Results from In Vitro and In Vivo Research
In Vitro Studies
There is preliminary in vitro evidence of the ability of CQ and HCQ to inhibit SARS-CoV-2 activity. Liu et al (7) found a similar 50% cytotoxic concentration (CC50 – the concentration which results in 50% cell death) for the two drugs, however, the 50% maximal effective concentration (EC50 – the concentration at which viral RNA increase is inhibited by 50%) was lower for CQ than HCQ, irrespective of the multiplicity of infection (MOI – the ratio of virions to host cells) (7).
By contrast, Yao et al (1) found that HCQ was more potent against SARS-CoV-2 than CQ in vitro (EC50 of 0.72 uM and 5.47 uM, respectively. MOI = 0.01). Wang et al reported in vitro antiviral activity of CQ, with an EC50 of 1.13uM and CC50 >100uM at an MOI of 0.05, and with high selectivity for SARS-CoV-2 rather than host cells (8).
In Vivo Clinical Trials
The empirical evidence for the effectiveness of CQ/HCQ in COVID-19 is currently very limited. First clinical results were reported in a news briefing by the Chinese government in February 2020, revealing that the treatment of over 100 patients with chloroquine phosphate in China had resulted in significant improvements of pneumonia and lung imaging, with reductions in the duration of illness (9). No adverse events were reported. It appears that these findings were a result of combining data from several ongoing trials using a variety of study designs. No empirical data supporting these findings have been published so far.
On the 17th of March 2020, the first clinical trial data were published by Gautret and colleagues in France (2). The researchers conducted an open-label non-randomised controlled trial with 36 patients diagnosed with SARS-CoV-2. Six of these patients were asymptomatic, 22 had upper respiratory tract infection symptoms and eight had lower respiratory tract infection symptoms. Twenty patients were assigned to the treatment group, and received HCQ 200mg three times a day for ten days. The control group received usual care. Six of the patients in the treatment group were also prescribed azithromycin to prevent bacterial superinfection.
The main outcome of the trial was SARS-CoV-2 carriage at Day 6, tested using PCR of SARS-CoV-2 RNA from nasopharyngeal swabs. The results showed that patients in the treatment group were significantly more likely to test negative for the virus on Day 6 than patients in the control group (70% vs 12.5% virologically cured, p<0.001). Moreover, all of the six patients who were treated with a combination of HCQ and azithromycin tested negative on Day 6. The authors argue that this finding speaks to the effectiveness of HCQ and a potential synergistic effect of its combined treatment with azithromycin.
Following the promising results of these first clinical trials, official guidelines recommending the treatment of COVID-19 using CQ/HCQ were published. The National Health Commission of the People’s Republic of China published their recommendation mid-February, suggesting to treat patients with 500mg chloroquine phosphate (300mg for CQ) twice per day, for a maximum of 10 days (10). In Italy, the L. Spallanzani National Institute for the Infectious Disease published their recommendations for treatment on the 17th of March, which included the provision of 400mg of HCQ per day or 500mg CQ per day, in combination with another antiviral agent (11)...
Biological Mechanism of Chloroquine
A number of potential mechanisms of action of CQ/HCQ against SARS-CoV-2 have been postulated. The virus is believed to enter cells by binding to a cell surface enzyme called angiotensin-converting enzyme 2 (ACE2) (16). ACE2 expression is also believed to be upregulated by infection with SARS-CoV-2 (17). Chloroquine may reduce glycosylation of ACE2, thereby preventing COVID-19 from effectively binding to host cells (18). Furthermore, Savarino et al (19) hypothesise that CQ might block the production of pro-inflammatory cytokines (such as interleukin-6), thereby blocking the pathway that subsequently leads to acute respiratory distress syndrome (ARDS). Some viruses enter host cells through endocytosis; the virus is transported within the host cell in a cell-membrane derived vesicle called an endosome, within which the virus can replicate (19). When the endosome fuses with the acidic intracellular lysosome, this leads to rupture of the endosome with the release of the viral contents (19). Chloroquine has been found to accumulate in lysosomes, interfering with this process (20). Chloroquine is also believed to raise the pH level of the endosome, which may interfere with virus entry and/or exit from host cells (6).
https://www.cebm.net/covid-19/chloroquine-and-hydroxychloroquine-current-evidence-for-their-effectiveness-in-treating-covid-19/