Anti-il6 Treatment of Serious COVID-19 Disease With Threatening Respiratory Failure (TOCIVID)

Effectiveness of Interleukin-6 Receptor Inhibitors in the Management of Patients With Severe SARS-CoV-2 Pneumonia: An Open-Label, Multicenter Sequential and Cluster Randomized Trial

Coronavirus disease 2019 (COVID-19) is caused by the newly discovered coronavirus, SARS-CoV-2. The median time from onset of symptoms of COVID-19 to development of acute respiratory distress syndrome (ARDS) has been reported as short as 9 days. No effective prophylactic or post-exposure therapy is currently available. According to data from the Danish Health Authority (www.sst.dk/corona), as of March 21st, 2020, there were 1326 patients infected with the disease in Denmark, more than 250 are admitted to a hospital, and >50 of them have required intensive care. Nearly 350.000 cases and 15.000 deaths have been reported globally. These numbers are likely to markedly increase during the coming weeks, challenging the capacity of health systems worldwide.

In patients infected with SARS-CoV-2, it has been described that disease severity and outcomes are related to the characteristics of the immune response. Interleukin (IL)-6 and other components of the inflammatory cascade contribute to host defense against infections. However, exaggerated synthesis of IL-6 can lead to an acute severe systemic inflammatory response known as 'cytokine storm'. In the pathogenesis of SARS-CoV-2 pneumonia, a study found that a cytokine storm involving a considerable release of proinflammatory cytokines occurred, including IL-6, IL-12, and tumor necrosis factor α (TNF-α). Studies on the Middle East respiratory syndrome caused by another coronavirus (MERS-CoV), indicate that cytokine genes of IL-6, IL-1β, and IL-8 can be markedly upregulated. Similarly, patients with SARS-CoV-2 pneumonia admitted to an intensive care unit had higher plasma levels of cytokines including IL-6, IL-2, IL-7, IL-10, granulocyte-colony stimulating factor (G-CSF), interferon-γ-inducible protein (IP10), monocyte chemoattractant protein (MCP1), macrophage inflammatory protein 1 alpha (MIP1A), and TNF-α. These findings indicate that the magnitude and characteristics of the cytokine response is related to the severity and prognosis of patients with SARS-CoV-2 pneumonia.

It has been suggested that IL-6 blockade may constitute a novel therapeutic strategy for other types of cytokine storm, such as the systemic inflammatory response syndrome including sepsis, macrophage activation syndrome and hemophagocytic lymphohistiocytosis. Remarkable beneficial effects of IL-6 blockade therapy using a IL-6 receptor inhibitor has been described in patients with severe SARS-CoV-2 pneumonia in a retrospective case series from China.

Currently, there are two available drugs based on human monoclonal antibodies against IL-6 receptor, tocilizumab (RoActemra, Roche) and sarilumab (Kevzara, Sanofi). IL-6 receptor inhibitors are currently licensed for several autoimmune disorders and are considered well tolerated and safe in general. The most common side effects reported are upper respiratory tract infections, headache, hypertension, and abnormal liver function tests. The most serious side effects are serious infections, complications of diverticulitis, and hypersensitivity reactions.

it is hypothesized that IL-6 might play a key role in the cytokine storm associated with serious adverse outcomes in patients infected with SARS-CoV-2 pneumonia, and that blockade of IL-6 would be suitable therapeutic target for these patients. The study will investigate the effect of different types of IL-6 inhibition versus no adjuvant treatment compared to standard of care in patients with severe SARS-CoV-2 pneumonia.

Primary objective: To compare the effect of either one of three IL-6 inhibitor administrations, relative to the standard of care, on time to independence from supplementary oxygen therapy, measured in days from baseline to day 28, in patients with severe SARS-CoV-2 pneumonia.

Study Overview

• Status: Terminated
• Conditions: Corona Virus Disease
• Intervention / Treatment: Drug: RoActemra iv; Other: Standard medical care; Drug: RoActemra sc; Drug: Kevzara sc

• Study Type: Interventional
• Enrollment (Actual): 20
• Phase: Phase 2

Contacts and Locations

Study Locations

• Denmark
  • Copenhagen, Denmark, 2000
    • Bispebjerg-Frederiksberg Hospital
  • Hillerød, Denmark
    • Hillerød Hospital

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• SARS-CoV-2 infection confirmed by real time-PCR and
• Positive imaging: consolidation, ground glass opacities, or bilateral pulmonary infiltration either by CT-scan or chest x-ray; and
• Need of oxygen therapy to maintain SO2>94% OR FiO2/PaO2 > 20 and at least two of the following laboratory measures:
• CRP level >70 mg/L
• CRP level >= 40 mg/L and doubled within 48 hours (without other confirmed infectious or non-infectious course),
• Lactatdehydrogenase > 250 U/L,
• thrombocytopenia < 120.000 x 10E9/L,
• lymphocyte count < 0.6 x 10E9/L,
• D-dimer > 1 ug/mL,
• serum ferritin > 300 ug/mL

Exclusion Criteria:

• pregnancy suspected or confirmed,
• severe heart failure,
• suspected or confirmed bacterial infection,
• current solid or hematological malignancy,
• neutropenia,
• ALAT elevation more than three times the laboratory upper limit,
• ASA class 5 (after COVID19 admission) or higher at inclusion (prior admission),
• severe chronic obstructive pulmonary disease or heart failure (NYHA class II or higher),
• pregnant or lactating women,
• current treatment with conventional synthetic disease-modifying antirheumatic drugs (DMARDs)/immunosuppressive agents including IL-6 inhibitors, or with Janus kinase inhibitors (JAKi) in the past 30 days or plans to receive during the study period,
• current use of chronic oral corticosteroids in a dose higher than prednisone 10 mg or equivalent per day,
• previous or active tuberculosis (TB),
• HIV infection regardless of immunological status, hepatitis,
• evidence of recent (30 days) invasive bacterial or fungal infections,
• patients who have received immunosuppressive antibody therapy within the past 5 months, including intravenous immunoglobulin or plans to receive during the study period,
• IV drug abuse,
• history of inflammatory bowel disease,
• diverticulitis,
• ulcer,
• perforated gastrointestinal tract,
• participation in any clinical research study evaluating an investigational product (IP) or therapy within 3 months and less than five half-lives of IP prior inclusion to the study,
• any physical examination findings and/or history of any illness that, in the opinion of the study investigator, might confound the results of the study or pose an additional risk to the patient by their participation in the study,
• inability to give informed consent.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Sequential Assignment
• Masking: None (Open Label)

Number of Arms

4

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Roactemra iv; Single dose treatment with 400 mg tocilizumab intravensously	Drug: RoActemra iv; single dose treatment with tocilizumab 400 mg intravenously; Other Names: tocilizumab 400 mg; Other: Standard medical care; management as usual
Experimental: Roactemra sc; Single dose treatment with 2 x 162 mg tocilizumab subcutaneously	Other: Standard medical care; management as usual; Drug: RoActemra sc; single dose treatment with tocilizumab 2 x 162 mg subcutaneously; Other Names: tocilizumab 2 x 162 mg
Experimental: Kevzara sc; Single dose treatment with 1 x 200 mg sarilumab subcutaneously	Other: Standard medical care; management as usual; Drug: Kevzara sc; single dose treatment with sarilumab 1 x 200 mg subcutaneously; Other Names: sarilumab 1 x 200 mg
Active Comparator: Standard care; Management as usual	Other: Standard medical care; management as usual

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Time Frame
Time to independence from supplementary oxygen therapy	days from enrolment up 28 days

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Number of deaths		28 days from enrolment
Days out of hospital and alive		28 days from enrolment
Ventilator free days alive and out of hospital		28 days from enrolment
C-reactive protein (CRP) level	Measured from standard blood test	baseline
C-reactive protein (CRP) level	Measured from standard blood test	peak during hospitalisation, up to 28 days
C-reactive protein (CRP) level	Measured from standard blood test	14 days
C-reactive protein (CRP) level	Measured from standard blood test	28 days
Number of participants with serious adverse events	Measured as occurrence of any serious adverse events	During treatment, up to 28 days

Collaborators and Investigators

• Sponsor: Marius Henriksen
• Investigators: Principal Investigator: Lars Erik Kristensen, PhD, The Parker Institute

Study record dates

Study Major Dates

• Study Start (Actual): April 5, 2020
• Primary Completion (Actual): October 8, 2020
• Study Completion (Actual): October 8, 2020

Study Registration Dates

• First Submitted: March 24, 2020
• First Submitted That Met QC Criteria: March 24, 2020
• First Posted (Actual): March 26, 2020

Study Record Updates

• Last Update Posted (Actual): October 9, 2020
• Last Update Submitted That Met QC Criteria: October 8, 2020
• Last Verified: October 1, 2020

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Infections; Virus Diseases
• Other Study ID Numbers: APPI2-CV-2020-01

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: Yes
• IPD Sharing Supporting Information Type: Study Protocol; Statistical Analysis Plan (SAP); Informed Consent Form (ICF); Clinical Study Report (CSR); Analytic Code

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No