US20230295236A1 - Compounds for use in inflammatory conditions - Google Patents

Compounds for use in inflammatory conditions Download PDF

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US20230295236A1
US20230295236A1 US17/908,526 US202117908526A US2023295236A1 US 20230295236 A1 US20230295236 A1 US 20230295236A1 US 202117908526 A US202117908526 A US 202117908526A US 2023295236 A1 US2023295236 A1 US 2023295236A1
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substituted
unsubstituted
compound
day
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Pablo AVILÉS MARÍN
Alejandro LOSADA GONZÁLEZ
José María FERNÁNDEZ SOUSA-FARO
Salvador FUDIO MUÑOZ
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Pharmamar SA
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Pharmamar SA
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    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
    • A61P31/00—Antiinfectives, i.e. antibiotics, antiseptics, chemotherapeutics
    • A61P31/12—Antivirals
    • A61P31/14—Antivirals for RNA viruses
    • C—CHEMISTRY; METALLURGY
    • C07—ORGANIC CHEMISTRY
    • C07K—PEPTIDES
    • C07K11/00—Depsipeptides having up to 20 amino acids in a fully defined sequence; Derivatives thereof
    • C07K11/02—Depsipeptides having up to 20 amino acids in a fully defined sequence; Derivatives thereof cyclic, e.g. valinomycins ; Derivatives thereof
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K31/00—Medicinal preparations containing organic active ingredients
    • A61K31/13—Amines
    • A61K31/135—Amines having aromatic rings, e.g. ketamine, nortriptyline
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K31/00—Medicinal preparations containing organic active ingredients
    • A61K31/13—Amines
    • A61K31/135—Amines having aromatic rings, e.g. ketamine, nortriptyline
    • A61K31/138—Aryloxyalkylamines, e.g. propranolol, tamoxifen, phenoxybenzamine
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K31/00—Medicinal preparations containing organic active ingredients
    • A61K31/33—Heterocyclic compounds
    • A61K31/335—Heterocyclic compounds having oxygen as the only ring hetero atom, e.g. fungichromin
    • A61K31/34—Heterocyclic compounds having oxygen as the only ring hetero atom, e.g. fungichromin having five-membered rings with one oxygen as the only ring hetero atom, e.g. isosorbide
    • A61K31/341—Heterocyclic compounds having oxygen as the only ring hetero atom, e.g. fungichromin having five-membered rings with one oxygen as the only ring hetero atom, e.g. isosorbide not condensed with another ring, e.g. ranitidine, furosemide, bufetolol, muscarine
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K31/00—Medicinal preparations containing organic active ingredients
    • A61K31/33—Heterocyclic compounds
    • A61K31/395—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins
    • A61K31/41—Heterocyclic compounds having nitrogen as a ring hetero atom, e.g. guanethidine or rifamycins having five-membered rings with two or more ring hetero atoms, at least one of which being nitrogen, e.g. tetrazole
    • A61K31/4164—1,3-Diazoles
    • A61K31/4178—1,3-Diazoles not condensed 1,3-diazoles and containing further heterocyclic rings, e.g. pilocarpine, nitrofurantoin
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K31/00—Medicinal preparations containing organic active ingredients
    • A61K31/56—Compounds containing cyclopenta[a]hydrophenanthrene ring systems; Derivatives thereof, e.g. steroids
    • A61K31/57—Compounds containing cyclopenta[a]hydrophenanthrene ring systems; Derivatives thereof, e.g. steroids substituted in position 17 beta by a chain of two carbon atoms, e.g. pregnane or progesterone
    • A61K31/573—Compounds containing cyclopenta[a]hydrophenanthrene ring systems; Derivatives thereof, e.g. steroids substituted in position 17 beta by a chain of two carbon atoms, e.g. pregnane or progesterone substituted in position 21, e.g. cortisone, dexamethasone, prednisone or aldosterone
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K38/00—Medicinal preparations containing peptides
    • A61K38/04—Peptides having up to 20 amino acids in a fully defined sequence; Derivatives thereof
    • A61K38/15—Depsipeptides; Derivatives thereof
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
    • A61P29/00—Non-central analgesic, antipyretic or antiinflammatory agents, e.g. antirheumatic agents; Non-steroidal antiinflammatory drugs [NSAID]
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
    • A61P31/00—Antiinfectives, i.e. antibiotics, antiseptics, chemotherapeutics
    • A61P31/12—Antivirals
    • A61P31/14—Antivirals for RNA viruses
    • A61P31/16—Antivirals for RNA viruses for influenza or rhinoviruses
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
    • A61P31/00—Antiinfectives, i.e. antibiotics, antiseptics, chemotherapeutics
    • A61P31/12—Antivirals
    • A61P31/14—Antivirals for RNA viruses
    • A61P31/18—Antivirals for RNA viruses for HIV
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61P—SPECIFIC THERAPEUTIC ACTIVITY OF CHEMICAL COMPOUNDS OR MEDICINAL PREPARATIONS
    • A61P37/00—Drugs for immunological or allergic disorders
    • A61P37/02—Immunomodulators
    • A61P37/06—Immunosuppressants, e.g. drugs for graft rejection
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K2300/00—Mixtures or combinations of active ingredients, wherein at least one active ingredient is fully defined in groups A61K31/00 - A61K41/00
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K38/00—Medicinal preparations containing peptides
    • Y—GENERAL TAGGING OF NEW TECHNOLOGICAL DEVELOPMENTS; GENERAL TAGGING OF CROSS-SECTIONAL TECHNOLOGIES SPANNING OVER SEVERAL SECTIONS OF THE IPC; TECHNICAL SUBJECTS COVERED BY FORMER USPC CROSS-REFERENCE ART COLLECTIONS [XRACs] AND DIGESTS
    • Y02—TECHNOLOGIES OR APPLICATIONS FOR MITIGATION OR ADAPTATION AGAINST CLIMATE CHANGE
    • Y02A—TECHNOLOGIES FOR ADAPTATION TO CLIMATE CHANGE
    • Y02A50/00—TECHNOLOGIES FOR ADAPTATION TO CLIMATE CHANGE in human health protection, e.g. against extreme weather
    • Y02A50/30—Against vector-borne diseases, e.g. mosquito-borne, fly-borne, tick-borne or waterborne diseases whose impact is exacerbated by climate change

Definitions

  • the present invention relates to the treatment of inflammation, and in particular, inflammation associated with or as a result of activation of Toll-like receptors.
  • the invention also relates to the treatment of pathogen-induced inflammation.
  • Inflammation is one of the main responses of the immune system to tissue damage and infections, and involves the major immune cells and extracellular mediators and regulators, such as cytokines.
  • TLRs Toll-like receptors
  • TLRs can detect various pathogens from viruses, bacteria, protozoa and fungi.
  • TLRs can detect bacterial lipopolysaccharide, lipoproteins, flagellin, bacterial CpG-DNA and viral single and double-stranded RNA.
  • PRRs are activated and trigger an intracellular signalling cascade ultimately resulting in the expression of pro-inflammatory cytokine molecules.
  • One signalling cascade results in the activation of the canonical NF- ⁇ B pathway, which is the pivotal regulator of inflammation and the central mediator of pro-inflammatory gene induction.
  • Activation of NF- ⁇ B transduction is responsible for the transcriptional induction of pro-inflammatory cytokines, chemokines and additional inflammatory mediators in different types of immune cells. These inflammatory mediators can both directly engage in the induction of inflammation and act indirectly through promoting the differentiation of inflammatory T cells.
  • a potent immune response is a crucial part of a host’s response to a pathogen infection
  • excessive or inappropriate inflammation e.g. hyperinflammation can be harmful.
  • excessive inflammation plays an important role in the pathogenesis of many infectious diseases.
  • excessive inflammation following pathogen infection leads to hypercytokinemia, commonly known as a cytokine storm.
  • a cytokine storm results from an uncontrolled and excessive release of pro-inflammatory cytokines. This sudden and excessive release of cytokines is particularly harmful to the host, and can lead to multi-system organ failure and death.
  • acute lung injury ALI is a common consequence of a cytokine storm in the lung alveolar environment and systemic circulation.
  • ARDS acute respiratory distress syndrome
  • macrophage effector function significantly affects the quality, duration and magnitude of an inflammatory response, and while this response is important for host defence, when uncontrolled, activated macrophages can cause significant tissue damage.
  • inflammation and cytokine storms are a common clinical feature in serious and lethal infections by a number of viral infections.
  • respiratory viruses such as Orthomyxoviridae.
  • They also include infections by single stranded (+) RNA viruses, including members of the families Flaviviridae, Picornaviridae, Togaviridae, Caliciviridae, Roniviridae, Retroviridae and Coronaviridae.
  • the agent responsible for the lethality is not the cytolytic activity of the virus, but the immunopathological response of the host.
  • Flaviviridae Picornaviridae, Togaviridae, Caliciviridae, Retroviridae, Coronaviridae, Orthomyxoviridae, Phlebovirus, Arenaviridae and Herpesviridae are particularly associated with inflammation and cytokine storms.
  • the present invention is directed to a compound of general formula I, or a pharmaceutically acceptable salt or stereoisomer thereof,
  • X is selected from O and NH
  • the present invention is directed to a compound as defined above (and herein), for use in the treatment of inflammation associated with activation of Toll-like receptors.
  • the present invention is directed to a compound as defined above (and herein), for use in the treatment of a disorder selected from acute respiratory syndrome (ARDS), pneumonia and immunopathology, and in particular hypercytokinemia (cytokine storm syndrome), sepsis and graft-versus-host disease.
  • ARDS acute respiratory syndrome
  • pneumonia pneumonia
  • immunopathology and in particular hypercytokinemia (cytokine storm syndrome), sepsis and graft-versus-host disease.
  • hypercytokinemia cytokine storm syndrome
  • sepsis sepsis and graft-versus-host disease.
  • the present invention is directed to a compound as defined above (and herein), for use in the treatment of pathogen-induced inflammation.
  • the pathogen is a bacteria or virus.
  • the present invention is directed to a compound as defined above (and herein), for use in the combined treatment of inflammation associated with activation of Toll-like receptors or inflammation associated with pathogen-induced inflammation and in the treatment of a viral infection.
  • the present invention is directed to a compound as defined above (and herein), for use as an anti-inflammatory and an antiviral.
  • the compound of general formula I is PLD, or a pharmaceutically acceptable salt or stereoisomer thereof.
  • the compound of general formula I is DidemninB, or a pharmaceutically acceptable salt or stereoisomer thereof.
  • the present invention is also directed to a pharmaceutical composition
  • a pharmaceutical composition comprising a compound as defined herein, and a pharmaceutically acceptable carrier, for use according to the present invention.
  • the present invention is directed to the use of a compound as defined herein, in the manufacture of a medicament for the treatment of inflammation.
  • the present invention is directed to the use of a compound as defined herein, in the manufacture of a medicament for the treatment of inflammation associated with activation of Toll-like receptors.
  • the present invention is directed to the use of a compound as defined herein, in the manufacture of a medicament for the treatment of a disorder selected from pneumonia, acute respiratory syndrome (ARDS), hypercytokinemia (cytokine storm syndrome), sepsis and graft-versus-host disease.
  • ARDS acute respiratory syndrome
  • hypercytokinemia cytokine storm syndrome
  • sepsis graft-versus-host disease
  • the present invention is directed to the use of a compound as defined herein, in the manufacture of a medicament for the treatment of pathogen-induced inflammation.
  • the present invention is directed to the use of a compound as defined herein, in the manufacture of a medicament for the combined treatment of inflammation associated with activation of Toll-like receptors or inflammation associated with pathogen-induced inflammation and in the treatment of a viral infection.
  • the present invention is directed to the use of a compound as defined herein, in the manufacture of a medicament for use as an anti-inflammatory and an antiviral.
  • the present invention is directed to a method for treating inflammation in any mammal, preferably a human, wherein the method comprises administering to an individual in need thereof a therapeutically effective amount of a compound as defined herein.
  • the present invention is directed to a method for treating any mammal, preferably a human, for inflammation associated with activation of Toll-like receptors, wherein the method comprises administering to an individual in need thereof a therapeutically effective amount of a compound as defined herein.
  • the present invention is directed to a method for treating any mammal, preferably a human, for a disorder selected from pneumonia, acute respiratory syndrome (ARDS), hypercytokinemia (cytokine storm syndrome), sepsis and graft-versus-host disease, wherein the method comprises administering to an individual in need thereof a therapeutically effective amount of a compound as defined herein.
  • ARDS acute respiratory syndrome
  • hypercytokinemia cytokine storm syndrome
  • sepsis graft-versus-host disease
  • the present invention is directed to a method for treating any mammal, preferably a human, for pathogen-induced inflammation, wherein the method comprises administering to an individual in need thereof a therapeutically effective amount of a compound as defined herein.
  • the present invention is directed to a method of combined treatment of any mammal, preferably a human, for inflammation associated with activation of Toll-like receptors or inflammation associated with pathogen-induced inflammation and a viral infection, wherein the method comprises administering to a individual in need thereof a therapeutically effective amount of a compound as defined herein.
  • the present invention is directed to a method of anti-inflammatory and antiviral treatment, wherein the method comprises administering to an individual in need thereof a therapeutically effective amount of a compound as defined herein.
  • kits comprising the compound as defined herein, together with instructions for treating inflammation; for treating inflammation associated with activation of Toll-like receptors; for treating a disorder selected from pneumonia, hypercytokinemia (cytokine storm syndrome), sepsis and graft-versus-host disease; for treating pathogen-induced inflammation; for the combined treatment of inflammation associated with activation of Toll-like receptors or inflammation associated with pathogen-induced inflammation and in the treatment of a viral infection; or for use as an anti-inflammatory and an antiviral.
  • the kit may also comprise instructions for treating a viral infection, preferably a SARS-CoV or SARS-CoV-2 infection.
  • the pathogen may be a virus.
  • the Toll-like receptors may be activated by the virus.
  • the virus is a RNA virus. More preferably, the virus is selected from. Flaviviridae, Picornaviridae, Togaviridae, Caliciviridae, Retroviridae, Coronaviridae, Orthomyxoviridae, Phlebovirus and Arenaviridae.
  • the virus is a dsDNA virus, preferably selected from Herpesviridae.
  • the virus is a respiratory virus.
  • R 3 and R 4 may be independently selected from hydrogen and substituted or unsubstituted C 1 -C 6 alkyl.
  • R 3 may be isopropyl and R 4 may be hydrogen.
  • R 3 and R 4 may be methyl (this compound is also designated a compound of general formula II).
  • R 11 may be selected from hydrogen and substituted or unsubstituted C 1 -C 6 alkyl.
  • R 11 may be methyl or isobutyl.
  • R 1 , R 5 , R 9 , and R 15 may be independently selected from hydrogen and substituted or unsubstituted C 1 -C 6 alkyl.
  • R 1 may be selected from sec-butyl and isopropyl
  • R 5 may be isobutyl
  • R 9 may be p-methoxybenzyl
  • R 15 may be selected from methyl and benzyl.
  • R 8 , R 10 , R 12 , and R 16 may be independently selected from hydrogen and substituted or unsubstituted C 1 -C 6 alkyl.
  • R 8 , R 10 and R 12 may be methyl, and R 16 may be hydrogen.
  • R 6 and R 14 may be independently selected from hydrogen and substituted or unsubstituted C 1 -C 6 alkyl.
  • R 6 may be selected from hydrogen and methyl, and R 14 may be hydrogen.
  • R 7 and R 13 may be independently selected from hydrogen and substituted or unsubstituted C 1 -C 6 alkyl.
  • R 7 may be methyl and R 13 may be selected from hydrogen, methyl, isopropyl, isobutyl, and 3-amino-3-oxopropyl.
  • R 6 and R 7 and/or R 13 and R 14 together with the corresponding N atom and C atom to which they are attached may form a substituted or unsubstituted pyrrolidine group.
  • R 2 may be selected from hydrogen, substituted or unsubstituted C 1 -C 6 alkyl, and COR a , and wherein R a may be a substituted or unsubstituted C 1 -C 6 alkyl. R 2 may be hydrogen.
  • R 17 may be selected from hydrogen, COR a , COOR a , CONHR b , (C ⁇ S)NHR b , and SO 2 R c , and wherein each R a , R b , and R c may be independently selected from substituted or unsubstituted C 1 -C 6 alkyl, substituted or unsubstituted C 2 -C 6 alkenyl, substituted or unsubstituted C 2 -C 6 alkynyl, substituted or unsubstituted aryl, and substituted or unsubstituted heterocyclic group.
  • R 17 may be selected from hydrogen, COObenzyl, CObenzo[b]thiophen-2-yl, SO 2 (p-methylphenyl), COCOCH 3 and COOC(CH 3 ) 3 .
  • X may be NH.
  • X may be O.
  • Y may be CO.
  • Y may be —COCH(CH 3 )CO—.
  • the compound may be PLD, or pharmaceutically acceptable salts or stereoisomers thereof.
  • the compound may be PLD.
  • the compound may be didemninB, or pharmaceutically acceptable salts or stereoisomers thereof.
  • the compound may be didemninB.
  • the inflammation may be due to COVID-19.
  • the CoV infection may be mild infection; and/or moderate infection; and/or severe infection.
  • the CoV infection may be acute CoV infection, preferably wherein the CoV infection is acute COVID-19 infection; and/or may be ongoing symptomatic CoV infection, preferably wherein the CoV infection is ongoing symptomatic COVID-19 infection; and/or may be post-CoV syndrome, CoV persistent or long CoV; preferably wherein the CoV infection is post-COVID-19 syndrome, COVID persistent or long COVID.
  • the post-CoV syndrome, CoV persistent or long CoV may include one or more symptoms arising from the cardiovascular, respiratory, gastrointestinal, neurological, musculoskeletal, metabolic, renal, dermatological, otolaryngological, haematological and autonomic systems; psychiatric problems, generalised pain, fatigue and/or persisting fever.
  • the use may include use in the treatment of a patient with signs and symptoms of CoV infection (preferably COVID-19) for up to 4 weeks; and/or from 4 weeks to 12 weeks; and/or for more than 12 weeks.
  • signs and symptoms of CoV infection preferably COVID-19
  • the use may include use in the prophylaxis, reduction or treatment of COVID persistent, long COVID or post-COVID syndrome; preferably wherein the prophylaxis, reduction or treatment minimises the likelihood that a patient suffers from COVID persistent, long COVID or post-COVID syndrome symptoms; and/or reduces the severity of such symptoms; further preferably wherein the treatment minimising the symptoms of CoV infection.
  • the use may reduce the infectivity of CoV patients; including wherein the patient is asymptomatic or not very symptomatic yet has a high viral load.
  • the use may reduce the occurrence of supercontagators (asymptomatic or not very symptomatic patients with high viral loads (e.g. TC ⁇ 25)).
  • the use may reduce complications associated with pathogen infection, including hospitalization, ICU and death.
  • the pathogen is preferably a CoV infection.
  • the use may be in the prophylaxis, reduction or treatment of COVID persistent (also known as long COVID or post-COVID syndrome).
  • the compound may be administered in combination with a corticosteroid, preferably dexamethasone.
  • a corticosteroid preferably dexamethasone.
  • the compound and corticosteroid may be administered concurrently, separately or sequentially.
  • the compound may be administered according to a regimen of a once daily dose for 10 days, 9 days, 8 days, 7 days, 6 days, 5 days, 4 days, 3 days, 2 days or 1 day; preferably 2-5 days, 3-5 days, or 3, 4 or 5 days; most preferably 3 days or 5 days; most preferably 3 days.
  • the compound may be administered at a dose of 5 mg a day or less, 4.5 mg a day or less, 4 mg a day or less, 3.5 mg a day or less, 3 mg a day or less, 2.5 mg a day or less or 2 mg a day or less; 0.5 mg/day, 1 mg/day, 1.5 mg/day, 2 mg/day, 2.5 mg/day, 3 mg/day, 3.5 mg/day, 4 mg/day, 4.5 mg/day, or 5 mg/day; preferably 1 mg/day, 1.5 mg/day, 2 mg/day or 2.5 mg/day; preferably 1.5-2.5 mg/day; further preferably 1.5 mg/day, 2 mg/day or 2.5 mg/day.
  • the compound may be administered at a total dose of 1-50 mg, 1-40 mg, 1-30 mg, 1-20 mg, 1-15 mg, 3-15 mg, 3-12 mg, 4-12 mg, 4-10 mg, or 4.5-10 mg; 4 mg, 4.5 mg, 5 mg, 5.5 mg, 6 mg, 6.5 mg, 7 mg, 7.5 mg, 8 mg, 8.5 mg, 9 mg, 9.5 mg or 10 mg; preferably 4.5 mg, 5 mg, 6 mg, 7.5 mg, 8 mg, 9 mg or 10 mg; more preferably 4.5-7.5 mg/day.
  • the total dose may be split over 1, 2, 3, 4, 5, 6, 7, 8, 9 or 10 days, preferably 3 days or 5 days; most preferably 3 days.
  • the compound may be administered at a once daily dose for 3 days at a dose of 1.5-2.5 mg/day.
  • the dose may be 1.5 mg/day.
  • the dose may be 2.5 mg/day.
  • the compound may be PLD administered as a 1.5-hour infusion, once a day for 3 consecutive days.
  • 1.5 mg of PLD may be administered as a 1.5-hour infusion, once a day for 3 consecutive days.
  • 2 mg of PLD may be administered as a 1.5-hour infusion, once a day for 3 consecutive days.
  • 2.5 mg of PLD may be administered as a 1.5-hour infusion, once a day for 3 consecutive days.
  • 1 mg of PLD may be administered as a 1.5-hour infusion, once a day for 5 consecutive days.
  • 2 mg of PLD may be administered as a 1.5-hour infusion, once a day for 5 consecutive days.
  • the regimen may be a single dose (1 day).
  • the compound may be administered as a single dose of 1-10 mg, 4-10 mg, 4.5-10 mg; 4 mg, 4.5 mg, 5 mg, 5.5 mg, 6 mg, 6.5 mg, 7 mg, 7.5 mg, 8 mg, 8.5 mg, 9 mg, 9.5 mg or 10 mg; preferably 4.5 mg, 5 mg, 6 mg, 7.5 mg, 8 mg, 9 mg or 10 mg; more preferably 5-9 mg, 6.5-8.5 mg, 7-8 mg or 7.5 mg.
  • the compound may be PLD administered as a single dose 1.5-hour infusion.
  • the single dose regimen may be utilised with all therapies set out in the present invention.
  • the combination use with corticosteroids may in embodiments be used with the single dose regimen.
  • the multi-day regimen may be utilised with all therapies set out in the present invention.
  • the corticosteroid may be administered daily on the same day(s) as administering a compound according to the present invention.
  • the corticosteroid may be administered on one or more subsequent days.
  • the corticosteroid may be administered on 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 or more subsequent days.
  • the corticosteroid may be administered at a higher dose when administered on the same day(s) as a compound according to the present invention and at a lower dose on subsequent days.
  • the corticosteroid may be dexamethasone.
  • the compound according to the present invention may be administered at a dose according to the present invention on days 1-3 of the dosage regimen.
  • the corticosteroid may be administered intravenously on days 1-3 of the dosage regimen.
  • the corticosteroid may thereafter be administered by oral administration or IV from Day 4 and up to Day 10 (as per physician judgement according to patient clinical condition and evolution).
  • the corticosteroid may be dexamethasone.
  • the dose may be 6.6 mg/day IV on Days 1 to 3 (for example 8 mg dexamethasone phosphate), followed by dexamethasone 6 mg/day (for example 7.2 mg dexamethasone phosphate or 6 mg dexamethasone base) oral administration or IV from Day 4 and up to Day 10.
  • dexamethasone is dexamethasone phosphate and is administered at a dose of 8 mg/day IV on Days 1 to 3, followed by dexamethasone 7.2 mg/day oral administration or IV from Day 4 and up to Day 10.
  • the compound according to the present invention may be administered as an infusion, preferably a 1 hour infusion, a 1.5 hour infusion, a 2 hour infusion, a 3 hour infusion or longer; particularly preferably a 1.5 hour infusion.
  • the regimen may be 1.5 mg of plitidepsin administered as a 1.5-hour infusion, once a day for 3 consecutive days; or 2 mg of plitidepsin administered as a 1.5-hour infusion, once a day for 3 consecutive days; or 2.5 mg of plitidepsin administered as a 1.5-hour infusion, once a day for 3 consecutive days; or 1 mg of plitidepsin administered as a 1.5-hour infusion, once a day for 5 consecutive days; or 2 mg of plitidepsin administered as a 1.5-hour infusion, once a day for 5 consecutive days.
  • the regimen may be 7.5 mg of plitidepsin administered as a 1.5-hour infusion, as a single dose on day 1.
  • the compound according to the present invention may be administered using a loading dose and a maintenance dose.
  • the regimen according to the present invention may be:
  • the compound according to the present invention may be administered in combination with a corticosteroid.
  • the corticosteroid may be administered on the same day(s) as administration of the compound.
  • the corticosteroid may also be administered on one or more subsequent days.
  • the corticosteroid is administered with the compound on days 1-3 and the corticosteroid is further administered on one or more of days 4-10.
  • the corticosteroid may be administered intravenously on days when the compound is administered but administered by oral administration or IV on subsequent days.
  • the corticosteroid may be dexamethasone.
  • Dexamethasone may be administered at a dose of 6.6 mg/day IV on days when the compound is administered.
  • Dexamethasone may be administered at a dose of 6 mg/day oral administration or IV on subsequent days, preferably one or more of days 4, 5, 6, 7, 8, 9 and 10.
  • the dexamethasone dose as defined herein refers to the base weight.
  • the dose can therefore be adjusted if used in salt form.
  • the dexamethasone may be dexamethasone phospate such that 8 mg/day is equivalent to 6.6 mg of dexamethasone base, and 7.2 mg/day is equivalent to 6 mg of dexamethasone base.
  • the compound according to the present invention may be administered 1.5 mg/day intravenous (IV) combined with dexamethasone 6.6 mg/day IV on Days 1 to 3, followed by dexamethasone 6 mg/day oral administration (PO)/IV from Day 4 and up to Day 10 (as per physician judgement according to patient clinical condition and evolution).
  • IV intravenous
  • PO dexamethasone 6 mg/day oral administration
  • the compound according to the present invention may be administered 2.0 mg/day intravenous (IV) combined with dexamethasone 6.6 mg/day IV on Days 1 to 3, followed by dexamethasone 6 mg/day oral administration (PO)/IV from Day 4 and up to Day 10 (as per physician judgement according to patient clinical condition and evolution).
  • IV intravenous
  • PO dexamethasone 6 mg/day oral administration
  • the compound according to the present invention may be administered 2.5 mg/day intravenous (IV) combined with dexamethasone 6.6 mg/day IV on Days 1 to 3, followed by dexamethasone 6 mg/day oral administration (PO)/IV from Day 4 and up to Day 10 (as per physician judgement according to patient clinical condition and evolution).
  • IV intravenous
  • PO dexamethasone 6 mg/day oral administration
  • the corticosteroid may be administered 20 to 30 minutes prior to starting treatment with the compound as defined herein.
  • the patient may additionally receive the following medications, preferably 20 to 30 minutes prior to starting treatment with the compound according to the present invention:
  • patients may receive ondansetron (or equivalent) 4 mg twice a day PO.
  • patients When administered as a single dose, patients may receive the following prophylactic medications 20-30 minutes prior to plitidepsin infusion:
  • Ondansetron 4 mg orally may be given every 12 hours for 3 days after plitidepsin administration to relieve drug-induced nausea and vomiting. If plitidepsin is administered in the morning the patient may receive the first dose of ondansetron in the afternoon.
  • FIG. 1 shows that NF- ⁇ B transactivation in response to the activation of Toll-like receptors is inhibited by PLD.
  • Human monocytic cells TNF-1 were stably transfected with a NF-kB-Luc plasmid and (A) levels of NF-kB transactivation measured in the presence and absence of PLD.
  • B Compound-induced cytotoxicity was tested by the MTT cell proliferation assay. Cultures were exposed to PLD at 100 nM for 6 hours. RQ – Resiquimod at 10 ⁇ g/mL.
  • Poly-C – Polyinosinic-polycytidylic at 500 ⁇ g/mL.
  • TNF- ⁇ was used as a positive control. *** p ⁇ 0.001; ** p ⁇ 0.01
  • FIG. 2 shows that Plitidepsin negatively regulates TLR-trigged cytokine secretion.
  • NF- ⁇ B transactivation in response to the activation of Toll-like receptors leads to increased secretion of the pro-inflammatory cytokines: IL,-1(a), IL-6 (b), IL-8 (c) and TNF- ⁇ (d).
  • Cultures were exposed to PLD at 100 nM or DMSO for 6 hours. At 6 hours post-treatment secreted cytokines were analysed by ELISA. TNF- ⁇ was used as a positive control. *** p ⁇ 0.001; ** p ⁇ 0.01
  • FIG. 3 shows the ex-vivo down-regulation of cytokines IL-6, IL-10 and TNF- ⁇ by PLD.
  • FIG. 4 shows a decrease in classically activated macrophages in LPS-challenged mice.
  • FIG. 5 shows the effects of plitidepsin on alveolar macrophage recruitment in LPS treated mice.
  • FIG. 6 Graphical representation of the antiviral activity (- ⁇ - RLUs) and toxicity (- ⁇ -Viability) of several concentrations ( ⁇ M) of compound 3 in MT-2 cells ( FIG. 6 A ) and in preactivated PBMCs ( FIG. 6 B ), both infected with a recombinant virus (NL4.3 Luc). Graphical representations are at least mean of two independent experiments for MT-2 cells and four for PBMCs.
  • FIG. 7 Graphical representation of the antiviral activity (- ⁇ - RLUs) and toxicity (- ⁇ -Viability) of several concentrations ( ⁇ M) of compound 8 in MT-2 cells ( FIG. 7 A ) and in preactivated PBMCs ( FIG. 7 B ), both infected with a recombinant virus (NL4.3 Luc). Graphical representations are at least mean of two independent experiments for MT-2 cells and four for PBMCs.
  • FIG. 8 Graphical representation of the antiviral activity (- ⁇ - RLUs) and toxicity (- ⁇ -Viability) of several concentrations ( ⁇ M) of compound 9 in MT-2 cells ( FIG. 8 A ) and in preactivated PBMCs ( FIG. 8 B ), both infected with a recombinant virus (NL4.3 Luc). Graphical representations are at least mean of two independent experiments for MT-2 cells and four for PBMCs.
  • FIG. 9 Graphical representation of the antiviral activity (- ⁇ - RLUs) and toxicity (- ⁇ -Viability) of several concentrations ( ⁇ M) of compound 10 in MT-2 cells ( FIG. 9 A ) and in preactivated PBMCs ( FIG. 9 B ), both infected with a recombinant virus (NL4.3 Luc). Graphical representations are at least mean of two independent experiments for MT-2 cells and four for PBMCs.
  • FIG. 10 Graphical representation of the antiviral activity (- ⁇ - RLUs) and toxicity (- ⁇ -Viability) of several concentrations ( ⁇ M) of compound 11 in MT-2 cells ( FIG. 10 A ) and in preactivated PBMCs ( FIG. 10 B ), both infected with a recombinant virus (NL4.3 Luc).
  • Graphical representations are at least mean of two independent experiments for MT-2 cells and four for PBMCs.
  • FIGS. 11 - 15 show fluorescence images showing a) cell growth and b) antiviral activity for DMSO 24 hpi against HCoV-229E infected Huh-7 cells (A1, A2, A3, A4, A5 from Table 2). It can be seen that cells remain viable but that no antiviral effect is seen.
  • FIGS. 16 - 19 show fluorescence images showing a) cell growth and b) antiviral activity for Compound 240 (DidemninB) 24 hpi against HCoV-229E infected Huh-7 cells at 50 nM, 5 nM and 0.5 nM concentrations (B1, B2, B3, B4 from Table 2 respectively). It can be seen that cells remain viable at all concentrations, including high concentrations; and that remarkable antiviral properties are seen across all concentrations, even at sub nano-molar concentrations.
  • Compound 240 Compound 240
  • FIGS. 20 - 23 show fluorescence images showing a) cell growth and b) antiviral activity for PLD 24 hpi against HCoV-229E infected Huh-7 cells at 50 nM, 5 nM and 0.5 nM concentrations (C1, C2, C3, C4 from Table 2 respectively). Again, it can be seen that cells remain viable at all concentrations, including high concentrations; and that remarkable antiviral properties are seen across all concentrations, even at sub nano-molar concentrations.
  • FIGS. 24 - 26 show fluorescence images showing a) cell growth and b) antiviral activity for Compound 9 24 hpi against HCoV-229E infected Huh-7 cells at 50 nM, 5 nM and 0.5 nM concentrations (D1, D2, D3, from Table 2 respectively). Again, it can be seen that cells remain viable at all concentrations, including high concentrations; and that remarkable antiviral properties are seen across all concentrations, even at sub nano-molar concentrations.
  • FIGS. 27 - 29 show fluorescence images showing a) cell growth and b) antiviral activity for Compound 10 24 hpi against HCoV-229E infected Huh-7 cells at 50 nM, 5 nM and 0.5 nM concentrations (E1, E2, E3, from Table 2 respectively). Again, it can be seen that cells remain viable at all concentrations, including high concentrations; and that remarkable antiviral properties are seen across all concentrations, even at sub nano-molar concentrations.
  • FIGS. 30 - 33 show fluorescence images showing a) cell growth and b) antiviral activity for PLD (second run) 24 hpi against HCoV-229E infected Huh-7 cells at 50 nM, 5 nM and 0.5 nM concentrations (F1, F2, F3, F4 from Table 2 respectively). Again, it can be seen that cells remain viable at all concentrations, including high concentrations; and that remarkable antiviral properties are seen across all concentrations, even at sub nano-molar concentrations.
  • FIGS. 34 and 35 show total plasma concentration profiles vs. time predicted for dosing schedules and administration according to the present invention.
  • FIG. 36 shows total plasma concentration profiles vs. time predicted for further dosing schedules and administration according to the present invention.
  • FIG. 37 shows dose response curves showing the antiviral effect of PLD on SARS-CoV-2 in vero cells.
  • FIG. 38 shows dose response curves showing the antiviral effect of PLD on SARS-CoV-2 in vero cells.
  • FIG. 39 shows x-rays showing the effects of PLD administration on a patient with bilateral pneumonia.
  • FIG. 40 shows x-rays showing the effects of PLD administration on a patient with unilateral pneumonia.
  • FIG. 41 shows C-reactive protein tests for patients treated with PLD.
  • FIG. 42 shows the viral load log of Patient 4 ( FIG. 42 a ), Patient 5 ( FIG. 42 b ), Patient 6 ( FIG. 42 c ) and Patient 7 ( FIG. 42 d ). Patients were administered PLD as a 90 minute IV infusion daily for 3 consecutive days (day 1-3) with viral load assessed by PCR at baseline, day 4, day 7, day 15 and day 31.
  • FIG. 43 shows the inflammatory profile in the BALF of mice infected with influenza virus with (PR8) or without (PC) treatment with PLD.
  • FIG. 44 shows the titre of influenza virus in the lung of mice with or without treatment with PLD.
  • the antiviral activity of PLD was quantified by qPCR measuring the mRNA level of viral NP (NP- PR8).
  • FIG. 45 shows a quantitative measurement of the level of immune cell infiltration, particularly AMs (alveolar macrophages) in the BALF of influenza infected mice treated with (PR8) or without (PC) PLD.
  • AMs alveolar macrophages
  • FIG. 46 shows WNV-GFP infection efficiency in VeroE6 cells.
  • Plitidepsin dose-response curves for infection efficiency GFP; green line
  • DAPI cell biomass
  • FIG. 47 shows WNV-GFP infection efficiency in Huh-7 cells.
  • Plitidepsin dose-response curves for infection efficiency GFP; green line
  • DAPI cell biomass
  • FIG. 48 shows the impact of plitidepsin on WNV extracellular infectivity titers.
  • FIG. 49 shows the impact of plitidepsin on intracellular WNV RNA levels.
  • FIG. 50 shows the effect of plitidepsin (APL) pre-treatment at 1 nM, 10 nM and 50 nM on secretion of the pro-inflammatory cytokines IL6 (a), IL8 (b), IL1 ⁇ (c) and TNF- ⁇ (d).
  • APL plitidepsin
  • FIG. 50 shows the effect of 1 nM, 10 nM and 50 nM PLD treatment on cell viability (as a percent of control).
  • THP-1 cells were treated with 1 nM, 10 nM or 50 nM APL or DMSO (0.2%) followed by stimulus with Resiquimod at 2.5 or 5 ⁇ g/mL at 8 hours.
  • Resiquimod at 2.5 or 5 ⁇ g/mL at 8 hours.
  • cytokines or cell viability was measured.
  • FIG. 51 shows the effect of plitidepsin treatment on the production of the pro-inflammatory cytokines, IL-6 (c), IL-10 (d) and TNF- ⁇ (e) mediated by LPS-B5 in CD45 + cells isolated from bronco-alveolar lavages (BALF).
  • (a) shows the percent of CD45 + live cells in control, LPS-B5 and LPS-B5 and PLD treated cells.
  • (b) shows cell survival as a percent of control in LPS-B5 and LPS-B5 and PLD treated cells.
  • FIG. 52 shows the effect of plitidepsin treatment on the production of the pro-inflammatory cytokines TNF- ⁇ mediated by Resiquimod.
  • FIG. 53 shows total vs. plasma concentration profiles for single dose plitidepsin 7.5 mg and 1.5, 2.0 and 2.5 mg on day 1 to 3, using a 1.5 hour infusion.
  • Treat”, “treating”, and “treatment” in the context of a viral infection may refer to one or more of the following: 1) reduction in the number of infected cells; 2) reduction in the number of virions present in the serum, including reduction in viral titre (which can be measured by qPCR); 3) inhibition (i.e., slowing to some extent, preferably stopping) the rate of viral replication; 4) reduction in the viral RNA load; 5) reduction in the viral infectivity titre (the number of virus particles capable of invading a host cell); and 6) relieving or reducing to some extent one or more of the symptoms associated with the viral infection. This may include inflammation associated with viral infection.
  • Patient includes humans, non-human mammals (e.g., dogs, cats, rabbits, cattle, horses, sheep, goats, swine, deer, and the like) and non-mammals (e.g., birds, and the like).
  • non-human mammals e.g., dogs, cats, rabbits, cattle, horses, sheep, goats, swine, deer, and the like
  • non-mammals e.g., birds, and the like.
  • the patient my require hospitalisation for management of inflammation and/or infection.
  • Plitidepsin is a cyclic depsipeptide originally isolated from the marine tunicate Aplidium albicans. PLD is also known as Aplidin or Aplidine. Such terms are used interchangeably herein. PLD analogues are those analogues as defined herein as compounds of Formula I, II or III. In a preferred embodiment, the present invention relates to the use of PLD.
  • PLD has particular efficacy in the treatment of inflammation.
  • PLD has particular efficacy in treating inflammation as a result of pathogen infection.
  • PLD can inhibit the secretion of a number of key pro-inflammatory cytokines.
  • PLD can inhibit the transactivation of NF-kB through the Toll-like receptors (TLR) and subsequent secretion of pro-inflammatory cytokines.
  • TLR Toll-like receptors
  • the Toll-like receptors are activated in response to a number of infectious stimuli. Binding of a TLR ligand (i.e.
  • a stimuli) to a Toll-like receptor triggers a downstream signalling cascade that ultimately leads to the activation of the transcription factor nuclear factor-kappa B (NF-kB), which controls induction of pro-inflammatory cytokines and chemokines.
  • NF-kB transcription factor nuclear factor-kappa B
  • PLD significantly blocks this cascade, consequently leading to a reduction in the release or secretion of pro-inflammatory cytokines.
  • PLD can be used to prevent inflammation following activation of the Toll-like receptors.
  • PLD can be used to inhibit NF- kB transactivation or NF- kB-induced expression or secretion of pro-inflammatory cytokines.
  • PLD can be used to inhibit expression and/or secretion of pro-inflammatory cytokines.
  • PLD significantly reduces levels of macrophage activation and/or recruitment, particularly in response to a pathogen stimulus.
  • Activated macrophages are a key mediator of inflammation and inhibition of activation is central to treating inflammation.
  • PLD can also be used to treat pathogen-induced inflammation, particularly by reducing macrophage activation and/or recruitment.
  • PLD has also been shown to bind to the human translation elongation factor eEF1A (eukaryotic translation elongation factor 1 alpha 1) with a high-affinity and a low rate of dissociation.
  • FLIM-phasor FRET experiments on tumor cells demonstrate that PLD localises in tumor cells sufficiently close to eEF1A to suggest the formation of a drug-protein complex in living cells.
  • PLD-resistant cell lines also show reduced levels of eEF1A protein and ectopic expression of eEF1A in these resistant cells restores the sensitivity to PLD, demonstrating that eEF1A is directly involved in the mechanism of action of PLD.
  • the N protein of a number of viruses such as SARS-CoV and SARS-CoV-2, also bind to eEF1A, and this binding is essential for viral replication.
  • administration and subsequent binding of PLD to eEF1A prohibits or reduces the binding of the viral N-protein to eEF1A. This in turn prevents virus replication.
  • the interaction between PLD and EF1A could therefore reduce the efficiency of de novo viral capsid synthesis and consequently cause a decrease in viral load.
  • PLD binding to eEF1A prevents eEF1A from interacting with its usual binding partners.
  • One such binding-partner is the dsRNA-activated protein kinase (PKR or eIF2AK2). Binding of PLD to eEF1A releases PKR from a complex with eEF1A leading to the activation of PKR.
  • PLD dsRNA-activated protein kinase
  • protein 4a of viruses such as CoVs potently suppresses the activation of PKR through the sequestration of dsRNA. PLD bypasses this viral response, leading to activation of PKR by releasing PKR from the eEF1A complex, as can be seen from the activation of PKR in the absence of viral infection.
  • compounds of the present invention can be used to treat both a viral infection and any inflammation arising from the viral infection.
  • compounds of the present invention as a single therapy can be used to treat two indications that arise from a viral infection – the infection itself (inhibition of viral synthesis and elimination of virus) and any (subsequently) excessive host inflammatory response – i.e. hypercytokinemia.
  • compounds of the present invention can be used in the treatment inflammation, and in particular inflammation associated with either the activation of Toll-like receptors and/or inflammation as a result of pathogen infection.
  • the present invention may be useful in relation to the following viruses:
  • Flaviviridae viruses are responsible for many important diseases that affect public health worldwide.
  • the Flaviviridae viruses include yellow fever virus (YFV), Zika virus (ZIKV), Japanese encephalitis virus (JEV), West Nile Virus (WNV), hepatitis C virus (HCV) and dengue virus (DENV).
  • Flaviviridae pathogens usurp cellular pathways in infected cells, generating an environment that is permissive for viral replication. Through its interaction with the 3′(+) stem loop of the viral RNA and with several replication complex proteins, eEF1A has an important role in minus-strand RNA synthesis and viral replication.
  • Elongation factor eEF1A interacts with the 3′-terminal stem loop of the RNAs of several divergent flaviviruses, including a tick-borne flavivirus, and colocalized with dengue virus replication complexes in infected cells. These results suggest that eEF1 A plays a similar role in RNA replication for all flaviviruses. Also characteristic of all flavivirus-caused diseases is that a fraction of the patients suffer from the exacerbation of the inflammatory response to the viral infection (cytokine storm), which eventually generates tissue damage and worsen the pathological process caused by the virus.
  • cytokine storm cytokine storm
  • Dengue is caused by any of the four dengue viruses (DENV-1–4), belonging to the Flaviviridae family.
  • DENV are small enveloped viruses containing a single-stranded (+) RNA approximately 10 kilobases in length that encodes a single polyprotein that is cleaved to produce 10 viral proteins.
  • DENV infection is a major health problem in the tropical and subtropical regions of the world. Initial DENV infection can be asymptomatic or produce dengue fever (DF), an acute febrile disease accompanied by headache, arthralgia and rash, from which patients usually recover without complications.
  • DF dengue fever
  • a second infection with a heterologous dengue virus serotype can produce the Dengue Hemorrhagic Fever/Dengue Shock Syndrome (DHF/DSS) characterized by plasma leakage and abnormal bleeding that can lead to shock and death.
  • DHF/DSS Dengue Hemorrhagic Fever/Dengue Shock Syndrome
  • the hallmark of severe dengue is a transient perturbation in blood vessel integrity and coagulation. Recovery is usually rapid and complete, suggesting that the key mechanisms are functional rather than structural changes in the vasculature, most likely due to effects of locally produced cytokines.
  • Studies demonstrating exaggerated immune activation in severe dengue strongly suggest a critical role of the immune response in the pathogenesis of dengue. Both innate and adaptive immunity (and their interactions) are involved in this process.
  • Eukaryotic elongation factor 1A is a direct activator of SphK1.
  • DENV-2 RNA co-localizes and co-precipitates with eEF1A from infected cells.
  • the reduction in SpbK1 activity late in DENV-2-infected cells could be a consequence of DENV-2 out-competing SpbK1 for eEF1A binding and hijacking cellular eEF1A for its own replication strategy.
  • Zika virus the causative pathogen of Zika fever, belongs to the Flaviviridae family.
  • ZIKV is a small enveloped ss (+) RNA virus with a genome of around 11 kilobases in length that encodes a single polyprotein that is cleaved to produce 10 viral proteins.
  • ZIKV infections in humans were sporadic before emerging in the Pacific and the Americas in the last decade. Indeed, ZIKV infection was associated with only mild illness prior to the large French Polynesian outbreak in 2013 and 2014, when severe neurological complications were reported, and the emergence in Brazil of a dramatic increase in severe congenital malformations (microcephaly) associated with ZIKV infection during pregnancy.
  • Yellow fever is a lethal viral hemorrhagic fever (VHF) caused by the Yellow Fever Virus (YFV) belonging to the Flaviviridae family.
  • YFV is a small enveloped ss (+) RNA virus with a genome of around 11 kilobases in length that encodes a single polyprotein that is cleaved to produce 10 viral proteins. While most YFV infections are asymptomatic or have very mild symptoms, severe YF occurs in around 12% of patients, manifesting with jaundice, hemorrhage and multi-organ failure.
  • YFV infection is characterized by severe hepatitis, renal failure, hemorrhage, and rapid terminal events with shock and multi-organ failure.
  • Yellow fever a flu-like illness characterized by fever, headache, nausea and myalgia
  • the “infection” phase a flu-like illness characterized by fever, headache, nausea and myalgia
  • the peak of viremia occurs during this infection phase.
  • a “remission” period after which most patients recover.
  • the intoxication phase in which the hemorrhagic and hepatic signs of illness occur, along with multi-organ dysfunction.
  • cytokine storm a sudden systemic inflammatory response syndrome
  • YF virus predominantly replicates in lymphoid tissues and this replication extends beyond the appearance of neutralizing antibodies. Lymphoid tissues undergo profound changes in YF infection and the activation of cells in these tissues contributes to the systemic terminal features of YF, characterized by release of pro-inflammatory cytokines. The terminal events occur swiftly and are characterized clinically by cardiovascular shock and multi-organ failure.
  • WNV West Nile virus
  • ssRNA single-stranded RNA
  • WNV pathogenesis follow three phases, the early phase initial infection and spread (the early phase), peripheral viral amplification (the visceral-organ dissemination phase) and neuroinvasion (the central nervous system (CNS) phase).
  • the innate immune response including type I interferon (IFN) and innate cell-mediated responses is responsible for the early control of WNV
  • the adaptive immune response including humoral and adaptive immune cell mediated responses (CD4+, CD8+ and regulatory T cells), is essential for WNV clearance and limiting possible immune response-mediated damage in the later stages of infection.
  • WNV The early phase after subcutaneous infection is defined by WNV replication in keratinocytes and skin-resident DCs, followed by viral amplification within the draining lymph node, which results in viremia and spread to visceral organs.
  • the specific target cells for WNV infection are not well defined, but are thought to be subsets of DCs, macrophages and possibly neutrophils.
  • WNV invasion of the CNS tissues constitutes the third phase of the infection. WNV may enter the brain though a combination of mechanisms that facilitates viral neuroinvasion, such as direct infection with or without a breakdown of the blood-brain barrier (BBB) and/or virus transport along peripheral neurons.
  • BBB blood-brain barrier
  • Innate antiviral defenses are essential for the control of WNV infection, including the production of type I IFNs and pro-inflammatory cytokines, the expression of antiviral genes and the subsequent activation of the adaptive immune response.
  • the innate immune activity is mainly triggered by RIG-1 like receptor (RLR) signaling, although Toll-like receptors (TLRs) could also contribute to NF- ⁇ B activation and the production of type I interferons and pro-inflammatory cytokines.
  • RLR RIG-1 like receptor
  • TLRs Toll-like receptors
  • DCs and macrophages both of which are innate immune sentinel cells and target cells of WNV infection, are pivotal in linking innate and adaptive immune responses.
  • Macrophages and DCs are readily activated by WNV, releasing pro-inflammatory cytokines and chemokines such as type I IFN, TNF, IL-1 ⁇ , CCL2, CCL3, CCL5 and IL-8.
  • cytokines are important in regulating innate cell-mediated responses (involving NK cells, neutrophils and ⁇ T cells) as well as in developing adaptive immune responses.
  • a major hallmark of WNV pathogenesis is neuroinflammation, which is caused by exaggerated innate and acquired immune response. Accumulation of inflammatory monocytes into the brain and their differentiation to macrophages and microglia can also worsen neuroinflammation and CNS injury, as demonstrated in a murine model of nonlethal WNV infection.
  • TLRs Recognition of WNV nucleic acid in monocytes/microglia by TLRs may lead to the production of TNF- ⁇ , which results in a loss of tight junctions, allowing the entry of WNV and immune cells into the perivascular space of the brain in mice.
  • activation of cells of the monocyte/macrophage system by WNV appears to result in important neuropathological consequences, and exaggerated innate responses may cause inflammation, altering the blood brain barrier permeability and allowing the virus to enter the CNS.
  • treatment of infected neuronal cells with antibodies blocking TNF- ⁇ and other pro-inflammatory mediators results in a significant reduction of WNV-mediated neuronal death, suggesting that such mediators play a major role in the pathogenesis of WNV infection in the CNS.
  • Hepatitis C virus (HCV) infection causes a progressive liver disease that deteriorates from chronic inflammation to fibrosis, cirrhosis and even to hepatocellular carcinoma. HCV-caused hepatitis has an estimated prevalence of 71 million infected people and causes around 400000 deaths per year. Belonging to the Flaviviridae family, Hepatitis C Virus (HCV) is a small enveloped virus containing a single-stranded (+) RNA approximately 10 kilobases in length, which encodes a single polyprotein that is cleaved by cellular and viral proteases to generate 10 viral proteins.
  • HCV Hepatitis C virus
  • hepatocytes and immune cells Upon HCV infection, hepatocytes and immune cells (macrophages, mast cells, dendritic cells and natural killer cells) recruited to the liver initiate the innate immune response, resulting in the spontaneous elimination of acute HCV infection.
  • the immune responses fail to eliminate the virus during the acute phase, leading to chronic infection.
  • Persistent HCV replication in hepatocytes leads to uncontrolled inflammation and chemokine production.
  • the excessive cytokines, as inflammatory agents, further cause inflammation in the liver, which eventually exacerbates tissue damage and liver disease progression.
  • Direct antiviral treatment is the first choice for HCV treatment, but antivirals alone are insufficient to block the severe inflammation and liver injury in HCV-infected individuals.
  • HCV is just the trigger for pathophysiological processes, but persistent inflammatory cytokine storms and HCV-induced hepatocyte damage exacerbate the progression of severe liver diseases.
  • HCV RNA elicits TLR-mediated NF- ⁇ B activation and inflammatory cytokine release, while HCV proteins activate NLRP3. The released inflammatory factors bind to their corresponding receptors and then induce NF- ⁇ B activation, leading to downstream inflammatory response. Therefore, a long-term, persistent and uncontrolled inflammatory response is a hallmark of these diseases and further leads to hepatic injury and more severe disease progression.
  • Tick-borne encephalitis virus causes a severe disease that can lead to permanent neurological conditions or even death.
  • the severity of TBE varies depending on the viral subtype, the European (TBEV-Eu), the Siberian (TBEV-Sib), and the Far-Eastern (TBEV-FE).
  • TBEV-Eu is the mildest variant ( ⁇ 2% lethality), while TBEV-FE is the worst variant with important rates of neurological sequelae and up to 40% fatalities.
  • TBEV is a small enveloped virus containing a single-stranded (+) RNA of approximately 11 kilobases, encoding a single polyprotein that is cleaved by cellular and viral proteases to generate 10 viral proteins.
  • Tick-borne encephalitis is a syndrome with a triphasic course, beginning with a flu-like illness (characterized by fever, fatigue and body pain) after which 65-70% of infected individuals clear the virus. Around one third of the patients follow with the asymptomatic disease phase, and finally the neuroinvasive phase with neurological symptoms of variable severity, ranging from meningitis to severe meningoencephalitis with or without myelitis.
  • Cytokines may facilitate this process. Cytokines such as TNF- ⁇ and IL-6 have an impact on endothelial cell permeability that may induce a BBB disruption, leading to crossover of the virus into the CNS.
  • TBEV-infected immune cells such as dendritic cells, neutrophils, monocytes, macrophages, and T cells could also migrate into the parenchymal compartment causing infection of neurons or other cells in the brain and the spinal cord.
  • TBEV infection activates type 1 IFN production through TLR3 recognition of viral dsRNA in the extracellular environment or in the cytoplasm.
  • the IFN- ⁇ system appears to play a key role in activation of the innate immunity. It affects activation of immunocompetent cells and induction of other pro-inflammatory cytokines. In mice models, TBEV induces a cytokine storm during the terminal stage of infection, which could be considered as a cytokine storm.
  • S1P in blood and cerebrospinal fluid are highly elevated. This increase might promote a proinflammatory response.
  • An increased production of extracellular S1P can be regulated by modulators of the S1P pathway.
  • elongation factor eEF1A binds to and activates SPHK to phosphorylate sphingosine and produce S1P.
  • Plitidepsin targets eEF1A, inhibiting the production of S1P in treated cells.
  • Classical swine fever (CSF) remains one of the most important transboundary viral diseases of swine worldwide. It has tremendous impact on animal health and pig industry and is therefore notifiable to the World Organization for Animal Health.
  • Classical swine fever virus (CSFV) is an small enveloped virus belongs to the Flaviviridae family. It has a single-stranded (+) RNA genome of approximately 12.3 kb which is translated into one polyprotein. Co- and post-translational processing of the precursor protein by viral and cellular proteases results in 13 mature proteins.
  • a putative receptor for the virus in porcine cells is CD46.
  • Classical swine fever can be divided into the following forms of the disease: an acute (transient or lethal), a chronic and a persistent course, which usually requires infection during pregnancy (34).
  • the acute phase is characterized by unspecific (often referred to as “atypical”) clinical signs like high fever, anorexia, gastrointestinal symptoms, general weakness, and conjunctivitis.
  • neurological signs can occur including incoordination, paresis, paralysis and convulsions.
  • skin hemorrhages or cyanosis can appear in different locations of the body such as the ears, limbs, and ventral abdomen. These late signs are the textbook cases and are therefore referred to as “typical” CSF signs.
  • IFN interferon
  • Retroviridae are a family of positive-sense single stranded RNA viruses characterised by their expression of reverse transcriptase, an RNA-dependent DNA polymerase that generates DNA from their RNA genome, which is then subsequently integrated into the host genome of infected plants.
  • Retroviridae viruses include HIV-1 and HIV-2 which cause AIDS and HTLV (human T-lymphotropic virus). HIV infection in particular triggers an immune response that manifests as acute retroviral syndrome (ARS) and in some individuals or advanced cases of infection, an inflammatory syndrome consistent with cytokine storm syndrome.
  • ARS acute retroviral syndrome
  • Picornaviruses are non-enveloped, small, single-stranded (+) RNA viruses. Their small genome spans over 8 kilobases, containing an open reading frame that is translated into a singlepolypeptide which is subsequently processed by viral proteases into 11-12 individual viral proteins.
  • the family comprises enteroviruses (EVs), hepatoviruses, parechoviruses, rhinoviruses, aphthoviruses, and cardioviruses.
  • EVs enteroviruses
  • hepatoviruses hepatoviruses
  • parechoviruses rhinoviruses
  • aphthoviruses aphthoviruses
  • cardioviruses One of the major features of severe pathogenic diseases as a result of several picornavirus infections (type 1 diabetes, myocarditis, or paralysis) is a strong association with autoimmunity.
  • the simplest explanation may be that infection with cytopathic infectious agents results in cell death or injury, thus releasing either sequestered or cellular autoantigens which are present at low concentrations prior to infection, thus preventing autosensitization.
  • cytopathic infectious agents results in cell death or injury, thus releasing either sequestered or cellular autoantigens which are present at low concentrations prior to infection, thus preventing autosensitization.
  • picornaviruses including poliomyelitis virus (PV), coxsackievirus (CVB), and foot-and-mouth disease virus, can induce persistent viral infections, chronic activation of MDA5 and upregulation of IFN-I could produce the adjuvant effect attributed by some investigators as the major contributing factor in picornavirus infections to induce autoimmunity.
  • FMDV Foot-and-mouth disease virus
  • Picornaviridae family a small non-enveloped virus from the Picornaviridae family, has a single stranded (+) RNA genome of about 8.5 Kb in length encoding a single polyprotein which undergoes proteolytic processing by viral proteases to generate 14 viral proteins.
  • Viral infections can stimulate multiple pathways to induce type-I and type-III IFNs which have antiviral, antiproliferative, and immunomodulatory functions. Maturation of dendritic cells (DC) is promoted by IFN-I, influencing the efficacy of the adaptive immune responses induced. Some viral proteases can inhibit type-I IFN production and NF- ⁇ B signaling through the cleavage of receptors, adaptors, and regulators participating in these pathways. The IFN response is then amplified and spread to surrounding uninfected cells by the expression of hundreds of IFN-stimulated genes. MDA5 is involved in recognizing picornaviruses.
  • RNA-dependent protein kinase R The relevance of the type 1 IFN induced double-stranded RNA-dependent protein kinase R (PKR) in the inhibition of FMDV replication has been well-documented in swine and bovine cells.
  • Elongation factor eEF1A2 binds PKR and maintains the kinase on hold.
  • Plitidepsin binds to eEF1A2, releasing PKR from the complex with the elongation factor and activating the kinase (48). This way plitidepsin could enhance the response against FMDV infection.
  • HFMD Hand, foot, and mouth disease
  • the main manifestations are fever, vesicular rashes on hand, feet and buttocks and ulcers in the oral mucosa.
  • HFMD is self-limiting, with patients presenting fever, a maculopapular or papulovesicular rash on the hands and soles of the feet, and painful oral ulcerations that usually resolve in less than ten days. Nevertheless, a small proportion of children may experience severe complications including meningitis, encephalitis, acute flaccid paralysis and neurorespiratory syndrome, and even death.
  • HFMD is caused by two pathogens, the enterovirus 71 (EV-A71) and the coxsackievirus A16 (CV-A16).
  • EV-A71 is a small, icosahedral, non-enveloped, single-stranded (+) RNA virus from the Picornaviridae family.
  • the approximately 7.4-kb genome of EV71 encodes a single polyprotein that is proteolytically cleaved to various structural and nonstructural viral proteins.
  • Lethal EV-A71 infections course with extensive neuronal degeneration, severe CNS inflammation and necrosis, and pulmonary congestion and hemorrhaging.
  • a systemic inflammatory response coupled with CNS inflammation and cytokine storm may play an important role in the development of EV71-related fulminant pulmonary edema.
  • Brain-derived proinflammatory cytokines may enter the systemic circulation after the occurrence of postencephalitis blood-brain barrier disruption to systemically activate an inflammatory cascade, thereby contributing to the development of postencephalitis systemic inflammatory response syndrome (SIRS) and subsequent cardiopulmonary failure and pulmonary edema.
  • SIRS postencephalitis systemic inflammatory response syndrome
  • Coxsackieviruses are relatively common enteroviruses associated with a number of serious human diseases, including myocarditis and meningoencephalitis.
  • Coxsackieviruses are small, icosahedral, non-enveloped, single-stranded (+) RNA viruses from the Picornaviridae family, with a genome of 7-8 kilobases covalently linked to the viral protein VPg, which acts as a primer for RNA synthesis. Transmission is through the fecal-oral route.
  • Coxackieviruses can be divided into two groups, A and B. Group A viruses infect preferentially the skin and mucous membranes, causing diseases as hand, foot and mouth disease (HFMD).
  • HFMD hand, foot and mouth disease
  • CVB Group coxsackieviruses
  • CVB3 serotype B3 viruses
  • CV is a relatively common pediatric virus, typically causing mild infections ranging from subclinical to flu-like symptoms and mild gastroenteritis. CV has been shown to infect the heart, pancreas, and CNS. In some cases CVs cause severe systemic inflammatory diseases such meningoencephalitis, pancreatitis, and myocarditis, all of which can be fatal or result in lasting organ dysfunction, including dilated cardiomyopathy and encephalomyelitis, with a mortality rate as high as 10%.
  • CVB3 Infects and replicates in lymphocytes and macrophages of Peyer’s patches and the spleen. Subsequently, infectious virions are released into the bloodstream and disseminate into organs such as the heart and pancreas.
  • the development of viral myocarditis is generally divided into three distinct phases. The first 3-4 days are the ‘acute’ phase, which is characterized by virus replication. Cell lysis produced by the virus and the recognition of PAMPs by TLRs induce the expression of proinflammatory cytokines including IL-1b, IL-6, IL-18, TNF- ⁇ , and type I and type II interferons (IFNs).
  • cytokines are produced by cardiac resident cells, including myocytes, fibroblasts, endothelial cells, and dendritic cells (DCs). These cytokine signals activate local macrophages and upregulate endothelial adhesion molecules as well as chemokines and chemokine receptors to collectively trigger the recruitment of innate immune cells.
  • the subacute phase commences with infiltration of the heart by cells of the innate immune system. Monocytes engage in phagocytosis of dead cells and strongly augment the expression of proinflammatory cytokines.
  • the immune response not only eliminates infected and dead cells but also significantly contributes to irreversible cardiac damage.
  • the third stage of viral myocarditis starts after complete elimination of the virus and is characterized by cardiac repair and replacement of dead tissue by a fibrotic scar, affecting cardiac function in the long term.
  • HRVs Human rhinoviruses
  • HRVs Human rhinoviruses
  • HRVs are transmitted from person to person via contact (either direct or through a fomite) or aerosol (small or large particle).
  • HRVs belong to the family Picornaviridae and are single stranded (+) RNA viruses with a genome of around 7,200 bp encompassing a single ORF which encodes a poly-protein that is cleaved by virally encoded proteases to produce the 11 viral proteins.
  • HRV-A and -B serotypes enter airway epithelial cells via ICAM-1, a member of the immunoglobulin superfamily. HRV is infrequently associated with cytopathology of the upper respiratory tract. In addition to a direct effect on respiratory epithelial cells, the innate and adaptive host responses also have a role in the pathogenesis of HRV infection.
  • the type I interferon (IFN) response is mediated by MDA-5 and RIG-1. These receptors maximize the induction of type I and II IFNs and proinflammatory cytokines, including RANTES, IP-10, IL-6, IL-8, and ENA-78.
  • HRV stimulation of IL-8 production is mediated in part by an NF- ⁇ -dependent transcriptional activation pathway.
  • Levels of IL-8 correlated with symptom severity (rhinorrhea and nasal obstruction) and peaked at 48 to 72 h after virus inoculation.
  • Hepatitis A virus causes around 1.4 million cases of enterically transmitted hepatitis per year (WHO Fact sheet N°328, Hepatitis A, 2013), being still a source of mortality despite the existence of a successful vaccine. Unlike the rest of picornaviruses, HAV has an envelope that makes it tremendously stable and cannot shut down host protein synthesis. The cell surface molecule TIM-1 acts as a receptor for HAV. Disease severity is age-dependent, being mild or asymptomatic in young children and presenting with acute hepatitis (jaundice, fatigue, general malaise, etc) and a higher incidence of fulminant hepatitis at older ages. Fulminant hepatitis affects those aged over 50, with mortality rates up to 5.4%.
  • HAV is a single stranded (+) RNA pseudo-enveloped virus belonging to the Picornaviridae family. Its genome spans 7.5 kb, containing a single open reading frame that encodes for a polyprotein that is cut by viral proteases into 10 viral proteins. The RNA genome lacks a 5′ cap structure but is bound to a VPg protein.
  • HAV infection has no chronic carrier state and does not lead to chronic hepatitis or cirrhosis.
  • the cytosolic RNA of picornaviruses such as HAV is sensed by MDA5 but, in contrast to HCV, HAV minimally stimulates IFN responses in the infected liver.
  • HAV 3C protease cleaves NF- ⁇ B essential modulator (NEMO), thereby attenuating nuclear factor- ⁇ B (NF- ⁇ B) activation downstream of both MAVS and TLR3. Liver injury could not be directly caused by HAV but caused by immune-mediated mechanisms instead.
  • Togaviridae family contains only one genus, Alphaviridae, with 31 species.
  • Alphavirus are small enveloped icosahedral viruses with a single stranded (+) RNA genome of around 11-12 kilobases. This capped RNA genome is divided into a nonstructural domain encoding the nonstructural proteins (5′-terminal two-thirds of the genome) and a structural domain encoding the three structural proteins of the virus (3′-terminal one-third of the genome).
  • the nonstructural proteins are translated as one or two polyproteins from the genomic RNA itself.
  • polyproteins are cleaved to produce nsP1, nsP2, nsP3, and nsP4, as well as a number of cleavage intermediates that possess important functions distinct from the final products.
  • the structural domain is translated as a polyprotein from a capped subgenomic mRNA, the 26S mRNA.
  • the alphaviruses are a serious or potential threat to human health in many areas.
  • Eastern Equine Encephalitis Virus (EEEV) and Western Equine Encephalitis Virus (WEEV) regularly cause fatal encephalitis in humans in both North America and South America, although the number of cases is small.
  • Venezuelan Equine Encephalitis Virus (VEEV) also causes human illness.
  • Chikungunya Virus (CHIKV) and its close relative O’Nyong-Nyong Virus (ONNV) have caused millions of cases of serious, but not deathly, disease characterized by fever, rash, and a painful arthralgia.
  • RRV Ross River Virus
  • BFV Barmah Forest Virus
  • SINV Sindbis Virus
  • SFV Semliki Forest Virus
  • Chikungunya virus is the etiological agent of the mosquito-borne disease chikungunya fever, a debilitating arthritic disease that causes immeasurable morbidity and some mortality in humans, including newborn babies.
  • CHIKV has a single-stranded (+) RNA genome of approximately 12 kilobases. This genome is organized in two open reading frames, the 5′ ORF which is translated from genomic RNA and encodes four non-structural proteins, and the 3′ ORF which is translated from a subgenomic 26S RNA and encodes for a polyprotein that is cleaved into 5 structural proteins.
  • Chikungunya fever has an incubation period of less than 10 days.
  • Asymptomatic patients are less than 30%, fewer than in other alphaviruses diseases.
  • Symptomatic patients suffer from a sudden onset of high fever, polyarthralgia, headache and fatigue.
  • Polyarthralgia represents the most characteristic symptom, especially peripheral joints pain.
  • Myalgia is also frequent. Cutaneous manifestation happens in half of the patients, including macular rash.
  • a variety of other clinical symptoms have been reported during the acute stage of chikungunya fever, such as conjunctivitis, neuroretinitis, iridocyclitis, myocarditis, pericarditis, pneumonia, dry cough, lymphadenopathy, nephritis, hepatitis and pancreatitis.
  • the reported causes of death were heart failure, multiple organ failure syndrome, toxic hepatitis, encephalitis, bullous dermatosis, respiratory failure, renal failure, pneumonia, acute myocardial infarction, cerebrovascular disease, hypothyroidism or septicemia.
  • the CHIKV RNA genome can trigger host pattern recognition receptors (PRRs) including endosomal Toll-like (TLR3 and TLR7) and cytoplasmic RIG-I-like (RIG-I and MDA5) receptors, which activate downstream adaptor molecules (TRIF, MyD88, and MAVS) to induce nuclear translocation of interferon-regulatory (IRF1, IRF3, IRF5, and IRF7) and NF- ⁇ B transcription factors, which induce expression of type I IFNs, IFN-stimulated genes (ISGs), and pro-inflammatory cytokines and chemokines.
  • PRRs host pattern recognition receptors
  • TLR3 and TLR7 endosomal Toll-like receptor 7
  • RIG-I and MDA5 receptors cytoplasmic RIG-I-like receptors
  • TLR3 and TLR7 cytoplasmic RIG-I-like receptors
  • TLR3 and TLR7 cytoplasmic RIG-I-like receptors
  • Inflammatory cytokines and chemokines are thought to be involved in the pathogenesis of CHIKV and are associated with severe clinical presentations as well as with development of abrupt and persistent arthralgia.
  • a significant increase of IL-1 ⁇ and IL-6 levels in severe compared with non-severe CF cases has been reported.
  • the analysis of inflammatory cytokines revealed a remarkable and strong increase of circulating type-I IFN, as well as of the IL-6 pro-inflammatory cytokine, consistent with a possible role of type-I IFN in the CHIKV-driven cytokine storm that, in turn, may have contributed to enhanced tissue injury and death.
  • Sindbis virus (SinV) is the most widely distributed of all known arthropod-transmitted viruses.
  • the Pogosta, Ockelbo and Karelian fever viruses belong to the Sindbis group.
  • Ockelbo disease characterized by arthritis, rash, and sometimes fever, was first recognized in Ockelbo village in central Sweden. Later on, the same disease was described in Finland as Pogosta disease. In Russia the disease was named Karelian fever.
  • the incubation time varies from 2 to 10 days, the symptomatic illness starts suddenly and the duration of the disease is short, less than 20 days. There are, however, a good proportion of SinV infections that may course with chronic illness.
  • Semliki Forest virus is a single stranded (+) RNA virus of the genus Alphavirus of the family Togaviridae.
  • the genome of SFV is 13 kilobases in length, encoding for only 9 proteins in two open reading frames (ORF).
  • ORF open reading frames
  • Four non-structural proteins are encoded as a polyprotein in the first ORF, located in 5′ region of the genome and directly translated from the genomic DNA.
  • the remaining 5 structural proteins are encoded as a polyprotein in a second ORF which is translated from a subgenomic RNA species called 26S and located in the 3′ region of the genome. Polyproteins are then cut by viral proteases into individual proteins.
  • the original L10 isolate of SFV shows complete virulence in inbred mouse strains, causing lethal encephalitis by infection of the central nervous system (CNS).
  • CNS central nervous system
  • a critical difference between virulent and nonlethal strains could be the swift induction of neuronal damage in the CNS, causing the death of infected mice before the immune system can intervene.
  • Infection with nonlethal SFV strains induces inflammatory spongiform lesions in mouse brain. Those lesions are delayed in mice treated with the immunosuppressive drug cyclophosphamide (Berger ML, 1980). Therefore, direct viral cytolysis is not essential in the production of pathology.
  • nude mice suffer the same inflammatory spongiform lesions although lacking functional T cells indicates that the immunopathology does not depend on them. Instead, the lesions seem to be due to the presence of mononuclear cells from the monocyte-macrophage lineage, which can be recruited into the infected tissue and produce spongiform necrosis.
  • EEEV Eastern, Western and Venezuelan equine encephalitisviruses
  • WEEV Eastern, Western and Venezuelan equine encephalitisviruses
  • VEEV equine encephalitisviruses
  • EEEV was first identified in humans in 1938 during an important outbreak affecting Massachusetts.
  • Most EEEV infections in adult humans are asymptomatic or produce a mild illness characterized by fever, chills, headache, nausea, vomiting and myalgia.
  • the fatality rate in symptomatic patients approaches 80%, many survivors exhibiting important sequelae as mental retardation, convulsions, and paralysis.
  • Lethality of WEEV ranges between 3 and 7% with 15-50% of the encephalitis survivors, especially young children, suffering permanent neurological damage.
  • VEEV-associated encephalitis has caused serious morbidity and mortality in outbreaks in Columbia and Venezuela, with more than 75000 affected people, over 3000 patients suffering neurologic conditions and over 300 deaths.
  • EEEV, WEEV and VEEV are single stranded (+) RNA viruses with a short, capped genome of around 11.7 kilobases.
  • the genome has two ORFs, the 5′ ORF encoding four non-structural proteins which are translated as a single polypeptide from genomic RNA, and the 3′ ORF which is translated from a subgenomic 26S RNA as a single polypeptide containing three structural proteins. Polypeptides are cut into individual proteins by viral proteases.
  • EEEV In experimentally infected laboratory mice, EEEV produces neurologic disease that resembles that following human and equine infections. Virus is detected in the brain on day 1 postinfection (PI), and signs of disease are evident on days 3 to 4 PI. Clinical signs of murine disease include ruffled hair, anorexia, vomiting, lethargy, posterior limb paralysis, convulsions, and coma. Pathological changes in infected mice include neuronal degeneration, cellular infiltration, and perivascular cuffing, similar to the CNS pathological changes described in naturally infected humans. VEEV infects dendritic cells (DCs) and macrophages in lymphoid tissues, fueling a serum viremia and facilitating neuroinvasion. In contrast, EEEV replicates poorly in lymphoid tissues.
  • DCs dendritic cells
  • macrophages in lymphoid tissues, fueling a serum viremia and facilitating neuroinvasion. In contrast, EEEV replicates
  • Rubella virus (RV) infection of children and adults is usually asymptomatic (up to 50% of cases) or characterized by a mild fever, sore throat, lymphadenopathy and a maculopapular rush.
  • RV causes birth defects and fetal death.
  • RV is a major public health concern since more than 100,000 cases of congenital rubella syndrome (CRS) occur every year.
  • Rubella virus (RV) the sole member of the rubivirus genus within the Togaviridae family, has a single stranded (+) RNA genome of around 10 kilobases that encodes for five proteins.
  • the genome contains two ORFs, 5′ ORF which encodes two nonstructural proteins directly translated from the genomic RNA and a second 3′ ORF which encodes three structural proteins translated from a subgenomic mRNA.
  • RV infection during critical stages of organ development in fetus can result in CRS, a syndrome characterized by severe defects in sensory organs (eyes and ears), central nervous system and cardiovascular system.
  • CRS rubella virus is able to infect the placenta, spread to the fetus, and alter the function of multiple fetal systems by interfering with organ formation and causing systemic inflammation.
  • Rubella virus-associated uveitis (RVU) is one of the inflammatory syndromes caused by RV. This inflammatory process is characterized by high intraocular levels of inflammatory cytokines, including IL-6, IL-6ra and MCP-1.
  • Caliciviridae family is composed by 11 genera, with seven genera (Lagovirus, Norovirus, Nebovirus, Recovirus, Sapovirus, Valovirus and Vesivirus) infecting mammals, two genera (Bavovirus and Nacovirus) infecting birds and two genera (Minovirus and Salovirus) infecting fish.
  • Caliciviruses cause species-specific infections, with most noroviruses, sapoviruses and neboviruses restricted to the gastrointestinal tract, while lagoviruses, saloviruses and vesiviruses can cause severe systemic infections in their natural hosts.
  • the family includes non-enveloped viruses with single stranded (+) RNA genomes of around 7-8 kilobases, organized in two, three or four ORFs.
  • Caliciviruses are similar to picornaviruses in the presence of VPg protein attached to the 5′ terminus of their genome and the in sequence of several proteins.
  • Norovirus is a genus of the Caliciviridae family composed by a single species, Norwalk virus. Human norovirus is a major cause of epidemic and sporadic acute gastroenteritis worldwide, and can chronically infect immunocompromised patients. NoV infection generates typical gastroenteritis symptoms, including diarrhea, vomiting, and stomach pain, and may also provoke fever, headache and body aches.
  • Novoviruses are non-enveloped viruses with a single stranded (+) RNA genome of around 7.5 kilobases. The genome is organized into three or four ORFs. The 5′ ORF1 encodes a large polyprotein that is cleaved by viral proteases into 6 nonstructural proteins.
  • ORF2 encodes a single structural capsid protein.
  • ORF3 encodes for a minor structural protein.
  • a subgenomic RNA encodes for two additional structural proteins.
  • ORF4 (which overlaps with ORF2) in murine novovirus encodes for an additional protein, the virulence factor 1.
  • the 5′ ends of NoV genomic and subgenomic RNAs are covalently linked to a small virus-encoded protein known as VPg and the 3′ ends are polyadenlyated.
  • NoVs antigen presenting cells
  • MuNoVs efficiently replicate in primary dendritic cells and macrophages, as well as a number of macrophage-like cell lines, in vitro.
  • the ability of NoVs to infect intestinal immune cells undoubtedly has a significant impact on NoV pathogenesis and the host immune response to NoV infection. Consistent with the short duration of NoV symptoms, innate immunity - and in particular type I IFNs - is critical for controlling acute NoV infections.
  • Coronaviruses are pathogens that can infect animal and human hosts, mostly causing mild to severe enteric or respiratory diseases that can be life threatening in some cases, as with MERS-CoV, SARS-CoV or the new SARS-CoV-2, this latter causing the COVID-19 disease which recently originated in Wuhan, Hubei province, China.
  • SARS-CoV-2 and the closely related SARS-CoV belong to the subgenus Sarbecoviridae, within the genus Betacoronaviridae (to which also MERS-CoV belongs), one of the four genus of Coronaviridae.
  • Coronaviruses are enveloped, single stranded (+) RNA viruses with genomes of around 26-32 kilobases in size, the largest known genome for an RNA virus. They were identified for the first time in 1964, by June Almeida. Their name comes from the similarity their electron microscope images share with the solar corona. Their genome encodes for 14 open reading frames, i.e., the replicase ORFs 1a and 1b (which encode for 15 or 16 mature nonstructural proteins also known as replicase proteins), the four common CoV structural protein genes (S, E, M, and N) and the ORFs encoding so-called accessory proteins.
  • the replicase proteins seem to have multiple functions, being essential for the synthesis or processing of viral RNA, but also to stablish virus-host interactions to facilitate viral entry, gene expression, RNA synthesis or virus release.
  • the CoV N proteins are structural proteins of 350 to 450 amino acids, broadly phosphorylated in serine residues, highly basic, and its main function is to associate with viral RNA to form a long helical ribonucleoprotein. N proteins are also involved in viral RNA transcription, translation, and virus exit.
  • the N protein of SARS-CoV shares a high homology with its SARS-CoV-2.
  • MERS-CoV, SARS-CoV and SARS-CoV-2 can cause acute respiratory distress syndrome (ARDS), the most acute and fatal stage of the disease, characterized by wide-spread inflammation in the lungs resulting from the aberrant immune response to the viral infection.
  • ARDS acute respiratory distress syndrome
  • SARS Severe Acute Respiratory Syndrome
  • SARS-CoV Severe Acute Respiratory Syndrome
  • the genome of SARS-CoV comprises 29.7 kilobases, containing 11 ORFs that encode for 23 proteins.
  • SARS severe severes .
  • atypical form of pneumonia with acute respiratory distress resulting from acute lung damage.
  • Several factors including advanced age, male sex, a high peak lactate dehydrogenase level, a high peak creatine kinase level, and a high initial absolute neutrophil count were significant predictive factors for intense care unit admission and death.
  • An excessive inflammatory response in the lungs explains the development of acute lung injury, moreover when patients still manifest lung injury at a time when the viral load is falling.
  • Acute viral infection might produce damage to host cells by direct cytopathy or by indirect immunopathological damage.
  • cytopathy In the early stage, cytopathy is accompanied by viral amplification, time at which the treatment with antiviral drugs may be especially effective.
  • viral clearance In the later stage, when an adaptive immune response is mounted, viral clearance can be accompanied by severe inflammatory damage.
  • An IFN- ⁇ -related cytokine storm may happen in this latter phase of SARS coronavirus infection, and this cytokine storm might be involved in the immunopathological damage in SARS patients.
  • MERS-CoV Middle East respiratory syndrome
  • MERS myalgia
  • arthralgia The most common symptoms of MERS are fever, cough, chills, sore throat, myalgia, and arthralgia, followed by dyspnoea and rapid progression to pneumonia within the first week, often requiring ventilatory and other organ support. While younger individuals experience mild-moderate clinical illness, elderly individuals or those with comorbid conditions such as diabetes, obesity, heart failure, and renal failure among others experience severe disease after infection with MERS-CoV. In its most severe form, MERS causes an acute highly lethal pneumonia. Individuals with severe MERS show elevated levels of serum pro-inflammatory cytokines (IL-6 and IFN- ⁇ ) and chemokines (IL-8, CXCL-10, and CCL5) compared to those with mild to moderate disease.
  • IL-6 and IFN- ⁇ IL-8, CXCL-10, and CCL5
  • High serum cytokine and chemokine levels in MERS patients correlated with increased neutrophil and monocyte numbers in lungs and in the peripheral blood, being those cells the predominant source of cytokines and chemokines associated with the lethal acute respiratory distress syndrome that kills MERS patients.
  • SARS-CoV-2 genome encodes for 14 open reading frames, including the replicase ORFs 1a and 1b (which encode for 15 or 16 mature nonstructural proteins also known as replicase proteins), the four common CoV structural protein genes (S, E, M, and N) and the ORFs encoding so-called accessory proteins.
  • the replicase proteins seem to have multiple functions, being essential for the synthesis or processing of viral RNA, but also for other steps of the virus life cycle.
  • the N protein is a broadly phosphorylated, highly basic structural protein, whose main function is to associate with viral RNA to form a long helical ribonucleoprotein. N protein is also involved in viral RNA transcription, translation, and virus exit.
  • the N protein of SARS-CoV and SARS-CoV-2 share a high homology.
  • Several cellular proteins collaborate with viral proteins to support viral proliferation, among them eEF1A, which interacts with N protein to support viral replication and spreading.
  • ARDS Acute Respiratory Distress Syndrome
  • SARS-CoV-2 macrophages present CoV antigens to Th17 cells, leading to a massive release of pro-inflammatory cytokines such as IL-1, IL-6, IL-8, IL-21, TNF-b and MCP-1. This is responsible for immune amplification and is partly responsible for the tissue damage in the respiratory alveoli, bronchioles and pulmonary interstitial walls.
  • the increased expression of the inflammatory mediators has a down regulatory effect on NK cells and CD8 cells, which are also important to clear the virus (Kaul. D (2020)).
  • hypercytokinemia has emerged as a main factor driving a more severe clinical outcome.
  • the present invention may be treating SARS-CoV-2 infection.
  • the treatment may be treating COVID-19 infection.
  • the treatment may be the treatment of COVID-19.
  • the treatment may be the treatment of a disease that results from infection by CoV.
  • the treatment may be the treatment of a disease that results from infection by SARS-CoV-2.
  • the treatment may be the treatment of pneumonia caused by infection by CoV.
  • the treatment may be the treatment of pneumonia caused by infection by SARS-CoV-2.
  • the treatment may be the treatment of pneumonia caused by infection by COVID-19.
  • the treatment may be the treatment of pneumonia caused by COVID-19.
  • the treatment may be the treatment of acute respiratory syndrome (ARDS) caused by infection by SARS-CoV-2.
  • ARDS acute respiratory syndrome
  • the infection may be moderate infection.
  • the infection may be severe infection.
  • the infection may be mild infection.
  • the treatment may be reducing complications associated with CoV infection, including hospitalization, ICU and death.
  • the present invention may be useful to treat acute COVID-19 infection (signs and symptoms of COVID-19 for up to 4 weeks); treat (or miniminse) ongoing symptomatic COVID-19 (signs and symptoms of COVID-19 from 4 weeks up to 12 weeks); or treat or minimise post-COVID-19 syndrome (signs and symptoms that develop during or following an infection consistent with COVID-19, continue for more than 12 weeks and are not explained by an alternative diagnosis. It usually presents with clusters of symptoms, often overlapping, which can fluctuate and change over time and can affect any system in the body. Post-COVID-19 syndrome may be considered before 12 weeks while the possibility of an alternative underlying disease is also being assessed).
  • the compounds of the present invention may treat a patient with signs and symptoms of COVID-19 for up to 4 weeks.
  • the compounds of the present invention may treat a patient with signs and symptoms of COVID-19 from 4 weeks to 12 weeks.
  • the compounds of the present invention may treat a patient with signs and symptoms of COVID-19 for more than 12 weeks.
  • the treatment may be prophylaxis, reduction or treatment of COVID persistent (also known as long COVID or post-COVID syndrome).
  • COVID persistent also known as long COVID or post-COVID syndrome.
  • the compounds according to the present invention can minimise the likelihood of a patient suffering from COVID persistent symptoms.
  • the compounds according to the present invention may alternatively reduce the severity of such symptoms, preferably may minimise the symptoms of CoV infection.
  • Post-COVID syndrome may be considered as signs and symptoms that develop during or following an infection consistent with COVID-19 which continue for more than 12 weeks and are not explained by an alternative diagnosis.
  • the condition usually presents with clusters of symptoms, often overlapping, which may change over time and can affect any system within the body.
  • Many people with post-COVID syndrome can also experience generalised pain, fatigue, persisting high temperature and psychiatric problems.
  • Symptoms include (but are not limited to) symptoms arising in the cardiovascular, respiratory, gastrointestinal, neurological, musculoskeletal, metabolic, renal, dermatological, otolaryngological, haematological and autonomic systems, in addition to psychiatric problems, generalised pain, fatigue and persisting fever.
  • the treatment may be reducing the infectivity of CoV patients.
  • the present invention achieves a rapid and significant reduction in the viral burden. Reducing the viral burden may reduce the infectiveness of patients. This is particular beneficial with patients who are asymptomatic or not very symptomatic yet have a high viral loads (e.g. TC ⁇ 25). Such patients may be supercontagators or superspreaders. Administration of compounds according to the present invention upon detection of infection can reduce the viral burden and therefore reduce the infectiveness of the patient.
  • the treatment may result in a reduction of viral load. This may be expressed as a replication cycle threshold (Ct) value greater than 30 (Ct> 30), on day 6 after the administration.
  • the treatment may reduce viral load from baseline. This may be expressed as a reduction in the percentage of patients requiring hospitalisation following administration. This may be expressed as a reduction in the percentage of patients requiring invasive mechanical ventilation and / or admission to the ICU following administration. This may be expressed as a reduction of patients who develop sequelae related to persistent disease. This may be expressed as an increase in the percentage of patients with normalization of analytical parameters chosen as poor prognosis criteria (including, for example, lymphopenia, LDH, D-dimer or PCR).
  • This may be expressed as an increase in the percentage of patients with normalization of clinical criteria (disappearance of symptoms), including, for example: headache, fever, cough, fatigue, dyspnea (shortness of breath), arthromyalgia or diarrhoea.
  • Phleboviruses are negative or ambisense single-stranded, enveloped RNA viruses from the Bunyavirus family with genomes in the range of approximately 11-12 kb. Phleboviruses can be broadly divided into two groups, the sandfly fever virus group (SFV) and the Uukuniemi-like virus (ULV) group. SFVs are transmitted by dipterans, including phlebotomines and mosquitoes, and are endemic in the Mediterranean and other regions. Symptoms of SFV infection include fever, headache, muscle and joint pain, fatigue, and abdominal pain. Patients typically recover within 7-14 days. In some cases, infection of the CNS can lead to encephalitis and meningitis. The ULV group is transmitted by ticks but they are non-pathogenic in humans.
  • RVF Rift Valley fever
  • phlebovirus The best-studied phlebovirus is Rift Valley fever (RVF) virus, which predominantly infects domesticated animals but it can also cause moderate-to-severe infection in humans.
  • RVF Rift Valley fever
  • Human outbreaks of RVF have occurred in sub-Saharan Africa and Arabia via infected animals or mosquitoes. Symptoms are usually mild, flu-like and may include a biphasic fever.
  • a small proportion of patients develop serious complications, such as hemorrhagic fever, encephalitis or retinitis.
  • Neurological disease is a delayed-onset, often fatal, complication, which may occur 5-30 days after the initial illness. During the 2000 Saudi outbreak, there was a 50% mortality rate for patients with CNS complications.
  • the interaction of viral proteins with the host immune response may play a role in pathogenicity and may explain why the clinical presentation of RVF varies between individuals.
  • Chemokines, pro-inflammatory cytokines and anti-inflammatory cytokines were significantly increased (IL-8, CXCL9, MCP-1, IP-10, IL-10) or decreased (RANTES) in fatal cases during the 2010/2011 South African outbreak.
  • IL-8, CXCL9, MCP-1, IP-10, IL-10) or decreased (RANTES) in fatal cases during the 2010/2011 South African outbreak.
  • levels of IL-8, IL-10, IP-10, MCP-2, MCP-3, fractalkine and GRO- ⁇ were increased, with MCP-2 and IP-10 levels correlating with viral load.
  • the elevated levels of pro-inflammatory markers in the three Kenyan patients normalised as patients recovered.
  • genetic polymorphisms in innate immune pathways, including IL-6 may be associated with the varying severity of RVFV symptoms.
  • the host inflammatory response may affect the outcome of RVF
  • Arenaviruses are a family of enveloped, pleomorphic, single-stranded RNA viruses, with an approximate genome size of 11 kb spanning a small and large segment, with each segment encoding for two proteins in an ambisense manner. Transmission to humans occurs by exposure to rodents. Some arenaviruses can cause mild-to-severe illness in humans, including haemorrhagic illness. After a long incubation period of 6-21 days, AV infection usually starts with fever, general weakness and malaise, followed by headache, sore throat, nausea, vomiting, diarrhea, and abdominal pain. In more severe cases, symptoms may include hemorrhaging, shock, seizures, coma and even death.
  • AVs can be divided into two serogroups, ‘Old World’ and ‘New World’.
  • ‘Old World’ viruses include Lassa fever and lymphocytic choriomeningitis virus. Lassa fever is endemic in Western African regions, causing approximately 5,000 deaths per year. Lassa fever causes systemic disease but the majority of infections are asymptomatic. Severe disease caused by viral haemorrhagic fever occurs in 20% of individuals. The overall fatality is about 1%. For patients admitted to hospital, the mortality rate is 15%- 25%. Fatal cases in humans are characterized by necrosis in the liver, spleen and adrenal glands.
  • ‘New World’ viruses include Pichinde virus and the Argentine, Venezuelan and Venezuelan haemorrhagic fevers. Pichinde virus is non-pathogenic in humans. South American hemorrhagic fever has a 6–14-day prodromic phase. After 8 –12 days, approximately 20–30% of patients progress to the neurologic and hemorrhagic phase. Symptoms include confusion, convulsions, coma and bleeding from body orifices. Case fatality rates within endemic regions can be 10–30%.
  • Arenaviruses initially target macrophages and dendritic cells in humans, which produce high levels of interferons and cytokines. Infection of these antigen-presenting cells is likely responsible for spreading the virus, establishing systemic infections and allowing for significant viral product and release. Infection with Lassa virus suppresses the type I interferon response, which is critical for controlling the infection, leading to uncontrolled virus production. In contrast, infection with ‘New World’ arenaviruses is associated with high levels of interferons and cytokines in severe and fatal cases.
  • HSVs Herpesviruses
  • HSVs are large, enveloped, double-stranded DNA viruses with complex genomes. HSV genomes range in size from 125-240 kbp and encode for dozens of viral genes. Transmission of HSVs is via skin or oral contact between infected humans, with the main route being sexual transmission. Symptoms of herpes include painful blisters or ulcers at the site of infection, but most infections are asymptomatic. As such, HSVs are very prevalent in humans and animals, with an estimated 90% of the world’s population is infected with either one or both of herpes simplex virus type-1 (HSV-1) and herpes simplex virus type-2 (HSV-2). HSV-1 is associated with orofacial infections, while HSV-2 can cause genital infections. Infants can also be infected with HSV-2 during childbirth, causing serious disease of the central nervous system or disseminated infection.
  • HSV-1 herpes simplex virus type-1
  • HSV-2 herpes simplex virus type-2
  • HSVs can establish latency in neuronal cells.
  • HSV-1 can establish latency in trigeminal ganglia
  • HSV-2 can establish latency in sacral ganglia.
  • the viral genome may become integrated into host cell DNA or it may remain extra-chromosomal.
  • Latency-associated RNA transcripts are expressed which regulate the host cell genome and suppress host cell death mechanisms, preserving the viral infection of host cells and allowing subsequent recurrences of non-latent periods.
  • the non-latent periods are usually symptomatic and allow the virus to infect a new host.
  • HSV infection can lead to encephalitis.
  • HSV encephalitis begins with flu-like symptoms and progresses into neurological deterioration that can be fatal if left untreated.
  • the systemic inflammatory response to viral HSV infection can lead to organ damage and dysfunction, which may lead to death.
  • Orthomyxoviridae is a family of negative-sense RNA viruses and contains significant pathogens of both humans and animals. There are seven genera in the family, including Influenzavirus A, Influenzavirus B, Influenzavirus C, Thogotovirus, Quaranjavirus, and Isavirus
  • influenza viruses There are four classes of influenza viruses: A, B, C and D, with influenza virus A and B in particular causing winter epidemics of flu, causing around 300 to 650 thousand deaths a year.
  • Influenza A viruses are of particular clinical significance as they have been the cause of a number of flu pandemics where many countries have been affected by large outbreaks.
  • Influenza A viruses are are negative-sense, single-stranded, segmented RNA viruses that are divided into subtypes based on two proteins on the surface of the virus: hemagglutinin (H) and neuraminidase (N).
  • influenza virus There are 18 different hemagglutinin subtypes and 11 different neuraminidase subtypes (H1 through H18 and N1 through N11, respectively), therefore there are many subtypes of influenza virus that may be circulating in the population at any given time, causing the disease known as flu.
  • Flu Flu is characterized by a mild to severe disease which symptoms include high fever, runny nose, sore throat, muscle and joint pain, headache, coughing and tiredness, although vomiting and diarrhea can also occur in children infected with the virus. These symptoms typically appear one to four days after exposure and are generally self-limiting, however in some cases, particularly in those with weaker immune systems, complications such as pneumonia and sepsis can occur.
  • cytokine storm Severe influenza infection has been associated with significant pathological changes in pulmonary tissues associated with heightened levels of inflammatory cytokines and chemokines. This exuberant immune response, known as the cytokine storm, is associated with high levels of pro-inflammatory cytokines and widespread tissue damage. In fact, the term “cytokine storm” was first coined when describing the immune response to influenza-associated encephalopathy.
  • influenza infection of epithelial cells in the respiratory tract leads to a wave of inflammatory cytokine production from these cells, driving various interferon-regulated genes that go on to cause further downstream cytokine production through activation of innate immune cells such as macrophages, neutrophils and dendritic cells which, in severe cases, can proceed to cause tissue damage and chronic inflammation. It is this positive feedback loop of inflammation that can result in complications relating to influenza infection, and can ultimately result in death for patients most severely affected.
  • Alkyl groups may be branched or unbranched, and preferably have from 1 to about 12 carbon atoms. One more preferred class of alkyl groups has from 1 to about 6 carbon atoms. Even more preferred are alkyl groups having 1, 2, 3 or 4 carbon atoms. Methyl, ethyl, n-propyl, isopropyl and butyl, including n-butyl, tert-butyl, sec-butyl and isobutyl are particularly preferred alkyl groups in the compounds of the present invention. As used herein, the term alkyl, unless otherwise stated, refers to both cyclic and noncyclic groups, although cyclic groups will comprise at least three carbon ring members.
  • alkenyl and alkynyl groups in the compounds of the present invention may be branched or unbranched, have one or more unsaturated linkages and from 2 to about 12 carbon atoms.
  • One more preferred class of alkenyl and alkynyl groups has from 2 to about 6 carbon atoms. Even more preferred are alkenyl and alkynyl groups having 2, 3 or 4 carbon atoms.
  • Suitable aryl groups in the compounds of the present invention include single and multiple ring compounds, including multiple ring compounds that contain separate and/or fused aryl groups.
  • Typical aryl groups contain from 1 to 3 separated or fused rings and from 6 to about 18 carbon ring atoms.
  • Preferably aryl groups contain from 6 to about 10 carbon ring atoms.
  • Specially preferred aryl groups include substituted or unsubstituted phenyl, substituted or unsubstituted naphthyl, substituted or unsubstituted biphenyl, substituted or unsubstituted phenanthryl, and substituted or unsubstituted anthryl.
  • Suitable heterocyclic groups include heteroaromatic and heteroalicyclic groups containing from 1 to 3 separated or fused rings and from 5 to about 18 ring atoms.
  • Preferably heteroaromatic and heteroalicyclic groups contain from 5 to about 10 ring atoms, most preferably 5, 6 or 7 ring atoms.
  • Suitable heteroaromatic groups in the compounds of the present invention contain one, two or three heteroatoms selected from N, O or S atoms and include, e.g., coumarinyl including 8-coumarinyl, quinolyl including 8-quinolyl, isoquinolyl, pyridyl, pyrazinyl, pyrazolyl including pyrazol-3-yl, pyrazol-4-yl and pyrazol-5-yl, pyrimidinyl, furanyl including furan-2-yl, furan-3-yl, furan-4-yl and furan-5-yl, pyrrolyl, thienyl, thiazolyl including thiazol-2-yl, thiazol-4-yl and thiazol-5-yl, isothiazolyl, thiadiazolyl including thiadiazol-4-yl and thiadiazol-5-yl, triazolyl, tetrazolyl, isoxazolyl
  • Suitable heteroalicyclic groups in the compounds of the present invention contain one, two or three heteroatoms selected from N, O or S atoms and include, e.g., pyrrolidinyl, tetrahydrofuranyl, dihydrofuranyl, tetrahydrothienyl, tetrahydrothiopyranyl, piperidinyl including piperidin-3-yl, piperidin-4-yl and piperidin-5-yl, morpholinyl, thiomorpholinyl, thioxanyl, piperazinyl, azetidinyl, oxetanyl, thietanyl, homopiperidyl, oxepanyl, thiepanyl, oxazepinyl, diazepinyl, thiazepinyl, 1,2,3,6-tetrahydropyridyl, 2-pyrrolinyl, 3-pyrrolinyl, dihydropyrrolyl,
  • Suitable halogen substituents in the compounds of the present invention include F, Cl, Br and I.
  • salts refers to any salt which, upon administration to the patient is capable of providing (directly or indirectly) a compound as described herein. It will be appreciated that non-pharmaceutically acceptable salts also fall within the scope of the invention since those may be useful in the preparation of pharmaceutically acceptable salts.
  • the preparation of salts can be carried out by methods known in the art. For instance, pharmaceutically acceptable salts of compounds provided herein are synthesized from the parent compound, which contains a basic or acidic moiety, by conventional chemical methods. Generally, such salts are, for example, prepared by reacting the free acid or base forms of these compounds with a stoichiometric amount of the appropriate base or acid in water or in an organic solvent or in a mixture of the two.
  • nonaqueous media like ether, ethyl acetate, ethanol, isopropanol or acetonitrile are preferred.
  • acid addition salts include mineral acid addition salts such as, for example, hydrochloride, hydrobromide, hydroiodide, sulphate, nitrate, phosphate, and organic acid addition salts such as, for example, acetate, trifluoroacetate, maleate, fumarate, citrate, oxalate, succinate, tartrate, malate, mandelate, methanesulfonate and p-toluenesulfonate.
  • alkali addition salts include inorganic salts such as, for example, sodium, potassium, calcium and ammonium salts, and organic alkali salts such as, for example, ethylenediamine, ethanolamine, N,N-dialkylenethanolamine, triethanolamine and basic amino acids salts.
  • the compounds of the invention may be in crystalline form either as free compounds or as solvates (e.g. hydrates, alcoholates, particularly methanolates) and it is intended that both forms are within the scope of the present invention. Methods of solvation are generally known within the art.
  • the compounds of the invention may present different polymorphic forms, and it is intended that the invention encompasses all such forms
  • any compound referred to herein is intended to represent such specific compound as well as certain variations or forms.
  • compounds referred to herein may have asymmetric centres and therefore exist in different enantiomeric or diastereomeric forms.
  • any given compound referred to herein is intended to represent any one of a racemate, one or more enantiomeric forms, one or more diastereomeric forms, and mixtures thereof.
  • stereoisomerism or geometric isomerism about the double bond is also possible, therefore in some cases the molecule could exist as (E)-isomer or (Z)-isomer (trans and cis isomers).
  • each double bond will have its own stereoisomerism, that could be the same or different than the stereoisomerism of the other double bonds of the molecule.
  • compounds referred to herein may exist as atropisomers. All the stereoisomers including enantiomers, diastereoisomers, geometric isomers and atropisomers of the compounds referred to herein, and mixtures thereof, are considered within the scope of the present invention.
  • R 1 , R 5 , R 9 , R 11 , and R 15 are independently selected from hydrogen and substituted or unsubstituted C 1 -C 6 alkyl. More preferred R 1 , R 5 , R 9 , R 11 , and R 15 are independently selected from hydrogen, substituted or unsubstituted methyl, substituted or unsubstituted ethyl, substituted or unsubstituted n-propyl, substituted or unsubstituted isopropyl and substituted or unsubstituted butyl, including substituted or unsubstituted n-butyl, substituted or unsubstituted tert-butyl, substituted or unsubstituted isobutyl, and substituted or unsubstituted sec-butyl.
  • R 1 is selected from sec-butyl and isopropyl, being sec-butyl the most preferred.
  • Particularly preferred R 5 is selected from isobutyl and 4-aminobutyl, being isobutyl the most preferred.
  • Particularly preferred R 11 is methyl and isobutyl.
  • Particularly preferred R 9 is selected from p-methoxybenzyl, p-hydroxybenzyl, and cyclohexylmethyl, being p-methoxybenzyl the most preferred.
  • Particularly preferred R 15 is selected from methyl, n-propyl, and benzyl, being methyl and benzyl the most preferred.
  • R 1 , R 5 , R 9 , and R 15 are independently selected from hydrogen and substituted or unsubstituted C 1 -C 6 alkyl. More preferred R 1 , R 5 , R 9 , and R 15 are independently selected from hydrogen, substituted or unsubstituted methyl, substituted or unsubstituted ethyl, substituted or unsubstituted n-propyl, substituted or unsubstituted isopropyl and substituted or unsubstituted butyl, including substituted or unsubstituted n-butyl, substituted or unsubstituted tert-butyl, substituted or unsubstituted isobutyl, and substituted or unsubstituted sec-butyl.
  • substituents may be chosen from the foregoing list.
  • Hydrogen, methyl, n-propyl, isopropyl, isobutyl, sec-butyl, 4-aminobutyl, 3-amino-3-oxopropyl, benzyl, p-methoxybenzyl, p-hydroxybenzyl, and cyclohexylmethyl are the most preferred R 1 , R 5 , R 9 , and R 15 groups.
  • particularly preferred R 1 is selected from sec-butyl and isopropyl, being sec-butyl the most preferred.
  • Particularly preferred R 5 is selected from isobutyl and 4-aminobutyl, being isobutyl the most preferred.
  • Particularly preferred R 9 is selected from p-methoxybenzyl, p-hydroxybenzyl, and cyclohexylmethyl, being p-methoxybenzyl the most preferred.
  • Particularly preferred R 15 is selected from methyl, n-propyl, and benzyl, being methyl and benzyl the most preferred.
  • R 8 , R 10 , R 12 , and R 16 are independently selected from hydrogen and substituted or unsubstituted C 1 -C 6 alkyl. More preferred R 8 , R 10 , R 12 , and R 16 are independently selected from hydrogen, methyl, ethyl, n-propyl, isopropyl and butyl, including n-butyl, tert-butyl, isobutyl and sec-butyl, and even more preferred they are independently selected from hydrogen and methyl. Specifically, particularly preferred R 8 , R 10 and R 12 are methyl, and particularly preferred R 16 is hydrogen.
  • R 3 and R 4 are independently selected from hydrogen and substituted or unsubstituted C 1 -C 6 alkyl. More preferred R 3 and R 4 are independently selected from hydrogen, substituted or unsubstituted methyl, substituted or unsubstituted ethyl, substituted or unsubstituted n-propyl, substituted or unsubstituted isopropyl, and substituted or unsubstituted butyl, including substituted or unsubstituted n-butyl, substituted or unsubstituted tert-butyl, substituted or unsubstituted isobutyl and substituted or unsubstituted sec-butyl.
  • substituents may be chosen from the foregoing list.
  • Hydrogen, methyl, isopropyl, and sec-butyl are the most preferred R 3 and R 4 groups.
  • particularly preferred R 3 is selected from methyl and isopropyl and particularly preferred R 4 is methyl or hydrogen.
  • R 6 and R 7 are independently selected from hydrogen and substituted or unsubstituted C 1 -C 6 alkyl. More preferred R 7 is selected from hydrogen, substituted or unsubstituted methyl, substituted or unsubstituted ethyl, substituted or unsubstituted n-propyl, substituted or unsubstituted isopropyl and substituted or unsubstituted butyl, including substituted or unsubstituted n-butyl, substituted or unsubstituted tert-butyl, substituted or unsubstituted isobutyl, and substituted or unsubstituted sec-butyl.
  • R 6 is selected from hydrogen, methyl, ethyl, n-propyl, isopropyl and butyl, including n-butyl, tert-butyl, isobutyl and sec-butyl. Most preferred R 6 is selected from hydrogen and methyl and most preferred R 7 is methyl.
  • R 6 and R 7 together with the corresponding N atom and C atom to which they are attached form a substituted or unsubstituted heterocyclic group.
  • preferred heterocyclic group is a heteroalicyclic group containing one, two or three heteroatoms selected from N, O or S atoms, most preferably one N atom, and having from 5 to about 10 ring atoms, most preferably 5, 6 or 7 ring atoms.
  • a pyrrolidine group is the most preferred.
  • R 13 and R 14 are independently selected from hydrogen and substituted or unsubstituted C 1 -C 6 alkyl. More preferred R 13 is selected from hydrogen, substituted or unsubstituted methyl, substituted or unsubstituted ethyl, substituted or unsubstituted n-propyl, substituted or unsubstituted isopropyl and substituted or unsubstituted butyl, including substituted or unsubstituted n-butyl, substituted or unsubstituted tert-butyl, substituted or unsubstituted isobutyl, and substituted or unsubstituted sec-butyl.
  • R 14 is selected from hydrogen, methyl, ethyl, n-propyl, isopropyl and butyl, including n-butyl, tert-butyl, isobutyl and sec-butyl.
  • Most preferred R 13 is selected from hydrogen, methyl, isopropyl, isobutyl, and 3-amino-3-oxopropyl and most preferred R 14 is hydrogen.
  • R 13 and R 14 together with the corresponding N atom and C atom to which they are attached form a substituted or unsubstituted heterocyclic group.
  • preferred heterocyclic group is a heteroalicyclic group containing one, two or three heteroatoms selected from N, O or S atoms, most preferably one N atom, and having from 5 to about 10 ring atoms, most preferably 5, 6 or 7 ring atoms.
  • a pyrrolidine group is the most preferred.
  • R 2 is selected from hydrogen, substituted or unsubstituted C 1 -C 6 alkyl, and COR a , wherein R a is a substituted or unsubstituted C 1 -C 6 alkyl, and even more preferred R a is methyl, ethyl, n-propyl, isopropyl and butyl, including n-butyl, tert-butyl, sec-butyl and isobutyl. More preferably R 2 is hydrogen.
  • substituents may be chosen from the foregoing list.
  • Hydrogen, COR a , COOR a , and SO 2 R c are the most preferred R 17 groups, and hydrogen, COObenzyl, CObenzo[b]thiophen-2-yl, SO 2 (p-methylphenyl), COCOCH 3 and COOC(CH 3 ) 3 are even most preferred.
  • Y is CO. In another embodiment, it is particularly preferred that Y is –COCH(CH 3 )CO-.
  • X is O. In another embodiment, it is particularly preferred that X is NH.
  • n, p and q are 0. In another embodiment, it is particularly preferred that n is 1 and p and q are 0. In another embodiment, it is particularly preferred that n and p are 1 and q is 0. In another embodiment, it is particularly preferred that n, p, and q are 1. In another embodiment, it is particularly preferred that n and p are 1 and q is 2.
  • p and q are 0. In another embodiment, it is particularly preferred that p is 1 and q is 0. In another embodiment, it is particularly preferred that p and q are 1. In another embodiment, it is particularly preferred that p is 1 and q is 2.
  • R a , R b , and R c present in the compounds of the invention, and unless it is stated explicitly so, it should be understood that they can be each independently different within the given definition, i.e. R a does not represent necessarily the same group simultaneously in a given compound of the invention.
  • X, Y, n, p, q, and R 1 -R 17 are as defined above, and when Y is —COCH(CH 3 )CO— it has the following stereochemistry:
  • Particularly preferred compounds of the invention are the following:
  • the compounds of general formula I, II and III may be prepared following any of the synthetic processes disclosed in Vera et al. Med. Res. Rev. 2002, 22(2), 102-145, WO 2011/020913 (see in particular Examples 1-5), WO 02/02596, WO 01/76616, and WO 2004/084812, which are incorporated herein by reference.
  • the preferred compound is PLD or pharmaceutically acceptable salts or stereoisomers thereof. Most preferred is PLD.
  • plitidepsin is (-)-(3S,6R,7S,10R,11S,15S,17S,20S,25aS)-11-hydroxy-3-(4-methoxybenzyl)-2,6,17-trimethyl-15-(1-methylethyl)-7-[[(2R)-4-methyl-2-[methyl[[(2S)-1-(2-oxopropanoyl)pyrrolidin-2-yl]carbonyl] amino]pentanoyl]amino]-10- [(1S)-1-methylpropyl]-20-(2-methylpropyl)tetradecahydro-15H-pyrrolo[2,1-f]-[1,15,4,7,10,20]dioxatetrazacyclotricosine-1,4,8,13,16,18,21(17H)-heptone corresponding to the molecular formula C 57 H 87 N 7 O 15 . It has a relative molecular mass of 1110.
  • Plitidepsin is a cyclic depsipeptide originally isolated from a Mediterranean marine tunicate (Aplidium albicans) and currently manufactured by full chemical synthesis. It is licensed and marketed in Australia under the brand name plitidepsin for the treatment of multiple myeloma.
  • plitidepsin In eukaryotic cells, plitidepsin has been shown to target the eukaryotic elongation factor (eEF1A), which has a key role in modulating interaction with other proteins, some of which are believed to be essential in viral replication. It is noteworthy that one of the aforementioned proteins is the coronavirus N protein, which is produced abundantly within infected cells and is known to interact with elongation factor EF1A. As said above, the interaction between plitidepsin and EF1A could therefore reduce the efficacy of de novo viral capsid synthesis and consequently lead to a decrease in viral load.
  • eEF1A eukaryotic elongation factor
  • the present invention provides the use of a compound of the present invention in the treatment of inflammation.
  • the invention provides the use of a compound of the present invention in the treatment of inflammation, and in particular inflammation associated with either the activation of Toll-like receptors and/or inflammation as a result of pathogen infection.
  • a compound of the present invention for use in the treatment of inflammation.
  • a compound of the present invention in another aspect of the invention, in the use of a compound of the present invention, in the manufacture of a medicament for the treatment of inflammation.
  • a method for the treatment of inflammation comprising administering to an individual in need thereof a therapeutically effective amount of a compound of the present invention.
  • the inflammation is characterised by excessive or increased production or secretion of pro-inflammatory cytokines, and preferably at least one of IL-12, IL-10, IL-1, IL-6, IL-8, CCL-2 and TNF- ⁇ and more preferably at least one of IL-1, IL-6, IL-8 and TNF- ⁇ .
  • the inflammation is hyperinflammation. Hyperinflammation is characterised by excessive cytokine production or secretion (also known as a cytokine storm).
  • hyperinflammation is defined by high levels (higher than normal levels) of at least one of the following cytokines: interleukin (IL)-1, IL-2, IL-6, GM-CSF, IFN- ⁇ , and TNF, as well as the chemokines, C-C motif chemokine ligand (CCL)-2, CCL-3, and CCL-5.
  • IL interleukin
  • IL-6 interleukin-1
  • IL-6 interleukin-6
  • GM-CSF GM-CSF
  • IFN- ⁇ interleukin
  • TNF TNF
  • the inflammation is chronic inflammation.
  • the virus is SARS-CoV-2 and the associated COVID-19 disease.
  • Mortality associated with COVID-19 disease appears to be associated with a) severe respiratory failure secondary to respiratory distress and b) an inflammatory status caused by a cytokine storm.
  • the proportion of patients with severe disease requiring hospitalisation with or without high-flow oxygen supplements and patients requiring mechanical ventilatory support was estimated to be close to 15% and 5%, respectively, in the initial series from China.
  • the figures reported by the health authorities are higher, reaching 30% of serious cases requiring hospitalisation (in the city of Madrid) without the need for mechanical ventilation and close to 10% of patients requiring mechanical ventilation.
  • the duration of the need for mechanical ventilation in the Chinese series is much shorter than that reported in cities such as Madrid, so the usual flow of patients to intensive care units is being altered by the prolonged stay of patients. This is putting an enormous burden on hospital services, which has made it necessary to take extraordinary, unprecedented measures. It is believed that the magnitude of the complications initially described can be avoided or reduced through the use of the present invention in patients with early-stage COVID-19 pneumonia, since once the cytokine storm and respiratory distress take place, it is typically harder for an antiviral drug to have a beneficial therapeutic effect. However, in embodiments, the compounds of the present invention are also useful at a later stage of the viral infection, for example in patients where cytokine storm and respiratory distress have taken place.
  • Plitidepsin demonstrated potent antiviral effects in vivo, using a previously described mouse model of adenovirus-mediated hACE2 infected with SARS-CoV-2. Plitidepsin also demonstrated potent antiviral effects in vivo using a previously described model of transgenic mice expressing hACE2 driven by the cytokeratin-18 gene promoter (K18-hACE2) infected with SARS-CoV-2.
  • Innate immunity is the first line of defence against invading pathogens.
  • SARS-CoV-2 the entry of the virus into host epithelial cells is mediated by the interaction between the viral envelope spike (S) protein and the cell surface receptor ACE2.
  • Viral RNAs as pathogen associated molecular patterns, are then detected by the host pattern recognition receptors, which include the family of toll like receptors.
  • Toll like receptors then upregulate antiviral and proinflammatory mediators, such as interleukin (IL) 6, IL 8, and interferon (IFN)-y, through activation of the transcription factor nuclear factor kappa B (NF- ⁇ B).
  • IL interleukin
  • IFN interferon
  • NF- ⁇ B in pro-inflammatory gene expression, particularly in the lungs, has been highlighted by studies exploring SARS CoV infection in nonclinical species as well as in patients. In mice infected with SARS CoV, the pharmacologic inhibition of NF- ⁇ B resulted in higher survival rates and reduced expression of tumour necrosis factor alpha (TNF ⁇ ), CCL2, and CXCL2 in lungs.
  • TNF ⁇ tumour necrosis factor alpha
  • plitidepsin induces down-regulation of NF ⁇ B in tumour cells. Subsequently, both in vitro and ex vivo studies were also performed to assess the effects of plitidepsin on immune cells.
  • THP-1 cells a spontaneously immortalised monocyte-like cell line derived from the peripheral blood of a childhood case of acute monocytic leukaemia, that is widely used for investigating monocyte structure and function.
  • FIGS. 1 and 2 all the pathogen-associated molecular patterns-mimicking compounds induced the production of proinflammatory cytokines in THP-1 cells and the addition of plitidepsin significantly reduced the secretion of the proinflammatory cytokines.
  • a compound as defined herein for use in the treatment of inflammation associated with (or caused by) activation of Toll-like receptors.
  • a compound as defined herein in the manufacture of a medicament for the treatment of inflammation associated with activation of Toll-like receptors.
  • a method for the treatment of inflammation associated with activation of Toll-like receptors comprising administering to an individual in need thereof a therapeutically effective amount of a compound as defined herein.
  • inflammation associated with activation of Toll-like receptors inflammation that arises from agonism (i.e. stimulation) of one or more Toll-like receptor (TLR) and activation of the toll-like receptor signalling cascade or increased signalling through at least one TLR (that may be caused by increased expression of at least one TLR).
  • TLR Toll-like receptor
  • Methods for measuring activation of TLR signalling in response to a known or possible TLR agonist would be well-known to the skilled person, but in one example, levels of NF- ⁇ B transactivation may be used as an indicator of TLR activation. As described herein NF- ⁇ B transactivation may be measured using luciferase-tagged NF- ⁇ B transactivation as described in the Examples.
  • TLR activation can be determined by measuring any one of IRAK1 (IL-receptor-associated kinase), IRAK4 phosphorylation and TAK1 activation (transforming growth factor- ⁇ -activated kinase-1). Other indicators of TLR activation would be known in the art (see for example, Kawai & Akira, 2007, which describes the TLR pathway).
  • the TLR is TLR-3, TLR4, TLR7 or TLR8.
  • Toll-like receptors or TLRs can be activated by microbial pathogens.
  • the microbial pathogen may be a bacteria, a virus, a parasite, fungus or other microorganism.
  • the Toll-like receptor is activated by a virus.
  • the virus is an RNA virus.
  • the virus is a single stranded (+) RNA virus.
  • the virus is selected from the family: Flaviviridae, Picornaviridae, Togaviridae, Caliciviridae, Retroviridae and Coronaviridae.
  • the virus is a respiratory virus.
  • the virus is a Flaviviridae virus
  • the virus is selected from Hepatitis C, Yellow fever virus (YFV), West Nile Virus (WNV), Dengue virus (DENV), Japanese encephalitis virus (JEV), Tick-borne encephalitis virus (TBEV), classical swine fever virus and Zika virus (ZIKV).
  • the virus is a Picornaviridae virus
  • the virus is selected from foot and mouth disease virus, enterovirus A71, Coxsackieviruses, Rhinovirus and Hepatitis A.
  • the virus is selected from Alphaviridae, and in particular, Chikungunya Virus, Sindbis Virus, Semliki Forest Virus, Eastern Equine Encephalitis Virus / Western Equine Encephalitis Virus / Venezuelan Equine Encephalitis Virus and Rubella virus.
  • the virus is selected from Lagovirus, Norovirus, Nebovirus, Recovirus, Sapovirus, Valovirus and Vesivirus, and in particular, Norwalk virus.
  • the viral infection is a CoV infection.
  • CoV infection means any infection from a virus in the family Coronaviridae and the sub-family Orthocoronavirinae.
  • the infection is from a virus in the genus Betacoronavirus, which includes Betacoronavirus 1, Human coronavirus HKU1, Murine coronavirus, Pipistrellus bat coronavirus HKU5, Rousettus bat coronavirus HKU9, Severe acute respiratory syndrome-related coronavirus (SARS-CoV), Tylonycteris bat coronavirus HKU4, Middle East respiratory syndrome-related coronavirus, Human coronavirus OC43 and Hedgehog coronavirus 1 (EriCoV).
  • the virus is selected from the ⁇ -type HCoV-229E, HCoV-NL63; the ⁇ -type HCoV-HKU1, SARS-CoV, MERS-CoV, and HCoV-OC43; and SARS-CoV-2.
  • SARS-CoV-2 was previously called 2019-nCoV and such terms may be used interchangeably herein.
  • the virus is Retroviridae
  • HIV Human Immunodeficiency Virus
  • the virus is a negative sense single-stranded RNA virus.
  • the virus is selected from the family Orthomyxoviridae, Phlebovirus and Arenaviridae.
  • the Orthomyxoviridae virus is selected from Influenzavirus A, Influenzavirus B, Influenzavirus C, Thogotovirus, Quaranjavirus, and Isavirus.
  • the Orthomyxoviridae virus is Influenza A, preferably selected from H1N1, H1N2 and H3N2.
  • the Orthomyxoviridae virus is influenza B, preferably selected from the Yamagata or Victoria lineages.
  • the virus is from the family Phlebovirus
  • the virus is Sandfly fever virus or Rift valley fever virus.
  • the virus is Pichinde virus.
  • the virus is a dsDNA virus.
  • the virus is selected from the family Herpesviridae, preferably, Herpes simplex virus 1 or 2.
  • the virus is a respiratory virus.
  • Respiratory viruses include rhinoviruses and enteroviruses (Picornaviridae), orthomyxoviridae, (influenza) parainfluenza, metapneumoviruses and respiratory syncytial viruses (Paramyxoviridae), coronaviruses (Coronaviridae), and several adenoviruses. With the exception of adenoviruses, all possess an RNA genome.
  • the compound of the invention may be further administered in combination with an anti-viral agent.
  • the anti-viral agent may be administered concurrently, sequentially or separately to administration of a compound of the invention.
  • the compound of the invention may be used as an anti-inflammatory to treat inflammation or hyperinflammation associated or as a consequence of the viral infection.
  • a compound as defined herein for use in the treatment of a disorder selected from pneumonia and immunopathology, in particular hypercytokinemia (cytokine storm syndrome), sepsis and, graft-versus-host disease
  • a compound as defined herein for use in the treatment of a disorder selected from pneumonia and immunopathology, in particular hypercytokinemia (cytokine storm syndrome), sepsis and, graft-versus-host disease
  • a compound as defined herein in the manufacture of a medicament for the treatment of a disorder selected from pneumonia and immunopathology, in particular hypercytokinemia (cytokine storm syndrome), sepsis and graft-versus-host disease.
  • a method for the treatment of a disorder selected from pneumonia and immunopathology, in particular hypercytokinemia (cytokine storm syndrome) sepsis and, graft-versus-host disease comprising administering to an individual in need thereof a therapeutically effective amount of a compound as defined herein.
  • the disorder is immunopathology and in particular, hypercytokinemia.
  • a compound as defined herein for use in the treatment of pathogen-induced inflammation.
  • a compound as defined herein for use in the treatment of pathogen-induced inflammation.
  • a method for the treatment of pathogen-induced inflammation comprising administering to an individual in need thereof a therapeutically effective amount of a compound as defined herein.
  • a compound as defined herein for use in the combined treatment of a viral infection and inflammation associated with activation of Toll-like receptors or inflammation associated with pathogen-infection.
  • a compound as defined herein in the manufacture of a medicament for the combined treatment of a viral infection and inflammation associated with activation of Toll-like receptors or inflammation associated with pathogen-infection.
  • a method for the combined treatment of a viral infection and inflammation associated with activation of Toll-like receptors or inflammation associated with pathogen-infection comprising administering to an individual in need thereof a therapeutically effective amount of a as defined herein.
  • the inflammation may be hypercytokinemia.
  • pathogen-induced inflammation is meant any inflammation or immunopathology caused by infection of a pathogen. Accordingly, in one aspect of the invention there is provided compounds and methods as described herein for the treatment of immunopathology.
  • the pathogen may be a microbial pathogen. More preferably, the microbial pathogen may be a bacteria, a virus, a parasite, fungus or other microorganism.
  • the pathogen causes activation of the TLRs. In an alternative embodiment, the pathogen does not cause activation of the TLRs. In a further embodiment, the pathogen causes macrophage activation.
  • the inflammation may be chronic inflammation.
  • the pathogen is a virus.
  • the Toll-like receptor is activated by a virus.
  • the virus is a positive sense single stranded (+) RNA virus.
  • the virus is selected from the family: Flaviviridae, Picornaviridae, Togaviridae, Caliciviridae, Retroviridae and Coronaviridae.
  • the virus is selected from Hepatitis C, Yellow fever virus (YFV), West Nile Virus (WNV), Dengue virus (DENV), Japanese encephalitis virus (JEV), Tick-borne encephalitis virus (TBEV), classical swine fever virus and Zika virus (ZIKV).
  • the virus is selected from foot and mouth disease virus, enterovirus A71, Coxsackieviruses, Rhinovirus and Hepatitis A.
  • the virus is selected from Alphaviridae, and in particular, Chikungunya Virus, Sindbis Virus, Semliki Forest Virus, Eastern Equine Encephalitis Virus / Western Equine Encephalitis Virus / Venezuelan Equine Encephalitis Virus and Rubella virus.
  • the virus is a Caliciviridae virus
  • the virus is selected from Lagovirus, Norovirus, Nebovirus, Recovirus, Sapovirus, Valovirus and Vesivirus, and in particular, Norwalk virus.
  • the viral infection is a CoV infection.
  • CoV infection means any infection from a virus in the family Coronaviridae and the sub-family Orthocoronavirinae .
  • the infection is from a virus in the genus Betacoronavirus , which includes Betacoronavirus 1, Human coronavirus HKU1, Murine coronavirus, Pipistrellus bat coronavirus HKU5, Rousettus bat coronavirus HKU9, Severe acute respiratory syndrome-related coronavirus (SARS-CoV), Tylonycteris bat coronavirus HKU4, Middle East respiratory syndrome-related coronavirus, Human coronavirus OC43 and Hedgehog coronavirus 1 (EriCoV).
  • the virus is selected from the ⁇ -type HCoV-229E, HCoV-NL63; the ⁇ -type HCoV-HKU1, SARS-CoV, MERS-CoV, and HCoV-OC43; and SARS-CoV-2.
  • SARS-CoV-2 was previously called 2019-nCoV and such terms may be used interchangeably herein.
  • the virus is Retroviridae
  • HIV Human Immunodeficiency Virus
  • the virus is a negative sense single-stranded RNA virus.
  • the virus is selected from the family Orthomyxoviridae, Phlebovirus and Arenaviridae.
  • the Orthomyxoviridae virus is selected from Influenzavirus A, Influenzavirus B, Influenzavirus C, Thogotovirus, Quaranjavirus, and Isavirus.
  • the Orthomyxoviridae virus is Influenza A, preferably selected from H1N1, H1N2 and H3N2.
  • the Orthomyxoviridae virus is influenza B, preferably selected from the Yamagata or Victoria lineages.
  • the virus is from the family Phlebovirus
  • the virus is Sandfly fever virus or Rift valley fever virus.
  • the virus is Pichinde virus.
  • the virus is a dsDNA virus.
  • the virus is selected from the family Herpesviridae, preferably, Herpes simplex virus 1 or 2.
  • the virus is a respiratory virus.
  • Respiratory viruses include rhinoviruses and enteroviruses (Picornaviridae), parainfluenza, metapneumoviruses and respiratory syncytial viruses (Paramyxoviridae), coronaviruses (Coronaviridae), and several adenoviruses. With the exception of adenoviruses, all possess an RNA genome.
  • a compound as defined herein for use in the combined treatment of a SARS-CoV-2 infection and hypercytokinemia The host inflammatory response to infection may also cause pneumonia or ARDS. Accordingly, in a further embodiment, there is provided a compound as defined herein for use in the combined treatment of a SARS-CoV-2 infection and (associated) pneumonia (also referred to as COVID-19 pneumonia) or associated ARDS. In another aspect of the invention, there is provided the use of a compound of as defined herein in the manufacture of a medicament for the combined treatment of a SARS-CoV-2 infection and hypercytokinemia.
  • a compound as defined herein in the manufacture of a medicament for the combined treatment of a SARS-CoV-2 infection and COVID-19 pneumonia.
  • a compound of as defined herein in the manufacture of a medicament for the combined treatment of a SARS-CoV-2 infection and ARDS.
  • a method for the combined treatment of a SARS-CoV-2 infection and hypercytokinemia comprising administering to an individual in need thereof a therapeutically effective amount of a compound as defined herein.
  • a method for the combined treatment of a SARS-CoV-2 infection and COVID-19 pneumonia comprising administering to an individual in need thereof a therapeutically effective amount of a compound as defined herein.
  • a method for the combined treatment of a SARS-CoV-2 infection and ARDS comprising administering to an individual in need thereof a therapeutically effective amount of a compound as defined herein.
  • the viral infection is a HIV (human immunodeficiency virus) infection.
  • HIV human immunodeficiency virus
  • a compound as defined herein use in the combined treatment of a HIV infection and hypercytokinemia.
  • the use of a compound as defined herein in the manufacture of a medicament for the combined treatment of a HIV infection and hypercytokinemia is provided.
  • a method for the combined treatment of a HIV infection and hypercytokinemia comprising administering to an individual in need thereof a therapeutically effective amount of a compound as defined herein.
  • compositions having biological/pharmacological activity may be used in pharmaceutical compositions having biological/pharmacological activity for the treatment of the above mentioned conditions.
  • These pharmaceutical compositions comprise a compound of the invention together with a pharmaceutically acceptable carrier.
  • carrier refers to a diluent, adjuvant, excipient or vehicle with which the active ingredient is administered. Suitable pharmaceutical carriers are described in “Remington’s Pharmaceutical Sciences” by E. W. Martin, 1995.
  • Examples of pharmaceutical compositions include any solid (tablets, pills, capsules, granules, etc.) or liquid (solutions, suspensions, emulsions, etc.) compositions for oral, topical or parenteral administration.
  • Pharmaceutical compositions containing compounds of the invention may be delivered by liposome or nanosphere encapsulation, in sustained release formulations or by other standard delivery means.
  • compositions as described in WO9942125 are in the form of powder for solution for infusion.
  • compositions as described in WO9942125 for example, a lyophilised preparation of a compound of the invention including water-soluble material and secondly a reconstitution solution of mixed solvents.
  • a particular example is a lyophilised preparation of PLD and mannitol and a reconstitution solution of mixed solvents, for example PEG-35 castor oil, ethanol and water for injections.
  • Each vial for example may contain 2 mg of PLD.
  • each mL of reconstituted solution may contain: 0.5 mg of PLD, 158 mg of PEG-35 castor oil, and ethanol 0.15 mL/mL.
  • the specific dosage and treatment regimen for any particular patient may be varied and will depend upon a variety of factors, including the activity of the specific compound employed, the particular formulation being used, the mode of application, the age, body weight, general health, sex, diet, time of administration, rate of excretion, drug combination, reaction sensitivities, and the severity of the particular disease or condition being treated.
  • the compounds of the present invention may be administered according to a dosing regimen of a daily dose.
  • the compounds of the present invention may be administered according to a dosing regimen of a once daily dose.
  • the compounds of the present invention may be administered according to a dosing regimen of a daily dose for 10 days, 9 days, 8 days, 7 days, 6 days, 5 days, 4 days, 3 days, 2 days or 1 day.
  • Preferred regimen is 2-5 days, or 3-5 days, or 3, 4 or 5 days, most preferably 3 days or 5 days.
  • the dose may be a dose of 5 mg a day or less, 4.5 mg a day or less, 4 mg a day or less, 3.5 mg a day or less, 3 mg a day or less, 2.5 mg a day or less or 2 mg a day or less.
  • Particular doses include 0.5 mg/day, 1 mg/day, 1.5 mg/day, 2 mg/day, 2.5 mg/day, 3 mg/day, 3.5 mg/day, 4 mg/day, 4.5 mg/day, or 5 mg/day.
  • Preferred doses are 1 mg/day, 1.5 mg/day, 2 mg/day and 2.5 mg/day.
  • the compounds of the present invention may be administered according to a total dose of 1-50 mg, 1-40 mg, 1-30 mg, 1-20 mg, 1-15 mg, 3-15 mg, 3-12 mg, 4-12 mg, 4-10 mg, or 4.5-10 mg.
  • Total doses may be 4 mg, 4.5 mg, 5 mg, 5.5 mg, 6 mg, 6.5 mg, 7 mg, 7.5 mg, 8 mg, 8.5 mg, 9 mg, 9.5 mg or 10 mg.
  • Preferred total doses are 4.5 mg, 5 mg, 6 mg, 7.5 mg, 8 mg, 9 mg or 10 mg.
  • the total dose may be split over 1, 2, 3, 4, 5, 6, 7, 8, 9 or 10 days, preferably 3 days or 5 days.
  • the compounds of the present invention may be administered according to a dosing regimen of a once daily dose for 5 days, at a dose of 2.5 mg a day or less.
  • the compounds of the present invention may be administered according to a dosing regimen of a once daily dose for 5 days, at a dose of 2 mg a day or less.
  • the compounds of the present invention may be administered according to a dosing regimen of a once daily dose for 3 days, at a dose of 1.5 mg a day or less.
  • the compounds of the present invention may be administered according to a dosing regimen of a once daily dose for 3 days, at a dose of 2 mg a day or less.
  • the compounds of the present invention may be administered according to a dosing regimen of a once daily dose for 3 days, at a dose of 2.5 mg a day or less.
  • the compounds of the present invention may be administered according to a dosing regimen of a once daily dose for 3 days, at a dose of 1.5 mg a day.
  • the compounds of the present invention may be administered according to a dosing regimen of a once daily dose for 3 days, at a dose of 2.0 mg a day.
  • the compounds of the present invention may be administered according to a dosing regimen of a once daily dose for 3 days, at a dose of 2.5 mg a day.
  • the compounds of the present invention may be administered according to a dosing regimen of a once daily dose for 3 days, at a dose of 1.5 to 2.5 mg a day.
  • An alternative regimen is a single dose on day 1.
  • the single dose may be 1-10 mg, 4-10 mg, 4.5-10 mg; 4 mg, 4.5 mg, 5 mg, 5.5 mg, 6 mg, 6.5 mg, 7 mg, 7.5 mg, 8 mg, 8.5 mg, 9 mg, 9.5 mg or 10 mg; preferably 4.5 mg, 5 mg, 6 mg, 7.5 mg, 8 mg, 9 mg or 10 mg; more preferably 5-9 mg, 6.5-8.5 mg, 7-8 mg or 7.5 mg.
  • the compounds of the present invention may be administered according to the present invention, wherein the compounds of the present invention are administered with a corticosteroid.
  • the corticosteroid is dexamethasone.
  • the corticosteroid may be administered daily with the compounds of the present invention. Administration may be sequential, concurrent or consecutive.
  • the corticosteroid may be further administered on the days following administration of compounds according to the present invention. By way of example, with a 3 day dosing regimen, the corticosteroid may be administered on days 1-3 and then further administered daily for 3, 4, 5, 6, 7, 8, 9 or 10 or more further days.
  • the corticosteroid may be administered is administered on days 1-3 as an intravenous administration and then on days 6-10 as an oral administration.
  • the dosage of corticosteroid may be higher during the co-administration phase with the compounds of the present invention, and is lowered during the subsequent days.
  • Particular dosing schedules include:
  • patients may receive the following medications 20 to 30 minutes prior to starting the infusion with a compound according to the present invention:
  • on Days 4 and 5 patients treated with compounds according to the present invention may receive ondansetron 4 mg twice a day PO.
  • Doses of dexamethasone, ondansetron and ranitidine are herein defined on the basis of the base form.
  • the dose of diphenhydramine hydrochloride is given on the basis of the hydrochloride salt.
  • Doses of compounds of the invention are given on the basis of the base form.
  • the daily doses may be administered as an infusion.
  • the infusion may be a 1 hour infusion, a 1.5 hour infusion, a 2 hour infusion, a 3 hour infusion or longer.
  • the infusion is 1.5 hours.
  • the dose may be administered according to a regimen which uses a loading dose and a maintenance dose.
  • Loading/maintenance doses according to the present invention includes:
  • the daily dose may be reduced in the final day or days of the regimen.
  • the dose may be reduced to 1 mg on days 4 and 5.
  • Particular regimens include:
  • a single dose regimen includes:
  • patients may be selected for treatment with compounds of the present invention based on clinical parameters and/or patient characteristics. Suitable parameters may be measurements disclosed in the present application.
  • a method of decreasing the expression and/or secretion of one or more pro-inflammatory cytokine in a subject or in a sample obtained from a subject or in a cell culture comprising administering a compound as defined herein.
  • a method of increasing macrophage activation in a subject or in a sample obtained from a subject or in a cell culture comprising administering a compound as defined herein.
  • the present invention is directed to a compound for use according to the present invention, wherein the compound is administered in combination with one or more of the following prophylactic medications: diphenhydramine hydrochloride, ranitidine, dexamethasone, ondansetron.
  • diphenhydramine hydrochloride 25 mg iv or equivalent; Ranitidine 50 mg iv or equivalent; Dexamethasone 8 mg intravenous; Ondansetron 8 mg i.v. in slow infusion of 15 minutes or equivalent.
  • Patients may receive said prophylactic medications 20-30 minutes before the infusion of plitidepsin.
  • Dexamethasone 8 mg intravenous may be dexamethasone phosphate leading to 6.6 mg dexamethasone base.
  • Compound 240 known as DidemninB and shown by the structure below:
  • PLD inhibits in vitro the transactivation of NF- ⁇ B.
  • THP-1 cells stably transfected with an NF ⁇ B luciferase reporter plasmid.
  • TNF ⁇ an activator of NF- ⁇ B
  • TLR3 ligand 500 ⁇ g/mL poly I:C
  • TLR4 ligand 10 ⁇ g/mL LPS-B5
  • TLR-7 ⁇ 8 ligand 10 ⁇ g/mL Resiquimod
  • PLD also inhibits in vitro the secretion of the pro-inflammatory cytokines IL-1, IL-6, IL-8 and TNF-alpha in human monocytes.
  • THP-1 cells treated THP-1 cells with 100 ng/mL TNF ⁇ (an activator of NF- ⁇ B), 500 ⁇ g/mL poly I:C (TLR3 ligand), 10 ⁇ g/mL LPS-B5 (TLR4 ligand) or 10 ⁇ g/mL Resiquimod (TLR-7 ⁇ 8 ligand).
  • TNF ⁇ an activator of NF- ⁇ B
  • TLR3 ligand poly I:C
  • TLR4 ligand 10 ⁇ g/mL LPS-B5
  • TLR-7 ⁇ 8 ligand 10 ⁇ g/mL Resiquimod
  • poly I:C, LPS and Resiquimod induce the secretion of IL-1, IL-6, IL-8 and TNF- ⁇ .
  • plitidepsin clearly inhibited the production of IL-1, IL-6, IL-8 and TNF- ⁇ .
  • TNF- ⁇ failed to increase the secretion of IL-1 and IL-6. It is possible that THP-1 cells need other TNF- ⁇ exposure times to secret these cytokines.
  • plitidepsin was unable to reduce IL-8 and TNF- ⁇ in TNF- ⁇ stimulated cells. That is because we measured TNF- ⁇ secreted and TNF ⁇ added to the cell culture medium. As such, the treatment with TNF- ⁇ masked the levels of secreted TNF- ⁇ .
  • plitidepsin clearly inhibited the secretion of pro-inflammatory cytokines IL-1, IL-6, IL-8.
  • PLD inhibits ex-vivo secretion of the pro-inflammatory cytokines, IL-6, IL-8 and TNF-alpha in murine isolated from BAL (Bronchoalveolar lavage).
  • plitidepsin inhibits the LPS-trigged cytokine secretion in alveolar macrophages.
  • mice were injected i.v. with plitidepsin (1 mg/kg) or vehicle and 12 hours after administration bronchoalveolar lavage fluid (BAL) was collected.
  • BAL bronchoalveolar lavage fluid
  • Cells were plated and treated ex-vivo or not with 15 ⁇ g/mL of LPS-B5 for 3 or 6 hours and secreted cytokines were measured.
  • LPS induce the secretion of IL-6, IL-10 and TNF- ⁇ (grey bars).
  • the drug clearly inhibited the production of pro-inflammatory cytokines IL-6, and TNF- ⁇ induced by LPS (red bars) and led to an overall anti-inflammatory effect.
  • FIG. 51 This is further shown again in FIG. 51 .
  • plitidepsin was able to significantly reduce the secretion of IL-6, IL-10 and TNF ⁇ induced by LPS-B5 at 3 and 6 hours in CD45 + cells isolated from bronco-alveolar lavages. This effect was unrelated to cell viability as shown in FIG. 51 ( b ) .
  • PLD reduces the number of macrophages in BAL.
  • mice treated mice with plitidepsin (1 mg/kg) i.v., with LPS (20 ⁇ g/kg) i.p. in sterile saline or with plitidepsin (1 mg/kg; i.v.) in combination with LPS (20 ⁇ g/kg, i.p.).
  • LPS 20 ⁇ g/kg
  • plitidepsin 1 mg/kg; i.v.
  • bronchoalveolar lavages were collected. Bronchoalveolar lavage cells were obtained by centrifugation and analyzed by flow cytometry ( FIG. 4 b ).
  • Upper panels show the strategy of analysis of macrophage population present in the samples.
  • Lower right panel show the same result expressed as percentage of cells.
  • PLD is distributed to the lungs in the mouse (which is the nonclinical species used in the pharmacological models).
  • similar plasma exposures are achieved in non-clinical species and patients.
  • the concentration of plitidepsin in lungs was consistently higher than that in plasma at any sampling time, with a lung-to-plasma ratio (calculated as lung AUC 0- ⁇ / plasma AUC 0- ⁇ ) in mice, rats and hamsters of 133, 460 and 909, respectively, thus confirming the distribution of plitidepsin into the lung.
  • NF- ⁇ B transactivation was assayed using the Bright-GloTM Luciferase Assay System following the manufacturer’s instructions.
  • the compounds were used either alone or combined with 100 nM plitidepsin for 6 hours. Luminescence was measured in a Perkin-Elmer EnVision reader. A MTT (3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide) cell proliferation assay was simultaneously performed to control the cytotoxicity of the compounds. Cell survival was expressed as percentage of control cell growth. The data presented are the average of three independent experiments performed in triplicate.
  • THP1-NF ⁇ B-LUC cell cultures were treated as described above, and the culture medium was sampled at 6 hours post-treatment to assay for secreted cytokines by ELISA. Media samples were stored at 4° C.
  • IL-8, IL-1 ⁇ , IL-6 and TNF- ⁇ protein secretion into culture medium was quantitated using highly specific and sensitive ELISA kits.
  • Human IL-1b, human IL-6, human IL-8 and human TNF OptEIATM ELISA kits were obtained from BD Biosciences and performed as described by the manufacturer. The data presented are the average of three independent experiments performed in triplicate.
  • mice were randomized into groups of five animals to receive the treatments. Mice were injected intra venous (i.v.) with plitidepsin (1 mg/kg) and 12 hours after administration were euthanised. Control group received plitidepsin vehicle diluted with saline (Cremophor/Ethanol/Water). Bronchoalveolar lavage fluid (BAL) of each group was collected and centrifugated to obtain bronchoalveolar lavage cells. Cells underwent red blood cell lysis (Roche) and were plated and treated ex-vivo or not with 15 ⁇ g/mL of LPS-B5 for 3 or 6 hours. Secreted cytokines were measured using highly specific and sensitive ELISA kits. Mouse IL-6, mouse IL-10 and mouse TNF DuoSet ELISA kits were obtained from R&D Systems and performed as described by the manufacturer. Data presented here are representative from a series of at three independent experiments.
  • mice were randomiced into groups of two animals to receive the treatments. Mice were challenged with plitidepsin (1 mg/kg) intra venous (i.v.), with LPS (20 ⁇ g/kg) intra peritoneal (i.p.) in sterile saline or with plitidepsin (1 mg/kg; i.v.) in combination with LPS (20 ⁇ g/kg, i.p.).
  • the control group received plitidepsin vehicle (Cremophor/Ethanol/Water) diluted with saline.
  • animals were euthanised and bronchoalveolar lavage collected (a total of 1.2 ml, PBS). Bronchoalveolar lavage cells were obtained by centrifugation and analyzed by flow cytometry. Data presented here are representative from a series of at three independent experiments.
  • mice were randomized into groups of two animals to receive the treatments. Mice were challenged with plitidepsin (1 mg/kg) intra venous (i.v.) followed by Resiquimod (50 ⁇ g/mouse, intranasal;) 1 hour later. The control group received plitidepsin vehicle (Cremophor/Ethanol/Water) diluted with saline. One and 3 hours later, animals were euthanized, bronchoalveolar lavage collected (a total of 1.2 ml, PBS) and then, TNF ⁇ quantified by ELISA kits. Data presented here are representative from a series of at three independent experiments.
  • Bronchoalveolar lavage cells were stained with anti- F4/80-BV510, CD45-APC700, CD11b-BV650, CD11c-APC-Fire, CD24-PC7 and Ly6C-BV605 monoclonal antibodies (Biolegend) and a LIVE/DEADTM Fixable Green Dead Cell Stain Kit, for 488 nm excitation (Thermofisher). Macrophages (F4/80+) were gated on alive immune cells (CD45+ LIVE/DEAD dye-), while alveolar macrophages (F4/80+ CD24-) were specifically gated on CD11c+ CD11b- population from alive immune cells. Isotype controls and compensation beads were used to set compensations and gating strategies.
  • the recombinant virus assay was performed in both, MT-2 cells and PBMCs previously activated with PHA + IL-2.
  • Cells were infected with supernatants obtained from 293t cells transfected with full-length infectious HIV-1 plasmids: pNL4.3-Luc (X4 tropic virus), pNL4.3-Renilla (X4 tropic virus able to develop more than one round of replication), pNL4.3- ⁇ env-Luc plus pVSV-env (HIV pseudotyped with the G protein of VSV) or pJR-Renilla (R5 tropic virus able to develop more than one round of replication).
  • Resistant viruses were obtained cloning in NL4.3-Renilla the pol gene of viruses from different infected donors.
  • Virus 9D carry the following mutations: 41L, 67N, 70R, 98G, 118I, 184V, 215F, 219Q, 74I and virus 4D: K65R, K70R, V75I, F77L, F116Y, Q151M, M184I, L10I.
  • the assay was then performed in 96 well microplates seeded with 100 ⁇ l containing 250.000 (PBMCs) or 100.000 (MT-2) cells/well.
  • the compounds to be tested were added to the culture in concentrations ranging from 50 to 0.0016 ⁇ g/ml (100 ⁇ l/well).
  • HIV-1 replication inhibition was evaluated by measuring the reduction of luciferase-renilla activity or RLUs (Relative light units) in a luminometre, being the 100% the infection of non-treated cells.
  • RLUs Relative light units
  • FIGS. 6 A and 6 B showed antiviral activity in both MT-2 cells and PBMCs (IC 50 1.39 ⁇ M and 0.16 ⁇ M, respectively). This compound was more toxic in PBMCs, as shown in FIG. 6 . Toxic concentrations were not reached at 57.3 ⁇ M in MT-2 cells, while in PBMCS CC 50 value was about 27 ⁇ M.
  • Compound 8 ( FIGS. 7 A and 7 B ) showed also antiviral activity in both MT-2 cells and PBMCs. Although at concentrations of 50 ⁇ M it was non-specific, at 10 ⁇ M it was specific, with an IC 50 value 100 fold lower.
  • FIGS. 8 A and 8 B Compounds 9 ( FIGS. 8 A and 8 B ), 10 ( FIGS. 9 A and 9 B ), and 11 ( FIGS. 10 A and 10 B ) were the most potent compounds of all tested compounds. Compounds 9, 10, and 11 showed IC50s values in the nanomolar range in PBMCs (0.63, 0.86, and 69.4 nM, respectively), and they are among the most potent of the antiviral compounds in vitro existing in the literature.
  • HCoV-229E has a multiplication and propagation mechanism very similar to SARS-COV-2. Indeed, the N protein of HCoV-229E has a protein homology greater than 90% with the homologous N protein in SARS-CoV-2. It is believed that all coronaviruses need their N (nucleocapsid) protein to bind to EF1A in order to replicate effectively and synthesise viral proteins. Reducing or abolishing the binding of N to EF1A reduces the viability for the spread of the virus.
  • Huh-7 cells human hepatoma cell line
  • Huh-7 cells grown to confluence in a M96 well plate
  • Huh-7 cells were infected with HCoV-229E-GFP virus at a moi (multiplicity of infection) of 0.01 pfu.
  • Virus stock was HCoV-229E-GFP (from 31 Jan. 2013) at 3 ⁇ 10 7 pfu/ml.
  • FIGS. 11 - 15 50 nM 5 nM 0.5 nM 5 nM 0.5 nM B ( FIGS. 16 - 19 ) 50 nM 5 nM 0.5 nM 0.5 nM C ( FIGS. 20 - 23 ) 50 nM 5 nM 0.5 nM 0.5 nM D ( FIGS. 24 - 26 ) 50 nM 5 nM 0.5 nM E ( FIGS. 27 - 29 ) 50 nM 5 nM 0.5 nM F ( FIGS.
  • Fluorescent cells were observed 24 hpi. Photos were obtained using an automated system. Cells were fixed for 30 min with PFA 4%, washed with PBS, and cell nuclei were stained with DAPI 1:200 in PBS 20 min RT. Images in green show GFP tagged vial particles. Images in blue show DAPI stained nuclei.
  • the primary objective of the study was to determine the safety and toxicological profile of plitidepsin at each dose level administered according to the proposed administration scheme in patients admitted for COVID-19.
  • the secondary objectives were to assess the efficacy of plitidepsin in patients with COVID-19 at the proposed dose levels by reference to: change in SARS-CoV-2 viral load from baseline; time until negative detection of SARS-CoV-2 by PCR; cumulative incidence of disease severity (evaluation based on: mortality; need for invasive mechanical ventilation and/or ICU admission; need for non-invasive mechanical ventilation; need for oxygen therapy) and selection of the recommended dose levels of plitidepsin for a phase II/III efficacy study.
  • Plitidepsin is supplied as a powder for concentrate for solution for infusion at a concentration of 2 mg/vial.
  • the vials are reconstituted with 4 ml of reconstitution solution to obtain a colourless to slightly yellowish solution containing 0.5 mg/ml of plitidepsin, 25 mg/ml of mannitol, 0.15 ml/ml of macrogolglycerol ricinoleate oil, 0.15 ml/ml of ethanol and 0.70 ml/ml of water for injection.
  • An additional dilution should be made in any suitable intravenous solution prior to infusion.
  • Plitidepsin 2 mg is supplied in a Type I clear glass vial with a bromobutyl rubber stopper covered with an aluminium seal. Each vial contains 2 mg of plitidepsin.
  • the solvent for the reconstitution of macrogolglycerol ricinoleate (polyoxyl 35 castor oil)/absolute ethanol/water for injection, 15%/15%/70% (v/v/v) is supplied in a Type I colourless glass vial.
  • the ampoules have a volume of 4 ml.
  • Plitidepsin will be labelled with the study protocol code, the batch number, the content, the expiry date, the storage conditions, the name of the investigator and the sponsor.
  • the study drug will be labelled in accordance with Annex 13 of the European Good Manufacturing Practices.
  • Plitidepsin should be stored between 2° C. and 8° C. and the vials should be kept in the outer carton to protect them from light. The drug in these conditions is stable for 60 months.
  • the reconstituted solution After reconstitution of the 2 mg plitidepsin vial with 4 ml of the solution for reconstitution of macrogolglycerol ricinoleate/ethanol/water for injection, the reconstituted solution should be diluted and used immediately after preparation. If not used immediately, storage times and conditions until use are the responsibility of the user.
  • the reconstituted concentrated solution of the drug product has been shown to be physically, chemically and microbiologically stable for 24 hours under refrigerated conditions (5° C. ⁇ 3° C.) and for 6 hours when stored in the original vial under indoor light at room temperature. If storage is required before administration, solutions should be stored refrigerated and protected from light and should be used within 24 hours after reconstitution.
  • FIG. 34 illustrates the simulation of the total plasma plitidepsin concentration profiles vs. time after a daily dose (D1-D5) of 1.0 mg and 2.0 mg.
  • the horizontal black lines represent the total plasma concentrations associated with the concentrations in lung equivalent to IC50, IC90 and 3xIC90 in vitro. With both dose levels (1.0 mg and 2.0 mg), plasma concentrations above IC50 would be obtained throughout the treatment period, and would remain above IC90 during most of the administration interval. Accumulation after five repeated administrations is minimal.
  • a further dosage regimen is 1.5 mg daily for 5 days.
  • a further regimen is illustrated in FIG. 35 which simulates plitidepsin total plasma concentrations associated to an initial flat dose of 1 mg (Day 1) given as a 1-h i.v. infusion, followed by daily doses of 0.5 mg (D2-D5).
  • plitidepsin plasma concentrations are above the IC50 during the entire treatment period, and remains above IC90 during 18 and 14 hours, after 1 mg and 0.5 mg dose infusion, respectively.
  • minimal accumulation after repeated administration is foreseen.
  • This regimen provides a loading dose of 1 mg of plitidepsin given as 1-h i.v. infusion on the first day of treatment, followed by a maintenance dose of 0.5 mg once daily for 4 days.
  • FIG. 36 illustrates the simulation of the total plasma plitidepsin concentration profiles vs. time after a daily dose (D1-D3) of 1.5 mg, 2.0 mg and 2.5 mg.
  • the horizontal black lines represent the total plasma concentrations associated with concentrations in lungs equivalent to IC50, IC90 and 3xIC90 in vitro.
  • IC50 concentrations in lungs equivalent to IC50, IC90 and 3xIC90 in vitro.
  • plasma concentrations above IC50 would be obtained throughout the treatment period and would remain above IC90 during most of the administration interval. Accumulation after three repeated administrations is minimal.
  • PLD PLD was administered as a 90 minute IV infusion daily for 3 consecutive days (day 1-3) with viral load assessed by PCR at baseline, day 4, day 7 and day 15 and day 31.
  • PCR COVID 19 test POSITIVE at baseline, converted to NEGATIVE (no viral load) by day 4.
  • PLD 1.5 mg ⁇ 3 removed viral load by day 4.
  • PLD achieved an acute clinical improvement, including removing all viral burden and treating bilateral pneumonia to enable hospital discharge by day 7.
  • Patient 2 40 year old male, bilateral pneumonia. Received PLD 1.5 mg ⁇ 3. By day six, lack of improvement and cross over to Remdesivir + TOL + Corticoids + Opiates. PCR converted to negative by day 15, Hospital discharge by Day 19.
  • Patient 3 53 year old male, bilateral pneumonia. Received PLD 1.5 mg ⁇ 3. PLD prevented clinical deterioration. Hospital discharge by day 10, PCR converted to negative by day 31.
  • Patient 4 42 year old male, bilateral pneumonia. Received PLD 2.0 mg ⁇ 3. Corticoid therapy required.
  • PCR COVID 19 test POSITIVE at baseline, and still positive at day 7. By day 15 the patient was PCR negative, as shown in FIG. 42 a . Patient recovered sufficiently for hospital discharge by day 10.
  • Patient 5 33 year old female, bilateral pneumonia at entry. Received PLD 1.5 mg ⁇ 3.
  • Bilateral pneumonia is evident in FIG. 39 a .
  • FIG. 39 b After treatment with PLD, improvement was seen on day 6.
  • Laminar atelectasis is evidenced FIG. 39 b .
  • a follow up x-ray on day 15 showed return to normal FIG. 39 c .
  • PLD 1.5 mg x 3 removed viral load by day 4.
  • PLD achieved major clinical improvement, including removing all viral burden and treating bilateral pneumonia to enable hospital discharge by day 8.
  • Patient 6 69 year old female, highly symptomatic COPD. Unilateral pneumonia on entry. Received PLD 1.5 mg ⁇ 3.
  • PCR COVID 19 test POSITIVE at baseline, converted to NEGATIVE (no viral load) by day 7 as shown in FIG. 42 c .
  • Patient discharged by day 8. X-rays showing pneumonia progression shown in FIGS. 40 a - c . Unilateral pneumonia is evident in FIG. 40 a which progressed to bilateral pneumonia in FIG. 40 b . In FIG. 40 c , improvement is seen.
  • PLD achieved major clinical improvement, including removing all viral burden and treating pneumonia as shown in FIG. 40 d to enable hospital discharge by day 8.
  • PCR COVID 19 test POSITIVE at baseline, converted to NEGATIVE (no viral load) by day 7 as shown in FIG. 42 d . Following treatment with PLD, major clinical improvement. Hospital discharge by day 8.
  • Patient 8 32 year old male. Received PLD 1.5 mg ⁇ 3. Not evaluable for efficacy, hospital discharge by day 4.
  • FIG. 41 The effect of PLD on inflammatory cytokines was also measured for patients 5, 7 and 9 and the results of C-reactive protein tests are shown in FIG. 41 .
  • patient 5 FIG. 41 a
  • patients 7 FIG. 41 b
  • 9 FIG. 41 c
  • an acute fall is seen by day 3.
  • the study was a Phase 1, multicentre, open-label study in which 45 patients hospitalised for management of COVID-19 were randomised into 3 dose groups, comprising 1.5, 2.0, and 2.5 mg plitidepsin administered as a 1.5-hour IV infusion once a day for 3 consecutive days.
  • the primary objective of this study was to determine the safety and toxicological profile at each dose level, based on (1) frequency of Grade ⁇ 3 treatment-emergent adverse events (TEAE) at Days 3, 7, 15, and 31 using National Cancer Institute (NCI) Common Terminology Criteria for Adverse Events (CTCAE) version 5.0 criteria; (2) percentage of patients unable to complete treatment and reasons; (3) percentage of patients with TEAEs and SAEs at Days 3, 7, 15, and 31; (4) change from baseline haematologic and non-haematologic parameters on Days 3, 7, 15, and 31; and (5) percentage of patients with ECG abnormalities on Days 2, 3, 4, 5, 6, 7, 15, and 31.
  • a secondary objective was to select a recommended dose for a pivotal study.
  • SARS-CoV-2 was obtained from Korea Centers for Disease Control and Prevention (KCDC). Vero cells were acquired from the American Type Culture Collection (ATCC CCL-81).
  • the compound was prepared a two-fold serial dilutions at 20-point concentrations with DMSO and Ampolla (Cremophor:Ethanol:Water (15:15:70)) respectively. 24 hours after cell seeding, the compound was treated in the cells with the top concentration at 5uM. After an hour, plates were transferred into the BSL-3 containment facility for viral infection and SARS-CoV-2 was added at a multiplicity of infection (MOI) of 0.0125. The plates were incubated at 37° C. for 24 hours. The cells were fixed at 24 hpi with 4% paraformaldehyde (PFA) for permeabilization.
  • MOI multiplicity of infection
  • Anti-SARS-CoV-2 Nucleocapsid (N) 1st antibody and 488-conjugated goat anti-rabbit IgG 2nd antibody were treated to the cells and Hoechst 33342 were treated to dye the cells for the analysis by immunofluorescence.
  • the acquired images with Operetta (Perkin Elmer) were analyzed using in-house software to quantify cell numbers and infection ratios, and antiviral activity was normalized to positive (mock) and negative (0.5% DMSO) controls in each assay plate.
  • Dose-response curves are shown in FIGS. 37 A-C (three repeats). The blue squares represent inhibition of virus infection (%) and the red triangles represent cell viability (%). Means ⁇ SD were calculated from duplicate experiments. Plitidepsin was able to inhibit viral-induced cytopathic effects (squares) at concentrations where no cytotoxic effects of the drug were observed (circles) in all experiments. In this experiment, plitidepsin had an IC 50 of 0.0033-0.0039 ⁇ M versus a CC 50 of 0.178-0.431 ⁇ M giving an SI of 49.95-129.92.
  • Vero E6 cells ATCC CRL-1586 were cultured in Dulbecco’s modified Eagle medium, (DMEM; Lonza) supplemented with 5% fetal calf serum (FCS; EuroClone), 100 U/mL penicillin, 100 ⁇ g/mL streptomycin, and 2 mM glutamine (all ThermoFisher Scientific).
  • DMEM Dulbecco’s modified Eagle medium, (DMEM; Lonza) supplemented with 5% fetal calf serum (FCS; EuroClone), 100 U/mL penicillin, 100 ⁇ g/mL streptomycin, and 2 mM glutamine (all ThermoFisher Scientific).
  • FCS fetal calf serum
  • SARS-CoV-2 virus was isolated from a nasopharyngeal swab collected from an 89-year-old male patient giving informed consent and treated with Betaferon and hydroxychloroquine for 2 days before sample collection.
  • the swab was collected in 3 mL medium (Deltaswab VICUM) to reduce viscosity and stored at -80° C. until use.
  • Vero E6 cells were cultured on a cell culture flask (25 cm 2 ) at 1,5 ⁇ 10 6 cells overnight prior to inoculation with 1 mL of the processed sample, for 1 h at 37° C. and 5% CO 2 .
  • Viral RNA was extracted directly from the virus stock using the Indimag Pathogen kit (Indical Biosciences) and transcribed to cDNA using the PrimeScriptTM RT reagent Kit (Takara) using oligo-dT and random hexamers, according to the manufacturer’s protocol.
  • DNA library preparation was performed using SWIFT amplicon SARS-CoV-2 panel (Swift Biosciences). Sequencing ready libraries where then loaded onto Illumina MiSeq platform and a 300 bp paired-end sequencing kit. Sequence reads were quality filtered and adapter primer sequences were trimmed using trimmomatic. Amplification primer sequences were removed using cutadapt (Martin, 2011).
  • Plitidepsin was used at a concentration ranging from 100 ⁇ M to 0.0512 nM at 1 ⁇ 5 serial dilutions, and also assayed from 10 ⁇ M to 0.5 nM at 1 ⁇ 3 dilutions.
  • Increasing concentrations of Plitidepsin was added to Vero E6 cells together with 10 1.8 TCID 50 /mL of SARS-CoV-2, a concentration that achieves a 50% of cytopathic effect.
  • Non-exposed cells were used as negative controls of infection.
  • Vero E6 cells were equally cultured in the presence of increasing drug concentrations, but in the absence of virus. Cytopathic or cytotoxic effects of the virus or drugs were measured at 3 days post infection, using the CellTiter-Glo luminescent cell viability assay (Promega). Luminescence was measured in a Fluoroskan Ascent FL luminometer (ThermoFisher Scientific).
  • the cytopathic effect on Vero E6 cells exposed to a fixed concentration of SARS-CoV-2 in the presence of increasing concentrations of plitidepsin is shown in FIG. 38 .
  • Drug was used at a concentration ranging from 10 ⁇ M to 0.5 nM at 1 ⁇ 3 dilutions.
  • Non-linear fit to a variable response curve from one representative experiment with two replicates is shown (squares).
  • the particular IC 50 value of this experiment is indicated in the figure.
  • Cytotoxic effect on Vero E6 cells exposed to increasing concentrations of plitidepsin in the absence of virus is also shown (circles).
  • a constant concentration of SARS-CoV-2 was mixed with increasing concentrations of plitidepsin and added to Vero E6 cells.
  • Vero E6 cells were also cultures with increasing concentrations of plitidepsin in the absence of SARS-CoV-2.
  • Plitidepsin was able to inhibit viral-induced cytophatic effects (red squares) at concentrations where no cytotoxic effects of the drug were observed (grey circles).
  • the mean IC 50 value and standard deviation of plitidepsin in two experiments with two replicates each was 0.06 ⁇ 0.02 ⁇ M.
  • the aim here was to evaluate in vivo the effects of plitidepsin in the treatment of severe pneumonia caused by the mouse-adapted A/H1N1 influenza virus infection (A/Puerto Rico/8/34), and also on viral titre levels.
  • mice Female mice at the age of 9 weeks were anesthetized by intraperitoneal injection of ketamine-xylazine solution and infection was performed by intranasal administration of virus solution PBS into 20 ul per nares.
  • mice that were receiving the treatment were injected subcutaneously with 0.3 mg/kg or 0.15 mg/kg of plitidepsin. Subsequently, survival and body weight loss was monitored until day 3 p.i.. No death mice or mice with a weight loss of more than 30% of the starting body weight was recorded during the time of the treatment.
  • FIG. 43 shows the inflammatory profile in the BALF of infected mice with or without treatment with plitidepsin.
  • plitidepsin strongly reduced the levels of IL-6, CCL2, IL-1 ⁇ , IFN- ⁇ and TNF- ⁇ . Mice that were receiving only half-dose of the drug were less protected and showed an intermediated phenotype.
  • the viral titer in the lungs was also assessed. As shown in FIG. 44 , plitidepsin reduced the viral titre in the lungs at both 0.3 mg/kg and 0.15 mg/kg.
  • the BALF cellular composition is defined as a marker of lung immune response viral infection. Quantitative measurement of infiltrating cells in correlation to inflammatory cytokine levels was assessed in influenza infected mice. Treatment with plitidepsin did not reduce the total cellular composition of the BALF (CD45 + ⁇ 10 6 ). As shown in FIG. 45 we also found an increase in alveolar macrophage (AM) infiltration suggesting that AMs contribute to viral clearance.
  • AM alveolar macrophage
  • target cell lines Vero-E6 and Huh7 were inoculated with an infectious virus stock dilution in the presence of increasing concentrations of plitidepsin, starting at 2.3 pM or 2.5 pg/ml and using 4.5 ⁇ M or 5 ⁇ g/ml as the highest concentration. Infection efficiency was evaluated at 48 hours, after the virus has spread to a substantial fraction of the target cells in vehicle-treated cultures.
  • Relative infection efficiency was assessed by automated fluorescence microscopy in the green channel and overall cell biomass/well was estimated by nuclear staining with DAPI in the blue channel, as a preliminary assessment of the compound effective doses as well as overall compound cytotoxicity.
  • WNV-GFP infection efficiency rapidly decreased at doses around 5 nM in VeroE6 cells, reaching background fluorescence levels at 36 nM and above.
  • the cell number remained unchanged up to 36 nM, but significantly decreased at higher concentrations (180 nM; p ⁇ 0.05), suggesting that plitidepsin interferes with cell duplication capacity at concentrations above 36 nM.
  • the estimated EC50 value for plitidepsin in VeroE6 cells is 4.9 nM and the EC90 is 9.5 nM. Based on the cell biomass the CC50 value is 2330 nM.
  • the therapeutic index expressed as the ratio CC50/EC50 in VeroE6 cells is 475.
  • Huh7 cells as shown in FIG. 47 , there is a dose-dependent reduction in infection efficiency with EC50 and EC90 values of 0.665 and 3.86 nM respectively. This reduction is associated with a parallel loss of cell biomass in the well, which is statistically significant at 7.2 nM (p ⁇ 0.05) with a CC50 value of 14.7 and a therapeutic index of 22.
  • plitidepsin interferes with WNV-GFP propagation in cell culture infection models in both Vero-E6 and Huh-7 cells.
  • antiviral activity in the absence of measurable interference with cell viability may be observed at 1.5 nM (p ⁇ 0.05) in Huh-7 cells and 7.2 nM (p ⁇ 0.05) in Vero-E6 cells.
  • Vero-E6 or Huh-7 cells were inoculated (MOI 0.01) with a recombinant virus based on the NY99 WNV strain. Infection was performed in the presence of the vehicle or a dose range of plitidepsin
  • Extracellular infectivity titers show that the presence of plitidepsin strongly interfered with WNV propagation as shown in FIG. 48 , with reductions >3 orders of magnitude at 45 nM in VeroE6 and Huh-7 cells. This phenomenon is dose- dependent in both cell lines.
  • Intracellular WNV RNA load was determined by RT-qPCR in control and plitidepsin- treated cells. Remarkably, as shown in FIG. 49 , no RNA could be recovered from Huh-7 cells treated with 45 nM plitidepsin. Nevertheless, viral RNA load was determined in the rest of the sample groups in both cell lines. In agreement with the trend exhibited by the extracellular infectivity titers, viral RNA load significantly decreased in a dose-dependent manner at 15 and 45 nM in Vero-E6 cells, while the viral load at 5 and 1.5 nM were not distinguishable from those in the control ( FIG. 49 ). Similarly, Huh-7 showed a marked reduction in viral load at 15 nM, magnitude of which declined in a dose-dependent manner.
  • the WNV infection propagation efficiency data suggest that plitidepsin interferes with viral replication at doses above 5 nM in both Vero-E6 and Huh-7 cells, although some degree of interference could be observed at lower concentrations in Huh-7 cells.
  • the results measuring overall propagation efficiency using functional (infectivity) as well as molecular (RT-qPCR) approaches confirm that plitidepsin reduces virus propagation efficiency in the expected range of concentrations based on the data obtained with WNV-GFP.
  • Compound preparation Pre-weighted solid was diluted to a final 1 mg/ml solution in dimethylsulfoxyde (DMSO) and aliquoted at -20° C. until further use.
  • Cell culture Subconfluent Vero-E6 cells and Huh-7cell cultures were maintained in complete media [(DMEM supplemented with 10 mM HEPES, 1x non-essential amino acids (Gibco), 100 U/ mL penicillin-streptomycin (Gibco) and 10% Fetal Bovine Serum (heat-inactivated at 56° C. for 30 min)].
  • Viruses WNV (NY99) and WNV-GFP recombinant viruses were rescued from cloned cDNA as previously described. Stock infectivity titers were determined by plaque assay on Vero- E6 cells as previously described.
  • infectivity titration infectivity titers were determined using endpoint dilution and immunofluorescence microscopy using a monoclonal antibody against Flavivirus E protein (4G2; ATCC® HB-112TM). Briefly, Huh-7 cells were inoculated with supernatant dilutions in a 96-well format. Forty-eight hours post infection, cells were fixed for 30 minutes at room temperature with a 4% formaldehyde solution in PBS, washed twice with PBS and incubated with binding buffer (0.3% Triton X100, 3%BSA in PBS) for 1 hour.
  • binding buffer (0.3% Triton X100, 3%BSA in PBS
  • Reverse-transcription and qPCR 60 ng of total cellular RNA were subjected to RT-qPCR using NZYSpeedy One-Step qPCR probe master mix, using manufacturer’s recommendations and the primers.
  • Example 12 A Phase 3, Multicentre, Randomised, Controlled Trial to Determine the Efficacy and Safety of Two Dose Levels of Plitidepsin Versus Control in Adult Patients Requiring Hospitalisation for Management of Moderate COVID 19 Infection
  • CRP C-reactive protein [CRP]
  • LDH lactate dehydrogenase
  • ferritin ferritin
  • IL-1 ⁇ interleukin-6
  • IL-10 tumour necrosis factor alpha
  • IMC Independent Data Monitoring Committee
  • Patients will be included in the study if presenting with acute clinical infection (onset of symptoms in the previous 5 days), in which the diagnosis of COVID-19 infection is reached through a diagnostic method that could be a positive antigen test or a positive PCR test.
  • the study comprises two arms:
  • Ondansetron 4 mg orally is given every 12 hours for 3 days after plitidepsin administration to relieve drug-induced nausea and vomiting. If plitidepsin is administered in the morning the patient receives the first dose of ondansetron in the afternoon.
  • the study will show that a single dose of plitidepsin administered to patients results in a reduction of viral load. This may be expressed as a replication cycle threshold (Ct) value greater than 30 (Ct> 30), on day 6 after the administration.
  • Ct replication cycle threshold
  • the study will show that patients with COVID-19 infection who are to be discharged from the Emergency Department show a reduction in viral load on day 6 after discharge of emergencies expressed as a replication cycle threshold (Ct) value greater than 30 (Ct> 30), when administered with a single dose of plitidepsin.
  • This may be expressed as a reduction in SARS-CoV-2 viral load from baseline. This may be expressed as a reduction in the percentage of patients requiring hospitalisation following administration.
  • This may be expressed as a reduction in the percentage of patients requiring invasive mechanical ventilation and / or admission to the ICU following administration. This may be expressed as a reduction of patients who develop sequelae related to persistent disease. This may be expressed as an increase in the percentage of patients with normalization of analytical parameters chosen as poor prognosis criteria (including, for example, lymphopenia, LDH, D-dimer or PCR). This may be expressed as an increase in the percentage of patients with normalization of clinical criteria (disappearance of symptoms), including, for example: headache, fever, cough, fatigue, dyspnea (shortness of breath), arthromyalgia or diarrhea.
  • FIG. 53 shows the results and it can be seen that plasma concentrations above IC50 and IC90 can be obtained for more than 6 days.

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