Selective inhibitors of hepatitis C virus replication.

Worldwide over 170 million people are chronically infected with the hepatitis C virus and hence at high risk to develop fatal liver disease. There is no vaccine available and the standard therapy [(pegylated) interferon alfa plus ribavirin] is only effective in 50-60% of patients and is associated with important side-effects. The discovery of novel antiviral strategies to selectively inhibit HCV replication has long been hindered by the lack of convenient cell culture models for the propagation of HCV. This hurdle has been overcome first with the establishment of the HCV replicon system in 1999 and, in 2005, with the development of robust HCV cell culture models. In recent years also mouse models have been elaborated that will be instrumental in assessing the in vivo efficacy of novel drugs. The viral serine protease and the viral RNA dependent RNA polymerase have shown to be excellent targets for selective anti-HCV therapy. Clinical studies with a limited number of HCV protease and polymerase inhibitors resulted in encouraging results. However, and not unexpected, preclinical evidence suggest that the virus may become rapidly resistant to such inhibitors. Combination therapy of drugs with different mode of action and resistance profiles may thus be required. Alternative strategies, such as the use of non-immunosuppressive cyclosporin A analogues with potent anti-HCV activity, may prove important, in particular since such compounds may have a resistance profile that is very different from that of protease or polymerase inhibitors.