IDCases 21 (2020) e00864

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IDCases
journal homepage: www.elsevier.com/locate/idcr

Editorial

Doxycycline as a potential partner of COVID-19 therapies

A R T I C L E I N F O A B S T R A C T

Article history: Coronavirus disease 2019 (COVID-19) is a major public health challenge, and the current antiviral arsenal
Received 26 May 2020 for treatment is limited, with questionable efficacy. Major efforts are under way for discovery of new
effective agents, but the validation of new potential treatments for COVID-19 may take a long time.
Keywords: Therefore, the repurposing of existing drugs for new indications is needed. In this article, we argue for the
COVID-19 potential benefits of using doxycycline with either hydroxycholoroquine or other putative agents for
Hydroxychloroquine COVID-19 treatment, as doxycycline has antiviral and anti-inflammatory activities by dampening the
Doxycycline
cytokine storm and to prevent lung damage.
2019 novel coronavirus
Remdesivir
© 2020 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction use of treatment in less-ill patients, this antimicrobial combination

has generated a great deal of interest [4].
The 2019 novel coronavirus infection, dubbed COVID-19, has However, the hydroxychloroquine and azithromycin combina-
created an unprecedented public health crisis and threatened the tion has raised major safety concerns, specifically, drug-drug
lives of millions of people worldwide [1]. The immunopatho- interactions and cardiotoxicity, including fatal arrhythmia, partic-
genesis of severe COVID-19 is partially understood and it is likely ularly among infected elderly patients with underlying cardiopul-
involves both a virus-driven damage and an exuberant host monary chronic illness [5]. The heightened risk of cardiotoxicity
inflammatory response, both contributing to acute lung injury, among older patients is of particular concern [6]. Also, patients
acute respiratory distress syndrome (ARDS), and multiple organ with COVID-19 may develop infection-related cardiomyopathy
failure [2]. Since there is no clear evidence of efficacy among (frequency is unknown) with direct and indirect cardiovascular
available antivirals for COVID-19 and since the discovery and complications, including acute myocardial injury, fulminant
clinical testing of novel antiviral agents takes a long time, myocarditis (with a mortality rate up to 40 %–70 %), arrhythmias,
repurposing of existing drugs is of paramount importance. Priority and venous thromboembolism [5,7–9].
should be given to drugs that combine antiviral and anti-
inflammatory effects. In addition, candidate drugs should have Antiviral effects of doxycycline
an acceptable tolerability profile with no major adverse events or
toxic effects. Given the risks of hydroxychloroquine and azithromycin in
combination, we suggest hydroxychloroquine with doxycycline as
Hydroxychloroquine with or without azithromycin a better alternative to azithromycin. Doxycycline and other
tetracycline derivatives such as minocycline exhibit anti-inflam-
Several agents, including hydroxychloroquine have purported in matory effects along with in vitro antiviral activity against several
vitro activity against severe acute respiratory syndrome coronavirus RNA viruses. Use of these agents have been associated with clinical
2 (SARS-CoV-2), the virus that causes COVID-19 [3]. The anti-viral improvement, even reversal of cytokine storm in some infections
mechanism of hydroxychloroquine has not been entirely elucidated, caused by RNA viruses, such as dengue fever [10].
but likely occurs through a change in pH at the surface of the cell The mechanism of the antiviral effects of tetracycline deriva-
membrane that inhibits the fusion and assembly of the virus [3]. tives may be secondary to transcriptional upregulation of
Recent uncontrolled clinical data by Gautret et al. demonstrated that intracellular zinc finger antiviral protein (ZAP), an encoding gene
hydroxychloroquine treatment is associated with rapid virologic in host cells [11,12]. ZAP can also bind to specific target viral mRNAs
clearance, which occurred at day 6 in 70 % of patients on and represses the RNAs translation [13,14]. Experimental studies
monotherapy versus in 12.5 % of patients on supportive care; adding have used tetracycline to induce the overexpression of host ZAP in
azithromycin slightly enhanced this effect, with virologic clearance HEK293, rats and monkeys cell lines (Vero cells), which
occurring at day 5 in 100 % of patients given the combination [4]. contributed to inhibition of RNA viruses such as the Dengue,
Despite the notable limitations of that study, including small number Ebola, Human Immunodeficiency Virus, Zika, and Influenza A
of patients, absence of randomization, selection bias for controls, and viruses [11,12,15–18].

https://doi.org/10.1016/j.idcr.2020.e00864
2214-2509/© 2020 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
2 A.E. Malek et al. / IDCases 21 (2020) e00864

Also, in vitro studies have showed that doxycycline can repress through activation of MMPs, leading to ventilation-induced lung
Dengue virus infection in Vero cells through the inhibition of injury [34].
dengue serine protease enzymes and of viral entry [17,19]. As mentioned earlier, doxycycline is a strong and broad-spectrum
Doxycycline showed the capacity to inhibit dengue virus replica- inhibitor of MMPs (a family of more than 24 zinc-dependent
tion in Vero cells culture and likely it interacts with the dengue proteases). Furthermore, experimental studies have showed that
virus E protein that is required for virus entry [19]. Similarly, treatment with doxycycline conferred a protective role in lung injury
doxycycline controls Chikungunya virus (CHIKV) infection through [35,36]. A prophylactic use of doxycycline in mice infected with
the inhibition of CHIKV cysteine protease of Vero cells and showed virulent influenza H3N2 virus attenuates the occurrence of acute
significant reduction of CHIKV blood titer of mice [20]. lung injury [37]. The tetracycline class of antimicrobials overall has
In addition, tetracycline derivatives such as doxycycline are proven a clinically useful tool in MMP inhibition through their ability
highly lipophilic antimicrobials that chelate zinc compounds on to chelate the catalytic Zn2+ ion, which is essential for MMP activity,
matrix metalloproteinases (MMPs) of mammalian cells [21], and independently of their antimicrobial properties [34]. Among the
an in vitro study showed that murine coronaviruses rely on MMPs tetracycline derivatives, doxycycline is the most potent MMP
for cell fusion and viral replication [22]. Other mechanisms of viral inhibitor, even at a subantimicrobial dose (25 mg) [34]. As lung
fusion and replication by coronaviruses utilize host proteases [22], immune injury/ARDS is prominent in patients with severe COVID-19,
could be a possible target to doxycycline. inhibiting MMPs may help repair the damaged lung tissue and
enhance recovery [38].
Anti-inflammatory effects of doxycycline
Future study design considerations
In COVID-19, elevated levels of blood interleukin (IL)-6 have
been more commonly observed in severe COVID-19 illness and In light of these potential benefits, we propose the use of
among non-survivors, suggesting that mortality might be due to doxycycline (preferably) or minocycline as a partner agent with
virally-driven hyperinflammation and to cytokine storm [23]. hydroxychloroquine or with other promising antiviral COVID-19
Intense proinflammatory state has a central role in the pathogen- therapies such as remdesivir, particularly in elderly patients with
esis of dengue and hemorrhagic fever, leading to cytokine storm multiple health conditions, especially cardiac comorbidities.
[24]. Importantly, doxycycline reduced pro-inflammatory cyto- Doxycycline is usually prescribed as a part of empiric treatment
kines, including IL-6 and tumor necrosis factor (TNF)-α, in patients for atypical bacterial pneumonia or community-acquired pneu-
with dengue hemorrhagic fever, and the mortality rate was 46 % monia based on the recent evidence-based clinical practice
lower in the doxycycline-treated group (11.2 %) than in the guidelines [39]. Therefore, it may be useful to conduct a large
untreated group (20.9 %) [24]. Moreover, doxycycline was more retrospective cohort study assessing disease severity, co-infec-
effective than tetracycline in the reduction of these pro- tions, mortality rate, length of hospitalization, and the need for
inflammatory cytokines [25]. invasive ventilation among COVID-19–infected patients who
Similarly, an in vitro study suggested that treatment with received a doxycycline-based or other tetracycline-based empiric
minocycline had dual anti-inflammatory effects and viral replica- antimicrobial regimen.
tion in cells infected with Enterovirus 71 infection, as minocycline In addition, placebo-controlled randomized clinical trials
reduced the viral cytopathic effect, viral protein expression, viral divided into two arms (treatment arm, antiviral (i.e. remdesivir)
titers, levels of IL-6 and IL-8, and relative mRNA expression of TNF- plus doxycycline versus the control arm, antiviral plus placebo)
α. Also, in a murine model, minocycline inhibited IL-6 and and should enroll COVID-19 patients regardless of the severity of
granulocyte colony-stimulating factor in plasma and TNF-α in illness at presentation. Primary end points, in addition to mortality
the cerebellum [26]. rate, should include clinical improvement (defervescence), pro-
In addition, severe acute respiratory syndrome–related coro- gression to respiratory failure, need for mechanical ventilation
navirus (SARS-CoV) encompasses a papain-like protease that (duration and extubation), virologic clearance, and length of stay at
significantly triggers an early growth response protein 1 (Egr-1)– the hospital.
dependent activation of transforming growth factor beta 1 (TGF-
β1), resulting in upregulation of pro-fibrotic responses in vitro and Conclusion
in vivo in the lungs [27,28]. Recent computational methods study
identified doxycycline among the drugs that could potentially be Because patients with COVID-19 are in need of both antiviral
used to inhibit SARS-CoV-2 papain-like protease [29]. and anti-inflammatory treatment as well as protection against
lung damage, studies of proposed combination therapy is
Severe COVID-19, ARDS, and pathophysiologic and therapeutic warranted. As doxycycline is inexpensive and widely available,
considerations has a safe tolerability profile, and is an attractive option for the
treatment of COVID-19 as well as potentially alleviating the lung
Respiratory failure from ARDS is the leading cause of mortality sequelae and also providing coverage against atypical bacterial
in COVID-19 patients [30]. Various pro-inflammatory cytokines pneumonia such as Mycoplasma pneumoniae and Legionella
and chemokines, including IL-6, TNF-α, and profibrotic factors pneumophilia.
(TGFB1, CCN2, and PDGFA), are also implicated in tissue damage and
vascular leakage and can stimulate pulmonary fibrosis in SARS- Funding
CoV infection [31]. The pathologic features of COVID-19 closely
resemble those of SARS-CoV infection, which causes massive lung No funding of any kind has been received.
tissue remodeling through the urokinase, coagulation, and wound-
healing pathways and through extracellular matrix proteins, CRediT authorship contribution statement
including MMPs [31]. MMPs are involved in lung remodeling
and destruction of the extracellular matrix, leading to damage of Alexandre E. Malek: Conceptualization, Methodology, Writing
the endothelial basal lamina and increased vascular permeability - original draft, Writing - review & editing. Bruno P. Granwehr:
[32,33]. Importantly, mechanical ventilation, which has a primary Writing - original draft. Dimitrios P. Kontoyiannis: Conceptuali-
role in ARDS management, is associated with further lung injury zation, Supervision, Writing - review & editing.
 A.E. Malek et al. / IDCases 21 (2020) e00864 3

Declaration of Competing Interest [22] Phillips JM, Gallagher T, Weiss SR. Neurovirulent Murine Coronavirus JHM.SD
uses cellular zinc metalloproteases for virus entry and cell-cell fusion. J Virol
2017, doi:http://dx.doi.org/10.1128/jvi.01564-16.
None of the authors have any financial or personal relationships [23] Zhou F, Yu T, Du R, et al. Clinical course and risk factors for mortality of adult
with other people or organizations that might pose a conflict of inpatients with COVID-19 in Wuhan, China: a retrospective cohort study.
interest in connection with the submitted article. Lancet 2020, doi:http://dx.doi.org/10.1016/S0140-6736(20)30566-3.
[24] Fredeking T, Zavala-Castro J, Gonzalez-Martinez P, et al. Dengue patients
treated with doxycycline showed lower mortality associated to a reduction in
Acknowledgments IL-6 and TNF Levels. Recent Pat Antiinfect Drug Discov 2015, doi:http://dx.doi.
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