By David R. Ha, PharmD, BCIDP, and William Alegria, PharmD, BCIDP

Dr. Ha and Dr. Alegria are Infectious Diseases and Antimicrobial Stewardship Pharmacists, Stanford Antimicrobial Safety and Sustainability Program, Stanford Healthcare, Palo Alto, CA.

Dr. Ha and Dr. Alegria report no financial relationships relevant to this field of study.

The 2019 novel coronavirus (2019-nCoV) is the causative pathogen of 2019 coronavirus disease (SARS-CoV-2), an acute respiratory illness, which can range from asymptomatic carriage to life-threatening, severe disease.1 At the time of this writing, there have been more than 1,000 reported cases in the United States.2 The global outbreak of 2019-nCoV has spawned interest in potential treatment options, particularly for those with more severe illness. This article provides a brief summary of selected pharmacotherapy options proposed for COVID-19.

REMDESIVIR

Remdesivir is a prodrug of an adenosine nucleoside, which inhibits viral RNA-dependent RNA polymerase.3,4 At the time of this writing, remdesivir is not approved by the Food and Drug Administration (FDA) and is available only as an investigational drug through Gilead Sciences.5 It was studied originally for Ebola virus disease and found to have no benefit vs. comparators. Despite this, remdesivir has been found to have a broad spectrum of activity against various coronaviruses, including SARS-CoV, MERS-CoV, and 2019-nCoV in pre-clinical studies.6,7

Although reports on clinical outcomes of remdesivir therapy are limited, it was used in the first confirmed case of COVID-19 in the United States. Initially the patient presented with mild symptoms, but after the first week of largely supportive care, had progression of the disease to pneumonia requiring supplemental oxygenation, which prompted the initiation of remdesivir through compassionate use. The patient’s clinical condition subsequently improved.8

At the time of writing, multiple randomized clinical trials (NCT04252664, NCT04257656, and NCT04280705) are being conducted on remdesivir for treatment of COVID-19 in the United States. In these trials, remdesivir is given as either a five-day or 10-day course, dosed at 200 mg intravenously on day 1, and 100 mg intravenously daily thereafter. Exclusions vary between trials, but, notably, they generally exclude patients 17 years of age or younger, those with severe hepatic or renal impairment, and pregnant or breastfeeding women.9-11

CHLOROQUINE OR HYDROXYCHLOROQUINE

Chloroquine has been proposed as another pharmacotherapy consideration for COVID-19 and has been found to have in vitro activity against SARS-CoV-2.7 Its antiviral activity may be afforded by an increase in endosomal pH and interference with glycosylation of cellular receptors of SARS-CoV.12

Initial reports from more than 100 patients asserted that there was superiority of chloroquine to control treatment in inhibiting exacerbation of pneumonia, promoting negative conversion, and shortening the disease. However, this information is per a news briefing in China and, at the time of this writing, no patient data has been released yet.12 The purported treatment dosage of chloroquine is 500 mg orally twice daily for 10 days.13 There is an ongoing Phase III, placebo-controlled clinical trial (NCT04261517) of hydroxychloroquine for pneumonia caused by 2019-nCoV. In this trial, the treatment regimen is hydroxychloroquine 400 mg orally daily for five days.14

LOPINAVIR

Lopinavir is an HIV protease inhibitor that has been reported to have activity against SARS-CoV-2. It is unclear whether inhibitors of HIV protease (in the aspartic protease family) can effectively inhibit that of 2019-nCoV (in the cysteine protease family).15 Use for COVID-19 is based largely on trials in severe acute respiratory syndrome (SARS) suggesting that lopinavir was associated with improved clinical outcomes and mortality.16,17

As opposed to remdesivir and chloroquine, however, several detailed reports on clinical experience with lopinavir have been published. That said, the data are not encouraging. In a study of five patients with COVID-19 in Singapore who received lopinavir/ritonavir, the clinical benefit was equivocal, and progressive disease occurred in two patients. Of note, this study used a lower dose (200/100 mg orally twice daily) of lopinavir/ritonavir.18 In a study, four patients in Shanghai with COVID-19, two with mild disease and two with severe disease, received lopinavir/ritonavir (400/100 mg orally twice daily for six to 15 days), along with other treatments including arbidol and traditional Chinese medicine. Three patients improved, two of whom had negative viral testing at the end of data collection. The fourth patient, with severe COVID-19, showed signs of improvement at the end of data collection.19

Guidelines for 2019-nCoV pneumonia from the Zhongnan Hospital of Wuhan University Novel Coronavirus Management and Research Team provided a weak recommendation for the use of lopinavir/ritonavir based on benefits found in patients with SARS or Middle East respiratory syndrome (MERS), especially with earlier administration.20

ADJUNCTIVE THERAPIES

Adjunctive corticosteroids have not shown clinical benefit, have delayed viral RNA clearance in other coronavirus disease (SARS and MERS), and may increase the risk of side effects (e.g., psychosis, diabetes, and avascular necrosis) and increased mortality in influenza.21 Chinese guidance has suggested the use of tocilizumab for cytokine storm in patients with severe disease (e.g., acute respiratory distress syndrome) and elevated interleukin-6 levels.22 

Table 1: Selected Potential Antiviral or Adjunctive Therapies for COVID-1915,20,22

  • Remdesivir
  • Chloroquine
  • Hydroxychloroquine
  • Lopinavir/ritonavir
  • Darunavir/cobicistat
  • Ribavirin
  • Nitazoxanide
  • Nelfinavir
  • Penciclovir
  • Mefloquine
  • Oseltamivir
  • Tocilizumab
  • Interferon alfa (nebulized)
  • Intravenous immunoglobulin
  • Baricitinib

REFERENCES

  1. Centers for Disease Control and Prevention. Coronavirus Disease 2019 (COVID-19) Situation Summary. https://www.cdc.gov/coronavirus/2019-ncov/summary.html. Published March 7, 2020.
  2. Coronavirus COVID-19 (2019-nCoV) Global Cases by Johns Hopkins CSSE. https://www.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6. Accessed March 8, 2020.
  3. Siegel D, Hui HC, Doerffler E, et al. Discovery and synthesis of a phosphoramidate prodrug of a pyrrolo[2,1-f][triazin-4-amino] adenine C-nucleoside (GS-5734) for the treatment of Ebola and emerging viruses. J Med Chem 2017;60:1648-1661.
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  5. Gilead Sciences. COVID-19: Gilead Sciences update on the company’s ongoing response to COVID-19.
    https://www.gilead.com/purpose/advancing-global-health/covid-19. Accessed March 5, 2020.
  6. Mulangu S, Dodd LE, Davey RT Jr, et al. A randomized, controlled trial of Ebola virus disease therapeutics. N Engl J Med 2019;381:2293-2303.
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  17. Chu CM, Cheng VC, Hung IF, et al. Role of lopinavir/ritonavir in the treatment of SARS: Initial virological and clinical findings. Thorax 2004;59:252-256.
  18. Young BE, Ong SWX, Kalimuddin S, et al. Epidemiologic features and clinical course of patients infected with SARS-CoV-2 in Singapore. JAMA 2020 March 3. doi:10.1001/jama.2020.3204. [Epub ahead of print].
  19. Wang Z, Chen X, Lu Y, et al. Clinical characteristics and therapeutic procedure for four cases with 2019 novel coronavirus pneumonia receiving combined Chinese and Western medicine treatment. Biosci Trends 2020; doi:10.5582/bst.2020.01030. [Epub ahead of print].
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  21. Russell CD, Millar JE, Baillie JK. Clinical evidence does not support corticosteroid treatment for 2019-nCoV lung injury. Lancet 2020;395:473-475.
  22. Interpretation of new coronavirus pneumonia diagnosis and treatment scheme (trial version 7). http://www.nhc.gov.cn/yzygj/s7652m/202003/a31191442e29474b98bfed5579d5af95.shtml. Accessed March 6, 2020.