Canakinumab as treatment for COVID-19-related pneumonia: A prospective case-control study

Since January 2020 Elsevier has created a COVID-19 resource centre with

free information in English and Mandarin on the novel coronavirus

COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the

company's public news and information website.

Elsevier hereby grants permission to make all its COVID-19-related

research that is available on the COVID-19 resource centre - including this

research content - immediately available in PubMed Central and other

publicly funded repositories, such as the WHO COVID database with rights

for unrestricted research re-use and analyses in any form or by any means

with acknowledgement of the original source. These permissions are

granted for free by Elsevier for as long as the COVID-19 resource centre

Canakinumab

as

treatment

for

COVID-19-related

pneumonia:

A

prospective

case-control

study

Daniele

Generali

*

,

Giancarlo

Bosio

,

Fabio

Malberti

,

Antonio

Cuzzoli

,

Sophie

Testa

,

Laura

Romanini

,

Antonio

Fioravanti

,

Alessandro

Morandini

,

Luca

Pianta

,

Guglielmo

Giannotti

,

Erika

Maria

Viola

,

Matteo

Giorgi-Pierfranceschi

,

Marina

Foramitti

,

Rosa

Angela

Tira

,

Ilaria

Zangrandi

,

Giulia

Chiodelli

,

Andrea

Machiavelli

,

Maria

Rosa

Cappelletti

,

Alessia

Giossi

,

Valeria

De

Giuli

,

Chiara

Costanzi

_,

_Chiara

_Campana

_,

_Ottavia

_Bernocchi

_,

_Marianna

_Sirico

_,

Alessia

Zoncada

,

Alfredo

Molteni

,

Sergio

Venturini

,

Fabiola

Giudici

,

Maurizio

Scaltriti

_,

_Angelo

_Pan

a

COVIDUnit,AziendaSocioSanitariaTerritorialediCremona,Cremona,Italy

b

DepartmentofMedical,SurgeryandHealthSciences,UniversityofTrieste,Trieste,Italy

c

PharmacyUnit,AziendaSocioSanitariaTerritorialediCremona,Cremona,Italy

d_{HaemostasisandThrombosisCenter,AziendaSocioSanitariaTerritorialediCremona,Cremona,Italy}

e_{RadiologyUnit,AziendaSocioSanitariaTerritorialediCremona,Cremona,Italy}

f

DepartmentofCardiac,Thoracic,VascularSciencesandPublicHealth,UniversityofPadova,Padova,Italy

g

DepartmentofManagement,UniversityofTurin,Turin,Italy

h

CentreforResearchonHealthandSocialCareManagement(CERGAS),SDABocconiSchoolofManagement,Milan,Italy

i

DepartmentofPathologyandHumanOncologyandPathogenesisProgram,MemorialSloanKetteringCancerCenter,NewYork,NY,USA

ARTICLE INFO

Articlehistory:

Received24September2020

Receivedinrevisedform23December2020

Accepted23December2020 Keywords: COVID-19 Pneumonia SARS-CoV-2 Canakinumab ABSTRACT

Objectives:CanakinumabisanIL-1βantibodythatneutralisestheactivityofIL-1β.Thisstudyexamined theefficacyandsafetyofcanakinumabinpatientswithmoderateCOVID-19-relatedpneumonia. Design:Thisstudyaimedtoevaluatethereductionindurationofhospitalisationwithadequateoxygen status.Forty-eightpatientswithmoderateCOVID-19-relatedpneumoniawereaskedtoparticipateinthe prospectivecase-controlstudy:33patients(cases)signedinformedconsentandreceivedcanakinumab (Cohort1)and15patients(Controls)refusedtoreceivetheexperimentaldrugandreceivedinstitutional standardofcare(Cohort2).

Results:Hospitaldischargewithin21dayswasseenin63%ofpatientsinCohort1vs.0%inCohort2 (median14vs.26days,respectively;p<0.001).Therewassignificantclinicalimprovementinventilation regimesfollowingadministrationofcanakinumabcomparedwithCohort2(Stuart-Maxwelltestfor paireddata,p<0.001).PatientstreatedwithcanakinumabexperiencedasignificantincreaseinPaO2:

FiO2(p<0.001)andreductioninlungdamagebyCT(p=0.01),alongwithsignificantdecreasesin

immune/inflammationmarkersthatwerenotobservedinCohort2.Onlymildside-effectswereseenin patientstreatedwithcanakinumab;survivalat60dayswas90.0%(95%CI71.9–96.7)inpatientstreated withcanakinumaband73.3%(95%CI43.6–89.1)forCohort2.

Conclusions: Treatment with canakinumab in patients with COVID-19-related pneumonia rapidly restored normal oxygen status, decreased the need for invasive mechanical ventilation, and was associatedwithearlierhospitaldischargeandfavourableprognosisversusstandardofcare.

©2021TheAuthors.PublishedbyElsevierLtdonbehalfofInternationalSocietyforInfectiousDiseases. ThisisanopenaccessarticleundertheCCBY-NC-NDlicense( http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

SARScoronaviruses (SARS-CoV)are a largefamilyof viruses that normally cause mild-to-moderate upper respiratory tract illnesses(Trivedietal.,2019).ThenovelcoronavirusSARS-CoV-2is

*Correspondingauthorat:DepartmentofMedical,SurgeryandHealthSciences,

University of Trieste, Azienda Socio-Sanitaria Territoriale di Cremona, Viale

Concordia1,26100Cremona,Italy.

E-mailaddress:dgenerali@units.it(D.Generali).

https://doi.org/10.1016/j.ijid.2020.12.073

1201-9712/©2021TheAuthors.PublishedbyElsevierLtdonbehalfofInternationalSocietyforInfectiousDiseases.ThisisanopenaccessarticleundertheCCBY-NC-ND

ContentslistsavailableatScienceDirect

International

Journal

of

Infectious

Diseases

currentlycausing a globalpandemic, as declared bytheWorld HealthOrganizationon11March2020.Sepsis,respiratoryfailure, acute respiratory distress syndrome (ARDS), and multiorgan failurearethecommoncomplicationsofanapparentlyaberrant hostimmuneresponse(Huangetal.,2020).Huangetal.reported the clinical features of patients infected by COVID-19 and suggestedthathyperstimulationofcytokines–suchasinterferon gamma,interleukin (IL)-1,IL-6,and tumournecrosisfactor α–is associated with the severity and clinical complexity of the infection(Huangetal.,2020).Indeed,itisbecomingincreasingly evident that these complications are related to the so-called cytokinestormobservedinsomeseverepatients,involvingrelease of cytokines includingIL-6, IL-18 and interferon (Mehta et al., 2020; Zhang et al., 2020). The clinical complications impede alveolar gas exchange and trigger dissemination of systemic thrombosis.Consistently,infectionofcellsinthelowerrespiratory tractbyCOVID-19cangiverisetosevereARDS,withconsequent release of additional pro-inflammatory cytokines suchas IL-1β (Contietal.,2020;Toldoetal.,2020).

To date, therapeutic options for severe COVID-19 remain limited.Antiviraldrugssuchaslopinavir/ritonavirhaveshown no benefits compared to standard care (Cao et al., 2020). Recently, remdesivir was reported to have modest clinical benefits inpatientsaffectedbyCOVID-19(Beigeletal.,2020). Thus,newtreatmentstrategiesareurgentlyneededtoachievea significantimpactonprognosisofCOVID-19.Thesuspicionthat overzealousimmuneresponsesinsomeCOVID-19patientshave given risetointerestin anti-cytokine therapytomitigatethe cytokine storm (Megna et al., 2020; Zhou et al., 2020).

Accordingly, immune-modulatory agents such as anti-IL-6,

anti-IL-6R and anti-IL-1 antibodies are under investigation. Recently, the anti-IL-1R agent anakinra and anti-IL-6R agent tocilizumab have shown promising results in patients with COVID-19 andARDS (Campochiaro et al., 2020; Cavalli et al., 2020; Colaneri et al., 2020). Canakinumab is a high-affinity human monoclonal antihuman IL-1β antibody of the IgG1/

k

Thisstudyinvestigatedtheclinicalefficacyofcanakinumabin patientswithmoderateCOVID-19pneumonia.Itaimedtoevaluate thereductioninhospitaldurationwithadequateoxygenstatus.In addition, it focused on survival without the need for invasive mechanicalventilation,adverseevents,modulationofbiological parameters,andchestcomputedtomography(CT)response. Methods

Studydesign

Themainfocuswastoobtaininformationontheactivityand safety of canakinumab in patients with moderate COVID-19-relatedpneumonia. Thisprospective,case-control,single-center, observational study carried out at the Azienda Socio-Sanitaria TerritorialediCremona(ASST),Cremona(Italy)wasapprovedby theASSTofCremonaInstitutionalReviewBoardandiswithouta trial registration number. All study participants gave written informed consent for participation. Studies were conducted in conformity with applicable local requirements and regulations regarding the protection of the rights and welfare of human subjects that were enrolled. The authors conceived the study, collectedalldata,vouchedfortheaccuracyandcompletenessof thedata,andmadethedecision,afterthefinalversion,tosubmit themanuscriptforpublication.Thefirstdraftofthemanuscript was conceived and prepared by the first author who was the principalinvestigatorofthestudy.Thestudydrug–canakinumab– wasprovidedbyNovartisFarma,SpA.

Patientpopulation

Forty-eight patients with moderate COVID-19-related pneu-monia were enrolled in this prospective case-control study between 01–25 April 2020 at a single institution. Thirty-three

patients were treated with canakinumab (Cohort 1) and 15

patients continued with the standard of care (Cohort 2). All patientswhowereenrolledmetcriteriadefinedbythe vademe-cumoftheLombardySectionoftheItalianSocietyofInfectiousand TropicalDiseases(LombardySectionItalianSocietyandTropical, 2020).Fordiagnosis,throatswabs wereobtainedunderaseptic conditionsandanalysedbyreal-timeRT-PCR;chestX-rayand/or CTwithsignsofpneumonia(e.g.lateralmultiplelobularand sub-segmentalareas ofground-glass opacityor consolidation)were alsoconsideredfordiagnosis.Criteriafordiagnosisof moderate conditionsaredescribed inthesupplementalmaterials.Clinical features–includingbodytemperature,concentrationof oxygen inhalationandoxygensaturations–wererecordeddailyduring treatment.Clinicalimprovementwasbasedonanordinalclinical improvementscalethatcomparedwithbaselineventilationstatus ofpatientswithrespecttolastfollow-up.

Scoresonthescaleweredefinedasfollows:0,notreceiving supplementaloxygen; (1) high-flow nasal cannula; (2) Venturi mask oxygen therapy; (3) mask with reservoir bag; (4) non-invasiveventilation(NIV)andcontinuouspositiveairwaypressure (CPAP);and(5) intubation.Thecumulativeincidenceof clinical improvementwasdefinedbyeitheradecreaseof1pointonthe 6-pointordinalscaleorlivedischarge.

Whole blood white cell counts along with markers of

inflammation(C-reactiveprotein(CRP),IL-6,fibrinogen,D-dimer,

andferritin)weremonitored.Mostpatientshadundergonespiral chest CT upon admission and before dischargeusing a 64-row spiralRevolutionEVO(GEHealthcare)inawhole-lung,low-dosage exposuremode,scanningwith1.25-mmslices.Thesoftwareused forCTscananalysiswasThoracicVCAR,usingamodifiedprotocol with a suitable threshold to detect solid/sub-solid pulmonary changes. Lung involvement was automatically reported as a percentage by two independent radiologists. The mean of the scoreswasusedforsubsequentanalysis.Safetyandadverseevents weremonitoredusingNationalCancerInstituteCommon Termi-nologyCriteriaforAdverseEvents,version4.03.

Treatment

Canakinumab (150 mg) was administered by subcutaneous

injectiononday1andonday7,asapprovedforauto-inflammatory conditions(EMAauthorisation30January2020).Theschedulewas empiricallyinterruptedinthreecasesafterthefirstdose,giventhe substantialclinicalandradiologicalbenefitsthatwereobserved. Allpatientsmeetingeligibilitycriteriawhohadsignedaconsent formandwhohadbegunexperimentaltreatmentwereevaluated as a case group (Cohort 1). All eligible patients who initiated treatmentwereevaluatedforadverseevents.Patientshospitalised

in the same period who refused to be treated with the

experimentaldrug(Cohort2)wereusedasacontrolgroup. Statisticalanalysis

Twoindependentstatisticiansblindedtoeachotheranalysed thedata.Continuousvariableswereexpressedasmedian(range) or mean (standard deviation), according to data distribution checkedwiththe Shapiro–Wilktest. Categoricalvariables were expressedasabsolutefrequenciesandpercentages.Homogeneity ofbaselinecharacteristicsbetweenthetwocohortswereassessed

through t-test or Mann–Whitney test. One-way ANOVA or

Friedmantestforrepeatedmeasureswereperformedtoevaluate

D.Generali,G.Bosio,F.Malbertietal. InternationalJournalofInfectiousDiseases104(2021)433–440

differences in clinical parameters over time for both cohorts (separately).Pairwisepost-hoccontrastswereconsideredand p-valuesadjustedformultiplecomparisons(Holmmethod).Typeof ventilation beforeandafter treatmentwascompared usingthe Stuart-Maxwelltest.Spearman’slinearcoefficientwascalculated toassesscorrelationbetweenvariablesofinterest.Linear

mixed-effect models (LMEM) for repeated measures were used to

investigate changes in values over time with respect togroup assignment.Themethodusedtotreatmissingdatawascomplete dataanalysis:thepercentageofmissingvaluesacrossvariablesof interest over time varied between 0%–27% for Cohort 1 (at maximumninemissingvaluesforvariables)andbetween0%_–13% for patients in Cohort 2 (at maximum two missing values for variables).Missingvaluescanbeconsideredascompletelyrandom duetotheemergencysituation.Overallsurvivalwasdefinedasthe timefromdateofadmissiontohospitaltodeath,andestimated withtheKaplan-Meiermethod.Thelastfollow-upupdatewason 27May2020.Thelog-ranktestwasconductedtoassess between-groupdifferences.AllstatisticalanalyseswereperformedusingR version4.0.0.Statisticalsignificancewassetasp<0.05. Results

Patientcharacteristics

From01to25April2020,48patientswithmoderateCOVID-19 andpneumoniawereincluded:33weretreatedwithcanakinumab (Cohort1)and15(Cohort2)receivedtheinstitutionalstandardof

care. All patients were managed outside of the ICU. Baseline characteristicsaresummarisedinTable1.Medianagewassimilar inCohort1(70years,range29–89)andCohort2(69years,range 44–85).Themajorityofpatientsweremale(76%forCohort1and 87% in Cohort 2). The range of comorbidities and presenting symptomswerebroadlysimilarinbothgroups.Patientsinboth groups had received treatment with antivirals, hydroxychloro-quine and antibiotics (see Supplementary Appendix) before entering the study. For treating COVID-19-related pneumonia, patientsinCohort1receivedcanakinumabandheparinandthose inCohort2receivedhigh-dose(10,000IU)heparinonly. Ventilation,oxygenationstatusandchestCT

Atbaseline,mostpatientsreceivingcanakinumab(75.8%)were onnon-invasiveventilationsuchasCPAP(30.4%)orsupplemental oxygen(withnasalprongs)(45.4%);theremaining24.2%hadNIV. InCohort2,46.7%ofpatientshadsupplementaloxygen,40%had CPAPand13.3%hadNIV.

At10days afterthelast administration ofcanakinumab, no clinicalneedforNIVandareduction(15.1%)intheuseofCPAPwith animprovement ofuseof supplementaloxygenby63.7% were observed; 21.2% restored breathing with ambient air. The improvementinventilationregimesfollowing administrationof canakinumab was statistically significant in Cohort 1 (Stuart-Maxwell test for paired data, p < 0.001). In Cohort 2, which receivedhigh-doseheparinonly,therewerenosignificantchanges inclinicalbenefitand/orreductioninventilationneededat

pre-Table1

Demographiccharacteristicsofpatientsenrolledintheprospectiveinterventionalstudy.

Characteristic Cohort1 Cohort2 p-value

(n=33) (n=15)

Medianage,years 70(29–89) 69(44–85) 0.38

Agecategory,N(%) 0.54 <50years 1(3%) 1(6%) 50–70years 13(39%) 4(27%) 70years 19(58%) 10(67%) Gender 0.47 Male 25(76%) 13(87%) Female 8(24%) 2(13%) Comorbidities Cardiovasculardisease 18(54%) 8(53%) 0.94 Pulmonarydisorder 0 0 Cancer 1(3%) 0 Metabolicdisordersa 9(27%) 3(20%) Neurologicaldisorder 10(30%) 3(20%)

ConcomitantTherapies,N(%) Beforeb

Afterb Beforec Afterc 0.75d Antivirals 23(70%) 0 12(80%) 0 Hydroxychloroquine 30(91%) 1(3%) 14(93%) 2(13%) Antibiotics 25(76%) 2(6%) 8(53%) 2(13%) Heparin 33(100%) 33(100%) 14(93%) 14(93%) Corticosteroids 17(52%) 4(12%) 4(27%) 0 Hospitaldays Median(min–max) 14(5–40) 26(21–42) <0.001 Hospitaldays,N(%) <14 11(33%) 0(0%) 14–21 10(30%) 0(0%) <0.001 21 12(36%) 15(100%) Symptoms,N(%) 0.85 Fever 29(89%) 10(67%) Cough 13(39%) 8(53%) Dyspnoea 23(70%) 10(67%) Fatigue 4(12%) 2(13%) Gastrointestinal 4(12%) 1(6%) a

Type2diabetes,hypercholesterolaemia.

b

Beforeandaftertreatmentwithcanakinumab.

c

Sametimeframeinwhichcasesweretreatedwithcanakinumab.

d

treatment and post-treatmenttimes (p= 0.28).While 13.3%of patientsstill needed NIV,26.7% weremaintainedonCPAP, and supplementaloxygenwasneededfor53.3%ofpatients.Attheend ofthesameperiodofobservation,6.7%ofpatientswerenolonger inneedofsupplementaloxygen.

This study also compared the PaO2:FiO2 ratio and chest CT

beforestarting canakinumabandat 7–10daysafterthesecond injection of the anti-IL1β antibody. The same comparison was performed inCohort 2during thesametime frameof patients receiving canakinumab. The ventilation approaches in the two cohorts were comparable at baseline; however, more patients neededless invasivetypesofventilationafteradministrationof canakinumab. As shown in Table 2, compared with baseline, patients treated with canakinumab experienced a significant

increaseinthePaO2:FiO2ratio(p<0.001)andareductioninlung

damageevaluatedbyCT(p=0.01).Cohort2hadclinicalbenefit onlyinthePaO2:FiO2ratio(p=0.05).Nosignificantcorrelationwas

observedbetweenthechange(

D

D

damageincontrols(TableS1).Figure1showsthechangesinlung damagerelatedtoCOVID-19inducedbycanakinumab.

Modulationofimmune-inflammatorymarkers

Laboratory immune and inflammatory markers were tested priortoadministrationofcanakinumabatdays1and7andat7–10 days after the second injection of the antibody (Table S2). Canakinumabledtoareductioninwhitebloodcells(p<0.001), platelets(p=0.005)andneutrophils(p<0.001),andanincreasein

Table2

ChangesinPaO2/FiO2ratioandlungdamageevaluatedbychestCT(%)inCohort1(a)andCohort2(b)duringthesametimeperiodbeforetreatmentwithcanakinumabandat

7–10daysafterthesecondadministrationofcanakinumab.(c)Comparisonbetweenthechangesmeasuredbetweenbeforethefirstadministrationofcanakinumabandat

follow-upbetweenthetwocohortswithregardstothePaO2/FiO2ratioandlungdamageonchestCTscan(%).

a)Cohort1

Cohort1 Beforefirstadministration Atfollow-up P-value

(n=33atbaseline)

PaO2:FiO2ratio

Mean(min–max) 142.2(59.0) 257.4(105.8) <0.001

Lungdamage(%)

Mean(SD) 48.5(21.1) 38.6(18.5) 0.01

b)Cohort2

Cohort2 Beforefirstadministration Atfollow-up P-value

(n=15atbaseline)

PaO2:FiO2ratio

Mean(SD) 148.1(58.4) 197.1(46.8) 0.05

Lungdamage(%)

Mean(SD) 37.9(15.4) 35.7(10.0) 0.68

c)Comparisonbetweenthechangesmeasuredbetweenbeforethefirstadministrationofcanakinumabandatfollow-upbetweenthetwocohortswithregardstothe

PaO2/FiO2ratioandlungdamageonchestCTscan(%).

Variable Cohort1 Cohort2 P-value

ChangeinPaO2:FiO2ratio

Mean(SD) 99.9(62.2) 50.5(63.3) 0.03

Changeinlungdamage(%)

Mean(SD) 17.1%(31.1%)a

11.7%(58.3%) 0.03

a

Matched-pairanalysiswasavailablefor23patients.

Figure1.Changesinlungdamagebefore((A)Diffusegroundglassopacitieswithperipheralnodularconsolidation)andafteradministration((B)Lessperipheralgroundglass

opacities)ofcanakinumab.

D.Generali,G.Bosio,F.Malbertietal. InternationalJournalofInfectiousDiseases104(2021)433–440

lymphocytes(p=0.01),overthetimeofmeasurement,whileno significant variations were found for the same parameters in Cohort 2 (Figure 2a). The changes over time in immune and inflammatorymarkersarereportedinTablesS3aandS3b,andin Tables S4a and S4b, respectively. Moreover, the neutrophil/ lymphocyteratio,consideredasasurrogate markerofresponse totreatmentinothersettingssuchascancer(Kimetal.,2019), showedasignificantincrease(p<0.001)overtime.Thistrendwas notobservedin Cohort2, whereonlyanincreasein neutrophil countwasseenpre-treatmentandbeforethesecond administra-tion(p=0.05).

With regards to in_flammatory markers, canakinumab treat-mentwasassociatedwithpromptreductionsinserumCRP(p< 0.001),IL-6(p<0.03)andferritin(p<0.001).InCohort2,onlya reductioninthelevelofD-dimerwasnoted(p=0.05)(Figure2b), whichwaslikelyduetothehigherdoseofheparinusedcompared withCohort1.

Effectofcanakinumabonlaboratorymarkers

Effectsoftime,irrespectiveoftreatment,werefoundinWBC, neutrophils and at the limit of statistical significance in CRP. Interactions between time and treatment were significant for WBC, lymphocytes, neutrophils, platelets,CRP, and the neutro-phils/lymphocyteratio(TableS5andFigure2a).

Survival,clinicaloutcomesandadverseevents

Clinicaloutcomesofthe33patientstreatedwithcanakinumab were compared with those of the 15 patients who received standardtreatmentonly.AnimprovementinsurvivalinCohort1 wasobserved.Thesurvivalrateat60dayswas90.0%(95%CI71.9– 96.7)inthecanakinumab-treatedcohortvs.73.3%(95%CI43.6– 89.1)inCohort2(Figure3a).Moreover,63%ofpatientsinCohort1 werehospitalised for <21 dayscompared with0% in Cohort2 (median14vs.26days,respectively;p<0.001)(Table1).Ofthe30 patientswhoreceivedtwoadministrationsofcanakinumab(three patients received only one subcutaneous injectiondue tovery rapid improvement in ventilation), 21 (72%) experienced an improvement in respiratory function.The Kaplan–Meiercurves forthetimetoimprovementontheordinalclinicalimprovement scaleareshowninFigure3b.Theunivariatehazardratioforclinical improvementinCohort1comparedwithCohort2was4.20(95%CI 1.56–11.32,p=0.005).

Causes of death in patients receiving canakinumab were pulmonary thromboembolism (n = 2) and multiorgan failure (n=2).CausesofdeathinpatientsinCohort2weresepsis(n=1),

multiorgan failure (n = 1) and pulmonary thromboembolism

(n=2).

Inbothcohorts,heparin,independentlyofthedose,waswell tolerated without any serious adverse events. Four patients in Cohort1experiencedinjectionsitereactions,whiletwo experi-encednausea(Grade1)andonepatientreferredheadache(Grade 1).ThesesymptomswerenotrecordedinpatientsinCohort2. Discussion

In the absence of standard of care, existing therapies can potentiallyberepurposedtotreatCOVID-19.Thispandemichas favoured the off-label or compassionate use of investigational agents suchas remdesivir, immune-modulating compounds or convalescentplasma(Limaetal.,2020;Manhasetal.,2020)that areapprovedorlicensedforotherindications.Todate,theuseof

other immunomodulatory agents such as tocilizumab and

anakinra for the treatment of the cytokine storm related to COVID-19hashighlightedthepotentialimportanceofmodulating

Figure2. (a)Changesovertimeinimmuneresponse-relatedmarkers:comparison

between Cohort 1 and Cohort 2 (T0: basal; T1 after first administration of

canakinumab;T2after7–10daysfromthesecondadministrationofcanakinumab).

TheN/Lratioisalsoreported.(b)Changesovertimein

Figure3.(a)OverallsurvivalinCohort1andCohort2.(b)Cumulativeincidenceofclinicalimprovementfromhospitaladmissiontohospitaldischarge.

D.Generali,G.Bosio,F.Malbertietal. InternationalJournalofInfectiousDiseases104(2021)433–440

this pathway inpreventing worsening ofdisease (Campochiaro etal.,2020;Cavallietal.,2020;Colanerietal.,2020).Ithasalso beenreportedthattocilizumabreducesadmissionstotheICUand mortalityinpatientswithCOVID-19(Klopfensteinetal.,2020).

Arecentretrospectiveanalysisof10patientswith COVID-19-pneumoniawhoweresafelytreatedwithcanakinumab(Ucciferri et al.,2020)showed thatallpatientsrecoveredwithin45days, alongwithanimprovementinoxygenationandadecreaseinthe systemicinflammatoryresponse.ThePaO2:FiO2ratioincreasedin

82% of patients, while improvement in the oxygen-support

category was observed in 61% of cases. Overall, mortality was 13.6%.

This study reports, in a real-world setting, the activity of canakinumabforthetreatmentofpatientswithmoderate COVID-19pneumonia.Therecentdataabouttheintenseinflammasome formationcharacterisingthelungsofpatientswithfatalCOVID-19 diseasedue toARDS supportarationalrole ofcanakinumab in managing COVID-19-related complications (Conti et al., 2020; Toldoetal.,2020).Moreover,itfoundthathypoxaemiaandlungCT opacity bothrapidly improvedin mostpatientsafter treatment with canakinumab (heavily pre-treated with antivirals and hydroxychloroquine) compared with Cohort 2, suggesting that IL-1β blockadecould playan important role inmodulating the cytokine storm.Of note,canakinumabwas alsoassociatedwith significanttimetoclinicalimprovementvs.Cohort2.

Anincreaseinthepercentageoflymphocyteswitha concomi-tant increase in neutrophils is considered to be an important indicatorforimmuneresponseinclinicalsettings(Zahorec,2001). Levels of both CRP and IL-6 decreased during therapy with canakinumab(p=0.02;FigureS1),alongwithaslightreductionin markers related tocomplements C3 and C4(data not shown), supportingtheroleofcanakinumabin modulatingtheimmune response/cytokine storm.It is likely that canakinumab is more efficaciousbeforethepatient’sconditionprogressesfrommildto severe (e.g. increased lung opacity, increased IL-6, CRP, and hypoxaemia), as early treatment may effectively control the deterioration of symptoms and complications related to the massivecytokine stormobservedinpatientswithsevereforms of COVID-19. However, the long-term safety of IL-1 inhibition remains tobe investigated. Specifically,canakinumab produces sustainedIL-1suppressionandthereforevigilanceisnecessaryto monitorforadverseevents.

All of the current patients weretreated with hydroxychlor-oquine,lopinavir/ritonavirorremdesivir,aloneorincombination, beforestartingcanakinumab.Thevarietyoftreatmentschedules used wasrelatedtotheabsenceofdefinedtreatment protocols duringthefirstfewweeksoftheCOVID-19epidemic.Thecurrent analysisevaluatedthepotentialtherapeuticefficacyof canakinu-mab/heparin versus heparin alone without the interference of other drugs, which were suspended before starting the study, accordinglytoSIMITguidelines(SIMIT,2021).

Evenconsideringtheemergencysituationwhenthestudywas performed, there were several limitations to this study. The number of patients was relatively limited, as in many similar studies with preliminarybut encouragingfindings. The uncon-trollednatureofthestudymandatescautionininterpretationof theresults:itwasaprospective,non-randomisedstudyandsome bias may have occurred. However, based on these results, a randomised controlled trial with canakinumab in COVID-19-pneumoniaiswarrantedinoutpatientswithmanageabledisease. ArandomisedphaseIIIclinicaltrialwithintravenouscanakinumab inhospitalisedpatientswithCOVID-19-inducedpneumoniais on-going(NCT04362813),butthisstudywillassesstheefficacyofa higherdose(administeredIVandbybodyweight).

Canakinumab appears to decrease the need for invasive

mechanicalventilationandimproveclinicalsymptomsinpatients

withCOVID-19.Blockadeofthecytokinestormwithcanakinumab preventsclinicaldeteriorationof patientswithCOVID-19 pneu-monia, thereby favouring earlier hospital discharge and better prognosis.

Ethicalapproval

This investigator-driven, single-center, prospective, observa-tionalstudycarriedoutattheAziendaSocio-SanitariaTerritoriale diCremona(ASST),Cremona(Italy)wasapprovedbytheASSTof Cremona Institutional Review Board and is without a trial registrationnumber.Allstudyparticipantsgavewritteninformed consentforparticipation.

Conflictofinterest Nonedeclare. Funding

Thisresearchdidnotreceiveanyspecificgrantfromfunding agencies in the public, commercial or not-for-profit sectors. Maurizio Scaltrici is funded by the National Cancer Institute (NCI),USAundertheMSKCancerCenterSupportGrant/CoreGrant (P30CA008748).

Authorcontributions

Researchdesign:AP,AM,BG,FM,MGP,ST,DG.Clinicalresearch anddatacollection:DG,GB,FM,AC,ST,LR,AF,AM,LP,GG,EV,MGP, MF,RT,IZ,GC,AM,MC,AG,VDG,CC,CC,OB,MS,AM,AP.Statistical analysis,dataanalysisandpharmacologydatainterpretation:SV, FG,MS,DG.Writingthepaper:SV,FG,MS,DG.

Acknowledgments

VirzìG,VismarraM,ZambolinG,ZadehS,ZelianiC,ZoncadaA, CaninoR.

AppendixA.Supplementarydata

Supplementarydataassociatedwiththisarticlecanbefound,in theonlineversion,atdoi:10.1016/j.ijid.2020.12.073.

References

BeigelJH,TomashekKM,DoddLE,MehtaAK,ZingmanBS,KalilAC,etal.Remdesivir

forthetreatmentofCovid-19–preliminaryreport.NEnglJMed2020;383:1813–

26.

CampochiaroC,Della-TorreE,CavalliG,DeLucaG,RipaM,BoffiniN,etal.Efficacy

and safety of tocilizumab in severe COVID-19 patients: a single-centre

retrospectivecohortstudy.EurJInternMed2020;76:43–9.

CaoB,WangY,WenD,LiuW,WangJ,FanG,etal.AtrialofLopinavir-Ritonavirin

adultshospitalizedwithsevereCovid-19.NEnglJMed2020;382(19):1787–99.

Cavalli G,De LucaG, CampochiaroC, Della-TorreE,Ripa M,CanettiD,et al.

Interleukin-1blockadewithhigh-doseanakinrainpatientswithCOVID-19,

acuterespiratorydistresssyndrome,andhyperinflammation:aretrospective

cohortstudy.LancetRheumatol2020;2(6):e325–31.

Colaneri M, Bogliolo L, ValsecchiP, Sacchi P, ZuccaroV, Brandolino F, et al.

TocilizumabfortreatmentofSevereCOVID-19patients:preliminaryresults

fromSMAtteoCOvid19REgistry(SMACORE).Microorganisms2020;8(5).

ContiP,RonconiG,CaraffaA,GallengaCE,RossR,FrydasI,etal.Inductionof

pro-inflammatorycytokines(IL-1andIL-6)andlunginflammationby

Coronavirus-19 (COVI-19 or SARS-CoV-2): anti-inflammatory strategies. J Biol Regul

HomeostAgents2020;34(2):327–31.

GohAX,Bertin-MaghitS,PingYeoS,HoAW,DerksH,MortellaroA,etal.Anovel

humananti-interleukin-1betaneutralizingmonoclonalantibodyshowingin

vivoefficacy.MAbs2014;6(3):765–73.

HuangC,WangY,LiX,RenL,ZhaoJ,HuY,etal.Clinicalfeaturesofpatientsinfected

with2019novelcoronavirusinWuhan,China.Lancet2020;395(10223):497–

506.

KimHY,KimTH,YoonHK,LeeA.Theroleofneutrophil-lymphocyteratioand

platelet-lymphocyteratioinpredictingneoadjuvantchemotherapyresponsein

breastcancer.JBreastCancer2019;22(3):425–38.

KlopfensteinT,ZayetS,LohseA,BalblancJC,BadieJ,RoyerPY,etal.Tocilizumab

therapyreducedintensivecareunitadmissionsand/ormortalityinCOVID-19

patients.MedMalInfect2020;50(5):397–400.

LimaWG,BritoJCM,OverhageJ,NizerW.Thepotentialofdrugrepositioningasa

short-termstrategyforthecontrolandtreatmentofCOVID-19(SARS-CoV-2):a

systematicreview.ArchVirol2020;165(8):1729–37.

LombardySectionItalianSocietyI,TropicalD.Vademecumforthetreatmentof

peoplewithCOVID-19.Edition2.0,13March2020.InfezMed2020;28(2):143–

52.

ManhasS,AnjaliA,MansoorS,SharmaV,AhmadA,RehmanMU,etal.Covid-19

pandemicandcurrentmedicalinterventions.ArchMedRes2020;51(6):473–81.

MegnaM,NapolitanoM,FabbrociniG.MayIL-17havearoleinCOVID-19infection?.

MedHypotheses2020;140:109749.

MehtaP,McAuleyDF,BrownM,SanchezE,TattersallRS,MansonJJ,etal.COVID-19:

considercytokinestormsyndromesandimmunosuppression.Lancet2020;395

(10229):1033–4.

SIMIT.Availableat:

http://www.simit.org/medias/1569-covid19-vademecum-13-03-202.pdf.[Accessed2May2020].

Toldo S, Bussani R, Nuzzi V, Bonaventura A, Mauro AG, Cannata A, et al.

InflammasomeformationinthelungsofpatientswithfatalCOVID-19.Inflamm

Res2020;2020(October).

TrivediSU,MiaoC,SanchezJE,CaidiH,TaminA,HaynesL,etal.Developmentand

evaluationofamultiplexedimmunoassayforsimultaneousdetectionofserum

IgGantibodiestosixhumancoronaviruses.SciRep2019;9(1):1390.

Ucciferri C,AuricchioA, DiNicola M,PotereN, AbbateA,Cipollone F, etal.

CanakinumabinasubgroupofpatientswithCOVID-19.LancetRheumatol

2020;2(8)e457-ee8.

ZahorecR.Ratioofneutrophiltolymphocytecounts–rapidandsimpleparameterof

systemicinflammationandstressincriticallyill.BratislLekListy2001;102

(1):5–14.

ZhangB,ZhouX,QiuY,SongY,FengF,FengJ,etal.Clinicalcharacteristicsof82cases

ofdeathfromCOVID-19.PLoSOne2020;15(7)e0235458.

ZhouF,YuT,DuR,FanG,LiuY,LiuZ,etal.Clinicalcourseandriskfactorsfor

mortalityofadultinpatientswithCOVID-19inWuhan,China:aretrospective

cohortstudy.Lancet2020;395(10229):1054–62.

D.Generali,G.Bosio,F.Malbertietal. InternationalJournalofInfectiousDiseases104(2021)433–440