Stay well. 

Sandra Lora Cremers, MD, FACS 

Pursuing Safe and Effective Anti-Viral Drugs for COVID-19

Posted on April 17th, 2020 by Dr. Francis Collins

Stock photo/SoumenNath

Right now, the world is utterly focused on the coronavirus outbreak known as COVID-19. That’s certainly true for those of us at NIH. Though I am working from home to adhere rigorously to physical distancing, I can’t remember ever working harder, trying to do everything I can to assist in the development of safe and effective treatments and vaccines.

Over the past several weeks, a mind-boggling array of possible therapies have been considered. None have yet been proven to be effective in rigorously controlled trials, but for one of them, it’s been a busy week. So let’s focus on an experimental anti-viral drug, called remdesivir, that was originally developed for the deadly Ebola virus. Though remdesivir failed to help people with Ebola virus disease, encouraging results from studies of coronavirus-infected animals have prompted the launch of human clinical trials to see if this drug might fight SARS-CoV-2, the novel coronavirus that causes COVID-19.

You may wonder how a drug could possibly work for Ebola and SARS-CoV-2, since they are very different viruses that produce dramatically different symptoms in humans. The commonality is that both viruses have genomes made of ribonucleic acid (RNA), which must be copied by an enzyme called RNA-dependent RNA polymerase for the virus to replicate.

Remdesivir has an affinity for attaching to this kind of polymerase because its structure is very similar to one of the RNA letters that make up the viral genome [1]. Due to this similarity, when an RNA virus attempts to replicate, its polymerase is tricked into incorporating remdesivir into its genome as a foreign nucleotide, or anomalous letter. That undecipherable, extra letter brings the replication process to a crashing halt—and, without the ability to replicate, viruses can’t infect human cells.

Would this work on a SARS-CoV-2 infection in a living organism? An important step was just posted as a preprint yesterday—a small study showed infusion of remdesivir was effective in limiting the severity of lung disease in rhesus macaques [2]. That’s encouraging news. But the only sure way to find out if remdesivir will actually help humans who are infected with SARS-CoV-2 is to conduct a randomized, controlled clinical trial.

In late February, NIH’s National Institute of Allergy and Infectious Diseases (NIAID) did just that, when it launched a randomized, controlled clinical trial to test remdesivir in people with COVID-19. The study, led by investigators at the University of Nebraska Medical Center, Omaha, has already enrolled 805 patients at 67 testing sites. Most sites are in the United States, but there are also some in Singapore, Japan, South Korea, Mexico, Spain, the United Kingdom, Denmark, Greece, and Germany.

All trial participants must have laboratory-confirmed COVID-19 infections and evidence of lung involvement, such as abnormal chest X-rays, rattling sounds when breathing (rales) with a need for supplemental oxygen, or a need for mechanical ventilation. They are randomly assigned to receive either a round of treatment with remdesivir or a harmless placebo with no therapeutic effect. To avoid bias from creeping into patient care, the study is double-blind, meaning neither the medical staff nor the participants know who is receiving remdesivir.

There is also an early hint from another publication that remdesivir may benefit some people with COVID-19. Since the end of January 2020, Gilead has provided daily, intravenous infusions of the drug on a compassionate basis to more than 1,800 people hospitalized with advanced COVID-19 around the world. In a study of a subgroup of 53 compassionate-use patients with advanced complications of COVID-19, nearly two-thirds improved when given remdesivir for up to 10 days [3]. Most of the participants were men over age 60 with preexisting conditions that included hypertension, diabetes, high cholesterol, and asthma.

This may sound exciting, but these preliminary results, published in the New England Journal of Medicine, come with major caveats. There were no controls, participants were not randomized, and the study lacked other key features of the more rigorously designed NIH clinical trial. We can all look forward to the results from the NIH trial, which are are expected within a matter of weeks. Hopefully these will provide much-needed scientific evidence on remdesivir’s safety and efficacy in people with COVID-19.

In the meantime, basic researchers continue to learn more about remdesivir and its interaction with the novel coronavirus that causes COVID-19. In a recent study in the journal Science, a research team, led by Quan Wang, Shanghai Tech University, China, mapped the 3D atomic structure of the novel coronavirus’s polymerase while it was complexed with two other vital parts of the viral replication machinery [4]. This was accomplished using a high-resolution imaging approach called cryo-electron microscopy (cryo-EM), which involves flash-freezing molecules in liquid nitrogen and bombarding them with electrons to capture their images with a special camera.

With these atomic structures in hand, the researchers then modeled exactly how remdesivir binds to the polymerase of the novel coronavirus. The model will help inform future efforts to tweak the structure of the drug and optimize its ability to disrupt viral replication. Such detailed biochemical information will be vital in the weeks ahead, especially if data generated by the NIH clinical trial indicate that remdesivir is a worthwhile lead to pursue in our ongoing search for anti-viral drugs to combat the global COVID-19 pandemic.

References:

[1] Nucleoside analogues for the treatment of coronavirus infections. Pruijssers AJ, Denison MR. Curr Opin Virol. 2019 Apr;35:57-62.

[2] Respiratory disease and virus shedding in rhesus macaques inoculated with SARS-CoV-2 . Munster VJ, Feldmann F, Williamson BN, Scott D, Fischer ER, de Wit E et. al. BioRxiv. Preprint posted 21 March 2020.

[3] Compassionate use of remdesivir for patients with severe Covid-19. Grein J, Ohmagari N, Shin D, Brainard DM, Childs R, Flanigan T. et. al. N Engl J Med. 2020 Apr 10. [Epub ahead of publication]

[4] Structure of the RNA-dependent RNA polymerase from COVID-19 virus. Gao Y, Yan L, Liu F, Wang Q, Lou Z, Rao A, et al. Science. 10 April 2020. [Epub ahead of publication]