Here are some of the medications being tested to treat the coronavirus | Dr. Nirmal Joshi
As the entire clinical and research community across the world scrambles to find specific treatment options for COVID-19, several new pieces of information are becoming available. Although high quality research trials are still limited, preliminary data is summarized below:
a. Medications that show promise (may work to improve outcomes)
Remdesivir
It is an investigational intravenous antiviral drug that works by preventing the replication (multiplication) of the virus. It has shown activity in the laboratory against SARS CoV-2 (the virus causing COVID-19) as well as activity against many related coronaviruses.
Several research trials are underway in hospitalized, more severe cases of COVID-19 infection. In addition to enrolling their patients in clinical trials, physicians can also request the drug on a “compassionate use basis” through the manufacturer in selected patients. In other words, the drug is currently available from the company (Gilead) to clinicians only when requested in this manner. The treatment duration thus far has been about 10 days. However, due to short supply access to the drug may be limited.
Chloroquine/ Hydroxychloroquine
Chloroquine has been used for malaria prevention and treatment for a long time and Hydroxychloroquine (Plaquenil) is a related drug used for the treatment of rheumatoid arthritis and systemic lupus. Both drugs are known to have potency against coronaviruses, including both SARS CoV as well as SARS CoV-2. Hydroxychloroquine has higher potency specifically against SARS-CoV-2. After a Chinese study reported clinical and virologic benefit, chloroquine was added as a treatment regimen for COVID-19 patients in China, Chinese experts recommend patients diagnosed with mild to moderate disease as well as severe disease with pneumonia be treated with chloroquine.
Chloroquine and hydroxychloroquine are now recommended for treatment in several countries. Due to its more potent activity in the lab and wider availability (particularly in the United States) compared to chloroquine, hydroxychloriquine has been administered to hospitalized COVID-19 patients in many countries including the United States.
A recent French study of 42 patients with COVID-19 reported very encouraging results with hydroxychloroquine administered orally 200 mg. by mouth three times a day for 10 days. At the end of six days, almost 70 percent of patients in the hydroxychloroquine group were considered “virologically cured” compared to only 12.5 percent in the control group (not receiving the drug). In a smaller sub-group of patients in this study who received an additional antibiotic, azithromycin (commonly available as Zithromax in the United States) together with hydroxychloroquine, 100 percent of patients had no virus detected at day six.
President Trump recently communicated appropriate optimism regarding these medications. More information is needed from larger trials, but at a time when no reasonable alternatives exist, this is certainly cause for optimism. Several countries, including some clinicians in the United States, are beginning to use hydroxychloroquine for this purpose.
Tocilizumab
This is a medication that has been approved by the FDA for many years for treatment of moderate to severe Rheumatoid Arthritis. Interest in its use in critically ill patients with COVID-19 stems from the fact that such patients may have a severe response to the infection called a “Cytokine Storm:” release of numerous chemicals that are designed to protect the body but end up severely hurting the lungs. One such chemical is Interleukin-6 (IL-6); tocilizumab inhibits this chemical, theoretically minimizing lung injury.
Several studies in China, Italy, United States and other countries are now under way. As we await the results, this is a drug that some centers are using as an off-label use, since it is already available. It is used in patients who are critically sick with severe pneumonia along with other antiviral agents.
b. Medications that may not work (initial data showing no, or very limited, improvement in outcomes)
Lopinavir-Ritovanir
In a recent Chinese study involving nearly 200 patients, this antiviral drug combination, known for activity against SARS and MERS-related coronaviruses, did not show any benefit for COVID-19. Specific, selected patients may still benefit, but this is not known at the current time.
c. Data on concomitant use of commonly used medications (such as Ibuprofen and some blood pressure medications)
There were initial theoretical concerns that maybe medications such as Ibuprofen may dampen the body’s immune response to COVID-19 and therefore worsen outcomes. However, no specific data has emerged related to this concern and the WHO states that it “does not recommend against the use” of Ibuprofen. Acetaminophen (Tylenol) is certainly considered safe and is often used in such settings as a fever reducer.
Based on the mechanism of SARS Cov-2 entry into the cells, a theoretical possibility was raised that some commonly used blood pressure medications in the class of ACE-inhibitors and ARB’s (such as lisinopril and losartan), may worsen outcomes in COVID-19 infection. This hypothesis has also not borne out, and a clear statement from U.S. Heart groups, including the American Heart Association, recommends that patients with COVID-19 infection who are on these medications should indeed continue to use them.
The recent seemingly differing points of view expressed by President Trump (one of optimism) and by Dr. Anthony Fauci (cautious optimism) from the same national stage, represent the honest struggle between the immediate need to use drugs that may help treat a rapidly spreading potentially fatal disease, and the need for scientific rigor in evaluating such drugs before widespread use.