What COVID-19 therapy is the real “Game-Changer”?

— Hydroxychloroquine or Zinc?

Andrew J. Maxwell, M.D., FACC

April 6, 2020

There has been a tremendous amount of buzz regarding the use of hydroxychloroquine (HC) for the treatment of COVID-19. This has been touted as everything from a “game-changer” and “a gift from God” to begin mostly dismissed for lack of convincing evidence. The skeptics, me being one, have cited the majority of the literature demonstrating negative outcomes. Nonetheless, the pressure to forego formal clinical trials and urgently employ the drug in the face of many impending deaths of an epidemic has been enormous and completely understandable.

A survey reported 2 days ago of doctors around the world who have been managing COVID-19 patients place it as “the most effective coronavirus treatment” to date. The survey, conducted by Sermo, a global health care polling company, asked 6,227 physicians in 30 countries to find out what is the most effective against SARS-CoV-2.

Doctors Rate Hydroxychloroquine ‘Most Effective’ Coronavirus Treatment

That is to say, of 6,000+ doctors surveyed, 37% considered HC the most effective available. This begs the question what the other 63% considered more effective than HC and it also seems to highlight the sorry state of what we have available as treatment since the therapy considered most effective has mostly shown no beneficial effect in the small clinical trials conducted to date. They didn’t report all the breakdown of how the voting went and which were the other 14 drug choices these doctors were allowed to choose from, but it likely included the antivirals remdesivir, lopinavir, and ritonavir. Giving such options essentially creates the same phenomenon we just witnessed in the Democratic primary voting, that multiple choices of relatively similar drugs causes the one slightly different, but not necessarily a winner, to get the most votes. This is especially true if doctors were not allowed to vote on combinations such as the lopinavir/ritonavir and such.

Other outcomes of the survey revealed that:

The three most commonly prescribed treatments among COVID-19 treaters are 56% analgesics, 41% Azithromycin, and 33% HC

HC usage among COVID-19 treaters is 72% in Spain, 49% in Italy, 41% in Brazil, 39% in Mexico, 28% in France, 23% in the U.S., 17% in Germany, 16% in Canada, 13% in the UK and 7% in Japan [note that of those listed, Japan is the lowest user and China, South Korea and Singapore are not even on the list]

HC was overall chosen as the most effective therapy among COVID-19 treaters from a list of 15 options (37% of COVID-19 treaters); 75% in Spain, 53% Italy, 44% in China, 43% in Brazil, 29% in France, 23% in the U.S. and 13% in the U.K. [Note that Japan, China, South Korea, and Singapore are not among the doctors who thought HC was most effective]

Clinical Studies of Hydroxychloroquine

Indeed, one study that initially lit fire to the world was the French study of the use of HC in combination with azithromycin.

It did not take long however for this study to be roundly criticized and dismissed by the medical community before the pre-proof ever hit publication. Another study of the very same combination also from France showed no effect.

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In contrast, a study out of Wuhan posted on March 31st showed a positive but modest result. This was the first randomized, controlled trial to show clinical benefits.

In this trial, 62 hospitalized patients were randomized to receive standard therapy with or without HC 200 mg twice daily for 5 days. They found that the time to recovery of body temperature was shorter (2.2 days compared to 3.2 days), cough remission was shorter and 81% showed improved pneumonia by CT scan as compare to 55% in controls. This last outcome is an impressive outcome and should not be dismissed. Hydroxychloroquine seems to have some benefit in that regard.

Despite the lack of compelling clinical evidence, it’s understandable the interest in HC given the presumed mechanism of action to stop viral replication. Chloroquine analogs (quinolines) have been shown to inhibit the acidification of endosomes and to exhibit in vitro a non-specific antiviral activity at high micromolar concentration against a broad range of emerging virus (HIV, dengue, hepatitis C, chikungunya, influenza, Ebola, SARS and MERS viruses) and more recently COVID-19. Furthermore, all the clinical studies are being performed on hospitalized sick patients and the question still remains whether such a therapy would have a more significant effect if started early in the illness or even prophylactically before the onset of the illness.

Hydroxychloroquine and Zinc

Aside from these clinical trials of various quality and weak or negative outcomes, there have been two recent striking clinical observations by clinicians that have played powerfully in the media because of the obviously striking outcomes. These are not clinical trials but rather anecdotal observations of larger populations of patients treated for presumed COVID-19 infections and they did not involve just hydroxychloroquine alone. But just because they are not rigorous clinical trials shouldn’t mean we should discard any clinical benefit that is so obvious that we don’t need a statistical analysis to reveal it particularly if corroborating reports are coming in from multiple observers.

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The first one was reported by Dr. Vladimir Zelenko from Monroe, NY whereby he reported on March 21 that his team had seen about 900 patients with possible coronavirus symptoms, treating about 350 with his regimen of HC, azithromycin and zinc. None had died as of April 2nd, he said, though six were hospitalized and two were on ventilators. Despite the criticism that this was not a randomized controlled trial, still, if one can believe that the 350 patients did indeed mostly have coronavirus and can believe the numbers that this wasn’t such a bad outcome. Still, skepticism remained because of these lingering questions.

LA doctor seeing success with hydroxychloroquine to treat COVID-19

This morning, another such pronouncement was made. Dr. Anthony Cardillo of Los Angeles said he has seen very promising results when prescribing HC in combination with zinc for the most severely-ill COVID-19 patients. He did not report the dosages of either the hydroxychloroquine or the zinc.

“Every patient I’ve prescribed it to has been very, very ill and within 8 to 12 hours, they were basically symptom-free. So clinically I am seeing a resolution.”

Reconciling the negative trials versus dramatic clinical observations

So how do we reconcile the negative clinical trials of HC with the dramatic clinical observations made by these two clinicians? One point that Dr. Cardillo made very clear was that those patients he treated with HC alone, did not respond. It was clear to him that zinc supplementation was needed to have the dramatic effect he saw. Indeed, the one commonality between Dr. Zelenko’s regimen of HC/Azithromycin/Zinc and Dr. Cardillo’s HC/Zinc besides HC is Zinc. So maybe the real hero is zinc. Maybe HC is just a doorman assisting the irreplaceable zinc but there are many other doormen out there that can help just as well.

By the way, these doctors are not the first to consider the combination of HC with zinc. There is currently an ongoing clinical trial in Turkey to look at the efficacy and safety of hydroxychloroquine with zinc in the management of COVID-19.

Proflaxis Using Hydroxychloroquine Plus Vitamins-Zinc During COVID-19 Pandemia — Full Text View …

Zinc as an anti-viral

Zinc is known to inhibit viral replication by a few mechanisms. The first is that zinc shuts down the very enzyme that the RNA virus needs to replicate itself inside the cell. It inhibits RNA-dependent RNA polymerase (RdRP).

Rather than I explain this further, I recommend this most excellent video by Dr Seheult on how zinc behaves as an anti-viral and how chloroquine helps get zinc into cells to stop viral replication. To be efficient with your time, skip ahead to 1:34 and watch to 10:25. That’s all you need to know for this.

Figure. Schematic representation of zinc homeostasis. Intracellular labile zinc is modulated by the coordinated activity of a large family of zinc transporters (ZnT and ZIP) and zinc-binding proteins, such as metallothionein or ionophore molecules.

In short, Zinc has been shown to block RNA-dependent RNA polymerase activity of many RNA viruses and now this includes the SARS COV-2 virus. But it must get into the cell in order to do this.

Zinc utilizes zinc transport proteins to get into cells. Zinc from the extracellular milieu and from intracellular compartments enters the cytoplasm through 14 specialized trans-membrane proteins of the ZIP/SLC39 family. These transport proteins are very good at keeping zinc out unless induced to open.

Substances that open ion channels or that shuttle ions across membranes independent of channels are called ionophores. Zinc ionophores therefore are important in getting zinc into cells to block replication.

A study done in 2014, long before coronavirus was around, found that chloroquine behaved as an ionophore to open zinc channels and could therefore allow zinc into cells in sufficient quantity to stop viral replication.

Intracellular zinc ion distribution with and without chloroquine treatment with low and high extracellular zinc concentrations. Chloroquine is effective in getting zinc into cells.

In addition to inhibiting RNA-dependent RNA polymerase, zinc also is a potent inhibitor of the signalling cascade of interferons-lamba3, which are a family of pro-inflammatory cytokines. You may recall hearing about the dreaded ‘cytokine storm’ that suddenly alters a relatively mild case of COVID-19 tending toward recovery to sudden cyanosis with Adult Respiratory Distress Syndrome (ARDS). Zinc may play a role in preventing that storm.

Zinc Homeostasis as a major player in COVID-19 Pathology

Now that it seems plausible that zinc transport into cells is a crucial part of control of the coronavirus, it might make sense that any health condition that interferes with zinc transport would worsen COVID-19 disease and anything that promotes zinc transport would improve outcome.

It turns out that diabetes and cardiovascular disease reduce zinc transport while estrogen is an inducer of the ZIP6 zinc transporter. Conversely, dysfunctions of zinc transporters are promoting factors in cardiovascular diseases, diabetes, Alzheimer’s disease, and cancer.

Perhaps the effect of diabetes and heart disease on zinc transport explains why patients with heart disease and diabetes are at such high risk of morbidity and mortality with COVID-19 infections.

The effect of estrogen to induce zinc transport may further explain why men get infected with SARS COV-2 at a higher rate and have a relative risk of death 3 times that of women.

Are there other ionophores better than chloroquine and hydroxychloroquine?

Ionophore activity is in no way unique to chloroquine and HC. There are many other substances that either open zinc transporter channels or shuttle zinc into a cell across a cell membrane. hiokitiol, pyrrolidine dithiocarbamate, pyrithione all transport zinc and have been shown in vitro to inhibit viral replication. Hinokitiol is a natural substance isolated from Taiwamese ninoki tree and used as a topical antibacterial in Japan.

Figure . Inhibition of the in vitro RNA-synthesizing activity of isolated RTCs by Zn2+ in the presence of the ionophore pyrthione. Incorporation of [α-32P]CMP into viral RNA by EAV (A) and SARS-CoV (B) in RTC assays in the presence of various Zn2+ concentrations, as indicated above each lane.

Pyrithione might be considered the gold-standard zinc ionophore in that it is used in studies looking at ability to get zinc into cells to inhibit replication. It is also a natural compound found in Persian shallot which is an Asian species of onion growing in central and southwestern Asia. It is for topical use only and often in medicated dandruff shampoos. So, even though hinokitiol and pyrithione are natural, it doesn’t look like they would be practical replacements for HC.

Perhaps reasonable choices as substitutes for chloroquine and hydroxychloroquine are quercetin and Epigallocatechin-3-gallate (EGCG) and even tonic water which contains small amounts of quinine (added to tonic water to make the gin and tonic a little bitter and more palatable).

Quercetin is a plant flavonol found in many fruits, vegetables, leaves, seeds, and grains; red onions and kale. It is found in highest concentration in capers, sorrel and radish leaves. Quercetin is a very popular supplement used as an anti-mast cell and antihistamine therapy. EGCG is a water-soluble flavonoid present in green tea. Quinine is the naturally occurring parent compound from which chloroquine and HC are synthesized. It is isolated from the bark of the cinchona (qui-qui) tree. Quinine was used liberally during the flu pandemic of 1918. Whether it helped or not, no one know because no one stopped to do clinical trials.

Quercetin is a plant flavonol from the flavonoid group of polyphenols. It is found in many fruits, vegetables, leaves, seeds, and grains; red onions and kale are common foods containing appreciable amounts of quercetin.[2] Quercetin has a bitter flavor and is used as an ingredient in dietary supplements, beverages, and foods.

Epigallocatechin gallate (EGCG), also known as epigallocatechin-3-gallate, is the ester of epigallocatechin and gallic acid, and is a type of catechin.

Quercetin and EGCG are among the most consumed and most studied polyphenols in the human diet .Flavonoids are considered bioactive micronutrients whose regular consumption, either as food components, or as dietary supplements and nutraceuticals, entails benefits for human health, including prevention and amelioration of cancers, diabetes, and cardiovascular and neurodegenerative diseases.

Many of the health benefits of flavonoids have historically been ascribed to their antioxidant activity, which they exert directly by scavenging reactive oxygen species and indirectly by inhibiting transcription factors and pro-oxidant enzymes. However, it is currently believed that the levels of polyphenols achieved through ingestion are not enough to justify their wide array of biological actions.

Diverse polyphenols have been shown able to form complexes with the redox-inactive transition metal zinc. Several studies have shown that flavonoids affect zinc metabolism including, for the purposes of this story, acting as ionophores that shuttles zinc into cells effectively.

A study done in 2014 in Barcelona looked at the ability of quercetin and EGCG to allow zinc into cells. This was compared against the drug clioquinol, a drug that has both anti-protozoal and anti-viral properties but has too much neurotoxicity to be considered an option for COVID-19. But it provides a positive control for the study. Unfortunately, the study did not include quinine or compare it against chloroquine or hydroxychloroquine.

Figure 2. Effect of quercetin (QCT) , Epigallocatechin gallate (EGCG), and a drug called clioquinol (CQ) on the cytoplasmic pool of labile zinc in Hepa 1–6 cells. Hepa 1–6 cells were first treated with 100 μM QCT, EGCG, or CQ, in the presence or absence of 50 μM ZnCl2 for 1 and 4 h. The medium was then removed, and 3 μM FluoZin-3 (AM, cell permeant) was added. After 30 min incubation, cells were washed and examined using a confocal fluorescence microscope. Control cells were treated with vehicle (final 0.05% ethanol, 0.1% DMSO). Scale bars are 50 μm. However, when 50 μM ZnCl2 was added, both QCT and EGCG doubled the amount of FluoZin-3-detectable zinc after 1 h, and CQ increased this pool of zinc 10-fold with respect to the control (50 μM ZnCl2 in the absence of any of QCT, EGCG, or CQ) (Figure 3), suggesting a slower ionophore action of the flavonoids as compared to CQ. After 4 h treatment with additional 50 μM ZnCl2, all treatments triggered a significant increase in fluorescence intensity. In the case of the control, the increase of the cytoplasmic labile zinc is associated with the plasma membrane ZIP transporters, whereby zinc ions are transported into the cell. QCT doubled the amount of labile zinc attained with only 50 μM zinc, EGCG quadrupled this value, and CQ increased it 7-fold.

Figure 3. Intensity of FluoZin-3 fluorescence signal from images in Figure 2 was quantified using quanta program and considering an equal number of cells in each field. All values are mean ± SEM of three independent experiments. Significant differences between treatments were determined using one-way ANOVA (Tukey test). *P ≤ 0.05; **P ≤ 0.01.

These investigators found that zinc entry into cells improved with addition of quercetin or EGCG by 4 hours into treatment although not to the extent of clioquinol. Thus, natural flavonoids quercetin and EGCG from green tea can be added to an arsenal of drugs that may be used to modulate zinc homeostasis and regulate zinc-dependent biological pathways.

Is there a relationship between Asia’s consumption of green tea, their low COVID-19 infection rate and their lack of embracing hydroxychloroquine?

To date, Japan and Singapore are among the countries with the lowest new case rates and lowest deaths per capita in the world. South Korea fared well in this respect and if one can believe China’s numbers, then overall it also kept its daily death count low throughout the pandemic. This phenomenon in Japan and Singapore is despite their rejection of the use of HC as other countries have done.

The Sermo study quoted above reports that only 7% of Japanese doctors use HC and no percentage worth reporting considered it their first choice. Sermo did not seem to find China or South Korea embracing HC much either or their doctors did so at a rate less than 7% and not reported. How can this be if HC is such the ‘game changer’?

Green tea is the major source of the polyphenol, epigallocatechin gallate. In Japan, 72.3% of people drink green tea daily in Japan, and 89.6% of people drink green tea more than once a week. In fact, as people get older, more people prefer to drink green tea. Of course China and South Korea, and Singapore are high consumers of green tea as well. All of these Asian countries had relatively low death rates compared to EU, UK and the US. So, could there be a protective effect of green tea against COVID-19? Could these countries found HC less useful given this fact?

Would tonic water work just as well?

The same question might be asked as to whether there is a protective effect for those who consume tonic water which contains quinine (either alone or in the form of gin and tonics etc.). While medicinal tonic water of the past contained quite a bit of quinine, the FDA now limits the quinine content of tonic water to 83 ppm (83mg per liter) whereas, just for comparison, the modern-day studies on the use of quinine for malaria (yes, quinine can still sometimes be used for malaria) would use 3,500 mg daily. Furthermore, pharmacological doses of quinine would be expected to cause all the same cardiac and neurotoxic side effects as chloroquine and hydroxychloroquine. Just to highlight this, the antiarrhythmic drug, quinidine, is just the stereo-isomer of quinine, can easily cause fatal arrhythmias if taken in just a slightly high dose (normal dosing ranges of quinidine is 600–1,200mg daily). So as long as tonic water consumption remains below 7 liters per day, one would likely avoid the side effects but would also likely be far from the beneficial effects on zinc transport as well. But there is certainly no harm in reasonable consumption and there may be some benefit as a zinc ionophore particularly in the same parts of the body the cornavirus first invades, the throat. As has been said, ‘what have you got to lose?’

Should Quercetin and Green Tea be used instead of hydroxychloroquine?

Who knows? That’s why we do clinical trials. But from a theoretical standpoint, they may work as well as HC given that we now understand that both are just the unsung doorman letting in the irreplaceable zinc. Further studies should be performed on zinc in conjunction with quercetin and epigallocatechin gallate to consider the potential for arresting SARS COV-2 replication in the clinical setting.

In the meantime, zinc with one or more of these nutrients might be particularly useful as a long-term prophylactic against SARS COV-2 since zinc, quercetin and EGCG are all considered GRAS substances (generally recognized as safe) by the FDA. Even if it is determined that HC (plus zinc of course) is majorly helpful in preventing or in treating COVID-19 when started early, we can’t be taking it long-term and when to start HC might be tricky given that testing for the virus remains hard. So, some of us might believe it’s time to start when we feel the first signs of flu and, later, after having completed a course, realize that the next bout of flu-like symptoms might be the real deal. So, getting though the pandemic might require multiple courses of HC until at least one’s serology shows immunity (IgG antibodies are present). It won’t be a problem to be taking zinc and quercetin with green tea throughout the day, day after day. These may be the real game-changers.

References:

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