- Nguyenla, Xammy;
- Wehri, Eddie;
- Van Dis, Erik;
- Biering, Scott B;
- Yamashiro, Livia H;
- Zhu, Chi;
- Stroumza, Julien;
- Dugast-Darzacq, Claire;
- Graham, Thomas GW;
- Wang, Xuanting;
- Jockusch, Steffen;
- Tao, Chuanjuan;
- Chien, Minchen;
- Xie, Wei;
- Patel, Dinshaw J;
- Meyer, Cindy;
- Garzia, Aitor;
- Tuschl, Thomas;
- Russo, James J;
- Ju, Jingyue;
- Näär, Anders M;
- Stanley, Sarah;
- Schaletzky, Julia
SARS coronavirus 2 (SARS-CoV-2) has caused an ongoing global pandemic with significant mortality and morbidity. At this time, the only FDA-approved therapeutic for COVID-19 is remdesivir, a broad-spectrum antiviral nucleoside analog. Efficacy is only moderate, 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. This 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 5A (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 report that HCV NS5A inhibitors act on the SARS-CoV-2 exonuclease proofreader, providing a possible explanation for the synergy observed with nucleoside analog remdesivir. FDA-approved Hepatitis C therapeutics Epclusa® (velpatasvir/sofosbuvir) and Zepatier® (elbasvir/grazoprevir) could be further optimized to achieve potency and pharmacokinetic properties that support clinical evaluation in combination with remdesivir.