Treatment Considerations for COVID-19: A Critical Review of the Evidence (or Lack Thereof)

Abstract

The novel severe acute respiratory syndrome coronavirus 2 is causing a worldwide pandemic that may lead to a highly morbid and potentially fatal coronavirus disease 2019 (COVID-19). There is currently no drug that has been proven as an effective therapy for COVID-19. Several candidate drugs are being considered and evaluated for treatment. This includes clinically available drugs, such as chloroquine, hydroxychloroquine, and lopinavir/ritonavir, which are being repurposed for the treatment of COVID-19. Novel experimental therapies, such as remdesivir and favipiravir, are also actively being investigated for antiviral efficacy. Clinically available and investigational immunomodulators, such as the interleukin 6 inhibitors tocilizumab and sarilumab and the anti-granulocyte-macrophage colony-stimulating factor lenzilumab, are being tested for their anticipated effect in counteracting the pro-inflammatory cytokine environment that characterizes severe and critical COVID-19. This review article examines the evidence behind the potential use of these leading drug candidates for the treatment of COVID-19. The authors conclude, based on this review, that there is still no high-quality evidence to support any of these proposed drug therapies. The authors, therefore, encourage the enrollment of eligible patients to multiple ongoing clinical trials that assess the efficacy and safety of these candidate therapies. Until the results of controlled trials are available, none of the suggested therapeutics is clinically proven as an effective therapy for COVID-19.

Figure 1

A, Chest x-ray showing diffuse bilateral opacities in a patient with coronavirus disease 2019 and acute respiratory distress syndrome. B, Computed tomography scan of the chest showing peripherally based ground-glass opacities and pulmonary infiltrates.

Figure 2

Hypothetical algorithm for treatment of coronavirus disease 2019. GM-CSF = granulocyte-macrophage colony-stimulating factor; IL-6 = interluekin-6; LPV/r = lopinavir/ritonavir; PCR = polymerase chain reaction; SARS-CoV-2 = severe acute respiratory syndrome coronavirus 2; USFDA = US Food and Drug Administration.