There are hundreds of clinical trials underway evaluating the potential effectiveness of existing drugs and new drugs and testing the viability of vaccines and blood products. This article outlines a list of high-profile treatments that have been tested against the virus, starting with those currently in clinical use and ending with those still undergoing investigation.
As of April 2022, the following covid-19 treatments have full approval from the U.S. Food and Drug Administration (FDA), in order of approval:
- Remdesivir (April 2022 for those 28 days of age and older)
- The Pfizer-BioNTech mRNA vaccine (August 2021 for ages 16+)
- The Moderna mRNA vaccine (January 2022 for ages 18+).
Other treatments currently have an emergency use authorization, meaning that the FDA has allowed for their use but they are still under investigation. These include:
- Convalescent plasma (August 2020)
- Bamlanivimab and etesevimab (November 2020)
- Baricitinib with remdesivir (November 2020)
- Casirivimab with imdevimab (November 2020)
- The Pfizer-BioNTech mRNA vaccine (May 2021 for ages 12 to 15; October 2021 for ages 5 to 11)
- The Johnson & Johnson adenovirus-vectored vaccine (February 2021 for ages 18+)
- Tocilizumab (June 2021)
- Paxlovid (December 2021)
- Molnupiravir (December 2021)
- Evusheld (December 2021)
- Bebtelovimab (February 2022)
Remdesivir was initially developed as a treatment against Ebola. In vitro studies showed it may be effective against COVID-19. In May 2020, it became the first treatment option for COVID-19 to receive emergency use authorization from the FDA. The FDA has permitted it to be used in adults and children hospitalized with severe cases of the disease. In October 2020, remdesivir became the first drug approved by the FDA to treat COVID-19 without an emergency use authorization. In November, it was also authorized for a new EUA when used in combination with baricitinib (see “Biologics” below).
What the Research Says
A clinical trial—the Adaptive COVID-19 Treatment Trial (ACTT)—by the National Institutes of Health (NIH)—showed that people with severe COVID-19 infections treated with the drug had improvement in symptoms four days sooner (31% faster) than those who were not treated. People with moderate infections, however, did not show significant improvement. Data released by the drug manufacturer Gilead Sciences found that people in the treatment group (remdesivir, n=541) recovered five days sooner than those in the control group (placebo, n=521), needed fewer days of oxygen support, and were more likely to be discharged sooner.
In contrast, the World Health Organization (WHO) found no clinical benefit in their Solidarity trial. This study included nearly 11,300 hospitalized people with COVID-19 across 30 countries. Study participants received one of four treatments: hydroxychloroquine, interferon, lopinavir-ritanovir, or remdesivir. None of the treatments decreased the mortality rate over 28 days or the need to start ventilator therapy. Since that time, WHO has formally advised against using the drug for hospitalized patients.
In October 2020, the FDA gave full approval for remdesivir, now named Veklury, for people hospitalized with severe COVID-19 infections if they were 12 years or older and weighed at least 40 kg. An emergency use authorization for people requiring oxygen without ventilator therapy continued for hospitalized adults and for pediatric patients if they weighed between 3.5 kg and 40 kg.
In January 2022, the FDA expanded remdesivir’s emergency use authorization to include people who were not hospitalized but who had mild-to-moderate symptoms and were considered at high risk for complications. A three-day course of treatment is recommended in these cases.
On April 25, 2022, the FDA expanded the approval of remdesivir treatment to include young children 28 days of age and older (weighing at least 3 Kg) who are either hospitalized or who have mild-to-moderate symptoms and are considered at high risk for complications. This is the first COVID-19 treatment to be approved for patients under 12 years of age.
The National Institutes of Health recommends remdesivir, dexamethasone, or a combination of remdesivir with dexamethasone for hospitalized COVID-19 patients who require conventional oxygen therapy.
Dexamethasone and Methylprednisolone
Dexamethasone and are steroids that are often used to treat inflammation. They come in both oral and IV formulations. COVID-19 has been associated with a severe inflammatory reaction in many cases, and researchers looked to investigate the benefits of using these common anti-inflammatory drugs.
What the Research Says
The RECOVERY (Randomised Evaluation of COVid-19 therapy) trial found that people treated with 10 days of dexamethasone did better than those on placebo. Specifically, mortality rates decreased from 41% to 29% for people who needed ventilators and from 26% to 23% for people requiring oxygen without ventilator therapy.
A meta-analysis sponsored by the World Health Organization (WHO) reviewed seven randomized clinical trials including approximately 1,700 critically ill COVID-19 patients. Published in JAMA, the study found that the 28-day mortality rate was significantly lower for people treated with steroids (dexamethasone, hydrocortisone, or methylprednisolone) than those treated with usual care or placebo (32% mortality rate for steroids vs. 40% for controls).
Steroids have shown benefits when used in combination with tocilizumab (see “Biologics” section below). A study in the Annals of the Rheumatic Diseases looked at people who had both COVID-19 and cytokine storm, a syndrome of overactive inflammation in the body. They were treated with five days of steroids, and if they did not improve within two days, they also received a dose of IV tocilizumab. This treatment group was 79% more likely to have a clinical improvement in respiratory symptoms over 7 days, 65% less likely to die in the hospital, and 71% less likely to need mechanical ventilation. Another study, this one in Chest, confirmed the benefit of combined therapy in 5,776 patients hospitalized with COVID-19. Steroids decreased mortality by 34%, but the mortality rate decreased by 56% when combined with tocilizumab.
Children who develop multisystem inflammatory syndrome in children (MIS-C) may benefit from methylprednisolone, according to a study in JAMA. In the study, 111 children with the syndrome were treated with IV immunoglobulin with or without methylprednisolone. Children that received both treatments had improved outcomes, notably reduced fever within two days and decreased fever recurrence over seven days.
Casirivimab and Imdevimab (formerly REGEN-COV2)
Regeneron Pharmaceuticals Inc. developed a man-made antibody cocktail initially called REGEN-COV2, now known as casirivimab and imdevimab. The investigational treatment includes two antibodies targeted against COVID-19. The company announced preliminary data suggesting that viral loads and COVID-19 symptoms were reduced within seven days of treatment. President Donald Trump, who reported positive COVID-19 test results on October 1, was treated with REGEN-COV2 on October 2, 2020.
Regeneron later released Phase 3 trial results, announcing in a press release that their casirivimab-imdevimab cocktail decreased COVID-19 infection in people with high-risk exposures. People who received the cocktail (n=186) did not develop symptomatic infections, although 10 developed asymptomatic infections. The placebo group (n=223), however, developed 8 symptomatic infections and 23 asymptomatic infections. Altogether, the treatment decreased the rate of any COVID-19 infection by half (5% for the treatment group vs. 10% for placebo) and fully protected against symptomatic infection.
In November 2020, the FDA granted emergency use authorization for the antibody cocktail for people with COVID-19 with mild to moderate disease who are at high risk for complications, who are not hospitalized, and who do not require supplemental oxygen.
In April 2021, Regeneron announced that the monoclonal antibody combination decreased the risk for symptomatic COVID-19 in contacts when household contacts were positive. The Phase 3 trial recruited 1505 people and treated them with either casirivimab-imdevimab or placebo within four days of a positive test in the household. The treatment was 81% effective in decreasing symptomatic infections. For those who became infected despite treatment, their symptoms resolved much faster than people who received a placebo (one week vs. three weeks).
In July 2021, the FDA authorized the treatment for post-exposure prophylaxis. This allows it to be used for “people exposed to an infected individual, or who are at high risk of exposure to an infected individual in settings such as nursing homes or prisons.”
By January 2022, the majority of COVID-19 cases in the U.S. were attributable to the omicron variant. Unfortunately, REGEN-COV2 has not been as effective against this version of the virus. This is the reason the FDA limited emergency use authorization for the medication unless a patient was known to be infected with a different variant.
Other Synthetic Antibodies
The following COVID-targeted antibodies are listed in order of their development and use.
Sponsored in part by the National Institute of Allergy and Infectious Diseases, Eli Lilly and Company has developed a monoclonal antibody (initially known as LY-CoV555, since named bamlanivimab) intended to neutralize COVID-19. A Phase 3 trial treated 769 COVID-19 patients with the monoclonal antibody combination or placebo. All participants were 12 years or older, were considered high-risk, had mild-to-moderate symptoms, and were not hospitalized at the start of the study. Four people in the treatment group eventually required hospitalization (4/511) while 15 people in the placebo group were hospitalized (15/258), 4 of whom died. Altogether, the bamlanivimab-etesevimab combination decreased the risk for hospitalization or death by 87%.
In November 2020, the FDA issued an emergency use authorization for this treatment for high-risk people who have mild to moderate COVID-19, who are not hospitalized, and who are not requiring oxygen therapy because of their COVID-19 infection.
In a January 2021 press release, Eli Lilly reported the effectiveness of bamlanivimab as a preventive therapy. In their BLAZE-2 trial, 965 nursing home residents who initially tested negative for COVID-19 were treated with the monoclonal antibody or placebo. Over eight weeks, those treated with bamlanivimab were 57% less likely to develop symptomatic COVID-19. Four people died from their infection, but none of them were in the treatment group.
In February 2021, the FDA granted an emergency use authorization for a combination of the monoclonal antibodies bamlanivimab and etesevimab. The treatment is intended for non-hospitalized patients with mild-to-moderate COVID-19 symptoms who do not require supplemental oxygen. Patients should be 12 years or older, weigh at least 40 kg, and be considered high risk (e.g., be 65 years or older, have certain chronic medical conditions, etc.). A randomized, double-blind, placebo-controlled clinical trial study of 1,035 people found that those who received this treatment were less likely to be hospitalized or die from COVID-19 (2% vs. 7%).
In April 2021, the emergency use authorization for bamlanivimab monotherapy was revoked due to decreased efficacy against virus variants. Combination therapy with bamlanivimab and etesevimab remains a treatment option.
Bamlanivimab and Virus Variants
Virus variants have had increasing resistance to bamlanivimab. For this reason, the Department of Health and Human Services no longer distributes this treatment on its own. It was authorized for combination treatment with etesevimab for a time. However, even combination treatment has been ineffective against the omicron variant, and the FDA has since limited its use.
Sotrovimab (formerly VIR-7831)
GlaxoSmithKline and Vir Biotechnology have come together to develop an investigational monoclonal antibody treatment called sotrovimab. Their Phase 3 trial included 583 people at high risk for hospitalization from COVID-19 infection. Emergency use authorization was granted by the FDA on May 26, 2021.
Due to increasing resistance to the BA.2 omicron variant, the FDA began restricting the use of sotrovimab in March 2022. Then, in April 2022, the agency announced that sotrovimab was no longer authorized to treat COVID-19 in the U.S. due to an increase in the proportion of COVID-19 cases caused by this omicron variant.
Evusheld (formerly AZD7442)
AstraZeneca developed investigation antibodies (tixagevimab and cilgavimab, formerly known as AZD7442) to treat and hopefully prevent COVID-19 infection in people exposed to the virus. Evusheld may be more effective as a preventive treatment than a post-exposure treatment.
A Phase 3 trial involved more than 5,000 adults at high risk for COVID-19 infection. Their risk was either due to underlying medical conditions or circumstances that increase their risk for exposure. People treated with these antibodies were 77% less likely to develop symptomatic COVID-19 infection. No cases of severe COVID-19 were detected in the treatment group. The placebo group, however, had three cases of severe COVID-19 and two deaths.
In December 2021, the FDA granted an emergency use authorization to Evusheld as a preventive treatment for people with weak immune systems or for those who had a serious reaction to a COVID vaccine or one of its components. It is intended to be used in people 12 years and older who weigh at least 40 kg, who do not currently have COVID infection, and who have not recently been exposed to someone with COVID.
Due to increasing resistance to some virus variants, the FDA has recommended that the dose of Evusheld be doubled.
BRII-196 and BRII-198
Brii Biosciences has developed a combination of monoclonal antibodies, BRII-196 and BRII-198. A Phase III trial, sponsored by the National Institute of Allergy and Infectious Diseases, included 837 participants that were diagnosed with COVID-19 within the past 10 days. Those that received the antibody treatment were 78% less likely to need hospitalization (12 in the treatment group and 45 in the placebo group). The treatment also decreased mortality by 10% (1 in the treatment group and 9 in the placebo group).
Vaccines for COVID-19
The best hope for managing COVID-19 long-term: vaccines. Vaccines expose your body to an antigen—a substance that causes an immune response, in this case from a virus—and trigger antibody production from your immune system. The goal is to make antibodies against the virus without causing an infection. That way, if you are exposed to that antigen again, your body will remember how to make those antibodies against it. Hopefully, your immune response will be so strong you won’t get sick at all. But if you do get sick, your symptoms will be milder than if you did not get the vaccine.
Some strains of the virus, also known as variants, have developed mutations in the spike protein that could change the effectiveness of some vaccines. Many variants have been discovered to date.
- British variant: Also known as B.1.1.7, this variant includes 8 mutations in the spike protein and was first detected in September 2020.
- South African variant: Also known as B.1.351, this variant includes 10 mutations in the spike protein and was first detected in October 2020.
- Delta variant: Also known as B.1.617.2, this variant includes 10 mutations in the spike protein and was first detected in December 2020.
- Brazilian variant: Also known as B.1.28.1, this variant includes 3 mutations in the spike protein and was first detected in January 2021.
- Omicron variant: Also known as B.1.1.529, this variant includes 32 mutations in the spike protein and was first detected in November 2021. By January 2022, this variant accounted for approximately 99% of the cases in the United States. A new omicron variant, BA.2, has since been discovered.
Pfizer Inc. — Comirnaty (formerly BNT162b2)
Efficacy: In November 2020, early data from a Phase 3 trial found an mRNA-vectored vaccine developed by Pfizer and BioNTech to be 90% effective in preventing COVID-19. The vaccine is administered in a two-dose series, three weeks apart. When looking at infection rates seven days after a second dose, 94 people developed symptomatic COVID-19 from a study population of 43,538 people. The company released additional data nine days later on November 18, noting that 170 cases of symptomatic COVID-19 had occurred in trial participants, 8 cases in those who took the vaccine, and 162 in people who took the placebo. This improved their data to show a 95% efficacy rate overall and a 94% efficacy rate in people over 65 years old.
Vaccination of nearly 600,00 people in Israel has shown results similar to those in the Pfizer clinical trials. After the second dose, it was noted to be 92% effective against COVID-19 at large—94% against symptomatic disease and 90% against asymptomatic disease.
A U.K. case-control study also looked at the effectiveness of vaccination in the real world. Looking at approximately 157,000 seniors over 70 years old, a single dose of vaccine was 61% effective against symptomatic disease after 28 days. After a second dose, effectiveness increased to 85% to 90%. People who developed symptomatic COVID-19 after their first dose were 43% less likely to require hospitalization within 14 days of their diagnosis and were 51% less likely to die from their infection.
Similarly, the Centers for Disease Control and Prevention reported that partial vaccination in skilled nursing residents was 63% effective. Their analysis included 463 residents in Connecticut nursing homes where there was an outbreak of COVID-19. Residents were included in the analysis if they had received one dose of the vaccine (and were more than 14 days after their dose) or two doses (if they were less than seven days after their second dose).
- British: Pfizer assessed the serum of 40 people who had received both doses of the vaccine and tested it against the British variant. Serum from younger study participants (23-55 years old) neutralized the British variant at a 78% rate and those from older participants (57-73 years old) at an 83% rate.
- South African: Neutralizing antibody assays against the British and South African variants were performed on the serum of 20 vaccinated people. In 6 of the sera, titers were only half as effective against the South African variant. That said, in 10 of the sera, titers were twice as high against the British variant.17 A report of serum from 15 vaccinated recipients was later published in the New England Journal of Medicine, noting a two-thirds decreased ability to neutralize the South African variant.
- Delta: In June 2021, the U.K. reported that two-dose vaccination was 96% effective against hospitalizations due to the delta variant. In July 2021, Canadian research showed two doses to be 87% effective against symptomatic infection from the delta variant.19 Israel, however, found it to be less effective, at 64%; the data for that has not yet been formally released. In July 2021, a study in the New England Journal of Medicine reported that the two-dose series of the Pfizer vaccination is 93.7% effective against symptomatic disease when looking at the original virus and 88.0% against the delta variant.
- Results from a Phase 3 trial of 2,260 adolescents 12 to 15 years old showed the vaccine to be 100% effective against COVID-19 one month after the second dose. There were 18 cases of COVID-19 in the placebo group and none in the treatment group. On May 10, 2021, the FDA granted an emergency use authorization for this age group.
- On October 29, 2021, the FDA authorized vaccination in children 5 to 11 years old, noting that the vaccine had no serious side effects and was 90.7% effective in preventing infection in this group.
- Unfortunately, the two-dose vaccine series was not successful for children 6 months to 5 years old in early trials and is still under investigation.
- The CDC reports a small increase in myocarditis cases with vaccination. Based on data through May 31, 2021, people 16 to 24 years old accounted for 52.5% of vaccine-related myocarditis cases, even though they only represented 8.7% of the people vaccinated. These cases were reported within 21 days of a vaccine dose. Looking at people 16 to 39 years old, the second dose was associated with the greatest risk, more so for boys and young men. Rates were at 10.4 cases per million people for the Pfizer vaccine.
- Israel reported 148 cases of myocarditis in young men, out of 5 million doses, that was associated in time with the vaccine.
The risk for myocarditis remains very low, and most people tend to recover quickly. Noting that the risks of COVID-19 are greater than those for myocarditis, the CDC continues to recommend vaccination for everyone 12 years and older.
Approval: On December 11, 2020, the FDA granted emergency use authorization in the United States, and the first Americans were vaccinated on December 14. In August 2021, the vaccine, now referred to as Comirnaty, was given full approval by the FDA for anyone 16 years and older. The vaccine remains under an emergency use authorization for children and adolescents 5 to 15 years old.
- The booster dose for Pfizer is recommended for everyone age 12 and older (regardless of risk).
- In January 2021, the FDA approved booster doses for 16- and 17-year-olds and then for those 12 to 15 years old. Later that month, the FDA announced that booster doses could be given five months after the initial series for anyone 12 and older.
- In March 2022, the FDA approved a second mRNA booster dose for anyone 50 years or older and for anyone 12 or older with certain kinds of immunocompromise. This dose can be given four months after the last booster dose.
The FDA has allowed a “mix and match” booster dosing regimen. This means that you can receive either a Pfizer, Moderna, or Johnson & Johnson vaccine after completing your initial vaccine series for any of these vaccines (although mRNA COVID-19 vaccines—Moderna and Pfizer—are recommended in most situations).
Moderna Inc. — Vaccine Candidate mRNA-1273
Efficacy: This mRNA-vectored vaccine was funded by the National Institute of Allergy and Infectious Diseases (NIAID) and the Biomedical Advanced Research and Development Authority (BARDA). In November 2020, data from their Phase 3 trial showed the Moderna vaccine to be 94.5% against COVID-19. When looking at infection rates two weeks after a second dose, 95 people developed symptomatic COVID-19 from a study population of more than 30,000 people. As much as 42% of the population had high-risk conditions such as diabetes, heart disease, or obesity. Of those who contracted the disease, 11 cases were listed as severe, but none of those had received the vaccine. In December, they released additional data, noting that 196 cases of symptomatic infection had occurred in trial participants, 11 cases in those who took the vaccine (none had severe COVID-19), and 185 in people who took the placebo. This suggested 94.1% efficacy for COVID-19 at large and 100% efficacy against severe disease.
- Moderna performed an in vitro analysis, testing the serum from 8 vaccinated people from their Phase I trial against the B.1.1.7 and B.1.351 variants. The company claims there was no significant decrease in neutralizing titers against the British variant but noted a 6-fold decrease in titers to the South African variant.
- A preliminary report of serum from vaccinated recipients in the New England Journal of Medicine found a marginal 1.2-fold decrease in the ability to neutralize the B.1.17 variant but a 6.4-fold decrease against the B.1.351 variant.22 Moderna has since developed a new vaccine targeted against the B.1.351 variant.
- A Phase II trial of this new vaccine was tested in 40 people who had previously received the 2-dose vaccination series but who had low antibody titers to variants B.1.351 and P.1. The booster dose was administered six to eight months after the initial series and showed a boost in immunity against these two variants.
- A Canadian study reported that one dose of the vaccine protected against symptomatic infection (72%) but did not provide information regarding two-dose effectiveness.
Children: Their Phase 2/3 study, referred to as teenCOVE, enrolled 3,723 adolescents between 12 and 17 years old. One dose was 93% effective against COVID-19 after 14 days. Effectiveness increased to 100% two weeks after the second dose. Four COVID-19 cases were detected in the placebo group. Based on these results, Moderna requested emergency use authorization for use in children 12 to 17 years old in June 2021. However, due to concerns about myocarditis, there has been a delay in the authorization.
Complications: Similar to the mRNA-based Pfizer vaccine, there has been an increase in myocarditis for people shortly after the mRNA-based Moderna vaccination (see above). Within 21 days of a Moderna vaccine dose, rates for myocarditis were reported by the CDC to be at 24.7 cases per million people, more so in younger males. Since the CDC reports that the risks of COVID-19 far outweigh the risks of myocarditis, vaccination continues to be recommended.
Approval: The FDA granted the Moderna vaccine emergency use authorization on December 18, 2020. The FDA granted full approval for the two-dose mRNA vaccine series in January 2022. Now called Spikevax, the Moderna vaccine is approved for people 18 and older. Extra primary doses for people who are immunocompromised and booster doses remain under an emergency use authorization (see below).
- The Moderna booster dose is now recommended for all adults age 18 and older (regardless of age or risk).
- In January 2021, the FDA narrowed the booster interval to 5 months.
- In March 2022, the FDA approved a second booster dose for anyone older than 50 years old and for anyone 18 or older who is immunocompromised. This dose can be given 4 months after the last booster dose.
Johnson & Johnson — Vaccine Candidate Ad26.COV2.S
Efficacy: This vaccine was developed by Janssen Pharmaceutical Companies, a division of Johnson and Johnson. It is an adenovirus-vectored vaccine that attacks the spike protein expressed by SARS-CoV-2. Their Phase 3 trial included more than 43,000 people, and there were 468 cases of symptomatic COVID-19. The vaccine was most effective against severe infection, showing 85% effectiveness after 28 days with no cases detected after day 49. Effectiveness overall was 66%, (72% in the United States, 66% in Latin America, and 57% in South Africa). Of note, 95% of the cases in South Africa were from the B.1.351 variant. In September 2021, Johnson & Johnson released real-world data involving more than 390,000 people vaccinated with one dose. The vaccine was 75% effective against severe COVID-19 overall. When looking specifically at the United States, it was 74% effective against severe COVID-19, 89% against hospitalization, and 83% against COVID-19-related death.
Virus Variants: A small study of 20 vaccinated people showed that immunity remained strong against the South African and Brazilian variants. The amount of neutralizing antibodies produced was not as high as it was with other strains of COVID-19, but the T cell response remained strong.23 A July 2021 press release announced that the vaccine was protective against the delta variant (n=8), generating neutralizing antibodies at levels higher than it did against the South African variant.
- In October 2020, Johnson & Johnson reported an unexplained illness in one of their study participants. The company paused its clinical trial for 11 days until it was certain the illness was not related to the vaccine.
- The CDC and FDA recommended a temporary pause in using the vaccine due to concerns about possible blood clots. Of the more than 6.8 million doses administered by early April 2021, 6 women developed cerebral venous sinus thrombosis and low platelet levels. Symptoms occurred six to 13 days after vaccination. After careful review, the pause on the vaccine was lifted on April 23. Updated data showed 15 cases of thrombosis and thrombocytopenia syndrome in 7.98 million vaccine doses. Overall, the rate for these complications was 1.9 per 1 million doses overall but 7 per 1 million doses in women 18 to 49 years old.
- In July 2021, the FDA added warning and precautions to the EUA, this time for an increased risk for Guillain-Barre syndrome. They noted that the risk for the condition increased within 42 days of vaccination. There were approximately 100 cases reported over 12.8 million vaccinations.
Booster Dose: Although the vaccine was initially released for one-time dosing, Johnson & Johnson reports that a booster dose may incur increased immunity. Their Phase III trial found that a second dose given two months after the first dose was 100% effective against severe COVID-19 infections. Globally, it was 75% effective against moderate infection, but the rate was even better in the United States at 94%. On October 15, 2021, an FDA panel unanimously recommended a booster shot two months from the first vaccine dose, and it granted an emergency use authorization for the dose on October 20. However, the CDC now recommends the preferred use of the Pfizer and Moderna vaccines for primary and booster vaccination due to the risks of the Johnson & Johnson vaccine.
AstraZeneca — Vaccine Candidate AZD1222 (previously ChAdOx1)
Efficacy: Partnered with AstraZeneca, Oxford University’s Jenner Institute has surged ahead in vaccine research. Because its vaccine for a different type of coronavirus showed promise in smaller human trials last year, the Jenner Institute was able to move forward quickly.
- In December 2020, AstraZeneca published peer-reviewed data on more than 11,000 study participants across two different study trials. The vaccine efficacy rate was 62% after two full doses of the vaccine were administered a month apart (n=8,895) and 90% when given a half dose followed by a full dose a month later (n=2,741), for a combined efficacy rate of 70.4%.
- In February 2021, they released more Phase 3 data, this time data on a larger population of more than 17,100 participants. Efficacy after a single dose was noted to be 76% after 22 to 90 days (59% for the full dose group, 86% for the half-dose group). Efficacy 14 days after a two-dose regimen was 67% against symptomatic COVID-19 (57% for the full dose group, 74% for the half-dose group). Interestingly, efficacy was also affected by the timing of the doses. It was as low as 55% when the doses were administered less than six weeks apart (33% for the full dose group, 67% for the half-dose group) but increased to 82% when doses were separated by at least 12 weeks (63% for the full dose group, 92% for the half-dose group).25 Of note, this efficacy is based on someone developing symptoms from COVID-19 and does not reflect asymptomatic COVID-19 infection.
- In March 2021, a preprint case-control study from the United Kingdom looked at the effectiveness of single-dose vaccination in people over 70 years old. The researchers looked at approximately 157,000 people who were tested for COVID-19 in the real world. Vaccine effectiveness against the symptomatic disease was 22% at 14 days, 45% at 21 days, 60% at 28 days, and 73% at 35 days. People who developed symptomatic COVID-19 despite vaccination were 37% less likely to require hospitalization within 14 days of their diagnosis.
- In March 2021, an AstraZeneca press release announced results from a Phase 3 trial in the United States involving 32,449 participants, 60% of who had pre-existing conditions that increased the risk for severe infection (e.g., diabetes, heart disease, obesity). Overall, there were 141 cases of symptomatic COVID-19. The company claimed that the vaccine was 79% effective against symptomatic COVID-19 (80% for people 65 and older) and 100% effective against severe infection and hospitalization. The National Institute of Allergy and Infectious Diseases later raised concern over the validity of the results, stating that the announcements focused on outdated information. AstraZeneca then released updated information, noting a 76% efficacy (85% for people 65 and older) and 100% effectiveness against severe disease.
- To check efficacy against the B.1.1.7 variant, researchers sequenced the viral genome from 499 Phase 2/3 participants who contracted COVID-19. There was a 9-fold decrease in neutralizing antibodies against B.1.1.7 when compared to the original virus. For people exposed to the B.1.1.7 variant, efficacy was 75% against symptomatic COVID-19 infection but only 27% against asymptomatic infection. This was in contrast to 84% and 75%, respectively, for the original strain.26 Effectiveness against the B.1.351 variant was considerably lower.
- A study in the New England Journal of Medicine looked at more than 2,000 people who had received at last one dose of the vaccine in South Africa. The vaccine prevented mild-to-moderate COVID-19 only 22% of the time. Of the people who were infected, 93% were infected with the B.1.35 variant. Altogether, efficacy against that variant was only 10%.
- The U.K. reported that this vaccine was 92% effective against hospitalization from the delta variant. A study in the New England Journal of Medicine found that the two-dose Astra Zeneca vaccination was 74.5% effective against symptomatic disease when looking at the original virus and 67.0% against the delta variant.
- The vaccine temporarily halted its Phase 3 trial in September 2020 after a participant developed transverse myelitis, a neurologic condition that can be triggered by viruses. After determining that the illness was not associated with the vaccine, AstraZeneca resumed its trial after six weeks.
- Several European countries temporarily halted the administration of the vaccine in March 2021 due to concerns for associated blood clots with low platelets (7 cases of disseminated intravascular coagulation and 18 cases of cerebral venous sinus thrombosis out of 20 million vaccinated people). Later that month, the European Medicines Agency concluded that the benefits of the AstraZeneca vaccine outweigh the potential risks.
- Since then, two studies confirmed thrombosis or bleeding problems after vaccination, including the development of anti-platelet antibodies. The first identified 11 cases (9 women, 2 men) in Germany and Norway between 5 and 16 days after vaccination. The second found 5 cases (4 women, 1 man) in Norway between 7 and 10 days of vaccination.
- Another study in Scotland reviewed the risk for blood clots, low platelet counts, or bleeding in the brain in 1.71 million people vaccinated with the AstraZeneca vaccine. Nineteen cases of cerebral venous sinus thrombosis (CSVT) were identified, but only six of them occurred after vaccination. ITP was also very rare, affecting only 1.13 in 100,000 vaccinated people.
Novavax Inc. — Vaccine Candidate NVX-CoV2373
Preliminary Results: Sponsored by the National Institute of Allergy and Infectious Diseases (NIAID) and the Biomedical Advanced Research and Development Authority (BARDA), this vaccine uses nanoparticle technology to develop an antibody response against the spike protein. Like many other vaccines, it is administered in two doses 21 days apart. Phase 1/2 clinical trials have shown an antibody response that is greater than that seen in convalescent plasma from patients who were symptomatic of COVID-19.
Efficacy: In a press release, the company announced preliminary results from their Phase III trial in the U.K. (more than 15,000 participants) and their Phase 2 trial in South Africa (more than 4,400 participants). In the former study, 62 participants developed symptomatic COVID-19 (6 in the treatment group vs. 56 in the placebo group). Overall, the effectiveness of the vaccine was 89.3%. This broke down to 95.6% against the original strain and 85.6% against the British variant. The latter study was less successful, noting 44 cases of symptomatic COVID-19 (15 in the treatment group vs. 29 cases in the placebo group), with overall effectiveness of 60%. Sequencing was only done on 27 of the positive cases, but 25 of those were confirmed to be the South African variant. In May 2021, a study in the New England Journal of Medicine reported similar findings in South Africa with a 60% decrease in risk for symptomatic infection in people without HIV and 49% for people with HIV.
GlaxoSmithKline and Medicago – Vaccine Candidate CoVLP
GlaxoSmithKline and Medicago have come together to develop a novel vaccine based on a plant-based technology. A bacterial vector is used to infect a specific type of plant, N. benthamiana. The plants are then allowed to grow until enough vaccine material is grown. They are then harvested, and the vaccine material is extracted and isolated.
Efficacy: The companies released a press release in December 2021. A Phase 3 clinical trial included more than 24,000 adults across six countries and treated participants with a two-dose series 21 days apart. The overall efficacy rate of the vaccine was 71% but increased to 75.3% against the delta variant of COVID-19.
INOVIO Pharmaceuticals Inc. — Vaccine Candidate INO-4800
The Coalition for Epidemic Preparedness Innovations and The Bill and Melinda Gates Foundation are among the multiple funding sources for this vaccine candidate. The first injections of this DNA vaccine developed by INOVIO Pharmaceuticals, Inc. were administered to healthy subjects on April 6, 2020. In September 2020, the FDA put Phase 2/3 clinical trials on hold as it evaluates the safety of its delivery device, which injects DNA into cells.
Severe cases of COVID-19 have been associated with what is called a cytokine storm. As part of the normal immune response, the body recruits cytokines—proteins secreted by immune system cells—to the site of infection. In some cases, however, that process becomes hyperresponsive, and excess cytokines are released. Some of these cytokines are inflammatory in nature and can lead to worsening respiratory symptoms or organ failure. Biologic agents—pharmaceutical treatments created from biological sources—are now being considered to address this.
Baricitinib is a JAK1/JAK2 inhibitor, a class of medications used to quell inflammation by decreasing the effect of certain cytokines.
What the research says: As part of the Adaptive COVID-19 Treatment Trial (ACTT-2), a Phase 3 randomized double-blind placebo-controlled trial has shown early promise for the drug. Approximately 1,000 patients hospitalized with COVID-19 were randomized to receive remdesivir alone or remdesivir with baricitinib. On average, patients clinically improved one day earlier with the combination treatment.
In November 2020, the FDA authorized the drug combination (not baricitinib alone) for an emergency use authorization for the treatment of hospitalized patients who required oxygen supplementation, ventilator treatment, or extracorporeal membrane oxygenation (ECMO). The National Institutes of Health, however, has stated that there is not enough evidence to support this regimen as a preferred treatment when dexamethasone is available.
Interferons are a natural part of your immune system. These cytokines boost the immune response to viruses. Currently, interferons are currently an injected treatment used for viral hepatitis.
What the research says: Since COVID-19 is a pulmonary condition in most cases, researchers looked to see if breathing interferon beta-1a into the lungs could help to boost the immune response against the virus. A Phase 2, randomized, double-blinded clinical trial in The Lancet Respiratory Medicine looked at approximately 100 adults hospitalized with COVID-19. Participants were treated with inhaled interferon beta-1a via nebulizer or placebo for 14 days. The interferon group had twice the clinical improvement after 15 to 16 days and three times the improvement at day 28. While the length of a hospital stay did not decrease, there was a 79% decrease in the severity of disease or death.
Tocilizumab is a monoclonal antibody that blocks cell receptors from binding to interleukin-6 (IL-6), one of the pro-inflammatory cytokines. This, in theory, would help to decrease the severity of the cytokine storm and help people to recover faster.
What the research says:
A study in Lancet Rheumatology found a 39% decreased risk for ventilator use or death in COVID-19 pneumonia patients who were treated with tocilizumab when compared to those treated with standard therapy. However, tocilizumab acts as an immunosuppressant, and the researchers also found that those treated with the drug also had a 3-fold increase in developing other new infections like invasive aspergillosis.36 According to a study of 154 patients in Clinical Infectious Diseases, tocilizumab decreased the mortality rate in COVID-19 patients who required a ventilator by 45% when compared to those not treated with the drug. Although those treated with tociluzumab were more likely to develop superinfections (54% vs. 26%) over a follow-up of 47 days, they did not have increased death as a result of those superinfections.
Three studies were published in JAMA Internal Medicine in October 2020, but the results were inconsistent. An American study treated 433 people with severe COVID-19 within two days of their admission into an intensive care unit. Their mortality rate was 29%, compared to 41% for ICU patients who did not receive tocilizumab.38 French and Italian studies, however, did not find a clinical benefit in their randomized open-label trials for people with COVID-19 pneumonia. The former study looked at 130 people with moderate-to-severe disease, and the latter at 126 people. They found no difference in the mortality rate at 28 days or symptom improvement with treatment after 14 days, respectively. Another study in the New England Journal of Medicine looked at nearly 400 people who had COVID-19 pneumonia. Those treated with tocilizumab were less likely to need mechanical ventilation by day 28 (12% vs. 19% when compared to standard care). Although clinical outcomes were improved, mortality rates did not significantly change.
Unfortunately, not all studies have shown a benefit. In a Brazilian study, 129 critically ill COVID-19 patients were treated with tocilizumab and standard care or standard care alone. At 15 days, mortality was actually higher for those treated with tocilizumab, 17% vs. 3%. At 29 days, mortality rates were not statistically significant between the two groups. Although other studies have shown a survival benefit, this study raises significant issues for safety. In fact, this study was terminated early for that reason.
The National Institutes of Health currently recommends tocilizumab plus dexamethasone for COVID-19 patients in the ICU who require mechanical ventilation or high-flow nasal cannula oxygen. Non-ICU patients who develop hypoxia and need noninvasive ventilation or high-flow oxygen can qualify for this regimen, too, if they also have elevated inflammatory markers. That said, tocilizumab should not be used for people who are significantly immunocompromised.
The FDA granted an emergency use authorization for tocilizumab as a treatment for COVID-19 on June 24, 2021. It is intended for hospitalized patients 2 years and older who have severe COVID-19. Specifically, these patients must also be receiving treatment with steroids and oxygen, ventilators, or extracorporeal membrane oxygenation (ECMO). Although tocilizumab has been FDA-approved for other medical conditions (e.g., rheumatoid arthritis), its use for COVID-19 is limited to the EUA at this time.
Medications are one way to target COVID-19, but our own bodies may offer a way to combat the disease, too. When we are exposed to a foreign substance like COVID-19, our immune system can develop antibodies against it. Blood that contains these antibodies is referred to as convalescent plasma.
What the Research Says
A study in Mayo Clinic Proceedings noted that convalescent plasma was generally safe when used to treat 20,000 hospitalized COVID-19 patients and decreased mortality, especially when administered earlier in the course of the illness.42 A trial of more than 35,000 hospitalized patients found that treatment with plasma that had high antibody levels lowered mortality if given within 3 days of the diagnosis.43 A study of 160 COVID-19 patients found treating seniors 65 and older within 3 days of mild symptoms decreased their risk of progressing to severe respiratory disease by half (16% with treatment vs. 31% with placebo) over 15 days. The researchers estimated only seven seniors would need to be treated to decrease severe illness in one adult.
Not all research has been as favorable. A study of nearly 500 adults noted that while convalescent plasma reduced viral loads within 7 days, there was no decrease in mortality rates. A randomized-controlled study including 228 adults with COVID-19 pneumonia found no clinical benefit for those treated with convalescent plasma over 30 days. The National Institutes of Health halted a clinical trial in March 2021 noting a lack of benefit for people with mild to moderate COVID symptoms. A subsequent study in the New England Journal of Medicine found that administration of convalescent plasma within seven days of COVID-19 symptoms did not slow down the disease when compared to placebo. All of the patients enrolled in the study were 50 years or older or otherwise considered to be high risk.
Without more consistent or robust data, there has been controversy about the FDA’s emergency authorization for convalescent plasma as a treatment for COVID-19 in August 2020. In February 2021, the EUA was updated. Only high-antibody-titer convalescent plasma was authorized for use. It has also been limited to hospitalized patients early in the course of their disease or in hospitalized patients who are immunocompromised.
A randomized, controlled trial in Nature Medicine was published in August 2021. It suggested that treatment with convalescent plasma may increase the risk for complications in people with severe COVID-19 infections, including intubation and death. This occurred 33.4% of the time in people treated with plasma vs. 26.4% in people who were not treated.
There are a number of antiviral treatments—medications that prevent a virus’s ability to reproduce—being investigated for COVID-19 at this time.
Molnupiravir is an oral antiviral medication that does not target the spike protein as the vaccines do. Instead, it is a drug that blocks the replication of some RNA viruses. Specifically, it is a prodrug, an inactive medication, that is metabolized to its active form (N4-hydroxycytidine) in the body. The drug has been developed by Merck and Ridgeback Biotherapeutics.
What the research says: Their Phase 3 trial, referred to as MOVe-OUT, included 775 adults who had mild to moderate COVID-19 and who were not hospitalized. Study participants were treated within 5 days of symptoms and they also had at least one factor (e.g., age 60 or older, diabetes, heart disease, obesity, etc.) that increased the risk for a bad outcome. When compared to people treated with a placebo, those treated with molnupiravir were approximately 50% less likely to be hospitalized or to die within 29 days (7.3% in the treatment group vs. 14.1% in the placebo group). Of note, there were no deaths in the treatment group, but there were 8 deaths in the placebo group.
Updated data was presented to the FDA in November 2021 that included 1,433 adults. The effectiveness remained high but was lower than previously reported, 30% instead of 50%.
The FDA granted emergency use authorization for molnupiravir in December 2022. It is intended for use for people 18 years and older, who have a positive COVID test, who have mild to moderate symptoms, and who are at high risk for developing complications from the disease. Treatment should begin within five days of symptom onset.
Paxlovid (PF-07321332 and ritonavir)
Paxlovid is a new antiviral regimen developed by Pfizer. It is a combination of two medications, PF-07321332, and ritonavir. PF-07321332 prevents replication of the virus by blocking the SARS-CoV-2-3CL protease. The ritonavir does not attack the COVID virus directly. Instead, it is a cytochrome P450 inhibitor that helps to slow down the breakdown of PF-07321332 in the body so that it can act longer.
What the research says: Their Phase 2/3 trial, referred to as EPIC-HR (Evaluation of Protease Inhibition for COVID-19 in High-Risk Patients) decreased hospitalizations or deaths caused by COVID-19 when given within three days of symptoms to people who were considered to be high risk. After 28 days, only 3 out of 389 people treated with Paxlovid required hospitalization and none died. The placebo group had 27 hospitalizations out of 385 people and 7 died.
When treatment was given within five days of symptoms, results remained strong. Six out of 607 people receiving Paxlovid were hospitalized and none died, whereas 41 out of 612 people in the placebo group were hospitalized and 10 died. Altogether, the effectiveness of treatment is estimated to be 89%.
The FDA granted emergency use authorization for Paxlovid in December 2021. It is intended for use for people 12 years and older who weigh at least 40 kg, who have a positive COVID test, who have mild to moderate symptoms, and who are at high risk for developing complications from the disease.
Favipiravir and arbidol are antiviral medications used to treat influenza. In high concentrations, they may be effective against COVID-19.
What the research says: In a study of 240 COVID-19 patients, researchers compared favipiravir effectiveness to arbidol. Symptoms of cough and fever improved much quicker with favipiravir than with arbidol, but there was no significant difference in the recovery rate by day seven. Both medications were well-tolerated with only mild side effects.
Ivermectin is a medication currently FDA-approved for the treatment of certain parasitic infections. In humans, it has a pill form specifically used to treat intestinal strongyloidiasis, onchocerciasis, scabies, and pediculosis (e.g., lice). In animals, it is used to treat heartworm and other parasitic diseases. Researchers are looking to repurpose this medication as an antiviral medication.
What the Research Says:
Ivermectin as a treatment for COVID-19 remains controversial. In vitro studies (i.e., those that are not performed on animals or humans, but on cells) have shown that it may also prevent the replication of some viruses, including SARS-CoV-2. In those cases, individual cells are infected with the virus and are treated with the medication.
This may sound promising, but there is concern about the dose needed to achieve this effect. Viral replication is not affected until a certain dose is reached. To achieve that dose in a live person, the theoretical dose required would be more than nine times the FDA-approved dose. Altogether, the high doses increase the risk for serious side effects from the medication, including hypotension, tachycardia, and seizures.
Decreased viral replication has been shown in animal studies with mice and pigs, but again, doses are administered at higher doses in those animals than in humans. Studies on humans have generally had a low number of patients treated with the drug but suggest that there may be a decreased risk for ICU stays, mechanical ventilation, and death in people who had severe COVID-19 disease. There have not been many benefits seen for people with mild to moderate disease or for preventing infection.
It is important to note that the quality of available studies is low. The doses of ivermectin are not readily comparable across studies, and there is a lot of bias in the studies. In many studies, other COVID-19 treatments that patients received are not taken into account. This makes it harder to tell which medication truly had the desired effect. Many of the available studies are also not registered as clinical trials.
At this time, the FDA does not recommend ivermectin for the treatment of COVID-19.
Lopinavir-ritonavir is a pair of antiviral medications used to treat HIV that may be effective against COVID-19.
What the research says: In a study of 199 people with pneumonia from COVID-19 and low oxygen levels, 94 were given lopinavir-ritonavir and the rest were given a placebo. Although more people treated with lopinavir-ritonavir had improved symptoms by day 14 (45.5% vs. 30%), there was no significant difference between the two groups when it came to the duration of oxygen therapy, the need for mechanical ventilation, the length of hospitalization, or mortality rate.
Another study randomized 127 hospitalized adults with COVID-19 to either triple therapy with lopinavir-ritonavir, ribavirin and interferon β-1b or to lopinavir-ritonavir alone. People in the triple-therapy group stopped shedding the virus sooner (7 days vs. 12 days), had earlier improvement in symptoms (4 days vs. 8 days), and left the hospital sooner (9 days vs. 15 days).
Hydroxychloroquine and Chloroquine
Hydroxychloroquine and chloroquine are medications currently FDA-approved to treat malaria and autoimmune diseases such as lupus and rheumatoid arthritis. By interfering with protein glycosylation and other enzymatic processes, it is believed these medications could prevent COVID-19 from binding to, entering, and replicating in human cells.
What the Research Says
A French study led the way in hydroxychloroquine and chloroquine research. It initially included 26 COVID-19 patients treated with a hydroxychloroquine regimen and 16 untreated control patients. Six of the patients treated with hydroxychloroquine were also treated with azithromycin (also known as a Z-Pack, which is prescribed for several infections). By day six, the study authors noted that people treated with hydroxychloroquine decreased their viral load—the amount of virus in their blood—by 57%, and those also treated with azithromycin had cleared the virus altogether.
While the FDA granted emergency use authorization for both chloroquine phosphate and hydroxychloroquine sulfate products for COVID-19 in March, on June 15, it revoked the authorization, citing ineffectiveness and serious side effects.
Unfortunately, subsequent studies have not shown the same benefits. A second French study followed the same protocol as the original study but found that hydroxychloroquine did not significantly improve symptoms or decrease the clearance of the virus from the body. Multiple other studies have shown hydroxychloroquine not to be more effective than placebo when treating people who had COVID-19. In September 2020, a double-blind placebo-controlled randomized clinical trial in JAMA Internal Medicine concluded that hydroxychloroquine was ineffective in preventing infection in 132 healthcare workers.
More concerning are the potential side effects of these medications. A Brazilian study had to be discontinued early due to complications from high doses of chloroquine. A JAMA study showed that treatment with hydroxychloroquine prolonged the QT interval in more than 20% of COVID-19 patients, a finding on an electrocardiogram (ECG) that can be associated with the development of life-threatening cardiac arrhythmias.
Not all reports are bad. A study has been released that shows potential benefits for hydroxychloroquine in the treatment of COVID-19. Researchers studied over 2,500 adults and found that people treated with the drug had a mortality of 14% compared to 26% without it. When hydroxychloroquine was combined with azithromycin, mortality was 20%. There is controversy over the study, however, because the number of people treated with the steroid dexamethasone was considerably higher in the treatment groups, suggesting that the benefit may derive from the steroid rather than hydroxychloroquine or azithromycin. While 68% of all study participants were treated with steroids, only 35% in the non-treatment group received dexamethasone. Approximately 79% in the hydroxychloroquine group and 74% in the combined hydroxychloroquine with azithromycin group had also received steroids.
The FDA does not recommend treatment with hydroxychloroquine or chloroquine for treatment of COVID-19 at this time.