Modulation of thromboinflammation in hospitalized COVID-19 patients with aprotinin, low molecular weight heparin, and anakinra: the DAwn- AntiCo study

Background/Introduction: Thromboinflammation in severe COVID-19 is associated with disease severity and outcome. The kallikrein pathway is suggested to mediate thromboinflammation in COVID-19 by activating inflammatory pathways and contactmediated coagulation. Purpose(s): The DAWn-antico study investigates if a multitarget modulation of the thromboinflammatory response improves outcomes in hospitalized patients with severe COVID-19. Method(s): In this multicenter open-label randomized clinical trial (EudraCT 2020-001739-28), patients hospitalized with COVID- 19 were 1:2 randomized to receive standard of care (SOC) or SOC plus study intervention. The intervention consisted of aprotinin (2,000,000 IE IV four times daily) combined with low-molecular-weight heparin (LMWH;SC 50 IU/kg twice daily at the ward, 75 IU/kg twice daily at intensive care). Additionally, patients with predefined hyperinflammation received the interleukin-1- receptor antagonist anakinra (100mg IV four times daily). The primary outcome was time to a sustained 2-point improvement on the 7-point WHO ordinal scale for clinical status, or discharge. The trial was funded by Life Sciences Research Partners, Research Foundation Flanders (G0G4720N), and KU Leuven COVID-19 fund. Result(s): Between 24 June 2020 and 01 February 2021, 105 patients were randomized, and 102 patients were included in the full analysis set (intervention N=67 vs. SOC N=35). Twenty-five patients from the intervention group (37%) received anakinra. The intervention did not affect the primary outcome (HR 0.77 [CI 0.50;1.19], p=0.24) or mortality (intervention n=3 (4.6%) vs. SOC n=2 (5.7%), HR 0.82, [CI 0.14;4.94], p=0.83). There was one treatment-related adverse event in the intervention group (hematuria, 1.49%). There was one thrombotic event in the intervention group (1.49%) and one in the SOC group (2.86%), but no major bleedings. Conclusion(s): In hospitalized COVID-19 patients, modulation of thromboinflammation with high-dose aprotinin and LMWH with or without anakinra did not improve outcome in patients with moderate to severe COVID-19. (Disclosure: this RCT was presented at ISTH 2022 in London and will be published in Research and Practise in Thrombosis and Haemostasis).

A multicenter randomized clinical trial of modulation of host thromboinflammatory response in hospitalized patients with COVID-19: The DAWn-Antico study

Background: Thromboinflammation in severe COVID-19 is associated with disease severity and inferior outcome. Evidence suggests that the kallikrein pathway potentially plays a vital role in COVID-19 associated thromboinflammation as it both activates downstream inflammatory pathways and contact-mediated coagulation. Aim(s): To investigate whether modulation of this pronounced thromboinflammatory response can improve outcomes in hospitalized patients with severe COVID-19. Method(s): This multicenter randomized clinical trial was approved by the ethics committee and supported by the KU Leuven COVID-19 fund and Research Foundation Flanders (FWO). After informed consent, eligible patients were 1:2 randomized to receive standard of care (SOC) or SOC plus study intervention (figure 1). The intervention consisted of off-label -kallikrein-inhibiting -aprotinin combined with low molecular weight heparin (LMWH). Additionally, patients with predefined hyperinflammation were treated with the interleukin-1 receptor antagonist anakinra. The primary endpoint was time to sustain a 2-point improvement in the WHO ordinal scale for clinical status. Result(s): Three hospitals in Belgium included 102 patients (35 SOC vs. 67 intervention). Twenty-five patients from the intervention group (37%) were treated with anakinra. Patients had elevated D-dimers (mean 1012.4 mug/L;SD 991.9 mug/L) and C-reactive protein (mean 81.4 mg/L;SD 59.6 mg/L) at admission confirming baseline activation of coagulation and inflammatory pathways. During hospitalization, 37% of patients were admitted to the ICU (29% SOC vs. 42% intervention), and 20% needed invasive ventilation (12% SOC vs. 25% intervention). The intervention did not affect the time to sustained clinical improvement or hospital discharge (figure 2), nor secondary clinical endpoints. Except for D-dimers at day 3, there was no significant C-reactive protein or D-dimer reductions. There were no differences in treatment-related adverse events. Conclusion(s): In hospitalized COVID-19 patients, additional modulation of thromboinflammation with high-dose aprotinin and LMWH with or without anakinra was feasible and safe but did not improve clinical nor biochemical outcomes.

LBA78 A microsimulation model to assess the impact of SARS-CoV-2 on cancer outcomes, healthcare organization and economic burden

Background: SARS-CoV-2 pandemic has deeply modified healthcare seeking and services in Europe since February 2020 with delays in treatment delivery and changes in the standards of care. The organization of cancer centers (CC) has been transformed to minimize virus exposure in cancer patients (pts). Real-time assessment of the impact on cancer outcomes can optimize decision-making for future epidemic episodes. Methods: A discrete-event simulation (DES) model was developed to model individual pt pathways during the pandemic in a context of constrained medical resources. Cancer pt care is modeled based on pandemic-adapted guidelines for medical practice. Pt flow is derived from medico-administrative databases using time series methods to estimate the proportion of punctual / late visits and associated delay and to extrapolate future flows. Finally, the impact of modified care on survival is estimated using literature data. Results: From March to December 2020, based on data from Gustave Roussy CC in France (n= 4877 included pts), estimated overall treatment delay is <= 7 days in 86,6% of pts and 5,2% of pts have a delay higher than 2 months. More than 94% of this duration is delay in pt request for care, causing 99 pts to suffer a major prognosis change upon arrival. Delayed pt flows result in a highly time-variable use of medical resources, with important queues forecast for surgery care and chemotherapy. The handling of such queues will require intensified healthcare professionals effort. Projections show that, in the best-case scenario, ie without a 2nd pandemic wave, treatment delays and modifications will result in around 49 additional 5-year cancer-specific deaths (+ 2,25% of 5-year deaths), mainly in liver, sarcomas and head and neck cancer pts. Conclusions: In a resource-constrained context, optimization of the benefit-risk ratio between COVID-19 and cancer care is key. Simulations of individual projections from actual hospital data, show a 2.25% increase of the 5-year risk of death and that pandemic-related cancer burden is mainly due to patient-induced lateness in seeking care. Defining optimal strategies in terms of screening, monitoring and prioritization for care could minimize the impact of future pandemic episodes. Legal entity responsible for the study: The authors. Funding: Has not received any funding. Disclosure: A. Bardet: Advisory/Consultancy: Roche. M. Faron: Travel/Accommodation/Expenses: Ipsen;Travel/Accommodation/Expenses: Novartis;Travel/Accommodation/Expenses: Pfizer;Honoraria (self): HRA Pharma;Honoraria (self): Ipsen. I. Borget: Honoraria (self): Merck;Honoraria (self): CSL Berhing;Honoraria (self): Allergan;Honoraria (self): Novartis;Research grant/Funding (institution): BMS. S. Michiels: Advisory/Consultancy: IDDI;Advisory/Consultancy: Janssen Cilag;Honoraria (self), IDMC member: Hexal;Honoraria (self), IDMC member: Steba;Honoraria (self), IDMC member: IQVIA;Honoraria (self), IDMC member: Roche;Honoraria (self), IDMC member: Sensorion;Honoraria (self), IDMC member: Biophytis;Honoraria (self), IDMC member: Servier;Honoraria (self), IDMC member: Yuhan. F. Barlesi: Honoraria (self), further elements to be provided: AstraZeneca;Honoraria (self): Bayer;Honoraria (self): Bristol-Myers Squibb;Honoraria (self): Boehringer-Ingelheim;Honoraria (self): Eli Lilly Oncology;Honoraria (self): F.Hoffmann-La Roche Ltd;Honoraria (self): Novartis;Honoraria (self): Merck;Honoraria (self): MSD;Honoraria (self): Pierre Fabre;Honoraria (self): Pfizer;Honoraria (self): Takeda;Honoraria (institution): AbbVie;Honoraria (institution): Amgen;Honoraria (institution): AstraZeneca;Honoraria (institution): Bayer;Honoraria (institution): Bristol-Myers Squibb;Honoraria (institution): Boehringer-Ingelheim;Honoraria (institution): Eisai;Honoraria (institution): Eli Lilly Oncology;Honoraria (institution): F. Hoffmann-La Roche Ltd;Honoraria (institution): Genentech;Honoraria (institution): Ipsen;Honoraria (institution): Ignyta;Honoraria (institution): Innate Pharma;Honoraria (institu ion): Loxo;Honoraria (institution): Novartis;Honoraria (institution): MedImmune;Honoraria (institution): Merck, MSD, Pierre Fabre, Pfizer, Sanofi-Aventis, Takeda;Research grant/Funding (institution): AstraZeneca, BMS, Merck, Pierre Fabre, F. Hoffmann-La Roche Ltd. J. Bonastre: Honoraria (self): Bristol-Myers Squibb;Advisory/Consultancy: Bristol-Myers Squibb;Advisory/Consultancy: MSD;Advisory/Consultancy: PharmaMar (Inst);Advisory/Consultancy: Bristol-Myers Squibb (Inst);Advisory/Consultancy: Merck Serono;Travel/Accommodation/Expenses: Bristol-Myers Squibb. All other authors have declared no conflicts of interest.

Monocyte-driven atypical cytokine storm and aberrant neutrophil activation as key mediators of COVID-19 disease severity.

Epidemiological and clinical reports indicate that SARS-CoV-2 virulence hinges upon the triggering of an aberrant host immune response, more so than on direct virus-induced cellular damage. To elucidate the immunopathology underlying COVID-19 severity, we perform cytokine and multiplex immune profiling in COVID-19 patients. We show that hypercytokinemia in COVID-19 differs from the interferon-gamma-driven cytokine storm in macrophage activation syndrome, and is more pronounced in critical versus mild-moderate COVID-19. Systems modelling of cytokine levels paired with deep-immune profiling shows that classical monocytes drive this hyper-inflammatory phenotype and that a reduction in T-lymphocytes correlates with disease severity, with CD8+ cells being disproportionately affected. Antigen presenting machinery expression is also reduced in critical disease. Furthermore, we report that neutrophils contribute to disease severity and local tissue damage by amplification of hypercytokinemia and the formation of neutrophil extracellular traps. Together our findings suggest a myeloid-driven immunopathology, in which hyperactivated neutrophils and an ineffective adaptive immune system act as mediators of COVID-19 disease severity.

A randomized, open-label, adaptive, proof-of-concept clinical trial of modulation of host thromboinflammatory response in patients with COVID-19: the DAWn-Antico study.

BACKGROUND: The peak of the global COVID-19 pandemic has not yet been reached, and many countries face the prospect of a second wave of infections before effective vaccinations will be available. After an initial phase of viral replication, some patients develop a second illness phase in which the host thrombotic and inflammatory responses seem to drive complications. Severe COVID-19 disease is linked to high mortality, hyperinflammation, and a remarkably high incidence of thrombotic events. We hypothesize a crucial pathophysiological role for the contact pathway of coagulation and the kallikrein-bradykinin pathway. Therefore, drugs that modulate this excessive thromboinflammatory response should be investigated in severe COVID-19. METHODS: In this adaptive, open-label multicenter randomized clinical trial, we compare low molecular weight heparins at 50 IU anti-Xa/kg twice daily-or 75 IU anti-Xa twice daily for intensive care (ICU) patients-in combination with aprotinin to standard thromboprophylaxis in hospitalized COVID-19 patients. In the case of hyperinflammation, the interleukin-1 receptor antagonist anakinra will be added on top of the drugs in the interventional arm. In a pilot phase, the effect of the intervention on thrombotic markers (D-dimer) will be assessed. In the full trial, the primary outcome is defined as the effect of the interventional drugs on clinical status as defined by the WHO ordinal scale for clinical improvement. DISCUSSION: In this trial, we target the thromboinflammatory response at multiple levels. We intensify the dose of low molecular weight heparins to reduce thrombotic complications. Aprotinin is a potent kallikrein pathway inhibitor that reduces fibrinolysis, activation of the contact pathway of coagulation, and local inflammatory response. Additionally, aprotinin has shown in vitro inhibitory effects on SARS-CoV-2 cellular entry. Because the excessive thromboinflammatory response is one of the most adverse prognostic factors in COVID-19, we will add anakinra, a recombinant interleukin-1 receptor antagonist, to the regimen in case of severely increased inflammatory parameters. This way, we hope to modulate the systemic response to SARS-CoV-2 and avoid disease progressions with a potentially fatal outcome. TRIAL REGISTRATION: The EU Clinical Trials Register 2020-001739-28 . Registered on April 10, 2020.

Keeping exhausted T-cells in check in COVID-19

Background: Clinical data suggest an aggravated COVID-19 disease course in cancer patients treated with immune checkpoint inhibitors (ICI). European guidelines advise to defer ICI therapy until complete resolution of COVID-19. However, mechanistic insight into how ICI impacts COVID-19 immunopathology is absent. Methods: We performed single-cell RNA- and T-Cell Receptor-sequencing (TCR-seq) on bronchoalveolar lavage fluid of COVID-19 pneumonia (n=19) and non-COVID pneumonia (n=10), and co-analyzed CD8+ T-cells with publicly available tumor-infiltrating T-cell data of treatment-naïve and ICI-treated patients (Sade-Feldman, Cell, 2018;Lambrechts, Nat Med, 2018). Cell lineages were determined by trajectory inference (Slingshot, Monocle v2) and stratified per condition. Pathogen- or tumor-directed T-cells were defined based on clonal selection (Zhang, Nature, 2018). To identify ICI responsive cells, we calculated a score derived from a validated gene set denoting ICI reactivity (Okamura, J. Autoimmun, 2019). Results: We identified 3 CD8+ T-cell lineages, with ‘Naïve’ T-cells transitioning into ‘Effector Memory’ cells and then branching into either ‘Recently Activated Effector Memory (TEMRA)’, ‘Exhausted (TEX)’ or ‘Resident Memory (TRM)’ T-cells. In COVID-19, clonal expansion indicating a SARS-CoV-2 antigen-specific T-cell response, was mainly observed in the highly cytotoxic ‘TEMRA’ lineage. In contrast, tumor-specific T-cells were found in the ‘TEX’ lineage. Of importance, the ICI responsiveness score was significantly higher in the non-pathogen-directed ‘TRM’ and ‘TEX’ cells in COVID-19. In cancer, ‘TEX’ cells were shown to be ICI responsive as expected. [Formula presented] Conclusions: We are the first to provide a mechanistic rationale for an aggravated COVID-19 disease course in ICI-treated patients. Whereas ICI reactivates tumor-directed ‘exhausted’ T-cells in cancer, it preferentially potentiates non-pathogen-directed T-cells in COVID-19, thereby contributing to lung damage without boosting the antiviral immune response. Clinical trial identification: In-depth Immunological Investigation of COVID-19 (COntAGIouS). - Clinical Trial identifier: NCT04327570. - Ethical approval obtained by the Ethics Committee of University Hospitals - KU Leuven. File number S63881. Legal entity responsible for the study: University Hospitals - KU Leuven. Funding: Kom op tegen Kanker (Stand up to Cancer). Disclosure: All authors have declared no conflicts of interest.

Anticoagulant therapy in COVID-19 critically ill: Should we go for more?

Critically ill COVID-19 patients often develop a severe pro-thrombotic milieu, as reflected by the markedly increased d-dimer levels. Several cohort studies have reported high rates of thrombotic complications, including deep venous thrombosis (DVT) and pulmonary embolism (PE), myocardial infarction, stroke and microvascular thrombosis. Accordingly, COVID-19 patients who are hospitalized either at a normal, non-intensive care unit (ICU) or at the ICU need to receive appropriate dosages of anticoagulant therapy to prevent or treat these thrombotic complications. This manuscript summarizes the institutional guidance for the antithrombotic prophylaxis and treatment of VTE as outlined by a multidisciplinary team of experts during the first weeks of the COVID-19 pandemic in Europe. Controlled studies are needed to verify the optimal anticoagulation for both prophylaxis and treatment.