Prioritization of Anti‐SARS‐Cov‐2 Drug Repurposing Opportunities Based on Plasma and Target Site Concentrations Derived from their Established Human Pharmacokinetics
Usman Arshad, Henry Pertinez, Helen Box, Lee Tatham, Rajith K R Rajoli, Paul Curley, Megan Neary, Joanne Sharp, Neill J Liptrott, Anthony Valentijn, Christopher David, Steve P Rannard, Paul M O’neill, Ghaith Aljayyoussi, Shaun H Pennington, Stephen A Ward, Andrew Hill, David J Back, Saye H Khoo, Patrick G Bray, Giancarlo A Biagini, Andrew Owen
Clinical Pharmacology & Therapeutics, doi:10.1002/cpt.1909
There is a rapidly expanding literature on the in vitro antiviral activity of drugs that may be repurposed for therapy or chemoprophylaxis against severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2). However, this has not been accompanied by a comprehensive evaluation of the target plasma and lung concentrations of these drugs following approved dosing in humans. Accordingly, concentration 90% (EC 90 ) values recalculated from in vitro anti-SARS-CoV-2 activity data was expressed as a ratio to the achievable maximum plasma concentration (C max ) at an approved dose in humans (C max /EC 90 ratio). Only 14 of the 56 analyzed drugs achieved a C max /EC 90 ratio above 1. A more in-depth assessment demonstrated that only nitazoxanide, nelfinavir, tipranavir (ritonavir-boosted), and sulfadoxine achieved plasma concentrations above their reported anti-SARS-CoV-2 activity across their entire approved dosing interval. An unbound lung to plasma tissue partition coefficient (K p U lung ) was also simulated to derive a lung C max /half-maximal effective concentration (EC 50 ) as a better indicator of potential human efficacy. Hydroxychloroquine, chloroquine, mefloquine, atazanavir (ritonavirboosted), tipranavir (ritonavir-boosted), ivermectin, azithromycin, and lopinavir (ritonavir-boosted) were all predicted to achieve lung concentrations over 10-fold higher than their reported EC 50 . Nitazoxanide and sulfadoxine also exceeded their reported EC 50 by 7.8-fold and 1.5-fold in lung, respectively. This analysis may be used to select potential candidates for further clinical testing, while deprioritizing compounds unlikely to attain target concentrations for antiviral activity. Future studies should focus on EC 90 values and discuss findings in the context of achievable exposures in humans, especially within target compartments, such as the lungs, in order to maximize the potential for success of proposed human clinical trials.
SUPPORTING INFORMATION Supplementary information accompanies this paper on the Clinical Pharmacology & Therapeutics website (www.cpt-journal.com).
ACKNOWLEDGMENTS The authors thank Nathan Morin from Alberta Health Services for being proactive in making them aware of previously published data for indomethacin. The authors also thank Articulate Science for publication support. CONFLICT OF INTEREST D.J.B. has received honoraria or advisory board payments from AbbVie, Gilead, ViiV, Merck, Janssen, and educational grants from AbbVie, Gilead, ViiV, Merck, Janssen, and Novartis. A.O. and S.P.R. are Directors of Tandem Nano Ltd. A.O. has received research funding from ViiV, Merck, Janssen, and consultancy from Gilead, ViiV and Merck not related to the current paper. P.O.N. is currently engaged in a collaboration with Romark LLC but this interaction did not influence the prioritization or conclusions in the current paper. All other authors declared no competing interests for this work.
AUTHOR CONTRIBUTIONS All authors wrote the paper. A.O. designed the research. U.A., H.B., L.T., H.P., and A.O. performed the research. R.R., H.P., U.A., and A.O. analyzed the data.
References
Amici, La Frazia, Brunelli, Balsamo, Angelini et al., Inhibition of viral protein translation by indomethacin in vesicular stomatitis virus infection: role of eIF2alpha kinase PKR, Cell Microbiol
Anderson, Curran, Nitazoxanide, None, Drugs
Ben-Zvi, Kivity, Langevitz, Shoenfeld, Hydroxychloroquine: from malaria to autoimmunity, Clin. Rev. Allergy Immunol
Bland, Altman, Statistical methods for assessing agreement between two methods of clinical measurement, Lancet
Browning, Pharmacology of chloroquine and hydroxychloroquine
Bukreyeva, Mantlo, Sattler, Huang, Paessler et al., The IMPDH inhibitor merimepodib suppresses SARS-CoV-2 replication in vitro, J bioRxiv,
doi:10.1101/2020.04.07.028589Burger, Agarwala, Child, Been-Tiktak, Wang et al., Effect of rifampin on steady-state pharmacokinetics of atazanavir with ritonavir in healthy volunteers, Antimicrobial Agents Chemother
Caly, Druce, Catton, Jans, Wagstaff, The FDA-approved drug ivermectin inhibits the replication of SARS-CoV-2 in vitro, Antiviral Res
Chan-Tack, Struble, Birnkrant, Intracranial hemorrhage and liver-associated deaths associated with tipranavir/ritonavir: review of cases from the FDA's Adverse Event Reporting System, AIDS Patient Care STDS
Chandrasekaran, Ahmad, Shen, Demaio, Hultin et al., Disposition of bazedoxifene in rats, Xenobiotica
Chen, Detectable serum SARS-CoV-2 viral load (RNAaemia) is closely associated with drastically elevated interleukin 6 (IL-6) level in critically ill COVID-19 patients, Clin. Infect. Dis,
doi:10.1101/2020.02.29.20029520Chen, Mook, Premont, Wang, Niclosamide: beyond an antihelminthic drug, Cell. Signal
Choy, lopinavir, emetine, and homoharringtonine inhibit SARS-CoV-2 replication in vitro, Antiviral. Res
Clerici, Trabattoni, Pacei, Biasin, Rossignol, The anti-infective nitazoxanide shows strong immumodulating effects, J. Immuno
Corbett, Lim, Kashuba, Kaletra (lopinavir/ ritonavir), Ann. Pharmacother
Damle, Stogniew, Dowell, Pharmacokinetics and tissue distribution of anidulafungin in rats, Antimicrob. Agents Chemother
De Kock, Pharmacokinetics of sulfadoxine and pyrimethamine for intermittent preventive treatment of malaria during pregnancy and after delivery, CPT Pharmacometrics Syst. Pharmacol
Drachman, Kadlecek, Pourfathi, Xin, Profka et al., In vivo pH mapping of injured lungs using hyperpolarized [1-(13) C]pyruvate, Magn. Reson. Med
Fintelman-Rodrigues, Atazanavir inhibits SARS-CoV-2 replication and pro-inflammatory cytokine production, J bioRxiv,
doi:10.1101/2020.04.04.020925Fitch, Chevli, Gonzalez, Chloroquine-resistant Plasmodium falciparum: effect of substrate on chloroquine and amodiaquin accumulation, Antimicrob. Agents Chemother
Flexner, Bate, Kirkpatrick, Tipranavir, None, Nat. Rev. Drug Discovery
Fox, Saravolatz, Nitazoxanide: a new thiazolide antiparasitic agent, Clin. Infect. Dis
Garnock-Jones, Eltrombopag, None, Drugs
Gassen, SKP2 attenuates autophagy through Beclin1-ubiquitination and its inhibition reduces MERS-Coronavirus infection, Nat. Commun
Geary, Divo, Jensen, Zangwill, Ginsburg, Kinetic modelling of the response of Plasmodium falciparum to chloroquine and its experimental testing in vitro. Implications for mechanism of action of and resistance to the drug, Biochem. Pharmacol
Gekonge, Bardin, Montaner, Short communication: Nitazoxanide inhibits HIV viral replication in monocyte-derived macrophages, AIDS Res. Hum. Retroviruses
Ginsburg, Nissani, Krugliak, Alkalinization of the food vacuole of malaria parasites by quinoline drugs and alkylamines is not correlated with their antimalarial activity, Biochem. Pharmacol
Goel, Gerriets, Chloroquine, StatPearls
Gonzalez, Schmidt, Derendorf, Importance of relating efficacy measures to unbound drug concentrations for antiinfective agents, Clin. Microbiol. Rev
Gu, Han, Wang, COVID-19: Gastrointestinal manifestations and potential fecal-oral transmission, Gastroenterology
Guo, The origin, transmission and clinical therapies on coronavirus disease 2019 (COVID-19) outbreak -an update on the status, Mil Med Res
Gupta, Tulsankar, Bhatta, Misra, Pharmacokinetics, metabolism, and partial biodistribution of "pincer therapeutic" nitazoxanide in mice following pulmonary delivery of inhalable particles, Mol. Pharm
Haffizulla, Effect of nitazoxanide in adults and adolescents with acute uncomplicated influenza: a double-blind, randomised, placebo-controlled, phase 2b/3 trial, Lancet Infect Dis
Harrison, Scott, Atazanavir, None, Drugs
Hickson, Margineantu, Hockenbery, Simon, Geballe, Inhibition of vaccinia virus replication by nitazoxanide, Virology
Hirani, Raucy, Lasker, Conversion of the HIV protease inhibitor nelfinavir to a bioactive metabolite by human liver CYP2C19, Drug Metab. Dispos
Hoffmann, SARS-CoV-2 cell entry depends on ACE2 and TMPRSS2 and is blocked by a clinically proven protease inhibitor, Cell
James, Nelfinavir (Viracept) approved: fourth protease inhibitor available, AIDS Treat. News
Jurgeit, Mcdowell, Moese, Meldrum, Schwendener et al., Niclosamide is a proton carrier and targets acidic endosomes with broad antiviral effects, PLoS Pathog
Justice, Drug toxicity, HIV progression, or comorbidity of aging: does tipranavir use increase the risk of intracranial hemorrhage?, Clin. Infect. Dis
Justice, Drug toxicity, HIV progression, or comorbidity of aging: does tipranavir use increase the risk of intracranial hemorrhage?, Clin. Infect. Dis
Kawai, Mathew, Tanaka, Rowland, Physiologically based pharmacokinetics of cyclosporine A: extension to tissue distribution kinetics in rats and scale-up to human, J. Pharmacol. Exp. Ther
King, Acosta, Tipranavir, None, Clin. Pharmacokinet
Krudsood, New fixed-dose artesunate-mefloquine formulation against multidrug-resistant Plasmodium falciparum in adults: a comparative phase iib safety and pharmacokinetic study with standard-dose nonfixed artesunate plus mefloquine, Antimicrob. Agents Chemother
Kruse, The steady-state pharmacokinetics of nelfinavir in combination with tenofovir in HIV-infected patients, Antivir. Ther
La Porte, Sabo, Beique, Cameron, Lack of effect of efavirenz on the pharmacokinetics of tipranavirritonavir in healthy volunteers, Antimicrob. Agents Chemother
Li, Angiotensin-converting enzyme 2 is a functional receptor for the SARS coronavirus, Nature
Li, Inhibition of STAT3 by niclosamide synergizes with erlotinib against head and neck cancer, PLoS One
Lien, Solheim, Ueland, Distribution of tamoxifen and its metabolites in rat and human tissues during steady-state treatment, Cancer Res
Lin, Preclinical evaluation of a nanoformulated antihelminthic, niclosamide, in ovarian cancer, Oncotarget
Liu, Ruhnke, Meersseman, Paiva, Kantecki et al., Pharmacokinetics of anidulafungin in critically ill patients with candidemia/invasive candidiasis, Antimicrob. Agents Chemother
Lovegrove, Kain, Chapter 6 -malaria prevention
Lu, Liu, Jia, -nCoV transmission through the ocular surface must not be ignored, Lancet
Lv, Chu, Wang, HIV protease inhibitors: a review of molecular selectivity and toxicity, HIV AIDS
Markowitz, Long-term efficacy and safety of tipranavir boosted with ritonavir in HIV-1-infected patients failing multiple protease inhibitor regimens: 80-week data from a phase 2 study, J. Acquir. Immune Defic. Syndr
Mcchesney, Banks, Jr & Fabian, Tissue distribution of chloroquine, hydroxychloroquine, and desethylchloroquine in the rat, Toxicol. Appl. Pharmacol
Mchutchison, A randomized, double-blind, placebocontrolled dose-escalation trial of merimepodib (VX-497) and interferon-alpha in previously untreated patients with chronic hepatitis C, Antivir. Ther
Miller, Kok, Li, The virus inoculum volume influences outcome of influenza A infection in mice, Lab. Anim
Miller, Lobel, Satriale, Kuritsky, Stern et al., Severe cutaneous reactions among American travelers using pyrimethamine-sulfadoxine (Fansidar) for malaria prophylaxis, Am. J. Trop. Med. Hyg
Miner, Drug repurposing: the anthelmintics niclosamide and nitazoxanide are potent TMEM16A antagonists that fully bronchodilate airways, Front. Pharmacol
Moss, Wagner, Kanaoka, Olson, Yueh et al., The comparative disposition and metabolism of dolutegravir, a potent HIV-1 integrase inhibitor, in mice, rats, and monkeys, Xenobiotica
Motoya, Characterization of nelfinavir binding to plasma proteins and the lack of drug displacement interactions, HIV Med
Murdoch, Plosker, Anidulafungin, None, Drugs
Na-Bangchang, Limpaibul, Thanavibul, Tan-Ariya, Karbwang, The pharmacokinetics of chloroquine in healthy Thai subjects and patients with Plasmodium vivax malaria, Br. J. Clin. Pharmacol
Nalamachu, Wortmann, Role of indomethacin in acute pain and inflammation management: a review of the literature, Postgrad. Med
Orman, Perry, Tipranavir: a review of its use in the management of HIV infection, Drugs
Pober, Sessa, Evolving functions of endothelial cells in inflammation, Nat. Rev. Immunol
Porche, Ritonavir, Norvir), J. Assoc. Nurses AIDS Care
Price, Artesunate/mefloquine treatment of multi-drug resistant falciparum malaria, Trans. R Soc. Trop. Med. Hyg
Pugin, Dunn-Siegrist, Dufour, Tissieres, Charles et al., Cyclic stretch of human lung cells induces an acidification and promotes bacterial growth, Am. J. Respir. Cell Mol. Biol
Qin, Dysregulation of immune response in patients with COVID-19 in Wuhan, China, Clin. Infect. Dis,
doi:10.1093/cid/ciaa248Rainsford, Effects of misoprostol on the pharmacokinetics of indomethacin in human volunteers, Clin. Pharmacol. Ther
Raja, Lebbos, Kirkpatrick, Atazanavir sulphate, Nat. Rev. Drug Discov
Ritchie, Block, Nevin, Psychiatric side effects of mefloquine: applications to forensic psychiatry, J. Am. Acad. Psychiatry Law
Rivulgo, Comparative plasma exposure and lung distribution of two human use commercial azithromycin formulations assessed in murine model: a preclinical study, Biomed. Res. Int
Rodgers, Leahy, Rowland, Physiologically based pharmacokinetic modeling 1: predicting the tissue distribution of moderate-to-strong bases, J. Pharm. Sci
Rodgers, Rowland, Mechanistic approaches to volume of distribution predictions: understanding the processes, Pharm. Res
Rodgers, Rowland, Physiologically based pharmacokinetic modelling 2: predicting the tissue distribution of acids, very weak bases, neutrals and zwitterions, J. Pharm. Sci
Rossignol, La Frazia, Chiappa, Ciucci, Santoro et al., a new class of anti-influenza molecules targeting viral hemagglutinin at the post-translational level, J. Biol. Chem
Rossignol, Nitazoxanide, a new drug candidate for the treatment of Middle East respiratory syndrome coronavirus, J. Infect. Public Health
Rossignol, Nitazoxanide: a first-in-class broad-spectrum antiviral agent, Antiviral Res
Shida, Takahashi, Nohda, Hirama, Pharmacokinetics and pharmacodynamics of eltrombopag in healthy Japanese males, Jpn. J. Clin. Pharmacol. Ther
Smith, Kulkarni, Chen, Goldstein, Influenza virus inoculum volume is critical to elucidate age-dependent mortality in mice, Aging Cell
Streeck, Rockstroh, Review of tipranavir in the treatment of drug-resistant HIV, Ther. Clin. Risk Manag
Sun, Wang, Liu, Liu, Role of the Eye in Transmitting Human Coronavirus: What We Know and What We Do Not Know, Frontiers in Public Health,
doi:10.3389/fpubh.2020.00155Tett, Cutler, Beck, Day, Concentration-effect relationship of hydroxychloroquine in patients with rheumatoid arthritis-a prospective, dose ranging study, J. Rheumatol
Tilmanis, Van Baalen, Oh, Rossignol, Hurt, The susceptibility of circulating human influenza viruses to tizoxanide, the active metabolite of nitazoxanide, Antiviral Res
Touret, In vitro screening of a FDA approved chemical library reveals potential inhibitors of SARS-CoV-2 replication, J bioRxiv,
doi:10.1101/2020.04.03.023846Trabattoni, Thiazolides elicit anti-viral innate immunity and reduce HIV replication, Sci. Rep
Unis, Mitochondrial mechanisms of nelfinavir toxicity in human brain microvascular endothelial cells, The FASEB Journal
Vanderkooi, Prapunwattana, Yuthavong, Evidence for electrogenic accumulation of mefloquine by malarial parasites, Biochem. Pharmacol
Wang, Antiviral activities of niclosamide and nitazoxanide against chikungunya virus entry and transmission, Antiviral Res
Wang, Remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-nCoV) in vitro, Cell Res
Weston, Haupt, Logue, Matthews, Frieman, FDA approved drugs with broad anti-coronaviral activity inhibit SARS-CoV-2 in vitro, J bioRxiv,
doi:10.1101/2020.03.25.008482Wong, Lui, Sung, COVID-19 and the digestive system, J. Gastroenterol. Hepatol
Xu, Gao, Wu, Selinger, Zhou, Indomethacin has a potent antiviral activity against SARS CoV-2 in vitro and canine coronavirus in vivo, J bioRxiv,
doi:10.1101/2020.04.01.017624Yamamoto, Matsuyama, Hoshino, Yamamoto, Nelfinavir inhibits replication of severe acute respiratory syndrome coronavirus 2 in vitro, J bioRxiv,
doi:10.1101/2020.04.06.026476Yao, In vitro antiviral activity and projection of optimized dosing design of hydroxychloroquine for the treatment of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), Clin. Infect. Dis,
doi:10.1093/cid/ciaa237Yeh, Pharmacokinetic overview of indomethacin and sustained-release indomethacin, Am. J. Med
Zhang, Circulating metabolites of the human immunodeficiency virus protease inhibitor nelfinavir in humans: structural identification, levels in plasma, and antiviral activities, Antimicrob. Agents Chemother
Zhang, Molecular and serological investigation of 2019-nCoV infected patients: implication of multiple shedding routes, Emerg. Microbes Infect
Zhang, Shi, Wang, Liver injury in COVID-19: management and challenges, Lancet Gastroenterol. Hepatol
Zhang, Site-specific N-glycosylation characterization of recombinant SARS-CoV-2 spike proteins using highresolution mass spectrometry, J bioRxiv,
doi:10.1101/2020.03.28.013276.Zhang, The digestive system is a potential route of 2019-nCov infection: a bioinformatics analysis based on single-cell transcriptomes, J bioRxiv,
doi:10.1101/2020.01.30.927806.Zhang, Tumor-associated inflammatory microenvironment in non-small cell lung cancer: correlation with FGFR1 and TLR4 expression via PI3K/Akt pathway, J. Cancer
Zhang, Yap, Old drugs as lead compounds for a new disease? Binding analysis of SARS coronavirus main proteinase with HIV, psychotic and parasite drugs, Bioorg. Med. Chem
Zhao, Zhao, Wang, Zhou, Ma et al., Singlecell RNA expression profiling of ACE2, the receptor of SARS-CoV-2, J bioRxiv
