Pharmacotherapy in COVID-19; A narrative review for emergency providers

Am J Emerg Med. 2020 Jul;38(7):1488-1493. doi: 10.1016/j.ajem.2020.04.035. Epub 2020 Apr 15.

Abstract

Introduction: The COVID-19 pandemic has been particularly challenging due to a lack of established therapies and treatment guidelines. With the rapid transmission of disease, even the off-label use of available therapies has been impeded by limited availability. Several antivirals, antimalarials, and biologics are being considered for treatment at this time. The purpose of this literature review is to synthesize the available information regarding treatment options for COVID-19 and serve as a resource for health care professionals.

Objectives: This narrative review was conducted to summarize the effectiveness of current therapy options for COVID-19 and address the controversial use of non-steroidal anti-inflammatory drugs (NSAIDs), angiotensin converting enzyme (ACE) inhibitors, and angiotensin receptor blockers (ARBs). PubMed and SCOPUS were queried using a combination of the keywords "COVID 19," "SARS-CoV-2," and "treatment." All types of studies were evaluated including systematic reviews, case-studies, and clinical guidelines.

Discussion: There are currently no therapeutic drugs available that are directly active against SARS-CoV-2; however, several antivirals (remdesivir, favipiravir) and antimalarials (chloroquine, hydroxychloroquine) have emerged as potential therapies. Current guidelines recommend combination treatment with hydroxychloroquine/azithromycin or chloroquine, if hydroxychloroquine is unavailable, in patients with moderate disease, although these recommendations are based on limited evidence. Remdesivir and convalescent plasma may be considered in critical patients with respiratory failure; however, access to these therapies may be limited. Interleukin-6 (IL-6) antagonists may be used in patients who develop evidence of cytokine release syndrome (CRS). Corticosteroids should be avoided unless there is evidence of refractory septic shock, acute respiratory distress syndrome (ARDS), or another compelling indication for their use. ACE inhibitors and ARBs should not be discontinued at this time and ibuprofen may be used for fever.

Conclusion: There are several ongoing clinical trials that are testing the efficacy of single and combination treatments with the drugs mentioned in this review and new agents are under development. Until the results of these trials become available, we must use the best available evidence for the prevention and treatment of COVID-19. Additionally, we can learn from the experiences of healthcare providers around the world to combat this pandemic.

Keywords: COVID 19; Favipiravir; Hydroxychloroquine; Remdesivir; SARS-CoV-2.

Publication types

  • Review

MeSH terms

  • Adenosine Monophosphate / analogs & derivatives
  • Adenosine Monophosphate / therapeutic use
  • Adrenal Cortex Hormones
  • Alanine / analogs & derivatives
  • Alanine / therapeutic use
  • Amides / therapeutic use
  • Angiotensin-Converting Enzyme Inhibitors / therapeutic use
  • Antiviral Agents / therapeutic use*
  • Betacoronavirus / drug effects
  • Coronavirus Infections / drug therapy*
  • Drug Therapy, Combination
  • Emergency Service, Hospital
  • Humans
  • Hydroxychloroquine / therapeutic use
  • Interleukin-6 / antagonists & inhibitors
  • Pandemics
  • Pneumonia, Viral / drug therapy*
  • Pyrazines / therapeutic use
  • Randomized Controlled Trials as Topic

Substances

  • Adrenal Cortex Hormones
  • Amides
  • Angiotensin-Converting Enzyme Inhibitors
  • Antiviral Agents
  • IL6 protein, human
  • Interleukin-6
  • Pyrazines
  • remdesivir
  • Adenosine Monophosphate
  • Hydroxychloroquine
  • favipiravir
  • Alanine

Supplementary concepts

  • COVID-19
  • severe acute respiratory syndrome coronavirus 2