Rastelli E.J., Coltart D.M. Savarino A, Di Trani L, Donatelli I, Cauda R, Cassone A. Bawa S., Kumar S., Drabu S., Kumar R. Structural Modifications of Quinoline-Based Antimalarial Agents: Recent Developments. Inorg. Hems W.P., Jackson W.P., Nightingale P., Bryant R. Practical Asymmetric Synthesis of (+)-Erythro Mefloquine Hydrochloride. Studies on X-Ray Diffraction, Thermogravimetric Stability, Antibacterial- Antifungal Activity of Fe(II), Ni(II), Cu(II) Metal Chloroquine Complexes Against Bacterial Strains and Fungal Spore. 5, Yellow Fever Vaccine & Malaria Prevention Information, by Country). Stop taking mefloquine and call your doctor right away if have any of these side effects: headache, ringing in your ears, dizziness, loss of balance, problems with coordination, anxiety, depression, paranoia, hallucinations, or thoughts about suicide or hurting yourself. Methotrexate has an average rating of 6.5 out of 10 from a total of 303 ratings on Drugs.com. DE 683692. Nearly a year into the COVID-19 pandemic, we still lack effective anti-SARS-CoV-2 drugs with substantial impact on mortality rates except for dexamethasone. Joshi P., Chakraborty S., Dey S., Shanker V., Ansari Z.A., Singh S.P., Chakrabarti P. Binding of ChloroquineConjugated Gold Nanoparticles with Bovine Serum Albumin. Wanjari A.K. 8600 Rockville Pike It is active through the destruction of the asexual forms of the Plasmodium parasite. Zhou G., Liu X., Liu X., Nie H., Zhang S., Chen W. A Stereospecific Synthesis and Unambiguous Assignment of the Absolute Configuration of ()-Erythro-Mefloquine Hydrochloride. However, larger studies are needed in order to provide more solid data. Photochemical Decomposition of Mefloquine in Water. All authors have read and agreed to the published version of the manuscript. Sehailia, M. Chemat, S. Antimalarial-agent artemisinin and derivatives portray more potent binding to Lys353 and Lys31-binding hotspots of SARS-CoV-2 spike protein than hydroxychloroquine: potential repurposing of artenimol for COVID-19. The only antiviral drug with proven benefit, remdesivir, has been shown to shorten symptom duration in a large RCT that included >1000 patients. Cavalcanti AB, Zampieri FG, Rosa RG et al. EXAFS experiments indicated the proximity of the iron atom to quinoline N-1 and neighboring carbon atoms of chloroquine [143]. Hu Y.-Q., Gao C., Zhang S., Xu L., Xu Z., Feng L.-S., Wu X., Zhao F. Quinoline Hybrids and Their Antiplasmodial and Antimalarial Activities. government site. Risk of hospitalization for Covid-19 outpatients treated with various drug regimens in Brazil: comparative analysis. A Neuberger, FOIA The RECOVERY Collaborative group trial compared 1561 patients treated with HCQ to 3155 patients that received standard of care. These drugs include chloroquine, hydroxychloroquine, quinacrine, primaquine, mefloquine, halofantrine, lumefantrine and tafenoquine. Discovery of berberine, abamectin and ivermectin as antivirals against chikungunya and other alphaviruses. Chloroquine-containing chitosan-tripolyphosphate (CS-TPP) nanoparticles were prepared in order to investigate their protective effect on the liver in P. berghei NK65 infection. Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. Pharmacology of Chloroquine and Hydroxychloroquine. Yu F., Li J., Xie Y., Sleightholm R.L., Oupick D. Polymeric Chloroquine as an Inhibitor of Cancer Cell Migration and Experimental Lung Metastasis. The research community has produced a vast amount of new research. For HCQ and chloroquine we found ample in vitro evidence of antiviral activity. Zarbl E., Lammerhofer M., Woschek A., Hammerschmidt F., Parenti C., Cannazza G., Lindner W. Strong versus Weak Chiral Cation Exchangers: Comparative Evaluation for Enantiomer Separation of Chiral Bases by Non-Aqueous CEC. Also in the X-ray crystal structure of gallium(III), protoporphyrin IX with CQ (2:2 stoichiometry) ionic and hydrogen-bonding interactions was found rather than covalent coordination links (Figure 8) [145]. Phosphonate-Chloroquine Conjugates and Methods Using Same. Bisphosphonates for Delivering Drugs to Bone. De Villiers K.A., Gildenhuys J., le Roex T. Iron(III) Protoporphyrin IX Complexes of the Antimalarial Cinchona Alkaloids Quinine and Quinidine. Summary of hydroxy(chloroquine) derivatives and available in vitro and in vivo experimental data. Considerations when choosing a drug for malaria prophylaxis: Recommendations for drugs to prevent malaria differ by country of travel and can be found in Malaria Information by Country. Qin H.-L., Zhang Z.-W., Lekkala R., Alsulami H., Rakesh K.P. Antiviral effects of artesunate on polyomavirus BK replication in primary human kidney cells. Browning D.J. As the search for effective antiviral agents continues, we aimed to review data on the potential of repurposing antiparasitic drugs against viruses in general, with an emphasis on coronaviruses. Baxter A., Harris M.J., Brown S. Resolution of Mefloquine with O,O-Di-p-aroyltartaric Acid. This research was funded by National Science Center (NCN, Poland) grant number 2018/30/E/ST5/00242. Nord K., Karlsen J., Tnnesen H.H. However, efforts were at times fragmented and the methodology of many clinical trials that were performed was of low quality. 7. A Living WHO Guideline on Drugs to Prevent Covid-19. US 2546658. Rajapakse C.S.K., Martnez A., Naoulou B., Jarzecki A.A., Surez L., Deregnaucourt C., Sinou V., Schrvel J., Musi E., Ambrosini G., et al. Tambo E, Khater EI, Chen JH, Bergquist R, Zhou XN. Such a search may prove beneficial in this pandemic, or in future outbreaks yet to come. As the level of evidence of these data is likely low, the efficacy of ivermectin against COVID-19 remains to be proven. Treatment with hydroxychloroquine, azithromycin, and combination in patients hospitalized with COVID-19. WO 2017079260 A1. Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel. All authors have read and approved the contents of this manuscript. Its inclusion in clinical trials using differing protocols is ethical as no excess mortality was shown in the Solidarity trials.10 We call for the continuation of pre-clinical research of existing compounds with potential antiviral effect against SARS-COV-2. Varghese FS, Kaukinen P, Glsker S et al. and P.J.B. Moore D.E., Hemmens V.J. Careers, Unable to load your collection due to an error. Efficacy and safety of the mosquitocidal drug ivermectin to prevent malaria transmission after treatment: a double-blind, randomized, clinical trial. EP 0553778 B1. Five hospitalized patients showed a positive outcome with two patients weaned from mechanical ventilation. Perche F., Yi Y., Hespel L., Mi P., Dirisala A., Cabral H., Miyata K., Kataoka K. Hydroxychloroquine-Conjugated Gold Nanoparticles for Improved SiRNA Activity. To study the efficacy of the drug Mefloquine, tablet 250 mg, for the treatment of patients with coronavirus infection (light and medium-heavy form), the appointment in the "off-label" in comparison with the drug Hydroxychloroquine tablets 200 mg, when administered in the mode "off label". Earlier virological clearance was observed in the ivermectin group compared to placebo, but not in the ivermectin and doxycycline group.80, A retrospective cohort study demonstrated lower mortality in the ivermectin group compared with the standard of care (15.0 vs 25.2%, OR 0.52, 95% CI 0.290.96, P=0.03) and lower mortality of patients with severe pulmonary disease treated with ivermectin (38.8 vs 80.7%, OR 0.15, CI 0.050.47, P=0.001), but with no significant differences in the rates of successful weaning from mechanical ventilation (36.1 vs 15.4%, OR 3.11 (0.8811.00), P=0.07).81 Other small, non-randomized trials, which are potentially biased, have reported conflicting results regarding the benefit of ivermectin.8284. Vincent MJ, Bergeron E, Benjannet S et al. (chloroquine); preliminary writing, D.J.K., M.K.J. Email: Received 2020 Nov 26; Revisions requested 2021 Jan 11; Revised 2021 Jan 7; Accepted 2021 Jan 12. That's when your body's immune system attacks your cells and tissue by mistake. Villarreal W., Colina-Vegas L., Rodrigues de Oliveira C., Tenorio J.C., Ellena J., Gozzo F.C., Cominetti M.R., Ferreira A.G., Ferreira M.A.B., Navarro M., et al. Hydroxychloroquine, Malarone, Quinine. Knight J.D., Sauer S.J., Coltart D.M. Remdesivir is therefore only modestly effective, and the search for more active anti-SARS-CoV-2 continues.6. Metal organic frameworks (MOF) with incorporated chloroquine were reported. The COVID-19 pandemic has already incurred a shocking price in terms of lives lost, worldwide economic recession, political tensions and psychological stress.1,2 This pandemics effects on high-risk populations are still being studied.3 Since time is critical, and no treatment except dexamethasone has been proven to decrease mortality,4 there is now a worldwide rush to find an effective antiviral agent. Both medicines are used to treat malaria and certain autoimmune diseases. {4-[(7-Chloro-4-Quinolyl)Amino]-N,N-Diethylpentanaminium}(Triphenylphosphine) Gold(I) Dinitrate. Hydroxychloroquine with or without azithromycin in mild-to-moderate Covid-19. 7-Chloro-4-[5-(n-Ethyl-n-2-Hydroxyethylamino)-2-Pentyl] Aminoquinoline, Its Acid Addition Salts, and Method of Preparation. Compassionate use of hydroxychloroquine in clinical practice for patients with mild to severe Covid-19 in a French university hospital. Flobinus A, Taudon N, Desbordes M et al. Cardiac toxicity is rare but may be life threatening.9 According to current knowledge, significant QT prolongation occurs in 313% of patients, with increasing incidence with age and among patients that are co-treated with azithromycin. Division of Internal Medicine, Rambam Health Care Campus, Haifa, Israel. Kuter D., Benjamin S.J., Egan T.J. An official website of the United States government. For patients taking hydroxychloroquine to prevent malaria: Your doctor may want you to start taking this medicine 2 weeks before you travel to an area where there is a chance of getting malaria. NTZ exhibits antiviral activity against MERS-CoV and other coronaviruses by inhibiting the expression of the viral N protein,94,95 and inhibits the SARS-CoV-2 at a low-micromolar concentration.23 One small prospective non-controlled study that assessed NTZ treatment of in and outpatients with COVID-19 was performed. Cinchona Alkaloids in Synthesis and Catalysis: Ligands, Immobilization and Organocatalysis. Furthermore, patients in the HCQ group that were not undergoing mechanical ventilation at baseline had a higher frequency of invasive mechanical ventilation or death (30.7 vs 26.9%; risk ratio, 1.14; 95% CI, 1.031.27).41 The WHO solitary study compared 954 patients treated with HCQ to 909 patients receiving its control. Hydroxychloroquine (Plaquenil) helps minimize joint damage in RA. In vivo activity of amodiaquine against Ebola virus infection. 7 In various studies of healthy adults, the mean elimination half-life of mefloquine varied between 2 and 4 weeks, with a mean half-life of approximately 21 days. Photosensitization by Antimalarial Drugs. Effect of artemisinin/artesunate as inhibitors of hepatitis B virus production in an "in vitro" replicative system, Artesunate demonstrates in vitro synergism with several antiviral agents against human cytomegalovirus. Sleightholm R., Yang B., Yu F., Xie Y., Oupick D. Chloroquine-Modified Hydroxyethyl Starch as a Polymeric Drug for Cancer Therapy. The Hebrew University of Jerusalem, Jerusalem, Israel, Sheba Medical Center, Geographic Medicine and Tropical Diseases, Ramat Gan, Israel, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. Preparation and Physico-Chemical Studies of Some Novel Mixed-Ligand Cyanonitrosyl CrNO5 Complexes of Chromium(I) with Some Antimalarial, Antibacterial and Antidyspeptic Drugs. Although torsades de pointes has not been recorded in small cohorts of COVID-19 patients, it is possible that fatal arrhythmias will be encountered if the drug will be used extensively.1012, Chloroquine is active in vitro and in animal models against several viruses, including human immunodeficiency virus (HIV),13 hepatitis C virus (HCV),14 influenza type H1N1,15 H5N1,16 flaviviruses such as dengue virus and Zika,17 MERS virus1820 and SARS-CoV-1.2125, In early in vitro studies, chloroquine was found effective in blocking SARS-CoV-2 infection at low concentrations.23 Recent in vitro and physiologically based pharmacokinetic modelling studies found higher potency for HCQ compared to chloroquine in reducing SARS-CoV-2.26,27, From the onset of the COVID-19 pandemic, HCQ was administered in most affected countries. Division of Internal Medicine, Rambam Health Care Campus, Haifa, Israel; Chloroquine, artemisinins, nitazoxanide, COVID-19, corona, SARS, viruses. Mastrangelo E, Pezzullo M, de Burghgraeve T et al. Schmid R., Broger E.A., Cereghetti M., Crameri Y., Foricher J., Lalonde M., Mller R.K., Scalone M., Schoettel G., Zutter U. In this review, we screened in vivo and in vitro studies that focus on antiviral activities of several antiparasitic agents, including specific activity against COVID-19 and other coronavirus-related infections [Middle East respiratory syndrome (MERS), SARS and SARS-CoV-1]. Haffizulla J, Hartman A, Hoppers M et al. In contrast, out of thousands of analogs of chloroquine, just a few described above were prepared from commercially available chloroquine. Grellepois F., Grellier P., Bonnet-Delpon D., Bgu J.-P. Design, Synthesis and Antimalarial Activity of TrifluoromethylartemisininMefloquine Dual Molecules. Division of Internal Medicine, Rambam Health Care Campus, Haifa, Israel, Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel, Division of Internal Medicine, Unit of Infectious Diseases, Rambam Healthcare Campus, Haifa, Israel, Institute of Drug Research, School of Pharmacy-Faculty of Medicine & Institute of Criminology - Faculty of Law. Widely used worldwide, conflicting results in observational studies, no benefit in RCTs. Kohout M., Vandenbussche J., Roller A., Tma J., Bogaerts J., Bultinck P., Herrebout W., Lindner W. Absolute Configuration of the Antimalarial ErythroMefloquineVibrational Circular Dichroism and X-Ray Diffraction Studies of Mefloquine and Its Thiourea Derivative. Reviews. Hydroxychloroquine vs Chloroquine - Indications for Use. Malaria parasites can enter the body through these mosquito bites, and then live in body tissues such as red blood cells or the liver. Two reviewers independently screened all studies published before 15 November 2020. In the current review, all the modifications sites and reactivity types are summarized and provide insight into the chemistry of these molecules. Nobel prize for the artemisinin and ivermectin discoveries: a great boost towards elimination of the global infectious diseases of poverty, Nuclear localization of dengue virus (DENV) 1-4 non-structural protein 5; protection against all 4 DENV serotypes by the inhibitor Ivermectin. Zarbl E., Lmmerhofer M., Franco P., Petracs M., Lindner W. Development of Stereoselective Nonaqueous Capillary Electrophoresis System for the Resolution of Cationic and Amphoteric Analytes. Gonalves R.S.B., Kaiser C.R., Loureno M.C.S., de Souza M.V.N., Wardell J.L., Wardell S.M.S.V., da Silva A.D. Synthesis and Antitubercular Activity of New Mefloquine-Oxazolidine Derivatives. Snchez-Delgado R.A., Navarro M., Prez H., Urbina J.A. FT-IR spectroscopy indicated conjugation of chloroquine with CS-TPP and red blood cell surface. Trapped in Misbelief for Almost 40 Years: Selective Synthesis of the Four Stereoisomers of Mefloquine. Although initial observational trials suggested benefit of HCQ, larger high-quality trials provide ample evidence that HCQ should not be used neither for treatment nor for prevention of COVID-19. ; original draft preparation, D.J.K., writingreview and editing, P.J.B. A synergistic effect with HCQ has been suggested. Piedade R., Traub S., Bitter A., Nssler A.K., Gil J.P., Schwab M., Burk O. Carboxymefloquine, the Major Metabolite of the Antimalarial Drug Mefloquine, Induces Drug-Metabolizing Enzyme and Transporter Expression by Activation of Pregnane X Receptor. For example, complexes with - and -cyclodextrins [140] and cucurbit [7] uril [141] all displayed 1:1 stoichiometry. Bethesda, MD 20894, Web Policies Chloroquine Manufacture. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (. Most adverse reactions of HCQ are mild and include gastrointestinal adverse effects, skin rash and photosensitivity. Ouedraogo AL, Bastiaens GJH, Tiono AB et al. Biot C., Delhaes L., Abessolo H., Domarle O., Maciejewski L.A., Mortuaire M., Delcourt P., Deloron P., Camus D., Dive D., et al. de Wilde AH, Jochmans D, Posthuma CC et al. 8600 Rockville Pike A synergistic effect of ivermectin and HCQ has also been suggested.34, Recently, few countries in Latin America used ivermectin as a routine, yet unproven, treatment of COVID-19. The terminal elimination half-life of mefloquine ranges from 0.9 - 13.8 days, according to one pharmacokinetic review. Wang X., Zeng Y., Sheng L., Larson P., Liu X., Zou X., Wang S., Guo K., Ma C., Zhang G., et al. Activity of selected antiparasitic agents against different coronaviruses. Preparation, Optical Purity, and Absolute Stereochemistry. 6 Altmetric Metrics Abstract Several of the antimalarial drugs are chiral and administered as the racemate. Tnnesen H.H. In cases of disagreement, a third reviewer acted as arbitrator. We performed a review by screening in vitro and in vivo studies that assessed the antiviral activity of several antiparasitic agents: chloroquine, hydroxychloroquine (HCQ), mefloquine, artemisinins, ivermectin, nitazoxanide (NTZ), niclosamide, atovaquone and albendazole. Preinerstorfer B., Lindner W., Lmmerhofer M. Polymethacrylate-Type Monoliths Functionalized with Chiral Amino Phosphonic Acid-Derived Strong Cation Exchange Moieties for Enantioselective Nonaqueous Capillary Electrochromatography and Investigation of the Chemical Composition of the Monolithic Polymer. Patra M., Joshi T., Pierroz V., Ingram K., Kaiser M., Ferrari S., Spingler B., Keiser J., Gasser G. DMSO-Mediated Ligand Dissociation: Renaissance for Biological Activity of N-Heterocyclic-[Ru(H6-Arene)Cl2] Drug Candidates. Preinerstorfer B., Hoffmann C., Lubda D., Lmmerhofer M., Lindner W. Enantioselective Silica-Based Monoliths Modified with a Novel Aminosulfonic Acid-Derived Strong Cation Exchanger for Electrically Driven and Pressure-Driven Capillary Chromatography. being able to get an erection, but not having it last long enough for sex. Federal government websites often end in .gov or .mil. The few controlled trials that have been performed are somewhat disappointing; the protease inhibitor lopinavir/ritonavir has failed to demonstrate clear superiority over a placebo in one randomized controlled trial (RCT). Hydroxychloroquine is most often used to treat autoimmune disorders. A Concise and Highly Enantioselective Total Synthesis of (+)-Anti-and ()-Syn-Mefloquine Hydrochloride: Definitive Absolute Stereochemical Assignment of the Mefloquines. Photoreactivity of Biological Active Compounds, X: Photoreactivity of Chloroquine in Aqueous Solution. Quinine and quinidine are also stereoisomers, although they are given separately rather than in combination. Kwong C.H.T., Mu J., Li S., Fang Y., Liu Q., Zhang X., Kam H., Lee S.M.Y., Chen Y., Deng F., et al. Nitazoxanide, a new drug candidate for the treatment of Middle East respiratory syndrome coronavirus. Brickelmaier M, Lugovskoy A, Kartikeyan R et al. Photochemical Stability of Biologically Active Compounds. Surrey A.R. Gildenhard M., Rono E.K., Diarra A., Boissire A., Bascunan P., Carrillo-Bustamante P., Camara D., Krger H., Mariko M., Mariko R., et al. FOIA In the current review, all the modifications sites and reactivity types are summarized and provide insight into the chemistry of these molecules. Chloroquine is a potent inhibitor of SARS coronavirus infection and spread. Middle East respiratory syndrome and severe acute respiratory syndrome: current therapeutic options and potential targets for novel therapies. National Library of Medicine In a cell culture, mefloquine inhibits the cytopathic effect of two coronaviruses closely related to SARS CoV-2: the pangolin coronavirus GX_P2V/pangolin/2017/Guangxi and feline coronavirus.71,72 To the best of our knowledge, no RCT is currently assessing the possible use of mefloquine for COVID-19. Orienting the Heterocyclic Periphery: A Structural Model for Chloroquines Antimalarial Activity. The site is secure. Nord K., Orsteen A.L., Karlsen J., Tnnesen H.H. Khan MSI, Khan MSI, Debnath CR et al. Mefloquine is an antimalarial similar in structure to quinine. Bis(Trifluoromethyl)-Alpha-(2-Piperidyl)-4-Quinolinemethanols. Abd-Elsalam S, Esmail ES, Khalaf M et al. Ding J., Hall D.G. Careers, Unable to load your collection due to an error. Mild and Selective Reductions of Aryl Halides Catalyzed by Low-Valent Nickel Complexes. Plaquenil has an average rating of 6.5 out of 10 from a total of 158 ratings on Drugs.com. React. Graphene OxideChloroquine Nanoconjugate Induce Necroptotic Death in A549 Cancer Cells through Autophagy Modulation. Navarro M., Vsquez F., Snchez-Delgado R.A., Prez H., Sinou V., Schrvel J. Nitazoxanide inhibits paramyxovirus replication by targeting the fusion protein folding: role of glycoprotein-specific thiol oxidoreductase ERp57, Nitazoxanide: a first-in-class broad-spectrum antiviral agent. Rodrigues F.A.R., da Bomfim I.S., Cavalcanti B.C., Pessoa C., Goncalves R.S.B., Wardell J.L., Wardell S.M.S.V., de Souza M.V.N. Via Fluoride Ion-Catalyzed Wittig Rearrangement, I. Adam S. A Straightforward Mid High Yielding Synthesis of MefloquineII. Hydroxychloroquine and Chloroquine Retinopathy. However, fully conclusive data was not obtained. Ibrahim S., Tagami T., Ozeki T. Effective-Loading of PlatinumChloroquine into PEGylated Neutral and Cationic Liposomes as a Drug Delivery System for Resistant Malaria Parasites. II. Wong W., Bai X.-C., Sleebs B.E., Triglia T., Brown A., Thompson J.K., Jackson K.E., Hanssen E., Marapana D.S., Fernandez I.S., et al. Effect of hydroxychloroquine on clinical status at 14 days in hospitalized patients with COVID-19: a randomized clinical trial, Hydroxychloroquine in patients with mainly mild to moderate coronavirus disease 2019: open label, randomised controlled trial, A pilot study of hydroxychloroquine in treatment of patients with moderate COVID-19. Asymmetric Synthesis of (+)-. Chugh A., Kumar A., Verma A., Kumar S., Kumar P. A Review of Antimalarial Activity of Two or Three Nitrogen Atoms Containing Heterocyclic Compounds. Several months into the outbreak, the number of large, well-conducted RCTs that have been published is still small, despite the millions of infected people worldwide. Ivermectin was evaluated in one RCT and few observational studies, demonstrating conflicting results. Nitazoxanide against COVID-19 in three explorative scenarios, Inhibition of severe acute respiratory syndrome coronavirus replication by niclosamide, Specific plant terpenoids and lignoids possess potent antiviral activities against severe acute respiratory syndrome coronavirus, SKP2 attenuates autophagy through Beclin1-ubiquitination and its inhibition reduces MERS-coronavirus infection, Broad spectrum antiviral agent niclosamide and its therapeutic potential, Potential antivirals and antiviral strategies against SARS coronavirus infections. The https:// ensures that you are connecting to the Prophylaxis should begin 1-2 weeks before travel to malaria-endemic areas. Conflicting results. As the level of evidence of these data is low, the efficacy of ivermectin against COVID-19 remains to be proven. Chen J., Gonciarz R.L., Renslo A.R. A J Domb, We found no relevant studies for atovaquone and albendazole. (mefloquine) and M.K.J. Kaur R., Kumar K. Synthetic and Medicinal Perspective of Quinolines as Antiviral Agents. Lauterwasser E.M.W., Fontaine S.D., Li H., Gut J., Katneni K., Charman S.A., Rosenthal P.J., Bogyo M., Renslo A.R. Li X.-Q., Bjrkman A., Andersson T.B., Gustafsson L.L., Masimirembwa C.M. Maurya R.C., Mishra D.D. Carmack M., Bullitt O.H., Handrick G.R., Kissinger L.W., Von I. Sheba Medical Center, Geographic Medicine and Tropical Diseases, Ramat Gan, Israel. are not active (see Sec. For example, virtually none of the thousands of derivatives of Cinchona alkaloids were obtained by the total synthesis. These viruses include, among others, parainfluenza, respiratory syncytial virus, canine coronavirus, rhinovirus and flaviviruses, including HCV, hepatitis B virus, HIV and influenza.8590 NTZ has an in vitro synergistic effect against influenza A virus when combined with oseltamivir and zanamivir.91 NTZ acts against influenza viruses by blocking the maturation of the viral hemagglutinin at the post-translational level.92 Tizoxanide, the active circulating metabolite of NTZ, is capable of inhibiting the replication of several strains of influenza A and B-16 strains of influenza A/H1N1, H3N2, H3N2v, H3N8, H5N9, H7N1 and one strain of influenza B.89 In an RCT that included 624 patients with influenza virus infection, NTZ was associated with a reduction in the duration of symptoms compared to a placebo.90 In another RCT conducted among patients with acute respiratory illness that required hospital admission in Mexico (6.6% of whom were infected with various coronaviruses), NTZ was not associated with any benefits compared to placebo.93 Patients in this study, however, had multiple causative agents, both bacterial and viral, so the measure of effect of NTZ on specific pathogens was impossible to assess. 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