Coronavirus Disease 2019 Treatment: A Review of Early and Emerging Options

McCreary, Erin K; Pogue, Jason M

Given their antiviral activity against influenza, considerable attention has been paid to oseltamivir, and to a lesser degree baloxavir, as potential treatment options for COVID-19. This was exacerbated by the initial report from Huang et al [1] in Wuhan where patients managed with COVID-19 received oseltamivir in addition to broad-spectrum antimicrobials. It is important to note that use of oseltamivir was not as targeted therapy of SARS-CoV-2 but rather driven by the lack of a knowledge of the causative pathogen at the time of treatment and the desire to empirically treat influenza. The authors do not suggest the use of oseltamivir for COVID-19 in that publication, and there are no data that suggest in vitro activity of oseltamivir against SARS-CoV-2. In fact, the only data assessing oseltamivir activity against coronaviruses demonstrated it to be ineffective at inhibiting SARS-CoV-1, even at a concentration of 10 000 µM/L [56] . Coronaviruses do not utilize neuraminidase, and thus there is no enzyme to be inhibited by oseltamivir. This would hold true for zanamivir, peramivir, or any other neuraminidase inhibitor agents. Similarly, neither a defined mechanism nor in vitro data have suggested that baloxavir would demonstrate activity against SARS-CoV-2 or other coronaviruses. Therefore, given the critical need for these agents in the management of influenza and concern for drug shortages with oseltamivir, these agents should be avoided in patients with COVID-19 once influenza has been ruled out. Table 2 lists agents that are being investigated and/or theoretically considered for the management of SARS-CoV-2-infected patients. At this time, no recommendation can be made for any of these agents. In general, they should be avoided without additional supporting evidence.