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Wannigama DL, Hurst C, Phattharapornjaroen P, Hongsing P, Sirichumroonwit N, Chanpiwat K, Rad S.M. AH, Storer RJ, Ounjai P, Kanthawee P, Ngamwongsatit N, Kupwiwat R, Kupwiwat C, Brimson JM, Devanga Ragupathi NK, Charuluxananan S, Leelahavanichkul A, Kanjanabuch T, Higgins PG, Badavath VN, Amarasiri M, Verhasselt V, Kicic A, Chatsuwan T, Pirzada K, Jalali F, Reiersen AM, Abe S, Ishikawa H. Early treatment with fluvoxamine, bromhexine, cyproheptadine, and niclosamide to prevent clinical deterioration in patients with symptomatic COVID-19: a randomized clinical trial. EClinicalMedicine 2024; 70:102517. [PMID: 38516100 PMCID: PMC10955208 DOI: 10.1016/j.eclinm.2024.102517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 02/08/2024] [Accepted: 02/19/2024] [Indexed: 03/23/2024] Open
Abstract
Background Repurposed drugs with host-directed antiviral and immunomodulatory properties have shown promise in the treatment of COVID-19, but few trials have studied combinations of these agents. The aim of this trial was to assess the effectiveness of affordable, widely available, repurposed drugs used in combination for treatment of COVID-19, which may be particularly relevant to low-resource countries. Methods We conducted an open-label, randomized, outpatient, controlled trial in Thailand from October 1, 2021, to June 21, 2022, to assess whether early treatment within 48-h of symptoms onset with combinations of fluvoxamine, bromhexine, cyproheptadine, and niclosamide, given to adults with confirmed mild SARS-CoV-2 infection, can prevent 28-day clinical deterioration compared to standard care. Participants were randomly assigned to receive treatment with fluvoxamine alone, fluvoxamine + bromhexine, fluvoxamine + cyproheptadine, niclosamide + bromhexine, or standard care. The primary outcome measured was clinical deterioration within 9, 14, or 28 days using a 6-point ordinal scale. This trial is registered with ClinicalTrials.gov (NCT05087381). Findings Among 1900 recruited, a total of 995 participants completed the trial. No participants had clinical deterioration by day 9, 14, or 28 days among those treated with fluvoxamine plus bromhexine (0%), fluvoxamine plus cyproheptadine (0%), or niclosamide plus bromhexine (0%). Nine participants (5.6%) in the fluvoxamine arm had clinical deterioration by day 28, requiring low-flow oxygen. In contrast, most standard care arm participants had clinical deterioration by 9, 14, and 28 days. By day 9, 32.7% (110) of patients in the standard care arm had been hospitalized without requiring supplemental oxygen but needing ongoing medical care. By day 28, this percentage increased to 37.5% (21). Additionally, 20.8% (70) of patients in the standard care arm required low-flow oxygen by day 9, and 12.5% (16) needed non-invasive or mechanical ventilation by day 28. All treated groups significantly differed from the standard care group by days 9, 14, and 28 (p < 0.0001). Also, by day 28, the three 2-drug treatments were significantly better than the fluvoxamine arm (p < 0.0001). No deaths occurred in any study group. Compared to standard care, participants treated with the combination agents had significantly decreased viral loads as early as day 3 of treatment (p < 0.0001), decreased levels of serum cytokines interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), and interleukin-1 beta (IL-1β) as early as day 5 of treatment, and interleukin-8 (IL-8) by day 7 of treatment (p < 0.0001) and lower incidence of post-acute sequelae of COVID-19 (PASC) symptoms (p < 0.0001). 23 serious adverse events occurred in the standard care arm, while only 1 serious adverse event was reported in the fluvoxamine arm, and zero serious adverse events occurred in the other arms. Interpretation Early treatment with these combinations among outpatients diagnosed with COVID-19 was associated with lower likelihood of clinical deterioration, and with significant and rapid reduction in the viral load and serum cytokines, and with lower burden of PASC symptoms. When started very soon after symptom onset, these repurposed drugs have high potential to prevent clinical deterioration and death in vaccinated and unvaccinated COVID-19 patients. Funding Ped Thai Su Phai (Thai Ducks Fighting Danger) social giver group.
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Affiliation(s)
- Dhammika Leshan Wannigama
- Department of Infectious Diseases and Infection Control, Yamagata Prefectural Central Hospital, Yamagata, Japan
- Department of Microbiology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- Center of Excellence in Antimicrobial Resistance and Stewardship, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- School of Medicine, Faculty of Health and Medical Sciences, The University of Western Australia, Nedlands, Western Australia, Australia
- Biofilms and Antimicrobial Resistance Consortium of ODA Receiving Countries, The University of Sheffield, Sheffield, United Kingdom
- Pathogen Hunter's Research Collaborative Team, Department of Infectious Diseases and Infection Control, Yamagata Prefectural Central Hospital, Yamagata, Japan
- Yamagata Prefectural University of Health Sciences, Kamiyanagi, Yamagata, 990-2212, Japan
| | - Cameron Hurst
- Molly Wardaguga Research Centre, Charles Darwin University, Queensland, Australia
| | - Phatthranit Phattharapornjaroen
- Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- Institute of Clinical Sciences, Department of Surgery, Sahlgrenska Academy, Gothenburg University, 40530, Gothenburg, Sweden
| | - Parichart Hongsing
- Mae Fah Luang University Hospital, Chiang Rai, Thailand
- School of Integrative Medicine, Mae Fah Luang University, Chiang Rai, Thailand
| | - Natchalaikorn Sirichumroonwit
- Institute of Medical Research and Technology Assessment, Department of Medical Services, Ministry of Public Health, Thailand
| | | | - Ali Hosseini Rad S.M.
- Department of Microbiology and Immunology, University of Otago, Dunedin, 9010, Otago, New Zealand
- Center of Excellence in Immunology and Immune-Mediated Diseases, Chulalongkorn University, Bangkok, 10330, Thailand
| | - Robin James Storer
- Office of Research Affairs, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Puey Ounjai
- Department of Biology, Faculty of Science, Mahidol University, Bangkok, Thailand
| | - Phitsanuruk Kanthawee
- Public Health Major, School of Health Science, Mae Fah Luang University, Chiang Rai, Thailand
| | - Natharin Ngamwongsatit
- Department of Clinical Sciences and Public Health, Faculty of Veterinary Science, Mahidol University, Nakhon Pathom, Thailand
| | - Rosalyn Kupwiwat
- Department of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chaisit Kupwiwat
- Department of Critical Care Medicine, Vibhavadi Hospital, Bangkok, Thailand
| | - James Michael Brimson
- Department of Innovation and International Affair, Faculty of Allied Health Sciences, Chulalongkorn University, Bangkok, Thailand
| | - Naveen Kumar Devanga Ragupathi
- Biofilms and Antimicrobial Resistance Consortium of ODA Receiving Countries, The University of Sheffield, Sheffield, United Kingdom
- Department of Chemical and Biological Engineering, The University of Sheffield, Sheffield, United Kingdom
- Division of Microbial Interactions, Department of Research and Development, Bioberrys Healthcare and Research Centre, Vellore, 632009, India
| | - Somrat Charuluxananan
- Department of Anesthesiology, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Asada Leelahavanichkul
- Department of Microbiology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- Translational Research in Inflammation and Immunology Research Unit (TRIRU), Department of Microbiology, Chulalongkorn University, Bangkok, Thailand
| | - Talerngsak Kanjanabuch
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Center of Excellence in Kidney Metabolic Disorders, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Dialysis Policy and Practice Program (DiP3), School of Global Health, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- Peritoneal Dialysis Excellence Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Paul G. Higgins
- Institute for Medical Microbiology, Immunology and Hygiene, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
- German Centre for Infection Research, Partner Site Bonn-Cologne, Cologne, Germany
- Center for Molecular Medicine Cologne, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50935, Cologne, Germany
| | - Vishnu Nayak Badavath
- School of Pharmacy & Technology Management, SVKM's Narsee Monjee Institute of Management Studies (NMIMS), Hyderabad, 509301, India
| | - Mohan Amarasiri
- Laboratory of Environmental Hygiene, Department of Health Science, School of Allied Health Sciences, Graduate School of Medical Sciences, Kitasato University, Kitasato, Sagamihara-Minami, Kanagawa, 252-0373, Japan
| | - Valerie Verhasselt
- Centre of Research for Immunology and Breastfeeding (CIBF), Medical School and School of Biomedical Science, University of Western Australia, Perth, Western Australia, 6009, Australia
- Immunology and Breastfeeding Group, Neonatal and Life Course Health Program, Telethon Kids Institute, Perth, Western Australia, 6009, Australia
| | - Anthony Kicic
- Telethon Kids Institute, University of Western Australia, Nedlands, 6009, Western Australia, Australia
- Centre for Cell Therapy and Regenerative Medicine, Medical School, The University of Western Australia, Nedlands, 6009, Western Australia, Australia
- Department of Respiratory and Sleep Medicine, Perth Children's Hospital, Nedlands, 6009, Western Australia, Australia
- School of Public Health, Curtin University, Bentley, 6102, Western Australia, Australia
| | - Tanittha Chatsuwan
- Department of Microbiology, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- Center of Excellence in Antimicrobial Resistance and Stewardship, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kashif Pirzada
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Ontario, Canada
| | - Farid Jalali
- Department of Gastroenterology, Saddleback Medical Group, Laguna Hills, CA, United States
| | - Angela M. Reiersen
- Department of Psychiatry, School of Medicine, Washington University in St. Louis, St. Louis, MO, United States
| | - Shuichi Abe
- Department of Infectious Diseases and Infection Control, Yamagata Prefectural Central Hospital, Yamagata, Japan
| | - Hitoshi Ishikawa
- Yamagata Prefectural University of Health Sciences, Kamiyanagi, Yamagata, 990-2212, Japan
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Rajasekhar P, Carbone SE, Johnston ST, Nowell CJ, Wiklendt L, Crampin EJ, She Y, DiCello JJ, Saito A, Sorensen L, Nguyen T, Lee KM, Hamilton JA, King SK, Eriksson EM, Spencer NJ, Gulbransen BD, Veldhuis NA, Poole DP. TRPV4 is expressed by enteric glia and muscularis macrophages of the colon but does not play a prominent role in colonic motility. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.01.09.574831. [PMID: 38260314 PMCID: PMC10802399 DOI: 10.1101/2024.01.09.574831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Background Mechanosensation is an important trigger of physiological processes in the gastrointestinal tract. Aberrant responses to mechanical input are associated with digestive disorders, including visceral hypersensitivity. Transient Receptor Potential Vanilloid 4 (TRPV4) is a mechanosensory ion channel with proposed roles in visceral afferent signaling, intestinal inflammation, and gut motility. While TRPV4 is a potential therapeutic target for digestive disease, current mechanistic understanding of how TRPV4 may influence gut function is limited by inconsistent reports of TRPV4 expression and distribution. Methods In this study we profiled functional expression of TRPV4 using Ca2+ imaging of wholemount preparations of the mouse, monkey, and human intestine in combination with immunofluorescent labeling for established cellular markers. The involvement of TRPV4 in colonic motility was assessed in vitro using videomapping and contraction assays. Results The TRPV4 agonist GSK1016790A evoked Ca2+ signaling in muscularis macrophages, enteric glia, and endothelial cells. TRPV4 specificity was confirmed using TRPV4 KO mouse tissue or antagonist pre-treatment. Calcium responses were not detected in other cell types required for neuromuscular signaling including enteric neurons, interstitial cells of Cajal, PDGFRα+ cells, and intestinal smooth muscle. TRPV4 activation led to rapid Ca2+ responses by a subpopulation of glial cells, followed by sustained Ca2+ signaling throughout the enteric glial network. Propagation of these waves was suppressed by inhibition of gap junctions or Ca2+ release from intracellular stores. Coordinated glial signaling in response to GSK1016790A was also disrupted in acute TNBS colitis. The involvement of TRPV4 in the initiation and propagation of colonic motility patterns was examined in vitro. Conclusions We reveal a previously unappreciated role for TRPV4 in the initiation of distension-evoked colonic motility. These observations provide new insights into the functional role of TRPV4 activation in the gut, with important implications for how TRPV4 may influence critical processes including inflammatory signaling and motility.
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Affiliation(s)
- Pradeep Rajasekhar
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC 3052, Australia
- Centre for Dynamic Imaging, WEHI, Parkville, VIC 3052, Australia
- Department of Medical Biology, The University of Melbourne, Parkville, VIC 3010, Australia
| | - Simona E Carbone
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC 3052, Australia
| | - Stuart T Johnston
- School of Mathematics and Statistics, The University of Melbourne, Parkville, VIC 3010, Australia
| | - Cameron J Nowell
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC 3052, Australia
| | - Lukasz Wiklendt
- College of Medicine & Public Health, Flinders Health and Medical Research Institute, Flinders University, Bedford Park, SA, Australia
| | - Edmund J Crampin
- School of Mathematics and Statistics, The University of Melbourne, Parkville, VIC 3010, Australia
| | - Yinghan She
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC 3052, Australia
| | - Jesse J DiCello
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC 3052, Australia
| | - Ayame Saito
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC 3052, Australia
| | - Luke Sorensen
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC 3052, Australia
| | - Thanh Nguyen
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC 3052, Australia
| | - Kevin Mc Lee
- Department of Medicine, The University of Melbourne, Royal Melbourne Hospital, Parkville, VIC 3010, Australia
| | - John A Hamilton
- Department of Medicine, The University of Melbourne, Royal Melbourne Hospital, Parkville, VIC 3010, Australia
| | - Sebastian K King
- Department of Paediatric Surgery, The Royal Children's Hospital, Parkville, VIC 3052, Australia
- Surgical Research, Murdoch Children's Research Institute, Parkville, VIC 3052, Australia
- Department of Paediatrics, The University of Melbourne, Parkville, VIC 3010, Australia
| | - Emily M Eriksson
- Population Health and Immunity, WEHI, Parkville, VIC 3052, Australia
- Department of Medical Biology, The University of Melbourne, Parkville, VIC 3010, Australia
| | - Nick J Spencer
- College of Medicine & Public Health, Flinders Health and Medical Research Institute, Flinders University, Bedford Park, SA, Australia
| | | | - Nicholas A Veldhuis
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC 3052, Australia
| | - Daniel P Poole
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC 3052, Australia
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Hurtado KA, Janda J, Schnellmann RG. Lasmiditan promotes recovery from acute kidney injury through induction of mitochondrial biogenesis. Am J Physiol Renal Physiol 2023; 324:F56-F63. [PMID: 36326468 PMCID: PMC9762961 DOI: 10.1152/ajprenal.00249.2022] [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: 09/24/2022] [Revised: 10/27/2022] [Accepted: 10/31/2022] [Indexed: 11/06/2022] Open
Abstract
Acute kidney injury (AKI) involves rapid loss of renal function and occurs in 8-16% of hospitalized patients. AKI can be induced by drugs, sepsis, and ischemia-reperfusion (I/R). Hallmarks of AKI include mitochondrial and microvasculature dysfunction as well as renal tubular injury. There is currently no available therapeutic for AKI. Previously, our group identified that serotonin (5-HT)1F receptor agonism with lasmiditan accelerated endothelial cell recovery and induced mitochondrial biogenesis (MB) in vitro. We hypothesized that lasmiditan, a Federal Drug Administration-approved drug, would induce MB and improve microvascular and renal function in a mouse model of AKI. Male mice were subjected to renal I/R and treated with lasmiditan (0.3 mg/kg) or vehicle beginning 24 h after injury and then daily until euthanasia at 6 or 12 days. Serum creatinine was measured to estimate glomerular filtration rate. The renal cortex was assessed for mitochondrial density, vascular permeability and integrity, tubular damage, and interstitial fibrosis. Lasmiditan increased mitochondrial number (1.4-fold) in renal cortices. At 6 days, serum creatinine decreased 41% in the I/R group and 72% with lasmiditan. At 6 or 12 days, kidney injury molecule-1 increased in the I/R group and decreased 50% with lasmiditan. At 12 days, interstitial fibrosis decreased with lasmiditan by 50% and collagen type 1 by 38%. Evan's blue dye leakage increased 2.5-fold in the I/R group and was restored with lasmiditan. The tight junction proteins zonula occludens-1, claudin-2, and claudin-5 decreased in the I/R group and recovered with lasmiditan. At 6 or 12 days, peroxisome proliferator-activated receptor-γ coactivator-1α and electron transport chain complexes increased only with lasmiditan. In conclusion, lasmiditan treatment beginning AKI induces MB, attenuated vascular and tubular injury, decreased interstitial fibrosis, and lowered serum creatinine. Given that lasmiditan is a Federal Drug Administration-approved drug, these preclinical data support repurposing lasmiditan as a therapeutic for AKI.NEW & NOTEWORTHY AKI pathology involves a rapid decline in kidney function and occurs in 8-16% of hospitalized patients. There is currently no therapeutic for AKI. AKI results in mitochondria dysfunction, microvasculature injury, and loss of renal tubular function. In an I/R-induced AKI mouse model, treatment with the FDA-approved 5-HT1F receptor-selective agonist lasmiditan induced mitochondrial biogenesis, improved vascular integrity, reduced fibrosis, and reduced proximal tubule damage. These data support repurposing lasmiditan for the treatment of AKI.
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Affiliation(s)
- Kevin A Hurtado
- Department of Pharmacology and Toxicology, College of Pharmacy, University of Arizona, Tucson, Arizona
| | - Jaroslav Janda
- Department of Pharmacology and Toxicology, College of Pharmacy, University of Arizona, Tucson, Arizona
| | - Rick G Schnellmann
- Department of Pharmacology and Toxicology, College of Pharmacy, University of Arizona, Tucson, Arizona
- Southern Arizona Veterans Affairs Health Care System, Tucson, Arizona
- Southwest Environmental Health Science Center, University of Arizona, Tucson, Arizona
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