key: cord-0854871-lh0ucm2c
authors: Li, Hui; Xiong, Nian; Li, Changjun; Gong, Yanhong; Liu, Li; Yang, Heping; Tan, Xiangping; Jiang, Nan; Zong, Qiao; Wang, Jing; Lu, Zuxun; Yin, Xiaoxv
title: Efficacy of ribavirin and interferon-α therapy for hospitalized patients with COVID-19: a multicenter, retrospective cohort study
date: 2021-01-28
journal: Int J Infect Dis
DOI: 10.1016/j.ijid.2021.01.055
sha: d7696cb7f1a9e6e62cbfa28e3e3ae04e9528eef3
doc_id: 854871
cord_uid: lh0ucm2c

OBJECTIVE: To assess the efficacy and safety of ribavirin and interferon-α (RBV/IFN-α) therapy in patients with COVID-19. METHODS: This multi-center, retrospective cohort study included patients with COVID-19 admitted to four hospitals in Hubei Province, China, from 31 December, 2019 to 31 March, 2020. Patients were divided into two groups according to their exposure to RBV/IFN-α therapy within 48 hours of admission. Mixed-effect Cox model and Logistic regression were used to explore the association between early treatments of RBV/IFN-α with primary outcomes. RESULTS: Of 2037 patients eventually included, 1281 patients received RBV/IFN-α (RBV alone/IFN-α alone/RBV combined with IFN-α) treatments and 756 patients received none of these treatments. In mixed effect model, RBV/IFN-α therapy was not associated with progression from non-severe into severe type (aHR = 1.09, 95%CI: 0.88-1.36) or with reduction in 30-day mortality (aHR = 0.89, 95%CI: 0.61-1.30). However, it was associated with a higher probability of length of hospital stay over 15 days (aOR = 2.11, 95%CI: 1.68-2.64) compared with No RBV/IFN-α therapy. Moreover, the propensity score-matched cohort and subgroup analysis displayed similar results. CONCLUSION: RBV/IFN-α therapy was not observed to any benefit in improving clinical outcomes in patients with COVID-19, suggesting that RBV/IFN-α therapy should be avoided in COVID-19 patients.

The coronavirus disease 2019 pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has affected more than 83.3 million patients with more than 1,831,000 deaths worldwide (WHO, 2021) . This pandemic has brought a huge challenge to the global public health (WHO, 2020; Wu and McGoogan, 2020) . However, except for the treatment experience of earlier strains of coronavirus, SARS-CoV and Middle East respiratory syndrome coronavirus (MERS-CoV), there was insufficient evidence to support a specific antiviral therapy (Sanders et al., 2020) . Despite the urgency of developing a vaccine, looking for effective therapy for patients with COVID-19 is also an important issue.

Many repurposed drugs have been shown to have in-vitro activity against the close relatives of SARS-CoV-2, which are all beta-coronaviruses Sallard et al., 2020) . Among them, some antivirals such as ribavirin and interferon-α are provisionally recommended in the Chinese guidelines of treatments against COVID-19 and such as ribavirin and interferon-β are recommended in the Iranian treatment protocol (National Health Commission of China, 2020; Jamaati et al., 2020) . However, the guidelines issued by the WHO and National Institutes of Health recommend that interferons (α, β) with or without ribavirin not be administered as treatment or prophylaxis for COVID-19, outside of the context of clinical trials (WHO, 2021; National Institutes of Health, 2020) . Ribavirin is a common antiviral drug that inhibits the replication and spread of multiple viruses.

Interferon-α is an important type-I interferon with a broad antiviral activity in vitro. Reviews of the available scientific literature suggested that ribavirin and interferon-α might be used alone or in combination to treat coronavirus infections, including SARS and MERS, but conclusions about their clinical efficacy were inconsistent (Chen et al., 2004; Khalid et al., 2015; Omrani et al., 2014; Arabi et al., 2020; Falzarano et al., 2013; Arabi et al., 2017) . For J o u r n a l P r e -p r o o f example, a retrospective cohort study found that ribavirin and interferon-α therapy was associated with significantly improved survival at14 days in patients with severe MERS, but not at 28 days (Omrani et al., 2014) . Another multicenter observational study showed that ribavirin and interferon therapy for critically ill patients with MERS was not associated with reduction in 90-day mortality or in faster MERS-CoV RNA clearance (Arabi et al., 2020) .

Moreover, the combination of interferon-α with ribavirin gave excellent results in MERS-CoV infected rhesus macaques (Falzarano et al., 2013) , but was inconclusive in human (Arabi et al., 2017) .

Although SARS-COV-2 presents similar properties with SARS-COV and MERS-CoV, the viral load of SARS and MERS peaks at around day 7-10 after symptom onset, whereas the viral load of COVID-19 peaks at the time of presentation, similar to influenza To et al., 2020) . Some researchers think that interferon therapy should be limited to the early phases of the infection (Sallard, et al., 2020; To et al., 2020; Siddiqi et al., 2020) .

Reliable evidence on whether early therapy with ribavirin and interferon-α alone or in combination has an impact on progression, outcome, and safety in admitted patients with COVID-19 is required. Large randomized controlled trials (RCTs) can provide the best evidence for drug efficacy evaluation. A randomized, open-label clinical trial in China evaluated the effectiveness of ribavirin plus interferon-α, lopinavir/ritonavir plus interferon-α, and ribavirin plus lopinavir/ritonavir plus interferon-α in patients with mild to moderate COVID-19, indicating that there were no significant differences among the three regimens in terms of antiviral effectiveness (Huang et al., 2020) . Although the current clinical trials have provided some evidence of the efficacy of ribavirin and interferon-α therapy (Huang et al., 2020; Zhou et al., 2020) , the sample size of these studies was small and more researches are still needed. Therefore, this study used a retrospective cohort design to assess the impact of the early J o u r n a l P r e -p r o o f 6 treatments of interest on disease progression, mortality rate, length of hospital stay and safety in hospitalized patients with COVID-19, to provide clinical evidence for screening effective antiviral drugs and optimizing treatment regimens for patients with COVID-19. China, 2020) . Based on the definition of the protocol, patients were divided into non-severe and severe type according to the respiratory rate, pulse oxygen saturation and acute organ failure. Patients were severe type if they had any of the following criteria: respiratory rate (RR)≥30 breaths/min, pulse oxygen saturation (SpO2)≤93%, shock, or acute organ failure. In this study, the inclusion criteria contained: 1) patients with COVID-19, aged≥18 years, who were admitted to the above-mentioned hospitals from 31 December, 2019 to 31 March, 2020;

2) patients who received treatments of interest and none of these treatments within 48 hours J o u r n a l P r e -p r o o f of admission. The exclusion criteria contained: 1) patients with incomplete medical records (e.g., transfer to any other hospitals); 2) patients who were intubated, dead, or discharged within 24 hours of admission; 3) patients with pregnancy, acute lethal organ injury (e.g., acute myocardial infarction, acute pulmonary embolism, or acute stroke), acquired immune deficiency syndrome, or leukemia. These specific criteria were established to avoid non-uniform enrolment of patients, which could skew the interpretation of the results.

Following data were collected including demographic information, clinical characteristics, medical history, laboratory data, in-hospital medication, and clinical outcomes. The patient demographic information (age and gender), clinical characteristics (e.g., fever, cough, respiratory rate and pulse oxygen saturation), medical history (e.g., length of hospital stay, and comorbidities), in-hospital medication and clinical outcomes were obtained from the electronic medical system. Laboratory data (including blood counts, liver function, renal function, cardiac function and other indicators) were collected from the laboratory information system. The personal identification information including name and ID was anonymized and a new study ID was generated for each patient to protect patient privacy. The data were carefully reviewed and confirmed by experienced physicians to guarantee the accuracy of data extraction procedures. The full dataset and statistical code in this study are available from the corresponding author on reasonable request.

The early treatments of interest were defined as patients receiving therapy with ribavirin and interferon-α (RBV/IFN-α) within 48 hours of admission. RBV/IFN-α therapy included three groups: RBV alone, IFN-α alone, and RBV combined with IFN-α (RBV&IFN-α). Three different subtypes of IFN-α were used in patients: IFN-α2a, IFN-α2b or FN-α1b. Patients who did not receive RBV/IFN-α were classified as the control group. The used dosing J o u r n a l P r e -p r o o f protocol of RBV/IFN-α is shown in Table S1 .

The primary outcomes of this study were: 1) progressing from non-severe COVID-19 into severe type; 2) all-cause mortality during 30 days; 3) length of hospital stay over 15 days.

The secondary outcomes were indicators of drug safety including blood counts, liver function, renal function, cardiac function and other indicators.

Data are presented as the medians and interquartile ranges (IQRs), or numbers and percentages (%), as appropriate. Comparisons of parameters for continuous variables were We also adjusted for the disease severity in 30-day mortality and length of hospital stay. Site was modeled as a random effect in the mixed-effect Cox model and Logistic regression model. To minimize the effect of potential confounding factors associated with exposure, we adjusted for the differences in baseline characteristics by establishing propensity score-matched cohorts, including age, symptoms (fever and shortness of breath), CKD and drug therapy (antibiotics and corticosteroid drugs). Finally, a matched cohort of RBV/IFN-α group and No RBV/IFN-α group was established with the pairing ratio at 1:1.

To identify the effect of different treatment regimens, we assessed the impact of the three treatments (RBV alone, IFN-α alone, and RBV&IFN-α) on outcomes compared with No RBV/IFN-α, and performed subgroup analyses examining the association of RBV alone J o u r n a l P r e -p r o o f compared to No RBV, IFN-α alone compared to No IFN-α, and RBV&IFN-α compared to No RBV&IFN-α. We further carried out sensitivity analyses to evaluate the effect of different subtypes of IFN-α (IFN-α2a, IFN-α2b, and IFN-α1b) on the outcomes.

We employed the difference-in-difference (DID) methodology to assess the impact of treatments of interest on drug safety indicators, while controlling for confounding factors in linear regression analysis (Wing et al., 2018; Pinheiro et al., 2020) . The DID estimations from linear regression models were able to capture the net effects of the treatments of interest. In our study, a negative or positive estimate from the DID models would indicate that a measure of blood examination indicator decreased or increased more over time in patients receiving RBV/IFN-α than those receiving No RBV/IFN-α. All analyses were performed using SAS 9.4 (by SAS Institute Inc., Cary, NC, USA) and SPSS version 23. A p value < 0.05 was considered statistically significant.

Overall, 2501 patients with COVID-19 were admitted to 4 hospitals in Hubei Province, China.

According to the inclusion/exclusion criteria, after excluding 464 patients, eventually 2037 patients were included in the analysis (Figure 1 ). Of these, 1281 patients received RBV/IFN-α (840 received RBV alone, 214 received IFN-α alone, and 227 received RBV&IFN-α) treatments and 756 patients did not receive RBV/IFN-α treatments.

Between the two groups, there were no significant differences in demographic characteristics, symptoms and comorbidities except for age, fever, shortness of breath, CLD, CKD, antibiotic and corticosteroid therapies (Table 1 ). In addition, the RBV/IFN-α group had a higher percentage of severe patients (51.05% vs. 40.87%; P < 0.001), but had shorter median days from symptom onset to admission (8 days vs. 11 days [IQRs 6-21]; J o u r n a l P r e -p r o o f P < 0.001) than the No RBV/IFN-α group. In the RBV/IFN-α group, patient characteristics in three treatment groups were shown in Table S2 . Among subtypes of IFN-α, IFNα-2a was most frequently used, accounting for 89.25% in IFN-α alone group and 60.79% in RBV&IFN-α group. Furthermore, 68.78% of patients in the control group received other antivirals, mainly including abidor, oseltamivir, lopenavir-ritonavir, and combination of these drugs.

During the follow-up of 30 days, 498 of the 1496 patients admitted with non-severe type (Table 2) . Compared with No RBV/IFN-α therapy, the three treatment groups were also not significantly associated with reduction in 30-day mortality. The analysis with propensity score-matched cohort showed similar results (aHR=0.81, 95%CI: 0.52-1.28) ( Table 3) .

Of 2037 patients, 1888 were eventually discharged. The median length of hospital stay was 18 days in the RBV/IFN-α group and 12 days in the No RBV/IFN-α group (P <0.001). The mixed-effects model (aOR=2.11, 95% CI: 1.68-2.64) and further analysis with propensity score-matched cohort (aOR=2.23, 95% CI: 1.73-2.86) showed that RBV/IFN-α use was associated with a higher probability of length of hospital stay over 15 days (Table 2 and 3) .

Moreover, RBV alone and RBV&IFN-α groups were also associated with a higher probability of length of stay over 15 days.

Subgroup analyses of RBV alone vs. No RBV, IFN-α alone vs. No IFN-α, and RBV&IFN-α vs. No RBV&IFN-α were almost consistent with results of overall analysis. In the mixed-effects model, the RBV&IFN-α group was associated with reduction in 30-day mortality (aHR=0.54, 95%CI: 0.29-0.99) ( Table 2 ), but no association was found after propensity score matching (aHR=0.44, 95%CI: 0.17-1.11) ( Table 3) . Three treatment subgroups were associated with a higher probability of length of stay over 15 days. In addition, the results of sensitivity analysis did not show differences in efficacy between different subtypes of IFN-α (IFN-α2a, IFN-α2b, and IFN-α1b) (Table S3 and S4).

After adjusting for age, sex, comorbidities, disease severity, and drug therapies, the results of DID model showed significant differences in some indicators of blood count, liver function, J o u r n a l P r e -p r o o f and renal function between the RBV/IFN-α group and No RBV/IFN-α group (Table S5) .

However, in further analysis with propensity score-matched cohort, DID estimators were only statistically significant at the 5% level in haemoglobin and uric acid. Compared with No RBV/IFN-α group, haemoglobin in RBV/IFN-α group decreased by 7.3 g/L and uric acid increased by 29.7μmmol/L (Table 4 ).

Considering differences in baseline, disease severity, site (hospital), and time, this retrospective study found that RBV/IFN-α therapy was not associated with progression from non-severe COVID-19 into severe type or with decreased risk of 30-day mortality. Of note, RBV/IFN-α therapy might prolong length of hospital stay in the final discharged patients with COVID-19.

Although preclinical studies showed that RBV/IFN-α therapy was beneficial (Chen et al., 2004; Falzarano et al., 2013) , our study did not find clinical benefit of RBV/IFN-α (including RBV alone, IFN-α alone, or RBV&IFN-α) therapy for patients with COVID-19. The possible explanations were as follows: first, the concentration and administration of RBV/IFN-α therapy differed between studies. In MERS-CoV-infected rhesus macaques model with positive effect (Falzarano et al., 2013) , the experimenter initiated a subcutaneous injection of 5 mega international units (MIU)/kg of IFN-α2b and an intravenous ribavirin (30 mg per kg body weight). Subsequently, the concentration of RBV/IFN-α therapy was adjusted according to the regimens. In a retrospective cohort study (Omrani et al., 2014) , patients with severe MERS were given oral ribavirin (dose based on calculated creatinine clearance, for 8-10 days) and subcutaneous pegylated interferon IFN-α2a (180 μg per week for 2 weeks), finding significant improvement in survival at 14 days, but not at 28 days. In our study, patients with COVID-19 were given intravenous ribavirin (500 mg twice a day or adjusted according to creatinine clearance) and vapor-inhaled IFN-α (5 million U or equivalent). Although the J o u r n a l P r e -p r o o f administration by vapor inhalation currently performed in China offered the advantage of targeting specifically the respiratory tract (Sallard et al., 2020; Dong et al., 2020) , our results indicated that the pharmacodynamics of such an administration might not be ideal. Second, the used types of IFN-I differed between studies. One study examined the in vitro MERS-CoV susceptibility to different types of IFN (IFN-α2b, IFN-γ, IFN-α2a, IFN-β et al) and found that IFN-β had the strongest MERS-CoV inhibition (Hart et al., 2014) . It was repeatedly shown that IFN-β was a more potent inhibitor of coronaviruses than IFN-α (Clementi et al., 2020; Stockman et al., 2006; Hensley et al., 2004) . Our patients with COVID-19 were treated based on IFN-α rather than IFN-β. The above differences in clinical Therefore, we suggest that RBV/IFN-α therapy should be avoided in the clinical treatment of patients with COVID-19.

After removing deaths and controlling for potential confounders, we still found that the median length of hospital stay in RBV/IFN-α group was longer than No RBV/IFN-α group.

Studies suggested that the timing of IFN-I administration played a crucial role in therapeutic efficacy and IFN-I might fail to inhibit viral replication and had proinflammatory side-effects when administration was delayed (Hung et al., 2020; Channappanavar et al., 2019) . In a recent study finding the advantages of early triple antiviral therapy (Hung et al., 2020) , IFN-β1b injection was omitted to avoid its side-effects when patients with COVID-19 were recruited and treated between days 7 and 14 of symptom onset. Of note, the median number of days from symptom onset to admission was 10 days (IQR 5-15) for our patients recruited, but the use timing of IFN-α was not restricted. Therefore, the inappropriate timing of IFN-α might lead to delayed rehabilitation of discharged patients and thus prolonged hospital stay.

In terms of drug safety, there was no difference in side-effects between the two groups except for decreased hemoglobin and increased uric acid. Anemia was a recognized complication of ribavirin therapy and was noted in previous studies investigating the role of ribavirin in the treatment of SARS coronavirus infection (Omrani et al., 2014; Knowles et al., 2003) . Although RBV/IFN-α therapy had a significant effect on uric acid levels, the change did not result in serious renal dysfunction according to the data (uric acid=324.7μmmol/L) after treatment.

This study comprehensively and in detail evaluated the clinical efficacy and safety of RBV/IFN-α therapy in patients with COVID-19. The consistency between overall analysis and subgroup analysis suggested the robustness of the conclusions. However, our study had several limitations. First, due to the retrospective cohort design, we could not exclude the J o u r n a l P r e -p r o o f influence of unmeasured confounders on the results, although we have carried on the statistical analysis of multiple factors and multiple models. Second, there was a lack of outcome measures that directly reflect the efficacy of antiviral drugs, for example, time to achieve a negative RT-PCR result for SARS-CoV-2, time to resolution of symptoms. Because of the emergency situation and the lack of medical personnel, we were unable to timely record relevant data. Hence we chose to the changes in disease progression and 30-day mortality to reflect drug efficacy as far as possible. Third, part of the combination of RBV and IFN-α might be due to chance. Since this study was retrospective, some combinations might be not planned a priori but be at the physician's discretion, although we had defined the combination therapy. Our data also do not apply to the use of any treatment regimen in the outpatient or out-of-hospital settings. However, our study still provided referable clinical evidence for efficacy evaluations of the RBV/IFN-α therapy in patients with COVID-19.

This study found that RBV/IFN-α therapy was not associated with progression from non-severe COVID-19 into severe type or with reduction in 30-day mortality. In contrast, the inappropriate timing of IFN-α might prolong the patients' hospital stay. Based on the above results and relevant guidelines, we suggested that RBV/IFN-α therapy should be avoided in patients with COVID-19. Under the current pandemic, looking for other specific antiviral therapy and promoting effective vaccines remain the priorities in responding to COVID-19. 

The authors declare that there are no conflicts of interest.

The authors declare that there are no conflicts of interest. Table 3 . Relative risk for outcomes in RBV/IFN-α group and No RBV/IFN-α group after propensity-score matching (1:1) aHR= adjusted hazard ratio; aOR= adjusted odds ratio; COPD=chronic obstructive pulmonary disease; CLD=chronic liver disease; CKD=chronic kidney disease; a For the outcome of progression to severe type, Cox proportional hazards regression model was adjusted for the following variables: age, sex, hypertension, diabetes, COPD, CLD, CKD, antibiotic therapy, and corticosteroid therapy. b For the outcome of 30-day mortality, Cox proportional hazards regression model was adjusted for the following variables: age, sex, hypertension, diabetes, COPD, CLD, CKD, disease severity, antibiotic therapy and corticosteroid therapy.

c For the outcome of length of hospital stay>15 days, Logistic regression was adjusted for the following variables: age, sex, hypertension, diabetes, COPD, CLD, CKD, disease severity, antibiotic therapy and corticosteroid therapy. d Site (hospital) was modeled as a random effect in the multivariate analyses of mixed-effect Cox model and Logistic regression. The propensity score-matched (1:1) cohort was established with adjusted age, fever, shortness of breath, CKD, antibiotic and corticosteroid therapies. 

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We thank all the staff of the Central Hospital and Red Cross Hospital of Wuhan, the Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, and Lichuan People's Hospital for supporting. We also appreciate all study participants who have contributed to the procedure of data collection.J o u r n a l P r e -p r o o f