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Effect of a novel adenosine deaminase inhibitor (co-vidarabine, co-V) upon the antiviral activity in vitro and in vivo of vidarabine (Vira-Atm) for DNA virus replication.

A new potent inhibitor of adenosine deaminase (co-vidarabine) was used in combination studies with adenine arabinoside (vidarabine, Vira-ATM) to protect this purine nucleoside from enzymatic deamination to the more weakly active metabolite, hypoxanthine arabinoside. Comparing the combination to vidarabine alone, a significant increase (10-fold) of the antiviral activity of the combined drugs was observed against herpes and vaccinia viruses in tissue culture and subcutaneously, against cranial herpesvirus infections in mice. Several other investigators have also recently reported several-fold enhancement of vidarabine activity by newly described deaminase inhibitors. They observed that plaque formation by several large DNA-containing viruses (herpes, vaccinia, varicella zoster) and an RNA-containing oncogenic virus was markedly prevented by the combination compared to vidarabine alone. In animals, enhanced protection (increased survivors) and/or highly significant increase in the life span of dying mice treated with the 2-drug combination, was also observed compared to vidarabine administered singly. These observations in animals clearly indicate that combination studies with vidarabine (Vira-ATM) and co-vidarabine (deaminase inhibitor) deserve serious consideration as future therapy for systemic virus infections in man including herpesvirus encephalitis.

Adenosine Deaminase Inhibitors

Iontophoresis of vidarabine monophosphate into rabbit eyes.

In order to investigate the efficacy of iontophoresis for increasing the penetration of vidarabine monophosphate into the eye, tritium-labeled vidarabine monophosphate was applied to rabbit eyes by topical and iontophoretic application, and the penetration of the compound into the eye, and its subsequent metabolism, were studied. At 20 min after treatment, the ratios of radioactivity for cathodal iontophoresis compared to topical application alone were cornea 8.6, aqueous humor 4.8, and iris 2.4; for 60 min the ratios were cornea 12.2 aqueous humor 17.5 and iris 2.5. In addition, the acid-soluble components were extracted from the cornea and aqueous humor. Vidarabine monophosphate, vidarabine, hypoxanthine arabinoside, adenosine, hypoxanthine, and adenine from the acid-soluble fraction were separated by thin-layer chromatography. The amount of vidarabine monophosphate and vidarabine in the cornea and aqueous humor from the iontophoretically treated group was six to 15 times higher than from the group that received topical application of the drug. It was concluded that cathodal iontophoresis resulted in significantly increased penetration of the antiviral drug vidarabine monophosphate into the anterior chamber of the eye. The effects of iontophoresis of vidarabine monophosphate on corneal epithelium, as observed by scanning electron micrographs, were equal to or less than those seen with the topical application of widely used preservatives in ophthalmic preparations.

Adenine

Pharmacokinetics of vidarabine in the treatment of polyarteritis nodosa.

The pharmacokinetics of vidarabine were studied in 8 patients with polyarteritis nodosa related to hepatitis B virus infection. The drug was administered by continuous infusion for three weeks at doses of 15 (1 week) and 7.5 (2 weeks) mg/kg per day, during which time 15 plasma exchanges were performed. Plasma was assayed for vidarabine and its principal metabolite, hypoxanthine arabinoside by high pressure liquid chromatography. Vidarabine was not detected in the plasma of any patients. Hypoxanthine arabinoside levels were used to evaluate vidarabine kinetics. The serum levels of hypoxanthine arabinoside ranged from 3.6 to 21.5 mg/l. The mean elimination half-life (+/- SD) was 3.0 +/- 1.7 h. The plasma clearance (mean +/- SD) was 195 +/- 270 ml/min when the dose was 7.5 mg/kg per day and 66.3 +/- 47 ml/min for a 15 mg/kg per day/dose (NS). Except for the elimination half-life, these results were not fully consistent with those observed in other studies. The influence of multiple plasma exchanges on vidarabine kinetics is limited and dosage adjustment is not required based on the continuous infusion of vidarabine.

Humans

Vidarabine therapy of simple and IDU-complicated herpetic keratitis.

Large scale, multiclinic evaluations of vidarabine (Ara-A, Vira A, adenine arabinoside) for treating herpetic keratitis have been conducted as double-blind studies (169 patients) in comparison with IDU and open studies (146 patients). In the open studies, the disease in the majority of patients had been refractory to IDU. The effects of vidarabine and IDU were approximately the same in improvement of symptoms (lacrimination, photophobia, sensitivity) and percent of and time for corneal reepithelialization. With vidarabine, significantly more patients had improved distant visual acuity than did with IDU. In the open studies, vidarabine also was effective. Of 116 patients whose ulcers had not responded to IDU, 91 (78%) had reepithelialization within four weeks of treatment with vidarabine. On the basis of results from these studies, vidarabine appears to be a safe and effective drug for treating herpes simplex keratitis.

Adolescent

A clinical trial of topically applied 3 percent vidarabine against recurrent herpes labialis.

Seventy-six participants were enrolled in a clinical trial to determine therapeutic effectiveness of 3 percent vidarabine applied topically to recurrent perioral herpetic lesions. Following a 6- to- 12-month natural history phase, a 12-month clinical trial was conducted. Seventy participants developed 463 lesions during 361 episodes. Three percent vidarabine in a water-miscible gel was applied six times daily for 7 days to each lesion in the experimental group. Identically packaged placebo was used by the control group. Group assignment was by computer-generated randomization. Lesion size was reduced when vidarabine, rather than placebo, was applied. The difference was statistically significant (Student's t test, P = 0.02). Vesiculation followed tingling more rapidly when vidarabine, rather than placebo, was applied prior to vesiculation (P = 0.05). No significant difference between the two groups was found in episode frequency or lesion duration. Adverse reactions to vidarabine were not experienced.

Administration, Topical

HBsAg-positive chronic liver disease: inhibition of DNA polymerase activity by vidarabine.

Four patients who had chronic liver disease and were positive for hepatitis B surface antigen (HBsAg) were treated with vidarabine, a synthetic purine nucleoside that inhibits DNA polymerase activity in vitro and in vivo. Before treatment all had raised serum DNA polymerase concentrations. Three also had hepatitis B e (HBe) and were shown by electron microscopy to have hepatitis B virus (Dane) particles in their serum. In all patients 10 days' treatment with vidarabine resulted in an immediate loss of DNA polymerase activity. In three patients the activity returned when treatment was stopped. In those three patients Dane particles and HBe antigen persisted during and after treatment; in the fourth patient, who remained negative for DNA polymerase, HBsAg titres fell. Although vidarabine inhibited virus replication, virus particles did not disappear from the blood in these patients, presumably because the particles were cleared only slowly. Similar results with interferon suggest that the virus disappears, and HBsAg titres fall, some weeks after the fall in DNA polymerase activity. Continued treatment may therefore have a sustained effect on viral replication. Whether vidarabine can permanently clear HBsAg and so arrest chronic liver disease remains to be seen, but at the very least it could reduce the spread of infection.

Adult

Effect of an adenosine deaminase inhibitor on the uptake and metabolism of arabinosyl adenine (Vidarabine) by intact human erythrocytes.

Tritium-labeled vidarabine was incubated with fresh citrated human blood in the absence and presence of an adenosine deaminase inhibitor, co-vidarabine was rapidly deaminated to form ara-Hx with minimal incorporation into the erythrocytes. Ara-HxMP was identified as the major component in the erythrocytic nucleotide pool, together with small amounts of IMP, adenosine nucleotides and traces of arabinosyl nucleotides. Addition of the inhibitor completely protected vidarabine from enzymatic deamination and resulted in much greater accumulation of vidarabine 5'-mono-, di-, and triphosphates in the erythrocytes.

Adenosine Deaminase Inhibitors

Use of vidarabine in epidemic keratoconjunctivitis due to adenovirus types 3, 7, 8, and 19.

Adenovirus types 3,7,8, and 19 were isolated during an outbreak of epidemic keratoconjunctivitis. There was no clinically recognizable difference in the severity of the disease produced by each adenovirus type. Twenty-nine patients with positive viral cultures were given either 3.3% vidarabine ointment or polyvinyl alcohol eyedrops within five days of the onset od disease, and were observed for at least 14 days. An observer unaware of which medication was prescribed found subepithelial corneal infiltrates in 81% of vidarabine-treated patients and in 63% of control subjects. Vidarabine was ineffective in preventing subepithelial corneal infiltrates in keratoconjunctivitis caused by adenovirus.

Adenoviridae Infections

Herpes simplex encephalitis treated with vidarabine (adenine arabinoside).

Vidarabine, an antiviral chemotherapeutic agent shown to have in vitro activity against the herpes group of viruses, was administered to five patients with brain biopsy-proved herpes simplex virus encephalitis. The mortality in this small number of patients (one of five or 20%) was less than that in most published reports of patients receiving other treatment modalities or no treatment other than supportive measures. No apparent toxicity was found that was attributable to vidarabine. Neuropsychological impairment of varying degree was noted in four surviving patients tested at two months after treatment and again 12 to 21 months later. Progressive improvement had occurred in three.

Adolescent

Treatment of vaccinial keratitis with vidarabine.

Vaccinial epithelial keratitis was produced in rabbits. When the therapeutic effect of vidarabine on the experimentally-induced disease was evaluated and compared to the effect of idoxuridine, vidarabine was found to be highly effective, substantially more effective than idoxuridine, and nontoxic to the eye.

Animals

Vidarabine therapy for severe herpesvirus infections. An unusual syndrome of chronic varicella and transient immunologic deficiency.

Six patients with severe herpesvirus infections were successfully treated with vidarabine. One patient had a previously undescribed syndrome of chronic cutaneous varicella infection of eight months' duration, associated with transient but complete duppression of lymphocyte response to conconavalin A. Other diagnoses were severe varicella pneumonia, progressive cytomegalovirus pneumonia associated with acute lymphocytic leukemia, herpes simplex encephalitis, severe zoster associated with stage IV lymphoma, and disseminated herpes simplex in a patient receiving high doses of steroids. All patients showed cessation of new lesions or abrupt clinical improvement between days 2 and 4 after initiation of therapy, and all were cured of their clinical infection. Dramatic improvement in all of our patients and the minimal toxicity observed make vidarabine suitable for use in severe herpesvirus infections.

Adolescent

The effect of vidarabine on the development of the offspring of rats, rabbits, and monkeys.

The effect of vidarabine, a new antiviral agent, on the offspring of rats, rabbits, and monkeys was studied by varying routes of administration during several periods of gestation. Vidarabine demonstrated a dose-related teratogenic effect in rats when given parenterally at doses of 30 mg/kg and greater. The drug was also teratogenic in the rabbit at dosages of 5 mg/kg and greater by the parenteral route or when applied topically in 10% concentration to 5 or 10% of the body surface area. The pattern of malformation was similar in the two species, and consisted of multiple, severe abnormalities of the head, trunk, and limbs. The drug had no demonstrable teratogenic effect in a limited study in the rhesus monkey; nor were there adverse effects on the offspring when it was applied intravaginally to pregnant rats in the perinatal period.

Abnormalities, Drug-Induced

Vidarabine therapy of complicated herpes simplex keratitis.

Patients with active herpetic epithelial keratitis who had toxic reactions or were resistant to idoxuridine received vidarabine. Only one of 35 cases of herpetic epithelial keratitis without stromal disease failed to heal. Of 21 patients with active epithelial keratitis complicating stromal keratitis or uveitis. 11 had complete reepithelialization by day 14. Two patients were removed from the trial as treatment failures. The remaining cases healed in 21 to 48 days. In most instances the stromal keratitis was inactivated when the epithelial ulcer healed. In our patients treated with vidarabine, healing of herpes simplex epithelial ulcers was biphasic: Stage 1, progression from an active to an inactive viral ulcer, and Stage 2, complete reepithelialization.

Adrenal Cortex Hormones

Cytomegalovirus encephalitis in immunologically normal adults. Successful treatment with vidarabine.

Acute cytomegalovirus (CMV) encephalitis developed in two immunologically normal adults. The diagnosis was confirmed by isolation of CMV from the CSF and urine in one case and from temporal lobe biopsy tissue, CSF, and urine in the second case. Both patients were treated with vidarabine and showed dramatic clinical improvement. Virus excretion, which had been chronic in one case, cleared after therapy. To our knowledge, these are the first persons with CMV encephalitis evidenced by isolation of the virus from the CNS. The response to vidarabine was impressive and warrants further evaluation.

Acute Disease

[Treatment of herpes simplex keratitis with Vidarabin ointment (author's transl)].

In 20 cases of herpes simplex keratitis the efficacy of Vidarabin ointment has been tested, in 19 cases after corneal abrasion. The eyes were treated once a day and padded until the epithelial defects had closed. Thereafter the ointment was applied 4 times per day for about one week more. On the average epithelial closure had been achieved after 2.4 days, complete normalization of the epithelium after a total of 3.6 days. This therapy results in a considerable shortening of the healing process as compared to the topical use of anti-viral medication alone. From this aspect Vidarabin ointment has proved to be a valuable adjuvant.

Clinical Trials as Topic

[Treatment of herpes simplex of the lid margin with vidarabin ointment (author's transl)].

Twenty cases of herpes simplex of the lid margin were treated with vidarabin ointment applied topically 4 to 5 times daily together with an antibiotic ointment 2 to 4 times per day. Healing of the skin eruptions was observed within 3 to 12 days (average 6 days). Vidarabin eye ointment was well tolerated in all cases. A comparison with other locally-applied virustatic preparations is drawn.

Administration, Topical

Effect of vidarabine and related compounds on corneal endothelium.

The endothelial surface of rabbit corneas was perfused with vidarabine monophosphate (with and without adenosine deaminase inhibitor), vidarabine (with and without adenosine deaminase inhibitor), and ara-Hx. In concentrations 10 times to 1,500 times higher than those that have been obtained in the aqueous humor following topical, subconjunctival, or systemic administration, none of the compounds had any effect on corneal endothelial cell function or ultrastructure for the duration of the experimental model.

Animals