Convalescent plasma in patients admitted to hospital with COVID-19 (RECOVERY): a randomised controlled, open-label, platform trial

SummaryBackground Azithromycin has been proposed as a treatment for COVID-19 on the basis of its immunomodulatoryactions. We aimed to evaluate the safety and efficacy of azithromycin in patients admitted to hospital with COVID-19.Methods In this randomised, controlled, open-label, adaptive platform trial (Randomised Evaluation of COVID-19Therapy [RECOVERY]), several possible treatments were compared with usual care in patients admitted to hospitalwith COVID-19 in the UK. The trial is underway at 176 hospitals in the UK. Eligible and consenting patients wererandomly allocated to either usual standard of care alone or usual standard of care plus azithromycin 500 mg once perday by mouth or intravenously for 10 days or until discharge (or allocation to one of the other RECOVERY treatmentgroups). Patients were assigned via web-based simple (unstratified) randomisation with allocation concealment andwere twice as likely to be randomly assigned to usual care than to any of the active treatment groups. Participants andlocal study staff were not masked to the allocated treatment, but all others involved in the trial were masked to theoutcome data during the trial. The primary outcome was 28-day all-cause mortality, assessed in the intention-to-treatpopulation. The trial is registered with ISRCTN, 50189673, and ClinicalTrials.gov, NCT04381936.Findings Between April 7 and Nov 27, 2020, of 16 442 patients enrolled in the RECOVERY trial, 9433 (57%) wereeligible and 7763 were included in the assessment of azithromycin. The mean age of these study participants was65·3 years (SD 15·7) and approximately a third were women (2944 [38%] of 7763). 2582 patients were randomlyallocated to receive azithromycin and 5181 patients were randomly allocated to usual care alone. Overall,561 (22%) patients allocated to azithromycin and 1162 (22%) patients allocated to usual care died within 28 days(rate ratio 0·97, 95% CI 0·87–1·07; p=0·50). No significant difference was seen in duration of hospital stay (median10 days [IQR 5 to >28] vs 11 days [5 to >28]) or the proportion of patients discharged from hospital alive within 28 days(rate ratio 1·04, 95% CI 0·98–1·10; p=0·19). Among those not on invasive mechanical ventilation at baseline, nosignificant difference was seen in the proportion meeting the composite endpoint of invasive mechanical ventilationor death (risk ratio 0·95, 95% CI 0·87–1·03; p=0·24).Interpretation In patients admitted to hospital with COVID-19, azithromycin did not improve survival or otherprespecified clinical outcomes. Azithromycin use in patients admitted to hospital with COVID-19 should be restrictedto patients in whom there is a clear antimicrobial indication

Effect of ISO-1 and dexamethasone on ozone-induced changes in AHR and lung function.

<p>Mouse lung function measurements of pulmonary resistance (R_L; A), -logPC₁₀₀ (B), FEV₇₅ (C), lung compliance (C_chord; D), total lung capacity (TLC; E) and functional residual capacity (FRC; F). Data are expressed as mean±SD for 6 animals per group. *<i>p</i><0.05 and **<i>p</i><0.01 compared to air controls, ^#<i>p</i><0.05 compared to ozone-exposed group.</p

Effect of ISO-1 and dexamethasone on ozone-induced lung inflammation.

<p>Cytokine mRNA (A, C, E & G) and protein (B, D, F & H) expression levels in the lung of ozone exposed and ISO-1- or dexamethasone-treated mice. KC (A&B), GM-CSF (C&D), TNF-α (E&F), and MIF (G&H). Data are expressed as mean±SD for 6 animals per group. *<i>p</i><0.05 and **<i>p</i><0.01 compared to air controls, ^#<i>p</i><0.05 compared to ozone exposed group.</p

Sputum transcriptomics reveal upregulation of IL-1 receptor family members in patients with severe asthma

Background: Sputum analysis in asthmatic patients is used to define airway inflammatory processes and might guide therapy. Objective: We sought to determine differential gene and protein expression in sputum samples from patients with severe asthma (SA) compared with nonsmoking patients with mild/moderate asthma. Methods: Induced sputum was obtained from nonsmoking patients with SA, smokers/ex-smokers with severe asthma, nonsmoking patients with mild/moderate asthma (MMAs), and healthy nonsmoking control subjects. Differential cell counts, microarray analysis of cell pellets, and SOMAscan analysis of sputum analytes were performed. CRID3 was used to inhibit the inflammasome in a mouse model of SA. Results: Eosinophilic and mixed neutrophilic/eosinophilic inflammation were more prevalent in patients with SA compared with MMAs. Forty-two genes probes were upregulated (&gt;2-fold) in nonsmoking patients with severe asthma compared with MMAs, including IL-1 receptor (IL-1R) family and nucleotide-binding oligomerization domain, leucine-rich repeat and pyrin domain containing 3 (NRLP3) inflammasome members (false discovery rate &lt; 0.05). The inflammasome proteins nucleotide-binding oligomerization domain, leucine rich repeat and pyrin domain containing 1 (NLRP1), NLRP3, and nucleotide-binding oligomerization domain (NOD)-like receptor C4 (NLRC4) were associated with neutrophilic asthma and with sputum IL-1β protein levels, whereas eosinophilic asthma was associated with an IL-13–induced TH2 signature and IL-1 receptor–like 1 (IL1RL1) mRNA expression. These differences were sputum specific because no activation of NLRP3 or enrichment of IL-1R family genes in bronchial brushings or biopsy specimens in patients with SA was observed. Expression of NLRP3 and of the IL-1R family genes was validated in the Airway Disease Endotyping for Personalized Therapeutics cohort. Inflammasome inhibition using CRID3 prevented airway hyperresponsiveness and airway inflammation (both neutrophilia and eosinophilia) in a mouse model of severe allergic asthma. Conclusion: IL1RL1 gene expression is associated with eosinophilic SA, whereas NLRP3 inflammasome expression is highest in patients with neutrophilic SA. TH2-driven eosinophilic inflammation and neutrophil-associated inflammasome activation might represent interacting pathways in patients with SA.</p

Effect of ISO-1 and dexamethasone on ozone-induced BAL inflammation.

<p>Cytokine protein levels in mouse BAL of ozone exposed and ISO-1- or dexamethasone-treated mice measured by ELISA. KC (A), GM-CSF (B), TNF-α (C) and MIF (D). Data are expressed as mean±SD for 6 animals per group. *<i>p</i><0.05 and **<i>p</i><0.01 compared to air controls, # <i>p</i><0.05 compared to ozone exposed group.</p

Effect of ISO-1 and dexamethasone in combination on ozone-induced lung inflammation.

<p>Cytokine mRNA (A & C) and protein (B & D) expression levels in the lung of ozone exposed and the combination of ISO-1- plus dexamethasone-treated mice. KC (A&B) and MIF (C&D). Pulmonary resistance (R_L; E) was also measured. Data are expressed as mean±SD for 6 animals per group. *<i>p</i><0.05 and **<i>p</i><0.01 compared to air controls, ^#<i>p</i><0.05 compared to ozone exposed group.</p