key: cord-0711892-sksoeu8x
authors: Sozio, Emanuela; De Monte, Amato; Sermann, Giovanni; Bassi, Flavio; Sacchet, Davide; Sbrana, Francesco; Ripoli, Andrea; Curcio, Francesco; Fabris, Martina; Marengo, Stefania; Italiani, Daniele; Luciana Boccalatte-Rosa, Daniela; Tascini, Carlo
title: CORonavirus-19 mild to moderate pneumonia Management with blood Ozonization in patients with Respiratory failure (CORMOR) multicentric prospective randomized clinical trial
date: 2021-06-12
journal: Int Immunopharmacol
DOI: 10.1016/j.intimp.2021.107874
sha: 078bb451bd8f8dbc02b24b6a407e865ee6d6ef6b
doc_id: 711892
cord_uid: sksoeu8x

BACKGROUND: Following positive experience on the use of blood ozonation in SARS-CoV-2, the CORMOR randomized trial was designed to evaluate the adjuvant role of oxygen/ozone therapy in mild to moderate SARS-CoV-2 pneumonia. METHODS: The trial (ClinicalTrial.gov NCT04388514) was conducted in four different Italian centers (April-October 2020). Patients were treated according to best available standard of care (SoC) therapy, with or without O3-autohemotherapy (O3-AHT). RESULTS: A total of 92 patients were enrolled: SoC + O3-AHT (48 patients) were compared to the SoC treatment (44 patients). The two groups differed in steroids therapy administration (72.7% in SoC arm vs. 50.0% in O3-AHT arm; p= 0.044). Steroid therapy was routinely started when it was subsequently deemed as effective for the treatment of COVID-19 disease. No significant differences in mortality rates, length of hospital stay, mechanical ventilation requirement and ICU admission were observed. Clinical improvement in patients with pneumonia was assessed according to a specifically designed score (decrease in SIMEU class, improvement in radiology imaging, improvement in PaO2/FiO2, reduction in LDH and requirement of oxygen therapy ≤5 days). Score assessment was performed on day-3 (T3) and day-7 (TEnd) of O3-AHT treatment. A significant increase in the score was reported at TEnd, in the O3-AHT treatment arm (0 [0-1] in the SoC arm vs. 2 [1], [2], [3] the O3-AHT arm; p= 0.018). No adverse events related O3-AHT treatment was observed. CONCLUSION: In mild-to-moderate pneumonia due to SARS-CoV-2, adjuvant oxygen/ozone therapy did not show any effect on mortality, or mechanical intubation but show a clinical improvement a day 7 from randomization in a composite clinical endpoint. Larger Randomized prospective studies alone or in combination with steroids are needed to confirm our results.

Nowadays, in vitro studies have demonstrated a beneficial impact of early therapy administration whereby serious complications of the disease such as acute respiratory failure are reduced [1] .

Concerning the best therapeutic approach, we refer to lessons learned from the use of viral agents on viruses belonging to the same Betacoronavirus family such as viruses belonging to the SARS, MERS (Middle East respiratory syndrome) and Ebola virus outbreaks [2, 3] .

Currently, there are no specific therapeutic agents available for the treatment of SARS COV 2 disease, although treatment with lopinavir/ritonavir did show decreased risk of adverse clinical outcomes as well as reduction of viral loads for the treatment of SARS infection during the 2003 outbreak [4] . Moreover, preclinical data suggests in vitro antiviral activity against SARS-CoV-2 by hydroxychloroquine (HCQ) [5] [6] [7] .

In the present study, designed in the initial phase of the pandemic in 2020, we considered these drugs as backbone therapy and thus evaluated their efficacy and safety as well as assessing the effects of additional blood ozonization.

The Italian Medical Agency (AIFA) approved the "off label" use of Lopinavir / Ritonavir (or Darunavir in combination with Cobicistat or Ritonavir) along with antimalarial HCQ for the treatment of SARS-CoV-2, only in prospective randomized trials [8].

Following a positive case-control experience employing blood ozonation [9] , and the confirmed lack of toxicity [10] , this study aimed to assess the adjuvant effects of blood ozonization in patients with SARS-CoV-2 respiratory failure by means of a multicentric randomized trial.

Since the First World War, blood ozonization provided effective bactericidal activity for the treatment of infections, wounds and multiple disease. Furthermore, cases of Ebola treatment with ozone therapy are reported in the literature, showing stimulation of oxygen metabolism and activation of the immune system along with a direct-action on human lung [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] .

The rationale of the CORMOR (CORonavirus-19 mild to moderate pneumonia Management with blood Ozonization in patients with Respiratory failure) study is to evaluate the additive antiinflammatory and immunomodulatory ozone-mediated action on hospitalized patients affected by SARS-CoV-2 [23, 24] . Randomization was performed by a central computer system whereby stratification occurred according to the number of patients to be assigned to the two study arms. The flow chart is depicted in Figure 1 while Table 1 reports the CORMOR study schedule of assessments. Clinical biochemistry and total blood count assessments were determined at baseline upon admission, including ABG, White Blood Cells (WBC), lymphocytes and platelet count, creatine phosphokinase (CPK), lactate dehydrogenase (LDH), Mid Regional pro-ADM (MR-proADM) and interleukin-6 (IL-6) blood level. in June 2020 [26, 27] hence, many patients were subsequently also treated with steroids (Dexamethasone 6 mg once daily for up to 10 days) even if this therapy was not initially included in the planned protocol drafting. Furthermore, a score for the assessment of patient improvement was elaborated during their inhospital stay. The score was evaluated at T 3 as: improvement of SIMEU class, presence of radiological improvement, 10% improvement in the PaO 2 /FiO 2 ratio, 10% reduction in LDH concentration (score from 0 to 4); while at T End the Pulmonary improvement score was evaluated as: improvement of SIMEU class, presence of radiological improvement, 10% improvement in the PaO 2 /FiO 2 ratio, 10% reduction in LDH concentration and length of oxygen therapy <5 days (score from 0 to 5). This score denotes patient improvement based on Clinical, Biochemical and Radiological variables. Because it considered: i) clinical aspects (SIMEU phenotype, length of O 2 therapy and PaO 2 /FiO 2 ratio); ii) biochemical parameters (LDH improvement); and iii) radiologic improvement.

Statistical analyses: All variables were expressed as mean ± standard deviation, median and interquartile interval or proportion, depending on their distributions. Consequently, comparisons between groups were performed with unpaired sample t-test, Mann-Whitney test or chi-squared test with continuity correction. In order to quantify the improvement of patients during their inhospital stay, we computed a score given by the sum of five binary variables, each indicating a specific condition: a percentual decrease of a least 10% in LDH, a percentual increase of at least 10% in PaO 2 /FiO 2 ratio, a decrease of at least 1 point in SIMEU class, the presence of radiological improvement, a less than 5 days duration of oxygen therapy. All the analyses were performed in the R software environment [28] , a p value less than 0.05 was considered statistically significant. The baseline characteristics of the patients in the two groups were well matched and balanced and are reported in Table 2 . A significant difference in symptoms was seen in patients reporting dyspnea.

Drug therapy and safety: The SoC therapies were comparable, with the exception of steroids, among both groups as shown in Table 3 ). Steroid therapy was started after seven days from onset of COVID-19 symptoms. Within the SoC cohort, 72,7% of patients received concomitant steroid therapy whereas 50% of patients in the O 3 -AHT arm (p= 0.043) were administered steroids.

No adverse event related to O 3 -AHT was reported. Diarrhoea and QT interval prolongation were the main adverse event reported (see Table 3 ) in association with subsequent antiretroviral and/or HCQ discontinuation.

Efficacy end points: No differences in SIMEU class improvement at T 3 and at T End in terms of admission to ICU, mortality rate, length of hospital stays, improving of the chest imaging, invasive ventilation or IOT need and cytokine levels ( Table 4) were observed between the two treatment groups. At the T 3 timepoint, the O 3 -ATH group presented a significant difference in terms of low white blood cells count and elevated C reactive protein as opposed to the SoC arm. These differences were not observed at the T End timepoint ( Table 4) . To note that no significant differences were note in IL-6 and MR-proADM levels. Moreover, the laboratory parameters time course is show ed in Table 5 ).

Furthermore, a significant increase in the ad-hoc designed score values (for the assessment of patient improvement during their in-hospital stay), was reported at T End (score 0 [0-1] in SoC group vs. score 2 [1] [2] [3] the O 3 -AHT group; p= 0.018) timepoint demonstrating a clinical improvement of the patients with O 3 -AHT (Figure 2 ).

The CORMOR study is the first randomized trial for the evaluation of blood ozonization as adjuvant therapy in the treatment of adult patients with confirmed COVID-19 mild to moderate pneumonia.

Ozone therapy application is known to reduce oxidative stress whereas COVID-19 activates reninangiotensin-aldosterone system inducing oxidative stress leading eventually to cytokine storm.

Ozone therapy is recommended to counter the disruptive effects of severe COVID-19 on lung tissues, especially if administered in early stages of the disease, thereby preventing the progression of COVID-19 lung disease [23] , as well as the favourable rheological and tissue perfusion properties to limit ischemic lung damage [29] [30] [31] .

The therapeutic effect of ozone is maximized in the early phases of disease development when blood oxygenation is hampered by interstitial edema and alveoli fluid exudates, but only with a limited extension of lung tissue consolidation [32, 33]. Our approach with respect to enrolled patients stratified according to SIMEU clinical phenotype 2 or 3 was thus based on these pathophysiological arguments. Although the two groups had a baseline significant difference in dyspnea it has not a significant change in the baseline PaO 2 / FiO 2 ratio ( Table 4 ) and this parameter had better time-course in the O 3 -AHT arm ( Table 5 ).

In this randomized trial we observed a significant improvement in patient's lung function during their in-hospital stay (Figure 2 ) albeit missing the primary efficacy end point. A possible explanation of this may reside in the fact that a good proportion of enrolled patients were administered concomitant steroid therapy, although this drug was not allowed in the baseline protocol. Moreover, the SoC arm had a significantly higher use of steroid therapy as opposed to the SoC+O 3 -AHT one (see Table 3 We believe that the therapeutic effect of ozone is maximized in the early development of the disease when blood oxygenation is hampered by interstitial edema and exudation of fluid into the alveoli leading to ventilation/perfusion mismatch. This is the clinical evolution described by CT scan features as ground glass opacities image and crazy paving appearance. Ozone treatment in this phase might prevent further evolution of lung damage, when the ARDS develop and treatment is more difficult.

For Ozone therapy it has been postulated an anti-inflammatory effect especially in reducing proinflammatory cytokines and other authors have also observed a decreased of IL-6 levels after ozone treatment [10, 35, 38 ]. In our prospective study, we did not observe this effect, respect to the control group, on the reduction of IL-6 level.

In own study, the mortality rate was the same in both groups of patients with mild to moderate Table 3 for detail). Legend: ACE -angiotensin-converting enzyme; BMI -body mass index; COPD -chronic obstructive pulmonary disease. Legend: CPAP -continues positive air pressure; ICU -intensive care unit; IL-6 -interleukin-6; IOT -orotracheal intubation; LDH -lactate dehydrogenase; MR-proADM -mid Regional pro-ADM;

SIMEU -Italian Society of Emergency and Urgency Medicine; SOFA -Sequential Organ Failure Assessment score; WBC -white blood cells. 

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Legend: T 0 -study inclusion; T 3 -after the 3 rd blood ozonization treatment; T End -follow-up visit at one week after the end of blood ozonization

MR-proADM -mid Regional pro-ADM

WBC -white blood cells