Ritonavir Treatment Research Articles

The effect of lopinavir - ritonavir on mortality in COVID-19 pneumonia

Aim: COVID-19 is a lethal disease for which there is still no specific treatment. The study aims to retrospectively investigate the effect of adding lopinavir/ritonavir to the treatment of patients using favipiravir (in the ward or intensive care unit) on mortality. Methods: This study was conducted in 181 Rt-PCR(+) adult patients with severe and critical COVID-19. Demographic and laboratory data, antiviral agents used in treatment (with or without lopinavir-ritonavir), presence of intubation, and clinical outcome were recorded. The patients were categorized into Group 1 (not receiving lopinavir-ritonavir), Group 2 (administered lopinavir-ritonavir in ward), and Group 3 (administered lopinavir-ritonavir in the intensive care unit). Results: The lowest mortality rate was found with Group 2 (21.4%) while this rate was 77.9% for Group 3 and 42.3% for Group 1 (p<0.001). There was no significant difference in length of hospital stay among groups (p>0.05). While 35.2% (25 patients) of Group 1 needed intubation, this rate was 21.4% (9 patients) in Group 2 (p<0.001). Conclusions: This study demonstrated that lopinavir / ritonavir treatment reduced mortality and the need for intubation when initiated before the critical pneumonia phase. Lopinavir/ritonavir may be useful in the treatment of COVID-19, especially as part of the combination regimen.

Pre- and Post-Exposure Prophylaxis for HIV in Patients Taking Anti-Seizure Medications.

The prevention of human immunodeficiency virus (HIV) infection has recently emphasized the use of pre- and post-exposure prophylaxis (PrEP and PEP), both of which were highly effective in prevention of HIV infection. Since the last published guidance regarding the cotreatment of people with anti-seizure medications (ASM) and antiretroviral treatments (ARTs) in 2012, both fields have numerous new medication options. Historically, cotreatment of HIV and seizures could be challenging with increased risk of virologic failure and barriers in access to health care due to global availability, social determinants of health, and stigma of both HIV and seizures. In this narrative review, we describe the data-driven and expected bidirectional pharmacokinetic (PK) interactions between guideline-based PrEP and PEP treatment and ASM, as well as overlapping side effects. There are many ASMs with no known interaction with PrEP or PEP regimens. The interactions focus on enzyme inducing ASMs, valproate, and lamotrigine. Most prominently, enzyme inducing ASMs lower serum levels of tenofovir-containing PrEP regimens and elements of PEP (dolutegravir, raltegravir, and ritonavir), which increased risk of virologic treatment failure in people with HIV but have unclear clinical significance on the effectiveness of PrEP and PEP. In addition, ritonavir treatment in PEP may significantly lower lamotrigine serum levels even during the 4 weeks of treatment, which may increase risk for breakthrough seizures during PEP and skin reactions after discontinuation of ritonavir. In addition to PK interactions, overlapping side effects are common including osteopenia, hepatic toxicity, and other gastrointestinal effects. This narrative review aims to be a resource for all clinicians prescribing ASMs so that they can create a welcoming environment to enable successful treatment of seizures and reduce the risk of HIV infection in people at risk. In addition, we highlight knowledge gaps and areas of unmet need that can be addressed with future studies.

Time Course of the Interaction Between Oral Short-Term Ritonavir Therapy with Three Factor Xa Inhibitors and the Activity of CYP2D6, CYP2C19, and CYP3A4 in Healthy Volunteers.

We investigated the effect of a 5-day low-dose ritonavir therapy, as it is used in the treatment of COVID-19 with nirmatrelvir/ritonavir, on the pharmacokinetics of three factor Xa inhibitors (FXaI). Concurrently, the time course of the activities of the cytochromes P450 (CYP) 3A4, 2C19, and 2D6 was assessed. In an open-label, fixed sequence clinical trial, the effect and duration of a 5-day oral ritonavir (100mg twice daily) treatment on the pharmacokinetics of three oral microdosed FXaI (rivaroxaban 25µg, apixaban 25µg, and edoxaban 50µg) and microdosed probe drugs (midazolam 25µg, yohimbine 50µg, and omeprazole 100µg) was evaluated in eight healthy volunteers. The plasma concentrations of all drugs were quantified using validated liquid chromatography-tandem mass spectrometry (LC-MS/MS) methods and pharmacokinetics were analysed using non-compartmental analyses. Ritonavir increased the exposure of apixaban, edoxaban, and rivaroxaban, but to a different extent the observed area under the plasma concentration-time curve (geometric mean ratio 1.29, 1.46, and 1.87, respectively). A strong CYP3A4 inhibition (geometric mean ratio >10), a moderate CYP2C19 induction 2days after ritonavir (0.64), and no alteration of CYP2D6 were observed. A CYP3A4 recovery half-life of 2.3days was determined. This trial with three microdosed FXaI suggests that at most the rivaroxaban dose should be reduced during short-term ritonavir, and only in patients receiving high maintenance doses. Thorough time series analyses demonstrated differential effects on three different drug-metabolising enzymes over time with immediate profound inhibition of CYP3A4 and only slow recovery after discontinuation. EudraCT number: 2021-006643-39.

Influence of a Short Course of Ritonavir Used as Booster in Antiviral Therapies Against SARS-CoV-2 on the Exposure of Atorvastatin and Rosuvastatin.

Early antiviral treatment with nirmatrelvir/ritonavir is recommended for SARS-CoV-2-infected patients at high risk for severe courses. Such patients are usually chronically ill and susceptible to adverse drug interactions caused by ritonavir. We investigated the interactions of short-term low-dose ritonavir therapy with atorvastatin and rosuvastatin, two statins commonly used in this population. We assessed exposure changes (area under the concentration-time curve (AUC∞) and maximum concentration (Cmax)) of a single dose of 10 mg atorvastatin and 10 mg rosuvastatin before and on the fifth day of ritonavir treatment (2 × 100 mg/day) in healthy volunteers and developed a semi-mechanistic pharmacokinetic model to estimate dose adjustment of atorvastatin during ritonavir treatment. By the fifth day of ritonavir treatment, the AUC∞ of atorvastatin increased 4.76-fold and Cmax 3.78-fold, and concurrently, the concentration of atorvastatin metabolites decreased to values below the lower limit of quantification. Pharmacokinetic modelling indicated that a stepwise reduction in atorvastatin dose during ritonavir treatment with a stepwise increase up to 4 days after ritonavir discontinuation can keep atorvastatin exposure within safe and effective margins. Rosuvastatin pharmacokinetics were only mildly modified; ritonavir significantly increased the Cmax 1.94-fold, while AUC∞ was unchanged. Atorvastatin doses should likely be adjusted during nirmatrelvir/ritonavir treatment. For patients on a 20-mg dose, we recommend half of the original dose. In patients taking 40 mg or more, a quarter of the dose should be taken until 2 days after discontinuation of nirmatrelvir/ritonavir. Patients receiving rosuvastatin do not need to change their treatment regimen. EudraCT number: 2021-006634-39. DRKS00027838.

Nirmatrelvir-Ritonavir and COVID-19 Mortality and Hospitalization Among Patients With Vulnerability to COVID-19 Complications

Postmarket analysis of individuals who receive nirmatrelvir and ritonavir (Paxlovid [Pfizer]) is essential because they differ substantially from individuals included in published clinical trials. To examine the association of nirmatrelvir and ritonavir with prevention of death or admission to hospital in individuals with different risks of complications from COVID-19 infection. This is a cohort study of adult patients in British Columbia, Canada, between February 1, 2022, and February 3, 2023. Patients were eligible if they belonged to 1 of 4 higher-risk groups of individuals who received priority for COVID-19 vaccination. Two groups included clinically extremely vulnerable (CEV) people who were severely (CEV1) or moderately immunocompromised (CEV2). CEV3 individuals were not immunocompromised but had medical conditions associated with a high risk for complications from COVID-19. A fourth expanded eligibility (EXEL) group was added to allow wider access to nirmatrelvir and ritonavir for certain other higher-risk individuals who were not in a CEV group, such as those older than 70 years who were unvaccinated. Patients with COVID-19 who received nirmatrelvir and ritonavir were matched to patients in the same vulnerability group; who were of the same sex, age, and propensity score for nirmatrelvir and ritonavir treatment; and who were also infected within 1 month of the individual treated with nirmatrelvir and ritonavir. The primary outcome was death from any cause or emergency hospitalization with COVID-19 within 28 days. There were 6866 individuals included in the study, of whom 3888 (56.6%) were female and whose median (IQR) age was 70 (57-80) years. Compared with unexposed controls, treatment with nirmatrelvir and ritonavir was associated with statistically significant relative reductions in the primary outcome in the CEV1 group (560 patients; risk difference [RD], -2.5%, 95% CI, -4.8% to -0.2%) and the CEV2 group (2628 patients; RD, -1.7%; 95% CI, -2.9% to -0.5%). In the CEV3 group, the RD was -1.3%, but the findings were not statistically significant (2100 patients; 95% CI, -2.8% to 0.1%). In the EXEL group, treatment was associated with higher risk of the outcome (RD, 1.0%), but the findings were not statistically significant (1578 patients; 95% CI, -0.9% to 2.9%). In this cohort study of 6866 individuals in British Columbia, nirmatrelvir and ritonavir treatment was associated with reduced risk of COVID-19 hospitalization or death in CEV individuals, with the greatest benefit observed in severely immunocompromised individuals. No reduction in the primary outcome was observed in lower-risk individuals, including those aged 70 years or older without serious comorbidities.

Effectiveness of nirmatrelvir plus ritonavir treatment for patients with chronic lymphocytic leukemia during the Omicron surge

AbstractPatients with chronic lymphoid leukemia (CLL), even in the Omicron era and after vaccination, suffer from persistent COVID-19 infection, higher complications, and mortality compared with the general population. In this study, we evaluated retrospectively the effectiveness of nirmatrelvir + ritonavir among 1080 patients with CLL who were infected with severe acute respiratory syndrome coronavirus 2. Nirmatrelvir administration was associated with a reduction in COVID-19–related hospitalization or death by day 35. Specifically, the rate of COVID-19–related hospitalization or death in the treated group compared with the untreated group was 4.8% (14 out of 292) vs 10.2% (75 out of 733), respectively. Moreover, we report a 69% relative risk reduction in COVID-19–related hospitalization or death in patients with CLL at the age of ≥65 years. Multivariate analysis indicates that patients aged >65 years, patients who received heavy treatment (>2 previous treatments), patients with recent hospitalizations, intravenous immunoglobulin (IVIG) treatment, and comorbidity had significant improvement outcomes after treatment with nirmatrelvir.

Safely Prescribing Nirmatrelvir and Ritonavir—Avoiding Drug-Drug Interactions

This Teachable Moment discusses drug-drug interactions with nirmatrelvir and ritonavir (Paxlovid) treatment for COVID-19 and considerations when prescribing.

Real-world effectiveness of nirmatrelvir–ritonavir against BA.4 and BA.5 omicron SARS-CoV-2 variants

Real-world effectiveness of nirmatrelvir–ritonavir against BA.4 and BA.5 omicron SARS-CoV-2 variants

EE495 Threshold Price in the US to Achieve Cost-Effective Use of Molnupiravir and PF-07321332/Ritonavir for the Prevention of Severe COVID-19 in High-Risk Adults

EE495 Threshold Price in the US to Achieve Cost-Effective Use of Molnupiravir and PF-07321332/Ritonavir for the Prevention of Severe COVID-19 in High-Risk Adults

Oral Drugs Against COVID-19.

Five-day oral therapies against early COVID-19 infection have recently been conditionally approved in Europe. In the drug combination nirmatrelvir + ritonavir (nirmatrelvir/r), the active agent, nirmatrelvir, is made bioavailable in clinically adequate amounts by the additional administration of a potent inhibitor of its first-pass metabolism by way of cytochrome P450 [CYP] 3A in the gut and liver. In view of the central role of CYP3A in the clearance of many different kinds of drugs, and the fact that many patients with COVID-19 are taking multiple drugs to treat other conditions, it is important to assess the potential for drug interactions when nirmatrelvir/r is given, and to minimize the risks associated with such interactions. We defined the interaction profile of ritonavir on the basis of information derived from two databases (Medline, GoogleScholar), three standard electronic texts on drug interactions, and manufacturer-supplied drug information. We compiled a list of drugs and their potentially relevant interactions, developed a risk min - imization algorithm, and applied it to the substances in question. We also compiled a list of commonly prescribed drugs for which there is no risk of interaction with nirmatrelvir/r. Out of 190 drugs and drug combinations, 57 do not need any special measures when given in combination with brief, low-dose ritonavir treatment, while 15 require dose modification or a therapeutic alternative, 8 can be temporarily discontinued, 9 contraindicate ritonavir use, and 102 should preferably be combined with a different treatment. We have proposed measures that are simple to carry out for the main types of drug that can interact with ritonavir. These measures can be implemented under quarantine conditions before starting a 5-day treatment with nirmatrelvir/r.

A dossier on COVID-19 chronicle.

The dissemination of the 2019 novel coronavirus (2019-nCoV) is presenting the planet with a new health emergency response or threat to health. The virus emerged in bats and was disseminated to humans in December 2019 via still unknown intermediate species in Wuhan, China. It is disseminated by inhalation or breaks out with infected droplets and the incubation period is between 2 and 14days. The symptoms usually include high body temperature, cough, sore throat, dyspnea, low energy or tiredness, and weakness. The condition is moderate in most people; but in the elderly and those with comorbidities, it advances to pneumonia, acute respiratory distress syndrome (ARDS), and multiple organ failure. Popular research work includes normal/low WBC with upraised C-reactive protein (CRP). Treatment is generally supportive and requires home seclusion of suspected persons and rigorous infection control methods at hospitals. The Covid-19 has lower fatality than SARS and MERS. Among the proposed therapeutic regimen, hydroxychloroquine, chloroquine, remdisevir, azithromycin, toclizumab, and cromostat mesylate have shown promising results, and the limited benefit was seen with lopinavir-ritonavir treatment in hospitalized adult patients with severe COVID-19. Early development of the SARS-CoV-2 vaccine started based on the full-length genome analysis of severe acute respiratory syndrome coronavirus. Several subunit vaccines, peptides, nucleic acids, plant-derived, and recombinant vaccines are under pipeline. Research work, development of new medicines and vaccines, and efforts to reduce disease morbidity and mortality must be encouraged to improve our position in the fight against this disease and to protect human life.

Antiviral monotherapy for hospitalised patients with COVID-19 is not enough

In The Lancet, the RECOVERY Collaborative Group1 report the clinical results from the RECOVERY trial—one of the largest and most productive platform trials to date among patients admitted to hospital with COVID-19—on the effectiveness of lopinavir–ritonavir treatment. Compared with the first randomised trial to investigate lopinavir–ritonavir in patients with COVID-19 by Cao and colleagues (including the authors of this Comment),2 the size of the lopinavir–ritonavir group in the RECOVERY trial was much larger and hence provides a more solid evidence base regarding possible lopinavir–ritonavir treatment effects.

An evidence-based systematic review on emerging therapeutic and preventive strategies to treat novel coronavirus (SARS-CoV-2) during an outbreak scenario.

A novel coronavirus infection coronavirus disease 2019 (COVID-19) emerged from Wuhan, Hubei Province of China, in December 2019 caused by SARS-CoV-2 is believed to be originated from bats in the local wet markets. Later, animal to human and human-to-human transmission of the virus began and resulting in widespread respiratory illness worldwide to around more than 180 countries. The World Health Organization declared this disease as a pandemic in March 2020. There is no clinically approved antiviral drug or vaccine available to be used against COVID-19. Nevertheless, few broad-spectrum antiviral drugs have been studied against COVID-19 in clinical trials with clinical recovery. In the current review, we summarize the morphology and pathogenesis of COVID-19 infection. A strong rational groundwork was made keeping the focus on current development of therapeutic agents and vaccines for SARS-CoV-2. Among the proposed therapeutic regimen, hydroxychloroquine, chloroquine, remdisevir, azithromycin, toclizumab and cromostat mesylate have shown promising results, and limited benefit was seen with lopinavir-ritonavir treatment in hospitalized adult patients with severe COVID-19. Early development of SARS-CoV-2 vaccine started based on the full-length genome analysis of severe acute respiratory syndrome coronavirus. Several subunit vaccines, peptides, nucleic acids, plant-derived, recombinant vaccines are under pipeline. This article concludes and highlights ongoing advances in drug repurposing, therapeutics and vaccines to counter COVID-19, which collectively could enable efforts to halt the pandemic virus infection.

Possible Retinal Impairment Secondary to Ritonavir Use in SARS-CoV-2 Patients: A Narrative Systematic Review.

Some reports described a possible ritonavir-related retinal toxicity. The objective of this research was to review and analyze previous studies conducted on ritonavir administration and retinal impairment in a narrative synthesis. PubMed was used to perform a systematic review of ritonavir effects and retinal damage. All studies up to December 2019 were considered. Seven single cases and one case series, reporting a total of 10 patients affected by retinal changes secondary to long-term ritonavir treatment, were included in the review. Variable degrees of outer retina and retinal pigment epithelium changes were detected in most of the patients, with two patients showing macular telangiectasia, four patients presenting intraretinal crystal deposits, two patients disclosing a bull's eye maculopathy, and two patients revealing midperipheral bone spicule-like pigment changes. In the present study, we hypothesized that the use of ritonavir in life-saving treatments of severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) pneumonia might expose these patients to the risk of developing a retinotoxicity. We aimed to alert ophthalmologists on the importance of recognizing ritonavir-induced retinal impairment in SARS-CoV-2 patients. These findings are the target for personalized medicine.

Clinical Analysis of 25 COVID-19 Infections in Children.

To describe the characteristics of clinical manifestations of children with 2019 novel coronavirus (2019-nCoV) infection in Chongqing. All 25 children with laboratory-confirmed 2019-nCoV infection by real-time reverse transcription-PCR (RNA-PCR) were admitted from the 4 designated treatment hospitals of 2019-nCoV in Chongqing from January 19 to March 12, 2020. Clinical data and epidemiologic history of these patients were retrospectively collected and analyzed. The diagnosis was confirmed through RNA-PCR testing. Among the 25 cases, 14 were males and 11 were females. The median age was 11.0 (6.3-14.5) years (range 0.6-17.0 years). All children were related to a family cluster outbreak, and 7 children (28%) with a travel or residence history in Hubei Province. These patients could be categorized into different clinical types, including 8 (32%) asymptomatic, 4 (16%) very mild cases and 13 (52%) common cases. No severe or critical cases were identified. The most common symptoms were cough (13 cases, 52%) and fever (6 cases, 24%). The duration time of clinical symptoms was 13.0 (8.0-25.0) days. In the 25 cases, on admission, 21 cases (84%) had normal white blood cell counts, while only 2 cases (8%) more than 10 × 10/L and 2 cases (8%) less than 4 × 10/L, respectively; 22 cases(88%) had normal CD4+ T lymphocyte counts, while in the remaining 3 cases(8%) this increased mildly; 23 cases had normal CD8+ T lymphocyte counts, while in the remaining 2 cases (8%) CD8+ T lymphocyte counts were mildly increased as well. All Lymphocyte counts were normal. There were no statistical differences of lab results between the groups of asymptomatic cases, mild cases and common cases. There were only 13 cases with abnormal CT imaging, most of which were located in the subpleural area of the bottom of the lung. All patients were treated with interferon, 6 cases combined with Ribavirin, and 12 cases combined with lopinavir or ritonavir. The days from onset to RNA turning negative was 15.20 ± 6.54 days. There was no significant difference of RNA turning negative between the groups of interferon, interferon plus ribavirin and interferon plus lopinavir or ritonavir treatment. All the cases recovered and were discharged from hospital. The morbidity of 2019-nCoV infection in children is lower than in adults and the clinical manifestations and inflammatory biomarkers in children are nonspecific and milder than that in adults. RNA-PCR test is still the most reliable diagnostic method, especially for asymptomatic patients.

Persistent Immune Activation in HIV-1-Infected Ex Vivo Model Tissues Subjected to Antiretroviral Therapy: Soluble and Extracellular Vesicle-Associated Cytokines.

Residual immune activation after successful antiretroviral therapy (ART) in HIV-1-infected patients is associated with the increased risk of complications. Cytokines, both soluble and extracellular vesicle (EV)-associated, may play an important role in this immune activation. Ex vivo tissues were infected with X4LAI04 or R5SF162 HIV-1. Virus replicated for 16 days, or tissues were treated with the anti-retroviral drug ritonavir. Viral replication and production of 33 cytokines in soluble and EV-associated forms were measured with multiplexed bead-based assays. Both variants of HIV-1 efficiently replicated in tissues and triggered upregulation of soluble cytokines, including IL-1β, IL-7, IL-18, IFN-γ, MIP-1α, MIP-1β, and RANTES. A similar pattern was observed in EV-associated cytokine release by HIV-infected tissues. In addition, TNF-α and RANTES demonstrated a significant shift to a more soluble form compared with EV-associated cytokines. Ritonavir treatment efficiently suppressed viral replication; however, both soluble and EV-associated cytokines remained largely upregulated after 13 days of treatment. EV-associated cytokines were more likely to remain elevated after ART. Treatment of uninfected tissues with ritonavir itself did not affect cytokine release. We demonstrated that HIV-1 infection of ex vivo lymphoid tissues resulted in their immune activation as evaluated by upregulation of various cytokines, both soluble and EV-associated. This upregulation persisted despite inhibition of viral replication by ART. Thus, similar to in vivo, HIV-1-infected human tissues ex vivo continue to be immune-activated after viral suppression, providing a new laboratory model to study this phenomenon.

The protease inhibition with Ritonavir impairs endothelial function and promotes vascular smooth cell proliferation via RANTES/C‐C chemokine receptor type 5 and Nox1‐derived reactive oxygen species pathway.

Thanks to the advent of highly active antiretroviral therapy (HAART), the life of people living with HIV has been extended to close to that of healthy people. However, patients with HIV are now presenting with accelerated development of cardiovascular disease (CVD) and CVD is currently the leading cause of death in patients with HIV on HAART. Herein, we tested the hypothesis that the protease inhibitor ritonavir contributes to HAART‐associated CVD by impairing vascular function via C‐C chemokine receptor type 5 (CCR5)‐ and reactive oxygen species‐mediated mechanisms. We treated 8–10‐week‐old male C57BL6/J with ritonavir for 4 consecutive weeks (5mg/kg/day, i.p). At the end of the treatment, blood was collected and aortas excised to measure H2O2 via Amplex Red and vascular function via wire myography. Aorta from ritonavir treated animals exhibited higher H2O2 levels, impaired relaxation to acetylcholine (Ach) and increased contractility to phenylephrine (Phe). Nox1 inhibition with GKT771, (10μM) fully restored endothelial function in rings from ritonavir treated animals. Ritonavir treatment also elevated RANTES (CCR5 ligand) plasma levels, as well as CCR5, NADPH oxidase 1 (Nox1) and NoxA1 transcript levels in the aorta. No difference was observed for others oxidases, such as Nox2 and Nox4. Repetition of the ritonavir treatment in CCR5 deficient mice revealed that CCR5 deficiency protects vessels from ritonavir induced‐endothelial dysfunction and upregulation of Nox1 and NoxA1 enzymes. To analyze the direct effects of RANTES on the vasculature, thoracic aorta, endothelial, and vascular smooth muscle cells were exposed to RANTES in different times (20ng/mL). RANTES elevated endothelial NOX1 expression and impaired ACh‐mediated relaxation. Concomitantly, Nox1 inhibition prevented RANTES‐mediated endothelial dysfunction. In addition, RANTES time‐dependently stimulated rat aortic smooth muscle cell proliferation, as measured by Ki67 expression, which was partially reverted by Nox1 inhibition. Our data suggest that the protease inhibitor ritonavir contributes to vascular dysfunction and cardiovascular disease by increasing RANTES‐mediated CCR5 activation ultimately leading to increases in Nox1 expression, ROS production, endothelial dysfunction and vascular smooth muscle cell proliferation. Taken together, these findings provide potential explanation for the increased risk of cardiovascular disease developed by patients living with HIV and present CCR5 as a potential target for treatment.Support or Funding Information1R01HL130301‐01 to EBC; K99: 1K99HL140139‐01A1; R00: 4R00HL140139‐03 to TBN

A Trial of Lopinavir–Ritonavir in Adults Hospitalized with Severe Covid-19

BackgroundNo therapeutics have yet been proven effective for the treatment of severe illness caused by SARS-CoV-2.MethodsWe conducted a randomized, controlled, open-label trial involving hospitalized adult patients with confirmed SARS-CoV-2 infection, which causes the respiratory illness Covid-19, and an oxygen saturation (Sao2) of 94% or less while they were breathing ambient air or a ratio of the partial pressure of oxygen (Pao2) to the fraction of inspired oxygen (Fio2) of less than 300 mm Hg. Patients were randomly assigned in a 1:1 ratio to receive either lopinavir–ritonavir (400 mg and 100 mg, respectively) twice a day for 14 days, in addition to standard care, or standard care alone. The primary end point was the time to clinical improvement, defined as the time from randomization to either an improvement of two points on a seven-category ordinal scale or discharge from the hospital, whichever came first.ResultsA total of 199 patients with laboratory-confirmed SARS-CoV-2 infection underwent randomization; 99 were assigned to the lopinavir–ritonavir group, and 100 to the standard-care group. Treatment with lopinavir–ritonavir was not associated with a difference from standard care in the time to clinical improvement (hazard ratio for clinical improvement, 1.31; 95% confidence interval [CI], 0.95 to 1.80). Mortality at 28 days was similar in the lopinavir–ritonavir group and the standard-care group (19.2% vs. 25.0%; difference, −5.8 percentage points; 95% CI, −17.3 to 5.7). The percentages of patients with detectable viral RNA at various time points were similar. In a modified intention-to-treat analysis, lopinavir–ritonavir led to a median time to clinical improvement that was shorter by 1 day than that observed with standard care (hazard ratio, 1.39; 95% CI, 1.00 to 1.91). Gastrointestinal adverse events were more common in the lopinavir–ritonavir group, but serious adverse events were more common in the standard-care group. Lopinavir–ritonavir treatment was stopped early in 13 patients (13.8%) because of adverse events.ConclusionsIn hospitalized adult patients with severe Covid-19, no benefit was observed with lopinavir–ritonavir treatment beyond standard care. Future trials in patients with severe illness may help to confirm or exclude the possibility of a treatment benefit. (Funded by Major Projects of National Science and Technology on New Drug Creation and Development and others; Chinese Clinical Trial Register number, ChiCTR2000029308.)

Ginsenoside Rb1 Blocks Ritonavir-Induced Oxidative Stress and eNOS Downregulation through Activation of Estrogen Receptor-Beta and Upregulation of SOD in Human Endothelial Cells.

We have previously shown that ritonavir (RTV), a highly active anti-retroviral therapy (HAART) drug, can cause endothelial dysfunction through oxidative stress. Several antioxidants including ginsenoside Rb1, a compound with antioxidant effect, can effectively block this side effect of RTV in endothelial cells. In the current study, we explored a mechanism by which ginsenoside Rb1 could protect these cells via binding of estrogen receptors (ERs). We found that several human endothelial cell lines differentially expressed ER-β and had very low levels of ER-α. RTV treatment significantly increased the production of reactive oxygen species (ROS) and decreased the expression of endothelial nitric oxidase synthase (eNOS) and superoxide dismutase (SOD) in HUVECs, while Rb1 effectively blocked these effects of RTV. These effects of Rb1 were effectively inhibited by silencing ER-β, indicating that ginsenoside Rb1 requires ER-β for its antioxidant activity in inhibiting the deleterious effect of RTV in human endothelial cells. Furthermore, Rb1 specifically activated ER-β transactivation activity by ER-β luciferase reporter assay. Rb1 competitively bound to ER-β, which was determined by the high sensitive fluorescent polarization assay.

Endoplasmic reticulum stress leads to mitochondria-mediated apoptosis in cells treated with anti-HIV protease inhibitor ritonavir.

Endoplasmic reticulum (ER) stress is a growing concern for drug-induced toxicity which causes several side effects. Ritonavir, a potent HIV protease inhibitor, induces both ER and mitochondrial stress; however, the missing link between ER stress and mitochondrial damage has been unknown. In the present study, we have studied the sequential events that occur during ritonavir-induced cell cytotoxicity and elucidate the link between ER stress and mitochondrial damage. Cytotoxicity of ritonavir was calculated on different cells; Huh-7.5, 293T, HeLa, and Hepa RG cells using the MTT assay and also by measuring total protein content. Cellular stress response was evaluated by RT-PCR for stress marker genes. Entry of drug into the mitochondrial compartment was evaluated by HPLC. Mitochondria-mediated apoptosis was analyzed by western blotting. Ritonavir treatment initially triggered ER stress during the early hours of treatment. Consequently, the BAX was activated which permeabilized the mitochondrial outer membrane. Simultaneously, upon entry of the drug into the mitochondrial compartment, change in mitochondrial membrane potential was observed which led to the release of cytochrome c in the cytoplasm. Release of cytochrome c activated mitochondria-mediated apoptosis by the activation of caspase-9/7 and parp-1. The cytotoxic effects of ritonavir involved the interplay of ER stress and mitochondria-mediated apoptosis. This unusual mechanism of drug-induced toxicity expands our knowledge in understanding side effects caused by ritonavir.