Is lithium a potential treatment for the novel Wuhan (2019-nCoV) coronavirus? A scoping review

Jan K Nowak; Jarosław Walkowiak

doi:10.12688/f1000research.22299.1

. 2020 Feb 7;9:93. [Version 1] doi: 10.12688/f1000research.22299.1

Is lithium a potential treatment for the novel Wuhan (2019-nCoV) coronavirus? A scoping review

Jan K Nowak ^1,^a, Jarosław Walkowiak ¹

PMCID: PMC7255895 PMID: 32518634

Abstract

The current rapid spread of the novel coronavirus (2019-nCoV) originating from Wuhan, China, calls for a rapid response from the research community. Lithium is widely used to treat bipolar disorder, but has been shown to exhibit antiviral activity. This brief review took a systematic approach to identify five in vitro studies reporting on the influence of lithium on coronaviral infections. We propose that in the case of urgent need, lithium be explored as a potential treatment or prophylaxis for the novel Wuhan coronavirus (2019-nCoV).

Keywords: coronavirus, Coronaviridae, Wuhan, 2019-nCoV, lithium, lithium carbonate, lithium orotate, antiviral, apoptosis, glycogen synthase kinase 3-beta, GSK-3β

Introduction

The current rapid spread of the novel coronavirus (2019-nCoV) originating from Wuhan, China, calls for a rapid response from the research community. Lithium is known to exhibit antiviral activity, but the knowledge of its potential as a possible therapy for coronoviral infections has not been summarized yet. The aim of this brief report is to draw attention to lithium as potential 2019-nCoV treatment and prophylaxis.

Methods

On February 1 ^st 2020 the following PubMed search was conducted with no language or time restrictions: (lithium and (coronavirus or *coronavirus or sarbecovirus or SARS or “severe acute respiratory syndrome” or MERS or “Middle East respiratory syndrome” or nobecovirus or merbecovirus or hibecovirus or embecovirus or andecovirus or buldecovirus or herdecovirus or moordecovirus or cegacovirus or igacovirus or “microhyla lentovirus” or milecovirus or alphaletovirus or tegacovirus or setracovirus or rhinacovirus or pedacovirus or “porcine epidemic diarrhea” or nyctacovirus or “nectalus velutinus” or myotacovirus or “myotis ricketti” or minunacovirus or minacovirus or luchacovirus or duvinacovirus or decacovirus or “Rhinolophus ferrumequinum” or “transmissible gastroenteritis virus” or “feline infectious peritonitis virus” or “canine coronavirus” or “murine hepatitis virus”)). The search yielded 45 articles, of which all the abstracts were charted and reviewed by two researchers.

Results

Five studies reporting on the influence of lithium on coronaviral infections were identified ( Figure 1).

In Vero cells, lithium chloride was shown to be effective in suppressing infection with the porcine epidemic diarrhea virus (PEDV), a member of the Coronaviridae family ¹. Not only PEDV entry and replication were inhibited in the presence of LiCl, but apoptosis as well. In MARC-145 cells, LiCl reduced the production of RNA and proteins specific to the porcine reproductive and respiratory syndrome virus. The authors, however, cautioned that the effect might have been dependent on LiCl presence during the early stages of infection and the increase of tumor necrosis factor-α ². In vitro studies of another porcine coronavirus causing transmissible gastroenteritis indicated that LiCl acts on both early and late stages of infection and inhibits apoptosis ³. The same research group from Harbin in China reported earlier that LiCl reduced the cytopathic effect of the avian infectious bronchitis virus (also a coronavirus) in primary chicken embryo kidney cells ⁴. In Vero cells, African green monkey kidney-derived epithelial cells, and immortalized chicken embryo fibroblasts LiCl suppressed the avian coronavirus infectious bronchitis. The antiviral activity of lithium was ascribed to a cellular effect ⁵.

Discussion

The possible molecular mechanisms of reduced apoptosis include the inhibition of glycogen synthase kinase 3-beta (GSK-3β) ^6,
7. Moreover, PEDV requires the PI3K/Akt/GSK-3α/β pathway, which can be targeted at GSK-3β by lithium ⁸. Curiously, GSK-3β is required for template switching, a process seemingly indispensable for the production of coronaviral genomic RNA. The inhibition of GSK-3β prevents longer viral subgenomic mRNAs and the genomic RNA from being synthesized ⁹. Their production would require GSK-3β-dependent phosphorylation of the viral nucleocapsid and subsequent recruitment of helicase DDX1.

Lithium carbonate is an orphan drug widely used in the treatment of bipolar disorder. Its safety, when used correctly, is excellent ¹⁰. The main concern in the setting of an infectious disease unit would be the potential for interactions with other medication, possibly leading to the elevation of lithium levels and acute toxicity, mostly renal. This may be prevented by monitoring serum lithium concentrations. To our best knowledge, no interactions between lithium carbonate and ribavirin, lopinavir or ritonavir exist. In unconscious patients lithium carbonate could be given via a nasogastric tube. In case of lithium carbonate unavailability, lithium orotate could be explored, which, however, remains much less known to medical science despite being available as a dietary supplement. Overall, we propose that in the case of urgent need lithium be explored by physicians as a potential treatment or prophylaxis for the novel Wuhan coronavirus (2019-nCoV).

Data availability

Underlying data

All data underlying the results are available as part of the article and no additional source data are required.

Reporting guidelines

Zenodo: PRISMA ScR checklist for ‘Is lithium a potential treatment for the novel Wuhan (2019-nCoV) coronavirus? A scoping review’. https://doi.org/10.5281/zenodo.3637574 ¹¹.

The adapted reporting guidelines checklist is available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

Funding Statement

The author(s) declared that no grants were involved in supporting this work.

[version 1; peer review: 1 approved with reservations

References

1. Li HJ, Gao DS, Li YT, et al. : Antiviral effect of lithium chloride on porcine epidemic diarrhea virus in vitro. Res Vet Sci. 2018;118:288–94. 10.1016/j.rvsc.2018.03.002 [DOI] [PMC free article] [PubMed] [Google Scholar]
2. Cui J, Xie J, Gao M, et al. : Inhibitory effects of lithium chloride on replication of type II porcine reproductive and respiratory syndrome virus in vitro. Antivir Ther. 2015;20(6):565–72. 10.3851/IMP2924 [DOI] [PubMed] [Google Scholar]
3. Ren X, Meng F, Yin J, et al. : Action mechanisms of lithium chloride on cell infection by transmissible gastroenteritis coronavirus. PLoS One. 2011;6(5):e18669. 10.1371/journal.pone.0018669 [DOI] [PMC free article] [PubMed] [Google Scholar]
4. Li J, Yin J, Sui X, et al. : Comparative analysis of the effect of glycyrrhizin diammonium and lithium chloride on infectious bronchitis virus infection in vitro. Avian Pathol. 2009;38(3):215–21. 10.1080/03079450902912184 [DOI] [PubMed] [Google Scholar]
5. Harrison SM, Tarpey I, Rothwell L, et al. : Lithium chloride inhibits the coronavirus infectious bronchitis virus in cell culture. Avian Pathol. 2007;36(2):109–14. 10.1080/03079450601156083 [DOI] [PMC free article] [PubMed] [Google Scholar]
6. Zaheer A, Knight S, Zaheer A, et al. : Glia maturation factor overexpression in neuroblastoma cells activates glycogen synthase kinase-3beta and caspase-3. Brain Res. 2008;1190:206–14. 10.1016/j.brainres.2007.11.011 [DOI] [PMC free article] [PubMed] [Google Scholar]
7. Choi SE, Kang Y, Jang HJ, et al. : Involvement of glycogen synthase kinase-3beta in palmitate-induced human umbilical vein endothelial cell apoptosis. J Vasc Res. 2007;44(5):365–74. 10.1159/000102321 [DOI] [PubMed] [Google Scholar]
8. Kong N, Wu Y, Meng Q, et al. : Suppression of Virulent Porcine Epidemic Diarrhea Virus Proliferation by the PI3K/Akt/GSK-3α/β Pathway. PLoS One. 2016;11(8):e0161508. 10.1371/journal.pone.0161508 [DOI] [PMC free article] [PubMed] [Google Scholar]
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F1000Res. 2020 Feb 21. doi: 10.5256/f1000research.24598.r59736

Reviewer response for version 1

Jean-Martin Beaulieu ¹

The authors identified five previous studies reporting an effect of lithium (mostly LiCl) in corona virus in cellular systems. This is obviously a very timely question. All studies point toward beneficial effects of lithium and thus underscore the possible beneficial effect of targeting lithium sensitive biochemical pathways, namely GSK3 mediated signaling for corona virus treatment or prophylaxis.

As a technical issue lithium not only targets GSK3b but also GSK3-alpha and inositol monophosphatases. So the emphasis on GSK3-beta may be a bit premature.

A more important issue is that none of the studies shown an effect of lithium at a 1-1.5mM concentrations. Effects are reported at Li+ concentrations that are 5mM or higher. These concentrations are not toxic for cells in culture. However, in humans, serum lithium concentration above 1.5-2.0mM (or mEq, which stands for the mM concentration of the lithium ion) are considered toxic (Haussmann et al., 2015 ¹).

The prescription of lithium in the context of the current epidemic thus appears not to be supportable by the findings. The cure may kill the patients.

More detailed studies using lithium in animal models at tolerable concentrations would thus be needed.

Unfortunately these limitations are not addressed in the manuscript.

Is the work clearly and accurately presented and does it cite the current literature?

Yes

If applicable, is the statistical analysis and its interpretation appropriate?

Not applicable

Are all the source data underlying the results available to ensure full reproducibility?

Yes

Is the study design appropriate and is the work technically sound?

Partly

Are the conclusions drawn adequately supported by the results?

Are sufficient details of methods and analysis provided to allow replication by others?

Yes

Reviewer Expertise:

Gsk3 signaling

I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.

References

1. : Treatment of lithium intoxication: facing the need for evidence. Int J Bipolar Disord.2015;3(1) : 10.1186/s40345-015-0040-2 23 10.1186/s40345-015-0040-2 [DOI] [PMC free article] [PubMed] [Google Scholar]

F1000Res. 2020 Mar 17.

Jan Nowak ¹

Poznań, March 16 ^th, 2020

Dear Prof. Beaulieu,

We are grateful for the comments that you have provided. They helped to improve our manuscript. Please find our responses below.

Sincerely yours,

Jan Nowak and Jarosław Walkowiak

As a technical issue lithium not only targets GSK3b but also GSK3-alpha and inositol monophosphatases. So the emphasis on GSK3-beta may be a bit premature.

We thank the reviewer for this comment. This is now referred to early in the discussion:

“The major putative molecular mechanisms of antiviral activity and reduced apoptosis is the inhibition of glycogen synthase kinase 3-beta (GSK-3β) ^7,8. However, lithium also inhibits GSK-3α, inositol monophosphatases, and may indirectly act via the electrolyte balance.”

This important comment has triggered a number of major changes in the manuscript. In order not to mislead the readers we propose a new title, which is more neutral:

“Lithium and coronaviral infections. A scoping review.”

The conclusion of the abstract was changed:

“We propose mechanistic investigation of the influence of lithium – alone and with chloroquine – on the SARS-CoV-2 infection.”

The conclusion at the end of the discuss was altered:

“In the light of the reviewed data lithium appears as a possible candidate for therapy of COVID-2019. We propose mechanistic investigation of the influence of lithium (0.5-1 mM) – alone and with chloroquine or other drugs – on the SARS-CoV-2 infection.”

Throughout the results section we now report and comment on LiCl concentrations, which are clearly above the levels, which are safe for humans. Examples:

“In Vero cells, lithium chloride (investigated at 1–15 mM) was shown to be dose-dependently effective in suppressing infection with the porcine epidemic diarrhea virus (PEDV), a member of the Coronaviridae family ¹.“
“Yet, LiCl at 1 mM (safe in patients) was not effective. At 5 mM LiCl reduced viral RNA levels by 30% (p < 0.001).”
“The relative viral mRNA level decreased by more than 30% (p < 0.001) at the concentration of 10 mM and by 50% at 20 mM (p < 0.001).”
“Both virus titer reduction and cell survival at 70–90% were achieved with LiCl at 25 mM (10–50% at 5 mM).”
“The results suggest that the dose of 5 mM was beneficial (20% inhibition) when applied one hour after infection, but not 8 hours post infection.”
“Relative virus titers in both cell lines were reduced by at least 45% at 5 mM and 70–90% at 10 mM. Viral mRNA concentration decreased 20 times in both cell types cultured with 5 mM LiCl.”
“One study was identified outside the main search reports on the activity of high LiCl concentrations (10-60 mM) against porcine deltacoronavirus: at 10 mM 50% relative mRNA reduction was found with no accompanying effect on the viral titer ⁶.”

Crucially, the discussion now opens with:

“The available evidence comes only from studies of cell cultures and indicates that lithium effectively inhibits coronaviral infections when administered at concentrations that are toxic to humans.”

The prescription of lithium in the context of the current epidemic thus appears not to be supportable by the findings. The cure may kill the patients.

As cited above, the discussion now starts by stating:

“The available evidence comes only from studies of cell cultures and indicates that lithium effectively inhibits coronaviral infections when administered at concentrations that are toxic to humans.”

However, hypothesizing that lithium could be useful in treating viral infections is now supported by some other evidence:

“There is some evidence that lithium may affect the course of viral diseases in humans. In a retrospective cohort study of patients with affective disorders a decrease in the rate of recurrent labial herpes was found in the lithium group (n = 177, p < 0.001) but not in the alternative treatment group (n = 59, p = 0.53) ¹³. In research previously conducted by Prof. J. Rybakowski at our hospital, lithium prevented labial herpes recurrence in thirteen out of 28 eligible psychiatric patients. Lithium also seemed to bring improvement in a proof-of-concept randomized double-blind placebo-controlled trial involving eleven healthy adults with recurrent HSV infections ¹⁴ and in a randomized study of ten women with genital herpes conducted by the same research group from Philadelphia.”

Therefore it seems that in some instances lithium exhibits antiviral activity at concentrations, which are safe and maintained long-term (for years) in patients with affective disorders.

Additionally, the discussion of lithium safety is now broader.

“Lithium concentration may be, on the other hand, increased by loop or thiazide diuretics, angiotensin-converting enzyme inhibitors, and non-steroid anti-inflammatory drugs. It is also is not clear if the use of lithium would be safe in acute disease accompanied by dehydration and unstable electrolyte levels. Cardiotoxicity of lithium may occur not only with concentrations larger than 1.5 mmol/L, but also when levels of the ion rapidly change ²¹. Although QTc prolongation is absent in most patients receiving lithium, QT dispersion ratio may increase; longer QT was also described in some cases. Concurrent use of lithium with chloroquine would need to be especially cautious in patients with QT prolongation.”

More detailed studies using lithium in animal models at tolerable concentrations would thus be needed.

As we mentioned, this has been adapted to be the conclusion of our study.

“In the light of the reviewed data lithium appears as a possible candidate for therapy of COVID-2019. We propose mechanistic investigation of the influence of lithium (0.5-1 mM) – alone and with chloroquine or other drugs – on the SARS-CoV-2 infection.”

Unfortunately these limitations are not addressed in the manuscript.

We thank for the critique, which has helped to transform our manuscript.

The references were updated

Li HJ, Gao DS, Li YT, et al.: Antiviral effect of lithium chloride on porcine epidemic diarrhea virus in vitro. Res Vet Sci. 2018;118:288–94. 29547727 10.1016/j.rvsc.2018.03.002

Cui J, Xie J, Gao M, et al.: Inhibitory effects of lithium chloride on replication of type II porcine reproductive and respiratory syndrome virus in vitro. Antivir Ther. 2015;20(6):565–72. 25560301 10.3851/IMP2924

Ren X, Meng F, Yin J, et al.: Action mechanisms of lithium chloride on cell infection by transmissible gastroenteritis coronavirus. PLoS One. 2011;6(5):e18669. 21573100 10.1371/journal.pone.0018669 3089605

Li J, Yin J, Sui X, et al.: Comparative analysis of the effect of glycyrrhizin diammonium and lithium chloride on infectious bronchitis virus infection in vitro. Avian Pathol. 2009;38(3):215–21. 19468938 10.1080/03079450902912184

Harrison SM, Tarpey I, Rothwell L, et al.: Lithium chloride inhibits the coronavirus infectious bronchitis virus in cell culture. Avian Pathol. 2007;36(2):109–14. 17479370 10.1080/03079450601156083

Zhai X, Wang S, Zhu M, He W, Pan Z, Su S. Antiviral Effect of Lithium Chloride and Diammonium Glycyrrhizinate on Porcine Deltacoronavirus In Vitro. Pathogens. 2019 Sep;8(3):144.

Zaheer A, Knight S, Zaheer A, et al.: Glia maturation factor overexpression in neuroblastoma cells activates glycogen synthase kinase-3beta and caspase-3. Brain Res. 2008;1190:206–14. 18054898 10.1016/j.brainres.2007.11.011 2343001

Choi SE, Kang Y, Jang HJ, et al.: Involvement of glycogen synthase kinase-3beta in palmitate-induced human umbilical vein endothelial cell apoptosis. J Vasc Res. 2007;44(5):365–74. 17483602 10.1159/000102321

Kong N, Wu Y, Meng Q, et al.: Suppression of Virulent Porcine Epidemic Diarrhea Virus Proliferation by the PI3K/Akt/GSK-3α/β Pathway. PLoS One. 2016;11(8):e0161508. 27560518 10.1371/journal.pone.0161508 4999130

Wu CH, Chen PJ, Yeh SH: Nucleocapsid phosphorylation and RNA helicase DDX1 recruitment enables coronavirus transition from discontinuous to continuous transcription. Cell Host Microbe. 2014;16(4):462–72. 25299332 10.1016/j.chom.2014.09.009

Multicenter collaboration group of Department of Science and Technology of Guangdong Province and Health Commission of Guangdong Province for chloroquine in the treatment of novel coronavirus pneumonia. [Expert consensus on chloroquine phosphate for the treatment of novel coronavirus pneumonia]. Zhonghua Jie He He Hu Xi Za Zhi. 2020 Mar 12;43(3):185–8.

Eldar-Finkelman H, Martinez A. GSK-3 Inhibitors: Preclinical and Clinical Focus on CNS. Front Mol Neurosci. 2011;4:32.

Amsterdam JD, Maislin G, Rybakowski J. A possible antiviral action of lithium carbonate in herpes simplex virus infections. Biol Psychiatry. 1990 Feb 15;27(4):447–53.

Amsterdam JD, Maislin G, Hooper MB. Suppression of herpes simplex virus infections with oral lithium carbonate--a possible antiviral activity. Pharmacotherapy. 1996 Dec;16(6):1070–5.

Chen Y, Kong D, Cai G, Jiang Z, Jiao Y, Shi Y, et al. Novel antiviral effect of lithium chloride on mammalian orthoreoviruses in vitro. Microb Pathog. 2016 Apr;93:152–7.

Zhao F-R, Xie Y-L, Liu Z-Z, Shao J-J, Li S-F, Zhang Y-G, et al. Lithium chloride inhibits early stages of foot-and-mouth disease virus (FMDV) replication in vitro. J Med Virol. 2017;89(11):2041–6.

Qian K, Cheng X, Zhang D, Shao H, Yao Y, Nair V, et al. Antiviral effect of lithium chloride on replication of avian leukosis virus subgroup J in cell culture. Arch Virol. 2018 Apr 1;163(4):987–95.

Sarhan MA, Abdel-Hakeem MS, Mason AL, Tyrrell DL, Houghton M. Glycogen synthase kinase 3β inhibitors prevent hepatitis C virus release/assembly through perturbation of lipid metabolism. Sci Rep [Internet]. 2017 May 31 [cited 2020 Mar 14];7. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5451429/

Rybakowski JK: Challenging the Negative Perception of Lithium and Optimizing Its Long-Term Administration. Front Mol Neurosci. 2018;11:349. 30333722 10.3389/fnmol.2018.00349 6175994

Decloedt EH, Lesosky M, Maartens G, Joska JA. Renal safety of lithium in HIV-infected patients established on tenofovir disoproxil fumarate containing antiretroviral therapy: analysis from a randomized placebo-controlled trial. AIDS Res Ther. 2017 Feb 4;14(1):6.

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Nowak JK, Walkowiak J: PRISMA Scoping Review checklist for Nowak and Walkowiak 2020. Zenodo. 2020. http://www.doi.org/10.5281/zenodo.3637575

F1000Res. 2020 Feb 12. doi: 10.5256/f1000research.24598.r59741

Reviewer response for version 1

Fangqiang Wei ¹, Weier Wang ²

The wide spread of infection of 2019-nCoV has arouse an international concern since its original outbreak in Wuhan, China. Scientists and health workers around the world are currently working together to wipe out the virus and the novel coronavirus pneumonia (NCP), which has killed more than a thousand lives, by far, worldwide.

With the current epidemic being so severe, it is necessary and urgent to make potentially reasonable recommendations for the treatment or prevention for 2019-nCoV or NCP. The two authors clearly proposed that lithium might be a potential treatment or prophylaxis for 2019-nCoV or NCP based on a summary of existing literature that reported the in vitro effects of lithium on coronaviral infections and discussed potential mechanisms, which sound reasonable to some extent, but still not rigorous.

Specifically, there are few related studies available and only in vitro data have been reported. The authors may need more related studies and solid evidence to support their hypothesis to make it more scientific and rigorous. As reported, lithium can be toxic due to its side effects, mainly thyroid, renal, and cognitive disturbances. Readers may wish to see more clinical information of lithium in treating viral infection cases, if not available, or in treating other diseases.

In terms of discussion, the authors reviewed some existing literature and suggested a potential mechanism of reduced apoptosis by lithium, the glycogen synthase kinase 3-beta (GSK-3β) inhibitor. The possibility that targeting at GSK-3β by lithium may potentially affect the coronavirus is an interesting topic. However, direct in vitro evidence is lacking regarding 2019-nCoV or related coronaviruses including severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) coronaviruses.

Moreover, relevant literature is still needed although the authors state that there is no interaction between lithium carbonate and ribavirin, lopinavir, or ritonavir exist. Another aspect worth noting is that the authors indicate that monitoring serum lithium concentration can be helpful in preventing side effects of lithium, however it should be emphasized that the in vivo relationship between the effective dose and toxic dose of lithium is still unclear, with some studies reporting a dose-dependent manner of the inhibitory effect of lithium in vitro. Thus, it warrants more data, both in vitro and in vivo, to clarify this issue.

Collectively, this study proposes a potential role of lithium in treating or preventing 2019-nCoV or NCP with some possible mechanisms. However, by far, solid evidence is lacking to validate this hypothesis. The time of developing lithium orotate for clinical use, even in emergency, is not yet.

Is the work clearly and accurately presented and does it cite the current literature?

Yes

If applicable, is the statistical analysis and its interpretation appropriate?

Not applicable

Are all the source data underlying the results available to ensure full reproducibility?

Yes

Is the study design appropriate and is the work technically sound?

Partly

Are the conclusions drawn adequately supported by the results?

Partly

Are sufficient details of methods and analysis provided to allow replication by others?

Yes

Reviewer Expertise:

We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however we have significant reservations, as outlined above.

F1000Res. 2020 Mar 17.

Jan Nowak ¹

Poznań, March 16 ^th, 2020

Dear Prof. Wei and Prof. Wang,

We would like to thank you for all the comments. They helped to improve the manuscript. Please find our responses below.

Sincerely yours,

Jan Nowak and Jarosław Walkowiak

With the current epidemic being so severe, it is necessary and urgent to make potentially reasonable recommendations for the treatment or prevention for 2019-nCoV or NCP. The two authors clearly proposed that lithium might be a potential treatment or prophylaxis for 2019-nCoV or NCP based on a summary of existing literature that reported the in vitro effects of lithium on coronaviral infections and discussed potential mechanisms, which sound reasonable to some extent, but still not rigorous.

We appreciate the critique, which has helped to improve our manuscript.

Specifically, there are few related studies available and only in vitro data have been reported. The authors may need more related studies and solid evidence to support their hypothesis to make it more scientific and rigorous.

More details are provided in the results. New paragraphs also discuss the antiviral activity in humans and cell cultures challenged with other viruses.

As reported, lithium can be toxic due to its side effects, mainly thyroid, renal, and cognitive disturbances. Readers may wish to see more clinical information of lithium in treating viral infection cases, if not available, or in treating other diseases.

Lithium cardiotoxicity is now discussed in more detail.

“Lithium concentration may be, on the other hand, increased by loop or thiazide diuretics, angiotensin-converting enzyme inhibitors, and non-steroid anti-inflammatory drugs. It is also is not clear if the use of lithium would be safe in acute disease accompanied by dehydration and unstable electrolyte levels. Cardiotoxicity of lithium may occur not only with concentrations larger than 1.5 mmol/L, but also when levels of the ion rapidly change ²¹. Although QTc prolongation is absent in most patients receiving lithium, QT dispersion ratio may increase; longer QT was also described in some cases. Concurrent use of lithium with chloroquine would need to be especially cautious in patients with QT prolongation.”

A paragraph on lithium and herpes infections in patients with affective disorders was added. The results of the cited studies are the best evidence for the antiviral activity of lithium that comes from studies conducted in patients.

“There is some evidence that lithium may affect the course of viral diseases in humans. In a retrospective cohort study of patients with affective disorders a decrease in the rate of recurrent labial herpes was found in the lithium group (n = 177, p < 0.001) but not in the alternative treatment group (n = 59, p = 0.53) ¹³. In research previously conducted by Prof. J. Rybakowski at our hospital, lithium prevented labial herpes recurrence in thirteen out of 28 eligible psychiatric patients. Lithium also seemed to bring improvement in a proof-of-concept randomized double-blind placebo-controlled trial involving eleven healthy adults with recurrent HSV infections ¹⁴ and in a randomized study of ten women with genital herpes conducted by the same research group from Philadelphia.”

More information on the activity of lithium in other viral infections was also provided.

“LiCl was shown to dose-dependently inhibit reovirus (10-60 mM) ¹⁵ and food-and-mouth disease virus (10-40 mM) ¹⁶. At 5 mM concentration LiCl reduced the replication of avian leukosis virus subgroup J in chicken embryo fibroblast cells ¹⁷. Yet, lithium at 50 µM concentration (12-20 times smaller than usually maintained in bipolar disorder) significantly reduced hepatitis C virus copy number (P = 0.0002) in supernatant from Huh7.5 cell culture ¹⁸. The latter study gives hope that lithium may indeed be efficient at clinically relevant levels.”

In terms of discussion, the authors reviewed some existing literature and suggested a potential mechanism of reduced apoptosis by lithium, the glycogen synthase kinase 3-beta (GSK-3β ) inhibitor. The possibility that targeting at GSK-3β by lithium may potentially affect the coronavirus is an interesting topic. However, direct in vitro evidence is lacking regarding 2019-nCoV or related coronaviruses including severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) coronaviruses.

Certainly, the evidence is lacking. The discussion is speculative. We have added the following:

"The major putative molecular mechanisms of antiviral activity and reduced apoptosis is the inhibition of glycogen synthase kinase 3-beta (GSK-3β) ^7,8. However, lithium also inhibits GSK-3α, inositol monophosphatases, and may indirectly act via the electrolyte balance."

And also:

“Chloroquine (hydroxychloroquine) – which is thought to be effective in COVID-2019 ¹¹ – was shown to inhibit GSK-3β and potentiate GSK-3β inhibition caused by lithium. This indicates that mechanistic studies could investigate not only 0.5-1.2 mM lithium, but lithium with chloroquine as well. This also brings zinc to the spotlight since zinc inhibits GSK-3β at micromolar concentrations ¹².”

Moreover, relevant literature is still needed although the authors state that there is no interaction between lithium carbonate and ribavirin, lopinavir, or ritonavir exist.

Information on tenofovir is now provided:

“A randomized study in tenofovir-treated patients with HIV revealed that 24-week addition of lithium at target serum concentrations of 0.6-1.0 mmol/L was not associated with nephrotoxicity ²⁰.”

Another aspect worth noting is that the authors indicate that monitoring serum lithium concentration can be helpful in preventing side effects of lithium, however it should be emphasized that the in vivo relationship between the effective dose and toxic dose of lithium is still unclear, with some studies reporting a dose-dependent manner of the inhibitory effect of lithium in vitro. Thus, it warrants more data, both in vitro and in vivo, to clarify this issue.

Throughout the results section, information on the concentrations of lithium were given and commented on.

Moreover, the discussion opens with:

“The available evidence comes only from studies of cell cultures and indicates that lithium effectively inhibits coronaviral infections when administered at concentrations that are toxic to humans.”

The reference to lithium orotate was removed.

The conclusion was changed:

“In the light of the reviewed data lithium appears as a possible candidate for therapy of COVID-2019. We propose mechanistic investigation of the influence of lithium (0.5-1 mM) – alone and with chloroquine or other drugs – on the SARS-CoV-2 infection.”

We would like the reviewers for their input, which has guided us in improving the text.

Please note that following the remarks of Prof. Beaulieu and that change of the nomenclature (2019-nCoV no longer used) we have proposed a new title, which seems more neutral and therefore more representative of the softened conclusions:

“Lithium and coronaviral infections. A scoping review.”