Subcutaneous sarilumab for the treatment of hospitalized patients with moderate to severe COVID19 disease: A pragmatic, embedded randomized clinical trial.
<h4>Importance and objective</h4>The aim of this pragmatic, embedded, adaptive trial was to measure the effectiveness of the subcutaneous anti-IL-6R antibody sarilumab, when added to an evolving standard of care (SOC), for clinical management of inpatients with moderate to severe COVID-1...
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Public Library of Science (PLoS)
2022-01-01
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| author | Westyn Branch-Elliman Ryan Ferguson Gheorghe Doros Patricia Woods Sarah Leatherman Judith Strymish Rupak Datta Rekha Goswami Matthew D Jankowich Nishant R Shah Thomas H Taylor Sarah T Page Sara J Schiller Colleen Shannon Cynthia Hau Maura Flynn Erika Holmberg Karen Visnaw Rupali Dhond Mary Brophy Paul A Monach |
| author_facet | Westyn Branch-Elliman Ryan Ferguson Gheorghe Doros Patricia Woods Sarah Leatherman Judith Strymish Rupak Datta Rekha Goswami Matthew D Jankowich Nishant R Shah Thomas H Taylor Sarah T Page Sara J Schiller Colleen Shannon Cynthia Hau Maura Flynn Erika Holmberg Karen Visnaw Rupali Dhond Mary Brophy Paul A Monach |
| author_sort | Westyn Branch-Elliman |
| collection | DOAJ |
| description | <h4>Importance and objective</h4>The aim of this pragmatic, embedded, adaptive trial was to measure the effectiveness of the subcutaneous anti-IL-6R antibody sarilumab, when added to an evolving standard of care (SOC), for clinical management of inpatients with moderate to severe COVID-19 disease.<h4>Design</h4>Two-arm, randomized, open-label controlled trial comparing SOC alone to SOC plus sarilumab. The trial used a randomized play-the-winner design and was fully embedded within the electronic health record (EHR) system.<h4>Setting</h4>5 VA Medical Centers.<h4>Participants</h4>Hospitalized patients with clinical criteria for moderate to severe COVID-19 but not requiring mechanical ventilation, and a diagnostic test positive for SARS-CoV-2.<h4>Interventions</h4>Sarilumab, 200 or 400 mg subcutaneous injection. SOC was not pre-specified and could vary over time, e.g., to include antiviral or other anti-inflammatory drugs.<h4>Main outcomes and measures</h4>The primary outcome was intubation or death within 14 days of randomization. All data were extracted remotely from the EHR.<h4>Results</h4>Among 162 eligible patients, 53 consented, and 50 were evaluated for the primary endpoint of intubation or death. This occurred in 5/20 and 1/30 of participants in the sarilumab and SOC arms respectively, with the majority occurring in the initial 9 participants (3/4 in the sarilumab and 1/5 in the SOC) before the sarilumab dose was increased to 400 mg and before remdesivir and dexamethasone were widely adopted. After interim review, the unblinded Data Monitoring Committee recommended that the study be stopped due to concern for safety: a high probability that rates of intubation or death were higher with addition of sarilumab to SOC (92.6%), and a very low probability (3.4%) that sarilumab would be found to be superior.<h4>Conclusions and relevance</h4>This randomized trial of patients hospitalized due to respiratory compromise from COVID-19 but not mechanical ventilation found no benefit from subcutaneous sarilumab when added to an evolving SOC. The numbers of patients and events were too low to allow definitive conclusions to be drawn, but this study contributes valuable information about the role of subcutaneous IL-6R inhibition in the treatment of hospitalized COVID-19 patients. Methods developed and piloted during this trial will be useful in conducting future studies more efficiently.<h4>Trial registration</h4>Clinicaltrials.gov-NCT04359901; https://clinicaltrials.gov/ct2/show/NCT04359901?cond=NCT04359901&draw=2&rank=1. |
| format | Article |
| id | doaj-art-0f93913ce462481c84ad214cf1534dd7 |
| institution | Kabale University |
| issn | 1932-6203 |
| language | English |
| publishDate | 2022-01-01 |
| publisher | Public Library of Science (PLoS) |
| record_format | Article |
| series | PLoS ONE |
| spelling | doaj-art-0f93913ce462481c84ad214cf1534dd72025-02-05T05:32:53ZengPublic Library of Science (PLoS)PLoS ONE1932-62032022-01-01172e026359110.1371/journal.pone.0263591Subcutaneous sarilumab for the treatment of hospitalized patients with moderate to severe COVID19 disease: A pragmatic, embedded randomized clinical trial.Westyn Branch-EllimanRyan FergusonGheorghe DorosPatricia WoodsSarah LeathermanJudith StrymishRupak DattaRekha GoswamiMatthew D JankowichNishant R ShahThomas H TaylorSarah T PageSara J SchillerColleen ShannonCynthia HauMaura FlynnErika HolmbergKaren VisnawRupali DhondMary BrophyPaul A Monach<h4>Importance and objective</h4>The aim of this pragmatic, embedded, adaptive trial was to measure the effectiveness of the subcutaneous anti-IL-6R antibody sarilumab, when added to an evolving standard of care (SOC), for clinical management of inpatients with moderate to severe COVID-19 disease.<h4>Design</h4>Two-arm, randomized, open-label controlled trial comparing SOC alone to SOC plus sarilumab. The trial used a randomized play-the-winner design and was fully embedded within the electronic health record (EHR) system.<h4>Setting</h4>5 VA Medical Centers.<h4>Participants</h4>Hospitalized patients with clinical criteria for moderate to severe COVID-19 but not requiring mechanical ventilation, and a diagnostic test positive for SARS-CoV-2.<h4>Interventions</h4>Sarilumab, 200 or 400 mg subcutaneous injection. SOC was not pre-specified and could vary over time, e.g., to include antiviral or other anti-inflammatory drugs.<h4>Main outcomes and measures</h4>The primary outcome was intubation or death within 14 days of randomization. All data were extracted remotely from the EHR.<h4>Results</h4>Among 162 eligible patients, 53 consented, and 50 were evaluated for the primary endpoint of intubation or death. This occurred in 5/20 and 1/30 of participants in the sarilumab and SOC arms respectively, with the majority occurring in the initial 9 participants (3/4 in the sarilumab and 1/5 in the SOC) before the sarilumab dose was increased to 400 mg and before remdesivir and dexamethasone were widely adopted. After interim review, the unblinded Data Monitoring Committee recommended that the study be stopped due to concern for safety: a high probability that rates of intubation or death were higher with addition of sarilumab to SOC (92.6%), and a very low probability (3.4%) that sarilumab would be found to be superior.<h4>Conclusions and relevance</h4>This randomized trial of patients hospitalized due to respiratory compromise from COVID-19 but not mechanical ventilation found no benefit from subcutaneous sarilumab when added to an evolving SOC. The numbers of patients and events were too low to allow definitive conclusions to be drawn, but this study contributes valuable information about the role of subcutaneous IL-6R inhibition in the treatment of hospitalized COVID-19 patients. Methods developed and piloted during this trial will be useful in conducting future studies more efficiently.<h4>Trial registration</h4>Clinicaltrials.gov-NCT04359901; https://clinicaltrials.gov/ct2/show/NCT04359901?cond=NCT04359901&draw=2&rank=1.https://journals.plos.org/plosone/article/file?id=10.1371/journal.pone.0263591&type=printable |
| spellingShingle | Westyn Branch-Elliman Ryan Ferguson Gheorghe Doros Patricia Woods Sarah Leatherman Judith Strymish Rupak Datta Rekha Goswami Matthew D Jankowich Nishant R Shah Thomas H Taylor Sarah T Page Sara J Schiller Colleen Shannon Cynthia Hau Maura Flynn Erika Holmberg Karen Visnaw Rupali Dhond Mary Brophy Paul A Monach Subcutaneous sarilumab for the treatment of hospitalized patients with moderate to severe COVID19 disease: A pragmatic, embedded randomized clinical trial. PLoS ONE |
| title | Subcutaneous sarilumab for the treatment of hospitalized patients with moderate to severe COVID19 disease: A pragmatic, embedded randomized clinical trial. |
| title_full | Subcutaneous sarilumab for the treatment of hospitalized patients with moderate to severe COVID19 disease: A pragmatic, embedded randomized clinical trial. |
| title_fullStr | Subcutaneous sarilumab for the treatment of hospitalized patients with moderate to severe COVID19 disease: A pragmatic, embedded randomized clinical trial. |
| title_full_unstemmed | Subcutaneous sarilumab for the treatment of hospitalized patients with moderate to severe COVID19 disease: A pragmatic, embedded randomized clinical trial. |
| title_short | Subcutaneous sarilumab for the treatment of hospitalized patients with moderate to severe COVID19 disease: A pragmatic, embedded randomized clinical trial. |
| title_sort | subcutaneous sarilumab for the treatment of hospitalized patients with moderate to severe covid19 disease a pragmatic embedded randomized clinical trial |
| url | https://journals.plos.org/plosone/article/file?id=10.1371/journal.pone.0263591&type=printable |
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