Skip to main content

Antiviral activity of 5-aminolevulinic acid against variants of severe acute respiratory syndrome coronavirus 2



Genetic variants of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) began to emerge in 2020 and have been spreading globally during the coronavirus disease 2019 (COVID-19) pandemic. Despite the presence of different COVID-19 vaccines, the discovery of effective antiviral therapeutics for the treatment of patients infected with SARS-CoV-2 are still urgently needed. A natural amino acid, 5-aminolevulinic acid (5-ALA), has exhibited both antiviral and anti-inflammatory activities. In a previous study, we demonstrated an in vitro antiviral effect of 5-ALA against SARS-CoV-2 infection without significant cytotoxicity. In the present study, we sought to investigate whether 5-ALA with or without sodium ferrous citrate (SFC) can inhibit in vitro both the original SARS-CoV-2 Wuhan strain and its variants, including the Alpha, Beta, Gamma and Delta strains.


The antiviral activity of ALA with or without SFC was determined in Vero-E6 cell. The virus inhibition was quantified by real time RT-PCR.


Co-administration of 5-ALA and SFC inhibited the Wuhan, Alpha and Delta variants of SARS-CoV-2 with IC50 values of 235, 173 and 397 µM, respectively, and the Beta and Gamma variants with IC50 values of 1311 and 1516 µM.


Our study suggests that 5-ALA with SFC warrants accelerated clinical evaluation as an antiviral drug candidate for treating patients infected with SARS-CoV-2 variants.


The outbreak of coronavirus disease (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a serious threat to global public health [1]. SARS-CoV-2 belongs to a beta-coronavirus subfamily and is a single-stranded positive RNA virus of roughly 29.9 kb in size [2]. Structurally, SARS-CoV-2 has a double-layered lipid envelope, including a spike glycoprotein (S), envelope protein (E), membrane protein (M) and nucleocapsid protein (N) [3]. The spike protein receptor-binding do main mediates recognition of the host cell receptor, angiotensin-converting enzyme 2 (ACE 2) [4, 5]. As of 18 October 2021, more than 241 million confirmed cases and 4.9 million deaths have been recorded in more than 220 countries around the world [6]. The clinical presentation of COVID-19 can vary from asymptomatic to mild, severe, or critical [7]; and serious respiratory system, gastrointestinal and neurological symptoms may arise as a result of infection [8,9,10,11].

Due to their low fidelity of genome replication, viruses acquire mutations over time, leading to variants of the original isolate. To date, thousands of genetic variants of SARS-CoV-2 are known to be circulating worldwide; however, four major SARS-CoV-2 variants of concern exist, namely, the Alpha (B.1.1.7), Beta (B.1.351), Gamma (P.1), and Delta (B.1.617.2) variants on Pango lineages [12]. Individual SARS-CoV-2 variants may display differences in transmission potential, virulence, clinical disease presentations (either milder or more severe), recognition by specific viral diagnostic tests, response by natural- or vaccine-induced immunity, and susceptibility to therapeutic agents [13,14,15,16]. Efficacious vaccines are being applied worldwide, and 39.3% of the world population has received at least one dose of a COVID-19 vaccine (i.e., 5.25 billion doses total) [17]. As of April 2021, 169 countries were actively administering vaccines, and the global vaccination campaign continues to progress [18]. Although a large fraction of the global population remains unvaccinated, the expectation of a continuously mutating virus that may come to exhibit at least partial resistance to vaccines emphasizes that drug development must proceed [19]. Moreover, it will take a long time to safely attain herd immunity against COVID-19 through vaccination, so effective therapies are required to prevent and treat COVID-19 [20].

Clinical investigations have focused on several approved antiviral drugs, including remdesivir [21], molnupiravir [22] and 3C-like protease inhibitors [23]. A natural amino acid, 5-aminolevulinic acid (5-ALA) commonly occurs in animals, plants, fungi and bacteria. So far, 5-ALA has been clinically used for metabolic improvement in human diseases, including diabetes [24] and the diagnosis and treatment of various cancers [25]. The conjugation of eight molecules of 5-ALA produces protoporphyrin IX (PPIX), which produces heme by the insertion of a ferrous ion [26]. Moreover, PPIX has shown antiviral effects against Dengue, Zika, chikungunya, and influenza A viruses [27,28,29]. The present study aims to evaluate the in vitro antiviral activity of 5-ALA against the Wuhan, Alpha, Beta, Gamma and Delta variants of SARS-CoV-2. Since previous papers on the potential of 5-ALA for heme oxigenas-1 induction [30] and anti-malarial activity [31] have shown that the addition of iron enhances the effect of 5-ALA, studies have been performed with and without iron. The ratio of 5-ALA to SFC was fixed as 4:1 according to our previous report on 5-ALA action to SARS-CoV-2 infection in Vero E6 and Caco-2 cells [32].

Materials and methods

Virus and cells

In this study, we used five SARS-CoV-2 strains; namely, the original Wuhan strain (hCoV-19/Japan/TY/WK-521,2019, GenBank_LC522975), the Alpha variant (hCoV-19/Japan/QK002/2020, EPI_ISL768526), the Beta variant (hCoV-19/Japan/TY8-612/2020, EPI_ISL1123289), the Gamma variant (hCoV-19/Japan/TY7-501/2020, EPI_ISL833366), and the Delta variant (hCoV-19/Japan/TY11-330-P1//2021, EPI_ISL2158613). The strains were provided by the Japan National Institute of Infectious Diseases and propagated in VeroE6 cells cultured in minimum essential medium supplemented with 10% fetal calf serum. Virus stocks were kept in a − 80 °C freezer as aliquots until testing. All experiments using infectious SARS-CoV-2 were performed in a biosafety level 3 (BSL3) laboratory at Nagasaki University according to standard BSL3 guidelines.


5-ALA was donated by Neopharma Japan (Tokyo, Japan) and was dissolved to 100 mM in water. Sodium ferrous citrate (SFC) was also donated by Neopharma Japan and was dissolved to 25 mM in water with 1 M of hydrogen chloride. Remdesivir (Gilead Sciences, Foster City, CA, USA) was dissolved to 10 mM in DMSO.

Evaluation of antiviral activity assay

Remdesivir, 5-ALA-only, and 5-ALA with SFC were diluted at different concentrations in 2% fetal calf serum in minimum essential medium. For 72 h (h) before infection with SARS-CoV-2, Vero E6 cells were treated with the diluted compounds, then were seeded in 96-well plates. SARS-CoV-2, with a multiplicity of infection of 0.02, was subsequently added and incubated in the presence of the compounds at 37 °C until 48 h post infection (pi). Infected cell supernatants were then harvested and quantified by quantitative real-time reverse-transcription polymerase chain reaction (qRT-PCR). As ‘SFC only’ did not show antiviral activity in the previous report [24], the efficacy of ‘SFC only’ was not examined in the present study.

Viral RNA extraction and quantitative real-time RT-PCR

A total of 100 μL of infected cell supernatant was harvested for viral RNA extraction by a Nextractor NX-48 robot, using an NX-48S viral Nucleic Acid (NA) kit (Genolution Inc., Seoul, South Korea) according to the manufacturer’s instructions. A total of 5 μL of RNA was used for quantitative real-time RT-PCR, and amplification of the N gene was performed using a total of 20 µL of reaction mixture consisting of 5 μL of Taqman master mix, 7 µL of nuclease water, 1 µL of 0.5-µM forward and reverse primers, and 1 μL of a 0.25-µM probe with SARS-CoV-2 N primers of the TaqMan Fast Virus 1-Step Master Mix (Life Technologies, Carlsbad, CA, USA) [33]. The primers and probes are referred to in more detail in our previous report [34].

Cell viability assay

Vero E6 cells in 96-well plates were treated with samples for 3 days, and a cell viability assay was conducted in parallel with an antiviral assay. To determine the concentration that triggered a 50% reduction in cell survival (CC50), the results of the cell viability assay were evaluated by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide according to the manufacturer’s instructions (Promega, Madison, WI, USA). Optical density was measured at 570 nm using a microplate reader (Synergy H1 M; BioTek Instruments, Winooski, VT, USA). Cell viability was determined using the following equation: cell viability (%) = (sample value)/(cell control) × 100. In addition, viral inhibition by 50% (IC50) was calculated as viral inhibition (%) = quantity of virus copies in (virus control − sample)/virus control × 100.

Statistical analysis

Data were analyzed using GraphPad Prism version 9 (GraphPad Software, Inc., San Diego, CA, USA). Continuous variables are presented as mean ± standard deviation values. Group comparisons were performed using a one-way analysis of variance. A t test was used to compare continuous variables between two groups. For all calculations, a P value of less than 0.05 was considered to be statistically significant.


To evaluate the antiviral effects of the compounds, we first tested an approved antiviral drug, remdesivir, against the Wuhan, Alpha, Beta, Gamma and Delta SARS-CoV-2 strains; assayed as virus copy number in the cell supernatant using a specific qRT-PCR-based assay. The antiviral effect IC50 value of remdesivir was confirmed to be 0.1–1 µM against the Wuhan strain and four SARS-CoV-2 variants (Fig. 1).

Fig. 1
figure 1

Corroboration of the antiviral effect of remdesivir against SARS-CoV-2 variants. Vero E6 cells were pretreated with remdesivir for 72 h and challenged with SARS-CoV-2. Infected cell supernatants at 48 h pi (MOI 0.02) were quantified by quantitative real time RT-PCR assay. The blue and red lines represent the CC50 and IC50, respectively; the blue squares represent cell viability (%) and the red circles represent SARS-CoV-2 infection inhibition (%). All experiments were performed in replicate

By applying the same qRT-PCR assay, the antiviral effects of 5-ALA and SFC were determined; and no cytotoxic effects with 2000 µM of 5-ALA and 500 µM of SFC in Vero E6 cells were observed. The resulting 5-ALA treatment and co-treatment with 5-ALA and SFC of VeroE6 cells inhibited the Wuhan strain of SARS-CoV-2 infection in a dose-dependent manner, with IC50 values of 207 and 235/59 µM, respectively (Fig. 2A, B). Furthermore, the antiviral effect IC50 values associated with 5-ALA and 5-ALA plus SFC treatments were 104 and 173/43 µM against the Alpha variant in a dose-dependent manner (Fig. 2C, D) and 1592, 1311/328 µM against the Beta variant in a dose-dependent manner (Fig. 2E, F), respectively.

Fig. 2
figure 2

Antiviral effect of 5-ALA (panels A, C, and E) and 5ALA with SFC (panels B, D, and F) against Wuhan (panels A and B), Alpha (panels C and D) and Beta strains (panels E and F). Vero E6 cells were pretreated with ALA with and without SFC for 72 h and challenged with SARS-CoV-2. Infected cell supernatants at 48 h pi (MOI 0.02) were quantified by quantitative real time RT-PCR assay. The blue and red lines represent the CC50 and IC50, respectively; the blue squares represent cell viability (%) and the red circles represent SARS-CoV-2 infection inhibition (%). All experiments were performed in replicate

Conversely, there was no viral inhibition and little viral inhibition after administration of 5-ALA to the Gamma (Fig. 3A) and Delta variants (Fig. 3C) SARS-CoV-2, respectively. However, co-treatment of 5-ALA and SFC led to viral inhibition IC50 values of 1516/379 and 397/99 µM after infection with the Gamma and Delta variants (Fig. 3B, D). The IC50 and CC50 of 5-ALA and 5-ALA with SFC against SARS-CoV-2 variants are described in Table 1.

Fig. 3
figure 3

Antiviral effect of 5-ALA (panels A and C) and 5ALA with SFC (panels B and D) against Gamma (panels A and B) and Delta (panels C and D) strains. Vero E6 cells were pretreated with ALA with and without SFC for 72 h and challenged with SARS-CoV-2. Infected cell supernatants at 48 h pi (MOI 0.02) were quantified by quantitative real time RT-PCR assay. The blue and red lines represent the CC50 and IC50, respectively; the blue squares represent cell viability (%) and the red circles represent SARS-CoV-2 infection inhibition (%). All experiments were performed in replicate

Table 1 IC50 and CC50 values of 5-ALA and 5-ALA with SFC against SARS-CoV-2 variants


New clinical features due to multiple SARS-CoV-2 variants are occurring globally [35]. Despite the development of COVID-19 vaccines, the search for new therapeutics is still necessary. In our previous study, we investigated the antiviral effects of 5-ALA and SFC on SARS-CoV-2 clinical isolates from a Japanese patient using an immunofluorescence-based assay [32]. In this study, we report the virucidal activity of 5-ALA with and without concurrent SFC administration on the original strain of SARS-CoV-2 and several variants. A low concentration of 5-ALA with SFC could inhibit the Wuhan, Alpha and Delta strains, whereas a high concentration of 5-ALA with SFC acts against the Beta and Gamma strains. Thus, our results indicate that 5-ALA with SFC had antiviral effects against Wuhan and SARS-CoV-2 variants without cytotoxicity. Treatment with 5-ALA only inhibited the Wuhan, Alpha and Beta SARS-CoV-2 strains, suggesting a specific antiviral effect.

Recent research demonstrated that a molecular target, a G-quadruplex (G4) structure, is of potential interest given its antiviral activity, which inhibits SARS-CoV-2 replication [36, 37]. G4s are nucleic-acid secondary structures that may form in single-stranded DNA and RNA guanine-rich sequences under physiological conditions [38]. G4 structures have been reported in several DNA and RNA viruses, including coronaviruses, and implicated in the control of key viral processes [39]. Many algorithms have been developed for prediction of G4 propensity at the genome-wide level; namely, Quad-Parser, QGRS Mapper, G4P Calculator, QuadBase, cGcC score, G4Hunter, and G4RNA screener [40]. In the RNA genome of SARS-CoV-2, about 25 putative quadruplex forming sequences (PQSs) were found using QGRS Mapper [36, 41, 42], and G4RNA screener [43]. Among them, a G4 forming RNA in the coding sequence region of SARS-CoV-2 nucleocapsid phosphoprotein can be stabilized by a G4 ligand, a pyridostatin derivative. The expression of SARS-CoV-2 N were decreased both in vitro and in cells by a pyridostatin derivative [37]. Many G4 binding molecules have been reported as therapeutic strategies to target G4s, including porphyrins [43]. We previously reported that the intracellular production of the porphyrins PPIX and hemin, which are metabolized from 5-ALA, are novel G4 binding agents [44,45,46,47]. Here, we showed that exogenously supplied 5-ALA inhibited SARS-CoV-2 infection. This may be caused by increased generation of PPIX. These data indicate a novel therapeutic strategy that targets G4 against SARS-CoV-2 by intracellular generation of porphyrins from 5-ALA. However, the SARS-CoV-2 genome contains a significantly lower density of PQSs using the computational predicted algorithms, suggesting the G4 folding capacity of predicted SARS-CoV-2 PQSs consists of many ‘weak G4s’. As the PQSs do not differ between SARS-CoV-2 variants, other mechanisms of 5-ALA may be involved. Differences in the efficiency of virus invasion to the cell is one of the reasons. Since PQRs is only a bioinformatic analysis, it is necessary to identify G4s in the virus genome biologically in the future.

5-ALA is produced from most animals and plants, and thus us present in our food and may be taken by an oral route due to high bioavailability [48]. 5-ALA with SFC is a supplement formulation registered in Japan as a food with functional claims. In a recent clinical study, Japanese patients with COVID-19 who were given 5-ALA and SFC capsules orally experienced a shorter time to recovery than that reported for patients who received only standard care for SARS-CoV-2 infection [49]. Registration for the specified clinical trials on the effects of the treatment on human and its aftereffects has been completed and the data is now being analyzed (Japan Registry of Clinical Trials CRB 7180001 and 3190006, respectively).


The present study demonstrates antiviral effects of 5-ALA and SFC against SARS-CoV-2 variants in vitro and may reveal these components as therapeutics and preventive measures for COVID-19.

Availability of data and materials

Not applicable.



Severe acute respiratory syndrome coronavirus 2


Coronavirus disease 2019


5-Aminolevulinic acid


Sodium ferrous citrate


Spike glycoprotein


Envelope protein


Membrane protein


Nucleocapsid protein

ACE 2:

Angiotensin-converting enzyme 2


Protoporphyrin IX


Biosafety level 3


Quantitative real time reverse-transcription polymerase chain reaction


Nucleic acid


50% Reduction in cell survival


50% Virus inhibition




Putative quadruplex forming sequences


  1. Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al. Early transmission dynamics in Wuhan, China, of novel coronavirus–infected pneumonia. N Engl J Med. 2020;382:1199–207.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  2. Lu R, Zhao X, Li J, Niu P, Yang B, Wu H, et al. Genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding. Lancet. 2020;395:565–74.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Zhang YZ, Holmes EC. A genomic perspective on the origin and emergence of SARS-CoV-2. Cell. 2020;181:223–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  4. Hoffmann M, Kleine-Weber H, Schroeder S, Krüger N, Herrler T, Erichsen S, et al. SARS-CoV-2 cell entry depends on ACE2 and TMPRSS2 and is blocked by a clinically proven protease inhibitor. Cell. 2020;181:271–80.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  5. Lan J, Ge J, Yu J, Shan S, Zhou H, Fan S, et al. Structure of the SARS-CoV-2 spike receptor-binding domain bound to the ACE2 receptor. Nature. 2020;581:215–20.

    Article  CAS  PubMed  Google Scholar 

  6. World Health Organization. Accessed 27 Aug 2021.

  7. He F, Deng Y, Li W. Coronavirus disease 2019: what we know? J Med Virol. 2020;92:719–25.

    Article  CAS  PubMed  Google Scholar 

  8. Zhou Z, Kang H, Li S, Zhao X. Understanding the neurotropic characteristics of SARS-CoV-2: from neurological manifestations of COVID-19 to potential neurotropic mechanisms. J Neurol. 2020;267:2179–84.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  9. Ahmed MU, Hanif M, Ali MJ, Haider MA, Kherani D, Memon GM, et al. Neurological manifestations of COVID-19 (SARS-CoV-2): a review. Front Neurol. 2020.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Kim GU, Kim MJ, Ra SH, Lee J, Bae S, et al. Clinical characteristics of asymptomatic and symptomatic patients with mild COVID-19. Clin Microbiol Infect. 2020.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Lin L, Jiang X, Zhang Z, Huang S, Zhang Z, Fang Z, et al. Gastrointestinal symptoms of 95 cases with SARS-CoV-2 infection. Gut. 2020;69:997–1001.

    Article  CAS  PubMed  Google Scholar 

  12. World Health Organization. Accessed 25 Aug 2021.

  13. Wu K, Werner AP, Moliva JI, Koch M, Choi A, et al. mRNA-1273 vaccine induces neutralizing antibodies against spike mutants from global SARS-CoV-2 variants. bioRxiv. 2021.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Xie X, Zou J, Fontes-Garfias CR, Xia H, Swanson KA, et al. Neutralization of N501Y mutant SARS-CoV-2 by BNT162b2 vaccine-elicited sera. bioRxiv. 2021.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Weisblum Y, Schmidt F, Zhang F, DaSilva J, Poston D, Lorenzi JCC, et al. Escape from neutralizing antibodies 1 by SARS-CoV-2 spike protein variants. eLife. 2020;9:1.

    Article  Google Scholar 

  16. Resende PC, Bezerra JF, Vasconcelos RHT, Arantes I, Appolinario L, Mendoncą AC, et al. Severe acute respiratory syndrome coronavirus 2 P.2 lineage associated with reinfection case, Brazil, June–October 2020. Emerg Infect Dis. 2021;27:1789–94.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  17. World Health Organization. Coronavirus disease (COVID-19) pandemic. 2020.

  18. Mathieu E, Ritchie H, Ortiz-Ospina E, Roser M, Hasell J, Appel C, et al. A global database of COVID-19 vaccinations. Nat Hum Behav. 2021;5:947–53.

    Article  PubMed  Google Scholar 

  19. Zahradník J, Marciano S, Shemesh M, Zoler E, Harari D, Chiaravalli J, et al. SARS-CoV-2 variant prediction and antiviral drug design are enabled by RBD in vitro evolution. Nat Microbiol. 2021;6:1188–98.

    Article  CAS  PubMed  Google Scholar 

  20. Ashburn TT, Thor KB. Drug repositioning: identifying and developing new uses for existing drugs. Nat Rev Drug Discov. 2004;3:673–83.

    Article  CAS  PubMed  Google Scholar 

  21. Wang Y, Zhang D, Du G, Du R, Zhao J, Jin Y, et al. Remdesivir in adults with severe COVID-19: a randomised, double-blind, placebo-controlled, multicentre trial. Lancet. 2020;395:1569–78.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  22. Fischer W, Eron JJ, Holman W, Cohen MS, Fang L, Szewczyk LJ, et al. Molnupiravir, an oral antiviral treatment for COVID-19. medRxiv. 2021.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Boras B, Jones RM, Anson BJ, Arenson D, Aschenbrenner L, Bakowski MA, et al. Preclinical characterization of an intravenous coronavirus 3CL protease inhibitor for the potential treatment of COVID19. Nat Commun. 2021;12:6055.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  24. Rehani PR, Iftikhar H, Nakajima M, Tanaka T, Jabbar Z, Rehani RN. Safety and mode of action of diabetes medications in comparison with 5-aminolevulinic acid (5-ALA). J Diabetes Res. 2019.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Yang X, Palasuberniam P, Kraus D, Chen B. Aminolevulinic acid-based tumor detection and therapy: molecular mechanisms and strategies for enhancement. Int J Mol Sci. 2015;16:25865–80.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  26. Fujino M, Nishio Y, Ito H, Tanaka T, Li XK. 5-Aminolevulinic acid regulates the inflammatory response and alloimmune reaction. Int Immunopharmacol. 2016;37:71–8.

    Article  CAS  PubMed  Google Scholar 

  27. Assunção-Miranda I, Cruz-Oliveira C, Neris RL, Figueiredo CM, Pereira LP, Rodrigues D, Araujo DF, Da Poian AT, Bozza MT. Inactivation of dengue and yellow fever viruses by heme, cobalt-protoporphyrin IX and tin-protoporphyrin IX. J Appl Microbiol. 2016;120:790–804.

    Article  PubMed  Google Scholar 

  28. Neris RLS, Figueiredo CM, Higa LM, Araujo DF, Carvalho CAM, Verçoza BRF, et al. Co-protoporphyrin IX and Sn-protoporphyrin IX inactivate Zika, Chikungunya and other arboviruses by targeting the viral envelope. Sci Rep. 2018;8:1–13.

    Article  CAS  Google Scholar 

  29. Ma LL, Zhang P, Wang HQ, Li YF, Hu J, Jiang JD, et al. Heme oxygenase-1 agonist CoPP suppresses influenza virus replication through IRF3-mediated generation of IFN-α/β. Virology. 2019.

    Article  PubMed  Google Scholar 

  30. Ito H, Nishio Y, Hara T, Hidemitsu S, Tanaka T, Li X. Oral administration of 5-aminolevulinic acid induces heme oxygenase-1 expression in peripheral blood mononuclear cells of healthy human subjects in combination with ferrous iron. Eur J Pharmacol. 2018;833:25–33.

    Article  CAS  PubMed  Google Scholar 

  31. Suzuki S, Hikosaka K, Balogun EO, Komatsuya K, Niikura M, Kobayashi F, et al. In vivo curative and protective potential of orally administered 5-aminolevulinic acid plus ferrous ion against malaria. Antimicrob Agents Chemother. 2015;59:6960–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  32. Sakurai Y, Ngwe Tun MM, Kurosaki Y, Sakura T, Inaoka DK, Fujine K, et al. 5-Amino levulinic acid inhibits SARS-CoV-2 infection in vitro. Biochem Biophys Res Commun. 2021;545:203–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  33. Tun MMN, Muthugala R, Nabeshima T, Soe AM, Dumre SP, Rajamanthri L, et al. Complete genome analysis and characterization of neurotropic dengue virus 2 cosmopolitan genotype isolated from the cerebrospinal fluid of encephalitis patients. PLoS ONE. 2020;15(6):1–15.

    Google Scholar 

  34. Shirato K, Nao N, Katano H, Takayama I, Saito S, Kato F, et al. Development of genetic diagnostic methods for detection for novel coronavirus 2019 (nCoV-2019) in Japan. Jpn J Infect Dis. 2020;73:304–7.

    Article  CAS  PubMed  Google Scholar 

  35. Alhadrami HA, Sayed AM, Hassan HM, Youssif KA, Gaber Y, Moatasim Y, et al. Cnicin as an anti-SARS-CoV-2: an integrated in silico and in vitro approach for the rapid identification of potential covid-19 therapeutics. Antibiotics. 2021;10(5):542.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  36. Panera N, Tozzi AE, Alisi A. The G-quadruplex/helicase world as a potential antiviral approach against COVID-19. Drugs. 2020;80:941–6.

    Article  CAS  PubMed  Google Scholar 

  37. Zhao C, Qin G, Niu J, Wang Z, Wang C, Ren J, Qu X. Targeting RNA G-quadruplex in SARS-CoV-2: a promising therapeutic target for COVID-19? Angew Chem Int Ed. 2020;60:432–8.

    Article  Google Scholar 

  38. Lipps HJ, Rhodes D. G-quadruplex structures: in vivo evidence and function. Trends Cell Biol. 2009;19:414–22.

    Article  CAS  PubMed  Google Scholar 

  39. Lavezzo E, Berselli M, Frasson I, Perrone R, Palù G, Brazzale AR, et al. G-quadruplex forming sequences in the genome of all known human viruses: a comprehensive guide. PLoS Comput Biol. 2018;14:1–20.

    Article  Google Scholar 

  40. Asamitsu S, Takeuchi M, Ikenoshita S, Imai Y, Kashiwagi H, Shioda N. Perspectives for applying G-quadruplex structures in neurobiology and neuropharmacology. Int J Mol Sci. 2019;20:1–15.

    Article  Google Scholar 

  41. Ji D, Juhas M, Tsang CM, Kwok CK, Li Y, Zhang Y. Discovery of G-quadruplex-forming sequences in SARS-CoV-2. Brief Bioinform. 2021;22:1150–60.

    Article  CAS  PubMed  Google Scholar 

  42. Cui H, Zhang L. G-quadruplexes are present in human coronaviruses including SARS-CoV-2. Front Microbiol. 2020.

    Article  PubMed  PubMed Central  Google Scholar 

  43. Asamitsu S, Obata S, Yu Z, Bando T, Sugiyama H. Recent progress of targeted G-quadruplex-preferred ligands toward cancer therapy. Molecules. 2019;24(3):429.

    Article  PubMed Central  Google Scholar 

  44. Shioda N, Yabuki Y, Yamaguchi K, Onozato M, Li Y, Kurosawa K, et al. Targeting G-quadruplex DNA as cognitive function therapy for ATR-X syndrome article. Nat Med. 2018;24:802–13.

    Article  CAS  PubMed  Google Scholar 

  45. Wada T, Suzuki S, Shioda N. 5-Aminolevulinic acid can ameliorate language dysfunction of patients with ATR-X syndrome. Congenit Anom (Kyoto). 2020;60:147–8.

    CAS  Google Scholar 

  46. Asamitsu S, Yabuki Y, Ikenoshita S, Wada T, Shioda N. Pharmacological prospects of G-quadruplexes for neurological diseases using porphyrins. Biochem Biophys Res Commun. 2020;531:51–5.

    Article  CAS  PubMed  Google Scholar 

  47. Asamitsu S, Yabuki Y, Ikenoshita S, Kawakubo K, Kawasaki M, Usuki S, et al. CGG repeat RNA G-quadruplexes interact with FMRpolyG to cause neuronal dysfunction in fragile X-related tremor/ataxia syndrome. Sci Adv. 2021;7:1–14.

    Article  Google Scholar 

  48. Dalton JT, Yates CR, Yin D, Straughn A, Marcus SL, Golub AL, et al. Clinical pharmacokinetics of 5-aminolevulinic acid in healthy volunteers and patients at high risk for recurrent bladder cancer. J Pharmacol Exp Ther. 2002;301:507–12.

    Article  CAS  PubMed  Google Scholar 

  49. Nakajima M, Kaketani K. Safety, tolerability, and efficacy of 5-aminolevulinic acid phosphate, an inducer of heme oxygenase 1, in combination with sodium ferrous citrate for the treatment of COVID-19 patients. Open COVID J. 2021.

    Article  Google Scholar 

Download references


The authors thank Dr. Chris Smith (Nagasaki University) for supporting manuscript preparation.


This work was supported by grants from Japan Agency for Medical Research and Development (Grant Number JP21wm0125006) and Nagasaki University “Doctoral Program for World-leading Innovative and Smart Education” for Global Health, “Global Health Elite Programme for Building a Healthier World”.

Author information

Authors and Affiliations



MMNT, JY, KK, and KM: conceptualization, study design. MMNT, TS, YS, YK, and DI: data analysis and investigation. MMNT: writing-original draft preparation. MMNT, NS, YS, YK, and KK: writing-review and editing. JY, KK, and KM: supervision and funding acquisition. All authors read and approved the final manuscript.

Corresponding authors

Correspondence to Mya Myat Ngwe Tun, Jiro Yasuda, Kiyoshi Kita or Kouichi Morita.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

Kita K. is a Scientific Advisor of Neopharma Japan. The other authors declare no competing interests.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Ngwe Tun, M.M., Sakura, T., Sakurai, Y. et al. Antiviral activity of 5-aminolevulinic acid against variants of severe acute respiratory syndrome coronavirus 2. Trop Med Health 50, 6 (2022).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: