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CTAG Position Statement: Investigational immunomodulatory medicines for COVID-19 Approved: 01/06/2020 Version 2.0 of 33

In partnership with

Posi tion Statement: Use of investigational immunomodulatory

medic ines for COVID-19

Interim support for UK hospital c l inic ians


COVID-19 Therapeutics Advice & Support Group partners

Brighton and Sussex University Hospitals NHS Trust Cardiff and Vale University Health Board Guys & St Thomas’ NHS Foundation Trust Imperial College Healthcare Imperial College London Liverpool University Hospitals NHS Foundation Trust London North West University Healthcare NHS Trust NHS Greater Glasgow and Clyde Public Health England Royal Free London NHS Foundation Trust Royal Liverpool and Broadgreen University Hospitals NHS Trust Sheffield Teaching Hospital NHS Foundation Trust St George's University of London The Christie NHS Foundation Trust The Newcastle Upon Tyne Hospitals NHS Foundation Trust University College London University College London Hospitals NHS Foundation Trust University Hospital Southampton NHS Foundation Trust University of East Anglia University of Oxford

Document management This document will be continuously reviewed. If you identify any information that needs to be updated please contact [email protected].

Initiated by: HLH Across Speciality Collaboration (HASC)

Groups / Individuals who have overseen the development of this guidance (alphabetical order):

Content: Dr AS Carr1, Dr A Duncombe2, Dr B Goulden1, Dr M Leandro1,3, Dr J Manson1,3, Dr P Mehta1,3, Dr A Patel4, Dr E Raith1, Dr R Tattersall5, Dr C Duncan6

Formulary/Governance: Dr R Sofat1,3,7, Dr P Bodalia1,7, Mr J Hartwell1, Mr G Grewal7, Mr A Barron7

1 University College London Hospitals NHS Foundation Trust 2 University Hospital Southampton NHS Foundation Trust 3 University College London 4 The Christie NHS Foundation Trust, Manchester 5 Sheffield Teaching Hospitals NHS Foundation Trust 6 The Newcastle upon Tyne Hospitals NHS Foundation Trust 7 North Central London Joint Formulary Committee

Groups which were consulted: COVID-19 Therapeutics Advice & Support Group (CTAG) –Immunomodulators subgroup.

Version number: V2.0

Available on: https://www.ctag-support.org.uk/immunomodulators

Publication date: 01 June 2020

Review date: This document will be continuously reviewed. If you identify any information that needs to be updated please contact [email protected].

mailto:[email protected]

https://www.ctag-support.org.uk/immunomodulators




Contents

Document management ........................................................................................................ 2 Abbreviations....................................................................................................................... 4 Key messages ....................................................................................................................... 4 1. Introduction.................................................................................................................. 5 2. Aim.............................................................................................................................. 6 3. Supporting information .................................................................................................. 7 4. UK clinical studies ........................................................................................................ 10 Membership and provenance ............................................................................................... 16 Document control............................................................................................................... 17 Appendix 1: Publications for investigational immunomodulatory medicines to treat hyperinflammation associated with COVID-19 ........................................................................ 18 References......................................................................................................................... 30


Abbreviations Abbreviation Meaning

CMO Chief Medical Officer

NIHR National Institute for Health Research

R&D Research and Development

SARS-Cov-2 Severe acute respiratory syndrome coronavirus 2

sHLH Secondary haemophagocytic lymphohistocytosis

SoC Standard of Care

Key m e ssa g e s

Key messages • A subset of patients with COVID-19 may experience an exaggerated hyperinflammatory

response • COVID-19 associated hyperinflammation predominantly involves the lung however may

progress to secondary haemophagocytic lymphohistocytosis (sHLH) which is a systemic and multi-organ condition

• The optimal treatment for COVID-19 associated hyperinflammation is unknown and trials are needed

• As far as possible, the use of investigative immunomodulatory medicines should be used in the context of a national priority clinical trial

• Patients who meet diagnostic criteria for sHLH should be managed within established pathways, guided by a specialist familiar with hyperinflammation


1. Introduction 1.1. A subset of patients with COVID-19 experience an exaggerated host hyperinflammatory

response associated with hypercytokinaemia1,2, following or associated with the initial viral response phase1.

1.2. Terminology regarding hyperinflammation is heterogeneous however ‘hyperinflammation’ is generally considered an umbrella term for a number of syndromes associated with severe systemic macrophage activation (Figure 1). The most prevalent is secondary haemophagocytic lymphohistocytosis (sHLH) which is a systemic and multi-organ condition. This manifests as organomegaly, cytopenias and liver function derangement.

1.3. Hyperinflammation in the context of COVID-19 predominantly involves the lung without the systemic effects of sHLH. However, COVID-19 associated hyperinflammation can progress to multi-organ disease characteristic of sHLH.3 Current knowledge describing differences between hyperinflammation in the context of COVID-19 and sHLH is available https://www.ncbi.nlm.nih.gov/pubmed/32251717.

1.4. A significant systemic inflammatory response has also been recognised in a small number of paediatric cases; “paediatric multisystem inflammatory syndrome” has been associated with COVID-19 infection. Certain research registries and trials are including paediatric patients.4

1.5. The optimal treatment strategy for COVID-19 associated hyperinflammation is unknown. Immunomodulation is not a specific therapy for the coronavirus (SARS-Cov-2) that causes COVID-19 however it is hypothesised that immunomodulatory medicines may prevent or limit clinical deterioration in COVID-19, in a subgroup of patients with associated hyperinflammation.5 It is unknown whether the potential benefit of immunomodulation outweighs any potential risks.6

1.6. Of note, if individuals progress to and meet the diagnostic criteria for sHLH (e.g. H-Score, HLH 2004 criteria), treatment should follow pre-defined guidance available locally, which ideally should involve input from a specialist familiar with hyperinflammation.

1.7. Clinical trials are being designed to explore the risk:benefit ratio of immunomodulatory medicines that target the proinflammatory cytokine pathways implicated in COVID-19 associated hyperinflammation. Examples include inhibiting IL-1 (anakinra and canakinumab), IL-6 (tocilizumab, siltuximab and sarilumab), Bruton’s tyrosine kinase (BTK) pathway (acalabrutinib), JAK-STAT pathway (ruxolitinib) and dipeptidyl peptidase 1 (DPP1) inhibitors (brensocatib).

Figure 1: Terminology associated with hyperinflammation (note that variation exists in the literature)

Hyperinflammation (aka Cytokine Storm Syndrome)

Primary or Familial haemophagocytic

lymphohistiocytosis (fHLH)

Secondary haemophagocytic lymphohistiocytosis (sHLH)

Cytokine release

syndrome (CRS)

COVID-19 associated

hyper-inflammation

Overarching term

Syndrome name

Sub-category syndrome name

Underlying cause Genetic abnormalities

CAR-T therapy,

therapeutic antibodies, allogeneic stem cell transplant

SARS-Cov-2 Infection (inc. SARS-Cov-2) and sepsis

Rheumatic disease

Malignancy

Immuno-deficiency

(inc. transplant)

Macrophage activation-like

syndrome (MALS)

Macrophage activation syndrome

(MAS)

No specific term

https://www.ncbi.nlm.nih.gov/pubmed/32251717


2. Aim 2.1. To provide interim supporting information on the appropriate use of investigational

immunomodulatory medicines in the management of COVID-19 associated hyperinflammation. This position statement will be updated in response to national developments and superseded when specific guidance is published by UK health technology assessment bodies (e.g. National Institute for Health and Care Excellence, All Wales Medicines Strategy Group or Scottish Medicines Consortium).

2.2. Information contained within this position statement does not represent a ‘recommendation’, however it is intended to provide support to healthcare professionals when considering available treatment options in specific patients with COVID-19 where hyperinflammation warrants the consideration of immunomodulation.


3. Supporting information 3.1. There are no immunomodulatory medicines approved to treat COVID-19 associated

hyperinflammation. The standard of care in managing COVID-19 associated hyperinflammation is yet to be defined. Randomised controlled trials to address this are ongoing.

3.2. Several investigative immunomodulatory medicines have potential to be repurposed for the management of COVID-19 associated hyperinflammation (including and not limited to anakinra, interferon-beta, tocilizumab, sarilumab, canakinumab and ruxolitinib); the evidence-base for these medicines is summarised in Appendix 1.

3.3. It is recognised that access to clinical trials offering immunomodulatory options may not be available at all sites at the point of patient need. However, as far as possible, investigative agents should be used in the context of a clinical triala using supplies allocated for clinical trial use (e.g. via trial sponsor or Public Health England). The off-label or ‘non-trial’ use of medicines should be avoided because:

• Medicines currently available within the NHS supply chain are needed for the patients already prescribed within licensed indications7

• Medicines supplies are limited therefore their use outside the context of a clinical trial may compromise the feasibility of required trials.

3.4. Hospitals managing COVID-19 cases should make every effort to enrol COVID-19 patients in national priority clinical trials8,9 – refer to Section 4.

3.5. The following prioritised trials for investigative immunomodulatory medicines are open to recruitment (Figure 2):

• RECOVERY (in hospital trial; UK study open to all Trusts) added a second randomisation for patients with progressive disease and evidence of hyperinflammation

• REMAP-CAP (critical care trial; international with UK sites) added immunomodulatory and anti-viral domains for COVID-19

• ACCORD-2 (in hospital trial; UK multicentre study) • CANCOVID (International study with UK sites) • RUXCOVID (International study with UK sites) • CATALYST (UK study, multicentre) • TACTIC-R (UK study, multicentre) • REALIST (UK study, multicentre)

3.6. It should be noted that existing pathways for patients who meet the diagnostic criteria for sHLH (e.g. H-score, HLH 2004 criteria) are not affected by these recommendations.

3.7. If off-label or ‘non-trial’ immunosuppressant medicines are used in a patient with COVID-19, enrolment into ISARIC-CCP is encouraged so safety data can be collated (Figure 3).

3.8. Suspected side effects to medicines used in coronavirus treatment should be reported via the Yellow Card COVID-19 reporting site: https://coronavirus-yellowcard.mhra.gov.uk/

3.9. Immunomodulation is not considered a specific therapy for SARS-Cov-2 that causes COVID-19. Supporting information for the use of investigational antiviral medicines for SARS-Cov-2 (including remdesivir, ritonavir/lopinavir, hydroxychloroquine, chloroquine, azithromycin and interferon-beta) is available at https://www.ctag-support.org.uk/antivirals. Be aware that recruitment into one trial (e.g. of investigative antivirals) does not necessarily preclude recruitment into another (e.g. of investigative immunomodulators).

a Chief Medical Officers strongly discourage the use of off-licence treatments outside of a trial, where participation in a trial is possible

https://www.recoverytrial.net/

https://www.icnarc.org/Our-Research/Studies/Remap-Cap/About

https://www.icnarc.org/Our-Research/Studies/Remap-Cap/Information-For-Sites/Site-Set-Up

https://www.nihr.ac.uk/covid-studies/study-detail.htm?entryId=282769




https://cctu.org.uk/portfolio/COVID-19/TACTIC/TACTIC-R


https://coronavirus-yellowcard.mhra.gov.uk/

https://www.ctag-support.org.uk/antivirals

https://scanmail.trustwave.com/?c=8248&d=nZSE3lHXO7folknBQrjPGuIcDEzf9mk3FLlKGGYf4Q&u=https%3a%2f%2fwww%2ecas%2emhra%2egov%2euk%2fViewAndAcknowledgment%2fviewAttachment%2easpx%3fAttachment%5fid%3d103495


Figure 2: Immunomodulatory components of recruiting UK Clinical Studies as of 01 June 2020. SoC; standard of care. † Nationally prioritised research study for COVID-19 https://www.nihr.ac.uk/covid-studies/. ‡ These studies also include domains which are outside the scope of this document (e.g. antivirals, ventilation strategies, anticoagulation). § Tocilizumab is currently an intervention active at some sites; sarilumab, interferon-beta-1a and anakinra will be available to sites shortly. ¶ Not all treatment arms are currently active

Primary care Hospitalised

Adults on ITU†,‡,§ Immunomodulators domain: SoC vs tocilizumab vs interferon-beta-1a vs

sarilumab vs anakinra

Critical care

= Recruitment period Key

Inte

rven

tiona

l

First randomisation: Hospitalised adults†,‡ SoC vs. antivirals (refer to CTAG Antivirals position statement)

Second randomisation: Progressive COVID-19 and evidence of

hyperinflammation SoC vs. tocilizumab + SoC (both in addition to first randomisation antiviral)

Coordination between RECOVERY and REMAP-CAP is described here: https://www.recoverytrial.net/files/professional-downloads/coordination-of-recovery-and-remap-cap.pdf

Hospitalised adults with severe disease†

Placebo + SoC vs Canakinumab + SoC CANCOVID

Hospitalised adults (16 or over)†

Gemtuzumab ozogamicin with SoC vs SoC only CATALYST

Hospitalised adults with severe disease†

Placebo + SoC vs Ruxolitinib + SoC RUXCOVID

Hospitalised adults (18 or over)†

Baricitinib + SoC vs Ravulizumab + SoC vs SoC only

Hospitalised adults with mild to severe disease†,‡,¶

Multiple protocols (each IMP with SoC vs SoC alone): bemcentinib;. MEDI3506;. acalabrutinib;. zilucoplan

Adults on ITU with ARDS†

Placebo + SoC vs SoC + Human umbilical cord derived CD362 enriched

mesenchymal stem cells

REALIST

Hospital inpatients† (observational study)

Obs

erva

tiona

l

https://www.nihr.ac.uk/covid-studies/

https://www.ctag-support.org.uk/antivirals

https://www.recoverytrial.net/files/professional-downloads/coordination-of-recovery-and-remap-cap.pdf



https://www.remapcap.org/


https://clinicaltrials.gov/ct2/show/record/NCT04280705






https://isaric.tghn.org/UK-CCP/


Figure 3: Recruiting UK Observational Studies as of 22 May 2020. † Nationally prioritised research study for COVID-19 https://www.nihr.ac.uk/covid-studies/.

Primary care Hospitalised Critical care

= Recruitment period Key

Hospital inpatients† (observational study)

Obs

erva

tiona

l Critical care† (observational study)

Hospitalised adults (observational study) COV-HI

Hospitalised children (<16 years) with or without COVID-19 (observational study)

With either evidence of hyperinflammation; typical or atypical Kawasaki disease; or typical or atypical toxic shock syndrome



https://genomicc.org/uk/




4. UK clinical studies 4.1. The Chief Medical Officers recommends that any treatment given for coronavirus other than

general supportive care and treatment for underlying conditions should currently be as part of a trial, where participation in a trial is possible.8

4.2. The NIHR is working with the Department of Health and Social Care to coordinate the national research agenda.10

4.3. Organisations should prioritise support for studies which have been nationally prioritised.10 Non-prioritised research should continue, subject to it not having a negative impact on the system’s ability to recruit participants and provide the resources needed to support priority clinical studies.9

4.4. A complete list of nationally prioritised research studies for COVID-19 is available on the NIHR website https://www.nihr.ac.uk/covid-studies/

4.5. Immunomodulatory interventional studies and observational studies of relevance to COVID-19 associated hyperinflammation are summarised below:

• Table 1: Recruiting studies • Table 2: Proposed studies • Table 3: Closed to recruitment



Table 1: Recruiting in the UK – Immunomodulatory interventional clinical trials and observational studies

Status Trial Population Specific to hyperinflammation?

Intervention arms Re

crui

ting

Inte

rven

tiona

l RECOVERY†,‡ (UK study open to all Trusts) (ISRCTN50189673)

First randomisation: Hospital inpatients; adults and paediatrics (any age) with suspected or confirmed COVID-19 Second randomisation: Progressive COVID-19 (SpO2 <92% on room air or requiring oxygen) and CRP ≥75 mg/L

First randomisation: No Second randomisation: Yes CRP ≥75 mg/L

First randomisation: SoC vs. antivirals (refer to CTAG Antivirals position statement) Second randomisation:

– SoC – Tocilizumab + SoC

(both in addition to first randomisation antiviral)

REMAP-CAP†,‡,§ (International study with UK sites) (NCT02735707)

Critical care; adults with suspected or confirmed COVID-19

No Immunomodulatory domains for COVID-19: – SoC – Tocilizumab – Interferon-beta-1a – Anakinra – Sarilumab

CANCOVID† (International study with UK sites) (NCT04362813)

Hospital inpatients; adults with confirmed COVID-19 (severe disease; SpO2 ≤ 93% on room air or PaO2/FiO2 <300 mmHg) and evidence of cytokine release syndrome

Yes CRP ≥20 mg/L or ferritin level ≥600 μg/L

– Placebo + SoC – Canakinumab + SoC

Note: All patients to receive SOC per local practice for COVID-19-induced pneumonia; SOC may include anti-viral treatment, corticosteroid and/or supportive care.

RUXCOVID† (International study with UK sites) (NCT04362137)

Hospital inpatients; patients ≥ 12 years with confirmed COVID-19 (severe disease; respiratory frequency ≥ 30/min or SpO2 ≤ 93% on room air or PaO2/FiO2 <300 mmHg)

No – Placebo + SoC – Ruxolitinib + SoC

Note: All patients to receive SoC per local practice for COVID-19-induced pneumonia.


http://www.isrctn.com/ISRCTN50189673

https://ctag-support.org.uk/docs/immunomodulators.pdf

https://ctag-support.org.uk/docs/immunomodulators.pdf


https://clinicaltrials.gov/ct2/show/NCT02735707

https://www.icnarc.org/Our-Research/Studies/Remap-Cap/Information-For-Sites/Site-Set-Up








crui

ting

Inte

rven

tiona

l

ACCORD-2†,‡,¶ (UK study, multicentre) (Eudract 2020-001736-95)

Adult inpatients with confirmed SARS-CoV-2 infection; mild disease (with or without oxygen therapy) or severe disease (with non-invasive ventilation or high flow oxygen). Note: inclusion/exclusion criteria may vary between subprotocols

No Multiple subprotocols: – Bemcentinib + SoC vs. SoC – MEDI3506 + SoC vs. SoC – Acalabrutinib + SoC vs. SoC – Zilucoplan + SoC vs. SoC

CATALYST† (UK study, multicentre) (ISRCTN 40580903)

Hospital inpatients; adults (16 or older) with confirmed COVID-19 (SaO2 of ≤ 94% on room air or PaO2:FiO2 ≤ 300 mmHg)

No – Gemtuzumab ozogamicin + SoC – SoC only

TACTIC-R† (UK study, multicentre) (NCT04390464)

Adult patients (18 or over) with confirmed or suspected COVID-19

No – Baricitinib + SoC – Ravulizumab + SoC – SoC only

Note: Patients to be maintained on VTE prophylaxis or current maintenance therapy as per local guidelines.

REALIST†

(UK study, multicentre) (NCT03042143)

Critical care; mechanically ventilated patients with Acute Respiratory Distress Syndrome with confirmed COVID-19

No – SoC + Human umbilical cord derived CD362 enriched mesenchymal stem cells

– SoC + placebo (Plasma-Lyte 148)


https://www.clinicaltrialsregister.eu/ctr-search/trial/2020-001736-95/GB


http://www.isrctn.com/ISRCTN40580903








crui

ting

Obs

erva

tiona

l

ISARIC-CCP† (International study) (NCT04262921)

Hospital inpatients (children and adults); confirmed COVID-19

N/A – N/A – study has multiple objectives (see protocol); including describing clinical features and response to treatments. Case Record Forms (CRF) are available.

GenOMICC† (International study)

Critical care; confirmed or suspected COVID-19

N/A – N/A – study designed to identify host genetic variants underlying susceptibility to severe adverse outcomes.

COV-HI (UK study with limited UK sites)

Hospital inpatients; adults with confirmed COVID-19

N/A – N/A – study designed to understand which patients are more likely to develop hyperinflammation associated with COVID-19.

BPSU surveillance study (UK study)

Children <16 years with or without COVID-19, with either evidence of hyperinflammation; typical or atypical Kawasaki disease; or typical or atypical Toxic Shock Syndrome

N/A – N/A – study designed to understand the incidence and prevalence of new hyperinflammatory syndrome in relation to COVID, and compared to Kawasaki disease or Toxic Shock Syndrome.

† Nationally prioritised research study for COVID-19 https://www.nihr.ac.uk/covid-studies/. ‡ These studies also include domains which are outside the scope of this document (e.g. antivirals, ventilation strategies). § Tocilizumab is currently an intervention active at some sites; sarilumab, interferon-beta-1a and anakinra will be available to sites shortly. ¶ Not all treatment arms are currently active

https://isaric.tghn.org/



https://isaric.tghn.org/COVID-19-CRF/

https://isaric.tghn.org/COVID-19-CRF/

https://genomicc.org/

https://www.rcpch.ac.uk/work-we-do/bpsu/study-multisystem-inflammatory-syndrome-kawasaki-disease-toxic-shock-syndrome



Table 2: Proposed in the UK – Immunomodulatory interventional clinical trials and observational studies


Intervention arms Pr

opos

ed

Obs

erva

tiona

l COVID19_BMT (UK study, multicentre) (NCT04349540)

Allogeneic stem cell transplant recipients with COVID-19

Yes

N/A

REACT (International study with UK sites)

Hospital patients treated with anti-cytokine therapy for COVID-19

Yes Fever, CRP

N/A

Inte

rven

tiona

l

TOCIVID (International Phase II study) (NCT04317092)

Hospital inpatients; adults with confirmed COVID-19 (severe disease; SpO2 ≤ 93% on room air or requiring supplemental oxygen)

No Single arm study: Tocilizumab + SoC

STOP-COVID19† (in setup, pending Health Research Authority approval)

Awaiting further information Awaiting further information

– Brensocatib + SoC – Placebo + SoC

Awaiting further information

ILIAD 7† (in setup, HRA approval received)

Awaiting further information Awaiting further information

– CYT107

† Nationally prioritised research study for COVID-19 https://www.nihr.ac.uk/covid-studies/


https://www.swedish.org/for-health-professionals/research/react-covid19/protocol-synopsis






Table 3: Closed to recruitment in the UK - Immunomodulatory interventional clinical trials

Status Trial Population Interventions

Clos

ed t

o re

crui

tmen

t COVACTA† (International study with UK sites) (NCT04320615)

Hospital inpatients; adults with confirmed COVID-19 (severe disease; SpO2 ≤ 93% on room air or PaO2/FiO2 <300 mmHg)

– SoC – Tocilizumab + SoC

† Nationally prioritised research study for COVID-19 https://www.nihr.ac.uk/covid-studies/

https://www.nihr.ac.uk/urgent-public-health-research-studies-for-covid-19/a-study-to-evaluate-tcz-in-patients-with-severe-covid-19-pneumonia/24549




Membership and provenance Support within this document is provided by the COVID-19 Therapeutics Advice & Support Group (CTAG) immunomodulatory subgroup. The provenance for this subgroup is the HLH Across Speciality Collaboration (HASC).

Subgroup membership (listed in alphabetical order, first by organisation, then surname):

Organisation Name Role The Christie NHS Foundation Trust

Dr Amit Patel Consultant, Haematology and Intensive Care

The Newcastle Upon Tyne Hospitals NHS Foundation Trust

Dr Christopher Duncan* Consultant, Infectious Diseases

Sheffield Teaching Hospital NHS Foundation Trust

Dr Rachel Tattersall Consultant, Adolescent and Adult Rheumatology HASC Co-Chair

University College London Hospitals NHS Foundation Trust

Dr Aisling Carr Consultant, Neurology Mr James Hartwell Pharmacist Dr Maria Leandro* Consultant, Adolescent and Adult

Rheumatology Dr Jessica Manson Consultant, Rheumatology

HASC Co-Chair Dr P Mehta Specialist Registrar, Rheumatology Dr B Goulden Specialist Registrar, Rheumatology

University Hospital Southampton NHS Foundation Trust

Dr Andrew Duncombe Consultant, Haematologist

* Subgroup co-convenors

The immunomodulatory subgroup will refer specific agenda items to HASC for consideration. HASC has approximately 150 members with multispecialty representation from across the UK; for more information regarding HASC, please contact [email protected]. For the purposes of clarity, HASC is not a subgroup of CTAG although HASC co-Chairs do form part of the immunomodulators subgroup.



Document control Date Version Amendments

22 April 2020 1.0 New document

07 May 2020 1.1 Updated evidence summaries in Appendix 1.

01 June 2020 2.0 Updated tables of trials and evidence summaries to include new proposed investigational products


Appendix 1: Publications for investigational immunomodulatory medicines to treat hyperinflammation associated with COVID-19 The NIHR list of nationally prioritised studies was searched to identify novel treatments for Covid-19. The Cochrane database of Covid-19 studies was searched to identify the current evidence-base for COVID-19 (Drugs Searched: tocilizumab; sarilumab; anakinra; ruxolitinib; siltuximab, brensocatib):

• Randomised controlled trials https://covid-nma.com/living_data/index.php • Observational studies https://covid-nma.com/observational_studies/

Healthcare professionals involved in the prescription and administration of an immunomodulatory agent should familiarise themselves with the medication safety profile before use. Data in Table A1 is correct to 22 May 2020.

Table A1: Evidence base for specific therapies for SARS-CoV-2 infection: Inadequate data to recommend compassionate use, await further data Therapy Data: Other forms of hyperinflammation Data: SARS-CoV-2 induced hyperinflammation Safety profile in SARS-CoV-2

induced hyperinflammation UK feasibility

Anakinra IL-1 specific inhibitor used off-label to treat HLH and approved for this indication at several NHS Trusts in the UK. It is licensed in the UK to treat Still’s disease (including systemic juvenile idiopathic arthritis and Adult-Onset Still’s disease), which is recognized in progressing to hyperinflammation.11,12 In a double-blind RCT in 893 sepsis patients, anakinra did not lengthen survival time compared to placebo however two post-hoc analyses found survival benefit in patients with ‘≥1 organ dysfunction’13 or ‘disseminated intravascular coagulation and hepatobiliary dysfunction’14 (features suggestive of sHLH). It is unknown whether these data apply to patients with sHLH due to the post-hoc analysis (risk of Type 1 error) and the absence of prospectively confirmed sHLH diagnosis. Multiple case-series15–19 find a high proportion of patients

A NICE evidence summary (correct to 13 May 2020) performed a review to determine the efficacy, safety, cost-effectiveness and potential benefit to particular subgroups from the administration of anakinra for COVID-19 associated sHLH in patients of all ages.20 No relevant published papers were identified. Two unpublished, non-peer reviewed papers were identified (one was a systematic review that did not identify any published literature on anakinra; the other paper is discussed below21). A case series included 7 intensive care patients in Greece and one non-ICU patient in the Netherlands, each with sHLH due to COVID-19.21 The ICU patients were given anakinra after mechanical ventilation and also received hydroxychloroquine, azithromycin and broad-spectrum antibiotics. Five ICU patients had decreased lung infiltrates; six ICU patients had reduced vasopressor requirement. Initial decreases in pO2/FiO2 ratio were seen, though this increased in all seven patients by two days post end of

In the study on sepsis patients, the single serious adverse event reported more commonly in anakinra patients versus placebo was cardiopulmonary arrest 11% versus 8%), with similar numbers in each group thought to be related to anakinra or placebo. The authors of the post-hoc analysis stated that this trial and others that investigated anakinra did not find an increased mortality rate or serious/non-serious reactions versus placebo.

An active interventional arm in the REMAP-CAP trial.


https://covid-nma.com/living_data/index.php

https://covid-nma.com/observational_studies/



Therapy Data: Other forms of hyperinflammation Data: SARS-CoV-2 induced hyperinflammation Safety profile in SARS-CoV-2 induced hyperinflammation

UK feasibility

with sHLH/macrophage activation syndrome (MAS) treated with anakinra survive. These reports were limited by the lack of a control arm, and small number of patients. In a recent NICE evidence summary, it is advised that policy decisions on anakinra for COVID-19 associated sHLH will need to consider data extrapolated from studies assessing anakinra for other hyperinflammatory states.

treatment. Three ICU patients died following refractory shock. The non-ICU patient was given anakinra and was discharged nine days later following improvement in domains of H-score criteria. This study was limited by the lack of active comparator and small number of patients.

A retrospective cohort study in Italy compared the outcomes of 52 adult patients with COVID-19, moderate-to-severe ARDS and hyperinflammation (CRP ≥100 mg/L, ferritin ≥900 ng/mL, or both), who were managed with non-invasive ventilation outside ICU.22 The study compared outcomes for patients treated with low or high-dose anakinra with a historical cohort who did not receive anakinra (the SoC cohort). 16 patients received SoC (including hydroxychloroquine and lopinavir/ritonavir), 29 patients received high-dose intravenous anakinra (5mg/kg/twice daily over one hour) and SoC, and seven patients received low-dose subcutaneous anakinra (100mg BD). The low-dose anakinra arm was terminated at day seven due to paucity in anti-inflammatory or clinical efficacy. At day 21 of follow-up, the high-dose anakinra group had received a median of 9 days treatment; 21 patients showed improvements with reduction in CRP and progressive improvements in respiratory function; five patients progressed to mechanical ventilation and three patients died. At day 21 in the SoC group, eight patients showed respiratory improvement; one patient progressed to mechanical ventilation and seven died. At day 21, survival in the high-dose anakinra group was 90% versus 56% in the SoC group (p=0.009); there was no statistical difference in mechanical ventilation-free survival (p=0.15). This study attempted to draw comparisons against SoC alone, but is limited by the retrospective design and the

The NICE evidence summary recognizes that newer studies consider intravenous anakinra for related hyperinflammatory states in patients with COVID-19 and ARDS, and warns that this is off-label use which raises safety concerns. Caution is also advised when using such immunomodulatory therapies in critically ill people with suspected infection due to the risk of complications. However, it is proposed that anakinra may be an option if immunomodulation is considered necessary because it has a relatively short half-life and can be discontinued quickly if an adverse effect or concern for worsening infection arises. In the retrospective cohort study in Italy,22 treatment was discontinued for seven patients receiving high-dose anakinra after receiving treatment for a median of nine days; bacteraemia occurred in four patients (14%) (two patients (13%) receiving SoC alone also had bacteraemia); and three



UK feasibility

lack of randomisation, the small number of patients and use of concomitant investigative agents.

A case series in France treated nine patients with moderate to severe COVID-19 pneumonia and who were deemed at risk of worsening.23 One patient was withdrawn from treatment after suffering acute respiratory failure after the first dose of anakinra. Most patients had reduced oxygen flow requirement and CRP decreased (normalising in five patients). Patient H-scores before treatment were reported. This study is limited by the lack of active comparator and small number of patients and lack of information of concomitant therapies.

patients (10%) had increasing liver enzymes (five patients (31%) receiving SoC alone also had raised liver enzymes).

Canakinumab Canakinumab binds with interleukin-1 beta to prevent its inflammatory activity. It is licensed in the UK to treat Still’s disease (including systemic juvenile idiopathic arthritis and Adult-Onset Still’s disease), which is recognized in progressing to hyperinflammation. No evidence in the form of a clinical study could be identified to demonstrate the efficacy of canakinumab in treating patients suffering from other hyperinflammatory states.

No results yet reported. No safety data has been reported in the COVID-19 population.

An interventional treatment arm in CANCOVID

Tocilizumab Tocilizumab binds to both soluble and membrane bound interleukin-6 receptors, and is licensed in the UK following demonstration of efficacy in treating CRS associated with the CAR-T therapies such as tisagenlecleucel and axicabtagene ciloleucel.24 As part of clinical trials for CAR-T therapy, tocilizumab was included in the protocol to treat CAR-T induced CRS. Co-medication with corticosteroids was allowed and no comparative data were available at the time of licensing; however, rapid effects on objective

A case series in severe or critical COVID-19 infection in China25 found 15/20 patients (75%) given tocilizumab had lowered oxygen requirements and one patient needed no further oxygen therapy; lung lesions improved in 19 patients (90.5%) and 19 patients were discharged (90.5%), including two patients from critical care. All patients also received standard of care which included lopinavir and methylprednisolone. However, no control arm was included and only a small number of participants was used. This study was not peer reviewed.

The marketing authorization holder for tocilizumab was asked to supply further data on safety in CAR-T induced CRS due to low numbers of patients exposed to higher doses. No adverse events were reported in the first case series from China25, and the second case series from China did not report on safety.26

An interventional arm of the REMAP-CAP, RECOVERY and COVACTA trials.







UK feasibility

early endpoints (e.g. vital signs) provided sufficient evidence for the role of tocilizumab in the resolution of a life-threatening condition with a previously unmet need.

A case series in China treated 15 patients with tocilizumab.26 Eight patients were also given methylprednisolone. The study describes the kinetics of CRP and IL-6 changes following tocilizumab administration. One patient demonstrated clinical improvement, nine patients stabilised, two demonstrated disease aggravation and three patients died. This study was limited by the lack of a control arm, short follow-up and small number of patients.

A press release suggests the results from the French CORIMUNO-TOCI study of 129 patients27 show a significantly lower proportion of patients reaching the primary composite outcome (requirement for ventilation or death by day 14) among those receiving tocilizumab and standard of care versus standard of care alone. A publication in a peer-reviewed journal is awaited.

A case series from Qatar reported 25 ICU patients treated with tocilizumab and at least two investigative antiviral agents (median five).28 Nine patients were discharged from the ICU and three died; the remaining 13 patients were still in ICU at the end of the study. The proportion of patients on mechanical ventilation decreased from 84% at baseline to 60% on day 7 and 28% on day 14. Other improvements were seen in inflammatory markers and imaging. The study was limited by the lack of a control arm, use of concomitant investigational products, short follow-up and small number of patients.

A prospective study in Italy treated 100 consecutive patients with COVID-19 and acute respiratory distress syndrome (ARDS) with two (87) or 3 (13) infusions of tocilizumab with SoC (SoC could include lopinavir/ritonavir or remdesivir; azithromycin, ceftriaxone or

The prospective study in Italy screened patients for contraindications prior to tocilizumab therapy, and assessed patients 24-72 hours after administration (and again 10 days later). Two patients developed septic shock and died; one patient suffered from gastrointestinal perforation and underwent urgent surgery.29 The case-series in France found two patients develop mild hepatic cytolysis and one patient developed ventilator associated pneumonia.33 The case-series in the UK found four patients who had two tocilizumab doses required additional antibiotic treatments; three patients tested positive for bacterial cultures.34 A case-series in the US investigated the possible association between tocilizumab and secondary infections.35 28 adult ICU patients with COVID-19 were given tocilizumab in one (n=25) or two (n=3) administrations; bacterial and fungal infection rates were



UK feasibility

piperacillin/tazobactam; hydroxychloroquine; and corticosteroids). Patients were screened for contraindications for tocilizumab before entering the study. Assessments were taken 24-72 hours after tocilizumab and 10 days after.29 57 patients were on non-invasive ventilation (NIV) at baseline; 37 of these patients improved and suspended NIV; seven remained stable on NIV; three patients were admitted to ICU; ten patients died. 43 patients were treated in the ICU and were on a ventilator at baseline; 32 of these patients had improvements in ARDS severity scores (with 17 taken off the ventilator and discharged to a ward); one patient remained stable; ten patients died. Two patients developed septic shock and died. One patient suffered from gastrointestinal perforation requiring urgent surgery. This study is limited by the lack of an active comparator, short-follow up period and uncontrolled baseline status of patients. A retrospective case-control study in France treated 20 patients with tocilizumab and SoC, and compared against 25 patients receiving SoC alone (SoC could include hydroxychloroquine, lopinavir/ritonavir, antibiotics and corticosteroids).30 A composite of death and/or ICU admission was significantly higher in the standard treatment group versus tocilizumab group (72% vs. 25%). Of this difference, mortality alone did not reach significance (48% vs 25%) but the number of patients requiring mechanical ventilation did (32% vs 0%). This study is limited as it was a retrospective study with a small number of patients.

A prospective single-arm multicentre study in Italy treated 63 patients with either intravenous or subcutaneous tocilizumab (based on availability).31 Only 5 patients required mechanical ventilation at admission. The primary outcome of safety demonstrated no moderate to severe

compared against 32 adult ICU COVID-19 patients without tocilizumab. Tocilizumab was associated with higher incidence of secondary bacterial infections (64.3% vs 31.3% [p=0.010]). There was a higher incidence of fungal infections in the tocilizumab group, though the risk of fungal infections was not statistically different. A post-mortem analysis showed evidence of pneumonia in three patients receiving tocilizumab; out of four patients not given tocilizumab, two showed evidence of aspiration pneumonia, and the other two showed changes consistent with diffuse alveolar damage without evidence of pneumonia. This study is limited by the small number of patients, the lack of information on concomitant pharmacological therapies and lack of information on the number of patients receiving other supportive measures that could increase the risk of infection (e.g. number of



UK feasibility

adverse events following tocilizumab administration and overall mortality at 14 days was 11%. Secondary outcomes saw improvements in CRP, ferritin, D-Dimer and lymphocyte count. This study is limited by the lack of comparator, the open-label design, small number of patients, use of varying routes of administration and lack of information on trial registration or protocol adherence.

A retrospective single-centre analysis of patients with haematological malignancies who contracted SARS-CoV-2 was conducted in Spain.32 34 patients were identified in this analysis; tocilizumab had been administered to eight patients who fit initiation criteria of high IL-6 and ARDS. Five patients survived and three died (p=1.0). This analysis was not aimed at investigating the role of tocilizumab; it is limited by the extremely small number of patients and lack of comparator.

A case-series in France treated 30 patients with tocilizumab and compared against a matched control group.33 Tocilizumab significantly reduced the requirement for subsequent mechanical ventilation (weighted OR=0.42 [95% CI 0.20 to 0.89]) and tocilizumab given to patients treated outside ICU significantly reduced ICU admission (weighted OR=0.17 [95% CI 0.06 to 0.48]). Tocilizumab was associated with a trend towards reduced mortality that was not significant after weighted analysis. This study is limited by the lack of comparator, small number of patients and use of other non-standard of care therapies. This study was not peer-reviewed.

A case-series in the UK treated 11 patients with tocilizumab (seven in ICU mechanically ventilated, and four receiving high flow oxygen in general ward areas).34 Of the patients in ICU, two patients died and five were extubated (two of

patients mechanically ventilated). This study has not been peer-reviewed.



UK feasibility

whom were discharged from ICU). The four ward patients were discharged from hospital. Improvements in other clinical parameters were seen (such as CRP, temperature and respiratory function). There was no effect on LDH and worsening of D-Dimers following tocilizumab therapy. This study is limited by the small number of patients, the lack of comparator and uncontrolled baseline status of patients. This study was not peer-reviewed.

Sarilumab Sarilumab binds to both soluble and membrane bound interleukin-6 receptors, preventing IL-6 mediated signaling. It is licensed in the UK for the treatment of moderate to severe rheumatoid arthritis.36 No evidence in the form of a clinical study could be identified to demonstrate the efficacy of sarilumab in treating patients suffering from other hyperinflammatory states.

A press release suggests that results from the Phase 2 portion of the US Phase 2/3 study (NCT04315298)37 shows sarilumab lowers CRP, compared to placebo. A “pre-specified exploratory analysis” of patients with ‘severe’ disease (requiring oxygen supplementation without mechanical or high-flow oxygenation) and ‘critical’ disease (requiring mechanical ventilation or high-flow oxygenation or required treatment in an intensive care unit) found sarilumab had no benefit on clinical outcomes. Further analysis found negative trends for most outcomes in the ‘severe’ group and positive trends for the ‘critical’ group. The Phase 3 portion of the US trial was subsequently amended to enrol ‘critical’ patients only. A publication in a peer-reviewed journal is awaited.

No safety data has been reported in the COVID-19 population.

Proposal to add as an interventional arm to the RECOVERY trial.

An interventional treatment arm in the REMAP-CAP trial.

Siltuximab Siltuximab binds with interleukin-6 to prevent binding with soluble and membrane-bound IL-6 receptors. It is licensed in the UK to treat Castleman’s disease.38 No evidence in the form of a clinical study could be identified to demonstrate the efficacy of siltuximab in treating patients suffering from other hyperinflammatory states.

A case series in 21 patients in Italy39 reports reduced CRP in 16 patients, with an improvement in clinical condition in 7 patients (33%), stabilisation with no worsening in 9 patients (43%) and 5 patients experienced a worsening in condition including one patient who died (24%). This study was not peer reviewed. This study did not have a control arm and the low number of patients were followed up for 8 days.

Of the patients that deteriorated in the SARS-CoV-2 case series, one suffered a cerebrovascular event.

Not available under a clinical trial in the UK currently

CYT107 CYT107 is an intravenous recombinant human interleukin-7 agent. It is also being investigated for use in patients with refractory


An interventional

https://clinicaltrials.gov/ct2/show/NCT04315298?term=Sarilumab&cond=COVID-19&draw=2&rank=1






UK feasibility

nontuberculous mycobacterial lung disease, metastatic urothelial carcinoma, lymphopaenia in sepsis patients and in viral disease. The proposed use is based on data to suggest there is an underlying lymphopaenia in COVID-19 patients that leads to progression to ICU; an international, double-blind, placebo-controlled RCT in ICU patients with vasopressor dependent septic shock and at least one organ failure (n=27) suggests CYT107 was well tolerated with no development of a cytokine storm, and resulted in a three- to four-fold increase in lymphocyte counts and circulating CD4+ and CD8+ T-cells (though no difference in mortality rates).40,41

treatment arm in ILIAD 7

MEDI3506 MEDI3506 is an unlicensed monoclonal antibody targeting IL-33. It is currently being investigated for diabetic kidney disease, atopic dermatitis and COPD. IL-33 is recognized as a cytokine released by pulmonary epithelial cells following viral infection; a recent publication also makes the case for targeting IL-33 as it is an upstream activator of HLH.42 A literature search could not identify any studies using MEDI3506 to treat other hyperinflammatory states.


An interventional treatment arm in ACCORD-2.

Ruxolitinib Ruxolitinib is a selective Janus-associated kinase (JAK) 1 and 2 inhibitor responsible for cytokine signaling. Ruxolitinib is licensed in the UK to treat myelofibrosis and thrombocythaemia. A case report in which a patient was given ruxolitinib for sHLH refractory to standard of care therapy43 (including IVIG, dexamethasone, etoposide and rituximab) describes an improvement in biomarkers (except no resolution of


An interventional treatment arm in RUXCOVID






UK feasibility

pancytopaenia), though still ultimately led to death. An open-label pilot trial in five sHLH patients found resolution of symptoms and disease-related laboratory abnormalities following treatment with 15mg twice daily of ruxolitinib. Six adverse events were reported and classified as a possible or probable consequence of ruxolitinib. One was a serious adverse event (febrile neutropaenia) and one grade two adverse event of pain in extremity caused discontinuation. This study had a long follow-up period but is limited by the open-label single arm design and only five participants.44 A further case series described the efficacy of ruxolitinib in two patients meeting criteria for sHLH refractory to other treatments. Due to being a case series, it is limited by the study design.45

Baricitinib Baricitinib is a JAK1 and JAK2 reversible inhibitor responsible for cytokine signaling. It is licensed in the UK to treat moderate to severe active rheumatoid arthritis. A recent publication suggests baricitinib could also prevent SARS-CoV-2 endocytosis through other mechanisms (inhibition of AP-2 associated protein kinase 1 (AAK1) and binding to cyclin-g associated kinase (GAK), both of which regulate endocytosis through lung AT2 alveolar epithelial cells).46 A literature search could not identify any studies using baricitinib to treat other hyperinflammatory states.

A case series in 12 patients in Italy47 reports baricitinib given at 4mg/day added onto lopinavir/ritonavir; 12 patients receiving hydroxychloroquine and lopinavir/ritonavir acted as a control group. Significant improvements in laboratory and respiratory parameters are reported compared to baseline in the baricitinib group; fever, SpO2, PaO2/FiO2, CRP, and MEWS improved significantly in the baricitinib group versus control group. Seven patients in the baricitinib group were discharged after two weeks versus one in the control group. The SoC used in this study is not common to the UK, and pre-defined endpoints or control group was not used. This case series is published as a letter to the editor and hence was not peer reviewed.

In the case series, one patient in the baricitinib group discontinued due to raised transaminases. No other serious adverse events were recorded in the study.

An interventional treatment in TACTIC-R.




UK feasibility

Acalabrutinib Acalabrutinib is a Bruton tyrosine kinase (BTK) inhibitor licensed by the FDA licensed to treat chronic lymphocytic leukaemia and mantle cell lymphoma (currently unlicensed in the UK). Acalabrutinib binds in the active site of BTK, which prevents downstream activation of B-cell proliferation and cytokine receptor pathways. The manufacturer suggests dysregulated BTK-dependent macrophage signaling may be central to the production of multiple inflammatory cytokines and chemokines, leading to an exaggerated inflammatory response.48 A literature search could not identify any studies using acalabrutinib to treat other hyperinflammatory states.



Bemcentinib Bemcentinib is an unlicensed AXL kinase inhibitor that is currently being investigated in phase II trials as a potential treatment option for several forms of solid and haematological tumours. AXL mediates proliferation and survival of leukaemic cells. The manufacturer states this mechanism also blocks viral entry and enhances anti-viral type I interferon response against viral infection.49 A literature search could not identify any studies using bemcentinib to treat other hyperinflammatory states.



Gemtuzumab ozogamicin

Gemtuzumab ozogamicin is a recombinant antibody conjugated with a calicheamicin cytotoxic antibiotic licensed in the UK as part of a protocol to treat CD-33 positive acute myeloid leukaemia. It binds to the CD-33 antigen expressed by haematopoietic cells and is internalized, followed by release of the calicheamicin derivative binds to the DNA and


An interventional treatment arm in CATALYST.






UK feasibility

induces cell death. A study in mice models with hallmarks of HLH/MAS found ablation of myeloid cells (and not lymphoid cells) reversed the disease process; gemtuzumab ozogamicin was effective in restoring red cell count, improving appearance, splenomegaly and bone marrow cellularity. Targeting CD33 was proposed as a potential therapeutic approach in cases refractory to current therapies.50 A literature search could not identify any studies using gemtuzumab ozogamicin to treat other hyperinflammatory states.

Zilucoplan Zilucoplan is an unlicensed terminal complement inhibitor specific to protein C5. It is currently being investigated for the treatment of generalised myasthenia gravis, immune-mediated necrotizing myopathy and paroxysmal nocturnal haemaglobinuria. As with ravulizumab, the complement system has been identified as an important mediator in the systemic inflammatory response to SARS-CoV.51 A literature search could not identify any studies using zilucoplan to treat other hyperinflammatory states.



Ravulizumab Ravulizumab is a terminal complement inhibitor specific to protein C5 with high affinity, preventing the formation of C5a, C5b and C5b9. It is licensed in the UK for the treatment of adult patients with paroxysmal nocturnal haemoglobinuria. A study in mice infected with SARS-CoV identified the complement system to be an important mediator and suggests that complement activation regulates a systemic inflammatory response to SARS-CoV.51 A


An interventional treatment in TACTIC-R.





UK feasibility

literature search could not identify any studies using ravulizumab to treat other hyperinflammatory states.

Brensocatib Brensocatib is an unlicensed selective reversible inhibitor of dipeptidyl peptidase 1 (DPP1), an enzyme that activates neutrophil serine proteases during neutrophil maturation in the bone marrow. Neutrophils play an important role in lung inflammation including in ARDS.52 Brensocatib has recently completed a phase 2 trial in patients with non-cystic fibrosis bronchiectasis (preliminary results reported by the company indicate success though is not published; common adverse effects seen with brensocatib was cough, headache, sputum increase, dyspnea, fatigue, and upper respiratory tract infection.).53 A literature search could not identify any studies using brensocatib to treat other hyperinflammatory states.


Proposed as an interventional treatment in STOP-COVID19.

Disclaimer

Due to the urgency for interim guidance, only a limited number of agents have been assessed and a wholly systematic approach to assessing the evidence (such as GRADE) has not been performed. Some subjective judgments are solely the consensus opinion of the authors and consulted experts



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position statement: use of investigational immunomodulatory … · immunomodulators domain: soc vs...

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