key: cord-0780649-hl5rkrcs
authors: Xia, Qi; Xu, Kaijin; Ni, Qin; Li, Yongtao; Liu, Jun; Zhao, Hong; Guo, Yongzheng; Yu, Liang; Yi, Ping; Su, Junwei; Lang, Guanjing; Tao, Jingjing; Shi, Ding; Wu, Wenrui; Wu, Xiaoxin; Xu, Yan; Xu, Min; Yu, Ling; Wang, Xiaoyan; Cai, Hongliu; Fang, Qiang; Zhou, Jianying; Qiu, Yunqing; Li, Lanjuan
title: Clinical efficacy of Methylprednisolone and the combined use of Lopinavir/Ritonavir with Arbidol in treatment of Coronavirus Disease 2019
date: 2021-01-15
journal: J Med Virol
DOI: 10.1002/jmv.26798
sha: ec13a2cfe237c7e1bbb1a9765803a34696816c01
doc_id: 780649
cord_uid: hl5rkrcs

OBJECTIVE: This study aims to comparatively analyze the therapeutic efficacy upon multiple medication plans over Lopinavir/Ritonavir (LPV/r), Arbidol (ARB) and Methylprednisolone on patients with Coronavirus Disease 2019 (COVID‐19). METHODS: Totally 75 COVID‐19 patients admitted to The First Affiliated Hospital, Zhejiang University School of Medicine from January 22, 2020 to February 29, 2020 were recruited and grouped based on whether or not LPV/r and ARB were jointly used and whether or not Methylprednisolone was used. Indexes including body temperature, time for nucleic acid negative conversion, hospital stays and laboratory indexes were examined and compared. RESULTS: For all patients, there were no significant differences in the change of body temperature, the time for negative conversion and hospital stays whether LPV/r and ARB were jointly used or not. While for severe and critically severe patients, Methylprednisolone noticeably reduced the time for negative conversion. Meanwhile, the clinical efficacy was superior on patients receiving Methylprednisolone within 3 days upon admission, and the duration of hospital stays was much shorter when Methylprednisolone was given at a total dose of 0‐400 mg than a higher dose of >400 mg if all patients received a similar dose per day. Nonetheless, no significant changes across hepatic, renal and myocardial function indexes were observed. CONCLUSION: LPV/r combined with ARB produced no noticeably better effect on COVID‐19 patients relative to the single agent treatment. Additionally, Methylprednisolone was efficient in severe and critically severe cases, and superior efficacy could be realized upon its early, appropriate and short‐term application. This article is protected by copyright. All rights reserved.

The novel coronavirus pneumonia (officially named as Coronavirus Disease 2019, that outbroke in December 2019 is highly contagious with a relatively low cure rate, and patients always develop fever, cough, myalgia, fatigue and diarrhea when they get infected 1 . Due to the failure of virus strain isolation, emerging evidence that the impact caused by the outbreak is more dramatic than initially thought and the presence of international transmission that has been driven by travelers, the ongoing COVID-19 outbreak has posed great challenges for the Public Health Laboratory 3 . Therefore, it is urgent to carry out research on prevention of coronavirus disease.

To know more about the COVID-19, some similar respiratory diseases, such as SARS and MERS (Middle East Respiratory Syndrome), which happened before can be studied for reference. Coronaviruses that cause SARS and MERS (SARS-CoV and MERS-CoV) are two types of viruses present in human in the early 21th century characterized by a high rate of transmissibility and fatality. SARS which broke out in 2002 caused 8,422 infectious worldwide by August 15, 2003 and 916 deaths with a fatality rate around 10% 4, 5 . While for MERS, the fatality rate was up to 35% 6 .

However, we do not know whether the COVID-19 epidemic is similar to SARS/MERS or manifests different clinical characteristics. At present, no specific antiviral drugs or vaccines available for COVID-19 have been developed, which prompts us to find suitable therapeutic medicine as soon as possible.

In view of the treatment experience towards SARS and MERS, 20 drugs that could be potentially active against the COVID-19 virus are identified. Among the drugs, Lopinavir (LPV), Ritonavir (RTV) and Arbidol (ARB) are the three drugs commonly used in clinical treatment. LPV is a protease inhibitor against HIV-1 and its half-life period can be prolonged upon inhibition of cytochrome P4507 and combined use with RTV. RTV is a type of broad-spectrum antiviral drug as well as a nucleotide analog prodrug that has superior in vitro antiviral activity across various RNA viruses. As a therapeutic drug, RTV is also able to greatly reduce severe lung pathology 9 . It is proven that the combined use of Lopinavir/Ritonavir (LPV/r) and interferon β (IFN-β) makes effect in patients infected with SARS-CoV 10 . ARB is a small indole-derivative molecule and has been used in prevention and treatment of influenza and other respiratory viral infections 12 . As well, ARB is a broad-spectrum antiviral drug and is effective in process of anti-influenza viruses by targeting the hemagglutinin fusion machinery 13 . Although LPV, RTV and ARB are reported to play a part in patients with SARS/MERS, their role in COVID-19 has not been demonstrated.

Other than the anti-viral drugs, some hormone drugs may produce certain effect on COVID-19 virus as well. Methylprednisolone is a non-halogenated corticosteroid characterized by relatively high intrinsic activity with a methyl group at C6 15 . It is established that treatment efficacy can be affected from various aspects, including the severity of disease, time to interventional treatment, the dosage of hormone drugs and the duration time. As reported, hormonotherapy used in treatment of patients with severe acute respiratory distress syndrome (ARDS) is able to reduce pulmonary fibrosis and prevent progressive pathological deterioration 16 . Through previous studies, we can see that the application of glucocorticoids (GCs) can lead to a significant decrease in mortality of adult patients with severe pneumonia, while the use of corticosteroids can contribute to a shorter time of clinical cure, length of hospital and ICU stays, with no respiratory failure or shock developed upon the bout of pneumonia, as well as the incidence of pneumonia complications 18 . Hence, it is also significant to study the possible clinical efficacy that Methylprednisolone may produce on the patients with COVID-19.

Here, we performed an observational retrospective study on patients with COVID-19 who received diverse medication plans over LPV/r, ARB and Methylprednisolone. Roughly, differences in body temperature, time for nucleic acid negative conversion, hospital stays and laboratory indexes were comparatively analyzed in patients with different medication plans. Based on the observational results, therapeutic effects of Methylprednisolone and the combined use of LPV/r and ARB were then evaluated. Overall, our research findings may help clinicians Accepted Article apply LPV/r, ARB and Methylprednisolone these three types of drugs in a more reasonable manner.

A total of 75 patients with COVID-19 who were admitted to The First Affiliated Hospital, Zhejiang University School of Medicine in the period of January 22 to February 29, 2020 were enrolled and their respiratory tract nucleic acid (nCoV-RNA here) testing turned out to be positive as detected by quantitative PCR.

The cohort was comprised of 41 males and 34 females with an average age of (51.6 ± 15.0) years old.

All subjects were identified as mild (n=4), moderate (n=22), severe (n=39) and critically severe (n=10) patients according to the following criteria:

(1) Mild cases: the clinical symptoms are mild with no pneumonia manifestations appeared in imaging;

(2) Moderate cases: fever and respiratory symptoms are developed and pneumonia manifestations can be found in imaging;

(3) Severe cases: adults who meet one of the following criteria are identified as severe cases: respiratory rate (RR) ≥ 30 times/min; the figure oxygen saturation under the resting state, SpO 2 ≤ 93%; arterial partial pressure of oxygen (PaO 2 ) /oxygen concentration (FiO 2 ) ≤ 300 mmHg; patients who have noticeable lesion progression >50% within 24-48 h are treated as severe cases;

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(4) Critically severe cases: patients who are in line with one of the criteria below: respiratory failure that requires mechanical ventilation; presence of shock; other organ failure which needs monitoring and treatment in ICU.

Here, mild and moderate cases were collectively referred to mild cases, while severe and critically severe cases were called severe cases jointly. Afterwards, patients were sub-grouped into 4 groups based on their therapeutic regimens: combination of LPV/r and ARB /un-combination and Methylprednisolone/control groups.

For patients in the combination group and un-combination group, the medication plan was designed as below: LPV/r tablet was given 2 tablets once per 12 h, by oral. While ARB was given 200 mg thrice daily, by oral. For patients receiving Methylprednisolone, Methylprednisolone was given by intravenous injection one or two times per day with the total accumulative dose of (0.75-1.5) mg/kg.

(1) Body temperature: changes of body temperature are monitored daily upon admission for consecutive 10 days and the highest temperature is taken;

(2) Blood routine and abnormal lymphocyte: total hemoglobin count (Hb, g/L), total white blood cell count (WBC, 10 9 /L), neutrophil count (10 9 /L), lymphocyte count (10 9 /L);

(3) Hepatic, renal and myocardial function indexes: C-reactive protein (CRP, mg/L), total cholesterol (mmol/L), albumin (g/L), total bilirubin (μmol/L), direct bilirubin (μmol/L), alanine aminotransferase (ALT, U/L), aspartate aminotransferase This article is protected by copyright. All rights reserved.

(AST, U/L), creatine kinase isoenzyme (CK-MB, U/L), creatine phosphokinase (CPK, U/L), glomerular filtration rate (GFR, mL/min);

(4) Immune related indexes: immunoglobulin M (IGM, mg/dL), IGA (mg/dL), IGG (mg/dL), TNF-γ (pg/mL), interleukin-10 (IL-10, pg/mL), IL-6 (pg/mL), IL-2 (pg/mL), IL-4 (pg/mL),;

(5) Procalcitonin examination: procalcitonin (PCT, ng/mL); (6) Pulmonary CT imaging: pulmonary CT scan for baseline evaluation was usually performed upon admission and required a review 2-3 days after if ideal therapeutic efficacy is not reached, but 5-7 days after if the symptoms are stable or improved after treatment. For critically severe patients, portable chest X-ray is recommended daily. 

All data were processed on SPSS 22.0. Enumeration data between groups were comparatively analyzed using Fisher's precise test, while part of the data were presented as mean ± standard deviation (SD) with t test applied for verification.

P<0.05 was set as the threshold for statistical significance. This article is protected by copyright. All rights reserved.

As most patients had developed fever upon admission, the change of body temperature was taken as an important indicator and monitored daily from the beginning of treatment for consecutive 10 days. It turned out that no matter for mild or severe patients, the change of body temperature showed no significant difference between patients receiving combination treatment and single agent treatment These results demonstrated that the body temperature of patients with COVID-19 was not greatly affected by Methylprednisolone or LPV/r combined with ARB.

After analysis on the body temperature, the time for nCoV-RNA turned to negative and hospital stays were recorded and compared. As for the combination and un-combination groups, there was no significant difference towards these two indexes in both mild and severe patients ( Figure 2 unveiled that increased dose of Methylprednisolone could contribute to a decreased time of negative conversion, yet the time for hospital stays was reduced first and then increased. It was worth noting that when the total dose was higher than 400 mg, despite the significant reduction of negative conversion time, the nCoV-RNA would be repeatedly converted to positive, in turn resulting in the remarkable prolong of hospital stays (around 24 days) (Figure 2) . In view of this, we considered that Methylprednisolone at a routine dose (0-400 mg) would produce superior efficacy on severe patients. Nevertheless, Methylprednisolone in our study was usually used in severe and critically severe patients at a dose of (0.75-1.5) mg/kg per day, and our study found that a total dose of either 0-200 mg or 200-400 mg of Methylprednisolone presented no significant difference in therapeutic efficacy on patients (Figure 2) . Hence, we believed that under the circumstance that a certain dose range of Methylprednisolone was given to each patient per day, prolonged use of Methylprednisolone was not much efficient in severe patients. Overall, we proposed that Methylprednisolone should be used at a routine dose with a short-term duration as early as possible.

Pulmonary imaging test is vital for diagnosis, efficacy monitoring and evaluation upon discharge of patients with COVID-19. Hence, we conducted such This article is protected by copyright. All rights reserved.

test in our subjects upon admission as well as during treatment. As unveiled by the imaging, the time to achieve improved lesions the first time was not much variate between patients undergoing Methylprednisolone within 3 days (6.70±3.70 days) and after 3 days (8.88±4.62 days) upon admission. While for patients who were given Methylprednisolone at a total dose of 0-400 mg or over 400 mg, significant difference was observed where the time for patients with 0-400 mg was 6.92±3.70 days shorter than 11.00±0.82 days for patients with over 400 mg. Given the findings, Methylprednisolone at a routine dose could bring benefit for improvement of lung lesions.

As the above section mentioned, Methylprednisolone at a routine dose was able to produce superior therapeutic efficacy on severe patients. In this part, some significant physiological and biochemical indexes of the cohort upon admission (baseline) and discharge were test and recorded on the basis of whether Methylprednisolone was used in a routine dosage or not used. In total, 14 relevant indexes, including CRP, total Hb, total WBC, neutrophil, lymphocyte, IGM, IGA, IGG, TNF-γ, IL-10, IL-6, IL-2, IL-4, PCT, were analyzed. Regarding the baseline levels, no noticeable difference in the abnormal proportions (the percentage of severe patients with abnormal indexes in all severe patients of the corresponding group) of all these indexes was monitored between the two groups (p>0.05). While after treatment, the proportions across CRP, total Hb, lymphocyte and PCT upon discharge were all decreased in a certain degree relative to baseline values in patients who received Methylprednisolone at a total dose of (0-400) mg, and such reduction was also seen in some pro-inflammatory factors like IGM, IGG, IL-10 and IL-6. Nonetheless, the proportions in patients who were not treated with This article is protected by copyright. All rights reserved.

Methylprednisolone at the time of discharge showed no significant difference with those in patients receiving (0-400) mg dose of Methylprednisolone (p>0.05). Taken together, Methylprednisolone at a total dose of (0-400) mg made minor effect on physiological and biochemical indexes in severe patients. 

The purpose of this study was to comparatively analyze the clinical therapeutic efficacy upon the combined use of LPV/r with ARB and single agent use of LPV/r This article is protected by copyright. All rights reserved.

or ARB. In the meantime, the efficiency that Methylprednisolone may produce in clinical treatment was also discussed.

For detection of coronavirus infection, body temperature is the most noticeable indicator that can be detected in a highest speed. While for COVID-19 virus infection, fever also turns out the main initial symptom as revealed by a statistical analysis on 78 patients with COVID-19 reported by Liu Wei et al., and 57 patients (73.1%) sought for treatment due to fever, with a high temperature of (37.3-38) ℃ most common in 31 (39.7%) patients. In addition, patients (n=99) admitted to Wuhan Jinyintan Hospital were analyzed by Chen Nanshan 7 , and it was found that up to 82 cases (83%) manifested fever. Our study signified that the therapeutic efficacy regarding body temperature which produced by the combination treatment of LPV/r and ARB in either mild or severe cases showed no significant difference with that caused by single agent treatment. In the meantime, Methylprednisolone also exhibited no superior effect. It could be seen that whether LPV/r and ARB were jointly used or whether Methylprednisolone was applied, no noticeable improvement of body temperature was observed in patients with COVID-19.

Methylprednisolone was reported to play a part in improvement of pulmonary mechanics and respiratory function in a low dosage upon rescue administration 24 days after the onset of ARDS, which in turn experienced accelerated separation from extra corporeal membrane oxygenation 22 . Additionally, it was reported that the occurrence of clinical adverse complications of SARS patients who underwent treatment with GCs was in a dosage-dependent manner 24, 25 . In our study, we also found that a short-term use of Methylprednisolone at a routine dose of 0-400 mg in an early stage could produce superior effect on reduction of time for negative conversion as well as hospital stays of patients in severe and critically severe This article is protected by copyright. All rights reserved.

conditions. Moreover, no noticeable toxic and side effects were developed during the Methylprednisolone treatment.

Changes in some indexes like cytokines and inflammatory factors can also be seen during the COVID-19 virus infection. Wang Dawei et al. 26 found that most patients occurred noticeable lymphopenia during hospitalization. In the meantime, the count of WBC and neutrophil appeared to be higher in non-survivors than those in survivors, suggesting that COVID-19 virus infection might be responsible for cellular immunity deficiency, blood coagulation activation, myocardial injury, liver and kidney damage. Similarly, Huang Chaolin et al. 21 In conclusion, this study confirmed that the combined use of LPV/r and ARB was not superior to single agent treatment with LPV/r or ARB in treatment of patients with COVID-19. In the meantime, Methylprednisolone could noticeably reduce the time for negative conversion and hospital stays of severe and critically severe patients and its early use at a routine dose of a short-term duration could This article is protected by copyright. All rights reserved.

produce dramatic therapeutic efficacy, accompanied by accelerated inflammatory absorption and certain alleviation of cytokine storm, with no noticeable toxic and side effects developed. In view of the findings, we suggested that for critically severe patients, routine-dose Methylprednisolone of a short-term duration is recommended in clinical diagnosis as early as possible. Nevertheless, some limitations still exist in this study mainly referring to the data missing of some patients during treatment, which led to the results not precise enough. Hence, clinical sample size will be enlarged in future in-depth research for a more precise analysis.

The authors declare that they have no potential conflicts of interest.

Not applicable. 

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