Chapter

38
Antiviral Agents and
Protease Inhibitors
P AT R I C K M. W O S T E R

Drugs Covered in This Chapter*

Acyclic nucleoside analogues Antiretroviral agents: Nonnucleoside • Fosamprenavir
• Acyclovir reverse transcriptase inhibitors • Indinavir
• Adefovir dipivoxil • Delavirdine • Lopinavir
• Cidofovir • Efavirenz • Nelfinavir
• 6-Deoxyacyclovir • Nevirapine • Ritonavir
• Famciclovir Conventional nucleoside analogues • Saquinavir
• Ganciclovir • Tipranavir
• Cytarabine
• Valacyclovir • Idoxuridine Inhibitors of viral attachment,
Agents affecting the ribosome • Ribavirin penetration, or early replication
• Methisazone • Trifluorothymidine • Amantadine
Antiretroviral agents: Nucleoside • Vidarabine • Interferon
reverse transcriptase inhibitors Fusion inhibitors • Rimantadine
• Abacavir • Enfuvirtide Neuraminidase inhibitors
• Didanosine • Maraviroc • Oseltamivir
• Emtricitabine HIV integrase inhibitors • Peramivir
• Lamivudine • Zanamivir
• Raltegravir
• Stavudine Non nucleoside analogues
HIV protease inhibitors
• Tenofovir disoproxil • Boceprevir
• Zalcitabine • Amprenavir
• Fomivirsen†
• Zidovudin • Atazanavir
• Foscarnet
• Darunavir
• Telaprevir

Abbreviations
AIDS, acquired immunodeficiency AUC, area under plasma concentration– CMV, cytomegalovirus
syndrome time curve CNS, central nervous system
ara-HX, arabinosyl hypoxanthine CCD, catalytic core domain CSF, cerebrospinal fluid
ARC, AIDS-related complex cDNA, complementary DNA D4T, stavudine
*
Drugs listed include those available inside and outside of the United States; drugs available outside of the United States are shown in italics.
†
Fomivirsen has been withdrawn from the U.S. market. Kaduse.com
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1268 PART III / PHARMACODYNAMIC AGENTS
DANA, 2-deoxy-2,3-dehydro-N- HAV, hepatitis A virus
acetylneuraminic acid HBV, hepatitis B virus
ddI, didanosine HCV, hepatitis C virus
ddC, zalcitabine HEV, hepatitis E virus
DMSO, dimethylsulfoxide HHV, human herpesvirus
EBV, Epstein-Barr virus HIV, human immunodeficiency virus
FDA, U.S. Food and Drug Administration HPV, human papilloma virus
GI, gastrointestinal HSV, herpes simplex virus
HA, hemagglutinin HTLV-1, human T-cell leukemia virus 1
HAART, highly active antiretroviral IC50, half maximal inhibitory
therapy concentration
SCENARIO
Douglas Slain, PharmD, BCPS
WM is a 37-year-old white woman who is employed as a nurses’
aid in an elder care nursing home. She presents to the hospital
with extreme flu-like symptoms and is having difficulty breath-
ing. She is placed in the intensive care unit where she ultimately
requires intubation and mechanical ventilation to maintain her
respiratory function. WM is also given empiric broad-spectrum
antibiotics in case of bacterial pneumonia. A rapid influenza
test is positive. She needs anti-influenza therapy, but oral osel-
tamivir and inhaled zanamivir cannot be reliably delivered given
her sedation, intubation, and mechanical ventilation. Many of
INTRODUCTION
Viruses are the smallest of the human infectious agents
and range in size from about 20 nm to about 300 nm
in diameter (1,2). They contain one kind of nucleic
acid, either RNA or DNA, as their entire genome, which
codes for a variety of enzymes and other proteins used in
replication and transmission of the organism. It can be
argued that a virus does not qualify as a true life form,
since it is nothing more than a nucleic acid strand with
associated proteins, and it cannot move on its own power.
However, when it attaches itself to a host cell, it internal-
izes itself and forces the host to make additional copies
of the virus, demonstrating a clear reproductive plan.
During replication, it uses host cellular biochemicals
and processes and, thus in a sense, takes in “nutrients”
in order to survive and multiply. In some cases, viruses
respond to external conditions and escape the immune
response by integrating into the host DNA, demonstrat-
ing the ability to respond to external stimuli. Although
viruses are simple organisms, they are a significant caus-
ative agent for numerous human diseases and, as such,
represent one of the major challenges in the area of drug
discovery. Agents that are used clinically for a variety of
viral diseases act by targeting processes that are specific
to the virus, such as a unique viral enzyme or a neces-
sary process such as transcription. However, to date, no
drug has been discovered that is truly curative for viral
infection. In addition, because viruses have the ability to
IV, intravenous
MHC, major histocompatibility complex
NA, neuraminidase
RNAi, RNA interference
RSV, respiratory syncytial virus
RT, reverse transcriptase
siRNA, short interfering RNAs
3TC, lamivudine
VZV, varicella-zoster virus
ZDV, zidovudine
the residents of her nursing home had an H1N1 strain of influ-
enza that has the neuraminidase-resistant H274Y mutation. This
mutation will drastically reduce the effectiveness of neuramini-
dase inhibitors that are dependent on C6 hydrophobic binding.
Most circulating strains have also been resistant to rimantadine.
Treatment options to consider are investigational intravenous
zanamivir and investigational intravenous peramivir.
(The reader is directed to the clinical solution and chemical analy-
sis of this case at the end of the chapter.)
undergo mutations, resistance to existing therapies can
develop. The discovery of new antiviral agents is thus an
important ongoing effort in medicinal chemistry.
VIRUS STRUCTURE AND CLASSIFICATION (1,2)
Numerous species of virus that infect bacteria, plants,
and animals have been identified, and they exhibit a
remarkable range of diversity. All viruses exist as obli-
gate cellular parasites, and as such, they do not possess
the complex biochemical machinery that is charac-
teristic of higher organisms. However, they do have a
defined macromolecular structure that is designed
to protect them from the environment and facilitate
their entry into cells. The basic subunit of a virus is
its genome, which can be made up of either DNA or
RNA. The nucleic acid portion of a virus can be sin-
gle or double stranded, and may be present in linear
or circular form. Viral genomic DNA or RNA is often
associated with basic nucleoproteins and may be sur-
rounded by a symmetrical protein known as a capsid.
The capsid is made up of repeating structural units
known as protomers, which themselves are made up
of nonidentical protein subunits. The combination
of the nucleic acid core and the capsid is termed the
nucleocapsid, and in some cases, this comprises the
entire virus. In other cases, the nucleocapsid structure
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 CHAPTER 38 / ANTIVIRAL AGENTS AND PROTEASE INHIBITORS
derived during viral maturation, when the virus undergoes
budding through the host cell membrane. The com-
plete virus particle, with or without an envelope, is
termed the virion. Viral architecture can be grouped
into three types based on the arrangement of morpho-
logic subunits, and each virus exhibits cubic (icosahe-
dral) symmetry, helical symmetry, or has a complex
structure. Icosahedral virions are symmetrical struc-
tures that contain 20 surfaces, each of which is an equi-
lateral triangle. A sufficient number of capsid structural
units must be employed in the icosahedron to make a
capsid large enough to encapsulate the viral genome.
Morphologic units called capsomeres are seen on the
surface of icosahedral virus particles. These structures
are clusters of polypeptides, but they do not necessarily
correspond to the chemically defined structural units.
Some viruses arrange their structural subunits into a
standard helical formation. In viruses with helical sym-
metry, protein subunits systematically bind to the viral
nucleic acid, ultimately forming a nucleocapsid helix.
The filamentous nucleocapsid is then coiled inside a
lipid-containing envelope. Unlike icosahedral virions,
regular, periodic interaction between capsid protein
CLINICAL SIGNIFICANCE
Antiviral agents include diverse
compounds with varied actions.
A thorough clinical understanding
of most of these compounds is depen-
dent on a basic appreciation of biochem-
istry and medicinal chemistry. Viruses are mainly composed of
either RNA or DNA nucleic acid strands. As such, one of the
most ideal targets for treating viral pathogens has been the inhi-
bition of viral replication. Successful viral replication is depen-
dent on enzyme-mediated transcription of viral RNA or DNA. A
significant number of antiviral agents, including HIV nucleoside
reverse transcriptase inhibitors, and a majority of antiherpes
agents are designed to be “false” substrates of viral transcrip-
tion enzymes. It is through competitive inhibition that these
agents are able to fulfill their intended effect. Their chemical
structures are similar to naturally occurring substrate nucleo-
side purines (adenosine and guanosine) and pyrimidines (thy-
midine and cytidine). However, as they are purposely modified
in key positions with functional groups designed to foil poly-
merase enzymes, their incorporation will lead to termination of
replication. While these nucleoside antiviral agents are often
actively carried into cells via specific nucleoside transporting
proteins, they typically require triphosphorylation to become
active intracellularly. It is important to recognize that resistance
to these antiviral medications can develop when genetic muta-
tions alter the ability for viral enzymes to phosphorylate the
drugs. Drugs like cidofovir and tenofovir are nucleotide analogs,
which means they are already monophosphorylated. As a result,
1269
and viral nucleic acid prevents the formation of “empty”
helical particles. Finally, some virus particles, such as
the large and complex poxviruses, do not exhibit cubic
or helical symmetry, but instead form more compli-
cated structures that can be spherical, brick-shaped,
or ovoid. A subset of complex viruses is termed pleo-
morphic, in that they assume multiple complex mor-
phologies. Advances in the visualization of viral capsid
structure suggest that the assembly and processing of
viral proteins could serve as a new target for antiviral
drug development (3).
Viral taxonomy is complex, and viruses are classified
according to a number of factors, including morphol-
ogy, properties of the genome (i.e., DNA vs. RNA, single
strand vs. double strand, linear vs. circular, sense vs. anti-
sense), physicochemical properties, structure of associ-
ated proteins, replication strategy, and so on. Viruses are
separated into major groups called families, with names
that end in the suffix –viridae, and then into genera
that end in –virus. Thus, pox viruses are in the family
Poxviridae, and in the genus Poxvirus. A comparison of
the genetic and structural features of viral families with
members that can infect humans appears in Table 38.1.
these agents can maintain activity against viruses that have
developed resistance to other nucleoside agents through certain
resistant mutations.
In clinical practice, HIV antiretroviral regimens usually
require a pair of nucleoside reverse transcriptase inhibitors in
the regimen. It is of paramount importance that combinations
of “like” nucleosides analogs (e.g., two thymidine, two cytosine)
are not used together as they have displayed antagonism and
reduced viral load suppression. Nonnucleoside reverse transcrip-
tase inhibitors are not structurally related to nucleic purines and
pyrimidines; therefore, they do not act as substrates of the tar-
get enzyme.
Protease inhibitors, which are the most potent antiretrovi-
ral agents available, were the end result of coordinated chemical
design and structure-based computational analysis of the prote-
ase enzyme. With identification of the protease crystalline struc-
ture and identification of active binding sites, scientists were
able to create compounds that would fit the protease enzyme
with strong affinity, and cause an inhibition of protease func-
tion. The clinical impact of these man-made drugs is regarded
by many as the greatest single advance in the treatment of HIV
infection.
Douglas Slain, PharmD, BCPS
Associate Professor
College of Pharmacy
West Virginia University
Morgantown, WV
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TABLE 38.1 Characteristics of Virus Families Containing Members That Infect Humans
Family Examples Genome Capsid Size Envelope Diseases
Symmetry (nm−1)

Parvoviridae Parvovirus B19 ssDNA sense or Icosahedral 18–26 No Erythema infectiosum (fifth
antisense disease); polyarthralgia
arthritis; aplastic crisis, anemia
Papillomaviridae Human papilloma (wart) ds, circular DNA Icosahedral 55 No Warts; salivary gland
virus; polyoma virus; infection; multifocal
SV 40 leukoencephalopathy; tumors
(i.e., cervical)
Adenoviridae Multiple types dsDNA Icosahedral 70–90 No Infections of the eye and
(40 adenoviruses and respiratory tract; tumors
mastadenovirus)
Hepadnaviridae Hepadnavirus, hepatitis dsDNA, circular, Icosahedral 40–48 Yes Hepatitis B; tumors
B virus one ss region
Herpesviridae Herpes simplex I and II; dsDNA Icosahedral 150–200 Yes Eye, skin and genital infection;
varicella zoster; herpes chickenpox; shingles;
zoster; cytomegalovirus; mononucleosis; tumors
Epstein-Barr virus
Poxviridae Variola; vaccinia dsDNA Complex 230–400 Complex Smallpox; cowpox;
chickenpox; tumors
Picornaviridae Hepatitis A virus; ssRNA, sense Icosahedral 28–30 No Respiratory diseases;
poliovirus; enterovirus; gastrointestinal diseases;
rhinovirus, coxsackie polio; aseptic meningitis
virus A and B
Astroviridae Astrovirus ssRNA, sense Icosahedral 28–30 No Diarrhea in infants and
immunocompromised patients
Caliciviridae Norwalk virus ssRNA, sense Icosahedral 27–40 No Epidemic gastroenteritis
Togaviridae Rubella virus; ssRNA, sense Icosahedral 50–70 Yes Measles (rubella)
alphavirus, arbovirus
Flaviviridae Hepatitis C virus; arbo- ssRNA, sense Complex 40–60 Yes Hepatitis C; yellow fever;
virus; yellow fever virus; dengue fever; encephalitis;
dengue virus; West Nile tumors
virus
Coronaviridae Coronavirus ssRNA, sense Complex 120–160 Yes Colds; gastroenteritis in
infants; SARS
Retroviridae HIV I and II; lentivirus; ssRNA as dimer Complex 80–100 Yes AIDS; AIDS-related complex;
human T-cell breast cancer; human T-cell
lymphotropic viruses leukemia; nasopharyngeal
carcinoma
Arenaviridae Arenavirus ssRNA, antisense Complex 50–300 Yes Lassa fever; hemorrhagic
fever; choriomeningitis
Orthomyxoviridae Influenza virus A, B, C ssRNA, antisense Helical 80–120 Yes Influenza
Bunyaviridae Hantavirus ssRNA, antisense Helical 80–120 Yes Hemorrhagic fever
Rhabdoviridae Rhabdovirus; rabies ssRNA, antisense Helical 75–180 Yes Rabies; encephalitis
virus; encephalitis virus
Paramyxoviridae Syncytial virus; ssRNA, antisense Helical 150–300 Yes Mumps; measles (rubeola)
parainfluenza virus
Filoviridae Marburg virus; ssRNA, antisense Helical 80–800 Yes Marburg viral fever; ebola
Ebola virus hemorrhagic fever
Reoviridae Reovirus; rotavirus; dsRNA in 10–12 Icosahedral 60–80 No Mild respiratory and
orbivirus pieces gastrointestinal infection;
Colorado tick fever
Prion Prion proteinaceous None NA NA No Bovine spongiform
material encephalopathy; Creu
tzfeldt-Jakob disease
ds, double stranded; NA, not applicable; SARS, severe acute respiratory syndrome; ss, single stranded.
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VIRAL REPLICATION, CELLULAR EFFECTS, AND
PATHOGENESIS (2,4)
As mentioned earlier, all viruses exist as obligate intra-
cellular parasites, and as such, they rely on the cellular
machinery of the host for their growth, development,
and replication. In order to synthesize the proteins
needed for viral replication, the organism must be capa-
ble of producing usable mRNA in sufficient quantities to
compete with host mRNA for protein synthesis. During
viral replication, all of the macromolecules required by
the virus are synthesized in a highly organized sequence.
The replication cycle (Fig. 38.1) begins when the intact
virion binds to a host cell through electrostatic adsorp-
tion to a specific “receptor” site. This process is known
as the attachment phase. Attachment is most likely a for-
tuitous event resulting from structural complementarity
between the exterior structure of the virion and a nor-
mal cell surface structure on the host cell. For example,
HIV binds to the CD4 receptor on cells of the immune
system, rhinoviruses bind ICAM-1, and Epstein-Barr virus
recognizes the CD21 receptor on B cells. Recent studies
suggest that some mammalian cells can develop proteins
that restrict the binding of viral capsid structures, thus
preventing entry into noninfected cells (5). When attach-
ment has been achieved, the virion enters the penetra-
tion phase, the process by which it gains entry into the
host cell. Penetration may occur by receptor-mediated
endocytosis, fusion of the viral envelope with the cell
membrane, or in some cases direct penetration of the
membrane. Following penetration of the cell, viruses
must be uncoated, resulting either in the naked nucleic
acid or in the nucleocapsid form, which usually contains
polymerase enzymes. After they have been uncoated,
viruses are no longer infectious.
Once the virus has penetrated the cell and uncoated,
it enters a segment of its life cycle known as the eclipse
period, the length of which varies with the type of virus.
It is during this time that the virus utilizes host resources
to replicate and produce necessary viral proteins. Cells
that can support viral reproduction are termed permis-
sive, and as a result, the infection is known as productive,
since it results in new viral particles. When new infectious
viral particles are produced, host cellular metabolism may
be completely directed to the production of viral prod-
ucts, resulting in destruction of the cell. In other cases,
host cell metabolism is not dramatically altered, and the
infected cell can survive. During viral reproduction, up
to 100,000 new virions can be produced, and the replica-
tion cycle can vary from a few hours to more than 3 days.
Some cells types, called nonpermissive, are unable to
support the reproduction of an infective virion, resulting
in an abortive infection. Abortive infections also occur
when the virus itself is defective. Either situation can lead
to a latent infection, where the viral genome may persist
in a surviving host cell. As will be described below, such

ADENOVIRUS Cytoplasm
1
ADSORPTION Nucleus
10 2
RELEASE PENETRATION

9 Viral DNA 3
ASSEMBLY UNCOATING
Early proteins
Viral mRNA
Viral capsid Viral DNA in
Viral protein the nucleus
Ribosomes

Transfer of capsid
proteins to nucleus 4
8
EARLY
CONDENSATION Synthesis of late TRANSCRIPTION
proteins (capsid Synthesis of early
proteins) proteins (enzymes such
Synthesis of
as DNA polymerase)
early mRNA
Synthesis of viral
DNA and late mRNA
7 5
LATE EARLY
TRANSLATION TRANSLATION

6
DNA SYNTHESIS
AND LATE
TRANSCRIPTION

FIGURE 38.1 Steps involved in the viral life cycle. (Used with permission from Brooks GF, Butel JS, Morse SA, et al.
Jawetz, Melnick and Adelberg’s Medical Microbiology, 23rd Ed. New York: McGraw-Hill Companies, 2004.)
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1272 PART III / PHARMACODYNAMIC AGENTS
an infection can lead to the transformation of a cell from
normal to malignant.
DNA Virus
The strategies used by various viruses to replicate vary
widely, but all are characterized by the need to tran-
scribe mRNA that is suitable for translation of viral
proteins. There are several pathways leading to the
required mRNA, after which the host enzymes and raw
materials are used to make viral proteins. Early viral
proteins used in replication are synthesized immedi-
ately after infection, while late proteins used to pro-
duce the complete virion structure are synthesized after
viral nucleic acid synthesis. Most DNA viruses contain
double-stranded DNA as their genome and thus can
replicate using host cell machinery to produce mRNA
directly. Papillomavirus, adenovirus, and herpesvirus
are replicated in the host nucleus, and thus use tran-
scriptional enzymes of the host (i.e., DNA-dependent
RNA polymerase) to synthesize mRNA. This mRNA is
then translated to form proteins needed by the virus,
including enzymes (e.g., DNA-dependent DNA poly-
merase) used to produce progeny DNA copies. These
progeny DNA strands are infectious. By contrast, pox-
viruses replicate in the cytoplasm using a mechanism
that is not well understood, wherein the genome is ini-
tially transcribed by a viral enzyme in the virion core.
Parvoviruses contain a single-stranded DNA genome,
and must synthesize double-stranded DNA in the host
nucleus prior to synthesis of mRNA and translation of
proteins. This process may or may not require a helper
virus such as herpes simplex. The hepatitis B viral
genome, comprised of double-stranded DNA, contains
numerous gaps that must be repaired using a DNA poly-
merase packaged in the virion before transcription to
form mRNA.
RNA Virus
Compared to DNA viruses, those viruses with RNA-based
genomes have evolved a wide variety of reproductive strat-
egies. The single-stranded RNA viruses may be divided
into three groups that differ in the method by which
the RNA genome is utilized. In all three groups, the
RNA genome must serve two functions: to be translated
to form protein and to be replicated to form progeny
RNA strands. The first group is comprised of viruses such
as picornaviruses, flaviviruses, and togaviruses that have
an RNA genome that can be used directly as mRNA.
Viral RNA that can be used as mRNA is by convention
termed (+) or sense-strand RNA. In most cases (e.g.,
picornaviruses), this sense-strand RNA binds to the
host ribosome shortly after entering the cell, where it
is read and used to produce a single polypeptide called
the polyprotein. The polyprotein is then processed by
autocatalysis and various proteolytic enzymes to produce
the required viral proteins. In some cases (e.g., togavi-
ruses), only a portion of the RNA genome is available to
be translated by the host ribosome. Following the initial
translation of the sense strand, it serves a second func-
tion, namely to serve as a template for the synthesis of
a (–) or antisense strand via an RNA-dependent RNA
polymerase. This antisense strand then can be used to
produce additional sense-strand RNAs that are infectious
and can also serve as mRNA. These progeny sense RNA
strands are then packaged into an intact virion prior to
transmission to another host cell.
The second group of single-stranded RNA viruses,
including orthomyxoviruses, bunyaviruses, arenavi-
ruses, paramyxoviruses, filoviruses, and rhabdoviruses,
all contain an antisense RNA genome that can only be
used for transcription of new RNA. All antisense RNA
viruses contain an RNA transcriptase as part of their
virion, because the host cell does not have this type of
RNA-dependent RNA polymerase. In the first round of
genome expression, a series of short sense-strand RNAs
are made and then translated to form the required viral
enzymes for replication. Ultimately, these enzymes are
used to produce a full-length sense RNA strand, which
is then used to make multiple copies of the antisense
viral genome. The progeny antisense DNA strands by
themselves are not infectious, because they have not yet
been packaged with the required RNA transcriptase.
When the progeny antisense RNA has been synthe-
sized, it is packaged into an intact virion, in which form
it becomes infectious prior to transmission to another
cell.
The third group of RNA viruses is the retroviruses, in
which single-stranded RNA exists as a dimer of a sense
and antisense strand. The genomic RNA strands can
be base-paired, although the structure of this complex
is not well understood, or the strands can be hydrogen
bonded to other macromolecules in the virion. Retroviral
genomic RNA serves a single function, namely, to act as
a template for the formation of double-stranded viral
DNA. Host cells do not contain an enzyme that can form
DNA from viral RNA, and thus the virion of a retrovi-
rus must contain a reverse transcriptase (RT) enzyme, as
well as various host tRNA molecules. Transcription of the
genome begins when a complex of RT and tRNA binds to
the viral genome. A complimentary DNA strand is then
synthesized using one of the host tRNAs as a primer, and
the original RNA strand is digested by RNAse H, and viral
ribonuclease packaged in the virion. A complimentary
DNA strand is then synthesized, and the resulting dou-
ble-stranded DNA is translocated to the nucleus, where
viral enzymes incorporate genome-length viral DNA
into the host genome. In some cases, the viral portion
of the genome can remain dormant for long periods, or
it may be immediately used to make progeny viral RNA,
a process that is catalyzed by host RNA polymerase II.
Transcription produces both shortened segments that
are used to make polyproteins and full length progeny
RNA. The polyproteins are processed to form various
viral proteins, while the full-length RNA is packaged into
an infectious virion.
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 CHAPTER 38 / ANTIVIRAL AGENTS AND PROTEASE INHIBITORS
Virus Protein
In addition to replication of the viral genome, a number
of other structures associated with the complete virion
can also be made. A number of viral proteins may be syn-
thesized that have important functions in the structure,
transmission, and survival of the virus. These proteins can
protect the genetic material in the virus from destruc-
tion by nucleases, participate in the attachment process,
and provide structure and symmetry to the virion. In
addition, in certain cases where the virus requires an
enzymatic process for which there is no host enzyme, a
virion may include enzymes such as RNA polymerases or
an RT. Some viruses require a lipid envelope that con-
tains transmembrane proteins specifically coded for by
the virus and that envelops the genetic material during
viral budding. Viral envelopes contain glycoproteins that
are involved in cell recognition during attachment to the
host cell. These glycoproteins often reflect the composi-
tion of glycoproteins in the host cell. They are a determi-
nant of the antigenic nature of viruses, and thus facilitate
recognition by the immune system of the host. However,
depending on their composition, they can also help the
virus elude neutralization by the immune system.
Cellular Egress
Viruses use one of two strategies for exiting infected cells.
Nonenveloped viruses (picornaviruses, rheoviruses, etc.)
complete their maturation by assembling into their corre-
sponding virion within the cell nucleus or the cytoplasm.
For example, picornaviruses assemble by clustering 60
copies of each of three viral proteins, called VP0, VP1,
and VP3, into a structure called a procapsid. Viral RNA
is then packaged into the procapsid, and proteolytic
cleavage of VP0 produces two new viral proteins called
VP2 and VP4. The resulting conformational change pro-
duces a stable and symmetrical structure that shields the
genome from degradation by host nucleases. In most
cases, destruction of the host cell is required when the
virion exits. Enveloped viruses (all antisense RNA viruses,
togaviruses, flaviviruses, coronaviruses, hepadnaviruses,
herpesviruses, and retroviruses) contain proteins that
carry signal sequences and markers that cause them to
be inserted into the inner and outer surface of the host
cell cytoplasmic membrane. Viral proteins on the outer
surface are glycosylated using host enzymes and then dis-
place host cell surface proteins and collect into patches.
Viral nucleocapsids recognize proteins on the inner sur-
face of the membrane, where they bind and are engulfed
by the patch area of the membrane. The completed
virion exits the cell by budding and release into the extra-
cellular space. Viral egress can have a variety of effects
on the host cell, ranging from destruction of the cell to
minimal noncytolytic effects. Herpesviruses differ from
other enveloped viruses in the manner in which they
form their envelope. The nucleocapsid is formed in the
nucleus, and final maturation of the virion occurs only
on the inner surface of the host cell membrane, forming
1273
vesicles that are stored in between the inner and outer
aspect of the cell membrane. Egress of the herpesvirus
vesicle always occurs through destruction of the host cell.
Virus Pathogenesis
A complete discussion of viral pathogenesis is beyond the
scope of this chapter. However, in general it may be con-
sidered that the symptoms of a viral infection arise from
the response to viral replication and cell injury in the host.
These responses range from asymptomatic or subclinical
to severe clinical manifestations, and may be either local
or systemic. Understanding the biochemical events that
produce viral diseases can aid in the design of effective
and specific therapies. Not surprisingly, viral pathogen-
esis occurs in distinct steps: 1) viral entry into the host
and primary viral replication; 2) viral spread; 3) cellular
injury and host immune response; 4) viral clearance or
establishment of persistent infection; and 5) viral shed-
ding. Most viruses enter the host through the respiratory
or gastrointestinal tract, but may also penetrate the skin,
urogenital tract, or conjunctiva. In a few cases, virus par-
ticles can enter through direct injection (e.g., HIV and
hepatitis) or through insect bites (arboviruses). When
a local infection occurs, the virus replicates near the
site of entry, and the underlying tissue is not affected.
However, some viruses are able to migrate to other sites,
usually through the bloodstream or lymphatic system, to
produce systemic infections. When infection occurs at
a remote site, most viruses demonstrate tissue or organ
preference (e.g., herpesvirus localizes in nerve ganglia,
and the rabies virus migrates to the CNS). Localization
of a virus in a particular tissue can be the result of cell
receptor specificity or can arise because a virus may be
activated by proteolytic enzymes in a specific cell type.
Clinical disease develops through a complex series of
events when virus-infected cells are destroyed or their
function is impaired, and some symptoms such as mal-
aise and anorexia can result from host responses such as
cytokine release. Disease-mediated damage may become
chronic when cell types that do not regenerate (e.g.,
brain tissue) are involved. Ultimately, the host either
succumbs to the infection; develops a chronic, latent, or
subclinical infection; or completely recovers. In chronic
infections, the virus can be continuously detected, at low
levels, and either mild or no clinical symptoms may pres-
ent. By contrast, latent infections are those in which the
virus persists for extended periods of time in an inactive
form or a location not exposed to the immune response.
Intermittent flare-ups of clinical disease can occur, during
which time infectious virus can be detected. Subclinical
infections are those that give no overt sign of their pres-
ence. Humoral and cell-mediated immunity, interferon
and other cytokines, and other host defense factors,
depending on the type of virus, are common mediators
of recovery, and begin to develop very soon after infec-
tion. Infiltration with mononuclear cells and lymphocytes
is responsible for the inflammatory reaction in uncom-
plicated viral lesions. Virus-infected cells can be lysed by
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1274 PART III / PHARMACODYNAMIC AGENTS
T lymphocytes through recognition of viral polypeptides
on the cell surface, and humoral immunity protects the
host against reinfection by the same virus. Neutralizing
antibodies that are directed against capsid proteins can
prevent viral infection by disrupting viral attachment or
uncoating. Interestingly, viruses have evolved a variety of
survival tactics that serve to suppress or evade the host
immune response. Because viruses are obligate intracel-
lular parasites, a method of transmission from one host
to another is required for survival of the species. Thus,
during an active infection, shedding of the infectious
virion into the environment is a required step in the life
cycle of the virus and ensures transmission of the virus to
new hosts. Shedding usually occurs at the same site where
the infection was initiated and can occur at various stages
of the disease course.
VIRAL DISEASES (6,7)
HIV
The human immunodeficiency virus (HIV-1) was first
identified in 1979 and was found to be the cause of
acquired immunodeficiency syndrome (AIDS) in 1981
(8). Since that time, AIDS had become a serious world-
wide epidemic that continues to expand. The Joint
United Nations Program on HIV/AIDS estimated that by
the end of 2005, a total of 40.3 million people worldwide
were living with HIV/AIDS, the majority having been
infected by heterosexual contact. After four decades,
the number of infected individuals has begun to drop
slightly, and that number stands at 33.3 million in 2010.
Only 5 million of these patients are receiving treatment
for the disease. In 2005, more than 3.1 million people
died of AIDS, and 4.9 million new cases of HIV were diag-
nosed, including more than 700,000 children (9). The
number of new infections dropped to 2.9 million in 2009,
and annual deaths decreased to 1.8 million (10). The
incidence of the disease varies by location, with sub-Saharan
Africa having the highest incidence of the disease. In
the Third World, HIV infection is often comorbid with
neglected tropical diseases (trypanosomiasis, leishmani-
asis), malaria, and tuberculosis, causing a higher level of
mortality (11). Because it is sexually transmitted, a high
percentage of infected individuals are young adult work-
ers, and as such, the disease has a significant economic
impact in some regions. In addition, infected mother-to-
fetus transmission occurs between 13% and 40% of the
time. Although a variety of drugs have been developed
for treating AIDS patients, none have proven successful
in curing the disease. The basic difficulty experienced
with this viral infection is the ability of virus to mutate,
leading to rapid drug resistance.
The HIV-1 genome consists of two identical 9.2-kb
single-stranded RNA molecules within the virion, each
of which contains information for only nine genes.
Following infection of the host cell, the persistent form
of the HIV-1 genome is proviral double-stranded DNA.
Mature HIV virions are spherical and consist of a lipid
bilayer membrane surrounding a nucleocapsid that con-
tains genomic RNA, a viral protease, RT, an integrase,
and some other cellular factors. The HIV life cycle is
depicted in Figure 38.2, and begins when the viral extra-
cellular protein gp120 attaches to the CD4 receptor on
T lymphocytes. Following attachment, the viral envelope
and host cell membrane are fused, and the nucleocap-
sid is released into the cytoplasm. The nucleocapsid is
uncoated, and the resulting RNA serves as a substrate
for RT, producing a proviral double-stranded DNA that
migrates to the nucleus and is incorporated into host
DNA by integrase. This DNA is not expressed in resting
1. Virus attach and fusion
RT
2. Reverse transcription IN
3. Integration
4. Transcription
viral transcripts
p57, Gag-Pol genomic
RNA
5. Translation
gp160
PR
6. Assemble, budding
and maturation
FIGURE 38.2 Replicative cycle of HIV. (1) The virus gp120 pro-
tein binds to CD4, resulting in fusion of the viral envelope and
the cellular membrane and the release of viral nucleocapsid into
the cytoplasm. (2) The nucleocapsid is uncoated, and viral RNA is
reverse transcribed by reverse transcriptase (RT). (3) The resulting
double-stranded proviral DNA migrates into the cell nucleus and
is integrated into the cellular DNA by integrase (IN). (4) Proviral
DNA is transcribed by the cellular RNA polymerase II. (5) The
mRNAs are translated by the cellular polysomes. (6) Viral proteins
and genomic RNA are transported to the cellular membrane and
assemble. Immature virions are released. Polypeptide precursors
are processed by the viral protease (PR) to produce mature viral
particles. (Used with permission from Tyler KL, Fields BN. Fields
Virology, 2nd Ed. New York: Raven Press, 1990:191–239.)
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 CHAPTER 38 / ANTIVIRAL AGENTS AND PROTEASE INHIBITORS
T lymphocytes, but when the cell is activated, proviral
DNA is transcribed by host RNA polymerase II. The
viral RNA and proteins are transported to the cell mem-
brane, where they assemble, form a viral bud, and are
released from the lymphocyte membrane. This produces
an immature virion, and processing of the viral surface
proteins by HIV protease then affords the mature, infec-
tious virus.
About 50% of HIV infections are asymptomatic,
whereas the other 50% produce flu-like symptoms within
4 weeks. During this initial phase, viral titers are very high
and decline as specific antibodies are formed. The latent
period is mediated by factors that are not well understood
and can last several years. During this time, viral replica-
tion continues, and the level of CD4-positive T lympho-
cytes steadily declines. Eventually, the patient immune
system becomes compromised, resulting in a variety of
opportunistic infections. RT sometimes makes mistakes
reading the viral RNA sequence, leading to mutations
in the virus and changes in the structure of the surface
proteins. Thus vaccines, which induce the production of
antibodies that recognize and bind to very specific viral
surface molecules, are unlikely to be effective in HIV
therapy. As will be discussed below, other viral processes,
such as reverse transcription and proteolytic processing,
are viable targets for small-molecule therapy.
Kaposi sarcoma is a common complication of AIDS
and has been shown to arise from a complex interaction
between HIV and the human herpesvirus 8 (HHV-8).
This disease presents as a reddish or purple lesion on var-
ious areas of the skin, and in advanced state may involve
the lungs or gastrointestinal tract. HHV-8 does not work
alone, but rather in combination with a patient’s altered
response to cytokines and the HIV-1 transactivating pro-
tein Tat, which promotes the growth of endothelial cells.
HHV-8 can then encode interleukin-6 viral proteins,
specific cytokines that stimulate cell growth in the skin.
HHV-8 destroys the immune system further by directing
a cell to remove the major histocompatibility complex
(MHC-1) proteins that protect it from invasion. These
proteins are then transferred to the interior of the cell
and are destroyed, leaving the cell unguarded and vul-
nerable to pathogens that would normally be cleared by
the immune system. It has recently been discovered that
xCT, the 12-transmembrane light chain of the human
cystine/glutamate exchange transporter system, serves
as a receptor for internalization of HHV-8 (12).
Herpesvirus (2)
The herpesvirus family contains several of the most
important human pathogens, which are responsible for
causing a spectrum of common diseases. A common and
significant feature of the herpesviruses is their ability
to establish lifelong persistent infections in their hosts
and to undergo periodic reactivation. Herpesviruses pos-
sess a large number of genes, and some of the resulting
proteins are targets for antiviral chemotherapy. The her-
pesviruses that commonly infect humans include herpes
1275
simplex virus (HSV) types 1 and 2, varicella-zoster virus,
cytomegalovirus, Epstein-Barr virus, human herpesvi-
ruses 6 (HHV-6) and 7 (HHV-7), and Kaposi sarcoma–
associated herpesvirus HHV-8 (also known as KSHV).
Herpesviruses are large viruses that have identical mor-
phology and consist of a core of linear, double-stranded
DNA surrounded by a protein coat that exhibits icosahe-
dral symmetry and has 162 capsomeres. The genome is
large and encodes at least 100 different proteins, includ-
ing polypeptides involved in viral structure, the viral enve-
lope, and enzymes involved in nucleic acid metabolism,
DNA synthesis, and protein regulation. Oral cold sores
and genital herpes infections are caused by HSV1 and
HSV2, respectively. These viruses can establish a latent
infection in the ganglia of nerves that supply the site of
the primary infection, and the latent disease is reacti-
vated by a number of stress factors. It is estimated that
virtually 100% of adult humans are infected with HSV1,
although many infections are subclinical and asymptom-
atic. The varicella virus is the cause of chickenpox, and
the herpes zoster virus is responsible for shingles. Human
cytomegalovirus rarely causes disease in healthy people,
but when infection occurs in adulthood, it may cause
an infectious mononucleosis-like illness. Primary infec-
tion with the Epstein-Barr virus is the cause of infectious
mononucleosis, and this virus is thought to be a factor in
the development of Burkitt lymphoma and other malig-
nancies. HHV-6 is thought to cause roseola and mono-
nucleosis, whereas HHV-7 is probably not involved in any
human diseases. The role of HHV-8 in the pathogenesis
of Kaposi sarcoma has been discussed earlier.
Hepatitis (2)
Viral hepatitis is a systemic disease, but primarily involves
the liver. Hepatitis A virus (HAV) is responsible for infec-
tious hepatitis, hepatitis B virus (HBV) is associated with
serum hepatitis, and hepatitis C virus (HCV) is a common
cause of posttransfusion hepatitis. Another viral agent,
hepatitis E virus (HEV), causes an enterically transmit-
ted form of hepatitis. On occasion, disease can arise from
hepatic infection with yellow fever virus, cytomegalovirus,
Epstein-Barr virus, herpes simplex virus, rubella virus,
and the enteroviruses. Viral hepatitis usually involves
acute inflammation of the liver, fever, nausea, vomiting,
and jaundice, and all forms of hepatitis produce identi-
cal histopathologic lesions in the liver during acute dis-
ease. HAV is a member of the picornavirus family and
carries a single-stranded RNA genome; only one strain of
the virus exists. The onset of HAV hepatitis occurs within
24 hours, in contrast to the slower onset of clinical symp-
toms with HBV and HCV infection. Complete recovery
occurs in most HAV cases, and chronic infection never
occurs. HBV is classified as a hepadnavirus with a double-
stranded circular DNA genome. The outcome of HBV
infection ranges from complete recovery to progression
to chronic hepatitis and, rarely, death. HBV establishes
chronic infections, especially in infants; 80% to 95% of
infants and young children infected with HBV become
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1276 PART III / PHARMACODYNAMIC AGENTS
chronic carriers and are at high risk of developing hepa-
tocellular carcinoma. In adults, 65% to 80% of infections
are asymptomatic, and 90% to 95% of all patients recover
completely. HCV is a positive-stranded RNA flavivirus
and exists in at least six major genotypes. Most cases of
posttransfusion hepatitis are caused by HCV, and these
infections are usually subclinical with minor elevation of
liver enzymes and a low incidence of jaundice. However,
70% to 90% of HCV patients develop chronic hepatitis,
and many are at risk of progressing to chronic active
hepatitis and cirrhosis decades later. HEV is transmitted
enterically and occurs in epidemic form in developing
countries, where water supplies are sometimes contam-
inated with feces. The disease is more severe in adults
than in children, who are usually asymptomatic.
Influenza (2)
Respiratory illnesses commonly known as colds and flu
account for more than half of all acute illnesses in the
United States each year. Influenza viruses belong to
the Orthomyxoviridae family and are a major source of
morbidity and mortality caused by respiratory disease.
Outbreaks of infection can occur in worldwide epi-
demics that have resulted in millions of deaths world-
wide. Genetic mutations often cause antigenic changes
in the structure of viral surface glycoproteins, making
influenza viruses extremely difficult to control. Three
immunologic types of influenza viruses are known and
are termed influenza A, B, and C. Antigenic changes are
very common in the type A group of influenza viruses,
which are responsible for the majority of influenza epi-
demics. Influenza type B undergoes more infrequent
antigenic changes and is less often the cause of an influ-
enza epidemic, whereas influenza type C is antigenically
stable and causes only mild illness in immunocompetent
individuals. The viruses carry a single-stranded, negative-
sense RNA genome that has eight segments in influenza
A and B. Influenza C viruses contain only seven segments
of RNA and lack a neuraminidase gene (see below). The
complete virion in each type contains nine different
structural proteins. A nucleoprotein associates with viral
RNA to form a ribonucleoprotein structure that makes
up the viral nucleocapsid. Three other large proteins are
bound to the viral ribonuclear protein and are respon-
sible for RNA transcription and replication. A matrix
protein is also included in the virion that forms a shell
underneath the viral lipid envelope and comprises about
40% of all viral protein.
The influenza virion structure also includes a lipid
envelope derived from the host cell. This envelope con-
tains two viral surface glycoproteins called hemagglutinin
(HA) and neuraminidase (NA). Mutations cause anti-
genic changes in the structure of these two surface gly-
coproteins, and thus, they are the main determinants of
antigenicity and host immunity. The ability of the virus to
change the structure of HA on the virus surface is primar-
ily responsible for the continual evolution of new strains,
sometimes leading to subsequent influenza epidemics.
NA is an enzyme that removes sialic acid from surface
glycoproteins during viral maturation and is required
to produce infectious particles and lower the viscosity
of the mucin layer of the respiratory tract. Influenza
virus spreads through airborne droplets or contact with
contaminated hands or surfaces and has an incubation
period that varies from 1 to 4 days. However, transmission
of the virus begins to occur 24 hours prior to the onset of
symptoms. Interferon is detectable in respiratory secre-
tions at the onset of symptoms, and the host response
to interferon contributes to recovery. Antibodies and
other cell-mediated responses are seen 1 to 2 weeks after
infection. It is well established that secondary infections
from other viruses or bacteria can occur, and Reye syn-
drome, an acute encephalopathy occurring in children
and adolescents, is a rare complication of influenza B,
influenza A, and herpesvirus varicella-zoster infections.
The chances of contracting Reye syndrome are increased
when salicylates are used in children suffering from influ-
enza and related respiratory diseases.
Tumor Viruses (2,13–17)
Viruses are etiologic factors in the development of sev-
eral types of human tumors, most notably cervical can-
cer and liver cancer. At least 15% of all human tumors
worldwide have a viral cause. Tumor viruses can be found
in both the RNA and DNA virus kingdoms (18). The
list of human viruses presently known to be involved in
tumor development includes four DNA viruses (Epstein-
Barr virus [EBV], certain papilloma viruses, HBV, and
the Kaposi sarcoma herpesvirus HHV-8) and two RNA
viruses, (human T-cell leukemia virus 1 [HTLV-1] and
HCV). Nearly every case of cervical cancer is known to
be caused by human papillomavirus (HPV), a fact that
spurred the development of the HPV vaccines Gardasil
and Cervarix (19). Tumor viruses alter cellular behav-
ior through the use of a small amount of genetic infor-
mation, using two general strategies. The tumor virus
either introduces a new “transforming gene” into the cell
(direct-acting), or the virus alters the expression of a pre-
existing cellular gene or genes (indirect-acting). In both
cases, normal regulation of cellular growth processes is
lost. Viruses alone cannot act as carcinogens, and other
events are necessary to disable regulatory pathways and
checkpoints in order to produce transformed, malignant
cells. The processes used in the transformation of host
cells by human tumor viruses are very diverse.
Cellular transformation may be defined as a stable,
heritable change in the growth control of cells that
results in tumor formation. Transformation from a nor-
mal to a neoplastic cell generally requires the retention
of viral genes in the host cell. In the majority of cases,
this is accomplished by the integration of certain viral
genes into the host cell genome. Retroviruses incorpo-
rate their proviral DNA, formed through the action of
reverse transcriptase, into host cell DNA. By contrast,
DNA tumor viruses integrate a portion of the DNA of the
viral genome into the host cell chromosome.
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 CHAPTER 38 / ANTIVIRAL AGENTS AND PROTEASE INHIBITORS
All RNA tumor viruses are members of the retrovi-
rus family and belong to one of two classes (14,15,17).
Class I RNA viruses are direct-transforming and carry
an oncogene obtained through accidental incorpora-
tion from the host cell. No class I RNA viruses are known
to produce tumors in humans. Class II or chronic RNA
tumor viruses are weakly transforming and do not carry
host cell–derived oncogenes. The two known cancer-
causing retroviruses in humans act indirectly. They often
act by inserting their proviral DNA into the immediate
neighborhood of a host cellular oncogene. The human
adult T-cell leukemia virus HTLV-1 acts in this man-
ner, thus increasing the number of preneoplastic cells
and facilitating secondary cellular changes leading to
transformation.
DNA tumor virus strains exist among the papilloma-,
polyoma-, adeno-, herpes-, hepadna-, and poxvirus groups
(16). DNA tumor viruses encode viral oncoproteins that
are important for viral replication, but also affect cellular
growth control pathways. For example, inactivation of Rb
and the p53 pathway by viral transforming proteins is a
common strategy used by papillomaviruses and adenovi-
ruses. As mentioned earlier, all DNA tumor viruses kill
their host cell when the infectious virion is released to
infect other cells. Thus, transformation and tumorigenic-
ity are entirely dependent on a host cell interaction with
the virus that does not involve viral spread to other cells,
and cells transformed by DNA tumor viruses depend
on the continued expression of the virally encoded
oncogene.
Recent studies have revealed that the human tumor
viruses EBV, HHV-8, HPV, HBV, HCV, and HTLV-1
express proteins that are targeted to the mitochondria
(13). Because the mitochondria play a critical role in
energy production, cell death, calcium homeostasis,
and redox balance, these proteins have profound effects
on host cell physiology. Further study of these proteins
and their interactions with mitochondria will aid in the
understanding of the mechanisms of viral replication
and tumorigenesis and could reveal important new tar-
gets for antitumor therapy.
Prion Diseases (20–22)
Although they are not viruses, the infective proteins
known as prions have sufficient similarities to viruses
to warrant their discussion in this chapter. Prions are
small proteins that have been shown to cause a variety
of transmissible spongiform encephalopathies, which
are rare neurodegenerative disorders typified by symp-
toms in the central nervous system (CNS) such as spon-
giform changes, neuronal loss, glial activation, and the
accumulation of amyloid aggregates of an abnormally
folded host protein. Human prion diseases include
kuru, Creutzfeldt-Jakob disease (variant, sporadic, famil-
ial, and iatrogenic), Gerstmann-Sträussler-Scheinker
syndrome, and fatal familial insomnia. The disease in
cattle known as bovine spongiform encephalopathy and
the related disease scrapie exhibit similar pathologic
1277
features. Following exposure, prions accumulate in
lymphoid tissue such as the spleen, lymph nodes, and
tonsils and in Peyer’s patches (specialized lymphoid fol-
licles located in the submucosa of the small intestine).
This accumulation of the infectious agent is necessary
for invasion of the CNS. In humans, the incubation
period of the disease can vary between 18 months and
40 years. Prions appear to be variant, improperly folded
versions of a normal cellular protein called PrPc, a 30-
to 35-kd protein with two sites for N-glycosylation that is
anchored in the neuronal cell membrane. PrPc protein
contains three α-helices, a short β-pleated sheet region,
and a long, unstructured portion that comprises half of
the molecule. The variant, infectious form of the protein
is known as PrPsc and is produced autocatalytically from
PrPc. Prion diseases are always fatal, with no known cases
of remission or recovery. The host shows no inflamma-
tory response or immune response and no production
of interferon, and there is no effect on host B-cell or
T-cell function. At present, there are no effective agents
to treat prion diseases.
VIRAL CHEMOTHERAPY
General Approaches (23,24)
The principles involved in the design of antiviral agents
are similar to those used in the design of all chemothera-
peutic agents. Drugs in this category are targeted to some
process in the virus that is not present in the host cell.
The earliest examples of antiviral agents did not achieve
this goal, and these drugs were toxic at therapeutic lev-
els or had a limited spectrum of activity. A variety of fac-
tors make the design of effective antiviral agents difficult,
including their ability to undergo antigenic changes, the
latent period during which there are no symptoms, and
their reliance on host enzymes and other processes. This
problem is compounded by the fact that host immunity
is not well understood and that symptoms of viral infec-
tion may not appear until replication is complete and
the viral genome has been incorporated into infected
cells. Nonetheless, the continuing identification of new
targets for antiviral agents provides new avenues for the
discovery of small-molecule therapies. The following sec-
tion includes information on currently marketed antivi-
ral compounds that have been designed in eight general
areas:
1. Agents that disrupt virus attachment to host cell
receptors, penetration, or uncoating.
2. Agents that inhibit virus-associated enzymes such
as DNA polymerases and others.
3. Agents that inhibit viral transcription.
4. Agents that inhibit viral translation.
5. Agents that interfere with viral regulatory proteins.
6. Agents that interfere with glycosylation, phos-
phorylation, sulfation, and so on.
7. Agents that interfere with the assembly of viral
proteins.
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1278 PART III / PHARMACODYNAMIC AGENTS

8. Agents that prohibit the release of viruses from
cell surface membranes.
The remainder of this chapter deals primarily with small-
molecule antiviral agents that have been approved by
the U.S. Food and Drug Administration (FDA) and are
clinically effective in the treatment of viral infection.
Immunizing biologic agents such as vaccines, as well
as antineoplastic agents with antiviral activity, are not
covered. Some compounds used primarily in the treat-
ment of bacterial infections, such as rifampicin, bleo-
mycin, doxorubicin, and actinomycin, also inhibit viral
replication. However, these antibiotics do not affect
the transcription or translation of viral mRNA and are
only effective in high concentrations. Therefore, such
antibiotics are not commonly used for viral infections.
There is a continuing need for new antiviral agents,
primarily because viral infections are not curable after
the virus invades the host cell and begins to replicate.
Vaccines are effective, but they are only able to pre-
vent an infection, and only in cases where specific
virus strains are involved. For example, immunization
against influenza, which is a yearly routine in many
parts of the world, can only provide immunity against
specific strains that are represented in that prepara-
tion. New virulent strains may arise from nonhuman
sources, such as the so-called swine flu or avian flu
viruses, and currently available vaccines would have no
effect against these new strains. With regard to small-
molecule antiviral agents, the ideal drug would have
broad-spectrum antiviral activity, completely inhibit
viral replication, maintain efficacy against mutant viral
strains, and reach the target organ without interfering
with normal cellular processes or the immune system
of the host.
ANTIVIRAL AGENTS (23,24)
Agents Inhibiting Virus Attachment, Penetration,
and Early Viral Replication (Table 38.2)
Amantadine
MECHANISM OF ACTION Amantadine hydrochloride
(1-adamantanamine hydrochloride) is a symmetrical tri-
cyclic primary amine that inhibits penetration of RNA
virus particles into the host cell (Fig. 38.3)(25). It also
inhibits the early stages of viral replication by blocking
the uncoating of the viral genome. Recent studies suggest
that amantadine inhibits viral replication by blocking the
influenza A virus M2 proton-selective ion channel.
CLINICAL APPLICATION Amantadine is clinically effective
in preventing and treating all A strains of influenza,
particularly A2 strains of Asian influenza virus and, to
a lesser extent, German measles (rubella) or togavirus.
It also shows in vitro activity against influenza B, para-
influenza (paramyxovirus), respiratory syncytial virus
(RSV), and some RNA viruses (murine, Rous, and Esh
sarcoma viruses). Many prototype influenza A viruses

TABLE 38.2 Antiviral Agents Interfering with Cellular Penetration and Early Replication
Generic Name Trade Name Spectrum of Activity Dosage Form

Amantadine Symmetrel Influenza A Cap (100 mg), syrup (50 mg/5 mL)

Rimantadine Flumadine Influenza A Cap (100 mg)

Interferon α-2a Roferon A Chronic hepatitis, CMV, HSV, Injectable (3, 5, 10, 18, 25, and 50
Alferon papillomavirus, rhinovirus, million units/mL)
Intron and others
Wellferon

Interferon α-2b Interon A Chronic hepatitis B and C, Injectable (3, 5, 10, 18, 25, and 50
many other viruses million units/mL)

γ-Interferon Actimmune Chronic hepatitis B and C, Injectable (100 mcg/0.5 mL)

many other viruses

Tilorone Amixin IC Induces the production of Variable single doses given by

interferons injection

Zanamivir Relenza Influenza A and B Inhaled powder (5 mg)

Oseltamivir Tamiflu Influenza A and B Cap (75 mg)

Peramivir Experimental H1N1 600 mg daily by IV administration

Enfuvirtide Fuzeon HIV Adult: 90 mg SQ BID

Age 6–16: 2 mg/kg SQ BID

Maraviroc Selzentry HIV 300 mg orally twice daily

BID, twice a day; Cap, capsule; SQ, subcutaneous.

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 CHAPTER 38 / ANTIVIRAL AGENTS AND PROTEASE INHIBITORS
NH2
H2N CH3
HCl HCl
Amantadine Rimantadine
FIGURE 38.3 Agents that inhibit virus attachment, penetration,
and early viral replication.
of different human subtypes (H1N1, Fort Dix, H2N2,
Asian type, and H3N2, Hong Kong type) are also inhib-
ited by amantadine hydrochloride in vitro and in ani-
mal model systems. If given within the first 48 hours of
onset of symptoms, amantadine hydrochloride is effec-
tive in respiratory tract illness resulting from influenza
A but not influenza B virus infection, adenoviruses,
and RSV.
PHARMACOKINETICS Amantadine is well absorbed orally,
and the usual dosage for oral administration is 100 mg
twice daily. A 100-mg oral dose produces blood serum
levels of 0.3 mg/mL within 1 to 8 hours. Maximum tis-
sue concentration is reached in 48 hours when a 100-mg
dose is given every 12 hours. In healthy adults receiv-
ing 25-, 100-, and 150-mg doses of the drug twice daily,
steady-state trough plasma concentrations were 110, 302,
and 588 mg/mL, respectively. Usually, no neurotoxic-
ity is observed if the plasma level of amantadine is no
more than 1.00 mg/mL. Amantadine crosses the blood–
brain barrier and is distributed in saliva, nasal secretions,
and breast milk (26). Approximately 90% of the drug is
excreted unchanged by the kidney, primarily through
glomerular filtration and tubular secretion, and there
are no reports of metabolic products. Acidification of
urine increases the rate of amantadine excretion. The
half-life of the drug is 15 to 20 hours in patients with nor-
mal renal function.
SIDE EFFECTS Generally, the drug has low toxicity at ther-
apeutic levels but may cause severe CNS symptoms such
as nervousness, confusion, headache, drowsiness, insom-
nia, depression, and hallucinations. Gastrointestinal
(GI) side effects include nausea, diarrhea, constipation,
and anorexia. Convulsions and coma occur with high
doses and in patients with cerebral arteriosclerosis and
convulsive disorders. Chronic toxicity with amantadine
is unexpected since few side effects have been expe-
rienced when the drug has been used for long-term
therapy for Parkinson disease. Some serious reactions,
however, include depression, orthostatic hypotension,
psychosis, urinary retention, and congestive heart fail-
ure. Amantadine hydrochloride should be used with
caution in patients who have a history of epilepsy, severe
arteriosclerosis, liver diseases, and eczematoid derma-
titis. Because amantadine does not appear to interfere
with the immunogenicity of inactivated influenza A virus
vaccine, patients may continue the use of amantadine
1279
for 1 week after influenza A vaccination. A virus resis-
tant to amantadine has been obtained in cell culture
and from animals, but these reports are not confirmed
in humans.
Rimantadine
MECHANISM OF ACTION Rimantadine hydrochloride
(α-methyl-1-adamantanemethylamine hydrochloride)
is a synthetic adamantane derivative that is structurally
and pharmacologically related to amantadine (Fig. 38.3)
(27,28). It appears to be more effective than amantadine
hydrochloride against influenza A virus with fewer CNS
side effects. Rimantadine hydrochloride is thought to
interfere with virus uncoating by inhibiting the release
of specific proteins. It may act by inhibiting RT or the
synthesis of virus-specific RNA but does not inhibit virus
adsorption or penetration. It appears to produce a viru-
static effect early in the virus replication. It is used widely
in Russia and Europe.
CLINICAL APPLICATION Rimantadine hydrochloride has
activity against most strains of influenza A including
H1N1, H2N2, and H3N2 but has no activity against influ-
enza B virus. It is used for prevention of infection caused
by various human, animal, or avian strains of influenza A
virus in adults and children. The side effects are night-
mares, hallucinations, and vomiting. The most common
side effects of rimantadine are associated with the CNS
and GI tract.
PHARMACOKINETICS Rimantadine is metabolized in the
liver, and about 90% is excreted in the urine within
24 hours. The major urinary metabolites are ring-
hydroxylated derivatives, a small percentage of which
are glucuronidated. The half-life of rimantadine in
adults ranges from 24 to 36 hours. Over 90% of riman-
tadine doses are absorbed in 3 to 6 hours. Steady-state
plasma concentrations range from 0.10 to 2.60 mg/mL
at doses of 3 mg/kg/d in infants to 100 mg twice daily
in the elderly. Nasal fluid concentrations of rimanta-
dine at steady-state were 1.5 times higher than plasma
concentration.
Interferon (29,30)
Isaacs and Lindenmann discovered interferon in 1957.
When they infected cells with viruses, interference
with the cellular effects of viral infection was observed.
Interferon was subsequently isolated and found to pro-
tect the cells from further infection. When interferon
was administered to other cells or animals, it displayed
biologic properties such as inhibition of viral growth,
cell multiplication, and immunomodulatory activities.
The results led to the speculation that interferon may
be a natural antiviral factor, possibly formed before anti-
body production, and may be involved in the normal
mechanism of resistance displayed against viral infec-
tion. Some investigators relate interferon to the poly-
peptide hormones and suggest that interferon functions
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1280 PART III / PHARMACODYNAMIC AGENTS
in cell-to-cell communication by transmitting specific
messages. Recently, antitumor and anticancer proper-
ties of interferon have evoked worldwide interest in the
possible use of this agent in therapy for viral diseases,
cancer, and immunodeficiency disorders. Host cells in
response to various inducers synthesize interferons.
INTERFERON STRUCTURE Interferon consists of a mixture
of small proteins with molecular weights ranging from
20,000 to 160,000 daltons. They are glycoproteins that
exhibit species-specific antiviral activity. Human interfer-
ons are classified into three types: alpha (α), beta (β),
and gamma (γ) (31). The α-type is secreted by human
leukocytes (white blood cells, non–T lymphocytes), and
the β-type is secreted by human fibroblasts. Lymphoid
cells (T lymphocytes), which either have been exposed
to a presensitized antigen or have been stimulated to
divide by mitogens, secrete α-interferon. γ-Interferon is
also called “immune” interferon. Interferons are active
in extremely low concentrations.
MECHANISM OF ACTION Although, interferons are mediators
of immune response, different mechanisms for the antiviral
action of interferon have been proposed. α-Interferon
possesses broad-spectrum antiviral activity, and acts on
virus-infected cells by binding to specific cell surface
receptors. It inhibits the transcription and translation of
mRNA into viral nucleic acid and protein. Studies in cell
free systems have shown that the addition of adenosine
triphosphate and double-stranded RNA to extracts of
interferon-treated cells activates cellular RNA proteins
and a cellular endonuclease. This activation causes the
formation of translation inhibitory protein, which termi-
nates production of viral enzyme, nucleic acid, and struc-
tural proteins (32). Interferon may also act by blocking
synthesis of a cleaving enzyme required for viral release.
CLINICAL APPLICATION Interferon has been tested for use in
chronic HBV infection, herpetic keratitis, herpes genitalis,
herpes zoster, varicella-zoster, chronic hepatitis, influenza,
and common cold infections. Other uses of interferon are
in the treatment of cancers, such as breast cancer, lung car-
cinoma, and multiple myeloma. Interferon has had some
success when used as a prophylactic agent for cytomegalo-
virus (CMV) infection in renal transplant recipients. The
scarcity of interferon and the difficulty in purifying it have
limited clinical trials. Supplies have been augmented by
recombinant DNA technology, which allows cloning of
the interferon gene (33), although the high cost still hin-
ders clinical application. The FDA has approved recom-
binant interferon α-2a and α-2b and γ-interferon for the
treatment of hairy cell leukemia (a rare form of cancer),
AIDS-related Kaposi sarcoma, and genital warts (condy-
loma acuminatum). Subcutaneous injection of recombi-
nant interferon α-2b has been approved for the treatment
of chronic HCV. Some foreign countries have approved
α-interferon for the treatment of cancers such as multiple
myeloma (cancer of plasma cells), malignant melanoma
(skin cancer), and Kaposi sarcoma (cancer associated
with AIDS). Both β- and γ-interferons and interleukin-2
may be commercial drugs of the future for the treatment
of cancers and viral infections, including genital warts
and the common cold.
PHARMACOKINETICS The pharmacokinetics of interferon
are not well understood. Maximum levels in blood after
intramuscular injection were obtained in 5 to 8 hours.
Interferon does not penetrate well into cerebrospinal
fluid (CSF). Oral administration of interferon does
not indicate a detectable serum level, and as such, oral
administration is clinically ineffective. After intramus-
cular or subcutaneous injection, drug concentration in
the plasma is dose related. Clinical use of interferon is
limited to topical administration (nasal sprays) for pro-
phylaxis and treatment of rhinovirus infections. Adverse
reactions and toxicity include influenza-like syndrome of
fever, chills, headache, myalgias, nausea, vomiting, diar-
rhea, bone marrow suppression, mental confusion, and
behavioral changes. Intranasal administration produces
mucosal friability, ulceration, and dryness. Two long-
acting forms of interferon have recently become available.
The addition of polyethylene glycol to the formulation of
interferon α-2a and interferon α-2b affords an injectable
form of each drug that has an extended half-life.
Because viruses were found to induce the release of
interferon, efforts were made to induce the produc-
tion or release of interferon in humans by the admin-
istration of chemical “inducers” (34). Various small
molecules (substituted propanediamine) and large poly-
mers (double-stranded polynucleotides) were used to
induce interferons. Statolon, a natural double-stranded
RNA produced in Penicillium stoloniferum culture, and a
double-stranded complex of polyriboinosinic acid and
polyribocytidylic acid (poly I:C) have been used as non-
viral inducers for releasing preformed interferons. A
modification of poly I:C stabilized with poly-l-lysine and
carboxymethylcellulose (poly ICLC) has been used exper-
imentally in humans. Clinically, it prevented coryza when
used locally in the nose and conjunctival sacs. This sub-
stance was found to be a better interferon inducer than
poly I:C. Another interferon inducer is Ampligen, a poly-
nucleotide derivative of poly I:C with spaced uridines. It
has anti-HIV activity in vitro and is an immunomodulator.
Other chemical inducers, such as pyran copolymers,
tilorone, diethylaminoethyl dextran, and heparin, have
also been used. Tilorone is an effective inducer of inter-
feron in mice but is relatively ineffective in humans.
Initial use of interferon and its inducers instilled intrana-
sally after rhinovirus exposure was successful in the pre-
vention of respiratory diseases.
O
N O O N
Tilorone
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 CHAPTER 38 / ANTIVIRAL AGENTS AND PROTEASE INHIBITORS 1281

The clinical success of interferon and its inducers has not
yet been established, although they may play a significant
role in cell-mediated immunity to viral infections and
cancer. Disadvantages of interferon use include unac-
ceptable side effects, such as fever, headache, myalgias,
leukopenia, nausea, vomiting, diarrhea, hypotension,
alopecia, anorexia, and weight loss.
Neuraminidase Inhibitors (35)
Virus Activation
The role played by the surface glycoproteins HA, an
enzyme important for viral binding to host cell recep-
tors via a terminal sialic acid residue, and NA, an enzyme
involved in various aspects of activation of influenza
viruses, was discussed earlier. Freshly shed virus particles
are coated with sialic acid residues. NA is found in both
influenza A and B viruses and is thought to be involved
in catalytically cleaving glycosidic bonds between terminal
sialic acid residues and adjacent sugars on HA. The cleav-
age of sialic acid bonds facilitates the spread of viruses by
enhancing adsorption to cell surface receptors, and thus
increases the infective level of the virus. In the absence of
sialic acid cleavage from HA, viral aggregation or inappro-
priate binding to HA will occur, interfering with the spread
of the infection. NA also appears to play a role in prevent-
ing viral inactivation by respiratory mucus (Fig. 38.4).
Mechanism of Action
Since NA plays such an important role in the activa-
tion of newly formed viruses, it is not surprising that the
development of NA inhibitors has become an important
HO
OH COOH
HO
H3C NH O O sugar-GP
HO
O HO
NA
HO
HO
OH
HO COOH OH
H3C NH O HO
HO H3C NH
O HO
O HO
Transition state
potential means of inhibiting the spread of viral infections.
X-ray crystallography of NA has shown that while the
amino acid sequence of NA from various viruses is con-
siderably different, the sialic acid binding site is quite
similar for type A and B influenza viruses. In addition,
it is believed that the hydrolysis of sialic acid proceeds
through an oxonium cation–stabilized carbonium ion
as shown in Figure 38.4. Mimicking the transition state
with novel carbocyclic derivatives of sialic acid has led
to the development of transition state–based inhibitors
(36). The first of these compounds, 2-deoxy-2,3-dehydro-
N-acetylneuraminic acid (DANA; Fig. 38.5), was found to
be an active neuraminidase inhibitor but lacked specific-
ity for viral neuraminidase. Upon determination of the
crystal structure of neuraminidase, more sophisticated
measurements of the binding site for sialic acid led to the
development of zanamivir and, later, oseltamivir.
Specific Drugs
ZANAMIVIR Crystallographic studies of DANA bound to
NA defined the receptor site to which the sialic acid por-
tion of the virus binds. These studies suggested that substi-
tution of the 4-hydroxy with an amino group or the larger
guanidino group should increase binding of the inhibitor
to NA. The 4-amino derivative was found to bind to a glu-
tamic acid (Glu 119) in the receptor through a salt bridge,
whereas the 4-guanidino derivative was able to form both
a salt bridge to Glu 119 and a charge–charge interaction
with a glutamic acid at position 227. The result of these
substitutions was a dramatic increase in binding capacity
of the 4-amino and 4-guanidino derivatives to NA, lead-
ing to effective competitive inhibition of the enzyme. The
result has been the development of the 4-guanidino ana-
log as zanamivir (Fig. 38.5), which has become an effec-
tive agent against influenza A and B virus.
OH HO OH
H
1 H
HO H 6 O HO H O
N COOH N COOH
H3C C 5 2 H 3C C
O HO 4 3
O HN
HN NH2
O COOH HO
DANA Zanamivir
OH
O
H2N
COOH
OH
HO

Sialic acid
HO
OH COOH OH
HO O H H
H3C NH O O H + Sugar GP HN COOH
HO HN COOC2H5
H3C O
O
H3C HN
O H2N H3PO4 NH
N-Acetylsialic acid H2N

FIGURE 38.4 Neuraminidase-catalyzed removal of a sialic acid Peramivir

Oseltamivir phosphate
residue from a glycoprotein chain. GP, glycoprotein; NA, neur-
aminidase. FIGURE 38.5
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Neuraminidase inhibitors based on sialic acid.
1282 PART III / PHARMACODYNAMIC AGENTS
Zanamivir is effective when administered via the nasal,
intraperitoneal, and intravenous routes but is inactive
when given orally (Table 38.2). Animal studies have shown
68% recovery of the drug in the urine following intra-
peritoneal administration, 43% urinary recovery follow-
ing nasal administration, and only 3% urinary recovery
following oral administration. Human data gave similar
results to those obtained in animal models. Human effi-
cacy studies with nasal drops or sprays demonstrated that
the drug was effective when administered before exposure
and after exposure to influenza A or B virus. When given
before viral inoculation, the drug reduced viral shedding,
infection, and symptoms. When administered beginning
at either 26 or 32 hours after inoculation, there was a
reduction in shedding, viral titer, and fever. Presently the
drug is available as a dry powder for oral inhalation by
adults and adolescents who have been symptomatic for
no more than 2 days. Zanamivir is able to more rapidly
resolve influenza symptoms and improve recovery (from
7 days with placebo to 4 days with treatment). Additional
studies have suggested the prophylactic benefit of zanami-
vir when administered to family members after one mem-
ber of the family developed flu-like symptoms. As a result,
the manufacturer has submitted an application for the
use of the drug for the prevention of influenza A and B.
OSELTAMIVIR X-ray crystallographic studies further dem-
onstrated that additional binding sites exist between
NA and substrate involving the C-5 acetamido carbonyl
of DANA and an arginine (Arg 152), the C-2 carboxyl
and arginines as 118, 292, and 371, and the potential for
hydrophobic binding to substituents at C-6 (with glutamic
acid, alanine, arginine, and isoleucine). Structure–activity
relationship studies showed that maximum binding
occurred to NA when C-6 (based on DANA numbering)
was substituted with the 3-pentyloxy side chain such as
the one found in oseltamivir (Fig. 38.5). In addition,
esterification with ethanol gave rise to a compound that
is orally effective. Oseltamivir phosphate was approved
as the first orally administered NA inhibitor used against
influenza A and B (Table 38.2). The drug is indicated for
the treatment of uncomplicated acute illness due to influ-
enza infection. Recently, the manufacturer has submitted
a request for approval of the drug for prevention of influ-
enza A and B for use in adults, adolescents, and children
1 year of age and older. The drug is effective in treat-
ing influenza if administered within 2 days after onset of
symptoms. The recommended dose is 75 mg twice daily
for 5 days. The prophylactic dose is 75 mg taken once
daily for 7 days. Oseltamivir is readily absorbed from the
GI tract following oral administration. It is a prodrug
that is extensively metabolized in the liver undergoing
ester hydrolysis to the active carboxylic acid (Fig. 38.6).
Two oxidative metabolites have also been isolated, with
the major oxidation product being the ω-carboxylic acid
(37). Side effects with oseltamivir are minor, consisting
of nausea and vomiting that occur primarily in the first
2 days of therapy.
O H O H
HN COOC2H5 HN COOH
H3 C H3 C
O H 2N O H2N
Oseltamivir Active metabolite
ω-Oxidation
HO HO
O H O O H
HN COOC2H5 HN COOC2H5
H3 C H3C
O H 2N O H2N
FIGURE 38.6 Metabolism of oseltamivir by hydrolysis and
ω-oxidation.
PERAMIVIR In 2009, the experimental NA inhibitor peramivir
(Fig. 38.5, Table 38.2) received emergency FDA approval
for use in treatment of certain hospitalized patients with
known or suspected H1N1 influenza infections. This rep-
resents the first time in which an experimental drug in
phase III clinical trials has received an emergency use
approval. The drug is only available by electronic request
from the U.S. Strategic National Stockpile. The use of per-
amivir is restricted to severe H1N1 influenza cases where
other antiviral agents (including NA inhibitors) have
failed (38). For example, a patient infected with an H1N1
strain of influenza that is resistant to oseltamivir and who is
unable to inhale zanamivir would be a candidate for pera-
mivir treatment. Peramivir is structurally distinct from osel-
tamivir and zanamivir in that it contains a cyclopentane
ring structure that replaces the sialic acid core and because
it does not contain a glycerol side chain, which is thought
to reduce the oral bioavailability of oseltamivir and zanami-
vir. The structure of peramivir was proposed using the tech-
nique of structure-based design. In this approach, in silico
docking of proposed NA inhibitors suggested that perami-
vir bound most efficiently to the four known binding pock-
ets in the viral NA catalytic site. Peramivir is administered
intravenously as a single dose (0.5 to 8 mg/kg) or as two
daily doses (4 mg/kg). It has a serum half-life of 7.7 to
20 hours, and 90% of the drug is excreted unchanged in
the urine. Because peramivir is still in phase III clinical tri-
als, efficacy data have not yet been released.
Entry (Fusion) Inhibitors
Enfuvirtide (39,40)
N-acetyl-Tyr-Thr-Ser-Leu-Ile-His-Ser-Leu-Ile-Glu-Glu-Ser-Gln-Asp-
Gln-Gln-Glu-Lys-Asp-Glu-Gln-Glu-Leu-Leu-Glu-Leu-Asp-Lys-Try-Ala-
Ser-Leu-Try-Asp-Try-Phe-NH2
Enfuvirtide
Entry inhibitors, also known as fusion inhibitors, are
a new class of drugs for the treatment of HIV infec-
tion, and enfuvirtide is the first compound of this
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family to be approved for clinical use. Enfuvirtide is an
oligopeptide consisting of 36 amino acids. It is a syn-
thetic peptide that mimics an HR2 fragment of gp41,
blocking the formation of a six-helix bundle struc-
ture that is critical in the fusion of the HIV-1 virion
to a CD4-positive T lymphocyte. Specifically, it binds
to the tryptophan-rich region of the gp41 protein.
Enfuvirtide is used in combination with other antiret-
rovirals and works against a variety of HIV-1 variants,
but it is not active against HIV-2. Resistance to enfu-
virtide can develop when the virus produces changes
in a 10–amino acid domain between residues 36 to
45 in the gp41 HIV surface glycoprotein. The drug is
administered twice daily as a subcutaneous injection
and has a complex absorption pattern. Enfuvirtide is
highly bound to plasma protein (∼92%) and is prone
to proteolytic metabolism. Adverse reactions include
pain, erythema, and pruritus at the site of injection
and insomnia.
F F
H H H pesvirus than in normal cells because acyclovir is a poor
N
H3C H
N
H3C
O N CH3
H is further converted to di- and triphosphates by a normal
H N H N
N N
N N
H3C H3C
Maraviroc Maraviroc metabolite
Maraviroc
CCR5 is a protein produced by humans that is a member
of the chemokine coreceptor family and is located in the
cell membrane of specific human cells (i.e., T cells, mac-
rophages, dendritic cells, microglia). Although there are a
number of natural substrates for this receptor protein, HIV
can use this G protein–coupled receptor in part as a core-
ceptor for entry into its targeted cells. In addition, indi-
viduals who have a mutation in the CCR5 gene (CCR5-δ32)
have a deletion of a portion of the CCR5 gene, which in
turn leads to reduced or absent expression of CCR5 in
heterozygous or homozygous genotypes, respectively, with
no apparent deleterious consequences. Individuals homo-
zygous with respect to CCR5-δ32 have a high degree of
resistance to HIV infection, whereas heterozygotes have
a reduced rate of disease progression. As a result, CCR5
antagonists represent a promising new class of cell entry
inhibitor drugs under development for the treatment of
HIV-1 infection (fusion inhibitor). The CCR5 antagonist
maraviroc has potent anti-HIV activity in vitro and is safe
and well-tolerated at multiple doses up to 300 mg twice daily
in healthy volunteers. Maraviroc was recently approved by
the FDA (Selzentry; Pfizer). Maraviroc is an orally adminis-
tered drug available as 150- and 300-mg film-coated tablets.
The current FDA-approved dosage of maraviroc is 300 mg
twice daily, and it must be used in combination with other
antiretroviral medications. Maraviroc is actively absorbed
following oral administration but has a low bioavailability
CHAPTER 38 / ANTIVIRAL AGENTS AND PROTEASE INHIBITORS 1283
(∼23%) and is a substrate for P-glycoprotein, possibly
accounting for the poor bioavailability. The drug is highly
bound to plasma proteins (∼76%) and is metabolized to
inactive metabolites via CYP3A4. The major metabolite
results from N-dealkylation.
Agents Interfering with Viral Nucleic Acid
Replication (Table 38.3)
Acyclic Nucleoside Analogs (Fig. 38.7)
ACYCLOVIR
Mechanism of Action Acyclovir is a synthetic analog of
deoxyguanosine in which the carbohydrate moiety is acy-
clic (Fig. 38.7) (41). Because of this difference in structure
as compared to other antiviral compounds (idoxuridine,
vidarabine, and trifluridine, see below), acyclovir pos-
sesses a unique mechanism of antiviral activity. The mode
of action of acyclovir consists of three consecutive mecha-
nisms (42). The first of these mechanisms involves conver-
sion of the drug to active acyclovir monophosphate within
cells by viral thymidine kinase (Fig. 38.8). This phosphory-
lation reaction occurs faster within cells infected by her-
substrate for the normal cell thymidine kinase. Acyclovir
CH3
cellular enzyme called guanosine monophosphate kinase.
In the second mechanism, viral DNA polymerase is com-
petitively inhibited by acyclovir triphosphate with a lower
half maximal inhibitory concentration (IC50) concentra-
tion than that for cellular DNA polymerase. Acyclovir
triphosphate is incorporated into the viral DNA chain dur-
ing DNA synthesis. Because acyclovir triphosphate lacks
the 3’-hydroxyl group of a cyclic sugar, it terminates fur-
ther elongation of the DNA chain. The third mechanism
depends on preferential uptake of acyclovir by herpes-
infected cells as compared to uninfected cells, resulting
in a higher concentration of acyclovir triphosphate and
leading to a high therapeutic index between herpes-
infected cells to normal cells. Acyclovir is active against
certain herpes virus infections. These viruses induce virus-
specific thymidine kinase and DNA polymerase, which are
inhibited by acyclovir. Thus, acyclovir significantly reduces
DNA synthesis in virus-infected cells without significantly
disturbing the active replication of uninfected cells.
Clinical Application Acyclovir has potent activity against
several DNA viruses including HSV-1, the common cause
of labial herpes (cold sore), and HSV-2, the common
cause of genital herpes (Table 38.3) (43). Varicella-zoster
virus (VZV) and some isolates of EBV are affected to a
lesser extent by acyclovir. However, CMV is less sensitive
to acyclovir, which has no activity against vaccinia virus,
adenovirus, and parainfluenza infections. An ointment
containing 5% acyclovir has been used in a regimen of
five times a day for up to 14 days for the treatment of
herpetic keratitis and primary and recurrent infections
of herpes genitalis. Mild pain, transient burning, sting-
ing, pruritus, rash, and vulvitis have been noted. The
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1284 PART III / PHARMACODYNAMIC AGENTS

TABLE 38.3 Antiviral Agents Interfering with Viral Nucleic Acid Replication
Generic Name Common Trade Spectrum of Activity Dosage Form (mg/unit)
Name Name

Acyclic nucleoside analogs (Fig. 38.7)

Acyclovir Acyclo-G Zovirax HSV-1; HSV-2; VZV; 5% Oint, Inj (5mg/ml), Cap
EBV (200), Tab (400, 800), Susp
(200/5 mL)

Valacyclovir Valtrex HSV-1; VZV; CMV Tab (500)

Cidofovir HPMPC Vistide CMV; HSV-1; HSV-2; Inj (75/mL)

VZV; CMV; EBV

Famciclovir FCV Famvir HSV; VZV; EBV; Tab (125, 250, 500)
chronic HBV

Ganciclovir DHPG Cytovene CMV retinitis Inj (50/mL), Cap (250, 500),
Vitrasert Insert (4.5/insert)

Adefovir dipivoxil Hepsera Hepatitis B Tab (10)

Conventional nucleoside analogs (Fig. 38.11)

Idoxuridine 5-IUDR Herplex HSV keratitis 0.1% Sol, 0.5% Oint

Stoxil

Ribavirin Virazole RSV; influenza A and B; Aerosol (20/mL)

HIV-1; parainfluenza

Trifluorothymidine TFT, FT3 Viroptic HSV-1 1% Sol

Vidarabine Ara-A Vira A HSV-1; HSV-2 3% Oint (monohydrate)

Cytarabine Ara-C Cytosar Herpes zoster Inj (10, 20, 50, 100/mL)

Non-nucleoside analogs (Fig. 38.13)

Boceprevir Victrelis HCV Tab (200)

Fomivirsen CMV retinitis

Foscarnet PFA Foscavir CMV retinitis; HSV Inj (24/mL)

Telaprevir Incivek HCV Tab (375)

CMV, cytomegalovirus; EBV, Epstein-Barr virus; HBV, hepatitis B virus; HSV, herpes simplex virus; VZV, varicella-zoster virus.

FDA has approved topical and intravenous (IV) acyclovir
preparations for initial herpes genitalis and HSV-1 and
HSV-2 infections in immunocompromised patients (44).
In these individuals, early use of acyclovir shortens the
duration of viral shedding and lesion pain. Oral doses
of 200 mg of acyclovir, taken five times a day for 5 to 10
days, have not proven successful because of the low bio-
availability of current preparations. Oral doses of 800 mg
of the drug given five times daily for 7 to 10 days have
been approved by the FDA for treatment of herpes zoster
infection. This treatment shortens the duration of viral
shedding in chickenpox and shingles. The IV injection of
the drug (10 mg/kg three times daily for 10 to 12 days)
has been approved for the treatment of herpes simplex
encephalitis (45). Excessive and high doses of acyclovir
have, however, caused viruses to develop resistance to
the drug. This resistance results from reduction of virus-
encoded thymidine kinase, which does not effectively
activate the drug.
Pharmacokinetics Pharmacokinetic studies show that
IV dose administration of acyclovir 2.5 mg/kg results in
peak plasma concentrations of 3.4 to 6.8 mg/mL (46,47).
The bioavailability of acyclovir is 15% to 30%, and it is
metabolized to 9-carboxymethoxymethylguanine, which
is inactive. Plasma protein binding averages 15%, and
approximately 70% of acyclovir is excreted unchanged in
the urine by both glomerular filtration and tubular secre-
tion. The half-life of the drug is approximately 3 hours
in patients with normal renal function. In an individual
with renal diseases, the half-life of the drug is prolonged.
Therefore, acyclovir dosage adjustment is necessary for
patients with renal impairment. Acyclovir easily pen-
etrates the lung, brain, muscle, spleen, uterus, vaginal
mucosa, intestine, liver, and kidney.
VALACYCLOVIR Valacyclovir hydrochloride is an amino
acid ester prodrug of acyclovir, which exhibits antiviral
activity only after metabolism in the intestine or liver to
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O O
N HN
HN
H2N N N H2N N N
HOCH2 (CH3)2CH CH C OCH2
O O
NH2 O
Acyclovir Valacyclovir
O NH2
N N
HN
H2N N N H2N N N
H3C C OCH2 HOCH2
O
O O
O OH
C CH3
O
Famciclovir Ganciclovir
FIGURE 38.7 Agents that interfere with viral nucleic acid replication: acyclic nucleosides.
acyclovir followed by conversion to the triphosphate as
shown in Figure 38.8 (48). Structurally, it differs from
acyclovir by the presence of the amino acid valine attached
to the 5′-hydroxyl group of the nucleoside. Valacyclovir’s
benefit comes from an increased GI absorption resulting
in higher plasma concentrations of acyclovir, which is
normally poorly absorbed from the GI tract. As with acy-
clovir, valacyclovir is active against HSV-1, VZV, and CMV
because of its affinity for the viral form of the enzyme thy-
midine kinase. Oral valacyclovir is used for the treatment
of acute, localized herpes zoster (shingles) in immuno-
competent patients and may be given without meals. It is
also used for the initial and recurrent episodes of genital
herpes infections (Table 38.3). The adverse effects are
similar to acyclovir and include nausea, headache, vomit-
ing, constipation, and anorexia. The binding of valacy-
clovir to human plasma proteins ranges from 13.5% to
17.9%. The plasma elimination half-life of acyclovir is
2.5 to 3.3 hours. The bioavailability of valacyclovir hydro-
chloride is 54% compared to approximately 20% for oral
acyclovir. It is as effective as acyclovir in decreasing the
duration of pain associated with posttherapeutic neural-
gia and episodes of genital lesion healing. The related
analog 6-deoxyacyclovir (Fig. 38.8) is a prodrug form of
acyclovir that is activated through metabolism by xan-
thine oxidase. This drug, which has improved solubility
characteristics when compared to acyclovir, is used for
the treatment of VZV infection.
CIDOFOVIR
Mechanism of Action Cidofovir (1-[(S)-3-hydroxy-2-
(phosphonomethoxy)propyl]cytosine) is a synthetic acy-
clic purine nucleotide analog of cytosine (Fig. 38.7) (49).
It is a phosphorylated nucleotide that is additionally
phosphorylated by host cell enzymes to its active intra-
cellular metabolite, cidofovir diphosphate. This reaction
occurs without initial virus-dependent phosphorylation
CHAPTER 38 / ANTIVIRAL AGENTS AND PROTEASE INHIBITORS 1285
NH2
N N N N
H2N N N O N
HOCH2 CH2 O
O H C O CH2 P OH
CH2OH OH
6-Deoxyacyclovir Cidofovir
N N
N
O
N O
N
O P O O
O
O
Adefovir dipivoxil
by viral nucleoside kinases. It produces antiviral effects
through interfering with DNA synthesis and inhibiting
viral replication.
Clinical Application Cidofovir is active against herpes
viruses including HSV-1 and HSV-2, VZV, CMV, and EBV.
It is effective against acyclovir-resistant strains of HSV and
ganciclovir-resistant strains of CMV. Cidofovir is a long-
acting drug for the treatment of CMV retinitis in AIDS
patients given as IV infusion or intravitreal injection. It is
not a curative drug, and its benefit over foscarnet or gan-
ciclovir is yet to be determined. The major adverse effect
is nephrotoxicity, which appears to result in renal tubular
damage. Concomitant administration of cidofovir with
probenecid is contraindicated because of increased risk
of nephrotoxicity. Topical cidofovir (0.2%) is as effec-
tive as trifluridine (1%) in reducing HSV-1 shedding and
healing time in rabbits with dendritic keratitis. Cidofovir
is administered IV, topically, and by ocular implant (Table
38.3). Peak plasma concentration of 3.1 to 23.6 mg/mL
is achieved with doses of 1.0 to 10.0 mg/kg, respectively.
The terminal plasma half-life is 2.6 hours, and 90% of the
drug is excreted in the urine. It has a variable bioavail-
ability (2% to 26%).
FAMCICLOVIR
Mechanism of Action Famciclovir is a synthetic purine
nucleoside analog related to guanine (50,51). It is the
diacetyl 6-deoxy ester of penciclovir, which is structur-
ally related to ganciclovir. Its pharmacologic and micro-
biologic activities are similar to acyclovir. Famciclovir is
a prodrug of penciclovir (Fig. 38.9), which is formed in
vivo by hydrolysis of the acetyl groups and oxidation at
the 6-position by mixed function oxidases. Penciclovir
and its metabolite penciclovir triphosphate possess
antiviral activity resulting from inhibition of viral DNA
polymerase.
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1286 PART III / PHARMACODYNAMIC AGENTS

O O
N N N N N N
HN HN

H2N N N H2N N N H2N N N H2N N N

CH C OCH2 HOCH2 H3C C OCH2 HOCH2

NH2 O O O O

Valacyclovir 6-Deoxyacyclovir O OH
C CH3
O
O
Famciclovir Penciclovir
HN N
O
H2N N N
HN N
HOCH2
O H2N N N
HOCH2
O
Acyclo-G (acyclovir)

OH
O O Ganciclovir
HN N N
HN FIGURE 38.9 Metabolic activation of famciclovir.
H2N N N N
H2N N
O
O (HO)2 P OCH2
HO C
O
O is ganciclovir triphosphate, which is an inhibitor of viral
rather than cellular DNA polymerase. The phosphoryla-
9-Carboxymethoxy Acylo-G monophosphate
tion of ganciclovir does not require a virus-specific thymi-
methylguanine
dine kinase for its activity against CMV. The mechanism of
action is similar to that of acyclovir; however, ganciclovir
O
is more toxic to human cells than is acyclovir. Ganciclovir
N
has greater activity than acyclovir against CMV and EBV
HN
infection in immunocompromised patients. It is also
N
H2N N active against HSV infection and in some mutants resis-
O
H O P O CH2
tant to acyclovir. In AIDS patients, ganciclovir stopped
O progressive hemorragic retinitis and symptomatic pneu-
OH
3 monitis related to CMV infection.
Acyclo-G triphosphate
Clinical Application Ganciclovir is absorbed and phos-
FIGURE 38.8 Metabolic reactions of acyclovir and valacyclovir. phorylated by infection-induced kinases of HSV and VZV
infections. Common side effects are leukopenia, neutro-
Clinical Application Famciclovir is active against recur- penia, and thrombocytopenia. Ganciclovir with zidovu-
rent HSV (genital herpes and cold sores), VZV, and EBV dine causes severe hematologic toxicity. Ganciclovir is
but less active against CMV (Table 38.3). It is used in the available only as an IV infusion because oral bioavailabil-
treatment of recurrent localized herpes zoster and geni- ity is poor (Table 38.3). It is given in doses of 5 mg/kg
tal herpes in immunocompetent adults and is also prom- twice daily for 14 to 21 days. When ganciclovir is given
ising for the treatment of chronic HBV reinfection after by IV administration, concentrations of the drug in the
liver transplantation. CSF and the brain vary from 25% to 70% of the plasma
concentration. After minimal metabolism, ganciclovir is
Pharmacokinetics Famciclovir can be given with or excreted in the urine. In adults with normal renal func-
without food. The most common adverse effects are tion, the serum half-life of the drug is approximately
headache and GI disturbances. Concomitant use of fam- 3 hours. Ganciclovir has been approved by the FDA for
ciclovir with probenecid results in increased plasma con- the treatment of CMV retinitis in immunocompromised
centrations of penciclovir. The recommended dose of and AIDS patients.
famciclovir is 500 mg every 8 hours for 7 days. The abso-
lute bioavailability of famciclovir is 77%, and area under ADEFOVIR DIPIVOXIL (53)
plasma concentration–time curve (AUC) is 86 mcg/mL. Mechanism of Action Adefovir dipivoxil is an orally
Famciclovir with digoxin increased plasma concentration active prodrug indicated for the treatment of chronic
of digoxin to 19% as compared to digoxin given alone. HBV (Fig. 38.7). The drug is hydrolyzed by extracellular
esterases to produce adefovir, which in turn is phosphor-
GANCICLOVIR ylated by adenylate kinase to adefovir phosphate, which
Mechanism of Action Ganciclovir sodium is an acyclic inhibits HBV DNA polymerase. Incorporation of adefo-
deoxyguanosine analog of acyclovir (52). Its active form vir into viral DNA also leads to DNA chain termination.
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 CHAPTER 38 / ANTIVIRAL AGENTS AND PROTEASE INHIBITORS 1287

NH2 O
Esterase N R
N HN
Adefovir dipivoxil Idoxuridine (R = I, X = OH)
N N O X O N
Fluorodeoxyuridine (R = F, X = OH)
O P O O
Bromodeoxyuridine (R = Br, X = OH)
Adefovir O
5'-Aminoidoxuridine (R = I, X = NH2)
OH

Adenylate kinase O O
CF3
NH2 H2N N HN
N N
N HO N HO O N
O O
N N O O
O P O P O
O O OH OH OH

Adefovir phosphate Ribavirin Trifluorothymidine

(TFT, F3T)
FIGURE 38.10 Activation of the prodrug adefovir dipivoxyl by
NH2 NH2
esterase and adenylate kinase.
N N N

N N O N
HO HO
As shown in Figure 38.10, adefovir dipivoxil is activated HO HO
O O
in two steps involving an esterase that exposes a free
phosphate group (adefovir), followed by addition of a OH OH
second phosphate by adenylate kinase to form adefovir
Vidarabine (ara-A) Cytarabine
phosphate.
(ara-C)

Pharmacokinetics Adefovir is poorly absorbed orally, but
the bioavailability of adefovir dipivoxil reaches approx-
imately 59%. The drug is absorbed to an equal extent
with or without the presence of food, and it is excreted
unchanged by the kidney. Adefovir dipivoxil joins inter-
feron and lamivudine in the treatment of chronic HBV.
It can be used singly or in combination with lamivudine.
Early clinical studies indicate benefit of the use of adefo-
vir dipivoxil to treat lamivudine-resistant HBV with a low
level of resistant virus developing to monotherapy with
adefovir dipivoxil.
Conventional Nucleoside Analogs (Fig. 38.11)
IDOXURIDINE
Mechanism of Action Idoxuridine is a nucleoside ana-
log of thymidine containing a halogenated pyrimidine
(54). It acts as an antiviral agent against DNA viruses by
interfering with their replication based through com-
petitive inhibition. Idoxuridine is first phosphorylated by
the host cell virus-encoded enzyme thymidine kinase to
an active triphosphate form. The phosphorylated drug
inhibits cellular DNA polymerase to a lesser extent than
HSV DNA polymerase, which is necessary for the synthe-
sis of viral DNA. The triphosphate form of the drug is
then incorporated during viral nucleic acid synthesis by a
false pairing system that replaces thymidine. When tran-
scription occurs, faulty viral proteins are formed, result-
ing in defective viral particles (55).
Clinical Application Idoxuridine is available as ophthal-
mic drops (0.1%) and ointment (0.5%) for the treat-
ment of HSV keratoconjunctivitis (Table 38.3). Because
of its poor solubility, the drug is ineffective in labial or
FIGURE 38.11 Agents that interfere with viral nucleic acid repli-
cation: conventional nucleosides.
genital HSV or for cutaneous herpes zoster infection.
Idoxuridine in dimethylsulfoxide (DMSO), however,
has been used in mucocutaneous HSV infection of the
mouth and nose. Because DMSO facilitates drug absorp-
tion and also has some therapeutic effect, a 40% solution
of idoxuridine in DMSO is more effective than idox-
uridine used without this vehicle. Therefore, the FDA
approved idoxuridine only for topical treatment of her-
pes simplex keratitis, and it is more effective in epithelial
than in stromal infections. It is less effective for recurrent
herpes keratitis, probably because of the development of
drug-resistant virus strains.
Side Effects Adverse reactions of idoxuridine include
such local reactions as pain, pruritus, edema, burning,
and hypersensitivity. Systemic administration of idox-
uridine by IV injection may be given in an emergency
but leads to bone marrow toxicities such as leukopenia,
thrombocytopenia, and anemia. It may also induce sto-
matitis, nausea, vomiting, abnormalities of liver func-
tions, and alopecia. Idoxuridine has a plasma half-life of
30 minutes and is rapidly metabolized in the blood to
idoxuracil and uracil.
Other halogenated uridine derivatives can also be used
as antiviral agents (Fig. 38.11). Fluorodeoxyuridine has in
vitro antiviral activity but is not used in clinical practice.
Bromodeoxyuridine has been used in subacute scleros-
ing panencephalitis, a deadly virus-induced CNS disease.
This agent appears to interfere with DNA synthesis in the
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1288 PART III / PHARMACODYNAMIC AGENTS
same way as idoxuridine. The 5′-amino analog of idox-
uridine (5-iodo-5′-amino-2,′5′-dideoxyuridine) is a bet-
ter antiviral agent than idoxuridine and is less toxic. It
is metabolized in herpesvirus-infected cells only by thy-
midine kinase to di- and triphosphoramidates. These
metabolites inhibit HSV-specific late RNA transcription,
causing reduction of less infective abnormal viral pro-
teins. Although all of these analogs of idoxuridine have
been studied for various clinical applications, none are
presently marketed in the United States.
RIBAVIRIN
Mechanism of Action Ribavirin, a guanosine analog, has
broad-spectrum antiviral activity against both DNA and
RNA viruses (Fig. 38.11) (56,57). It is phosphorylated by
adenosine kinase to the triphosphate, resulting in inhibi-
tion of viral-specific RNA polymerase, disrupting messen-
ger RNA and nucleic acid synthesis.
Clinical Application Ribavirin is highly active against
influenza A and B and the parainfluenza group of
viruses, genital herpes, herpes zoster, measles, and acute
hepatitis types A, B, and C. Aerosolized ribavirin has been
approved by the FDA for the treatment of lower respira-
tory tract infections (bronchiolitis and pneumonia) and
serious RSV infections, but it can cause cardiopulmonary
and immunologic disorders in children. Ribavirin inhib-
its in vitro replication of HIV-1; clinically, ribavirin was
shown to delay the onset of full-blown AIDS in patients
with early symptoms of HIV infection. Some viruses are
less susceptible, for example, poliovirus, herpes viruses
excluding varicella, vaccinia, mumps, reovirus, and rota-
virus. A randomized double-blind study of aerosolized
ribavirin treatment of infants with RSV infections indi-
cated significant improvement in the severity of infection
with a decrease in viral shedding (58).
Pharmacokinetics Oral or IV forms of ribavirin are use-
ful in the prevention and treatment of Lassa fever. The
oral bioavailability is approximately 45%, and serum
half-life is 9 hours. Peak plasma level after 1 hour is
1 to 3 mg/mL. IV administration of the drug has higher
peak plasma levels. Aerosol preparation delivery of drug
(0.8 mg/kg/hour) produced drug levels in respiratory
secretions of 50 to 200 mg/mL (Table 38.3). The clinical
benefits of this agent have yet to be confirmed. Its few
side effects are generally limited to GI disturbances, such
as nausea, vomiting, and diarrhea. The drug is contra-
indicated in asthma patients because of deterioration of
pulmonary function. Viral strains susceptible to ribavirin
have not been found to develop drug resistance, as is the
case with other antiviral agents, such as acyclovir, idoxuri-
dine, and bromovinyldeoxyuridine.
TRIFLUOROTHYMIDINE
Mechanism of Action Trifluorothymidine is a fluori-
nated pyridine nucleoside structurally related to idoxuri-
dine (Fig. 38.11) (59). It has been approved by the FDA
and is a potent, specific inhibitor of replication of HSV-1
in vitro. Its mechanism of action is similar to that of idox-
uridine. Like other antiherpes drugs, it is first phosphory-
lated by thymidine kinase to mono-, di-, and triphosphate
forms, which are then incorporated into viral DNA in
place of thymidine to stop the formation of late virus
mRNA and subsequent synthesis of the virion proteins.
Clinical Application Because of its greater solubility in
water, it is active against HSV-1 and HSV-2. It is also useful
in treating infections caused by human CMV and VZV
infections. The advantage of use of this agent over idox-
uridine is its high topical efficacy in the cure of primary
keratoconjunctivitis and recurrent epithelial keratitis. It
is also useful for difficult cases of herpetic iritis and estab-
lished stromal keratitis.
Pharmacokinetics Trifluorothymidine is available as a
1% ophthalmic solution, which is effective in dendritic
ulcers (Table 38.3). Generally, a 1% eye solution of triflu-
orothymidine is well tolerated. Cross-hypersensitivity and
cross-toxicity between trifluorothymidine, idoxuridine,
and vidarabine are rare. The most frequent side effects
are temporary burning, stinging, localized edema, and
bone marrow toxicity. It is less toxic but more expen-
sive than idoxuridine. Trifluorothymidine, given intra-
venously, shows a plasma half-life of 18 minutes and is
excreted in urine unchanged or as the inactive metabo-
lite 5-carboxyuracil.
VIDARABINE
Mechanism of Action Vidarabine is an adenosine nucle-
oside obtained from cultures of Streptomyces antibioticus
(Fig. 38.11) (60). Cellular enzymes convert vidarabine
to mono-, di-, and triphosphate derivatives that interfere
with viral nucleic acid replication, specifically inhibiting
the early steps in DNA synthesis. This agent was used orig-
inally as an antineoplastic drug. Its antiviral effect is, in
some cases, superior to that of idoxuridine or cytarabine.
Clinical Application Vidarabine is used mainly in human
HSV-1 and HSV-2 encephalitis, decreasing the mortality
rate from 70% to 30%. Whitley et al. (61) reported that
early vidarabine therapy is helpful in controlling com-
plications of localized or disseminated herpes zoster in
immunocompromised patients. Vidarabine is also use-
ful in neonatal herpes labialis or genitalis, vaccinia virus,
adenovirus, RNA viruses, papovavirus, CMV, and small-
pox virus infections. Given the efficacy of vidarabine in
certain viral infections, the FDA approved a 3% ointment
for the treatment of herpes simplex keratoconjunctivitis
and recurrent epithelial keratitis and a 2% IV injection
for the treatment of herpes simplex encephalitis and her-
pes zoster infections (Table 38.3). A topical ophthalmic
preparation of vidarabine is useful in herpes simplex ker-
atitis but shows little promise in herpes simplex labialis
or genitalis. The monophosphate esters of vidarabine are
more water-soluble and can be used in smaller volumes
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and even intramuscularly. These esters are under clini-
cal investigation for the treatment of HBV, systemic and
cutaneous herpes simplex, and herpes zoster virus infec-
tions in immunocompromised patients.
Pharmacokinetics Vidarabine is deaminated rapidly by
adenosine deaminase, which is present in serum and
red blood cells. The enzyme converts vidarabine to its
principal metabolite, arabinosyl hypoxanthine (ara-HX),
which has weak antiviral activity (Fig. 38.12) (62). The
half-life of vidarabine is approximately 1 hour, whereas
ara-HX has a half-life of 3.5 hours. The drug is detected
mostly in the kidney, liver, and spleen because 50% of it
is recovered in the urine as ara-HX. Levels of vidarabine
in CSF are 50% of those in the plasma. The most com-
mon side effects of vidarabine are GI disturbances such
as anorexia, nausea, vomiting, and diarrhea. CNS side
effects include tremors, dizziness, pain syndromes, and
seizures. Bone marrow suppression is reported at higher
doses. Because vidarabine is reported to be mutagenic,
carcinogenic, and teratogenic in animal studies, its use
in pregnant women is to be avoided. Allopurinol and
theophylline may interfere with the metabolism of vida-
rabine at higher doses because of the xanthine oxidase
metabolism of vidarabine. Therefore, this agent should
be avoided or given with caution to patients receiving
these medications concurrently. Also, adjustment of the
dose is necessary in patients with renal insufficiency.
CYTARABINE
Mechanism of Action Cytarabine (1-β′-arabinofu-
ranosylcytosine) is a pyrimidine nucleoside related to
idoxuridine (Fig. 38.11) (63). It is used primarily as an
anticancer rather than an antiviral agent (see Chapter 37).
Cytarabine acts by blocking the utilization of deoxycytidine,
thereby inhibiting the replication of viral DNA. The drug
is first converted to mono-, di-, and triphosphates, which
interfere with DNA synthesis by inhibiting both DNA poly-
merase and the reductase that promotes the conversion of
cytidine diphosphate into its deoxy derivatives.
Clinical Application Cytarabine is used to treat Burkitt
lymphoma and both myeloid and lymphatic leukemias.
Its antiviral use is in the treatment of herpes zoster
NH2 O
N N HN
N N N N
HO HO
HO Adenosine HO
O O
deamination
OH OH
Vidarabine Arabinofuranosylhypoxanthine
(ara-A) (ara-HX)
FIGURE 38.12 Metabolism of vidarabine by adenosine
deaminase.
CHAPTER 38 / ANTIVIRAL AGENTS AND PROTEASE INHIBITORS 1289
(shingles) infection. It is also used to treat herpetic
keratitis and viral infections resistant to idoxuridine. The
drug is usually used topically, but it has been given by
IV injection to individuals with serious herpes infection
(64). Cytarabine is deaminated rapidly in the body to an
inactive compound, arabinosyluracil, which is excreted
in the urine. The half-life of the drug in plasma is 3 to
5 hours. The toxic effects of cytarabine are chiefly on
bone marrow, the GI tract, and the kidney. The drug is
not given in the early months of pregnancy because of its
teratogenic and carcinogenic effects in animals.
Nonnucleoside Analogs (Fig. 38.13)
FOMIVIRSEN SODIUM Fomivirsen was the first antisense oli-
gonucleotide agent approved as an alternative medicine
for patients with CMV retinitis for whom other agents
did not work. Fomivirsen is a 21-mer phosphorothio-
ate oligodeoxynucleotide (Fig. 38.13). Fomivirsen was
used to treat CMV, which causes opportunistic retinitis
in patients with AIDS. Such patients respond to fomi-
virsen but not to other treatment for CMV retinitis, which
leads to blindness (65). It works by inhibiting synthesis
of proteins responsible for the regulation of viral gene
expression that is involved in infection of CMV retinitis.
Fomivirsen has recently been withdrawn from the market
by the drug manufacturer Novartis and is thus no longer
available.
FOSCARNET SODIUM Foscarnet is a trisodium phosphofor-
mate hexahydrate that inhibits DNA polymerase of her-
pes viruses including CMV and retroviral RT (Fig. 38.13)
(66). It is not phosphorylated into an active form by viral
host cell enzymes. Therefore, it has the advantage of not
requiring an activation step before attacking the target
viral enzyme. Foscarnet sodium was approved by the FDA
5'-GCG TTT GCT CTT CTT CTT GCG-3'
Fomivirsen
H3C CH3
H H O
H
N NH2
O N
H H
N N O O
O P COO
(Na )3 O
O
O
Foscarnet sodium Boceprevir
N
H H O
H H
N N
O N
H
O O
N N
N O
H
O CH3
N
Telaprevir
FIGURE 38.13
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Nonnucleoside inhibitors of viral replication.
1290 PART III / PHARMACODYNAMIC AGENTS
for the treatment of CMV retinitis in AIDS patients. In
combination with ganciclovir, the results have been prom-
ising, even in progressive disease with ganciclovir-resistant
strains. Foscarnet sodium is also effective in the treatment
of mucocutaneous diseases caused by acyclovir-resistant
strains of HSV and VZV in AIDS patients. The drug is
administered intravenously (60 mg/kg) three times a day
for initial therapy and at a dose of 90 to 120 mg/kg daily
for maintenance therapy (Table 38.3). The plasma-half life
is 3 to 6 hours. Foscarnet sodium penetrates into the CSF
and the eye. The drug is neurotoxic, and common adverse
effects include phlebitis, anemia, nausea, vomiting, and
seizures. Foscarnet sodium carries risk of severe hypocal-
cemia, especially with concurrent use of IV pentamidine.
Foscarnet sodium used with zidovudine has an additive
effect against CMV and acts synergistically against HIV.
BOCEPREVIR AND TELAPREVIR Boceprevir (SCH 503034,
Victrelis) (67) and telaprevir (VX-950, Incivek) (68)
represent significant advances in the treatment of HCV
infection (Fig. 38.13) (Table 38.3). HCV is an enveloped,
single-stranded sense RNA virus that encodes a polyprot-
ein precursor of about 3,000 amino acids. The essential
HCV enzyme NS3-4A protease is responsible for cleaving
this HCV polyprotein at four sites to generate four pep-
tides called NS4A, NS4B, NS5A, and NS5B. Boceprevir
and telaprevir act as potent inhibitors of the HCV NS3-4A
protease, and this inhibition prevents the processing of
the HCV polyprotein and prevents the virus from replicat-
ing. Both compounds have recently been approved by the
FDA and can be used in combination with pegylated inter-
feron and ribavirin (69). For untreated HCV infection, tel-
aprevir is administered for the first 12 weeks of therapy at
750 mg three times per day in combination with pegylated
interferon α-2a 180 μg/week, and ribavirin 1.0 to 1.2 g/
day according to body weight. After 12 weeks, telaprevir
is discontinued, and pegylated interferon α-2a and riba-
virin are continued until HCV RNA is undetectable in
serum. Boceprevir must be administered using a different
regimen. For untreated HCV infection, pegylated inter-
feron α-2b and ribavirin are given alone for 4 weeks, and
then boceprevir (800 mg three times a day) is given in
combination with pegylated interferon α-2b (1.5 μg/kg/
week) and ribavirin (0.8 to 1.4 g/day according to body
weight) for 24 weeks. Total treatment duration is 28 weeks
if patients test negative for HCV RNA but may need to be
continued for an additional 20 weeks to clear the infec-
tion if HCV RNA is still detected after 28 weeks.
Agents Affecting Translation by the Ribosome
H
N
N NH2
S The synthesis of viral DNA under the direction of RT
O
N
R sides and nucleotides. Therefore, it is not surprising that
Methisazone ( R = CH3)
Methisazone (70)
Methisazone interferes with the translation of mRNA
message at the ribosome, preventing the synthesis of
protein synthesis. Ultimately, it produces a defect in
protein incorporation into the virus. Although viral
DNA increases and host cells are damaged, an infec-
tious virus is not produced. Methisazone is active
against poxviruses, including variola and vaccinia (71).
Some RNA viruses, such as rhinoviruses, echoviruses,
reoviruses, influenza, parainfluenza, and polioviruses
are also inhibited. Therapeutically, methisazone is
given in 1.5- to 3.0-g doses, twice daily by mouth. It has
also been used as a prophylactic agent against small-
pox. Historically, methisazone was one of the first anti-
viral compounds used in clinical practice. It is orally
absorbed, with nausea and vomiting as the principal side
effects. The drug is also used in vaccinia gangrenosa
and disseminated vaccinia infections. This drug is not
available in the United States, but it has been used in
Europe for some time. Several analogs of methisazone
(R = H, R = ethyl) possess activity against variola, neu-
rovaccinia, smallpox in mice, Rous sarcoma virus, and
vaccinia generalisata.
Antiretroviral (Anti-HIV) Agents Including Protease
Inhibitors (72,73)
While there can be no permanent cure of AIDS with-
out prevention or elimination of HIV infection, AIDS
patients can prolong their life if the disease is diagnosed
early and treatment is promptly initiated. Initial HIV
treatment requires specific drugs that inhibit RT and
HIV protease. In advanced HIV infection, AIDS is com-
plicated by other organisms that proliferate in immuno-
compromised hosts, known as opportunistic infections.
Such patients are treated symptomatically with a vari-
ety of drugs depending on the opportunistic infections
(74–76). Anti-HIV agents have side effects, but patients
can be managed by a careful monitoring of the drugs.
Opportunistic diseases include infections by parasites,
bacteria, fungi, and viruses. Neoplasms including Kaposi
sarcoma and Burkitt lymphoma also commonly occur.
Anti-HIV agents are classified according to the mode
of action. The drugs inhibiting RT interfere with repli-
cation of HIV and stop synthesis of infective viral par-
ticles. They are further classified into nucleoside and
nonnucleoside RT inhibitors. The drugs inhibiting HIV
protease inactivate RT activity and block release of viral
particles from the infected cells. The chemistry, pharma-
cokinetics, side effects, toxicity, and drug interactions of
RT inhibitors and protease inhibitors are discussed in the
following sections.
Nucleoside Reverse Transcriptase Inhibitors (77,78)
requires availability of purines and pyrimidine nucleo-
a variety of chemical modifications of natural nucleo-
sides have been investigated. Two such modifications
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 CHAPTER 38 / ANTIVIRAL AGENTS AND PROTEASE INHIBITORS 1291

have resulted in active drugs. Removal of the ribosyl
3′-hydroxyl group of the deoxynucleosides has given rise
to dideoxyadenosine (didanosine is the prodrug for this
derivative) (79,80), dideoxycytidine (81–83), and didehy-
drodideoxythymidine (84). Replacement of the 3′-deoxy
with an azido group has given 3′-azidothymidine (85–88)
and 3′-azidouridine (no longer used as a drug) (Fig. 38.14
and Table 38.4) (89). All of these drugs have similar
mechanisms of action in that their incorporation into
the viral DNA will ultimately lead to chain-terminating
blockade due to the lack of a 3′-hydroxyl needed for the
DNA propagation.
ZIDOVUDINE
Mechanism of Action Zidovudine (ZDV) is an analog of
thymidine in which the azido group is substituted at the
3-carbon atom of the dideoxyribose moiety (Fig. 38.14).
It is active against RNA tumor viruses (retroviruses)
that are the causative agents of AIDS and T-cell leuke-
mia. Retroviruses, by virtue of RT, direct the synthesis of
a provirus (DNA copy of a viral RNA genome). Proviral
DNA integrates into the normal cell DNA, leading to the
HIV infection. ZDV is converted to 5′-mono-, di-, and tri-
phosphates by the cellular thymidine kinase. These phos-
phates are then incorporated into proviral DNA, because
RT uses ZDV-triphosphate as a substrate. This process
prevents normal 5′,3′-phosphodiester bonding, result-
ing in termination of DNA chain elongation due to the
presence of an azido group in ZDV. The multiplication of
HIV is halted by selective inhibition of RT and thus viral
DNA polymerase by ZDV-triphosphate at the required
dose concentration. ZDV is a potent inhibitor of HIV-1
but also inhibits HIV-2 and EBV.
Clinical Application ZDV is used in AIDS and AIDS-
related complex (ARC) to control opportunistic infec-
tions by raising absolute CD4+ lymphocyte counts. ZDV
was first synthesized by Horwitz (1964) (90), biologic
activity was reported by Ostertag et al. (1974) (91), and
in 1986, Yarchoan et al. (92) demonstrated application
of ZDV in clinical trials of AIDS and related diseases.
ZDV is recommended in the control of the disease in
asymptomatic patients in whom absolute CD4+ lympho-
cyte counts are less than 200/mm3. It prolongs the life
of patients affected with Pneumocystis jirovecii pneumonia
and improves the condition of patients with advanced
ARC by reducing the severity and frequency of opportu-
nistic infections. Substantial benefits are obtained when
the drug is given after the CD4+ cell counts fall below
500/mm3. Therefore, ZDV is used in early and advanced
symptomatic treatment of AIDS or ARC patients. ZDV
with other RT inhibitors or in combination with prote-
ase inhibitors is more beneficial when resistance to ZDV
occurs.
HIV attacks susceptible cells and interacts mainly with
CD4+ cell surface proteins of helper T cells. As discussed
earlier, the viral glycoprotein gp120 forms a complex
with CD4 receptor on host cells and enters the cells by
endocytosis. The sequence of events is shown in Figure
38.2. Ultimately, the immune system of the host is altered
and AIDS symptoms appear. AIDS patients have symp-
toms such as high fever, weight loss, lymphadenopathy,
chronic diarrhea, myalgias, fatigue, and night sweats.
ZDV is given in such conditions. However, the drug is
toxic to the bone marrow and causes macrocytic anemia,
neutropenia, and granulocytopenia. Other adverse reac-
tions include headache, insomnia, nausea, vomiting, sei-
zures, myalgias, and confusion.
Pharmacokinetics ZDV is available in 100-mg capsules
for oral administration. For asymptomatic adults, the
initial recommended dosage is 1,200 mg daily (200 mg
every 4 hours) reducing to 600 mg daily (100 mg every
4 hours) for patients with advanced disease (Table 38.4).

O O
O NH2
CH3 CH3
HN N HN
HN N
HO O N HO N HO HO O N
N O N
O O O O

N3
Didanosine(ddI) Zalcitabine Stavudine
Zidovudine(AZT) (2',3'-Dideoxy-2',3'-didehydro-
(2',3'-Dideoxycytidine, ddC)
thymidine, D4T)

NH2 HN NH2 NH2

N N F
N N N N
O
HO O N H2N N N N N O HO O N
O O
O HO O P O
O
O
S CH3 S
O O

O
Lamivudine Abacavir (ABC) Tenofovir disoproxil Emtricitabine
(2'-Deoxy-3'-thiacytidine, 3TC)

FIGURE 38.14 Nucleoside reverse transcriptase inhibitors (NRTIs).

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1292 PART III / PHARMACODYNAMIC AGENTS

TABLE 38.4 HIV Reverse Transcriptase Inhibitors

Generic Name Common Name Trade Name Dosage Form (mg/unit)

Nucleoside reverse transcriptase inhibitors

Zidovudine AZT Retrovir Tab (300), Cap (100), Syrup (50/5 mL), Inj (10/mL)
ZDV

Didanosine ddI Videx Tab (25, 50, 100, 150, 200)

Dideoxyadenosine ddA Powder for oral Sol (100, 167, 250)

Zalcitabine ddC Hivid Tab (0.375)

Stavudine D4T Zerit Cap (15, 20, 30, 40)

Powder for oral Sol (1/mL)

Lamivudine 3TC Epivir Tab (150), Sol (10/mL)

Epivir HBV Tab (100), Sol (5/mL)

Abacavir ABC Ziagen Tab (300), Sol (20/mL)

Tenofovir disoproxil Viread Tab (300)

Emtricitabine Emtriva Cap (200)

Nonnucleoside reverse transcriptase inhibitors

Nevirapine Viramune Tab (200)

Delavirdine Rescriptor Tab (100)

Efavirenz Sustiva Cap (50, 100, 200)

Cap, capsule; Inj, injection; Sol, solution; Tab, tablet.

The maintenance dose is 600 mg daily in symptomatic
patients. ZDV is sensitive to heat and light because of its
azide group and should be stored in colored bottles at
15° to 25°C. ZDV is well absorbed through the GI tract.
It concentrates in the body tissues and fluids, includ-
ing CSF. The bioavailability of the drug was found to be
approximately 65%. Its half-life is approximately 1 hour.
IV doses of 2.5 mg/kg or oral doses of 5 mg/kg yielded
peak plasma concentrations of 5 mmol/L. Plasma pro-
tein binding was approximately 30%. Most of the drug
is converted to its inactive glucuronide metabolite and
is excreted unchanged through urine. ZDV also crosses
the blood–brain barrier. Pentamidine, dapsone, ampho-
tericin B, flucytosine, and doxorubicin may increase the
toxic effects of ZDV. Probenecid prolongs the plasma
half-life of the drug.
DIDANOSINE
Mechanism of Action Didanosine (ddI) is a purine
dideoxynucleoside analog of inosine. Chemically, it is
2′,3′-dideoxyinosine and differs from inosine by having
hydrogen atoms in place of 2′- and 3′-hydroxyl groups on
the ribose ring (Fig. 38.14). ddI is a prodrug that is bioac-
tivated by metabolism to dideoxyadenosine triphosphate.
Dideoxyadenosine triphosphate is a competitive inhibi-
tor of viral RT and is incorporated into the developing
viral DNA in place of deoxyladenosine triphosphate.
As such this agent causes chain termination due to the
absence of a 3′-hydroxyl group. ddI inhibits HIV RT and
exerts a virustatic effect on the retroviruses. Combined
with ZDV, antiretroviral activity of ddI is increased.
Pharmacokinetics ddI has a plasma half-life of 1.5 hours
and is given in 200-mg dose twice daily. Oral bioavailabil-
ity of the drug is approximately 25% at doses of 7 mg/kg
or less. It significantly decreases p24 antigen levels and
increases CD4+ cell counts. In some cases, viral resistance
to ddI has been known to occur after treatment for
1 year. It is given in advanced HIV infection, ZDV intoler-
ance, or significant clinical/immunologic deterioration.
The major side effects of ddI are painful peripheral neu-
ropathy and pancreatitis. Some of the minor side effects
include abdominal pain, nausea, and vomiting. The use
of products, such as pentamidine, sulfonamides, and
cimetidine should be avoided with ddI.
ZALCITABINE Zalcitabine (ddC) is a useful alternate to ZDV
and is a synthetic pyrimidine nucleoside analog. It differs
from 2′-deoxycytidine in that the 3′-hydroxyl group of the
2′-deoxyribose moiety is replaced with a hydrogen atom
(Fig. 38.14). It is given in combination with ZDV when
CD4+ cell counts fall below 300 cells/mm3. Monotherapy
with ddC was more active than ZDV. Its oral bioavailabil-
ity is 87%, and plasma half-life is approximately 1 hour.
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 CHAPTER 38 / ANTIVIRAL AGENTS AND PROTEASE INHIBITORS
It has side effects such as stomatitis, rash, fever, malaise,
arthritis, and arthralgia. In low doses (0.005 mg/kg
every 4 hours), ddC produced sustained decrease in p24
antigen level and increase in CD4+ cell counts. The CSF
fluid/plasma ratio of ddC is 0.2.
After oral administration, bioavailability of ddC was
less than 80%, which was further reduced with food. The
mean maximum plasma concentration of the drug was
also reduced from 25.2 to 15.5 ng/mL when the drug was
taken with food. Dideoxyuridine is the major metabolite
in urine and feces. The drug demonstrated penetration
through blood–brain barrier. The major toxicity of ddC
is peripheral neuropathy, in which case it should be dis-
continued. Pancreatitis occurs in some cases when given
alone or in combination with ZDV.
STAVUDINE Stavudine (D4T) is a pyrimidine nucleo-
side analog that has significant activity against HIV-1
after intracellular conversion of the drug to a D4T-
triphosphate. It differs in structure from thymidine by
the replacement of the 3′-hydroxyl group with a hydro-
gen atom and a double bond in the 2′ and 3′ positions
on the deoxyribose ring (Fig. 38.14). It decreased p24
antigen and raised CD4+ cell counts. D4T is beneficial
for patients in whom CD4+ cell counts do not decrease
below 300 cells/mm3 with ZDV and ddI. It was shown to
be more effective than ZDV or ddC in delaying the pro-
gression of HIV infection. It is recommended for patients
with advanced HIV infection.
Pharmacokinetics D4T is rapidly absorbed, and abso-
lute bioavailability in adults is 85% at an oral dose of
4 mg/kg. A peak plasma concentration in a dose-depen-
dent manner occurs within an hour. It can be taken with
food. The apparent volume of distribution after oral
dose is 66 L. The plasma half-life of D4T is approximately
1.5 hours, and the intracellular half-life of D4T-triphosphate
is 3.5 hours. It is less toxic to bone marrow but causes
peripheral neuropathic toxicity. The side effects include
pain, tingling, and numbness in the hands and feet.
LAMIVUDINE Lamivudine (3TC) is an analog of ddC in
which 3′-methylene group is replaced with a sulfur (S)
atom in the ribose ring (Fig. 38.14) (93). It exerts viru-
static effect against retroviruses by competitively inhibit-
ing HIV RT after intracellular conversion of the drug to
its active 5′-3TC-triphosphate form. It is usually given with
other antiretroviral agents, such as ZDV or D4T. 3TC in a
600 mg/day dose reduced HIV cells by 75%, and in com-
bination with ZDV, the reduction in viral load was 94%.
3TC is rapidly absorbed through the GI tract. Its bioavail-
ability is approximately 86% after oral administration
of 2 mg/kg twice daily; peak serum 3TC concentration
was approximately 2 mg/mL. 3TC binding to human
plasma was approximately 36%. In vivo, it is converted to
trans sulfoxide metabolite, and a majority of the drug is
eliminated unchanged in urine. The FDA approved 3TC
in combination with ZDV for the treatment of disease
1293
progression caused by HIV infection. The combinations
of 3TC with ddI, ddC, or D4T also are used for advanced
HIV infection. Such combinations have the ability to
delay resistance to ZDV and restore ZDV sensitivity in
AIDS patients. Recently, oral therapy in lower doses of
3TC (Table 38.4) has been approved by the FDA for
treatment of chronic HBV. Peripheral neuropathy and
GI disturbances are the major side effects of 3TC. The
minor side effects are nausea, vomiting, and diarrhea.
ABACAVIR SULFATE Abacavir was approved in 1998 as a
nucleoside reverse transcriptase inhibitor to be used in
combination with other drugs for the treatment of HIV
and AIDS. The drug is extensively metabolized via step-
wise phosphorylation to 5′-mono-, di-, and triphosphate.
Abacavir is well absorb (>75%) and penetrates the CNS
and can be taken without regard to meals. The drug does
not show any clinically significant drug–drug interactions
but has been reported to produce life-threatening hyper-
sensitivity reactions. The major use of abacavir appears
to be in combination with other nucleoside reverse tran-
scriptase inhibitors. A fixed combination product has
recently been approved by the FDA under the trade name
of Trizivir and consists of 300 mg of abacavir, 150 mg of
3TC, and 300 mg of ZDV. The combination has been
shown to be superior to other combinations in reducing
viral load as well as showing improvement in CD4+ cell
count. The most common adverse effects reported with
abacavir include headache, nausea, vomiting, malaise,
and diarrhea.
TENOFOVIR DISOPROXIL (94)
Mechanism of Action Tenofovir is a prodrug with a bio-
availability of 25%, which is improved in the presence of
food (35%). The drug is approved for the treatment of
HIV infections in adult patients. Tenofovir diphosphate
is an HIV reverse transcriptase inhibitor. The drug is
hydrolyzed via plasma esterase to tenofovir, which is then
phosphorylated to the active tenofovir diphosphate, as
shown in Figure 38.15. The diphosphate competes with
NH2 NH2
O
N N
N
O
N
O
N N O N N O
Esterase O P O H
O P O
O O H
CH3 CH3
O O
Cellular
kinase
O
Tenofovir disoproxil Tenofovir
NH2
N
N
N N O O
O P O P OH
O O
CH3
Tenofovir diphosphate
FIGURE 38.15
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Metabolic activation of tenofovir disoproxil.
1294 PART III / PHARMACODYNAMIC AGENTS
deoxyadenosine triphosphate for incorporation into viral
DNA, and when incorporated, tenofovir diphosphate
results in premature termination of DNA growth and
inhibition of DNA polymerase. Tenofovir disoproxil is
indicated for treatment-experienced patients with HIV-1.
The drug appears to also be effective in treatment-naive
patients, but initial approval is for treatment-experienced
patients. The drug is administered as one tablet once
daily (300 mg). It is recommended that the drug be
combined with other reverse transcriptase inhibitors or
HIV protease inhibitors, which results in additive or syn-
ergistic activity. At present, two fixed combinations exist
that contain tenofovir: tenofovir disoproxil fumarate
plus emtricitabine (Truvada) and a fixed triple combina-
tion of tenofovir, emtricitabine, and efavirenz (Atripla).
Other fixed-dose products may be approved in the future
for treatment of HIV.
EMTRICITABINE (95) Emtricitabine is an orally active nucle-
oside RT inhibitor (Fig. 38.14). It is metabolized in vivo
to the 5′-triphosphate, which in turn competes with the
normal substrate (deoxycytidine-5′-triphosphate) for
incorporation into DNA. In addition, incorporation
of emtricitabine into viral DNA inhibits further chain
elongation, resulting in chain termination. The drug is
administered orally once daily. The (–)-enantiomer is
the most active form of the drug, although the (+)-isomer
is also active. Emtricitabine is not bound to plasma pro-
tein, and approximately 86% is excreted unchanged in
the urine. The only metabolites identified consist of the
3′-sulfoxide and the 2′-O-glucuronide. Emtricitabine is
reported to be more active than 3TC with a low level
of resistance developing when used in combination
therapy with efavirenz and ddI. As indicated earlier, the
drug is also available in fix-dosed combinations with
tenofovir.
Nonnucleoside Reverse Transcriptase Inhibitors
The FDA has recently approved several nonnucleosides
that inhibit RT activity (Fig. 38.16 and Table 38.4). They
are used with nucleoside drugs to obtain synergistic
O
H3C O CH(CH3)2
HN H HN
H3C S N O or reduced in patients receiving cimetidine or rifabutin,
N O C N N respectively.
N N N N
H
Nevirapine Delavirdine
F3C C C
Cl
O
N
H
O ments in CD4+ cell counts, p24 antigen levels, and RNA
Efavirenz
FIGURE 38.16 Nonnucleoside reverse transcriptase inhibitors
(NNRTI).
activity in decreasing the viral load and increasing CD4+
cell count. These drugs are primarily designed and syn-
thesized by protein structure-based drug design meth-
odologies. Their use as monotherapy may be limited
because of rapid onset of resistance and hypersensitivity
reactions. However, interaction of nonnucleoside drugs
with other protease inhibitors, such as saquinavir, indi-
navir, and ritonavir, is being investigated. In addition,
interaction of these drugs with clarithromycin, ketocon-
azole, rifabutin, and rifampin is under study.
NEVIRAPINE
Mechanism of Action Nevirapine and its analogs exhibit
antiretroviral effects against AZT-resistant HIV strains
(96). Nevirapine in combination with ZDV and ddI
produced approximately 18% higher CD4+ cell counts
and a decrease in viral load compared with ZDV and
ddI. Nevirapine is recommended with nucleosides for
HIV-1–infected patients who have experienced clinical or
immunologic deterioration. The significant side effects
of nevirapine are liver dysfunction and skin rashes.
Nevirapine is a dipyridodiazepinone derivative, which
binds directly to RT. Thus, it blocks RNA- and DNA-
dependent polymerase activities by causing a disrup-
tion of the RT catalytic site. HIV-2 RT and human DNA
polymerases are not inhibited by nevirapine. The 50%
inhibitory concentration ranged from 10 to 100 nmol/L
against HIV-1.
Pharmacokinetics Nevirapine is rapidly absorbed after
oral administration, and its bioavailability is approxi-
mately 95%. Peak plasma nevirapine concentrations of
2 ± 0.4 mg/mL (7.5 mmol/L) are obtained in 4 hours
after a single 200-mg dose (Table 38.4). Following
multiple doses, nevirapine concentrations appear to
increase linearly in the dose range of 200 to 400 mg/
day. Nevirapine is about 60% bound to plasma proteins
in the plasma concentration range of 1 to 10 mg/mL.
It readily crossed the placenta and was found in breast
milk. Nevirapine is metabolized as glucuronide conju-
gates of hydroxylated metabolites, which are excreted
in urine. In vivo, ketoconazole did not produce any
significant inhibitory effect on nevirapine metabolism.
The plasma concentrations of nevirapine were elevated
DELAVIRDINE Delavirdine, a bisheteroarylpiperazine deriv-
ative, is a potent nonnucleoside RT inhibitor with activity
specific for HIV-1 (97). The FDA has approved this drug
in combination with other anti-HIV agents (Table 38.4).
In phase I/II trials, it demonstrated sustained improve-
viral load. Promising results were obtained when the
drug was used in two- or three-drug combination with
nucleoside drugs. Combination of delavirdine with ddI,
ddC, or ZDV demonstrated additive or synergistic effect.
However, delavirdine with ZDV was more beneficial in
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 CHAPTER 38 / ANTIVIRAL AGENTS AND PROTEASE INHIBITORS 1295

early HIV infection. Combinations of nevirapine and TABLE 38.5 HIV Protease Inhibitors
delavirdine have an antagonistic effect on HIV-1 RT inhi-
bition. Delavirdine directly inhibits RT and DNA-directed Generic Name Trade Name Dosage Form (mg/unit)
DNA polymerase activities of HIV-1 after the formation of
Saquinavir Invirase Cap (200)
the enzyme–substrate complexes, thereby causing chain
termination effects. Fortovase Cap (200)

Ritonavir Norvir Cap (200)

Pharmacokinetics Delavirdine is rapidly absorbed by
oral administration, and peak plasma concentration is
obtained in 1 hour. The single-dose bioavailability of
delavirdine tablets relative to oral solution was approxi-
mate 85%. The 50% inhibitory concentration for dela-
virdine against RT activity was 6.0 nmol/L. Delavirdine
is extensively bound to plasma protein (∼98%).
Delavirdine is metabolized to its inactive N-desisopropyl
metabolite in liver, and the pharmacokinetics is non-
linear. This reaction is catalyzed by CYP3A4, and dela-
virdine appears to be an inhibitor of this enzyme,
increasing the risk for drug–drug interactions with
other drugs that are substrates for this cytochrome iso-
form. Skin rashes are the major side effect of delavir-
dine therapy. Cross-resistance between delavirdine and
protease inhibitors, such as indinavir, nelfinavir, ritona-
vir, and saquinavir, is unlikely because they act at differ-
ent target enzymes.
EFAVIRENZ Efavirenz is a new nonnucleoside RT inhibi-
tor that was approved by the FDA (Table 38.4) as a
potent inhibitor of wild-type and resistant mutant HIV-1,
which is inhibited up to 95% with efavirenz concentra-
tions of 1.5 mmol/L (98). In combination with indi-
navir, a mean reduction in HIV-RNA of 1.68 log and
an increase in CD4+ cell counts of 96 cells/mm3 were
reported. Coadministration of efavirenz with indinavir
reduced indinavir concentration (AUC) by approxi-
mately 35%.
Pharmacokinetics Efavirenz is administered once a day
and can be used as a substitute for indinavir in combina-
tion therapy with standard drugs, such as ZDV and 3TC
(also as a fixed combination of tenofovir, emtricitabine,
and efavirenz [Atripla]). Because it is given once a day,
this cuts down the number of pills that an AIDS patient
has to swallow. In the current cocktail therapy of AIDS
patients, efavirenz is a good option for reducing the
many side effects of cocktail therapy. It is administered
to both adults and children and may be less expensive
than indinavir. The side effects of efavirenz include diz-
ziness, insomnia, impaired concentration, abnormal
dreams, and drowsiness. The most common adverse
effect is a skin rash. Other side effects are diarrhea,
headache, and dizziness. Efavirenz is recommended to
be taken at bedtime with or without food. Avoiding driv-
ing or operating machinery and intake of high-fat meals
are recommended. It should always be taken in combi-
nation with at least one other anti-HIV agent. Efavirenz
is contraindicated with midazolam, triazolam, or ergot
derivatives.
Indinavir Crixivan Cap (200, 400)
Nelfinavir Viracept Tab (250), Powder (50/g)
Amprenavir Agenerase Cap (50, 150)
Sol (15/mL)
Lopinavir/ritonavir Kaletra Cap (133.3/33.3)
Sol (80/20 per mL)
Atazanavir Reyataz Cap (150, 200)
Fosamprenavir Lexiva Tab (700)
Tipranavir Aptivus Cap (250)
Darunavir Prezista Tab (75, 150, 300, 400 or 600)
Cap, capsule; Sol, solution; Tab, tablet.
HIV Protease Inhibitors (Table 38.5) (99)
Mechanism of Action
The HIV genome contains various structural genes,
such as the gag and gag-pol genes, that are translated into
precursor polyproteins that form immature viral par-
ticles. These precursor protein molecules are processed
(cleaved) by an essential viral pol-encoded aspartic pro-
teinase, HIV protease, to form the desired structural pro-
teins of the mature viral particle that are necessary for
virus replication and survival. For example, the structural
proteins p7, p9, p17, and p24, which play important roles
in infectivity of HIV, are products of the pol gene. HIV
protease also activates RT and plays an important role
in the release of infectious viral particles. Thus, an area
of considerable interest has been the development of
drugs that act as inhibitors of HIV protease. Such inhibi-
tors act on HIV protease and prevent posttranslational
processing and budding of immature viral particles from
the infected cells. This group of drugs represents a major
breakthrough in treatment of HIV when used in combi-
nation with RT inhibitors, and their development is one
of the most significant advances in medicinal chemistry.
Functional HIV protease exists as a dimer in which
each monomer contains one of two conserved aspartate
residues at the active site. There are several HIV protease
cleavage sites on the protein precursors, but the enzyme
prefers to perform the hydrolysis of the peptide bond on
the amino terminal side of a proline (100). As shown in
Figure 38.17, the amino acid R groups flanking the scis-
sile bond are designated P1, P2, and so on, on the amino
terminus, and P1′, P2′, and so on, on the carboxyl termi-
nus of the cleavage site (Fig. 38.17A). The corresponding
pockets on the enzyme that are responsible for binding
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1296 PART III / PHARMACODYNAMIC AGENTS

Scissile bond +
Asp25 O Asp25 O
S3 S1 S2'
O O
H H
P3 O P1 O P2' O H H
O H O N O N
H H
N N N O O
N N N N H H
H H H H N N
O P2 O P1' O P3' N N
O O
S2 S1 ' S 3' OH
O
H H
A. Nomenclature of amino acid side chains (P) and bind- OH
ing pockets (S) surrounding a protease cleavage site. O
Asp25 O
Asp25 O

Asp25 Asp25 B. Role pf twp Asp25 residues in formation of the

O O
hydrolytic transition state.
O O
S2
H H
S1'
O
O O OH
H H H
N N N COOH
N N
H H
S4 O O O

S3 S2 '
S1

C. Coordination of the Asp25 residues by the transition state

analog pepstatin.

FIGURE 38.17 Principles of the design of transition-state analog inhibitors of HIV protease.

the P groups are termed S1, S2, S1′, S2′, and so on. In the most useful of these are selective for the viral enzyme
active site, a pair of aspartates (the Asp25 on each of the HIV-1 protease. Structurally, these agents are either pep-
two subunits of the protein) work together to complete tidomimetic or nonpeptide compounds. Their effective-
the reaction (Fig. 38.17B). One coordinates the water ness is related to their ability to inhibit the processing of
that performs the hydrolysis, while the other coordinates the gag-pol precursor polyprotein to p24, p55, and p160.
the carboxyl group on the P1′ amino acid. Rationally Consequently, the infectivity of HIV-1 is diminished.
designed drugs that inhibit HIV protease are designed Although, some compounds exhibit in vitro and in vivo
as transition-state mimics that align at the active site of antiviral activities, optimization of their pharmacokinetic
HIV-1 protease, as defined by three-dimensional crystal- and pharmacodynamic properties has presented major
lographic analysis of the protein structure. Figure 38.17C problems. In view of the great demand for successful
shows the aspartic protease inhibitor pepstatin bound in anti-AIDS drugs, the FDA has approved the protease
the HIV protease active site. Pepstatin is an inhibitor of inhibitors described in the following sections using the
all aspartic proteases, but can be used to illustrate the accelerated approval process. The structures of cur-
mechanism by which transition-state analogs inhibit HIV rently marketed HIV protease inhibitors are shown inn
protease (101). Pepstatin contains an unnatural amino Figure 38.20.
acid core known as statine (Fig. 38.18), and the hydroxyl-
bearing sp3 carbon of this core mimics the tetrahedral
transition state that occurs during hydrolysis of the pep-
tide bond. Other transition-state cores have been used in R1
H
O
the design of highly potent aspartic protease inhibitors, N
N
N
including the hydroxyethylene and hydroxyethylamine H H
O R2 OH O
cores (Fig. 38.18). The crystal structures of several HIV
Native peptide Statine
protease inhibitors bound to wild-type and mutant HIV
proteases have been solved by x-ray crystallography. The
structure of the HIV protease inhibitor lopinavir bound R1 O R1 R2
to wild-type HIV protease is depicted in Figure 38.19. N N N
H H H
Note that the hydroxyl group of the transition-state core OH R2 OH O
is hydrogen bonded to the two Asp25 carboxylate moi-
Hydroxyethylene Hydroxyethylamine
eties at a distance of about 3 Å. A number of oligopep-
tide-like analogs have been synthesized that differentially FIGURE 38.18 Transition-state mimics used in the design of HIV
inhibit viral and mammalian aspartic proteases, and the protease inhibitors.
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 CHAPTER 38 / ANTIVIRAL AGENTS AND PROTEASE INHIBITORS 1297

..ccoomm
u
u s
s e
e
K Ka
a d
d
ww..
wwww
FIGURE 38.19 Model of the HIV protease inhibitor lopinavir bound to wild-type HIV protease.

m
m
Potential Drug Interactions not slow progression of disease, CD4+ cell counts were

e
e . o
o
Protease inhibitors have a high potential for drug inter-

. cc
actions, stemming from the fact that they are substrates
for and inhibitors of the CYP3A4 enzyme system. As a
increased in patients infected with HIV in the United
States and European countries. Triple therapy with saqui-
navir, ZDV, and ddC has been more effective than double

dd us
s
result, concurrent use of protease inhibitors with other

u
drugs metabolized by CYP3A4 may be contraindicated,
therapy with saquinavir plus ZDV or ddC. Thus, combi-
nation therapy slowed disease progression and mortality.

aa
and in some cases, the resulting drug interactions can The IC50 concentration of saquinavir in both acutely

KK
be life-threatening. The most potent CYP450 inhibitor and chronically infected cells was 1 to 30 nmol/L. In

ww..
in this class is ritonavir (used to advantage in combina-
tion with lopinavir and other HIV protease inhibitors),
combination with ZDV, ddC, or ddI, the activity of saqui-
navir was increased without increased cytotoxicity. The

ww
followed by indinavir, nelfinavir, and amprenavir (mod-

ww
erate inhibitors) and saquinavir (the least potent inhibi-
tor). Drug interactions have been reported with bepridil,
dihydroergotamine, and a number of benzodiazepines.
Marked increases in the activity of amiodarone, lidocaine
resistance of HIV isolates to saquinavir was observed due
to substitution mutations in the HIV protease at amino
acid positions 48 (glycine to valine) and 90 (leucine to
methionine).

(systemic), quinidine, the tricyclic antidepressants, and
warfarin might be expected (102). Other interactions
have been reported with rifampin, rifabutin, phenobar-
bital, phenytoin, dexamethasone, or carbamazepine.
Because the protease inhibitors are themselves metabo-
lized by CYP450, their action may be altered by other
agents that induce or inhibit this system. In the case of
rifabutin, which inhibits CYP3A4 in the gut, relative bio-
Pharmacokinetics The bioavailability of saquinavir in a
single 600-mg dose following a high-fat meal was shown
to be about 4%. Approximately 30% of a 600-mg dose of
saquinavir reached the liver, where it showed first-pass
metabolism. The metabolites, various mono- and dihy-
droxylated compounds of which the major metabolites
are the monohydroxylated products shown in Figure
38.21, are not active. Approximately, 88% and 19% of a
600-mg oral dose was found in the feces and urine, respec-

m
m
availability of the protease inhibitors is increased, and the

o
o
dose of the protease inhibitor may need to be decreased. tively. The volume of distribution after IV administration

c
c
of a 12-mg dose of saquinavir was 700 L. The drug is 98%

sse
e ..
HIV Protease Inhibitors that are Used Clinically
bound to plasma proteins, and a very low concentration
of saquinavir was found in CSF. The steady-state AUC was

uu
(Fig. 38.20) 2.5 times higher than that observed after a single dose
SAQUINAVIR MESYLATE

K Kaadd
Clinical Application Saquinavir was the first prote-
of 600 mg in HIV-infected patients after a meal as com-
pared to multiple dosing. Saquinavir has a plasma half-life

..
ase inhibitor approved by the FDA in December 1995 of approximately 1.8 hours. Although saquinavir hard-gel
(103,104). It is a carboxamide derivative used in the capsule in combination with other antiretroviral drugs

wwww
treatment of advanced HIV infection in selected patients.
Saquinavir is used concomitantly in either ZDV-untreated
reduced the risk of disease progression or death, it has
limited bioavailability. To overcome this limitation, the

ww
patients or ddC-treated patients previously treated with
prolonged ZDV therapy. Although combined therapy did
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FDA has approved saquinavir soft-gel capsules. Saquinavir
is well tolerated in combination with ZDV and/or ddC
1298 PART III / PHARMACODYNAMIC AGENTS

O O O
N O H H N OH OH
H C NH N N H
N N N N O N N
N N H H N
H H CH3 O OH
O S S C O
OH
O NH-C(CH3)3
H N
O NH2
H2SO4 H2SO4
H3C SO3H

Saquinavir Ritonavir Indinavir

O
Ca2 O P
S NH2 O NH2
O OH O
CH3 O H H
C NH O N N O N N
HO O S O S
N N O O O O
H H O O
OH
H
H3C SO3H

Nelfinavir Amprenavir Fosamprenavir calcium

N OH
H O
CH3 N
OH O O OH O S
H H H O
N N NH N N N O
O N CH3O N N CH3 O O N
H H H
CH3 O O O O
CF3
Lopinavir Atazanavir Tipranavir

NH2
OH
H
O O N N
S
O H2C O O
O

Darunavir

FIGURE 38.20 Structures of HIV protease inhibitors that are used clinically.

and has few side effects, but GI disturbances were com-
mon adverse effects. Saquinavir has a few mild side effects,
such as headache, rhinitis, nausea, and diarrhea.
RITONAVIR Ritonavir is another HIV protease inhibitor
that was approved by the FDA in March 1996 (Fig. 38.20)
(105). Ritonavir is a peptidomimetic inhibitor of both
the HIV-1 and HIV-2 proteases. A 50% reduction in viral
replication was obtained at a 3.8 to 153 nmol/L concen-
tration of ritonavir.
Pharmacokinetics After a 600-mg dose of an oral solu-
tion, peak concentrations of ritonavir were obtained in
approximately 2 or 4 hours under fasting or nonfasting
conditions, respectively. Under nonfasting conditions,
peak ritonavir concentrations decreased 23%, and the
extent of absorption decreased 7% relative to fasting
conditions. In two separate studies, the capsule and oral
solution indicated AUC values of 129.5 ± 47.1 and 129.0 ±
39.3 mg/hour/mL, respectively, when a 600-mg dose was
given under nonfasting conditions. Five ritonavir metab-
olites have been isolated from human urine and feces.
The isopropylthiazole oxidation product was the major
active metabolite (M2) (Fig. 38.22).
As with saquinavir, ritonavir is metabolized by CYP3A4
and is an inhibitor of the CYP450 system. Ritonavir is
contraindicated with several compounds, such as clar-
ithromycin, desipramine, ethinyl estradiol, rifabutin, sul-
famethoxazole, and trimethoprim because of increased
concentrations of these drugs in the plasma due to inhib-
ited oxidative metabolism. Ritonavir alone or in combi-
nation with 3TC, ZDV, saquinavir, or ddC increased CD4+
cell counts and decreased HIV RNA particle levels. Cross-
resistance between ritonavir and RT inhibitors is unlikely
because of the different mode of action and enzyme
involved. Common adverse reactions, such as nausea,
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 CHAPTER 38 / ANTIVIRAL AGENTS AND PROTEASE INHIBITORS 1299

isolates and clinical resistant virus to indinavir analogs, is

H C CH3
O 3 C 25 to 100 nmol/L in drug combination studies with ZDV
Saquinavir N O H CH H C NH CH2 and ddI. However, HIV has shown ritonavir resistance
H 2
N
N N OH in some patients. This resistance is due to mutation of
H
O H CH2H H OH the virus that is correlated with the expression of amino
H acid substitutions in the viral protease. Cross-resistance to
O NH2
indinavir is observed with other protease inhibitors but
M-7 not with the RT inhibitor. For this reason, indinavir is
beneficial with ZDV and other nucleoside drugs.

Pharmacokinetics Indinavir is rapidly absorbed in fast-

H C CH3 ing patients, and plasma peak concentration is observed
O 3 C
N O H H C NH CH3
H CH2 in about 1 hour. At a dose of 800 mg every 8 hours, peak
N
N N
H
plasma concentration is approximately 300 nmol/L. The
O H CH2H H OH
drug is approximately 60% bound to human plasma pro-
H
O NH2 teins. Indinavir is metabolized via oxidation and glucuro-
HO nide conjugation. These metabolites were recovered in
M-2
feces and urine, with about 20% of the drug excreted in the
urine. The half-life of indinavir is approximately 1.8 hours.
FIGURE 38.21 Major metabolic products from saquinavir. Because of indinavir’s metabolism, a number of drug
interactions are possible. Indinavir interacts with rifabu-
tin or ketoconazole, leading to increased or decreased
diarrhea, vomiting, anorexia, abdominal pain, and indinavir concentration, respectively, in the blood plasma.
neurologic disturbances, were reported with the use of Administration of drug combinations of indinavir with
ritonavir alone or in combination with other nucleoside antiviral nucleoside analogs, cimetidine, quinidine, tri-
analogs. Ritonavir is used for the treatment of advanced methoprim–sulfamethoxazole, fluconazole, or isoniazid
HIV infection including opportunistic infections. In resulted in an increased activity of indinavir. Indinavir is
combination with nucleoside drugs, ritonavir reduced contraindicated in patients taking triazolam or midazolam
the risk of mortality and clinical progression. because inhibition of metabolism of these drugs may result
in prolonged sedation, nephrolithiasis, asymptomatic
INDINAVIR SULFATE Indinavir, a pentanoic acid amide hyperbilirubinemia, and GI problems (anorexia, constipa-
derivative, was approved by the FDA in March 1996 tion, dyspepsia, and gastritis). The usual oral dose for indi-
(Fig. 38.20) (106). The 95% inhibitory concentration navir alone or in combination with other antiviral agents
against laboratory-adapted HIV variants, primary clinical is one 800-mg capsule every 8 hours. The drug is well
absorbed if given on an empty stomach or 1 hour before or
2 hours after a light meal with water. The dose is reduced to
H3C CH3
600 mg every 8 hours if given concurrently with ketocon-
O
H
CH2 azole. Indinavir activity is increased when combined with
N N RT inhibitors.
N N NH2
Ritonavir CH3
H
O H 2C OH
S
NELFINAVIR MESYLATE Nelfinavir is a peptidomimetic drug
M1
that is effective in HIV-1 and HIV-2 wild-type and ZDV-
resistant strains (Fig. 38.20). ED50 concentrations range
from 9 to 60 nmol/L (95% effective dose was 0.04 mg/mL)
H3C CH3
O
H
CH2 O (107). After IV administration, the elimination half-life
N N N
N
N O
of nelfinavir was about 1 hour. In combination with D4T,
HO H H nelfinavir reduced HIV viral load by about 98% after
CH3 O H2C OH S
S
4 weeks. It is well tolerated when used with azole anti-
M2 N fungals (ketoconazole, fluconazole, or itraconazole) or
macrolide antibiotics (erythromycin, clarithromycin, or
H3C CH3 azithromycin). However, it causes diarrhea and other
O CH2 O
H
H
N
side effects common to nonnucleoside drugs. Following
N N N O oral administration, nelfinavir peak levels in plasma
H H
CH3 O H2C OH S ranged from 0.34 mg/mL (10 mg/kg in the dog) to
N 1.7 mg/mL (50 mg/kg in the rat). Nelfinavir was slowly
M11
absorbed, and bioavailability was 47% in the dog. The
FIGURE 38.22 Major metabolic products from CYP3A4 metabo- drug appeared to be metabolized in the liver, and the
major excretory route was in feces.
lism of ritonavir.
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1300 PART III / PHARMACODYNAMIC AGENTS
AMPRENAVIR Amprenavir is the fifth in a series of pro-
tease inhibitors to be approved for marketing in the
United States. While structurally unique from the previ-
ous agents, its pharmacologic profile does not appear to
differ significantly from the previously marketed agents.
Early studies suggest that a different resistance profile
may exist and that the drug may be effective against some
resistant strains of HIV. Side effects appear to be more
common than with other protease inhibitors and include
nausea, vomiting, paresthesia, depression, and rash.
Because amprenavir is a sulfonamide, there is some con-
cern for cross-sensitivity with antibacterial sulfonamides.
Although this has not been reported, care should be
taken if sensitivity to trimethoprim–sulfamethoxazole,
used in Pneumocystis jirovecii pneumonia, is reported.
Pharmacokinetics Amprenavir is rapidly absorbed follow-
ing oral administration and may be taken with or without
food. High-fat meals decrease the absorption of the drug
and therefore should be avoided. The product is avail-
able in capsule and liquid form. The recommended adult
and adolescent dose of 1,200 mg twice daily requires the
patient to take eight capsules (150 mg) twice daily. The liq-
uid preparation is recommended for children between 4
and 12 years of age or for patients 13 to 16 years of age who
weigh less than 50 kg. The dose is 22.5 mg/kg twice daily or
17 mg/kg three times a day. Since this preparation contains
the excipient propylene glycol, it is not recommended for
children less than 4 years of age and certain other individu-
als who are unable to metabolize this alcohol.
FOSAMPRENAVIR CALCIUM (108) Fosamprenavir has been
approved for the treatment of HIV in adults when used
in combination with other anti-HIV drugs. It is a prodrug
that, upon hydrolysis by serum phosphatases, gives rise to
amprenavir, which as indicated earlier is a peptidomimetic
transition-state inhibitor that targets HIV-1 protease and
reduces viral replication and, thus, infectiousness of HIV-1.
It is commonly administered in combination with RT inhib-
itors to produce excellent efficacy in AIDS patients. The
drug is administered as two 700-mg tablets twice daily or,
in combination with ritonavir, can be given as two 700-mg
tablets once daily or one 700-mg tablet twice daily.
Fosamprenavir is a slow-release version of amprenavir and,
as a result, decreases the pills required for the patient and
lowers the “pill burden” in AIDS patients.
LOPINAVIR/RITONAVIR Recently, the FDA has approved the
release of lopinavir/ritonavir combination in patients who
have not responded to other regimens for treatment of
HIV. The product is available in a soft gelatin capsule con-
taining 133.3 mg of lopinavir and 33.3 mg of ritonavir, as
well as oral solutions containing 80 mg/mL of lopinavir
and 20 mg/mL of ritonavir. The small amount of ritonavir
is not expected to have antiretroviral activity, but rather the
ritonavir is meant to increase the plasma concentrations of
lopinavir by inhibiting lopinavir’s metabolism by CYP3A4.
These drugs, in combination with other antiretroviral
agents, have been approved for use in adults and patients
between the ages of 6 months and 12 years. This is the first
protease inhibitor to be indicated for the very young.
ATAZANAVIR CALCIUM (109) Atazanavir is an antiretroviral
agent approved for use in combination with other anti-
retroviral agents for the treatment of HIV infections
(Fig. 38.20). It targets HIV-1 protease and reduces viral
replication and thus virulence of HIV-1. Similar to saqui-
navir, ritonavir, indinavir, nelfinavir, amprenavir, and lopi-
navir, the drug is used in combination with RT inhibitors
to produce excellent efficacy in AIDS patients. Atazanavir
is dosed orally once daily, thus reducing “pill burden,” and
seems to have a minimum impact on lipid parameters, but
does increase total bilirubin. The drug is well absorbed
when administered orally with food (bioavailability ∼68%).
The drug is highly bound to plasma protein (86%) and is
metabolized by CYP3A isoenzyme. Atazanavir is a moder-
ate inhibitor of CYP3A, and potential drug–drug interac-
tions are possible with CYP3A inhibitors and inducers.
TIPRANAVIR Tipranavir is a recently approved, nonpep-
tidic inhibitor of HIV protease (Fig. 38.20) (110). It is
indicated for patients who have developed resistance to
other antiretroviral drugs, including other HIV protease
inhibitors. Although it is very potent, it also exhibits more
severe side effects than other HIV protease inhibitors,
including intracranial hemorrhage, hepatitis, and diabe-
tes mellitus. It is dosed at 500 mg twice daily in combina-
tion with 200 mg of ritonavir to suppress metabolism by
cytochrome P450 (111). There is evidence that tipranavir
induces its own metabolism, but using twice-daily coad-
ministration of tipranavir and ritonavir at varying doses,
tipranavir levels were 24- to 70-fold higher than levels
achieved with administration of tipranavir alone.
DARUNAVIR Darunavir is a second-generation HIV protease
inhibitor that can be used in treatment-naive and treatment-
experienced adult and pediatric patients (Fig. 38.20) (112).
It was designed to bind tightly and specifically to HIV pro-
tease and thereby overcome the problems associated with
first-generation drugs, including toxicity, high dose, expen-
sive manufacture, and susceptibility to resistance. Like
other HIV protease inhibitors, darunavir is metabolized by
cytochrome P450, and thus, the drug is dosed at 800 mg
once daily in combination with 100 mg of ritonavir (113).
HIV Integrase Inhibitors
RALTEGRAVIR
O O
N N
N N N
H H
O N
H3C H3C OH F
O
Mechanism of Action Raltegravir (Isentress) is the first
(and thus far only) FDA-approved treatment for HIV that
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 CHAPTER 38 / ANTIVIRAL AGENTS AND PROTEASE INHIBITORS
acts by inhibition of HIV integrase (114). A second HIV
integrase inhibitor, elvitegravir, is currently in phase III
clinical trials. Like HIV protease, HIV integrase is essen-
tial for replication of the HIV virus and, as such, has
become a validated target for drug discovery. Each HIV
particle contains 40 to 100 integrase molecules the role
of which is to facilitate the insertion of viral complemen-
tary DNA (cDNA) into the host cell genome. Following
host cell infection, the viral RNA is converted to cDNA via
the action of RT. The preparation of cDNA for insertion
requires integrase-mediated trimming of the 3′-ends of the
viral DNA (3′-processing). The 3′-processing occurs within
the cytoplasm, and the processed cDNA plus integrase
complex, which also contains viral and cellular protein, is
referred to as the preintegration complex. This complex
is transported into the nucleus of the host cell where inte-
gration into the host DNA occurs through the catalytic
action of integrase. The 3′-OH of the cDNA is joined to
the 5′-phosphate of the host chromosome with both ends
of the cDNA being joined to the host DNA. This very com-
plex integration of cDNA into the host genome involves
numerous viral and host proteins. Integrase itself is a 32-kd
protein with three structural domains: 1) amino-terminal
domain; 2) catalytic core domain (CCD); and 3) carboxy-
terminal domain. All three domains are essential for inte-
gration, whereas only the CCD is required for the reverse
reaction referred to as disintegration. The amino-terminal
domain binds zinc, while the CCD binds manganese
(Mn2+) and magnesium (Mg2+). It has been proposed that
raltegravir acts by inhibiting cDNA integration via chela-
tion to the divalent cations in the CCD at the interface the
integrase-donor-acceptor complex (Fig. 38.23).
Pharmacokinetics Raltegravir is readily absorbed fol-
lowing oral administration. The drug is highly bound
to plasma protein (∼83%). Food does not appear
to affect the rate of absorption. The major route of
metabolism is glucuronidation mediated by uridine
diphosphate-glucuronosyl-transferase.
O O
N
N
N
N
N
H
N
H
O delayed emergence of ZDV-resistant HIV strains.
F COOH O CH3 CH3
O O
OH
HO
OH
Approximately 51% of the drug is recovered in the feces
unchanged, and 32% is recovered in the urine where
23% is the glucuronide. Glucuronidation inhibitors have
the potential for drug–drug interactions, although there
was no clinically significant effect when administered
with atazanavir. Raltegravir is recommend for use in com-
bination therapy and in patients who have demonstrated
resistance to previous regimens.
Raltegravir was approved in 2008 for use in individu-
als whose infection has proven resistant to highly active
1301
F
O NH
N N
N N
H
O O
O N Me2- R Acid residue
H3C H3C O in integrase
O
O
Raltegravir
FIGURE 38.23 Chelation complex between raltegravir and inte-
grase.
antiretroviral therapy drugs (see next section), and in
2009, the FDA expanded approval for use in all patients.
It is taken twice daily, and doses of 200, 400, and 600 mg
have been used.
Combination Drug Therapy (115,116)
When several antiretroviral drugs, typically three or four,
are taken in combination for the treatment of HIV, the
approach is known as highly active antiretroviral therapy
(HAART). Multiple HAART therapies have been under-
taken, and the National Institutes of Health recommends
that all infected patients should be treated in this man-
ner (114). The synergistic antiviral effects of rimantadine
with ribavirin and tiazofurin against influenza B virus and
ganciclovir with foscarnet against HSV-1 and HSV-2 are
noteworthy. The synergistic action of either trifluorothy-
midine or acyclovir with leukocyte interferon has been
used in the topical treatment of human herpetic keratitis.
During the past decade, research into combination anti-
retroviral therapy for AIDS patients has made remarkable
progress. ZDV, the first approved drug for HIV-infected
patients, produced bone marrow toxicity. To overcome
toxic effects, combinations of ZDV with foscarnet, ddC, or
ddI have been used. Such combination therapy indicated
improved efficacy and decreased side effects as compared
to either drug used alone. The combination of ZDV with
α-interferon has been used to treat patients with AIDS-
related Kaposi sarcoma. This combination drug therapy
A combination of granulocyte-macrophage colony-
stimulating factor with ZDV and α-interferon has been
successful in managing treatment-related cytopenia in
HIV-infected patients. The advantages of combination
therapy include therapeutic antiviral effect, decreased
toxicity, and low incidence of drug-resistant infection.
In recent years, emergence of drug resistance has been
demonstrated in patients receiving single antiviral agent
therapy. Resistance to amantadine, acyclovir, ribavirin,
ganciclovir, ZDV, and other antiviral agents is noteworthy.
Combined antiretroviral drug therapy serves different
purposes. It prolongs the life of AIDS patients, removes
drug resistance, and/or reduces toxicity of drugs. With
these objectives, successful combinations of ZDV have
been reported with ddC, ddI, 3TC, or D4T. Recently,
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1302 PART III / PHARMACODYNAMIC AGENTS
combinations of nucleosides drugs (ZDV, ddC, ddI, 3TC)
are used with protease inhibitors (saquinavir, indinavir,
ritonavir) for delaying HIV infection. Combined nucleo-
side drugs are known to delay progression of HIV infection.
Antiretroviral therapy includes nucleosides or non-
nucleoside RT inhibitors and protease inhibitors. These
drugs inhibit HIV replication at different stages of viral
infection. Nucleoside and nonnucleoside drugs inhibit RT
by preventing RNA formation or viral protein synthesis.
Nonnucleoside drugs inhibit RT by inactivating the cata-
lytic site of the enzyme. Protease inhibitors act after HIV
provirus has integrated into the human genome. These
drugs inhibit protease, which is an enzyme responsible for
cleaving viral precursor polypeptides into effective virions.
Thus, protease inhibitors combined with RT inhibitors act
by a synergistic mechanism to interrupt HIV replication.
Two-drug combinations, such as ZDV plus ddI or ddC,
3TC plus ZDV, and D4T plus ddI, have been successful in
raising CD4+ cell counts and decreasing HIV RNA viral
load. Triple-drug therapy consisting of ZDV, 3TC, and a
protease inhibitor (indinavir, ritonavir, nelfinavir) has been
more effective than two-drug therapy consisting of two
nonnucleoside analog combinations. In addition, fewer
opportunistic infections were noted when patients took the
three-drug combination. ZDV can also be combined with
immunomodulators to increase immunologic response in
AIDS patients. ZDV has been combined with α-interferon
to obtain synergistic activity of the drug. An ideal approach
of combined antiretroviral drug therapy would be drugs
acting at different stages of HIV cell replication.
Investigational Antiviral Agents: Short Interfering
RNA (117)
The field of directed RNA interference (RNAi) has rapidly
developed into a highly promising approach for specifically
interrupting gene function in order to alleviate disease
pathology. This technique was first described in 1998, and
the inventors of this technology, Andrew Fire and Craig C.
Mello, were awarded a Nobel Prize in 2006 for their work
with RNAi. RNAi is a natural mechanism for silencing gene
expression that has been conserved through evolution in
eukaryotes ranging from plants to humans. In this process,
SCENARIO: OUTCOME AND ANALYSIS
Outcome
Douglas Slain, PharmD, BCPS
WM was started on the investigational zanamivir intravenous
formulation. After about 5 days of therapy, the patient became
clinically stable and was able to come off of mechanical ventila-
tion. She ultimately recovered. Resistance testing did show that
she had an H1N1 strain that had the H274Y mutation.
double-stranded duplexes 21 to 25 nucleotides in length
are created from a parent double-stranded RNA molecule
by an enzyme known as dicer. These short interfering RNAs
(siRNA) bind to specific mRNAs that feature a complimen-
tary sequence to form an RNA-induced silencing complex,
and thereby block the expression of predetermined spe-
cific proteins at the posttranscriptional level. This bind-
ing also appears to direct the cell to cleave target mRNA/
siRNA complexes. Many research groups are attempting
to develop RNAi therapies that induce the degradation of
target mRNA involved in inherited or acquired disorders.
This technology is especially well suited to treating viral
infections, and numerous examples now illustrate that a
wide range of viruses can be inhibited with RNAi, both in
vitro and in vivo. Antiviral RNAi therapies can be tailored to
the biochemical characteristics of each pathogen and can
be made more specific through choice of delivery vehicle,
route of administration, selection of gene targets, and reg-
ulation of RNAi induction. As mentioned earlier, success-
ful antiviral therapeutics possess the ability to discriminate
virus from host. However, because viruses rely extensively
on host cell machinery for many functions and activities
involved in viral replication, they offer a very limited num-
ber of therapeutic targets. Because RNAi specifically targets
a short stretch of viral nucleic acids rather than a viral pro-
tein, even a small viral genome can provide a large number
of potential targets.
Researchers are continuing to look for suitable siRNA
treatments for viral infections such as HBV, HCV, and
HIV. Despite extensive research, the development of an
siRNA-based therapy for viral infection faces significant
barriers including poor siRNA stability, inefficient cellular
uptake, widespread biodistribution, activation of immune
response, and occurrence of nonspecific (i.e., off-target)
effects (118). The most notable of these barriers is the
delivery of intact siRNA molecules to the interior of virus-
infected cells. A number of approaches have been tried,
including bioconjugation of siRNA with lipids, incorpora-
tion into nanoparticles, and in situ biosynthesis of siRNAs.
Although this strategy for antiviral development shows
great promise, a reliable siRNA-based therapy for viral
infection will likely not be realized in the near future.
Chemical Analysis
Victoria Roche and S. William Zito
These three antiviral molecules all take advantage of the research
conducted to map the binding site of the influenza virus activat-
ing enzyme neuraminidase. Neuraminidase facilitates the spread
of shed viruses by cleaving sialic acid (N-acetylneuraminic acid)
from the saccharide-coated viral particles, which promotes their
receptor-mediated absorption into unaffected cells.
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