Chloroquine and hydroxychloroquine as available weapons to fight COVID-19
- Details
- Category: Covid
- Created: Saturday, 07 August 2021 22:27
- Written by Philippe Colson, Jean-Marc Rolain, Jean-Christophe Lagier, Philippe Brouqui, and Didier Raoult
Repositioning of drugs for use as antiviral treatments is a critical need [1]. It is commonly very badly perceived by virologists, as we experienced when reporting the effectiveness of azithromycin for Zika virus [2]. A response has come from China to the respiratory disease caused by the new coronavirus (SARS-CoV-2) that emerged in December 2019 in this country. Indeed, following the very recent publication of results showing the in vitro activity of chloroquine against SARS-CoV-2 [3], data have been reported on the efficacy of this drug in patients with SARS-CoV-2-related pneumonia (named COVID-19) at different levels of severity [4,5]. Thus, following the in vitro results, 20 clinical studies were launched in several Chinese hospitals. The first results obtained from more than 100 patients showed the superiority of chloroquine compared with treatment of the control group in terms of reduction of exacerbation of pneumonia, duration of symptoms and delay of viral clearance, all in the absence of severe side effects [4,5]. This has led in China to include chloroquine in the recommendations regarding the prevention and treatment of COVID-19 pneumonia [4,6].
There is a strong rationality for the use of chloroquine to treat infections with intracellular micro-organisms. Thus, malaria has been treated for several decades with this molecule [7]. In addition, our team has used hydroxychloroquine for the first time for intracellular bacterial infections since 30 years to treat the intracellular bacterium Coxiella burnetii, the agent of Q fever, for which we have shown in vitro and then in patients that this compound is the only one efficient for killing these intracellular pathogens [8,9].
Since then, we have also shown the activity of hydroxychloroquine on Tropheryma whipplei, the agent of Whipple's disease, which is another intracellular bacterium for which hydroxychloroquine has become a reference drug [10,11]. Altogether, one of us (DR) has treated ~4000 cases of C. burnetii or T. whipplei infections over 30 years (personal data).
Regarding viruses, for reasons probably partly identical involving alkalinisation by chloroquine of the phagolysosome, several studies have shown the effectiveness of this molecule, including against coronaviruses among which is the severe acute respiratory syndrome (SARS)-associated coronavirus [1,12,13] (Table 1 ). We previously emphasised interest in chloroquine for the treatment of viral infections in this journal [1], predicting its use in viral infections lacking drugs. Following the discovery in China of the in vitro activity of chloroquine against SARS-CoV-2, discovered during culture tests on Vero E6 cells with 50% and 90% effective concentrations (EC50 and EC90 values) of 1.13 μM and 6.90 μM, respectively (antiviral activity being observed when addition of this drug was carried out before or after viral infection of the cells) [3], we awaited with great interest the clinical data [14]. The subsequent in vivo data were communicated following the first results of clinical trials by Chinese teams [4] and also aroused great enthusiasm among us. They showed that chloroquine could reduce the length of hospital stay and improve the evolution of COVID-19 pneumonia [4,6], leading to recommend the administration of 500 mg of chloroquine twice a day in patients with mild, moderate and severe forms of COVID-19 pneumonia. At such a dosage, a therapeutic concentration of chloroquine might be reached. With our experience on 2000 dosages of hydroxychloroquine during the past 5 years in patients with long-term treatment (>1 year), we know that with a dosage of 600 mg/day we reach a concentration of 1 μg/mL [15]. The optimal dosage for SARS-CoV-2 is an issue that will need to be assessed in the coming days. For us, the activity of hydroxychloroquine on viruses is probably the same as that of chloroquine since the mechanism of action of these two molecules is identical, and we are used to prescribe for long periods hydroxychloroquine, which would be therefore our first choice in the treatment of SARS-CoV-2. For optimal treatment, it may be necessary to administer a loading dose followed by a maintenance dose.
Table 1
Main results of studies on the activity of chloroquine or hydroxychloroquine on coronavirusesa
| Reference | Compound(s) | Targeted virus | System used for antiviral activity screening | Antiviral effect |
|---|---|---|---|---|
| [12] | Chloroquine | SARS-CoV | Vero (African green monkey kidney) E6 cells | EC50 = 8.8 ± 1.2 μM |
| [16] | Chloroquine | Vero E6 cells | EC50 = 4.4 ± 1.0 μM | |
| [17] | Chloroquine, chloroquine monophosphate, chloroquine diphosphate | SARS-CoV (four strains) | Vero 76 cells | Chloroquine: EC50 = 1–4 μM Chloroquine monophosphate: EC50 = 4–6 μM Chloroquine diphosphate: EC50 = 3–4 μM |
| BALB/c mice | Intraperitoneal or intranasal chloroquine administration, beginning 4 h prior to virus exposure: 50 mg/kg but not 10 mg/kg or 1 mg/kg reduced for the intranasal route (but not the intraperitoneal route) viral lung titres from mean ± S.D. of 5.4 ± 0.5 to 4.4 ± 1.2 in log10 CCID50/g at Day 3 (considered as not significant) | |||
| [18] | Chloroquine, hydroxychloroquine | SARS-CoV | Vero cells | Chloroquine: EC50 = 6.5 ± 3.2 μM Hydroxychloroquine: EC50 = 34 ± 5 μM |
| Feline coronavirus | Crandell–Reese feline kidney (CRFK) cells | Chloroquine: EC50 > 0.8 μM Hydroxychloroquine: EC50 = 28 ± 27 μM |
||
| [19] | Chloroquine | HCoV-229E | Human epithelial lung cells (L132) | Chloroquine at concentrations of 10 μM and 25 μM inhibited HCoV-229E release into the culture supernatant |
| [20] | Chloroquine | HCoV-OC43 | HRT-18 cells | EC50 = 0.306 ± 0.0091 μM |
| Newborn C57BL/6 mice; chloroquine administration transplacentally and via maternal milk | 100%, 93%, 33% and 0% survival rate of pups when mother mice were treated per day with 15, 5, 1 and 0 mg/kg body weight, respectively | |||
| [21] | Chloroquine | Feline infectious peritonitis virus (FIPV) | Felis catus whole fetus-4 cells | FIPV replication was inhibited in a chloroquine concentration-dependent manner |
| [22] | Chloroquine | SARS-CoV | Vero E6 cells | EC50 = 4.1 ± 1.0 μM |
| MERS-CoV | Huh7 cells (human liver cell line) | EC50 = 3.0 ± 1.1 μM | ||
| HCoV-229E-GFP (GFP-expressing recombinant HCoV-229E) | Huh7 cells (human liver cell line) | EC50 = 3.3 ± 1.2 μM | ||
| [3] | Chloroquine | SARS-CoV-2 | Vero E6 cells | EC50 = 1.13 μM |
CCID50, 50% cell culture infectious dose; CoV, coronavirus; EC50, 50% effective concentration (mean ± S.D.); GFP, green fluorescent protein; HCoV, human coronavirus; MERS, Middle East respiratory syndrome; SARS, severe acute respiratory syndrome; S.D., standard deviation.
Acknowledgments
Funding: This work was supported by the French Government under the ‘Investments for the Future’ program managed by the National Agency for Research (ANR) [Méditerranée Infection 10-IAHU-03]. The funding sources had no role in the preparation, review or approval of the manuscript.
Competing interests: None declared.
Ethical approval: Not required.
References
1. Rolain J.M., Colson P., Raoult D. Recycling of chloroquine and its hydroxyl analogue to face bacterial, fungal and viral infections in the 21st century. Int J Antimicrob Agents. 2007;30:297–308. doi: 10.1016/j.ijantimicag.2007.05.015. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
2. Bosseboeuf E., Aubry M., Nhan T., de Pina J.J., Rolain J.M., Raoult D. Azithromycin inhibits the replication of Zika virus. J Antivir Antiretrovir. 2018;10:6–11. doi: 10.4172/1948-5964.1000173. [CrossRef] [Google Scholar]
3. Wang M., Cao R., Zhang L., Yang X., Liu J., Xu M. Remdesivir and chloroquine effectively inhibit the recently emerged novel coronavirus (2019-nCoV) in vitro. Cell Res. 2020 Feb 4 doi: 10.1038/s41422-020-0282-0. [Epub ahead of print] [PMC free article] [PubMed] [CrossRef] [Google Scholar]
4. Gao J., Tian Z., Yang X. Breakthrough: chloroquine phosphate has shown apparent efficacy in treatment of COVID-19 associated pneumonia in clinical studies. Biosci Trends. 2020 Feb 19 doi: 10.5582/bst.2020.01047. [Epub ahead of print] [PubMed] [CrossRef] [Google Scholar]
6. Multicenter Collaboration Group of Department of Science and Technology of Guangdong Province and Health Commission of Guangdong Province for Chloroquine in the Treatment of Novel Coronavirus Pneumonia Expert consensus on chloroquine phosphate for the treatment of novel coronavirus pneumonia [in Chinese] Zhonghua Jie He He Hu Xi Za Zhi. 2020;43:E019. doi: 10.3760/cma.j.issn.1001-0939.2020.0019. [PubMed] [CrossRef] [Google Scholar]
7. Al-Bari M.A. Chloroquine analogues in drug discovery: new directions of uses, mechanisms of actions and toxic manifestations from malaria to multifarious diseases. J Antimicrob Chemother. 2015;70:1608–1621. doi: 10.1093/jac/dkv018. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
8. Raoult D., Drancourt M., Vestris G. Bactericidal effect of doxycycline associated with lysosomotropic agents on Coxiella burnetii in P388D1 cells. Antimicrob Agents Chemother. 1990;34:1512–1514. doi: 10.1128/aac.34.8.1512. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
9. Raoult D., Houpikian P., Tissot Dupont H., Riss J.M., Arditi-Djiane J., Brouqui P. Treatment of Q fever endocarditis: comparison of 2 regimens containing doxycycline and ofloxacin or hydroxychloroquine. Arch Intern Med. 1999;159:167–173. doi: 10.1001/archinte.159.2.167. [PubMed] [CrossRef] [Google Scholar]
10. Boulos A., Rolain J.M., Raoult D. Antibiotic susceptibility of Tropheryma whipplei in MRC5 cells. Antimicrob Agents Chemother. 2004;48:747–752. doi: 10.1128/aac.48.3.747-752.2004. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
11. Fenollar F., Puéchal X., Raoult D. Whipple's disease. N Engl J Med. 2007;356:55–66. doi: 10.1056/NEJMra062477. [PubMed] [CrossRef] [Google Scholar]
12. Keyaerts E., Vijgen L., Maes P., Neyts J., Van Ranst M. In vitro inhibition of severe acute respiratory syndrome coronavirus by chloroquine. Biochem Biophys Res Commun. 2004;323:264–268. doi: 10.1016/j.bbrc.2004.08.085. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
13. Savarino A., Di Trani L., Donatelli I., Cauda R., Cassone A. New insights into the antiviral effects of chloroquine. Lancet Infect Dis. 2006;6:67–69. doi: 10.1016/S1473-3099(06)70361-9. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
14. Colson P., Rolain J.M., Raoult D. Chloroquine for the 2019 novel coronavirus SARS-CoV-2. Int J Antimicrob Agents. 2020 doi: 10.1016/j.ijantimicag.2020.105923. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
15. Lagier J.C., Fenollar F., Lepidi H., Giorgi R., Million M., Raoult D. Treatment of classic Whipple's disease: from in vitro results to clinical outcome. J Antimicrob Chemother. 2014;69:219–227. doi: 10.1093/jac/dkt310. [PubMed] [CrossRef] [Google Scholar]
16. Vincent M.J., Bergeron E., Benjannet S., Erickson B.R., Rollin P.E., Ksiazek T.G. Chloroquine is a potent inhibitor of SARS coronavirus infection and spread. Virol J. 2005;2:69. doi: 10.1186/1743-422X-2-69. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
17. Barnard D.L., Day C.W., Bailey K., Heiner M., Montgomery R., Lauridsen L. Evaluation of immunomodulators, interferons and known in vitro SARS-coV inhibitors for inhibition of SARS-coV replication in BALB/c mice. Antivir Chem Chemother. 2006;17:275–284. doi: 10.1177/095632020601700505. [PubMed] [CrossRef] [Google Scholar]
18. Biot C., Daher W., Chavain N., Fandeur T., Khalife J., Dive D. Design and synthesis of hydroxyferroquine derivatives with antimalarial and antiviral activities. J Med Chem. 2006;49:2845–2849. doi: 10.1021/jm0601856. [PubMed] [CrossRef] [Google Scholar]
19. Kono M., Tatsumi K., Imai A.M., Saito K., Kuriyama T., Shirasawa H. Inhibition of human coronavirus 229E infection in human epithelial lung cells (L132) by chloroquine: involvement of p38 MAPK and ERK. Antiviral Res. 2008;77:150–152. doi: 10.1016/j.antiviral.2007.10.011. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
20. Keyaerts E., Li S., Vijgen L., Rysman E., Verbeeck J., Van Ranst M. Antiviral activity of chloroquine against human coronavirus OC43 infection in newborn mice. Antimicrob Agents Chemother. 2009;53:3416–3421. doi: 10.1128/AAC.01509-08. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
21. Takano T., Katoh Y., Doki T., Hohdatsu T. Effect of chloroquine on feline infectious peritonitis virus infection in vitro and in vivo. Antiviral Res. 2013;99:100–107. doi: 10.1016/j.antiviral.2013.04.016. 7. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
22. de Wilde A.H., Jochmans D., Posthuma C.C., Zevenhoven-Dobbe J.C., van Nieuwkoop S., Bestebroer T.M. Screening of an FDA-approved compound library identifies four small-molecule inhibitors of Middle East respiratory syndrome coronavirus replication in cell culture. Antimicrob Agents Chemother. 2014;58:4875–4884. doi: 10.1128/AAC.03011-14. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
Source : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7135139/
