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Park H, Yu C, Pirofski LA, Yoon H, Wu D, Li Y, Tarpey T, Petkova E, Antman EM, Troxel AB. Association between COVID-19 convalescent plasma antibody levels and COVID-19 outcomes stratified by clinical status at presentation. BMC Infect Dis 2024; 24:639. [PMID: 38926676 PMCID: PMC11201301 DOI: 10.1186/s12879-024-09529-0] [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: 02/15/2024] [Accepted: 06/18/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND There is a need to understand the relationship between COVID-19 Convalescent Plasma (CCP) anti-SARS-CoV-2 IgG levels and clinical outcomes to optimize CCP use. This study aims to evaluate the relationship between recipient baseline clinical status, clinical outcomes, and CCP antibody levels. METHODS The study analyzed data from the COMPILE study, a meta-analysis of pooled individual patient data from 8 randomized clinical trials (RCTs) assessing the efficacy of CCP vs. control, in adults hospitalized for COVID-19 who were not receiving mechanical ventilation at randomization. SARS-CoV-2 IgG levels, referred to as 'dose' of CCP treatment, were retrospectively measured in donor sera or the administered CCP, semi-quantitatively using the VITROS Anti-SARS-CoV-2 IgG chemiluminescent immunoassay (Ortho-Clinical Diagnostics) with a signal-to-cutoff ratio (S/Co). The association between CCP dose and outcomes was investigated, treating dose as either continuous or categorized (higher vs. lower vs. control), stratified by recipient oxygen supplementation status at presentation. RESULTS A total of 1714 participants were included in the study, 1138 control- and 576 CCP-treated patients for whom donor CCP anti-SARS-CoV2 antibody levels were available from the COMPILE study. For participants not receiving oxygen supplementation at baseline, higher-dose CCP (/control) was associated with a reduced risk of ventilation or death at day 14 (OR = 0.19, 95% CrI: [0.02, 1.70], posterior probability Pr(OR < 1) = 0.93) and day 28 mortality (OR = 0.27 [0.02, 2.53], Pr(OR < 1) = 0.87), compared to lower-dose CCP (/control) (ventilation or death at day 14 OR = 0.79 [0.07, 6.87], Pr(OR < 1) = 0.58; and day 28 mortality OR = 1.11 [0.10, 10.49], Pr(OR < 1) = 0.46), exhibiting a consistently positive CCP dose effect on clinical outcomes. For participants receiving oxygen at baseline, the dose-outcome relationship was less clear, although a potential benefit for day 28 mortality was observed with higher-dose CCP (/control) (OR = 0.66 [0.36, 1.13], Pr(OR < 1) = 0.93) compared to lower-dose CCP (/control) (OR = 1.14 [0.73, 1.78], Pr(OR < 1) = 0.28). CONCLUSION Higher-dose CCP is associated with its effectiveness in patients not initially receiving oxygen supplementation, however, further research is needed to understand the interplay between CCP anti-SARS-CoV-2 IgG levels and clinical outcome in COVID-19 patients initially receiving oxygen supplementation.
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Affiliation(s)
- Hyung Park
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA
| | - Chang Yu
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA
| | - Liise-Anne Pirofski
- Department of Medicine, Division of Infectious Diseases, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Hyunah Yoon
- Department of Medicine, Division of Infectious Diseases, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA
| | - Danni Wu
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA
| | - Yi Li
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA
| | - Thaddeus Tarpey
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA
| | - Eva Petkova
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA
- Department of Child and Adolescent Psychiatry, NYU Grossman School of Medicine, New York, NY, USA
| | - Elliott M Antman
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrea B Troxel
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA.
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Wu D, Goldfeld KS, Petkova E, Park HG. Improving Individualized Treatment Decisions: A Bayesian Multivariate Hierarchical Model for Developing a Treatment Benefit Index using Mixed Types of Outcomes. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2023.11.17.23298711. [PMID: 38014277 PMCID: PMC10680905 DOI: 10.1101/2023.11.17.23298711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
Background Precision medicine has led to the development of targeted treatment strategies tailored to individual patients based on their characteristics and disease manifestations. Although precision medicine often focuses on a single health outcome for individualized treatment decision rules (ITRs), relying only on a single outcome rather than all available outcomes information leads to suboptimal data usage when developing optimal ITRs. Methods To address this limitation, we propose a Bayesian multivariate hierarchical model that leverages the wealth of correlated health outcomes collected in clinical trials. The approach jointly models mixed types of correlated outcomes, facilitating the "borrowing of information" across the multivariate outcomes, and results in a more accurate estimation of heterogeneous treatment effects compared to using single regression models for each outcome. We develop a treatment benefit index, which quantifies the relative treatment benefit of the experimental treatment over the control treatment, based on the proposed multivariate outcome model. Results We demonstrate the strengths of the proposed approach through extensive simulations and an application to an international Coronavirus Disease 2019 (COVID-19) treatment trial. Simulation results indicate that the proposed method reduces the occurrence of erroneous treatment decisions compared to a single regression model for a single health outcome. Additionally, the sensitivity analysis demonstrates the robustness of the model across various study scenarios. Application of the method to the COVID-19 trial exhibits improvements in estimating the individual-level treatment efficacy (indicated by narrower credible intervals for odds ratios) and optimal ITRs. Conclusion The study jointly models mixed types of outcomes in the context of developing ITRs. By considering multiple health outcomes, the proposed approach can advance the development of more effective and reliable personalized treatment.
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Affiliation(s)
- Danni Wu
- Department of Population Health, New York University Grossman School of Medicine, 180 Madison Avenue, New York, 10016, New York, USA
| | - Keith S. Goldfeld
- Department of Population Health, New York University Grossman School of Medicine, 180 Madison Avenue, New York, 10016, New York, USA
| | - Eva Petkova
- Department of Population Health, New York University Grossman School of Medicine, 180 Madison Avenue, New York, 10016, New York, USA
| | - Hyung G. Park
- Department of Population Health, New York University Grossman School of Medicine, 180 Madison Avenue, New York, 10016, New York, USA
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Maxwell L, Shreedhar P, Levis B, Chavan SA, Akter S, Carabali M. Overlapping research efforts in a global pandemic: a rapid systematic review of COVID-19-related individual participant data meta-analyses. BMC Health Serv Res 2023; 23:735. [PMID: 37415216 PMCID: PMC10327330 DOI: 10.1186/s12913-023-09726-8] [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: 10/24/2022] [Accepted: 06/20/2023] [Indexed: 07/08/2023] Open
Abstract
BACKGROUND Individual participant data meta-analyses (IPD-MAs), which involve harmonising and analysing participant-level data from related studies, provide several advantages over aggregate data meta-analyses, which pool study-level findings. IPD-MAs are especially important for building and evaluating diagnostic and prognostic models, making them an important tool for informing the research and public health responses to COVID-19. METHODS We conducted a rapid systematic review of protocols and publications from planned, ongoing, or completed COVID-19-related IPD-MAs to identify areas of overlap and maximise data request and harmonisation efforts. We searched four databases using a combination of text and MeSH terms. Two independent reviewers determined eligibility at the title-abstract and full-text stages. Data were extracted by one reviewer into a pretested data extraction form and subsequently reviewed by a second reviewer. Data were analysed using a narrative synthesis approach. A formal risk of bias assessment was not conducted. RESULTS We identified 31 COVID-19-related IPD-MAs, including five living IPD-MAs and ten IPD-MAs that limited their inference to published data (e.g., case reports). We found overlap in study designs, populations, exposures, and outcomes of interest. For example, 26 IPD-MAs included RCTs; 17 IPD-MAs were limited to hospitalised patients. Sixteen IPD-MAs focused on evaluating medical treatments, including six IPD-MAs for antivirals, four on antibodies, and two that evaluated convalescent plasma. CONCLUSIONS Collaboration across related IPD-MAs can leverage limited resources and expertise by expediting the creation of cross-study participant-level data datasets, which can, in turn, fast-track evidence synthesis for the improved diagnosis and treatment of COVID-19. TRIAL REGISTRATION 10.17605/OSF.IO/93GF2.
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Affiliation(s)
- Lauren Maxwell
- Heidelberger Institut Für Global Health, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 130/3, 69120, Heidelberg, Germany.
| | - Priya Shreedhar
- Heidelberger Institut Für Global Health, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 130/3, 69120, Heidelberg, Germany
| | - Brooke Levis
- Centre for Clinical Epidemiology, Lady Davis Institute for Medical Research, Jewish General Hospital, 3755 Cote Ste Catherine Road, Montreal, QC, H3T 1E2, Canada
| | - Sayali Arvind Chavan
- Institute of Tropical Medicine and Public Health, Charité - Universitätsmedizin Berlin, Südring 2-3, 13353, Berlin, Germany
| | - Shaila Akter
- Heidelberger Institut Für Global Health, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 130/3, 69120, Heidelberg, Germany
| | - Mabel Carabali
- Department of Epidemiology, Biostatistics and Occupational Health, School of Population and Global Health, McGill University, 2001 McGill College Avenue, Montréal, H3A 1G1, Canada
- Department of Social and Preventive Medicine, School of Public Health, Universite de Montreal, 7101 Parc Avenue, Montreal, H3N 1X9, Canada
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4
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Wu D, Goldfeld KS, Petkova E. Developing a Bayesian hierarchical model for a prospective individual patient data meta-analysis with continuous monitoring. BMC Med Res Methodol 2023; 23:25. [PMID: 36698073 PMCID: PMC9875783 DOI: 10.1186/s12874-022-01813-4] [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: 06/13/2022] [Accepted: 12/05/2022] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Numerous clinical trials have been initiated to find effective treatments for COVID-19. These trials have often been initiated in regions where the pandemic has already peaked. Consequently, achieving full enrollment in a single trial might require additional COVID-19 surges in the same location over several years. This has inspired us to pool individual patient data (IPD) from ongoing, paused, prematurely-terminated, or completed randomized controlled trials (RCTs) in real-time, to find an effective treatment as quickly as possible in light of the pandemic crisis. However, pooling across trials introduces enormous uncertainties in study design (e.g., the number of RCTs and sample sizes might be unknown in advance). We sought to develop a versatile treatment efficacy assessment model that accounts for these uncertainties while allowing for continuous monitoring throughout the study using Bayesian monitoring techniques. METHODS We provide a detailed look at the challenges and solutions for model development, describing the process that used extensive simulations to enable us to finalize the analysis plan. This includes establishing prior distribution assumptions, assessing and improving model convergence under different study composition scenarios, and assessing whether we can extend the model to accommodate multi-site RCTs and evaluate heterogeneous treatment effects. In addition, we recognized that we would need to assess our model for goodness-of-fit, so we explored an approach that used posterior predictive checking. Lastly, given the urgency of the research in the context of evolving pandemic, we were committed to frequent monitoring of the data to assess efficacy, and we set Bayesian monitoring rules calibrated for type 1 error rate and power. RESULTS The primary outcome is an 11-point ordinal scale. We present the operating characteristics of the proposed cumulative proportional odds model for estimating treatment effectiveness. The model can estimate the treatment's effect under enormous uncertainties in study design. We investigate to what degree the proportional odds assumption has to be violated to render the model inaccurate. We demonstrate the flexibility of a Bayesian monitoring approach by performing frequent interim analyses without increasing the probability of erroneous conclusions. CONCLUSION This paper describes a translatable framework using simulation to support the design of prospective IPD meta-analyses.
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Affiliation(s)
- Danni Wu
- grid.137628.90000 0004 1936 8753Department of Population Health, New York University Grossman School of Medicine, New York, USA
| | - Keith S. Goldfeld
- grid.137628.90000 0004 1936 8753Department of Population Health, New York University Grossman School of Medicine, New York, USA
| | - Eva Petkova
- grid.137628.90000 0004 1936 8753Department of Population Health, New York University Grossman School of Medicine, New York, USA ,grid.137628.90000 0004 1936 8753Department of Child and Adolescent Psychiatry, New York University Grossman School of Medicine, New York, USA ,grid.250263.00000 0001 2189 4777Nathan Kline Institute for Psychiatric Research, Orangeburg, USA
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5
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Di Stefano L, Ogburn EL, Ram M, Scharfstein DO, Li T, Khanal P, Baksh SN, McBee N, Gruber J, Gildea MR, Clark MR, Goldenberg NA, Bennani Y, Brown SM, Buckel WR, Clement ME, Mulligan MJ, O’Halloran JA, Rauseo AM, Self WH, Semler MW, Seto T, Stout JE, Ulrich RJ, Victory J, Bierer BE, Hanley DF, Freilich D. Hydroxychloroquine/chloroquine for the treatment of hospitalized patients with COVID-19: An individual participant data meta-analysis. PLoS One 2022; 17:e0273526. [PMID: 36173983 PMCID: PMC9521809 DOI: 10.1371/journal.pone.0273526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 08/09/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Results from observational studies and randomized clinical trials (RCTs) have led to the consensus that hydroxychloroquine (HCQ) and chloroquine (CQ) are not effective for COVID-19 prevention or treatment. Pooling individual participant data, including unanalyzed data from trials terminated early, enables more detailed investigation of the efficacy and safety of HCQ/CQ among subgroups of hospitalized patients. METHODS We searched ClinicalTrials.gov in May and June 2020 for US-based RCTs evaluating HCQ/CQ in hospitalized COVID-19 patients in which the outcomes defined in this study were recorded or could be extrapolated. The primary outcome was a 7-point ordinal scale measured between day 28 and 35 post enrollment; comparisons used proportional odds ratios. Harmonized de-identified data were collected via a common template spreadsheet sent to each principal investigator. The data were analyzed by fitting a prespecified Bayesian ordinal regression model and standardizing the resulting predictions. RESULTS Eight of 19 trials met eligibility criteria and agreed to participate. Patient-level data were available from 770 participants (412 HCQ/CQ vs 358 control). Baseline characteristics were similar between groups. We did not find evidence of a difference in COVID-19 ordinal scores between days 28 and 35 post-enrollment in the pooled patient population (odds ratio, 0.97; 95% credible interval, 0.76-1.24; higher favors HCQ/CQ), and found no convincing evidence of meaningful treatment effect heterogeneity among prespecified subgroups. Adverse event and serious adverse event rates were numerically higher with HCQ/CQ vs control (0.39 vs 0.29 and 0.13 vs 0.09 per patient, respectively). CONCLUSIONS The findings of this individual participant data meta-analysis reinforce those of individual RCTs that HCQ/CQ is not efficacious for treatment of COVID-19 in hospitalized patients.
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Affiliation(s)
- Leon Di Stefano
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Elizabeth L. Ogburn
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Malathi Ram
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Daniel O. Scharfstein
- Division of Biostatistics, Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah, United States of America
| | - Tianjing Li
- University of Colorado Denver, Anschutz Medical Campus, Denver, Colorado, United States of America
| | - Preeti Khanal
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Sheriza N. Baksh
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Nichol McBee
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Joshua Gruber
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Marianne R. Gildea
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Megan R. Clark
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Neil A. Goldenberg
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
- Johns Hopkins All Children’s Institute for Clinical and Translational Research, Johns Hopkins All Children’s Hospital, St. Petersburg, Florida, United States of America
| | - Yussef Bennani
- Louisiana State University Health Sciences Center, New Orleans, Louisiana, United States of America
- University Medical Center, New Orleans, New Orleans, Louisiana, United States of America
| | - Samuel M. Brown
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, Utah, United States of America
- University of Utah, Salt Lake City, Utah, United States of America
| | - Whitney R. Buckel
- Pharmacy Services, Intermountain Healthcare, Murray, Utah, United States of America
| | - Meredith E. Clement
- Louisiana State University Health Sciences Center, New Orleans, Louisiana, United States of America
- University Medical Center, New Orleans, New Orleans, Louisiana, United States of America
| | - Mark J. Mulligan
- Department of Medicine, Division of Infectious Diseases and Immunology, New York University Grossman School of Medicine, New York, New York, United States of America
- Vaccine Center, New York University Grossman School of Medicine, New York, New York, United States of America
| | - Jane A. O’Halloran
- Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri, United States of America
| | - Adriana M. Rauseo
- Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri, United States of America
| | - Wesley H. Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Matthew W. Semler
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Todd Seto
- Department of Medicine, University of Hawaii John A. Burns School of Medicine, Honolulu, Hawaii, United States of America
| | - Jason E. Stout
- Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Robert J. Ulrich
- Department of Medicine, Division of Infectious Diseases and Immunology, New York University Grossman School of Medicine, New York, New York, United States of America
| | - Jennifer Victory
- Bassett Research Institute, Bassett Medical Center, Cooperstown, New York, United States of America
| | - Barbara E. Bierer
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Daniel F. Hanley
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Daniel Freilich
- Department of Internal Medicine, Division of Infectious Diseases, Bassett Medical Center, Cooperstown, New York, United States of America
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6
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Di Stefano L, Ogburn EL, Ram M, Scharfstein DO, Li T, Khanal P, Baksh SN, McBee N, Gruber J, Gildea MR, Clark MR, Goldenberg NA, Bennani Y, Brown SM, Buckel WR, Clement ME, Mulligan MJ, O’Halloran JA, Rauseo AM, Self WH, Semler MW, Seto T, Stout JE, Ulrich RJ, Victory J, Bierer BE, Hanley DF, Freilich D. Hydroxychloroquine/chloroquine for the treatment of hospitalized patients with COVID-19: An individual participant data meta-analysis. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2022:2022.01.10.22269008. [PMID: 35043124 PMCID: PMC8764733 DOI: 10.1101/2022.01.10.22269008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background Results from observational studies and randomized clinical trials (RCTs) have led to the consensus that hydroxychloroquine (HCQ) and chloroquine (CQ) are not effective for COVID-19 prevention or treatment. Pooling individual participant data, including unanalyzed data from trials terminated early, enables more detailed investigation of the efficacy and safety of HCQ/CQ among subgroups of hospitalized patients. Methods We searched ClinicalTrials.gov in May and June 2020 for US-based RCTs evaluating HCQ/CQ in hospitalized COVID-19 patients in which the outcomes defined in this study were recorded or could be extrapolated. The primary outcome was a 7-point ordinal scale measured between day 28 and 35 post enrollment; comparisons used proportional odds ratios. Harmonized de-identified data were collected via a common template spreadsheet sent to each principal investigator. The data were analyzed by fitting a prespecified Bayesian ordinal regression model and standardizing the resulting predictions. Results Eight of 19 trials met eligibility criteria and agreed to participate. Patient-level data were available from 770 participants (412 HCQ/CQ vs 358 control). Baseline characteristics were similar between groups. We did not find evidence of a difference in COVID-19 ordinal scores between days 28 and 35 post-enrollment in the pooled patient population (odds ratio, 0.97; 95% credible interval, 0.76-1.24; higher favors HCQ/CQ), and found no convincing evidence of meaningful treatment effect heterogeneity among prespecified subgroups. Adverse event and serious adverse event rates were numerically higher with HCQ/CQ vs control (0.39 vs 0.29 and 0.13 vs 0.09 per patient, respectively). Conclusions The findings of this individual participant data meta-analysis reinforce those of individual RCTs that HCQ/CQ is not efficacious for treatment of COVID-19 in hospitalized patients.
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Affiliation(s)
- Leon Di Stefano
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Elizabeth L. Ogburn
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Malathi Ram
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Daniel O. Scharfstein
- Division of Biostatistics, Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah
| | - Tianjing Li
- University of Colorado Denver, Anschutz Medical Campus, Denver, Colorado
| | - Preeti Khanal
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Sheriza N. Baksh
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Nichol McBee
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Joshua Gruber
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Marianne R. Gildea
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, Maryland
- Current address: FHI 360, Durham, North Carolina
| | - Megan R. Clark
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Neil A. Goldenberg
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
- Johns Hopkins All Children’s Institute for Clinical and Translational Research, Johns Hopkins All Children’s Hospital, St. Petersburg, Florida
| | - Yussef Bennani
- Louisiana State University Health Sciences Center, New Orleans, Louisiana
- University Medical Center, New Orleans, New Orleans, Louisiana
| | - Samuel M. Brown
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, Utah
- University of Utah, Salt Lake City, Utah
| | | | - Meredith E. Clement
- Louisiana State University Health Sciences Center, New Orleans, Louisiana
- University Medical Center, New Orleans, New Orleans, Louisiana
| | - Mark J. Mulligan
- Department of Medicine, Division of Infectious Diseases and Immunology, New York University Grossman School of Medicine, New York, New York
- Vaccine Center, New York University Grossman School of Medicine, New York, New York
| | - Jane A. O’Halloran
- Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri
| | - Adriana M. Rauseo
- Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri
| | - Wesley H. Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew W. Semler
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Todd Seto
- Department of Medicine, University of Hawaii John A. Burns School of Medicine, Honolulu, Hawaii
| | - Jason E. Stout
- Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina
| | - Robert J. Ulrich
- Department of Medicine, Division of Infectious Diseases and Immunology, New York University Grossman School of Medicine, New York, New York
| | - Jennifer Victory
- Bassett Research Institute, Bassett Medical Center, Cooperstown, New York
| | - Barbara E. Bierer
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Daniel F. Hanley
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Daniel Freilich
- Department of Internal Medicine, Division of Infectious Diseases, Bassett Medical Center, Cooperstown, New York
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7
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Ortigoza MB, Yoon H, Goldfeld KS, Troxel AB, Daily JP, Wu Y, Li Y, Wu D, Cobb GF, Baptiste G, O'Keeffe M, Corpuz MO, Ostrosky-Zeichner L, Amin A, Zacharioudakis IM, Jayaweera DT, Wu Y, Philley JV, Devine MS, Desruisseaux MS, Santin AD, Anjan S, Mathew R, Patel B, Nigo M, Upadhyay R, Kupferman T, Dentino AN, Nanchal R, Merlo CA, Hager DN, Chandran K, Lai JR, Rivera J, Bikash CR, Lasso G, Hilbert TP, Paroder M, Asencio AA, Liu M, Petkova E, Bragat A, Shaker R, McPherson DD, Sacco RL, Keller MJ, Grudzen CR, Hochman JS, Pirofski LA, Parameswaran L, Corcoran AT, Rohatgi A, Wronska MW, Wu X, Srinivasan R, Deng FM, Filardo TD, Pendse J, Blaser SB, Whyte O, Gallagher JM, Thomas OE, Ramos D, Sturm-Reganato CL, Fong CC, Daus IM, Payoen AG, Chiofolo JT, Friedman MT, Wu DW, Jacobson JL, Schneider JG, Sarwar UN, Wang HE, Huebinger RM, Dronavalli G, Bai Y, Grimes CZ, Eldin KW, Umana VE, Martin JG, Heath TR, Bello FO, Ransford DL, Laurent-Rolle M, Shenoi SV, Akide-Ndunge OB, Thapa B, Peterson JL, Knauf K, Patel SU, Cheney LL, Tormey CA, Hendrickson JE. Efficacy and Safety of COVID-19 Convalescent Plasma in Hospitalized Patients: A Randomized Clinical Trial. JAMA Intern Med 2022; 182:115-126. [PMID: 34901997 PMCID: PMC8669605 DOI: 10.1001/jamainternmed.2021.6850] [Citation(s) in RCA: 52] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE There is clinical equipoise for COVID-19 convalescent plasma (CCP) use in patients hospitalized with COVID-19. OBJECTIVE To determine the safety and efficacy of CCP compared with placebo in hospitalized patients with COVID-19 receiving noninvasive supplemental oxygen. DESIGN, SETTING, AND PARTICIPANTS CONTAIN COVID-19, a randomized, double-blind, placebo-controlled trial of CCP in hospitalized adults with COVID-19, was conducted at 21 US hospitals from April 17, 2020, to March 15, 2021. The trial enrolled 941 participants who were hospitalized for 3 or less days or presented 7 or less days after symptom onset and required noninvasive oxygen supplementation. INTERVENTIONS A unit of approximately 250 mL of CCP or equivalent volume of placebo (normal saline). MAIN OUTCOMES AND MEASURES The primary outcome was participant scores on the 11-point World Health Organization (WHO) Ordinal Scale for Clinical Improvement on day 14 after randomization; the secondary outcome was WHO scores determined on day 28. Subgroups were analyzed with respect to age, baseline WHO score, concomitant medications, symptom duration, CCP SARS-CoV-2 titer, baseline SARS-CoV-2 serostatus, and enrollment quarter. Outcomes were analyzed using a bayesian proportional cumulative odds model. Efficacy of CCP was defined as a cumulative adjusted odds ratio (cOR) less than 1 and a clinically meaningful effect as cOR less than 0.8. RESULTS Of 941 participants randomized (473 to placebo and 468 to CCP), 556 were men (59.1%); median age was 63 years (IQR, 52-73); 373 (39.6%) were Hispanic and 132 (14.0%) were non-Hispanic Black. The cOR for the primary outcome adjusted for site, baseline risk, WHO score, age, sex, and symptom duration was 0.94 (95% credible interval [CrI], 0.75-1.18) with posterior probability (P[cOR<1] = 72%); the cOR for the secondary adjusted outcome was 0.92 (95% CrI, 0.74-1.16; P[cOR<1] = 76%). Exploratory subgroup analyses suggested heterogeneity of treatment effect: at day 28, cORs were 0.72 (95% CrI, 0.46-1.13; P[cOR<1] = 93%) for participants enrolled in April-June 2020 and 0.65 (95% CrI, 0.41 to 1.02; P[cOR<1] = 97%) for those not receiving remdesivir and not receiving corticosteroids at randomization. Median CCP SARS-CoV-2 neutralizing titer used in April to June 2020 was 1:175 (IQR, 76-379). Any adverse events (excluding transfusion reactions) were reported for 39 (8.2%) placebo recipients and 44 (9.4%) CCP recipients (P = .57). Transfusion reactions occurred in 2 (0.4) placebo recipients and 8 (1.7) CCP recipients (P = .06). CONCLUSIONS AND RELEVANCE In this trial, CCP did not meet the prespecified primary and secondary outcomes for CCP efficacy. However, high-titer CCP may have benefited participants early in the pandemic when remdesivir and corticosteroids were not in use. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04364737.
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Affiliation(s)
- Mila B Ortigoza
- Division of Infectious Disease, Department of Medicine, NYU Grossman School of Medicine, New York, New York.,Department of Microbiology, NYU Grossman School of Medicine, New York, New York
| | - Hyunah Yoon
- Division of Infectious Disease, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
| | - Keith S Goldfeld
- Department of Population Health, NYU Grossman School of Medicine, New York, New York
| | - Andrea B Troxel
- Department of Population Health, NYU Grossman School of Medicine, New York, New York
| | - Johanna P Daily
- Division of Infectious Disease, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York.,Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, New York
| | - Yinxiang Wu
- Department of Population Health, NYU Grossman School of Medicine, New York, New York
| | - Yi Li
- Department of Population Health, NYU Grossman School of Medicine, New York, New York
| | - Danni Wu
- Department of Population Health, NYU Grossman School of Medicine, New York, New York
| | - Gia F Cobb
- Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | - Gillian Baptiste
- Department of Surgery, NYU Grossman School of Medicine, New York, New York
| | - Mary O'Keeffe
- Department of Medicine, NYU Long Island School of Medicine, Mineola, New York
| | - Marilou O Corpuz
- Division of Infectious Disease, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
| | - Luis Ostrosky-Zeichner
- Division of Infectious Disease, Department of Internal Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston
| | - Amee Amin
- Department of Emergency Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston
| | - Ioannis M Zacharioudakis
- Division of Infectious Disease, Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | - Dushyantha T Jayaweera
- Division of Infectious Disease, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida.,Miami Clinical and Translational Science Institute, University of Miami Miller School of Medicine Miami, Florida
| | - Yanyun Wu
- Department of Pathology, University of Miami Miller School of Medicine, Miami, Florida
| | - Julie V Philley
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, The University of Texas Health Science Center at Tyler, UTHealth East Texas, Tyler
| | - Megan S Devine
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, The University of Texas Health Science Center at Tyler, UTHealth East Texas, Tyler
| | - Mahalia S Desruisseaux
- Section of Infectious Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Alessandro D Santin
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut
| | - Shweta Anjan
- Division of Infectious Disease, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Reeba Mathew
- Division of Critical Care, Department of Internal Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston
| | - Bela Patel
- Division of Critical Care, Department of Internal Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston
| | - Masayuki Nigo
- Division of Infectious Disease, Department of Internal Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston
| | - Rabi Upadhyay
- Department of Medicine, NYU Grossman School of Medicine, New York, New York.,Laura and Isaac Perlmutter Cancer Center, NYU Grossman School of Medicine, New York, New York
| | - Tania Kupferman
- Division of Infectious Disease, Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | - Andrew N Dentino
- Department of Internal Medicine, The University of Texas Rio Grande Valley, Edinburg
| | - Rahul Nanchal
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Christian A Merlo
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - David N Hager
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Kartik Chandran
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, New York
| | - Jonathan R Lai
- Department of Biochemistry, Albert Einstein College of Medicine, Bronx, New York
| | - Johanna Rivera
- Division of Infectious Disease, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York.,Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, New York
| | - Chowdhury R Bikash
- Department of Biochemistry, Albert Einstein College of Medicine, Bronx, New York
| | - Gorka Lasso
- Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, New York
| | - Timothy P Hilbert
- Department of Pathology, NYU Grossman School of Medicine, New York, New York
| | - Monika Paroder
- Department of Pathology, Albert Einstein College of Medicine, Bronx, New York
| | - Andrea A Asencio
- Division of Infectious Disease, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
| | - Mengling Liu
- Department of Population Health, NYU Grossman School of Medicine, New York, New York.,Department of Environmental Health, NYU Grossman School of Medicine, New York, New York
| | - Eva Petkova
- Department of Population Health, NYU Grossman School of Medicine, New York, New York.,Department of Child and Adolescent Psychiatry, NYU Grossman School of Medicine, New York.,Nathan S. Kline Institute for Psychiatric Research, Orangeburg, New York
| | - Alexander Bragat
- Clinical Research Information Technology and Informatics, NYU Grossman School of Medicine, New York, New York
| | - Reza Shaker
- Clinical and Translational Science Institute of Southern Wisconsin, Medical College of Wisconsin Milwaukee
| | - David D McPherson
- Center for Clinical and Translational Sciences, Division of Cardiovascular Medicine, Department of Internal Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston
| | - Ralph L Sacco
- Miami Clinical and Translational Science Institute, University of Miami Miller School of Medicine Miami, Florida
| | - Marla J Keller
- Division of Infectious Disease, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York.,Harold and Muriel Block Institute for Clinical and Translational Research, Albert Einstein College of Medicine and Montefiore Medical Center Bronx, New York
| | - Corita R Grudzen
- Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, New York.,NYC Health and Hospitals Corporation Clinical and Translational Science Institute, NYU Grossman School of Medicine, New York, New York
| | - Judith S Hochman
- NYC Health and Hospitals Corporation Clinical and Translational Science Institute, NYU Grossman School of Medicine, New York, New York.,Leon H. Charney Division of Cardiology, Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | - Liise-Anne Pirofski
- Division of Infectious Disease, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York.,Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, New York
| | | | - Lalitha Parameswaran
- Division of Infectious Disease, Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | - Anthony T Corcoran
- Department of Urology, NYU Long Island School of Medicine, Mineola, New York
| | - Abhinav Rohatgi
- Department of Medicine, NYU Long Island School of Medicine, Mineola, New York
| | - Marta W Wronska
- Department of Medicine, NYU Long Island School of Medicine, Mineola, New York
| | - Xinyuan Wu
- Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | - Ranjini Srinivasan
- Department of Pediatrics, NYU Grossman School of Medicine, New York, New York
| | - Fang-Ming Deng
- Department of Pathology, NYU Grossman School of Medicine, New York, New York
| | - Thomas D Filardo
- Division of Infectious Disease, Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | - Jay Pendse
- Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | - Simone B Blaser
- Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | - Olga Whyte
- Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | | | - Ololade E Thomas
- Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | - Danibel Ramos
- Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | | | - Charlotte C Fong
- Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | - Ivy M Daus
- Department of Medicine, NYU Grossman School of Medicine, New York, New York
| | | | - Joseph T Chiofolo
- Department of Pathology, NYU Long Island School of Medicine, Mineola, New York
| | - Mark T Friedman
- Department of Pathology, NYU Long Island School of Medicine, Mineola, New York
| | - Ding Wen Wu
- Department of Pathology, NYU Grossman School of Medicine, New York, New York
| | - Jessica L Jacobson
- Department of Pathology, NYU Grossman School of Medicine, New York, New York
| | - Jeffrey G Schneider
- Department of Medicine, NYU Long Island School of Medicine, Mineola, New York
| | - Uzma N Sarwar
- Division of Infectious Disease, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York.,Pfizer Vaccine Clinical Research and Development, Pfizer Inc, Pearl River, New York
| | - Henry E Wang
- Department of Emergency Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston.,Department of Emergency Medicine, The Ohio State University, Ohio
| | - Ryan M Huebinger
- Department of Emergency Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston
| | - Goutham Dronavalli
- Division of Critical Care, Department of Internal Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston
| | - Yu Bai
- Department of Pathology and Laboratory Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston
| | - Carolyn Z Grimes
- Division of Infectious Disease, Department of Internal Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston
| | - Karen W Eldin
- Department of Pathology and Laboratory Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston
| | - Virginia E Umana
- Division of Infectious Disease, Department of Internal Medicine, The University of Texas Health Science Center at Houston, McGovern Medical School, Houston
| | - Jessica G Martin
- Department of Internal Medicine, The University of Texas Rio Grande Valley, Edinburg
| | - Timothy R Heath
- Department of Internal Medicine, The University of Texas Rio Grande Valley, Edinburg
| | - Fatimah O Bello
- Department of Internal Medicine, The University of Texas Rio Grande Valley, Edinburg
| | - Daru Lane Ransford
- Miami Clinical and Translational Science Institute, University of Miami Miller School of Medicine Miami, Florida
| | - Maudry Laurent-Rolle
- Section of Infectious Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Sheela V Shenoi
- Section of Infectious Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Oscar Bate Akide-Ndunge
- Section of Infectious Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Bipin Thapa
- Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Jennifer L Peterson
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee
| | - Kelly Knauf
- Clinical and Translational Science Institute of Southern Wisconsin, Medical College of Wisconsin Milwaukee
| | - Shivani U Patel
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Laura L Cheney
- Division of Infectious Disease, Department of Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York
| | - Christopher A Tormey
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Jeanne E Hendrickson
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut.,Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut
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8
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Bar KJ, Shaw PA, Choi GH, Aqui N, Fesnak A, Yang JB, Soto-Calderon H, Grajales L, Starr J, Andronov M, Mastellone M, Amonu C, Feret G, DeMarshall M, Buchanan M, Caturla M, Gordon J, Wanicur A, Monroy MA, Mampe F, Lindemuth E, Gouma S, Mullin AM, Barilla H, Pronina A, Irwin L, Thomas R, Eichinger RA, Demuth F, Luning Prak ET, Pascual JL, Short WR, Elovitz MA, Baron J, Meyer NJ, Degnan KO, Frank I, Hensley SE, Siegel DL, Tebas P. A randomized controlled study of convalescent plasma for individuals hospitalized with COVID-19 pneumonia. J Clin Invest 2021; 131:e155114. [PMID: 34788233 PMCID: PMC8670841 DOI: 10.1172/jci155114] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 11/01/2021] [Indexed: 11/17/2022] Open
Abstract
BackgroundAntibody-based strategies for COVID-19 have shown promise in prevention and treatment of early disease. COVID-19 convalescent plasma (CCP) has been widely used but results from randomized trials supporting its benefit in hospitalized patients with pneumonia are limited. Here, we assess the efficacy of CCP in severely ill, hospitalized adults with COVID-19 pneumonia.MethodsWe performed a randomized control trial (PennCCP2), with 80 adults hospitalized with COVID-19 pneumonia, comparing up to 2 units of locally sourced CCP plus standard care versus standard care alone. The primary efficacy endpoint was comparison of a clinical severity score. Key secondary outcomes include 14- and 28-day mortality, 14- and 28-day maximum 8-point WHO ordinal score (WHO8) score, duration of supplemental oxygenation or mechanical ventilation, respiratory SARS-CoV-2 RNA, and anti-SARS-CoV-2 antibodies.ResultsEighty hospitalized adults with confirmed COVID-19 pneumonia were enrolled at median day 6 of symptoms and day 1 of hospitalization; 60% were anti-SARS-CoV-2 antibody seronegative. Participants had a median of 3 comorbidities, including risk factors for severe COVID-19 and immunosuppression. CCP treatment was safe and conferred significant benefit by clinical severity score (median [MED] and interquartile range [IQR] 10 [5.5-30] vs. 7 [2.75-12.25], P = 0.037) and 28-day mortality (n = 10, 26% vs. n = 2, 5%; P = 0.013). All other prespecified outcome measures showed weak evidence toward benefit of CCP.ConclusionTwo units of locally sourced CCP administered early in hospitalization to majority seronegative participants conferred a significant benefit in clinical severity score and 28-day mortality. Results suggest CCP may benefit select populations, especially those with comorbidities who are treated early.Trial RegistrationClinicalTrials.gov NCT04397757.FundingUniversity of Pennsylvania.
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Affiliation(s)
- Katharine J. Bar
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Pamela A. Shaw
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Kaiser Permanente Washington Health Research Group, Seattle, Washington, USA
| | - Grace H. Choi
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nicole Aqui
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew Fesnak
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jasper B. Yang
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Kaiser Permanente Washington Health Research Group, Seattle, Washington, USA
| | | | - Lizette Grajales
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Julie Starr
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michelle Andronov
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Miranda Mastellone
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Chigozie Amonu
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Geoff Feret
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Maureen DeMarshall
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Marie Buchanan
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Maria Caturla
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - James Gordon
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Alan Wanicur
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - M. Alexandra Monroy
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Felicity Mampe
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Emily Lindemuth
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sigrid Gouma
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anne M. Mullin
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Holly Barilla
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anastasiya Pronina
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Leah Irwin
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Raeann Thomas
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Risa A. Eichinger
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Faye Demuth
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Eline T. Luning Prak
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jose L. Pascual
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - William R. Short
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michal A. Elovitz
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jillian Baron
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Nuala J. Meyer
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Kathleen O. Degnan
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ian Frank
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Scott E. Hensley
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Donald L. Siegel
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Pablo Tebas
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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