Nitazoxanide/azithromycin combination for COVID-19: A suggested new protocol for early management

Azithromycin has been shown to have a clinical efficacy against severe acute respiratory syndrome coronavirus 2; ivermectin has also demonstrated a remarkable experimental efficacy with a potential to be used for Coronavirus disease 2019. Further, BCG vaccination is being considered for clinical trials aiming to test its potential for lowering COVID-19 morbidity and mortality. This article illustrates some structural and functional relationships that may gather these drugs and the author, basing on a combined pathophysiological and pharmacological approach, recommends the FDA-approved antidiarrhea drug; nitazoxanide, which has been previously suggested but unfortunately widely ignored, to be tested in combination with azithromycin for their potential activity against SARS CoV-2, soonest. The author also recommends testing their combined administration as early during the clinical course of COVID-19 as possible. Further, basing on the same represented concept, the author suggests more trials for interferons to be tested against SARS CoV-2, especially in severe and critical COVID-19 cases.

Nonalcoholic fatty liver disease: current and potential therapies

Nonalcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver injury worldwide. It covers a wide spectrum of hepatic disorders ranging from simple steatosis, through steatohepatitis (steatosis with inflammation), to cirrhosis. The molecular and cellular mechanisms underlying hepatic injury in NAFLD are not clear. Several evidences suggest that multiple mechanisms including insulin resistance, oxidative stress, inflammation, and genetic factors interact to initiate the development of NAFLD. Despite that there is currently no approved drug therapy for NAFLD, many approaches appear to be beneficial. Insulin sensitizers, antioxidants and antiinflammatory agents showed promising effects. This review highlights the current as well as the potential therapies of NAFLD.

Early use of non-steroidal anti-inflammatory drugs in COVID-19 might reverse pathogenesis, prevent complications and improve clinical outcomes

The pathogenesis of Coronavirus disease 2019 is still obscure and the need for exploration of possible mechanisms to suggest drugs based on knowledge should never be delayed. In this manuscript, we present a novel theory to explain the pathogenesis of COVID-19; lymphocyte distraction theory upon which the author has used, in a preprinted protocol, non-steroidal anti-inflammatory drugs (NSAIDs); diclofenac potassium, ibuprofen and ketoprofen, successfully to treat COVID-19 patients. Furthermore, we agree with a recommendation that glucocorticoids should not be used routinely for COVID-19 patients and suggested to be beneficial only for patients with late acute respiratory distress syndrome. A clinical proof of ibuprofen safety in COVID-19 has been published by other researchers and we suggest that early administration of NSAIDs, including ibuprofen, in COVID-19 is not only safe but it might also prevent COVID-19 complications and this manuscript explains some of the suggested associated protective mechanisms.

Effect of Metformin and Sitagliptin on Doxorubicin-Induced Cardiotoxicity in Rats: Impact of Oxidative Stress, Inflammation, and Apoptosis

Doxorubicin (DOX) is a widely used antineoplastic drug whose efficacy is limited by its cardiotoxicity. The aim of this study was to investigate the possible protective role of the antidiabetic drugs metformin (250 mg/kg dissolved in DW p.o. for seven days) and sitagliptin (10 mg/kg dissolved in DW p.o. for seven days) in a model of DOX-induced (single dose 15 mg/kg i.p. at the fifth day) cardiotoxicity in rats. Results of our study revealed that pretreatment with metformin or sitagliptin produced significant (P < 0.05) cardiac protection manifested by a significant decrease in serum levels of LDH and CK-MB enzymes and cardiac MDA and total nitrites and nitrates levels, a significant increase in cardiac SOD activity, and remarkable improvement in the histopathological features as well as a significant reduction in the immunohistochemical expression of COX-2, iNOS, and caspase-3 enzymes as compared to DOX group. These results may suggest using metformin and/or sitagliptin as preferable drugs for diabetic patients suffering from cancer and receiving DOX in their chemotherapy regimen.

Resveratrol protects against cisplatin-induced ovarian and uterine toxicity in female rats by attenuating oxidative stress, inflammation and apoptosis

Cisplatin is an important antineoplastic drug used in multiple chemotherapeutic regimens but unfortunately causes serious toxic effects as ovarian and uterine toxicity. This study aimed to investigate the potential protective effect of resveratrol (RSV) against cisplatin-induced ovarian and uterine toxicity in female rats. Thirty-two female Wistar rats were divided randomly into four groups (n = 8 in each). Control group received oral normal saline for 28 days; RSV group received RSV (10 mg/kg; daily) via oral gavage; CIS group received a single dose of CIS (7 mg/kg; i.p.) on the 21st day; (CIS + RSV) group received both RSV and CIS by the same schedules and doses of RSV and CIS groups, respectively. Results demonstrated a significant decrease in MDA level and a significant increase in both glutathione content and activity of the antioxidant enzymes GPx, SOD, and CAT in the tissues of the ovary and uterus of CIS + RSV group in comparison to that of CIS group (P<0.05), also there are significantly decreased tissue levels of the proinflammatory cytokines and enzymes (NF-κB, IL-1β, IL-6, TNF-α, COX-2, and iNOS), increased estradiol, progesterone, prolactin and decreased FSH serum levels in CIS + RSV group compared to CIS group (P < 0.05). Moreover, there is downregulation of tissues Cleaved Caspase-3, NF-κB and Cox-2 proteins as shown in Western blot analysis, also apoptosis was significantly inhibited, evidenced by downregulation of Bax and upregulation of Bcl-2 proteins, and the ovarian and uterine histological architecture and integrity were maintained in CIS + RSV group compared to CIS group. In conclusion, these findings indicate that RSV has beneficial effects in ameliorating cisplatin-induced oxidative stress, inflammation, and apoptosis in the ovarian and uterine tissues of female rats.

Effect of captopril and telmisartan on methotrexate-induced hepatotoxicity in rats: impact of oxidative stress, inflammation and apoptosis

Methotrexate (MTX) is a commonly used antineoplastic and anti-rheumatoid drug whose efficacy is limited by its hepatotoxicity. The aim of this study was to investigate the possible protective role of captopril (100 mg/kg/day, p.o. for seven days), an angiotensin converting enzyme inhibitor, and telmisartan (10 mg/kg/day p.o. for seven days), an angiotensin II receptor blocker with peroxisome proliferative receptor gamma (PPARγ) agonism, in a model of MTX (single dose 20 mg/kg i.p. at the fifth day) induced hepatotoxicity in rats. Results of the present study revealed MTX-induced hepatotoxicity as demonstrated by increased level of liver enzymes and confirmed by histopathology. Pretreatment with captopril or telmisartan produced a significant hepatic protection manifested as a significant (p < 0.05) decrease in serum levels of alanine transferase (ALT) and aspartate transferase (AST) and alkaline phosphatase (ALP) enzymes; hepatic malondialdehyde (MDA) and total nitrites and nitrates (NOx) levels; as well as a significant increase in hepatic superoxide dismutase (SOD) activity. In addition, there was a remarkable improvement in the histopathological features and a significant reduction in the expression of COX-2, iNOS and caspase-3 enzymes as compared with the MTX group. We recommend considering captopril/Telmisartan, if tolerated and not contraindicated, as preferable antihypertensive agents in patients receiving MTX in their chemotherapy protocols.

NSAIDs/nitazoxanide/azithromycin repurposed for COVID-19: potential mitigation of the cytokine storm interleukin-6 amplifier via immunomodulatory effects

INTRODUCTION

Mediators of immunity and inflammation are playing a crucial role in COVID-19 pathogenesis and complications as demonstrated by several genetic and clinical studies. Thus, repurposing of drugs that possess anti-inflammatory and/or immune-modulatory effects for COVID-19 is considered a rational approach.

AREAS COVERED

We analyze selected studies that correlated COVID-19 with dysregulated interferon and inflammatory responses while reflecting on our academic and real-life experience using non-steroidal anti-inflammatory drugs, nitazoxanide and azithromycin for management of COVID-19. Moreover, we interpret the results that suggested a potential survival benefit of low-dose aspirin and colchicine when used for COVID-19.

EXPERT OPINION

Nitazoxanide/azithromycin combination has been first hypothesized by the author and practiced by him and several researchers to benefit COVID-19 patients due to a potential ability to augment the natural interferon response as well as their positive immunomodulatory effects on several cytokines. Furthermore, NSAIDs, that are unfortunately currently at best of second choice after paracetamol, have been early postulated and clinically practiced by the author to prevent or ameliorate COVID-19 complications and mortality due to their anti-inflammatory and immunomodulatory properties. Finally, we repeat our previous call to adopt our observational study that used these drugs in sufficiently powered double blind randomized clinical trials.

ACEIs, ARBs, ibuprofen originally linked to COVID-19: the other side of the mirror

During the COVID-19 pandemic, a correspondence, published at the Lancet Respiratory Medicine, that linked angiotensin-converting enzyme inhibitors, angiotensin receptor blockers and ibuprofen to a higher risk of SARS CoV-2 infection and complications, has influenced, when adopted by official health authorities, the practical management of COVID-19 with regard to non-steroidal anti-inflammatory drugs that were avoided in all COVID-19 management protocols all over the world. This manuscript discusses, from a pharmacological point of view, the points of weakness in the mentioned correspondence and it also lists some important contradictory review articles as well as clinical results that refuted its claims. The author chose to argue against each claim represented in the mentioned correspondence to confirm that ACEIs, ARBs and NSAIDs including ibuprofen should not be considered hazardous to be administered for COVID-19 patients and to warn against any future adoption of such unproved claims.

Nitro-aspirin is a potential therapy for non alcoholic fatty liver disease

Non-alcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver injury; however its therapeutic strategy has not been established yet. Nitro-aspirin (NO-aspirin) is a new molecule in which aspirin and a NO-donating group are covalently linked. This study investigated the potential protective effect of NO-aspirin on NAFLD. Experimental rats were assigned into 4 groups. Group 1 was fed with normal diet and served as normal control group. Group 2 was fed with 2% cholesterol diet and received vehicle as positive control NAFLD group. Group 3 was fed with 2% cholesterol diet plus NO-aspirin (100 mg/kg/day). Group 4 was fed with 2% cholesterol diet plus aspirin (55 mg/kg/day). Rats were treated for 8 weeks. The results showed that NO-aspirin (but not aspirin) prevented the development of NAFLD as evidenced by significant reduction in liver weight/body weight ratio (liver index) and histopathologic changes. The protective effect of NO-aspirin is accompanied with significant decrease in triglycerides, malondialdehyde (MDA), and nitric oxide (NO) in hepatic tissue. Semi-quantitative immunohistochemical studies showed significant decrease in expression of inducible nitric oxide synthase (iNOS) and cyclooxygenase-2 (COX-2) in hepatic tissue. In conclusion, NO-aspirin inhibited multiple pathways involved in the pathogenesis of NAFLD indicating that it might serve as a new therapeutic strategy.

Tocilizumab, Remdesivir, Favipiravir, and Dexamethasone Repurposed for COVID-19: a Comprehensive Clinical and Pharmacovigilant Reassessment

In this manuscript, we discuss the expectations versus the real-world results of four repurposed COVID-19 drugs: tocilizumab, remdesivir, favipiravir, and dexamethasone from a clinical and pharmacovigilant point of view. We suggest that though the results of two-phase III double-blind clinical trials have been less than expected, tocilizumab has a real remaining potential to treat selected critical cases of COVID-19 beyond clinical trials until more data are revealed. On the contrary, remdesivir, though its FDA approval, and favipiravir are least likely to benefit COVID-19 patients. Moreover, we recommend that the RECOVERY dexamethasone should only be considered for critical hospitalized COVID-19 patients and we urge physicians in developing countries to avoid using it in mild-moderate COVID-19 cases. Finally, we recommend considering a personalized risk-benefit ratio before a decision is made using any of these drugs.

Resveratrol-zinc nanoparticles or pterostilbene-zinc: Potential COVID-19 mono and adjuvant therapy

In this manuscript we provide the scientific basis to adopt a novel combination of two widely available nutraceuticals; resveratrol and zinc in management of COVID-19 recommending their administration using a nano-carrier based drug-delivery system. Resveratrol, a well-known antioxidant and anti-inflammatory triphenolic stilbene, is abundant in red grapes, red wine, dark chocolate, and peanut butter. Alternatively, pterostilbene-zinc combination might be also considered without using a nano-carrier. We recommend conducting prompt clinical trials to assess the potential of the suggested combinations as a monotherapy for mild COVID-19 with a potential to prevent its progression to moderate-severe disease for which we recommend their trial as an adjuvant therapy. Furthermore, the suggested combinations might also possess a pharmacotherapeutic potential that exceeds COVID-19 to various inflammatory, immunologic, and oncologic diseases.

NSAIDs and Kelleni's protocol as potential early COVID-19 treatment game changer: could it be the final countdown?

We have previously published several papers illustrating numerous immunomodulatory and anti-inflammatory potential benefits when we repurposed safe, generic non-steroidal anti-inflammatory drugs (NSAIDs)/nitazoxanide/azithromycin (Kelleni's protocol), to early manage our COVID-19 pediatric, adult, and pregnant patients. In this manuscript, we discuss some recently published meta-analysis and clinical studies supporting our practice and discuss a molecular study that might be interpreted as an academic proof that our protocol might also prevent SARS-CoV-2 replication. Moreover, after aspirin has been suggested to be independently associated with reduced risk of mechanical ventilation, ICU admission and in-hospital mortality of COVID-19, we claim that the molecular interpretation of the results that led to this suggestion was not scientifically accurate, and we provide our academic interpretation confirming that low-dose aspirin is least likely to improve COVID-19 mortality through anticoagulation as was suggested. Furthermore, we describe other potential benefits related to aspirin-triggered lipoxins and resolvins while illustrating how NSAIDs interfere with COX-1, COX-2, SARS-CoV-2/ SARS-CoV-2 ORF protein-dependent activation of caspases and their subsequent mitochondrial dysfunction, endoplasmic reticulum stress, apoptosis and necroptosis which were associated with COVID-19 complications. Similarly, NSAIDs are known caspase inhibitors and thus they might independently inhibit other caspase-related COVID-19-associated downstream pathological signaling mechanisms. Finally, we postulated that CARD-14, a caspase recruitment domain-containing protein, polymorphisms might play a role in the development of severe and critical COVID-19 and confirmed our old call to early adopt NSAIDs, as an integral part of Kelleni's protocol, as of choice in its management aiming to end this pandemic.

The African Kelleni's roadmap using nitazoxanide and broad-spectrum antimicrobials to abort returning to COVID-19 square one

For over 3.5 years, SARS CoV-2 is continuing to evolve threatening to return all and any improvement the world has made into square one. In this clinically oriented systematic review and perspective, the author explains how the best current medical evidence is strongly supporting the use of the low cost, widely available and very safe nitazoxanide in early management of COVID-19, debates the relevant theoretical studies that negated or doubted this benefit, and suggests an African roadmap to preempt the worst-case scenario if or when a new SARS CoV-2 (sub) variant or even a new respiratory virus causes a new global surge of morbidity and mortality. Kelleni's protocol, including nitazoxanide as an integral component, is continuing to perfectly save lives of patients infected with many viruses, including SARS CoV-2 and the author stresses that respiratory RNA viruses are best managed with early pharmacological treatment. Broad-spectrum antimicrobials as nitazoxanide and azithromycin together with other therapeutics as non-steroidal anti-inflammatory drugs and the antihistaminic loratadine should be considered first to personalize the clinical management of COVID-19 and selected other alarming viral infections.

Real-world practice of the Egyptian Kelleni's protocol amid changing tropism of SARS-CoV-2 omicron BA.5.2.1.7, XBB 1.5 and CH.1.1 subvariants: a multi-purpose protocol

The Egyptian immune-modulatory Kelleni's protocol, including nitazoxanide as an integral component, is being safely and effectively practiced to manage SARS-CoV-2, RSV, influenza infections in pediatric, adult and pregnant patients with negligible requirements for the relatively expensive diagnostic molecular tests. Most recently, Kelleni's protocol is being likewise used to manage potential norovirus infection which is currently confused with SARS-CoV-2 Omicron new enterotropic subvariants and the antihistaminic loratadine has been co-administered in selected patients. Notably, Africa has the least mandates, restrictions and SARS-CoV-2 vaccination rates and yet the least COVID-19 mortality.

COVID-19, Ebola virus disease, and Nipah virus infection reclassification as novel acute immune dysrhythmia syndrome (n-AIDS): potential crucial role for immunomodulators

In this manuscript, COVID-19, Ebola virus disease, Nipah virus infection, SARS, and MERS are suggested to be considered for a novel immunological reclassification as acute onset immune dysrhythmia syndrome (n-AIDS) due to altered monocytic, Th1/Th2, as well as cytokines and chemokines balances. n-AIDs is postulated to be the cause of the acute respiratory distress and multi-inflammatory syndromes which are described with fatal COVID-19, and immunomodulators are suggested to effectively manage the mentioned diseases as well as for other disorders caused by Th1/Th2 imbalance. Meanwhile, para COVID syndrome is suggested to describe various immune-related complications, whether before or after recovery, and to embrace a potential of a latent infection, that might be discovered later, as occurred with Ebola virus disease. Finally, our hypothesis has evolved out of our real-life practice that uses immunomodulatory drugs to manage COVID-19 safely and effectively.

BCG vaccination potential for COVID-19: an analytical approach

In order to assess the possible protective potential of BCG vaccination as regards to COVID-19, we have analyzed BCG vaccination status and SARS CoV-2 morbidity and mortality in China and we have also examined other studies performed in other countries to assess the potential of booster doses of BCG vaccination for adults. We have concluded that BCG vaccination early in life is highly unlikely to be a tool that might prevent SARS CoV-2 infection in adults. Furthermore, we have suggested that BCG vaccination potential benefit to decrease COVID-19 morbidity and mortality in children is confounded by many factors, e.g. age limitations of exposure and other vaccines. However, BCG vaccination booster doses in adults might be of protective value until the results of well-designed clinical trials are published to confirm, or refute, this potential.

What would Hippocrates have sworn upon witnessing the COVID-19 mandates and mortality paradox

For the first time in human history, hundreds of millions of people all over the world have been subjected to compulsory vaccination with a new type of nucleic acid based vaccines in order to keep their jobs or be able to travel due to some notorious coronavirus disease 2019 (COVID-19) mandates. The vast majority of African countries were either initially deprived of these vaccines, or later, a majority of the population was too skeptical to receive them and preferred a safe early treatment pharmacological approach. Yet, Africa had the lowest COVID-19 mortality rate compared to those countries that adopted mass vaccination. This letter to the editor adds African insights that should be helpful in future pandemics to save millions of precious lives.

Repurposing metformin to manage idiopathic or long COVID Tinnitus: self-report adopting a pathophysiological and pharmacological approach

Chronic tinnitus is a common neurological disorder that affects millions of patients globally with no available successful pharmacotherapy. It can be extremely bothersome to some patients to the extent that it occasionally qualifies as a disability that can hinder them from leading a normal life. In this short communication, the author discusses how he suffered from idiopathic tinnitus and how he managed to adopt a combined pathophysiological and pharmacological approach to the reason for the first time in the medical literature that low-dose metformin might be safely and effectively repurposed to manage at least a subset of tinnitus patients while discussing the potential role of adenosine receptor agonists as potential future tinnitus therapeutics.

Protective effects of selenium on malathion-induced testicular toxicity in mice

The aim of this study was to investigate the possible protective effect of the antioxidant sodium selenite (0.1 mg/kg/day) via gavage once a day for 30 days for the first time in a model of malathion (27 mg/kg/day) via gavage once a day for 30 days induced testicular toxicity in mice. Results of this study revealed that concomitant administration of selenium has prevented the decrease in mean final and relative body weight as well as testicular and relative testicular weight as compared to malathion group. Concomitant selenium administration has also decreased malondialdehyde contents and increased serum levels of follicle stimulating hormone, luteinizing hormone, testosterone, acetylcholinesterase and testicular levels and activities of glutathione, glutathione peroxidase, catalase, superoxide dismutase and improved the testicular histopathological features as compared to malathion group.