What is CRISPR-Cas9?

CRISPR-Cas9 is a genome editing tool that is creating a buzz in the science world. It is faster, cheaper and more
accurate than previous techniques of editing DNA and has a wide range of potential applications.
What is CRISPR-Cas9?
CRISPR-Cas9 is a unique technology that enables geneticists and medical researchers to edit parts of
the genome((An organism’s complete set of genetic instructions. Each genome contains all of the
information needed to build that organism and allow it to grow and develop. Our genome is
approximately 3,000,000,000 base pairs long and is packaged into 23 pairs of chromosomes.) by
removing, adding or altering sections of the DNA(A long molecule that contains our unique genetic code. It
holds the instructions for making all the proteins in our bodies.) sequence. 
It is currently the simplest, most versatile and precise method of genetic manipulation and is therefore causing a
buzz in the science world.
How does it work?
The CRISPR-Cas9 system consists of two key molecules that introduce a change (mutation (A change that
occurs in a DNA sequence. Mutations are relatively common in our DNA, but most have no detectable
effect.) into the DNA. These are:
an enzyme(Biological molecules, usually proteins that are responsible for thousands of metabolic
processes essential to life.) called Cas9. This acts as a pair of ‘molecular scissors’ that can cut the two strands
of DNA at a specific location in the genome so that bits of DNA can then be added or removed. 
a piece of RNA? called  guide RNA (gRNA). This consists of a small piece of pre-designed RNA sequence (about 20
bases long) located within a longer RNA scaffold. The scaffold part binds to DNA and the pre-designed sequence
‘guides’ Cas9 to the right part of the genome. This makes sure that the Cas9 enzyme cuts at the right point in the
genome.
The guide RNA is designed to find and bind to a specific sequence in the DNA. The guide RNA has
RNA bases? that are complementary (The preferential binding of bases A to T (or U) and C to G in DNA or
RNA. For example, if there is a GTC on the DNA strand, the complementary RNA or DNA sequence
will be CAG. This complementarity maintains the double helical structure of DNA) to those of the target
DNA sequence in the genome. This means that, at least in theory, the guide RNA will only bind to the target
sequence and no other regions of the genome. 
The Cas9 follows the guide RNA to the same location in the DNA sequence and makes a cut across both strands
of the DNA. 
At this stage the cell? recognises that the DNA is damaged and tries to repair it.
Scientists can use the DNA repair machinery to introduce changes to one or more genes (Section of DNA within
the genome that carries the information to make a molecule, usually a protein. They contain the instructions for
our individual characteristics, like eye and hair colour. In humans and other complex organisms, genes are split
into coding (exons) and non-coding sequences (introns). These split sections allow some genes to make more
than one type of protein.  ) in the genome of a cell of interest.
Diagram showing how the CRISPR-Cas9 editing tool works. Image credit: Genome Research Limited.
How was it developed?
Some bacteria? have a similar, built-in, gene editing system to the CRISPR-Cas9 system that they use to respond
to invading pathogens? like viruses,? much like an immune system. 
Using CRISPR the bacteria snip out parts of the virus DNA and keep a bit of it behind to help them recognise and
defend against the virus next time it attacks. 
Scientists adapted this system so that it could be used in other cells from animals, including mice and humans. 
What other techniques are there for altering genes?
Over the years scientists have learned about genetics? and gene function by studying the effects of changes in
DNA.
If you can create a change in a gene, either in a cell line or a whole organism, it is possible to then study the
effect of that change to understand what the function of that gene is.
For a long time geneticists used chemicals or radiation to cause mutations. However, they had no way of
controlling where in the genome the mutation would occur. 
For several years scientists have been using ‘gene targeting’ to introduce changes in specific places in the
genome, by removing or adding either whole genes or single bases. 
Traditional gene targeting has been very valuable for studying genes and genetics, however it takes a long time
to create a mutation and is fairly expensive. 
Several ‘gene editing’ technologies have recently been developed to improve gene targeting methods, including
CRISPR-Cas systems, transcription activator-like effector nucleases (TALENs) and zinc-finger nucleases (ZFNs). 
The CRISPR-Cas9 system currently stands out as the fastest, cheapest and most reliable system for ‘editing’
genes.  
What are the applications and implications?
CRISPR-Cas9 has a lot of potential as a tool for treating a range of medical conditions that have a genetic
component, including cancer?, hepatitis B or even high cholesterol. 
Many of the proposed applications involve editing the genomes of somatic? (non-reproductive) cells but there
has been a lot of interest in and debate about the potential to edit germline?(reproductive) cells.
Because any changes made in germline cells will be passed on from generation to generation it has important
ethical implications. 
Carrying out gene editing in germline cells is currently illegal in the UK and most other countries. 
By contrast, the use of CRISPR-Cas9 and other gene editing technologies in somatic cells is uncontroversial.
Indeed they have already been used to treat human disease on a small number of exceptional and/or life-
threatening cases.

A sperm and egg cell. Carrying out gene editing in germline cells is currently illegal in the UK.
Image credit: Shutterstock
What’s the future of CRISPR-Cas9?
It is likely to be many years before CRISPR-Cas9 is used routinely in humans. 
Much research is still focusing on its use in animal models or isolated human cells, with the aim to eventually use
the technology to routinely treat diseases in humans. 
There is a lot of work focusing on eliminating ‘off-target’ effects, where the CRISPR-Cas9 system cuts at a
different gene to the one that was intended to be edited.  
Better targeting of CRISPR-Cas9
In most cases the guide RNA consists of a specific sequence of 20 bases. These are complementary to the target
sequence in the gene to be edited. However, not all 20 bases need to match for the guide RNA to be able to
bind. 
 The problem with this is that a sequence with, for example, 19 of the 20 complementary bases may exist
somewhere completely different in the genome. This means there is potential for the guide RNA to bind there
instead of or as well as at the target sequence. 
The Cas9 enzyme will then cut at the wrong site and end up introducing a mutation in the wrong location. While
this mutation may not matter at all to the individual, it could affect a crucial gene or another important part of
the genome. 
Scientists are keen to find a way to ensure that the CRISPR-Cas9 binds and cuts accurately. Two ways this may be
achieved are through: 
the design of better, more specific guide RNAs using our knowledge of the DNA sequence of the genome and the
'off-target' behaviour of different versions of the Cas9-gRNA complex.
the use of a Cas9 enzyme that will only cut a single strand of the target DNA rather than the double strand. This
means that two Cas9 enzymes and two guide RNAs have to be in the same place for the cut to be made. This
reduces the probability of the cut being made in the wrong place. 

Anti Retroviral Agents (HAART) -Highly Active

Antiretroviral Therapy
Pharmacology 4,036 Views

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Highly active antiretroviral therapy is initiated for decreasing mortality relating to HIV.
HIV
HIV leads to chronic persistant infection with gradual increase in clinical symptoms. Symptoms appear late,
replication has already occurred without knowledge. HIV belongs to retrovirus family. There are two main types:
1. HIV -1 (human immunodeficiency virus type 1)
2. HIV -2
Three types of genes:
1. N gene
2. Gag
3. Pol
HIV -1 type gets attached to surface of host cell where CD4 present on host cell surface helper T cells within
lymphocytes and macrophages. Additionally viruses also consist of glycoproteins. Basic unit is gp160 having
subunits gp120 and gp41.
Besides, HIV has 3 enzymes:
1. Reverse transcriptase RNA dependent DNA polymerase
2. Integrase
3. Protease
Which participate in replication.
Different anti-retroviral agents target different steps in HIV replication. Glycoprotein components 120 and 41 are
also targets, as are the enzymes involved.
 Life Cycle of HIV
1. Attachment of HIV to cell surface enveloped viruses. Envelope attaches cell surface membrane.
2. Glycoproteins attach CD4 cells on surface, present in macrophages and lymphocytes.
3. Conformational change occurs in receptors and glycoproteins, leading to attachment of viral proteins present
on surface to core receptors. Two types within host cells:
1. CCR5
2. CXCR4
4. Further conformational change occurs, a pore is formed and viral structural components enter host cell
5. Envelope is removed. Within cytoplasm viral RNA is convereted into viral DNA by reverse transcriptase
enzyme
6. It enters nucleus of host cell and imparts into DNA, which is faciliatated by integrase enzyme.
7. Transcription and translation occur, nucleic acids proteins are formed.
8. Assembly occurs leading to release and budding of mature viral particles which is under control of protease
enzyme
9. Released from mature infected cell as virion spreads infection.
Thus different anti-retroviral drugs are derived on basis of this:
1. Reverse transcriptase inhibitors
2. Integrase inhibitors
3. Protease inhibitors –inhibit budding and release
4. Fusion inhibitors –inhibit fusion of lipoproteins to host cell surface receptors.

Nucleoside & Nucleotide  Reverse Transcriptase Inhibitors (NRTIs)

Agents which inhibit HIV reverse transcriptase enzyme. Before bringing about effects, they have to be
phosphorylated in 3 steps, as a result activated to triphosphate form.
Mechanism of Action:
1. Activation via Phosphorylation by cellular enzymes to triphophosphate form.
2. Acts by competitive inhibition of HIV-1 reverse transcriptase and also can be incorporated into growing viral
DNA chain to cause chain termination
Zidovudine (Azidothymidine AZT)
 First licensed Anti retroviral agent
 Is a deoxythymidine analog.
 Combined with lamivudine, didanosine, protease inhibitor
 Resistance may occur with monotherapy so always given in combination.
 Bioavailability 60%, well distributed, CSF levels 65% of  plasma
 T ½  1 hour, but after intracellular phosphorylation T 1/ 2 becomes 7hours
 Glucuronidation by liver
 Eliminated by kidney

Therapeutic uses
In combination with other anti-retroviral agents especially with Lamivudine for:
1.   HIV  Infections
2.   HIV associated dementia, thrombocytopenia
3.   Prophylaxis pregnancy (mother-baby)
 Inhibit vertical transfer of HIV from mother to baby, 14-37 weeks of gestation, orally Zidovudine is given
 I/V at time of labour in HIV infected pregnant lady.
 Given as syrup to neonates for 6 weeks after birth.
 Specific for HIV 1 and II.
Adverse Effects  Used for Zidovudine resistant HIV infection.
1. Myelosuppression –  Anemia, Neutropenia Pharmacokinetics
2. GIT intolerance,  Orally on an empty stomach, food decreases its
3. headache, absorption
4. insomnia,  PPB – low (<5%)
5. extremity fat loss,  Excreted by glomerular filtration and tubular
6. myopathy, secretion
7. fatigue, Adverse Effects

8. malaise, 1. Dose dependent pancreatitis.

9. lactic acidosis, 2. Dose related peripheral painful distal neuropathy.

10. steatosis and 3. Diarrhea, hepatitis, esophageal ulceration,

11. hyperpigmentation cardiomyopathy.

12. Higher doses: – Anxiety, confusion, 4. CNS toxicity – headache, irritability, insomnia.

tremulousness (CNS effects) 5. Asymptomatic hyperuricemia, may precipitate

Didanosine attack of gout in susceptible individuals.
 Synthetic analog of deoxyadenosine. 6. Retinal changes and optic neuritis.
Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs)
Also effective anti-retroviral agents. Main differences from NRTI include:
1. No Phosphorylation & no competition with nucleoside triphosphates
2. Bind directly to active site on HIV-I reverse transcriptase
3. Have different site present on HIV I reverse transcriptase enzyme, bind directly to active site
4. blockade of RNA and DNA dependent DNA polymerase activities.
5. Metabolized by CYP450
6. May acts as enzyme inducer, inhibitor or mixed (depending upon dose and other drugs combined).
Nevirapine
Pharmacokinetics
 Given orally, bioavailability is high – >90%, absorption is not food dependent.
 Half life is 25-30 hours. Cross blood brain barrier.
 Metabolized in liver
 Excreted in urine.
Therapeutic Uses:
1. Component of combination antiretroviral regimen.
2. Single dose is effective in prevention of vertical transmission when given at onset of labor, followed by oral
dose given to neonate within 3 days after delivery.
Adverse Effects
1. Hypersensitivity – Rash occurs in 17% patients mostly in 4-6 weeks.
2. Life threatening skin rashes, including Stevens-Johnson syndrome, and toxic epidermal necrolysis.
3. Fulminant hepatitis.
4. Fever, Nausea, headache, somnolence.
Moderate inducer of hepatic enzyme resulting in decreased levels of other drugs.
Efavirenz
1st FDA approved drug in this category as given once a day, having high tolerability. It is highly tolerated by
children and is highly convenient. Due to high effectiveness, it is still an ideal agent in HIV infections specifically
highly recommended in USA.
HIV Protease Inhibitors
Mechanism of Action:
 HIV proteases convert polyproteins into mature functional polyproteins, by cleavage at the appropriate position.
 These drugs inhibit protease enzyme, thus preventing cleavage of Gag pole mature polyproteins,  resulting in
the production of immature, non infectious viral particles, thus not able to spread infection.
 Directed against HIV I and II.
 For action, no intracellular phosphorylation and activation is required.
Adverse effects:
1. A syndrome of redistribution and accumulation of body fats
2. Associated with increased spontaneous bleeding in Hemophilia A or B.
3. All Protease Inhibitors are substrate and inhibitors of CYP3A4,
Ritonavir is most pronounced in these actions.
Saquinavir is least pronounced.
Atazanavir (along with Ritonavir and not alone)
Once daily dose. Absorption is better in acidic medium, half life is 6-7 hours.
Adverse Drug Reactions
1. Nausea, vomiting, diarrhea, abdominal pain
2. CNS effects –headache, anxiety, skin rash
3. Increase in hepatic enzyme levels.
Fusion Inhibitors
Agents blocking entry of HIV within host cell. Surface of virus has gp 120 and 41 constituting gp 160 components.
When these combined and attached to host cell surface, gp120, 41 attach CD4 on cells of host surface receptors.
Conformational change within gp120 occurs, which gets attached to chemokine receptor CCR5 and CXCR4.
Further conformational change in gp120 facilitates binding of gp41 (subunit of viral glycoprotein), fusion takes
place.
Inhibitors inhibit this fusion. No conformational change occurs and no pore is formed. Entry of virus capsid is
inhibited.
Newly discovered, effective only against HIV I and not against HIV II.
 Enfuvirtide:
 Newly approved anti retroviral agent.
 Synthetic – 36 amino acid peptide.
 S/C administered.
Mechanism of Action
 Blocks entry into the cell.
 Binds to viral glycoprotein envelop, preventing conformational changes, required for fusion of viral and cellular
membranes.
Side effects
1. Pain at site of infection
2. Eosinophilia
3. Hypersensitivity
Integrase Inhibitors
Raltegravir
Viral RNA is converted into viral DNA and gets entry into nucleus, where it is incorporated. This process is
facilitated by integrase enzyme.
Only one drug is available, which is chemically pyrimidinone analog.
Unlike other drugs, its absorption and bioavailability is not food dependent.
It is metabolized in liver and is devoid of drug interactions, as little effects on cytochrome p450 are seen.
Care is taken not to administer the drug with other anti-retroviral agents or enzyme inducers (rifampicin –anti-
tuberculosis).
Adverse effects
The drug is devoid of most adverse effects.
1. Nausea
2. Vomiting
3. Diarrhea
4. Dizziness
Monotherapy is not indicated, always given in combination with other drugs, but not with enzyme inducers or
inhibitors.
All the drugs mentioned above do not cure the disease. Once host cell is infected, rapid multiplication occurs.
Signs and symptoms appear at a very late stage, when the viral load has increased to tremendous values. It
becomes very difficult to suppress or cure the condition. The main focus is to slow down the progression of
disease. The aim is HAART therapy to decrease viral load viremia and to restore CD4+ cells to normal value.
Thus the therapy is only supportive and not curative.
 Anti Influenza Agents
Influenza can be type A, B or C depending upon type. Influenza A and B are more common. Effective drugs have
been discovered.
Life cycle
After binding host cell, fusion and entry occurs, gene is transferred, nucleic acid component is produced, leading
to release of virus.
Two additional components are present:
1.      Heme agglutinin
Influenza virus binds heme agglutinin on host cell epithelial surface specifically respiratory tract.
2.      Neuraminidase on surface
Enzymes present within influenza virus on surface and enhance cleavage of newly formed mature virus
components. These are cleaved and released to infect others, neuraminidase facilitates.
Mechanism of action
Basis of mechanism of action of most anti-influenzal agents are same, hemeagglutination, others neuraminidase.
A number of strains of humans and animals were endemic in 2003 and beyond resistant strains were discovered.
H5, N1, swine flu and there is fear that transmission might occur.
Amantadine/Rimantadine
Specifically for influenza A virus. Bind M2 proteins, necessary for fusion of viral membrane to cell membrane, as a
result fusion does not take place.
Some effects are also seen against release of new virions.
Mechanism of Action:
 Active against influenza A virus only.
 These drugs block M2 proteins that act as an ion channel, and  necessary for fusion of viral membrane to the
cell membrane.
 Also interfere with release of new virions.
Pharmacokinetics:
 Orally, well absorbed .
 Amantadine well distributed including CNS,  Rimantadine does not cross BBB to same extent.
 Amantadine excreted unmetabolized in urine,  Rimantadine undergoes extensive metabolism by hydroxylation,
conjugation, glucuronidation before urinary excretion.
 T ½ = 12 – 18 hrs for Amantadine while it is 24 – 36 hrs for Rimantadine
Adverse effects
Amantadine:
1. Insomia,
2. dizziness,
3. ataxia,
4. nervousness,
5. light headedness.
Rimantadine:
1. causes fewer CNS disturbances.
2. contraindicated in pregnant and lactating women.

3. Amantadine Rimantidine

Half life 12-18 hours 36 hours

PPB 67% 14%

Metabolism Not metabolized Extensively metabolized

Excretion in urine Unchanged Metabolite form

ADRs As readily cross BBB, most Cause fewer CNS disturbances

troublesome CNS related:
1. Insomnia
2. Dizziness
3. Ataxia
4. Nervousness
5. Light headedness
Zanamivir & Oseltamivir
Active against both influenza A & B.
Mechanism of Action:
They inhibit neuraminidase, that is essential for viral replication and release.
Zanamivir:
 Oral/inhalation route and is approved for 7yrs and above.
 Absence of significant metabolism
 Rapid renal clearance
 Nasal & throat discomfort
 Bronchospasm in patients with reactive airway disease
Oseltamivir:
 Given orally and approved for one yr and above.
 Prodrug activated in gut and liver
 t ½ – 6 – 10 hrs
 Excreted in urine
Adverse Effects:
Nausea and vomiting which decreases by administration with food.
Ribavirin
 Synthetic guanosine analog.
 Effective against a broad spectrum of RNA & DNA viruses.
 Orally, I/V, as an aerosol
 Drug & metabolites excreted in urine.
Mechanism of Action:
 Ribavirin inhibits viral mRNA by converting into ribavirin triphosphate (RTP).
 Ribavirin triphophate inhibits replication of wide range of DNA, RNA viruses, including influenza A and B,
Parainfluenza respiratory syncitial  and Paramyxovirurs, HCV and HIV
Therapeutic Uses
1. Respiratory syncytial viral pneumonia and broncholitis.
2. Aerosolized ribavirin used to treat influenza A & B infection.
3. I/V Ribavirin decreases mortality in lassa fever & haemorrhagic fever if started.
4. Severe measles pneumonitis.
Adverse Effects
1. Dose dependent Anemia.
2. Increased bilirubin levels
3. Aerosolized ribavirin cause conjunctival or bronchial irritation.

Anti Hepatitis Drugs

Hepatitis is the inflammation of liver cells, caused by drugs, toxins, organisms. A number of viruses are more
prone to cause hepatitis (type A, B, C, D, E or G). among these viruses leading to hepatitis, B and C are more
troublesome, being more prone to chronic illness, if immediate treatment is not initiated, and liver transplant is the
only option left.
To prevent acute phase from progressing to chronic stage, anti-hepatitis therapy is initiated. Rapid multiplication
of hepatitis virus occurs within liver cells.
Aims of treatment
1. To reduce viremia/viral load, inhibiting viral replication
2. Inhibit progress to chronic stage.
Chances for complications and the need for liver transplant is to be reduced and. We have to reduce the elevated
hepatic aminotransferase enzymes.
In hepatitis B, drugs recommended are:
 Lamivudine (dose of 100 mg once daily orally )
  Adefovir    (Adefovir dipivoxil once daily orally )
 Entecavir (once daily 0.5 mg)
 Tinofavir (300 mg once daily)
 Talbevedine (600 mg once daily)
Besides Interferons are used:
1. Interferon alfa 2b (SC) (dose 50 million units once)
2. Pegelated alfa 2a (180 micrograms once weekly)
Hepatitis C
Aim of treatment is to decrease viral load and to inhibit progress to chronic phase. Therapy is initiated, if after 12
weeks viremia is still present, only then anti-viral therapy is initiated.
Complications include
1. cirrhosis,
2. massive damage,
3. renal cell carcinoma
Drugs for chronic hepatitis include:
 Interferon alfa 2a (subcutaneous or I/M route)
 Interferon alfa 2b
 Peg Interferon alfa 2a
 Peg interferon alfa 2b
Ribavirin (oral) is also established drug, interferons are not effective alone, when combined therapeutic effects
occur.
Immunomodulators
Interferons (IFN)
 Interferons (endogenous glycoproteins) are low molecular weight cytokines produced by host cells in response
to viral infections.
 Released in response to various biochemical changes in cell.
 Having antiviral, immunomodulatory & antiproliferative activities.
 Synthesized by DNA recombinant technique.
 Used in a number of carcinoma.
Mechanism of Action
Interferons are induced by various inducers and bring about a number of biochemical changes.
1. IFN- induced in ribosomes of host’s cells cause production of enzymes (e. g. Protein kinase, 2 – 5
oligoadenylate synthase, phosphodiesterase).
These enzymes inhibit translation of viral mRNA into viral proteins, stopping the production of viruses.
2. Interferon alpha causes inhibition of:
1. viral penetration,
2. translation,
3. transcription,
4. protein processing
5. maturation and
6. release.
3. Increased expression of major histocompatibity complex antigen.
4. Anti-proliferative causing enhanced phagocytosis.
5. Enhance apoptosis
6. Augmentation of proliferation and survival of cytotoxic T cells.
7. Interferons alfa and beta type possess potent anti-viral activity.
8. Interferons act as signal transduction transmission by JAK/STAT pathway. Number of proteins and steps are
involved, final step inhibition leads to inhibition of synthesis of viral proteins, growth and multiplication.
Types
Two types:
1. Interferon type I
 Alpha –synthesized by leukocytes
 Beta –synthesized by epithelial cells
Both of type I are acid stable having potent anti-viral activity. Interferon alpha has high anti-viral activity, it is
divided into:
 2a
 2b
Both are administered I/M or by subcutaneous route.
2. Interferon type II –gamma –not potent so no role in anti-viral treatment, synthesized by lymphocytes.
Newer type are the pegelated interferons:
 2a
 2b
These are superior to the older ones and possess polyethylene glycol structure which makes covalent bond,
hence improve pharmacokinetic profile of interferons. By virtue of polyethylene glycol component:
1. Clearance is decreased
2. More sustained plasma levels
3. Longer half life -168 hours
4. Better bioavailability
5. Less frequent doses as compared with conventional treatment
Efficacy is more towards management of chronic hepatitis C. activity is further enhanced when combined
with Ribavarin.
Therapeutic uses
Beside anti-viral agents:
1. Chronic Hepatitis B & C
2.  Genital warts, caused by papilloma virus.
3. Malignant melanoma
4. Carcinoid syndrome
5.  Hairy cell Leukemia.
6. Renal cell carcinoma
7.  Kaposi’s Sarcoma.
8.  Relapsing remitting multiple sclerosis
9.  Chronic – granulomatous disease
10. HSV HZV and CMV infection in immunocompromised patients.
Adverse effects
1. Commonly occuring 6. edema
Flue like syndrome, 7. hypotension
1. Headache, 8. rashes,
2. vomiting, 9. alopecia
3. anorexia, 2. Dose limiting toxicity
4. fatigue 1. Thrombocytopenia,
5. myalgias 2. Granulocytopenia,
3. increased aminotransferase 6. hepatotoxicity
4. proteinurea 7. Induction of autoantibodies.
5. azotemia Contraindications

3. CVS 1. Autoimmune diseases,

1. hypotension 2. cardiac arrhythmias,

2. tachycardia 3. hepatic decompansation/cirrhosis.

4. CNS 4. psychosis
Lamivudine
1. confusion
 For clinical treatment of Hepatitis B infection.
2. seizures
 Prolong T1/2  in HBV cells  17-19hrs
3. depression
 short T1/2 in HIV cells  10-15 hrs
4. behavorial changes
 Safe for decompensated liver disease.
5. pneumonia
Mechanism of Action
Lamivudine is antiretroviral agent which inhibits HBV DNA polymerase and HIV reverse transcriptase by
competing with deoxyuridine triphosphate and leads to chain termination.
It has to be phosphorylated to triphosphate compound.
Adverse effects
Excellent safety profile for doses used against Hepatitis B infections but risk of pancreatitus in case of HIV
infections.
Ribavarin (with anti-influenza agents)

DNA Polymerase Inhibitors

Agents To Treat HSV & VZV Infections
Acyclovir (Zovirax)
 Inhibit DNA polymerase enzyme. Chemically acyclic guanosine derivative.
 Active against HSV-1 HSV-2 (herpes simplex virus), EBV (ebstein barr virus), CMV (cytomegalo virus), HHV-6
(herpes human virus) & VZV (varicella zoster virus)
 Highly active against HSV and varicella virus.
 HSV causes cold sores, conjunctivitis, mouth ulcers, genital infections and rarely encephalitis in
immunocompromised patients.
a)      HSV 1 causes mouth and face, skin and esophagus infections
b)      HSV II causes infection of rectum, genitals, hands and skin.
 n  VZV causes shingles, chicken pox.
Mechanism of Action
 Highly specific for herpes simplex and varicella zoster.
 Accumulated in the infected cell.
 Infected cell has to be activated by phosphorylation in 3 steps:
1. Virus thymidine kinase phosphorylate Acyclovir into monophosphate.
2. Host cell kinases convert monophosphate to diphosphate & triphosphate compounds.
3. Acyclovir triphosphate inhibits viral DNA synthesis by
4. Competitive inhibition of DNA Polymerase
5.  Incorporation into viral DNA strand, hence lengthening and elongation does not occur.
Pharmacokinetics
 Oral, I/V or topical. Highly effective orally.
 Oral bioavailability 15-20%.
 t ½ = 3 hrs. Once administration.
 Widely distributed to all compartments.
 Clearance by glomerular filtration.
Therapeutic Uses
Oral Acylovir
1. Primary genital herpes, recurrent genital herpes.
2. Long term chronic suppression of genital herpes.
3. Recurrent herpes labialis
4. Herpes proctitis
5. Mucocutaneous herpes in immunocompromised patients
6. Decreases total number of lesions and duration of varicella and cutaneous zoster infections.
   I/V Acyclovir
1. Prophylactically before organ transplantation, it prevents reactivation of HSV.
2. Herpes simplex encephalitis.
3. Neonatal HSV infection.
4. Serious HSV or HZV infections.
5. I/v acyclovir reduces incidence of cutaneous and visceral dissemination in immunocompromised patients with
zoster.
Adverse Effects
 Well tolerated, minimum adverse effects.
 GIT -Nausea, diarrhoea, headache (orally)
  I/V infusion – reversible renal dysfunction, due to crystalline nephropathy and neurological toxicity (tremors,
delirium, seizures).
Resistance: Due to thymidine kinase alteration
Valacyclovir
 L valyl ester of  Acyclovir.
 Oral bioavailability  > 3-5 times
 Potency> acyclovir
Additional uses:
 Cytomegalovirus infections after organ transplantation
Adverse effects
1. Rash
2. GIT
3. In AIDS pts taking high doses, increased incidence of GIT upset, thrombotic thrombocytopenic purpura and
hemolytic uremic syndrome.
4. At high doses confusion, hallucinations and seizures.
Famciclovir
 Acyclic Guanosine analogue
 Converted to penciclovir.
Mechanism of Action
 Activation by phosphorylation catalyzed  by viral thymidine kinase
 Penciclovir triphosphate causes competitive inhibition of viral DNA polymerase to block DNA synthesis.
 Does not cause chain termination.
Therapeutic Uses
1. First episode of genital herpes
2. Recurrent genital herpes
3. Chronic genital herpes suppression
4. Acute herpes zoster (shingles)
5. Well tolerated with no significant side effects.
Agents to Treat Cytomegalovirus Infections
Ganciclovir
Acyclic guanosine analog.
Mechanism of Action:
 Activation by triphosphorylation.
 Initial phosphorylation by virus specified protein kinase phosphotransferase UL97 in CMV – infected cells.
 Active drug competitively inhibits viral DNA polymerase thus causing termination of viral DNA elongation.
Pharmacokinetics
 Oral, I/V or  intraocular implant.
 t ½ = 2-4 hours, may be increased to 6 hours or more.
 Bioavailability is poor 6-9 %
 CSF concentration 50%.
 Elimination by kidneys.
Spectrum of Activity
 CMV, HSV, VZV, EBV, HHV-6 & 8
 Potency > acyclovir for CMV
Therapeutic uses
I/V administration use
1. To delay progression of CMV retinitis (Foscarnet) in AIDS patients.
2. CMV colitis and esophagitis.
3. To reduce risk of CMV infection in transplant patients (Acyclovir).
4. To treat CMV pneumonitis in immunocompromised patients, alongwith CMV immunoglobulin (more chances of
resistance if used alone)
5. Risk of Kaposi sarcoma is reduced in AIDS patients treated by Ganiciclovir.
Oral Administration, used in
1. Prevention of end organ CMV in AIDS patient.
2. As maintenance therapy for CMV retinitis
Intraocular uses
 To treat CMV retinitis. Intraocular implant remains for 6-8 weeks. Sometimes have to remove implant surgically.
Adverse Effects
1. Myelosuppression particularly Neutropenia –most common
2. CNS toxicity – headache, insomnia, seizures,  peripheral neuropathy, (rare).
3. Fever, rash, nausea, diarrhea, abnormal liver function.
4. Vitreous hemorrhage and retinal detachment.
Foscarnet
Spectrum of activity:
 CMV, HSV-1,HSV-2, VZV, EBV, HHV-6 HHV-8
 For Acyclovir  resistant HSV,VZV infections
Only Intravenous route of administration
Only 40-65% reaches CSF
30% deposited in Bones
Mechanism of action:
1. Inhibits directly viral DNA polymerase
2. RNA Polymerase &  HIV Reverse transcriptase –effective agent for HIV related infections.
Anti-retroviral agent.
Therapeutic uses:
Besides resistant cases of herpes simplex, varicella zoster virus and those resistant to Acyclovir:
1.  CMV retinitis
2.  CMV colitis
3.  CMV esophagitis
4.  Decreased incidence of Kaposi sarcoma
Adverse effects:
1. Renal toxicity,
2. electrolyte imbalance, and
3. CNS toxicity.