Reavaliação do nirmatrelvir/ritonavir para o tratamento de pacientes com COVID-19 não hospitalizados e com alto risco de doença grave / Revalidation of nirmatrelvir/ritonavir for the treatment of patients with COVID-19 who are not hospitalized and with a high risk of serious illness

INTRODUÇÃO: Pacientes com fatores de risco como idade avançada, imunodepressão, obesidade e doenças cardiovasculares têm risco aumentado de internação, intubação e morte. De acordo com dados brasileiros, o risco de morte por covid-19 aumenta com o número de fatores de risco que o paciente apresenta, sendo igual a 17% em pacientes com 2 fatores de risco e 76% na presença de 8 fatores de risco. Além disso, mesmo aqueles pacientes que sobrevivem a uma internação em terapia intensiva frequentemente enfrentam sequelas e representam alto custo para o sistema público. O medicamento nirmatrelvir associado ao ritonavir têm o objetivo de prevenir internações, complicações e morte. Ele é indicado para pacientes com Covid-19 leve a moderada, não hospitalizados, até 5 dias do início dos sintomas. Apesar dos avanços da vacinação no Brasil, evidências sobre a falha vacinal em idosos e imunodeprimidos destacam a importância da disponibilidade de alternativas terapêuticas para essas populações. O presente relatório teve por objetivo avaliar evidências sobre a efetividade do tratamento em pacientes vacinados com alto risco de agravamento da doença. PERGUNTA: O medicamento nirmatrelvir/ritonavir é eficaz, seguro e custo-efetivo para pacientes com covid19 leve a moderada não hospitalizados vacinados que apresentam alto risco de agravamento da doença? EVIDÊNCIAS CLÍNICAS: Resultados obtidos a partir de estudos observacionais de mundo real confirmaram os resultados do ensaio clínico do medicamento nirmatrelvir/ritonavir, demonstrando que o tratamento de pacientes de grupos de risco é capaz de reduzir o risco de desfechos desfavoráveis como internação e óbito entre cerca de 50% e 70%, inclusive entre pacientes previamente vacinados. ANÁLISE DE IMPACTO ORÇAMENTÁRIO: A análise de impacto orçamentário do relatório de recomendação do nirmatrelvir/ritonavir foi atualizada considerando-se o cenário atual da pandemia no Brasil. De acordo com a nova análise, o uso do nirmatrelvir/ritonavir por pacientes com idade ≥ 65 anos e imunossuprimidos com idade ≥ 18 anos, resultaria em uma economia de recursos de R$ 408.957.111,38 em 5 anos. Ressalta-se, no entanto, que devido à dinâmica de difícil previsão da pandemia, este montante está sujeito à incerteza. Considerando-se a análise realizada anteriormente no relatório de recomendação, pode-se concluir que o montante economizado se reduz proporcionalmente à redução do número de casos da doença na população alvo. CONSIDERAÇÕES FINAIS: De acordo com as evidências atualmente disponíveis, o uso do nirmatrelvir/ritonavir é efetivo e seguro para pacientes com covid-19 leve a moderada não hospitalizados vacinados que apresentam alto risco de agravamento da doença. O impacto orçamentário está sujeito a incertezas já que o número de casos da doença no horizonte temporal da análise é de difícil previsão. RECOMENDAÇÃO PRELIMINAR DA CONITEC: Diante do exposto, os membros do Comitê de Medicamentos da Conitec, em sua 16ª Reunião Extraordinária, realizada no dia 1º de novembro de 2023, deliberaram que a matéria fosse disponibilizada em Consulta Pública com recomendação preliminar favorável à incorporação no SUS do nirmatrelvir/ritonavir para o tratamento de pacientes com Covid-19 não hospitalizados com idade a partir de 65 anos ou pacientes imunossuprimidos a partir de 18 anos de idade. Os membros do Comitê concordaram na manutenção da indicação de uso, não havendo ampliação do público-alvo, justificada pela restrição orçamentária, considerando que há incremento de custo da aquisição da tecnologia, ainda que haja economia de recursos ao serem evitadas internações e óbitos. CONSULTA PÚBLICA: Das nove contribuições recebidas, cinco contribuições foram de cunho técnico-científico e quatro contribuições de experiência ou opinião. Todas as contribuições concordaram com a recomendação preliminar da Conitec de incorporar o nirmatrelvir/ritonavir. Duas contribuições técnico-científicassugeriram ampliação da população elegível ao tratamento com o medicamento com a inclusão de indicação para pacientes com taxa de filtração glomerular menor que 30 ml/min/1,73m2 e de pacientes adultos com asma grave independentemente da faixa etária. Uma contribuição técnico-científica enviada pela empresa fabricante do medicamento expressou sua concordância com e solicitou a inclusão de informaçõea adicionais no relatório. As contribuições de experiência ou opinião ressaltaram a eficácia e segurança do medicamento para a população alvo. RECOMEDAÇÃO FINAL DA CONITEC: Diante do exposto, os membros do Comitê de Medicamentos, presentes na 126ª Reunião Ordinária da Conitec, realizada no dia 01 de fevereiro de 2024, deliberaram, por unanimidade, após reavaliação, manter a incorporação do nirmatrelvir/ritonavir, no SUS, para o tratamento da Covid-19 nos seguintes grupos de pacientes com sintomas leves a moderados, que não requerem oxigênio suplementar, independentemente do status vacinal: a) imunocomprometidos com idade ≥ 18 anos; b) com idade ≥ 65 anos. Foi assinado o registro de deliberação nº 874/2024. DECISÃO: manter a incorporação, no âmbito do Sistema Único de Saúde - SUS, de nirmatrelvir/ritonavir para o tratamento da Covid-19 para pacientes com sintomas leves a moderados, que não requerem oxigênio suplementar, independentemente do status vacinal e com idade igual ou superior a 65 anos ou imunocomprometidos com idade igual ou superior a 18 anos, publicada no Diário Oficial da União nº 46, seção 1, página 54, em 07 de março de 2024.

The PI3K/Akt Cascade Is Involved in the Antidiabetic Effect of Compound GSB-214, a Low-Molecular-Weight BDNF Mimetic.

In our previous studies on the streptozotocin model of diabetes we hypothesized that activation of the PI3K/Akt signaling pathway is essential for the realization of the antidiabetic effect of low-molecular-weight NGF and BDNF mimetics. Here we analyze the effect of a specific PI3K/Akt pathway inhibitor (LY 294002) on the antidiabetic effect of the BDNF loop 1 mimetic GSB-214. The experiments on C57BL/6 mice with streptozotocin-induced diabetes showed that GSB-214 attenuated the hyperglycemic effect of streptozotocin and prevented weight loss typical of diabetes, while LY 294002 eliminated these effects of GSB-214. These findings clearly demonstrate the involvement of PI3K/Akt pathway in the implementation of the effects of this low-molecular-weight BDNF mimetic.

Intermolecular interactions of cn-716 and acyl-KR-aldehyde dipeptide inhibitors against Zika virus.

The emergent Zika virus (ZIKV) infection has become a threat to global health due to its association with severe neurological abnormalities, namely Guillain-Barré Syndrome (GBS) in adults and Congenital Zika virus Syndrome (CZS) in neonates. Many studies are nowadays being conducted to find an effective antiviral drug against ZIKV. In particular, NS2B-NS3 protease is an attractive drug target due to its essential function in viral replication, although a drug is not yet commercially available. In this context, we present here a comparative structural study, based on quantum chemistry calculations, to analyze the intermolecular binding energies between the crystallographic structure of NS2B-NS3 protease and dipeptide boronic acid (cn-716) and aldehyde (acyl-KR-aldehyde) peptidomimetic inhibitors, by using the molecular fractionation with conjugate caps (MFCC) scheme within the density functional theory (DFT) formalism. Most intermolecular interactions in cn-716/NS2B-NS3 (acyl-KR-aldehyde/NS2B-NS3) are due to the amino acid residues Asp83*, His51, Asp129, Ser81*, Gly133, Ala132, Tyr161, Asn152 and Asp75 (Asp83*, Asp129, His51, Asn152, Tyr161, Tyr130, Gly153, Gly151, Asp75, Pro131, and Gly82). Additionally, we have considered missense mutation analysis of these residues to evaluate the destabilization and the increase of the flexibility of the protease, showing that mutation of the residues Tyr161 and Tyr130 causes more impact. Our simulations are a valuable tool for a better understanding of the binding mechanism of recognized inhibitors of NS2B-NS3 protease, and can lead to the rational design and development of novel anti-Zika drugs with improved efficiency.

Peptidomimetic inhibitors targeting the membrane-binding site of the neutrophil proteinase 3.

Proteinase 3 (PR3), together with other serine proteases, such as neutrophil elastase (NE) and cathepsin G (CG), regulates inflammatory and immune responses. However, in comparison with NE and CG, there is increasing evidence that PR3 functions significantly differ. In particular, PR3 can bind to cell membranes and such membrane-bound PR3 (mbPR3) might be differently involved in the activation of cytokines, growth factors, cellular receptors, and in the regulation of cell apoptosis. For instance, PR3 membrane binding can block some "eat me" signals, notably, phosphatidylserine membrane lipid, and facilitate non-resolving inflammation. Based on the clear evidence that PR3 membrane binding affects the biological functions of PR3, we designed peptidomimetic inhibitors that can remove mbPR3 from the membrane surface in vitro without influencing PR3 catalytic activity. Such inhibitors, which specifically target PR3 binding to membranes, are still lacking. In particular, we found peptidomimetics that inhibit binding of PR3 to POPC:PS liposomes, which mimic the biological environment of PR3.

Recent advances in peptidomimetics antagonists targeting estrogen receptor α-coactivator interaction in cancer therapy.

Estrogen receptor α (ERα) is a crucial target for ERα positive breast cancer treatment. Previous drug discovery efforts were focused on developing inhibitors that targeted the canonical ligand binding pockets of the ligand binding domain (LBD) of ERα. However, significant percentage of patients developed cancer relapse with drug-resistance. ERα peptidomimetic modulators have been considered as promising treatments for drug resistant breast cancers as they are targeting ERα-coactivator interacting interface instead of the ligand binding pocket of ERα. Herein, we reviewed the recent development of ERα peptidomimetics antagonists.

Targeting ß-catenin dependent Wnt signaling via peptidomimetic inhibitors in murine chondrocytes and OA cartilage.

OBJECTIVE: The canonical Wnt signaling pathway has been shown to be involved in regulating chondrocyte hypertrophic differentiation during Osteoarthritis (OA). The aim of this study was to test the therapeutic potential of two stapled peptide canonical Wnt inhibitors - SAH-Bcl9 and StAx-35R - in preventing Wnt induced cartilage changes in OA. METHODS: Primary neonatal murine chondrocytes and cartilage explants from OA patients undergoing total joint replacement for knee OA, were used for microscopy to determine matrix and cell penetrating capacity of fluorescein isothiocyanate FITC-tagged SAH-Bcl9 and StAx-35R peptides. T cell factor/lymphoid enhancer-binding factor (TCF/LEF) reporter assays were used to monitor the inhibition of Wnt3a induced ß-catenin signaling by each peptide. Changes in chondrocyte phenotypic marker gene expression were analyzed by qRT PCR. RESULTS: Both peptides localized intercellular in primary murine chondrocytes and cartilage explants. They inhibited Wnt3a induced TCF/LEF promoter activity in primary murine chondrocytes. Both inhibitors did not rescue Wnt3a altered expression of chondrocyte phenotypic genes (Sox9, Col2a1, Acan) and hypertrophy marker gene (Col10a1) at high doses (100 ng/ml). Upon application of 10 ng/ml Wnt3a, StAx-35R partially reversed the Wnt effect on Sox9 and Col2a1 gene expression. Both peptides, however, reversed the downregulation of SOX9 and aggrecan (ACAN), and decrease of COL10A1 gene expression in preserved human OA cartilage explants. CONCLUSION: These data indicate that blockade of canonical Wnt signaling might be a therapeutic strategy to treat early OA cases and protect further cartilage degradation by preventing chondrocyte hypertrophic differentiation.

Natural Tripeptide-Based Inhibitor of Multifaceted Amyloid ß Toxicity.

Accumulation of amyloid beta (Aß) peptide and its aggregates in the human brain is considered as one of the hallmarks of Alzheimer's disease (AD). The polymorphic oligomers and fully grown fibrillar aggregates of Aß exhibit different levels of neuronal toxicity. Moreover, aggregation of Aß in the presence of redox-active metal ions like Cu(2+) is responsible for the additional trait of cellular toxicity induced by the generation of reactive oxygen species (ROS). Herein, a multifunctional peptidomimetic inhibitor (P6) has been presented, based on a naturally occurring metal chelating tripeptide (GHK) and the inhibitor of Aß aggregation. It was shown by employing various biophysical studies that P6 interact with Aß and prevent the formation of toxic Aß forms like oligomeric species and fibrillar aggregates. Further, P6 successfully sequestered Cu(2+) from the Aß-Cu(2+) complex and maintained it in a redox-dormant state to prevent the generation of ROS. P6 inhibited membrane disruption by Aß oligomers and efficiently prevented DNA damage caused by the Aß-Cu(2+) complex. PC12 cells were rescued from multifaceted Aß toxicity when treated with P6, and the amount of ROS generated in cells was reduced. These attributes make P6 a potential therapeutic candidate to ameliorate the multifaceted Aß toxicity in AD.

Phosphoramidate-based peptidomimetic inhibitors of membrane type-1 matrix metalloproteinase.

Membrane-type I matrix metalloproteinases (MT1-MMP) is an enzyme critical to the remodeling and homeostasis of extracellular matrix, and when over expressed it contributes to metastasis and cancer cell progression. Because of its role and implication as a biomarker that is upregulated in various cancers, MT1-MMP has become an attractive target for drug discovery. A small pilot library of peptidomimetics containing a phosphoramidate core as a zinc-binding group was synthesized and tested for inhibitory potency against MT1-MMP. From this library, a novel two residue peptidomimetic scaffold was identified that confers potency against MT1-MMP at submicromolar concentrations. The results of this study confirm that for this scaffold, valine is favored as a P1 residue and leucine in the P1' position. Furthermore, steric tolerance was observed for the N-terminus, thus implicating that a second-generation library could be constructed to extend the scaffold to P2 without concomitant loss of affinity within the MT1-MMP catalytic domain.

NMR-assisted computational studies of peptidomimetic inhibitors bound in the hydrophobic pocket of HIV-1 glycoprotein 41.

Due to the inherently flexible nature of a protein-protein interaction surface, it is difficult both to inhibit the association with a small molecule, and to predict how it might bind to the surface. In this study, we have examined small molecules that mediate the interaction between a WWI motif on the C-helix of HIV-1 glycoprotein-41 (gp41) and a deep hydrophobic pocket contained in the interior N-helical trimer. Association between these two components of gp41 leads to virus-cell and cell-cell fusion, which could be abrogated in the presence of an inhibitor that binds tightly in the pocket. We have studied a comprehensive combinatorial library of α-helical peptidomimetics, and found that compounds with strongly hydrophobic side chains had the highest affinity. Computational docking studies produced multiple possible binding modes due to the flexibility of both the binding site and the peptidomimetic compounds. We applied a transferred paramagnetic relaxation enhancement experiment to two selected members of the library, and showed that addition of a few experimental constraints enabled definitive identification of unique binding poses. Computational docking results were extremely sensitive to side chain conformations, and slight variations could preclude observation of the experimentally validated poses. Different receptor structures were required for docking simulations to sample the correct pose for the two compounds. The study demonstrated the sensitivity of predicted poses to receptor structure and indicated the importance of experimental verification when docking to a malleable protein-protein interaction surface.