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Ramos da Silva Grillo VT, Bertanha M, da Silva Rodrigues L, de Lima MA, Mellucci Filho PL, Rahal Guaragna Machado R, Durigon EL, Dias Sertorio N, de Assis Golim M, Moroz A, Marques Braz AM, de Moraes LN, Leite MA, Bonciani Nader H, de Campos GC, Rodrigues Guzzo Carvalho C, Florença Cardoso F, Magro AJ, Caputo Nunes H, Tommasini Grotto RM, de Cássia Alvarado R, de Moura Campos Pardini MI, Lima Sobreira M, da Costa EAPN, Naime Barbosa A, Fortaleza CMCB. Nebulized enriched heparin improves respiratory parameters in patients with COVID-19: a phase I/II randomized and triple-blind clinical trial. Sci Rep 2024; 14:19902. [PMID: 39191809 DOI: 10.1038/s41598-024-70064-8] [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: 03/23/2024] [Accepted: 08/12/2024] [Indexed: 08/29/2024] Open
Abstract
To evaluate the safety and the potential antiviral treatment of inhaled enriched heparin in patients with COVID-19. The specific objectives were to investigate the anticoagulation profile, antiviral and anti-inflammatory effects, and respiratory evolution of inhaled enriched heparin. We conducted a randomized, triple-blind, placebo-controlled Phase I/II clinical trial in hospitalized adults with COVID-19 receiving inhalation of enriched heparin or saline (placebo) every 4 h for 7 days. Among the 27 patients who completed the study, no changes in blood coagulation parameters were observed, indicating the safety of inhaled enriched heparin. The group receiving enriched heparin showed a significant reduction in the need for supplemental oxygen and improvement in respiratory parameters, such as the PaO2/FiO2 ratio. Inhalation of enriched heparin is shown to be safe and has also demonstrated potential therapeutic benefits for patients with COVID-19. These promising results justify the continuation of the study to the next phase, Phase II/III, to further evaluate the therapeutic efficacy of inhaled enriched heparin in the treatment of COVID-19-associated viral pneumonia.Trial registration: ClinicalTrials.gov. 08/02/2021. Identifier: NCT04743011.
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Affiliation(s)
- Vinicius Tadeu Ramos da Silva Grillo
- Department of Surgery and Orthopedics, Botucatu Medical School, São Paulo State University - UNESP, Clinical Hospital, Professor Montenegro Avenue, Botucatu, SP, 18618687, Brazil
| | - Matheus Bertanha
- Department of Surgery and Orthopedics, Botucatu Medical School, São Paulo State University - UNESP, Clinical Hospital, Professor Montenegro Avenue, Botucatu, SP, 18618687, Brazil.
- Applied Biotechnology Laboratory, Research Nucleus of Clinical Hospital, Botucatu Medical School, São Paulo State University - UNESP, Botucatu, SP, Brazil.
| | - Lenize da Silva Rodrigues
- Department of Surgery and Orthopedics, Botucatu Medical School, São Paulo State University - UNESP, Clinical Hospital, Professor Montenegro Avenue, Botucatu, SP, 18618687, Brazil
- Applied Biotechnology Laboratory, Research Nucleus of Clinical Hospital, Botucatu Medical School, São Paulo State University - UNESP, Botucatu, SP, Brazil
| | - Marcelo Andrade de Lima
- Centre for Glycoscience, School of Life Sciences, Keele University, Newcastle-Under-Lyme, Staffordshire, UK
| | - Pedro Luciano Mellucci Filho
- Department of Surgery and Orthopedics, Botucatu Medical School, São Paulo State University - UNESP, Clinical Hospital, Professor Montenegro Avenue, Botucatu, SP, 18618687, Brazil
| | | | - Edson Luiz Durigon
- Department of Microbiology, Institute of Biomedical Sciences, University of Sao Paulo, - USP, São Paulo, Brazil
- Scientific Platform Pasteur USP (SPPU), University of São Paulo, São Paulo, Brazil
| | - Nathália Dias Sertorio
- Department of Surgery and Orthopedics, Botucatu Medical School, São Paulo State University - UNESP, Clinical Hospital, Professor Montenegro Avenue, Botucatu, SP, 18618687, Brazil
| | - Marjorie de Assis Golim
- Applied Biotechnology Laboratory, Research Nucleus of Clinical Hospital, Botucatu Medical School, São Paulo State University - UNESP, Botucatu, SP, Brazil
| | - Andrei Moroz
- Department of Bioprocess and Biotechnology, School of Pharmaceutical Sciences, São Paulo State University - UNESP, Araraquara, SP, Brazil
| | - Aline Márcia Marques Braz
- Applied Biotechnology Laboratory, Research Nucleus of Clinical Hospital, Botucatu Medical School, São Paulo State University - UNESP, Botucatu, SP, Brazil
| | - Leonardo Nazário de Moraes
- Applied Biotechnology Laboratory, Research Nucleus of Clinical Hospital, Botucatu Medical School, São Paulo State University - UNESP, Botucatu, SP, Brazil
| | - Marco Antonio Leite
- Clinical Hospital of the Botucatu Medical School, São Paulo State University - UNESP, Botucatu, SP, Brazil
| | - Helena Bonciani Nader
- Department of Biochemistry, Federal University of São Paulo - UNIFESP, São Paulo, SP, Brazil
| | - Gustavo Constantino de Campos
- Department of Orthopedics and Traumatology, School of Medical Sciences, University of Campinas - UNICAMP, Campinas, SP, Brazil
| | | | - Fábio Florença Cardoso
- Department of Biophysics and Pharmacology, Institute of Biosciences, São Paulo State University - UNESP, Botucatu, SP, Brazil
| | - Angelo José Magro
- Department of Biophysics and Pharmacology, Institute of Biosciences, São Paulo State University - UNESP, Botucatu, SP, Brazil
| | - Helga Caputo Nunes
- Teaching and Research Center of the Albert Einstein Hospital, São Paulo, SP, Brazil
| | - Rejane Maria Tommasini Grotto
- Applied Biotechnology Laboratory, Research Nucleus of Clinical Hospital, Botucatu Medical School, São Paulo State University - UNESP, Botucatu, SP, Brazil
- Bioprocessing and Biotechnology Department, School of Agriculture, São Paulo State University - UNESP, Botucatu, SP, Brazil
| | - Rita de Cássia Alvarado
- Applied Biotechnology Laboratory, Research Nucleus of Clinical Hospital, Botucatu Medical School, São Paulo State University - UNESP, Botucatu, SP, Brazil
| | | | - Marcone Lima Sobreira
- Department of Surgery and Orthopedics, Botucatu Medical School, São Paulo State University - UNESP, Clinical Hospital, Professor Montenegro Avenue, Botucatu, SP, 18618687, Brazil
| | | | - Alexandre Naime Barbosa
- Department of Infectious Diseases, Botucatu Medical School, São Paulo State University - UNESP, Botucatu, SP, Brazil
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Xiao LX, Zhu DL, Chen J, Lv J, Liu MJ, Dai X, Wang DX, Deng W. Exploring the therapeutic role of early heparin administration in ARDS management: a MIMIC-IV database analysis. J Intensive Care 2024; 12:9. [PMID: 38409068 PMCID: PMC10895755 DOI: 10.1186/s40560-024-00723-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 02/18/2024] [Indexed: 02/28/2024] Open
Abstract
BACKGROUND Acute respiratory distress syndrome (ARDS) is a severe respiratory condition characterized by a high mortality rate, the management of which relies on supportive care and a profound understanding of its pathophysiology. Heparin, with its anticoagulant and potential anti-inflammatory properties, offers a new therapeutic opportunity for the treatment of ARDS. METHODS In this retrospective cohort study, we examined the MIMIC-IV database for ARDS patients who received prophylactic heparin within the first 72 h of ICU admission. Employing propensity score matching and inverse probability weighting (IPW) analysis, we evaluated the impact of early heparin use on patient outcomes, focusing on mortality rates. RESULTS Patients who received prophylactic heparin had a significantly lower in-hospital mortality rate compared to those who did not (13.55% vs 17.93%, HR = 0.71, 95% CI: 0.54-0.93, P = 0.012). This result remained significant after propensity score matching (12.75% vs 17.93%, HR = 0.65, 95% CI 0.47-0.90, P = 0.010). Analysis using five different statistical models indicated that early use of heparin significantly reduced the in-hospital mortality rate, with HR = 0.669 (95% CI 0.487-0.919, P = 0.013) in the doubly robust model without balanced covariates; HR = 0.705 (95% CI 0.515-0.965, P = 0.029) with all covariates considered; HR = 0.660 (95% CI 0.491-0.888, P = 0.006) in the propensity score (IPW) model; HR = 0.650 (95% CI 0.470-0.900, P = 0.010) in the propensity score matching model; and HR = 0.706 (95% CI 0.536-0.930, P = 0.013) in the multivariate Cox regression model. Secondary outcomes indicated that heparin use was also associated with reduced mortality rates at 60 days, and 90 days. CONCLUSION This research highlights that early prophylactic administration of heparin may substantially lower mortality in ARDS patients. These findings underscore the potential of heparin as a key component in the management of ARDS, offering a new perspective and novel strategies for clinical treatment.
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Affiliation(s)
- Ling-Xi Xiao
- Department of Pulmonary and Critical Care Medicine, Second Affiliated Hospital of Chongqing Medical University, 76 Linjiang Road, Yuzhong District, Chongqing, 400010, China
| | - De Liang Zhu
- Department of Gastrointestinal Surgery, China-Japan Union Hospital of Jilin University, No. 126, Xiantai Street, Changchun, 130033, China
| | - Juan Chen
- Department of Pulmonary and Critical Care Medicine, Second Affiliated Hospital of Chongqing Medical University, 76 Linjiang Road, Yuzhong District, Chongqing, 400010, China
| | - Jing Lv
- Department of Pulmonary and Critical Care Medicine, Second Affiliated Hospital of Chongqing Medical University, 76 Linjiang Road, Yuzhong District, Chongqing, 400010, China
| | - Mei-Jun Liu
- Department of Pulmonary and Critical Care Medicine, Second Affiliated Hospital of Chongqing Medical University, 76 Linjiang Road, Yuzhong District, Chongqing, 400010, China
| | - Xue Dai
- Department of Pulmonary and Critical Care Medicine, Second Affiliated Hospital of Chongqing Medical University, 76 Linjiang Road, Yuzhong District, Chongqing, 400010, China
| | - Dao-Xin Wang
- Department of Pulmonary and Critical Care Medicine, Second Affiliated Hospital of Chongqing Medical University, 76 Linjiang Road, Yuzhong District, Chongqing, 400010, China
| | - Wang Deng
- Department of Pulmonary and Critical Care Medicine, Second Affiliated Hospital of Chongqing Medical University, 76 Linjiang Road, Yuzhong District, Chongqing, 400010, China.
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Shute JK. Heparin, Low Molecular Weight Heparin, and Non-Anticoagulant Derivatives for the Treatment of Inflammatory Lung Disease. Pharmaceuticals (Basel) 2023; 16:ph16040584. [PMID: 37111341 PMCID: PMC10141002 DOI: 10.3390/ph16040584] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 04/06/2023] [Accepted: 04/07/2023] [Indexed: 04/29/2023] Open
Abstract
Unfractionated heparin has multiple pharmacological activities beyond anticoagulation. These anti-inflammatory, anti-microbial, and mucoactive activities are shared in part by low molecular weight and non-anticoagulant heparin derivatives. Anti-inflammatory activities include inhibition of chemokine activity and cytokine synthesis, inhibitory effects on the mechanisms of adhesion and diapedesis involved in neutrophil recruitment, inhibition of heparanase activity, inhibition of the proteases of the coagulation and complement cascades, inhibition of neutrophil elastase activity, neutralisation of toxic basic histones, and inhibition of HMGB1 activity. This review considers the potential for heparin and its derivatives to treat inflammatory lung disease, including COVID-19, ALI, ARDS, cystic fibrosis, asthma, and COPD via the inhaled route.
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Affiliation(s)
- Janis Kay Shute
- School of Pharmacy and Biomedical Sciences, University of Portsmouth, Portsmouth PO1 2UP, UK
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Gupta B, Chandrakar S, Gupta N, Jain G. Nebulized Heparin to Reduce COVID-19-induced Acute Lung Injury: A Prospective Observational Study. Indian J Crit Care Med 2023; 27:222-224. [PMID: 36960112 PMCID: PMC10028714 DOI: 10.5005/jp-journals-10071-24420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 02/04/2023] [Indexed: 03/06/2023] Open
Abstract
Background High mortality due to COVID-19 disease has been a serious concern, a few of the causes being disseminated intravascular coagulation (DIC) and venous thromboembolism. Considering this, some experts have used heparin. However, its role still needs to be validated. Materials and methods This study predicts the role of nebulized heparin in decreasing the severity of lung injury caused by COVID-19. Thirty patients admitted with COVID-19 acute respiratory distress syndrome (ARDS) in the intensive care unit (ICU) of All India Institute of Medical Sciences, Rishikesh, were included in this study, which was conducted over a period of 3 months. Patients were nebulized with 2 mL of heparin 5,000 units/mL IV formulation diluted with 3 mL of 0.9% sodium chloride, every 6 hours for a total duration of 7 days. Improvement in oxygenation (ratio of partial pressure of oxygen in blood and fraction of inspired oxygen delivered, pO2/FiO2 ratio) was calculated as the primary outcome. Other parameters like effect on inflammatory markers (neutrophil-lymphocyte ratio, total leukocyte count, interleukin (IL-6), and D-dimer values), time to liberate from mechanical ventilation, and hospital stay were calculated as secondary outcomes. Results In our study population, the mean age was 54.5 years and the majority of patients were males (79.0%). All patients received prone ventilation and none of them required tracheostomy. However, 5 patients (16.6%) succumbed to illness. After nebulization with unfractionated heparin, no statistically significant difference was seen in the neutrophil-lymphocyte ratio (mean = 6.87, p = 0.318) and interleukin (IL-6) levels (mean = 62.85, p = 0.6) over 7 days. Similarly, the D-dimer level also had no statistically significant change (mean = 1853.73 p = 0.570). However, there was a statistically significant improvement in oxygenation (pO2/FiO2 ratio) over 7 days (mean = 184.96, p = 0.00). Similarly, there was a significant improvement in PaO2 (84.17 ± 33.82) and SO2 (92.30 ± 3.49). Although, no significant changes were seen in the partial pressure of carbon dioxide on nebulized heparin administration. Conclusion Administration of nebulized heparin in COVID-19 pneumonia with mild ARDS may improve oxygenation and result in the improvement of inflammatory markers with variable sensitivity and specificity. How to cite this article Gupta B, Chandrakar S, Gupta N, Jain G. Nebulized Heparin to Reduce COVID-19-induced Acute Lung Injury: A Prospective Observational Study. Indian J Crit Care Med 2023;27(3): 222-224.
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Affiliation(s)
- Bhavna Gupta
- Department of Anaesthesia and Critical Care, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Saurabh Chandrakar
- Department of Anaesthesia and Critical Care, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Nidhi Gupta
- Department of Anaesthesia and Critical Care, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
- Nidhi Gupta, Department of Anaesthesia and Critical Care, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India, Phone: +91 9760672721, e-mail:
| | - Gaurav Jain
- Department of Anaesthesia and Critical Care, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
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McNicholas BA. Is It Time to Re-Imagine Clinical Trials in Nephrology? J Am Soc Nephrol 2023; 34:366-368. [PMID: 36735335 PMCID: PMC10103358 DOI: 10.1681/asn.0000000000000070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 12/15/2022] [Indexed: 01/26/2023] Open
Affiliation(s)
- Bairbre A. McNicholas
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospital, Saolta Hospital Group, Galway, Ireland
- School of Medicine, University of Galway, Galway, Ireland
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Hogwood J, Gray E, Mulloy B. Heparin, Heparan Sulphate and Sepsis: Potential New Options for Treatment. Pharmaceuticals (Basel) 2023; 16:271. [PMID: 37259415 PMCID: PMC9959362 DOI: 10.3390/ph16020271] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 01/22/2023] [Accepted: 02/07/2023] [Indexed: 08/31/2023] Open
Abstract
Sepsis is a life-threatening hyperreaction to infection in which excessive inflammatory and immune responses cause damage to host tissues and organs. The glycosaminoglycan heparan sulphate (HS) is a major component of the cell surface glycocalyx. Cell surface HS modulates several of the mechanisms involved in sepsis such as pathogen interactions with the host cell and neutrophil recruitment and is a target for the pro-inflammatory enzyme heparanase. Heparin, a close structural relative of HS, is used in medicine as a powerful anticoagulant and antithrombotic. Many studies have shown that heparin can influence the course of sepsis-related processes as a result of its structural similarity to HS, including its strong negative charge. The anticoagulant activity of heparin, however, limits its potential in treatment of inflammatory conditions by introducing the risk of bleeding and other adverse side-effects. As the anticoagulant potency of heparin is largely determined by a single well-defined structural feature, it has been possible to develop heparin derivatives and mimetic compounds with reduced anticoagulant activity. Such heparin mimetics may have potential for use as therapeutic agents in the context of sepsis.
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Affiliation(s)
- John Hogwood
- National Institute for Biological Standards and Control, Blanche Lane, South Mimms EN6 3QG, UK
| | - Elaine Gray
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King’s College London, Stamford St., London SE1 9NH, UK
| | - Barbara Mulloy
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King’s College London, Stamford St., London SE1 9NH, UK
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Bertini S, Alekseeva A, Elli S, Pagani I, Zanzoni S, Eisele G, Krishnan R, Maag KP, Reiter C, Lenhart D, Gruber R, Yates E, Vicenzi E, Naggi A, Bisio A, Guerrini M. Pentosan polysulfate inhibits attachment and infection by SARS-CoV-2 in vitro: insights into structural requirements for binding. Thromb Haemost 2022; 122:984-997. [PMID: 35322395 PMCID: PMC9252607 DOI: 10.1055/a-1807-0168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Two years since the outbreak of the novel coronavirus SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) pandemic, there remain few clinically effective drugs to complement vaccines. One is the anticoagulant, heparin, which in 2004 was found able to inhibit invasion of SARS-CoV (CoV-1) and which has been employed during the current pandemic to prevent thromboembolic complications and moderate potentially damaging inflammation. Heparin has also been shown experimentally to inhibit SARS-CoV-2 attachment and infection in susceptible cells. At high therapeutic doses however, heparin increases the risk of bleeding and prolonged use can cause heparin-induced thrombocytopenia, a serious side effect. One alternative, with structural similarities to heparin, is the plant-derived, semi-synthetic polysaccharide, pentosan polysulfate (PPS). PPS is an established drug for the oral treatment of interstitial cystitis, is well-tolerated, and exhibits weaker anticoagulant effects than heparin. In an established Vero cell model, PPS and its fractions of varying molecular weights inhibited invasion by SARS-CoV-2. Intact PPS and its size-defined fractions were characterized by molecular weight distribution and chemical structure using nuclear magnetic resonance spectroscopy and liquid chromatography–mass spectrometry, then employed to explore the structural basis of interactions with SARS-CoV-2 spike protein receptor-binding domain (S1 RBD) and the inhibition of Vero cell invasion. PPS was as effective as unfractionated heparin, but more effective in inhibiting cell infection than low-molecular-weight heparin (on a weight/volume basis). Isothermal titration calorimetry and viral plaque-forming assays demonstrated size-dependent binding to S1 RBD and inhibition of Vero cell invasion, suggesting the potential application of PPS as a novel inhibitor of SARS-CoV-2 infection.
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Affiliation(s)
- Sabrina Bertini
- Istituto di Ricerche Chimiche e Biochimiche G. Ronzoni, Milan, Italy
| | - Anna Alekseeva
- Centro Alta Tecnologia Istituto di Ricerche Chimiche e Biochimiche G. Ronzoni, Milan, Italy
| | - Stefano Elli
- Istituto di Ricerche Chimiche e Biochimiche G. Ronzoni, Milan, Italy
| | - Isabel Pagani
- IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Serena Zanzoni
- Centro Piattaforme Tecnologiche, University of Verona, Verona, Italy
| | - Giorgio Eisele
- Centro Alta Tecnologia Istituto di Ricerche Chimiche e Biochimiche G. Ronzoni, Milan, Italy
| | - Ravi Krishnan
- Paradigm Biopharmaceuticals Ltd, Melbourne, Australia
| | - Klaus P Maag
- bene pharmaChem GmbH & Co.KG, Geretsried, Germany
| | | | | | | | - Edwin Yates
- Structural and Chemical Biology, University of Liverpool, Liverpool, United Kingdom of Great Britain and Northern Ireland
| | - Elisa Vicenzi
- IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Annamaria Naggi
- Istituto di Ricerche Chimiche e Biochimiche G. Ronzoni, Milan, Italy
| | - Antonella Bisio
- Istituto di Ricerche Chimiche e Biochimiche G. Ronzoni, Milan, Italy
| | - Marco Guerrini
- Istituto di Ricerche Chimiche e Biochimiche G. Ronzoni, Milan, Italy
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