Potential Medication Options for COVID-19 - LECOM

Potential Medication Options for COVID-19

Thursday, 04 June 2020

Christey Wilkinson, PharmD; Abbey Krysiak, PharmD, BCPP; Brandon Sing, PharmD, MS

The COVID-19 pandemic has led to a surge in drug trials. Numerous pharmaceutical companies are working hard to find a cure or create a vaccination to prevent this deadly virus. Many potential treatment options have made the headlines including remdesivir, hydroxychloroquine, and the combination antiretroviral medication lopinavir/ritonavir.

One of the potential treatment options that may be the most promising so far is remdesivir.1 It is a direct-acting antiretroviral that was granted emergency use authorization (EUA) on May 1, 2020 by the U.S. Food and Drug Administration (FDA).1 This authorization allows adults and children to be treated with remdesivir if they are hospitalized with severe COVID-19 disease. Severe disease is defined as “SpO2 ≤94% on ambient air, requiring supplemental oxygen, mechanical ventilation, or extracorporeal membrane oxygenation” per the National Institutes of Health (NIH).2 Preliminary trials show that a 10-day course of remdesivir may lead to a shorter median time to recovery.3 Trials are still in progress at this time. Dosing is provided in Table 1.

Another potential treatment option under investigation is hydroxychloroquine.1 This anti-malarial agent has historically been used to treat malaria, systemic lupus erythematosus (SLE), and rheumatoid arthritis.

The FDA issued an EUA for hydroxychloroquine in April, allowing healthcare providers to request the medication from the Strategic National Stockpile for adults and adolescents who weigh 50 kg or more and are hospitalized with COVID-19.1 These patients are either not able to participate in a clinical trial or there is not one that is available. The data for hydroxychloroquine use is variable and for that reason the NIH and the Infectious Diseases Society of America (IDSA) both recommend to only use hydroxychloroquine if it is in the setting of a clinical trial.2,4 This recommendation also applies to the addition of azithromycin to hydroxychloroquine, stating that the risk for adverse effects with the combination, such as QT prolongation, outweighs the potential benefit.2,4 Dosing is provided in Table 1.

Use of antiretroviral medications indicated for human immunodeficiency virus (HIV) have also been readily studied in clinical trials for COVID-19 treatment. The most common studied is the combination protease inhibitor, lopinavir/ritonavir.1 Similar to hydroxychloroquine, the NIH and IDSA recommend against using any protease inhibitors, including lopinavir/ritonavir, unless the patient is in a clinical trial.2,4 A study showed that time to clinical improvement was not shorter with lopinavir/ritonavir compared to standard care.5 This medication class has adverse effects that were not tolerated well in trials including nausea, diarrhea, and abdominal discomfort.4 Dosing is provided in Table 1.

Although the three medications discussed above are the most studied, there are many other potential treatment options that have been considered as well. Examples of antiviral medications studied are oseltamivir and baloxavir.1 These potential treatment options were found to have no data to support their use in COVID-19 patients.1 There are many other potential supportive treatment options available. An assessment  of all studied treatments can be found at: https://www.ashp.org/COVID-19

 

Table 1. Medication Dosing for Potential Treatment Options
Medication Dosing
Remdesivir6 Adults and children > 40 kg: 200 mg IV on day 1, then 100 mg IV on days 2-10

Children 3.5 kg to <40 kg: 5 mg/kg by IV infusion on day 1, followed by 2.5 mg/kg by IV infusion once daily on days 2-10

Hydroxychloroquine7,8,9 Various doses studied including:

400 mg twice daily on day 1, then 200 mg twice daily on days 2-5

800 mg on day 1, then 400 mg daily for 4-7 days

400 mg once or twice daily for 5-10 days

Azithromycin dose, if added: 500 mg on day 1, then 250 mg once daily for 4 days

Lopinavir/ritonavir3 Lopinavir 400 mg/ ritonavir 100 mg orally twice daily for 10-14 days

 

References:

  1. American Society of Health-System Pharmacists. Assessment of evidence for COVID-19-related treatments. https://www.ashp.org/-/media/assets/pharmacy-practice/resource-centers/Coronavirus/docs/ASHP-COVID-19-Evidence-Table.ashx. Published May 21, 2020. Updated May 21, 2020. Accessed May 24, 2020.
  2. National Institutes of Health. COVID-19 Treatment guidelines panel. Coronavirus disease 2019 (COVID-19) treatment guidelines. https://www.covid19treatmentguidelines.nih.gov/. Published May 2020. Accessed May 24, 2020.
  3. National Institutes of Health. NIH clinical trial shows remdesivir accelerates recovery from advanced COVID-19. https://www.nih.gov/news-events/ news-releases/nih-clinical-trial-shows-remdesivir-accelerates-recovery-advanced-covid-19. Published Apr 29, 2020. Accessed May 24, 2020.
  4. Infectious Diseases Society of America. IDSA guidelines on the treatment and management of patients with COVID-19. https:// idsociety.org/practice-guideline/covid-19-guideline-treatment-and-management/. Published Apr 11, 2020. Accessed May 24, 2020.
  5. Cao B, Wang Y, Wen D et al. A trial of lopinavir-ritonavir in adults hospitalized with severe COVID-19. N Engl J Med. 2020;382(19):1787-99.
  6. US Food and Drug Administration. Fact sheet for health care providers emergency use authorization (EUA) of remdesivir. https://www.fda.gov/media/137566/download. Accessed May 24,2020.
  7. Yao X, Ye F, Zhang M et al. In vitro antiviral activity and projection of optimized dosing design of hydroxychloroquine for the treatment of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Clin Infect Dis. 2020; doi:10.1093/cid/ciaa237
  8. Perinel S, Launay M, Botelho-Nevers, et al. Towards optimization of hydroxychloroquine dosing in intensive care unit COVID-19 patients. Clin Infect Dis. 2020; doi:10.1093/cid/ciaa395.
  9. Chen J, Liu D, Liu L, et al. A pilot study of hydroxychloroquine in treatment of patients with moderate COVID-19. Zhejiang Da Xue Xue Bao Yi Xue Ban. 2020;49(2):215‐
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