"Off-label" use of hydroxychloroquine, azithromycin, lopinavir-ritonavir and chloroquine in COVID-19: A survey of cardiac adverse drug reactions by the French Network of Pharmacovigilance Centers

An artificial intelligence algorithm for co-clustering to help in pharmacovigilance before and during the COVID-19 pandemic

AIMS

Monitoring drug safety in real-world settings is the primary aim of pharmacovigilance. Frequent adverse drug reactions (ADRs) are usually identified during drug development. Rare ones are mostly characterized through post-marketing scrutiny, increasingly with the use of data mining and disproportionality approaches, which lead to new drug safety signals. Nonetheless, waves of excessive numbers of reports, often stirred up by social media, may overwhelm and distort this process, as observed recently with levothyroxine or COVID-19 vaccines. As human resources become rarer in the field of pharmacovigilance, we aimed to evaluate the performance of an unsupervised co-clustering method to help the monitoring of drug safety.

METHODS

A dynamic latent block model (dLBM), based on a time-dependent co-clustering generative method, was used to summarize all regional ADR reports (n = 45 269) issued between 1 January 2012 and 28 February 2022. After analysis of their intra and extra interrelationships, all reports were grouped into different cluster types (time, drug, ADR).

RESULTS

Our model clustered all reports in 10 time, 10 ADR and 9 drug collections. Based on such clustering, three prominent societal problems were detected, subsequent to public health concerns about drug safety, including a prominent media hype about the perceived safety of COVID-19 vaccines. The dLBM also highlighted some specific drug-ADR relationships, such as the association between antiplatelets, anticoagulants and bleeding.

CONCLUSIONS

Co-clustering and dLBM appear as promising tools to explore large pharmacovigilance databases. They allow, 'unsupervisedly', the detection, exploration and strengthening of safety signals, facilitating the analysis of massive upsurges of reports.

Prevalence and predictors of self-medication to prevent or treat COVID-19 among undergraduate students in Southern Brazil

Self-medication (SM) is the practice of consuming medicines without a prescription. Despite being a potentially dangerous action, SM is practiced globally and has been highlighted during the COVID-19 pandemic. The aim of this study was to evaluate SM for the prevention or treatment of COVID-19 and the factors associated with this practice among undergraduate students in Southern Brazil. A cross-sectional study was conducted between July and November 2020 using an electronic questionnaire to collect information about the practice of SM and the associated sociodemographic characteristics, health perception, and lifestyle. We collected 1,553 responses and identified a prevalence of 14.9% for SM. The risk factors for SM were earning between BRL 2,101 and BRL 5,250, studying at a public university, and studying a distance undergraduate course. The protective factors were age above 30 years, female sex, working or participating in internships, occasionally recommending their own medications to other people, and worsening health during the pandemic. The main drugs or products used were ivermectin, vitamins C and D, tea, azithromycin, zinc, and propolis. Our data could help in the development of health education measures to reduce SM among undergraduate students and guide the population regarding the risks of this practice.

Drug-induced cardiac toxicity and adverse drug reactions, a narrative review

Drug-induced cardiotoxicity is a primary concern in both drug development and clinical practice. Although the heart is not a common target for adverse drug reactions, some drugs still cause various adverse cardiac events, with sometimes severe consequences. Direct cardiac toxicity encompasses functional and structural changes of the cardiovascular system due to possible exposure to medicines. This phenomenon extends beyond cardiovascular drugs to include non-cardiovascular drugs including anticancer drugs such as tyrosine kinase inhibitors, anthracyclines and immune checkpoint inhibitors (ICIs), as well as various antipsychotics, venlafaxine, and even some antibiotics (such as macrolides). Cardiac ADRs comprise an array of effects, ranging from heart failure and myocardial ischemia to valvular disease, thrombosis, myocarditis, pericarditis, arrhythmias, and conduction abnormalities. The underlying mechanisms may include disturbances of ionic processes, induction of cellular damage via impaired mitochondrial function, and even hypercoagulability. To mitigate the impact of drug-induced cardiotoxicity, multi-stage evaluation guidelines have been established, following the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use (ICH) guidelines for in vitro and in vivo testing. Despite preclinical safeguards, post-marketing surveillance remains critical, as certain cardiotoxic drugs may escape initial scrutiny. Indeed, historical data show that cardiovascular ADRs contribute to almost 10% of market withdrawals. The impact of drug-induced cardiotoxicity on cardiac issues, particularly heart failure, is often underestimated, with incidence rates ranging from 11.0% to over 20.0%. We here comprehensively examine different patterns of drug-induced cardiotoxicity, highlighting current concerns and emerging pharmacovigilance signals. Understanding the underlying mechanisms and the associated risk factors is critical in order to promptly identify, effectively manage, and proactively prevent drug-induced cardiac adverse events. Collaborative efforts between physicians and cardiologists, coupled with thorough assessment and close monitoring, are essential to ensuring patient safety in the face of potential drug-induced cardiotoxicity.

QTc Prolongation to Predict Mortality in Patients Admitted with COVID-19 Infection: An Observational Study

BACKGROUND

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) causes Coronavirus disease 2019 (COVID-19), characterized by pulmonary infection ranging from asymptomatic forms to respiratory insufficiency and death. Evidence of cardiac involvement in COVID-19 is increasing, and systemic inflammation or direct heart damage by SARS-CoV-2 can prolong the corrected QT interval (QTc).

METHODS

In this observational study, a total of 333 consecutive patients admitted to the Covid Center of Verona University Hospital from November 2020 to April 2021 were included. Patients with bundle branch block, pacemaker-controlled heart rhythm and heart rate >120 beats/min were excluded. A complete electrocardiogram (ECG) was performed at admission, and QTc values of ≥440 ms for males and ≥460 ms for females were considered prolonged.

RESULTS

Overall, 153 patients had prolonged QTc (45.5%). In multivariate logistic regression analysis, male sex (odds ratio (OR)=6.612, p=0.046), troponin (OR=1.04, p=0.015) and lymphocyte count (OR=3.047, p=0.019) were independently associated with QTc prolongation. Multivariate logistic regression showed that QTc was independently associated with mortality (OR=4.598, p=0.036). Age, sex, the ratio between the partial pressure of oxygen (PaO2) and the fraction of inspired oxygen (FiO2) (P/F), and fibrosis-4 index for liver fibrosis (FIB-4) were also independently associated with mortality.

CONCLUSION

QTc interval prolongation appears to be a frequent finding in patients with COVID-19. Moreover, prolonged QTc may be predictive of more severe forms of COVID-19 and worse outcome.

Adverse drug reactions to chloroquine/hydroxychloroquine in combination with azithromycin in COVID-19 in-patients: data from intensive pharmacovigilance in Morocco, 2020

In Morocco, chloroquine/hydroxychloroquine + azithromycin have been used off-label for COVID-19 treatment. This study aimed to describe the distribution, nature and seriousness of the adverse drug reactions (ADRs) associated with the two drug combinations in COVID-19 in-patients. We conducted a prospective observational study based on intensive pharmacovigilance in national COVID-19 patients' management facilities from April 1 to June 12, 2020. Hospitalized patients treated with chloroquine/hydroxychloroquine + azithromycin and who experienced ADRs during their hospital stay were included in the study. The causality and seriousness of the ADRs were assessed using the World Health Organization-Uppsala Monitoring Centre method and the agreed criteria in the ICH guideline (E2A) respectively. A total of 237 (51.7%) and 221 (48.3%) COVID-19 in-patients treated respectively with chloroquine + azithromycin and hydroxychloroquine + azithromycin experienced 946 ADRs. Serious ADRs occurred in 54 patients (11.8%). Gastrointestinal system was most affected both in patients taking chloroquine + azithromycin (49.8%) or hydroxychloroquine + azithromycin (54.2%), followed by nervous system and psychiatric. Eye disorders were more frequent in patients receiving chloroquine + azithromycin (10.3%) than those receiving hydroxychloroquine + azithromycin (1.2%). Cardiac ADRs accounted for 6.4% and 5.1% respectively. Chloroquine + azithromycin caused more ADRs by patients than hydroxychloroquine + azithromycin (2.6 versus 1.5 ADRs/patient). Causality assessment was possible for 75.7% of the ADRs. Diabetes was identified as a risk factor for serious ADRs (ORa 3.56; IC: 95% 1.5-8.6). The off-label use of the two drug combinations in COVID-19 in-patients according to the national therapeutic protocol seems to be safe and tolerable. ADRs were mainly expected. However, precaution should be taken in using the drugs in diabetic patients to prevent the risk of serious ADRs.

Monitoring the safety of drugs and COVID-19 vaccines by the French Pharmacovigilance Centers during the pandemic: A win-win bet with Health Authorities!

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) pandemic virus was a "health crisis" and a significant burden also for the French pharmacovigilance system. It took its toll in 2 phases, the first being in early 2020 when very little was known, and during which the missions of the 31 Regional Pharmacovigilance Centers (RPVCs) from university hospitals were to detect adverse reactions of drugs used in the context of the disease. Whether as a possible aggravating role on COVID-19, or displaying a different safety profile during its course, or to assess safety of curative treatment, this phase preceded that of the arrival of dedicated vaccines. Then the RPVCs' missions were to detect, as early as possible, any new serious adverse effect leading to a potential signal that would modify the benefit/risk ratio of a vaccine and require the implementation of health safety measures. During these two distinct periods, signal detection remained the core business of the RPVCs. Each RPVC had to organize itself to handle an unprecedented surge of declarations and requests for advice, from health care professionals and patients alike. "Leading" RPVCs, who were in charge of monitoring vaccines, had to deal with an extraordinary workload (still going on to this date), to generate in real-time and on a weekly basis, a summary of all the adverse drug reaction (ADR) reports as well as an extended analysis of the different safety signals. The organization put in place at the beginning of the health crisis, adapted to the context of the vaccines, allowed to meet the challenge of real-time pharmacovigilance monitoring, and to identify many safety signals. Efficient "short-circuits exchanges" with the French Regional Pharmacovigilance Centers Network (RPVCN) were paramount to the National Agency for the Safety of Medicines and Health Products (ANSM) to develop an optimal collaborative partnership. The French RPVCN has shown at this occasion both agility and flexibility, swiftly adapting to vaccine- and media-related unrest, and demonstrated its effectiveness in the early detection of safety signals. This crisis also confirmed the superiority of manual/human signal detection over automated ones, as the most effective and powerful tool to date to rapidly detect and validate a new ADR and enable to elaborate rapid risk reduction measures. To maintain the performance of French RPVCN in signal detection and to monitor all drugs as they should, and as expected by our fellow citizens, a new funding model should be considered.

Pharmacovigilance follow-up of patients in the context of the COVID-19 pandemic

INTRODUCTION

In the context of COVID-19 pandemic, a national pharmacovigilance survey was set up in March 2020. The purpose of this survey was to ensure continuous monitoring of adverse drug reactions (ADRs) in patients with COVID-19, not only related to the drugs used in this indication but also related to all drugs administered to these patients or suspected of having promoted the infection.

MATERIAL AND METHODS

This descriptive study was based on data extracted from the French Pharmacovigilance Database from 1 January 2020 to 30 September 2021. Misuse was also analysed through the MESANGE project. The ADRs were classified according to three groups: "drugs used to treat COVID-19", "other drugs administered to COVID-19 positive patients" and "drugs suspected of having promoted COVID-19". The data were also presented according to 2 periods (period one was from January to June 2020 and period two from July 2020 onwards).

RESULTS

Among 2189 included cases, 67.1% were serious. Cases were mainly related to "other drugs administrated to COVID-19 positive patients" (58.5%) followed by "drugs used to treat COVID-19" (33.7%) and "drugs suspected of having promoted COVID-19" (7.8%). Drugs used to treat COVID-19 and their main safety profile were different depending on the period: mostly hydroxychloroquine (51%) with heart injury and lopinavir/ritonavir (42%) with liver injury for the first period, and dexamethasone (46%) with hyperglycemia and tocilizumab (28%) with liver injury for the second period. The drugs suspected of worsening COVID-19 differed in both periods especially for non-steroidal anti-inflammatory drugs mainly reported in period 1 (41.5% versus 8.2% in period 2). Other immunosuppressive drugs were in the majority in the second period (85.7%), with mainly methotrexate (15.3%), anti-CD20 (15.3%) and anti-TNF alpha (10.5%). No confirmed safety signal was identified among other drugs administered to patients with COVID-19. The profile of ADRs and suspected drugs was similar between the 2 periods. The study of misuse in outpatient settings identified in both periods mainly hydroxychloroquine, azithromycin, ivermectin and zinc±vitamin C.

DISCUSSION

This survey, based on real-time pharmacological and medical assessment of ADRs and weekly meetings in a specific national committee, made it possible to identify relevant safety signals which contribute to patient care with no delay. The main safety signal highlighted was serious cardiac damage under hydroxychloroquine, alone or combined with azithromycin and also with lopinavir/ritonavir. This signal has contributed to the evolution of the recommendations for these 2 drugs. The methodology of this survey has been taken over and is still going on for the pharmacovigilance monitoring of vaccines against COVID-19, for monoclonal antibodies used against COVID-19 and also for Paxlovid® (nirmatrelvir/ritonavir) which benefit from dedicated surveys.

[Monitoring the safety of drugs and COVID-19 vaccines by the French Pharmacovigilance Centers during the pandemic: a win-win bet with Health Authorities!]

The pandemic subsequent to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus resulted, for the French institutional pharmacovigilance, in a "health crisis" in 2 phases: the coronavirus disease 2019 - "COVID-19" phase during which the missions of the Regional Pharmacovigilance Centres (RPVC) were to detect a possible impact of drugs on this disease, as whether existed a possible aggravating role of certain drugs, or the safety profile of drugs used for the management of COVID-19 could evolve. The second phase followed the availability of COVID-19 vaccines, during which the RPVCs' missions were to detect as early as possible any new serious adverse effect, source of a potential signal that would modify the benefit/risk ratio of a vaccine and require the implementation of health safety measures. During these two periods, signal detection remained the core business of the RPVCs. The RPVCs had to organize themselves to handle an historical surge of declarations and requests for advice, whereas the RPVCs in charge of monitoring vaccines had to deal with an extraordinary dense activity over a long period of time, in order to produce in real time and on a weekly basis, a summary of all the declarations and an analysis of safety signals. The national organization put in place made it possible to meet the challenge of real-time pharmacovigilance monitoring of 4 vaccines with conditional marketing authorizations. Short-circuit efficient exchanges with the French Regional Pharmacovigilance Centres Network was paramount for the French National Agency for medicines and health products (Agence nationale de sécurité du médicament et des produits de santé) to develop an optimal collaborative partnership. The RPVC network has shown agility and flexibility, has been able to adapt swiftly and demonstrated its effectiveness in the early detection of safety signals. This crisis confirmed the superiority of manual/human signal detection as the most effective and powerful tool to date, to rapidly detect a new adverse drug reaction and enable to elaborate rapid measures of risk reduction. In order to maintain the performance of French RPVCs in signal detection and to monitor all drugs as they should and as expected by our fellow citizens, a new funding model correcting the inadequacy of RPVCs' expertise resources in relation to the volume of reports should be considered.

Clinical innovation ethics frameworks: A systematic narrative review

BACKGROUND

It is common for doctors to engage in clinical innovation-i.e. to use novel interventions that differ from standard practice, and that have not yet been shown to be safe or effective according to the usual standards of evidence-based medicine-in the belief that this will benefit their patients. Clinical innovation is currently poorly defined and lacks cohesive oversight mechanisms.

METHODS

A systematic narrative review, with the aim of identifying areas of similarity and divergence in innovation ethics frameworks developed across different medical specialties.

RESULTS

47 articles were included in the review. Few ethical issues raised by the ethics frameworks appear to be unique to distinct areas of practice. While variations exist in the oversight mechanisms suggested, these are again not specific to areas of practice, but rather reflect either cautious or more permissive attitudes towards clinical innovation.

CONCLUSIONS

There is considerable overlap amongst ethics frameworks developed for use in diverse areas of practice. This reflects a tendency to treat innovative interventions in each area of practice as "exceptional" and a failure to develop "higher order" frameworks such as those that have been developed for research. Those involved in the oversight of clinical innovation need to aim for a balance between exceptionalism and harmonisation.

Characterization of adverse events to hydroxychloroquine, ivermectin, azithromycin and tocilizumab in patients hospitalized due to COVID-19 in a Peruvian Social Health Insurance hospital

OBJECTIVE.

To characterize the adverse events (AEs) related to the off-label use of hydroxychloroquine (HQ), azithromycin (AZI), tocilizumab (TOB) and ivermectin (IVM) for the treatment of COVID-19 in hospitalized patients.

MATERIALS AND METHODS.

We conducted a secondary cross-sectional analysis of the Peruvian Social Health Insurance (EsSalud) pharmacovigilance system database of AE notifications to HQ, AZI, TOB and IVM in the Edgardo Rebagliati Martins National Hospital from April to October 2020. Information was collected from digital medical records. We estimated AE reporting rates and evaluated their characteristics by drug type, time of occurrence, type by the affected organ-system, severity and causality.

RESULTS.

We identified 154 notifications describing a total of 183 AE possibly related to HQ, AZI, TOB and IVM; the reporting rate was 8%. The median time of AE occurrence was 3 days (IQR: 2-5). Most were cardiovascular events; prolongation of the QT interval was the most frequent. Hepatobiliary AEs were mainly associated with TOB. Most cases were moderate, however, 10.4% were severe.

CONCLUSIONS.

We found AEs potentially associated with the use of HQ, AZI, TOB and IVM against COVID-19; cardiovascular events were the most frequent. Although AZI, HQ and IVM have known safety profiles, their use against COVID-19 could increase the occurrence of AE due to the risk factors inherent to this infection. Surveillance systems must be improved, especially those for TOB.

Trends in the Use of Sedative-Hypnotics, Opioids, and Neuromuscular Blockers in Hospitalized Patients During the COVID-19 Pandemic: Observational Retrospective Study

Background

The coronavirus disease 2019 (COVID-19) pandemic has increased the use of drugs administered for mechanical ventilation, leading to shortages in some countries.

Objective

The aim was to identify trends in the consumption of sedatives, hypnotics, neuromuscular blockers, and opioids used for anesthetic induction and deep sedation in hospitals in Colombia.

Method

This was a descriptive, longitudinal, and retrospective study with monthly follow-up of sedative, hypnotic, opioid, and neuromuscular blocker dispensing in 20 clinics and hospitals from January to November 2020. The frequencies of use of each drug and variations in the institutions and intensive care units (ICUs) were identified.

Results

A total of 1,252,576 units of the analyzed drugs were delivered to 79,094 treated patients, 55.0% of whom were women (n = 43,521). The drugs with the greatest increase in consumption were rocuronium (1058% variation in March–November) and propofol (511%). The consumption of midazolam and vecuronium initially increased, but by the end of the study period, it decreased. Among drugs dispensed only in ICUs, 920,170 units were delivered (73.5% of the drugs dispensed during the study), and the most often dispensed drugs were fentanyl (n = 251,519; 27.3% of the drugs used in the ICU) and midazolam (5 mg/5 mL) solution (n = 188,568; 20.5%). Specifically in the ICU, the drugs with the greatest increase in use were rocuronium (19,709%), propofol (2622%), and ketamine (2591%).

Conclusion

Rapid changes in the use of drugs were evident, which demonstrates the need for closer cooperation among treating physicians, service providers, pharmaceutical managers, and state institutions to maintain a sufficient and timely supply of critical drugs in this type of contingency.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40801-022-00337-z.

[Adverse reactions to drugs used for COVID-19 in five Latin American countriesReações adversas a medicamentos utilizados para a COVID-19 em cinco países da América Latina]

Objective

Characterize and describe reports of suspected adverse reactions to a group of drugs used in Colombia, Costa Rica, Cuba, Chile, El Salvador, Mexico, and Peru to treat or prevent coronavirus disease (COVID-19) between 1 March and 31 August 2020.

Methods

A list of the 13 drugs used to treat or prevent COVID-19 was prepared, based on official and unofficial sources. Drawing on the databases of the national pharmacovigilance programs of the participating countries, reports of suspected adverse reactions to these drugs were collected for the period from 1 March and 31 August 2020.

Results

A total of 3 490 reports of suspected adverse reactions were received from the pharmacovigilance programs of Peru (n = 3 037), Cuba (n = 270), Colombia (n = 108), Chile (n = 72), and El Salvador (n = 3). The drugs with the highest number of reported adverse reactions were azithromycin, ivermectin, and hydroxychloroquine. Diarrhea was the most frequent event (15.0%). Of the total suspected adverse reactions, 11.9% were reported as serious. The most frequent was QT prolongation following use of hydroxychloroquine. Of these suspected serious adverse reactions, 54.5% occurred in people over 65 years of age.

Conclusions

While it is not possible to establish a causal relationship from the evaluation of spontaneous reports, the present study confirms the presence of adverse reactions-some of them serious-involving drugs used to treat or prevent COVID-19.

Use of Drugs Associated with QT Interval Prolongation at the Hospital Level during the COVID-19 Pandemic in Colombia

Background. Many of the therapeutic proposals for COVID-19 have been associated with adverse effects, including the risk of QT interval prolongation and torsades de pointes (TdP). The objective was to determine the use of drugs with a risk of QT interval prolongation in 21 clinics/hospitals in Colombia from January to December 2020. Methods. This cross-sectional study identified drug use according to pharmacological groups with potential risk of QT interval prolongation according to a risk classification: conditional, possible, and known risk of TdP. Descriptive analyses were performed. Results. A total of 355,574 patients who received QT-prolonging drugs were identified (equivalent to 51.4% of all inpatients treated during the study period). Of the group of patients on QT drugs, 54.4% used at least one drug with conditional risk, 52.6% with possible risk, and 40.3% with known risk. The most commonly used belonged to the group of drugs for the nervous system (63.0%), alimentary tract and metabolism (56.8%), anti-infectives for systemic use (13.0%), and the cardiovascular system (11.7%). On average, patients received $2.0\pm 1.5$ risk drugs. Regarding drugs initially considered against COVID-19, 2,120 patients (0.6%) received azithromycin, 802 (0.2%) received chloroquine, 517 received hydroxychloroquine (0.1%), and 265 received lopinavir/ritonavir (0.1%). Conclusion. The high proportion of patients treated at the hospital level who receive drugs with risk of prolonging the QT interval should alert those responsible for their care to avoid fatal outcomes, especially during the COVID-19 epidemic, when some QT drugs are being used more frequently.

Pharmacovigilance and Its Importance for Primary Health Care Professionals

Pharmacovigilance is used to detect, assess, understand, and prevent the adverse effects of medications. The need for safety monitoring has evolved around unfortunate incidents in history, with deaths caused by anesthesia and congenital malformations from thalidomide use. Reports from adverse drug reactions (ADRs) are stored in a global database and can be used to evaluate the associations between various medications and associated ADRs. Clinicians play an important role in the recognition and reporting of ADRs to national pharmacovigilance centers (NPCs). The purpose of NPCs is to make the clinicians understand their functions, including the monitoring, investigation, and assessment of ADR reports, along with periodical benefit-risk assessments of medications via multiple sources. A case study on NPCs and the types of safety issues evaluated by them are provided to illustrate their role in medicine safety surveillance. ADR monitoring was also combined with vaccine safety surveillance approaches. Overall, this study will provide insights to clinicians on the importance of pharmacovigilance in maintaining patient safety with the proper use of medications.

Sales of "COVID kit" drugs and adverse drug reactions reported by the Brazilian Health Regulatory Agency

Off-label use of azithromycin, hydroxychloroquine, and ivermectin (the "COVID kit") has been suggested for COVID-19 treatment in Brazil without clinical or scientific evidence of efficacy. These drugs have known adverse drug reactions (ADR). This study aimed to analyze if the sales of drugs in the "COVID kit" are correlated to the reported number of ADR after the COVID-19 pandemic began. Data was obtained from the Brazilian Health Regulatory Agency (Anvisa) website on reported sales and ADRs for azithromycin, hydroxychloroquine, and ivermectin for all Brazilian states. The period from March 2019 to February 2020 (before the pandemic) was compared to that from March 2020 to February 2021 (during the pandemic). Trend adjustment was performed for time series data and cross-correlation analysis to investigate correlation between sales and ADR within the same month (lag 0) and in the following months (lag 1 and lag 2). Spearman's correlation coefficient was used to assess the magnitude of the correlations. After the pandemic onset, sales of all investigated drugs increased significantly (69.75% for azithromycin, 10,856,481.39% for hydroxychloroquine, and 12,291,129.32% for ivermectin). ADR levels of all medications but azithromycin were zero before the pandemic, but increased after its onset. Cross-correlation analysis was significant in lag 1 for all drugs nationwide. Spearman's correlation was moderate for azithromycin and hydroxychloroquine but absent for ivermectin. Data must be interpreted cautiously since no active search for ADR was performed. Our results show that the increased and indiscriminate use of "COVID kit" during the pandemic correlates to an increased occurrence of ADRs.

A comprehensive review of adverse events to drugs used in COVID-19 patients: Recent clinical evidence

BACKGROUND

Since the breakthrough of the pandemic, several drugs have been used to treat COVID-19 patients. This review aims to gather information on adverse events (AE) related to most drugs used in this context.

METHODS

We performed a literature search to find articles that contained information about AE in COVID-19 patients. We analysed and reviewed the most relevant studies in the Medline (via PubMed), Scopus and Web of Science. The most frequent AE identified were grouped in our qualitative analysis by System Organ Class (SOC), the highest level of the MedDRA medical terminology for each of the drugs studied.

RESULTS

The most frequent SOCs among the included drugs are investigations (n = 7 drugs); skin and subcutaneous tissue disorders (n = 5 drugs); and nervous system disorders, infections and infestations, gastrointestinal disorders, hepatobiliary disorders, and metabolism and nutrition disorders (n = 4 drugs). Other SOCs also emerged, such as general disorders and administration site conditions, renal and urinary disorders, vascular disorders and cardiac disorders (n = 3 drugs). Less frequent SOC were eye disorders, respiratory, thoracic and mediastinal disorders, musculoskeletal and connective tissue disorders, and immune system disorders (n = 2 drugs). Psychiatric disorders, and injury, poisoning and procedural complications were also reported (n = 1 drug).

CONCLUSIONS

Some SOCs seem to be more frequent than others among the COVID-19 drugs included, although neither of the studies included reported causality analysis. For that purpose, further clinical studies with robust methodologies, as randomised controlled trials, should be designed and performed.

Safety of Drugs Used during the First Wave of COVID-19: A Hospital-Registry-Based Study

The emergency of the coronavirus disease 2019 (COVID-19) pandemic led to the off-label use of drugs without data on their toxicity profiles in patients with COVID-19, or on their concomitant use. Patients included in the COVID-19 Patient Registry of a tertiary hospital during the first wave were analyzed to evaluate the adverse drug reactions (ADRs) with the selected treatments. Twenty-one percent of patients (197 out of 933) had at least one ADR, with a total of 240 ADRs. Patients with ADRs were more commonly treated with multiple drugs for COVID-19 infection than patients without ADRs (p < 0.001). They were younger (median 62 years vs. 70.1 years; p < 0.001) and took less medication regularly (69.5% vs. 75.7%; p = 0.031). The most frequent ADRs were gastrointestinal (67.1%), hepatobiliary (10.8%), and cardiac disorders (3.3%). Drugs more frequently involved included lopinavir/ritonavir (82.2%), hydroxychloroquine (72.1%), and azithromycin (66.5%). Although most ADRs recovered without sequelae, fatal cases were described, even though the role of the disease could not be completely ruled out. In similar situations, efforts should be made to use the drugs in the context of clinical trials, and to limit off-label use to those drugs with a better benefit/risk profile in specific situations and for patients at high risk of poor disease prognosis.

Hydroxychloroquine Blood Concentrations Can Be Clinically Relevant Also After Drug Discontinuation

BACKGROUND AND OBJECTIVE

Hydroxychloroquine was widely used during the severe acute respiratory syndrome coronavirus 2 pandemic as an antiviral drug. Most previous pharmacokinetic/pharmacodynamic studies on hydroxychloroquine were conducted on healthy volunteers or patients receiving long-term therapy. There are no studies on the elimination of hydroxychloroquine after short-term treatments. Hydroxychloroquine is known to have a pro-arrhythmic effect through QT interval prolongation, but data in this setting are not conclusive. Our aims were to estimate the time needed for hydroxychloroquine concentrations (CHCQ) to drop to a safe concentration (500 ng/mL) after a short-term therapeutic cycle and to correlate the corrected QT interval with CHCQ.

METHODS

We collected blood samples and electrocardiograms of patients who underwent short-term therapy with hydroxychloroquine during drug intake and after discontinuation. Hydroxychloroquine concentrations were determined by high-performance liquid chromatography-tandem mass spectrometry and analysed with a linear regression model to estimate the elimination time of the drug after its discontinuation. We conducted a multivariate analysis of the corrected QT interval correlation with CHCQ.

RESULTS

Our data suggest that short-term hydroxychloroquine courses can generate significant CHCQ persisting above 500 ng/mL up to 16 days after discontinuation of treatment. Corrected QT interval prolongation significantly correlates with CHCQ.

CONCLUSIONS

The study confirms the long half-life of hydroxychloroquine and its effect on the corrected QT interval even after short-term courses of the drug. This can inform the clinician using hydroxychloroquine treatments that it would be safer to start or re-initiate treatments with corrected QT interval-prolonging potential 16 days after hydroxychloroquine discontinuation.

Serious Cardiovascular Adverse Events Associated with Hydroxychloroquine/Chloroquine Alone or with Azithromycin in Patients with COVID-19: A Pharmacovigilance Analysis of the FDA Adverse Event Reporting System (FAERS)

BACKGROUND

The use of hydroxychloroquine or chloroquine (HCQ/CQ) as monotherapy or combined with azithromycin for the treatment of coronavirus disease 2019 (COVID-19) may increase the risk of serious cardiovascular adverse events (SCAEs).

OBJECTIVE

Our objective was to describe and evaluate the risk of SCAEs with HCQ/CQ as monotherapy or combined with azithromycin compared with that for therapeutic alternatives.

METHODS

We performed a disproportionality analysis and descriptive case series using the US FDA Adverse Event Reporting System.

RESULTS

Compared with remdesivir, HCQ/CQ was associated with increased reporting of SCAEs (reporting odds ratio [ROR] 2.1; 95% confidence interval [CI] 1.8-2.5), torsade de pointes (TdP)/QTc prolongation (ROR 35.4; 95% CI 19.4-64.5), and ventricular arrhythmia (ROR 2.5; 95% CI 1.6-3.9); similar results were found in comparison with other therapeutic alternatives. Compared with lopinavir/ritonavir, HCQ/CQ was associated with increased reporting of ventricular arrhythmia (ROR 10.5; 95% CI 3.3-33.4); RORs were larger when HCQ/CQ was used in combination with azithromycin. In 2020, 312 of the 575 reports of SCAEs listed concomitant use of HCQ/CQ and azithromycin, including QTc prolongation (61.4%), ventricular arrhythmia (12.0%), atrial fibrillation (8.2%), TdP (4.9%), and cardiac arrest (4.4%); 88 (15.3%) cases resulted in hospitalization and 79 (13.7%) resulted in death. In total, 122 fatal QTc prolongation-related cardiovascular reports were associated with 1.4 times higher odds of reported death than those induced by SCAEs; 87 patients received more than one QTc-prolonging agent.

CONCLUSIONS

Patients treated with HCQ/CQ monotherapy or HCQ/CQ + azithromycin may be at increased risk of SCAEs, TdP/QTc prolongation, and ventricular arrhythmia. Cardiovascular risks need to be considered when evaluating the benefit/harm balance of treatment with HCQ/CQ, especially with the concurrent use of QTc-prolonging agents and cytochrome P450 3A4 inhibitors when treating COVID-19.

Safety profile of hydroxychloroquine used off‐label for the treatment of patients with COVID‐19: A descriptive study based on EudraVigilance data

At the beginning of the COVID‐19 pandemic, worldwide attempts were made to identify potential drugs effective against the COVID‐19. Hydroxychloroquine was among the first receiving attention. However, following its use in therapy, it has been shown that hydroxychloroquine was not only ineffective but probably, due to its known side effects, even responsible of increased mortality of patients. The objective of this study was to review the safety profile of hydroxychloroquine used off‐label for the treatment of COVID‐19. We analyze the reports of suspected adverse drug reactions (ADRs) collected in EudraVigilance, the European database of ADR reports. We collected 2266 reports for 2019 and 6525 for 2020. The most reported ADRs during 2020 were those relating to cardiac, hepatic, renal toxicity such as QT prolongation with 400 cases in 2020 (of which, 345 cases—9.97%—with COVID‐19 as a therapeutic indication) versus 1 case only in 2019 (0.01%), long QT syndrome: 38 cases in 2020 (36 as COVID‐19 treatment) versus 0 in 2019, hepatitis: 13 cases in 2019 (0.11%) and 132 in 2020, and 32 cases (24, 0.69%) of acute kidney injury in 2020 and only 3 cases in 2019. Moreover, some important vision‐related ADRs also increased significantly during 2020, such as retinal toxicity with 92 cases in 2020 versus 7 in 2019. Even though with its intrinsic limitations, our results may be added to the most recent scientific evidence to confirm the unfavorable risk profile of hydroxychloroquine in its off‐label use in the treatment of COVID‐19 disease.

Comparative study of the adverse event profile of hydroxychloroquine before and during the Sars-CoV2 pandemic

Aims

At the beginning of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, there were no clinically-tested medications for the effective treatment of coronavirus disease. In this context, on 5 March 2020, the French Public Health Council issued several recommendations for the therapeutic management of this new disease, including the use of hydroxychloroquine (HCQ). An unexpected cardiovascular safety signal was quickly identified as being more frequent than expected thanks to the reports of adverse drug reactions (ADRs) submitted to French regional pharmacovigilance centres (RPVC). The objective of this study was to compare all ADRs reported with HCQ used in its usual indication, collected before the pandemic period (1985 to 31 December, 2019) with those reported with the coronavirus disease 2019 (COVID-19) indication (1 January to 21 July, 2020).

Methods

For this purpose, reports were extracted from the French pharmacovigilance database and analysed for these two periods.

Results

Our study showed a different safety profile in COVID-19 patients with more cardiac disorders (57% of ADRs versus 5% before the pandemic period), especially QT interval prolongation, resulting from an interaction with azithromycin in more than 20% of cases. Hepatobiliary disorders were also significantly more frequent.

Conclusions

These observations could be associated with the effect of the virus itself on the various organs, the profile of the patients treated, and concomitant drug treatments.

Mining Electronic Health Records for Drugs Associated With 28-day Mortality in COVID-19: Pharmacopoeia-wide Association Study (PharmWAS)

BACKGROUND

Patients hospitalized for a given condition may be receiving other treatments for other contemporary conditions or comorbidities. The use of such observational clinical data for pharmacological hypothesis generation is appealing in the context of an emerging disease but particularly challenging due to the presence of drug indication bias.

OBJECTIVE

With this study, our main objective was the development and validation of a fully data-driven pipeline that would address this challenge. Our secondary objective was to generate pharmacological hypotheses in patients with COVID-19 and demonstrate the clinical relevance of the pipeline.

METHODS

We developed a pharmacopeia-wide association study (PharmWAS) pipeline inspired from the PheWAS methodology, which systematically screens for associations between the whole pharmacopeia and a clinical phenotype. First, a fully data-driven procedure based on adaptive least absolute shrinkage and selection operator (LASSO) determined drug-specific adjustment sets. Second, we computed several measures of association, including robust methods based on propensity scores (PSs) to control indication bias. Finally, we applied the Benjamini and Hochberg procedure of the false discovery rate (FDR). We applied this method in a multicenter retrospective cohort study using electronic medical records from 16 university hospitals of the Greater Paris area. We included all adult patients between 18 and 95 years old hospitalized in conventional wards for COVID-19 between February 1, 2020, and June 15, 2021. We investigated the association between drug prescription within 48 hours from admission and 28-day mortality. We validated our data-driven pipeline against a knowledge-based pipeline on 3 treatments of reference, for which experts agreed on the expected association with mortality. We then demonstrated its clinical relevance by screening all drugs prescribed in more than 100 patients to generate pharmacological hypotheses.

RESULTS

A total of 5783 patients were included in the analysis. The median age at admission was 69.2 (IQR 56.7-81.1) years, and 3390 (58.62%) of the patients were male. The performance of our automated pipeline was comparable or better for controlling bias than the knowledge-based adjustment set for 3 reference drugs: dexamethasone, phloroglucinol, and paracetamol. After correction for multiple testing, 4 drugs were associated with increased in-hospital mortality. Among these, diazepam and tramadol were the only ones not discarded by automated diagnostics, with adjusted odds ratios of 2.51 (95% CI 1.52-4.16, Q=.1) and 1.94 (95% CI 1.32-2.85, Q=.02), respectively.

CONCLUSIONS

Our innovative approach proved useful in generating pharmacological hypotheses in an outbreak setting, without requiring a priori knowledge of the disease. Our systematic analysis of early prescribed treatments from patients hospitalized for COVID-19 showed that diazepam and tramadol are associated with increased 28-day mortality. Whether these drugs could worsen COVID-19 needs to be further assessed.

Self-medication and the ‘infodemic’ during mandatory preventive isolation due to the COVID-19 pandemic

Aim:

Quarantine due to the COVID-19 pandemic altered the supply and demand of health services. This, together with the ‘infodemic’ and generalized panic, could alter the patterns of self-medication in the population. The objective was to characterize the patterns of self-medication in four cities of Colombia during mandatory preventive isolation in 2020.

Methods:

This was a cross-sectional study done in four Colombian cities during mandatory national preventive isolation between June and September 2020. A sample of 397 adults who responded to an online survey, based on the Instrument for Systematic Data Collection for Self-medication (Instrumento de Recolección Sistemática de Datos para la Automedicación–IRIS-AM), was obtained. The use of social networks (including WhatsApp) as the source of information about medications was explored.

Results:

The 397 people surveyed had a median age of 31.0 years, and 58.2% were women. The prevalence of self-medication during lockdown was 34.3% (n = 136). Medications targeting the nervous system (n = 117; 86.0% of those participants with self-medication) and the musculoskeletal system (n = 68; 50.0%) were the most commonly used. Ten (7.4%) of the self-medicated patients reported doing so to prevent COVID-19, and 15 (11.0%) named social networks as the source of information.

Conclusion:

More than one-third of the participants reported self-medication during COVID-19 lockdown, mainly with analgesic-type nervous system medications. People who reported self-medication to prevent COVID-19 often got their information from social networks, the Internet, and WhatsApp.

Plain Language Summary

Does the public know when a scientific controversy is over? Public perceptions of hydroxychloroquine in France between April 2020 and June 2021

Objectives

In the early stages of the coronavirus disease 2019 (COVID-19) pandemic, chloroquine and its derivatives such as hydroxychloroquine (HCQ) were widely commented upon both within the scientific community and in the media. This paper explores the different factors that influenced public perceptions in France of the efficacy of HCQ as well as their evolution between April 2020 and June 2021.

Methods

This article draws on 5 surveys conducted among representative samples of the French population (projects COCONEL and TRACTRUST; quota method, n = 1006; 1004; 2006; 1014 and 1005). We asked questions on the effectiveness of chloroquine against COVID-19. We also collected sociodemographic variables and attitudes toward politics and science.

Results

Between April and June 2021, the proportion of respondents who believed in the efficacy of HCQ decreased rapidly from 35% to 14%. The proportion of respondents who believed that HCQ is ineffective rose gradually from 6% to 21%. After adjusting for the temporal effect, the logistic regression showed a very strong association between political orientation and the belief in the efficacy of HCQ. Respondents who felt closest to the more radical parties (far-right and far-left) were more likely to believe in the efficacy of HCQ than those who felt closest to the political center (O.R. 2.48 [1.95–3.15] and 1.87 [1.44–2.43]). The role of trust in the government and in science and of the degree of political engagement were investigated in the two waves conducted after the scientific consensus was established during the summer of 2020. High levels of trust in the government and in science and of politicization are associated with belief of HCQ proven inefficacy. Across the whole period, a majority of respondents were uncertain. Even in 2021, 41.5% stated that the data were insufficient to decide whether or not HCQ is effective and 25.2% stating that they did not know.

Conclusion

Because media coverage of scientific controversies is higher in times of uncertainty than after these controversies have died down, the publicization of therapeutic promises can have lasting consequences on attitudes towards science and medicine.

Prevalence and risk factors of QTc prolongation in prostate cancer patients undergoing brachytherapy

QTc prolongation is linked to Torsade de Pointes, sudden cardiac death, and overall cardiovascular mortality. 754 prostate cancer patients undergoing brachytherapy were analyzed, prolonged QTc was defined as ≥450ms. A prolonged QTc was more frequent (10.1% vs 5.1%, p = 0.040) in patients with high-risk cancer than in low to intermediate risk patients. The absolute QTc-time was correlated with age (r = 0.125), neutrophil count (r = 0.130) and negatively correlated with the testosterone level (r=-0.205). Treating physicians should be aware of this and monitor the QTc during ADT to possibly decrease cardiac morbidity/mortality in these patients who are more likely to require ADT.

Herb-Drug Interaction Between Xiyanping Injection and Lopinavir/Ritonavir, Two Agents Used in COVID-19 Pharmacotherapy

The global epidemic outbreak of the coronavirus disease 2019 (COVID-19), which exhibits high infectivity, resulted in thousands of deaths due to the lack of specific drugs. Certain traditional Chinese medicines (TCMs), such as Xiyanping injection (XYPI), have exhibited remarkable benefits against COVID-19. Although TCM combined with Western medicine is considered an effective approach for the treatment of COVID-19, the combination may result in potential herb-drug interactions in the clinical setting. The present study aims to verify the effect of XYPI on the oral pharmacokinetics of lopinavir (LPV)/ritonavir (RTV) using an in vivo rat model and in vitro incubation model of human liver microsomes. After being pretreated with an intravenous dose of XYPI (52.5 mg/kg) for one day and for seven consecutive days, the rats received an oral dose of LPV/RTV (42:10.5 mg/kg). Except for the t_1/2 of LPV is significantly prolonged from 4.66 to 7.18 h (p < 0.05) after seven consecutive days pretreatment, the pretreatment resulted in only a slight change in the other pharmacokinetic parameters of LPV. However, the pharmacokinetic parameters of RTV were significantly changed after pretreatment with XYPI, particularly in treatment for seven consecutive days, the AUC_0-∞ of RTV was significantly shifted from 0.69 to 2.72 h μg/mL (p < 0.05) and the CL exhibited a tendency to decrease from 2.71 L/h to 0.94 L/h (p < 0.05), and the t_1/2 of RTV prolonged from 3.70 to 5.51 h (p < 0.05), in comparison with the corresponding parameters in untreated rats. After administration of XYPI, the expression of Cyp3a1 protein was no significant changed in rats. The in vitro incubation study showed XYPI noncompetitively inhibited human CYP3A4 with an apparent Ki value of 0.54 mg/ml in a time-dependent manner. Our study demonstrated that XYPI affects the pharmacokinetics of LPV/RTV by inhibiting CYP3A4 activity. On the basis of this data, patients and clinicians can take precautions to avoid potential drug-interaction risks in COVID-19 treatment.

Photo-mediated and advanced oxidative processes applied for the treatment of effluents with drugs used for the treatment of early COVID-19: Review

The COVID-19 pandemic is proving to be one of the most challenging health and social crises ever faced by humanity. Several drugs have been proposed as potential antiviral agents for the treatment of COVID-19 since the beginning of the health crisis. Among them are chloroquine (CQ), hydroxychloroquine (HCQ), ivermectin (IVM), and the combination of QC or HCQ and azithromycin (AZI). The use of these and several other drugs has grown sharply, even if there is proof of ineffectiveness in the early treatment or mild cases of COVID-19. Thus, there is great concern about the potential environmental impacts of the effluents released with the presence of these drugs. Therefore, this work aimed to carry out a literature review on wastewater treatment processes, focusing on removing these substances through advanced oxidation process. As the conventional effluent treatment processes do not have high efficiency for removal, it was concentrated in the literature that had as scope advanced and photo-mediated techniques to remove CQ, HCQ, IVM, and AZI. It is expected, with this work, to highlight the importance of conducting research that contributes to the control of pollution and contamination.

Assessment of proarrhythmogenic risk for chloroquine and hydroxychloroquine using the CiPA concept

Chloroquine and hydroxychloroquine have been proposed recently as therapy for SARS-CoV-2-infected patients, but during 3 months of extensive use concerns were raised related to their clinical effectiveness and arrhythmogenic risk. Therefore, we estimated for these compounds several proarrhythmogenic risk predictors according to the Comprehensive in vitro Proarrhythmia Assay (CiPA) paradigm. Experiments were performed with either CytoPatch™2 automated or manual patch-clamp setups on HEK293T cells stably or transiently transfected with hERG1, hNav1.5, hKir2.1, hKv7.1+hMinK, and on Pluricyte® cardiomyocytes (Ncardia), using physiological solutions. Dose-response plots of hERG1 inhibition fitted with Hill functions yielded IC50 values in the low micromolar range for both compounds. We found hyperpolarizing shifts of tens of mV, larger for chloroquine, in the voltage-dependent activation but not inactivation, as well as a voltage-dependent block of hERG current, larger at positive potentials. We also found inhibitory effects on peak and late I_Na and on I_K1, with IC50 of tens of μM and larger for chloroquine. The two compounds, tested on Pluricyte® cardiomyocytes using the β-escin-perforated method, inhibited I_Kr, I_CaL, I_{Na peak}, but had no effect on I_f. In current-clamp they caused action potential prolongation. Our data and those from literature for I_to were used to compute proarrhythmogenic risk predictors B_net (Mistry HB, 2018) and Q_net (Dutta S et al., 2017), with hERG1 blocking/unblocking rates estimated from time constants of fractional block. Although the two antimalarials are successfully used in autoimmune diseases, and chloroquine may be effective in atrial fibrillation, assays place these drugs in the intermediate proarrhythmogenic risk group.

[Treatments for SARS-CoV2 infection: a retrospective study of drug-drug interactions and safety]

Objectifs

Réaliser un état des lieux des associations à risque d’interactions médicamenteuses (IAM) rencontrées et des événements indésirables (EI) médicamenteux survenus chez les patients traités pour une infection à SARS-CoV-2 lors de la première vague épidémique au Centre Hospitalier Universitaire de Tenon.

Méthodes

Une analyse rétrospective de l’ensemble des patients ayant reçu un médicament utilisé dans le SARS-CoV-2 (Azithromycine, Hydroxychloroquine et/ou Lopinavir/ritonavir) a été conduite sur la période du 15 mars 2020 au 17 avril 2020. Pour chaque patient, la recherche d’associations médicamenteuses à risque d’IAM en lien avec les médicaments utilisés dans le SARS-CoV-2 et la survenue d’EI a été faite rétrospectivement dans les dossiers médicaux. Chaque événement indésirable identifié a été analysé par le Centre régional de pharmacovigilance (CRPV) afin de déterminer l’imputabilité des médicaments.

Résultats

L’analyse des prescriptions de 312 patients a retrouvé 157 associations à risque d’IAM chez 110 patients, soit 35,3 % des patients de la cohorte. De plus, 26 événements indésirables ont été observés chez ces patients. Après analyse de l’imputabilité médicamenteuse, le CRPV a identifié 10 EI liés aux médicaments, soit un taux d’iatrogénie de 3,2 %. Seuls 2 de ces cas impliquaient une IAM avec les médicaments utilisés dans le SARS-CoV-2.

Conclusions

Notre étude a montré un taux faible d’EI liés aux médicaments utilisés dans le SARS-CoV-2. Malgré un nombre important d’associations à risque d’IAM identifiées, seul 0,6 % des patients ont présenté un EI lié à une IAM.

Prolonged corrected QT interval in hospitalized patients with coronavirus disease 2019 in Dubai, United Arab Emirates: a single-center, retrospective study

OBJECTIVE

To evaluate the association of a prolonged corrected QT (QTc) interval in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and its association with in-patient mortality.

METHODS

A cohort of 745 patients were recruited from a single center between 1 March 2020 and 31 May 2020. We analyzed the factors associated with a prolonged QTc and mortality.

RESULTS

A prolonged QTc interval >450 ms was found in 27% of patients admitted with SARS-CoV-2 infection. These patients were predominantly older, on a ventilator, and had hypertension, diabetes mellitus, or ischemic heart disease. They also had high troponin and D-dimer concentrations. A prolonged QTc interval had a significant association with the requirement of ventilator support and was associated with an increased odds of mortality. Patients who died were older than 55 years, and had high troponin, D-dimer, creatinine, procalcitonin, and ferritin concentrations, a high white blood cell count, and abnormal potassium concentrations (hypo- or hyperkalemia).

CONCLUSIONS

A prolonged QTc interval is common in patients with SARS-CoV-2 infection and it is associated with worse outcomes. Older individuals and those with comorbidities should have an electrocardiogram performed, which is noninvasive and easily available, on admission to hospital to identify high-risk patients.

Incidence of adverse reaction of drugs used in COVID-19 management: a retrospective, observational study

Background

An urgent need for coronavirus infectious disease (COVID-19) treatment has resulted in off-label drug use. Although previous studies had investigated the adverse drug reaction (ADR) of the medications for COVID-19 in their respective local settings, the safety profile in a Malaysian setting remains unknown. Our study aims to establish the incidence of ADR for drugs used in COVID-19 management in a Malaysian tertiary hospital.

Methods

This retrospective observational study enrolled patients started on drugs for COVID-19 in Sungai Buloh Hospital from 1 March 2020 to 31 May 2020. The clinical staging of COVID-19 patients was decided by the treating physician in accordance with the Clinical Management of Confirmed COVID-19 Case in Adults (Annex 2E). Suspected ADRs were evaluated with a trigger tool of pre-defined laboratory values or the adverse events listed in the registered product insert. Causality assessment was conducted when an ADR was suspected using the World Health Organization-Uppsala Monitoring Centre (WHO-UMC) system, and only cases classified as certain, probable and possible ADR were considered. Data analysis was completed with descriptive, univariate and multivariate analysis.

Results

The study (N = 1,080) identified 217 patients (20.1%) who experienced ADR, with 246 adverse events detected. Most events were related to the gastrointestinal (43.5%), hepatobiliary (36.2%) and cardiac (16.3%) systems. The most commonly suspected drugs were atazanavir (52.7%), chloroquine (36.8%) and lopinavir/ritonavir (34.6%). The independent risk factors of ADR were female (adjusted odds ratio (OR): 1.53; 95% CI 1.06–2.20; P = 0.024), diagnosis of COVID-19 stage 3 (adjusted OR: 2.58; 95% CI 1.20–5.55; P = 0.015) and stage 4 (adjusted OR: 4.17; 95% CI 1.79–9.73; P = 0.001), and the number of COVID-19 drugs (adjusted OR: 3.34; 95% CI 2.51–4.44; P < 0.001). Only 49 adverse events (19.9%) were manually reported by healthcare professionals, with hyperbilirubinaemia (65.3%) and QT prolongation (28.6%) most frequently reported.

Conclusion

Medications used in COVID-19 management had resulted in one in five patients experiencing ADR. Our study has provided an overview on incidence of ADR for off-label use of medications used in COVID-19 management, which suggests a similar safety profile when used for FDA-approved indications.

COVID-19-specific skin changes related to SARS-CoV-2: Visualizing a monumental public health challenge

The novel coronavirus SARS-CoV-2 has caused coronavirus disease-2019, known as COVID-19, now a pandemic stressing millions of individuals worldwide. COVID-19 is a systemic respiratory infection that may have dermatologic signs and systemic sequelae, a devastating public health challenge with parallels to the two great influenza pandemics of the last century. Skin lesions linked with COVID-19 have been grouped into six categories, with three distinct indicative patterns: vesicular (varicella-like), vasculopathic, and chilblains-like (including “COVID toes” and “COVID fingers”) plus the following three less suggestive patterns: dermatitic, maculopapular, and urticarial morphologies. Vasculopathic changes are the most concerning, in some patients, reflecting a devastating blood clotting dysfunction. We discuss the ways to detect, prevent, and treat COVID-19, keeping in mind the context of possible cutaneous markers of COVID-19 to enhance detection.

Drug repurposing of dermatologic medications to treat coronavirus disease 2019: Science or fiction?

No pharmaceutical products have been demonstrated to be safe and effective to specifically treat coronavirus disease 2019 (COVID-19); therefore, the therapy administered to infected patients remains symptomatic and empiric. Alongside the development of new, often high-cost drugs, a different tactic is being applied in parallel, investigating long-established, inexpensive medications originally designed for a variety of diseases to study their potential in treating COVID-19. The skin is the largest organ of the human body. With more than 3,000 skin conditions identified, the specialty of dermatology offers a rich armamentarium of systemic therapeutic agents aimed to treat the various chronic immunologically mediated, metabolic, infectious, occupational, inherited, or paraneoplastic dermatoses. Dermatologists have extensive experience with many drugs that have demonstrated promising in vitro antiviral action (directly targeting the viral replication). Many of these drugs have been used as nonspecific immunosuppressive strategies, such as glucocorticoids, synthetic antimalarials, colchicine, or other immunomodulators, and a number of targeted therapeutics have been directed at controlling hyperinflammatory processes similar to the "cytokine storm" associated with COVID-19 infection. We discuss several dermatologic drugs that have already been used or may have a promising role in the treatment of COVID-19.

Adverse Cardiovascular Effects of Anti-COVID-19 Drugs

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or COVID-19 infection is the cause of the ongoing global pandemic. Mortality from COVID-19 infection is particularly high in patients with cardiovascular diseases. In addition, COVID-19 patients with preexisting cardiovascular comorbidities have a higher risk of death. Main cardiovascular complications of COVID-19 are myocardial infarction, myocarditis, acute myocardial injury, arrhythmias, heart failure, stroke, and venous thromboembolism. Therapeutic interventions in terms of drugs for COVID-19 have many cardiac adverse effects. Here, we review the relative therapeutic efficacy and adverse effects of anti-COVID-19 drugs.

COVID-19 challenges and its therapeutics

COVID-19, an infectious disease, has emerged as one of the leading causes of death worldwide, making it one of the severe public health issues in recent decades. nCoV, the novel SARS coronavirus that causes COVID-19, has brought together scientists in the quest for possible therapeutic and preventive measures. The development of new drugs to manage COVID-19 effectively is a challenging and time-consuming process, thus encouraging extensive investigation of drug repurposing and repositioning candidates. Several medications, including remdesivir, hydroxychloroquine, chloroquine, lopinavir, favipiravir, ribavirin, ritonavir, interferons, azithromycin, capivasertib and bevacizumab, are currently under clinical trials for COVID-19. In addition, several medicinal plants with considerable antiviral activities are potential therapeutic candidates for COVID-19. Statistical data show that the pandemic is yet to slow down, and authorities are placing their hopes on vaccines. Within a short period, four types of vaccines, namely, whole virus, viral vector, protein subunit, and nucleic acid (RNA/DNA), which can confer protection against COVID-19 in different ways, were already in a clinical trial. SARS-CoV-2 variants spread is associated with antibody escape from the virus Spike epitopes, which has grave concerns for viral re-infection and even compromises the effectiveness of the vaccines. Despite these efforts, COVID-19 treatment is still solely based on clinical management through supportive care. We aim to highlight the recent trends in COVID-19, relevant statistics, and clinical findings, as well as potential therapeutics, including in-line treatment methods, preventive measures, and vaccines to combat the prevalence of COVID-19.

Heart Muscle Microphysiological System for Cardiac Liability Prediction of Repurposed COVID-19 Therapeutics

Despite global efforts, it took 7 months between the proclamation of global SARS-CoV-2 pandemic and the first FDA-approved treatment for COVID-19. During this timeframe, clinicians focused their efforts on repurposing drugs, such as hydroxychloroquine (HCQ) or azithromycin (AZM) to treat hospitalized COVID-19 patients. While clinical trials are time-consuming, the exponential increase in hospitalizations compelled the FDA to grant an emergency use authorization for HCQ and AZM as treatment for COVID-19, although there was limited evidence of their combined efficacy and safety. The authorization was revoked 4 months later, giving rise to controversial political and scientific debates illustrating important challenges such as premature authorization of potentially ineffective or unsafe therapeutics, while diverting resources from screening of effective drugs. Here we report on a preclinical drug screening platform, a cardiac microphysiological system (MPS), to rapidly identify clinically relevant cardiac liabilities associated with HCQ and AZM. The cardiac MPS is a microfabricated fluidic system in which cardiomyocytes derived from human induced pluripotent stem cells self-arrange into a uniaxially beating tissue. The drug response was measured using outputs that correlate with clinical measurements such as action potential duration (proxy for clinical QT interval) and drug-biomarker pairing. The cardiac MPS predicted clinical arrhythmias associated with QT prolongation and rhythm instabilities in tissues treated with HCQ. We found no change in QT interval upon acute exposure to AZM, while still observing a significant increase in arrhythmic events. These results suggest that this MPS can not only predict arrhythmias, but it can also identify arrhythmias even when QT prolongation is absent. When exposed to HCQ and AZM polytherapy, this MPS faithfully reflected clinical findings, in that the combination of drugs synergistically increased QT interval when compared to single drug exposure, while not worsening the overall frequency of arrhythmic events. The high content cardiac MPS can rapidly evaluate the cardiac safety of potential therapeutics, ultimately accelerating patients' access to safe and effective treatments.

Hydroxychloroquine in mild-to-moderate coronavirus disease 2019: a placebo-controlled double blind trial

OBJECTIVES

To determine whether hydroxychloroquine decreases the risk of adverse outcome in patients with mild to moderate coronavirus disease 2019 (COVID-19) at high risk of worsening.

METHODS

We conducted a multicentre randomized double-blind placebo-controlled trial evaluating hydroxychloroquine in COVID-19 patients with at least one of the following risk factors for worsening: need for supplemental oxygen, age ≥75 years, age between 60 and 74 years and presence of at least one co-morbidity. Severely ill patients requiring oxygen therapy >3 L/min or intensive care were excluded. Eligible patients were randomized in a 1:1 ratio to receive either 800 mg hydroxychloroquine on day 0 followed by 400 mg per day for 8 days or a placebo. The primary end point was a composite of death or start of invasive mechanical ventilation within 14 days following randomization. Secondary end points included mortality and clinical evolution at days 14 and 28, and viral shedding at days 5 and 10.

RESULTS

The trial was stopped after 250 patients were included because of a slowing down of the pandemic in France. The intention-to-treat population comprised 123 and 124 patients in the placebo and hydroxychloroquine groups, respectively. The median age was 77 years (interquartile range 58-86 years) and 151/250 (60.4%) patients required oxygen therapy. The primary end point occurred in 9/124 (7.3%) patients in the hydroxychloroquine group and 8/123 (6.5%) patients in the placebo group (relative risk 1.12; 95% CI 0.45-2.80). The rates of positive SARS-CoV-2 RT-PCR tests at days 5 and 10 were 72.8% (75/103) and 57.1% (52/91) in the hydroxychloroquine group, versus 73.0% (73/100) and 56.6% (47/83) in the placebo group, respectively. No difference was observed between the two groups in any of the other secondary end points.

CONCLUSION

In this underpowered trial involving mainly older patients with mild to moderate COVID-19, patients treated with hydroxychloroquine did not experience better clinical or virological outcomes than those receiving the placebo.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04325893 (https://clinicaltrials.gov/ct2/show/NCT04325893).

Off-label Medication Use: A Double-edged Sword

Agarwal V. Off-label Medication Use: A Double-edged Sword. Indian J Crit Care Med 2021;25(8):845-846.

The Role of Advanced Technologies Supplemented with Traditional Methods in Pharmacovigilance Sciences

BACKGROUND

The immediate automatic systemic monitoring and reporting of adverse drug reactions, improving the efficacy is the utmost need of the medical informatics community. The venturing of advanced digital technologies into the health sector has opened new avenues for rapid monitoring. In recent years, data shared through social media, mobile apps, and other social websites has increased manifolds requiring data mining techniques.

OBJECTIVE

The objective of this report is to highlight the role of advanced technologies together with the traditional methods to proactively aid in the early detection of adverse drug reactions concerned with drug safety and pharmacovigilance.

METHODS

A thorough search was conducted on papers and patents regarding pharmacovigilance. All articles with respect to the relevant subject were explored and mined from public repositories such as Pubmed, Google Scholar, Springer, ScienceDirect (Elsevier), Web of Science, etc. Results: The European Union's Innovative Medicines Initiative WEB-RADR project has emphasized the development of mobile applications and social media data for reporting adverse effects. Only relevant data has to be captured through the data mining algorithms (DMAs) as it plays an important role in timely prediction of risk with high accuracy using two popular approaches; the frequentist and Bayesian approach. Pharmacovigilance at the pre-marketing stage is useful for the prediction of adverse drug reactions in the early developmental stage of a drug. Later, post-marketing safety reports and clinical data reports are important to be monitored through electronic health records, prescription-event monitoring, spontaneous reporting databases, etc. Conclusion: The advanced technologies supplemented with traditional technologies are the need of the hour for evaluating a product's risk profile and reducing risk in population especially with comorbid conditions and on concomitant medications.

Targeting COVID-19 in Parkinson's Patients: Drugs Repurposed

The last couple of months have witnessed the world in a state of virtual standstill. The SARS-CoV-2 virus has overtaken the globe to economic and social lockdown. Many patients with COVID-19 have compromised immunity, especially in an aged population suffering from Parkinson 's disease (PD). Alteration in dopaminergic neurons and deficiency of dopamine in PD patients are the most common symptoms affecting 1% population above the age of 60 years. The compromised immune system and inflammatory manifestation in PD patients make them an easy target. The most common drugs under trial for COVID-19 are remdesivir, favipiravir, chloroquine and hydroxychloroquine, azithromycin along with adjunct drugs like amantadine with some monoclonal antibodies. Presently, clinically US FDA approved drugs in PD include Levodopa, catechol-O-methyl transferase (COMT) inhibitors, (Entacapone and Tolcapone), dopamine agonists (Bromocriptine, Ropinirole, Pramipexole, and Rotigotine), monoamine oxidase B (MAO-B) inhibitors (Selegiline and Rasagiline), amantadine and antimuscarinic drugs. The drugs have established mechanisms of action on PD patients with known pharmacodynamics and pharmacokinetic properties along with dose and adverse effects. Conclusion and relevance of this review focus on the drugs that can be tried on PD patients with SAR CoV-2 infection, in particular, amantadine that has been approved by all the developed countries as a common drug possessing both antiviral properties by downregulation of CTSL, lysosomal pathway disturbance and change in pH necessary to uncoat the viral proteins and anti- Parkinson properties. To deal with the significant prognostic adverse effect of SARS-CoV-2 on PD, the present-day treatment options, clinical presentation and various mechanisms are the need of the hour.

Preliminary findings from stimulated spontaneous reporting of adverse drug reactions during COVID-19 pandemic: an experience from Ghana

Background

The novel coronavirus disease 2019 (COVID-19) is an ongoing pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). There is limited information on the safety of drugs used for the treatment of COVID-19.

Objective

Objective of this study is to describe the pattern of stimulated spontaneous adverse drug reaction (ADR) reports received from healthcare professionals for SARS-CoV-2 positive patients in Ghana and lessons learnt particularly for low- and middle-income countries.

Methods

This is a study of individual case safety reports (ICSRs) received from healthcare professionals between 1^st April 2020 to 31^st July 2020 in SARS-CoV-2 positive patients in Ghana. The ICSRs were retrieved from the SafetyWatch System and descriptive statistics used to describe the ADRs by System Organ Classification and Preferred Term.

Results

Information was received from 40 COVID-19 Treatment Centres across the country with 9 centres submitting a total of 53 ICSRs containing 101 ADRs; approximately two ADRs per ICSR. Females accounted for 29(54.7%) of the ICSRs and males 24(45.3%). Newly reported ADRs of interest were one report each of tremor for doxycycline; scrotal pain, dyspnoea, gait disturbances and dysgeusia for chloroquine; and dry throat, hyperhidrosis, restlessness and micturition frequency increased for hydroxychloroquine. A strong spontaneous system with the availability of focal persons at the Treatment Centres played a key role in reporting ADRs during the pandemic.

Conclusion

This is the first experience with spontaneous reporting during COVID-19 pandemic in Ghana. The profile of most of the ADRs reported appears consistent with what is expected from the summary of product characteristics. A study with a larger sample size with well-defined denominator in future studies is paramount in determining the relative risk of these medications in SARS-CoV-2 positive patients.

Funding

None declared

Insights into SARS-CoV-2: Medicinal Chemistry Approaches to Combat Its Structural and Functional Biology

Coronavirus disease 2019, caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is still a pandemic around the world. Currently, specific antiviral drugs to control the epidemic remain deficient. Understanding the details of SARS-CoV-2 structural biology is extremely important for development of antiviral agents that will enable regulation of its life cycle. This review focuses on the structural biology and medicinal chemistry of various key proteins (Spike, ACE2, TMPRSS2, RdRp and M^pro) in the life cycle of SARS-CoV-2, as well as their inhibitors/drug candidates. Representative broad-spectrum antiviral drugs, especially those against the homologous virus SARS-CoV, are summarized with the expectation they will drive the development of effective, broad-spectrum inhibitors against coronaviruses. We are hopeful that this review will be a useful aid for discovery of novel, potent anti-SARS-CoV-2 drugs with excellent therapeutic results in the near future.

Addressing the global surge of COVID-19 cases: Insights from diagnostics, improved treatment strategies, vaccine development and application

BACKGROUND AND AIM

As the rage of coronavirus disease 2019 (COVID-19) pandemic continues to spread globally, much effort is being directed to contain it through various efforts - genomic studies, drug discoveries, clinical trials, vaccine development, and the innovation of diagnostic techniques. However, some pertinent areas involving accurate and sensitive diagnostics, immunoglobulin specificity, evolution of mutant strains of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and the drug combination strategy to combat it still require more attention.

METHODS

This review critically examines the COVID-19 response and containment operations. It also addresses some standing challenges involving the areas of diagnostics, vaccine development and prospect, and treatment strategies in relation to antiviral drug treatment and immunotherapy. Designated set of keywords such as "SARS-CoV-2;" "coronavirus;" "severe acute respiratory syndrome coronavirus;" "repurposed;" "vaccination;" "containment;" "laboratory diagnostic;" "immunotherapy;" "antiviral;" "antiparasitic;" "antibiotic;" "antiprotozoal;" "antibody;" "anti-inflammatory;" "antitumor;" "corticosteroid;" "hypertensive drug;" "statin;" "supplement;" and "biological" along with "COVID-19" were inserted on electronic databases to retrieve articles and clinical trial information relevant to the study objectives. The search databases included ClinicalTrials.gov, NIH.gov, PubMed, Scinapse, CINAHL, Medline, Google Scholar, Academic Search Premier, SAGE, EBSCO Host, and Scopus.

RELEVANCE FOR PATIENTS

The difficulties associated with SARS-CoV-2 rapid mutations are unceasingly evolving and re-evolving. These pose serious concerns and downplay the efficacy and effectiveness of the current pipeline antiviral drugs and vaccines. Entities encompassing immunotherapy, antiviral drug therapies, viral genomics, protein-protein interaction, and improved diagnostics as well as drug combination strategy against the emerging genetic variability of SARS-CoV-2 were critically appraised. This study suggests that robust collaborations in the development of more sensitive, rapid and accurate diagnostics, development of immunoglobulin specific agents and improved anti-viral treatment focus against multiple mutant genes of SARS-CoV-2 should be aggressively pursued for the overall benefits of COVID-19 patients.

COVID-19, a tale of two pandemics: novel coronavirus and fake news messaging

The emergence of COVID-19, caused by novel Coronavirus SARS-CoV-2, became a pandemic in just 10 weeks. Without effective medications or vaccines available, authorities turned toward mitigation measures such as use of face masks, school's closings, shelter-in-place, telework and social distancing. People found refuge on the internet and social media apps; however, there was a proliferation of instant messaging containing hoaxed, deliberate misleading information: fake news messaging (FNM). The aim of this study was to assess FNM through content analysis and to discriminate them in a proposed taxonomy structure. A sample of convenience of messages, memes, tweets or cartoons in several languages was selected from the most popular social media outlets, i.e. Facebook, WhatsApp, Twitter etc. More than 300 FNM were identified. Descriptive statistics were used for highlighting potential relationships between variables. Content analysis determined that FNM could be divided into Health- and non-health-related types. There are several sub-types considering, but not limited to, religious beliefs, politics, economy, nutrition, behaviors, prevention of the infection, the origin of the disease and conspiracy theories. The parallel FNM pandemic affected the response from an already debilitated public health system through the confusion created in the community and the erosion in the credibility of genuine media. Public health practitioners had to face people's unpredictable behaviors, panic, tensions with the communities and, in some cases, a hostile climate toward frontline workers. Public health practitioners must adjust ongoing and future health promotion and education interventions including plans to neutralize fake news messages.

Assessment of COVID-19 Treatment containing both Hydroxychloroquine and Azithromycin: A natural clinical trial

The goal of this study was to assess the clinical effectiveness and safety profile of the COVID-19 treatment protocol (containing both hydroxychloroquine (HCQ) and azithromycin) in an Iraqi specialised hospital.

METHODS

This prospective study used a pre- and post-intervention design without a comparison group. The intervention was routine Ministry of Health (MOH) approved the management of COVID-19 for all patients. The study was conducted in a public healthcare setting in Baghdad, Iraq from March 1st to May 25, 2020. The study outcome measures included the changes in clinical and biochemical parameters during the hospitalisation period. Paired t-test and Chi-square test were used to compare the measures of vital signs, lab tests and symptoms before and after treatment.

RESULTS

The study included 161 patients who were admitted with positive RT-PCR and clinical symptoms of COVID-19. In terms of severity, 53 (32.9%) patients had amild condition, 47 (29.2%) had moderate condition, 35 (21.7%) had severe condition and 26 (16.1%) had critical condition. Most patients (84.5%) recovered and were discharged without symptoms after testing negative with RT-PCR, while 11 (6.8%) patients died during the study period. The signs and symptoms of COVID-19 were reduced significantly in response to a therapy regimen containing HCQ and azithromycin. The most common reported side effects were stomach pain, hypoglycemia, dizziness, itching, skin rash, QT prolongation, arrhythmia, and conjunctivitis.

CONCLUSIONS

This natural trial showed that the COVID-19 regimen containing both HCQ and azithromycin can be helpful to promote the recovery of most patients and reduced their signs and symptoms significantly. It also shows some manageable side effects mostly those related to heart rhythm. In the absence of FDA-approved medications to treat COVID-19, the repurposing of HCQ and azithromycin to control the disease signs and symptoms can be useful.

QT prolongation associated with hydroxychloroquine and protease inhibitors in COVID-19

What is known and Objective

Hydroxychloroquine and protease inhibitors were widely used as off‐label treatment options for COVID‐19 but the safety data of these drugs among the COVID‐19 population are largely lacking. Drug‐induced QTc prolongation is a known adverse reaction of hydroxychloroquine, especially during chronic treatment. However, when administered concurrently with potential pro‐arrhythmic drugs such as protease inhibitors, the risk of QTc prolongation imposed on these patients is not known. We aim to investigate the incidence of QTc prolongation events and potential factors associated with its occurrence in COVID‐19 population.

Methods

We included 446 SARS‐CoV‐2 RT‐PCR‐positive patients taking at least one treatment drug for COVID‐19 within a period of one month (March–April 2020). In addition to COVID‐19‐related treatment (HCQ/PI), concomitant drugs with risks of QTc prolongation were considered. We defined QTc prolongation as QTc interval of ≥470 ms in postpubertal males, and ≥480 ms in postpubertal females.

Results and Discussion

QTc prolongation events occurred in 28/446 (6.3%) patients with an incidence rate of 1 case per 100 person‐days. A total of 26/28 (93%) patients who had prolonged QTc intervals received at least two pro‐QT drugs. Multivariate analysis showed that HCQ and PI combination therapy had five times higher odds of QTc prolongation as compared to HCQ‐only therapy after controlling for age, cardiovascular disease, SIRS and the use of concurrent QTc‐prolonging agents besides HCQ and/or PI (OR 5.2; 95% CI, 1.11‐24.49; p = 0.036). Independent of drug therapy, presence of SIRS resulted in four times higher odds of QTc prolongation (OR 4.3; 95% CI, 1.66‐11.06; p = 0.003). In HCQ‐PI combination group, having concomitant pro‐QT drugs led to four times higher odds of QTc prolongation (OR 3.8; 95% CI, 1.53‐9.73; p = 0.004). Four patients who had prolonged QTc intervals died but none were cardiac‐related deaths.

What is new and conclusion

In our cohort, hydroxychloroquine monotherapy had low potential to increase QTc intervals. However, when given concurrently with protease inhibitors which have possible or conditional risk, the odds of QTc prolongation increased fivefold. Interestingly, independent of drug therapy, the presence of systemic inflammatory response syndrome (SIRS) resulted in four times higher odds of QTc prolongation, leading to the postulation that some QTc events seen in COVID‐19 patients may be due to the disease itself. ECG monitoring should be continued for at least a week from the initiation of treatment.

Cyclodextrins in Antiviral Therapeutics and Vaccines

The present review describes the various roles of cyclodextrins (CDs) in vaccines against viruses and in antiviral therapeutics. The first section describes the most commonly studied application of cyclodextrins—solubilisation and stabilisation of antiviral drugs; some examples also refer to their beneficial taste-masking activity. The second part of the review describes the role of cyclodextrins in antiviral vaccine development and stabilisation, where they are employed as adjuvants and cryopreserving agents. In addition, cyclodextrin-based polymers as delivery systems for mRNA are currently under development. Lastly, the use of cyclodextrins as pharmaceutical active ingredients for the treatment of viral infections is explored. This new field of application is still taking its first steps. Nevertheless, promising results from the use of cyclodextrins as agents to treat other pathologies are encouraging. We present potential applications of the results reported in the literature and highlight the products that are already available on the market.

The serotonin reuptake inhibitor Fluoxetine inhibits SARS-CoV-2 in human lung tissue

To circumvent time-consuming clinical trials, testing whether existing drugs are effective inhibitors of SARS-CoV-2, has led to the discovery of Remdesivir. We decided to follow this path and screened approved medications "off-label" against SARS-CoV-2. Fluoxetine inhibited SARS-CoV-2 at a concentration of 0.8 µg/ml significantly in these screenings, and the EC50 was determined with 387 ng/ml. Furthermore, Fluoxetine reduced viral infectivity in precision-cut human lung slices showing its activity in relevant human tissue targeted in severe infections. Fluoxetine treatment resulted in a decrease in viral protein expression. Fluoxetine is a racemate consisting of both stereoisomers, while the S-form is the dominant serotonin reuptake inhibitor. We found that both isomers show similar activity on the virus, indicating that the R-form might specifically be used for SARS-CoV-2 treatment. Fluoxetine inhibited neither Rabies virus, human respiratory syncytial virus replication nor the Human Herpesvirus 8 or Herpes simplex virus type 1 gene expression, indicating that it acts virus-specific. Moreover, since it is known that Fluoxetine inhibits cytokine release, we see the role of Fluoxetine in the treatment of SARS-CoV-2 infected patients of risk groups.

COVID-19 Drugs Chloroquine and Hydroxychloroquine, but Not Azithromycin and Remdesivir, Block hERG Potassium Channels

Drug-induced long QT syndrome (LQTS) is an established cardiac side effect of a wide range of medications and represents a significant concern for drug safety. The rapidly and slowly activating delayed rectifier K⁺ currents, mediated by channels encoded by the human ether-a-go-go-related gene (hERG) and KCNQ1 + KCNE1, respectively, are two main currents responsible for ventricular repolarization. The common cause for drugs to induce LQTS is through impairing the hERG channel. For the recent emergence of COVID-19, caused by severe acute respiratory syndrome coronavirus 2, several drugs have been investigated as potential therapies; however, there are concerns about their QT prolongation risk. Here, we studied the effects of chloroquine, hydroxychloroquine, azithromycin, and remdesivir on hERG channels. Our results showed that although chloroquine acutely blocked hERG current (I_hERG), with an IC₅₀ of 3.0 µM, hydroxychloroquine acutely blocked I_hERG 8-fold less potently, with an IC₅₀ of 23.4 µM. Azithromycin and remdesivir did not acutely affect I_hERG When these drugs were added at 10 µM to the cell culture medium for 24 hours, remdesivir increased I_hERG by 2-fold, which was associated with an increased mature hERG channel expression. In addition, these four drugs did not acutely or chronically affect KCNQ1 + KCNE1 channels. Our data provide insight into COVID-19 drug-associated LQTS and cardiac safety concerns. SIGNIFICANCE STATEMENT: This work demonstrates that, among off-label potential COVID-19 treatment drugs chloroquine, hydroxychloroquine, azithromycin, and remdesivir, the former two drugs block hERG potassium channels, whereas the latter two drugs do not. All four drugs do not affect KCNQ1 + KCNE1. As hERG and KCNQ1 + KCNE1 are two main K⁺ channels responsible for ventricular repolarization, and most drugs that induce long QT syndrome (LQTS) do so by impairing hERG channels, these data provide insight into COVID-19 drug-associated LQTS and cardiac safety concerns.