Drugs with mechanisms of action that reduce inflammation and cytokine storm in the lungs are being evaluated in patients with severe COVID-19 pneumonia. 
 
Corticosteroids
 
Three studies evaluating dexamethasone and hydrocortisone in the treatment of COVID-19 with acute respiratory failure were recently published in JAMA. All three studies (CAPE COVID, CoDEX, REMAP-CAP) are likely underpowered, because they were stopped early after results of the British RECOVERY trial (NCT04381936) demonstrated efficacy with dexamethasone in the treatment of hospitalized patients with COVID-19. The data from the three trials suggested a benefit with the use of corticosteroids in patients with COVID-19 and acute respiratory failure. To further examine the role of corticosteroids the World Health Organization (WHO) sponsored a meta-analysis of seven trials involving 1,700 critically ill COVID-19 patients. The analysis found the 28-day mortality rate lower with corticosteroids (32% vs. 40%) compared to not receiving corticosteroids. Based on the results of the trials and the meta-analysis, the WHO now recommends 6 mg of dexamethasone orally or intravenously daily or 50 mg of hydrocortisone intravenously every 8 hours for 7 to 10 days in severe and critical COVID-19 patients. The WHO also recommends that corticosteroids not be used in non-severe COVID-19 patients.
 
Dexamethasone
  • The 15,000 patient RECOVERY trial (NCT04381936) has several arms testing lopinavir-ritonavir, dexamethasone, hydroxychloroquine, azithromycin, tocilizumab, convalescent plasma, immunoglobulin (IVIG) and a monoclonal antibody combination REGN-COV2. A final version of the preliminary report of the dexamethasone arm of the RECOVERY trial was published in the New England Journal of Medicine. The results included 2,104 patients that received dexamethasone (6 mg for 10 days) compared to 4,321 patients that received supportive care only. Overall 28-day mortality was 22.9% with dexamethasone compared to 25.7% with placebo. The mortality rate for patients on ventilators was 29.3% with dexamethasone compared to 41.4% with supportive care only. Dexamethasone also had a lower mortality rate in patients requiring oxygen, but not on a ventilator (23.3% vs. 26.2%) but did not reduce mortality in patients not receiving respiratory support at enrollment (17.8% vs. 14.0%).
  • In a 28-day, 299 patient, Phase III, open-label, Brazilian CoDEX trial (NCT04327401), patients treated with dexamethasone had 2.6 fewer days requiring a ventilator compared to placebo in patients with COVID-19 and moderate to severe acute respiratory failure. Use of dexamethasone did not decrease mortality or ICU days. The CoDEX trial was stopped early, at the recommendation of the data and safety monitoring board (299 of the planned 350 patients), when the British RECOVERY trial (NCT04381936) demonstrated efficacy with dexamethasone. As part of standard of care, patients in CoDEX received hydroxychloroquine (24% in the dexamethasone group and 19% in the control group), azithromycin (69%, 74%), other antibiotics (88%, 86%) and oseltamivir (29%, 35%).
  • Based on the RECOVERY trial, the National Institute of Health recommends use of dexamethasone 6 mg daily for up to ten days in COVID-19 patients the require supplemental oxygen with or without mechanical ventilation. NIH recommends against using dexamethasone in patients that do not require supplemental oxygen.
  • The WHO recommends that dexamethasone only be used in patients with severe or critical disease.
  • Researchers at Montefiore Medical Center retrospectively reviewed the medical records of 1,806 hospitalized COVID-19 patients and found that glucocorticoids administered within 48 hours of admission was not associated with a decrease in mortality or mechanical ventilation. However, patients with a CRP of 20 mg/dL or greater had a reduced risk of mortality and mechanical ventilation, while use in patients with a CRP < 10 mg/dL was associated with an increased risk of mortality or mechanical ventilation.
  • NIH discontinued enrollment in the 29-day, Phase III, ACTT-4 trial (NCT04640168) after 1,000 patients when an interim analysis found it was unlikely that baricitinib plus remdesivir would reduce the need for mechanical ventilation or death compared to dexamethasone plus remdesivir in hospitalized COVID-19 patients on supplemental oxygen.
Hydrocortisone
  • In a 21-day, 148 patient, Phase III French, CAPE COVID trial (NCT02517489), treatment with hydrocortisone did not reduce mortality or the persistent need for ventilators/high flow oxygen compared to placebo (42.1% vs 50.7%) in critically ill patients with COVID-19 and acute respiratory failure. However, the trial was stopped early, due to the recommendation of the data and safety monitoring board (DSMB), so the trial was likely underpowered (149 patients of the planned 290). The DSMB recommended stopping the trial due to slowing in patient recruitment and the British RECOVERY trial (NCT04381936) demonstrating efficacy with dexamethasone. Patients in the trial were also treated with hydroxychloroquine (58% in the dexamethasone group and 64% in the control group), hydroxychloroquine plus azithromycin (30%, 38%), ritonavir plus lopinavir (13%, 15%), eculizimab (4%, 3%), remdesivir (3%, 4%) and toclizumab (1%, 3%).
  • The 21-day, 379 patient, Phase IV, open-label, international, REMAP-CAP trial (NCT02735707), found a 93% probability that a fixed 7-day course of hydrocortisone and an 80% probability that a shock-dependent course would reduce ICU-based respiratory or cardiovascular support compared placebo in critically ill patients with COVID-19 requiring ICU-based respiratory or cardiovascular support. The trial was stopped early, due to the recommendation of the blinded international trial steering committee, so the trial was likely underpowered (379 patients of the British RECOVERY trial (NCT04381936) RECOVERY trial demonstrating efficacy with dexamethasone. Data on concomitant drugs were not included in the published description of REMAP-CAP.
Methylprednisolone
  • In a 10-day, 86 patient, Iranian study, treatment with methylprednisolone 2 mg/kg/day improved the 9-point WHO ordinal scale (0 - uninfected to death 8) compared to dexamethasone 6 mg/day at five days (4.02 vs. 5.21) and 10 days (2.90 vs. 4.71) in hospitalized COVID-19 patients. Methylprednisolone also decreased the length of hospital stay (7.43 vs 10.52 days) and the need for mechanical ventilation (18.2% vs 38.1%). It should be noted the relative dose of methylprednisolone was higher than dexamethasone.
Budesonide
  • Interim data from the 2,422 patients enrolled in the 28-day, Phase III, PRINCIPLE trial, found that inhaled budesonide added to usual care decreased time to recovery by 3-days compared to usual care alone in outpatients with COVID-19.
  • In the 28-day, 146 patient, open-label, Phase III, STOIC trial (NCT04416399), 3% of patients treated with inhaled budesonide added to usual care required urgent care or hospitalization compared to 15% with usual care alone in outpatients with COVID-19. Clinical recovery was also one-day less with budesonide.
Interferon-beta
  • NIH currently recommends against the use of interferons for the treatment of severe and critical COVID-19, unless the patient is participating in a clinical trial. NIH does not recommend for or against the use of interferon in the treatment of mild and moderate COVID-19.
  • Subcutaneous interferon-beta-1a
    • Interim results from the WHO sponsored, 11,330 patient, Phase II/III SOLIDARITY trial (NCT04315948), did not find an improvement in hospitalized COVID-19 patients treated with remdesivir, hydroxychloroquine, lopinavir or subcutaneous interferon compared to no drug in mortality, initiation of ventilation or duration of hospital stay. But some analysts did not agree with the study’s findings. A physician reviewer speculated that remdesivir may be more effective when given early in the infection to patients at high risk for progression. An editorialist highlighted the benefit of remdesivir“to change the course of hospitalization in some patients”. A second editorialist pointed out that SOLIDARITY was not designed to measure time to recovery or clinical improvement
    • In a 28-day, 81 patient, Israeli trial, adding subcutaneous interferon beta 1a to hydroxychloroquine plus lopinavir/ritonavir or atazanavir/ritonavir did not decrease the time to clinical response, but did increase discharge rate on day 14 and decreased 28-day mortality, compared to not adding interferon in patients with severe COVID-19.
    • In an 89 patient trial in Oman, favipiravir and nebulized interferon beta-1b did not improve time to recovery, decrease in inflammatory markers nor improvement in oxygenations compared to hydroxychloroquine in hospitalized patients with moderate to severe COVID-19 pneumonia. Almost all patients also received antibiotics, one-third received tocilizumab, two-thirds received a corticosteroid and over half received convalescent plasma.
  • SNG001 is a nebulizer formulation of interferon-beta-1a. 
    • SNG001 is being evaluated as a potential treatment for COVID-19 because of data from two trials showing an improvement in lung function in patients with asthma and a respiratory viral infection.
    • In a 28-day, 101 patient, Phase II trial (NCT04385095), patients treated with nebulized interferon beta-1a were twice as likely to have improved their WHO Ordinal Scale for Clinical Improvement by day 15-16 and three times as likely by day 28 in hospitalized British patients with COVID-19.
    • Synairgen announced that in a 28-day, 120 patient, Phase II trial (NCT04385095), only two patients in the placebo group advanced to hospitalization compared to none in the nebulized interferon beta-1a group in high risk, British outpatients with COVID-19. Due to the low incidence of hospitalizations, prevention of progression to severe COVID-19 could not be calculated. An analysis of a small group of patients with severe breathlessness suggested that use of nebulized interferon beta-1a may help patients recover more quickly. When combining all patients who were markedly or severely breathless in both the home treatment cohort and hospital treatment cohort, treatment with nebulized interferon beta-1 increased the likelihood of recovery.
IL-6 Inhibitors

A meta-analysis, by the World Health Organization, of 27 trials involving 10,930 patients, evaluated IL-6 inhibitors in the treatment of COVID-19.  At 28-days the mortality risk in tocilizumab or sarilumab patients was 22% compared to 25% with usual care or placebo. The mortality benefit was maintained in patients receiving corticosteroids (21% vs 25%). The data supporting tocilizumab was more robust than sarilumab due to the larger patient population and the trials being conducted later in the pandemic, when use of corticosteroids became more common. There was not enough data (one trial) to estimate the effect of using siltuximab. Based on the data, the WHO now recommends that either tocilizumab or sarilumab be added to corticosteroids for the treatment of severe or critical COVID-19 infections.

NIH recommended adding tocilizumab to dexamethasone in hospitalized patients who are exhibiting rapid respiratory decompensation due to COVID-19, which includes patients within 24 hours of admission to the ICU that require invasive mechanical ventilation, noninvasive mechanical ventilation or high-flow nasal cannula oxygen, and non-ICU patients recently admitted to the hospital with a rapidly increasing need for oxygen that have significantly increased markers of inflammation. Some NIH Panel members would also recommend tocilizumab if patients exhibit rapidly increasing oxygen needs while receiving dexamethasone and have a C-reactive protein level of 75 mg/L or greater but who do not yet require noninvasive mechanical ventilation or high-flow nasal cannula oxygen.

IDSA has updated their COVID-19 guidelines with a conditional recommendation to add tocilizumab to a corticosteroid in patients with severe or critical COVID-19 with elevated systemic inflammation.

Tocilizumab (Actemra, Roche) is an interleukin 6 (IL-6) monoclonal antibody.
  • The FDA granted an EUA for tocilizumab (Actemra, Roche) to treat hospitalized adults and pediatric patients two years of age or older, with COVID-19 and who are receiving a systemic corticosteroid and require supplemental oxygen, invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO).
  • Italian clinicians described a reduction in COVID-19 pneumonia in two patients treated with tocilizumab. BARDA ceased funding IL-6 inhibitor trials evaluating tocilizumab and sarilumab as treatments for severe COVID-19 in August 2020. Tocilizumab and sarilumab have each failed to demonstrate improvements in clinical trials.
  • Chinese researchers announced that in a 21 patient, open-label trial, patients treated with tocilizumab had a reduction in fever and 15/20 patients had a reduction in their need for supplemental oxygen in hospitalized patients with a COVID-19 infection. 
  • Italian researchers announced that in a 123 patient trial, treatment with tocilizumab did not reduce admission to intensive care (28.3% vs. 27.0%) or 30-day mortality (3.3% vs. 3.2%) compared to placebo in patients with early-stage COVID-19 pneumonia.
  • In a 544 patient, retrospective Italian study, treatment with tocilizumab reduced the risk of mechanical ventilation or death, but had a higher incidence of new infections compared to standard of care alone after the patient sample was adjusted for sex, age, recruiting center, duration of symptoms, and Sequential Organ Failure Assessment (SOFA) score. Standard of care in Italy at the time of the study (February 21 to April 30, 2020) included treatment with oxygen, hydroxychloroquine, azithromycin, lopinavir–ritonavir or darunavir–cobicistat, and low molecular weight heparin.
  • In an observational trial, University of Michigan researchers examined outcomes in 154 mechanically ventilated patients with severe COVID-19 that received tocilizumab to those not receiving tocilizumab. Around a quarter of patients in each group received hydroxychloroquine and/or a corticosteroid and 3% received remdesivir. Patients that received tocilizumab were younger (55 vs. 60), less likely to have chronic pulmonary disease (10% vs. 28%), and lower D-dimer values (2.4 vs. 6.5 mg/dL). During a 47-day follow-up, tocilizumab patients had a higher rate of superinfections (54% vs. 26%), but a lower 28-day mortality rate (18% vs. 36%).
  • In the 28-day, 452 patient, Phase III COVACTA trial (NCT04320615), treatment with tocilizumab improved the clinical status (7 point scale ranging from discharge or death) by a non-significant 1 point compared to placebo in hospitalized patients with severe COVID-19-associated pneumonia. There was no difference in mortality between tocilizumab and placebo, but patients treated with tocilizumab were discharged six days sooner, spent 5.8 less days in ICU and needed a ventilator for 5.5 fewer days.
  • In the 28-day, 389 patient, Phase III EMPACTA trial (NCT04372186), 12% of patients treated with tocilizumab progressed to mechanical ventilation or death compared to 19.3% of patients treated with placebo in hospitalized patients with COVID-19 who did not require noninvasive or invasive mechanical ventilation. Almost 85% of patients were non-white with the majority being Hispanic, with inclusion of Native American and Black populations.
  • In a 126 patient, Phase II, Italian trial (NCT04346355), treatment with tocilizumab did not reduce intensive care admission with invasive mechanical ventilation, death from all causes, or clinical aggravation compared to placebo in patients with early-stage COVID-19 pneumonia.
  • In a 131 patient, Phase II, French trial (NCT04331808), treatment with tocilizumab did not improve clinical progression at day 4, but did reduce death or the need for high-flow oxygen or ventilation at day 14 (24% vs. 36%) compared to placebo in patients with moderate-to-severe COVID-19 pneumonia.
  • A 3,924 patient retrospective U.S. analysis found a lower risk for death in 433 patients that received tocilizumab compared with those not treated with tocilizumab in critically ill COVID-19 patients.
  • In a 243 patient, Phase III, U.S. trial (NCT04356937), treatment with tocilizumab did not reduce intubation or death compared to placebo in patients with severe COVID-19.
  • In the 15-day, 129 patient, Phase III, TOCIBRAS trial (NCT04403685), treatment with tocilizumab did not reduce a composite of death or mechanical ventilation (28% vs 20%) compared to placebo in patients with COVID-19 who were receiving supplemental oxygen or mechanical ventilation and had abnormal levels of at least two serum biomarkers (C reactive protein, D dimer, lactate dehydrogenase, or ferritin). At 15-days, mortality was higher with tocilizumab compared to placebo (17% vs 3%), but the difference was no longer significant at day 29.
  • BARDA ceased funding IL-6 inhibitor trials evaluating tocilizumab and sarilumab as treatments for severe COVID-19 in August 2020. Tocilizumab and sarilumab have each failed to demonstrate improvements in clinical trials.
  • In the 21-day, 803 patient, Phase IV, REMAP-COVID trial (NCT02735707), the number of organ support-free days were 10 for tocilizumab, 11 for sarilumab and none for standard of care in patients with critical COVID-19 receiving organ support in intensive care. In-hospital mortality was 27% with the pooled interleukin-6 receptor antagonist groups (tocilizumab and sarilumab), compared to 36% with standard of care. A third of patients received remdesivir and 80% received a corticosteroid. REMAP-COVID is a sub-study of the REMAP-CAP trial.
  • In the 28-day, 4,116 patient, Phase III, DISCOVERY trial (NCT04381936), adding tocilizumab to usual care resulted in 31% mortality compared to 35% with usual care alone in hospitalized adults with COVID-19 with oxygen saturation < 92% or requiring oxygen therapy and C-reactive protein of 75 mg/L or >. Corticosteroids were used in 82% of the study population.
  • Roche announced that in the 28-day, 450 patient, Phase III REMDACTA trial (NCT04409262), adding tocilizumab to remdesivir did not decrease time to hospital discharge compared to remdesivir alone in patient with severe COVID-19. The addition of tocilizumab also did not improve clinical status, decrease mortality, or decrease the need for mechanical ventilation.
Sarilumab (Kevzara, Regeneron, Sanofi) is an interleukin 6 (IL-6) monoclonal antibody. 
  • Sanofi and Regeneron discontinued a Phase III trial, when an interim analysis of 194 patients revealed that treatment with sarilumab did not improve the percentage of patients who achieved at least a 1-point change from baseline on a 7-point scale (death to hospital discharge) compared to placebo in COVID-19 patients requiring mechanical ventilation.
  • In a 28-day, 56-patient, observational study, 28 patients that received sarilumab were compared to 28 that did not receive the drug. Treatment with sarilumab did not improve clinical status or mortality in patients with severe COVID-19 pneumonia and systemic hyperinflammation. The study suggested that sarilumab may speed recovery in patients with minor lung consolidation at baseline. This study used a subset of patients from the Italian, 1,000 patient, COVID-BioB observational study (NCT04318366).
  • Sanofi announced that in a non-U.S., 420 patient, Phase III trial (NCT04327388), treatment with sarilumab did not improve symptoms compared to placebo in hospitalized patients with severe or critical COVID-19. 
  • BARDA ceased funding IL-6 inhibitor trials evaluating tocilizumab and sarilumab as treatments for severe COVID-19 in August 2020. Tocilizumab and sarilumab have each failed to demonstrate improvements in clinical trials.
  • Sanofi and Regeneron ceased evaluation of sarilumab in the treatment of COVID-19 in September 2020.
  • In the 21-day, 803 patient, Phase IV, REMAP-COVID trial (NCT02735707), the number of organ support-free days were 10 for tocilizumab, 11 for sarilumab and none for standard of care in patients with critical COVID-19 receiving organ support in intensive care. In-hospital mortality was 27% with the pooled interleukin-6 receptor antagonist groups (tocilizumab and sarilumab), compared to 36% with standard of care. A third of patients received remdesivir and 80% received a corticosteroid. REMAP-COVID is a sub-study of the REMAP-CAP trial.
Siltuximab (Sylvant, EUSA Pharma) is an interleukin 6 (IL-6) monoclonal antibody. The drug is being evaluated in the Italian SISCO trial sponsored by EUSA. 
  • Sanofi and Regeneron discontinued a Phase III trial when an interim analysis of 194 patients revealed that treatment with sarilumab did not improve the percentage of patients who achieved at least a 1-point change from baseline on a 7-point scale (death to hospital discharge) compared to placebo in COVID-19 patients requiring mechanical ventilation. 
  • As of early July 2020, a Sanofi study evaluating sarilumab in the treatment of severe and critical COVID-19 remained active after an interim analysis. 
Aspirin: In a retrospective review of data from 412 hospitalized patients with COVID-19, 36% of patients receiving aspirin progressed to mechanical ventilation compared to 48% that did not receive aspirin. A multivariable adjustment found a 44% reduced risk for mechanical ventilation with aspirin without an increased risk for major bleeding.

Baricitinib (Olumiant, Lilly), a JAK1 and JAK2 inhibitor. It is theorized that JAK inhibition may reduce cytokine storm associated with COVID-19 infection and decrease viral reproduction. 
  • Lilly is evaluating the effect of baricitinib on mortality or the need for ventilation/high flow oxygen in the 28-day, 400 patient, Phase III, COV-BARRIER trial (NCT04421027).
  • In the NIAID sponsored 29-day, 1,033 patient, Phase III, ACTT 2 trial (NCT04401579), baricitinib added to remdesivir reduced the time to recovery by one day (7 vs 8 days) compared to remdesivir alone in hospitalized patients with moderate to severe COVID-19. The largest effect was seen in patients receiving high-flow oxygen or non-invasive ventilation (10 vs 18 days).
  • Lilly announced that in the 1,525 patient, Phase III, COV-BARRIER trial (NCT04421027), adding baricitinib to standard of care did not decrease the need for ventilation (non-invasive or mechanical) or death compared to standard of care alone in hospitalized patients with COVID-19.
  • The FDA granted an EUA for the combination of baricitinib (Olumiant. Lilly) plus remdesivir (Veklury, Gilead) to treat hospitalized adults and pediatric patients two years of age or older, with COVID-19 and who require supplemental oxygen, invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO).
  • NIH discontinued enrollment in the 29-day, Phase III, ACTT-4 trial (NCT04640168) after 1,000 patients when an interim analysis found it was unlikely that baricitinib plus remdesivir would reduce the need for mechanical ventilation or death compared to dexamethasone plus remdesivir in hospitalized COVID-19 patients on supplemental oxygen.
  • NIH did not find enough evidence to recommend for or against use of baricitinib in combination with remdesivir for the treatment of hospitalized patients in cases where corticosteroids can be used instead. If corticosteroids cannot be used NIH recommends use of baricitinib plus remdesivir in hospitalized, nonintubated patients who require oxygen supplementation. NIH found insufficient evidence to support the use of baricitinib in patients already receiving corticosteroids. Except for clinical trials, NIH does not recommend the use of baricitinib without remdesivir.
Bisindole (VERU-111) binds to and crosslinks the alpha and beta tubulin subunits of microtubules and intermediate filaments of cells resulting in disruption of the cytoskeleton. Veru is developing bisindole for the treatment of castration resistant prostate cancer and triple negative breast cancer. Veru is evaluating bisindole as a treatment for COVID-19 because of antiviral and anti-inflammatory effects.
  • Due to its direct effects on S protein-microtubule trafficking, bisindole may decrease viron production and virus replication. Bisindole is also an anti-inflammatory agent and may reduce virally induced severe inflammation and cytokine storm. 
  • Veru announced that in a 38 patient, Phase II trial (NCT04388826), a 21-day treatment with bisindole resulted in 94.4% of patients being alive without respiratory failure at Day 29 compared to 70% with placebo in hospitalized COVID-19 patients at high risk for developing Acute Respiratory Distress Syndrome (ARDS).
Canakinumab (Ilaris,Novartis) is an interleukin-1 beta monoclonal antibody approved as a treatment for  auto-inflammatory periodic fever syndromes. systemic juvenile idiopathic arthritis and Still's disease. 
  • Novartis announced interim data from the 29-day, 454 patient, CAN-COVID trial (NCT04362813), where treatment with canakinumab did not decrease mortality without the need for invasive mechanical ventilation, compared with placebo in hospitalized patients with COVID-19 pneumonia and cytokine release syndrome.
CM4620-IE is a CRAC channel inhibitor that may prevent cytokine storm in severe COVID-19 pneumonia is being developed by CalciMedica and evaluated in a Phase II trial. Colchicine: The 15,000 patient RECOVERY trial (NCT04381936) has several arms testing lopinavir-ritonavir, dexamethasone, hydroxychloroquine, azithromycin, tocilizumab, convalescent plasma, immunoglobulin (IVIG), the monoclonal antibody combination REGN-COV2, aspirin, baricitinib, and colchicine. British researchers discontinued enrollment in the colchicine arm of the trial, when the independent Data Monitoring Committee did not find a reduction in 28-day mortality (20% colchicine vs 19% usual care alone).
  • NIH has determined there is not enough evidence to recommend for or against the use of colchicine to treat COVID-19 in non-hospitalized patients and colchicine should not be used in hospitalized patients, except as part of a trial.
  • In the 30-day, 4,488 patient, Phase III, COLCORONA trial (NCT04322682), treatment with colchicine did not reduce hospitalizations or mortality compared to placebo in outpatients with COVID-19 diagnosed by PCR testing or clinical criteria, who were at least 40 years old and had at least one risk factor for more severe disease. Among the 4,159 patients with PCR confirmed infection there was a small benefit with colchicine with 4.6% of patients requiring hospitalization or dying compared to 6% with placebo.
Emricasan is a pan-caspase inhibitor being developed by Histogen for the treatment of nonalcoholic steatohepatitis. Because of emricasan ability to reduce inflammation, Histogen is evaluating the drug for the treatment of COVID-19. 
  • Histogen announced that in a 45-day, 13 patient, Phase I trial (NCT04803227), treatment with emricasan resulted in complete resolution of symptoms by day seven compared to no resolution in the placebo arm in patients with mild symptomatic COVID-19.
Fluvoxamine, a selective serotonin reuptake inhibitor and sigma-1 receptor (S1R) agonist, approved for the treatment of obsessive-compulsive disorder, is being evaluated for the treatment of COVID-19. Inhibiting S1R decreases cytokine production through its interaction with the endoplasmic reticulum stress sensor inositol-requiring enzyme 1alpha (IRE1). The decrease in cytokines reduces the inflammatory response, which diminishes progression of COVID-19.
  • In a 15-day, 152 patient, Phase II trial (NCT04342663), no patient treated with fluvoxamine experienced clinical deterioration (shortness of breath or oxygen saturation of 92% or less) compared to 8.7% with placebo in nonhospitalized patients with severe acute respiratory syndrome from COVID-19. Patients were mostly white and over half were female with a median age of 45 to 46.
  • In a 14-day, 113 patient, non-randomized, Phase III trial (NCT04668950), no patient treated with fluvoxamine required hospitalization compared to 12.5% of observation patients with COVID-19. At day 14, no fluvoxamine patient continued to have symptoms compared to 60% of observation patients. The patient population was mostly male Latinos with a median age of 42 recruited from an occupational setting with congregate living at a horse racing track in California. Fewer patients that chose to receive fluvoxamine were asymptomatic (38% vs 58%) at the beginning of the study.​
  • NIH has determined there is not enough evidence to recommend for or against the use of fluvoxamine to treat COVID-19.
Lenzilumab is a GM-CSF monoclonal antibody being developed to suppress the cytokine storm seen in graft-versus-host disease and with CAR-T cancer therapies. Because of lenzilumab effect on decreasing cytokine storm, Humanigen is evaluating the drug as a treatment for severe COVID-19 pneumonia. 
  • An unpublished, unedited article described 12 patients with severe COVID-19 pneumonia treated under an FDA emergency IND with lenzilumab. Treatment with lenzilumab resulted in at least a 2-point improvement in an 8-point scale (death to discharged) in 11/12 of patients. 
  • NIAID is comparing lenzilumab plus remdesivir to remdesivir monotherapy on the need for mechanical ventilation in hospitalized patients with COVID-19, in the 28-day, 200 patient, BIG EFFECT trial (NCT04583969).
  • In a pre-publication draft of the 28-day, 520 patient, Phase III, LIVE-AIR trial (NCT04351152), treatment with Humanigen’s lenzilumab improved ventilator-free survival by 54% in the mITT population and by 90% in the ITT population compared to placebo in hospitalized hypoxic COVID-19 patients not requiring invasive mechanical ventilation. In the trial, 93.7% of patients received a corticosteroid, 72.4% received remdesivir, and 69.1% received both. Ventilator-free survival was improved by 92% in patients where lenzilumab was added to both corticosteroids and remdesivir.
  • Humanigen requested an Emergency Use Authorization (EUA) for lenzilumab for the treatment of patients hospitalized with COVID-19, based on results from the LIVE-AIR trial
Mavrilimumab is a granulocyte macrophage colony stimulating factor antagonist and is being developed by MedImmune as a treatment for rheumatoid arthritis. By inhibiting GM-CSK, mavrilimumab is thought to prevent the activation or amplification of several pro-inflammatory cytokine pathways leading to a reduction in inflammation caused by cytokine storm in severe COVID-19 pneumonia.
  • In a 28-day, 39 patient trial, all patients treated with mavrilimumab (n=13) plus hydroxychloroquine, azithromycin and lopinavir–ritonavir improved by two or more points (7-point scale of death to discharge) compared to 65% treated with hydroxychloroquine, azithromycin and lopinavir–ritonavir without mavrilimumab (n=26) in non-ventilated patients COVID-19 pneumonia and systemic hyperinflammation.
  • Kiniksa Pharmaceuticals is evaluating mavrilimumab in the treatment of severe COVID-19 pneumonia and systemic hyperinflammation in a 15-day, 573 patient, Phase II/III trial (NCT04447469).​
  • In a 14-day, 39 patient, Phase II trial (NCT04399980, NCT04463004, and NCT04492514), treatment with mavrilimumab (n=21) did not decrease morbidity or the need for supplemental oxygen compared to placebo (n=19) in non-ventilated hospitalized COVID-19 patients with hypoxemia, and a C-reactive protein concentration of 5 mg/dL or greater.
PhaseBio is evaluating PB1046 as a treatment for hospitalized COVID-19 patients at risk for clinical deterioration and acute respiratory distress syndrome (ARDS) in the 210 patient, Phase II, VANGARD trial. The trial is expected to begin at the end of June with results from the trial expected by the end of 2020. PB1046 is an investigational vasoactive intestinal peptide (VPAC2) receptor-selective agonist being developed by PhaseBio as a treatment of pulmonary arterial hypertension.

PTC299, a dihydroorotate dehydrogenase (DHODH) inhibitor that is being developed by PTC Therapeutics as a treatment for acute myeloid leukemia. PTC299 has been shown in vitro to inhibit replication of the SARS-CoV-2 virus and modulate the immune response by attenuating the stress-induced inflammatory cytokine storm.
  • The effect of PTC299 on respiratory symptoms is being evaluated in a 40 patient Phase II trial, followed by a 340 patient Phase III trial.
Remestemcel-L is a Mesenchymal Precursor Cell (Stem cell therapy) being developed by Mesoblast for the treatment of Acute Graft Versus Host Disease following allogeneic bone marrow transplantation. Remestemcel-L decreases pro-inflammatory cytokines, increases anti-inflammatory cytokines, and increases recruitment of naturally occurring anti- inflammatory cells to involved tissues. Due to these properties, Mesoblast is evaluating remestemcel-L to reduce cytokine storm in acute respiratory distress syndrome (ARDS) due to COVID-19 infection. 
  • The FDA granted remestemcel-L, a Fast Track designation for the treatment of acute respiratory distress syndrome (ARDS) due to COVID-19 infection.
  • Mesoblast announced that in a 60-day, 222 patient, Phase III trial (NCT04371393), treatment with remestemcel-L added to standard of care (SOC) did not reduce all-cause mortality compared to SOC in ventilator-dependent patients with moderate to severe acute respiratory distress syndrome (ARDS) due to COVID-19. In a pre-specified analysis of 123 patients under age 65, remestemcel-L reduced mortality by 46% by day 60, but not in 94 patients 65 or older. The Data Safety Monitoring Board (DSMB) recommended the trial be stopped when an interim analysis of 30-day data for 180 patients found it unlikely the trial would achieve a 43% reduction in mortality at the target enrollment of 300 patients. The DSMB recommended the trial be completed with the 222 patients already enrolled. 
Tofacitinib (Xeljanz, Pfizer) is a JAK1 and JAK3 inhibitor with partial JAK2 inhibition. It is theorized that JAK inhibition may reduce cytokine storm associated with COVID-19 infection and decrease viral reproduction. 
  • In the 28-day, 289 patient, Phase III, STOP-COVID trial (NCT04469114), 18.1% of patients treated with tofacitinib plus standard of care required ventilation or died compared to 29% with standard of care alone in hospitalized Brazilian patients with COVID-19. Mortality was 2.8% with tofacitinib and 5.5% with placebo.
Tradipitant is a neurokinin-1 receptor (NK-1R) antagonist being developed by Vanda Pharmaceuticals for the treatment of diabetic gastroparesis, motion sickness, and atopic dermatitis. By inhibiting NK-1R, tradipitant is thought to decrease inflammatory lung injury associated with severe or critical COVID-19 pneumonia.
  • Vanda Pharmaceuticals reported that interim results from 60 COVID-19 patients enrolled in the 28-day, 300 patient, Phase III, ODYSSEY trial (NCT04326426), where a 14-day treatment with tradipitant reduced the time to improvement after 7-days compared to placebo. Despite a numerical advantage, the improvement was not significant at 28 days (10 days vs 28 days), likely due to the small number of patients. There was also no statistical difference between tradipitant and placebo in the overall percentage of patients improving (57% vs 50%) or mortality (14.2% vs 16.6%).
​NIH will evaluate the effect of three anti-inflammatories on suppressing cytokine storm in COVID-19 patients in the 2,100 Patient, Phase III ACTIV-1 IM trial. The drugs that will be used in ACTIV-1 IM include TNF blocker, infliximab (Remicade, J&J); the CTLA-4 immunoglobulin, abatacept (Orencia, BMS); and the investigational CCR2/CCR5 agonist cenicriviroc (AbbVie).