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Vlaar APJ, Witzenrath M, van Paassen P, Heunks LMA, Mourvillier B, de Bruin S, Lim EHT, Brouwer MC, Tuinman PR, Saraiva JFK, Marx G, Lobo SM, Boldo R, Simon-Campos JA, Cornet AD, Grebenyuk A, Engelbrecht JM, Mukansi M, Jorens PG, Zerbib R, Rückinger S, Pilz K, Guo R, van de Beek D, Riedemann NC, Witzenrath M, van Paassen P, Heunks LM, Mourvillier B, de Bruin S, Lim EH, Brouwer MC, Tuinman PR, Saraiva JFK, Marx G, Lobo S, Boldo R, Simon-Campos J, Cornet AD, Grebenyuk A, Engelbrecht J, Mukansi M, Jorens PG, Zerbib R, Rückinger S, Pilz K, Guo R, van de Beek D, Riedemann NC, Bulpa P, Taccone FS, Hermans G, Diltoer M, Piagnerelli M, De Neve N, Freire AT, Pizzol FD, Marinho AK, Sato VH, Arns da Cunha C, Neuville M, Dellamonica J, Annane D, Roquilly A, Diehl JL, Schneider F, Mira JP, Lascarrou JB, Desmedt L, Dupuis C, Schwebel C, Thiéry G, Gründling M, Berger M, Welte T, Bauer M, Jaschinski U, Matschke K, Mercado-Longoria R, Gomez Quintana B, Zamudio-Lerma JA, Moreno Hoyos Abril J, Aleman Marquez A, Pickkers P, Otterspoor L, Hercilla Vásquez L, Seas Ramos CR, Peña Villalobos A, Gianella Malca G, Chávez V, Filimonov V, Kulabukhov V, Acharya P, Timmermans SA, Busch MH, van Baarle FL, Koning R, ter Horst L, Chekrouni N, van Soest TM, Slim MA, van Vught LA, van Amstel RB, Olie SE, van Zeggeren IE, van de Poll MC, Thielert C, Neukirchen D. Anti-C5a antibody (vilobelimab) therapy for critically ill, invasively mechanically ventilated patients with COVID-19 (PANAMO): a multicentre, double-blind, randomised, placebo-controlled, phase 3 trial. Lancet Respir Med 2022; 10:1137-1146. [PMID: 36087611 PMCID: PMC9451499 DOI: 10.1016/s2213-2600(22)00297-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 07/29/2022] [Accepted: 08/03/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Vilobelimab, an anti-C5a monoclonal antibody, was shown to be safe in a phase 2 trial of invasively mechanically ventilated patients with COVID-19. Here, we aimed to determine whether vilobelimab in addition to standard of care improves survival outcomes in this patient population. METHODS This randomised, double-blind, placebo-controlled, multicentre phase 3 trial was performed at 46 hospitals in the Netherlands, Germany, France, Belgium, Russia, Brazil, Peru, Mexico, and South Africa. Participants aged 18 years or older who were receiving invasive mechanical ventilation, but not more than 48 h after intubation at time of first infusion, had a PaO2/FiO2 ratio of 60-200 mm Hg, and a confirmed SARS-CoV-2 infection with any variant in the past 14 days were eligible for this study. Eligible patients were randomly assigned (1:1) to receive standard of care and vilobelimab at a dose of 800 mg intravenously for a maximum of six doses (days 1, 2, 4, 8, 15, and 22) or standard of care and a matching placebo using permuted block randomisation. Treatment was not continued after hospital discharge. Participants, caregivers, and assessors were masked to group assignment. The primary outcome was defined as all-cause mortality at 28 days in the full analysis set (defined as all randomly assigned participants regardless of whether a patient started treatment, excluding patients randomly assigned in error) and measured using Kaplan-Meier analysis. Safety analyses included all patients who had received at least one infusion of either vilobelimab or placebo. This study is registered with ClinicalTrials.gov, NCT04333420. FINDINGS From Oct 1, 2020, to Oct 4, 2021, we included 368 patients in the ITT analysis (full analysis set; 177 in the vilobelimab group and 191 in the placebo group). One patient in the vilobelimab group was excluded from the primary analysis due to random assignment in error without treatment. At least one dose of study treatment was given to 364 (99%) patients (safety analysis set). 54 patients (31%) of 177 in the vilobelimab group and 77 patients (40%) of 191 in the placebo group died in the first 28 days. The all-cause mortality rate at 28 days was 32% (95% CI 25-39) in the vilobelimab group and 42% (35-49) in the placebo group (hazard ratio 0·73, 95% CI 0·50-1·06; p=0·094). In the predefined analysis without site-stratification, vilobelimab significantly reduced all-cause mortality at 28 days (HR 0·67, 95% CI 0·48-0·96; p=0·027). The most common TEAEs were acute kidney injury (35 [20%] of 175 in the vilobelimab group vs 40 [21%] of 189 in the placebo), pneumonia (38 [22%] vs 26 [14%]), and septic shock (24 [14%] vs 31 [16%]). Serious treatment-emergent adverse events were reported in 103 (59%) of 175 patients in the vilobelimab group versus 120 (63%) of 189 in the placebo group. INTERPRETATION In addition to standard of care, vilobelimab improves survival of invasive mechanically ventilated patients with COVID-19 and leads to a significant decrease in mortality. Vilobelimab could be considered as an additional therapy for patients in this setting and further research is needed on the role of vilobelimab and C5a in other acute respiratory distress syndrome-causing viral infections. FUNDING InflaRx and the German Federal Government.
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Affiliation(s)
- Alexander P J Vlaar
- Department of Intensive Care, Amsterdam UMC, Amsterdam Neuroscience, University of Amsterdam, Amsterdam, Netherlands,Prof Alexander P J Vlaar, Department of Intensive Care, University of Amsterdam, Amsterdam UMC, 1100DD Amsterdam, Netherlands
| | - Martin Witzenrath
- Department of Infectious Diseases and Respiratory Medicine, Charité-Universitätsmedizin Berlin, German Center for Lung Research, Berlin, Germany
| | | | - Leo M A Heunks
- Department of Intensive Care, Amsterdam UMC, Amsterdam Neuroscience, University of Amsterdam, Amsterdam, Netherlands
| | - Bruno Mourvillier
- Medical Intensive Care Unit, University Hospital of Reims, Reims, France
| | - Sanne de Bruin
- Department of Intensive Care, Amsterdam UMC, Amsterdam Neuroscience, University of Amsterdam, Amsterdam, Netherlands
| | - Endry H T Lim
- Department of Intensive Care, Amsterdam UMC, Amsterdam Neuroscience, University of Amsterdam, Amsterdam, Netherlands
| | - Matthijs C Brouwer
- Department of Neurology, Amsterdam UMC, Amsterdam Neuroscience, University of Amsterdam, Amsterdam, Netherlands
| | - Pieter R Tuinman
- Department of Intensive Care, Amsterdam UMC, Amsterdam Neuroscience, University of Amsterdam, Amsterdam, Netherlands
| | | | - Gernot Marx
- Uniklinik RWTH Aachen, Klinik für Operative Intensivmedizin und Intermediate Care, Aachen, Germany
| | | | - Rodrigo Boldo
- Associação Educadora São Carlos, Hospital Mãe de Deus, Centro de Pesquisa, Porto Alegre, Brazil
| | | | | | | | | | - Murimisi Mukansi
- Helen Joseph Hospital, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | | | | | | | - Diederik van de Beek
- Department of Neurology, Amsterdam UMC, Amsterdam Neuroscience, University of Amsterdam, Amsterdam, Netherlands
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