Protease inhibitor (pharmacology)

For natural protease inhibitors, see Protease inhibitor (biology).

Protease inhibitors (PIs) are medications that act by interfering with enzymes that cleave proteins. Some of the most well known are antiviral drugs widely used to treat HIV/AIDS, hepatitis C and COVID-19. These protease inhibitors prevent viral replication by selectively binding to viral proteases (e.g. HIV-1 protease) and blocking proteolytic cleavage of protein precursors that are necessary for the production of infectious viral particles.

Protease inhibitors that have been developed and are currently used in clinical practice include:

Given the specificity of the target of these drugs there is the risk, like with antibiotics, of the development of drug-resistant mutated viruses. To reduce this risk, it is common to use several different drugs together that are each aimed at different targets.

In addition to those non-human proteases listed above, inhibitors of human proteases may be used to treat cancer. See the articles matrix metalloproteinase inhibitor (–mastat) and proteasome inhibitor (–zomib).[1]

Antiretroviral protease inhibitors

Antiretroviral protease inhibitors act by binding to the catalytic site of HIV protease, preventing cleavage of viral polyprotein precursor proteins into functional viral proteins required for viral replication.[4] Most ARPIs are peptide-like molecules which resemble the substrate of the viral protease.[4]

Protease inhibitors were the second class of antiretroviral drugs developed. The first members of this class, saquinavir, ritonavir, and indinavir, were approved in late 1995–1996. Within 2 years, annual deaths from AIDS in the United States fell from over 50,000 to approximately 18,000[5] Prior to this the annual death rate had been increasing by approximately 20% each year.

The number of people in the U.S. dying of HIV fell by 60% in the 2 years following the introduction of the first HIV protease inhibitors
The number of people in the U.S. dying of HIV fell by 60% in the 2 years following the introduction of the first HIV protease inhibitors
Name Trade name Company Patent FDA approval date Notes
Saquinavir Invirase, Fortovase Hoffmann–La Roche U.S. patent 5,196,438 December 6, 1995 The first protease inhibitor approved by the U.S. Food and Drug Administration (FDA).
Ritonavir Norvir AbbVie U.S. patent 5,541,206 March 1, 1996 AbbVie was part of Abbott Laboratories when patent was granted. As well as being a protease inhibitor in its own right, ritonavir inhibits the breakdown of other protease inhibitors. This property makes it very useful in drug combinations.[6]
Indinavir Crixivan Merck & Co. U.S. patent 5,413,999 March 13, 1996 —
Nelfinavir Viracept Hoffmann–La Roche U.S. patent 5,484,926 March 14, 1997 —
Amprenavir Agenerase GlaxoSmithKline U.S. patent 5,585,397 April 15, 1999 The sixteenth FDA-approved antiretroviral. It was the first protease inhibitor approved for twice-a-day dosing instead of needing to be taken every eight hours. The convenient dosing came at a price, as the dose required is 1,200 mg, delivered in 8 very large gel capsules. Production was discontinued by the manufacturer December 31, 2004, as it has been superseded by fosamprenavir.
Lopinavir Kaletra AbbVie U.S. patent 5,914,332 September 15, 2000 Is only marketed as a fixed-dose combination with ritonavir (see lopinavir/ritonavir). AbbVie was part of Abbott Laboratories when patent was granted.
Atazanavir Reyataz Bristol-Myers Squibb U.S. patent 5,849,911 June 20, 2003 Atazanavir was the first PI approved for once-daily dosing. It appears to be less likely to cause lipodystrophy and elevated cholesterol as side effects. It may also not be cross-resistant with other PIs.
Fosamprenavir Lexiva, Telzir GlaxoSmithKline — October 20, 2003 A prodrug of amprenavir. The human body metabolizes fosamprenavir in order to form amprenavir, which is the active ingredient. That metabolization increases the duration that amprenavir is available, making fosamprenavir a slow release version of amprenavir and thus reduces the number of pills required versus standard amprenavir.
Tipranavir Aptivus Boehringer Ingelheim — June 22, 2005 Also known as tipranavir disodium.
Darunavir Prezista Janssen Therapeutics U.S. patent 6,248,775 June 23, 2006 As of 2016, darunavir is an OARAC recommended treatment option for treatment-naïve and treatment-experienced adults and adolescents.[7] Several ongoing phase III trials are showing a high efficiency for the darunavir/ritonavir combination being superior to the lopinavir/ritonavir combination for first-line therapy.[8] Darunavir is the first drug in a long time that did not come with a price increase. It leapfrogged two other approved drugs of its type, and is matching the price of a third.[9][10][11]

Non-antiretroviral antiviral activity

A drug combination targeting SARS-CoV-2, Paxlovid, was approved in December 2021 to treat COVID-19.[12] It is a combination of nirmatrelvir, a protease inhibitor targeted to the SARS-CoV-2 3C-like protease, and ritonavir, which inhibits the metabolism of nirmatrelvir, thereby prolonging its effect.[13]

Side effects

Protease inhibitors can cause a syndrome of lipodystrophy, hyperlipidemia, diabetes mellitus type 2, and kidney stones.[14] This lipodystrophy is colloquially known as "Crix belly", after indinavir (Crixivan).[15]

See also

References

  1. ^ a b c "The Use of Stems in the Selection of International Nonproprietary Names (INN) for Pharmaceutical Substances" (PDF). World Health Organization. Retrieved 5 November 2016.
  2. ^ Programme on International Nonproprietary Names (INN) (February 2023). "Pre-stems: Suffixes used in the selection of INN - February 2023". World Health Organization.
  3. ^ Ahmad B, Batool M, Ain QU, Kim MS, Choi S (August 2021). "Exploring the Binding Mechanism of PF-07321332 SARS-CoV-2 Protease Inhibitor through Molecular Dynamics and Binding Free Energy Simulations". International Journal of Molecular Sciences. 22 (17): 9124. doi:10.3390/ijms22179124. PMC 8430524. PMID 34502033.
  4. ^ a b "Protease Inhibitors (HIV)", LiverTox: Clinical and Research Information on Drug-Induced Liver Injury, Bethesda (MD): National Institute of Diabetes and Digestive and Kidney Diseases, 2012, PMID 31644200, retrieved 2024-06-20
  5. ^ "HIV Surveillance --- United States, 1981--2008". Retrieved 8 November 2013.
  6. ^ British National Formulary 69 (69 ed.). Pharmaceutical Pr. March 31, 2015. p. 426. ISBN 9780857111562.
  7. ^ "Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents" (PDF). Developed by the DHHS Panel on Antiretroviral Guidelines for Adults and Adolescents—A Working Group of the Office of AIDS Research Advisory Council (OARAC). July 14, 2016. Retrieved 5 November 2016.
  8. ^ Madruga JV, Berger D, McMurchie M, et al. (Jul 2007). "Efficacy and safety of darunavir-ritonavir compared with that of lopinavir-ritonavir at 48 weeks in treatment-experienced, HIV-infected patients in TITAN: a randomised controlled phase III trial". Lancet. 370 (9581): 49–58. doi:10.1016/S0140-6736(07)61049-6. PMID 17617272. S2CID 26084893.
  9. ^ Liz Highleyman, Patient Advocates Commend Pricing of New PI Darunavir, http://www.hivandhepatitis.com/recent/2006/ad1/063006_a.html
  10. ^ Darunavir - first molecule to treat drug-resistant HIV
  11. ^ Borman S (2006). "Retaining Efficacy Against Evasive HIV: Darunavir analog to AIDS-virus shapeshifters: Resistance may be futile". Chemical & Engineering News. 84 (34): 9. doi:10.1021/cen-v084n034.p009.
  12. ^ "First doses of Paxlovid, Pfizer's new COVID pill, are released to states". NPR. 23 December 2021. Retrieved 23 December 2021.
  13. ^ "Paxlovid: Drug label information". DailyMed, US National Library of Medicine. 18 October 2023. Retrieved 14 June 2024.
  14. ^ Fantry, LE (2003). "Protease inhibitor-associated diabetes mellitus: A potential cause of morbidity and mortality". Journal of Acquired Immune Deficiency Syndromes. 32 (3): 243–4. doi:10.1097/00126334-200303010-00001. PMID 12626882.
  15. ^ Capaldini, L. (1997). "Protease inhibitors' metabolic side effects: cholesterol, triglycerides, blood sugar, and "Crix belly"". AIDS Treatment News (277): 1–4. PMID 11364559.