Antiviral Research 96 (2012) 391-404

Antiviral Research 96 (2012) 391–404
Contents lists available at SciVerse ScienceDirect
Antiviral Research
journal homepage: www.elsevier.com/locate/antiviral
Review
Targeting the host or the virus: Current and novel concepts for antiviral
approaches against influenza virus infection
Suki Man-Yan Lee, Hui-Ling Yen ⇑
Centre of Influenza Research, School of Public Health, The University of Hong Kong, Hong Kong
HKU-Pasteur Research Centre, Hong Kong
a r t i c l e i n f o a b s t r a c t
Article history: Influenza epidemics and pandemics are constant threats to human health. The application of antiviral
Received 28 March 2012 drugs provides an immediate and direct control of influenza virus infection. At present, the major strat-
Revised 11 September 2012 egy for managing patients with influenza is through targeting conserved viral proteins critical for viral
Accepted 17 September 2012
replication. Two classes of conventional antiviral drugs, the M2 ion channel blockers and the neuramin-
Available online 26 September 2012
idase inhibitors, are frequently used. In recent years, increasing levels of resistance to both drug classes
has become a major public health concern, highlighting the urgent need for the development of alter-
Keywords:
native treatments. Novel classes of antiviral compounds or biomolecules targeting viral replication
Influenza
Antivirals
mechanism are under development, using approaches including high-throughput small-molecule
Immunomodulators screening platforms and structure-based designs. In response to influenza virus infection, host cellular
Neuraminidase inhibitor resistance mechanisms are triggered to defend against the invaders. At the same time, viruses as obligate intracel-
Cyclooxygenase-2 inhibitors lular pathogens have evolved to exploit cellular responses in support of their efficient replication,
including antagonizing the host type I interferon response as well as activation of specific cellular
pathways at different stages of the replication cycle. Numerous studies have highlighted the possibility
of targeting virus–host interactions and host cellular mechanisms to develop new treatment regimens.
This review aims to give an overview of current and novel concepts targeting the virus and the host for
managing influenza.
Ó 2012 Elsevier B.V. All rights reserved.
Contents
1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 392
2. Antiviral approaches that target the influenza viruses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 392
2.1. Replication of influenza A virus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 392
2.2. M2 ion channel blockers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 393
2.3. NA inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 394
2.4. Ribavirin. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 395
2.5. Antiviral compounds under development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 395
2.5.1. Nucleoside analog: favipiravir (T-705) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 395
2.5.2. Other RNA polymerase inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 395
2.5.3. Nucleozin and its derivatives. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 396
2.5.4. Blocking the fusogenic conformational change in HA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 396
2.5.5. Cross-reactive antibodies that target the HA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 396
2.5.6. NS1 inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 396
3. Targeting the host to block virus entry. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 396
3.1. Sialidase . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 396
3.2. Protease inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 397
4. Targeting host signaling pathways . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 398
4.1. Antiviral approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 398
4.1.1. MEK inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 398
⇑ Corresponding author at: HKU-Pasteur Research Centre, 2F, Dexter HC Man Building, No. 8 Sassoon Road, Pokfulam, Hong Kong. Tel.: +852 2816 8417; fax: +852 2872
5782.
E-mail address: [email protected] (H.-L. Yen).
0166-3542/$ - see front matter Ó 2012 Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.antiviral.2012.09.013
392 S.Man-Yan Lee, H.-L. Yen / Antiviral Research 96 (2012) 391–404
4.1.2. NF-jB and IKK2 inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 398

4.2. Immunomodulatory approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 398
4.2.1. COX-2 inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 398
4.2.2. S1P agonists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 399
4.2.3. Isopentenyl pyrophosphate and aminobisphosphonate pamidronate expanded gamma-delta T cells . . . . . . . . . . . . . . . . . . . . . 399
4.2.4. Peroxisome proliferator-activated receptor agonists . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 399
4.2.5. Statins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 399
5. Concluding remarks . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 400
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 400
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 400
1. Introduction new classes of compounds that target different viral proteins; and
the application of combination therapy.
Influenza epidemics and pandemics are constant threats to hu- Other approaches, which remain under-explored, may have the
man health. A large gene pool of influenza A viruses resides in di- potential to be developed into useful therapeutic interventions.
verse animal reservoirs (Webster et al., 1992), thus influenza One under-appreciated therapy is traditional Chinese medical
viruses with novel genetic composition are able to emerge through herbs. With a 3000-year history, traditional Chinese medicine
genetic reassortment over time, as recently seen with the (TCM) has its own unique system in diagnosis and therapy. Unlike
A(H1N1)pdm09 virus (Smith et al., 2009). The error-prone RNA- modern medicine which focuses on specific targets, TCM empha-
dependent RNA polymerase (Lauring and Andino, 2010) of the sizes body homeostasis (Yin-Yang Theory). For example, Kakkon-
influenza virus further increases the diversity of the influenza gen- to, a TCM prescription for treating colds and influenza, has been
ome through random mutation, further increasing the challenge of shown to have immunomodulatory effects. Treatment of influenza
controlling influenza infections. virus-infected mice with Kakkon-to significantly reduced weight
Southeast Asia has long been termed the ‘‘epicentre’’ for influ- loss in the infected animals (Kurokawa et al., 2002). Instead of
enza virus (Shortridge and Stuart-Harris, 1982), where a unique investigating the effect of TCM crude extracts in influenza treat-
ecology and large human and domestic animal populations con- ment, future research should focus on identifying effective com-
tribute to the human-animal interface, which may have facilitated pounds isolated from TCM and developing a scientific and
the emergence of 1957 and 1968 pandemic influenza (Kawaoka systemic platform to categorize TCMs.
et al., 1989). The highly pathogenic H5N1 virus that causes zoo- In response to influenza virus infection, host antiviral mecha-
notic human infections also emerged from this region in the late nisms are triggered to defend the cells against the invaders. At
1990s and has spread to a number of countries in Eurasia and Afri- the same time, the viruses have evolved to hijack cellular mecha-
ca and evolved into different lineages. Long-term surveillance has nisms for their own efficient replication (Nagata et al., 2008;
been established in this region for decades, and the results have Watanabe et al., 2010). Severe influenza, leading to tissue damage,
provided information on the evolution of animal influenza viruses results both from viral replication and host immune responses.
and mechanisms leading to interspecies transmission events Numerous studies have highlighted the possibility of targeting
(Smith et al., 2009; Vijaykrishna et al., 2011). The challenge re- virus–host interactions and host cellular mechanisms to develop
mains for scientists to forecast the emergence of a potential influ- new regimens of influenza therapy (Ludwig, 2011). Specifically
enza pandemic. blocking certain signaling pathways has led to reductions in viral
Currently available control measures for influenza include vac- titers as well as modulation of host responses to infection, and
cination and two classes of antiviral compounds, the M2 ion chan- some immune modulators can be applied in combination with
nel blockers and the neuraminidase (NA) inhibitors. The use of antiviral compounds to both dampen tissue damage and effectively
vaccines for the control of influenza requires timely vaccine pro- control infection. In this review, we will discuss current and novel
duction (which takes more than 6 months) and knowledge of the concepts of antiviral approaches against influenza, from the point
antigenic properties of the new circulating strains. This has been of view of targeting the virus and the host.
a challenging task for annual seasonal influenza vaccine produc-
tion, as suboptimally matched vaccine strains or delays in produc-
2. Antiviral approaches that target the influenza viruses
tion could lower the benefit of vaccination. Furthermore,
vaccination may not achieve full protection in certain age groups
Antiviral compounds target functionally conserved domains of
or patients, as the effectiveness of a vaccine depends on the im-
viral proteins to achieve cross-protection against different strains
mune competence of its recipients (Fiore et al., 2009).
of influenza viruses. These conserved domains play critical roles
Traditional antiviral compounds such as M2 ion channel block-
during the viral replication cycle.
ers or NA inhibitors that target functionally conserved domains of
viral proteins generally provide inhibitory activity against different
influenza viruses, including newly emerged pandemic influenza, 2.1. Replication of influenza A virus
and can be used for both treatment and prophylaxis of infection.
The major challenges of using antiviral compounds for the control Influenza viruses belong to the family Orthomyxoviridae and
of influenza is the development of drug resistance and the difficul- have single-stranded, segmented RNA genomes of negative polarity
ties in treating patients with severe influenza (Hayden, 2009). (Palese and Shaw, 2007). The eight-segmented genome of influenza
Resistance to both drug classes has become a major public health A virus encodes the RNA polymerase complex (PB2, PB1, PA), the
concern, and viruses with decreased sensitivity to both classes of nucleoprotein (NP), the surface glycoproteins HA and NA, which
antivirals have been reported. Thus, there is an urgent need to de- function as a receptor binding protein and sialidase, respectively,
velop alternative influenza treatments. Novel antiviral compounds the matrix protein (M1), the M2 ion channel and the nonstructural
are under development. Strategies include improving currently proteins NS1 and NS2/NEP (Palese and Shaw, 2007). In addition,
available drugs in design, route of delivery, or potency; identifying most influenza A viruses encode a mitochondria-targeting
S.Man-Yan Lee, H.-L. Yen / Antiviral Research 96 (2012) 391–404 393
nonstructural PB1-F2 protein of varying length, with a pro-apopto- tadine and rimantadine, are effective in blocking the M2 ion chan-
tic function (Chen et al., 2001). Furthermore, N40 and PA-x are new- nel activity of influenza A viruses, but exhibit no inhibition of the
ly identified polypeptides encoded by the PB1 and PA genes, BM2 ion channel of influenza B viruses (Mould et al., 2003). The
respectively (Jagger et al., 2012; Wise et al., 2009). mechanism of action is exerted via an ‘‘early antiviral effect,’’ by
Infection is initiated after the attachment of HA to sialic acid- preventing the dissociation of RNPs from M1 proteins, as well as
containing glycoprotein and glycolipid receptors on host cells a ‘‘late antiviral effect,’’ by causing early HA conformational change
(Gamblin and Skehel, 2010). The entry of influenza viruses has in the trans-Golgi (Lamb and Pinto, 2006) (Table 1).
been shown to occur via clathrin-dependent endocytosis and Besides the lack of an inhibitory effect against influenza B virus,
macropinocytosis (de Vries et al., 2011). The HA is an important the major limitation for the use of amantadine and rimantadine for
host range determinant, as influenza viruses from different hosts the control of influenza A virus infection is the rapid emergence of
show different preferred recognition patterns for sialyl receptors resistant variants in vitro and in vivo. Single-amino-acid substitu-
(Rogers and Paulson, 1983). The acidic environment within the tions at multiple positions (residues 26, 27, 30, 31, or 34) within
endosome following virus entry triggers a conformational change the trans-membrane domain of the M2 protein confer cross-resis-
of HA, exposing the fusion protein to mediate the fusion of the viral tance to amantadine and rimantadine (Gubareva and Hayden,
envelope with the endosome membrane (Skehel and Wiley, 2000). 2006). Treatment of influenza virus infection with M2 ion-channel
M2 ion channels permit proton flow from the endosome into the blockers can cause the emergence of fully pathogenic and trans-
interior of the virion, disrupting protein–protein interactions and missible resistant variants in 30–80% of individuals, depending
freeing the ribonucleoproteins (RNPs) from the M1 proteins. The on the detection method used (Gubareva and Hayden, 2006).
M2 ion channel also regulates the pH of the trans-Golgi network V27A, L26F, and S31N mutations have been reported from surveil-
to prevent premature conformational changes of HA at later stages lance results as transmissible variants (Wang et al., 2011), with
in the replication cycle (Lamb and Pinto, 2006). S31N as the most prevalent mutation. The current use of adaman-
The RNPs are transported into the nucleus for viral mRNA syn- tine for the treatment of influenza A infection has been limited for
thesis and viral genome replication (Resa-Infante et al., 2011). The H3N2 viruses, since the resistant variant became dominant in 2005
PB1 protein functions as a RNA-dependent RNA polymerase, while (Deyde et al., 2007). Furthermore, highly pathogenic H5N1 viruses
the PB2 contains a cap-binding domain, and the PA possesses the that evolved into different clades have exhibited variable degrees
endonuclease activity required for cap-snatching and viral mRNA of sensitivity to amantadine (Gutierrez et al., 2009). In addition,
synthesis. Newly synthesized viral proteins (PB1, PB2, PA, NP) the newly emerged A(H1N1)pdm09 viruses were also resistant to
and genome segments are packaged as RNPs and transported to adamatanes, due to the presence of the S31N mutation (Gubareva
the cell membrane for final assembly and budding. The NA func- et al., 2010).
tions as a sialidase that cleaves terminal sialic acid residues from Derivatives of adamantanamine or adamantanaminoalcohols
the receptor, and is essential for the efficient release and spread have been reported which have a greater inhibitory effect than
of virions from the infected host cell (Air, 2011). amantadine on influenza virus replication (Zoidis et al., 2010).
Derivatives of the spirene guanidine analog, 2-[3-azaspiro(5,5)
2.2. M2 ion channel blockers undecanol]-2-imidazoline (BL-1743) (Kurtz et al., 1995) have also
been identified which have a stronger M2 ion channel-inhibiting
The proton-conducting ion channel regulates virion pH during effect than amantadine (Wang et al., 2009). Furthermore, spirene
its entry in the endosome; it is a homo-tetramer, consisting of 4 derivatives [spiro(5,5)undecan-3-amine] inhibit the L26F and
M2 integral membrane proteins of 97 amino acids. Amantadine V27A variants, which otherwise confer resistance (Balannik et al.,
(1-adamantanamine hydrochloride) was first approved for prophy- 2009). Recent studies on the transmembrane domain of the M2 tet-
laxis against H2N2 influenza in 1966 and subsequently approved ramer complexed with amantadine or rimantadine have revealed
for prophylaxis and treatment of influenza A infections in 1976 two potential inhibitor binding sites, a high-affinity binding site
(Gubareva and Hayden, 2006). The adamantane derivatives, aman- at the N0 -terminal channel lumen, in proximity to the reported
Table 1
Antiviral agents for influenza virus in current use or under development.
Class of antiviral agent Stage of viral replication Inhibitor Route of administration

M2 ion channel blockers Inhibit viral uncoating at the early phase and Amantadine Oral
promote premature HA conformational change in Rimantadine Oral
the trans-Golgi during the late phase of the
replication cycle
NA inhibitors Inhibit NA enzyme activity important for initiation Zanamivir Inhalation, IV (under named-
of infection and release of viral progeny patient program)
Oseltamivir Oral
Peramivir IV, IM
Lanamivir Inhalation, long-acting
Nucleoside analogs Depletion of cellular GTP pools, RNA elongation, Ribavirin Oral
mutagen
RNA elongation Favipiravir (T-705) Oral
Nucleozin and derivatives NP oligomer formation and nuclear transportation Nucleozin IP (mouse model)
Endonuclease inhibitor Inhibit the cap-snatching endonuclease activity of 4-Substituted, 2,4-dioxo-4-phenylbutanoic acid -
PA
Fusion blockers Inhibit HA fusogenic conformational change Arbidol Oral
HA2 mAb IV
Protein inhibitor (F-HB80.4) –
NS1 inhibitors Inhibit NS1 activity in type I interferon-competent NSC109834 –
cells NSC128164
NSC95676
NSC125044
mutations, that confers resistance to the adamantanes, and a low- As the NA inhibitors are structurally similar to the natural li-
affinity binding site at the C0 -terminal protein surface (Cady et al., gand, sialic acid, it was once thought that mutations at conserved
2010). As amantadine was not structurally designed to fit the M2 NA residues that confer drug resistance would also decrease NA
ion channel, future optimization of M2 ion channel blockers, based activity or stability, compromising viral fitness. We and others
on recent structural information, may provide new possibilities for have attempted to understand the effect of different NA mutations
pharmaceutical investigation (Cady et al., 2010). on fitness, including the pathogenicity and transmission potential
of resistant variants (Abed et al., 2006; Kiso et al., 2011; Yen
2.3. NA inhibitors et al., 2007). Among the NA mutations that confer resistance to
NA inhibitors, the H275Y NA mutation (N1 numbering) has been
The sialidase activity of the NA has been shown to play an the most extensively studied to date, due to its significance in
important role during the initiation of infection and the release the seasonal H1N1, highly pathogenic H5N1, or more recently in
and spread of viral progeny (Air, 2011; Matrosovich et al., 2004). the A(H1N1)pdm09 virus. This mutation was first reported during
Although the HA and NA surface glycoproteins are subject to hu- clinical trials among patients receiving oseltamivir (Gubareva
moral immune selection pressure, resulting in antigenic drift, the et al., 2001). It was generally detected at a low frequency among
presence of conserved residues within the NA active site across community isolates prior to the 2007–8 influenza season (Monto
all influenza subtypes has provided a desirable target for drug de- et al., 2006; Sheu et al., 2008). However, an increasing number of
sign (von Itzstein et al., 1993). Zanamivir (Relenza; 4-guanidino- H1N1 seasonal influenza viruses encoding the H275Y mutation
Neu5Ac2en, GG167) was the first small molecule against influenza (N1 numbering) emerged in northern Europe in late 2007 and sub-
developed through structure-based drug design (von Itzstein et al., sequently spread globally, resulting in dominance of the H275Y
1993). It is administered via inhalation. Further antiviral develop- variant over the wild-type virus in 2008 (Dharan et al., 2009; Lack-
ment resulted in the orally administered compound, oseltamivir enby et al., 2008). The detailed mechanism that enables the trans-
phosphate [Tamiflu; ethyl(3R,4R,5S)-4-acetamido-5-amino-3-(1- mission of the H275Y variant is still under research (Bloom et al.,
ethylpropoxy)-1-cyclohexene-1-carboxylate, GS4104], which is 2010; Rameix-Welti et al., 2011).
converted into its active form, oseltamivir carboxylate [(3R,4R,5S)- The H275Y NA mutation confers resistance to oseltamivir and
4-acetamido-5-amino-3-(1-ethylpropoxy)-1-cyclohexene-1-car- peramivir, but not to zanamivir or laninamivir. While A/Brisbane/
boxylic acid, GS4071] by hepatic esterases (Kim et al., 1996) (Ward 59/07-like viruses with the H275Y NA mutation were resistant to
et al., 2005) and the intravenously administered compound, per- oseltamivir, they remained largely sensitive to zanamivir or M2-
amivir [(1S,2S,3S,4R)-3-(1S)-1-acetylamino-2- hydroxycyclopen- ion channel blockers. However, dual resistance to both oseltamivir
tane carboxylic acid, BCX-1812, RWJ-270201] (Babu et al., 2000). and M2-ion channel blockers were detected at an increasing rate
Zanamivir and oseltamivir have been approved for the prophylaxis among H1N1 seasonal influenza viruses isolate between 2008–
and therapy of influenza A and B since 1999 in the USA and subse- 10, with a 28% (7/25) detection rate reported by the US Centers
quently in other countries, while peramivir is currently under phase for Disease Control and Prevention (CDC) during the 2009–10 sea-
III clinical trial in the USA, and is only available in Korea and Japan. son, before seasonal H1N1 was replaced by the newly emerged
NA inhibitors are currently the predominant antiviral drugs used A(H1N1)pdm09 virus (Cheng et al., 2010; Sheu et al., 2011). Inter-
for the treatment and prophylaxis of influenza. Oseltamivir is more estingly, most dual-resistant strains emerged through genetic reas-
frequently used than zanamivir clinically, due to its oral route of sortment, acquiring the M gene from a clade 2C virus with a S31N
administration. It has also been approved for use in a wider age mutation that confers resistance to amantadine into a clade 2B
group, including children 1–6 years old. viruses that already carried the H275Y NA mutation (Sheu et al.,
As the NA inhibitors are analogs of sialic acids, the mechanism 2011).
of their antiviral activity is through competition with the natural As mentioned previously, the A(H1N1)pdm09 viruses that
ligand, blocking the enzyme active site. NA inhibitors are effective emerged in 2009 carry the S31N mutation in the M2 protein that
against influenza A and B viruses, and even different NA subtypes, confers resistance to amantadine and rimantadine. Dual-resistant
since the conserved enzyme site is relatively conserved, and only A(H1N1)pdm09 viruses that acquired NA mutations conferring
subtle structural differences have been identified (Russell et al., resistance to NA inhibitors have been identified at <2% of the iso-
2006). Specifically, different NA subtypes of influenza A virus can lates tested for susceptibility (Hurt et al., 2012). The H275Y NA
be grouped based on phylogenetic analysis. Group 1 contains N1, mutation was the most frequently identified mutation among
N4, N5, and N8, and group 2 contains the N2, N3, N6, N7, and N9 A(H1N1)pdm09 viruses that exhibited resistance to NA inhibitors.
subtypes. Compared to Group 2 NAs, Group 1 NAs possess an ex- Other variants carrying NA mutations I223R/K/V, H275Y + I223R,
tended cavity (the 150-cavity) due to the differences in amino acid S247N, S247N + H275Y, Q313R + I427T, or I117V have also been re-
residues within the 150-loop (residues 147–152) (Russell et al., ported (Hurt et al., 2012). Recent studies that characterized the fit-
2006). The extended cavity has provided new insights for NA inhib- ness and transmission potential of the A(H1N1)pdm09 viruses
itor design (Rudrawar et al., 2010). Interestingly, the carrying the H275Y NA mutation showed variable findings, with
A(H1N1)pdm09 virus has been reported to lack the 150-cavity (Li most transmission studies in animals supporting a comparable or
et al., 2010). slightly delayed transmission potential for the H275Y variant
Resistant viral variants have been isolated in in vitro studies (Duan et al., 2010; Kiso et al., 2010; Memoli et al., 2011; Seibert
through serial passage in the presence of NA inhibitors, and also et al., 2010; Wong et al., 2012).
arise in patients treated with NA inhibitors (Gubareva, 2004; The long-acting NA inhibitor laninamivir (R-125489) has been
McKimm-Breschkin, 2000). Due to the differential interaction be- approved in Japan since 2010 for the treatment of influenza A
tween oseltamivir and zanamivir with conserved residues at the and B. The prodrug, laninamivir octanoate (CS-8958 or R-118958)
NA enzyme site, mutations that confer resistance to oseltamivir of- is processed into laninamivir in the lungs after being administered
ten do not confer resistance to zanamivir or laninamivir (Hayden, by inhalation (Kubo et al., 2010) (Table 1). A single nasal adminis-
2009). While most of oseltamivir-resistant variants have emerged tration leads to long retention of the drug in the lungs, providing
during therapeutic usage, clinically derived resistance to zanamivir long lasting anti-influenza activity in vivo (Yamashita et al.,
occurs at lower frequency (Hurt et al., 2009). Furthermore, clini- 2009). Laninamivir and zanamivir possess a 4-guanidino group
cally-derived NA mutations that confer resistance to oseltamivir which has been shown to result in greater potency against
are subtype-specific. group-1 NA subtypes with the cavity formed by the 150-loop
(Vavricka et al., 2011). Clinical trials have reported comparable tion therapy using ribavirin and pegylated interferon-alpha was
effectiveness of laninamivir versus other NA inhibitors against established in early 2000 and it has become the standard treat-
A(H1N1)pdm09 virus, seasonal H3N2 influenza virus, or influenza ment for chronic hepatitis C virus (HCV) infection in adults (De
B virus (Ikematsu and Kawai, 2011; Shobugawa et al., in press). Clercq, 2009). Treatment for severe respiratory syncytial virus
Besides novel NA inhibitors, improvements in the route of (RSV) infection using aerosolized ribavirin was approved in 1985,
administration such as intravenous zanamivir delivery have been although its clinical benefit is still debatable (De Clercq, 2009).
tested under the Emergency Investigational New Drug (EIND) For influenza, ribavirin monotherapy has been tested in clinical tri-
scheme in the USA or the named-patient program in other coun- als or under EIND for severe infections. The results of these studies
tries, depending on their regulations (Boltz et al., 2010) (Table 1). are inconclusive, due to small sample size or differences in treat-
Peramivir was also administered to hospitalized adults or children ment dose and duration; the potential clinical benefit of ribavirin
with severe viral pneumonia under EIND or Emergency Use Autho- for the treatment of influenza infection therefore remains to be fur-
rization (EUA) in the USA during the 2009 pandemic (Hernandez ther clarified (Chan-Tack et al., 2009). Importantly, resistance to
et al., 2011; Sorbello et al., 2012; Yu et al., 2012). ribavirin has not been reported for HCV, RSV or influenza viruses.
In addition, double- or triple-combination chemotherapy with
oseltamivir, adamantane and ribavirin have shown additive or syn- 2.5. Antiviral compounds under development
ergistic effects in vitro and in animal models (Hoopes et al., 2011; Ily-
ushina et al., 2008; Ilyushina et al., 2007; Nguyen et al., 2010; Smee 2.5.1. Nucleoside analog: favipiravir (T-705)
et al., 2009). Combination therapy may also play a role in limiting the Favipiravir (T-705; 6-Fluoro-3-hydroxypyrazine-2-carboxam-
emergence of drug-resistant viruses. A recent clinical trial that ap- ide) is a pyrazine derivative first identified in 2002, which inhibits
plied combination therapy with oseltamivir and zanamivir did not influenza A, B, and C viruses in vitro and influenza A virus in a
show greater protection than monotherapy against seasonal influ- mouse model (Furuta et al., 2002). Its action is mediated via its
enza (mainly H3N2) infection in humans (Duval et al., 2010). Simi- processed forms, T-705 ribofuranosyl phosphates, which include
larly, a retrospective study that compared the effect of oseltamivir the monophosphate and triphosphate forms. The triphosphate
mono-therapy to triple-combination treatment with oseltamivir, form is mis-recognized by the influenza virus polymerase as a pur-
amantadine and ribavirin of A(H1N1)pdm09-infected patients that ine nucleotide during RNA elongation, inhibiting polymerase activ-
required ventilator support reported comparable clinical outcomes ity (Furuta et al., 2005). Unlike ribavirin, the host enzyme can
for the two groups (Kim et al., 2011). Further studies are required differentiate favipiravir and its phosphorylated form from the nat-
to understand the effects of combinational therapy in humans and ural nucleotides; favipiravir therefore shows little inhibitory effect
their role in limiting the emergence of resistant variants. on host cells and less cytotoxity than ribavirin (Furuta et al., 2009).
The antiviral activity of T-705 can vary, depending on the host cells
2.4. Ribavirin used; differences in uptake efficiency and/or the effectiveness of
conversion of favipiravir into its ribofuranosyl phosphates by
Ribavirin (1-(b-D-Ribofuranosyl)-1H-1,2,4-triazole-3-carbox- host-cell enzymes may determine its antiviral activity (Furuta
amide) is a nucleoside analog that exhibits a broad range of antivi- et al., 2009). Synergistic effects between oseltamivir and favipiravir
ral activities against RNA and DNA viruses (De Clercq, 2009; have been reported in mice against H1N1, H3N2 or H5N1 influenza
Sidwell et al., 1972). It is processed by cellular adenosine kinase virus infections (Smee et al., 2010).
into ribavirin monophosphate (RMP), followed by subsequent Besides influenza virus, favipiravir inhibits other RNA viruses,
phosphorylation into di- or triphosphate (RTP) forms (Graci and including arenaviruses, bunyaviruses, West Nile virus, alphavirus-
Cameron, 2006). Its major antiviral activity is conferred by the es, poliovirus, rhinoviruses and RSV. Favipiravir exhibits no inhib-
RMP form, which is structurally similar to cellular inosine mono- itory effect against DNA viruses, including herpes simplex virus-1,
phosphate (IMP). RMP and IMP therefore can compete for the human cytomegalovirus and adenoviruses, with EC50 values above
IMP dehydrogenase (IMPDH) active site, leading to depletion of 640 lM (Furuta et al., 2009). As ribavirin has shown inhibitory ef-
the cellular GTP pool (Table 1). Such depletion has a general effect fects against DNA viruses, it is possible that the DNA viral polymer-
on viral and host RNA, DNA, and protein synthesis, and is consid- ase can differentiate favipiravir better than ribavirin. Limited
ered to be the cause of ribavirin’s broad antiviral activity against resistance to favipiravir has been reported; no resistant variant
different RNA and DNA viruses (De Clercq, 2009; Graci and Cam- was detected after 30 serial passages of the A/PR/8/34 influenza
eron, 2006). virus (Furuta et al., 2009). Favipiravir began Phase III clinical trial
As a nucleoside analog, ribavirin may also directly interact with in Japan in October, 2009, and Phase II clinical trials in the USA
the viral polymerase. For influenza viruses, RTP has been shown to in February, 2010. We may therefore see increased use of favipira-
interact with the RNA polymerase in a cell-free system and exhibit vir in the near future for the treatment of influenza.
competitive inhibition with GTP and ATP, but not with UTP or CTP
(Eriksson et al., 1977). However, a higher concentration of RTP is 2.5.2. Other RNA polymerase inhibitors
required to fully inhibit influenza virus RNA elongation than that The influenza polymerase complex is a heterotrimer formed by
0 0
in competition with the GTP or ATP, suggesting that RTP can be the PB2, PB1, and PA proteins. The conserved PAC -term–PB1N -term
incorporated into the influenza viral genome (Parker, 2005). This binding domain has also been explored as a target for influenza
mechanism may increase error-prone replication, leading to er- antivirals (Das et al., 2010; Ghanem et al., 2007). Peptides derived
ror-catastrophe and a reduction in yield of infectious virus (Vig- from the PB1N’-term have been shown to bind to PA, inhibiting viral
nuzzi et al., 2005). replication and transcription (Ghanem et al., 2007; Wunderlich
Despite reports of the broad in vitro antiviral activity of ribavi- et al., 2009). Combined with knowledge derived from the crystal
rin, its clinical application for influenza has been limited, due to structure of PA-PB1 complex (He et al., 2008; Obayashi et al.,
toxicity and limited evidence of clinical efficacy. Variable results 2008), these studies have provided the first step in identifying
have been reported from trials using oral or aerosolized ribavirin and designing small molecules that specifically disrupt protein–
for influenza A or B patients (Chan-Tack et al., 2009) or from pa- protein interactions.
tients receiving intravenous ribavirin under an EIND scheme (Riner The synthesis of influenza genomic vRNA and cRNA occurs de
et al., 2009). Ribavirin is available as an oral form for influenza novo, while mRNA synthesis for virus protein production requires
treatment in Mexico (Eichelberger et al., 2008) (Table 1). Combina- host-derived mRNA-derived 50 -caps as primers (Das et al., 2010).
The cap-binding domain of the influenza polymerase has been entry (Smee et al., 2008); a peptide derived from a fibroblast
identified within PB2 (Guilligay et al., 2008), while endonuclease growth-factor-4 signal sequence that possesses an inhibitory effect
cap-snatching activity is conferred by the N0 -terminus of PA (Dias on viral attachment to cells (Jones et al., 2006); nitazoxanide,
et al., 2009). Furthermore, compound (L-735882), which inhibits which targets a post-translational stage, blocking HA maturation
endonuclease cap-snatching activity, has been reported (Tomassini and transportation (Rossignol et al., 2009); and the high-molecu-
et al., 1994) (Table 1). With knowledge of the catalytic site (Dias lar-weight sulphated polysaccharide iota-carrageenan, derived
et al., 2009; Yuan et al., 2009), two recent studies have solved from red seaweed, that inhibits viral spread as well as entry (Leib-
the co-crystal structures of the PA endonuclease domain with brandt et al., 2010).
known or predicted inhibitors (Dubois et al., 2012; Kowalinski
et al., 2012). Together with in vitro assays that measure their 2.5.5. Cross-reactive antibodies that target the HA
anti-endonuclease or antiviral activity, new insights have been Recent studies have identified naturally occurring human anti-
proposed on the development of potential PA endonuclease inhib- bodies from vaccinated or exposed individuals that can bind differ-
itors (Dubois et al., 2012; Kowalinski et al., 2012). ent HA types. These cross-reactive antibodies possess neutralizing
activity, by inhibiting the HA fusogenic conformational change
2.5.3. Nucleozin and its derivatives (Corti et al., 2011; Ekiert et al., 2011; Sui et al., 2009; Throsby
By screening chemical libraries using a cell-based influenza et al., 2008) or by targeting the HA globular head, preventing viral
infection assay, three laboratories independently identified the attachment to cells (Yoshida et al., 2009). Defining HA-Fab interac-
small-molecule compound, nucleozin, which induces NP oligomer tion by resolution of the crystal structure has revealed a series of
formation (Gerritz et al., 2011; Kao et al., 2010; Su et al., 2010) conserved epitopes within the HA stalk region (Corti et al., 2011;
(Table 1). The inhibitory effect was associated with the inhibition Ekiert et al., 2011; Sui et al., 2009). These antibodies have been
of NP transportation from the cytoplasm into the nucleus (Kao tested in vitro and in mice and ferrets, and exhibited significant
et al., 2010). Resolution of the crystal structure of a nucleozin ana- protection upon challenge using different viral subtypes (Friesen
log bound to NP has revealed that NP dimer formation occurs via et al., 2010; Koudstaal et al., 2009). The use of adoptive immuno-
two ligand binding sites on each NP monomer; a hexameric struc- therapy may be considered for pandemic preparedness, as cross-
ture was also observed, consisting of three NP dimers (Gerritz protection can be achieved regardless of the subtype of the emerg-
et al., 2011). Analogs of nucleozin have been identified which pos- ing strains. Research is ongoing to identify the immune determi-
sess potent inhibitory effects in vitro and in vivo; however, resis- nants that lead to the cross-reactive antibody response targeting
tance can develop after just 5 in vitro passages (Kao et al., 2010). the HA2 domain (Wang and Palese, 2011).
Resistance to nucleozin has also been observed among naturally
circulating influenza strains, including the A(H1N1)pdm09 virus, 2.5.6. NS1 inhibitors
which possesses mutations at the ligand-binding pocket (Gerritz The multifunctional NS1 protein interacts with many viral and
et al., 2011; Kao et al., 2010; Su et al., 2010). These studies support host proteins during the replication cycle (Hale et al., 2008).
the concept that NP is a potential target for novel antivirals, but Among these multiple functions, the most essential is the ability
further optimization of nucleozin analogs will be required to in- of NS1 to antagonize the type I interferon response, which is
crease their specificity and minimize drug resistance. achieved through several mechanisms including (1) interacting
with TRIM25 to prevent RIG-I activation, (2) binding to CPSF and
2.5.4. Blocking the fusogenic conformational change in HA poly-(A) binding protein II to limit the exportation of cellular
The influenza HA mediates receptor binding and membrane fu- mRNA, (3) directly binding to and inhibiting the activation of
sion activity, via its variable globular head region and its conserved PKR, and (4) binding to double-stranded RNA from detection of
stem region, respectively. Structure-based design has resulted in 20 -50 -oligoadenylate synthase (OAS) (Gack et al., 2009; Hale et al.,
small molecules that inhibit the fusogenic conformational change 2008).
of HA; however, these compounds cannot presently provide pro- A yeast-based assay was developed to screen small molecules
tection across a range of different HA subtypes (Bodian et al., for anti-NS1 activity (Basu et al., 2009). Four compounds were
1993; Vanderlinden et al., 2010). However, an exception is arbidol found to possess anti-influenza activity, specifically showed reduc-
[(ethyl-6-bromo-4- [(dimethylamino)methyl]-5-hydroxy-1- tion in viral protein synthesis or viral RNA production (Table 1).
methyl-2-[(phenylthio)methyl]-indole-3-carboxylate hydrochlo- They demonstrated specificity against influenza virus, but not
ride monohydrate)], which has been licensed in Russia for the against RSV, and were only effective in interferon-competent cells.
treatment of influenza A and B viruses (Leneva et al., 2009). Arbidol Derivatives of one of the 4 compounds (NSC125044) were synthe-
exerts immunemodulatory effects, as well as broad antiviral activ- sized (Jablonski et al., 2012; Walkiewicz et al., 2011), and one of
ity against influenza virus, RSV, rhinoviruses, coxsackie virus, HCV them showed an anti-influenza effect that was dependent on host
and chikungunya virus (Delogu et al., 2011; Shi et al., 2007). The RNase L activity (Walkiewicz et al., 2011). These results suggest
mechanism of its antiviral activity against influenza was demon- that NS1 is a potential target for novel influenza virus inhibitors.
strated through the identification of resistant variants with single
amino acid changes in the HA2, which affected the HA fusion pH 3. Targeting the host to block virus entry
and conformational change (Leneva et al., 2009) (Table 1). An alter-
native approach made use of computational design of protein 3.1. Sialidase
inhibitors targeting the HA stem region to block fusion. Protein
inhibitors with improved cross-reactive binding affinity for group At the earliest step of the viral replication cycle, influenza virus
1 HA have been achieved through screening of DNA-encoded li- binds to host cells through the interaction between the viral HA
brary of protein variants, using yeast surface display followed by and terminally-linked sialyl receptors present on the cell surface.
deep sequencing (Whitehead et al., 2012). Removal of sialic acid from the cell surface is therefore an approach
In addition to the compounds mentioned above that target the that can be utilized to disrupt virus-host interaction (Table 2).
fusion mechanism, other inhibitors under development that target DAS181 is a sialidase fusion construct designed to remove sialic
the HA include a cyanobacterium-derived protein (Cyanovirin-N) acid from cell surfaces. It is composed of a catalytic domain of sial-
that binds to high-mannose structures on the HA to block viral idase from the bacteria Actinomyces viscosus, with a human respi-
Table 2
Agents under development that target the host to achieve antiviral and/or immunomodulatory effects.
Potential therapeutic candidates Antiviral effect Immunomodulatory effect

Sialidase Removes sialic acid receptors on the cell surface, blocking –
interaction with the viral HA
Protease inhibitors Inhibit cleavage of the precursor HA0 into functional HA1/HA2 –
MEK inhibitors Block the MAPK/ERK protein kinase cascade, suppress the –
function of nuclear export protein, resulting in nuclear retention
of viral RNPs
NF-jB and IKK2 inhibitors Suppress the action of caspase and inhibit the release of viral RNP Decrease proinflammatory cytokine and chemokine
from the nucleus.Inhibit SOCS-3 induction, removing the production upon H5N1 infection
inhibitory effect on ISG production mediated via the JAK/STAT
pathway
COX-2 inhibitors Suppress viral gene transcription, viral protein expression and Attenuate H5N1-hyperinduced cytokines in the
progeny virus production in H5N1-infected cells proinflammatory cascade
S1P agonists – Suppress cytokine release by T-cells and affect the
antigen presentation ability of dendritic cells
IPP and PAM expanded gamma-delta – Expanded Vc9Vd2 T cell population to enhance the host
T-cells immune response
PPAR agonists – Suppress inflammatory cytokine expression through
trans-repression of NF-jB and AP-1
Statins – Suppress inducible MHC-II expression and activity of
LFA-1
ratory epithelium-anchoring domain fused to its C-terminus. 3.2. Protease inhibitors

DAS181 is well tolerated by the human immune system, as A. visco-
sus is a common oral bacterium. The human respiratory epithe- As noted above, the influenza HA glycoprotein functions as a
lium-anchoring domain contains a heparin-binding sequence that binding receptor and as a fusion protein. It is composed of two sub-
increases retention time and drug-potency (Malakhov et al., units, HA1 and HA2, which are cleaved by host proteases from their
2006). The sialidase activity of DAS181 can remove both the SA- HA0 precursor (Skehel and Waterfield, 1975). The cleavage of HA0
a2–3 and SA-a2–6-linked residues which are recognized by avian into functional HA1/HA2 activates virus infectivity, and is impor-
and human influenza viruses, respectively. tant for pathogenicity in human and avian hosts (Steinhauer,
DAS181 has demonstrated prophylactic and therapeutic effects 1999). Functional HA is able to undergo conformational change
against H5N1 virus infection in mice (Belser et al., 2007). Treat- in the low-pH endosomal environment, to induce membrane fu-
ment with DAS181 leads to desialylation in human lung or bron- sion followed by infection (Skehel and Wiley, 2000). Two prote-
chial tissues ex vivo, as well as in primary pneumocytes or ases, human airway trypsin-like protease (HAT) and
airway epithelial cells, and thereby inhibits a broad spectrum of transmembrane protease serine S1 member 2 (TMPRSS2), cleave
influenza viruses including the H5N1, the newly emerged the monobasic cleavage site of some HAs (Bottcher et al., 2006).
A(H1N1)pdm09 virus and oseltamivir-resistant viruses (Chan Expression of these two proteases in MDCK cells supports the
et al., 2009; Triana-Baltzer et al., 2009a,b). DAS181 is also effective propagation of seasonal influenza viruses, in the absence of trypsin
against human parainfluenza viruses in vitro and in vivo (Moscona (Bottcher et al., 2009). Recently, TMPRSS4 was identified, and it
et al., 2010). was found to have a similar role in the activation of HA (Chaipan
Reducing influenza virus infection by using DAS181 to remove et al., 2009). The HA of some highly pathogenic influenza viruses
sialic acids from the cell surface has raised concerns for the poten- possess a multibasic protease cleavage site, which is cleaved by
tial exposure of cryptic receptors that might allow bacterial adher- furin and other related cellular proteases located in the trans-Golgi
ence and increase susceptibility to bacterial infection (Zhang, apparatus (Stieneke-Grober et al., 1992). However, the acquisition
2008). However, recent data suggested that DAS181 treatment of a multibasic cleavage site within the HA does not always trans-
does not enhance the colonization of Streptococcus pneumoniae, form a low-pathogenic virus into a highly pathogenic one (Stech
either in vitro or in vivo (Hedlund et al., 2010). et al., 2009).
Unlike M2 and NA blockers, DAS181 does not target the virus, Earlier reports have described protease inhibitors as a means to
but the respiratory epithelial cells of the host. Recent studies have suppress the replication of influenza viruses (Zhirnov et al., 1984)
demonstrated that influenza virus variants selected through serial (Table 2). Recently, peptide-mimetic protease inhibitors of HAT
passage in the presence of DAS181 are attenuated, and possess an and TMPRSS2 were demonstrated to block viral replication
unstable resistance phenotype. DAS181-selected H3N2 and influ- in vitro, by inhibiting HA cleavage at the cell surface and within
enza B viruses regained their sensitivity when the drug was re- cells, respectively (Bottcher-Friebertshauser et al., 2010). Improve-
moved (Triana-Baltzer et al., 2011). Thus, the development of ment in selectivity and potency was achieved by incorporating a
resistance in the future could be low. DAS181 has also proven to synthetic amino acid residue, norvaline, into the protease inhibitor
be safe in mice exposed to high concentrations (up to 3 mg/kg/ (Sielaff et al., 2011). The use of single-stranded DNA-like antisense
day) in dry-powder formulations. DAS181 was well tolerated at agents to block the expression of TMPRSS2 also inhibits influenza
all dose levels; body size, food consumption and other parameters virus infection in human airway epithelial cells (Bottcher-Friebert-
were not affected (Larson et al., 2011). In humans, an international shauser et al., 2011). All of these studies have highlighted protease
phase II clinical trial was conducted, involving 297 patients with inhibitors as an alternative therapeutic approach. In addition to
H1N1, H3N2 or influenza B virus infections. A significant decrease influenza, a recent report has also demonstrated that protease
in viral shedding was seen in patients who received low-dose inhibitors are potential therapeutic agents against other respira-
treatment with DAS181 for three consecutive days (Moss et al., tory viruses, including the SARS-coronavirus (Matsuyama et al.,
2011). No adverse effects were reported. 2010), and thus may have wider applications future.
4. Targeting host signaling pathways Although the NF-jB pathway mediates antiviral activity, influ-
enza viruses have also evolved to evade and control the activity
4.1. Antiviral approaches of NF-jB. For example, the viral NS1 protein antagonizes the NF-
jB pathway, IFN-b induction and signaling (Wang et al., 2000).
Like other RNA viruses, influenza viruses take advantage of acti- As noted above, novel small-molecule inhibitors of NS1 have re-
vated cellular signaling to support their replication. Novel antiviral stored the interferon-induced antiviral state in a number of recent
drugs that disrupt these hijacked signaling events could therefore studies (Babu et al., 2000; Jablonski et al., 2012; Walkiewicz et al.,
be considered for development. 2011), suggesting the high potential of inhibitors of viral IFN antag-
onists as antiviral drugs.
Influenza virus infection also induces the expression of TRAIL
4.1.1. MEK inhibitors
and FasL, which stimulate caspase 3 action (Wurzer et al., 2003,
The Raf/MEK/ERK signaling pathway belongs to the mitogen-
2004). Caspase-3 plays a major role in nuclear disassembly, by
activated protein kinase (MAPK) cascade, which consist of a series
cleaving cellular proteins which increase the diffusion limit
of serine-threonine kinases. This cascade is an important pathway
through the nuclear membrane (Faleiro and Lazebnik, 2000). Nu-
which converts the ligation of extracellular molecules into intra-
clear retention of viral RNP complexes was observed when inhibi-
cellular signals for the control of cell proliferation, differentiation
tors of caspase or NF-jB were applied to infected cells, suggesting
and survival (Su and Karin, 1996). Its activation is triggered by
that caspase activity is crucial for viral RNP trafficking (Mazur
G-protein-coupled receptors or receptor tyrosine kinase, leading
et al., 2007; Wurzer et al., 2003). On the other hand, influenza
to stepwise phosphorylation and activation of Raf kinases, the ser-
viruses could also induce the expression of suppressor of cytokine
ine/ threonine kinases that participate in a sequential cascade to
signaling-3 (SOCS-3), via NF-jB signaling. Induction of SOCS-3
activate MEK1/2, which in turn activates ERK1/2. Numerous stim-
leads to inhibition of IFN-induced activation of the JAK/STAT path-
uli, including growth factors, hormones and cytokines, can trigger
way, which controls the expression of antiviral IFN-stimulated
this pathway.
genes (ISGs) (Kubo et al., 2003) (Table 2).
Activation of the MAPK cascade is now recognized as a hallmark
NF-jB is a novel therapeutic target for influenza therapy. Vari-
signaling pathway activated by influenza A or B virus (Pleschka
ous studies have shown that inhibition of the NF-jB pathway can
et al., 2001), including the highly pathogenic avian H5N1 and
reduce the viral titer. For example, acetylsalicylic acid (ASA), com-
pdmH1N1viruses (Droebner et al., 2011). Specific inhibitors such
monly known as aspirin, an inhibitor of IKK2, inhibited influenza
as U0126, which blocks the cascade at the MAPK/ERK kinase
virus replication in vitro and in vivo, and did not generate resistant
(MEK) level, result in nuclear retention of viral RNP complexes
strains in a multi-passage experiment (Mazur et al., 2007). How-
and impair the function of the nuclear export protein (NEP/NS2),
ever, it should be cautioned that aspirin has been linked with
suppressing virus production (Pleschka et al., 2001) (Table 2). A
Reye’s syndrome in children with influenza (Eyers et al., 2010;
further study suggested that activation of the MAPK cascade leads
Starko, 2009) and with prominent systemic symptoms in adults
to efficient RNP export as well as virus production, achieved by the
with H1N1 virus infection, compared to those who received aman-
accumulation of the viral HA on the cell surface, resulted from en-
tadine alone (Younkin et al., 1983). Recently, pyrrolidine dithiocar-
hanced viral polymerase activity (Marjuki et al., 2007). U0126
bamate (PDTC), an inhibitor of the NF-jB pathway, was shown to
exhibited high antiviral activity and low cytotoxicity in vitro and
increase survival in H1N1-infected mice (Wiesener et al., 2011),
in vivo (Droebner et al., 2011; Pleschka et al., 2001), making it a
while others have shown that treatment with inhibitors of the
promising drug.
Raf/MEK/ERK cascade and NF-jB significantly reduced virus titers
Clinical investigation is the next important phase to test the
and cytokine expression, both in vitro and in vivo (Pinto et al.,
efficiency of MAPK cascade inhibitors to block influenza virus rep-
2011). Phosphatidylinositol-3-kinase (PI3K) has also been sug-
lication in humans. To date, the evaluation of MEK inhibitors in
gested to be a cellular factor that is activated in response to influ-
virus-infected mice has been limited to U0126 administered by
enza virus infection, and to play an important role in the regulation
the aerosol route (Droebner et al., 2011; Haasbach et al., 2011),
of virus replication (Ehrhardt et al., 2006).
which is not commonly employed in humans. As more MEK inhib-
itors that have been used in clinical trials with cancer patients be-
come commercially available, further research is warranted. 4.2. Immunomodulatory approaches
Although the immune system provides a necessary response to

4.1.2. NF-jB and IKK2 inhibitors
infection, it may not always successfully eliminate the threat posed
NF-jB signaling is another important pathway that is com-
by influenza viruses. Some viruses may be directly cytopathic,
monly activated after influenza virus infection. Upon recognition
while others, such as the highly pathogenic H5N1 virus, cause
of pathogen infection or tissue damage, the NF-jB pathway is
cytokine dysregulation, upregulating proinflammatory cytokines
strongly activated by cellular pattern recognition receptors, includ-
and leading to a fatal outcome. The use of immunomodulators to
ing toll-like receptors and multiple cytosolic receptors, such as ret-
return the immune response to homeostasis should therefore be
inoic inducible gene I (RIG-I)-like helicases and NOD family
a promising strategy to deal with the deleterious host response
proteins. NF-jB-responsive genes affect a diverse array of cellular
triggered by such viruses.
processes, including apoptosis and cell survival, and often directly
control the course of infection by up-regulating a variety of antivi-
ral genes (Iversen and Paludan, 2010). Influenza virus infection 4.2.1. COX-2 inhibitors
activates the NF-jB pathway through activation of IKK2, as a result Cyclooxygenase-2 (COX-2) is a component of the arachidonic-
of the production of various cytokines (Julkunen et al., 2001). NF- acid cascade that is thought to be involved in inflammation and
jB is known as the key regulator of cytokine expression, including immune responses, and is therefore a target of anti-inflammatory
interferon (IFN)-b (Pahl, 1999). IFN-b initiates the type I IFN de- drugs. As noted above, it was shown that ASA, which blocks NF-B
fense program to mediate antiviral activities (Wolff and Ludwig, activation and the activity of COX, inhibits influenza virus replica-
2009), by binding to the cell-surface type I IFN receptor and acti- tion (Mazur et al., 2007). However, treatment with indomethacin, a
vating the JAK/STAT and other pathways, which control the expres- pure COX inhibitor that inhibits both COX-1 and COX-2, failed to
sion of various antiviral genes (Platanias, 2005). show any effect on virus replication. It was therefore concluded
that ASA blocks influenza virus replication via inhibition of NF-B development of agonists that target specific S1P receptors is there-
signaling (Mazur et al., 2007). fore needed. A recent study by Teijaro et al. demonstrated that
Unlike the inducible COX-2, COX-1 is constitutively expressed in treatment with the S1P1 receptor specific agonist, CYM-5442, sig-
most normal body tissues, including bronchiolar and alveolar epi- nificantly reduced cytokine and chemokine responses associated
thelial cells and pulmonary alveolar macrophages in rats and non- with influenza virus-induced injury in vivo. However, unlike AAL-
human primates (Ermert et al., 1998; Khan et al., 2000; Wilborn R, it did not impair dendritic cell activation, enabling the initiation
et al., 1995). It is involved in important physiological functions, of a T-cell response (Teijaro et al., 2011) (Table 2).
such as vasodilatation, bronchodilation and surfactant synthesis
(Brannon et al., 1998). Treatment with indomethacin therefore 4.2.3. Isopentenyl pyrophosphate and aminobisphosphonate
not only blocks not only COX-2 activity, but the activity of the phys- pamidronate expanded gamma-delta T cells
iologically important COX-1, thus perhaps leading to detrimental Enhancement of innate immune responses, the first line of de-
effects on virus-infected cells. In fact, an in vivo study demonstrated fense against viral infection, could also be considered as an alterna-
that defects in COX-1 or COX-2 led to opposite effects in H3N2 tive therapeutic approach for influenza. Natural killer (NK) cells are
virus-infected mice: while COX-1 deficiency was detrimental, key effectors of innate immunity, keeping infections under control
COX-2 deficiency improved survival (Carey et al., 2005). in the early phase, by killing virus-infected cells. However, influ-
COX-2 has been shown to play a regulatory role in the induction enza virus could evade this innate immune defense by infecting
of pro-inflammatory responses by the H5N1 virus. Selective COX-2 NK cells and inhibiting their cytotoxic activity (Mao et al., 2009,
inhibitors that are commonly used to treat rheumatoid arthritis, 2010). Human gamma-delta (cd) T cells share the characteristics
osteoarthritis and acute pain had immunomodulatory effects, sup- of T cells, NK cells and antigen-presenting cells, mediating innate
pressing hyper-cytokine induction after H5N1 infection (Lee et al., and adaptive responses to infection (Born et al., 2006; Brandes
2008). In a recent study, we further demonstrated that selective et al., 2005). Unlike NK cells, cd T cells are not susceptible to influ-
COX-2 inhibitors suppressed H5N1 virus replication in vitro, sug- enza A virus infection. Expansion of cd T cells may therefore be
gesting that viral replication was dependent on the activation of considered an alternative therapeutic approach (Table 2).
COX-2 signaling pathways (Lee et al., 2011). Another study showed cd T cells constitute only 2–10% of T lymphocytes in the periph-
that treatment of H5N1 virus-infected mice with the COX-2 inhib- eral blood. In humans, cells with the Vc9Vd2 receptor are the ma-
itor celecoxib, in combination with mesalazine and zanamivir, sig- jor cd T cells in the peripheral blood and lymphoid organs (Carding
nificantly improved survival (Zheng et al., 2008). These studies and Egan, 2002). Isopentenyl pyrophosphate (IPP)-expanded
have highlighted the possibility of targeting COX-2 to regulate both Vc9Vd2 T cells have shown specific cytotoxicity towards influenza
virus replication and host immune response for the development virus-infected human monocyte-derived macrophages, in a dose-
of new treatment regimens (Table 2). dependent manner (Qin et al., 2009). Expanded Vc9Vd2 T cells
Some studies have highlighted the role of COX-2 in the resolu- have also demonstrated antiviral activity against seasonal H1N1,
tion of late-stage inflammation (Chan and Moore, 2010; Fukunaga avian H5N1 and H9N2 influenza A viruses (Qin et al., 2009). Amin-
et al., 2005), and its inhibition may have detrimental effects in obisphosphonate pamidronate (PAM) was also recently shown to
treating acute lung injury (Lukkarinen et al., 2006). Future work have an effect similar to IPP, resulting in the killing of infected cells
should aim to identify host factors in COX-2-induced downstream and inhibition of influenza virus replication by Vc9Vd2 T cells. PAM
pathways that are crucial for H5N1 virus replication. This may lead treatment of influenza-infected humanized mice has also demon-
to the separation of antiviral effects from the induction of media- strated a benefit, by expanding the population of Vc9Vd2 T cells
tors that are important for the resolution of inflammation and (Tu et al., 2011). Expansion of Vc9Vd2 T cells by IPP and PAM
recovery from lung injury. may thus provide a novel, safe approach to influenza therapy, by
enhancing the immune system’s first line of defense.
4.2.2. S1P agonists
Sphingosine-1-phosphate (S1P) is a ligand for a family of 5 G- 4.2.4. Peroxisome proliferator-activated receptor agonists
protein-coupled receptors (GPCRs), S1P1 -S1P5, which are differen- Peroxisome proliferator-activated receptors (PPARs) are nuclear
tially expressed on various cell types. The binding of S1P to its hormone receptors which are categorized into three subtypes, a,
receptors enables the control of a variety of cellular activities, d(b), and c. Each subtype is expressed in a diverse array of cell
including adhesion, migration, cytokine secretion and barrier types, and is activated by different ligands (Kliewer et al., 1994).
integrity, and plays an important role in inflammation and immu- PPAR-c is expressed in adipose tissue, monocytes, and macro-
nity (Rivera et al., 2008). phages, and plays a role in glucose metabolism and adipocyte dif-
AAL-R, a broad-spectrum agonist of S1P receptors, was shown ferentiation (Tontonoz et al., 1994). Numerous studies have found
to impair the activation of dendritic cells, down-modulate influ- that PPAR-c may be involved in regulating cytokine production.
enza virus-specific T-cell responses and dampen the release of Activation of the PPAR-c receptor by its ligand inhibits the pro-
pro-inflammatory cytokines, leading to decreased lung injury dur- duction of TNF-a, IL-1b and IL-6 and other pro-inflammatory cyto-
ing influenza virus infection (Marsolais et al., 2008) (Table 2). kines in many cell types, such as monocytes and T lymphocytes,
Interestingly, although there was significant T cell suppression, through trans-repression of NF-jB and AP-1 (Clark et al., 2000;
the production of protective antibodies by infected mice was not Jiang et al., 1998; Pascual et al., 2005) (Table 2). In a recent study,
affected by AAL-R treatment. This differed from the action of anti- treatment of mice with the PPAR-c agonist (pioglitazone) before
viral drugs such as oseltamivir, in which the reduction in tissue influenza virus challenge led to suppression of CCL-2 production
damage was the result of reduced viral burden. If AAL-R is used (Herold et al., 2008), a reduction in infiltration of TNF/iNOS-pro-
to treat influenza A infection in combination with antivirals, it will ducing monocytes in the lungs and improved survival (Aldridge
promote viral clearance as well as the clinical course (Walsh et al., et al., 2009). These results suggest that PPAR agonists may be used
2011). These data indicate that AAL-R may be a useful drug for to modulate the immune response to influenza virus infection,
influenza treatment, either alone or in combination, dampening reducing immunopathology and tissue damage.
cytokine responses and reducing lung injury, while maintaining
the benefits of the protective immune response. 4.2.5. Statins
Although S1P signaling appears to be a promising therapeutic Statins have been widely used to treat high blood cholesterol
target, it also mediates various kinds of cellular activities; the levels. They reversibly and competitively inhibit the activity of 3-
hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase, For the control of influenza, is it best to target the virus or the
reducing synthesis of cholesterol and mevalonate (Chong et al., host? While targeting the virus provides a specific and direct inhib-
2001). In addition to their lipid-lowering activity, statins exert itory effect, targeting the host certainly provides other advantages,
immunomodulatory effects (Table 2). They suppress the MHC-II including a lower likelihood of drug resistance and immunomodu-
expression induced by IFN-c, without modulating constitutive latory effects that may decrease tissue damage. Novel approaches
MHC-II expression, by reducing the inducible expression of CIITA, that have both immunomodulatory and antiviral effects therefore
a general MHC-II controller, by inhibiting the activity of CIITA pro- deserve special attention. Furthermore, the application of antiviral
moter IV. Inhibition of the inducible expression of MHC-II sup- drugs in combination with immunomodulatory agents provides a
presses activation of CD4 T lymphocytes, reducing the promising direction, as seen in recent in vivo studies (Zheng
inflammatory response (Kwak et al., 2000). Statins also have an- et al., 2008; Walsh et al., 2011). Further preclinical and clinical tri-
other immunomodulatory mechanism, via interaction with lym- als will be needed to study the underlying mechanisms of action
phocyte function-associated antigen-1 (LFA-1), a glycoprotein in and confirm their beneficial effects against influenza in humans.
the b2-integrin family (Weitz-Schmidt et al., 2001). LFA-1 is acti-
vated by engagement of the T-cell or chemokine receptor, and Acknowledgements
binds to the intracellular adhesion molecule-1 (ICAM-1) to drive
various downstream activities, including lymphocyte recirculation Funding was provided by the Research Fund for the Control of
and leukocyte extravasation (Carlos and Harlan, 1994). Infectious Diseases (Project No.: 08070532, 10090142 and
The therapeutic potential of statins for influenza therapy has re- 11101312) from the Food and Health Bureau, Hong Kong SAR
cently been demonstrated, in a study showing a significantly re- and the Area of Excellence Scheme of the University Grants Com-
duced risk of death in influenza patients who were receiving mittee (AoE/M-12/06), Hong Kong SAR. The authors thank Prof.
statins (Frost et al., 2007; Kwong et al., 2009). However, such ret- Malik Peiris and Dr. Sophie Valkenburg for their critical review of
rospective studies have potential biases, and the patients were the manuscript.
being treated with statins before they acquired influenza. The ben-
eficial effect of statins has recently been challenged, as no benefi-
References
cial effects on influenza patients were observed (Fleming et al.,
2010; Viasus et al., 2011). Further investigation should be carried Abed, Y., Baz, M., Boivin, G., 2006. Impact of neuraminidase mutations conferring
out, especially to identify a possible beneficial effect of initiating influenza resistance to neuraminidase inhibitors in the N1 and N2 genetic
backgrounds. Antivir. Ther. 11, 971–976.
statins near the onset of influenza illness or at the time of
Air, G.M., 2011. Influenza neuraminidase. Influenza Other Respi. Viruses 6, 245–256.
hospitalization. Aldridge Jr., J.R., Moseley, C.E., Boltz, D.A., Negovetich, N.J., Reynolds, C., Franks, J.,
The molecular mechanisms of statin activity in influenza infec- Brown, S.A., Doherty, P.C., Webster, R.G., Thomas, P.G., 2009. TNF/iNOS-
tion also remain poorly understood. One possibility is that the inhi- producing dendritic cells are the necessary evil of lethal influenza virus
infection. Proc. Natl. Acad. Sci. USA 106, 5306–5311.
bition and depletion of cholesterol biosynthesis disrupt the Babu, Y.S., Chand, P., Bantia, S., Kotian, P., Dehghani, A., El-Kattan, Y., Lin, T.H.,
structure of membrane-resident lipid rafts, resulting in loose inter- Hutchison, T.L., Elliott, A.J., Parker, C.D., Ananth, S.L., Horn, L.L., Laver, G.W.,
actions between these micro-lipid domains. Activation of the Raf/ Montgomery, J.A., 2000. BCX-1812 (RWJ-270201): discovery of a novel, highly
potent, orally active, and selective influenza neuraminidase inhibitor through
MEK/ERK signal cascade required efficient nuclear cytoplasmic structure-based drug design. J. Med. Chem. 43, 3482–3486.
RNP localization, which is triggered by the accumulation of the Balannik, V., Wang, J., Ohigashi, Y., Jing, X., Magavern, E., Lamb, R.A., Degrado, W.F.,
influenza HA in cell membranes, and thus has a close association Pinto, L.H., 2009. Design and pharmacological characterization of inhibitors of
amantadine-resistant mutants of the M2 ion channel of influenza A virus.
with lipid rafts. Statin treatment might interfere with this chain Biochemistry 48, 11872–11882.
of events by lowering cholesterol biosynthesis during influenza Basu, D., Walkiewicz, M.P., Frieman, M., Baric, R.S., Auble, D.T., Engel, D.A., 2009.
infection, impairing the production of infectious virus. Novel influenza virus NS1 antagonists block replication and restore innate
immune function. J. Virol. 83, 1881–1891.
Belser, J.A., Lu, X., Szretter, K.J., Jin, X., Aschenbrenner, L.M., Lee, A., Hawley, S., Kim
do, H., Malakhov, M.P., Yu, M., Fang, F., Katz, J.M., 2007. DAS181, a novel
5. Concluding remarks sialidase fusion protein, protects mice from lethal avian influenza H5N1 virus
infection. J. Infect. Dis. 196, 1493–1499.
Bloom, J.D., Gong, L.I., Baltimore, D., 2010. Permissive secondary mutations enable
Influenza virus infection in humans can lead to mild to severe the evolution of influenza oseltamivir resistance. Science 328, 1272–1275.
illness, as a result of both viral replication and the host immune re- Bodian, D.L., Yamasaki, R.B., Buswell, R.L., Stearns, J.F., White, J.M., Kuntz, I.D., 1993.
sponse. Early treatment with NA inhibitors and M2 ion channel Inhibition of the fusion-inducing conformational change of influenza
hemagglutinin by benzoquinones and hydroquinones. Biochemistry 32, 2967–
blockers is currently the mainstay for patient management. How- 2978.
ever, the response to antiviral therapy has been variable, and the Boltz, D.A., Aldridge Jr., J.R., Webster, R.G., Govorkova, E.A., 2010. Drugs in
development of drug resistance has raised public health concerns. development for influenza. Drugs 70, 1349–1362.
Born, W.K., Reardon, C.L., O’Brien, R.L., 2006. The function of gammadelta T cells in
The identification of resistant variants with transmissibility or innate immunity. Curr. Opin. Immunol. 18, 31–38.
pathogenicity comparable to their wild-type counterparts high- Bottcher-Friebertshauser, E., Freuer, C., Sielaff, F., Schmidt, S., Eickmann, M.,
lights the need to improve the design of NA inhibitors and to devel- Uhlendorff, J., Steinmetzer, T., Klenk, H.D., Garten, W., 2010. Cleavage of
influenza virus hemagglutinin by airway proteases TMPRSS2 and HAT differs in
op new classes of antiviral compounds. subcellular localization and susceptibility to protease inhibitors. J. Virol. 84,
In this review, we have discussed approaches under develop- 5605–5614.
ment for the control of influenza virus infection, including (1) Bottcher-Friebertshauser, E., Stein, D.A., Klenk, H.D., Garten, W., 2011. Inhibition of
influenza virus infection in human airway cell cultures by an antisense peptide-
improving the design, potency and route of delivery for existing conjugated morpholino oligomer targeting the hemagglutinin-activating
inhibitors; (2) identifying novel classes of compounds or biomole- protease TMPRSS2. J. Virol. 85, 1554–1562.
cules that inhibit virus replication; (3) blocking virus-host interac- Bottcher, E., Freuer, C., Steinmetzer, T., Klenk, H.D., Garten, W., 2009. MDCK cells
that express proteases TMPRSS2 and HAT provide a cell system to propagate
tions, to reduce viral replication efficiency; (4) modulating the host
influenza viruses in the absence of trypsin and to study cleavage of HA and its
immune response to alleviate tissue damage; and (5) combination inhibition. Vaccine 27, 6324–6329.
therapy. Current research aims to improve existing therapies, by Bottcher, E., Matrosovich, T., Beyerle, M., Klenk, H.D., Garten, W., Matrosovich, M.,
targeting either influenza viruses or cellular factors that affect viral 2006. Proteolytic activation of influenza viruses by serine proteases TMPRSS2
and HAT from human airway epithelium. J. Virol. 80, 9896–9898.
replication and host innate immune responses (summarized in Ta- Brandes, M., Willimann, K., Moser, B., 2005. Professional antigen-presentation
bles 1 and 2). function by human gammadelta T Cells. Science 309, 264–268.
Brannon, T.S., MacRitchie, A.N., Jaramillo, M.A., Sherman, T.S., Yuhanna, I.S., Margraf, Eichelberger, M.C., Hassantoufighi, A., Wu, M., Li, M., 2008. Neuraminidase activity
L.R., Shaul, P.W., 1998. Ontogeny of cyclooxygenase-1 and cyclooxygenase-2 provides a practical read-out for a high throughput influenza antiviral screening
gene expression in ovine lung. Am. J. Physiol. 274, L66–71. assay. Virol. J. 5, 109.
Cady, S.D., Schmidt-Rohr, K., Wang, J., Soto, C.S., Degrado, W.F., Hong, M., 2010. Ekiert, D.C., Friesen, R.H., Bhabha, G., Kwaks, T., Jongeneelen, M., Yu, W., Ophorst, C.,
Structure of the amantadine binding site of influenza M2 proton channels in Cox, F., Korse, H.J., Brandenburg, B., Vogels, R., Brakenhoff, J.P., Kompier, R.,
lipid bilayers. Nature 463, 689–692. Koldijk, M.H., Cornelissen, L.A., Poon, L.L., Peiris, M., Koudstaal, W., Wilson, I.A.,
Carding, S.R., Egan, P.J., 2002. Gammadelta T cells: functional plasticity and Goudsmit, J., 2011. A highly conserved neutralizing epitope on group 2
heterogeneity. Nat. Rev. Immunol. 2, 336–345. influenza A viruses. Science 333, 843–850.
Carey, M.A., Bradbury, J.A., Seubert, J.M., Langenbach, R., Zeldin, D.C., Germolec, D.R., Eriksson, B., Helgstrand, E., Johansson, N.G., Larsson, A., Misiorny, A., Noren, J.O.,
2005. Contrasting effects of cyclooxygenase-1 (COX-1) and COX-2 deficiency on Philipson, L., Stenberg, K., Stening, G., Stridh, S., Oberg, B., 1977. Inhibition of
the host response to influenza A viral infection. J. Immunol. 175, 6878–6884. influenza virus ribonucleic acid polymerase by ribavirin triphosphate.
Carlos, T.M., Harlan, J.M., 1994. Leukocyte-endothelial adhesion molecules. Blood Antimicrob. Agents Chemother. 11, 946–951.
84, 2068–2101. Ermert, L., Ermert, M., Goppelt-Struebe, M., Walmrath, D., Grimminger, F., Steudel,
Chaipan, C., Kobasa, D., Bertram, S., Glowacka, I., Steffen, I., Tsegaye, T.S., Takeda, M., W., Ghofrani, H.A., Homberger, C., Duncker, H., Seeger, W., 1998.
Bugge, T.H., Kim, S., Park, Y., Marzi, A., Pohlmann, S., 2009. Proteolytic activation Cyclooxygenase isoenzyme localization and mRNA expression in rat lungs.
of the 1918 influenza virus hemagglutinin. J. Virol. 83, 3200–3211. Am. J. Respir. Cell Mol. Biol. 18, 479–488.
Chan-Tack, K.M., Murray, J.S., Birnkrant, D.B., 2009. Use of ribavirin to treat Eyers, S., Weatherall, M., Shirtcliffe, P., Perrin, K., Beasley, R., 2010. The effect on
influenza. N. Engl. J. Med. 361, 1713–1714. mortality of antipyretics in the treatment of influenza infection: systematic
Chan, M.M., Moore, A.R., 2010. Resolution of inflammation in murine autoimmune review and meta-analysis. J. R. Soc. Med. 103, 403–411.
arthritis is disrupted by cyclooxygenase-2 inhibition and restored by Faleiro, L., Lazebnik, Y., 2000. Caspases disrupt the nuclear-cytoplasmic barrier. J.
prostaglandin E2-mediated lipoxin A4 production. J. Immunol. 184, 6418–6426. Cell Biol. 151, 951–959.
Chan, R.W., Chan, M.C., Wong, A.C., Karamanska, R., Dell, A., Haslam, S.M., Sihoe, Fiore, A.E., Bridges, C.B., Cox, N.J., 2009. Seasonal influenza vaccines. Curr. Top.
A.D., Chui, W.H., Triana-Baltzer, G., Li, Q., Peiris, J.S., Fang, F., Nicholls, J.M., 2009. Microbiol. Immunol. 333, 43–82.
DAS181 inhibits H5N1 influenza virus infection of human lung tissues. Fleming, D.M., Verlander, N.Q., Elliot, A.J., Zhao, H., Gelb, D., Jehring, D., Nguyen-
Antimicrob. Agents Chemother. 53, 3935–3941. Van-Tam, J.S., 2010. An assessment of the effect of statin use on the incidence of
Chen, W., Calvo, P.A., Malide, D., Gibbs, J., Schubert, U., Bacik, I., Basta, S., O’Neill, R., acute respiratory infections in England during winters 1998–1999 to 2005–
Schickli, J., Palese, P., Henklein, P., Bennink, J.R., Yewdell, J.W., 2001. A novel 2006. Epidemiol. Infect. 138, 1281–1288.
influenza A virus mitochondrial protein that induces cell death. Nat. Med. 7, Friesen, R.H., Koudstaal, W., Koldijk, M.H., Weverling, G.J., Brakenhoff, J.P., Lenting,
1306–1312. P.J., Stittelaar, K.J., Osterhaus, A.D., Kompier, R., Goudsmit, J., 2010. New class of
Cheng, P.K., To, A.P., Leung, T.W., Leung, P.C., Lee, C.W., Lim, W.W., 2010. monoclonal antibodies against severe influenza: prophylactic and therapeutic
Oseltamivir- and amantadine-resistant influenza virus A (H1N1). Emerg. efficacy in ferrets. PLoS ONE 5, e9106.
Infect. Dis. 16, 155–156. Frost, F.J., Petersen, H., Tollestrup, K., Skipper, B., 2007. Influenza and COPD
Chong, P.H., Seeger, J.D., Franklin, C., 2001. Clinically relevant differences between mortality protection as pleiotropic, dose-dependent effects of statins. Chest
the statins: implications for therapeutic selection. Am. J. Med. 111, 390–400. 131, 1006–1012.
Clark, R.B., Bishop-Bailey, D., Estrada-Hernandez, T., Hla, T., Puddington, L., Padula, Fukunaga, K., Kohli, P., Bonnans, C., Fredenburgh, L.E., Levy, B.D., 2005.
S.J., 2000. The nuclear receptor PPAR gamma and immunoregulation: PPAR Cyclooxygenase 2 plays a pivotal role in the resolution of acute lung injury. J.
gamma mediates inhibition of helper T cell responses. J. Immunol. 164, 1364–1371. Immunol. 174, 5033–5039.
Corti, D., Voss, J., Gamblin, S.J., Codoni, G., Macagno, A., Jarrossay, D., Vachieri, S.G., Furuta, Y., Takahashi, K., Fukuda, Y., Kuno, M., Kamiyama, T., Kozaki, K., Nomura, N.,
Pinna, D., Minola, A., Vanzetta, F., Silacci, C., Fernandez-Rodriguez, B.M., Agatic, Egawa, H., Minami, S., Watanabe, Y., Narita, H., Shiraki, K., 2002. In vitro and
G., Bianchi, S., Giacchetto-Sasselli, I., Calder, L., Sallusto, F., Collins, P., Haire, L.F., in vivo activities of anti-influenza virus compound T-705. Antimicrob. Agents
Temperton, N., Langedijk, J.P., Skehel, J.J., Lanzavecchia, A., 2011. A neutralizing Chemother. 46, 977–981.
antibody selected from plasma cells that binds to group 1 and group 2 influenza Furuta, Y., Takahashi, K., Kuno-Maekawa, M., Sangawa, H., Uehara, S., Kozaki, K.,
A hemagglutinins. Science 333, 850–856. Nomura, N., Egawa, H., Shiraki, K., 2005. Mechanism of action of T-705 against
Das, K., Aramini, J.M., Ma, L.C., Krug, R.M., Arnold, E., 2010. Structures of influenza A influenza virus. Antimicrob. Agents Chemother. 49, 981–986.
proteins and insights into antiviral drug targets. Nat. Struct. Mol. Biol. 17, 530– Furuta, Y., Takahashi, K., Shiraki, K., Sakamoto, K., Smee, D.F., Barnard, D.L., Gowen,
538. B.B., Julander, J.G., Morrey, J.D., 2009. T-705 (favipiravir) and related
De Clercq, E., 2009. Another ten stories in antiviral drug discovery (part C): ‘‘Old’’ compounds: novel broad-spectrum inhibitors of RNA viral infections.
and ‘‘new’’ antivirals, strategies, and perspectives. Med. Res. Rev. 29, 611–645. Antiviral Res. 82, 95–102.
de Vries, E., Tscherne, D.M., Wienholts, M.J., Cobos-Jimenez, V., Scholte, F., Garcia- Gack, M.U., Albrecht, R.A., Urano, T., Inn, K.S., Huang, I.C., Carnero, E., Farzan, M.,
Sastre, A., Rottier, P.J., de Haan, C.A., 2011. Dissection of the influenza A virus Inoue, S., Jung, J.U., Garcia-Sastre, A., 2009. Influenza A virus NS1 targets the
endocytic routes reveals macropinocytosis as an alternative entry pathway. ubiquitin ligase TRIM25 to evade recognition by the host viral RNA sensor RIG-I.
PLoS Pathog. 7, e1001329. Cell Host Microbe 5, 439–449.
Delogu, I., Pastorino, B., Baronti, C., Nougairede, A., Bonnet, E., de Lamballerie, X., Gamblin, S.J., Skehel, J.J., 2010. Influenza hemagglutinin and neuraminidase
2011. In vitro antiviral activity of arbidol against Chikungunya virus and membrane glycoproteins. J. Biol. Chem. 285, 28403–28409.
characteristics of a selected resistant mutant. Antiviral Res. 90, 99–107. Gerritz, S.W., Cianci, C., Kim, S., Pearce, B.C., Deminie, C., Discotto, L., McAuliffe, B.,
Deyde, V.M., Xu, X., Bright, R.A., Shaw, M., Smith, C.B., Zhang, Y., Shu, Y., Gubareva, Minassian, B.F., Shi, S., Zhu, S., Zhai, W., Pendri, A., Li, G., Poss, M.A., Edavettal, S.,
L.V., Cox, N.J., Klimov, A.I., 2007. Surveillance of resistance to adamantanes McDonnell, P.A., Lewis, H.A., Maskos, K., Mortl, M., Kiefersauer, R., Steinbacher,
among influenza A(H3N2) and A(H1N1) viruses isolated worldwide. J. Infect. S., Baldwin, E.T., Metzler, W., Bryson, J., Healy, M.D., Philip, T., Zoeckler, M.,
Dis. 196, 249–257. Schartman, R., Sinz, M., Leyva-Grado, V.H., Hoffmann, H.H., Langley, D.R.,
Dharan, N.J., Gubareva, L.V., Meyer, J.J., Okomo-Adhiambo, M., McClinton, R.C., Meanwell, N.A., Krystal, M., 2011. Inhibition of influenza virus replication via
Marshall, S.A., St. George, K., Epperson, S., Brammer, L., Klimov, A.I., Bresee, J.S., small molecules that induce the formation of higher-order nucleoprotein
Fry, A.M., 2009. Infections with oseltamivir-resistant influenza A(H1N1) virus in oligomers. Proc. Natl. Acad. Sci. USA 108, 15366–15371.
the United States. JAMA 301, 1034–1041. Ghanem, A., Mayer, D., Chase, G., Tegge, W., Frank, R., Kochs, G., Garcia-Sastre, A.,
Dias, A., Bouvier, D., Crepin, T., McCarthy, A.A., Hart, D.J., Baudin, F., Cusack, S., Schwemmle, M., 2007. Peptide-mediated interference with influenza A virus
Ruigrok, R.W., 2009. The cap-snatching endonuclease of influenza virus polymerase. J. Virol. 81, 7801–7804.
polymerase resides in the PA subunit. Nature 458, 914–918. Graci, J.D., Cameron, C.E., 2006. Mechanisms of action of ribavirin against distinct
Droebner, K., Pleschka, S., Ludwig, S., Planz, O., 2011. Antiviral activity of the MEK- viruses. Rev. Med. Virol. 16, 37–48.
inhibitor U0126 against pandemic H1N1v and highly pathogenic avian Gubareva, L.V., 2004. Molecular mechanisms of influenza virus resistance to
influenza virus in vitro and in vivo. Antiviral Res. 92, 195–203. neuraminidase inhibitors. Virus Res. 103, 199–203.
Duan, S., Boltz, D.A., Seiler, P., Li, J., Bragstad, K., Nielsen, L.P., Webby, R.J., Webster, Gubareva, L.V., Hayden, F.G., 2006. The anti-influenza activity of M2 and
R.G., Govorkova, E.A., 2010. Oseltamivir-resistant pandemic H1N1/2009 neuraminidase inhibotors. In: Kawaoka, Y. (Ed.), Influenza Virology: Current
influenza virus possesses lower transmissibility and fitness in ferrets. PLoS Topics. Caister Academic Press, England, pp. 169–202.
Pathog. 6, e1001022. Gubareva, L.V., Kaiser, L., Matrosovich, M.N., Soo-Hoo, Y., Hayden, F.G., 2001.
Dubois, R.M., Slavish, P.J., Baughman, B.M., Yun, M.K., Bao, J., Webby, R.J., Webb, T.R., Selection of influenza virus mutants in experimentally infected volunteers
White, S.W., 2012. Structural and biochemical basis for development of treated with oseltamivir. J. Infect. Dis. 183, 523–531.
influenza virus inhibitors targeting the PA endonuclease. PLoS Pathog. 8, Gubareva, L.V., Trujillo, A.A., Okomo-Adhiambo, M., Mishin, V.P., Deyde, V.M.,
e1002830. Sleeman, K., Nguyen, H.T., Sheu, T.G., Garten, R.J., Shaw, M.W., Fry, A.M., Klimov,
Duval, X., van der Werf, S., Blanchon, T., Mosnier, A., Bouscambert-Duchamp, M., A.I., 2010. Comprehensive assessment of 2009 pandemic influenza A (H1N1)
Tibi, A., Enouf, V., Charlois-Ou, C., Vincent, C., Andreoletti, L., Tubach, F., Lina, B., virus drug susceptibility in vitro. Antivir. Ther. 15, 1151–1159.
Mentre, F., Leport, C., 2010. Efficacy of oseltamivir-zanamivir combination Guilligay, D., Tarendeau, F., Resa-Infante, P., Coloma, R., Crepin, T., Sehr, P., Lewis, J.,
compared to each monotherapy for seasonal influenza: a randomized placebo- Ruigrok, R.W., Ortin, J., Hart, D.J., Cusack, S., 2008. The structural basis for cap
controlled trial. PLoS Med. 7, e1000362. binding by influenza virus polymerase subunit PB2. Nat. Struct. Mol. Biol. 15,
Ehrhardt, C., Marjuki, H., Wolff, T., Nurnberg, B., Planz, O., Pleschka, S., Ludwig, S., 500–506.
2006. Bivalent role of the phosphatidylinositol-3-kinase (PI3K) during influenza Gutierrez, R.A., Naughtin, M.J., Horm, S.V., San, S., Buchy, P., 2009. A(H5N1) virus
virus infection and host cell defence. Cell. Microbiol. 8, 1336–1348. evolution in South East Asia. Viruses 1, 335–361.
Haasbach, E., Pauli, E.K., Spranger, R., Mitzner, D., Schubert, U., Kircheis, R., Planz, O., Kiso, M., Ozawa, M., Le, M.T., Imai, H., Takahashi, K., Kakugawa, S., Noda, T.,
2011. Antiviral activity of the proteasome inhibitor VL-01 against influenza A Horimoto, T., Kawaoka, Y., 2011. Effect of an asparagine-to-serine mutation at
viruses. Antiviral Res. 91, 304–313. position 294 in neuraminidase on the pathogenicity of highly pathogenic H5N1
Hale, B.G., Randall, R.E., Ortin, J., Jackson, D., 2008. The multifunctional NS1 protein influenza A virus. J. Virol. 85, 4667–4672.
of influenza A viruses. J. Gen. Virol. 89, 2359–2376. Kiso, M., Shinya, K., Shimojima, M., Takano, R., Takahashi, K., Katsura, H., Kakugawa,
Hayden, F., 2009. Developing new antiviral agents for influenza treatment: what S., Le, M.T., Yamashita, M., Furuta, Y., Ozawa, M., Kawaoka, Y., 2010.
does the future hold? Clin. Infect. Dis. 48 (Suppl 1), S3–13. Characterization of oseltamivir-resistant 2009 H1N1 pandemic influenza A
He, X., Zhou, J., Bartlam, M., Zhang, R., Ma, J., Lou, Z., Li, X., Li, J., Joachimiak, A., Zeng, viruses. PLoS Pathog. 6, e1001079.
Z., Ge, R., Rao, Z., Liu, Y., 2008. Crystal structure of the polymerase PA(C)–PB1(N) Kliewer, S.A., Forman, B.M., Blumberg, B., Ong, E.S., Borgmeyer, U., Mangelsdorf, D.J.,
complex from an avian influenza H5N1 virus. Nature 454, 1123–1126. Umesono, K., Evans, R.M., 1994. Differential expression and activation of a
Hedlund, M., Aschenbrenner, L.M., Jensen, K., Larson, J.L., Fang, F., 2010. Sialidase- family of murine peroxisome proliferator-activated receptors. Proc. Natl. Acad.
based anti-influenza virus therapy protects against secondary pneumococcal Sci. USA 91, 7355–7359.
infection. J. Infect. Dis. 201, 1007–1015. Koudstaal, W., Koldijk, M.H., Brakenhoff, J.P., Cornelissen, L.A., Weverling, G.J.,
Hernandez, J.E., Adiga, R., Armstrong, R., Bazan, J., Bonilla, H., Bradley, J., Dretler, R., Friesen, R.H., Goudsmit, J., 2009. Pre- and postexposure use of human
Ison, M.G., Mangino, J.E., Maroushek, S., Shetty, A.K., Wald, A., Ziebold, C., Elder, monoclonal antibody against H5N1 and H1N1 influenza virus in mice. Viable
J., Hollister, A.S., Sheridan, W., 2011. Clinical experience in adults and children alternative to oseltamivir. J. Infect. Dis. 200, 1870–1873.
treated with intravenous peramivir for 2009 influenza A (H1N1) under an Kowalinski, E., Zubieta, C., Wolkerstorfer, A., Szolar, O.H., Ruigrok, R.W., Cusack, S.,
Emergency IND program in the United States. Clin. Infect. Dis. 52, 695–706. 2012. Structural analysis of specific metal chelating inhibitor binding to the
Herold, S., Steinmueller, M., von Wulffen, W., Cakarova, L., Pinto, R., Pleschka, S., endonuclease domain of Influenza pH1N1 (2009) polymerase. PLoS Pathog. 8,
Mack, M., Kuziel, W.A., Corazza, N., Brunner, T., Seeger, W., Lohmeyer, J., 2008. e1002831.
Lung epithelial apoptosis in influenza virus pneumonia: the role of Kubo, M., Hanada, T., Yoshimura, A., 2003. Suppressors of cytokine signaling and
macrophage-expressed TNF-related apoptosis-inducing ligand. J. Exp. Med. immunity. Nat. Immunol. 4, 1169–1176.
205, 3065–3077. Kubo, S., Tomozawa, T., Kakuta, M., Tokumitsu, A., Yamashita, M., 2010. Laninamivir
Hoopes, J.D., Driebe, E.M., Kelley, E., Engelthaler, D.M., Keim, P.S., Perelson, A.S., prodrug CS-8958, a long-acting neuraminidase inhibitor, shows superior anti-
Rong, L., Went, G.T., Nguyen, J.T., 2011. Triple combination antiviral drug (TCAD) influenza virus activity after a single administration. Antimicrob. Agents
composed of amantadine, oseltamivir, and ribavirin impedes the selection of Chemother. 54, 1256–1264.
drug-resistant influenza A virus. PLoS ONE 6, e29778. Kurokawa, M., Tsurita, M., Brown, J., Fukuda, Y., Shiraki, K., 2002. Effect of
Hurt, A.C., Chotpitayasunondh, T., Cox, N.J., Daniels, R., Fry, A.M., Gubareva, L.V., interleukin-12 level augmented by Kakkon-to, a herbal medicine, on the early
Hayden, F.G., Hui, D.S., Hungnes, O., Lackenby, A., Lim, W., Meijer, A., Penn, C., stage of influenza infection in mice. Antiviral Res. 56, 183–188.
Tashiro, M., Uyeki, T.M., Zambon, M., 2012. Antiviral resistance during the 2009 Kurtz, S., Luo, G., Hahnenberger, K.M., Brooks, C., Gecha, O., Ingalls, K., Numata, K.,
influenza A H1N1 pandemic: public health, laboratory, and clinical Krystal, M., 1995. Growth impairment resulting from expression of influenza
perspectives. Lancet Infect. Dis. 12, 240–248. virus M2 protein in Saccharomyces cerevisiae: identification of a novel inhibitor
Hurt, A.C., Holien, J.K., Parker, M., Kelso, A., Barr, I.G., 2009. Zanamivir-resistant of influenza virus. Antimicrob. Agents Chemother. 39, 2204–2209.
influenza viruses with a novel neuraminidase mutation. J. Virol. 83, 10366– Kwak, B., Mulhaupt, F., Myit, S., Mach, F., 2000. Statins as a newly recognized type of
10373. immunomodulator. Nat. Med. 6, 1399–1402.
Ikematsu, H., Kawai, N., 2011. Laninamivir octanoate: a new long-acting Kwong, J.C., Li, P., Redelmeier, D.A., 2009. Influenza morbidity and mortality in
neuraminidase inhibitor for the treatment of influenza. Expert Rev. Anti elderly patients receiving statins: a cohort study. PLoS ONE 4, e8087.
Infect. Ther. 9, 851–857. Lackenby, A., Hungnes, O., Dudman, S.G., Meijer, A., Paget, W.J., Hay, A.J., Zambon,
Ilyushina, N.A., Hay, A., Yilmaz, N., Boon, A.C., Webster, R.G., Govorkova, E.A., 2008. M.C., 2008. Emergence of resistance to oseltamivir among influenza A(H1N1)
Oseltamivir-ribavirin combination therapy for highly pathogenic H5N1 viruses in Europe. Euro. Surveill. 13, pii: 8026.
influenza virus infection in mice. Antimicrob. Agents Chemother. 52, 3889– Lamb, R.A., Pinto, L.H., 2006. The proton selective ion channels of influenza A and B
3897. viruses. In: Kawaoka, Y. (Ed.), Influenza Virology: Current Topics. Caister
Ilyushina, N.A., Hoffmann, E., Salomon, R., Webster, R.G., Govorkova, E.A., 2007. Academic Press, England, pp. 65–93.
Amantadine-oseltamivir combination therapy for H5N1 influenza virus Larson, J.L., Kang, S.K., Choi, B.I., Hedlund, M., Aschenbrenner, L.M., Cecil, B.,
infection in mice. Antivir. Ther. 12, 363–370. Machado, G., Nieder, M., Fang, F., 2011. A safety evaluation of DAS181, a
Iversen, M.B., Paludan, S.R., 2010. Mechanisms of type III interferon expression. J. sialidase fusion protein, in rodents. Toxicol. Sci. 122, 567–578.
Interferon Cytokine Res. 30, 573–578. Lauring, A.S., Andino, R., 2010. Quasispecies theory and the behavior of RNA viruses.
Jablonski, J.J., Basu, D., Engel, D.A., Geysen, H.M., 2012. Design, synthesis, and PLoS Pathog. 6, e1001005.
evaluation of novel small molecule inhibitors of the influenza virus protein NS1. Lee, S.M., Cheung, C.Y., Nicholls, J.M., Hui, K.P., Leung, C.Y., Uiprasertkul, M., Tipoe,
Bioorg. Med. Chem. 20, 487–497. G.L., Lau, Y.L., Poon, L.L., Ip, N.Y., Guan, Y., Peiris, J.S., 2008. Hyperinduction of
Jagger, B.W., Wise, H.M., Kash, J.C., Walters, K.A., Wills, N.M., Xiao, Y.L., Dunfee, R.L., cyclooxygenase-2-mediated proinflammatory cascade: a mechanism for the
Schwartzman, L.M., Ozinsky, A., Bell, G.L., Dalton, R.M., Lo, A., Efstathiou, S., pathogenesis of avian influenza H5N1 infection. J. Infect. Dis. 198, 525–535.
Atkins, J.F., Firth, A.E., Taubenberger, J.K., Digard, P., 2012. An overlapping Lee, S.M., Gai, W.W., Cheung, T.K., Peiris, J.S., 2011. Antiviral effect of a selective
protein-coding region in influenza A virus segment 3 modulates the host COX-2 inhibitor on H5N1 infection in vitro. Antiviral Res. 91, 330–334.
response. Science 337, 199–204. Leibbrandt, A., Meier, C., Konig-Schuster, M., Weinmullner, R., Kalthoff, D.,
Jiang, C., Ting, A.T., Seed, B., 1998. PPAR-gamma agonists inhibit production of Pflugfelder, B., Graf, P., Frank-Gehrke, B., Beer, M., Fazekas, T., Unger, H.,
monocyte inflammatory cytokines. Nature 391, 82–86. Prieschl-Grassauer, E., Grassauer, A., 2010. Iota-carrageenan is a potent
Jones, J.C., Turpin, E.A., Bultmann, H., Brandt, C.R., Schultz-Cherry, S., 2006. inhibitor of influenza A virus infection. PLoS ONE 5, e14320.
Inhibition of influenza virus infection by a novel antiviral peptide that targets Leneva, I.A., Russell, R.J., Boriskin, Y.S., Hay, A.J., 2009. Characteristics of arbidol-
viral attachment to cells. J. Virol. 80, 11960–11967. resistant mutants of influenza virus: implications for the mechanism of anti-
Julkunen, I., Sareneva, T., Pirhonen, J., Ronni, T., Melen, K., Matikainen, S., 2001. influenza action of arbidol. Antiviral Res. 81, 132–140.
Molecular pathogenesis of influenza A virus infection and virus-induced Li, Q., Qi, J., Zhang, W., Vavricka, C.J., Shi, Y., Wei, J., Feng, E., Shen, J., Chen, J., Liu, D.,
regulation of cytokine gene expression. Cytokine Growth Factor Rev. 12, 171– He, J., Yan, J., Liu, H., Jiang, H., Teng, M., Li, X., Gao, G.F., 2010. The 2009
180. pandemic H1N1 neuraminidase N1 lacks the 150-cavity in its active site. Nat.
Kao, R.Y., Yang, D., Lau, L.S., Tsui, W.H., Hu, L., Dai, J., Chan, M.P., Chan, C.M., Wang, P., Struct. Mol. Biol. 17, 1266–1268.
Zheng, B.J., Sun, J., Huang, J.D., Madar, J., Chen, G., Chen, H., Guan, Y., Yuen, K.Y., Ludwig, S., 2011. Disruption of virus-host cell interactions and cell signaling
2010. Identification of influenza A nucleoprotein as an antiviral target. Nat. pathways as an anti-viral approach against influenza virus infections. Biol.
Biotechnol. 28, 600–605. Chem. 392, 837–847.
Kawaoka, Y., Krauss, S., Webster, R.G., 1989. Avian-to-human transmission of the Lukkarinen, H., Laine, J., Aho, H., Asikainen, E., Penttinen, P., Kaapa, P., 2006.
PB1 gene of influenza A viruses in the 1957 and 1968 pandemics. J. Virol. 63, Inhibition of COX-2 aggravates neutrophil migration and pneumocyte apoptosis
4603–4608. in surfactant-depleted rat lungs. Pediatr. Res. 59, 412–417.
Khan, K.N., Stanfield, K., Trajkovic, D., Harris, R.K., 2000. Cyclooxygenase-2 Malakhov, M.P., Aschenbrenner, L.M., Smee, D.F., Wandersee, M.K., Sidwell, R.W.,
expression in inflammatory lung lesions of nonhuman primates. Vet. Pathol. Gubareva, L.V., Mishin, V.P., Hayden, F.G., Kim, D.H., Ing, A., Campbell, E.R., Yu,
37, 512–516. M., Fang, F., 2006. Sialidase fusion protein as a novel broad-spectrum inhibitor
Kim, C.U., Lew, W., Williams, M., Zhang, L., Swaminathan, S., Bischofberger, N., Chen, of influenza virus infection. Antimicrob. Agents Chemother. 50, 1470–1479.
M.S., Mendel, D., Li, W., Tai, L., Escarpe, P., Cundy, K.C., Eisenberg, E.J., Lacy, S., Mao, H., Tu, W., Liu, Y., Qin, G., Zheng, J., Chan, P.L., Lam, K.T., Peiris, J.S., Lau, Y.L.,
Sidwell, R.W., Stevens, R.C., Laver, G.W., 1996. New potent, orally active 2010. Inhibition of human natural killer cell activity by influenza virions and
neuraminidase inhibitors as anti-influenza agents: in vitro and in vivo hemagglutinin. J. Virol. 84, 4148–4157.
activity of GS4071 and analogs. In: 36th Interscience Conference on Mao, H., Tu, W., Qin, G., Law, H.K., Sia, S.F., Chan, P.L., Liu, Y., Lam, K.T., Zheng, J.,
Antimicrobial Agents and Chemotherapy. American Society for Microbiology, Peiris, M., Lau, Y.L., 2009. Influenza virus directly infects human natural killer
Washington, DC. cells and induces cell apoptosis. J. Virol. 83, 9215–9222.
Kim, W.Y., Young Suh, G., Huh, J.W., Kim, S.H., Kim, M.J., Kim, Y.S., Kim, H.R., Ryu, Y.J., Marjuki, H., Yen, H.L., Franks, J., Webster, R.G., Pleschka, S., Hoffmann, E., 2007.
Han, M.S., Ko, Y.G., Chon, G.R., Lee, K.H., Choi, S.H., Hong, S.B., 2011. Triple- Higher polymerase activity of a human influenza virus enhances activation of
combination antiviral drug for pandemic H1N1 influenza virus infection in the hemagglutinin-induced Raf/MEK/ERK signal cascade. Virol. J. 4, 134.
critically ill patients on mechanical ventilation. Antimicrob. Agents Chemother. Marsolais, D., Hahm, B., Edelmann, K.H., Walsh, K.B., Guerrero, M., Hatta, Y.,
55, 5703–5709. Kawaoka, Y., Roberts, E., Oldstone, M.B., Rosen, H., 2008. Local not systemic
modulation of dendritic cell S1P receptors in lung blunts virus-specific immune Rudrawar, S., Dyason, J.C., Rameix-Welti, M.A., Rose, F.J., Kerry, P.S., Russell, R.J., van
responses to influenza. Mol. Pharmacol. 74, 896–903. der Werf, S., Thomson, R.J., Naffakh, N., von Itzstein, M., 2010. Novel sialic acid
Matrosovich, M.N., Matrosovich, T.Y., Gray, T., Roberts, N.A., Klenk, H.D., 2004. derivatives lock open the 150-loop of an influenza A virus group-1 sialidase. Nat
Neuraminidase is important for the initiation of influenza virus infection in Commun 1, 113.
human airway epithelium. J. Virol. 78, 12665–12667. Russell, R.J., Haire, L.F., Stevens, D.J., Collins, P.J., Lin, Y.P., Blackburn, G.M., Hay, A.J.,
Matsuyama, S., Nagata, N., Shirato, K., Kawase, M., Takeda, M., Taguchi, F., 2010. Gamblin, S.J., Skehel, J.J., 2006. The structure of H5N1 avian influenza
Efficient activation of the severe acute respiratory syndrome coronavirus spike neuraminidase suggests new opportunities for drug design. Nature 443, 45–49.
protein by the transmembrane protease TMPRSS2. J. Virol. 84, 12658–12664. Seibert, C.W., Kaminski, M., Philipp, J., Rubbenstroth, D., Albrecht, R.A., Schwalm, F.,
Mazur, I., Wurzer, W.J., Ehrhardt, C., Pleschka, S., Puthavathana, P., Silberzahn, T., Stertz, S., Medina, R.A., Kochs, G., Garcia-Sastre, A., Staeheli, P., Palese, P., 2010.
Wolff, T., Planz, O., Ludwig, S., 2007. Acetylsalicylic acid (ASA) blocks influenza Oseltamivir-resistant variants of the 2009 pandemic H1N1 influenza A virus are
virus propagation via its NF-kappaB-inhibiting activity. Cell. Microbiol. 9, 1683– not attenuated in the guinea pig and ferret transmission models. J. Virol. 84,
1694. 11219–11226.
McKimm-Breschkin, J.L., 2000. Resistance of influenza viruses to neuraminidase Sheu, T.G., Deyde, V.M., Okomo-Adhiambo, M., Garten, R.J., Xu, X., Bright, R.A.,
inhibitors – a review. Antiviral Res. 47, 1–17. Butler, E.N., Wallis, T.R., Klimov, A.I., Gubareva, L.V., 2008. Surveillance for
Memoli, M.J., Davis, A.S., Proudfoot, K., Chertow, D.S., Hrabal, R.J., Bristol, T., neuraminidase inhibitor resistance among human influenza A and B viruses
Taubenberger, J.K., 2011. Multidrug-resistant 2009 pandemic influenza circulating worldwide from 2004 to 2008. Antimicrob. Agents Chemother. 52,
A(H1N1) viruses maintain fitness and transmissibility in ferrets. J. Infect. Dis. 3284–3292.
203, 348–357. Sheu, T.G., Fry, A.M., Garten, R.J., Deyde, V.M., Shwe, T., Bullion, L., Peebles, P.J., Li, Y.,
Monto, A.S., McKimm-Breschkin, J.L., Macken, C., Hampson, A.W., Hay, A., Klimov, A., Klimov, A.I., Gubareva, L.V., 2011. Dual resistance to adamantanes and
Tashiro, M., Webster, R.G., Aymard, M., Hayden, F.G., Zambon, M., 2006. oseltamivir among seasonal influenza A(H1N1) viruses: 2008–2010. J. Infect.
Detection of influenza viruses resistant to neuraminidase inhibitors in global Dis. 203, 13–17.
surveillance during the first 3 years of their use. Antimicrob. Agents Chemother. Shi, L., Xiong, H., He, J., Deng, H., Li, Q., Zhong, Q., Hou, W., Cheng, L., Xiao, H., Yang,
50, 2395–2402. Z., 2007. Antiviral activity of arbidol against influenza A virus, respiratory
Moscona, A., Porotto, M., Palmer, S., Tai, C., Aschenbrenner, L., Triana-Baltzer, G., Li, syncytial virus, rhinovirus, coxsackie virus and adenovirus in vitro and in vivo.
Q.X., Wurtman, D., Niewiesk, S., Fang, F., 2010. A recombinant sialidase fusion Arch. Virol. 152, 1447–1455.
protein effectively inhibits human parainfluenza viral infection in vitro and Shobugawa, Y., Saito, R., Sato, I., Kawashima, T., Dapat, C., Dapat, I.C., Kondo, H.,
in vivo. J. Infect. Dis. 202, 234–241. Suzuki, Y., Saito, K., Suzuki, H., in press. Clinical effectiveness of neuraminidase
Moss, R., Steigbigel, R., Wurtman, D., Hansen, C., Tranel, K.C., M., Larson, J., Sanders, inhibitors-oseltamivir, zanamivir, laninamivir, and peramivir-for treatment of
R., Hawley, S., Li, T., Fang, F., 2011. A phase 2A dose-ranging clinical trial of influenza A(H3N2) and A(H1N1)pdm09 infection: an observational study in the
DAS181 for treatment of influenza in health dults. In: 51st Interscience 2010–2011 influenza season in Japan. J. Infect. Chemother.
Conference on Antimicrobial Agents and Chemotherapy. American Society for Shortridge, K.F., Stuart-Harris, C.H., 1982. An influenza epicentre? Lancet 2, 812–
Microbiology, Washington, DC 813.
Mould, J.A., Paterson, R.G., Takeda, M., Ohigashi, Y., Venkataraman, P., Lamb, R.A., Sidwell, R.W., Huffman, J.H., Khare, G.P., Allen, L.B., Witkowski, J.T., Robins, R.K.,
Pinto, L.H., 2003. Influenza B virus BM2 protein has ion channel activity that 1972. Broad-spectrum antiviral activity of virazole: 1-beta-D-ribofuranosyl-
conducts protons across membranes. Dev. Cell 5, 175–184. 1,2,4-triazole-3-carboxamide. Science 177, 705–706.
Nagata, K., Kawaguchi, A., Naito, T., 2008. Host factors for replication and Sielaff, F., Bottcher-Friebertshauser, E., Meyer, D., Saupe, S.M., Volk, I.M., Garten, W.,
transcription of the influenza virus genome. Rev. Med. Virol. 18, 247–260. Steinmetzer, T., 2011. Development of substrate analogue inhibitors for the
Nguyen, J.T., Hoopes, J.D., Le, M.H., Smee, D.F., Patick, A.K., Faix, D.J., Blair, P.J., de human airway trypsin-like protease HAT. Bioorg. Med. Chem. Lett. 21, 4860–
Jong, M.D., Prichard, M.N., Went, G.T., 2010. Triple combination of amantadine, 4864.
ribavirin, and oseltamivir is highly active and synergistic against drug resistant Skehel, J.J., Waterfield, M.D., 1975. Studies on the primary structure of the influenza
influenza virus strains in vitro. PLoS ONE 5, e9332. virus hemagglutinin. Proc. Natl. Acad. Sci. USA 72, 93–97.
Obayashi, E., Yoshida, H., Kawai, F., Shibayama, N., Kawaguchi, A., Nagata, K., Tame, Skehel, J.J., Wiley, D.C., 2000. Receptor binding and membrane fusion in virus entry:
J.R., Park, S.Y., 2008. The structural basis for an essential subunit interaction in the influenza hemagglutinin. Annu. Rev. Biochem. 69, 531–569.
influenza virus RNA polymerase. Nature 454, 1127–1131. Smee, D.F., Bailey, K.W., Wong, M.H., O’Keefe, B.R., Gustafson, K.R., Mishin, V.P.,
Pahl, H.L., 1999. Activators and target genes of Rel/NF-kappaB transcription factors. Gubareva, L.V., 2008. Treatment of influenza A (H1N1) virus infections in mice
Oncogene 18, 6853–6866. and ferrets with cyanovirin-N. Antiviral Res. 80, 266–271.
Palese, P., Shaw, M., 2007. Orthomyxoviridae: the viruses and their replication. In: Smee, D.F., Hurst, B.L., Wong, M.H., Bailey, K.W., Morrey, J.D., 2009. Effects of double
Knipe, D.M., Howley, P.M. (Eds.), Fields Virology. Lippincott Williams & Wilkins, combinations of amantadine, oseltamivir, and ribavirin on influenza A (H5N1)
Philadelphia, PA, pp. 1647–1690. virus infections in cell culture and in mice. Antimicrob. Agents Chemother. 53,
Parker, W.B., 2005. Metabolism and antiviral activity of ribavirin. Virus Res. 107, 2120–2128.
165–171. Smee, D.F., Hurst, B.L., Wong, M.H., Bailey, K.W., Tarbet, E.B., Morrey, J.D., Furuta, Y.,
Pascual, G., Fong, A.L., Ogawa, S., Gamliel, A., Li, A.C., Perissi, V., Rose, D.W., Willson, 2010. Effects of the combination of favipiravir (T-705) and oseltamivir on
T.M., Rosenfeld, M.G., Glass, C.K., 2005. A SUMOylation-dependent pathway influenza A virus infections in mice. Antimicrob. Agents Chemother. 54, 126–
mediates transrepression of inflammatory response genes by PPAR-gamma. 133.
Nature 437, 759–763. Smith, G.J., Vijaykrishna, D., Bahl, J., Lycett, S.J., Worobey, M., Pybus, O.G., Ma, S.K.,
Pinto, R., Herold, S., Cakarova, L., Hoegner, K., Lohmeyer, J., Planz, O., Pleschka, S., Cheung, C.L., Raghwani, J., Bhatt, S., Peiris, J.S., Guan, Y., Rambaut, A., 2009.
2011. Inhibition of influenza virus-induced NF-kappaB and Raf/MEK/ERK Origins and evolutionary genomics of the 2009 swine-origin H1N1 influenza A
activation can reduce both virus titers and cytokine expression epidemic. Nature 459, 1122–1125.
simultaneously in vitro and in vivo. Antiviral Res. 92, 45–56. Sorbello, A., Jones, S.C., Carter, W., Struble, K., Boucher, R., Truffa, M., Birnkrant, D.,
Platanias, L.C., 2005. Mechanisms of type-I- and type-II-interferon-mediated Gada, N., Camilli, S., Chan, I., Dallas, S., Scales, T., Kosko, R., Thompson, E.,
signalling. Nat. Rev. Immunol. 5, 375–386. Goodman, J., Francis, H., Dal Pan, G., 2012. Emergency use authorization for
Pleschka, S., Wolff, T., Ehrhardt, C., Hobom, G., Planz, O., Rapp, U.R., Ludwig, S., 2001. intravenous peramivir: evaluation of safety in the treatment of hospitalized
Influenza virus propagation is impaired by inhibition of the Raf/MEK/ERK patients infected with 2009 H1N1 influenza A virus. Clin. Infect. Dis. 55, 1–7.
signalling cascade. Nat. Cell Biol. 3, 301–305. Starko, K.M., 2009. Salicylates and pandemic influenza mortality, 1918–1919
Qin, G., Mao, H., Zheng, J., Sia, S.F., Liu, Y., Chan, P.L., Lam, K.T., Peiris, J.S., Lau, Y.L., Tu, pharmacology, pathology, and historic evidence. Clin. Infect. Dis. 49, 1405–
W., 2009. Phosphoantigen-expanded human gammadelta T cells display potent 1410.
cytotoxicity against monocyte-derived macrophages infected with human and Stech, O., Veits, J., Weber, S., Deckers, D., Schroer, D., Vahlenkamp, T.W., Breithaupt,
avian influenza viruses. J. Infect. Dis. 200, 858–865. A., Teifke, J., Mettenleiter, T.C., Stech, J., 2009. Acquisition of a polybasic
Rameix-Welti, M.A., Munier, S., Le Gal, S., Cuvelier, F., Agou, F., Enouf, V., Naffakh, N., hemagglutinin cleavage site by a low-pathogenic avian influenza virus is not
van der Werf, S., 2011. Neuraminidase of 2007–2008 influenza A(H1N1) viruses sufficient for immediate transformation into a highly pathogenic strain. J. Virol.
shows increased affinity for sialic acids due to the D344N substitution. Antivir. 83, 5864–5868.
Ther. 16, 597–603. Steinhauer, D.A., 1999. Role of hemagglutinin cleavage for the pathogenicity of
Resa-Infante, P., Jorba, N., Coloma, R., Ortin, J., 2011. The influenza virus RNA influenza virus. Virology 258, 1–20.
synthesis machine: advances in its structure and function. RNA Biol. 8, 207– Stieneke-Grober, A., Vey, M., Angliker, H., Shaw, E., Thomas, G., Roberts, C., Klenk,
215. H.D., Garten, W., 1992. Influenza virus hemagglutinin with multibasic cleavage
Riner, A., Chan-Tack, K.M., Murray, J.S., 2009. Original research: intravenous site is activated by furin, a subtilisin-like endoprotease. EMBO J. 11, 2407–2414.
ribavirin – review of the FDA’s emergency investigational new drug database Su, B., Karin, M., 1996. Mitogen-activated protein kinase cascades and regulation of
(1997–2008) and literature review. Postgrad. Med. 121, 139–146. gene expression. Curr. Opin. Immunol. 8, 402–411.
Rivera, J., Proia, R.L., Olivera, A., 2008. The alliance of sphingosine-1-phosphate and Su, C.Y., Cheng, T.J., Lin, M.I., Wang, S.Y., Huang, W.I., Lin-Chu, S.Y., Chen, Y.H., Wu,
its receptors in immunity. Nat. Rev. Immunol. 8, 753–763. C.Y., Lai, M.M., Cheng, W.C., Wu, Y.T., Tsai, M.D., Cheng, Y.S., Wong, C.H., 2010.
Rogers, G.N., Paulson, J.C., 1983. Receptor determinants of human and animal High-throughput identification of compounds targeting influenza RNA-
influenza virus isolates: differences in receptor specificity of the H3 dependent RNA polymerase activity. Proc. Natl. Acad. Sci. USA 107, 19151–
hemagglutinin based on species of origin. Virology 127, 361–373. 19156.
Rossignol, J.F., La Frazia, S., Chiappa, L., Ciucci, A., Santoro, M.G., 2009. Thiazolides, a Sui, J., Hwang, W.C., Perez, S., Wei, G., Aird, D., Chen, L.M., Santelli, E., Stec, B.,
new class of anti-influenza molecules targeting viral hemagglutinin at the post- Cadwell, G., Ali, M., Wan, H., Murakami, A., Yammanuru, A., Han, T., Cox, N.J.,
translational level. J. Biol. Chem. 284, 29798–29808. Bankston, L.A., Donis, R.O., Liddington, R.C., Marasco, W.A., 2009. Structural and
functional bases for broad-spectrum neutralization of avian and human Webster, R.G., Bean, W.J., Gorman, O.T., Chambers, T.M., Kawaoka, Y., 1992.
influenza A viruses. Nat. Struct. Mol. Biol. 16, 265–273. Evolution and ecology of influenza A viruses. Microbiol. Rev. 56, 152–179.
Teijaro, J.R., Turner, D., Pham, Q., Wherry, E.J., Lefrancois, L., Farber, D.L., 2011. Weitz-Schmidt, G., Welzenbach, K., Brinkmann, V., Kamata, T., Kallen, J., Bruns, C.,
Cutting edge: tissue-retentive lung memory CD4 T cells mediate optimal Cottens, S., Takada, Y., Hommel, U., 2001. Statins selectively inhibit leukocyte
protection to respiratory virus infection. J. Immunol. 187, 5510–5514. function antigen-1 by binding to a novel regulatory integrin site. Nat. Med. 7,
Throsby, M., van den Brink, E., Jongeneelen, M., Poon, L.L., Alard, P., Cornelissen, L., 687–692.
Bakker, A., Cox, F., van Deventer, E., Guan, Y., Cinatl, J., ter Meulen, J., Lasters, I., Whitehead, T.A., Chevalier, A., Song, Y., Dreyfus, C., Fleishman, S.J., De Mattos, C.,
Carsetti, R., Peiris, M., de Kruif, J., Goudsmit, J., 2008. Heterosubtypic Myers, C.A., Kamisetty, H., Blair, P., Wilson, I.A., Baker, D., 2012. Optimization of
neutralizing monoclonal antibodies cross-protective against H5N1 and H1N1 affinity, specificity and function of designed influenza inhibitors using deep
recovered from human IgM + memory B cells. PLoS ONE 3, e3942. sequencing. Nat. Biotechnol. 30, 543–548.
Tomassini, J., Selnick, H., Davies, M.E., Armstrong, M.E., Baldwin, J., Bourgeois, M., Wiesener, N., Zimmer, C., Jarasch-Althof, N., Wutzler, P., Henke, A., 2011. Therapy of
Hastings, J., Hazuda, D., Lewis, J., McClements, W., et al., 1994. Inhibition of cap experimental influenza virus infection with pyrrolidine dithiocarbamate. Med.
(m7G pppXm)-dependent endonuclease of influenza virus by 4-substituted 2,4- Microbiol. Immunol. 200, 115–126.
dioxobutanoic acid compounds. Antimicrob. Agents Chemother. 38, 2827– Wilborn, J., DeWitt, D.L., Peters-Golden, M., 1995. Expression and role of
2837. cyclooxygenase isoforms in alveolar and peritoneal macrophages. Am. J.
Tontonoz, P., Hu, E., Spiegelman, B.M., 1994. Stimulation of adipogenesis in Physiol. 268, L294–301.
fibroblasts by PPAR gamma 2, a lipid-activated transcription factor. Cell 79, Wise, H.M., Foeglein, A., Sun, J., Dalton, R.M., Patel, S., Howard, W., Anderson, E.C.,
1147–1156. Barclay, W.S., Digard, P., 2009. A complicated message: identification of a novel
Triana-Baltzer, G.B., Gubareva, L.V., Klimov, A.I., Wurtman, D.F., Moss, R.B., Hedlund, PB1-related protein translated from influenza A virus segment 2 mRNA. J. Virol.
M., Larson, J.L., Belshe, R.B., Fang, F., 2009a. Inhibition of neuraminidase 83, 8021–8031.
inhibitor-resistant influenza virus by DAS181, a novel sialidase fusion protein. Wolff, T., Ludwig, S., 2009. Influenza viruses control the vertebrate type I interferon
PLoS ONE 4, e7838. system: factors, mechanisms, and consequences. J. Interferon Cytokine Res. 29,
Triana-Baltzer, G.B., Gubareva, L.V., Nicholls, J.M., Pearce, M.B., Mishin, V.P., Belser, 549–557.
J.A., Chen, L.M., Chan, R.W., Chan, M.C., Hedlund, M., Larson, J.L., Moss, R.B., Katz, Wong, D.D., Choy, K.T., Chan, R.W., Sia, S.F., Chiu, H.P., Cheung, P.P., Chan, M.C.,
J.M., Tumpey, T.M., Fang, F., 2009b. Novel pandemic influenza A(H1N1) viruses Peiris, J.S., Yen, H.L., 2012. Comparable fitness and transmissibility between
are potently inhibited by DAS181, a sialidase fusion protein. PLoS ONE 4, e7788. oseltamivir-resistant pandemic 2009 and seasonal H1N1 influenza viruses with
Triana-Baltzer, G.B., Sanders, R.L., Hedlund, M., Jensen, K.A., Aschenbrenner, L.M., the H275Y neuraminidase mutation. J. Virol. 86, 10558–10570.
Larson, J.L., Fang, F., 2011. Phenotypic and genotypic characterization of Wunderlich, K., Mayer, D., Ranadheera, C., Holler, A.S., Manz, B., Martin, A., Chase, G.,
influenza virus mutants selected with the sialidase fusion protein DAS181. J. Tegge, W., Frank, R., Kessler, U., Schwemmle, M., 2009. Identification of a PA-
Antimicrob. Chemother. 66, 15–28. binding peptide with inhibitory activity against influenza A and B virus
Tu, W., Zheng, J., Liu, Y., Sia, S.F., Liu, M., Qin, G., Ng, I.H., Xiang, Z., Lam, K.T., Peiris, replication. PLoS ONE 4, e7517.
J.S., Lau, Y.L., 2011. The aminobisphosphonate pamidronate controls influenza Wurzer, W.J., Ehrhardt, C., Pleschka, S., Berberich-Siebelt, F., Wolff, T., Walczak, H.,
pathogenesis by expanding a gammadelta T cell population in humanized mice. Planz, O., Ludwig, S., 2004. NF-kappaB-dependent induction of tumor necrosis
J. Exp. Med. 208, 1511–1522. factor-related apoptosis-inducing ligand (TRAIL) and Fas/FasL is crucial for
Vanderlinden, E., Goktas, F., Cesur, Z., Froeyen, M., Reed, M.L., Russell, C.J., Cesur, N., efficient influenza virus propagation. J. Biol. Chem. 279, 30931–30937.
Naesens, L., 2010. Novel inhibitors of influenza virus fusion: structure–activity Wurzer, W.J., Planz, O., Ehrhardt, C., Giner, M., Silberzahn, T., Pleschka, S., Ludwig, S.,
relationship and interaction with the viral hemagglutinin. J. Virol. 84, 4277– 2003. Caspase 3 activation is essential for efficient influenza virus propagation.
4288. EMBO J. 22, 2717–2728.
Vavricka, C.J., Li, Q., Wu, Y., Qi, J., Wang, M., Liu, Y., Gao, F., Liu, J., Feng, E., He, J., Yamashita, M., Tomozawa, T., Kakuta, M., Tokumitsu, A., Nasu, H., Kubo, S., 2009. CS-
Wang, J., Liu, H., Jiang, H., Gao, G.F., 2011. Structural and functional analysis of 8958, a prodrug of the new neuraminidase inhibitor R-125489, shows long-
laninamivir and its octanoate prodrug reveals group specific mechanisms for acting anti-influenza virus activity. Antimicrob. Agents Chemother. 53, 186–
influenza NA inhibition. PLoS Pathog. 7, e1002249. 192.
Viasus, D., Pano-Pardo, J.R., Cordero, E., Campins, A., Lopez-Medrano, F., Villoslada, Yen, H.L., Herlocher, L.M., Hoffmann, E., Matrosovich, M.N., Monto, A.S., Webster,
A., Farinas, M.C., Moreno, A., Rodriguez-Bano, J., Oteo, J.A., Martinez-Montauti, J., R.G., Govorkova, E.A., 2005. Neuraminidase inhibitor-resistant influenza viruses
Torre-Cisneros, J., Segura, F., Carratala, J., 2011. Effect of immunomodulatory may differ substantially in fitness and transmissibility. Antimicrob. Agents
therapies in patients with pandemic influenza A (H1N1) 2009 complicated by Chemother. 49, 4075–4084.
pneumonia. J. Infect. 62, 193–199. Yen, H.L., Ilyushina, N.A., Salomon, R., Hoffmann, E., Webster, R.G., Govorkova, E.A.,
Vignuzzi, M., Stone, J.K., Andino, R., 2005. Ribavirin and lethal mutagenesis of 2007. Neuraminidase inhibitor-resistant recombinant A/Vietnam/1203/04
poliovirus: molecular mechanisms, resistance and biological implications. Virus (H5N1) influenza viruses retain their replication efficiency and pathogenicity
Res. 107, 173–181. in vitro and in vivo. J. Virol. 81, 12418–12426.
Vijaykrishna, D., Smith, G.J., Pybus, O.G., Zhu, H., Bhatt, S., Poon, L.L., Riley, S., Bahl, J., Yoshida, R., Igarashi, M., Ozaki, H., Kishida, N., Tomabechi, D., Kida, H., Ito, K.,
Ma, S.K., Cheung, C.L., Perera, R.A., Chen, H., Shortridge, K.F., Webby, R.J., Takada, A., 2009. Cross-protective potential of a novel monoclonal antibody
Webster, R.G., Guan, Y., Peiris, J.S., 2011. Long-term evolution and transmission directed against antigenic site B of the hemagglutinin of influenza A viruses.
dynamics of swine influenza A virus. Nature 473, 519–522. PLoS Pathog. 5, e1000350.
von Itzstein, M., Wu, W.Y., Kok, G.B., Pegg, M.S., Dyason, J.C., Jin, B., Van Phan, T., Younkin, S.W., Betts, R.F., Roth, F.K., Douglas Jr., R.G., 1983. Reduction in fever and
Smythe, M.L., White, H.F., Oliver, S.W., et al., 1993. Rational design of potent symptoms in young adults with influenza A/Brazil/78 H1N1 infection after
sialidase-based inhibitors of influenza virus replication. Nature 363, 418–423. treatment with aspirin or amantadine. Antimicrob. Agents Chemother. 23, 577–
Walkiewicz, M.P., Basu, D., Jablonski, J.J., Geysen, H.M., Engel, D.A., 2011. Novel 582.
inhibitor of influenza non-structural protein 1 blocks multi-cycle replication in Yu, Y., Garg, S., Yu, P.A., Kim, H.J., Patel, A., Merlin, T., Redd, S., Uyeki, T.M., 2012.
an RNase L-dependent manner. J. Gen. Virol. 92, 60–70. Peramivir use for treatment of hospitalized patients with influenza
Walsh, K.B., Teijaro, J.R., Wilker, P.R., Jatzek, A., Fremgen, D.M., Das, S.C., Watanabe, A(H1N1)pdm09 under emergency use authorization, October 2009–June
T., Hatta, M., Shinya, K., Suresh, M., Kawaoka, Y., Rosen, H., Oldstone, M.B., 2011. 2010. Clin. Infect. Dis. 55, 8–15.
Suppression of cytokine storm with a sphingosine analog provides protection Yuan, P., Bartlam, M., Lou, Z., Chen, S., Zhou, J., He, X., Lv, Z., Ge, R., Li, X., Deng, T.,
against pathogenic influenza virus. Proc. Natl. Acad. Sci. USA 108, 12018–12023. Fodor, E., Rao, Z., Liu, Y., 2009. Crystal structure of an avian influenza
Wang, J., Cady, S.D., Balannik, V., Pinto, L.H., DeGrado, W.F., Hong, M., 2009. polymerase PA(N) reveals an endonuclease active site. Nature 458, 909–913.
Discovery of spiro-piperidine inhibitors and their modulation of the dynamics Zhang, H., 2008. Concerns of using sialidase fusion protein as an experimental drug
of the M2 proton channel from influenza A virus. J. Am. Chem. Soc. 131, 8066– to combat seasonal and pandemic influenza. J. Antimicrob. Chemother. 62, 219–
8076. 223.
Wang, J., Qiu, J.X., Soto, C., DeGrado, W.F., 2011. Structural and dynamic Zheng, B.J., Chan, K.W., Lin, Y.P., Zhao, G.Y., Chan, C., Zhang, H.J., Chen, H.L., Wong,
mechanisms for the function and inhibition of the M2 proton channel from S.S., Lau, S.K., Woo, P.C., Chan, K.H., Jin, D.Y., Yuen, K.Y., 2008. Delayed antiviral
influenza A virus. Curr. Opin. Struct. Biol. 21, 68–80. plus immunomodulator treatment still reduces mortality in mice infected by
Wang, T.T., Palese, P., 2011. Biochemistry. Catching a moving target. Science 333, high inoculum of influenza A/H5N1 virus. Proc. Natl. Acad. Sci. USA 105, 8091–
834–835. 8096.
Wang, X., Li, M., Zheng, H., Muster, T., Palese, P., Beg, A.A., Garcia-Sastre, A., 2000. Zhirnov, O.P., Ovcharenko, A.V., Bukrinskaya, A.G., 1984. Suppression of influenza
Influenza A virus NS1 protein prevents activation of NF-kappaB and induction of virus replication in infected mice by protease inhibitors. J. Gen. Virol. 65 (Pt 1),
alpha/beta interferon. J. Virol. 74, 11566–11573. 191–196.
Ward, P., Small, I., Smith, J., Suter, P., Dutkowski, R., 2005. Oseltamivir (Tamiflu) and Zoidis, G., Kolocouris, N., Kelly, J.M., Prathalingam, S.R., Naesens, L., De Clercq, E.,
its potential for use in the event of an influenza pandemic. The Journal of 2010. Design and synthesis of bioactive adamantanaminoalcohols and
antimicrobial chemotherapy 55 (Suppl 1), i5–i21. adamantanamines. Eur. J. Med. Chem. 45, 5022–5030.
Watanabe, T., Watanabe, S., Kawaoka, Y., 2010. Cellular networks involved in the
influenza virus life cycle. Cell Host Microbe 7, 427–439.

Antiviral Research 96 (2012) 391-404

Uploaded by

Document Informationclick to expand document information

Copyright:

Available Formats

Antiviral Research 96 (2012) 391-404

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Antiviral Research 96 (2012) 391-404

Uploaded by

Copyright:

Available Formats

Antiviral Research 96 (2012) 391–404

Contents lists available at SciVerse ScienceDirect

4.1.2. NF-jB and IKK2 inhibitors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 398

Class of antiviral agent Stage of viral replication Inhibitor Route of administration

Potential therapeutic candidates Antiviral effect Immunomodulatory effect

ratory epithelium-anchoring domain fused to its C-terminus. 3.2. Protease inhibitors

Although the immune system provides a necessary response to

You might also like