Structural and molecular characterization of lopinavir and ivermectin as breast cancer resistance protein (BCRP/ABCG2) inhibitors.

A current clinical challenge in cancer is multidrug resistance (MDR) mediated by ABC transporters. Breast cancer resistance protein (BCRP) or ABCG2 transporter is one of the most important ABC transporters implicated in MDR and the use of inhibitors is a promising approach to overcome the resistance in cancer. This study aimed to characterize the molecular mechanism of ABCG2 inhibitors identified by a repurposing drug strategy using antiviral, anti-inflammatory and antiparasitic agents. Lopinavir and ivermectin can be considered as pan-inhibitors of ABC transporters, since both compounds inhibited ABCG2, P-glycoprotein and MRP1. They inhibited ABCG2 activity showing IC50 values of 25.5 and 23.4 µM, respectively. These drugs were highly cytotoxic and not transported by ABCG2. Additionally, these drugs increased the 5D3 antibody binding and did not affect the mRNA and protein expression levels. Cell-based analysis of the type of inhibition suggested a non-competitive inhibition, which was further corroborated by in silico approaches of molecular docking and molecular dynamics simulations. These results showed an overlap of the lopinavir and ivermectin binding sites on ABCG2, mainly interacting with E446 residue. However, the substrate mitoxantrone occupies a different site, binding to the F436 region, closer to the L554/L555 plug. In conclusion, these results revealed the mechanistic basis of lopinavir and ivermectin interaction with ABCG2. See also the Graphical abstract(Fig. 1).

Evaluation of the polymorphic forms of ritonavir and lopinavir in raw materials and co-milled systems.

Recently, the U.S. Food and Drug Administration (FDA) approved the first oral antiviral drug to treat mild to moderate cases of coronavirus disease. The combination of nirmatrelvir with an already used protease inhibitor class drug, ritonavir, has led to Paxlovid®. Several studies considered drug repositioning as the first trial for new drugs. The precise identification and quantification of polymorphs in raw materials and finished products are important to researchers involved in pharmaceutical development and quality control processes. In this work, we study the solid-state behavior of the antiretroviral drugs ritonavir and lopinavir in raw materials and in milled compositions. The results indicate that mixtures of ritonavir Forms I and II are found in different batches of raw materials from the same manufacturer; besides three equal crystalline samples, an amorphous batch was found in lopinavir. Furthermore, the milling process of the already amorphous lopinavir seems to facilitate the amorphization of ritonavir as well as the production of some unexpected crystalline forms of ritonavir. A phase transition of ritonavir Form I to Form II is only observed when co-milling with amorphous lopinavir. These findings reveal significant variations in phase purity of raw materials that affect the processing and solid-state properties, representing risks for the product quality.

Combination of lipid nanoparticles and iontophoresis for enhanced lopinavir skin permeation: Impact of electric current on lipid dynamics.

Nanostructured lipid carriers (NLC)-loaded with lopinavir (LPV) were developed for its iontophoretic transdermal delivery. Electronic paramagnetic resonance (EPR) spectroscopy of fatty acid spin labels and differential scanning calorimetry (DSC) were applied to investigate the lipid dynamic behavior of NLC before and after the electrical current. In vitro release and permeation studies, with and without anodic and cathodic iontophoresis were also performed. NLC-LPV had nanometric size (179.0 ± 2.5 nm), high drug load (∼x223C 4.14%) and entrapment efficiency (EE) (∼x223C 80%). NLC-LPV was chemically and physically stable after applying an electric current. The electrical current reduced EE after 3 h (67.21 ± 2.64%), resulting in faster LPV in vitro release. EPR demonstrated that iontophoresis decreased NLC lipid dynamics, which is a long-lasting effect. DSC studies demonstrated that electrical current could trigger the polymorphic transition of NLC and drug solubilization in the lipid matrix. NLC-LPV, combined with iontophoresis, allowed drug quantification in the receptor medium, unlike unloaded drugs. Cathodic iontophoresis enabled the quantification of about 7.9 µg/cm2 of LPV in the receptor medium. Passive NLC-LPV studies had to be done for an additional 42 h to achieve similar concentrations. Besides, anodic iontophoresis increased by 1.8-fold the amount of LPV in the receptor medium, demonstrating a promising antiviral therapy strategy.

Lopinavir/Ritonavir: A Review of Analytical Methodologies for the Drug Substances, Pharmaceutical Formulations and Biological Matrices.

Lopinavir/ritonavir is a potent coformulation of protease inhibitors used against HIV infection. Lopinavir is the main responsible for viral load suppression, whereas ritonavir is a pharmacokinetic enhancer. Both of them have recently gained relevance as candidate drugs against severe coronavirus disease (COVID-19). However, significant beneficial effects were not observed in randomized clinical trials. This review summarizes the main physical-chemical, pharmacodynamic, and pharmacokinetic properties of ritonavir and lopinavir, along with the analytical methodologies applied for biological matrices, pharmaceutical formulations, and stability studies. The work also aimed to provide a comprehensive impurity profile for the combined formulation. Several analytical methods in four different pharmacopeias and 37 articles in literature were evaluated and summarized. Chromatographic methods for these drugs frequently use C8 or C18 stationary phases with acetonitrile and phosphate buffer (with ultraviolet detection) or acetate buffer (with tandem mass spectrometry detection) as the mobile phase. Official compendia methods show disadvantages as extended total run time and complex mobile phases. HPLC tandem-mass spectrometry provided high sensitivity in methodologies applied for human plasma and serum samples, supporting the therapeutic drug monitoring in HIV patients. Ritonavir and lopinavir major degradation products arise in alkaline and acidic environments, respectively. Other non-chromatographic methods were also summarized. Establishing the impurity profile for the combined formulation is challenging due to a large number of impurities reported. Easier and faster analytical methods for impurity assessment are still needed.

Repositioning Lopinavir, an HIV Protease Inhibitor, as a Promising Antifungal Drug: Lessons Learned from Candida albicans-In Silico, In Vitro and In Vivo Approaches.

The repurposing strategy was applied herein to evaluate the effects of lopinavir, an aspartic protease inhibitor currently used in the treatment of HIV-infected individuals, on the globally widespread opportunistic human fungal pathogen Candida albicans by using in silico, in vitro and in vivo approaches in order to decipher its targets on fungal cells and its antifungal mechanisms of action. Secreted aspartic proteases (Saps) are the obviously main target of lopinavir. To confirm this hypothesis, molecular docking assays revealed that lopinavir bound to the Sap2 catalytic site of C. albicans as well as inhibited the Sap hydrolytic activity in a typically dose-dependent manner. The inhibition of Saps culminated in the inability of C. albicans yeasts to assimilate the unique nitrogen source (albumin) available in the culture medium, culminating with fungal growth inhibition (IC50 = 39.8 µM). The antifungal action of lopinavir was corroborated by distinct microscopy analyses, which evidenced drastic and irreversible changes in the morphology that justified the fungal death. Furthermore, our results revealed that lopinavir was able to (i) arrest the yeasts-into-hyphae transformation, (ii) disturb the synthesis of neutral lipids, including ergosterol, (iii) modulate the surface-located molecules, such as Saps and mannose-, sialic acid- and N-acetylglucosamine-containing glycoconjugates, (iv) diminish the secretion of hydrolytic enzymes, such as Saps and esterase, (v) negatively influence the biofilm formation on polystyrene surface, (vi) block the in vitro adhesion to epithelial cells, (vii) contain the in vivo infection in both immunocompetent and immunosuppressed mice and (viii) reduce the Sap production by yeasts recovered from kidneys of infected animals. Conclusively, the exposed results highlight that lopinavir may be used as a promising repurposing drug against C. albicans infection as well as may be used as a lead compound for the development of novel antifungal drugs.

Toxicodermia as an adverse event in a covid-19 patient: case report

ABSTRACT: Introduction: SARS-COV2 infection, which was initially associated with respiratory manifestations only, can also cause gastrointestinal, kidney, neurological and cardiovascular symptoms according to some reports. Case presentation: A 36-year-old female patient attended the emergency department due to dyspnea, asthenia, adynamia, mild odynophagia. and headache. The patient's medical history included obesity, smoking, and working as a health care worker. Considering the symptoms, antimalarial and antiretroviral treatment was indicated to treat COVID-19, a diagnosis that was confirmed three days after admission. However, on the fourth day of treatment, the patient presented with polydipsia and macular, pruritic, and generalized rash. Due to suspicion of toxicoderma, the treatment was suspended, and the skin condition improved. After 8 days of hospitalization, the patient was discharged with biosecurity recommendations and mandatory isolation for 28 days. Conclusion: The described case is a report of toxicoderma in a patient with COVID-19 under treatment with antiretroviral and antimalarial drugs. Based on the findings, a thorough examination of skin and mucosa of patients with suspected or confirmed COVID-19 will undoubtedly contribute to the correct characterization of this new disease.

RESUMEN Introducción. La infección por SARS-COV2, que en principio se pensó solo causaba manifestaciones respiratorias, también puede ocasionar síntomas gastrointestinales, renales, neurológicos, cardiovasculares e incluso cutáneos según algunos reportes. Presentación del caso. Paciente femenina de 36 años quien asistió al servicio de urgencias por cuadró clínico consistente en disnea, astenia, adinamia, odinofagia leve y cefalea. Como antecedentes de relevancia se registró obesidad, tabaquismo y ocupación como trabajadora de la salud. Dados los síntomas, se indicó tratamiento antimalárico y antirretroviral para tratar COVID-19, diagnóstico que fue confirmado a los tres días de ingreso, pero al cuarto día de instaurado este manejo la mujer presentó polidipsia y rash macular, pruriginoso y generalizado. Por sospecha de toxicodermia, el tratamiento fue suspendido y con esto el cuadro cutáneo mejoró. Luego de 8 días de hospitalización, la paciente recibió el alta, junto con recomendaciones de bioseguridad y confinamiento durante 28 días. Conclusiones. El caso descrito corresponde a un evento de toxicodermia en una paciente con COVID-19 en manejo con antirretroviral y antimalárico. A partir de los hallazgos, se establece que la exploración minuciosa de piel y mucosas en los pacientes con sospecha o diagnóstico confirmado de COVID-19 puede ser de gran ayuda para la correcta caracterización de esta nueva enfermedad.

Repurposing Drugs for the Management of Patients with Confirmed Coronavirus Disease 2019 (COVID-19).

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), termed coronavirus disease 2019 (COVID-19) by the World Health Organization, is a newly emerging zoonotic agent that emerged in China in December 2019. No specific treatment for COVID-19 is currently available. Usual palliative treatment includes maintaining hydration and nutrition and controlling fever and cough. The clinical severity and extent of transmission need to be determined, and therapeutic options need to be developed and optimized. METHODS: The present review discusses the recent repurposing of drugs for COVID-19 treatment. RESULTS: Several compounds, including remdesivir, lopinavir, ritonavir, interferon-ß, ribavirin, chloroquine/ hydroxychloroquine, azithromycin, tocilizumab, and ivermectin, have emerged as promising alternatives. They block the virus from entering host cells, prevent viral replication, and attenuate exacerbation of the host's immune response. CONCLUSION: Although some evidence indicates the positive actions of different classes of compounds for the treatment of COVID-19, few clinical assays have been established to definitively demonstrate their therapeutic value in humans. Multicenter clinical studies are urgently needed to validate and standardize therapeutic regimens that involve these agents. Although science has not yet presented us with a specific drug against COVID-19, the repurposing of drugs appears to be promising in our fight against this devastating disease.

The effect of protease inhibitor-based dual antiretroviral regimens on CD4/CD8 ratio during the first year of therapy in ART-naïve patients with HIV-infection.

OBJECTIVES: To assess the effect of protease inhibitor (PI)-based dual therapy on CD4/CD8 ratio during the first year of therapy in antiretroviral therapy (ART)-naïve patients using data from randomized controlled clinical trials. METHODS: We pooled data from the GARDEL and ANDES studies, both randomized controlled clinical trials that recruited ART-naïve people living with HIV and randomly assigned them to receive PI-based dual therapy (DT) or triple therapy (TT) aiming to compare viral efficacy. We compared median CD4/CD8 ratios and the proportion of patients with CD4/CD8 ratio > 1 at 48 weeks after ART initiation in both treatment arms using the Mann-Whitney U-test and the χ2 test. We performed subgroup analysis for patients > 50 years old, with baseline CD4 counts ≤ 200 cells/µL, viral load > 100 000 HIV RNA copies/mL, and ritonavir-boosted lopinavir-based therapy. RESULTS: We analysed data from 571 patients: 292 on DT and 279 on TT. No differences were observed in CD4/CD8 ratio (0.632 vs. 0.617, P = 0.729) or in the proportion of patients with CD4/CD8 ratio > 1 (17.9% vs. 19.3%, P = 0.678) 48 weeks after ART initiation. Subgroup analysis showed no further differences. CONCLUSION: The impact of PI-based DT regimens on the CD4/CD8 ratio during the first year of treatment for ART-naïve patients is similar to that of TT.

[Adverse effects of lopinavir/ritonavir in critically ill patients with COVID-19]. / Efectos adversos de lopinavir/ritonavir en enfermedad grave por coronavirus (COVID-19).

During the SARSCoV-2 pandemic many drugs have been used as potential treatments in order to improve the clinical outcome and reduce the mortality. But since it is a currently unknown disease, the evidence about efficacy and safety is built as the drugs are prescribed. In this context, intensive pharmacovigilance allows early detection of adverse events, and thereby infer the safety profile of the indication. We conducted an observational, retrospective, single-center study involving adult patients with severe SARS-CoV-2 infection. All adverse events detected in 23 patients in the Intensive Care Unit between March 15 and June 15, 2020 were registered. We describe type and severity of the adverse events and if treatment suspension was needed. The results show a high rate of adverse events (10/23, 43%) in treatment with lopinavir/ritonavir. In most cases early treatment suspension was required. Even though the limitations of our study derived from the small sample size, these results could help in building evidence about the safety of using lopinavir/ritonavir for severe SARS-CoV-2 infection.

Durante el transcurso de la pandemia causada por el virus SARS-CoV-2 se han utilizado diferentes fármacos como potenciales tratamientos específicos con el objetivo de lograr mejoría clínica y/o disminuir la mortalidad de los afectados, pero al tratarse de una enfermedad hasta ahora desconocida, la evidencia acerca de su seguridad y eficacia se va construyendo a medida que se los prescribe. La farmacovigilancia intensiva en este contexto permite detectar eventos adversos y mediante su reporte y análisis inferir el perfil de seguridad en cada indicación. Se realizó un estudio observacional, retrospectivo, en un único centro, en el cual se relevaron los eventos adversos en 23 pacientes adultos en estado crítico, de los cuales 18 recibieron lopinavir/ritonavir como tratamiento empírico, entre el 15 de marzo y el 15 de junio de 2020, durante su internación en una Unidad de Cuidados Intensivos. Se describe el tipo de eventos adversos, su gravedad y si fueron motivo de suspensión del tratamiento. Los resultados del presente análisis muestran una alta tasa de eventos adversos (10/23, 43%) entre los que recibieron lopinavir/ritonavir, llevando en la mayoría de los casos a la decisión de suspender el mismo antes de completar el tratamiento. Aun con las limitaciones propias del reducido número de casos, la divulgación de dichos resultados aporta evidencia para definir el perfil de seguridad de la combinación lopinavir/ritonavir usado en enfermedad grave por SARS-CoV-2.

Efectos adversos de lopinavir/ritonavir en enfermedad grave por coronavirus (COVID-19) / Adverse effects of lopinavir/ritonavir in critically ill patients with COVID-19

Resumen Durante el transcurso de la pandemia causada por el virus SARS-CoV-2 se han utilizado diferentes fármacos como potenciales tratamientos específicos con el objetivo de lograr mejoría clínica y/o disminuir la mortalidad de los afectados, pero al tratarse de una enfermedad hasta ahora desconocida, la evidencia acerca de su seguridad y eficacia se va construyendo a medida que se los prescribe. La farmacovigilancia intensiva en este contexto permite detectar eventos adversos y mediante su reporte y análisis inferir el perfil de seguridad en cada indicación. Se realizó un estudio observacional, retrospectivo, en un único centro, en el cual se relevaron los eventos adversos en 23 pacientes adultos en estado crítico, de los cuales 18 recibieron lopinavir/ ritonavir como tratamiento empírico, entre el 15 de marzo y el 15 de junio de 2020, durante su internación en una Unidad de Cuidados Intensivos. Se describe el tipo de eventos adversos, su gravedad y si fueron motivo de suspensión del tratamiento. Los resultados del presente análisis muestran una alta tasa de eventos adversos (10/23, 43%) entre los que recibieron lopinavir/ritonavir, llevando en la mayoría de los casos a la decisión de suspender el mismo antes de completar el tratamiento. Aun con las limitaciones propias del reducido número de casos, la divulgación de dichos resultados aporta evidencia para definir el perfil de seguridad de la combinación lopinavir / ritonavir usado en enfermedad grave por SARS-CoV-2.

Abstract During the SARS-CoV-2 pandemic many drugs have been used as potential treatments in order to improve the clinical outcome and reduce the mortality. But since it is a currently unknown disease, the evidence about efficacy and safety is built as the drugs are prescribed. In this context, intensive pharmacovigilance allows early detection of adverse events, and thereby infer the safety profile of the indication. We conducted an observational, retrospective, single-center study involving adult patients with severe SARS-CoV-2 infection. All adverse events detected in 23 patients in the Intensive Care Unit between March 15 and June 15, 2020 were registered. We describe type and severity of the adverse events and if treatment suspension was needed. The results show a high rate of adverse events (10/23, 43%) in treatment with lopinavir/ritonavir. In most cases early treatment suspension was required. Even though the limitations of our study derived from the small sample size, these results could help in building evidence about the safety of using lopinavir/ritonavir for severe SARS-CoV-2 infection.

Lopinavir-ritonavir for COVID-19: A living systematic review.

OBJECTIVE: Provide a timely, rigorous, and continuously updated summary of the evidence on the role of lopinavir/ritonavir in the treatment of patients with COVID-19. METHODS: We conducted searches in the special L·OVE (Living OVerview of Evidence) platform for COVID-19, a system that performs regular searches in PubMed, Embase, CENTRAL, and other 33 sources. We searched for randomized trials and non-randomized studies evaluating the effect of lopinavir/ritonavir versus placebo or no treatment in patients with COVID-19. Two reviewers independently evaluated potentially eligible studies, according to predefined selection criteria, and extracted data using a predesigned standardized form. We performed meta-analyses using random-effect models and assessed overall certainty in evidence using the GRADE approach. A living, web-based version of this review will be openly available during the COVID-19 pandemic. RESULTS: Our search strategy yielded 862 references. Finally, we identified 12 studies, including two randomized trials, evaluating lopinavir/ritonavir, in addition to standard care versus standard care alone in 250 adult inpatients with COVID-19. The evidence from randomized trials shows lopinavir/ritonavir may reduce mortality (relative risk: 0.77; 95% confidence interval: 0.45 to 1.3; low certainty evidence), but the anticipated magnitude of the absolute reduction in mortality, varies across different risk groups. Lopinavir/ritonavir also had a slight reduction in the risk of requiring invasive mechanical ventilation, developing respiratory failure, or acute respiratory distress syndrome. However, it did not lead to any difference in the duration of hospitalization and may lead to an increase in the number of total adverse effects. The overall certainty of the evidence was low or very low. CONCLUSIONS: For severe and critical patients with COVID-19, lopinavir/ritonavir might play a role in improving outcomes, but the available evidence is still limited. A substantial number of ongoing studies should provide valuable evidence to inform researchers and decision-makers soon.

OBJETIVO: Esta revisión sistemática viva tiene como objetivo entregar un resumen oportuno, riguroso y constantemente actualizado de la evidencia disponible sobre los efectos de lopinavir/ritonavir en pacientes con COVID-19. MÉTODOS: Se realizó una búsqueda en la plataforma L·OVE COVID-19 (Living OVerview of Evidence), un sistema que mantiene búsquedas regulares en PubMed/Medline, Embase, Cochrane Central Register of Controlled Trials (CENTRAL) y otras 33 fuentes. Se buscaron ensayos aleatorios y estudios no aleatorios que evaluaran el uso de lopinavir/ritonavir versus placebo o ningún tratamiento en pacientes con COVID-19. Dos revisores evaluaron de forma independiente los artículos potencialmente elegibles, de acuerdo con criterios de selección predefinidos, y extrajeron los datos mediante un formulario estandarizado. Los resultados fueron combinados mediante un metanálisis utilizando modelos de efectos aleatorios y evaluamos la certeza de la evidencia utilizando el método GRADE. Una versión viva de esta revisión estará disponible durante la pandemia de COVID-19. RESULTADOS: La búsqueda inicial arrojó 862 referencias. Finalmente, identificamos 12 estudios incluyendo 2 ensayos aleatorios, que evaluaban lopinavir/ritonavir adicionado al tratamiento estándar versus tratamiento estándar en 250 pacientes adultos hospitalizados con COVID-19. Los resultados provenientes de los ensayos aleatorios muestran que el uso de lopinavir/ritonavir puede reducir la mortalidad (riesgo relativo: 0,77; intervalo de confianza 95%: 0,45 a 1,3; certeza de evidencia baja), pero la magnitud de la reducción absoluta de la mortalidad varía según los diferentes grupos de riesgo. El uso de lopinavir/ritonavir mostró además una ligera reducción en el riesgo de requerir ventilación mecánica invasiva, desarrollar insuficiencia respiratoria o síndrome de dificultad respiratoria aguda. No se observó diferencias en la duración de la hospitalización y su uso puede producir un aumento en el número de efectos adversos totales. La certeza global de la evidencia fue baja o muy baja. CONCLUSIONES: Para pacientes graves y críticos con COVID-19, el uso de lopinavir/ritonavir podría desempeñar un papel en la mejora de los resultados, pero la evidencia disponible aún es limitada. La gran cantidad de estudios en curso deberían proporcionar evidencia valiosa para informar a los investigadores y los tomadores de decisiones en el futuro cercano.

Lopinavir/ritonavir for COVID-19: a living systematic review / Lopinavir/ritonavir para COVID-19: una revisión sistemática viva

Objective: Provide a timely, rigorous, and continuously updated summary of the evidence on the role of lopinavir/ritonavir in the treatment of patients with COVID-19. Methods: We conducted searches in the special L·OVE (Living OVerview of Evidence) platform for COVID-19, a system that performs regular searches in PubMed, Embase, CENTRAL, and other 33 sources. We searched for randomized trials and non-randomized studies evaluating the effect of lopinavir/ritonavir versus placebo or no treatment in patients with COVID-19. Two reviewers independently evaluated potentially eligible studies, according to predefined selection criteria, and extracted data using a predesigned standardized form. We performed meta-analyses using random-effect models and assessed overall certainty in evidence using the GRADE approach. A living, web-based version of this review will be openly available during the COVID-19 pandemic. Results: Our search strategy yielded 862 references. Finally, we identified 12 studies, including two randomized trials, evaluating lopinavir/ritonavir, in addition to standard care versus standard care alone in 250 adult inpatients with COVID-19. The evidence from randomized trials shows lopinavir/ritonavir may reduce mortality (relative risk: 0.77; 95% confidence interval: 0.45 to 1.3; low certainty evidence), but the anticipated magnitude of the absolute reduction in mortality, varies across different risk groups. Lopinavir/ritonavir also had a slight reduction in the risk of requiring invasive mechanical ventilation, developing respiratory failure, or acute respiratory distress syndrome. However, it did not lead to any difference in the duration of hospitalization and may lead to an increase in the number of total adverse effects. The overall certainty of the evidence was low or very low. Conclusions: For severe and critical patients with COVID-19, lopinavir/ritonavir might play a role in improving outcomes, but the available evidence is still limited. A substantial number of ongoing studies should provide valuable evidence to inform researchers and decision-makers soon.

Objetivo: Esta revisión sistemática viva tiene como objetivo entregar un resumen oportuno, riguroso y constantemente actualizado de la evidencia disponible sobre los efectos de lopinavir/ritonavir en pacientes con COVID-19. Métodos: Se realizó una búsqueda en la plataforma L·OVE COVID-19 (Living OVerview of Evidence), un sistema que mantiene búsquedas regulares en PubMed/Medline, Embase, Cochrane Central Register of Controlled Trials (CENTRAL) y otras 33 fuentes. Se buscaron ensayos aleatorios y estudios no aleatorios que evaluaran el uso de lopinavir/ritonavir versus placebo o ningún tratamiento en pacientes con COVID-19. Dos revisores evaluaron de forma independiente los artículos potencialmente elegibles, de acuerdo con criterios de selección predefinidos, y extrajeron los datos mediante un formulario estandarizado. Los resultados fueron combinados mediante un metanálisis utilizando modelos de efectos aleatorios y evaluamos la certeza de la evidencia utilizando el método GRADE. Una versión viva de esta revisión estará disponible durante la pandemia de COVID-19. Resultados: La búsqueda inicial arrojó 862 referencias. Finalmente, identificamos 12 estudios incluyendo 2 ensayos aleatorios, que evaluaban lopinavir/ritonavir adicionado al tratamiento estándar versus tratamiento estándar en 250 pacientes adultos hospitalizados con COVID-19. Los resultados provenientes de los ensayos aleatorios muestran que el uso de lopinavir/ritonavir puede reducir la mortalidad (riesgo relativo: 0,77; intervalo de confianza 95%: 0,45 a 1,3; certeza de evidencia baja), pero la magnitud de la reducción absoluta de la mortalidad varía según los diferentes grupos de riesgo. El uso de lopinavir/ritonavir mostró además una ligera reducción en el riesgo de requerir ventilación mecánica invasiva, desarrollar insuficiencia respiratoria o síndrome de dificultad respiratoria aguda. No se observó diferencias en la duración de la hospitalización y su uso puede producir un aumento en el número de efectos adversos totales. La certeza global de la evidencia fue baja o muy baja. Conclusiones: Para pacientes graves y críticos con COVID-19, el uso de lopinavir/ritonavir podría desempeñar un papel en la mejora de los resultados, pero la evidencia disponible aún es limitada. La gran cantidad de estudios en curso deberían proporcionar evidencia valiosa para informar a los investigadores y los tomadores de decisiones en el futuro cercano.

Posibles estrategias de tratamiento para COVID-19 / Possible treatment strategies for COVID-19

No hay tratamiento antiviral específico para el COVID-19. Sin embargo, conocimientos adquiridos durante los brotes del SARS y el MERS, en conjunto con la información obtenida con COVID-19, han permitido detectar varios objetivos terapéuticos en el ciclo de replicación del virus, y en su patogénesis. Se incluye la evidencia actual con respecto a los principales tratamientos propuestos para COVID-19, reutilizados o experimentales, mediante una revisión de la literatura científica a la fecha. Debido a la falta de ensayos controlados aleatorios, se incluyeron: informes de casos, series de casos y artículos de revisión. Globalmente se están llevando a cabo múltiples estudios con el fin de identificar agentes que sean efectivos ante COVID-19, en los siguientes objetivos estratégicos: inhibición de la entrada/fusión del virus (anticuerpos neutralizantes, inhibidores de proteasa de serina transmembrana 2, cloroquina, hidroxicloroquina y umifenovir); interrupción de la replicación viral (remdesivir, favipiravir, lopinavir/ritonavir e ivermectina) y supresión de la respuesta inflamatoria excesiva (corticosteroides, tocilizumab, e inmunoglobulina). Aún no existe un tratamiento efectivo y seguro contra COVID-19; los fármacos descritos en esta revisión se administran como uso compasivo de drogas, o bien, como parte de un ensayo clínico. La terapia de soporte continúa siendo el pilar del manejo de COVID-19.(AU)

There is no specific antiviral treatment for COVID-19. However, knowledge acquired during the SARS and MERS outbreaks, together with the information obtained with COVID-19, have allowed the detection of various therapeutic targets in the virus replication cycle, and in its pathogenesis. The current evidence regarding the leading treatments proposed for COVID-19, reused or experimental, is included through a review of the scientific literature to date. Due to the lack of randomized controlled trials, the following were involved: case reports, case series and review articles. Globally, multiple studies are being carried out in order to identify agents that are effective against COVID-19, upon the following strategic objectives: inhibition of viral entry/fusion (neutralizing antibodies, transmembrane serine protease 2 inhibitors, chloroquine, hydroxychloroquine, and umifenovir); interruption of viral replication (remdesivir, favipiravir, lopinavir/ritonavir and ivermectin), and suppression of excessive inflammatory response (corticosteroids, tocilizumab, and immunoglobulin). There is still no effective and safe treatment against COVID-19; the medications described in this review are given as compassionate drug use, or as part of a clinical trial. Support therapy continues to be COVID-19 management cornerstone.(AU)

Intervenciones farmacológicas para el tratamiento de la Enfermedad por Coronavirus (COVID-19) / Pharmacological interventions for the treatment of Coronavirus Disease (COVID-19)

RESUMEN Varios fármacos han sido propuestos como alternativas terapéuticas para COVID-19. Se efectuó una búsqueda sistematica en MEDLINE (vía PubMed) hasta el 20 de marzo de 2020, con el fin de identificar la evidencia disponible sobre intervenciones farmacológicas para tratamiento específico de COVID-19. 947 publicaciones fueron identificadas y 15 estudios seleccionados: 3 ensayos clínicos, 5 series de casos y 7 reportes de casos. La calidad de la evidencia procedente de ensayos clínicos fue evaluada según la metodología GRADE. La evidencia existente para hidroxicloroquina, favipiravir y lopinavir/ritonavir procede de ensayos clínicos que reportan resultados favorables para los dos primeros fármacos en tanto que no se observó ningún beneficio al adicionar lopinavir/ritonavir al tratamiento estándar. Sin embargo, debido a las limitaciones metodológicas, la evidencia es de muy baja certeza para hidroxicloroquina y de baja certeza para favipiravir y lopinavir/ritonavir. Respecto al uso de arbidol interferón, o el uso combinado de estos con lopinavir/ritonavir, la evidencia es limitada ya que deriva de serie de casos o reporte de casos con resultados no determinantes. No se identificaron estudios que permitan determinar la eficacia y seguridad de intervenciones farmacológicas frente a COVID-19.

ABSTRACT Several drugs have been proposed as therapeutic alternatives for COVID-19. An electronic systematic search of MEDLINE (via PubMed) was carried out until March 20th 2020, in order to identify the available evidence on pharmacological interventions for specific treatment of COVID-19. The quality of the evidence from clinical trials was evaluated according to the GRADE methodology. 947 publications were identified and 15 studies were selected: 3 clinical trials, 5 case series and 7 case reports. The existing evidence for hydroxychloroquine, favipiravir and lopinavir/ritonavir comes from clinical trials reporting favorable results for the first two drugs, while no benefit was observed when lopinavir/ritonavir was added to standard treatment. However, due to methodological issues, the evidence for hydroxychloroquine is very low. For favipiravir and lopinavir/ritonavir the evidence is low. Regarding the use of arbidol interferon, or the combined use of these with lopinavir/ritonavir, the evidence is limited since it derives from case series or case report with non-determining results. No studies were identified that reliably demonstrate the efficacy and safety of any pharmacological intervention against COVID-19.

COVID-19: En este momento podría ser útil el tratamiento antiviral en casos leves / COVID-19: Antiviral treatment in mild cases could be useful at this time

RESUMEN La letalidad por COVID-19 así como su rápida diseminación son responsables de la actual crisis mundial; por ello, desde un inicio se buscaron medicamentos con acción antiviral frente a este agente. Es imposible, por ahora, saber qué persona en estado leve desarrollará una elevada carga viral o tiene una predisposición a desarrollar una respuesta extremada del sistema inmune, pero un tratamiento temprano en los casos leves no sólo garantizaría una mayor eficacia, sino que se evitarían los casos severos. En la actualidad no se dispone de ensayos clínicos, doble ciego, aleatroizados, ni metaanálisis para tomar decisiones seguras; mientras tanto, la pandemia avanza en nuestro país, generando dolor y muerte. En este contexto, en el Perú, las sociedades científicas han manifestado la necesidad del uso de medicamentos antivirales, aún con poca evidencia, basado en la probabilidad de éxito previo a un tratamiento, por sus efectos in vitro y por sus efectos clínicos tempranos, tales como: cloroquina, hidroxicloroquina, azitromicina, lopinavir, ritonavir. De esta manera, en el país desde el 29 de marzo de 2020, se dispone de una norma técnica del Ministerio de Salud, que facilita el uso de estos a nivel nacional para los casos moderados y severos. Consideramos que bajo un sistema estructurado, los centros de primer nivel de atención podrían tratar los casos leves de COVID-19. Nuestro país, a través de las estrategias de prevención y control de TB y de ITS/VIH/SIDA, tiene experiencia en el manejo de programas de tratamiento en dicho nivel. Los costos serán menores que los requeridos en el fortalecimiento del tercer nivel de atención.

ABSTRACT COVID-19's lethality as well as its rapid spread are responsible for the current world crisis; therefore, from the beginning, drugs with antiviral action against this agent were sought. It is impossible, for now, to know which person in a mild state will develop a high viral load or have a predisposition to develop an extreme response from the immune system, but early treatment in mild cases would not only guarantee greater efficacy, but would avoid severe cases. Currently, there are no double blind, randomized clinical trials or meta-analyzes available to make safe decisions; meanwhile, the pandemic is advancing in our country, generating pain and death. In this context, in Peru, scientific societies have expressed the need for the use of antiviral drugs, even with little evidence, based on the probability of success prior to treatment, for their in vitro effects and for their early clinical effects, such as: chloroquine, hydroxychloroquine, azithromycin, lopinavir, ritonavir. Thus, in the country since march 29, 2020, there is a technical standard from the Ministry of Health, which facilitates the use of these at the national level for moderate and severe cases. We believe that under a structured system, first-level care centers could treat mild cases of COVID-19. Our country, through strategies for the prevention and control of TB and ITS/HIV/AIDS, has experience in managing treatment programs at this level. The costs will be less than those required to strengthen the third level of care.

Lopinavir and curcumin directly alters BAX/BCL2 and VEFG165b mRNA levels to suppress human squamous cervical carcinoma cell growth / Lopinavir y curcumina alteran directamente los niveles de ARNm de BAX/ BCL 2 y VEFG165 para suprimir el crecimiento de células de carcinoma cervical escamoso humano

Following the success of the highly active antiretroviral therapy, the potential of multidrug combination regimen for the management of cancer is intensely researched. The anticancer effects of curcumin on some human cell lines have been documented. Lopinavir is a FDA approved protease inhibitor with known apoptotic activities. Dysregulated apoptosis is important for the initiation of cancer while angiogenesis is required for cancer growth and development, this study therefore investigated the effects of the combination of lopinavir and curcumin on cell viability, apoptosis and the mRNA expression levels of key apoptotic and angiogenic genes; BAX, BCL2 and VEGF165b in two human cervical cell lines; human squamous cell carcinoma cells - uterine cervix (HCS-2) and transformed normal human cervical cells (NCE16IIA). The two human cervical cell lines were treated with physiologically relevant concentrations of the agents for 120 h following which BAX, BCL2 and VEGF165b mRNA expression were determined by Real Time qPCR. The Acridine Orange staining for the morphological evaluation of apoptotic cells was also performed. The combination of lopinavir and curcumin up-regulated pro-apoptotic BAX and antiangiogenic VEGF165b but down-regulated the mRNA levels of anti-apoptotic BCL2 mRNA in the human squamous cell carcinoma (HCS-2) cells only. The fold changes were statistically significant. Micrographs from Acridine Orange staining showed characteristic evidence of apoptosis in the human squamous cell carcinoma (HCS-2) cells only. The findings reported here suggest that the combination of curcumin and the FDA approved drug-lopinavir modulate the apoptotic and angiogenic pathway towards the inhibition of cervical cancer.

Tras el éxito de la terapia antirretroviral altamente activa, se investiga intensamente el potencial del régimen de combinación de múltiples fármacos para el tratamiento del cáncer. Se han documentado los efectos anticancerígenos de la curcumina en algunas líneas celulares humanas. Lopinavir es un inhibidor de proteasa aprobado por la FDA con actividades apoptóticas conocidas. La apoptosis disrregulada es importante para el inicio del cáncer, mientras que la angiogénesis es necesaria para el crecimiento y desarrollo del cáncer. Por lo tanto, este estudio investigó los efectos de la combinación de lopinavir y curcumina sobre la viabilidad celular, la apoptosis y los niveles de expresión del ARNm de genes apoptóticos y angiogénicos clave: BAX, BCL2 y VEGF165b en dos líneas celulares cervicales humanas; células de carcinoma de células escamosas humanas: cérvix uterino (HCS-2) y células cervicales humanas transformadas (NCE16IIA). Las dos líneas celulares cervicales humanas se trataron con concentraciones fisiológicamente relevantes de los agentes durante 120 horas, después de lo cual la expresión de ARNm de BAX, BCL2 y VEGF165b se determinó mediante qPCR en tiempo real. También se realizó la tinción con naranja de acridina para la evaluación morfológica de células apoptóticas. La combinación de lopinavir y curcumina reguló incrementando BAX proapoptósicos y VEGF165b antiangiogénicos, pero reguló a la baja los niveles de ARNm del BCL2 antiapoptótico en células de carcinoma de células escamosas humanas (HCS-2) únicamente. Los cambios en el pliegue fueron estadísticamente significativos. Las micrografías de la tinción con naranja de acridina mostraron evidencia característica de apoptosis solo en las células del carcinoma de células escamosas humanas (HCS-2). Los hallazgos reportados aquí sugieren que la combinación de curcumina y el fármaco aprobado por la FDA lopinavir modulan la vía apoptótica y angiogénica hacia la inhibición del cáncer cervical.

HIV aspartyl protease inhibitors modify the percentage of activated leukocytes, as well as serum levels of IL-17A and NO during experimental leishmaniasis.

HIV aspartyl protease inhibitors are able to modulate multiple defense mechanisms. However, their influence on the immune response against Leishmania has rarely been investigated. The aim of our study was to investigate whether in vivo treatment with HIV aspartyl protease inhibitors is able to modulate the immune response during Leishmania infection. Using Leishmania (L.) amazonensis-infected mice, we analyzed the disease evolution and parasite load, immunophenotypic profiles of splenic T and B lymphocytes, numbers of lymphoid aggregates in the spleen, percentages of circulating atypical lymphocytes and reactive monocytes, and serum levels of cytokines and nitric oxide (NO) after 30 days of oral treatment with lopinavir/ritonavir (LPV/RTV) or atazanavir (ATV). We observed that LPV/RTV and ATV did not modify the disease evolution or parasite load. However, the antiretroviral treatment induced an increase in activated lymphocytes in the spleen and blood, as well as a decrease in CD69 expression in T and B lymphocytes in the spleen. The treatment also resulted in an increase in activated monocytes in the blood. In addition, antiretrovirals decreased levels of IL-17A and increased levels of NO in sera from Leishmania-infected mice. Thus, our results demonstrate for the first time that in vivo treatment with HIV aspartyl protease inhibitors modifies innate and adaptative immune responses during Leishmania infection and suggest that these drugs could change the clinical course of leishmaniasis in HIV infected-individuals.

Raltegravir versus lopinavir/ritonavir for treatment of HIV-infected late-presenting pregnant women.

Background Late-presenting pregnant women pose a challenge in the prevention of HIV-1 mother-to-child-transmission. We compared the safety and efficacy of raltegravir and lopinavir/ritonavir for this population. Methods We did a single-center, pilot, open-label, randomized trial in Brazil (N = 44). We randomly allocated late-presenting HIV-infected pregnant women (older than 18 years with a plasma HIV-1 RNA >1000 copies/mL) to receive raltegravir 400 mg twice a day or lopinavir/ritonavir 400/100 mg twice a day plus zidovudine and lamivudine (1:1). The primary endpoint was virological suppression at delivery (HIV-1 RNA <50 copies per mL), in all patients who received at least one dose of study drugs (modified intention-to-treat analysis). Missing information was treated as failure. We assessed safety in all patients. Results We enrolled and randomly assigned treatment to 33 patients (17 in raltegravir group) between June 2015 and June 2017. The study was interrupted by the IRB because a significant difference between arms was detected in an interim analysis. All patients completed follow up at delivery. At delivery, virological suppression was achieved by 13/17 (76.5%) of patients in raltegravir group, versus 4/16 (25.0%) in lopinavir/ritonavir group (RR 3.1, 95% CI: 1.3-7.4). Patients in raltegravir group had significantly higher proportion of virological suppression at 2, 4, and 6 weeks than lopinavir/ritonavir group. Adverse events were most of mild intensity, but patients in lopinavir/ritonavir group had significantly more gastrointestinal adverse events. There was neither discontinuation nor deaths in this trial. Conclusion Raltegravir might be a first-line option for treatment of HIV-infected late-presenting pregnant women.

Nelfinavir and lopinavir impair Trypanosoma cruzi trypomastigote infection in mammalian host cells and show anti-amastigote activity.

There is an urgent need to implement new strategies and to search for new chemotherapeutic targets to combat Chagas' disease. In this context, repositioning of clinically approved drugs appears as a viable tool to combat this and several other neglected pathologies. An example is the use of aspartic peptidase inhibitors (PIs) currently applied in human immunodeficiency virus (HIV) treatment against different infectious agents. Therefore, the main objective of this work was to verify the effects of the HIV-PIs nelfinavir and lopinavir against Trypanosoma cruzi using in vitro models of infection. Cytotoxicity assays with LLC-MK2 epithelial cells and RAW macrophages allowed an evaluation of the effects of HIV-PIs on the interaction between trypomastigotes and these cells as well as the survival of intracellular amastigotes. Pre-treatment of trypomastigotes with nelfinavir and lopinavir inhibited the association index with LLC-MK2 cells and RAW macrophages in a dose- and time-dependent manner. In addition, nelfinavir and lopinavir also significantly reduced the number of intracellular amastigotes in both mammalian cell lineages, particularly when administered in daily doses. Both compounds had no effect on nitric oxide production in infected RAW macrophages. These results open the possibility for the use of HIV-PIs as a tangible alternative in the treatment of Chagas' disease. However, the main mechanism of action of nelfinavir and lopinavir has yet to be elucidated, and more studies using in vivo models must be conducted.

[Lopinavir/ritonavir in new initial antiretroviral treatment strategies]. / Lopinavir/ritonavir en nuevas estrategias de tratamiento antirretroviral de inicio.

According to evidence from randomized controlled trials and epidemiological data, the antiretroviral treatment (ART) of choice has consisted of the combination of 2 nucleoside analog reverse-transcriptase inhibitors (NRTI) plus 1 non-nucleoside analog reverse-transcriptase inhibitor (NNRTI) or a protease inhibitor (PI) for more than 17 years. There are several unresolved issues, notably the toxocity associated with NRTI, especially thymidine analogs, and the possibility of cross resistance, which may affect subsequent treatment. The development of new antiretroviral drugs with simpler dosing regimens and lower toxicity has led to evaluation of innovative strategies such as dual therapy for initial ART in treatment-naive, with the aim of preventing long-term toxicity and increasing treatment adherence. Despite encouraging results, some combinations have proven unsatisfactory. The strategies with favorable results to date consist of twice-daily lopinavir/ritonavir (LPV/r)-based regimens, those in the PROGRESS (LPV/r + raltegravir) and GARDEL (LPV/r + lamivudine) trials, and the combination of darunavir and raltegravir (NEAT 001 trial), although the latter observed a higher tendency (statistically nonsignificant) to virological failure in the dual combination arm. These trials were based on the use of NRTI-sparing regimens consisting of 2-3 fully- active agents for highly-active ART in treatment-naïve HIV-positive patients. Recent studies provide evidence supporting the use of NRTI-sparing regimens in HIV-infected patients with failure to an initial NNRTI-based ART regimen. The present review will discuss only LPV/r-based innovative strategies in initial ART regimens.