COVID-19 medical therapy: Difference between revisions

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* Pilot study in [[COVID19]] showed symptoms improvement including [[fever]], [[cough]], [[tightness of breath]],[[chest pain]] <ref name="pmid32253318">{{cite journal |vauthors=Duan K, Liu B, Li C, Zhang H, Yu T, Qu J, Zhou M, Chen L, Meng S, Hu Y, Peng C, Yuan M, Huang J, Wang Z, Yu J, Gao X, Wang D, Yu X, Li L, Zhang J, Wu X, Li B, Xu Y, Chen W, Peng Y, Hu Y, Lin L, Liu X, Huang S, Zhou Z, Zhang L, Wang Y, Zhang Z, Deng K, Xia Z, Gong Q, Zhang W, Zheng X, Liu Y, Yang H, Zhou D, Yu D, Hou J, Shi Z, Chen S, Chen Z, Zhang X, Yang X |title=Effectiveness of convalescent plasma therapy in severe COVID-19 patients |journal=Proc. Natl. Acad. Sci. U.S.A. |volume=117 |issue=17 |pages=9490–9496 |date=April 2020 |pmid=32253318 |pmc=7196837 |doi=10.1073/pnas.2004168117 |url=}}</ref>'''PMID: 32253318'''
* Pilot study in [[COVID19]] showed symptoms improvement including [[fever]], [[cough]], [[tightness of breath]],[[chest pain]] <ref name="pmid32253318">{{cite journal |vauthors=Duan K, Liu B, Li C, Zhang H, Yu T, Qu J, Zhou M, Chen L, Meng S, Hu Y, Peng C, Yuan M, Huang J, Wang Z, Yu J, Gao X, Wang D, Yu X, Li L, Zhang J, Wu X, Li B, Xu Y, Chen W, Peng Y, Hu Y, Lin L, Liu X, Huang S, Zhou Z, Zhang L, Wang Y, Zhang Z, Deng K, Xia Z, Gong Q, Zhang W, Zheng X, Liu Y, Yang H, Zhou D, Yu D, Hou J, Shi Z, Chen S, Chen Z, Zhang X, Yang X |title=Effectiveness of convalescent plasma therapy in severe COVID-19 patients |journal=Proc. Natl. Acad. Sci. U.S.A. |volume=117 |issue=17 |pages=9490–9496 |date=April 2020 |pmid=32253318 |pmc=7196837 |doi=10.1073/pnas.2004168117 |url=}}</ref>'''PMID: 32253318'''


* Serious side effects were not reported. '''PMID: 32253318'''
* Serious side effects were not reported.<ref name="pmid32253318">{{cite journal |vauthors=Duan K, Liu B, Li C, Zhang H, Yu T, Qu J, Zhou M, Chen L, Meng S, Hu Y, Peng C, Yuan M, Huang J, Wang Z, Yu J, Gao X, Wang D, Yu X, Li L, Zhang J, Wu X, Li B, Xu Y, Chen W, Peng Y, Hu Y, Lin L, Liu X, Huang S, Zhou Z, Zhang L, Wang Y, Zhang Z, Deng K, Xia Z, Gong Q, Zhang W, Zheng X, Liu Y, Yang H, Zhou D, Yu D, Hou J, Shi Z, Chen S, Chen Z, Zhang X, Yang X |title=Effectiveness of convalescent plasma therapy in severe COVID-19 patients |journal=Proc. Natl. Acad. Sci. U.S.A. |volume=117 |issue=17 |pages=9490–9496 |date=April 2020 |pmid=32253318 |pmc=7196837 |doi=10.1073/pnas.2004168117 |url=}}</ref> '''PMID: 32253318'''


=== Anticoagulation ===
=== Anticoagulation ===

Revision as of 15:30, 11 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Syed Hassan A. Kazmi BSc, MD [2]Sabawoon Mirwais, M.B.B.S, M.D.[3]

Overview

COVID-19 is an inflammatory hypercytokinemia disease. The aim of therapy is the inhibition of the replication of the virus and controlling the inflammatory process.

antiviral agents

Remdesivir


  1. Significant reduction in viral load in bronchoaleolar lavage.
  2. Inhibition of SARS-COV replication in nasal and bronchial airway epithelial cells.
  • Indicated only for in-hospital setting for adults and children that:
  • Laboratory confirmed COVID-19 disease
  • Severe COVID-19 disease.

Severe COVID-19 disease defined as:

  1. SO2ᐸ%94 on room air,
  2. Need to supplement oxygen,
  3. Mechanical ventilation,
  4. extracorporeal membrane oxygenation (ECMO)
  • Contraindications:

Severe renal impairment (eGFR <30 ml/min)

Severe hepatic dysfunction or alanin transferase (ALT)ᐳ 5-times upper limit


Hydroxychloroquine and Chloroquine

  • Mechanism of action: inhibit entry of SARS-COV-2 and prevent fusion of viral spike protein to ACE2 receptor.
  • May more effective in the early stage of infection, before COVID-19 lessens ACE2 expression and activity.
  • Reducing cytokine storm by anti -inflammatory effect on TH-17 related cytokines(IL-6,IL17,IL22)[3]
  • Recovery of lymphopnea due to anti-inflamatory effect
  • The US FDA has issued emergency authorization for the use of chloroquine and hydroxychloroquine for the treatment of COVID-19
  • Intracellular uptake, was enhanced with combination with Zinc[4]
  • High doses of chloroquine 600 mg twice daily for 10 days or a total dose of 12 g may be related to cardiac risks.

Lopinavir-Ritonavir or kalerta

  • Inhibit the activity of the HIV-1 protease.
  • There is no benefit in the administration of lopinavir-ritonavir in COVID-19
  • In an open-label randomized controlled trial comparison between patients with COVID-19 received either lopinavir-ritonavir 400/100 mg, orally twice daily plus standard of care or standard care alone showed no benefit of administration of lopinavir-ritonavir[5]
  • Only one study in Korea in the initial phase of outbreak accepted using this combination [6]PMID: 32056407
  • Side effects: Diarrhea, nausea, asthenia

Umifenovir (Arbidol)

  • Mechanism of action: inhibit the fusion virus to the cell membrane and hydrogen binding to membrance phospholipids.[8]PMID: 20527735
  • In a retrospective cohort study showed improvement in chest ct scan of COVID-19 patients received a combination of umifenovir and lopinavir-ritonavir.[9]PMID: 32171872
  • In prospective study, umifenovir had inferior outcomes in clinical recovery rate and relief of fever and cough , compared with favipiravir[10]
https://doi.org/10.1101/2020.03.17.20037432
  • Safety and efficacy in COVID-19 is under investigation in china with two randomized open trials.

Favipiravir (Avigan)

  • It has been used in 2014 in Japan for the treatment of influenza resistant to neuraminidase inhibitors and has been used in the treatment of infectious diseases caused by RNA viruses such as influenza, Ebola, and norovirus [11]PMID: 28769016 [12]PMID: 31389664
  • Mechanism of action: after entering the infected cells and being phosphorylated, inhibits viral RNA replication.
  • SARS-CoV-2 is an enveloped, positive-sense, single-strand RNA virus and studies showed the efficacy of favipiravir on SARS-COV-2.
  • A randomized control trial has shown that COVID-19 patients treated with favipiravir have superior recovery rate (71.43%) than that treated with umifenovir (55.86%), and the duration of fever and cough relief time are significantly shorter in favipiravir group than in umifenovir group [10]

Doi.org/10.1101/2020.03.17.20037432

  • Two randomized and nonrandomized controlled trials are evaluating the safety and efficacy of favipiravir for treatment of COVID-19 disease.

Oseltamivir (Tamiflu)

  • The study in wohan showed no positive outcomes were observed in COVID-19 patients after recieving osetamivir[14]
doi:10.1001/jama.2020.1585

supportive agents

azithromycin

  • It has been effective in the treatment of Zika and Ebola viruses and prevented severe respiratory tract infection[16] PMID: 27911847
  • Mechanism of action is binding to 50S subunit of the bacteria ribosom,then inhibits traslation mRNA.
  • Effects of azithromycin in treatment of viral respiratory tract infection include:1. antibacterial coverage 2. mmunomodulatory and anti-inflammatory effects [17]

doi: 10.1016/j.ijantimicag.2020.105949.

  • Many trials in COVID-19 patients showed the effectiveness of azithromycin combined with hydroxychloroquine.
  • A trial in france reported  %100 viral clearance in nasopharengeal swap after recieving hydroxychloroquin with azithromycin [17]doi: 10.1016/j.ijantimicag.2020.105949.
  • Data about benefits of azithromycin in COVID-19 disease is still inadequate and needs further evaluation.

Vitamin C (Ascorbic Acid)

Effects in viral agents include:[18]PMID: 29534432

  • Maturation of T lymphocytes and NK( natural killer) cells which are involved in the immune response to viral agents
  • Inhibition of reactive oxygen species (ROS) production
  • Remodulation of the cytokine network in systemic inflammatory syndrome

Study in COVID-19 patients in china showed administration of high dose IV,Vitamin C (1500mg per day) in moderate and severe cases was correlated with improvement in oxygenation indexes and recovery .[19]PMID: 32328576

Corticosteroids

  1. Effects of Low doses of methylprednisolone in COVID-19 include:[20][21] PMID: 30097460 PMID: 32043983
  • Controlling the hypercytocynemia
  • Anti-inflammation which is caused by infection superimposed in COVID-19
  • Increase blood pressure when it is low
  • Decreased ventilation days
  • Decreased mortality
  • .Due to suppression in the immune system, the role of corticosteroid in COVID-19 would be evaluated by further investigation. PMID: 32043983

Niclosamide and Ivermectin

Inhibition of binding of coronavirus onto the cells [24]PMID: 15215127

Niclosamid inhibits replication of MERS-COV AND SARS-COV-2[25] PMID: 31852899

Ivermectin inhibits viral replication in dengue virus, flavivirus,influenza [25]PMID: 31852899

Study showed Ivermectin inhibited SARS-COV-2 up to 5000 fold at 48 h in vitro[26] https://doi.org/10.1016/j.antiviral.2020.104787

Convalescent Plasma

  • Transfusion of plasma loaded with antibodies after improvement from COVID-19 PMID: 69403361
  • Serious side effects were not reported.[28] PMID: 32253318

Anticoagulation

  • Efficacy of heparin in COVID-19 including  : 1.anti inflammatory properties,2. prevention of viral attachment via changing in spike protein https://doi.org/10.1101/2020.02.29.971093
  • Efficacy of low molecular weight heparin in COVID-19 includes: reduction in level of IL-6 and cytokin storm. https://doi.org/10.1101/2020.03.28.20046144
  • Prophylactic anticoagulant therapy is necessary for hospitalized patients
  • In patients with rapidly progressing respiratory distress and the probability of thrombosis, treatment doses of anticoagulant is considered.

Ibuprofen

  • nonsteroidal anti-inflammatory drug (NSAID) and block the renin-angiotensin pathway
  • Anti-inflammatory effect
  • Activator of ACE2 receptor PMID: 16007097
  • No strong evidence between intake of NSAID and worsening SARS-COV-2
  • Approved by FDA for treatment of COVID-19

Thiazolidinediones

  • It has been used against pulmonary disease induced by respiratory syncytial virus (RSV) or H1N1 influenza infection PMID: 17425601
  • Upregulation ACE2 receptor, which is identified as receptor for SARS-CoV-2 in host cell PMID: 32171062
  • No strong evidence for therapeutic efficacy against coronavirus infection

References

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