The Fight to Treat COVID-19: Sorting Through Therapeutics From Antivirals to Anti-inflammatories

Since SARS-CoV-2 emerged in 2019, there’s been a frenzy of scientific research on many fronts to help us understand and deal with this virus, the most prominent of which has been vaccines. That’s because vaccines prepare the body to deal with a pathogen it hasn’t encountered yet.

A vaccine or vaccine series primes the immune system to fight the virus long after the vaccine itself has left the body, for months, years, or a lifetime. The benefits are in the bank before you even get exposed, which makes vaccines an amazing tool.

What are the limits of vaccines? Well, it takes time to develop an immune response to a vaccine or booster, so it’s best to act before you see a surge of cases in your area—and certainly before you’re directly exposed.

Meanwhile, the virus is evolving to produce more breakthrough infections. Though milder, these still sometimes require treatment. Vaccinated or not, millions of people are still getting COVID-19, so we definitely need additional tools to deal with this virus.

Antivirals: Timing is everything

One primary research focus has been on antiviral medicines. Antivirals interfere with a virus by blocking some stage in its replication cycle. They might block it from attaching to a cell, block the cell from assembling pieces of a virus, or block the new viruses from leaving the cell.

In an acute illness such as COVID-19, you need to get antivirals into the system during the narrow window when the virus is multiplying quickly for them to help. Unfortunately, a lot of that window has passed when symptoms begin.

As an example, many people are familiar with Tamiflu, an antiviral drug used to treat the flu. Physicians quickly put patients on it if they have the flu, but the data showed patients have to start taking it quickly after developing symptoms and it would only shorten the duration of being sick by a half-day to one day.

That’s because, even after the virus is stopped from multiplying, the body still has to fight it off, which is the same conundrum with COVID-19. The idea behind antivirals is that by decreasing the peak viral load or stopping ongoing replication after the peak, we reduce the chances of a damaging cytokine storm and ramp down inflammation more quickly, which reduces accumulating damage to the lungs and body.

But the antivirals that have been developed thus far cause several adverse effects (AEs) and have drug interactions with other medications. That makes using them difficult and not an ideal drug to treat large numbers of people.

In other words, despite the news hype, antivirals are not something the masses will use for COVID-19. They’re not as useful in reducing mild to moderate symptoms and their AE profile causes us to reserve their use for the most high-risk patients. In my opinion, the inflammatory response, which is just kicking into gear as symptoms begin, is really what we want to modulate.

Steroids: For rare and serious cases

In a previous post, I addressed immune-suppressing steroids for COVID-19. Their drawback is that you need your immune system working hard to fight the virus, so steroids can prolong the infection or open the door to secondary bacterial infections.

Steroids need to be used with delicate caution when the immune system is already making progress against the virus. Even then, they are risky, so we use them when the severity of the situation warrants the risk. Unfortunately, this is when COVID-19 has already progressed and caused damage.

Anti-inflammatories: A go-to for the general public

Finally, we have our anti-inflammatory drugs, including non-steroidal anti-inflammatories, and antihistamines. Many of these drugs, which have already been cleared as safe, can be very effective at calming certain, very reactive parts of the immune system while leaving other parts free to work.

That means anti-inflammatories can be offered to more people with less risk than other post-exposure strategies. We can explore their ability to reduce mild to moderate symptoms, as well as the frequency of progression to severe cases.

I’m also interested in their ability to prevent long COVID symptoms from occurring, as we explore the relationship between long COVID and inflammation in the brain. For most of this pandemic, the focus of research has been on the efficacy of vaccines and the possibility of antiviral drugs to treat breakthrough and unvaccinated COVID cases.

In 6 months, I believe the focus will be on anti-inflammatories, and whether they can hone the immune response to do less collateral damage from COVID-19 and even reduce the virus itself.

About the Author

Jackie Iversen, RPh, MS, founder and head of Clinical Development, Sen-Jam Pharmaceutical.