key: cord-0850071-lekwgiyc
authors: Kyriazopoulou, E.; Poulakou, G.; Milionis, H.; Metallidis, S.; Adamis, G.; Tsiakos, K.; Fragkou, A.; Rapti, A.; Danoulari, C.; Fantoni, M.; Kalomenidis, I.; Chrysos, G.; Angheben, A.; Kainis, I.; Alexiou, Z.; Castelli, F.; Serino, F. S.; Bakakos, P.; Nicastri, E.; Tzavara, V.; Kostis, E.; Dagna, L.; Koufargyris, P.; Dimakou, K.; Tzatzagou, G.; Chini, M.; Bassetti, M.; Katrini, K.; Kotsis, V.; Tsoukalas, G.; Selmi, C.; Bliziotis, I.; Samarkos, M.; Doumas, M.; Ktena, S.; Masgala, A.; Papanikolaou, I.; Argyraki, A.; Cardellino, C. S.; Katsigianni, E.-I.; Giannitsioti, E.; Cingolani, A.; Akinosogl,
title: Early Anakinra Treatment for COVID-19 Guided by Urokinase Plasminogen Receptor
date: 2021-05-18
journal: nan
DOI: 10.1101/2021.05.16.21257283
sha: 9613a5aaf8f8d523508063bc2aa5a53c1ffc3a34
doc_id: 850071
cord_uid: lekwgiyc

Background In a previous open-label trial, early anakinra treatment guided by elevated soluble urokinase plasminogen activator receptor (suPAR) prevented progression of COVID-19 pneumonia into respiratory failure. Methods In the SAVE-MORE multicenter trial, 594 hospitalized patients with moderate and severe COVID-19 pneumonia and plasma suPAR 6 ng/ml or more and receiving standard-of-care were 1:2 randomized to subcutaneous treatment with placebo or 100 mg anakinra once daily for 10 days. The primary endpoint was the overall clinical status of the 11-point World Health Organization ordinal Clinical Performance Scale (WHO-CPS) at day 28. The changes of the WHO-CPS and of the sequential organ failure assessment (SOFA) score were the main secondary endpoints. Results Anakinra-treated patients were distributed to lower strata of WHO-CPS by day 28 (adjusted odds ratio-OR 0.36; 95%CI 0.26-0.50; P<0.001); anakinra protected from severe disease or death (6 or more points of WHO-CPS) (OR: 0.46; P: 0.01). The median absolute decrease of WHO-CPS in the placebo and anakinra groups from baseline was 3 and 4 points respectively at day 28 (OR 0.40; P<0.0001); and 2 and 3 points at day 14 (OR 0.63; P: 0.003); the absolute decrease of SOFA score was 0 and 1 points (OR 0.63; P: 0.004). 28-day mortality decreased (Hazard ratio: 0.45; P: 0.045). Hospital stay was shorter. Conclusions Early start of anakinra treatment guided by suPAR provides 2.78 times better improvement of overall clinical status in moderate and severe COVID-19 pneumonia. (Sponsored by the Hellenic Institute for the Study of Sepsis ClinicalTrials.gov identifier, NCT04680949)

Results Anakinra-treated patients were distributed to lower strata of WHO-CPS by day 28 (adjusted odds ratio-OR 0.36; 95%CI 0.26-0.50; P<0.001); anakinra protected from severe disease or death (6 or more points of WHO-CPS) (OR: 0.46; P: 0.010).

The median absolute decrease of WHO-CPS in the placebo and anakinra groups from baseline was 3 and 4 points respectively at day 28 (OR 0.40; P<0.0001); and 2 and 3 points at day 14 (OR 0.63; P: 0.003); the absolute decrease of SOFA score was 0 and 1 points (OR 0.63; P: 0.004). 28-day mortality decreased (hazard ratio: 0.45; P: 0.045). Hospital stay was shorter.

Conclusions Early start of anakinra treatment guided by suPAR provides 2.78 times better improvement of overall clinical status in moderate and severe COVID-19 pneumonia.

(Sponsored by the Hellenic Institute for the Study of Sepsis ClinicalTrials.gov identifier, NCT04680949) All rights reserved. No reuse allowed without permission.

(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 18, 2021. ; https://doi.org/10.1101/2021.05.16.21257283 doi: medRxiv preprint 7 Key-words: anakinra; suPAR; pneumonia; COVID-19; WHO Clinical Progression Scale All rights reserved. No reuse allowed without permission.

(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. increase is an indicator of the release of danger-associated molecular patterns (DAMPs), namely calprotectin (S100A8/A9) and interleukin (IL)-1 α 3,4 . Calprotectin in turn stimulates the aberrant production of interleukin (IL)-1β by the circulating monocytes 4 whereas knock-outing of IL-1α is protective for the host 3 . These observations frame the hypothesis that early detection of increased suPAR may guide targeted therapeutics against IL-1α and IL-1β. Indeed, in the open-label phase II study SAVE, early administration of anakinra guided by suPAR decreased the relative risk for progression into SRF by 70% compared to standard-of-care treatment; significant reduction of 28-day mortality was also found. The recombinant IL-1 receptor antagonist anakinra blocks both IL-1α and IL-1β 5 .

Despite the important information provided by the SAVE trial, one prospective randomized clinical trial (RCT) is necessary to prove the effectiveness of this approach. SAVE-MORE (suPAR-guided Anakinra treatment for Validation of the risk and Early Management Of seveRE respiratory failure by COVID-19) is a pivotal, confirmatory, phase III RCT aiming to evaluate the efficacy and safety of early start of anakinra guided by suPAR in patients with COVID-19 pneumonia. The primary objective was to evaluate the efficacy and safety of early targeting of IL-1α/β on the clinical state of patients with COVID-19 pneumonia and elevated suPAR levels, over All rights reserved. No reuse allowed without permission.

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Enrolled patients were adults of either gender; with molecular diagnosis of infection by SARS-CoV-2; with involvement of the lower respiratory tract as confirmed by chest computed tomography or X-ray; in need for hospitalization; and with plasma suPAR 6 ng/ml or more. Main exclusion criteria were: ratio or partial All rights reserved. No reuse allowed without permission.

(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 18, 2021. ; 1 0 oxygen pressure to fraction of inspired oxygen less than 150; need of non-invasive ventilation (CPAP or BPAP) or mechanical ventilation; neutropenia; stage IV malignancy; end-stage renal disease; severe hepatic failure; immunodeficiencies; and chronic intake of corticosteroids and biological anti-cytokine drugs. All patients or their legal representatives provided written informed consent before enrollment.

Patients meeting all inclusion criteria and not meeting any exclusion criterion were subject to blood draw. suPAR was measured in plasma using the suPARnostic ® Quick Triage kit (Virogates S/A, Birkerød, Denmark) and a point-of care reader.

Patients with suPAR 6 ng/ml or more were electronically 1:2 randomized into treatment with placebo or anakinra using four randomization strata: classification into moderate or severe disease using the WHO definition 6 ; need for dexamethasone intake; body mass index (BMI) more than 30 kg/m 2 ; and country. The study drug was administered subcutaneously once daily in the thigh or in the abdomen for seven to 10 days. Patients allocated to placebo treatment were daily injected 0.67 ml of 0.9% sodium chloride; and those allocated to active drug 100 mg of anakinra at a final volume of 0.67 ml. Study drug was prepared by an unblinded pharmacist with access to the electronic study system using a separate username and a password.

Administration was done by a blind study nurse. All patients were receiving predefined standard-of-care (SoC) which consisted of regular monitoring of physical signs, oximetry and anti-coagulation. Patients with severe disease by the WHO definition 6 were also receiving intravenous 6 mg daily dexamethasone for 10 days.

Remdesivir treatment was left at the discretion of the attending physicians; other biologicals targeting cytokines and kinase inhibitors were not allowed. 1 1 Study visits were done daily for 10 days; on day 14; and on day 28. At each study-visit the following were recorded: non-serious and serious treatment-emergent adverse events (TEAEs); WHO-CPS; sequential organ failure assessment (SOFA) score; and co-administered treatment. Visits were done by phone for patients discharged by day 7. Data were captured after review of all medical and nursing charts by a physicians' team blinded to the allocation group. Blood samples and nasopharyngeal swabs were collected before start of the study drug and at days 4 and 7 for the measurements of biomarkers.

All serious and non-serious TEAEs were graded according to the Common Terminology Criteria for Adverse Events (version 5.0).

The primary study endpoint was the overall comparison of the distribution of frequencies of the scores from the 11-point WHO Clinical Progression ordinal Scale (CPS) between the two arms of treatment at Day 28. Secondary endpoints included the changes of WHO-CPS by days 14 and 28 from the baseline (before start of the study drug); the change of SOFA score by day 7 from baseline; the time until hospital discharge; the time of stay in the intensive care unit (ICU) for patients eventually admitted to the ICU; and the comparison of biomarkers.

The sample size was calculated based on the finding from the phase II SAVE trial 5 that 42% of comparators and 16.3% of anakinra-treated patients by day 28 were presented with 6 or more points of the WHO-CPS. To achieve such a difference in the WHO-CPS scores with 90% power at the 5% level of significance, allocation of All rights reserved. No reuse allowed without permission.

(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. 200 patients to SoC and placebo treatment and 400 patients to SoC and anakinra treatment were planned. Data were analyzed for the intention-to-treat (ITT) population. Missing data were imputed by last observation carried forward (LOCF).

WHO-CPS is an ordinal 11-point variable ranging from 0 to 10 and comparisons were done by univariate and multivariate ordinal regression analysis using logit function.

Results were expressed as the odds ratio (OR) and 95% confidence intervals (CI).

The two basic assumptions of the model, i.e., proportional odds and the goodness-offit test were checked. According to EMA's COVID-ETF advice the variables used for stratified randomization entered as co-variates in the multivariate model, i.e., disease severity, intake of dexamethasone, BMI more than 30, and country. According to the same advice, the analysis of the primary endpoint should have been supported by three analyses: comparison of the WHO-CPS by day 14; logistic regression analysis separately for patients at the two spectra of WHO-CPS at day 28; and time progression to respiratory failure by day 14. The first spectrum of the WHO-CPS was defined as patients fully recovered with negative viral load (WHO-CPS 0 points) contrary to patients with persistent disease (WHO-CPS between points 1 to 10). The second spectrum was defined as patients pointed 6 or more in the WHO-CPS (severe hospitalized and dead) contrary to patients pointed 5 or less. Five sensitivity analyses were conducted to assess robustness: exclusion of population deviating from the SoC; population receiving at least 7 doses of the study drug; complete analysis set; responder analysis treating missing values as non-responders; and comparison of the unadjusted and the adjusted treatment effects. Analysis was conducted using IBM SPSS Statistics v. 26.0. All P values were two-sided and any P value <0.05 was considered as statistically significant. The complete statistical analysis plan is provided in the Supplementary Appendix. All rights reserved. No reuse allowed without permission.

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The copyright holder for this preprint this version posted May 18, 2021. ; 1 3

From December 2020 through March 2021, 1060 patients were screened and 606 were randomized. 12 patients withdrew consent and requested removal of all data, leaving a final ITT analysis cohort of 594 patients; 189 patients were allocated to the SoC and placebo arm, and 405 patients were allocated to the SoC and anakinra arm. Only one patient was lost to follow-up ( Figure 1 ). Baseline characteristics and co-administered treatments were similar between the two arms (Table 1) .

The unadjusted OR of the WHO-CPS by day 28 was 0.36 (95%CI 0.26-0.49; P<0.001) (Figure 2A and Table 2 (Table S1) showing also All rights reserved. No reuse allowed without permission.

(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. that anakinra treatment was the only variable affecting the outcome of patients by day 14. Regarding the second confirmatory analysis the multivariate logistic regression model for the first spectrum of the WHO-CPS showed that anakinra treatment and baseline severity were associated with persistence of the disease by day 28; anakinra was protective from disease persistence (OR: 0.36; 95% CI 0.25-0.53; P<0.001) ( Table S2 ). The multivariate logistic regression model for the second spectrum of the WHO-CPS showed that anakinra treatment was the only variable that was associated with severe disease or death; anakinra was protective (OR: 0.46; 95% CI 0.26-0.83; P: 0.010) (Table S2) . 28-day mortality was also lower among patients allocated to SoC and anakinra treatment (6.9% versus 3.2% respectively) ( Figure S2 ). The third confirmatory analysis validated the results of the phase 2 SAVE trial. In this analysis, anakinra treatment prevented the progression to respiratory failure by day 14 ( Figure S3 and Table S3 ) (31.7% in the SoC and placebo arm versus 20.7% in the SoC and anakinra arm).

The rate of protocol deviations from the SoC treatment was significantly greater among patients allocated to the placebo arm than patients allocated to the anakinra arm (14.3% versus 3.2% respectively; P<0.001). These protocol deviations in the SoC and placebo arm were mainly related to increasing the dose and/or duration of dexamethasone administration (Table S4 ). All five sensitivity analyses confirmed further the analysis of the primary endpoint (Table S5) .

Analysis of the five clinical secondary endpoints showed a significant benefit from anakinra treatment on all of these endpoints. More precisely, the decreases of the WHO-CPS score from baseline by days 28 and 14 and of the SOFA score from baseline by day 7 were significantly greater in the SoC and anakinra arm ( Table 2 and Tables S6 to S8). Moreover, in the anakinra group, the average time until All rights reserved. No reuse allowed without permission.

(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 18, 2021. ; 1 5 hospital discharge was one 1 day shorter and the time until ICU discharge was 4 days shorter (Table 2 and Figures S4 and S5 ).

Over-time follow-up of laboratory values showed that among patients treated with anakinra: a) the absolute lymphocyte count was increased by day 7; b) circulating IL-6 was decreased by days 4 and 7; and c) plasma C-reactive protein (CRP) was decreased by day 7 ( Figure S6 ).

Overall, the incidence of serious TEAEs through day 28 was lower in patients in the anakinra and SoC group (16.5%) compared to the placebo and SoC group (21.2%). The non-serious TEAEs were similar in both treatment groups (Table 3 and Tables S9 and S10).

The SAVE-MORE trial showed an impressive efficacy of 10 days subcutaneous administration of anakinra in patients with COVID-19 and plasma suPAR 6 ng/ml or more. The global improvement of the overall clinical status was 2.78 times and it was evenly distributed in all scales of the day 28 WHO-CPS. The benefit was already apparent from day 14 and this is of major clinical importance since the first 14 days is the period during which a patient is expected to worsen; anakinra benefit was expanded until day 28. The magnitude of the efficacy of anakinra was shown in all multivariate analyses where in the presence of anakinra treatment the effect of disease severity on the final outcome was lost. The proportion of patients fully recovered exceeded 50% and those who remained under severe disease were reduced by 54%; the significant relative decrease of 28-day mortality All rights reserved. No reuse allowed without permission.

(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 18, 2021. ; 1 7 patients with critical illness with plasma levels of CRP and ferritin strongly exceeding the levels of the SAVE-MORE study population [7] [8] [9] [10] . The clinical benefit of tocilizumab has been studied in six RCTs. In four of these RCTs, the patient populations were much similar to the population of the SAVE-MORE trial 15-18 . Clinical benefit from tocilizumab treatment was shown in only one of these four trials. On the opposite, most of clinical benefit from tocilizumab treatment was found in the other two trials, namely RECOVERY 19 and REMAP-CAP 20 , with participants suffering from critical illness. Mortality was decreased from 35% with usual care to 31% in the RECOVERY trial 19 whilst the median number of organ support-free days were increased from 0 days with usual care to 10 days with tocilizumab treatment in the REMAP-CAP trial 20 . The benefit of the more severe patients by tocilizumab may be explained by the biology of the critical illness. We have previously shown that circulating monocytes in critical COVID-19 present with All rights reserved. No reuse allowed without permission.

(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 18, 2021. ; 1 8 complex immune dysregulation characterized by decreased efficiency for antigenpresentation and inappropriate maintenance of the potential for excess cytokine production: this dysregulation was restored upon exposure to tocilizumab 21 .

In conclusion, the SAVE-MORE trial showed that early start of treatment with anakinra and SoC guided by the biomarker suPAR in patients hospitalized with moderate and severe COVID-19 is leading to 2.78 times better improvement of the overall clinical status as expressed by the WHO-CPS. The frequency for full recovery is increased and the incidence of respiratory failure or death is decreased. This leads to shorter hospital stay. This finding is of outmost clinical importance and carries a major public health dimension, given the ICU overload during the COVID-19 pandemic, especially in countries with limited ICU capacity. All rights reserved. No reuse allowed without permission.

(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. 

Soluble urokinase plasminogen activator receptor (suPAR) as an early predictor of severe respiratory failure in patients with COVID-19 pneumonia

Soluble urokinase receptor (suPAR) in COVID-19-related AKI

IL-1 mediates tissue specific inflammation and severe respiratory failure In Covid-19: clinical and experimental evidence

Inflammasomes are activated in response to SARS-CoV-2 infection and are associated with COVID-19 severity in patients

An open label trial of anakinra to prevent respiratory failure in COVID-19

Anakinra combined with methylprednisolone in patients with severe COVID-19 pneumonia and hyperinflammation: An observational cohort study

Interleukin-1 and interleukin-6 inhibition compared with standard management in patients with COVID-19 and hyperinflammation: a cohort study

Anakinra treatment in critically ill COVID-19 patients: a prospective cohort study

No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted

Tocilizumab in patients admitted to hospital with COVID-19 (RECOVERY): a randomised, controlled, open-label, platform trial

Interleukin-6 receptor antagonists in critically ill patients with Covid-19

Complex immune dysregulation in COVID-19 patients with severe respiratory failure

Age, years, mean (SD)

Charlson's comorbidity index, mean (SD)

Laboratory values, median

White blood cell count, cells per mm 3 5910

Lymphocyte count, cells per mm 3 730

Abbreviations: FiO 2 : fraction of inspired oxygen; PaO 2 : partial oxygen pressure; SD standard deviation; SOFA sequential organ failure assessment.; Q quartile; WHO World Health Organization All rights reserved. No reuse allowed without permission. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The copyright holder for this preprint this version posted

The authors wish to express their gratitude to the members of the Data Monitoring and Safety Committee Professors Michael Niederman, Jos WM van der Meer and Konrad Reinhart for their valuable contribution and for their critical review of the submitted manuscript. All rights reserved. No reuse allowed without permission.(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.The copyright holder for this preprint this version posted May 18, 2021.

All rights reserved. No reuse allowed without permission.(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. The other authors do not have any competing interest to declare. All rights reserved. No reuse allowed without permission.(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.The copyright holder for this preprint this version posted May 18, 2021. ; https://doi.org/10.1101/2021.05.16.21257283 doi: medRxiv preprint