Comparison of Tocilizumab Versus Tocilizumab/Infliximab in Patients With COVID-19-associated Cytokine Storm Syndrome
Study Details
Study Description
Brief Summary
Since the end of 2019, Egypt and the whole world have been suffering from the Coronavirus Disease 2019 (COVID-19) pandemic, which is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). According to the World Health Organization (WHO), since the emergence of this new pandemic, there have been more than 97 million confirmed cases of COVID-19 patients and two million death globally; around 160 thousand of these cases are in Egypt.
Tocilizumab play role among the unique therapeutic alternatives for the management of cytokine release syndrome (CRS), a life-threatening complication of chimeric antigen receptor (CAR) - T cell therapy. CRS occurs as a result of uncontrolled immune activation with release of pro-inflammatory cytokines and chemokines. Up till now, clinical trial and expertise with tocilizumab in COVID-19 patients has been limited. Despite preliminary encouraging results, recent studies suffered from limitations such as the absence of consistent treatment outline, a short post-treatment follow-up, and the absence of a comparison group.
A recent study discussed the possible beneficial effect of tumor necrosis factor (TNF) inhibitors in severe COVID-19. Specifically, TNF may aggravate lymphopenia through direct killing via TNF/TNFR1 signaling in T cells, and T cell dysfunction reveals an important yet underestimated target for immunomodulatory therapeutic approaches. Accordingly, anti-TNF may be considered as an encouraging therapeutic option in severe COVID-19.
These promising clinical findings encouraged us to use infliximab (IFX), a chimeric monoclonal anti-TNF antibody, as an experimental therapy in patients with moderate and severe COVID-19 in the absence of IBD.
In this study, we compare the outcomes of a large cohort of patients with moderate and severe COVID-19 pneumonia treated with tocilizumab in addition to standard management, with those of concomitantly hospitalized patients who received infliximab and tocilizumab in addition to standard management.
Condition or Disease | Intervention/Treatment | Phase |
---|---|---|
Study Design
Arms and Interventions
Arm | Intervention/Treatment |
---|---|
Group 1 Moderate and severe patients who were infected with SARS-CoV-2 and received treatment with tocilizumab in addition to standard management. |
Drug: Tocilizumab
400 mg IV only once
Other Names:
|
Group 2 Moderate and severe patients who were infected with SARS-CoV-2 and received treatment with infliximab and tocilizumab in addition to standard management. |
Drug: Tocilizumab
400 mg IV only once
Other Names:
Drug: Infliximab
5 mg/kg/day IV for 2 doses 12-24 hours
Other Names:
|
Outcome Measures
Primary Outcome Measures
- Patients' clinical status improvement using six category scale [Two weeks]
The categories were defined as follows: 1) patient discharged, 2) hospitalization not requiring supplemental oxygen, 3) hospitalization requiring supplemental low-flow oxygen, 4) hospitalization requiring high-flow supplemental oxygen, 5) hospitalization requiring invasive mechanical ventilation, 6) death.
- Time to improvement in oxygenation [48 hours]
Increase in SpO2/FiO2 of 50 or greater compared to the baseline SpO2/FiO2
- Duration of hospitalization [Two weeks]
Total admission period
- Mortality rate [Two weeks]
Death during hospitalization
Secondary Outcome Measures
- Incidence of non-invasive mechanical ventilation [Two weeks]
Need for non-invasive mechanical ventilation
- Duration of non-invasive mechanical ventilation [Two weeks]
Time required for non-invasive mechanical ventilation
- Incidence of invasive mechanical ventilation [Two weeks]
Need for invasive mechanical ventilation
- Duration of invasive mechanical ventilation [Two weeks]
Time required for invasive mechanical ventilation
- Occurrence of Secondary infections [Two weeks]
Especially Sepsis
- Monitoring of adverse events [Two weeks]
Monitoring of adverse events especially elevation of liver enzymes daily
- Occurrence of cardiovascular events [Two weeks]
Prevalence of heart failure, tachycardia and hypertension
Eligibility Criteria
Criteria
Inclusion Criteria:
-
Age 18-65 years.
-
Able to provide informed consent.
-
Patients hospitalized with pneumonia proved by chest X-ray or CT scan.
-
Confirmed infection with COVID-2019 using RT-PCR or strongly suspected to be infected with pending confirmation studies.
-
Hyper-inflammation defined as elevation in either C-reactive protein (CRP, ≥ 100 mg/L, normal values <6 mg/L) or ferritin (≥ 900 ng/mL, normal value <400 ng/mL), in the presence of increased lactate dehydrogenase (LDH, >220 U/L).
-
And at least one of the following:
-
Respiratory frequency ≥30/min.
-
Blood oxygen saturation ≤93% on room air (RA).
-
Partial pressure of arterial oxygen to fraction of inspired oxygen ratio (PaO2/FiO2) <300 [18].
-
Worsening of lung involvement, defined as an increase in number and/or extension of pulmonary areas of consolidation, need for increased FiO2 to maintain stable O2 saturation, or worsening O2 saturation of >3% with stable FiO2.
Exclusion Criteria:
-
Evidence of concomitant bacterial infection.
-
Concomitant use of other immunosuppressive biologic drugs.
-
Baseline elevation of alanine aminotransferase (ALT) or aspartate aminotransferase (AST) levels > 5-fold the upper limit of the normal range.
-
Pregnancy.
-
Treatment with any TNFα inhibitor in the past 30 days.
-
Known hypersensitivity to any TNFα inhibitor, murine proteins, or any component of the formulation.
-
Known or suspected active tuberculosis (TB) or a history of incompletely treated or latent TB.
-
Serious co-morbidity, including:
-
Myocardial infarction (within last month).
-
Moderate or severe heart failure (New York Heart Association (NYHA) class III or IV).
-
Hepatic patients child Pugh class C.
Contacts and Locations
Locations
Site | City | State | Country | Postal Code | |
---|---|---|---|---|---|
1 | Teachers Hospital | Cairo | Please Select | Egypt | 11314 |
Sponsors and Collaborators
- Ain Shams University
- Misr International University
Investigators
- Principal Investigator: Neven Sarhan, PhD, Misr International University
Study Documents (Full-Text)
None provided.More Information
Publications
None provided.- COVID-Infliximab