The outbreak of COVID-19 started in December 2019 in Wuhan, China and has since spread around the globe, infecting nearly 500,000 people and resulting in more than 22,000 deaths (at writing), and the numbers are continuously increasing. To date, there is no vaccine or approved treatment for COVID-19, and various trials are under study. However, considering the extent of the pandemic and challenges associated with its management, the compassionate use of various treatment therapies is a hot topic of discussion. Most treatment options are based on expert opinion or non-randomized trials. With all this evolving information, we can summarize the progress on currently proposed treatment options:
- Remdesivir: Displays potent in vitro activity against SARS-CoV-2, with a high genetic barrier to resistance in coronaviruses. Four clinical trials are currently enrolling patients in the United States. Its compassionate use is only considered for hospitalized patients with polymerase chain reaction (PCR)-confirmed SARS-CoV-2 requiring mechanical ventilation. Emerging clinical evidence and available in vitro data suggest that remdesivir can be a promising agent for the treatment of COVID-19, but we need to wait for trial results and safety data before prescribing across the board.
- Chloroquine and hydroxychloroquine: They have anti-inflammatory and immunomodulatory activities, with potent in vitro activity of chloroquine against SARS-CoV-2. No efficacy data are available for hydroxychloroquine in COVID-19, with a currently ongoing trial. Cardiovascular toxicity concerns limit the use of chloroquine. The initial experience in China and France is encouraging for the potential role of chloroquine, or alternatively hydroxychloroquine, for the management of PCR-positive COVID-19. No data to support prophylactic use as of now.
- Lopinavir/Ritonavir: Limited data suggest no advantage over standard care for SARS-CoV-2/COVID-19, either as monotherapy or in combination.
- Tocilizumab: It is a humanized monoclonal antibody that inhibits both membrane-bound and soluble interleukin-6 (IL-6) receptors and is being considered as a treatment option for severe or critical cases of COVID-19, with elevated IL-6 having hyper-inflammatory states and cytokine storming. Two ongoing trials in China are evaluating that safety and efficacy of this therapy; to date, no concerning adverse events have been reported yet.
- Nitazoxanide: It has demonstrated potent in vitro activity against SARS-CoV-2. It interferes with host regulated pathways involved in viral replication, and is, hence, considered broad spectrum. More data are clearly needed to determine its role in the management of COVID-19.
- Corticosteroids: The risks and benefits of corticosteroids need to be carefully weighed on the individual patient level. Large-dose glucocorticoid suppresses the immune system and could delay clearance of SARS-CoV-2.
- Ribavirin +/- Interferon: Based on the poor in vitro activity, absence of animal or human data and significant toxicity profile of interferon, avoid use in patients with COVID-19 at this time. Despite the limited-to-poor data, Chinese have used ribavirin 500 mg IV 2-3 times daily in combination with Lopinavir/ritonavir or inhaled INF-α on expert opinion.
- Oseltamivir and Baloxavir: Coronaviruses do not utilize neuraminidase, and thus, there is no enzyme to be inhibited by oseltamivir. This would hold true for zanamivir, peramivir, or any other neuraminidase inhibitor agents. Baloxavir has not demonstrated in vitro activity against SARS CoV-2 or other coronaviruses.
- Convalescent Plasma: It has been used previously for SARS-CoV-1, Middle East respiratory syndrome, Ebola virus disease, and H1N1 influenza with reported success. The safety and efficacy of convalescent plasma transfusion in SARS-CoV-2-infected patients has not been established yet and is still under study.