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

Infectious Diseases and Antimicrobial Stewardship Pharmacists, Stanford Antimicrobial Safety and Sustainability Program, Stanford Healthcare, Palo Alto, CA

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

The 2019 novel coronavirus (SARS-CoV-2) is the causative pathogen of 2019 coronavirus disease (COVID-19), 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 hundreds of thousands of reported cases in the United States.2 The global outbreak of SARS-CoV-2 has spawned interest in potential treatment options, particularly for those with more severe illness. This article provides a 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 produce no benefit vs. comparators. Despite this, remdesivir has demonstrated a broad spectrum of activity against various coronaviruses, including SARS-CoV, MERS-CoV, and SARS-CoV-2 in preclinical 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. The patient presented with mild symptoms. However, after the first week of largely supportive care, the patient progressed 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 of remdesivir (NCT04252664, NCT04257656, and NCT04280705) are in progress to determine its efficacy against 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 treatment for COVID-19 and has exhibited 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 exhibited activity against SARS-CoV-2. It is unclear whether inhibitors of HIV protease (in the aspartic protease family) can effectively inhibit that of SARS-CoV-2 (in the cysteine protease family).15 Use for COVID-19 is based largely on trials in severe acute respiratory syndrome (SARS), suggesting lopinavir was associated with improved clinical outcomes and mortality.16,17 However, as opposed to remdesivir and chloroquine, 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 produced negative viral tests 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

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