March 17, 2021
By Douglas L. Jennings, PharmD, FACC, FAHA, FCCP, FHFSA, BCPS
Volume 1, Issue 3
There is no "I" in team.
As case counts continue to fall across the country, the recent approval of a third COVID-19 vaccine in the United States brings new hope to the fight against this calamitous pandemic. But as success on the vaccination front continue to mount, so do disappointments in the drug therapy arena. We remain with relatively few effective treatments for patients who contract COVID-19, as many therapies prove ineffective or possibly dangerous. In this week's issue of Talking Therapeutics, we explore the latest evidence for two potential COVID-19 drug therapies and discuss whether options belong on your drug therapy team.
Point 1: Leave the I-vermectin On the Bench
Ivermectin is an antiparasitic drug used to treat several neglected tropical diseases, including onchocerciasis, helminthiases, and scabies. Preliminary in vitro data suggested that ivermectin has antiviral properties via inhibition of the attachment of the SARS-CoV-2 spike protein to human cells, which generated initial excitement that lead to some clinicians to try ivermectin. In fact, in April of last year the FDA had to publish a warning against consumption of the veterinary forms of the drug as desperate patients flooded veterinary pharmacies. Unfortunately, the pharmacokinetic and pharmacodynamic studies suggest that achieving the plasma concentrations necessary for the antiviral effect would require administration of doses up to 100-fold higher than those approved for use in humans, and several retrospective studies in COVID-19 have mostly shown no effect. Recently, a randomized trial conducted in Colombia found that among 400 adults with mild COVID-19, a 5-day course of ivermectin, compared with placebo, did not significantly improve the time to resolution of symptoms. In light of these data, ivermectin should be left to ride the pine for now.
Point 2: Does tocilizumab belong on the team?
The immunomodulator tocilizumab has been studies extensively for managing COVID-19, mostly to no avail. In October, I railed against the use of tocilizumab, but on March 5th, 2021 the NIH has changed its recommendations in light of new data. They now suggest that a single dose of 8 mg/kg of tocilizumab can be considered in patients who are exhibiting rapid respiratory decompensation due to COVID-19. While these guidelines cite recent evidence from the REMAP-CAP and RECOVERY trials, they do not seem to include the results from the recently published COVACTA trial, which showed no effect of tocilizumab in patients hospitalized with severe COVID-19 pneumonia. Given the overall limited benefit seen in the available literature, I don’t think that we want tocilizumab on the COVID-19 treatment team except perhaps in the sickest patients who are rapidly decompensating.
Dr Jennings is currently an Associate Professor of Pharmacy at Long Island University and the clinical pharmacist for the Heart Transplant and LVAD teams at NewYork- Presbyterian Hospital Columbia University Irving Medical Center. He is an active researcher in his field, and he has published over 120 peer-reviewed abstracts and manuscripts, primarily focusing on the pharmacotherapy of patients under mechanical circulatory support. As a recognized expert in this area, he has been invited to speak at numerous national and international venues, including meetings in France, Saudia Arabia, India. Finally, Dr. Jennings has been active in professional organizations throughout his career. He is a fellow of the American College of Clinical Pharmacy, the American College of Cardiology, the Heart Failure Society of America, and the American Heart Association.
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