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Batool S, Chokkakula S, Song MS. Influenza Treatment: Limitations of Antiviral Therapy and Advantages of Drug Combination Therapy. Microorganisms 2023; 11. [PMID: 36677475 DOI: 10.3390/microorganisms11010183] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 12/23/2022] [Accepted: 01/09/2023] [Indexed: 01/15/2023] Open
Abstract
Influenza infection is serious and debilitating for humans and animals. The influenza virus undergoes incessant mutation, segment recombination, and genome reassortment. As a result, new epidemics and pandemics are expected to emerge, making the elimination challenging of the disease. Antiviral therapy has been used for the treatment of influenza since the development of amantadine in the 1960s; however, its use is hampered by the emergence of novel strains and the development of drug resistance. Thus, combinational therapy with two or more antivirals or immunomodulators with different modes of action is the optimal strategy for the effective treatment of influenza infection. In this review, we describe current options for combination therapy, their performance, and constraints imposed by resistance, calling attention to the advantages of combination therapy against severe influenza infections. We also discuss the challenges of influenza therapy and the limitations of approved antiviral drugs.
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Santos IA, Pereira AKDS, Guevara-Vega M, de Paiva REF, Sabino-Silva R, Bergamini FRG, Corbi PP, Jardim ACG. Repurposing potential of rimantadine hydrochloride and development of a promising platinum(II)-rimantadine metallodrug for the treatment of Chikungunya virus infection. Acta Trop 2022; 227:106300. [PMID: 34979144 DOI: 10.1016/j.actatropica.2021.106300] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 12/23/2021] [Accepted: 12/29/2021] [Indexed: 11/15/2022]
Abstract
Most of the patients infected with Chikungunya virus (CHIKV) develop chronic manifestations characterized by pain and deformity in joints, impacting their quality of life. The aminoadamantanes, in their turn, have been exploited due to their biological activities, with amantadine and memantine recently described with anti-CHIKV activities. Here we evaluated the antiviral activity of rimantadine hydrochloride (rtdH), a well-known antiviral agent against influenza A, its platinum complex (Pt-rtd), and the precursor cis-[PtCl2(dmso)2], against CHIKV infection in vitro. The rtdH demonstrated significant antiviral activity in all stages of CHIKV replication (29% in pre-treatment; 57% in early stages of infection; 60% in post-entry stages). The Pt-rtd complex protected the cells against infection in 92%, inhibited 100% of viral entry, mainly by a virucidal effect, and impaired 60% of post-entry stages. Alternatively, cis-[PtCl2(dmso)2] impaired viral entry in 100% and post-entry steps in 60%, but had no effect in protecting cells when administered prior to CHIKV infection. Collectively, the obtained data demonstrated that rtdH and Pt-rtd significantly interfered in the early stages of CHIKV life cycle, with the strongest effect observed to Pt-rtd complex, which reduced up to 100% of CHIKV infection. Moreover, molecular docking analysis and infrared spectroscopy data (ATR-FTIR) suggest an interaction of Pt-rtd with CHIKV glycoproteins, potentially related to the mechanism of inhibition of viral entry by Pt-rtd. Through a migration retardation assay, it was also shown that Pt-rtd and cis-[PtCl2(dmso)2] interacted with the dsRNA in 87% and 100%, respectively. The obtained results highlight the repurposing potential of rtdH as an anti-CHIKV drug, as well as the synthesis of promising platinum(II) metallodrugs with potential application for the treatment of CHIKV infections. Importance Chikungunya fever is a disease that can result in persistent symptoms due to the chronic infection process. Infected patients can develop physical disability, resulting and high costs to the health system and significant impacts on the quality of life of affected individuals. Additionally, there are no licensed vaccines or antivirals against the Chikungunya virus (CHIKV) and the virus is easily transmitted due to the abundance of viable vectors in epidemic regions. In this context, our study highlights the repurposing potential of the commercial drug rimantadine hydrochloride (rtdH) as an antiviral agent for the treatment of CHIKV infections. Moreover, our data demonstrated that a platinum(II)-rimantadine metallodrug (Pt-rtd) poses as a potent anti-CHIKV molecule with potential application for the treatment of Chikungunya fever. Altogether, rtdH and Pt-rtd significantly interfered in the early stages of CHIKV life cycle, reducing up to 100% of CHIKV infection in vitro.
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Affiliation(s)
- Igor Andrade Santos
- Laboratory of Virology, Institute of Biomedical Sciences, Federal University of Uberlândia, Uberlândia-MG 38405-302, Brazil
| | | | - Marco Guevara-Vega
- Innovation Center in Salivary Diagnostic and Nanotheranostics, Department of Physiology, Institute of Biomedical Sciences, Federal University of Uberlandia, Minas Gerais, Brazil
| | | | - Robinson Sabino-Silva
- Innovation Center in Salivary Diagnostic and Nanotheranostics, Department of Physiology, Institute of Biomedical Sciences, Federal University of Uberlandia, Minas Gerais, Brazil
| | - Fernando R G Bergamini
- Laboratory of Synthesis of Bioinspired Molecules, Institute of Chemistry, Federal University of Uberlândia, Uberlândia-MG 34000-902, Brazil.
| | - Pedro P Corbi
- Institute of Chemistry, University of Campinas-UNICAMP, Campinas-SP 13083-871, Brazil.
| | - Ana Carolina G Jardim
- Laboratory of Virology, Institute of Biomedical Sciences, Federal University of Uberlândia, Uberlândia-MG 38405-302, Brazil; Institute of Biosciences, Humanities and Exact Sciences (Ibilce), São Paulo State University (Unesp), Campus São José do Rio Preto, São José do Rio Preto, São Paulo, Brazil.
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Ji S, Bai Q, Wu X, Zhang DW, Wang S, Shen JL, Fei GH. Unique synergistic antiviral effects of Shufeng Jiedu Capsule and oseltamivir in influenza A viral-induced acute exacerbation of chronic obstructive pulmonary disease. Biomed Pharmacother 2019; 121:109652. [PMID: 31734578 DOI: 10.1016/j.biopha.2019.109652] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Revised: 10/25/2019] [Accepted: 11/06/2019] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND The aim of the present study was to investigate the synergistic effects and interactive mechanisms of Shufeng Jiedu Capsule (SFJDC) combined with oseltamivir in the treatment of acute exacerbation of chronic obstructive pulmonary disease (AECOPD) induced by the influenza A virus (IAV). METHODS The extraction of SFJDC was analyzed by UHPLC/ESI Q-Orbitrap Mass Spectrometry. Human bronchial epithelial cells were isolated from COPD (DHBE) bronchial tissues, co-cultured with IAV for 24 h, and were subsequently treated with SFJDC and/or oseltamivir. Cell viability was detected by MTT assay. A rat model of COPD with IAV infection was established and treated with SFJDC and/or oseltamivir. Interleukin (IL)-1β and IL-18 in serum and bronchoalveolar lavage fluid (BALF) were measured by ELISA. Additionally, mRNA and protein levels of NLRP3 inflammasome pathway were measured by quantitative real-time PCR and Western blotting, respectively. RESULTS SFJDC and/or oseltamivir, at their optimal concentrations, had no significant cytotoxicity against DHBEs. The levels of NLRP3-inflammasome-associated components were significantly elevated after cells were inoculated with IAV, whereas the mRNA and protein levels of these components were significantly decreased after treatment with SFJDC and/or oseltamivir in vitro. Moreover, in vivo, the combination of SFJDC and oseltamivir improved survival rates, attenuated clinical symptoms, induced weight gain, alleviated lung damage, and significantly reduced IL-1β and IL-18 levels in serum and BALF, as well as reduced the expression levels of NLRP3-associated components and viral titers in lung homogenates. CONCLUSION SFJDC combined with oseltamivir treatment significantly attenuated IAV-induced airway inflammation and lung viral titers. Hence, our findings may provide a novel therapeutic strategy for IAV-induced respiratory infection.
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Affiliation(s)
- Shuang Ji
- Department of Respiratory and Critical Care Medicine, First Affiliated Hospital of Anhui Medical University, Hefei, 230022, Anhui Province, PR China
| | - Qin Bai
- Department of Respiratory and Critical Care Medicine, First Affiliated Hospital of Anhui Medical University, Hefei, 230022, Anhui Province, PR China
| | - Xu Wu
- Department of Respiratory and Critical Care Medicine, First Affiliated Hospital of Anhui Medical University, Hefei, 230022, Anhui Province, PR China
| | - Da-Wei Zhang
- Department of Respiratory and Critical Care Medicine, First Affiliated Hospital of Anhui Medical University, Hefei, 230022, Anhui Province, PR China
| | - Sheng Wang
- The Center for Scientific Research of Anhui Medical University, Hefei, 230032, Anhui Province, PR China
| | - Ji-Long Shen
- Department of Pathogen Biology and Provincial Laboratories of Pathogen Biology and Zoonoses, Anhui Medical University, Hefei, 230032, Anhui Province, PR China
| | - Guang-He Fei
- Department of Respiratory and Critical Care Medicine, First Affiliated Hospital of Anhui Medical University, Hefei, 230022, Anhui Province, PR China.
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Melville K, Rodriguez T, Dobrovolny HM. Investigating Different Mechanisms of Action in Combination Therapy for Influenza. Front Pharmacol 2018; 9:1207. [PMID: 30405419 PMCID: PMC6206389 DOI: 10.3389/fphar.2018.01207] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [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: 06/29/2018] [Accepted: 10/03/2018] [Indexed: 01/15/2023] Open
Abstract
Combination therapy for influenza can have several benefits, from reducing the emergence of drug resistant virus strains to decreasing the cost of antivirals. However, there are currently only two classes of antivirals approved for use against influenza, limiting the possible combinations that can be considered for treatment. However, new antivirals are being developed that target different parts of the viral replication cycle, and their potential for use in combination therapy should be considered. The role of antiviral mechanism of action in the effectiveness of combination therapy has not yet been systematically investigated to determine whether certain antiviral mechanisms of action pair well in combination. Here, we use a mathematical model of influenza to model combination treatment with antivirals having different mechanisms of action to measure peak viral load, infection duration, and synergy of different drug combinations. We find that antivirals that lower the infection rate and antivirals that increase the duration of the eclipse phase perform poorly in combination with other antivirals.
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Affiliation(s)
- Kelli Melville
- Physics Department, East Carolina University, Greenville, NC, United States
| | - Thalia Rodriguez
- Department of Physics and Astronomy, Texas Christian University, Fort Worth, TX, United States
| | - Hana M. Dobrovolny
- Department of Physics and Astronomy, Texas Christian University, Fort Worth, TX, United States
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Ma C, Zhang J, Wang J. Pharmacological Characterization of the Spectrum of Antiviral Activity and Genetic Barrier to Drug Resistance of M2-S31N Channel Blockers. Mol Pharmacol 2016; 90:188-98. [PMID: 27385729 DOI: 10.1124/mol.116.105346] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 06/30/2016] [Indexed: 12/11/2022] Open
Abstract
Adamantanes (amantadine and rimantadine) are one of the two classes of Food and Drug Administration-approved antiviral drugs used for the prevention and treatment of influenza A virus infections. They inhibit viral replication by blocking the wild-type (WT) M2 proton channel, thus preventing viral uncoating. However, their use was discontinued due to widespread drug resistance. Among a handful of drug-resistant mutants, M2-S31N is the predominant mutation and persists in more than 95% of currently circulating influenza A strains. We recently designed two classes of M2-S31N inhibitors, S31N-specific inhibitors and S31N/WT dual inhibitors, which are represented by N-[(5-cyclopropyl-1,2-oxazol-3-yl)methyl]adamantan-1-amine (WJ379) and N-[(5-bromothiophen-2-yl)methyl]adamantan-1-amine (BC035), respectively. However, their antiviral activities against currently circulating influenza A viruses and their genetic barrier to drug resistance are unknown. In this report, we evaluated the therapeutic potential of these two classes of M2-S31N inhibitors (WJ379 and BC035) by profiling their antiviral efficacy against multidrug-resistant influenza A viruses, in vitro drug resistance barrier, and synergistic effect with oseltamivir. We found that M2-S31N inhibitors were active against several influenza A viruses that are resistant to one or both classes of Food and Drug Administration-approved anti-influenza drugs. In addition, M2-S31N inhibitors display a higher in vitro genetic barrier to drug resistance than amantadine. The antiviral effect of WJ379 was also synergistic with oseltamivir carboxylate. Overall, these results reaffirm that M2-S31N inhibitors are promising antiviral drug candidates that warrant further development.
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Affiliation(s)
- Chunlong Ma
- Department of Pharmacology and Toxicology, College of Pharmacy, and BIO5 Institute, University of Arizona, Tucson, Arizona
| | - Jiantao Zhang
- Department of Pharmacology and Toxicology, College of Pharmacy, and BIO5 Institute, University of Arizona, Tucson, Arizona
| | - Jun Wang
- Department of Pharmacology and Toxicology, College of Pharmacy, and BIO5 Institute, University of Arizona, Tucson, Arizona
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Marathe BM, Wong SS, Vogel P, Garcia-Alcalde F, Webster RG, Webby RJ, Najera I, Govorkova EA. Combinations of Oseltamivir and T-705 Extend the Treatment Window for Highly Pathogenic Influenza A(H5N1) Virus Infection in Mice. Sci Rep 2016; 6:26742. [PMID: 27221530 PMCID: PMC4879667 DOI: 10.1038/srep26742] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 04/25/2016] [Indexed: 12/23/2022] Open
Abstract
Current anti-influenza therapy depends on administering drugs soon after infection, which is often impractical. We assessed whether combinations of oseltamivir (a neuraminidase inhibitor) and T-705 (a nonspecific inhibitor of viral polymerases) could extend the window for treating lethal infection with highly pathogenic A(H5N1) influenza virus in mice. Combination therapy protected 100% of mice, even when delayed until 96 h postinoculation. Compared to animals receiving monotherapy, mice receiving combination therapy had reduced viral loads and restricted viral spread in lung tissues, limited lung damage, and decreased inflammatory cytokine production. Next-generation sequencing showed that virus populations in T-705–treated mice had greater genetic variability, with more frequent transversion events, than did populations in control and oseltamivir-treated mice, but no substitutions associated with resistance to oseltamivir or T-705 were detected. Thus, combination therapy extended the treatment window for A(H5N1) influenza infection in mice and should be considered for evaluation in a clinical setting.
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Affiliation(s)
- Bindumadhav M Marathe
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee, United States
| | - Sook-San Wong
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee, United States
| | - Peter Vogel
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee, United States
| | - Fernando Garcia-Alcalde
- Roche Pharma Research and Early Development, Infectious Diseases, Roche Innovation Center Basel, F. Hoffmann-La Roche Ltd., Basel, Switzerland
| | - Robert G Webster
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee, United States
| | - Richard J Webby
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee, United States
| | - Isabel Najera
- Roche Pharma Research and Early Development, Infectious Diseases, Roche Innovation Center Basel, F. Hoffmann-La Roche Ltd., Basel, Switzerland
| | - Elena A Govorkova
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee, United States
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Alame MM, Massaad E, Zaraket H. Peramivir: A Novel Intravenous Neuraminidase Inhibitor for Treatment of Acute Influenza Infections. Front Microbiol 2016; 7:450. [PMID: 27065996 PMCID: PMC4815007 DOI: 10.3389/fmicb.2016.00450] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [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: 01/14/2016] [Accepted: 03/21/2016] [Indexed: 12/20/2022] Open
Abstract
Peramivir is a novel cyclopentane neuraminidase inhibitor of influenza virus. It was approved by the Food and Drug Administration in December 2014 for treatment of acute uncomplicated influenza in patients 18 years and older. For several months prior to approval, the drug was made clinically available under Emergency Use authorization during the 2009 H1N1 influenza pandemic. Peramivir is highly effective against human influenza A and B isolates as well as emerging influenza virus strains with pandemic potential. Clinical trials demonstrated that the drug is well-tolerated in adult and pediatric populations. Adverse events are generally mild to moderate and similar in frequency to patients receiving placebo. Common side effects include gastrointestinal disorders and decreased neutrophil counts but are self-limiting. Peramivir is administered as a single-dose via the intravenous route providing a valuable therapeutic alternative for critically ill patients or those unable to tolerate other administration routes. Successful clinical trials and post-marketing data in pediatric populations in Japan support the safety and efficacy of peramivir in this population where administration of other antivirals might not be feasible.
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Affiliation(s)
- Malak M Alame
- The School of Pharmacy, Lebanese International University Beirut, Lebanon
| | - Elie Massaad
- Department of Experimental Pathology, Immunology, and Microbiology, Faculty of Medicine, American University of Beirut Beirut, Lebanon
| | - Hassan Zaraket
- Department of Experimental Pathology, Immunology, and Microbiology, Faculty of Medicine, American University of BeirutBeirut, Lebanon; Center for Infectious Diseases Research, Faculty of Medicine, American University of BeirutBeirut, Lebanon
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Aoki FY. Antiviral Drugs for Influenza and Other Respiratory Virus Infections. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. Elsevier; 2015. pp. 531-545.e5. [DOI: 10.1016/b978-1-4557-4801-3.00044-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Kelesidis T, Mastoris I, Metsini A, Tsiodras S. How to approach and treat viral infections in ICU patients. BMC Infect Dis 2014; 14:321. [PMID: 25431007 PMCID: PMC4289200 DOI: 10.1186/1471-2334-14-321] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Accepted: 06/11/2014] [Indexed: 12/21/2022] Open
Abstract
Patients with severe viral infections are often hospitalized in intensive care units (ICUs) and recent studies underline the frequency of viral detection in ICU patients. Viral infections in the ICU often involve the respiratory or the central nervous system and can cause significant morbidity and mortality especially in immunocompromised patients. The mainstay of therapy of viral infections is supportive care and antiviral therapy when available. Increased understanding of the molecular mechanisms of viral infection has provided great potential for the discovery of new antiviral agents that target viral proteins or host proteins that regulate immunity and are involved in the viral life cycle. These novel treatments need to be further validated in animal and human randomized controlled studies.
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Affiliation(s)
| | | | | | - Sotirios Tsiodras
- 4th Department of Internal Medicine, Attikon University Hospital, National and Kapodistrian University of Athens School of Medicine, 1 Rimini Street, GR-12462 Haidari, Athens, Greece.
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Abstract
BACKGROUND Influenza is an acute respiratory illness caused by influenza A and B viruses. Complications may occur, especially among children and the elderly. OBJECTIVES To assess the effectiveness and safety of amantadine and rimantadine in preventing, treating and shortening the duration of influenza A in children and the elderly. SEARCH METHODS We searched CENTRAL (2014, Issue 9), MEDLINE (1966 to September week 4, 2014) and EMBASE (1980 to October 2014). SELECTION CRITERIA Randomised controlled trials (RCTs) or quasi-RCTs comparing amantadine and/or rimantadine with no intervention, placebo, other antivirals or different doses or schedules of amantadine or rimantadine in children and the elderly with influenza A. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the search results. We extracted and analysed data using the standard Cochrane methodology. MAIN RESULTS We identified 12 studies (2494 participants: 1586 children and 908 elderly) comparing amantadine and rimantadine with placebo, paracetamol (one trial: 69 children) or zanamivir (two trials: 545 elderly) to treat influenza A.Amantadine was effective in preventing influenza A in children (773 participants, risk ratio (RR) 0.11; 95% confidence interval (CI) 0.04 to 0.30). The assumed risk of influenza A in the control group was 10 per 100. The corresponding risk in the rimantadine group was one per 100 (95% CI 0 to 3). Nevertheless, the quality of the evidence was low and the safety of the drug was not well established.For treatment, rimantadine was beneficial in abating fever on day three of treatment in children: one selected study with low risk of bias, moderate evidence quality and 69 participants (RR 0.36; 95% CI 0.14 to 0.91). The assumed risk was 38 per 100. The corresponding risk in the rimantadine group was 14 per 100 (95% CI 5 to 34).Rimantadine did not show any prophylactic effect in the elderly. The quality of evidence was very low: 103 participants (RR 0.45; 95% CI 0.14 to 1.41). The assumed risk was 17 per 100. The corresponding risk in the rimantadine group was 7 per 100 (95% CI 2 to 23).There was no evidence of adverse effects caused by treatment with amantadine or rimantadine.We found no studies assessing amantadine in the elderly. AUTHORS' CONCLUSIONS The quality of the evidence combined with a lack of knowledge about the safety of amantadine and the limited benefits of rimantadine, do not indicate that amantadine and rimantadine compared to control (placebo or paracetamol) could be useful in preventing, treating and shortening the duration of influenza A in children and the elderly.
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Affiliation(s)
- Márcia G Alves Galvão
- Municipal Secretariat of HealthAvenida Ayrton Senna, 250/ 205Barra da Tijuca. Alfa Barra 1Rio de JaneiroRJBrazil22793‐000
| | | | - Antonio JL Alves da Cunha
- School of Medicine, Federal University of Rio de JaneiroDepartment of PediatricsAv. Carlos Chagas Filho, 373Edificio do CCS ‐ Bloco K ‐ 2o. andar, Sala K49Rio de JaneiroRio de JaneiroBrazil21941‐902
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Dunning J, Baillie JK, Cao B, Hayden FG; International Severe Acute Respiratory and Emerging Infection Consortium (ISARIC). Antiviral combinations for severe influenza. Lancet Infect Dis 2014; 14:1259-70. [PMID: 25213733 DOI: 10.1016/S1473-3099(14)70821-7] [Citation(s) in RCA: 144] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Observational data suggest that the treatment of influenza infection with neuraminidase inhibitors decreases progression to more severe illness, especially when treatment is started soon after symptom onset. However, even early treatment might fail to prevent complications in some patients, particularly those infected with novel viruses such as the 2009 pandemic influenza A H1N1, avian influenza A H5N1 virus subtype, or the avian influenza A H7N9 virus subtype. Furthermore, treatment with one antiviral drug might promote the development of antiviral resistance, especially in immunocompromised hosts and critically ill patients. An obvious strategy to optimise antiviral therapy is to combine drugs with different modes of action. Because host immune responses to infection might also contribute to illness pathogenesis, improved outcomes might be gained from the combination of antiviral therapy with drugs that modulate the immune response in an infected individual. We review available data from preclinical and clinical studies of combination antiviral therapy and of combined antiviral-immunomodulator therapy for influenza. Early-stage data draw attention to several promising antiviral combinations with therapeutic potential in severe infections, but there remains a need to substantiate clinical benefit. Combination therapies with favourable experimental data need to be tested in carefully designed aclinical trials to assess their efficacy.
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Park S, Kim JI, Lee I, Lee S, Hwang MW, Bae JY, Heo J, Kim D, Jang SI, Kim H, Cheong HJ, Song JW, Song KJ, Baek LJ, Park MS. Combination effects of peramivir and favipiravir against oseltamivir-resistant 2009 pandemic influenza A(H1N1) infection in mice. PLoS One 2014; 9:e101325. [PMID: 24992479 PMCID: PMC4081560 DOI: 10.1371/journal.pone.0101325] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [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] [Received: 03/21/2014] [Accepted: 06/04/2014] [Indexed: 12/18/2022] Open
Abstract
Antiviral drugs are being used for therapeutic purposes against influenza illness in humans. However, antiviral-resistant variants often nullify the effectiveness of antivirals. Combined medications, as seen in the treatment of cancers and other infectious diseases, have been suggested as an option for the control of antiviral-resistant influenza viruses. Here, we evaluated the therapeutic value of combination therapy against oseltamivir-resistant 2009 pandemic influenza H1N1 virus infection in DBA/2 mice. Mice were treated for five days with favipiravir and peramivir starting 4 hours after lethal challenge. Compared with either monotherapy, combination therapy saved more mice from viral lethality and resulted in increased antiviral efficacy in the lungs of infected mice. Furthermore, the synergism between the two antivirals, which was consistent with the survival outcomes of combination therapy, indicated that favipiravir could serve as a critical agent of combination therapy for the control of oseltamivir-resistant strains. Our results provide new insight into the feasibility of favipiravir in combination therapy against oseltamivir-resistant influenza virus infection.
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Affiliation(s)
- Sehee Park
- Department of Microbiology, College of Medicine, and the Institute for Viral Diseases, Korea University, Seoul, Republic of Korea; Department of Microbiology, College of Medicine, Hallym University, Chuncheon, Gangwon-do, Republic of Korea
| | - Jin Il Kim
- Department of Microbiology, College of Medicine, and the Institute for Viral Diseases, Korea University, Seoul, Republic of Korea; Department of Microbiology, College of Medicine, Hallym University, Chuncheon, Gangwon-do, Republic of Korea
| | - Ilseob Lee
- Department of Microbiology, College of Medicine, and the Institute for Viral Diseases, Korea University, Seoul, Republic of Korea; Department of Microbiology, College of Medicine, Hallym University, Chuncheon, Gangwon-do, Republic of Korea
| | - Sangmoo Lee
- Department of Microbiology, College of Medicine, and the Institute for Viral Diseases, Korea University, Seoul, Republic of Korea; Department of Microbiology, College of Medicine, Hallym University, Chuncheon, Gangwon-do, Republic of Korea
| | - Min-Woong Hwang
- Department of Microbiology, College of Medicine, and the Institute for Viral Diseases, Korea University, Seoul, Republic of Korea; Department of Microbiology, College of Medicine, Hallym University, Chuncheon, Gangwon-do, Republic of Korea
| | - Joon-Yong Bae
- Department of Microbiology, College of Medicine, and the Institute for Viral Diseases, Korea University, Seoul, Republic of Korea; Department of Microbiology, College of Medicine, Hallym University, Chuncheon, Gangwon-do, Republic of Korea
| | - Jun Heo
- Department of Microbiology, College of Medicine, and the Institute for Viral Diseases, Korea University, Seoul, Republic of Korea; Department of Microbiology, College of Medicine, Hallym University, Chuncheon, Gangwon-do, Republic of Korea
| | - Donghwan Kim
- Department of Microbiology, College of Medicine, Hallym University, Chuncheon, Gangwon-do, Republic of Korea
| | - Seok-Il Jang
- Department of Microbiology, College of Medicine, Hallym University, Chuncheon, Gangwon-do, Republic of Korea
| | - Hyejin Kim
- Department of Microbiology, College of Medicine, and the Institute for Viral Diseases, Korea University, Seoul, Republic of Korea
| | - Hee Jin Cheong
- Division of Infectious Diseases, Korea University Guro Hospital, College of Medicine, Korea University, Seoul, Republic of Korea
| | - Jin-Won Song
- Department of Microbiology, College of Medicine, and the Institute for Viral Diseases, Korea University, Seoul, Republic of Korea
| | - Ki-Joon Song
- Department of Microbiology, College of Medicine, and the Institute for Viral Diseases, Korea University, Seoul, Republic of Korea
| | - Luck Ju Baek
- Department of Microbiology, College of Medicine, and the Institute for Viral Diseases, Korea University, Seoul, Republic of Korea
| | - Man-Seong Park
- Department of Microbiology, College of Medicine, and the Institute for Viral Diseases, Korea University, Seoul, Republic of Korea; Department of Microbiology, College of Medicine, Hallym University, Chuncheon, Gangwon-do, Republic of Korea
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Chairat K, Tarning J, White NJ, Lindegardh N. Pharmacokinetic properties of anti-influenza neuraminidase inhibitors. J Clin Pharmacol 2013; 53:119-39. [PMID: 23436258 DOI: 10.1177/0091270012440280] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2011] [Accepted: 11/09/2011] [Indexed: 01/21/2023]
Abstract
Neuraminidase inhibitors are the mainstay of anti-influenza treatment. Oseltamivir is the most widely used drug but is currently available only as an oral formulation. Resistance spreads rapidly in seasonal H1N1 influenza A viruses, which were universally resistant in 2008, because of the H275Y mutation in the neuraminidase (NA) gene. Oseltamivir is a prodrug for the active carboxylate metabolite. Ex vivo conversion in blood samples may have confounded early pharmacokinetic studies. Oseltamivir shows dose linear kinetics, and oseltamivir carboxylate has an elimination half-life (t(1/2) β) after oral administration in healthy individuals of approximately 7.7 hours. Oseltamivir carboxylate is eliminated primarily by tubular secretion, and both clearance and tissue distribution are reduced by probenecid. The H275Y mutation in NA confers high-level oseltamivir resistance and intermediate peramivir resistance but does not alter zanamivir susceptibility. Zanamivir is available as a powder for inhalation, and a parenteral form is under development. Zanamivir distributes in an apparent volume of distribution approximating that of extracellular water and is rapidly eliminated (t(1/2) β of approximately 3.0 hours). Peramivir is slowly eliminated (t(1/2) β of 7.7-20.8 hours) and is prescribed as either a once-daily injection or as a single infusion. Laninamivir is a recently developed slowly eliminated compound for administration by inhalation.
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Affiliation(s)
- Kalayanee Chairat
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
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15
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Abstract
Antiviral drugs for influenza therapy and prophylaxis are either of the adamantane or neuraminidase inhibitor (NAI) class. However, the NAIs are mainly prescribed nowadays, because of widespread adamantane resistance among influenza A viruses and ineffectiveness of adamantanes against influenza B. Emergence and spread of NAI resistance would further limit our therapeutic options. Taking into account the previous spread of oseltamivir-resistant viruses during the 2007/2008 season preceding the last pandemic, emergence of yet another naturally NAI-resistant influenza virus may not be an unlikely event. This previous incident also underlines the importance of resistance surveillance and asks for a better understanding of the mechanisms underlying primary resistance development. We provide an overview of the major influenza antiviral resistance mechanisms and future therapies for influenza. Here, we call for a better understanding of the effect of virus mutations upon antiviral treatment and for a tailored antiviral approach to severe influenza virus infections.
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Abstract
Compounds undergoing preclinical development for anti-influenza virus activity require evaluation in small animal models. Laboratory mice are most commonly used for initial studies because of size, cost, and availability. Cotton rats, guinea pigs, and ferrets (particularly) have been used for more advanced studies. Each animal infection model has certain limitations relative to human influenza infections. For example, the fever response that is evident in humans only occurs with consistency in ferrets. Mice infected with mouse-adapted viruses and ferrets infected with highly pathogenic avian influenza viruses suffer severe disease, whereas cotton rats and guinea pigs manifest few symptoms. Thus, for each animal model there is a certain set of disease parameters that can be measured. Here we describe methods for assessing the efficacy of anti-influenza virus compounds in each of these animal species.
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Affiliation(s)
- Donald F Smee
- Department of Animal, Dairy, and Veterinary Sciences, Institute for Antiviral Research, Utah State University, Logan, UT, USA
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Simeonova L, Gegova G, Galabov AS. Prophylactic and therapeutic combination effects of rimantadine and oseltamivir against influenza virus A (H3N2) infection in mice. Antiviral Res 2012; 95:172-81. [DOI: 10.1016/j.antiviral.2012.05.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2011] [Revised: 05/03/2012] [Accepted: 05/09/2012] [Indexed: 11/20/2022]
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Cianci C, Gerritz SW, Deminie C, Krystal M. Influenza nucleoprotein: promising target for antiviral chemotherapy. Antivir Chem Chemother 2012; 23:77-91. [PMID: 22837443 DOI: 10.3851/imp2235] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2012] [Indexed: 12/25/2022] Open
Abstract
In the search for new anti-influenza agents, the viral polymerase has often been targeted due to the involvement of multiple conserved proteins and their distinct activities. Polymerase associates with each of the eight singled-stranded negative-sense viral RNA segments. These transcriptionally competent segments are coated with multiple copies of nucleoprotein (NP) to form the ribonucleoprotein. NP is an abundant essential protein, possessing operative and structural functions, and participating in genome organization, nuclear trafficking and RNA transcription and replication. This review examines the NP structure and function, and explores NP as an emerging target for anti-influenza drug development, focusing on recently discovered aryl piperazine amide inhibitor chemotypes.
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Smee DF, Julander JG, Tarbet EB, Gross M, Nguyen J. Treatment of oseltamivir-resistant influenza A (H1N1) virus infections in mice with antiviral agents. Antiviral Res 2012; 96:13-20. [PMID: 22809862 DOI: 10.1016/j.antiviral.2012.07.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2011] [Revised: 06/11/2012] [Accepted: 07/06/2012] [Indexed: 12/13/2022]
Abstract
Influenza A/Mississippi/03/2001 (H1N1) and A/Hong Kong/2369/2009 (H1N1) viruses containing the neuraminidase gene mutation H275Y (conferring resistance to oseltamivir) were adapted to mice and evaluated for suitability as models for lethal infection and antiviral treatment. The viral neuraminidases were resistant to peramivir and oseltamivir carboxylate but sensitive to zanamivir. Similar pattern of antiviral activity were seen in MDCK cell assays. Lethal infections were achieved in mice with the two viruses. Oral oseltamivir at 100 and 300mg/kg/day bid for 5day starting at -2h gave 30% and 60% protection from death, respectively, due to the A/Mississippi/03/2001 infection. Intraperitoneal treatments with zanamivir at 30 and 100mg/kg/day starting at -2h gave 60% and 90% protection, respectively. Neither compound at <300mg/kg/day protected mice when treatments began at +24h. Amantadine was effective at 10, 30, and 100mg/kg/day, rimantadine was protective at 10 and 30mg/kg/day (highest dose tested), and ribavirin was active at 30 and 75mg/kg/day, with survival ranging from 60-100% for oral treatments initiated at -2h. For treatments begun at +24h, amantadine was protective at 30 and 100mg/kg/day, rimantadine showed efficacy at 10 and 30mg/kg/day, and ribavirin was active at 75mg/kg/day, with 60-100% survival per group. In the A/Hong Kong/2369/2009 infection, oral oseltamivir at 100 and 300mg/kg/day starting at -2h gave 50% and 70% protection from death, respectively. These infection models will be useful to study newly discovered anti-influenza virus agents and to evaluate compounds in combination.
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Affiliation(s)
- Donald F Smee
- Institute for Antiviral Research, Utah State University, Logan, UT 84322, USA.
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Meisen I, Dzudzek T, Ehrhardt C, Ludwig S, Mormann M, Rosenbrück R, Lümen R, Kniep B, Karch H, Müthing J. The human H3N2 influenza viruses A/Victoria/3/75 and A/Hiroshima/52/2005 preferentially bind to α2-3-sialylated monosialogangliosides with fucosylated poly-N-acetyllactosaminyl chains. Glycobiology 2012; 22:1055-76. [DOI: 10.1093/glycob/cws077] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
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Tarbet EB, Maekawa M, Furuta Y, Babu YS, Morrey JD, Smee DF. Combinations of favipiravir and peramivir for the treatment of pandemic influenza A/California/04/2009 (H1N1) virus infections in mice. Antiviral Res 2012; 94:103-10. [PMID: 22429564 DOI: 10.1016/j.antiviral.2012.03.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2011] [Revised: 02/28/2012] [Accepted: 03/05/2012] [Indexed: 01/30/2023]
Abstract
Favipiravir, an influenza virus RNA polymerase inhibitor, and peramivir, an influenza virus neuraminidase inhibitor, were evaluated alone and in combination against pandemic influenza A/California/04/2009 (H1N1) virus infections in mice. Infected mice were treated twice daily for 5 d starting 4 h after virus challenge. Favipiravir was 40%, 70%, and 100% protective at 20, 40, and 100 mg/kg/d. Peramivir was 30% protective at 0.5 mg/kg/d, but ineffective at lower doses when used as monotherapy. Combinations of favipiravir and peramivir increased the numbers of survivors by 10-50% when the 0.025, 0.05, and 0.1 mg/kg/d doses of peramivir were combined with 20 mg/kg/d favipiravir and when all doses of peramivir were combined with 40 mg/kg/d favipiravir. Three-dimensional analysis of drug interactions using the MacSynergy method indicates strong synergy for these drug combinations. In addition, an increase in lifespan for groups of mice treated with drug combinations, compared to the most effective monotherapy group, was observed for the 0.025, 0.05, and 0.1 mg/kg/d doses of peramivir combined with favipiravir at the 20 mg dose level. Therefore, the 20 mg/kg/d dose of favipiravir was selected for further combination studies. Increased survival was exhibited when this dose was combined with peramivir doses of 0.1, 0.25 and 0.5 mg/kg/d (1 mg/kg/d of peramivir alone was 100% protective in this experiment). Improved body weight relative to either compound alone was evident using 0.25, 0.5, and 1 mg/kg/d of peramivir. Significant reductions in lung hemorrhage score and lung weight were evident on day 6 post-infection. In addition, virus titers were reduced significantly on day 4 post-infection by combination therapy containing favipiravir combined with peramivir at 0.25 and 0.5 mg/kg/d. These data demonstrate that combinations of favipiravir and peramivir perform better than suboptimal doses of each compound alone for the treatment of influenza virus infections in mice.
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Affiliation(s)
- E Bart Tarbet
- Institute for Antiviral Research, Department of Animal, Dairy and Veterinary Sciences, Utah State University, Logan, United States.
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Abstract
BACKGROUND The effectiveness and safety of amantadine (AMT) and rimantadine (RMT) for preventing and treating influenza A in adults has been systematically reviewed. However, little is known about these treatments in children and the elderly. OBJECTIVES To systematically review the effectiveness and safety of AMT and RMT in preventing and treating influenza A in children and the elderly. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 2) which contains the Cochrane Acute Respiratory Infections (ARI) Group's Specialised Register, MEDLINE (1966 to June week 3, 2011) and EMBASE (1980 to June 2011). SELECTION CRITERIA Randomised controlled trials (RCTs) or quasi-RCTs comparing AMT and/or RMT with placebo, control, other antivirals or different doses or schedules of AMT or RMT, or both, or no intervention, in children and the elderly. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials for inclusion and assessed methodological quality. We resolved disagreements by consensus. In all comparisons except for one, we separately analysed the trials in children and the elderly using Review Manager software. MAIN RESULTS A total of 12 studies involving 2494 participants (1586 children and adolescents and 908 elderly) compared AMT and RMT with placebo, paracetamol (one trial; 69 children) or zanamivir (two trials; 545 seniors). All studies were RCTs but most were still susceptible to bias. Two trials in the elderly had a high risk of bias because of incomplete outcome data. In one of those trials there was also a lack of outcome assessment blinding. Risk of bias was unclear in 10 studies due to unclear random sequence generation and allocation concealment. Only two trials in children were considered to have a low risk of bias.AMT was effective in preventing influenza A in children. A total of 773 participants were included in this outcome (risk ratio (RR) 0.11; 95% confidence interval (CI) 0.04 to 0.30). The assumed risk of influenza in the control group was 10 per 100 and the corresponding risk in the RMT group was one per 100 (95% CI 0 to 3). The quality of the evidence was considered low. For treatment purposes, RMT was beneficial for abating fever on day three of treatment. For this purpose one study was selected with low risk of bias and included 69 children (RR 0.36; 95% CI 0.14 to 0.91). The assumed risk was 38 per 100 and the corresponding risk in the RMT group was 14 per 100, 95% CI 5 to 34. The quality of the evidence was moderate.RMT did not show a prophylactic effect against influenza in the elderly, but the quality of evidence was considered very low. There were 103 participants (RR 0.45; 95% CI 0.14 to 1.41, for an assumed risk of 17 per 100 and a corresponding risk in the RMT group of 7 per 100, 95% CI 2 to 23). We did not identify any AMT trials in the elderly that met our inclusion criteria.There was no evidence of adverse effects of AMT and RMT in children or an adverse effect of RMT in the elderly. We did not identify any AMT trials in the elderly that met our inclusion criteria. AUTHORS' CONCLUSIONS AMT is effective in preventing influenza A in children but the NNTB is high (NNTB: 12 (95% CI 9 to 17). RMT probably helps the abatement of fever on day three of treatment, but the quality of the evidence is poor. Due to the small number of available studies, we could not reach a definitive conclusion on the safety of AMT or the effectiveness of RMT in preventing influenza in children and the elderly.
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Abstract
PURPOSE OF REVIEW The 2009 influenza pandemic introduced a new influenza A/H1N1 subtype in the human population. This pandemic 2009 influenza A/H1N1 virus has natural resistance to the adamantanes class and has a low threshold to become resistant to the neuraminidase class of antiviral drugs. This review describes recent findings on influenza antiviral resistance in pandemic 2009 influenza A/H1N1 virus. RECENT FINDINGS Pandemic 2009 viruses have emerged with novel resistance patterns to the neuraminidase inhibitors. In addition, the identification of mutations that facilitated oseltamivir resistance in prepandemic influenza emphasizes the ability of influenza to become resistant to antiviral drugs without significant loss of fitness. SUMMARY Novel initiatives are required to find and develop high genetic barrier influenza therapeutic regimens for effective treatment of severe influenza virus infections.
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Atiee G, Lasseter K, Baughman S, McCullough A, Collis P, Hollister A, Hernandez J. Absence of pharmacokinetic interaction between intravenous peramivir and oral oseltamivir or rimantadine in humans. J Clin Pharmacol 2011; 52:1410-9. [PMID: 21960669 DOI: 10.1177/0091270011414574] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Peramivir, an intravenously administered neuraminidase inhibitor, may be used concomitantly with other influenza antivirals. Two studies were conducted to assess the potential for pharmacokinetic interactions of peramivir when coadministered with oseltamivir or rimantadine. Twenty-one healthy subjects were enrolled in each randomized, open-label, crossover study, and they received 1 intravenous dose of peramivir (600 mg), 1 oral dose of oseltamivir (75 mg) or rimantadine (100 mg), or a combination of peramivir with oseltamivir or rimantadine. Assessment of the 90% confidence interval for the geometric mean ratio of peramivir and oseltamivir carboxylate or rimantadine pharmacokinetic parameters showed no effect of oseltamivir or rimantadine on the pharmacokinetics of peramivir and no effect of peramivir on the pharmacokinetics of oseltamivir carboxylate or rimantadine. The drugs were well tolerated. These results suggest no reason to expect an effect of concomitant administration of oseltamivir or rimantadine on the safety profile of peramivir in patients with influenza.
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Affiliation(s)
- George Atiee
- Icon Development Solutions, San Antonio, Texas, USA
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25
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Bantia S, Upshaw R, Babu Y. Characterization of the binding affinities of peramivir and oseltamivir carboxylate to the neuraminidase enzyme. Antiviral Res 2011; 91:288-91. [DOI: 10.1016/j.antiviral.2011.06.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2011] [Revised: 05/09/2011] [Accepted: 06/16/2011] [Indexed: 10/18/2022]
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