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Mutations in the influenza M2 membrane protein which confer resistance to the antiviral drug amantadine are exclusively located within the transmembrane region of the molecule. The influence of specific amino acid substitutions on the activity of the M2 protein in influenza A virus-infected cells is assessed in this report by their effects upon haemagglutinin (HA) stability and virus growth. A number of amino acid substitutions, e.g., L26H, A30T, S31 N and G34E reduced the activity of the M2 protein of A/chicken/Germany/34 (Rostock) and caused a substantial increase in expression of the low-pH form of HA. The adverse effects of the mutations on virus replication were evident from changes selected during subsequent passage of the mutant viruses in the presence or absence of amantadine: reversion to wt, the acquisition of a second suppressor mutation in M2, or the appearance of a complementary mutation in HA which increased its pH stability. In contrast, 127T and 127S, mutations which were most readily selected following passage of the wt virus in the presence of drug, caused an increase in M2 activity. Furthermore, in double mutants the 127T mutation suppressed the attenuating effects of the A30T and S31 N mutations on M2 activity. The influence of primary structure on the consequences of particular amino acid changes was further emphasized by the contrasting effects of the G34E mutation on the activities of two closely related proteins, causing an increase in the activity of the M2 of A/chicken/Germany/27 (Weybridge) as opposed to the decrease in activity of the Rostock protein. Estimates of differences in trans Golgi pH based on the degree of conversion of HA to the low-pH form, or complementation of differences in pH stability of mutant HAs, indicate that changes in M2 may influence pH within the transport pathway by as much as 0.6. The results thus provide further evidence that M2 regulates transmembrane pH gradients in the trans Golgi. Incompatibility between particular HA and M2 components and the selection of M2 mutants with suboptimal activity stresses the essential relationship between the structures and functions of these two virus proteins.

The susceptibility of H7 influenza A viruses to the M2-mediated alteration in HA resulting from treatment with amantadine or rimantadine depends both on the pH stability of HA and the pH encountered during transport to the plasma membrane of the particular virus-infected cell. pH stabilities of a range of virus mutant HAs exhibited an inverse correlation with drug sensitivity and the proportion of low-pH HA expressed on the surface of infected cells in the absence of drug. The lowest pH encountered during transport was thus estimated from the proportion of HA expressed in its native conformation and its pH stability profile. Lower drug sensitivity and improved HA maturation of MDCK cells compared to that in CEF reflect the higher pH within the appropriate compartment of the former. Differences in apparent pH resulting from infection with two closely related virus strains, Rostock or Weybridge, e.g., approximately 6.0 and 5.4, respectively, in CEF, were abrogated by rimantadine treatment (pH approximately 5.2 in CEF) and were attributable to intrinsic properties of their respective M2 proteins. The greater activity of the Rostock M2, which was estimated to be capable of increasing vesicular pH by as much as 0.8 pH units, correlates with the lower pH stability of the HA. This emphasizes the essential relationship between the characteristics of the two virus proteins as well as the subtle role of M2 in regulating the pH of the transport pathway to protect the structural integrity of the hemagglutinin glycoprotein.

The influence of rimantadine-resistance mutations on the virulence of human H3N2 viruses in ferrets was examined. The similarities in virulence of the drug-resistant mutants with single amino acid substitutions at three different locations, 27, 30, and 31, within the M2 sequence and their corresponding sensitive wild-type isolates contrasted with differences in virulence between the three pairs of viruses. These data provide further evidence that rimantadine-resistant viruses that emerge during treatment of patients with the drug are unaltered both in their growth characteristics and virulence.

Numerous clinical studies carried out over the years have documented the efficacy of amantadine and rimantadine in the prophylaxis and treatment of influenza A infections 1–9. Although initially licensed in 1966, the use of amantadine in both the United States and the United Kingdom has been limited. Rimantadine, more widely used in the Soviet Union in recent years3 has recently been licensed in France and awaits approval for use in the United States. The reticence to use these agents has been due to several factors, not least the extreme specificity of the drugs for influenza A viruses and the lack of any benefit against influenza B infections which are responsible for a significant proportion of recurrent disease in the human population. This has not, however, precluded the successful prophylactic use of amantadine following identification of influenza A outbreaks to limit their spread within semi-closed communities such as boarding schools and nursing homes8,9. Initial concerns regarding adverse side-effects have now largely been allayed and rimantadine which causes a lower incidence of neurological reactions1,10,11 is now generally perceived as the drug of choice.