key: cord-0964792-ebax2sn8
authors: Zahr, Noël; Urien, Saik; Llopis, Benoit; Pourcher, Valérie; Paccoud, Olivier; Bleibtreu, Alexandre; Mayaux, Julien; Gandjbakhch, Estelle; Hekemian, Guillaume; Combes, Alain; Benveniste, Olivier; Saadoun, David; Allenbach, Yves; Pinna, Bruno; Cacoub, Patrice; Funck-Brentano, Christian; Salem, Joe-Elie
title: Pharmacokinetics and pharmacodynamics of hydroxychloroquine in hospitalized patients with COVID-19
date: 2021-01-28
journal: Therapie
DOI: 10.1016/j.therap.2021.01.056
sha: 7912f0b64f46932c5d7e58a2e8d0dbb051d34c55
doc_id: 964792
cord_uid: ebax2sn8

Background.- Hydroxychloroquine (HCQ) dosage required to reach circulating levels that inhibit SARS-Cov-2 are extrapolated from pharmacokinetic data in non-COVID-19 patients. Methods: We performed a population-pharmacokinetic analysis from 104 consecutive COVID-19 hospitalized patients (31 in intensive care units, 73 in medical wards, n = 149 samples). Plasma HCQ concentration were measured using high-performance liquid chromatography with fluorometric detection. Modelling used Monolix-2019R2. Results.- HCQ doses ranged from 200 to 800 mg/day administered for 1 to 11 days and median HCQ plasma concentration was 151 ng/mL. Among the tested covariates, only bodyweight influenced elimination oral clearance (CL) and apparent volume of distribution (Vd). CL/F (F for unknown bioavailability) and Vd/F (relative standard-error, %) estimates were 45.9L/h (21.2) and 6690L (16.1). The derived elimination half-life (t1/2) was 102 h. These parameters in COVID-19 differed from those reported in patients with lupus, where CL/F, Vd/F and t1/2 are reported to be 68 L/h, 2440 L and 19.5 h, respectively. Within 72h of HCQ initiation, only 16/104 (15.4%) COVID-19 patients had HCQ plasma levels above the in-vitro half maximal effective concentration of HCQ against SARS-CoV-2 (240 ng/mL). HCQ did not influence inflammation status (assessed by C-reactive protein) or SARS-CoV-2 viral clearance (assessed by real-time reverse transcription-PCR nasopharyngeal swabs). Conclusion: The inter-individual variability of HCQ pharmacokinetic parameters in severe COVID-19 patients was important and differed from that previously reported in non-COVID-19 patients. Loading doses of 1600 mg HCQ followed by 600 mg daily doses are needed to reach concentrations relevant to SARS-CoV-2 inhibition within 72 hours in ≥60% (95% confidence-interval: 49.5-69.0%) of COVID-19 patients.

variability of HCQ pharmacokinetic parameters in severe COVID-19 patients was important and differed from that previously reported in non-COVID-19 patients. Loading doses of 1600 mg HCQ followed by 600 mg daily doses are needed to reach concentrations relevant to SARS-CoV-2 inhibition within 72 hours in ≥60% (95% confidence-interval: 49.5-69.0%) of COVID-19 patients. Steady-state pharmacokinetics of HCQ has previously been reported in healthy volunteers, adult patients with malaria [15] , systemic lupus erythematosus (SLE) [16, 17] and rheumatoid arthritis (RA) [18] [19] [20] and are summarized in Table 1 . Herein, we analyzed plasma and blood concentration data in a cohort of consecutive patients hospitalized with COVID-19 who received HCQ. The aim of this work was to characterize HCQ pharmacokinetics in the setting of COVID-19 and to identify its main influencing covariates. The pharmacokinetic model developed from COVID-19 patients then allowed us to determine the best HCQ dosing regimen to rapidly reach relevant theoretical antiviral concentrations, i.e. higher than HCQ EC50 on SARS-CoV-2. We finally analyzed if there was any HCQ dose-efficacy relationship on SARS-CoV-2 clearance and inflammation parameters.

We conducted a monocenter study in consecutive patients with confirmed COVID-19 (positive for SARS-CoV-2 with reverse transcription polymerase chain reaction (RT-PCR), sampled for HCQ therapeutic drug monitoring left at the discretion of the treating physicians. Patients were treated with oral hydroxychloroquine sulfate (Plaquenil ® , Sanofi-Winthrop, Paris, France). Concentrations of HCQ and its metabolites in whole blood and plasma were assayed by ultra-high performance liquid chromatography (U-HPLC) with fluorometric detection [21] . This retrospective study was based on For bodyweight, allometric scaling theory dictates that PWR are typically 1 and 0.75 for volumes and clearance terms, respectively [23] . The goodness-of-fit of each model was evaluated by the observed-predicted (population and individual) concentration scatter plots, by the visual inspection of the individual concentration-time courses, and the prediction-corrected visual predictive checks.

A one-compartment open model best described HCQ pharmacokinetics, whatever the sampling reference, blood or plasma. The parameters of the model were the elimination oral clearance (CL/F), the apparent volume of distribution (V/F) and the absorption rate constant, Ka (with F, as the unknown bioavailability). Given the lack of data on the absorption phase, Ka was fixed to 0.75 and 1.15 h -1 in blood and plasma respectively as previously reported [23] . Between-subject variabilities were estimated for CL/F and V/F parameters and the residual variability was described by a proportional model. F stands for unknown bioavailability.

Different covariates, including HCQ concentration, thought to influence the time-to-PCR negativation were tested using the R-program [24] and the survival package [25] . The Kaplan-Meier method and log-Rank test were used for this purpose. Patients were split according to their individual model-predicted HCQ plasma concentration at 48 h using the 1 st , 50 th or 75 th quartile. Thereafter, two

Kaplan-Meyer curves were generated for each splitting factor. The time to negativation was the first occurrence when two successive RT-PCR were negative.

The CRP time-courses were modelled as a function of time and plasma HCQ concentration (Cp) as:

where CRP0, fHCQ, Cp50 and t50 denote the initial CRP concentration, fractional effect of HCQ, HCQ concentration or time that produce a 50% decrease in the CRP0 level. The model stands for the effect of HCQ (fHCQ and Cp50) plus an independent time-related effect ([1 -fHCQ] and t50) which simultaneously decrease the initial CRP0 level. Figure 1 shows plasma and blood HCQ concentrations available in our cohort.

The population plasma and blood HCQ pharmacokinetic parameter estimates and their influencing covariates are summarized in Table 3, and supplementary Table 1 , respectively. These parameters estimates were different from those reported in other diseases (lupus, malaria, rheumatoid arthritis) or in healthy volunteers (Table 1 ). Figure 2A shows the visual predictive checks for the HCQ plasma final model in COVID-19 (for blood final model, see Figure 2B ). The observed concentrations percentiles are well included in the corresponding model-predicted 90% confidence interval bands.

Among the tested covariates (age, bodyweight, gender, hepatic and renal function, CRP, intensive care vs. medical wards care, macrolide/azithromycin co-prescription, platelet count), bodyweight (based on allometry principles) was the sole variable having an effect on plasma or blood HCQ CL/F and V/F prediction that improved the model. Platelet count had an additional significant effect on V/F estimation for blood HCQ (supplementary Table 1 ).

Relying on our final pharmacokinetics parameters modelling, we generated representative plasma HCQ concentrations-time courses using various dosing regimens of major COVID-19

prospective trials testing HCQ ( Figure 3A ). Concentration vs. time profiles were also drawn according to documented plasma HCQ pharmacokinetics parameters estimates (Table 1) and 3rd body weight quartiles on CL and Vd population parameters are shown in Figure 5A and HCQ plasma concentration-times courses for patients weighing 79 kg (median bodyweight) using their individualized pharmacokinetic parameters are depicted in Figure- 5B. An important between patient's variability, leading to low or unexpectedly high (potentially toxic) HCQ plasma concentrations, ensues despite administering a standardized HCQ dosing ( Figure 5B ).

A total of 75 patients were available for a SARS-CoV-2 viral status analysis using nasopharyngeal swab. PCR follow-up was negative in 40 (53%). To assess the effect of plasma HCQ concentration on time-to-PCR negativation, patients were grouped as follows: individual predicted plasma HCQ concentration at 48 h below versus above 25th (72 ng/mL), 50th (95.5 ng/mL), 75th quantile (129 ng/mL). There were no significant differences in time-to-PCR negativation for all tested comparisons ( Figure 6 ). In our cohort, only 4 and 16 patients among 104 had observed or imputed (in patients with data available after 72 hours) HCQ plasma levels >240ng/mL, the in-vitro half maximal effective concentration of HCQ against SARS-CoV-2, at 48 and 72 hours, respectively. There was also no significant effect of HCQ plasma concentration on the CRP time-course. All attempts gave nonsignificant values for fHCQ, or Cp50 parameters that stand for the effect of HCQ on CRP time-course, meaning that the effect of HCQ on the inflammation status could not be demonstrated.

In this study, we developed a plasma and blood population pharmacokinetics models of HCQ based on data obtained in hospitalized COVID-19 patients in intensive care units and in medical wards. The blood and plasma pharmacokinetics were described by a one-compartment model with first-order absorption. Body weight had a significant effect on CL and Vd in both matrices. HCQ pharmacokinetic parameters in COVID-19 patients are different from those of other pathologies (lupus, malaria, rheumatoid arthritis) and healthy volunteers [15, 16, 20] . The theoretical ideal lowest dose to achieve a target plasma concentration >EC50 (240 ng/mL) within 48/72 hours in most patients was 1600 mg as a loading dose, followed by 200 mg/8 h thereafter. Nevertheless, plasma concentrations of HCQ showed a high interindividual variability (Figure 1) Of note, our PK blood parameters estimates were concordant with those estimated by Thémans et al [30] and other groups [28, 30, 31] providing evidence that a high HCQ loading dose is needed to reach circulating levels in COVID-19 patients theoretically relevant as compared to in-vitro SARS-CoV-2 inhibitory concentrations.

In our cohort including over 100 COVID-19 patients, subjects had different profiles ranging from hospitalization in medicine to intensive care unit, with variable renal and hepatic functions, as well as co-prescription with macrolides, most of which are cytochrome P-450 inhibitors [32] . None influenced HCQ plasma and blood pharmacokinetics in COVID-19 except weight, or weight and platelet count, respectively. This finding is concordant with other HCQ pharmacokinetic studies in lupus and malaria settings, in which body mass index and platelet count were also significant contributing covariates in the model [16, 33] .

Of note, the relationship between circulating concentrations of HCQ and clinical efficacy has been demonstrated in rheumatoid arthritis and systemic lupus erythematosus [17] [18] [19] 34] . However, our study did not show any association between plasma HCQ concentration and time to negativation of SARS-CoV-2 viral load in hospitalized patients, or resolution of inflammation (assessed by CRP).

We are currently studying the association between the blood and plasma concentration of HCQ and arrhythmias) [27] in patients with COVID-19 to further assess cardiovascular safety of HCQ in COVID-19 setting [35] . Indeed, the risks of cardiotoxicity associated with HCQ during the COVID-19 pandemic might increase for several reasons. Patients with COVID-19 have multiple risk factors for drug-induced QT prolongation and proarrhythmia: hypokalemia; fever amplifying drug-induced IKr blockade; and an increase in interleukin-6, as seen in COVID-19 infection which has been suggested as a mechanism of the QT prolongation associated with inflammation [36] . The French

Pharmacovigilance Network has reported 103 notifications of cardiac adverse drug reactions associated with "off-label" use of hydroxychloroquine since March 2020 up to April 2020 [37] . These observations, on top of its lack of efficacy, justified limiting the prescription of HCQ in COVID-19

patients [38] .

The retrospective, observational design of our work is the main limitation. The blood and nasopharyngeal samples were not systematically assessed for all patients during the treatment period.

This may have biased our results by precluding to demonstrate that there was an association between plasma HCQ levels and negative viral loads. Unfortunately, the detailed time course of viral load was unknot available, precluding further analysis. However, multiple lines of evidence are emerging against HCQ efficacy in hospitalized COVID-19, even with theoretically effective high dosing regimen such as in the RECOVERY randomized controlled trial [39] [40] [41] . In that study, patients received a loading dose of 2.4 g then 400 mg every 12 hours. HCQ was not associated with reduced mortality but was associated with an increased length of hospital stay and a trend towards increased risk of progression to invasive mechanical ventilation or death [36, 42] . Indeed, the dosing regimen used in the RECOVERY trial was even higher than the adapted dosing regimen that we can recommend based on in vitro HCQ EC50 on SARS-CoV-2 and HCQ human pharmacokinetic parameters in COVID-19, identified in this work.

Interindividual variability of HCQ pharmacokinetics parameters in hospitalized COVID-19 patients was important and parameters differed from those identified in non-COVID-19 patients. No effect of HCQ was found on SARS-CoV-2 (nasopharyngeal) viral clearance nor on inflammation resolution.

Loading doses of 1600 mg HCQ followed by 600 mg daily doses reached within 72 hours, 

This research received no external funding

The authors declare no conflict of interest

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