The FDA-approved drug ivermectin inhibits the replication of SARS-CoV-2 in vitro
et al., Antiviral Research, doi:10.1016/j.antiviral.2020.104787, Apr 2020
Ivermectin for COVID-19
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In vitro study showing that ivermectin is an inhibitor of SARS-CoV-2, with a single addition to Vero-hSLAM cells 2h post infection with SARS-CoV-2 able to effect ~5000-fold reduction in viral RNA at 48h.
There are claims that this study shows that therapeutic concentrations cannot be reached in humans, however this is incorrect. The authors explain why using this in vitro study to determine the effective dose in vivo is a fallacy in this presentation1 @1:32. Authors indicate that the concentration required is very unlikely to be an issue. The study used monkey kidney cells (the only choice at the time of the experiments), which they note lack adaptive immune responses and do not produce interferon. Authors also note that ivermectin accumulates in lung and other tissues, and that the average lung concentration shown in modeling studies exceeds the effective level in their study. Authors have also repeated experiments with human lung cells showing 6-8 times improved IC50.
Author's have also responded noting that "ivermectin's key direct target in mammalian cells is a not a viral component, but a host protein important in intracellular transport; the fact that it is a host-directed agent (HDA) is almost certainly the basis of its broad-spectrum activity against a number of different RNA viruses in vitro. The way a HDA can reduce viral load is by inhibiting a key cellular process that the virus hijacks to enhance infection by suppressing the host antiviral response. Reducing viral load by even a modest amount by using a HDA at low dose early in infection can be the key to enabling the body's immune system to begin to mount the full antiviral response before the infection takes control." Authors note that ivermectin works with the immune system and a 1:1 ratio of drug to virus is unlikely to be required1.
In further research, authors note that they find efficacy for prophylactic use, and that smaller repeated doses is more efffective than a single larger dose1.
Rajter et al. summarize the author, noting that “the antiviral activities of ivermectin have been derived from laboratory experiments that largely involve high, generally non physiologic, multiplicities of infection, and cell mono layer cultures, often of cell lines such as Vero cells that are not clinically relevant. The EC50 values should not be interpreted beyond the fact that they reveal robust, dose dependent antiviral activity in the cell model system used, and it would be naive to strive for μM concentrations of ivermectin in the clinic based on them.”4.
74 preclinical studies support the efficacy of ivermectin for COVID-19:
Ivermectin, better known for antiparasitic activity, is a broad spectrum antiviral with activity against many viruses including H7N775, Dengue41,76,77 , HIV-177, Simian virus 4078, Zika41,79,80 , West Nile80, Yellow Fever81,82, Japanese encephalitis81, Chikungunya82, Semliki Forest virus82, Human papillomavirus61, Epstein-Barr61, BK Polyomavirus83, and Sindbis virus82.
Ivermectin inhibits importin-α/β-dependent nuclear import of viral proteins75,77,78,84 , shows spike-ACE2 disruption at 1nM with microfluidic diffusional sizing42, binds to glycan sites on the SARS-CoV-2 spike protein preventing interaction with blood and epithelial cells and inhibiting hemagglutination45,85, shows dose-dependent inhibition of wildtype and omicron variants40, exhibits dose-dependent inhibition of lung injury65,70, may inhibit SARS-CoV-2 via IMPase inhibition41, may inhibit SARS-CoV-2 induced formation of fibrin clots resistant to degradation13, inhibits SARS-CoV-2 3CLpro58, may inhibit SARS-CoV-2 RdRp activity32, may minimize viral myocarditis by inhibiting NF-κB/p65-mediated inflammation in macrophages64, may be beneficial for COVID-19 ARDS by blocking GSDMD and NET formation86, may interfere with SARS-CoV-2's immune evasion via ORF8 binding8, may inhibit SARS-CoV-2 by disrupting CD147 interaction87-90, shows protection against inflammation, cytokine storm, and mortality in an LPS mouse model sharing key pathological features of severe COVID-1963,91, may be beneficial in severe COVID-19 by binding IGF1 to inhibit the promotion of inflammation, fibrosis, and cell proliferation that leads to lung damage12, may minimize SARS-CoV-2 induced cardiac damage44,52, may counter immune evasion by inhibiting NSP15-TBK1/KPNA1 interaction and restoring IRF3 activation92, may disrupt SARS-CoV-2 N and ORF6 protein nuclear transport and their suppression of host interferon responses5, reduces TAZ/YAP nuclear import, relieving SARS-CoV-2-driven suppression of IRF3 and NF-κB antiviral pathways39, increases Bifidobacteria which play a key role in the immune system93, has immunomodulatory55 and anti-inflammatory74,94 properties, and has an extensive and very positive safety profile95.
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Lefebvre et al., Characterization and Fluctuations of an Ivermectin Binding Site at the Lipid Raft Interface of the N-Terminal Domain (NTD) of the Spike Protein of SARS-CoV-2 Variants, Viruses, doi:10.3390/v16121836.
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Caly et al., 3 Apr 2020, peer-reviewed, 5 authors.
In vitro studies are an important part of preclinical research, however results may be very different in vivo.
The FDA-approved drug ivermectin inhibits the replication of SARS-CoV-2 in vitro
Antiviral Research, doi:10.1016/j.antiviral.2020.104787
Although several clinical trials are now underway to test possible therapies, the worldwide response to the COVID-19 outbreak has been largely limited to monitoring/containment. We report here that Ivermectin, an FDA-approved anti-parasitic previously shown to have broad-spectrum anti-viral activity in vitro, is an inhibitor of the causative virus (SARS-CoV-2), with a single addition to Vero-hSLAM cells 2 h post infection with SARS-CoV-2 able to effect ~5000-fold reduction in viral RNA at 48 h. Ivermectin therefore warrants further investigation for possible benefits in humans.
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