1
|
Taliaferro LP, Cassatt DR, Horta ZP, Satyamitra MM. Meeting Report: A Poly-Pharmacy Approach to Mitigate Acute Radiation Syndrome. Radiat Res 2021; 196:436-446. [PMID: 34237144 PMCID: PMC8532024 DOI: 10.1667/rade-21-00048.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 06/03/2021] [Indexed: 11/03/2022]
Abstract
The National Institute of Allergy and Infectious Diseases, Radiation and Nuclear Countermeasures Program, was tasked by the United States Congress and the U.S. Department of Health and Human Services to identify and fund early-to-mid-stage development of medical countermeasures (MCMs) to treat radiation-induced injuries. In developing MCMs to treat various sub-syndromes (e.g., hematopoietic, gastrointestinal, lung), it is important to investigate whether a poly-pharmacy approach (i.e., drug cocktails) can provide additive benefits to mitigate injuries arising from the acute radiation syndrome (ARS). In addition, potential drug-drug interactions must be examined. For this reason, a workshop was held, which centered on understanding the current state of research investigating poly-pharmacy approaches to treat radiation injuries. The first session set the stage with an introduction to the concept of operations or support available for the response to a nuclear incident, as this is the key to any emergency response, including MCM availability and distribution. The second session followed the natural history of ARS in both humans and animal models to underscore the complexity of ARS and why a poly-pharmacy approach may be necessary. The third session featured talks from investigators conducting current MCM poly-pharmacy research. The meeting closed with a focus on regulatory considerations for the development of poly-pharmacy approaches or combination treatments for ARS.
Collapse
Affiliation(s)
- Lanyn P. Taliaferro
- Radiation and Nuclear Countermeasures Program (RNCP), Division of
Allergy, Immunology and Transplantation (DAIT), National Institute of Allergy
and Infectious Diseases (NIAID), National Institutes of Health (NIH), Rockville,
Maryland
| | - David R. Cassatt
- Radiation and Nuclear Countermeasures Program (RNCP), Division of
Allergy, Immunology and Transplantation (DAIT), National Institute of Allergy
and Infectious Diseases (NIAID), National Institutes of Health (NIH), Rockville,
Maryland
| | | | - Merriline M. Satyamitra
- Radiation and Nuclear Countermeasures Program (RNCP), Division of
Allergy, Immunology and Transplantation (DAIT), National Institute of Allergy
and Infectious Diseases (NIAID), National Institutes of Health (NIH), Rockville,
Maryland
| |
Collapse
|
2
|
Cheng LL, Guan WJ, Duan CY, Zhang NF, Lei CL, Hu Y, Chen AL, Li SY, Zhuo C, Deng XL, Cheng FJ, Gao Y, Zhang JH, Xie JX, Peng H, Li YX, Wu XX, Liu W, Peng H, Wang J, Xiao GM, Chen PY, Wang CY, Yang ZF, Zhao JC, Zhong NS. Effect of Recombinant Human Granulocyte Colony-Stimulating Factor for Patients With Coronavirus Disease 2019 (COVID-19) and Lymphopenia: A Randomized Clinical Trial. JAMA Intern Med 2021; 181:71-78. [PMID: 32910179 PMCID: PMC7489414 DOI: 10.1001/jamainternmed.2020.5503] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
IMPORTANCE Lymphopenia is common and correlates with poor clinical outcomes in patients with coronavirus disease 2019 (COVID-19). OBJECTIVE To determine whether a therapy that increases peripheral blood leukocyte and lymphocyte cell counts leads to clinical improvement in patients with COVID-19. DESIGN, SETTING AND PARTICIPANTS Between February 18 and April 10, 2020, we conducted an open-label, multicenter, randomized clinical trial at 3 participating centers in China. The main eligibility criteria were pneumonia, a blood lymphocyte cell count of 800 per μL (to convert to ×109/L, multiply by 0.001) or lower, and no comorbidities. Severe acute respiratory syndrome coronavirus 2 infection was confirmed with reverse-transcription polymerase chain reaction testing. EXPOSURES Usual care alone, or usual care plus 3 doses of recombinant human granulocyte colony-stimulating factor (rhG-CSF, 5 μg/kg, subcutaneously at days 0-2). MAIN OUTCOMES AND MEASURES The primary end point was the time from randomization to improvement of at least 1 point on a 7-category disease severity score. RESULTS Of 200 participants, 112 (56%) were men and the median (interquartile range [IQR]) age was 45 (40-55) years. There was random assignment of 100 patients (50%) to the rhG-CSF group and 100 (50%) to the usual care group. Time to clinical improvement was similar between groups (rhG-CSF group median of 12 days (IQR, 10-16 days) vs usual care group median of 13 days (IQR, 11-17 days); hazard ratio, 1.28; 95% CI, 0.95-1.71; P = .06). For secondary end points, the proportion of patients progressing to acute respiratory distress syndrome, sepsis, or septic shock was lower in the rhG-CSF group (rhG-CSF group, 2% vs usual care group, 15%; difference, -13%; 95%CI, -21.4% to -5.4%). At 21 days, 2 patients (2%) had died in the rhG-CSF group compared with 10 patients (10%) in the usual care group (hazard ratio, 0.19; 95%CI, 0.04-0.88). At day 5, the lymphocyte cell count was higher in the rhG-CSF group (rhG-CSF group median of 1050/μL vs usual care group median of 620/μL; Hodges-Lehmann estimate of the difference in medians, 440; 95% CI, 380-490). Serious adverse events, such as sepsis or septic shock, respiratory failure, and acute respiratory distress syndrome, occurred in 29 patients (14.5%) in the rhG-CSF group and 42 patients (21%) in the usual care group. CONCLUSION AND RELEVANCE In preliminary findings from a randomized clinical trial, rhG-CSF treatment for patients with COVID-19 with lymphopenia but no comorbidities did not accelerate clinical improvement, but the number of patients developing critical illness or dying may have been reduced. Larger studies that include a broader range of patients with COVID-19 should be conducted. TRIAL REGISTRATION Chinese Clinical Trial Registry: ChiCTR2000030007.
Collapse
Affiliation(s)
- Lin-Ling Cheng
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, China.,Guangzhou Eighth People's Hospital, Guangzhou Medical University, Guangzhou, China
| | - Wei-Jie Guan
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, China
| | - Chong-Yang Duan
- State Key Laboratory of Organ Failure Research, National Clinical Research Center for Kidney Disease, Department of Biostatistics, School of Public Health, Southern Medical University, Guangzhou, China
| | - Nuo-Fu Zhang
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, China
| | - Chun-Liang Lei
- Guangzhou Eighth People's Hospital, Guangzhou Medical University, Guangzhou, China
| | - Yu Hu
- Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Ai-Lan Chen
- Medical Department, Hankou Hospital of Wuhan City, Wuhan, China
| | - Shi-Yue Li
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, China.,Guangzhou Eighth People's Hospital, Guangzhou Medical University, Guangzhou, China
| | - Chao Zhuo
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, China
| | - Xi-Long Deng
- Guangzhou Eighth People's Hospital, Guangzhou Medical University, Guangzhou, China
| | - Fan-Jun Cheng
- Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yong Gao
- Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Jian-Heng Zhang
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, China.,Medical Department, Hankou Hospital of Wuhan City, Wuhan, China
| | - Jia-Xing Xie
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, China.,Medical Department, Hankou Hospital of Wuhan City, Wuhan, China
| | - Hong Peng
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, China.,Medical Department, Hankou Hospital of Wuhan City, Wuhan, China
| | - Ying-Xian Li
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, China.,Medical Department, Hankou Hospital of Wuhan City, Wuhan, China
| | - Xiao-Xiong Wu
- Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Wen Liu
- Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Hui Peng
- Guangzhou Eighth People's Hospital, Guangzhou Medical University, Guangzhou, China
| | - Jian Wang
- Guangzhou Eighth People's Hospital, Guangzhou Medical University, Guangzhou, China
| | - Guang-Ming Xiao
- Guangzhou Eighth People's Hospital, Guangzhou Medical University, Guangzhou, China
| | - Ping-Yan Chen
- State Key Laboratory of Organ Failure Research, National Clinical Research Center for Kidney Disease, Department of Biostatistics, School of Public Health, Southern Medical University, Guangzhou, China
| | - Chun-Yan Wang
- Department of Haematology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Zi-Feng Yang
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, China
| | - Jin-Cun Zhao
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, China
| | - Nan-Shan Zhong
- State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou Medical University, Guangzhou, China
| |
Collapse
|
3
|
Satyamitra M, Kumar VP, Biswas S, Cary L, Dickson L, Venkataraman S, Ghosh SP. Impact of Abbreviated Filgrastim Schedule on Survival and Hematopoietic Recovery after Irradiation in Four Mouse Strains with Different Radiosensitivity. Radiat Res 2017; 187:659-671. [PMID: 28362168 DOI: 10.1667/rr14555.1] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Filgrastim (Neupogen®, granulocyte-colony stimulating factor) is among the few countermeasures recommended for management of patients in the event of lethal total-body irradiation. Despite the plethora of studies using filgrastim as a radiation countermeasure, relatively little is known about the optimal dose schedule of filgrastim to mitigate radiation lethality. We evaluated the efficacy of filgrastim in improving 30-day survival of CD2F1 mice irradiated with a lethal dose (LD70/30) in the AFRRI cobalt-60 facility. We tested different schedules of 1, 3, 5, 10 or 16 once-daily injections of filgrastim initiated one day after irradiation. Time optimization studies with filgrastim treatment were also performed, beginning 6-48 h postirradiation. Maximum survival was observed with 3 daily doses of 0.17 mg/kg filgrastim. Survival efficacy of the 3-day treatment was compared against the conventional 16-day filgrastim treatment after irradiation in four mouse strains with varying radiation sensitivities: C3H/HeN, C57BL/6, B6C3F1 and CD2F1. Blood indices, bone marrow histopathology and colony forming unit assays were also evaluated. Filgrastim significantly increased 30-day survival (P < 0.001) with a 3-day treatment compared to 16-day treatment. Filgrastim did not prevent cytopenia nadirs, but facilitated faster recovery of white blood cells, neutrophils, red blood cells, platelets, lymphocytes and hematocrits in all four strains. Accelerated hematopoietic recovery was also reflected in faster bone marrow reconstitution and significant increase in hematopoietic progenitors (P < 0.001) in all four mouse strains. These data indicate that prompt and abbreviated filgrastim treatment has potential benefit for triage in the event of a radiological incident for treating acute hematopoietic syndrome.
Collapse
Affiliation(s)
- Merriline Satyamitra
- a Radiation and Nuclear Countermeasure Program, DAIT, NIAID, NIH, Bethesda, Maryland 20889
| | - Vidya P Kumar
- b Armed Forces Radiobiology Research Institute (AFRRI), Uniformed Services University of the Health Sciences, Bethesda, Maryland 20889
| | - Shukla Biswas
- b Armed Forces Radiobiology Research Institute (AFRRI), Uniformed Services University of the Health Sciences, Bethesda, Maryland 20889
| | - Lynnette Cary
- b Armed Forces Radiobiology Research Institute (AFRRI), Uniformed Services University of the Health Sciences, Bethesda, Maryland 20889
| | - Leonora Dickson
- b Armed Forces Radiobiology Research Institute (AFRRI), Uniformed Services University of the Health Sciences, Bethesda, Maryland 20889
| | - Srinivasan Venkataraman
- b Armed Forces Radiobiology Research Institute (AFRRI), Uniformed Services University of the Health Sciences, Bethesda, Maryland 20889
| | - Sanchita P Ghosh
- b Armed Forces Radiobiology Research Institute (AFRRI), Uniformed Services University of the Health Sciences, Bethesda, Maryland 20889
| |
Collapse
|
4
|
Adhikari M, Arora R. The flavonolignan-silymarin protects enzymatic, hematological, and immune system against γ-radiation-induced toxicity. ENVIRONMENTAL TOXICOLOGY 2016; 31:641-654. [PMID: 25411116 DOI: 10.1002/tox.22076] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Revised: 10/24/2014] [Accepted: 10/31/2014] [Indexed: 06/04/2023]
Abstract
The main focus of this study is evaluation of radioprotective efficacy of silymarin, a flavonolignan, against γ-radiation-induced damage to hematological, vital organs (liver and intestine), and immune system. Survival studies revealed that silymarin (administered orally for 3 days) provided maximum protection (67%) at 70 mg/kg body weight (b.wt.) against lethal 9 Gy γ-irradiation (dose reduction factor = 1.27). The study revealed significant (p < 0.05) changes in levels of catalase (12.57 ± 2.58 to 30.24 ± 4.89 units), glutathione peroxidase (6.23 ± 2.95 to 13.26 ± 1.36 µg of reduced glutathione consumed/min/mg protein), glutathione reductase (0.25 ± 5.6 to 11.65 ± 2.83 pM NADPH consumed/min/mg protein), and superoxide dismutase (11.74 ± 0.2 to 16.09 ± 3.47 SOD U/mg of protein) activity at 30th day. Silymarin pretreated irradiated group exhibited increased proliferation in erythrocyte count (1.76 ± 0.41 × 10(6) to 9.25 ± 0.24 × 10(6) ), hemoglobin (2.15 ± 0.48g/dL to 14.77 ± 0.25g/dL), hematocrit (4.55 ± 0.24% to 37.22 ± 0.21%), and total leucocyte count (1.4 ± 0.15 × 10(6) to 8.31 ± 0.47 × 10(6) ) as compared with radiation control group on 15th day. An increase in CD4:CD8 ratio was witnessed (0.2-1%) at 30th day time interval using flow cytometry. Silymarin also countered radiation-induced decrease (p < 0.05) in regulatory T-cells (Tregs ) (11.23% in radiation group at 7th day versus 0.1% in pretreated silymarin irradiated group at 15th day). The results of this study indicate that flavonolignan-silymarin protects enzymatic, hematological, and immune system against γ-radiation-induced toxicity and might prove useful in management of nuclear and radiological emergencies. © 2014 Wiley Periodicals, Inc. Environ Toxicol 31: 641-654, 2016.
Collapse
Affiliation(s)
- Manish Adhikari
- Radiation Biotechnology Group, Division of Radiation Biosciences, Institute of Nuclear Medicine and Allied Sciences, Defence Research and Development Organisation, Brig SK Mazumdar Marg, Delhi, 110054, India
| | - Rajesh Arora
- Radiation Biotechnology Group, Division of Radiation Biosciences, Institute of Nuclear Medicine and Allied Sciences, Defence Research and Development Organisation, Brig SK Mazumdar Marg, Delhi, 110054, India
- Office of the Distinguished Scientist and Director General-Life Sciences, DRDO Head Quarters, DRDO Bhawan, Rajaji Marg, New Delhi, 110011, India
| |
Collapse
|