CERTIFICATE

This is to certify that the project report entitled

“CORONAVIRUS DISEASE 2019 AND PROBABLE DRUGS
FOR ITS TREATMENT” is an authentic record of research work
carried out by TUSHARKANTA BEHERA under my supervision in
partial fulfilment of the requirement for the BSc in chemistry of
DHENKANAL AUTONOMOUS COLLEGE, DHENKANAL.

Place: Dhenkanal Dr. Debasis Mohanty

Date: ___/___/____
 ACKNOWLEDGEMENT

I gratefully acknowledge my deep sense of gratitude to

all who provided help and support to me during the course of
my project work. I am extremely thankful to Dr. Debasis
Mohanty, who offered me the chance to do work in the field
of Biochemistry under his supervision. His constant guidance
invaluable discussions and perpetual inspiration always
acted as motivating factor to my project work, in the trusted
sense, played the ideal role of a philosopher and a guide to
me. I am extremely grateful to Department of chemistry
Dhenkanal autonomous college, Dhenkanal for her
indefatigable help through my entire BSc. Study. I am also
thankful to my parents and friends, their encouragement and
invaluable contribution to my BSc. Study and this work.
Above all, all I would like to thank God, The Almighty, for
having made everything possible by giving me strength and
courage to do this work.
 DECLARATION

I hereby declare that the project work entitled

“CORONAVIRUS DISEASE 2019 AND PROBABLE
DRUGS FOR ITS TREATMENT” submitted to Dhenkanal
Autonomous college, Dhenkanal is a record of an original
work done by me and this project work is submitted in the
partial fulfilment of the requirement for the awards of degree
of bachelor of science in chemistry. The results embodied in
this project have not been submitted to any other university
or institution for the award of any degree or diploma.

TUSHARKANTA BEHERA
(17CHE031)
 CONTENTS

1. INTRODUCTION & OBJECTIVE

2. REVIEW OF LITRATURE

3. DISCUSSION

4. CONCLUSION & SCOPE FOR FUTURE STUDY

5. REFERENCE
I. INTRODUCTION & OBJECTIVE:
Coronavirus disease 2019 (COVID-19) is an infectious disease caused
by most recently discovered corona virus. Corona viruses are the group of
viruses that cause illness in animals or humans. In case of humans several
corona viruses are known to cause respiratory infections ranging from the
common cold to more severe disease such as Middle East Respiratory
Syndrome (MERS) and Severe Acute Respiratory Syndrome (SARS). The
most recently discovered corona virus i.e. Severe Acute Respiratory Syndrome
corona virus 2 (SARS CoV-2) Causes COVID-19. This disease was first
identified in December in Wuhan, China and eventually the corresponding
virus was discovered.[1]
COVID-19 was declared as a pandemic by the WHO on 11 march, 2020.[2]
As of 20 June, 2020 more than 8.68 million people reported COVID-19
positive and more than 460,000 deaths across the world. More than 4.26
million people has been recovered.[3]
This disease gets transmitted from one person to other mainly through droplets
produced by coughing sneezing and talking. People can also be gets infected
by touching a contaminated surface and then touching their face. The standard
method of diagnosis of this disease is by real time reverse transcription
polymerase chain reaction.
The symptoms of this disease are quite similar to those of influenza such as
fever, cough, fatigue, shortness of breath and loss of smell and test. While the
majority of cases result in mild symptoms, some progress to acute respiratory
distress syndrome (ARDS) possibly precipitated by cytokine storm, multi-
organ failure, septic shock, and blood clots. Recommended measures to
prevent infection include frequent hand washing, maintaining physical
distance from others (especially from those with symptoms), quarantine
(especially for those with symptoms), covering coughs, and keeping unwashed
hands away from the face.[3]
Generally, 80% of people recover from this disease without needing hospital
treatment. Around 1 of the 5 patients who gets COVID-19 becomes seriously
ill and develops difficulty breathing. Older peoples and those with underlying
medical problems like high blood pressure, heart and lung problems, diabetes
or cancer are at higher risk of serious illness. However, any one can catch
COVID-19 and become seriously ill.[1]
 Till now there is no therapy or medication or vaccine to treat or prevent
COVID-19.[1] The WHO, with partners, has launched solidarity clinical trial
for COVID-19 treatment on 18 march 2020.[2] The main aim of this trial is to
compare four untested treatments for hospitalized people with severe COVID-
19 illness. These four drugs are remdesivir, hydroxychloroquine, Lopinavir-
Ritonavir and Lopinavir-Ritonavir with Interferon (ß1a).
In this project I we have selected three drugs out of the above four, remdesivir,
hydroxychloroquine, Lopinavir-Ritonavir, to review their efficacy against
COVID-19. Although these drugs were not originally developed for COVID-
19 but these were being repurposed against COVID-19. In addition to these
drugs we have also reviewed the structure and lifecycle of the SARS CoV-2 in
detail.
To carry out our work we have visited various websites and we also have gone
through different research papers, review papers and studies.

II. REVIEW OF LITERATURE:

Coronavirus disease 2019 (COVID-19) is an infectious disease caused
by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It was
first identified in December 2019 in Wuhan, China, and has resulted in an
ongoing pandemic. The first confirmed case has been traced back to 17
November 2019.
Common symptoms include fever, cough, fatigue, shortness of breath,
and loss of smell and taste. While the majority of cases result in mild
symptoms, some progress to acute respiratory distress syndrome (ARDS)
possibly precipitated by cytokine storm, multi-organ failure, septic shock,
and blood clots. The time from exposure to onset of symptoms is typically
around five days, but may range from two to fourteen days.
The virus is primarily spread between people during close contact, most often
via small droplets produced by coughing, sneezing, and talking. The droplets
usually fall to the ground or onto surfaces rather than travelling through air
over long distances. Less commonly, people may become infected by touching
a contaminated surface and then touching their face. It is most contagious
during the first three days after the onset of symptoms, although spread is
possible before symptoms appear, and from people who do not show
symptoms. The standard method of diagnosis is by real-time reverse
transcription polymerase chain reaction (rRT-PCR) from a nasopharyngeal
swab. Chest CT imaging may also be helpful for diagnosis in individuals where
there is a high suspicion of infection based on symptoms and risk factors;
however, guidelines do not recommend using CT imaging for routine
screening.
HISTORY:
The virus is thought to be natural and has an animal origin, through spill
over infection. The first known human infections were in China. A study of the
first 41 cases of confirmed COVID-19, published in January 2020 in The
Lancet, reported the earliest date of onset of symptoms as 1 December 2019.
Official publications from the WHO reported the earliest onset of symptoms
as 8 December 2019. Human-to-human transmission was confirmed by the
WHO and Chinese authorities by 20 January 2020. According to official
Chinese sources, these were mostly linked to the Huanan Seafood Wholesale
Market, which also sold live animals. In May 2020, George Gao, the director
of the Chinese Center for Disease Control and Prevention, said animal samples
collected from the seafood market had tested negative for the virus, indicating
that the market was the site of an early superspreading event, but it was not the
site of the initial outbreak.

During the early stages of the outbreak, the number of cases doubled
approximately every seven and a half days. In early and mid-January 2020, the
virus spread to other Chinese provinces, helped by the Chinese New Year
migration and Wuhan being a transport hub and major rail interchange. On 20
January, China reported nearly 140 new cases in one day, including two people
in Beijing and one in Shenzhen. Later official data shows 6,174 people had
already developed symptoms by then, and more may have been infected. A
report in The Lancet on 24 January indicated human transmission, strongly
recommended personal protective equipment for health workers, and said
testing for the virus was essential due to its "pandemic potential". On 30
January, the WHO declared the coronavirus a public health emergency of
international concern. By this time, the outbreak spread by a factor of 100 to
200 time.
STRUCTURAL BIOLOGY:
Each SARS-CoV-2 virion is 50–200 nanometres in diameter. Like other
coronaviruses, SARS-CoV-2 has four structural proteins, known as the Spike,
Envelope, Membrane and Nucleocapsid proteins. The spike protein, which has
been imaged at the atomic level
using cryogenic electron microscopy, is the
protein responsible for allowing the virus to
attach to and fuse with the membrane of a
host cell; specifically, its S1 subunit
catalyses attachment, the S2 subunit fusion.
VIROLOGY: FIG.2 STRUCTURE OF SARS-CoV-2

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is

a novel severe acute respiratory syndrome coronavirus, first isolated from
three people with pneumonia connected to the cluster of acute respiratory
illness cases in Wuhan. All features of the novel SARS-CoV-2 virus occur in
related coronaviruses in nature. Outside the human body, the virus is killed by
household soap, which bursts its protective bubble.
SARS-CoV-2 is closely related to the original SARS-CoV. It is thought to
have an animal (zoonotic) origin. Genetic analysis has revealed that the
coronavirus genetically clusters with the genus Betacoronavirus, in subgenus
Sarbecovirus (lineage B) together with two bat-derived strains. It is 96%
identical at the whole genome level to other bat coronavirus samples (BatCov
RaTG13). In February 2020, Chinese researchers found that there is only
one amino acid difference in the binding domain of the S protein between the
coronaviruses from pangolins and those from humans; however, whole-
genome comparison to date found that at most 92% of genetic material was
shared between pangolin coronavirus and SARS-CoV-2, which is insufficient
to prove pangolins to be the intermediate host.
PATHOPHYSIOLOGY:
The lungs are the organs most affected by COVID-19 because the virus
accesses host cells via the enzyme angiotensin-converting enzyme 2 (ACE2),
which is most abundant in type II alveolar cells of the lungs. The virus uses a
special surface glycoprotein called a "spike" (peplomer) to connect to ACE2
and enter the host cell. The density of ACE2 in each tissue correlates with the
severity of the disease in that tissue and some have suggested decreasing ACE2
activity might be protective, though another view is that increasing ACE2
using angiotensin II receptor blocker medications could be protective. As the
alveolar disease progresses, respiratory failure might develop and death may
follow.
SARS-CoV-2 may also cause respiratory failure through affecting the
brainstem as other coronaviruses have been found to invade the central nervous
system (CNS). While virus has been detected in cerebrospinal fluid of
autopsies, the exact mechanism by which it invades the CNS remains unclear
and may first involve invasion of peripheral nerves given the low levels of
ACE2 in the brain.

The virus also affects gastrointestinal organs as ACE2 is abundantly expressed

in the glandular cells of gastric, duodenal and rectal epithelium as well
as endothelial cells and enterocytes of the small intestine.
The virus can cause acute myocardial injury and chronic damage to
the cardiovascular system. An acute cardiac injury was found in 12% of
infected people admitted to the hospital in Wuhan, China, and is more frequent
in severe disease. Rates of cardiovascular symptoms are high, owing to the
systemic inflammatory response and immune system disorders during disease
progression, but acute myocardial injuries may also be related to ACE2
receptors in the heart. ACE2 receptors are highly expressed in the heart and are
involved in heart function. A high incidence of thrombosis (31%) and venous
thromboembolism (25%) have been found in ICU patients with COVID-19
infections, and may be related to poor prognosis. Blood vessel dysfunction and
clot formation (as suggested by high D-dimer levels) are thought to play a
significant role in mortality, incidences of clots leading to pulmonary
embolisms, and ischaemic events within the brain have been noted as
complications leading to death in patients infected with SARS-CoV-2.
Infection appears to set off a chain of vasoconstrictive responses within the
body, constriction of blood vessels within the pulmonary circulation has also
been posited as a mechanism in which oxygenation decreases alongside the
presentation of viral pneumonia. [3]
Till now there is no medicine or vaccine to treat or prevent COVID-19. The
following are three drugs, which are in lime light these days, for probable
treatment for COVID-19. These drugs are remdesivir, hydroxychloroquine,
Lopinavir-Ritonavir, these drugs are also included in the solidarity trial
launched by WHO.
1. REMDESIVIR:

Remdesivir is a broad-spectrum antiviral drug developed by the

biopharmaceutical company Gilead Science. This drug is administrated via
injection into a vain.[4]
Chemical formula: C27H35N6O8P
Molar mass: 602.585 g/mol
Structure:

FIG.2 Structure of Remdesivir[4]

SYNTHESIS:
The figure shown below was the synthesis route developed by Chun and
co-authors from Gilead Sciences. In this method, intermediate a is firstly
prepared from L-alanine and phenyl phosphorodichloridate in presence of
triethylamine and dichloromethane. Then triple benzyl-protected ribose is
oxidized by dimethyl sulfoxide with acetic anhydride and give the lactone
intermediate b. Now pyrrolo[2,1-f] [1,2,4]triazin-4-amine is brominated, and
the amine group is protected by excess trimethylsilyl chloride. n-Butyllithium
undergoes a halogen-lithium exchange reaction with the bromide at −78 °C
(−108 °F) to yield the intermediate c. The intermediate b is then added to a
solution containing intermediate c dropwise. After quenching the reaction in a
weakly acidic aqueous solution, a mixture of 1: 1 anomers was obtained. It was
then reacted with an excess of trimethylsilyl cyanide in dichloromethane at −78
°C (−108 °F) for 10 minutes. Trimethylsilyl triflate was added and reacts for
one additional hour, and the mixture was quenched in an aqueous sodium
hydrogen carbonate. A nitrile intermediate was obtained. The protective group,
benzyl, was then removed with boron trichloride in dichloromethane at −20 °C
(−4 °F). The excess of boron trichloride was quenched in a mixture of
potassium carbonate and methanol. A benzyl-free intermediate was obtained.
The isomers were then separated via reversed-phase high performance liquid
chromatography. The optically pure compound and intermediate a are reacted
with trimethyl phosphate and methylimidazole to obtain diastereomer mixture
of remdesivir. In the end, optically pure remdesivir can be obtained through
chiral resolution methods.[6]

Fig.3 Synthesis of Remdesivir [6]

ACTIVATION:
Remdesivir is a Prodrug that is able to diffuse into cells where it is converted
to mono-phosphate of nucleoside via the actions of esterase and a
phosphoamidase; this in turn is further phosphorylated to its active metabolite
triphosphate by nucleoside-phosphate kinases.[7]

Fig.4 Activation of Remdesivir [4]

MECHANISM OF ACTION:
and evades proofreading by viral exoribonuclease (ExoN), causing a
decrease in viral RNA production. In some viruses such as the respiratory
syncytial virus it causes the RNA-dependent RNA polymerases to pause, but
its predominant effect (as in Ebola) is to induce an irreversible chain
termination. Unlike with many other chain terminators, this is not mediated by
preventing addition of the immediately subsequent nucleotide, but is instead
delayed, occurring after five additional bases have been added to the growing
RNA chain.[ For the RNA-Dependent RNA Polymerase of MERS-CoV,
SARS-CoV-1, and SARS-CoV-2 arrest of RNA synthesis occurs after
incorporation of three additional nucleotides. Hence, remdesivir is classified
as a direct-acting antiviral agent that works as a delayed chain terminator. [6]
SIDE EFFECTS:
The most common adverse effects in studies of remdesivir for
COVID‑19 include respiratory failure and organ impairment, including low
albumin, low potassium, low count of red blood cells, low count of platelets
that help with clotting, and yellow discoloration of the skin.[5]
INVENTION AND RESEARCH WORKS:
Remdesivir was originally produced by Gilead Science in 2009, as part
of company’s research and development programme for hepatitis C. But the
result was not as expected i.e. this drug was failed Hepatitis C. Then under the
direction of scientist Tomas Cihlar this drug was repurposed against Ebola
virus and Marburg virus. Again, subsequently it was discovered by Gilead
Science that this drug had antiviral activity in-vitro against multiple filoviruses,
pneumoviruses, and corona viruses.
On April 9, 2019 the UPTO granted two patents on Remdesivir to Gilead
Science: one for Filoviruses and one which covered both Arena viruses and
Corona viruses.
In October 2015 United States Army Medical Research Institute of
Infectious Diseases (USAMRIID)announced preclinical results that
remdesivir had blocked the Ebola virus in Rheus monkeys. This drug was
rapidly pushed through rapid clinical trials due the west African Ebola virus
pandemic of 2013- 20016, eventually being used in people with the disease.
with the promising preliminary results, it was used in emergency setting during
the Kivu Ebola epidemic that started in 2018, along with further clinical trials.
This, clinical trials continued till aug. 2019, when Congolese health officials
announced that this drug was significantly less effective than monoclonal
antibody treatments such as mab114 and regn- eb3. However, these trials
established the safety profile of this drug.
During COOVID-19 pandemic this drug was the main focus of research
for different institutions. this drug was tested at different institutions and
research is being continued on this drug to use t against the SARS-CoV-2 virus,
that cause the covid-19 disease.[4]
On February 5, 2020, a phase 3 randomized, quadruple-blind, placebo-
controlled clinical trial was registered at Capital Medical University, with the
goal to determine safety and efficacy of remdesivir in patients with mild to
moderate SARS-CoV-2 infection (NCT04252664, since suspended).78 A day
later, a second trial (NCT04257656, since terminated) was registered at the
same location, focused on patients with advanced COVID-19 respiratory
disease.79 Both trials had planned to track the primary outcome as time to
clinical improvement, up to 28 days: normalization of fever, oxygen saturation,
and respiratory rate, and alleviation of cough which is sustained for 72 h. Both
trials delivered remdesivir as a 200 mg loading dose on the first day, with 9
subsequent days of maintenance dosing at 100 mg; this regime is identical to
that utilized in the previous NCT03719586 Ebola trial, which appears to be the
model for all subsequent trials involving remdesivir (discussed below; Figure
4 and Table 1, registered trials of remdesivir. Contemporaneous to the
development of the Chinese trials, the first cases of COVID-19 were emerging
in the USA. On January 20, 2020, a patient reported to urgent care in
Snohomish County, Washington with subjective fever and a 4-day history of
cough, later to be confirmed as the first positive case of COVID-19 in the
USA.80 On the seventh day of hospitalization and after worsening clinical
status, the patient was given IV remdesivir under compassionate use access
(Gilead Sciences), with no adverse events observed on infusion.80 The
patient’s clinical condition improved the next day, though concurrent treatment
with acetaminophen, ibuprofen, guaifenesin, vancomycin, cefepime, and
supplemental oxygen confound the direct interpretation of remdesivir’s impact
Subsequently, 12 patients were confirmed to be infected with SARS-
CoV-2 between January 20, 2020, and February 5, 2020.81 Of these 12
patients, seven were hospitalized and three received remdesivir
(compassionate use access; Gilead Sciences) upon worsening clinical disease.
Treatment was continued for 4 −10 days with 200 mg IV on the first day and
100 mg each following day. Following the initial dose, all patients experienced
“transient gastrointestinal symptoms, including nausea, vomiting,
gastroparesis, or rectal bleeding, ” although treatment was continued until
improvement in respiratory symptoms, with all 12 patients reporting symptom
resolution by February 22, 2020.81 The small sample size and lack of
controlled randomization preclude analysis of clinical efficacy or safety.
The National Institute of Allergies and Infectious Diseases (NIAID), NIH
initiated the Adaptive COVID-19 Treatment Trial (ACTT), a double-blind,
randomized, placebo-controlled phase 3 trial to evaluate the safety and efficacy
of remdesivir compared with a remdesivir placebo-control (NCT04280705).82
NIAID developed this study in part based on the existing Chinese clinical trials
in addition to consulting with the WHO.83 This study is currently recruiting
patients, tracking the primary outcome of patient status severity on an eight-
point ordinal scale, with multiple secondary outcomes of interest.
 Subsequently, Gilead Sciences initiated two clinical trials that began in
mid-March, comparing remdesivir to standard of care in patients with
moderate or severe coronavirus disease (COVID-19) in an open-label,
randomized trial, NCT04292899.84 This trial will explore the safety and
efficacy of remdesivir in combination with standard of care to compare study
arms of 5- or 10-day remdesivir dosing on the primary outcome of fever and
oxygen saturation. NCT04292730 maintains three study arms to compare
remdesivir provided over 5 or 10 days, to standard of care alone, with the
primary outcome being the proportion of patients discharged by the 14th day.
Remdesivir has demonstrated efficacy in both in vitro and in vivo
models against coronaviruses. Recently, through a compassionate use
indication, remdesivir has supportive evidence for yielding some clinical
improvement in COVID19 patients.107 In addition, an interim analysis of the
Adaptive COVID-19 Treatment Trial (NCT04280705) supports improvement
in the primary endpoint for patients receiving remdesivir, compared to control,
with a 31% faster time to recovery.108 Based on these initial findings, the U.S.
Food and Drug Administration has issued an Emergency Use Authorization for
the emergency use of remdesivir for the treatment of hospitalized COVID-19
patients. With no drug having FDA approval for marketing as a treatment for
SARS-CoV-2, this is the first FDA authorization of an investigational
therapeutic for use in treating SARS-CoV-2.109 While remdesivir represents
one compound whose recent use authorization may, in part, mitigate the
morbidity, mortality, and strain on global While remdesivir represents one
compound whose consideration may yet play a role in mitigating the morbidity,
mortality, and strain on global healthcare systems caused by COVID-19,
ongoing clinical trials will provide much-needed clarity surrounding the
repurposing of approved drugs and experimental agents against SARS-CoV-
2.[8]
2. HYDROXYCHLOROQUINE:
Hydroxychloroquine is a 4-aminoquinoline with immunosuppressive,
antiautophagy, and antimalarial activities. This drug is used to treat and prevent
malaria in areas where malaria remain sensitive to chloroquine. Hydroxy
Chloroquine is also used to treat rheumatoid arthritis, lupus, and porphyria
cutanea tarda. This drug is taken orally.
Hydroxychloroquine and a related drug, chloroquine, have been under
study as possible treatments for COVID-19 (the illness caused by the new
coronavirus). However, the FDA has just revoked its emergency use
authorization for these two drugs. This is because the drugs may not be
effective in treating COVID-19, and their risks may outweigh their potential
benefits for this use.[13] However this drug is under study to treat COVID-19.
Chemical formula: C18H26ClN3O
Molar mass: 335.872 g/mol
IUPAC name: 7-chloro-4-[4-[ethyl(2-hydroxyethyl)amino]-1-
methylbutylamino]quinoline
Structure:

Fig.5 Structure of Hydroxychloroquine [11]

SIDE EFFECTS:
The most common side effects include vomiting, headache, change in
vision, and muscle weakness. This drug has also some severe side effects
including allergic reactions, vision problems and heart problems.[9]
Retinopathy is one of the most serious adverse effect of this drug. It's caused
by damage to the blood vessels of the light-sensitive tissue at the retina.[6]
Hydroxychloroquine (HCQ) retinopathy can result in permanent vision loss. In
early stages of HCQ retinopathy, patients are usually asymptomatic with
preservation of visual acuity. In fact, objective changes typically precede a
patient's complaint of vision loss.[14]
Hydroxychloroquine is extremely toxic in overdose. The symptoms of
overdose generally occur within an hour of ingestion. The symptoms include
sleepiness, vision change, coma, stopping of breathing and heart problems.[9]
SYNTHESIS:
Hydroxychloroquine is prepared by reacting 1-chloro-4-pentanone with
2-ethylaminoethanol, this gives the corresponding aminoketone, which
undergoes reductive amination to give 4-[ethyl(2-hydroxyethyl)amino]-1-
methylamine. This reacts with 4,7-dichloroquine gives hydroxy
chloroquine.[11]

Hydroxychloroquine

Fig.6 Synthesis of Hydroxychloroquine [11]

MECHANISM OF ACTION:
There is no precise model for mechanism of action for this drug. This
drug may suppress immune function by interfering with the processing and
presentation of antigens and the production of cytokines. As a lysosomotropic
agent, hydroxychloroquine raises intralysosomal pH, impairing autophagic
protein degradation; hydroxychloroquine-mediated accumulation of
ineffective autophagosomes may result in cell death in tumor cells reliant on
autophagy for survival. In addition, this agent is highly active against the
erythrocytic forms of P. vivax and malariae and most strains of P. falciparum
but not the gametocytes of P. falciparum.[10]
HOW THIS DRUG WORK AGAINST COVID-19:
As per the life cycle of the SARS Cov-2, that causes COVID-19, when
the virus enters the host cell it forms endosomes. Then this endosome binds to
lysosomes of host cell to Endolysosome. The lysosomes contain lysosomal
protease that breaks the outer envelope of the SARS Cov-2 virus and lead to
release of the viral genome to the cell. But this drug increases the pH of the
endolysosome and thus inhibits the lysosomal protease. Thus, further growth
of the virus is blocked.
CLINICAL TRIALS AGAINST COVID-19:
There is no strong scientific evidence to support the use of
hydroxychloroquine for preventing or treating coronavirus disease 2019
(COVID‑19).[1] While its use is not approved by the FDA for COVID‑19
treatment, from April to June 2020, there was an emergency use authorization
for its use in the United States.[15]
On 15 June, the FDA revoked its emergency use authorization, stating
that it was "no longer reasonable to believe" that the drug was effective against
COVID-19 or that its benefits outweighed "known and potential risks".[10]
A Multicentre, open label, randomised controlled trial was conducted to
assess the efficacy and safety of hydroxychloroquine plus standard of care
compared with standard of care alone in adults with coronavirus disease 2019
(covid-19). This trial was conducted from 11 to 29 feb, 2020 at 16 government
designated COVID-19 centre in china.
In this trial 150 patients admitted to hospital with laboratory confirmed
covid-19 were included in the intention to treat analysis (75 patients assigned
to hydroxychloroquine plus standard of care, 75 to standard of care alone).
Hydroxychloroquine administrated at a loading dose of 1200 mg daily
for three days followed by a maintenance dose of 800 mg daily (total treatment
duration: two or three weeks for patients with mild to moderate or severe
disease, respectively).
In this trial out of 150 patients, 148 had mild to moderate disease and
two had severe disease. The mean duration from symptom onset to
randomisation was 16.6 (SD 10.5; range 3-41) days. A total of 109 (73%)
patients (56 standard of care; 53 standard of care plus hydroxychloroquine) had
negative conversion well before 28 days, and the remaining 41 (27%) patients
(19 standard of care; 22 standard of care plus hydroxychloroquine) were
censored as they did not reach negative conversion of virus. The probability of
negative conversion by 28 days in the standard of care plus
hydroxychloroquine group was 85.4% (95% confidence interval 73.8% to
93.8%), similar to that in the standard of care group (81.3%, 71.2% to 89.6%).
The difference between groups was 4.1% (95% confidence interval –10.3% to
18.5%). In the safety population, adverse events were recorded in 7/80 (9%)
hydroxychloroquine non-recipients and in 21/70 (30%) hydroxychloroquine
recipients. The most common adverse event in the hydroxychloroquine
recipients was diarrhoea, reported in 7/70 (10%) patients. Two
hydroxychloroquine recipients reported serious adverse events.
So, from this trial it was concluded that Administration of
hydroxychloroquine did not result in a significantly higher probability of
negative conversion than standard of care alone in patients admitted to hospital
with mainly persistent mild to moderate covid-19. Adverse events were higher
in hydroxychloroquine recipients than in non-recipients.[12]

3. LOPINAVIR-RITONAVIR:
Lopinavir with some amount of ritonavir, an antiretroviral drug, is a
potent drug in prevention and treatment of HIV, sold under the brand name
Kaletra®. It is the first and only co-formulated HIV-1 protease inhibitor
(PI).[4] Large clinical trials have demonstrated lopinavir/ritonavir’s clinical
efficacy in both antiretroviral-naïve and -experienced patients. The
immunologic and virologic benefits of treatment with this agent have been
proven in HIV-infected adults, adolescents, and children. The drug is
characterized by a high genetic barrier to resistance, and appears to be more
forgiving of non-adherence than earlier, unboosted PIs. The current tablet
formulation of lopinavir/ ritonavir was approved by the US Food and drug
administration in October 2005.[16]
Lopinavir
Chemical formula: C37H48N4O5
Molecular weight: 628.80 g/mol
Structure:

Fig.7 Structure of Lopinavir

Ritonavir
Chemical formula: C37H48N6O5S2
Molecular weight: 720.95

Structure:

Fig.8 Structure of Ritonavir

PHARMACOKINETICS:
The standard adult dose of lopinavir/ritonavir is 400 mg/100 mg twice
daily. A once-daily dosing regimen of 800 mg/200 mg may be used in therapy-
naïve patients. This regimen is not recommended for therapy experienced
patients. The tablets should be swallowed whole, and should not be chewed,
crushed, or broken. Food intake does not affect absorption of the tablet
formulation. However, the liquid formulation should be taken with food to
improve absorption. The absolute bioavailability of lopinavir co-formulated
with ritonavir in humans has not been established. At steady state, lopinavir is
approximately 98%–99% bound to plasma proteins. Lopinavir is lipid-soluble
and penetrates the cerebrospinal fluid (CSF). It produces significant reductions
in the CSF viral load. Lopinavir undergoes rapid first-pass metabolism in the
liver by CYP3A4 and CYP3A5. Ritonavir inhibits the CYP3A4 isoenzyme in
the human liver microsomes and results in increased concentrations of
lopinavir when the two drugs are co-administered. Lopinavir/ritonavir is
primarily eliminated by the fecal route with urinary excretion accounting for ˂
2% of the eliminated drug.[18]
MECHANISM OF ACTION:
HIV-1 protease is an aspartic protease that cleaves both structural and
functional proteins from precursor viral polypeptide strands and fulfills an
essential role in the viral lifecycle. Inhibition of the protease produces
immature, non-infectious virions. Lopinavir is a potent inhibitor of HIV-1
protease. The lopinavir/ritonavir coformulation produces its antiviral effect by
inhibiting the formation of infectious virions, thus preventing subsequent
waves of cellular infection.[18]
ADVERSE REACTION:
Lopinavir/ritonavir-containing antiretroviral regimens are generally
well tolerated. The most frequent side effects reported are diarrhea, nausea, and
vomiting. These gastrointestinal adverse effects are generally mild to
moderate. Diarrhea related to lopinavir/ritonavir therapy is reported by 15%–
25% of patients. The newer tablet formulation is better tolerated than the
capsule formulation. However, patients who switched therapy from another PI-
based regimen to lopinavir/ ritonavir based regimen showed an overall
improvement in side effects and health related quality of life. Immune
reconstitution syndrome has been reported in patients treated with
antiretroviral regimens containing lopinavir/ritonavir, manifested as an infl
ammatory response to indolent opportunistic infections. Serious side effects of
lopinavir/ritonavir therapy are unusual. Pancreatitis has been seen rarely in
patients on lopinavir/ritonavir therapy, and may have been related to marked
elevations in triglyceride levels. Patients with a known history of pancreatitis
are more likely to develop pancreatitis on lopinavir/ritonavir therapy.
Lopinavir/ritonavir can cause transient elevations in transaminase levels, but
these are usually not clinically significant. The incidence of severe hepatic
events in patients receiving lopinavir/ritonavir is very low. Hepatitis C
coinfection and baseline elevations in transaminases may be associated with
severe liver events in lopinavir/ritonavir recipients. Like other members of the
protease inhibitor class, lopinavir/ritonavir may cause significant lipid
elevations and fat redistribution. Hypertriglyceridemia (triglycerides ˃750
mg/dL) and hypercholesterolemia (total cholesterol ˃300 mg/dL) were the
most frequently observed laboratory abnormalities in lopinavir/ritonavir
recipients in clinical trials. Lopinavir/ritonavir have been associated with
insulin resistance, new onset diabetes, and worsening of pre-existing diabetes
requiring hypoglycemic agents in some patients. Hyperglycemia may persist
in patients even after discontinuation of lopinavir/ritonavir. Less common
adverse effects of lopinavir/ritonavir therapy include allergic reaction,
asthenia, malaise, headache, myalgias, arthralgias, myocardial infarction,
seizures, and lactic acidosis.[18]
INVENTION AND RESEARCH WORK:
The availability of PIs changed the landscape of HIV therapy. Treatment
with these agents produced virologic and immunologic improvements not
previously seen with the nucleoside reverse transcriptase inhibitors (NRTIs).
They offered, for the first time, the possibility of long-term survival to persons
living with HIV/AIDS (PLWHAs. However, all of the early PIs had limited
bioavailability, high protein binding, large pill burdens, and short half-lives
producing low trough levels and requiring frequent dosing. They were also
associated with significant side-effects that compromised adherence and thus
promoted the development of drug resistance.
In 1997, Abbott Laboratories unveiled its new protease inhibitor, ABT-378,
later to be named lopinavir, at the 4th Conference on Retroviruses and
Opportunistic Infections. It was developed in an attempt to retain activity
despite mutations in the HIV-1 protease gene. Lopinavir was found to be 3 to
4 times more active against HIV than ritonavir. Administered alone, lopinavir
exhibits poor bioavailability. However, its blood levels are dramatically
increased by low doses of ritonavir, a potent inhibitor of cytochrome P450
3A4. Coformulated lopinavir/ritonavir was the first combination pill to contain
a drug (lopinavir) not available separately.[18]
CLINICAL TRIALS:
Lopinavir/ritonavir has been extensively studied for use in the management of
HIV-infection in both treatment-naïve and treatment-experienced patients.
According to the guidelines for the treatment of HIV infection by the US
Department of Health and Human Services and British HIV Association,
lopinavir/ritonavir is one of the preferred PIs for use in the first-line treatment
regimens of HIV-infected adults and adolescents.[18]
Treatment in naïve patient:
Abbott 720 was a randomized blinded, multi-center trial evaluating treatment
with lopinavir/ritonavir at 3 dose levels (200/100 mg twice daily, 400/100 mg
twice daily, and 400/200 mg twice daily) together with stavudine (40 mg bid)
and lamivudine (150 mg bid). All patients were switched to lopinavir/ritonavir
400/100 mg twice daily between weeks 48 and 72. Through 360 weeks of
treatment, the proportion of patients with HIV-1 RNA ˂ 400 copies/mL and ˂
50 copies/mL were 61% and 59% respectively (n = 100). Among patients
completing 360 weeks of treatment with CD4+ cell count measurements (n =
60), the mean (median) increase in CD4+ lymphocyte count was 501 (457)
cells/mm3 above baseline. This study established the antiviral efficacy of
lopinavir/ritonavir, and the extremely long follow-up provided evidence for the
sustained effect of this agent over time.
In a randomized, double-blind, multi-center trial (n = 653) comparing
lopinavir/ritonavir (400/100 mg twice daily) plus stavudine and lamivudine
versus nelfinavir (750 mg 3 times daily) plus stavudine and lamivudine, a
significantly larger proportion of patients treated with lopinavir/ritonavir than
with nelfinavir achieved the endpoints of ˂ 400 copies/mL of HIV RNA (75%
vs 63%, p ˂ 0.001) and ˂ 50 copies/mL (67% vs 52%, p ˂ 0.001). None of the
patients treated with lopinavir/ritonavir in this study developed HIV protease
mutations, in contrast to 33% of those treated with nelfinavir (p ˂ 0.001).
Similar mean increases from baseline CD4+ lymphocyte counts to week 48
were observed in the lopinavir/ritonavir group and the nelfinavir group (207
and 195 cells/mm3, respectively). This study demonstrated the superiority of
lopinavir/ritonavir over unboosted nelfinavir, which was the previous standard
of care.
Treatment of experienced patients:
Lopinavir/ritonavir has been extensively evaluated versus other protease
inhibitors in patients who are antiretroviral therapy experienced after virologic
failure on previous regimens. An open-label, randomized, multi-center trial of
lopinavir/ritonavir with nevirapine and nucleoside reverse transcriptase
inhibitors versus investigator-selected protease inhibitor(s) plus nevirapine and
nucleoside reverse transcriptase inhibitors in 288 single protease inhibitor
experienced, non-nucleoside reverse transcriptase inhibitor (NNRTI)-naïve
patients showed a greater proportion of patients with virologic suppression
among those treated with lopinavir/ritonavir based regimens.
Research for COVID – 19:
Beginning in December 2019, a novel coronavirus, designated SARS-CoV-2,
has caused an international outbreak of respiratory illness termed Covid-19.
The full spectrum of Covid-19 ranges from mild, self-limiting respiratory tract
illness to severe progressive pneumonia, multiorgan failure, and death. Thus
far, there are no specific therapeutic agents for coronavirus infections. After
the emergence of severe acute respiratory syndrome (SARS) in 2003,
screening of approved drugs identified lopinavir, a human immunodeficiency
virus (HIV) type 1 aspartate protease inhibitor, as having in vitro inhibitory
activity against SARS-CoV, the virus that causes SARS in humans. Ritonavir
is combined with lopinavir to increase its plasma half-life through the
inhibition of cytochrome P450.[20]
To evaluate the efficacy and safety of oral lopinavir–ritonavir for SARS-CoV-
2 infection, a randomized, controlled, open-label trial was conducted, LOTUS
China (Lopinavir Trial for Suppression of SARS-Cov-2 in China), in adult
patients hospitalized with Covid-19.
This was an open-label, individually randomized, controlled trial conducted
from January 18, 2020, through February 3, 2020, at Jin Yin-Tan Hospital,
Wuhan, Hubei Province, China. Because of the emergency nature of the trial,
placebos of lopinavir–ritonavir were not prepared. Eligible patients were
randomly assigned in a 1:1 ratio to receive either lopinavir–ritonavir (400 mg
and 100 mg, orally; freely provided by the national health authority) twice
daily, plus standard care, or standard care alone, for 14 days. Standard care
comprised, as necessary, supplemental oxygen, non-invasive and invasive
ventilation, antibiotic agents, vasopressor support, renal-replacement therapy,
and extracorporeal membrane oxygenation (ECMO).
Patients were assessed once daily by trained nurses using diary cards that
captured data on a seven-category ordinal scale and on safety from day 0 to
day 28, hospital discharge, or death. Safety was monitored by the Good
Clinical Practice office from Jin Yin-tan Hospital. Serial oropharyngeal swab
samples were obtained on day 1 (before lopinavir–ritonavir was administered)
and on days 5, 10, 14, 21, and 28 until discharge or death had occurred and
were tested at Teddy Clinical Research Laboratory, using quantitative real-
time RT-PCR. RNA was extracted from clinical samples with the MagNA Pure
96 system, detected and quantified by Cobas z480 qPCR (Roche), with the use
of LightMix Modular Wuhan CoV assays (TIB MOBIOL). These samples
were obtained for all 199 patients who were still alive at every time point.
Sampling did not stop. when a swab at a given time point was negative.
Baseline throat swabs were tested for detection of E gene, RdRp gene, and N
gene, and samples on the subsequent visits were quantitatively and
qualitatively detected for E gene. Clinical data were recorded on paper case
record forms and then double-entered into an electronic database and validated
by trial staff.
This randomized trial found that lopinavir–ritonavir treatment added to
standard supportive care was not associated with clinical improvement or
mortality in seriously ill patients with Covid-19 different from that associated
with standard care alone. However, in the modified intentionto-treat analysis,
which excluded three patients with early death, the between-group difference
in the median time to clinical improvement (median, 15 days vs. 16 days) was
significant, albeit modest. Of note, the overall mortality in this trial (22.1%)
 was substantially higher than the 11% to 14.5% mortality reported in initial
descriptive studies of hospitalized patients with Covid-19, which indicates that
we enrolled a severely ill population.
Our patient population was heterogeneous with regard to duration and severity
of illness at enrollment; accelerated clinical recovery (16.0 days vs. 17.0 days)
and reduced mortality (19.0% vs. 27.1%) were observed in a post hoc subgroup
of those treated within 12 days after the onset of symptoms, but not in those
treated later (Fig. S2A and S2B). The question of whether earlier lopinavir–
ritonavir treatment in Covid-19 could have clinical benefit is an important one
that requires further study. The finding is consistent with studies showing that
patients with SARSCoV-2 viral pneumonia have progression in the second
week of illness1 and with the time-totreatment effects observed in previous
antiviral studies in SARS20 and severe influenza.21-23 In addition, we found
that the numbers of lopinavir–ritonavir recipients who had serious
complications (acute kidney injury and secondary infections) or requiring
noninvasive or invasive mechanical ventilation for respiratory failure were
fewer than in those not receiving treatment. These observations are hypothesis-
generating and require additional studies to determine whether lopinavir–
ritonavir treatment given at a certain stage of illness can reduce some
complications in Covid-19.
A detectability as compared with standard supportive care alone. SARS-CoV-
2 RNA was still detected in 40.7% of the patients in the lopinavir–ritonavir
group at end of the trial (day 28). A recent report showed that the median
duration of viral shedding in Covid-19 was 20 days in patients with severe
illness and could be as long as 37 days.24 Neither that study nor the current
one found evidence that lopinavir–ritonavir exerted a significant antiviral
effect. In conclusion, we found that lopinavir–ritonavir treatment did not
significantly accelerate clinical improvement, reduce mortality, or diminish
throat viral RNA detectability in patients with serious Covid-19.

III. RESULT & DISCUSSION:

In the last few months COVID 19 has spread all over the world in 122
countries and the patient count is about to reach 90.2 lakhs and the death
count is almost 4.7 lakhs. In India the case count has crossed the 4 lakhs mark
with 13 thousand deaths. With its low mortality rate but still due to its
contagious nature it has been declared as a pandemic. Many universities,
industries are searching for a cure to this pandemic, still they have not found
any drug or vaccine to treat the disease. Many organisation claim to have
developed medications and many vaccination trials have been done all over
the world, but there is no promising result in the development of health
condition of the patients.
In this paper I have chosen three antiviral drugs which may have the potential
to be the cure for this pandemic. These drugs are among those, on which
research are going on to develop medication. These drugs are
Lopinavir/Ritonavir, Remdesivir and Hydroxychloroquine.
Lopinavir/Ritonavir was first developed for the HIV – 1 patient and it showed
promising result in slowing the life cycle of the virus. It is a protease inhibitor
drug; it makes the virus non-infectious, thus slows the development of AIDS
in the patients. It has been tested for SARS-CoV-2 at Jin Yin-Tan hospital,
China. The result of the test was not that promising, in some cases some
improvements are observed, some faces side effects of this medication and
withdraw themselves from the trial. But still many believe it has the potential
and many researches are going on to make it more effective.
Remdesivir an antiviral drug, was very effective in case of Ebola virus. It
evades proofreading by virus exoribonuclease (ExoN) causing a decrease in
viral RNA production. It also shows promising results in cases of MERS-CoV
and SARS-CoV-1. This drug was tested at different institutions and research is
being continued on this drug to use it against the SARS-CoV-2 virus, that cause
the COVID-19 disease. It has showed efficacy in in both in vitro and in vivo
models against corona virus. Patients treating with Remdesivir shows 32%
faster recovery rate. It is one of the drugs to get FAD approval to be used to
treat SARS-CoV-2 patients in US. There is still research going on to increase its
efficacy.
Hydroxychloroquine is an antimalaria drug, immunosuppressive drug.
Hydroxychloroquine and related drugs, chloroquine, have been under study
for possible treatment for COVID – 19. Later, FAD revoked its emergency for
treating COVID – 19 taking into consideration of its low efficacy, side effects
of the drug and no evidence for its effect on the SARS-CoV-2. Regardless of no
evidence still it is a possible medication for the virus and it is under study by
many organisations.
These all three medications do not show enough evidence to be a drug for
treatment of SARS-CoV-2. But these may have the potential and is among the
drugs, which are under study for treatment COVID – 19. Among the three
 antiviral drugs Remdesivir showed more promising results in the trials from
the others. It may be the possible treatment for the pandemic.

IV. CONCLUSION & SCOPE FOR FUTURE

STUDY:
Before COVID-19 outbreak the world was going in its way with a claim that
science has solution for everything. But suddenly this Covid-19 outbreak
struck the human and within no time it became a pandemic. The fighting
against COVID-19 is not only for human it is also for the science. We should
keep a hope and never give up.
The SARS CoV-2 virus, that cause the COVID-19 disease, can attack people
from any age group and any person can get seriously ill due to this disease. A
basic problem is that the symptoms of this disease are similar to that of
influenza. So, a common man can’t get a clue regarding infection by the SARS
CoV-2 virus and can’t do more to stop the spreading of this disease.
There are various medicines, therapies and vaccines are under trial to prevent
or to treat this disease. Among the three drugs remdesivir and lopinavir are
showing promising results but outcomes from the trials for
hydroxychloroquine are not encouraging. Although the drugs (remdesivir and
lopinavir) are showing promising results but still these drugs are not 100%
efficient. So further developments of these drugs and research on these drugs
are necessary for this situation.
Any way until there is no 100% efficient vaccine or treatment for this drug,
there is an ultimate vaccine that is maintaining social distance. If we maintain
Social distance then we will be able to break the infection chain of COVID-19.
Also staying at home, until there no necessity to go out, can also help to stop
spreading of the COVID-19. So these days there is a popular slogan that is
“Stay Home Stay Safe”
V. REFERENCE:

1. Q&A on coronaviruses (COVID-19),

https://www.who.int/emergencies/diseases/novel-coronavirus-
2019/question-and-answers-hub/q-a-detail/q-a-coronaviruses
2. WHO Timeline - COVID-19, https://www.who.int/news-
room/detail/27-04-2020-who-timeline---covid-19
3. Coronavirus disease 2019, Wikipedia,
https://en.wikipedia.org/wiki/Coronavirus_disease_2019
4. Remdesivir, Wikipedia
https://en.wikipedia.org/wiki/Remdesivir
5. Wang Y, Zhang D, Du G, Du R, Zhao J, Jin Y & Co., Remdesivir in adults
with severe COVID-19: a randomised, double-blind, placebo-
controlled, multicentre trial, The Lancet, 395 (10236): 1569–1578,
doi:10.1016/S0140-6736(20)31022-9
6. Chun BK, Clarke MO, Doerffler E, Hui HC, Jordan R, Mackman RL,
Parrish JP, Ray AS, Siegel D, Methods for treating Filoviridae virus
infections, published 5 May 2016, issued 8 August 2017, assigned to
Gilead Sciences Inc.
7. Gordon CJ, Tchesnokov EP, Woolner E, Perry JK, Feng JY, Porter DP,
Gotte M, Remdesivir is a direct-acting antiviral that inhibits RNA-
dependent RNA polymerase from severe acute respiratory syndrome
coronavirus 2 with high potency, The Journal of Biological Chemistry,
295 (20): 6785–6797, doi:10.1074/jbc.RA120.013679
8. J.H. Beigel, K.M. Tomashek, L.E. Dodd, A.K. Mehta, & Co., Remdesivir
for the Treatment of Covid-19 — Preliminary Report, The New
England Journal of Medicine, May 22, 2020, DOI:
10.1056/NEJMoa2007764
9. Hydroxychloroquine, Wikipedia,
https://en.wikipedia.org/wiki/Hydroxychloroquine
10.Hydroxychloroquine,
https://pubchem.ncbi.nlm.nih.gov/compound/Hydroxychloroquine
11.R.S. Vardanyan, V.J. Hruby Drugs for Treating Protozoan Infections,
https://www.sciencedirect.com/topics/chemistry/hydroxychloroquine
12.Wei Tang, Zhujun Cao, Mingfeng Han, Zhengyan Wang, Junwen Chen,
& Co., Hydroxychloroquine in patients with mainly mild to moderate
 coronavirus disease 2019: open label, randomised controlled trial, The
British Medical Journal, BMJ2020;369:m1849, doi:
10.1136/bmj.m1849
13.Hydroxychloroquin, Oral Tablet,
https://www.medicalnewstoday.com/articles/hydroxychloroquine-
oral-tablet
14.Hemang K Pandya, Mark Robinson, Nawajes Mandal, and Vinay A
Shah. Hydroxychloroquine retinopathy: A review of imaging, Indian
Journal of Ophthalmology, 2015 Jul; 63(7): 570–574., doi:
10.4103/0301-4738.167120
15.Information for Clinicians on Investigational Therapeutics for Patients
with COVID-19, https://www.cdc.gov/coronavirus/2019-
ncov/hcp/therapeutic-options.html
16.Kaletra tablet, https://www.rxlist.com/kaletra-tablets-
drug.htm#description
17.The Science of HIV & AIDS, http://www.avert.org/professionals/hiv-
science
18.Ashish Chandwani & Jonathan Shuter, Lopinavir/Ritonavir in
treatment of HIV – 1, Ther Clin Risks Manag. 2008 Oct.,
doi:10.2147/tcrm.s3285
19.Lopinavir/Ritonavir, Wikipedia,
https://en.wikipedia.org/wiki/Lopinavir/ritonavir
20.B. Cao, Y. Wang, D. Wen, W. Liu, Jingli Wang, G. Fan, L. Ruan and Co.,
A Trial of Lopinavir–Ritonavir in Adults Hospitalized with Severe Covid-
19, The new england journal of medicine, march 18,2020,
doi:10.1056/NEJMoa2001282
 EVALUATION SHEET

Subject - Project Work

Exam Roll No. – 17CHE031
Project title- Coronavirus disease 2019 and probable drugs
for its treatment
Total Mark- 100
TOPIC TOTAL MARK
MARK AWARDED
A PROJECT
INTRODUCTION 10
REVIEW OF 10
LITRATURE
DISCUSSION 10

CONCLUSION 10
REFFERENCE 10
B VIVA 20

C SEMINAR 30

TOTAL 100

Signature of the Internal Signature of the External

Date- Date-