Drug Repurposing Against SARS-CoV2 E-Book
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- Herausgeber: Bentham Science Publishers
- Kategorie: Fachliteratur
- Sprache: Englisch
- Veröffentlichungsjahr: 2008
Drug repurposing is a cost-effective method of discovering new treatments for diseases than traditional drug development methods. It involves virtual screening of chemical candidates with the aid of computational methods like molecular docking.
Drug Repurposing against SARS-CoV2 focuses on current trends in drug repurposing against the novel coronavirus strains. The book aims to give readers an overview of drug repurposing against COVID-19 and various techniques involved in the process. The book consolidates available information on the pathophysiology, drug targets, and drug repurposing against COVID-19 into a single, convenient resource.
Key features
• An up-to-date compilation of the evidence that supports the drug repurposing for COVID-19.
• How to use repurposing of available drugs for disease therapy.
• Provides an improved understanding of pathophysiology and SARS-CoV2 viral entry pathways.
• Provides references for further reading
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FOREWORD
Drug repurposing is a process of identifying new uses of approved or investigated drugs. In the current scenario of deadly contagious coronavirus disease 2019 (COVID-19), where no specific treatment options are available, drug repurposing is considered a very effective drug discovery strategy and could be considered the new avenue for the treatment of COVID-19. The book entitled “Drug Repurposing against SARS-CoV2” offers comprehensive and systematic coverage of repurposed and adjuvant drugs highlighting their therapeutic status in COVID-19 patients while assessing the challenges and ethical issues related to repurposing drugs.
The pathophysiology of SARS-CoV2 replication in COVID-19 and their modulation by repurposing drugs is explained in simple and lucid language and also through enriched illustrations. The wealth of information assembled by the authors will be useful to both Pharmacologists and Clinicians.
PREFACE
There are seven chapters in this book entitled " Drug Repurposing against SARS-CoV2." The book focuses on current trends in drug repurposing against SARS-CoV2.
The goal of this book is to give readers an overview of drug repurposing in life-threating diseases, drug repurposing in COVID-19, as well as various techniques involved in drug repurposing. The book aims to target students, research scholars, and physicians interested in the topic. The book's structure is well-organized and updated.
Chapter 1 by Ruchi Chawla discusses repurposing drugs: a new paradigm and hopes for life-threatening diseases.
Anand et al., in Chapter 2, outline the repurposed and adjuvant drugs in COVID-19 patients, as well as challenges and ethical issues related to drug repurposing. Chapter 3 by Neelam et al. presents the repurposed drugs against SARS-CoV-2 replication in COVID-19. In Chapter 4, Awesh Yadav et al., describe the targeting of viral entry pathways through repurposed drugs in SARS-CoV-2 infection.
Repurposed drugs or potential pharmacological agents targeting cytokine release, and induction of coagulation in COVID-19 are discussed in Chapter 5 by Arpita Singh et al. In Chapter 6, Qidwai et al., discuss the High-throughput screening (HTS) method for screening of known drugs. The last chapter by Khan et al., discusses drug repurposing for COVID-19 using computational methods.
I believe this book will be of tremendous interest to students, doctors, researchers, and even patients and their families. Finally, I would like to express my gratitude to all of the contributors to this book, as well as the Bentham Publishing Editorial Board for providing us with this invaluable opportunity.
List of Contributors
Repurposing Drugs: A New Paradigm and Hopes for Life-threatening Diseases
Ruchi Chawla1,*,Varsha Rani1,Krishan Kumar1,Mohini Mishra1Abstract
The process of repurposing drugs is an alternative to the conventional drug discovery process. It is a cost-effective and time-efficient process with high returns and low risk that utilizes mechanistic information of the existing drugs to investigate their novel applications against other disease conditions. The most significant benefit of drug repositioning is that it brings new life against novel/ orphan/ resistant diseases and pandemic outbreaks like COVID-19. As a result, widespread use of the drug repurposing strategy will not only aid in the more efficient fight against pandemics but will also combat life-threatening diseases. Therefore, repurposing drugs can provide a quick response to these unpredictable situations. In this chapter, we have tried to focus on various drug-repurposing strategies along with therapeutics for repurposing drugs against life-threatening diseases wherein little or no treatment is readily available.
INTRODUCTION
Drug repositioning is an alternative approach in drug development that opens new avenues for diseases wherein there is lack of appropriate treatment approaches. Drug repositioning (also known as drug repurposing, drug reprofiling, or drug re-tasking) is the process of identifying new modes of action, new indications, as well as new targets for already approved drugs or investigational drugs which have not been mentioned in any of the existing medical indications [1]. The availability of pre-clinical and clinical data allows for effective repurposing and the possibility of failure is relatively low in comparison to that of a new drug. As a result, the repurposed medicinal products require less time for clinical trials and regulatory approval [2]. The process of repurposing provides an abridged route to
the conventional drug discovery process. It is a cost-effective and time-efficient process with high returns and low risk that utilizes mechanistic information of the existing drugs to investigate their novel application against other diseases and pathological conditions [3]. The most significant benefit of drug repositioning is that it brings new life against novel, orphan, resistant diseases and pandemic outbreaks like COVID-19. As a result, widespread use of the drug repurposing strategy will not only aid in the more efficient fight against pandemics but will also combat life-threatening diseases [4].
Life-threatening diseases are chronic, mainly debilitating diseases that significantly reduce a person's life expectancy. Major life-threatening diseases include cancer, diabetes, neurological conditions, coronary cardiovascular conditions and HIV/Aids [5], which are significantly impacting the global health economy. These life-threatening diseases can be prevented and treated, however, at times there is lack of response from the existing therapy. There might be a need for an alternative therapeutic regimen wherein, repurposing drugs can provide a potential backup for the same [4]. Sometimes, there are unexpected pandemics when life-threatening conditions emerge and no treatment is available, and under such circumstances, repurposition of drug products could be helpful. The majority of drugs currently repositioned in the market are a result of serendipity. The well-known cardiovascular benefits of aspirin are among one of the most appropriately proven examples of repurposing. The results of clinical trial shifted the use of sildenafil from coronary artery disease to erectile dysfunction. Bupropion was initially developed as an antidepressant before its application in cessation of smoking. Botox (on botulinum toxin A) which was first used to treat eye muscle disorders, is currently having a widespread application in cosmetic and beauty industry. Minoxidil was used to treat high blood pressure prior to the discovery of its effect on hair growth. Thalidomide and its extracts have been repurposed to treat leprosy, multiple myeloma, myelodysplastic syndrome, mantle cell lymphoma, and metastatic prostate cancer [6, 7].
New drug development is a challenging process requiring enormous investment of money and time, with unpredictable return on investment [1]. De novo drug development takes around 10 to 15 years, which includes basic discovery, design of medicines, in vitro and in vivo studies (including safety and efficacy), clinical studies and ultimately market registration of drugs. In contrast, repurposing medication for life-threatening diseases takes only 5-11 years, as many intermediary steps are bypassed if the therapeutic potential of the drug for the disease is confirmed as shown in Fig. (1) [8, 9]. This approach provides several benefits over conventional drug development with lower costs in a shorter timeframe with fewer risks, as the effectiveness and safety of the original medication have already been established and approved by regulatory agencies [4]. In this chapter, we will highlight various drug-repurposing strategies along with therapeutics for repurposing drugs against life-threatening diseases where little or no treatment is available.
Fig. (1)) The approximate time and major steps in the process of de novo drug development and repurposing of drugs.Drug Repurposing Strategies
The primary objective of the drug discovery and development is to establish the therapeutic effectiveness with a very low toxicity-to-benefit ratio. As a result, strategies that use drug candidates with known therapeutic profiles (for drug repurposing) can significantly contribute to the drug development process, thereby reducing development time and costs. Drug candidates with known safety profiles can typically be selected from (a) approved FDA drugs, (b) drugs being studied for a different application, or (c) drugs abandoned or unsuccessful in clinical trials (phase II or III). The success of drug repositioning depends on maximizing therapeutic effectiveness for new targets while reducing off-target effects [10].
Repositioning of drugs is not a new concept, what is new is the ability to do it in a systematic and rational manner rather than relying on serendipity. As the prominence of drug repositioning is gaining practical applications, a number of companies are shifting their focus on developing strategies to make it a systematic exercise. Before moving the applicant drug further down the development pipeline, a drug repurposing strategy usually consists of three steps; (1) Identifying a drug applicant molecule for a new indication (hypothesis generation for new target), (2) Investigation of drug or disease-related mechanisms or signalling pathways, (3) Evaluation of Phase II and III clinical trials for efficacy (assuming that the phase I studies conducted during the original indication provides sufficient safety data). The selection of the appropriate drug for a given indication is the most important of all the mentioned steps, and it is here that modern approaches to hypothesis generation may be most useful [2]. Since the initial success of drug repurposing, several new methods for determining and validating ideas of repurposing drug targets have been developed and proposed. These repurposing approaches are frequently classified as experimental, clinical, or computational as shown in Fig. (2) [2].
Fig. (2)) Various drug-repurposing approaches: experimental, clinical and computational approaches.Experimental Approaches
Experimental drug screening approaches include target associated screening (binding assay for identification of target candidates) and phenotype-based screening as shown in Fig. (3) [11]. In drug repurposing, during experimental screening, multiple molecules are tested through pharmacological assays against certain or more targets or phenotypes. This broad approach is based on the concept that the more is the number of compounds tested, the more is the confidence in the repositioning of the drug candidates, of which the promising ones can be passed for in depth experimental testing. Both drug development and drug repurposing utilize experimental screening approaches to discover hits, but there are substantial variations in their application and results. Although the percentage of positive hits remains low (out of the overall screened compounds), comparatively low cost is involved thus making this a successful repurposing strategy [11]. Drug discovery process usually investigates de novo hits that are generated via high throughput screening, which considers highly specialized screens and multi-million-compound libraries. As against this, during repurposing in-depth screening of smaller compounds libraries is done, which are either approved compounds or failed compounds having some information on their safety and mechanism of action (MoA). There are approximately 500-2000 compounds available in approved compound libraries, with an equal number of unapproved compounds. Some may include annotations as well as information on safety and MoA. Compound libraries are managed by drug discovery laboratories and academics which open up possibilities for identifying the hits of drug candidates for a clinical development programme [12].
Fig. (3)) Experimental approaches for identifying repurposing potential of drugs.Target Associated Screening/Binding Assays to Identify Target Candidate
The targets for the potential drug candidates are identified by proteomics, mass spectrometry, and chromatography techniques [13]. For example, the cellular thermostability assay (CTSA) determines the thermal stabilization of target proteins after binding of high-cellular-affinity compounds. Recently, cellular targets for tyrosine kinase inhibitor (TKI) crizotinib [14] and quinone reductase 2 as an off-target of acetaminophen have been identified [15]. Brehmer et al. performed a study with the help of HeLa cell extract to detect gefitinib protein targets. Mass spectrometry results have shown that gefitinib can interact with 20 distinct protein kinases that can be considered potential targets for gefitinib [13].
Phenotype-based Repurposing
Drug candidates have also been discovered accidentally by phenotypic drug screening methods. New therapeutic molecules can be identified on the basis of in-vitro and in-vivo modelling or even clinical observations [16, 17]. For example, a compound library is screened using cell lines and based on the cellular response lead compounds are identified, for a specific phenotype along with the mechanisms of action. Further, evaluation of a series of compounds in an array of independent models with the aim of identifying a novel activity among one or more of the tested models fulfils the strategic requirements needed for effective drug repositioning for effective reusability of the medicinal product [18, 19].
In-vitro phenotypic screens require the identification and confirmation of candidates from repositories of known medicines or drug-like molecules. In vitro tests can be used to study new diseases based on which repositioning of the drugs can be done. In order to achieve a therapeutic effect over a full concentration range, compounds with a different mechanism of action over the range can also be evaluated [20].
In vivo phenotypical screening is conducted on few selected high-quality drug applicants or compounds rather than on assessing compound libraries. These models can evaluate efficiency, tolerance and safety in general [21]. Genome editing techniques, like CRISPR/Cas-9, are being utilized in combination with preclinical animal studies to model human diseases and perform in-vivo screening of old drugs for the phenotypic effects [22].
Clinical Approaches
As most drugs fail in Phase II/III studies, most of the clinical studies do not reach the completion stage. Sometimes, different outcomes are observed during the post-marketing surveillance stage after the drug has reached the market. During this phase, even adverse reactions are observed and on the other hand, cures for diseases, not studied during the clinical trials i.e. without any indication on the label can also be discovered. Numerous drugs have already been repurposed as a result of such trials. Some examples include apomorphine, which was originally prescribed for Parkinson’s disease but repurposed for erectile dysfunction; drospirenone used as an oral contraceptive and repurposed in hypertension, and dapoxetine which was to be used for analgesia and depression, was later repurposed for hypertension. These are just a few indications of therapeutically repurposed drugs; there are several drugs that have been repurposed for a variety of new indications [23].
Computational Approaches
Computational methods are mainly data-driven; these include the systematic information of data (for instance expression of genes, chemical structure, genotypes or proteomic data, or electronic health records) that lead to the formulation of hypotheses for repurposing of drugs [24]. Computational methods help in identifying drugs, which can be repurposed at reduced costs and time. This strategy allows the collective analysis of data from various sources, including genomic data, and biomedical and pharmacological data to improve the efficiency of drug repositioning [25]. In general, computer approaches are classified as target-based, knowledge-based, signature-based, pathway and target mechanism-based approaches as shown in Fig. (4).
Fig. (4)) Different computational approaches can be used as stand-alone or in combination strategies to screen multiple data types to extract valuable insights for hypothesis testing for the repurposing of drugs.Re-profiling of Drugs Based on Target / Molecular Docking
Target-based drug repurposing involves high throughput and high content screening (HTS/HCS) of pharmacologically active compounds by utilizing proteins and biomarkers, followed by in silico ligand or docking based screening of drug compounds [26, 27]. In this screening, no biological or pharmacological information about drug products is incorporated as the screening is blinded. The target-based approach links targets with mechanisms or pathophysiology of disease and thus improves the drug discovery process. The advantage of the targeted approach is that almost all drug molecules of recognized chemical structures can be screened. However, target-based strategies cannot identify unknown mechanisms beyond known objectives [2].
Knowledge-Based
In this drug repurposing approach, models are developed for predicting unidentified targets, bio-markers or disease mechanisms, using drug-related information, such as drug targets, chemical structures, pathways, adverse effects, etc. This strategy includes drug reposition based on targets, pathways and targets mechanisms [2].
Signature Based
Signature-based techniques concentrate on identifying genetic factors associated with disease pathophysiologies, such as differentially expressed genes, genetic regulation profiles, and transcription factors. These approaches are elucidating the molecular mechanisms underlying disease pathogenesis. This provides a pathway for the discovery of the drug target mechanisms. Numerous computational tools (such as CMap, GWAS, LINCS, and HGSOC) have been developed to investigate genetic messengers [28].
Pathway Based Repurposing
Protein-protein interactions, cell signalling pathways, and metabolic pathways can all be used to predict how disease and drugs will interact. The best illustration is the information available from the central patient database that can identify the methods of drug repositioning for a specific disease [29].
Target-Mechanism-Based Repurposing
To explore new possible mechanisms for drugs, target mechanism-based drug repurposing combines signalling pathway information using omics data and interacting proteins networks [16]. Such drug-repurposing strategies are stimulated by the growing demand for precision medicine. The advantage of these strategies is that they seek to identify mechanisms not only for disasters but also for drug therapies for specific illnesses [25]. A detailed enumeration of various methodologies of drug repositioning is mentioned in Table 1.
Therapeutic Potential of Repurposing of Drugs for Life-threatening Diseases
Drug repurposing or drug re-profiling is the procedure of redevelopment of an existing drug for approval for use as a licensed drug for the different routes of administration with other therapeutic indications [32]. Various drugs and drug categories have been extensively screened with the perspective of repurposing them for urgent and rapid treatment of life-threatening diseases, especially during disease outbreaks or pandemics. The various strategies for the development of repurposed drug encourage the elimination of unnecessary preclinical and clinical protocols and the safety assessment procedures that are required during the development of safe and effective drug for life-threatening diseases [33]. The “Polypharmhacology” aspects of a drug acting on more than one biological target generally led to undesirable side effects due to its off-target activity. As a blessing in disguise, this off-target polypharmacological activity of drugs is being widely utilized for drug repurposing [34, 35]. Government, academics and industries are exploring the repositioning of drugs for different therapeutic purposes. Regulatory agencies of the European Union and United Nation started the initiative known as STAMP which means Safe and Timely Access to Medicines for Patients. Also, drug repurposing programme for supervision and authorization of off-patent medicinal products and launching a workshop with industry, academia and the patient to spread knowledge to support drug repurposing initiatives have been started by the National Institute of Health (NIH). The repositioning of a drug requires computational and experimental data validated for three major criteria: (1) lead candidate selection with all information and indications; (2) theoretical recognition and assessment of drug based on preclinical studies; and (3) safety and efficacy studies of phase II clinical trials [36]. The use of computational approaches for elucidation of chemical structure, genetic expressions through gene mapping pathways especially through genome-wide associated studies (GWAS), proteomic data of the drug candidates, computational molecular docking and clinical analysis have fastened the drug repurposing process [37]. The introduction of the Orphan Drug Act (ODA;1983) for the economic drug development of orphan diseases facilitates rapid approval from the FDA along with funding support to study them for treatment of unknown and rare diseases [38]. After preclinical and clinical analysis, the FDA approves the marketing of the drug with “on-label drug use” extensively for therapeutic purposes. When there is no treatment available for life-threatening diseases, the repurposed drug with proven therapeutic action is known as off-label drugs. Various drugs are repositioned for the treatment of another disease more efficiently than originally reported medications enlisted in Table 2.
Advantages of Drug Repurposing
The repurposing of drugs reduces costs, and shortens the timelines and complications, generally associated with the discovery of new drugs.
Cost and Time Minimization
The cost involved in designing a new drug entity restricts the more considerable outcomes of drug discovery. An estimated overview of expenses required for repurposing drugs is estimated to be approximately $1.6 billion which is much lesser than the development of new molecular entities which cost around $12 billion. Moreover, various pharmaceutical companies have reported that $20 billion in annual sales in 2012 were mainly utilized to reposition failed drugs by different pharmaceutical companies. Further, there has been a significant fall in the new drug molecules reaching the market after the year 2000 as reported by Eroom’s Law. In contrast, drug repositioning offers lower development time and cost with reduced risk [4]. The biotech drug repositioning companies adopted a business model (Platform, Product, Vertical and Hybrid models) to speed up the development process, shorten the lengthy R&D timeframe, and assessment of drug safety profile and mechanism of action [52].
Accessibility of Information Related to the Drug for Development of Repurposed Drug
The drug-related information like formulation, route of administration, dosing strength, dosage regimen, pharmacokinetic and pharmacodynamics profile, bioavailability data, adverse effects and toxicological data of already approved drugs facilitates the entrance of repurposed drugs in the clinical field with novel therapeutic manifestation. The bioinformatics and cheminformatics databases like Entrez-Gene genetic databases, proteomic database (UniProt), and DrugBank/Drug Central/PubChem are pharmaceutical databases that play a crucial role to build more specific information related to chemical structure and genetic expression for further repositioning of drug [53]. All preclinical, clinical, safety and efficacy data guide the researchers in decision-making to select the orphan drugs with sound scientific basis without any constraints [54].
Dosing Strength and Frequency
The determination of dose accuracy is a complex exercise during drug repositioning that will require substantial development costs, even though API is approved with clear specifications of dosing strength and dosing parameters. The applicability of the therapeutic profile of the drugs for different diseases needs new clinical trials mainly to understand the efficacy of existing drugs to treat life-threatening disorders at suitable dosing strength and frequency. Sildenafil a phosphodiesterase V inhibitor marketed for erectile dysfunction at 25, 50, and 100 mg dosing strength, was repurposed for the treatment of pulmonary hypertension as “Revatio” at dosing strengths 5 and 20 mg [55].
Therapeutic Potential of Repurposed Drugs for the Treatment of Life-threatening Diseases
Life-threatening diseases are chronically debilitating and caused by pathogens and other factors associated. COVID-19 is a health crisis threatening the world by affecting the respiratory system thus known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) also affects other organs of the body due to oxygen insufficiency. Due to their high complexity and low frequency, important gaps still exist in their prevention, diagnosis, and treatment. Pharmaceutical companies show relatively low interest in orphan drug research and development due to the high cost of investments compared to the low market return of the product due to expensive and time-consuming processes involved in new drug discovery. Therefore, drug repurposing-based approaches appear cost-effective and time-saving strategies for the development of therapeutic opportunities for life-threatening diseases. The understanding of the efficacy and advantages of drug repurposing that has been used earlier for the treatment of various diseases including antiviral infections, tuberculosis, cancer, pulmonary diseases, cardiac diseases and renal dysfunctions has been discussed below.
Tuberculosis
Non-steroidal anti-inflammatory drugs have shown the potential for use as selective anti-mycobacterial for the treatment of tuberculosis. The acid hydrazones and amides of Diclofenac show anti-tubercular activity by inhibiting the incorporation of thymidine and the synthesis of DNA [56]. Mefenamic, meclofenamic acid, indomethacin, and tenoxicam complexes have been found to have anti-tubercular activity against M. tuberculosis with <1 µg/mL minimum inhibitory concentration (MIC) values [57]. Celecoxib is a selective COX-2 inhibitor with reported activity against methicillin-resistant Staphylococcus aureus and works by inhibiting the bacterial efflux by regulating MDR-1 pump homology in human beings [58]. Ibuprofen has the ability to inhibit inflammatory cytokines mainly tumour necrosis (TNFα) and block the formation of granuloma with minimal threat of liver damage that is generally associated with paracetamol and aspirin [59]. Fluoroquinolones, moxifloxacin and gatifloxacin are broad-spectrum antibiotics that primarily inhibit topoisomerase II and IV, thereby disrupting DNA replication and have shown mycobactericidal activity in phase III clinical trials with pretomanid and pyrazinamide (PaMZ) [60]. Clofazimine is a riminophenazine developed for the treatment of leprosy and has been found beneficial for the treatment of drug-resistant tuberculosis [61]. Biapenem and tebipenem are carbapenem classes of drugs mainly designed to treat infection against Pseudomonas aeruginosa and have been repurposed for respiratory pneumonia with MIC90 value 2.5-5 ug/ml as anti-tubercular agents with effectiveness against H37Rv M.tuberculosis strain with MIC90 value 1.25-2.5ug/ml [62]. Ebselen is a seleno-organic compound having antioxidant, anti-inflammatory and anti-atherosclerotic activity and has shown the potential to treat methicillin-resistant tuberculosis. Isoprinosine is an anti-viral immunomodulatory drug that showed in-vivo antibacterial activity against M.tuberculosis with first-line TB drugs [63].
Moreover, statins reduce the cholesterol level in human macrophages destabilize the membrane and minimize the entrance of pathogens inside macrophages. Simvastatin and pravastatin are examples of cholesterol-lowering agents that have been found to be effective in decreasing bacterial load in TB [64]. Metformin is an oral hypoglycemic agent that mainly targets the host immune response that effectively controls the growth and invasion of M.tuberculosis by inhibiting intracellular growth of H37Rv and that of MDR strain in monocyte-derived human macrophages [65].
Cancer
Discovery of new chemotherapeutics by repositioning drugs to overcome multidrug resistance for cancer is being done by docking-based virtual screening (in-sillico approach and pharmacophore modelling) for reprofiling of small drug molecules against multidrug-resistant cancer. An anti-schizophrenic drug “Fluspirilene” has shown the therapeutic potential for the treatment of hepatocellular carcinoma by inhibiting dopamine D2 receptors and blocking the calcium channel, thereby inhibiting the Cyclin-dependent kinase 2 (CDK2) and thus inhibiting cell proliferation and tumour growth [66]. Anti-helminthic drugs Mebendazole and flubendazole are tubulin depolymerization agents, that inhibit tumour growth through inhibition of spindle formation and then apoptosis [67]. Raloxifene is an anti-resorptive agent with the potential to treat cancers by inhibiting the protein-protein IL-6/GP130 interaction [68]. Fenofibrate is a receptor-α agonist (peroxisome proliferator-activated receptor) generally used for dyslipidemia and hypertriglyceridemia, which also inhibits the multiplication of melanoma cells (B16-F10 cells) by downregulation of phosphorylation of Akt and thus suppression of primary tumours’ growth [69]. Itraconazole is an antimycotic drug that has also been proven to be efficacious in skin cancer treatment mediated via suppressing Wnt, Hedgehog, and PI3K/mTOR signalling pathways [70]. Leflunomide, mainly used for rheumatoid arthritis, acts as an enzyme dihydroorotate dehydrogenase (DHODH) inhibitor which reduces neuroblastoma cell proliferation and induces apoptosis [71]. Some beta-blockers have also shown their potential to treat cancer by inhibiting the pathways involving cyclic adenosine monophosphate (cAMP)-protein kinase that prevents cell proliferation and cell migration in human cancer cell lines, especially in infantile hemangioma (vascular tumor of infancy) [72].
Pulmonary Diseases
Drugs like sildenafil, thalidomide, and raloxifene have been effectively repurposed for the treatment of pulmonary diseases. Slidenafil is a 5 phosphodiesterase (PDE 5) selective inhibitor which has been used for the treatment of angina pectoris and hypertension since 1989 and has also shown a pronounced effect on erectile dysfunction (1998). It was approved for pulmonary arterial hypertension by U.S. Food and Drug Administration (FDA) and Europe, the Middle East, and Africa (EMEA) for treatment of PAH (from 2005 onwards) [73]. Pirfenidone (collagen synthesis inhibitor) is currently approved as an orally active anti-fibrotic molecule for the therapy of idiopathic pulmonary fibrosis (IPF) and reduces radiation-induced fibrosis by inhibiting Type I and III of Collagen Synthesis and mRNA production. Oral pirfenidone has shown good potential for regulating the progression of IPF disease. Preclinical studies with inhaled pirfenidone have shown good antifibrosis activity compared to oral pirfenidone. Pirfenidone has antifibrotic activity and causes reduction of inflammatory cytokines and tumor necrosis factor-alpha (TNF-α), pro-fibrotic growth factors including growth factor-beta (TGF-β), oxidative stress and lipid peroxidation [74].
Cardiac Diseases
Methotrexate is used in the conventional treatment of dyslipidaemia, diabetes and hypertension. Recent studies have shown its potential for treating atherosclerosis and endothelial dysfunction by acetylcholine-mediated and nitroprusside-mediated vasodilation. It also reduces the concentration of IL-6 and TNF-α, thus averting the ICAM-1 and vascular cell adhesion molecule 1, an expression induced by TNF-α that favours the adhesion of leukocytes adhesion to the endothelium in the beginning stages of atherosclerosis [75]. A randomized placebo-controlled study of metformin on the reduction of insulin dependence and carotid artery disease in diabetic patients showed a significant reduction in carotid intima-media thickness, a prolonged therapy of metformin leads to reduced LDL cholesterol, HbA1c levels and estimated glomerular filtration rate (eGFR); further, it has not shown any reduction in the cardiovascular events and HbA1c levels [76].
Antiviral Infections
The viral infections such as Ebola virus, yellow fever virus, Zika virus, Nipah virus, West, Nile virus, dengue virus, SARS-CoV, Middle East respiratory syndrome (MERS-CoV), Influenza virus and human immunodeficiency virus (HIV) have been pestering the mankind every now and then. The surging demand during these viral outbreaks in the absence of vaccines has led to the repositioning of manyexisting drugs. Mycophenolic acid (immunosuppressant) and daptomycin (antibiotic) were the propitious therapeutics in Zika virus infection by restricting viral replication into the host cell. Some antibiotics like novobiocin, niclosamide and temoporfin act as novel zika virus inhibitors targeting NS3/NS2B protease [77]. In contrast, ribavirin and chloroquine were also effective in reducing ZIKV vertical transmission in infected pregnant mice [78]. Statins were also clinically proven for their anti-inflammatory and immunomodulatory effects besides their cardioprotective activity, improving the patient's health in case of severe influenza [79]. Besides this, Nitazoxanide (thiazolide anti-infective) designed to treat parasitic infections, has also shown anti-influenza properties through intracellular trafficking and insertion into the host plasma membrane through selective inhibition of viral glycoprotein HA maturation. Phase IIb/III trial clinical trial (NCT01610245) has shown the efficacy of nitazoxanide in influenza [80
