Preventive effects of Pycnogenol® on cardiovascular risk factors (including endothelial function) and microcirculation in subjects recovering from coronavirus disease 2019 (COVID-19)

Effects of Pycnogenol® in people with post-COVID-19 condition (PYCNOVID): study protocol for a single-center, placebo controlled, quadruple-blind, randomized trial

BACKGROUND

A significant proportion of the global population has been infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) at some point since the onset of the pandemic. Although most individuals who develop coronavirus disease 2019 (COVID-19) recover without complications, about 6% have persistent symptoms, referred to as post-COVID-19 condition (PCC). Intervention studies investigating treatments that potentially alleviate PCC-related symptoms and thus aim to mitigate the global public health burden and healthcare costs linked to PCC are desperately needed. The PYCNOVID trial investigates the effects of Pycnogenol®, a French maritime pine bark extract with anti-inflammatory and antioxidative properties, versus placebo on patient-reported health status in people with PCC.

METHODS

This is a single-center, placebo-controlled, quadruple blind, randomized trial. We aim to randomly assign 150 individuals with PCC (1:1 ratio) to receive either 200 mg Pycnogenol® or placebo daily for 12 weeks. Randomization is stratified for duration of PCC symptoms (≤ 6 months versus > 6 months) and presence of symptomatic chronic disease(s). The primary endpoint is perceived health status at 12 weeks (EuroQol-Visual Analogue Scale) adjusted for baseline values and stratification factors. Secondary endpoints include change in self-reported PCC symptoms, health-related quality of life, symptoms of depression and anxiety, cognitive function, functional exercise capacity, physical activity measured with accelerometry, and blood biomarkers for endothelial health, inflammation, coagulation, platelet function, and oxidative stress. Investigators, study participants, outcome assessors, and data analysts are blinded regarding the intervention assignment. Individuals with PCC were involved in the design of this study.

DISCUSSION

This is the first trial to investigate the effects of Pycnogenol® versus placebo on patient-reported health status in people with PCC. Should the trial proof clinical effectiveness, Pycnogenol® may serve as a therapeutic approach to mitigate symptoms associated with PCC.

TRIAL REGISTRATION

The study is registered at ClinicalTrials.gov. :NCT05890534, June 6, 2023.

Long COVID: pathophysiological factors and abnormalities of coagulation

Acute COVID-19 infection is followed by prolonged symptoms in approximately one in ten cases: known as Long COVID. The disease affects ~65 million individuals worldwide. Many pathophysiological processes appear to underlie Long COVID, including viral factors (persistence, reactivation, and bacteriophagic action of SARS CoV-2); host factors (chronic inflammation, metabolic and endocrine dysregulation, immune dysregulation, and autoimmunity); and downstream impacts (tissue damage from the initial infection, tissue hypoxia, host dysbiosis, and autonomic nervous system dysfunction). These mechanisms culminate in the long-term persistence of the disorder characterized by a thrombotic endothelialitis, endothelial inflammation, hyperactivated platelets, and fibrinaloid microclots. These abnormalities of blood vessels and coagulation affect every organ system and represent a unifying pathway for the various symptoms of Long COVID.

Long COVID: major findings, mechanisms and recommendations

Long COVID is an often debilitating illness that occurs in at least 10% of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections. More than 200 symptoms have been identified with impacts on multiple organ systems. At least 65 million individuals worldwide are estimated to have long COVID, with cases increasing daily. Biomedical research has made substantial progress in identifying various pathophysiological changes and risk factors and in characterizing the illness; further, similarities with other viral-onset illnesses such as myalgic encephalomyelitis/chronic fatigue syndrome and postural orthostatic tachycardia syndrome have laid the groundwork for research in the field. In this Review, we explore the current literature and highlight key findings, the overlap with other conditions, the variable onset of symptoms, long COVID in children and the impact of vaccinations. Although these key findings are critical to understanding long COVID, current diagnostic and treatment options are insufficient, and clinical trials must be prioritized that address leading hypotheses. Additionally, to strengthen long COVID research, future studies must account for biases and SARS-CoV-2 testing issues, build on viral-onset research, be inclusive of marginalized populations and meaningfully engage patients throughout the research process.

Long COVID: Clinical Framing, Biomarkers, and Therapeutic Approaches

More than two years after the onset of the COVID-19 pandemic, healthcare providers are facing an emergency within an emergency, the so-called long COVID or post-COVID-19 syndrome (PCS). Patients diagnosed with PCS develop an extended range of persistent symptoms and/or complications from COVID-19. The risk factors and clinical manifestations are many and various. Advanced age, sex/gender, and pre-existing conditions certainly influence the pathogenesis and course of this syndrome. However, the absence of precise diagnostic and prognostic biomarkers may further complicate the clinical management of patients. This review aimed to summarize recent evidence on the factors influencing PCS, possible biomarkers, and therapeutic approaches. Older patients recovered approximately one month earlier than younger patients, with higher rates of symptoms. Fatigue during the acute phase of COVID-19 appears to be an important risk factor for symptom persistence. Female sex, older age, and active smoking are associated with a higher risk of developing PCS. The incidence of cognitive decline and the risk of death are higher in PCS patients than in controls. Complementary and alternative medicine appears to be associated with improvement in symptoms, particularly fatigue. The heterogeneous nature of post-COVID symptoms and the complexity of patients with PCS, who are often polytreated due to concomitant clinical conditions, suggest a holistic and integrated approach to provide useful guidance for the treatment and overall management of long COVID.

Complications after administration of mRNA vaccine against COVID-19 - case report and short review

The pandemic of the disease COVID-19 (COronaVIrus Disease 2019) caused by the SARS-CoV-2 coronavirus (severe acute respiratory syndrome coronavirus 2) resulted in millions of deaths and many patients have chronic consequences after overcoming the acute condition. Several vaccines have been developed in an effort to stop the spread of the virus, but they have potentially serious adverse effects. We present a case report of a patient with acute (myocarditis, exacerbation of bronchial asthma) and long-term (postural orthostatic tachycardia syndrome - POTS) complications after vaccination with the second dose of mRNA vaccine BNT162b2 (Comirnaty®). Treatment consists of regimen measures, numerous pharmacotherapy (metoprolol, ivabradine, corticosteroids, antihistamines, antiphlogistics, bronchodilators) and several nutraceuticals (maritime pine bark extract, quercetin, vitamins, magnesium, phosphatidylcholine). In the discussion, we analyze post-vaccination injury and present a short review of the current literature.

Risk factors and preventive interventions for post Covid-19 condition: systematic review

This systematic review examined pre-existing and clinical risk factors for post Covid-19 condition (≥12 weeks after onset), and interventions during acute and post-acute phases of illness that could potentially prevent post Covid-19 condition. The review focuses on studies collecting data during the early phases of the pandemic and prior to the emergence of variants of concern and widespread vaccination. We searched bibliographic databases and grey literature. Two investigators independently reviewed abstracts and full-text articles, and data extraction and risk of bias assessments were verified. Meta-analysis was performed when suitable and we assessed the certainty of evidence using GRADE. We included 31 studies. We found small-to-moderate associations (e.g. adjusted odds ratios 1.5 to <2.0) between female sex and higher non-recovery, fatigue, and dyspnea (moderate certainty). Severe or critical acute-phase Covid-19 severity (versus not) has probably (moderate certainty) a large association (adjusted ratio ≥2.0) with increased cognitive impairment, a small-to-moderate association with more non-recovery, and a little-to-no association with dyspnea. There may be (low certainty) large associations between hospitalization and increased non-recovery, increased dyspnea, and reduced return to work. Other outcomes had low certainty of small-to-moderate or little-to-no association or very low certainty. Several potential preventive interventions were examined, but effects are very uncertain. Guidelines in relation to surveillance, screening, and other services such as access to sickness and disability benefits, might need to focus on females and those with previously severe Covid-19 illness. Continuous assessment of emerging evidence, especially on whether different variants and vaccination impact outcomes, will be important. PROSPERO registration: CRD42021270354.

A Scoping Review of Pharmacological Management of Postacute Sequelae of Severe Acute Respiratory Syndrome Coronavirus 2 Infection in 2021

BACKGROUND

Postacute sequelae of severe acute respiratory syndrome coronavirus 2 infection (PASC), or long-COVID, are signs and symptoms that persist after the acute phase of Coronavirus disease 2019 infection has passed. PASC is newly recognized, and research is ongoing to answer questions about pathology, symptoms, diagnosis, and optimal treatment.

AREAS OF UNCERTAINTY

Use of pharmacologic treatment for symptoms of PASC is currently evolving. This scoping review aims to assess medical literature for any evidence supporting or refuting use of any medications to specifically treat PASC.

DATA SOURCES

PubMed, EMBASE, Web of Science, and gray literature sources were searched for any study of medication use for PASC. Studies were included if they described medication use in patients with PASC. There were no exclusion criteria based on study type or if results were reported. Studies were divided into completed works and ongoing research.

RESULTS

Fifty-two records were included in final analysis from an initial 3524 records found, including 2 randomized controlled trials, 7 prospective, open-label or observational studies, 14 case reports or case series, 1 survey, 1 correspondence, 1 retrospective analysis, and 26 studies in progress. Seven of the 26 completed works investigate ivabradine or beta-blockers, whereas 7 investigate local or systemic corticosteroids. Three investigate multi-ingredient nutritional supplements. The other 9 completed works as well as the 26 studies in progress investigate a wide variety of other treatments including drugs in development, drugs used for other conditions, herbals, supplements, and vitamins.

CONCLUSIONS

There is limited, but evolving, literature on medication treatment for PASC. Providers who opt to use pharmacologic therapy for PASC need to be vigilant in their knowledge of these evolving data.