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Eisele-Metzger A, Bollig C, Meerpohl JJ. Systematic reviews should be at the heart of continuing medical education. J Eur CME 2021; 10:2014096. [PMID: 34925964 PMCID: PMC8676680 DOI: 10.1080/21614083.2021.2014096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Today, keeping up with the fast evolving evidence is more challenging than ever for practising physicians. A huge number of studies are published every day, and it is no longer possible to read all the relevant individual studies. Many physicians prefer attending continuing medical education (CME) to reading international scientific publications. Consequently, it is critical that CME is based on the best available evidence and presented in an unbiased manner free of conflicts of interest. Systematic reviews and Cochrane reviews in particular can thus provide a valuable resource of up-to-date and high-quality information on health care questions for CME providers. Of note, systematic reviews might become outdated quickly. Furthermore, some systematic reviews are fraught with limitations such as poor methodology and conduct or incomplete and misleading reporting. This article provides a brief overview of systematic reviews and Cochrane reviews, outlines how systematic reviews can be “kept alive” using today’s digital opportunities and points to several common problems of systematic reviews with suggestions for solutions.
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Affiliation(s)
- Angelika Eisele-Metzger
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Cochrane Germany, Cochrane Germany Foundation, Freiburg, Germany
| | - Claudia Bollig
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Cochrane Germany, Cochrane Germany Foundation, Freiburg, Germany
| | - Joerg J Meerpohl
- Institute for Evidence in Medicine, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Cochrane Germany, Cochrane Germany Foundation, Freiburg, Germany
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Highly Neutralizing COVID-19 Convalescent Plasmas Potently Block SARS-CoV-2 Replication and Pneumonia in Syrian Hamsters. J Virol 2021; 96:e0155121. [PMID: 34818068 PMCID: PMC8865546 DOI: 10.1128/jvi.01551-21] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Despite various attempts to treat severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-infected patients with COVID-19 convalescent plasmas, neither appropriate approach nor clinical utility has been established. We examined the efficacy of administration of highly neutralizing COVID-19 convalescent plasma (hn-plasmas) and such plasma-derived IgG administration using the Syrian hamster COVID-19 model. Two hn-plasmas, which were in the best 1% of 340 neutralizing activity-determined convalescent plasmas, were intraperitoneally administered to SARS-CoV-2-infected hamsters, resulting in a significant reduction of viral titers in lungs by up to 32-fold compared to the viral titers in hamsters receiving control nonneutralizing plasma, while with two moderately neutralizing plasmas (mn-plasmas) administered, viral titer reduction was by up to 6-fold. IgG fractions purified from the two hn-plasmas also reduced viral titers in lungs more than those from the two mn-plasmas. The severity of lung lesions seen in hamsters receiving hn-plasmas was minimal to moderate as assessed using microcomputerized tomography, which histological examination confirmed. Western blotting revealed that all four COVID-19 convalescent plasmas variably contained antibodies against SARS-CoV-2 components, including the receptor-binding domain and S1 domain. The present data strongly suggest that administering potent neutralizing activity-confirmed COVID-19 convalescent plasmas would be efficacious in treating patients with COVID-19. IMPORTANCE Convalescent plasmas obtained from patients who recovered from a specific infection have been used as agents to treat other patients infected with the very pathogen. To treat using convalescent plasmas, despite that more than 10 randomized controlled clinical trials have been conducted and more than 100 studies are currently ongoing, the effects of convalescent plasma against COVID-19 remained uncertain. On the other hand, certain COVID-19 vaccines have been shown to reduce the clinical COVID-19 onset by 94 to 95%, for which the elicited SARS-CoV-2-neutralizing antibodies are apparently directly responsible. Here, we demonstrate that highly neutralizing effect-confirmed convalescent plasmas significantly reduce the viral titers in the lung of SARS-CoV-2-infected Syrian hamsters and block the development of virally induced lung lesions. The present data provide a proof of concept that the presence of highly neutralizing antibody in COVID-19 convalescent plasmas is directly responsible for the reduction of viral replication and support the use of highly neutralizing antibody-containing plasmas in COVID-19 therapy with convalescent plasmas.
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Estcourt LJ, Turgeon AF, McQuilten ZK, McVerry BJ, Al-Beidh F, Annane D, Arabi YM, Arnold DM, Beane A, Bégin P, van Bentum-Puijk W, Berry LR, Bhimani Z, Birchall JE, Bonten MJM, Bradbury CA, Brunkhorst FM, Buxton M, Callum JL, Chassé M, Cheng AC, Cove ME, Daly J, Derde L, Detry MA, De Jong M, Evans A, Fergusson DA, Fish M, Fitzgerald M, Foley C, Goossens H, Gordon AC, Gosbell IB, Green C, Haniffa R, Harvala H, Higgins AM, Hills TE, Hoad VC, Horvat C, Huang DT, Hudson CL, Ichihara N, Laing E, Lamikanra AA, Lamontagne F, Lawler PR, Linstrum K, Litton E, Lorenzi E, MacLennan S, Marshall J, McAuley DF, McDyer JF, McGlothlin A, McGuinness S, Miflin G, Montgomery S, Mouncey PR, Murthy S, Nichol A, Parke R, Parker JC, Priddee N, Purcell DFJ, Reyes LF, Richardson P, Robitaille N, Rowan KM, Rynne J, Saito H, Santos M, Saunders CT, Serpa Neto A, Seymour CW, Silversides JA, Tinmouth AA, Triulzi DJ, Turner AM, van de Veerdonk F, Walsh TS, Wood EM, Berry S, Lewis RJ, Menon DK, McArthur C, Zarychanski R, Angus DC, Webb SA, Roberts DJ, Shankar-Hari M. Effect of Convalescent Plasma on Organ Support-Free Days in Critically Ill Patients With COVID-19: A Randomized Clinical Trial. JAMA 2021. [PMID: 34606578 DOI: 10.1101/2021.06.11.21258760] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
IMPORTANCE The evidence for benefit of convalescent plasma for critically ill patients with COVID-19 is inconclusive. OBJECTIVE To determine whether convalescent plasma would improve outcomes for critically ill adults with COVID-19. DESIGN, SETTING, AND PARTICIPANTS The ongoing Randomized, Embedded, Multifactorial, Adaptive Platform Trial for Community-Acquired Pneumonia (REMAP-CAP) enrolled and randomized 4763 adults with suspected or confirmed COVID-19 between March 9, 2020, and January 18, 2021, within at least 1 domain; 2011 critically ill adults were randomized to open-label interventions in the immunoglobulin domain at 129 sites in 4 countries. Follow-up ended on April 19, 2021. INTERVENTIONS The immunoglobulin domain randomized participants to receive 2 units of high-titer, ABO-compatible convalescent plasma (total volume of 550 mL ± 150 mL) within 48 hours of randomization (n = 1084) or no convalescent plasma (n = 916). MAIN OUTCOMES AND MEASURES The primary ordinal end point was organ support-free days (days alive and free of intensive care unit-based organ support) up to day 21 (range, -1 to 21 days; patients who died were assigned -1 day). The primary analysis was an adjusted bayesian cumulative logistic model. Superiority was defined as the posterior probability of an odds ratio (OR) greater than 1 (threshold for trial conclusion of superiority >99%). Futility was defined as the posterior probability of an OR less than 1.2 (threshold for trial conclusion of futility >95%). An OR greater than 1 represented improved survival, more organ support-free days, or both. The prespecified secondary outcomes included in-hospital survival; 28-day survival; 90-day survival; respiratory support-free days; cardiovascular support-free days; progression to invasive mechanical ventilation, extracorporeal mechanical oxygenation, or death; intensive care unit length of stay; hospital length of stay; World Health Organization ordinal scale score at day 14; venous thromboembolic events at 90 days; and serious adverse events. RESULTS Among the 2011 participants who were randomized (median age, 61 [IQR, 52 to 70] years and 645/1998 [32.3%] women), 1990 (99%) completed the trial. The convalescent plasma intervention was stopped after the prespecified criterion for futility was met. The median number of organ support-free days was 0 (IQR, -1 to 16) in the convalescent plasma group and 3 (IQR, -1 to 16) in the no convalescent plasma group. The in-hospital mortality rate was 37.3% (401/1075) for the convalescent plasma group and 38.4% (347/904) for the no convalescent plasma group and the median number of days alive and free of organ support was 14 (IQR, 3 to 18) and 14 (IQR, 7 to 18), respectively. The median-adjusted OR was 0.97 (95% credible interval, 0.83 to 1.15) and the posterior probability of futility (OR <1.2) was 99.4% for the convalescent plasma group compared with the no convalescent plasma group. The treatment effects were consistent across the primary outcome and the 11 secondary outcomes. Serious adverse events were reported in 3.0% (32/1075) of participants in the convalescent plasma group and in 1.3% (12/905) of participants in the no convalescent plasma group. CONCLUSIONS AND RELEVANCE Among critically ill adults with confirmed COVID-19, treatment with 2 units of high-titer, ABO-compatible convalescent plasma had a low likelihood of providing improvement in the number of organ support-free days. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02735707.
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Affiliation(s)
- Lise J Estcourt
- NHS Blood and Transplant, Oxford, England
- Radcliffe Department of Medicine and BRC Hematology Theme, University of Oxford, Oxford, England
| | - Alexis F Turgeon
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Quebec City, Quebec, Canada
- CHU de Québec-Université Laval Research Center, Population Health and Optimal Health Practices Unit, Trauma-Emergency-Critical Care Medicine, CHU de Québec-Université Laval, Quebec City, Quebec, Canada
| | - Zoe K McQuilten
- Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Clinical Hematology, Monash Health, Melbourne, Australia
| | - Bryan J McVerry
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Farah Al-Beidh
- Division of Anesthetics, Pain Medicine, and Intensive Care Medicine, Department of Surgery and Cancer, Imperial College London and Imperial College Healthcare NHS Trust, London, England
| | - Djillali Annane
- Intensive Care Unit, Raymond Poincaré Hospital, Paris, France
- Simone Veil School of Medicine, University of Versailles, Versailles, France
- University Paris Saclay, Garches, France
| | - Yaseen M Arabi
- Intensive Care Department, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | | | - Abigail Beane
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, England
| | | | - Wilma van Bentum-Puijk
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | | | - Zahra Bhimani
- Li Ka Shing Knowledge Institute, Unity Health Toronto, St Michael's Hospital, Toronto, Ontario, Canada
| | | | - Marc J M Bonten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Charlotte A Bradbury
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, England
- Faculty of Health Sciences, University of Bristol, Bristol, England
| | - Frank M Brunkhorst
- Center for Clinical Studies and Center for Sepsis Control and Care, Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Meredith Buxton
- Global Coalition for Adaptive Research, San Francisco, California
| | - Jeannie L Callum
- Canadian Blood Services, Ottawa, Ontario, Canada
- Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre and Queens University, Kingston, Ontario, Canada
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | - Allen C Cheng
- Infection Prevention and Healthcare Epidemiology Unit, Alfred Health, Melbourne, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Matthew E Cove
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - James Daly
- Australian Red Cross Lifeblood, Sydney and Perth, Australia
| | - Lennie Derde
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Intensive Care Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | | | - Menno De Jong
- Department of Medical Microbiology, University of Amsterdam Medical Center, University of Amsterdam, the Netherlands
| | - Amy Evans
- NHSBT Clinical Trials Unit, NHS Blood and Transplant, Cambridge, England
| | - Dean A Fergusson
- Ottawa Hospital Research Institute, Clinical Epidemiology Unit, Ottawa, Ontario, Canada
| | - Matthew Fish
- School of Immunology and Microbial Sciences, Kings College London, London, England
| | | | - Claire Foley
- NHSBT Clinical Trials Unit, NHS Blood and Transplant, Cambridge, England
| | - Herman Goossens
- Department of Microbiology, Antwerp University Hospital, Antwerp, Belgium
| | - Anthony C Gordon
- Division of Anesthetics, Pain Medicine, and Intensive Care Medicine, Department of Surgery and Cancer, Imperial College London and Imperial College Healthcare NHS Trust, London, England
| | - Iain B Gosbell
- Australian Red Cross Lifeblood, Sydney and Perth, Australia
- Western Sydney University, Sydney, Australia
| | - Cameron Green
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Rashan Haniffa
- Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | | | - Alisa M Higgins
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | | | | | | | - David T Huang
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Nao Ichihara
- Department of Healthcare Quality Assessment, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Emma Laing
- NHSBT Clinical Trials Unit, NHS Blood and Transplant, Cambridge, England
| | | | | | - Patrick R Lawler
- Cardiac Intensive Care Unit, Peter Munk Cardiac Centre, University Health Network, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kelsey Linstrum
- Clinical Research Investigation and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Edward Litton
- School of Medicine and Pharmacology, University of Western Australia, Crawley
| | | | | | - John Marshall
- Li Ka Shing Knowledge Institute, Unity Health Toronto, St Michael's Hospital, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - Daniel F McAuley
- Centre for Experimental Medicine, School of Medicine, Dentistry, and Biomedical Sciences, Queen's University Belfast, Belfast, Ireland
| | - John F McDyer
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Shay McGuinness
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
- Medical Research Institute of New Zealand, Wellington
| | | | - Stephanie Montgomery
- Clinical Research Investigation and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Paul R Mouncey
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, England
| | - Srinivas Murthy
- School of Medicine, University of British Columbia, Vancouver, Canada
| | - Alistair Nichol
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Anesthesia and Intensive Care, St Vincent's University Hospital, Dublin, Ireland
- School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
- Department of Intensive Care, Alfred Health, Melbourne, Australia
| | - Rachael Parke
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
- Medical Research Institute of New Zealand, Wellington
- School of Nursing, University of Auckland, Auckland, New Zealand
| | - Jane C Parker
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Nicole Priddee
- Scottish National Blood Transfusion Service, Edinburgh, Scotland
| | - Damian F J Purcell
- Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, Australia
| | - Luis F Reyes
- Universidad de La Sabana, Chia, Colombia
- Clinica Universidad de La Sabana, Chia, Colombia
| | | | - Nancy Robitaille
- Héma-Québec, Montreal, Quebec, Canada
- Division of Hematology and Oncology, Department of Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada
- Department of Pediatrics, Université de Montréal, Montreal, Quebec, Canada
| | - Kathryn M Rowan
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, England
| | - Jennifer Rynne
- School of Immunology and Microbial Sciences, Kings College London, London, England
| | - Hiroki Saito
- Department of Emergency and Critical Care Medicine, St Marianna University School of Medicine, Yokohama City Seibu Hospital, Yokohama, Japan
| | - Marlene Santos
- Li Ka Shing Knowledge Institute, Unity Health Toronto, St Michael's Hospital, Toronto, Ontario, Canada
| | | | - Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Christopher W Seymour
- Clinical Research Investigation and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Jon A Silversides
- Centre for Experimental Medicine, School of Medicine, Dentistry, and Biomedical Sciences, Queen's University Belfast, Belfast, Ireland
| | - Alan A Tinmouth
- Ottawa Hospital Research Institute, Clinical Epidemiology Unit, Ottawa, Ontario, Canada
| | - Darrell J Triulzi
- Department of Pathology, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Anne M Turner
- Medical Research Institute of New Zealand, Wellington
| | - Frank van de Veerdonk
- Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Erica M Wood
- Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Clinical Hematology, Monash Health, Melbourne, Australia
| | | | - Roger J Lewis
- Berry Consultants LLC, Austin, Texas
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - David K Menon
- University Division of Anesthesia, Addenbrooke's Hospital Cambridge, Cambridge, England
| | - Colin McArthur
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, England
- Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Ryan Zarychanski
- Department of Medicine, Critical Care and Hematology/Medical Oncology, University of Manitoba, Winnipeg, Canada
| | - Derek C Angus
- Clinical Research Investigation and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Steve A Webb
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- St John of God Hospital, Subiaco, Australia
| | - David J Roberts
- NHS Blood and Transplant, Oxford, England
- Radcliffe Department of Medicine and BRC Hematology Theme, University of Oxford, Oxford, England
| | - Manu Shankar-Hari
- School of Immunology and Microbial Sciences, Kings College London, London, England
- Guy's and St Thomas' NHS Foundation Trust, ICU Support Offices, St Thomas' Hospital, London, England
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Mikolajewska A, Fischer AL, Piechotta V, Mueller A, Metzendorf MI, Becker M, Dorando E, Pacheco RL, Martimbianco ALC, Riera R, Skoetz N, Stegemann M. Colchicine for the treatment of COVID-19. Cochrane Database Syst Rev 2021; 10:CD015045. [PMID: 34658014 PMCID: PMC8521385 DOI: 10.1002/14651858.cd015045] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND The development of severe coronavirus disease 2019 (COVID-19) and poor clinical outcomes are associated with hyperinflammation and a complex dysregulation of the immune response. Colchicine is an anti-inflammatory medicine and is thought to improve disease outcomes in COVID-19 through a wide range of anti-inflammatory mechanisms. Patients and healthcare systems need more and better treatment options for COVID-19 and a thorough understanding of the current body of evidence. OBJECTIVES To assess the effectiveness and safety of Colchicine as a treatment option for COVID-19 in comparison to an active comparator, placebo, or standard care alone in any setting, and to maintain the currency of the evidence, using a living systematic review approach. SEARCH METHODS We searched the Cochrane COVID-19 Study Register (comprising CENTRAL, MEDLINE (PubMed), Embase, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, and medRxiv), Web of Science (Science Citation Index Expanded and Emerging Sources Citation Index), and WHO COVID-19 Global literature on coronavirus disease to identify completed and ongoing studies without language restrictions to 21 May 2021. SELECTION CRITERIA We included randomised controlled trials evaluating colchicine for the treatment of people with COVID-19, irrespective of disease severity, age, sex, or ethnicity. We excluded studies investigating the prophylactic effects of colchicine for people without severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection but at high risk of SARS-CoV-2 exposure. DATA COLLECTION AND ANALYSIS We followed standard Cochrane methodology. We used the Cochrane risk of bias tool (ROB 2) to assess bias in included studies and GRADE to rate the certainty of evidence for the following prioritised outcome categories considering people with moderate or severe COVID-19: all-cause mortality, worsening and improvement of clinical status, quality of life, adverse events, and serious adverse events and for people with asymptomatic infection or mild disease: all-cause mortality, admission to hospital or death, symptom resolution, duration to symptom resolution, quality of life, adverse events, serious adverse events. MAIN RESULTS We included three RCTs with 11,525 hospitalised participants (8002 male) and one RCT with 4488 (2067 male) non-hospitalised participants. Mean age of people treated in hospital was about 64 years, and was 55 years in the study with non-hospitalised participants. Further, we identified 17 ongoing studies and 11 studies completed or terminated, but without published results. Colchicine plus standard care versus standard care (plus/minus placebo) Treatment of hospitalised people with moderate to severe COVID-19 All-cause mortality: colchicine plus standard care probably results in little to no difference in all-cause mortality up to 28 days compared to standard care alone (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.93 to 1.08; 2 RCTs, 11,445 participants; moderate-certainty evidence). Worsening of clinical status: colchicine plus standard care probably results in little to no difference in worsening of clinical status assessed as new need for invasive mechanical ventilation or death compared to standard care alone (RR 1.02, 95% CI 0.96 to 1.09; 2 RCTs, 10,916 participants; moderate-certainty evidence). Improvement of clinical status: colchicine plus standard care probably results in little to no difference in improvement of clinical status, assessed as number of participants discharged alive up to day 28 without clinical deterioration or death compared to standard care alone (RR 0.99, 95% CI 0.96 to 1.01; 1 RCT, 11,340 participants; moderate-certainty evidence). Quality of life, including fatigue and neurological status: we identified no studies reporting this outcome. Adverse events: the evidence is very uncertain about the effect of colchicine on adverse events compared to placebo (RR 1.00, 95% CI 0.56 to 1.78; 1 RCT, 72 participants; very low-certainty evidence). Serious adverse events: the evidence is very uncertain about the effect of colchicine plus standard care on serious adverse events compared to standard care alone (0 events observed in 1 RCT of 105 participants; very low-certainty evidence). Treatment of non-hospitalised people with asymptomatic SARS-CoV-2 infection or mild COVID-19 All-cause mortality: the evidence is uncertain about the effect of colchicine on all-cause mortality at 28 days (Peto odds ratio (OR) 0.57, 95% CI 0.20 to 1.62; 1 RCT, 4488 participants; low-certainty evidence). Admission to hospital or death within 28 days: colchicine probably slightly reduces the need for hospitalisation or death within 28 days compared to placebo (RR 0.80, 95% CI 0.62 to 1.03; 1 RCT, 4488 participants; moderate-certainty evidence). Symptom resolution: we identified no studies reporting this outcome. Quality of life, including fatigue and neurological status: we identified no studies reporting this outcome. Adverse events: the evidence is uncertain about the effect of colchicine on adverse events compared to placebo . Results are from one RCT reporting treatment-related events only in 4412 participants (low-certainty evidence). Serious adverse events: colchicine probably slightly reduces serious adverse events (RR 0.78, 95% CI 0.61 to 1.00; 1 RCT, 4412 participants; moderate-certainty evidence). Colchicine versus another active treatment (e.g. corticosteroids, anti-viral drugs, monoclonal antibodies) No studies evaluated this comparison. Different formulations, doses, or schedules of colchicine No studies assessed this. AUTHORS' CONCLUSIONS Based on the current evidence, in people hospitalised with moderate to severe COVID-19 the use of colchicine probably has little to no influence on mortality or clinical progression in comparison to placebo or standard care alone. We do not know whether colchicine increases the risk of (serious) adverse events. We are uncertain about the evidence of the effect of colchicine on all-cause mortality for people with asymptomatic infection or mild disease. However, colchicine probably results in a slight reduction of hospital admissions or deaths within 28 days, and the rate of serious adverse events compared with placebo. None of the studies reported data on quality of life or compared the benefits and harms of colchicine versus other drugs, or different dosages of colchicine. We identified 17 ongoing and 11 completed but not published RCTs, which we expect to incorporate in future versions of this review as their results become available. Editorial note: due to the living approach of this work, we monitor newly published results of RCTs on colchicine on a weekly basis and will update the review when the evidence or our certainty in the evidence changes.
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Affiliation(s)
- Agata Mikolajewska
- Department of Infectious Diseases and Respiratory Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Anna-Lena Fischer
- Department of Anaesthesia and Intensive care, Universitätsklinikum Leipzig, 04103 Leipzig, Germany
| | - Vanessa Piechotta
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Anika Mueller
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Maria-Inti Metzendorf
- Cochrane Metabolic and Endocrine Disorders Group, Institute of General Practice, Medical Faculty of the Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Marie Becker
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Elena Dorando
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Rafael L Pacheco
- Center of Health Technology Assessment, Hospital Sírio-Libanês, São Paulo, Brazil
- Núcleo de Ensino e Pesquisa em Saúde Baseada em Evidências e Avaliação Tecnológica em Saúde (NEP-Sbeats), Universidade Federal de São Paulo, São Paulo, Brazil
- Cochrane Affiliate Rio de Janeiro, Cochrane, Petrópolis, Brazil
| | - Ana Luiza C Martimbianco
- Center of Health Technology Assessment, Hospital Sírio-Libanês, São Paulo, Brazil
- Cochrane Affiliate Rio de Janeiro, Cochrane, Petrópolis, Brazil
- Postgraduate Program in Health and Environment, Universidade Metropolitana de Santos (UNIMES), Santos, Brazil
- Núcleo de Ensino e Pesquisa em Saúde Baseada em Evidências e Avaliação de Tecnologias em Saúde (NEP-Sbeats), Universidade Federal de São Paulo, São Paulo, Brazil
| | - Rachel Riera
- Cochrane Affiliate Rio de Janeiro, Cochrane, Petrópolis, Brazil
- Núcleo de Ensino e Pesquisa em Saúde Baseada em Evidências e Avaliação de Tecnologias em Saúde (NEP-Sbeats), Universidade Federal de São Paulo, São Paulo, Brazil
- Centre of Health Technology Assessment, Hospital Sírio-Libanês, São Paulo, Brazil
| | - Nicole Skoetz
- Cochrane Cancer, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Miriam Stegemann
- Department of Infectious Diseases and Respiratory Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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Körper S, Weiss M, Zickler D, Wiesmann T, Zacharowski K, Corman VM, Grüner B, Ernst L, Spieth P, Lepper PM, Bentz M, Zinn S, Paul G, Kalbhenn J, Dollinger MM, Rosenberger P, Kirschning T, Thiele T, Appl T, Mayer B, Schmidt M, Drosten C, Wulf H, Kruse JM, Jungwirth B, Seifried E, Schrezenmeier H. Results of the CAPSID randomized trial for high-dose convalescent plasma in patients with severe COVID-19. J Clin Invest 2021; 131:e152264. [PMID: 34464358 DOI: 10.1172/jci152264] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 08/26/2021] [Indexed: 02/01/2023] Open
Abstract
BACKGROUNDCOVID-19 convalescent plasma (CCP) has been considered a treatment option for COVID-19. This trial assessed the efficacy of a neutralizing antibody containing high-dose CCP in hospitalized adults with COVID-19 requiring respiratory support or intensive care treatment.METHODSPatients (n = 105) were randomized 1:1 to either receive standard treatment and 3 units of CCP or standard treatment alone. Control group patients with progress on day 14 could cross over to the CCP group. The primary outcome was a dichotomous composite outcome of survival and no longer fulfilling criteria for severe COVID-19 on day 21.ResultsThe primary outcome occurred in 43.4% of patients in the CCP group and 32.7% in the control group (P = 0.32). The median time to clinical improvement was 26 days in the CCP group and 66 days in the control group (P = 0.27). The median time to discharge from the hospital was 31 days in the CCP group and 51 days in the control group (P = 0.24). In the subgroup that received a higher cumulative amount of neutralizing antibodies, the primary outcome occurred in 56.0% of the patients (vs. 32.1%), with significantly shorter intervals to clinical improvement (20 vs. 66 days, P < 0.05) and to hospital discharge (21 vs. 51 days, P = 0.03) and better survival (day-60 probability of survival 91.6% vs. 68.1%, P = 0.02) in comparison with the control group.ConclusionCCP added to standard treatment was not associated with a significant improvement in the primary and secondary outcomes. A predefined subgroup analysis showed a significant benefit of CCP among patients who received a larger amount of neutralizing antibodies.Trial registrationClinicalTrials.gov NCT04433910.FundingBundesministerium für Gesundheit (German Federal Ministry of Health): ZMVI1-2520COR802.
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Affiliation(s)
- Sixten Körper
- Institute for Clinical Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Transfusion Service Baden-Württemberg-Hessen and University Hospital Ulm, and Institute of Transfusion Medicine, and
| | - Manfred Weiss
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Ulm, Ulm University, Ulm, Germany
| | - Daniel Zickler
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, corporate member of Free University Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Thomas Wiesmann
- Department of Anaesthesiology and Intensive Care Medicine, Philipps University Marburg, Marburg, Germany
| | - Kai Zacharowski
- Clinic of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany
| | - Victor M Corman
- Institute of Virology, Charité - Universitätsmedizin Berlin, corporate member of Free University Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health and German Centre for Infection Research, Berlin, Germany
| | - Beate Grüner
- Division of Infectious Diseases, University Hospital and Medical Center Ulm, Ulm, Germany
| | - Lucas Ernst
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, corporate member of Free University Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Peter Spieth
- Department of Anesthesiology and Critical Care Medicine, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Philipp M Lepper
- Department of Internal Medicine V - Pneumology, Allergology, Intensive Care Medicine, Saarland University Hospital, Homburg, Germany
| | - Martin Bentz
- Department of Internal Medicine III, Hospital of Karlsruhe, Karlsruhe, Germany
| | - Sebastian Zinn
- Clinic of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany
| | - Gregor Paul
- Department of Gastroenterology, Hepatology, Pneumology and Infectious Diseases, Klinikum Stuttgart, Stuttgart, Germany
| | - Johannes Kalbhenn
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | | | - Peter Rosenberger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Tübingen, Tübingen, Germany
| | - Thomas Kirschning
- Department of Anaesthesiology and Surgical Intensive Care Medicine, University of Heidelberg, University Medical Centre Mannheim, Mannheim, Germany
| | - Thomas Thiele
- Institute of Immunology and Transfusion Medicine, University Hospital Greifswald, Greifswald, Germany
| | - Thomas Appl
- Institute for Clinical Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Transfusion Service Baden-Württemberg-Hessen and University Hospital Ulm, and Institute of Transfusion Medicine, and
| | - Benjamin Mayer
- Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany
| | - Michael Schmidt
- Institute of Transfusion Medicine and Immunohematology, German Red Cross Blood Transfusion Service Baden-Württemberg-Hessen, Frankfurt, Germany
| | - Christian Drosten
- Institute of Virology, Charité - Universitätsmedizin Berlin, corporate member of Free University Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health and German Centre for Infection Research, Berlin, Germany
| | - Hinnerk Wulf
- Department of Anaesthesiology and Intensive Care Medicine, Philipps University Marburg, Marburg, Germany
| | - Jan Matthias Kruse
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, corporate member of Free University Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Bettina Jungwirth
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Ulm, Ulm University, Ulm, Germany
| | - Erhard Seifried
- Institute of Transfusion Medicine and Immunohematology, German Red Cross Blood Transfusion Service Baden-Württemberg-Hessen, Frankfurt, Germany
| | - Hubert Schrezenmeier
- Institute for Clinical Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Transfusion Service Baden-Württemberg-Hessen and University Hospital Ulm, and Institute of Transfusion Medicine, and
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56
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Kimber C, Valk SJ, Chai KL, Piechotta V, Iannizzi C, Monsef I, Wood EM, Lamikanra AA, Roberts DJ, McQuilten Z, So-Osman C, Estcourt LJ, Skoetz N. Hyperimmune immunoglobulin for people with COVID-19. Hippokratia 2021. [DOI: 10.1002/14651858.cd015167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
| | - Sarah J Valk
- Center for Clinical Transfusion Research/Clinical Epidemiology; Sanquin/Leiden University Medical Center; Leiden Netherlands
| | - Khai Li Chai
- Transfusion Research Unit, School of Public Health and Preventive Medicine; Monash University; Melbourne Australia
| | - Vanessa Piechotta
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cochrane Haematology; Faculty of Medicine and University Hospital Cologne, University of Cologne; Cologne Germany
| | | | - Ina Monsef
- Faculty of Medicine and University Hospital Cologne, University of Cologne; Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Cochrane Haematology; Cologne Germany
| | - Erica M Wood
- Transfusion Research Unit, School of Public Health and Preventive Medicine; Monash University; Melbourne Australia
| | | | - David J Roberts
- Systematic Review Initiative; NHS Blood and Transplant; Oxford UK
| | - Zoe McQuilten
- Transfusion Research Unit, School of Public Health and Preventive Medicine; Monash University; Melbourne Australia
| | - Cynthia So-Osman
- Sanquin Blood Bank; Erasmus Medical Center; Amsterdam Netherlands
| | - Lise J Estcourt
- Haematology/Transfusion Medicine; NHS Blood and Transplant; Oxford UK
| | - Nicole Skoetz
- Faculty of Medicine and University Hospital Cologne, Department of Internal Medicine; Center for Integrated Oncology, University of Cologne; Cologne Germany
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57
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Glatt TN, Hilton C, Nyoni C, Swarts A, Swanevelder R, Cowley J, Mmenu C, Moyo-Gwete T, Moore PL, Kutama M, Jaza J, Phayane I, Brits T, Koekemoer J, Jentsch U, Nelson D, van den Berg K, Vermeulen M. Rapid and Successful Implementation of a COVID-19 Convalescent Plasma Programme-The South African Experience. Viruses 2021; 13:2050. [PMID: 34696480 PMCID: PMC8539971 DOI: 10.3390/v13102050] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 10/04/2021] [Accepted: 10/04/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND COVID-19 convalescent plasma (CCP) has been considered internationally as a treatment option for COVID-19. CCP refers to plasma collected from donors who have recovered from and made antibodies to SARS-CoV-2. To date, convalescent plasma has not been collected in South Africa. As other investigational therapies and vaccination were not widely accessible, there was an urgent need to implement a CCP manufacture programme to service South Africans. METHODS The South African National Blood Service and the Western Cape Blood Service implemented a CCP programme that included CCP collection, processing, testing and storage. CCP units were tested for SARS-CoV-2 Spike ELISA and neutralising antibodies and routine blood transfusion parameters. CCP units from previously pregnant females were tested for anti-HLA and anti-HNA antibodies. RESULTS A total of 987 CCP units were collected from 243 donors, with a median of three donations per donor. Half of the CCP units had neutralising antibody titres of >1:160. One CCP unit was positive on the TPHA serology. All CCP units tested for anti-HLA antibodies were positive. CONCLUSION Within three months of the first COVID-19 diagnosis in South Africa, a fully operational CCP programme was set up across South Africa. The infrastructure and skills implemented will likely benefit South Africans in this and future pandemics.
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Affiliation(s)
- Tanya Nadia Glatt
- Medical Division, South African National Blood Service, Roodepoort 1709, South Africa; (C.N.); (A.S.); (R.S.); (U.J.); (D.N.); (K.v.d.B.)
| | - Caroline Hilton
- Medical Division, Western Cape Blood Service, Cape Town 7405, South Africa;
| | - Cynthia Nyoni
- Medical Division, South African National Blood Service, Roodepoort 1709, South Africa; (C.N.); (A.S.); (R.S.); (U.J.); (D.N.); (K.v.d.B.)
| | - Avril Swarts
- Medical Division, South African National Blood Service, Roodepoort 1709, South Africa; (C.N.); (A.S.); (R.S.); (U.J.); (D.N.); (K.v.d.B.)
| | - Ronel Swanevelder
- Medical Division, South African National Blood Service, Roodepoort 1709, South Africa; (C.N.); (A.S.); (R.S.); (U.J.); (D.N.); (K.v.d.B.)
| | - James Cowley
- Operations Division, South African National Blood Service, Roodepoort 1709, South Africa; (J.C.); (C.M.); (M.K.); (J.J.); (I.P.); (M.V.)
| | - Cordelia Mmenu
- Operations Division, South African National Blood Service, Roodepoort 1709, South Africa; (J.C.); (C.M.); (M.K.); (J.J.); (I.P.); (M.V.)
| | - Thandeka Moyo-Gwete
- National Institute for Communicable Diseases of the National Health Laboratory Services, Johannesburg 2192, South Africa; (T.M.-G.); (P.L.M.)
- MRC Antibody Immunity Research Unit, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2000, South Africa
| | - Penny L. Moore
- National Institute for Communicable Diseases of the National Health Laboratory Services, Johannesburg 2192, South Africa; (T.M.-G.); (P.L.M.)
- MRC Antibody Immunity Research Unit, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg 2000, South Africa
| | - Munzhedzi Kutama
- Operations Division, South African National Blood Service, Roodepoort 1709, South Africa; (J.C.); (C.M.); (M.K.); (J.J.); (I.P.); (M.V.)
| | - Jabulisile Jaza
- Operations Division, South African National Blood Service, Roodepoort 1709, South Africa; (J.C.); (C.M.); (M.K.); (J.J.); (I.P.); (M.V.)
| | - Itumeleng Phayane
- Operations Division, South African National Blood Service, Roodepoort 1709, South Africa; (J.C.); (C.M.); (M.K.); (J.J.); (I.P.); (M.V.)
| | - Tinus Brits
- Information Technology Division, South African National Blood Service, Roodepoort 1709, South Africa; (T.B.); (J.K.)
| | - Johan Koekemoer
- Information Technology Division, South African National Blood Service, Roodepoort 1709, South Africa; (T.B.); (J.K.)
| | - Ute Jentsch
- Medical Division, South African National Blood Service, Roodepoort 1709, South Africa; (C.N.); (A.S.); (R.S.); (U.J.); (D.N.); (K.v.d.B.)
| | - Derrick Nelson
- Medical Division, South African National Blood Service, Roodepoort 1709, South Africa; (C.N.); (A.S.); (R.S.); (U.J.); (D.N.); (K.v.d.B.)
| | - Karin van den Berg
- Medical Division, South African National Blood Service, Roodepoort 1709, South Africa; (C.N.); (A.S.); (R.S.); (U.J.); (D.N.); (K.v.d.B.)
- Division of Clinical Haematology, Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town 7935, South Africa
- Division of Clinical Haematology, University of the Free State, Bloemfontein 9301, South Africa
| | - Marion Vermeulen
- Operations Division, South African National Blood Service, Roodepoort 1709, South Africa; (J.C.); (C.M.); (M.K.); (J.J.); (I.P.); (M.V.)
- Division of Clinical Haematology, University of the Free State, Bloemfontein 9301, South Africa
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Convalescent Plasma for Patients Hospitalized With Coronavirus Disease 2019: A Meta-Analysis With Trial Sequential Analysis of Randomized Controlled Trials. Transfus Med Rev 2021; 36:16-26. [PMID: 34782209 PMCID: PMC8502250 DOI: 10.1016/j.tmrv.2021.09.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 09/24/2021] [Accepted: 09/29/2021] [Indexed: 02/06/2023]
Abstract
Current evidence from randomized controlled trials (RCTs) and systematic reviews on the utility of convalescent plasma (CP) in patients with coronavirus disease 2019 (COVID-19) suggests a lack of benefit. We conducted an updated meta-analysis of RCTs with trial sequential analysis to investigate whether convalescent plasma is futile in reducing mortality in patients hospitalized with COVID-19. We searched 6 databases from December 1, 2019 to August 1, 2021 for RCTs comparing the use of CP with standard of care or transfusion of non-CP standard plasma in patients with COVID-19. The risk of bias was assessed using the Cochrane Risk-of-Bias 2 Tool. Random effects (DerSimonian and Laird) meta-analyses were conducted. The primary outcome was the aggregate risk for in-hospital mortality between both arms. We conducted a trial sequential analysis (TSA) based on the pooled relative risks (RRs) for in-hospital mortality. Secondary outcomes included the pooled RR for receipt of mechanical ventilation and mean difference in hospital length of stay. We included 18 RCTs (8702 CP, 7906 control). CP was not associated with a significant mortality benefit (RR: 0.95, 95%-CI: 0.86-1.04, P = .27, high certainty). Subgroup analysis did not find any significant differences (pinteraction = 0.30) between patients who received CP within 8 days of symptom onset (RR: 0.97, 95%-CI: 0.79-1.19, P = .80), or after 8 days (RR: 0.79, 95%-CI: 0.57-1.10, P = .16). TSA based on a RR reduction of 10% from a baseline mortality of 20% found that CP was not effective, with the pooled effect within the boundary for futility. CP did not significantly reduce the requirement for mechanical ventilation (RR: 1.00, 95%-CI: 0.91-1.10, P = .99, moderate certainty) or hospital length of stay (+1.32, 95%-CI: -1.86 to +4.52, P = .42, low certainty). CP does not improve relevant clinical outcomes in patients with COVID-19, especially in severe disease. The pooled effect of mortality was within the boundary of futility, suggesting the lack of benefit of CP in patients hospitalized with COVID-19.
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59
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Cao H, Ming L, Chen L, Zhu X, Shi Y. The Effectiveness of Convalescent Plasma for the Treatment of Novel Corona Virus Disease 2019: A Systematic Review and Meta-Analysis. Front Med (Lausanne) 2021; 8:641429. [PMID: 34646833 PMCID: PMC8502818 DOI: 10.3389/fmed.2021.641429] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 08/24/2021] [Indexed: 12/19/2022] Open
Abstract
Background: Coronavirus disease 2019 (COVID-19), sweeping across the world, has created a worldwide pandemic. Effective treatments of COVID-19 are extremely urgent. Objective: To analyze the efficacy and safety of convalescent plasma (CCP) on patients with COVID-19. Methods: All the relevant studies were searched from PubMed, EMBASE,Cochrane library, Scopus, Web of Science, CBM, CNKI, Wan fang, VIP, Medrxiv, Biorxiv, and SSRN on July 19, 2021. PICOS criteria were as follows: (P) the study interests were human subjects with the infection of COVID-19; (I) the intervention of interest was CCP; (C) comparator treatments contained placebo, sham therapy, and standard treatment; (O) the primary outcome was mortality rates by the novel coronavirus. The secondary outcomes included the incidence of serious adverse events, the rate of ICU admission and mechanical ventilation (MV); the length of hospital stay; the duration of MV and ICU stay; the antibody levels, inflammatory factor levels, and viral loads. (S) Only randomized controlled trials (RCTs) of CCP were included. Subanalysis, quality assessment, sensitive analysis, and publication bias were conducted by two reviewers independently. Results: Sixteen RCTs were included and enrolled a total of 16,296 participants in this meta-analysis. The pooled data showed that no significant difference was observed in reducing the rate of overall mortality between CCP treatment group and placebo group (OR 0.96; 95% CI 0.90 to 1.03; p = 0.30; I 2 = 6%). According to the results of subgroup analysis, severe or critical patients with CCP showed significant difference in reducing the 28-day mortality of compared with placebo (OR 0.58, 95% CI 0.36 to 0.93, p = 0.02, I 2 = 0%). CCP groups have a significantly shorter duration of MV compared with the control group (weighted MD -1.00, 95% CI -1.86 to -0.14 d p = 0.02, I 2 = 0%). No significant difference was observed in the length of hospital stay, the duration of ICU, and the rate of ICU and MV. There is no conclusive evidence about the safety of CCP. Conclusion: Convalescent plasma can significantly reduce the 28-day mortality of severe or critical COVID-19 patients and the duration of MV. However, more evidence was needed to prove the safety of convalescent plasma.
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Affiliation(s)
- Huiling Cao
- Department of Neonatology, Children's Hospital of Chongqing Medical University, Chongqing, China
- National Clinical Research Center for Child Health and Disorders, Chongqing, China
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Li Ming
- National Clinical Research Center for Child Health and Disorders, Chongqing, China
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
- Department of Cardiology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Long Chen
- Department of Neonatology, Children's Hospital of Chongqing Medical University, Chongqing, China
- National Clinical Research Center for Child Health and Disorders, Chongqing, China
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Xingwang Zhu
- Department of Pediatrics, Jiulongpo People's Hospital, Chongqing, China
| | - Yuan Shi
- Department of Neonatology, Children's Hospital of Chongqing Medical University, Chongqing, China
- National Clinical Research Center for Child Health and Disorders, Chongqing, China
- Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing, China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing, China
- Chongqing Key Laboratory of Pediatrics, Chongqing, China
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60
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Safety and Efficacy of Convalescent Plasma in COVID-19: An Overview of Systematic Reviews. Diagnostics (Basel) 2021; 11:diagnostics11091663. [PMID: 34574004 PMCID: PMC8467957 DOI: 10.3390/diagnostics11091663] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 09/06/2021] [Accepted: 09/09/2021] [Indexed: 12/27/2022] Open
Abstract
Convalescent plasma (CP) from patients recovered from COVID-19 is one of the most studied anti-viral therapies against SARS-COV-2 infection. The aim of this study is to summarize the evidence from the available systematic reviews on the efficacy and safety of CP in COVID-19 through an overview of the published systematic reviews (SRs). A systematic literature search was conducted up to August 2021 in Embase, PubMed, Web of Science, Cochrane and Medrxiv databases to identify systematic reviews focusing on CP use in COVID-19. Two review authors independently evaluated reviews for inclusion, extracted data and assessed quality of evidence using AMSTAR (A Measurement Tool to Assess Reviews) and GRADE tools. The following outcomes were analyzed: mortality, viral clearance, clinical improvement, length of hospital stay, adverse reactions. In addition, where possible, subgroup analyses were performed according to study design (e.g., RCTs vs. non-RCTs), CP neutralizing antibody titer and timing of administration, and disease severity. The methodological quality of included studies was assessed using the checklist for systematic reviews AMSTAR-2 and the GRADE assessment. Overall, 29 SRs met the inclusion criteria based on 53 unique primary studies (17 RCT and 36 non-RCT). Limitations to the methodological quality of reviews most commonly related to absence of a protocol (11/29) and funding sources of primary studies (27/29). Of the 89 analyses on which GRADE judgements were made, effect estimates were judged to be of high/moderate certainty in four analyses, moderate in 38, low in 38, very low in nine. Despite the variability in the certainty of the evidence, mostly related to the risk of bias and inconsistency, the results of this umbrella review highlight a mortality reduction in CP over standard therapy when administered early and at high titer, without increased adverse reactions.
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Bégin P, Callum J, Jamula E, Cook R, Heddle NM, Tinmouth A, Zeller MP, Beaudoin-Bussières G, Amorim L, Bazin R, Loftsgard KC, Carl R, Chassé M, Cushing MM, Daneman N, Devine DV, Dumaresq J, Fergusson DA, Gabe C, Glesby MJ, Li N, Liu Y, McGeer A, Robitaille N, Sachais BS, Scales DC, Schwartz L, Shehata N, Turgeon AF, Wood H, Zarychanski R, Finzi A, Arnold DM. Convalescent plasma for hospitalized patients with COVID-19: an open-label, randomized controlled trial. Nat Med 2021; 27:2012-2024. [PMID: 34504336 PMCID: PMC8604729 DOI: 10.1038/s41591-021-01488-2] [Citation(s) in RCA: 176] [Impact Index Per Article: 58.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 08/02/2021] [Indexed: 12/24/2022]
Abstract
The efficacy of convalescent plasma for coronavirus disease 2019 (COVID-19) is unclear. Although most randomized controlled trials have shown negative results, uncontrolled studies have suggested that the antibody content could influence patient outcomes. We conducted an open-label, randomized controlled trial of convalescent plasma for adults with COVID-19 receiving oxygen within 12 d of respiratory symptom onset (NCT04348656). Patients were allocated 2:1 to 500 ml of convalescent plasma or standard of care. The composite primary outcome was intubation or death by 30 d. Exploratory analyses of the effect of convalescent plasma antibodies on the primary outcome was assessed by logistic regression. The trial was terminated at 78% of planned enrollment after meeting stopping criteria for futility. In total, 940 patients were randomized, and 921 patients were included in the intention-to-treat analysis. Intubation or death occurred in 199/614 (32.4%) patients in the convalescent plasma arm and 86/307 (28.0%) patients in the standard of care arm—relative risk (RR) = 1.16 (95% confidence interval (CI) 0.94–1.43, P = 0.18). Patients in the convalescent plasma arm had more serious adverse events (33.4% versus 26.4%; RR = 1.27, 95% CI 1.02–1.57, P = 0.034). The antibody content significantly modulated the therapeutic effect of convalescent plasma. In multivariate analysis, each standardized log increase in neutralization or antibody-dependent cellular cytotoxicity independently reduced the potential harmful effect of plasma (odds ratio (OR) = 0.74, 95% CI 0.57–0.95 and OR = 0.66, 95% CI 0.50–0.87, respectively), whereas IgG against the full transmembrane spike protein increased it (OR = 1.53, 95% CI 1.14–2.05). Convalescent plasma did not reduce the risk of intubation or death at 30 d in hospitalized patients with COVID-19. Transfusion of convalescent plasma with unfavorable antibody profiles could be associated with worse clinical outcomes compared to standard care. A randomized trial in patients hospitalized with COVID-19 showed no benefit and potentially increased harm associated with the use of convalescent plasma, with subgroup analyses suggesting that the antibody profile in donor plasma is critical in determining clinical outcomes.
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Affiliation(s)
- Philippe Bégin
- Department of Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada. .,Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada.
| | - Jeannie Callum
- Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre and Queen's University, Kingston, Ontario, Canada. .,Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada. .,Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada. .,Canadian Blood Services, Ottawa, Ontario, Canada.
| | - Erin Jamula
- McMaster Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - Richard Cook
- Department of Statistics and Actuarial Science, University of Waterloo, Waterloo, Ontario, Canada
| | - Nancy M Heddle
- Canadian Blood Services, Ottawa, Ontario, Canada.,McMaster Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Alan Tinmouth
- Canadian Blood Services, Ottawa, Ontario, Canada.,Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Ottawa Hospital Centre for Transfusion Research, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Michelle P Zeller
- Canadian Blood Services, Ottawa, Ontario, Canada.,McMaster Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada.,Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Guillaume Beaudoin-Bussières
- Département de Microbiologie, Infectiologie et Immunologie, Université de Montréal, Montreal, Quebec, Canada.,CHUM Research Center, Montreal, Quebec, Canada
| | - Luiz Amorim
- Hemorio, Hospital and Regional Blood Center, Rio de Janeiro, Brazil
| | - Renée Bazin
- Héma-Québec, Medical Affairs and Innovation, Quebec City, Quebec, Canada
| | | | - Richard Carl
- Patient representative, Montreal, Quebec, Canada
| | - Michaël Chassé
- Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada.,Innovation Hub, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Melissa M Cushing
- Transfusion Medicine and Cellular Therapy, New York-Presbyterian, New York, NY, USA.,Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Nick Daneman
- Department of Medicine, Division of Infectious Diseases, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Dana V Devine
- Canadian Blood Services, Vancouver, British Columbia, Canada.,Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jeannot Dumaresq
- Département de médecine, CISSS de Chaudière-Appalaches, Lévis, Quebec, Canada.,Département de microbiologie-infectiologie et d'immunologie, Faculté de Médecine, Université Laval, Quebec City, Quebec, Canada
| | - Dean A Fergusson
- Canadian Blood Services, Ottawa, Ontario, Canada.,Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Caroline Gabe
- McMaster Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - Marshall J Glesby
- Division of Infectious Diseases, Weill Cornell Medical College, New York, NY, USA
| | - Na Li
- McMaster Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.,Department of Computing and Software, McMaster University, Hamilton, Ontario, Canada
| | - Yang Liu
- McMaster Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada
| | - Allison McGeer
- Department of Microbiology, Sinai Health System, Toronto, Ontario, Canada.,Department of Laboratory Medicine and Pathobiology and Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Nancy Robitaille
- Héma-Québec, Montreal, Quebec, Canada.,Division of Hematology and Oncology, Department of Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada.,Department of Pediatrics, Université de Montréal, Montreal, Quebec, Canada
| | - Bruce S Sachais
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, NY, USA.,New York Blood Center Enterprises, New York, NY, USA
| | - Damon C Scales
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.,Department of Medicine, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Lisa Schwartz
- Department of Health Research Methods, Evidence & Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Nadine Shehata
- Canadian Blood Services, Ottawa, Ontario, Canada.,Departments of Medicine, Laboratory Medicine and Pathobiology, Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Division of Hematology, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Alexis F Turgeon
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Faculty of Medicine, Université Laval, Quebec City, Quebec, Canada.,CHU de Québec-Université Laval Research Centre, Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Université Laval, Quebec City, Quebec, Canada
| | - Heidi Wood
- Zoonotic Diseases and Special Pathogens, National Microbiology Laboratory, Public Health Agency of Canada, Winnipeg, Manitoba, Canada
| | - Ryan Zarychanski
- Department of Internal Medicine, Sections of Hematology/Medical Oncology and Critical Care, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Andrés Finzi
- Département de Microbiologie, Infectiologie et Immunologie, Université de Montréal, Montreal, Quebec, Canada.,CHUM Research Center, Montreal, Quebec, Canada
| | | | - Donald M Arnold
- McMaster Centre for Transfusion Research, McMaster University, Hamilton, Ontario, Canada. .,Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
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Kreuzberger N, Hirsch C, Chai KL, Tomlinson E, Khosravi Z, Popp M, Neidhardt M, Piechotta V, Salomon S, Valk SJ, Monsef I, Schmaderer C, Wood EM, So-Osman C, Roberts DJ, McQuilten Z, Estcourt LJ, Skoetz N. SARS-CoV-2-neutralising monoclonal antibodies for treatment of COVID-19. Cochrane Database Syst Rev 2021; 9:CD013825. [PMID: 34473343 PMCID: PMC8411904 DOI: 10.1002/14651858.cd013825.pub2] [Citation(s) in RCA: 75] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Monoclonal antibodies (mAbs) are laboratory-produced molecules derived from the B cells of an infected host. They are being investigated as a potential therapy for coronavirus disease 2019 (COVID-19). OBJECTIVES To assess the effectiveness and safety of SARS-CoV-2-neutralising mAbs for treating patients with COVID-19, compared to an active comparator, placebo, or no intervention. To maintain the currency of the evidence, we will use a living systematic review approach. A secondary objective is to track newly developed SARS-CoV-2-targeting mAbs from first tests in humans onwards. SEARCH METHODS: We searched MEDLINE, Embase, the Cochrane COVID-19 Study Register, and three other databases on 17 June 2021. We also checked references, searched citations, and contacted study authors to identify additional studies. Between submission and publication, we conducted a shortened randomised controlled trial (RCT)-only search on 30 July 2021. SELECTION CRITERIA We included studies that evaluated SARS-CoV-2-neutralising mAbs, alone or combined, compared to an active comparator, placebo, or no intervention, to treat people with COVID-19. We excluded studies on prophylactic use of SARS-CoV-2-neutralising mAbs. DATA COLLECTION AND ANALYSIS Two authors independently assessed search results, extracted data, and assessed risk of bias using the Cochrane risk of bias tool (RoB2). Prioritised outcomes were all-cause mortality by days 30 and 60, clinical progression, quality of life, admission to hospital, adverse events (AEs), and serious adverse events (SAEs). We rated the certainty of evidence using GRADE. MAIN RESULTS We identified six RCTs that provided results from 17,495 participants with planned completion dates between July 2021 and December 2031. Target sample sizes varied from 1020 to 10,000 participants. Average age was 42 to 53 years across four studies of non-hospitalised participants, and 61 years in two studies of hospitalised participants. Non-hospitalised individuals with COVID-19 Four studies evaluated single agents bamlanivimab (N = 465), sotrovimab (N = 868), regdanvimab (N = 307), and combinations of bamlanivimab/etesevimab (N = 1035), and casirivimab/imdevimab (N = 799). We did not identify data for mortality at 60 days or quality of life. Our certainty of the evidence is low for all outcomes due to too few events (very serious imprecision). Bamlanivimab compared to placebo No deaths occurred in the study by day 29. There were nine people admitted to hospital by day 29 out of 156 in the placebo group compared with one out of 101 in the group treated with 0.7 g bamlanivimab (risk ratio (RR) 0.17, 95% confidence interval (CI) 0.02 to 1.33), 2 from 107 in the group treated with 2.8 g (RR 0.32, 95% CI 0.07 to 1.47) and 2 from 101 in the group treated with 7.0 g (RR 0.34, 95% CI 0.08 to 1.56). Treatment with 0.7 g, 2.8 g and 7.0 g bamlanivimab may have similar rates of AEs as placebo (RR 0.99, 95% CI 0.66 to 1.50; RR 0.90, 95% CI 0.59 to 1.38; RR 0.81, 95% CI 0.52 to 1.27). The effect on SAEs is uncertain. Clinical progression/improvement of symptoms or development of severe symptoms were not reported. Bamlanivimab/etesevimab compared to placebo There were 10 deaths in the placebo group and none in bamlanivimab/etesevimab group by day 30 (RR 0.05, 95% CI 0.00 to 0.81). Bamlanivimab/etesevimab may decrease hospital admission by day 29 (RR 0.30, 95% CI 0.16 to 0.59), may result in a slight increase in any grade AEs (RR 1.15, 95% CI 0.83 to 1.59) and may increase SAEs (RR 1.40, 95% CI 0.45 to 4.37). Clinical progression/improvement of symptoms or development of severe symptoms were not reported. Casirivimab/imdevimab compared to placebo Casirivimab/imdevimab may reduce hospital admissions or death (2.4 g: RR 0.43, 95% CI 0.08 to 2.19; 8.0 g: RR 0.21, 95% CI 0.02 to 1.79). We are uncertain of the effect on grades 3-4 AEs (2.4 g: RR 0.76, 95% CI 0.17 to 3.37; 8.0 g: RR 0.50, 95% CI 0.09 to 2.73) and SAEs (2.4 g: RR 0.68, 95% CI 0.19 to 2.37; 8.0 g: RR 0.34, 95% CI 0.07 to 1.65). Mortality by day 30 and clinical progression/improvement of symptoms or development of severe symptoms were not reported. Sotrovimab compared to placebo We are uncertain whether sotrovimab has an effect on mortality (RR 0.33, 95% CI 0.01 to 8.18) and invasive mechanical ventilation (IMV) requirement or death (RR 0.14, 95% CI 0.01 to 2.76). Treatment with sotrovimab may reduce the number of participants with oxygen requirement (RR 0.11, 95 % CI 0.02 to 0.45), hospital admission or death by day 30 (RR 0.14, 95% CI 0.04 to 0.48), grades 3-4 AEs (RR 0.26, 95% CI 0.12 to 0.60), SAEs (RR 0.27, 95% CI 0.12 to 0.63) and may have little or no effect on any grade AEs (RR 0.87, 95% CI 0.66 to 1.16). Regdanvimab compared to placebo Treatment with either dose (40 or 80 mg/kg) compared with placebo may decrease hospital admissions or death (RR 0.45, 95% CI 0.14 to 1.42; RR 0.56, 95% CI 0.19 to 1.60, 206 participants), but may increase grades 3-4 AEs (RR 2.62, 95% CI 0.52 to 13.12; RR 2.00, 95% CI 0.37 to 10.70). 80 mg/kg may reduce any grade AEs (RR 0.79, 95% CI 0.52 to 1.22) but 40 mg/kg may have little to no effect (RR 0.96, 95% CI 0.64 to 1.43). There were too few events to allow meaningful judgment for the outcomes mortality by 30 days, IMV requirement, and SAEs. Hospitalised individuals with COVID-19 Two studies evaluating bamlanivimab as a single agent (N = 314) and casirivimab/imdevimab as a combination therapy (N = 9785) were included. Bamlanivimab compared to placebo We are uncertain whether bamlanivimab has an effect on mortality by day 30 (RR 1.39, 95% CI 0.40 to 4.83) and SAEs by day 28 (RR 0.93, 95% CI 0.27 to 3.14). Bamlanivimab may have little to no effect on time to hospital discharge (HR 0.97, 95% CI 0.78 to 1.20) and mortality by day 90 (HR 1.09, 95% CI 0.49 to 2.43). The effect of bamlanivimab on the development of severe symptoms at day 5 (RR 1.17, 95% CI 0.75 to 1.85) is uncertain. Bamlanivimab may increase grades 3-4 AEs at day 28 (RR 1.27, 95% CI 0.81 to 1.98). We assessed the evidence as low certainty for all outcomes due to serious imprecision, and very low certainty for severe symptoms because of additional concerns about indirectness. Casirivimab/imdevimab with usual care compared to usual care alone Treatment with casirivimab/imdevimab compared to usual care probably has little or no effect on mortality by day 30 (RR 0.94, 95% CI 0.87 to 1.02), IMV requirement or death (RR 0.96, 95% CI 0.90 to 1.04), nor alive at hospital discharge by day 30 (RR 1.01, 95% CI 0.98 to 1.04). We assessed the evidence as moderate certainty due to study limitations (lack of blinding). AEs and SAEs were not reported. AUTHORS' CONCLUSIONS: The evidence for each comparison is based on single studies. None of these measured quality of life. Our certainty in the evidence for all non-hospitalised individuals is low, and for hospitalised individuals is very low to moderate. We consider the current evidence insufficient to draw meaningful conclusions regarding treatment with SARS-CoV-2-neutralising mAbs. Further studies and long-term data from the existing studies are needed to confirm or refute these initial findings, and to understand how the emergence of SARS-CoV-2 variants may impact the effectiveness of SARS-CoV-2-neutralising mAbs. Publication of the 36 ongoing studies may resolve uncertainties about the effectiveness and safety of SARS-CoV-2-neutralising mAbs for the treatment of COVID-19 and possible subgroup differences.
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Affiliation(s)
- Nina Kreuzberger
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Caroline Hirsch
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Khai Li Chai
- Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Eve Tomlinson
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Zahra Khosravi
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Maria Popp
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Miriam Neidhardt
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Vanessa Piechotta
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Susanne Salomon
- Laboratory of Experimental Immunology, Institute of Virology, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Sarah J Valk
- Jon J van Rood Center for Clinical Transfusion Research, Sanquin/Leiden University Medical Center, Leiden, Netherlands
| | - Ina Monsef
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Christoph Schmaderer
- Department of Nephrology, Technical University of Munich, School of Medicine, Klinikum rechts der Isar, Munich, Germany
| | - Erica M Wood
- Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | | | - David J Roberts
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Zoe McQuilten
- Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Lise J Estcourt
- Haematology/Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
| | - Nicole Skoetz
- Cochrane Cancer, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
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González Rodríguez P, Pérez-Moneo Agapito B, Albi Rodríguez MS, Aizpurua Galdeano P, Aparicio Rodrigo M, Fernández Rodríguez MM, Esparza Olcina MJ, Ochoa Sangrador C. [COVID-19: Critical appraisal of the evidence]. An Pediatr (Barc) 2021; 95:207.e1-207.e13. [PMID: 38620739 PMCID: PMC8173476 DOI: 10.1016/j.anpedi.2021.05.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 05/28/2021] [Indexed: 12/18/2022] Open
Abstract
We present the summary of a critical appraisal document of the available evidence on COVID-19, developed with a clinical practice guide format following GRADE methodology. The document tries to provide answers to a series of structured clinical questions, with an explicit definition of the population, intervention/exposure, comparison and outcome, and a rating of the clinical relevance of the outcome measures. We conducted a systematic review of the literature to answer the questions, grouped into six chapters: epidemiology, clinical practice, diagnosis, treatment, prevention, and vaccination. We assessed the risk of bias of the selected studies with standard instruments (RoB-2, ROBINS-I, QUADAS and Newcastle-Ottawa). We constructed evidence tables and, when necessary and possible, meta-analysis of the of the most relevant outcome measures. We followed the GRADE system to synthesize the evidence, assessing its quality, and, when appropriate, giving recommendations, rated according to the quality of the evidence, the values and preferences, the balance between benefits, risks and costs, equity and feasibility.
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Huang L, Zhang C, Zhou X, Zhao Z, Wang W, Leng W, Su X, Lian Q. Convalescent plasma is of limited clinical benefit in critically ill patients with coronavirus disease-2019: a cohort study. J Transl Med 2021; 19:365. [PMID: 34446049 PMCID: PMC8390032 DOI: 10.1186/s12967-021-03028-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 08/06/2021] [Indexed: 01/08/2023] Open
Abstract
Background Recently, convalescent plasma (CP) transfusion was employed for severe or critically ill patients with coronavirus disease-2019. However, the benefits of CP for patients with different conditions are still in debate. To contribute clinical evidence of CP on critically ill patients, we analyze the characteristics and outcomes of patients with or without CP transfusion. Methods In this cohort study, 14 patients received CP transfusion based on the standard treatments, whereas the other 10 patients received standard treatments as control. Clinical characteristics and outcomes were analyzed. The cumulative survival rate was calculated by Kaplan–Meier survival analysis. Results Data analysis was performed on 24 patients (male/female: 15/9) with a median age of 64.0 (44.5–74.5) years. Transient fever was reported in one patient. The cumulative mortality was 21% (3/14) in patients receiving CP transfusion during a 28-day observation, whereas one dead case (1/10) was reported in the control group. No significant difference was detected between groups in 28-day mortality (P = 0.615) and radiological alleviation of lung lesions (P = 0.085). Conclusion In our current study, CP transfusion was clinically safe based on the safety profile; however, the clinical benefit was not significant in critically ill patients with more comorbidities at the late stage of disease during a 28-day observation. Graphic abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1186/s12967-021-03028-5.
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Affiliation(s)
- Li Huang
- The Joint Center for Infection and Immunity, Guangzhou Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou 510623, China; Institute Pasteur of Shanghai, Chinese Academy of Science, Shanghai, 200031, China.,Clinical Research Centre, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Che Zhang
- Clinical Research Centre, Taihe Hospital, Hubei University of Medicine, Shiyan, China.,Intensive Care Unit, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Xihui Zhou
- Intensive Care Unit, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Zhou Zhao
- Intensive Care Unit, Shiyan People Hospital, Shiyan, China
| | - Weiping Wang
- Department of Respiratory Medicine, Shiyan Xiyuan Hospital, Shiyan, China
| | - Weidong Leng
- Clinical Research Centre, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Xiao Su
- The Joint Center for Infection and Immunity, Guangzhou Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou 510623, China; Institute Pasteur of Shanghai, Chinese Academy of Science, Shanghai, 200031, China.
| | - Qizhou Lian
- The Joint Center for Infection and Immunity, Guangzhou Institute of Pediatrics, Guangzhou Women and Children's Medical Center, Guangzhou 510623, China; Institute Pasteur of Shanghai, Chinese Academy of Science, Shanghai, 200031, China. .,Department of Medicine, LKS Faculty of Medicine, The University of Hong Kong, Hong Kong, China. .,HKUMed Laboratory of Cellular Therapeutics, The University of Hong Kong, Hong Kong, China.
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Andreas M, Piechotta V, Skoetz N, Grummich K, Becker M, Joos L, Becker G, Meissner W, Boehlke C. Interventions for palliative symptom control in COVID-19 patients. Cochrane Database Syst Rev 2021; 8:CD015061. [PMID: 34425019 PMCID: PMC8406995 DOI: 10.1002/14651858.cd015061] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Individuals dying of coronavirus disease 2019 (COVID-19) may experience distressing symptoms such as breathlessness or delirium. Palliative symptom management can alleviate symptoms and improve the quality of life of patients. Various treatment options such as opioids or breathing techniques have been discussed for use in COVID-19 patients. However, guidance on symptom management of COVID-19 patients in palliative care has often been derived from clinical experiences and guidelines for the treatment of patients with other illnesses. An understanding of the effectiveness of pharmacological and non-pharmacological palliative interventions to manage specific symptoms of COVID-19 patients is required. OBJECTIVES To assess the efficacy and safety of pharmacological and non-pharmacological interventions for palliative symptom control in individuals with COVID-19. SEARCH METHODS We searched the Cochrane COVID-19 Study Register (including Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (PubMed), Embase, ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), medRxiv); Web of Science Core Collection (Science Citation Index Expanded, Emerging Sources); CINAHL; WHO COVID-19 Global literature on coronavirus disease; and COAP Living Evidence on COVID-19 to identify completed and ongoing studies without language restrictions until 23 March 2021. We screened the reference lists of relevant review articles and current treatment guidelines for further literature. SELECTION CRITERIA We followed standard Cochrane methodology as outlined in the Cochrane Handbook for Systematic Reviews of Interventions. We included studies evaluating palliative symptom management for individuals with a confirmed diagnosis of COVID-19 receiving interventions for palliative symptom control, with no restrictions regarding comorbidities, age, gender, or ethnicity. Interventions comprised pharmacological as well as non-pharmacological treatment (e.g. acupressure, physical therapy, relaxation, or breathing techniques). We searched for the following types of studies: randomized controlled trials (RCT), quasi-RCTs, controlled clinical trials, controlled before-after studies, interrupted time series (with comparison group), prospective cohort studies, retrospective cohort studies, (nested) case-control studies, and cross-sectional studies. We searched for studies comparing pharmacological and non-pharmacological interventions for palliative symptom control with standard care. We excluded studies evaluating palliative interventions for symptoms caused by other terminal illnesses. If studies enrolled populations with or exposed to multiple diseases, we would only include these if the authors provided subgroup data for individuals with COVID-19. We excluded studies investigating interventions for symptom control in a curative setting, for example patients receiving life-prolonging therapies such as invasive ventilation. DATA COLLECTION AND ANALYSIS: We used a modified version of the Newcastle Ottawa Scale for non-randomized studies of interventions (NRSIs) to assess bias in the included studies. We included the following outcomes: symptom relief (primary outcome); quality of life; symptom burden; satisfaction of patients, caregivers, and relatives; serious adverse events; and grade 3 to 4 adverse events. We rated the certainty of evidence using the GRADE approach. As meta-analysis was not possible, we used tabulation to synthesize the studies and histograms to display the outcomes. MAIN RESULTS: Overall, we identified four uncontrolled retrospective cohort studies investigating pharmacological interventions for palliative symptom control in hospitalized patients and patients in nursing homes. None of the studies included a comparator. We rated the risk of bias high across all studies. We rated the certainty of the evidence as very low for the primary outcome symptom relief, downgrading mainly for high risk of bias due to confounding and unblinded outcome assessors. Pharmacological interventions for palliative symptom control We identified four uncontrolled retrospective cohort studies (five references) investigating pharmacological interventions for palliative symptom control. Two references used the same register to form their cohorts, and study investigators confirmed a partial overlap of participants. We therefore do not know the exact number of participants, but individual reports included 61 to 2105 participants. Participants received multimodal pharmacological interventions: opioids, neuroleptics, anticholinergics, and benzodiazepines for relieving dyspnea (breathlessness), delirium, anxiety, pain, audible upper airway secretions, respiratory secretions, nausea, cough, and unspecified symptoms. Primary outcome: symptom relief All identified studies reported this outcome. For all symptoms (dyspnea, delirium, anxiety, pain, audible upper airway secretions, respiratory secretions, nausea, cough, and unspecified symptoms), a majority of interventions were rated as completely or partially effective by outcome assessors (treating clinicians or nursing staff). Interventions used in the studies were opioids, neuroleptics, anticholinergics, and benzodiazepines. We are very uncertain about the effect of pharmacological interventions on symptom relief (very low-certainty evidence). The initial rating of the certainty of evidence was low since we only identified uncontrolled NRSIs. Our main reason for downgrading the certainty of evidence was high risk of bias due to confounding and unblinded outcome assessors. We therefore did not find evidence to confidently support or refute whether pharmacological interventions may be effective for palliative symptom relief in COVID-19 patients. Secondary outcomes We planned to include the following outcomes: quality of life; symptom burden; satisfaction of patients, caregivers, and relatives; serious adverse events; and grade 3 to 4 adverse events. We did not find any data for these outcomes, or any other information on the efficacy and safety of used interventions. Non-pharmacological interventions for palliative symptom control None of the identified studies used non-pharmacological interventions for palliative symptom control. AUTHORS' CONCLUSIONS We found very low certainty evidence for the efficacy of pharmacological interventions for palliative symptom relief in COVID-19 patients. We found no evidence on the safety of pharmacological interventions or efficacy and safety of non-pharmacological interventions for palliative symptom control in COVID-19 patients. The evidence presented here has no specific implications for palliative symptom control in COVID-19 patients because we cannot draw any conclusions about the effectiveness or safety based on the identified evidence. More evidence is needed to guide clinicians, nursing staff, and caregivers when treating symptoms of COVID-19 patients at the end of life. Specifically, future studies ought to investigate palliative symptom control in prospectively registered studies, using an active-controlled setting, assess patient-reported outcomes, and clearly define interventions. The publication of the results of ongoing studies will necessitate an update of this review. The conclusions of an updated review could differ from those of the present review and may allow for a better judgement regarding pharmacological and non-pharmacological interventions for palliative symptom control in COVID-19 patients.
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Affiliation(s)
- Marike Andreas
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Vanessa Piechotta
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Nicole Skoetz
- Cochrane Cancer, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Kathrin Grummich
- Cochrane Germany, Cochrane Germany Foundation, Freiburg, Germany
| | - Marie Becker
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Lisa Joos
- Department of Palliative Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Gerhild Becker
- Department of Palliative Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Winfried Meissner
- Department for Anesthesiology and Intensive Care Medicine/ Department of Palliative Care, University Hospital of Jena, Jena, Germany
| | - Christopher Boehlke
- Department of Palliative Care, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Wagner C, Griesel M, Mikolajewska A, Mueller A, Nothacker M, Kley K, Metzendorf MI, Fischer AL, Kopp M, Stegemann M, Skoetz N, Fichtner F. Systemic corticosteroids for the treatment of COVID-19. Cochrane Database Syst Rev 2021; 8:CD014963. [PMID: 34396514 PMCID: PMC8406706 DOI: 10.1002/14651858.cd014963] [Citation(s) in RCA: 80] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Systemic corticosteroids are used to treat people with COVID-19 because they counter hyper-inflammation. Existing evidence syntheses suggest a slight benefit on mortality. So far, systemic corticosteroids are one of the few treatment options for COVID-19. Nonetheless, size of effect, certainty of the evidence, optimal therapy regimen, and selection of patients who are likely to benefit most are factors that remain to be evaluated. OBJECTIVES To assess whether systemic corticosteroids are effective and safe in the treatment of people with COVID-19, and to keep up to date with the evolving evidence base using a living systematic review approach. SEARCH METHODS We searched the Cochrane COVID-19 Study Register (which includes PubMed, Embase, CENTRAL, ClinicalTrials.gov, WHO ICTRP, and medRxiv), Web of Science (Science Citation Index, Emerging Citation Index), and the WHO COVID-19 Global literature on coronavirus disease to identify completed and ongoing studies to 16 April 2021. SELECTION CRITERIA We included randomised controlled trials (RCTs) that evaluated systemic corticosteroids for people with COVID-19, irrespective of disease severity, participant age, gender or ethnicity. We included any type or dose of systemic corticosteroids. We included the following comparisons: systemic corticosteroids plus standard care versus standard care (plus/minus placebo), dose comparisons, timing comparisons (early versus late), different types of corticosteroids and systemic corticosteroids versus other active substances. We excluded studies that included populations with other coronavirus diseases (severe acute respiratory syndrome or Middle East respiratory syndrome), corticosteroids in combination with other active substances versus standard care, topical or inhaled corticosteroids, and corticosteroids for long-COVID treatment. DATA COLLECTION AND ANALYSIS We followed standard Cochrane methodology. To assess the risk of bias in included studies, we used the Cochrane 'Risk of bias' 2 tool for RCTs. We rated the certainty of evidence using the GRADE approach for the following outcomes: all-cause mortality, ventilator-free days, new need for invasive mechanical ventilation, quality of life, serious adverse events, adverse events, and hospital-acquired infections. MAIN RESULTS We included 11 RCTs in 8075 participants, of whom 7041 (87%) originated from high-income countries. A total of 3072 participants were randomised to corticosteroid arms and the majority received dexamethasone (n = 2322). We also identified 42 ongoing studies and 16 studies reported as being completed or terminated in a study registry, but without results yet. Hospitalised individuals with a confirmed or suspected diagnosis of symptomatic COVID-19 Systemic corticosteroids plus standard care versus standard care plus/minus placebo We included 10 RCTs (7989 participants), one of which did not report any of our pre-specified outcomes and thus our analysis included outcome data from nine studies. All-cause mortality (at longest follow-up available): systemic corticosteroids plus standard care probably reduce all-cause mortality slightly in people with COVID-19 compared to standard care alone (median 28 days: risk difference of 30 in 1000 participants fewer than the control group rate of 275 in 1000 participants; risk ratio (RR) 0.89, 95% confidence interval (CI) 0.80 to 1.00; 9 RCTs, 7930 participants; moderate-certainty evidence). Ventilator-free days: corticosteroids may increase ventilator-free days (MD 2.6 days more than control group rate of 4 days, 95% CI 0.67 to 4.53; 1 RCT, 299 participants; low-certainty evidence). Ventilator-free days have inherent limitations as a composite endpoint and should be interpreted with caution. New need for invasive ventilation: the evidence is of very low certainty. Because of high risk of bias arising from deaths that occurred before ventilation we are uncertain about the size and direction of the effects. Consequently, we did not perform analysis beyond the presentation of descriptive statistics. Quality of life/neurological outcome: no data were available. Serious adverse events: we included data on two RCTs (678 participants) that evaluated systemic corticosteroids compared to standard care (plus/minus placebo); for adverse events and hospital-acquired infections, we included data on five RCTs (660 participants). Because of high risk of bias, heterogeneous definitions, and underreporting we are uncertain about the size and direction of the effects. Consequently, we did not perform analysis beyond the presentation of descriptive statistics (very low-certainty evidence). Different types, dosages or timing of systemic corticosteroids We identified one study that compared methylprednisolone with dexamethasone. The evidence for mortality and new need for invasive mechanical ventilation is very low certainty due to the small number of participants (n = 86). No data were available for the other outcomes. We did not identify comparisons of different dosages or timing. Outpatients with asymptomatic or mild disease Currently, there are no studies published in populations with asymptomatic infection or mild disease. AUTHORS' CONCLUSIONS Moderate-certainty evidence shows that systemic corticosteroids probably slightly reduce all-cause mortality in people hospitalised because of symptomatic COVID-19. Low-certainty evidence suggests that there may also be a reduction in ventilator-free days. Since we are unable to adjust for the impact of early death on subsequent endpoints, the findings for ventilation outcomes and harms have limited applicability to inform treatment decisions. Currently, there is no evidence for asymptomatic or mild disease (non-hospitalised participants). There is an urgent need for good-quality evidence for specific subgroups of disease severity, for which we propose level of respiratory support at randomisation. This applies to the comparison or subgroups of different types and doses of corticosteroids, too. Outcomes apart from mortality should be measured and analysed appropriately taking into account confounding through death if applicable. We identified 42 ongoing and 16 completed but not published RCTs in trials registries suggesting possible changes of effect estimates and certainty of the evidence in the future. Most ongoing studies target people who need respiratory support at baseline. With the living approach of this review, we will continue to update our search and include eligible trials and published data.
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Affiliation(s)
- Carina Wagner
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Mirko Griesel
- Department of Anaesthesiology and Intensive Care, University of Leipzig Medical Center, Leipzig, Germany
| | - Agata Mikolajewska
- Department of Infectious Diseases and Respiratory Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Anika Mueller
- Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Monika Nothacker
- AWMF Institute for Medical Knowledge Management, Marburg, Germany
| | - Karoline Kley
- Department of Anaesthesiology and Intensive Care, University of Leipzig Medical Center, Leipzig, Germany
| | - Maria-Inti Metzendorf
- Cochrane Metabolic and Endocrine Disorders Group, Institute of General Practice, Medical Faculty of the Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Anna-Lena Fischer
- Department of Anaesthesia and Intensive care, Universitätsklinikum Leipzig, 04103 Leipzig, Germany
| | - Marco Kopp
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Miriam Stegemann
- Department of Infectious Diseases and Respiratory Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Nicole Skoetz
- Cochrane Cancer, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Falk Fichtner
- Department of Anaesthesiology and Intensive Care, University of Leipzig Medical Center, Leipzig, Germany
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Garraud O, Burnouf T. Convalescent Covid-19 plasma: Back-to-basics and ethics, and next steps. Transfus Clin Biol 2021; 28:225-227. [PMID: 34362557 PMCID: PMC8330381 DOI: 10.1016/j.tracli.2021.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Affiliation(s)
- O Garraud
- Transfusion Clinique et Biologique, inserm_1059, university of Lyon, Faculty of medicine of Saint-Etienne, 42000 Saint-Etienne, France.
| | - T Burnouf
- Transfusion Clinique et Biologique, Graduate Institute of Biomedical Materials and Tissue Engineering & International PhD Program in Biomedical Engineering, College of Biomedical Engineering, Taipei Medical University, Taipei, Taiwan
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Nguyen D, Simmonds P, Steenhuis M, Wouters E, Desmecht D, Garigliany M, Romano M, Barbezange C, Maes P, Van Holm B, Mendoza J, Oyonarte S, Fomsgaard A, Lassaunière R, Zusinaite E, Resman Rus K, Avšič-Županc T, Reimerink JH, Brouwer F, Hoogerwerf M, Reusken CB, Grodeland G, Le Cam S, Gallian P, Amroun A, Brisbarre N, Martinaud C, Leparc Goffart I, Schrezenmeier H, Feys HB, van der Schoot CE, Harvala H. SARS-CoV-2 neutralising antibody testing in Europe: towards harmonisation of neutralising antibody titres for better use of convalescent plasma and comparability of trial data. ACTA ACUST UNITED AC 2021; 26. [PMID: 34240697 PMCID: PMC8268650 DOI: 10.2807/1560-7917.es.2021.26.27.2100568] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
We compared the performance of SARS-CoV-2 neutralising antibody testing between 12 European laboratories involved in convalescent plasma trials. Raw titres differed almost 100-fold differences between laboratories when blind-testing 15 plasma samples. Calibration of titres in relation to the reference reagent and standard curve obtained by testing a dilution series reduced the inter-laboratory variability ca 10-fold. The harmonisation of neutralising antibody quantification is a vital step towards determining the protective and therapeutic levels of neutralising antibodies.
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Affiliation(s)
- Dung Nguyen
- University of Oxford, Oxford, United Kingdom
| | | | - Maurice Steenhuis
- Department of Immunopathology, Sanquin Research and Landsteiner Laboratory Academic Medical Centre, Amsterdam, Netherlands
| | - Elise Wouters
- Transfusion Research Centre, Belgian Red Cross-Flanders, Ghent, Belgium
| | - Daniel Desmecht
- Department of Pathology, Faculty of Veterinary Medicine, Liège University, Liège, Belgium
| | - Mutien Garigliany
- Department of Pathology, Faculty of Veterinary Medicine, Liège University, Liège, Belgium
| | - Marta Romano
- Immune Response service, Sciensano, Brussels, Belgium
| | | | - Piet Maes
- KU Leuven, Rega Institute, Clinical and Epidemiological Virology, Leuven, Belgium
| | - Bram Van Holm
- KU Leuven, Rega Institute, Clinical and Epidemiological Virology, Leuven, Belgium
| | | | - Salvador Oyonarte
- Andalusian Network of Transfusion Medicine, Tissues and Cells, Sevilla, Spain
| | - Anders Fomsgaard
- Virus and Microbiological Special Diagnostics, Statens Serum Institute, Copenhagen, Denmark
| | - Ria Lassaunière
- Virus and Microbiological Special Diagnostics, Statens Serum Institute, Copenhagen, Denmark
| | - Eva Zusinaite
- Tartu University Institute of Technology, Tartu, Estonia
| | | | | | - Johan Hj Reimerink
- Centre for Infectious Disease Control, WHO COVID-19 Reference Laboratory, RIVML, Bilthoven, the Netherlands
| | - Fiona Brouwer
- Centre for Infectious Disease Control, WHO COVID-19 Reference Laboratory, RIVML, Bilthoven, the Netherlands
| | - Marieke Hoogerwerf
- Centre for Infectious Disease Control, WHO COVID-19 Reference Laboratory, RIVML, Bilthoven, the Netherlands
| | - Chantal Bem Reusken
- Centre for Infectious Disease Control, WHO COVID-19 Reference Laboratory, RIVML, Bilthoven, the Netherlands
| | - Gunnveig Grodeland
- Dep. of Immunology, University of Oslo and Oslo University Hospital, Oslo, Norway
| | - Sophie Le Cam
- Etablissement Français du Sang, La Plaine Saint Denis, France
| | - Pierre Gallian
- Etablissement Français du Sang, La Plaine Saint Denis, France.,Unité des Virus Émergents (Aix-Marseille University - IRD 190 - Inserm 1207 - IHU Méditerranée Infection), Marseille, France
| | - Abdennour Amroun
- Unité des Virus Émergents (Aix-Marseille University - IRD 190 - Inserm 1207 - IHU Méditerranée Infection), Marseille, France
| | - Nadège Brisbarre
- Unité des Virus Émergents (Aix-Marseille University - IRD 190 - Inserm 1207 - IHU Méditerranée Infection), Marseille, France.,Etablissement français du Sang Provence Alpes Côte d'Azur et Corse, Marseille, France
| | | | | | - Hubert Schrezenmeier
- Department of Transfusion Medicine, Ulm University, Ulm, Germany.,Institute for Clinical Transfusion Medicine and Immunogenetics, German Red Cross Blood Transfusion Service Baden-Wurttemberg - Hessen and University Hospital Ulm, Ulm, Germany
| | - Hendrik B Feys
- Transfusion Research Centre, Belgian Red Cross-Flanders, Ghent, Belgium
| | - C Ellen van der Schoot
- Department of Immunopathology, Sanquin Research and Landsteiner Laboratory Academic Medical Centre, Amsterdam, Netherlands
| | - Heli Harvala
- Microbiology Services, NHS Blood and Transplant, Colindale, United Kingdom.,University College of London, London, United Kingdom
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Sachdev S, Pathak S, Sharma RR, Mahapatra M. Convalescent Plasma the Old Warhorse First to be Inducted in Pandemics is not the Zippy Chippy of Derby. Indian J Hematol Blood Transfus 2021; 37:345-346. [PMID: 34177140 PMCID: PMC8213530 DOI: 10.1007/s12288-021-01457-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Suchet Sachdev
- Department of Transfusion Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Sangeeta Pathak
- Transfusion Medicine, Max Super Speciality Hospital, Delhi, India
| | - Ratti Ram Sharma
- Department of Transfusion Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Manoranjan Mahapatra
- Department of Haematology, All India Institute of Medical Sciences, New Delhi, India
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Piechotta V, Iannizzi C, Chai KL, Valk SJ, Kimber C, Dorando E, Monsef I, Wood EM, Lamikanra AA, Roberts DJ, McQuilten Z, So-Osman C, Estcourt LJ, Skoetz N. Convalescent plasma or hyperimmune immunoglobulin for people with COVID-19: a living systematic review. Cochrane Database Syst Rev 2021; 5:CD013600. [PMID: 34013969 PMCID: PMC8135693 DOI: 10.1002/14651858.cd013600.pub4] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Convalescent plasma and hyperimmune immunoglobulin may reduce mortality in patients with viral respiratory diseases, and are being investigated as potential therapies for coronavirus disease 2019 (COVID-19). A thorough understanding of the current body of evidence regarding benefits and risks of these interventions is required. OBJECTIVES: Using a living systematic review approach, to assess whether convalescent plasma or hyperimmune immunoglobulin transfusion is effective and safe in the treatment of people with COVID-19; and to maintain the currency of the evidence. SEARCH METHODS To identify completed and ongoing studies, we searched the World Health Organization (WHO) COVID-19 Global literature on coronavirus disease Research Database, MEDLINE, Embase, the Cochrane COVID-19 Study Register, the Epistemonikos COVID-19 L*OVE Platform, and trial registries. Searches were done on 17 March 2021. SELECTION CRITERIA We included randomised controlled trials (RCTs) evaluating convalescent plasma or hyperimmune immunoglobulin for COVID-19, irrespective of disease severity, age, gender or ethnicity. For safety assessments, we also included non-controlled non-randomised studies of interventions (NRSIs) if 500 or more participants were included. We excluded studies that included populations with other coronavirus diseases (severe acute respiratory syndrome (SARS) or Middle East respiratory syndrome (MERS)), as well as studies evaluating standard immunoglobulin. DATA COLLECTION AND ANALYSIS We followed standard Cochrane methodology. To assess bias in included studies, we used the Cochrane 'Risk of Bias 2' tool for RCTs, and for NRSIs, the assessment criteria for observational studies, provided by Cochrane Childhood Cancer. We rated the certainty of evidence, using the GRADE approach, for the following outcomes: all-cause mortality, improvement and worsening of clinical status (for individuals with moderate to severe disease), development of severe clinical COVID-19 symptoms (for individuals with asymptomatic or mild disease), quality of life (including fatigue and functional independence), grade 3 or 4 adverse events, and serious adverse events. MAIN RESULTS We included 13 studies (12 RCTs, 1 NRSI) with 48,509 participants, of whom 41,880 received convalescent plasma. We did not identify any completed studies evaluating hyperimmune immunoglobulin. We identified a further 100 ongoing studies evaluating convalescent plasma or hyperimmune immunoglobulin, and 33 studies reporting as being completed or terminated. Individuals with a confirmed diagnosis of COVID-19 and moderate to severe disease Eleven RCTs and one NRSI investigated the use of convalescent plasma for 48,349 participants with moderate to severe disease. Nine RCTs compared convalescent plasma to placebo treatment or standard care alone, and two compared convalescent plasma to standard plasma (results not included in abstract). Effectiveness of convalescent plasma We included data on nine RCTs (12,875 participants) to assess the effectiveness of convalescent plasma compared to placebo or standard care alone. Convalescent plasma does not reduce all-cause mortality at up to day 28 (risk ratio (RR) 0.98, 95% confidence interval (CI) 0.92 to 1.05; 7 RCTs, 12,646 participants; high-certainty evidence). It has little to no impact on clinical improvement for all participants when assessed by liberation from respiratory support (RR not estimable; 8 RCTs, 12,682 participants; high-certainty evidence). It has little to no impact on the chance of being weaned or liberated from invasive mechanical ventilation for the subgroup of participants requiring invasive mechanical ventilation at baseline (RR 1.04, 95% CI 0.57 to 1.93; 2 RCTs, 630 participants; low-certainty evidence). It does not reduce the need for invasive mechanical ventilation (RR 0.98, 95% CI 0.89 to 1.08; 4 RCTs, 11,765 participants; high-certainty evidence). We did not identify any subgroup differences. We did not identify any studies reporting quality of life, and therefore, do not know whether convalescent plasma has any impact on quality of life. One RCT assessed resolution of fatigue on day 7, but we are very uncertain about the effect (RR 1.21, 95% CI 1.02 to 1.42; 309 participants; very low-certainty evidence). Safety of convalescent plasma We included results from eight RCTs, and one NRSI, to assess the safety of convalescent plasma. Some of the RCTs reported on safety data only for the convalescent plasma group. We are uncertain whether convalescent plasma increases or reduces the risk of grade 3 and 4 adverse events (RR 0.90, 95% CI 0.58 to 1.41; 4 RCTs, 905 participants; low-certainty evidence), and serious adverse events (RR 1.24, 95% CI 0.81 to 1.90; 2 RCTs, 414 participants; low-certainty evidence). A summary of reported events of the NRSI (reporting safety data for 20,000 of 35,322 transfused participants), and four RCTs reporting safety data only for transfused participants (6125 participants) are included in the full text. Individuals with a confirmed diagnosis of SARS-CoV-2 infection and asymptomatic or mild disease We identified one RCT reporting on 160 participants, comparing convalescent plasma to placebo treatment (saline). Effectiveness of convalescent plasma We are very uncertain about the effect of convalescent plasma on all-cause mortality (RR 0.50, 95% CI 0.09 to 2.65; very low-certainty evidence). We are uncertain about the effect of convalescent plasma on developing severe clinical COVID-19 symptoms (RR not estimable; low-certainty evidence). We identified no study reporting quality of life. Safety of convalescent plasma We do not know whether convalescent plasma is associated with a higher risk of grade 3 or 4 adverse events (very low-certainty evidence), or serious adverse events (very low-certainty evidence). This is a living systematic review. We search weekly for new evidence and update the review when we identify relevant new evidence. Please refer to the Cochrane Database of Systematic Reviews for the current status of this review. AUTHORS' CONCLUSIONS We have high certainty in the evidence that convalescent plasma for the treatment of individuals with moderate to severe disease does not reduce mortality and has little to no impact on measures of clinical improvement. We are uncertain about the adverse effects of convalescent plasma. While major efforts to conduct research on COVID-19 are being made, heterogeneous reporting of outcomes is still problematic. There are 100 ongoing studies and 33 studies reporting in a study registry as being completed or terminated. Publication of ongoing studies might resolve some of the uncertainties around hyperimmune immunoglobulin therapy for people with any disease severity, and convalescent plasma therapy for people with asymptomatic or mild disease.
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Affiliation(s)
- Vanessa Piechotta
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Claire Iannizzi
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Khai Li Chai
- Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Sarah J Valk
- Jon J van Rood Center for Clinical Transfusion Research, Sanquin/Leiden University Medical Center, Leiden, Netherlands
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands
| | - Catherine Kimber
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Elena Dorando
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Ina Monsef
- Cochrane Haematology, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Erica M Wood
- Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | | | - David J Roberts
- Systematic Review Initiative, NHS Blood and Transplant, Oxford, UK
| | - Zoe McQuilten
- Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Cynthia So-Osman
- Sanquin Blood Bank, Amsterdam, Netherlands
- Erasmus Medical Centre, Rotterdam, Netherlands
| | - Lise J Estcourt
- Haematology/Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
| | - Nicole Skoetz
- Cochrane Cancer, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
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