British Medical Bulletin (1985) Vol. 41, No. 4, pp.

309-314

reduced the multiplication of the virus would reveal its effect by

prolonging the survival time of the embryos.
A HISTORY OF THE DISCOVERY AND In the climate of opinion prevailing at this time, the possibility
CLINICAL APPLICATION OF of finding a clinically useful antiviral agent seemed remote or even
impossible. Although little was known about the methods of
ANTIVIRAL DRUGS multiplication of viruses, it was clear that they were so closely
associated with the host cell that there seemed no possibility of
destroying one without the other. Nevertheless, Brownlee and
D J Bauer Hamre, having devised a test system, decided to use it for testing
possible antiviral drugs. The thiosemicarbazones were very much
Wellcome Research Laboratories in the news at the time and, whether for this or some other reason,
Beckenham, Kent Brownlee and Hamre conducted their first tests with p-aminoben-
zaldehyde thiosemicarbazone, and immediately found it to be
active, producing an effect equivalent to a reduction of 70% of the
infecting dose of virus. Thus, the first antiviral agent was discov-
ered by a combination of chance and opportunity. Hamre, Bern-
The accelerating pace of the discovery of clinically effective stein and Donovick3 laid the foundations of the quantitative
antiviral drugs is in marked contrast to the slow progress made at the approach, essential for assessing the relative potencies of com-
beginning of the search. Whereas effective antibacterials were known pounds belonging to an active series, and also of unrelated
in the late 1930s, the discovery of the first antiviral compounds did compounds active against the same virus. They determined the
not come until 1950, and it was not until 1960 that two of them came antiviral effect of a number of parasubstituted benzaldehyde
into clinical use, namely idoxuridine for the treatment of herpetic
keratitis, and methisazone for the prophylaxis of smallpox in contacts
thiosemicarbazones in eggs infected with vaccinia virus; sulphur in
and the treatment of the infective complications of smallpox vaccina- the side-chain was essential for activity, and the most active
tion. Idoxuridine has remained the mainstay of the treatment of derivative tested was the 4-methoxy compound. Structure-activity
herpetic keratitis, but is being supplanted by newer compounds, in relationships could also be worked out in mice infected with
particular acyclovir, which has the advantage of being effective vaccinia virus intracerebrally and given the compounds in the diet.
against numerous other manifestations of disease caused by the It was also possible to construct rudimentary dose-response lines
herpes group of viruses. An active search for antirhinovirus com-
pounds has yielded dichloroflavan, the most active antiviral com-
from the reciprocal of the survival time in fertile eggs treated with a
pound yet discovered, yet clinical success still remains elusive. compound and infected with different dose levels of virus. This was
the first instance of an attempt to introduce the precise quantitation
which is essential when numerous members of a series are being
synthesized with a view to selecting the most suitable compound for
further development and possible clinical evaluation. Hamre et al.4
made another very important observation that benzaldehyde
thiosemicarbazone did not inactivate vaccinia virus in vitro, thus
In contrast to the early discovery and rapid development of showing that it was exerting a true intracellular antiviral effect.
antibacterial compounds, the first antiviral agents were relatively Thompson et al.5 carried this pioneer work an important step
slow to appear, yet their discovery is linked with that of the earliest further by showing that antiviral activity was not confined to
antibacterials in a remarkable way. After the discovery of the thiosemicarbazones of substituted benzaldehyde. Activity was also
sulphonamides, it occurred to Domagk to try and enhance their present with other ring systems, in particular isatin. They showed
weak action against the tubercle bacillus by cyclizing the sulphur- that, in mice infected intracerebrally with vaccinia virus, the
containing side-chain, using thiosemicarbazones of benzaldehyde administration of isatin 3-thiosemicarbazone in the diet would
as the starting material. The resulting thiadiazoles were sent for confer protection to the extent of 2 log units. This observation was
test against Mycobacterium tuberculosis. All were inactive except taken further by Bauer,6 who showed that the degree of protection
one, a sample of benzaldehyde thiosemicarbazone that had been was much greater than that observed by Thompson et al.3
included in error.1 This led to further investigation, and thiaceta- amounting to over 4 log units, equivalent to a 99.99% reduction in
zone, a related compound, has been in use in treating tuberculosis the infecting dose. This opened the possibility of clinical use, and
up to the present day. Bauer suggested that it might be effective in the prophylaxis of
At the same time, progress was being made in a different field, smallpox, but the opportunity to put this to the test did not arise
the handling of viruses in the laboratory. Present-day tissue until eight years later. When a useful degree of activity is discov-
culture techniques did not become available until much later, and ered in a compound it is essential to prepare a series of derivatives
viruses were therefore grown in animals and fertile eggs. Many of and examine them with the object of selecting its compound with
the virus groups known today had not been discovered, and the highest activity. For this purpose a satisfactory method of
objects for study were largely limited to influenza and vaccinia measuring activity is required, and it was evident that the titre
virus. reduction measure of Thompson et al. in addition to being
cumbersome, did not afford the desirable degree of accuracy. It
should be borne in mind that tissue culture methods were not
Early Discovery of ao Inhibitor of Vaccinia Virus available at this time, so that it was necessary to devise an assay in
Brownlee and Hamre2 discovered that when vaccinia virus was animals. It was generally known, but not particularly remarked on,
injected into the yolk sac of fertile eggs on the 6th day of that the survival time of infected animals bore some relation to the
incubation, the survival time of the embryos was inversely propor- infecting dose of virus, in that animals infected with lower doses
tional to the amount of virus injected. This clearly afforded a tended to survive longer. The same proportionality could be
means of detecting antiviral activity, since any compound which observed between survival time and dose of isatin 3-thiosemicarba-

309
HISTORY OF ANTIVIRAL DRUGS D J Bauer
zone, in that animals treated with higher doses survived longer pox vaccination may lead to a generalized eruption (eczema
than animals infected with the same dose of virus and treated with vaccinatum) resembling smallpox itself, with a mortality that may
a lower dose of the compound, in some cases surviving beyond the be as high as 30%. In the early 1960s, smallpox cases were
period of observation without showing any signs of illness. Such occurring in the UK and vaccination was widely practised, with
animals pose a problem to any quantitative assessment based upon the result that many cases of eczema vaccinatum inevitably
survival time, since this is clearly indefinite. To remove them from reappeared. One such case was treated with Methisazone by
the calculation would create 100% mortality in all groups, thus Turner, Bauer and Nimmc-Smith.10 The patient was a boy aged 7
obscuring the efficacy of the treatment. This problem was over- months suffering from infantile eczema who had contracted vacci-
come by Bauer and Sadler7 by deeming the animals to survive for a nia from his vaccinated mother. Extensive lesions were present on
notional infinite period and then converting all survival times to the scalp, face and limbs, with pyrexia, prostration and toxaemia.
reciprocals, when infinity becomes zero. The reciprocal survival Treatment with antivaccinial gamma-globulin was without effect,
times can now be added without giving rise to distortion, and but rapid recovery occurred after treatment with Methisazone by
divided by the number of animals to give the mean reciprocal mouth in a dose of 250 mg/kg every 24 h. This may well have been
survival time. Bauer and Sadler showed that this had a linear the first instance of the use of an antiviral drug in man. During the
regression on the log of the dose of test compound. It was thus next three years Methisazone was used in varying doses in a
possible to obtain accurate dose-response lines of isatin 3-thiosem- number of cases of eczema vaccinatum, and 22 of those have been
icarbazone and of its derivatives. If the dose-response line of a reviewed by Bauer.11 A clear relationship between dose and
compound lies to the left (i.e. at lower dose levels) of the line for clinical result emerged in that all twelve patients given higher doses
the reference compound, it is clearly more active, to an extent recovered; four of these had failed to respond to antivaccinial
given by the antilog of the horizontal distance between the two gamma-globulin. In the ten patients given lower doses, the results
lines multiplied by the ratio between the two sets of dose levels. By ranged from less effective (one of seven died) to ineffective (all
this method it was found that substitutions in the aromatic ring of three died). On the basis of this dose-response analysis, the dosage
isatin reduced activity, whereas activity was increased by alkyl recommended was an initial 200 mg/kg followed by eight doses of
substituents in the 1-position. The most active compound found 50 mg/kg six-hourly, to give a total course of 600 mg/kg.
was 1-ethylisatin 3-thiosemicarbazone but, on account of its low A much more serious infective complication of smallpox vacci-
solubility, the 1-methyl analogue was chosen for further evalu- nation is vaccinia gangrenosa. In immunocompromised patients
ation, and the stage was now set for the first trial of antiviral such as children with hypogammaglobulinaemia, and patients of
activity in clinical practice. any age undergoing treatment with immunosuppressive drugs, the
The work so far had been carried out with vaccinia virus, but the lesion of primary smallpox vaccination fails to heal, but spreads
main clinical target was clearly smallpox, and it was first necessary widely, giving rise to ever-increasing necrotic lesions which inevita-
to investigate whether variola, a related but nevertheless distinct bly lead to death in the absence of treatment. Cure may be
pox virus, was also susceptible to 1-methylisatin 3-thiosemicarba- obtained with antivaccinial gamma-globulin, but many cases fail
zone. This was by no means a foregone conclusion, since it was to respond to such treatment. Davidson and Hayhoe12 obtained a
already known8 that isatin 3-thiosemicarbazone had no effect in successful outcome in a patient suffering from leukaemia who was
mice infected with ectromelia, a closely related pox virus. Variola is vaccinated as a contact of a suspected case of smallpox. In a review
more troublesome to handle than vaccinia, quite apart from of ten such cases carried out by Bauer,11 five patients, two of
problems of containment. It will produce fatal encephalitis on whom had failed to respond to antivaccinial gamma-globulin,
intracerebral injection, but only in mice less than 10 days of age. recovered after a mean total dosage of 638 mg/kg. Cures were also
Mice older than 10 days were insusceptible to the infection. The reported by Van Rooyen et al, 13 Brainerd et al.14 and Kempe et
problem was investigated by Bauer et al. 9 who pooled litters of mice al.15 In all these cases the cure was of the vaccinial infection, and
less than 24 h old and redistributed them to the mothers to form the patients inevitably succumbed to the underlying condition.
comparable experimental groups. The mice were then infected with Methisazone was also used in the prophylaxis of smallpox. In a
a dose of variola virus sufficient to cause fatal encephalitis within a trial carried out in Madras,16 it was given to 2610 close home
few days, and individual groups were treated with selected doses of contacts of smallpox patients; 2815 similar contacts were given a
test compound which were injected with a micrometer syringe; other placebo as a control group. During an observation period of 16
groups were left untreated as controls. Litters treated with 1-methyl days, 18 cases of smallpox occurred among the treated contacts,
3-thiosemicarbazone in a dose of 25 mg/kg survived without compared with 116 in the control group. Prophylactic treatment
showing any signs of infection, as compared with 100% mortality in was thus effective in providing a six-fold reduction in case inci-
the untreated control litters. The dose conferring 50% protection dence, and there was a similar reduction in mortality. In a small-
lay between 2.5 and 5 mg/kg. By this time the 1-methyl derivative scale repetition of this trial, Rao et al. 17 recorded 2 cases among 17
had been selected as the compound for definitive investigation, and treated contacts and 8 among 19 untreated controls. They stated
had been given the generic name Methisazone. that the effect was not significant, but the probability by Fisher's
exact method was in fact 0.047. The trial thus confirmed the first
one insofar as it went. Ribeiro do Valle et al.1B obtained a five-fold
Field Trials of Methisazone against Smallpox and Vaccinia
reduction in case incidence in a much larger trial carried out on
Preparations were in hand for carrying out a trial of Methis- contacts of alastrim, a milder form of smallpox prevalent in South
azone in the prophylaxis of smallpox contacts, but opportunities America at that time.
also arose for evaluating it in vaccinia infections. Smallpox
vaccination consists of an artificial infection of the skin with The Discovery of tbe First Antiviral Compounds
vaccinia virus, which produces a self-limited lesion leading to Against Herpes Virus
healing and immunity to both vaccinia and smallpox. In other
cases, however, the clinical course is not so benign. In individuals Antiviral chemotherapy had meanwhile been progressing
suffering from eczema, or having an eczematous diathesis, small- towards clinical realization in a different direction. Whereas the

310
 HISTORY OF ANTIVIRAL DRUGS D J Bauer
discovery of the thiosemicarbazones was a chance affair, a pro- ride would also inhibit the multiplication of rubella virus and this
gramme of directed research was leading to the development of work was extended by Oxford and Schild,30 who found that a
synthetic nucleosides with the object of finding inhibitors of the concentration of 40 UM would reduce the yield of infective virus by
pathways of DNA synthesis as potential antineoplastic agents. The two log units. However, no antiviral effect could be observed in
compound of this class chosen for further evaluation was idoxuri- rhesus monkeys infected intranasally or parenterally and given
dine (IDU). Preliminary clinical results were reported by Calabresi amantadine in drinking water,31 and Oxford and Schild32 were
et al.19 but the compound has failed to establish itself as an unable to find any antiviral effect in hamsters and rabbits. On the
antineoplastic agent. However, Kaufman20 decided to try its effect other hand, there was no difficulty in demonstrating activity of
on DNA viruses, which depended upon the synthesis of DNA in amantadine in animal experiments against influenza virus. When
their replication, and was able to show that repeated instillation of given in doses of 40 mg/kg by intraperitoneal, subcutaneous or oral
a solution of IDU would cure experimental herpetic keratitis in administration, it produced a reduction in mortality and a prolon-
rabbits and also in man. Methisazone was also being used gation of survival time in mice infected intranasally with strains of
clinically at this time. It is not clear fom the literature which was influenza A virus,28 and this could be confirmed by a number of
the first antiviral agent to be used in practice, but it is certain at other workers. Amantadine hydrochloride is a primary amine; it
least that 1962 was the year in which antiviral chemotherapy had been known for some time that amines are active inhibitors of
became a clinical reality. Kaufman's findings were confirmed by influenza virus replication in vitro26 and this is evidently the basis of
numerous other workers (e.g. Maxwell21) and treatment with IDU its antiviral activity. Preliminary trials in man were carried out by
has been standard practice in cases of herpetic keratitis until Jackson et al. 33 They infected around 200 volunteers lacking
recently, when newer antiviral agents have become available. antibody with the Asian strain of influenza A virus: one-half were
In retrospect, it is interesting to note that the two first antiviral treated with amantadine hydrochloride and the remainder given
agents were discovered and developed by experiments in animals. placebo. Influenza developed in 37% of the amantadine group and
However, a revolution in test methods was being set off by the in 66% of the placebo group. The reduction in case incidence was
development by the plaque inhibition test by Rada et al.22 and highly significant (p < 0.01) and showed clearly that amantadine
independently by Herrmann.23 The test, which works on the same hydrochloride had a prophylactic effect against influenza. Tyrrell
principle as antibiotic sensitivity tests in bacteria, enables large et al.3* were unable to confirm this in a small-scale trial, but positive
numbers of compounds to be evaluated for antiviral activity with results were obtained in a number of subsequent trials, particularly
minimal effort, and the further development of the plaque reduc- one carried out in a natural outbreak of influenza by coordinated
tion test enabled accurate dose-response lines to be obtained, groups of general practitioners.33 In spite of these findings,
greatly facilitating the examination of structure-activity relation- amantadine hydrochloride was not licensed initially in the USA for
ships. The further development of antiviral chemotherapy from the treatment of influenza caused by the Hong Kong variant, and
this time on was largely devoted to the treatment of other has not come subsequently into widespread use. In the UK, apart
manifestations of herpesvirus infections with IDU and other anti- from its use in the treatment of Parkinsonism, it is licensed for use in
DNA agents developed subsequently but, before recording this, it the treatment of patients suffering from influenza A in whom
is of interest to note that RNA viruses were also coming under complications are to be expected.
attack. Derivatives of benzimidazole, a constituent of the molecule
of vitamin B 12 , were investigated for antiviral action by Tamm et
al, 24 who found that the 2,5-dimethyl derivative would inhibit the Development of Cytarabine, TrifluorothvmidiDe, Vidarabine
multiplication of influenza virus. In further work, attention be- and Acyclovir
came concentrated on 2-{a-hydroxybenzyl) benzimidazole (HBB), Meanwhile, the attack against herpesviruses had made further
which was found to be a selective inhibitor of picornavirus progress, perhaps because they provide a more tractable target for
replication, including certain coxsackieviruses, most types of echo- therapeutic attack. Cytarabine, trifluorothymidine (TFT) and,
virus and the three types of poliomyelitis virus. This work was all later on, vidarabine were found to have antiviral activity. These
carried out in tissue culture and appeared to offer a promising lead, compounds were all products of the further exploration of the
but came to a standstill when HBB was found to have no synthetic nucleosides.
protective effect in animal experiments.23 Cytarabine was first developed as an antitumor compound,
since it would inhibit the growth of sarcoma 180 and Ehrlich
Inhibitors of Influenza Virus carcinoma in mice,36'37 and it is now in clinical use in the treatment
of certain forms of leukaemia. It was found to be an inhibitor of
It had been known for some time that ammonium ions would DNA synthesis, and it was therefore logical to expect it to possess
inhibit the multiplication of influenza virus in tissue. This resulted antiviral action against DNA viruses. Underwood38 found that it
from the chance observation by Jensen et al. 26 that the cytopathic was effective in treating experimental herpetic keratitis in rabbits,
effect produced by A/PR8 virus in dog kidney cell cultures was and other workers found that it inhibited other herpes viruses in
inhibited in cultures that had been incubated with ammonium tissue cultures39'*0
chloride. This was not a direct virucidal effect, since the virus was The antiviral activity of TFT was first observed in animal
unaffected by incubation for 5 h at 37°C with 100 ng/ml am- experiments. Kaufman and Heidelberger*1 found that eye drops
monium chloride. The multiplication of other myxoviruses was not containing 0.1% TFT were effective in eliminating the ulcers in
affected. This work was significantly extended by Jensen and Liu,27 rabbits with experimental herpetic keratitis. Hyndiuk et al.*2
who found that inhibition could also be obtained with aliphatic demonstrated activity against herpes virus in plaque inhibition
amines, which may be regarded as substituted derivatives of tests, and Bauer and Collins*3 showed that a 5% solution in
ammonia. It is not clear whether the discovery in 1964 of the dimethylsulphoxide applied to the skin was effective in suppressing
antiviral effect of amantadine hydrochloride by Davies et al.28 was lesions in guinea pigs infected with herpesvirus by cutaneous
an extension of this work or a random observation. In the same scarification. Apart from these and a few other reports, the
year Maassab and Cochran29 found that amantadine hydrochlo- literature on laboratory work with TFT is remarkably scanty.

311
HISTORY OF ANTIVIRAL DRUGS D J Bauer

Clinical evaluation followed with greater speed than is possible it was the most active antiviral compound known, with 10 times
nowadays. Initial experience with cytarabine was disappointing, the activity of IDU and 600 times that of vidarabine. It was very
since Kaufman et al. 44 found an unacceptable degree of toxicity effective against herpetic keratitis in the rabbit eye model,38 and
when it was used in patients with herpetic keratitis. However, Juel- produced a rapid cure of skin lesions in guinea pigs infected with
Jensen and MacCallum43 obtained satisfactory cures in two herpesvirus. The first clinical observation of effectiveness in the
patients with generalized herpes. Cytarabine has also been used in treatment of herpetic keratitis was made by Jones et al, 3 ' and this
the treatment of generalized zoster. McKelvey and Kwaan46 was confirmed in a controlled trial on 73 patients carried out by
reported on a patient who developed generalized zoster during Laibson et al.60 who also found it as effective as vidarabine. La
immunosuppressive treatment; the condition was arrested after Lau et al.61 found it as effective as TFT.
intravenous administration of cytarabine for 3 days. However, Acyclovir forms a sodium salt with an aqueous solubility of 2%,
doubts have grown as to the clinical effectiveness of cytarabine and which renders it suitable for intravenous use. In a placebo-
the compound is no longer used as an antiviral agent. controlled trial carried out on 97 immunocompromised patients
TFT has been more successful as an antiviral in the clinic. with mucocutaneous herpes simplex, intravenous administration
Waitings et al. 47 compared it with IDU in a double-blind trial was found to be very effective in reducing pain, the shedding of
carried out on patients with dendritic or amoeboid herpetic virus and the time to healing.62 A great advantage of acyclovir for
keratitis. Both compounds were administered as eye drops. Heal- intravenous use is the fact that it is excreted largely unchanged,
ing occurred in 37 of 40 (92.5%) patients treated with TFT and in whereas vidarabine is rapidly degraded to its hypoxanthine ana-
23 of 38 (60.5%) treated with IDU. The mean time to healing was logue which only possesses 15% of the antiviral activity of the
two days less in the former group. The authors concluded that parent compound.
TFT was superior to IDU. McGill et al. 48 obtained satisfactory Up to this time, two very common forms of herpes infection had
cures in 24 patients with herpetic keratitis which was resistant to defied all treatment, namely herpes labialis and genital herpes.
IDU, and in 8 patients who were allergic to IDU. TFT has now Cutaneous herpes was reported by Hall Smith et al. 63 to respond
become one of the standard treatments for herpetic keratitis, but is to treatment with the standard ophthalmic ointment of IDU, but
not used in other types of herpes infection, since its properties this could not be confirmed in a double-blind trial of the same
render it suitable only for topical use. preparation carried out by Juel-Jensen and MacCallum.64 Acyclo-
Encephalitis is a rare manifestation of herpes infection, but it vir in polyethylene glycol was also ineffective,65 but when the
carries a high mortality. The first report of specific treatment is vehicle was changed to a cream affording better skin penetration,
that of Brendan et al, 49 who obtained recovery in a man aged 34 favourable results were obtained. Thus, in a placebo-controlled
treated with IDU in a total dose of 500 mg/kg over seven days by trial of acyclovir cream carried out in 49 patients who began
intravenous infusion. Many other favourable reports followed (for treatment during the prodromal phase of recurrences of labial
a summary see Bauer30), but there were also negative ones and herpes treatment, acyclovir was found to inhibit lesion formation,
doubt about the efficacy of IDU began to grow until it was the reduce itching and shorten the duration of the attack.66 The phase
subject of a multicentre double-blind trial set by the Boston of virus multiplication in herpes labialis is very short, and to obtain
Interhospital Vims Study Group." This showed conclusively that benefit it is essential to begin treatment as soon as possible.
IDU was ineffective, and severe toxic reactions led to the trial Genital herpes also responded rapidly to treatment with acyclo-
being abandoned. vir. In a controlled trial on 69 patients with attacks of primary
Vidarabine entered the field somewhat later. It also began life as genital herpes, treatment with acyclovir ointment reduced the
an antitumour agent, until DeRudder and Privat de Garilhe52 duration of virus shedding, duration of pain and itching and mean
showed that it profoundly inhibited the yield of vaccinia and time to healing in comparison with the results of application of
herpesviruses in tissue culture. No further work appeared until placebo. It had no effect on recurrent attacks.67 Better results were
1968, when Schabel33 confirmed the antiviral activity against obtained when acyclovir was administered orally:68 a similar
herpes, and also reported in-vitro antiviral activity against cytome- reduction in the parameters of the disease was seen in 29 patients
galovirus and varicella. Vidarabine was introduced into clinical with primary attacks and in 61 patients with recurrences. Intra-
practice in 1972, when Pavan-Langston and Dohitnan34 compared venous administration was also found to be effective in the
its activity with that of IDU in a double-blind trial carried out on treatment of primary attacks.69
27 patients with herpetic keratitis; both treatments were found to
be equally effective, and the authors concluded that vidarabine was
Current Antivirals
a satisfactory alternative treatment. It also had a favourable effect
on the course of the disease in a double-blind, placebo-controlled This review of the discovery and development of antiviral drugs
trial carried out on immunosuppressed patients suffering from has now arrived at the end of 1984. Of the compounds described,
localized or disseminated herpes zoster.33 two have passed out of use: cytarabine through unacceptable
In contrast to the success achieved in treating herpetic keratitis, toxicity and doubts as to efficacy, and methisazone, on account of
the problem of herpetic encephalitis had remained unsolved; this the eradication of smallpox and the consequent disappearance of
changed with the advent of vidarabine. The results of a collabora- all indications for its use. There remain the four compounds in use
tive study carried out by Whitley et a 36 on 28 patients with herpetic for the treatment of herpesvirus infections, IDU, TFT, vidarabine
encephalitis proved by brain biopsy showed that vidarabine was and acyclovir. In selecting one of these for clinical use it is
effective in reducing mortality from 70% to 28% and the treated desirable to examine these properties of clinical relevance. These
group suffered fewer neurological sequelae. Since then, vidarabine are set out in Table 1, from which it will be seen that the only ones
has become the accepted treatment for herpetic encephalitis to suitable for systemic use are vidarabine and acyclovir, and the
such an extent that it is no longer ethically permissible to carry out latter has the advantage of undergoing very little metabolic
further placebo controlled trials. degradation. It also appears to be remarkably free from toxic side-
An advance in the treatment of herpesvirus infections has now effects. Amantadine hydrochloride remains in use to a certain
come with the introduction of acyclovir." At the time of discovery extent. While the problem of treating DNA virus infections has

312
 HISTORY OF ANTIVIRAL DRUGS D J Bauer

Table 1 only be carried out by the pharmaceutical industry, or in

Ginically relevant properties of the antiherpes nucleosides laboratories coordinated and funded by a supranational agency.
Idoxundine Trifluorothymidine Vkten trine Acyclovw Economic factors inevitably play a part, and a pharmaceutical
company is much more likely to seek a specific common cold
Sohibilrty (%) 0.8 6 006 2*
Stability of soln at Stable Unstable No information Stable cure, with an estimated global market value of £250 000 000,
pH7 than a cure for mumps or measles. The greatest obstacle to
Harf-lrfe after - 05h 1h 2-3 h
i.v. injection further progress, however, is the impossibility at present of
Metabolites Inactive Inactive Less active Activet designing a compound that will inhibit the multiplication of a
Active by mouth No No Uncertain Yes
Crosses blood-brain No Not reported Yes Yes specific virus. The concept of drug design is of no help here. It
bemer depends upon the pharmacological system of agonists and re-
Enters aqueous Yes Yes Yes Yes
Terstogenic Yes Yes No No ceptors, the agonists being simple molecules which can form
1 mm u nosupprass rve Yes Not reported No YesJ models for blocking agents. In antiviral chemotherapy this
• As sodium salt situation does not exist. One approach advocated is to identify a
t Active after conversion to the tnphosphate key viral enzyme, such as the RNA polymerase induced by
X Only in high doses
influenza virus, determine the structure of its active site and
design a molecule which will fit there and act as an inhibitor.
largely been solved, and other antiherpes compounds are ap- This is possible with present technology but, in order to obtain
proaching evaluation, much remains to be done in the field of the necessary specificity, the procedure would have to be re-
RNA virus infections. There is intense activity in the field of peated with the RNA polymerases of the normal host cell so as
antirhinovirus chemotherapy, which has led to the development of to be able to design a compound which will inhibt the virus
4',6-dichloroflavan, the most active antiviral compound yet discov- enzyme but not the others. The project then becomes too
ered, with an IC 30 in tissue culture measured in picomoles,70 and cumbersome to be practicable. This approach would not have
this and other compounds are undergoing clinical evaluation. detected acyclovir, which is not an inhibitor of the herpes-
There is also a need for an anti-influenza compound more effective induced thymidine kinase but a preferential substrate which is
than amantadine hydrochloride. However, there are severe limita- phosphorylated by it and then converted further to the triphos-
tions to the prospects of further advances in the field of antiviral phate, which is the actual antiviral molecule.71 Nor would it
chemotherapy. Many virus infections cannot be diagnosed without have detected amantadine hydrochloride or 4',6-dichloroflavan.
carrying out virological investigations, and specific treatment is Further discoveries will therefore probably come from random
therefore impossible unless a wide-spectrum antiviral agent can be screening and by modification of biologically important mole-
found. There are also economic difficulties. cules such as nucleosides, methods which have yielded such
antivirals as we possess today. If this is too pessimistic a view, it
is clearly not shared by the WHO Committee on the nomencla-
Economic Aspects of the Search for Antiviral Drugs ture of drugs, which has decreed that the names of further
antiviral drugs shall end in -vir. Evidently they are expecting
The scale of the operation required to find a new antiviral and
some more to be found.
develop it to the stage of an issued product is such that it can

REFERENCES

1 Domagk G, Behnisch R, Mietzsch F, Schmidt H. Ober due neue, gegen 11 Bauer DJ. Clinical experience with the antiviral drug Marboran (1-
Tuberkelbazillen in vitro wirksame Verbindungsklasse. Naturwissen- methylisatin 3-thiosemicarbazone). Ann NY Acad Sci 1965; 130 Art 1:
schaften 1946; 33: 315 110-117
2 Brownlee KA, Hamre DA. Studies on chemotherapy of vaccinia virus. I. 12 Davidson E, Hayhoe FGJ. Prolonged generalized vaccinia complicating
An experimental design for testing antiviral agents. J Bact 1951; 61: acute leukaemia. Br Med J 1962; 2: 1298-1299
127-134 13 Van Rooyen CE, Casey J, Lee SHS, Faulkner R, Dincsoy HP. Vaccinia
3 Hamre DA, Bernstein J, Donovick R. Activity of />-aminobenzal- gangrenosa and 1-methylisatin 3-thiosemicarbazone (methisazone).
dehyde, 3-thiosemicarbazone on vaccinia virus in the chick embryo and Can Med Assoc J 1967; 97: 160-165
in the mouse. Proc Soc Exp Biol Med 1950; 73: 275-278 14 Brainerd HD, Hanna I, Jawetz E. Methisazone in progressive vaccinia.
4 Hamre DA, Brownlee KA, Donovick R. Studies on the chemotherapy N Engl J Med 1967; 276: 620-622
of vaccinia virus, n. The activity of some thiosemicarbazones. J 15 Kempe CH, Fulginiti V, Sieber O. Chemotherapy of life-threatening
Immunol 1951; 67: 305-312 dermal complications of smallpox vaccination. Fifth Internationa]
5 Thompson RL, Minton SA Jr, Officer JE, Hitchmgs GH. Effect of Congress of Chemotherapy. Vienna 1967; Abstracta Pt 2: 1234
heterocyclic and other thiosemicarbazones on vaccinia infection in the 16 Bauer DJ, St Vincent L, Kempe CH, Young PA, Downie AW.
mouse. J Immunol 1953; 70: 229-234 Prophylaxis of smallpox with methisazone Am J Epidemiol 1969; 90:
6 Bauer DJ. The antiviral and synergic actions of isatin thiosemicarba- 130-145
zone and certain phenoxypyrimidines in vaccinia infection in mice. Br J 17 Rao AR, Jacobs ES, Kamalakshi S, Bradbury A, Swamy A. Chemo-
ExpPath 1955; 36: 105-114 prophylaxis and chemotherapy in variola major. Part 1. An assessment
7 Bauer DJ, Sadler PW. The structure-activity relationships of the of CG 662 and Marboran in prophylaxis of contacts of variola major.
antiviral chemotherapeutic activity of isatin p-thiosemicarbazone. Br J Indian J Med Res 1969; 57: 477-483
Pharmacol I960; 15: 101-110 18 Do Valle LAR, de Melo PR, de Salles Gomes LF, Proenca LM.
8 Bauer DJ, Sadler PW. Derivatives of isatin beta-thiosemkarbazone Methisazone in prevention of variola minor among contacts. Lancet
with anti-viral chemotherapeutic activity against ectromelia infection. 1965; 2: 976-978
Nature 1961; 190: 1167-1169 19 Calabresi P, Finch SC, Cardoso SS, Welch AD. Preliminary clinical
9 Bauer DJ, Dumbell KR, Fox-Hulme P, Sadler PW. The chemotherapy experience with 5-iododeoxyuridine [Abstract]. Proc Am Assoc Cancer
of variola major infection. Bull WHO 1962; 26: 727-732 Res 1960; 3: 99
10 Turner W, Bauer DJ, Nimmo-Smith RH. Eczema vaccinatum treated with 20 Kaufman HE. Clinical cure of herpes simplex keratitis by
W-methylisatin p-thiosemicarbazone. Br Med J 1962; 1: 1317-1319 5-iodo-2'-deoxyuridine. Proc Soc Exp Biol Med 1962; 109: 251-252

313
HISTORY OF ANTIVIRAL DRUGS D J Bauer
21 Maxwell E. Treatment of corneal disease with 5-iodo-2'-deoxyuridine nated herpes zoster in a patient with IgG hypoglobulinemia. Blood
(IDU). A clinical evaluation of 500 cases. Am J Ophthalmol 1963; 55: 1969; 34: 706-711
237-238 47 Wellings PC, Awdry PN, Bors FH, Jones BR, Brown DC, Kaufman
22 Rada B, Bla5kovi6 D, Sorm F, Skoda J. The inhibitory effect HE. Clinical evaluation of tnfluorothymidine in the treatment of herpes
of 6-azauraci] riboside on the multiplication of vaccinia virus. Experien- simplex comeal ulcers. Am J Ophthalmol 1972; 73: 932-942
tia 1960; 16: 487 48 McGill J, Holt-Wilson AD, McKinnon JR, Williams HP, Jones BR.
23 Herrmann EC Jr. Plaque inhibition test for detection of specific Some aspects of the clinical use of trifluorothymidine in the treatment of
inhibitors of DNA containing viruses. Proc Soc Exp Biol Med 1961; herpetic ulceration of the cornea. Trans Ophthalmol Soc UK 1974; 94:
107: 142-145 342-352
24 Tamm L, Folkers K, Horsfall FL Jr. Inhibition of influenza virus 49 Breeden CJ, Hall TC, Tyler HR. Herpes simplex encephalitis treated
multiplication by 2,5-dimethylbenzimidazole. Yale J Biol Med 1952; 24: with systemic 5-iodo-2'-deoxyuridine. Ann Intern Med 1966; 65:
559-567 1050-1056
25 Hollinshead AC, Smith PK. Effects of certain purincs and related 50 Bauer DJ. The specific treatment of virus diseases. Lancaster, MTP,
compounds on virus propagation. J Pharmacol Exp Ther 1958; 123: 1977; 106-107
54-62 51 Boston Interhospital Virus Study Group. Failure of high-dose 5-iodo-
26 Jensen EM, Force EE, Unger JB. Inhibitory effect of ammonium ions 2"-deoxyuridine in the therapy of herpes simplex virus encephalitis.
on influenza virus in tissue culture. Proc Soc Exp Biol Med 1961; 107: Evidence of unacceptable toxicity. N Engl J Med 1975; 292: 599-603
447^*51 52 De Rudder J, Privat de Gariihe M. Inhibitory effect of some nudeosides
27 Jensen EM, Liu OC. Inhibitory effect of simple aliphatic amines on on the growth of various human viruses in tissue culture. Antimicrob
influenza virus in tissue culture. Proc Soc Exp Biol Med 1963; 112: Agents Chemother 1965; 5: 578-584
456-459 53 Schabel FM Jr. The antiviral activity of 9-P-D-arabinofuranosyladenme
28 Davies WL, Grunert RR, Haff RF, et al. Antiviral activity of 1- (ARA-A). Chemotherapy 1968; 13: 321-338
adamantanamine (Amantadine). Science 1964; 144: 862-863 54 Pavan-Langston D, Dohiman CH. A double blind clinical study of
29 Maassab HF, Cochran K.W. Rubella virus: inhibition in vitro by adenine arabinoside therapy of viral keratoconjunctivitis. A. J Ophthal-
amantadine hydrochloride. Science 1964; 145: 1443-1444 mol 1972; 74: 81-88
30 Oxford JS, Schild GC. Inhibition of the growth of influenza and rubella 55 Whitley RJ, Ch'ien LT, Dolin R. et al. Adenine arabinoside therapy of
viruses by amines and ammonium salts. Br J Exp Pathol 1967; 48: herpes zoster in the unmunosuppressed. N Engl J Med 1976; 294:
235-243 1193-1199
31 Stephenson JA, Artenstein MS, Parkman PD, Buescher EL, Druzd AD. 56 Whitley RJ, Soong S-J, Dolin R, et al. Adenine arabinoside therapy of
Effect of amantadine hydrochloride on rubella virus infection in the biopsy-proved herpes simplex encephalitis. N Engl J Med 1977; 297:
rhesus monkey. Antimicrob Agents Chemother 1965; 5: 548-552 289-294
32 Oxford JS, Schild GC. The evaluation of antiviral compounds for 57 Schaeffer HJ, Beauchamp L, de Miranda P, Elion GB, Bauer DJ,
rubella virus using organ cultures. Arch Ges Virusforsch 1967; 22: Collins P. 9-<2-hydroxyethoxymethyl)guanine activity against viruses of
349-356 the herpes group. Nature 1978; 272: 583-585
33 Jackson GG, Muldoon RL, Akers LW. Serological evidence for 58 Bauer DJ. Acyclovir treatment of experimental herpetic keratitis in the
prevention of influenzal infection in volunteers by an anti-influenzal rabbit eye. Am J Med 1982; 731 A: 109-111
drug adamantanamine hydrochloride. Antimicrob Agents Chemother 59 Jones BR, Coster DJ, Fison PN, Thompson GM, Cobo LM, Falcon
1963; 3: 703-707 MG. Efficacy of acycloguanosine (Welkome-248U) against herpes-
34 Tyrrell DAJ, Bynoe ML, Hoorn B. Studies on antiviral activity of 1- simplex comeal ulcers. Lancet 1979; 1: 243-244
adamantanamine. Br J Exp Pathol 1965; 46: 370-375 60 Laibson PR, Pavan-Langston D, Yeakley WR, Lsss J. Acyclovir and
35 Galbraith AW, Oxford JS, Schild GC, Watson GI. Protective effect of vidarabine for the treatment of herpes simplex keratitis. Am J Med
1'adamantanamine hydrochloride on influenza A2 infections in the 1982; 7311A: 281-285
family environment A controlled double-blind study. Lancet 1969; 2: 61 La Lau C, Oosterhuis JA, Versteeg J, Van Rij G, Renardel de Lavalette
1026-1028 JGC, Graandijk A, Lamers WRMJ, Mierlobensteyn Th. Multicenter
36 Evans JS, Musser EA, Mengel GD, Forsblad KR, Hunter JH. Anti- trial of acyclovir and trifluorothymidine in herpetic keratitis. Am J Med
tumor activity of 1-p-D-arabinofuranosylcytosine hydrochloride. Proc 1982; 7311 A: 305-306
Soc Exp Biol Med 1961; 106: 350-353 62 Myers JD, Wade JC, Mitchell CD et al. Multicenter collaborative trial
37 Evans JS, Musser EA, Bostwick L, Mengel GD. The effect of l-f-D- of intravenous acyclovir for treatment of mucocutaneous herpes sim-
arabinofuranosylcytosine hydrochloride on murine neoplasms. Cancer plex virus infection in the immunocompromised host Am J Med 1982;
Res 1964; 24: 1285-1293 7311 A: 229-235
38 Underwood GE. Activity of 1-P-D-arabinofuranosylcytosine hydrochlo- 63 Hall-Smith SP, Corrigan MJ, Gilkes MJ. Treatment of herpes simplex
ride against herpes simplex keratitis. Proc Soc Exp Biol Med 1962; 111: with 5-iodo-2'deoxyuridine. Br Med J 1962; 2: 1515-1516
660-664 64 Juel-Jensen BE, MacCallum FO. Treatment of herpes lesions of the face
39 Rapp F. Inhibition by metabolic analogues of plaque formation by with idoxuridine: results of a double-blind controlled trial. Br Med J
herpes zoster and herpes simplex viruses. J Immunol 1964; 93: 643-648 1964; 2: 987-988
40 Buthala DA. Cell structure studies on antiviral agents. I. Action of 65 Spruance SL, Crumpacker CS. Topical 5 percent acyclovir in polyethyl-
cytosine arabinoside and some comparisons with S-iodo-^-deoxyuri- ene glycol for herpes simplex labialis. Antiviral effect without clinical
dine. Proc Soc Exp Biol Med 1964; 115: 69-77 benefit. Am J Med 1982; 7311A: 315-319
41 Kaufman HE, Heidelberger C. Therapeutic antiviral action of 5- 66 Yeo JM, Fiddian AP. Acyclovir in the management of herpes labialis. J
trifluoromethyl-2'deoxyuridine in herpes simplex keratitis. Science 1964; Antimicrob Chemother 1983; 12 (suppl B): 95-103
145: 585-586 67 Corey L, Benedetti JK, Critchlow CW et al. Double-blind controlled
42 Hyndiuk RA, Kaufman HE, Ellison E, Centifanto Y. Newer antiviral trial of topical acyclovir in genital herpes simplex virus infections. Am J
agents - comparative assays in vivo and in vitro. Chemotherapy 1968; Med 1982; 7311 A: 326-334
13: 139-145 68 Fiddian AP, Halsos AM, Kinge BR, Nilsen AE, Wikstrom K. Oral
43 Bauer DJ, Collins P. 1974; unpublished work acyclovir in the treatment of genital herpes. Preliminary report of a
44 Kaufman HE, Capella JA, Maloney ED, Robbins JE, Cooper GM, multicenter trial. Am J Med 1982; 7311A: 335-341
Uotila MH. Corneal toxicity of cytosine arabinoside. Arch Ophthalmol 69 Mindel A, Adler MW, Sutherland S, Fiddian AP. Intravenous acyclovir
1964; 72: 535-540 in genital herpes. An interim report. Am J Med 1982; 7311 A: 347-350
45 Juel-Jensen BE, MacCallum FO. Herpes simplex, varicella and zoster. 70 Bauer DJ, Selway JWT, Batchelor JF, Tisdale M, CaldweU IC, Young
London: Clinical manifestations and treatment. Hdnemann Medical, DAB. 4',6-dichloroflavan (BW683C), a new anti-rhinovirus compound.
1972 Nature 1981; 292: 369-370
46 McKelvey EM, Kwaan HC. Cytosine arabinoside therapy for dissemi- 71 EUon GB. Mechanism of action and selectivity of acyclovir. Am J Med
1982; 7311 A: 7-10

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