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Kosari M, Khorvash F, Sayyah MK, Ansari Chaharsoughi M, Najafi A, Momen-Heravi M, Karimian M, Akbari H, Noureddini M, Salami M, Ghaderi A, Amini Mahabadi J, Khamechi SP, Yeganeh S, Banafshe HR. The influence of propolis plus Hyoscyamus niger L. against COVID-19: A phase II, multicenter, placebo-controlled, randomized trial. Phytother Res 2024; 38:400-410. [PMID: 37992760 DOI: 10.1002/ptr.8047] [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: 10/20/2022] [Revised: 08/15/2023] [Accepted: 08/16/2023] [Indexed: 11/24/2023]
Abstract
The incubation period of COVID-19 symptoms, along with the proliferation and high transmission rate of the SARS-CoV-2 virus, is the cause of an uncontrolled epidemic worldwide. Vaccination is the front line of prevention, and antiinflammatory and antiviral drugs are the treatment of this disease. In addition, some herbal therapy approaches can be a good way to deal with this disease. The aim of this study was to evaluate the effect of propolis syrup with Hyoscyamus niger L. extract in hospitalized patients with COVID-19 with acute disease conditions in a double-blinded approach. The study was performed on 140 patients with COVID-19 in a double-blind, randomized, and multicentral approach. The main inclusion criterion was the presence of a severe type of COVID-19 disease. The duration of treatment with syrup was 6 days and 30 CC per day in the form of three meals. On Days 0, 2, 4, and 6, arterial blood oxygen levels, C-reactive protein (CRP), erythrocyte sedimentation rate, and white blood cell, as well as the patient's clinical symptoms such as fever and chills, cough and shortness of breath, chest pain, and other symptoms, were recorded and analyzed. Propolis syrup with H. niger L. significantly reduces cough from the second day, relieving shortness of breath on the fourth day, and significantly reduces CRP, weakness, and lethargy, as well as significantly increased arterial blood oxygen pressure on the sixth day compared to the placebo group (p < 0.05). The results in patients are such that in the most severe conditions of the disease 80% < SpO2 (oxygen saturation), the healing process of the syrup on reducing CRP and increasing arterial blood oxygen pressure from the fourth day is significantly different compared with the placebo group (p < 0.05). The use of syrup is associated with a reduction of 3.6 days in the hospitalization period compared with the placebo group. Propolis syrup with H. niger L. has effectiveness in the viral and inflammatory phases on clinical symptoms and blood parameters and arterial blood oxygen levels of patients with COVID-19. Also, it reduces referrals to the intensive care unit and mortality in hospitalized patients with COVID-19. So, this syrup promises to be an effective treatment in the great challenge of COVID-19.
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Affiliation(s)
- Morteza Kosari
- Physiology Research Center, Institute for Basic Sciences, Kashan University of Medical Sciences, Kashan, Iran
- Department of Biology, Science and Research Branch, Islamic Azad University, Tehran, Iran
| | - Farzin Khorvash
- Department of Infectious Disease, Medical School, Isfahan University of Medical Science, Isfahan, Iran
- Nosocomial Infection Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammad Kazem Sayyah
- Department of Infectious Diseases Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | - Maryam Ansari Chaharsoughi
- Department of Infectious Diseases, Infectious Diseases and Tropical Medicine Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ahmad Najafi
- Department of Infectious Diseases Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | - Mansooreh Momen-Heravi
- Department of Infectious Diseases Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | - Mohammad Karimian
- Department of Molecular and Cell Biology, Faculty of Basic Sciences, University of Mazandaran, Babolsar, Iran
| | - Hossein Akbari
- Social Determinants of Health Research Center, Department of Biostatistics and Epidemiology, School of Public Health, Kashan University of Medical Sciences, Kashan, Iran
| | - Mehdi Noureddini
- Physiology Research Center, Institute for Basic Sciences, Kashan University of Medical Sciences, Kashan, Iran
| | - Mahmoud Salami
- Physiology Research Center, Institute for Basic Sciences, Kashan University of Medical Sciences, Kashan, Iran
| | - Amir Ghaderi
- Department of Addiction Studies, School of Medical, Clinical Research Development Unit-Matini/Kargarnejad Hospital, Kashan University of Medical Sciences, Kashan, Iran
| | - Javad Amini Mahabadi
- Anatomical Research Center, Kashan University of Medical Sciences, Kashan, Iran
- Sarem Fertility and Infertility Research Center, Sarem Women's Hospital, Iran University of Medical Sciences (IUMS), Tehran, Iran
- Sarem Cell Research Center, Sarem Women's Hospital, Tehran, Iran
| | - Seyed Peyman Khamechi
- Department of Persian Medicine, School of Persian Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Somayeh Yeganeh
- Department of Mathematical Sciences, Isfahan University of Technology, Isfahan, Iran
| | - Hamid Reza Banafshe
- Physiology Research Center, Institute for Basic Sciences, Kashan University of Medical Sciences, Kashan, Iran
- Department of Pharmacology, School of Medicine, Kashan University of Medical Sciences, Kashan, Iran
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Di Stefano L, Ogburn EL, Ram M, Scharfstein DO, Li T, Khanal P, Baksh SN, McBee N, Gruber J, Gildea MR, Clark MR, Goldenberg NA, Bennani Y, Brown SM, Buckel WR, Clement ME, Mulligan MJ, O’Halloran JA, Rauseo AM, Self WH, Semler MW, Seto T, Stout JE, Ulrich RJ, Victory J, Bierer BE, Hanley DF, Freilich D. Hydroxychloroquine/chloroquine for the treatment of hospitalized patients with COVID-19: An individual participant data meta-analysis. PLoS One 2022; 17:e0273526. [PMID: 36173983 PMCID: PMC9521809 DOI: 10.1371/journal.pone.0273526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 08/09/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Results from observational studies and randomized clinical trials (RCTs) have led to the consensus that hydroxychloroquine (HCQ) and chloroquine (CQ) are not effective for COVID-19 prevention or treatment. Pooling individual participant data, including unanalyzed data from trials terminated early, enables more detailed investigation of the efficacy and safety of HCQ/CQ among subgroups of hospitalized patients. METHODS We searched ClinicalTrials.gov in May and June 2020 for US-based RCTs evaluating HCQ/CQ in hospitalized COVID-19 patients in which the outcomes defined in this study were recorded or could be extrapolated. The primary outcome was a 7-point ordinal scale measured between day 28 and 35 post enrollment; comparisons used proportional odds ratios. Harmonized de-identified data were collected via a common template spreadsheet sent to each principal investigator. The data were analyzed by fitting a prespecified Bayesian ordinal regression model and standardizing the resulting predictions. RESULTS Eight of 19 trials met eligibility criteria and agreed to participate. Patient-level data were available from 770 participants (412 HCQ/CQ vs 358 control). Baseline characteristics were similar between groups. We did not find evidence of a difference in COVID-19 ordinal scores between days 28 and 35 post-enrollment in the pooled patient population (odds ratio, 0.97; 95% credible interval, 0.76-1.24; higher favors HCQ/CQ), and found no convincing evidence of meaningful treatment effect heterogeneity among prespecified subgroups. Adverse event and serious adverse event rates were numerically higher with HCQ/CQ vs control (0.39 vs 0.29 and 0.13 vs 0.09 per patient, respectively). CONCLUSIONS The findings of this individual participant data meta-analysis reinforce those of individual RCTs that HCQ/CQ is not efficacious for treatment of COVID-19 in hospitalized patients.
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Affiliation(s)
- Leon Di Stefano
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Elizabeth L. Ogburn
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Malathi Ram
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Daniel O. Scharfstein
- Division of Biostatistics, Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah, United States of America
| | - Tianjing Li
- University of Colorado Denver, Anschutz Medical Campus, Denver, Colorado, United States of America
| | - Preeti Khanal
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Sheriza N. Baksh
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Nichol McBee
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Joshua Gruber
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Marianne R. Gildea
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Megan R. Clark
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Neil A. Goldenberg
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
- Johns Hopkins All Children’s Institute for Clinical and Translational Research, Johns Hopkins All Children’s Hospital, St. Petersburg, Florida, United States of America
| | - Yussef Bennani
- Louisiana State University Health Sciences Center, New Orleans, Louisiana, United States of America
- University Medical Center, New Orleans, New Orleans, Louisiana, United States of America
| | - Samuel M. Brown
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, Utah, United States of America
- University of Utah, Salt Lake City, Utah, United States of America
| | - Whitney R. Buckel
- Pharmacy Services, Intermountain Healthcare, Murray, Utah, United States of America
| | - Meredith E. Clement
- Louisiana State University Health Sciences Center, New Orleans, Louisiana, United States of America
- University Medical Center, New Orleans, New Orleans, Louisiana, United States of America
| | - Mark J. Mulligan
- Department of Medicine, Division of Infectious Diseases and Immunology, New York University Grossman School of Medicine, New York, New York, United States of America
- Vaccine Center, New York University Grossman School of Medicine, New York, New York, United States of America
| | - Jane A. O’Halloran
- Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri, United States of America
| | - Adriana M. Rauseo
- Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri, United States of America
| | - Wesley H. Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Matthew W. Semler
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Todd Seto
- Department of Medicine, University of Hawaii John A. Burns School of Medicine, Honolulu, Hawaii, United States of America
| | - Jason E. Stout
- Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina, United States of America
| | - Robert J. Ulrich
- Department of Medicine, Division of Infectious Diseases and Immunology, New York University Grossman School of Medicine, New York, New York, United States of America
| | - Jennifer Victory
- Bassett Research Institute, Bassett Medical Center, Cooperstown, New York, United States of America
| | - Barbara E. Bierer
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Daniel F. Hanley
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Daniel Freilich
- Department of Internal Medicine, Division of Infectious Diseases, Bassett Medical Center, Cooperstown, New York, United States of America
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Identification of Suitable Drug Combinations for Treating COVID-19 Using a Novel Machine Learning Approach: The RAIN Method. Life (Basel) 2022; 12:life12091456. [PMID: 36143492 PMCID: PMC9505329 DOI: 10.3390/life12091456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 09/12/2022] [Accepted: 09/13/2022] [Indexed: 11/29/2022] Open
Abstract
Simple Summary This study follows an improved approach to systematic reviews, called the Systematic Review and Artificial Intelligence Network Meta-Analysis (RAIN), registered within PROSPERO (CRD42021256797), in which, the PRISMA criterion is still considered. Drugs used in the treatment of COVID-19 were searched in the databases of ScienceDirect, Web of Science (WoS), ProQuest, Embase, Medline (PubMed), and Scopus. In addition, using artificial intelligence and the measurement of the p-value between human genes affected by COVID-19 and drugs that have been suggested by clinical experts, and reported within the identified research papers, suitable drug combinations are proposed for the treatment of COVID-19. During the systematic review process, 39 studies were selected. Our analysis shows that most of the reported drugs, such as azithromycin and hydroxyl-chloroquine on their own, do not have much of an effect on the recovery of COVID-19 patients. Based on the result of the new artificial intelligence, on the other hand, at a significance level of less than 0.05, the combination of the two drugs therapeutic corticosteroid + camostat with a significance level of 0.02, remdesivir + azithromycin with a significance level of 0.03, and interleukin 1 receptor antagonist protein + camostat with a significance level 0.02 are considered far more effective for the treatment of COVID-19 and are therefore recommended. Abstract COVID-19 affects several human genes, each with its own p-value. The combination of drugs associated with these genes with small p-values may lead to an estimation of the combined p-value between COVID-19 and some drug combinations, thereby increasing the effectiveness of these combinations in defeating the disease. Based on human genes, we introduced a new machine learning method that offers an effective drug combination with low combined p-values between them and COVID-19. This study follows an improved approach to systematic reviews, called the Systematic Review and Artificial Intelligence Network Meta-Analysis (RAIN), registered within PROSPERO (CRD42021256797), in which, the PRISMA criterion is still considered. Drugs used in the treatment of COVID-19 were searched in the databases of ScienceDirect, Web of Science (WoS), ProQuest, Embase, Medline (PubMed), and Scopus. In addition, using artificial intelligence and the measurement of the p-value between human genes affected by COVID-19 and drugs that have been suggested by clinical experts, and reported within the identified research papers, suitable drug combinations are proposed for the treatment of COVID-19. During the systematic review process, 39 studies were selected. Our analysis shows that most of the reported drugs, such as azithromycin and hydroxyl-chloroquine on their own, do not have much of an effect on the recovery of COVID-19 patients. Based on the result of the new artificial intelligence, on the other hand, at a significance level of less than 0.05, the combination of the two drugs therapeutic corticosteroid + camostat with a significance level of 0.02, remdesivir + azithromycin with a significance level of 0.03, and interleukin 1 receptor antagonist protein + camostat with a significance level 0.02 are considered far more effective for the treatment of COVID-19 and are therefore recommended. Additionally, at a significance level of less than 0.01, the combination of interleukin 1 receptor antagonist protein + camostat + azithromycin + tocilizumab + oseltamivir with a significance level of 0.006, and the combination of interleukin 1 receptor antagonist protein + camostat + chloroquine + favipiravir + tocilizumab7 with corticosteroid + camostat + oseltamivir + remdesivir + tocilizumab at a significant level of 0.009 are effective in the treatment of patients with COVID-19 and are also recommended. The results of this study provide sets of effective drug combinations for the treatment of patients with COVID-19. In addition, the new artificial intelligence used in the RAIN method could provide a forward-looking approach to clinical trial studies, which could also be used effectively in the treatment of diseases such as cancer.
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Formation and activity of NLRP3 inflammasome and histopathological changes in the lung of corpses with COVID-19. J Mol Histol 2022; 53:883-890. [PMID: 36100803 PMCID: PMC9470508 DOI: 10.1007/s10735-022-10101-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Accepted: 09/02/2022] [Indexed: 12/03/2022]
Abstract
COVID-19 is a contagious disease that attacks many organs but the lungs are the main organs affected. The inflammasome activation results in the exacerbation of inflammatory response in infectious disease. The aim of this study is to investigate the formation and activity of the NLRP3 inflammasome complex and the histopathological changes caused by the coronavirus in the lung of deceased persons with COVID-19. In total, 10 corpses; 5 corpses with no history of any infectious diseases and COVID-19 and 5 corpses with the cause of death of COVID-19 were included in this study. Lung tissue samples were harvested during autopsy under safe conditions. Fresh tissues in each group were used to measure the genes expression and proteins level of NLRP3, ASC, Caspase-1, IL-1β, IL-6 and TNF-α and a routine hematoxylin and eosin staining was performed for histological assessment. Data are represented as the means ± SD. Statistical significance difference was accepted at a p-value less than 5%. The NLRP3, ASC, Caspase-1, IL-1β, IL-6 and TNF-α genes expression and proteins level were elevated in the lung of the COVID-19 group in comparison with the control group. Histological findings presented the increasing number of polymorphonuclear leukocytes, macrophages and also pulmonary fibrosis in the lungs of corpses with the cause of death of COVID-19. High expression of NLRP3 inflammasome components and its relation with the pathophysiology of the coronavirus-infected lung suggested that targeting the NLRP3 inflammasome could be helpful in achieving a more effective treatment in patients with COVID-19.
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Nepali K, Sharma R, Sharma S, Thakur A, Liou JP. Beyond the vaccines: a glance at the small molecule and peptide-based anti-COVID19 arsenal. J Biomed Sci 2022; 29:65. [PMID: 36064696 PMCID: PMC9444709 DOI: 10.1186/s12929-022-00847-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 08/16/2022] [Indexed: 02/08/2023] Open
Abstract
Unprecedented efforts of the researchers have been witnessed in the recent past towards the development of vaccine platforms for the control of the COVID-19 pandemic. Albeit, vaccination stands as a practical strategy to prevent SARS-CoV-2 infection, supplementing the anti-COVID19 arsenal with therapeutic options such as small molecules/peptides and antibodies is being conceived as a prudent strategy to tackle the emerging SARS-CoV-2 variants. Noteworthy to mention that collective efforts from numerous teams have led to the generation of a voluminous library composed of chemically and mechanistically diverse small molecules as anti-COVID19 scaffolds. This review article presents an overview of medicinal chemistry campaigns and drug repurposing programs that culminated in the identification of a plethora of small molecule-based anti-COVID19 drugs mediating their antiviral effects through inhibition of proteases, S protein, RdRp, ACE2, TMPRSS2, cathepsin and other targets. In light of the evidence ascertaining the potential of small molecule drugs to approach conserved proteins required for the viral replication of all coronaviruses, accelerated FDA approvals are anticipated for small molecules for the treatment of COVID19 shortly. Though the recent attempts invested in this direction in pursuit of enrichment of the anti-COVID-19 armoury (chemical tools) are praiseworthy, some strategies need to be implemented to extract conclusive benefits of the recently reported small molecule viz. (i) detailed preclinical investigation of the generated anti-COVID19 scaffolds (ii) in-vitro profiling of the inhibitors against the emerging SARS-CoV-2 variants (iii) development of assays enabling rapid screening of the libraries of anti-COVID19 scaffold (iv) leveraging the applications of machine learning based predictive models to expedite the anti-COVID19 drug discovery campaign (v) design of antibody-drug conjugates.
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Affiliation(s)
- Kunal Nepali
- School of Pharmacy, College of Pharmacy, Taipei Medical University, 250 Wuxing Street, Taipei, 11031, Taiwan
- TMU Research Center for Drug Discovery, Taipei Medical University, Taipei, 11031, Taiwan
| | - Ram Sharma
- School of Pharmacy, College of Pharmacy, Taipei Medical University, 250 Wuxing Street, Taipei, 11031, Taiwan
| | - Sachin Sharma
- School of Pharmacy, College of Pharmacy, Taipei Medical University, 250 Wuxing Street, Taipei, 11031, Taiwan
| | - Amandeep Thakur
- School of Pharmacy, College of Pharmacy, Taipei Medical University, 250 Wuxing Street, Taipei, 11031, Taiwan
| | - Jing-Ping Liou
- School of Pharmacy, College of Pharmacy, Taipei Medical University, 250 Wuxing Street, Taipei, 11031, Taiwan.
- TMU Research Center for Drug Discovery, Taipei Medical University, Taipei, 11031, Taiwan.
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Di Stefano L, Ogburn EL, Ram M, Scharfstein DO, Li T, Khanal P, Baksh SN, McBee N, Gruber J, Gildea MR, Clark MR, Goldenberg NA, Bennani Y, Brown SM, Buckel WR, Clement ME, Mulligan MJ, O’Halloran JA, Rauseo AM, Self WH, Semler MW, Seto T, Stout JE, Ulrich RJ, Victory J, Bierer BE, Hanley DF, Freilich D. Hydroxychloroquine/chloroquine for the treatment of hospitalized patients with COVID-19: An individual participant data meta-analysis. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2022:2022.01.10.22269008. [PMID: 35043124 PMCID: PMC8764733 DOI: 10.1101/2022.01.10.22269008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background Results from observational studies and randomized clinical trials (RCTs) have led to the consensus that hydroxychloroquine (HCQ) and chloroquine (CQ) are not effective for COVID-19 prevention or treatment. Pooling individual participant data, including unanalyzed data from trials terminated early, enables more detailed investigation of the efficacy and safety of HCQ/CQ among subgroups of hospitalized patients. Methods We searched ClinicalTrials.gov in May and June 2020 for US-based RCTs evaluating HCQ/CQ in hospitalized COVID-19 patients in which the outcomes defined in this study were recorded or could be extrapolated. The primary outcome was a 7-point ordinal scale measured between day 28 and 35 post enrollment; comparisons used proportional odds ratios. Harmonized de-identified data were collected via a common template spreadsheet sent to each principal investigator. The data were analyzed by fitting a prespecified Bayesian ordinal regression model and standardizing the resulting predictions. Results Eight of 19 trials met eligibility criteria and agreed to participate. Patient-level data were available from 770 participants (412 HCQ/CQ vs 358 control). Baseline characteristics were similar between groups. We did not find evidence of a difference in COVID-19 ordinal scores between days 28 and 35 post-enrollment in the pooled patient population (odds ratio, 0.97; 95% credible interval, 0.76-1.24; higher favors HCQ/CQ), and found no convincing evidence of meaningful treatment effect heterogeneity among prespecified subgroups. Adverse event and serious adverse event rates were numerically higher with HCQ/CQ vs control (0.39 vs 0.29 and 0.13 vs 0.09 per patient, respectively). Conclusions The findings of this individual participant data meta-analysis reinforce those of individual RCTs that HCQ/CQ is not efficacious for treatment of COVID-19 in hospitalized patients.
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Affiliation(s)
- Leon Di Stefano
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Elizabeth L. Ogburn
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Malathi Ram
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Daniel O. Scharfstein
- Division of Biostatistics, Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah
| | - Tianjing Li
- University of Colorado Denver, Anschutz Medical Campus, Denver, Colorado
| | - Preeti Khanal
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Sheriza N. Baksh
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Nichol McBee
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Joshua Gruber
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Marianne R. Gildea
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, Maryland
- Current address: FHI 360, Durham, North Carolina
| | - Megan R. Clark
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Neil A. Goldenberg
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
- Johns Hopkins All Children’s Institute for Clinical and Translational Research, Johns Hopkins All Children’s Hospital, St. Petersburg, Florida
| | - Yussef Bennani
- Louisiana State University Health Sciences Center, New Orleans, Louisiana
- University Medical Center, New Orleans, New Orleans, Louisiana
| | - Samuel M. Brown
- Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center, Murray, Utah
- University of Utah, Salt Lake City, Utah
| | | | - Meredith E. Clement
- Louisiana State University Health Sciences Center, New Orleans, Louisiana
- University Medical Center, New Orleans, New Orleans, Louisiana
| | - Mark J. Mulligan
- Department of Medicine, Division of Infectious Diseases and Immunology, New York University Grossman School of Medicine, New York, New York
- Vaccine Center, New York University Grossman School of Medicine, New York, New York
| | - Jane A. O’Halloran
- Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri
| | - Adriana M. Rauseo
- Department of Medicine, Washington University School of Medicine, Saint Louis, Missouri
| | - Wesley H. Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew W. Semler
- Division of Allergy, Pulmonary and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Todd Seto
- Department of Medicine, University of Hawaii John A. Burns School of Medicine, Honolulu, Hawaii
| | - Jason E. Stout
- Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina
| | - Robert J. Ulrich
- Department of Medicine, Division of Infectious Diseases and Immunology, New York University Grossman School of Medicine, New York, New York
| | - Jennifer Victory
- Bassett Research Institute, Bassett Medical Center, Cooperstown, New York
| | - Barbara E. Bierer
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Daniel F. Hanley
- Division of Brain Injury Outcomes, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Daniel Freilich
- Department of Internal Medicine, Division of Infectious Diseases, Bassett Medical Center, Cooperstown, New York
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Abdel Moneim A, Radwan MA, Yousef AI. COVID-19 and cardiovascular disease: manifestations, pathophysiology, vaccination, and long-term implication. Curr Med Res Opin 2022; 38:1071-1079. [PMID: 35575011 DOI: 10.1080/03007995.2022.2078081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic is caused by a new coronavirus family member, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and is linked with many disease manifestations in multiple organ systems on top of pulmonary manifestations. COVID-19 is also accompanied by several cardiovascular pathologies including myocarditis, acute myocardial infarction, stress cardiomyopathy, arterial and venous thromboembolism, pericarditis, and arrhythmias. The pathophysiological mechanisms explaining these clinical symptoms are multifactorial including systemic inflammation (cytokine storm), coagulopathy, direct viral invasion through angiotensin-converting enzyme 2, hypoxemia, electrolyte imbalance, and fever. Several case reports have shown the development of an unusual cardiovascular event after receiving SARS-CoV-2 vaccines. The current article aimed to review cardiovascular involvement in the COVID-19 pandemic with respect to clinical features, pathogenesis, long-term effects, and the adverse effects of treatments and vaccines based on the latest evidence.
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Affiliation(s)
- Adel Abdel Moneim
- Molecular Physiology Division, Faculty of Science, Beni-Suef University, Egypt
| | - Marwa A Radwan
- Molecular Physiology Division, Faculty of Science, Beni-Suef University, Egypt
| | - Ahmed I Yousef
- Molecular Physiology Division, Faculty of Science, Beni-Suef University, Egypt
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Liao ZM, Zhang ZM, Liu Q. Hydroxychloroquine/chloroquine and the risk of acute kidney injury in COVID-19 patients: a systematic review and meta-analysis. Ren Fail 2022; 44:415-425. [PMID: 35253579 PMCID: PMC8903764 DOI: 10.1080/0886022x.2022.2046609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Objectives Hydroxychloroquine/chloroquine has been widely used as part of the standard treatment for patients with coronavirus disease 2019 (COVID-19). We conducted a systematic review and meta-analysis to determine whether hydroxychloroquine/chloroquine increases the risk of acute kidney injury (AKI) in COVID-19 patients. Methods PubMed and Embase were searched for related publications from inception to Dec 31, 2021, including randomized controlled trials (RCTs) and non-randomized studies of interventions (NRSIs) comparing the risk of AKI and/or increased creatinine in COVID-19 patients receiving hydroxychloroquine/chloroquine and other controls (active treatment and placebo). We conducted separate meta-analyses for RCTs and NRSIs based on fixed-effect model, with odds ratios (ORs) being considered as effect sizes. Results We included 21 studies in the analysis, with 12 were RCTs. Based on the RCTs, compared to placebo, the OR was 1.19 (95% confidence interval [CI]: 0.86, 1.64; p = .30, n = 4, moderate quality) for AKI and 1.00 (95%CI: 0.64, 1.56; p = .99, n = 5, moderate quality) for increased creatinine for patients received hydroxychloroquine/chloroquine treatment; compared to active treatment, the odds was 1.28 (95%CI: 0.65, 2.53; p = .47, n = 2, low quality) for AKI and 0.64 (95%CI: 0.13, 3.20; p = .59, n = 1, low quality) for increased creatine. Evidence from NRSIs showed slightly increased odds of AKI, with low quality. Conclusion Based on current available studies which were graded as low to moderate quality, there is insufficient evidence to conclude that hydroxychloroquine/chloroquine use is associated with increased risk of AKI or raised creatinine. Abbreviations: AKI: acute kidney injury; COVID-19: Coronavirus Disease 2019; RCT: randomized controlled trials; NRSI: non-randomized studies of interventions; OR: odds ratios; ROBIS-I: Risk Of Bias In Non-randomized Studies – of Interventions
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Affiliation(s)
- Zheng-Ming Liao
- Department of Urology, Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan, China
| | - Zhong-Min Zhang
- Affiliated Hospital of Hubei University of Chinese Medicine, Wuhan, China
| | - Qi Liu
- Hubei Province Academy of Traditional Chinese Medicine, Wuhan, China
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Gupta T, Thakkar P, Kalra B, Kannan S. Hydroxychloroquine in the treatment of coronavirus disease 2019: Rapid updated systematic review and meta-analysis. Rev Med Virol 2022; 32:e2276. [PMID: 34245622 PMCID: PMC8420202 DOI: 10.1002/rmv.2276] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 06/30/2021] [Accepted: 07/03/2021] [Indexed: 12/15/2022]
Abstract
Coronavirus disease 2019 (COVID-19) caused by the novel severe acute respiratory syndrome coronavirus 2 continues to grow and spread throughout the world since being declared a pandemic. Despite extensive scientific research globally including repurposing of several existing drugs, there is no effective or proven therapy for this enigmatic disease which is still largely managed empirically This systematic review evaluated the role of hydroxychloroquine (HCQ) in the treatment of COVID-19 infection and was conducted using Cochrane methodology for systematic reviews of interventional studies including risk of bias assessment and grading of the quality of evidence. Only prospective clinical trials randomly assigning COVID-19 patients to HCQ plus standard of care therapy (test arm) versus placebo/standard of care (control arm) were included. Data were pooled using the random-effects model and expressed as risk ratio (RR) with 95% confidence interval (CI). A total of 10,492 patients from 19 randomised controlled trials were included. The use of HCQ was not associated with higher rates of clinical improvement (RR = 1.00, 95% CI: 0.96-1.03, p = 0.79) or reduction in all-cause mortality by Day14 (RR = 1.07, 95% CI: 0.97-1.19, p = 0.19) or Day28 (RR = 1.08, 95% CI: 0.99-1.19, p = 0.09) compared to placebo/standard of care. There was no significant difference in serious adverse events between the two arms (RR = 1.01, 95% CI: 0.85-1.19, p = 0.95). There is low-to-moderate certainty evidence that HCQ therapy is generally safe but does not reduce mortality or enhance recovery in patients with COVID-19 infection.
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Affiliation(s)
- Tejpal Gupta
- Department of Radiation OncologyClinical Research CentreAdvanced Centre for Treatment Research & Education in Cancer (ACTREC)Tata Memorial CentreHomi Bhabha National Institute (HBNI)KhargharNavi MumbaiIndia
| | - Prafulla Thakkar
- Division of Internal MedicineClinical Research CentreAdvanced Centre for Treatment Research & Education in Cancer (ACTREC)Tata Memorial CentreHomi Bhabha National Institute (HBNI)KhargharNavi MumbaiIndia
| | - Babusha Kalra
- Department of Radiation OncologyClinical Research CentreAdvanced Centre for Treatment Research & Education in Cancer (ACTREC)Tata Memorial CentreHomi Bhabha National Institute (HBNI)KhargharNavi MumbaiIndia
| | - Sadhana Kannan
- Clinical Research SecretariatClinical Research CentreAdvanced Centre for Treatment Research & Education in Cancer (ACTREC)Tata Memorial CentreHomi Bhabha National Institute (HBNI)KhargharNavi MumbaiIndia
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Peltan ID, Caldwell E, Admon AJ, Attia EF, Gundel SJ, Mathews KS, Nagrebetsky A, Sahetya SK, Ulysse C, Brown SM, Chang SY, Goodwin AJ, Hope AA, Iwashyna TJ, Johnson NJ, Lanspa MJ, Richardson LD, Vranas KC, Angus DC, Baron RM, Haaland BA, Hayden DL, Thompson BT, Rice TW, Hough CL. Characteristics and Outcomes of US Patients Hospitalized With COVID-19. Am J Crit Care 2022; 31:146-157. [PMID: 34709373 PMCID: PMC8891038 DOI: 10.4037/ajcc2022549] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Understanding COVID-19 epidemiology is crucial to clinical care and to clinical trial design and interpretation. OBJECTIVE To describe characteristics, treatment, and outcomes among patients hospitalized with COVID-19 early in the pandemic. METHODS A retrospective cohort study of consecutive adult patients with laboratory-confirmed, symptomatic SARS-CoV-2 infection admitted to 57 US hospitals from March 1 to April 1, 2020. RESULTS Of 1480 inpatients with COVID-19, median (IQR) age was 62.0 (49.4-72.9) years, 649 (43.9%) were female, and 822 of 1338 (61.4%) were non-White or Hispanic/Latino. Intensive care unit admission occurred in 575 patients (38.9%), mostly within 4 days of hospital presentation. Respiratory failure affected 583 patients (39.4%), including 284 (19.2%) within 24 hours of hospital presentation and 413 (27.9%) who received invasive mechanical ventilation. Median (IQR) hospital stay was 8 (5-15) days overall and 15 (9-24) days among intensive care unit patients. Hospital mortality was 17.7% (n = 262). Risk factors for hospital death identified by penalized multivariable regression included older age; male sex; comorbidity burden; symptoms-to-admission interval; hypotension; hypoxemia; and higher white blood cell count, creatinine level, respiratory rate, and heart rate. Of 1218 survivors, 221 (18.1%) required new respiratory support at discharge and 259 of 1153 (22.5%) admitted from home required new health care services. CONCLUSIONS In a geographically diverse early-pandemic COVID-19 cohort with complete hospital folllow-up, hospital mortality was associated with older age, comorbidity burden, and male sex. Intensive care unit admissions occurred early and were associated with protracted hospital stays. Survivors often required new health care services or respiratory support at discharge.
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Affiliation(s)
- Ithan D. Peltan
- assistant professor, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Intermountain Medical Center, Murray, Utah, and an adjunct assistant professor, Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City
| | - Ellen Caldwell
- data analyst/biostatistician, Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle
| | - Andrew J. Admon
- clinical instructor, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan School of Medicine, Ann Arbor
| | - Engi F. Attia
- assistant professor, Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington
| | - Stephanie J. Gundel
- research coordinator, Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington
| | - Kusum S. Mathews
- assistant professor, Division of Pulmonary and Critical Care Medicine, Department of Medicine and Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Alexander Nagrebetsky
- assistant professor, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Sarina K. Sahetya
- assistant professor, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christine Ulysse
- statistician, Division of Biostatistics, Department of Medicine, Massachusetts General Hospital
| | - Samuel M. Brown
- professor, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Intermountain Medical Center, and Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Utah School of Medicine
| | - Steven Y. Chang
- professor, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Ronald Reagan UCLA Medical Center, David Geffen School of Medicine at University of California, Los Angeles (UCLA)
| | - Andrew J. Goodwin
- professor, Division of Pulmonary, Critical Care, Allergy, and Sleep Medicine, Department of Medicine, Medical University of South Carolina, Charleston
| | - Aluko A. Hope
- associate professor, Division of Critical Care Medicine, Department of Medicine, Montefiore Medical Center and Albert Einstein School of Medicine, Bronx, New York
| | - Theodore J. Iwashyna
- professor, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Michigan School of Medicine, and Veterans Affairs (VA) Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Nicholas J. Johnson
- associate professor, Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, and Department of Emergency Medicine, University of Washington
| | - Michael J. Lanspa
- associate professor, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Intermountain Medical Center, and Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Utah School of Medicine
| | - Lynne D. Richardson
- professor, Departments of Emergency Medicine and Population Health Sciences, and codirector, Institute for Health Equity Research, Icahn School of Medicine at Mount Sinai
| | - Kelly C. Vranas
- assistant professor, Center to Improve Veteran Involvement in Care, VA Portland Health Care System, Portland, Oregon, and Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health and Science University, Portland
| | - Derek C. Angus
- professor and chair, Department of Critical Care Medicine, University of Pittsburgh Medical Center and University of Pittsburgh Schools of the Health Sciences, Pittsburgh, Pennsylvania
| | - Rebecca M. Baron
- associate professor, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston
| | - Benjamin A. Haaland
- associate professor, Department of Population Health Sciences, University of Utah School of Medicine
| | - Douglas L. Hayden
- assistant professor, Division of Biostatistics, Department of Medicine, Massachusetts General Hospital
| | - B. Taylor Thompson
- professor, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital and Harvard Medical School
| | - Todd W. Rice
- associate professor, Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Catherine L. Hough
- professor and chief, Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Oregon Health and Science University
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11
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Yogendrakumar V, Dewar B, McGuinty M, Dowlatshahi D, Dyason C, Kwok ES, Ramsay T, Lund H, Shamy M. Many trials of hydroxychloroquine for SARS-CoV-2 were redundant and potentially unethical: an analysis of the NIH clinical trials registry. J Clin Epidemiol 2022; 143:73-80. [PMID: 34780978 PMCID: PMC8590481 DOI: 10.1016/j.jclinepi.2021.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 10/29/2021] [Accepted: 11/06/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE We sought to map the landscape of trials investigating hydroxychloroquine (HCQ) for SARS-CoV-2 in order to draw conclusions about how clinical trials have been conducted in the pandemic environment and offer potential regulatory recommendations. STUDY DESIGN AND SETTING We identified and captured data related to registered studies using HCQ to treat SARS-CoV-2 registered with the publicly available National Institutes of Health (NIH) Clinical Trials Registry between February and November 2020. RESULTS Between February and November 2020, 206 studies investigating HCQ in SARS-CoV-2 were registered with the NIH Clinical Trials Registry. As of November 2020, 135 studies were listed as ongoing, 22 have been completed, and 46 are either suspended or have been terminated. Reasons for suspension or termination included difficulties with patient recruitment (n = 9), emerging evidence showing a lack of benefit of HCQ (n = 7), and recommendations by regulatory boards to discontinue (n = 10). CONCLUSION Many clinical trials of HCQ were launched in the first months of the pandemic, and a significant proportion of them remained active as of November 2020. The medical community appears to have responded very quickly to political interest in HCQ, while responding much more slowly to the evolving medical evidence of its lack of efficacy.
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Affiliation(s)
- Vignan Yogendrakumar
- Department of Medicine, The Ottawa Hospital, University of Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada
| | - Brian Dewar
- Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada.
| | - Michaeline McGuinty
- Department of Medicine, The Ottawa Hospital, University of Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada
| | - Dar Dowlatshahi
- Department of Medicine, The Ottawa Hospital, University of Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada
| | - Claire Dyason
- Department of Medicine, The Ottawa Hospital, University of Ottawa, Ontario, Canada
| | - Edmond Sh Kwok
- Department of Emergency Medicine, The Ottawa Hospital, Ontario, Canada
| | - Tim Ramsay
- Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada; Ottawa Methods Center, University of Ottawa, Ontario, Canada
| | - Hans Lund
- Section of Evidence-Based Practice, Western Norway University of Applied Sciences, Bergen, Norway
| | - Michel Shamy
- Department of Medicine, The Ottawa Hospital, University of Ottawa, Ontario, Canada; Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada
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12
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Wüstner S, Hogger S, Gartner-Freyer D, Lebioda A, Schley K, Leverkus F. Clinical Evidence Informing Treatment Guidelines on Repurposed Drugs for Hospitalized Patients During the Early COVID-19 Pandemic: Corticosteroids, Anticoagulants, (Hydroxy)chloroquine. Front Public Health 2022; 10:804404. [PMID: 35252090 PMCID: PMC8896497 DOI: 10.3389/fpubh.2022.804404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 01/24/2022] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION In early 2020, the coronavirus disease 2019 (COVID-19) pandemic spread worldwide, overwhelming hospitals with severely ill patients and posing the urgent need for clinical evidence to guide patient care. First treatment options available were repurposed drugs to fight inflammation, coagulopathy, and viral replication. A vast number of clinical studies were launched globally to test their efficacy and safety. Our analysis describes the development of global evidence on repurposed drugs, in particular corticosteroids, anticoagulants, and (hydroxy)chloroquine in hospitalized COVID-19 patients based on different study types. We track the incorporation of clinical data in international and national treatment guidelines and identify factors that characterize studies and analyses with the greatest impact on treatment recommendations. METHODS A literature search in MEDLINE was conducted to assess the clinical evidence on treatment with corticosteroids, anticoagulants, and (hydroxy)chloroquine in hospitalized COVID-19 patients during the first year of the pandemic. Adoption of the evidence from this clinical data in treatment guidelines of the World Health Organization (WHO), Germany, and United States (US) was evaluated over time. RESULTS We identified 106 studies on corticosteroids, 141 studies on anticoagulants, and 115 studies on (hydroxy)chloroquine. Most studies were retrospective cohort studies; some were randomized clinical trials (RCTs), and a few were platform trials. These studies were compared to studies directly and indirectly referred to in WHO (7 versions), German (5 versions), and US (21 versions) guidelines. We found that initially large, well-adjusted, mainly retrospective cohort studies and ultimately large platform trials or coordinated meta-analyses of RCTs provided best available clinical evidence supporting treatment recommendations. DISCUSSION Particularly early in the pandemic, evidence for the efficacy and safety of repurposed drugs was of low quality, since time and scientific rigor seemed to be competing factors. Pandemic preparedness, coordinated efforts, and combined analyses were crucial to generating timely and robust clinical evidence that informed national and international treatment guidelines on corticosteroids, anticoagulants, and (hydroxy)chloroquine. Multi-arm platform trials with master protocols and coordinated meta-analyses proved particularly successful, with researchers joining forces to answer the most pressing questions as quickly as possible.
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Affiliation(s)
| | - Sara Hogger
- AMS Advanced Medical Services GmbH, Munich, Germany
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Vegivinti CTR, Evanson KW, Lyons H, Akosman I, Barrett A, Hardy N, Kane B, Keesari PR, Pulakurthi YS, Sheffels E, Balasubramanian P, Chibbar R, Chittajallu S, Cowie K, Karon J, Siegel L, Tarchand R, Zinn C, Gupta N, Kallmes KM, Saravu K, Touchette J. Efficacy of antiviral therapies for COVID-19: a systematic review of randomized controlled trials. BMC Infect Dis 2022; 22:107. [PMID: 35100985 PMCID: PMC8802260 DOI: 10.1186/s12879-022-07068-0] [Citation(s) in RCA: 51] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 01/14/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) continues to pose a significant threat to public health worldwide. The purpose of this study was to review current evidence obtained from randomized clinical trials on the efficacy of antivirals for COVID-19 treatment. METHODS A systematic literature search was performed using PubMed to identify randomized controlled trials published up to September 4, 2021 that examined the efficacy of antivirals for COVID-19 treatment. Studies that were not randomized controlled trials or that did not include treatment of COVID-19 with approved antivirals were excluded. Risk of bias was assessed using the Scottish Intercollegiate Guidelines Network (SIGN) method. Due to study heterogeneity, inferential statistics were not performed and data were expressed as descriptive statistics. RESULTS Of the 2,284 articles retrieved, 31 (12,440 patients) articles were included. Overall, antivirals were more effective when administered early in the disease course. No antiviral treatment demonstrated efficacy at reducing COVID-19 mortality. Sofosbuvir/daclatasvir results suggested clinical improvement, although statistical power was low. Remdesivir exhibited efficacy in reducing time to recovery, but results were inconsistent across trials. CONCLUSIONS Although select antivirals have exhibited efficacy to improve clinical outcomes in COVID-19 patients, none demonstrated efficacy in reducing mortality. Larger RCTs are needed to conclusively establish efficacy.
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Affiliation(s)
- Charan Thej Reddy Vegivinti
- Department of Internal Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, 1400 Pelham Pkwy S, Bronx, NY, USA
| | - Kirk W Evanson
- Superior Medical Experts, 1425 Minnehaha Ave E, P.O. Box 6000545, St Paul, MN, 55106, USA
| | - Hannah Lyons
- Nested Knowledge, 1430 Avon Street N, Saint Paul, MN, 55117, USA
- Ohio University Heritage College of Osteopathic Medicine, 6775 Bobcat Way, Dublin, OH, 43016, USA
| | - Izzet Akosman
- Nested Knowledge, 1430 Avon Street N, Saint Paul, MN, 55117, USA
- Weill Cornell Medical College, 1300 York Ave, New York, NY, 10065, USA
| | - Averi Barrett
- Nested Knowledge, 1430 Avon Street N, Saint Paul, MN, 55117, USA
| | - Nicole Hardy
- Nested Knowledge, 1430 Avon Street N, Saint Paul, MN, 55117, USA
| | - Bernadette Kane
- Superior Medical Experts, 1425 Minnehaha Ave E, P.O. Box 6000545, St Paul, MN, 55106, USA
| | - Praneeth Reddy Keesari
- Kamineni Academy of Medical Sciences and Research Center, Hyderabad, Telangana, 500068, India
| | | | - Erin Sheffels
- Superior Medical Experts, 1425 Minnehaha Ave E, P.O. Box 6000545, St Paul, MN, 55106, USA.
| | - Prasanth Balasubramanian
- Department of Internal Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, 1400 Pelham Pkwy S, Bronx, NY, USA
| | - Richa Chibbar
- Department of Medicine, Lakeridge Health, 1 Hospital Crt, Oshawa, ON, L1G 2B9, Canada
| | | | - Kathryn Cowie
- Nested Knowledge, 1430 Avon Street N, Saint Paul, MN, 55117, USA
| | - J Karon
- Nested Knowledge, 1430 Avon Street N, Saint Paul, MN, 55117, USA
| | - Lauren Siegel
- Nested Knowledge, 1430 Avon Street N, Saint Paul, MN, 55117, USA
| | - Ranita Tarchand
- Nested Knowledge, 1430 Avon Street N, Saint Paul, MN, 55117, USA
| | - Caleb Zinn
- Nested Knowledge, 1430 Avon Street N, Saint Paul, MN, 55117, USA
| | - Nitin Gupta
- Department of Infectious Disease, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
- Manipal Center for Infectious Diseases, Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Kevin M Kallmes
- Nested Knowledge, 1430 Avon Street N, Saint Paul, MN, 55117, USA
| | - Kavitha Saravu
- Department of Infectious Disease, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
- Manipal Center for Infectious Diseases, Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Jillienne Touchette
- Superior Medical Experts, 1425 Minnehaha Ave E, P.O. Box 6000545, St Paul, MN, 55106, USA
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Alunno A, Najm A, Machado PM, Bertheussen H, Burmester GRR, Carubbi F, De Marco G, Giacomelli R, Hermine O, Isaacs JD, Koné-Paut I, Magro-Checa C, McInnes IB, Meroni PL, Quartuccio L, Ramanan AV, Ramos-Casals M, Rodríguez Carrio J, Schulze-Koops H, Stamm TA, Tas SW, Terrier B, McGonagle DG, Mariette X. 2021 update of the EULAR points to consider on the use of immunomodulatory therapies in COVID-19. Ann Rheum Dis 2022; 81:34-40. [PMID: 34620584 PMCID: PMC8507408 DOI: 10.1136/annrheumdis-2021-221366] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 09/29/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To update the EULAR points to consider (PtCs) on the use of immunomodulatory therapies in COVID-19. METHODS According to the EULAR standardised operating procedures, a systematic literature review up to 14 July 2021 was conducted and followed by a consensus meeting of an international multidisciplinary task force. The new statements were consolidated by formal voting. RESULTS We updated 2 overarching principles and 12 PtC. Evidence was only available in moderate to severe and critical patients. Glucocorticoids alone or in combination with tocilizumab are beneficial in COVID-19 cases requiring oxygen therapy and in critical COVID-19. Use of Janus kinase inhibitors (baricitinib and tofacitinib) is promising in the same populations of severe and critical COVID-19. Anti-SARS-CoV-2 monoclonal antibodies and convalescent plasma may find application in early phases of the disease and in selected subgroups of immunosuppressed patients. There was insufficient robust evidence for the efficacy of other immunomodulators with further work being needed in relation to biomarker-based stratification for IL-1 therapy CONCLUSIONS: Growing evidence supports incremental efficacy of glucocorticoids alone or combined with tocilizumab/Janus kinase inhibitors in moderate to severe and critical COVID-19. Ongoing studies may unmask the potential application of other therapeutic approaches. Involvement of rheumatologists, as systemic inflammatory diseases experts, should be encouraged in clinical trials of immunomodulatory therapy in COVID-19.
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Affiliation(s)
- Alessia Alunno
- Internal Medicine and Nephrology Unit, Department of Life, Health & Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Aurélie Najm
- Institute of Infection, Immunity and Inflammation, College of Medical Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Pedro M Machado
- Centre for Rheumatology and Department of Neuromuscular Diseases, University College London, London, UK
- National Institute for Health Research (NIHR) University College London Hospitals (UCLH) Biomedical Research Centre (BRC), University College London Hospitals NHS Foundation Trust, London, UK
- Department of Rheumatology, Northwick Park Hospital, London North West University Healthcare NHS Trust, London, UK
| | | | - Gerd-Rüdiger R Burmester
- Department of Rheumatology and Clinical Immunology, Charité - Universitätsmedizin Berlin, Freie Universität und Humboldt-Universität Berlin, Berlin, Germany
| | - Francesco Carubbi
- Internal Medicine and Nephrology Unit, Department of Life, Health & Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Gabriele De Marco
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds & The NIHR Leeds Biomedical Research Centre, Chapel Allerton Hospital, Leeds, UK
| | - Roberto Giacomelli
- Rheumatology and Clinical Immunology Unit, University of Rome "Campus Biomedico" School of Medicine, Rome, Italy
| | - Olivier Hermine
- Department of Hematology, Hôpital Necker, Assistance Publique - Hôpitaux de Paris, Paris, France
- Institut Imagine, Université de Paris, INSERM UMR1183, Paris, France
| | - John D Isaacs
- Translational and Clinical Research Institute, Newcastle University and Musculoskeletal Unit, Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Isabelle Koné-Paut
- Department of Paediatric Rheumatology, Reference Centre for Autoinflammatory Diseases and Amyloidosis (CEREMAIA), Bicêtre University Hospital, AP-HP, Le Kremlin-Bicetre, France
- University of Paris Sud Saclay, Paris, France
| | - César Magro-Checa
- Department of Rheumatology, Zuyderland Medical Centre Heerlen, Heerlen, Netherlands
| | - Iain B McInnes
- Institute of Infection, Immunity and Inflammation, College of Medical Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Pier Luigi Meroni
- Experimental Laboratory of Immunological and Rheumatologic Researches, Istituto Auxologico Italiano IRCCS, Milano, Italy
| | - Luca Quartuccio
- Department of Medicine, Rheumatology Clinic, University of Udine, ASUFC Udine, Udine, Italy
| | - A V Ramanan
- University Hospitals Bristol NHS Foundations Trust, Bristol, UK
- Translational Health Sciences, University of Bristol, Bristol, UK
| | - Manuel Ramos-Casals
- Department of Autoimmune Diseases, ICMiD, Laboratory of Autoimmune Diseases Josep Font, IDIBAPS-CELLEX, Department of Autoimmune Diseases, ICMiD, University of Barcelona, Hospital Clínic, Barcelona, Spain
| | - Javier Rodríguez Carrio
- Department of Functional Biology, Immunology Area, Faculty of Medicine, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), University of Oviedo, Oviedo, Spain
| | - Hendrik Schulze-Koops
- Division of Rheumatology and Clinical Immunology, Department of Internal Medicine IV, Ludwig-Maximilians University Munich, Munich, Germany
| | - Tanja A Stamm
- Section for Outcomes Research, Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna and Ludwig Boltzmann Institute for Arthritis and Rehabilitation, Wien, Austria
| | - Sander W Tas
- Department of Rheumatology and Clinical Immunology, Amsterdam Rheumatology and immunology Center, Amsterdam University Medical Centres, AMC/University of Amsterdam, Amsterdam, Netherlands
| | - Benjamin Terrier
- Department of Internal Medicine, Cochin University Hospital, Paris, France; National Referral Centre for Systemic and Autoimmune Diseases, University Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Dennis G McGonagle
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds & The NIHR Leeds Biomedical Research Centre, Chapel Allerton Hospital, Leeds, UK
| | - Xavier Mariette
- Department of Rheumatology, INSERM UMR1184, Le Kremlin Bicêtre, France
- Department of Rheumatology, Université Paris-Saclay, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, INSERM UMR1184, Le Kremlin Bicêtre, France
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Crichton ML, Goeminne PC, Tuand K, Vandendriessche T, Tonia T, Roche N, Chalmers JD. The impact of therapeutics on mortality in hospitalised patients with COVID-19: systematic review and meta-analyses informing the European Respiratory Society living guideline. Eur Respir Rev 2021; 30:210171. [PMID: 34911695 PMCID: PMC8796659 DOI: 10.1183/16000617.0171-2021] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 09/08/2021] [Indexed: 12/15/2022] Open
Abstract
Hospitalised patients with coronavirus disease 2019 (COVID-19) have a high mortality rate. There are an increasing number of published randomised controlled trials for anti-inflammatory, anti-viral and other treatments. The European Respiratory Society Living Guidelines for the Management of Hospitalised Adults with COVID-19 were published recently, providing recommendations on appropriate pharmacotherapy.Patient, Intervention, Comparator and Outcomes questions for key interventions were identified by an international panel and systematic reviews were conducted to identify randomised controlled trials meeting the inclusion criteria. The importance of end-points were rated, and mortality was identified as the key "critical" outcome for all interventions. Random-effects meta-analysis was used to pool studies and provide effect estimates for the impact of treatments on mortality.Corticosteroids, hydroxychloroquine, azithromycin, remdesivir, anti-interleukin (IL)-6 monoclonal antibodies, colchicine, lopinavir/ritonavir and interferon-β have been reviewed.Our results found further evidence in support of the use of corticosteroids, particularly dexamethasone, and anti-IL-6 receptor monoclonal antibody therapy. These data support the need to identify additional therapies with beneficial effects on mortality.
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Affiliation(s)
| | | | - Krizia Tuand
- KU Leuven Libraries - 2Bergen - Learning Centre Désiré Collen, Leuven, Belgium
| | | | - Thomy Tonia
- Institute of Social and Preventive Medicine, University Bern, Bern, Switzerland
| | - Nicolas Roche
- Respiratory Medicine, Cochin Hospital, APHP Centre-University of Paris, Cochin Institute (INSERM UMR1016), Paris, France
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Bassetti M, Giacobbe DR, Bruzzi P, Barisione E, Centanni S, Castaldo N, Corcione S, De Rosa FG, Di Marco F, Gori A, Gramegna A, Granata G, Gratarola A, Maraolo AE, Mikulska M, Lombardi A, Pea F, Petrosillo N, Radovanovic D, Santus P, Signori A, Sozio E, Tagliabue E, Tascini C, Vancheri C, Vena A, Viale P, Blasi F. Clinical Management of Adult Patients with COVID-19 Outside Intensive Care Units: Guidelines from the Italian Society of Anti-Infective Therapy (SITA) and the Italian Society of Pulmonology (SIP). Infect Dis Ther 2021; 10:1837-1885. [PMID: 34328629 PMCID: PMC8323092 DOI: 10.1007/s40121-021-00487-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 06/15/2021] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION The Italian Society of Anti-Infective Therapy (SITA) and the Italian Society of Pulmonology (SIP) constituted an expert panel for developing evidence-based guidance for the clinical management of adult patients with coronavirus disease 2019 (COVID-19) outside intensive care units. METHODS Ten systematic literature searches were performed to answer ten different key questions. The retrieved evidence was graded according to the Grading of Recommendations Assessment, Development, and Evaluation methodology (GRADE). RESULTS AND CONCLUSION The literature searches mostly assessed the available evidence on the management of COVID-19 patients in terms of antiviral, anticoagulant, anti-inflammatory, immunomodulatory, and continuous positive airway pressure (CPAP)/non-invasive ventilation (NIV) treatment. Most evidence was deemed as of low certainty, and in some cases, recommendations could not be developed according to the GRADE system (best practice recommendations were provided in similar situations). The use of neutralizing monoclonal antibodies may be considered for outpatients at risk of disease progression. For inpatients, favorable recommendations were provided for anticoagulant prophylaxis and systemic steroids administration, although with low certainty of evidence. Favorable recommendations, with very low/low certainty of evidence, were also provided for, in specific situations, remdesivir, alone or in combination with baricitinib, and tocilizumab. The presence of many best practice recommendations testified to the need for further investigations by means of randomized controlled trials, whenever possible, with some possible future research directions stemming from the results of the ten systematic reviews.
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Affiliation(s)
- Matteo Bassetti
- Infectious Diseases Unit, Ospedale Policlinico San Martino-IRCCS, L.go R. Benzi, 10, 16132, Genoa, Italy.
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy.
| | - Daniele Roberto Giacobbe
- Infectious Diseases Unit, Ospedale Policlinico San Martino-IRCCS, L.go R. Benzi, 10, 16132, Genoa, Italy.
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy.
| | - Paolo Bruzzi
- Clinical Epidemiology Unit, Ospedale Policlinico San Martino-IRCCS, Genoa, Italy
| | - Emanuela Barisione
- Interventional Pulmonology, Ospedale Policlinico San Martino-IRCCS, Genoa, Italy
| | - Stefano Centanni
- Department of Health Sciences, University of Milan, Respiratory Unit, ASST Santi Paolo e Carlo, Milan, Italy
| | - Nadia Castaldo
- Infectious Diseases Clinic, Santa Maria Misericordia Hospital, Udine, Italy
| | - Silvia Corcione
- Department of Medical Sciences, Infectious Diseases, University of Turin, Turin, Italy
- Tufts University School of Medicine, Boston, MA, USA
| | | | - Fabiano Di Marco
- Department of Health Sciences, University of Milan, Respiratory Unit, ASST Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Andrea Gori
- Infectious Diseases Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
- Centre for Multidisciplinary Research in Health Science (MACH), University of Milan, Milan, Italy
| | - Andrea Gramegna
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Internal Medicine Department, Respiratory Unit and Cystic Fibrosis Adult Center, Milan, Italy
| | - Guido Granata
- Clinical and Research Department for Infectious Diseases, National Institute for Infectious Diseases L. Spallanzani, IRCCS, Rome, Italy
| | - Angelo Gratarola
- Department of Emergency and Urgency, San Martino Policlinico Hospital, IRCCS, Genoa, Italy
| | | | - Malgorzata Mikulska
- Infectious Diseases Unit, Ospedale Policlinico San Martino-IRCCS, L.go R. Benzi, 10, 16132, Genoa, Italy
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
| | - Andrea Lombardi
- Infectious Diseases Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Federico Pea
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
- SSD Clinical Pharmacology Unit, University Hospital, IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
| | - Nicola Petrosillo
- Clinical and Research Department for Infectious Diseases, National Institute for Infectious Diseases L. Spallanzani, IRCCS, Rome, Italy
- Infection Control and Infectious Disease Service, University Hospital "Campus-Biomedico", Rome, Italy
| | - Dejan Radovanovic
- Division of Respiratory Diseases, Ospedale L. Sacco, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Pierachille Santus
- Division of Respiratory Diseases, Ospedale L. Sacco, ASST Fatebenefratelli-Sacco, Milan, Italy
- Department of Biomedical and Clinical Sciences (DIBIC), Università degli Studi di Milano, Milan, Italy
| | - Alessio Signori
- Department of Health Sciences, Section of Biostatistics, University of Genoa, Genoa, Italy
| | - Emanuela Sozio
- Infectious Diseases Clinic, Santa Maria Misericordia Hospital, Udine, Italy
| | - Elena Tagliabue
- Interventional Pulmonology, Ospedale Policlinico San Martino-IRCCS, Genoa, Italy
| | - Carlo Tascini
- Infectious Diseases Clinic, Santa Maria Misericordia Hospital, Udine, Italy
| | - Carlo Vancheri
- Regional Referral Centre for Rare Lung Diseases-University Hospital "Policlinico G. Rodolico", Catania, Italy
- Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Antonio Vena
- Infectious Diseases Unit, Ospedale Policlinico San Martino-IRCCS, L.go R. Benzi, 10, 16132, Genoa, Italy
| | - Pierluigi Viale
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Bologna, Italy
- Infectious Diseases Unit, University Hospital IRCCS Policlinico Sant'Orsola, Bologna, Italy
| | - Francesco Blasi
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Internal Medicine Department, Respiratory Unit and Cystic Fibrosis Adult Center, Milan, Italy
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17
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Catherino WH. From the Editor-in-Chief. F&S SCIENCE 2021; 2:315. [PMID: 35559856 DOI: 10.1016/j.xfss.2021.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 10/08/2021] [Indexed: 06/15/2023]
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Popp M, Stegemann M, Riemer M, Metzendorf MI, Romero CS, Mikolajewska A, Kranke P, Meybohm P, Skoetz N, Weibel S. Antibiotics for the treatment of COVID-19. Cochrane Database Syst Rev 2021; 10:CD015025. [PMID: 34679203 PMCID: PMC8536098 DOI: 10.1002/14651858.cd015025] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The effect of antibiotics with potential antiviral and anti-inflammatory properties are being investigated in clinical trials as treatment for COVID-19. The use of antibiotics follows the intention-to-treat the viral disease and not primarily to treat bacterial co-infections of individuals with COVID-19. A thorough understanding of the current evidence regarding effectiveness and safety of antibiotics as anti-viral treatments for COVID-19 based on randomised controlled trials (RCTs) is required. OBJECTIVES To assess the efficacy and safety of antibiotics compared to each other, no treatment, standard of care alone, placebo, or any other active intervention with proven efficacy for treatment of COVID-19 outpatients and inpatients. SEARCH METHODS: We searched the Cochrane COVID-19 Study Register (including MEDLINE, Embase, ClinicalTrials.gov, WHO ICTRP, medRxiv, CENTRAL), Web of Science and WHO COVID-19 Global literature on coronavirus disease to identify completed and ongoing studies to 14 June 2021. SELECTION CRITERIA RCTs were included that compared antibiotics with each other, no treatment, standard of care alone, placebo, or another proven intervention, for treatment of people with confirmed COVID-19, irrespective of disease severity, treated in the in- or outpatient settings. Co-interventions had to be the same in both study arms. We excluded studies comparing antibiotics to other pharmacological interventions with unproven efficacy. DATA COLLECTION AND ANALYSIS We assessed risk of bias of primary outcomes using the Cochrane risk of bias tool (ROB 2) for RCTs. We used GRADE to rate the certainty of evidence for the following primary outcomes: 1. to treat inpatients with moderate to severe COVID-19: mortality, clinical worsening defined as new need for intubation or death, clinical improvement defined as being discharged alive, quality of life, adverse and serious adverse events, and cardiac arrhythmias; 2. to treat outpatients with asymptomatic or mild COVID-19: mortality, clinical worsening defined as hospital admission or death, clinical improvement defined as symptom resolution, quality of life, adverse and serious adverse events, and cardiac arrhythmias. MAIN RESULTS We included 11 studies with 11,281 participants with an average age of 54 years investigating antibiotics compared to placebo, standard of care alone or another antibiotic. No study was found comparing antibiotics to an intervention with proven efficacy. All studies investigated azithromycin, two studies investigated other antibiotics compared to azithromycin. Seven studies investigated inpatients with moderate to severe COVID-19 and four investigated mild COVID-19 cases in outpatient settings. Eight studies had an open-label design, two were blinded with a placebo control, and one did not report on blinding. We identified 19 ongoing and 15 studies awaiting classification pending publication of results or clarification of inconsistencies. Of the 30 study results contributing to primary outcomes by included studies, 17 were assessed as overall low risk and 13 as some concerns of bias. Only studies investigating azithromycin reported data eligible for the prioritised primary outcomes. Azithromycin doses and treatment duration varied among included studies. Azithromycin for the treatment of COVID-19 compared to placebo or standard of care alone in inpatients We are very certain that azithromycin has little or no effect on all-cause mortality at day 28 compared to standard of care alone (risk ratio (RR) 0.98; 95% confidence interval (CI) 0.90 to 1.06; 8600 participants; 4 studies; high-certainty evidence). Azithromycin probably has little or no effect on clinical worsening or death at day 28 (RR 0.95; 95% CI 0.87 to 1.03; 7311 participants; 1 study; moderate-certainty evidence), on clinical improvement at day 28 (RR 0.96; 95% CI 0.84 to 1.11; 8172 participants; 3 studies; moderate-certainty evidence), on serious adverse events during the study period (RR 1.11; 95% CI 0.89 to 1.40; 794 participants; 4 studies; moderate-certainty evidence), and cardiac arrhythmias during the study period (RR 0.92; 95% CI 0.73 to 1.15; 7865 participants; 4 studies; moderate-certainty evidence) compared to placebo or standard of care alone. Azithromycin may increase any adverse events slightly during the study period (RR 1.20; 95% CI 0.92 to 1.57; 355 participants; 3 studies; low-certainty evidence) compared to standard of care alone. No study reported quality of life up to 28 days. Azithromycin for the treatment of COVID-19 compared to placebo or standard of care alone in outpatients Azithromycin may have little or no effect compared to placebo or standard of care alone on all-cause mortality at day 28 (RR 1.00 ; 95% CI 0.06 to 15.69; 876 participants; 3 studies; low-certainty evidence), on admission to hospital or death within 28 days (RR 0.94 ; 95% CI 0.57 to 1.56; 876 participants; 3 studies; low-certainty evidence), and on symptom resolution at day 14 (RR 1.03; 95% CI 0.95 to 1.12; 138 participants; 1 study; low-certainty evidence). We are uncertain whether azithromycin increases or reduces serious adverse events compared to placebo or standard of care alone (0 participants experienced serious adverse events; 454 participants; 2 studies; very low-certainty evidence). No study reported on adverse events, cardiac arrhythmias during the study period or quality of life up to 28 days. Azithromycin for the treatment of COVID-19 compared to any other antibiotics in inpatients and outpatients One study compared azithromycin to lincomycin in inpatients, but did not report any primary outcome. Another study compared azithromycin to clarithromycin in outpatients, but did not report any relevant outcome for this review. AUTHORS' CONCLUSIONS We are certain that risk of death in hospitalised COVID-19 patients is not reduced by treatment with azithromycin after 28 days. Further, based on moderate-certainty evidence, patients in the inpatient setting with moderate and severe disease probably do not benefit from azithromycin used as potential antiviral and anti-inflammatory treatment for COVID-19 regarding clinical worsening or improvement. For the outpatient setting, there is currently low-certainty evidence that azithromycin may have no beneficial effect for COVID-19 individuals. There is no evidence from RCTs available for other antibiotics as antiviral and anti-inflammatory treatment of COVID-19. With accordance to the living approach of this review, we will continually update our search and include eligible trials to fill this evidence gap. However, in relation to the evidence for azithromycin and in the context of antimicrobial resistance, antibiotics should not be used for treatment of COVID-19 outside well-designed RCTs.
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Affiliation(s)
- Maria Popp
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Miriam Stegemann
- Department of Infectious Diseases and Respiratory Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Manuel Riemer
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Maria-Inti Metzendorf
- Cochrane Metabolic and Endocrine Disorders Group, Institute of General Practice, Medical Faculty of the Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Carolina S Romero
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, General University Hospital Valencia, Valencia, Spain
| | - Agata Mikolajewska
- Department of Infectious Diseases and Respiratory Medicine, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Peter Kranke
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Nicole Skoetz
- Cochrane Cancer, Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Stephanie Weibel
- Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
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Zhang C, Jin H, Wen YF, Yin G. Efficacy of COVID-19 Treatments: A Bayesian Network Meta-Analysis of Randomized Controlled Trials. Front Public Health 2021; 9:729559. [PMID: 34650951 PMCID: PMC8506153 DOI: 10.3389/fpubh.2021.729559] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 09/01/2021] [Indexed: 01/09/2023] Open
Abstract
Background: We provided a comprehensive evaluation of efficacy of available treatments for coronavirus disease 2019 (COVID-19). Methods: We searched for candidate COVID-19 studies in WHO COVID-19 Global Research Database up to August 19, 2021. Randomized controlled trials for suspected or confirmed COVID-19 patients published on peer-reviewed journals were included, regardless of demographic characteristics. Outcome measures included mortality, mechanical ventilation, hospital discharge and viral clearance. Bayesian network meta-analysis with fixed effects was conducted to estimate the effect sizes using posterior means and 95% equal-tailed credible intervals (CrIs). Odds ratio (OR) was used as the summary measure for treatment effect. Bayesian hierarchical models were used to estimate effect sizes of treatments grouped by the treatment classifications. Results: We identified 222 eligible studies with a total of 102,950 patients. Compared with the standard of care, imatinib, intravenous immunoglobulin and tocilizumab led to lower risk of death; baricitinib plus remdesivir, colchicine, dexamethasone, recombinant human granulocyte colony stimulating factor and tocilizumab indicated lower occurrence of mechanical ventilation; tofacitinib, sarilumab, remdesivir, tocilizumab and baricitinib plus remdesivir increased the hospital discharge rate; convalescent plasma, ivermectin, ivermectin plus doxycycline, hydroxychloroquine, nitazoxanide and proxalutamide resulted in better viral clearance. From the treatment class level, we found that the use of antineoplastic agents was associated with fewer mortality cases, immunostimulants could reduce the risk of mechanical ventilation and immunosuppressants led to higher discharge rates. Conclusions: This network meta-analysis identified superiority of several COVID-19 treatments over the standard of care in terms of mortality, mechanical ventilation, hospital discharge and viral clearance. Tocilizumab showed its superiority compared with SOC on preventing severe outcomes such as death and mechanical ventilation as well as increasing the discharge rate, which might be an appropriate treatment for patients with severe or mild/moderate illness. We also found the clinical efficacy of antineoplastic agents, immunostimulants and immunosuppressants with respect to the endpoints of mortality, mechanical ventilation and discharge, which provides valuable information for the discovery of potential COVID-19 treatments.
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Affiliation(s)
- Chenyang Zhang
- Department of Statistics and Actuarial Science, University of Hong Kong, Hong Kong SAR, China
| | - Huaqing Jin
- Department of Statistics and Actuarial Science, University of Hong Kong, Hong Kong SAR, China
| | - Yi Feng Wen
- Key Laboratory of Shaanxi Province for Craniofacial Precision Medicine Research, College of Stomatology, Xi'an Jiaotong University, Xi'an, China
| | - Guosheng Yin
- Department of Statistics and Actuarial Science, University of Hong Kong, Hong Kong SAR, China.,Department of Biostatistics, MD Anderson Cancer Center, Houston, TX, United States
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20
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Hinks TSC, Cureton L, Knight R, Wang A, Cane JL, Barber VS, Black J, Dutton SJ, Melhorn J, Jabeen M, Moss P, Garlapati R, Baron T, Johnson G, Cantle F, Clarke D, Elkhodair S, Underwood J, Lasserson D, Pavord ID, Morgan S, Richards D. Azithromycin versus standard care in patients with mild-to-moderate COVID-19 (ATOMIC2): an open-label, randomised trial. THE LANCET. RESPIRATORY MEDICINE 2021; 9:1130-1140. [PMID: 34252378 PMCID: PMC8270523 DOI: 10.1016/s2213-2600(21)00263-0] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 05/27/2021] [Accepted: 05/28/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND The antibacterial, anti-inflammatory, and antiviral properties of azithromycin suggest therapeutic potential against COVID-19. Randomised data in mild-to-moderate disease are not available. We assessed whether azithromycin is effective in reducing hospital admission in patients with mild-to-moderate COVID-19. METHODS This prospective, open-label, randomised superiority trial was done at 19 hospitals in the UK. We enrolled adults aged at least 18 years presenting to hospitals with clinically diagnosed, highly probable or confirmed COVID-19 infection, with fewer than 14 days of symptoms, who were considered suitable for initial ambulatory management. Patients were randomly assigned (1:1) to azithromycin (500 mg once daily orally for 14 days) plus standard care or to standard care alone. The primary outcome was death or hospital admission from any cause over the 28 days from randomisation. The primary and safety outcomes were assessed according to the intention-to-treat principle. This trial is registered at ClinicalTrials.gov (NCT04381962) and recruitment is closed. FINDINGS 298 participants were enrolled from June 3, 2020, to Jan 29, 2021. Three participants withdrew consent and requested removal of all data, and three further participants withdrew consent after randomisation, thus, the primary outcome was assessed in 292 participants (145 in the azithromycin group and 147 in the standard care group). The mean age of the participants was 45·9 years (SD 14·9). 15 (10%) participants in the azithromycin group and 17 (12%) in the standard care group were admitted to hospital or died during the study (adjusted OR 0·91 [95% CI 0·43-1·92], p=0·80). No serious adverse events were reported. INTERPRETATION In patients with mild-to-moderate COVID-19 managed without hospital admission, adding azithromycin to standard care treatment did not reduce the risk of subsequent hospital admission or death. Our findings do not support the use of azithromycin in patients with mild-to-moderate COVID-19. FUNDING National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford and Pfizer.
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Affiliation(s)
- Timothy S C Hinks
- Respiratory Medicine Unit and National Institute for Health Research Oxford Biomedical Research Centre, Nuffield Department of Medicine Experimental Medicine, University of Oxford, Oxford, UK.
| | - Lucy Cureton
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Ruth Knight
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Ariel Wang
- Respiratory Medicine Unit and National Institute for Health Research Oxford Biomedical Research Centre, Nuffield Department of Medicine Experimental Medicine, University of Oxford, Oxford, UK
| | - Jennifer L Cane
- Respiratory Medicine Unit and National Institute for Health Research Oxford Biomedical Research Centre, Nuffield Department of Medicine Experimental Medicine, University of Oxford, Oxford, UK
| | - Vicki S Barber
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Joanna Black
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Susan J Dutton
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
| | | | - Maisha Jabeen
- Respiratory Medicine Unit and National Institute for Health Research Oxford Biomedical Research Centre, Nuffield Department of Medicine Experimental Medicine, University of Oxford, Oxford, UK
| | - Phil Moss
- Emergency Department Clinical Research Unit, St George's Hospital, London, UK
| | | | - Tanya Baron
- Emergency Department, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Graham Johnson
- University Hospitals of Derby and Burton, Royal Derby Hospital, Derby, UK; University of Nottingham, Lenton, Nottingham UK
| | - Fleur Cantle
- Department of Emergency Medicine, King's College Hospital, London, UK
| | | | - Samer Elkhodair
- Emergency Department, University College London Hospital, London UK
| | - Jonathan Underwood
- Department of Infectious Diseases, Cardiff and Vale University Health Board, Cardiff, UK; Division of Infection and Immunity, Cardiff University, Cardiff, UK
| | - Daniel Lasserson
- Department of Geratology, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, UK; Department of Acute Medicine, Sandwell and West Birmingham Hospitals NHS Trust, City Hospital, Birmingham, UK; Warwick Medical School, University of Warwick, Coventry, UK
| | - Ian D Pavord
- Respiratory Medicine Unit and National Institute for Health Research Oxford Biomedical Research Centre, Nuffield Department of Medicine Experimental Medicine, University of Oxford, Oxford, UK
| | - Sophie Morgan
- Respiratory Medicine Unit and National Institute for Health Research Oxford Biomedical Research Centre, Nuffield Department of Medicine Experimental Medicine, University of Oxford, Oxford, UK
| | - Duncan Richards
- Oxford Clinical Trials Research Unit, Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
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21
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Alunno A, Najm A, Mariette X, De Marco G, Emmel J, Mason L, McGonagle DG, Machado PM. Immunomodulatory therapies for the treatment of SARS-CoV-2 infection: an update of the systematic literature review to inform EULAR points to consider. RMD Open 2021; 7:e001899. [PMID: 34725262 PMCID: PMC8562527 DOI: 10.1136/rmdopen-2021-001899] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 10/12/2021] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To update the EULAR 2020 systematic literature review (SLR) on efficacy and safety of immunomodulatory agents in SARS-CoV-2 infection. METHODS As part of a EULAR taskforce, a systematic literature search update was conducted from 11 December 2020 to 14 July 2021. Two reviewers independently identified eligible studies and extracted data on efficacy and safety of immunomodulatory agents used therapeutically in SARS-CoV-2 infection at any stage of disease. The risk of bias (RoB) was assessed with validated tools. RESULTS Of the 26 959 records, 520 articles were eligible for inclusion. Studies were mainly at high or unclear RoB. New randomised controlled trials (RCTs) on tocilizumab clarified its benefit in patients with severe and critical COVID-19, mainly if associated with glucocorticoids. There are emergent data on the usefulness of baricitinib and tofacitinib in severe COVID-19. Other therapeutic strategies such as the use of convalescent plasma and anti-SARS-CoV-2 monoclonal antibodies showed efficacy in subjects not mounting normal anti-SARS-CoV-2 antibody responses. CONCLUSION This new SLR confirms that some immunomodulators (tocilizumab and JAK inhibitors) have a role for treating severe and critical COVID-19. Although better evidence is available compared with the previous SLR, the need of RCT with combination therapy (glucocorticoids+anti-cytokines) versus monotherapy with glucocorticoids still remains alongside the need for standardisation of inclusion criteria and outcomes to ultimately improve the care and prognosis of affected people. This SLR informed the 2021 update of the EULAR points to consider on the use of immunomodulatory therapies in COVID-19.
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Affiliation(s)
- Alessia Alunno
- Internal Medicine and Nephrology Unit, Department of Life, Health & Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Aurélie Najm
- Institute of Infection, Immunity and Inflammation, College of Medical Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Xavier Mariette
- Department of Rheumatology, Université Paris-Saclay, Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, INSERM UMR1184, Le Kremlin-Bicêtre, France
| | - Gabriele De Marco
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds & The NIHR Leeds Biomedical Research Centre, Chapel Allerton Hospital, Leeds, UK
| | - Jenny Emmel
- Library & Evidence Research Centre, Medical Education, Leeds Teaching Hospitals NHS Trust, Leeds UK, Leeds, UK
| | - Laura Mason
- Library & Evidence Research Centre, Medical Education, Leeds Teaching Hospitals NHS Trust, Leeds UK, Leeds, UK
| | - Dennis G McGonagle
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds & The NIHR Leeds Biomedical Research Centre, Chapel Allerton Hospital, Leeds, UK
| | - Pedro M Machado
- National Institute for Health Research (NIHR) University College London Hospitals (UCLH) Biomedical Research Centre (BRC), University College London Hospitals (UCLH) NHS Foundation Trust, London, UK
- Department of Rheumatology, Northwick Park Hospital, London North West University Healthcare NHS Trust, London, UK
- Centre for Rheumatology & Department of Neuromuscular Diseases,University College London, London, UK
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22
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Liu D, Zeng X, Ding Z, Lv F, Mehta JL, Wang X. Adverse Cardiovascular Effects of Anti-COVID-19 Drugs. Front Pharmacol 2021; 12:699949. [PMID: 34512335 PMCID: PMC8424204 DOI: 10.3389/fphar.2021.699949] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 08/13/2021] [Indexed: 12/15/2022] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or COVID-19 infection is the cause of the ongoing global pandemic. Mortality from COVID-19 infection is particularly high in patients with cardiovascular diseases. In addition, COVID-19 patients with preexisting cardiovascular comorbidities have a higher risk of death. Main cardiovascular complications of COVID-19 are myocardial infarction, myocarditis, acute myocardial injury, arrhythmias, heart failure, stroke, and venous thromboembolism. Therapeutic interventions in terms of drugs for COVID-19 have many cardiac adverse effects. Here, we review the relative therapeutic efficacy and adverse effects of anti-COVID-19 drugs.
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Affiliation(s)
- Dongling Liu
- Henan Key Laboratory of Medical Tissue Regeneration, Xinxiang Medical University, Xinxiang, China
| | - Xiang Zeng
- Laboratory of Environmental Medicine and Developmental Toxicology, Guangdong Key Laboratory of Environmental Pollution and Health, School of Environment, Jinan University, Guangzhou, China
| | - Zufeng Ding
- Division of Cardiology, University of Arkansas for Medical Sciences and Central Arkansas Veterans Healthcare System, Little Rock, AR, United States
| | - Fenghua Lv
- Department of Cardiology, Xinxiang Medical University First Affiliated Hospital, Weihui, China
| | - Jawahar L. Mehta
- Division of Cardiology, University of Arkansas for Medical Sciences and Central Arkansas Veterans Healthcare System, Little Rock, AR, United States
| | - Xianwei Wang
- Henan Key Laboratory of Medical Tissue Regeneration, Xinxiang Medical University, Xinxiang, China
- Department of Cardiology, Xinxiang Medical University First Affiliated Hospital, Weihui, China
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