ABSTRACT
Background: Molnupiravir (MOV), the orally administered prodrug of the antiviral ribonucleoside analogue, N-hydroxycytidine (NHC) has received emergency use authorization for treatment of COVID-19. NHC inhibits viral replication by introduction of random transition errors across the viral genome, resulting in non-infectious virus. In the Phase II/III (MOVe-OUT) study, non-hospitalized participants received MOV or placebo (PBO) for 5 days and followed to Day 29. Viral RNA was sequenced to determine the rate, distribution and type of viral errors observed. Methods: SARS-CoV-2 RNA isolated from nasopharyngeal swabs was quantified by RT-PCR followed by complete genome NGS using the Ion AmpliSeq SARS-CoV-2 Research panel and Ion Torrent sequencing. To distinguish between nucleotide errors resulting from the mechanism of action of MOV and those potentially associated with reduced susceptibility to NHC, two different analyses were used. To measure impact of MOV on accumulation of low-frequency errors in the viral quasispecies, nucleotide variants were identified using VarScan 2.4 mutation caller with 0.4% minimum variant allele frequency cut-off. Resistance-associated changes were identified as amino acid substitutions occurring in D3 or D5 samples from ≥2 participants with a frequency of ≥5% of NGS reads. Phenotypic analysis of selected amino acid substitutions was performed using a replicon model. Results: NGS results showed a relationship between the number of random errors across the viral genome with increasing MOV dose. By Day 5 the mean number of viral genome errors were 21, 83, 129 and 223 in the PBO, 200, 400 and 800 mg groups, respectively. Among the sequence changes observed, the majority were transitions errors, consistent with MOV's mechanism of action. After MOV treatment, few treatment-emergent amino acid substitutions were identified in the viral replicase genes. These included nsp12 (T731I) and nsp14 (A220S/T/V, V466I, S503L/P);none associated with loss of susceptibility to MOV. Changes in spike protein in both PBO and MOV groups were at sites previously described in circulating variants. Conclusion: Consistent with the mechanism of action, MOV treatment resulted in a dose-dependent increase in transition errors across the SARS-CoV-2 genome. No resistance-associated mutations were identified in the viral replicase and no evidence that MOV treatment selected for unique mutations in spike protein not previously observed in circulating variants.
ABSTRACT
Antiviral drugs for managing infections with human coronaviruses are not yet approved, posing a serious challenge to current global efforts aimed at containing the outbreak of severe acute respiratory syndrome-coronavirus 2 (CoV-2). Remdesivir (RDV) is an investigational compound with a broad spectrum of antiviral activities against RNA viruses, including severe acute respiratory syndrome-CoV and Middle East respiratory syndrome (MERS-CoV). RDV is a nucleotide analog inhibitor of RNA-dependent RNA polymerases (RdRps). Here, we co-expressed the MERS-CoV nonstructural proteins nsp5, nsp7, nsp8, and nsp12 (RdRp) in insect cells as a part a polyprotein to study the mechanism of inhibition of MERS-CoV RdRp by RDV. We initially demonstrated that nsp8 and nsp12 form an active complex. The triphosphate form of the inhibitor (RDV-TP) competes with its natural counterpart ATP. Of note, the selectivity value for RDV-TP obtained here with a steady-state approach suggests that it is more efficiently incorporated than ATP and two other nucleotide analogs. Once incorporated at position i, the inhibitor caused RNA synthesis arrest at position i + 3. Hence, the likely mechanism of action is delayed RNA chain termination. The additional three nucleotides may protect the inhibitor from excision by the viral 3'-5' exonuclease activity. Together, these results help to explain the high potency of RDV against RNA viruses in cell-based assays.