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Toldo S, Mezzaroma E, Buckley LF, Potere N, Di Nisio M, Biondi-Zoccai G, Van Tassell BW, Abbate A. Targeting the NLRP3 inflammasome in cardiovascular diseases. Pharmacol Ther 2021; 236:108053. [PMID: 34906598 PMCID: PMC9187780 DOI: 10.1016/j.pharmthera.2021.108053] [Citation(s) in RCA: 108] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 11/21/2021] [Accepted: 12/06/2021] [Indexed: 02/05/2023]
Abstract
The NACHT, leucine-rich repeat (LRR), and pyrin domain (PYD)-containing protein 3 (NLRP3) inflammasome is an intracellular sensing protein complex that plays a major role in innate immunity. Following tissue injury, activation of the NLRP3 inflammasome results in cytokine production, primarily interleukin(IL)-1β and IL-18, and, eventually, inflammatory cell death - pyroptosis. While a balanced inflammatory response favors damage resolution and tissue healing, excessive NLRP3 activation causes detrimental effects. A key involvement of the NLRP3 inflammasome has been reported across a wide range of cardiovascular diseases (CVDs). Several pharmacological agents selectively targeting the NLRP3 inflammasome system have been developed and tested in animals and early phase human studies with overall promising results. While the NLRP3 inhibitors are in clinical development, multiple randomized trials have demonstrated the safety and efficacy of IL-1 blockade in atherothrombosis, heart failure and recurrent pericarditis. Furthermore, the non-selective NLRP3 inhibitor colchicine has been recently shown to significantly reduce cardiovascular events in patients with chronic coronary disease. In this review, we will outline the mechanisms driving NLRP3 assembly and activation, and discuss the pathogenetic role of the NLRP3 inflammasome in CVDs, providing an overview of the current and future therapeutic approaches targeting the NLRP3 inflammasome.
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Affiliation(s)
- Stefano Toldo
- VCU Pauley Heart Center, Division of Cardiology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Eleonora Mezzaroma
- VCU Pauley Heart Center, Division of Cardiology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA; Department of Pharmacotherapy and Outcome Studies, Virginia Commonwealth University, Richmond, VA, USA
| | - Leo F Buckley
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Nicola Potere
- Department of Innovative Technologies in Medicine and Dentistry, "G. d'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | - Marcello Di Nisio
- Department of Medicine and Ageing Sciences, "G. d'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | - Giuseppe Biondi-Zoccai
- Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy; Mediterranea Cardiocentro, Napoli, Italy
| | - Benjamin W Van Tassell
- VCU Pauley Heart Center, Division of Cardiology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA; Department of Pharmacotherapy and Outcome Studies, Virginia Commonwealth University, Richmond, VA, USA
| | - Antonio Abbate
- VCU Pauley Heart Center, Division of Cardiology, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA; Wright Center for Clinical and Translational Research, Virginia Commonwealth University, Richmond, VA, USA.
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Dravid A, Kashiva R, Khan Z, Memon D, Kodre A, Potdar P, Mane M, Borse R, Pawar V, Patil D, Banerjee D, Bhoite K, Pharande R, Kalyani S, Raut P, Bapte M, Mehta A, Reddy MS, Bhayani K, Laxmi SS, Vishnu PD, Srivastava S, Khandelwal S, More S, Shinde R, Pawar M, Harshe A, Kadam S, Mahajan U, Joshi G, Mane D. Combination therapy of Tocilizumab and steroid for management of COVID-19 associated cytokine release syndrome: A single center experience from Pune, Western India. Medicine (Baltimore) 2021; 100:e26705. [PMID: 34398044 PMCID: PMC8294888 DOI: 10.1097/md.0000000000026705] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 05/26/2021] [Accepted: 06/19/2021] [Indexed: 01/08/2023] Open
Abstract
ABSTRACT Cytokine release syndrome (CRS) or cytokine storm is thought to be the cause of inflammatory lung damage, worsening pneumonia and death in patients with COVID-19. Steroids (Methylprednislone or Dexamethasone) and Tocilizumab (TCZ), an interleukin-6 receptor antagonist, are approved for treatment of CRS in India. The aim of this study was to evaluate the efficacy and safety of combination therapy of TCZ and steroid in COVID-19 associated CRS.This retrospective cohort study was conducted at Noble hospital and Research Centre (NHRC), Pune, India between April 2 and November 2, 2020. All patients administered TCZ and steroids during this period were included. The primary endpoint was incidence of all cause mortality. Secondary outcomes studied were need for mechanical ventilation and incidence of systemic and infectious complications. Baseline and time dependent risk factors significantly associated with death were identified by Relative risk estimation.Out of 2831 admitted patients, 515 (24.3% females) were administered TCZ and steroids. There were 135 deaths (26.2%), while 380 patients (73.8%) had clinical improvement. Mechanical ventilation was required in 242 (47%) patients. Of these, 44.2% (107/242) recovered and were weaned off the ventilator. Thirty seven percent patients were managed in wards and did not need intensive care unit (ICU) admission. Infectious complications like hospital acquired pneumonia, blood stream bacterial and fungal infections were observed in 2.13%, 2.13% and 0.06% patients respectively. Age ≥ 60 years (P = .014), presence of co-morbidities like hypertension (P = .011), IL-6 ≥ 100 pg/ml (P = .002), D-dimer ≥ 1000 ng/ml (P < .0001), CT severity index ≥ 18 (P < .0001) and systemic complications like lung fibrosis (P = .019), cardiac arrhythmia (P < .0001), hypotension (P < .0001) and encephalopathy (P < .0001) were associated with increased risk of death.Combination therapy of TCZ and steroids is likely to be safe and effective in management of COVID-19 associated cytokine release syndrome. Efficacy of this anti-inflammatory combination therapy needs to be validated in randomized controlled trials.
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Affiliation(s)
- Ameet Dravid
- Department of Infectious Diseases and HIV/AIDS, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - Reema Kashiva
- Department of Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - Zafer Khan
- Department of Critical Care Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - Danish Memon
- Department of Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - Aparna Kodre
- Department of Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - Prashant Potdar
- Department of Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - Milind Mane
- Department of Critical Care Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - Rakesh Borse
- Department of Critical Care Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - Vishal Pawar
- Department of Critical Care Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - Dattatraya Patil
- Department of Critical Care Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - Debashis Banerjee
- Department of Critical Care Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - Kailas Bhoite
- Department of Critical Care Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - Reshma Pharande
- Department of Critical Care Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - Suraj Kalyani
- Department of Critical Care Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - Prathamesh Raut
- Department of Critical Care Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - Madhura Bapte
- Department of Critical Care Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - Anshul Mehta
- Department of Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - M. Sateesh Reddy
- Department of Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - Krushnadas Bhayani
- Department of Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - S. S. Laxmi
- Department of Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - P. D. Vishnu
- Department of Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - Shipra Srivastava
- Department of Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - Shubham Khandelwal
- Department of Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - Sailee More
- Department of Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - Rohit Shinde
- Department of Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - Mohit Pawar
- Department of Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - Amol Harshe
- Department of Pathology, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - Sagar Kadam
- Department of Radiology, Noble hospital and Research Centre, Pune, Maharashtra, India
| | - Uma Mahajan
- VMK Diagnostics Private Limited, Pune, Maharashtra, India
| | | | - Dilip Mane
- Department of Medicine, Noble hospital and Research Centre, Pune, Maharashtra, India
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Wei Q, Lin H, Wei RG, Chen N, He F, Zou DH, Wei JR. Tocilizumab treatment for COVID-19 patients: a systematic review and meta-analysis. Infect Dis Poverty 2021; 10:71. [PMID: 34001244 PMCID: PMC8128625 DOI: 10.1186/s40249-021-00857-w] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 05/07/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) has killed over 2.5 million people worldwide, but effective care and therapy have yet to be discovered. We conducted this analysis to better understand tocilizumab treatment for COVID-19 patients. MAIN TEXT We searched major databases for manuscripts reporting the effects of tocilizumab on COVID-19 patients. A total of 25 publications were analyzed with Revman 5.3 and R for the meta-analysis. Significant better clinical outcomes were found in the tocilizumab treatment group when compared to the standard care group [odds ratio (OR) = 0.70, 95% confidential interval (C): 0.54-0.90, P = 0.007]. Tocilizumab treatment showed a stronger correlation with good prognosis among COVID-19 patients that needed mechanical ventilation (OR = 0.59, 95% CI, 0.37-0.93, P = 0.02). Among stratified analyses, reduction of overall mortality correlates with tocilizumab treatment in patients less than 65 years old (OR = 0.68, 95% CI: 0.60-0.77, P < 0.00001), and with intensive care unit patients (OR = 0.62, 95% CI: 0.55-0.70, P < 0.00001). Pooled estimates of hazard ratio showed that tocilizumab treatment predicts better overall survival in COVID-19 patients (HR = 0.45, 95% CI: 0.24-0.84, P = 0.01), especially in severe cases (HR = 0.58, 95% CI 0.49-0.68, P < 0.00001). CONCLUSIONS Our study shows that tocilizumab treatment is associated with a lower risk of mortality and mechanical ventilation requirement among COVID-19 patients. Tocilizumab may have substantial effectiveness in reducing mortality among COVID-19 patients, especially among critical cases. This systematic review provides an up-to-date evidence of potential therapeutic role of tocilizumab in COVID-19 management.
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Affiliation(s)
- Qiu Wei
- Department of Respiratory and Critical Care, The Fifth Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530022, People's Republic of China
- Clinical Medical Laboratory Center, The Fifth Affiliated Hospital of Guangxi Medical University, 89 Qixing Road, Nanning, 530022, Guangxi, China
| | - Hua Lin
- Clinical Medical Laboratory Center, The Fifth Affiliated Hospital of Guangxi Medical University, 89 Qixing Road, Nanning, 530022, Guangxi, China
| | - Rong-Guo Wei
- Clinical Medical Laboratory Center, The Fifth Affiliated Hospital of Guangxi Medical University, 89 Qixing Road, Nanning, 530022, Guangxi, China
| | - Nian Chen
- Department of Infectious Diseases, The Fifth Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530022, People's Republic of China
| | - Fan He
- Department of Hematology, School of Medicine, Washington University in St Louis, St. Louis, MO, 63130, USA
| | - Dong-Hua Zou
- Clinical Medical Laboratory Center, The Fifth Affiliated Hospital of Guangxi Medical University, 89 Qixing Road, Nanning, 530022, Guangxi, China.
| | - Jin-Ru Wei
- Clinical Medical Laboratory Center, The Fifth Affiliated Hospital of Guangxi Medical University, 89 Qixing Road, Nanning, 530022, Guangxi, China.
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Wu J, Shen J, Han Y, Qiao Q, Dai W, He B, Pang R, Zhao J, Luo T, Guo Y, Yang Y, Wu Q, Jiang W, Zhang J, Zhang M, Li N, Li W, Xia X. Upregulated IL-6 Indicates a Poor COVID-19 Prognosis: A Call for Tocilizumab and Convalescent Plasma Treatment. Front Immunol 2021; 12:598799. [PMID: 33746945 PMCID: PMC7969719 DOI: 10.3389/fimmu.2021.598799] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 02/04/2021] [Indexed: 02/05/2023] Open
Abstract
A comprehensive understanding of the dynamic changes in interleukin-6 (IL-6) levels is essential for monitoring and treating patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2). By analyzing the correlations between IL-6 levels and health conditions, underlying diseases, several key laboratory detection indices, and the prognosis of 1,473 patients with the coronavirus disease 2019 (COVID-19), the role of IL-6 during SARS-CoV-2 infection was demonstrated. Our results indicated that IL-6 levels were closely related to age, sex, body temperature, oxygen saturation (SpO2) of blood, and underlying diseases. As a stable indicator, the changes in IL-6 levels could indicate the inflammatory conditions during a viral infection. Two specific treatments, namely, tocilizumab and convalescent plasma therapy (CPT), decreased the level of IL-6 and relieved inflammation. CPT has an important role in the therapy for patients with critical COVID-19. We also found that patients with IL-6 levels, which were 30-fold higher than the normal level, had a poor prognosis compared to patients with lower levels of IL-6.
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Affiliation(s)
- Jian Wu
- COVID-19 Research Center, The First School of Clinical Medicine, Institute of Laboratory Medicine, Jinling Hospital, Nanjing University School of Medicine, Southern Medical University, Nanjing, China
| | - Jiawei Shen
- COVID-19 Research Center, The First School of Clinical Medicine, Institute of Laboratory Medicine, Jinling Hospital, Nanjing University School of Medicine, Southern Medical University, Nanjing, China
| | - Ying Han
- COVID-19 Research Center, The First School of Clinical Medicine, Institute of Laboratory Medicine, Jinling Hospital, Nanjing University School of Medicine, Southern Medical University, Nanjing, China
| | - Qinghua Qiao
- Medical and Technical Support Department, Pingdingshan Medical District, The 989th Hospital Pingingshan, Pingdingshan, China
- Joint Expert Group for COVID-19, Department of Laboratory Medicine & Blood Transfusion, Wuhan Huoshenshan Hospital, Wuhan, China
| | - Wei Dai
- COVID-19 Research Center, The First School of Clinical Medicine, Institute of Laboratory Medicine, Jinling Hospital, Nanjing University School of Medicine, Southern Medical University, Nanjing, China
| | - Bangshun He
- COVID-19 Research Center, The First School of Clinical Medicine, Institute of Laboratory Medicine, Jinling Hospital, Nanjing University School of Medicine, Southern Medical University, Nanjing, China
- General Clinical Research Center, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Rongrong Pang
- COVID-19 Research Center, The First School of Clinical Medicine, Institute of Laboratory Medicine, Jinling Hospital, Nanjing University School of Medicine, Southern Medical University, Nanjing, China
- Department of Laboratory Medicine, Nanjing Red Cross Blood Center, Nanjing, China
| | - Jun Zhao
- COVID-19 Research Center, The First School of Clinical Medicine, Institute of Laboratory Medicine, Jinling Hospital, Nanjing University School of Medicine, Southern Medical University, Nanjing, China
| | - Tao Luo
- COVID-19 Research Center, The First School of Clinical Medicine, Institute of Laboratory Medicine, Jinling Hospital, Nanjing University School of Medicine, Southern Medical University, Nanjing, China
| | - Yanju Guo
- COVID-19 Research Center, The First School of Clinical Medicine, Institute of Laboratory Medicine, Jinling Hospital, Nanjing University School of Medicine, Southern Medical University, Nanjing, China
| | - Yang Yang
- COVID-19 Research Center, The First School of Clinical Medicine, Institute of Laboratory Medicine, Jinling Hospital, Nanjing University School of Medicine, Southern Medical University, Nanjing, China
| | - Qiuyue Wu
- COVID-19 Research Center, The First School of Clinical Medicine, Institute of Laboratory Medicine, Jinling Hospital, Nanjing University School of Medicine, Southern Medical University, Nanjing, China
| | - Weijun Jiang
- COVID-19 Research Center, The First School of Clinical Medicine, Institute of Laboratory Medicine, Jinling Hospital, Nanjing University School of Medicine, Southern Medical University, Nanjing, China
| | - Jing Zhang
- COVID-19 Research Center, The First School of Clinical Medicine, Institute of Laboratory Medicine, Jinling Hospital, Nanjing University School of Medicine, Southern Medical University, Nanjing, China
| | - Mingchao Zhang
- COVID-19 Research Center, The First School of Clinical Medicine, Institute of Laboratory Medicine, Jinling Hospital, Nanjing University School of Medicine, Southern Medical University, Nanjing, China
- Institute of Blood Transfusion, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Na Li
- COVID-19 Research Center, The First School of Clinical Medicine, Institute of Laboratory Medicine, Jinling Hospital, Nanjing University School of Medicine, Southern Medical University, Nanjing, China
- Department of Blood Transfusion, Jingling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Weiwei Li
- COVID-19 Research Center, The First School of Clinical Medicine, Institute of Laboratory Medicine, Jinling Hospital, Nanjing University School of Medicine, Southern Medical University, Nanjing, China
| | - Xinyi Xia
- COVID-19 Research Center, The First School of Clinical Medicine, Institute of Laboratory Medicine, Jinling Hospital, Nanjing University School of Medicine, Southern Medical University, Nanjing, China
- Joint Expert Group for COVID-19, Department of Laboratory Medicine & Blood Transfusion, Wuhan Huoshenshan Hospital, Wuhan, China
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Aziz M, Haghbin H, Abu Sitta E, Nawras Y, Fatima R, Sharma S, Lee-Smith W, Duggan J, Kammeyer JA, Hanrahan J, Assaly R. Efficacy of tocilizumab in COVID-19: A systematic review and meta-analysis. J Med Virol 2020; 93:1620-1630. [PMID: 32918755 DOI: 10.1002/jmv.26509] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Revised: 09/04/2020] [Accepted: 09/08/2020] [Indexed: 02/06/2023]
Abstract
The efficacy of tocilizumab (TOC), monoclonal antibody against interleukin-6 (IL-6) receptor, in patients with coronavirus disease-2019 (COVID-19) patients has led to conflicting results. We performed a systematic review and meta-analysis to compare the efficacy of addition of TOC to standard of care (SOC) versus SOC in patients with COVID-19. We performed a comprehensive literature search of PubMed, Embase, Web of Science, WHO COVID, LitCOVID, and Cochrane databases. Pooled outcomes (overall mortality, need for mechanical ventilation, intensive care unit admission, and secondary infections) were compared using DerSimonian-Laird/Random-effects approach. Risk difference (RD), confidence interval (CI), and p values were generated. A total of 23 studies with 6279 patients (1897 in TOC and 4382 in SOC group, respectively) were included. The overall mortality was lower in TOC group compared to SOC group (RD: -0.06; CI: -0.12 to -0.01; p = .03). Subgroup analysis including studies with only severe cases revealed lower mortality (RD: -0.12; CI: -0.18 to -0.06; p < .01) and need for mechanical ventilation (RD: -0.11; CI: -0.19 to -0.02; p = .01) in TOC group compared to SOC group. The addition of TOC to SOC has the potential to reduce mortality and need for mechanical ventilation in patients with severe COVID-19. Randomized controlled trials are needed to validate this.
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Affiliation(s)
- Muhammad Aziz
- Division of Gastroenterology and Hepatology, University of Toledo Medical Center, Toledo, Ohio, USA
| | - Hossein Haghbin
- Department of Internal Medicine, University of Toledo Medical Center, Toledo, Ohio, USA
| | - Emad Abu Sitta
- Division of Infectious Disease, University of Toledo Medical Center, Toledo, Ohio, USA
| | - Yusuf Nawras
- Department of Internal Medicine, University of Toledo Medical Center, Toledo, Ohio, USA
| | - Rawish Fatima
- Department of Internal Medicine, University of Toledo Medical Center, Toledo, Ohio, USA
| | - Sachit Sharma
- Department of Internal Medicine, University of Toledo Medical Center, Toledo, Ohio, USA
| | - Wade Lee-Smith
- University of Toledo Libraries, University of Toledo Medical Center, Toledo, Ohio, USA
| | - Joan Duggan
- Division of Infectious Disease, University of Toledo Medical Center, Toledo, Ohio, USA
| | - Joel A Kammeyer
- Division of Infectious Disease, University of Toledo Medical Center, Toledo, Ohio, USA
| | - Jennifer Hanrahan
- Division of Infectious Disease, University of Toledo Medical Center, Toledo, Ohio, USA
| | - Ragheb Assaly
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Toledo Medical Center, Toledo, Ohio, USA
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Winkler MS, Korsten P, Binder C, Tampe B. Correspondence on 'Interleukin-6 receptor blockade with subcutaneous tocilizumab in severe COVID-19 pneumonia and hyperinflammation: case-control study'. Ann Rheum Dis 2020:annrheumdis-2020-218836. [PMID: 32958511 DOI: 10.1136/annrheumdis-2020-218836] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 08/16/2020] [Indexed: 01/08/2023]
Affiliation(s)
- Martin Sebastian Winkler
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University Medical Center Göttingen, Göttingen, Germany
| | - Peter Korsten
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, Göttingen, Germany
| | - Claudia Binder
- Department of Hematology and Medical Oncology, University Medical Center Göttingen, Göttingen, Germany
| | - Björn Tampe
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, Göttingen, Germany
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Winthrop KL, Mariette X. To immunosuppress: whom, when and how? That is the question with COVID-19. Ann Rheum Dis 2020; 79:1129-1131. [PMID: 32753413 PMCID: PMC7456547 DOI: 10.1136/annrheumdis-2020-218694] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 07/29/2020] [Accepted: 07/29/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Kevin L Winthrop
- Divisions of Infectious Diseases and Public Health, Oregon Health and Sciences University, Portland, Oregon, USA
| | - Xavier Mariette
- Rheumatology, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Paris-Sud, Hôpital Bicêtre, Le Kremlin Bicêtre, France
- Université Paris-Sud, Center for Immunology of Viral Infections and Autoimmune Diseases (IMVA), Institut pour la Santé et la Recherche Médicale (INSERM) UMR 1184, Université Paris-Saclay, Le Kremlin Bicêtre, France
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8
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Buckley L. Correspondence on ‘Interleukin-6 receptor blockade with subcutaneous tocilizumab in severe COVID-19 pneumonia and hyperinflammation: a case–control study’ by Potereet al. Ann Rheum Dis 2020; 81:e194. [DOI: 10.1136/annrheumdis-2020-218693] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Accepted: 07/26/2020] [Indexed: 01/20/2023]
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9
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Potere N, Di Nisio M, Rizzo G, La Vella M, Polilli E, Agostinone A, Spacone A, Di Carlo S, Costantini A, Abbate A, Porreca E, Parruti G. Low-dose subcutaneous tocilizumab to prevent disease progression in patients with moderate COVID-19 pneumonia and hyperinflammation. Int J Infect Dis 2020; 100:421-424. [PMID: 32768701 PMCID: PMC7406468 DOI: 10.1016/j.ijid.2020.07.078] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 07/04/2020] [Accepted: 07/23/2020] [Indexed: 12/24/2022] Open
Abstract
Aim This study aimed to evaluate the safety and efficacy profile of low-dose tocilizumab (TCZ), to prevent disease progression, subcutaneously administered to patients with moderate COVID-19 pneumonia and hyperinflammation. Methods Clinical characteristics and outcomes were retrospectively analysed of patients – with laboratory-confirmed bilateral COVID-19 pneumonia, hyperinflammation (C-reactive protein (CRP) ≥20 mg/dL), no hypoxaemia (oxygen saturation >90%), and no contraindications to TCZ – who were treated with subcutaneous TCZ (324 mg) administered within 48 h from hospitalization on top of standard of care (SOC). They were compared with matched controls treated with SOC only before TCZ was available at the institution. Clinical data were available for all patients until death or until day 35 for those discharged from hospital. Findings Ten consecutive patients (six males, median age 55 years) treated with TCZ on top of SOC, and ten patients (six males, median age 56 years) treated with SOC only were included. TCZ was well-tolerated with no clinically relevant adverse events. TCZ was associated with a reduction in CRP at day 1 (–50%, IQR –28 to –80) and day 3 (–89%, IQR –79 to –96; p = 0.005 for within-group), whereas there was no significant change in CRP values in the SOC group (p < 0.001 for between-group comparisons at both time points). TCZ resulted in a parallel improvement in oxygenation, as assessed by the ratio of partial pressure of oxygen to fraction of inspired oxygen (P/F) ratio, which increased at day 1 (+11%, IQR +6 to +16; p = 0.005 for within-group and p = 0.006 for between-group comparisons), and day 3 (+23%, IQR +16 to +34; p = 0.005 for within-group and p = 0.003 for between-group comparisons). None of the TCZ-treated patients had disease progression, defined as requirement of oxygen therapy or mechanical ventilation, whereas progression occurred in five (50%) patients among the SOC group. Conclusions Low-dose subcutaneous TCZ may be a safe and promising therapeutic option administered on top of SOC to prevent disease progression in hospitalised patients with moderate COVID-19 and hyperinflammation.
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Affiliation(s)
- Nicola Potere
- Department of Medical, Oral and Biotechnological Sciences, 'G. D'Annunzio' University, Chieti, Italy; VCU Pauley Heart Center, Virginia Commonwealth University, Richmond VA, USA
| | - Marcello Di Nisio
- Department of Medicine and Ageing Sciences, 'G. D'Annunzio' University, Chieti-Pescara, Italy; Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Giulia Rizzo
- Department of Medical, Oral and Biotechnological Sciences, 'G. D'Annunzio' University, Chieti, Italy
| | - Matteo La Vella
- Department of Medical, Oral and Biotechnological Sciences, 'G. D'Annunzio' University, Chieti, Italy
| | - Ennio Polilli
- Unit of Clinical Pathology, Pescara General Hospital, Pescara, Italy
| | | | | | - Silvio Di Carlo
- Respiratory Medicine Unit, Pescara General Hospital, Pescara, Italy
| | | | - Antonio Abbate
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond VA, USA
| | - Ettore Porreca
- Department of Medical, Oral and Biotechnological Sciences, 'G. D'Annunzio' University, Chieti, Italy
| | - Giustino Parruti
- Infectious Diseases Unit, Pescara General Hospital, Pescara, Italy.
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Buckley LF, Wohlford GF, Ting C, Alahmed A, Van Tassell BW, Abbate A, Devlin JW, Libby P. Role for Anti-Cytokine Therapies in Severe Coronavirus Disease 2019. Crit Care Explor 2020; 2:e0178. [PMID: 32832913 PMCID: PMC7419062 DOI: 10.1097/cce.0000000000000178] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
The causative agent for coronavirus disease 2019, severe acute respiratory syndrome coronavirus 2, appears exceptional in its virulence and immunopathology. In some patients, the resulting hyperinflammation resembles a cytokine release syndrome. Our knowledge of the immunopathogenesis of coronavirus disease 2019 is evolving and anti-cytokine therapies are under active investigation. This narrative review summarizes existing knowledge of the immune response to coronavirus infection and highlights the current and potential future roles of therapeutic strategies to combat the hyperinflammatory response of patients with coronavirus disease 2019. DATA SOURCES Relevant and up-to-date literature, media reports, and author experiences were included from Medline, national newspapers, and public clinical trial databases. STUDY SELECTION The authors selected studies for inclusion by consensus. DATA EXTRACTION The authors reviewed each study and selected approrpriate data for inclusion through consensus. DATA SYNTHESIS Hyperinflammation, reminiscent of cytokine release syndromes such as macrophage activation syndrome and hemophagocytic lymphohistiocytosis, appears to drive outcomes among adults with severe coronavirus disease 2019. Cytokines, particularly interleukin-1 and interleukin-6, appear to contribute importantly to such systemic hyperinflammation. Ongoing clinical trials will determine the efficacy and safety of anti-cytokine therapies in coronavirus disease 2019. In the interim, anti-cytokine therapies may provide a treatment option for adults with severe coronavirus disease 2019 unresponsive to standard critical care management, including ventilation. CONCLUSIONS This review provides an overview of the current understanding of the immunopathogenesis of coronavirus disease 2019 in adults and proposes treatment considerations for anti-cytokine therapy use in adults with severe disease.
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Affiliation(s)
- Leo F Buckley
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA
| | - George F Wohlford
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University, Richmond, VA
| | - Clara Ting
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA
| | - Abdullah Alahmed
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA
- Department of Pharmacy Practice, Qassim University, Buraydah, Saudi Arabia
| | - Benjamin W Van Tassell
- Department of Pharmacotherapy and Outcomes Science, Virginia Commonwealth University, Richmond, VA
| | - Antonio Abbate
- Division of Cardiology, Virginia Commonwealth University, Richmond, VA
| | - John W Devlin
- School of Pharmacy, Northeastern University, Boston, MA
| | - Peter Libby
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA
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