Discussion
SARS-Cov-2 infection, death, multiorgan dysfunction, Hyperinflammation, RDS, ill, deaths, CL-1
RESPIRATORY FAILURE, DISEASE, COMPLICATION, RESPIRATORY DISTRESS SYNDROME, CORONAVIRUS, SEVERE ACUTE RESPIRATORY SYNDROME
We present the results of a single-center randomized phase II clinical trial with the combination of ruxolitinib and simvastatin for the treatment of COVID19. Up to 100 hospitalized patients were included and allocated in a 1:1 ratio to SOC or the experimental arm. Treatment was well tolerated but no differences were found regarding the primary objective, number of cases progressing to grade 5 or higher of the OSCI. Thus, the administration of ruxolitinib and simvastatin did not impact the outcome of COVID19.A comprehensive cytokine profiling was also completed. Up to 48 cytokines were determined in peripheral blood at baseline and during hospital stay. The ratio MIP-1α/M-CSF reliably classified cases in poor (cluster 1 [CL-1]) and good (cluster 2 [CL-2]) prognosis groups. CL-1 presented a higher likelihood of worsening SpFiOAdditionally, a decision tree was designed by ML algorithms that accurately predicted patient deterioration 48 hours before occurring. Both tools, baseline immunoprofiling, and decision tree, could greatly help in the early recognition of patients at risk of severe disease and the precise moment where more intensive care is required.Although vaccines have dramatically changed the outcomes of patients, the pandemic is far from being controlled since new variants are emerging (Hyperinflammation is an over exaggerated reaction of the immune system due to the SARS-Cov-2 infection that can lead to multiorgan dysfunction and particularly to a respiratory distress syndrome (RDS). This complication is responsible for most deaths and a major cause of long-term effects caused by COVID (In this setting, dexamethasone has demonstrated an impact on overall mortality in a randomized phase III clinical trial and has been adopted as standard of care (JAK inhibitors have also been proposed as potential alternatives in precluding hyperinflammation. Baricitinib and tofacitinib have communicated positive results in phase III randomized trials (named ACTT-2 and STOP-COVID respectively), while ruxolitinib has not (RUXCOVID trial).RUXCOVID was an international trial of ruxolitinib plus standard of care versus placebo plus standard of care in patients with COVID-19. Patients who were hospitalised but not on mechanical ventilation were randomly assigned (2:1) to oral ruxolitinib 5 mg twice per day or placebo for 14 days. 432 were included in the study. The primary objective (a composite of death, respiratory failure, or ICU care) was not met.The RUXCOVID-DEVENT trial compared the activity of two doses of ruxolitinib (5 mg or 15mg twice a day) versus placebo in more than 200 cases hospitalized with severe acute respiratory syndrome due coronavirus 2 (Finally, a single blinded phase II randomized trial that included 43 cases allocated 1:1 to ruxolitinib or placebo did not show significant differences either (Though our study did not reach positive results, some limitations must be discussed.First, our work represents a smaller population compared to prior trials (1067 in ACTT-2, 287 in STOP-COVID and 432 in RUXCOVID) and was not placebo controlled. Thus, our design could be underpowered to identify statistically significant differences.Secondly, we decided to focus on moderate disease excluding patients with an OSCI grade of 5 or higher. This is an important factor since corticosteroids, IL-6 antagonists and JAKi have shown a greater clinical impact in severely ill patients.Thirdly, any concurrent treatment was allowed at investigators discretion in Ruxo-Sim. Thus, 77% of patients received corticosteroids and 29% tocilizumab. In comparison, only 22% received corticosteroids in the ACT-2 trail and Il-6 antagonists were not allowed in either ACTT-2 or STOP-COVID. Thus, a redundant activity between different anti-inflammatory drugs is plausible.Additionally, the deterioration rate (less than 15% [11 out of 92]) and overall mortality (5% [4 out of 92]) observed in our study was significantly better than expected in a first wave of COVID-19. This could suggest an effectiveness of the control arm more than a poor performance of the experimental arm.Finally, though prior treatment with statins was a stratification factor, the presence of a component of the combination in the control arm itself determines a significant bias.Regarding the cytokine profiling analysis, several authors have classified COVID-19 patients in prognostic groups based on immunoprofiles defined with a variety of methods from multiplex cytokines to flow or mass cytometry, scRNAseq, and machine learning (As a whole, these studies confirm the interest in characterizing the immune response to predict the clinical course of COVID-19. Unfortunately, most results are far from a clinical application because of the high complexity of the methods, that are not available in most centers.In contrast, our strategy, taking into account not only the higher concentrations of predefined cytokines but also assessing the difference between up- and down-regulated cytokines, was able to reduce the number of determinations required for a reliable prediction. Since several pairs of cytokines reached an optimal threshold of accuracy, most clinical centers could use determinations already available at their institutions to implement this model. This is key in a global threat like COVID-19.Interestingly, there was no difference regarding cluster distribution between patients on ruxolitinib plus simvastatin or SOC. This result points to the notion than the extensive use of standard of care treatments, capable of altering the inflammatory state, could preclude the formal evaluation of the real therapeutic role of the experimental agents in our study.Regarding the decision tree, it has proven to accurately predict the appearance of biochemical alterations 24 hours and clinical deterioration 48 hours before occurring.This suggests a progressive deterioration of conditions, in which an alteration of the cytokine profile manifests after one day in an inflammatory process, with altered D-dimer and CRP, but with no impact yet in the blood oxygenation, which is only affected after two days.In summary, though the combination of ruxolitinib plus simvastatin did not show to be superior to standard of care in our study, design limitations like allowing statins in both arms or the better performance than expected of the control arm preclude a definitive conclusion.Several cytokines, assessed in pairs, classified COVID-19 patients into high- and low-risk groups. A decision tree predicted clinical deterioration 48 hours before occurring. Both tools could help to better tailor treatment for COVID-19 patients.