nature reviews drug discovery https://doi.org/10.

1038/s41573-024-00914-7

Review article Check for updates

The landscape of small-molecule

prodrugs
Zachary Fralish , Ashley Chen2, Shaharyar Khan3, Pei Zhou
1 4
& Daniel Reker 1

Abstract Sections

Prodrugs are derivatives with superior properties compared with Introduction

the parent active pharmaceutical ingredient (API), which undergo Rationales for prodrug
biotransformation after administration to generate the API in situ. development

Although sharing this general characteristic, prodrugs encompass a Prodrug indications

wide range of different chemical structures, therapeutic indications Chemical diversity
and properties. Here we provide the first holistic analysis of the current of promoieties

landscape of approved prodrugs using cheminformatics and data Multiple prodrugs for the
same API
science approaches to reveal trends in prodrug development. We
highlight rationales that underlie prodrug design, their indications, Prodrug biotransformation
into APIs
mechanisms of API release, the chemistry of promoieties added to APIs
to form prodrugs and the market impact of prodrugs. On the basis of Physicochemical properties
of prodrugs
this analysis, we discuss strengths and limitations of current prodrug
Opportunities and challenges
approaches and suggest areas for future development. for prodrug development

Conclusion

Department of Biomedical Engineering, Duke University, Durham, NC, USA. 2Department of Computer
1

Science, Duke University, Durham, NC, USA. 3Rivus Pharmaceuticals, Charlottesville, VA, USA. 4Department of
Biochemistry, Duke University School of Medicine, Durham, NC, USA. e-mail: [email protected]

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Review article

Introduction 30 prodrugs) or solubility (15%, 13 prodrugs) of the parent drug. Many

Prodrugs are molecular derivatives of active pharmaceutical ingredi- permeability-improving prodrugs (such as benazepril; Fig. 1b) esterify a
ents (APIs) with little or no expected biological activity themselves, but carboxylic acid with an ethyl chain; however, esterification with various
they exhibit beneficial properties compared with their corresponding chemical structures has been implemented (for example, ampicillin
APIs, including improved pharmacokinetics or reduced side effects. prodrugs; Fig. 1b). Most prodrugs designed to increase solubility use
After administration, prodrugs undergo biotransformation through phosphorylation (for example, fospropofol; Fig. 1c), but some (such
various enzymatic and/or chemical processes to release their APIs as isavuconazonium; Fig. 1c) incorporate more complex function-
(Fig. 1a). By improving on properties of the APIs, prodrug strategies alizations. The other prodrugs designed to improve bioavailability
can enhance drug delivery and effectiveness in several ways, includ- (8%, seven prodrugs) harness endogenous mechanisms for cellular
ing but not limited to enabling oral and parenteral administration, trafficking, as exemplified by valganciclovir, a ganciclovir prod-
augmenting cellular permeability, prolonging the duration of action, rug that is a substrate of the intestinal peptide transporter peptide
improving tissue-specific activity to reduce off-tissue side effects and transporter 1 (PEPT1), enabling active transport across the intestinal
increasing effective drug concentrations1. membrane17 (Fig. 1d).
Drug delivery researchers are using increasingly advanced Aside from bioavailability, other common goals of prodrug devel-
approaches to combat absorption, distribution, metabolism, excre- opment include enabling targeted drug delivery to a tissue of inter-
tion or toxicity (ADMET) challenges for small-molecule therapeu- est (24%, 20 prodrugs): for example, sulfasalazine being selectively
tics, thereby improving their safety and efficacy. Nanoparticle activated by intestinal bacteria18 (Fig. 1e). Prolonging the duration of
formulations2, functional excipient combinations3 and other advanced action was a design goal for 15% of the prodrugs (13 prodrugs), such as
delivery vehicles4,5 can address some drug delivery challenges, but are selexipag by being slowly hydrolysed into its active form19 (Fig. 1f). Mini-
often complex to manufacture, require intravenous injection or have mizing toxicity was a design goal for 7% of the prodrugs (six prodrugs),
specific storage and reconstitution requirements that hinder their including tenofovir alafenamide undergoing mostly intracellular con-
broad deployment — especially in a global or rural health setting. Con- version, thereby decreasing its side effects20 (Fig. 1g). Finally, improving
versely, small-molecule prodrugs are often easy to synthesize, purify, stability of the API against chemical or metabolic degradation was a
distribute and administer but can be more difficult to design because design goal for 6% of the prodrugs in our dataset (five prodrugs): for
multi-objective optimization of synthesizability and ADMET properties example, the valine ester of the prodrug valbenazine increasing plasma
is required for each project. Additionally, to gain regulatory approval protein binding21 (Fig. 1h).
requires thorough investigation of all degradation products, extending Prodrugs may also be developed to solve multiple ADMET issues
the development pathway for prodrugs. Accordingly, to minimize risk, of the API simultaneously — in total, we found ten prodrugs in our data-
current prodrug design often relies on simple functionalization, such as base that solve at least two issues for the API. For example, capecitabine,
shielding a hydrophilic group through a short alkyl chain (for example, an anticancer chemotherapy prodrug of 5-fluorouracil, has reduced
benazepril; Fig. 1b) or adding a phosphate group to a lipophilic drug gastrointestinal toxicity owing to improved absorption compared
to improve solubility (for example, fospropofol; Fig. 1c). There are a with the API and enables targeted tumour delivery22 (Fig. 1i). Addi-
few approved prodrugs that include more complex promoieties, but tionally, prodrugs have been developed by combining two APIs into a
many of these were discovered serendipitously (such as tafenoquine; single prodrug structure, which is known as the ‘co-drug’ approach23.
Table 1 and Box 1). More recently, the pharmaceutical research and For example, the orally available prodrug sultamicillin, which com-
development community has proposed that the rational design of more bines the β-lactam antibiotic ampicillin with the β-lactamase inhibitor
advanced prodrugs can enable the delivery of life-saving medications sulbactam, enables activity against drug-resistant bacteria that would
with further improved safety and efficacy1,6,7 (Box 2). otherwise inactivate ampicillin by producing β-lactamases24.
For this Review, we have taken a cheminformatic and data sci- Overall, the large proportions of prodrugs developed to improve
ence approach to holistically characterize the current landscape of solubility25 or membrane permeability26,27 corroborates the general
small-molecule prodrugs (Box 3). After aggregating and curating data notion that the bioavailability of an API can be readily improved
on prodrugs from five different databases and literature sources1,7–10 by developing a prodrug. Although precedents for prodrugs that
and reviewing recent FDA approvals11–14 (Table 1), we identified 178 address toxicity1,20 and targeted delivery1,18 clearly validate the fea-
FDA-approved prodrugs (Supplementary Table 1), which account sibility of a prodrug approach to mitigate more complex ADMET
for approximately 9% of all approved small-molecule drugs15. We ana- challenges, the limited number of examples of prodrugs designed
lysed various characteristics of these prodrugs, including the ration- for purposes beyond bioavailability indicate that the development
ales for their development, their indications, their physicochemical of these prodrugs has been underused, possibly owing to difficulty in
properties and their mechanisms of biotransformation, and we discuss implementation. However, recent approval trends suggest that a new
challenges and opportunities in prodrug development based on the era of prodrug design to address more complex ADMET properties
trends we observed. has already begun: since 2015, more than two-thirds (five) of the seven
approved prodrugs with identified design goals improve properties
Rationales for prodrug development beyond bioavailability.
We analysed the rationales for developing the 178 prodrugs by extract- To further scrutinize this trend, we next included investigational
ing their design goals from the Therapeutic Target Database16, resulting prodrugs16 in our analysis (Supplementary Tables 3 and 4). As it is
in data for 85 prodrugs and 95 design goals, as not all prodrugs are impossible to create an exhaustive set of investigational prodrugs,
annotated but some prodrugs analysed have multiple design goals we instead aimed to analyse a representative set. To avoid the intro-
(Fig. 2a, Box 3 and Supplementary Table 2). More than half of the prod- duction of our own bias, we extracted data from the peer-reviewed
rugs with annotated design goals (59%, 50 prodrugs) were designed to Therapeutic Target Database16 — which to the best of our knowledge
improve bioavailability, mostly by increasing the permeability (35%, is one of the largest publicly available datasets of drugs in clinical and

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preclinical development, with no apparent bias for specific indication, improve bioavailability, exploitation of differences in the availability
therapeutics, manufacturer or other such characteristics. For the of prodrug biotransformation mechanisms can provide an avenue
294 prodrugs with identified design goals that are currently in clini- for targeted therapy and reduction of side effects; in fact, 20% (7/35)
cal trials and preclinical development (Supplementary Table 3), the of approved prodrugs in these categories were designed for such pur-
proportion of prodrugs designed to improve bioavailability falls to poses. For example, targeted delivery of the nitroimidazole prodrug
42% (124/294) whereas the number of tissue-targeted prodrugs grows benznidazole29 for Chagas disease is enabled by its biotransformation
to 26.5% (78/294) — an increase of 5% compared with our dataset for by NADH-dependent type I nitroreductases that are found specifi-
approved prodrugs alone. This shift indicates that prodrugs in current cally in trypanosomes such as Trypanosoma cruzi and Trypanosoma
development are increasingly being used to mitigate more complex brucei29. Similarly, capecitabine is a prodrug of 5-fluorouracil that
delivery problems. We anticipate that our resources (Supplementary exhibits higher tumour specificity owing to its final transformation step
Tables 1–4) could point prodrug developers to concrete examples being catalysed by thymidine phosphorylases that are more strongly
of such prodrugs and thereby provide blueprints for future prodrug expressed in tumours22.
development (Box 2). Beyond these approved examples, a series of target-tissue acti-
vated prodrugs to combat antibacterial resistance30 (Box 2) or to
Prodrug indications allow for tumour targeting31 are under development, and a myriad of
We next curated the indications of our dataset of 178 approved prod- tumour-specific prodrugs that use approaches such as hypoxic32 and
rugs using DrugBank data15 and primary literature sources (Fig. 2b reactive oxygen species33 activation have been developed. However,
and Supplementary Table 1), which yielded 186 total indications, they have shown limited efficacy in large-scale clinical trials owing to
as some prodrugs are approved for multiple indications. Overall, extensive variability between tumours32,33, indicating the need for a
we found that the largest group of currently approved prodrugs is larger future role for biomarkers and personalized medicine when
anti-infectives (33%, 58 prodrugs), followed by chemotherapeu- selecting the appropriate prodrug approach for a specific patient
tics (18%, 32 prodrugs), anti-hypertensives (14%, 25 prodrugs) and or tissue.
anti-inflammatory drugs (12%, 21 prodrugs). Among all 1,799 approved More recently, anti-infective prodrugs are increasingly being
small-molecule drugs identified from DrugBank (Box 3), only 296 approved for underserved indications. From 2018 to 2022, multiple
(16%) are anti-infectives and only 202 (11%) are chemotherapeutics. prodrugs were approved for tropical infectious diseases, including
This means that prodrugs are enriched in the arsenal of anti-infectives tafenoquine and artesunate for malaria, pretomanid for tuberculo-
(P < 0.0001, Fisher’s Exact Test) and chemotherapeutics (P < 0.05, sis, fexinidazole for sleeping sickness and nifurtimox for Chagas dis-
Fisher’s Exact Test). These trends could be rooted in the general ease (Table 1). Additionally, when analysing the Therapeutic Targets
physicochemical properties of anti-infective and chemothera- Database16 for investigational prodrugs, we found several prodrugs
peutic drugs, which often differ from those of drugs approved for under development for each of these diseases. For example, a series
other indications28 and thus may need prodrug strategies to address of orally bioavailable benzoxaborole prodrugs are under develop-
delivery challenges. ment that are activated by parasite carboxypeptidases that selectively
To investigate possible factors underlying these trends, we com- target CPSF3-mediated mRNA maturation in intracellular T. cruzi, the
pared the APIs of anti-infective and chemotherapeutic prodrugs with causative agent of Chagas disease34. These targeted prodrugs exhibit
other approved anti-infective and chemotherapeutic drugs, respec- uniformly curative effects in non-human primates with no overt toxic-
tively. For both therapeutic areas, APIs that require a prodrug approach ity. Furthermore, prodrug approaches that improve medicinal stability
significantly differed in multiple properties from non-prodrug APIs. and bioavailability can be especially impactful in a global health setting
For example, APIs of anti-infective and chemotherapeutic prodrugs by enabling the development of oral medicines that potentially do not
had a statistically significant increase in rotatable bonds, hydrogen require cold storage.
bond acceptors, hydrogen bond donors and heteroatoms relative to
the total number of atoms and a statistically significant decrease in cal- Chemical diversity of promoieties
culated partition coefficient (P < 0.05, Wilcoxon rank-sum test). When Our comprehensive analysis of prodrugs provides an opportunity to
including the promoiety to compare the complete prodrug structures holistically understand how prodrugs differ from their APIs to chart
with the non-prodrug anti-infective and chemotherapeutic APIs, the the design space of prodrugs. It is important to note that prodrug
prodrugs still showed a statistically significant decrease in calculated biotransformation mechanisms can be broadly classified into three
partition coefficient. However, neither group of prodrugs exhibits a distinct types: type 1 are prodrugs that have additional atoms compared
statistically significant increase in hydrogen bond donors or rotatable with the API and require cleavage of these promoieties to release the
bonds — potentially hinting that prodrug development creates deriva- API (such as fospropofol, Fig. 1b); type 2 are prodrugs that are sub-
tives of problematic APIs that more closely resemble successful APIs for structures of APIs and require metabolic additions to produce the
the same therapeutic area in terms of their physicochemical properties. API (such as ganciclovir); and type 3 are prodrugs for which the API is
Although as simple rules of thumb they are likely not sufficient to guar- produced via molecular rearrangements and replacements (such as
antee success, our analysis suggests that physicochemical property omeprazole, Fig. 3f).
analysis might enable researchers to prioritize prodrug modifications Of the 178 FDA-approved prodrugs in our dataset (Supplemen-
that alter the API properties to be more ‘drug-like’. tary Table 1), 102 FDA-approved prodrugs (57%) are larger derivatives
In addition to required changes in physicochemical properties, with promoieties attached to the API that are cleaved by endogenous
these two largest categories for prodrugs (anti-infectives and chemo- mechanisms to release the API (type 1). Reflecting the established uses
therapeutics) involve treatment of pathogens or diseased tissues with of some prodrug moieties, such as phosphate groups to improve the
targetable variations from healthy tissues. Although most (51%, 18/35) solubility of APIs1, these 102 prodrugs use only 56 distinct promoieties
of the anti-infective and chemotherapeutic prodrugs are designed to (Supplementary Table 9). To quantify how common particular prodrug

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a Classical prodrug strategy d Trafficking

Valine
Pharmacological impediment Improved efficacy/safety O N O
Valganciclovir
N R= O
Drug (API) N
N NH2
H O
H2N
R Esterase
Ganciclovir
Prodrug OH R = OH

e Targeted delivery Mesalamine

Promoiety R
O
R= N Sulfasalazine
N
N O OH
b Increased permeability
N
S
Hydroxyethyl O Bacterial azo OH
H
O reductase
R= Benazepril
R
O R = NH2 Sulfapyridine

NH Esterase f Duration of action

O R = OH
Benazeprilat R= HN O
N Selexipag
S
O
HO Hydroxyethyl ethyl carbonate R O Methanesulfonamide
N
O R= O O O
N Carboxylesterase
O
O R O Bacampicillin
N
R = OH ACT-333679
Hydroxyisobenzofuranone
O N O
R= O O
S
Talampicillin g Minimized toxicity
Phenol lsopropyl L-alanine
HN
O R2 =
O R1 =
O P O O
H2N R1 Tenofovir
Hydroxymethyl pivalate N
R 2 H alafenamide
O
R= O O Pivampicillin
N N
Carboxylesterase Amidase
O N
NH2
Esterase R1 = OH R2 = OH Tenofovir
N

R = OH Ampicillin
h Improved API stability Valine
c Increased solubility Hydroxymethyl phosphate NH2
O O O
R
OH Valbenazine
P Fospropofol O R=
R= O O OH O
N-(3-acetoxypropyl)- R
Phosphatase
N-methylamino- Esterase
carboxymethyl N Propofol N
R = OH
O R = OH Dihydrotetrabenazine
O N
O
Esterases
i Multiple goals
NH O N N Pentyl carbamate O
and chemical O
conversion F
N N N N HN
HN O
Isavuconazonium OH OH Isavuconazole
F O N
F F N
5’-deoxy-
N N
O 5-fluorouridine
S S O N
Carboxylesterase
and cytidine
F F O deaminase OH OH
N N
Thymidine
Bipiperidine carboxylic acid OH OH
O
phosphorylase
O Methyltetra-
hydrofurandiol O
O N R= O N
Irinotecan
F
HN
O Esterase N Capecitabine 5-Fluorouracil
OH N
R SN-38 O N
R = OH H

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Fig. 1 | Prodrug structures and purposes. a, The most commonly applied rearrangements or replacements to produce the API (not shown). b, Example
prodrug approach historically involves derivatizing an active pharmaceutical prodrugs designed for increased permeability. c, Increased solubility. d, Cellular
ingredient (API) with a chemical group known as a promoiety to circumvent trafficking. e, Targeted delivery. f, Modulated duration of action. g, Minimized
a pharmacological liability of the API, such as poor solubility. The prodrug toxicity. h, Improved API stability. i, Multiple goals. Prodrug names and
is biotransformed back into the API in the body, for example, through promoieties are highlighted in gold, and API names are highlighted in light blue.
enzymatic hydrolysis. Some prodrugs require metabolic additions, molecular Enzymes responsible for biotransformation are highlighted in dark blue.

modifications are, we analysed the chemical identity of the promoieties accessible to phosphorylation may not be present in the original
in the 102 prodrugs that incorporate them (analysing 116 promoieties in drug or may be sterically hindered, limiting the viability of this strat-
total, as some prodrugs incorporate more than one promoiety). Over- egy for certain APIs. More complex functionalizations, such as the
all, most promoieties are aliphatic groups (85 promoieties, 73%). Many sarcosine-based promoiety in the antifungal isavuconazonium 39
of the aliphatic groups are either simple alkyl chains (28 promoieties, and the carbamate-linked bipiperidine in the antineoplastic agent
25%) or esterified alkyl chains (25 promoieties, 21%), with the remaining irinotecan40 (Fig. 1c), illustrate the potential of innovative approaches
aliphatic promoieties (32 promoieties, 28%) incorporating additional to enhance the solubility of compounds that are not suitably
heteroatoms (Fig. 2c). The second largest group of promoieties are improved by or accessible to phosphorylation.
aromatic rings (18 promoieties, 16%), which are mainly carbon-only, Additionally, 42 (24%) approved prodrugs are substructures of
and the remainder (13 promoieties, 11%) are phosphate groups. Overall, the API and have functional groups added by endogenous mecha-
the data indicate that simple promoieties are commonly used among nisms after administration to produce the API (type 2). Most of these
approved prodrugs, and these workhorses in prodrug development (25 prodrugs, 61%) require the addition of phosphate groups (for
can serve as an established arsenal (Supplementary Table 1) for future example, emtricitabine). Others require the addition of hydroxyl
prodrug design. groups (eight prodrugs, 19%; for example, tamoxifen) or ketones
As these modifications are likely to affect the physicochemi- (two prodrugs, 5%; for example, allopurinol). The remaining six prod-
cal properties of the prodrug differently, we further investigated rugs (14%) require the addition of multiple or more complex organic
whether the distribution of the promoieties would differ depending groups such as acetyl-CoA for bempedoic acid and porphyrin rings
on the purpose of the prodrug. Esterification of an ethyl chain onto for aminolevulinic acid.
a carboxylic acid is used in eight approved prodrugs, accounting for Finally, 34 (19%) prodrugs require molecular rearrangements
27% of the 30 prodrugs identified as being designed to improve drug and replacements to produce the API (type 3). Of these, 14 prodrugs
permeability. Notably, this strategy has been commonly used for (41%) undergo a functional group replacement, such as the conver-
angiotensin-converting enzyme (ACE) inhibitors such as benazepril, sion of nepafenac into amfenac through replacement of an amide
enalapril, moexipril, perindopril, quinapril, spirapril and trandolapril. with a carboxylic acid. Ten (29%) involve promoiety removal and
Including other organic chains and rings, esterification of carboxylic the formation of new bonds, such as the formation of ketones when the
acids and primary alcohols accounts for 57% (17/30) and 17% (5/30), tafenoquine ester promoieties are removed during bioconversion.
respectively, of the functionalizations used in prodrugs to improve Eight prodrugs (24%) undergo both a ring rearrangement and an
permeability. Taken together, 73% (22/30) of permeability-enhancing addition, as for all approved proton pump inhibitors, and two prod-
prodrugs use simple esterifications of a hydrophilic group. However, rugs (6%) simply undergo a ring rearrangement, as illustrated by the
esterifications with more complex chemical structures can potentially conversion of proguanil into cycloguanil through the formation of a
further enhance permeability by exploiting active transport, as epito- nitrogenous ring.
mized by gabapentin enacarbil, a permeability-enhancing prodrug that
also exhibits increased and extended transport rates over gabapentin Multiple prodrugs for the same API
as it is a substrate of multiple high-capacity nutrient transport path- In total, 16 FDA-approved prodrugs (9%) share an API with another
ways, allowing for higher dosing and prevention of uptake saturation prodrug and the drugs differ only in their promoiety structure, which
at clinical doses35. provides an opportunity to understand the differential impact of
Simple direct phosphorylation accounts for the majority alternative prodrug strategies. Of prodrugs with a shared API, nine
(54%, 7/13) of the chemical functionalizations used to improve solu- (56%) were developed to achieve the same goal. For example, various
bility (for example, as in ceftaroline fosamil and fosaprepitant). structures can be used to modify the permeability and bioavailability
This increases to 69% (9/13) when including indirect phosphoryla- of a drug, as epitomized by the three varied promoieties of orally bio-
tion through formaldehyde linkers (for example, as in fosphenytoin available prodrugs of ampicillin: the EU-approved pivampicillin, the
and fostemsavir). This widely implemented prodrug approach has FDA-approved but discontinued bacampicillin and the investigational
even shown promise for ‘beyond-rule-of-5’ molecules that exhibit drug talampicillin41 (Fig. 1c). Bacampicillin has a diethyl carbonate
physicochemical properties far removed from typical orally bio- moiety and is the least lipophilic, with a logP of 1.17. Pivampicillin has
available drugs. For example, ABBV-167, a phosphate prodrug of the an ethyl pivalate moiety and is more lipophilic, with a logP of 1.43.
BCL-2 inhibitor venetoclax, exhibits suitable conversion back to its Finally, talampicillin has a phthalide promoiety and is the most lipo-
complex API while providing significantly increased solubility and philic, with a logP of 1.53. Such promoiety–property relationships could
even reducing food effects in humans36. However, phosphate-based be exploited in the future to guide prodrug development. Similarly,
prodrugs may adversely impact tissue permeability owing to numerous esterified alkyl chains and rings were incorporated onto
being deprotonated at physiological pH37 and are typically rapidly PKC modulators to fine-tune prodrug stability and activation times42.
metabolized, which renders them unsuitable for tissue-targeted Alternatively, distinct alterations using different prodrug modifica-
or slow-release formulations38. Furthermore, functional groups tions can highlight various pathways to modulate the properties of the

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Table 1 | Prodrugs approved by the FDA 2018–2022 (in order of approval date)

Prodrug name (brand name) Indication Activity Bioactivation method Approval date

Fostamatinib (Tavalisse) Chronic immune SYK inhibitor Phosphatase 17 Apr. 2018

thrombocytopenia
Fosnetupitant (part of Akynzeo IV, Chemotherapy-induced emesis NK1 receptor antagonist Phosphatase 19 Apr. 2018
which also contains palonosetron)
Tafenoquine (Krintafel) Plasmodium vivax malaria Aminoquinoline antimalarial Cytochrome P450 20 Jul. 2018
Baloxavir marboxil (Xofluza) Acute uncomplicated influenza Polymerase acidic endonuclease Esterase 24 Oct. 2018
inhibitor
Pretomanid (Pretomanid) Tuberculosis Mycolic acid biosynthesis Nitroreductase 14 Aug. 2019
inhibitor
Diroximel fumarate (Vumerity) Relapsed multiple sclerosis NRF2 activator Esterase 30 Oct. 2019
Bempedoic acid (Nexletol) HeFH or atherosclerotic ACL inhibitor Ligase 21 Feb. 2020
cardiovascular disease
Artesunate (Artesunate) Severe malaria Artemisinin antimalarial Esterase 27 May 2020
Fostemsavir (Rukobia) HIV Attachment inhibitor Phosphatase 2 Jul. 2020
Triheptanoin (Dojolvi) Fatty acid oxidation disorders Fatty acid source Esterase 30 Jun. 2020
Nifurtimox (Lampit) Chagas disease Nitrofuran antiprotozoal Nitroreductase 7 Aug. 2020
Remdesivir (Veklury) COVID-19 Nucleotide analogue RNA Esterase, hydrolase, kinase 22 Oct. 2020
polymerase inhibitor
Melphalan flufenamide (Pepaxto) Relapsed or refractory multiple Alkylating agent Esterase, hydrolase 26 Feb. 2021
myeloma
Serdexmethylphenidate (part ADHD CNS stimulant Unknown 2 Mar. 2021
of Azstarys, which also contains
dexmethylphenidate)
Brincidofovir (Tembexa) Smallpox Slow viral DNA synthesis Esterase, kinase 4 Jun. 2021
Fexinidazole (Fexinidazole) Sleeping sickness Nitroimidazole antimicrobial Nitroreductase 19 Jul. 2021
Terlipressin (Terlivaz) Kidney function in hepatorenal Vasopressin receptor agonist Peptidase 14 Sep. 2022
syndrome
Omidenepag isopropyl (Omlonti) Intra-ocular pressure in Prostaglandin E2 receptor Esterase 22 Sep. 2022
open-angle glaucoma or ocular agonist
hypertension
5-HT3, 5-hydroxytryptamine receptor 3; ACL, adenosine triphosphate-citrate lyase; ADHD, attention deficit–hyperactivity disorder; COVID-19, coronavirus disease 2019; CNS, central nervous
system; HeFH, heterozygous familial hypercholesterolaemia; NK1; neurokinin 1; NRF2, nuclear factor (erythroid-derived 2)-like 2; SYK, spleen tyrosine kinase.

same drug. For example, two modifications have been made to prolong used as a therapeutic, the rapid blood–brain barrier permeation
the duration of action of dihydrotetrabenazine: the incorporation of achieved by heroin through the incorporation of acetyl groups high-
deuterium in the prodrug deutetrabenazine slows drug metabolism43 lights opportunities to improve brain targeting in future prodrug
or the addition of valine in the prodrug valbenazine increases plasma development46.
protein binding21. Another example is the anti-inflammatory drug prednisolone,
The remaining seven prodrugs (44%) with shared APIs overcome which has two prodrug versions. The prodrug prednisolone phos-
different ADMET challenges. For example, the various prodrug ver- phate is functionalized with a phosphate group to effectively improve
sions of morphine provide interesting insights into how distinct modi- solubility47. More interesting is the additional prodrug formulation
fications can lead to vastly different pharmacokinetics. Specifically, prednisone, which is both a prodrug and an inactive metabolite of
the addition of a benzene ring and fatty acid onto the alcohol groups prednisolone and therefore has lower peak plasma concentrations to
of morphine in the scheduled drug myrophine slows delivery, allow- allow for higher dosing48.
ing for long-lasting pain reduction44. Conversely, the esterification Different promoieties on the same API have also been used to
of one alcohol group with a carbon atom in codeine leads to milder develop prodrugs for entirely different indications, as seen with
analgesic effects that used to be considered a safer choice for mild three FDA-approved prodrugs (2% of all approved prodrugs). For
pain with over-the-counter availability in multiple countries. However, the antimetabolite 5-fluorouracil, there are four prodrug formu-
the increasing evidence that codeine carries the same risks and side lations (including the EU-approved anticancer prodrug tegafur),
effects as morphine coupled with a widely variable activity time-frame three of which are used for cancer therapy and one of which is
based upon person-to-person cytochrome P450 variability45 has an antifungal therapy. Floxuridine is an intra-arterially adminis-
caused hesitation about codeine usage and serves as a striking exam- tered cytotoxic anti­cancer agent that is rapidly metabolized into
ple of the complex ADMET properties of prodrugs. Although not 5-­fluorouracil. The anticancer prodrug tegafur allows for oral delivery

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of 5-fluorouracil and is combined with uracil to provide long-lasting colon and that is responsible for unwanted side effects52, prompt-
blood levels of the API49. Capecitabine incorporates an additional ing the development of subsequent prodrug formulations. Olsala-
carbamate promoiety that allows for almost complete absorption zine delivers two molecules of mesalamine through a co-drug
following crossing of the gastrointestinal barrier22. As previously formulation53, and balsalazide incorporates an inert promoiety
mentioned, the final stage of capecitabine biotransformation occurs (4-aminobenzoyl-β-alanine) in place of the sulfapyridine, improving
by thymidine phosphorylases that have higher levels of activity patient tolerance54.
within tumours, allowing capecitabine not only to avoid gastroin- There are other examples of additional prodrug versions devel-
testinal toxicity but also to have some tumour specificity22. Beyond oped for the same API to mitigate issues not fully addressed by the
cancer indications, 5-fluorocytosine is an antifungal 5-fluorouracil original prodrug (Box 2). For example, the double ester prodrug
prodrug that is deaminated within fungal target cells to inhibit DNA tenofovir disoproxil fumarate was developed to allow for oral delivery
and RNA synthesis50. of the antiviral API tenofovir, but unfortunately retained the off-target
Of the 16 prodrugs for which different promoieties are used renal and osteoblast damage of tenofovir owing to biotransforma-
to derivatize the same API, 11 are used for targeted delivery. This tion of the prodrug to tenofovir in plasma20. To further improve this
is epitomized by all the widely used proton pump inhibitors that therapy, tenofovir alafenamide fumarate was developed. This phos-
use site-selective bioactivation within the gastrointestinal tract phonamidate prodrug undergoes primarily intracellular conversion
to deliver sulfenamides51. Similarly, the prodrugs of mesalamine to tenofovir by additionally leveraging amidases for bioactivation,
leverage bacterial azo reductases in the colon for localized release which leads to decreased side effects20. This multistep bioactivation
of mesalamine. However, sulfasalazine, the first mesalamine prod- pathway is shared with other phosphonamidate prodrugs, such as
rug serendipitously discovered to be effective for ulcerative coli- the recently developed coronavirus disease 2019 (COVID-19) prodrug
tis, contains a sulfapyridine promoiety that is absorbed from the remdesivir.

Box 1

Case studies of serendipity and surprises in prodrug discovery

and design
Serendipity has historically been intertwined with prodrug discovery. showed that this approach could also effectively target primary
For example, 8-aminoquinolines, which include tafenoquine, were lung cells to inhibit respiratory virus replication75. This serendipitous
discovered to exhibit antimalarial activity in vivo72. The fact that discovery has enabled the development of phosphoramidate
cytochrome P450 2D6 (CYP2D6) is responsible for their bioactivation prodrugs for lung delivery, including the development of remdesivir
into active metabolites was elucidated only after analysis of for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)
polymorphisms in patients who failed to respond to the therapy in infection.
clinical trials72. Similarly, isoniazid’s method of bioactivation was not The discovery that a compound is a prodrug can also resolve
discovered until more than 40 years after its introduction6. In another seemingly contradictory experimental results. Tamoxifen was
example, although heroin was originally considered a substitute for an ‘unlikely’ drug development story of a lead that showed
morphine with reduced risk of addiction, it was later revealed that it potent anti-oestrogen activity in utero despite low affinity for its
is, in fact, a prodrug that is rapidly transformed into morphine, and receptor in vitro76. This discrepancy was later unravelled once
it is classified as a schedule I drug with a higher risk for abuse than the it was discovered that tamoxifen undergoes cytochrome P450-
schedule II morphine73. mediated metabolic hydroxylation and N-demethylation, producing
More recently, although there has been an immense gain in metabolites with significantly more anti-oestrogenic and anti-
knowledge and a push for the rational design of more complex aromatase activity77. This finding has particular clinical significance
prodrugs, serendipity still often has a significant role during given that CYP2D6 polymorphisms affect clinical response
prodrug design. For example, broad-spectrum antifungals of and exposure to endoxifen, the primary active metabolite of
the triazole class have poor water solubility, which limits their tamoxifen70.
clinical utility and necessitates complexation with cyclodextrins Finally, even if a drug is known to be a prodrug, the mechanism
for delivery, which increases the risk of kidney toxicity. To combat of its bioactivation might still be unknown. For example,
this issue, isavuconazonium (Fig. 1c) was originally developed methylphenidate is a fast-acting and rapidly cleared central
as a prodrug for parenteral administration, with its triazolium nervous system stimulant, which presents challenges for once-daily
ring and sarcosine moiety significantly enhancing water solubility. dosing and shows high variability in addressing patient symptoms.
Serendipitously, this prodrug approach enhanced oral bio­ Serdexmethylphenidate, a prodrug of methylphenidate, was
availability as well and isavuconazonium is now approved for discovered serendipitously to undergo delayed metabolism to
oral administration74. Additionally, although it has been known methylphenidate in the gastrointestinal tract, thereby producing a
that aryloxy phosphoramidate prodrug moieties could deliver delayed-release pharmacokinetic profile78. The enzyme responsible
antiviral nucleoside monophosphate payloads into specific cells for the slow metabolism of serdexmethylphenidate into the active
such as immune cells and hepatocytes, recent experimental data methylphenidate has not yet been identified.

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Box 2

Emerging strategies in rational prodrug design

Although currently approved prodrugs often use established linkers tumour to mitigate cardiac toxicity65. For targeting of neuroactive
and simple promoieties (Figs. 2c and 4d), medicinal chemists are drugs to the brain, redox strategies with dihydropyridine-type
increasingly creating various innovative prodrug strategies to compounds have long been used83,84. Recently, researchers have
circumvent complex issues of therapy (Fig. 4e). built upon this strategy to create ‘bio-oxidizable’ prodrugs of
For example, the emergence of antibiotic resistance has been acetylcholinesterase inhibitors by masking a positively charged
identified as one of the major threats to human health and is nitrogen through piperidine replacement with a dihydropyridine
increasingly impeding the efficacy of established antibiotics79. At the ring85. As the nitrogen of dihydropyridine is not basic enough to be
same time, the increasing recognition of the value of the commensal protonated at physiological pH, it exhibits significantly decreased
microbiome is making broad-spectrum antibiotics a less desirable inhibitory activity while being lipophilic enough to cross the blood–
option. To combat the formidable challenge of mitigating the brain barrier. Following brain penetration, oxidoreductase-mediated
threat of antibiotic resistance while sparing commensal microbes activation converts the dihydropyridine into the corresponding
of patients, researchers have specifically designed prodrugs that pyridinium. This restores inhibitory activity and traps the drug in
harness evolutionary adaptations of resistant microbes as therapeutic the brain to prevent peripheral cholinergic adverse effects. To
opportunities to selectively target resistant pathogenic strains. For ensure the precise balance of stability outside the brain and facile
example, β-lactamase-cleavable promoieties have been used to conversion within the brain, medicinal chemists carefully optimized
make ciprofloxacin prodrugs that are active only against β-lactamase- the placement of an electron-withdrawing group at the C-3 position
producing bacteria, sparing collateral damage to other microbiota80. of the pyridine moiety85.
Cephalosporin is a β-lactamase substrate, which makes it highly With the continued advancement of computational approaches
susceptible to antimicrobial resistance, but medicinal chemists to support drug design, machine learning might soon be poised to
exploited this liability to create a prodrug motif with efficient substrate support rational design of innovative prodrugs. This could accelerate
turnover without inhibiting the β-lactamase enzyme. To ensure that prodrug development by steering the designs towards ideal
the cephem portion of the intact prodrug remained inert to enable absorption, distribution, metabolism, excretion or toxicity (ADMET)
high selectivity against β-lactamase-producing microbes, bulky profiles86,87, ease of synthesis88–90, non-toxic metabolite formation and
benzylic substituents were incorporated at the para position. minimal pharmacological activity of inactive prodrugs. Beyond these
Innovative prodrug design can also allow for active transport. approaches, metabolic models can be leveraged to guide promoiety
For example, siderophore conjugations hijack bacterial uptake design through biotransformation predictions to ensure appropriate
systems for iron acquisition to increase uptake of antibiotics81. drug release. Although many metabolic models were designed
By exploiting the structures of naturally occurring siderophores to predict only cytochrome P450-catalysed transformations91–93,
through biosynthetic gene cluster analysis and metabolomics with the advancement to multi-system metabolic models94,95 may soon
additional chemical optimization, they have been successfully used more holistically analyse relevant metabolic pathways that could
as cleavable linkers to release antibiotic payloads within bacteria, activate or deactivate prodrugs. Exploratory work has already
boosting potency against resistant Gram-negative bacteria82. applied metabolic modelling to prodrug release through enzymatic
Trafficking to the diseased tissue can also be achieved modelling96 and density functional theory97. Further incorporation of
through other innovative strategies. For example, aldoxorubicin is administration methods, biodistribution and predictive confidence
functionalized with a maleimide promoiety that covalently binds into computational models will better position them to support
to serum albumin and hijacks the accumulation of albumin in the prodrug design.

Prodrug biotransformation into APIs significant portion of the prodrug biotransformation machinery
We next analysed the mechanisms by which all 178 approved prod- (17%, 33/197).
rugs are activated to release their API in vivo, resulting in 197 total For nonenzymatic biotransformations (6%, 12/197), 5% (9/197)
biotransformations, as some prodrugs use more than one class are accomplished via pH, 1% (2/197) via glutathione and 0.5% (1/197)
of biotransformation (Fig. 2d and Supplementary Table 1). The via nonenzymatic hydrolysis. Interestingly, 4% of conversions (8/197)
vast majority of biotransformations are enzymatic (94%, 185/197). are catalysed by non-human nitroreductases, and these inter-species
Hydrolases are responsible for 49% (96/197) of conversions as follows: transformations have been utilized for targeted activity within the
esterases are responsible for 37% (72/197) of biotransformations, gastrointestinal tract (examples are olsalazine53, balsalazide54 and
phosphatases are responsible for 7% (13/197) of biotransformations sulfasalazine18). Along with species-specific antimicrobial target-
and other hydrolases are responsible for 6% (11/197) of biotransfor- ing (benznidazole29 and secnidazole55), these examples highlight
mations. Oxidoreductases are also commonly harnessed (17%, 33/197 opportunities to leverage biological knowledge of both commen-
biotransformations), most notably owing to the use of cytochrome sal and pathogenic organisms for prodrug development. In addi-
P450 proteins, which account for 12% (24/197) of all prodrug transfor- tion, complex prodrugs can simultaneously benefit from targeted
mations. Kinases that activate nucleotide analogues make up another release while further enhancing pharmacokinetic properties through

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Review article

additional pathways. For example, not only is valacyclovir bioactivated commonly catalysed by easily accessible enzymes such as plasma
through valacyclovirase within target cells such as enterocytes and phosphatases (for example, in the biotransformation of fospheny-
hepatocytes56, but it also leverages transport by PEPT1 to increase toin, fludarabine phosphate and fosnetupitant), but also include more
intestinal absorption57. The released acyclovir is then further con- complex bioconversion pathways that involve multiple enzymes (for
verted into the active form acyclovir triphosphate by virally encoded example, in the biotransformation of remdesivir). In contrast, nearly
thymidine kinases. half (45%, 15) of the 33 orally administered prodrugs exhibit a half-life
Additionally, we analysed the turnover rate of prodrugs by min- of >2 h. These include many prodrugs that require esterases for release
ing their half-lives from DrugBank15 and classified the 45 prodrugs (for example, fenofibrate, valbenazine and lovastatin), as well as
for which data are available into groups (Fig. 2e and Supplementary prodrugs that require metabolic additions (for example, fingolimod)
Table 5). Most (64%, 29/45) of the analysed prodrugs have a half-life or multistep biotransformations (for example, brincidofovir).
of <2 h, with many leveraging rapid activation by hydrolases or There can be a substantial difference between prodrug conver-
oxidore­ductases to release the API immediately after crossing the sion rates when following different routes of administration. For
first pharmacokinetic barriers. For example, alkaline phosphatases example, following intravenous administration, the half-life of the
of the intestinal lumen rapidly hydrolyse fostemsavir into temsavir, esterase-activated prodrug beclomethasone dipropionate is 0.5 h,
its active metabolite, rendering the prodrug fostemsavir generally and the half-life of its active metabolite beclomethasone 17-propionate
undetectable in patient plasma after oral delivery58. However, multiple (17-BMP) is 2.7 h. However, with oral administration, no beclometha-
approved prodrugs act as sustained-release formulations to increase sone dipropionate can be detected in the plasma, and the half-life of
the duration of action of the API. For example, selexipag leverages its active metabolite is increased to 8.8 h (ref. 60). This may be caused
hepatic carboxylesterase 1 activation to reduce peak-trough fluctua- by the metabolism of the prodrug beclomethasone occurring primar-
tion via slowed hepatic hydrolysis19, and haloperidol decanoate forms ily either directly in the gut or in the liver, causing conversion before
a depot from which it is slowly released into the bloodstream to delay systemic absorption after oral administration whereas intravenous
bioconversion rates59. administration will show higher plasma levels of beclomethasone
Release can be further impacted by the mode of administration; dipropionate in advance of hepatic metabolism. The longer half-life
for example, through release by gastric enzymes or microbes in oral of the active metabolite after oral administration might be rooted in
delivery compared with plasma and liver enzymes after injection. the limited oral bioavailability of the prodrug, causing the creation of
Therefore, we analysed prodrug release based on the administration a drug depot in the gut that slowly releases active metabolite through
methods. The vast majority (92%, 11) of the 12 intravenously admin- bioconversion. With established success in using a wide range of prod-
istered prodrugs have a half-life of <2 h. These fast conversions are rug activation and release methods, we expect that there will be further

Box 3

Collection, curation and analysis of data on prodrugs

Our database of 178 clinically approved prodrugs (Supplementary The background distribution of all drug approvals was derived
Table 1) was aggregated from the ChEBI database10, the Therapeutic from DrugBank (2022)15 by selecting all approved small-molecule
Target Database16 and using manual extraction from previous drugs. Anti-infective and chemotherapeutic drugs were identified
prodrug reviews1,7,8. Additionally, we manually screened recent from this background distribution. We maintained a broad definition
FDA approvals11–14 in the past 5 years to include prodrugs that of chemotherapeutics that includes newer targeted therapies
were not yet covered in databases and reviews. We did not restrict such as kinase inhibitors based upon the classification used
our analysis to a specific time period and aimed to identify all by DrugBank. A total of 294 investigational prodrugs and their
prodrugs approved by the end of 2022. Additional information purposes (Supplementary Table 3), 155 investigational prodrugs
for prodrugs, including the CHEBI ID and SMILES for the prodrug and API structures (Supplementary Table 4) and 125 investigational
and its active pharmaceutical ingredient (API) and general promoieties (Supplementary Table 10) were extracted from the
description, was extracted from PubChem98. FDA approval dates Therapeutic Target Database16 and their physicochemical properties
were sourced from the FDA website. were calculated from their chemical structures.
Only small-molecule prodrugs were considered in the selection Sales of blockbuster drugs (Supplementary Table 11) were
of prodrugs; antibody–drug conjugates such as brentuximab vedotin, retrieved from quarterly financial reports from Shire (Vyvanse and
soft drugs such as clevidipine and PEGylated molecules such as Adderall), Novartis (Ritalin) and Gilead (Viread, Vemlidy, Truvada,
lonapegsomatropin were excluded. Descovy and Biktarvy). Prodrugs within the top 300 most prescribed
Bioactivation details for prodrugs were curated from the medications in the USA (Supplementary Table 12) were identified
Therapeutic Target Database16 and DrugBank15, and were manually from the publicly available ClinCalc DrugStats Database.
supplemented by primary literature sources when information was Physicochemical properties of prodrugs, APIs and promoieties
not available in these databases. Data on half-life, clearance and were calculated from their chemical structures using RDKit nodes in
volume of distribution at steady state were obtained from DrugBank15 KNIME (v. 4.5.3). Statistical significance tests were performed using
(Supplementary Tables 5–7). scipy in python.

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Review article

a Prodrug design goals (n = 95) b Prodrug indications (n = 186)

Improved bioavailability (53%)
Increased
permeability
(32%) Chemotherapeutic
(17%)

Increased
solubility Anti-inflammatory
(14%) (11%)

Synergistic
effect (1%) Trafficking
(7%) Anti-infective (31%)
Stability
Anti-psychotic (2%)
(5%) Anti-convulsant (5%)
Uric acid reducer (2%)
Toxicity
(6%) Anti-coagulant (2%)
Proton pump
Anti-emetic (2%) inhibitor (3%)
Duration of
Miscellaneous (6%) Hormone (2%)
action (14%)
Narcotic (2%)
Targeted
Anti-cholesterolaemia (2%)
delivery (21%)
Anti-hypertensive (13%)

c Promoiety composition (n = 116) d Biotransformation mechanisms (n = 197)

Carbon-only Enzymatic (94%)

(11%) Aromatics
(16%)
Heteroatom
rings (4%) Alkyl chains
Esterase (37%)
(25%)
Nonenzymatic (1%)
hydrolysis
Aliphatics Phosphatase
Glutathione (1%)
Phosphates (73%) (7%)
(11%) Hydrolase (other) Nonenzymatic (6%)
(6%)
pH (5%)
Nitroreductase
(4%) Oxidoreductase
Heteroatoms Transferase (3%) (other) (5%)
(28%) Esterified Lyase (2%)
alkyl chains Peptidase (2%) CYP (12%)
(21%)
Unknown (1%)
Ligase (1%)
Kinase (17%)

e Half-life (n = 45) f Clearance (n = 68) High g Vdss (n = 82)

High
>1,000 ml min−1 >100 l (38%)
>2 h (36%) (16%)
Low Low
Slow <100 ml min−1 (24%) <20 l (20%)
>5 h (24%)
Immediate
Moderate <0.1 h (13%)
<5 h (11%)

Rapid
<0.5 h (20%)

Fast
<2 h (31%) Moderate Moderate
<2 h (64%) 100–1,000 ml min−1 20–100 l
(60%) (43%)
Fig. 2 | Characterization of currently approved prodrugs. a, Design goals prodrugs of this type (type 1). Some prodrugs have multiple promoieties
for approved prodrugs for cases where it was possible to assign these goals. and so data for 116 promoieties are shown. d, Methods of prodrug activation
This analysis encompasses 85 prodrugs and 95 design goals, as some prodrugs (biotransformation) for all 178 approved prodrugs in the dataset. Some
analysed have multiple goals. The figure shows the proportions based on the prodrugs have multiple methods of biotransformation and so data for
95 design goals, whereas the main text highlights the number of prodrugs from 197 biotransformations are shown. e, Half-life data for the subset of 45 approved
the 85 with a particular design goal. b, Indications for which the 178 approved prodrugs for which such data are available in DrugBank. f, Clearance data for the
prodrugs in the overall dataset (Supplementary Table 1) are currently approved. 68 approved prodrugs for which such data are available in DrugBank. g, Volume
Some prodrugs have multiple indications and so data for 186 indications of distribution at steady state (Vdss) data for the 82 approved prodrugs for which
are shown. c, Classes of chemistry used for promoieties of the 102 approved such data are available in DrugBank.

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research into the purposeful design of spatiotemporally controlled into groups (Fig. 2f,g and Supplementary Tables 6 and 7). Nearly a
release during prodrug development. In combination with other drug quarter of prodrugs for which data were available (24%, 16 prodrugs)
delivery systems such as hydrogels and nanoparticles, release can be exhibit low clearance (<100 ml min−1), more than half (60%, 41 prod-
further modulated by encapsulating prodrugs61,62. rugs) show moderate (100–1,000 ml min−1) clearance and fewer than
We also analysed the absolute clearance and volume of distribu- a quarter (16%, 31 prodrugs) exhibit high (>1,000 ml min−1) clearance.
tion at steady state (Vdss) of prodrugs by mining these properties from However, for Vdss, fewer than a quarter (20%, 16 prodrugs) show a
DrugBank15 and classified the prodrugs for which data are available relatively low Vdss (5–20 l). Additionally, only 43% (35 prodrugs) exhibit

a e
Diaminohexanamide Simvastatin Simvastatin hydroxyacid
O
NH2 Lisdexamfetamine
R= N O O
R H O
NH2 Esterase
O O
O O OH OH
Peptidase
HO HO

Amphetamine
R = NH2

b f Omeprazole Omeprazole cyclic sulfenamide

O lsopropyl carbonoperoxoate O S
O
O P O O N
H O
R R= O Tenofovir disoproxil O N N+
R fumarate pH
O S N N
N N N O
Carboxylesterase
N
NH2 g Esomeprazole Omeprazole cyclic sulfenamide
N
R = OH Tenofovir
O S
O
H N
c O N pH N+ O
O S N N
O P Phenol lsopropyl L-alanine N O
R1
R2
O
R1 = R2 =
N N N
O Tenofovir h 2,500 i 1,500
H alafenamide Vyvanse Viread
O 2,000 Adderall Vemlidy
Sales (millions)

Sales (millions)

N Ritalin
NH2 1,000
N 1,500

Carboxylesterase Amidase 1,000

500
500
R1 = OH R2 = OH Tenofovir
0 0
2007 2009 2011 2013 2015 2017 2014 2016 2018 2020 2022
O Year
d Year

OH Levodopa
j 4,000 Truvada k 15,000
NH2 Viread
HO Descovy Vemlidy
Sales (millions)

Sales (millions)

3,000 Truvada
HO 10000
Descovy
DOPA decarboxylase 2,000 Biktarvy

5,000
NH2 Dopamine 1,000

HO 0 0
2014 2016 2018 2020 2022 2014 2016 2018 2020 2022
HO Year Year

Fig. 3 | Examples of prodrugs that have had a substantial market impact. hydrolysis or rearrangements (simvastatin, omeprazole and esomeprazole), the
Chemical structures and biotransformations. a, Lisdexamfetamine. b, Tenofovir prodrugs and APIs are shown explicitly. h, Sales of Vyvanse, Adderall and Ritalin
disoproxil fumarate. c, Tenofovir alafenamide. d, Levodopa. e, Simvastatin. from 2008 to 2017. i, Sales of Viread and Vemlidy from 2015 to 2022. j, Sales of
f, Omeprazole. g, Esomeprazole. Prodrug names and promoieties are highlighted Truvada and Descovy from 2015 to 2022. k, Sales of Viread, Vemlidy, Truvada,
in gold, API names are highlighted in light blue and enzymes responsible for Descovy and Biktarvy from 2015 to 2022.
biotransformation are highlighted in dark blue. For prodrugs that undergo ring

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Review article

more moderate Vdss (20–100 l) whereas more than a quarter (38%, such as phosphorylation or esterification with an ethyl chain (Fig. 4d),
31 prodrugs) exhibit a high Vdss (>100 l). As such, prodrugs tend to have and could potentially inform future promoiety selection and design.
a higher Vdss, which may be indicative of the targeted nature of some Nevertheless, as the chemical modifications are often small and
prodrugs, leading to more rapid tissue accumulation. chemically simple, many of the currently approved prodrugs exhibit
For the few prodrugs for which we were able to obtain clear- physicochemical properties similar to those of their APIs. However,
ance (eight in total) and Vdss (seven in total) data for both the par- when comparing property differences between approved prodrugs
ent API and the prodrug (Supplementary Table 8), there were no and their APIs compared with investigational prodrugs and their APIs,
clear general trends, with an even split of prodrugs with increased or we noted that the investigational prodrugs differed more strongly from
decreased values compared with their APIs for both clearance (four their APIs (Supplementary Fig. 1a) and are often more complex (Fig. 4c).
increase, four decrease) and Vdss (three increase, three decrease, one For example, investigational promoieties are often larger (Supplemen-
no change). However, the original purpose of the prodrug design did tary Table 10) with their molecular weights ranging from 15 to 640 Da,
appear to correlate with effects on these properties. For example, with an average of 197 Da compared with the average approved pro-
fospropofol disodium and fosnetupitant are phosphate prodrugs moiety weight of 84 Da. Interestingly, these trends towards complex-
designed to improve solubility that subsequently resulted in more ity were independent of the purpose for which these investigational
than an order of magnitude decrease in both clearance rates and Vdss prodrugs were designed, with permeability- and solubility-enhancing
compared with their corresponding APIs. For fospropofol, slower promoieties showing similar increases to promoieties for active target-
pharmacokinetics allow for better predictability of desired clinical ing (Fig. 4c,e). Together, these comparisons highlight how prodrug
effects compared with propofol, but any inadvertent deep sedations development is evolving from reliance on only simple functionaliza-
are extended owing to its more gradual elimination63. On the other tions to improve bioavailability towards inclusion of more complex
hand, some prodrugs designed to increase permeability to allow for chemistries to change the pharmacokinetics and functionality of APIs
oral delivery, such as the tenofovir prodrugs tenofovir disoproxil more dramatically for design goals such as targeted delivery22,64,65,
and tenofovir alafenamide, exhibit higher clearance rates and Vdss reduced toxicity22,42,65 and sustained release42,66,67 (Box 2).
than their APIs.
Opportunities and challenges for prodrug
Physicochemical properties of prodrugs development
As promoieties are introduced to improve the ADMET properties of an Although currently approved prodrugs use only a small fraction of avail-
API, many of which are closely linked to the physicochemical properties able chemical fragment space as promoieties (Supplementary Table 9),
of the molecule, we set out to quantify the magnitude of changes in these our analysis suggests a trend towards the creation of more complex
properties between the APIs and the corresponding prodrugs in the prodrugs (Box 2). This shift in complexity of prodrug design constitutes
context of their design goals. As expected, for the subset of 30 prod- an opportunity to mitigate even the most challenging ADMET proper-
rugs designed to increase cellular permeability, there is a statistically ties but poses a challenge for prodrug designers to efficiently navigate
significant (P < 0.05, Wilcoxon signed-rank test) increase in lipophi- this larger design space. Developments in parallel chemical synthesis
licity compared with their APIs, whereas the subset of 13 prodrugs coupled with rapid growth of available building blocks have led to an
designed to increase solubility exhibit a decrease (Fig. 4a). Interestingly, explosion in the purchasable chemical space, with vendors now offer-
in both groups the prodrugs differed in both absolute and relative ing billions of on-demand molecules68. Expansive fragment libraries
lipophilicity — showing that successful prodrug design even for prop- provide vast arrays of promising and available chemical structures for
erties that are often considered relatively simple requires careful type 1 prodrug development, and lab automation could potentially
­consideration of context. accelerate the rapid prototyping and testing of innovative prodrug
We next analysed promoieties for the 102 approved type 1 prod- structures. The expertise of medicinal chemists will be required to drive
rugs in our dataset and how their addition changes the properties of this discovery process and guide its optimization. Furthermore, with
these prodrugs compared with their APIs. Not including co-drugs, increasing amounts of data on prodrug solutions and their optimization
approved promoiety molecular weights vary from 15 to 280 Da, with campaigns, computer-assisted prodrug design can have an increasing
an average of 84 Da (Supplementary Table 9). Promoiety size is not role in this process in the future. For example, the years of research into
correlated to API size (r2 = 0.0048) but instead is more directly related pharmacodynamics, pharmacokinetics, human biology and cellular
to the purpose of the promoiety (for example, the largest promoie- transport can be leveraged for designer intracellular and tissue- or
ties are often large hydrocarbon chains or fatty acids used to increase disease-specific prodrug formulations. Beyond implementing prodrug
permeability). approaches to improve on approved drugs with ADMET liabilities as
For properties linked to the size of the molecules, including molec- illustrated by various examples discussed above, early consideration
ular weight, number of atoms and solvent-accessible surface area, we of the potential for prodrug strategies could potentially expedite the
observed significant increases for all type 1 prodrugs irrespective of clinical translation of novel chemical entities.
whether they were designed to enhance permeability, enhance solu- As an additional dimension of complexity, it is becoming clearer
bility or enable targeting (Fig. 4b), as expected. More interesting are that pharmacogenomic differences in patients can lead to patient-
the changes in properties that differ between prodrugs designed for to-patient variability in prodrug release. Examples include modu­
different purposes. For example, permeability-enhancing prodrugs lation of the half-life of codeine by cytochrome P450 activity45,
exhibit significant decreases in the number of hydrogen bond accep- the influence of flavin-containing monooxygenase 3 enzymes on the
tors, heteroatoms and the relative number of heavy atoms, whereas metabolism rates of sulindac69, the dependency of the bioconversion
solubility-enhancing prodrugs exhibit significant increases in these of prednisone on liver activity48 and the regulation of the activity of
three properties and in the number of rotatable bonds. These proper- tamoxifen by cytochrome P450 2D6 (ref. 70). Such inter-individual
ties track the types of promoiety added for these distinct purposes, variations might hinder the deployment of prodrugs, especially

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Review article

a b Solubility Permeability Targeting

SASA
Solubility enhancing

SMR
MW
Atoms
SlogP
Heteroatoms
HBA
HBD
sp3
TPSA
Permeability enhancing

Amide bonds
Rotatable bonds
Heavy atoms
Stereocentres

c Solubility Permeability Targeting

SASA
SMR ns
P < 0.05
MW P < 0.001
Stereocentres P < 0.0001

–4 –2 0 2 4 6 8
SlogP

d Increased solubility Increased permeability Targeted delivery

H2N
N
O HO
OH N
HO O N
P
HO N O O
O H
HO O N
N O P
H N HO
H O
O O O O
O O
OH
Prednisolone phosphate Enalapril Remdesivir

e Increased solubility Increased permeability Targeted delivery

Cl
NH2

N NH
H2N
N
O O S
S
N N N O
O
O
F F
O O P
O O HO
O NH OH O O
O
O
TXY541 N Talampicillin MB07133 N
O

Fig. 4 | Physicochemical properties of currently approved prodrugs. a, Shifts The direction of the arrow indicates the direction of change from promoieties of
in predicted lipophilicity (SlogP) for prodrugs (blue stars) designed to improve approved prodrugs to promoieties of investigational prodrugs (up, positive; down,
solubility or permeability compared with their APIs (red circles). b, Differences negative). d, Representative approved prodrugs designed to improve bioavailability
in predicted physicochemical properties between the prodrug and API for the by increasing solubility (prednisolone phosphate) or permeability (enalapril) and
subset of 102 prodrugs with added promoieties intended to enhance solubility designed for active targeting (remdesivir), with chemical structures of promoieties
(13 prodrugs), permeability (30 prodrugs) or to enable targeting (20 prodrugs). highlighted in gold. e, Representative investigational prodrugs designed to improve
The arrow colour represents the statistical significance of the change based on the bioavailability by increasing solubility (TXY541) or permeability (talampicillin)
Wilcoxon signed-rank test as shown in the key (white represents not significant (ns), and designed for targeting (MB07133), with chemical structures of promoieties
light blue represents P < 0.05, blue represents P < 0.001 and dark blue represents highlighted in gold. For further information on the analyses shown, see Box 3. HBA,
P < 0.0001). The direction of the arrow indicates direction of change (up, positive; number of hydrogen bond acceptors; HBD, number of hydrogen bond donors; MW,
down, negative). c, Difference in predicted properties between promoieties of molecular weight; SASA, solvent-accessible surface area; SMR, molar refractivity;
approved prodrugs compared with promoieties of investigational prodrugs. sp3, fraction of sp3 carbons; TPSA, topological polar surface area.

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Box 4

Prodrugs in the market

Prodrugs may outcompete other drugs for the same indication in medicines using these antivirals (Fig. 3j) and were largely due to
terms of sales owing to improved efficacy and safety profiles, and provider recommendations and the patient’s perception of improved
some have achieved blockbuster status (Supplementary Table 11). safety according to a US national cohort study that identified
For example, lisdexamfetamine (Vyvanse, Fig. 3a), which was 277 participants who switched from Truvada (a combination therapy
approved in 2007 for the treatment of attention deficit–hyperactivity containing tenofovir disoproxil fumarate) to Descovy (a combination
disorder (ADHD), showed promise owing to lower drug–drug and therapy containing tenofovir alafenamide) from 2019 to 2020101. In
drug–food interactions, extended activity time-frames that allow for 2018, Biktarvy (another combination therapy containing tenofovir
once-daily dosing and reduced abuse potential compared with other alafenamide) became a blockbuster in its very first year102 (Fig. 3k).
ADHD medications that were already approved before 200799. This Biktarvy has become the most prescribed HIV regimen across
led Vyvanse to become the best-selling ADHD medicine, overtaking most major markets and since 2020 has been one of the top-ten
other, previously approved, ADHD medications such as Adderall and best-selling drugs globally103–105. Together, these examples highlight
Ritalin (Fig. 3h). the potential of prodrugs to overcome the first-to-market advantage
Prodrugs with a strong market presence can be surpassed by by providing benefits to patients106.
novel prodrugs with even further improved absorption, distribution, Prodrugs can also exhibit sustainable market control, as
metabolism, excretion or toxicity (ADMET) profiles. For example, the epitomized by levodopa (Sinemet, Fig. 3d), which has been the
prodrug tenofovir disoproxil fumarate (Viread, Fig. 3b), approved in most prescribed Parkinson disease treatment since its approval in
2001 for the treatment of HIV, was one of the best-selling therapies 1975107. To determine current trends in prodrug prescription rates,
for HIV. In 2015, the prodrug tenofovir alafenamide (Vemlidy, we additionally analysed the contribution of prodrugs to the top
Fig. 3c), which has a lower risk of bone mineral density loss and 300 prescriptions from 2013–2020 in the USA using the ClinCalc
drug-induced kidney injury, was approved. Within 3 years after DrugStats Database. Although prodrugs make up only a small
its approval, growth in the prescriptions of tenofovir alafenamide fraction of all approved small-molecule drugs (9%) and the top
led to its sales surpassing those of tenofovir disoproxil fumarate 300 most prescribed medications (8.9%), they are more frequently
(Fig. 3i), although the availability of a generic version of tenofovir prescribed (11.4% of all prescriptions from the 300 most prescribed
disoproxil fumarate from December 2017 will probably also have medications are for prodrugs) (Supplementary Table 12). These
contributed to a decline in sales of the branded drug from this point. prescription trends are largely driven by widely prescribed prodrugs,
For example, tenofovir alafenamide prescription rates matched those such as the anti-cholesteraemia prodrug simvastatin (Zocor, Fig. 3e)
for tenofovir disoproxil fumarate at Duke University Hospital by early and the proton pump inhibitor prodrugs omeprazole (Prilosec,
2018100. These sales trends were similar but delayed for combination Fig. 3f) and esomeprazole (Nexium, Fig. 3g).

for drugs with a narrow therapeutic window. Similarly, many recent approved drug compounds, some have been heavily prescribed (Box 4
attempts at tumour targeting prodrug approaches using hypoxic32 and Supplementary Table 12) and have found particular utility for
and reactive oxygen species33 activation have been significantly hin- diseases such as cancer and infections (Fig. 2b and Supplementary
dered by tumour-to-tumour variability, which can prevent a patient Table 1). With the increasing chemical complexity used during drug
from responding to treatment. However, we believe that these for- design, it is likely that the application of prodrug strategies will become
midable challenges highlight an opportunity for personalized prod- more common.
rug design. For example, an arsenal of targeted prodrugs that are Our analysis found that specific functional groups are commonly
enzymatically activated by various cancer-related enzymes could used for the optimization of physicochemical properties, such as
be coupled with tumour biomarker screening; this would enable phosphate groups to improve solubility and aliphatic chains to improve
clinicians to prescribe prodrugs preferentially activated within can- permeability (Fig. 1b,c). These simple moieties are widely implemented
cerous tissues of a specific patient to reduce the off-target effects owing to their proven ability to overcome simple ADMET liabilities, as
of cytotoxic APIs — similar to precise prescription of personalized well as a good understanding of their biological effects and synthesis.
chemotherapeutics based on tumour biopsies or cellular therapies71. Typically, these chemical groups are cleaved by ubiquitous hydrolases
With consideration of genetic backgrounds, known allergies and (Fig. 2d) that allow for rapid bioactivation (Fig. 2e) with low risk of
external factors, including diet, chemical exposures and medication genetic influence or enzyme saturation, but they have limited utility for
regimens, prodrugs may also be designed for personalized medicine targeted therapeutic development or personalized medicine. However,
applications to ensure minimal adverse effects and improve efficacy years of learning from both serendipity (Box 1) and evaluation of novel
and patient quality of life. strategies (Box 2) have provided a wealth of knowledge to support
medicinal chemists pursuing these difficult design goals.
Conclusion Currently, most approved prodrugs improve solubility or perme-
The analysis of approved prodrugs highlights the range of possible ability (Fig. 2a and Supplementary Table 2), but investigational prod-
approaches that have been successfully used to circumvent liabili- rugs have been developed that increasingly address more complex
ties of APIs. Although prodrugs only make up a small fraction of all ADMET challenges (Box 2). Through rational design to encapsulate

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Review article

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