Antivirals Flashcards

1
Q

Treatment of respiratory infections

A

Influenza A, B and RSV

  • Neuramindase inhibitors: Oseltamivir, Zanamivir
  • Inhibitors of viral uncoating: Amantadine, rimantadine
  • Synthetic Guanosine Analog: Ribavirin
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2
Q

Oseltamivir, Zanamivir

A
  • Neuraminidase inhibitor
  • Effective against BOTH Type A and Type B Influenza
  • Administered prior to exposure as prophylaxis
  • Administered within 24 - 48h after infection drugs have modest effect on symptoms
  • Oseltamivir indicated for influenza A & B Pt w severe asthma

MOA

  • Analogs / inhibitors of sialic acid substrate for neuraminidase
  • Inhibit release of virus

PK

  • Oseltamivir: orally active prodrug (hydrolyzed in liver)
  • Zanamivir: NOT orally active (inhaled, intranasal)
    • Indicated for children > 7 yo
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3
Q

Neuramindase - Adverse

A
  • Oseltamivir: GI discomfort, nausea (alleviated when taken with food)
  • Zanamivir: **airway irritation (avoid in severe asthma, COPD) **

Resistance: Less infective & virulent neuraminidase mutations identified

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4
Q

Amantadine, Rimantadine

A
  • ion channel blockers -> blocks uncoating
  • EXCLUSIVELY ACTIVE ON INFLUENZA A VIRUS
  • Equally effective in prophylaxis and treatment (70- 90%)
  • Since 2006 not recommended as first-line treatments due to resistance

MOA

  • Block viral membrane protein, M2 (H+ channel)
  • Channel is required for fusion of viral with cell membrane to endosome (requirement for viral uncoating)

PK

  • Oral
  • Amantadine is widely distributed & crosses BBB (Rimantadine is NOT), not extensively metabolized & excreted into urine where it may accumulate
  • Rimantadine IS metabolized before elimination in urine

Resistance

  • Up to 50% individuals are naturally resistant
  • Cross-resistance between drugs occurs
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5
Q

Ion channel blockers - Adverse

A
  • Amantadine: CNS (~10%) (insomnia, dizziness, ataxia leading to hallucinations, seizures)
  • Rimantadine: fewer problems
  • Both: GI intolerance

Contraindications

  • Amantadine should be monitored in psychiatric patients, cerebral atherosclerosis, renal impairment, epilepsy
  • Pregnancy, nursing (FDA Category C): not recommended in both pregnancy and nursing
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6
Q

Ribavirin

A
  • synthetic guanosine analog
  • Active against broad spectrum of RNA & DNA viruses (eg, RSV, HCV, Lassa fever)
  • Commonly used in combination with interferon alpha for the treatment of HCV

MOA

  • Converted to ribavirin-triphosphate which inhibits guanosine triphosphate formation and prevents viral mRNA capping.
  • Inhibits RNA-dependent RNA polymerase resulting in inhibition of viral protein synthesis

PK

  • Oral, IV, & aerosolized
  • Distribution significantly prolonged in RBC (16-40 days)
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7
Q

Ribavirin - Adverse

A
  • Dose-dependent transient anemia (can bind to RBC)
  • GI (nausea, anorexia)
  • CNS (fatigue, headache, insomnia)

Contraindications

  • Pregnancy (FDA Category X); Never give to pregnant women or male Pt living with a pregnant women due to aerosolization
  • Negative pregnancy tests required before treatment and monthly during treatment of female patients or female partners of male patients
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8
Q

Hepatitis viral infection Rx

A
  • Interferon: Interferon alpha
  • **Nucleotide / Nucleoside Analogs: **Lamivudine, Entecavir, Ribavirin
  • Protease Inhibitors: Boceprevir, Telaprevir
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9
Q

Interferon alpha

A
  • Naturally occurring, inducible glycoproteins / cytokines
  • alpha and beta produced by many cell types, gamma by immune cells (T cells)

MOA

  • Use innate immune response.
  • DO NOT target viral gene products directly
  • Inhibit RNA & DNA synthesis by activating / inducing protein expression that inhibit virus infection eg, PKR

Clinical applications

  • HCV (in combination with ribavirin)
  • HBV, condyloma acuminata, hairy-cell leukemia, Kaposi’s sarcoma

PK

  • Not orally active (IV, subcutaneously, intralesionally)
  • Cellular uptake and metabolism by liver & kidney
  • Usually pegylated to improve PK profile
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10
Q

Interferon alpha - Adverse & Interactions

A
  • Flu-like (fever, chills, myalgias & GI disturbances)
  • Fatigue & mental depression

Interactions

  • Interferes with hepatic drug metabolism. Can cause toxic accumulation of theophylline; due to small therapeutic window
  • May potentiate zidovudine induced myelosuppression
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11
Q

Lamivudine

A
  • Nucleoside/nucleotide analogs
  • Must be phosphorylated by cellular enzymes to triphosphate (active) form
  • Actions are suppressive rather than curative

Clinical applications: Effective against hepatitis B and HIV

MOA

  • Triphosphate form inhibits HBV and HIV reverse transcriptase
  • Monophosphate form is incorporated into DNA (by HBV polymerase) resulting in chain termination
  • Well tolerated (headache, dizziness, GI complaints)
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12
Q

Entecavir

A
  • Nucleoside/nucleotide analogs
  • Must be phosphorylated by cellular enzymes to triphosphate (active) form
  • Actions are suppressive rather than curative

Clinical applications: Effective against lamivudine-resistant strains of HBV & HIV

MOA

  • Phosphorylated form competes with natural substrates for viral polymerase.
  • Subsequent inhibition of polymerase blocks reverse transcriptase activity
  • Monitor after discontinuation in case of exacerbation of severe hep
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13
Q

Boceprevir, Telaprevir

A
  • Used in the treatment of HCV in adult patients who have been previously untreated or failed treatment with interferon alpha and ribavirin
  • Administered in combination with interferon alpha and ribavirin

MOA: Bind reversibly to nonstructural protein 3 (NS3) serine protease and inhibit replication of HCV

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14
Q

Protease inhibitors - Adverse

A
  • fatigue
  • anemia
  • nausea
  • headache
  • dysgeusia
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15
Q

Herpes rx

A
  • Herpes can form latent infection. Available drugs are for replicating virus only (useless during viral dormant part of lifecycle)
  • Purine / Pyrimidine Analogs: Acyclovir, Valacyclovir, Cidofovir, Ganciclovir, Valganciclovir, Penciclovir, Trifluridine
  • Foscarnet
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16
Q

Acyclovir

A
  • Prototypic antiherpetic therapeutic agent
  • Activity against: herpes simplex virus (HSV) Types 1 and 2, varicella-zoster virus (VZV) & some Epstein- Barr (HSV4) infections
  • TREATMENT OF CHOICE IN HSV ENCEPHALITIS
  • Commonly used for genital herpes infections & prophylactically in immunocompromised and transplant patients
  • CMV is resistant at clinically achievable levels (does not encode thymidine kinase)
  • Valacyclovir (Val = more bioavailable): prodrug of acyclovir

MOA

  • Requires 3 phosphorylation steps for activation
  • Monophosphorylated by herpes virus-encoded enzyme (thymidine kinase)
  • Host cell enzymes complete phosphorylation to di- and triphosphate forms
  • Competes with dGTP; once incorporated into DNA causes chain termination & inhibition of viral DNA polymerase

Resistance

  • Resistance is rare in immunocompetent host
  • Cross resistance to other ‘cyclovirs’ does occur
  • Occurs by:
    • Altered or deficient thymidine kinases
    • Altered viral DNA polymerase with decreased affinity for acyclovir

Resistance

  • IV, oral or topical
  • Valacyclovir has greater oral bioavailability than acyclovir
  • Partially metabolized thus can accumulate with renal failure
17
Q

Acyclovir - Adverse

A

Depends on route of admin. eg,

  • topical = local irritation
  • oral = headache, diarrhea, nausea & vomiting
  • IV = acute renal failure. Risk can be minimized by slow infusion and prior hydration of patient
18
Q

Ganciclovir

A
  • Valganciclovir = pro-drug with greater oral bioavailability
  • Analog of acyclovir (8-20 x activity against CMV)
  • Drug of choice for CMV retinitis & CMV prophylaxis in immunocompromised

MOA

  • Phosphorylated by viral (UL97) and cell kinases
  • DNA chain terminator & DNA polymerase inhibitor

Resistance

  • Reduced intracellular phosphorylation
  • Mutations in phosphotranferase (UL97), or viral DNA polymerase

PK

  • Ganciclovir (IV)
  • Valganciclovir (oral) undergoes rapid hydrolysis in intestine & liver to ganciclovir
  • Excretion via urine
19
Q

Ganciclovir - Adverse

A
  • Myelosuppression
  • Severe dose-dependent neutropenia

Contraindications: Pregnancy (FDA Category C)

20
Q

Cidofovir

A
  • Major use is treatment of CMV-induced retinitis in HIV/AIDS
  • Not phosphorylated by viral kinases
  • Requires activation by host cell kinases
  • Effective against HSV & ganciclovir resistant HSV

MOA: DNA chain terminator & DNA polymerase inhibitor

Resistance: Mutations in viral DNA polymerase

PK:

  • IV, intravitreal & topical
  • Must be co-administered with probenecid (blocks renal tubular secretion)
21
Q

Cidofovir - Adverse

A

Nephrotoxicity

22
Q

Penciclovir

A
  • Active against HSV-1, 2 and VZV
  • Used for the topical treatment of HSV (cold sores)

MOA

  • Monophosphorylated by viral thymidine kinase
  • Further phosphorylation occurs to give active triphosphate form
  • Inhibit HSV DNA polymerase / chain terminator

Resistance: Low occurrence clinically

PK: Topical only

23
Q

Penciclovir - Adverse

A

Dermatologic: mild erythema

24
Q

Trifluridine

A
  • Effective against HSV-1, 2, and vaccina virus
  • Drug of choice for HSV keratoconjunctivitis and recurrent epithelial keratitis

MOA: Triphosphate form incorporated into viral DNA causing fragmentation

PK:

  • Ophthalmic ointment (too toxic for systemic)
  • t1/2 = ~12 min (apply frequently)
25
Q

Trifluridine - Adverse

A

Transient irritation of eye & palpebral (eyelid) edema

26
Q

Foscarnet

A
  • Organic analog of inorganic pyrophosphate
  • DOES NOT require phosphorylation!!
  • Used for CMV retinitis in immunocompromised patients, acyclovir-resistant HSV & CMV retinitis & ganciclovir-resistant CMV & VZV

MOA: Structural analog of the anion pyrophosphate that selectively inhibits the pyrophosphate binding site on viral DNA polymerases

Resistance: Point mutations in polymerase

PK: IV only

27
Q

Foscarnet - Adverse

A
  • Nephrotoxicity
  • Electrolyte disturbances (Ca2+, Mg2+, K+, PO43-) -> cardiac problems
  • Anemia,
  • Genital ulceration (mainly men)
  • CNS: hallucinations, seizures, headache (25%)