Evaluation of reverse transcriptase and protease inhibitors in two-drug combinations against human immunodeficiency virus replication

Current treatments for human immunodeficiency virus (HIV) include both reverse transcriptase and protease inhibitors. Results from in vitro and clinical studies suggest that combination therapy can be more effective than single drugs in reducing viral burden. To evaluate compounds for combination therapy, stavudine (d4T), didanosine (ddI), or BMS-186,318, an HIV protease inhibitor, were combined with other clinically relevant compounds and tested in a T-cell line (CEM-SS) that was infected with HIV-RF or in peripheral blood mononuclear cells infected with a clinical HIV isolate. The combined drug effects were analyzed by the methods described by Chou and Talalay (Adv. Enzyme Regul. 22:27-55, 1984) as well as by Prichard et al. (Antimicrob. Agents Chemother. 37:540-545, 1993). The results showed that combining two nucleoside analogs (d4T-ddI, d4T-zidovudine [AZT], and d4T-zalcitabine [ddC]), two HIV protease inhibitors (BMS-186,318-saquinavir, BMS-186,318-SC-52151, and BMS-186,318-MK-639) or a reverse transcriptase and a protease inhibitor (BMS-186,318-d4T, BMS-186,318-ddI, BMS-186,318-AZT, d4T-saquinavir, d4T-MK-639, and ddI-MK-639) yielded additive to synergistic antiviral effects. In general, analysis of data by either method gave consistent results. In addition, combined antiviral treatments involving nucleoside analogs gave slightly different outcomes in the two cell types, presumably because of a difference in phosphorylation patterns. Importantly, no strong antagonism was observed with the drug combinations studied. These data should provide useful information for the design of clinical trials of combined chemotherapy.

[1]  M. Hitchcock.  2′,3′-Didehydro-2′,3′-dideoxythymidine (D4T), an anti-HIV Agent , 1991 .

[2]  J. Craig,et al.  In vitro anti-HIV and Cytotoxicological Evaluation of the Triple Combination: AZT and ddC with HIV Proteinase Inhibitor Saquinavir (Ro 31-8959) , 1994 .

[3]  S. Yerly,et al.  Early and prolonged decrease of viremia in HIV-1-infected patients treated with didanosine. , 1995, Journal of acquired immune deficiency syndromes and human retrovirology : official publication of the International Retrovirology Association.

[4]  D. Richman,et al.  HIV with reduced sensitivity to zidovudine (AZT) isolated during prolonged therapy. , 1989, Science.

[5]  H. Mitsuya,et al.  Anti-human immunodeficiency virus type 1 activity of hydroxyurea in combination with 2',3'-dideoxynucleosides. , 1994, Molecular pharmacology.

[6]  J. Craig,et al.  Antiviral Synergy between Inhibitors of HIV Proteinase and Reverse Transcriptase , 1993 .

[7]  S D Kemp,et al.  Rapid in vitro selection of human immunodeficiency virus type 1 resistant to 3'-thiacytidine inhibitors due to a mutation in the YMDD region of reverse transcriptase. , 1993, Proceedings of the National Academy of Sciences of the United States of America.

[8]  Roy E. Byington,et al.  Two drug combinations of zidovudine, didanosine, and recombinant interferon-alpha inhibit replication of zidovudine-resistant human immunodeficiency virus type 1 synergistically in vitro. , 1991, Disease markers.

[9]  Paul Kellam,et al.  Convergent combination therapy can select viable multidrug-resistant HIV-1 in vitro , 1993, Nature.

[10]  E. De Clercq.  HIV resistance to reverse transcriptase inhibitors. , 1994, Biochemical pharmacology.

[11]  M. Hirsch,et al.  Synergistic inhibition of replication of human immunodeficiency virus type 1, including that of a zidovudine-resistant isolate, by zidovudine and 2',3'-dideoxycytidine in vitro , 1992, Antimicrobial Agents and Chemotherapy.

[12]  R. Schooley,et al.  Synergistic inhibition of human immunodeficiency virus in vitro by azidothymidine and recombinant alpha A interferon , 1987, Antimicrobial Agents and Chemotherapy.

[13]  D. Taylor,et al.  Synergistic Inhibition of Human Immunodeficiency Virus Type 1 in vitro by 6-0-butanoylcastanospermine (MDL 28574) in Combination with Inhibitors of the Virus-Encoded Reverse Transcriptase and Proteinase , 1995 .

[14]  E. Clercq.  HIV resistance to reverse transcriptase inhibitors , 1994 .

[15]  A. Karlsson,et al.  Hydroxyurea increases the phosphorylation of 3'-fluorothymidine and 3'-azidothymidine in CEM cells. , 1989, European journal of biochemistry.

[16]  S. Vasavanonda,et al.  Symmetry-based inhibitors of HIV protease. Structure-activity studies of acylated 2,4-diamino-1,5-diphenyl-3-hydroxypentane and 2,5-diamino-1,6-diphenylhexane-3,4-diol. , 1993, Journal of medicinal chemistry.

[17]  M. Hirsch,et al.  Combination therapy for infection due to human immunodeficiency virus type 1. , 1994, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[18]  D. Lambert,et al.  Synergistic drug interactions of an HIV-1 protease inhibitor with AZT in different in vitro models of HIV-1 infection. , 1993, Antiviral research.

[19]  M. Hirsch,et al.  Three-drug synergistic inhibition of HIV-1 replication in vitro by zidovudine, recombinant soluble CD4, and recombinant interferon-alpha A. , 1990, The Journal of infectious diseases.

[20]  L. Reichman,et al.  Fixed-Dose Combinations of Antituberculous Medications To Prevent Drug Resistance , 1995, Annals of Internal Medicine.

[21]  J. Craig,et al.  Effects of a Specific Inhibitor of HIV Proteinase (Ro 31-8959) on Virus Maturation in a Chronically Infected Promonocytic Cell Line (U1) , 1991 .

[22]  J. Hansen,et al.  Evaluation of the combination effect of different antiviral compounds against HIV in vitro. , 1993, Scandinavian journal of infectious diseases.

[23]  J. Fitzgibbon,et al.  Human immunodeficiency virus type 1 pol gene mutations which cause decreased susceptibility to 2',3'-dideoxycytidine , 1992, Antimicrobial Agents and Chemotherapy.

[24]  T. Chou,et al.  Quantitative analysis of dose-effect relationships: the combined effects of multiple drugs or enzyme inhibitors. , 1984, Advances in enzyme regulation.

[25]  R. Schooley,et al.  Circulating p24 antigen levels and responses to dideoxycytidine in human immunodeficiency virus (HIV) infections. A phase I and II study. , 1989, Annals of internal medicine.

[26]  C. Pettinelli,et al.  2',3'-dideoxyinosine (ddI) in patients with the acquired immunodeficiency syndrome or AIDS-related complex. A phase I trial. , 1990, The New England journal of medicine.

[27]  M A Fischl,et al.  The efficacy of azidothymidine (AZT) in the treatment of patients with AIDS and AIDS-related complex. A double-blind, placebo-controlled trial. , 1987, The New England journal of medicine.

[28]  M. Boyd,et al.  New soluble-formazan assay for HIV-1 cytopathic effects: application to high-flux screening of synthetic and natural products for AIDS-antiviral activity. , 1989, Journal of the National Cancer Institute.

[29]  J. Grange,et al.  Suppression of HIV production in resting lymphocytes by combining didanosine and hydroxamate compounds , 1994, The Lancet.

[30]  M. Hirsch,et al.  Human immunodeficiency virus type 1 (HIV-1) inhibitory interactions between protease inhibitor Ro 31-8959 and zidovudine, 2',3'-dideoxycytidine, or recombinant interferon-alpha A against zidovudine-sensitive or -resistant HIV-1 in vitro. , 1992, The Journal of infectious diseases.

[31]  J. Barrish,et al.  Antiviral properties of aminodiol inhibitors against human immunodeficiency virus and protease , 1995, Antimicrobial agents and chemotherapy.

[32]  M. Hirsch,et al.  Two-drug combinations of zidovudine, didanosine, and recombinant interferon-alpha A inhibit replication of zidovudine-resistant human immunodeficiency virus type 1 synergistically in vitro. , 1991, The Journal of infectious diseases.

[33]  K. Chong,et al.  Bisheteroarylpiperazine reverse transcriptase inhibitor in combination with 3'-azido-3'-deoxythymidine or 2',3'-dideoxycytidine synergistically inhibits human immunodeficiency virus type 1 replication in vitro , 1994, Antimicrobial Agents and Chemotherapy.

[34]  Ann Collier,et al.  Combination and Monotherapy with Zidovudine and Zalcitabine in Patients with Advanced HIV Disease , 1995, Annals of Internal Medicine.

[35]  Hui Li,et al.  Genotypic and phenotypic analysis of human immunodeficiency virus type 1 isolates from patients on prolonged stavudine therapy. , 1994, The Journal of infectious diseases.

[36]  Thomas C. Merigan,et al.  HIV Resistance to Dideoxynucleoside Inhibitors , 1993 .

[37]  J. Ritter,et al.  Once-daily administration of 2',3'-dideoxyinosine (ddI) in patients with the acquired immunodeficiency syndrome or AIDS-related complex. Results of a Phase I trial. , 1990, The New England journal of medicine.

[38]  J. Weinstein,et al.  In vitro inhibition of human immunodeficiency virus (HIV) type 1 replication by C2 symmetry-based HIV protease inhibitors as single agents or in combinations , 1992, Antimicrobial Agents and Chemotherapy.

[39]  F. Calderazzo,et al.  Inhibition of ribonucleotide reductase by 2'-substituted deoxycytidine analogs: possible application in AIDS treatment. , 1994, Proceedings of the National Academy of Sciences of the United States of America.

[40]  M. Prichard,et al.  Strategic design and three-dimensional analysis of antiviral drug combinations , 1993, Antimicrobial Agents and Chemotherapy.

[41]  I B Duncan,et al.  Rational design of peptide-based HIV proteinase inhibitors. , 1990, Science.

[42]  R A Mueller,et al.  Discovery of a novel class of potent HIV-1 protease inhibitors containing the (R)-(hydroxyethyl)urea isostere. , 1993, Journal of medicinal chemistry.

[43]  S. Broder,et al.  Differential phosphorylation of azidothymidine, dideoxycytidine, and dideoxyinosine in resting and activated peripheral blood mononuclear cells. , 1993, The Journal of clinical investigation.

[44]  D. Richman.  Resistance of clinical isolates of human immunodeficiency virus to antiretroviral agents , 1993, Antimicrobial Agents and Chemotherapy.

[45]  A. Meyerhans,et al.  Restriction and enhancement of human immunodeficiency virus type 1 replication by modulation of intracellular deoxynucleoside triphosphate pools , 1994, Journal of virology.