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Hu J, Sun Y, Zuo X, Zou Y. Assessment of adverse events related to anti-interleukin-6 receptor monoclonal antibodies using the FDA adverse event reporting system:a real-world pharmacovigilance study. Expert Opin Drug Saf 2024:1-13. [PMID: 39049740 DOI: 10.1080/14740338.2024.2382227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Accepted: 07/03/2024] [Indexed: 07/27/2024]
Abstract
BACKGROUND Interleukin-6 (IL-6) monoclonal antibodies are commonly acknowledged for their efficacy in managing coronavirus disease 2019 (COVID-19); however, there remains a paucity of comprehensive studies on their potential adverse effects. RESEARCH DESIGN AND METHODS This is a retrospective pharmacovigilance investigation. We employed FAERS using OpenVigil FDA to detect adverse reactions linked to the interleukin-6 antagonist tocilizumab and sarilumab. RESULTS Completely 17,037,364 reports were collected from the FAERS database, with 67,976 reports identified as 'primary suspected (PS)' adverse events (AEs) for tocilizumab, and 12,560 reports for sarilumab. AEs induced by both drugs involved 27 organ systems. 109 significant disproportionality preferred terms (PTs) of tocilizumab and 158 significant disproportionality PTs meeting the criteria of sarilumab across all four algorithms were retained simultaneously. A higher incidence of adverse reactions occurred in females aged 45-64 years, with a higher rate of subsequent hospitalization. Both drugs exhibited adverse reactions consistent with previously reported side effects, such as leukopenia, elevated liver enzymes, and hypercholesterolemia. Additionally, there was a strong correlation with gastrointestinal issues. Unexpected significant adverse events, including diabetes, fluctuations in blood pressure, drug ineffectiveness, malignancies, and disorders of the nervous system, were also observed. Gender and age differences existed in AEs signals related to IL-6RAs. CONCLUSION Our study identified significant new AE signals for interleukin-6 receptor antagonists, potentially supporting clinical monitoring and risk identification for this class of drugs.
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Affiliation(s)
- Jing Hu
- Department of Pharmacy, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, People's Republic of China
| | - Yao Sun
- Department of Pharmacy, Children's Hospital of Nanjing Medical University, Nanjing, Jiangsu, People's Republic of China
| | - Xiangrong Zuo
- Department of Critical Care Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, People's Republic of China
| | - Ying Zou
- Department of Pharmacy, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, People's Republic of China
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2
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Chan JFW, Yuan S, Chu H, Sridhar S, Yuen KY. COVID-19 drug discovery and treatment options. Nat Rev Microbiol 2024; 22:391-407. [PMID: 38622352 DOI: 10.1038/s41579-024-01036-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2024] [Indexed: 04/17/2024]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused substantial morbidity and mortality, and serious social and economic disruptions worldwide. Unvaccinated or incompletely vaccinated older individuals with underlying diseases are especially prone to severe disease. In patients with non-fatal disease, long COVID affecting multiple body systems may persist for months. Unlike SARS-CoV and Middle East respiratory syndrome coronavirus, which have either been mitigated or remained geographically restricted, SARS-CoV-2 has disseminated globally and is likely to continue circulating in humans with possible emergence of new variants that may render vaccines less effective. Thus, safe, effective and readily available COVID-19 therapeutics are urgently needed. In this Review, we summarize the major drug discovery approaches, preclinical antiviral evaluation models, representative virus-targeting and host-targeting therapeutic options, and key therapeutics currently in clinical use for COVID-19. Preparedness against future coronavirus pandemics relies not only on effective vaccines but also on broad-spectrum antivirals targeting conserved viral components or universal host targets, and new therapeutics that can precisely modulate the immune response during infection.
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Affiliation(s)
- Jasper Fuk-Woo Chan
- State Key Laboratory of Emerging Infectious Diseases, The University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, China
- Carol Yu Centre for Infection, Department of Microbiology, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, China
- Department of Infectious Diseases and Microbiology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong Province, China
- Centre for Virology, Vaccinology and Therapeutics, Hong Kong Science and Technology Park, Shatin, Hong Kong Special Administrative Region, China
| | - Shuofeng Yuan
- State Key Laboratory of Emerging Infectious Diseases, The University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, China
- Carol Yu Centre for Infection, Department of Microbiology, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, China
- Department of Infectious Diseases and Microbiology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong Province, China
- Centre for Virology, Vaccinology and Therapeutics, Hong Kong Science and Technology Park, Shatin, Hong Kong Special Administrative Region, China
| | - Hin Chu
- State Key Laboratory of Emerging Infectious Diseases, The University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, China
- Carol Yu Centre for Infection, Department of Microbiology, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, China
- Department of Infectious Diseases and Microbiology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong Province, China
- Centre for Virology, Vaccinology and Therapeutics, Hong Kong Science and Technology Park, Shatin, Hong Kong Special Administrative Region, China
| | - Siddharth Sridhar
- State Key Laboratory of Emerging Infectious Diseases, The University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, China
- Carol Yu Centre for Infection, Department of Microbiology, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, China
- Department of Infectious Diseases and Microbiology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong Province, China
| | - Kwok-Yung Yuen
- State Key Laboratory of Emerging Infectious Diseases, The University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, China.
- Carol Yu Centre for Infection, Department of Microbiology, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, China.
- Department of Infectious Diseases and Microbiology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong Province, China.
- Centre for Virology, Vaccinology and Therapeutics, Hong Kong Science and Technology Park, Shatin, Hong Kong Special Administrative Region, China.
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Dijk SW, Krijkamp E, Kunst N, Labrecque JA, Gross CP, Pandit A, Lu CP, Visser LE, Wong JB, Hunink MGM. Making Drug Approval Decisions in the Face of Uncertainty: Cumulative Evidence versus Value of Information. Med Decis Making 2024; 44:512-528. [PMID: 38828516 PMCID: PMC11283736 DOI: 10.1177/0272989x241255047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 04/07/2024] [Indexed: 06/05/2024]
Abstract
BACKGROUND The COVID-19 pandemic underscored the criticality and complexity of decision making for novel treatment approval and further research. Our study aims to assess potential decision-making methodologies, an evaluation vital for refining future public health crisis responses. METHODS We compared 4 decision-making approaches to drug approval and research: the Food and Drug Administration's policy decisions, cumulative meta-analysis, a prospective value-of-information (VOI) approach (using information available at the time of decision), and a reference standard (retrospective VOI analysis using information available in hindsight). Possible decisions were to reject, accept, provide emergency use authorization, or allow access to new therapies only in research settings. We used monoclonal antibodies provided to hospitalized COVID-19 patients as a case study, examining the evidence from September 2020 to December 2021 and focusing on each method's capacity to optimize health outcomes and resource allocation. RESULTS Our findings indicate a notable discrepancy between policy decisions and the reference standard retrospective VOI approach with expected losses up to $269 billion USD, suggesting suboptimal resource use during the wait for emergency use authorization. Relying solely on cumulative meta-analysis for decision making results in the largest expected loss, while the policy approach showed a loss up to $16 billion and the prospective VOI approach presented the least loss (up to $2 billion). CONCLUSION Our research suggests that incorporating VOI analysis may be particularly useful for research prioritization and treatment implementation decisions during pandemics. While the prospective VOI approach was favored in this case study, further studies should validate the ideal decision-making method across various contexts. This study's findings not only enhance our understanding of decision-making strategies during a health crisis but also provide a potential framework for future pandemic responses. HIGHLIGHTS This study reviews discrepancies between a reference standard (retrospective VOI, using hindsight information) and 3 conceivable real-time approaches to research-treatment decisions during a pandemic, suggesting suboptimal use of resources.Of all prospective decision-making approaches considered, VOI closely mirrored the reference standard, yielding the least expected value loss across our study timeline.This study illustrates the possible benefit of VOI results and the need for evidence accumulation accompanied by modeling in health technology assessment for emerging therapies.
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Affiliation(s)
- Stijntje W. Dijk
- Department of Epidemiology, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Eline Krijkamp
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Natalia Kunst
- Centre for Health Economics, University of York, York, UK
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University School of Medicine, New Haven, CT, USA
| | - Jeremy A. Labrecque
- Department of Epidemiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Cary P. Gross
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale University School of Medicine, New Haven, CT, USA
| | - Aradhana Pandit
- Department of Epidemiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Chia-Ping Lu
- Department of Epidemiology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Loes E. Visser
- Department of Hospital Pharmacy, Erasmus University Medical Center, Rotterdam, The Netherlands
- Hospital Pharmacy, Haga Teaching Hospital, The Hague, The Netherlands
| | - John B. Wong
- Division of Clinical Decision Making, Tufts Medical Center, Boston, USA
| | - M. G. Myriam Hunink
- Department of Epidemiology, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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4
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Bhimraj A, Morgan RL, Shumaker AH, Baden L, Cheng VCC, Edwards KM, Gallagher JC, Gandhi RT, Muller WJ, Nakamura MM, O’Horo JC, Shafer RW, Shoham S, Murad MH, Mustafa RA, Sultan S, Falck-Ytter Y. Infectious Diseases Society of America Guidelines on the Treatment and Management of Patients With COVID-19 (September 2022). Clin Infect Dis 2024; 78:e250-e349. [PMID: 36063397 PMCID: PMC9494372 DOI: 10.1093/cid/ciac724] [Citation(s) in RCA: 54] [Impact Index Per Article: 54.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 08/30/2022] [Indexed: 02/07/2023] Open
Abstract
There are many pharmacologic therapies that are being used or considered for treatment of coronavirus disease 2019 (COVID-19), with rapidly changing efficacy and safety evidence from trials. The objective was to develop evidence-based, rapid, living guidelines intended to support patients, clinicians, and other healthcare professionals in their decisions about treatment and management of patients with COVID-19. In March 2020, the Infectious Diseases Society of America (IDSA) formed a multidisciplinary guideline panel of infectious disease clinicians, pharmacists, and methodologists with varied areas of expertise to regularly review the evidence and make recommendations about the treatment and management of persons with COVID-19. The process used a living guideline approach and followed a rapid recommendation development checklist. The panel prioritized questions and outcomes. A systematic review of the peer-reviewed and grey literature was conducted at regular intervals. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to assess the certainty of evidence and make recommendations. Based on the most recent search conducted on 31 May 2022, the IDSA guideline panel has made 32 recommendations for the treatment and management of the following groups/populations: pre- and postexposure prophylaxis, ambulatory with mild-to-moderate disease, and hospitalized with mild-to-moderate, severe but not critical, and critical disease. As these are living guidelines, the most recent recommendations can be found online at: https://idsociety.org/COVID19guidelines. At the inception of its work, the panel has expressed the overarching goal that patients be recruited into ongoing trials. Since then, many trials were conducted that provided much-needed evidence for COVID-19 therapies. There still remain many unanswered questions as the pandemic evolved, which we hope future trials can answer.
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Affiliation(s)
- Adarsh Bhimraj
- Division of Infectious Diseases, Houston Methodist Hospital, Houston, Texas
| | - Rebecca L Morgan
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, Case Western Reserve University, School of Medicine, Cleveland, Ohio
| | - Amy Hirsch Shumaker
- Department of Medicine, Case Western Reserve University, School of Medicine, Cleveland, Ohio
- VA Northeast Ohio Healthcare System, Cleveland, Ohio
| | | | - Vincent Chi Chung Cheng
- Queen Mary Hospital, Department of Microbiology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Kathryn M Edwards
- Division of Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center,Nashville, Tennessee
| | - Jason C Gallagher
- Department of Pharmacy Practice, Temple University, Philadelphia, Pennsylvania
| | - Rajesh T Gandhi
- Infectious Diseases Division, Department of Medicine, Massachusetts General Hospital, and Harvard Medical School, Boston, Massachusetts
| | - William J Muller
- Division of Pediatric Infectious Diseases, Ann & Robert H. Lurie Children’s Hospital of Chicago and Northwestern University, Chicago, Illinois
| | - Mari M Nakamura
- Antimicrobial Stewardship Program and Division of Infectious Diseases, Boston Children’s Hospital and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - John C O’Horo
- Division of Infectious Diseases, Joint Appointment Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
| | - Robert W Shafer
- Division of Infectious Diseases, Department of Medicine, Stanford University, Palo Alto, California
| | - Shmuel Shoham
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - M Hassan Murad
- Division of Public Health, Infectious Diseases and Occupational Medicine, Mayo Clinic, Rochester, Minnesota
| | - Reem A Mustafa
- Division of Nephrology and Hypertension, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Shahnaz Sultan
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis VA Healthcare System, Minneapolis, Minnesota
| | - Yngve Falck-Ytter
- Department of Medicine, Case Western Reserve University, School of Medicine, Cleveland, Ohio
- VA Northeast Ohio Healthcare System, Cleveland, Ohio
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5
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Focosi D, Franchini M, Maggi F, Shoham S. COVID-19 therapeutics. Clin Microbiol Rev 2024; 37:e0011923. [PMID: 38771027 PMCID: PMC11237566 DOI: 10.1128/cmr.00119-23] [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] [Indexed: 05/22/2024] Open
Abstract
SUMMARYSince the emergence of COVID-19 in 2020, an unprecedented range of therapeutic options has been studied and deployed. Healthcare providers have multiple treatment approaches to choose from, but efficacy of those approaches often remains controversial or compromised by viral evolution. Uncertainties still persist regarding the best therapies for high-risk patients, and the drug pipeline is suffering fatigue and shortage of funding. In this article, we review the antiviral activity, mechanism of action, pharmacokinetics, and safety of COVID-19 antiviral therapies. Additionally, we summarize the evidence from randomized controlled trials on efficacy and safety of the various COVID-19 antivirals and discuss unmet needs which should be addressed.
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Affiliation(s)
- Daniele Focosi
- North-Western Tuscany Blood Bank, Pisa University Hospital, Pisa, Italy
| | - Massimo Franchini
- Division of Hematology and Transfusion Medicine, Carlo Poma Hospital, Mantua, Italy
| | - Fabrizio Maggi
- National Institute for Infectious Diseases "Lazzaro Spallanzani" IRCCS, Rome, Italy
| | - Shmuel Shoham
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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6
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Triebwasser JE, Davies JK, Nestani A. COVID-19 therapeutics for the pregnant patient. Semin Perinatol 2024; 48:151920. [PMID: 38866675 DOI: 10.1016/j.semperi.2024.151920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/14/2024]
Abstract
SARS-CoV-2 infection can cause severe disease among pregnant persons. Pregnant persons were not included in initial studies of therapeutics for COVID-19, but cumulative experience demonstrates that most are safe for pregnant persons and the fetus, and effective for prevention or treatment of severe COVID-19.
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Affiliation(s)
- Jourdan E Triebwasser
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Michigan, United States.
| | - Jill K Davies
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Michigan, United States
| | - Ajleeta Nestani
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Michigan, United States
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7
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Zhang F, Li T, Bai Y, Liu J, Qin J, Wang A, Zhu Y, Zhang M, Ma Z, Zhou X, Wang L, Gao M, Wu X, Shao Y, Zhao X, Wen J, Guan J, Wang J, Ma J, Tao H, Hu Y. Treatment strategies with combined agency against severe viral pneumonia in patients with advanced cancer. J Transl Int Med 2024; 12:317-320. [PMID: 39081279 PMCID: PMC11285019 DOI: 10.2478/jtim-2024-0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2024] Open
Affiliation(s)
- Fan Zhang
- Senior Department of Oncology, The Fifth Medical Center of PLA General Hospital, Beijing100039, China
| | - Tao Li
- Senior Department of Oncology, The Fifth Medical Center of PLA General Hospital, Beijing100039, China
| | - Yibing Bai
- Senior Department of Oncology, The Fifth Medical Center of PLA General Hospital, Beijing100039, China
- Medical School of Chinese PLA, Beijing100853, China
| | - Jiayi Liu
- Senior Department of Oncology, The Fifth Medical Center of PLA General Hospital, Beijing100039, China
- School of medicine, Nankai University, Tianjin300071, China
| | - Jiapei Qin
- Senior Department of Oncology, The Fifth Medical Center of PLA General Hospital, Beijing100039, China
- Medical School of Chinese PLA, Beijing100853, China
| | - An Wang
- Senior Department of Oncology, The Fifth Medical Center of PLA General Hospital, Beijing100039, China
- Medical School of Chinese PLA, Beijing100853, China
| | - Yimin Zhu
- Department of Oncology, The Eighth Medical Center of PLA General Hospital, Beijing100091, China
| | - Min Zhang
- Senior Department of Nephrology, The First Medical Center of PLA General Hospital, Beijing100853, China
| | - Zhiqiang Ma
- Senior Department of Oncology, The Fifth Medical Center of PLA General Hospital, Beijing100039, China
| | - Xin Zhou
- Senior Department of Oncology, The Fifth Medical Center of PLA General Hospital, Beijing100039, China
- Medical School of Chinese PLA, Beijing100853, China
| | - Lijie Wang
- Senior Department of Oncology, The Fifth Medical Center of PLA General Hospital, Beijing100039, China
| | - Ming Gao
- Senior Department of Oncology, The Fifth Medical Center of PLA General Hospital, Beijing100039, China
| | - Xiaodong Wu
- Senior Department of Oncology, The Fifth Medical Center of PLA General Hospital, Beijing100039, China
| | - Yan Shao
- Senior Department of Oncology, The Fifth Medical Center of PLA General Hospital, Beijing100039, China
| | - Xiangfei Zhao
- Department of Oncology, the Sixth Medical Center of PLA General Hospital, Beijing100048, China
| | - Juyi Wen
- Department of Oncology, the Sixth Medical Center of PLA General Hospital, Beijing100048, China
| | - Jingzhi Guan
- Department of Oncology, The Eighth Medical Center of PLA General Hospital, Beijing100091, China
| | - Jinliang Wang
- Senior Department of Oncology, The Fifth Medical Center of PLA General Hospital, Beijing100039, China
| | - Junxun Ma
- Senior Department of Oncology, The Fifth Medical Center of PLA General Hospital, Beijing100039, China
| | - Haitao Tao
- Senior Department of Oncology, The Fifth Medical Center of PLA General Hospital, Beijing100039, China
| | - Yi Hu
- Senior Department of Oncology, The Fifth Medical Center of PLA General Hospital, Beijing100039, China
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8
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Rezabakhsh A, Mojtahedi F, Tahsini Tekantapeh S, Mahmoodpoor A, Ala A, Soleimanpour H. Therapeutic Impact of Tocilizumab in the Setting of Severe COVID-19; an Updated and Comprehensive Review on Current Evidence. ARCHIVES OF ACADEMIC EMERGENCY MEDICINE 2024; 12:e47. [PMID: 38994467 PMCID: PMC11239185 DOI: 10.22037/aaem.v12i1.2217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 07/13/2024]
Abstract
Introduction The COVID-19 pandemic caused by SARS-CoV-2 has been the major health concern in 2019 globally. Considering the severity and phase of the disease, various pharmacotherapy schedules were proposed. Here, we set out to provide close-up insights on the clinical utility of Tocilizumab (TCZ), a biologic monoclonal antibody in this regard. Methods In this comprehensive review, various databases, including Scopus, PubMed Central, Medline, Embase, Google Scholar, and preprint publishers (med/bioRxiv) were searched until January 30, 2024, according to the keywords and search criteria. Results Besides the pros and cons, compelling evidence purported the safety and efficacy of TCZ and indicated that it exhibits great potential to reduce short-term and all-cause (28-30-day) mortality. TCZ significantly drops the adverse events if administered in the right time course (in the inflammatory phase) during critical/severe COVID-19 pneumonia. Despite contradictory results, the benefits of TCZ appear significant, especially in combination with add-on therapies, such as corticosteroids. Although the safety of TCZ is acceptable, solid data is lacking as to its benefits during pregnancy. There are limited data on TCZ combination therapies, such as hemoperfusion, intravenous immunoglobulin (IVIG), simple O2 therapy, vasopressor support, convalescent plasma therapy, and even in vaccinated patients and COVID-19 reinfection, especially in elderly persons. In addition, the impact of TCZ therapy on the long-lasting COVID-19 is unclear. Conclusion Personalized medicine based on individual characteristics and pertinent clinical conditions must be considered in the clinicians' decision-making policy. Finally, to mitigate the risk-to-benefit ratio of TCZ, a treatment algorithm, based on available literature and updated national institute of health (NIH) and Infectious Diseases Society of America (IDSA) guidelines, is also proposed.
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Affiliation(s)
- Aysa Rezabakhsh
- Cardiovascular Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
- These authors contributed equally as the first co-authors
| | - Fatemeh Mojtahedi
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
- These authors contributed equally as the first co-authors
| | - Sepideh Tahsini Tekantapeh
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
- Department of Rheumatology, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Ata Mahmoodpoor
- Department of Anesthesiology, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Alireza Ala
- Emergency and Trauma Care Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hassan Soleimanpour
- Road Traffic Injury Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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Kumar A, Kumar N, Pattanayak A, Kumar A, Palavesam S, Manigowdanahundi Nagaraju P, Das R. Comparative evaluation of tocilizumab and itolizumab for treatment of severe COVID-19 in India: a retrospective cohort study. Acute Crit Care 2024; 39:234-242. [PMID: 38556909 PMCID: PMC11167418 DOI: 10.4266/acc.2023.00983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 01/31/2024] [Accepted: 02/04/2024] [Indexed: 04/02/2024] Open
Abstract
BACKGROUND Itolizumab downregulates the synthesis of proinflammatory cytokines and adhesion molecules by inhibiting CD6 leading to lower levels of interferon-γ, interleukin-6, and tumor necrotic factor-α and reduced T-cell infiltration at inflammatory sites. This study aims to compare the effects of tocilizumab and itolizumab in the management of severe coronavirus disease 2019 (COVID-19). METHODS The study population was adults (>18 years) with severe COVID-19 pneumonia admitted to the intensive care unit receiving either tocilizumab or itolizumab during their stay. The primary outcome was clinical improvement (CI), defined as a two-point reduction on a seven-point ordinal scale in the status of the patient from initiating the drug or live discharge. The secondary outcomes were time until CI, improvement in PO2 /FiO2 ratio, best PO2 /FiO2 ratio, need for mechanical ventilation after administration of study drugs, time to discharge, and survival days. RESULTS Of the 126 patients included in the study, 92 received tocilizumab and 34 received itolizumab. CI was seen in 46.7% and 61.7% of the patients in the tocilizumab and itolizumab groups, respectively and was not statistically significant (P=0.134). The PO2 /FiO2 ratio was significantly better with itolizumab compared to tocilizumab (median [interquartile range]: 315 [200-380] vs. 250 [150-350], P=0.043). The incidence of serious adverse events due to the study drugs was significantly higher with itolizumab compared to tocilizumab (14.7% vs. 3.3%, P=0.032). CONCLUSIONS The CI with itolizumab is similar to tocilizumab. Better oxygenation can be achieved with itolizumab and it can be a substitute for tocilizumab in managing severe COVID-19.
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Affiliation(s)
- Abhyuday Kumar
- Department of Anaesthesiology, All India Institute of Medical Sciences (AIIMS) Patna, Patna, India
| | - Neeraj Kumar
- Department of Anaesthesiology, All India Institute of Medical Sciences (AIIMS) Patna, Patna, India
| | - Arunima Pattanayak
- Department of Anaesthesiology, All India Institute of Medical Sciences (AIIMS) Bhubaneswar, Bhubaneswar, India
| | - Ajeet Kumar
- Department of Anaesthesiology, All India Institute of Medical Sciences (AIIMS) Patna, Patna, India
| | - Saravanan Palavesam
- Department of Anaesthesiology, All India Institute of Medical Sciences (AIIMS) Patna, Patna, India
| | | | - Rekha Das
- Department of Anaesthesiology, Acharya Harihar Post Graduate Institute of Cancer, Cuttack, India
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10
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Steuber TD, Rosandich T, Cadwallader T, Steil L, Belk M, Yendrapalli U, Hassoun A, Edwards J. Dosing and Administration Strategies of Tocilizumab in Patients With COVID-19: A Retrospective Cohort Analysis. Ann Pharmacother 2024; 58:391-397. [PMID: 37522616 DOI: 10.1177/10600280231190401] [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] [Indexed: 08/01/2023] Open
Abstract
BACKGROUND Tocilizumab may reduce the risk of death, length of stay, and time of mechanical ventilation in patients hospitalized with COVID-19. Limited data are available evaluating low-dose subcutaneous administration of tocilizumab in this setting. OBJECTIVE To compare outcomes of 2 tocilizumab dosing and administration strategies in patients hospitalized with COVID-19. METHODS A retrospective, observational cohort study was conducted to compare clinical outcomes in patients hospitalized with COVID-19 receiving tocilizumab 400 mg intravenously (400 mg IV) or 162 mg subcutaneously (162 mg SC). Hospitalized patients receiving a single dose of tocilizumab were eligible for inclusion and grouped by dosing and administration strategy. The primary endpoint was ventilator-free days at day 28. Secondary endpoints included length of stay (LOS), intensive care unit (ICU) LOS, mechanical ventilation required after dose, 28-day readmission, 28-day mortality, and change in inflammatory markers. RESULTS A total of 303 patients were included, with 147 who received tocilizumab 400 mg IV and 156 who received 162 mg SC. There was no significant difference in average ventilator-free days at day 28 in patients receiving 400 mg IV compared with 162 mg SC (26.4 ± 5.3 vs 25.6 ± 6.8 days, respectively; P = 0.812). There was also no difference in LOS (10.4 ± 12.6 vs 10.5 ± 14.0 days; P = 0.637), ICU LOS (3.9 ± 9.0 vs 3.5 ± 8.3 days; P = 0.679), mechanical ventilation after dose (15.6% vs 19.2%; P = 0.412), 28-day readmission (6.1% vs 9.6%; P = 0.268), or 28-day mortality (23.1% vs 25.6%; P = 0.611). Finally, there was no difference regarding change in inflammatory markers at 48 hours (P > 0.05 for all interactions). CONCLUSION AND RELEVANCE In this retrospective study involving hospitalized patients with COVID-19, there was no difference between tocilizumab 162 mg SC and 400 mg IV in terms of efficacy. The 162 mg SC dose may be a reasonable alternative to traditional doses.
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Affiliation(s)
- Taylor D Steuber
- School of Pharmacy, University of Missouri-Kansas City, Columbia, MO, USA
- Harrison College of Pharmacy, Auburn University, Auburn, AL, USA
| | - Thomas Rosandich
- Harrison College of Pharmacy, Auburn University, Auburn, AL, USA
| | | | - Lauren Steil
- Harrison College of Pharmacy, Auburn University, Auburn, AL, USA
| | - Madeline Belk
- Department of Pharmacy, Huntsville Hospital, Huntsville, AL, USA
| | - Usha Yendrapalli
- Department of Internal Medicine, Huntsville Hospital, Huntsville, AL, USA
| | - Ali Hassoun
- Alabama Infectious Disease Center, Huntsville, AL, USA
| | - Jonathan Edwards
- Department of Pharmacy, Huntsville Hospital, Huntsville, AL, USA
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11
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Cozzi-Lepri A, Borghi V, Rotundo S, Mariani B, Ferrari A, Del Borgo C, Bai F, Colletti P, Miraglia P, Torti C, Cattelan AM, Cenderello G, Berruti M, Tascini C, Parruti G, Coladonato S, Gori A, Marchetti G, Lichtner M, Coppola L, Sorace C, D'Abramo A, Mazzotta V, Guaraldi G, Franceschini E, Meschiari M, Sarmati L, Antinori A, Nicastri E, Mussini C. Development and validation of a prediction score for failure to casirivimab/imdevimab in hospitalized patients with COVID-19 pneumonia. Front Med (Lausanne) 2024; 11:1293431. [PMID: 38529120 PMCID: PMC10961453 DOI: 10.3389/fmed.2024.1293431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 02/19/2024] [Indexed: 03/27/2024] Open
Abstract
Introduction Casirivimab and imdevimab (CAS/IMV) are two non-competing, high-affinity human IgG1 anti-SARS-CoV-2 monoclonal antibodies, that showed a survival benefit in seronegative hospitalized patients with COVID-19. This study aimed to estimate the day-28 risk of mechanical ventilation (MV) and death in individuals hospitalized for severe COVID-19 pneumonia and receiving CAS/IMV. Additionally, it aimed to identify variables measured at the time of hospital admission that could predict these outcomes and derive a prediction algorithm. Methods This is a retrospective, observational cohort study conducted in 12 hospitals in Italy. Adult patients who were consecutively hospitalized from November 2021 to February 2022 receiving CAS/IMV were included. A multivariable logistic regression model was used to identify predictors of MV or death by day 28 from treatment initiation, and β-coefficients from the model were used to develop a risk score that was derived by means of leave-one-out internal cross-validation (CV), external CV, and calibration. Secondary outcome was mortality. Results A total of 480 hospitalized patients in the training set and 157 patients in the test set were included. By day 28, 36 participants (8%) underwent MV and 28 died (6%) for a total of 58 participants (12%) experiencing the composite primary endpoint. In multivariable analysis, four factors [age, PaO2/FiO2 ratio, lactate dehydrogenase (LDH), and platelets] were independently associated with the risk of MV/death and were used to generate the proposed risk score. The accuracy of the score in the area under the curve (AUC) was 0.80 and 0.77 in internal validation and test for the composite endpoint and 0.87 and 0.86 for death, respectively. The model also appeared to be well calibrated with the raw data. Conclusion The mortality risk reported in our study was lower than that previously reported. Although CAS/IMV is no longer used, our score might help in identifying which patients are not likely to benefit from monoclonal antibodies and may require alternative interventions.
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Affiliation(s)
- Alessandro Cozzi-Lepri
- Centre for Clinical Research, Epidemiology, Modelling and Evaluation (CREME), Institute for Global Health, University College London, London, United Kingdom
| | - Vanni Borghi
- Clinic of Infectious Diseases, Azienda Ospedaliero-Universitaria Policlinico, Modena, Italy
| | - Salvatore Rotundo
- Unit of Infectious and Tropical Diseases, University Magna Græcia, Catanzaro, Italy
| | - Bianca Mariani
- Unità Organizzativa Complessa Malattie Infettive, Fondazione Istituto di Ricovero e Cura a Caratetre Scientifico, Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Anna Ferrari
- Unità Organizzativa Complessa Malattie Infettive, Azienda Ospedale Università, Padova, Italy
| | - Cosmo Del Borgo
- Unità Organizzativa Complessa Malattie Infettive, Ospedale SM Goretti, Latina, Italy
| | - Francesca Bai
- Clinica delle Malattie Infettive, Dipartimento di Scienze della Salute, ASST Santi Paolo e Carlo, University of Milano, Milan, Italy
| | - Pietro Colletti
- Unit of Infectious Diseases, Paolo Borsellino Hospital, ASP Trapani, Trapani, Italy
| | - Piermauro Miraglia
- Unit of Infectious Diseases, Paolo Borsellino Hospital, ASP Trapani, Trapani, Italy
| | - Carlo Torti
- Unit of Infectious and Tropical Diseases, University Magna Græcia, Catanzaro, Italy
| | - Anna Maria Cattelan
- Unità Organizzativa Complessa Malattie Infettive, Azienda Ospedale Università, Padova, Italy
| | | | - Marco Berruti
- SC Malattie Infettive Asl1 Imperiese, Imperia, Italy
| | - Carlo Tascini
- Clinic of Infectious Diseases, University of Udine, Udine, Italy
| | - Giustino Parruti
- Unit of Infectious Diseases, Hospital of Pescara, Pescara, Italy
| | | | - Andrea Gori
- Infectious Disease Unit, Ospedale L. Sacco, University of Milano, Milan, Italy
| | - Giulia Marchetti
- Clinica delle Malattie Infettive, Dipartimento di Scienze della Salute, ASST Santi Paolo e Carlo, University of Milano, Milan, Italy
| | - Miriam Lichtner
- Unità Organizzativa Complessa Malattie Infettive, Ospedale SM Goretti, Latina, Italy
| | - Luigi Coppola
- Clinical Infectious Diseases, Tor Vergata University, Rome, Italy
| | - Chiara Sorace
- Clinical Infectious Diseases, Tor Vergata University, Rome, Italy
| | | | | | - Giovanni Guaraldi
- Department of Surgical, Medical, Dental and Morphological Sciences, University of Modena and Reggio Emilia, Modena, Emilia-Romagna, Italy
| | - Erica Franceschini
- Department of Surgical, Medical, Dental and Morphological Sciences, University of Modena and Reggio Emilia, Modena, Emilia-Romagna, Italy
| | - Marianna Meschiari
- Department of Surgical, Medical, Dental and Morphological Sciences, University of Modena and Reggio Emilia, Modena, Emilia-Romagna, Italy
| | - Loredana Sarmati
- Clinical Infectious Diseases, Tor Vergata University, Rome, Italy
| | - Andrea Antinori
- Istituto Nazionale Malattie Infettive L. Spallanzani, Rome, Italy
| | | | - Cristina Mussini
- Department of Surgical, Medical, Dental and Morphological Sciences, University of Modena and Reggio Emilia, Modena, Emilia-Romagna, Italy
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12
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Kaneko T, Ezra S, Abdo R, Voss C, Zhong S, Liu X, Hovey O, Slessarev M, Van Nynatten LR, Ye M, Fraser DD, Li SSC. Kinome and phosphoproteome reprogramming underlies the aberrant immune responses in critically ill COVID-19 patients. Clin Proteomics 2024; 21:13. [PMID: 38389037 PMCID: PMC10882830 DOI: 10.1186/s12014-024-09457-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 01/29/2024] [Indexed: 02/24/2024] Open
Abstract
SARS-CoV-2 infection triggers extensive host immune reactions, leading to severe diseases in certain individuals. However, the molecular basis underlying the excessive yet non-productive immune responses in severe COVID-19 remains incompletely understood. In this study, we conducted a comprehensive analysis of the peripheral blood mononuclear cell (PBMC) proteome and phosphoproteome in sepsis patients positive or negative for SARS-CoV-2 infection, as well as healthy subjects, using quantitative mass spectrometry. Our findings demonstrate dynamic changes in the COVID-19 PBMC proteome and phosphoproteome during disease progression, with distinctive protein or phosphoprotein signatures capable of distinguishing longitudinal disease states. Furthermore, SARS-CoV-2 infection induces a global reprogramming of the kinome and phosphoproteome, resulting in defective adaptive immune response mediated by the B and T lymphocytes, compromised innate immune responses involving the SIGLEC and SLAM family of immunoreceptors, and excessive cytokine-JAK-STAT signaling. In addition to uncovering host proteome and phosphoproteome aberrations caused by SARS-CoV-2, our work recapitulates several reported therapeutic targets for COVID-19 and identified numerous new candidates, including the kinases PKG1, CK2, ROCK1/2, GRK2, SYK, JAK2/3, TYK2, DNA-PK, PKCδ, and the cytokine IL-12.
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Affiliation(s)
- Tomonori Kaneko
- Departments of Biochemistry, Western University, London, ON, N6A 5C1, Canada
| | - Sally Ezra
- Departments of Biochemistry, Western University, London, ON, N6A 5C1, Canada
| | - Rober Abdo
- Department of Pathology and Laboratory Medicine, Western University, London, Canada
| | - Courtney Voss
- Departments of Biochemistry, Western University, London, ON, N6A 5C1, Canada
| | - Shanshan Zhong
- Departments of Biochemistry, Western University, London, ON, N6A 5C1, Canada
| | - Xuguang Liu
- Departments of Biochemistry, Western University, London, ON, N6A 5C1, Canada
| | - Owen Hovey
- Departments of Biochemistry, Western University, London, ON, N6A 5C1, Canada
| | - Marat Slessarev
- Departments of Medicine and Pediatrics, Western University, London, Canada
| | | | - Mingliang Ye
- CAS Key Laboratory of Separation Sciences for Analytical Chemistry, National Chromatographic R&A Center, Dalian Institute of Chemical Physics, Chinese Academy of Sciences (CAS), Dalian, 116023, China
| | - Douglas D Fraser
- Departments of Medicine and Pediatrics, Western University, London, Canada
- Lawson Health Research Institute, 750 Base Line Rd E, London, ON, N6C 2R5, Canada
| | - Shawn Shun-Cheng Li
- Departments of Biochemistry, Western University, London, ON, N6A 5C1, Canada.
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13
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Alipanah-Lechner N, Hurst-Hopf J, Delucchi K, Swigart L, Willmore A, LaCombe B, Dewar R, Lane HC, Lallemand P, Liu KD, Esserman L, Matthay MA, Calfee CS. Novel subtypes of severe COVID-19 respiratory failure based on biological heterogeneity: a secondary analysis of a randomized controlled trial. Crit Care 2024; 28:56. [PMID: 38383504 PMCID: PMC10882728 DOI: 10.1186/s13054-024-04819-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 01/25/2024] [Indexed: 02/23/2024] Open
Abstract
BACKGROUND Despite evidence associating inflammatory biomarkers with worse outcomes in hospitalized adults with COVID-19, trials of immunomodulatory therapies have met with mixed results, likely due in part to biological heterogeneity of participants. Latent class analysis (LCA) of clinical and protein biomarker data has identified two subtypes of non-COVID acute respiratory distress syndrome (ARDS) with different clinical outcomes and treatment responses. We studied biological heterogeneity and clinical outcomes in a multi-institutional platform randomized controlled trial of adults with severe COVID-19 hypoxemic respiratory failure (I-SPY COVID). METHODS Clinical and plasma protein biomarker data were analyzed from 400 trial participants enrolled from September 2020 until October 2021 with severe COVID-19 requiring ≥ 6 L/min supplemental oxygen. Seventeen hypothesis-directed protein biomarkers were measured at enrollment using multiplex Luminex panels or single analyte enzyme linked immunoassay methods (ELISA). Biomarkers and clinical variables were used to test for latent subtypes and longitudinal biomarker changes by subtype were explored. A validated parsimonious model using interleukin-8, bicarbonate, and protein C was used for comparison with non-COVID hyper- and hypo-inflammatory ARDS subtypes. RESULTS Average participant age was 60 ± 14 years; 67% were male, and 28-day mortality was 25%. At trial enrollment, 85% of participants required high flow oxygen or non-invasive ventilation, and 97% were receiving dexamethasone. Several biomarkers of inflammation (IL-6, IL-8, IL-10, sTNFR-1, TREM-1), epithelial injury (sRAGE), and endothelial injury (Ang-1, thrombomodulin) were associated with 28- and 60-day mortality. Two latent subtypes were identified. Subtype 2 (27% of participants) was characterized by persistent derangements in biomarkers of inflammation, endothelial and epithelial injury, and disordered coagulation and had twice the mortality rate compared with Subtype 1. Only one person was classified as hyper-inflammatory using the previously validated non-COVID ARDS model. CONCLUSIONS We discovered evidence of two novel biological subtypes of severe COVID-19 with significantly different clinical outcomes. These subtypes differed from previously established hyper- and hypo-inflammatory non-COVID subtypes of ARDS. Biological heterogeneity may explain inconsistent findings from trials of hospitalized patients with COVID-19 and guide treatment approaches.
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Affiliation(s)
- Narges Alipanah-Lechner
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California, Room M-1083, 505 Parnassus Ave., San Francisco, CA, 94143, USA.
| | - James Hurst-Hopf
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California, Room M-1083, 505 Parnassus Ave., San Francisco, CA, 94143, USA
| | - Kevin Delucchi
- Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, CA, USA
| | - Lamorna Swigart
- Department of Laboratory Medicine, University of California, San Francisco, CA, USA
| | - Andrew Willmore
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California, Room M-1083, 505 Parnassus Ave., San Francisco, CA, 94143, USA
| | - Benjamin LaCombe
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California, Room M-1083, 505 Parnassus Ave., San Francisco, CA, 94143, USA
| | - Robin Dewar
- Virus Isolation and Serology Laboratory, Applied and Developmental Directorate, Frederick National Laboratory, Frederick, MD, USA
| | - H Clifford Lane
- Division of Clinical Research, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Perrine Lallemand
- Virus Isolation and Serology Laboratory, Applied and Developmental Directorate, Frederick National Laboratory, Frederick, MD, USA
| | - Kathleen D Liu
- Cardiovascular Research Institute, University of California, San Francisco, CA, USA
- Division of Nephrology, University of California, San Francisco, CA, USA
| | - Laura Esserman
- Department of Surgery, University of California, San Francisco, CA, USA
| | - Michael A Matthay
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California, Room M-1083, 505 Parnassus Ave., San Francisco, CA, 94143, USA
- Department of Anesthesia, University of California, San Francisco, CA, USA
| | - Carolyn S Calfee
- Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, University of California, Room M-1083, 505 Parnassus Ave., San Francisco, CA, 94143, USA
- Department of Anesthesia, University of California, San Francisco, CA, USA
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14
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La Vecchia G, Del Buono MG, Bonaventura A, Vecchiè A, Moroni F, Cartella I, Saponara G, Campbell MJ, Dagna L, Ammirati E, Sanna T, Abbate A. Cardiac Involvement in Patients With Multisystem Inflammatory Syndrome in Adults. J Am Heart Assoc 2024; 13:e032143. [PMID: 38348793 PMCID: PMC11010102 DOI: 10.1161/jaha.123.032143] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 12/20/2023] [Indexed: 02/21/2024]
Abstract
Multisystemic inflammatory syndrome in adults is a hyperinflammatory condition following (within 4-12 weeks) SARS-CoV-2 infection. Here, the dysregulation of the immune system leads to a multiorgan involvement often affecting the heart. Cardiac involvement in multisystemic inflammatory syndrome in adults has been described mainly in young men without other comorbidities and may present with different clinical scenarios, including acute heart failure, life-threatening arrhythmias, pericarditis, and myocarditis, with a nonnegligible risk of mortality (up to 7% of all cases). The heterogeneity of its clinical features and the absence of a clear case definition make the differential diagnosis with other postinfectious (eg, infective myocarditis) and hyperinflammatory diseases (eg, adult Still disease and macrophage activation syndrome) challenging. Moreover, the evidence on the efficacy of specific treatments targeting the hyperinflammatory response underlying this clinical condition (eg, glucocorticoids, immunoglobulins, and other immunomodulatory agents) is sparse and not supported by randomized clinical trials. In this review article, we aim to provide an overview of the clinical features and the diagnostic workup of multisystemic inflammatory syndrome in adults with cardiac involvement, highlighting the possible pathogenetic mechanisms and the therapeutic management, along with remaining knowledge gaps in this field.
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Affiliation(s)
- Giulia La Vecchia
- Department of Cardiovascular and Pulmonary SciencesCatholic University of the Sacred HeartRomeItaly
- Center of Excellence in Cardiovascular SciencesIsola Tiberina Hospital Gemelli IsolaRomeItaly
- Department of Cardiovascular MedicineFondazione Policlinico Universitario A. Gemelli IRCCSRomeItaly
| | - Marco Giuseppe Del Buono
- Department of Cardiovascular and Pulmonary SciencesCatholic University of the Sacred HeartRomeItaly
- Department of Cardiovascular MedicineFondazione Policlinico Universitario A. Gemelli IRCCSRomeItaly
| | - Aldo Bonaventura
- S.C. Medicina Generale 1Medical Center, Ospedale di Circolo e Fondazione Macchi, Department of Internal Medicine, ASST Sette LaghiVareseItaly
| | - Alessandra Vecchiè
- S.C. Medicina Generale 1Medical Center, Ospedale di Circolo e Fondazione Macchi, Department of Internal Medicine, ASST Sette LaghiVareseItaly
| | - Francesco Moroni
- Robert M. Berne Cardiovascular Research Center and Division of Cardiovascular Medicine, Department of Medicine, Heart and Vascular CenterUniversity of VirginiaCharlottesvilleVirginiaUSA
| | - Iside Cartella
- Department of Cardiology, De Gasperis Cardio Center, ASST GrandeOspedale Metropolitano NiguardaMilanItaly
| | - Gianluigi Saponara
- Department of Cardiovascular MedicineFondazione Policlinico Universitario A. Gemelli IRCCSRomeItaly
| | - Michael J. Campbell
- Division of Pediatric Cardiology, Department of PediatricsDuke University Medical Center2301 Erwin Road, DUMC Box 3127DurhamNCUSA
| | - Lorenzo Dagna
- Unit of Immunology, Rheumatology, Allergy and Rare DiseasesIRCCS San Raffaele Hospital, Vita‐Salute San Raffaele UniversityMilanItaly
| | - Enrico Ammirati
- Department of Cardiology, De Gasperis Cardio Center, ASST GrandeOspedale Metropolitano NiguardaMilanItaly
| | - Tommaso Sanna
- Department of Cardiovascular and Pulmonary SciencesCatholic University of the Sacred HeartRomeItaly
- Department of Cardiovascular MedicineFondazione Policlinico Universitario A. Gemelli IRCCSRomeItaly
| | - Antonio Abbate
- Robert M. Berne Cardiovascular Research Center and Division of Cardiovascular Medicine, Department of Medicine, Heart and Vascular CenterUniversity of VirginiaCharlottesvilleVirginiaUSA
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15
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Liu WD, Wang JT, Shih MC, Chen KH, Huang ST, Huang CF, Chang TH, Tsai MJ, Kuo PH, Yeh YC, Tsai WC, Pan MY, Li GC, Chen YJ, Lin KY, Huang YS, Cheng A, Chen PY, Pan SC, Sun HY, Ku SC, Chang SY, Sheng WH, Fang CT, Hung CC, Chen YC, Ho YL, Wu MS, Chang SC. Effect of early dexamethasone on outcomes of COVID-19: A quasi-experimental study using propensity score matching. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2024:S1684-1182(24)00039-2. [PMID: 38402071 DOI: 10.1016/j.jmii.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 01/15/2024] [Accepted: 02/13/2024] [Indexed: 02/26/2024]
Abstract
BACKGROUND The RECOVERY trial demonstrated that the use of dexamethasone is associated with a 36% lower 28-day mortality in hospitalized patients with COVID-19 on invasive mechanical ventilation. Nevertheless, the optimal timing to start dexamethasone remains uncertain. METHODS We conducted a quasi-experimental study at National Taiwan University Hospital (Taipei, Taiwan) using propensity score matching to simulate a randomized controlled trial to receive or not to receive early dexamethasone (6 mg/day) during the first 7 days following the onset of symptoms. Treatment was standard protocol-based, except for the timing to start dexamethasone, which was left to physicians' decision. The primary outcome is 28-day mortality. Secondary outcomes include secondary infection within 60 days and fulfilling the criteria of de-isolation within 20 days. RESULTS A total of 377 patients with COVID-19 were enrolled. Early dexamethasone did not decrease 28-day mortality in all patients (adjusted odds ratio [aOR], 1.03; 95% confidence interval [CI], 0.97-1.10) or in patients who required O2 for severe/critical disease at admission (aOR, 1.05; 95%CI, 0.94-1.18); but is associated with a 24% increase in superinfection in all patients (aOR, 1.24; 95% CI, 1.12-1.37) and a 23% increase in superinfection in patients of O2 for several/critical disease at admission (aOR, 1.23; 95% CI, 1.02-1.47). Moreover, early dexamethasone is associated with a 42% increase in likelihood of delayed clearance of SARS-CoV-2 virus (adjusted hazard ratio, 1.42; 95% CI, 1.01-1.98). CONCLUSION An early start of dexamethasone (within 7 days after the onset of symptoms) could be harmful to hospitalized patients with COVID-19.
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Affiliation(s)
- Wang-Da Liu
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan; Department of Medicine, National Taiwan University Cancer Center, Taipei, Taiwan.
| | - Jann-Tay Wang
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan; National Institute of Infectious Diseases and Vaccinology, National Health Research Institutes, Zhunan, Taiwan.
| | - Ming-Chieh Shih
- School of Medicine, National Tsing Hua University, Hsinchu, Taiwan.
| | - Kai-Hsiang Chen
- Department of Internal Medicine, National Taiwan University Hsinchu Branch, Hsinchu, Taiwan.
| | - Szu-Ting Huang
- Department of Internal Medicine, National Taiwan University Hsinchu Branch, Hsinchu, Taiwan.
| | - Chun-Fu Huang
- Department of Internal Medicine, National Taiwan University Hospital Yunlin Branch, Yunlin, Taiwan.
| | | | - Ming-Jui Tsai
- Department of Internal Medicine, National Taiwan University Hospital Yunlin Branch, Yunlin, Taiwan.
| | - Po-Hsien Kuo
- Department of Internal Medicine, National Taiwan University Hsinchu Branch, Hsinchu, Taiwan.
| | - Yi-Chen Yeh
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan.
| | - Wan-Chen Tsai
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan.
| | - Mei-Yan Pan
- Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan.
| | - Guei-Chi Li
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
| | - Yi-Jie Chen
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
| | - Kuan-Yin Lin
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
| | - Yu-Shan Huang
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
| | - Aristine Cheng
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
| | - Pao-Yu Chen
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
| | - Sung-Ching Pan
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
| | - Hsin-Yun Sun
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
| | - Shih-Chi Ku
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
| | - Sui-Yuan Chang
- Department of Clinical Laboratory Sciences and Medical Biotechnology, College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Laboratory Medicine, National Taiwan University Hospital, Taipei, Taiwan.
| | - Wang-Huei Sheng
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan; Department of Medical Education, National Taiwan University Hospital, Taipei, Taiwan; School of Medicine, National Taiwan University College of Medicine, Taipei, Taiwan.
| | - Chi-Tai Fang
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan; School of Medicine, National Taiwan University College of Medicine, Taipei, Taiwan; Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan.
| | - Chien-Ching Hung
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan; Department of Internal Medicine, National Taiwan University Hospital Yunlin Branch, Yunlin, Taiwan; Department of Tropical Medicine and Parasitology, National Taiwan University College of Medicine, Taipei, Taiwan.
| | - Yee-Chun Chen
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan.
| | - Yi-Lwun Ho
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan; School of Medicine, National Taiwan University College of Medicine, Taipei, Taiwan.
| | - Ming-Shiang Wu
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan; School of Medicine, National Taiwan University College of Medicine, Taipei, Taiwan.
| | - Shan-Chwen Chang
- Department of Internal Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan; School of Medicine, National Taiwan University College of Medicine, Taipei, Taiwan.
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16
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English A, McDaid D, Lynch SM, McLaughlin J, Cooper E, Wingfield B, Kelly M, Bhavsar M, McGilligan V, Irwin RE, Bucholc M, Zhang SD, Shukla P, Rai TS, Bjourson AJ, Murray E, Gibson DS, Walsh C. Genomic, Proteomic, and Phenotypic Biomarkers of COVID-19 Severity: Protocol for a Retrospective Observational Study. JMIR Res Protoc 2024; 13:e50733. [PMID: 38354037 PMCID: PMC10868637 DOI: 10.2196/50733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 10/23/2023] [Accepted: 11/09/2023] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Health organizations and countries around the world have found it difficult to control the spread of COVID-19. To minimize the future impact on the UK National Health Service and improve patient care, there is a pressing need to identify individuals who are at a higher risk of being hospitalized because of severe COVID-19. Early targeted work was successful in identifying angiotensin-converting enzyme-2 receptors and type II transmembrane serine protease dependency as drivers of severe infection. Although a targeted approach highlights key pathways, a multiomics approach will provide a clearer and more comprehensive picture of severe COVID-19 etiology and progression. OBJECTIVE The COVID-19 Response Study aims to carry out an integrated multiomics analysis to identify biomarkers in blood and saliva that could contribute to host susceptibility to SARS-CoV-2 and the development of severe COVID-19. METHODS The COVID-19 Response Study aims to recruit 1000 people who recovered from SARS-CoV-2 infection in both community and hospital settings on the island of Ireland. This protocol describes the retrospective observational study component carried out in Northern Ireland (NI; Cohort A); the Republic of Ireland cohort will be described separately. For all NI participants (n=519), SARS-CoV-2 infection has been confirmed by reverse transcription-quantitative polymerase chain reaction. A prospective Cohort B of 40 patients is also being followed up at 1, 3, 6, and 12 months postinfection to assess longitudinal symptom frequency and immune response. Data will be sourced from whole blood, saliva samples, and clinical data from the electronic care records, the general health questionnaire, and a 12-item general health questionnaire mental health survey. Saliva and blood samples were processed to extract DNA and RNA before whole-genome sequencing, RNA sequencing, DNA methylation analysis, microbiome analysis, 16S ribosomal RNA gene sequencing, and proteomic analysis were performed on the plasma. Multiomics data will be combined with clinical data to produce sensitive and specific prognostic models for severity risk. RESULTS An initial demographic and clinical profile of the NI Cohort A has been completed. A total of 249 hospitalized patients and 270 nonhospitalized patients were recruited, of whom 184 (64.3%) were female, and the mean age was 45.4 (SD 13) years. High levels of comorbidity were evident in the hospitalized cohort, with cardiovascular disease and metabolic and respiratory disorders being the most significant (P<.001), grouped according to the International Classification of Diseases 10 codes. CONCLUSIONS This study will provide a comprehensive opportunity to study the mechanisms of COVID-19 severity in recontactable participants. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/50733.
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Affiliation(s)
- Andrew English
- Personalised Medicine Centre, School of Medicine, Ulster University, Derry/Londonderry, United Kingdom
- National Horizons Centre, Teesside University, Middlesbrough, United Kingdom
| | - Darren McDaid
- Personalised Medicine Centre, School of Medicine, Ulster University, Derry/Londonderry, United Kingdom
| | - Seodhna M Lynch
- Personalised Medicine Centre, School of Medicine, Ulster University, Derry/Londonderry, United Kingdom
| | - Joseph McLaughlin
- Personalised Medicine Centre, School of Medicine, Ulster University, Derry/Londonderry, United Kingdom
| | - Eamonn Cooper
- Personalised Medicine Centre, School of Medicine, Ulster University, Derry/Londonderry, United Kingdom
| | - Benjamin Wingfield
- Personalised Medicine Centre, School of Medicine, Ulster University, Derry/Londonderry, United Kingdom
| | - Martin Kelly
- Western Health Social Care Trust, Londonderry, United Kingdom
| | - Manav Bhavsar
- Western Health Social Care Trust, Londonderry, United Kingdom
| | - Victoria McGilligan
- Personalised Medicine Centre, School of Medicine, Ulster University, Derry/Londonderry, United Kingdom
| | - Rachelle E Irwin
- Personalised Medicine Centre, School of Medicine, Ulster University, Derry/Londonderry, United Kingdom
| | - Magda Bucholc
- Personalised Medicine Centre, School of Medicine, Ulster University, Derry/Londonderry, United Kingdom
| | - Shu-Dong Zhang
- Personalised Medicine Centre, School of Medicine, Ulster University, Derry/Londonderry, United Kingdom
| | - Priyank Shukla
- Personalised Medicine Centre, School of Medicine, Ulster University, Derry/Londonderry, United Kingdom
| | - Taranjit Singh Rai
- Personalised Medicine Centre, School of Medicine, Ulster University, Derry/Londonderry, United Kingdom
| | - Anthony J Bjourson
- Personalised Medicine Centre, School of Medicine, Ulster University, Derry/Londonderry, United Kingdom
| | - Elaine Murray
- Personalised Medicine Centre, School of Medicine, Ulster University, Derry/Londonderry, United Kingdom
| | - David S Gibson
- Personalised Medicine Centre, School of Medicine, Ulster University, Derry/Londonderry, United Kingdom
| | - Colum Walsh
- Department of Biomedical and Clinical Sciences, Linköping University, Uppsala, Sweden
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17
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Rong N, Wei X, Liu J. The Role of Neutrophil in COVID-19: Positive or Negative. J Innate Immun 2024; 16:80-95. [PMID: 38224674 PMCID: PMC10861219 DOI: 10.1159/000535541] [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: 09/16/2023] [Accepted: 11/27/2023] [Indexed: 01/17/2024] Open
Abstract
BACKGROUND Neutrophils are the first line of defense against pathogens. They are divided into multiple subpopulations during development and kill pathogens through various mechanisms. Neutrophils are considered one of the markers of severe COVID-19. SUMMARY In-depth research has revealed that neutrophil subpopulations have multiple complex functions. Different subsets of neutrophils play an important role in the progression of COVID-19. KEY MESSAGES In this review, we provide a detailed overview of the developmental processes of neutrophils at different stages and their recruitment and activation after SARS-CoV-2 infection, aiming to elucidate the changes in neutrophil subpopulations, characteristics, and functions after infection and provide a reference for mechanistic research on neutrophil subpopulations in the context of SARS-CoV-2 infection. In addition, we have also summarized research progress on potential targeted drugs for neutrophil immunotherapy, hoping to provide information that aids the development of therapeutic drugs for the clinical treatment of critically ill COVID-19 patients.
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Affiliation(s)
- Na Rong
- NHC Key Laboratory of Human Disease Comparative Medicine, Beijing Key Laboratory for Animal Models of Emerging and Reemerging Infectious Diseases, Institute of Laboratory Animal Science, Chinese Academy of Medical Sciences and Comparative Medicine Center, Peking Union Medical College, Beijing, China,
| | - Xiaohui Wei
- NHC Key Laboratory of Human Disease Comparative Medicine, Beijing Key Laboratory for Animal Models of Emerging and Reemerging Infectious Diseases, Institute of Laboratory Animal Science, Chinese Academy of Medical Sciences and Comparative Medicine Center, Peking Union Medical College, Beijing, China
| | - Jiangning Liu
- NHC Key Laboratory of Human Disease Comparative Medicine, Beijing Key Laboratory for Animal Models of Emerging and Reemerging Infectious Diseases, Institute of Laboratory Animal Science, Chinese Academy of Medical Sciences and Comparative Medicine Center, Peking Union Medical College, Beijing, China
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18
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Bonelli M, Kerschbaumer A, Kastrati K, Ghoreschi K, Gadina M, Heinz LX, Smolen JS, Aletaha D, O'Shea J, Laurence A. Selectivity, efficacy and safety of JAKinibs: new evidence for a still evolving story. Ann Rheum Dis 2024; 83:139-160. [PMID: 37923366 PMCID: PMC10850682 DOI: 10.1136/ard-2023-223850] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 05/18/2023] [Indexed: 11/07/2023]
Abstract
Fundamental insight gained over the last decades led to the discovery of cytokines as pivotal drivers of inflammatory diseases such as rheumatoid arthritis, psoriasis/psoriasis arthritis, inflammatory bowel diseases, atopic dermatitis and spondylarthritis. A deeper understanding of the pro-inflammatory and anti-inflammatory effects of various cytokines has prompted new cytokine-targeting therapies, which revolutionised the treatment options in the last years for patients with inflammatory disorders. Disease-associated immune responses typically involve a complex interplay of multiple cytokines. Therefore, blockade of one single cytokine does not necessarily lead to a persistent remission in all patients with inflammatory disorders and fostered new therapeutic strategies targeting intracellular pathways shared by multiple cytokines. By inhibiting JAK-STAT signalling pathways common to families of cytokines, JAK-inhibitors (JAKinibs) have created a new paradigm for the treatment of inflammatory diseases. Multiple agents have been approved for various disorders and more are being investigated for several new indications. Second-generation selective JAKinibs have been devised with the aim to achieve an increased selectivity and a possible reduced risk of side effects. In the current review, we will summarise the current body of evidence of pan versus selective JAKinibs and the most recent insights on new side effects and indications, including COVID-19.
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Affiliation(s)
- Michael Bonelli
- Division of Rheumatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Andreas Kerschbaumer
- Division of Rheumatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Kastriot Kastrati
- Division of Rheumatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Kamran Ghoreschi
- Department of Dermatology, Venereology and Allergology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Massimo Gadina
- Molecular Immunology and Inflammation Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Leonhard X Heinz
- Division of Rheumatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Josef S Smolen
- Division of Rheumatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Daniel Aletaha
- Division of Rheumatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - John O'Shea
- Molecular Immunology and Inflammation Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Arian Laurence
- Translational Gastroenterology Unit, Department of Haematology, University College Hospital, UCLH Hospitals NHS Trust, University of Oxford, Oxford, UK
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19
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Gasmi A, Noor S, Menzel A, Khanyk N, Semenova Y, Lysiuk R, Beley N, Bolibrukh L, Gasmi Benahmed A, Storchylo O, Bjørklund G. Potential Drugs in COVID-19 Management. Curr Med Chem 2024; 31:3245-3264. [PMID: 37461346 DOI: 10.2174/0929867331666230717154101] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 05/27/2023] [Accepted: 06/05/2023] [Indexed: 11/18/2023]
Abstract
The SARS-CoV-2 virus first emerged in China in December 2019 and quickly spread worldwide. Despite the absence of a vaccination or authorized drug specifically developed to combat this infection, certain medications recommended for other diseases have shown potential effectiveness in treating COVID-19, although without definitive confirmation. This review aims to evaluate the existing literature on the efficacy of these medications against COVID-19. The review encompasses various potential treatments, including antiviral medications, anti-malaria and anti-rheumatic drugs, vaccines, corticosteroids, non-steroidal anti-inflammatory drugs (NSAIDs), antipyretic and analgesic medicines, antiparasitic drugs, and statins. The analysis also addresses the potential benefits and drawbacks of these medications, as well as their effects on hypertension and diabetes. Although these therapies hold promise against COVID-19, further research, including suitable product production or clinical testing, is needed to establish their therapeutic efficacy.
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Affiliation(s)
- Amin Gasmi
- Société Francophone de Nutrithérapie et de Nutrigénétique Appliquée, Villeurbanne, France
| | - Sadaf Noor
- Institute of Molecular Biology and Biotechnology, Bahauddin Zakariya University, Multan, Pakistan
| | | | - Nataliia Khanyk
- Danylo Halytsky Lviv National Medical University, Lviv, Ukraine
- CONEM Ukraine Life Science Research Group, Danylo Halytsky Lviv National Medical University, Lviv, Ukraine
| | - Yuliya Semenova
- Nazarbayev University School of Medicine, Astana, Kazakhstan
| | - Roman Lysiuk
- Danylo Halytsky Lviv National Medical University, Lviv, Ukraine
- CONEM Ukraine Life Science Research Group, Danylo Halytsky Lviv National Medical University, Lviv, Ukraine
| | - Nataliya Beley
- I. Ya. Horbachevsky Ternopil National Medical University, Ternopil, Ukraine
| | | | | | - Olha Storchylo
- Medical Chemistry Department, Odessa National Medical University, Odesa, Ukraine
| | - Geir Bjørklund
- Council for Nutritional and Environmental Medicine (CONEM), Mo i Rana, Norway
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20
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Khan S. Interleukin 6 Antagonists in Severe COVID-19 Disease: Cardiovascular and Respiratory Outcomes. Protein Pept Lett 2024; 31:178-191. [PMID: 38375841 DOI: 10.2174/0109298665266730240118054023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 12/17/2023] [Accepted: 12/27/2023] [Indexed: 02/21/2024]
Abstract
BACKGROUND Inhibitors of interleukin 6 [IL-6] have been utilized to treat severe COVID-19 disease. Their immunosuppressive or immunomodulating impact may be beneficial in COVID-19. OBJECTIVES To discuss the role of IL-6 inhibitors and assess various trials conducted to evaluate the efficacy of IL-6 inhibitors in COVID-19 disease. SUMMARY Two of the most common causes of mortality in COVID-19-infected critically ill individuals are acute respiratory distress syndrome (ARDS) and multiorgan failure. Increased levels of inflammatory cytokines suggest that a cytokine storm, also known as cytokine release syndrome (CRS), is involved in the etiology of COVID-19. Most tissue damage, sepsis, and pulmonary and cardiovascular problems are caused mainly by the host defense system. Therefore, regulating this inflammatory cascade using immunomodulators is a prudent strategy. Although corticosteroids, as immunomodulators, are routinely used in COVID-19 management, interleukin (IL) inhibitors, especially IL-6 inhibitors, are also tested in many trials. Many studies have demonstrated that IL-6 inhibitors improve disease outcomes and decrease mortality, whereas others have shown that they are ineffective. In this paper, we briefly examined the role of IL-6 in COVID-19 pathogenesis and trials that support or refute the use of IL-6 inhibitors in treating COVID-19 disease. RESULTS Though mixed results are coming from trials regarding the adjuvant use of IL-6 inhibitors and standard anti-viral therapy with dexamethasone, a consensus favors using IL-6 inhibitors in severely ill COVID-19 patients regardless of the outcome.
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Affiliation(s)
- Shahzad Khan
- Department of Biomedical Sciences, College of Clinical Pharmacy, King Faisal University, Al Hofuf, Saudi Arabia
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21
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Alfaqeeh M, Zakiyah N, Suwantika AA, Shabrina Z. Evaluation of Global Post-Outbreak COVID-19 Treatment Interventions: A Systematic Review and Bibliometric Analysis of Randomized Controlled Trials. J Multidiscip Healthc 2023; 16:4193-4209. [PMID: 38152831 PMCID: PMC10752030 DOI: 10.2147/jmdh.s448786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 12/18/2023] [Indexed: 12/29/2023] Open
Abstract
Purpose The outbreak of COVID-19 has led to a global pandemic with millions of cases and deaths. Many randomized controlled trials (RCTs) were conducted to establish effective therapies. However, the methodological quality of these trials is paramount, as it directly impacts the reliability of results. This systematic review and bibliometric analysis aim to assess the methodological approach, execution diversity, global trends, and distribution of COVID-19 treatment RCTs post-outbreak, covering the period from the second wave and onward up to the present. Methods We utilize articles from three electronic databases published from September 1, 2020, to April 1, 2023. Inclusion and exclusion criteria were applied to identify relevant RCTs. Data extraction involved the collection of various study details. Risk of Bias (RoB) 2 tool assessed methodological quality, while implementation variability was evaluated against registration information. Bibliometric analysis, including keyword co-occurrence and country distribution, used VOSviewer and Tableau software. Results Initially, 501 studies were identified, but only 22 met the inclusion criteria, of which 19 had registration information. The methodological quality assessment revealed deficiencies in five main domains: randomization process (36%), deviations from intended interventions (9%), missing outcome data (4%), measurement of the outcome (18%), and selection of reported results (4%). An analysis of alignment between research protocols and registration data revealed common deviations in eight critical aspects. Bibliometric findings showcased global collaboration in COVID-19 treatment RCTs, with Iran and Brazil prominently contributing, while keyword co-occurrence analysis illuminated prominent research trends and terms in study titles and abstracts. Conclusion This study offers valuable insights into the evaluation of COVID-19 treatment RCTs. The scarcity of high-quality RCTs highlights the importance of enhancing trial rigor and transparency in global health emergencies.
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Affiliation(s)
- Mohammed Alfaqeeh
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung, Indonesia
| | - Neily Zakiyah
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung, Indonesia
- Center of Excellence for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung, Indonesia
| | - Auliya A Suwantika
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung, Indonesia
- Center of Excellence for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung, Indonesia
- Center for Health Technology Assessment, Universitas Padjadjaran, Bandung, Indonesia
| | - Zahratu Shabrina
- Department of Geography, King’s College London, London, UK
- Regional Innovation, Graduate School, Universitas Padjadjaran, Bandung, Indonesia
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22
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Uemura Y, Ozaki R, Shinozaki T, Ohtsu H, Shimizu Y, Izumi K, Saito S, Matsunaga N, Ohmagari N. Comparative effectiveness of tocilizumab vs standard care in patients with severe COVID-19-related pneumonia: a retrospective cohort study utilizing registry data as a synthetic control. BMC Infect Dis 2023; 23:849. [PMID: 38049729 PMCID: PMC10694888 DOI: 10.1186/s12879-023-08840-6] [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: 04/27/2023] [Accepted: 11/23/2023] [Indexed: 12/06/2023] Open
Abstract
BACKGROUND The severity of coronavirus disease 2019 (COVID-19) infections has led to the development of several therapeutic agents, with tocilizumab becoming increasingly used to treat patients with COVID-19-related pneumonia. This study compared the use of tocilizumab treatment with the standard of care (SOC) to determine its efficacy against severe COVID-19-related pneumonia in Japan. METHODS This retrospective cohort study was designed to evaluate the efficacy of tocilizumab in two different databases: the JA42434 single-arm study and COVID-19 Registry Japan (COVIREGI-JP), with a synthetic control group from the COVIREGI-JP cohort as a benchmark for the tocilizumab group. The study's primary objective was to evaluate the efficacy of tocilizumab in treating severe COVID-19-related pneumonia compared to the SOC among patients included in the above two databases. The SOC group was extracted as the synthetic control group using exact matching and a propensity score matching in sequence per subject. As a secondary objective, the efficacy of tocilizumab compared to the SOC was evaluated exclusively among patients included in the COVIREGI-JP database. In each objective, the primary endpoint was defined as the time to discharge or the status of awaiting discharge. RESULTS For the primary endpoint, the hazard ratio (HR) of the tocilizumab group against the SOC group was 1.070 (95% confidence interval [CI]: 0.565-2.028). The median time from Study Day 1 to discharge or the state of awaiting discharge was 15 days in the tocilizumab group and 16 days in the SOC group. The HRs for the secondary endpoints, namely, time to improvement in the clinical state, time to clinical failure, and time to recovery, were 1.112 (95% CI: 0.596-2.075), 0.628 (95% CI: 0.202-1.953), and 1.019 (95% CI: 0.555-1.871), respectively. Similarly, the HR of the primary endpoint for the secondary objective was 0.846 (95% CI: 0.582-1.230). CONCLUSIONS Tocilizumab did not demonstrate a positive effect on time to discharge or the state of awaiting discharge. Furthermore, no statistically significant differences in other clinical outcomes, such as time to improvement in the clinical state, time to clinical failure, and time to recovery, were observed among the groups.
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Affiliation(s)
- Yukari Uemura
- Biostatistics Section, Department of Data Science, Center for Clinical Sciences, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjyuku-ku, Tokyo, 162-8655, Japan.
| | - Ryoto Ozaki
- Biometrics Department, Clinical Development Division, Chugai Pharmaceutical CO., LTD, Tokyo, Japan
| | - Tomohiro Shinozaki
- Department of Information and Computer Technology, Faculty of Engineering, Tokyo University of Science, Tokyo, Japan
| | - Hiroshi Ohtsu
- Clinical Pharmacology and Regulatory Sciences, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Yousuke Shimizu
- Biostatistics Section, Department of Data Science, Center for Clinical Sciences, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjyuku-ku, Tokyo, 162-8655, Japan
| | - Kazuo Izumi
- Center for Clinical Sciences, National Center for Global Health and Medicine, Tokyo, Japan
| | - Sho Saito
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Nobuaki Matsunaga
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Norio Ohmagari
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
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23
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Vivarelli E, Matucci A, Lucenteforte E, Bormioli S, Virgili G, Trotta M, Spinicci M, Bartoloni A, Zammarchi L, Peris A, Pieralli F, Lavorini F, Fontanari P, Morettini A, Nozzoli C, Poggesi L, Rossi O, Annunziato F, Almerigogna F, Vultaggio A. Effectiveness of tocilizumab in hospitalized moderate-to-severe COVID-19 patients: a real-life study. Panminerva Med 2023; 65:473-478. [PMID: 35274908 DOI: 10.23736/s0031-0808.21.04523-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND To assess the clinical effectiveness of Tocilizumab (TCZ) in moderate-to-severe hospitalized COVID-19 patients and factors associated with clinical response. METHODS Five hundred eight inpatients with moderate-to-severe SARS-CoV-2 infection were enrolled. TCZ effect in addition to standard medical therapy was evaluated in terms of death during hospital stay. Unadjusted and adjusted risk of mortality for TCZ treated patients versus TCZ untreated ones was estimated using robust Cox regression model. We considered the combination of TCZ and ICU as time-dependent exposure and created a model using duplication method to assess the TCZ effect in very severe COVID-19 patients. RESULTS TCZ reduced death during hospital stay in the unadjusted model (HR 0.54, 95%CI 0.33-0.88) and also in the adjusted model, although with loss of statistical significance (HR 0.72, 0.43-1.20). Better effectiveness was observed in patients with low SpO2/FiO2 ratio (HR 0.35, 0.21-0.61 vs. 1.61, 0.54-4.82, P<0.05), and, without statistical significance, in patients with high CRP (HR 0.51, 0.30-0.87 vs. 0.41, 0.12-1.37, P=NS) and high IL-6 (HR 0.49, 0.29-0.82 vs. 1.00, 0.28-3.55, P=NS). TCZ was effective in patients not admitted to ICU, both in the unadjusted (HR 0.33, 0.14-0.74) and in the adjusted (HR 0.39, 0.17-0.91) model but no benefit was observed in critical ICU-admitted patients both in the unadjusted (HR 0.66, 0.37-1.15) and in the adjusted model (HR 0.95, 0.54-1.68). CONCLUSIONS Our real-life study suggests clinical efficacy of TCZ in moderate-to-severe COVID-19 patients but not in end-stage disease. Thus, to enhance TCZ effectiveness, patients should be selected before grave compromise of clinical conditions.
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Affiliation(s)
| | - Andrea Matucci
- Unit of Immunoallergology, Careggi University Hospital, Florence, Italy
| | - Ersilia Lucenteforte
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Susanna Bormioli
- Unit of Immunoallergology, Careggi University Hospital, Florence, Italy
| | - Gianni Virgili
- Department of Ophthalmology, Careggi University Hospital, Florence, Italy
| | - Michele Trotta
- Unit of Infectious and Tropical Diseases, Department of Experimental and Clinical Medicine, Careggi University Hospital, Florence, Italy
| | - Michele Spinicci
- Unit of Infectious and Tropical Diseases, Department of Experimental and Clinical Medicine, Careggi University Hospital, Florence, Italy
| | - Alessandro Bartoloni
- Unit of Infectious and Tropical Diseases, Department of Experimental and Clinical Medicine, Careggi University Hospital, Florence, Italy
| | - Lorenzo Zammarchi
- Unit of Infectious and Tropical Diseases, Department of Experimental and Clinical Medicine, Careggi University Hospital, Florence, Italy
| | - Adriano Peris
- Intensive Care Unit, Regional ECMO Referral Center, Careggi University Hospital, Florence, Italy
| | - Filippo Pieralli
- Intermediate Care Unit, Careggi University Hospital, Florence, Italy
| | - Federico Lavorini
- Pneumology and Intensive Care Unit, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Paolo Fontanari
- Cardiac Anesthesia and Intensive Care Unit, Careggi University Hospital, Florence, Italy
| | | | - Carlo Nozzoli
- Internal Medicine Unit1, Careggi University Hospital, Florence, Italy
| | - Loredana Poggesi
- Internal Medicine Unit3, Careggi University Hospital, Florence, Italy
| | - Oliviero Rossi
- Unit of Immunoallergology, Careggi University Hospital, Florence, Italy
| | - Francesco Annunziato
- Department of Experimental and Clinical Medicine, Flow Cytometry Diagnostic Center, and Immunotherapy (CDCI), Careggi University Hospital, Florence, Italy
| | - Fabio Almerigogna
- Unit of Immunoallergology, Careggi University Hospital, Florence, Italy
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Dubowski K, Braganza GT, Bozack A, Colicino E, DeFelice N, McGuinn L, Maru D, Lee AG. COVID-19 subphenotypes at hospital admission are associated with mortality: a cross-sectional study. Ann Med 2023; 55:12-23. [PMID: 36444856 PMCID: PMC10795648 DOI: 10.1080/07853890.2022.2148733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 11/13/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND We have an incomplete understanding of COVID-19 characteristics at hospital presentation and whether underlying subphenotypes are associated with clinical outcomes and therapeutic responses. METHODS For this cross-sectional study, we extracted electronic health data from adults hospitalized between 1 March and 30 August 2020 with a PCR-confirmed diagnosis of COVID-19 at five New York City Hospitals. We obtained clinical and laboratory data from the first 24 h of the patient's hospitalization. Treatment with tocilizumab and convalescent plasma was assessed over hospitalization. The primary outcome was mortality; secondary outcomes included intubation, intensive care unit (ICU) admission and length of stay (LOS). First, we employed latent class analysis (LCA) to identify COVID-19 subphenotypes on admission without consideration of outcomes and assigned each patient to a subphenotype. We then performed robust Poisson regression to examine associations between COVID-19 subphenotype assignment and outcome. We explored whether the COVID-19 subphenotypes had a differential response to tocilizumab and convalescent plasma therapies. RESULTS A total of 4620 patients were included. LCA identified six subphenotypes, which were distinct by level of inflammation, clinical and laboratory derangements and ranged from a hypoinflammatory subphenotype with the fewest derangements to a hyperinflammatory with multiorgan dysfunction subphenotypes. Multivariable regression analyses found differences in risk for mortality, intubation, ICU admission and LOS, as compared to the hypoinflammatory subphenotype. For example, in multivariable analyses the moderate inflammation with fever subphenotype had 3.29 times the risk of mortality (95% CI 2.05, 5.28), while the hyperinflammatory with multiorgan failure subphenotype had 17.87 times the risk of mortality (95% CI 11.56, 27.63), as compared to the hypoinflammatory subphenotype. Exploratory analyses suggested that subphenotypes may differential respond to convalescent plasma or tocilizumab therapy. CONCLUSION COVID-19 subphenotype at hospital admission may predict risk for mortality, ICU admission and intubation and differential response to treatment.KEY MESSAGEThis cross-sectional study of COVID patients admitted to the Mount Sinai Health System, identified six distinct COVID subphenotypes on admission. Subphenotypes correlated with ICU admission, intubation, mortality and differential response to treatment.
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Affiliation(s)
- Kathryn Dubowski
- Division of Pulmonary, Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Giovanna T. Braganza
- School of Public Health, State University of New York, Downstate Health Sciences University, Brooklyn, NY, USA
| | - Anne Bozack
- School of Public Health, Environmental Health Sciences, University of California Berkeley, Berkeley, CA, USA
| | - Elena Colicino
- Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nicholas DeFelice
- Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Laura McGuinn
- Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Duncan Maru
- Department of Global Health, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alison G. Lee
- Division of Pulmonary, Critical Care and Sleep Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Li T, Wang D, Wei H, Xu X. Cytokine storm and translating IL-6 biology into effective treatments for COVID-19. Front Med 2023; 17:1080-1095. [PMID: 38157195 DOI: 10.1007/s11684-023-1044-4] [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: 05/15/2023] [Accepted: 10/23/2023] [Indexed: 01/03/2024]
Abstract
As of May 3, 2023, the Coronavirus disease 2019 (COVID-19) pandemic has resulted in more than 760 million confirmed cases and over 6.9 million deaths. Several patients have developed pneumonia, which can deteriorate into acute respiratory distress syndrome. The primary etiology may be attributed to cytokine storm, which is triggered by the excessive release of proinflammatory cytokines and subsequently leads to immune dysregulation. Considering that high levels of interleukin-6 (IL-6) have been detected in several highly pathogenic coronavirus-infected diseases, such as severe acute respiratory syndrome in 2002, the Middle East respiratory syndrome in 2012, and COVID-19, the IL-6 pathway has emerged as a key in the pathogenesis of this hyperinflammatory state. Thus, we review the history of cytokine storm and the process of targeting IL-6 signaling to elucidate the pivotal role played by tocilizumab in combating COVID-19.
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Affiliation(s)
- Tiantian Li
- Department of Geriatric Medicine, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230001, China
| | - Dongsheng Wang
- Respiratory and Critical Care Medicine, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230001, China
| | - Haiming Wei
- Institute of Immunology and the CAS Key Laboratory of Innate Immunity and Chronic Disease, School of Life Science and Medical Center, University of Science and Technology of China, Hefei, 230001, China
- Hefei National Laboratory for Physical Sciences at Microscale, University of Science and Technology of China, Hefei, 230001, China
| | - Xiaoling Xu
- Respiratory and Critical Care Medicine, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, 230001, China.
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26
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Keske Ş, Akyol M, Tanrıöver C, Özlüşen B, Akcan RE, Güler U, Sait B, Kaçmaz B, Gönen M, Ergönül Ö. Effectiveness of tocilizumab in non-intubated cases with COVID-19: a systematic review and meta-analysis. Infection 2023; 51:1619-1628. [PMID: 37162716 PMCID: PMC10170028 DOI: 10.1007/s15010-023-02047-2] [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: 10/02/2022] [Accepted: 05/03/2023] [Indexed: 05/11/2023]
Abstract
PURPOSE Tocilizumab, a monoclonal IL-6 receptor blocker, is an effective agent for severe-to-critical cases of COVID-19; however, its target patients for the optimum use need to be detailed. We performed a systematic review and meta-analysis to define its effect among severely ill but non-intubated cases with COVID-19. METHODS We searched PubMed, Scopus, Web of Science, MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), Medrxiv, and Biorxiv until February 13, 2022, for non-intubated cases, and included randomized-controlled trials (RCT) based on bias assessment. The primary outcomes were the requirement of invasive mechanical ventilation and mortality. Random effect and fixed-effect models were used. The heterogeneity was measured using the χ2 and I2 statistics, with χ2 p ≤ 0.05 and I2 ≥ 50% indicating the presence of significant heterogeneity. We registered the study to the International Prospective Register of Systematic Reviews (PROSPERO) with the registration number CRD42021232575. RESULTS Among 261 articles, 11 RCTs were included. The pooled analysis of the 11 RCTs demonstrated that the rate of mortality was significantly lower in the tocilizumab group than in the control group (20.0% and 24.2%, OR: 0.84, 95% CI 0.73-0.96, and heterogeneity I2 = 0%. p = 0.82.). The mechanical ventilation rate was lower in the tocilizumab group than the control group (27% vs 35.2%, OR: 0.76, 95% CI 0.67-0.86, and heterogeneity I2 = 6%. p = 0.39). CONCLUSION Among non-intubated severe COVID-19 cases, tocilizumab reduces the risk of invasive mechanical ventilation and mortality compared to standard-of-care treatment.
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Affiliation(s)
- Şiran Keske
- Department of Infectious Diseases and Clinical Microbiology, School of Medicine, Koç University, Davutpaşa Cd. No:4, Zeytinburnu, 34010, Istanbul, Turkey.
- Koç University Isbank Center for Infectious Diseases (KUISCID), Istanbul, Turkey.
| | - Merve Akyol
- Department of Infectious Diseases and Clinical Microbiology, School of Medicine, Koç University, Davutpaşa Cd. No:4, Zeytinburnu, 34010, Istanbul, Turkey
- Koç University Isbank Center for Infectious Diseases (KUISCID), Istanbul, Turkey
| | - Cem Tanrıöver
- Department of Infectious Diseases and Clinical Microbiology, School of Medicine, Koç University, Davutpaşa Cd. No:4, Zeytinburnu, 34010, Istanbul, Turkey
- Koç University Isbank Center for Infectious Diseases (KUISCID), Istanbul, Turkey
| | - Batu Özlüşen
- Department of Infectious Diseases and Clinical Microbiology, School of Medicine, Koç University, Davutpaşa Cd. No:4, Zeytinburnu, 34010, Istanbul, Turkey
- Koç University Isbank Center for Infectious Diseases (KUISCID), Istanbul, Turkey
| | - Rüştü Emre Akcan
- Department of Infectious Diseases and Clinical Microbiology, School of Medicine, Koç University, Davutpaşa Cd. No:4, Zeytinburnu, 34010, Istanbul, Turkey
- Koç University Isbank Center for Infectious Diseases (KUISCID), Istanbul, Turkey
| | - Ulaş Güler
- Department of Infectious Diseases and Clinical Microbiology, School of Medicine, Koç University, Davutpaşa Cd. No:4, Zeytinburnu, 34010, Istanbul, Turkey
- Koç University Isbank Center for Infectious Diseases (KUISCID), Istanbul, Turkey
| | - Bilgin Sait
- Department of Internal Medicine, American Hospital, Istanbul, Turkey
| | - Bahar Kaçmaz
- Department of Infectious Diseases, American Hospital, Istanbul, Turkey
| | - Mehmet Gönen
- Department of Infectious Diseases and Clinical Microbiology, School of Medicine, Koç University, Davutpaşa Cd. No:4, Zeytinburnu, 34010, Istanbul, Turkey
- Koç University Isbank Center for Infectious Diseases (KUISCID), Istanbul, Turkey
- Department of Industrial Engineering, College of Engineering, Koç University, Istanbul, Turkey
| | - Önder Ergönül
- Department of Infectious Diseases and Clinical Microbiology, School of Medicine, Koç University, Davutpaşa Cd. No:4, Zeytinburnu, 34010, Istanbul, Turkey
- Koç University Isbank Center for Infectious Diseases (KUISCID), Istanbul, Turkey
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27
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Colás-Algora N, Muñoz-Pinillos P, Cacho-Navas C, Avendaño-Ortiz J, de Rivas G, Barroso S, López-Collazo E, Millán J. Simultaneous Targeting of IL-1-Signaling and IL-6-Trans-Signaling Preserves Human Pulmonary Endothelial Barrier Function During a Cytokine Storm-Brief Report. Arterioscler Thromb Vasc Biol 2023; 43:2213-2222. [PMID: 37732482 DOI: 10.1161/atvbaha.123.319695] [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: 06/06/2023] [Accepted: 09/06/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND Systemic inflammatory diseases, such as sepsis and severe COVID-19, provoke acute respiratory distress syndrome in which the pathological hyperpermeability of the microvasculature, induced by uncontrolled inflammatory stimulation, causes pulmonary edema. Identifying the inflammatory mediators that induce human lung microvascular endothelial cell barrier dysfunction is essential to find the best anti-inflammatory treatments for critically ill acute respiratory distress syndrome patients. METHODS We have compared the responses of primary human lung microvascular endothelial cells to the main inflammatory mediators involved in cytokine storms induced by sepsis and SARS-CoV2 pulmonary infection and to sera from healthy donors and severely ill patients with sepsis. Endothelial barrier function was measured by electric cell-substrate impedance sensing, quantitative confocal microscopy, and Western blot. RESULTS The human lung microvascular endothelial cell barrier was completely disrupted by IL (interleukin)-6 conjugated with soluble IL-6R (IL-6 receptor) and by IL-1β (interleukin-1beta), moderately affected by TNF (tumor necrosis factor)-α and IFN (interferon)-γ and unaffected by other cytokines and chemokines, such as IL-6, IL-8, MCP (monocyte chemoattractant protein)-1 and MCP-3. The inhibition of IL-1 and IL-6R simultaneously, but not separately, significantly reduced endothelial hyperpermeability on exposing human lung microvascular endothelial cells to a cytokine storm consisting of 8 inflammatory mediators or to sera from patients with sepsis. Simultaneous inhibition of IL-1 and JAK (Janus kinase)-STAT (signal transducer and activator of transcription protein), a signaling node downstream IL-6 and IFN-γ, also prevented septic serum-induced endothelial barrier disruption. CONCLUSIONS These findings strongly suggest a major role for both IL-6 trans-signaling and IL-1β signaling in the pathological increase in permeability of the human lung microvasculature and reveal combinatorial strategies that enable the gradual control of pulmonary endothelial barrier function in response to a cytokine storm.
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Affiliation(s)
- Natalia Colás-Algora
- Centro de Biología Molecular Severo Ochoa, CSIC-UAM, Cantoblanco, Madrid, Spain (N.C.-A., P.M.-P., C.C.-N., G.d.R., S.B., J.M.)
| | - Pablo Muñoz-Pinillos
- Centro de Biología Molecular Severo Ochoa, CSIC-UAM, Cantoblanco, Madrid, Spain (N.C.-A., P.M.-P., C.C.-N., G.d.R., S.B., J.M.)
| | - Cristina Cacho-Navas
- Centro de Biología Molecular Severo Ochoa, CSIC-UAM, Cantoblanco, Madrid, Spain (N.C.-A., P.M.-P., C.C.-N., G.d.R., S.B., J.M.)
| | - José Avendaño-Ortiz
- The Innate Immune Response Group, IdiPAZ, La Paz University Hospital, Madrid, Spain (J.A.O., E.L.-C.)
- CIBER of Respiratory Diseases (CIBERES), Madrid, Spain (J.A.O., E.L.-C.)
| | - Gema de Rivas
- Centro de Biología Molecular Severo Ochoa, CSIC-UAM, Cantoblanco, Madrid, Spain (N.C.-A., P.M.-P., C.C.-N., G.d.R., S.B., J.M.)
| | - Susana Barroso
- Centro de Biología Molecular Severo Ochoa, CSIC-UAM, Cantoblanco, Madrid, Spain (N.C.-A., P.M.-P., C.C.-N., G.d.R., S.B., J.M.)
| | - Eduardo López-Collazo
- The Innate Immune Response Group, IdiPAZ, La Paz University Hospital, Madrid, Spain (J.A.O., E.L.-C.)
- CIBER of Respiratory Diseases (CIBERES), Madrid, Spain (J.A.O., E.L.-C.)
| | - Jaime Millán
- Centro de Biología Molecular Severo Ochoa, CSIC-UAM, Cantoblanco, Madrid, Spain (N.C.-A., P.M.-P., C.C.-N., G.d.R., S.B., J.M.)
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28
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Skarbinski J, Fischer H, Hong V, Liu L, Yau VM, Incerti D, Qian L, Ackerson BK, Amsden LB, Shaw SF, Tartof SY. Real-World Evidence to Supplement Randomized Clinical Trials: Tocilizumab for Severe COVID-19 Pneumonia vs. a Cohort Receiving Standard of Care. Clin Pharmacol Ther 2023; 114:1073-1081. [PMID: 37571812 DOI: 10.1002/cpt.3020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 08/01/2023] [Indexed: 08/13/2023]
Abstract
Randomized controlled trials (RCTs) remain the gold standard for evaluating treatment efficacy, but real-world evidence can supplement RCT results. Tocilizumab was not found to reduce 28-day mortality in a phase III, double-blind, placebo-controlled trial (COVACTA) among hospitalized patients with severe coronavirus disease 2019 (COVID-19) pneumonia. We created a real-world external comparator arm mirroring the COVACTA trial to confirm findings and assess the feasibility of using an external comparator arm to supplement an RCT. Eligible COVACTA participants in both the tocilizumab treatment and placebo arms were matched 1:1 using propensity score matching to persons without tocilizumab exposure in an external comparator arm. Adjusted Cox proportional hazard models estimated differences in 28-day mortality comparing COVACTA participants to matched external comparator arm participants. Patients in the COVACTA tocilizumab treatment arm had a similar risk of death compared with patients in the external comparator arm (hazard ratio (HR): 1.09, 95% confidence interval (CI): 0.64-1.84) with similar estimated 28-day mortality in the COVACTA tocilizumab treatment arm compared with the external comparator arm (18%, 95% CI: 13-24 vs. 19%, 95% CI: 13-24, P > 0.9). COVACTA placebo treatment arm participants had a similar risk of mortality (adjusted HR: 0.69, 95% CI: 0.32-1.46) compared with the external comparator arm. Using an external comparator arm has the potential to supplement RCT data and support results of primary RCT analyses.
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Affiliation(s)
- Jacek Skarbinski
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
- Department of Infectious Diseases, Oakland Medical Center, Kaiser Permanente Northern California, Oakland, California, USA
| | - Heidi Fischer
- Department of Research & Evaluation, Kaiser Permanente Southern California, California, Pasadena, USA
| | - Vennis Hong
- Department of Research & Evaluation, Kaiser Permanente Southern California, California, Pasadena, USA
| | - Liyan Liu
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Vincent M Yau
- Genentech, a Member of the Roche Group, South San Francisco, California, USA
| | - Devin Incerti
- Genentech, a Member of the Roche Group, South San Francisco, California, USA
| | - Lei Qian
- Department of Research & Evaluation, Kaiser Permanente Southern California, California, Pasadena, USA
| | - Bradley K Ackerson
- Southern California Permanente Medical Group, Harbor City, California, USA
| | - Laura B Amsden
- Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Sally F Shaw
- Department of Research & Evaluation, Kaiser Permanente Southern California, California, Pasadena, USA
| | - Sara Y Tartof
- Department of Research & Evaluation, Kaiser Permanente Southern California, California, Pasadena, USA
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
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29
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Aljuhani O, Al Sulaiman K, B Korayem G, Alharbi A, Altebainawi AF, Aldkheel SA, Alotaibi SG, Vishwakarma R, Alshareef H, Alsohimi S, AlFaifi M, Al Shaya A, Alhaidal HA, Alsubaie RM, Alrashidi H, Albarqi KJ, Alangari DT, Alanazi RM, Altaher NM, Al-Dorzi HM. The use of Tocilizumab in COVID-19 critically ill patients with renal impairment: a multicenter, cohort study. Ren Fail 2023; 45:2268213. [PMID: 37870869 PMCID: PMC11001317 DOI: 10.1080/0886022x.2023.2268213] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 10/03/2023] [Indexed: 10/24/2023] Open
Abstract
Tocilizumab (TCZ) is recommended in patients with COVID-19 who require oxygen therapy or ventilatory support. Despite the wide use of TCZ, little is known about its safety and effectiveness in patients with COVID-19 and renal impairment. Therefore, this study evaluated the safety and effectiveness of TCZ in critically ill patients with COVID-19 and renal impairment. A multicenter retrospective cohort study included all adult COVID-19 patients with renal impairment (eGFR˂60 mL/min) admitted to the ICUs between March 2020 and July 2021. Patients were categorized into two groups based on TCZ use (Control vs. TCZ). The primary endpoint was the development of acute kidney injury (AKI) during ICU stay. We screened 1599 patients for eligibility; 394 patients were eligible, and 225 patients were included after PS matching (1:2 ratio); there were 75 TCZ-treated subjects and 150 controls. The rate of AKI was higher in the TCZ group compared with the control group (72.2% versus 57.4%; p = 0.03; OR: 1.83; 95% CI: 1.01, 3.34; p = 0.04). Additionally, the ICU length of stay was significantly longer in patients who received TCZ (17.5 days versus 12.5 days; p = 0.006, Beta coefficient: 0.30 days, 95% CI: 0.09, 0.50; p = 0.005). On the other hand, the 30-day and in-hospital mortality were lower in patients who received TCZ compared to the control group (HR: 0.45, 95% CI: 0.27, 0.73; p = 0.01 and HR: 0.63, 95% CI: 0.41, 0.96; p = 0.03, respectively). The use of TCZ in this population was associated with a statistically significantly higher rate of AKI while improving the overall survival on the other hand. Further research is needed to assess the risks and benefits of TCZ treatment in critically ill COVID-19 patients with renal impairment.
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Affiliation(s)
- Ohoud Aljuhani
- Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - 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, Riyadh, Saudi Arabia
- Saudi Critical Care Pharmacy Research (SCAPE) Platform, Riyadh, Saudi Arabia
| | - Ghazwa B Korayem
- Department of Pharmacy Practice, College of Pharmacy, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Aisha Alharbi
- Pharmaceutical Care Department, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Ali F. Altebainawi
- Pharmaceutical Care Services, King Salman Specialist Hospital, Hail Health Cluster, Ministry of Health, Hail, Saudi Arabia
- Department of Clinical Pharmacy, College of Pharmacy, University of Hail, Hail, Saudi Arabia
| | - Shatha A. Aldkheel
- Department of Pharmacy Practice, College of Pharmacy, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Sarah G. Alotaibi
- Department of Pharmacy Practice, College of Pharmacy, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | | | - Hanan Alshareef
- Department of Pharmacy Practice, Faculty of Pharmacy, University of Tabuk, Tabuk, Saudi Arabia
| | - Samiah Alsohimi
- Pharmaceutical Care Services, King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia
- Pharmaceutical Care Services, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Mashael AlFaifi
- Pharmaceutical Care Department, King Saud Medical City, Riyadh, Saudi Arabia
| | - Abdulrahman Al Shaya
- 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, Riyadh, Saudi Arabia
| | - Haifa A. Alhaidal
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Raghad M. Alsubaie
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Hessah Alrashidi
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Khalid J. Albarqi
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Dalal T. Alangari
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Reem M. Alanazi
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Noora M. Altaher
- College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Hasan M. Al-Dorzi
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Intensive Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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30
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Marko M, Pawliczak R. Assessment of the available therapeutic approaches for severe COVID-19: a meta-analysis of randomized controlled trials. Sci Rep 2023; 13:17114. [PMID: 37816884 PMCID: PMC10564895 DOI: 10.1038/s41598-023-44463-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 10/09/2023] [Indexed: 10/12/2023] Open
Abstract
The study aimed to evaluate severe COVID-19 treatment approaches. We conducted a meta-analysis of randomized controlled trials (RTCs) with standard of care (SoC) as a control group and/or placebo. Database searching was performed separately for severe COVID-19 treatment such as anakinra, remdesivir, baricitinib, ivermectin, ritonavir, tocilizumab, sarilumab, sotrovimab, casirivimab/imdevimab. The results are presented as Risk Ratio (RR), 95% Confidence Interval (CI), and heterogeneity (I2). We obtained the most statistically significant outcomes favorable tocilizumab compared to SoC for death incidents RR 0.87 [95% CI 0.80, 0.95], overall effect p = 0.002, heterogeneity p = 0.85, I2 = 0%, need for mechanical ventilation RR 0.78 [95% CI 0.68, 0.89], overall effect p = 0.0004, heterogeneity p = 0.55, I2 = 0%, and number of patients discharged from hospital. RR 1.13 [95% CI 1.07, 1.20], overall effect p < 0.00001, heterogeneity p = 0.009, I2 = 85%. This meta-analysis has revealed that a considerable amount of research characterized by a very diverse methodology is available. Despite the limited data that met the criteria for inclusion in the meta-analysis, we showed that the available treatment options for severe COVID-19 are effective.
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Affiliation(s)
- Monika Marko
- Division of Biomedical Science, Department of Immunopathology, Faculty of Medicine, Medical University of Lodz, 7/9 Zeligowskiego St, 90-752, Lodz, Poland
| | - Rafał Pawliczak
- Division of Biomedical Science, Department of Immunopathology, Faculty of Medicine, Medical University of Lodz, 7/9 Zeligowskiego St, 90-752, Lodz, Poland.
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31
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Kolloli A, Ramasamy S, Kumar R, Nisa A, Kaplan G, Subbian S. A phosphodiesterase-4 inhibitor reduces lung inflammation and fibrosis in a hamster model of SARS-CoV-2 infection. Front Immunol 2023; 14:1270414. [PMID: 37854602 PMCID: PMC10580809 DOI: 10.3389/fimmu.2023.1270414] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 09/14/2023] [Indexed: 10/20/2023] Open
Abstract
Introduction The Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2) infection involves pulmonary inflammation that can progress to acute respiratory distress syndrome, a primary cause of lung damage/fibrosis in patients with Coronavirus Disease-2019 (COVID-19). Currently, there is no efficacious therapy available to alleviate lung fibrosis in COVID-19 cases. In this proof-of-concept study, we evaluated the effect of CC-11050, a small molecule phosphodiesterase-4 inhibitor, in dampening lung inflammation and fibrosis in a hamster model of SARS-CoV-2 infection. Methods Following intranasal inoculation with SARS-CoV-2/WA- 1/2000 strain, hamsters were treated with CC-11050 or placebo by gavage from day-1 until day-16 post-infection (dpi). Animals were monitored for body weight changes, virus titers, histopathology, fibrotic remodeling, cellular composition in the lungs between 2 and 16 dpi. Results We observed significant reduction in lung viral titer with concomitant reduction in inflammation and fibrotic remodeling in CC-11050 treated hamsters compared to untreated animals. The reductions in immunopathologic manifestations were associated with significant downregulation of inflammatory and fibrotic remodeling gene expression, reduced infiltration of activated monocytes, granulocytes, and reticular fibroblasts in CC-11050 treated animals. Cellular studies indicate a link between TNF-α and fibrotic remodeling during CC-11050 therapy. Discussion These findings suggest that CC-11050 may be a potential host-directed therapy to dampen inflammation and fibrosis in COVID-19 cases.
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Affiliation(s)
- Afsal Kolloli
- Public Health Research Institute (PHRI) at New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ, United States
| | - Santhamani Ramasamy
- Public Health Research Institute (PHRI) at New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ, United States
| | - Ranjeet Kumar
- Public Health Research Institute (PHRI) at New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ, United States
| | - Annuurun Nisa
- Public Health Research Institute (PHRI) at New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ, United States
| | - Gilla Kaplan
- University of Cape Town, Cape Town, South Africa
| | - Selvakumar Subbian
- Public Health Research Institute (PHRI) at New Jersey Medical School, Rutgers, The State University of New Jersey, Newark, NJ, United States
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32
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Madi K, Flumian C, Olivier P, Sommet A, Montastruc F. Quality of reporting of adverse events in clinical trials of covid-19 drugs: systematic review. BMJ MEDICINE 2023; 2:e000352. [PMID: 37779893 PMCID: PMC10537984 DOI: 10.1136/bmjmed-2022-000352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 06/27/2023] [Indexed: 10/03/2023]
Abstract
Objective To assess the quality of reporting of adverse events in clinical trials of covid-19 drugs based on the CONSORT (Consolidated Standards of Reporting Trials) harms extension and according to clinical trial design, and to examine reporting of serious adverse events in drug trials published on PubMed versus clinical trial summaries on ClinicalTrials.gov. Design Systematic review. Data sources PubMed and ClinicalTrials.gov registries were searched from 1 December 2019 to 17 February 2022. Eligibility criteria for selecting studies Randomised clinical trials evaluating the efficacy and safety of drugs used to treat covid-19 disease in participants of all ages with suspected, probable, or confirmed SARS-CoV-2 infection were included. Clinical trials were screened on title, abstract, and text by two authors independently. Only articles published in French and English were selected. The Cochrane risk of bias tool for randomised trials (RoB 2) was used to assess risk of bias. Results The search strategy identified 1962 randomised clinical trials assessing the efficacy and safety of drugs used to treat covid-19, published in the PubMed database; 1906 articles were excluded after screening and 56 clinical trials were included in the review. Among the 56 clinical trials, no study had a high score for quality of reporting of adverse events, 60.7% had a moderate score, 33.9% had a low score, and 5.4% had a very low score. All clinical trials with a very low score for quality of reporting of adverse events were randomised open label trials. For reporting of serious adverse events, journal articles published on PubMed under-reported 51% of serious adverse events compared with clinical trial summaries published on ClinicalTrials.gov. Conclusions In one in three published clinical trials on covid-19 drugs, the quality of reporting of adverse events was low or very low. Differences were found in the number of serious adverse events reported in journal articles versus clinical trial summaries. During the covid-19 pandemic, risk assessment of drugs in clinical trials of covid-19 drugs did not comply with good practice recommendations for publication of results. Systematic review registration European Network of Centres for Pharmacoepidemiology and Pharmacovigilance (ENCePP) EUPAS45959.
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Affiliation(s)
- Karima Madi
- CIC 1436, Team PEPSS (Pharmacologie En Population cohorteS et biobanqueS), Toulouse University Hospital, Toulouse, France
| | - Clara Flumian
- CIC 1436, Team PEPSS (Pharmacologie En Population cohorteS et biobanqueS), Toulouse University Hospital, Toulouse, France
- Department of Medical and Clinical Pharmacology, Centre of PharmacoVigilance and Pharmacoepidemiology, Faculty of Medicine, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Pascale Olivier
- Department of Medical and Clinical Pharmacology, Centre of PharmacoVigilance and Pharmacoepidemiology, Faculty of Medicine, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Agnès Sommet
- CIC 1436, Team PEPSS (Pharmacologie En Population cohorteS et biobanqueS), Toulouse University Hospital, Toulouse, France
- Department of Medical and Clinical Pharmacology, Centre of PharmacoVigilance and Pharmacoepidemiology, Faculty of Medicine, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - François Montastruc
- CIC 1436, Team PEPSS (Pharmacologie En Population cohorteS et biobanqueS), Toulouse University Hospital, Toulouse, France
- Department of Medical and Clinical Pharmacology, Centre of PharmacoVigilance and Pharmacoepidemiology, Faculty of Medicine, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
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Milošević I, Barać A, Jovanović J, Vujović A, Stevanović G, Todorović N, Milošević B. A single-center experience of early administration of tocilizumab and corticosteroids in patients with COVID-19 pneumonia. Trans R Soc Trop Med Hyg 2023; 117:668-672. [PMID: 37103332 DOI: 10.1093/trstmh/trad026] [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: 08/24/2022] [Revised: 02/16/2023] [Accepted: 04/12/2023] [Indexed: 04/28/2023] Open
Abstract
BACKGROUND We investigated the therapeutic response of tocilizumab (TCZ) therapy in patients with coronavirus disease 2019 (COVID-19) pneumonia. METHODS This observational retrospective study included 205 patients with confirmed COVID-19 pneumonia with SpO2˂93% and a markedly increased level of at least two biomarkers of inflammation. The TCZ was given in combination with corticosteroids. Clinical and laboratory results were analyzed and compared before TCZ therapy and 7 d after. RESULTS The mean value of C-reactive protein (CRP) was significantly lower (p=0.001) on the seventh day after administration of TCZ compared with before (10.7 and 173.6 mg/L, respectively). Only in 9/205 (4.3%) patients, the CRP level did not decrease during the week-long period, and this was related to disease progression. The mean level of interleukin-6 before TCZ administration was 88±113 pg/mL, while after it was 32.7±21.7 pg/mL (p=0.01). After 7 d of TCZ therapy, almost 50% of patients who needed high-flow oxygen or ventilation support started to receive low-flow oxygen, while 73/205 (35.6%) patients who received low-flow oxygen before TCZ administration did not receive further oxygen support anymore (p=0.001). Although they received TCZ treatment, 38/205 (18.5%) severely sick patients died. CONCLUSIONS Tocilizumab improves clinical outcomes in hospitalized COVID-19 patients. These advantages were evident independent of the patient's comorbidities and were in addition to the advantages of systemic corticosteroids. In COVID-19 patients at risk of cytokine storms, TCZ appears to be an effective therapy choice.
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Affiliation(s)
- Ivana Milošević
- Clinic for Infectious and Tropical Diseases, University Clinical Center of Serbia, Bul. Oslobodjenja 16, 11000 Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Dr Subotica 1, 11000 Belgrade , Serbia
| | - Aleksandra Barać
- Clinic for Infectious and Tropical Diseases, University Clinical Center of Serbia, Bul. Oslobodjenja 16, 11000 Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Dr Subotica 1, 11000 Belgrade , Serbia
| | - Jaroslava Jovanović
- Clinic for Infectious and Tropical Diseases, University Clinical Center of Serbia, Bul. Oslobodjenja 16, 11000 Belgrade, Serbia
| | - Ankica Vujović
- Clinic for Infectious and Tropical Diseases, University Clinical Center of Serbia, Bul. Oslobodjenja 16, 11000 Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Dr Subotica 1, 11000 Belgrade , Serbia
| | - Goran Stevanović
- Clinic for Infectious and Tropical Diseases, University Clinical Center of Serbia, Bul. Oslobodjenja 16, 11000 Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Dr Subotica 1, 11000 Belgrade , Serbia
| | - Nevena Todorović
- Clinic for Infectious and Tropical Diseases, University Clinical Center of Serbia, Bul. Oslobodjenja 16, 11000 Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Dr Subotica 1, 11000 Belgrade , Serbia
| | - Branko Milošević
- Clinic for Infectious and Tropical Diseases, University Clinical Center of Serbia, Bul. Oslobodjenja 16, 11000 Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Dr Subotica 1, 11000 Belgrade , Serbia
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Burger BJ, Epps SM, Cardenas VM, Jagana R, Meena NK, Atchley WT. Tocilizumab Is Associated with Increased Risk of Fungal Infections among Critically Ill Patients with COVID-19 and Acute Renal Failure: An Observational Cohort Study. Life (Basel) 2023; 13:1752. [PMID: 37629609 PMCID: PMC10455962 DOI: 10.3390/life13081752] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 08/09/2023] [Accepted: 08/10/2023] [Indexed: 08/27/2023] Open
Abstract
RESEARCH QUESTION Does treatment with tocilizumab increase the risk of a fungal infection in critically ill patients with coronavirus-19? BACKGROUND Numerous therapies have been evaluated as possible treatments for coronavirus-2019 caused by severe acute respiratory syndrome coronavirus-2. Tocilizumab is a humanized monoclonal antibody directed against the interleukin-6 receptor that has found a role as a therapy for patients with severe coronavirus-19 pneumonia. The immunomodulatory effects of tocilizumab may have the unintended consequence of predisposing recipients to secondary infections. We sought to assess the risk of invasive fungal disease and the therapeutic impact of tocilizumab on the hospital length of stay, duration of mechanical ventilation, and intensive-care-unit length of stay in critically ill patients with severe coronavirus-19 pneumonia. METHODS Records of critically ill patients with coronavirus-2019 admitted from March to September 2020 at our institution were reviewed. The risk for fungal infections, intensive-care-unit length of stay, hospital length of stay, and duration of mechanical ventilation in those that received tocilizumab in addition to standard coronavirus-2019 treatments was assessed. RESULTS Fifty-six critically ill patients treated with dexamethasone and remdesivir for coronavirus-2019 were included, of which 16 patients also received tocilizumab. The majority of the cohort was African American, Asian, or of other ethnic minorities (53.6%). Invasive fungal infections occurred in 10.7% of all patients, and infection rates were significantly higher in the tocilizumab group than in the control group (31.2% vs. 2.5%, risk difference [RD] = 28.8%, p < 0.01). The increased risk in the tocilizumab group was strongly associated with renal replacement therapy. There was a dose-response relationship between the risk of fungal infection and number of tocilizumab doses received, with 2.5% of infections occurring with zero doses, 20% with a single dose (RD = 17.5%), and 50% with two doses (RD = 47.5%) (trend test p < 0.001). In addition, ICU LOS (23.4 days vs. 9.0 days, p < 0.01), the duration of mechanical ventilation (18.9 vs. 3.5 days, p = 0.01), and hospital length of stay (LOS) (29.1 vs. 15.5, p < 0.01) were increased in patients that received tocilizumab. CONCLUSIONS Repurposed immunomodulator therapies, such as tocilizumab, are now recommended treatments for severe coronavirus-2019 pneumonia, but safety concerns remain. In this early pandemic cohort, the addition of tocilizumab to dexamethasone was associated with an increased risk of fungal infection in those that were critically ill and received renal replacement therapy. Tocilizumab use was also associated with increased ICU and hospital LOSs and duration of mechanical ventilation.
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Affiliation(s)
- Barrett J. Burger
- Division of Pulmonary and Critical Care Medicine, University of Arkansas for Medical Sciences, 4301 West Markham Street, Little Rock, AR 72205, USA; (S.M.E.); (N.K.M.)
| | - Sarenthia M. Epps
- Division of Pulmonary and Critical Care Medicine, University of Arkansas for Medical Sciences, 4301 West Markham Street, Little Rock, AR 72205, USA; (S.M.E.); (N.K.M.)
| | - Victor M. Cardenas
- Department of Epidemiology, University of Arkansas for Medical Sciences, 4301 West Markham Street, Little Rock, AR 72205, USA
| | - Rajani Jagana
- Division of Pulmonary and Critical Care Medicine, University of Arkansas for Medical Sciences, 4301 West Markham Street, Little Rock, AR 72205, USA; (S.M.E.); (N.K.M.)
| | - Nikhil K. Meena
- Division of Pulmonary and Critical Care Medicine, University of Arkansas for Medical Sciences, 4301 West Markham Street, Little Rock, AR 72205, USA; (S.M.E.); (N.K.M.)
| | - William T. Atchley
- Division of Pulmonary and Critical Care Medicine, University of Arkansas for Medical Sciences, 4301 West Markham Street, Little Rock, AR 72205, USA; (S.M.E.); (N.K.M.)
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Barbosa AN, Chebabo A, Starling C, Pérez C, Cunha CA, de Luna D, Nunes EP, Zambrano G, Ferreira JC, Croda J, Falavigna M, Gomes-da-Silva MM, Thormann M, Cimerman S, Parahiba SM, Tanni S, Bernardo WM, Rodriguez-Morales AJ. Pan-American Guidelines for the treatment of SARS-CoV-2/COVID-19: a joint evidence-based guideline of the Brazilian Society of Infectious Diseases (SBI) and the Pan-American Association of Infectious Diseases (API). Ann Clin Microbiol Antimicrob 2023; 22:67. [PMID: 37550690 PMCID: PMC10408214 DOI: 10.1186/s12941-023-00623-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 07/28/2023] [Indexed: 08/09/2023] Open
Abstract
BACKGROUND Since the beginning of the COVID-19 pandemic, therapeutic options for treating COVID-19 have been investigated at different stages of clinical manifestations. Considering the particular impact of COVID-19 in the Americas, this document aims to present recommendations for the pharmacological treatment of COVID-19 specific to this population. METHODS Fifteen experts, members of the Brazilian Society of Infectious Diseases (SBI) and the Pan-American Association of Infectious Diseases (API) make up the panel responsible for developing this guideline. Questions were formulated regarding prophylaxis and treatment of COVID-19 in outpatient and inpatient settings. The outcomes considered in decision-making were mortality, hospitalisation, need for mechanical ventilation, symptomatic COVID-19 episodes, and adverse events. In addition, a systematic review of randomised controlled trials was conducted. The quality of evidence assessment and guideline development process followed the GRADE system. RESULTS Nine technologies were evaluated, and ten recommendations were made, including the use of tixagevimab + cilgavimab in the prophylaxis of COVID-19, tixagevimab + cilgavimab, molnupiravir, nirmatrelvir + ritonavir, and remdesivir in the treatment of outpatients, and remdesivir, baricitinib, and tocilizumab in the treatment of hospitalised patients with severe COVID-19. The use of hydroxychloroquine or chloroquine and ivermectin was discouraged. CONCLUSION This guideline provides recommendations for treating patients in the Americas following the principles of evidence-based medicine. The recommendations present a set of drugs that have proven effective in the prophylaxis and treatment of COVID-19, emphasising the strong recommendation for the use of nirmatrelvir/ritonavir in outpatients as the lack of benefit from the use of hydroxychloroquine and ivermectin.
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Affiliation(s)
- Alexandre Naime Barbosa
- Infectious Diseases Department - Botucatu School of Medicine - UNESP, Av. Prof. Mário R. G. Montenegro, s/n, Botucatu, SP, CEP 18.618-687, Brazil.
- Universidade Estadual Paulista, Julio de Mesquita Filho, Distrito de Rubiao Jr, s/n, Botucatu, SP, CEP 18618-970, Brazil.
| | - Alberto Chebabo
- Universidade Federal do Rio de Janeiro, Avenida Professor Rodolpho Paulo Rocco, 255, 50. Andar, Rio de Janeiro, RJ, CEP 21941-913, Brazil
- Brazilian Society for Infectious Diseases, Rua Teixeira da Silva, 660, São Paulo, SP, CEP 04002-033, Brazil
| | - Carlos Starling
- Sociedade Mineira de Infectologia - SMI, Avenida João Pinheiro, 161, Belo Horizonte, MG, CEP 30130-180, Brazil
| | - Clevy Pérez
- Universidad Autónoma de Santo Domingo (UASD), Avenida Simón Bolívar, 902, Santo Domingo, 10108, República Dominicana
| | - Clóvis Arns Cunha
- Brazilian Society for Infectious Diseases, Rua Teixeira da Silva, 660, São Paulo, SP, CEP 04002-033, Brazil
- Universidade Federal do Paraná, Rua XV de Novembro, 1299, Curitiba, PR, CEP 80060-000, Brazil
| | - David de Luna
- Comisión Nacional de Arbitraje Médico, C Mitla, 250, Ciudad de México, 03020, México
| | - Estevão Portela Nunes
- Instituto Nacional de Infectologia (INI), Fiocruz, Avenida Brasil, 4365, Rio de Janeiro, RJ, CEP 21040-360, Brazil
| | - Gabriela Zambrano
- Faculty of Medicine, Department of Infectious Diseases, Universidad Central del Ecuador, Quito, Ecuador
- Pontificia Universidad Católica del Ecuador, Facultad de Medicina, Posgrado de Medicina Interna, Quito, Ecuador
| | - Juliana Carvalho Ferreira
- Divisão de Pneumologia, Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Universidade de São Paulo, Avenida Dr. Enéas Carvalho de Aguiar, 44, São Paulo, SP, CEP 05403-900, Brazil
- Intensive Care Unit, AC Camargo Cancer Center, Rua Prof. Antônio Prudente, 211, São Paulo, SP, CEP 01509-001, Brazil
| | - Julio Croda
- Oswaldo Cruz Foundation, Avenida Costa e Silva, s/n, Cidade Universitária, Campo Grande, MS, CEP 79070-900, Brazil
| | - Maicon Falavigna
- HTAnalyze Consulting and Training, Rua João Abbott, 109, Porto Alegre, RS, CEP 90460-150, Brazil
| | - Monica Maria Gomes-da-Silva
- Infectious Disease Control Service, Clinical Hospital, Universidade Federal Do Paraná, Rua General Carneiro, 181, Curitiba, PR, CEP 80060-900, Brazil
| | - Monica Thormann
- Hospital Salvador Bienvenido Gautier, Calle Alexander Fleming, 177, Santo Domingo, 10514, Dominican Republic
| | - Sergio Cimerman
- Brazilian Society for Infectious Diseases, Rua Teixeira da Silva, 660, São Paulo, SP, CEP 04002-033, Brazil
- Institute of Infectious Diseases Emilio Ribas, Avenida Dr. Arnaldo, 165, São Paulo, SP, CEP 05402-000, Brazil
| | - Suena Medeiros Parahiba
- HTAnalyze Consulting and Training, Rua João Abbott, 109, Porto Alegre, RS, CEP 90460-150, Brazil
| | - Suzana Tanni
- Universidade Estadual Paulista, Julio de Mesquita Filho, Distrito de Rubiao Jr, s/n, Botucatu, SP, CEP 18618-970, Brazil
| | - Wanderley Marques Bernardo
- Medical Education Development Center (CEDEM) of Medical Faculty of São Paulo University (FMUSP), São Paulo, SP, Brazil
| | - Alfonso J Rodriguez-Morales
- Grupo de Investigación Biomedicina, Faculty of Medicine, Fundación Universitaria Autónoma de Las Américas-Institución Universitaria Visión de Las Américas, 660003, Pereira, Risaralda, Colombia.
- Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, Universidad Científica del Sur, Lima, 4861, Peru.
- Gilbert and Rose-Marie Chagoury School of Medicine, Lebanese American University, P.O. Box 36, Beirut, Lebanon.
- Latin American Network of Coronavirus Disease 2019 - COVID-19 Research (LANCOVID-19), Pereira, Risaralda, Colombia.
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Wendler A, Wehling M. Translatability scoring in prospective and retrospective COVID drug development cases. Eur J Clin Pharmacol 2023; 79:1051-1071. [PMID: 37278822 PMCID: PMC10243273 DOI: 10.1007/s00228-023-03517-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 05/24/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND The ongoing pandemic of severe acute respiratory syndrome coronavirus 2 has led to an enormous surge of clinical research. So far, the speed and success rate of related drug development projects, especially of vaccines, is unprecedented. For the first time, this situation allowed for the opportunistic evaluation of a translatability score, originally proposed in 2009, in a prospective manner. METHODS Several vaccines and treatments under development in clinical phase III trials were selected for translational scoring with the translatability score. Six prospective and six retrospective case studies were performed. The scores had to be determined for a fictive date before any results of the phase III trial were reported in any media. Spearman correlation analysis and a Kruskal Wallis test were performed for statistical evaluation. RESULTS A significant correlation between the translatability scores and the clinical outcomes in translation was found, as judged on the basis of positive/intermediate/negative endpoint studies or market approval. The Spearman correlation analysis of all cases (r = 0.91, p < 0.001), the prospective cases alone (r = 0.93, p = 0.008), and the retrospective cases alone (r = 0.93, p = 0.008) showed a strong correlation between the score and outcome; R2 demonstrated a score-derived determination of outcomes by 86%. CONCLUSIONS The score detects strengths and weaknesses of a given project, resulting in the opportunity of selective amelioration of a project, as well as prospective portfolio risk balancing. Its substantial predictive value that has been demonstrated here for the first time could be of particular interest for biomedical industry (pharmaceutical and device manufacturers), funding agencies, venture capitalists, and researchers in the area. Future evaluations will have to address the generalizability of results obtained in an exceptional pandemic situation, and the potential adaptations of weighing factors/items to particular therapeutic areas.
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Affiliation(s)
- Alexandra Wendler
- Clinical Pharmacology, Faculty of Medicine, Ruprecht-Karls-University of Heidelberg, 68167, Mannheim, Germany
| | - Martin Wehling
- Clinical Pharmacology, Faculty of Medicine, Ruprecht-Karls-University of Heidelberg, 68167, Mannheim, Germany.
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Metry A, Pandor A, Ren S, Shippam A, Clowes M, Dark P, McMullan R, Stevenson M. Cost-effectiveness of therapeutics for COVID-19 patients: a rapid review and economic analysis. Health Technol Assess 2023; 27:1-92. [PMID: 37840452 PMCID: PMC10591210 DOI: 10.3310/nafw3527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2023] Open
Abstract
Background Severe acute respiratory syndrome coronavirus 2 is the virus that causes coronavirus disease 2019. Over six million deaths worldwide have been associated with coronavirus disease 2019. Objective To assess the cost-effectiveness of treatments used for the treatment of coronavirus disease 2019 in hospital or used in the community in patients with coronavirus disease 2019 at high risk of hospitalisation. Setting Treatments provided in United Kingdom hospital and community settings. Methods Clinical effectiveness estimates were taken from the coronavirus disease-network meta-analyses initiative and the metaEvidence initiative. A mathematical model was constructed to explore how the interventions impacted on patient health, measured in quality-adjusted life-years gained. The costs associated with treatment, including those of hospital care, were also estimated and used to form a cost per quality-adjusted life-year gained value which was compared with thresholds published by the National Institute for Health and Care Excellence. Estimates of cost-effectiveness compared against current standard of care were produced in both the hospital and community settings at three different levels of efficacy: mean, low and high. Public list prices were used for interventions with neither confidential patient access schemes nor confidential list prices considered. Results incorporating confidential pricing data were provided to the National Institute for Health and Care Excellence appraisal committee. Results The treatments were estimated to be clinically effective although not all reached statistical significance. All treatments in the hospital setting, or community, were estimated to plausibly have a cost per quality-adjusted life-year gained value below National Institute for Health and Care Excellence's thresholds when compared with standard of care. However, almost all drugs could plausibly have cost per quality-adjusted life-years above National Institute for Health and Care Excellence's thresholds. However, there is considerable uncertainty in the results as the prevalent severe acute respiratory syndrome coronavirus 2 variant, vaccination status, history of being infected with severe acute respiratory syndrome coronavirus 2 and standard of care have all evolved since the pivotal studies were conducted which could have significant impact on the efficacy of each drug. For drugs used in high-risk patients in the community setting, the proportion of people at high risk who need hospital admission was a large driver of the cost per quality-adjusted life-year. Limitations No studies were identified that were conducted in current conditions. This may be a large limitation as the severe acute respiratory syndrome coronavirus 2 variant changes. No head-to-head studies of interventions were identified. Conclusions The results produced could be informative to decision-makers, although conclusions regarding the most clinical - and cost-effectiveness of each intervention should be tentative due to the evolving nature of the decision problem and, in this report, the use of list prices only. Comparisons between interventions should also be treated with caution due to potentially large heterogeneity between studies. Future work Research assessing the relative clinical effectiveness of interventions within head-to-head studies in current conditions would be beneficial. Contemporary information related to the probability of hospital admission and death for patients at high risk in the community would improve the precision of the estimates generated. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Evidence Synthesis programme (NIHR135564) and will be published in full in Health Technology Assessment; Vol. 27, No. 14. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Andrew Metry
- School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK
| | - Abdullah Pandor
- School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK
| | - Shijie Ren
- School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK
| | - Andrea Shippam
- School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK
| | - Mark Clowes
- School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK
| | - Paul Dark
- The University of Manchester, Manchester, UK
| | - Ronan McMullan
- School of Medicine, Dentistry and Biomedical Sciences, Wellcome Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Matt Stevenson
- School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK
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Peng R, Yang T, Tong Y, Wang J, Zhou H, Yang M, Zhu J, Yang L, Shi Z, Liu Y. Efficacy and safety of interleukin-6 receptor antagonists in adult patients admitted to intensive care unit with COVID-19: A systematic review and meta-analysis of randomized controlled trials. Prev Med Rep 2023; 34:102276. [PMID: 37309358 PMCID: PMC10247142 DOI: 10.1016/j.pmedr.2023.102276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/01/2023] [Accepted: 06/03/2023] [Indexed: 06/14/2023] Open
Abstract
The purpose of the systematic review was to evaluate the efficacy and safety of interleukin-6 receptor (IL-6) antagonists (tocilizumab, sarilumab) in adult patients with severe or critical COVID-19. A systematic review of the literature was conducted in Medline, Cochrane and Embase databases, and World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov from the inception dates to10 January 2023. Randomized clinical trials comparing IL-6 receptor antagonists (tocilizumab, sarilumab) with a placebo or usual care treatment for adult patients with severe or critical COVID-19 were identified. Two independent reviewers performed the assessment and selection of eligible studies, assessed study quality and extracted data. Relative risk (RR), mean difference (MD), and 95% confidence interval (CI) with random-effects models was performed in meta-analysis. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology was used to assess the quality of the evidence. The search retrieved a total of 11 RCTs involving 5028 participants were eligible for meta-analysis. Our findings suggest that as the new drug used in adult patients with severe or critical COVID-19, IL-6 antagonists (tocilizumab, sarilumab) may reduce the length of ICU stay and hospital stay. However, they did not significantly increase the risks of serious adverse events and did not reduce all-cause mortality (28-day, 14-day, and 7-day).
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Affiliation(s)
- Rong Peng
- Clinical Medical College & Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Ting Yang
- College of Pharmacy, Zunyi Medical University, Zunyi, Guizhou, China
- Clinical Medical College & Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Yu Tong
- Clinical Medical College & Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Ji Wang
- Clinical Medical College & Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Hui Zhou
- Clinical Medical College & Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Minglong Yang
- Clinical Medical College & Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Junchen Zhu
- Clinical Medical College & Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Lijun Yang
- Clinical Medical College & Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Zheng Shi
- Clinical Medical College & Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Ya Liu
- Clinical Medical College & Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
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Guo TJF, Singhera GK, Leung JM, Dorscheid DR. Airway Epithelial-Derived Immune Mediators in COVID-19. Viruses 2023; 15:1655. [PMID: 37631998 PMCID: PMC10458661 DOI: 10.3390/v15081655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 07/17/2023] [Accepted: 07/21/2023] [Indexed: 08/27/2023] Open
Abstract
The airway epithelium, which lines the conducting airways, is central to the defense of the lungs against inhaled particulate matter and pathogens such as SARS-CoV-2, the virus that causes COVID-19. Recognition of pathogens results in the activation of an innate and intermediate immune response which involves the release of cytokines and chemokines by the airway epithelium. This response can inhibit further viral invasion and influence adaptive immunity. However, severe COVID-19 is characterized by a hyper-inflammatory response which can give rise to clinical presentations including lung injury and lead to acute respiratory distress syndrome, viral pneumonia, coagulopathy, and multi-system organ failure. In response to SARS-CoV-2 infection, the airway epithelium can mount a maladaptive immune response which can delay viral clearance, perpetuate excessive inflammation, and contribute to the pathogenesis of severe COVID-19. In this article, we will review the barrier and immune functions of the airway epithelium, how SARS-CoV-2 can interact with the epithelium, and epithelial-derived cytokines and chemokines and their roles in COVID-19 and as biomarkers. Finally, we will discuss these immune mediators and their potential as therapeutic targets in COVID-19.
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Affiliation(s)
- Tony J. F. Guo
- Centre for Heart Lung Innovation, Providence Healthcare Research Institute, St. Paul’s Hospital, University of British Columbia, 1081 Burrard St., Vancouver, BC V6Z 1Y6, Canada
| | - Gurpreet K. Singhera
- Centre for Heart Lung Innovation, Providence Healthcare Research Institute, St. Paul’s Hospital, University of British Columbia, 1081 Burrard St., Vancouver, BC V6Z 1Y6, Canada
- Department of Medicine, University of British Columbia, 2775 Laurel St., Vancouver, BC V5Z 1M9, Canada
| | - Janice M. Leung
- Centre for Heart Lung Innovation, Providence Healthcare Research Institute, St. Paul’s Hospital, University of British Columbia, 1081 Burrard St., Vancouver, BC V6Z 1Y6, Canada
- Department of Medicine, University of British Columbia, 2775 Laurel St., Vancouver, BC V5Z 1M9, Canada
| | - Delbert R. Dorscheid
- Centre for Heart Lung Innovation, Providence Healthcare Research Institute, St. Paul’s Hospital, University of British Columbia, 1081 Burrard St., Vancouver, BC V6Z 1Y6, Canada
- Department of Medicine, University of British Columbia, 2775 Laurel St., Vancouver, BC V5Z 1M9, Canada
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Chen S, Zhang C, Chen D, Dong L, Chang T, Tang ZH. Advances in attractive therapeutic approach for macrophage activation syndrome in COVID-19. Front Immunol 2023; 14:1200289. [PMID: 37483597 PMCID: PMC10358730 DOI: 10.3389/fimmu.2023.1200289] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 06/12/2023] [Indexed: 07/25/2023] Open
Abstract
Nowadays, people have relaxed their vigilance against COVID-19 due to its declining infection numbers and attenuated virulence. However, COVID-19 still needs to be concern due to its emerging variants, the relaxation of restrictions as well as breakthrough infections. During the period of the COVID-19 infection, the imbalanced and hyper-responsive immune system plays a critical role in its pathogenesis. Macrophage Activation Syndrome (MAS) is a fatal complication of immune system disease, which is caused by the excessive activation and proliferation of macrophages and cytotoxic T cells (CTL). COVID-19-related hyperinflammation shares common clinical features with the above MAS symptoms, such as hypercytokinemia, hyperferritinemia, and coagulopathy. In MAS, immune exhaustion or defective anti-viral responses leads to the inadequate cytolytic capacity of CTL which contributes to prolonged interaction between CTL, APCs and macrophages. It is possible that the same process also occurred in COVID-19 patients, and further led to a cytokine storm confined to the lungs. It is associated with the poor prognosis of severe patients such as multiple organ failure and even death. The main difference of cytokine storm is that in COVID-19 pneumonia is mainly the specific damage of the lung, while in MAS is easy to develop into a systemic. The attractive therapeutic approach to prevent MAS in COVID-19 mainly includes antiviral, antibiotics, convalescent plasma (CP) therapy and hemadsorption, extensive immunosuppressive agents, and cytokine-targeted therapies. Here, we discuss the role of the therapeutic approaches mentioned above in the two diseases. And we found that the treatment effect of the same therapeutic approach is different.
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Affiliation(s)
- Shunyao Chen
- Department of Trauma Surgery, Emergency Surgery & Surgical Critical, Tongji Trauma Center, Wuhan, China
- Department of Emergency and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Cong Zhang
- Department of Trauma Surgery, Emergency Surgery & Surgical Critical, Tongji Trauma Center, Wuhan, China
- Department of Emergency and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Deng Chen
- Department of Trauma Surgery, Emergency Surgery & Surgical Critical, Tongji Trauma Center, Wuhan, China
- Department of Emergency and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Liming Dong
- Department of Trauma Surgery, Emergency Surgery & Surgical Critical, Tongji Trauma Center, Wuhan, China
- Department of Emergency and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Teding Chang
- Department of Trauma Surgery, Emergency Surgery & Surgical Critical, Tongji Trauma Center, Wuhan, China
- Department of Emergency and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Zhao-Hui Tang
- Department of Trauma Surgery, Emergency Surgery & Surgical Critical, Tongji Trauma Center, Wuhan, China
- Department of Emergency and Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Flisiak R, Flisiak-Jackiewicz M, Rzymski P, Zarębska-Michaluk D. Tocilizumab for the treatment of COVID-19. Expert Rev Anti Infect Ther 2023; 21:791-797. [PMID: 37326214 DOI: 10.1080/14787210.2023.2226867] [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: 03/26/2023] [Accepted: 06/14/2023] [Indexed: 06/17/2023]
Abstract
INTRODUCTION Since the beginning of the COVID-19 pandemic, the repurposing of medicines has been pursued to find interventions effective in preventing fatal outcome of the disease. One of these drugs was tocilizumab, an interleukin-6 inhibiting monoclonal antibody, previously used to treat several immune-related disorders. AREAS COVERED In this article, we present the results of the initial observational studies and subsequent randomized clinical trials on the efficacy and safety of tocilizumab in the treatment of COVID-19. Despite conflicting results, possibly due to the heterogeneity of the studied populations, large studies have ultimately proven that preventing IL-6 from attaching to its receptors can effectively reverse the fatal course of the disease. We also discuss the meta-analyses, which mostly supported the validity of tocilizumab therapy. We show how tocilizumab found its place in the most important recommendations on COVID-19 treatment and obtained authorization from the major regulatory authorities. EXPERT OPINION The criteria for optimizing tocilizumab therapy in COVID-19 still need to be established. They are also important considering the existing risks of future zoonotic spillovers and epidemics that may trigger hyperinflammation that could be efficiently blocked. The experience gained with tocilizumab shall be perceived as preparedness for future challenges.
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Affiliation(s)
- Robert Flisiak
- Department of Infectious Diseases and Hepatology, Medical University of Białystok, Białystok, Poland
| | - Marta Flisiak-Jackiewicz
- Department of Pediatrics, Gastroenterology, Hepatology, Nutrition and Allergology, Medical University of Bialystok, Bialystok, Poland
| | - Piotr Rzymski
- Department of Environmental Medicine, Poznan University of Medical Sciences, Poznań, Poland
- Integrated Science Association (ISA), Universal Scientific Education and Research Network (USERN), Poznań, Poland
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Kyriazopoulou E, Giamarellos-Bourboulis EJ, Akinosoglou K. Biomarkers to guide immunomodulatory treatment: where do we stand? Expert Rev Mol Diagn 2023; 23:945-958. [PMID: 37691280 DOI: 10.1080/14737159.2023.2258063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 08/20/2023] [Accepted: 09/08/2023] [Indexed: 09/12/2023]
Abstract
INTRODUCTION This review summarizes current progress in the development of biomarkers to guide immunotherapy in oncology, rheumatology, and critical illness. AREAS COVERED An extensive literature search was performed about biomarkers classifying patients' immune responses to guide immunotherapy in oncology, rheumatology, and critical illness. Surface markers, such as programmed death-ligand 1 (PD-L1), genetic biomarkers, such as tumor mutation load, and circulating tumor DNA are biomarkers associated with the effectiveness of immunotherapy in oncology. Genomics, metabolomics, and proteomics play a crucial role in selecting the most suitable therapeutic options for rheumatologic patients. Phenotypes and endotypes are a promising approach to detect critically ill patients with hyper- or hypo-inflammation. Sepsis trials using biomarkers such as ferritin, lymphopenia, HLA-DR expression on monocytes and PD-L1 to guide immunotherapy have been already conducted or are currently ongoing. Immunotherapy in COVID-19 pneumonia, guided by C-reactive protein and soluble urokinase plasminogen activator receptor (suPAR) has improved patient outcomes globally. More research is needed into immunotherapy in other critical conditions. EXPERT OPINION Targeted immunotherapy has improved outcomes in oncology and rheumatology, paving the way for precision medicine in the critically ill. Transcriptomics will play a crucial role in detecting the most suitable candidates for immunomodulation.
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Affiliation(s)
- Evdoxia Kyriazopoulou
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Athens, Greece
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Lee JH. Treatment mechanism of immune triad from the repurposing drug against COVID-19. TRANSLATIONAL MEDICINE OF AGING 2023; 7:33-45. [PMID: 37388715 PMCID: PMC10290163 DOI: 10.1016/j.tma.2023.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 03/31/2023] [Accepted: 06/23/2023] [Indexed: 07/01/2023] Open
Abstract
COVID-19 is an immune-mediated disease whose pathophysiology uses SAMHD1 tetramerization and cGAS-STING signaling, toll-like receptor 4 (TLR4) cascade, spike protein- inflammasome activation, and neuropilin 1 (NRP1) signaling. Variants of concern, such as SARS-CoV-2 Omicron Subvariants BQ.1, BQ.1.1, BA.4.6, BF.7, BA.2.75.2, and other mutants, have emerged. The longitudinal memory T-cell response to SARS-CoV-2 persists for eight months after symptom onset. Therefore, we must achieve viral clearance to coordinate immune cell reactions. Aspirin, dapsone, and dexamethasone as anticatalysis medicines have been used to treat COVID-19. They are shown to work harmoniously with modulating ILCs. Therefore, it needs to prescribe this immune triad to alleviate the clinical pathologic course and block exacerbation mechanisms due to diverse SARS-CoV-2 variants.
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Affiliation(s)
- Jong Hoon Lee
- Science and Research Center, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
- Department of Respiratory Medicine, Seoul Metropolitan Seobuk Hospital, 49 Galhyeon-ro 7-gil, Yeokchon-dong Eunpyeong-gu, Seoul, 03433, Republic of Korea
- Geoje Public Health Center, Suyang-ro 506 (Yangjeong-dong ), Geoje city, Gyeongsangnam-do, 53236, Republic of Korea
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Ghosn L, Assi R, Evrenoglou T, Buckley BS, Henschke N, Probyn K, Riveros C, Davidson M, Graña C, Bonnet H, Jarde A, Ávila C, Nejstgaard CH, Menon S, Ferrand G, Kapp P, Breuer C, Schmucker C, Sguassero Y, Nguyen TV, Devane D, Meerpohl JJ, Rada G, Hróbjartsson A, Grasselli G, Tovey D, Ravaud P, Chaimani A, Boutron I. Interleukin-6 blocking agents for treating COVID-19: a living systematic review. Cochrane Database Syst Rev 2023; 6:CD013881. [PMID: 37260086 PMCID: PMC10237088 DOI: 10.1002/14651858.cd013881.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND It has been reported that people with COVID-19 and pre-existing autoantibodies against type I interferons are likely to develop an inflammatory cytokine storm responsible for severe respiratory symptoms. Since interleukin 6 (IL-6) is one of the cytokines released during this inflammatory process, IL-6 blocking agents have been used for treating people with severe COVID-19. OBJECTIVES To update the evidence on the effectiveness and safety of IL-6 blocking agents compared to standard care alone or to a placebo for people with COVID-19. SEARCH METHODS We searched the World Health Organization (WHO) International Clinical Trials Registry Platform, the Living OVerview of Evidence (L·OVE) platform, and the Cochrane COVID-19 Study Register to identify studies on 7 June 2022. SELECTION CRITERIA We included randomized controlled trials (RCTs) evaluating IL-6 blocking agents compared to standard care alone or to placebo for people with COVID-19, regardless of disease severity. DATA COLLECTION AND ANALYSIS Pairs of researchers independently conducted study selection, extracted data and assessed risk of bias. We assessed the certainty of evidence using the GRADE approach for all critical and important outcomes. In this update we amended our protocol to update the methods used for grading evidence by establishing minimal important differences for the critical outcomes. MAIN RESULTS This update includes 22 additional trials, for a total of 32 trials including 12,160 randomized participants all hospitalized for COVID-19 disease. We identified a further 17 registered RCTs evaluating IL-6 blocking agents without results available as of 7 June 2022. The mean age range varied from 56 to 75 years; 66.2% (8051/12,160) of enrolled participants were men. One-third (11/32) of included trials were placebo-controlled. Twenty-two were published in peer-reviewed journals, three were reported as preprints, two trials had results posted only on registries, and results from five trials were retrieved from another meta-analysis. Eight were funded by pharmaceutical companies. Twenty-six included studies were multicenter trials; four were multinational and 22 took place in single countries. Recruitment of participants occurred between February 2020 and June 2021, with a mean enrollment duration of 21 weeks (range 1 to 54 weeks). Nineteen trials (60%) had a follow-up of 60 days or more. Disease severity ranged from mild to critical disease. The proportion of participants who were intubated at study inclusion also varied from 5% to 95%. Only six trials reported vaccination status; there were no vaccinated participants included in these trials, and 17 trials were conducted before vaccination was rolled out. We assessed a total of six treatments, each compared to placebo or standard care. Twenty trials assessed tocilizumab, nine assessed sarilumab, and two assessed clazakizumab. Only one trial was included for each of the other IL-6 blocking agents (siltuximab, olokizumab, and levilimab). Two trials assessed more than one treatment. Efficacy and safety of tocilizumab and sarilumab compared to standard care or placebo for treating COVID-19 At day (D) 28, tocilizumab and sarilumab probably result in little or no increase in clinical improvement (tocilizumab: risk ratio (RR) 1.05, 95% confidence interval (CI) 1.00 to 1.11; 15 RCTs, 6116 participants; moderate-certainty evidence; sarilumab: RR 0.99, 95% CI 0.94 to 1.05; 7 RCTs, 2425 participants; moderate-certainty evidence). For clinical improvement at ≥ D60, the certainty of evidence is very low for both tocilizumab (RR 1.10, 95% CI 0.81 to 1.48; 1 RCT, 97 participants; very low-certainty evidence) and sarilumab (RR 1.22, 95% CI 0.91 to 1.63; 2 RCTs, 239 participants; very low-certainty evidence). The effect of tocilizumab on the proportion of participants with a WHO Clinical Progression Score (WHO-CPS) of level 7 or above remains uncertain at D28 (RR 0.90, 95% CI 0.72 to 1.12; 13 RCTs, 2117 participants; low-certainty evidence) and that for sarilumab very uncertain (RR 1.10, 95% CI 0.90 to 1.33; 5 RCTs, 886 participants; very low-certainty evidence). Tocilizumab reduces all cause-mortality at D28 compared to standard care/placebo (RR 0.88, 95% CI 0.81 to 0.94; 18 RCTs, 7428 participants; high-certainty evidence). The evidence about the effect of sarilumab on this outcome is very uncertain (RR 1.06, 95% CI 0.86 to 1.30; 9 RCTs, 3305 participants; very low-certainty evidence). The evidence is uncertain for all cause-mortality at ≥ D60 for tocilizumab (RR 0.91, 95% CI 0.80 to 1.04; 9 RCTs, 2775 participants; low-certainty evidence) and very uncertain for sarilumab (RR 0.95, 95% CI 0.84 to 1.07; 6 RCTs, 3379 participants; very low-certainty evidence). Tocilizumab probably results in little to no difference in the risk of adverse events (RR 1.03, 95% CI 0.95 to 1.12; 9 RCTs, 1811 participants; moderate-certainty evidence). The evidence about adverse events for sarilumab is uncertain (RR 1.12, 95% CI 0.97 to 1.28; 4 RCT, 860 participants; low-certainty evidence). The evidence about serious adverse events is very uncertain for tocilizumab (RR 0.93, 95% CI 0.81 to 1.07; 16 RCTs; 2974 participants; very low-certainty evidence) and uncertain for sarilumab (RR 1.09, 95% CI 0.97 to 1.21; 6 RCTs; 2936 participants; low-certainty evidence). Efficacy and safety of clazakizumab, olokizumab, siltuximab and levilimab compared to standard care or placebo for treating COVID-19 The evidence about the effects of clazakizumab, olokizumab, siltuximab, and levilimab comes from only one or two studies for each blocking agent, and is uncertain or very uncertain. AUTHORS' CONCLUSIONS In hospitalized people with COVID-19, results show a beneficial effect of tocilizumab on all-cause mortality in the short term and probably little or no difference in the risk of adverse events compared to standard care alone or placebo. Nevertheless, both tocilizumab and sarilumab probably result in little or no increase in clinical improvement at D28. Evidence for an effect of sarilumab and the other IL-6 blocking agents on critical outcomes is uncertain or very uncertain. Most of the trials included in our review were done before the waves of different variants of concern and before vaccination was rolled out on a large scale. An additional 17 RCTs of IL-6 blocking agents are currently registered with no results yet reported. The number of pending studies and the number of participants planned is low. Consequently, we will not publish further updates of this review.
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Affiliation(s)
- Lina Ghosn
- Cochrane France, Paris, France
- Centre d'Epidémiologie Clinique, AP-HP, Hôpital Hôtel Dieu, F-75004, Paris, France
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), F-75004, Paris, France
| | - Rouba Assi
- Cochrane France, Paris, France
- Centre d'Epidémiologie Clinique, AP-HP, Hôpital Hôtel Dieu, F-75004, Paris, France
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), F-75004, Paris, France
| | - Theodoros Evrenoglou
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), F-75004, Paris, France
| | | | | | | | - Carolina Riveros
- Centre d'Epidémiologie Clinique, AP-HP, Hôpital Hôtel Dieu, F-75004, Paris, France
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), F-75004, Paris, France
| | - Mauricia Davidson
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), F-75004, Paris, France
| | - Carolina Graña
- Cochrane France, Paris, France
- Centre d'Epidémiologie Clinique, AP-HP, Hôpital Hôtel Dieu, F-75004, Paris, France
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), F-75004, Paris, France
| | - Hillary Bonnet
- Cochrane France, Paris, France
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), F-75004, Paris, France
| | - Alexander Jarde
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), F-75004, Paris, France
| | | | - Camilla Hansen Nejstgaard
- Centre for Evidence-Based Medicine Odense (CEBMO) and Cochrane Denmark, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Open Patient data Explorative Network (OPEN), Odense University Hospital, Odense, Denmark
| | | | | | - Philipp Kapp
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Claudia Breuer
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Cochrane Germany, Cochrane Germany Foundation, Freiburg, Germany
| | - Christine Schmucker
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Cochrane Germany, Cochrane Germany Foundation, Freiburg, Germany
| | | | | | - Declan Devane
- Evidence Synthesis Ireland, Galway, Ireland
- Cochrane Ireland and HRB-Trials Methodology Research Network, Galway, Ireland
- University of Galway, Galway, Ireland
| | - Joerg J Meerpohl
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Cochrane Germany, Cochrane Germany Foundation, Freiburg, Germany
| | - Gabriel Rada
- Epistemonikos Foundation, Santiago, Chile
- UC Evidence Center, Cochrane Chile Associated Center, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Asbjørn Hróbjartsson
- Centre for Evidence-Based Medicine Odense (CEBMO) and Cochrane Denmark, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Open Patient data Explorative Network (OPEN), Odense University Hospital, Odense, Denmark
| | - Giacomo Grasselli
- Department of Anesthesia, Intensive Care and Emergency Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | | | - Philippe Ravaud
- Cochrane France, Paris, France
- Centre d'Epidémiologie Clinique, AP-HP, Hôpital Hôtel Dieu, F-75004, Paris, France
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), F-75004, Paris, France
| | - Anna Chaimani
- Cochrane France, Paris, France
- Centre d'Epidémiologie Clinique, AP-HP, Hôpital Hôtel Dieu, F-75004, Paris, France
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), F-75004, Paris, France
| | - Isabelle Boutron
- Cochrane France, Paris, France
- Centre d'Epidémiologie Clinique, AP-HP, Hôpital Hôtel Dieu, F-75004, Paris, France
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), F-75004, Paris, France
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McManus D, Davis MW, Ortiz A, Britto-Leon C, Dela Cruz CS, Topal JE. Immunomodulatory Agents for Coronavirus Disease-2019 Pneumonia. Clin Chest Med 2023; 44:299-319. [PMID: 37085221 PMCID: PMC9678826 DOI: 10.1016/j.ccm.2022.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Morbidity and mortality from COVID-19 is due to severe inflammation and end-organ damage caused by a hyperinflammatory response. Multiple immunomodulatory agents to attenuate this response have been studied. Corticosteroids, specifically dexamethasone, have been shown to reduce mortality in hospitalized patients who require supplemental oxygen. Interleukin-6 antagonist, tocilizimab, and Janus kinase inhibitors have also been shown to reduce mortality. However, patients who have severe pulmonary end-organ damage requiring mechanical ventilation or extracorporeal membrane oxygenation appear not to benefit from immunomodulatory therapies. This highlights the importance of appropriate timing to initiate immunomodulatory therapies in the management of severe COVID-19 disease.
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Affiliation(s)
- Dayna McManus
- Department of Pharmacy Services, Yale New Haven Hospital, 20 York Street, New Haven, CT 06510, USA.
| | - Matthew W Davis
- Department of Pharmacy Services, Yale New Haven Hospital, 20 York Street, New Haven, CT 06510, USA
| | - Alex Ortiz
- Pulmonary, Critical Care & Sleep Medicine, 300 Cedar Street, P.O. Box 208057, New Haven, CT 06520-8057, USA
| | - Clemente Britto-Leon
- Pulmonary, Critical Care & Sleep Medicine, 300 Cedar Street, P.O. Box 208057, New Haven, CT 06520-8057, USA
| | - Charles S Dela Cruz
- Pulmonary, Critical Care & Sleep Medicine, 300 Cedar Street, P.O. Box 208057, New Haven, CT 06520-8057, USA
| | - Jeffrey E Topal
- Department of Pharmacy Services, Yale New Haven Hospital, 20 York Street, New Haven, CT 06510, USA.
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Talukdar D, Bandopadhyay P, Ray Y, Paul SR, Sarif J, D'Rozario R, Lahiri A, Das S, Bhowmick D, Chatterjee S, Das B, Ganguly D. Association of gut microbial dysbiosis with disease severity, response to therapy and disease outcomes in Indian patients with COVID-19. Gut Pathog 2023; 15:22. [PMID: 37161621 PMCID: PMC10170741 DOI: 10.1186/s13099-023-00546-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 04/13/2023] [Indexed: 05/11/2023] Open
Abstract
BACKGROUND Severe coronavirus disease 2019 (COVID-19) is associated with systemic hyper-inflammation. An adaptive interaction between gut microbiota and host immune systems is important for intestinal homeostasis and systemic immune regulation. The association of gut microbial composition and functions with COVID-19 disease severity is sparse, especially in India. We analysed faecal microbial diversity and abundances in a cohort of Indian COVID-19 patients to identify key signatures in the gut microbial ecology in patients with severe COVID-19 disease as well as in response to different therapies. The composition of the gut microbiome was characterized using 16Sr RNA gene sequences of genomic DNA extracted from faecal samples of 52 COVID-19 patients. Metabolic pathways across the groups were predicted using PICRUSt2. All statistical analyses were done using Vegan in the R environment. Plasma cytokine abundance at recruitment was measured in a multiplex assay. RESULTS The gut microbiome composition of mild and severe patients was found to be significantly different. Immunomodulatory commensals, viz. Lachnospiraceae family members and Bifidobacteria producing butyrate and short-chain fatty acids (SCFAs), were under represented in patients with severe COVID-19, with an increased abundance of opportunistic pathogens like Eggerthella. The higher abundance of Lachnoclostridium in severe disease was reduced in response to convalescent plasma therapy. Specific microbial genera showed distinctive trends in enriched metabolic pathways, strong correlations with blood plasma cytokine levels, and associative link to disease outcomes. CONCLUSION Our study indicates that, along with SARS-CoV-2, a dysbiotic gut microbial community may also play an important role in COVID-19 severity through modulation of host immune responses.
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Affiliation(s)
- Daizee Talukdar
- Functional Genomics Laboratory, Translational Health Science and Technology Institute, Faridabad, India
| | - Purbita Bandopadhyay
- CSIR-Indian Institute of Chemical Biology, Kolkata, India
- Academy of Scientific and Innovative Research, Ghaziabad, India
| | - Yogiraj Ray
- Department of Medicine, Infectious Diseases and Beleghata General Hospital, Kolkata, India
- Department of Infectious Disease, SSKM Hospital, Kolkata, India
| | - Shekhar Ranjan Paul
- Department of Medicine, Infectious Diseases and Beleghata General Hospital, Kolkata, India
| | - Jafar Sarif
- CSIR-Indian Institute of Chemical Biology, Kolkata, India
- Academy of Scientific and Innovative Research, Ghaziabad, India
| | - Ranit D'Rozario
- CSIR-Indian Institute of Chemical Biology, Kolkata, India
- Academy of Scientific and Innovative Research, Ghaziabad, India
| | - Abhishake Lahiri
- CSIR-Indian Institute of Chemical Biology, Kolkata, India
- Academy of Scientific and Innovative Research, Ghaziabad, India
| | - Santanu Das
- Functional Genomics Laboratory, Translational Health Science and Technology Institute, Faridabad, India
| | - Debaleena Bhowmick
- CSIR-Indian Institute of Chemical Biology, Kolkata, India
- Academy of Scientific and Innovative Research, Ghaziabad, India
| | - Shilpak Chatterjee
- CSIR-Indian Institute of Chemical Biology, Kolkata, India
- Academy of Scientific and Innovative Research, Ghaziabad, India
| | - Bhabatosh Das
- Functional Genomics Laboratory, Translational Health Science and Technology Institute, Faridabad, India.
| | - Dipyaman Ganguly
- CSIR-Indian Institute of Chemical Biology, Kolkata, India.
- Academy of Scientific and Innovative Research, Ghaziabad, India.
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Bello S, Lasierra AB, López-Vergara L, de Diego C, Torralba L, de Gopegui PR, Lahoz R, Abadía C, Godino J, Cebollada A, Jimeno B, Bello C, Tejada A, Torres A. IL-6 and cfDNA monitoring throughout COVID-19 hospitalization are accurate markers of its outcomes. Respir Res 2023; 24:125. [PMID: 37147677 PMCID: PMC10161166 DOI: 10.1186/s12931-023-02426-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 04/18/2023] [Indexed: 05/07/2023] Open
Abstract
BACKGROUND Severe COVID-19 entails a dysregulated immune response, most likely inflammation related to a lack of virus control. A better understanding of immune toxicity, immunosuppression balance, and COVID-19 assessments could help determine whether different clinical presentations are driven by specific types of immune responses. The progression of the immune response and tissular damage could predict outcomes and may help in the management of patients. METHODS We collected 201 serum samples from 93 hospitalised patients classified as moderately, severely, and critically ill. We differentiated the viral, early inflammatory, and late inflammatory phases and included 72 patients with 180 samples in separate stages for longitudinal study and 55 controls. We studied selected cytokines, P-selectin, and the tissue damage markers lactate dehydrogenase (LDH) and cell-free DNA (cfDNA). RESULTS TNF-α, IL-6, IL-8, and G-CSF were associated with severity and mortality, but only IL-6 increased since admission in the critical patients and non-survivors, correlating with damage markers. The lack of a significant decrease in IL-6 levels in the critical patients and non-survivors in the early inflammatory phase (a decreased presence in the other patients) suggests that these patients did not achieve viral control on days 10-16. For all patients, lactate dehydrogenase and cfDNA levels increased with severity, and cfDNA levels increased in the non-survivors from the first sample (p = 0.002) to the late inflammatory phase (p = 0.031). In the multivariate study, cfDNA was an independent risk factor for mortality and ICU admission. CONCLUSIONS The distinct progression of IL-6 levels in the course of the disease, especially on days 10-16, was a good marker of progression to critical status and mortality and could guide the start of IL-6 blockade. cfDNA was an accurate marker of severity and mortality from admission and throughout COVID-19 progression.
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Affiliation(s)
- Salvador Bello
- Department of Pulmonary Medicine, Miguel Servet University Hospital, CIBERES, Instituto de Investigación Sanitaria (ISS) Aragón, Avenida Isabel La Católica 1-9, 50009, Zaragoza, Spain.
| | | | - Lucía López-Vergara
- Department of Pulmonary Medicine, Miguel Servet University Hospital, CIBERES, Instituto de Investigación Sanitaria (ISS) Aragón, Avenida Isabel La Católica 1-9, 50009, Zaragoza, Spain
| | - Cristina de Diego
- Department of Pulmonary Medicine, Miguel Servet University Hospital, CIBERES, Instituto de Investigación Sanitaria (ISS) Aragón, Avenida Isabel La Católica 1-9, 50009, Zaragoza, Spain
| | - Laura Torralba
- Department of Pulmonary Medicine, Miguel Servet University Hospital, CIBERES, Instituto de Investigación Sanitaria (ISS) Aragón, Avenida Isabel La Católica 1-9, 50009, Zaragoza, Spain
| | | | - Raquel Lahoz
- Department of Biochemistry, Miguel Servet University Hospital, Zaragoza, Spain
| | - Claudia Abadía
- Department of Biochemistry, Miguel Servet University Hospital, Zaragoza, Spain
| | - Javier Godino
- Department of Cytometry and Cell Separation, Aragon Institute of Health Sciences (IACS), Zaragoza, Spain
| | - Alberto Cebollada
- Biocomputing Technical Scientific Service, Aragon Institute of Health Sciences (IACS), Zaragoza, Spain
| | - Beatriz Jimeno
- Department of Cytometry and Cell Separation, Aragon Institute of Health Sciences (IACS), Zaragoza, Spain
| | - Carlota Bello
- Department of Radiology, Hospital Clínico Lozano Blesa, Zaragoza, Spain
| | - Antonio Tejada
- Intensive Care Unit, Miguel Servet University Hospital, Zaragoza, Spain
| | - Antoni Torres
- Servei de Pneumologia, Hospital Clinic, Universitat de Barcelona, IDIBAPS, ICREA, CIBERESUCICOVID, Barcelona, Spain
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48
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Morishita M, Hojo M. Treatment options for patients with severe COVID-19. Glob Health Med 2023; 5:99-105. [PMID: 37128231 PMCID: PMC10130548 DOI: 10.35772/ghm.2023.01024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 04/04/2023] [Accepted: 04/06/2023] [Indexed: 05/03/2023]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has affected the world for over 3 years. Treatment options have improved substantially during this period, including antiviral drugs, antibody drugs, immune-based agents, and vaccination. While these improvements have reduced mortality rates in patients with COVID-19, some patients still develop severe illness. In this review, we aimed to provide an overview of treatments for patients with severe COVID-19 from study reports and clinical experience. We discussed the treatments from two perspectives: respiratory care and drug treatments. In the respiratory care section, we discussed the usefulness of high-flow nasal cannula therapy and non-invasive ventilation as an alternative to invasive ventilation. In the drug treatments section, we focused on three classes for severe COVID-19 treatment: antiviral drugs, immune-based agents, and anticoagulation therapy. We did not discuss antibody drugs and vaccination, as they are not used for severe COVID-19 treatment.
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Affiliation(s)
| | - Masayuki Hojo
- Address correspondence to:Masayuki Hojo, Department of Respiratory Medicine, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Japan.
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49
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Koh JY, Ko JH, Lim SY, Bae S, Huh K, Cho SY, Kang CI, Chung DR, Chung CR, Kim SH, Peck KR, Lee JS. Triple immune modulator therapy for aberrant hyperinflammatory responses in severe COVID-19. Clin Immunol 2023; 251:109628. [PMID: 37119951 PMCID: PMC10139747 DOI: 10.1016/j.clim.2023.109628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 04/11/2023] [Accepted: 04/26/2023] [Indexed: 05/01/2023]
Abstract
A dysregulated hyperinflammatory response is a key pathogenesis of severe COVID-19, but optimal immune modulator treatment has not been established. To evaluate the clinical effectiveness of double (glucocorticoids and tocilizumab) and triple (plus baricitinib) immune modulator therapy for severe COVID-19, a retrospective cohort study was conducted. For the immunologic investigation, a single-cell RNA sequencing analysis was performed in serially collected PBMCs and neutrophil specimens. Triple immune modulator therapy was a significant factor in a multivariable analysis for 30-day recovery. In the scRNA-seq analysis, type I and II IFN response-related pathways were suppressed by GC, and the IL-6-associated signature was additionally downregulated by TOC. Adding BAR to GC and TOC distinctly downregulated the ISGF3 cluster. Adding BAR also regulated the pathologically activated monocyte and neutrophil subpopulation induced by aberrant IFN signals. Triple immune modulator therapy in severe COVID-19 improved 30-day recovery through additional regulation of the aberrant hyperinflammatory immune response.
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Affiliation(s)
| | - Jae-Hoon Ko
- Division of Infectious Diseases, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - So Yun Lim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seongman Bae
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Kyungmin Huh
- Division of Infectious Diseases, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sun Young Cho
- Division of Infectious Diseases, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Cheol-In Kang
- Division of Infectious Diseases, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Doo Ryeon Chung
- Division of Infectious Diseases, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Chi Ryang Chung
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sung-Han Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
| | - Kyong Ran Peck
- Division of Infectious Diseases, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
| | - Jeong Seok Lee
- Genome Insight, Inc., San Diego, La Jolla, CA, USA; Graduate School of Medical Science and Engineering, Korea Advanced Institute of Science and Technology (KAIST), Daejeon, Republic of Korea.
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50
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Nappi F, Avtaar Singh SS. SARS-CoV-2-Induced Myocarditis: A State-of-the-Art Review. Viruses 2023; 15:916. [PMID: 37112896 PMCID: PMC10145666 DOI: 10.3390/v15040916] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 03/25/2023] [Accepted: 03/31/2023] [Indexed: 04/05/2023] Open
Abstract
In this review, we investigated whether severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can directly cause myocarditis with severe myocardial damage induced by viral particles. A review of the major data published from 2020 to 2022 was performed by consulting the major databases alongside first-hand experiences that emerged from the cardiac biopsies and autopsy examinations of patients who died of SARS-CoV-2 infections. From this study, a significantly large amount of data suggests that the Dallas criteria were met in a residual percentage of patients, demonstrating that SARS-CoV-2 myocarditis was a rare clinical and pathological entity that occurred in a small percentage of subjects. All cases described here were highly selected and subjected to autopsies or endomyocardial biopsies (EMBs). The most important discovery, through the detection of the SARS-CoV-2 genome using the polymerase chain reaction, consisted in the presence of the viral genome in the lung tissue of most of the patients who died from COVID-19. However, the discovery of the SARS-CoV-2 viral genome was a rare event in cardiac tissue from autopsy findings of patients who died of myocarditis It is important to emphasize that myocardial inflammation alone, as promoted by macrophages and T cell infiltrations, can be observed in noninfectious deaths and COVID-19 cases, but the extent of each cause is varied, and in neither case have such findings been reported to support clinically relevant myocarditis. Therefore, in the different infected vs. non-infected samples examined, none of our findings provide a definitive histochemical assessment for the diagnosis of myocarditis in the majority of cases evaluated. We report evidence suggesting an extremely low frequency of viral myocarditis that has also been associated with unclear therapeutic implications. These two key factors strongly point towards the use of an endomyocardial biopsy to irrefutably reach a diagnosis of viral myocarditis in the context of COVID-19.
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Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France
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