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Siempos II, Kalil AC, Belhadi D, Veiga VC, Cavalcanti AB, Branch-Elliman W, Papoutsi E, Gkirgkiris K, Xixi NA, Kotanidou A, Hermine O, Porcher R, Mariette X. Immunomodulators for immunocompromised patients hospitalized for COVID-19: a meta-analysis of randomized controlled trials. EClinicalMedicine 2024; 69:102472. [PMID: 38361992 PMCID: PMC10867612 DOI: 10.1016/j.eclinm.2024.102472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 01/21/2024] [Accepted: 01/22/2024] [Indexed: 02/17/2024] Open
Abstract
Background Although immunomodulators have established benefit against the new coronavirus disease (COVID-19) in general, it is uncertain whether such agents improve outcomes without increasing the risk of secondary infections in the specific subgroup of previously immunocompromised patients. We assessed the effect of immunomodulators on outcomes of immunocompromised patients hospitalized for COVID-19. Methods The protocol was prospectively registered with PROSPERO (CRD42022335397). MEDLINE, Cochrane Central Register of Controlled Trials and references of relevant articles were searched up to 01-06-2022. Authors of potentially eligible randomized controlled trials were contacted to provide data on immunocompromised patients randomized to immunomodulators vs control (i.e., placebo or standard-of-care). Findings Eleven randomized controlled trials involving 397 immunocompromised patients hospitalized for COVID-19 were included. Ten trials had low risk of bias. There was no difference between immunocompromised patients randomized to immunomodulators vs control regarding mortality [30/182 (16.5%) vs 41/215 (19.1%); RR 0.93, 95% CI 0.61-1.41; p = 0.74], secondary infections (RR 1.00, 95% CI 0.64-1.58; p = 0.99) and change in World Health Organization ordinal scale from baseline to day 15 (weighed mean difference 0.27, 95% CI -0.09-0.63; p = 0.15). In subgroup analyses including only patients with hematologic malignancy, only trials with low risk of bias, only trials administering IL-6 inhibitors, or only trials administering immunosuppressants, there was no difference between comparators regarding mortality. Interpretation Immunomodulators, compared to control, were not associated with harmful or beneficial outcomes, including mortality, secondary infections, and change in ordinal scale, when administered to immunocompromised patients hospitalized for COVID-19. Funding Hellenic Foundation for Research and Innovation.
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Affiliation(s)
- Ilias I. Siempos
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Andre C. Kalil
- Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Drifa Belhadi
- Département d'Épidémiologie, Biostatistiques et Recherche Clinique, Assistance Publique Hôpitaux de Paris, Hôpital Bichat, Paris, France
- Université Paris Cité, Inserm, IAME, Paris F-75018, France
| | - Viviane Cordeiro Veiga
- BP-A Beneficência Portuguesa de São Paulo, São Paulo, Brazil
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil
| | - Alexandre Biasi Cavalcanti
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil
- HCor Research Institute, São Paulo, Brazil
| | - Westyn Branch-Elliman
- Department of Medicine, VA Boston Healthcare System, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Eleni Papoutsi
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Konstantinos Gkirgkiris
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Nikoleta A. Xixi
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Anastasia Kotanidou
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Olivier Hermine
- Département d'hématologie, Hôpital Necker, Assistance Publique Hôpitaux de Paris, Université de Paris, Institut Imagine, INSERM U1183, Paris, France
| | - Raphaël Porcher
- Centre de Recherche Épidémiologie et Statistique Sorbonne Paris Cité (CRESS-UMR1153), Inserm / Université Paris, Centre d'épidémiologie Clinique, Hôpital Hôtel-Dieu, France
| | - Xavier Mariette
- Département de Rhumatologie, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Université Paris Saclay, INSERM UMR 1184, Le Kremlin Bicêtre, France
| | - CORIMUNO-19 Collaborative Group
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Weill Cornell Medicine, New York, NY, USA
- Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
- Département d'Épidémiologie, Biostatistiques et Recherche Clinique, Assistance Publique Hôpitaux de Paris, Hôpital Bichat, Paris, France
- Université Paris Cité, Inserm, IAME, Paris F-75018, France
- BP-A Beneficência Portuguesa de São Paulo, São Paulo, Brazil
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil
- HCor Research Institute, São Paulo, Brazil
- Department of Medicine, VA Boston Healthcare System, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Département d'hématologie, Hôpital Necker, Assistance Publique Hôpitaux de Paris, Université de Paris, Institut Imagine, INSERM U1183, Paris, France
- Centre de Recherche Épidémiologie et Statistique Sorbonne Paris Cité (CRESS-UMR1153), Inserm / Université Paris, Centre d'épidémiologie Clinique, Hôpital Hôtel-Dieu, France
- Département de Rhumatologie, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Université Paris Saclay, INSERM UMR 1184, Le Kremlin Bicêtre, France
| | - DisCoVeRy Study Group
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Weill Cornell Medicine, New York, NY, USA
- Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
- Département d'Épidémiologie, Biostatistiques et Recherche Clinique, Assistance Publique Hôpitaux de Paris, Hôpital Bichat, Paris, France
- Université Paris Cité, Inserm, IAME, Paris F-75018, France
- BP-A Beneficência Portuguesa de São Paulo, São Paulo, Brazil
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil
- HCor Research Institute, São Paulo, Brazil
- Department of Medicine, VA Boston Healthcare System, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Département d'hématologie, Hôpital Necker, Assistance Publique Hôpitaux de Paris, Université de Paris, Institut Imagine, INSERM U1183, Paris, France
- Centre de Recherche Épidémiologie et Statistique Sorbonne Paris Cité (CRESS-UMR1153), Inserm / Université Paris, Centre d'épidémiologie Clinique, Hôpital Hôtel-Dieu, France
- Département de Rhumatologie, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Université Paris Saclay, INSERM UMR 1184, Le Kremlin Bicêtre, France
| | - ACTT-2 Study Group
- First Department of Critical Care Medicine and Pulmonary Services, Evangelismos Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Weill Cornell Medicine, New York, NY, USA
- Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
- Département d'Épidémiologie, Biostatistiques et Recherche Clinique, Assistance Publique Hôpitaux de Paris, Hôpital Bichat, Paris, France
- Université Paris Cité, Inserm, IAME, Paris F-75018, France
- BP-A Beneficência Portuguesa de São Paulo, São Paulo, Brazil
- Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil
- HCor Research Institute, São Paulo, Brazil
- Department of Medicine, VA Boston Healthcare System, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Département d'hématologie, Hôpital Necker, Assistance Publique Hôpitaux de Paris, Université de Paris, Institut Imagine, INSERM U1183, Paris, France
- Centre de Recherche Épidémiologie et Statistique Sorbonne Paris Cité (CRESS-UMR1153), Inserm / Université Paris, Centre d'épidémiologie Clinique, Hôpital Hôtel-Dieu, France
- Département de Rhumatologie, Hôpital Bicêtre, Assistance Publique Hôpitaux de Paris, Université Paris Saclay, INSERM UMR 1184, Le Kremlin Bicêtre, France
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2
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Livorsi DJ, Branch-Elliman W, Drekonja D, Echevarria KL, Fitzpatrick MA, Goetz MB, Graber CJ, Jones MM, Kelly AA, Madaras-Kelly K, Morgan DJ, Stevens VW, Suda K, Trautner BW, Ward MJ, Jump RLP. Research agenda for antibiotic stewardship within the Veterans' Health Administration, 2024-2028. Infect Control Hosp Epidemiol 2024:1-7. [PMID: 38305034 PMCID: PMC11294492 DOI: 10.1017/ice.2024.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024]
Affiliation(s)
- Daniel J Livorsi
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans' Affairs (VA) Health Care System, Iowa City, Iowa
- Division of Infectious Diseases, University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Westyn Branch-Elliman
- VA Boston Healthcare System, Department of Medicine, Section of Infectious Diseases. Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Dimitri Drekonja
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Kelly L Echevarria
- VHA Pharmacy Benefits and Antimicrobial Stewardship Task Force, Department of Veterans' Affairs, Washington, DC
| | - Margaret A Fitzpatrick
- Center of Innovation for Veteran-Centered and Value-Driven Care, VA Eastern Colorado Healthcare System, Aurora, Colorado
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Matthew Bidwell Goetz
- VA Greater Los Angeles Healthcare System, Los Angeles, California
- David Geffen School of Medicine at the University of California, Los Angeles, California
| | - Christopher J Graber
- VA Greater Los Angeles Healthcare System, Los Angeles, California
- David Geffen School of Medicine at the University of California, Los Angeles, California
| | - Makoto M Jones
- Informatics, Decision Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Allison A Kelly
- VHA Pharmacy Benefits and Antimicrobial Stewardship Task Force, Department of Veterans' Affairs, Washington, DC
- Cincinnati Veterans' Affairs Medical Center, Cincinnati, Ohio
- University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Karl Madaras-Kelly
- Boise Veterans' Affairs Medical Center, Boise, Idaho
- Idaho State University, College of Pharmacy, Meridian, Idaho
| | - Daniel J Morgan
- Department of Medicine, VA Maryland Healthcare System, Baltimore, Maryland
- Center for Innovation in Diagnosis, University of Maryland School of Medicine, Baltimore, Maryland
| | - Vanessa W Stevens
- Informatics, Decision Enhancement, and Analytic Sciences (IDEAS) Center of Innovation, VA Salt Lake City Health Care System, Salt Lake City, Utah
- Division of Epidemiology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Katie Suda
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Barbara W Trautner
- Center for Innovations in Quality, Effectiveness, and Safety (IQuESt), Michael E. DeBakey Veterans' Affairs Medical Center, Houston, Texas
- Section of Health Services Research, Baylor College of Medicine, Houston, Texas
| | - Michael J Ward
- Geriatric Research, Education, and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, Tennessee
- Department of Emergency Medicine and Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robin L P Jump
- Technology Enhancing Cognition and Health Geriatric Research Education and Clinical Center (TECH-GRECC) at the VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of Geriatric Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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3
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Mei H, Xie J, Qin Y, Li Y. Network and covariate adjusted response-adaptive design for binary response. Stat Med 2023; 42:5369-5388. [PMID: 37750440 DOI: 10.1002/sim.9915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 08/31/2023] [Accepted: 09/13/2023] [Indexed: 09/27/2023]
Abstract
Randomization is a distinguishing feature of clinical trials for unbiased assessment of treatment efficacy. With a growing demand for more flexible and efficient randomization schemes and motivated by the idea of adaptive design, in this article we propose the network and covariate adjusted response-adaptive (NCARA) design that can concurrently manage three challenges: (1) maximizing benefits of a trial by assigning more patients to the superior treatment group randomly; (2) balancing social network ties across treatment arms to eliminate potential network interference; and (3) ensuring balance of important covariates, such as age, gender, and other potential confounders. We conduct simulation with different network structures and a variety of parameter settings. It is observed that the NCARA design outperforms four alternative randomization designs in solving the above-mentioned problems and has comparable power and type I error for detecting true difference between treatment groups. In addition, we conduct real data analysis to implement the new design in two clinical trials. Compared to equal randomization (the original design utilized in the trials), the NCARA design slightly increases power, largely increases the percentage of patients assigned to the better-performing group, and significantly improves network and covariate balances. It is also noted that the advantages of the NCARA design are augmented when the sample size is small and the level of network interference is high. In summary, the proposed NCARA design assists researchers in conducting clinical trials with high-quality and high-efficiency.
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Affiliation(s)
- Hao Mei
- Center for Applied Statistics, Renmin University of China, Beijing, China
- School of Statistics, Renmin University of China, Beijing, China
| | - Jiaxin Xie
- School of Statistics, Renmin University of China, Beijing, China
| | - Yichen Qin
- Department of Operations, Business Analytics and Information Systems, University of Cincinnati, Cincinnati, Ohio, USA
| | - Yang Li
- Center for Applied Statistics, Renmin University of China, Beijing, China
- School of Statistics, Renmin University of China, Beijing, China
- Statistical Consulting Center, Renmin University of China, Beijing, China
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4
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Tseng PT, Zeng BS, Thompson T, Stubbs B, Hsueh PR, Su KP, Chen YW, Chen TY, Wu YC, Lin PY, Carvalho AF, Hsu CW, Li DJ, Yeh TC, Sun CK, Cheng YS, Shiue YL, Liang CS, Tu YK. Placebo effects on all-cause mortality of patients with COVID-19 in randomized controlled trials of interleukin 6 antagonists: A systematic review and network meta-analysis. Psychiatry Clin Neurosci 2023; 77:638-645. [PMID: 37646204 DOI: 10.1111/pcn.13592] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 08/14/2023] [Accepted: 08/23/2023] [Indexed: 09/01/2023]
Abstract
AIM Many randomized controlled trials (RCTs) have investigated the use of interleukin 6 antagonists for the treatment of coronavirus disease 2019 (COVID-19), yielding inconsistent results. This network meta-analysis (NMA) aimed to identify the source of these inconsistent results by reassessing whether participants treated with standard of care (SoC) plus placebo have different all-cause mortality from those treated with SoC alone and to reevaluate the efficacy of interleukin 6 antagonists in the treatment of COVID-19. METHODS We conducted a systematic search for relevant RCTs from the inception of electronic databases through 1 September 2022. The primary outcome was all-cause mortality. The secondary outcomes were the incidences of major medical events, secondary infections, all-cause discontinuation, and serious adverse events. RESULTS The results of NMA of 33 RCTs showed that patients with COVID-19 treated with SoC plus placebo had lower odds of all-cause mortality than those who received SoC alone (OR, 0.75 [95% confidence interval, 0.58-0.97]). This finding remained consistent after excluding studies with no incident deaths. In addition, when we consider the impact of the widely promoted COVID-19 vaccination and newly developed antiviral treatment strategy, the results from the analysis of the RCT published in 2021 and 2022 remained similar. CONCLUSION These findings suggest the potential influence of placebo effects on the treatment outcomes of COVID-19 in RCTs. When evaluating the efficacy of treatment strategies for COVID-19, it is crucial to consider the use of placebo in the design of clinical trials.
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Affiliation(s)
- Ping-Tao Tseng
- Institute of Biomedical Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan
- Department of Psychology, College of Medical and Health Science, Asia University, Taichung, Taiwan
- Prospect Clinic for Otorhinolaryngology & Neurology, Kaohsiung, Taiwan
- Institute of Precision Medicine, National Sun Yat-sen University, Kaohsiung City, Taiwan
| | - Bing-Syuan Zeng
- Institute of Biomedical Sciences, National Sun Yat-sen University, Kaohsiung, Taiwan
- Department of Internal Medicine, E-Da Cancer Hospital, I-Shou University, Kaohsiung, Taiwan
| | - Trevor Thompson
- Centre for Chronic Illness and Ageing, University of Greenwich, London, UK
| | - Brendon Stubbs
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- Physiotherapy Department, South London and Maudsley NHS Foundation Trust, London, UK
- Faculty of Health, Social Care Medicine and Education, Anglia Ruskin University, Chelmsford, UK
| | - Po-Ren Hsueh
- Departments of Laboratory Medicine and Internal Medicine, China Medical University Hospital, Taichung, Taiwan
- School of Medicine, China Medical University, Taichung, Taiwan
| | - Kuan-Pin Su
- College of Medicine, China Medical University, Taichung, Taiwan
- Mind-Body Interface Laboratory (MBI-Lab), China Medical University and Hospital, Taichung, Taiwan
- An-Nan Hospital, China Medical University, Tainan, Taiwan
| | - Yen-Wen Chen
- Prospect Clinic for Otorhinolaryngology & Neurology, Kaohsiung, Taiwan
| | - Tien-Yu Chen
- Department of Psychiatry, Tri-Service General Hospital; School of Medicine, National Defense Medical Center, Taipei, Taiwan
- Institute of Brain Science, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Cheng Wu
- Department of Sports Medicine, Landseed International Hospital, Taoyuan, Taiwan
| | - Pao-Yen Lin
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Institute for Translational Research in Biomedical Sciences, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Andre F Carvalho
- Innovation in Mental and Physical Health and Clinical Treatment (IMPACT) Strategic Research Centre, School of Medicine, Barwon Health, Deakin University, Geelong, Victoria, Australia
| | - Chih-Wei Hsu
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Dian-Jeng Li
- Department of Addiction Science, Kaohsiung Municipal Kai-Syuan Psychiatric Hospital, Kaohsiung City, Taiwan
| | - Ta-Chuan Yeh
- Department of Psychiatry, Tri-Service General Hospital; School of Medicine, National Defense Medical Center, Taipei, Taiwan
| | - Cheuk-Kwan Sun
- Department of Emergency Medicine, E-Da Hospital, I-Shou University, Kaohsiung, Taiwan
- School of Medicine for International Students, College of Medicine, I-Shou University Kaohsiung, Kaohsiung, Taiwan
| | - Yu-Shian Cheng
- Department of Psychology, College of Medical and Health Science, Asia University, Taichung, Taiwan
- Department of Psychiatry, Tsyr-Huey Mental Hospital, Kaohsiung Jen-Ai's Home, Kaohsiung, Taiwan
| | - Yow-Ling Shiue
- Department of Internal Medicine, E-Da Cancer Hospital, I-Shou University, Kaohsiung, Taiwan
- Institute for Translational Research in Biomedical Sciences, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Chih-Sung Liang
- Department of Psychiatry, Beitou Branch, Tri-Service General Hospital; School of Medicine, National Defense Medical Center, Taipei, Taiwan
- Department of Psychiatry, National Defense Medical Center, Taipei, Taiwan
| | - Yu-Kang Tu
- Institute of Health Data Analytics & Statistics, College of Public Health, National Taiwan University, Taipei, Taiwan
- Department of Dentistry, National Taiwan University Hospital, Taipei, Taiwan
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5
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Ghosn L, Assi R, Evrenoglou T, Buckley BS, Henschke N, Probyn K, Riveros C, Davidson M, Graña C, Bonnet H, Jarde A, Ávila C, Nejstgaard CH, Menon S, Ferrand G, Kapp P, Breuer C, Schmucker C, Sguassero Y, Nguyen TV, Devane D, Meerpohl JJ, Rada G, Hróbjartsson A, Grasselli G, Tovey D, Ravaud P, Chaimani A, Boutron I. Interleukin-6 blocking agents for treating COVID-19: a living systematic review. Cochrane Database Syst Rev 2023; 6:CD013881. [PMID: 37260086 PMCID: PMC10237088 DOI: 10.1002/14651858.cd013881.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND It has been reported that people with COVID-19 and pre-existing autoantibodies against type I interferons are likely to develop an inflammatory cytokine storm responsible for severe respiratory symptoms. Since interleukin 6 (IL-6) is one of the cytokines released during this inflammatory process, IL-6 blocking agents have been used for treating people with severe COVID-19. OBJECTIVES To update the evidence on the effectiveness and safety of IL-6 blocking agents compared to standard care alone or to a placebo for people with COVID-19. SEARCH METHODS We searched the World Health Organization (WHO) International Clinical Trials Registry Platform, the Living OVerview of Evidence (L·OVE) platform, and the Cochrane COVID-19 Study Register to identify studies on 7 June 2022. SELECTION CRITERIA We included randomized controlled trials (RCTs) evaluating IL-6 blocking agents compared to standard care alone or to placebo for people with COVID-19, regardless of disease severity. DATA COLLECTION AND ANALYSIS Pairs of researchers independently conducted study selection, extracted data and assessed risk of bias. We assessed the certainty of evidence using the GRADE approach for all critical and important outcomes. In this update we amended our protocol to update the methods used for grading evidence by establishing minimal important differences for the critical outcomes. MAIN RESULTS This update includes 22 additional trials, for a total of 32 trials including 12,160 randomized participants all hospitalized for COVID-19 disease. We identified a further 17 registered RCTs evaluating IL-6 blocking agents without results available as of 7 June 2022. The mean age range varied from 56 to 75 years; 66.2% (8051/12,160) of enrolled participants were men. One-third (11/32) of included trials were placebo-controlled. Twenty-two were published in peer-reviewed journals, three were reported as preprints, two trials had results posted only on registries, and results from five trials were retrieved from another meta-analysis. Eight were funded by pharmaceutical companies. Twenty-six included studies were multicenter trials; four were multinational and 22 took place in single countries. Recruitment of participants occurred between February 2020 and June 2021, with a mean enrollment duration of 21 weeks (range 1 to 54 weeks). Nineteen trials (60%) had a follow-up of 60 days or more. Disease severity ranged from mild to critical disease. The proportion of participants who were intubated at study inclusion also varied from 5% to 95%. Only six trials reported vaccination status; there were no vaccinated participants included in these trials, and 17 trials were conducted before vaccination was rolled out. We assessed a total of six treatments, each compared to placebo or standard care. Twenty trials assessed tocilizumab, nine assessed sarilumab, and two assessed clazakizumab. Only one trial was included for each of the other IL-6 blocking agents (siltuximab, olokizumab, and levilimab). Two trials assessed more than one treatment. Efficacy and safety of tocilizumab and sarilumab compared to standard care or placebo for treating COVID-19 At day (D) 28, tocilizumab and sarilumab probably result in little or no increase in clinical improvement (tocilizumab: risk ratio (RR) 1.05, 95% confidence interval (CI) 1.00 to 1.11; 15 RCTs, 6116 participants; moderate-certainty evidence; sarilumab: RR 0.99, 95% CI 0.94 to 1.05; 7 RCTs, 2425 participants; moderate-certainty evidence). For clinical improvement at ≥ D60, the certainty of evidence is very low for both tocilizumab (RR 1.10, 95% CI 0.81 to 1.48; 1 RCT, 97 participants; very low-certainty evidence) and sarilumab (RR 1.22, 95% CI 0.91 to 1.63; 2 RCTs, 239 participants; very low-certainty evidence). The effect of tocilizumab on the proportion of participants with a WHO Clinical Progression Score (WHO-CPS) of level 7 or above remains uncertain at D28 (RR 0.90, 95% CI 0.72 to 1.12; 13 RCTs, 2117 participants; low-certainty evidence) and that for sarilumab very uncertain (RR 1.10, 95% CI 0.90 to 1.33; 5 RCTs, 886 participants; very low-certainty evidence). Tocilizumab reduces all cause-mortality at D28 compared to standard care/placebo (RR 0.88, 95% CI 0.81 to 0.94; 18 RCTs, 7428 participants; high-certainty evidence). The evidence about the effect of sarilumab on this outcome is very uncertain (RR 1.06, 95% CI 0.86 to 1.30; 9 RCTs, 3305 participants; very low-certainty evidence). The evidence is uncertain for all cause-mortality at ≥ D60 for tocilizumab (RR 0.91, 95% CI 0.80 to 1.04; 9 RCTs, 2775 participants; low-certainty evidence) and very uncertain for sarilumab (RR 0.95, 95% CI 0.84 to 1.07; 6 RCTs, 3379 participants; very low-certainty evidence). Tocilizumab probably results in little to no difference in the risk of adverse events (RR 1.03, 95% CI 0.95 to 1.12; 9 RCTs, 1811 participants; moderate-certainty evidence). The evidence about adverse events for sarilumab is uncertain (RR 1.12, 95% CI 0.97 to 1.28; 4 RCT, 860 participants; low-certainty evidence). The evidence about serious adverse events is very uncertain for tocilizumab (RR 0.93, 95% CI 0.81 to 1.07; 16 RCTs; 2974 participants; very low-certainty evidence) and uncertain for sarilumab (RR 1.09, 95% CI 0.97 to 1.21; 6 RCTs; 2936 participants; low-certainty evidence). Efficacy and safety of clazakizumab, olokizumab, siltuximab and levilimab compared to standard care or placebo for treating COVID-19 The evidence about the effects of clazakizumab, olokizumab, siltuximab, and levilimab comes from only one or two studies for each blocking agent, and is uncertain or very uncertain. AUTHORS' CONCLUSIONS In hospitalized people with COVID-19, results show a beneficial effect of tocilizumab on all-cause mortality in the short term and probably little or no difference in the risk of adverse events compared to standard care alone or placebo. Nevertheless, both tocilizumab and sarilumab probably result in little or no increase in clinical improvement at D28. Evidence for an effect of sarilumab and the other IL-6 blocking agents on critical outcomes is uncertain or very uncertain. Most of the trials included in our review were done before the waves of different variants of concern and before vaccination was rolled out on a large scale. An additional 17 RCTs of IL-6 blocking agents are currently registered with no results yet reported. The number of pending studies and the number of participants planned is low. Consequently, we will not publish further updates of this review.
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Affiliation(s)
- Lina Ghosn
- Cochrane France, Paris, France
- Centre d'Epidémiologie Clinique, AP-HP, Hôpital Hôtel Dieu, F-75004, Paris, France
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), F-75004, Paris, France
| | - Rouba Assi
- Cochrane France, Paris, France
- Centre d'Epidémiologie Clinique, AP-HP, Hôpital Hôtel Dieu, F-75004, Paris, France
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), F-75004, Paris, France
| | - Theodoros Evrenoglou
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), F-75004, Paris, France
| | | | | | | | - Carolina Riveros
- Centre d'Epidémiologie Clinique, AP-HP, Hôpital Hôtel Dieu, F-75004, Paris, France
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), F-75004, Paris, France
| | - Mauricia Davidson
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), F-75004, Paris, France
| | - Carolina Graña
- Cochrane France, Paris, France
- Centre d'Epidémiologie Clinique, AP-HP, Hôpital Hôtel Dieu, F-75004, Paris, France
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), F-75004, Paris, France
| | - Hillary Bonnet
- Cochrane France, Paris, France
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), F-75004, Paris, France
| | - Alexander Jarde
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), F-75004, Paris, France
| | | | - Camilla Hansen Nejstgaard
- Centre for Evidence-Based Medicine Odense (CEBMO) and Cochrane Denmark, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Open Patient data Explorative Network (OPEN), Odense University Hospital, Odense, Denmark
| | | | | | - Philipp Kapp
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Claudia Breuer
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Cochrane Germany, Cochrane Germany Foundation, Freiburg, Germany
| | - Christine Schmucker
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Cochrane Germany, Cochrane Germany Foundation, Freiburg, Germany
| | | | | | - Declan Devane
- Evidence Synthesis Ireland, Galway, Ireland
- Cochrane Ireland and HRB-Trials Methodology Research Network, Galway, Ireland
- University of Galway, Galway, Ireland
| | - Joerg J Meerpohl
- Institute for Evidence in Medicine (for Cochrane Germany Foundation), Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Cochrane Germany, Cochrane Germany Foundation, Freiburg, Germany
| | - Gabriel Rada
- Epistemonikos Foundation, Santiago, Chile
- UC Evidence Center, Cochrane Chile Associated Center, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Asbjørn Hróbjartsson
- Centre for Evidence-Based Medicine Odense (CEBMO) and Cochrane Denmark, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Open Patient data Explorative Network (OPEN), Odense University Hospital, Odense, Denmark
| | - Giacomo Grasselli
- Department of Anesthesia, Intensive Care and Emergency Department of Anesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | | | - Philippe Ravaud
- Cochrane France, Paris, France
- Centre d'Epidémiologie Clinique, AP-HP, Hôpital Hôtel Dieu, F-75004, Paris, France
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), F-75004, Paris, France
| | - Anna Chaimani
- Cochrane France, Paris, France
- Centre d'Epidémiologie Clinique, AP-HP, Hôpital Hôtel Dieu, F-75004, Paris, France
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), F-75004, Paris, France
| | - Isabelle Boutron
- Cochrane France, Paris, France
- Centre d'Epidémiologie Clinique, AP-HP, Hôpital Hôtel Dieu, F-75004, Paris, France
- Université Paris Cité and Université Sorbonne Paris Nord, Inserm, INRAE, Center for Research in Epidemiology and StatisticS (CRESS), F-75004, Paris, France
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6
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Dassum SR, Ferguson R, Woods P, Flynn M, Visnaw K, Holmberg E, Schiller S, Shannon C, Brophy M, Monach P, Leatherman S, Branch-Elliman W. Patient- reported reasons for non-participation in a COVID-19 therapeutics clinical trial: Findings from a multi-center investigation. Contemp Clin Trials 2023; 126:107082. [PMID: 36632925 PMCID: PMC9827740 DOI: 10.1016/j.cct.2023.107082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 12/15/2022] [Accepted: 01/06/2023] [Indexed: 01/11/2023]
Abstract
BACKGROUND Early in the pandemic, there were no evidence-based treatments for SARS-CoV-2, creating an urgent need to identify effective therapeutics. However, public participation in medical research is low; trial enrollment in the US is typically 10-20%. Thus, the aim of this study was to identify common themes underpinning patient reasons to decline participation and evaluate the impact of specific contextual factors. METHODS This sub-study was conducted in five VISN-1 Clinical Trials Network participating facilities from 4/10/2020-2/3/2021. The trial evaluated the addition of the IL-6-inhibitor, Sarilumab, to the current standard of care for inpatients with moderate-to-severe SARS-CoV-2. Consent procedures varied by site and included fully in-person and fully remote processes. Reasons for declining enrollment were collected among eligible patients who declined to participate but agreed to answer a short follow-up question. Qualitative data were analyzed using directed content analysis. Enrollment rates were assessed using simple, descriptive statistics. RESULTS N = 417 COVID-19 positive inpatients were screened and 53/162 eligible patients enrolled. Enrollment varied across study sites and by study period. Prior to identification of effective treatment, the enrollment rate was 10/11 (91%) versus 43/144 (30%) during the later period of the study. N = 85/102 patients who did not enroll answered the follow-up question. The most commonly reported responses were: concerns about the study drug and participation in clinical research in general, comorbidity concerns, competing priorities, external factors, and external advice and influence from family members and clinicians. CONCLUSIONS Identifying reasons behind declining to enroll may help investigators develop strategies to increase research participation.
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Affiliation(s)
- Samira Reyes Dassum
- Beth Israel Deaconess Medical Center, Department of Infectious Disease, Boston, MA, United States.
| | - Ryan Ferguson
- VA Boston Healthcare System, Cooperative Studies Program, Boston, MA, United States; Boston University School of Medicine, Boston, MA, United States of America; Boston University School of Public Health, Boston, MA, United States of America
| | - Patricia Woods
- VA Boston Healthcare System, Cooperative Studies Program, Boston, MA, United States
| | - Maura Flynn
- VA Boston Healthcare System, Cooperative Studies Program, Boston, MA, United States
| | - Karen Visnaw
- VA Boston Healthcare System, Cooperative Studies Program, Boston, MA, United States
| | - Erika Holmberg
- VA Boston Healthcare System, Cooperative Studies Program, Boston, MA, United States
| | - Sara Schiller
- VA Boston Healthcare System, Cooperative Studies Program, Boston, MA, United States
| | - Colleen Shannon
- VA Boston Healthcare System, Cooperative Studies Program, Boston, MA, United States
| | - Mary Brophy
- VA Boston Healthcare System, Cooperative Studies Program, Boston, MA, United States; Boston University School of Medicine, Boston, MA, United States of America
| | - Paul Monach
- VA Boston Healthcare System, Cooperative Studies Program, Boston, MA, United States; VA Boston Healthcare System, Department of Medicine, Boston, MA, United States; Harvard Medical School, Boston, MA, United States of America
| | - Sarah Leatherman
- VA Boston Healthcare System, Cooperative Studies Program, Boston, MA, United States
| | - Westyn Branch-Elliman
- VA Boston Healthcare System, Department of Medicine, Boston, MA, United States; VA Boston Center for Healthcare Organization and Implementation Research (CHOIR), Boston, MA, United States; Harvard Medical School, Boston, MA, United States of America
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7
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Albuquerque AM, Eckert I, Tramujas L, Butler-Laporte G, McDonald EG, Brophy JM, Lee TC. Effect of tocilizumab, sarilumab, and baricitinib on mortality among patients hospitalized for COVID-19 treated with corticosteroids: a systematic review and meta-analysis. Clin Microbiol Infect 2023; 29:13-21. [PMID: 35863630 PMCID: PMC9293401 DOI: 10.1016/j.cmi.2022.07.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 07/10/2022] [Accepted: 07/11/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Randomized controlled trials (RCT) established the mortality reduction by tocilizumab (Actemra), baricitinib (Olumiant), and sarilumab (Kevzara) in hospitalized COVID-19 patients. However, uncertainty remains about which treatment performs best in patients receiving corticosteroids. OBJECTIVES To estimate probabilities of noninferiority between baricitinib and sarilumab compared to tocilizumab in patients treated with corticosteroids. DATA SOURCES PubMed, Embase, Cochrane Library, and MedRxiv. STUDY ELIGIBILITY CRITERIA Eligible RCTs assigning hospitalized adults with COVID-19 treated with corticosteroids to tocilizumab or baricitinib or sarilumab versus standard of care or placebo (control). METHODS Reviewers independently abstracted published data and assessed study quality with the Risk of Bias 2 tool. Unpublished data, if required, were requested from authors of included studies. The outcome of interest was all-cause mortality at 28 days. PARTICIPANTS Twenty-seven RCTs with 13 549 patients were included. Overall, the risk of bias was low. Bayesian pairwise meta-analyses were used to aggregate results of each treatment versus control. The average odds ratio for mortality was 0.78 (95% credible interval [CrI]: 0.65, 0.94) for tocilizumab; 0.78 (95% CrI: 0.56, 1.03) for baricitinib; and 0.91 (95% CrI: 0.60, 1.40) for sarilumab. The certainty of evidence (GRADE) ranged from moderate to low. Bayesian meta-regressions with multiple priors were used to estimate probabilities of noninferiority (margin of 13% greater effect by tocilizumab). Compared to tocilizumab, there were ≤94% and 90% probabilities of noninferiority with baricitinib and sarilumab, respectively. RESULTS All but two studies included data with only indirect evidence for the comparison of interest. CONCLUSIONS Among hospitalized COVID-19 treated with corticosteroids, there are high probabilities that both baricitinib and sarilumab are associated with similar mortality reductions in comparison to tocilizumab.
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Affiliation(s)
| | - Igor Eckert
- Department of Nutrition, Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, Brazil
| | | | - Guillaume Butler-Laporte
- Division of Infectious Diseases, Department of Medicine, McGill University, Montréal, Canada,Department of Epidemiology, Occupational Health, and Biostatistics, McGill University, Montréal, Canada
| | - Emily G. McDonald
- Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montréal, Canada,Division of General Internal Medicine, Department of Medicine, McGill University, Montréal, Canada
| | - James M. Brophy
- Department of Epidemiology, Occupational Health, and Biostatistics, McGill University, Montréal, Canada,Division of Cardiology, Department of Medicine, McGill University, Montréal, Canada
| | - Todd C. Lee
- Division of Infectious Diseases, Department of Medicine, McGill University, Montréal, Canada,Department of Epidemiology, Occupational Health, and Biostatistics, McGill University, Montréal, Canada,Clinical Practice Assessment Unit, Department of Medicine, McGill University, Montréal, Canada,Corresponding author. Todd C. Lee, Royal Victoria Hospital, 1001 Decarie Blvd Room E5.1820, Montréal, QC H4A3J1, Canada
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8
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The COVID-19 hospitalization metric in the pre- and postvaccination eras as a measure of pandemic severity: A retrospective, nationwide cohort study. Infect Control Hosp Epidemiol 2022; 43:1767-1772. [PMID: 35012694 PMCID: PMC9021586 DOI: 10.1017/ice.2022.13] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) hospitalization definitions do not include a disease severity assessment. Thus, we sought to identify a simple and objective mechanism for identifying hospitalized severe cases and to measure the impact of vaccination on trends. METHODS All admissions to a Veterans' Affairs (VA) hospital, where routine inpatient screening is recommended, between March 1, 2020, and November 22, 2021, with laboratory-confirmed severe acute respiratory coronavirus virus 2 (SARS-CoV-2) were included. Moderate-to-severe COVID-19 was defined as any oxygen supplementation or any oxygen saturation (SpO2) <94% between 1 day before and 2 weeks after the positive SARS-CoV-2 test. Admissions with moderate-to-severe disease were divided by the total number of admissions, and the proportion of admissions with moderate-to-severe COVID-19 was modelled using a penalized spline in a Poisson regression and stratified by vaccination status. Dexamethasone receipt and its correlation with moderate-to-severe cases was also assessed. RESULTS Among 67,025 admissions with SARS-CoV-2, the proportion with hypoxemia or supplemental oxygen fell from 64% prior to vaccine availability to 56% by November 2021, driven in part by lower rates in vaccinated patients (vaccinated, 52% versus unvaccinated, 58%). The proportion of cases of moderate-to-severe disease identified using SpO2 levels and oxygen supplementation was highly correlated with dexamethasone receipt (correlation coefficient, 0.95), and increased after July 1, 2021, concurrent with δ (delta) variant predominance. CONCLUSIONS A simple and objective definition of COVID-19 hospitalizations using SpO2 levels and oxygen supplementation can be used to track pandemic severity. This metric could be used to identify risk factors for severe breakthrough infections, to guide clinical treatment algorithms, and to detect trends in changes in vaccine effectiveness over time and against new variants.
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9
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Battaglini D, Cruz F, Robba C, Pelosi P, Rocco PRM. Failed clinical trials on COVID-19 acute respiratory distress syndrome in hospitalized patients: common oversights and streamlining the development of clinically effective therapeutics. Expert Opin Investig Drugs 2022; 31:995-1015. [PMID: 36047644 DOI: 10.1080/13543784.2022.2120801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
INTRODUCTION The coronavirus disease 2019 (COVID-19) pandemic has put a strain on global healthcare systems. Despite admirable efforts to develop rapidly new pharmacotherapies, supportive treatments remain the standard of care. Multiple clinical trials have failed due to design issues, biased patient enrollment, small sample sizes, inadequate control groups, and lack of long-term outcomes monitoring. AREAS COVERED This narrative review depicts the current situation around failed and success COVID-19 clinical trials and recommendations in hospitalized patients with COVID-19, oversights and streamlining of clinically effective therapeutics. PubMed, EBSCO, Cochrane Library, and WHO and NIH guidelines were searched for relevant literature up to 5 August 2022. EXPERT OPINION The WHO, NIH, and IDSA have issued recommendations to better clarify which drugs should be used during the different phases of the disease. Given the biases and high heterogeneity of published studies, interpretation of the current literature is difficult. Future clinical trials should be designed to standardize clinical approaches, with appropriate organization, patient selection, addition of control groups, and careful identification of disease phase to reduce heterogeneity and bias and should rely on the integration of scientific societies to promote a consensus on interpretation of the data and recommendations for optimal COVID-19 therapies.
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Affiliation(s)
- Denise Battaglini
- Dipartimento di Anestesia e Rianimazione, Policlinico San Martino, IRCCS per l'Oncologia e le Neuroscienze, Genoa, Italy
| | - Fernanda Cruz
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Chiara Robba
- Policlinico San Martino, IRCCS per l'Oncologia e Neuroscienze, Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università degli Studi di Genova, Genoa, Italy
| | - Paolo Pelosi
- Dipartimento di Anestesia e Rianimazione, Policlinico San Martino, IRCCS per l'Oncologia e le Neuroscienze, Genoa, Italy.,Policlinico San Martino, IRCCS per l'Oncologia e Neuroscienze, Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università degli Studi di Genova, Genoa, Italy
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil.,COVID-19 Virus Network from Ministry of Science, Technology, and Innovation, Brazilian Council for Scientific and Technological Development, and Foundation Carlos Chagas Filho Research Support of the State of Rio de Janeiro, Rio de Janeiro, Brazil
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