Antiviral Drugs

Muhammad Asaduzzaman, PhD

 Overview
• Viruses are obligate intracellular parasites;
their replication depends primarily on
synthetic processes of the host cell.
• Therefore, to be effective, antiviral agents
must either block viral entry into or exit
from the cell or be active inside the host
cell.
• As a consequence, nonselective inhibitors of
virus replication may interfere with host cell
function and result in toxicity.
Virus replication steps

1. Attachment of the virus to receptors on the host cell surface

2. Entry of the virus through the host cell membrane
3. Uncoating of viral nucleic acid
4. Synthesis of early regulatory proteins, eg, nucleic acid polymerases
synthesis of new viral RNA or DNA
5. Synthesis of late, structural proteins
6. Assembly (maturation) of viral particles
7. Release from the cell.
• Viruses have no metabolic machinery of their own, so to replicate they must first attach to and
penetrate a living host cell – animal, plant or bacterial – and hijack the victim’s own metabolic
processes.
• The first step in this process is facilitated by polypeptide binding sites on the envelope or capsid
which interact with receptors on the host cell.
• These ‘receptors’ are normal membrane constituents, for example, receptors for cytokines,
neurotransmitters or hormones, ion channels, integral membrane glycoproteins, etc.
• Following attachment, the receptor–virus complex enters the cell, often utilizing receptor-
mediated endocytosis.
• The virus coat is removed by host cell enzymes (often lysosomal in nature) and the virion is
dismantled.
• Within the host cell the viral nucleic acid is released and then utilizes the host cellular machinery
to synthesize nucleic acids and proteins.
• These are subsequently assembled into new virus particles and released from the cell during the
shedding (or budding) phase or after host cell lysis.
 Virus Classification
• Viruses can infect virtually all living organisms, and they are a common cause of disease in
humans.

• Viruses are generally characterized either as DNA or RNA viruses, depending on the nature of
their nucleic acid content.

• These two broad categories are conventionally subdivided into subgroups, which classify
viruses according to whether they contain single- or double-stranded nucleic acids and how
this functions during replication.

• DNA viruses usually enter the host cell nucleus and direct the generation of new viruses.

• Viral DNA enters the host cell nucleus (and may become incorporated into host DNA), where
transcription into mRNA occurs. Translation of the mRNA into virus-specific proteins then
takes place.
• Examples: poxviruses (smallpox), herpesviruses (herpes simplex viruses, chickenpox,
shingles), adenoviruses (sore throat, conjunctivitis) and papillomaviruses (warts).
Virus Classification
• RNA viruses usually direct the generation of new viruses without involving the host cell
nucleus (the influenza virus is an exception).

• Enzymes within the virion synthesize its mRNA from the viral RNA template (sometimes
the viral RNA serves as its own mRNA). This is translated by the host cell into various
enzymes, including RNA polymerase (which directs the synthesis of more viral RNA), and
also into structural proteins for the virion.

• Examples: orthomyxoviruses (influenza), paramyxoviruses (measles, mumps, respiratory

tract infections), rubella virus (German measles), rhabdoviruses (rabies), Coronaviruses
(SARS, COVID-19, MERS)

• RNA retroviruses (AIDS, T-cell leukaemia), contain an enzyme, reverse transcriptase,

which makes a DNA copy of the viral RNA. This DNA copy is integrated into the host cell
genome and directs the generation of new virus particles.
Antiviral Drugs
• The initial phases of viral infection are often asymptomatic therefore, treatment
is often not initiated until the infection is well established.
• Antiviral drugs share the common property of being virustatic; they are active
only against replicating viruses and do not affect latent virus.
• Some infections require monotherapy for brief periods of time (eg, acyclovir for
herpes simplex virus),
• Others require dual therapy for prolonged periods of time (interferon
alfa/ribavirin for HCV),
• Some infection require multiple drug therapy for indefinite periods (HIV)
Antiviral Drugs

• Viruses hijack many of the metabolic processes of the host cell itself, which
makes it difficult to find drugs that are selective for the pathogen.
• However, there are some enzymes that are virus-specific and these have proved
to be useful drug targets.
• Antiviral drugs, of which many are now available, are hence conveniently grouped
according to their mechanisms of action.
Major sites of action of antiviral drugs
Mechanism of action of antiviral drugs
1. Inhibition of early events

E.g. Amantadine prevents uncoating of influenza A viruses, absorption and

penetration occur normally but no viral replication, influenza B and influenza C are
not affected.

2. Inhibition of viral nucleic acid synthesis

E.g. Idoxuridine and trifluridine

3. Inhibition of viral protein synthesis

E.g Interferons.
Neuraminidase Inhibitors and Inhibitors Of Viral Coat Disassembly

• Viral neuraminidase is one of three transmembrane proteins coded by the

influenza genome.
• Infection with these RNA viruses begins with the attachment of the viral
haemagglutinin to neuraminic (sialic) acid residues on host cells.
• The viral particle then enters the cell by endocytosis. The endosome is
acidified through another viral protein, the M2 ion channel.
• This facilitates the disassembly of the viral structure, allowing the RNA to
enter the host nucleus, thus initiating a round of viral replication.
• Newly replicated virions escape from the host cell by budding from the cell
membrane.
• Influenza viruses employ a specific neuraminidase that is inserted into the
host cell membrane for the purpose of releasing newly formed virions and is
an important enzyme for viral replication.
A. Neuraminidase inhibitors
Mechanism of action:
• Oseltamivir and zanamivir selectively inhibit neuraminidase, thereby preventing the release of
new virions and their spread from cell to cell.
• Zanamivir is however administered via inhalation and is not recommended for patients with
underlying respiratory conditions like asthma and COPD.
• Can be used in Influenza A and B and respiratory syncytial virus (RSV).

B. Adamantane antivirals
• Adamantanes interfere with the function of the viral M2 protein, possibly blocking uncoating of
the virus particle and preventing viral release within infected cells.

• Active against influenza A virus (an RNA virus) but has no action against influenza B virus.

• However, high rates of resistance have developed and hence, these drugs are not frequently
prescribed anymore.

Example: Amantadine, rimantadine.

The endosome is
acidified to release
the viral material
by viral M2 protein
• Pharmacokinetics:
Oseltamivir is an orally active prodrug that is rapidly hydrolyzed by the
liver to its active form. Zanamivir is not active orally and is administered
via inhalation. Both drugs are eliminated unchanged in the urine.

• Adverse effects:
1. Gastrointestinal discomfort
2. Nausea
3. Bronchospasm (Zanamivir)
DNA Polymerase Inhibitors
• DNA polymerases are enzymes that catalyze the synthesis of DNA molecules from nucleoside
triphosphates, the molecular precursors of DNA, thereby facilitating DNA replication.
• DNA viruses, as well as their host cells, require a DNA-dependent DNA polymerase to faithfully
replicate their genomes.
• Retroviruses encode an unusual DNA polymerase called reverse transcriptase, which is an RNA-
dependent DNA polymerase that synthesizes DNA from a template of RNA.
• As viral DNA polymerases play a central role in viral genome replication and transcription, They
are the specific target of a number of antiviral drugs currently used to inhibit viral replication.
• Most antiviral drugs that inhibit viral genome replication, and nearly all of these inhibit a DNA
polymerase.
• Inhibitors of viral polymerases target certain human herpesviruses, the retrovirus HIV (human
immunodeficiency virus) and the hepadnavirus HBV (hepatitis B virus).
• Most of these drugs are nucleoside analogs, including acyclovir, which is commonly used to treat
certain varieties of herpes viruses.
 Acyclovir
• The development of the landmark drug acyclovir launched the era of effective selective antiviral therapy.

• Used as a treatment for herpes virus infections.

• A guanosine analog that is monophosphorylated by a viral thymidine kinase then metabolized by host cell
kinases to the trisphosphate nucleotide analogs.

• The analog inhibits viral DNA polymerase, terminating the nucleotide chain and preventing further replication.

• It is 30 times more potent against the herpes virus enzyme than the host enzyme, as the viral enzyme is much
more effective in carrying out the phosphorylation than the enzyme of the host cell.

• Acyclovir is thus selectively activated in cells with actively replicating viruses and uninfected cells do not
phosphorylate acyclovir

• Resistance caused by changes in the viral genes coding for thymidine kinase or DNA polymerase has been
reported
Pharmacokinetics of Acyclovir

• Oral bioavailability : 20-30%

• Distribution to all body tissues including CNS

• Renal excretion is >80%

• Half lives : 2-5 hours

• Administration : Topical , Oral , IV

Adverse effect of acyclovir

• Nausea, Vomiting,

• Diarrhea

• Nephrotoxicity

• crystalluria, Heamaturia

• Neutropenia, thrombocytopenia
Clinical use of acyclovir

• Herpes simplex virus 1 and 2

• Herpes simplex encephalitis ( type 1)

• Varicella zoster virus

• HSV genital infections

• HSV encephalitis

• HSV infections in immunocompromised patient

Other DNA Polymerase Inhibitors
1. Valacyclovir

2. Famciclovir / Penciclovir

3. Ganciclovir

4. Cidofovir

5. Trifluridine /Idoxuridine/ Vidarabine

6. Foscarnet

• Valacyclovir is prodrug of acyclovir with better bioavailability.

• Famciclovir is hydrolyzed to Penciclovir and has greatest bioavailability.

• Penciclovir is used only topically whereas Famciclovir can be administered orally.

Mechanism of action
 Other DNA Polymerase Inhibitors

• Ganciclovir, valganciclovir, cidofovir, fomivirsen are used against herpes simplex virus
(HSV), varicella zoster virus (VZV), epstein-barr virus (EBV) and cytomegalovirus (CMV).

• Ganciclovir is a commonly prescribed for patients with CMV, especially CMV retinitis
(Inflammation of retina due to CMV).

• The mechanism of action of these drugs is similar to that of acyclovir

• Cidofovir incorporates itself into viral DNA to stop DNA Replication. It is also used as a
treatment of CMV retinitis.

• The prominent side effect of all these agents is myelosuppression.

 Other DNA Polymerase Inhibitors

• Idoxuridine and trifluridine, are both halogenated analogs of pyrimidine bases that
block the DNA base pairing. They are administered in eye drops to treat
inflammation of the cornea caused by a herpes virus

• Foscarnet is a structural mimic of the anion pyrophosphate that selectively inhibits

the pyrophosphate binding site on viral DNA polymerases. Foscarnet is an analogue
that does not need to be metabolized first.

• It is principally used for the treatment of ganciclovir-resistant cytomegalovirus

(CMV) infections
Antiretroviral Drugs (Anti HIV)
• One of the most commonly studied retrovirus is the Human Immunodeficiency Virus (HIV)

• In HIV patients, The levels of CD4 T Cells (cells responsible for immune responses) decrease as
the HIV virus infects the body. This indicates that the immune activity is compromised or
weakened the longer the virus remains and infects more host cells.

• Prior to approval of zidovudine in 1987, treatment of HIV infections focused on decreasing the
occurrence of opportunistic infections that caused a high degree of morbidity and mortality in
AIDS patients.

• Today, the viral life cycle is understood, and a combination of drugs is used to suppress
replication of HIV and restore the number of CD4 cells and immunocompetence to the host.

• This multidrug regimen is commonly referred to as “highly active antiretroviral therapy,” or

HAART.
 Retroviral HIV Infection
1. Binding: During the first stage of HIV’s life cycle, the virus binds to receptors on the surface of
CD4 cells. CD4 cells, also called helper T cells, are a type of white blood cell that alerts other
immune cells that there’s an infection in your body.

2. Fusion: Once HIV binds to receptors on CD4 cells, it initiates the fusion of its envelope with the
membrane of the CD4 cell using a glycoprotein. Fusing with the membrane of your CD4 cells
allows the virus to enter the cell.

3. Reverse Transcription: The virus converts its RNA into DNA by releasing an enzyme called
reverse transcriptase (RT). This process allows the virus’ genetic information to enter the nucleus
of your CD4 cell.

4. Integration: Once HIV has converted its RNA into DNA, it then releases another enzyme called
integrase inside the nucleus of your CD4 cell. The virus uses this enzyme to combine its DNA into
the DNA of your CD4 cell.
 Retroviral HIV Infection
5. Replication: Once the virus is integrated into your CD4 cell’s DNA, it can use that cell’s
machinery to generate viral proteins. During this time, it can also produce more of its genetic
material (RNA). These two things allow it to create more viral particles.

6. Assembly: In the assembly stage, new HIV proteins and RNA are sent to the edge of your CD4
cell and become immature HIV. These viruses are non-infectious in their current form.

7. Budding: During the budding stage, the immature viruses push out of your CD4 cell. They then
release an enzyme called protease that modifies proteins in the virus and creates a mature and
infectious version. The viral protease cleaves the nascent viral polypeptides (steps 7 and 8) into
enzymes (integrase, reverse transcriptase, protease) and structural proteins for new virions.

8. The new virions are released from the cells, initiating a fresh round of infection.
Fig: Steps of HIV
infection, from attachment
to the cell to release of
new virions, are shown.
Antiretroviral Drugs for HIV

There are five classes of antiretroviral drugs, each of which targets one
of the four viral processes.

1. Nucleoside/nucleotide reverse transcriptase inhibitors (NRTIs)

2. Nonnucleoside reverse transcriptase inhibitors (NNRTIs)
3. Protease inhibitors (PIs)
4. Entry inhibitors
5. The integrase inhibitors.
Entry Inhibitors

• Enfuvirtide inhibits the fusion of HIV with host cells.

• It is generally given by subcutaneous injection in combination with
other drugs to treat HIV when resistance becomes a problem or when
the patient is intolerant of other antiretroviral drugs.
NRTIs

• NRTIs are analogs of native ribosides (nucleosides or nucleotides

containing ribose), which all lack a 3′ -hydroxyl group.
• Once they enter cells, they are phosphorylated by cellular enzymes to
the corresponding triphosphate analog, which is preferentially
incorporated into the viral DNA by RT.
• Because the 3′ -hydroxyl group is not present, a 3′ ,5′ -phosphodiester
bond between an incoming nucleoside triphosphate and the growing
DNA chain cannot be formed and DNA chain elongation is terminated.
• Example: Abacavir, Lamivudine, Stavudine, Didanosine, Zidovudine.
NNRTIs

• NNRTIs are highly selective, noncompetitive inhibitors of HIV-1 RT.

• They bind to HIV RT at an allosteric hydrophobic site adjacent to the
active site, inducing a conformational change that results in enzyme
inhibition.
• They do not require activation by cellular enzymes.
• These drugs have common characteristics that include cross
resistance with other NNRTIs, drug interactions, and a high incidence
of hypersensitivity reactions, including rash.
• Example: Delavirdine, Efavirenz, Nevirapine.
Protease Inhibitors

• All of the drugs in this group are reversible inhibitors of the HIV
aspartyl protease (retropepsin).
• This viral enzyme responsible for cleavage of the viral polyprotein into
a number of essential enzymes (RT, protease, and integrase) and
several structural proteins.
• The inhibition prevents maturation of the viral particles and results in
the production of noninfectious virions.
• Example: Atazanavir, Indinavir, Nelfinavir.
Integrase Inhibitors

• Raltegravir and related agents act by inhibiting HIV DNA integrase,

the enzyme that splices viral DNA into the host genome when forming
the provirus.

• It is used for the treatment of HIV as part of combination therapy, and

is generally reserved for cases that are resistant to other antiretroviral
agents.
 Other Antiviral Drugs
Biopharmaceutical antiviral drugs such as interferons, immunoglobulin preparations and monoclonal
antibodies are also used as antiviral agents.

Immunoglobulins
• Pooled immunoglobulin contains antibodies against various viruses present in the population. The
antibodies are directed against the virus envelope and can ‘neutralise’ some viruses and prevent their
attachment to host cells.
• If used before the onset of signs and symptoms, it may attenuate or prevent measles, German measles,
infectious hepatitis, rabies or poliomyelitis.
• Hyperimmune globulin, specific against particular viruses, is used against hepatitis B, varicella zoster and
rabies.

Palivizumab
• Related in terms of its mechanism of action to immunoglobulins is palivizumab, a monoclonal antibody
directed against a glycoprotein on the surface of respiratory syncytial virus.
• It is used as an intramuscular injection, under specialist supervision, in children at high risk to prevent
infection by this organism.
Interferons
• Interferons are a family of naturally occurring, inducible glycoproteins synthesized by
mammalian cells

• The interferons are synthesized by recombinant DNA technology.

• At least three types of interferons exist—α, β, and γ

Mechanism of action:

• They interfere with the ability of viruses to infect cells, however, the antiviral mechanism
is incompletely understood.
• In host ribosomes, they induce the production of enzymes that inhibit the translation of
viral mRNA into viral proteins, thus halting viral replication ultimately leading to the
degradation of viral mRNA and tRNA.
• They have a broad spectrum of action and inhibit the replication of most viruses in vitro
Ribavirin

• Ribavirin is an antiviral medication used to treat RSV infection, hepatitis C and

some viral hemorrhagic fevers.

• Usually used in combination with other medications such as simeprevir,

sofosbuvir, peginterferon α-2b or peginterferon α-2a.
• It is a guanosine (ribonucleic) analog used to stop viral RNA synthesis, thus, it is a
nucleoside inhibitor. However, the mechanism of action of ribavirin is not entirely
clear.
• Use during pregnancy results in harm to the baby.
HEPATIC VIRAL INFECTIONS
• The hepatitis viruses thus far identified (A, B, C, D, and E) each have a
pathogenesis specifically involving replication in and destruction of
hepatocytes.
• Of this group, hepatitis B (a DNA virus) and hepatitis C (an RNA virus)
are the most common causes of chronic hepatitis, cirrhosis, and
hepatocellular carcinoma.
• Oral therapy for chronic hepatitis B includes NTRIs like lamivudine,
adefovir, entecavir, tenofovir, or telbivudine.
• The preferred treatment for chronic hepatitis C is the combination of
peginterferon-α-2a or peginterferon-α-2b plus ribavirin.
Case study
A 75-year-old man with chronic obstructive pulmonary disease is
diagnosed with suspected influenza based on his complaints of flu-like
symptoms that began 24 hours ago. Which of the following agents is
most appropriate to initiate for the treatment of influenza?

A. Ribavirin.
B. Oseltamivir.
C. Zanamivir.
D. Rimantadine.
E. Amantadine
Solution

• Oseltamivir is the best choice since it is administered orally and not

associated with resistance.
• Zanamivir is administered via inhalation and is not recommended for
patients with underlying COPD.
• High rates of resistance have developed to adamantanes
(amantadine, rimantadine), and these drugs are infrequently
indicated.
• Ribavirin is not indicated for treatment of influenza.
Case study

A 24-year-old female is diagnosed with genital herpes simplex virus infection.

Which of the following agents is indicated for use in this diagnosis?
1. Valacyclovir
2. Cidofovir
3. Ganciclovir
4. Zanamivir
5. Lamivudine
Solution

• Cidofovir and ganciclovir are used for CMV retinitis.

• Zanamivir is indicated for influenza.

• Lamivudine is indicated for HIV and hepatitis B.

But Valacyclovir is indicated for herpes simplex infection. So, the choice
of drug is valacyclovir.
Diseases controlled by antiviral drugs

Viruses controlled by current antiviral therapy include :

1. Cytomegalo virus (CMV)
2. Hepatitis virus (HBV)
3. Herpes simplex virus (HSV)
4. Human immunodeficiency virus (HIV)
5. Influenza virus (flu) and
6. Respiratory syncytial virus (RSV)