Advances in therapy for hepatitis C infection

The first approved therapy for chronic hepatitis C virus (HCV) infection was recombinant interferon. Subsequently, controlled studies demonstrated that the combination of interferon-alpha and ribavirin leads to significantly higher virologic sustained responses in patients with chronic hepatitis C. A novel modification of the interferon molecule resulted in the formulation of pegylated interferons, which have a longer half-life than standard interferon. Two recent trials have established the superiority of pegylated interferons compared with interferon-alpha in inducing sustained virologic responses in patients with chronic HCV infection, with or without cirrhosis. Presumably, pegylated interferons will replace standard interferon in treating HCV infection. Phase 3 trials of pegylated interferons in combination with ribavirin are currently under way. Noninterferon-based therapies for the treatment of HCV infection are also in the developmental and experimental phases. Our aims in this review are to present the currently available therapeutic options for HCV infection and the evidence supporting their use in typical patients with chronic hepatitis C or in patients with special circumstances. We also briefly review novel therapeutic approaches, including noninterferon-based therapies.     

Some biological properties of the human amniotic membrane interferon.

Human amniotic interferon was investigated to define the species specificity of its antiviral action and to compare its anti-cellular and NK cell stimulating activities with those of other human interferons. The antiviral effect was titrated in bovine (RV-IAL) and monkey (VERO) cells. Amniotic interferon exhibited, in bovine cells, 5% of the activity seen in monkey cells, while alpha interferon displayed 200%. No effect was detected with either beta or gamma interferon in bovine cells. Daudi cells were exposed to different concentrations of various interferons and the cell numbers were determined. The anticellular effect of the amniotic interferon reached its peak on the third day of incubation. Results suggested a higher activity for alpha and gamma interferons and a lower activity for beta when compared to amniotic interferon. Using total mononuclear cells as effector cells and K 562 as target cells in a 51Cr release assay, it was demonstrated that low concentrations of amniotic interferon consistently stimulated NK cell activity in cells derived from several donors, the results indicating a higher level of activity with this interferon than with alpha and beta interferons.     

The interferon receptors

Early studies on the mode of action of interferons have indicated that a receptor system on the cell surface is involved in its action. The first direct evidence to a high-affinity binding site was found only after pure interferon was available. Two different receptors, one specific for interferons-alpha and beta, and the other for interferon-gamma were recognized. A correlation between affinity to the receptor and specific activity was established. Cross-linked complexes of labeled interferons with their receptors were visualized on gel electrophoresis and even partially purified. Internalization of interferons after binding to the receptor was reported. The role of gangliosides as helpers of interferon binding was recently investigated. Fragments of interferons which still retained binding capacity were described and helped in elucidating the binding site on the interferon molecule.     

Effect of mouse interferons on the development of Ehrlich ascitic carcinoma

Intraperitoneal injection of various preparations of mouse interferons (L cell tissue culture interferons, concentrated or partly purified, and also serum interferon) significantly inhibited the development of Ehrlich's ascites carcinoma in randombred mice. In view of comparatively low activity of serum interferon, the effect of normal mouse serum on the tumour development and its action on L cell tissue culture interferon was investigated. It was shown that normal mouse serum inhibits the action of L cell tissue culture interferon and promotes the development of Ehrlich's ascites carcinoma.     

Antiviral and protein-inducing activities of recombinant human leukocyte interferons and their hybrids.

The antiviral activities of recombinant human leukocyte interferons IFN-alpha A and IFN-alpha D as well as five hybrids of these interferons against retroviruses, vesicular stomatitis virus, and encephalomyocarditis virus were studied in feline, human, and murine cells. Although these interferon species had widely different potencies, their activities against these viruses were, in general, proportional. The IFN-alpha A/D (Bgl) hybrid was the most potent species, and the IFN-alpha D/A (Bgl) hybrid was the least potent. However, the latter species did not interfere with the action of the former species. Like natural human leukocyte interferon, each of the seven species of recombinant interferons induced the synthesis of at least five proteins in human fibroblasts, whereas induction of only one such protein was readily detected in a feline fibroblast line in which these interferon species inhibited the replication of all three viruses.     

Enzymatic modifications of human fibroblast and leukocyte interferons

The sensitivity of highly purified human fibroblast interferon and partially purified human leukocyte interferon to several proteolytic and glycolytic enzymes was determined with respect to antiviral activity, isoelectric point, molecular weight, and thermal stability. Leucine aminopeptidase altered the distribution of isoelectric points for both interferons but produced little change in molecular weights; this enzyme somewhat reduced the activity of only leukocyte interferon. Treatment of fibroblast interferon with carboxypeptidases A and B did not greatly decrease antiviral activity, but it did slightly reduce the molecular weight of the interferon and substantially altered the distribution of isoelectric point values; similar treatment of leukocyte interferon caused some loss in activity, especially of the 17,000-molecular-weight species. Both interferons were inactivated rapidly by treatment with the endoproteases trypsin, pepsin, bromelain, and subtilisin. Chymotrypsin shifted the isoelectric points of both interferons, but only leukocyte interferon was significantly inactivated. Treatment with neuraminidase and beta-galactosidase changed the isoelectric point distribution but did not affect the activity or thermal stability of either interferon; such a treatment reduced the molecular weight of fibroblast interferon and the size heterogeneity of leukocyte interferon. Treatment with neuraminidase and then leucine aminopeptidase greatly reduced the activity of both interferons, especially leukocyte interferon. The data indicate that biologically active forms of fibroblast and leukocyte interferons can be distinguished by their relative sensitivity to certain proteases.     

Interferon: effects on the immune response and the mechanism of activation of the cellular response.

The discovery of interferon in 1957 by Drs. Isaacs and Lindenmann led to major revisions in the concepts of man's defenses against viral infections. There are at least two types of interferon. Along with their antiviral properties, they have recently been shown to exert a suppressive effect on the humoral and cellular immune response; they affect both B and T lymphocytes. A variety of substances, including virus, polyribonucleotides, and mitogens for T lymphocytes, are good interferon inducers. T lymphocytes seem to be necessary for these inducers to exert their immunosuppressive effects. The immunosuppressive effects of interferon inducers suggests that interferons may be mediators of suppressor T lymphocyte effects. In the virus system, interferon does not exert its antiviral effects by direct action on the virus, but rather derepresses a cell gene that results in the production of an antiviral protein. This antiviral protein is probably the mediator of inhibition of virus replication. This is a complex sequence of events that results in the interaction of interferon with the cell membrane and the resulting production of the antiviral state in the cell. This review will examine the various steps of this involved process.     

Purification techniques for human interferons

This article outlines the development and general status of present purification methods for human interferons. The isolation of each interferon species from natural sources is extremely difficult because of molecular characteristics, high losses of activity and the small amount of interferon protein present in production media. Few of the highly sophisticated methods meet the requirements for scale-up or give acceptable recoveries for a production process. The adaptation of purification procedures to the different interferon species is described, such as initial concentration, the extraction of beta interferon (IFN-β) by aqueous two-phase systems and the final purification of alpha interferon (IFN-α) and beta interferon to homogeneity. H.p.l.c. techniques are discussed in more detail together with problems in the purification of beta interferon and gamma interferon (IFN-γ). The range of interferon expression and excretion in recombinant microbial and animal cells is reviewed and different approaches for the solubilization and purification of intracellular recombinant interferons are described, which are covered mainly in patent applications.     

Some species of human leukocyte interferon are glycosylated

The carbohydrate content of all of the species of human leukocyte interferon (IFN-alpha) which have been derived from patients with chronic myelogeneous leukemia (CML) and purified to homogeneity has now been determined. Amino sugar content was measured by high-performance liquid chromatography and fluorescamine detection of acid hydrolysates of each sample. Two species showed significant amounts of glucosamine. Most of the purified species of leukocyte interferon from a myeloblast cell line were also tested, and two species were found to contain sugar residues. These forms also differed from the CML interferons in that they revealed the presence of greater amounts of galactosamine. The apparent lack of carbohydrate in some of the higher-molecular-weight species of interferon implicated factors other than glycosylation in the molecular weight differences. The results indicate that some species of IFN-alpha are glycosylated to various degrees.     

Therapeutic anti-inflammatory mechanism of action of Type I interferons

Interferon-beta is used for the treatment of relapsing-remitting multiple sclerosis and other Type I interferons are being studied as potential immune therapies for immune disorders. Yet, the therapeutic anti-inflammatory mechanism of action remains to be clearly elucidated. Herein described is a novel model for Type I interferon therapeutic anti-inflammatory mechanism of action. When administered orally or subcutaneously at a site distal to inflammation, Type I interferons induce a partial state of immune activation through the expression of proinflammatory factors counter-regulated by the expression of tolerance inducing factors in antigen presenting cells proximal to the site of administration. Disease-associated T-cells are recruited to and interact with interferon affected antigen presenting cells, and in the context of non-immune reactive lymphoid tissues, the immature antigen presenting cells induce T-cell apoptosis, anergy, and the conversion to and the de novo expansion of T-regulatory cell populations. The result is a systemic reduction of disease-associated T-cells with a proportional increase in T-regulatory cells and tolerance mediating antigen presenting cells. T-regulatory cells are then recruited to sites of tissue inflammation and engage inflammation associated activated antigen presenting cells, down-regulating activation to produce a therapeutic benefit.     

New interferons in the treatment of chronic hepatitis C

The current standard therapy for chronic HCV infection is a combination of pegylated-interferon (PEG-IFN) and weight-based ribavirin, administered for 24-48 weeks, according to the viral genotype. Although the weekly administration of pegylated interferons provides superior antiviral efficacy over standard interferon alpha, the rate of sustained virological response rarely overpasses 50% in patients infected with HCV genotypes 1 and 4. Consequently, multiple clinical trials with congeners of interferon (consensus interferon, interferon lambda, albinterferon, and controlled-release interferons) are ongoing. Their main advantages consist in maintenance of viral suppression across a longer dosing interval, avoidance of interdose trough and reduced dosing frequencies (twice or even once per month compared to once per week for the actual PEG-IFNs). Along with these superior pharmacokinetic properties, new interferons are expected to have improved side-effect profiles and better tolerability compared with the currently available formulations, providing an option for otherwise difficult to treat, challenging populations. New interferon formulation can be incorporated into future combination with direct acting antivirals, in order to maintain viral suppression over longer periods and minimize the development of viral resistance.     

Relative Sensitivities of Viruses to Different Species of Interferon

Some viruses were found to be more sensitive than others to the action of interferons from certain species of animals but less sensitive to interferons from other species. Vaccinia virus was the most sensitive to mouse and hamster interferons of five viruses tested, but the least sensitive of these five viruses to human, rabbit, and bat interferons. The relative sensitivities of the viruses to interferons were found to be characteristic for each of the species tested, with those closely related phylogenetically exhibiting similar patterns of relative interferon-induced virus resistance. The amount of synthetic double-stranded polynucleotide polyinosinic acid-polycytidylic acid required to induce resistance to each of the viruses in each of the cell species correlated with the interferon sensitivities of the viruses.     

Interferon: the pathways of discovery I. Molecular and cellular aspects

This historical account covers 50 years of seminal research work on interferon done since its discovery in 1957. Topics related to molecular structure, production and action of interferons are considered from the viewpoint of how our insights have expanded and deepened within the context of evolving tools and general knowledge in cellular and molecular biology. Lines of thought that linked each discovery to the next are expounded.     

Interferon: pharmacokinetics and toxicity

Interferons disappear rapidly from the serum of animals and man, and the kidney may be the major site of interferon destruction. The relevance of serum levels of interferons to their therapeutic activity has not been clearly established, particularly as the stimulation of host defence mechanisms by interferons may be important. Relatively low serum levels of antiviral activity are seen after intramuscular injections of fibroblast interferon compared with those after the same dose of leucocyte interferon. Injections of very pure leucocyte and lymphoblastoid interferons from several sources cause fever, headaches, malaise and myalgia associated with a corticosteroid response and probably with inflammatory prostaglandin synthesis. These reactions become less with repeated dosing but very large doses of lymphoblastoid interferon have been shown to cause liver damage and serious metabolic disturbances. Treatment with moderate doses of exogenous interferons may occasionally be associated with the development of neutralizing antibodies.     

Regulatory effects of macrophage-secreted factors on T-lymphocyte colony growth.

Human fibroblast and leukocyte interferons were found to suppress lymphocyte mitogenesis induced by optimal doses of phytohemagglutinin and concanavalin A. In certain situations (low doses of mitogen and/or low doses of interferon), however, interferon significantly enhanced mitogenesis. In experiments using varying concentrations of interferon, dose-response curves with different slopes were obtained for fibroblast and leukocyte interferons. The effect of interferon was apparently exerted during early stages of the lymphocyte cell cycle. There was no inhibitory effect of interferon if the lymphocytes were washed with medium before being exposed to mitogen. Interferon increased the binding of radiolabeled mitogens to cells. The results suggest that the immunological effects of interferon are consequences of actions on lymphoid cells. Fibroblast and leukocyte interferons seem to have different modes of action, or to bind differently to target cells. Possible mechanisms for the suppressive and enhancing effects of interferons on lymphoid cells are discussed.     

Interferons as cell-regulatory molecules

Summary This review presents the current evidence for interferons as cell-regulatory molecules. Apart from inducing an antiviral state, interferon preparations are powerful inhibitors of cell growth and have selective effects on cellular protein synthesis. In addition, interferons are produced during most immune reactions and can exert positive and negative influences on these reactions. Thus interferon molecules are of interest to cell biologists, immunologists, and oncologists. Interferon as a cell regulator offers a unique approach to cancer therapy, but for its judicious use, more understanding of basic mechanisms of action is required.     

Renaturation of Inactivated Interferons by “Defensive Reversible Denaturation”

Interferon preparations whose activities had been either partially or completely destroyed by a variety of denaturing conditions could be restored to full activity by converting the inactive conformations to linear random coils and “defending” these linear polypeptides with the anionic detergent, sodium dodecyl sulfate, prior to renaturation. Complete restoration of biological activity of both mouse interferons and human fibroblast interferon required that disulfide bonds be reduced prior to renaturation, but partial reactivation was possible without reduction; these data suggest that both mouse and human fibroblast interferon preparations contain distinct molecular species of interferons.     

Interferon Induction by Viruses

Interferons are proteins of cellular origin capable of conferring virus resistance to vertebrate cells. Most cells do not produce interferons except in response to proper stimulation. Clearly, the stimulation of interferon production encompasses two phenomena. When stimulated, some cell systems produce their interferons by synthesizing new proteins. Other cell systems do not require the synthesis of new proteins to produce interferons, and still other cell systems may produce interferons by both means. Before much can be learned from the detailed study of the nature of the molecules which stimulate interferons, the type of phenomenon which the stimulus induces must be identified. Chick embryo tissues apparently make interferons by synthesizing new proteins. Many viruses stimulate interferon production in chick embryo tissues. Data available suggest that neither the protein nor nucleic acid moieties of the added virions act as inducing molecules. Also, double-stranded replicative form is probably not responsible. It is suggested that the inducer molecule may be cellular in nature and may be produced in response to a wide variety of insults among which are viral infections.     

Synergy of small molecular inhibitors of hepatitis C virus replication directed at multiple viral targets

Chronic hepatitis C virus (HCV) infection is a significant worldwide health problem with limited therapeutic options. A number of novel, small molecular inhibitors of HCV replication are now entering early clinical trials in humans. Resistance to small molecular inhibitors is likely to be a significant hurdle to their use in patients. A systematic assessment of combinations of interferon and/or novel anti-hepatitis C virus agents from several different mechanistic classes was performed in vitro. Combinations of inhibitors with different mechanisms of action consistently demonstrated more synergy than did compounds with similar mechanisms of action. These results suggest that combinations of inhibitors with different mechanisms of action should be prioritized for assessment in clinical trials for chronic hepatitis C virus infection.