Usage of Drugs for Prevention/Treatment of Covid-19

OPINION

Different opinions have been circulating about the use of drugs especially Chloroquine and Hydroxychloroquine during the Corona virus /Covid-19 pandemic suggesting that either drug is useful for prevention or treatment.

As a result, the medicines are currently being searched for by suspecting individuals and as health professionals we shall be asked to advise on the issue regarding the evidence of these and other drugs. Below is a summary of the current evidence regarding use of drugs for treatment/prevention of corona virus/covid-19.

Drug Treatment and Prevention of Corona virus/covid-19

According to the World Health Organisation (WHO), the Centers for Disease Control and Prevention (CDC) and the US Food and Drug Administration (FDA), there are no medicines/vaccines to-date approved and proven and to be effective in the treatment of Corona virus/Covid-19.

This is despite a claim by President Donald Trump who stated while briefing the White House on 19/3/2020 that the FDA had approved the anti-malarial drug Chloroquine for treatment of Covid-19.

Chloroquine and Hydroxychloroquine are approved drugs in the USA and other countries for mainly Malaria and Arthritis respectively and the FDA and other Drug authorities are only currently evaluating the evidence linking any drugs including chloroquine/hydroxychloroquine to improvement of outcomes in patients with Covid-19.

The approval process usually includes pre-clinical laboratory and animal studies, clinical trials in humans for safety and efficacy and review of an application for approval by a competent drug authority to ensure that the drug works correctly and consistently and that its benefits outweigh its risks to the population.

This review process usually lasts up to 2 years but can be expedited to within a few months for promising therapies that treat a serious life threatening disease like covid-19.

Evidence based usage of Chloroquine/Hydroxychloroquine.

Numerous clinical studies have been conducted globally regarding the performance of Chloroquine and its variant Hydroxychloroquine since the beginning of the pandemic.

Most recently a French study and earlier studies in China have shown that these drugs may have positive effects when used in patients with covid-19. Earlier evidence suggests that Hydroxychloroquine is more potent than Chloroquine and may therefore be used in smaller doses.

Usage of these two drugs in countries where they have been tried has mainly been restricted to patients through compassionate use in hospital settings. Compassionate use of a drug refers to the use of a promising unapproved drug to treat a seriously ill patient when no other treatments are available.

This is mainly availed to patients participating in an investigational study known as a clinical trial.

It should be remembered that Chloroquine as drug has a narrow therapeutic window i.e the difference between the effective and toxic doses is small and may cause life-threatening cardiac toxicity/arythmias especially when used in high doses for long.

Whereas chloroquine may be relatively safe at lower doses and in pregnancy, inappropriate self-use may also stimulate malaria resistance. Patients/clients should therefore be adequately informed of these concerns especially potential toxicities and the uncertain efficacy.

Access to these drugs should not divert the public from optimal supportive care for any patient and preventive and control measures as prescribed by the ministry of Health that have shown favorable outcomes.

Chloroquine/Hydroxychloroquine should not be used in patients with heart problems associated with QTc prolongation, Myasthenia gravis, retinal pathology, porphyria, epilepsy and patients on certain drugs like mefloquine, cimetidine e.tc

Use of other drugs in patients with corona virus/covid-19

Other anti-viral drugs that have been tried for treating covid-19 include remdesivir (not available locally in Uganda) and an Anti-HIV drug Lopinavir/ritonavir (Aluvia/Kaletra).

Concerns have also emerged about theoretical interferences between receptors used for corona virus entry and some medicines such as anti-hypertensive drugs called Angiotensin Converting Enzyme (ACE) inhibitors,/Angiotensin receptor blockers (ARBs) as well as non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroids.

Anti-hypertensive drugs e.g ACE inhibitors/ARBs

There is so far no scientific evidence to date to support the assertion that treatment with a class of anti-hypertensive drugs like losartan could predispose individuals to a higher risk of covid-19 or adverse effects when infected with covid-19. It has therefore been the position of several scientific and professional societies that patients should continue their ACE inhibitors and ARBs unless specifically advised to stop by their medical teams.

NSAIDS/Ibuprofen

The management of Corona virus/covid-19 symptoms may involve the use of antipyretics and/or anti-inflammatory drugs for fever and mild pain. Currently there is no conclusive evidence to establish a direct association between the use of non-steroidal anti-inflammatory drugs (including ibuprofen) and increased risk of infection with corona virus/covid-19 or severity of disease. Notwithstanding, other medicines such as paracetamol should be as first choice for the management of fever in covid-19 patients.

Corticosteroids

Corticosteroids are not recommended for viral pneumonia and acute respiratory distress syndrome and should be avoided because of potential for prolonging viral replications.
 

References

Zhou F et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study. Lancet Published Online First: 11 March 2020. doi:10.1016/S0140-6736(20)30566-3

Gautret et al. Hydroxychloroquine and azithromycin as a treatment of COVID-19: results of an open-label non-randomized clinical trial. International Journal of Antimicrobial Agents. In Press.

Russell CD et al. Clinical evidence does not support corticosteroid treatment for 2019-nCoV lung injury. Lancet 2020; 395:473-475.

Sabrina VL et al. Interim clinical guidance for Patients suspected of/confirmed with covid-19 in Belgium, 19 March 2020. Published Online First: 2020. https://epedimio.wiv-isp.be/ID/Covi-19/COVID-19_Interim Guidelines_Treatment. (accessed 20 Mar2020)

International Pharmaceutical Federation. FIP Position statement between the use of non-steroidal anti-bitorsinflammatory medicines, ACE inhibitors, ARBs and corticosteroids and an icreased risk of corona virus/COVID-19 infection/disease severity.

www.fda.gov. drug development

www.medscape.com