Discovery of SARS-CoV-2 antiviral synergy between remdesivir and approved drugs in human lung cells

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Abstract

The SARS coronavirus 2 (SARS-CoV-2) has caused an ongoing global pandemic with currently 29 million confirmed cases and close to a million deaths. At this time, there are no FDA-approved vaccines or therapeutics for COVID-19, but Emergency Use Authorization has been granted for remdesivir, a broad-spectrum antiviral nucleoside analog. However, remdesivir is only moderately efficacious against SARS-CoV-2 in the clinic, and improved treatment strategies are urgently needed. To accomplish this goal, we devised a strategy to identify compounds that act synergistically with remdesivir in preventing SARS-CoV-2 replication. We conducted combinatorial high-throughput screening in the presence of submaximal remdesivir concentrations, using a human lung epithelial cell line infected with a clinical isolate of SARS-CoV-2. We identified 20 approved drugs that act synergistically with remdesivir, many with favorable pharmacokinetic and safety profiles. Strongest effects were observed with established antivirals, Hepatitis C virus nonstructural protein 5 A (HCV NS5A) inhibitors velpatasvir and elbasvir. Combination with their partner drugs sofosbuvir and grazoprevir further increased efficacy, increasing remdesivir’s apparent potency 25-fold. We therefore suggest that the FDA-approved Hepatitis C therapeutics Epclusa (velpatasvir/sofosbuvir) and Zepatier (elbasvir/grazoprevir) should be fast-tracked for clinical evaluation in combination with remdesivir to improve treatment of acute SARS-CoV-2 infections.

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  1. SciScore for 10.1101/2020.09.18.302398: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Institutional Review Board Statementnot detected.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.
    Sex as a biological variablenot detected.
    Cell Line Authenticationnot detected.

    Table 2: Resources

    Antibodies
    SentencesResources
    Cells were then washed with PBS, fixed in 4% paraformaldehyde (PFA) in PBS for 15 minutes, washed again with PBS, permeabilized with 0.2% saponin in blocking buffer (2% BSA, 2% FBS in PBS) for 30 minutes at room temperature (RT), and incubated with 1:1000 mouse antibody specific for SARS-CoV-2 nucleocapsid protein (Sino Biological, Beijing, China 40143-MM05) overnight at 4°C in blocking buffer consisting of 2% FBS and 2% BSA.
    SARS-CoV-2 nucleocapsid protein
    suggested: (Bioss Cat# bsm-41414M, RRID:AB_2848129)
    The following day, plates were washed 3X with PBS, incubated with a 1:1000 dilution of goat anti-mouse AlexaFluor647 antibody (Abcam, Cambridge, United Kingdom) and DAPI/Hoechst (Invitrogen) in blocking buffer for 1h at RT, washed again 3x with PBS, fixed in 4% PFA, and replaced in PBS.
    anti-mouse
    suggested: None
    Experimental Models: Cell Lines
    SentencesResources
    Cells and virus: Vero E6 and Calu-3 cells (Calu-3:ATCC HTB-55; Vero E6: ATCC, CRL-1586) were maintained in high glucose DMEM (Gibco, Waltham, MA, USA) supplemented with 10% FBS (R&D Systems, Minneapolis, MN, USA), 1X GlutaMAX (Gibco, Waltham, MA, USA), and 1X PenStrep (Gibco, Waltham, MA, USA) at 37°C and 5% CO2.
    Vero E6
    suggested: None
    2500 Vero E6 (12 μl/well) or 10000 Calu-3 (12μl/well) were seeded in 384-well white optical-bottom tissue culture plates (Nunc) with the Multidrop Combi liquid handling instrument (Thermo Fisher Scientific, Waltham, MA).
    Calu-3
    suggested: None
    Software and Algorithms
    SentencesResources
    The data was plotted and analyzed with spotfire (Tibco) and GraphPad Prism.
    GraphPad Prism
    suggested: (GraphPad Prism, RRID:SCR_002798)
    GSEA Analysis: Compounds were annotated with targets, pathways and mechanisms of actions using the Center for Emerging and Neglected Diseases’ database and for pharmacokinetic data and transporter inhibition data, the DrugBank database 42.
    GSEA
    suggested: (SeqGSEA, RRID:SCR_005724)
    DrugBank
    suggested: (DrugBank, RRID:SCR_002700)
    Images were analyzed for N stain per nuclei with the CellProfiler 3.1.9 software (Broad Institute, Cambridge, MA).
    CellProfiler
    suggested: None
    Custom code written in MATLAB (available at https://gitlab.com/tjian-darzacq-lab/second-derivative-cq-analysis) was used to take the numerical second derivative of fluorescence intensity with respect to cycle number, using a sliding window of ± 3 cycles.
    MATLAB
    suggested: (MATLAB, RRID:SCR_001622)

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).


    Results from LimitationRecognizer: An explicit section about the limitations of the techniques employed in this study was not found. We encourage authors to address study limitations.

    Results from TrialIdentifier: No clinical trial numbers were referenced.


    Results from Barzooka: We found bar graphs of continuous data. We recommend replacing bar graphs with more informative graphics, as many different datasets can lead to the same bar graph. The actual data may suggest different conclusions from the summary statistics. For more information, please see Weissgerber et al (2015).


    Results from JetFighter: We did not find any issues relating to colormaps.


    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    About SciScore

    SciScore is an automated tool that is designed to assist expert reviewers by finding and presenting formulaic information scattered throughout a paper in a standard, easy to digest format. SciScore checks for the presence and correctness of RRIDs (research resource identifiers), and for rigor criteria such as sex and investigator blinding. For details on the theoretical underpinning of rigor criteria and the tools shown here, including references cited, please follow this link.