Fact or Fiction: Exploring Treatments for COVID-19—Opinion

^{By Douglas L. Jennings, PharmD, FACC, FAHA, FCCP, FHFSA, BCPS}

With the explosion of COVID-19 cases across the globe, myriad pharmacologic treatments have emerged as potential therapies, with varying levels of purported evidentiary benefit. In this blog we explore some of the more commonly advocated therapies, and highlight where the data may support use for SARS-CoV-2.

1. Hydroxychloroquine (and chloroquine): somewhat FACT

Two recent studies (both from France) have suggested significant reductions in viral load with hydroxychloroquine, while a third found no difference. None of the studies had a robust control group, so the positive outcomes to date must be viewed in the context of a non-randomized analysis. Still, there is a biologically plausible antiviral mechanism for these medications, and hydroxychloroquine is relatively well-tolerated, so this drug can be considered for some patients, especially those with significant respiratory symptoms or in those who are hospitalized.

2. Azithromycin: mostly fiction

The same French studies included azithromycin in combination with hydroxychloroquine and reported numerically higher rates of viral clearance with the combination versus hydroxychloroquine monotherapy. However, the numbers were very small in both analyses, and this medication lacks a biologically plausible mechanism for antiviral activity. For now, azithromycin cannot be routinely recommended unless there is suspicion for a superimposed community-acquired pneumonia.

3. Melatonin: fiction

Melatonin has well-described anti-inflammatory and anti-oxidant properties, which may be beneficial in combating the cytokine release syndrome that can afflict patients with COVID-19. While these theoretical salutary effects—when combined with an excellent safety profile—may attract attention for melatonin, there is simply no evidence to support the use of this agent for SARS-CoV-2.   

4. Zinc: fiction

Zinc has long been purported to be effective for fighting rhinoviruses, which has tempted some to advocate for its use to ward off COVID-19. Unfortunately there is simply no data to support any efficacy for zinc against coronaviruses, and as such this therapy cannot be endorsed at this time.

5. ACE inhibitors and angiotensin receptor blockers (ARB): mostly fiction

The impact of COVID-19 on the cardiovascular system was explored in a recent blog of mine, which also addressed the issue of ACE inhibitors and ARBs. While there are biologically plausible mechanisms for both benefit and harm with these drugs classes, the data are simply insufficient to make any substantive claims. Hence all major professional cardiovascular medical societies recommend that these medications should neither be stopped nor started for solely COVID-related reasons.

6. Nitazoxanide: fiction

Nitazoxanide is an antiprotozoal agent that is currently used for various forms of infectious diarrhea caused by giardia or cryptosporidium. While some very limited in vitro data suggest antiviral properties against SARS-CoV-2, there are no clinical data evaluating this agent, and therefore it cannot be recommended at this time.

Dr Jennings is currently an Associate Professor of Pharmacy at Long Island University and the clinical pharmacist for the Heart Transplant and LVAD teams at NewYork- Presbyterian Hospital Columbia University Irving Medical Center.  He is an active researcher in his field, and he has published over 120 peer-reviewed abstracts and manuscripts, primarily focusing on the pharmacotherapy of patients under mechanical circulatory support. As a recognized expert in this area, he has been invited to speak at numerous national and international venues, including meetings in France, Saudia Arabia, India. Finally, Dr. Jennings has been active in professional organizations throughout his career. He is a fellow of the American College of Clinical Pharmacy, the American College of Cardiology, the Heart Failure Society of America, and the American Heart Association. 

Acknowledgements:

The author would like to kindly thank Madison Knox, MSN, for her copy-editing expertise.