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Favipiravir co-administration with lopinavir-ritonavir increased favipiravir clearance by twofold in COVID-19 patientsTrial shows favipiravir and lopinavir-ritonavir do not stop COVID-19

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Key Takeaway
Note that favipiravir did not demonstrate antiviral activity at the dose used in this trial.

This Phase 2a randomized, double-blind, 2x2 factorial placebo-controlled trial evaluated the effects of favipiravir in combination with lopinavir-ritonavir in a population of patients with COVID-19. The study utilized viral dynamic models (n=235) and pharmacokinetic models (n=59) to assess drug interactions and antiviral efficacy.

Pharmacokinetic modeling showed that co-administration of favipiravir with lopinavir-ritonavir increased the mean apparent clearance (CL/F) by twofold. Other reported values included a mean apparent clearance of 1.73 L/h and a mean apparent volume of distribution of 22.1 L for favipiravir. Viral sequencing did not show a clear mutagenic signature.

Despite the interaction, the antiviral effect of favipiravir and lopinavir-ritonavir on the mean death rate of infected cells (delta) did not improve model fit. The study noted that favipiravir does not have antiviral activity at the dose used in this trial. Safety data were not reported.

A primary limitation is the unknown mechanistic basis of the drug-drug interaction with lopinavir-ritonavir. Given the lack of observed antiviral activity at the tested dose, clinical application for COVID-19 remains unsupported by these findings.

How this fits prior evidence

How this fits prior evidence: This study addresses a gap regarding favipiravir interactions in COVID-19 treatment. While previous reports noted that nirmatrelvir-ritonavir reduced viral production by approximately 55% in BA.2-infected patients, this trial found no antiviral activity for favipiravir at the dose used. Additionally, while prior evidence showed that none of the evaluated treatments alone reduced mortality in severe COVID-19 cases within a specific cohort, these results confirm that favipiravir lacks sufficient potency in this study's context.

When doctors look for ways to fight COVID-19, they often test combinations of different drugs to see if they work better together. This study looked at how favipiravir performed when given alongside lopinavir and ritonavir. Researchers wanted to see if this specific mix could help clear the virus from the body.

The results showed that the combination did not improve the model for antiviral activity. While the drugs interacted in an unexpected way, they did not show a measurable effect on the rate of death for infected cells at the doses tested. The study also found no clear signs of mutations in the viral genome after treatment.

Because the trial was still in an early phase, there are some gaps in what we know. For example, researchers do not yet know the exact reason why these two drugs interacted the way they did. Most importantly, the study confirmed that favipiravir did not show antiviral activity at the specific dose used during this trial.

What this means for you:
Favipiravir showed no antiviral activity against COVID-19 at the doses tested in this study.

Common questions

Does this combination of drugs work against COVID-19?

No, the study found that favipiravir did not show antiviral activity at the dose used in this trial. While the drug interacted with lopinavir and ritonavir in an unexpected way, it did not improve the model for stopping the virus's spread in infected cells.

What are the risks of using these medications together?

The study noted an unexpected interaction between favipiravir and lopinavir-ritonavir, which caused a twofold increase in clearance. However, because this was an early phase trial, specific safety data or side effects were not reported for patients.

Did the treatment cause mutations in the virus?

The researchers performed viral whole-genome sequencing to check for changes. They did not find a clear mutagenic signature, which means they did not see evidence of the virus mutating significantly during the study.

Study Details

Study typeRct
Sample sizen = 235
EvidenceLevel 2
PublishedJul 2026
View Original Abstract ↓
AIMS: The repurposed use of favipiravir in COVID-19 has been reported to have limited clinical efficacy, yet it has been widely used in some countries. Favipiravir causes mutagenesis in RNA viruses, and it is currently unknown whether it may have a measurable effect on the virus in humans. In this study, we report the secondary endpoints from the phase 2a randomized, double-blind, 2 × 2 factorial placebo-controlled FLARE trial, which studied the combination of favipiravir and lopinavir-ritonavir. METHODS: Population pharmacokinetic and viral dynamic models including data from 59 and 235 participants respectively were developed to assess the drug effect of favipiravir in combination with lopinavir-ritonavir. Viral whole-genome sequencing was performed. RESULTS: The final joint model consisted of a slope-intercept exponential decay viral dynamic model and a one-compartment model with first-order absorption and elimination for favipiravir pharmacokinetics. The mean death rate of infected cells (δ) was 0.96 day. Favipiravir mean apparent clearance (CL/F) and mean apparent volume of distribution were 1.73 L/h and 22.1 L, respectively. Favipiravir co-administration with lopinavir-ritonavir increased CL/F by twofold, representing an unexpected drug-drug interaction. Favipiravir and lopinavir-ritonavir drug effects on δ did not improve model fit in the final joint model, indicating that neither drug has any antiviral effect against SARS-CoV-2. Viral sequencing did not show a clear mutagenic signature. CONCLUSIONS: Our findings suggest that favipiravir does not have antiviral activity at the dose used in our study, and further work to understand the mechanistic basis of the drug-drug interaction with lopinavir-ritonavir is required.
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