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Hammond SP, Rangaraju M, Sumner M, Timmler B, Chandrasekar P, Avery RK. A Multicenter Assessment of the Outcomes and Toxicities of Foscarnet for Treatment of Acyclovir-Resistant Mucocutaneous Herpes Simplex in Immunocompromised Patients. Open Forum Infect Dis 2024; 11:ofae046. [PMID: 38444818 PMCID: PMC10914364 DOI: 10.1093/ofid/ofae046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 01/24/2024] [Indexed: 03/07/2024] Open
Abstract
Background Acyclovir-resistant mucocutaneous herpes simplex virus (HSV) infection is an uncommon problem typically seen in immunocompromised hosts. Systemic treatment options are limited. The performance of foscarnet and its toxicities in this population are poorly characterized. Methods This was a multicenter retrospective study of adults treated with foscarnet for HSV infection between January 2012 and December 2017. Relevant data were collected including demographics, baseline conditions, previous anti-HSV medications, concomitant medications, HSV outcomes, and adverse events. Acyclovir-resistant HSV infection was defined based on genotypic or phenotypic testing results; refractory infection was defined as infection not improving after 5 days of treatment-dosed antiviral therapy in those not tested for resistance. Results Twenty-nine patients had 31 episodes of HSV (15/18 resistant; among episodes without resistance testing, 7/10 refractory; 3 not evaluable) treated with foscarnet. All patients were immunocompromised including 19 (66%) with hematologic malignancy and 9 (31%) with HIV. Median duration of foscarnet was 16 days (range, 6-85 days). Fifteen episodes (48%) healed by the end of or after foscarnet. Median time to healing among those with resolution was 38 days (range, 9-1088 days). At least 1 adverse event during therapy was reported in 26 (84%) treatment episodes including 23 (74%) that were considered drug related. Common adverse events were electrolyte disturbance (20 [65%]) and kidney dysfunction (13 [42%]). Foscarnet was discontinued in 10 episodes (32%) due to an adverse event, including 6 due to kidney dysfunction. Conclusions Among 31 episodes of HSV treated with foscarnet, only half resolved with treatment, and adverse events were common.
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Affiliation(s)
- Sarah P Hammond
- Divisions of Infectious Diseases and Hematology/Oncology, Massachusetts General Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | | | - Pranatharthi Chandrasekar
- Karmanos Cancer Institute, Division of Infectious Diseases, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Robin K Avery
- Division of Infectious Diseases, Johns Hopkins University, Baltimore, Maryland, USA
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Birkmann A, Bonsmann S, Kropeit D, Pfaff T, Rangaraju M, Sumner M, Timmler B, Zimmermann H, Buschmann H, Ruebsamen-Schaeff H. Discovery, Chemistry, and Preclinical Development of Pritelivir, a Novel Treatment Option for Acyclovir-Resistant Herpes Simplex Virus Infections. J Med Chem 2022; 65:13614-13628. [PMID: 36202389 PMCID: PMC9620171 DOI: 10.1021/acs.jmedchem.2c00668] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
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When the nucleoside analogue acyclovir was introduced
in the early
1980s, it presented a game-changing treatment modality for herpes
simplex virus infections. Since then, work has been ongoing to improve
the weaknesses that have now been identified: a narrow time window
for therapeutic success, resistance in immunocompromised patients,
little influence on frequency of recurrences, relatively fast elimination,
and poor bioavailability. The present Drug Annotation focuses on the
helicase–primase inhibitor pritelivir currently in development
for the treatment of acyclovir-resistant HSV infections and describes
how a change of the molecular target (from viral DNA polymerase to
the HSV helicase–primase complex) afforded improvement of the
shortcomings of nucleoside analogs. Details are presented for the
discovery process leading to the final drug candidate, the pivotal
preclinical studies on mechanism of action and efficacy, and on how
ongoing clinical research has been able to translate preclinical promises
into clinical use.
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Affiliation(s)
| | | | - Dirk Kropeit
- AiCuris Anti-Infective Cures AG, 42117 Wuppertal, Germany
| | - Tamara Pfaff
- AiCuris Anti-Infective Cures AG, 42117 Wuppertal, Germany
| | | | - Melanie Sumner
- AiCuris Anti-Infective Cures AG, 42117 Wuppertal, Germany
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Wald A, Timmler B, Magaret A, Warren T, Tyring S, Johnston C, Fife K, Selke S, Huang ML, Stobernack HP, Zimmermann H, Corey L, Birkmann A, Ruebsamen-Schaeff H. Effect of Pritelivir Compared With Valacyclovir on Genital HSV-2 Shedding in Patients With Frequent Recurrences: A Randomized Clinical Trial. JAMA 2016; 316:2495-2503. [PMID: 27997653 DOI: 10.1001/jama.2016.18189] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Current therapy of herpes infections relies on nucleoside analogues. Pritelivir is a well-tolerated novel herpes simplex virus (HSV) helicase-primase inhibitor that reduced genital shedding and lesions. OBJECTIVE To compare the efficacy of pritelivir with valacyclovir for suppression of genital HSV-2 infection. DESIGN, SETTING, AND PARTICIPANTS A phase 2, randomized, double-blind, crossover clinical trial at clinical research centers in 4 US cities (October 2012-July 2013) compared daily oral doses of 100 mg of pritelivir with 500 mg of valacyclovir. The planned sample size was 98 adults, allowing for detection of a 50% reduction in viral shedding between the study treatments. Healthy adults with 4 to 9 annual genital HSV-2 recurrences were eligible. 45 participants were randomized to receive pritelivir [corrected] and 46 to receive valacyclovir first when the US Food and Drug Administration placed the trial on clinical hold based on findings in a concurrent nonclinical toxicity study, and the sponsor terminated the study. INTERVENTIONS Participants took the first drug for 28 days followed by 28 days of washout before taking the second drug for 28 days. Throughout treatment, the participants collected genital swabs 4 times daily for testing by HSV polymerase chain reaction assays. MAIN OUTCOMES AND MEASURES The primary end point was within-participant genital HSV shedding while receiving pritelivir compared with valacyclovir. Secondary end points included the quantity of HSV in positive swabs and the frequency of genital lesions and shedding episodes. RESULTS Of the 91 randomized participants (median age, 48 years; 57 women [63%]), 56 had completed both treatment periods at the time of the study's termination. In intent-to-treat analyses, HSV shedding was detected in 2.4% (173 of 7276 ) of swabs during pritelivir treatment compared with 5.3% (392 of 7453) during valacyclovir treatment (relative risk [RR], 0.42 [corrected]; 95% CI, 0.21 to 0.82; P = .01). In swabs with HSV, the mean quantity of HSV was 3.2 log10 copies/mL during pritelivir treatment vs 3.7 log10 copies/mL during valacyclovir treatment (difference, -0.1; 95% CI, -0.6 to 0.5; P = .83). Genital lesions were present on 1.9% of days in the pritelivir group vs 3.9% in the valacyclovir group (RR, 0.40; 95% CI, 0.17-0.96; P = .04). The frequency of shedding episodes did not differ by group, with 1.3 per person-month for pritelivir and 1.6 per person-month for valacyclovir (RR, 0.80; 95% CI, 0.52 to 1.22; P = .29). Treatment-emergent adverse events occurred in 62.3% of participants in the pritelivir group and 69.2% of participants in the valacyclovir group. CONCLUSIONS AND RELEVANCE Among adults with frequently recurring genital HSV-2, the use of pritelivir compared with valacyclovir resulted in a lower percentage of swabs with HSV detection over 28 days. Further research is needed to assess longer-term efficacy and safety. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01658826.
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Affiliation(s)
- Anna Wald
- University of Washington & Fred Hutchinson Cancer Research Center, Seattle
| | | | - Amalia Magaret
- University of Washington & Fred Hutchinson Cancer Research Center, Seattle
| | | | - Stephen Tyring
- University of Texas Health Science Center & Center for Clinical Studies, Houston
| | - Christine Johnston
- University of Washington & Fred Hutchinson Cancer Research Center, Seattle
| | - Kenneth Fife
- Indiana University School of Medicine, Indianapolis
| | - Stacy Selke
- University of Washington & Fred Hutchinson Cancer Research Center, Seattle
| | - Meei-Li Huang
- University of Washington & Fred Hutchinson Cancer Research Center, Seattle
| | | | | | - Lawrence Corey
- University of Washington & Fred Hutchinson Cancer Research Center, Seattle
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Schiffer JT, Swan DA, Magaret A, Corey L, Wald A, Ossig J, Ruebsamen-Schaeff H, Stoelben S, Timmler B, Zimmermann H, Melhem MR, Van Wart SA, Rubino CM, Birkmann A. Mathematical modeling of herpes simplex virus-2 suppression with pritelivir predicts trial outcomes. Sci Transl Med 2016; 8:324ra15. [PMID: 26843190 DOI: 10.1126/scitranslmed.aad6654] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Pharmacokinetic and pharmacodynamic models estimate the potency of antiviral agents but do not capture viral and immunologic factors that drive the natural dynamics of infection. We designed a mathematical model that synthesizes pharmacokinetics, pharmacodynamics, and viral pathogenesis concepts to simulate the activity of pritelivir, a DNA helicase-primase inhibitor that targets herpes simplex virus. Our simulations recapitulate detailed viral kinetic shedding features in five dosage arms of a phase 2 clinical trial. We identify that in vitro estimates of median effective concentration (EC50) are lower than in vivo values for the drug. Nevertheless, pritelivir potently decreases shedding at appropriate doses based on its mode of action and long half-life. Although pritelivir directly inhibits replication in epithelial cells, our model indicates that pritelivir also indirectly limits downstream viral spread from neurons to genital keratinocytes, within genital ulcers, and from ulcer to new mucosal sites of infection. We validate our model based on its ability to predict outcomes in a subsequent trial with a higher dose. The model can therefore be used to optimize dose selection in clinical practice.
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Affiliation(s)
- Joshua T Schiffer
- Department of Medicine, University of Washington, Seattle, WA 98105, USA. Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA. Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA.
| | - David A Swan
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA
| | - Amalia Magaret
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA. Department of Laboratory Medicine, University of Washington, Seattle, WA 98105, USA
| | - Lawrence Corey
- Department of Medicine, University of Washington, Seattle, WA 98105, USA. Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA. Department of Laboratory Medicine, University of Washington, Seattle, WA 98105, USA
| | - Anna Wald
- Department of Medicine, University of Washington, Seattle, WA 98105, USA. Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA 98109, USA. Department of Laboratory Medicine, University of Washington, Seattle, WA 98105, USA. Department of Epidemiology, University of Washington, Seattle, WA 98105, USA
| | | | | | | | | | | | - Murad R Melhem
- Institute for Clinical Pharmacodynamics, Latham, NY 12307, USA
| | - Scott A Van Wart
- Institute for Clinical Pharmacodynamics, Latham, NY 12307, USA. School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, State University of New York, Buffalo, NY 14260, USA
| | - Christopher M Rubino
- Institute for Clinical Pharmacodynamics, Latham, NY 12307, USA. School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, State University of New York, Buffalo, NY 14260, USA
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Edlefsen PT, Birkmann A, Huang ML, Magaret CA, Kee JJ, Diem K, Goldner T, Timmler B, Stoelben S, Ruebsamen-Schaeff H, Zimmermann H, Warren T, Wald A, Corey L. No Evidence of Pritelivir Resistance Among Herpes Simplex Virus Type 2 Isolates After 4 Weeks of Daily Therapy. J Infect Dis 2016; 214:258-64. [PMID: 27056950 PMCID: PMC4918824 DOI: 10.1093/infdis/jiw129] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 03/24/2016] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Pritelivir is a novel helicase-primase inhibitor in clinical development for treatment of herpes simplex virus type 2 (HSV-2) infections. In preclinical work, resistance-mediating mutations were identified in the HSV-2 genome at 3 loci in the UL5 gene and 1 locus in UL52. METHODS To evaluate whether daily pritelivir treatment results in emergence of resistance-mediating mutations, we analyzed HSV-2 strains detected in genital swab specimens from trial participants who were randomly assigned to receive different dosages of pritelivir. We sequenced resistance regions from 87 participants' samples, the UL5 gene in 73 samples from 44 participants, and the UL52 gene in 71 samples from 43 participants. RESULTS We found no evidence that pritelivir induced known resistance-mediating mutations or for amino acid variation at other loci. In one participant's HSV-2 isolate, we found a previously unidentified mutation close to the putative resistance-mediating region in UL5 and subsequently determined in vitro susceptibility to pritelivir. We characterized mutations from 32 cultivated HSV-2 isolates previously found to be susceptible to pritelivir in vitro and identified several novel mutations that most likely reflect preexisting variation in circulating HSV-2. CONCLUSIONS This study demonstrates evidence of retained susceptibility of HSV-2 to pritelivir in immunocompetent persons following daily therapy for up to 28 days.
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Affiliation(s)
- Paul T Edlefsen
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center Department of Biostatistics
| | | | - Meei-Li Huang
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center Department of Laboratory Medicine
| | - Craig A Magaret
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center
| | - Jia Jin Kee
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center Department of Biostatistics
| | - Kurt Diem
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center Department of Laboratory Medicine
| | | | | | | | | | | | | | - Anna Wald
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center Department of Laboratory Medicine Department of Epidemiology Department of Medicine, University of Washington, Seattle
| | - Lawrence Corey
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center Department of Laboratory Medicine Department of Medicine, University of Washington, Seattle
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Wald A, Corey L, Timmler B, Magaret A, Warren T, Tyring S, Johnston C, Kriesel J, Fife K, Galitz L, Stoelben S, Huang ML, Selke S, Stobernack HP, Ruebsamen-Schaeff H, Birkmann A. Helicase-primase inhibitor pritelivir for HSV-2 infection. N Engl J Med 2014; 370:201-10. [PMID: 24428466 DOI: 10.1056/nejmoa1301150] [Citation(s) in RCA: 98] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Pritelivir, an inhibitor of the viral helicase-primase complex, exhibits antiviral activity in vitro and in animal models of herpes simplex virus (HSV) infection. We tested the efficacy and safety of pritelivir in otherwise healthy persons with genital HSV-2 infection. METHODS We randomly assigned 156 HSV-2-positive persons with a history of genital herpes to receive one of four doses of oral pritelivir (5, 25, or 75 mg daily, or 400 mg weekly) or placebo for 28 days. Participants obtained daily swabs from the genital area for HSV-2 testing, which was performed with a polymerase-chain-reaction assay. Participants also maintained a diary of genital signs and symptoms. The primary end point was the rate of genital HSV shedding. RESULTS HSV shedding among placebo recipients was detected on 16.6% of days; shedding among pritelivir recipients was detected on 18.2% of days among those receiving 5 mg daily, 9.3% of days among those receiving 25 mg daily, 2.1% of days among those receiving 75 mg daily, and 5.3% of days among those receiving 400 mg weekly. The relative risk of viral shedding with pritelivir, as compared with placebo, was 1.11 (95% confidence interval [CI], 0.65 to 1.87) with the 5-mg daily dose, 0.57 (95% CI, 0.31 to 1.03) with the 25-mg daily dose, 0.13 (95% CI, 0.04 to 0.38) with the 75-mg daily dose, and 0.32 (95% CI, 0.17 to 0.59) with the 400-mg weekly dose. The percentage of days with genital lesions was also significantly reduced, from 9.0% in the placebo group to 1.2% in both the group receiving 75 mg of pritelivir daily (relative risk, 0.13; 95% CI, 0.02 to 0.70) and the group receiving 400 mg weekly (relative risk, 0.13; 95% CI, 0.03 to 0.52). The rate of adverse events was similar in all groups. CONCLUSIONS Pritelivir reduced the rates of genital HSV shedding and days with lesions in a dose-dependent manner in otherwise healthy men and women with genital herpes. (Funded by AiCuris; ClinicalTrials.gov number, NCT01047540.).
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Affiliation(s)
- Anna Wald
- From the University of Washington and Fred Hutchinson Cancer Research Center, Seattle (A.W., L.C., A.M., C.J., M.-L.H., S. Selke); AiCuris, Wuppertal, Germany (B.T., S. Stoelben, H.-P.S., H.R.-S., A.B.); Westover Heights Clinic, Portland, OR (T.W.); University of Texas, Houston (S.T.); University of Utah, Salt Lake City (J.K.); Indiana University School of Medicine, Indianapolis (K.F.); and Cetero Research, Miami (L.G.)
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Birkmann A, McCormick D, Kropeit D, Timmler B, Stoelben S, Wald A, Field H, Richard MP, Zimmermann H, Rübsamen-Schaeff H. P3.446 Excellent Efficacy of PRITELIVIR (AIC316) in Suppression of Genital Herpes, a Novel Drug Against Herpes Simplex Virus (HSV) Type 1 and 2. Br J Vener Dis 2013. [DOI: 10.1136/sextrans-2013-051184.0896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Wald A, Stoelben S, Tyring S, Warren T, Johnston C, Huang ML, Timmler B, Ruebsamen-Schaeff H, Corey L, Birkmann A. O3-S5.01 Impact of AIC316, a novel antiviral helicase-primase inhibitor, on genital HSV shedding: randomised, double-blind, placebo-controlled trial. Sex Transm Infect 2011. [DOI: 10.1136/sextrans-2011-050109.127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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