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Choudhary MC, Deo R, Evering TH, Chew KW, Giganti MJ, Moser C, Ritz J, Regan J, Flynn JP, Crain CR, Wohl DA, Currier JS, Eron JJ, Margolis D, Zhu Q, Zhon L, Ya L, Greninger AL, Hughes MD, Smith D, Daar ES, Li JZ. Characterization of Treatment Resistance and Viral Kinetics in the Setting of Single-Active Versus Dual-Active Monoclonal Antibodies Against Severe Acute Respiratory Syndrome Coronavirus 2. J Infect Dis 2024; 230:394-402. [PMID: 38716969 PMCID: PMC11326811 DOI: 10.1093/infdis/jiae192] [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: 03/15/2024] [Accepted: 04/11/2024] [Indexed: 08/04/2024] Open
Abstract
BACKGROUND Monoclonal antibodies (mAbs) represent a crucial antiviral strategy for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, but it is unclear whether combination mAbs offer a benefit over single-active mAb treatment. Amubarvimab and romlusevimab significantly reduced the risk of hospitalizations or death in the ACTIV-2/A5401 trial. Certain SARS-CoV-2 variants are intrinsically resistant against romlusevimab, leading to only single-active mAb therapy with amubarvimab in these variants. We evaluated virologic outcomes in individuals treated with single- versus dual-active mAbs. METHODS Participants were nonhospitalized adults at higher risk of clinical progression randomized to amubarvimab plus romlusevimab or placebo. Quantitative SARS-CoV-2 RNA levels and targeted S-gene next-generation sequencing was performed on anterior nasal samples. We compared viral load kinetics and resistance emergence between individuals treated with effective single- versus dual-active mAbs depending on the infecting variant. RESULTS Study participants receiving single- or dual-active mAbs had similar demographics, baseline nasal viral load, symptom score, and symptom duration. Compared with single-active mAb treatment, treatment with dual-active mAbs led to faster viral load decline at study days 3 (P < .001) and 7 (P < .01). Treatment-emergent resistance mutations were more likely to be detected after amubarvimab plus romlusevimab treatment than with placebo (2.6% vs 0%; P < .001) and were more frequently detected in the setting of single-active compared with dual-active mAb treatment (7.3% vs 1.1%; P < .01). Single-active and dual-active mAb treatment resulted in similar decrease in rates of hospitalizations or death. CONCLUSIONS Compared with single-active mAb therapy, dual-active mAbs led to similar clinical outcomes but significantly faster viral load decline and a lower risk of emergent resistance.
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Affiliation(s)
- Manish C Choudhary
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Rinki Deo
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Teresa H Evering
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Kara W Chew
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Mark J Giganti
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Carlee Moser
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Justin Ritz
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - James Regan
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - James P Flynn
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Charles R Crain
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David Alain Wohl
- Department of Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Judith S Currier
- Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Joseph J Eron
- Department of Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | | | - Qing Zhu
- Brii Biosciences, Durham, North Carolina, USA
| | - Lijie Zhon
- Brii Biosciences, Durham, North Carolina, USA
| | - Li Ya
- Brii Biosciences, Durham, North Carolina, USA
| | - Alexander L Greninger
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Michael D Hughes
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Davey Smith
- Department of Medicine, University of California, San Diego, La Jolla, California, USA
| | - Eric S Daar
- Department of Medicine, Lundquist Institute at Harbor-UCLA Medical Center, Torrance, California, USA
| | - Jonathan Z Li
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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2
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Nair MS, Luck MI, Huang Y, Sabo Y, Ho DD. Persistence of an infectious form of SARS-CoV-2 post protease inhibitor treatment of permissive cells in vitro. J Infect Dis 2024:jiae385. [PMID: 39132824 DOI: 10.1093/infdis/jiae385] [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: 04/30/2024] [Revised: 06/28/2024] [Accepted: 08/09/2024] [Indexed: 08/13/2024] Open
Abstract
Reports have described SARS-CoV-2 rebound in COVID-19 patients treated with nirmatrelvir, a 3CL protease inhibitor. The cause remains a mystery, although drug resistance, re-infection, and lack of adequate immune responses have been excluded. We now present virologic findings that provide a clue to the cause of viral rebound, which occurs in ∼20% of the treated cases. Persistence of infectious SARS-CoV-2 was experimentally documented in vitro after treatment with nirmatrelvir or another 3CL protease inhibitor, but not with a polymerase inhibitor, remdesivir. This infectious form decayed slowly with a half-life of ∼1 day, suggesting that its persistence could outlive the treatment course to re-ignite SARS-CoV-2 infection as the drug is eliminated. Notably, extending nirmatrelvir treatment beyond 8 days abolished viral rebound in vitro. Our findings point in a particular direction for future investigation of virus persistence and offer a specific treatment recommendation that should be tested clinically.
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Affiliation(s)
- Manoj S Nair
- Aaron Diamond AIDS Research Center, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, 10032, USA
- Division of Infectious Diseases, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, 10032, USA
| | - Maria I Luck
- Aaron Diamond AIDS Research Center, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, 10032, USA
- Division of Infectious Diseases, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, 10032, USA
| | - Yaoxing Huang
- Aaron Diamond AIDS Research Center, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, 10032, USA
- Division of Infectious Diseases, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, 10032, USA
| | - Yosef Sabo
- Aaron Diamond AIDS Research Center, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, 10032, USA
- Division of Infectious Diseases, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, 10032, USA
| | - David D Ho
- Aaron Diamond AIDS Research Center, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, 10032, USA
- Division of Infectious Diseases, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, 10032, USA
- Department of Microbiology and Immunology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, 10032, USA
- Lead contact
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3
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Camp D, Caputo M, Echevarria FM, Achenbach CJ. COVID-19 clinical rebound after treatment with nirmatrelvir/ritonavir. RESEARCH SQUARE 2024:rs.3.rs-4497916. [PMID: 38947049 PMCID: PMC11213215 DOI: 10.21203/rs.3.rs-4497916/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Background Nirmatrelvir/ritonavir (NM/r) is a safe and effective oral antiviral therapeutic used for treatment of mild-to-moderate COVID-19. Case reports described a clinical rebound syndrome whereby individuals experience a relapse of symptoms shortly after completing successful treatment. There is a lack of information on frequency of COVID-19 rebound after NM/r in routine clinical care, contributing factors, and clinical outcomes. Methods We reviewed electronic medical records to verify COVID-19 diagnosis, symptoms, and treatment with NM/r from January-June 2022. We defined COVID-19 clinical rebound as clear improvement in symptoms followed by recurrence or worsening of symptoms within 30 days of a five-day course of NM/r. Results We studied 268 adults with median age 57 (IQR 47, 68), 80% White race, 85% non-Hispanic ethnicity, 55% female, 80% vaccinated and boosted against SARS-CoV-2, and 68% with any co-morbidity. Sixteen (6.0%) of studied patients were determined to have COVID-19 clinical rebound. The median time from starting NM/r to rebound was 11 days (IQR 9, 13). Notable demographic and clinical factors with higher proportion (not statistically significant) among COVID-19 rebound patients were female sex (75% rebound vs 54.5% no rebound), Black race (12.5% rebound vs 4.9% no rebound), presence of at least one co-morbidity (81.3% rebound vs 67.5% no rebound), and lack of prior SARS-CoV-2 infection (100% rebound vs 92.9% no rebound). Only one patient (6.25%) was hospitalized after COVID-19 rebound. Conclusions COVID-19 clinical rebound after treatment with NM/r is mild with favorable outcomes and more common than previously reported from real-world clinical care studies.
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Kelly SP, McEwen LM, Isaksson M, Murphy S, White S, Levy ME, McCrone JT, Levan G, Santhanam S, Baniecki ML, Bramson C, Rubino H, Hendrick V, Soares H, Hammond J, Luo S. Viral SARS-CoV-2 Rebound Rates in Linked Commercial Pharmacy-Based Testing and Health Care Claims. Open Forum Infect Dis 2024; 11:ofae243. [PMID: 38854397 PMCID: PMC11161861 DOI: 10.1093/ofid/ofae243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 04/29/2024] [Indexed: 06/11/2024] Open
Abstract
Background Viral SARS-CoV-2 rebound (viral RNA rebound) is challenging to characterize in large cohorts due to the logistics of collecting frequent and regular diagnostic test results. Pharmacy-based testing data provide an opportunity to study the phenomenon in a large population, also enabling subgroup analyses. The current real-world evidence approach complements approaches focused on smaller, prospective study designs. Methods We linked real-time reverse transcription quantitative polymerase chain reaction test data from national pharmacy-based testing to health care claims data via tokenization to calculate the cumulative incidence of viral RNA rebound within 28 days following positive test results in nirmatrelvir/ritonavir (NMV-r)-treated and untreated individuals during the Omicron era (December 2021-November 2022) and prior to the Omicron era (October 2020-November 2021). Results Among 30 646 patients, the rate of viral RNA rebound was 3.5% (95% CI, 2.0%-5.7%) in NMV-r-treated infections as compared with 1.5% (95% CI, 1.3%-1.7%) in untreated infections during the Omicron era and 1.9% (95% CI, 1.7%-2.1%) prior to the Omicron era. Viral RNA rebound in patients who were vaccinated (n = 8151), high risk (n = 4411), or older (≥65 years, n = 4411) occurred at comparable rates to the overall cohort (range, 1.1%-4.8%). Viral rebounds to high RNA levels in NMV-r-treated infections occurred in 8% of viral rebounds as compared with 5% to 11% in untreated infections. Rates of hospitalization were comparable between patients with NMV-r-treated infections with viral RNA rebound (0%) and untreated patients with viral RNA rebound (0%-1.2%). Conclusions Our findings suggest viral RNA rebound is rare (< 5%), with rates that were consistent with those from the EPIC-HR trial (Evaluation of Protease Inhibition for COVID-19 in High-Risk Patients). Most occurrences of viral RNA rebound were associated with low viral RNA levels, and viral RNA rebound progression to severe disease was not observed.
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Affiliation(s)
| | | | | | | | | | | | - John T McCrone
- Helix Inc, San Mateo, California, USA
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
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Smith-Jeffcoat SE, Biddle JE, Talbot HK, Morrisey KG, Stockwell MS, Maldonado Y, McLean HQ, Ellingson KD, Bowman NM, Asturias E, Mellis AM, Johnson S, Kirking HL, Rolfes MA, Olivo V, Merrill L, Battan-Wraith S, Sano E, McLaren SH, Vargas CY, Goodman S, Sarnquist CC, Govindaranjan P, Petrie JG, Belongia EA, Ledezma K, Pryor K, Lutrick K, Bullock A, Yang A, Haehnel Q, Rao S, Zhu Y, Schmitz J, Hart K, Grijalva CG, Salvatore PP. Symptoms, Viral Loads, and Rebound Among COVID-19 Outpatients Treated With Nirmatrelvir/Ritonavir Compared With Propensity Score-Matched Untreated Individuals. Clin Infect Dis 2024; 78:1175-1184. [PMID: 37963102 PMCID: PMC11090981 DOI: 10.1093/cid/ciad696] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 10/23/2023] [Accepted: 11/03/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND Nirmatrelvir/ritonavir (N/R) reduces severe outcomes from coronavirus disease 2019 (COVID-19); however, rebound after treatment has been reported. We compared symptom and viral dynamics in individuals with COVID-19 who completed N/R treatment and similar untreated individuals. METHODS We identified symptomatic participants who tested severe acute respiratory syndrome coronavirus 2-positive and were N/R eligible from a COVID-19 household transmission study. Index cases from ambulatory settings and their households contacts were enrolled. We collected daily symptoms, medication use, and respiratory specimens for quantitative polymerase chain reaction for 10 days during March 2022-May 2023. Participants who completed N/R treatment (treated) were propensity score matched to untreated participants. We compared symptom rebound, viral load (VL) rebound, average daily symptoms, and average daily VL by treatment status measured after N/R treatment completion or 7 days after symptom onset if untreated. RESULTS Treated (n = 130) and untreated participants (n = 241) had similar baseline characteristics. After treatment completion, treated participants had greater occurrence of symptom rebound (32% vs 20%; P = .009) and VL rebound (27% vs 7%; P < .001). Average daily symptoms were lower among treated participants without symptom rebound (1.0 vs 1.6; P < .01) but not statistically lower with symptom rebound (3.0 vs 3.4; P = .5). Treated participants had lower average daily VLs without VL rebound (0.9 vs 2.6; P < .01) but not statistically lower with VL rebound (4.8 vs 5.1; P = .7). CONCLUSIONS Individuals who completed N/R treatment experienced fewer symptoms and lower VL but rebound occured more often compared with untreated individuals. Providers should prescribe N/R, when indicated, and communicate rebound risk to patients.
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Affiliation(s)
- Sarah E. Smith-Jeffcoat
- Coronavirus and Other Respiratory Viruses Division, Centers for Disease Control and Prevention, Atlanta, GA
| | - Jessica E. Biddle
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, GA
| | | | | | - Melissa S. Stockwell
- Division of Child and Adolescent Health, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons
- Department of Population and Family Health Columbia University Mailman School of Public Health
- New York-Presbyterian Hospital, New York, NY
| | | | | | | | | | | | | | - Sheroi Johnson
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, GA
| | - Hannah L. Kirking
- Coronavirus and Other Respiratory Viruses Division, Centers for Disease Control and Prevention, Atlanta, GA
| | | | | | | | | | - Ellen Sano
- New York-Presbyterian Hospital, New York, NY
- Department of Emergency Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Son H. McLaren
- New York-Presbyterian Hospital, New York, NY
- Department of Emergency Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Celibell Y. Vargas
- Division of Child and Adolescent Health, Department of Pediatrics, Columbia University Vagelos College of Physicians and Surgeons
| | - Sara Goodman
- Stanford University School of Medicine, Stanford, CA
| | | | | | | | | | - Karla Ledezma
- University of Arizona College of Medicine, Tucson, AZ
| | | | - Karen Lutrick
- University of Arizona College of Medicine, Tucson, AZ
| | | | - Amy Yang
- University of North Carolina, Chapel Hill, NC
| | | | | | - Yuwei Zhu
- Vanderbilt University Medical Center, Nashville, TN
| | | | | | | | - Phillip P. Salvatore
- Coronavirus and Other Respiratory Viruses Division, Centers for Disease Control and Prevention, Atlanta, GA
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6
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Meyerowitz EA, Li Y. Review: The Landscape of Antiviral Therapy for COVID-19 in the Era of Widespread Population Immunity and Omicron-Lineage Viruses. Clin Infect Dis 2024; 78:908-917. [PMID: 37949817 DOI: 10.1093/cid/ciad685] [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: 09/11/2023] [Revised: 11/01/2023] [Accepted: 11/08/2023] [Indexed: 11/12/2023] Open
Abstract
The goals of coronavirus disease 2019 (COVID-19) antiviral therapy early in the pandemic were to prevent severe disease, hospitalization, and death. As these outcomes have become infrequent in the age of widespread population immunity, the objectives have shifted. For the general population, COVID-19-directed antiviral therapy should decrease symptom severity and duration and minimize infectiousness, and for immunocompromised individuals, antiviral therapy should reduce severe outcomes and persistent infection. The increased recognition of virologic rebound following ritonavir-boosted nirmatrelvir (NMV/r) and the lack of randomized controlled trial data showing benefit of antiviral therapy for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection for standard-risk, vaccinated individuals remain major knowledge gaps. Here, we review data for selected antiviral agents and immunomodulators currently available or in late-stage clinical trials for use in outpatients. We do not review antibody products, convalescent plasma, systemic corticosteroids, IL-6 inhibitors, Janus kinase inhibitors, or agents that lack Food and Drug Administration approval or emergency use authorization or are not appropriate for outpatients.
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Affiliation(s)
- Eric A Meyerowitz
- Division of Infectious Diseases, Department of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Yijia Li
- Division of Infectious Diseases, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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7
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Yang Z, Xu Y, Zheng R, Ye L, Lv G, Cao Z, Han R, Li M, Zhu Y, Cao Q, Ding Y, Wang J, Tan Y, Liu F, Wei D, Tan W, Jiang W, Sun J, Sun S, Shao J, Deng Y, Gao W, Wang W, Zhao R, Qiu L, Chen E, Zhang X, Wang S, Ning G, Xu Y, Bi Y. COVID-19 Rebound After VV116 vs Nirmatrelvir-Ritonavir Treatment: A Randomized Clinical Trial. JAMA Netw Open 2024; 7:e241765. [PMID: 38477921 PMCID: PMC10938176 DOI: 10.1001/jamanetworkopen.2024.1765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 01/19/2024] [Indexed: 03/14/2024] Open
Abstract
Importance With the widespread use of anti-SARS-CoV-2 drugs, accumulating data have revealed potential viral load rebound after treatment. Objective To compare COVID-19 rebound after a standard 5-day course of antiviral treatment with VV116 vs nirmatrelvir-ritonavir. Design, Setting, and Participants This is a single-center, investigator-blinded, randomized clinical trial conducted in Shanghai, China. Adult patients with mild-to-moderate COVID-19 and within 5 days of SARS-CoV-2 infection were enrolled between December 20, 2022, and January 19, 2023, and randomly allocated to receive either VV116 or nirmatrelvir-ritonavir. Interventions Participants in the VV116 treatment group received oral 600-mg VV116 tablets every 12 hours on day 1 and 300 mg every 12 hours on days 2 through 5. Participants in the nirmatrelvir-ritonavir treatment group received oral nirmatrelvir-ritonavir tablets with 300 mg of nirmatrelvir plus 100 mg of ritonavir every 12 hours for 5 days. Participants were followed up every other day until day 28 and every week until day 60. Main Outcomes and Measures The primary outcome was viral load rebound (VLR), defined as a half-log increase in viral RNA copies per milliliter compared with treatment completion. Secondary outcomes included a reduction in the cycle threshold value of 1.5 or more, time until VLR, and symptom rebound, defined as an increase of more than 2 points in symptom score compared with treatment completion. The primary outcome and secondary outcomes were analyzed using the full analysis set. Sensitivity analyses were conducted using the per protocol set. Adverse events were analyzed using the safety analysis set. Results The full analysis set included 345 participants (mean [SD] age, 53.2 [16.8] years; 175 [50.7%] were men) who received VV116 (n = 165) or nirmatrelvir-ritonavir (n = 180). Viral load rebound occurred in 33 patients (20.0%) in the VV116 group and 39 patients (21.7%) in the nirmatrelvir-ritonavir group (P = .70). Symptom rebound occurred in 41 of 160 patients (25.6%) in the VV116 group and 40 of 163 patients (24.5%) in the nirmatrelvir-ritonavir group (P = .82). Viral whole-genome sequencing of 24 rebound cases revealed the same lineage at baseline and at viral load rebound in each case. Conclusions and Relevance In this randomized clinical trial of patients with mild-to-moderate COVID-19, viral load rebound and symptom rebound were both common after a standard 5-day course of treatment with either VV116 or nirmatrelvir-ritonavir. Prolongation of treatment duration might be investigated to reduce COVID-19 rebound. Trial Registration Chinese Clinical Trial Registry Identifier: ChiCTR2200066811.
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Affiliation(s)
- Zhitao Yang
- Emergency Department, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yu Xu
- Department of Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- National Clinical Research Center for Metabolic Diseases (Shanghai), Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission, National Research Center for Translational Medicine, State Key Laboratory of Medical Genomics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ruizhi Zheng
- Department of Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- National Clinical Research Center for Metabolic Diseases (Shanghai), Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission, National Research Center for Translational Medicine, State Key Laboratory of Medical Genomics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lei Ye
- Department of Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- National Clinical Research Center for Metabolic Diseases (Shanghai), Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission, National Research Center for Translational Medicine, State Key Laboratory of Medical Genomics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Gang Lv
- Shanghai Institute of Hematology, National Research Center for Translational Medicine, State Key Laboratory of Medical Genomics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Zhujun Cao
- Department of Infectious Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Rulai Han
- Department of Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- National Clinical Research Center for Metabolic Diseases (Shanghai), Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission, National Research Center for Translational Medicine, State Key Laboratory of Medical Genomics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Mian Li
- Department of Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- National Clinical Research Center for Metabolic Diseases (Shanghai), Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission, National Research Center for Translational Medicine, State Key Laboratory of Medical Genomics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuanyue Zhu
- Department of Geriatrics, Medical Center on Aging, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qiuyu Cao
- Department of Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- National Clinical Research Center for Metabolic Diseases (Shanghai), Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission, National Research Center for Translational Medicine, State Key Laboratory of Medical Genomics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yi Ding
- Department of Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- National Clinical Research Center for Metabolic Diseases (Shanghai), Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission, National Research Center for Translational Medicine, State Key Laboratory of Medical Genomics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jiqiu Wang
- Department of Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- National Clinical Research Center for Metabolic Diseases (Shanghai), Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission, National Research Center for Translational Medicine, State Key Laboratory of Medical Genomics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yun Tan
- Shanghai Institute of Hematology, National Research Center for Translational Medicine, State Key Laboratory of Medical Genomics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Feng Liu
- Shanghai Institute of Hematology, National Research Center for Translational Medicine, State Key Laboratory of Medical Genomics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Dong Wei
- Department of Infectious Diseases, Research Laboratory of Clinical Virology, National Research Center for Translational Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wei Tan
- Department of Infectious Diseases, Research Laboratory of Clinical Virology, National Research Center for Translational Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Weiwei Jiang
- Research and Development Administration Department, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jing Sun
- Department of Gastroenterology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shouyue Sun
- Department of Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- National Clinical Research Center for Metabolic Diseases (Shanghai), Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission, National Research Center for Translational Medicine, State Key Laboratory of Medical Genomics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jie Shao
- Department of Pediatrics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yang Deng
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Weiyi Gao
- Division of Medical Affairs, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Weiqing Wang
- Department of Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- National Clinical Research Center for Metabolic Diseases (Shanghai), Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission, National Research Center for Translational Medicine, State Key Laboratory of Medical Genomics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ren Zhao
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Liping Qiu
- Administrative Office, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Erzhen Chen
- Emergency Department, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xinxin Zhang
- Department of Infectious Diseases, Research Laboratory of Clinical Virology, National Research Center for Translational Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Clinical Trials Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shengyue Wang
- Shanghai Institute of Hematology, National Research Center for Translational Medicine, State Key Laboratory of Medical Genomics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Guang Ning
- Department of Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- National Clinical Research Center for Metabolic Diseases (Shanghai), Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission, National Research Center for Translational Medicine, State Key Laboratory of Medical Genomics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yiping Xu
- Clinical Trials Center, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yufang Bi
- Department of Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- National Clinical Research Center for Metabolic Diseases (Shanghai), Key Laboratory for Endocrine and Metabolic Diseases of the National Health Commission, National Research Center for Translational Medicine, State Key Laboratory of Medical Genomics, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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8
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Meyerowitz EA, Scott J, Richterman A, Male V, Cevik M. Clinical course and management of COVID-19 in the era of widespread population immunity. Nat Rev Microbiol 2024; 22:75-88. [PMID: 38114838 DOI: 10.1038/s41579-023-01001-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/28/2023] [Indexed: 12/21/2023]
Abstract
The clinical implications of COVID-19 have changed since SARS-CoV-2 first emerged in humans. The current high levels of population immunity, due to prior infection and/or vaccination, have been associated with a vastly decreased overall risk of severe disease. Some people, particularly those with immunocompromising conditions, remain at risk for severe outcomes. Through the course of the pandemic, variants with somewhat different symptom profiles from the original SARS-CoV-2 virus have emerged. The management of COVID-19 has also changed since 2020, with the increasing availability of evidence-based treatments in two main classes: antivirals and immunomodulators. Selecting the appropriate treatment(s) for patients with COVID-19 requires a deep understanding of the evidence and an awareness of the limitations of applying data that have been largely based on immune-naive populations to patients today who most likely have vaccine-derived and/or infection-derived immunity. In this Review, we provide a summary of the clinical manifestations and approaches to caring for adult patients with COVID-19 in the era of vaccine availability and the dominance of the Omicron subvariants, with a focus on the management of COVID-19 in different patient groups, including immunocompromised, pregnant, vaccinated and unvaccinated patients.
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Affiliation(s)
- Eric A Meyerowitz
- Division of Infectious Diseases, Montefiore Medical Center, Bronx, NY, USA
| | - Jake Scott
- Division of Infectious Diseases and Geographic Medicine, School of Medicine, Stanford University, Palo Alto, CA, USA
| | - Aaron Richterman
- Division of Infectious Diseases, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Victoria Male
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Muge Cevik
- Division of Infection and Global Health Research, School of Medicine, University of St Andrews, St Andrews, UK.
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9
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Andrews HS, Herman JD, Gandhi RT. Treatments for COVID-19. Annu Rev Med 2024; 75:145-157. [PMID: 37722709 DOI: 10.1146/annurev-med-052422-020316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/20/2023]
Abstract
The treatment for COVID-19 has evolved rapidly since the start of the pandemic and now consists mainly of antiviral and immunomodulatory agents. Antivirals, such as remdesivir and nirmatrelvir-ritonavir, have proved to be most useful earlier in illness (e.g., as outpatient therapy) and for less severe disease. Immunomodulatory therapies, such as dexamethasone and interleukin-6 or Janus kinase inhibitors, are most useful in severe disease or critical illness. The role of anti-SARS-CoV-2 monoclonal antibodies has diminished because of the emergence of viral variants that are not anticipated to be susceptible to these treatments, and there still is not a consensus on the use of convalescent plasma. COVID-19 has been associated with increased rates of venous thromboembolism, but the role of antithrombotic therapy is limited. Multiple investigational agents continue to be studied, which will alter current treatment paradigms as new data are released.
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Affiliation(s)
- Hayden S Andrews
- Division of Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; ,
| | - Jonathan D Herman
- Division of Infectious Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA;
- Ragon Institute of Mass General, MIT, and Harvard, Cambridge, Massachusetts, USA
| | - Rajesh T Gandhi
- Division of Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; ,
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10
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Li Y, Choudhary MC, Regan J, Boucau J, Nathan A, Speidel T, Liew MY, Edelstein GE, Kawano Y, Uddin R, Deo R, Marino C, Getz MA, Reynolds Z, Barry M, Gilbert RF, Tien D, Sagar S, Vyas TD, Flynn JP, Hammond SP, Novack LA, Choi B, Cernadas M, Wallace ZS, Sparks JA, Vyas JM, Seaman MS, Gaiha GD, Siedner MJ, Barczak AK, Lemieux JE, Li JZ. SARS-CoV-2 viral clearance and evolution varies by type and severity of immunodeficiency. Sci Transl Med 2024; 16:eadk1599. [PMID: 38266109 PMCID: PMC10982957 DOI: 10.1126/scitranslmed.adk1599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 12/18/2023] [Indexed: 01/26/2024]
Abstract
Despite vaccination and antiviral therapies, immunocompromised individuals are at risk for prolonged severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, but the immune defects that predispose an individual to persistent coronavirus disease 2019 (COVID-19) remain incompletely understood. In this study, we performed detailed viro-immunologic analyses of a prospective cohort of participants with COVID-19. The median times to nasal viral RNA and culture clearance in individuals with severe immunosuppression due to hematologic malignancy or transplant (S-HT) were 72 and 40 days, respectively, both of which were significantly longer than clearance rates in individuals with severe immunosuppression due to autoimmunity or B cell deficiency (S-A), individuals with nonsevere immunodeficiency, and nonimmunocompromised groups (P < 0.01). Participants who were severely immunocompromised had greater SARS-CoV-2 evolution and a higher risk of developing resistance against therapeutic monoclonal antibodies. Both S-HT and S-A participants had diminished SARS-CoV-2-specific humoral responses, whereas only the S-HT group had reduced T cell-mediated responses. This highlights the varied risk of persistent COVID-19 across distinct immunosuppressive conditions and suggests that suppression of both B and T cell responses results in the highest contributing risk of persistent infection.
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Affiliation(s)
- Yijia Li
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
- University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - Manish C. Choudhary
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - James Regan
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Julie Boucau
- Ragon Institute of MGH, MIT and Harvard, Cambridge, MA 02139, USA
| | - Anusha Nathan
- Ragon Institute of MGH, MIT and Harvard, Cambridge, MA 02139, USA
- Program in Health Sciences and Technology, Harvard Medical School and Massachusetts Institute of Technology, Boston, MA 02115, USA
| | - Tessa Speidel
- Center for Virology and Vaccine Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - May Yee Liew
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
- Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Gregory E. Edelstein
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Yumeko Kawano
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Rockib Uddin
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
- Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Rinki Deo
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Caitlin Marino
- Ragon Institute of MGH, MIT and Harvard, Cambridge, MA 02139, USA
| | - Matthew A. Getz
- Ragon Institute of MGH, MIT and Harvard, Cambridge, MA 02139, USA
| | - Zahra Reynolds
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Mamadou Barry
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Rebecca F. Gilbert
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Dessie Tien
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Shruti Sagar
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Tammy D. Vyas
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - James P. Flynn
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Sarah P. Hammond
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Lewis A. Novack
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Bina Choi
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Manuela Cernadas
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Zachary S. Wallace
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Jeffrey A. Sparks
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Jatin M. Vyas
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
- Ragon Institute of MGH, MIT and Harvard, Cambridge, MA 02139, USA
| | - Michael S. Seaman
- Center for Virology and Vaccine Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Gaurav D. Gaiha
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
- Ragon Institute of MGH, MIT and Harvard, Cambridge, MA 02139, USA
| | - Mark J. Siedner
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Amy K. Barczak
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
- Ragon Institute of MGH, MIT and Harvard, Cambridge, MA 02139, USA
| | - Jacob E. Lemieux
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
- Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
| | - Jonathan Z. Li
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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11
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Mao L, Shaabani N, Zhang X, Jin C, Xu W, Argent C, Kushnareva Y, Powers C, Stegman K, Liu J, Xie H, Xu C, Bao Y, Xu L, Zhang Y, Yang H, Qian S, Hu Y, Shao J, Zhang C, Li T, Li Y, Liu N, Lin Z, Wang S, Wang C, Shen W, Lin Y, Shu D, Zhu Z, Kotoi O, Kerwin L, Han Q, Chumakova L, Teijaro J, Royal M, Brunswick M, Allen R, Ji H, Lu H, Xu X. Olgotrelvir, a dual inhibitor of SARS-CoV-2 M pro and cathepsin L, as a standalone antiviral oral intervention candidate for COVID-19. MED 2024; 5:42-61.e23. [PMID: 38181791 DOI: 10.1016/j.medj.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 08/18/2023] [Accepted: 12/03/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND Oral antiviral drugs with improved antiviral potency and safety are needed to address current challenges in clinical practice for treatment of COVID-19, including the risks of rebound, drug-drug interactions, and emerging resistance. METHODS Olgotrelvir (STI-1558) is designed as a next-generation antiviral targeting the SARS-CoV-2 main protease (Mpro), an essential enzyme for SARS-CoV-2 replication, and human cathepsin L (CTSL), a key enzyme for SARS-CoV-2 entry into host cells. FINDINGS Olgotrelvir is a highly bioavailable oral prodrug that is converted in plasma to its active form, AC1115. The dual mechanism of action of olgotrelvir and AC1115 was confirmed by enzyme activity inhibition assays and co-crystal structures of AC1115 with SARS-CoV-2 Mpro and human CTSL. AC1115 displayed antiviral activity by inhibiting replication of all tested SARS-CoV-2 variants in cell culture systems. Olgotrelvir also inhibited viral entry into cells using SARS-CoV-2 Spike-mediated pseudotypes by inhibition of host CTSL. In the K18-hACE2 transgenic mouse model of SARS-CoV-2-mediated disease, olgotrelvir significantly reduced the virus load in the lungs, prevented body weight loss, and reduced cytokine release and lung pathologies. Olgotrelvir demonstrated potent activity against the nirmatrelvir-resistant Mpro E166 mutants. Olgotrelvir showed enhanced oral bioavailability in animal models and in humans with significant plasma exposure without ritonavir. In phase I studies (ClinicalTrials.gov: NCT05364840 and NCT05523739), olgotrelvir demonstrated a favorable safety profile and antiviral activity. CONCLUSIONS Olgotrelvir is an oral inhibitor targeting Mpro and CTSL with high antiviral activity and plasma exposure and is a standalone treatment candidate for COVID-19. FUNDING Funded by Sorrento Therapeutics.
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Affiliation(s)
- Long Mao
- ACEA Therapeutics, Inc., San Diego, CA 92121, USA
| | | | - Xiaoying Zhang
- ACEA Pharmaceutical Co., Ltd., Hangzhou, Zhejiang, P.R. China
| | - Can Jin
- ACEA Therapeutics, Inc., San Diego, CA 92121, USA
| | - Wanhong Xu
- ACEA Pharmaceutical Co., Ltd., Hangzhou, Zhejiang, P.R. China
| | | | | | - Colin Powers
- Sorrento Therapeutics, Inc., San Diego, CA 92121, USA
| | - Karen Stegman
- Sorrento Therapeutics, Inc., San Diego, CA 92121, USA
| | - Jia Liu
- ACEA Therapeutics, Inc., San Diego, CA 92121, USA
| | - Hui Xie
- Sorrento Therapeutics, Inc., San Diego, CA 92121, USA
| | - Changxu Xu
- ACEA Pharmaceutical Co., Ltd., Hangzhou, Zhejiang, P.R. China
| | - Yimei Bao
- ACEA Pharmaceutical Co., Ltd., Hangzhou, Zhejiang, P.R. China
| | - Lijun Xu
- ACEA Pharmaceutical Co., Ltd., Hangzhou, Zhejiang, P.R. China
| | - Yuren Zhang
- ACEA Pharmaceutical Co., Ltd., Hangzhou, Zhejiang, P.R. China
| | - Haigang Yang
- ACEA Pharmaceutical Co., Ltd., Hangzhou, Zhejiang, P.R. China
| | - Shengdian Qian
- ACEA Pharmaceutical Co., Ltd., Hangzhou, Zhejiang, P.R. China
| | - Yong Hu
- ACEA Pharmaceutical Co., Ltd., Hangzhou, Zhejiang, P.R. China
| | - Jianping Shao
- ACEA Pharmaceutical Co., Ltd., Hangzhou, Zhejiang, P.R. China
| | - Can Zhang
- ACEA Pharmaceutical Co., Ltd., Hangzhou, Zhejiang, P.R. China
| | - Tingting Li
- ACEA Pharmaceutical Co., Ltd., Hangzhou, Zhejiang, P.R. China
| | - Yi Li
- ACEA Pharmaceutical Co., Ltd., Hangzhou, Zhejiang, P.R. China
| | - Na Liu
- ACEA Pharmaceutical Co., Ltd., Hangzhou, Zhejiang, P.R. China
| | - Zhenhao Lin
- ACEA Pharmaceutical Co., Ltd., Hangzhou, Zhejiang, P.R. China
| | - Shanbo Wang
- ACEA Pharmaceutical Co., Ltd., Hangzhou, Zhejiang, P.R. China
| | - Chao Wang
- ACEA Pharmaceutical Co., Ltd., Hangzhou, Zhejiang, P.R. China
| | - Wei Shen
- ACEA Pharmaceutical Co., Ltd., Hangzhou, Zhejiang, P.R. China
| | - Yuanlong Lin
- Shenzhen Third People's Hospital, SUSTech, Shenzhen, P.R. China
| | - Dan Shu
- Shenzhen Third People's Hospital, SUSTech, Shenzhen, P.R. China
| | - Zhenhong Zhu
- ACEA Therapeutics, Inc., San Diego, CA 92121, USA
| | - Olivia Kotoi
- ACEA Therapeutics, Inc., San Diego, CA 92121, USA
| | - Lisa Kerwin
- Sorrento Therapeutics, Inc., San Diego, CA 92121, USA
| | - Qing Han
- Structure Based Design, Inc., San Diego, CA 92121, USA
| | | | - John Teijaro
- Department of Immunology and Microbial Science, The Scripps Research Institute, La Jolla, CA 92037, USA
| | - Mike Royal
- Sorrento Therapeutics, Inc., San Diego, CA 92121, USA
| | | | - Robert Allen
- Sorrento Therapeutics, Inc., San Diego, CA 92121, USA
| | - Henry Ji
- Sorrento Therapeutics, Inc., San Diego, CA 92121, USA
| | - Hongzhou Lu
- Shenzhen Third People's Hospital, SUSTech, Shenzhen, P.R. China.
| | - Xiao Xu
- ACEA Therapeutics, Inc., San Diego, CA 92121, USA.
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12
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Harrington PR, Cong J, Troy SB, Rawson JM, O’Rear JJ, Valappil TI, McGarry Connelly S, Farley J, Birnkrant D. Evaluation of SARS-CoV-2 RNA Rebound After Nirmatrelvir/Ritonavir Treatment in Randomized, Double-Blind, Placebo-Controlled Trials - United States and International Sites, 2021-2022. MMWR. MORBIDITY AND MORTALITY WEEKLY REPORT 2023; 72:1365-1370. [PMID: 38127674 PMCID: PMC10754264 DOI: 10.15585/mmwr.mm7251a2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
Rebound of SARS-CoV-2 shedding or COVID-19 signs and symptoms has been described after treatment with nirmatrelvir/ritonavir (Paxlovid). The direct association of nirmatrelvir/ritonavir to COVID-19 rebound remains unclear because most reports are based on individual cases or nonrandomized studies. Viral RNA shedding data from two phase 2/3, randomized, double-blind, placebo-controlled clinical trials of nirmatrelvir/ritonavir (Evaluation of Protease Inhibition for COVID-19 in High-Risk Patients [EPIC-HR] and Evaluation of Protease Inhibition for COVID-19 in Standard-Risk Patients [EPIC-SR]) were analyzed to investigate the role of nirmatrelvir/ritonavir treatment in COVID-19 rebound. Rates of rebound of SARS-CoV-2 RNA shedding, identified based on an increase in nasopharyngeal viral RNA levels from day 5 (end-of-treatment) to day 10 or day 14, were similar between nirmatrelvir/ritonavir and placebo recipients. Among subjects with a virologic response through day 5, viral RNA rebound occurred in 6.4%-8.4% of nirmatrelvir/ritonavir recipients and 5.9%-6.5% of placebo recipients across EPIC-HR and the 2021/pre-Omicron and 2022/Omicron enrollment periods of EPIC-SR. Viral RNA rebound after nirmatrelvir/ritonavir treatment was not associated with COVID-19-related hospitalization or death. Data from randomized trials demonstrated that SARS-CoV-2 rebound can occur with or without antiviral treatment, supporting the Food and Drug Administration's determination of safety and efficacy of nirmatrelvir/ritonavir in eligible patients at high risk for severe COVID-19.
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13
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Nair MS, Luck MI, Huang Y, Sabo Y, Ho DD. Persistence of an infectious form of SARS-CoV-2 post protease inhibitor treatment of permissive cells in vitro. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.12.20.572655. [PMID: 38187654 PMCID: PMC10769372 DOI: 10.1101/2023.12.20.572655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2024]
Abstract
Reports have described SARS-CoV-2 rebound in COVID-19 patients treated with nirmatrelvir, a 3CL protease inhibitor. The cause remains a mystery, although drug resistance, re-infection, and lack of adequate immune responses have been excluded. We now present virologic findings that provide a clue to the cause of viral rebound, which occurs in ~20% of the treated cases. The persistence of an intermediary form of infectious SARS-CoV-2 was experimentally documented in vitro after treatment with nirmatrelvir or another 3CL protease inhibitor, but not with a polymerase inhibitor, remdesivir. This infectious intermediate decayed slowly with a half-life of ~1 day, suggesting that its persistence could outlive the treatment course to re-ignited SARS-CoV-2 infection as the drug is eliminated. Additional studies are needed to define the nature of this viral intermediate, but our findings point to a particular direction for future investigation and offer a specific treatment recommendation that should be tested clinically.
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Affiliation(s)
- Manoj S. Nair
- Aaron Diamond AIDS Research Center, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
- Division of Infectious Diseases, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Maria I. Luck
- Aaron Diamond AIDS Research Center, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
- Division of Infectious Diseases, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Yaoxing Huang
- Aaron Diamond AIDS Research Center, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
- Division of Infectious Diseases, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Yosef Sabo
- Aaron Diamond AIDS Research Center, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
- Division of Infectious Diseases, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - David D. Ho
- Aaron Diamond AIDS Research Center, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
- Division of Infectious Diseases, Department of Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
- Department of Microbiology and Immunology, Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
- Lead contact
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14
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Edelstein GE, Boucau J, Uddin R, Marino C, Liew MY, Barry M, Choudhary MC, Gilbert RF, Reynolds Z, Li Y, Tien D, Sagar S, Vyas TD, Kawano Y, Sparks JA, Hammond SP, Wallace Z, Vyas JM, Barczak AK, Lemieux JE, Li JZ, Siedner MJ. SARS-CoV-2 Virologic Rebound With Nirmatrelvir-Ritonavir Therapy : An Observational Study. Ann Intern Med 2023; 176:1577-1585. [PMID: 37956428 PMCID: PMC10644265 DOI: 10.7326/m23-1756] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Data are conflicting regarding an association between treatment of acute COVID-19 with nirmatrelvir-ritonavir (N-R) and virologic rebound (VR). OBJECTIVE To compare the frequency of VR in patients with and without N-R treatment for acute COVID-19. DESIGN Observational cohort study. SETTING Multicenter health care system in Boston, Massachusetts. PARTICIPANTS Ambulatory adults with acute COVID-19 with and without use of N-R. INTERVENTION Receipt of 5 days of N-R treatment versus no COVID-19 therapy. MEASUREMENTS The primary outcome was VR, defined as either a positive SARS-CoV-2 viral culture result after a prior negative result or 2 consecutive viral loads above 4.0 log10 copies/mL that were also at least 1.0 log10 copies/mL higher than a prior viral load below 4.0 log10 copies/mL. RESULTS Compared with untreated persons (n = 55), those taking N-R (n = 72) were older, received more COVID-19 vaccinations, and more commonly had immunosuppression. Fifteen participants (20.8%) taking N-R had VR versus 1 (1.8%) who was untreated (absolute difference, 19.0 percentage points [95% CI, 9.0 to 29.0 percentage points]; P = 0.001). All persons with VR had a positive viral culture result after a prior negative result. In multivariable models, only N-R use was associated with VR (adjusted odds ratio, 10.02 [CI, 1.13 to 88.74]; P = 0.038). Virologic rebound was more common among those who started therapy within 2 days of symptom onset (26.3%) than among those who started 2 or more days after symptom onset (0%) (P = 0.030). Among participants receiving N-R, those who had VR had prolonged shedding of replication-competent virus compared with those who did not have VR (median, 14 vs. 3 days). Eight of 16 participants (50% [CI, 25% to 75%]) with VR also reported symptom rebound; 2 were completely asymptomatic. No post-VR resistance mutations were detected. LIMITATIONS Observational study design with differences between the treated and untreated groups; positive viral culture result was used as a surrogate marker for risk for ongoing viral transmission. CONCLUSION Virologic rebound occurred in approximately 1 in 5 people taking N-R, often without symptom rebound, and was associated with shedding of replication-competent virus. PRIMARY FUNDING SOURCE National Institutes of Health.
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Affiliation(s)
| | - Julie Boucau
- Ragon Institute of MGH, MIT and Harvard, Cambridge, Massachusetts (J.B., C.M.)
| | - Rockib Uddin
- Massachusetts General Hospital, Boston, Massachusetts (R.U., M.Y.L., M.B., R.F.G., Z.R., D.T., S.S., T.D.V., S.P.H., Z.W.)
| | - Caitlin Marino
- Ragon Institute of MGH, MIT and Harvard, Cambridge, Massachusetts (J.B., C.M.)
| | - May Y Liew
- Massachusetts General Hospital, Boston, Massachusetts (R.U., M.Y.L., M.B., R.F.G., Z.R., D.T., S.S., T.D.V., S.P.H., Z.W.)
| | - Mamadou Barry
- Massachusetts General Hospital, Boston, Massachusetts (R.U., M.Y.L., M.B., R.F.G., Z.R., D.T., S.S., T.D.V., S.P.H., Z.W.)
| | - Manish C Choudhary
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (M.C.C., J.Z.L.)
| | - Rebecca F Gilbert
- Massachusetts General Hospital, Boston, Massachusetts (R.U., M.Y.L., M.B., R.F.G., Z.R., D.T., S.S., T.D.V., S.P.H., Z.W.)
| | - Zahra Reynolds
- Massachusetts General Hospital, Boston, Massachusetts (R.U., M.Y.L., M.B., R.F.G., Z.R., D.T., S.S., T.D.V., S.P.H., Z.W.)
| | - Yijia Li
- Brigham and Women's Hospital and Massachusetts General Hospital, Boston, Massachusetts, and University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania (Y.L.)
| | - Dessie Tien
- Massachusetts General Hospital, Boston, Massachusetts (R.U., M.Y.L., M.B., R.F.G., Z.R., D.T., S.S., T.D.V., S.P.H., Z.W.)
| | - Shruti Sagar
- Massachusetts General Hospital, Boston, Massachusetts (R.U., M.Y.L., M.B., R.F.G., Z.R., D.T., S.S., T.D.V., S.P.H., Z.W.)
| | - Tammy D Vyas
- Massachusetts General Hospital, Boston, Massachusetts (R.U., M.Y.L., M.B., R.F.G., Z.R., D.T., S.S., T.D.V., S.P.H., Z.W.)
| | - Yumeko Kawano
- Brigham and Women's Hospital, Boston, Massachusetts (G.E.E., Y.K., J.A.S.)
| | - Jeffrey A Sparks
- Brigham and Women's Hospital, Boston, Massachusetts (G.E.E., Y.K., J.A.S.)
| | - Sarah P Hammond
- Massachusetts General Hospital, Boston, Massachusetts (R.U., M.Y.L., M.B., R.F.G., Z.R., D.T., S.S., T.D.V., S.P.H., Z.W.)
| | - Zachary Wallace
- Massachusetts General Hospital, Boston, Massachusetts (R.U., M.Y.L., M.B., R.F.G., Z.R., D.T., S.S., T.D.V., S.P.H., Z.W.)
| | - Jatin M Vyas
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (J.M.V.)
| | - Amy K Barczak
- Ragon Institute of MGH, MIT and Harvard, Cambridge, Massachusetts, and Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts (A.K.B.)
| | - Jacob E Lemieux
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, and Broad Institute, Cambridge, Massachusetts (J.E.L.)
| | - Jonathan Z Li
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts (M.C.C., J.Z.L.)
| | - Mark J Siedner
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, and Africa Health Research Institute, KwaZulu-Natal, South Africa (M.J.S.)
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15
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Chan GCK, Lui GCY, Wong CNS, Yip SST, Li TCM, Cheung CSK, Sze RKH, Szeto CC, Chow KM. Safety Profile and Clinical and Virological Outcomes of Nirmatrelvir-Ritonavir Treatment in Patients With Advanced Chronic Kidney Disease and Coronavirus Disease 2019. Clin Infect Dis 2023; 77:1406-1412. [PMID: 37531093 DOI: 10.1093/cid/ciad371] [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: 04/03/2023] [Indexed: 08/03/2023] Open
Abstract
BACKGROUND Nirmatrelvir-ritonavir is currently not recommended in patients with an estimated glomerular filtration rate (eGFR) <30 mL/minute/1.73 m2. METHODS To determine the safety profile and clinical and virological outcomes of nirmatrelvir-ritonavir use at a modified dosage in adults with chronic kidney disease (CKD), a prospective, single-arm, interventional trial recruited patients with eGFR <30 mL/minute/1.73 m2 and on dialysis. Primary outcomes included safety profile, adverse/serious adverse events, and events leading to drug discontinuation. Disease symptoms, virological outcomes by serial severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) viral polymerase chain reaction (PCR) tests, rapid antigen tests, and virological and symptomatic rebound were also recorded. RESULTS Fifty-nine (69.4%) of the 85 participants had stage 5 CKD and were on dialysis. Eighty (94.1%) completed the full treatment course; 9.4% and 5.9% had adverse and serious adverse events, and these were comparable between those with eGFR < or >30 mL/minute/1.73 m2. The viral load significantly decreased on days 5, 15, and 30 (P < .001 for all), and the reduction was consistent in the subgroup with eGFR <30 mL/minute/1.73 m2. Ten patients had virological rebound, which was transient and asymptomatic. CONCLUSIONS Among patients with CKD, a modified dose of nirmatrelvir-ritonavir is a well-tolerated therapy in mild COVID-19 as it can effectively suppress the SARS-CoV-2 viral load with a favorable safety profile. Virological and symptomatic rebound, although transient with low infectivity, may occur after treatment. Nirmatrelvir-ritonavir should be considered for use in patients with CKD, including stage 5 CKD on dialysis. Clinical Trials Registration. Clinical Trials.gov; identifier: NCT05624840.
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Affiliation(s)
- Gordon Chun Kau Chan
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong Special Administrative Region (SAR), China
| | - Grace Chung Yan Lui
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong Special Administrative Region (SAR), China
- The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Candy Ngai Sze Wong
- The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Sindy Sin Ting Yip
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong Special Administrative Region (SAR), China
| | - Timothy Chun Man Li
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong Special Administrative Region (SAR), China
| | - Catherine Siu King Cheung
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong Special Administrative Region (SAR), China
| | - Ryan Kin Ho Sze
- Department of Microbiology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Cheuk Chun Szeto
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong Special Administrative Region (SAR), China
| | - Kai Ming Chow
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong Special Administrative Region (SAR), China
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16
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Chew KW, Malani PN, Gandhi RT. COVID-19 Therapeutics for Nonhospitalized Patients-Updates and Future Directions. JAMA 2023; 330:1519-1520. [PMID: 37773595 DOI: 10.1001/jama.2023.19542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/01/2023]
Abstract
In this Viewpoint, the authors summarize the therapeutic landscape for COVID-19, discuss who is most likely to benefit from treatment, provide an update on managing illness in immunocompromised individuals, and highlight how to improve COVID-19 treatment.
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Affiliation(s)
- Kara W Chew
- Department of Medicine, Division of Infectious Diseases, David Geffen School of Medicine at University of California Los Angeles, Los Angeles
| | - Preeti N Malani
- Department of Internal Medicine, Division of Infectious Diseases, University of Michigan, Ann Arbor
- Deputy Editor, JAMA
| | - Rajesh T Gandhi
- Department of Medicine, Division of Infectious Diseases, Massachusetts General Hospital, Harvard Medical School, Boston
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17
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Panza F, Fiorino F, Pastore G, Fiaschi L, Tumbarello M, Medaglini D, Ciabattini A, Montagnani F, Fabbiani M. Does Nirmatrelvir/Ritonavir Influence the Immune Response against SARS-CoV-2, Independently from Rebound? Microorganisms 2023; 11:2607. [PMID: 37894265 PMCID: PMC10609571 DOI: 10.3390/microorganisms11102607] [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: 09/10/2023] [Revised: 10/14/2023] [Accepted: 10/20/2023] [Indexed: 10/29/2023] Open
Abstract
Recurrence of coronavirus disease 19 (COVID-19) symptoms and SARS-CoV-2 viral load relapse have been reported in people treated with nirmatrelvir/ritonavir (NM/r). However, little is understood about the etiology of this phenomenon. Our aim was to investigate the relation between the host's immune response and viral rebound. We described three cases of COVID-19 rebound that occurred after treatment with nirmatrelvir/ritonavir (group A). In addition, we compared spike-specific antibody response and plasma cytokine/chemokine patterns of the rebound cases with those of (i) control patients treated with nirmatrelvir/ritonavir who did not show rebound (group B), and (ii) subjects not treated with any anti-SARS-CoV-2 drug (group C). The anti-spike antibodies and plasma cytokines/chemokines were similar in groups A and B. However, we observed a higher anti-BA.2 spike IgG response in patients without antiviral treatment (group C) [geometric mean titer 210,807, 5.1- and 8.2-fold higher compared to group A (p = 0.039) and group B (p = 0.032)]. Moreover, the patients receiving antiviral treatment (groups A-B) showed higher circulating levels of platelet-derived growth factor subunit B (PDGF-BB) and vascular endothelial growth Factors (VEGF) and lower levels of interleukin-9 (IL-9), interleukine-1 receptor antagonist (IL-1 RA), and regulated upon activation normal T cell expressed and presumably secreted chemokine (RANTES) when compared to group C. In conclusion, we observed lower anti-spike IgG levels and different cytokine patterns in nirmatrelvir/ritonavir-treated patients compared to those not treated with anti-SARS-CoV-2 drugs. This suggests that early antiviral treatment, by reducing viral load and antigen presentation, could mitigate the immune response against SARS-CoV-2. The clinical relevance of such observation should be further investigated in larger populations.
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Affiliation(s)
- Francesca Panza
- Department of Medical Biotechnologies, University of Siena, 53100 Siena, Italy; (F.P.); (L.F.); (M.T.)
- Infectious and Tropical Diseases Unit, Azienda Ospedaliera Universitaria Senese, 53100 Siena, Italy;
| | - Fabio Fiorino
- Laboratory of Molecular Microbiology and Biotechnology, Department of Medical Biotechnologies, University of Siena, 53100 Siena, Italy; (F.F.); (G.P.); (D.M.); (A.C.)
- Department of Medicine and Surgery, LUM University “Giuseppe Degennaro”, Casamassima, 70010 Bari, Italy
| | - Gabiria Pastore
- Laboratory of Molecular Microbiology and Biotechnology, Department of Medical Biotechnologies, University of Siena, 53100 Siena, Italy; (F.F.); (G.P.); (D.M.); (A.C.)
| | - Lia Fiaschi
- Department of Medical Biotechnologies, University of Siena, 53100 Siena, Italy; (F.P.); (L.F.); (M.T.)
| | - Mario Tumbarello
- Department of Medical Biotechnologies, University of Siena, 53100 Siena, Italy; (F.P.); (L.F.); (M.T.)
- Infectious and Tropical Diseases Unit, Azienda Ospedaliera Universitaria Senese, 53100 Siena, Italy;
| | - Donata Medaglini
- Laboratory of Molecular Microbiology and Biotechnology, Department of Medical Biotechnologies, University of Siena, 53100 Siena, Italy; (F.F.); (G.P.); (D.M.); (A.C.)
| | - Annalisa Ciabattini
- Laboratory of Molecular Microbiology and Biotechnology, Department of Medical Biotechnologies, University of Siena, 53100 Siena, Italy; (F.F.); (G.P.); (D.M.); (A.C.)
| | - Francesca Montagnani
- Department of Medical Biotechnologies, University of Siena, 53100 Siena, Italy; (F.P.); (L.F.); (M.T.)
- Infectious and Tropical Diseases Unit, Azienda Ospedaliera Universitaria Senese, 53100 Siena, Italy;
| | - Massimiliano Fabbiani
- Infectious and Tropical Diseases Unit, Azienda Ospedaliera Universitaria Senese, 53100 Siena, Italy;
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18
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Narovlyansky AN, Filimonova MV, Tsyshkova NG, Pronin AV, Grebennikova TV, Karamov EV, Larichev VF, Kornilayeva GV, Fedyakina IT, Dolzhikova IV, Mezentseva MV, Isaeva EI, Poloskov VV, Koval LS, Marinchenko VP, Surinova VI, Filimonov AS, Shitova AA, Soldatova OV, Sanin AV, Zubashev IK, Ponomarev AV, Veselovsky VV, Kozlov VV, Stepanov AV, Khomich AV, Kozlov VS, Ivanov SA, Shegai PV, Kaprin AD, Ershov FI, Gintsburg AL. In Vitro Antiviral Activity of a New Indol-3-carboxylic Acid Derivative Against SARS-CoV-2. Acta Naturae 2023; 15:83-91. [PMID: 38234608 PMCID: PMC10790354 DOI: 10.32607/actanaturae.26623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 10/26/2023] [Indexed: 01/19/2024] Open
Abstract
The coronavirus disease (COVID-19) pandemic has brought into sharp relief the threat posed by coronaviruses and laid the foundation for a fundamental analysis of this viral family, as well as a search for effective anti-COVID drugs. Work is underway to update existent vaccines against COVID-19, and screening for low-molecular-weight anti-COVID drug candidates for outpatient medicine continues. The opportunities and ways to accelerate the development of antiviral drugs against other pathogens are being discussed in the context of preparing for the next pandemic. In 2012-2015, Tsyshkova et al. synthesized a group of water-soluble low-molecular-weight compounds exhibiting an antiviral activity, whose chemical structure was similar to that of arbidol. Among those, there were a number of water-soluble compounds based on 5-methoxyindole-3-carboxylic acid aminoalkyl esters. Only one member of this rather extensive group of compounds, dihydrochloride of 6-bromo-5-methoxy-1-methyl-2-(1-piperidinomethyl)-3-(2-diethylaminoethoxy) carbonylindole, exhibited a reliable antiviral effect against SARS-CoV-2 in vitro. At a concentration of 52.0 μM, this compound completely inhibited the replication of the SARS-CoV-2 virus with an infectious activity of 106 TCID50/mL. The concentration curves of the analyzed compound indicate the specificity of its action. Interferon-inducing activity, as well as suppression of syncytium formation induced by the spike protein (S-glycoprotein) of SARS-CoV-2 by 89%, were also revealed. In view of its synthetic accessibility - high activity (IC50 = 1.06 μg/mL) and high selectivity index (SI = 78.6) - this compound appears to meets the requirements for the development of antiviral drugs for COVID-19 prevention and treatment.
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Affiliation(s)
- A. N. Narovlyansky
- National Research Centre for Epidemiology and Microbiology named after the honorary academician N.F. Gamaleya, Ministry of Health of the Russian Federation, Moscow, 123098 Russian Federation
| | - M. V. Filimonova
- National Medical Research Center for Radiology, Ministry of Health of the Russian Federation, Obninsk, 249036 Russian Federation
| | - N. G. Tsyshkova
- National Medical Research Center for Radiology, Ministry of Health of the Russian Federation, Obninsk, 249036 Russian Federation
| | - A. V. Pronin
- National Research Centre for Epidemiology and Microbiology named after the honorary academician N.F. Gamaleya, Ministry of Health of the Russian Federation, Moscow, 123098 Russian Federation
| | - T. V. Grebennikova
- National Research Centre for Epidemiology and Microbiology named after the honorary academician N.F. Gamaleya, Ministry of Health of the Russian Federation, Moscow, 123098 Russian Federation
| | - E. V. Karamov
- National Research Centre for Epidemiology and Microbiology named after the honorary academician N.F. Gamaleya, Ministry of Health of the Russian Federation, Moscow, 123098 Russian Federation
| | - V. F. Larichev
- National Research Centre for Epidemiology and Microbiology named after the honorary academician N.F. Gamaleya, Ministry of Health of the Russian Federation, Moscow, 123098 Russian Federation
| | - G. V. Kornilayeva
- National Research Centre for Epidemiology and Microbiology named after the honorary academician N.F. Gamaleya, Ministry of Health of the Russian Federation, Moscow, 123098 Russian Federation
| | - I. T. Fedyakina
- National Research Centre for Epidemiology and Microbiology named after the honorary academician N.F. Gamaleya, Ministry of Health of the Russian Federation, Moscow, 123098 Russian Federation
| | - I. V. Dolzhikova
- National Research Centre for Epidemiology and Microbiology named after the honorary academician N.F. Gamaleya, Ministry of Health of the Russian Federation, Moscow, 123098 Russian Federation
| | - M. V. Mezentseva
- National Research Centre for Epidemiology and Microbiology named after the honorary academician N.F. Gamaleya, Ministry of Health of the Russian Federation, Moscow, 123098 Russian Federation
| | - E. I. Isaeva
- National Research Centre for Epidemiology and Microbiology named after the honorary academician N.F. Gamaleya, Ministry of Health of the Russian Federation, Moscow, 123098 Russian Federation
| | - V. V. Poloskov
- National Research Centre for Epidemiology and Microbiology named after the honorary academician N.F. Gamaleya, Ministry of Health of the Russian Federation, Moscow, 123098 Russian Federation
| | - L. S. Koval
- National Medical Research Center for Radiology, Ministry of Health of the Russian Federation, Obninsk, 249036 Russian Federation
| | - V. P. Marinchenko
- National Medical Research Center for Radiology, Ministry of Health of the Russian Federation, Obninsk, 249036 Russian Federation
| | - V. I. Surinova
- National Medical Research Center for Radiology, Ministry of Health of the Russian Federation, Obninsk, 249036 Russian Federation
| | - A. S. Filimonov
- National Medical Research Center for Radiology, Ministry of Health of the Russian Federation, Obninsk, 249036 Russian Federation
| | - A. A. Shitova
- National Medical Research Center for Radiology, Ministry of Health of the Russian Federation, Obninsk, 249036 Russian Federation
| | - O. V. Soldatova
- National Medical Research Center for Radiology, Ministry of Health of the Russian Federation, Obninsk, 249036 Russian Federation
| | - A. V. Sanin
- National Research Centre for Epidemiology and Microbiology named after the honorary academician N.F. Gamaleya, Ministry of Health of the Russian Federation, Moscow, 123098 Russian Federation
| | - I. K. Zubashev
- National Research Centre for Epidemiology and Microbiology named after the honorary academician N.F. Gamaleya, Ministry of Health of the Russian Federation, Moscow, 123098 Russian Federation
| | - A. V. Ponomarev
- National Research Centre for Epidemiology and Microbiology named after the honorary academician N.F. Gamaleya, Ministry of Health of the Russian Federation, Moscow, 123098 Russian Federation
| | - V. V. Veselovsky
- N.D. Zelinsky Institute of Organic Chemistry, Russian Academy of Sciences, Moscow, 119991 Russian Federation
| | - V. V. Kozlov
- National Research Centre for Epidemiology and Microbiology named after the honorary academician N.F. Gamaleya, Ministry of Health of the Russian Federation, Moscow, 123098 Russian Federation
| | - A. V. Stepanov
- N.D. Zelinsky Institute of Organic Chemistry, Russian Academy of Sciences, Moscow, 119991 Russian Federation
| | | | - V. S. Kozlov
- National Research Centre for Epidemiology and Microbiology named after the honorary academician N.F. Gamaleya, Ministry of Health of the Russian Federation, Moscow, 123098 Russian Federation
| | - S. A. Ivanov
- National Medical Research Center for Radiology, Ministry of Health of the Russian Federation, Obninsk, 249036 Russian Federation
| | - P. V. Shegai
- National Medical Research Center for Radiology, Ministry of Health of the Russian Federation, Obninsk, 249036 Russian Federation
| | - A. D. Kaprin
- National Medical Research Center for Radiology, Ministry of Health of the Russian Federation, Obninsk, 249036 Russian Federation
| | - F. I. Ershov
- National Research Centre for Epidemiology and Microbiology named after the honorary academician N.F. Gamaleya, Ministry of Health of the Russian Federation, Moscow, 123098 Russian Federation
| | - A. L. Gintsburg
- National Research Centre for Epidemiology and Microbiology named after the honorary academician N.F. Gamaleya, Ministry of Health of the Russian Federation, Moscow, 123098 Russian Federation
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19
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Han J, Bae S, Jung J, Kim MJ, Chong YP, Lee SO, Choi SH, Kim YS, Chang E, Kim SH. Clinical characteristics of COVID-19 rebound after nirmatrelvir-ritonavir or molnupiravir therapy: A prospective cohort study. Medicine (Baltimore) 2023; 102:e35094. [PMID: 37773854 PMCID: PMC10545339 DOI: 10.1097/md.0000000000035094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 08/15/2023] [Indexed: 10/01/2023] Open
Abstract
The clinical characteristics of the rebound phenomenon after antiviral therapy in patients with Coronavirus disease-2019 (COVID-19) are largely unknown. There are few data comparing the rebound phenomenon after molnupiravir therapy to that after nirmatrelvir-ritonavir therapy. We investigated the incidence and risk factors associated with COVID-19 rebound after nirmatrelvir-ritonavir or molnupiravir therapy during the Omicron era. This prospective cohort study enrolled patients with mild-to-moderate COVID-19 who received nirmatrelvir-ritonavir or molnupiravir. We conducted weekly questionnaires of symptom scores from day 0 to day 28, with an additional day when patients experienced reappearing symptoms. We defined COVID-19 rebound as when patients experienced a 50% increase in symptom scores compared to the lowest symptom score between days 0 and 14. Among the 150 patients, 93 (62%) and 57 (38%) received nirmatrelvir-ritonavir therapy and molnupiravir, respectively. Of these, 11 patients (7.3%; 95% CI, 3.1-11.5) experienced COVID-19 rebound. The median duration from antiviral therapy to rebound was 12 days. Patients with clinical rebound had a higher symptom score at antiviral therapy initiation than those without (median, 5 vs 4; P = .02). There was no significant difference in the clinical rebounds associated with nirmatrelvir-ritonavir and molnupiravir therapy (5.4% vs 10.5%; P = .39). Approximately one-tenth of patients with mild-to-moderate COVID-19 who received antiviral therapy experienced rebound phenomena after treatment. Regardless of antiviral therapy type, high initial symptom scores were associated with a more frequent rebound phenomenon.
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Affiliation(s)
- Jaijun Han
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seongman Bae
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jiwon Jung
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Min Jae Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yong Pil Chong
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Oh Lee
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sang-Ho Choi
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Yang Soo Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Euijin Chang
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung-Han Kim
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
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20
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Ribeiro RM, Choudhary MC, Deo R, Giganti MJ, Moser C, Ritz J, Greninger AL, Regan J, Flynn JP, Wohl DA, Currier JS, Eron JJ, Hughes MD, Smith DM, Chew KW, Daar ES, Perelson AS, Li JZ. Variant-Specific Viral Kinetics in Acute COVID-19. J Infect Dis 2023; 228:S136-S143. [PMID: 37650233 PMCID: PMC10469346 DOI: 10.1093/infdis/jiad314] [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] [Indexed: 09/01/2023] Open
Abstract
Understanding variant-specific differences in severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) viral kinetics may explain differences in transmission efficiency and provide insights on pathogenesis and prevention. We evaluated SARS-CoV-2 kinetics from nasal swabs across multiple variants (Alpha, Delta, Epsilon, Gamma) in placebo recipients of the ACTIV-2/A5401 trial. Delta variant infection led to the highest maximum viral load and shortest time from symptom onset to viral load peak. There were no significant differences in time to viral clearance across the variants. Viral decline was biphasic with first- and second-phase decays having half-lives of 11 hours and 2.5 days, respectively, with differences among variants, especially in the second phase. These results suggest that while variant-specific differences in viral kinetics exist, post-peak viral load all variants appeared to be efficiently cleared by the host. Clinical Trials Registration. NCT04518410.
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Affiliation(s)
- Ruy M Ribeiro
- Theoretical Biology and Biophysics Group, Los Alamos National Laboratory, New Mexico
| | - Manish C Choudhary
- Division of Infectious Diseases, Brigham & Women's Hospital, Harvard Medical School, Cambridge, Massachusetts
| | - Rinki Deo
- Division of Infectious Diseases, Brigham & Women's Hospital, Harvard Medical School, Cambridge, Massachusetts
| | - Mark J Giganti
- Center for Biostatistics in AIDS Research, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Carlee Moser
- Center for Biostatistics in AIDS Research, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Justin Ritz
- Center for Biostatistics in AIDS Research, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | | | - James Regan
- Division of Infectious Diseases, Brigham & Women's Hospital, Harvard Medical School, Cambridge, Massachusetts
| | - James P Flynn
- Division of Infectious Diseases, Brigham & Women's Hospital, Harvard Medical School, Cambridge, Massachusetts
| | - David A Wohl
- Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill
| | - Judith S Currier
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles
| | - Joseph J Eron
- Department of Medicine, School of Medicine, University of North Carolina at Chapel Hill
| | - Michael D Hughes
- Center for Biostatistics in AIDS Research, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Davey M Smith
- Division of Infectious Diseases and Global Public Health, University of California, San Diego, La Jolla, California
| | - Kara W Chew
- Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles
| | - Eric S Daar
- Lundquist Institute, Harbor-UCLA Medical Center, Torrance, California
| | - Alan S Perelson
- Theoretical Biology and Biophysics Group, Los Alamos National Laboratory, New Mexico
| | - Jonathan Z Li
- Division of Infectious Diseases, Brigham & Women's Hospital, Harvard Medical School, Cambridge, Massachusetts
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21
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Edelstein GE, Boucau J, Uddin R, Marino C, Liew MY, Barry M, Choudhary MC, Gilbert RF, Reynolds Z, Li Y, Tien D, Sagar S, Vyas TD, Kawano Y, Sparks JA, Hammond SP, Wallace Z, Vyas JM, Barczak AK, Lemieux JE, Li JZ, Siedner MJ. SARS-CoV-2 virologic rebound with nirmatrelvir-ritonavir therapy. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.06.23.23288598. [PMID: 37425934 PMCID: PMC10327262 DOI: 10.1101/2023.06.23.23288598] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
Objective To compare the frequency of replication-competent virologic rebound with and without nirmatrelvir-ritonavir treatment for acute COVID-19. Secondary aims were to estimate the validity of symptoms to detect rebound and the incidence of emergent nirmatrelvir-resistance mutations after rebound. Design Observational cohort study. Setting Multicenter healthcare system in Boston, Massachusetts. Participants We enrolled ambulatory adults with a positive COVID-19 test and/or a prescription for nirmatrelvir-ritonavir. Exposures Receipt of 5 days of nirmatrelvir-ritonavir treatment versus no COVID-19 therapy. Main Outcome and Measures The primary outcome was COVID-19 virologic rebound, defined as either (1) a positive SARS-CoV-2 viral culture following a prior negative culture or (2) two consecutive viral loads ≥4.0 log10 copies/milliliter after a prior reduction in viral load to <4.0 log10 copies/milliliter. Results Compared with untreated individuals (n=55), those taking nirmatrelvir-ritonavir (n=72) were older, received more COVID-19 vaccinations, and were more commonly immunosuppressed. Fifteen individuals (20.8%) taking nirmatrelvir-ritonavir experienced virologic rebound versus one (1.8%) of the untreated (absolute difference 19.0% [95%CI 9.0-29.0%], P=0.001). In multivariable models, only N-R was associated with VR (AOR 10.02, 95%CI 1.13-88.74). VR occurred more commonly among those with earlier nirmatrelvir-ritonavir initiation (29.0%, 16.7% and 0% when initiated days 0, 1, and ≥2 after diagnosis, respectively, P=0.089). Among participants on N-R, those experiencing rebound had prolonged shedding of replication-competent virus compared to those that did not rebound (median: 14 vs 3 days). Only 8/16 with virologic rebound reported worsening symptoms (50%, 95%CI 25%-75%); 2 were completely asymptomatic. We detected no post-rebound nirmatrelvir-resistance mutations in the NSP5 protease gene. Conclusions and Relevance Virologic rebound occurred in approximately one in five people taking nirmatrelvir-ritonavir and often occurred without worsening symptoms. Because it is associated with replication-competent viral shedding, close monitoring and potential isolation of those who rebound should be considered.
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Affiliation(s)
| | - Julie Boucau
- Ragon Institute of MGH, MIT and Harvard, Cambridge, MA, USA
| | | | - Caitlin Marino
- Ragon Institute of MGH, MIT and Harvard, Cambridge, MA, USA
| | - May Y. Liew
- Massachusetts General Hospital, Boston, MA, USA
| | | | - Manish C. Choudhary
- Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | | | | | - Yijia Li
- Brigham and Women’s Hospital, Boston, MA, USA
- Massachusetts General Hospital, Boston, MA, USA
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Dessie Tien
- Massachusetts General Hospital, Boston, MA, USA
| | | | | | | | | | | | | | - Jatin M. Vyas
- Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Amy K. Barczak
- Ragon Institute of MGH, MIT and Harvard, Cambridge, MA, USA
- Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Jacob E. Lemieux
- Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Broad Institute, Cambridge, MA, USA
| | - Jonathan Z. Li
- Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Mark J. Siedner
- Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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22
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Toussi SS, Hammond JL, Gerstenberger BS, Anderson AS. Therapeutics for COVID-19. Nat Microbiol 2023; 8:771-786. [PMID: 37142688 DOI: 10.1038/s41564-023-01356-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 03/09/2023] [Indexed: 05/06/2023]
Abstract
Vaccines and monoclonal antibody treatments to prevent severe coronavirus disease 2019 (COVID-19) illness were available within a year of the pandemic being declared but there remained an urgent need for therapeutics to treat patients who were not vaccinated, were immunocompromised or whose vaccine immunity had waned. Initial results for investigational therapies were mixed. AT-527, a repurposed nucleoside inhibitor for hepatitis C virus, enabled viral load reduction in a hospitalized cohort but did not reduce viral load in outpatients. The nucleoside inhibitor molnupiravir prevented death but failed to prevent hospitalization. Nirmatrelvir, an inhibitor of the main protease (Mpro), co-dosed with the pharmacokinetic booster ritonavir, reduced hospitalization and death. Nirmatrelvir-ritonavir and molnupiravir received an Emergency Use Authorization in the United States at the end of 2021. Immunomodulatory drugs such as baricitinib, tocilizumab and corticosteroid, which target host-driven COVID-19 symptoms, are also in use. We highlight the development of COVID-19 therapies and the challenges that remain for anticoronavirals.
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