The antimicrobial medication malarone (atovaquone/proguanil) is used as a fixed-dose
combination for treating children and adults with uncomplicated malaria or as
chemoprophylaxis for preventing malaria in travelers. It is an inexpensive, efficacious,
and safe drug frequently prescribed around the world. Following anecdotal evidence from
17 patients in the provinces of Quebec and Ontario, Canada, suggesting that
malarone/atovaquone may present some benefits in protecting against COVID-19, we sought
to examine its antiviral potential in limiting the replication of SARS-CoV-2 in cellular
models of infection. In VeroE6 expressing human TMPRSS2 and human lung Calu-3 epithelial
cells, we show that the active compound atovaquone at micromolar concentrations potently
inhibits the replication of SARS-CoV-2 and other variants of concern including the
alpha, beta, and delta variants. Importantly, atovaquone retained its full antiviral
activity in a primary human airway epithelium cell culture model. Mechanistically, we
demonstrate that the atovaquone antiviral activity against SARS-CoV-2 is partially
dependent on the expression of TMPRSS2 and that the drug can disrupt the interaction of
the spike protein with the viral receptor, ACE2. Additionally, spike-mediated membrane
fusion was also reduced in the presence of atovaquone. In the United States, two
clinical trials of atovaquone administered alone or in combination with azithromycin
were initiated in 2020. While we await the results of these trials, our findings in
cellular infection models demonstrate that atovaquone is a potent antiviral FDA-approved
drug against SARS-CoV-2 and other variants of concern in vitro.