There is no cure for the coronavirus. But there are drugs that can help with symptoms at home and ones that, in a hospital environment, may – or may not – improve the chances of a person who is seriously ill.
The state-of-the-art of COVID-19 pharmacology seems to change by the day.
Medical experts around the world are sharing as much information as quickly as they can as researchers race to find therapies to quell the coronavirus pandemic.
“It’s kind of nuts. In the last four months, there have been more than 2,000 publications for COVID-19-related therapies, descriptions of the disease – it’s just an insane amount of data to keep up with, and unfortunately none of it is of the highest quality,” said Matthew Miller, who has a doctorate in pharmacy and is a clinical specialist in infectious diseases at UCHealth University of Colorado Hospital and the University of Colorado Skaggs School of Pharmacy, both at the Anschutz Medical Campus.
Miller shared with UCHealth Today his state of knowledge as of the afternoon of March 23. He considered drugs for the specific coronavirus, which causes COVID-19, SARS-CoV-2, on two fronts: medications that a person who has contracted the virus can take at home to ease symptoms, and ones that hospital providers are using for those admitted for serious cases.
Particularly important with hospital-supplied drugs is that prescription hydroxychloroquine/chloroquine – decades-old antimalarials that have proven effective with autoimmune diseases such as rheumatoid arthritis and lupus – may or may not help COVID-19 patients. President Trump’s statements to the contrary, there’s just not enough evidence yet. And there’s zero evidence at this point that these drugs provide a prophylactic shield against contracting the coronavirus, a misapprehension that cost an Arizona man his life. More on this under “At the Hospital” below.
Try this at home
Roughly 80% of coronavirus cases do not require hospitalization. Testing for COVID-19 is being reserved mostly for patients with symptoms serious enough to merit hospitalization (typically, serious breathing problems or heart issues). Most cases, identified via a test or not, can be cared for just as well at home, test or not. You treat the symptoms as you would that of a bad flu – adding a major focus on hand hygiene and household disinfection to prevent the coronavirus from spreading to others in the household, Miller says.
- Hydrate with water or other clear fluids (the caffeine in coffee, cola, and many teas is a mild diuretic, diminishing the hydrating effect). “People with high fevers can lose more fluids,” Miller said.
- Pain relievers and fever reducers – including NSAIDs such as ibuprofen – should be fine. A March 11 article in the British medical journal The Lancet raised temporary alarm about the hypothetical possibility of ibuprofen/NSAIDs being a hindrance to COVID-19 treatment. That has since been contradicted by World Health Organization and the Food and Drug Administration. With the exception of patients with conditions that would preclude ibuprofen and other NSAIDs anyway (kidney conditions, high blood pressure, and others), “There’s no specific reason to avoid NSAIDs,” Miller said.
- Lozenges, cough drops, and over-the-counter medicines such as dextromethorphan (Robitussin and others) and guaifenesin (Mucinex and others) can help with the cough that often comes with COVID-19. Dextromethorphan could be the choice for the dry cough that COVID-19 is best known for; guaifenesin that for wetter coughs. Some formulations include both. Again, the idea is to improve symptoms – neither will address the underlying virus.
- Sinus congestion and runny nose isn’t a typical symptom, but over-the-counter decongestants can help here.
- Zinc lozenges may help (or may not) reduce viral replication in the nose and throat, but their effectiveness with SARS-CoV-2 remains unproven.
- Those taking ACE inhibitors or ARBs for cardiovascular issues should continue to do so, Miller says, citing a March 17 American College of Cardiology statement that reads, in part, “The continued highest standard of care for cardiovascular disease patients diagnosed with COVID-19 is top priority, but there are no experimental or clinical data demonstrating beneficial or adverse outcomes among COVID-19 patients using ACE-I or ARB medications.” The statement does add the caveat that the recommendation could change with a better understanding of COVID-19 on these patients.
Miller says that a community pharmacist can help recommend specific products for specific patients. He urges those with symptoms to send a proxy for onsite inquiries, though. People who have any symptoms of illness – such as a fever, cough or shortness of breath, should stay home and isolate themselves so they don’t infect anyone else since COVID-19 is proving to be extremely contagious.
At the hospital
To repeat: there is no cure for the coronavirus. Further, at present, there are no therapies proven with much more than anecdotal evidence that they improve the lot of patients with serious-to-critical cases of COVID-19. But in addition to supplemental oxygen and, in critical cases, mechanical ventilation, doctors at UCHealth and around the world are trying a handful of therapies with the hope that, despite a dearth of scientific evidence, something works.
Hydroxychloroquine/chloroquine is front and center at the moment. As noted, this is a decades-old drug that was used to prevent and treat malaria. Malaria has largely developed resistance to the chloroquine, but it’s effective with rheumatoid autoimmune diseases.
Hydroxychloroquine was, as of March 19, the first-line treatment for patients on ventilation or expected to need ventilation within 48 hours at UCHealth hospitals. But consider that the main reasons for this were lab-based studies showing ability to inhibit SARS-CoV-2 at low concentrations, unpublished reports from China describing improved patient outcomes with chloroquine, and a single clinical study that paired hydroxychloroquine (trade name Plaquenil) with the antibiotic azithromycin (that of the Z-Pak). The study involved a couple dozen patients at a single hospital in Marseilles, France.
Remember that typically, FDA-approved drugs involve three phases of trials – to determine safety, dosage and effectiveness across hundreds or thousands of patients with varying degrees of whatever disease or condition it is that the drug in question might treat. Besides knowing that chloroquine is quite safe and doesn’t interact with many drugs – such knowledge a function of the drug having been in formularies for decades – none of that is yet understood with respect to COVID-19. It’s not even certain that, given the study’s design, whether it really worked for that small number of patients on the Mediterranean coast.
This French study was posted in draft form on Tuesday, March 17. By Thursday, March 19, UCHealth had listed it as its first-line treatment for serious and critical patients. There can hardly be a clearer indication of the state of pharmaceutical affairs with respect to COVID-19 treatment.
Now, this could all change – perhaps larger studies currently underway will establish better evidence for chloroquine and hydroxychloroquine’s effectiveness with respect to COVID-19, and quickly. But for the time being, unless you’re a medical provider in a hospital, Miller emphasizes the importance of leaving chloroquine and hydroxychloroquine be if for no other reason that others need it for rheumatic conditions.
“Don’t go out and try to get a prescription and deplete the supply of this drug unnecessarily, because it’s taking away from patients who have a legitimate indication and those who may benefit during this current pandemic,” he said.
Another good reason to avoid experimenting with chloroquine and hydroxychloroquine: you can poison yourself, which is what happened to the man in Arizona. Dr. Christopher Hoyte, a UCHealth and University of Colorado School of Medicine Emergency Medicine physician and toxicologist, is also medical director at the Rocky Mountain Poison & Drug Safety. An overdose of chloroquine or hydroxychloroquine, Hoyte says, can “do a lot of things to the human body,” none of them good. Among them: stark drops in blood pressure; severe nausea, vomiting, and diarrhea; irregular heart rhythms; and plummeting potassium levels, which ushers in its own problems.
“People should not be taking this on their own,” Hoyte said. “They have to have a consultation with a physician.”
To underscore that point, hydroxychloroquine was added to the American Society of Health-System Pharmacists Drug Shortages List on Thursday, March 19, followed by chloroquine the next day.
Antivirals lopinavir and ritonavir, in combination with ribavirin (an old hepatitis-C drug), are UCHealth’s second-line therapy is a combination of the antivirals. Unlike hydroxychloroquine, these preliminary studies as to its effectiveness with COVID-19 are not terribly promising (New England Journal of Medicine report here; commentary here).
Nitazoxanide, the third-line treatment, is generally used to treat diarrhea caused by cryptosporidium and giardia. It showed some promise in treating MERS, a SARS-CoV-19 cousin, and was effective in a laboratory model using SARS-CoV-2. There is presently no published clinical evidence of its use for treating patients suffering from COVID-19, though.
Remdesivir, from Gilead Sciences, is another treatment used with serious-to-critical COVID-19 patients. This is an antiviral that lab studies have shown to interfere with SARS-CoV-2 viral replication by gumming up the works of the pathogen’s RNA synthesis. Remdesivir has been around for years, and was considered as an Ebola treatment before other drugs took the fore. It hasn’t been approved by the FDA for any treatments. On Sunday, March 22, Gilead suspended its “compassionate use” program, which had sent remdesivir to hundreds of patients in Europe, Japan and the United States – including to patients at UCHealth hospitals. The company is working with the FDA to quickly expand access to the drug through a different program. In the meantime, several major studies on the drug’s effectiveness with COVID-19 have launched. (NPR’s story here has a wealth of information and links to several remdesivir studies.)
Scientists aren’t stopping with remdesivir. Often, Miller says, the first stop is to take a closer look at drugs already approved or in development but perhaps stalled after disappointing against a different virus. Such therapies, if effective against COVID-19, could be moved to widespread use more quickly than a brand-new formulation – though new-drug development is happening, too, he says.
“There’s a lot of research being done to identify novel compounds that are directly active against the virus,” Miller said.
That’s the rundown on the prospects for coronavirus drugs now. They will probably have a shelf life shorter than a carton of raspberries someone forgot to refrigerate – a good thing, too, as the antiquation of information related to therapies for COVID-19 will reflect scientific progress that saves lives.