 2.5% received a tricyclic antidepressants (TCAs); 0.8% received other topical lidocaine; and < 1% received capsaicin. Observed first-line use of the lidocaine patch and gabapentin was higher in patients aged ≥ 65 years relative to patients aged < 65 years. When separated by age group, only 24.6% of patients aged < 65 years and 38.5% of patients aged ≥ 65 years were prescribed a recommended first-line treatment for initial PHN therapy (gabapentin, lidocaine patch, pregabalin, and TCAs). Comparisons of treatment costs of PHN patients to matched HZ patients without PHN indicated that PHN patients initiated on opioids had the highest mean additional health care expenditure compared with PHN patients initiated on other medications. On average, PHN patients initiated on opioids had $7,601 additional health care expenditure compared with HZ patients with no PHN; additional expenditures were $6,428 for pregabalin, $4,213 for lidocaine patches, $3,478 for gabapentin, $3,304 for NSAIDs, and $2,797 for TCAs, respectively.

CONCLUSIONS

Management of PHN is associated with substantial utilization of opioid-based therapies across all ages. Medications supported by evidence either as first-line therapies or as part of a multimodal regimen for the management of PHN are underused relative to opioid-based PHN therapies. Improving adherence to evidence-based PHN treatment regimens offers the potential to reduce opioid prescribing first line and reduce overall treatment costs. Given the emphasis to reduce opioid prescribing to minimize the risk of dependence, abuse, and diversion, multimodal analgesic treatments that can avoid or reduce opioid use should be considered.

DISCLOSURES

Research funding was provided by SCILEX Pharmaceuticals. The sponsor reviewed and approved the research plan and provided support for manuscript preparation through Patel's role as a coauthor of this manuscript. The sponsor's product (lidocaine patch) was not used in this study. Patel is a paid employee of SCILEX Pharmaceuticals. Goss is an employee and minority owner of Boston Healthcare Associates, which received a research grant from SCILEX Pharmaceuticals to conduct this study. Gudin reports advisory board fees from AcelRx Pharmaceuticals and BioDelivery Sciences International and consulting fees from Averitas, Daiichi, Hisumitsu, Nektar, Purdue, Quest Diagnostics, SCILEX Pharmaceuticals, and US WorldMeds, unrelated to this study. Fudin reports advisory board fees from AcelRx Pharmaceuticals, Human Half-Cell, Quest Diagnostics, GlaxoSmithKline, SCILEX Pharmaceuticals, BioDelivery Sciences, Daiichi Sankyo, and Salix Pharmaceuticals; speaker fees from Daiichi Sankyo, Salix Pharmaceuticals, Abbott Laboratories, Acutis Diagnostics, and AstraZeneca; and consulting fees from Firstox Laboratories, unrelated to this study. The other authors have nothing to disclose. Parts of this research were presented at the AMCP Managed Care & Specialty Pharmacy Annual Meeting; April 22, 2016; San Francisco, CA, and at the 35th Annual Scientific Meeting of the American Pain Society; May 11-14, 2016; Austin, TX.

Infectious neuropathies

PURPOSE OF REVIEW

Infections are important, potentially treatable causes of peripheral nervous system disease. This article reviews the clinical presentation and management of several common peripheral nervous system diseases due to viral, bacterial, spirochetal, and parasitic infections.

RECENT FINDINGS

The clinical presentation and evaluation of infectious peripheral nervous system diseases are well established. Advances in the treatment and, in some cases, the prevention of these diseases are still evolving.

SUMMARY

A diverse range of peripheral nervous system diseases, including peripheral neuropathy, radiculopathy, radiculomyelopathy, cranial neuropathy, and motor neuropathy, are caused by numerous infectious agents. In some patients, peripheral neuropathy may be a side effect of anti-infectious drugs. Infectious neuropathies are important to recognize as they are potentially treatable. This article discusses the clinical presentation, evaluation, and treatment of several common peripheral nervous system diseases caused by viral, bacterial, spirochetal, and parasitic infections, as well as some peripheral nerve disorders caused by adverse effects of the treatments of these infectious diseases.

Herpes zoster: A rash demanding careful evaluation

This article discusses the incidence, epidemiology, clinical presentation, diagnosis, and treatment of herpes zoster, complications such as postherpetic neuralgia, and prevention through vaccination. Information on vaccine cost and insurance coverage is provided as well as two case studies illustrating various clinical presentations.

Vaccination against and treatment of acute herpes zoster for prevention of post-herpetic neuralgia

Zostavax (zoster vaccine) is a 1-dose, high-potency, live, attenuated varicella zoster virus (VZV) vaccine that boosts VZV-specific cell-mediated immunity (CMI), and this is its presumed mechanism of action. Other strategies focus on preventing the major complication of HZ, post-herpetic neuralgia (PHN). Evidence that the vaccine is effective in older patients comes from the pivotal Shingles Prevention Study. That study demonstrated that HZ vaccine significantly reduced morbidity due to HZ and PHN in older patients. However, the duration of efficacy beyond 5 years after vaccination remains unclear. The Long-Term Persistence Substudy, currently under analysis, may provide additional data on the duration of efficacy for zoster vaccine. This review discusses vaccination against HZ, and further reviews recent pharmacotherapy for prevention of PHN.

Varicella zoster virus latency

Primary infection by varicella zoster virus (VZV) typically results in childhood chickenpox, at which time latency is established in the neurons of the cranial nerve, dorsal root and autonomic ganglia along the entire neuraxis. During latency, the histone-associated virus genome assumes a circular episomal configuration from which transcription is epigenetically regulated. The lack of an animal model in which VZV latency and reactivation can be studied, along with the difficulty in obtaining high-titer cell-free virus, has limited much of our understanding of VZV latency to descriptive studies of ganglia removed at autopsy and analogy to HSV-1, the prototype alphaherpesvirus. However, the lack of miRNA, detectable latency-associated transcript and T-cell surveillance during VZV latency highlight basic differences between the two neurotropic herpesviruses. This article focuses on VZV latency: establishment, maintenance and reactivation. Comparisons are made with HSV-1, with specific attention to differences that make these viruses unique human pathogens.

Compliance with herpes zoster vaccination in young and adult individuals in two regions of Italy

BACKGROUND

The purpose of this work was to explore the knowledge and acceptance of Varicella Zoster Virus (VZV)-Herpes Zoster (HZ) vaccination in the general Italian population, where the HZ vaccine has not yet been distributed, using a prevalence study of subjects from two regions in Italy.

METHODS

A group of 3,173 individuals were interviewed using a questionnaire. The youngest age group (<or= 20 year) was composed of students interviewed at university. The middle age group (21-40 years) and the older age group (>or= 41 years) were interviewed by general practitioners in their office.

RESULTS

In both regions, the majority of subjects had been infected with varicella, and only 165 (5.2%) subjects reported receiving the VZV vaccination. Regarding HZ, 2,749 (86.6%) individuals stated that they knew of the virus and 2,233 (70%) were willing to be vaccinated against HZ. The majority of people willing to be vaccinated were in the middle and older age groups (36.6% and 44.7%, respectively).

CONCLUSION

Compliance versus vaccination results were satisfactory and probably, with the upcoming availability of the HZ vaccine in Italy, adults will be favourably disposed towards vaccination.