1 Potential therapeutic effects of dipyridamole to the severely ill patients

2 with COVID-19
3 Xiaoyan Liu1#, Zhe Li2#, Shuai Liu1,3#, Jing Sun4#, Zhanghua Chen5,6#, Min Jiang7# , Qingling Zhang4#,
4 Yinghua Wei#, Xin Wang8, Yi-You Huang2, Yinyi Shi3, Yanhui Xu5, Huifang Xian5, Fan Bai6,
5 Changxing Ou4, Bei Xiong1, Andrew M Lew9, Jun Cui10, Hui Huang11, Jincun Zhao4*, Xuechuan
6 Hong12,13*, Yuxia Zhang5*, Fuling Zhou1*, and Hai-Bin Luo2*
1
7 Department of Hematology, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
2
8 Guangdong Provincial Key Laboratory of New Drug Design and Evaluation, School of
9 Pharmaceutical Sciences, Sun Yat-sen University, Guangzhou, 510006, China
3
10 Dawu County People's Hospital, Xiaogan City, 432826, China
4
11 State Key Laboratory of Respiratory Diseases, National Clinical Research Center for Respiratory
12 Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou
13 Medical University, 151 Yanjiang Road, Guangzhou, 510120, China
5
14 Guangzhou Institute of Pediatrics, Guangzhou Women and Children's Medical Center, State Key
15 Laboratory of Respiratory Diseases, Guangzhou Medical University, Guangzhou, 510623, China
6
16 Biomedical Pioneering Innovation Center (BIOPIC), School of Life Sciences, Peking University,
17 Beijing, 100871, China
7
18 Department of Infectious disease and Department of Pediatrics, The First Affiliated Hospital of
19 Guangxi Medical University, Nanning, Guangxi, 530021, China
8
20 Center for Innovative Marine Drug Screening & Evaluation (QNLM), School of Medicine and
21 Pharmacy, Ocean University of China, 23 Xianggang E Road, Qingdao, 266100, China
9
22 Walter and Eliza Hall Institute of Medical Research and Department of Microbiology & Immunology,
23 University of Melbourne, Parkville, Vic, 3052, Australia
10
24 School of Life Sciences, Sun Yat-sen University, Guangzhou, 510006, China
11
25 Cardiovascular Department, The Eighth Affiliated Hospital, Sun Yat-sen University, Shenzhen,
26 518000, China
12
27 State Key Laboratory of Virology, College of Science, Innovation Center for Traditional Tibetan
28 Medicine Modernization and Quality Control, Medical College, Tibet University, Lhasa, 850000,
29 China
13
30 Key Laboratory of Combinatorial Biosynthesis and Drug Discovery (MOE), Hubei Province

1
31 Engineering and Technology Research Center for Fluorinated Pharmaceuticals, Wuhan University
32 School of Pharmaceutical Sciences, Wuhan, 430071, China
33 #Equal contribution
34 *Correspondence

35 luohb77@mail.sysu.edu.cn (Hai-Bin Luo), zhoufuling@whu.edu.cn (Fuling Zhou),

36 yuxia.zhang@gwcmc.org (Yuxia Zhang), zhaojincun@gird.cn (Jincun Zhao), or xhy78@whu.edu.cn
37 (Xuechuan Hong).
38

39 Abstract

40 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection can cause acute respiratory
41 distress syndrome, hypercoagulability, hypertension, and extrapulmonary multiorgan dysfunction.
42 Effective antiviral and anti-coagulation agents with safe clinical profiles are urgently needed to
43 improve the overall prognosis. In an analysis of a randomly collected cohort of 124 patients with
44 COVID-19, we found that hypercoagulability as indicated by elevated concentrations of D-dimers was
45 associated with disease severity. By virtual screening of an FDA approved drug library, we identified
46 an anticoagulation agent dipyridamole (DIP) in silico, which suppressed SARS-CoV-2 replication with
47 an EC50 of 100 nM in vitro. In a proof-of-concept trial involving 31 patients with COVID-19, DIP
48 supplementation was associated with significantly decreased concentrations of D-dimers (P < 0.05),
49 increased lymphocyte and platelet recovery in the circulation, and markedly improved clinical
50 outcomes in comparison to the control patients. In particular, all 8 of the DIP-treated severely ill
51 patients showed remarkable improvement: 7 patients (87.5%) achieved clinical cure and were
52 discharged from the hospitals while the remaining 1 patient (12.5%) was in clinical remission. In
53 contrast, for the 12 severely ill patients in the control group, 4 patients (33.3%) were discharged, 2
54 patients (16.7%) were in remission, and 2 patients (16.7%) died. In summary, patients with COVID-
55 19 could potentially benefit from DIP adjunctive therapy by suppressing viral replication, reducing the
56 risk of hypercoagulability, and enhancing immune cell recovery.

57 Keyword: Dipyridamole, SARS-CoV-2, Pneumonia, Treatment, D-dimer

58 One sentence summary: Dipyridamole adjunctive therapy potentially reduces viral replication and

59 the risk of pulmonary embolism in patients with COVID-19.

2
60 Introduction

61 Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2, formerly known as 2019-nCoV)

62 outbreak had emerged from Wuhan, Hubei Province, China in December 2019 (1, 2). As of March 17,

63 2020, coronavirus disease 2019 (COVID-19) had been confirmed in 81,135 cases, including 3,231

64 deaths in China. More than 104,000 infections have also been reported in other 149 countries, such as

65 Italy, Iran, Spain, South Korea, Germany, France, U.S.A., and U.K.; this rapid spread has been declared

66 a global pandemic. To date, no agents have been reported to be specific to treat severely ill patents.

67 Identification of readily available drugs for repositioning in COVID-19 therapy avails a relatively rapid

68 way to clinical treatment (3).

69

70 SARS-CoV-2, together with SARS-CoV and MERS-CoV, belongs to the Beta-coronavirus genus,

71 which is an enveloped, positive-stranded RNA virus with approximately 30,000 nucleotides (4, 5).

72 Angiotensin I converting enzyme 2 (ACE2) is the receptor that engages the Spike surface glycoprotein

73 of SARS-CoV and SARS-CoV-2 (6, 7). ACE2 is highly expressed in many organs, including the lung,

74 heart, kidney, and intestine. Notably, in experimental models of SARS-CoV infection, Spike protein

75 engagement decreases ACE2 expression and activates the renin-angiotensin system (RAS) (6). RAS

76 activation promotes platelet adhesion and aggregation, and increases the risk for pulmonary embolism,

77 hypertension and fibrosis (8-11). It also accelerates cardiac and kidney injury by increasing local

78 angiotensin II concentrations (12-14). Apart from affecting the classic RAS pathway, ACE2 deficiency

79 in the intestine is associated with malnutrition and colonic inflammation (15).

80

81 Infection from SARS-CoV can result in severe lymphopenia, prolonged coagulation profiles, lethal

82 acute respiratory distress syndrome (ARDS), watery diarrhea, cardiac disease, and sudden death (9,

83 16-18). Many features have also been reported for COVID-19, such as prolonged coagulation profiles,

84 elevated concentrations of D-dimers, severe lymphopenia, ARDS, hypertension, and acute heart injury

3
 85 in ICU-admitted patients (2, 19). Given that angiotensin II concentrations were highly elevated in the

86 SARS-CoV-2 infected patients (20), RAS was likely a major pathogenic contributor of disease

87 progression. Indeed, in a recent study describing 1099 patients with COVID-19, the concentrations of

88 D-dimers were elevated in 40% and 60% of the non-severe and severe cases at hospital admission (21),

89 respectively. Furthermore, Zhou et al showed that a concentration of D-dimer greater than 1 mg/L on

90 admission was associated with significantly increased risk of mortality for patients with COVID-19

91 (22). Thus, prophylactic anti-coagulation therapy should be considered for alleviating the multi-organ

92 damage for patients with COVID-19.

93

94 After viral entry to the host cells, the coronavirus messenger RNA is first translated to yield the

95 polyproteins, which are subsequently cleaved by two viral proteinases, 3C-like protease (3CLP, aka

96 nsp5 or Mpro) and papain-like protease (PLP, or nsp3), to yield non-structural proteins essential for

97 viral replication (23). Inhibitors that suppress the activity of these proteases may inhibit viral

98 replication and offer an avenue for the SARS-CoV-2 therapy.

99

100 Dipyridamole (DIP) is an antiplatelet agent and acts as a phosphodiesterase (PDE) inhibitor that

101 increases intracellular cAMP/cGMP (24). Apart from the well-known antiplatelet function, DIP may

102 provide potential therapeutic benefits to patients with COVID-19. First, published studies (25-30),

103 including clinical trials conducted in China (31-33), have demonstrated that DIP has a broad spectrum

104 antiviral activity, particularly efficacious against the positive-stranded RNA viruses (26). Second, it

105 suppresses inflammation and promotes mucosal healing (34). Third, as a pan-PDE inhibitor, DIP may

106 prevent acute injury and progressive fibrosis of the lung, heart, liver, and kidney (35). Here we provide

107 evidence advocating DIP as an adjunctive therapy.

108

109 Results

4
110 DIP suppresses SARS-CoV-2 replication in Vero E6 cells

111 We virtually screened an FDA approved drug library and found that DIP bound to the SARS-CoV-2

112 protease Mpro (Figure 1A and Figure S1). Hydrophobic and hydrogen bond (H-bond) interactions are

113 the main driving forces for the binding between DIP and Mpro. By free energy perturbation

114 calculations, the binding free energy of Gpred was -8.60 kcal/mol with a predicted IC50 pred value of

115 490 nM by the equation Gpred = RT ln (IC50, pred). The inhibitory potency of DIP against Mpro was

116 then subjected to an enzymatic assay using a previously published method (36). As a result, DIP

117 exhibited an IC50, exp value of 530  10 nM (Figure 1B), which was consistent with the theoretical

118 prediction of the IC50, pred values.

119

120 To demonstrate directly that DIP suppresses SARS-CoV-2 replication in vitro, we measured viral titers

121 using a susceptible cell line, the Vero E6 cells. Chloroquine was used as a positive control (37, 38).

122 Remarkably, at concentration 100 nM, DIP suppressed more than 50% of SARS-CoV-2 replication

123 (Figure 1C). This is four times less than the predicted and experimentally confirmed IC50 to suppress

124 Mpro activity, which is consistent with previous findings showing that DIP possesses additional

125 antiviral effects (25-30). DIP (50 mg oral TID) has been used in patients to prevent hypercoagulability

126 (39), and the serum drug concentration was reported to be around 3 M (40). Collectively, these data

127 suggest that the therapeutic dosages of DIP used to treat hypercoagulability could potentially suppress

128 SARS-CoV-2 replication in the infected patients.

129

130 Demographics and baseline characteristics of the study participants

131 We first retrospectively analyzed a randomly collected cohort of 124 patients with COVID-19. This

132 has revealed that decreased lymphocyte counts, increased concentrations of D-dimers, CRP, and IL-6

5
133 concentrations were significantly associated with disease severity (Table S1).

134

135 To evaluate the therapeutic potential of DIP as an adjunctive therapy to promote virus clearance and

136 reduce the risk of hypercoagulability, an open label clinical study involving 31 patients was conducted

137 in Dawu County People's Hospital (1st hospital) and Huangpo Chinese Medicine Hospital (2nd hospital),

138 Hubei province, China from February 3 to March 8, 2020. 12 patients and 10 controls were recruited

139 from the 1st hospital, and 2 patients and 7 controls were recruited from the 2nd hospital. Patients were

140 treated in different isolation wards by different attending physicians. Standard treatment procedures

141 were applied for all patients according to the guidelines formulated by the General Office of National

142 Health Committee. DIP was used in all patients of the selected wards by two specialists each from the

143 two hospitals. Patients from other wards without DIP adjunctive therapy were used as controls.

144

145 Baseline characteristics of the two groups were shown in Table 1. The average ages of the patients

146 were 56 years. All patients manifested a cough, >75% had shortness of breath, and 35-57% had nausea

147 and vomiting. Chest CT scan revealed bilateral pneumonia in the 14 DIP-treated patients and 17

148 patients in the control group. In addition, RT-PCR test of SARS-CoV-2 RNA was positive for all

149 patients. D-dimer concentrations were elevated in 50% (4/8) and 42% (5/12) of the severely ill patients

150 in the DIP-treated group and the control group, respectively. Comorbidities, including diabetes mellitus,

151 cardiovascular, and cerebrovascular diseases, were found in 6 patients in each of the DIP and control

152 groups. Patients with diabetes (Table 1) were treated with insulin injections, and those with

153 cardiovascular diseases were treated with nifedipine. Patients with cerebrovascular disease was treated

154 with aspirin.

155

6
156 DIP adjunctive therapy increases the clinical cure and remission rates in the severely ill patients

157 with COVID-19

158 DIP adjunctive therapy was provided in 14 patients. The treatment protocol comprised of 50 mg oral

159 tablets administered thrice daily (a total of 150 mg) for 14 consecutive days. All patients received

160 ribavirin, glucocorticoids, and oxygen therapy, but none received antifungal treatment. Mechanical

161 ventilation was required for all of the critically ill patients from the DIP-treated (n = 2), and 1 each

162 from the severely and critically ill patients in the control group (n = 2). Other treatment included

163 antibiotics (42.9% vs 58.8%) and intravenous immunoglobulin (14.3% vs 23.5%).

164

165 DIP adjunctive therapy was associated with markedly improved clinical cure and remission rates in

166 both the non-severe and severely ill patients (odds ratio 23.75, P=0.06) (Table 2-3). In particular, for

167 the 8 severely ill patients in the DIP-treated group, 7 patients (87.5%) achieved clinical cure and were

168 discharged from the hospitals, and the remaining 1 patient (12.5%) was in clinical remission. In

169 contrast, for the 12 severely ill patients in the control group, 4 patients (33.3%) were discharged, 2

170 patients (16.7%) were in remission, and 2 patients (16.7%) died, respectively.

171

172 It should be mentioned that due to the urgent situation and the lack of resources to perform viral RNA

173 detection by the participating hospitals, we were unable to accurately determine the effects of DIP to

174 viral clearance. However, according to the qualitative RT-PCR result of SARS-CoV-2 RNA provided

175 by local Centers for Disease Control and Prevention, the average time for virus clearance was

176 shortened by 1.6 days for the severe cases in the DIP-treated group in comparison to the control group.

177

178 DIP adjunctive therapy improves the coagulation profiles and promotes immune cell recovery in

7
179 the severely ill patients

180 In analysis of the laboratory indices, we observed continuously increased, albeit not statistically

181 significant, lymphocyte and platelet counts in patients receiving DIP treatment in comparison to the

182 control patients (Figure 2). Given that lymphocytopenia and thrombocytopenia are markers of disease

183 severity for patients with COVID-19 (20), immune recovery may contribute to infection resolution in

184 DIP-treated patients. It should be noted that 50% and 42% of the severely ill patients from the DIP-

185 treated and control group had increased baseline concentrations of D-dimer, respectively (Table 1).

186 We calculated the dynamic changes for each patient in reference to their own baseline value, and found

187 that D-dimer rose continuously in the control group, whereas they were decreased in the DIP-treated

188 group (Figure 2).

189

190 DIP adjunctive therapy in the two critically ill patients

191 We also examined two critically ill patients who received DIP adjunctive therapy. A 70-year-old man

192 who had suffered from hypoxia and multiorgan dysfunction at hospital admission unfortunately died

193 5 days after initiation of DIP treatment. He had an extremely high concentration of D-dimer (16.2 mg/L,

194 Figure 3A) and a very low lymphocyte count (0.37X109/L) at the time of receiving DIP adjunctive

195 therapy. Additionally, his oxygen saturation remained low throughout. In contrast, the other severely

196 ill patient who also had very low oxygen saturation and high D-dimer concentration (8.83 mg/L) at

197 administration had been in clinically remission by the time of manuscript submission. His D-dimer

198 concentration initially increased as high as 15.72 mg/L two days after DIP treatment, but has gradually

199 declined to 2.79 mg/L 4-5 days after DIP adjunctive therapy. This reinforces that high concentrations

200 of D-dimer and low lymphocyte counts are associated with poor prognosis and suggest that DIP

201 treatment should be initiated before the progression to a critical state (Figure 3B).

8
202

203 Chest CT findings with DIP adjunctive therapy

204 All patients received chest CT scans and showed typical multiple patchy ground-glass shadows in the

205 lungs before the treatment. For the DIP-treated patients, the lesions from all patients had a varied

206 degree of absorption after treatment. In the control group, CT images in 1 of the 12 severely ill patients

207 showed progression (Figure 4 and Table S2).

208

209 Discussion

210 Despite the enormous threat of SARS-CoV-2, no drugs have been claimed to be specific including the

211 existing drugs used to treat other viruses. In reference to SARS-CoV-2 infection, we hypothesized that

212 the SARS-CoV-2 Spike protein engagement may activate RAS in the lung (6, 41). This hypothesis was

213 supported by published clinical characteristics and biochemical data of the severe and critically ill

214 patients with COVID-19, who showed ARDS, hypertension, acute heart, kidney injury, and positive

215 D-dimer results (2, 19, 20). In searching for available anticoagulants, we focused on DIP because of

216 its broad-spectrum antiviral, anti-inflammatory, and anti-fibrotic effects. Very importantly, we found

217 that an EC50 value of 100nM to suppress SARS-CoV-2 replication in vitro indicated that the

218 therapeutic dosage of DIP may potentiate effective antiviral responses in infected patients. These

219 findings are in concordance with our clinical findings of the overall remarkable outcomes in the

220 severely ill patients receiving two weeks of DIP adjunctive therapy. All the 8 DIP-treated severely ill

221 patients showed remarkable improvement after DIP treatment, with 87.5% discharged from the

222 hospitals and a further 12.5% showing clinical remission. In contrast, for the 12 severely ill patients in

223 the control group, only 33.3% were discharged and death occurred in 16.7%.

224

9
225 In a recent publication describing 1099 patients with COVID-19, D-dimer concentrations were

226 elevated in 40% and 60% of the non-severe and severe cases at hospital admission (21). It has been

227 reported that a D-dimer concentration greater than 1 mg/L on admission was associated with

228 significantly increased risk of mortality for patients with COVID-19 (22). We found that DIP

229 adjunctive treatment blunted the increase in D-dimer concentrations, and increased the circulating

230 platelet and leucocytes counts. High concentrations of D-dimers are closely correlated with pulmonary

231 embolism (42), vascular thrombosis, and renal dysfunction (43). It is a crucial prognostic factor and is

232 important to determine whether ICU-patients recover from severe infections (44, 45). Thus,

233 prophylactic anti-coagulation therapy with DIP should be considered in patients with COVID-19 to

234 reduce the risk of hypercoagulability and multi-organ damage.

235

236 It should be mentioned that several factors have limited our ability to fully investigate the therapeutic

237 effects of DIP adjunctive therapy, these include the small number of enrolled patients, the lack of

238 resources to quantify viral replication, and the requirement to follow the treatment guidelines under

239 the circumstances of SARS-CoV-2 outbreak. However, we advocate further trials for DIP adjunctive

240 therapy for patients with COVID-19, particularly for those with early signs of elevated concentrations

241 of D-dimer. DIP has been used world-wide to treat coagulopathy. Additionally, it also exerts anti-

242 inflammatory and antiviral effects in experimental settings and clinical trials. The wide availability,

243 safety, and affordability of DIP argue for further investigation into its therapeutic use in COVID-19,

244 particularly as SARS-CoV-2 infection has been declared a global pandemic.

245

246 Methods

247 Ethics statement

248 The Ethics Committees from Zhongnan Hospital of Wuhan University, Dawu County People's

10
249 Hospital, and the First Affiliated Hospital of Guangzhou Medical University approved the study and

250 all patients signed informed consents. Clinical trial (ChiCTR2000030055) was registered.

251

252 Study design

253 An open label clinical study involving 31 patients was conducted in Dawu County People's Hospital

254 (1st hospital) and Huangpo Chinese Medicine Hospital (2nd hospital), Hubei province, China (from

255 February 3 to March 8, 2020). We recruited 12 patients and 10 controls from the 1st hospital, and 2

256 patients and 7 controls from the 2nd hospital. Patients were treated in different isolation wards by

257 different attending physicians. Standard treatment procedures were applied for all patients according

258 to the guidelines formulated by the Chinese General Office of National Health Committee. DIP was

259 used in all patients of the selected wards by two specialists each from the two hospitals. Patients from

260 other wards without DIP adjunctive therapy were recruited as controls. Informed written consents were

261 obtained from all patients. The condition of the patients was monitored daily by the attending

262 physicians. Routine laboratory test of the coagulation variables and blood indexes were carried out

263 before, during, and after the treatment. Clinical symptoms and laboratory data were independently

264 validated by two independent investigators for assurance of data accuracy.

265

266 SARS-CoV-2 RNA test by RT-PCR

267 SARS-CoV-2 RNA from nasopharyngeal swabs were detected upon request of the charging physicians

268 by the local Centers for Disease Control and Prevention. Only qualitative data were available for the

269 patients.

270

271 Disease severity assessment

11
272 All patients had positive RT-PCR test of SARS-CoV-2 RNA from the nasopharyngeal swab specimens,

273 performed by the local Chinese Center for Disease Prevention and Control. The diagnosis of severe

274 case was made if patients met any of the following criteria: (1) respiratory rate ≥ 30 breaths/min; (2)

275 SpO2 ≤ 93% while breathing room air; (3) PaO2/FiO2 ≤ 300 mmHg. A critically ill case was diagnosed

276 if any of the following criteria was met: (1) respiratory failure which requiring mechanical ventilation;

277 (2) shock; (3) combined with other organ failure and need to be admitted to ICU.

278

279 Retrospective analysis of the coagulation indices in 124 patients

280 As of February 8, 2020, 124 confirmed COVID-19 cases had been identified from Zhongnan Hospital

281 of Wuhan University (Table S1). All patients met the diagnostic criteria of "Diagnosis and Treatment

282 Scheme of Novel Coronavirus–Infected Pneumonia (trial 6th)" formulated by the General Office of

283 National Health Committee (46). A retrospective review of the medical records of these patients was

284 conducted to retrieve coagulation indexes and platelet parameters, including prothrombin time (PT),

285 activated partial thromboplastin time (APTT), plasma fibrinogen (FIB), D-dimer, platelet (PLT) count,

286 and mean platelet volume (MPV). Systemic inflammation was assessed according to the C-reactive

287 protein (CRP), procalcitonin (PCT), and interleukin 6 (IL-6) concentrations.

288

289 Treatment procedures

290 Anticoagulant therapy was provided via oral DIP tablets. The daily treatment protocol comprised of

291 150 mg in three separate doses for 14 consecutive days. All patients were monitored daily for possible

292 adverse events. All patients received antiviral (ribavirin, 0.5 g, Q12h), corticoid (methylprednisolone

293 sodium succinate, 40 mg, qid), oxygen therapy, and nutritional support as necessary. Patients with

294 diabetes were treated with insulin injections (Table 1), and those with cardiovascular diseases were

12
295 treated with nifedipine. Other patients with cerebrovascular diseases were treated with aspirin.

296 Free energy perturbation prediction

297 We virtually screened an FDA-approved drug database using the SARS-CoV-2 protease Mpro as a

298 drug target. DIP (PubChem CID: 3108, Figure 1A) was identified as a lead drug. In order to obtain

299 the binding pattern and calculate the binding free energy between DIP and Mpro, DIP was firstly

300 docked onto Mpro by using Glide, and the optimal binding pose (Figure S1) was further assessed by

301 absolute binding free energy calculation with free energy perturbation (47). The calculations were

302 carried out in Gromacs 2019, and the thermodynamic cycle and procedure was similar to that used by

303 Matteo et al (48). In the calculation, the ligand electrostatic and van der Waals interactions were

304 decoupled using a linear alchemical pathway with Δλ = 0.10 for the van der Waals and Δλ = 0.20 for

305 electrostatic interactions. Restraints were added for keeping the relative position between receptor and

306 ligand, which consist of one distance, two angles, and three dihedrals harmonic potentials with a force

307 constant of 10 kcal/mol/Å2 [rad2]. The distance and angles for the restraints were determined by the

308 values of the last 2 ns of the 4 ns preliminary MD simulations. In the FEP calculations, 4 ns simulations

309 were performed for each window. The sampled ΔU in the simulations were fitted by Gaussian

310 algorithms and the free energy estimates were obtained by using the Bennet acceptance ratio (BAR)

311 method (49).

312

313 Foci forming assay

314 Vero E6 cells were seeded in 96-well plates. The cells were pretreated with different dosages of DIP

315 or chloroquine for an hour before infected with SARS-CoV2 200 foci forming units (FFU) per well，

316 and overlaid with 1.6% carboxymethylcellulose with different dosages of DIP or chloroquine. After

317 24 hours incubation, cells were fixed with 4% paraformaldehyde and permeabilized with 0.2% Triton

13
318 X-100. And then incubated with a rabbit anti- SARS-CoV 2 nucleocapsid protein polyclonal antibody

319 (Sino Biological), followed by a HRP-labelled goat anti-rabbit secondary antibody (Jackson). The foci

320 were visualized by TrueBlue reagent, and counted with an ELISPOT reader (CTL S6 Ultra). Viral

321 titers were calculated as FFU per ml.

322

323 Statistical analysis

324 Statistical analyses and graphics production were performed using R v3.5.3 (Foundation for Statistical

325 Computing) and GraphPad Prism 8. Categorical variables were described as frequencies or percentages,

326 and continuous variables were shown as mean with standard deviation/error. Comparison for two

327 independent groups was conducted using Student’s t test (for normally distributed data) or Mann-

328 Whitney test (for non-normally distributed data). Comparison for laboratory indices between the DIP-

329 treatment and control groups during the treatment course was conducted using generalized mixed

330 linear model. Logistic regression was performed to identify factors associated with the clinical

331 outcomes. P < 0.05 was considered statistically significant. Detailed descriptions of data comparison

332 and statistical tests were specified in the figure legends.

333

334 Reference:
335 1. N. Chen, M. Zhou, X. Dong, J. Qu, F. Gong, Y. Han, Y. Qiu, J. Wang, Y. Liu, Y. Wei, J. Xia, T. Yu, X. Zhang, L.
336 Zhang, Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan,
337 China: a descriptive study. Lancet 395, 391-393 (2020).
338 2. C. Huang, Y. Wang, X. Li, L. Ren, J. Zhao, Y. Hu, L. Zhang, G. Fan, J. Xu, X. Gu, Z. Cheng, T. Yu, J. Xia, Y. Wei, W.
339 Wu, X. Xie, W. Yin, H. Li, M. Liu, Y. Xiao, H. Gao, L. Guo, J. Xie, G. Wang, R. Jiang, Z. Gao, Q. Jin, J. Wang, B.
340 Cao, Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 395, 497-506 (2020).
341 3. M. L. Holshue, C. DeBolt, S. Lindquist, K. H. Lofy, J. Wiesman, H. Bruce, C. Spitters, K. Ericson, S. Wilkerson, A.
342 Tural, G. Diaz, A. Cohn, L. Fox, A. Patel, S. I. Gerber, L. Kim, S. Tong, X. Lu, S. Lindstrom, M. A. Pallansch, W. C.
343 Weldon, H. M. Biggs, T. M. Uyeki, S. K. Pillai, V. C. I. T. Washington State -nCo, First Case of 2019 Novel
344 Coronavirus in the United States. N Engl J Med, (2020). DOI: 10.1056/NEJMoa2001191
345 4. J. F. Chan, K. H. Kok, Z. Zhu, H. Chu, K. K. To, S. Yuan, K. Y. Yuen, Genomic characterization of the 2019 novel
346 human-pathogenic coronavirus isolated from a patient with atypical pneumonia after visiting Wuhan. Emerg Microbes

14
347 Infect 9, 221-236 (2020).
348 5. A. Wu, Y. Peng, B. Huang, X. Ding, X. Wang, P. Niu, J. Meng, Z. Zhu, Z. Zhang, J. Wang, J. Sheng, L. Quan, Z. Xia,
349 W. Tan, G. Cheng, T. Jiang, Genome composition and divergence of the novel coronavirus (2019-nCoV) originating
350 in China. Cell Host Microbe, (2020). DOI: 10.1016/j.chom.2020.02.001
351 6. K. Kuba, Y. Imai, S. Rao, H. Gao, F. Guo, B. Guan, Y. Huan, P. Yang, Y. Zhang, W. Deng, L. Bao, B. Zhang, G. Liu,
352 Z. Wang, M. Chappell, Y. Liu, D. Zheng, A. Leibbrandt, T. Wada, A. S. Slutsky, D. Liu, C. Qin, C. Jiang, J. M.
353 Penninger, A crucial role of angiotensin converting enzyme 2 (ACE2) in SARS coronavirus-induced lung injury. Nat
354 Med 11, 875-879 (2005).
355 7. R. Lu, X. Zhao, J. Li, P. Niu, B. Yang, H. Wu, W. Wang, H. Song, B. Huang, N. Zhu, Y. Bi, X. Ma, F. Zhan, L. Wang,
356 T. Hu, H. Zhou, Z. Hu, W. Zhou, L. Zhao, J. Chen, Y. Meng, J. Wang, Y. Lin, J. Yuan, Z. Xie, J. Ma, W. J. Liu, D.
357 Wang, W. Xu, E. C. Holmes, G. F. Gao, G. Wu, W. Chen, W. Shi, W. Tan, Genomic characterisation and epidemiology
358 of 2019 novel coronavirus: implications for virus origins and receptor binding. Lancet 395, 565-574 (2020).
359 8. R. P. Marshall, The pulmonary renin-angiotensin system. Curr Pharm Des 9, 715-722 (2003).
360 9. Y. Imai, K. Kuba, S. Rao, Y. Huan, F. Guo, B. Guan, P. Yang, R. Sarao, T. Wada, H. Leong-Poi, M. A. Crackower, A.
361 Fukamizu, C. C. Hui, L. Hein, S. Uhlig, A. S. Slutsky, C. Jiang, J. M. Penninger, Angiotensin-converting enzyme 2
362 protects from severe acute lung failure. Nature 436, 112-116 (2005).
363 10. L. Kalinowski, T. Matys, E. Chabielska, W. Buczko, T. Malinski, Angiotensin II AT1 receptor antagonists inhibit
364 platelet adhesion and aggregation by nitric oxide release. Hypertension 40, 521-527 (2002).
365 11. T. Chung, D. Connor, J. Joseph, L. Emmett, R. Mansberg, M. Peters, D. Ma, L. Kritharides, Platelet activation in
366 acute pulmonary embolism. J Thromb Haemost 5, 918-924 (2007).
367 12. K. Yamamoto, M. Ohishi, T. Katsuya, N. Ito, M. Ikushima, M. Kaibe, Y. Tatara, A. Shiota, S. Sugano, S. Takeda, H.
368 Rakugi, T. Ogihara, Deletion of angiotensin-converting enzyme 2 accelerates pressure overload-induced cardiac
369 dysfunction by increasing local angiotensin II. Hypertension 47, 718-726 (2006).
370 13. G. Y. Oudit, A. M. Herzenberg, Z. Kassiri, D. Wong, H. Reich, R. Khokha, M. A. Crackower, P. H. Backx, J. M.
371 Penninger, J. W. Scholey, Loss of angiotensin-converting enzyme-2 leads to the late development of angiotensin II-
372 dependent glomerulosclerosis. Am J Pathol 168, 1808-1820 (2006).
373 14. M. A. Crackower, R. Sarao, G. Y. Oudit, C. Yagil, I. Kozieradzki, S. E. Scanga, A. J. Oliveira-dos-Santos, J. da Costa,
374 L. Zhang, Y. Pei, J. Scholey, C. M. Ferrario, A. S. Manoukian, M. C. Chappell, P. H. Backx, Y. Yagil, J. M. Penninger,
375 Angiotensin-converting enzyme 2 is an essential regulator of heart function. Nature 417, 822-828 (2002).
376 15. T. Hashimoto, T. Perlot, A. Rehman, J. Trichereau, H. Ishiguro, M. Paolino, V. Sigl, T. Hanada, R. Hanada, S. Lipinski,
377 B. Wild, S. M. Camargo, D. Singer, A. Richter, K. Kuba, A. Fukamizu, S. Schreiber, H. Clevers, F. Verrey, P.
378 Rosenstiel, J. M. Penninger, ACE2 links amino acid malnutrition to microbial ecology and intestinal inflammation.
379 Nature 487, 477-481 (2012).
380 16. G. Y. Oudit, Z. Kassiri, C. Jiang, P. P. Liu, S. M. Poutanen, J. M. Penninger, J. Butany, SARS-coronavirus modulation
381 of myocardial ACE2 expression and inflammation in patients with SARS. Eur J Clin Invest 39, 618-625 (2009).
382 17. J. S. Peiris, Y. Guan, K. Y. Yuen, Severe acute respiratory syndrome. Nat Med 10, S88-97 (2004).
383 18. J. S. Peiris, K. Y. Yuen, A. D. Osterhaus, K. Stohr, The severe acute respiratory syndrome. N Engl J Med 349, 2431-
384 2441 (2003).
385 19. D. Wang, B. Hu, C. Hu, F. Zhu, X. Liu, J. Zhang, B. Wang, H. Xiang, Z. Cheng, Y. Xiong, Y. Zhao, Y. Li, X. Wang,
386 Z. Peng, Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in
387 Wuhan, China. JAMA, (2020). DOI: 10.1001/jama.2020.1585
388 20. Y. Liu, Y. Yang, C. Zhang, F. Huang, F. Wang, J. Yuan, Z. Wang, J. Li, J. Li, C. Feng, Z. Zhang, L. Wang, L. Peng, L.
389 Chen, Y. Qin, D. Zhao, S. Tan, L. Yin, J. Xu, C. Zhou, C. Jiang, L. Liu, Clinical and biochemical indexes from 2019-
390 nCoV infected patients linked to viral loads and lung injury. Sci China Life Sci, (2020). DOI: 10.1007/s11427-020-
391 1643-8

15
392 21. W. J. Guan, Z. Y. Ni, Y. Hu, W. H. Liang, C. Q. Ou, J. X. He, L. Liu, H. Shan, C. L. Lei, D. S. C. Hui, B. Du, L. J. Li,
393 G. Zeng, K. Y. Yuen, R. C. Chen, C. L. Tang, T. Wang, P. Y. Chen, J. Xiang, S. Y. Li, J. L. Wang, Z. J. Liang, Y. X.
394 Peng, L. Wei, Y. Liu, Y. H. Hu, P. Peng, J. M. Wang, J. Y. Liu, Z. Chen, G. Li, Z. J. Zheng, S. Q. Qiu, J. Luo, C. J. Ye,
395 S. Y. Zhu, N. S. Zhong, C. China medical treatment expert group for, clinical characteristics of coronavirus disease
396 2019 in China. N Engl J Med, (2020). DOI: 10.1056/NEJMoa2002032
397 22. F. Zhou, R. Du, G. Fan, Y. Liu, Z. Liu, J. Xiang, Y. Wang, B. Song, X. Gu, L. Guan, Y. Wei, H. Li, X. Wu, J. Xu, S.
398 Tu, Y. Zhang, H. Chen, B. Cao, Clinical course and risk factors for mortality of adult inpatients with COVID-19 in
399 Wuhan, China: a retrospective cohort study. The Lancet, (2020). DOI: 10.1016/S0140-6736(20)30566-3
400 23. A. O. Adedeji, S. G. Sarafianos, Antiviral drugs specific for coronaviruses in preclinical development. Curr Opin
401 Virol 8, 45-53 (2014).
402 24. P. Gresele, S. Momi, E. Falcinelli, Anti-platelet therapy: phosphodiesterase inhibitors. Br J Clin Pharmacol 72, 634-
403 646 (2011).
404 25. E. Tonew, M. K. Indulen, D. R. Dzeguze, Antiviral action of dipyridamole and its derivatives against influenza virus
405 A. Acta Virol 26, 125-129 (1982).
406 26. C. L. Fata-Hartley, A. C. Palmenberg, Dipyridamole reversibly inhibits mengovirus RNA replication. J Virol 79,
407 11062-11070 (2005).
408 27. R. B. Tenser, A. Gaydos, K. A. Hay, Inhibition of herpes simplex virus reactivation by dipyridamole. Antimicrob
409 Agents Chemother 45, 3657-3659 (2001).
410 28. J. Szebeni, S. M. Wahl, M. Popovic, L. M. Wahl, S. Gartner, R. L. Fine, U. Skaleric, R. M. Friedmann, J. N. Weinstein,
411 Dipyridamole potentiates the inhibition by 3'-azido-3'-deoxythymidine and other dideoxynucleosides of human
412 immunodeficiency virus replication in monocyte-macrophages. Proc Natl Acad Sci U S A 86, 3842-3846 (1989).
413 29. M. S. Kozhukharova, A. N. Slepushkin, T. Radeva Kh, L. A. Lavrukhina, S. A. Demidova, [Evaluation of
414 dipyridamole efficacy as an agent for preventing acute respiratory viral diseases]. Vopr Virusol 32, 294-297 (1987).
415 30. K. Kuzmov, A. S. Galabov, K. Radeva, M. Kozhukharova, K. Milanov, [Epidemiological trial of the prophylactic
416 effectiveness of the interferon inducer dipyridamole with respect to influenza and acute respiratory diseases]. Zh
417 Mikrobiol Epidemiol Immunobiol, 26-30 (1985).
418 31. H. Xie, Efficacy of dipyridamole in the treatment of 116 children with acute upper respiratory tract infections. Chin
419 J Sch Doc 24, 921-921 (2010).
420 32. X. Hu, X. Wang, Treatment of viral upper respiratory tract infection in children with dipyridamole. Chin J Hospital
421 Pharmacy 15, 401-401 (1995).
422 33. Y. Sui, Clinical observation of 45 cases of upper respiratory tract infection treated with dipyridamole. The Medical
423 Forum 000, 4360-4361 (2014).
424 34. B. Huang, Z. Chen, L. Geng, J. Wang, H. Liang, Y. Cao, H. Chen, W. Huang, M. Su, H. Wang, Y. Xu, Y. Liu, B. Lu,
425 H. Xian, H. Li, H. Li, L. Ren, J. Xie, L. Ye, H. Wang, J. Zhao, P. Chen, L. Zhang, S. Zhao, T. Zhang, B. Xu, D. Che,
426 W. Si, X. Gu, L. Zeng, Y. Wang, D. Li, Y. Zhan, D. Delfouneso, A. M. Lew, J. Cui, W. H. Tang, Y. Zhang, S. Gong,
427 F. Bai, M. Yang, Y. Zhang, Mucosal profiling of pediatric-onset colitis and IBD reveals common pathogenics and
428 therapeutic pathways. Cell 179, 1160-1176 e1124 (2019).
429 35. P. A. Insel, F. Murray, U. Yokoyama, S. Romano, H. Yun, L. Brown, A. Snead, D. Lu, N. Aroonsakool, cAMP and
430 Epac in the regulation of tissue fibrosis. Br J Pharmacol 166, 447-456 (2012).
431 36. Z. Jin, X. Du, Y. Xu, Y. Deng, M. Liu, Y. Zhao, B. Zhang, X. Li, L. Zhang, Y. Duan, J. Yu, L. Wang, K. Yang, F. Liu,
432 T. You, X. Liu, X. Yang, F. Bai, H. Liu, X. Liu, L. W. Guddat, G. Xiao, C. Qin, Z. Shi, H. Jiang, Z. Rao & H. Yang,
433 Structure-based drug design, virtual screening and high-throughput screening rapidly identify antiviral leads targeting
434 COVID-19. bioRxiv, (2020). DOI: 10.1101/2020.02.26.964882
435 37. M. J. Vincent, E. Bergeron, S. Benjannet, B. R. Erickson, P. E. Rollin, T. G. Ksiazek, N. G. Seidah, S. T. Nichol,
436 Chloroquine is a potent inhibitor of SARS coronavirus infection and spread. Virol J 2, 69 (2005).

16
437 38. M. Wang, R. Cao, L. Zhang, X. Yang, J. Liu, M. Xu, Z. Shi, Z. Hu, W. Zhong, G. Xiao, Remdesivir and chloroquine
438 effectively inhibit the recently emerged novel coronavirus (2019-nCoV) in vitro. Cell Res 30, 269–271 (2020).
439 39. T. D. Bjornsson, C. Mahony, Clinical pharmacokinetics of dipyridamole. Thromb Res Suppl 4, 93-104 (1983).
440 40. V. Serebruany, E. Sabaeva, C. Booze, O. D. Atar, C. Eisert, D. Hanley, F. Aggrenox Compliance Task, Distribution
441 of dipyridamole in blood components among post-stroke patients treated with extended release formulation. Thromb
442 Haemost 102, 538-543 (2009).
443 41. Y. Imai, K. Kuba, J. M. Penninger, The discovery of angiotensin-converting enzyme 2 and its role in acute lung injury
444 in mice. Exp Physiol 93, 543-548 (2008).
445 42. J. A. Kline, J. S. Garrett, E. J. Sarmiento, C. C. Strachan, D. M. Courtney, Over-testing for suspected pulmonary
446 embolism in American emergency departments: The Continuing Epidemic. Circ Cardiovasc Qual Outcomes 13,
447 e005753 (2020).
448 43. J. C. Schefold, J. L. Gerber, M. C. Angehrn, M. Muller, A. S. Messmer, A. B. Leichtle, G. M. Fiedler, A. K.
449 Exadaktylos, C. A. Pfortmueller, Renal function-adjusted D-Dimer levels in critically ill Patients with suspected
450 thromboembolism. Crit Care Med, (2020). DOI: 10.1097/CCM.0000000000004204
451 44. J. Zhou, W. Mao, L. Shen, H. Huang, Plasma D-dimer as a novel biomarker for predicting poor outcomes in HBV-
452 related decompensated cirrhosis. Medicine (Baltimore) 98, e18527 (2019).
453 45. O. Adekanmbi, S. Lakoh, A favorable outcome of dengue hemorrhagic fever despite poor prognostic indices: a case
454 report with a mix of classic and unusual clinical and laboratory features. Pan Afr Med J 34, 74 (2019).
455 46. Chinese General Office of National Health Committee, Diagnosis and treatment scheme of novel coronavirus-infected
456 pneumonia (trial version 6). Http://www.nhc.gov.cn, (2020).
457 47. Z. Li, Y. Huang, Y. Wu, J. Chen, D. Wu, C. G. Zhan, H. B. Luo, Absolute binding free energy calculation and design
458 of a subnanomolar inhibitor of phosphodiesterase-10. J Med Chem 62, 2099-2111 (2019).
459 48. M. Aldeghi, A. Heifetz, M. J. Bodkin, S. Knapp, P. C. Biggin, Accurate calculation of the absolute free energy of
460 binding for drug molecules. Chem Sci 7, 207-218 (2016).
461 49. C. HBennett, Efficient estimation of free energy differences from Monte Carlo data. J Comput Phys 22, 245-268
462 (1976).
463

464 SUPPLEMENTARY MATERIALS

465 Table S1. Clinical variables in 124 patients with COVID-19.

466 Table S2. CT images of the DIP-treated and control patients.

467 Figure S1. The putative binding pattern of dipyridamole (DIP) and the SARS-CoV-2 protease Mpro

468 after molecular docking.

469

470 Acknowledgments: We cordially acknowledge Tencent Cloud and National Supercomputing centers

471 in Guangzhou, Shenzhen, and Tianjin for providing HPC resources for virtual screening and free

17
472 energy perturbation calculations, and Prof. H. Ke at the University of North Carolina, Chapel Hill for

473 comments.

474 Funding: Zhejiang University special scientific research fund for COVID-19 prevention and control,

475 National Health & Medical Research of Australia (1080321, 1143976, and 1150425), Taikang

476 Insurance Group Co., Ltd and Beijing Taikang Yicai Foundation, and philanthropy donation from

477 individuals. The funders had no roles in the design and execution of the study.

478 Contributors: JZ, XH, YZ, FZ, and HBL co-designed the study and co-led overall data interpretation.

479 SL, XL, YW, QZ, YS, BX, and JM provided patient care and collected clinical data. ZL, XW, JC, HH,

480 and YH performed the virtual screening and enzymatic assay, JS and JZ performed viral suppression

481 assay. ZC, YZ, and HBL analyzed data and generated the tables and figures. YZ drafted the manuscript

482 with significant input from AML. All authors interpreted the results and critically revised the

483 manuscript for scientific content. All authors approved the final version of the article.

484 Competing interests: There are no conflict of interests for all authors.

485 Data and materials availability: All data associated with this study are present in the paper or

486 Supplementary Materials.

487

18
488 Figure Legends
489 Figure 1. Suppressive effects of DIP and chloroquine on SARS-CoV-2 replication in vitro. (A)
490 Chemical structure of DIP. (B) Enzyme activity of Mpro in the presence of ascending concentrations
491 of DIP. (C) Dose-dependent suppression of SARS-CoV-2 replication by DIP and chloroquine in vitro.
492 Virus titers were measured by Foci forming assay, inhibition rates were performed by indirect
493 immunoinfluscent assay, and calculated inhibition rate of different dosages of DIP or chloroquine
494 compared with virus control. P values were calculated by ANOVA.
495

496 Figure 2. Changes of the study variables during the course of treatment. Dynamic changes in the
497 routine blood indexes (LYM, NEU, HGB, and PLT) and coagulation variable (D-dimer) in reference
498 to the baseline values. Data are shown as the means ±SE across different time bins during the treatment
499 course. The comparison for each index between the DIP and control groups during the treatment was
500 conducted by generalized mixed linear model. For each specific time bin, comparison for variables
501 between the two groups was conducted using Student’s t test (*, P < 0.05).
502

503 Figure 3. Changes of D-dimer and oxygen saturation in the two severely ill patients who received
504 DIP treatment. Schematics of the treatment overview and clinical parameters of the deceased
505 critically ill patient (top) and the surviving patient (bottom) who received DIP adjunctive therapy.
506

507 Figure 4. Chest CT images in the axial (left panel) and coronal view (right panel) of represented
508 patients with severe COVID-19. (A) Chest CT scans at -10 day, -5 day, -2 day, +2 day, and +7 day
509 of a patient received DIP treatment. (B) Chest CT scans at +3 day, +8 day, +15 day, and +21 day of a
510 control patient.
511
512
513

19
514
Table 1. Baseline characteristics of the 31 enrolled patients
Variable Dipyridamole group Control group
(n = 14) (n = 17)
General Characteristic
Age (yr) — mean±sd (range) 56±12 (32-74) 56±15 (23-74)
Gender— male no. / female no. 8/6 13 / 4
Group
Non-severe no. / Severe no. / Critical no. 4/8/2 3 / 12 / 2
Clinical variables
Cough— no. (%) 14 (100.0%) 17 (100.0%)
Shortness of breath — no. (%) 11 (78.6%) 13 (76.5%)
Nausea and vomiting— no. (%) 8 (57.1%) 6 (35.3%)
Systolic blood pressure (mmHg) 127±12 (120-155) 128±13 (107-153)
— mean±sd (range) /81±11 (57-124) /78±10 (56-96)

Partial pressure of oxygen (mmHg)

86±12 (58-93) 92±9 (76-96)
— mean±sd (range)
Laboratory values
1.07±0.57 0.82±0.45
Lymphocyte (109/L) — mean±sd (range)
(0.29-2.28) (0.17-1.85)
Decrease in concentrations of Lymphocyte
9 (64.3%) 12 (70.6%)
— no. (%)
— no. of non-severe cases (%) 1 /4 (25%) 2/3 (66.7%)
— no. of severe cases (%) 7/8 (87.5%) 9/12 (75%)
— no. of critical cases (%) 1/2 (50%) 1/2 (50%)
D-dimer (mg/L) — mean±sd (range) 2.00±2.54 1.50±2.73
(0.19-6.84) (0.01-8.43)
Increase in concentrations of D-dimer
— no. (%) 6/14 (42.9%) 5/17 (29.4%)
— no. of non-severe cases (%) 1/4 (25%) 0
— no. of severe cases (%) 4/8 (50%) 5/12 (41.7%)
— no. of critical cases (%) 1/2 (50%) 0
Respiratory pathogens
The nucleic acid of SARS-CoV-2 — no. (%) 14 (100.0%) 17 (100.0%)
Unilateral pneumonia — no. (%) 0 1 (5.9%)
Bilateral pneumonia — no. (%) 14 (100.0%) 16 (94.1%)
Comorbidities
Diabetes mellitus — no. (%) 3 (21.4%) 1 (5.9%)
Cardiovascular disease — no. (%) 2 (14.3%) 3 (17.6%)
Cerebrovascular disease — no. (%) 1 (7.1%) 2 (11.8%)
515

20
516

Table 2. Treatment and clinical outcomes of 31 enrolled patients

Dipyridamole group Control group

Variable
(n = 14) (n = 17)
Group
— Non-severe no. / Severe no. / Critical no. 4/8/2 3 / 12 / 2
Treatment
Oxygen therapy — no. (%) 14 (100.0%) 17 (100.0%)
Mechanical ventilation — no. (%) 2 (14.3%) 2 (11.8%)
— no. of non-severe cases (%) 0 0
— no. of severe cases (%) 0 1/12 (8.3%)
— no. of critical cases (%) 2/2(100%) 1/2 (50%)
Antibiotic treatment — no. (%) 6 (42.9%) 10 (58.8%)
Antifungal treatment — no. (%) 0 0
Antiviral treatment — no. (%) 14 (100.0%) 17 (100.0%)
Glucocorticoids — no. (%) 14 (100.0%) 17 (100.0%)
Outcome
Discharge rate — no. (%) 11/14 (78.6%) 7/17 (41.2%)
— no. of non-severe cases (%) 4/4 (100%) 3/3 (100%)
— no. of severe cases (%) 7/8 (87.5%) 4/12 (33.3%)
— no. of critical cases (%) 0 0
Average time for viral clearance (days) - -
— severe cases (%) 15.4 17.0
Remission rate — no. (%) 2/14 (14.3%) 2/17 (11.8%)
— no. of severe cases (%) 1/8 (12.5%) 2/12 (16.7%)
— no. of critical cases (%) 1/2 (50%) 0
Progression rate — no. (%) 0 1 /17 (5.9%)
— no. of non-severe cases (%) 0 0
— no. of severe cases (%) 0 1/12 (8.3%)
Death rate — no. (%) 1/14 (7.1%) 4/17 (23.5%)
— no. of severe cases (%) 0 2/12 (8.3%)
— no. of critical cases (%) 1/2 (50%) 2/2 (100%)
517

Table 3. Multivariate analyses of clinical outcome associated factors

Gender Dipyridamole Ventilation Antibiotic IVIG
Variable Age
(M vs F) (Yes vs No) (Yes vs No) (Yes vs No) (Yes vs No)
Coefficients 0.01 0.81 3.17 -20.45 -3.59 0.86
Odd ratio 1.01 2.24 23.75 0 0.03 2.37
95% CI 0.92-1.11 0.09-55.44 0.87-648 0- 0-0.59 0.09-65.08
P value 0.918 0.623 0.06 0.995 0.022 0.609

518

21
519 Figure 1

520

521 Figure 2

522

523

524

525

22
526 Figure 3.

527
528

23
529 Figure 4.

530

531

532

533

24
534 Graphic abstract

535

25
Table S1. Clinical variables in 124 patients with COVID-19
Variable Normal Non-severe (n=87) Severe (n=25) Critical (n=12) Total (n=124) Total Total
range — mean±sd — mean±sd — mean±sd — mean±sd Increased Decreased
(range) (range) (range) (range) — no. (%) — no. (%)
PLT (109/L) 125-350 193.5±70.5 187.6±100.0 187.3±103.7 191.7±80.0 3 25
(83-396) (54-525) (85-442) (54-525) (2.4%) (20.2%)
Lymphocyte (109/L) 1.1-3.2 1.1±0.3 *0.8±0.3 *0.6±0.4 0.9±0.6 - -
(0.1-5.0) (0.3-1.7) (0.3-1.4) (0.1-5.0)
— Decrease no. (%) - 57 22 10 - 2 89
(65.5%) (88.0%) (83.3%) (1.6%) (71.8%)
MPV (fL) 6-12 9.1±1.2 9.1±1.5 9.4±1.7 9.1±1.3 1 0
(6.6-11.9) (7.3-12.3) (6.6-11.2) (6.6-12.3) (0.8%)
PT (S) 9.4-12.5 12.9±1.4 13.0±1.5 13.3±1.6 13.0±1.4 77 1
(8.6-17.8) (11.1-17.6) (11.4-15.8) (8.6-17.8) (62.1%) (0.8%)
APTT (S) 25.1-36.5 30.4±3.1 30.4±2.5 29.3±4.5 30.3±3.2 2 9
(22.9-38.1) (26.6-34.8) (22.4-35.3) (22.4-38.1) (1.6%) (7.3%)
FIB (mg/dL) 238-498 430.2±80.3 428.9±91.0 428.8±139.4 429.8±88.7 27 2
(256-717) (214-582) (203-750) (203-750) (21.8%) (1.6%)
D-dimer (g/L) 0-500 746.5±2279.7 1178.4±4267.5 *4138.3±7506.7 1168.6±3652.7 - -
(59-18825) (35-21611) (82-26315) (35-26315)
— Increase no. (%) - 15 4 7 - 26 -
(17.2%) (16.0%) (58.3%) (21.0%)
CRP (mg/L) 0-10 37.0±43.4 *61.5±63.8 *75.0±59.4 46.0±51.4 80 -
(0.4-173.7) (0.7-290.1) (11.6-203.7) (0.4-290.1) (64.5%)
PCT (ng/mL) < 0.05 0.2±0.2 0.3±0.3 0.2±0.2 0.2±0.2 38 -
(<0.05-0.65) (<0.05-0.94) (0.07-0.52) (<0.05-0.94) (30.6%)
IL-6 (pg/mL) 0-7 39.3±71.1 55.6±44.4 *81.4±65.6 48.3±66.5 79 -
(2.03-522.2) (2.64-180.5) (7.69-204.3) (2.03-522.2) (63.7%)
*, P < 0.05 when compared to the non-severe group
Table S2. CT images of the DIP-treated and control patients.
DIP group Case and Status CT image when hospitalized CT image during the course of
treatment
N0.1 non-severe case, discharged

Feb. 09 Mar. 02
N0.2 non-severe case, discharged

Jan. 24 Feb. 09
N0.3 non-severe case, discharged
 Jan. 24 Feb. 15

N0.4 non-severe case, discharged

Feb. 02 Feb. 18
N0.5 severe case, discharged

Feb. 01 Feb. 10
N0.6 severe case, discharged

Jan. 31 Feb. 17
N0.7 severe case, discharged

Feb. 07 Feb. 23
N0.8 severe case, discharged

Feb. 11 Feb. 24
N0.9 severe case, discharged

Feb. 10 Mar. 01
N0.10 severe case, discharged

Feb. 10 Feb. 27
N0.11 severe case, discharged

Feb. 17 Mar. 08
N0.12 severe case, in remission

Feb. 15 Mar. 04
N0.13 critical case, in remission No image*

N0.14 critical case, died No image*

Control group Case and Status CT image when hospitalized CT image during the course of
treatment
N0.1 non-severe case, discharged

Feb. 07 Feb. 17
N0.2 non-severe case, discharged

Feb. 02 Feb. 07
N0.4 non-severe case, discharged

Feb. 05 Feb. 22
N0.5 severe case, discharged

Feb. 10 Feb. 20
N0.3 severe case, discharged

Feb. 16 Feb. 22
N0.6 severe case, discharged

Jan. 31 Feb. 09
N0.7 severe case, discharged

Feb. 14 Mar. 03
N0.8 severe case NO image*

N0.9 severe case

Feb. 23 Mar. 04
N0.10 severe case

Feb. 05 Mar. 05
N0.11 severe case

Feb. 28 Mar. 07
N0.12 severe case

Feb. 18
N0.13 severe case

Feb. 03 Mar. 05
N0.14 severe case NO image#

N0.15 severe case NO image#

 N0.16 critical case, died

Feb. 06 Feb. 22
N0.17 critical case, died NO image*

*，These patients were in critical condition without CT and without bedside chest film when hospitalized.

#
，These patients were transferred from other hospitals, and we can't obtain the CT images.
Figure S1. The putative binding pattern of dipyridamole (DIP) and the SARS-CoV-2 protease Mpro after molecular docking. Red dotted

line represents H-bond.