Antiviral treatment selection for SARS-CoV-2 pneumonia

ABSTRACT

Introduction

Therapy of coronavirus disease 2019 (COVID-19) involves evolving algorithms that include drugs aimed at reducing disease progression by counteracting two different, but intertwined processes: (i) the damage caused by the virus (with antivirals); (ii) the damage caused by a dysregulated host response (with immunomodulatory agents).

Areas covered

Herein, we discuss the available evidence on the efficacy and safety of antiviral agents employed over the past months for the treatment of COVID-19, and the reasons to be considered for antiviral selection.

Expert opinion

The available evidence from randomized controlled trials (RCT) currently discourages the use of lopinavir/ritonavir, hydroxychloroquine, and interferons, which did not show improved efficacy compared to standard care or placebo. Regarding remdesivir, the current body of evidence may conditionally support its use in COVID-19 patients requiring oxygen supplementation but still not requiring invasive mechanical ventilation. Finally, neutralizing monoclonal antibodies have been proven efficacious in reducing the risk of severe disease development if administered early in the course of the disease to patients at risk of progression. The results of the ongoing RCT will certainly be crucial to further improve our understanding of the optimal place in therapy of antiviral agents for COVID-19.

KEYWORDS:

• SARS-CoV-2
• COVID-19
• coronavirus
• antiviral
• remdesivir
• hydroxychloroquine
• lopinavir/ritonavir

Article highlights

• At the very beginning of the COVID-19 pandemic, the use of antiviral agents for treating SARS-CoV-2 infection was mostly based on the promising results of in vitro studies or limited, previous experiences in patients with SARS-CoV infection

• The available evidence from RCT currently discourage the use of lopinavir/ritonavir, hydroxychloroquine and interferons, which did not show improved efficacy compared to standard care or placebo.

• With regard to remdesivir, the current body of evidence may support its use in COVID-19 patients requiring oxygen supplementation but still not requiring invasive mechanical ventilation.

• Research efforts in this field should not be discontinued. Indeed, the results of ongoing RCT will certainly be crucial to further improve our understanding of the optimal place in therapy of antiviral agents for COVID-19.

Declaration of interest

Outside of the submitted work, M Bassetti has received funding for scientific advisory boards, travel and speaker honoraria from Angelini, Astellas, AstraZeneca, Basilea, Bayer, BioMérieux, Cidara, Correvio, Cubist, Menarini, Molteni, MSD, Nabriva, Paratek, Pfizer, Roche, Shionogi, Tetraphase, Thermo Fisher, and The Medicine Company. Outside of the submitted work, D R Giacobbe reports honoraria from Stepstone Pharma GmbH and unconditional grants from MSD Italia and Correvio Italia. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This work was not funded.