EXPERT REACTION: Coronavirus - Answers to your latest questions on treatments and drugs

Lots of talk about new treatments now -- what are the most promising candidates that you've read/studied/seen?

We ultimately need to find a vaccine, which will be the most effective way of stopping the spread. The vaccine needs to be developed and tested, going through the phases of a drug trial one through to three, which demonstrates that the drug is safe, des no harm and is efficacious ie it works. All other treatments may have antiviral components, which helps speeds up the process of getting well, but this virus is no different to influenza or the common cold (in fact COVID-19 is part of a common cold). We don’t have a one-size-fits-all drugs that fixes all viruses.

• Lots of talk about new treatments now -- what are the most promising candidates that you've read/studied/seen?

"To date over 100 human clinical trials are registered to assess different treatment against COVID-19. A recent report demonstrated that anti HIV treatment doesn’t seem to work on COVID19. There is lots of talk about the use of the antimalarial chloroquine or hydroxychloroquine as a possible treatment against COVID19. However as the results of the clinical trials are inconclusive and debated, it is too early to tell whether these antimalarials would be efficacious against COVID 19. As hydroxychloroquine is widely used to treat patients with Lupus, I urge people not to stockpile this medicine so that Lupus patients can be treated."

• Should we believe the hype that some drugs are looking like they can ‘cure’ coronavirus?

"Over 100 human clinical trials are underway against COVID 19. It is possible that some drugs could possibly 'cure' coronavirus but it is too early to tell. We at least know which ones don’t 'cure' coronavirus such as anti HIV drugs. Incoming weeks will give us a better idea of which drugs will be suitable to treat or cure the infection."

• Is it likely we will see chloroquine or hydroxychloroquine used in Australia as a treatment option?

"Recent results from clinical trials indicated a possible improvement in shortening the duration of the infection. However the results are disputed and the clinical trials inconclusive. To date there are no clear indications that Chloroquine or Hydroxychloroquine are a treatment option. Additional clinical trials will tell us whether hydroxychloroquine or chloroquine are viable options for COVID 19 treatments."

• Ibuprofen has been advised against using with COVID-19, then that's been overruled by the WHO recently. The advice keeps changing. What do people who are worried about this need to think about?

"The information seem indeed ambiguous and based on one study published recently in the Lancet. People are legitimately worried about the flow of information that is changing quickly. They should refer only to the official information from the state and federal department of Health or the WHO that are reliable and up to date on COVID 19 infection.

• Lots of talk about new treatments now -- what are the most promising candidates that you've read/studied/seen?

"There was a study this week showing  Hydroxychloroquine (used to treat malaria) and azithromycin (antibacterial antibiotic) together were effective in accelerating recovery from infection compared to untreated individuals. Some drugs that currently are effective as antiretrovirals for HIV have also been tested – and the preliminary results (also published this week) were not as encouraging. So more work needs to be done there."

• Should we believe the hype that some drugs are looking like they can ‘cure’ coronavirus?

"Treat rather than cure!"

• Is it likely we will see chloroquine or hydroxychloroquine used in Australia as a treatment option?

"I can't comment on this as I am not a clinician nor involved in clinical trials – but based on the data above I imagine clinicians would be considering this."

• There has been advice against the use of ibuprofen for COVID-19, then that's been overruled by the WHO recently. The advice keeps changing. What do people who are worried about this need to think about?

"Paracetamol has been recommended over ibuprofen. They both lower fever but through different ways. In general paracetamol has fewer side effects. Again, not being a clinician I cant really comment about what people should do in terms of treatments."

Remdesivir is an experimental treatment developed by Gilead, California, USA.  It was being developed by Gilead for Ebola infections and has shown activity against Covid-19 in laboratory experiments.  It is not marketed and has been made available on a compassionate use basis to treat at least two patients with Covid-19 infections.  It appeared to be effective in these cases but I have not seen the evidence.  Clinical trials are underway in China and elsewhere with remdesivir to establish its efficacy against Covid-19 infections in a larger number of patients.  It may be some weeks or months before we know the results of these trials.

Clinical studies are also underway to determine whether some marketed treatments for HIV (lopinavir and ritonavir) are effective against Covid-19 infections.  Together with another marketed drug, ribavirin, they may be effective when used in combination against Covid-19.  Again results from these trials are some way off.

It is important to communicate in relation to these potential treatments for Covid-19 that demonstrating effectiveness in laboratory experiments does not guarantee safety and efficacy in patients.  This needs to be determined in well conducted clinical trials.

Apparently, Elon Musk has been promoting the potential use of chloroquine or hydroxychloroquine against Covid-19 based on his personal experience with the use of these drugs for treating his malaria.  These are marketed drugs and clinical trials will need to be conducted to establish their use against Covid-19. 

Physicians may well wish to experiment with one or other of these marketed drugs and also with the experimental drug, Remdesivir, if they can obtain the latter under a compassionate use basis, for the treatment of seriously ill patients.  All drugs, including the above-mentioned marketed drugs have potential side-effects.  In the absence of rigorous clinical trials data, the use of all these drugs and combinations of them by physicians for the treatment of Covid-19 will be guided by a careful risk assessment in each patient.

As for a cure, it is possible that some of these drugs and their combinations might reduce the severity and duration of symptoms of Covid-19 infections in patients if started early.  This is much like the situation with influenza where administration of antivirals such as Relenza and Tamiflu within 48 hours of the first signs of the infection, can reduce the duration of symptoms by up to two or three days.  Relenza and Tamiflu have also been shown to reduce the severity of the disease (i.e. reduce morbidity) and to save lives for elderly patients and those with complications such as heart disease, diabetes etc. (i.e. reduce mortality)

In the case of influenza I am not aware of any restrictions on the use of either paracetamol, ibuprofen or other antipyretics, i.e. drugs that can reduce fever.  Antipyretics were allowed in the conduct of all clinical trials of both Relenza and Tamiflu.  There may be special circumstance in the case of Covid-19 infections but I am not aware of these.

• Ibuprofen has been advised against using with COVID-19, then that's been overruled by the WHO recently. The advice keeps changing. What do people who are worried about this need to think about?

 “This question is frequently raised in response to evolving situations.  In this case, the initial warning was based on a small number of cases where there appeared to be a concerning link.  However, as more evidence was gathered, the WHO was able to reverse its advice as the initial data was expanded and it was assessed as much lower risk (similar to normal risk).
 
Medicines are all about risk and benefit, and these assessments are made for every patient in daily clinical practice across a whole range of issues. WHO was initially being cautious and warning people to be careful and discuss their individual circumstances with the health care team as WHO cannot hope to provide individual level advice for each person’s individual circumstances.