Lung tissue distribution of drugs as a key factor for COVID-19
treatment
Yan Wang1,*, Lei Chen2
1Center for Translation Medicine Research and
Development, Shenzhen Institute of Advanced Technology, Chinese Academy
of Sciences, Shenzhen 518055, P.R. China
2Department of Genetics, Human Genetics Institute of
New Jersey, Rutgers University, Piscataway, NJ 08854, USA
*Correspondence: Dr. Yan Wang, Center for Translation Medicine
Research and Development, Shenzhen Institute of Advanced Technology,
Chinese Academy of Sciences, Shenzhen 518055, P.R. China; 86755-2641
7985; E-mail:
yan.wang@siat.ac.cn
Over 72,000 people around the world was killed by Coronavirus Disease
2019 (COVID-19). COVID-19 is caused by severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2). It is impossible to create novel drugs
against the coronavirus in very short time, as it often takes years;
therefore, the best strategy is to find new antiviral uses from approved
drugs [1]. Not surprisingly, SARS-CoV-2 shares a highly similar
viral genome sequence with SARS-CoV [2], suggesting that the
effective treatments for SARS may also work for COVID-19 treatment.
Lopinavir, a human immunodeficiency virus type 1 (HIV-1) protease
inhibitor, showed a good inhibitory effect on SARS-CoV replication in
cell-based assays. In clinical trials, lopinavir combined with ritonavir
benefited the patients with SARS by reducing the viral loads [3].
According to molecular docking and dynamics analysis, lopinavir has been
identified as a main protease inhibitor of SARS-CoV, and approved for
inhibiting the SARS-CoV replication [4]. Recent docking simulation
studies showed that lopinavir can also directly bind to catalytic pocket
of SARS-CoV-2 main protease, indicating its potential to reduce the
viral loads in patients with COVID-19 [5]. However, in clinical
trials, no benefit was observed with lopinavir-ritonavir treatment
beyond standard care in patients with COVID-19 [6].
Both SARS-CoV and SARS-CoV-2 can attach to angiotensin-converting enzyme
2 (ACE2) and then enter host cells [2]. Given that ACE2 is highly
expressed in AT2 cells in lung [7], lung becomes a major organ under
the coronavirus attack. Interestingly, ACE2 bound to the SARS-CoV-2
spike protein with ~15 nM affinity, which is
~10- to 20-fold higher than ACE2 binding to SARS-CoV
spike protein [8]. It is indicated that SARS-CoV-2 can enter AT2
cells in lung much easier comparing with SARS-CoV. The viral loads of
SARS-CoV-2, in turn, might be much higher than viral loads of SARS-CoV
in the lung tissue. Therefore, the anti-SARS-CoV-2 drugs should target
against the lung rather than other tissues.
In a previous study, the tissue distribution of isotope-labeled
lopinavir was examined in rats. The peak radioactivity levels in plasma
were achieved at 4 h post-administration. At 4 h after administration
(10 mg/kg), liver (52.24 μg equiv/ml), adrenals (4.80 μg equiv/ml), and
thyroid (4.41 μg equiv/ml) exhibited greater radioactivity levels than
plasma. The lung (1.18 μg equiv/ml) exhibited less radioactivity levels
than plasma, indicating that the distribution of lopinavir in the lung
tissue is relatively low [9]. We guess the concentration of
lopinavir in the lung is too low to inhibit SARS-CoV-2 replication well.
It might explain why lopinavir did not benefit the patients with
COVID-19.
Unlike lopinavir, chloroquine exhibited clinical and virologic benefits
in the treatment of COVID-19 patients, including improving lung image
findings and reducing viral loads. In preclinical studies, chloroquine
showed a strong inhibitory effect on SARS-CoV-2 replication in
cell-based assays (EC50 = 1.13 μM) [10]. Lung is one
of the major target tissues as evidenced in tissue distribution studies
of oral administration of chloroquine in rats. After an oral
administration of 14C-chloroquine (20 mg/kg) to albino
and pigmented rats, the lung tissue concentrations were similar (30.76 ±
0.85 and 34.76 ± 1.56 μg equiv/ml, respectively) [11]. In a 32-weeks
treatment (16.8 mg/kg/day), the lung tissue concentrations of
chloroquine were 51.7 ± 3.1 and 104 ± 7.0 μg/mg in male and female rats,
respectively [12]. Both these two pharmacokinetics studies showed
that the distribution of chloroquine is high in the lung distribution.
We believed that chloroquine can take an advantage of the high volume of
the lung distribution to inhibit the viral replication in the lung.
Together, we proposed that anti-SARS-CoV-2 drug repurposing studies
should pay more attentions to the lung tissue distribution of antiviral
drugs. The low volume of the lung distribution of antiviral drugs might
not be enough to inhibit the coronavirus replication due to the high
viral loads in the lung tissue. Among the anti-SARS-CoV-2 drugs in the
clinical trials, hydroxychloroquine is likely to be a promising drug
that benefit COVID-19 patients because of its high volume of the lung
distribution. In a 32-weeks treatment (19.4 mg/kg/day), the lung tissue
concentration of hydroxychloroquine is 55.7 ± 3.4 μg/mg [12]. So
far, the most potent inhibitor of SARS-CoV-2 in vitro is
remdesivir (EC50 = 0.77 μM) [10], which lacks of the
tissue distribution data in public. Although remdesivir was reported to
reduce MERS-CoV viral lung loads in animals [13], we are eager to
see its lung tissue distribution data. It would help to choose an
appropriate dosing and route of administration of remdesivir.