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Pociupany M, Snoeck R, Dierickx D, Andrei G. Treatment of Epstein-Barr Virus infection in immunocompromised patients. Biochem Pharmacol 2024; 225:116270. [PMID: 38734316 DOI: 10.1016/j.bcp.2024.116270] [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: 03/05/2024] [Revised: 05/06/2024] [Accepted: 05/06/2024] [Indexed: 05/13/2024]
Abstract
Epstein-Barr Virus (EBV), is a ubiquitous γ-Herpesvirus that infects over 95% of the human population and can establish a life-long infection without causing any clinical symptoms in healthy individuals by residing in memory B-cells. Primary infection occurs in childhood and is mostly asymptomatic, however in some young adults it can result in infectious mononucleosis (IM). In immunocompromised individuals however, EBV infection has been associated with many different malignancies. Since EBV can infect both epithelial and B-cells and very rarely NK cells and T-cells, it is associated with both epithelial cancers like nasopharyngeal carcinoma (NPC) and gastric carcinoma (GC), with lymphomas including Burkitt Lymphoma (BL) or Post-transplant Lymphoproliferative Disorder (PTLD) and rarely with NK/T-cell lymphomas. Currently there are no approved antivirals active in PTLD nor in any other malignancy. Moreover, lytic phase disease almost never requires antiviral treatment. Although many novel therapies against EBV have been described, the management and/or prevention of EBV primary infections or reactivations remains difficult. In this review, we discuss EBV infection, therapies targeting EBV in both lytic and latent state with novel therapeutics developed that show anti-EBV activity as well as EBV-associated malignancies both, epithelial and lymphoproliferative malignancies and emerging therapies targeting the EBV-infected cells.
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Affiliation(s)
- Martyna Pociupany
- Laboratory of Virology and Chemotherapy, Department of Microbiology, Immunology and Transplantation, Rega Institute for Medical Research, KU Leuven, Leuven, Belgium
| | - Robert Snoeck
- Laboratory of Virology and Chemotherapy, Department of Microbiology, Immunology and Transplantation, Rega Institute for Medical Research, KU Leuven, Leuven, Belgium
| | - Daan Dierickx
- Laboratory of Experimental Hematology, Department of Oncology, KU Leuven, Leuven, Belgium; Department of Hematology, University Hospitals Leuven, Leuven, Belgium
| | - Graciela Andrei
- Laboratory of Virology and Chemotherapy, Department of Microbiology, Immunology and Transplantation, Rega Institute for Medical Research, KU Leuven, Leuven, Belgium.
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2
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Hardinger KL, Brennan DC. Cytomegalovirus Treatment in Solid Organ Transplantation: An Update on Current Approaches. Ann Pharmacother 2024:10600280241237534. [PMID: 38501850 DOI: 10.1177/10600280241237534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024] Open
Abstract
OBJECTIVE The article reviews the safety and efficacy of treatments for cytomegalovirus (CMV) in solid organ transplantation. DATA SOURCES A literature review was conducted in PubMed, MEDLINE, and Clinicaltrials.gov from database inception through January 2024, using terms CMV, therapy, and solid organ transplantation. STUDY SELECTION AND DATA EXTRACTION Clinical trials, meta-analyses, cohort studies, case reports, and guidelines were included. Letters to the editor, reviews, and commentaries were excluded. DATA SYNTHESIS After abstract screening and full-text review of 728 citations for eligibility, 53 were included. Valganciclovir and intravenous ganciclovir are drugs of choice for CMV management and, until recently, the availability of alternative options has been restricted due to toxicity. For instance, foscarnet and cidofovir serve as second-line agents due to potential bone marrow and renal toxicity. In patients with refractory or resistant CMV, maribavir, a novel oral agent, has proven efficacy and a lower adverse effect profile. However, in refractory or resistant CMV, foscarnet and cidofovir are preferred in invasive disease (CMV gastritis, CMV retinitis, and CMV encephalitis), high viral loads, and inability to tolerate oral preparations. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE Consensus guidelines have not been revised since approval of novel antivirals in solid organ transplantation. Valganciclovir and ganciclovir remain drugs of choice for initial CMV therapy. Foscarnet, cidofovir, and maribavir are treatments for refractory or resistant-CMV. CONCLUSIONS Selection of CMV antiviral treatment should be determined by patient-specific factors, including severity of illness, resistant or refractory disease, dose-limiting adverse effects, and the preferred route of administration.
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Affiliation(s)
- Karen L Hardinger
- Division of Pharmacy Practice and Administration, School of Pharmacy, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Daniel C Brennan
- Johns Hopkins Comprehensive Transplant Center, Baltimore, MD, USA
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3
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Chou S, Watanabe J. Ganciclovir and maribavir cross-resistance revisited: Relative drug susceptibilities of canonical cytomegalovirus mutants. Antiviral Res 2024; 222:105792. [PMID: 38163624 PMCID: PMC10922325 DOI: 10.1016/j.antiviral.2023.105792] [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: 12/12/2023] [Revised: 12/26/2023] [Accepted: 12/27/2023] [Indexed: 01/03/2024]
Abstract
Therapeutic use of maribavir for human cytomegalovirus infection has renewed attention to the extent of cross-resistance with ganciclovir as the existing standard therapy. Each drug selects in vivo for a characteristic set of resistance mutations in the viral UL97 kinase gene. To improve the calibration of relative susceptibilities to each drug, genetic variants at relevant UL97 codons were extensively phenotyped using the same baseline viral clone, cell culture conditions and growth readout. Ganciclovir-selected mutations at codons 460, 520, 592, 594, 595 and 603 conferred 2.8-fold (C603Y) to 12-fold (M460I) increases in ganciclovir 50% inhibitory concentrations (EC50) over wild type baseline, while conferring maribavir EC50 fold changes ranging from 0.21-fold (M460I) to 1.9-fold (A594V). Maribavir-selected mutations at codons 409, 411 and 480 conferred maribavir EC50 fold changes ranging from 17 (H411Y) to 210 (C480F), while conferring ganciclovir EC50 fold changes ranging from 0.7 (H411Y) to 2.3 (C480F). The P-loop substitution F342Y, selected by either drug, is confirmed to confer 4.7-fold and 6-fold increases in maribavir and ganciclovir EC50s respectively, and suggests this part of the ATP-binding domain of UL97 to be involved in moderate resistance to both drugs. The maribavir hypersensitivity of M460I and M460V may be advantageous.
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Affiliation(s)
- Sunwen Chou
- Department of Veterans Affairs Medical Center, Portland, OR, USA; Division of Infectious Diseases, Oregon Health and Science University, USA.
| | - Justin Watanabe
- Department of Veterans Affairs Medical Center, Portland, OR, USA
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4
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Pearce H, Montgomery EK, Sheerin N, Ellam H. A Novel Case of CMV Resistance to Valganciclovir and Maribavir in a Renal Transplant Patient. Transpl Int 2024; 37:11985. [PMID: 38314399 PMCID: PMC10834638 DOI: 10.3389/ti.2024.11985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 01/10/2024] [Indexed: 02/06/2024]
Affiliation(s)
- Helen Pearce
- Newcastle Hospitals Trust, Newcastle upon Tyne, United Kingdom
| | - Emma K. Montgomery
- Renal Services, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Neil Sheerin
- Renal Services, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
- Immunity and Inflammation Theme, Faculty of Medical Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Helena Ellam
- Department of Virology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
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5
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Piret J, Boivin G. Management of Cytomegalovirus Infections in the Era of the Novel Antiviral Players, Letermovir and Maribavir. Infect Dis Rep 2024; 16:65-82. [PMID: 38247977 PMCID: PMC10801527 DOI: 10.3390/idr16010005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 01/08/2024] [Accepted: 01/12/2024] [Indexed: 01/23/2024] Open
Abstract
Cytomegalovirus (CMV) infections may increase morbidity and mortality in immunocompromised patients. Until recently, standard antiviral drugs against CMV were limited to viral DNA polymerase inhibitors (val)ganciclovir, foscarnet and cidofovir with a risk for cross-resistance. These drugs may also cause serious side effects. This narrative review provides an update on new antiviral agents that were approved for the prevention and treatment of CMV infections in transplant recipients. Letermovir was approved in 2017 for CMV prophylaxis in CMV-seropositive adults who received an allogeneic hematopoietic stem cell transplant. Maribavir followed four years later, with an indication in the treatment of adult and pediatric transplant patients with refractory/resistant CMV disease. The target of letermovir is the CMV terminase complex (constituted of pUL56, pUL89 and pUL51 subunits). Letermovir prevents the cleavage of viral DNA and its packaging into capsids. Maribavir is a pUL97 kinase inhibitor, which interferes with the assembly of capsids and the egress of virions from the nucleus. Both drugs have activity against most CMV strains resistant to standard drugs and exhibit favorable safety profiles. However, high-level resistance mutations may arise more rapidly in the UL56 gene under letermovir than low-grade resistance mutations. Some mutations emerging in the UL97 gene under maribavir can be cross-resistant with ganciclovir. Thus, letermovir and maribavir now extend the drug arsenal available for the management of CMV infections and their respective niches are currently defined.
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Affiliation(s)
| | - Guy Boivin
- Centre de Recherche en Infectiologie, CHU de Québec-Université Laval, Quebec City, QC G1V 4G2, Canada;
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6
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Sun K, Fournier M, Sundberg AK, Song IH. Maribavir: Mechanism of action, clinical, and translational science. Clin Transl Sci 2024; 17:e13696. [PMID: 38071422 PMCID: PMC10801391 DOI: 10.1111/cts.13696] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 10/20/2023] [Accepted: 11/21/2023] [Indexed: 01/24/2024] Open
Abstract
Maribavir is an oral benzimidazole riboside for treatment of post-transplant cytomegalovirus (CMV) infection/disease that is refractory to prior antiviral treatment (with or without resistance). Through competitive inhibition of adenosine triphosphate, maribavir prevents the phosphorylation actions of UL97 to inhibit CMV DNA replication, encapsidation, and nuclear egress. Maribavir is active against CMV strains with viral DNA polymerase mutations that confer resistance to other CMV antivirals. After oral administration, maribavir is rapidly and highly absorbed (fraction absorbed >90%). The approved dose of 400 mg twice daily (b.i.d.) achieves a steady-state area under the curve per dosing interval of 128 h*μg/mL and trough concentration of 4.90 μg/mL (13.0 μM). Maribavir is highly bound to human plasma proteins (98%) with a small apparent volume of distribution of 27.3 L. Maribavir is primarily cleared by hepatic CYP3A4 metabolism; its major metabolite, VP44669 (pharmacologically inactive), is excreted in the urine and feces. There is no clinically relevant impact on maribavir pharmacokinetics by age, sex, race/ethnicity, body weight, transplant type, or hepatic/renal impairment status. In phase II dose-ranging studies, maribavir showed similar rates of CMV viral clearance across 400, 800, or 1200 mg b.i.d. groups, ranging from 62.5-70% in study 202 (NCT01611974) and 74-83% in study 203 (EudraCT 2010-024247-32). In the phase III SOLSTICE trial (NCT02931539), maribavir 400 mg b.i.d. demonstrated superior CMV viremia clearance at week 8 versus investigator-assigned treatments, with lower treatment discontinuation rates. Dysgeusia, nausea, vomiting, and diarrhea were commonly experienced adverse events among patients treated with maribavir in clinical trials.
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Affiliation(s)
- Kefeng Sun
- Quantitative Clinical PharmacologyTakeda Development Center Americas, Inc.LexingtonMassachusettsUSA
| | - Martha Fournier
- Clinical Sciences, Rare Genetics & Hematology Therapeutic Area UnitTakeda Development Center Americas, Inc.LexingtonMassachusettsUSA
| | - Aimee K. Sundberg
- Clinical Sciences, Rare Genetics & Hematology Therapeutic Area UnitTakeda Development Center Americas, Inc.LexingtonMassachusettsUSA
| | - Ivy H. Song
- Quantitative Clinical PharmacologyTakeda Development Center Americas, Inc.LexingtonMassachusettsUSA
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7
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Wild M, Karner D, Eickhoff J, Wagner S, Kicuntod J, Chang W, Barry P, Jonjić S, Lenac Roviš T, Marschall M. Combined Treatment with Host-Directed and Anticytomegaloviral Kinase Inhibitors: Mechanisms, Synergisms and Drug Resistance Barriers. Pharmaceutics 2023; 15:2680. [PMID: 38140021 PMCID: PMC10748244 DOI: 10.3390/pharmaceutics15122680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 11/20/2023] [Accepted: 11/23/2023] [Indexed: 12/24/2023] Open
Abstract
Despite the availability of currently approved antiviral drugs, infections with human cytomegalovirus (HCMV) still cause clinically challenging, sometimes life-threatening situations. There is an urgent need for enhanced anti-HCMV drugs that offer improved efficacy, reduced dosages and options for long-term treatment without risk of the development of viral drug resistance. Recently, we reported the pronounced anti-HCMV efficacy of pharmacological inhibitors of cyclin-dependent kinases (CDKs), in particular, the potential of utilizing drug synergies upon combination treatment with inhibitors of host CDKs and the viral CDK-like kinase pUL97 (vCDK/pUL97). Here, we expand this finding by further assessing the in vitro synergistic antiviral interaction between vCDK and CDK inhibitors towards HCMV as well as non-human cytomegaloviruses. An extension of this synergy approach was achieved in vivo by using the recombinant MCMV-UL97/mouse model, confirming the high potential of combination treatment with the clinically approved vCDK inhibitor maribavir (MBV) and the developmental CDK7 inhibitor LDC4297. Moreover, mechanistic aspects of this synergistic drug combination were illustrated on the levels of intracellular viral protein transport and viral genome replication. The analysis of viral drug resistance did not reveal resistance formation in the case of MBV + LDC4297 combination treatment. Spanning various investigational levels, these new results strongly support our concept, employing the great potential of anti-HCMV synergistic drug treatment.
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Affiliation(s)
- Markus Wild
- Institute for Clinical and Molecular Virology, Friedrich-Alexander University of Erlangen-Nürnberg (FAU), Schlossgarten 4, 91054 Erlangen, Germany; (M.W.); (S.W.); (J.K.)
| | - Dubravka Karner
- Center for Proteomics, Faculty of Medicine, University of Rijeka, Brace Branchetta 20, 51000 Rijeka, Croatia; (D.K.); (S.J.); (T.L.R.)
| | - Jan Eickhoff
- Lead Discovery Center GmbH, Otto-Hahn-Str. 15, 44227 Dortmund, Germany;
| | - Sabrina Wagner
- Institute for Clinical and Molecular Virology, Friedrich-Alexander University of Erlangen-Nürnberg (FAU), Schlossgarten 4, 91054 Erlangen, Germany; (M.W.); (S.W.); (J.K.)
| | - Jintawee Kicuntod
- Institute for Clinical and Molecular Virology, Friedrich-Alexander University of Erlangen-Nürnberg (FAU), Schlossgarten 4, 91054 Erlangen, Germany; (M.W.); (S.W.); (J.K.)
| | - William Chang
- Department of Medical Microbiology and Immunology, California National Primate Research Center, University of California, 3146 Tupper Hall, 1 Shields Avenue, Davis, CA 95616, USA; (W.C.); (P.B.)
| | - Peter Barry
- Department of Medical Microbiology and Immunology, California National Primate Research Center, University of California, 3146 Tupper Hall, 1 Shields Avenue, Davis, CA 95616, USA; (W.C.); (P.B.)
| | - Stipan Jonjić
- Center for Proteomics, Faculty of Medicine, University of Rijeka, Brace Branchetta 20, 51000 Rijeka, Croatia; (D.K.); (S.J.); (T.L.R.)
| | - Tihana Lenac Roviš
- Center for Proteomics, Faculty of Medicine, University of Rijeka, Brace Branchetta 20, 51000 Rijeka, Croatia; (D.K.); (S.J.); (T.L.R.)
| | - Manfred Marschall
- Institute for Clinical and Molecular Virology, Friedrich-Alexander University of Erlangen-Nürnberg (FAU), Schlossgarten 4, 91054 Erlangen, Germany; (M.W.); (S.W.); (J.K.)
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8
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Walti CS, Khanna N, Avery RK, Helanterä I. New Treatment Options for Refractory/Resistant CMV Infection. Transpl Int 2023; 36:11785. [PMID: 37901297 PMCID: PMC10600348 DOI: 10.3389/ti.2023.11785] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 09/26/2023] [Indexed: 10/31/2023]
Abstract
Despite advances in monitoring and treatment, cytomegalovirus (CMV) infections remain one of the most common complications after solid organ transplantation (SOT). CMV infection may fail to respond to standard first- and second-line antiviral therapies with or without the presence of antiviral resistance to these therapies. This failure to respond after 14 days of appropriate treatment is referred to as "resistant/refractory CMV." Limited data on refractory CMV without antiviral resistance are available. Reported rates of resistant CMV are up to 18% in SOT recipients treated for CMV. Therapeutic options for treating these infections are limited due to the toxicity of the agent used or transplant-related complications. This is often the challenge with conventional agents such as ganciclovir, foscarnet and cidofovir. Recent introduction of new CMV agents including maribavir and letermovir as well as the use of adoptive T cell therapy may improve the outcome of these difficult-to-treat infections in SOT recipients. In this expert review, we focus on new treatment options for resistant/refractory CMV infection and disease in SOT recipients, with an emphasis on maribavir, letermovir, and adoptive T cell therapy.
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Affiliation(s)
- Carla Simone Walti
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Biomedicine and Clinical Research, University and University Hospital of Basel, Basel, Switzerland
| | - Nina Khanna
- Division of Infectious Diseases and Hospital Epidemiology, Departments of Biomedicine and Clinical Research, University and University Hospital of Basel, Basel, Switzerland
| | - Robin K. Avery
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Ilkka Helanterä
- Department of Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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9
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Giménez E, Guerreiro M, Gozalbo-Rovira R, Aguilar C, Albert E, Piñana JL, Solano C, Navarro D. In vitro assessment of the combined effect of letermovir and sirolimus on cytomegalovirus replication. REVISTA ESPANOLA DE QUIMIOTERAPIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE QUIMIOTERAPIA 2023; 36:526-530. [PMID: 37365797 PMCID: PMC10586729 DOI: 10.37201/req/016.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 04/12/2023] [Accepted: 05/08/2023] [Indexed: 06/28/2023]
Abstract
OBJECTIVE Letermovir (LMV) is used for prophylaxis of cytomegalovirus (CMV) reactivation and end-organ disease in adult CMV-seropositive allogeneic hematopoietic stem cell transplant recipients (allo-HSCT). In turn, sirolimus (SLM) which displays in vitro anti-CMV activity, is frequently employed for prophylaxis of Graft vs. Host disease in allo-HSCT. Here, we aimed at assessing whether LMV and SLM used in combination may act synergistically in vitro on inhibiting CMV replication. METHODS The antiviral activity of LMV and SLM alone or in combination was evaluated by a checkerboard assay, using ARPE-19 cells infected with CMV strain BADrUL131-Y. LMV and SLM were used at concentrations ranging from 24 nM to 0.38 nM and 16 nM to 0.06 nM, respectively. RESULTS The mean EC50 for LMV and SLM was 2.44 nM (95% CI, 1.66-3.60) and 1.40 nM (95% CI, 0.41-4.74), respective. LMV and SLM interaction yielded mainly additive effects over the range of concentrations tested. CONCLUSIONS The additive nature of the combination of LMV and SLM against CMV may have relevant clinical implications in management of CMV infection in allo-HSCT recipients undergoing prophylaxis with LMV.
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Affiliation(s)
| | | | | | | | | | | | | | - D Navarro
- David Navarro, Microbiology Service, Hospital Clínico Universitario, and Department of Microbiology, School of Medicine, Av. Blasco Ibáñez 17, 46010 Valencia, Spain.
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10
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Hume J, Sweeney EL, Lowry K, Fraser C, Clark JE, Whiley DM, Irwin AD. Cytomegalovirus in children undergoing haematopoietic stem cell transplantation: a diagnostic and therapeutic approach to antiviral resistance. Front Pediatr 2023; 11:1180392. [PMID: 37325366 PMCID: PMC10267881 DOI: 10.3389/fped.2023.1180392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 05/15/2023] [Indexed: 06/17/2023] Open
Abstract
Cytomegalovirus (CMV) is a ubiquitous virus which causes a mild illness in healthy individuals. In immunocompromised individuals, such as children receiving haematopoietic stem cell transplantation, CMV can reactivate, causing serious disease and increasing the risk of death. CMV can be effectively treated with antiviral drugs, but antiviral resistance is an increasingly common complication. Available therapies are associated with adverse effects such as bone marrow suppression and renal impairment, making the choice of appropriate treatment challenging. New agents are emerging and require evaluation in children to establish their role. This review will discuss established and emerging diagnostic tools and treatment options for CMV, including antiviral resistant CMV, in children undergoing haematopoietic stem cell transplant.
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Affiliation(s)
- Jocelyn Hume
- The University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Central Microbiology, Pathology Queensland, Brisbane, QLD, Australia
| | - Emma L. Sweeney
- The University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Kym Lowry
- The University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Chris Fraser
- Blood and Bone Marrow Transplant Program, Queensland Children’s Hospital, Brisbane, QLD, Australia
| | - Julia E. Clark
- Infection Management and Prevention Service, Queensland Children’s Hospital, Brisbane, QLD, Australia
| | - David M. Whiley
- The University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Central Microbiology, Pathology Queensland, Brisbane, QLD, Australia
| | - Adam D. Irwin
- The University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
- Infection Management and Prevention Service, Queensland Children’s Hospital, Brisbane, QLD, Australia
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11
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Kotton CN, Kamar N. New Insights on CMV Management in Solid Organ Transplant Patients: Prevention, Treatment, and Management of Resistant/Refractory Disease. Infect Dis Ther 2023; 12:333-342. [PMID: 36583845 PMCID: PMC9925645 DOI: 10.1007/s40121-022-00746-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 12/08/2022] [Indexed: 12/31/2022] Open
Abstract
Cytomegalovirus (CMV) infection can have both direct and indirect effects after solid-organ transplantation, with a significant impact on transplant outcomes. Prevention strategies decrease the risk of CMV disease, although CMV still occurs in up to 50% of high-risk patients. Ganciclovir (GCV) and valganciclovir (VGCV) are the main drugs currently used for preventing and treating CMV. Emerging data suggest that letermovir is as effective as VGCV with fewer hematological side effects. Refractory and resistant CMV also still occur in solid-organ-transplant patients. Maribavir has been shown to be effective and have less toxicity in the treatment of refractory and resistant CMV. In this review paper, we discuss prevention strategies, refractory and resistant CMV, and drug-related side effects and their impact, as well as optimal use of novel anti-CMV therapies.
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Affiliation(s)
- Camille Nelson Kotton
- grid.32224.350000 0004 0386 9924Transplant and Immunocompromised Host Infectious Diseases, Infectious Diseases Division, Massachusetts General Hospital, 55 Fruit Street, Cox 5, Boston, MA 02114 USA
- grid.38142.3c000000041936754XHarvard Medical School, Boston, MA USA
| | - Nassim Kamar
- grid.414295.f0000 0004 0638 3479Department of Nephrology and Organ Transplantation, Toulouse Rangueil University Hospital, CHU Toulouse Rangueil, TSA 50032, 31059 Toulouse Cedex 9, France
- grid.7429.80000000121866389INSERM UMR 1291, Toulouse Institute for Infectious and Inflammatory Diseases (Infinity), Toulouse, France
- grid.15781.3a0000 0001 0723 035XPaul Sabatier University, Toulouse, France
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12
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Khawaja F, Spallone A, Kotton CN, Chemaly RF. Cytomegalovirus infection in transplant recipients: newly approved additions to our armamentarium. Clin Microbiol Infect 2023; 29:44-50. [PMID: 35843567 DOI: 10.1016/j.cmi.2022.07.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 07/01/2022] [Accepted: 07/02/2022] [Indexed: 12/27/2022]
Abstract
BACKGROUND The burden that cytomegalovirus (CMV) portends for haematopoietic and solid-organ transplant recipients cannot be understated. Valganciclovir and ganciclovir have successfully been used for prevention and treatment of CMV infections, although with serious side effects such as leucopenia and some development of resistance. Until recently, available therapies for ganciclovir-resistant CMV have significant toxicities. Although advances have been made in the field, the unmet medical needs for effective and well-tolerated therapies are significant. OBJECTIVES This review aims to summarise the current and emerging CMV antiviral drugs and discusses future perspectives in the field. SOURCES We searched for relevant articles with pertinent keywords: "Cytomegalovirus OR CMV", "Transplant" and "Antiviral". Articles published after 2019 were given preference. Articles were reviewed by the authors for relevance and impact to the subject of interest. CONTENT We outline in this review current advances in prophylaxis of CMV infection with letermovir, breakthrough CMV infections while on or after prophylaxis, the development of resistant and refractory CMV infections, and the newly approved anti-CMV agent, maribavir, in haematopoietic and solid-organ transplant recipients. IMPLICATIONS Prevention of CMV infections after transplant has improved greatly over the past few years. Despite major advancements, breakthrough CMV infections and development of refractory and resistant CMV infections remain major complications post transplantation. We highlight emerging therapeutics that tolerably and effectively prevent and treat CMV infections, especially refractory and resistant cases.
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Affiliation(s)
- Fareed Khawaja
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amy Spallone
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Camille N Kotton
- Transplant Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA
| | - Roy F Chemaly
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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13
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Levien TL, Baker DE. Maribavir. Hosp Pharm 2022. [DOI: 10.1177/00185787221101480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Each month, subscribers to The Formulary Monograph Service receive 5 to 6 well-documented monographs on drugs that are newly released or are in late phase 3 trials. The monographs are targeted to Pharmacy & Therapeutics Committees. Subscribers also receive monthly 1-page summary monographs on agents that are useful for agendas and pharmacy/nursing in-services. A comprehensive target drug utilization evaluation/medication use evaluation (DUE/MUE) is also provided each month. With a subscription, the monographs are available online to subscribers. Monographs can be customized to meet the needs of a facility. Through the cooperation of The Formulary, Hospital Pharmacy publishes selected reviews in this column. For more information about The Formulary Monograph Service, contact Wolters Kluwer customer service at 866-397-3433.
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Challenges, Recent Advances and Perspectives in the Treatment of Human Cytomegalovirus Infections. Trop Med Infect Dis 2022; 7:tropicalmed7120439. [PMID: 36548694 PMCID: PMC9784992 DOI: 10.3390/tropicalmed7120439] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 11/30/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022] Open
Abstract
Human cytomegalovirus (HCMV) is ubiquitous worldwide and elicits global health problems. The diseases associated with HCMV are a serious threat to humans, especially for the sick, infant, elderly and immunocompromised/immunodeficient individuals. Although traditional antiviral drugs (e.g., ganciclovir, valganciclovir, cidofovir, foscarnet) can be used to treat or prevent acute HCMV infections, their efficacy is limited because of toxicity, resistance issues, side effects and other problems. Fortunately, novel drugs (e.g., letermovir and maribavir) with less toxicity and drug/cross-resistance have been approved and put on the market in recent years. The nucleic acid-based gene-targeting approaches including the external guide sequences (EGSs)-RNase, the clustered regularly interspaced short palindromic repeats (CRISPRs)/CRISPRs-associated protein 9 (Cas9) system and transcription activator-like effector nucleases (TALENs) have been investigated to remove both lytic and latent CMV in vitro and/or in vivo. Cell therapy including the adoptive T cell therapy (ACT) and immunotherapy have been tried against drug-resistant and recurrent HCMV in patients receiving hematopoietic stem cell transplantation (HSCT) or solid organ transplant (SOT), and they have also been used to treat glioblastoma (GBM) associated with HCMV infections. These newly developed antiviral strategies are expected to yield fruitful results and make a significant contribution to the treatment of HCMV infections. Despite this progress, the nucleic acid-based gene-targeting approaches are still under study for basic research, and cell therapy is adopted in a small study population size or only successful in case reports. Additionally, no current drugs have been approved to be indicated for latent infections. Therefore, the next strategy is to develop antiviral strategies to elevate efficacy against acute and/or latent infections and overcome challenges such as toxicity, resistance issues, and side effects. In this review, we would explore the challenges, recent advances and perspectives in the treatment of HCMV infections. Furthermore, the suitable therapeutic strategies as well as the possibility for compassionate use would be evaluated.
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Abstract
Maribavir was approved by the U.S. Food and Drug Administration in November 2021 for the treatment of adult and pediatric patients with post-transplant cytomegalovirus (CMV) infection/disease that is refractory to treatment (with or without genotypic resistance) with ganciclovir, valganciclovir, cidofovir, or foscarnet. Maribavir is an oral benzimidazole riboside with potent and selective multimodal anti-CMV activity. It utilizes a novel mechanism of action which confers activity against CMV strains that are resistant to traditional anti-CMV agents, and also offers a more favorable safety profile relative to the dose-limiting side effects of previously available therapies. Maribavir was initially studied as an agent for CMV prophylaxis in solid organ and hematopoietic stem cell recipients, but initial phase III trials failed to meet clinical efficacy endpoints. It has been more recently studied as a therapeutic agent at higher doses for refractory-resistant (R-R) CMV infections with favorable outcomes. After an overview of maribavir's chemistry and clinical pharmacology, this review will summarize clinical efficacy, safety, tolerability, and resistance data associated with maribavir therapy.
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16
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Kleiboeker HL, Descourouez JL, Schulz LT, Mandelbrot DA, Odorico JS, Rice JP, Saddler CM, Smith JA, Jorgenson MR. Maribavir for the Management of Cytomegalovirus in Adult Transplant Recipients: A Review of the Literature and Practical Considerations. Ann Pharmacother 2022; 57:597-608. [PMID: 36003036 DOI: 10.1177/10600280221118959] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To review the efficacy and safety of maribavir for management of cytomegalovirus (CMV) in solid organ transplant recipients. DATA SOURCES A literature search of PubMed and the Cochrane Controlled Trials Register (1960 to early July 2022) was performed using the following search terms: maribavir, 1263W94, and cytomegalovirus. STUDY SELECTION AND DATA EXTRACTION All relevant English-language studies were reviewed and considered, with a focus on phase 3 trials. DATA SYNTHESIS Maribavir, an orally available benzimidazole riboside with minimal adverse effects, was originally studied for universal prophylaxis in phase 3 trials but failed to demonstrate noninferiority over placebo and oral ganciclovir. It was effective for preemptive treatment in a dose-finding Phase 2 study. Maribavir is FDA approved for treatment of refractory/resistant CMV infection based on improved response rate at 8 weeks compared with investigator-assigned therapy (IAT) when initiated at median viral loads less than approximately 10 000 IU/mL (55.7% vs 23.9%, P < 0.001). Recurrence after 8-week treatment for refractory/resistant CMV was high (maribavir 50% vs IAT 39%). Significant drug interactions exist and must be managed by a pharmacotherapy expert to prevent harm. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE The addition of maribavir to the antiviral armamentarium should improve the management of refractory/resistant CMV, allowing early transition from toxic, high-cost, intravenous agents such as foscarnet and outpatient management. Optimal timing of initiation, duration, and potential alternative uses are unclear. CONCLUSION Future studies are needed to fully elucidate the role of maribavir in the management of CMV after transplant.
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Affiliation(s)
- Hanna L Kleiboeker
- Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Jillian L Descourouez
- Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Lucas T Schulz
- Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, WI, USA
| | - Didier A Mandelbrot
- Department of Medicine, Division of Nephrology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Jon S Odorico
- Department of Surgery, Division of Transplantation, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - John P Rice
- Department of Medicine, Division of Hepatology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Christopher M Saddler
- Department of Medicine, Division of Infectious Diseases, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Jeannina A Smith
- Department of Medicine, Division of Infectious Diseases, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Margaret R Jorgenson
- Department of Pharmacy, University of Wisconsin Hospital and Clinics, Madison, WI, USA
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17
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Majewska A, Mlynarczyk-Bonikowska B. 40 Years after the Registration of Acyclovir: Do We Need New Anti-Herpetic Drugs? Int J Mol Sci 2022; 23:ijms23073431. [PMID: 35408788 PMCID: PMC8998721 DOI: 10.3390/ijms23073431] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 03/10/2022] [Accepted: 03/18/2022] [Indexed: 01/17/2023] Open
Abstract
Herpes simplex virus types 1 and 2 HSV1 and 2, namely varicella-zoster VZV and cytomegalovirus CMV, are among the most common pathogens worldwide. They remain in the host body for life. The course of infection with these viruses is often asymptomatic or mild and self-limiting, but in immunocompromised patients, such as solid organ or bone marrow transplant recipients, the course can be very severe or even life-threatening. Unfortunately, in the latter group, the highest percentage of infections with strains resistant to routinely used drugs is observed. On the other hand, frequent recurrences of genital herpes can be a problem even in people with normal immunity. Genital herpes also increases the risk of acquiring sexually transmitted diseases, including HIV infection and, if present in pregnant women, poses a risk to the fetus and newborn. Even more frequently than herpes simplex, congenital infections can be caused by cytomegalovirus. We present the most important anti-herpesviral agents, the mechanisms of resistance to these drugs, and the associated mutations in the viral genome. Special emphasis was placed on newly introduced drugs such as maribavir and brincidofovir. We also briefly discuss the most promising substances in preclinical testing as well as immunotherapy options and vaccines currently in use and under investigation.
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Affiliation(s)
- Anna Majewska
- Department of Medical Microbiology, Medical University of Warsaw, Chałubińskiego 5, 02-004 Warsaw, Poland;
| | - Beata Mlynarczyk-Bonikowska
- Department of Dermatology, Immunodermatology and Venereology, Medical University of Warsaw, Koszykowa 82a, 02-008 Warsaw, Poland
- Correspondence: ; Tel.: +48-225021313
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18
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Gandhi RG, Kotton CN. Evaluating the Safety of Maribavir for the Treatment of Cytomegalovirus. Ther Clin Risk Manag 2022; 18:223-232. [PMID: 35308097 PMCID: PMC8926008 DOI: 10.2147/tcrm.s303052] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 02/28/2022] [Indexed: 12/18/2022] Open
Abstract
Purpose of Review Cytomegalovirus (CMV) infections are a common complication in solid organ (SOT) and hematopoietic stem cell transplant (HSCT) recipients, leading to increased morbidity and mortality. Currently available treatment options have reduced the burden of infection, but utilization of these agents can be limited by toxicities such as nephrotoxicity and/or myelosuppression as well as emergence of resistance. The expansion of our current armamentarium towards CMV infection is crucial. Here, we review an emerging therapy, maribavir, and the safety and efficacy of this potential new agent for the prophylaxis and treatment of CMV infections including resistant/refractory disease. Recent Findings Maribavir is a novel agent with CMV activity approved by Federal Food and Drug Administration (FDA) in December 2021 for resistant/refractory disease. Compared to currently available treatment for CMV infection, maribavir has a unique mechanism of action, retains activity against most (val)ganciclovir resistant strains, provides a more predictable pharmacokinetic profile, and fewer severe toxicities. Maribavir has been studied in phase 2 and 3 studies with ongoing phase 3 studies. While maribavir failed to meet the primary endpoints in the initial phase 3 study for prophylaxis therapy in allogeneic-HSCT and liver transplant recipients, results from the phase 2 study when used for pre-emptive therapy after HSCT show similar efficacy to valganciclovir, and results from the phase 3 study examining resistant/refractory disease demonstrate superiority to investigator-initiated therapy of (val)ganciclovir, foscarnet, or cidofovir. Summary Maribavir provides a new agent for the management of resistant/refractory CMV infection. Results of the recently published phase 3 study provide further insight into the role of this novel therapy.
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Affiliation(s)
- Ronak G Gandhi
- Department of Pharmacy, Massachusetts General Hospital, Boston, MA, USA
- Correspondence: Ronak G Gandhi, Senior Attending Pharmacist – Infectious Diseases, Department of Pharmacy, Massachusetts General Hospital, 55 Fruit Street, GRB 005, Boston, MA02114, USA, Tel +1 617-643-6570, Fax +1 617-726-9232, Email
| | - Camille N Kotton
- Infectious Diseases Division, Massachusetts General Hospital, Boston, MA, USA
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Dickter JK, Ross JA, Zain JM, Tegtmeier BR, Lee BV, Dadwal SS. Letermovir and maribavir for pan-resistant cytomegalovirus infection in a patient with haematologic malignancy: Consideration for combination therapy. J Clin Pharm Ther 2022; 47:699-702. [PMID: 35023177 DOI: 10.1111/jcpt.13585] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 12/06/2021] [Indexed: 10/19/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Management of pan-resistant cytomegalovirus infection (CMVi) requires a multifaceted approach, including host defence optimization by reducing immunosuppression, and standard or experimental antiviral therapy. CASE DESCRIPTION A 36-year-old man with anaplastic lymphoma kinase (ALK)-negative anaplastic large cell lymphoma, who underwent allogeneic haematopoietic stem cell transplant (alloHCT) with resultant graft-versus-host disease treated with immunosuppressive therapy, developed pan-resistant CMVi. He was successfully treated with combination therapy of maribavir and letermovir. WHAT IS NEW AND CONCLUSION Combination therapy, used for other infections to prevent cross-resistant, may apply for CMVi.
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Affiliation(s)
- Jana K Dickter
- Department of Medicine, Division of Infectious Diseases, City of Hope National Medical Center, Duarte, California, USA
| | - Justine A Ross
- Department of Pharmacy Services, City of Hope National Medical Center, Duarte, California, USA
| | - Jasmine M Zain
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California, USA
| | - Bernard R Tegtmeier
- Department of Pathology, Division of Clinical Pathology, City of Hope National Medical Center, Duarte, California, USA
| | - Brian V Lee
- Department of Pharmacy Services, City of Hope National Medical Center, Duarte, California, USA
| | - Sanjeet S Dadwal
- Department of Medicine, Division of Infectious Diseases, City of Hope National Medical Center, Duarte, California, USA
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20
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Hahn F, Hamilton ST, Wangen C, Wild M, Kicuntod J, Brückner N, Follett JEL, Herrmann L, Kheimar A, Kaufer BB, Rawlinson WD, Tsogoeva SB, Marschall M. Development of a PROTAC-Based Targeting Strategy Provides a Mechanistically Unique Mode of Anti-Cytomegalovirus Activity. Int J Mol Sci 2021; 22:12858. [PMID: 34884662 PMCID: PMC8657773 DOI: 10.3390/ijms222312858] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 11/24/2021] [Accepted: 11/24/2021] [Indexed: 12/31/2022] Open
Abstract
Human cytomegalovirus (HCMV) is a major pathogenic herpesvirus that is prevalent worldwide and it is associated with a variety of clinical symptoms. Current antiviral therapy options do not fully satisfy the medical needs; thus, improved drug classes and drug-targeting strategies are required. In particular, host-directed antivirals, including pharmaceutical kinase inhibitors, might help improve the drug qualities. Here, we focused on utilizing PROteolysis TArgeting Chimeras (PROTACs), i.e., hetero-bifunctional molecules containing two elements, namely a target-binding molecule and a proteolysis-inducing element. Specifically, a PROTAC that was based on a cyclin-dependent kinase (CDK) inhibitor, i.e., CDK9-directed PROTAC THAL-SNS032, was analyzed and proved to possess strong anti-HCMV AD169-GFP activity, with values of EC50 of 0.030 µM and CC50 of 0.175 µM (SI of 5.8). Comparing the effect of THAL-SNS032 with its non-PROTAC counterpart SNS032, data indicated a 3.7-fold stronger anti-HCMV efficacy. This antiviral activity, as illustrated for further clinically relevant strains of human and murine CMVs, coincided with the mid-nanomolar concentration range necessary for a drug-induced degradation of the primary (CDK9) and secondary targets (CDK1, CDK2, CDK7). In addition, further antiviral activities were demonstrated, such as the inhibition of SARS-CoV-2 replication, whereas other investigated human viruses (i.e., varicella zoster virus, adenovirus type 2, and Zika virus) were found insensitive. Combined, the antiviral quality of this approach is seen in its (i) mechanistic uniqueness; (ii) future options of combinatorial drug treatment; (iii) potential broad-spectrum activity; and (iv) applicability in clinically relevant antiviral models. These novel data are discussed in light of the current achievements of anti-HCMV drug development.
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Affiliation(s)
- Friedrich Hahn
- Institute for Clinical and Molecular Virology, Friedrich-Alexander University of Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (C.W.); (M.W.); (J.K.); (N.B.)
| | - Stuart T. Hamilton
- Serology and Virology Division, NSW Health Pathology Microbiology, Prince of Wales Hospital, Schools of Women’s and Children’s Health, Medicine and Biotechnology and Biomolecular Sciences, University of New South Wales, Sydney, NSW 2031, Australia; (S.T.H.); (J.E.L.F.); (W.D.R.)
| | - Christina Wangen
- Institute for Clinical and Molecular Virology, Friedrich-Alexander University of Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (C.W.); (M.W.); (J.K.); (N.B.)
| | - Markus Wild
- Institute for Clinical and Molecular Virology, Friedrich-Alexander University of Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (C.W.); (M.W.); (J.K.); (N.B.)
| | - Jintawee Kicuntod
- Institute for Clinical and Molecular Virology, Friedrich-Alexander University of Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (C.W.); (M.W.); (J.K.); (N.B.)
| | - Nadine Brückner
- Institute for Clinical and Molecular Virology, Friedrich-Alexander University of Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (C.W.); (M.W.); (J.K.); (N.B.)
| | - Jasmine E. L. Follett
- Serology and Virology Division, NSW Health Pathology Microbiology, Prince of Wales Hospital, Schools of Women’s and Children’s Health, Medicine and Biotechnology and Biomolecular Sciences, University of New South Wales, Sydney, NSW 2031, Australia; (S.T.H.); (J.E.L.F.); (W.D.R.)
| | - Lars Herrmann
- Institute of Organic Chemistry I, FAU, 91058 Erlangen, Germany; (L.H.); (S.B.T.)
| | - Ahmed Kheimar
- Institute of Virology, Freie Universität Berlin, 14163 Berlin, Germany; (A.K.); (B.B.K.)
| | - Benedikt B. Kaufer
- Institute of Virology, Freie Universität Berlin, 14163 Berlin, Germany; (A.K.); (B.B.K.)
| | - William D. Rawlinson
- Serology and Virology Division, NSW Health Pathology Microbiology, Prince of Wales Hospital, Schools of Women’s and Children’s Health, Medicine and Biotechnology and Biomolecular Sciences, University of New South Wales, Sydney, NSW 2031, Australia; (S.T.H.); (J.E.L.F.); (W.D.R.)
| | - Svetlana B. Tsogoeva
- Institute of Organic Chemistry I, FAU, 91058 Erlangen, Germany; (L.H.); (S.B.T.)
| | - Manfred Marschall
- Institute for Clinical and Molecular Virology, Friedrich-Alexander University of Erlangen-Nürnberg (FAU), 91054 Erlangen, Germany; (C.W.); (M.W.); (J.K.); (N.B.)
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21
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Abbas A, Zimmer AJ, Florescu D. Viral Enteritis in Solid-Organ Transplantation. Viruses 2021; 13:2019. [PMID: 34696449 PMCID: PMC8541384 DOI: 10.3390/v13102019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 09/22/2021] [Accepted: 09/27/2021] [Indexed: 12/13/2022] Open
Abstract
Solid organ transplant recipients are at increased risk for infections due to chronic immunosuppression. Diarrhea is a commonly encountered problem post transplantation, with infectious causes of diarrhea being a frequent complication. Viral infections/enteritides in solid organ transplant recipients often result from frequently encountered pathogens in this population such as cytomegalovirus, adenovirus, and norovirus. However, several emerging viral pathogens are increasingly being recognized as more sensitive diagnostic techniques become available. Treatment is often limited to supportive care and reduction in immunosuppression, though antiviral therapies mayplay a role in the treatment in certain diseases. Viral enteritis is an important entity that contributes to morbidity and mortality in transplant recipients.
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Affiliation(s)
- Anum Abbas
- Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, NE 68198, USA; (A.J.Z.); (D.F.)
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22
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Gao Y, Cao J, Xing P, Altmeyer R, Zhang Y. Evaluation of Small Molecule Combinations against Respiratory Syncytial Virus In Vitro. Molecules 2021; 26:molecules26092607. [PMID: 33946996 PMCID: PMC8125180 DOI: 10.3390/molecules26092607] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 04/03/2021] [Accepted: 04/21/2021] [Indexed: 11/16/2022] Open
Abstract
Respiratory syncytial virus (RSV) is a major pathogen that causes severe lower respiratory tract infection in infants, the elderly and the immunocompromised worldwide. At present no approved specific drugs or vaccines are available to treat this pathogen. Recently, several promising candidates targeting RSV entry and multiplication steps are under investigation. However, it is possible to lead to drug resistance under the long-term treatment. Therapeutic combinations constitute an alternative to prevent resistance and reduce antiviral doses. Therefore, we tested in vitro two-drug combinations of fusion inhibitors (GS5806, Ziresovir and BMS433771) and RNA-dependent RNA polymerase complex (RdRp) inhibitors (ALS8176, RSV604, and Cyclopamine). The statistical program MacSynergy II was employed to determine synergism, additivity or antagonism between drugs. From the result, we found that combinations of ALS8176 and Ziresovir or GS5806 exhibit additive effects against RSV in vitro, with interaction volume of 50 µM2% and 31 µM2% at 95% confidence interval, respectively. On the other hand, all combinations between fusion inhibitors showed antagonistic effects against RSV in vitro, with volume of antagonism ranging from −50 µM2 % to −176 µM2 % at 95% confidence interval. Over all, our results suggest the potentially therapeutic combinations in combating RSV in vitro could be considered for further animal and clinical evaluations.
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AHMAD NASEEM, AZAD MOHAMMADIRFAN, KHAN ABDULRAHMAN, AZAD IQBAL. BENZIMIDAZOLE AS A PROMISING ANTIVIRAL HETEROCYCLIC SCAFFOLD: A REVIEW. JOURNAL OF SCIENCE AND ARTS 2021. [DOI: 10.46939/j.sci.arts-21.1-b05] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Heterocyclic derivatives are unavoidable in many fields of natural disciplines. These derivatives play numerous significant roles in research, medication, and nature. Nitrogenous heterocyclic derivatives extremely are the main target of concern in synthetic chemistry to ensue active natural products with pharmaceuticals and agrochemicals interest. Benzimidazole skeleton is another example of some active heterocyclic moiety that significantly contributes in the numerous bioactive of essential compounds. Benzimidazole skeleton is studied as a prominent moiety of biologically active compounds with various activities including antimicrobial, antiprotozoal, anticancer, antiviral, acetylcholinesterase, antihistaminic, anti-inflammatory, antimalarial, analgesic, anti-HIV and antitubercular. Therefore, in this review we summarize the various antiviral activities of several benzimidazole derivatives and outline the correlation among the structures of different benzimidazoles scaffold with their therapeutic significance.
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Affiliation(s)
- NASEEM AHMAD
- Integral University, Department of Chemistry, 226026 Lucknow, India
| | - MOHAMMAD IRFAN AZAD
- Jamia Millia Islamia, Department of Chemistry, Jamia Nagar, 110025 New Delhi, India
| | | | - IQBAL AZAD
- Integral University, Department of Chemistry, 226026 Lucknow, India
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24
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Wild M, Kicuntod J, Seyler L, Wangen C, Bertzbach LD, Conradie AM, Kaufer BB, Wagner S, Michel D, Eickhoff J, Tsogoeva SB, Bäuerle T, Hahn F, Marschall M. Combinatorial Drug Treatments Reveal Promising Anticytomegaloviral Profiles for Clinically Relevant Pharmaceutical Kinase Inhibitors (PKIs). Int J Mol Sci 2021; 22:ijms22020575. [PMID: 33430060 PMCID: PMC7826512 DOI: 10.3390/ijms22020575] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 12/24/2020] [Accepted: 01/04/2021] [Indexed: 12/11/2022] Open
Abstract
Human cytomegalovirus (HCMV) is a human pathogenic herpesvirus associated with a variety of clinical symptoms. Current antiviral therapy is not always effective, so that improved drug classes and drug-targeting strategies are needed. Particularly host-directed antivirals, including pharmaceutical kinase inhibitors (PKIs), may help to overcome problems of drug resistance. Here, we focused on utilizing a selection of clinically relevant PKIs and determined their anticytomegaloviral efficacies. Particularly, PKIs directed to host or viral cyclin-dependent kinases, i.e., abemaciclib, LDC4297 and maribavir, exerted promising profiles against human and murine cytomegaloviruses. The anti-HCMV in vitro activity of the approved anti-cancer drug abemaciclib was confirmed in vivo using our luciferase-based murine cytomegalovirus (MCMV) animal model in immunocompetent mice. To assess drug combinations, we applied the Bliss independence checkerboard and Loewe additivity fixed-dose assays in parallel. Results revealed that (i) both affirmative approaches provided valuable information on anti-CMV drug efficacies and interactions, (ii) the analyzed combinations comprised additive, synergistic or antagonistic drug interactions consistent with the drugs’ antiviral mode-of-action, (iii) the selected PKIs, especially LDC4297, showed promising inhibitory profiles, not only against HCMV but also other α-, β- and γ-herpesviruses, and specifically, (iv) the combination treatment with LDC4297 and maribavir revealed a strong synergism against HCMV, which might open doors towards novel clinical options in the near future. Taken together, this study highlights the potential of therapeutic drug combinations of current developmental/preclinical PKIs.
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Affiliation(s)
- Markus Wild
- Institute for Clinical and Molecular Virology, Friedrich-Alexander University of Erlangen-Nürnberg (FAU), Schlossgarten 4, 91054 Erlangen, Germany; (M.W.); (J.K.); (C.W.); (S.W.); (F.H.)
| | - Jintawee Kicuntod
- Institute for Clinical and Molecular Virology, Friedrich-Alexander University of Erlangen-Nürnberg (FAU), Schlossgarten 4, 91054 Erlangen, Germany; (M.W.); (J.K.); (C.W.); (S.W.); (F.H.)
| | - Lisa Seyler
- Institute of Radiology, University Medical Center Erlangen, FAU, Palmsanlage 5, 91054 Erlangen, Germany; (L.S.); (T.B.)
| | - Christina Wangen
- Institute for Clinical and Molecular Virology, Friedrich-Alexander University of Erlangen-Nürnberg (FAU), Schlossgarten 4, 91054 Erlangen, Germany; (M.W.); (J.K.); (C.W.); (S.W.); (F.H.)
| | - Luca D. Bertzbach
- Institute of Virology, Freie Universität Berlin, Robert-von-Ostertag-Straße 7-13, 14163 Berlin, Germany; (L.D.B.); (A.M.C.); (B.B.K.)
| | - Andelé M. Conradie
- Institute of Virology, Freie Universität Berlin, Robert-von-Ostertag-Straße 7-13, 14163 Berlin, Germany; (L.D.B.); (A.M.C.); (B.B.K.)
| | - Benedikt B. Kaufer
- Institute of Virology, Freie Universität Berlin, Robert-von-Ostertag-Straße 7-13, 14163 Berlin, Germany; (L.D.B.); (A.M.C.); (B.B.K.)
| | - Sabrina Wagner
- Institute for Clinical and Molecular Virology, Friedrich-Alexander University of Erlangen-Nürnberg (FAU), Schlossgarten 4, 91054 Erlangen, Germany; (M.W.); (J.K.); (C.W.); (S.W.); (F.H.)
| | - Detlef Michel
- Institute for Virology, Ulm University Medical Center, Albert-Einstein-Allee 11, 89081 Ulm, Germany;
| | - Jan Eickhoff
- Lead Discovery Center GmbH, Otto-Hahn-Str. 15, 44227 Dortmund, Germany;
| | - Svetlana B. Tsogoeva
- Institute of Organic Chemistry I, FAU, Nikolaus-Fiebiger-Straße 10, 91058 Erlangen, Germany;
| | - Tobias Bäuerle
- Institute of Radiology, University Medical Center Erlangen, FAU, Palmsanlage 5, 91054 Erlangen, Germany; (L.S.); (T.B.)
| | - Friedrich Hahn
- Institute for Clinical and Molecular Virology, Friedrich-Alexander University of Erlangen-Nürnberg (FAU), Schlossgarten 4, 91054 Erlangen, Germany; (M.W.); (J.K.); (C.W.); (S.W.); (F.H.)
| | - Manfred Marschall
- Institute for Clinical and Molecular Virology, Friedrich-Alexander University of Erlangen-Nürnberg (FAU), Schlossgarten 4, 91054 Erlangen, Germany; (M.W.); (J.K.); (C.W.); (S.W.); (F.H.)
- Correspondence: ; Tel.: +49-9131-8526-089
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Sánchez-Céspedes J, Marrugal-Lorenzo JA, Martín-Gandul C, Rodríguez-Torres N, Montero-Mateos E, Serna-Gallego A, Escamilla-Gómez V, Merino L, Espigado I, Pachón J, Pérez-Simón JA, Aguilar-Guisado M. T-cells immune response controls the high incidence of adenovirus infection in adult allogenic hematopoietic transplantation recipients. Haematologica 2021; 106:275-278. [PMID: 31974194 PMCID: PMC7776353 DOI: 10.3324/haematol.2019.240101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
| | | | | | | | | | - Ana Serna-Gallego
- Institute of Biomedicine of Seville (IBiS), University Hospital Virgen del Rocío
| | | | - Laura Merino
- Institute of Biomedicine of Seville (IBiS), University Hospital Virgen del Rocío
| | - Ildefonso Espigado
- Hematology, University Hospital Virgen del Rocío, Institute of Biomedicine of Seville
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Piret J, Boivin G. Antiviral Drugs Against Herpesviruses. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1322:1-30. [PMID: 34258735 DOI: 10.1007/978-981-16-0267-2_1] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The discovery of the nucleoside analogue, acyclovir, represented a milestone in the management of infections caused by herpes simplex virus and varicella-zoster virus. Ganciclovir, another nucleoside analogue, was then used for the management of systemic and organ-specific human cytomegalovirus diseases. The pyrophosphate analogue, foscarnet, and the nucleotide analogue, cidofovir, have been approved subsequently and constitute the second-line antiviral drugs. However, the viral DNA polymerase is the ultimate target of all these antiviral agents with a possible emergence of cross-resistance between these drugs. Recently, letermovir that targets the viral terminase complex was approved for the prophylaxis of human cytomegalovirus infections in hematopoietic stem cell transplant recipients. Other viral targets such as the protein kinase and the helicase-primase complex are also evaluated for the development of novel potent inhibitors against herpesviruses.
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Affiliation(s)
| | - Guy Boivin
- CHU de Québec-Laval University, Quebec City, QC, Canada.
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Mehta Steinke SA, Alfares M, Valsamakis A, Shoham S, Arav-Boger R, Lees L, Ostrander D, Forman MS, Shedeck A, Ambinder RF, Jones RJ, Avery RK. Outcomes of transplant recipients treated with cidofovir for resistant or refractory cytomegalovirus infection. Transpl Infect Dis 2020; 23:e13521. [PMID: 33220125 DOI: 10.1111/tid.13521] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 10/15/2020] [Accepted: 11/01/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Treatment of ganciclovir-resistant (GCV-R)/refractory cytomegalovirus (CMV) infections in blood/marrow transplant (BMT) and solid organ transplant (SOT) recipients remains suboptimal. Cidofovir (CDV), a nucleotide analogue with anti-CMV activity, is nephrotoxic and oculotoxic. METHODS We retrospectively evaluated the outcomes of SOT and BMT patients with GCV-R/refractory CMV treated with CDV between 1/1/2008 and 12/31/2017. DATA COLLECTED baseline demographics, CMV serostatus, clinical and virologic presentations and outcomes, UL97 and UL54 genotype mutations, drug toxicities, and cause of death. Descriptive statistics were used. RESULTS 16 patients received CDV for treatment of CMV: six BMT and 10 SOT. Seven (47%) of the patients had high-risk donor/recipient serostatus: six (60%) SOT were D+/R-; one (16.7%) BMT was D-/R+. Median time to CMV DNAemia was 131 days post-transplant (IQR, 37.5-230.3). Proven tissue invasive disease was present in three patients (18.8%). Twelve (75%) had genotype testing; 10 (83.3%) of those had antiviral resistance mutations. While on CDV, six (37.5%) developed nephrotoxicity, and four (25%) developed uveitis (two had both uveitis and nephrotoxicity). Eight (50%) had failure to clear CMV DNAemia despite CDV treatment. Eight (50%) of the patients died; median time to death, after initiation of CDV, was 33.5 days [IQR22-988]. CONCLUSIONS In the absence of good therapeutic alternatives, CDV is used in GCV-R/refractory CMV infection. However, it is associated with a substantial risk of toxicity and failure to clear CMV DNAemia, highlighting the need for development of newer and less toxic therapies. The high mortality in this group of patients underscores the severity of illness in this population.
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Affiliation(s)
- Seema A Mehta Steinke
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins, Baltimore, MD, USA.,Pueblo Infectious Diseases, PLLC, Pueblo, CO, USA
| | - Mona Alfares
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins, Baltimore, MD, USA
| | - Alexandra Valsamakis
- Division of Medical Microbiology, Department of Pathology, Johns Hopkins, Baltimore, MD, USA.,Roche Molecular Diagnostics, Pleasanton, CA, USA
| | - Shmuel Shoham
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins, Baltimore, MD, USA
| | - Ravit Arav-Boger
- Department of Pediatrics, Johns Hopkins, Baltimore, MD, USA.,Children's Hospital of Wisconsin, Milwaukee, WI, USA
| | - Laura Lees
- Department of Pharmacy, Johns Hopkins, Baltimore, MD, USA
| | - Darin Ostrander
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins, Baltimore, MD, USA
| | - Michael S Forman
- Division of Medical Microbiology, Department of Pathology, Johns Hopkins, Baltimore, MD, USA
| | - Audra Shedeck
- Department of Hematology and Oncology, Johns Hopkins, Baltimore, MD, USA
| | - Richard F Ambinder
- Department of Hematology and Oncology, Johns Hopkins, Baltimore, MD, USA
| | - Richard John Jones
- Department of Hematology and Oncology, Johns Hopkins, Baltimore, MD, USA
| | - Robin K Avery
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins, Baltimore, MD, USA
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28
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A Fine Balance: Using Letermovir for Salvage Antiviral Treatment While Preserving Efficacy. Transplantation 2020; 104:240-241. [PMID: 31356579 DOI: 10.1097/tp.0000000000002885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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29
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Resistant or refractory cytomegalovirus infections after hematopoietic cell transplantation: diagnosis and management. Curr Opin Infect Dis 2020; 32:565-574. [PMID: 31567572 DOI: 10.1097/qco.0000000000000607] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Refractory or resistant cytomegalovirus (CMV) infections are challenging complications after hematopoietic cell transplantation (HCT). Most refractory or resistant CMV infections are associated with poor outcomes and increased mortality. Prompt recognition of resistant or refractory CMV infections, understanding the resistance pathways, and the treatment options in HCT recipients are imperative. RECENT FINDINGS New definitions for refractory and resistant CMV infections in HCT recipients have been introduced for future clinical trials. Interestingly, refractory CMV infections are more commonly encountered in HCT recipients when compared with resistant CMV infections. CMV terminase complex mutations in UL56, UL89, and UL51 could be associated with letermovir resistance; specific mutations in UL56 are the most commonly encountered in clinical practice. Finally, brincidofovir, maribavir, letermovir, and CMV-specific cytotoxic T-cell therapy expanded our treatment options for refractory or resistant CMV infections. SUMMARY Many advances have been made to optimize future clinical trials for management of refractory or resistant CMV infections, and to better understand new resistance mechanisms to novel drugs. New drugs or strategies with limited toxicities are needed to improve outcomes of difficult to treat CMV infections in HCT recipients.
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Abstract
PURPOSE OF REVIEW Cytomegalovirus (CMV) is the most common infection after organ transplant. In addition to causing a viral syndrome and infection, it also increases the risk for complications in the organ transplant, along with higher overall morbidity and mortality. Prevention and ideal treatment of CMV is paramount for optimal outcomes, both for individuals as well as for transplant programs. New guidelines and novel therapies are changing the way we manage disease. RECENT FINDINGS Several new antiviral agents have emerged in recent times, including letermovir, maribavir, and brincidofovir, enhancing our ability to prevent and treat CMV. Recent data on novel agents will be reviewed, with an emphasis on recent guidelines and best practices. SUMMARY Optimal treatment, influenced by recent advances in the field, including management of resistant virus, results in better outcomes with this significant and virulent virus.
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31
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The Cytomegalovirus Protein Kinase pUL97:Host Interactions, Regulatory Mechanisms and Antiviral Drug Targeting. Microorganisms 2020; 8:microorganisms8040515. [PMID: 32260430 PMCID: PMC7232230 DOI: 10.3390/microorganisms8040515] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 04/02/2020] [Accepted: 04/02/2020] [Indexed: 12/25/2022] Open
Abstract
Human cytomegalovirus (HCMV) expresses a variety of viral regulatory proteins that undergo close interaction with host factors including viral-cellular multiprotein complexes. The HCMV protein kinase pUL97 represents a viral cyclin-dependent kinase ortholog (vCDK) that determines the efficiency of HCMV replication via phosphorylation of viral and cellular substrates. A hierarchy of functional importance of individual pUL97-mediated phosphorylation events has been discussed; however, the most pronounced pUL97-dependent phenotype could be assigned to viral nuclear egress, as illustrated by deletion of the UL97 gene or pharmacological pUL97 inhibition. Despite earlier data pointing to a cyclin-independent functionality, experimental evidence increasingly emphasized the role of pUL97-cyclin complexes. Consequently, the knowledge about pUL97 involvement in host interaction, viral nuclear egress and additional replicative steps led to the postulation of pUL97 as an antiviral target. Indeed, validation experiments in vitro and in vivo confirmed the sustainability of this approach. Consequently, current investigations of pUL97 in antiviral treatment go beyond the known pUL97-mediated ganciclovir prodrug activation and henceforward include pUL97-specific kinase inhibitors. Among a number of interesting small molecules analyzed in experimental and preclinical stages, maribavir is presently investigated in clinical studies and, in the near future, might represent a first kinase inhibitor applied in the field of antiviral therapy.
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32
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Mullane KM. Human Cytomegalovirus Prophylaxis and Treatment in Lung Transplantation in the Current Era. CURRENT PULMONOLOGY REPORTS 2020. [DOI: 10.1007/s13665-020-00246-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Oiknine-Djian E, Bar-On S, Laskov I, Lantsberg D, Haynes RK, Panet A, Wolf DG. Artemisone demonstrates synergistic antiviral activity in combination with approved and experimental drugs active against human cytomegalovirus. Antiviral Res 2019; 172:104639. [PMID: 31654672 DOI: 10.1016/j.antiviral.2019.104639] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 10/10/2019] [Accepted: 10/21/2019] [Indexed: 12/30/2022]
Abstract
We have recently shown that the artemisinin derivative artemisone, which was screened against malaria in human clinical studies, is a potent inhibitor of human cytomegalovirus (HCMV). Here we evaluated the antiviral effect of artemisone when employed in 2-drug combinations with approved and experimental anti-HCMV agents. Using the Chou-Talalay method, we found that in-vitro combination of artemisone with cidofovir, brincidofovir, or with the HCMV UL97 inhibitor maribavir resulted in antiviral synergism and the combination of artemisone with ganciclovir or with the viral terminase inhibitors letermovir and BDCRB resulted in moderate synergism. Importantly, the combination of artemisone with maribavir demonstrated synergistic antiviral activity ex-vivo, in a clinically-relevant multicellular model of human placental tissues maintained in organ culture. Our findings provide the basis for the use of artemisone in synergistically acting drug combinations, to enhance viral control and reduce antiviral drug toxicities.
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Affiliation(s)
- Esther Oiknine-Djian
- Clinical Virology Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel; Department of Biochemistry and the Chanock Center for Virology, IMRIC, The Hebrew University Faculty of Medicine, Jerusalem, Israel; The Lautenberg Center for General and Tumor Immunology, IMRIC, The Hebrew University, Israel
| | - Shikma Bar-On
- Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ido Laskov
- Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Daniel Lantsberg
- Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, The Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Richard K Haynes
- Faculty of Health Sciences, North-West University, Potchefstroom, South Africa
| | - Amos Panet
- Department of Biochemistry and the Chanock Center for Virology, IMRIC, The Hebrew University Faculty of Medicine, Jerusalem, Israel
| | - Dana G Wolf
- Clinical Virology Unit, Hadassah Hebrew University Medical Center, Jerusalem, Israel; The Lautenberg Center for General and Tumor Immunology, IMRIC, The Hebrew University, Israel.
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Chou S, Wu J, Song K, Bo T. Novel UL97 drug resistance mutations identified at baseline in a clinical trial of maribavir for resistant or refractory cytomegalovirus infection. Antiviral Res 2019; 172:104616. [PMID: 31568799 DOI: 10.1016/j.antiviral.2019.104616] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 09/26/2019] [Accepted: 09/26/2019] [Indexed: 12/27/2022]
Abstract
In a Phase 2 clinical trial, 120 subjects with cytomegalovirus (CMV) infection refractory or resistant to standard therapy were randomized equally to 3 doses of oral maribavir treatment, and 70% achieved undetectable plasma CMV DNA within 12 weeks. At study entry, standard diagnostic UL97 genotyping was available for 71 subjects, with 60 (85%) revealing well-characterized ganciclovir resistance mutations that did not preclude a therapeutic response to maribavir. Central laboratory testing of a range of UL97 codons (288-468) not fully covered by standard genotyping was done on 93 subjects at baseline. This detected no previously known maribavir resistance mutations, but identified atypical mutations in 3 subjects, including a P-loop substitution F342Y, and ATP-binding region substitutions K359E/Q. By recombinant phenotyping, K359E and K359Q each conferred a nearly 4-fold increased ganciclovir 50% inhibitory concentration (EC50) without maribavir resistance, whereas F342Y conferred a 6-fold increased ganciclovir EC50 and a 4.5-fold increased maribavir EC50. The subject with F342Y detected at baseline did not achieve plasma CMV DNA clearance after 12 weeks of maribavir therapy and later developed an additional UL97 substitution H411Y known to confer 12- to 20-fold increased MBV EC50 by itself. The combination of F342Y and H411Y was shown to increase the maribavir EC50 by 56-fold. Diagnostic genotyping of UL97 should be expanded to cover the ATP-binding region beginning at codon 335 to enable the detection of atypical resistance mutations and further correlation of their clinical significance.
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Affiliation(s)
- Sunwen Chou
- Division of Infectious Diseases, Oregon Health and Science University, Department of Veterans Affairs Medical Center, Portland, Oregon, USA.
| | | | | | - Tien Bo
- Shire, a Takeda Company, Lexington, MA, USA
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35
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El Helou G, Razonable RR. Safety considerations with current and emerging antiviral therapies for cytomegalovirus infection in transplantation. Expert Opin Drug Saf 2019; 18:1017-1030. [PMID: 31478398 DOI: 10.1080/14740338.2019.1662787] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Introduction: Human cytomegalovirus (HCMV) is a major contributor of morbidity and mortality, and its management is essential for the successful outcome of solid organ and hematopoietic stem cell transplantation. Areas covered: This review discusses the safety profiles of currently available and emerging antiviral drugs and the other strategies for HCMV prevention and treatment after transplantation. Expert opinion: Strategies for management of HCMV rely largely on the use of antiviral agents that inhibit viral DNA polymerase (ganciclovir/valganciclovir, foscarnet, and cidofovir/brincidofovir) and viral terminase complex (letermovir), with different types and degrees of adverse effects. An investigational agent, maribavir, exerts its anti-CMV effect through UL97 inhibition, and its safety profile is under clinical evaluation. In choosing the antiviral medication to use, it is important to consider these safety profiles in addition to overall efficacy. In addition to antiviral drugs, reduction of immunosuppression is often generally needed in the management of HCMV infection, but with a potential risk of allograft rejection or graft-versus-host disease. The use of HCMV-specific or non-specific intravenous immunoglobulins remains debated, while adoptive HCMV-specific T cell therapy remains investigational, and associated with unique set of adverse effects.
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Affiliation(s)
- Guy El Helou
- Division of Infectious Diseases, Department of Medicine, and William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic College of Medicine and Science , Rochester , MN , USA
| | - Raymund R Razonable
- Division of Infectious Diseases, Department of Medicine, and William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic College of Medicine and Science , Rochester , MN , USA
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36
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El Helou G, Razonable RR. Letermovir for the prevention of cytomegalovirus infection and disease in transplant recipients: an evidence-based review. Infect Drug Resist 2019; 12:1481-1491. [PMID: 31239725 PMCID: PMC6556539 DOI: 10.2147/idr.s180908] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 04/08/2019] [Indexed: 12/12/2022] Open
Abstract
Cytomegalovirus (CMV) is a leading opportunistic infection in immune compromised patients, including allogeneic hematopoietic stem cell (HSCT) or solid organ transplant (SOT) recipients, where primary infection or reactivation is associated with increased morbidity and mortality. Antiviral drugs are the mainstay for the prevention of CMV infection and disease, most commonly with valganciclovir. However, valganciclovir use is often associated with adverse drug reactions, most notably leukopenia and neutropenia, and its widespread use has led to emergence of antiviral resistance. Foscarnet and cidofovir, however, are associated with nephrotoxicity. Letermovir, a novel CMV viral terminase inhibitor drug, was recently approved for CMV prophylaxis in allogeneic HSCT recipients. It has a favorable pharmacokinetic and tolerability profile. The aim of this paper is to review the evidence supporting the use of letermovir in allogeneic HSCT recipients, and how the drug impacts our contemporary clinical practice. In addition, we discuss the ongoing clinical trial of letermovir for the prevention of CMV in SOT recipients. The use of letermovir for treatment of CMV infection and disease is not yet approved. However, because of a unique mechanism of activity, we provide our perspective on the potential role of letermovir in the treatment of ganciclovir-resistant CMV infection and disease. Furthermore, drug-resistant CMV has emerged during use of letermovir for prophylaxis and treatment. Caution is advised on its use in order to preserve its therapeutic lifespan.
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Affiliation(s)
- Guy El Helou
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA.,William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA
| | - Raymund R Razonable
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA.,William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN, USA
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37
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Guglieri-Lopez B, Perez-Pitarch A, Garcia-Cadenas I, Gimenez E, Barba P, Rabella N, Hernandez-Boluda JC, Fox L, Valcarcel D, Esquirol A, Ferriols-Lisart R, Sierra J, Solano C, Navarro D, Martino R, Piñana JL. Effect of Sirolimus Exposure on the Need for Preemptive Antiviral Therapy for Cytomeglovirus Infection after Allogeneic Hematopoietic Stem Cell Transplantation. Biol Blood Marrow Transplant 2019; 25:1022-1030. [DOI: 10.1016/j.bbmt.2019.01.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 01/04/2019] [Indexed: 11/16/2022]
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38
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Piret J, Boivin G. Clinical development of letermovir and maribavir: Overview of human cytomegalovirus drug resistance. Antiviral Res 2019; 163:91-105. [PMID: 30690043 DOI: 10.1016/j.antiviral.2019.01.011] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 01/17/2019] [Accepted: 01/18/2019] [Indexed: 01/28/2023]
Abstract
The prevention and treatment of human cytomegalovirus (HCMV) infections is based on the use of antiviral agents that currently target the viral DNA polymerase and that may cause serious side effects. The search for novel inhibitors against HCMV infection led to the discovery of new molecular targets, the viral terminase complex and the viral pUL97 kinase. The most advanced compounds consist of letermovir (LMV) and maribavir (MBV). LMV inhibits the cleavage of viral DNA and its packaging into capsids by targeting the HCMV terminase complex. LMV is safe and well tolerated and exhibits pharmacokinetic properties that allow once daily dosing. LMV showed efficacy in a phase III prophylaxis study in hematopoietic stem cell transplant (HSCT) recipients seropositive for HCMV. LMV was recently approved under the trade name Prevymis™ for prophylaxis of HCMV infection in adult seropositive recipients of an allogeneic HSCT. Amino acid substitutions conferring resistance to LMV selected in vitro map primarily to the pUL56 and rarely to the pUL89 and pUL51 subunits of the HCMV terminase complex. MBV is an inhibitor of the viral pUL97 kinase activity and interferes with the morphogenesis and nuclear egress of nascent viral particles. MBV is safe and well tolerated and has an excellent oral bioavailability. MBV was effective for the treatment of HCMV infections (including those that are refractory or drug-resistant) in transplant recipients in two phase II studies and is further evaluated in two phase III trials. Mutations conferring resistance to MBV map to the UL97 gene and can cause cross-resistance to ganciclovir. MBV-resistant mutations also emerged in the UL27 gene in vitro and could compensate for the inhibition of pUL97 kinase activity by MBV. Thus, LMV and probably MBV will broaden the armamentarium of antiviral drugs available for the prevention and treatment of HCMV infections.
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Affiliation(s)
- Jocelyne Piret
- Research Center in Infectious Diseases, CHU of Quebec and Laval University, Quebec City, QC, Canada
| | - Guy Boivin
- Research Center in Infectious Diseases, CHU of Quebec and Laval University, Quebec City, QC, Canada.
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