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Self WH, Shotwell MS, Gibbs KW, de Wit M, Files DC, Harkins M, Hudock KM, Merck LH, Moskowitz A, Apodaca KD, Barksdale A, Safdar B, Javaheri A, Sturek JM, Schrager H, Iovine N, Tiffany B, Douglas IS, Levitt J, Busse LW, Ginde AA, Brown SM, Hager DN, Boyle K, Duggal A, Khan A, Lanspa M, Chen P, Puskarich M, Vonderhaar D, Venkateshaiah L, Gentile N, Rosenberg Y, Troendle J, Bistran-Hall AJ, DeClercq J, Lavieri R, Joly MM, Orr M, Pulley J, Rice TW, Schildcrout JS, Semler MW, Wang L, Bernard GR, Collins SP. Renin-Angiotensin System Modulation With Synthetic Angiotensin (1-7) and Angiotensin II Type 1 Receptor-Biased Ligand in Adults With COVID-19: Two Randomized Clinical Trials. JAMA 2023; 329:1170-1182. [PMID: 37039791 PMCID: PMC10091180 DOI: 10.1001/jama.2023.3546] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 02/24/2023] [Indexed: 04/12/2023]
Abstract
Importance Preclinical models suggest dysregulation of the renin-angiotensin system (RAS) caused by SARS-CoV-2 infection may increase the relative activity of angiotensin II compared with angiotensin (1-7) and may be an important contributor to COVID-19 pathophysiology. Objective To evaluate the efficacy and safety of RAS modulation using 2 investigational RAS agents, TXA-127 (synthetic angiotensin [1-7]) and TRV-027 (an angiotensin II type 1 receptor-biased ligand), that are hypothesized to potentiate the action of angiotensin (1-7) and mitigate the action of the angiotensin II. Design, Setting, and Participants Two randomized clinical trials including adults hospitalized with acute COVID-19 and new-onset hypoxemia were conducted at 35 sites in the US between July 22, 2021, and April 20, 2022; last follow-up visit: July 26, 2022. Interventions A 0.5-mg/kg intravenous infusion of TXA-127 once daily for 5 days or placebo. A 12-mg/h continuous intravenous infusion of TRV-027 for 5 days or placebo. Main Outcomes and Measures The primary outcome was oxygen-free days, an ordinal outcome that classifies a patient's status at day 28 based on mortality and duration of supplemental oxygen use; an adjusted odds ratio (OR) greater than 1.0 indicated superiority of the RAS agent vs placebo. A key secondary outcome was 28-day all-cause mortality. Safety outcomes included allergic reaction, new kidney replacement therapy, and hypotension. Results Both trials met prespecified early stopping criteria for a low probability of efficacy. Of 343 patients in the TXA-127 trial (226 [65.9%] aged 31-64 years, 200 [58.3%] men, 225 [65.6%] White, and 274 [79.9%] not Hispanic), 170 received TXA-127 and 173 received placebo. Of 290 patients in the TRV-027 trial (199 [68.6%] aged 31-64 years, 168 [57.9%] men, 195 [67.2%] White, and 225 [77.6%] not Hispanic), 145 received TRV-027 and 145 received placebo. Compared with placebo, both TXA-127 (unadjusted mean difference, -2.3 [95% CrI, -4.8 to 0.2]; adjusted OR, 0.88 [95% CrI, 0.59 to 1.30]) and TRV-027 (unadjusted mean difference, -2.4 [95% CrI, -5.1 to 0.3]; adjusted OR, 0.74 [95% CrI, 0.48 to 1.13]) resulted in no difference in oxygen-free days. In the TXA-127 trial, 28-day all-cause mortality occurred in 22 of 163 patients (13.5%) in the TXA-127 group vs 22 of 166 patients (13.3%) in the placebo group (adjusted OR, 0.83 [95% CrI, 0.41 to 1.66]). In the TRV-027 trial, 28-day all-cause mortality occurred in 29 of 141 patients (20.6%) in the TRV-027 group vs 18 of 140 patients (12.9%) in the placebo group (adjusted OR, 1.52 [95% CrI, 0.75 to 3.08]). The frequency of the safety outcomes was similar with either TXA-127 or TRV-027 vs placebo. Conclusions and Relevance In adults with severe COVID-19, RAS modulation (TXA-127 or TRV-027) did not improve oxygen-free days vs placebo. These results do not support the hypotheses that pharmacological interventions that selectively block the angiotensin II type 1 receptor or increase angiotensin (1-7) improve outcomes for patients with severe COVID-19. Trial Registration ClinicalTrials.gov Identifier: NCT04924660.
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Affiliation(s)
- Wesley H. Self
- Vanderbilt Institute for Clinical and Translational Research, Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew S. Shotwell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kevin W. Gibbs
- Department of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - Marjolein de Wit
- Department of Medicine, Virginia Commonwealth University, Richmond
| | - D. Clark Files
- Department of Medicine, Wake Forest University, Winston-Salem, North Carolina
| | - Michelle Harkins
- Department of Internal Medicine, University of New Mexico, Albuquerque
| | | | - Lisa H. Merck
- Department of Emergency Medicine, Virginia Commonwealth University Health System, Richmond
| | - Ari Moskowitz
- Department of Medicine, Montefiore Medical Center, Bronx, New York
| | | | - Aaron Barksdale
- Department of Emergency Medicine, University of Nebraska Medical Center, Omaha
| | - Basmah Safdar
- Department of Emergency Medicine, Yale University, New Haven, Connecticut
| | - Ali Javaheri
- Department of Medicine, Washington University, St Louis, Missouri
| | | | - Harry Schrager
- Department of Medicine, Tufts School of Medicine, Newton-Wellesley Hospital, Newton, Massachusetts
| | - Nicole Iovine
- Department of Medicine, University of Florida, Gainesville
| | | | - Ivor S. Douglas
- Department of Medicine, Denver Health Medical Center, Denver, Colorado
| | - Joseph Levitt
- Department of Medicine, Stanford University, Stanford, California
| | | | - Adit A. Ginde
- Department of Emergency Medicine, School of Medicine, University of Colorado, Aurora
| | - Samuel M. Brown
- Department of Pulmonary/Critical Care Medicine, Intermountain Medical Center, Murray, Utah
| | - David N. Hager
- Department of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Katherine Boyle
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Abhijit Duggal
- Department of Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Akram Khan
- Department of Medicine, Oregon Health & Science University, Portland
| | - Michael Lanspa
- Department of Pulmonary/Critical Care Medicine, Intermountain Medical Center, Murray, Utah
| | - Peter Chen
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Michael Puskarich
- Department of Emergency Medicine, University of Minnesota, Minneapolis
| | - Derek Vonderhaar
- Department of Medicine, Ochsner Medical Center, New Orleans, Louisiana
| | | | - Nina Gentile
- Department of Emergency Medicine, Temple University, Philadelphia, Pennsylvania
| | - Yves Rosenberg
- National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - James Troendle
- National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Amanda J. Bistran-Hall
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Josh DeClercq
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert Lavieri
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Meghan Morrison Joly
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael Orr
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jill Pulley
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Todd W. Rice
- Vanderbilt Institute for Clinical and Translational Research, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Matthew W. Semler
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Li Wang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Gordon R. Bernard
- Vanderbilt Institute for Clinical and Translational Research, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sean P. Collins
- Vanderbilt Institute for Clinical and Translational Research, Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Tennessee Valley Healthcare System, Nashville
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Balza E, Piccioli P, Carta S, Lavieri R, Gattorno M, Semino C, Castellani P, Rubartelli A. Proton pump inhibitors protect mice from acute systemic inflammation and induce long-term cross-tolerance. Cell Death Dis 2016; 7:e2304. [PMID: 27441656 PMCID: PMC4973356 DOI: 10.1038/cddis.2016.218] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 06/10/2016] [Accepted: 06/20/2016] [Indexed: 02/06/2023]
Abstract
Incidence of sepsis is increasing, representing a tremendous burden for health-care systems. Death in acute sepsis is attributed to hyperinflammatory responses, but the underlying mechanisms are still unclear. We report here that proton pump inhibitors (PPIs), which block gastric acid secretion, selectively inhibited tumor necrosis factor-α (TNF-α) and interleukin-1β (IL-1β) secretion by Toll-like receptor (TLR)-activated human monocytes in vitro, in the absence of toxic effects. Remarkably, the oversecretion of IL-1β that represents a hallmark of monocytes from patients affected by cryopyrin-associated periodic syndrome is also blocked. Based on these propaedeutic experiments, we tested the effects of high doses of PPIs in vivo in the mouse model of endotoxic shock. Our data show that a single administration of PPI protected mice from death (60% survival versus 5% of untreated mice) and decreased TNF-α and IL-1β systemic production. PPIs were efficacious even when administered after lipopolysaccharide (LPS) injection. PPI-treated mice that survived developed a long-term cross-tolerance, becoming resistant to LPS- and zymosan-induced sepsis. In vitro, their macrophages displayed impaired TNF-α and IL-1β to different TLR ligands. PPIs also prevented sodium thioglycollate-induced peritoneal inflammation, indicating their efficacy also in a non-infectious setting independent of TLR stimulation. Lack of toxicity and therapeutic effectiveness make PPIs promising new drugs against sepsis and other severe inflammatory conditions.
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Affiliation(s)
- E Balza
- Cell Biology Unit, IRCCS AOU San Martino-IST, 16132 Genoa, Italy
| | - P Piccioli
- Cell Biology Unit, IRCCS AOU San Martino-IST, 16132 Genoa, Italy
| | - S Carta
- Cell Biology Unit, IRCCS AOU San Martino-IST, 16132 Genoa, Italy
| | - R Lavieri
- Cell Biology Unit, IRCCS AOU San Martino-IST, 16132 Genoa, Italy
| | - M Gattorno
- Pediatrics II Unit, G Gaslini Institute, 16147 Genoa, Italy
| | - C Semino
- Protein Transport Unit, Division of Cell and Molecular Biology, San Raffaele Institute, 20132 Milan, Italy
| | - P Castellani
- Cell Biology Unit, IRCCS AOU San Martino-IST, 16132 Genoa, Italy
| | - A Rubartelli
- Cell Biology Unit, IRCCS AOU San Martino-IST, 16132 Genoa, Italy
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