Antiviral drugs are a class of medication used specifically for treating viral infections. Like antibiotics and broad-spectrum antibiotics for bacteria, most antivirals are used for specific viral infections, while a broad-spectrum antiviral is effective against a wide range of viruses. Unlike most antibiotics, antiviral drugs do not destroy their target pathogen; instead they inhibit their development.
Antiviral drugs are one class of antimicrobials, a larger group which also includes antibiotic (also termed antibacterial), antifungal and antiparasitic drugs, or antiviral drugs based on monoclonal antibodies. Most antivirals are considered relatively harmless to the host, and therefore can be used to treat infections. They should be distinguished from viricides, which are not medication but deactivate or destroy virus particles, either inside or outside the body. Natural antivirals are produced by some plants such as eucalyptus.
- 1 Medical uses
- 2 Virus life cycle
- 3 Limitations of vaccines
- 4 Anti-viral targeting
- 5 Approaches by life cycle stage
- 5.1 Before cell entry
- 5.2 During viral synthesis
- 5.3 Assembly
- 5.4 Release phase
- 6 Immune system stimulation
- 7 Acquired resistance
- 8 See also
- 9 References
- 10 Further reading
Most of the antiviral drugs now available are designed to help deal with HIV, herpes viruses, the hepatitis B and C viruses, and influenza A and B viruses. Researchers are working to extend the range of antivirals to other families of pathogens.
Designing safe and effective antiviral drugs is difficult, because viruses use the host's cells to replicate. This makes it difficult to find targets for the drug that would interfere with the virus without also harming the host organism's cells. Moreover, the major difficulty in developing vaccines and anti-viral drugs is due to viral variation.
The emergence of antivirals is the product of a greatly expanded knowledge of the genetic and molecular function of organisms, allowing biomedical researchers to understand the structure and function of viruses, major advances in the techniques for finding new drugs, and the intense pressure placed on the medical profession to deal with the human immunodeficiency virus (HIV), the cause of the deadly acquired immunodeficiency syndrome (AIDS) pandemic.
The first experimental antivirals were developed in the 1960s, mostly to deal with herpes viruses, and were found using traditional trial-and-error drug discovery methods. Researchers grew cultures of cells and infected them with the target virus. They then introduced into the cultures chemicals which they thought might inhibit viral activity, and observed whether the level of virus in the cultures rose or fell. Chemicals that seemed to have an effect were selected for closer study.
This was a very time-consuming, hit-or-miss procedure, and in the absence of a good knowledge of how the target virus worked, it was not efficient in discovering effective antivirals which had few side effects. Only in the 1980s, when the full genetic sequences of viruses began to be unraveled, did researchers begin to learn how viruses worked in detail, and exactly what chemicals were needed to thwart their reproductive cycle.
Virus life cycle
Viruses consist of a genome and sometimes a few enzymes stored in a capsule made of protein (called a capsid), and sometimes covered with a lipid layer (sometimes called an 'envelope'). Viruses cannot reproduce on their own, and instead propagate by subjugating a host cell to produce copies of themselves, thus producing the next generation.
Researchers working on such "rational drug design" strategies for developing antivirals have tried to attack viruses at every stage of their life cycles. Some species of mushrooms have been found to contain multiple antiviral chemicals with similar synergistic effects. Viral life cycles vary in their precise details depending on the species of virus, but they all share a general pattern:
- Attachment to a host cell.
- Release of viral genes and possibly enzymes into the host cell.
- Replication of viral components using host-cell machinery.
- Assembly of viral components into complete viral particles.
- Release of viral particles to infect new host cells.
Limitations of vaccines
Vaccines bolster the body's immune system to better attack viruses in the "complete particle" stage, outside of the organism's cells. They traditionally consist of an attenuated (a live weakened) or inactivated (killed) version of the virus. These vaccines can, in very rare cases, harm the host by inadvertently infecting the host with a full-blown viral occupancy. Recently "subunit" vaccines have been devised that consist strictly of protein targets from the pathogen. They stimulate the immune system without doing serious harm to the host. In either case, when the real pathogen attacks the subject, the immune system responds to it quickly and blocks it.
Vaccines are very effective on stable viruses, but are of limited use in treating a patient who has already been infected. They are also difficult to successfully deploy against rapidly mutating viruses, such as influenza (the vaccine for which is updated every year) and HIV. Antiviral drugs are particularly useful in these cases.
The general idea behind modern antiviral drug design is to identify viral proteins, or parts of proteins, that can be disabled. These "targets" should generally be as unlike any proteins or parts of proteins in humans as possible, to reduce the likelihood of side effects. The targets should also be common across many strains of a virus, or even among different species of virus in the same family, so a single drug will have broad effectiveness. For example, a researcher might target a critical enzyme synthesized by the virus, but not the patient, that is common across strains, and see what can be done to interfere with its operation.
Once targets are identified, candidate drugs can be selected, either from drugs already known to have appropriate effects, or by actually designing the candidate at the molecular level with a computer-aided design program.
The target proteins can be manufactured in the lab for testing with candidate treatments by inserting the gene that synthesizes the target protein into bacteria or other kinds of cells. The cells are then cultured for mass production of the protein, which can then be exposed to various treatment candidates and evaluated with "rapid screening" technologies.
Approaches by life cycle stage
Before cell entry
One anti-viral strategy is to interfere with the ability of a virus to infiltrate a target cell. The virus must go through a sequence of steps to do this, beginning with binding to a specific "receptor" molecule on the surface of the host cell and ending with the virus "uncoating" inside the cell and releasing its contents. Viruses that have a lipid envelope must also fuse their envelope with the target cell, or with a vesicle that transports them into the cell, before they can uncoat.
This stage of viral replication can be inhibited in two ways:
- Using agents which mimic the virus-associated protein (VAP) and bind to the cellular receptors. This may include VAP anti-idiotypic antibodies, natural ligands of the receptor and anti-receptor antibodies.[clarification needed]
- Using agents which mimic the cellular receptor and bind to the VAP. This includes anti-VAP antibodies, receptor anti-idiotypic antibodies, extraneous receptor and synthetic receptor mimics.
This strategy of designing drugs can be very expensive, and since the process of generating anti-idiotypic antibodies is partly trial and error, it can be a relatively slow process until an adequate molecule is produced.
A very early stage of viral infection is viral entry, when the virus attaches to and enters the host cell. A number of "entry-inhibiting" or "entry-blocking" drugs are being developed to fight HIV. HIV most heavily targets the immune system's white blood cells known as "helper T cells", and identifies these target cells through T-cell surface receptors designated "CD4" and "CCR5". Attempts to interfere with the binding of HIV with the CD4 receptor have failed to stop HIV from infecting helper T cells, but research continues on trying to interfere with the binding of HIV to the CCR5 receptor in hopes that it will be more effective.
HIV infects a cell through fusion with the cell membrane, which requires two different cellular molecular participants, CD4 and a chemokine receptor (differing depending on the cell type). Approaches to blocking this virus/cell fusion have shown some promise in preventing entry of the virus into a cell. At least one of theses entry inhibitors—a biomimetic peptide marketed under the brand name Fuzeon—has received FDA approval and has been in use for some time. Potentially, one of the benefits from the use of an effective entry-blocking or entry-inhibiting agent is that it potentially may not only prevent the spread of the virus within an infected individual but also the spread from an infected to an uninfected individual.
One possible advantage of the therapeutic approach of blocking viral entry (as opposed to the currently dominant approach of viral enzyme inhibition) is that it may prove more difficult for the virus to develop resistance to this therapy than for the virus to mutate or evolve its enzymatic protocols.
Pleconaril works against rhinoviruses, which cause the common cold, by blocking a pocket on the surface of the virus that controls the uncoating process. This pocket is similar in most strains of rhinoviruses and enteroviruses, which can cause diarrhea, meningitis, conjunctivitis, and encephalitis.
A second approach is to target the processes that synthesize virus components after a virus invades a cell.
One way of doing this is to develop nucleotide or nucleoside analogues that look like the building blocks of RNA or DNA, but deactivate the enzymes that synthesize the RNA or DNA once the analogue is incorporated. This approach is more commonly associated with the inhibition of reverse transcriptase (RNA to DNA) than with "normal" transcriptase (DNA to RNA).
The first successful antiviral, acyclovir, is a nucleoside analogue, and is effective against herpesvirus infections. The first antiviral drug to be approved for treating HIV, zidovudine (AZT), is also a nucleoside analogue.
An improved knowledge of the action of reverse transcriptase has led to better nucleoside analogues to treat HIV infections. One of these drugs, lamivudine, has been approved to treat hepatitis B, which uses reverse transcriptase as part of its replication process. Researchers have gone further and developed inhibitors that do not look like nucleosides, but can still block reverse transcriptase.
Another target being considered for HIV antivirals include RNase H – which is a component of reverse transcriptase that splits the synthesized DNA from the original viral RNA.
On 10 August 2011 researchers at MIT announced the publication of a new method of inhibiting RNA, the process selectively affected infected cells. The team named the process "Double-stranded RNA Activated Caspase Oligomerizer" (DRACO). According to the lead researcher "In theory, [DRACO] should work against all viruses."
Another target is integrase, which splices the synthesized DNA into the host cell genome.
Once a virus genome becomes operational in a host cell, it then generates messenger RNA (mRNA) molecules that direct the synthesis of viral proteins. Production of mRNA is initiated by proteins known as transcription factors. Several antivirals are now being designed to block attachment of transcription factors to viral DNA.
Genomics has not only helped find targets for many antivirals, it has provided the basis for an entirely new type of drug, based on "antisense" molecules. These are segments of DNA or RNA that are designed as complementary molecule to critical sections of viral genomes, and the binding of these antisense segments to these target sections blocks the operation of those genomes. A phosphorothioate antisense drug named fomivirsen has been introduced, used to treat opportunistic eye infections in AIDS patients caused by cytomegalovirus, and other antisense antivirals are in development. An antisense structural type that has proven especially valuable in research is morpholino antisense.
Morpholino oligos have been used to experimentally suppress many viral types:
Yet another antiviral technique inspired by genomics is a set of drugs based on ribozymes, which are enzymes that will cut apart viral RNA or DNA at selected sites. In their natural course, ribozymes are used as part of the viral manufacturing sequence, but these synthetic ribozymes are designed to cut RNA and DNA at sites that will disable them.
A ribozyme antiviral to deal with hepatitis C has been suggested, and ribozyme antivirals are being developed to deal with HIV. An interesting variation of this idea is the use of genetically modified cells that can produce custom-tailored ribozymes. This is part of a broader effort to create genetically modified cells that can be injected into a host to attack pathogens by generating specialized proteins that block viral replication at various phases of the viral life cycle.
Protein processing and targeting
Interference with post translational modifications or with targeting of viral proteins in the cell is also possible.
Some viruses include an enzyme known as a protease that cuts viral protein chains apart so they can be assembled into their final configuration. HIV includes a protease, and so considerable research has been performed to find "protease inhibitors" to attack HIV at that phase of its life cycle. Protease inhibitors became available in the 1990s and have proven effective, though they can have unusual side effects, for example causing fat to build up in unusual places. Improved protease inhibitors are now in development.
Protease inhibitors have also been seen in nature. A protease inhibitor was isolated from the Shiitake mushroom (Lentinus edodes). The presence of this may explain the Shiitake mushrooms noted antiviral activity in vitro.
The final stage in the life cycle of a virus is the release of completed viruses from the host cell, and this step has also been targeted by antiviral drug developers. Two drugs named zanamivir (Relenza) and oseltamivir (Tamiflu) that have been recently introduced to treat influenza prevent the release of viral particles by blocking a molecule named neuraminidase that is found on the surface of flu viruses, and also seems to be constant across a wide range of flu strains.
Immune system stimulation
A second category of tactics for fighting viruses involves encouraging the body's immune system to attack them, rather than attacking them directly. Some antivirals of this sort do not focus on a specific pathogen, instead stimulating the immune system to attack a range of pathogens.
One of the best-known of this class of drugs are interferons, which inhibit viral synthesis in infected cells. One form of human interferon named "interferon alpha" is well-established as part of the standard treatment for hepatitis B and C, and other interferons are also being investigated as treatments for various diseases.
A more specific approach is to synthesize antibodies, protein molecules that can bind to a pathogen and mark it for attack by other elements of the immune system. Once researchers identify a particular target on the pathogen, they can synthesize quantities of identical "monoclonal" antibodies to link up that target. A monoclonal drug is now being sold to help fight respiratory syncytial virus in babies, and antibodies purified from infected individuals are also used as a treatment for hepatitis B.
Almost all anti-microbials, including anti-virals, are subject to drug resistance as the pathogens mutate over time, becoming less susceptible to the treatment. For instance, a recent study published in Nature Biotechnology emphasized the urgent need for augmentation of oseltamivir (Tamiflu) stockpiles with additional antiviral drugs including zanamivir (Relenza) based on an evaluation of the performance of these drugs in the scenario that the 2009 H1N1 'Swine Flu' neuraminidase (NA) were to acquire the tamiflu-resistance (His274Tyr) mutation which is currently widespread in seasonal H1N1 strains.
- Antiretroviral drug (especially HAART for HIV)
- Discovery and development of CCR5 receptor antagonists (for HIV)
- Monoclonal antibody
- List of antiviral drugs
- Antiprion drugs and Astemizole
- "Medmicro Chapter 52". Archived from the original on 18 August 2000. Retrieved 21 February 2009.
- Rick Daniels; Leslie H. Nicoll. "Pharmacology - Nursing Management". Contemporary Medical-Surgical Nursing. Cengage Learning, 2011. p. 397.
- Kisung Ko, Yoram Tekoah, Pauline M. Rudd, David J. Harvey, Raymond A. Dwek, Sergei Spitsin, Cathleen A. Hanlon, Charles Rupprecht, Bernhard Dietzschold, Maxim Golovkin, and Hilary Koprowski (2003). "Function and glycosylation of plant-derived antiviral monoclonal antibody". PNAS. doi:10.1073/pnas.0832472100.
- Schnitzler, P; Schön, K; Reichling, J (2001). "Antiviral activity of Australian tea tree oil and eucalyptus oil against herpes simplex virus in cell culture". Die Pharmazie 56 (4): 343–7. PMID 11338678.
- Lindequist, Ulrike; Niedermeyer, Timo H. J.; Jülich, Wolf-Dieter (2005). "The Pharmacological Potential of Mushrooms". Evidence-Based Complementary and Alternative Medicine 2 (3): 285–99. doi:10.1093/ecam/neh107. PMC 1193547. PMID 16136207.
- Bishop NE (1998). "Examination of potential inhibitors of hepatitis A virus uncoating". Intervirology 41 (6): 261–71. doi:10.1159/000024948. PMID 10325536.
- Almela MJ, González ME, Carrasco L (May 1991). "Inhibitors of poliovirus uncoating efficiently block the early membrane permeabilization induced by virus particles". J. Virol. 65 (5): 2572–7. PMC 240614. PMID 1850030.
- Beringer, Paul; Troy, David A.; Remington, Joseph P. (2006). Remington, the science and practice of pharmacy. Hagerstwon, MD: Lippincott Williams & Wilkins. p. 1419. ISBN 0-7817-4673-6.
- Stein DA, Skilling DE, Iversen PL, Smith AW (2001). "Inhibition of Vesivirus infections in mammalian tissue culture with antisense morpholino oligomers". Antisense Nucleic Acid Drug Dev 11 (5): 317–25. doi:10.1089/108729001753231696. PMID 11763348.
- Deas, T. S.; Binduga-Gajewska, I.; Tilgner, M.; Ren, P.; Stein, D. A.; Moulton, H. M.; Iversen, P. L.; Kauffman, E. B.; Kramer, L. D.; Shi, P. -Y. (2005). "Inhibition of Flavivirus Infections by Antisense Oligomers Specifically Suppressing Viral Translation and RNA Replication". Journal of Virology 79 (8): 4599–4609. doi:10.1128/JVI.79.8.4599-4609.2005. PMC 1069577. PMID 15795246.
- Kinney, R. M.; Huang, C. Y.-H.; Rose, B. C.; Kroeker, A. D.; Dreher, T. W.; Iversen, P. L.; Stein, D. A. (2005). "Inhibition of Dengue Virus Serotypes 1 to 4 in Vero Cell Cultures with Morpholino Oligomers". J. Virol. 79 (8): 5116–28. doi:10.1128/JVI.79.8.5116-5128.2005. PMC 1069583. PMID 15795296.
- McCaffrey AP, Meuse L, Karimi M, Contag CH, Kay MA (2003). "A potent and specific morpholino antisense inhibitor of hepatitis C translation in mice". Hepatology 38 (2): 503–8. doi:10.1053/jhep.2003.50330. PMID 12883495.
- Neuman, B. W.; Stein, D. A.; Kroeker, A. D.; Paulino, A. D.; Moulton, H. M.; Iversen, P. L.; Buchmeier, M. J. (June 2004). "Antisense Morpholino-Oligomers Directed against the 5′ End of the Genome Inhibit Coronavirus Proliferation and Growth†". J. Virol. 78 (11): 5891–9. doi:10.1128/JVI.78.11.5891-5899.2004. PMC 415795. PMID 15140987.
- Ryu KJ, Lee SW (2003). "Identification of the most accessible sites to ribozymes on the hepatitis C virus internal ribosome entry site". J. Biochem. Mol. Biol. 36 (6): 538–44. doi:10.5483/BMBRep.2003.36.6.538. PMID 14659071.
- Bai J, Rossi J, Akkina R (March 2001). "Multivalent anti-CCR ribozymes for stem cell-based HIV type 1 gene therapy". AIDS Res. Hum. Retroviruses 17 (5): 385–99. doi:10.1089/088922201750102427. PMID 11282007.
- Alarcón B, González ME, Carrasco L (1988). "Megalomycin C, a macrolide antibiotic that blocks protein glycosylation and shows antiviral activity". FEBS Lett 231 (1): 207–11. doi:10.1016/0014-5793(88)80732-4. PMID 2834223.
- Anderson J, Schiffer C, Lee SK, Swanstrom R (2009). "Viral protease inhibitors". Handb Exp Pharmacol. Handbook of Experimental Pharmacology 189 (189): 85–110. doi:10.1007/978-3-540-79086-0_4. ISBN 978-3-540-79085-3. PMID 19048198.
- Flint, O. P.; Noor, M. A.; Hruz, P. W.; Hylemon, P. B.; Yarasheski, K.; Kotler, D. P.; Parker, R. A.; Bellamine, A. (2009). "The Role of Protease Inhibitors in the Pathogenesis of HIV-Associated Lipodystrophy: Cellular Mechanisms and Clinical Implications". Toxicol Pathol 37 (1): 65–77. doi:10.1177/0192623308327119. PMC 3170409. PMID 19171928.
- Odani S, Tominaga K, Kondou S (1999). "The inhibitory properties and primary structure of a novel serine proteinase inhibitor from the fruiting body of the basidiomycete, Lentinus edodes". European Journal of Biochemistry 262 (3): 915–23. doi:10.1046/j.1432-1327.1999.00463.x. PMID 10411656.
- Suzuki H, Okubo A, Yamazaki S, Suzuki K, Mitsuya H, Toda S (1989). "Inhibition of the infectivity and cytopathic effect of human immunodeficiency virus by water-soluble lignin in an extract of the culture medium of Lentinus edodes mycelia (LEM)". Biochemical and Biophysical Research Communications 160 (1): 367–73. doi:10.1016/0006-291X(89)91665-3. PMID 2469420.
- Sodeik B, Griffiths G, Ericsson M, Moss B, Doms RW (1994). "Assembly of vaccinia virus: effects of rifampin on the intracellular distribution of viral protein p65". J. Virol. 68 (2): 1103–14. PMC 236549. PMID 8289340.
- Samuel CE (October 2001). "Antiviral Actions of Interferons". Clin. Microbiol. Rev. 14 (4): 778–809. doi:10.1128/CMR.14.4.778-809.2001. PMC 89003. PMID 11585785.
- Burra P (2009). "Hepatitis C". Semin. Liver Dis. 29 (1): 53–65. doi:10.1055/s-0029-1192055. PMID 19235659.
- Nokes JD, Cane PA (December 2008). "New strategies for control of respiratory syncytial virus infection". Curr. Opin. Infect. Dis. 21 (6): 639–43. doi:10.1097/QCO.0b013e3283184245. PMID 18978532.
- Akay S, Karasu Z (November 2008). "Hepatitis B immune globulin and HBV-related liver transplantation". Expert Opin Biol Ther 8 (11): 1815–22. doi:10.1517/14712522.214.171.1245. PMID 18847315.
- Venkataramanan Soundararajan; Kannan Tharakaraman; Rahul Raman; S. Raguram; Zachary Shriver; V. Sasisekharan; Ram Sasisekharan (9 June 2009). "Extrapolating from sequence — the 2009 H1N1 'swine' influenza virus". Nature Biotechnology 27 (6): 510–3. doi:10.1038/nbt0609-510. PMID 19513050.