Efficacy and safety of baricitinib or ravulizumab in adult patients with severe COVID-19 (TACTIC-R): a randomised, parallel-arm, open-label, phase 4 trial

BACKGROUND

From early in the COVID-19 pandemic, evidence suggested a role for cytokine dysregulation and complement activation in severe disease. In the TACTIC-R trial, we evaluated the efficacy and safety of baricitinib, an inhibitor of Janus kinase 1 (JAK1) and JAK2, and ravulizumab, a monoclonal inhibitor of complement C5 activation, as an adjunct to standard of care for the treatment of adult patients hospitalised with COVID-19.

METHODS

TACTIC-R was a phase 4, randomised, parallel-arm, open-label platform trial that was undertaken in the UK with urgent public health designation to assess the potential of repurposing immunosuppressants for the treatment of severe COVID-19, stratified by a risk score. Adult participants (aged ≥18 years) were enrolled from 22 hospitals across the UK. Patients with a risk score indicating a 40% risk of admission to an intensive care unit or death were randomly assigned 1:1:1 to standard of care alone, standard of care with baricitinib, or standard of care with ravulizumab. The composite primary outcome was the time from randomisation to incidence (up to and including day 14) of the first event of death, invasive mechanical ventilation, extracorporeal membrane oxygenation, cardiovascular organ support, or renal failure. The primary interim analysis was triggered when 125 patient datasets were available up to day 14 in each study group and we included in the analysis all participants who were randomly assigned. The trial was registered on ClinicalTrials.gov (NCT04390464).

FINDINGS

Between May 8, 2020, and May 7, 2021, 417 participants were recruited and randomly assigned to standard of care alone (145 patients), baricitinib (137 patients), or ravulizumab (135 patients). Only 54 (39%) of 137 patients in the baricitinib group received the maximum 14-day course, whereas 132 (98%) of 135 patients in the ravulizumab group received the intended dose. The trial was stopped after the primary interim analysis on grounds of futility. The estimated hazard ratio (HR) for reaching the composite primary endpoint was 1·11 (95% CI 0·62-1·99) for patients on baricitinib compared with standard of care alone, and 1·53 (0·88-2·67) for ravulizumab compared with standard of care alone. 45 serious adverse events (21 deaths) were reported in the standard-of-care group, 57 (24 deaths) in the baricitinib group, and 60 (18 deaths) in the ravulizumab group.

INTERPRETATION

Neither baricitinib nor ravulizumab, as administered in this study, was effective in reducing disease severity in patients selected for severe COVID-19. Safety was similar between treatments and standard of care. The short period of dosing with baricitinib might explain the discrepancy between our findings and those of other trials. The therapeutic potential of targeting complement C5 activation product C5a, rather than the cleavage of C5, warrants further evaluation.

FUNDING

UK Medical Research Council, UK National Institute for Health Research Cambridge Biomedical Research Centre, Eli Lilly and Company, Alexion Pharmaceuticals, and Addenbrooke's Charitable Trust.

Educational case: a patient with proteinuria

This is an educational case suitable for all readers, but aimed particularly at trainees preparing for MRCP. Using the example of a patient presenting to clinic with proteinuria, aspects of differential diagnosis, pathology and management are explored.

Haemodialysis in acute paracetamol poisoning

A woman aged 23 years presented late with clinical and biochemical features of a life-threatening paracetamol (acetaminophen) overdose. Despite instigating N-acetylcysteine treatment, due to evidence of mitochondrial dysfunction together with an exceedingly high paracetamol level, the decision was made to dialyse the patient acutely to remove the parent drug. This was highly effective, and with on-going supportive care, the patient made a full recovery without the need for transplantation. This case highlights the role of extracorporeal therapy as a treatment option in selected cases of paracetamol overdose, consistent with the international guidelines.

Effect of Vitamin D Supplementation on Blood Pressure: A Systematic Review and Meta-analysis Incorporating Individual Patient Data

IMPORTANCE

Low levels of vitamin D are associated with elevated blood pressure (BP) and future cardiovascular events. Whether vitamin D supplementation reduces BP and which patient characteristics predict a response remain unclear.

OBJECTIVE

To systematically review whether supplementation with vitamin D or its analogues reduce BP.

DATA SOURCES

We searched MEDLINE, CINAHL, EMBASE, Cochrane Central Register of Controlled Trials, and http://www.ClinicalTrials.com augmented by a hand search of references from the included articles and previous reviews. Google was searched for gray literature (ie, material not published in recognized scientific journals). No language restrictions were applied. The search period spanned January 1, 1966, through March 31, 2014.

STUDY SELECTION

We included randomized placebo-controlled clinical trials that used vitamin D supplementation for a minimum of 4 weeks for any indication and reported BP data. Studies were included if they used active or inactive forms of vitamin D or vitamin D analogues. Cointerventions were permitted if identical in all treatment arms.

DATA EXTRACTION AND SYNTHESIS

We extracted data on baseline demographics, 25-hydroxyvitamin D levels, systolic and diastolic BP (SBP and DBP), and change in BP from baseline to the final follow-up. Individual patient data on age, sex, medication use, diabetes mellitus, baseline and follow-up BP, and 25-hydroxyvitamin D levels were requested from the authors of the included studies. For trial-level data, between-group differences in BP change were combined in a random-effects model. For individual patient data, between-group differences in BP at the final follow up, adjusted for baseline BP, were calculated before combining in a random-effects model.

MAIN OUTCOMES AND MEASURES

Difference in SBP and DBP measured in an office setting.

RESULTS

We included 46 trials (4541 participants) in the trial-level meta-analysis. Individual patient data were obtained for 27 trials (3092 participants). At the trial level, no effect of vitamin D supplementation was seen on SBP (effect size, 0.0 [95% CI, -0.8 to 0.8] mm Hg; P=.97; I2=21%) or DBP (effect size, -0.1 [95% CI, -0.6 to 0.5] mm Hg; P=.84; I2=20%). Similar results were found analyzing individual patient data for SBP (effect size, -0.5 [95% CI, -1.3 to 0.4] mm Hg; P=.27; I2=0%) and DBP (effect size, 0.2 [95% CI, -0.3 to 0.7] mm Hg; P=.38; I2=0%). Subgroup analysis did not reveal any baseline factor predictive of a better response to therapy.

CONCLUSIONS AND RELEVANCE

Vitamin D supplementation is ineffective as an agent for lowering BP and thus should not be used as an antihypertensive agent.

The effect of 25-hydroxyvitamin D on insulin sensitivity in obesity: is it mediated via adiponectin?

There has been substantial recent interest in using vitamin D to improve insulin sensitivity and preventing/delaying diabetes in those at risk. There is little consensus on the physiological mechanisms and whether the association is direct or indirect through enhanced production of insulin-sensitising chemicals, including adiponectin. We examined cross-sectional associations between serum 25-hydroxyvitamin D (25(OH)D) and insulin sensitivity (Matsuda index), parathyroid hormone (PTH), waist circumference, body mass index (BMI), triglycerides (TG), total and high molecular weight (HMW) adiponectin, HMW : total adiponectin ratio (HMW : total adiponectin), and total cholesterol : HDL cholesterol ratio (TC:HDL cholesterol) in 137 Caucasian adults of mean age 43.3 ± 8.3 years and BMI 38.8 ± 6.9 kg/m(2). Total adiponectin (standardised β = 0.446; p < 0.001), waist circumference (standardised β = -0.216; p < 0.05), BMI (standardised β = -0.212; p < 0.05), and age (standardised β = -0.298; p < 0.001) were independently associated with insulin sensitivity. Serum 25(OH)D (standardised β = 0.114; p = 0.164) was not associated with insulin sensitivity, total or HMW adiponectin, HMW : total adiponectin, or lipids. Our results provide the novel finding that 25(OH)D is not associated with HMW adiponectin or HMW : total adiponectin in nondiabetic, obese adults and support the lack of association between 25(OH)D and lipids noted by others in similar groups of patients.

Predictors of vitamin D status in predialysis chronic kidney disease patients: a cross-sectional analysis in a high ultraviolet climate

OBJECTIVE

To determine vitamin D status in a subtropical climate among an unselected, referred predialysis chronic kidney disease (CKD) population; assess risks and correlates; and review whether higher 25-hydroxyvitamin D (25-OHD) concentration can mitigate the decrement in circulating 1,25-dihydroxyvitamin D (1,25-OHD) normally encountered with advancing CKD.

DESIGN

Prospective cross-sectional cohort study.

SETTING

Renal unit in Brisbane, Australia (27°28' S).

SUBJECTS

Five hundred ninety-three consecutive CKD patients (stage 1 to 5).

MAIN OUTCOME MEASURE

25-OHD insufficiency (concentrations: 15 to 30 ng/mL) and deficiency (<15 ng/mL), bone-mineral parameters, including 1,25-OHD, calcium, and phosphate.

RESULTS

Despite potentially higher environmental ultraviolet (UV) exposure, only 48% of patients with CKD were 25-OHD sufficient. Traditional risks for hypovitaminosis D were maintained, and sufficiency was independently predicted by testing in the summer/autumn period (odds ratio [OR]: 2.77, 95% confidence interval [CI]: 1.88 to 4.08, P < .001), male gender (OR: 2.18, 95%CI: 1.46 to 3.24, P < .001), Caucasian race (OR: 2.28, 95%CI: 1.37 to 3.78, P = .001), hypoalbuminemia (OR: 0.47, 95%CI: 0.25 to 0.85, P = .01), macroalbuminuria (OR: 0.60, 95%CI: 0.39 to 0.92, P = .02), and normal body mass index (OR: 1.94, 95%CI: 1.22 to 3.07, P = .005). Vitamin D sufficiency was also associated with higher corrected calcium (0.4 mg/dL increments; OR: 1.29, 95%CI: 1.08 to 1.55, P = .005). Although circulating 25-OHD concentrations were relatively maintained across the range of renal function observed, 1,25-OHD concentrations decreased with advancing CKD.

CONCLUSION

25-OHD insufficiency is mitigated but still highly prevalent in patients with CKD in a high ambient UV environment. Despite the maintenance of relatively higher 25-OHD concentrations with advancing CKD, substrate availability does not appear to be a major determinant of circulating 1,25-OHD.

Shining D' light on chronic kidney disease: mechanisms that may underpin the cardiovascular benefit of vitamin D

Hypovitaminosis D is a significant health-care burden worldwide, particularly in susceptible populations such as those with chronic kidney disease (CKD). Recent epidemiological studies have identified that both higher serum vitamin D concentrations and use of vitamin D supplements may confer a survival benefit both in terms of all-cause and cardiovascular mortality. There is potential to investigate this inexpensive therapy for the CKD population, which suffers excessive cardiovascular events, although the mechanisms explaining this link have yet to be fully elucidated. This review discusses potential mechanisms identified in the basic science literature that may provide important insights into how vitamin D may orchestrate a change in cardiovascular risk profile through such diverse mechanisms as inflammation, atherogenesis, glucose homeostasis, vascular calcification, renin-angiotensin regulation and alterations in cardiac physiology. Where available, the clinical translation of these concepts to intervention trials in the CKD population will be reviewed.

Multimodality vascular imaging in CKD: divergence of risk between measured parameters

BACKGROUND

High cardiovascular risk in chronic kidney disease (CKD) patients appears only partly attributable to atherosclerosis, with much of the remaining risk being ascribed to other vasculature abnormalities, including endothelial dysfunction, arterial stiffness and vascular calcification (VC). To date, these factors have been primarily studied in isolation or in dialysis patients. This study performed a global vascular assessment in moderate CKD and assessed the relationships with both traditional and novel risk factors.

METHODS

This was a prospective cross-sectional analysis of 120 patients (age 60 ± 10 years; estimated glomerular filtration rate 25-60 mL/min/1.73m(2)). Demographic, clinical and biochemical characterization was performed. VC was characterized by lateral lumbar radiograph; arterial stiffness by aortic pulse-wave velocity (PWV); atheroma burden by carotid intima-media thickness (cIMT) and endothelial function by flow-mediated dilation (FMD) of the brachial artery.

RESULTS

VC was highly prevalent (74%), and FMD generally poor (FMDΔ 3.3 ± 3.3%). There were significant correlations between all vascular parameters; although these were predominantly explained by age. cIMT was independently associated with classical risks and also PWV (adjusted standardized β = 0.31, P = 0.001). However, traditional risks showed almost no independent associations with other vascular measurements. In contrast, serum phosphate and 1,25-dihydroxyvitamin D (1,25-OHD) correlated with PWV and the presence of VC, respectively. After adjustment, every 1 pg/mL increase in 1,25-OHD was related to a 3% reduction in the chance of VC (odds ratio 0.97; 95% confidence interval 0.94-1.00, P = 0.03). Medication use, HOMA-IR and C-reactive protein did not correlate with any of the vascular measures.

CONCLUSIONS

This study demonstrates extensive vascular disease across multimodality imaging in moderate CKD. Atherosclerotic burden correlated with traditional risks and PWV, while higher 1,25-OHD was associated with less VC. The lack of association between renal function and imaging indices raises the possibility of a threshold, rather than graded uraemic effect on vascular health that warrants further exploration.

Cardiorespiratory fitness is independently associated with 25-hydroxyvitamin D in chronic kidney disease

BACKGROUND AND OBJECTIVES

Vitamin D is an established important contributor to muscle function and aerobic metabolism. Hypovitaminosis D is highly prevalent in CKD patients and is associated with increased cardiovascular (CV) mortality via unknown mechanisms. Because aerobic-exercise capacity strongly predicts future CV events, we hypothesized that vitamin D status could be linked to CV outcomes via an effect on maximum aerobic-exercise capacity in patients with CKD and that this effect may be mediated in part via its actions on muscle strength and functional ability.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Baseline demographic, anthropometric, and biochemical data were collected in a cross-sectional study of patients with moderate CKD. Peak aerobic capacity was determined during treadmill stress testing using metabolic equivalence of tasks. Physical activity was assessed using the Active Australia questionnaire, grip strength by dynamometer, and functional capacity by "Up & Go" testing.

RESULTS

The study included 85 participants (age 59.5 ± 9.7 years, 60% male, 44% diabetic, 92% Caucasian; mean serum 25-hydroxyvitamin D [25-OHD] 78.4 ± 29.4 nmol/L). We demonstrated that 25-OHD status was independently associated with aerobic-exercise capacity (β = 0.2; P = 0.008). Aerobic-exercise capacity was also predicted by younger age, white race, smaller waist circumference, absence of a previous angina history, and increasing weekly physical activity. However, neither muscle strength nor functional ability were significantly associated with 25-OHD.

CONCLUSIONS

Vitamin D is independently associated with aerobic capacity in CKD patients, and this finding is not explained by changes in muscle strength or functional ability.

The role of 25-hydroxyvitamin D deficiency in promoting insulin resistance and inflammation in patients with chronic kidney disease: a randomised controlled trial

Background

Approximately 50% of patients with stage 3 Chronic Kidney Disease are 25-hydroxyvitamin D insufficient, and this prevalence increases with falling glomerular filtration rate. Vitamin D is now recognised as having pleiotropic roles beyond bone and mineral homeostasis, with the vitamin D receptor and metabolising machinery identified in multiple tissues. Worryingly, recent observational data has highlighted an association between hypovitaminosis D and increased cardiovascular mortality, possibly mediated via vitamin D effects on insulin resistance and inflammation. The main hypothesis of this study is that oral Vitamin D supplementation will ameliorate insulin resistance in patients with Chronic Kidney Disease stage 3 when compared to placebo. Secondary hypotheses will test whether this is associated with decreased inflammation and bone/adipocyte-endocrine dysregulation.

Methods/Design

This study is a single-centre, double-blinded, randomised, placebo-controlled trial. Inclusion criteria include; estimated glomerular filtration rate 30-59 ml/min/1.73 m²; aged ≥18 on entry to study; and serum 25-hydroxyvitamin D levels <75 nmol/L. Patients will be randomised 1:1 to receive either oral cholecalciferol 2000IU/day or placebo for 6 months. The primary outcome will be an improvement in insulin sensitivity, measured by hyperinsulinaemic euglycaemic clamp. Secondary outcome measures will include serum parathyroid hormone, cytokines (Interleukin-1β, Interleukin-6, Tumour Necrosis Factor alpha), adiponectin (total and High Molecular Weight), osteocalcin (carboxylated and under-carboxylated), peripheral blood mononuclear cell Nuclear Factor Kappa-B p65 binding activity, brachial artery reactivity, aortic pulse wave velocity and waveform analysis, and indirect calorimetry. All outcome measures will be performed at baseline and end of study.

Discussion

To date, no randomised controlled trial has been performed in pre-dialysis CKD patients to study the correlation between vitamin D status with supplementation, insulin resistance and markers of adverse cardiovascular risk. We remain hopeful that cholecalciferol may be a safe intervention, with health benefits beyond those related to bone-mineral homeostasis.

Trial registration

Australian and New Zealand Clinical Trials Registry ACTRN12609000246280.