Drugs that contain phosphates (and
phosphonates or phosphinates)
have intrinsic absorption issues and are therefore often delivered
in prodrug forms to promote their uptake. Effective prodrug forms
distribute their payload to the site of the intended target and release
it efficiently with minimal byproduct toxicity. The ability to balance
unwanted payload release during transit with desired release at the
site of action is critical to prodrug efficacy. Despite decades of
research on prodrug forms, choosing the ideal prodrug form remains
a challenge which is often solved empirically. The recent emergency
use authorization of the antiviral remdesivir for COVID-19 exemplifies
a new approach for delivery of phosphate prodrugs by parenteral dosing,
which minimizes payload release during transit and maximizes tissue
payload distribution. This review focuses on the role of metabolic
activation in efficacy during oral and parenteral dosing of phosphate,
phosphonate, and phosphinate prodrugs. Through examining prior structure–activity
studies on prodrug forms and the choices that led to development of
remdesivir and other clinical drugs and drug candidates, a better
understanding of their ability to distribute to the planned site of
action, such as the liver, plasma, PBMCs, or peripheral tissues, can
be gained. The structure–activity relationships described here
will facilitate the rational design of future prodrugs.