key: cord-0689548-2jx743bm
authors: Yang, Bryant; Fulcher, Jennifer A; Ahn, Jenny; Berro, Marlene; Goodman-Meza, David; Dhody, Kush; Sacha, Jonah B; Naeim, Arash; Yang, Otto O
title: Clinical Characteristics and Outcomes of COVID-19 Patients Receiving Compassionate Use Leronlimab
date: 2020-10-20
journal: Clin Infect Dis
DOI: 10.1093/cid/ciaa1583
sha: ed0960947311c0ca4d4028c773cd1c87f946c9dd
doc_id: 689548
cord_uid: 2jx743bm

BACKGROUND: Leronlimab, a monoclonal antibody blocker of CCR5 originally developed to treat HIV-1 infection, was administered as an open label compassionate use therapeutic for COVID-19. METHODS: 23 hospitalized severe/critical COVID-19 patients received 700mg leronlimab subcutaneously, repeated after seven days in 17/23 patients still hospitalized. 18/23 received other experimental treatments, including convalescent plasma, hydroxychloroquine, steroids, and/or tocilizumab. 5/23 received leronlimab after blinded placebo-controlled trials of remdesivir, sarilumab, selinexor, or tocilizumab. Outcomes and results were extracted from medical records. RESULTS: Mean age was 69.5±14.9 years. 20/23 had significant co-morbidities. At baseline, 22/23 were receiving supplemental oxygen (3/23 high flow, 7/23 mechanical ventilation). Blood showed markedly elevated inflammatory markers (ferritin, D-dimer, C-reactive protein) and elevated neutrophil:lymphocyte ratio. By day 30 after initial dosing, 17/23 were recovered, 2/23 were still hospitalized, and 4/23 had died. Of the 7 intubated at baseline, 4/7 were fully recovered off oxygen, 2/7 were still hospitalized, and 1/7 had died. CONCLUSIONS: Leronlimab appeared safe and well tolerated. The high recovery rate suggested benefit, and those with lower inflammatory markers had better outcomes. Some but not all patients appeared to have dramatic clinical responses, indicating that unknown factors may determine responsiveness to leronlimab. Routine inflammatory and cell prognostic markers did not markedly change immediately after treatment, although IL-6 tended to fall. In some persons C-reactive protein clearly dropped only after the second leronlimab dose, suggesting that a higher loading dose might be more effective. Future controlled trials will be informative.

Late in 2019, the novel coronavirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was identified as the cause of an outbreak of a pneumonia syndrome (eventually termed coronavirus disease 2019, in Wuhan, China. Rapid spread of the virus across the globe was declared a pandemic by March 11, and has been responsible for almost 8.3 million infections and 450,000 deaths as of June 17, 2020 [1] . To date the only drug treatments with established benefit have been the polymerase inhibitor remdesivir, which has a modest impact on recovery time but no definite improvement in mortality [2] , and dexamethasone, which may modestly reduce mortality in patients requiring supplemental oxygen or mechanical ventilation [3] . Therefore there has been a keen interest in developing treatments to reduce the mortality of COVID-19. Because the pathogenesis of fatal COVID- 19 involves both viral infection and a hyperinflammatory state causing end organ damage through a cytokine storm-like syndrome, therapeutic development has focused on both direct antiviral agents (such as remdesivir) and immunomodulatory agents.

Leronlimab is a humanized monoclonal antibody that binds CC-chemokine receptor-5 (CCR5), and has undergone extensive clinical testing for the treatment of Human Immunodeficiency Virus type 1 (HIV-1) infection [4] [5] [6] [7] . It acts as a competitive inhibitor by binding the N-terminus and second extracellular loop and blocking CCR5-mediated HIV-1 infection of cells. CCR5 is expressed predominantly on T cells, but also found on macrophages, dendritic cells, and eosinophils, to mediate chemotaxis in response to its cognate ligands that include CCL5 (RANTES), CCL3 (MIP-1), and CCL4 (MIP-1). These ligands are integral in the recruitment of these immune cells to inflammatory sites. Binding of leronlimab to CCR5 on cells not only blocks HIV-1 entry, but also prevents CCL5-mediated A c c e p t e d M a n u s c r i p t 4 calcium flux with an IC 50 of about 45 µg/mL [8] and is therefore a potent inhibitor of CCR5mediated chemotaxis.

The immunopathogenesis of COVID-19 likely involves the excessive influx of immune cells into the lung. The original SARS caused by the closely related virus SARS-CoV-1 has very similar clinical findings to 10] , and that virus elicits high levels of CCL5 expression by airway epithelial cells and macrophages [11, 12] . In SARS-CoV-2 infection, activated macrophages in the airways express high levels of CCL3, with the highest expression seen in patients with critical COVID-19 [13] . Thus it is likely that CCR5mediated chemotaxis similarly contributes to the excessive lung inflammation seen in COVID-19, and leronlimab has been proposed as an immunomodulatory treatment and tested in a few patients with anecdotal success [14, 15] . Here we report the outcomes of the 23 COVID-19 patients who received open label compassionate use leronlimab at our medical center in April of 2020, the largest reported series to date. Statistical analyses. Laboratory data were compared using non-parametric Mann-Whitney tests. All graphs and statistical analyses were performed using GraphPad Prism v8.4.2.

Role of the funding source. The funder had no role in the study design, data collection, analysis of data, interpretation of data, writing of the report, or decision to submit the manuscript for publication. Table S1 ). Reflecting our regional demographics of COVID-19 cases, these individuals were older than typical patients seen for infectious disease consultation at our A c c e p t e d M a n u s c r i p t 6 institution (mean 69.5, s.d. 14.9 years), had a slight male predominance (43% female versus 57% male), were racially and ethnically diverse (70% white, 17% Asian, and 9% other, with 35% Latinx), and had frequent medical co-morbidities (20/23 with significant underlying active chronic medical conditions). Few patients were underweight (2/23 with BMI<18.5), overweight (2/23 with BMI 25.0 to 29.9), or obese (3/23 with BMI >29.9). Co-morbidities were wide-ranging, most commonly hypertension (13/23), chronic kidney disease (8/23), and Safety of leronlimab, and concurrent treatments given for COVID-19. Leronlimab was well tolerated with no noted adverse events with the exception of one person (participant F) who developed a moderate maculopapular skin rash that was likely due to concurrent cephalosporin administration. 17 of 23 patients received two doses a week apart. Of the six who received only one dose, the second dose was not given to three due to hospital discharge before the second dose, one due to skin rash, and two due to death. In addition to leronlimab, 18/23 patients received other experimental treatments for COVID-19 (Table 1, supplementary Table S1, supplementary Figure S2 ). Co-administered treatments included Markers associated with recovery after leronlimab treatment. Among demographic and clinical factors, there were statistically insignificant trends for younger age ( Figure 1A ) and lower oxygen ( Figure 1B ) requirement, and no significance differences in BMI ( Figure 1C) or LDH level ( Figure 1D ) at baseline between those who had recovered by 30 days versus those who had not recovered. For inflammatory markers, baseline D-dimer ( Figure 1E ) and CRP ( Figure 1F ) were significantly higher in those who did not recover (p=0.007 and p=0.02 respectively), and ferritin was insignificantly higher ( Figure 1G ). Of blood leukocytes, neutrophil ( Figure 1H ) and lymphocyte ( Figure 1I ) counts were insignificantly higher and lower respectively in those who did not recover, but the ratio of neutrophils to lymphocytes ( Figure 1J ) was significantly higher (p=0.006). Monocytes were insignificantly lower in those who did not recover ( Figure 1K ). Most participants did not have serial plasma interleukin-6 (IL-6) measurements, but most of those who did exhibited reductions IL-6 temporally correlated to leronlimab administration, although several had confounding treatments (Supplementary Figure S1) . Overall, these findings were consistent with previous reports of predictors of risk in COVID-19.

Changes in inflammatory and cell markers after leronlimab treatment. Examination of disease markers in the 10 days after treatment with leronlimab suggested some differences between those who recovered versus those who did not. D-dimer levels in both subsets remained relatively stable during dosing, remaining moderately elevated in recovered persons and markedly elevated in unrecovered persons (Figure 2A) . CRP in the recovered group remained A c c e p t e d M a n u s c r i p t 9 relatively stable, perhaps dropping after the second dose, while in the unrecovered group seemed to remain persistently elevated perhaps with a slight decrease after the second dose ( Figure 2B ). Ferritin decreased in the unrecovered persons and increased slightly in the recovered group, converging at a similar level by 10 days in both groups ( Figure 2C ).

Absolute lymphocyte counts overall appeared unchanged in both groups but persistently lower in the unrecovered group ( Figure 2D ). Absolute neutrophil and monocyte counts were similarly unchanged, but persistently distinct between the recovered and unrecovered groups ( Figures 2E and 2F ). The neutrophil:lymphocyte ratio was unchanged in those who did recover, and was elevated but appeared to decrease with each leronlimab dose in those who did not recover ( Figure 2G ). While these were the general patterns noted, a confounder was the dropout of patients from these analyses ( Figure 2H ), due to early hospital discharge in the recovered group and death in the unrecovered group. Finally, only a few patients had plasma interleukin-6 (IL-6) levels monitored serially (Supplementary Figure S1) ; most of these exhibited acute reductions in IL-6.

The inflammatory marker CRP in some individuals appeared not to drop until the second dose of leronlimab. While across groups leronlimab treatment did not demonstrate marked effects on disease markers in the 10 day time span following the first dose (Figure 2A-H Given that leronlimab has shown a highly favorable safety profile in over 800 patients treated in FDA approval trials for the treatment of HIV-1 infection [4] [5] [6] [7] , we administered it to several individuals on an open label compassionate use basis, when therapeutic and clinical trials options were relatively limited. Leronlimab appeared well tolerated and safe in our population, with only one possible adverse event being a maculopapular rash that was attributable to concurrent use of a cephalosporin antibiotic.

Limited anecdotal evidence from two small studies has suggested that leronlimab may improve outcomes in COVID-19 infection. Patterson et al examined outcomes in ten "terminally ill" patients [14] of whom seven were on mechanical ventilation, one was on high flow oxygen, and two were on low flow oxygen. Six of ten survived 14 days after treatment with leronlimab, with two able to be successfully removed from mechanical ventilation. Similar to our study, there were no clear changes in general clinical markers (or several cytokines not monitored in our study) with the exception of a consistent drop in interleukin-6 (IL-6) in most persons. Akalin et al reported a small series of renal transplantation patients with COVID-19 of whom six received leronlimab [15] , and also observed a rapid drop in IL-6. Both studies also found changes in T cells, with normalization of CD4 + and CD8 + subsets amounts and ratios (particularly an increase in the CD8 + T cell subset).

Interestingly, our data suggested that the current leronlimab dosing regimen may be suboptimal, since several patients exhibited rapid drops in the inflammatory marker CRP only after the second dose. Given its estimated half-life of about ten days, the second dose A c c e p t e d M a n u s c r i p t 11 after seven days should achieve a higher peak than the first dose, and the maximal effect would not be achieved until after the second dose. This is consistent with the receptor occupancy data presented by Patterson et al [14] , showing maximal effect after the second dose of the same regimen. Also, our data do not appear to demonstrate a relationship between outcome after leronlimab to the duration of disease at the time of dosing (Supplementary Table S1 ).

Because this was not a controlled trial, the impact of leronlimab is not directly ascertainable.

However, the data provide anecdotal evidence for a benefit from treatment. Most of our patients had significant risk factors for severe disease, including age over 60 and comorbidities associated with poor outcome [17, 18] . Of the 23, seven required mechanical ventilation at the time of leronlimab dosing. Of these critically ill patients, six of seven were alive after >70 days, a substantially higher survival rate than other reports of critically ill COVID-19 patients [19] [20] [21] [22] , which range from 42% to 61% in cohorts followed about 30 days after hospitalization. Of the 15 with milder (but still "severe" as defined by supplemental oxygen requirement) illness, 13 no longer required further acute hospital care by 30 days. Thus, the overall outcomes for this high-risk group of patients was better than historically observed in multiple reports from the same time frame.

It was also notable that clinical responsiveness to treatment was highly variable; some patients appeared to have a rapid dramatic response to treatment (e.g. participants A and F who were rapidly extubated after being on ventilators, or participants B, C, and D who were weaned off supplemental oxygen and discharged home within three days), while others seemed to have less effect. Mechanistic studies may uncover determinants and markers for A c c e p t e d M a n u s c r i p t 12 leronlimab responsiveness, such as CCR5 occupancy [14] , and controlled trials will be required to assess the benefit of treatment.

Most of these patients did receive additional possibly confounding treatments for COVID-19.

Although several received hydroxychloroquine (including Participant V who had been chronically for rheumatoid arthritis), the effect of this treatment was unlikely to be significant, given the results of randomized controlled trials demonstrating no benefit [23, 24] . Interleukin-6 receptor blocking antibodies were given to two participants as open label treatments, and two others were in placebo-controlled trials of these agents. A recent press release regarding a controlled trial (EMPACTA) suggested that tocilizumab may modestly reduce mortality (from 19% to 12%) in severely ill patients [25] and a trial of sarilumab was halted for futility [26] ; thus the influence of these agents should be minimal in our cohort.

While remdesivir has been shown to be helpful particularly in persons requiring no more than low flow oxygen supplementation [2] , only one participant (on a ventilator) received this treatment. Several participants received convalescent plasma, but this intervention appears to have only a small effect on 30 day mortality particularly when given within three days of diagnosis [27] ; our participants mostly received plasma much later, so it would seem unlikely that plasma was a significant contributor to our survival rate 30 days after leronlimab.

Finally, three participants received high dose steroids, the intervention shown to have the greatest impact on survival [3] . However, the reported survival benefit of steroids is greatest for intubated patients (29% versus 41% mortality) and minimal for patients requiring only non-invasive oxygen supplementation (22% versus 25%), and only one of our participants who received steroids was intubated. Thus it is unlikely that steroids and other interventions aimed at treating COVID-19 markedly affected survival in our cohort overall.

A c c e p t e d M a n u s c r i p t 13 The prognostic value of some biomarkers was confirmed in our cohort, and these markers also reflected the severity of disease in our participants. In particular, higher C-reactive protein [17] and D-dimer [18, 28] blood levels predicted worse outcome in agreement with prior analyses of COVID-19 in general. Also highly significant was an increased ratio of blood neutrophils to lymphocytes, another previously reported marker of disease severity [29, 30] . The increased ratio appeared to be a combination of increased neutrophils and decreased lymphocytes, with low lymphocytes being a previously reported poor prognostic factor [17, 31] , although neither was statistically significant individually, perhaps due to limited sample size. Similarly, a trend for higher ferritin [32] in those who didn't meet recovery criteria was present but not statistically significant. As opposed to prior suggestions that blood monocyte elevation is a prognostic indicator of poor outcome [33, 34] , our recovered patients had slightly higher (but not statistically significant) monocyte levels than those who did not recover. Baseline LDH, also a previously reported factor [17, 31] , was also not significantly associated with outcome in our cohort. Some of these discrepancies were likely due to our limited sample size. Too few patients had serial measurements of interleukin-6 [32, 35] to assess this marker reliably. The relationship of inflammatory markers to response to leronlimab treatment is unclear. It is possible that persons with less inflammation had better outcomes after leronlimab treatment simply because they were less ill at baseline.

Alternatively, it can be hypothesized that leronlimab could be more effective earlier in the inflammatory response by preventing chemotaxis of immune cells to effector sites such as the lung, and less effective later because those sites are already maximally infiltrated with those cells.

A c c e p t e d M a n u s c r i p t 14 Overall, our findings suggest a benefit to leronlimab in the treatment of severe COVID-19, including persons requiring mechanical ventilation. Some routine clinical markers of disease severity (blood CRP, D-dimer, and neutrophil:lymphocyte ratio) were associated with outcome after leronlimab treatment while others were not (ferritin, lymphocyte count, monocyte count, LDH). Whether this is due to our small cohort size or differences between leronlimab treated versus untreated patients is unclear. Randomized placebo-controlled trials are now underway and should help provide more helpful data to clarify efficacy and predictors of response to leronlimab to treat COVID-19.

Remdesivir for the Treatment of Covid-19 -Preliminary Report

Effect of Dexamethasone in Hospitalized Patients with COVID-19: Preliminary Report. medRxiv : the preprint server for health sciences

PRO 140, a monoclonal antibody targeting CCR5, as a long-acting, single-agent maintenance therapy for HIV-1 infection

Phase 2a study of the CCR5 monoclonal antibody PRO 140 administered intravenously to HIV-infected adults

Antiviral activity of single-dose PRO 140, a CCR5 monoclonal antibody, in HIV-infected adults

Anti-HIV-1 activity of weekly or biweekly treatment with subcutaneous PRO 140, a CCR5 monoclonal antibody

Differential inhibition of human immunodeficiency virus type 1 fusion, gp120 binding, and CC-chemokine activity by monoclonal antibodies to CCR5

Pathogenic human coronavirus infections: causes and consequences of cytokine storm and immunopathology

Lung pathology of fatal severe acute respiratory syndrome

Chemokine up-regulation in SARS-coronavirusinfected, monocyte-derived human dendritic cells

Modeling the early events of severe acute respiratory syndrome coronavirus infection in vitro

COVID-19 severity correlates with airway epithelium-immune cell interactions identified by single-cell analysis

Disruption of the CCL5/RANTES-CCR5 Pathway Restores Immune Homeostasis and Reduces Plasma Viral Load in Critical COVID-19. medRxiv : the preprint server for health sciences

Covid-19 and Kidney Transplantation

Delivered oxygen concentrations using lowflow and high-flow nasal cannulas

COVID-19 patients' clinical characteristics, discharge rate, and fatality rate of meta-analysis

Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. The Lancet Respiratory medicine 2020

Epidemiology, clinical course, and outcomes of critically ill adults with COVID-19 in New York City: a prospective cohort study

Risk Factors Associated With Acute Respiratory Distress Syndrome and Death in Patients With Coronavirus Disease

Presenting Characteristics, Comorbidities, and Outcomes Among 5700 Patients Hospitalized With COVID-19 in the New York City Area

Effect of Hydroxychloroquine in Hospitalized Patients with COVID-19: Preliminary results from a multi-centre, randomized, controlled trial. medRxiv : the preprint server for health sciences

Rationale and Design of ORCHID: A Randomized Placebo-controlled Clinical Trial of Hydroxychloroquine for Adults Hospitalized with COVID-19

Roche's phase III EMPACTA study showed Actemra/RoActemra reduced the likelihood of needing mechanical ventilation in hospitalised patients with COVID-19 associated pneumonia

Sanofi and Regeneron provide update on Kevzara® (sarilumab) Phase 3 U.S. trial in COVID-19 patients

Effect of Convalescent Plasma on Mortality among Hospitalized Patients with COVID-19: Initial Three-Month Experience. medRxiv : the preprint server for health sciences

Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia

Neutrophil-to-lymphocyte ratio predicts critical illness patients with 2019 coronavirus disease in the early stage

Neutrophil-to-lymphocyte ratio as an independent risk factor for mortality in hospitalized patients with COVID-19

Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China

COVID-19: consider cytokine storm syndromes and immunosuppression

Pathogenic T-cells and inflammatory monocytes incite inflammatory storms in severe COVID-19 patients

COVID-19 infection induces readily detectable morphological and inflammation-related phenotypic changes in peripheral blood

A c c e p t e d M a n u s c r i p t A c c e p t e d M a n u s c r i p t 18 A c c e p t e d M a n u s c r i p t 20 monocytes, the severity of which correlate with patient outcome. medRxiv : the preprint server for health sciences 2020: 2020.03. 24 A c c e p t e d M a n u s c r i p t 25 Figure 2