Everything you need to know about the COVID-19 therapy trials

There are thousands of clinical trials investigating treatments and preventative measures for COVID-19.

Latest: 

Man on oxygen ss20
People hospitalised with COVID-19 often require oxygen therapy

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Researchers around the world are working at record speed to find the best ways to treat and prevent COVID-19, from investigating the possibility of repurposing existing drugs to searching for novel therapies against the virus.

Current approaches to COVID-19 therapies generally fall into two categories: antivirals — which prevent the virus from multiplying — and immune modulators — which help the immune system to fight the virus or stop it from overreacting dangerously. Some potential therapies act in a different way or via multiple mechanisms.

There are thousands of clinical trials of COVID-19 therapies taking place across the world. On 15 June 2020, the European Medicines Agency said it was in discussion with the developers of 132 potential COVID-19 treatments​[1]​.

This article collates the main treatments being studied, the evidence supporting their use and the trials they are being evaluated in. It will be updated on a regular basis.

Only evidence from randomised controlled trials comprising more than 100 participants is included, with the exception of select observational studies that have had a significant influence on ongoing research.

Contents

Antivirals:

Immune modulators:

Other or multiple mechanisms:

Antivirals

Image of "Remdesivir is a broad-spectrum antiviral which was originally developed to treat hepatitis C. It was the first COVID-19 treatment to be made available for use in the UK outside a clinical trial."
Remdesivir is a broad-spectrum antiviral which was originally developed to treat hepatitis C. It was the first COVID-19 treatment to be made available for use in the UK outside a clinical trial

Source: Shutterstock.com

Remdesivir

Evidence

Ongoing trials

Chloroquine/hydroxychloroquine

  • Antimalarials with in vitro activity against various viruses, including SAR-CoV-2 — the virus that causes COVID-19;
  • Anecdotal evidence in humans;
  • The US Food and Drug Administration has cautioned against use of hydroxychloroquine or chloroquine for COVID-19 outside of the hospital setting or a clinical trial due to risk of heart rhythm problems;
  • In June 2020, all UK clinical trials using hydroxychloroquine to treat or prevent COVID-19 were instructed by the Medicines and Healthcare products Regulatory Agency (MHRA) to stop recruiting further participants;
  • Approved for the treatment of rheumatoid arthritis and lupus.

Evidence

  • WHO guideline development panel make a strong recommendation against the use of hydroxychloroquine for individuals who do not have COVID-19 (2 March 2021); 
  • Rigorous randomised controlled trial among persons with recent exposure excluded a clinically meaningful effect of hydroxychloroquine as postexposure prophylaxis to prevent SARS-CoV-2 infection (Barnabas et al, 8 December 2020);
  • Interim results from the Solidarity trial suggest that remdesivir has little or no effect on mortality in patients who are hospitalised with COVID-19 (WHO Solidarity Trial Consortium, 2 December 2020); 
  • Post-exposure therapy with hydroxychloroquine did not prevent SARS-CoV-2 infection or symptomatic COVID-19 in healthy persons exposed to a PCR-positive case patient (Mitjà et al. 24 November 2020); 
  • Among adults hospitalised with respiratory illness from COVID-19, treatment with hydroxychloroquine, compared with placebo, did not significantly improve clinical status at day 14 (Self et al, 9 November 2020);
  • Pre-exposure prophylaxis with hydroxychloroquine once or twice weekly did not significantly reduce laboratory-confirmed COVID-19 or COVID-19-compatible illness among healthcare workers (Rajasingham et al, 17 October 2020);
  • Among patients hospitalised with COVID-19, those who received hydroxychloroquine did not have a lower incidence of death at 28 days than those who received usual care (The RECOVERY collaborative group, 8 October 2020);
  • Among hospital-based health care workers, daily hydroxychloroquine did not prevent SARS-CoV-2 infection, although the trial was terminated early and may have been underpowered to detect a clinically important difference (Abella et al, 30 September 2020)  
  • Among patients hospitalised with mild-to-moderate COVID-19, the use of hydroxychloroquine, alone or with azithromycin, did not improve clinical status at 15 days as compared with standard care (Cavalcanti et al, 23 July 2020) 
  • Hydroxychloroquine did not substantially reduce symptom severity in outpatients with early, mild COVID-19 (Skipper et al, 16 July 2020)
  • UK Medicines and Healthcare products Regulatory Agency (MHRA) suspends recruitment to COVID-19 hydroxychloroquine trials (5 June 2020)
  • Preliminary results from ‘Randomised Evaluation of COVID-19 Therapy’ (RECOVERY) trial (5 June 2020): no significant difference in mortality rate at 28 days (25.7% hydroxychloroquine vs. 23.5% usual care; hazard ratio 1.11 [95% confidence interval 0.98–1.26]; P =0.10);
  • Hydroxychloroquine did not prevent illness compatible with COVID-19 or confirmed infection when used as postexposure prophylaxis within four days after exposure (Boulware et al, 3 June 2020);
  • No evidence of benefit of hydroxychloroquine or chloroquine, when used alone or with a macrolide. Each of these drug regimens was associated with decreased in-hospital survival and an increased frequency of ventricular arrhythmias (Mehra et al, 22 May 2020). Study retracted by The Lancet on 5 June 2020 following concerns about the data;
  • Not enough data available to support the routine use of hydroxychloroquine and chloroquine as therapies for COVID-19 (Chowdhury et al, 29 May 2020);
  • Administration of hydroxychloroquine did not result in a significantly higher probability of negative conversion than standard of care alone (Tang et al, 14 May 2020).

Ongoing trials

Lopinavir/ritonavir combination

  • HIV type 1 aspartate protease inhibitors, indicated for treatment of HIV infection in combination with other antiretroviral drugs;
  • Lopinavir has in vitro inhibitory activity against SARS-CoV, the virus that causes severe acute respiratory syndrome (SARS);
  • Ritonavir is combined with lopinavir to increase its half-life;
  • Recommended for use in COVID-19 in several countries, including Italy and France.

Evidence

  • Interim results from the Solidarity trial suggest that remdesivir has little or no effect on mortality in patients who are hospitalised with COVID-19 (WHO Solidarity Trial Consortium, 2 December 2020); 
  • In patients admitted to hospital with COVID-19, lopinavir–ritonavir was not associated with reductions in 28-day mortality, duration of hospital stay, or risk of progressing to invasive mechanical ventilation or death (The RECOVERY collaborative group, 5 October 2020). 
  • Following a review of emerging data from the RECOVERY trial, researchers concluded that there was no beneficial effect of lopinavir/ritonavir on 28-day mortality in patients hospitalised with COVID-19 compared to usual care alone (Horby et al, 29 June 2020);
  • Evidence that early treatment with triple antiviral therapy of interferon (IFN) beta-1b, lopinavir/ritonavir, and ribavirin — alongside standard care — is safe and shortens duration of viral shedding compared with lopinavir-ritonavir alone (average 7 days vs. 12 days), in patients with mild-to-moderate COVID-19 (Hung et al, 8 May 2020);
  • Some evidence that lopinavir/ritonavir initiation within 12 days after symptom onset is associated with shorter time to clinical improvement. No significant differences in reduction of viral RNA load, duration of viral RNA detectability, duration of oxygen therapy, duration of hospitalisation, or time from randomization to death. Lopinavir/ritonavir stopped early in 13 patients because of adverse effects (Cao et al, 7 May 2020).

Ongoing trials

Favipiravir

  • Broad-spectrum antiviral with in vitro activity against various viruses, including coronaviruses;
  • Licensed in Japan and China for treatment of influenza;
  • Not currently included in any of the UK trials for COVID-19.

Ongoing trials

Umifenovir

  • Antiviral treatment used for influenza infection in Russia and China;
  • Proposed as a standard care option for COVID-19 based on its mechanism of action and its effects in treating influenza-associated pneumonia;
  • In vitro inhibitory activity against SARS-CoV, the virus that causes severe acute respiratory syndrome (SARS)

Ongoing trials:

Ribavirin

  • Broad-spectrum antiviral used to treat hepatitis C, respiratory syncytial virus (RSV) and bronchiolitis;
  • In vitro activity against SARS-CoV, the virus that causes severe acute respiratory syndrome (SARS);
  • Some evidence of efficacy as an adjunct therapy in SARS;
  • Evidence from mouse models in SARS-CoV suggested it could increase infectivity.

Evidence

  • Evidence that early treatment with triple antiviral therapy of IFN beta-1b, lopinavir-ritonavir, and ribavirin — alongside standard care — is safe and shortens duration of viral shedding compared with lopinavir-ritonavir alone (average 7 days vs. 12 days), in patients with mild to moderate COVID-19 (Hung et al, 8 May 2020).

EIDD-2801

  • Investigational oral nucleoside analogue with broad-spectrum antiviral activity against RNA viruses, including influenza and coronaviruses like SARS and Middle East respiratory syndrome (MERS).

Ongoing trials

Niclosamide

  • Anti-helminthic drug with potential antiviral activity against SARS-CoV-2;
  • Unlicensed in the UK.

Ongoing trials

Oseltamivir

  • A neuraminidase inhibitor approved for the treatment of influenza A and B;
  • Several clinical trials are evaluating the effectiveness of oseltamivir in treating SARS-CoV-2 both alone and in combination with other drugs.

Ongoing trials

Ivermectin

  • Anti-parasitic agent shown to have antiviral activity against a broad range of viruses;
  • Unlicensed in the UK;
  • Shown to inhibit the SARS-CoV-2 virus in vitro;
  • On 22 March 2021, the European Medicines Agency advises against use of ivermectin for the prevention or treatment of COVID-19 outside randomised clinical trials.

Evidence

  • Findings from a randomised controlled trial of 476 patients do not support the use of ivermectin for treatment of mild COVID-19, although larger trials may be needed to understand effects on other clinically relevant outcomes (López-Medina et al, 4 March 2021).

Ongoing trials

Immune modulators

Dexamethasone tablets
Dexamethasone was the first drug to be shown to improve survival in patients hospitalised with COVID-19

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Dexamethasone

  • Steroid that reduces inflammation by mimicking anti-inflammatory hormones produced by the body;
  • Indicated for the suppression of inflammatory and allergic disorders;
  • Only suitable for people who are already in hospital and receiving oxygen or mechanical ventilation;
  • It is the first drug to be shown to improve survival in COVID-19;
  • Approved for NHS use by UK government.

Evidence

  • In patients hospitalised with COVID-19, the use of dexamethasone resulted in lower 28-day mortality among those who were receiving either invasive mechanical ventilation or oxygen alone at randomization but not among those receiving no respiratory support (RECOVERY Collaborative Group, 25 February 2021).
  • Intravenous dexamethasone plus standard care, compared with standard of care alone, resulted in a statistically significant increase in the number of days alive and free of mechanical ventilation over 28 days. (Tomazini et al, 2 September 2020);
  • Preliminary results from the RECOVERY trial suggest that dexamethasone reduced deaths by 35% in ventilated patients and by 20% in other patients receiving oxygen only. There was no benefit among those patients who did not require respiratory support (Horby et al, 17 July 2020).

Ongoing trials

  • RECOVERY;
  • REMAP-CAP.

Hydrocortisone

  • Steroid that reduces inflammation by mimicking anti-inflammatory hormones produced by the body;
  • Used for a variety of conditions including adrenocortical insufficiency, rheumatoid arthritis, dermatitis, asthma and chronic obstructive pulmonary disorder;
  • Commonly used to manage septic shock in patients with COVID-19;
  • Evidence regarding corticosteroid use for severe COVID-19 is limited.

Evidence

  • Patients with severe COVID-19 who are treated intravenously with the steroid, hydrocorticosone, are up to 93% more likely to have a better outcome compared to patients who are not given the drug, principal findings from the REMAP-CAP trial suggest. However, the trial was stopped early and no treatment strategy met pre-specified criteria for statistical superiority (Angus et al, 2 September 2020); 
  • Low-dose hydrocortisone did not significantly reduce treatment failure in patients with COVID-19–related acute respiratory failure; however, the study was stopped early and was therefore likely underpowered (Dequin et al, 2 September 2020).

Ongoing trials

Budesonide (inhaled)

  • Inhaled budesonide is often used to treat asthma and chronic obstructive pulmonary disease, with no serious side-effects associated with short-term use;
  • In some patients with COVID-19, the body’s immune response to the virus can cause high levels of inflammation that can damage cells in the airways and lungs. Inhaling budesonide into the airways targets anti-inflammatory treatment where it is needed most, and can potentially minimise any lung damage that might otherwise be caused by the virus.

Evidence

  • Interim findings from the PRINCIPLE trial suggest that budesonide shortens recovery time in non-hospitalised patients with COVID-19 by a median of three days (12 April 2021);
  • Phase II randomised controlled trial suggests that early administration of inhaled budesonide reduces the likelihood of needing urgent medical care and reduces time to recovery after early COVID-19 (Ramakrishnan et al, 9 April 2021).

Ongoing trials

Convalescent plasma

  • Antibody-rich plasma of someone who has recovered from COVID-19;
  • There is some evidence suggesting possible benefits of convalescent plasma in patients with COVID-19, but available data to date are largely from case reports or series; confirmation from additional randomised controlled studies is required (Malani et al, 12 June 2020);
  • Has been approved for use in critically ill patients in the United States and UK.

Evidence

Ongoing trials

AZD7442

  • AZD7442 is a combination of two long-acting antibodies (LAABs) derived from convalescent patients after SARS-CoV-2 infection;
  • LAABs mimic natural antibodies and have the potential to treat and prevent disease progression in patients already infected with the virus, as well as to be given as a preventative intervention prior to exposure to the virus;
  • In pre-clinical experiments the two LAABs have been shown to block the binding of the SARS-CoV-2 virus to host cells and protect against infection in cell and animal models of disease.

Ongoing trials

Azithromycin

  • Macrolide antibiotic;
  • Some in vitro activity against some viruses, such as influenza A and zika;
  • May reduce cytokine levels, which can promote inflammation.

Evidence

Ongoing trials

  • RECOVERY;
  • PRINCIPLE.

Doxycycline

  • A broad-spectrum tetracycline-class antibiotic used in the treatment of infections caused by bacteria and certain parasites;
  • Considered as a potential treatments for COVID-19 in the community due to its anti-inflammatory, antibacterial and possibly antiviral effects;
  • It has been reported that doxycycline lowers significantly proinflammatory cytokines, including interleukin-6. 

Evidence

Ongoing trials

Interferons

  • Modulate immune response to some viral infections;
  • Only limited clinical trial data are currently available on the efficacy of IFNs for treatment of COVID-19;
  • Clinical trials are currently evaluating IFN beta-1a or IFN beta-1b, generally added to antivirals.

Evidence

  • Interim results from the Solidarity trial suggest that IFN beta-1a has little or no effect on mortality in patients who are hospitalised with COVID-19 (15 October 2020).

Ongoing trials

Tocilizumab

  • Monoclonal antibody that inhibits interleukin-6 (IL-6), which is vital in the immune response to SAR-CoV-2;
  • Indicated for treatment of rheumatoid arthritis;
  • May combat cytokine release syndrome in severely ill COVID-19 patients.

Evidence

Ongoing trials

Sarilumab

  • Monoclonal antibody that inhibits IL-6, which is vital in the immune response to SAR-CoV-2;
  • Indicated for treatment of rheumatoid arthritis;
  • May combat cytokine release syndrome and pulmonary symptoms in severely ill COVID-19 patients.

Evidence

Ongoing trials

Regdanvimab

  • A monoclonal antibody with activity against SARS-CoV-2;
  • Designed to attach to the spike protein of SARS-CoV-2 – when it attaches to the spike protein, the ability of the virus to enter the body’s cells is reduced;
  • This is expected to reduce the need for hospitalisation in patients with mild to moderate COVID-19.

Evidence

Canakinumab

  • Inhibits interleukin-1 (IL-1), which is vital in the immune response to SAR-CoV-2;
  • Indicated to treat certain periodic fever syndromes and gouty arthritis;
  • Potential to treat cytokine release syndrome in severely ill COVID-19 patients.

Evidence

  • An interim analysis of the CAN-COVID trial showed the drug did not meet the primary endpoint of clinical response, defined as survival without the need for mechanical ventilation up to day 29. The drug also failed on a key secondary endpoint, reduction in COVID-19-related death within four weeks after the treatment period.

Ongoing trials

Anakinra

Evidence

  • Anakinra did not improve outcomes in patients with mild-to-moderate COVID-19 pneumonia. Further studies are needed to assess the efficacy of anakinra in other selected groups of patients with more severe COVID-19 (The CORIMUNO-19 collaborative group, 22 January 2021).

Ongoing trials

  • REMAP-CAP.

Baricitinib

  • Janus-associated tyrosine kinase (JAK) 1 and JAK 2 inhibitor;
  • Modulates the immune response by regulating overactive signalling through the Janus kinase/signal transducers and activators of transcription (JAK-STAT) pathway;
  • Indicated for treatment of rheumatoid arthritis;
  • May potentially combat cytokine release syndrome (CRS) in severely ill patients;
  • Currently no known published controlled clinical trial evidence supporting efficacy or safety in patients with COVID-19.

Evidence

  • Baricitinib plus remdesivir was superior to remdesivir alone in reducing recovery time and accelerating improvement in clinical status among patients with COVID-19, notably among those receiving high-flow oxygen or non-invasive ventilation. The combination was associated with fewer serious adverse events (Kalil et al, 11 December 2020).

Ongoing trials

Ruxolitinib

  • Selective inhibitor of JAK 1 and JAK 2;
  • Modulates the immune response by regulating overactive signalling through the Janus kinase/signal transducers and activators of transcription (JAK-STAT) pathway;
  • Indicated for specialist treatments;
  • May combat CRS in severely ill patients;
  • Currently no known published clinical trial evidence supporting efficacy or safety in patients with COVID-19.

Evidence

Ongoing trials

Acalabrutinib

  • Bruton’s tyrosine kinase inhibitor;
  • In clinical development for people with chronic lymphocytic leukaemia, approved for this use in the United States;
  • Early clinical data have shown it can lead to a decrease in inflammation and reduction in the severity of COVID-19-induced respiratory distress.

Evidence

Ongoing trials

Brensocatib

  • Reversible inhibitor of the dipeptidyl peptidase-1 enzyme, which is known to be associated with pathogen destruction and inflammatory mediation;
  • Not licensed in the UK;
  • Could be beneficial for ARDS in severely ill COVID-19 patients.

Ongoing trials

Ravulizumab

  • Recombinant monoclonal antibody;
  • Used routinely in blood diseases where complement activation destroys red blood cells;
  • Potential to treat CRS in severely ill COVID-19 patients.

Ongoing trials

Gemtuzumab ozogamicin

  • Monoclonal antibody that binds to CD33-expressing tumour cells to induce cell cycle arrest and apoptotic cell death;
  • Indicated for CD33-positive acute myeloid leukaemia.

Ongoing trials

Namilumab

  • Human immunoglobulin G1 monoclonal antibody currently in late-stage trials for the treatment of rheumatoid arthritis and ankylosing spondylitis;
  • Currently being investigated to see if it can help manage inflammation associated with COVID-19.

Ongoing trials

  • CATALYST.

Infliximab

  • Chimeric monoclonal antibody indicated to treat inflammatory conditions, including rheumatoid arthritis and inflammatory bowel disease;
  • Currently being investigated to see if it can help manage inflammation associated with COVID-19.

Ongoing trials

  • CATALYST.

Adalimumab

  • An anti-tumour necrosis factor (TNF) drug already used for a wide-range of inflammatory conditions including rheumatoid arthritis and inflammatory bowel disease;
  • Recent studies of patients with COVID-19 have shown that patients already taking anti-TNF drugs for other conditions were less likely to be admitted to hospital.

Ongoing trials

Otilimab

  • Monoclonal antibody already in trials for the treatment of arthritis;
  • May be able to help to block the effects of one of the types of cytokine (known as GM-CSF).

Evidence

  • GlaxoSmithKline announced results from the phase II proof of concept OSCAR study with otilimab which showed that in patients of all ages treatment difference was not statistically significant between the otilimab and standard of care groups, but in analysis by age, patients 70 years and older had an increased chance of being alive and free of respiratory failure 28 days after treatment with otilimab compared to the standard care group (65.1% vs 45.9%);

Ongoing trials

Medi3506

  • Interleukin-33 monoclonal antibody developed for skin disorders.

Ongoing trials

  • ACCORD.

Antiviral antibody cocktail

  • Several companies are developing novel monoclonal antibodies to bind to and neutralise the SARS-CoV-2 virus;
  • This ‘antiviral antibody cocktail’ contains two antibodies and trials will investigate whether the therapy can improve the outcomes for COVID-19 patients;
  • It will also be tested as a preventive therapy in those who are healthy but at high risk of getting sick because they work in a healthcare setting or have been exposed to an infected person;
  • REGN-COV2 comprises two monoclonal antibodies, REGN10933 and REGN10987, and was designed specifically by Regeneron scientists to block infectivity of SARS-CoV-2.
  • REGEN-COV comprises casirivimab with imdevimab and is authorised for the treatment of mild-to-moderate COVID-19 in adults and paediatric patients with positive results of direct SARS-CoV-2 viral testing, and who are at high risk for progressing to severe COVID-19 and/or hospitalisation.

Evidence

  • Topline results from a phase III outcomes trial suggest that investigational REGEN-COV (casirivimab with imdevimab) significantly reduced the risk of hospitalisation or death by 70% (1,200 mg intravenous [IV]) and 71% (2,400 mg IV) compared to placebo. It also met all secondary endpoints, including the ability to reduce symptom duration (23 March 2021);
  • The European Medicines Agency’s Committee for Medicinal Products for Human Use concludes that REGN-COV2 can be used for the treatment of confirmed COVID-19 in patients who do not require supplemental oxygen and who are at high risk of progressing to severe COVID-19;
  • In an interim analysis, the REGN-COV2 antibody cocktail was found to reduce viral load, with a greater effect in patients whose immune response had not yet been initiated or who had a high viral load at baseline. Safety outcomes were similar in the combined REGN-COV2 dose groups and the placebo group (Weinreich et al. 17 December 2020);
  • Regeneron Pharmaceuticals, Inc. announces positive, prospective results from an ongoing Phase 2/3 seamless trial in the COVID-19 outpatient setting showing its investigational antibody cocktail, REGN-COV2, met the primary and key secondary endpoints. REGN-COV2 significantly reduced viral load and patient medical visits (28 October 2020).

Ongoing trials

Leronlimab

  • An investigational humanised monoclonal antibody targeted against the CCR5 receptor, which appears to play a central role in modulating immune cell trafficking to sites of inflammation;
  • Being looked at as a potential therapy in the treatment of triple negative breast cancer and HIV infection as well as COVID-19.

Ongoing trials

LY-CoV555/bamlanivimab

  • LY-CoV555 is a potent neutralising IgG1 monoclonal antibody directed against the spike protein on SARS-CoV-2;
  • Designed to block viral attachment and entry into human cells, thus neutralising the virus, potentially preventing and treating COVID-19.

Evidence

  • Eli Lilly announce new data from the BLAZE-1 Phase III study, demonstrating that bamlanivimab (LY-CoV555) 700mg and etesevimab (LY-CoV016) 1400mg together significantly reduced COVID-19 related hospitalizations and deaths (“events”) in high-risk patients recently diagnosed with COVID-19 (10 March 2021);
  • Initial results from the BLAZE-2 trial suggest that nursing home residents randomised to bamlanivimab have up to an 80% lower risk of contracting COVID-19 versus residents in the same facility randomised to placebo (21 January 2021);
  • Treatment with bamlanivimab and etesevimab combination therapy, but not bamlanivimab monotherapy, resulted in a reduction in SARS-CoV-2 log viral load at day 11 in patients with mild to moderate COVID-19 (Gottlieb et al, 21 January 2021);
  • Interim analysis of the BLAZE-1 trial found that one of three doses (2800mg) of the neutralizing antibody LY-CoV555 appeared to accelerate the natural decline in viral load over time in patients with mild or moderate COVID-19, whereas the other doses (700mg and 7000mg) administered had not by day 11 (Chen et al, 28 October 2020); 
  • The ACTIV-3 trial, which is evaluating multiple investigational agents in hospitalised patients with COVID-19, stopped randomising patients to treatment with LY-CoV555 based on an analysis suggesting that the antibody was not beneficial in this population (26 October 2020).

Ongoing trials

LY-CoV016/etesevimab

  • Also known as JS016, LY-CoV016 is a recombinant human monoclonal neutralising antibody;
  • Targets the SARS-CoV-2 spike protein and blocks binding of the virus to the ACE2 host cell surface receptor;
  • Effective for both prophylactic and therapeutic venues against SARS-CoV-2 infection in rhesus macaques.

Evidence

  • Eli Lilly announce new data from the BLAZE-1 Phase III study, demonstrating that bamlanivimab (LY-CoV555) 700mg and etesevimab (LY-CoV016) 1400mg together significantly reduced COVID-19 related hospitalizations and deaths (“events”) in high-risk patients recently diagnosed with COVID-19 (10 March 2021);
  • Treatment with bamlanivimab and etesevimab combination therapy, but not bamlanivimab monotherapy, resulted in a reduction in SARS-CoV-2 log viral load at day 11 in patients with mild to moderate COVID-19 (Gottlieb et al, 21 January 2021).

Ongoing trials

  • BLAZE-4;
  • BLAZE-1.

VIR-7831

  • VIR-7831 is an investigational dual-action SARS-CoV-2 monoclonal antibody;
  • Preclinical data suggest it has the potential to both block viral entry into healthy cells and clear infected cells;
  • The antibody binds to an epitope on SARS-CoV-2 that is shared with SARS-CoV-1 (the virus that causes SARS), indicating that the epitope is highly conserved, which may make it more difficult for resistance to develop.

Evidence

Ongoing trials

Risankizumab

  • Risankizumab is an anti-IL-23 monoclonal antibody developed by Boehringer Ingelheim and AbbVie;
  • Being investigated for the treatment of multiple inflammatory diseases, including psoriasis, Crohn’s disease, ulcerative colitis, atopic dermatitis and psoriatic arthritis;
  • Approved in the US in 2019 for the treatment of severe plaque psoriasis;
  • Will be tested in conjunction with the antiviral drug remdesivir, compared to a placebo plus remdesivir.

Ongoing trials

Lenzilumab

  • Investigational recombinant monoclonal antibody targeting human GM-CSF, which is thought to have a role in the pathogenesis of COVID-19–related immune hyper-response;
  • Currently being tested in a phase III COVID-19 study and in a phase 1b/2 study as sequenced therapy with CAR-T treatments.

Ongoing trials

IMU-838

  • IMU-838 is a next-generation selective immune modulator that inhibits the intracellular metabolism of activated immune cells by blocking the enzyme, dihydroorotate dehydrogenase;
  • Investigational drug under development as an oral tablet formulation for the treatment of relapsing-remitting multiple sclerosis, inflammatory bowel disease and other chronic inflammatory and autoimmune diseases;
  • Also being investigated as a potential treatment option for COVID-19.

Ongoing trials

Other or multiple mechanisms

Image of "Colchicine is used for treating inflammation and pain in conditions such as gout and could help ameliorate COVID-19 complications"
Colchicine is used for treating inflammation and pain in conditions such as gout and could help ameliorate COVID-19 complications

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Colchicine

  • Medicine for treating inflammation and pain in conditions such as gout;
  • Could help ameliorate COVID-19 complications, but there is minimal anecdotal experience and clinical trial data reported to date in COVID-19.

Evidence

Ongoing trials

Dimethyl fumarate

  • An immunomodulatory drug thought to prevent NLRP3 inflammasome activation and the process of inflammatory cell death through its action on the protein, gasdermin D;
  • Licensed to treat relapsing remitting multiple sclerosis and plaque psoriasis as a long-term immunomodulatory agent and is generally well-tolerated with no major safety concerns;
  • Has demonstrated anti-viral and anti-inflammatory effects against SARS-CoV-2 in vitro.

Ongoing trials

  • RECOVERY

Angiotensin-converting-enzyme inhibitors/angiotensin II receptor blockers

  • Indicated for the treatment of hypertension and heart failure;
  • There have been suggestions that the drugs can increase both the risk of infection and the severity of SARS-CoV2, but data are lacking;
  • May also have a protective effect against lung damage.

Evidence

  • Severity of COVID-19 is not associated with the use of angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers;
  • The BRACE CORONA trial, which tested temporarily stopping an ACE inhibitor/ARB for 30 days versus continuing ACE inhibitors/ARBs in patients who were taking these medications chronically and were hospitalised with a confirmed diagnosis of COVID-19, found no clinical difference, suggesting the medication should generally be continued for those with an indication (Lopes et al, presented at the European Society of Cardiology Congress 2020 on 1 September 2020).

Ongoing trials

Statins

  • Indicated for the treatment of cardiovascular disease;
  • Decrease inflammation, reduce blood clots, and prevent damage to endothelial tissue;
  • Some evidence they can act as antivirals;
  • Could potentially combat CRS in severely ill patients, but concrete data are lacking.

Ongoing trials

Aspirin

  • Triple effect of inhibiting virus replication, anticoagulation and anti-inflammatory.

Ongoing trials

Clopidogrel

  • Anti-platelet drug that could help prevent blood-clots associated with COVID-19.

Ongoing trials

  • C-19-ACS.

Anticoagulants

  • Potential role of anticoagulation in specific COVID-19 patients for improved mortality.

Evidence

  • Results of the INSPIRATION randomised clinical trial including 562 patients do not support routine empirical use of intermediate-dose prophylactic anticoagulation in unselected patients with COVID-19 admitted to the ICU (INSPIRATION investigators, 18 March 2021);
  • Early initiation of prophylactic anticoagulation compared with no anticoagulation among patients admitted to hospital with COVID-19 was associated with a decreased risk of 30 day mortality and no increased risk of serious bleeding events (Rentsch et al. 11 February 2021). 

Ongoing trials

Bemcentinib

  • Selectively inhibits AXL kinase, which blocks viral entry and enhances the antiviral type I IFN response;
  • Investigational treatment for COVID-19;
  • Reported to exhibit potent anti-viral activity in pre-clinical models against several enveloped viruses, including Ebola and Zika virus.

Ongoing trials

Omeprazole

  • Proton-pump inhibitor indicated for the treatment of gastroesophageal reflux disease (GORD);
  • Being investigated as an additive treatment for COVID-19.

Ongoing trials

  • C-19-ACS.

Famotidine

  • Histamine-2 receptor antagonist used in the treatment of GORD;
  • Some evidence to suggest it is associated with improved patient-reported outcomes in non-hospitalised patients with COVID-19.

Ongoing trials

Zilucoplan

  • Synthetic macrocyclic peptide inhibitor already in trial for potential treatment of the skeletomuscular disorder myasthenia gravis;
  • Could reduce damage to lung tissue caused by the virus.

Ongoing trials

  • ACCORD.

Ascorbic acid/vitamin C

  • Use of vitamin C could be effective in terms of mortality and secondary outcomes in patients with COVID-19 pneumonia due to its anti-inflammatory and antioxidant properties.

Evidence

  • Evidence from a randomised clinical trial of 214 patients suggests that treatment with zinc, ascorbic acid, or both does not affect SARS-CoV-2 symptoms (Thomas et al. 12 February 2021).

Ongoing trials

Vitamin D3

  • Vitamin D insufficiency is a potential risk factor for non-communicable and acute respiratory tract diseases, including viral infections;
  • It has been speculated that optimal serum levels of vitamin D may have immunomodulatory and anti-inflammatory properties, and could possibly benefit patients with COVID-19.

Evidence

  • Among hospitalized patients with COVID-19, a single high dose of vitamin D3, compared with placebo, did not significantly reduce hospital length of stay. The findings do not support the use of a high dose of vitamin D3 for treatment of moderate to severe COVID-19 (Murai et al, 17 February 2021).

Ongoing trials

Aviptadil

  • Synthetic form of human vasoactive intestinal peptide;
  • Indicated for treatment of erectile dysfunction;
  • Reduces inflammation in the lungs and protects the alveolar type II cells that are believed to be an entry route for the SARS-CoV-2 to invade the lungs.

Ongoing trials

Opaganib

  • Selectively inhibits sphingosine kinase-2 (SK2), a lipid-signalling molecule that promotes cancer growth;
  • Currently under investigation for oncology, inflammatory and gastrointestinal indications;
  • Pre-clinical studies have shown opaganib to have anti-inflammatory and anti-viral activity;
  • In vivo studies have shown opaganib to decrease fatality rates from influenza.

Ongoing trials:

Tradipitant

  • A neurokinin-1 receptor antagonist that works by blocking substance P, a neuropeptide secreted by neuronal cells and inflammatory cells that has multiple effects in different tissues;
  • Currently in clinical development for gastroparesis, motion sickness and atopic dermatitis.

Evidence

Ongoing trials

AZD1656

  • A glucokinase activator that has been shown to reduce blood glucose for up to four months in humans;
  • Has also been shown to activate the migration of T regulatory cells to sites of inflammation in preclinical experiments;
  • May prevent the development of cardiorespiratory complications observed in hospitalised patients with COVID-19;
  • AZD1656 has already undergone phase ll trials for use in type 2 diabetes and is currently under clinical investigation for renal transplant rejection.

Ongoing trials

Nitric oxide

  • Nitric oxide (NO) inhalation has been used as a pulmonary vasodilator and has been found to have antiviral activity against other coronavirus strains;
  • Preliminary data support a microbicidal effect of high concentration inhaled NO;
  • NO is being investigated to see if it can prevent the deterioration to a severe form of COVID-19 when administered at an early stage of the disease.

Ongoing trials

Razuprotafib

  • Investigational drug that activates Tie2 receptor proteins on the surface of endothelial cells to bind to angiopoietins; a key pathway in the formation, repair and stabilisation of blood vessels;
  • May prevent and treat respiratory distress in COVID-19 patients;
  • Pre-clinical studies and clinical data suggest promise for the drug in aiding COVID-19 patients.

Ongoing trials:

Fluvoxamine

  • Fluvoxamine is a selective serotonin reuptake inhibitor (SSRI) used primarily for the treatment of obsessive–compulsive disorder;
  • It is thought that fluvoxamine may prevent clinical deterioration in patients with COVID-19 by stimulating the σ-1 receptor, which regulates cytokine production.

Evidence

  • In a small preliminary study, adult outpatients with symptomatic COVID-19 treated with fluvoxamine, compared with placebo, had a lower likelihood of clinical deterioration over 15 days; however, determination of clinical efficacy would require larger randomized trials with more definitive outcome measures (Lenze et al. 12 November 2020). 

Ongoing trials

Proxalutamide

  • A non-steroidal anti-androgen developed for the treatment of prostate and breast cancer.

Evidence

Ongoing trials

Ruconest

  • A powder that is made up into a solution for injection; contains the active substance conestat alfa, a copy of the C1 esterase inhibitor protein that occurs naturally in the body;
  • Used in patients with hereditary angioedema that is linked to naturally low levels of a protein called C1 esterase inhibitor;
  • Studies are seeking to identify if the administration of ruconest can control or stop the systemic hyperinflammation syndrome or cytokine storm in COVID-19.

Ongoing trials

This article will be updated regularly as more information emerges. If there are any trials or treatments we have missed, let us know.

Other sources of information:

  1. 1
    Treatments and vaccines for COVID-19 . European Medicines Agency. 2020.https://www.ema.europa.eu/en/human-regulatory/overview/public-health-threats/coronavirus-disease-covid-19/treatments-vaccines-covid-19 (accessed 2021).

Last updated
Citation
The Pharmaceutical Journal, April 2021;Online:DOI:10.1211/PJ.2021.20208126