201
|
Urbina T, Lavillegrand JR, Garnier M, Mekinian A, Pacanowski J, Mario N, Dumas G, Hariri G, Pilon A, Darrivère L, Fartoukh M, Guidet B, Maury E, Leblanc J, Chantran Y, Fain O, Lacombe K, Voiriot G, Ait-Oufella H. Delayed inflammation decrease is associated with mortality in Tocilizumab-treated critically ill SARS-CoV-2 patients: A retrospective matched-cohort analysis. Innate Immun 2022; 28:3-10. [PMID: 35089113 PMCID: PMC8841634 DOI: 10.1177/17534259211064602] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Little is known about the immuno-inflammatory response to Tocilizumab and its association with outcome in critically-ill SARS-CoV2 pneumonia. In this multicenter retrospective cohort of SARS-CoV-2 patients admitted to three intensive care units between March and April 2020, we matched on gender and SAPS II 21 Tocilizumab-treated patients to 42 non-treated patients. Need for mechanical ventilation was 76% versus 79%. IL-6, C-reactive protein, and fibrinogen had been collected within the first days of admission (T1), 3 d (T2) and 7 d (T3) later. Tocilizumab-treated patients had persistently higher IL-6 plasma levels and persistently lower C-Reactive protein and fibrinogen levels. Among Tocilizumab-treated patients, baseline levels of inflammatory biomarkers were not different according to outcome. Conversely, C-reactive protein and fibrinogen decrease was delayed in non-survivors. C-Reactive protein decreased at T1 in survivors (45 [30–98] vs 170 [69–204] mg/l, P < 0.001) but only at T2 in non-survivors (37 [13–74] vs 277 [235–288], P = 0.03). Fibrinogen decreased at T2 in survivors (4.11 [3.58–4.69] vs 614 [5.61–7.85] g/l, P = 0.005) but not in non-survivors (4.79 [4.12–7.58] vs 7.24 [6.22–9.24] g/l, P = 0.125). Tocilizumab treatment was thus associated with a persistent both increase in plasma IL-6, and decrease in C-reactive protein and fibrinogen. Among Tocilizumab-treated patients, the decrease in inflammatory biomarkers was delayed in non-survivors.
Collapse
Affiliation(s)
- Tomas Urbina
- Service de Médecine Intensive-Réanimation, 37117Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, France.,27063Sorbonne Université, France
| | - Jean-Rémi Lavillegrand
- Service de Médecine Intensive-Réanimation, 37117Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, France.,27063Sorbonne Université, France
| | - Marc Garnier
- 27063Sorbonne Université, France.,Service d'Anesthésie-Réanimation, 37117Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, France
| | - Arsene Mekinian
- 27063Sorbonne Université, France.,Service de médecine interne, 37117Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, France
| | - Jerome Pacanowski
- Service de maladies infectieuses, 37117Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, France
| | - Nathalie Mario
- Département de Biochimie, Hormonologie et Suivi Thérapeutique, 37117Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, France
| | - Guillaume Dumas
- Service de Médecine Intensive-Réanimation, 55663Hôpital Saint-Louis, Assistance Publique-Hôpitaux de Paris, France
| | - Geoffroy Hariri
- Service de Médecine Intensive-Réanimation, 37117Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, France.,27063Sorbonne Université, France
| | - Antoine Pilon
- Département de Biochimie, Hormonologie et Suivi Thérapeutique, 37117Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, France
| | - Lucie Darrivère
- Service d'Anesthésie-Réanimation, 37117Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, France
| | - Muriel Fartoukh
- 27063Sorbonne Université, France.,Service de Médecine Intensive-Réanimation, 55705Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, France
| | - Bertrand Guidet
- Service de Médecine Intensive-Réanimation, 37117Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, France.,27063Sorbonne Université, France
| | - Eric Maury
- Service de Médecine Intensive-Réanimation, 37117Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, France.,27063Sorbonne Université, France
| | - Judith Leblanc
- Sorbonne Université, INSERM, Institut Pierre Louis d'Épidémiologie et de Santé Publique, France
| | - Yannick Chantran
- Département d'Immunologie Biologique, 37117Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, France
| | - Olivier Fain
- 27063Sorbonne Université, France.,Service de médecine interne, 37117Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, France
| | - Karine Lacombe
- 27063Sorbonne Université, France.,Service de maladies infectieuses, 37117Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, France
| | - Guillaume Voiriot
- 27063Sorbonne Université, France.,Service de Médecine Intensive-Réanimation, 55705Hôpital Tenon, Assistance Publique-Hôpitaux de Paris, France
| | - Hafid Ait-Oufella
- Service de Médecine Intensive-Réanimation, 37117Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris, France.,27063Sorbonne Université, France.,Inserm U970, Cardiovascular research center, Université de Paris, France
| |
Collapse
|
202
|
Liver Injury in Patients Hospitalized for COVID-19: Possible Role of Therapy. Vaccines (Basel) 2022; 10:vaccines10020192. [PMID: 35214651 PMCID: PMC8880796 DOI: 10.3390/vaccines10020192] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/21/2022] [Accepted: 01/23/2022] [Indexed: 02/06/2023] Open
Abstract
Patients with COVID-19 show a high prevalence of liver injury. The pattern of this liver damage is still not fully understood. Different etiopathogenetic factors may concur; from a direct cytopathic effect, once the virus binds to the ACE-2 receptors, to the immune-mediated collateral damage, due to cytokine storm. The presence of pre-existing chronic liver disease is a contributing factor for acute organ damage during SARS-CoV2 infection. Last but not least, treatments probably play a role, also, in determining hepatotoxicity: many of the drugs we have used or are still using to treat COVID-19, combined with non-invasive ventilation, are known to sometimes determine acute liver injury. Although liver damage associated with COVID-19 is often transient and can resolve without any special treatment, it is important to understand the underlying mechanisms, particularly to better treat its more severe forms.
Collapse
|
203
|
Wang Y, Zhu K, Dai R, Li R, Li M, Lv X, Yu Q. Specific Interleukin-1 Inhibitors, Specific Interleukin-6 Inhibitors, and GM-CSF Blockades for COVID-19 (at the Edge of Sepsis): A Systematic Review. Front Pharmacol 2022; 12:804250. [PMID: 35126138 PMCID: PMC8815770 DOI: 10.3389/fphar.2021.804250] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 11/23/2021] [Indexed: 12/13/2022] Open
Abstract
Sepsis is a syndrome with high mortality, which seriously threatens human health. During the pandemic of coronavirus disease 2019 (COVID-19), some severe and critically ill COVID-19 patients with multiple organ dysfunction developed characteristics typical of sepsis and met the diagnostic criteria for sepsis. Timely detection of cytokine storm and appropriate regulation of inflammatory response may be significant in the prevention and treatment of sepsis. This study evaluated the efficacy and safety of specific interleukin (IL)-1 inhibitors, specific IL-6 inhibitors, and GM-CSF blockades in the treatment of COVID-19 (at the edge of sepsis) patients through systematic review and meta-analysis. METHODOLOGY A literature search was conducted on PubMed, EMBASE, Clinical Key, Cochrane Library, CNKI, and Wanfang Database using proper keywords such as "SARS-CoV-2," "Corona Virus Disease 2019," "COVID-19," "anakinra," "tocilizumab," "siltuximab," "sarilumab," "mavrilimumab," "lenzilumab," and related words for publications released until August 22, 2021. Other available resources were also used to identify relevant articles. The present systematic review was performed based on PRISMA protocol. RESULTS Based on the inclusion and exclusion criteria, 43 articles were included in the final review. The meta-analysis results showed that tocilizumab could reduce the mortality of patients with COVID-19 (at the edge of sepsis) [randomized controlled trials, RCTs: odds ratio (OR) 0.71, 95%CI: 0.52-0.97, low-certainty evidence; non-RCTs: risk ratio (RR) 0.68, 95%CI: 0.55-0.84, very low-certainty evidence) as was anakinra (non-RCTs: RR 0.47, 95%CI: 0.34-0.66, very low-certainty evidence). Sarilumab might reduce the mortality of patients with COVID-19 (at the edge of sepsis), but there was no statistical significance (OR 0.65, 95%CI: 0.36-1.2, low-certainty evidence). For safety outcomes, whether tocilizumab had an impact on serious adverse events (SAEs) was very uncertain (RCTs: OR 0.87, 95%CI: 0.38-2.0, low-certainty evidence; non-RCTs 1.18, 95%CI: 0.83-1.68, very low-certainty evidence) as was on secondary infections (RCTs: OR 0.71, 95%CI: 0.06-8.75, low-certainty evidence; non-RCTs: RR 1.15, 95%CI: 0.89-1.49, very low-certainty evidence). CONCLUSIONS This systematic review showed that tocilizumab, sarilumab, and anakinra could reduce the mortality of people with COVID-19 (at the edge of sepsis), and tocilizumab did not significantly affect SAEs and secondary infections. The current evidence of the studies on patients treated with siltuximab, mavrilimumab, and lenzilumab is insufficient. In order to establish evidence with stronger quality, high-quality studies are needed. Systematic Review Registration: PROSPERO (https://www.crd.york.ac.uk/prospero/), identifier CRD42020226545.
Collapse
Affiliation(s)
- Ying Wang
- Department of Pharmacy, China-Japan Union Hospital of Jilin University, Jilin University, Changchun, China
| | - Kun Zhu
- Department of Pharmacy, China-Japan Union Hospital of Jilin University, Jilin University, Changchun, China
| | - Rulin Dai
- Center of Reproductive Medicine and Center of Prenatal Diagnosis, The First Hospital, Jilin University, Changchun, China
| | - Rui Li
- Department of Pharmacy, China-Japan Union Hospital of Jilin University, Jilin University, Changchun, China
| | - Miao Li
- Department of Neurosurgery, China-Japan Union Hospital of Jilin University, Jilin University, Changchun, China
| | - Xin Lv
- Center of Reproductive Medicine and Center of Prenatal Diagnosis, The First Hospital, Jilin University, Changchun, China
| | - Qian Yu
- Department of Pharmacy, China-Japan Union Hospital of Jilin University, Jilin University, Changchun, China
| |
Collapse
|
204
|
Characteristics and Outcomes of Patients With Frailty Admitted to ICU With Coronavirus Disease 2019: An Individual Patient Data Meta-Analysis. Crit Care Explor 2022; 4:e0616. [PMID: 35072081 PMCID: PMC8769107 DOI: 10.1097/cce.0000000000000616] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Supplemental Digital Content is available in the text. Frailty is often used in clinical decision-making for patients with coronavirus disease 2019, yet studies have found a variable influence of frailty on outcomes in those admitted to the ICU. In this individual patient data meta-analysis, we evaluated the characteristics and outcomes across the range of frailty in patients admitted to ICU with coronavirus disease 2019.
Collapse
|
205
|
Peng J, She X, Mei H, Zheng H, Fu M, Liang G, Wang Q, Liu W. Association between tocilizumab treatment and clinical outcomes of COVID-19 patients: a systematic review and meta-analysis. Aging (Albany NY) 2022; 14:557-571. [PMID: 35038318 PMCID: PMC8833131 DOI: 10.18632/aging.203834] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 12/29/2021] [Indexed: 11/25/2022]
Abstract
To explore and summarize the association between treatment with tocilizumab and clinical outcomes in COVID-19 patients. We performed a systematic review and meta-analysis (10 RCTs including 3378 patients in the tocilizumab group and 3142 patients in the control group). We systematically searched PubMed and MedRxiv for all RCTs as of June 1, 2021, to assess the benefits and harms of tocilizumab to treat patients with COVID-19. All analyses were carried out using RevMan version 5.4.1. There were nine RCTs published in peer-reviewed journals and one RCTs published as a preprint. The summary RR for all-cause mortality with tocilizumab was 0.89 (95% CI= 0.82-0.96, P= 0.003). There was no significant between-trial heterogeneity (I2= 28%, P= 0.19). However, all peer-reviewed RCTs showed no significant associations between treatment with tocilizumab and reductions in all-cause mortality. We notably found that tocilizumab significantly reduced the rate of intubation or death in patients with COVID-19 with 3 RCTs. Across the 8 RCTs, the summary RR for discharge with tocilizumab was 1.10 (95% CI= 1.03-1.16, P< 0.00001). There was no significant association of tocilizumab with harm on other patient-relevant clinical outcomes, including increasing secondary infection risk, patients of adverse events, or patients of serious adverse events. Tocilizumab significantly increased the rate of hospital discharges in COVID-19 patients. Still, it did not decrease all-cause mortality or increase the risk of secondary infections, patients of adverse events, or patients for serious adverse events. Evidence that tocilizumab affects clinical outcomes in patients with COVID-19 requires further proof.
Collapse
Affiliation(s)
- Jingwen Peng
- Department of Medical Mycology, Institute of Dermatology, Chinese Academy of Medical Science and Peking Union Medical College, Nanjing 210042, Jiangsu, People's Republic of China.,Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Nanjing 210042, Jiangsu, People's Republic of China
| | - Xiaodong She
- Department of Medical Mycology, Institute of Dermatology, Chinese Academy of Medical Science and Peking Union Medical College, Nanjing 210042, Jiangsu, People's Republic of China.,Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Nanjing 210042, Jiangsu, People's Republic of China
| | - Huan Mei
- Department of Medical Mycology, Institute of Dermatology, Chinese Academy of Medical Science and Peking Union Medical College, Nanjing 210042, Jiangsu, People's Republic of China.,Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Nanjing 210042, Jiangsu, People's Republic of China
| | - Hailin Zheng
- Department of Medical Mycology, Institute of Dermatology, Chinese Academy of Medical Science and Peking Union Medical College, Nanjing 210042, Jiangsu, People's Republic of China.,Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Nanjing 210042, Jiangsu, People's Republic of China
| | - Meihua Fu
- Department of Medical Mycology, Institute of Dermatology, Chinese Academy of Medical Science and Peking Union Medical College, Nanjing 210042, Jiangsu, People's Republic of China.,Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Nanjing 210042, Jiangsu, People's Republic of China
| | - Guanzhao Liang
- Department of Medical Mycology, Institute of Dermatology, Chinese Academy of Medical Science and Peking Union Medical College, Nanjing 210042, Jiangsu, People's Republic of China.,Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Nanjing 210042, Jiangsu, People's Republic of China
| | - Qiong Wang
- Department of Medical Mycology, Institute of Dermatology, Chinese Academy of Medical Science and Peking Union Medical College, Nanjing 210042, Jiangsu, People's Republic of China.,Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Nanjing 210042, Jiangsu, People's Republic of China
| | - Weida Liu
- Department of Medical Mycology, Institute of Dermatology, Chinese Academy of Medical Science and Peking Union Medical College, Nanjing 210042, Jiangsu, People's Republic of China.,Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing 211166, Jiangsu, People's Republic of China.,Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Nanjing 210042, Jiangsu, People's Republic of China
| |
Collapse
|
206
|
Evaluation of Treatment with a single (400mg) versus double dose (800mg) of Tocilizumab in Acute Respiratory Distress Syndrome Associated with COVID-19Pneumonia. JOURNAL OF CONTEMPORARY MEDICINE 2022. [DOI: 10.16899/jcm.1031086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
207
|
Morărașu BC, Basirat A, Kooblall M. Successful outcome using Tocilizumab in COVID-19 pneumonia with respiratory failure on a ward level. Arch Clin Cases 2022; 9:29-33. [PMID: 35529095 PMCID: PMC9066580 DOI: 10.22551/2022.34.0901.10200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
We describe the case of a 40-year-old man of Asian ethnicity, who presented with one week history of shortness of breath, productive cough, intermittent hemoptysis, temperature, and systemic symptoms. He had a positive nasopharyngeal swab for SARS-CoV-2, standard COVID panel admission blood tests, a chest X-ray and a CT Pulmonary Angiogram. Significant bilateral infiltrates and no pulmonary embolism were identified. The patient received standard COVID-19 treatment. After 36 hours, he deteriorated requiring initiation of non-invasive ventilatory (NIV) support. In the context of worsening clinical status, the patient received Tocilizumab as a single dose with good clinical response. Early Tocilizumab intervention in appropriately selected patients should improve the outcome and length of hospitalization in COVID-19 pneumonia. It can be used as an intensive therapy unit sparing agent allowing management of critically ill patients on a ward-based level. This may further contribute to prevention of intensive therapy unit related complications and increased mortality.
Collapse
|
208
|
Kumar PN, Hernández-Sánchez J, Nagel S, Feng Y, Cai F, Rabin J, Morse CG, Nadig NR, Ashraf O, Gotur DB, McComsey GA, Gafoor K, Perin P, Thornton SC, Stubbings W, Lin CJF, Tsai L. Safety and Efficacy of Tocilizumab 4 or 8 mg/kg in Hospitalized Patients With Moderate to Severe Coronavirus Disease 2019 Pneumonia: A Randomized Clinical Trial. Open Forum Infect Dis 2022; 9:ofab608. [PMID: 35024375 PMCID: PMC8690270 DOI: 10.1093/ofid/ofab608] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 12/01/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Tocilizumab, an interleukin 6 receptor (IL-6R) antagonist monoclonal antibody, has shown efficacy in patients with coronavirus disease 2019 (COVID-19) pneumonia, but the optimal dose is unknown. METHODS Patients hospitalized for moderate to severe COVID-19 pneumonia were randomized 1:1 to receive standard of care treatment and 1-2 doses of intravenous tocilizumab 4 mg/kg or 8 mg/kg (open-label). Primary pharmacokinetic and pharmacodynamic end points were serum concentrations of tocilizumab and soluble interleukin 6 receptor (sIL-6R), IL-6, ferritin, and C-reactive protein (CRP), from baseline to day 60. The secondary end point was safety. Key exploratory efficacy end points included clinical status, time to discharge, mortality rate, and incidence of mechanical ventilation. RESULTS Of 100 patients randomized, 49 received tocilizumab 4 mg/kg and 48 received 8 mg/kg. In pharmacokinetic and sIL-6R assessments, dose-dependent differences were seen in patients who received 1 or 2 doses of 4 or 8 mg/kg. Serum concentrations of IL-6, ferritin, and CRP and safety outcomes were comparable between groups. Through day 60, serious adverse events were reported in 30.6% and 25.0% of patients in the 4- and 8-mg/kg groups, respectively. Eight patients (16.3%) in the 4-mg/kg group and 6 (12.5%) in the 8-mg/kg group died. Exploratory time-to-event outcomes favored 8 mg/kg within the first 2 weeks. CONCLUSIONS In patients with moderate to severe COVID-19 pneumonia who received tocilizumab 4 or 8 mg/kg, pharmacokinetic and sIL-6R assessments showed expected dose-dependent effects; pharmacodynamic assessments and safety were comparable, with no new safety signals. Further study is required before a lower dose of tocilizumab can be recommended in patients with COVID-19 pneumonia. CLINICAL TRIALS REGISTRATION NCT04363736.
Collapse
Affiliation(s)
- Princy N Kumar
- Georgetown University Medical Center, Washington, District of Columbia, USA
| | | | | | - Yuning Feng
- Genentech, Inc, South San Francisco, California, USA
| | - Fang Cai
- Genentech, Inc, South San Francisco, California, USA
| | - Joseph Rabin
- University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Caryn G Morse
- Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Nandita R Nadig
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Obaid Ashraf
- Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - Deepa B Gotur
- Weill Cornell Medical College and Houston Methodist Hospital, Houston, Texas, USA
| | - Grace A McComsey
- University Hospitals of Cleveland and Case Western Reserve University, Cleveland, Ohio, USA
| | - Khalid Gafoor
- Jamaica Hospital Medical Center, Richmond Hill, New York, USA
| | | | - Sarah C Thornton
- Georgetown University Medical Center, Washington, District of Columbia, USA
| | | | - Celia J F Lin
- Genentech, Inc, South San Francisco, California, USA
| | - Larry Tsai
- Genentech, Inc, South San Francisco, California, USA
| |
Collapse
|
209
|
Barbosa AN, Silvinato A, Bacha H, Floriano I, Tanni S, Bernardo W. Use of disease-modifying drugs (tocilizumab, tofacitinib, and baricitinib—a biological or synthetic target specific) in patients hospitalized with COVID-19. Rev Assoc Med Bras (1992) 2022; 68:3-8. [DOI: 10.1590/1806-9282.2022d681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 11/19/2021] [Indexed: 11/22/2022] Open
|
210
|
Campochiaro C, Tomelleri A, Matucci-Cerinic M, Dagna L. One year later: The case of tocilizumab in COVID-19. Eur J Intern Med 2022; 95:5-6. [PMID: 34711474 PMCID: PMC8536517 DOI: 10.1016/j.ejim.2021.10.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 10/18/2021] [Indexed: 12/15/2022]
Affiliation(s)
- Corrado Campochiaro
- Unit of Immunology, Rheumatology, Allergy and Rare diseases, IRCCS San Raffaele Hospital, Via Olgettina 60, Milan 20132, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandro Tomelleri
- Unit of Immunology, Rheumatology, Allergy and Rare diseases, IRCCS San Raffaele Hospital, Via Olgettina 60, Milan 20132, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Marco Matucci-Cerinic
- Unit of Immunology, Rheumatology, Allergy and Rare diseases, IRCCS San Raffaele Hospital, Via Olgettina 60, Milan 20132, Italy; Department of Experimental and Clinical Medicine, and Division of Rheumatology AOUC, University of Florence, Florence, Italy
| | - Lorenzo Dagna
- Unit of Immunology, Rheumatology, Allergy and Rare diseases, IRCCS San Raffaele Hospital, Via Olgettina 60, Milan 20132, Italy; Vita-Salute San Raffaele University, Milan, Italy.
| |
Collapse
|
211
|
Majidpoor J, Mortezaee K. Interleukin-6 in SARS-CoV-2 induced disease: Interactions and therapeutic applications. Biomed Pharmacother 2022; 145:112419. [PMID: 34781146 PMCID: PMC8585600 DOI: 10.1016/j.biopha.2021.112419] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 11/07/2021] [Accepted: 11/10/2021] [Indexed: 02/07/2023] Open
Abstract
Interleukin-6 (IL-6) is a multi-tasking cytokine that represents high activity in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and cancer. High concentration of this pleiotropic cytokine accounts for hyperinflammation and cytokine storm, and is related to multi-organ failure in patients with SARS-CoV-2 induced disease. IL-6 promotes lymphopenia and increases C-reactive protein (CRP) in such cases. However, blockade of IL-6 is not a full-proof of complete response. Hypoxia, hypoxemia, aberrant angiogenesis and chronic inflammation are inter-related events occurring as a response to the SARS-CoV-2 stimulatory effect on high IL-6 activity. Taking both pro- and anti-inflammatory activities will make complex targeting IL-6 in patient with SARS-CoV-2 induced disease. The aim of this review was to discuss about interactions occurring within the body of patients with SARS-CoV-2 induced disease who are representing high IL-6 levels, and to determine whether IL-6 inhibition therapy is effective for such patients or not. We also address the interactions and targeted therapies in cancer patients who also have SARS-CoV-2 induced disease.
Collapse
Affiliation(s)
- Jamal Majidpoor
- Department of Anatomy, School of Medicine, Infectious Disease Research Center, Gonabad University of Medical Sciences, Gonabad, Iran
| | - Keywan Mortezaee
- Department of Anatomy, School of Medicine, Kurdistan University of Medical Sciences, Sanandaj, Iran.
| |
Collapse
|
212
|
Almeida PRL, Person OC, Puga MEDS, Giusti MF, Pinto ACPN, Rocha AP, Atallah ÁN. Effectiveness and safety of tocilizumab for COVID-19: a systematic review and meta-analysis of randomized clinical trials. SAO PAULO MED J 2022; 141:168-176. [PMID: 36102463 PMCID: PMC10005468 DOI: 10.1590/1516-3180.2022.0170.r1.01072022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 07/01/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Tocilizumab is an anti-human interleukin 6 receptor monoclonal antibody that has been used to treat coronavirus disease 2019 (COVID-19). However, there is no consensus on its efficacy for the treatment of COVID-19. OBJECTIVE To evaluate the effectiveness and safety of tocilizumab for treating COVID-19. DESIGN AND SETTING Systematic Review of randomized controlled trials (RCTs), Universidade Federal de São Paulo (UNIFESP), São Paulo (SP), Brazil. METHODS We searched MEDLINE via PubMed, EMBASE, CENTRAL, and IBECS for RCTs published up to March 2021. Two authors selected studies and assessed the risk of bias and the certainty of the evidence following Cochrane Recommendations. RESULTS Eight RCTs with 6,139 participants were included. We were not able to find differences between using tocilizumab compared to standard care on mortality in hospitalized patients with COVID-19 (risk ratio (RR) 0.97, 95% confidence interval (CI) 0.84 to 1.13; 8 trials; 5,950 participants; low-certainty evidence). However, hospitalized patients under tocilizumab plus standard care treatment seemed to present a significantly lower risk of needing mechanical ventilation (risk ratio = 0.78; 95% CI 0.64-0.94 moderate-certainty of evidence). CONCLUSIONS To date, the best evidence available shows no difference between using tocilizumab plus standard care compared to standard care alone for reducing mortality in patients with COVID-19. However, as a finding with a practical implication, the use of tocilizumab in association to standard care probably reduces the risk of progressing to mechanical ventilation in those patients. REGISTRATION osf.io/qe4fs.
Collapse
Affiliation(s)
- Paula Ribeiro Lopes Almeida
- MD. Otorhinolaryngologist and Postgraduate Student in Evidence-Based Health, Universidade Federal de São Paulo (UNIFESP), São Paulo (SP), Brasil
| | - Osmar Clayton Person
- MD, PhD. Full Professor, Department of Otorhinolaryngology, Universidade Santo Amaro (UNISA), São Paulo (SP), Brazil
| | | | | | - Ana Carolina Pereira Nunes Pinto
- PhD. Physiotherapist and Professor, Evidence-Based Health Program, Universidade Federal de São Paulo (UNIFESP), São Paulo (SP), Brazil
| | - Aline Pereira Rocha
- MSc. Pharmacist and Doctoral Student, Evidence-Based Health Program, Universidade Federal de São Paulo (UNIFESP), São Paulo (SP), Brazil
| | - Álvaro Nagib Atallah
- MD, PhD. Full Professor and Head of the Discipline of Emergency Medicine and Evidence-Based Medicine, Universidade Federal de São Paulo (UNIFESP), São Paulo (SP)
| |
Collapse
|
213
|
Tian Y, Carpp LN, Miller HER, Zager M, Newell EW, Gottardo R. Single-cell immunology of SARS-CoV-2 infection. Nat Biotechnol 2022; 40:30-41. [PMID: 34931002 PMCID: PMC9414121 DOI: 10.1038/s41587-021-01131-y] [Citation(s) in RCA: 64] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 10/15/2021] [Indexed: 02/07/2023]
Abstract
Gaining a better understanding of the immune cell subsets and molecular factors associated with protective or pathological immunity against severe acute respiratory syndrome coronavirus (SARS-CoV)-2 could aid the development of vaccines and therapeutics for coronavirus disease 2019 (COVID-19). Single-cell technologies, such as flow cytometry, mass cytometry, single-cell transcriptomics and single-cell multi-omic profiling, offer considerable promise in dissecting the heterogeneity of immune responses among individual cells and uncovering the molecular mechanisms of COVID-19 pathogenesis. Single-cell immune-profiling studies reported to date have identified innate and adaptive immune cell subsets that correlate with COVID-19 disease severity, as well as immunological factors and pathways of potential relevance to the development of vaccines and treatments for COVID-19. For facilitation of integrative studies and meta-analyses into the immunology of SARS-CoV-2 infection, we provide standardized, download-ready versions of 21 published single-cell sequencing datasets (over 3.2 million cells in total) as well as an interactive visualization portal for data exploration.
Collapse
Affiliation(s)
- Yuan Tian
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
- Translational Data Science Integrated Research Center, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Lindsay N Carpp
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Helen E R Miller
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Michael Zager
- Center for Data Visualization, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Evan W Newell
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.
| | - Raphael Gottardo
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.
- Translational Data Science Integrated Research Center, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.
- Biomedical Data Sciences, Lausanne University Hospital, Lausanne, Switzerland.
| |
Collapse
|
214
|
Yamakawa K, Yamamoto R, Terayama T, Hashimoto H, Ishihara T, Ishimaru G, Imura H, Okano H, Narita C, Mayumi T, Yasuda H, Yamada K, Yamada H, Kawasaki T, Shime N, Doi K, Egi M, Ogura H, Aihara M, Kushimoto S, Nishida O. Japanese rapid/living recommendations on drug management for COVID-19: updated guidelines (July 2022). Acute Med Surg 2022; 9:e789. [PMID: 36267628 PMCID: PMC9579991 DOI: 10.1002/ams2.789] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 09/07/2022] [Indexed: 12/15/2022] Open
Abstract
Background Coronavirus disease (COVID-19), an infectious disease caused by the novel coronavirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has spread worldwide since early 2020, and there are still no signs of resolution. The Japanese Clinical Practice Guidelines for the Management of Sepsis and Septic Shock (J-SSCG) 2020 Special Committee created the Japanese Rapid/Living recommendations on drug management for COVID-19 using the experience of creating the J-SSCG. Methods The Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) approach was used to determine the certainty of the evidence and strength of recommendations. The first edition of this guideline was released on September 9, 2020, and this is the revised edition (version 5.0; released on July 15, 2022). Clinical questions (CQs) were set for the following 10 drugs: favipiravir (CQ1), remdesivir (CQ2), corticosteroids (CQ4), tocilizumab (CQ5), anticoagulants (CQ7), baricitinib (CQ8), casirivimab/imdevimab (CQ9-1), sotrovimab (CQ9-2), molnupiravir (CQ10), and nirmatrelvir/ritonavir (CQ11). Recommendations Favipiravir is not suggested for all patients with COVID-19 (GRADE 2C). Remdesivir is suggested for patients with mild COVID-19 who do not require oxygen, and patients with moderate COVID-19 requiring supplemental oxygen/hospitalization (both GRADE 2B). Corticosteroids are recommended for moderate and severe COVID-19 (GRADE 1B, 1A). However, their administration is not recommended for mild COVID-19 (GRADE 1B). Tocilizumab is suggested for moderate and severe COVID-19 (GRADE 2B, 2C). Anticoagulant administration is recommended for moderate and severe COVID-19 (Good Practice Statement). Baricitinib is suggested for moderate and severe COVID-19 (both GRADE 2C). Casirivimab/imdevimab and sotrovimab are recommended for mild COVID-19 (both GRADE 2C). Molnupiravir and nirmatrelvir/ritonavir are recommended for mild COVID-19 (both GRADE 2C). SARS-CoV-2 mutant strains emerge occasionally, and each time, the treatment policy at clinics is forced to change drastically. We ask health-care professionals in the field to refer to the recommendations in these guidelines and use these to keep up to date with COVID-19 epidemiological information.
Collapse
Affiliation(s)
- Kazuma Yamakawa
- Department of Emergency and Critical Care MedicineOsaka Medical and Pharmaceutical UniversityTakatsukiJapan
| | - Ryo Yamamoto
- Department of Emergency and Critical Care MedicineKeio University School of MedicineTokyoJapan
| | - Takero Terayama
- Department of Psychiatry, School of MedicineNational Defense Medical CollegeTokorozawaJapan
| | - Hideki Hashimoto
- Department of Infectious DiseasesThe University of Tokyo HospitalTokyoJapan
| | - Tadashi Ishihara
- Department of Emergency and Critical Care MedicineJuntendo University Urayasu HospitalUrayasuJapan
| | - Go Ishimaru
- Department of General Internal MedicineSoka Municipal HospitalSokaJapan
| | - Haruki Imura
- Department of Infectious Diseases, Rakuwakai Otowa HospitalKyoto UniversityKyotoJapan
- Department of Health Informatics, School of Public HealthKyoto UniversityKyotoJapan
| | - Hiromu Okano
- Department of Critical Care and Emergency MedicineNational Hospital Organization Yokohama Medical CenterYokohamaJapan
| | - Chihiro Narita
- Department of Emergency Medicine and Intensive Care MedicineShizuoka General HospitalShizuokaJapan
| | - Takuya Mayumi
- Department of Internal MedicineKanazawa Municipal HospitalKanazawaJapan
| | - Hideto Yasuda
- Department of Emergency and Critical Care MedicineJichi Medical University Saitama Medical CenterSaitamaJapan
| | - Kohei Yamada
- Department of Traumatology and Critical Care MedicineNational Defense Medical CollegeTokorozawaJapan
| | - Hiroyuki Yamada
- Department of Primary Care and Emergency MedicineKyoto University HospitalKyotoJapan
| | - Tatsuya Kawasaki
- Department of Pediatric Critical CareShizuoka Children's HospitalShizuokaJapan
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health SciencesHiroshima UniversityHiroshimaJapan
| | - Kent Doi
- Department of Emergency and Critical Care Medicine, Graduate School of MedicineThe University of TokyoTokyoJapan
| | - Moritoki Egi
- Department of AnesthesiaKyoto University HospitalKyotoJapan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical MedicineOsaka University Medical SchoolSuitaJapan
| | - Morio Aihara
- Department of Gastroenterology and HematologyHirosaki University Graduate School of MedicineHirosakiJapan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care MedicineTohoku University Graduate School of MedicineSendaiJapan
| | - Osamu Nishida
- Department of Anesthesiology and Critical Care MedicineFujita Health University School of MedicineToyoakeJapan
| | | |
Collapse
|
215
|
Di Girolamo FG, Fiotti N, Sisto UG, Nunnari A, Colla S, Mearelli F, Vinci P, Schincariol P, Biolo G. Skeletal Muscle in Hypoxia and Inflammation: Insights on the COVID-19 Pandemic. Front Nutr 2022; 9:865402. [PMID: 35529457 PMCID: PMC9072827 DOI: 10.3389/fnut.2022.865402] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 03/09/2022] [Indexed: 12/23/2022] Open
Abstract
SARS-CoV-2 infection is often associated with severe inflammation, oxidative stress, hypoxia and impaired physical activity. These factors all together contribute to muscle wasting and fatigue. In addition, there is evidence of a direct SARS-CoV-2 viral infiltration into skeletal muscle. Aging is often characterized by sarcopenia or sarcopenic obesity These conditions are risk factors for severe acute COVID-19 and long-COVID-19 syndrome. From these observations we may predict a strong association between COVID-19 and decreased muscle mass and functions. While the relationship between physical inactivity, chronic inflammation, oxidative stress and muscle dysfunction is well-known, the effects on muscle mass of COVID-19-related hypoxemia are inadequately investigated. The aim of this review is to highlight metabolic, immunity-related and redox biomarkers potentially affected by reduced oxygen availability and/or muscle fatigue in order to shed light on the negative impact of COVID-19 on muscle mass and function. Possible countermeasures are also reviewed.
Collapse
Affiliation(s)
- Filippo G. Di Girolamo
- Department of Medical Surgical ad Health Science, Clinica Medica, Cattinara Hospital, University of Trieste, Trieste, Italy
- SC Assistenza Farmaceutica, Cattinara Hospital, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
- *Correspondence: Filippo G. Di Girolamo
| | - Nicola Fiotti
- Department of Medical Surgical ad Health Science, Clinica Medica, Cattinara Hospital, University of Trieste, Trieste, Italy
| | - Ugo G. Sisto
- Department of Medical Surgical ad Health Science, Clinica Medica, Cattinara Hospital, University of Trieste, Trieste, Italy
| | - Alessio Nunnari
- Department of Medical Surgical ad Health Science, Clinica Medica, Cattinara Hospital, University of Trieste, Trieste, Italy
| | - Stefano Colla
- SC Assistenza Farmaceutica, Cattinara Hospital, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Filippo Mearelli
- Department of Medical Surgical ad Health Science, Clinica Medica, Cattinara Hospital, University of Trieste, Trieste, Italy
| | - Pierandrea Vinci
- Department of Medical Surgical ad Health Science, Clinica Medica, Cattinara Hospital, University of Trieste, Trieste, Italy
| | - Paolo Schincariol
- SC Assistenza Farmaceutica, Cattinara Hospital, Azienda Sanitaria Universitaria Giuliano Isontina, Trieste, Italy
| | - Gianni Biolo
- Department of Medical Surgical ad Health Science, Clinica Medica, Cattinara Hospital, University of Trieste, Trieste, Italy
| |
Collapse
|
216
|
Rea IM, Alexander HD. Triple jeopardy in ageing: COVID-19, co-morbidities and inflamm-ageing. Ageing Res Rev 2022; 73:101494. [PMID: 34688926 PMCID: PMC8530779 DOI: 10.1016/j.arr.2021.101494] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 09/01/2021] [Accepted: 10/18/2021] [Indexed: 02/06/2023]
Abstract
Covid-19 endangers lives, has disrupted normal life, changed the way medicine is practised and is likely to alter our world for the foreseeable future. Almost two years on since the presumptive first diagnosis of COVID-19 in China, more than two hundred and fifty million cases have been confirmed and more than five million people have died globally, with the figures rising daily. One of the most striking aspects of COVID-19 illness is the marked difference in individuals' experiences of the disease. Some, most often younger groups, are asymptomatic, whereas others become severely ill with acute respiratory distress syndrome (ARDS), pneumonia or proceed to fatal organ disease. The highest death rates are in the older and oldest age groups and in people with co-morbidities such as diabetes, heart disease and obesity. Three major questions seem important to consider. What do we understand about changes in the immune system that might contribute to the older person's risk of developing severe COVID-19? What factors contribute to the higher morbidity and mortality in older people with COVID-19? How could immunocompetence in the older and the frailest individuals and populations be supported and enhanced to give protection from serious COVID-19 illness?
Collapse
Affiliation(s)
- Irene Maeve Rea
- School of Medicine, Dentistry and Biomedical Science, Queens University Belfast, Belfast, United Kingdom; Northern Ireland Centre for Stratified Medicine, Biomedical Sciences Research Institute, University of Ulster, C-TRIC Building, Altnagelvin Area Hospital, Londonderry, United Kingdom; Meadowlands Ambulatory Care Centre, Belfast Health and Social Care Trust, Belfast, United Kingdom.
| | - H Denis Alexander
- Northern Ireland Centre for Stratified Medicine, Biomedical Sciences Research Institute, University of Ulster, C-TRIC Building, Altnagelvin Area Hospital, Londonderry, United Kingdom
| |
Collapse
|
217
|
Castro P, Palomo M, Moreno-Castaño AB, Fernández S, Torramadé-Moix S, Pascual G, Martinez-Sanchez J, Richardson E, Téllez A, Nicolas JM, Carreras E, Richardson PG, Badimon JJ, Escolar G, Diaz-Ricart M. Is the Endothelium the Missing Link in the Pathophysiology and Treatment of COVID-19 Complications? Cardiovasc Drugs Ther 2022; 36:547-560. [PMID: 34097193 PMCID: PMC8181544 DOI: 10.1007/s10557-021-07207-w] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/24/2021] [Indexed: 02/08/2023]
Abstract
Patients with COVID-19 present a wide spectrum of disease severity, from asymptomatic cases in the majority to serious disease leading to critical care and even death. Clinically, four different scenarios occur within the typical disease timeline: first, an incubation and asymptomatic period; second, a stage with mild symptoms due mainly to the virus itself; third, in up to 20% of the patients, a stage with severe symptoms where a hyperinflammatory response with a cytokine storm driven by host immunity induces acute respiratory distress syndrome; and finally, a post-acute sequelae (PASC) phase, which present symptoms that can range from mild or annoying to actually quite incapacitating. Although the most common manifestation is acute respiratory failure of the lungs, other organs are also frequently involved. The clinical manifestations of the COVID-19 infection support a key role for endothelial dysfunction in the pathobiology of this condition. The virus enters into the organism via its interaction with angiotensin-converting enzyme 2-receptor that is present prominently in the alveoli, but also in endothelial cells, which can be directly infected by the virus. Cytokine release syndrome can also drive endothelial damage independently. Consequently, a distinctive feature of SARS-CoV-2 infection is vascular harm, with severe endothelial injury, widespread thrombosis, microangiopathy, and neo-angiogenesis in response to endothelial damage. Therefore, endothelial dysfunction seems to be the pathophysiological substrate for severe COVID-19 complications. Biomarkers of endothelial injury could constitute strong indicators of disease progression and severity. In addition, the endothelium could represent a very attractive target to both prevent and treat these complications. To establish an adequate therapy, the underlying pathophysiology and corresponding clinical stage should be clearly identified. In this review, the clinical features of COVID-19, the central role of the endothelium in COVID-19 and in other pathologies, and the potential of specific therapies aimed at protecting the endothelium in COVID-19 patients are addressed.
Collapse
Affiliation(s)
- Pedro Castro
- Medical Intensive Care Unit, Hospital Clinic, Barcelona, Spain
- School of Medicine, University of Barcelona, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
| | - Marta Palomo
- Josep Carreras Leukaemia Research Institute, Hospital Clinic, University of Barcelona, Barcelona, Spain
- Barcelona Endothelium Team, Barcelona, Spain
| | - Ana Belen Moreno-Castaño
- Barcelona Endothelium Team, Barcelona, Spain
- Hematopathology, Pathology Department, CDB, Hospital Clinic, Villarroel 170, 08036, Barcelona, Spain
| | - Sara Fernández
- Medical Intensive Care Unit, Hospital Clinic, Barcelona, Spain
- Barcelona Endothelium Team, Barcelona, Spain
| | - Sergi Torramadé-Moix
- IDIBAPS, Barcelona, Spain
- Hematopathology, Pathology Department, CDB, Hospital Clinic, Villarroel 170, 08036, Barcelona, Spain
| | | | - Julia Martinez-Sanchez
- Josep Carreras Leukaemia Research Institute, Hospital Clinic, University of Barcelona, Barcelona, Spain
- Barcelona Endothelium Team, Barcelona, Spain
| | - Edward Richardson
- Frank H. Netter M.D. School of Medicine At, Quinnipiac University, North Haven, CT, USA
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Adrián Téllez
- Medical Intensive Care Unit, Hospital Clinic, Barcelona, Spain
| | - Josep M Nicolas
- Medical Intensive Care Unit, Hospital Clinic, Barcelona, Spain
- School of Medicine, University of Barcelona, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
| | - Enric Carreras
- Josep Carreras Leukaemia Research Institute, Hospital Clinic, University of Barcelona, Barcelona, Spain
- Barcelona Endothelium Team, Barcelona, Spain
| | - Paul G Richardson
- Jerome Lipper Multiple Myeloma Center, Division of Hematologic Malignancy, Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Juan José Badimon
- Cardiology Department, Cardiovascular Institute, Mount Sinai Hospital, New York, NY, USA
- AtheroThrombosis Research Unit, Cardiovascular Institute, Icahn School of Medicine At Mount Sinai, New York, NY, USA
| | - Gines Escolar
- School of Medicine, University of Barcelona, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
- Barcelona Endothelium Team, Barcelona, Spain
- Hematopathology, Pathology Department, CDB, Hospital Clinic, Villarroel 170, 08036, Barcelona, Spain
| | - Maribel Diaz-Ricart
- School of Medicine, University of Barcelona, Barcelona, Spain.
- IDIBAPS, Barcelona, Spain.
- Barcelona Endothelium Team, Barcelona, Spain.
- Hematopathology, Pathology Department, CDB, Hospital Clinic, Villarroel 170, 08036, Barcelona, Spain.
| |
Collapse
|
218
|
Alhazzani W, Alshahrani M, Alshamsi F, Aljuhani O, Eljaaly K, Hashim S, Alqahtani R, Alsaleh D, Al Duhailib Z, Algethamy H, Al-Musawi T, Alshammari T, Alqarni A, Khoujah D, Tashkandi W, Dahhan T, Almutairi N, Alserehi HA, Al-Yahya M, Al-Judaibi B, Arabi YM, Abualenain J, Alotaibi JM, Al Bshabshe A, Alharbi R, Al-Hameed F, Elhazmi A, Almaghrabi RS, Almaghlouth F, Abedalthagafi M, Al Khathlan N, Al-Suwaidan FA, Bunyan RF, Baw B, Alghamdi G, Al Hazmi M, Mandourah Y, Assiri A, Enani M, Alawi M, Aljindan R, Aljabbary A, Alrbiaan A, Algurashi F, Alsaawi A, Alenazi TH, Alsultan MA, Alqahtani SA, Memish Z, Al-Tawfiq JA, Al-Jedai A. The Saudi Critical Care Society practice guidelines on the management of COVID-19 in the ICU: Therapy section. J Infect Public Health 2022; 15:142-151. [PMID: 34764042 PMCID: PMC8527699 DOI: 10.1016/j.jiph.2021.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 08/24/2021] [Accepted: 10/07/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The rapid increase in coronavirus disease 2019 (COVID-19) cases during the subsequent waves in Saudi Arabia and other countries prompted the Saudi Critical Care Society (SCCS) to put together a panel of experts to issue evidence-based recommendations for the management of COVID-19 in the intensive care unit (ICU). METHODS The SCCS COVID-19 panel included 51 experts with expertise in critical care, respirology, infectious disease, epidemiology, emergency medicine, clinical pharmacy, nursing, respiratory therapy, methodology, and health policy. All members completed an electronic conflict of interest disclosure form. The panel addressed 9 questions that are related to the therapy of COVID-19 in the ICU. We identified relevant systematic reviews and clinical trials, then used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach as well as the evidence-to-decision framework (EtD) to assess the quality of evidence and generate recommendations. RESULTS The SCCS COVID-19 panel issued 12 recommendations on pharmacotherapeutic interventions (immunomodulators, antiviral agents, and anticoagulants) for severe and critical COVID-19, of which 3 were strong recommendations and 9 were weak recommendations. CONCLUSION The SCCS COVID-19 panel used the GRADE approach to formulate recommendations on therapy for COVID-19 in the ICU. The EtD framework allows adaptation of these recommendations in different contexts. The SCCS guideline committee will update recommendations as new evidence becomes available.
Collapse
Affiliation(s)
- Waleed Alhazzani
- Department of Medicine, McMaster University, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada; GUIDE Center, St. Joseph's Healthcare Hamilton, Hamilton, Canada.
| | - Mohammed Alshahrani
- Department of Emergency and Critical Care, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Ohoud Aljuhani
- Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Khalid Eljaaly
- Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Samaher Hashim
- Department of Medicine, University of Tabuk, Tabuk, Saudi Arabia
| | - Rakan Alqahtani
- Department of Critical Care Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Doaa Alsaleh
- Department of Population Health Science and Policy, Icahn's School of Medicine at Mount Sinai, NYC, USA; King Abdullah International Medical Research Center, NGHA, Riyadh, Saudi Arabia
| | - Zainab Al Duhailib
- Critical Care Medicine Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Haifa Algethamy
- Department of Anesthesia and Critical Care, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Tariq Al-Musawi
- Department of Critical Care Medicine, Dr Sulaiman AlHabib Hospital, AlKhobar, Saudi Arabia; Royal College of Surgeons in Ireland- Medical University of Bahrain, Bahrain
| | - Thamir Alshammari
- Medication Safety Research Chair, King Saud University, Riyadh, Saudi Arabia; College of Pharmacy, Riyadh Elm University, Riyadh, Saudi Arabia
| | - Abdullah Alqarni
- Department of Emergencies, Disasters, and Medical Transportation, Ministry of Health, Riyadh, Saudi Arabia
| | - Danya Khoujah
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Wail Tashkandi
- Department of Surgery, King Abdulaziz University, Jeddah, Saudi Arabia; Department of Critical Care, Fakeeh Care Group, Jeddah, Saudi Arabia
| | - Talal Dahhan
- Critical Care Medicine Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia; Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, Duke University, Durham, USA
| | - Najla Almutairi
- Department of Emergencies, Disasters, and Medical Transportation, Ministry of Health, Riyadh, Saudi Arabia
| | | | - Maytha Al-Yahya
- Department of Emergency Medicine, King AbdulAziz Medical City (KAMC), Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | | | - Yaseen M Arabi
- King Saud Bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Centre, Riyadh, Saudi Arabia
| | - Jameel Abualenain
- Department of Emergency Medicine, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Jawaher M Alotaibi
- Department of Medicine, King Faisal Specialist Hospital and Research Center Riyadh, Saudi Arabia
| | - Ali Al Bshabshe
- Department of Medicine/Adult Critical Care, College of Medicine, King Khalid University, Abha, Saudi Arabia
| | - Reham Alharbi
- Critical Care Department, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Fahad Al-Hameed
- Department of Intensive Care, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia; King Abdullah International Medical Research Center, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Alyaa Elhazmi
- Dr. Sulaiman Al-Habib Medical Group, Critical Care Department, Riyadh, Saudi Arabia
| | - Reem S Almaghrabi
- Department of Medicine, King Faisal Specialist Hospital and Research Center, Saudi Arabia
| | - Fatma Almaghlouth
- Respiratory Care Department, Faculty of Rehabilitation Sciences, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Malak Abedalthagafi
- Genomics Research Department, Saudi Human Genome Project, King Fahad Medical City and King Abdulaziz City for Science and Technology, Riyadh, Saudi Arabia
| | - Noor Al Khathlan
- Respiratory Care Department, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Faisal A Al-Suwaidan
- Clinical Excellence Administration and King Fahad Medical City, Second Health Cluster in Riyadh, Ministry of Health, Saudi Arabia
| | - Reem F Bunyan
- Center for Improving Value in Health, Saudi Arabia; Department of Neurology, King Fahad Specialist Hospital Dammam, Saudi Arabia
| | - Bandar Baw
- Department of Medicine, McMaster University, Canada; Department of Emergency Medicine, King AbdulAziz Medical City (KAMC), Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Ghassan Alghamdi
- Department of Medicine and Intensive Care, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Manal Al Hazmi
- Department of Medicine, King Fahad Specialist-Dammam, E1 Cluster, Dammam, Saudi Arabia
| | - Yasser Mandourah
- General Directorate of Military Medical Services, Ministry of Defense, Saudi Arabia
| | - Abdullah Assiri
- Infection Prevention and Control, Ministry of Health, Riyadh, Saudi Arabia
| | - Mushira Enani
- Section of Infectious Diseases Medical Specialties Department, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Maha Alawi
- Department of Medical Microbiology, Parasitology, Infection Control and Environmental Health Unit, King Abdulaziz Hospital, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Reem Aljindan
- Department of Microbiology, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Ahmed Aljabbary
- Department of Intensive Care, Security Forces Hospital Program in Riyadh, Saudi Arabia
| | - Abdullah Alrbiaan
- Critical Care Medicine Department, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Fahd Algurashi
- Division of Anesthesia and Critical Care, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
| | - Abdulmohsen Alsaawi
- Department of Emergency Medicine, King AbdulAziz Medical City (KAMC), Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Thamer H Alenazi
- King Abdulaziz Medical City, King Abdullah International Medical Research Center, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
| | | | - Saleh A Alqahtani
- Liver Transplant Centre, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia; Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, USA
| | - Ziad Memish
- Research and Innovation Center, King Saud Medical City, Ministry of Health, & College of Medicine, Alfaisal University, Riyadh, Saudi Arabia; Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Jaffar A Al-Tawfiq
- Infectious Disease Division, Indiana University School of Medicine, IN, USA; Infectious Disease Division, Johns Hopkins University School of Medicine, Baltimore, USA; Quality Department, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
| | - Ahmed Al-Jedai
- Colleges of Medicine and Pharmacy, Alfaisal University, Riyadh, Saudi Arabia; Therapeutic Affairs, Ministry of Health, Riyadh, Saudi Arabia
| |
Collapse
|
219
|
Rubio-Rivas M, Mora-Luján JM, Montero A, Aguilar García JA, Méndez Bailón M, Fernández Cruz A, Oriol I, Teigell-Muñoz FJ, Dendariena Borque B, De la Peña Fernández A, Fernández González R, Gil Sánchez R, Fernández Fernández J, Catalán M, Cortés-Rodríguez B, Mella Pérez C, Montero Rivas L, Suárez Fuentetaja R, Ternero Vega JE, Ena J, Martin-Urda Díez-Canseco A, Pérez García C, Varona JF, Casas-Rojo JM, Millán Núñez-Cortés J. The Use of Corticosteroids or Tocilizumab in COVID-19 Based on Inflammatory Markers. J Gen Intern Med 2022; 37:168-175. [PMID: 34664188 PMCID: PMC8523009 DOI: 10.1007/s11606-021-07146-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 09/08/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND The inflammatory cascade is the main cause of death in COVID-19 patients. Corticosteroids (CS) and tocilizumab (TCZ) are available to treat this escalation but which patients to administer it remains undefined. OBJECTIVE We aimed to evaluate the efficacy of immunosuppressive/anti-inflammatory therapy in COVID-19, based on the degree of inflammation. DESIGN A retrospective cohort study with data on patients collected and followed up from March 1st, 2020, to May 1st, 2021, from the nationwide Spanish SEMI-COVID-19 Registry. Patients under treatment with CS vs. those under CS plus TCZ were compared. Effectiveness was explored in 3 risk categories (low, intermediate, high) based on lymphocyte count, C-reactive protein (CRP), lactate dehydrogenase (LDH), ferritin, and D-dimer values. PATIENTS A total of 21,962 patients were included in the Registry by May 2021. Of these, 5940 met the inclusion criteria for the present study (5332 were treated with CS and 608 with CS plus TCZ). MAIN MEASURES The primary outcome of the study was in-hospital mortality. Secondary outcomes were the composite variable of in-hospital mortality, requirement for high-flow nasal cannula (HFNC), non-invasive mechanical ventilation (NIMV), invasive mechanical ventilation (IMV), or intensive care unit (ICU) admission. KEY RESULTS A total of 5940 met the inclusion criteria for the present study (5332 were treated with CS and 608 with CS plus TCZ). No significant differences were observed in either the low/intermediate-risk category (1.5% vs. 7.4%, p=0.175) or the high-risk category (23.1% vs. 20%, p=0.223) after propensity score matching. A statistically significant lower mortality was observed in the very high-risk category (31.9% vs. 23.9%, p=0.049). CONCLUSIONS The prescription of CS alone or in combination with TCZ should be based on the degrees of inflammation and reserve the CS plus TCZ combination for patients at high and especially very high risk.
Collapse
Affiliation(s)
- Manuel Rubio-Rivas
- Department of Internal Medicine, Bellvitge University Hospital, Bellvitge Biomedical Research Institute-IDIBELL, University of Barcelona, Barcelona, Spain
| | - José M. Mora-Luján
- Department of Internal Medicine, Bellvitge University Hospital, Bellvitge Biomedical Research Institute-IDIBELL, University of Barcelona, Barcelona, Spain
| | - Abelardo Montero
- Department of Internal Medicine, Bellvitge University Hospital, Bellvitge Biomedical Research Institute-IDIBELL, University of Barcelona, Barcelona, Spain
| | | | - Manuel Méndez Bailón
- Department of Internal Medicine, San Carlos University Hospital, Complutense University, Madrid, Spain
| | - Ana Fernández Cruz
- Department of Internal Medicine, Puerta de Hierro University Hospital, Majadahonda, Madrid, Spain
| | - Isabel Oriol
- Infectious Disease Unit, Department of Internal Medicine, Moisès Broggi Hospital, Sant Joan Despí, Barcelona, Spain
| | | | | | | | | | | | | | - Marta Catalán
- Department of Internal Medicine, Sagunto University Hospital, Sagunto, Valencia Spain
| | | | - Carmen Mella Pérez
- Department of Internal Medicine, Ferrol Clinical University Hospital, El Ferrol, La Coruña, Spain
| | - Lorena Montero Rivas
- Department of Internal Medicine, Infanta Margarita Hospital, Cabra, Córdoba, Spain
| | | | | | - Javier Ena
- Department of Internal Medicine, Marina Baixa Hospital, Villajoyosa, Alicante, Spain
| | | | - Cristina Pérez García
- Department of Internal Medicine, Do Salnes Hospital, Vilagarcía de Arousa, Pontevedra, Spain
| | - José F. Varona
- Department of Internal Medicine, HM Montepríncipe University Hospital, Madrid, Spain
- Department of Internal Medicine, Infanta Cristina University Hospital, Parla, Madrid Spain
| | - José Manuel Casas-Rojo
- Department of Internal Medicine, Infanta Cristina University Hospital, Parla, Madrid, Spain
| | | | - on behalf of the SEMI-COVID-19 Network
- Department of Internal Medicine, Bellvitge University Hospital, Bellvitge Biomedical Research Institute-IDIBELL, University of Barcelona, Barcelona, Spain
- Department of Internal Medicine, Costa del Sol Hospital, Marbella, Málaga, Spain
- Department of Internal Medicine, San Carlos University Hospital, Complutense University, Madrid, Spain
- Department of Internal Medicine, Puerta de Hierro University Hospital, Majadahonda, Madrid, Spain
- Infectious Disease Unit, Department of Internal Medicine, Moisès Broggi Hospital, Sant Joan Despí, Barcelona, Spain
- Department of Internal Medicine, Infanta Cristina University Hospital, Parla, Madrid, Spain
- Department of Internal Medicine, San Pedro Hospital, Logroño, Spain
- Department of Internal Medicine, Son Llàtzer University Hospital, Palma de Mallorca, Spain
- Department of Internal Medicine, Ourense University Hospital, Ourense, Spain
- Department of Internal Medicine, La Fe Hospital, Valencia, Spain
- Department of Internal Medicine, Mataró Hospital, Mataró, Barcelona, Spain
- Department of Internal Medicine, Sagunto University Hospital, Sagunto, Valencia Spain
- Department of Internal Medicine, Alto Guadalquivir Hospital, Andújar, Jaén, Spain
- Department of Internal Medicine, Ferrol Clinical University Hospital, El Ferrol, La Coruña, Spain
- Department of Internal Medicine, Infanta Margarita Hospital, Cabra, Córdoba, Spain
- Department of Internal Medicine, Monforte de Lemos Hospital, Monforte de Lemos, Lugo, Spain
- Department of Internal Medicine, Vírgen del Rocío University Hospital, Sevilla, Spain
- Department of Internal Medicine, Marina Baixa Hospital, Villajoyosa, Alicante, Spain
- Department of Internal Medicine, Palamós Hospital, Palamós, Girona, Spain
- Department of Internal Medicine, Do Salnes Hospital, Vilagarcía de Arousa, Pontevedra, Spain
- Department of Internal Medicine, HM Montepríncipe University Hospital, Madrid, Spain
- Department of Internal Medicine, Infanta Cristina University Hospital, Parla, Madrid Spain
- Department of Internal Medicine, Gregorio Marañón General University Hospital, Madrid, Spain
| |
Collapse
|
220
|
Senderovich H, Vinoraj D, Stever M, Waicus S. Efficacy of COVID-19 treatments among geriatric patients: a systematic review. Ther Adv Infect Dis 2022; 9:20499361221095666. [PMID: 35677110 PMCID: PMC9168946 DOI: 10.1177/20499361221095666] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 03/29/2022] [Indexed: 11/29/2022] Open
Abstract
Introduction A majority of the fatalities due to COVID-19 have been observed in those over the age of 60. There is no approved and universally accepted treatment for geriatric patients. The aim of this review is to assess the current literature on efficacy of COVID-19 treatments in geriatric populations. Methods A systematic review search was conducted in PubMed, MedRxiv, and JAMA databases with the keywords COVID-19, geriatric, hydroxychloroquine, dexamethasone, budesonide, remdesivir, favipiravir, ritonavir, molnupiravir, tocilizumab, bamlanivimab, baricitinib, sotrovimab, fluvoxamine, convalescent plasma, prone position, or anticoagulation. Articles published from January 2019 to January 2022 with a population greater than or equal to 60 years of age were included. Interventions examined included hydroxychloroquine, remdesivir, favipiravir, dexamethasone, budesonide, tocilizumab, bamlanivimab, baricitinib, sotrovimab, convalescent plasma, prone position, and anticoagulation therapy. Outcome measures included viral load, viral markers, ventilator-free days, or clinical improvement. Results The search revealed 302 articles, 52 met inclusion criteria. Hydroxychloroquine, dexamethasone, and remdesivir revealed greater side effects or inefficiency in geriatric patients with COVID-19. Favipiravir, bamlanivimab, baricitinib, and supportive therapy showed a decrease in viral load and improvement of clinical symptoms. There is conflicting evidence with tocilizumab, convalescent plasma, and anticoagulant therapy in reducing mortality, ventilator-free days, and clinical improvements. In addition, there was limited evidence and lack of data due to ongoing trials for treatments with sotrovimab and budesonide. Conclusion No agent is known to be effective for preventing COVID-19 after exposure to the virus. Further research is needed to ensure safety and efficacy of each of the reviewed interventions for older adults.
Collapse
Affiliation(s)
- Helen Senderovich
- Baycrest, 3560 Bathurst Street, Toronto, ON M6A
2E1, Canada
- Department of Family and Community Medicine,
University of Toronto, Toronto, ON, Canada
- Division of Palliative Care, University of
Toronto, Toronto, ON, Canada
| | - Danusha Vinoraj
- Department of Psychiatry, Faculty of Medicine,
University of Ottawa, Ottawa, ON, Canada
| | | | - Sarah Waicus
- School of Medicine, Trinity College Dublin, The
University of Dublin, Dublin, Ireland
| |
Collapse
|
221
|
Gomon Y, Kolbin A, Strizheletsky V, Ivanov I, Sultanova F, Balykina Y. A systematic review and meta-analysis of the safety of anti-interleukin therapy in COVID-19. CLINICAL MICROBIOLOGY AND ANTIMICROBIAL CHEMOTHERAPY 2022. [DOI: 10.36488/cmac.2022.2.93-107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Objective.
To evaluate safety of anti-interleukin drugs used as a pathogenetic therapy of COVID-19 as assessed by risks of infectious complications.
Materials and Methods.
A systematic review of publications related to safety assessment of anti-interleukin drugs recommended as pathogenetic therapy in COVID-19 patients in terms of incidence of serious adverse events and adverse events of “Infections and Invasions” class and a meta-analysis of the data were performed.
Results.
The meta-analysis included 16 randomized and 3 non-randomized studies. The hazard ratio of serious adverse events between the comparison groups was 0.93 95% CI 0.85; 1.01, the hazard ratio of adverse event of “Infections and Invasions” class was 0.9 95% CI 0.8; 1.02, showing no differences in the incidence of those events.
Conclusions.
This meta-analysis did not demonstrate statistically significant differences in the relative risks of serious adverse events and adverse events of “Infections and Invasions” class for the use of antiinterleukin drugs in COVID-19 patients.
Collapse
Affiliation(s)
- Yu.M. Gomon
- Pavlov First Saint-Petersburg State Medical; St. George the Great Martyr Hospital (Saint-Petersburg, Russia)
| | - A.S. Kolbin
- Pavlov First Saint-Petersburg State Medical University; Saint-Petersburg State University (Saint-Petersburg, Russia)
| | - V.V. Strizheletsky
- St. George the Great Martyr Hospital; Saint-Petersburg State University (Saint-Petersburg, Russia)
| | - I.G. Ivanov
- St. George the Great Martyr Hospital; Saint-Petersburg State University (Saint-Petersburg, Russia)
| | - F.M. Sultanova
- St. George the Great Martyr Hospital (Saint-Petersburg, Russia)
| | - Yu.E. Balykina
- Saint-Petersburg State University (Saint-Petersburg, Russia)
| |
Collapse
|
222
|
Klopfenstein T, Gendrin V, Kadiane‐Oussou NJ, Conrozier T, Zayet S. Tocilizumab in COVID-19 pneumonia: Practical proposals based on a narrative review of randomised trials. Rev Med Virol 2022; 32:e2239. [PMID: 33882179 PMCID: PMC8250236 DOI: 10.1002/rmv.2239] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 04/08/2021] [Accepted: 04/09/2021] [Indexed: 01/08/2023]
Abstract
In this article, we express our opinion about tocilizumab as an effective treatment in coronavirus disease 2019, based on a narrative review and a deep analysis of tocilizumab randomised trial results. Eight trials were included. No one was in favour for controlled arm about main endpoint of death or mechanical ventilation incidence at day 28-30. Five trials on heterogenous populations seem to not demonstrate tocilizumab efficacy, but showed encouraging results in subgroup analysis on severe/critical patients (in favour for tocilizumab). Trials on severe/critical COVID-19 pneumonia as REMAP-CAP and RECOVERY showed mortality benefit of tocilizumab administration; CORIMUNO, REMAP-CAP and RECOVERY showed that tocilizumab decreased the incidence of mechanical ventilation. No safety signal about tocilizumab used was noticed in all trials. We concluded that tocilizumab reduces mortality and mechanical ventilation requirement if administered with the right timing in COVID-19 pneumonia. The challenge now is to define the optimal group and timing for tocilizumab benefit and we suggest that: (i) tocilizumab has a place in treatment of severe/critical COVID-19 pneumonia, with a high level of O2 flow or noninvasive ventilation or high flow nasal cannula; (ii) possibly early after intubation in patients on mechanical ventilation. Initiating tocilizumab in critically ill patients early before irreversible respiratory failure, especially in patients at an inflammatory stage could be the key to successful outcome.
Collapse
Affiliation(s)
| | - Vincent Gendrin
- Infectious Disease DepartmentNord Franche‐Comté HospitalMontbéliard‐BelfortFrance
| | | | - Thierry Conrozier
- Rheumatology DepartmentNord Franche‐Comté HospitalMontbéliard‐BelfortFrance
| | - Souheil Zayet
- Infectious Disease DepartmentNord Franche‐Comté HospitalMontbéliard‐BelfortFrance
| | | |
Collapse
|
223
|
Abstract
SARS-CoV-2 virus may cause COVID-19 disease, which causes mild-to-moderate disease in 80% of laboratory-confirmed cases which may be community-managed. A considerable age-dependent mortality is seen among elderly and other at-risk populations but among young and healthy individuals it is < 0.5%. Long-term health issues have been reported following severe COVID-19 requiring hospitalization as well as after cases of mild COVID-19 without hospitalization. Upon receiving COVID-19 suspected patients at hospitals, patients should be isolated and PPE should be worn by all health staff when in contact with the patients. Additionally, patients are tested for the presence of SARS-CoV-2 RNA by PCR, and blood samples are drawn. Imaging is not pivotal for the diagnosis, but chest X-ray is a relevant examination for all and is used to determine severity and treatment need Abnormal findings on CT scans are found in most patients, most frequently peripheral ground-glass opacity and bilateral patchy shadowing are present. Patients are, according to their needs and risks, treated with oxygen therapy, anticoagulation therapy, steroids, antivirals, or immunosupressive drugs on special indications. Convalescent plasma therapy and monoclonal antibodies have a limited role in the treatment, mostly in severely immunocompromised patients. Patients with long-term sequelae should be evaluated in a post-COVID outpatient clinic. The most frequent reported symptoms include cognitive impairment, dyspnea, loss of smell and taste, and mental and physical fatigue although a wide spectrum of symptoms from other organ systems are also reported. The current treatment is based on symptom relief and rehabilitation as there is no documented specific medical treatment.
Collapse
Affiliation(s)
- Martin Mølhave
- Dept of Infectious Diseases, Institute for Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Jane Agergaard
- Dept of Infectious Diseases, Institute for Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Christian Wejse
- Dept of Infectious Diseases, Institute for Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark; GloHAU, Center for Global Health, Dept of Public Health, Aarhus University, Aarhus, Denmark.
| |
Collapse
|
224
|
Jorgensen SC, Lapinsky SE. Tocilizumab for coronavirus disease 2019 in pregnancy and lactation: a narrative review. Clin Microbiol Infect 2022; 28:51-57. [PMID: 34438068 PMCID: PMC8381634 DOI: 10.1016/j.cmi.2021.08.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 08/13/2021] [Accepted: 08/16/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND Tocilizumab is a monoclonal antibody that interrupts interleukin-6 signalling, reducing downstream effects on inflammation and the innate immune response. It was shown to reduce mortality in patients with severe or critical coronavirus disease 2019 (COVID-19). Pregnant and breastfeeding people were largely excluded from clinical trials and hence, the extent to which results can be applied to these populations is not clear. OBJECTIVES To synthesize published data on tocilizumab in pregnancy and lactation, highlight important knowledge gaps, and help inform clinical decision-making about tocilizumab's use in these populations with COVID-19. SOURCES PubMed was searched for studies evaluating tocilizumab in pregnancy and lactation for COVID-19 and other indications. Literature on pharmacokinetics and reproductive/fetal safety of monoclonal antibodies in general was also sought. The US Food and Drug Administration and the European Medicines Agency guidance for the industry and regulatory approval documents were reviewed. CONTENT Published data on tocilizumab in pregnancy include 610 cases (n = 20 with COVID-19) together with seven mother-infant breastfeeding pairs. Higher rates of spontaneous abortion and premature birth have been reported compared with the general population, but multiple confounding variables limit interpretation. There is little data on tocilizumab exposure in the second and third trimesters when transplacental transport is highest. The effects of tocilizumab on the developing immune system are unclear. Pregnant patients with COVID-19 who received tocilizumab were often critically ill and corticosteroid use was uncommon. Neonatal follow up was limited. Tocilizumab appears to be compatible with breastfeeding. IMPLICATIONS Although the available data do not raise serious safety signals, they have significant limitations and are not sufficient to delineate the complete spectrum of potential adverse outcomes that may be associated with tocilizumab exposure during pregnancy and lactation. Diligent follow up and documentation of pregnancy outcomes will be important moving forward. A more effective regulatory framework to ensure equitable inclusion of pregnant people in research is clearly needed.
Collapse
Affiliation(s)
- Sarah C.J. Jorgensen
- Department of Pharmacy, Mount Sinai Hospital, Toronto, ON, Canada,Institute of Medical Science, University of Toronto, Toronto, ON, Canada,Corresponding author. Sarah C.J. Jorgensen, 600 University Avenue, Toronto, ON, M5G 1X5, Canada
| | - Stephen E. Lapinsky
- Division of Respirology, Mount Sinai Hospital, Toronto, ON, Canada,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
225
|
Currently available drugs for the treatment of Coronavirus-2. COMPUTATIONAL APPROACHES FOR NOVEL THERAPEUTIC AND DIAGNOSTIC DESIGNING TO MITIGATE SARS-COV-2 INFECTION 2022. [PMCID: PMC9300456 DOI: 10.1016/b978-0-323-91172-6.00018-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The Coronavirus disease 2019 (COVID-19) pandemic caused by the novel severe acute respiratory syndrome Coronavirus 2 (SARS CoV-2) has created a never-before-seen problem for humanity. The world was pushed into a position where we needed to identify the effective drugs for a disease that has unknown characteristics in the early 2020s. SARS CoV-2 Virology research suggested that several drugs could be the potential targets. Remdesivir was the first drug that was shown to have promising results in in vitro studies. Remdesivir became the first antiviral drug approved by USFDA for the management of COVID-19. But later studies show equivocal results. For this entirely new disease, we are still searching the perfect drug. Many existing drugs have been repurposed (steroids, anticoagulation, hydroxychloroquine) with varying success. Many new drugs have been researched for the management of this menace. In this review, we will discuss the mechanisms, uses, dosage, duration, and adverse effects of drugs used in COVID-19.
Collapse
|
226
|
Crichton ML, Goeminne PC, Tuand K, Vandendriessche T, Tonia T, Roche N, Chalmers JD. The impact of therapeutics on mortality in hospitalised patients with COVID-19: systematic review and meta-analyses informing the European Respiratory Society living guideline. Eur Respir Rev 2021; 30:210171. [PMID: 34911695 PMCID: PMC8796659 DOI: 10.1183/16000617.0171-2021] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 09/08/2021] [Indexed: 12/15/2022] Open
Abstract
Hospitalised patients with coronavirus disease 2019 (COVID-19) have a high mortality rate. There are an increasing number of published randomised controlled trials for anti-inflammatory, anti-viral and other treatments. The European Respiratory Society Living Guidelines for the Management of Hospitalised Adults with COVID-19 were published recently, providing recommendations on appropriate pharmacotherapy.Patient, Intervention, Comparator and Outcomes questions for key interventions were identified by an international panel and systematic reviews were conducted to identify randomised controlled trials meeting the inclusion criteria. The importance of end-points were rated, and mortality was identified as the key "critical" outcome for all interventions. Random-effects meta-analysis was used to pool studies and provide effect estimates for the impact of treatments on mortality.Corticosteroids, hydroxychloroquine, azithromycin, remdesivir, anti-interleukin (IL)-6 monoclonal antibodies, colchicine, lopinavir/ritonavir and interferon-β have been reviewed.Our results found further evidence in support of the use of corticosteroids, particularly dexamethasone, and anti-IL-6 receptor monoclonal antibody therapy. These data support the need to identify additional therapies with beneficial effects on mortality.
Collapse
Affiliation(s)
| | | | - Krizia Tuand
- KU Leuven Libraries - 2Bergen - Learning Centre Désiré Collen, Leuven, Belgium
| | | | - Thomy Tonia
- Institute of Social and Preventive Medicine, University Bern, Bern, Switzerland
| | - Nicolas Roche
- Respiratory Medicine, Cochin Hospital, APHP Centre-University of Paris, Cochin Institute (INSERM UMR1016), Paris, France
| | | |
Collapse
|
227
|
Islam KU, A-Elgadir TME, Afaq S, Ahmad T, Iqbal J. Molecular and Clinical Aspects of COVID-19 Vaccines and Other Therapeutic Interventions Apropos Emerging Variants of Concern. Front Pharmacol 2021; 12:778219. [PMID: 35002711 PMCID: PMC8734653 DOI: 10.3389/fphar.2021.778219] [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] [Received: 09/16/2021] [Accepted: 11/08/2021] [Indexed: 11/13/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) has overwhelmed the healthcare and economy of the world, with emerging new variants of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) posing an everlasting threat to humanity. While most COVID-19 vaccines provide adequate protective immunological response against the original SARS-CoV-2 variant, there is a pressing need to understand their biological and clinical responses. Recent evidence suggests that some of the new variants of SARS-CoV-2 evade the protection conferred by the existing vaccines, which may impede the ongoing efforts to expedite the vaccination programs worldwide. These concerns have also highlighted the importance of a pan-COVID-19 vaccine, which is currently in the making. Thus, it is imperative to have a better molecular and clinical understanding of the various COVID-19 vaccines and their immunological trajectory against any emerging variant of concerns (VOCs) in particular to break this vicious cycle. Furthermore, other treatment regimens based on cellular therapies and monoclonal antibodies should be explored systematically as an alternative and readily available option considering the possibility of the emergence of more virulent SARS-CoV-2 mutants. In this review, we shed light on the various molecular mechanisms and clinical responses of COVID-19 vaccines. Importantly, we review the recent findings of their long-term immune protection and efficacy against emerging VOCs. Considering that other targeted and effective treatments will complement vaccine therapy, we provide a comprehensive understanding of the role of cell-based therapies, monoclonal antibodies, and immunomodulatory agents as alternative and readily available treatment modalities against any emerging SARS-CoV-2 variant.
Collapse
Affiliation(s)
- Khursheed Ul Islam
- Multidisciplinary Centre for Advanced Research and Studies, Jamia Millia Islamia, New Delhi, India
| | | | - Sarah Afaq
- Department of Clinical Biochemistry, College of Medicine, King Khalid University, Abha, Saudi Arabia
| | - Tanveer Ahmad
- Multidisciplinary Centre for Advanced Research and Studies, Jamia Millia Islamia, New Delhi, India
| | - Jawed Iqbal
- Multidisciplinary Centre for Advanced Research and Studies, Jamia Millia Islamia, New Delhi, India
| |
Collapse
|
228
|
Karampitsakos T, Malakounidou E, Papaioannou O, Dimakopoulou V, Zarkadi E, Katsaras M, Tsiri P, Tsirikos G, Georgiopoulou V, Oikonomou I, Davoulos C, Velissaris D, Sampsonas F, Marangos M, Akinosoglou K, Tzouvelekis A. Tocilizumab improves 28-day survival in hospitalized patients with severe COVID-19: an open label, prospective study. Respir Res 2021; 22:317. [PMID: 34937570 PMCID: PMC8692825 DOI: 10.1186/s12931-021-01914-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 12/13/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Data on the safety and efficacy profile of tocilizumab in patients with severe COVID-19 needs to be enriched. METHODS In this open label, prospective study, we evaluated clinical outcomes in consecutive patients with COVID-19 and PaO2/FiO2 < 200 receiving tocilizumab plus usual care versus usual care alone. Tocilizumab was administered at the time point that PaO2/FiO2 < 200 was observed. The primary outcome was 28-day mortality. Secondary outcomes included time to discharge, change in PaO2/FiO2 at day 5 and change in WHO progression scale at day 10. FINDINGS Overall, 114 patients were included in the analysis (tocilizumab plus usual care: 56, usual care: 58). Allocation to usual care was associated with significant increase in 28-day mortality compared to tocilizumab plus usual care [Cox proportional-hazards model: HR: 3.34, (95% CI: 1.21-9.30), (p = 0.02)]. There was not a statistically significant difference with regards to hospital discharge over the 28 day period for patients receiving tocilizumab compared to usual care [11.0 days (95% CI: 9.0 to 16.0) vs 14.0 days (95% CI: 10.0-24.0), HR: 1.32 (95% CI: 0.84-2.08), p = 0.21]. ΔPaO2/FiO2 at day 5 was significantly higher in the tocilizumab group compared to the usual care group [42.0 (95% CI: 23.0-84.7) vs 15.8 (95% CI: - 19.4-50.3), p = 0.03]. ΔWHO scale at day 10 was significantly lower in the tocilizumab group compared to the usual care group (-0.5 ± 2.1 vs 0.6 ± 2.6, p = 0.005). CONCLUSION Administration of tocilizumab, at the time point that PaO2/FiO2 < 200 was observed, improved survival and other clinical outcomes in hospitalized patients with severe COVID-19 irrespective of systemic inflammatory markers levels.
Collapse
Affiliation(s)
| | - Elli Malakounidou
- Department of Respiratory Medicine, University Hospital of Patras, Pátrai, Greece
| | - Ourania Papaioannou
- Department of Respiratory Medicine, University Hospital of Patras, Pátrai, Greece
| | | | - Eirini Zarkadi
- Department of Respiratory Medicine, University Hospital of Patras, Pátrai, Greece
| | - Matthaios Katsaras
- Department of Respiratory Medicine, University Hospital of Patras, Pátrai, Greece
| | - Panagiota Tsiri
- Department of Respiratory Medicine, University Hospital of Patras, Pátrai, Greece
| | - Georgios Tsirikos
- Department of Respiratory Medicine, University Hospital of Patras, Pátrai, Greece
| | | | - Ioanna Oikonomou
- Department of Internal Medicine, University Hospital of Patras, Pátrai, Greece
| | - Christos Davoulos
- Department of Internal Medicine, University Hospital of Patras, Pátrai, Greece
| | | | - Fotios Sampsonas
- Department of Respiratory Medicine, University Hospital of Patras, Pátrai, Greece
| | - Markos Marangos
- Department of Internal Medicine, University Hospital of Patras, Pátrai, Greece
| | | | - Argyris Tzouvelekis
- Department of Respiratory Medicine, University Hospital of Patras, Pátrai, Greece.
| |
Collapse
|
229
|
Dolci G, Cassone G, Besutti G, Corsini R, Sampaolesi F, Iotti V, Galli E, Palermo A, Fontana M, Mancuso P. Tocilizumab or glucocorticoids treatment for patients with SARS-CoV-2 pneumonia: An observational study. Braz J Infect Dis 2021; 26:101702. [PMID: 34963560 PMCID: PMC8687752 DOI: 10.1016/j.bjid.2021.101702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Revised: 11/20/2021] [Accepted: 12/05/2021] [Indexed: 12/15/2022] Open
Abstract
Objective To estimate the effect of tocilizumab or glucocorticoids in preventing death and intubation in patients hospitalized with SARS-CoV-2 pneumonia. Methods This was a retrospective cohort study enrolling all consecutive patients hospitalized at Reggio Emilia AUSL between February the 11th and April 14th 2020 for severe COVID-19 and treated with tocilizumab or glucocorticoids (at least 80 mg/day of methylprednisolone or equivalent for at least 3 days). The primary outcome was death within 30 days from the start of the considered therapies. The secondary outcome was a composite outcome of death and/or intubation. All patients have been followed-up until May 19th 2020, with a follow-up of at least 30 days for every patient. To reduce confounding due to potential non-comparability of the two groups, those receiving tocilizumab and those receiving glucocorticoids, a propensity score was calculated as the inverse probability weighting of receiving treatment conditional on the baseline covariates. Results and conclusion Therapy with tocilizumab alone was associated with a reduction of deaths (OR 0.49, 95% CI 0.21-1.17) and of the composite outcome death/intubation (OR 0.35, 95% CI 0.13-0.90) compared to glucocorticoids alone. Nevertheless, this result should be cautiously interpreted due to a potential prescription bias.
Collapse
Affiliation(s)
- Giovanni Dolci
- Infectious Disease Unit, University of Modena and Reggio Emilia, Modena, Italy.
| | - Giulia Cassone
- Rheumatology Unit, IRCCS Arcispedale Santa Maria Nuova, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy; Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Giulia Besutti
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy; Radiology Unit, Department of Imaging and Laboratory Medicine, Azienda USL-IRCCS di Reggio Emilia, Italy
| | - Romina Corsini
- Infectious Disease Unit, Azienda USL-IRCCS di Reggio Emilia, Italy
| | - Fabio Sampaolesi
- Infectious Disease Unit, Azienda USL-IRCCS di Reggio Emilia, Italy
| | - Valentina Iotti
- Radiology Unit, Department of Imaging and Laboratory Medicine, Azienda USL-IRCCS di Reggio Emilia, Italy
| | - Elena Galli
- Rheumatology Unit, IRCCS Arcispedale Santa Maria Nuova, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Adalgisa Palermo
- Rheumatology Unit, IRCCS Arcispedale Santa Maria Nuova, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Matteo Fontana
- Pneumology Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Pamela Mancuso
- Servizio di epidemiologia, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Emilia-Romagna, Italy
| |
Collapse
|
230
|
Nurmohamed NS, Collard D, Reeskamp LF, Kaiser Y, Kroon J, Tromp TR, van den Born BJH, Coppens M, Vlaar APJ, Beudel M, van de Beek D, van Es N, Moriarty PM, Tsimikas S, Stroes ESG. Lipoprotein(a), venous thromboembolism and COVID-19: A pilot study. Atherosclerosis 2021; 341:43-49. [PMID: 34995986 PMCID: PMC8690577 DOI: 10.1016/j.atherosclerosis.2021.12.008] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 12/10/2021] [Accepted: 12/14/2021] [Indexed: 12/24/2022]
Abstract
Background and aims Thrombosis is a major driver of adverse outcome and mortality in patients with Coronavirus disease 2019 (COVID-19). Hypercoagulability may be related to the cytokine storm associated with COVID-19, which is mainly driven by interleukin (IL)-6. Plasma lipoprotein(a) [Lp(a)] levels increase following IL-6 upregulation and Lp(a) has anti-fibrinolytic properties. This study investigated whether Lp(a) elevation may contribute to the pro-thrombotic state hallmarking COVID-19 patients. Methods Lp(a), IL-6 and C-reactive protein (CRP) levels were measured in 219 hospitalized patients with COVID-19 and analyzed with linear mixed effects model. The baseline biomarkers and increases during admission were related to venous thromboembolism (VTE) incidence and clinical outcomes in a Kaplan-Meier and logistic regression analysis. Results Lp(a) levels increased significantly by a mean of 16.9 mg/dl in patients with COVID-19 during the first 21 days after admission. Serial Lp(a) measurements were available in 146 patients. In the top tertile of Lp(a) increase, 56.2% of COVID-19 patients experienced a VTE event compared to 18.4% in the lowest tertile (RR 3.06, 95% CI 1.61–5.81; p < 0.001). This association remained significant after adjusting for age, sex, IL-6 and CRP increase and number of measurements. Increases in IL-6 and CRP were not associated with VTE. Increase in Lp(a) was strongly correlated with increase in IL-6 (r = 0.44, 95% CI 0.30–0.56, p < 0.001). Conclusions Increases in Lp(a) levels during the acute phase of COVID-19 were strongly associated with VTE incidence. The acute increase in anti-fibrinolytic Lp(a) may tilt the balance to VTE in patients hospitalized for COVID-19.
Collapse
Affiliation(s)
- Nick S Nurmohamed
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Didier Collard
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Laurens F Reeskamp
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Yannick Kaiser
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Jeffrey Kroon
- Department of Experimental Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Tycho R Tromp
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | | | - Bert-Jan H van den Born
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Michiel Coppens
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Alexander P J Vlaar
- Department of Intensive Care, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Martijn Beudel
- Department of Neurology, Amsterdam Neuroscience Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Diederik van de Beek
- Department of Neurology, Amsterdam Neuroscience Institute, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Nick van Es
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Patrick M Moriarty
- Division of Clinical Pharmacology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Sotirios Tsimikas
- Division of Cardiovascular Medicine, University of California San Diego, La Jolla, CA, USA
| | - Erik S G Stroes
- Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
| |
Collapse
|
231
|
Taboada M, Rodríguez N, Varela PM, Rodríguez MT, Abelleira R, González A, Casal A, Díaz Peromingo JA, Lama A, Domínguez MJ, Rábade C, Páez EM, Riveiro V, Pernas H, Del Carmen Beceiro M, Caruezo V, Naveira A, Cariñena A, Cabaleiro T, Estany-Gestal A, Zarra I, Pose A, Valdés L, Álvarez-Escudero J. Effect of high versus low dose of dexamethasone on clinical worsening in patients hospitalised with moderate or severe COVID-19 Pneumonia: an open-label, randomised clinical trial. Eur Respir J 2021; 60:13993003.02518-2021. [PMID: 34916266 PMCID: PMC8678498 DOI: 10.1183/13993003.02518-2021] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2021] [Accepted: 12/02/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Low dose dexamethasone demonstrated clinical improvement in patients with coronavirus disease 2019 (COVID-19) needing oxygen therapy; however, evidence on the efficacy of high dose of dexamethasone is limited. METHODS We performed a randomised, open-label, controlled trial involving hospitalised patients with confirmed COVID-19 pneumonia needing oxygen therapy. Patients were randomly assigned in a 1:1 ratio to receive low dose dexamethasone (6 mg once daily for 10 days) or high dose dexamethasone (20 mg once daily for 5 days, followed by 10 mg once daily for additional 5 days). The primary outcome was clinical worsening within 11 days since randomisation. Secondary outcomes included 28-day mortality, time to recovery, and clinical status at day 5, 11, 14 and 28 on an ordinal scale ranging from 1 (discharged) to 7 (death). RESULTS A total of 200 patients (mean (sd) age, 64 (14) years; 62% male) were enrolled. Thirty-two patients of 102 (31.4%) enrolled in the low dose group and 16 of 98 (16.3%) in the high dose group showed clinical worsening within 11 days since randomisation (rate ratio, 0.427; 95% CI, 0.216-0.842; p=0.014). The 28-day mortality was 5.9% in the low dose group and 6.1% in the high dose group (p=0.844). There was no significant difference in time to recovery, and in the 7-point ordinal scale at day 5, 11, 14 and 28. CONCLUSIONS Among hospitalised COVID-19 patients needing oxygen therapy, high dose of dexamethasone reduced clinical worsening within 11 days after randomisation as compared with low dose.
Collapse
Affiliation(s)
- Manuel Taboada
- Department of Anesthesiology and Intensive Care Medicine, Clinical University Hospital of Santiago. Sanitary Research Institute of Santiago (IDIS), Spain
| | - Nuria Rodríguez
- Department of Pneumology, Clinical University Hospital of Santiago, Spain
| | - Pablo Manuel Varela
- Department Internal Medicine, Clinical University Hospital of Santiago, Spain
| | | | - Romina Abelleira
- Department of Pneumology, Clinical University Hospital of Santiago, Spain
| | - Amara González
- Department Internal Medicine, Clinical University Hospital of Santiago, Spain
| | - Ana Casal
- Department of Pneumology, Clinical University Hospital of Santiago, Spain
| | | | - Adriana Lama
- Department of Pneumology, Clinical University Hospital of Santiago, Spain
| | | | - Carlos Rábade
- Department of Pneumology, Clinical University Hospital of Santiago, Spain
| | - Emilio Manuel Páez
- Department Internal Medicine, Clinical University Hospital of Santiago, Spain
| | - Vanessa Riveiro
- Department of Pneumology, Clinical University Hospital of Santiago, Spain
| | - Hadrián Pernas
- Department Internal Medicine, Clinical University Hospital of Santiago, Spain
| | | | - Valentín Caruezo
- Department of Anesthesiology and Intensive Care Medicine, Clinical University Hospital of Santiago. Sanitary Research Institute of Santiago (IDIS), Spain
| | - Alberto Naveira
- Department of Anesthesiology and Intensive Care Medicine, Clinical University Hospital of Santiago. Sanitary Research Institute of Santiago (IDIS), Spain
| | - Agustín Cariñena
- Department of Anesthesiology and Intensive Care Medicine, Clinical University Hospital of Santiago. Sanitary Research Institute of Santiago (IDIS), Spain
| | - Teresa Cabaleiro
- Research Methodology Unit, Fundación Instituto de Investigaciones Sanitarias (FIDIS), Santiago, Spain
| | - Ana Estany-Gestal
- Research Methodology Unit, Fundación Instituto de Investigaciones Sanitarias (FIDIS), Santiago, Spain
| | - Irene Zarra
- Department Pharmacology, Clinical University Hospital of Santiago, Spain
| | - Antonio Pose
- Department Internal Medicine, Clinical University Hospital of Santiago, Spain
| | - Luis Valdés
- Department of Pneumology, Clinical University Hospital of Santiago, Spain
| | - Julián Álvarez-Escudero
- Department of Anesthesiology and Intensive Care Medicine, Clinical University Hospital of Santiago. Sanitary Research Institute of Santiago (IDIS), Spain
| |
Collapse
|
232
|
Early Use of Sarilumab in Patients Hospitalised with COVID-19 Pneumonia and Features of Systemic Inflammation. Antimicrob Agents Chemother 2021; 66:e0210721. [PMID: 34902262 PMCID: PMC8846457 DOI: 10.1128/aac.02107-21] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
In this phase II, open-label, randomized, controlled clinical trial of 115 patients hospitalized with COVID-19 and systemic inflammation, early use of sarilumab was associated with a low risk of acute respiratory distress syndrome requiring high-flow devices or mechanical ventilation. Objective: To investigate the efficacy and safety of early treatment with sarilumab, added to standard of care (SOC), in hospitalised adults with COVID-19. Methods: Phase II, open-label, randomized, controlled clinical trial of hospitalised patients with COVID-19 pneumonia and interleukin (IL)-6 levels ≥ 40 pg/mL and/or D-dimer > 1500 ng/mL. Participants were randomized (1:1:1) to receive SOC (control group), SOC plus a single subcutaneous dose of sarilumab 200 mg (Sarilumab-200) or SOC plus a single subcutaneous dose of sarilumab 400 mg (Sarilumab-400). The primary outcome variable was the development of acute respiratory distress syndrome (ARDS) requiring high-flow nasal oxygenation (HFNO), non-invasive mechanical ventilation (NIMV) or invasive mechanical ventilation (IMV) at day 28. Results: One-hundred and fifteen participants (control group, n = 39; Sarilumab-200, n = 37; Sarilumab-400, n = 39) were included. At randomization, 104 (90%) patients had supplemental oxygen and 103 (90%) received corticosteroids. Eleven (28%) patients in the control group, ten (27%) in Sarilumab-200 and five (13%) in Sarilumab-400 developed the primary outcome (hazard ratio [95% CI] of Sarilumab-400 vs control group: 0.41 [0.14-1.18]; p=0.09). Seven (6%) patients died: three in the control group and four in Sarilumab-200. There were no deaths in Sarilumab-400 (p = 0.079, log-rank test for comparisons with the control group). Conclusion: In patients recently hospitalised with COVID-19 pneumonia and features of systemic inflammation, early IL-6 blockade with a single dose of sarilumab 400 mg was safe and associated with a trend for better outcomes.
Collapse
|
233
|
Udovicic I, Stanojevic I, Djordjevic D, Zeba S, Rondovic G, Abazovic T, Lazic S, Vojvodic D, To K, Abazovic D, Khan W, Surbatovic M. Immunomonitoring of Monocyte and Neutrophil Function in Critically Ill Patients: From Sepsis and/or Trauma to COVID-19. J Clin Med 2021; 10:jcm10245815. [PMID: 34945111 PMCID: PMC8706110 DOI: 10.3390/jcm10245815] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 11/27/2021] [Accepted: 12/01/2021] [Indexed: 12/15/2022] Open
Abstract
Immune cells and mediators play a crucial role in the critical care setting but are understudied. This review explores the concept of sepsis and/or injury-induced immunosuppression and immuno-inflammatory response in COVID-19 and reiterates the need for more accurate functional immunomonitoring of monocyte and neutrophil function in these critically ill patients. in addition, the feasibility of circulating and cell-surface immune biomarkers as predictors of infection and/or outcome in critically ill patients is explored. It is clear that, for critically ill, one size does not fit all and that immune phenotyping of critically ill patients may allow the development of a more personalized approach with tailored immunotherapy for the specific patient. In addition, at this point in time, caution is advised regarding the quality of evidence of some COVID-19 studies in the literature.
Collapse
Affiliation(s)
- Ivo Udovicic
- Clinic of Anesthesiology and Intensive Therapy, Military Medical Academy, Crnotravska 17, 11000 Belgrade, Serbia; (I.U.); (D.D.); (S.Z.); (G.R.); (T.A.)
- Faculty of Medicine of the Military Medical Academy, University of Defence, Crnotravska 17, 11000 Belgrade, Serbia; (I.S.); (S.L.); (D.V.)
| | - Ivan Stanojevic
- Faculty of Medicine of the Military Medical Academy, University of Defence, Crnotravska 17, 11000 Belgrade, Serbia; (I.S.); (S.L.); (D.V.)
- Institute for Medical Research, Military Medical Academy, Crnotravska 17, 11000 Belgrade, Serbia
| | - Dragan Djordjevic
- Clinic of Anesthesiology and Intensive Therapy, Military Medical Academy, Crnotravska 17, 11000 Belgrade, Serbia; (I.U.); (D.D.); (S.Z.); (G.R.); (T.A.)
- Faculty of Medicine of the Military Medical Academy, University of Defence, Crnotravska 17, 11000 Belgrade, Serbia; (I.S.); (S.L.); (D.V.)
| | - Snjezana Zeba
- Clinic of Anesthesiology and Intensive Therapy, Military Medical Academy, Crnotravska 17, 11000 Belgrade, Serbia; (I.U.); (D.D.); (S.Z.); (G.R.); (T.A.)
- Faculty of Medicine of the Military Medical Academy, University of Defence, Crnotravska 17, 11000 Belgrade, Serbia; (I.S.); (S.L.); (D.V.)
| | - Goran Rondovic
- Clinic of Anesthesiology and Intensive Therapy, Military Medical Academy, Crnotravska 17, 11000 Belgrade, Serbia; (I.U.); (D.D.); (S.Z.); (G.R.); (T.A.)
- Faculty of Medicine of the Military Medical Academy, University of Defence, Crnotravska 17, 11000 Belgrade, Serbia; (I.S.); (S.L.); (D.V.)
| | - Tanja Abazovic
- Clinic of Anesthesiology and Intensive Therapy, Military Medical Academy, Crnotravska 17, 11000 Belgrade, Serbia; (I.U.); (D.D.); (S.Z.); (G.R.); (T.A.)
| | - Srdjan Lazic
- Faculty of Medicine of the Military Medical Academy, University of Defence, Crnotravska 17, 11000 Belgrade, Serbia; (I.S.); (S.L.); (D.V.)
- Institute of Epidemiology, Military Medical Academy, Crnotravska 17, 11000 Belgrade, Serbia
| | - Danilo Vojvodic
- Faculty of Medicine of the Military Medical Academy, University of Defence, Crnotravska 17, 11000 Belgrade, Serbia; (I.S.); (S.L.); (D.V.)
- Institute for Medical Research, Military Medical Academy, Crnotravska 17, 11000 Belgrade, Serbia
| | - Kendrick To
- Division of Trauma & Orthopaedic Surgery, University of Cambridge, Addenbrooke’s Hospital, Cambridge CB2 2QQ, UK; (K.T.); (W.K.)
| | - Dzihan Abazovic
- Emergency Medical Centar of Montenegro, Vaka Djurovica bb, 81000 Podgorica, Montenegro;
| | - Wasim Khan
- Division of Trauma & Orthopaedic Surgery, University of Cambridge, Addenbrooke’s Hospital, Cambridge CB2 2QQ, UK; (K.T.); (W.K.)
| | - Maja Surbatovic
- Clinic of Anesthesiology and Intensive Therapy, Military Medical Academy, Crnotravska 17, 11000 Belgrade, Serbia; (I.U.); (D.D.); (S.Z.); (G.R.); (T.A.)
- Faculty of Medicine of the Military Medical Academy, University of Defence, Crnotravska 17, 11000 Belgrade, Serbia; (I.S.); (S.L.); (D.V.)
- Correspondence: ; Tel.: +381-11-2665-125
| |
Collapse
|
234
|
Golnabi EY, Sanders JM, Johns ML, Lin K, Ortwine JK, Wei W, Mang NS, Cutrell JB. Therapeutic Options for Coronavirus Disease 2019 (COVID-19): Where Are We Now? Curr Infect Dis Rep 2021; 23:28. [PMID: 34924819 PMCID: PMC8665318 DOI: 10.1007/s11908-021-00769-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/22/2021] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Rapidly evolving treatment paradigms of coronavirus disease 2019 (COVID-19) introduce challenges for clinicians to keep up with the pace of published literature and to critically appraise the voluminous data produced. This review summarizes the clinical evidence from key studies examining the place of therapy of recommended drugs and management strategies for COVID-19. RECENT FINDINGS The global magnitude and duration of the pandemic have resulted in a flurry of interventional treatment trials evaluating both novel and repurposed drugs targeting various aspects of the viral life cycle. Additionally, clinical observations have documented various stages or phases of COVID-19 and underscored the importance of timing for the efficacy of studied therapies. Since the start of the COVID-19 pandemic, many observational, retrospective, and randomized controlled studies have been conducted to guide management of COVID-19 using drug therapies and other management strategies. Large, randomized, or adaptive platform trials have proven the most informative to guide recommended treatments to-date. Antimicrobial stewardship programs can play a pivotal role in ensuring appropriate use of COVID-19 therapies based on evolving clinical data and limiting unnecessary antibiotics given low rates of co-infection. SUMMARY Given the rapidly evolving medical literature and treatment paradigms, it is recommended to reference continuously updated, curated guidelines from national and international sources. While the drugs and management strategies mentioned in this review represent the current state of recommendations, many therapies are still under investigation to further define optimal COVID-19 treatment. SUPPLEMENTARY INFORMATION The online version contains supplementary material available at 10.1007/s11908-021-00769-8.
Collapse
Affiliation(s)
- Esther Y. Golnabi
- Department of Pharmacy, University of Texas Southwestern Medical Center, Dallas, US
| | - James M. Sanders
- Department of Pharmacy, University of Texas Southwestern Medical Center, Dallas, US
| | - Meagan L. Johns
- Department of Pharmacy, University of Texas Southwestern Medical Center, Dallas, US
| | - Kevin Lin
- Department of Pharmacy, Ochsner Medical Center, New Orleans, US
| | | | - Wenjing Wei
- Department of Pharmacy, Parkland Hospital, Dallas, US
| | | | - James B. Cutrell
- Department of Medicine, Division of Infectious Diseases and Geographic
Medicine, University of Texas Southwestern Medical Center, Dallas, US
| |
Collapse
|
235
|
Outcomes associated with tocilizumab with or without corticosteroid versus dexamethasone for treatment of patients with severe to critical COVID-19 pneumonia. J Infect Public Health 2021; 15:36-41. [PMID: 34883296 PMCID: PMC8611824 DOI: 10.1016/j.jiph.2021.11.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 11/09/2021] [Accepted: 11/21/2021] [Indexed: 12/15/2022] Open
Abstract
Introduction Immunomodulators, including dexamethasone (DEX), have been recommended by the Infectious Disease Society of America (IDSA) to treat moderate, severe, and critical COVID-19. Tocilizumab (TCZ) was added to the treatment recommendations based on recent data from two large randomized controlled trials and its potential synergistic effect with DEX. Method We included adult patients admitted from June until October 2020 with a PCR confirmed SARS-CoV-2 infection. 135 patients with severe to critical COVID-19 and received TCZ and/or corticosteroid or DEX were retrospectively evaluated and followed until hospital discharge or death. Results The cohort was divided into two different groups of patients; TCZ group received TCZ ± corticosteroid, N = 100 and DEX group received DEX, N = 35. Groups were analyzed for hospital mortality. The rate of hospital mortality was 36% in TCZ and 37% in the DEX group, p = 0.91. Age of 60 years and above was associated with higher mortality rate with OR = 1.030 and 95% CI = (1.004, 1.057). More than 50% of patients required MV in both groups. Development of bacterial or fungal infection post immunomodulator were similar in TCZ and DEX groups, 29% vs. 31.4%. Conclusion Our study revealed that age of 60 years and above is the only factor associated with higher mortality rate regardless of the type of immunomodulator therapy. Findings of this study also revealed the lack of synergistic effect between TCZ and DEX on the hospital mortality.
Collapse
|
236
|
Koritala T, Pattan V, Tirupathi R, Rabaan AA, Al Mutair A, Alhumaid S, Adhikari R, Deepika K, Jain NK, Bansal V, Tekin A, Zec S, Lal A, Khan SA, Garces JPD, Abu Saleh OM, Surani SR, Kashyap R. Infection risk with the use of interleukin inhibitors in hospitalized patients with COVID-19: A narrative review. LE INFEZIONI IN MEDICINA 2021; 29:495-503. [PMID: 35146357 PMCID: PMC8805476 DOI: 10.53854/liim-2904-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 11/12/2021] [Indexed: 02/05/2023]
Abstract
INTRODUCTION To date, only corticosteroids and interleukin-6 (IL-6) inhibitors have been shown to reduce mortality of hospitalized patients with COVID-19. In this literature review, we aimed to summarize infection risk of IL inhibitors, with or without the use of corticosteroids, used to treat hospitalized patients with COVID-19. METHODS A literature search was conducted using the following evidence-based medicine reviews: Cochrane Central Register of Controlled Trials; Cochrane Database of Systematic Reviews; Embase; Ovid Medline; and Epub Ahead of Print, In-Process, In-Data-Review & Other Non-Indexed Citations, Daily and Versions 1946 to April 28, 2021. All relevant articles were identified using the search terms COVID-19 or SARS-coronavirus-2, infections, interleukins, inpatients, adults, and i ncidence. RESULTS We identified 36 studies of which 2 were meta-analyses, 5 were randomized controlled trials, 9 were prospective studies, and 20 were retrospective studies. When anakinra was compared with control, 2 studies reported an increased risk of infection, and 3 studies reported a similar or decreased incidence of infection. Canakinumab had a lower associated incidence of infection compared with placebo in one study. When sarilumab was compared with placebo, one study reported an increased risk of infection. Nine studies comparing tocilizumab with placebo reported decreased or no difference in infection risk (odds ratio [OR] for the studies ranged from 0.39-1.21). Fourteen studies comparing tocilizumab with placebo reported an increased risk of infection, ranging from 9.1% to 63.0% (OR for the studies ranged from 1.85-5.04). Infection most commonly presented as bacteremia. Of the 6 studies comparing tocilizumab and corticosteroid use with placebo, 4 reported a nonsignificant increase toward corticosteroids being associated with bacterial infections (OR ranged from 2.76-3.8), and 2 studies reported no increased association with a higher infection risk. CONCLUSIONS Our literature review showed mixed results with variable significance for the association of IL-6 inhibitors with risk of infections in patients with COVID-19.
Collapse
Affiliation(s)
- Thoyaja Koritala
- Division of Hospital Internal Medicine, Mayo Clinic Health System, Mankato, USA
| | | | | | - Ali A. Rabaan
- Molecular Diagnostic Laboratory, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
- Department of Public Health and Nutrition, University of Haripur, Haripur, Pakistan
| | - Abbas Al Mutair
- Research Center, Almoosa Specialist Hospital, Al-Ahsa, Saudi Arabia
- College of Nursing, Princess Norah Bint Abdulrahman University, Riyadh, Saudi Arabia
- School of Nursing, Wollongong University, Wollongong, Australia
| | - Saad Alhumaid
- Administration of Pharmaceutical Care, Al-Ahsa Health Cluster, Al-Ahsa, Saudi Arabia
| | - Ramesh Adhikari
- Department of Hospital Medicine, Franciscan Health, Lafayette, USA
| | - Keerti Deepika
- Translational Health Disparities Science Research Program, Nemours Healthcare System for Children, Wilmington, USA
| | - Nitesh Kumar Jain
- Division of Community Critical Care, Mayo Clinic Health System, Mankato, USA
| | - Vikas Bansal
- Research Fellow, Mayo Clinic College of Medicine and Science, Rochester, USA
| | - Aysun Tekin
- Research Fellow, Mayo Clinic College of Medicine and Science, Rochester, USA
| | - Simon Zec
- Research Fellow, Mayo Clinic College of Medicine and Science, Rochester, USA
| | - Amos Lal
- Critical Care Internal Medicine Fellow, Mayo Clinic College of Medicine and Science, Rochester, USA
| | - Syed Anjum Khan
- Division of Community Critical Care, Mayo Clinic Health System, Mankato, USA
| | | | | | - Salim R. Surani
- Adjunct Clinical Professor of Medicine and Pharmacy, Texas A&M University, College Station, USA
- Research Collaborator (limited tenure), Mayo Clinic, Rochester, USA
| | - Rahul Kashyap
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, USA
| |
Collapse
|
237
|
Meyer A, Buetti N, Houhou-Fidouh N, Patrier J, Abdel-Nabey M, Jaquet P, Presente S, Girard T, Sayagh F, Ruckly S, Wicky PH, de Montmollin E, Bouadma L, Sonneville R, Descamps D, Timsit JF. HSV-1 reactivation is associated with an increased risk of mortality and pneumonia in critically ill COVID-19 patients. Crit Care 2021; 25:417. [PMID: 34872611 PMCID: PMC8647503 DOI: 10.1186/s13054-021-03843-8] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 11/25/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Data in the literature about HSV reactivation in COVID-19 patients are scarce, and the association between HSV-1 reactivation and mortality remains to be determined. Our objectives were to evaluate the impact of Herpes simplex virus (HSV) reactivation in patients with severe SARS-CoV-2 infections primarily on mortality, and secondarily on hospital-acquired pneumonia/ventilator-associated pneumonia (HAP/VAP) and intensive care unit-bloodstream infection (ICU-BSI). METHODS We conducted an observational study using prospectively collected data and HSV-1 blood and respiratory samples from all critically ill COVID-19 patients in a large reference center who underwent HSV tests. Using multivariable Cox and cause-specific (cs) models, we investigated the association between HSV reactivation and mortality or healthcare-associated infections. RESULTS Of the 153 COVID-19 patients admitted for ≥ 48 h from Feb-2020 to Feb-2021, 40/153 (26.1%) patients had confirmed HSV-1 reactivation (19/61 (31.1%) with HSV-positive respiratory samples, and 36/146 (24.7%) with HSV-positive blood samples. Day-60 mortality was higher in patients with HSV-1 reactivation (57.5%) versus without (33.6%, p = 0.001). After adjustment for mortality risk factors, HSV-1 reactivation was associated with an increased mortality risk (hazard risk [HR] 2.05; 95% CI 1.16-3.62; p = 0.01). HAP/VAP occurred in 67/153 (43.8%) and ICU-BSI in 42/153 (27.5%) patients. In patients with HSV-1 reactivation, multivariable cause-specific models showed an increased risk of HAP/VAP (csHR 2.38, 95% CI 1.06-5.39, p = 0.037), but not of ICU-BSI. CONCLUSIONS HSV-1 reactivation in critically ill COVID-19 patients was associated with an increased risk of day-60 mortality and HAP/VAP.
Collapse
Affiliation(s)
- Antoine Meyer
- INSERM, IAME, University of Paris, 75006, Paris, France.,Medical and Infectious Diseases Intensive Care Unit, APHP, Bichat University Hospital, Paris, France
| | - Niccolò Buetti
- INSERM, IAME, University of Paris, 75006, Paris, France. .,Infection Control Program and WHO Collaborating Centre on Patient Safety, Service PCI, University of Geneva Hospitals and Faculty of Medicine, Rue Gabrielle-Perret-Gentil 4, 1205, Geneva, Switzerland.
| | - Nadhira Houhou-Fidouh
- Virology Department, GH APHP.Nord, Bichat-Claude Bernard University Hospital, 75018, Paris, France
| | - Juliette Patrier
- Medical and Infectious Diseases Intensive Care Unit, APHP, Bichat University Hospital, Paris, France
| | - Moustafa Abdel-Nabey
- Medical and Infectious Diseases Intensive Care Unit, APHP, Bichat University Hospital, Paris, France
| | - Pierre Jaquet
- Medical and Infectious Diseases Intensive Care Unit, APHP, Bichat University Hospital, Paris, France
| | - Simona Presente
- Medical and Infectious Diseases Intensive Care Unit, APHP, Bichat University Hospital, Paris, France
| | - Tiphaine Girard
- Medical and Infectious Diseases Intensive Care Unit, APHP, Bichat University Hospital, Paris, France
| | - Faiza Sayagh
- Medical and Infectious Diseases Intensive Care Unit, APHP, Bichat University Hospital, Paris, France
| | - Stephane Ruckly
- INSERM, IAME, University of Paris, 75006, Paris, France.,Medical and Infectious Diseases Intensive Care Unit, APHP, Bichat University Hospital, Paris, France
| | - Paul-Henri Wicky
- Medical and Infectious Diseases Intensive Care Unit, APHP, Bichat University Hospital, Paris, France
| | - Etienne de Montmollin
- INSERM, IAME, University of Paris, 75006, Paris, France.,Medical and Infectious Diseases Intensive Care Unit, APHP, Bichat University Hospital, Paris, France
| | - Lila Bouadma
- INSERM, IAME, University of Paris, 75006, Paris, France.,Medical and Infectious Diseases Intensive Care Unit, APHP, Bichat University Hospital, Paris, France
| | - Romain Sonneville
- Medical and Infectious Diseases Intensive Care Unit, APHP, Bichat University Hospital, Paris, France.,INSERM, UMR1148, Université de Paris, 75018, Paris, France
| | - Diane Descamps
- Virology Department, GH APHP.Nord, Université de Paris, IAME INSERM UMR1137, Bichat-Claude Bernard University Hospital, 75018, Paris, France
| | - Jean-Francois Timsit
- INSERM, IAME, University of Paris, 75006, Paris, France.,Medical and Infectious Diseases Intensive Care Unit, APHP, Bichat University Hospital, Paris, France
| |
Collapse
|
238
|
Aslan A, Aslan C, Zolbanin NM, Jafari R. Acute respiratory distress syndrome in COVID-19: possible mechanisms and therapeutic management. Pneumonia (Nathan) 2021; 13:14. [PMID: 34872623 PMCID: PMC8647516 DOI: 10.1186/s41479-021-00092-9] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 11/20/2021] [Indexed: 02/07/2023] Open
Abstract
COVID-19 pandemic is a serious concern in the new era. Acute respiratory distress syndrome (ARDS), and lung failure are the main lung diseases in COVID-19 patients. Even though COVID-19 vaccinations are available now, there is still an urgent need to find potential treatments to ease the effects of COVID-19 on already sick patients. Multiple experimental drugs have been approved by the FDA with unknown efficacy and possible adverse effects. Probably the increasing number of studies worldwide examining the potential COVID-19 related therapies will help to identification of effective ARDS treatment. In this review article, we first provide a summary on immunopathology of ARDS next we will give an overview of management of patients with COVID-19 requiring intensive care unit (ICU), while focusing on the current treatment strategies being evaluated in the clinical trials in COVID-19-induced ARDS patients.
Collapse
Affiliation(s)
- Anolin Aslan
- Department of Critical Care Nursing, School of Nursing and Midwifery, Tehran University of Medical Science, Tehran, Iran
| | - Cynthia Aslan
- Immunology Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.,Department of Immunology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Naime Majidi Zolbanin
- Experimental and Applied Pharmaceutical Research Center, Urmia University of Medical Sciences, Urmia, Iran.,Department of Pharmacology and Toxicology, School of Pharmacy, Urmia University of Medical Sciences, Urmia, Iran
| | - Reza Jafari
- Nephrology and Kidney Transplant Research Center, Clinical Research Institute, Urmia University of Medical Sciences, Shafa St., Ershad Blvd., P.O. Box: 1138, Urmia, 57147, Iran. .,Hematology, Immune Cell Therapy, and Stem Cell Transplantation Research Center, Clinical Research Institute, Urmia University of Medical Sciences, Urmia, Iran.
| |
Collapse
|
239
|
Singh AK, Oks M, Husk G, Dechario SP, Mina B, Singh K, Kirschenbaum L, Carpati CM, Mahmoud O, Gabra NI, Ishikawa O, Altschultz E, Shah V, Mahajan A, Gautam A, Birnbaum B, Antonacci AC, Raoof S. Impact of Timing of Tocilizumab Use in Hospitalized Patients With SARS-CoV-2 Infection. Respir Care 2021; 66:1805-1814. [PMID: 34548407 PMCID: PMC9993783 DOI: 10.4187/respcare.08779] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) continues to be a global challenge due to the lack of definitive treatment strategies. We sought to determine the efficacy of early administration of anti-interleukin 6 therapy in reducing hospital mortality and progression to mechanical ventilation. METHODS This was a retrospective chart review of 11,512 patients infected with SARS-CoV-2 who were admitted to a New York health system from March to May 2020. Tocilizumab was administered to subjects at the nasal cannula level of oxygen support to maintain an oxygen saturation of >88%. The Charlson comorbidity index was used as an objective assessment of the burden of comorbidities to predict 10-year mortality. The primary outcome of interest was hospital mortality. Secondary outcomes were progression to mechanical ventilation; the prevalence of venous thromboembolism and renal failure; and the change in C-reactive protein, D-dimer, and ferritin levels after tocilizumab administration. Propensity score matching by using a 1:2 protocol was used to match the tocilizumab and non-tocilizumab groups to minimize selection bias. The groups were matched on baseline demographic characteristics, including age, sex, and body mass index; Charlson comorbidity index score; laboratory markers, including ferritin, D-dimer, lactate dehydrogenase, and C-reactive protein values; and the maximum oxygen requirement at the time of tocilizumab administration. Mortality outcomes were evaluated based on the level of oxygen requirement and the day of hospitalization at the time of tocilizumab administration. RESULTS The overall hospital mortality was significantly reduced in the tocilizumab group when tocilizumab was administered at the nasal cannula level (10.4% vs 22.0%; P = .002). In subjects who received tocilizumab at the nasal cannula level, the progression to mechanical ventilation was reduced versus subjects who were initially on higher levels of oxygen support (6.3% vs 18.7%; P < .001). There was no improvement in mortality when tocilizumab was given at the time of requiring non-rebreather, high-flow nasal cannula, noninvasive ventilator, or invasive ventilator. CONCLUSIONS Early use of anti-interleukin 6 therapy may be associated with improved hospital mortality and reduction in progression to more severe coronavirus disease 2019.
Collapse
Affiliation(s)
- Anup K Singh
- Department of Pulmonary Critical Care and Sleep Medicine, Lenox Hill Hospital - Northwell Health System, New York, New York.
| | - Margarita Oks
- Department of Pulmonary Critical Care and Sleep Medicine, Lenox Hill Hospital - Northwell Health System, New York, New York
| | - Gregg Husk
- Hospital Administration, Lenox Hill Hospital - Northwell Health System, New York, New York
| | - Samuel P Dechario
- Department of Surgery, Lenox Hill Hospital - Northwell Health System, New York, New York
| | - Bushra Mina
- Department of Pulmonary Critical Care and Sleep Medicine, Lenox Hill Hospital - Northwell Health System, New York, New York
| | - Kanwaljit Singh
- Critical Path Institute - International Neonatal Consortium, Tucson, Arizona
| | - Linda Kirschenbaum
- Department of Pulmonary Critical Care and Sleep Medicine, Lenox Hill Hospital - Northwell Health System, New York, New York
| | - Charles M Carpati
- Department of Pulmonary Critical Care and Sleep Medicine, Lenox Hill Hospital - Northwell Health System, New York, New York
| | - Omar Mahmoud
- Department of Pulmonary Critical Care and Sleep Medicine, Lenox Hill Hospital - Northwell Health System, New York, New York
| | - Nader Ishak Gabra
- Department of Pulmonary Critical Care and Sleep Medicine, Lenox Hill Hospital - Northwell Health System, New York, New York
| | - Oki Ishikawa
- Department of Pulmonary Critical Care and Sleep Medicine, Lenox Hill Hospital - Northwell Health System, New York, New York
| | - Erica Altschultz
- Department of Pulmonary Critical Care and Sleep Medicine, Lenox Hill Hospital - Northwell Health System, New York, New York
| | - Varun Shah
- Department of Pulmonary Critical Care and Sleep Medicine, Lenox Hill Hospital - Northwell Health System, New York, New York
| | - Akhilesh Mahajan
- Department of Pulmonary Critical Care and Sleep Medicine, Lenox Hill Hospital - Northwell Health System, New York, New York
| | - Arun Gautam
- Department of Pulmonary Critical Care and Sleep Medicine, Lenox Hill Hospital - Northwell Health System, New York, New York
| | - Brian Birnbaum
- Department of Pulmonary Critical Care and Sleep Medicine, Lenox Hill Hospital - Northwell Health System, New York, New York
| | - Anthony C Antonacci
- Department of Surgery, Lenox Hill Hospital - Northwell Health System, New York, New York
| | - Suhail Raoof
- Department of Pulmonary Critical Care and Sleep Medicine, Lenox Hill Hospital - Northwell Health System, New York, New York
| |
Collapse
|
240
|
Bassetti M, Giacobbe DR, Bruzzi P, Barisione E, Centanni S, Castaldo N, Corcione S, De Rosa FG, Di Marco F, Gori A, Gramegna A, Granata G, Gratarola A, Maraolo AE, Mikulska M, Lombardi A, Pea F, Petrosillo N, Radovanovic D, Santus P, Signori A, Sozio E, Tagliabue E, Tascini C, Vancheri C, Vena A, Viale P, Blasi F. Clinical Management of Adult Patients with COVID-19 Outside Intensive Care Units: Guidelines from the Italian Society of Anti-Infective Therapy (SITA) and the Italian Society of Pulmonology (SIP). Infect Dis Ther 2021; 10:1837-1885. [PMID: 34328629 PMCID: PMC8323092 DOI: 10.1007/s40121-021-00487-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 06/15/2021] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION The Italian Society of Anti-Infective Therapy (SITA) and the Italian Society of Pulmonology (SIP) constituted an expert panel for developing evidence-based guidance for the clinical management of adult patients with coronavirus disease 2019 (COVID-19) outside intensive care units. METHODS Ten systematic literature searches were performed to answer ten different key questions. The retrieved evidence was graded according to the Grading of Recommendations Assessment, Development, and Evaluation methodology (GRADE). RESULTS AND CONCLUSION The literature searches mostly assessed the available evidence on the management of COVID-19 patients in terms of antiviral, anticoagulant, anti-inflammatory, immunomodulatory, and continuous positive airway pressure (CPAP)/non-invasive ventilation (NIV) treatment. Most evidence was deemed as of low certainty, and in some cases, recommendations could not be developed according to the GRADE system (best practice recommendations were provided in similar situations). The use of neutralizing monoclonal antibodies may be considered for outpatients at risk of disease progression. For inpatients, favorable recommendations were provided for anticoagulant prophylaxis and systemic steroids administration, although with low certainty of evidence. Favorable recommendations, with very low/low certainty of evidence, were also provided for, in specific situations, remdesivir, alone or in combination with baricitinib, and tocilizumab. The presence of many best practice recommendations testified to the need for further investigations by means of randomized controlled trials, whenever possible, with some possible future research directions stemming from the results of the ten systematic reviews.
Collapse
Affiliation(s)
- Matteo Bassetti
- Infectious Diseases Unit, Ospedale Policlinico San Martino-IRCCS, L.go R. Benzi, 10, 16132, Genoa, Italy.
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy.
| | - Daniele Roberto Giacobbe
- Infectious Diseases Unit, Ospedale Policlinico San Martino-IRCCS, L.go R. Benzi, 10, 16132, Genoa, Italy.
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy.
| | - Paolo Bruzzi
- Clinical Epidemiology Unit, Ospedale Policlinico San Martino-IRCCS, Genoa, Italy
| | - Emanuela Barisione
- Interventional Pulmonology, Ospedale Policlinico San Martino-IRCCS, Genoa, Italy
| | - Stefano Centanni
- Department of Health Sciences, University of Milan, Respiratory Unit, ASST Santi Paolo e Carlo, Milan, Italy
| | - Nadia Castaldo
- Infectious Diseases Clinic, Santa Maria Misericordia Hospital, Udine, Italy
| | - Silvia Corcione
- Department of Medical Sciences, Infectious Diseases, University of Turin, Turin, Italy
- Tufts University School of Medicine, Boston, MA, USA
| | | | - Fabiano Di Marco
- Department of Health Sciences, University of Milan, Respiratory Unit, ASST Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Andrea Gori
- Infectious Diseases Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
- Centre for Multidisciplinary Research in Health Science (MACH), University of Milan, Milan, Italy
| | - Andrea Gramegna
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Internal Medicine Department, Respiratory Unit and Cystic Fibrosis Adult Center, Milan, Italy
| | - Guido Granata
- Clinical and Research Department for Infectious Diseases, National Institute for Infectious Diseases L. Spallanzani, IRCCS, Rome, Italy
| | - Angelo Gratarola
- Department of Emergency and Urgency, San Martino Policlinico Hospital, IRCCS, Genoa, Italy
| | | | - Malgorzata Mikulska
- Infectious Diseases Unit, Ospedale Policlinico San Martino-IRCCS, L.go R. Benzi, 10, 16132, Genoa, Italy
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Andrea Lombardi
- Infectious Diseases Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Federico Pea
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
- SSD Clinical Pharmacology Unit, University Hospital, IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
| | - Nicola Petrosillo
- Clinical and Research Department for Infectious Diseases, National Institute for Infectious Diseases L. Spallanzani, IRCCS, Rome, Italy
- Infection Control and Infectious Disease Service, University Hospital "Campus-Biomedico", Rome, Italy
| | - Dejan Radovanovic
- Division of Respiratory Diseases, Ospedale L. Sacco, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Pierachille Santus
- Division of Respiratory Diseases, Ospedale L. Sacco, ASST Fatebenefratelli-Sacco, Milan, Italy
- Department of Biomedical and Clinical Sciences (DIBIC), Università degli Studi di Milano, Milan, Italy
| | - Alessio Signori
- Department of Health Sciences, Section of Biostatistics, University of Genoa, Genoa, Italy
| | - Emanuela Sozio
- Infectious Diseases Clinic, Santa Maria Misericordia Hospital, Udine, Italy
| | - Elena Tagliabue
- Interventional Pulmonology, Ospedale Policlinico San Martino-IRCCS, Genoa, Italy
| | - Carlo Tascini
- Infectious Diseases Clinic, Santa Maria Misericordia Hospital, Udine, Italy
| | - Carlo Vancheri
- Regional Referral Centre for Rare Lung Diseases-University Hospital "Policlinico G. Rodolico", Catania, Italy
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Antonio Vena
- Infectious Diseases Unit, Ospedale Policlinico San Martino-IRCCS, L.go R. Benzi, 10, 16132, Genoa, Italy
| | - Pierluigi Viale
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
- Infectious Diseases Unit, University Hospital IRCCS Policlinico Sant'Orsola, Bologna, Italy
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Internal Medicine Department, Respiratory Unit and Cystic Fibrosis Adult Center, Milan, Italy
| |
Collapse
|
241
|
Khan M, Singh GK, Abrar S, Ganeshan R, Morgan K, Harky A. Pharmacotherapeutic agents for the management of COVID-19 patients with preexisting cardiovascular disease. Expert Opin Pharmacother 2021; 22:2455-2474. [PMID: 34464223 PMCID: PMC8425433 DOI: 10.1080/14656566.2021.1960311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 07/22/2021] [Indexed: 12/15/2022]
Abstract
INTRODUCTION The coronavirus disease 2019 (COVID-19) pandemic is the largest public health challenge of the twenty-first century. While COVID-19 primarily affects the respiratory system, manifesting as interstitial pneumonitis and severe acute respiratory distress syndrome (ARDS), it also has implications for the cardiovascular system. Moreover, those admitted to hospital with severe COVID-19 are more likely to have cardiovascular comorbidities such as hypertension and diabetes mellitus. The underlying pathophysiology of why COVID-19 onset can further decline cardiac pathologies as well as trigger acute onset of new cardiac complications is not yet well understood. AREAS COVERED In this review, the authors extensively review literature focused on the current understanding and approaches of managing patients who have underlying cardiovascular diseases and concomitant COVID-19 infection. Furthermore, the authors explore the possible cardiovascular implications of the suggested COVID-19 therapeutic agents that are used to treat this lethal disease. EXPERT OPINION Current evidence is evolving around the many trialed pharmacotherapeutic considerations for the management of coronavirus disease 2019 (COVID-19) in patients with cardiovascular disease. While we await such data, clinicians should advocate for careful consideration of all concomitant medications for those presenting with COVID-19 on a patient-by-patient basis.
Collapse
Affiliation(s)
- Maryam Khan
- School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, UK
| | | | - Sakina Abrar
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | | | - Kara Morgan
- Department of Cardiology, Manchester Royal Infirmary, Manchester, UK
- Division of Pharmacy & Optometry, School of Health Sciences, Faculty of Biology, Medicine & Health, The University of Manchester, Manchester, UK
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest, Liverpool, UK
| |
Collapse
|
242
|
Asili P, Mirahmad M, Tabatabaei-Malazy O, Manayi A, Haghighat E, Mahdavi M, Larijani B. Characteristics of published/registered clinical trials on COVID-19 treatment: A systematic review. Daru 2021; 29:449-467. [PMID: 34762250 PMCID: PMC8581284 DOI: 10.1007/s40199-021-00422-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 10/13/2021] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVES Due to the rapid spread of COVID-19 worldwide, many countries have designed clinical trials to find efficient treatments. We aimed to critically report the characteristics of all the registered and published randomized clinical trials (RCTs) conducted on COVID-19, and summarize the evaluation of potential therapies developed in various regions. EVIDENCE ACQUISITION We comprehensively searched PubMed, Cochrane Library, Web of Science, Scopus, and Clinicaltrial.gov databases to retrieve all the relevant studies up to July 19, 2021, in conformity with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart. We included all English-language published/registered RCTs on COVID-19, and excluded non-RCT, in-vitro/in-vivo, editorials, and review studies. Two reviewers independently evaluated all the records, and then analyzed by using SPSS 17. RESULTS Within 3018 included studies, 2801 (92.8%) and 217 (7.2%) were registered or published RCTs consisting of about 600 synthetic drugs. Herbal medicines have been studied in 23 trials (10.6%) among the published RCTs and in 357 registered RCTs (12.7%). Hydroxychloroquine 23 (10.6%) and convalescent plasma 194 (6.9%) alone or in combination with other agents were the most frequently used interventions in published and registered RCTs, respectively. Most published RCTs have been conducted in Western Pacific Region (WPRO) (50 trials, 23.0%) including 45 trials from China. Also, a greater proportion of registered RCTs have been conducted in the Region of the Americas (PAHO) (885 trials, 31.6%) including 596 RCTs from the United States (U.S). Globally, 283 registered trials have been conducted to assess new developed vaccines for COVID or previously established for other disorders. CONCLUSION The present study highlighted the wide range of potential therapeutic agents in published and registered COVID-19 clinical trials across a wide range of regions. However, it is urgently required to global coordination in order to conduct more well-designed trials and progress in discovering safe and effective treatments.
Collapse
Affiliation(s)
- Pooria Asili
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Mirahmad
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Ozra Tabatabaei-Malazy
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Azadeh Manayi
- Medicinal Plants Research Centre, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Elahe Haghighat
- Department of Pharmacognosy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Mahdavi
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Bagher Larijani
- Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| |
Collapse
|
243
|
Taramasso L, Magnasco L, Portunato F, Briano F, Vena A, Giacobbe DR, Dentone C, Robba C, Ball L, Loconte M, Patroniti N, Frisoni P, D'Angelo R, Dettori S, Mikulska M, Pelosi P, Bassetti M. Clinical presentation of secondary infectious complications in COVID-19 patients in intensive care unit treated with tocilizumab or standard of care. Eur J Intern Med 2021; 94:39-44. [PMID: 34511338 PMCID: PMC8403658 DOI: 10.1016/j.ejim.2021.08.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 08/17/2021] [Accepted: 08/24/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVES The hypothesis of this study is that tocilizumab should affect common signs of infection due to its immunosuppressive properties. Primary aim of the study was to investigate whether the administration of tocilizumab to critically ill patients with COVID-19, led to a different clinical presentation of infectious complications compared to patients who did not receive tocilizumab. Secondary aim was investigating differences in laboratory parameters between groups. METHODS Single-centre retrospective study, enrolling COVID-19 patients who developed a microbiologically confirmed infectious complication [ventilator associated pneumonia or bloodstream infection] after intensive care unit [ICU] admission and either treated with tocilizumab or not [controls]. RESULTS A total of 58 patients were included, 25 treated with tocilizumab and 33 controls. Median time from tocilizumab administration to infection onset was 10 days [range 2-26]. Patients were 78% male, with median age 65 years [range 45-79]. At first clinical presentation of the infectious event, the frequency of hypotension [11/25, 44% vs. 11/33, 33%], fever [8/25, 32% vs. 10/33, 30%] or hypothermia [0/25,0%, vs. 2/33, 6%], and oxygen desaturation [6/25, 28% vs 4/33, 12%], as well as the frequency of SOFA score increase of ≥ 2 points [4/25, 16%,vs. 4/33, 12%] was similar in tocilizumab treated patients and controls [p>0.1 for all comparisons]. Among laboratory parameters, C-Reactive Protein elevation was reduced in tocilizumab treated patients compared to controls [8/25, 32% vs. 22/33, 67%, p=0.009]. CONCLUSION The clinical features of infectious complications in critically ill patients with COVID-19 admitted to ICU were not affected by tocilizumab.
Collapse
Affiliation(s)
- Lucia Taramasso
- Infectious Diseases Unit, Department of Internal Medicine, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences, Genoa, Italy.
| | - Laura Magnasco
- Infectious Diseases Unit, Department of Internal Medicine, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Federica Portunato
- Infectious Diseases Unit, Department of Internal Medicine, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Federica Briano
- Infectious Diseases Unit, Department of Health Sciences [DISSAL], University of Genoa, Genoa, Italy
| | - Antonio Vena
- Infectious Diseases Unit, Department of Internal Medicine, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Daniele R Giacobbe
- Infectious Diseases Unit, Department of Internal Medicine, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences, Genoa, Italy; Infectious Diseases Unit, Department of Health Sciences [DISSAL], University of Genoa, Genoa, Italy
| | - Chiara Dentone
- Infectious Diseases Unit, Department of Internal Medicine, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Lorenzo Ball
- Anesthesia and Intensive Care, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences, Genoa, Italy; Department of Surgical Sciences and Integrated Diagnostics [DISC], University of Genoa, Genoa, Italy
| | - Maurizio Loconte
- Anesthesia and Intensive Care, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Nicolò Patroniti
- Anesthesia and Intensive Care, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences, Genoa, Italy; Department of Surgical Sciences and Integrated Diagnostics [DISC], University of Genoa, Genoa, Italy
| | - Paolo Frisoni
- Anesthesia and Intensive Care, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Raffaele D'Angelo
- Anesthesia and Intensive Care, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Silvia Dettori
- Infectious Diseases Unit, Department of Health Sciences [DISSAL], University of Genoa, Genoa, Italy
| | - Malgorzata Mikulska
- Infectious Diseases Unit, Department of Internal Medicine, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences, Genoa, Italy; Infectious Diseases Unit, Department of Health Sciences [DISSAL], University of Genoa, Genoa, Italy
| | - Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences, Genoa, Italy; Department of Surgical Sciences and Integrated Diagnostics [DISC], University of Genoa, Genoa, Italy
| | - Matteo Bassetti
- Infectious Diseases Unit, Department of Internal Medicine, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences, Genoa, Italy; Infectious Diseases Unit, Department of Health Sciences [DISSAL], University of Genoa, Genoa, Italy
| |
Collapse
|
244
|
Garcia-Muñoz R, Farfán-Quiroga G, Ruiz-de-Lobera N, Feliu J, Anton-Remirez J, Nájera Irazu MJ, Lisa Catón V, Oteo-Revuelta JA. Serology-based therapeutic strategy in SARS-CoV-2-infected patients. Int Immunopharmacol 2021; 101:108214. [PMID: 34649116 PMCID: PMC8491979 DOI: 10.1016/j.intimp.2021.108214] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 09/20/2021] [Accepted: 09/29/2021] [Indexed: 12/22/2022]
Abstract
SARS-CoV-2 infection can be a life-threatening disease. The optimal treatment of patients is not yet standardized. We use a serology-based therapeutic strategy based on the presence of antibodies against the SARS-CoV-2 virus, in which patients with positive serology receive aggressive anti-inflammatory treatment with high-dose dexamethasone and/or tocilizumab and patients with negative serology receive early convalescent plasma therapy. We also analyze the immunological impact of this therapy in the recovery of T cells, B cells and NK cells during hospitalization in a COVID-19 infectious ward. Our results suggest that aggressive therapy with early administration of convalescent plasma and high-dose dexamethasone may be of benefit in patients with SARS-CoV-2 infection and might avoid progression of lung damage or need of admission in intensive care. This strategy did not impair immune responses against SARS-CoV-2, as 93% of the patients generated antibodies against the virus. Independently of previous immunological status of the patients, serology-guided therapy might benefit even patients with a high CIRS-G score, immunosuppressed or medically debilitated individuals and elderly patients. T cell disturbances were most frequent in patients who required high-dose dexamethasone, and B cell depletion was most frequent in patients who received tocilizumab. Early passive immunotherapy with convalescent plasma does not affect lymphoid recovery.
Collapse
Affiliation(s)
- Ricardo Garcia-Muñoz
- Hematology Department, Hospital San Pedro, Logroño, La Rioja. C/Piqueras 98, PC 26006, Spain.
| | - Giovanna Farfán-Quiroga
- Hematology Department, Hospital San Pedro, Logroño, La Rioja. C/Piqueras 98, PC 26006, Spain.
| | - Noemí Ruiz-de-Lobera
- Emergency Department, Hospital San Pedro, Logroño, La Rioja. C/Piqueras 98, PC 26006, Spain.
| | - Jesus Feliu
- Hematology Department, Hospital San Pedro, Logroño, La Rioja. C/Piqueras 98, PC 26006, Spain.
| | - Judith Anton-Remirez
- Department of Physical Medicine and Rehabilitation. Complejo Hospitalario de Navarra, Pamplona, Spain.
| | - Maria José Nájera Irazu
- Hematology Department, Hospital San Pedro, Logroño, La Rioja. C/Piqueras 98, PC 26006, Spain.
| | | | | |
Collapse
|
245
|
Gallo CG, Fiorino S, Posabella G, Antonacci D, Tropeano A, Pausini E, Pausini C, Guarniero T, Hong W, Giampieri E, Corazza I, Federico L, de Biase D, Zippi M, Zancanaro M. COVID-19, what could sepsis, severe acute pancreatitis, gender differences, and aging teach us? Cytokine 2021; 148:155628. [PMID: 34411989 PMCID: PMC8343368 DOI: 10.1016/j.cyto.2021.155628] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 06/02/2021] [Accepted: 06/29/2021] [Indexed: 02/07/2023]
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes a potentially life-threatening disease, defined as Coronavirus Disease 19 (COVID-19). The most common signs and symptoms of this pathological condition include cough, fever, shortness of breath, and sudden onset of anosmia, ageusia, or dysgeusia. The course of COVID-19 is mild or moderate in more than 80% of cases, but it is severe or critical in about 14% and 5% of infected subjects respectively, with a significant risk of mortality. SARS-CoV-2 related infection is characterized by some pathogenetic events, resembling those detectable in other pathological conditions, such as sepsis and severe acute pancreatitis. All these syndromes are characterized by some similar features, including the coexistence of an exuberant inflammatory- as well as an anti-inflammatory-response with immune depression. Based on current knowledge concerning the onset and the development of acute pancreatitis and sepsis, we have considered these syndromes as a very interesting paradigm for improving our understanding of pathogenetic events detectable in patients with COVID-19. The aim of our review is: 1)to examine the pathogenetic mechanisms acting during the emergence of inflammatory and anti-inflammatory processes in human pathology; 2)to examine inflammatory and anti-inflammatory events in sepsis, acute pancreatitis, and SARS-CoV-2 infection and clinical manifestations detectable in patients suffering from these syndromes also according to the age and gender of these individuals; as well as to analyze the possible common and different features among these pathological conditions; 3)to obtain insights into our knowledge concerning COVID-19 pathogenesis. This approach may improve the management of patients suffering from this disease and it may suggest more effective diagnostic approaches and schedules of therapy, depending on the different phases and/or on the severity of SARS-CoV-2 infection.
Collapse
Affiliation(s)
- Claudio G Gallo
- Emilian Physiolaser Therapy Center, Castel S. Pietro Terme, Bologna, Italy.
| | - Sirio Fiorino
- Internal Medicine Unit, Budrio Hospital Azienda USL, Bologna, Italy
| | | | - Donato Antonacci
- Medical Science Department, "Casa Sollievo della Sofferenza" Hospital, San Giovanni Rotondo (FG), Italy
| | | | | | | | | | - Wandong Hong
- Department of Gastroenterology and Hepatology, First Affiliated Hospital of Wenzhou Medical University, Wenzhou City, Zhejiang, The People's Republic of China
| | - Enrico Giampieri
- Experimental, Diagnostic and Specialty Medicine Department, University of Bologna, Bologna, Italy
| | - Ivan Corazza
- Experimental, Diagnostic and Specialty Medicine Department, University of Bologna, Bologna, Italy
| | - Lari Federico
- Internal Medicine Unit, Budrio Hospital Azienda USL, Bologna, Italy
| | - Dario de Biase
- Department of Pharmacy and Biotechnology, University of Bologna, Bologna, Italy
| | - Maddalena Zippi
- Unit of Gastroenterology and Digestive Endoscopy, Sandro Pertini Hospital, Rome, Italy
| | | |
Collapse
|
246
|
Al Sulaiman K, Aljuhani O, Bin Salah K, Korayem GB, Eljaaly K, Al Essa M, Kharbosh A, Al Harbi F, Abuzaid M, Al Bilal S, Almagthali A, Alsohemi S, Alshabasy A, Noureldeen H, Aboudeif M, Alshehri A, Vishwakarma R. Single versus multiple doses of Tocilizumab in critically ill patients with coronavirus disease 2019 (COVID-19): A two-center, retrospective cohort study. J Crit Care 2021; 66:44-51. [PMID: 34438133 PMCID: PMC8381723 DOI: 10.1016/j.jcrc.2021.08.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 08/12/2021] [Accepted: 08/12/2021] [Indexed: 12/11/2022]
Abstract
PURPOSE To evaluate the effectiveness and safety of the optimal tocilizumab dosing regimen. METHODS A two-center, retrospective cohort study, for COVID19 critically ill patients admitted to the intensive care units (ICUs). We included critically ill patients aged 18 years or older who received tocilizumab during ICU stay. Patients were divided into two groups based on the number of the received tocilizumab doses. The primary outcome was the in-hospital and 30-day mortality. Propensity score (PS) matching was used (1:1 ratio) based on the selected criteria. RESULTS A total of 298 patients were included in the study; 70.4% (210 patients) received a single dose of tocilizumab. After adjusting for possible confounders, the 30-day mortality (HR 0.79 95% CI 0.43-1.45 P = 0.44) and in-hospital mortality (HR 0.81; 95% CI 0.46-1.49; P = 0.53) were not significantly different between the two groups. On the flip side, patients who received multiple doses had higher pneumonia odds than a single dose (OR 3.81; 95% CI 1.79-8.12 P = 0.0005). CONCLUSION Repeating tocilizumab doses were not associated with a mortality benefit in COVID-19 critically ill patients, but it was associated with higher odds of pneumonia compared to a single dose.
Collapse
Affiliation(s)
- Khalid Al Sulaiman
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia; College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; King Abdullah International Medical Research Center, Biostatistics and Bioinformatics Department, Riyadh, Saudi Arabia.
| | - Ohoud Aljuhani
- Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Khalid Bin Salah
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia; College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; King Abdullah International Medical Research Center, Biostatistics and Bioinformatics Department, Riyadh, Saudi Arabia
| | - Ghazwa B Korayem
- Department of Pharmacy Practice, College of Pharmacy, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Khalid Eljaaly
- Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia; College of Pharmacy, University of Arizona, Tucson, AZ, United States
| | - Mohammed Al Essa
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Abdullah Kharbosh
- Department of Clinical Pharmacy, College of Pharmacy, Taif University, Taif, Saudi Arabia
| | - Feras Al Harbi
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Maram Abuzaid
- Department of Clinical Pharmacy, Prince Mohamed bin Abdulaziz Hospital, Riyadh, Saudi Arabia
| | - Sarah Al Bilal
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia; King Abdullah International Medical Research Center, Biostatistics and Bioinformatics Department, Riyadh, Saudi Arabia
| | - Alaa Almagthali
- Pharmaceutical Care Department, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Samia Alsohemi
- Pharmaceutical Care Department, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Adel Alshabasy
- Department of Anesthesia and Intensive Care, King Abdulaziz University, Jeddah, Saudi Arabia; Department of Anesthesia and Intensive care, Ain Shams University, Egypt
| | - Haytham Noureldeen
- Department of Anesthesia and Intensive Care, King Abdulaziz University, Jeddah, Saudi Arabia; Department of Anesthesia and Intensive care, Ain Shams University, Egypt
| | - Mohammed Aboudeif
- Department of Anesthesia and Intensive Care, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Asma Alshehri
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia; King Abdullah International Medical Research Center, Biostatistics and Bioinformatics Department, Riyadh, Saudi Arabia
| | - Ramesh Vishwakarma
- King Abdullah International Medical Research Center, Biostatistics and Bioinformatics Department, Riyadh, Saudi Arabia
| |
Collapse
|
247
|
Naik NB, Puri GD, Kajal K, Mahajan V, Bhalla A, Kataria S, Singla K, Panigrahi P, Singh A, Lazar M, Chander A, Ganesh V, Hazarika A, Suri V, Goyal MK, Pandey VK, Kaloria N, Samra T, Saini K, Soni SL. High-Dose Dexamethasone Versus Tocilizumab in Moderate to Severe COVID-19 Pneumonia: A Randomized Controlled Trial. Cureus 2021; 13:e20353. [PMID: 35036193 PMCID: PMC8752381 DOI: 10.7759/cureus.20353] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2021] [Indexed: 12/15/2022] Open
Abstract
Background and objectives Recent randomized controlled trials (RCTs) have indicated potential therapeutic benefits with high-dose dexamethasone (HDD) or tocilizumab (TCZ) plus standard care in moderate to severe coronavirus disease 2019 (COVID-19) with acute respiratory distress syndrome (ARDS). No study has compared these two against each other. We aimed to compare the efficacy and safety of HDD against TCZ in moderate to severe COVID-ARDS. Methods Patients admitted with moderate to severe COVID-19 ARDS with clinical worsening within 48 hours of standard care were randomly assigned to receive either HDD or TCZ plus standard care. The primary outcome was ventilator-free days (VFDs) at 28 days. The main secondary outcomes were 28-day all-cause mortality and the incidence of adverse events. Our initial plan was to perform an interim analysis of the first 42 patients. Results VFDs were significantly lower in the HDD arm (median difference: 28 days; 95% confidence interval (CI): 19.35-36.65; Cohen's d = 1.14;p < 0.001). We stopped the trial at the first interim analysis due to high 28-day mortality in the HDD arm (relative risk (RR) of death: 6.5; p = 0.007; NNT (harm) = 1.91). The incidence of secondary infections was also significantly high in the HDD arm (RR: 5.5; p = 0.015; NNT (harm) = 2.33). Conclusions In our study population, HDD was associated with a very high rate of mortality and adverse events. We would not recommend HDD to mitigate the cytokine storm in moderate to severe COVID-19 ARDS. TCZ appears to be a much better and safer alternative.
Collapse
Affiliation(s)
- Naveen B Naik
- Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - Goverdhan D Puri
- Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - Kamal Kajal
- Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - Varun Mahajan
- Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - Ashish Bhalla
- Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | | | - Karan Singla
- Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - Pritam Panigrahi
- Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - Ajay Singh
- Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - Michelle Lazar
- Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - Anjuman Chander
- Anesthesia, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - Venkata Ganesh
- Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - Amarjyoti Hazarika
- Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - Vikas Suri
- Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - Manoj K Goyal
- Neurology, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - Vijayant Kumar Pandey
- Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - Narender Kaloria
- Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - Tanvir Samra
- Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - Kulbhushan Saini
- Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - Shiv L Soni
- Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| |
Collapse
|
248
|
Lovre D, Bateman K, Sherman M, Fonseca VA, Lefante J, Mauvais-Jarvis F. Acute estradiol and progesterone therapy in hospitalised adults to reduce COVID-19 severity: a randomised control trial. BMJ Open 2021; 11:e053684. [PMID: 34848523 PMCID: PMC8635865 DOI: 10.1136/bmjopen-2021-053684] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION As of November 2021, COVID-19 has killed more than 5 million people globally, including over 750 000 in the USA. Apart from corticosteroids, most available therapeutic options are at best marginally efficient in reducing disease severity and are extremely expensive. The systematic investigation of clinically approved drugs is a priority to determine what does mitigate disease severity. Oestradiol (E2) and progesterone (P4) produce a state of anti-inflammatory immune responses and immune tolerance, and enhanced antibody production. The goal of this trial is to evaluate the efficacy of a short E2 and P4 therapy, in addition to standard of care (SOC), in mitigating disease severity in COVID-19 hospitalised patients. METHODS AND ANALYSIS Phase 2, randomised, double blind, placebo-controlled, single-centre trial. Patients hospitalised for confirmed COVID-19, with scores 3-5 on the 9-point WHO ordinal scale are randomised between two arms: (1) Oestradiol cypionate intramuscular (IM) and micronised progesterone oral (PO), in addition to SOC, and (2) placebo, in addition to SOC. The primary outcome is the proportion of patients improving to scores 1 or 2 on the WHO scale through day 28. Secondary outcomes include length of hospital stay, duration of mechanical ventilation, cause of death, readmission rates, change in inflammatory biomarkers between admission and occurrence of primary endpoint, and adverse events. Study sample size will be up to 120 participants. The trial is currently recruiting subjects. ETHICS AND DISSEMINATION The sponsor of this study is the Center of Excellence in Sex-Based Biology & Medicine at Tulane University, New Orleans, Louisiana, USA. Ethical approval was obtained from the Tulane institutional review board on 14 May 2021. The study was reviewed by the US Food and Drug Administration and granted Investigational New Drug #152 499. Results of the study will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT04865029; Pre-results.
Collapse
Affiliation(s)
- Dragana Lovre
- Section of Endocrinology and Metabolism, John W. Deming Department of Medicine, Tulane University Health Sciences Center, New Orleans, Louisiana, USA
- Section of Endocrinology, Department of Medicine, Southeast Louisiana Veterans Health Care System, New Orleans, Louisiana, USA
- Tulane Center of Excellence in Sex-Based Biology & Medicine, Tulane University Health Sciences Center, New Orleans, Louisiana, USA
| | - Kristin Bateman
- Section of General Internal Medicine and Geriatrics, John W. Deming Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Mya Sherman
- Clinical Translational Unit, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Vivian A Fonseca
- Section of Endocrinology and Metabolism, John W. Deming Department of Medicine, Tulane University Health Sciences Center, New Orleans, Louisiana, USA
- Section of Endocrinology, Department of Medicine, Southeast Louisiana Veterans Health Care System, New Orleans, Louisiana, USA
| | - John Lefante
- Department of Biostatistics and Data Science, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana, USA
| | - Franck Mauvais-Jarvis
- Section of Endocrinology and Metabolism, John W. Deming Department of Medicine, Tulane University Health Sciences Center, New Orleans, Louisiana, USA
- Section of Endocrinology, Department of Medicine, Southeast Louisiana Veterans Health Care System, New Orleans, Louisiana, USA
- Tulane Center of Excellence in Sex-Based Biology & Medicine, Tulane University Health Sciences Center, New Orleans, Louisiana, USA
| |
Collapse
|
249
|
Mushtaq MZ, Mahmood SBZ, Almas A, Ather Wasti S, Ahsan Ali S. Tocilizumab in critically ill COVID-19 patients: An observational study. Int Immunopharmacol 2021; 102:108384. [PMID: 34838490 PMCID: PMC8604692 DOI: 10.1016/j.intimp.2021.108384] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 11/16/2021] [Accepted: 11/16/2021] [Indexed: 12/23/2022]
Abstract
Tocilizumab decreases inflammatory response in the cytokine storm which is one of the mechanisms behind the development of ARDS in COVID-19 patients. The objective of our study was to determine response of tocilizumab in patients suffering from COVID-19 by analyzing clinical parameters and inflammatory markers. A single-arm observational retrospective study was conducted from March 15, 2020 to March 15, 2021. Clinical outcomes in terms of mortality, weaning from mechanical ventilator, improvement in laboratory parameters including inflammatory cytokines, and length of hospital stay were documented. Reduction in values of inflammatory markers, and patients discharged home in stable condition were defined as an improvement after tocilizumab administration. A total of 514 patients received tocilizumab, majority of whom were critically sick 333 (64.8%). Out of the total sample 363 (70.6%) patients were discharged home in stable condition. Overall mean length of stay was 11.50 ± 8.4 days. There was significant difference in length of stay of patients who required invasive mechanical ventilation as compared to those who were kept only on supplemental oxygen (p < 0.05). Patients who were discharged home showed significant improvement in inflammatory markers and neutrophil to lymphocyte ratio as compared to those who expired (p < 0.05). A total of 21 (4.1%) patients had positive blood culture while 57 (11.1%) had positive culture of tracheal aspirate. Hence, tocilizumab is found to be a reasonable therapeutic option for worsening COVID-19 pneumonia by decreasing the need for mechanical ventilation. However, it is associated with adverse events including bacterial and fungal infections.
Collapse
Affiliation(s)
- Muhammad Z Mushtaq
- Department of Medicine, The Aga Khan University Hospital, Stadium Road, Karachi, Pakistan
| | - Saad B Z Mahmood
- Department of Medicine, The Aga Khan University Hospital, Stadium Road, Karachi, Pakistan
| | - Aysha Almas
- Department of Medicine, The Aga Khan University Hospital, Stadium Road, Karachi, Pakistan
| | - Syed Ather Wasti
- Department of Medicine, The Aga Khan University Hospital, Stadium Road, Karachi, Pakistan
| | - Syed Ahsan Ali
- Department of Medicine, The Aga Khan University Hospital, Stadium Road, Karachi, Pakistan.
| |
Collapse
|
250
|
Mabrey FL, Morrell ED, Wurfel MM. TLRs in COVID-19: How they drive immunopathology and the rationale for modulation. Innate Immun 2021; 27:503-513. [PMID: 34806446 PMCID: PMC8762091 DOI: 10.1177/17534259211051364] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
COVID-19 is both a viral illness and a disease of immunopathology. Proximal events within the innate immune system drive the balance between deleterious inflammation and viral clearance. We hypothesize that a divergence between the generation of excessive inflammation through over activation of the TLR associated myeloid differentiation primary response (MyD88) pathway relative to the TIR-domain-containing adaptor-inducing IFN-β (TRIF) pathway plays a key role in COVID-19 severity. Both viral elements and damage associated host molecules act as TLR ligands in this process. In this review, we detail the mechanism for this imbalance in COVID-19 based on available evidence, and we discuss how modulation of critical elements may be important in reducing severity of disease.
Collapse
Affiliation(s)
- F Linzee Mabrey
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, 7284University of Washington, USA
| | - Eric D Morrell
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, 7284University of Washington, USA
| | - Mark M Wurfel
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, 7284University of Washington, USA
| |
Collapse
|