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Innovative treatments for COVID-19

When COVID-19 engulfed the world in early 2020, there were two big medical questions that we all had: "Just when will we have a vaccine?" and "How can we treat those who get sick?"

Fortunately, the swift development of effective vaccines has emerged as one success story of the pandemic, even though their rollout has been uneven across the globe and continues to be a challenge. The Swiss Re Institute has previously written about COVID-19 vaccines and how their distribution affects the insurance industry.

While efforts, to date, to develop new treatments have been a journey marked both by success and failure, new developments on the drug front are giving medical professionals new options that promise to help us tame the pandemic.

Old drug, new terrain

The first great breakthrough with treatments came in June 2020 with the common and cheap corticosteroid dexamethasone, an older medicine that has long been part of doctors' toolkit.

With COVID-19, the virus sometimes kicks the immune systems of those infected into overdrive, known as a "cytokine storm". Still, it wasn't immediately obvious that a steroid would work against COVID-19. Even though steroids can supress a dangerously over-active immune system, a strong immune system is also needed to fight off an infection. Previous coronavirus epidemics like SARS and MERS were relatively isolated and lethal and did not generate enough data to show whether steroids were useful or not.

That changed with COVID-19 when a UK trial, called RECOVERY, demonstrated that using dexamethasone helped control severe inflammation, especially in the lungs, and had beneficial effects for hospitalised patients getting extra oxygen treatment. Rapidly gaining approval from the World Health Organization and global regulators, dexamethasone is thought to have cut mortality by around 20% in relevant patient groups.

Going (anti) viral

Antiviral medicines have been used successfully to treat the flu, but their use in treating COVID-19 has produced mixed evidence, so far. Antivirals aim to stop the virus from reproducing effectively, reducing the amount of virus, or viral load, against which the immune system must mount an attack.

One antiviral drug that found some success is remdesivir, with evidence to suggest that patients may need to spend less time in hospital or need less invasive ventilation. Still, current reviews of studies of use of remdesivir have focused on reducing the risk of death from COVID-19, and there the evidence has been mixed, with some concluding it produced very little significant benefit.

More recently, positive clinical trial results have been announced for a new oral drug from Merck, called molnupiravir, where it reduced deaths to zero within 29 days of the treatment starting. Additionally, it reduced hospitalisations by half in participants with at least one underlying condition, all of whom were unvaccinated.

Crucially, molnupiravir can be taken at any time after infection (although earlier is better), and can be taken at home, without the need for injections or medical supervision like are required with remdesivir. Merck are applying for authorisation in the United States and other countries shortly and hope to produce 10 million courses of treatment available by year's end.

Antiviral drugs are powerful medications. More research is needed before they are widely used, and unproven drugs without clinical evidence supporting their use should certainly not be taken without a doctor's advice. 

Monoclonal antibodies

The use of monoclonal antibodies developed to combat COVID-19 has received lots of attention. These drugs are mass-produced versions of the antibodies our immune systems make in response to COVID-19. Since this can take many days and even longer for the elderly or chronically ill whose immune systems may be compromised, administering manufactured monoclonal antibodies allow the body to skip the early stages of an immune response and get straight to fighting the infection quickly.

Ideally, these antibodies should be given soon after symptoms start for maximum effect, but the most frequently prescribed monoclonal antibody, REGEN-COV, has been shown to reduce death in patients at all treatment stages. These drugs are also believed to reduce transmission rates, by decreasing the viral load of the treated individual.

First rising to prominence early in its clinical trial in October 2020 when it was successfully used to treat U.S. President Donald Trump, REGEN-COV is now a standard frontline treatment for patients at risk of severe disease, in the US. Alongside other monoclonal antibodies, these are now being approved for use around the world. In some settings, such as care homes or cancer wards, monoclonal antibodies are also being used for prevention in people unable to be vaccinated, due to their underlying conditions.

Where do we go from here?

As we reach the end of 2021, our anti-COVID-19 arsenal is more robust than it was at the start of the year. Many countries have a range of treatments and vaccines at their disposal. We have seen some 6 billion vaccine doses administered globally, to protect not only the vulnerable, but entire populations. We have evidence that cheap steroids can cut down on deaths and powerful new antibody treatments can limit severe disease. Although not investigated in trials so far, it is likely that cases of Long Covid, where symptoms persist over weeks and months, would be minimised with earlier treatment that reduces the impact of the infection.

Vaccines, however, remain the great, first line of defence against COVID-19. There is little wisdom in spurning vaccination because another drug may help treat a disease, especially one like COVID-19 with its uncertain long-term effects. For those who do have access to the latest treatments, whether through government funding or insurance cover, a better recovery rate could be expected compared to the general population. A patient infected with COVID-19 will get an additive effect from being vaccinated and treated with these new medicines, further reducing his or her risk of severe disease or death.

The pandemic is not yet over, but our expanding array of tools mean that those who become sick now stand the best chance they have ever had of fighting off this terrible illness.

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