Oral corticoid, aspirin, anticoagulant, colchicine, and furosemide to improve the outcome of hospitalized COVID-19 patients - the COCAA-COLA cohort study

Oral Colchicine and Low-Dose Aspirin Combination Therapy for Non-elderly, Non-severe, Early Time From Onset, Adult Outpatients with Coronavirus Disease 2019 (COVID-19) during "The Fifth Pandemic Wave" in Japan

BACKGROUND

Treatment with antiviral drugs for non-severe, early time from onset, adult outpatients with Coronavirus Disease 2019 (COVID-19) had not been established in 2021. However, some new variants of SARS-CoV-2 had caused rapid exacerbation and hospitalization among non-elderly outpatients with COVID-19, contributing to widespread crises within healthcare systems.

METHODS

From July to October 2021, we urgently assessed a therapeutic program using oral colchicine (1.0 mg loading dose, followed approximately half a day later by 0.5 mg twice daily for 5 days, and then 0.5 mg once daily for 4 days) and low-dose aspirin (100 mg once daily for 10 days), for non-elderly, non-severe, early time from onset, adult outpatients with COVID-19. To verify its effectiveness, we set loxoprofen as a control arm, and com parison of these two arms was performed. The primary outcomes were hospitalization, criticality, and death rates.

RESULTS

Thirty-eight patients (23 receiving colchicine and low-dose aspirin [CA]; 15 receiving loxoprofen [LO]) were evaluated. Hospitalization rate was lower in the CA group (1/23; 4.3%) than in the LO group (2/15; 13.3%); however, no significant difference was found between the two groups (p=0.34). No critical cases, deaths, or severe adverse events were found in either group.

CONCLUSIONS

Our CA regimen did not show superiority over LO treatment. However, our clinical experience should be recorded as part of community health care activities carried out in Kurume City against the unprece dented COVID-19 pandemic.

Effect of increasing doses of colchicine on the treatment of 333 COVID-19 inpatients

BACKGROUND

Previous research done in Bulgaria demonstrated a fivefold reduction in mortality from COVID-19 with increased doses of colchicine from two hospitals in the country. We report here a further 333 cases of COVID-19 inpatients, treated with different doses of colchicine and its effect on mortality.

MATERIALS AND METHODS

A case-control comparison from two additional hospitals was conducted between increased doses of colchicine and added bromhexine to standard of care (SOC) versus current SOC. Risk and odds ratio, as well as subgroup analysis, was conducted with newly reported data, alongside aggregate data from all hospital centers to determine the extent of mortality reduction in COVID-19 inpatients.

RESULTS

There was a clear reduction in the mortality of inpatients with increasing doses of colchicine-between twofold and sevenfold. Colchicine loading doses of 4 mg are more effective than those with 2 mg. Despite these doses being higher than the so-called "standard doses," colchicine inpatients experienced lower mortality than SOC patients (5.7% vs. 19.53%). This mortality benefit was evident in different age subgroups, with a 4-mg loading dose of colchicine proving slightly superior to a 2-mg loading dose. Colchicine led to an overall relative risk reduction of 70.7%, with SOC patients having 3.91 higher odds of death. The safety of the doses was not different than the reported in the summary of product characteristics.

CONCLUSION

Inpatients in Bulgaria with added colchicine and bromhexine to SOC achieved better clinical and mortality outcomes than those on SOC alone. These results question the World Health Organization-recommended strategy to inhibit viral replication. We posit that our treatment strategy to inhibit the Severe acute respiratory syndrome coronavirus 2 entry into the cell with inhaled bromhexine and the hyperactivated NLRP3 inflammasome with higher doses of colchicine, prevents the development of cytokine storm. The timing of the initiation of treatment seems critical.

Fluid restriction management in the treatment of COVID-19: a single-center observational study

The relationship between fluid management and the severity of illness, duration of treatment, and outcome of coronavirus disease 2019 (COVID-19) is not fully understood. This study aimed to evaluate whether weight change during hospitalization was associated with COVID-19 severity, length of hospital stay, and route of admission. In this study, we assessed the effectiveness of fluid restriction management in patients with severe COVID-19. COVID-19 patients admitted to our hospital between July 2020 and October 2021 were analyzed. Patients were treated with standard drug therapy based on the Japanese guidelines and respiratory support according to the severity of the disease. Early enteral nutrition, defecation management, and anticoagulation therapy were also administered. Fluid restriction management was performed using furosemide and continuous renal replacement therapy as needed unless hemodynamic instability or hyperlactatemia was present. Patient background, route of admission (ambulance, A; transfer, T), weight at admission and discharge, the severity of illness (oxygen therapy, G1; mechanical ventilation, G2; extracorporeal membrane oxygenation, G3), in-hospital mortality, and length of hospital stay were analyzed. There were 116 subjects: G1 (n = 48), G2 (n = 43), and G3 (n = 25), with ages (median [IQR]) of 58 (47-70), 65 (53-71.5), 56 (51-62) years, 40 (83.3%), 31 (72.1%), and 19 (76.0%) males, respectively. Hospital stays were 4.5 (2-7), 10 (7-16), and 18 (15-26) days, and the in-hospital mortality rates were 0 (0%), 7 (16.3%), and 8 (32%), respectively. Body mass index on admission was 26 (23.1-30.2), 27.1 (22.7-31.1), and 31.5 (27.1-33.1) kg/m2, and weight loss during admission was 1.1 (0-2.9), 4.6 (2.3-5.7), 9.2 (5.6-10.5) kg (P < 0.001, Jonckheere-Terpstra test. Weight loss in the severe group (G2 + G3) was 3.4 (0.5-5.8) kg [A, n = 12] and 5.6 (4.4-9) kg [T, n = 43] [P = 0.026, Mann-Whitney U test]. The lengths of hospital stay were 5 (2-7), 9 (7-15), and 18 (12-26) days [P < 0.001, Jonckheere-Terpstra test]. In our fluid restriction management, patients with severe COVID-19 had significant longer hospital length of stay, weight loss, especially those who were transferred to the hospital.

Associations between the use of aspirin or other antiplatelet drugs and all-cause mortality among patients with COVID-19: A meta-analysis

Introduction: Whether aspirin or other antiplatelet drugs can reduce mortality among patients with coronavirus disease (COVID-19) remains controversial.

Methods: We identified randomized controlled trials, prospective cohort studies, and retrospective studies on associations between aspirin or other antiplatelet drug use and all-cause mortality among patients with COVID-19 in the PubMed database between March 2019 and September 2021. Newcastle–Ottawa Scale and Cochrane Risk of Bias Assessment Tool were used to assess the risk of bias. The I2 statistic was used to assess inconsistency among trial results. The summary risk ratio (RR) and odds ratio (OR) were obtained through the meta-analysis.

Results: The 34 included studies comprised three randomized controlled trials, 27 retrospective studies, and 4 prospective cohort studies. The retrospective and prospective cohort studies showed low-to-moderate risks of bias per the Newcastle–Ottawa Scale score, while the randomized controlled trials showed low-to-high risks of bias per the Cochrane Risk of Bias Assessment Tool. The randomized controlled trials showed no significant effect of aspirin use on all-cause mortality in patients with COVID-19 {risk ratio (RR), 0.96 [95% confidence interval (CI) 0.90–1.03]}. In retrospective studies, aspirin reduced all-cause mortality in patients with COVID-19 by 20% [odds ratio (OR), 0.80 (95% CI 0.70–0.93)], while other antiplatelet drugs had no significant effects. In prospective cohort studies, aspirin decreased all-cause mortality in patients with COVID-19 by 15% [OR, 0.85 (95% CI 0.80–0.90)].

Conclusion: The administration of aspirin may reduce all-cause mortality in patients with COVID-19.

Colchicine for the Treatment of Cardiac Injury in Hospitalized Patients With Coronavirus Disease-19

Introduction

The impact of colchicine on hospitalized patients with Coronavirus disease-19 (COVID-19) related cardiac injury is unknown.

Materials and Methods

In this multicenter randomized controlled open-label clinical trial, we randomized hospitalized adult patients with documented COVID-19 and evidence of cardiac injury in a 1:1 ratio to either colchicine 0.6 mg po twice daily for 30 days plus standard of care or standard of care alone. Cardiac injury was defined as elevated cardiac biomarkers, new arrhythmia, new/worsened left ventricular dysfunction, or new pericardial effusion. The primary endpoint was the composite of all-cause mortality, need for mechanical ventilation, or need for mechanical circulatory support (MCS) at 90 days. Key secondary endpoints included the individual components of the primary endpoint and change in and at least 2-grade reduction in the World Health Organization (WHO) Ordinal Scale at 30 days. The trial is registered with clinicaltrials.gov (NCT04355143).

Results

We enrolled 93 patients, 48 patients in the colchicine arm and 45 in the control arm. There was no significant difference in the primary outcome between the colchicine and control arms (19 vs. 15%, p = 0.78), nor in the individual components of all-cause mortality (17 vs. 15%, p = 1.0) and need for mechanical ventilation (8 vs. 5%, p = 0.68); no patients in either group required MCS. The change in (-1.8 ± 2.4 vs. -1.2 ± 2.0, p = 0.12) and at least 2-grade reduction (75 vs. 75%, p = 1.0) in the WHO ordinal scale was also similar between groups.

Conclusion

Patients hospitalized with COVID-19 and evidence of cardiac injury did not benefit from colchicine therapy.

Colchicine Against SARS-CoV-2 Infection: What is the Evidence?

Coronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a matter of concern worldwide and a huge challenge for rheumatologists. Indeed, several antirheumatic drugs are currently used at different stages of COVID-19, such as several cytokine inhibitors and colchicine. Colchicine is one of the oldest medicines with potent anti-inflammatory properties. In rheumatic diseases it is widely used for the treatment of gout, calcium pyrophosphate deposition disease, and familial Mediterranean fever. It is also used off-label in cardiology to treat atrial fibrillation, pericarditis, and myocardial infarction. Over the last few years, advances in the understanding of colchicine's mechanism of action and its pharmacology and safety have made colchicine a promising candidate agent for the fight against COVID-19. In this review, we discuss COVID-19 pathophysiology highlighting colchicine's mode of action, its pleiotropic effects on neutrophils, inflammasome inhibition, and its viral activity. Finally, we discuss the main clinical studies dealing with the use of colchicine in COVID-19. Given the large body of evidence that demonstrates its effectiveness, safety, and its simple way of administration, colchicine seems to be a promising drug to reduce the risk of severe COVID-19 disease.

Use of aspirin in reduction of mortality of COVID-19 patients: A meta-analysis

COVID-19 infection, affecting every one of us from the last year. Emerging reports have indicated thromboembolism in serious cases of COVID-19. The aspirin is useful to reduce mortality of serious patients with acute respiratory distress syndrome without COVID-19. Thus, we have conducted a metanalysis to find out the role of aspirin in the mortality of COVID-19 patients using RevMan 5. A total of 10 studies containing 56 696 COVID-19 patients were found appropriate for quantitative analysis. The quality of articles was assessed using Newcastle-Ottawa scale. The fixed-effect model was used to calculate the odds ratio with 95% confidence interval (CI). The odd ratio was found to be 0.70 [0.63, 0.77] which indicates a lesser likelihood of having death in COVID-19 patients in aspirin group as compared with non-aspirin group. However, no effect 0.00 [-0.04, 0.04] was observed after the exclusion of outliers. Thus, further clinical evidence is required to make valid conclusion.

Immunologic Dysregulation and Hypercoagulability as a Pathophysiologic Background in COVID-19 Infection and the Immunomodulating Role of Colchicine

In 2020, SARS-COV-2 put health systems under unprecedented resource and manpower pressure leading to significant number of deaths. Expectedly, researchers sought to shed light on the pathophysiologic background of this novel disease (COVID-19) as well as to facilitate the design of effective therapeutic modalities. Indeed, early enough the pivotal role of inflammatory and thrombotic pathways in SARS-COV-2 infection has been illustrated. The purpose of this article is to briefly present the epidemiologic and clinical features of COVID-19, analyze the pathophysiologic importance of immunologic dysregulation and hypercoagulability in developing disease complications and finally to present an up-to-date systematic review of colchicine's immunomodulating capacity in view of hindering coronavirus complications.

Repurposing Colchicine in Treating Patients with COVID-19: A Systematic Review and Meta-Analysis

Coronavirus disease 2019 (COVID-19) had caused huge health losses worldwide. Several drugs had been applied to treat patients with COVID-19, and repurposing colchicine had been proposed for its anti-inflammatory properties via several pathways. In this systematic review, we evaluated the effects of colchicine treatment. From inception to May 31, 2021, databases, including PubMed, EMbase, medRxiv, and Research Square were searched, and 11 studies were enrolled. A total of 17,205 COVID-19 patients with male predominance (62.9%) were analyzed. Patients with colchicine treatment had a significantly lower risk of mortality (odds ratio (OR): 0.57, 95% confidence interval (CI): 0.38-0.87, I2: 72%; p < 0.01) and a non-significantly lower rate of mechanical ventilation (OR: 0.67, 95%CI: 0.39-1.15). The side effects were mild and not significantly different (OR: 2.03, 95%CI: 0.51-8.09). Subgroup analysis with randomized controlled trials showed no statistically significant difference in the mortality (OR: 0.80, 95%CI: 0.44-1.46, I2: 33%; p = 0.22). In conclusion, our meta-analysis found that colchicine treatment was associated with a significantly lower risk of mortality in patients with COVID-19. However, this benefit was not observed in the subgroup analysis of randomized controlled trials. Further randomized controlled studies are required to confirm the potential benefits of colchicine treatment.

Application of an evidence-based, out-patient treatment strategy for COVID-19: Multidisciplinary medical practice principles to prevent severe disease

The COVID-19 pandemic has devastated individuals, families, and institutions throughout the world. Despite the breakneck speed of vaccine development, the human population remains at risk of further devastation. The decision to not become vaccinated, the protracted rollout of available vaccine, vaccine failure, mutational forms of the SARS virus, which may exhibit mounting resistance to our molecular strike at only one form of the viral family, and the rapid ability of the virus(es) to hitch a ride on our global transportation systems, means that we are will likely continue to confront an invisible, yet devastating foe. The enemy targets one of our human physiology's most important and vulnerable life-preserving body tissues, our broncho-alveolar gas exchange apparatus. Notwithstanding the fear and the fury of this microbe's potential to raise existential questions across the entire spectrum of human endeavor, the application of an early treatment intervention initiative may represent a crucial tool in our defensive strategy. This strategy is driven by evidence-based medical practice principles, those not likely to become antiquated, given the molecular diversity and mutational evolution of this very clever "world traveler".

Active prescription of low-dose aspirin during or prior to hospitalization and mortality in COVID-19: A systematic review and meta-analysis of adjusted effect estimates

Background

This study aimed to investigate whether the active prescription of low-dose aspirin during or prior to hospitalization affects mortality in patients with coronavirus disease 2019 (COVID-19). Aspirin is often prescribed for secondary prevention in patients with cardiovascular disease and other comorbidities that might increase mortality, and may therefore falsely demonstrate increased mortality. To reduce bias, only studies that performed an adjusted analysis were included in this review.

Methods

A systematic literature search of PubMed, Scopus, Embase and Clinicaltrials.gov was performed, from inception until 16 April 2021. The exposure was active prescription of low-dose aspirin during or prior to hospitalization. The primary outcome was mortality. The pooled adjusted effect estimate was reported as relative risk (RR).

Results

Six eligible studies were included in this meta-analysis, comprising 13,993 patients. The studies had low-to-moderate risk of bias based on the Newcastle–Ottawa Scale. The meta-analysis indicated that the use of low-dose aspirin was independently associated with reduced mortality {RR 0.46 [95% confidence interval (CI) 0.35–0.61], P < 0.001; I² = 36.2%}. Subgroup analysis on in-hospital low-dose aspirin administration also showed a significant reduction in mortality [RR 0.39 (95% CI 0.16–0.96), P < 0.001; I² = 47.0%].

Conclusion

Use of low-dose aspirin is independently associated with reduced mortality in patients with COVID-19, with low certainty of evidence.