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This article comes from WeChat WeChat official account:With freehand brushwork biotech (Biotech(ID：TXYBiotech), Author: Yang Yi, original title: "Anti-influenza drugs and market analysis", title map from: vision china.

The ugly SARS-CoV-19 has not been completely conquered by human beings, and the lingering influenza virus has begun to wreak havoc again. The struggle between human beings and viruses is like this."Scientific Progress-Virus Variation and Drug Resistance"It spirals up in this cycle. The periodic spread of seasonal influenza virus makes the importance of anti-influenza drug development stand out again.

Oseltamivir, which went on the market 24 years ago, is still the mainstay of anti-influenza drugs. Although the first new drug, Baloshavir, enriched the team of anti-influenza drugs, it went on the market five years ago. After learning the cruelty of SARS-CoV-19 virus, people need to make a breakthrough in the development of influenza drugs.

I. Classification of seasonal influenza

Seasonal influenza（Seasonal influenza）It is an acute respiratory infectious disease caused by influenza virus prevalent all over the world. There are four types of seasonal influenza viruses, A, B, C and D.(Chinese corresponds to influenza A, B, C and D). Influenza A and B viruses spread and cause seasonal epidemics.（seasonal epidemics）.

According to the hemagglutinin on the surface of the virus（HA， hemagglutinin）And neuraminidase（NA， neuraminidase）The combination of influenza A virus is further divided into different subtypes. At present, subtype A is transmitted among humans.（H1N1）And a（H3N2）Influenza virus. A（H1N1）Influenza virus is also written as A.（H1N1）Pdm09, because it caused a pandemic in 2009, replaced the seasonal influenza A spread before 2009.（H1N1）Viruses.

Only influenza A virus is known to cause a pandemic at present. Influenza B virus is not classified into subtypes, but can be classified into lineages. The currently popular influenza B virus belongs to B/Yamagata or B/Victoria pedigree. The detection frequency of influenza C virus is low, which usually causes mild infection, so it is not of public health importance. Influenza D virus mainly affects cattle and does not infect or cause human diseases.^[1]

Second, influenza treatment

Seasonal flu patients without complications, if they have symptoms, stay at home and do their bit to reduce the spread of the virus. By means of self-monitoring, we can decide whether to seek medical treatment.

Patients suffering from serious or progressive clinical diseases related to influenza, that is, pneumonia, septicemia or clinical syndrome aggravated by chronic basic diseases, should receive antiviral drugs as soon as possible. The most common anti-influenza drugs are neuraminidase inhibitors.（Neuraminidase inhibitors）Oseltamivir（oseltamivir）. Ideally, it should be taken within 48 hours of symptoms to maximize the curative effect. It is recommended to treat for at least 5 days, but it can be extended until the clinical improvement is satisfactory.

It should be noted that corticosteroids should not be used for influenza.(corticosteroid, such as prednisone, cortisone, hydrocortisone, etc.)Unless there are other reasons.(e.g. asthma and other specific conditions)Because corticosteroids may lead to prolonged virus clearance time and double infection of bacteria or fungi caused by immunosuppression.

At present, all popular influenza viruses are resistant to adamantane antiviral drugs.(Adamantane antivirals, such as amantadine and rimantadine)Because of their drug resistance, these drugs are not recommended for monotherapy.^[1]

Third, anti-influenza drugs

The main anti-influenza drugs are divided into adamantane, neuraminidase inhibitors and polymerase inhibitors.(Table 1).^[2]There are four kinds of anti-influenza drugs approved by FDA recommended by the Centers for Disease Control and Prevention: Rapivab. （peramivir），Relenza（zanamivir），Tamiflu （oseltamivir phosphate）And Xofluza（baloxavir marboxil）.^[3]

Table 1. Antiinfluenza drugs

1. Neuraminidase inhibitors（Neuraminidase inhibitors）　

Neuraminidase inhibitor（NAI）Targeted neuraminidase（NA）Glycoprotein, which is second only to hemagglutinin in human body.（HA）The most abundant surface glycoprotein. Neuraminidase inhibitors can achieve antiviral effect by inhibiting the emergence of new virus particles in host cells and preventing the enzyme activity necessary for virus transmission.^[4]

The four most common neuraminidase inhibitors are oseltamivir, zanamivir, peramivir and laninamivir.(Figure 1).

Fig. 1. Common neuraminidase inhibitors and their molecular structures.

Although their structures are similar, there are obvious differences in treatment schemes, routes of administration and drug resistance. The most widely used neuraminidase inhibitor is oseltamivir.(Trade name: Tamiflu)The treatment plan for adults is 75mg twice a day for 5 days. Due to zanamivir(trade name Relenza)The oral bioavailability of is low.（<5%）Therefore, it is approved as an inhalation drug, 5mg each time, twice a day for 5 days.

In 2019, intravenous zanamivir(trade name Dectova)Authorized by the European Union to be used under special circumstances.(e.g. in case of resistance to other anti-influenza drugs). Efforts to increase bioavailability and half-life have led to peramivir.(Trade name: Rapivab/Rapiacta/PeramiFlu)Development of, by intravenous infusion with a single dose of 600mg; And ranimivir (trade name Inavir), a more persistent neuraminidase inhibitor, showed therapeutic effect after a single nasal inhalation dose.^[5] Paramivir and Ranimivir are allowed to be used in a few countries around the world, while oseltamivir and zanamivir are more widely approved geographically.

Different neuraminidase inhibitors show different efficacy, which mainly depends on the subtype/pedigree of influenza virus that infects patients.For example, oseltamivir versus A（H1N1）, a（H3N2）And the seasonal uncomplicated influenza caused by influenza A and B virus is more effective. However, the effect of antiviral therapy may be limited by the resistance of influenza virus to neuraminidase inhibitors. Different neuraminidase inhibitors have different drug resistance.

In view of the drug resistance of common neuraminidase inhibitors, people are now focusing on emerging drugs in research. At least two new neuraminidase inhibitors and one neuraminidase blocker are in the first and second development stages.

HNC042(Guangzhou Hengnuokang Pharmaceutical Technology Co., Ltd. and Heilongjiang Zhenbaodao Pharmaceutical Co., Ltd.)In preclinical studies, it showed effective inhibitory activity against wild-type and oseltamivir-resistant NA-H274Y virus. HNC042 showed good safety, tolerability and linear pharmacokinetics in phase I trials in the United States.Learning (NCT04603989). HNC042 is used to prevent and treat influenza, especially for critically ill patients who need hospitalization.

AV5080(ChemRar, Russia, Viriom, USA, Figure 2)The preclinical evaluation revealed the activity against a variety of influenza viruses, including oseltamivir-resistant strains. Oral AV5080 shows good physicochemical and metabolic characteristics and good pharmacokinetic characteristics in animals.^[6]

Fig. 2. chemical structure of a new neuraminidase inhibitor drug candidate AV5080.

CD388 (Cidora Therapeutics Inc., USA)It is a long-acting neuraminidase blocker, and its structure is obtained by coupling neuraminidase of influenza virus to human antibody fragment.(Fc）Proprietary variants of the domain, so as to achieve two completely different and complementary mechanisms.(Figure 3). This new method of preventing and treating virus infection is expected to provide universal protection throughout the flu season. By targeting highly conserved virus areas, CD388 can potentially protect individuals from all influenza strains, including seasonal and pandemic influenza A, influenza B and major drug-resistant viruses with clinical characteristics.（NCT05523089）.

Figure 3. Schematic diagram of CDD components. (Source: CIDARA Therapeutics)

2. Polymerase inhibitors（Polymerase Inhibitors）　

Influenza virus RNA polymerase is very important for virus gene transcription and genome replication, which makes it the main goal of targeted drug design. They are highly conserved among influenza A, B, C and D viruses.^[7] Influenza virus RNA polymerase consists of three subunits: polymerase basic protein 1 in influenza A and B viruses. （PB1）Polymerase basic protein 2（PB2）And polymerase acidic protein.（PA）Or polymerase 3 protein in influenza viruses C and D.(P3) (Figure 4).

Fig. 4. Virus ribonucleoprotein (vRNP) complex model. In vRNP, the 5′ and 3′ ends of genomic antisense virus RNA (vRNA) fragment are bound by heterotrimeric RNA-dependent RNA polymerase, and the rest of vRNA is wrapped by nucleoprotein (NP). The complex is twisted into an antiparallel double helix structure, and its structure is maintained by the contact between NP monomers. The vRNA forms a loop opposite to the polymerase binding end 6. (Source: Nature)

The active sites of polymerase that bind, cleave and extend RNA are conserved in various types of influenza viruses, which is why RNA-dependent RNA polymerase is considered as the target of antiviral agents. Recently, several polymerase inhibitors have been developed for each subunit, including PB1 inhibitor favipiravir, PB2 inhibitor pimodivir and PA inhibitor baloxavir marboxil (Figure 5).

Among them, baloxavir marboxil is a relatively new drug, which belongs to hat-dependent endonuclease inhibitor.（cap-dependent endonuclease inhibitor， CENI）, a new anti-influenza drug with a new mechanism of action initiated in recent 20 years, was developed by Shionogi.（Shionogi）First developed by Pharmaceutical Co., Ltd., there is no equivalent generic drug, which has been proved to have similar symptom relief time and greater viral load reduction for healthy adults and oseltamivir.^[8]A retrospective study shows that baloxavir marboxil may reduce the hospitalization rate compared with neuraminidase inhibitors.^[9]

Fig. 5. Chemical structure of anti-influenza drugs of RNA polymerase inhibitors.

The drug resistance of Baloxavir marboxil, Favipiravir and Pimodivir and other defects highlight the need to develop other polymerase targeting molecules that can widely inhibit influenza A and B viruses.

Pre-clinical studies on various PB2-targeted small molecules are under way.^[10]At least one of them（CC-42344） In the first stage（NCT05202379）, the other one（ZSP1273）In the third stage of research(NCT04024137) (Figure 7). Substitutes for nucleoside inhibitors of Favipiravir, such as molnupiravir.(Figure 6)Because it is effective against various RNA viruses, it may be beneficial to the treatment of influenza, but they may also have teratogenic side effects similar to Favipiravir, so Merck, its developer, finally gave up the development of influenza viruses and turned to Covid-19 for treatment.The development of PB1 inhibitors based on nucleoside and non-nucleoside is in preclinical stage.^[11]But there is no clinical trial at present.

Baloxavir marboxil obviously provides a broad idea for developing polymerase inhibitor anti-influenza drugs, and many patents and in vitro studies focus on compounds or variants of Baloxavir marboxil skeleton.^[12] Although some of them have shown promising in vitro efficacy and pharmacodynamics in mice,^[13]However, candidate drugs such as AL-749 did not pass the Phase I test.

Cap-dependent endonuclease inhibitor TG-1000 (Dongyangguang Pharmaceutical)And GP681(Jiangxi Qingfeng and Yinxingshu Pharmaceutical Co-developed)Recently completed the second phase of the experiment.（NCT04706468、NCT04736758), and the recruitment of ZX-7101A phase 1 research is under way.（NCT05217732）. Various small molecules and peptides that disrupt the important protein-protein interaction between components of polymerase complex, including the key contact between PA and PB1 or between PB1 and PB2, are in the preclinical development stage.^[14]

Fig. 6. Chemical structure of a new polymerase inhibitor molnupiravir.

Fourth, the global market of anti-influenza drugs

According to the latest report released by Growth Plus Reports, the global influenza drug market is expected to reach US$ 1.51 billion by 2030, and it will grow at a compound annual growth rate of 4.8% during the forecast period. The number of influenza cases increases sharply every year, which is expected to promote the sustained growth of the influenza drug market.^[15]

North America accounts for most of the global influenza drug market.The high diagnosis rate of influenza, the wider basis of drug discovery and development, the wide availability of treatment methods, and the more significant medical expenditure contribute to the dominant position of influenza drugs in the North American market. The Asia-Pacific region has the second largest market share of influenza drugs in the world. The high prevalence rate, the government’s measures to control diseases, and the increase in health care expenditure have affected this growth.

Due to the increasing incidence of diseases and the existence of considerable influenza-related risk factors in the general population, it is expected that the European market will also see significant growth. NCBI(National Biotechnology Information Center)According to a new study, there are 27,600 respiratory deaths related to seasonal influenza in 28 EU countries every winter, of which 88% are people over 65. The mortality rate of this age group is about 35 times that of people aged 65 and under.

The main participants in the development and sales of influenza drugs include: Sanofi, Lupin, Teva, Shionogi, Macleods, Alvogen, AstraZaneca, BioCryst, La Roche, Novartis, Vitaris, etc.

V. Summary　

Although it is not as ugly as SARS-CoV-2 virus, influenza virus also kills many people, and treating influenza is still an arduous challenge for human beings. Like other antiviral drugs, the development of influenza drugs faces the difficulty of virus resistance. Baloxavir marboxil is the first new drug, which shows activity against some oseltamivir-resistant strains, and there is no significant difference in safety and effectiveness from the recently known drugs used to treat influenza. The listing of Baloxavir marboxil also brings new opportunities for combined treatment with two drugs with different mechanisms of action. Although this kind of research has not been carried out systematically, it provides a valuable new direction for influenza treatment.

In addition to Baloxavir marboxil, there are many drugs under research at different clinical stages.(Figure 7)They will be optimized in pharmacology, drug resistance, pharmacokinetics, etc., and stand on the shoulders of a few influenza drugs at present to launch a unremitting struggle against influenza virus.

Fig. 7. Overview of anti-influenza drugs in development. (Source: Antiviral Research)

References:

[1] WHO. Influenza (Seasonal). 12， 01， 2023. ↑[] Jones， J. C. et al. Influenza antivirals and their role in pandemic preparedness. Antiviral Research. 2023， 210， 105499.　

[2] Influenza (Flu) Antiviral Drugs and Related Information. FDA. 08， 12， 2022.　　

[3] Monto， A. S. et al. Influenza pandemics: history and lessons learned. Webster， R. G. et al (Eds.)， Textbook of Influenza (2 ed.)， Wiley Blackwell， West Sussex， United Kingdom (2013)， pp. 20-36　　

[4] Sugaya， N. et al. Long-acting neuraminidase inhibitor laninamivir octanoate (CS-8958) versus oseltamivir as treatment for children with influenza virus infection. Antimicrob. Agents Chemother. 2010， 54， 2575-2582

[5] Ivachtchenko， A. V. et al. Novel oral anti-influenza drug candidate AV5080. J. Antimicrob. Chemother. 2014， 69， 1892-1902.　　

[6] Peng， Q. et al. Structural insight into RNA synthesis by influenza D polymerase. Nat Microbiol. 2019， 4， 1750–1759.　　

[7] Hayden， F. G. et al. Baloxavir marboxil for uncomplicated influenza in adults and adolescentsN. Engl. J. Med. 2018， 379， 913-923.　

[8] Komeda， T. et al. Comparison of hospitalization incidence in influenza outpatients treated with baloxavir marboxil or neuraminidase inhibitors: a health insur ance claims database studyClin. Infect. Dis.， 2021， 73， e1181-e1190.　

[9] Chen， W. et al.　 Approaches for discovery of small-molecular antivirals targeting to influenza A virus PB2 subunit. Drug Discov. Today. 2022， 27， 1545-1553.　

[10] Hou， L. et al. Contemporary medicinal chemistry strategies for the discovery and optimization of influenza inhibitors targeting vRNP constituent proteins. Acta Pharm. Sin. B. 2022， 12， 1805-1824.　　

[11] Stevaert， A. et al. The influenza virus polymerase complex: an update on its structure， functions， and significance for antiviral drug design. Med. Res. Rev. 2016， 36， 1127-1173.　

[12] Ivashchenko， A. A. et al. Synthesis， inhibitory activity and oral dosing formulation of AV5124， the structural analogue of influenza virus endonuclease inhibitor baloxavir. J. Antimicrob. Chemother. 2021， 76， 1010-1018.　

[13] Massari， S. et al. Inhibition of influenza virus polymerase by interfering with its protein-protein interactions. ACS Infect. Dis. 2021， 7， 1332-1350.

[14] Influenza Medication Market – Global Outlook & Forecast 2022-2030. Growth Plus. 11， 10， 2022.　

This article comes from WeChat WeChat official account:With freehand brushwork biotech (Biotech(ID：TXYBiotech), author: Yang Yi

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　　Xinhua News Agency, Beijing, November 22 Question: Do you know the N things that make China a space power? – Uncovering a new blueprint for China’s space exploration dream

　　Xinhua News Agency reporters, Chen Fang, Yu Xiaojie, Hu Zhe

　　Tiangong, Tianyan, Wukong, Mozi… In the report of the 19th National Congress of the Communist Party of China, major breakthroughs in the aerospace field were "named". Aerospace powers "draw" a grand blueprint for building a modern socialist power in an all-round way.

　　The Beidou satellite navigation system has entered the era of global networking, and the Fengyun meteorological satellite "family" has added new members… In less than a month after the 19th National Congress of the Communist Party of China, China’s aerospace activities have been frequent. Facing the future, what new wonders will China’s aerospace write?

　　Long March 8’s maiden flight, rocket recycling: China’s aerospace "major project" takes over

　　Aerospace powers usually have advanced space power and large-scale launches, and can carry out lunar sampling and return, Mars landing and exploration, and build and operate space stations. Behind these "landmark" events, a country’s advanced manufacturing capabilities in design, technology, and materials, as well as the ability to coordinate multi-system research such as probes, launch sites, and measurement and control.

　　On November 16, the Academy of Launch Vehicle Technology of China Aerospace Science and Technology Corporation released the "2017-2045 Space Transportation System Development Roadmap", systematically planning the capacity building prospects and development blueprint of the Long March series of launch vehicles.

　　The Long March 8 will make its maiden flight in 2020, the heavy launch vehicle will make its maiden flight around 2030, the launch vehicle will be fully reused around 2035, the future generation of launch vehicles will be put into use around 2040, and the ability of large-scale man-machine collaborative exploration of space will be available in 2045…

　　Qin Xudong, deputy director of the General Office of the First Hospital of China Aerospace Science and Technology Corporation, introduced that the roadmap issued this time is detailed and has clear goals, whether it is hot topics such as space tourism and recyclable rockets that the public is more concerned about, or future smart rockets, manned moon landings, manned Mars landings, etc.

　　In order to explore the mysteries of the starry sky, generation after generation of astronauts have continued to struggle, our country has successfully developed more than ten types of Long March series carrier rockets, forming satellites, spacecraft and other spacecraft to any orbit of the earth, with the carrying capacity to carry out lunar and deep space exploration, which has strongly supported the successful implementation of major national projects such as "manned spaceflight", "Beidou navigation" and "lunar exploration".

　　The white paper "2016 China’s Aerospace" shows that since 2011, China’s aerospace industry has continued to develop rapidly, with a significant increase in its independent innovation capabilities and a significant increase in its ability to enter space.

　　Wu Yanhua, deputy director of the State Administration of Science and Industry for National Defense and deputy director of the National Space Administration, said that over the past 60 years, China’s aerospace industry has achieved a series of brilliant achievements represented by "two bombs and one satellite", manned spaceflight, and lunar exploration. With China’s continuous research on key technologies such as heavy-duty rockets, non-toxic and non-polluting medium-sized rockets, and low-cost transportation rockets in the future, China’s ability to enter space will be further enhanced, and the pace of exploration of the vast universe will be faster and faster.

　　Beidou to navigate, the wind and clouds to know the sky: will space tourism still be far away?

　　China’s aerospace industry is getting stronger and stronger. Will the space tourism expected by ordinary people be far behind? According to the plan, suborbital space tourism will become a reality around 2025.

　　In the future, commercial solid launch vehicles will work together with liquid launch vehicles to provide users with diverse, low-cost, and highly reliable commercial launch services such as "space hitchhiker", "space shuttle", and "VIP special car", providing a richer range of vehicles for humanity to jointly explore the universe.

　　Tang Yagang, president of China Aerospace Science and Technology Corporation’s First Institute Rocket Company, introduced that by around 2035, our country’s launch vehicles will be fully reused, and more ordinary people can take two-stage reusable vehicles to travel in space, enjoy the vastness of space and the splendor of the earth in the earth’s orbit, and realize the dream of flying.

　　Whether it is the Beidou-3 satellite that "shocks the world" or the Fengyun-3 satellite that "watches the wind and clouds and knows the sky", a batch of "high-end" aerospace technology has gradually been "transformed" into a convenient "welfare": no matter where you are, "Beidou" will help you navigate; without leaving home, "Fengyun" will help you know the sky; surfing the Internet and making phone calls in a plane at an altitude of 10,000 meters is no longer a dream.

　　On November 15, our country’s first interferometric hyperspectral greenhouse gas monitor, the Suifengyun-3 satellite, successfully entered the scheduled orbit of space. This "eye" can not only observe a variety of atmospheric components, but also detect the change in the concentration of carbon dioxide in the air by 4 parts per million, making it a powerful tool for scientists to study the carbon cycle. In its birthplace, the 508 Institute of the Fifth Academy of China Aerospace Science and Technology Corporation, it is understood that it has ranked 156th among the "brothers and sisters" of remote sensors that enter space and operate in orbit from here.

　　"China’s aerospace industry has long been more than just a representative of the’tall ‘." Gao Hongwei, chairperson of China Aerospace Science and Industry Corporation, believes that the needs and calls of the people are the voice of the times for scientific and technological progress and innovation. At present, more than 2,000 aerospace technology achievements in our country have benefited the national economy and people’s lives.

　　Mars and asteroids take turns to appear: the mystery of the starry sky never stops

　　Facing the future, there are still many "big moves" in our country’s aerospace industry. According to the relevant person in charge of the National Space Administration, in addition to continuing to implement existing projects, a number of new major aerospace projects will also be launched one after another, including deep space exploration projects represented by Mars exploration, asteroid exploration, planetary crossing exploration, and the much-watched "moon exploration project".

　　Lei Fanpei, chairperson of China Aerospace Science and Technology Corporation, said that by 2020, our country strives to achieve more than 200 spacecraft in orbit and about 30 launches a year, basically reaching the level of the world’s aerospace powers.

　　"At present, 30% of our country’s aerospace technology indicators have reached the international first-class level. By 2030, we will strive to increase this figure to 60%, ranking among the top aerospace powers in the world; by 2045, we will fully become a world aerospace power." Lei Fanpei said.

　　According to the plan, the future of our country’s heavy launch vehicles will be close to 10 meters in diameter, will use the thrust of 500 tons of liquid oxygen kerosene engine and thrust of 220 tons of liquid hydrogen liquid oxygen engine. That is to say, the future of our country’s launch vehicle capacity from the current more than 20 tons to increase 4 to 5 times, to 100 tons.

　　Lu Yu, director of the Science and Technology Committee of the First Academy of China Aerospace Science and Technology Corporation, said that by around 2030, our country’s heavy-lift carrier rocket will achieve its first flight. At that time, our heavy-lift carrier rocket with a 100-ton carrying capacity in low-Earth orbit will provide strong support for manned moon landing and sufficient carrying capacity for Mars sampling return.

　　"If you don’t forget your original intention, you have to stay the same." Zhang Zhongyang, president of the Second Academy of China Aerospace Science and Industry Corporation, said that looking back on the past, China Aerospace has written countless wonderful moments in the sky of history; in the future journey, China Aerospace will definitely mark the new height of China’s development with new achievements.