Ensitrelvir for Mild-to-Moderate Covid-19: Phase 3 Part of Phase 2/3 Study

Background: Ensitrelvir is a SARS-CoV-2 3CL protease inhibitor approved in Japan under emergency regulatory approval system as an oral treatment for COVID-19. Here we report the key analysis results of 125 mg group of phase3 part (SCORPIO-SR). Method(s): This study was a multicenter, randomized, double-blind, placebocontrolled study. Regardless of SARS-CoV-2 vaccination status and presence of risk factors for severe disease, patients with mild-to-moderate COVID-19 within 120 hours from onset were randomized to oral administration of ensitrelvir 125 mg (375 mg loading dose on Day1), ensitrelvir 250 mg (750 mg loading dose on Day1), and placebo once daily, for 5 days. The primary endpoint was time to resolution of 5 symptoms of COVID-19 (stuffy or runny nose, sore throat, cough, feeling hot or feverish, and low energy or tiredness), and the key secondary endpoints include change from baseline on Day4 in the amount of SARS-CoV-2 viral RNA and time to first negative of viral titer. The primary population for the primary and key secondary endpoints was patients with <72 hours from onset to randomization. Result(s): Median time to resolution of 5 symptoms was significantly shorter in 125 mg group (n=336, 167.9 hours) than placebo group (n=321, 192.2 hours) (p=0.0407). Mean change of viral RNA levels from baseline (log10 copies/mL) on Day4 was significantly greater in 125 mg group (-2.48) than in placebo group (-1.01) (p< 0.0001). The time to first negative of viral titer was significantly shorter in 125 mg group (n=199, 36.2 hours) compared to placebo group (n=211, 65.3 hours) (p< 0.0001). Mean changes from baseline in viral titers [log10(TCID50)/mL] were significantly greater in 125mg group on Day2 (-0.807, n=196) and Day4 (-1.108, n=197) than in the placebo group (-0.395, n=208 and -0.850, n=207, respectively) (p< 0.0001). (Table Presented) In the patients randomized within 120 hours of onset, median time to resolution of 5 symptoms was 189.7 hours in 125 mg group (n=582) and 200.3 hours in placebo group (n=572) (p=0.4352). No deaths or serious adverse drug reactions were reported in either group, and the incidence of serious adverse events between the two groups was comparable. Conclusion(s): Ensitrelvir demonstrated a significant reduction in the time to resolution of 5 typical symptoms of COVID-19, robust antiviral effects and good tolerability.

Investigation of Treatment-Emergent Amino Acid Substitutions in Nonstructural Protein 5 from Ph2a Study of Ensitrelvir, a Novel Oral SARS-CoV-2 3C-Like Protease Inhibitor

Background. Ensitrelvir is a novel oral SARS-CoV-2 3C-like protease inhibitor, and under late clinical development stage for COVID-19 disease. In Ph2a and Ph2b studies, ensitrelvir demonstrated rapid decline of viral titer and viral RNA compared with placebo, and tolerability. To investigate treatment-emergent amino acid substitutions (TEAASs), we analyzed viral RNA sequences of nonstructural protein 5 (NSP5), target of ensitrelvir from Ph2a study in Japan. Methods. In Ph2a study, 69 patients with confirmed SARS-CoV-2 infection were randomized 1:1:1 to ensitrelvir with the loading dose on Day 1/maintenance dose on Day 2-5 (375/125 mg or 750/250 mg), or placebo. Intent-to-treat (ITT) population was defined as participants confirmed with positivity by qualitative RT-PCR at baseline. TEAASs were defined as novel amino acid substitutions identified after treatment with ensitrelvir. NSP5 sequence analysis was performed with sanger sequencing using nasopharyngeal swab samples at Day 1, 6, 9, 14, and 21 with allowances from ITT population with ensitrelvir. Infectious viral titer was measured by virus-induced cytopathic effects in VeroE6/TMPRSS2 cells. Viral RNA was quantified by RT-PCR. Results. By NSP5 sequence analysis, TEAASs were observed in 1 patient from 375/125 mg group and 2 patients from 750/250 mg group. H246Y in 375/125 mg was detected from specimen on Day 8, and A234S and T198I in 750/250 mg were detected from specimens on Day 8 and Day 14, respectively. Structural analysis revealed that these mutations are located outside of the active center of 3C-like protease which is the binding site of ensitrelvir. Viral titer and viral RNA in each specimen, in which TEAASs were observed, were below lower limit of detection and lower limit of quantification, respectively. Furthermore, H246Y, A234S and T198I are rare substitution (< 0.05%) among SARS-CoV-2 variants according to Global Initiative on Sharing Avian Influenza Data. Conclusion. In Ph2a study, H246Y, A234S, and T198I in NSP5 were detected as TEAASs. However, results of viral titer and viral RNA, and structural information suggest that these mutations do not have the impact on antiviral efficacy of ensitrelvir.

Indoor Pedestrian Localization Methods Using Contact Information from Bluetooth Low Energy Beacons Between Smartphones

COVID-19 digital contact tracing applications for smartphones have become popular worldwide to reduce the effects of the pandemic. We considered that contact information between smartphones used in these applications can be used for the indoor localization of pedestrians. In this paper, we propose two indoor pedestrian localization methods based on contact information obtained from Bluetooth low energy (BLE) beacons installed in pedestrian's smartphones. Proposed method 1 is multilateration, and proposed method 2 solves a nonlinear optimization problem to further improve the accuracy of method 1. These two proposed methods comprise three steps: (1) the smartphones and anchor nodes recognize the proximity relationship with neighbor nodes using BLE signals transmitted from other smartphones and anchor nodes. The recognized proximity relationship is sent to a server. (2) The server estimates the distance between each node (smartphone or anchor node) from the proximity relationship. (3) The positions of smartphones are estimated based on the distance between nodes estimated by the server. We verified the localization accuracy of the proposed methods through simulation experiments. In an indoor area of 15 m × 30 m, the average localization error of the proposed method 2 was 0.74 m when the pedestrian density was 0.5 /m2. © 2022 IEEE.

COVID-19: DIARRHEA, INFLAMMATION AND INTESTINAL MICROBIOTA

Introduction: Increased inflammatory cytokines has been observed in COVID-19 patients and there is evidence showing an alteration in gut-microbiota composition. SARS-CoV-2 can cause gastrointestinal symptoms, such as diarrhea. Evidence of an altered gut-microbiota composition and cytokines levels in COVID-19 diarrhea patients is lacking. Objectives: To compare serum cytokine levels and gut microbiota between COVID-19 diarrhea (D-COVID- 19) and non-diarrhea (NonD-COVID-19) patients and non- COVID-19 controls (HC). Material and methods: We included 143 hospitalized COVID-19 patients (positive quantitative reverse transcription PCR) in a single University Hospital, and 53 ambulatory HC (negative rapid serological test) were included. Blood and stool samples were collected at hospital admission in COVID-19 patients and at the time of HC recruitment. 27- pro and anti-inflammatory cytokines (Bio-Plex Pro™, Bio- Rad) were measured. Gut microbiota composition and diversity profiles were characterized by sequencing the 16S rRNA gene V3-V4 region amplified using DNA extracted from stool samples. Bioinformatics analysis was performed with QIIME2 software. First, we compare cytokine levels between COVID- 19 and HC and then COVID-19 with and without diarrhea. All comparisons were adjusted for age, sex, and BMI with linear regression. Results: The mean age in COVID-19 patients was 54 +/- 15 years (F=50%) and 52 +/- 8 (F=62%) for HC. Diarrhea was present in 19 (13.29%) of COVID-19 patients. COVID-19 patients had significative higher levels of: IL- 1ra, IL-2, IL-6, IL-7, IL-8, IL-13, IP-10 and PDGF-bb. Significant lower values of: IL-9, FGF -basic, MIP-1β, TNF-α were observed in D-COVID-19 compared to NonD-COVID-19. COVID-19 patients had a significant reduction of bacterial species (p=0.0001), and diversity and complexity of the bacterial community (Shannon's index) (p=0.0001) compared to the HC. There was no difference between D-COVID-19 and NonD-COVID-19. There were also changes in the composition of the microbiota associated with COVID-19. At the phylum level, COVID-19 patients showed a significant decrease in Actinobacteria and Firmicutes, and an increase in Bacteroidetes. At species level, an increase of 4 species of the genus Bacteroides was observed in COVID-19 patients. 31 very diverse bacterial species were found, all decreased in D-COVID-19. Conclusions: An alteration in serum cytokine levels was observed between COVID-19 and HC. D-COVID-19 had a decrease in some proinflammatory cytokines. A significant decrease in richness and species diversity of gutmicrobiota was observed in COVID-19 patients compared to HC, but no significant differences were observed between D-COVID-19 and NonD-COVID-19. However, in D-COVID- 19, a decrease in some bacterial species was observed.(Table Presented)(Figure Presented)

GUT-BRAIN AXIS AND IRRITABLE BOWEL SYNDROME DURING SARS COV-2 PANDEMIC. A SURVEY BASED STUDY

INTRODUCTION: Irritable bowel syndrome (IBS) is a functional disorder with high prevalenceimpacting on patient’s quality of life. IBS is considered a multifactorial entity, in whichsocioemotional factors and social stress might play a central role in the generation andworsening of symptoms. The mandatory lockdown in response to SARS CoV-2 pandemic,represents a unique scenario of reduced social interaction and complexity, potentially impactingthe IBS-patients’ symptoms evolution. OBJECTIVE: To evaluate the impact of the mandatorylockdown due to the SARS CoV-2 pandemic on the brain-gut axis symptomatology inIBS patients. MATERIAL AND METHODS: All IBS-diarrhea and mixed bowel habits patternsubtype patients, from an existing Rome IV-defined cohort database, were invited to participate(n = 129, mean age 54 [+/-16], 78% female). Patients were assessed via an onlinesurvey or phone interview. The survey included Irritable Bowel Syndrome Severity Scale(IBS-SS), Likert scale, as well as measures of Bristol scale, anxiety and depression andsomatization. Further, patients were asked about comorbidities (pyrosis and/or regurgitation,dyspepsia, chronic fatigue, fibromyalgia, non-migraine headache, weight and eating habits).Most of this data was compared with pre-pandemic existing data. RESULTS: During lockdown,there was a significant decrease in severe IBS patients’ proportion (50.39 % vs 30%, p=0.000) compared to the pre pandemic state. Before pandemic, this cohort of patientshad a mean IBS-SS of 278.54 (+/- 88.64) compared to 212.36 (+/-117.50) during lockdown(difference -65.9 [95% CI: -89.4 to – 42.4];p = 0.000). Likewise, there was a decrease ofone average point on the Likert Scale on global IBS symptoms, pain, and distension, as wellas an improvement in stool consistency (2-point average decrease on Bristol Scale). Similarly,anxiety and somatization scores were improved and there was a significant decrease infibromyalgia and chronic fatigue symptoms during lockdown (in comparison with prepandemictimes). Conversely, headache and pyrosis and/or regurgitation symptoms increasedsignificantly. These effects remained when adjusted for confounders (age, sex, anxiety, anddepression), evidencing that the mandatory lockdown represented an independent protectivefactor for severe IBS-symptoms (OR 0.39, 95% CI 0.18-0.87;p=0.02). CONCLUSION: Incomparison with a pre-pandemic period, there was a significant improvement in IBS-severitysymptoms, anxiety and somatization during the SARS CoV-2 pandemic and mandatorylockdown. Lesser exposure to external stress burden during lockdown could have beeninvolved in a better control of affecting gut-brain axis factors.(Table Presented)(Image Presented)

ORAL TANNINS REDUCE PROINFLAMMATORY CYTOKINES ASSOCIATED WITH DIARRHEA AND PNEUMONIA IN HOSPITALIZED COVID-19 PATIENTS

INTRODUCTION: There is evidence that the gut microbiota and its relationship with the immune system could be involved in the pathogenesis of COVID-19. SARS-CoV-2 can cause gastrointestinal symptoms during the early phases of the disease. Intestinal dysfunction induces changes in intestinal microbes, and an increase in inflammatory cytokines. Therefore, microbiota modulation could play a role in COVID-19 treatment. Tannins have been shown to work as prebiotics on the gastrointestinal microbiota. In particular, quebracho and chestnut tannins have shown to regulate the immune response and decrease in vitro-cytokines production, through microbiota fermentation-secondary metabolites, such as quercetin and SCFAs. OBJECTIVE: To evaluate the efficacy and the effect on cytokine levels of a tannin specific natural extract in COVID-19 patients. MATERIAL AND METHODS: This prospective, doubleblind, and randomized study was approved by the Hospital de Clínicas, José de San Martín (Buenos Aires, Argentina). Blood and stool samples were collected at baseline (Day 0) and after treatment (Day 14) during July-October 2020, with final follow-up in November 2020. We randomly assigned 124 RT-PCR confirmed COVID-19 cases (>18 years) to receive oral dry extracts of quebracho and chestnut tannins (240 mg) and B12 vitamin (0.72 μg) or placebo, twice daily for 14 days as adjunct treatment to their standard of care management. 27-pro and anti-inflammatory cytokines were measured on day 0 and 14 (Bio-Plex Pro™, Bio-Rad). Final enrollment of 140 patients with matched fecal microbiome characterization (16S, WGS and metabolites) is expected. RESULTS. Of 124 patients who were randomized (mean age 55+/-15, 63 [50.81%] male), 121 (97.58%) completed the trial. No adverse events were observed in the tannin group. Patients presenting with diarrhea (13%) had a trend to have elevated blood MIP-1α levels, which were significantly reduced by tannin treatment (Table 1). At baseline, higher levels of MIP-1α were also associated with diagnosis of pneumonia (Fig. 1), which was maintained after adjusting for confounders (age, sex, diabetes;p=0.04). Moreover, at baseline there was a positive correlation between MIP-1 α and IL-1ra, IL-2, MIP-1b and TNF-α, with all of these cytokines decreasing mostly with tannin treatment. CONCLUSION: To our knowledge, this clinical trial represents the first study to target the gut microbiome in hospitalized COVID-19 patients. Oral tannins as adjunct treatment with standard-of-care management of these patients significantly reduced proinflammatory cytokine levels that are generally associated with poor predictive outcomes, i.e. pneumonia and diarrhea. Further, our prospective studies will determine which microbiome-mediated mechanisms may attenuate the cytokine storm that is evident in COVID-19 disease pathogenesis. (Table presented) (Figure presented)