key: cord-0758328-7uzmj0w6
authors: Bozzi, Giorgio; Mangioni, Davide; Minoia, Francesca; Aliberti, Stefano; Grasselli, Giacomo; Barbetta, Laura; Castelli, Valeria; Palomba, Emanuele; Alagna, Laura; Lombardi, Andrea; Ungaro, Riccardo; Agostoni, Carlo; Baldini, Marina; Blasi, Francesco; Cesari, Matteo; Costantino, Giorgio; Fracanzani, Anna Ludovica; Montano, Nicola; Monzani, Valter; Pesenti, Antonio; Peyvandi, Flora; Sottocorno, Marcello; Muscatello, Antonio; Filocamo, Giovanni; Gori, Andrea; Bandera, Alessandra
title: Anakinra combined with methylprednisolone in patients with severe COVID-19 pneumonia and hyperinflammation: an observational cohort study
date: 2020-11-19
journal: J Allergy Clin Immunol
DOI: 10.1016/j.jaci.2020.11.006
sha: b687299999c5e81438d447845ff306f1d09731ff
doc_id: 758328
cord_uid: 7uzmj0w6

Background Immunomodulants have been proposed to mitigate SARS-Cov-2-induced cytokine storm, which drives acute respiratory distress syndrome in COVID-19. Objective To determine efficacy and safety of the association of IL-1 receptor antagonist anakinra plus methylprednisolone in severe COVID-19 pneumonia with hyperinflammation. Methods Secondary analysis of prospective observational cohort studies at an Italian tertiary health-care facility. COVID-19 patients consecutively hospitalized (02/25/2020 to 03/30/2020), with hyperinflammation (ferritin ≥1000ng/mL and/or C-reactive protein >10mg/dL) and respiratory failure (oxygen therapy from 0.4 FiO2 Venturi mask to invasive mechanical ventilation) were evaluated to investigate the effect of high-dose anakinra plus methylprednisolone on survival. Patients were followed from study inclusion to day 28 or death. Crude and adjusted (sex, age, baseline PaO2:FiO2 ratio, Charlson Index, baseline mechanical ventilation, hospitalization to inclusion lapse) risks were calculated (Cox proportional regression model). Results 120 COVID-19 patients with hyperinflammation (median age 62 years, 80.0% males, median PaO2:FiO2 ratio 151, 32.5% on mechanical ventilation) were evaluated. Of these, 65 were treated with anakinra and methylprednisolone and 55 were untreated historical controls. At 28 days, mortality was 13.9% in treated patients and 35.6% in controls (Kaplan-Meier plots, p=0.005). Unadjusted and adjusted risk of death was significantly lower for treated patients compared to controls (HR 0.33 (95%CI 0.15-0.74), p=0.007 and HR 0.18 (95%CI 0.07-0.50), p=0.001, respectively). No significant differences in bloodstream infections or laboratory alterations were registered. Conclusions Treatment with anakinra plus methylprednisolone may be a valid therapeutic option in COVID-19 patients with hyperinflammation and respiratory failure, also on mechanical ventilation. Randomized, controlled trials including use of either agent alone are needed to confirm these results.

In the search for an optimal support treatment, combination of high-dose anakinra plus methylprednisolone may be beneficial in COVID-19 severe pneumonia with hyperinflammation. This combined treatment is candidate for further investigation. High levels of pro-inflammatory cytokines, C-reactive protein (CRP) and ferritin correlate with worse outcomes in patients with severe COVID-19 [2] [3] [4] . Growing evidence suggests that these patients develop a hyperinflammatory syndrome resembling cytokine storm syndromes (CSS), potentially benefiting from immunomodulatory treatment [5] .

IL-1-receptor antagonist anakinra is one of the cytokine-blocking agents employed for COVID-19 treatment [5] . While randomized clinical trials are ongoing [6] , single-center experiences have reported encouraging findings [7] [8] [9] [10] . The short half-life of anakinra enables to rapidly discontinue its action in case of adverse reactions or secondary infections, making its use suitable also for critically ill patients [7, 10] . IL-1 inhibition is also associated with reduction in endothelial dysfunction and microvascular alteration [11] , which seem crucial in COVID-19-related thromboembolic events [12] .

Corticosteroid treatment is a cornerstone in the management of non-infectious hyperinflammatory conditions, namely CSS [13] . Favorable data have recently emerged in support of the use of corticosteroids in patients with severe COVID-19, especially in those receiving invasive mechanical ventilation [14] [15] [16] [17] . In a recent meta-analysis of prospective, randomized clinical trials on critically ill patients with COVID-19, use of corticosteroids compared to placebo or standard of care (SOC) resulted in a significantly lower 28-day mortality [18] .

With this study, we aimed at investigating efficacy and safety of combined treatment with anakinra and methylprednisolone (anti-IL-1+MPD) in COVID-19 patients with hyperinflammation and respiratory failure.

J o u r n a l P r e -p r o o f Out of 476 COVID-19 patients admitted at our hospital between February 25 and March 30, 2020, a total of 120 (25.2%) patients with hyperinflammation and respiratory failure were included according to inclusion/exclusion criteria (see METHODS in the Online Repository). Of these, 65

were treated with anti-IL-1+MPD and 55 were untreated historical controls.

Median age of study population was 62 years (IQR 54.5-70), 80.0% (96/120) were males and median Charlson Comorbidity Index (CCI) was 0 (IQR 0-1). At inclusion, median PaO2: (Table 1) .

Within the 28-day follow-up, 28/120 (23%) patients died, 9/65 (13.9%) in the anti-IL-1+MPD group compared to 19/55 (35.6%) controls (Kaplan-Meier curves, p=0.004, Figure 1A ). Among patients without MV, mortality rate was 6/47 (12.8%) in anti-IL-1+MPD compared to 10/34 (29.4%) in controls (p=0.04, Figure 1B ). Among those with MV, it was 3/18 (16.7%) in anti-IL-1+MPD and 9/21 (42.8%) in controls (p=0.076, Figure 1C ). Overall cumulative risk of death at 28 days was significantly lower for anti-IL-1+MDP compared to controls (HR 0.33, 95%CI 0.15-0.74, p=0.007). Other factors significantly associated with survival were age <65 years, baseline PaO 2 :FiO 2 ratio >100 and CCI 0 compared to ≥1. No association to survival was found for antiviral treatment or for anticoagulant therapy (see Tables E1 and E2 in the Online Repository). At multivariable analysis, treatment with anti-IL-1+MPD was found to be independently associated J o u r n a l P r e -p r o o f with survival when adjusted by gender, age, baseline PaO 2 :FiO 2 ratio, CCI, MV at inclusion, and days between hospitalization and inclusion (HR 0.18, 95%CI 0.07-0.50, p=0.001) (see Table E3 in the Online Repository).

Treated patients experienced consistent improvements in respiratory function and a rapid lowering of serum CRP levels during treatment ( Figure 2 ).

Overall, anti-IL-1+MPD treatment was well tolerated. Grade ≥3 gamma-glutamyl transferase increase (27.7%), anemia (24.6%), alanine transaminase increase (6.2%), granulocytopenia (1.5%) were observed in treated patients. However, a comparable proportion of these AEs were observed within controls. No difference in AE were reported between intravenous and subcutaneous route of administration. Nine bloodstream infections (13.8%) were observed in anti-IL-1+MDP and 4 (7.3%) in controls (p=0.23).

To the best of our knowledge, this is the largest observational study evaluating efficacy of anakinra associated with methylprednisolone in COVID-19 patients with hyperinflammation and respiratory failure.

Several clinical trials are currently in progress to evaluate the benefits of anakinra treatment in COVID-19 [6] . In a retrospective study of COVID-19 patients with respiratory failure outside the ICU, Cavalli et al. found a survival benefit in high-dose anakinra (5 mg/kg twice a day intravenously) use compared to SOC (90% vs 56% at day 21) [9] . A significant reduction in a composite outcome of mortality and/or ICU admission was also observed in a French cohort treated with subcutaneous anakinra (100 mg twice a day for 72 hours, then 100 mg daily for 7 days) compared to historical controls (25% vs 73% at day 20) [10] . In contrast to these studies, our analysis encompassed almost one third of patients (32.5%) who were on MV at inclusion.

Moreover, combined treatment with high-dose anakinra and methylprednisolone was chosen based on widely approved treatment regimens used in severe cytokine storm syndromes [13] . Of note, corticosteroids such as dexamethasone [14, 15] and methylprednisolone [16, 17] have recently shown J o u r n a l P r e -p r o o f to be beneficial in COVID-19 patients with respiratory failure. In the RECOVERY trial, the addition of short-course dexamethasone (6mg q24h for 10 days or less) to SOC resulted in lower 28-day mortality compared to SOC alone among hospitalized COVID-19 patients (22.9% vs 25.7%, respectively) [14] . Interestingly, the highest beneficial effect was obtained in patients on invasive mechanical ventilation (29.3% mortality in the dexamethasone group compared to 41.4% mortality in the SOC group at day 28), whereas no difference was seen among those receiving no respiratory support. No treatment with anakinra was reported in any of the study arms. Conversely, in the CoDEX trial, the addition of intravenous dexamethasone (20 mg q24h for 5 days, followed by 10 mg q24h for additional 5 days) to SOC compared to SOC alone in mechanically ventilated COVID-19 patients with moderate to severe ARDS resulted in a significant benefit in the number of ventilator-free days (6.6 vs 4.0 days) but not in all-cause 28-day mortality (56.3% vs 61.5%, respectively) [15] . In their multicenter quasi-experimental study, Fadel et al. compared mortality and/or ICU admission of patients with moderate to severe COVID-19 either on early, short-course methylprednisolone (0.5 to 1 mg/kg/die for 3 days) or SOC [16] . The composite endpoint occurred at lower rate in the methylprednisolone group (34.9% vs 54.3% at day 14). Again, no patient was treated with anakinra. Ramiro et al. prospectively investigated the effect of high-dose intravenous methylprednisolone (250 mg on day 1 followed by 80 mg on days 2-5) on the outcome of patients with severe COVID-19-associated CSS and respiratory failure [17] . In 43% of cases anti-IL6 tocilizumab was added as escalation of immunosuppressive treatment, whereas no patients received anakinra. Compared to matched historical controls, hospital mortality was 65% lower and the need of mechanical ventilation was 71% lower in the treatment group. Table 2 summarizes the major clinical studies that have employed either anakinra alone or steroids alone for the treatment of severe COVID-19 so far.

In our study, patients treated with the combination of anakinra plus methylprednisolone experienced lower mortality than controls (13.9% vs 35.6% at day 28, p=0.004). Notably, mortality in treated patients who were on MV at baseline was as low as 16.7%, yet only a trend towards significance J o u r n a l P r e -p r o o f emerged compared to SOC group, possibly due to limited sample size. The outcomes of this population can be compared to the results of MV patients in the RECOVERY trial (no comparison can be made for non-MV patients due to different disease severity between studies) [14] . While the 28-day mortality is similar between MV patients in control groups (42.8% vs 41.4%), our cohort of patients treated with anti-IL-1+MPD seemed to have experienced a better outcome than patients in the dexamethasone arm of RECOVERY trial (16.7% vs 29.3% mortality at 28 day, respectively).

The use of anakinra as add-on therapy to corticosteroids may provide meaningful clinical benefits in this setting and warrants further consideration. The impact of combined treatment was confirmed after adjusting by age, comorbidities, respiratory dysfunction and length of hospitalization before inclusion, with a 18% reduction in mortality. Combined treatment was overall well tolerated, with no significant differences in AE compared to controls. Frequencies of bloodstream infections and laboratory alterations of patients treated with anakinra plus methylprednisolone were similar to those reported in studies investigating anakinra as a single agent [8] [9] [10] .

Our work has limitations. Firstly, the monocentric nature of the study might affect the generalizability of our results. Secondly, although controls have been recruited in the same setting, their number is lower than the cases, mainly because the association of anti-IL-1+MPD has been implemented relatively early during the pandemic. Thirdly, since no groups treated either with anakinra alone or methylprednisolone alone have been included in the analysis, no definitive conclusions could be drawn on the single or synergistic effect of the two drugs. Moreover, standardof-care consisted of evolving combinations of antivirals and anti-coagulant therapy which, although not significantly associated to survival, represent a potential bias. Lastly, no primary hard endpoint other than 28-day mortality was considered: intermediate endpoints may help better evaluating treatment efficacy in patients with different severity and length of disease.

In conclusion, combined treatment with anakinra and methylprednisolone may be a valid Legend: CRP C-reactive protein, IV intravenous, SOT standard of therapy, SC subcutaneous, CI confidence interval, MV mechanical ventilation, MPD methylprednisolone, ICU intensive care unit, TCZ tocilizumab (humanized monoclonal antibody against the interleukin-6 receptor) J o u r n a l P r e -p r o o f survival of all individuals exposed to combined treatment is shown in the red color, dotted line;

survival of the control group is shown in the blue color, continuous line; Panels B and C): survival of individuals exposed to combined treatment compared to controls in patients without and with mechanical ventilation at inclusion, respectively. 

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analysis of prospective, observational cohort studies (COVID-19_Network; nCOV-2019_ICU Study) was performed at Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico

Exclusion criteria were: data available for <48 hours or death within 48 hours from inclusion; symptoms for <7 days

treatment with anti-IL-1 or MPD alone

Treatment was implemented at a different time in distinct settings (i. e., COVID-19 intensive care unit, sub-intensive care unit, internal medicine), starting from the intensive care unit. Written informed consent for off-label use was obtained from all patients (except those on MV). The control group included COVID-19 patients admitted and followed from February 25, 2020, to the time of anti-IL-1+MPD introduction. Patients who retrospectively fulfilled all the inclusion and exclusion criteria for

Sweden) was administered subcutaneously at 200mg q8h for 3 days, then 100mg q8h up to day 14 [13]. MV patients were treated with off-label intravenous administration (3-hour infusion time

Also, since MV patients were on anti-coagulant therapy, subcutaneous administration could caused

Methylprednisolone was administered at 1mg/kg loading dose, then 1mg/kg/day (fractioned, two doses) for 5 days, then 0.5mg/kg/day (fractioned, two doses) for 5 days

According to the hospital internal guidelines, all patients received antithrombotic prophylaxis/treatment with enoxaparin sodium during hospitalization. Specifically, until mid March, 2020, hospital guidelines recommended prophylaxis with 100 U/kg q24h for patients <80Kg and 5000 U q12h for >80Kg (if normal renal function), irrespectively of the severity of the disease

dosage was increased and stratified according to the severity of the disease (and the corresponding risk of thromboembolic events): 100 U/kg q24h in COVID-19 internal medicine

70 U/kg q12h in COVID-19 sub-intensive care units, 100 U/kg q12h in COVID-19 intensive care unit

Kaplan-Meier plots were used for survival data. Patients were followed from t0 to day 28 or death. If discharged earlier than day 28, patient status was assessed by post-discharge follow-up phone calls. Unadjusted and adjusted Cox proportional regression models were performed after controlling for proportional hazards assumption. Factors associated with mortality at univariate analysis and hospitalization setting