Efficacy of Intravenous Anakinra and Ruxolitinib During COVID-19 Inflammation (JAKINCOV)

• ClinicalTrials.gov Identifier: NCT04366232
• Recruitment Status: Terminated
• First Posted: April 28, 2020
• Last Update Posted: December 16, 2020
• Sponsor: Centre Hospitalier Intercommunal de Toulon La Seyne sur Mer
• Collaborators: Hôpital d'instruction des armées Sainte-Anne; Assistance Publique Hopitaux De Marseille
• Information provided by (Responsible Party): Centre Hospitalier Intercommunal de Toulon La Seyne sur Mer

Study Description

Brief Summary:

During SARS-Cov2 infection with serious respiratory implication and high systemic inflammation level, intravenous ANAKINRA alone or associated with RUXOLITINIB for severe cases might reduce inappropriate systemic inflammatory response, improve breathing and decrease occurrence or duration of ARDS and associated mortality.

Condition or disease	Intervention/treatment	Phase
Covid-19	Drug: Anakinra alone (stages 2b/3); Drug: Anakinra and Ruxolitinib (overcome stage 3); Other: Standard of care	Phase 2

Detailed Description:

Two physiopathological phases exist during COVID-19 disease: The early phase is mainly induced by the virus itself. It is imperative not to decrease the immune host response during this phase by prohibiting the use of non steroidal anti-inflammatory drugs or corticosteroids at this stage and developing an anti-viral strategy. The late phase, around Day 7-9, depends only upon host response and is linked to an excessive inflammatory response with a major increase of inflammatory cytokines such as IL-6, MCP-1, GCSF indicative of IL-1b excess, as well as IP-10, MIP-1, indicative of IFNg signature, corresponding to a "cytokine storm". Clinical and biological features during Still's disease (complicated in 10% of cases with hemophagocytosic lymphohistiocytosis inducing cytopenia, hepatic insufficiency, major hyperferritinemia and multi-organ failure) are close to those reported during COVID-19 and underline physiopathological similarities.

Anakinra (KINERET) is an IL-1 pathway (IL-1ra) specific inhibitor that has been used for 15 years, also largely blocking IL-18 production. Adult Still's disease is very effectively treated with anakinra. During sepsis with hyperferritinemia, IL-1ra demonstrated patient survival improvement. Ruxolitinib (JAKAVI) inhibits the downstream IFNg pathway targeting JAK kinase receptor. It has recently proved its efficiency in hemophagocytosic lymphohistiocytosis refractory forms associated with a multi-organ failure.

Study Design

• Study Type: Interventional (Clinical Trial)
• Actual Enrollment: 2 participants
• Allocation: Randomized
• Intervention Model: Parallel Assignment
• Intervention Model Description: Assignment to one of two or more groups in parallel during the study No crossover
• Masking: None (Open Label)
• Primary Purpose: Treatment
• Official Title: Interleukin-1 (IL-1) and Interferon Gamma (IFNg) Inhibition During COVID 19 Inflammation: Randomized, Controlled Study Assessing Efficacy and Safety of Anakinra and Ruxolitinib
• Actual Study Start Date: August 19, 2020
• Actual Primary Completion Date: October 2, 2020
• Actual Study Completion Date: October 2, 2020

Arms and Interventions

Arm	Intervention/treatment
Experimental: Anakinra +/- Ruxolitinib; According to clinical stage (gradual strategy): Stage 2b or 3 : Anakinra 300 mg IV; Overcome stage 3 : Anakinra 300 mg IV and Ruxolitinib 5 mg x 2	Drug: Anakinra alone (stages 2b/3); Anakinra 300 mg 1/d Intravenous 5 days then dose tapering; Other Name: KINERET; Drug: Anakinra and Ruxolitinib (overcome stage 3); Anakinra 300 mg od Intravenous (maximum14 days) Ruxolitinib 5 mg bid per os (maximum 28 days); Other Name: KINERET and JAKAVI
Active Comparator: Standard of care; Treatment with drugs or procedures in routine clinical practice	Other: Standard of care; Routine clinical care for Covid-19

Outcome Measures

Primary Outcome Measures :

1. Biological criteria [ Time Frame: 7 days from enrolment ]

   At least 3 parameters are met including CRP and/or Ferritin among:

   1. CRP: decrease > 50%
   2. Ferritinemia: decrease > 1/3
   3. Serum creatinine: decrease > 1/3
   4. AST/ALT: decrease > 50%
   5. Eosinophils > 50 /mm3
   6. Lymphocytes > 1000 /mm3

Secondary Outcome Measures :

1. Duration of oxygen therapy (days) [ Time Frame: 28 days from enrolment ]
   Number of days without mechanical ventilation
2. Number of intensive care units admissions [ Time Frame: 28 days from enrolment ]
   Number of patients included in stage 2b
3. Number of days in intensive care units [ Time Frame: 28 days from enrolment ]
   Number of days in intensive care units for patients managed in intensive care units
4. Mortality rate [ Time Frame: 28 days from enrolment ]
   Mortality rate
5. Total number of days in hospital [ Time Frame: 28 days from enrolment ]
   Total number of days in hospital
6. Organ failure score modification (Sepsis-related Organ Failure Assessment (SOFA) score) [ Time Frame: 28 days from enrolment ]
   Organ failure score modification (Sepsis-related Organ Failure Assessment (SOFA) score); Sofa score's minimum and maximum values are 0 and 24, the lowest score corresponds to a better outcome.
7. Number of bacterial and/or fungal sepsis [ Time Frame: 28 days from enrolment ]
   Number of bacterial and/or fungal sepsis

Eligibility Criteria

• Ages Eligible for Study: 18 Years and older (Adult, Older Adult)
• Sexes Eligible for Study: All
• Accepts Healthy Volunteers: No

Criteria

Inclusion Criteria:

• Confirmed respiratory tract SARS-coV-2 infection by at least one PCR on nasopharygeal sample or a bronchoalveolar lavage

• Patient hospitalized with clinical, biological and radiological features corresponding to the following stages :

  • Stage 2b: hypoxic pneumonia (respiratory frequency > 30/mn, Sa02 < 90 mmHg on room air) associated with a clear biological inflammatory syndrome (CRP > 150 mg/l)
  • Stage 3: ARDS defined by a patient under mechanical ventilation with a ratio PaO2/FiO2 < 300 for more than 24h
  • Evolved stage 3: ARDS according to previous definition associated with another organ failure or syndrome among:
• A state of shock with noradrenaline dosing > 3mg/h
• Acute kidney failure oligo-anuric or justifying extra-renal purification
• Hepatocellular insufficiency or coagulopathy with a V factor < 50%
• Myocarditis responsible for acute heart failure and or cardiogenic shock
• Hemophagocytic syndrome
• Hyperferritinemia > 5000 ng/mL
• Subject or legal representative having expressed written consent after information
• Subject affiliated to or entitled to a social security regimen
• Patient presenting in a life-threatening emergency situation that does not allow consent to be obtained

Exclusion Criteria:

• Pregnancy or lactation
• Absolute neutrophil count less than 1.5 x 109/L
• Hepatic transaminases AST or ALT greater than 5 times normal values
• Platelet count less than 50,000 per mm3
• Solid organ or hematopoietic stem cell transplant patients
• Patients treated with immunosuppressants or immunomodulators
• Use of oral corticosteroids chronically at doses greater than 10 mg prednisone equivalent per day for a non-COVID-19 related condition.
• Uncontrolled autoimmune disease
• Patients with active, suspected or known, uncontrolled systemic bacterial, viral (excluding COVID-19) or fungal infections
• Hypersensitivity to anakinra and/or ruxolitinib and their excipients
• Vaccinations with live attenuated vaccines in the month prior to inclusion
• Patients with severe pre-existing uncontrolled organ dysfunction (heart, liver or kidney failure)
• Persons deprived of liberty by judicial or administrative decision or major persons under a legal protection measure.
• Person in exclusion period of another research protocol for SARS-CoV-2 infection.
• Person not mastering enough French understanding and reading to be able to consent to participate in the study.
• Persons under psychiatric care pursuant to Articles A3112-1 and L3113-1 who are not covered by the provisions of Article L1121-8
• Every condition which, according to investigator, might increase and compromise the person security in case of study participation or might interfere with research results.

Contacts and Locations

Locations

France

AP-HM, Hôpital de la Conception

Marseille, Bouches-du-Rhône, France, 13005

Hôpital Sainte-Musse

Toulon, VAR, France, 83000

Sainte Anne Teaching Military Hospital

Toulon, Var, France, 83000

Sponsors and Collaborators

Centre Hospitalier Intercommunal de Toulon La Seyne sur Mer

Hôpital d'instruction des armées Sainte-Anne

Assistance Publique Hopitaux De Marseille

Investigators

• Principal Investigator: David DELARBRE, MD; French Army Health Service

More Information

Publications of Results:

Mehta P, McAuley DF, Brown M, Sanchez E, Tattersall RS, Manson JJ; HLH Across Speciality Collaboration, UK. COVID-19: consider cytokine storm syndromes and immunosuppression. Lancet. 2020 Mar 28;395(10229):1033-1034. doi: 10.1016/S0140-6736(20)30628-0. Epub 2020 Mar 16.

Wu Z, McGoogan JM. Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention. JAMA. 2020 Apr 7;323(13):1239-1242. doi: 10.1001/jama.2020.2648.

Zalinger ZB, Elliott R, Weiss SR. Role of the inflammasome-related cytokines Il-1 and Il-18 during infection with murine coronavirus. J Neurovirol. 2017 Dec;23(6):845-854. doi: 10.1007/s13365-017-0574-4. Epub 2017 Sep 11.

• Responsible Party: Centre Hospitalier Intercommunal de Toulon La Seyne sur Mer
• ClinicalTrials.gov Identifier: NCT04366232
• Other Study ID Numbers: 2020-CHITS-003; 2020-001963-10 ( EudraCT Number )
• First Posted: April 28, 2020
• Last Update Posted: December 16, 2020
• Last Verified: December 2020

Individual Participant Data (IPD) Sharing Statement:

• Plan to Share IPD: No

• Studies a U.S. FDA-regulated Drug Product: No
• Studies a U.S. FDA-regulated Device Product: No

Keywords provided by Centre Hospitalier Intercommunal de Toulon La Seyne sur Mer:

COVID; SARS-CoV-2; Anakinra; Ruxolitinib; IL-1 inhibitors; JAK inhibitors

Additional relevant MeSH terms:

Inflammation; Pathologic Processes; Interleukin 1 Receptor Antagonist Protein; Antirheumatic Agents