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Li X, Feng J, Yuan Y, Zhang S, Xu Z, Xu Q, Song J, Ru L, Yuan Z, Wu W. Acute and subacute oral toxicity of artemisinin-hydroxychloroquine sulfate tablets in beagle dogs. Drug Chem Toxicol 2023; 46:995-1003. [PMID: 36039016 DOI: 10.1080/01480545.2022.2116645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 06/17/2022] [Accepted: 06/17/2022] [Indexed: 11/03/2022]
Abstract
Artemisinin-hydroxychloroquine sulfate tablets (AH) are regarded as a relatively inexpensive and novel combination therapy for the treatment of various forms of malaria, particularly aminoquinoline drugs-resistant strains of Plasmodium falciparum. Our aim was to conduct acute and subacute oral toxicity studies in non-rodents to obtain more nonclinical data on the safety of AH. Acute toxicity evaluation was performed in beagle dogs at single doses of 230, 530, 790, 1180, 2660, and 5000 mg/kg. Beagle dogs at doses of 0, 56, 84, and 126 mg/kg were used to assess subacute toxicity for 14 days. The approximate lethal dose range for acute oral administration of AH in dogs is found to be 790-1180 mg/kg, and toxic symptoms prior to death include gait instability, limb weakness, mental fatigue, tachypnea, and convulsion. Repeated doses of AH in dogs caused vomiting, soft feces, decreased activity, anorexia, and splenic red pulp vacuolation. Of note, AH could reduce body weight gain and prolong the QTc interval of individual dogs. Therefore, the no-observed-adverse-effect level (NOAEL) and lowest-observed-adverse-effect level (LOAEL) of oral administration of AH for 14 days in dogs are determined to be 84 mg/kg and 126 mg/kg, respectively.
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Affiliation(s)
- Xiaobo Li
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
- Sci-tech Industrial Park, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jianjia Feng
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yueming Yuan
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
- Sci-tech Industrial Park, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Shouya Zhang
- Sci-tech Industrial Park, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Zhiyong Xu
- Sci-tech Industrial Park, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Qin Xu
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
- The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jianping Song
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
- The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Li Ru
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
- Sci-tech Industrial Park, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Zheng Yuan
- Sci-tech Industrial Park, Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Wanting Wu
- Artemisinin Research Center, Guangzhou University of Chinese Medicine, Guangzhou, China
- The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
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Shirvani M, Sayad B, Shojaei L, Amini A, Shahbazi F. Remdesivir-Associated Significant Bradycardia: A Report of Three Cases. J Tehran Heart Cent 2022; 16:79-83. [PMID: 35082876 PMCID: PMC8742862 DOI: 10.18502/jthc.v16i2.7390] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 03/24/2021] [Indexed: 12/15/2022] Open
Abstract
Recently, remdesivir was approved by the United States Food and Drug Administration for patients with Coronavirus disease 2019 (COVID-19). We herein describe 3 patients with COVID-19 who showed significant bradycardia and QTc prolongation after remdesivir administration. Bradycardia did not respond to atropine treatment in 2 of the patients, one of whom received theophylline and the other required a temporary pacemaker. Fortunately, the patients’ heart rate and rhythm returned to normal after the discontinuation of remdesivir, albeit it lengthened their hospital stays. Careful monitoring during remdesivir infusion may decrease the risk of adverse cardiovascular side effects.
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Affiliation(s)
- Maria Shirvani
- Infectious Diseases Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Babak Sayad
- Infectious Diseases Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Lida Shojaei
- Department of Clinical Pharmacy, Faculty of Pharmacy, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Azadeh Amini
- Department of Pharmaceutical Biomaterials and Medical Biomaterials Research Center, School of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Foroud Shahbazi
- Department of Clinical Pharmacy, Faculty of Pharmacy, Kermanshah University of Medical Sciences, Kermanshah, Iran
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Eftekhari M, Enayati A, Doustimotlagh AH, Farzaei MH, Yosifova Aneva I. Natural Products in Combination Therapy for COVID-19: QT Prolongation and Urgent Guidance. Nat Prod Commun 2021. [DOI: 10.1177/1934578x211032471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Affiliation(s)
- Mahdieh Eftekhari
- Department of Pharmacognosy and Pharmaceutical Biotechnology, Faculty of Pharmacy, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Ayesheh Enayati
- Ischemic Research Center, Golestan University of Medical Sciences, Gorgan, Iran
| | | | - Mohammad Hosein Farzaei
- Pharmaceutical Sciences Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Ina Yosifova Aneva
- Institute of Biodiversity and Ecosystem Research, Bulgarian Academy of Sciences, Sofia, Bulgaria
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Faselis C, Zeng-Treitler Q, Cheng Y, Kerr GS, Nashel DJ, Liappis AP, Weintrob AC, Karasik PE, Arundel C, Boehm D, Heimall MS, Connell LB, Taub DD, Shao Y, Redd DF, Sheriff HM, Zhang S, Fletcher RD, Fonarow GC, Moore HJ, Ahmed A. Cardiovascular Safety of Hydroxychloroquine in US Veterans With Rheumatoid Arthritis. Arthritis Rheumatol 2021; 73:1589-1600. [PMID: 33973403 DOI: 10.1002/art.41803] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 05/04/2021] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Hydroxychloroquine (HCQ) may prolong the QT interval, a risk factor for torsade de pointes, a potentially fatal ventricular arrhythmia. This study was undertaken to examine the cardiovascular safety of HCQ in patients with rheumatoid arthritis (RA). METHODS We conducted an active comparator safety study of HCQ in a propensity score-matched cohort of 8,852 US veterans newly diagnosed as having RA between October 1, 2001 and December 31, 2017. Patients were started on HCQ (n = 4,426) or another nonbiologic disease-modifying antirheumatic drug (DMARD; n = 4,426) after RA diagnosis, up to December 31, 2018, and followed up for 12 months after therapy initiation, up to December 31, 2019. RESULTS Patients had a mean ± SD age of 64 ± 12 years, 14% were women, and 28% were African American. The treatment groups were balanced with regard to 87 baseline characteristics. There were 3 long QT syndrome events (0.03%), 2 of which occurred in patients receiving HCQ. Of the 56 arrhythmia-related hospitalizations (0.63%), 30 occurred in patients in the HCQ group (hazard ratio [HR] associated with HCQ 1.16 [95% confidence interval (95% CI) 0.68-1.95]). All-cause mortality occurred in 144 (3.25%) and 136 (3.07%) of the patients in the HCQ and non-HCQ groups, respectively (HR associated with HCQ 1.06 [95% CI, 0.84-1.34]). During the first 30 days of follow-up, there were no long QT syndrome events, 2 arrhythmia-related hospitalizations (none in the HCQ group), and 13 deaths (6 in the HCQ group). CONCLUSION Our findings indicate that the incidence of long QT syndrome and arrhythmia-related hospitalization is low in patients with RA during the first year after the initiation of HCQ or another nonbiologic DMARD. We found no evidence that HCQ therapy is associated with a higher risk of adverse cardiovascular events or death.
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Affiliation(s)
- Charles Faselis
- Washington DC VA Medical Center, George Washington University, and Uniformed Services University, Washington, DC
| | - Qing Zeng-Treitler
- Washington DC VA Medical Center and George Washington University, Washington, DC
| | - Yan Cheng
- Washington DC VA Medical Center and George Washington University, Washington, DC
| | - Gail S Kerr
- Washington DC VA Medical Center, Georgetown University, and Howard University, Washington, DC
| | - David J Nashel
- Washington DC VA Medical Center and Georgetown University, Washington, DC
| | - Angelike P Liappis
- Washington DC VA Medical Center, George Washington University, and Uniformed Services University, Washington, DC
| | - Amy C Weintrob
- Washington DC VA Medical Center and George Washington University, Washington, DC
| | - Pamela E Karasik
- Washington DC VA Medical Center, Georgetown University, George Washington University, and Uniformed Services University, Washington, DC
| | - Cherinne Arundel
- Washington DC VA Medical Center, George Washington University, and Uniformed Services University, Washington, DC
| | | | | | | | - Daniel D Taub
- Washington DC VA Medical Center and George Washington University, Washington, DC
| | - Yijun Shao
- Washington DC VA Medical Center and George Washington University, Washington, DC
| | | | - Helen M Sheriff
- Washington DC VA Medical Center and George Washington University, Washington, DC
| | | | | | | | - Hans J Moore
- Washington DC VA Medical Center, George Washington University, Uniformed Services University, Georgetown University, and US Department of Veterans Affairs, Washington, DC
| | - Ali Ahmed
- Washington DC VA Medical Center, George Washington University, and Georgetown University, Washington, DC
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Jain A, Prajapati SK, Tripathi M, Raichur AM, Kanwar JR. Exploring the room for repurposed hydroxychloroquine to impede COVID-19: toxicities and multipronged combination approaches with pharmaceutical insights. Expert Rev Clin Pharmacol 2021; 14:715-734. [PMID: 33769888 DOI: 10.1080/17512433.2021.1909473] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Introduction: SARS-CoV-2 has fatally affected the whole world with millions of deaths. Amidst the dilemma of a breakthrough in vaccine development, hydroxychloroquine (HCQ) was looked upon as a prospective repurposed candidate. It has confronted numerous controversies in the past few months as a chemoprophylactic and treatment option for COVID-19. Recently, it has been withdrawn by the World Health Organization for its use in an ongoing pandemic. However, its benefit/risk ratio regarding its use in COVID-19 disease remains poorly justified. An extensive literature search was done using Scopus, PubMed, Google Scholar, www.cdc.gov, www.fda.gov, and who.int.Areas covered: Toxicity vexations of HCQ; pharmaceutical perspectives on new advances in drug delivery approaches; computational modeling (PBPK and PD modeling) overtures; multipronged combination approaches for enhanced synergism with antiviral and anti-inflammatory agents; immuno-boosting effects.Expert commentary: Harnessing the multipronged pharmaceutical perspectives will optimistically help the researchers, scientists, biotech, and pharmaceutical companies to bring new horizons in the safe and efficacious utilization of HCQ alone or in combination with remdesivir and immunomodulatory molecules like bovine lactoferrin in a fight against COVID-19. Combinational therapies with free forms or nanomedicine based targeted approaches can act synergistically to boost host immunity and stop SARS-CoV-2 replication and invasion to impede the infection.
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Affiliation(s)
- Ankit Jain
- Department of Materials Engineering, Indian Institute of Science, Bangalore - Karnataka, India
| | - Shiv Kumar Prajapati
- Department of Pharmaceutical Sciences, Ram-Eesh Institute of Vocational and Technical Education, Greater Noida, Uttar Pradesh, India
| | - Madhavi Tripathi
- Department of Materials Engineering, Indian Institute of Science, Bangalore - Karnataka, India
| | - Ashok M Raichur
- Department of Materials Engineering, Indian Institute of Science, Bangalore - Karnataka, India
| | - Jagat R Kanwar
- Department of Biochemistry, All India Institute of Medical Sciences (AIIMS), Bhopal, Madhya Pradesh, India
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Manoharan L, Olliaro P, Horby PW, Watson CH. Chemoprophylaxis trial designs in epidemics: insights from a systematic review of COVID-19 study registrations. Trials 2021; 22:370. [PMID: 34051840 PMCID: PMC8164073 DOI: 10.1186/s13063-021-05323-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 05/11/2021] [Indexed: 11/12/2022] Open
Abstract
Background Chemoprophylactics against emerging epidemic and pandemic infectious diseases offer potential for prevention but require efficacy and safety analysis before widespread use can be recommended. Chemoprophylaxis with repurposed drugs enables deployment ahead of development of novel vaccines. It may have particular utility as a stopgap ahead of vaccine deployment or when vaccines become less effective on virus variants, in countries where there may be structural inaccessibility to vaccines or in specific risk-groups. Rapid implementation of robust trial designs is a persistent challenge in epidemics. We systematically reviewed SARS-CoV-2 and COVID-19 chemoprophylaxis trial registrations from the first 21 weeks of the pandemic to critically appraise significant design features and alignment of study populations to clinical and public health uses, and describe candidate chemoprophylactic agents. Methods We searched online international trial databases from 31 Dec 2019 to 26 May 2020 using keywords “proph*” or “prevention”. Trial protocols assessing efficacy of chemoprophylactic agents for COVID-19 were included. Trial components were screened for eligibility and relevant studies extracted. Key trial design features were assessed. Results We found 76 chemoprophylaxis study registrations, proposing enrolment of 208,367 people with median size of 490 (IQR 262–1710). A randomised design was specified for 63 trials, 61 included a control group and total proposed enrolment size was 197,010, median 600 (IQR 236–1834). Four protocols provided information on effect size sought. We estimate that for a control group attack rate of 10%, 66% of trials would be underpowered to detect a 50% effect size, and 97% of trials would be underpowered to detect a 30% effect size (at the 80% level). We found evidence of adaptive design in one trial registration only. Laboratory-confirmed infection with or without symptoms was the most common primary outcome. Polymerase chain reaction testing alone was used in 46% of trials, serological testing in 6.6% and 14.5% used both testing methods. Healthcare workers were the target population in 52/79 (65.8%) trials: 49 pre-exposure prophylaxis (PrEP) and 3 post-exposure prophylaxis (PEP). Sixteen trials (20.3%) planned PEP in close contacts. Five studies (6.3%) considered chemoprophylaxis in clinical-risk patients. Older adults were the focus of recruitment in only 3 (3.8%) studies (all long-term care facilities). Two (2.5%) studies of PrEP in the general population included older adults. Hydroxychloroquine was the most common candidate agent in 55/79 trials (69.6%), followed by chloroquine (4/79, 5.0%) and lopinavir/ritonavir (3/79, 3.8%). Conclusion Many registered COVID-19 chemoprophylaxis efficacy trials were underpowered to detect clinically meaningful protection at epidemiologically informed attack rates. This, compounded with the time that has taken to organise these trials as compared to the rapid development of COVID-19 vaccines, has rendered these trials of marginal importance. International coordination mechanisms and collaboration is required. Supporting the design of feasible chemoprophylaxis trials, large enough to generate strong evidence, early on in an epidemic using adaptive platform trial designs will allow structured entry and exit of candidate agents and rapid stand-up of trial infrastructure. Review protocol registration Our protocol is registered at https://www.osf.io/vp56f on May 20, 2020. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05323-4.
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Affiliation(s)
- Lakshmi Manoharan
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine University of Oxford, Old Road Campus, Roosevelt Dr, Oxford, OX3 7LG, UK
| | - Piero Olliaro
- International Severe Acute Respiratory and Emerging Infection Consortium (ISARIC) Global Support Centre, Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine University of Oxford, Old Road Campus, Roosevelt Dr, Oxford, OX3 7LG, UK
| | - Peter W Horby
- International Severe Acute Respiratory and Emerging Infection Consortium (ISARIC) Global Support Centre, Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine University of Oxford, Old Road Campus, Roosevelt Dr, Oxford, OX3 7LG, UK
| | - Conall H Watson
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine University of Oxford, Old Road Campus, Roosevelt Dr, Oxford, OX3 7LG, UK.
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Effect of Hydroxychloroquine on QTc in Patients Diagnosed with COVID-19: A Systematic Review and Meta-Analysis. J Cardiovasc Dev Dis 2021; 8:jcdd8050055. [PMID: 34068104 PMCID: PMC8152730 DOI: 10.3390/jcdd8050055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 04/25/2021] [Accepted: 05/08/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Hydroxychloroquine or chloroquine with or without the concomitant use of azithromycin have been widely used to treat patients with SARS-CoV-2 infection, based on early in vitro studies, despite their potential to prolong the QTc interval of patients. OBJECTIVE This is a systematic review and metanalysis designed to assess the effect of hydroxychloroquine with or without the addition of azithromycin on the QTc of hospitalized patients with COVID-19. MATERIALS AND METHODS PubMed, Scopus, Cochrane and MedRxiv databases were reviewed. A random effect model meta-analysis was used, and I-square was used to assess the heterogeneity. The prespecified endpoints were ΔQTc, QTc prolongation > 500 ms and ΔQTc > 60 ms. RESULTS A total of 18 studies and 7179 patients met the inclusion criteria and were included in this systematic review and meta-analysis. The use of hydroxychloroquine with or without the addition of azithromycin was associated with increased QTc when used as part of the management of patients with SARS-CoV-2 infection. The combination therapy with hydroxychloroquine plus azithromycin was also associated with statistically significant increases in QTc. Moreover, the use of hydroxychloroquine alone, azithromycin alone, or the combination of the two was associated with increased numbers of patients that developed QTc prolongation > 500 ms. CONCLUSION This systematic review and metanalysis revealed that the use of hydroxychloroquine alone or in conjunction with azithromycin was linked to an increase in the QTc interval of hospitalized patients with SARS-CoV-2 infection that received these agents.
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Ali AS, ASattar MA, Karim S, Kutbi D, Aljohani H, Bakhshwin D, Alsieni M, Alkreathy HM. Pharmacological basis for the potential role of Azithromycin and Doxycycline in management of COVID-19. ARAB J CHEM 2021; 14:102983. [PMID: 34909062 PMCID: PMC7797177 DOI: 10.1016/j.arabjc.2020.102983] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 12/27/2020] [Accepted: 12/28/2020] [Indexed: 01/25/2023] Open
Abstract
A novel corona virus SARS-CoV-2 has led to an outbreak of the highly infectious pandemic COVID-19 complicated viral pneumonia. Patients with risk factors frequently develop secondary infections where the role of appropriate antibiotics is mandatory. However, the efforts of drug repurposing lead to recognizing the role of certain antibiotics beyond the management of infection. The current review provided the detailed antiviral, immunomodulatory effect, unique pharmacokinetic profile of two antibiotics namely azithromycin (AZ) and doxycycline (DOX). It summarizes current clinical trials and concerns regarding safety issues of these drugs. Azithromycin (AZ) has amazing lung tissue access, wide range antibacterial efficacy, conceivable antiviral action against COVID-19. It also showed efficacy when combined with other antiviral drugs in limited clinical trials, but many clinicians raise concerns regarding cardiovascular risk in susceptible patients. DOX has a considerable role in the management of pneumonia, it has some advantages including cardiac safety, very good access to lung tissue, potential antiviral, and immunomodulation impact by several mechanisms. The pharmacological profiles of both drugs are heightening considering these medications for further studies in the management of COVID-19.
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Affiliation(s)
- Ahmed S Ali
- Department of Pharmacology Faculty of Medicine, King Abdulaziz University, Saudi Arabia
- Department of Pharmaceutics Faculty of Pharmacy, Assiut University, Egypt
| | - Mai A ASattar
- Department of Pharmacology Faculty of Medicine, King Abdulaziz University, Saudi Arabia
| | - Shahid Karim
- Department of Pharmacology Faculty of Medicine, King Abdulaziz University, Saudi Arabia
| | - Dina Kutbi
- Department of Pharmacology Faculty of Medicine, King Abdulaziz University, Saudi Arabia
| | - Hanin Aljohani
- Department of Pharmacology Faculty of Medicine, King Abdulaziz University, Saudi Arabia
| | - Duaa Bakhshwin
- Department of Pharmacology Faculty of Medicine, King Abdulaziz University, Saudi Arabia
| | - Mohammed Alsieni
- Department of Pharmacology Faculty of Medicine, King Abdulaziz University, Saudi Arabia
| | - Huda M Alkreathy
- Department of Pharmacology Faculty of Medicine, King Abdulaziz University, Saudi Arabia
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Cabral BP, Braga L, Mota F. Expert Opinions on the Most Promising Treatments and Vaccine Candidates for COVID-19: Global Cross-sectional Survey of Virus Researchers in the Early Months of the Pandemic. JMIR Public Health Surveill 2021; 7:e22483. [PMID: 33635275 PMCID: PMC7919842 DOI: 10.2196/22483] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 09/06/2020] [Accepted: 12/08/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The COVID-19 pandemic presents a great public health challenge worldwide, especially given the urgent need to identify effective drugs and develop a vaccine in a short period of time. Globally, several drugs and vaccine candidates are in clinical trials. However, because these drugs and vaccines are still being tested, there is still no definition of which ones will succeed. OBJECTIVE This study aimed to assess the opinions of over 1000 virus researchers with knowledge on the prevention and treatment of coronavirus-related human diseases to determine the most promising drug and vaccine candidates to address COVID-19. METHODS We mapped the clinical trials related to COVID-19 registered at ClinicalTrials.gov. These data were used to prepare a survey questionnaire about treatments and vaccine candidates for COVID-19. In May 2020, a global survey was conducted with authors of recent scientific publications indexed in the Web of Science Core Collection related to viruses, severe acute respiratory syndrome coronavirus, coronaviruses, and COVID-19. RESULTS Remdesivir, immunoglobulin from cured patients, and plasma were considered to be the most promising treatments in May 2020, while ChAdOx1 and mRNA-1273 were considered to be the most promising vaccine candidates. Almost two-thirds of the respondents (766/1219, 62.8%) believed that vaccines for COVID-19 were likely to be available in the next 18 months. Slightly fewer than 25% (289/1219, 23.7%) believed that a vaccine was feasible, but probably not within 18 months. CONCLUSIONS The issues addressed in this study are constantly evolving; therefore, the current state of knowledge has changed since the survey was conducted. However, for several months after the survey, the respondents' expectations were in line with recent results related to treatments and vaccine candidates for COVID-19.
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Affiliation(s)
- Bernardo Pereira Cabral
- Faculty of Economics, Federal University of Bahia, Salvador, Brazil.,Center for Strategic Studies, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Luiza Braga
- Center for Strategic Studies, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil.,Faculty of Economics, Fluminense Federal University, Niterói, Brazil
| | - Fabio Mota
- Center for Strategic Studies, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
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Cardenas MC, Bustos SS, Enninga EAL, Mofenson L, Chakraborty R. Characterising and managing paediatric SARSCoV-2 infection: Learning about the virus in a global classroom. Acta Paediatr 2021; 110:409-422. [PMID: 33175403 DOI: 10.1111/apa.15662] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 10/26/2020] [Accepted: 11/06/2020] [Indexed: 01/08/2023]
Abstract
AIM This study is a comprehensive review with the purpose of collecting the most relevant data in several sections including current treatment guidelines in the paediatric population. METHODS Literature was systematically searched in different databases. Results were limited to 2019+ and English, French and Spanish language. RESULTS Children can exhibit mild and less severe COVID-19 disease than adults and also have asymptomatic carriage of SARS-CoV-2, while severe disease is more frequently noted during infancy (<1 year). SARS-CoV-2 binds the angiotensin-converting enzyme 2 (ACE-2) receptor; age-, racial-, and gender-specific differences in ACE-2 expression need to be elucidated in order to explain the differential clinical profiles between children and adults. Multisystem inflammatory syndrome in children (MIS-C) is an important condition to recognise in children. The decision to use antiviral or immunomodulatory therapy in a child or adolescent should be individualised based on the clinical scenario. Remdesivir is the only FDA-approved therapy available for children older than 12 years old who require hospitalisation for COVID-19. CONCLUSION Further studies are urgently required to address prevention and treatment in at-risk and infected children, especially with underlying comorbidities. The chapter on the overall impact of COVID-19 in children has not yet been written. Nevertheless, SARS-CoV-2 has now joined a long list of human pandemics, which may forever change the world's history.
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Affiliation(s)
- Maria C. Cardenas
- Division of Pediatric Infectious Diseases Department of Mayo Clinic Rochester Minnesota USA
| | - Samyd S. Bustos
- Department of Surgery Mayo Clinic Rochester Minnesota USA
- Center for Regenerative Medicine Mayo Clinic Rochester Minnesota USA
| | | | - Lynne Mofenson
- Elizabeth Glaser Pediatric AIDS Foundation Washington District of Columbia USA
| | - Rana Chakraborty
- Division of Pediatric Infectious Diseases Department of Mayo Clinic Rochester Minnesota USA
- Department of Obstetrics and Gynecology Mayo Clinic Rochester Minnesota USA
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Of mice, microglia, and (wo)men: a case series and mechanistic investigation of hydroxychloroquine for complex regional pain syndrome. Pain Rep 2021; 5:e841. [PMID: 33490839 PMCID: PMC7808678 DOI: 10.1097/pr9.0000000000000841] [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] [Received: 03/09/2020] [Revised: 06/19/2020] [Accepted: 07/02/2020] [Indexed: 12/27/2022] Open
Abstract
Introduction Complex regional pain syndrome (CRPS) is a condition that occurs after minor trauma characterized by sensory, trophic, and motor changes. Although preclinical studies have demonstrated that CRPS may be driven in part by autoinflammation, clinical use of immune-modulating drugs in CRPS is limited. Hydroxychloroquine (HCQ) is a disease-modifying antirheumatic drug used to treat malaria and autoimmune disorders that may provide benefit in CRPS. Objectives To describe the use of HCQ in patients with refractory CRPS and investigate possible mechanisms of benefit in a mouse model of CRPS. Methods We initiated HCQ therapy in 7 female patients with refractory CRPS undergoing treatment at the Stanford Pain Management Center. We subsequently undertook studies in the mouse tibial fracture-casting model of CRPS to identify mechanisms underlying symptom reduction. We evaluated behavior using mechanical allodynia and spinal cord autoinflammation by immunohistochemistry and enzyme-linked immunosorbent assay. Results We treated 7 female patients with chronic, refractory CRPS with HCQ 200 mg twice daily for 2 months, followed by 200 mg daily thereafter. Two patients stopped HCQ secondary to lack of response or side effects. Overall, HCQ significantly improved average numerical rating scale pain from 6.8 ± 1.1 before HCQ to 3.8 ± 1.9 after HCQ treatment. In the tibial fracture-casting mouse model of CRPS, we observed reductions in allodynia, paw edema, and warmth following daily HCQ treatment starting at 3 weeks after injury. Spinal cord dorsal horn microglial activation and cytokine levels were also reduced by HCQ treatment. Conclusion Together, these preclinical and clinical results suggest that HCQ may benefit patients with CRPS at least in part by modulating autoinflammation and support further investigation into the use of HCQ for CRPS.
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Agarwal M, Ranjan P, Baitha U, Mittal A. Hydroxychloroquine as a Chemoprophylactic Agent for COVID-19: A Clinico-Pharmacological Review. Front Pharmacol 2020; 11:593099. [PMID: 33390974 PMCID: PMC7773916 DOI: 10.3389/fphar.2020.593099] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 11/04/2020] [Indexed: 12/11/2022] Open
Abstract
Hydroxychloroquine has gained much attention as one of the candidate drugs that can be repurposed as a prophylactic agent against SARS-CoV-2, the agent responsible for the COVID-19 pandemic. Due to high transmissibility and presence of asymptomatic carriers and presymptomatic transmission, there is need for a chemoprophylactic agent to protect the high-risk population. In this review, we dissect the currently available evidence on hydroxychloroquine prophylaxis from a clinical and pharmacological point of view. In vitro studies on Vero cells show that hydroxychloroquine effectively inhibits SARS-CoV-2 by affecting viral entry and viral transport via endolysosomes. However, this efficacy has failed to replicate in in vivo animal models as well as in most clinical observational studies and clinical trials assessing pre-exposure prophylaxis and postexposure prophylaxis in healthcare workers. An analysis of the pharmacology of HCQ in COVID-19 reveals certain possible reasons for this failure-a pharmacokinetic failure due to failure to achieve adequate drug concentration at the target site and attenuation of its inhibitory effect due to the presence of TMPRSS2 in airway epithelial cells. Currently, many clinical trials on HCQ prophylaxis in HCW are ongoing; these factors should be taken into account. Using higher doses of HCQ for prophylaxis is likely to be associated with increased safety concerns; thus, it may be worthwhile to focus on other possible interventions.
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Affiliation(s)
- Mudit Agarwal
- MBBS, All India Institute of Medical Sciences, New Delhi, India
| | - Piyush Ranjan
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Upendra Baitha
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Ankit Mittal
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
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13
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Omrani AS, Pathan SA, Thomas SA, Harris TR, Coyle PV, Thomas CE, Qureshi I, Bhutta ZA, Mawlawi NA, Kahlout RA, Elmalik A, Azad AM, Daghfal J, Mustafa M, Jeremijenko A, Soub HA, Khattab MA, Maslamani MA, Thomas SH. Randomized double-blinded placebo-controlled trial of hydroxychloroquine with or without azithromycin for virologic cure of non-severe Covid-19. EClinicalMedicine 2020; 29:100645. [PMID: 33251500 PMCID: PMC7678437 DOI: 10.1016/j.eclinm.2020.100645] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Revised: 10/27/2020] [Accepted: 10/29/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Hydroxychloroquine (HC) ± azithromycin (AZ) is widely used for Covid-19. The Qatar Prospective RCT of Expediting Coronavirus Tapering (Q-PROTECT) aimed to assess virologic cure rates of HC±AZ in cases of low-acuity Covid-19. METHODS Q-PROTECT employed a prospective, placebo-controlled design with blinded randomization to three parallel arms: placebo, oral HC (600 mg daily for one week), or oral HC plus oral AZ (500 mg day one, 250 mg daily on days two through five). At enrollment, non-hospitalized participants had mild or no symptoms and were within a day of Covid-19 positivity by polymerase chain reaction (PCR). After six days, intent-to-treat (ITT) analysis of the primary endpoint of virologic cure was assessed using binomial exact 95% confidence intervals (CIs) and χ2 testing. (ClinicalTrials.gov NCT04349592, trial status closed to new participants.). FINDINGS The study enrolled 456 participants (152 in each of three groups: HC+AZ, HC, placebo) between 13 April and 1 August 2020. HC+AZ, HC, and placebo groups had 6 (3·9%), 7 (4·6%), and 9 (5·9%) participants go off study medications before completing the medication course (p = 0·716). Day six PCR results were available for all 152 HC+AZ participants, 149/152 (98·0%) HC participants, and 147/152 (96·7%) placebo participants. Day six ITT analysis found no difference (p = 0·821) in groups' proportions achieving virologic cure: HC+AZ 16/152 (10·5%), HC 19/149 (12·8%), placebo 18/147 (12·2%). Day 14 assessment also showed no association (p = 0·072) between study group and viral cure: HC+AZ 30/149 (20·1%,), HC 42/146 (28·8%), placebo 45/143 (31·5%). There were no serious adverse events. INTERPRETATION HC±AZ does not facilitate virologic cure in patients with mild or asymptomatic Covid-19. FUNDING The study was supported by internal institutional funds of the Hamad Medical Corporation (government health service of the State of Qatar).
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Affiliation(s)
- Ali S. Omrani
- Department of Medicine, Hamad Medical Corporation Communicable Diseases Center, Doha, Qatar
| | - Sameer A. Pathan
- Department of Emergency Medicine, Hamad General Hospital, Doha 3050, Qatar
- Blizard Institute, Barts and The London School of Medicine, Queen Mary Univ. of London, UK
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Sarah A. Thomas
- BSc Candidate in Medical Biosciences, Faculty of Medicine, Imperial College London, UK
| | - Tim R.E. Harris
- Department of Emergency Medicine, Hamad General Hospital, Doha 3050, Qatar
- Blizard Institute, Barts and The London School of Medicine, Queen Mary Univ. of London, UK
| | - Peter V. Coyle
- Departments of Virology and Laboratory Medicine and Pathology, Hamad Medical Corporation, Doha
| | - Caroline E. Thomas
- Department of Emergency Medicine, Hamad General Hospital, Doha 3050, Qatar
| | - Isma Qureshi
- Department of Emergency Medicine, Hamad General Hospital, Doha 3050, Qatar
| | - Zain A. Bhutta
- Department of Emergency Medicine, Hamad General Hospital, Doha 3050, Qatar
| | - Naema Al Mawlawi
- Departments of Virology and Laboratory Medicine and Pathology, Hamad Medical Corporation, Doha
| | - Reham Al Kahlout
- Departments of Virology and Laboratory Medicine and Pathology, Hamad Medical Corporation, Doha
| | - Ashraf Elmalik
- Department of Pharmacy, Hamad General Hospital, Doha, Qatar
| | - Aftab M. Azad
- Department of Emergency Medicine, Hamad General Hospital, Doha 3050, Qatar
| | - Joanne Daghfal
- Department of Medicine, Hamad Medical Corporation Communicable Diseases Center, Doha, Qatar
| | - Mulham Mustafa
- Department of Medicine, Hamad Medical Corporation Communicable Diseases Center, Doha, Qatar
| | - Andrew Jeremijenko
- Department of Medicine, Hamad Medical Corporation Communicable Diseases Center, Doha, Qatar
| | - Hussam Al Soub
- Department of Medicine, Hamad Medical Corporation Communicable Diseases Center, Doha, Qatar
| | - Mohammed Abu Khattab
- Department of Medicine, Hamad Medical Corporation Communicable Diseases Center, Doha, Qatar
| | - Muna Al Maslamani
- Department of Medicine, Hamad Medical Corporation Communicable Diseases Center, Doha, Qatar
- Department of Medicine, Weill Cornell Medical College in Qatar, Doha, Qatar
| | - Stephen H. Thomas
- Department of Emergency Medicine, Hamad General Hospital, Doha 3050, Qatar
- Blizard Institute, Barts and The London School of Medicine, Queen Mary Univ. of London, UK
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14
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Gallus S, Clavenna A, Lugo A. Does hydroxychloroquine reduce mortality for COVID-19? Eur J Intern Med 2020; 82:21-22. [PMID: 33127218 PMCID: PMC7566795 DOI: 10.1016/j.ejim.2020.10.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 10/15/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Silvano Gallus
- Department of Environmental Health Sciences, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy.
| | - Antonio Clavenna
- Department of Public Health, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Alessandra Lugo
- Department of Environmental Health Sciences, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
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15
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Ibrahim D, Dulipsingh L, Zapatka L, Eadie R, Crowell R, Williams K, Wakefield DB, Cook L, Puff J, Hussain SA. Factors Associated with Good Patient Outcomes Following Convalescent Plasma in COVID-19: A Prospective Phase II Clinical Trial. Infect Dis Ther 2020; 9:913-926. [PMID: 32951151 PMCID: PMC7502154 DOI: 10.1007/s40121-020-00341-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 09/10/2020] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Coronavirus disease 2019 (COVID-19) is a viral respiratory syndrome caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This novel virus was discovered in Wuhan City, Hubei Province, China, in December 2019. As of September 6, 2020, confirmed cases have risen to more than 27,000,000 worldwide and more than 885,000 people have died. Currently, no cure or standard treatment for COVID-19 exists. We conducted a prospective single-arm open-label phase II clinical trial assessing the safety and efficacy of convalescent plasma in hospitalized patients with COVID-19. METHODS Convalescent plasma with sufficient total anti-SARS-CoV-2 IgG titer (1:320) obtained from recovered donors was administered to adult patients with either severe or critical COVID-19 illness. Primary outcomes were adverse events in association with plasma administration, and hospital mortality. Secondary outcomes included disease progression, recovery, length of stay, and hospital discharge. RESULTS Of the 38 patients included in the analysis, 24 (63%) recovered and were discharged, and 14 (37%) died. Patients who received convalescent plasma early in the disease course (severe illness group) as compared to the patients that received convalescent plasma later in the disease progression (critical illness group) had significantly lower hospital mortality 13% vs 55% (p < 0.02) and shorter mean hospital length of stay 15.4 vs 33 days (p < 0.01). One patient experienced a transient transfusion reaction. No other adverse effects of convalescent plasma infusion were observed. CONCLUSIONS Our results suggest that convalescent plasma with adequate anti-SARS-CoV-2 antibody titer is safe and has the potential for positive impact on clinical outcomes including recovery and survival if given to patients early in the course of COVID-19 disease. TRIAL REGISTRATION ClinicalTrials.gov. Identifier, NCT04343261, IND #19805.
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Affiliation(s)
| | | | - Lisa Zapatka
- Trinity Health of New England, Hartford, CT, USA
| | | | - Rebecca Crowell
- Research Department, Saint Francis Hospital, Hartford, CT, USA
| | - Kendra Williams
- Research Department, Saint Francis Hospital, Hartford, CT, USA
| | | | - Lisa Cook
- Diabetes Center, Saint Francis Hospital, Hartford, CT, USA
| | - Jennifer Puff
- Diabetes Center, Saint Francis Hospital, Hartford, CT, USA
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16
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Yang J, Guo Z, Liu X, Liu Q, Wu M, Yao X, Liu Y, Cui C, Li H, Song C, Liu D, Xue L. Cytotoxicity Evaluation of Chloroquine and Hydroxychloroquine in Multiple Cell Lines and Tissues by Dynamic Imaging System and Physiologically Based Pharmacokinetic Model. Front Pharmacol 2020; 11:574720. [PMID: 33658924 PMCID: PMC7919379 DOI: 10.3389/fphar.2020.574720] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 10/12/2020] [Indexed: 01/15/2023] Open
Abstract
Chloroquine (CQ) and hydroxychloroquine (HCQ) have been challenged in treating COVID-19 patients and still under debate due to the uncertainty regarding the effectiveness and safety, and there is still lack of the systematic study on the toxicity of these two drugs. To further uncover the toxicity profile of CQ and HCQ in different tissues, we evaluated the cytotoxicity of them in eight cell lines and further adopted the physiologically based pharmacokinetic models to predict the tissue risk, respectively. Retina, myocardium, lung, liver, kidney, vascular endothelium, and intestinal epithelium originated cells were included in the toxicity evaluation of CQ and HCQ, respectively. The proliferation pattern was monitored in 0–72 h by IncuCyte S3. CC50 and the ratio of tissue trough concentrations to CC50 (RTTCC) were brought into predicted toxicity profiles. Compared to CQ, HCQ was found to be less toxic in six cell types except Hep3B and Vero cells. In addition, RTTCC was significantly higher in CQ treatment group compared to HCQ group, which indicates relative safety of HCQ. To further simulate the situation of the COVID-19 patients who suffered the dyspnea and hypoxemia, we also tested the cytotoxicity upon hypoxia and normoxia (1, 5 vs. 21% O2). It was found that the cytotoxicity of CQ was more sensitive to hypoxia compared with that of HCQ, particularly in liver originated cells. Both CQ and HCQ showed cytotoxicity in time-dependent manner which indicates the necessity of short period administration clinically.
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Affiliation(s)
- Jianling Yang
- Center of Basic Medicine Research (CBMR), Peking University Third Hospital, Beijing, China
| | - Zhengyang Guo
- Center of Basic Medicine Research (CBMR), Peking University Third Hospital, Beijing, China
| | - Xu Liu
- Drug Clinical Trial Center, Peking University Third Hospital, Beijing, China.,Savaid Medical School, University of Chinese Academy of Sciences, Beijing, China
| | - Qi Liu
- Drug Clinical Trial Center, Peking University Third Hospital, Beijing, China
| | - Meng Wu
- Center of Basic Medicine Research (CBMR), Peking University Third Hospital, Beijing, China
| | - Xueting Yao
- Drug Clinical Trial Center, Peking University Third Hospital, Beijing, China
| | - Yang Liu
- Center of Basic Medicine Research (CBMR), Peking University Third Hospital, Beijing, China
| | - Cheng Cui
- Drug Clinical Trial Center, Peking University Third Hospital, Beijing, China
| | - Haiyan Li
- Drug Clinical Trial Center, Peking University Third Hospital, Beijing, China
| | - Chunli Song
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
| | - Dongyang Liu
- Drug Clinical Trial Center, Peking University Third Hospital, Beijing, China
| | - Lixiang Xue
- Center of Basic Medicine Research (CBMR), Peking University Third Hospital, Beijing, China
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17
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Vetta F, Marinaccio L, Vetta G, Marchese D. Electrical storm in a patient with COVID-19 treated with hydroxychloroquine: A case report. SAGE Open Med Case Rep 2020; 8:2050313X20974217. [PMID: 33240503 PMCID: PMC7675879 DOI: 10.1177/2050313x20974217] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 10/27/2020] [Indexed: 12/17/2022] Open
Abstract
Hydroxychloroquine (HCQ) is a widely used drug to treat patients with coronavirus
disease 19 (COVID-19). Although evidence of its efficacy and safety remains
limited and controversial, both cardiac and non-cardiac adverse events are known
to be associated with its use. To our knowledge, electrical storm in patients
with COVID-19, or in any case treated with HCQ, has not been reported. We report
the case of a 78-year-old male with an implantable cardiac resynchronization
defibrillator (CRT-D) and a non-severe form of COVID-19. After a few days of
home therapy with HCQ, an electrical storm was revealed that was associated with
an increase in QTc. Following admission to the intensive care unit, HCQ was
discontinued and progressive reduction of the QTc with electrical stabilization
was observed. This clinical case highlights the potential risk of arrythmia
associated with the use of HCQ and stresses the need for close
electrocardiographic monitoring, especially in patients with established heart
disease.
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Affiliation(s)
- Francesco Vetta
- Saint Camillus International University of Health Sciences, Rome, Italy
| | - Leonardo Marinaccio
- Department of Cardiology, Immacolata Concezione Hospital, Piove di Sacco, Italy
| | - Giampaolo Vetta
- Saint Camillus International University of Health Sciences, Rome, Italy
| | - Domenico Marchese
- Department of Cardiology, Immacolata Concezione Hospital, Piove di Sacco, Italy
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18
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Cobos-Siles M, Cubero-Morais P, Arroyo-Jiménez I, Rey-Hernández M, Hernández-Gómez L, Vargas-Parra DJ, González-Fernández M, Cazorla-González M, Gabella-Martín M, Ruíz-Albi T, Berezo-García JA, García-Cruces-Méndez JF, Miramontes-González JP, Corral-Gudino L. Cause-specific death in hospitalized individuals infected with SARS-CoV-2: more than just acute respiratory failure or thromboembolic events. Intern Emerg Med 2020; 15:1533-1544. [PMID: 32910363 PMCID: PMC7481346 DOI: 10.1007/s11739-020-02485-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 08/21/2020] [Indexed: 12/21/2022]
Abstract
Infection with SARS-CoV-2 is becoming the leading cause of death in most countries during the 2020 pandemic. The objective of this study is to assess the association between COVID-19 and cause-specific death. The design is retrospective cohort study. We included data from inpatients diagnosed with COVID-19 between March 18 and April 21, 2020, who died during their hospital stay. Demographic, clinical and management data were collected. Causes of death were ascertained by review of medical records. The sample included 128 individuals. The median age was 84 (IQR 75-89), 57% were men. In 109 patients, the death was caused by SARS-CoV-2 infection, whereas in 19 (14.8%, 95 CI 10-22%), the infection acted only as a precipitating factor to decompensate other pathologies. This second group of patients was older (88y vs 82, p < 0.001). In age-adjusted analysis, they had a greater likelihood of heart failure (OR 3.61 95% CI 1.15-11.32), dependency in activities of daily living (OR 12.07 95% CI 1.40-103.86), frailty (OR 8.73 95% CI 1.37-55.46). The presence of X-ray infiltrates was uncommon (OR 0.07, 95% CI 0.02-0.25). A higher percentage of patient deaths from causes unrelated to COVID-19 complications occurred during the two first weeks of the pandemic. Fifteen percent of patients with COVID-19 infection died from decompensation of other pathologies and the cause of death was unrelated to COVID-19 severe complications. Most of these patients had more comorbidities and were frail and elderly. These findings can partially explain the excess mortality in older people.
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Affiliation(s)
- Marta Cobos-Siles
- grid.411280.e0000 0001 1842 3755Department of Internal Medicine, Hospital Universitario Río Hortega (HURH), Valladolid, Spain
| | - Pablo Cubero-Morais
- grid.411280.e0000 0001 1842 3755Department of Internal Medicine, Hospital Universitario Río Hortega (HURH), Valladolid, Spain
| | - Irene Arroyo-Jiménez
- grid.411280.e0000 0001 1842 3755Department of Internal Medicine, Hospital Universitario Río Hortega (HURH), Valladolid, Spain
| | - María Rey-Hernández
- grid.411280.e0000 0001 1842 3755Department of Internal Medicine, Hospital Universitario Río Hortega (HURH), Valladolid, Spain
| | - Laura Hernández-Gómez
- grid.411280.e0000 0001 1842 3755Department of Internal Medicine, Hospital Universitario Río Hortega (HURH), Valladolid, Spain
| | - Derly Judith Vargas-Parra
- grid.411280.e0000 0001 1842 3755Department of Internal Medicine, Hospital Universitario Río Hortega (HURH), Valladolid, Spain
| | - María González-Fernández
- grid.411280.e0000 0001 1842 3755Department of Internal Medicine, Hospital Universitario Río Hortega (HURH), Valladolid, Spain
| | - Marina Cazorla-González
- grid.411280.e0000 0001 1842 3755Department of Internal Medicine, Hospital Universitario Río Hortega (HURH), Valladolid, Spain
| | - Miriam Gabella-Martín
- grid.411280.e0000 0001 1842 3755Department of Internal Medicine, Hospital Universitario Río Hortega (HURH), Valladolid, Spain
| | - Tomás Ruíz-Albi
- grid.411280.e0000 0001 1842 3755Department of Pneumology, Hospital Universitario Río Hortega, Valladolid, Spain
| | - José Angel Berezo-García
- grid.411280.e0000 0001 1842 3755Department of Critical Care Medicine, Hospital Universitario Río Hortega, Valladolid, Spain
| | - Jesús Fernando García-Cruces-Méndez
- grid.411280.e0000 0001 1842 3755Department of Preventive Medicine and Hospital Epidemiology, Hospital Universitario Río Hortega, Valladolid, Spain
| | - José Pablo Miramontes-González
- grid.411280.e0000 0001 1842 3755Department of Internal Medicine, Hospital Universitario Río Hortega (HURH), Valladolid, Spain
- grid.452531.4Instituto de Investigaciones Biomédicas de Salamanca-IBSAL, Salamanca, Spain
| | - Luis Corral-Gudino
- grid.411280.e0000 0001 1842 3755Department of Internal Medicine, Hospital Universitario Río Hortega (HURH), Valladolid, Spain
- grid.5239.d0000 0001 2286 5329Universidad de Valladolid, Valladolid, Spain
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19
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Stricker RB, Fesler MC. Flattening the Risk: Pre-Exposure Prophylaxis for COVID-19. Infect Drug Resist 2020; 13:3689-3694. [PMID: 33116688 PMCID: PMC7586021 DOI: 10.2147/idr.s264831] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 08/23/2020] [Indexed: 01/14/2023] Open
Abstract
To date, more than 35 million people worldwide have been infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the agent of coronavirus disease 2019 (COVID-19), and more than one million have died in the COVID-19 pandemic. International economies are stalled and social isolation based on palpable fear of death remains the order of the day. The United States and other countries are moving toward resuming work activities and social interaction to boost economic recovery. While this makes financial sense, from a medical perspective our population has already suffered and will continue to suffer severe losses in the absence of a viable aggressive prophylaxis strategy for SARS-CoV-2. Herein, we present a plan to address this problem.
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20
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Lauriola M, Pani A, Ippoliti G, Mortara A, Milighetti S, Mazen M, Perseghin G, Pastori D, Grosso P, Scaglione F. Effect of Combination Therapy of Hydroxychloroquine and Azithromycin on Mortality in Patients With COVID-19. Clin Transl Sci 2020; 13:1071-1076. [PMID: 32926573 PMCID: PMC7719367 DOI: 10.1111/cts.12860] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 07/13/2020] [Indexed: 01/10/2023] Open
Abstract
Conflicting evidence regarding the use of hydroxychloroquine (HCQ) and azithromycin for the treatment of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection do exist. We performed a retrospective single‐center cohort study including 377 consecutive patients admitted for pneumonia related to coronavirus disease 2019 (COVID‐19). Of these, 297 were in combination treatment, 17 were on HCQ alone, and 63 did not receive either of these 2 drugs because of contraindications. The primary end point was in‐hospital death. Mean age was 71.8 ± 13.4 years and 34.2% were women. We recorded 146 deaths: 35 in no treatment, 7 in HCQ treatment group, and 102 in HCQ + azithromycin treatment group (log rank test for Kaplan–Meier curve P < 0.001). At multivariable Cox proportional hazard regression analysis, age (hazard ratio (HR) 1.057, 95% confidence interval (CI) 1.035–1.079, P < 0.001), mechanical ventilation/continuous positive airway pressure (HR 2.726, 95% CI 1.823–4.074, P < 0.001), and C reactive protein above the median (HR 2.191, 95% CI 1.479–3.246, P < 0.001) were directly associated with death, whereas use of HCQ + azithromycin (vs. no treatment; HR 0.265, 95% CI 0.171–0.412, P < 0.001) was inversely associated. In this study, we found a reduced in‐hospital mortality in patients treated with a combination of HCQ and azithromycin after adjustment for comorbidities. A large randomized trial is necessary to confirm these findings.
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Affiliation(s)
| | - Arianna Pani
- Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milan, Italy
| | | | - Andrea Mortara
- Cardiology Department, Policlinico di Monza, Monza, Italy
| | | | - Marjieh Mazen
- Internal Medicine Department, Policlinico di Monza, Monza, Italy
| | - Gianluca Perseghin
- Internal Medicine Department, Policlinico di Monza, Monza, Italy.,Department of Medicine and Surgery, Università degli Studi di Milano Bicocca, Milan, Italy
| | - Daniele Pastori
- Department of Clinical, Internal, Anesthesiologic, and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Paolo Grosso
- Intensive Care Unit, Policlinico di Monza, Monza, Italy
| | - Francesco Scaglione
- Department of Oncology and Hemato-Oncology, Università degli Studi di Milano, Milan, Italy
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21
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Kavanagh O, Marie Healy A, Dayton F, Robinson S, O'Reilly NJ, Mahoney B, Arthur A, Walker G, Farragher JP. Inhaled hydroxychloroquine to improve efficacy and reduce harm in the treatment of COVID-19. Med Hypotheses 2020; 143:110110. [PMID: 33017904 PMCID: PMC7361049 DOI: 10.1016/j.mehy.2020.110110] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/08/2020] [Accepted: 07/12/2020] [Indexed: 02/06/2023]
Abstract
Current formulations and dose regimens of hydroxychloroquine (HCQ) put patients at risk of harm. An analysis of clinical trials registered on ClinicalTrials.gov revealed that this may continue as many studies combine HCQ with agents that prolong the QT interval. Further, almost all of the trials registered do not consider dosage adjustment in the elderly, a patient population most likely to require HCQ treatment. Here we describe an inhaled formulation of HCQ which has passed safety studies in clinical trials for the treatment of asthma and discuss how this approach may reduce side-effects and improve efficacy. As this simple formulation progressed to phase II studies, safety data can be used to immediately enable phase II trials in COVID-19.
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Affiliation(s)
- Oisín Kavanagh
- SSPC, The Science Foundation Ireland Research Centre for Pharmaceuticals, Ireland; Bernal Institute, University of Limerick, Ireland.
| | - Anne Marie Healy
- SSPC, The Science Foundation Ireland Research Centre for Pharmaceuticals, Ireland; School of Pharmacy and Pharmaceutical Sciences, Trinity College Dublin, Ireland
| | - Francis Dayton
- SSPC, The Science Foundation Ireland Research Centre for Pharmaceuticals, Ireland
| | - Shane Robinson
- SSPC, The Science Foundation Ireland Research Centre for Pharmaceuticals, Ireland; Janssen Sciences Ireland, Cork, Ireland
| | - Niall J O'Reilly
- SSPC, The Science Foundation Ireland Research Centre for Pharmaceuticals, Ireland; Pharmaceutical and Molecular Biotechnology Research Centre, Waterford Institute of Technology, Ireland
| | - Brian Mahoney
- SSPC, The Science Foundation Ireland Research Centre for Pharmaceuticals, Ireland
| | - Aisling Arthur
- SSPC, The Science Foundation Ireland Research Centre for Pharmaceuticals, Ireland
| | - Gavin Walker
- SSPC, The Science Foundation Ireland Research Centre for Pharmaceuticals, Ireland; Bernal Institute, University of Limerick, Ireland
| | - John P Farragher
- SSPC, The Science Foundation Ireland Research Centre for Pharmaceuticals, Ireland
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22
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Ramotar D. The status surrounding chloroquine and other drugs as potential anti-infective agents for COVID-19. Expert Rev Respir Med 2020; 14:863-864. [PMID: 32525706 PMCID: PMC7441791 DOI: 10.1080/17476348.2020.1782199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Affiliation(s)
- Dindial Ramotar
- College of Health and Life Sciences, Hamad Bin Khalifa University (HBKU), Doha, Qatar
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Infante M, Ricordi C, Alejandro R, Caprio M, Fabbri A. Hydroxychloroquine in the COVID-19 pandemic era: in pursuit of a rational use for prophylaxis of SARS-CoV-2 infection. Expert Rev Anti Infect Ther 2020; 19:5-16. [PMID: 32693652 PMCID: PMC7441799 DOI: 10.1080/14787210.2020.1799785] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Introduction Over the last few months, coronavirus disease 2019 (COVID-19) pandemic caused by the novel coronavirus SARS-CoV-2 has posed a serious threat to public health on a global scale. Given the current lack of an effective vaccine, several drugs have been repurposed for treatment and prophylaxis of COVID-19 in an attempt to find an effective cure. Areas covered The antimalarial drug hydroxychloroquine (HCQ) initially garnered widespread attention following the publication of preliminary results showing that this drug exerts an anti-SARS-CoV-2 activity in vitro. Expert opinion To date, clinical evidence suggests lack of benefit from HCQ use for the treatment of hospitalized patients with COVID-19. In such patients, HCQ also appears to be associated with an increased risk of QT interval prolongation and potentially lethal ventricular arrhythmias. Therefore, FDA has recently revoked the Emergency Use Authorization (EUA) for emergency use of HCQ and chloroquine to treat COVID-19. Conversely, whether HCQ use may represent an effective prophylactic strategy against COVID-19 is a separate question that still remains to be answered. In addition, relevant aspects regarding the potential risks and benefits of HCQ need to be clarified, in pursuit of a rational use of this drug in the COVID-19 pandemic era.
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Affiliation(s)
- Marco Infante
- Division of Endocrinology, CTO Andrea Alesini Hospital, ASL Roma 2, Department of Systems Medicine, University of Rome "Tor Vergata" , Rome, Italy.,UniCamillus, Saint Camillus International University of Health Sciences , Rome, Italy.,Diabetes Research Institute Federation (DRIF), Department of Systems Medicine, University of Rome "Tor Vergata" , Rome, Italy.,Network of Immunity in Infection, Malignancy and Autoimmunity (NIIMA), Universal Scientific Education and Research Network (USERN) , Rome, Italy.,Diabetes Research Institute (DRI), University of Miami Miller School of Medicine , Miami, FL, USA
| | - Camillo Ricordi
- Diabetes Research Institute (DRI), University of Miami Miller School of Medicine , Miami, FL, USA
| | - Rodolfo Alejandro
- Diabetes Research Institute (DRI), University of Miami Miller School of Medicine , Miami, FL, USA
| | - Massimiliano Caprio
- Laboratory of Cardiovascular Endocrinology, IRCCS San Raffaele Pisana , Rome, Italy.,Department of Human Sciences and Promotion of the Quality of Life, San Raffaele Roma Open University , Rome, Italy
| | - Andrea Fabbri
- Division of Endocrinology, CTO Andrea Alesini Hospital, ASL Roma 2, Department of Systems Medicine, University of Rome "Tor Vergata" , Rome, Italy.,Diabetes Research Institute Federation (DRIF), Department of Systems Medicine, University of Rome "Tor Vergata" , Rome, Italy
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24
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Hydroxychloroquine-associated QT interval prolongation. REACTIONS WEEKLY 2020. [PMCID: PMC7212241 DOI: 10.1007/s40278-020-78204-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Yang J, Guo Z, Liu X, Liu Q, Wu M, Yao X, Liu Y, Cui C, Li H, Song C, Liu D, Xue L. Cytotoxicity Evaluation of Chloroquine and Hydroxychloroquine in Multiple Cell Lines and Tissues by Dynamic Imaging System and Physiologically Based Pharmacokinetic Model. Front Pharmacol 2020. [PMID: 33658924 DOI: 10.1101/2020.04.22.056762] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2023] Open
Abstract
Chloroquine (CQ) and hydroxychloroquine (HCQ) have been challenged in treating COVID-19 patients and still under debate due to the uncertainty regarding the effectiveness and safety, and there is still lack of the systematic study on the toxicity of these two drugs. To further uncover the toxicity profile of CQ and HCQ in different tissues, we evaluated the cytotoxicity of them in eight cell lines and further adopted the physiologically based pharmacokinetic models to predict the tissue risk, respectively. Retina, myocardium, lung, liver, kidney, vascular endothelium, and intestinal epithelium originated cells were included in the toxicity evaluation of CQ and HCQ, respectively. The proliferation pattern was monitored in 0-72 h by IncuCyte S3. CC50 and the ratio of tissue trough concentrations to CC50 (RTTCC) were brought into predicted toxicity profiles. Compared to CQ, HCQ was found to be less toxic in six cell types except Hep3B and Vero cells. In addition, RTTCC was significantly higher in CQ treatment group compared to HCQ group, which indicates relative safety of HCQ. To further simulate the situation of the COVID-19 patients who suffered the dyspnea and hypoxemia, we also tested the cytotoxicity upon hypoxia and normoxia (1, 5 vs. 21% O2). It was found that the cytotoxicity of CQ was more sensitive to hypoxia compared with that of HCQ, particularly in liver originated cells. Both CQ and HCQ showed cytotoxicity in time-dependent manner which indicates the necessity of short period administration clinically.
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Affiliation(s)
- Jianling Yang
- Center of Basic Medicine Research (CBMR), Peking University Third Hospital, Beijing, China
| | - Zhengyang Guo
- Center of Basic Medicine Research (CBMR), Peking University Third Hospital, Beijing, China
| | - Xu Liu
- Drug Clinical Trial Center, Peking University Third Hospital, Beijing, China
- Savaid Medical School, University of Chinese Academy of Sciences, Beijing, China
| | - Qi Liu
- Drug Clinical Trial Center, Peking University Third Hospital, Beijing, China
| | - Meng Wu
- Center of Basic Medicine Research (CBMR), Peking University Third Hospital, Beijing, China
| | - Xueting Yao
- Drug Clinical Trial Center, Peking University Third Hospital, Beijing, China
| | - Yang Liu
- Center of Basic Medicine Research (CBMR), Peking University Third Hospital, Beijing, China
| | - Cheng Cui
- Drug Clinical Trial Center, Peking University Third Hospital, Beijing, China
| | - Haiyan Li
- Drug Clinical Trial Center, Peking University Third Hospital, Beijing, China
| | - Chunli Song
- Department of Orthopedics, Peking University Third Hospital, Beijing, China
| | - Dongyang Liu
- Drug Clinical Trial Center, Peking University Third Hospital, Beijing, China
| | - Lixiang Xue
- Center of Basic Medicine Research (CBMR), Peking University Third Hospital, Beijing, China
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