Professional Documents
Culture Documents
1
PK/PD approach to predict the efficacy of
repurposed antiviral drugs for COVID-19
Authors
Ahmed S Ali; Shahid Karim; Ibrahim M. Ayoub; AbdulHadi Burzangi Ragia Ghoneim,
Hanin Aljohani; Hmoud Alsamhan; Jehan Barakt
3
4
Objectives
1. Integration of pharmacokinetics (PK)-pharmacodynamics (PD) data to
predict the efficacy of repurposed antiviral drugs against COVID-19 in
clinical setting.
2. Validation of our hypothesis.
Background
o COVID-19 is a complicated viral pneumonia caused by SARS-CoV-2
o Some antiviral drugs were repurposed against the virus
o Preliminary choices were essentially based on their in-vitro efficacy
هل عرفت من نحن
6
PK/PD approach
to optimize use
of antibiotics in
bacterial lung
infection is well
known
7
In management of COVID-19??
8
Characteristics
of Covid-19/
SARS-CoV-2
• Covid-19 is an acute complicated viral pneumonia ;
• SARS-CoV-2 : an obligatory intracellular pathogen, which
infects ciliated bronchial epithelial cells, Type 1 pneumocystis,
()
• Huge number of virions produced and released per cell
• Virus production was approximately 3×106 plaque-forming
units per culture,
9
https://analyticalscience.wiley.com/do/10.1002/was.00020155
Methodology
10
Lopinavir/ritonavir (LPV/r)
• LPV is an antiretroviral protease inhibitor indicated
for the treatment of HIV-1 infection.
• It has been repurposed for management of COVID-
19,
• It is available in fixed combination with Ritonavir, a
potent inhibitor of CYP450 to enhance its oral
bioavailability
• LPV/r good bioavailability after oral administration
about 97%; peak level within 4 hr.
• Variability in drug level
11
PK/PD prediction of efficacy
In vitro In vivo
EC 50 ug/ml
30
total ug/ml
20 unbound ug/ ml
LPV Ug/ ml
EC 90
10
0.5
0.4
0.3
0.2
0.1
0.0
0 5 10 15
Time h
Fig. Total and free LPV median peak and trough levels in COVID-19 patients,
ritonavir-boosted Lopinavir 400/100 mg twice daily
Data adapted from [59]
High protein binding restricts the achievement of therapeutic level at target site
13
Clinical Trials
15
Remdesivir (RDV) (GS-5734) “The molecule of hope“ ???????
• A pro-drug, originally developed for hepatitis C. Later FDA
approval for COVID-19???
• Mechanism:
• It is categorized as RdRp (RNA polymerase) inhibitor
- Possible delayed chain termination (similar to entecavir)
• Adverse Events:
- Elevated LFTs (typically 2-3x normal), unclear significance
- GI symptoms (nausea, vomiting, gastroparesis, rectal bleeding)
18
Remdesivir IC50 and SARS-CoV-2
CC >100
IC50 = 0.770 nM 90 90
IC90 = 1,760 nM,
% Cytotoxicity
% Inhibition
cytotoxic concentration 60 60
>100 mM
30 30
0 0
-30 -30
0.1 1 10 100
Remdesivir [µM]
20
• Zou H et al. Front.
Pharmaco 2020
21
Suggested PK Limitations
❖ its rapid transformation (within 2 hr.) to a slightly polar nucleoside with expected
lower ability to transport across cell membrane compared to Remdesivir.
❖ level of the nucleoside ( 0.14 ug/ ml ) is very low compared to EC50 or EC90 (FIG 1)
❖ The bio activation of nucleoside into monophosphate is a rate-limiting step
❖ lung tissues have a lower ability to metabolize GS-441524 to the triphosphate form
compared to liver cells,
• Yan and Muller concluded that GS-441524 is superior to Remdesivir for COVID-19
treatment. GS-441524 has more simple synthesis and documented in vivo efficacy in
animals.[45].
• Other investigators suggested using both IV and inhalation route to achieve optimal
efficacy in the management of COVID-19 [46]
22
Fig 4: Total and free Remdesivir level, Nucleoside total level
Data adapted from[35]
It demonstrates the peak level of the pro drug is misleading, due to its short
half-life
1.0
EC50 ug/ml
0.5
Nuc ug/m
0.0
0 10 20 30
Time h
23
Remdesivir Randomized Controlled Trial in Adults with Severe COVID-19:
Results, Clinical Improvement Rates
Remdesivir Placebo
80
Clinical Improvement Rates (%)
65
60 58
40
27
23
20
3 3
0
Day 7 Day 14 Day 28
Days after Study Inclusion
Source: Wang Y, et al. Lancet. April 29, 2020 [Epub ahead of print]
Remdesivir
Placebo
20
15
15
13
Remdesivir Randomized
Deaths (%)
10
10
9
Controlled Trial in Adults
with Severe COVID-19:
6
5 Results, Mortality
5
Source: Wang Y, et al. Lancet. April
29, 2020 [Epub ahead of print]
0
Day 7 Day 14 Day 28
Days after Study Inclusion
WHO
26
Conclusion
• Integration of PK/PD data of the repurposed drug is an effective tool to predict their
efficacy
• clinical finding more or less agreed with the predication of PK limitation of most
antiviral drugs.
• The following parameters are suggested to extend our novel approach for other drugs.
1- Time of free drug level > IC90
(variables, peak & trough levels; EC90, protein binding and half-life )
2- AUC0-24/IC90
(variables, peak & trough levels; EC90, protein binding and half-life)
3- Extent of lung access; (free drug level, Vd)
(variables protein binding, Vt, Ion trapping)
27
• VENISSE, N., PEYTAVIN, G., BOUCHET, S., GAGNIEU, M.-C., GARRAFFO, R.,
GUILHAUMOU, R., SOLAS, C., ANRS-AC43 CLINICAL PHARMACOLOGY
COMMITTEE, S. T. D. M. & TREATMENT PERSONALIZATION, G. 2020.
Concerns about pharmacokinetic (PK) and pharmacokinetic-
pharmacodynamics (PK-PD) studies in the new therapeutic area of
COVID-19 infection. Antiviral research, 181, 104866-104866.
• ZOU, H., BANERJEE, P., LEUNG, S. S. Y. & YAN, X. 2020. Application of
Pharmacokinetic-Pharmacodynamics Modeling in Drug Delivery:
Development and Challenges. Frontiers in Pharmacology, 11.
Key • WALSH, T. J., GOUTELLE, S., JELLIFFE, R. W., GOLDEN, J. A., LITTLE, E. A.,
DEVOE, C., MICKIENE, D., HAYES, M. & CONTE, J. E. 2010. Intrapulmonary
pharmacokinetics and pharmacodynamics of micafungin in adult lung
transplant patients. Antimicrobial agents and chemotherapy, 54, 3451-
References •
3459.
CAO, B., WANG, Y., WEN, D., LIU, W., WANG, J., FAN, G., RUAN, L., SONG,
B., CAI, Y. & WEI, M. 2020. A trial of Lopinavir–ritonavir in adults
hospitalized with severe Covid-19. New England Journal of Medicine.
• Simulation :
https://bioquest.org/esteem/esteem_details.php?product_id=39111#
28
• Cao, B. et al. A trial of lopinavir-ritonavir in adults
hospitalized with severe Covid-19. N. Engl. J. Med. 382,
1787–1799 (2020).
• PubMed Article Google Scholar
• 144.Hung, I. F. et al. Triple combination of interferon
beta-1b, lopinavir-ritonavir, and ribavirin in the
Ref treatment of patients admitted to hospital with COVID-
19: an open-label, randomized, phase 2
trial. Lancet 395, 1695–1704 (2020).
documenting • CAS PubMed Coax Central Article Google Scholar
• 145.Chief Investigators of the RECOVERY Trial on
29
جزاكم هللا خيرا
30