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La combinación de tres antivirales ( interferón beta-1b más lopinavir-ritonavir y ribavirina) se muestra prometedora para tratar la Covid-19
Coronavirus: Una combinación de tres antivirales se muestra prometedora para tratar la Covid-19
Se trata de la combinación de interferón beta-1b más lopinavir-ritonavir y ribavirina
Un tratamiento de dos semanas de terapia antiviral con interferón beta-1b más lopinavir-ritonavir y ribavirina,
iniciado dentro de los siete días siguientes a la aparición de los
síntomas del Covid-19, es seguro y más eficaz para reducir la duración
de la excreción del virus que el lopinavir-ritonavir
solo en pacientes con enfermedad leve a moderada, según el primer
ensayo aleatorio de esta terapia de combinación triple en el que
participaron 127 adultos (a partir de 18 años) de seis hospitales
públicos de Hong Kong.
Estos primeros hallazgos, publicados en The Lancet,
no incluyen casos graves de Covid-19, y los autores subrayan la
necesidad de realizar ensayos de fase 3 más amplios para examinar la
eficacia de esta triple combinación en pacientes gravemente enfermos.
Los
resultados del nuevo estudio sugieren que la mejoría clínica y la
duración de la estancia hospitalaria pueden ser significativamente más
cortas en las personas tratadas con la triple combinación menos de 7
días después de mostrar síntomas, en comparación con el lopinavir-ritonavir solo.
"Nuestro ensayo demuestra que el tratamiento temprano del Covid-19 de leve a moderada con una combinación triple de fármacos antivirales
puede suprimir rápidamente la cantidad de virus en el cuerpo de un
paciente, aliviar los síntomas y reducir el riesgo para los
profesionales sanitarios al reducir la duración y la cantidad de la
excreción del virus (cuando el virus es detectable y potencialmente
transmisible). Además, la combinación de tratamientos parecía segura y
bien tolerada por los pacientes", explica el profesor Kwok-Yung Yuen de
la Universidad de Hong Kong, que dirigió la investigación.
En investigaciones anteriores se determinó que una combinación de lopinavir-ritonavir oral
(utilizado normalmente para tratar el VIH) y ribavirin (un fármaco oral
contra el virus de la hepatitis C) redujo significativamente la
insuficiencia respiratoria y la muerte de los pacientes hospitalizados
por el síndrome respiratorio agudo severo (SARS) durante el brote de
2003. El interferón beta-1b, que se desarrolló para tratar la esclerosis
múltiple (EM), ha demostrado reducir la carga viral y mejorar los
problemas pulmonares en los estudios en animales de la infección por
coronavirus del síndrome respiratorio de Oriente Medio (MERS).
Interferon y rividamina eran utilziados en la hepatitis C, hasta la llegada del Soldavi
*El 11 de Marzo realice una aproximación al tema con JC Sanchis sobre la relación de la fibrobisis y los antivirales Interferón y Rividamina de la hepatitis C aplicada al coronavirus, al
leer que habían casos que se provoca fibrosis en el pulmón, relacionándolo con
la fibrosis del hígado de la Hepatitis C
Triple combination of
interferon beta-1b, lopinavir–ritonavir, and ribavirin in the treatment
of patients admitted to hospital with COVID-19: an open-label,
randomised, phase 2 trial
Effective
antiviral therapy is important for tackling the coronavirus disease
2019 (COVID-19) pandemic. We assessed the efficacy and safety of
combined interferon beta-1b, lopinavir–ritonavir, and ribavirin for
treating patients with COVID-19.
Methods
This
was a multicentre, prospective, open-label, randomised, phase 2 trial
in adults with COVID-19 who were admitted to six hospitals in Hong Kong.
Patients were randomly assigned (2:1) to a 14-day combination of
lopinavir 400 mg and ritonavir 100 mg every 12 h, ribavirin 400 mg every
12 h, and three doses of 8 million international units of interferon
beta-1b on alternate days (combination group) or to 14 days of lopinavir
400 mg and ritonavir 100 mg every 12 h (control group). The primary
endpoint was the time to providing a nasopharyngeal swab negative for
severe acute respiratory syndrome coronavirus 2 RT-PCR, and was done in
the intention-to-treat population. The study is registered with ClinicalTrials.gov, NCT04276688.
Findings
Between
Feb 10 and March 20, 2020, 127 patients were recruited; 86 were
randomly assigned to the combination group and 41 were assigned to the
control group. The median number of days from symptom onset to start of
study treatment was 5 days (IQR 3–7). The combination group had a
significantly shorter median time from start of study treatment to
negative nasopharyngeal swab (7 days [IQR 5–11]) than the control group
(12 days [8–15]; hazard ratio 4·37 [95% CI 1·86–10·24], p=0·0010).
Adverse events included self-limited nausea and diarrhoea with no
difference between the two groups. One patient in the control group
discontinued lopinavir–ritonavir because of biochemical hepatitis. No
patients died during the study.
Interpretation
Early
triple antiviral therapy was safe and superior to lopinavir–ritonavir
alone in alleviating symptoms and shortening the duration of viral
shedding and hospital stay in patients with mild to moderate COVID-19.
Future clinical study of a double antiviral therapy with interferon
beta-1b as a backbone is warranted.
Funding
The Shaw-Foundation, Richard and Carol Yu, May Tam Mak Mei Yin, and Sanming Project of Medicine.
The
coronavirus disease 2019 (COVID-19) pandemic caused by the severe acute
respiratory syndrome coronavirus 2 (SARS-CoV-2) has affected more than 3
million patients with more than 200 000 deaths in more than 230
countries.
Besides respiratory and intensive care support to the extent of
extracorporeal membrane oxygenation, no specific antiviral treatment has
been recommended because of insufficient evidence from randomised
trials. Many repurposed drugs have been shown to have in-vitro activity
against the close relatives of SARS-CoV-2, which are all
beta-coronaviruses. Lopinavir and many interferons, particularly
interferon beta, have been shown to have modest activity in vitro
against SARS-CoV and Middle East respiratory syndrome (MERS)-CoV, and
can be used synergistically with ribavirin.
In 2003, we did an open-label trial using historical controls, and
showed that a combination of lopinavir–ritonavir with ribavirin reduced
the mortality and need for intensive respiratory support of patients
with SARS who had been admitted to hospital.
However 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.
Experience from the treatment of patients with influenza who are
admitted to hospital suggested that a combination of multiple antiviral
drugs is more effective than single drug treatments in this setting of
patients with a high viral load at presentation.
Therefore, we did this phase 2 randomised trial to establish whether a
combination of three modestly active drugs against SARS-CoV-2 can
improve the viral load profile and clinical parameters in adults with
COVID-19 requiring hospital admission.
Methods
Study design and patients
This
was a phase 2, multicentre, open-label, randomised trial. Adult
patients aged at least 18 years admitted to hospital from Feb 10, 2020,
for virologically confirmed COVID-19, were recruited from the Queen Mary
Hospital, Pamela Youde Nethersole Hospital, Ruttonjee Hospital, United
Christian Hospital, Queen Elizabeth Hospital, and Tuen Mun Hospital in
Hong Kong. These six major public hospitals are positioned across five
of the seven hospital clusters, and serve 75% of the 7·5 million
population. Public health ordinance in Hong Kong required all patients
tested positive for COVID-19 be admitted to hospital. Eligibility
criteria for the study were age at least 18 years, a national early
warning score 2 (NEWS2) of at least 1, and symptom duration of 14 days
or less upon recruitment (appendix pp 9–10).
The institutional review board of the University of Hong Kong Hospital
Authority approved this study (UW20–074). All patients gave written
consent for participation in the study.
Randomisation and masking
Patients
were randomly assigned to either the triple combination
lopinavir–ritonavir, ribavirin, and interferon beta-1b group or the
control group (lopinavir–ritonavir only), in the ratio of 2:1, by simple
randomisation with no stratification. Randomised treatment was
open-label. Patients were assigned to a serial number by the study
coordinator. Each serial number was linked to a computer-generated
randomisation list assigning the antiviral treatment regimens. The study
medications were dispensed by the hospital pharmacy and then to the
patients by the medical ward nurses.
Procedures
In
the combination group, patients who were recruited and treated less
than 7 days from symptom onset received a triple combination of 14 days
of oral lopinavir–ritonavir (lopinavir 400 mg and ritonavir 100 mg)
every 12 h (via nasogastric tube to intubated patients), ribavirin 400
mg every 12 h, and subcutaneous injection of one to three doses of
interferon beta-1b 1 mL (8 million international units [IU]) on
alternate days depending on the day of drug commencement (if commenced
on day 1–2 from symptom onset, the patient received all three doses of
interferon beta-1b; if commenced on day 3–4, the patient received two
doses; if commenced on day 5–6, the patient received one dose). For
those recruited and treated between days 7 and 14, interferon beta-1b
injection was omitted to avoid its proinflammatory effects. Patients
assigned to the control group received only oral lopinavir–ritonavir
(lopinavir 400 mg and ritonavir 100 mg) every 12 h for 14 days. For
patients who had no history of prolonged QTc syndrome, but were found to
have prolonged QTc less than 480 ms, first-degree heart block or bundle
branch block, or bradycardia upon ECG examination, and those who
developed increased alanine transaminase of three times the upper limit
of normal (ULN), the lopinavir–ritonavir treatment was reduced to once
per day. Lopinavir–ritonavir would be stopped if alanine transaminase
levels exceeded six times the ULN. The randomisation window from symptom
onset was extended from 10 to 14 days after trial commencement after
knowing that the incubation period could go beyond 14 days. Because a
placebo group was generally not accepted in Chinese culture, and our
previous study showed that interferon beta-1b and lopinavir–ritonavir
are active against SARS-CoV and MERS-CoV, lopinavir–ritonavir was used
in the control group whereas interferon beta-1b, lopinavir–ritonavir,
and ribavirin were used in the combination group for patients admitted
less than 7 days from symptom onset.
The
intervention treatment had to be started within 48 h after hospital
admission. Standard of care included oxygen, non-invasive and invasive
ventilatory support, extracorporeal membrane oxygenation support,
dialysis support, and antimicrobial treatment for secondary bacterial
infection as indicated clinically. Stress doses of corticosteroid (50 mg
hydrocortisone every 8 h intravenously, tapering over 7 days) were
given to patients who developed oxygen desaturation and required oxygen
support. Non-invasive or invasive ventilatory support beyond day 7 from
symptom onset was at the discretion of the consultants.
Clinical and laboratory monitoring
Clinical
findings including history and physical examination, and laboratory and
radiological investigation results were entered into a predesigned
database. Chest radiograph and ECG were taken at baseline and at regular
intervals for monitoring of patient progress and to detect early
cardiac rhythm changes. Patients with underlying cardiac conditions were
put on cardiac monitoring. High-resolution CT was done at the
consultants' discretion. All patients were followed up at the infectious
disease clinic within 30 days after discharge.
Initial
diagnosis of SARS-CoV-2 infection was made upon admission. All
recruited patients had to have laboratory confirmed SARS-CoV-2 infection
by RT-PCR in the nasopharyngeal swab. Daily nasopharyngeal swab,
posterior oropharyngeal saliva, throat swab, stool or rectal swabs, and
urine if available, were obtained until discharge, for quantification of
viral load and genetic mutation testing (appendix pp 20–23).
Complete blood count, liver and renal function tests, lactate
dehydrogenase, creatine kinase, C-reactive protein, erythrocyte
sedimentation rate, and cytokine profile were regularly checked until
discharge (appendix p 21).
Blood and urine samples for bacterial culture were taken when
clinically indicated. The nasopharyngeal swab upon admission was
assessed by BioFire FilmArray Respiratory Panel 2 plus (bioMérieux,
Marcy l'Etoile, France). Methods for assays by quantitative RT-PCR,
serum cytokine profiling, and nanopore sequencing for nsp5 mutation are in the appendix (pp 20–23).
Outcomes
The
primary endpoint was time to achieve a negative RT-PCR result for
SARS-CoV-2 in a nasopharyngeal swab sample. Secondary clinical endpoints
were time to resolution of symptoms defined as a NEWS2 of 0 maintained
for 24 h; daily NEWS2 and sequential organ failure assessment (SOFA)
score; length of hospital stay; and 30-day mortality. Other virological
endpoints included the time to achieve negative SARS-CoV-2 RT-PCR in all
clinical samples, including nasopharyngeal swab, posterior
oropharyngeal saliva, throat swab, stool, and urine; daily viral load
changes in the first 7 days; and emergence of amino acid mutations in
the nsp5 gene encoding a 3C-like protease. The serum cytokine
response was also measured. Safety endpoints were the frequencies and
duration of adverse events.
Statistical analysis
It
is important to note that COVID-19 is a new disease caused by
SARS-CoV-2, which is phylogenetically closest to the 2003 SARS-CoV. At
the time of study design in mid-January, 2020, there was insufficient
information on the mortality of COVID-19. Thus, we based our sample size
calculation on our own findings of lopinavir–ritonavir treatment in a
trial on the 2003 SARS-CoV.
The current study was designed on the basis of an estimated difference
of 26·4% in the 21-day mortality or acute respiratory distress syndrome
rate in patients with severe SARS-CoV-2 infection, when treated with
lopinavir–ritonavir (2·4%) versus historical controls without antiviral
treatment (28·8%). The necessary sample size had been calculated to be
30 patients per group to detect such a difference at a two-sided α level
of 0·05, with 80% power. The protocol proposed recruiting at least 35
patients per group to allow for a 17% dropout rate.
The
primary endpoint was assessed in the intention-to-treat population of
all randomised patients. Safety was assessed in all patients who
received at least one dose of their assigned drug. Categorical variables
were compared using the χ2 test and continuous variables
were compared using the Mann-Whitney U test, for both intention-to-treat
and subgroup analyses. For viral load, specimens with undetectable
viral load were assigned a value of 1 log10 copies per mL for
the purpose of statistical analysis. Hazard ratios (HRs) with 95% CIs
were calculated by Cox proportional hazards model. Factors significant
at univariable analysis (p<0·10) were further assessed by means of a
multivariable analysis by Cox proportional hazards model to identify the
independent factors for negative nasopharyngeal swab RT-PCR on day 7
after treatment. A p value of less than 0·05 was considered
statistically significant. Statistical analysis was performed using
SPSS, version 26.0 and PRISM, version 8. The study is registered with ClinicalTrials.gov, NCT04276688.
Role of the funding source
The
funders had no role in study design, data collection, data analysis,
data interpretation, or writing of the report. The corresponding author
had full access to all the data in the study and had final
responsibility for the decision to submit for publication.
Results
Between Feb 10 and March 20, 2020, 144 patients were screened, and 127 patients were recruited (figure 1). The number of patients screened accounted for 80% of the confirmed COVID-19 cases in Hong Kong
during this period. Nine patients did not fulfil the inclusion criteria
(four with second-degree and third-degree cardiac arrhythmia, two with
severe depression, and three because of pregnancy) and eight patients
declined the treatment regimen. One patient in the control group
required discontinuation of lopinavir–ritonavir because of alanine
transaminase six times greater than the ULN after 1 week of treatment.
The median age was 52 years (IQR 32–62); 68 (54%) patients were men
versus 59 (46%) women (table 1). 51 (40%) patients had underlying diseases. The median time to hospital admission from symptom onset was 5 days (IQR 3–7).
Table 1Baseline demographics of the study population
Combination group (n=86)
Control group (n=41)
Age
51·0 (31·0–61·3)
52·0 (33·5–62·5)
Sex
Men
45 (52%)
23 (56%)
Women
41 (48%)
18 (44%)
Time from symptoms onset to start of treatment, days
5 (4–7)
4 (3–8)
Underlying diseases
Diabetes
11 (13%)
6 (15%)
Hypertension
23 (27%)
13 (32%)
Coronary artery disease
5 (6%)
5 (12%)
Cerebrovascular disease
1 (1%)
1 (2%)
Hyperlipidaemia
18 (21%)
11 (27%)
Thyroid disease
3 (3%)
1 (2%)
Obstructive sleep apnoea
1 (1%)
1 (2%)
Crohn's disease
1 (1%)
0
Epilepsy
1 (1%)
0
Tuberculosis
2 (2%)
0
Chronic hepatitis B
2 (2%)
1 (2%)
Chronic hepatitis C
0
1 (2%)
Malignancy
1 (1%)
1 (2%)
Smoker
6 (7%)
1 (2%)
Symptoms and signs
Fever
70 (81%)
32 (78%)
Chills
13 (15%)
6 (15%)
Cough
45 (52%)
23 (56%)
Sputum
29 (34%)
13 (32%)
Shortness of breath
7 (8%)
7 (17%)
Sore throat
16 (19%)
10 (24%)
Myalgia
10 (12%)
8 (20%)
Malaise
19 (22%)
5 (12%)
Nausea or vomiting
1 (1%)
0
Diarrhoea
17 (20%)
7 (17%)
Rhinorrhoea
14 (16%)
10 (24%)
Anosmia
4 (5%)
1 (2%)
Headache
3 (3%)
3 (7%)
Chest tightness
2 (2%)
0
Anorexia
1 (1%)
0
Baseline laboratory findings (normal range)
Haemoglobin (11·5–14·8 g/dL)
13·4 (12·7–14·9)
13·5 (12·7–14·8)
White cell count (3·89–9·93 × 109 per L)
4·9 (3·7–6·2)
5·4 (4·6–6·4)
Neutrophils (2·01–7·42 × 109 per L)
3·4 (2·4–4·3)
3·5 (2·9–4·5)
Lymphocytes (1·06–3·61 × 109 per L)
1·0 (0·8–1·5)
1·3 (0·9–1·6)
Platelets (154–371 × 109 per L)
195·0 (171·8–260·0)
192·0 (160·5–244·5)
Alanine aminotransferase (8–45 U/L)
23·0 (15·0–33·3)
26·0 (14·5–43·0)
Alkaline phosphatase (42–110 U/L)
58·0 (48·0–75·0)
65·0 (52·5–75·0)
Lactate dehydrogenase (143–280 U/L)
194·0 (159·8–249·0)
167·5 (142·0–200·0)
Bilirubin (4–23 μmol/L)
7·9 (5·5–9·0)
7·5 (6·0–10·8)
Creatinine (49–82 μmol/L)
75·5 (65·0–92·0)
76·0 (62·5–96·0)
Urea (2·9–8·0 mmol/L)
4·0 (2·9–4·8)
3·7 (2·7–4·6)
Creatine kinase (22–198 U/L)
79·0 (50·0–151·0)
90·5 (54·5–141·5)
C-reactive protein (<0·76 mg/dL)
3·0 (2·0–9·2)
3·0 (1·5–7·2)
Erythrocyte sedimentation rate (<12 mm/h)
19·0 (11·0–48·0)
19·0 (9·8–37·8)
Baseline radiological findings (%)
Abnormal chest x-ray
64 (74%)
32 (78%)
Right upper zone infiltrate
0
0 (0%)
Right middle zone infiltrate
4 (5%)
6 (15%)
Right lower zone infiltrate
38 (44%)
18 (44%)
Left upper zone infiltrate
1 (1%)
0
Left middle zone infiltrate
7 (8%)
7 (17%)
Left lower zone infiltrate
27 (31%)
10 (24%)
High-resolution CT (performed in 22 patients)
14 (16%)
6 (15%)
Data
are n (%) or median (IQR). In the combination group 52 patients were
treated with triple combination of interferon beta-1b,
lopinavir–ritonavir, and ribavirin and 34 patients were treated with
lopinavir–ritonavir and ribavirin; in the control group, 41 patients
were treated with lopinavir–ritonavir. U/L=units per L.
Among
the 127 patients, 86 were randomly assigned to the combination group
and 41 patients were assigned to the control group. Within the
combination group, 52 patients were admitted to hospital less than 7
days from symptom onset and received the lopinavir–ritonavir, ribavirin,
and interferon beta-1b regimen, and 34 patients who were admitted 7
days or more after symptom onset received the lopinavir–ritonavir and
ribavirin only regimen. The median number of doses of interferon beta-1b
received was two. Median time from symptom onset to start of treatment
was 5 days (4–7) for the combination group and 4 days (3–8) for the
control group (table 1).
The age, sex, and baseline demographics in each group were similar.
Fever and unproductive cough were the most common presenting signs and
symptoms. Both diarrhoea and anosmia were infrequent. Most patients had
lymphopenia and increased C-reactive protein and erythrocyte
sedimentation rate upon presentation. One patient in the combination
group had concomitant rhinovirus infection upon presentation. Disease
severity upon presentation was mild based on NEWS2 and SOFA scores (table 2).
Table 2Clinical, viral load, and cytokine profile and concomitant treatments
Combination group (n=86)
Control group (n=41)
p value
NEWS2
Baseline
2 (1–2)
2 (2–2)
0·52
Day 1
1 (1–2)
2 (2–2)
<0·0001
Day 2
1·0 (0·0–2·0)
2·0 (1·5–3·0)
<0·0001
Day 3
0 (0–1)
2 (1–3)
<0·0001
Day 4
0 (0–1)
2 (1–2)
<0·0001
Day 5
0 (0–1)
2 (1–2)
<0·0001
Day 6
0·0 (0·0–1·0)
1·5 (1·0–2·0)
<0·0001
Day 7
0·0 (0·0–1·0)
1·0 (0·8–2·0)
0·0010
Time to NEWS2 of 0, days
4 (3–8)
8 (7–9)
<0·0001
SOFA score
Baseline
0 (0–1)
0 (0–1)
0·38
Day 1
0 (0–1)
0 (1–1)
0·21
Day 2
0 (0–2)
1 (0–2)
0·025
Day 3
0 (0–2)
1 (0–2)
0·010
Day 4
0·0 (0·0–1·3)
1·0 (0·0–2·0)
0·012
Day 5
0 (0–1)
1 (0–2)
0·010
Day 6
0 (0–1)
1 (0–2)
0·035
Day 7
0 (0–1)
1 (0–2)
0·028
Time to SOFA score of 0, days
3·0 (1·0–8·0)
8·0 (6·5–9·0)
0·041
Duration of hospital stay, days
9·0 (7·0–13·0)
14·5 (9·3–16·0)
0·016
30-day mortality
0 (0)
0 (0)
1·00
Time to negative viral load, days
Nasopharyngeal swab
7 (5–11)
12 (8–15)
0·0010
Posterior oropharyngeal saliva
6·0 (3·0–8·0)
8·0 (5·3–10·8)
0·044
Throat swab
4·5 (1·3–6·8)
7·0 (3·0–12·0)
0·039
Stool
5 (2–5)
7 (4–8)
0·030
All specimens
8 (6–12)
13 (8–15)
0·0010
Virological findings (RT-PCR), log10 copies per mL
For
the primary endpoint of time from start of study treatment to negative
nasopharyngeal swab, the combination group had a significantly shorter
median time (7 days [IQR 5–11]) than the control group (12 days [8–15];
HR 4·37 [95% CI 1·86–10·24], p=0·0010; table 2).
Clinical
improvement was significantly better in the combination group, with a
significantly shorter time to complete alleviation of symptoms, defined
as a NEWS2 of 0 (4 days [IQR 3–8] in the combination group vs 8 days [7–9] in the control group; HR 3·92 [95% CI 1·66–9·23], p<0·0001) and SOFA score of 0 (3·0 days [1·0–8·0] vs 8·0 days [6·5–9·0]; HR 1·89 [1·03–3·49], p=0·041; table 2). A similar pattern was observed on the daily NEWS2 (all p<0·0001; figure 2A) and daily SOFA score after treatment (all p<0·05 except day 1 [p=0·21]; table 2).
The significantly better clinical and virological response is also
reflected in the shorter median hospital stay in the combination group
than in the control group (9·0 days [7·0–13·0] vs 14·5 days [9·3–16·0]; HR 2·72 [1·2–6·13], p=0·016).
For
the virological outcome, the combination treatment was associated with
significantly shorter time to negative viral load in all specimens when
assessed individually (nasopharyngeal swab, posterior oropharyngeal
saliva, throat swab, and stool samples) as well as in all specimens
combined (table 2). All urine samples tested negative for viral load.
All
patients had a SARS-CoV-2 positive baseline nasopharyngeal swab. With
regards to the other clinical samples, 108 (85%) patients provided
posterior oropharyngeal saliva samples, 99 (78%) provided throat swabs,
36 (28%) provided stool samples, and 83 (65%) provided urine samples.
The baseline viral loads for all specimens were similar between the
combination group and control group (table 2).
The nasopharyngeal swab viral load was significantly lower in the
combination group than in the control group from day 1 to day 7 after
treatment (figure 2B). Similar results were found in the posterior oropharyngeal saliva, throat swab, and stool specimens after treatment (figure 2C–E).
Post-hoc
subgroup comparison of the 76 patients who started treatment less than 7
days after onset of symptoms showed better clinical and virological
outcomes in the combination group (52 patients, receiving
lopinavir–ritonavir, ribavirin, and interferon beta-1b) than in the
control group (24 patients; table 3)
across all measured variables except stool samples. However, no
significant differences between the treatment groups were measured in
these outcomes in the 51 patients who were treated 7 days or more after
symptom onset (34 in the combination group [receiving
lopinavir–ritonavir and ribavirin only] and 17 in the control group; appendix p 31).
Table 3Subgroup analysis of clinical, viral load, and cytokine profile
Started treatment <7 days from symptom onset
Started treatment ≥7 days from symptom onset
Combination group (with interferon beta-1b; n=52)
Control group (n=24)
p value
Combination group (without interferon beta-1b; n=34)
Control group (n=17)
p value
NEWS2
Baseline
2 (1–2)
2 (2–2)
0·11
2 (1–2)
2 (1–2)
0·49
Day 1
1 (1–1)
2 (2–2)
<0·0001
2 (1–2)
2 (1–2)
0·71
Day 2
1·0 (0·0–1·0)
2·0 (1·5–3·0)
<0·0001
1·5 (1·0–2·0)
2·0 (1·0–2·8)
0·41
Day 3
0·0 (0·0–1·0)
2·0 (1·0–3·0)
<0·0001
1·0 (1·0–2·0)
2·0 (0·3–2·8)
0·16
Day 4
0·0 (0·0–0·0)
2·0 (1·0–2·5)
<0·0001
1·0 (1·0–2·0)
2·0 (0·3–2·0)
0·37
Day 5
0 (0–0·5)
2 (1–2)
<0·0001
1 (0–1)
2 (0–2)
0·040
Day 6
0 (0–0·3)
1 (1–2)
<0·0001
1 (0–1)
1 (0–2)
0·14
Day 7
0 (0–0)
1 (0–2)
<0·0001
1 (0–1)
1 (0–1)
0·68
Time to NEWS2 of 0, days
4·0 (3·0–5·0)
8·0 (6·5–9·0)
<0·0001
6·0 (5·0–10·8)
8·0 (5·5–8·0)
0·90
SOFA score
Baseline
0 (0–1)
0 (0–1)
0·99
1 (0–1)
0 (0–1)
0·17
Day 1
0·0 (0·0–1·0)
1·0 (0·0–1·0)
0·030
1·0 (0·0–2·0)
1·0 (0·0–1·5)
0·67
Day 2
0 (0–1)
1 (0–2)
0·0060
1 (0–2)
1 (0–2)
0·72
Day 3
0 (0–1)
1 (0–2)
0·0050
1 (0–2)
1 (0–3)
0·49
Day 4
0 (0–1)
1 (0–2)
0·0060
1 (0–2)
1 (0–3)
0·48
Day 5
0·0 (0·0–0·8)
1·0 (0·0–2·0)
0·0030
1·0 (0·0–2·0)
1·0 (0·0–3·0)
0·55
Day 6
0·0 (0·0–0·0)
0·5 (0·0–2·0)
0·0010
1·0 (0·0–2·0)
1·0 (0·0–2·0)
0·88
Day 7
0·0 (0·0–0·0)
0·5 (0·0–2·0)
<0·0001
1·0 (0·0–2·0)
1·0 (0·0–2·0)
0·88
Time to SOFA score of 0, days
3 (1–5)
7 (1–9)
0·0010
8 (1–8)
8 (1–9)
0·23
Duration of hospital stay, days
8 (6–12·5)
15 (9–16)
0·0030
13 (8–15)
13·5 (12·3–21·8)
0·090
30-day mortality
0 (0)
0 (0)
1·00
0 (0)
0 (0)
1·00
Time to negative viral load, days
Nasopharyngeal swab
6·5 (4·0–8·0)
12·5 (8·0–14·8)
<0·0001
10·5 (8·0–12·3)
12·0 (8·0–17·0)
0·10
Posterior oropharyngeal saliva
6·0 (2·0–7·0)
8·5 (5·3–11·8)
<0·0001
8·0 (6·0–9·0)
8·0 (5·3–9·0)
0·79
Throat swab
4·0 (1·0–6·0)
8·0 (3·3–12·8)
0·0010
5·0 (1·5–8·0)
4·5 (2·0–9·0)
0·52
Stool
4·5 (2·0–5·0)
6·0 (3·0–7·0)
0·070
5·0 (2·0–10·0)
7·0 (5·5–8·5)
0·14
All specimens
7·0 (4·0–9·0)
13·0 (8·0–14·0)
<0·0001
12·0 (7·8–14·0)
12·0 (12·0–19·0)
0·080
Virological findings (RT-PCR), log10 copies per mL
Nasopharyngeal swab (baseline)
7 (5·2–8·4)
6·1 (4·3–7·7)
0·29
5·5 (3·8–7·3)
6·6 (3·8–8)
0·65
Posterior oropharyngeal saliva (baseline)
5·4 (3·9–7·3)
5·3 (3·9–7·5)
0·86
4·8 (3·8–6·2)
5·4 (4·9–6·8)
0·30
Throat swab (baseline)
4·8 (3·2–6·9)
4·4 (3·5–6·1)
0·81
4·5 (1·0–5·6)
5·0 (4·0–5·5)
0·52
Stool (baseline)
3·2 (1·9–6·2)
3·2 (2·9–5·6)
0·85
3·3 (2·8–3·9)
5·6 (1·9–7·4)
0·48
Cytokine concentration, log10 pg/mL
IL-6 (baseline)
1·4 (1–1·5)
1·4 (1·4–1·6)
0·13
1·4 (1–1·4)
1 (1–1·6)
0·45
TNFα (baseline)
1 (1–1)
1 (1–1)
0·87
1 (1–1)
1 (1–1)
0·82
Data are median (IQR). NEWS2=national early warning score 2. SOFA=sequential organ failure assessment.
17 (13%) of 127 patients developed oxygen desaturation and required oxygen treatment (table 2).
Six (5%) patients were admitted to the intensive care unit, of whom
five required non-invasive ventilator support and one 96-year-old female
patient with a past medical history of coronary artery disease required
intubation and ventilator support. She was in the control group and was
successfully extubated after 10 days of intensive care. 69 (54%)
patients received concomitant antibiotics. Eight (6%) patients were
given stress doses of corticosteroids in the second week from symptom
onset.
The serum cytokine profile
was analysed in the first 84 recruited patients. The IL-6 concentration
in the combination group was significantly lower than in the control
group on days 2, 6, and 8 (figure 2F). TNFα concentrations and IL-10 concentrations were not significantly different between the groups. No significant nsp5 mutations were identified in serial nasopharyngeal swab samples.
Multivariable
analysis showed that the combination group and having a normal baseline
chest x-ray were independently associated with day 7 negative
nasopharyngeal swab viral load. Of the two, the combination group was
the most significant independent factor (HR 4·27 [95% CI 1·82–10·02],
p=0·0010; appendix p 30).
Adverse
events were reported by 41 (48%) of 86 patients in the combination
group and 20 (49%) of 41 patients in the control group. The most common
adverse events were diarrhoea (52 [41%] of 127 patients), fever (48
[38%] patients), nausea (43 [34%]) and raised alanine transaminase level
(18 [14%]; table 4).
These side-effects mostly resolved within 3 days after drug initiation.
Sinus bradycardia was reported by four (3%) patients. There were no
differences between incidence of any of the adverse events or durations
of nausea or diarrhoea between the treatment groups. The peak median
alanine transaminase concentration was 38·0 units per L (24·5–62·5) and
peak median bilirubin was 22·0 μmol/L (17·0–32·5), in all patients. No
serious adverse events were reported in the combination group. One
patient in the control group had a serious adverse event of impaired
hepatic enzymes requiring discontinuation of treatment. No patients died
during the study.
In
this multicentre randomised open-label phase 2 trial in patients with
COVID-19, we showed that a triple combination of an injectable
interferon (interferon beta-1b), oral protease inhibitor
(lopinavir–ritonavir), and an oral nucleoside analogue (ribavirin), when
given within 7 days of symptom onset, is effective in suppressing the
shedding of SARS-CoV-2, not just in a nasopharyngeal swab, but in all
clinical specimens, compared with lopinavir–ritonavir alone.
Furthermore, the significant reductions in duration of RT-PCR positivity
and viral load were associated with clinical improvement as shown by
the significant reduction in NEWS2 and duration of hospital stay. Most
patients treated with the triple combination were RT-PCR negative in all
specimens by day 8. The side-effects were generally mild and
self-limiting.
Specific highly
active antiviral drugs are always needed for any novel emerging
infectious disease because the development of a new antiviral takes
years before its approval for clinical use. Therefore, drug repurposing
by testing existing broad-spectrum antiviral drugs that have been used
to treat other viral infections is the most feasible approach in a
pandemic. Many drugs have been shown to have some in-vitro activity
against betacoronaviruses, including remdesivir, favipiravir,
nitazoxanide, camostat mesilate, interferons, lopinavir–ritonavir,
ribavirin, chloroquine, hydroxychloroquine, and convalescent plasma
containing neutralising antibodies.
These drugs have known pharmacokinetic and pharmacodynamic properties,
side-effects, and dosing regimens. As expected, lopinavir–ritonavir
alone was shown to have similar effects to placebo on reducing viral
load when treatment was initiated at a median of 13 days after symptom
onset, despite some improvement in symptoms.
Up to now, only two open-label non-randomised trials have been
reported. One trial used a combination of oral hydroxychloroquine and
azithromycin in 20 patients with COVID-19 showing that this combination
might reduce viral load significantly by day 6 after treatment, compared
with 16 controls from another hospital, which could be due to chance
because this combination was not planned a priori and the addition of
azithromycin was at the physician's discretion.
A small retrospective analysis showed that viral load was negative at
day 7 post-treatment in 75% of patients with COVID-19 treated with
arbidol and lopinavir–ritonavir (16 patients) versus 35% of patients
treated with lopinavir–ritonavir alone (17 patients).
Under
the Hong Kong Special Administrative Region public health ordinance,
all patients with COVID-19 must stay in hospital until nasopharyngeal
swab viral loads are negative on 2 consecutive days. Thus, most patients
were admitted to hospital within 7 days of symptom onset, allowing
recruitment into the clinical trial during the early course of COVID-19.
With the memory of the 2003 SARS pandemic, most patients with COVID-19
in Hong Kong accepted antiviral treatment, which explained our high
recruitment rate. Despite being an open-label study, all patients were
enrolled consecutively without bias. Our case demographics and
proportion of patients with underlying diseases were similar to other
reported cohorts in China. The low crude mortality rate in Hong Kong
(four [0·4%] of 1041 cases) could be explained by the highly vigilant
infection control measures, efficient contact tracing, and early
hospital admission and treatment.
Early
treatment with a triple combination of modestly active antivirals is
appropriate for the treatment of COVID-19 because the viral load of
SARS-CoV-2 peaks at around the time of symptom onset. This is unlike the
situation of SARS and MERS when the antiviral treatment has time to
suppress the viral load before it peaks at around days 7–10 after
symptom onset. The viral load profile of COVID-19 is similar to that of
influenza, which has a high viral load at the time of initiation of
anti-influenza treatment. The emergence of resistant influenza virus
quasispecies during treatment has been well reported with single-drug
treatment by amantadine, baloxavir marboxil, and oseltamivir in the
setting of severe influenza or diseases caused by H5N1, H7N9, or in
immunosuppressed hosts.
Thus, the antiviral combination was considered a reasonable option to
improve the outcome of severe influenza. Indeed, we have previously
shown that a combination of naproxen and clarithromycin, with weak
anti-influenza virus activity in vitro individually, when combined with
oseltamivir can improve the morbidity and mortality and shorten the
duration of hospital stay in patients with influenza A/H3N2 pneumonia.
Furthermore, we have previously shown that a combination of
lopinavir–ritonavir and ribavirin significantly reduced mortality and
respiratory failure in patients during the 2003 SARS outbreak.
Thus, we hypothesised that a triple combination of modest antiviral
drugs might rapidly suppress the high initial viral load, improve the
clinical parameters, and reduce risk of health-care workers by reducing
the duration and quantity of virus shedding from these treated patients.
An in-vitro study in cell culture-based assays showed that the 50% effective concentration (EC50)
of lopinavir against SARS-CoV is about 17 μM and against MERS-CoV it is
about 8 μM, whereas the peak serum lopinavir concentration is about 15
μM with a half-life of 7·4–10·8 h after an oral dose of 400 mg lopinavir
and 100 mg ritonavir.
whereas its peak serum level is about 20 IU/mL with a half-life of 2–5 h
after a single subcutaneous dose of 8 million IU. Notably, the
maintenance of high serum interferon beta-1b level is not essential once
the antiviral status of exposed cells is induced. The EC50 of ribavirin against SARS-CoV-2 was 109 μM,
which greatly exceeds the drug's serum concentration with the usual
oral dosing. Nevertheless, synergistic activity between interferons and a
lower dose of ribavirin have been shown in checkerboard assays.
However, combining ribavirin with interferons (alfa-2a, alfa-2b, and
beta-1a) did not improve outcomes in critically ill patients with MERS.
Thus, the repurposing of this triple combination of modestly active
lopinavir–ritonavir, interferon beta-1b, and ribavirin for the treatment
of this novel pandemic virus should be a reasonable therapeutic
approach.
Furthermore, SARS-CoV-2
did not significantly induce types I, II, or III interferons in ex-vivo
infected human lung tissues compared with 2003 SARS-CoV.
Thus, the use of interferon beta-1b treatment to jump-start or improve
the antiviral response of patients would be a logical approach.
Additionally, interferon beta-1b was shown to decrease virus-induced
lung fibrosis in a mouse model, which might improve outcomes of patients
with COVID-19 complicated by acute respiratory distress syndrome.
Despite
the concern of major side-effects arising from a combination of three
drugs, no significant differences in incidence of adverse events between
treatment groups were reported in our cohort of 127 patients. No
haemolysis occurred from the short duration of low dose ribavirin. We
did not use triple combination for patients who started treatment 7 days
or more after symptom onset because of the concerns about the
proinflammatory side-effects of interferon beta-1b, despite that at most
three doses were used for each patient. Liver dysfunction was observed
in about 14% of these patients and it was mild and self-limiting, except
in one patient in the control group, in whom the biochemical hepatitis
warranted the discontinuation of lopinavir–ritonavir treatment.
Our
study had several limitations. This trial was open label, without a
placebo group, and confounded by a subgroup omitting interferon beta-1b
within the combination group, depending on time from symptom onset. A
subsequent phase 3 trial with interferon beta-1b as a backbone treatment
with a placebo control group should be considered, because subgroup
comparison suggested that interferon beta-1b appears to be a key
component of our combination treatment. Our absence of critically ill
patients did not allow the generalisation of our findings to severe
cases.
Triple antiviral therapy with
interferon beta-1b, lopinavir–ritonavir, and ribavirin were safe and
superior to lopinavir–ritonavir alone in shortening virus shedding,
alleviating symptoms, and facilitating discharge of patients with mild
to moderate COVID-19.
Contributors
IF-NH,
K-CL, EY-KT, JC, W-SL, Y-YN, T-CW, and K-YY were responsible for the
design, analysing, and writing of the manuscript. IF-NH, K-CL, EY-KT,
RL, TW-HC, M-YC, Y-YN, JL, ART, H-PS, VC, AK-LW, K-MS, W-LL, DCL, SS,
PY, RLi, KF, AY, T-CW, JW-MC, W-WY, W-MiC, AK-WL, VC-CC, T-LQ, and C-SL
were responsible for recruitment and clinical care of the patients.
IFN-H, JF-WC, KK-WT, K-YY were responsible for analysing and writing up
of the manuscript. CC-YY, RRZ, AY-FF, EY-WY, K-HL, AW-HC, W-MuC, AC-KN,
JDI, RLe, KF, DCL, AK-LW, VC-CC, T-LQ, K-HC were responsible for the
laboratory analysis. All authors reviewed and approved the final version
of the manuscript.
Declaration of interests
We declare no competing interests.
Data sharing
Qualified
researchers can request access to deidentified participant data or
anonymised clinical study reports, informed consent forms, and related
documents including the study protocol that underlie this Article
through submission of a proposal with a valuable research question to
the corresponding author, provided that the necessary data protection
agency and ethical committee approvals are in compliance with the
relevant registration. A contract will also be signed.
Acknowledgments
This
study was partly supported by Consultancy Service for Enhancing
Laboratory Surveillance of Emerging Infectious Diseases and Research
Capability on Antimicrobial Resistance for Department of Health of Hong
Kong; the Theme-Based Research Scheme (T11/707/15) of the Research
Grants Council, Hong Kong; Sanming Project of Medicine in Shenzhen,
China (no SZSM201911014); the Health and Medical Research Fund, Hong
Kong; and the High Level-Hospital Program, Health Commission of
Guangdong Province, China; and the donations of Richard Yu and Carol Yu,
the Shaw Foundation Hong Kong, Michael Seak-Kan Tong, May Tam Mak Mei
Yin, Respiratory Viral Research Foundation Limited, Hui Ming, Hui Hoy,
and Chow Sin Lan Charity Fund Limited, Chan Yin Chuen Memorial
Charitable Foundation, Marina Man-Wai Lee, the Hong Kong Hainan
Commercial Association South China Microbiology Research Fund, and the
Jessie & George Ho Charitable Foundation.
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