Anti-viral and anti-fungal drugs

Lecture Outline
Anti-viral and
• Selective toxicity
anti-fungal drugs • Viruses / antiviral drugs
• Fungi / antifungal drugs
Dr. Ross O’Shea
HS2 Room 308, 9479-1713
r.oshea@latrobe.edu.au

Suggested reading Infectious / invading organisms

• Bryant B and Knights K. Pharmacology for Health
Professionals, chapters 43, 45
• Rang HP et al. Rang and Dale’s Pharmacology,
chapters 49, 51, 52
• Waller DG et al. Medical Pharmacology &
Therapeutics, chapter 51
• Viruses
– lack biochemical machinery for synthesis, utilise
the machinery of the host cell
• Eukaryotes
– cells with nuclei (e.g. protozoa, fungi, helminths)
• Prokaryotes
– cells without nuclei (bacteria)
• Gram-negative vs Gram-positive
• Prions (e.g. in BSE – “mad cow disease”)
• Malignant / cancerous cells
• “Microbe” – viruses, fungi, bacteria

Ross O’Shea HBS3PCY

Anti-viral and anti-fungal drugs

“Magic Bullets” Selective toxicity

If we picture an organism as infected by a
certain species of bacterium, it will . . . be
easy to effect a cure if substances have been
discovered which have a specific affinity for
these bacteria and act…on these alone. . .
while they possess no affinity for the normal
constituents of the body. . . such substances
would then be . . . magic bullets.
Paul Ehrlich (1854-1915)
• Ideally an antimicrobial drug should be much more
toxic to the micro-organism causing infection than to
the host, eg. via:
– accumulation of a drug to higher concentration in
the microbe
– specific action on cellular processes or structure
unique to the microbe
– specific action on processes more critical to the
microbe than the host cell

Terminology Microbes and disease

• Chemotherapy - administration of a chemical that
destroys disease-causing cells whilst leaving the host Microbes are not always pathogenic!
unaffected
• Antibiotics - natural substances produced by micro- May be:
organisms which are antagonistic to the growth of
others (become synonymous with all antibacterial Commensal
agents)
• Antimicrobials - substances that kill or inhibits the Pathogenic only under certain conditions
growth of microorganisms such as bacteria, fungi, or (e.g. opportunistic infections)
protozoans. Antimicrobial drugs either kill microbes
(microbicidal) or prevent their growth (microbistatic).
Include synthetic compounds and chemical Always pathogenic
modifications of antibiotics

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Anti-viral and anti-fungal drugs

Viruses
• From the Latin word for poison
• Probably existed since the evolution of cells
• Discovered in the late 1800s (too small to be
seen by light microscope)

http://en.wikipedia.org/wiki/File:Viral_infections_and_involved_species.png

Structure of a virus Classification of viruses

● Genetic material - DNA or RNA
• DNA viruses
● Protein coat
• double-stranded DNA (e.g. Herpesviruses)
+/- Lipoprotein envelope • single-stranded DNA (e.g. Parvoviruses)
• double-stranded DNA, replicate using reverse transcriptase
Lipoprotein envelope (e.g. hepatitis B)

Capsomere
• RNA viruses
(protein units • double-stranded RNA (e.g. Rotavirus)
of the coat) • (+) single-stranded RNA viruses (e.g. hepatitis A)
• (-) single-stranded RNA viruses (e.g. Rabies virus)
• (+) single-stranded RNA-RT viruses with DNA intermediate
Nucleic acid core in life-cycle (“Retroviruses”, e.g. HIV1)

Adapted with permission from http://en.wikipedia.org/wiki/File:Viral_Replication_Cycle.svg

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Anti-viral and anti-fungal drugs

Viral Replication
Viral life cycle
1. Attachment to host cell / endocytosis
3 1
2. Release of viral genes into host cell 3
2
3. Replication of viral components using host-
cell machinery 3

4. Assembly of viral components into complete 4

viral particles
4
5. Release of viral particles to infect new host
cells
5

Modified with permission:

http://upload.wikimedia.org/wikipedia/commons/thumb/3/3a/Virus_Replication.svg/500px-Virus_Replication.svg.png

Difficulties with antiviral drugs Development of antiviral drugs

• Few targets for selective toxicity
(use host machinery for replication, etc)
• Symptoms often appear AFTER viral
replication has peaked
• As with other antimicrobials, drug resistance
is a problem
• Drugs generally need to be administered
before disease appears
• Little progress before sequencing of viral genes
• Modern antiviral drug design identifies protein
sequences or entire proteins to disable
• These "targets" are ideally unlike human
proteins and common to many strains of virus
• Once targets are found, candidate drugs can be
selected (from drugs known to have appropriate
actions) or computer designed

Ross O’Shea HBS3PCY

Anti-viral and anti-fungal drugs

Antiviral drugs Targets of antiviral

• Do not destroy virus, just inhibit development
• Specific for an individual virus
• Used to treat HIV, herpes viruses, hepatitis B
and C viruses, influenza A and B viruses
• NB: different to viricides, which destroy virus
particles outside the body (NOT medicines!)
• Immunisation is a different approach (later!)
Viral life cycledrugs
1. Attachment to host cell / endocytosis
2. Release of viral genes into host cell
3. Replication of viral components using host-
cell machinery
4. Assembly of viral components into complete
viral particles
5. Release of viral particles to infect new host
cells

Targets of antiviral
Viral life cycledrugs
Attachment of gp41 from virus
1. Attachment to host cell / endocytosis to gp120 on CD4+ T-lymphocyte

• Inhibit viral entry (interfere with binding of

virus to its entry target on the host cell)
E.g. Enfuvirtide (FUZEON®) blocks fusion of
HIV-1 with host cells (helper T cells) via cell
surface receptors - prevents creation of an
entry pore for the virus
Conformational changes
Peptide (36 AAs) ~USD$25,000 per year allow fusion / entry Enfuvirtide blocks these
conformational changes

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Anti-viral and anti-fungal drugs
Targets of antiviral
Viral life cycledrugs
2. Release of viral genes into host cell
• Inhibit viral uncoating
E.g. Amantadine (early influenza drug - 1966)
interferes with a viral protein required for the
viral particle to become "uncoated" once
inside a cell
Amantadine / Rimantadine (red) block H+ (yellow) transport
through pump, blocking virion uncoating and replication
Ross O’Shea
Targets of antiviral
Viral life cycledrugs
2. Release of viral genes into host cell
• Amantadine not effective against many (all?)
current strains of influenza
• Recent Cochrane review found no benefit
• Rimantadine (Flumadine®) more effective
Targets of antiviral
Viral life cycledrugs
3. Replication of viral components using host-
cell machinery
• Block synthesis of viral DNA, by targeting
enzymes involved in this synthesis
E.g. Aciclovir (analogue of guanosine,
component of DNA) inhibits viral DNA
polymerase; useful against HSV family; may
also delay HIV-1 progression
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Anti-viral and anti-fungal drugs
Guanosine Aciclovir
Targets of antiviral
Viral life cycledrugs
4. Assembly of viral components into complete
viral particles
• E.g. Rifampicin (also an antibacterial)
effective against vaccinia virus – inhibits the
formation of mature viruses by blocking the
proteins used as scaffolds in assembly
Ross O’Shea
Viral DNA replication
Targets of antiviral
Viral life cycledrugs
5. Release of viral particles to infect new host
cells
• Eg. Zanamivir (Relenza® – VCP/Monash) and
Oseltamivir (Tamiflu®) block neuraminidase
(molecule on the surface of influenza viruses)
that cleaves glycoproteins, allowing viral
release
• Animation of mode of action:
https://vimeo.com/83873138
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Anti-viral and anti-fungal drugs

Antiviral vaccines Treating the common cold

• Stimulate the immune system to attack viruses in the
"complete particle" stage • Most often caused by rhinovirus or coronavirus
• Mostly use an attenuated version of the virus • Antibiotics ineffective
• Occasionally cause full-blown infection (if there is no bacterial infection)
• Newer vaccines only use viral proteins - stimulate • Vitamin C ineffective
immune system without harm
• No anti-viral drugs are approved for cold
+ Very effective on stable viruses
- Little / no use in people who are already infected • Herbal remedies might alleviate symptoms, but
- Difficult to target viruses that mutate rapidly (e.g. not shorten the cold
influenza) - need new vaccine frequently; even then
it isn’t always effective

Zinc and the common cold Some issues with zinc

• Over the counter preparations vary in strength
• Cochrane Review, updated 2011 and bioavailability
• Reviewed 15 randomised controlled trials • Cochrane Review offered no guidelines on dose
involving 1360 participants of all ages, / formulation (Zn gluconate, Zn acetate, etc)
comparing zinc with placebo
• Potential side effects: effects on smell and taste
• Zinc (lozenges or syrup) found to be beneficial in (zinc nasal sprays taken off the market)
reducing the duration and severity of the
common cold in healthy people, when taken
within 24 hours of onset of symptoms
• Mechanisms: inhibition of rhinoviral replication,
anti-inflammatory

Ross O’Shea HBS3PCY

Anti-viral and anti-fungal drugs

Antiviral treatment of HIV/AIDS Antiviral treatment of HIV/AIDS

• HIV = retrovirus: RNA virus, uses reverse
• Even if a mutation produces resistance to one
transcriptase to make DNA from its RNA, DNA
of the drugs, the others can continue to work
then incorporated into the host genome
• “Fixed dose combinations” - multiple
• HIV lacks proof-reading enzymes in conversion
antiretroviral drugs combined into a single pill
of RNA to DNA – high rate of mutations
• Combines different modes of action to
• Most mutations are inferior, but high frequency
increase potency of action
increases the risk of resistance
• Makes life simpler – patients don’t need to
• > 20 antiretroviral drugs available to treat HIV
remember multiple pills, doses, times etc
• Combination therapy aims to reduce resistance
• Avoids issues with overlapping toxicity
by blocking HIV replication as much as possible

Fungal infections Fungi

• Fungal infections can range from mild (e.g.
ringworm) to life threatening (e.g.
cryptococcal meningitis)
• Fungi are eukaryotes: more similar to
humans than are viruses and bacteria
• More difficult to target differences!
• A diverse group that includes mushrooms,
yeasts and molds
• Fungi are a separate kingdom to plants,
animals and bacteria
• Have cell walls that contain chitin
(plant cell walls contain cellulose)
• Study of fungi: mycology
• Antifungal drugs: antimycotics

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Anti-viral and anti-fungal drugs

Fungi and humans Fungal infections

• Mushrooms a source of food throughout human
history
• Source of antibiotics including penicillin
• Other fungi used in cooking and production of alcohol:
 Baker's yeast = Saccharomyces cerevisiae
 “blue cheese”
 Yeast in brewing and winemaking
 Shoyu koji mold essential in brewing soy sauce and
sake, and making miso
 “magic mushrooms”
• MANY fungal disease, including:
aspergilloses, candidoses, cryptococcosis,
mycetomas, histoplasmosis,
• Immuno-compromised individuals very susceptible
• Other fungi can attack eyes, nails, hair and skin and
cause local infections (e.g. ringworm, athlete’s
foot, dandruff)
• Fungal spores are a major cause of allergies

Antifungal drugs (antimycotics)

“There are close parallels
between bacterial and fungal Fungi have rigid cell walls that contain chitin
resistance, though the problems
we face with the latter are (different to bacteria)
particularly worrying,” said Prof
Adilia Warris, a co-director of the
newly opened Centre for
Medical Mycology at Aberdeen more similar to human cells (ergosterol)
University.

“There are more than 20

different classes of antibacterial fewer targets for selective toxicity,  side effects
agents. By contrast, there are
only four classes of anti-fungal
agents. Our armoury for dealing
with deadly fungi is much
smaller than the one we have for
http://goo.gl/1nfoji dealing with bacteria.”

Ross O’Shea HBS3PCY

Anti-viral and anti-fungal drugs

Classes of antifungal drugs Polyene antimycotics

• Bind to sterols in the fungal cell membrane (esp.
• Polyenes ergosterol, vs cholesterol in animal cells)
• Make the membrane less fluid → leakage of small
• Imidazoles
molecules (esp. ions: K+, Na+, H+, and Cl-)
• Triazoles Azoles • Examples:
• Thiazoles Amphotericin B (e.g. Fungizone® - intravenus, tablets)
• Allylamines Nystatin (e.g. Nilstat® - tablets, ointment, pessaries)
• Echinocandins Natamycin (e.g. Natamet® - cream, eyedrops,
lozenges)
• Others / Alternatives

Amphotericin B
(these are just examples!)

Fungal cell wall and cell membrane

Azole antimycotics
• Fungistatic - interfere with the synthesis of fungal
ergosterols
→ inhibition of fungal growth
→ cell leakage and death
• Mostly applied topically (locally)  minimal absorption,
systemic side effects uncommon
• Examples:
Clotrimazole (Canesten®)
Ketoconazole (Nizoral®): cream, anti-dandruff shampoo
(tablet discontinued 2013 due to liver toxicity)
• Commonly used in treatment of athlete's foot,
ringworm, jock itch, oral or vaginal thrush
Polyenes (these are just examples!)

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Anti-viral and anti-fungal drugs

Fungal cell wall and cell membrane

Allylamine antimycotics
• Inhibit an enzyme (squalene epoxidase) that is part
of the fungal synthesis pathway for ergosterol
• Cell membrane permeability altered causing cell lysis
• Example:
Terbinafine hydrochloride (Lamisil®), cream, powder,
tablets
• Commonly used in treatment of athlete's foot,
ringworm, jock itch

Terbinafine
Azoles (these are just examples!)

Fungal cell wall and cell membrane

Echinocandin antimycotics
• Named after the chemical structure
• Inhibit the synthesis of glucan in the cell wall,
probably via inhibition of an enzyme (1,3-β glucan
synthase) -> disturbs wall structure
• Fungicidal against some yeasts (Candida species),
fungistatic against some molds (Aspergillus)
• Current echinocandins are semi-synthetic,
approved since 2000
• Poor oral bioavailability -
administered IV
Echinocandin B
• E.g. Caspofungin (Cancidas®)
Allylamines
(these are just examples!)

Ross O’Shea HBS3PCY

Anti-viral and anti-fungal drugs

Fungal cell wall and cell membrane

Other antimycotics
• Tea tree oil - useful against bacteria, viruses,
fungi, mites (e.g. scabies) and lice
* 5% solution effective against Malassezia
furfur, the most common cause of dandruff
• Griseofulvin (from a Penicillium mold) - binds
to tubulin (interferes with microtubules)
→ inhibits mitosis of fungi
* useful against a variety of Tinea fungi (e.g.
ringworm, athlete’s foot)
Echinocandins

Mechanism of action From this lecture you should be able to:

of antifungal drugs • Describe how selective toxicity is achieved and
why it is important in chemotherapy
• Polyenes Form pores in membrane • Understand the ways in which antiviral drugs exert
• Imidazoles their action (drug target and mechanism of action)
Inhibit • Describe the ways in which different classes of
• Triazoles Azoles antimycotic drugs exert their action (drug target
ergosterol
• Thiazoles syntheis and mechanism of action), giving examples of
drugs from the different groups
• Allylamines
• Understand the specific difficulties associated with
• Echinocandins Inhibit b-glucan synthesis treating fungal or viral infections, including drug
resistance

Ross O’Shea HBS3PCY