Efficacy and safety of baricitinib in patients with severe COVID-19: A systematic review and meta-analysis

BACKGROUND

This study aimed to investigate the efficacy and safety of baricitinib in patients with severe coronavirus disease 2019 (COVID-19).

METHODS

Databases were searched for studies that compared the clinical efficacy and adverse effects of baricitinib with standard therapy for the treatment of severe COVID-19 and clearly reported relevant outcomes published until December 31, 2022. The corresponding data were extracted from these studies. A fixed-effects model was used to calculate the pooled estimates. The study protocol can be accessed at PROSPERO (CRD42023394173).

RESULTS

The baricitinib group had a significantly lower mortality rate and proportion of patients who received mechanical ventilation than the control group (OR = 0.61, 0.57; P = .008, 0.02; 95% CI 0.42-0.88; 0.35-0.92; I2 = 71% and 86%, respectively). The length of hospital stay and rates of severe adverse events were not significantly different between the 2 groups.

CONCLUSION

Baricitinib reduces mortality and mechanical ventilation requirements in patients with severe COVID-19. Therefore, we developed a comprehensive understanding of the role of baricitinib in patients with severe COVID-19.

Effect of Thymalfasin (Thymosin-α-1) on Reversing Lymphocytopenia among Patients with COVID-19

Introduction

Thymosin-α-1 (Tα1) elevates lymphocyte counts among patients with COVID-19, but its effect on reversing lymphocytopenia is unknown.

Methods

24 patients treated with Tα1 and 100 patients in the control arm were included in this analysis. The incidence rate of reversing lymphocytopenia, overall and stratified by baseline oxygen support, above the threshold for classification of lymphocytopenia (i.e., Total Lymphocyte Count (TLC) < 1.5 x 10⁹/L) and severe lymphocytopenia (i.e., TLC < 1.0 x 10⁹/L) within 3, 5, and 7 days of treatment initiation was calculated, along with incidence rate ratios (IRRs) and 95% confidence intervals (CIs).

Results

Compared with the standard of care, the rate of reversing lymphocytopenia (IRR: 2.38, 95% CI: 0.92 – 5.81) and severe lymphocytopenia (IRR: 1.57, 95% CI: 0.59 – 3.72), especially among patients with severe lymphocytopenia on high flow oxygen support (IRR: 3.64, 95% CI: 0.71 – 23.44), was greater for patients treated with Tα1 within 3 days of treatment initiation, although analyses were not significant.

Conclusion

Among patients with hypoxemia and lymphocytopenia, Tα1 may reverse lymphocytopenia and severe lymphocytopenia, particularly within 3 days of treatment initiation, faster than the standard of care.

Pre-existing autoimmunity is associated with increased severity of COVID-19: A retrospective cohort study using data from the National COVID Cohort Collaborative (N3C)

Importance

Identifying individuals with a higher risk of developing severe COVID-19 outcomes will inform targeted or more intensive clinical monitoring and management.

Objective

To examine, using data from the National COVID Cohort Collaborative (N3C), whether patients with pre-existing autoimmune disease (AID) diagnosis and/or immunosuppressant (IS) exposure are at a higher risk of developing severe COVID-19 outcomes.

Design setting and participants

A retrospective cohort of 2,453,799 individuals diagnosed with COVID-19 between January 1 st , 2020, and June 30 th , 2022, was created from the N3C data enclave, which comprises data of 15,231,849 patients from 75 USA data partners. Patients were stratified as those with/without a pre-existing diagnosis of AID and/or those with/without exposure to IS prior to COVID-19.

Main outcomes and measures

Two outcomes of COVID-19 severity, derived from the World Health Organization severity score, were defined, namely life-threatening disease and hospitalization. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using logistic regression models with and without adjustment for demographics (age, BMI, gender, race, ethnicity, smoking status), and comorbidities (cardiovascular disease, dementia, pulmonary disease, liver disease, type 2 diabetes mellitus, kidney disease, cancer, and HIV infection).

Results

In total, 2,453,799 (16.11% of the N3C cohort) adults (age> 18 years) were diagnosed with COVID-19, of which 191,520 (7.81%) had a prior AID diagnosis, and 278,095 (11.33%) had a prior IS exposure. Logistic regression models adjusted for demographic factors and comorbidities demonstrated that individuals with a prior AID (OR = 1.13, 95% CI 1.09 - 1.17; p =2.43E-13), prior exposure to IS (OR= 1.27, 95% CI 1.24 - 1.30; p =3.66E-74), or both (OR= 1.35, 95% CI 1.29 - 1.40; p =7.50E-49) were more likely to have a life-threatening COVID-19 disease. These results were confirmed after adjusting for exposure to antivirals and vaccination in a cohort subset with COVID-19 diagnosis dates after December 2021 (AID OR = 1.18, 95% CI 1.02 - 1.36; p =2.46E-02; IS OR= 1.60, 95% CI 1.41 - 1.80; p =5.11E-14; AID+IS OR= 1.93, 95% CI 1.62 - 2.30; p =1.68E-13). These results were consistent when evaluating hospitalization as the outcome and also when stratifying by race and sex. Finally, a sensitivity analysis evaluating specific IS revealed that TNF inhibitors were protective against life-threatening disease (OR = 0.80, 95% CI 0.66-0.96; p =1.66E-2) and hospitalization (OR = 0.80, 95% CI 0.73 - 0.89; p =1.06E-05).

Conclusions and Relevance

Patients with pre-existing AID, exposure to IS, or both are more likely to have a life-threatening disease or hospitalization. These patients may thus require tailored monitoring and preventative measures to minimize negative consequences of COVID-19.

The Impact of Inflammatory Bowel Diseases and Related Medications on COVID-19 Severity and Outcome: A Tertiary Referral Center Experience from Turkey

BACKGROUND

Coronavirus disease-2019 has become a serious pandemic, and still remains a risk despite vaccines that have been devel- oped. Among inflammatory bowel disease patients old age, inflammatory bowel disease activation, the existence of the comorbid dis- ease, and using steroids are known risk factors for severe coronavirus disease-2019. But there are different data for drugs other than corticosteroids used. The aims of the study are to evaluate the prevalence and risk factors of severe coronavirus disease-2019 and the effect of inflammatory bowel disease drugs on severe coronavirus disease-2019.

METHODS

In this study among 1195 inflammatory bowel disease patients, 130 patients who were found to be positive for severe acute respiratory syndrome coronavirus-2 between March 2020 and May 2021 were evaluated. Patients were divided into 3 groups as mild, moderate, and severe coronavirus disease-2019.

RESULTS

Among 130 patients, 91 (70%) had mild, 16 (12.3%) had moderate, and 23 (17.7%) had severe coronavirus disease-2019. Being 60 years of age or older (P = .009), having at least 1 comorbid disease (P = .002), and having active inflammatory bowel disease (P = .001) were factors that increased the risk for severe coronavirus disease-2019. The use of mesalazine (P = .35), biologic agents (P = .23), and corticosteroids (P = .42) did not increase the risk of severe coronavirus disease-2019. The use of azathioprine seemed to decrease the risk of severe disease with univariate regression analysis however the significance disappeared with multivariate analysis.

CONCLUSION

Older age, active inflammatory bowel disease, and existence of at least 1 comorbid disease are risk factors for severe coro- navirus disease-2019. However, drugs used in inflammatory bowel disease management do not increase the risk of severe coronavirus disease-2019. But due to the small number of patients, it is difficult to reach a definite conclusion about corticosteroids.

Long-Term Effect on Health-Related Quality of Life in Patients With COVID-19 Requiring Hospitalization Compared to Non-hospitalized COVID-19 Patients and Healthy Controls

Background In this study, we aimed to evaluate the health-related quality of life (HRQL) in patients with severe coronavirus disease 2019 (COVID-19) six months after their hospitalization and compare it to that of non-hospitalized patients with mild COVID-19 and healthy controls. Methodology Participants were enrolled between September 2021 and April 2022 and included hospitalized COVID-19 patients at General Hospital of Athens "Hippocration" who had been discharged at least six months prior to enrollment, non-hospitalized patients with COVID-19, and healthy controls. Collected data included demographics, disease severity, medication history, and comorbidities. Participants completed a EuroQol 5 Dimensions 5Levels (EQ5D5L), a Short Form 36 version 2 (SF36v2), a Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F), and a Post-COVID-19 Functional Status Scale (PCFSS) regarding HRQL before and six months after infection with severe acute respiratory syndrome coronavirus 2. In the case of healthy controls, two sets of questionnaires were completed at least six months apart. Statistical analysis was performed using the SPSS version 25 software (IBM Corp., Armonk, NY, USA). Results A total of 151 participants were enrolled. Hospitalized patients with COVID-19 demonstrated a statistically significant deterioration in most parameters of SF36v2 as well as both parameters of the EQ5D5L and FACIT-F questionnaires. Hospitalized patients exhibited worse results in SF36v2 and EQ5D5L when compared to both healthy controls as well as those with mild COVID-19 (p < 0.05). Hospitalized women, in particular, were shown to fare worse than other women in parameters associated with both mental/psychological and physical health (p < 0.05). Hospitalized patients between 41 and 60 years old demonstrated a statistically significant drop in the scores of all three main questionnaires compared to their previous health status (p < 0.05). Hospitalized patients between 61 and 80 years old exhibited a similar trend, but statistical significance was achieved in fewer parameters. HRQL decline was greater in both age groups compared to that of healthy and milder disease counterparts. There was a significant correlation between the results from the three main questionnaires. Similarly, PCFS scale values were shown to correlate with disease severity (hospitalization or not) and age. Conclusions HRQL remained noticeably impacted six months after hospitalization due to COVID-19. The physical and mental/psychological stress of severe COVID-19 translated into lasting health deterioration, especially for women and those aged 41-60 years old. The use of questionnaires, such as those implemented in this study, might help in the early detection of patients who could benefit from rehabilitation programs. Psychological, as well as physical and social, support is crucial to alleviate the burden of post-COVID-19 symptomatology and expedite the recovery of this group of patients.

Comparative efficacy and safety of pharmacological interventions for severe COVID-19 patients: An updated network meta-analysis of 48 randomized controlled trials

BACKGROUND

To date, there has been little agreement on what drug is the "best" drug for treating severe COVID-19 patients. This study aimed to assess the efficacy and safety of different medications available at present for severe COVID-19.

METHODS

We searched databases for randomized controlled trials (RCTs) published up to February 28, 2022, with no language restrictions, of medications recommended for patients (aged 16 years or older) with severe COVID-19 infection. We extracted data on trials and patient characteristics, and the following primary outcomes: all-cause mortality (ACM), and treatment-emergent adverse events (TEAEs).

RESULTS

We identified 4021 abstracts and of these included 48 RCTs comprising 9147 participants through database searches and other sources. For decrease in ACM, we found that ivermectin/doxycycline, C-IVIG (i.e., a hyperimmune anti-COVID-19 intravenous immunoglobulin), methylprednisolone, interferon-beta/standard-of-care (SOC), interferon-beta-1b, convalescent plasma, remdesivir, lopinavir/ritonavir, immunoglobulin gamma, high dosage sarilumab (HS), auxora, and imatinib were effective when compared with placebo or SOC group. We found that colchicine and interferon-beta/SOC were only associated with the TEAEs of severe COVID-19 patients.

CONCLUSION

This study suggested that ivermectin/doxycycline, C-IVIG, methylprednisolone, interferon-beta/SOC, interferon-beta-1b, convalescent plasma (CP), remdesivir, lopinavir/ritonavir, immunoglobulin gamma, HS, auxora, and imatinib were efficacious for treating severe COVID-19 patients. We found that most medications were safe in treating severe COVID-19. More large-scale RCTs are still needed to confirm the results of this study.

In-hospital severe COVID-19 in a philanthropic tertiary hospital setting: is asthma a concern? A retrospective study

BACKGROUND

The frequency of coronavirus disease 2019 (COVID-19) cases among asthmatics has been reported to be reduced. However, the findings regarding the association between asthma and the risk of severe COVID-19 have been divergent.

OBJECTIVE

To investigate whether asthma is associated with a reduced risk of development of severe COVID-19.

DESIGN AND SETTING

Retrospective analysis on COVID-19 surveillance databases at two tertiary-level hospitals in São Paulo, Brazil.

METHODS

The medical records of patients hospitalized due to COVID-19 between March and August 2020 were reviewed in accordance with the clinical, laboratorial, radiological and epidemiological criteria for COVID-19, and for comorbidities.

RESULTS

Among the adult patients included (> 18 years of age) there were 52 asthmatics and 1,318 non-asthmatics. Their median ages and interquartile ranges (IQR) were, respectively, 54 (41-69) and 60 (44-72) years. At least one comorbidity was seen in 73% of asthmatics and 56% of the non-asthmatics. Among the asthmatics, most presented mild asthma (92%) and the prevalence of chronic obstructive pulmonary disease (COPD) was high (27%). The asthmatics presented an unadjusted odds ratio (OR) for severe COVID-19 of 0.89 (95% confidence interval, CI 0.5-1.56); and OR 0.88 (95% CI 0.5 -1.68) after multivariable adjustment. Age > 60 years, male sex, hypertension, diabetes, cancer and homelessness were covariates associated with increased odds for severe COVID-19. Kaplan-Meier estimated survival over hospitalization of up to 30 days did not differ between the groups (log-rank P = 0.09).

CONCLUSIONS

The association between asthma and decreased risk of severe COVID-19 or increased survival was statistically non-significant.

Validation of a clinical and genetic model for predicting severe COVID-19

Using nested case–control data from the Lifelines COVID-19 cohort, we undertook a validation study of a clinical and genetic model to predict the risk of severe COVID-19 in people with confirmed COVID-19 and in people with confirmed or self-reported COVID-19. The model performed well in terms of discrimination of cases and controls for all ages (area under the receiver operating characteristic curve (AUC) = 0.680 for confirmed COVID-19 and AUC = 0.689 for confirmed and self-reported COVID-19) and in the age group in which the model was developed (50 years and older; AUC = 0.658 for confirmed COVID-19 and AUC = 0.651 for confirmed and self-reported COVID-19). There was no evidence of over- or under-dispersion of risk scores but there was evidence of overall over-estimation of risk in all analyses (all P < 0.0001). In the light of large numbers of people worldwide remaining unvaccinated and continuing uncertainty regarding vaccine efficacy over time and against variants of concern, identification of people at high risk of severe COVID-19 may encourage the uptake of vaccinations (including boosters) and the use of non-pharmaceutical inventions.

Biologic correlates of beneficial convalescent plasma therapy in a COVID-19 patient reveal disease resolution mechanisms

BACKGROUND

While the biomarkers of COVID-19 severity have been thoroughly investigated, the key biological dynamics associated with COVID-19 resolution are still insufficiently understood.

MAIN BODY

We report a case of full resolution of severe COVID-19 due to convalescent plasma transfusion in a patient with underlying multiple autoimmune syndrome. Following transfusion, the patient showed fever remission, improved respiratory status, and rapidly decreased viral burden in respiratory fluids and SARS-CoV-2 RNAemia. Longitudinal unbiased proteomic analysis of plasma and single-cell transcriptomics of peripheral blood cells conducted prior to and at multiple times after convalescent plasma transfusion identified the key biological processes associated with the transition from severe disease to disease-free state. These included (i) temporally ordered upward and downward changes in plasma proteins reestablishing homeostasis and (ii) post-transfusion disappearance of a particular subset of dysfunctional monocytes characterized by hyperactivated Interferon responses and decreased TNF-α signaling.

CONCLUSIONS

Monitoring specific subsets of innate immune cells in peripheral blood may provide prognostic keys in severe COVID-19. Moreover, understanding disease resolution at the molecular and cellular level should contribute to identify targets of therapeutic interventions against severe COVID-19.

Role of Hypertension on the Severity of COVID-19: A Review

ABSTRACT

The novel coronavirus disease (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has rapidly evolved into a global pandemic. The substantial morbidity and mortality associated with the infection has prompted us to understand potential risk factors that can predict patient outcomes. Hypertension has been identified as the most prevalent cardiovascular comorbidity in patients infected with COVID-19 that demonstrably increases the risk of hospitalization and death. Initial studies implied that renin-angiotensin-aldosterone system inhibitors might increase the risk of viral infection and aggravate disease severity, thereby causing panic given the high global prevalence of hypertension. Nonetheless, subsequent evidence supported the administration of antihypertensive drugs and noted that they do not increase the severity of COVID-19 infection in patients with hypertension, rather may have a beneficial effect. To date, the precise mechanism by which hypertension predisposes to unfavorable outcomes in patients infected with COVID-19 remains unknown. In this mini review, we elaborate on the pathology of SARS-CoV-2 infection coexisting with hypertension and summarize potential mechanisms, focusing on the dual roles of angiotensin-converting enzyme 2 and the disorders of renin-angiotensin-aldosterone system in COVID-19 and hypertension. The effects of proinflammatory factors released because of immune response and gastrointestinal dysfunction in COVID-19 are also discussed.

No evidence of tocilizumab treatment efficacy for severe to critical SARS-CoV2 infected patients: Results from a retrospective controlled multicenter study

To assess tocilizumab (TCZ) efficacy associated to standard of care (SOC) compared to SOC alone in severe coronavirus associated disease 2019 (COVID-19) patients. In a matched case-control study from 3 French Hospital COVID-19 Departments, 27 patients with severe COVID-19 treated with TCZ and SOC were matched for baseline epidemiological and clinical features and compared to 27 severe COVID-19 patients treated with SOC alone. Baseline characteristics of the study population were comparable between groups. Eleven patients (20%) died. TCZ was not associated with clinical improvement as compared to SOC regarding oxygen-free status (44% vs 63%) and death (18.5% vs 22%), despite a higher decrease of the C-reactive protein at Day 7 (10.7 vs 52 mg/L; P < 10-3). Compared to the 43 patients alive at the end-of follow-up, patients who died were older (78 vs 64 years; P < 10-3), with 82% of them older than 72 years vs only 23% of live patients (P < 10-3). Age (OR = 1.15; 95%CI = 1.04-1.3; P = .008) and age over 72 years (OR) = 14.85; 95%CI = 2.7-80; P = .002) were independently associated with mortality. TCZ in addition to SOC for severe COVID-19 patients did not reduce mortality, subsequent need for invasive mechanical ventilation nor did it shorten the time of oxygen support, despite better control of the inflammatory response. More powerful and randomized controlled trials are warranted to determine if TCZ is effective in the management of COVID-19.

Predictors of Severity in Covid-19 Patients in Casablanca, Morocco

Background Morocco was affected, as were other countries, by the coronavirus disease 2019 (COVID-19) pandemic. Many risk factors of COVID-19 severity have been described, but data on infected patients in North Africa are limited. We aimed to explore the predictive factors of disease severity in COVID-19 patients in a tertiary hospital in Casablanca. Methods In this single-center, retrospective, observational study, we included all adult patients with confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, admitted to Sheikh Khalifa International University Hospital in Casablanca between March 18 and May 20, 2020. Patients were separated into two groups: Non-severe patients were those with mild or moderate forms of COVID-19, and severe patients were those admitted to the intensive care unit (ICU) who had one of the following signs-respiratory rate > 30 breaths/min; oxygen saturation < 93% on room air; acute respiratory distress syndrome (ARDS); or required mechanical ventilation. Demographic, clinical, laboratory data, and outcomes were reviewed. We used univariable and multivariable logistic regression to explore predictive factors of severity. Results We reported 134 patients with confirmed SARS-CoV-2 infection. The median age was 53 years (interquartile range [IQR], 36-64), and 73 (54.5%) were men. Eighty-nine non-severe patients (66.4%) were admitted to single bedrooms, and 45 (33.6%) were placed in the ICU. The median time from illness onset to hospital admission was seven days (IQR, 3.0-7.2). Ninety-nine patients (74%) were admitted directly to the hospital, and 35 (26%) were transferred from other structures. Also, 68 patients (65.4%) were infected in clusters. Of the 134 patients, 61 (45.5%) had comorbidities, such as hypertension (n = 36; 26.9%), diabetes (n = 19; 14.2%), and coronary heart disease (n = 16; 11.9%). The most frequent symptoms were fever (n = 61; 45.5%), dry cough (n = 59; 44%), and dyspnea (n = 39; 29%). A total of 127 patients received hydroxychloroquine and azithromycin (95%). Eleven critical cases received lopinavir/ritonavir (8.2%). Five patients received tocilizumab (3.7%). We reported 13 ARDS cases in ICU patients (29%), eight with acute kidney injury (17.8%), and four thromboembolic events (8.8%). Fourteen ICU patients (31.1%) died at 28 days. In univariable analysis, older men with one or more comorbidities, infection in a cluster, chest scan with the COVID-19 Reporting and Data System (CO-RADS) 5, lymphopenia, high rates of ferritin, C-reactive protein (CRP), D-dimer, and lactate dehydrogenase were associated with severe forms of COVID-19. Multivariable logistic regression model founded increasing odds of severity associated with older age (odds ratio [OR] 1.05, 95% confidence interval [CI] 1.01-1.09, P = .0039), men (OR 3.19, CI 1.06-9.60, P = .016), one or more comorbidities (OR 4.36, CI 1.32-14.45, P = .016), CRP > 10 mg/L (OR 5.47, CI 1.57-19.10, P = .008), and lymphopenia lower than 0.8 x10⁹/L (OR 6.65, CI 1.43-30.92, P = .016). Conclusions Clinicians should consider older male patients with comorbidities, lymphopenia, and a high CRP rate as factors to predict severe forms of COVID-19 earlier. The higher severity of infected patients in clusters must be confirmed by epidemiological and genetic studies.

Elevated D-Dimer Levels Are Associated With Increased Risk of Mortality in Coronavirus Disease 2019: A Systematic Review and Meta-Analysis

The 2019 novel coronavirus, declared a pandemic, has infected 2.6 million people as of April 27, 2020, and has resulted in the death of 181,938 people. D-dimer is an important prognostic tool, is often elevated in patients with severe coronavirus disease-19 (COVID-19) infection and in those who suffered death. In this systematic review, we aimed to investigate the prognostic role of D-dimer in COVID-19-infected patients. We searched PubMed, Medline, Embase, Ovid, and Cochrane for studies reporting admission D-dimer levels in COVID-19 patients and its effect on mortality. Eighteen studies (16 retrospective and 2 prospective) with a total of 3682 patients met the inclusion criteria. The pooled weighted mean difference (WMD) demonstrated significantly elevated D-dimer levels in patients who died versus those who survived (WMD, 6.13 mg/L; 95% confidence interval [CI] 4.16-8.11; P < 0.001). Similarly, the pooled mean D-dimer levels were significantly elevated in patients with severe COVID-19 infection (WMD, 0.54 mg/L; 95% CI 0.28-0.80; P < 0.001). The risk of mortality was fourfold higher in patients with positive D-dimer versus negative D-dimer (risk ratio, 4.11; 95% CI, 2.48-6.84; P < 0.001) and the risk of developing severe disease was twofold higher in patients with positive D-dimer levels versus negative D-dimer (risk ratio, 2.04; 95% CI, 1.34-3.11; P < 0.001). Our meta-analysis demonstrates that patients with COVID-19 infection presenting with elevated D-dimer levels have an increased risk of severe disease and mortality.