Patent Application
20230201308
The official copy of the sequence listing is submitted electronically via Patent Center as an XML formatted sequence listing with a file named 1339169_seqlist.xml, created on Aug. 11, 2022, and having a size of 16.6 KB, and is filed concurrently with the specification. The sequence listing contained in this xml formatted document is part of the specification and is herein incorporated by reference in its entirety.
The present disclosure provides methods for treating coronavirus virus infection, including the 2019-nCoV virus infection (SARS-CoV-2), and so relates to the fields of chemistry, medicinal chemistry, medicine, molecular biology, and pharmacology.
Coronaviruses (CoV) are a large family of viruses that cause illness ranging from the common cold to more severe diseases such as Middle East Respiratory Syndrome (MERS-CoV) and Severe Acute Respiratory Syndrome (SARS-CoV). Coronaviruses are zoonotic, meaning they are transmitted between animals and people. For example, detailed investigations found that SARS-CoV was transmitted from civet cats to humans and MERS-CoV from dromedary camels to humans. Several known coronaviruses are circulating in animals that have not yet infected humans.
A novel coronavirus (nCoV) is a new strain that has not been previously identified in humans, for example, SARS-CoV-2. SARS-CoV-2 is a novel coronavirus that has led to a global pandemic due to its relatively high transmissibility and potential to cause severe acute respiratory disease. See Huang C et al. “Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China,” Lancet 02 2020; 395(10223):497-506. doi:10.1016/50140-6736(20)30183-5. Common signs of infection include respiratory symptoms, fever, cough, shortness of breath, breathing difficulties, gastrointestinal symptoms, and covid-toes. In more severe cases, infection can cause pneumonia, severe acute respiratory syndrome, kidney failure and even death. Higher morbidity and mortality rates have been consistently observed in older human populations throughout the COVID-19 pandemic. Additionally, SARS-CoV-2 shows higher morbidity and mortality rates in individuals having cancer, chronic kidney disease, chronic obstructive pulmonary disease, Down Syndrome, heart conditions (such as heart failure, coronary artery disease, or cardiomyopathies), an immunocompromised state from solid organ transplant, obesity (including severe obesity), pregnancy, sickle cell disease, smoking, or Type 2 diabetes mellitus.
To date, there are only a few therapies for treatment of COVID-19 infection in outpatients that have been approved on an Emergency Use Authoriziation basis in the United States. These include Paxlovid™ (nirmatrelvir co-packaged with ritonavir), Veklury (remdesivir), Lagevrio (molnupiravir), and bebtelovimab. Several vaccines have also been developed and are at various stages of approval globally. As the pandemic has progressed, variants of SARS-CoV-2 have emerged, with varying succeptibility to vaccination and treatment. Thus, there continues to be an ongoing need for agents to treat Coronavirus infection, including novel forms that are zoonotic and have begun to infect humans, such as SARS-CoV-2, in both vaccinated and unvaccinated patients.
Interferon lambda signals through the interferon lambda receptors that have a restricted cellular expression pattern. Interferon lambda also exhibits distinct antiviral activities from interferon alpha, due in part to the differences in expression of the interferon receptors. In one aspect, methods of treating a coronavirus infection in a human subject are provided. In some embodiments, the method comprises subcutaneously administering to the subject a therapeutically effective amount of pegylated interferon lambda-1a (lambda). In some instances, the pegylated interferon lambda is administered once a week. In some instances, the pegylated interferon lambda is administered twice per week.
In some embodiments, the method comprises administering the pegylated interferon lambda for a first treatment period and a second treatment period. In some embodiments, the method comprises administering the pegylated interferon lambda for a first treatment period, a second treatment period, and a third treatment period. In some embodiments, the first treatment period is longer than the second treatment period. In some embodiments, the second treatment period is longer than the first treatment period. In some embodiments, the first treatment period and the second treatment period are the same length of time.
In some embodiments, the pegylated interferon lambda-1a is administered at a dose of 180 micrograms once a week (QW). In some embodiments, the pegylated interferon lambda-1a is administered at a dose of 120 micrograms QW. In some embodiments (i) 160-180 micrograms pegylated interferon lambda-1a is administered per week for a first treatment period and then 150-170 micrograms per week for a second treatment period; or (ii) 180 micrograms per week for a first treatment period and then between 120-170 micrograms per week for a second treatment period, wherein the doses for each of (i) and (ii) may be divided into more than one dose per week.
In some embodiments, the method comprises administering the pegylated interferon lambda-1a at a dose of 180 micrograms QW for a first treatment period and then at a dose of 120 micrograms QW for a second treatment period. In some embodiments, the method comprises administering the pegylated interferon lambda-1a at a dose of 120 micrograms QW for a first treatment period and then at a dose of 80 micrograms QW for a second treatment period. In some embodiments, the method further comprises administering the pegylated interferon lambda-1a at a dose of 80 micrograms QW for a third treatment period. In some embodiments, the method comprises administering the pegylated interferon lambda-1a at a dose of 180 micrograms QW for a first treatment period and then at a dose of 120 micrograms QW for a second treatment period followed by administering a dose of 60-110 micrograms QW for a third treatment period.
In some embodiments, the method comprises administering the pegylated interferon lambda-1a at a first dose of 180 micrograms QW for a first treatment period, at a second dose of 120 micrograms QW for a second treatment period, and at a third dose of 80-110 micrograms QW for a third treatment period.
In some embodiments, the symptoms of coronavirus infection include one or more of: pneumonia (e.g., lungs inflamed and the tiny sacs where oxygen moves from the air to the blood were filling with water), fever, cough, shortness of breath, and muscle ache. Other symptoms may include confusion, headache, and sore throat.
In some embodiments, treatment results in a reduction of coronavirus viral load in the subject of at least 2.0 log10 coronavirus RNA copies/mL serum. In some embodiments, treatment results in a coronavirus viral load that is below the level of detection. In some embodiments, prior to the onset of treatment, the subject has a serum alanine aminotransferase (ALT) level that is above the upper limit of normal (ULN), and the course of treatment results in an improvement in serum ALT level in the subject to a level that is below the ULN.
In some embodiments, prior to treatment, the subject has a baseline viral load of up to about 104 coronavirus RNA copies per mL sample.
In some embodiments, subjects having a low viral load have a higher percentage of BLQ response at 1 week and at 2 weeks post treatment. In some embodiments, subjects having a high viral load have a higher percentage of BLQ response at 1 week and at 2 weeks post treatment.
In one embodiment, the interferon lambda 180 μg treatment group, response rates differed between subjects with high (>6 logs) versus low (≤6 logs) baseline viral load. In one embodiment, at week 48, 38-43% and 33-40% of subjects with high versus low baseline viral loads respectively, reached coronavirus RNA levels BLQ.
In some embodiments, provided is a method of treating a coronavirus infection in a subject in which the subject is infected with a coronavirus of unknown variant identity, the method comprising subcutaneously administering to the subject a therapeutically effective amount of interferon lambda, optionally, pegylated interferon lambda-1a, until one or more of: a sustained reduction of coronavirus viral load is reached, a decrease in coronavirus RNA to undetectable levels is reached, a decrease in a rate or an amount of viral shedding is reached, or an improvement in the subject's symptoms is reached.
In some embodiments, provided is method of treating a coronavirus infection in a subject that is infected with a SARS-CoV-2 omicron variant virus, the method comprising subcutaneously administering to the subject a therapeutically effective amount of interferon lambda, optionally, pegylated interferon lambda-1a, until one or more of: a sustained reduction of coronavirus viral load is reached, a decrease in coronavirus RNA to undetectable levels is reached, a decrease in a rate or an amount of viral shedding is reached, or an improvement in the subject's symptoms is reached.
In some embodiments, provided is method of treating a second coronavirus infection in a subject, the method comprising subcutaneously administering to the subject a therapeutically effective amount of interferon lambda, optionally, pegylated interferon lambda-1a, until one or more of: a sustained reduction of coronavirus viral load is reached, a decrease in coronavirus RNA to undetectable levels is reached, a decrease in a rate or an amount of viral shedding is reached, or an improvement in the subject's symptoms is reached, wherein the subject has previously experienced a first coronavirus infection and had resolution of symptoms and/or reduction of coronavirus viral load to undetectable levels prior to the second coronavirus infection.
In some embodiments, provided is method of treating post-COVID symptoms in a subject, the method comprising subcutaneously administering to the subject a therapeutically effective amount of interferon lambda, optionally, pegylated interferon lambda-1a, wherein the subject has experienced a first coronavirus infection and is experiencing ongoing symptoms, optionally, one or more of the symptoms set forth in Table 27.
Other aspects and embodiments are described throughout this disclosure.
The terminology used herein is for the purpose of describing particular embodiments only, and is not intended to be limiting, because the scope of the present invention will be limited only by the appended claims. Unless defined otherwise, all technical and scientific terms used herein have the same meaning as commonly understood by one of ordinary skill in the art to which this invention belongs. In this specification and in the claims that follow, reference will be made to a number of terms that shall be defined to have the following meanings unless a contrary intention is apparent. In some cases, terms with commonly understood meanings are defined herein for clarity and/or for ready reference, and the inclusion of such definitions herein should not be construed as representing a substantial difference over the definition of the term as generally understood in the art.
Although any methods and materials similar or equivalent to those described herein can be used in the practice or testing of the present invention, the preferred methods, devices, and materials are now described. All technical and patent publications cited herein are incorporated herein by reference in their entirety. Nothing herein is to be construed as an admission that the invention is not entitled to antedate such disclosure by virtue of prior invention.
All numerical designations, e.g., pH, temperature, time, concentration, and molecular weight, including ranges, are approximations which are varied (+) or (−) by increments of 0.1 or 1.0, as appropriate. It is to be understood, although not always explicitly stated that all numerical designations are preceded by the term “about.”
The singular forms “a,” “an,” and “the” include plural referents unless the context clearly dictates otherwise. Thus, for example, reference to “a compound” includes a plurality of compounds.
The term “administration” refers to introducing a compound, a composition, or an agent of the present disclosure into a host, such as a human. In the context of the present disclosure, one preferred route of administration of the agents is subcutaneous administration. Other routes of administration include intravenous administration and oral administration.
The term “baseline,” unless otherwise specified or apparent from context, refers to a measurement (of, e.g., viral load, subject condition, ALT level) made prior to a course of therapy.
The term “comprising” is intended to mean that the compounds, compositions and methods include the recited elements, but does not exclude others. “Consisting essentially of” when used to define compounds, compositions and methods, shall mean excluding other elements that would materially affect the basic and novel characteristics of the claimed invention. Embodiments defined by each of these transition terms are within the scope of this invention.
The terms “course of treatment” and “course of therapy” are used interchangeably and refer to the medical interventions made after a subject is diagnosed, e.g., as being infected with coronavirus and in need of medical intervention. Medical interventions include, without limitation, the administration of drugs for a period of time, typically, for coronavirus infected subjects, at least one and typically several or many months or even years.
In the context of this disclosure, the terms “Coronavirus infection” and “COVID-19 infection” with respect to a human (host) refers to the fact that the host is suffering from Coronavirus infection and from an infection of SARS-CoV-2, respectively. Typically, an coronavirus infected human host will have a viral load of coronavirus of about 2 log10 copies per milliliter in the severe group and 10 log10 copies per milliliter; from about 1 log10 copies per milliliter in the severe group and 15 log10 copies per milliliter; 3 log10 copies per milliliter in the severe group and 5 log10 copies per milliliter; 4 log10 copies per milliliter in the severe group and 7.5 log10 copies per milliliter; 2 log10 copies per milliliter in the severe group and 8 log10 copies per milliliter. The sample may be from throat swabs, nasopharyngeal-swab, sputum or tracheal aspirate, urine fecal, and blood samples.
Known coronavirus isolates include SARS-CoV-2 (also referred to as “coronavirus 2019-nCoV” and “2019-nCoV”, new coronavirus identified in 2019 causing COVID-19) and variants thereof (e.g., the 501.V2 variant, the B.1.1.248 variant, the Cluster 5 variant, and the B.1.1.7 201/501Y.V1 variant), Canine coronavirus, Canine enteric coronavirus (strain INSAVC-1), Canine enteric coronavirus (strain K378), Feline coronavirus, Feline enteric coronavirus (strain 79-1683), Feline infectious peritonitis virus (FIPV), Human coronavirus 229E, Porcine epidemic diarrhea virus, Porcine epidemic diarrhea virus (strain Br1/87), Porcine epidemic diarrhea virus (strain CV777), Transmissible gastroenteritis virus, Porcine respiratory coronavirus, Porcine transmissible gastroenteritis coronavirus (STRAIN F5772/70), Porcine transmissible gastroenteritis coronavirus (strain Miller), Porcine transmissible gastroenteritis coronavirus (strain Neb72-RT), Porcine transmissible gastroenteritis coronavirus (STRAIN PURDUE), Bovine coronavirus, Bovine coronavirus (STRAIN F15), Bovine coronavirus (strain G95), Bovine coronavirus (STRAIN L9), Bovine coronavirus (strain LSU-94LSS-051), Bovine coronavirus (STRAIN LY-138), Bovine coronavirus (STRAIN MEBUS), Bovine coronavirus (strain OK-0514-3), Bovine coronavirus (strain Ontario), Bovine coronavirus (STRAIN QUEBEC), Bovine coronavirus (STRAIN VACCINE), Bovine enteric coronavirus (strain 98TXSF-110-ENT), Canine respiratory coronavirus, Chicken enteric coronavirus, Human coronavirus 0C43, Murine hepatitis virus, Murine coronavirus (strain DVIM), Murine hepatitis virus (strain A59), Murine hepatitis virus (strain JHM), Murine hepatitis virus (strain S), Murine hepatitis virus strain 1, Murine hepatitis virus strain 2, Murine hepatitis virus strain 3,Murine hepatitis virus strain 4, Murine hepatitis virus strain ML-11, Porcine hemagglutinating encephalomyelitis virus, Porcine hemagglutinating encephalomyelitis virus (strain 67N), Porcine hemagglutinating encephalomyelitis virus (strain IAF-404), Puffinosis virus Rat coronavirus, Rat coronavirus (strain 681), Rat coronavirus (strain NJ), Rat sialodacryoadenitis coronavirus, Turkey coronavirus Turkey coronavirus (strain Indiana), Turkey coronavirus (strain Minnesota), Turkey coronavirus (strain NC95), Avian infectious bronchitis virus, Avian infectious bronchitis virus (STRAIN 6/82), Avian infectious bronchitis virus (strain Arkansas 99), Avian infectious bronchitis virus (strain Beaudette CK), Avian infectious bronchitis virus (strain Beaudette M42), Avian infectious bronchitis virus (strain Beaudette US), Avian infectious bronchitis virus (strain Beaudette), Avian infectious bronchitis virus (strain D1466), Avian infectious bronchitis virus (strain D274), Avian infectious bronchitis virus (strain D3896), Avian infectious bronchitis virus (strain D41), Avian infectious bronchitis virus (strain DE072), Avian infectious bronchitis virus (strain GRAY), Avian infectious bronchitis virus (strain H120), Avian infectious bronchitis virus (strain H52), Avian infectious bronchitis virus (strain KB8523), Avian infectious bronchitis virus (strain M41), Avian infectious bronchitis virus (strain PORTUGAL/322/82), Avian infectious bronchitis virus (strain SAIB20), Avian infectious bronchitis virus (strain UK/123/82), Avian infectious bronchitis virus (strain UK/142/86), Avian infectious bronchitis virus (strain UK/167/84), Avian infectious bronchitis virus (strain UK/183/66), Avian infectious bronchitis virus (strain UK/68/84), Avian infectious bronchitis virus (strain V18/91), Avian infectious bronchitis virus (strain Vic S), Avian infectious laryngotracheitis virus, SARS coronavirus, SARS coronavirus, Beijing ZY-2003, SARS coronavirus BJ01, SARS coronavirus BJ02, SARS coronavirus BJ03, SARS coronavirus BJ04, SARS coronavirus CUHK-Su10, SARS coronavirus CUHK-W1, SARS coronavirus Frankfurt 1, SARS coronavirus GZ01, SARS coronavirus HKU-39849, SARS coronavirus Hong Kong ZY-2003, SARS coronavirus Hong Kong/03/2003, SARS coronavirus HSR 1, SARS coronavirus Sin2500, SARS coronavirus Sin2677, SARS coronavirus Sin2679, SARS coronavirus Sin2748, SARS coronavirus Sin2774, SARS coronavirus Taiwan, SARS coronavirus Taiwan JC-2003, SARS coronavirus Taiwan TC1, SARS coronavirus Taiwan TC2, SARS coronavirus Tort, SARS coronavirus TW1, SARS coronavirus TWC, SARS coronavirus Urbani, SARS coronavirus Vietnam, SARS coronavirus ZJ-HZ01, SARS coronavirus ZJO1, unclassified coronaviruses, Bovine respiratory coronavirus (strain 98TXSF-110-LUN), Human enteric coronavirus 4408, Enteric coronavirus, Equine coronavirus, and Equine coronavirus NC99.
The term “Lower Limit of Quantification” refers to the lowest concentration of a substance of analyte (e.g., a viral titer) that can be reliably quantified by a particular assay within a stated confidence limit.
The terms “subject,” “host,” or “subject,” are used interchangeably and refer to a human infected with coronavirus, including subjects previously infected with coronavirus in whom virus has cleared.
The term “pharmaceutical composition” is meant to encompass a composition suitable for administration to a subject. In general, a “pharmaceutical composition” is sterile, and preferably free of contaminants that are capable of eliciting an undesirable response within the subject (e.g., the compound(s) in the pharmaceutical composition is pharmaceutical grade). Pharmaceutical compositions can be designed for administration to subjects or subjects in need thereof via a number of different routes of administration including oral, intravenous, buccal, rectal, parenteral, intraperitoneal, intradermal, intratracheal, intramuscular, subcutaneous, inhalational, and the like.
A “sustained reduction” of coronavirus viral load means a reduction of viral load (e.g., a decrease of at least 0.5 log10 copies/ml of coronavirus in a sample, a decrease of at least 1 log10 copies/ml of coronavirus in a sample, a decrease of at least 1.5 log10 copies/ml of coronavirus in a sample, at least 2.0 log10 copies/ml of coronavirus in a sample or at least 2.5 log10 copies/ml of coronavirus in a sample, or a decrease in coronavirus to undetectable levels) for a period time (e.g., 1 month, 3 months, 6 months, 1 year, longer, forever or until a subsequent coronavirus infection). The sustained reduction may be a period of time during which the course of treatment is still ongoing or a period of time after the course of treatment is finished.
The term “therapeutically effective amount” as used herein refers to that amount of an embodiment of the agent (e.g., a compound, inhibitory agent, or drug) being administered that will treat to some extent a disease, disorder, or condition, e.g., relieve one or more of the symptoms of the disease, i.e., infection, being treated, and/or that amount that will prevent, to some extent, one or more of the symptoms of the disease, i.e., infection, that the subject being treated has or is at risk of developing.
The terms “treatment,” “treating,” and “treat” are defined as acting upon a disease, disorder, or condition with an agent to reduce or ameliorate the pharmacologic and/or physiologic effects of the disease, disorder, or condition and/or its symptoms. “Treatment,” as used herein, covers any treatment of a disease in a human subject, and includes: (a) reducing the risk of occurrence of the disease in a subject determined to be predisposed to the disease but not yet diagnosed as infected with the disease, (b) impeding the development of the disease, and/or (c) relieving the disease, e.g., causing regression of the disease and/or relieving one or more disease symptoms. “Treatment” is also meant to encompass delivery of an inhibiting agent to provide a pharmacologic effect, even in the absence of a disease or condition. For example, “treatment” encompasses delivery of an agent that provides for enhanced or desirable effects in the subject (e.g., reduction of viral load, reduction of disease symptoms, etc.).
The terms “undetectable” or “below the level of detection” or “BLD”, as used with reference to coronavirus RNA levels, means that no coronavirus RNA copies can be detected by the assay methodology employed. In some embodiments, the assay is quantitative RT-PCR.
The term “durable virologic response” or “DVR” as used herein refers to post-treatment response in a subject of coronavirus RNA below the limit of quantitation (BLQ) within one or more weeks after the end of treatment, or from between 2-12 weeks of ending treatment from between 12 and 24 weeks after ending treatment, from 1 day to 2-weeks; or from 12-48 weeks after ending treatment.
In one aspect, the present disclosure provides methods of treating Coronavirus infection by administering interferon lambda therapy to a coronavirus-infected subject. In some embodiments, a pegylated form of interferon lambda (e.g., pegylated interferon lambda-1a) is administered. In some embodiments, subjects receiving interferon lambda therapy (e.g., pegylated interferon lambda therapy) are also treated with an antiviral nucleoside or nucleotide analog (e.g., an anti-HBV nucleotide or nucleoside analog). In some embodiments, subjects receiving interferon lambda therapy (e.g., pegylated interferon lambda therapy) are not administered an antiviral nucleoside or nucleotide analog therapy.
As described herein, peginterferon lambda is the first antiviral agent that has demonstrated high efficacy across both a vaccinated population and an unvaccinated population and across multiple SARS-CoV-2 variants of concern, including Omicron variant (B.11529), the most infectious lineage identified to date. The impact of treatment was increased when patients received treatment within 3 days of symptom onset. None of the other interventions evaluated in the TOGETHER trial (ClinicalTrials.gov number, NCT04727424), including hydroxychloroquine (protocol 1), lopinavir/ritonavir (protocol 1), metformin, ivermectin, fluvoxamine, doxazosin, fluvoxamine plus inhaled budesonide, thus far have thus far done so (see, e.g., Reis, G. et al. JAMA 2021; Reis, G. et al. Lancet Regional Health 2022; Reis, G. et al. NEJM 2022; Reis, G. et al. Lancet Global Health 2022).
Results from the Phase 3 study described herein, conducted in a predominantly vaccinated population infected with multiple SARS-CoV-2 variants of concern, demonstrate the efficacy of a single subcutaneous dose of peginterferon lambda administered within 7 days of symptom onset. This regimen, administered an average of three days after symptom onset, resulted in a greater than 50% risk reduction in the primary endpoint of COVID-19-related hospitalization or retention in an emergency setting. For hospitalization alone, there was a 44% risk reduction. When using a comparable composite outcome as current oral therapies that had been granted Emergency Use Approval for early treatment of COVID-19, there was a risk reduction of 65% on the outcome of COVID-19-related hospitalization or all-cause death. When adjusted to enable a comparison based on comparable unvaccinated populations, there was a risk reduction of 89% on the outcome of COVID-19-related hospitalization or all-cause death. The efficacy observed on important outcomes was supported by planned subgroup analyses of the primary endpoint. The study findings were consistent across the variants of concern and across multiple vaccination subgroups.
Interferons are polypeptides that inhibit viral replication and cellular proliferation and modulate immune response. Interferons are produced as part of the innate immune response to viral infections, driving the induction of a broad array of host of genes with antiviral, anti-proliferative and immuno-regulatory properties. Based on the type of receptor through which they signal, human interferons have been classified into three major types (Types I, II, and III). Both Type I and Type III IFNs signal through the JAK-STAT pathway to drive ISG induction with comparable antiviral activity, however their systemic effects differ markedly due to the use of distinct receptors with different tissue distributions. All type I IFNs bind to a specific cell surface receptor complex known as the IFN-alpha receptor (IFNAR) that consists of IFNAR1 and IFNAR2 chains. The type I interferons present in humans are IFN-alpha, IFN-beta, IFN-epsilon, and IFN-omega. The type I IFN receptor is highly expressed on all cells in the body. Type II IFNs bind to IFN-gamma receptor (IFNGR) that consists of IFNGR1 and IFNGR2 chains. The type II interferon in humans is IFN-gamma. The type III interferon group includes three IFN-lambda molecules called IFN-lambda1, IFN-lambda1, and IFN-lambda3 (also called IL29, IL28A, and IL28B, respectively). These IFNs signal through a receptor complex consisting of IL10R2 (also called CRF2-4) and IFNLR1 (also called CRF2-12). Type III IFNs exert a similar antiviral state to IFN-alpha and IFN-beta but use a distinct receptor complex with high expression levels limited to epithelial cells in the lung, liver, and intestine as well as very limited expression in hematopoietic and central nervous system cells. See Syedbasha M & Egli A, “Interferon Lambda: Modulating Immunity in Infectious Diseases,” Front. Immunol. 2017; 8:119, doi:10.3389/fimmu.2017.00119. The more limited receptor expression profile can result in fewer systemic side effects. For example, interferon-lambda has been found to control respiratory viral infections in mice without the risk of promoting cytokine storm syndrome, as has been seen with Type I interferon treatment.
The term “interferon-lambda” or “IFN-λ” as used herein includes naturally occurring IFN-λ; synthetic IFN-λ; derivatized IFN-λ (e.g., PEGylated IFN-λ, glycosylated IFN-λ, and the like); and analogs of naturally occurring or synthetic IFN-λ. In some embodiments, an IFN-λ is a derivative of IFN-λ that is derivatized (e.g., chemically modified relative to the naturally occurring peptide) to alter certain properties such as serum half-life. As such, the term “IFN-λ” includes IFN-λ derivatized with polyethylene glycol (“PEGylated IFN-λ”), and the like. PEGylated IFN-λ (e.g., PEGylated IFN-λ-1a), and methods for making same, is discussed in, e.g., U.S. Pat. Nos. 6,927,040, 7,038,032, 7,135,170, 7,157,559, and 8,980,245; and PCT publication Nos. WO 2005/097165, WO 2007/012033, WO 2007/013944 and WO 2007/041713; all of which are herein incorporated by reference in their entirety. In some embodiments, the IFN-λ is an IFN-λ as disclosed in PCT/US2017/018466, which is incorporated by reference herein in its entirety. In some embodiments, the pegylated IFN-λ-1a has the structure described in U.S. Pat. No. 7,157,559, which is incorporated by reference herein in its entirety. IFN-λ has been found to be effective for acute respiratory disease due to the high expression of the IFN-λ receptor in lung epithelia.
As described in this disclosure, IFN-λ is effective as a therapeutic treatment of a SARS-CoV-2 infection including in patients with COVID-19. Without being bound by theory, it is believed that the effectiveness of IFN-λ is due to the high expression of the IFN-λ receptor in the lungs, intestine, and liver. This is consistent with the intestinal and hepatic involvement documented in patients with COVID-19. In some embodiments, this therapeutic treatment provides the benefit of reduced incidence of or the symptoms (intensity or kind) of cytokine storm syndrome in patients with COVID-19. This is consistent with the lack of the lambda receptor on hematopoietic cells. See Zhang W et al., “Molecular and serological investigation of 2019-nCoV infected patients: implication of multiple shedding routes,” Emerg. Microbes Infect. 2020; 9(1):386-389. doi:10.1080/22221751.2020.1729071.
In some embodiments, an interferon for use in a therapeutic method as described herein is a pegylated IFN-λ1 (e.g., pegylated IFN-λ-1a), pegylated IFN-λ-2, or pegylated IFN-λ-3. In some embodiments, the interferon is pegylated IFN-λ1 (e.g., pegylated IFN-λ-1a).
In some embodiments, pegylated IFN-λ1 has the amino acid sequence shown below (lines show intrachain disulfide bonds) [SEQ ID NO:1]:
In some embodiments, a subject to be treated with interferon lambda therapy as described herein is a subject having a Coronavirus infection, an acute Coronavirus infection, or a long term (persistent) Coronavirus infection. In some cases, the subject to be treated is identified as having a Coronavirus infection by a positive coronavirus antibody (Ab) test and/or detectable coronavirus RNA by qRT-PCR. In some instances, the molecular or antibody-based testing is performed using point-of-care (POC) testing, such as, e.g., Abbott ID NOW™ and/or Assure® COVID-19 IgG/IgM Rapid Test Device. In some embodiments, the subject to be treated has a Coronavirus infection of at least 1 month documented by a positive coronavirus Ab test, and/or detectable coronavirus RNA by qRT-PCR. In some embodiments, a subject to be treated with a therapeutic method described herein is a subject having an acute Coronavirus infection, one that is newly diagnosed or otherwise believed not to have existed in the subject for more than one week. Diagnosis of infection with SARS-CoV-2 and/or COVID-19 is described herein.
In some embodiments, a subject to be treated has a positive test for coronavirus infection. In some embodiments, the Coronavirus infection is an infection of a subject with SARS-CoV-2 or a variant thereof. In some embodiments, the viral load is detectable. In some embodiments, the viral load is at least 102 coronavirus RNA copies per mL of sample (e.g., throat swabs, nasopharyngeal-swab, sputum or tracheal aspirate, urine fecal, and blood samples). In some embodiments, the viral load is at least 102 copies/mL of sample, e.g., at least 103 coronavirus RNA copies per mL or at least 103 IU/mL sample, at least 104 coronavirus RNA copies per mL or at least 104 copies/mL sample, at least 105 coronavirus RNA copies per mL or at least 105 copies/mL sample, at least 106 coronavirus RNA copies per mL or at least 106 copies/mL sample, at least 107 coronavirus RNA copies per mL or at least 107 copies/mL sample, or at least 108 coronavirus RNA copies per mL or at least 108 copies/mL sample. In some embodiments, coronavirus viral load is measured using serum samples from the subject. In some embodiments, coronavirus viral load is measured using plasma samples from the subject. In some embodiments, viral load is measured by quantitative RT-PCR. qRT-PCR assays for quantification of coronavirus RNA in sample are known in the art, e.g., as described above. In some embodiments, a subject to be treated has a baseline viral load that is up to about 104 coronavirus RNA copies per mL sample or up to about 104 copies/mL sample. In some embodiments, a subject to be treated has a baseline viral load that is up to about 105 coronavirus RNA copies per mL sample or up to about 105 copies/mL sample. In some embodiments, a subject to be treated has a baseline viral load that is up to about 106 coronavirus RNA copies per mL sample or up to about 106 copies/mL sample.
In some embodiments, coronavirus viral load is measured using samples from the subject. In some embodiments, coronavirus viral load is measured using a serum or plasma sample from the subject. In some embodiments, viral load is measured by quantitative RT-PCR. qRT-PCR assays for quantification of coronavirus RNA in samples are known in the art, e.g., as described herein. In some instances, the sample from the subject is a respiratory sample, including but not limited to a nasopharyngeal aspirate or wash, an oropharyngeal aspirate or wash, a nasopharyngeal swab, an oropharyngeal swab, a broncheoalveolar lavage, a tracheal aspirate, and/or sputum.
In some embodiment, a subject to be treated by the methods provided herein has a positive test for coronavirus infection within 7 days, e.g., 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, or 7 days, or up to 3 days, or 3-7 days, of start of treatment.
In some embodiments, a subject to be treated exhibits one or more symptoms of coronavirus infection, e.g., fever, cough, shortness of breath. In some instances, the subject exhibits one or more of leukopenia, leukocytosis, lymphopenia, elevated alanine aminotransferase, and/or elevated aspartate aminotransferase levels.
In some embodiment, a subject to be treated by the methods provided herein has exhibited one or more symptoms of coronavirus infection for up to 7 days, e.g., 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, or 7 days, or up to 3 days, or 3-7 days prior to the start of treatment.
Coronaviruses like SARS-CoV-2 continuously evolve as changes in the genetic code (genetic mutations) occur during replication of the genome. A lineage is a genetically closely related group of virus variants derived from a common ancestor. A variant has one or more mutations that differentiate it from other variants of the SARS-CoV-2 viruses. Multiple variants of SARS-CoV-2 have been documented globally to date and will continue to evolve. In some embodiments, the subject to be treated is infected or at risk of infection with any SARS-CoV-2 variant. In some embodiments, the subject is infected or at risk of infection with any of the following variants: Alpha (B.1.1.7 and Q lineages), Beta (B.1.351 and descendent lineages), Gamma (P.1 and descendent lineages), Epsilon (B.1.427 and B.1.429), Eta (B.1.525), Iota (B.1.526), Kappa (B.1.617.1), 1.617.3, Lambda (C.37), Mu (B.1.621, B.1.621.1), Zeta (P.2), Delta (B.1.617.2 and AY lineages), Theta (P.3), or Omicron (B.1.1.529 and BA lineages). In some embodiments, the subject is infected or at risk of infection with Delta (B.1.617.2 and AY lineages) or Omicron (B.1.1.529 and BA lineages).
In some embodiments, the subject exhibits a DNA sequence variation, such as a a single nucleotide polymorphism. In some cases, for example, the subject may exhibit a single nucleotide polymorphism near the interleukin 28B (IL286) gene. In some instances, this single nucleotide polymorphism is strongly associated with response to treatment. In some cases, the single nucleotide polymorphism corresponds to an mRNA transcript that codes for interferon lambda 4 (IFNL4). See Prokunina-Olsson Let al., “A variant upstream of IFNL3 (IL28B) creating a new interferon gene IFNL4 is associated with impaired clearance of hepatitis C virus,” Nat. Genet., February 2013; 45(2):164-71. doi:10.1038/ng.2521.
In some embodiments, the subject to be treated will not have had any of the following: treatment with interferons (IFNs) immunomodulators and/or immunosuppressive or B-cell depleting medications within 12 months before screening; previous use of Interferon Lambda; history or evidence of any intolerance or hypersensitivity to IFNs; respiratory infection requiring invasive or non-invasive ventilatory support (bipap or intubation and mechanical ventilation); participation in a clinical trial with use of any investigational drug within 30 days before screening; or history of any of the following diseases or conditions: advanced or decompensated liver disease (presence or history of bleeding varices, ascites, encephalopathy or hepato-renal syndrome); immunologically mediated disease (e.g., rheumatoid arthritis, inflammatory bowel disease, severe psoriasis, systemic lupus erythematosus) that requires more than intermittent nonsteroidal anti-inflammatory medications for management or that requires use of systemic corticosteroids in the 6 months before screening (inhaled asthma medications are allowed); retinal disorder or clinically relevant ophthalmic disorder; or any malignancy within 5 years before screening.
In some embodiment, the subject to be treated may have had one or more of the following: a superficial dermatologic malignancy (e.g., squamous cell or basal cell skin cancer treated with curative intent); cardiomyopathy, significant ischemic cardiac or cerebrovascular disease (including history of angina, myocardial infarction, or interventional procedure for coronary artery disease), or cardiac rhythm disorder; chronic pulmonary disease (e.g., chronic obstructive pulmonary disease) associated with functional impairment; pancreatitis; severe or uncontrolled psychiatric disorder; active seizure disorder defined by either an untreated seizure disorder or continued seizure activity within the preceding year despite treatment with anti-seizure medication; bone marrow or solid organ transplantation; or any of the following abnormal laboratory test in the 12 months prior to enrollment: platelet count<90,000 cells/mm3; white blood cell (WBC) count<3,000 cells/mm3; absolute neutrophil count (ANC)<1,500 cells/mm3; hemoglobin<11 g/dL for women and <12 g/dL for men; estimated creatinine clearance (CrCl)<50 mL/min by Cockroft-Gault formulation; ALT and/or ALT levels>10 times the upper limit of normal; bilirubin level≥2.5 mg/dL unless due to Gilbert's syndrome; serum albumin level<3.5 g/dL; or an international normalized ratio (INR)≥1.5 (except patients maintained on anticoagulant medications).
In some embodiments, the subject to be treated has previously received at least one dose of a coronavirus vaccine, such as a vaccine against SARS-CoV-2. In some instances, the subject is fully vaccinated (i.e. has received initial vaccine dose(s) and approved booster shots). In some instances, the subject is partially vaccinated (i.e. has received at least an initial vaccine dose). The subject can have received one or more doses of any approved coronavirus vaccine. Vaccines can include compositions comprising viral protein subunits, viral vectors (replicating or non-replicating), DNA, RNA, inactivated virus, virus-like particles, live attenuated virus, antigen presenting cells, and/or bacterial antigen-spore expression vectors. Vaccines can have been administered to the subject subcutaneously, intra-dermally, intra-muscularly, intra-nasally, via aerosol, or otherwise inhaled. Exemplary vaccines include Convidecia (CanSino), Comirnaty (Pfizer/BioNTech), Nuvaxovid (Novavax), Spikevax (Moderna), Sputnik V (Gamaleya), Ad26/COV2.S (Janssen/Johnson & Johnson), Vaxzevria (Oxford/AstraZeneca), Covidshelid (Oxford/AstraZeneca formulation made by Serum Institute of India), Covovax (Novavax formulation made by Serum Institute of India), Covilo (Sinpharm), or CoronaVac (Sinovac), and Covaxin (Bharat Biotech).
In some embodiments, interferon lambda therapy comprises administering to the subject interferon lambda (e.g., pegylated interferon lambda-1a) at a dose of 180 micrograms (mcg) per week, 120 mcg per week, 110 mcg per week, 100 mcg per week, 90 mcg per week, 80 mcg per week, 120-70 mcg per week, 200-120 mcg per week, or 170-130 mcg per week. In some embodiments, interferon lambda is administered at a dose of 180 mcg QW. In some embodiments, interferon lambda is administered at a dose of 90 mcg two times per week. In some embodiments, interferon lambda is administered at a dose of 90 mcg every 3-4 days. In some embodiments, interferon lambda is administered at a dose of 80 mcg two times per week. In some embodiments, interferon lambda is administered at a dose of 80 mcg every 3-4 days. In some embodiments, interferon lambda is administered at a dose of 100-70 mcg two time per week. In some embodiments, interferon lambda is administered at a dose of 100-70 mcg every 3-4 days. In some embodiments, interferon lambda is administered at a dose of 120 mcg QW. In some embodiments, interferon lambda is administered at a dose of 80 mcg QW.
In some embodiments, a subject being treated for Coronavirus infection receives an adjustment in the dosing regimen of the interferon lambda therapy during the course of treatment. In some embodiments, the subject receives a dose reduction of interferon lambda, in that one or more later doses is a lower dose than one or more earlier doses. In some embodiments, a dose is reduced if the subject exhibits unacceptable side effects. In some embodiments, a subject may receive multiple dose reductions during the course of treatment with interferon lambda.
In some embodiments, the dosage administered to the subject is not reduced before 2 weeks of treatment at the first dosage (e.g., at a first dosage of 180 mcg QW), or before 3 week, or 2 weeks, or 3 weeks, or 4 weeks, or 5 weeks, or 6 weeks, or 7 weeks of treatment at the first dosage. In some embodiments, the dosage administered to the subject is not reduced before 9-12 weeks of treatment at the first dosage (e.g., at a first dosage of 180 mcg QW).
The interferon lambda therapy may comprise administering to the subject interferon lambda at differing doses between two or more treatment periods. In some embodiments, the interferon lambda therapy comprises administering to the subject interferon lambda at a dose of 180 micrograms per week for a first treatment period followed by administering to the subject interferon lambda at a dose of 120 micrograms per week for a second treatment period. In some embodiments, the length of time for the first treatment period is the same as the length of time for the second treatment period. In some embodiments, the first treatment period and the second treatment period are different lengths of time. In some embodiments, the first treatment period (i.e., interferon lambda at a dose of 180 mcg per week) is longer than the second treatment period (i.e., interferon lambda at a dose of 120 mcg per week). In some embodiments, the second treatment period (i.e., interferon lambda at a dose of 120 mcg per week) is longer than the first treatment period (i.e., interferon lambda at a dose of 180 mcg per week). In some embodiments, the interferon lambda therapy further comprises administering to the subject interferon lambda at a dose of 110-80 micrograms per week for a third treatment period. In some embodiments, the length of time for the third treatment period is the same as the length of time for the first and/or second treatment period. In some embodiments, the third treatment period and the first and/or second treatment period are different lengths of time. In some embodiments, the third treatment period (i.e., interferon lambda at a dose of 110-80 mcg per week) is longer than the first and/or second treatment period. In some embodiments, the third treatment period (i.e., interferon lambda at a dose of 80 mcg per week) is shorter than the first and/or second treatment period.
In some embodiments, the interferon lambda therapy comprises administering interferon lambda at a dose of 120 micrograms per week for a first treatment period followed by administering interferon lambda at a dose of 110-80 micrograms per week for a second treatment period. In some embodiments, the length of time for the first treatment period is the same as the length of time for the second treatment period. In some embodiments, the first treatment period and the second treatment period are different lengths of time. In some embodiments, the first treatment period (i.e., interferon lambda at a dose of 120 mcg per week) is longer than the second treatment period (i.e., interferon lambda at a dose of 80 mcg per week). In some embodiments, the second treatment period (i.e., interferon lambda at a dose of 80 mcg per week) is longer than the first treatment period (i.e., interferon lambda at a dose of 120 mcg per week).
In some embodiments, the interferon lambda therapy comprises administering interferon lambda at a first dose of 180 micrograms QW for a first treatment period, at a second dose of 170-120 micrograms QW for a second treatment period, and at a third dose of 110-80 micrograms QW for a third treatment period. In some embodiments, the first treatment period has a duration of at least 8 weeks, or from 1-8 weeks, or from 1-12 weeks. In some embodiments, the first treatment period has a duration of 8-12 weeks.
In some embodiments, the interferon lambda therapy comprises administering interferon lambda at a first dose of 160-180 micrograms per week for a first treatment period, at a second dose of 170-120 micrograms per week for a second treatment period, and at a third dose of 110-60 micrograms per week for a third treatment period. In some embodiments, the first treatment period has a duration of at least 8 weeks, or from 1-8 weeks, or from 1-12 weeks. In some embodiments, the first treatment period has a duration of 8-12 weeks. Doses may be given in multiple dose per week with the number of micrograms equaling the weekly dose.
In some embodiments, a treatment period (e.g., a first treatment period, second treatment period, and/or third treatment period) is at least 1 week in duration, e.g., at least 2, 3, 4 weeks or longer. In some embodiments, a treatment period (e.g., a first treatment period, second treatment period, and/or third treatment period) is at least 2 weeks in duration, e.g., at least 4, 6, 8, 10, 12, 16, 20, 24, 28, 32, 36, 40, 44, 48 weeks, or longer. In some embodiments, a treatment period is at least 8 weeks in duration. In some embodiments, a treatment period is up to about 4 weeks in duration, or up to about 6, 8, 10, 12, 16, 20, 24, 28, 32, 36, 40, 44, or 48 weeks in duration. In some embodiments, a treatment period is up to about 8 weeks in duration. In some embodiments, a treatment period is up to about 12 weeks in duration.
For a subject receiving a dose reduction, in some embodiments, a treatment period at a first dose is paused or stopped prior to starting a subsequent treatment period at a second lower dose. For example, in some embodiments, a first treatment period (e.g., at a dose of 180 mcg per week) is paused or stopped for a period of at least 1 week, 2 weeks, 3 weeks, 4 weeks or longer prior to starting a second treatment period (e.g., at a dose of 120 mcg per week).
In some embodiments, a subject is administered a first dose of 180 micrograms QW for at least 8 weeks before there is a dose reduction. In some embodiments, a subject is administered a first dose of 180 micrograms QW for at least 8-12 weeks before there is a dose reduction.
In some embodiments, if the subject has an absolute neutrophil count (ANC) of between to 500/mm3 and <750/mm3, or between to 400/mm3 and <650/mm3, or between to 400/mm3 and <850/mm3, the subject will begin the second treatment period.
In some embodiments, if the subject has an ANC of <500/mm3, dosing of the subject will stop until the subject has an ANC of >1000/mm3 and then dosing will be resumed for a second treatment period. In another embodiment, if the subject has an ANC of <400/mm3, dosing of the subject will stop until the subject has an ANC of >750/mm3 and then dosing will be resumed for a second treatment period.
In some embodiments, if the subject has a platelet level of <50,000 then subject will begin the second treatment period or if a subject has a platelet level of <25,000 then subject will discontinue treatment.
In some embodiments, if the subject has a total bilirubin (TBILI)>2.5×upper limit of the normal range (ULN) and direct bilirubin (DB)>3×ULN, dosing of the subject will stop until the subject has a TBILI≤1.5×ULN and then dosing will resume for a second treatment period.
In some embodiments, if the subject has a TBILI>3×ULN and DB>3×ULN, dosing of the subject will be interrupted until the TBILI≤1.5×ULN and then dosing will resume for a second treatment period.
In some embodiments, if the subject has an ALT (or AST)≥20×ULN and TBILI and/or international normalized ratio (INR)<Grade 2, dosing of the subject will be interrupted until the ALT/AST<10×ULN and then dosing will resume for a second treatment period. In some embodiments, if the subject has an absolute neutrophil count (ANC) of alanine aminotransferase (ALT) (or aspartate aminotransferase (AST))≥20×ULN and TBILI and/or INR<Grade 2 for a second time, dosing of the subject will be interrupted and then dosing will resume for a second treatment period.
In some embodiments. if the subject has an ALT (or AST)≥15-20×ULN and TBILI and/or INR<Grade 2, dosing of the subject will be interrupted dosing until the ALT/AST<10×ULN and then dosing will resume for a second treatment period; or if the subject has an ANC of ALT (or AST)≥15-20×ULN and TBILI and/or INR<Grade 2 for a second time, dosing of the subject will interrupt dosing until the ALT/AST<10×ULN and then dosing will resume for a second treatment period.
In some embodiments, the dose resumption after an interruption or stopping is resumed one week, two weeks, three weeks or four weeks after the interruption on stopping.
In some embodiments, if the subject has an ALT (or AST) 15×ULN and TBILI and/or INR<Grade 2, dosing of the subject will be interrupted until the ALT/AST<10×ULN and then dosing will resume for a second treatment period. In some embodiments, if the subject has an ANC of ALT (or AST) 15×ULN and TBILI and/or INR<Grade 2 for a second time, dosing of the subject will be interrupted and then dosing will resume for a second treatment period.
In some embodiments, if the subject has an ALT (or AST)≥5×ULN and TBILI and/or INR≥Grade 2, treatment of the subject will terminate.
In some embodiments, if the subject has an ALT (or AST)≥10×ULN and TBILI and/or INR≥Grade 3, treatment of the subject will terminate.
In some embodiments, if the subject experiences an adverse event Grade 3, dosing of the subject will stop until the event resolves or is ≤a Grade 1 and the dosing will resume for a second treatment period.
In some embodiments, if the subject experiences a second adverse event of≥Grade 3, dosing of the subject will be interrupted and then resume dosing for a third treatment period.
In some embodiments, if a subject has a creatinine clearance level of <50 mL/min, treatment of the subject is discontinued.
In certain embodiments, subjects with a 4×increase in baseline GGT, ALT/AST or alkaline phosphatases or >Bili 1.5 mg/dL, direct Bilirubin>0.6 (if Gilbert Syndrome is present) during any treatment period, may be prescribed ursodeoxycholic acid for “liver protection”.
In some embodiments, pegylated interferon lambda-1a is administered with a co-therapeutic agent. In some instances, the co-therapeutic agent is an antiviral compound for treatment of the coronavirus. In some instances, the co-therapeutic agent is a protease inhibitor for treatment of the coronavirus. In certain embodiments, the subject is administered at least one of remdesivir, chloroquine, tenofovir, or entecavir for treatment of the coronavirus infection. In certain embodiments, the subject is administered a protease inhibitor, such as at least one of lopinavir, ritonavir, or nirmatrelvir, alone or in any combination (e.g., SARS-CoV-2 MPRO protease inhibitor such as Paxlovid™ (nirmatrelvir co-packaged with ritonavir)), for treatment of the coronavirus infection.
In certain embodiments, the subject is also administered annexin-5, anti-PS monoclonal or polyclonal antibodies, bavituximab, and/or bind to viral glucocorticoid response elements (GREs), retinazone and RU486 or derivatives, cell entry inhibitors, uncoating inhibitors, reverse transcriptase inhibitors, integrase inhibitors, transcription inhibitors, antisense translation inhibitors, ribozyme translation inhibitors, prein processing and targeting inhibitors, protease inhibitors, assembly inhibitors, release phase inhibitors, immunosystem modulators and vaccines, including, but not limited to Abacavir, Ziagen, Trizivir, Kivexa/Epzicom, Aciclovir, Acyclovir, Adefovir, Amantadine, Amprenavir, Ampligen, Arbidol, Atazanavir, Atripla, Balavir, Cidofovir, Combivir, Dolutegravir, Darunavir, Delavirdine, Didanosine, Docosanol, Edoxudine, Efavirenz, Emtricitabine, Enfuvirtide, Entecavir, Ecoliever, Famciclovir, Fomivirsen, Fosamprenavir, Foscarnet, Fosfonet, Ganciclovir, Ibacitabine, Imunovir, Idoxuridine, Imiquimod, Indinavir, Inosine, Integrase inhibitor, Interferon type III, Interferon type II, Interferon type I, Interferon, Lamivudine, Lopinavir, Loviride, Maraviroc, Moroxydine, Methisazone, Nelfinavir, Nevirapine, Nexavir, Nucleoside analogues, Novir, Oseltamivir (Tamiflu), Paxlovid™, Peginterferon alfa-2a, Penciclovir, Peramivir, Pleconaril, Podophyllotoxin, Protease inhibitor, Raltegravir, Reverse transcriptase inhibitor, Ribavirin, Rimantadine, Ritonavir, Pyramidine, Saquinavir, Sofosbuvir, Stavudine, Synergistic enhancer, Tea tree oil, Telaprevir, Tenofovir, Tenofovir disoproxil, Tipranavir, Trifluridine, Trizivir, Tromantadine, Truvada, Valaciclovir, Valganciclovir, Vicriviroc, Vidarabine, Viramidine, Zalcitabine, Zanamivir, Zidovudine, and combinations thereof.
Subjects may receive interferon lambda therapy for a predetermined time, an indefinite time, or until an endpoint is reached. Treatment may be continued for at least one, two, or three weeks, or from one to 12 weeks. In some embodiments, therapy is administered weekly for at least 30 days, at least 60 days, at least 90 days, at least 120 days, at least 150 days, or at least 180 days. In some embodiments, weekly treatment is continued for at least 2 months, at least 3 months, at least 4 months, at least 5 months, at least 6 months, at least 7 months, at least 8 months, at least 9 months, at least 10 months, at least 11 months, at least one year, at least 15 months, at least 18 months, or at least 2 years. In some embodiments, therapy is for at least 6 weeks, 12 weeks, 18 weeks, 24 weeks, 30 weeks, 36 weeks, 42 weeks, 48 weeks, 60 weeks, 72 weeks, 84 weeks, or 96 weeks. In other embodiments, treatment is continued for the rest of the subject's life or until administration is no longer effective in maintaining the virus at a sufficiently low level to provide meaningful therapeutic benefit. In some embodiments, treatment (e.g., QW) is given for one to two weeks.
In accordance with the methods herein, some subjects with COVID-19 infection will respond to therapy as described herein by clearing virus to undetectable levels. In some embodiments, for subjects in which coronavirus RNA levels are below the level of detection, treatment is suspended unless and until the coronavirus levels return to detectable levels. Other subjects will experience a reduction in viral load and improvement of symptoms but will not clear the virus to undetectable levels but may remain on therapy for a defined period of time or so long as it provides therapeutic benefit.
In some embodiments, treatment with interferon lambda therapy results in a reduction of coronavirus viral load in the subject of at least 1.5 log10 coronavirus RNA copies/mL serum when measured after 48 weeks of treatment. In some embodiments, treatment with interferon lambda therapy results in a reduction of coronavirus viral load in the subject of at least 2.0 log10 coronavirus RNA copies/mL serum when measured after 48 weeks of treatment. In some embodiments, treatment with interferon lambda therapy results in a reduction of coronavirus viral load in the subject of at least 2.5 log10 coronavirus RNA copies/mL serum when measured after 48 weeks of treatment.
In some embodiments, treatment with interferon lambda therapy results in a sustained reduction of coronavirus viral load (e.g., a decrease of at least 1.5 log10 coronavirus RNA IU/mL serum, at least 2.0 log10 coronavirus RNA copies/mL serum or at least 2.5 log10 coronavirus RNA IU/mL serum, or a decrease in coronavirus RNA to undetectable levels) that is sustained for a period of time (e.g., 1 month, 3 months, 6 months) while the course of treatment is still ongoing.
In some embodiments, treatment with interferon lambda therapy results in a sustained reduction of coronavirus viral load, e.g., reduction of coronavirus viral load, that is sustained for a period of time (e.g., 1 month, 3 months, 6 months, 1 year or longer) or until re-infection occurs or forever, after the course of treatment is finished.
As used herein, duration of viral shedding may be, for example, determined by RT-PCR negativity. The duration of viral shedding may be determined, for example, by clinical improvement O2 status. In some embodiments, the rate or amount of viral shedding is determined by RT-PCR negativity or measurement of a reduced amount of virus (e.g., a reduced viral load).
In some embodiments, treatment with inteferon lambda therapy results in the production of antibodies against SAR-CoV-2 in the subject. In some embodiments, treatment with inteferon lambda therapy increases the quantity of SAR-CoV-2 antibodies in the subject.
In certain embodiments, the subjects have mild disease and are non-hospitalized; have mild to moderate disease and are non-hospitalized; have mild to moderate disease and are hospitalized; have mild to moderate disease, are hospitalized and requiring supportive O2; or exposed to SARS-CoV-2 with no symptoms. For example, the subject may receive a dose of 120 or 180 mcg weekly subcutaneous injection of interferon lambda.
In certain embodiments, the subjects have mild to moderate disease, are hospitalized and will be administered one or two doses of 120 or 180 mcg weekly subcutaneous injection of interferon lambda. In these embodiments, RT-PCR may be used to test for viral load on one or more of the days following administration (e.g., at days 7 and 14 after administration). Subjects receiving one or two administrations of interferon lambda may exhibits lower viral loads than those patients with similar disease status at initiation of treatment that received only supportive care.
In one embodiment, the subject with mild to moderate disease receives one or two administrations of lambda. In this embodiment, the subject may exhibit a lower level or duration of viral shedding (i.e. as compared to non-treated patients).
In one embodiment, subjects that are hospitalized and require supportive oxygen, are administered two doses of interferon lambda, such doses being administered a week apart. In this embodiment, the subject may demonstrate a clinical improvement in oxygen status (for example measured on an ordinal scale) as compared to subjects with similar disease status at initiation of treatment only receiving standard of care.
In one embodiment, subjects with mild to moderate disease and either non-hospitalized or hospitalized, receive two (2) doses of 120 or 180 mcg weekly subcutaneous injection of interferon lambda. In this embodiment, the subjects may have a lower rate of viral shedding as measured by RT-PCR negativity on one or more of the days following administration (e.g., at Day 7 and/or Day 14).
In some aspects, this disclosure provides a method of preventing an infection with SARS-CoV-2 in non-hospitalized subjects. According to one embodiment, two (2) doses of 120 or 180 mcg weekly subcutaneous injection of interferon lambda are administered to the subject.
In some aspects, the disclosure provides a method of preventing an infection with SARS-CoV-2 in subjects who have been exposed to SARS-CoV-2. In one embodiment, the subject receives one interferon lambda 180 mcg subcutaneous injection. In one embodiment, the subject then receives an RT-PCR test for viral load to determine if infection has happened. In one embodiment, subjects have lower conversion rate to infection than those that do not receive a lambda injection. In one embodiment, the subject is a subject that has had exposure with no confirmed infection. The subject has a decrease in conversion as compared to a subject that was exposed, had no treatment and resulted in a confirmed infection (control group).
In some aspects, the disclosure provides a method of treating an infection with SARS-CoV-2 in subjects having a confirmed SARS-CoV-2 infection. In one embodiment, the subject has confirmed mild COVID-19 infection with uncomplicated disease. In one embodiment, the subject is administered interferon lambda 180 mcg subcutaneous injection per week for two weeks. In one embodiment the subject is administered a single interferon lambda 180 mcg subcutaneous injection.
In one embodiment, interferon lambda 180 mcg is administered to a subject, wherein the subject has one or more of the following, as compared to a control: a reduced duration of viral shedding of SARS-CoV-2 virus, a reduction in the duration of symptoms; and a reduction in the rate of hospitalization following administration (e.g., reduced hospitalization between Day 1 and Day 28 of treatment). In one embodiment, the subject has mild COVID-19. In one embodiment, the subject has mild to moderate COVID-19.
In some embodiments, a subject who is administered interferon lambda therapy according to the present disclosure may also be treated with one or more other antiviral agents, and other agents.
In some embodiments, a subject who is administered interferon lambda therapy is treated with an antiviral agent that is used for the treatment of other viruses.
In some embodiments, interferon lambda can be formulated into a preparation for injection by dissolving, suspending or emulsifying the interferon lambda in an aqueous or nonaqueous solvent, such as vegetable or other similar oils, synthetic aliphatic acid glycerides, esters of higher aliphatic acids or propylene glycol; and if desired, with conventional additives such as solubilizers, isotonic agents, suspending agents, emulsifying agents, stabilizers and preservatives. Unit dosage forms for injection or intravenous administration may comprise in a composition as a solution in sterile water, normal saline or another pharmaceutically acceptable carrier. Appropriate amounts of the active pharmaceutical ingredient for unit dose forms of interferon lambda are provided herein.
In some embodiments, interferon lambda (e.g., an interferon lambda 1 such as interferon lambda 1a) or an analog thereof is formulated and/or administered and/or modified as described in any of U.S. Pat. Nos. 6,927,040, 7,038,032, 7,135,170, 7,157,559, and 8,980,245, US 2009/0326204, US 2010/0222266, US 2011/0172170, and US 2012/0036590, each of which is incorporated by reference herein in their entireties.
As used below, any reference to a series of embodiments is to be understood as a reference to each of those embodiments disjunctively (e.g., “Embodiments 1-4” is to be understood as “Embodiments 1, 2, 3, or 4”).
Embodiment 1 is a method of treating a coronavirus infection in a subject, the method comprising subcutaneously administering to the subject a therapeutically effective amount of pegylated interferon lambda-1a until one or more of: a sustained reduction of coronavirus viral load is reached, a decrease in coronavirus RNA to undetectable levels is reached, a decrease in a rate or an amount of viral shedding is reached, or an improvement in the subject's symptoms is reached.
Embodiment 2 is the method of embodiment(s) 1, wherein the pegylated interferon lambda-1a is administered for at least 1 week, 2 weeks, 3 weeks, 4 weeks, from 1-12 weeks, from 2-12 weeks, or from between 3 weeks and 24 weeks.
Embodiment 3 is the method of embodiment(s) 1 or 2, wherein the pegylated interferon lambda-1a is administered at a dose of 180 micrograms once a week, 90 micrograms twice per week, 80 micrograms twice per week, or 180 micrograms per week.
Embodiment 4 is the method of embodiment(s) 1 or 2, wherein the pegylated interferon lambda-1a is administered at a dose of 120 micrograms once a week, 60 micrograms twice per week, 70 micrograms twice per week, or 120 micrograms per week.
Embodiment 5 is the method of embodiment(s) 1 or 2, wherein the method comprises administering (i) 160-180 micrograms pegylated interferon lambda-1a per week for a first treatment period, and then 150-170 micrograms per week for a second treatment period; or (ii) 180 micrograms per week for a first treatment period, and then between 170-120 micrograms per week for a second treatment period, wherein the doses for each of (i) and (ii) may be divided into more than one dose per week.
Embodiment 6 is the method of embodiment(s) 1 or 2, wherein the method comprises administering the pegylated interferon lambda-1a at a dose of 120 micrograms per week for a first treatment period, and then at a dose of 80 micrograms per week for a second treatment period; or at a dose of 180-120 micrograms per week for a first treatment period and then at a dose of 120-80 micrograms per week for a second treatment period, wherein the doses may be divided into more than one dose per week.
Embodiment 7 is the method of embodiment(s) 5 or 6, wherein the first treatment period is longer than the second treatment period, or the second treatment period is longer than the first treatment period, or first treatment period and the second treatment period are the same length of time.
Embodiment 8 is the method of any one of embodiment(s) 5 to 7, wherein the first treatment period has a duration of at least 1 week, at least 2 weeks, at least 6 weeks, or at least 8 weeks.
Embodiment 9 is the method of any one of embodiment(s) 1 to 8, wherein treatment results in a reduction of coronavirus viral load in the subject of at least 2.0 log10 coronavirus RNA IU/mL serum.
Embodiment 10 is the method of any one of embodiment(s) 1 to 9, wherein treatment results in an improvement in the subject's symptoms.
Embodiment 11 is the method of any one of embodiment(s) 1 to 10, wherein the improvement in a subject's symptoms include a reduction in fever, feeling less tired, a decrease in coughs, less or no shortness of breath, decreased feeling of aches and pains, and less or no diarrhea.
Embodiment 12 is the method of any one of embodiment(s) 1 to 11, wherein treatment results in a coronavirus viral load that is below the level of detection.
Embodiment 13 is the method of any one of embodiment(s) 1 to 12, wherein the method further comprises administering to the subject a co-therapeutic agent.
Embodiment 14 is the method of any one of embodiment(s) 1 to 13, wherein the method further comprises administering to the subject an antiviral (i.e. an antiviral compound).
Embodiment 15 is the method of embodiment(s) 14, wherein the antiviral comprises one or more of remdesivir, chloroquine, tenofovir, or entecavir.
Embodiment 16 is the method of any one of embodiment(s) 1 to 15, wherein the method further comprises administering to the subject a protease inhibitor, optionally a SARS-CoV-2 MPRO protease inhibitor.
Embodiment 17 is the method of embodiment(s) 16, wherein the protease inhibitor comprises one or more of lopinavir, ritonavir, nirmatrelvir, or any combination thereof, optionally lopinavir/ritonavir or nirmatrelvir/ritonavir.
Embodiment 18 is the method of any one of embodiment(s) 1 to 17, wherein prior to treatment, the subject has a baseline viral load of up to about 104 coronavirus RNA copies per mL sample.
Embodiment 19 is the method of any one of embodiment(s) 1 to 18, wherein a durable virologic response (DVR) is seen in the subject after administration.
Embodiment 20 is the method of any one of embodiment(s) 1 to 19, where the subject has one or more of the following symptoms: pneumonia, fever, cough, shortness of breath, and muscle ache. Other symptoms my include confusion, headache and sore throat.
Embodiment 21 is the method of any one of embodiment(s) 1 to 20, wherein the coronavirus is a zoonotic virus.
Embodiment 22 is the method of any one of embodiment(s) 1 to 21, wherein the pegylated interferon lambda-1a is administered during an early phase of the coronavirus infection, and wherein the treatment shortens the duration of the coronavirus infection and prevents development of respiratory complications.
Embodiment 23 is the method of embodiment(s) 22, wherein the early phase of the coronavirus infection comprises one or more of: days 1-10 after initial viral load is determined, prior to experiencing respiratory symptoms that require hospitalization; a period when the subject is experiencing mild to moderate respiratory symptoms; a period when the subject is asymptomatic; or a period when the subject displays mild symptoms of respiratory infection with no respiratory distress.
Embodiment 24 is the method of any one of embodiment(s) 1-23, wherein the subject has a positive test for coronavirus infection within 7 days, e.g., 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, or 7 days, or within up to 3 days, or within 3-7 days, of start of treatment.
Embodiment 25 is the method of any one of embodiment(s) 1-24, wherein the subject has exhibited one or more symptoms of coronavirus infection for up to 7 days, e.g., 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, or 7 days, or up to 3 days, or up to 3-7 days prior to the start of treatment.
Embodiment 26 is the method of any one of embodiment(s) 1-25, wherein the subject has exhibited one or more symptoms of coronavirus and had a positive test for coronavirus infection within 7 days of start of treatment.
Embodiment 27 is the method of any one of embodiment(s) 1-26, wherein the subject has exhibited one or more symptoms of coronavirus and had a positive test for coronavirus infection within 3 days of the start of treatment.
Embodiment 28 is the method of embodiment(s) 23, wherein the mild symptoms of respiratory infection with no respiratory distress comprises a temperature<39.0 degrees C., respiratory rate<25, O2% Sat>95% in room air or with supplemental oxygen through nasal cannula, or P/F ratio>150.
Embodiment 29 is the method of any one of embodiment(s) 1 to 28, wherein the subject has not demonstrated one or more of the following abnormal laboratory test in the 12 months prior to administration: platelet count<90,000 cells/mm3; white blood cell (WBC) count<3,000 cells/mm3; absolute neutrophil count (ANC)<1,500 cells/mm3; hemoglobin<11 g/dL for women and <12 g/dL for men; estimated creatinine clearance (CrCl)<50 mL/min by Cockroft-Gault formulation; ALT and/or ALT levels>10 times the upper limit of normal; bilirubin level≥2.5 mg/dL unless due to Gilbert's syndrome; serum albumin level<3.5 g/dL; or international normalized ratio (INR)≥1.5 (except patients maintained on anticoagulant medications).
Embodiment 30 is the method of any one of embodiment(s) 1 to 29, wherein the subject has a SARS-CoV-2 infection.
Embodiment 31 is the method of any one of embodiment(s) 1 to 30, wherein the subject has previously received at least one dose of a coronavirus vaccine (e.g., is fully or partially vaccinated).
Embodiment 32 is the method of any one of embodiment(s) 1 to 30, wherein the subject is unvaccinated against coronavirus.
Embodiment 33 is the method of any one of embodiment(s) 1 to 32, wherein the subject is at high risk for COVID-19 disease progression or high risk for severe disease; optionally, wherein the subject is at leaest one of (i) elderly or has a chronic medical condition or underlying medical comorbidities, including one or more of diabetes, hypertension, or cardiovascular disease; (ii) is at least 50 years old or at least 55 years old; (iii) has a pre-existing condition comprising one more more of hypertension, obesity, chronic lung disease, diabetes mellitus, cardiovascular disease, organ transplant, chronic kidney disease (stage IV) or receiving dialysis, immunosuppressive therapy (10 mg prednisone daily or equivalent), or a cancer diagnosis within 6 months and/or is receiving cancer chemotherapy; or (iv) has presemted with severe symptoms, including documented fever and/or respiratory symptoms including cough, shortness of breath and/or pleuritic chest pain and/or myalgias.
Embodiment 34 is the method of any one of embodiment(s) 1 to 33, the subject has at least one of (i) age 50 years and/or has diabetes mellitus, hypertension requiring medication(s) for treatment, cardiovascular disease, lung disease, smoking, obesity (body mass index>30 kg/m2), organ transplant, chronic kidney disease (stage IV) or receiving dialysis, immunosuppressive therapy (≥10 mg prednisone daily or equivalent), or a cancer diagnosis within 6 months and/or is receiving cancer chemotherapy; (ii) has least one of age>55, hypertension, diabetes, obesity (BMI>30), or severe symptoms at presentation, including documented fever and/or respiratory symptoms including cough, shortness of breath and/or pleuritic chest pain and/or myalgias; or has at least one of age≥50 yr, obesity, hypertension, chronic cardiac disease, asthma (physician diagnosed), chronic pulmonary disease, diabetes mellitus type 2, cancer, or multiple comorbidities.
Embodiment 35 is the method of any one of embodiment(s) 1 to 34, wherein the the patient has a high baseline viral load, optionally, higher than 106 copies/mL.
Embodiment 36 is the method of any one of embodiment(s) 1 to 35, wherein the rate or amount of viral shedding is determined by RT-PCR negativity or a measurement of a reduced amount of virus.
Embodiment 37 is the method of any one of embodiment(s) 1 to 36, wherein an improvement in symptoms is determined by clinical improvement O2 status.
Embodiment 38 is the method of any one of embodiment(s) 1 to 37, wherein the subject is a mild, non-hospitalized subject; a mild to moderate, non-hospitalized subject; a mild to moderate, hospitalized subject; a mild to moderate, hospitalized and requiring supportive O2 subject; or an exposed subject with no symptoms.
Embodiment 39 is the method of any one of embodiment(s) 1 to 38, wherein the pegylated interferon lambda-1a is administered at a dose of 120 or 180 mcg weekly.
Embodiment 40 is the method of any one of embodiment(s) 1 to 39, wherein the subject is a mild to moderate, hospitalized subject, and wherein the pegylated interferon lambda-1a is administered as one or two doses of 120 or 180 mcg weekly.
Embodiment 41 is the method of any one of embodiment(s) 1 to 40, wherein RT-PCR is used to test for viral load at days 7 and 14 of treatment, and wherein the subject exhibits lower viral loads at days 7 and 14 than a patient with a similar disease status at initiation of treatment that received only standard supportive care.
Embodiment 42 is the method of any one of embodiment(s) 1 to 41, wherein the subject is a mild to moderate subject, and wherein the subject exhibits a decreased rate or amount of viral shedding.
Embodiment 43 is the method of any one of embodiment(s) 1 to 42, wherein the subject is a mild to moderate, hospitalized subject requiring supportive oxygen, and wherein the subject demonstrates clinical improvement in oxygen status (ordinal scale) as compared to a patient with similar disease status at initiation of treatment that only received standard supportive care.
Embodiment 44 is the method of embodiment 43, wherein the subject is administered two doses of interferon lambda one week apart.
Embodiment 45 is the method of any one of embodiment(s) 1 to 44, wherein the subject has mild to moderate disease, is non-hospitalized or hospitalized, wherein the pegylated interferon lambda-1a is administered at a dose of 120 or 180 mcg twice weekly, and wherein the subject exhibits a lower rate of viral shedding as measured by RT-PCR negativity following first administration of treatment (e.g., a first dose of interferon lambda; e.g., by Day 7 and/or Day 14 of treatment).
Embodiment 46 is a method of preventing or reducing the incidence of infection in a subject with SARS-CoV-2, the method comprising administering to the subject interferon lambda by subcutaneous injection in a dose of 120 or 180 mcg weekly or biweekly, wherein the subject is RT-PCR negative after a first dose of interferon lambda (e.g., by Day 7 and/or Day 14 of treatment).
Embodiment 47 is the method of embodiment(s) 46, wherein the subject has a lower RT-PCR level of SARS-CoV-2 than a subject receiving standard supportive care.
Embodiment 48 is a method of preventing or reducing the incidence of a SARS-CoV-2 infection in a subject exposed to SARS-CoV-2, the method comprising administering to the subject 180 mcg of interferon lambda as a subcutaneous injection, wherein the subject exhibits a lower viral load at day 7 after the injection than a subject with similar disease status at initiation of treatment receiving standard supportive care.
Embodiment 49 is the method of any one of embodiment(s) 1-48, wherein the subject exhibits a lower conversion rate to infection than a patient with similar disease status at initiation of treatment that was not administered interferon lambda.
Embodiment 50 is the method of any one of embodiment(s) 46-49, wherein the subject has exhibited one or more symptoms of SARS-CoV-2 infection for up to 7 days, e.g., 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, or 7 days, or up to 3 days, or 3-7 days prior to the start of treatment.
Embodiment 51 is the method of any one of embodiment(s) 37-41, wherein the subject has a positive test for SARS-CoV-2 infection within 7 days, e.g., 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, or 7 days, or up to 3 days, or 3-7 days, of start of treatment.
Embodiment 52 is the method of any one of embodiment(s) 46-50, wherein the subject has had exposure to SARS-CoV-2 with no confirmed infection.
Embodiment 53 is a method of treating a subject having a SARS-CoV-2 infection or having been exposed to SARS-CoV-2, the method comprising administering to the subject interferon lambda at a dose of 180 mcg, wherein the subject has one or more of the following, as compared to a control: a reduced duration of viral shedding of SARS-CoV-2 virus, a reduction in the duration of symptoms, or a reduction in the rate of hospitalization following first administration of treatment (e.g., a first dose of interferon lambda; e.g., between Day 1 and Day 28 of treatment).
Embodiment 54 is the method of any one of embodiments 46-53, wherein the interferon lambda is administered subcutaneously.
Embodiment 55 is the method of any one of embodiment(s) 46 to 54, wherein the interferon lambda is interferon lambda-1a.
Embodiment 56 is the method of any one of embodiment(s) 46 to 55, wherein the interferon lambda is pegylated interferon lambda.
Embodiment 57 is the method of any one of embodiments(s) 53 to 56, wherein the rate of hospitalization includes visits to an emergency room for over 6 hours.
Embodiment 58 is the method of any one of embodiment(s) 1 to 57, wherein the subject has a viral load equal to or greater than 6 log10 copies/mL.
Embodiment 59 is the method of any one of embodiment(s) 1 to 58, wherein the subject has a viral load of from about 6 log10 IU/mL to about 11 log10 IU/mL.
Embodiment 60 a method of treating a coronavirus infection in a subject, the method comprising subcutaneously administering to the subject from 120 mcg to 180 mcg of interferon lambda, wherein the subject has a viral load greater than or equal to 106 SARS-CoV-2 RNA copies/mL or greater than or equal to 6 log10 IU/mL.
Embodiment 61 is the method of embodiment 60, wherein the interferon lambda is administered at a dose of 120 mcg or 180 mcg, and wherein the subject exhibits a lower rate of viral shedding as measured by viral load negativity at Day 7, Day 14, and/or Day 28 of treatment as compared to at the initiation of treatment.
Embodiment 62 is the method of any one of embodiment(s) 60-61, wherein the subject has a viral load of from about 6 log10 IU/mL to about 11 log10 IU/mL.
Embodiment 63 is the method of embodiment 1 or embodiment 60, wherein the time to shedding cessation is faster in a seropositive subject relative to a seronegative subject at baseline.
Embodiment 64 is the method of any one of embodiment(s) 60-63, wherein the subject has a greater decline in SARS-CoV-2 RNA viral load decline from baseline at Day 5 of treatment, as compared to a control.
Embodiment 65 is the method of any one of embodiment(s) 60-64, wherein the subject is about 4.1-fold or 95% more likely to clear virus by Day 7 of treatment, as compared to a control.
Embodiment 66 is the method of any one of embodiment(s) 59-65, wherein the subject has a viral load greater than or equal to 6 log10 IU/mL, and wherein the subject is viral negative by Day 7 of treatment.
Embodiment 67 is the method of any one of embodiment(s) 59-66, wherein the subject clears the virus by Day 7 of treatment.
Embodiment 68 is the method of any one of embodiment(s) 59-67, wherein the interferon lambda is pegylated interferon lambda-1a.
Embodiment 6960 is the method of any one of embodiment(s) 53-68, wherein the subject has exhibited one or more symptoms of coronavirus infection for up to 7 days, e.g., 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, or 7 days, or up to 3 days, or 3-7 days prior to the start of treatment.
Embodiment 70 is the method of any one of embodiment(s) 53-69, wherein the subject has a positive test for coronavirus infection within 7 days, e.g., 1 day, 2 days, 3 days, 4 days, 5 days, 6 days, or 7 days, or up to 3 days, or 3-7 days, of start of treatment.
Embodiment 71 is the method of any one of embodiment(s) 53 to 70, wherein the subject has previously received at least one dose of a coronavirus vaccine (e.g., is fully or partially vaccinated).
Embodiment 72 is the method of any one of embodiment(s) 1-45 or 60-70, wherein the coronavirus is SARS-CoV-2.
Embodiment 73 is the method of any one of embodiment(s) 46-59 or 72, wherein the SARS-CoV-2 is a variant selected from Alpha (B.1.1.7 and Q lineages), Beta (B.1.351 and descendent lineages), Gamma (P.1 and descendent lineages), Epsilon (B.1.427 and B.1.429), Eta (B.1.525), Iota (B.1.526), Kappa (B.1.617.1), 1.617.3, Lambda (C.37), Mu (B.1.621, 6.1.621.1), Zeta (P.2), Delta (B.1.617.2 and AY lineages), Theta (P.3), or Omicron (B.1.1.529 and BA lineages).
Embodiment 74 is the method of any one of embodiment(s) 46-59 or 72, wherein the SARS-CoV-2 is variant Delta (B.1.617.2 and AY lineages) or Omicron (B.1.1.529 and BA lineages).
Embodiment 75 is a method of treating a subject having an infection by a coronavirus of unknown variant identity according to any of the above embodiments.
Embodiment 76 is a method of treating a coronavirus infection in a subject in which the subject is infected with a coronavirus of unknown variant identity, the method comprising subcutaneously administering to the subject a therapeutically effective amount of interferon lambda, optionally, pegylated interferon lambda-1a, until one or more of: a sustained reduction of coronavirus viral load is reached, a decrease in coronavirus RNA to undetectable levels is reached, a decrease in a rate or an amount of viral shedding is reached, or an improvement in the subject's symptoms is reached.
Embodiment 77 is the method of embodiment 64, wherein the coronavirus is determined to be SARS-CoV-2 based on symptom presentation or viral antigen detection.
Embodiment 78 is the method of any one of embodiment(s) 76 or 77, wherein the SARS-CoV-2 vrius is subsequently determined to be a variant selected from Alpha (B.1.1.7 and Q lineages), Beta (B.1.351 and descendent lineages), Gamma (P.1 and descendent lineages), Epsilon (6.1.427 and B.1.429), Eta (B.1.525), Iota (B.1.526), Kappa (B.1.617.1), 1.617.3, Lambda (C.37), Mu (B.1.621, B.1.621.1), Zeta (P.2), Delta (B.1.617.2 and AY lineages), Theta (P.3), or Omicron (B.1.1.529 and BA lineages).
Embodiment 79 is a method of treating a coronavirus infection in a subject that is infected with a SARS-CoV-2 omicron variant virus, the method comprising subcutaneously administering to the subject a therapeutically effective amount of interferon lambda, optionally, pegylated interferon lambda-1a, until one or more of: a sustained reduction of coronavirus viral load is reached, a decrease in coronavirus RNA to undetectable levels is reached, a decrease in a rate or an amount of viral shedding is reached, or an improvement in the subject's symptoms is reached.
Embodiment 80 is the method of embodiment 79, wherein the SARS-CoV-2 omicron variant virus is of B.1.1.529 lineage or BA lineage.
Embodiment 81 is a method of treating a second coronavirus infection in a subject, the method comprising subcutaneously administering to the subject a therapeutically effective amount of interferon lambda, optionally, pegylated interferon lambda-1a, until one or more of: a sustained reduction of coronavirus viral load is reached, a decrease in coronavirus RNA to undetectable levels is reached, a decrease in a rate or an amount of viral shedding is reached, or an improvement in the subject's symptoms is reached, wherein the subject has previously experienced a first coronavirus infection and had resolution of symptoms and/or reduction of coronavirus viral load to undetectable levels prior to the second coronavirus infection.
Embodiment 82 is the method of embodiment 81, wherein the first coronavirus infection and the second coronavirus infection are caused by different coronavirus variants.
Embodiment 83 is the method of embodiment 81, wherein the first coronavirus infection and the second coronavirus infection are caused by the same coronavirus variant.
Embodiment 84 is the method of embodiment 81, wherein the second coronavirus infection is reemergence of the first coronavirus infection in the subject.
Embodiment 85 is the method of embodiment 81, wherein the second coronavirus infection is a new infection of the subject.
Embodiment 86 is a method of treating post-COVID symptoms in a subject, the method comprising subcutaneously administering to the subject a therapeutically effective amount of interferon lambda, optionally, pegylated interferon lambda-1a, wherein the subject has experienced a first coronavirus infection and is experiencing ongoing symptoms, optionally, one or more of the symptoms set forthi in Table 27.
Embodiment 87 is the method of embodiment 86, wherein the subject is treated until one or more of: a sustained reduction of coronavirus viral load is reached, a decrease in coronavirus RNA to undetectable levels is reached, a decrease in a rate or an amount of viral shedding is reached, or an improvement in the subject's symptoms is reached.
Embodiment 88 is the method of any one of embodiment(s)s 76-87, wherein the interferon lambda is administered subcutaneously.
Embodiment 89 is the method of any one of embodiment(s) 76-88, wherein the interferon lambda is interferon lambda-1a.
Embodiment 90 is the method of any one of embodiment(s) 76-89, wherein the interferon lambda is pegylated interferon lambda.
Embodiment 91 is the method of any one of embodiment(s) 76-90, wherein the pegylated interferon lambda-1a is administered for at least 1 week, 2 weeks, 3 weeks, 4 weeks, from 1-12 weeks, from 2-12 weeks, or from between 3 weeks and 24 weeks.
Embodiment 92 is the method of any one of embodiment(s) 76-91, wherein the interferon lambda, optionally, pegylated interferon lambda-1a, is administered at a dose of 180 micrograms once a week, 90 micrograms twice per week, 80 micrograms twice per week, or 180 micrograms per week.
Embodiment 93 is the method of any one of embodiment(s) 76-91, wherein the interferon lambda, optionally, pegylated interferon lambda-1a, is administered at a dose of 120 micrograms once a week, 60 micrograms twice per week, 70 micrograms twice per week, or 120 micrograms per week.
Embodiment 94 is the method of any one of embodiment(s) 76-91, wherein the method comprises administering (i) 160-180 micrograms interferon lambda, optionally, pegylated interferon lambda-1a, per week for a first treatment period, and then 150-170 micrograms per week for a second treatment period; or (ii) 180 micrograms per week for a first treatment period, and then between 170-120 micrograms per week for a second treatment period, wherein doses administered for each of (i) and (ii) may be divided into more than one dose per week.
Embodiment 95 is the method of any one of embodiment(s) 76-91, wherein the method comprises administering the interferon lambda, optionally, pegylated interferon lambda-1a, at a dose of 120 micrograms per week for a first treatment period, and then at a dose of 80 micrograms per week for a second treatment period; or at a dose of 180-120 micrograms per week for a first treatment period and then at a dose of 120-80 micrograms per week for a second treatment period, wherein the doses may be divided into more than one dose per week.
Embodiment 96 is the method of embodiment 95, wherein the first treatment period is longer than the second treatment period, or the second treatment period is longer than the first treatment period, or first treatment period and the second treatment period are the same length of time.
Embodiment 97 is the method of embodiment 95, wherein the first treatment period has a duration of at least 1 week, at least 2 weeks, at least 6 weeks, or at least 8 weeks.
Embodiment 98 is the method of any one of embodiment(s) 76-97, wherein treatment results in a reduction of coronavirus viral load in the subject of at least 2.0 log10 coronavirus RNA copies/mL serum.
Embodiment 99 is the method of any one of embodiment(s) 76-98, wherein treatment results in an improvement in the subject's symptoms.
Embodiment 100 is the method of any one of embodiment(s) 76-99, wherein the improvement in a subject's symptoms include a reduction in fever, feeling less tired, a decrease in coughs, less or no shortness of breath, decreased feeling of aches and pains, and less or no diarrhea.
Embodiment 101 is the method of any one of embodiment(s) 76-100, wherein treatment results in a coronavirus viral load that is below the level of detection.
Embodiment 102 is the method of any one of embodiment(s) 76-101, wherein the method further comprises administering to the subject an antiviral.
Embodiment 103 is the method of embodiment(s) 90, wherein the antiviral comprises one or more of remdesivir, chloroquine, tenofovir, entecavir, or a protease inhibitor, optionally, lopinavir, ritonavir, and or a SARS-CoV-2/MPRO inhibitor, further optionally nirmatrelvir in combination with ritonavir.
Embodiment 104 is the method of any one of embodiment(s) 76-103, wherein prior to treatment, the subject has a baseline viral load of up to about 104 coronavirus RNA copies per mL sample.
Embodiment 105 is the method of any one of embodiment(s) 76-104, wherein a durable virologic response (DVR) is seen in the subject after administration.
Embodiment 106 is the method of any one of embodiment(s) 76-105, where the subject has one or more of the following symptoms: pneumonia, fever, cough, shortness of breath, and muscle ache.
Embodiment 107 is the method of any one of embodiment(s) 76-106, wherein the coronavirus is a zoonotic virus.
Embodiment 108 is the method of any one of embodiment(s) 76-107, wherein the interferon lambda, optionally, pegylated interferon lambda-1a, is administered during an early phase of the coronavirus infection, and wherein the method shortens the duration of the coronavirus infection and prevents development of respiratory complications.
Embodiment 109 is the method of embodiment 108, wherein the early phase of the coronavirus infection comprises one or more of: days 1-10 after initial viral load is determined, prior to experiencing respiratory symptoms that require hospitalization; a period when the subject is experiencing mild to moderate respiratory symptoms; a period when the subject is asymptomatic; or a period when the subject displays mild symptoms of respiratory infection with no respiratory distress.
Embodiment 110 is the method of embodiment 109, wherein the mild symptoms of respiratory infection with no respiratory distress comprises a temperature<39.0 degrees C., respiratory rate<25, O2% Sat>95% in room air or with supplemental oxygen through nasal cannula, or P/F ratio>150.
Embodiment 111 is the method ofany one of embodiment(s) 76-110, wherein the subject has exhibited one or more symptoms of coronavirus infection for up to 3 days, up to 7 days, or up to 3-7 days prior to the start of treatment.
Embodiment 112 is the method of any one of embodiment(s) 76-111, wherein the subject has not demonstrated one or more of the following abnormal laboratory test in the 12 months prior to administration: platelet count<90,000 cells/mm3; white blood cell (WBC) count<3,000 cells/mm3; absolute neutrophil count (ANC)<1,500 cells/mm3; hemoglobin<11 g/dL for women and <12 g/dL for men; estimated creatinine clearance (CrCl)<50 mL/min by Cockroft-Gault formulation; ALT and/or ALT levels>10 times the upper limit of normal; bilirubin level 2.5 mg/dL unless due to Gilbert's syndrome; serum albumin level<3.5 g/dL; or international normalized ratio (INR)≥1.5 (except patients maintained on anticoagulant medications).
Embodiment 113 is the method of any one of embodiment(s) 76-112, wherein the rate or amount of viral shedding is determined by RT-PCR negativity or a measurement of a reduced amount of virus.
Embodiment 114 is the method of any one of embodiment(s) 76-113, wherein an improvement in symptoms is determined by clinical improvement O2 status.
Embodiment 115 is the method of any one of embodiment(s) 76-114, wherein the subject is a mild, non-hospitalized subject; a mild to moderate, non-hospitalized subject; a mild to moderate, hospitalized subject; a mild to moderate, hospitalized and requiring supportive O2 subject; or an exposed subject with no symptoms.
Embodiment 116 is the method of any one of embodiment(s) 76-115, wherein the subject has received at least one dose of a coronavirus vaccine.
Embodiment 117 is the method of any one of embodiment(s) 76-116, wherein the subject is unvaccinated against coronavirus.
Embodiment 118 is the method of any one of embodiment(s) 1-117, wherein the subject is at high risk for COVID-19 disease progression or high risk for severe disease.
Embodiment 119 is the method of embodiment 118, wherein the subject is elderly or has a chronic medical condition or underlying medical comorbidities, including one or more of diabetes, hypertension, or cardiovascular disease.
Embodiment 120 is the method of any one of embodiment(s) 115-119, wherein the subject is at least 50 years old or at least 55 years old.
Embodiment 121 is the method of any one of embodiment(s) 115-120, wherein the subject has a pre-existing condition comprising one more more of hypertension, obesity, chronic lung disease, diabetes mellitus, cardiovascular disease, organ transplant, chronic kidney disease (stage IV) or receiving dialysis, immunosuppressive therapy ((10 mg prednisone daily or equivalent), or a cancer diagnosis within 6 months and/or is receiving cancer chemotherapy.
Embodiment 122 is the method of any one of embodiment(s) 115-121, wherein the subject has presemted with severe symptoms, including documented fever and/or respiratory symptoms including cough, shortness of breath and/or pleuritic chest pain and/or myalgias.
Embodiment 123 is the method of any one of embodiment(s) 115-122, wherein the subject is: (i) is age (50 years and/or has diabetes mellitus, hypertension requiring medication(s) for treatment, cardiovascular disease, lung disease, smoking, obesity (body mass index>30 kg/m2), organ transplant, chronic kidney disease (stage IV) or receiving dialysis, immunosuppressive therapy ((10 mg prednisone daily or equivalent), or a cancer diagnosis within 6 months and/or is receiving cancer chemotherapy; (ii) has least one of age>55, hypertension, diabetes, obesity (BMI>30), or severe symptoms at presentation, including documented fever and/or respiratory symptoms including cough, shortness of breath and/or pleuritic chest pain and/or myalgias; or (iii) has at least one of age 50 yr, obesity, hypertension, chronic cardiac disease, asthma (physician diagnosed), chronic pulmonary disease, diabetes mellitus type 2, cancer, or multiple comorbidities.
Embodiment 124 is the method of any one of embodiment(s) 115-123, wherein the patient has a high baseline viral load.
Embodiment 125 is the method ofany one of claims 76-124, wherein the interferon lambda, optionally, pegylated interferon lambda-1a, is administered at a dose of 120 or 180 mcg weekly.
Embodiment 126 is the method of any one of embodiment(s) 76-125, wherein the subject is a mild to moderate, hospitalized subject, and wherein the interferon lambda, optionally, pegylated interferon lambda-1a, is administered as one or two doses of 120 or 180 mcg weekly.
Embodiment 127 is the method of any one of embodiment(s) 76-126, wherein RT-PCR is used to test for viral load at days 7 and 14 of treatment, and wherein the subject exhibits lower viral loads at days 7 and 14 than a patient with similar disease status at initiation of treatment that received only standard supportive care.
Embodiment 128 is the method of any one of embodiment(s) 76-127, wherein the subject is a mild to moderate subject, and wherein the subject exhibits a decreased rate or amount of viral shedding.
Embodiment 129 is the method of any one of embodiment(s) 76-128, wherein the subject is a mild to moderate, hospitalized subject requiring supportive O2, and wherein the subject demonstrates clinical improvement in oxygen status (ordinal scale) as compared to a patient with similar disease status at initiation of treatment that only received standard supportive care.
Embodiment 130 is the method of embodiment(s) 129, wherein the subject is administered two doses of interferon lambda one week apart.
Embodiment 131 is the method of any one of embodiment(s) 76-130, wherein the subject has mild to moderate disease and is non-hospitalized or hospitalized, wherein the interferon lambda, optionally, pegylated interferon lambda-1a, is administered at a dose of 120 or 180 mcg twice weekly, and wherein the subject exhibits a lower rate of viral shedding as measured by RT-PCR negativity at Day 7 and/or Day 14 of treatment.
Embodiment 132 is the method of any one of embodiment(s) 1-131, wherein the subject is unvaccinated, high risk subject.
Embodiment 133 is the method of any one of embodiment(s) 1-132, wherein the subject has exhibited one or more symptoms of coronavirus infection for up to 3 days, up to 7 days, or up to 3-7 days prior to the start of treatment.
Embodiment 134 is a method of treating a subject having a coronavirus infection according to any of the above embodiments, wherein the subject is unvaccinated, high risk subject, and wherein the subject has exhibited one or more symptoms of coronavirus infection for up to 3 days, up to 7 days, or up to 3-7 days prior to the start of treatment.
The following examples are provided to illustrate, but not to limit, the claimed invention.
The incubation period is estimated at ˜5 days (95% confidence interval, 4 to 7 days). Frequently reported signs and symptoms include fever (83-98%), cough (76%-82%), and myalgia or fatigue (11-44%) at illness onset. Sore throat has also been reported in some patients early in the clinical course. Less commonly reported symptoms include sputum production, headache, hemoptysis, and diarrhea. The fever course among patients with SARS-CoV-2 infection is not fully understood; it may be prolonged and intermittent. Asymptomatic infection has been described in one child with confirmed SARS-CoV-2 infection and chest computed tomography (CT) abnormalities.
Risk factors for severe illness may include for older patients and those with chronic medical conditions may be at higher risk for severe illness. Nearly all reported cases have occurred in adults (median age 59 years). In one study of 425 patients with pneumonia and confirmed SARS-CoV-2 infection, 57% were male. Approximately one-third to one-half of reported patients had underlying medical comorbidities, including diabetes, hypertension, and cardiovascular disease.
This example describes a clinical study protocol for evaluating the safety, tolerability, and pharmacodynamics of pegylated interferon lambda monotherapy in subjects with chronic Coronavirus infection.
One method to detect SARS-CoV-2 is by using the Real-Time RT-PCR Panel for Detection 2019-Novel Coronavirus, by the Centers for Disease Control and Prevention, Respiratory Viruses Branch, Division of Viral Diseases. The publication of this method is hereby incorporated by reference.
Primers and Probes that may be used to detect SARS-CoV-2 are described below. For example, Table 1 provides exemplary primer sequences, which are identified herein as SEQ ID NOs: 2-13 (from top row to bottom row).
Diagnostic Testing of 2019-nCoV (SARS-CoV-2)
Currently, confirmation of SARS-CoV-2 infection (referred to below as 2019-nCoV infection) is performed at CDC using the CDC real-time RT-PCR assay for 2019-nCoV on respiratory specimens (which can include nasopharyngeal or oropharyngeal aspirates or washes, nasopharyngeal or oropharyngeal swabs, broncheoalveolar lavage, tracheal aspirates, or sputum) and serum. Information on specimen collection, handling, and storage is available at: Real-Time RT-PCR Panel for Detection 2019-Novel Coronavirus. After initial confirmation of 2019-nCoV infection, additional testing of clinical specimens can help inform clinical management, including discharge planning.
Laboratory and Radiographic Findings: 2019-nCoV (SARS-CoV-2)
The most common laboratory abnormalities reported among hospitalized patients with 2019-nCoV include pneumonia on admission, leukopenia (9-25%), leukocytosis (24-30%), lymphopenia (63%), and elevated alanine aminotransferase and aspartate aminotransferase levels (37%). Most patients had normal serum levels of procalcitonin on admission. Chest CT images have shown bilateral involvement in most patients. Multiple areas of consolidation and ground glass opacities are typical findings reported to date.
2019-nCoV RNA has been detected from upper and lower respiratory tract specimens, and the virus has been isolated from bronchoalveolar lavage fluid. The duration of shedding of 2019-nCoV RNA in the upper and lower respiratory tracts is not yet known but may be several weeks or longer, which has been observed in cases of MERS-CoV or SARS-CoV infection.
Subjects infected with SARS-CoV-2 will be evaluated for the safety and tolerability of treatment with subcutaneous (S.C.) injections of interferon lambda at doses of 120 or 180 mcg. Subjects will be compared to standard supportive care (control arm) of patients infected with SARS-CoV-2. The study will be a randomized, open label, 2 arm, pilot trial of interferon lambda 180 mcg administered S.C once weekly, for up to two weeks (2 injections at most), in addition to standard supportive care, compared to standard supportive care of up to 2 weeks, in a population of SARS-CoV-2 infected patients.
Patients will be randomized according to 1:1 ratio to one of the trial arms: interferon lambda 180 mcg S.C (intervention arm), or standard care (control arm). Up to 40 patients will be included, each with proven COVID-19 infection by PCR and diagnosed with mild to moderate respiratory symptoms.
Following initial diagnosis of COVID-19, patients will be admitted to a hospital (Day 0). Upon admission, patients will be randomized according to 1:1 ratio to one of the trial arms and receive either interferon lambda 180 mcg S.C (intervention arm) or standard of care (control arm). Patients' vital signs (temperature, blood pressure, pulse rate per minute, breath rate per minute and oxygen saturation), will be monitored according to standard of care (SoC). Symptom questionnaires will be collected from patients as well as adverse events (Aes) assessment and recording of the need for supportive respiratory measures (SRM) once daily during the period of hospitalization.
Efficacy of interferon lambda will be assessed by PCR analysis for COVID-19 (Fluxergy, Irvine, CA) from respiratory secretions obtained by nasopharyngeal and oropharyngeal swabs, collected consecutively at day 1, 3, 5, 7, 10, 14 and 21 following initial diagnosis or until patients are discharged following achievement of two consecutive PCR negative tests for COVID-19. Safety and tolerability of interferon lambda will be assessed by adverse event (AE) monitoring, vital signs assessment and clinical laboratory tests (complete blood count (CBC), and extended chemistry panel).
Patients will include: Female and male patients over the age of 18; confirmed COVID-19 infection by PCR analysis; hospitalized; and displaying mild to moderate symptoms of respiratory infection, including temperature<39.0 degrees C., respiratory rate<25, O2% Sat>95% in room air or with supplemental oxygen through nasal cannula, P/F ratio>150).
Patients will be excluded if they have had: treatment with interferons (IFNs) immunomodulators and/or immunosuppressive or B-cell depleting medications within 12 months before screening; previous use of Interferon Lambda; history or evidence of any intolerance or hypersensitivity to IFNs; respiratory infection requiring invasive or non-invasive ventilatory support (bipap or intubation and mechanical ventilation); participation in a clinical trial with use of any investigational drug within 30 days before screening; or history of any of the following diseases or conditions: advanced or decompensated liver disease (presence or history of bleeding varices, ascites, encephalopathy or hepato-renal syndrome); immunologically mediated disease (e.g., rheumatoid arthritis, inflammatory bowel disease, severe psoriasis, systemic lupus erythematosus) that requires more than intermittent nonsteroidal anti-inflammatory medications for management or that requires use of systemic corticosteroids in the 6 months before screening (inhaled asthma medications are allowed); retinal disorder or clinically relevant ophthalmic disorder; any malignancy within 5 years before screening.
Exceptions are superficial dermatologic malignancies (e.g., squamous cell or basal cell skin cancer treated with curative intent); cardiomyopathy, significant ischemic cardiac or cerebrovascular disease (including history of angina, myocardial infarction, or interventional procedure for coronary artery disease), or cardiac rhythm disorder; chronic pulmonary disease (e.g., chronic obstructive pulmonary disease) associated with functional impairment; pancreatitis; severe or uncontrolled psychiatric disorder; active seizure disorder defined by either an untreated seizure disorder or continued seizure activity within the preceding year despite treatment with anti-seizure medication; bone marrow or solid organ transplantation; or any of the following abnormal laboratory test in the 12 months prior to enrollment: platelet count<90,000 cells/mm3; white blood cell (WBC) count<3,000 cells/mm3; absolute neutrophil count (ANC)<1,500 cells/mm3; hemoglobin<11 g/dL for women and <12 g/dL for men; estimated creatinine clearance (CrCl)<50 mL/min by Cockroft-Gault formulation; ALT and/or ALT levels>10 times the upper limit of normal; bilirubin level≥2.5 mg/dL unless due to Gilbert's syndrome; serum albumin level<3.5 g/dL; international normalized ratio (INR)≥1.5 (except patients maintained on anticoagulant medications).
Efficacy endpoints include: the duration of viral shedding in days since initial diagnosis, as determined by RT-PCR to COVID-19; comparison of time to clinical recovery (TTCR) between interferon lambda and standard care arms; TTCR is defined as the time (in hours) from initiation of trial treatment (interferon lambda or standard care) until normalization of fever, respiratory rate, and oxygen saturation, and alleviation of cough, sustained for at least 72 hours; normalization and alleviation criteria: fever −≤36.9 ° C.-axilla or, ≤37.2 ° C. oral, respiratory rate≤24/minute in room air, oxygen saturation>94% in room air, cough—mild or absent on a patient reported scale of severe, moderate, mild, absent; comparison of the frequency of requirement for non-invasive or mechanical ventilation between the two treatment arms; comparison of the length of hospital stay between the two treatment arm; comparison of estimated p/f ratio for day of discharge between the study arms; comparison of all-cause mortality at 28 days between the two treatment arms; comparison of the proportion of patients reaching undetectable SARS-CoV-2 levels in respiratory secretions at days 7, 14 and 21 from diagnosis, between the two treatment arms; comparison of the duration of symptoms and signs of respiratory infection associated with COVID-19 between the two treatment arms; comparison of the SARS-CoV-2 viral load in respiratory secretions using a semi-quantitative method between the two treatment arms.
Other endpoints include, for example, the rate of treatment-emergent and treatment-related severe adverse events (SAEs); rate of Aes leading to early discontinuation of trial treatment in patients receiving interferon lambda; comparison of the rate of treatment-emergent changes in clinical laboratory (CBC, liver panel), between the two treatment arms; comparison of the rate of treatment-emergent changes in vital signs and physical examination results between the two treatment arms; and/or usage of concomitant medications during the trial.
The treatment with interferon lambda during early phases of COVID-19 infection shortens the duration of infection and prevents development of respiratory complications.
As shown in
Interferon lambda is a type III interferon whose receptors are largely limited to epithelial cells, including the lungs, liver, and gastrointestinal tract. Treatment with interferons has been employed as pan-viral treatment for several viral infections, including trials for the treatment of SARS-CoV-1 and MERS-CoV infections. Pegylated interferon lambda-1 (peg-IFN-λ1) has been used to treat hepatitis delta virus infection and is studied to treat COVID-19 infection. It was assessed whether peg-IFN-λ1 would initiate an antiviral program capable of inhibiting productive infection of primary human airway epithelial (HAE) cell cultures by SARS-CoV-2. Pretreatment of HAE with peg-IFN-λ1 provided a potent dose dependent reduction in SARS-CoV-2 infectious virus production, as shown in
To determine if this in vitro antiviral effect would translate to in vivo efficacy, prophylactic and therapeutic efficacy studies in BALB/c mice were performed. Peg-IFN-λ1 (2 μg) was subcutaneously administered 18 hr prior or 12 hr after infection with 105 pfu SARS-CoV-2 MA. Both prophylactic and therapeutic administration of peg-IFN-λ1 significantly diminished SARS-CoV-2 MA replication in the lung as shown in
Pegylated-IFN-λ1 treatment in vitro. Peg-interferon Lambda-1a was distributed into prefilled syringes, 0.18 mg/syringe (0.4 mg/mL). Primary human airway epithelium cell cultures (HAEs) were grown. Human tracheobronchial epithelial cells were obtained from airway specimens resected from patients undergoing surgery. Primary cells were expanded to generate passage 1 cells and passage 2 cells were plated at a density of 250,000 cells per well supports. HAEs were generated by differentiation at an air-liquid interface for 6 to 8 weeks to form well-differentiated, polarized cultures that resembled in vivo pseudostratified mucociliary epithelium. HAEs were treated with a range of peg-IFN-λ1 doses basolaterally for 24 hrs prior to infection. 1 μM remdesivir was used as a positive control. Cultures were infected at an MOI of 0.5 for 2 hours. Inoculum was removed and culture was washed three times with PBS. At 48 hrs post infection, apical washes were taken to measure viral replication via plaque assays as described above.
Pegylated-IFN-λ1 treatment in vivo. Mice were subcutaneously treated with a single 2 ug dose of peg-IFN-λ1 prophylactically at 18 hrs prior to infection, therapeutically at 12 hrs post infection, or PBS vehicle treated, and infected with 105 plaque forming units (PFU) of SARS-CoV-2 MA intranasally under ketamine/xylazine anesthesia. Body weight was monitored daily. On day 2 post infection, mice were euthanized by isoflurane overdose and tissue samples were harvested for titer analysis as described above.
Using the methods and criteria described above in Examples 1-3, a first trial was performed. In the first trial, 120 participants were enrolled; 70 (58.3%) were male, 75 (62.5%) identified as Latinx, and the median duration of symptoms prior to randomization was 5 days. Sixty participants were randomly assigned to receive 180 mcg pegylated interferon lambda-1a, and 60 participants were assigned to receive a placebo. At enrollment, 49 (40.8%) participants were SARS-CoV-2 IgG seropositive; seropositive participants had a significantly lower viral load at enrollment compared with seronegative (log10 viral load 2.0 vs. 4.4). Subjects viral samples were taken by oral pharyngeal swabs. The median time to cessation of viral shedding was 7 days in both arms (hazard ratio [HR] for duration of shedding 0.81 comparing Lambda vs. placebo; 95% confidence interval [CI] 0.56 to 1.19; p=0.29). No difference in time to resolution of symptoms was observed comparing interferon lambda vs. placebo (HR 0.94; 95% CI 0.64 to 1.39; p=0.76). Two serious adverse events were reported in each arm. Liver transaminase elevations were more common in the interferon lambda vs. placebo arm (15/60 vs 5/60; p=0.027).
In this study, a single dose of subcutaneous pegylated interferon lambda-1a compared to placebo was well tolerated, but neither shortened the duration of SARS-CoV-2 viral shedding nor improved symptoms.
It was observed that the time to shedding cessation was faster in seropositive subjects (p=0.03). Interferon lambda appeared to hasten shedding cessation among those who were seropositive at baseline and delayed shedding cessation relative to placebo among those who were seronegative at baseline. In the setting of an effective immune response, interferon lambda may augment viral clearance, whereas in the absence of an immune response, lambda protects cells from virus-mediated apoptotic cell lysis.
Using the methods and criteria described above in Examples 1-3, a second trial was performed to assess interferon lambda for immediate antiviral therapy at diagnosis in COVID-19 infections. The second trial included a randomized trial of pegylated interferon lambda in outpatients with mild to moderate COVID-19 infection.
Of 364 individuals approached for the second trial, 105 did not meet inclusion/exclusion criteria and 199 eligible individuals declined to participate as shown in
Thirty participants were randomly assigned to receive 180 mcg pegylated interferon lambda-1a, and 30 participants were assigned to receive a saline placebo. Patients were followed for 14 days. Nasopharyngeal samples were collected. The baseline SARS-CoV-2 viral load in the interferon lambda group was 6.2 log10 copies/mL and was 4.9 log10 copies/mL in the placebo group. In the interferon lambda group (19 subjects) and placebo (16 subjects) groups, there were a total of 35 subjects with viral loads great or equal to 6 log10 copies/mL. In the interferon lambda group, all subjects were below the level of shedding infectious virus at day 7, had more rapidly cleared the virus than the placebo group, and had a higher probability of clearing the virus at day 7 than the placebo group.
The primary efficacy outcome was the proportion of individuals with a negative MT swab for SARS-CoV-2 at Day 7. The primary safety outcome was the incidence of treatment-emergent severe adverse events by Day 14. Secondary outcomes included: time to SARS-CoV-2 undetectability, change in quantitative SARS-CoV-2 RNA over time, anti-SARS-CoV-2 IgG antibody positivity, the incidence and severity (mild/moderate/severe) of adverse events (Aes), and the proportion hospitalized by Day 14. Detailed directed and open-ended symptoms were assessed serially. Because of overlap between symptoms of COVID-19 and potential peginterferon-lambda Aes, symptoms were recorded and Aes were considered any symptom outside of the directed symptom assessment. Laboratory AE severity was graded using the Common Terminology Criteria for Adverse Events (CTCAE) Version 5.0. An independent Data and Safety Monitoring Committee (DSMC) reviewed safety data after 10, 20 and 30 patients completed 7 days of post-treatment follow-up. After review, the DSMC advised the study team whether to continue enrolment.
The decline in SARS-CoV-2 RNA was significantly greater in the peginterferon-lambda group than in the placebo group (p=0.04), as shown in
Overall, by Day 7, 24/30 (80%) in the peginterferon-lambda group were negative for SARS-CoV-2 RNA compared to 19/30 (63%) in the placebo arm (p=0.15), as shown in
The odds of viral clearance by Day 7 with peginterferon-lambda treatment compared to placebo increased with every log increase in baseline viral load as shown in
In contrast, in those with baseline viral load below 106 copies/mL at baseline, 9 of 11 (82%) in the peginterferon-lambda arm and 13 of 14 (93%) in the placebo arm were undetectable at Day 7 (OR 0.35, 95% CI 0.01-4.15, p=0.40), as shown in
No baseline covariates modified the association between baseline viral load and treatment assignment with clearance by Day 7, as summarized in Table 3. Participants who were asymptomatic were more likely to have baseline viral loads below 106 copies/mL than those with symptoms (91% vs 27%, p<0.001). At randomization, 5/51 (9.7%) participants with available samples were seropositive for SARS-CoV-2 IgG antibodies, of whom 4 had undetectable SARS-CoV-2 RNA. Antibody positivity increased in both groups over time as shown in
Participants with low viral loads also had milder symptoms at baseline with symptoms improving over time in both groups. Interferon lambda was well-tolerated with few adverse events, which included minimal elevations of transaminases which self-resolved.
Symptoms were grouped into 7 categories and reported as absent/mild/moderate or severe, as shown in Table 4. Respiratory and fever-syndrome symptoms were most common in both groups, as shown in
Laboratory Aes were mild and similar between groups. Aminotransferases were elevated at baseline in 3 (11%) participants in both groups and increased mildly, moreso in the peginterferon-lambda group, however only two individuals met the threshold of Grade 3 elevation, one in each arm. No other grade 3 or 4 laboratory Aes were reported, as summarized in Table 6. There were no elevations in direct or total bilirubin with the observed aminotransferase increases. Hemoglobin, white blood count and platelets were similar between groups with no episodes of myelosuppression in either group. D-dimers were elevated in both groups at baseline but declined over time only in the peginterferon-lambda group (Day 7: placebo 841 ug/L vs peginterferon-lambda 437 ug/L, p=0.02). Other inflammatory markers including ferritin and C-reactive protein were elevated at baseline in both groups and changed minimally over time, as shown in
Aes outside of the directed symptom categories occurred in one participant in the placebo arm (rectal bleeding) and in two in the peginterferon-lambda arm (confusion, pneumonia), all deemed unrelated to treatment. One serious adverse event was reported in each group. A participant in the placebo group was hospitalized on Day 1 post-injection with progressive shortness of breath attributed to worsening COVID-19. One participant in the peginterferon-lambda group was admitted to hospital on Day 14 with dyspnea and found to have a pulmonary embolism necessitating anticoagulation. No deaths occurred in either group.
Treatment with a single dose of peginterferon-lambda accelerated the viral load decline and, after controlling for baseline viral load, reduced the time to viral clearance in outpatients with COVID-19. The treatment effect was most apparent in those with high baseline viral loads. Peginterferon-lambda was well tolerated with similar symptoms reported to those treated with placebo.
Results for SARS-CoV-2 diagnostic testing are routinely reported dichotomously as positive or negative without viral load quantification. The current standard of reporting cycle threshold (Ct) values is only semi-quantitative, and therefore assays or even runs cannot be reliably compared. Quantification is useful clinically as higher viral levels have been correlated with greater severity of COVID-19 and the level of virus correlates with infectivity. As people clear the virus, they may have persistently very low levels of RNA detected at very high Ct values (>33), which are not infectious.
Although the second trial found that, after controlling for baseline viral load, the odds of clearance were greater in all study participants with peginterferon-lambda than with placebo, the effect of peginterferon-lambda was most evident when baseline viral loads were above 106 copies/mL. While the specific threshold for transmissible virus is unknown, using a standard infectivity assay, Bullard and colleagues reported that at Ct values above 24, corresponding to approximately 6-7 log copies/mL, infectious virus could not be detected. See Bullard et al., “Predicting infectious SARS-CoV-2 from diagnostic samples,” Clin. Infect. Dis., May 2020 (doi:10.1093/cid/ciaa638). It was observed that in individuals with low levels of virus, irrespective of their assigned group, spontaneous clearance occurred rapidly and near-universally by Day 7. Similarly, a recent evaluation of the REGN-COV2 monoclonal antibody cocktail demonstrated that individuals with the highest baseline viral loads exhibited the largest reduction in SARS-CoV-2 RNA with treatment, while those with detectable SARS-CoV-2 antibodies at baseline had low viral loads and did not benefit from therapy. See “Regeneron's REGN-COV2 Antibody Cocktail Reduced Viral Levels and Improved Symptoms in Non-Hospitalized COVID-19 Patients,” Press Release, Regeneron Pharmaceuticals, Inc., Sep. 29, 2020, available at https://investor.regeneron.com/news-releases/news-release-details/regenerons-regn-cov2-antibody-cocktail-reduced-viral-levels-and.
In the placebo group with high baseline viral load, 10 of 16 (63%) participants had detectable virus at Day 7, with 6 of 10 (60%) continuing to exceed 105 copies/mL, raising concern of persistent shedding of competent virus. In contrast, only 4 of 19 (21%) participants who received peginterferon-lambda had detectable virus at Day 7, all with viral loads below 106 copies/mL. If this effect is confirmed in larger studies, a strategy of reserving treatment for those with high viral loads (≥106copies/mL) may shorten the required period of isolation with a reduced likelihood of transmission for all infected individuals. While quantitative testing could likely be introduced wherever quantitative PCR is used for diagnosis and may have an added benefit by predicting those at risk of a severe clinical course, it is currently not widely available. Given the tolerability of a single dose of peginterferon-lambda, it may be reasonable to consider treatment irrespective of baseline viral load, as a simple, universal approach. Alternatively, a qualitative assay, ideally a point-of-care test, could be titrated to achieve an analytical sensitivity of approximately 106 copies/mL allowing for immediate risk stratification and determination of the need for treatment. Indeed, this could likely already be achieved using currently available rapid antigen tests, which demonstrate detection sensitivities in the range of 10-50,000 copies/mL, safely below the infectious threshold but avoiding those with extremely low viral loads who are unlikely to require any intervention.
Peginterferon-lambda was well tolerated with no safety concerns identified. Because the side effects of peginterferon-lambda may overlap with COVID-19 symptoms, it is difficult to distinguish whether Aes were related to treatment or persistent infectious symptoms. With detailed serial symptom assessment, it was found that symptoms improved in both treatment groups over time without obvious differences. Notably, among those who were asymptomatic at baseline, there was no difference in Aes between the treatment and placebo groups. Mild, reversible transaminase elevations were seen more frequently in the peginterferon-lambda group, which have been reported previously with this agent. Intriguingly, D-dimer levels fell with peginterferon-lambda treatment, which may be relevant given the association of high levels with more severe disease and increased all-cause mortality. The side effect profile and absence of hematological toxicity is in keeping with the better tolerability of Type III interferons compared to Type I interferons, such as IFN-alpha/IFN-beta. Treatment with interferon lambda may be particularly attractive given reports that impaired interferon production and the presence of autoantibodies to interferon alpha are associated with severe COVID-19. See Bastard et al., “Auto-antibodies against type I IFNs in patients with life-threatening COVID-19,” Science, September 2020 (doi:10.1126/science.abd4585); Zhang et al., “Inborn errors of type I IFN immunity in patients with life-threatening COVID-19,” Science, September 2020 (doi:10.1126/science.abd4570); Hadjadj et al., “Impaired type I interferon activity and inflammatory responses in severe COVID-19 patients,” Science, August 2020 (doi:10.1126/science.abc6027). Additional benefits include the broad activity of interferon lambda against multiple respiratory pathogens, including influenza, the very high barrier to resistance of interferon lambda, and the availability a long-acting formulation that permits a single subcutaneous injection.
Considerations for the study of the second trial: The sample size was small, but clearance rates in those with high viral loads were in line with the power calculations. Based on viral load and antibody data at the baseline visit, several participants were likely clearing or had cleared the virus, an observation reported in other COVID-19 outpatient studies. The benefit of treatment was mainly observed in the group with a high baseline viral load, requiring the introduction of quantitative assays or calibrated qualitative tests for COVID-19 diagnosis and risk stratification to operationalize its use. However, even those with low viral loads could be treated given the safety profile. A high proportion of potentially eligible individuals declined to participate in the study, likely based on the listed AE profile, which reflected weekly injections for a year for treatment of hepatitis B and C infections. Importantly, the enrolled population was diverse, with individuals born in 25 different countries.
A third trial was performed using the methods and criteria described below. The trial is known publicly as the TOGETHER trial (ClinicalTrials.gov number, NCT04727424).
1. Consent Process
Where feasible, individuals at the COVID-19 assessment centers or emergency departments will be offered evaluation using the ID NOW POC COVID-19 test and provided with information about the study. Those testing positive by ID NOW will be offered immediate evaluation for eligibility and enrolment. Where POC testing in the assessment centre or emergency room is not available, individuals will be given written information about the study and provided information to contact study staff by email or telephone if they are interested in study participation. The study will also be advertised on social media with contact information of the study team. Providers caring for patients with COVID-19 may also refer patients to the study after obtaining verbal consent to share contact information with the study team. Those with a positive POC test or referred to the study with confirmed positive results will be screened by study staff for other inclusion/exclusion criteria and will be provided a consent form in person or electronically for review. In addition to the consent to the trial, participants will be offered an additional optional consent for genetic testing (see, infra, Ex. 7, Section 9) and a second optional consent for collection of peripheral blood mononuclear cells (“PBMCs”) at participating sites (see, infra, Ex. 7, Section 10). The study coordinator will read the consent form verbatim while the patient reads along. When the patient consents, the study coordinator will sign his/her copy of the document, and this will be witnessed and signed by an impartial witness. This document will stay in the patient's study file. Upon coming to the clinic, the study team will provide the patient a paper copy to keep and not return to the study team. Those with a positive test for SARS-CoV-2 and who meet all inclusion/exclusion criteria and have signed consent will be randomized (see, infra, Ex. 7, Section 7).
2. Enrollment and Randomization
Those who test positive and remain symptomatic (to be called morning of visit for confirmation of persistent symptoms if no POC test is available in the assessment centre) will be invited to attend the outpatient clinic for completion of screening, enrolment and randomization (see, infra, Ex. 7, Section 7). Potential participants will be screened by phone for factors associated with severe COVID-19 (age>55 years, diabetes/hypertension/obesity, severe symptoms including documented fever and/or respiratory symptoms and/or myalgias). Consenting individuals will undergo a medical history evaluation, including current medication use, and complete a symptom survey to be recorded on a baseline case report form Women of childbearing potential will take a urine pregnancy test to confirm eligibility. Female participants who are concerned they may be pregnant will not be enrolled even if the test is negative (in case it is too early for a positive result). Female and male subjects will be advised to use appropriate measures to avoid pregnancy during the week following administration of peginterferon lambda and for at least 3 months after the dose of peginterferon lambda.
Vital signs, including blood pressure, temperature, pulse, respiratory rate and oxygen saturation in ambient air will be recorded. The eligibility checklist will be reviewed by a site sub-investigator (“sub-I)/principal investigator (“PI”) and if deemed to be necessary, a history and physical examination will be performed by the sub-I/PI. Potential participants meeting all inclusion and no exclusion criteria will be offered study enrollment. Eligible participants will have a POC COVID-19 test performed, a provider-collected NP swab for viral load quantification and will have blood drawn for routine laboratory (CBC, creatinine, liver profile) and inflammatory markers (LDH, ferritin, D-Dimers, c-reactive protein, creatine kinase), a research sample for plasma to be stored for future use, as well as optional blood for genetic and PBMC sub-studies (at participating sites) for those who consent. The genetic and/or PBMC sample will replace the research plasma sample, as plasma can be used after PBMC isolation or preparation for extraction of genetic material. Patients will also be instructed on self-collection of mid-turbinate nasal swab and will self-swab witnessed by the study staff.
Eligible patients included in the study will be assigned to one of the 2 treatment arms according to a standard computer-generated randomization schedule 1:1 in blocks of 4, stratified by POC test result (positive or negative). Numbered opaque envelopes with treatment arm allocation for randomized subjects will be stored at the outpatient site. Upon instruction to randomize from the PI or designate sub-I, the coordinator will open the envelope to reveal the treatment allocation. The study ID, month and year of birth and initials will be recorded on the randomization form as a unique identifier and emailed/faxed to the TCLD. The treatment codes will be maintained by the trial statistician in a password-protected file which cannot be accessed by other study personnel or subjects. In future study materials and analyses, the subject will be referred to only by the study identification number.
3. Study Interventions
Subjects randomized to the peginterferon lambda arm will receive a single SC injection in the lower abdomen of peginterferon lambda 180 mcg, and subjects randomized to placebo will receive a single SC injection in the lower abdomen of saline (and this will count as Day 0 of the study for the Schedule of Events shown in
After discharge, participants will follow the standard-of-care advice given to all individuals with COVID-19 at the Assessment Centre/ER. Participants will return home and remain in home isolation for at minimum 10 days from symptom onset according to current local Public Health recommendations. The exception to home isolation will be for study visits, as permitted by Public Health (for example, people with COVID-19 may attend medical appointments provided proper precautions are taken including wearing a mask at all times).
Participants will be contacted at a pre-specified time on multiple check days (proposed: days 1, 3, 5, 7, 10, 14, 17, 21, 24, and 28) by a study coordinator by phone/videoconference to review the symptom questionnaire and AE survey, concomitant medications, and to record the digital oral temperature and oxygen saturation. During the virtual visit, results will be recorded onto case report forms by the study coordinator and entered into the secure REDCap electronic case report form (eCRF) database. Participants will collect a mid-turbinate nasal swab after speaking to the study coordinator and, wherever possible, collection will be observed by the study coordinator using videoconferencing. On subsequent days, mid-turbinate nasal swabs will be self-collected without observation unless requested by the participant. The viral media with the swab will be stored in a plastic container inside a cooler that will be provided to the participant and stored until collection.
On Days 1-6, and 8-13, a self-collected mid-turbinate nasal swab will be taken and stored as above.
On Day 3, the self-collected mid-turbinate nasal swabs from Days 1, 2 and 3 will be retrieved by courier.
On Day 7, the participant will attend the outpatient clinic and a provider-collected NP swab and self-collected mid-turbinate nasal swab will be obtained. The Day 4, 5, and 6 mid-turbinate swabs will be retrieved at this visit. Blood will be drawn for routine laboratory and inflammatory markers, a research sample to be stored for future use and additional samples for those who consented to PBMC collection.
On Day 10, the self-collected mid-turbinate nasal swabs from Days 8, 9, and 10 will be retrieved by courier.
On Day 14 and/or Day 28, the participant will return to the outpatient clinic and a provider-collected nasopharyngeal swab and a self-collected mid-turbinate nasal swab will be obtained. The Day 11, 12, and 13 swabs will be retrieved at this visit. Blood will be drawn for routine laboratory and inflammatory markers, a research sample to be stored for future use and additional samples for those who consented to PBMC collection.
On Day 90+ (up to one year), participants will return to the outpatient clinic for a provider-collected NP swab, a final blood draw and to complete the symptom survey. Those who consent to Day 90 PBMC collection (even if they did not consent to PBMC collection during the treatment phase of the study) will have these additional tubes drawn. Up to 8 tubes of blood will be collected.
For participants who cannot travel to the clinic, the option of home visits by the study team will be discussed for the Day 7, 14 , and/or 28 visits (see, infra, Ex. 7, Section 5). Home visits will not be offered for the Day 90 visit.
4. Mid-Turbinate Swab Collection
The rationale for self-collection of mid-turbinate nasal swabs is to allow for more frequent sampling to determine the time of viral clearance and quantitative viral kinetics. Self-collection of mid-turbinate nasal swabs has been validated and was performed in the prior in studies of peginterferon-lambda for COVID-19. Understanding how quickly individuals clear SARS-CoV-2 is very important for determining when people could potentially end their self-isolation. In addition, viral kinetics using quantitative PCR may provide insights into the mechanisms of clearance, as has been successfully done with other viral infections. A previous study done by our group has shown that mid-turbinate nasal swabs can be reliably self-collected with only marginally lower sensitivity (69/71, 91% concordance) for influenza, rhinovirus and respiratory syncytial virus detection than standard nasopharyngeal swab.
Participants will be instructed and observed at the first visit on the collection of mid-turbinate nasal swabs and if possible, the first self-collection sample will be observed by the coordinator during the videoconferencing visit. Participants will be given written instructions on how to store the swabs. After putting the swab into the viral culture media, the swab will be placed into two clear biohazard bags inside the provided sealed cooler. A courier will retrieve the Day 1, 2 and 3 swabs on Day 3 and similarly on Day 10, the Days 8, 9 and 10 samples will be retrieved. At the Day 7 and 14 clinic visits, the participant will bring in samples 4, 5 and 6 (for Day 7) and 11, 12 and 13 (Day 14). To do so, they will place the cooler into 2 provided clear biohazard bags and bring the bags to the clinic. Upon receipt of the bags in the clinic, the outer bag will be decontaminated and then the specimens will be taken or sent to Toronto General Hospital for storage at −80° C. in the laboratory of the PI.
5. Home Visits
For participants unable to travel to clinic visits, home visits by study staff will be provided as an alternative, provided participants live within a 30-minute drive of the site from which they were recruited and are agreeable to having study staff visit their home. Procedures/precautions will be taken to ensure staff safety. For home visits, the study coordinator will drive to the participant home at an agreed up pre-specified time. Upon arrival, the coordinator will call the participant as notification. The coordinator will don personal protective equipment (mask, gown, gloves and face shield) and enter the home to carry out the study visit. Upon completion of the study visit, the coordinator will doff personal protective equipment and place it in a clear plastic bag. It will then be transported back to the hospital/clinic for appropriate disposal.
6. Household Contacts
For participants with household contacts, the coordinator will ask the participant at each contact to report a confirmed diagnosis of COVID-19 with the date of symptom onset in any household contacts. Participants will also record diagnosis of COVID-19 in household contacts in their symptom diaries. Participants will be contacted at Day 28 to specifically ask if any household contacts have been diagnosed with COVID-19 and the date of symptom onset. For the purpose of analysis, any confirmed COVID-19 diagnoses in household contacts within 3 days of study enrolment will be considered to be present prior to the study and will not count in assessment of incident infections.
7. Clinic Visits
Safety procedures will be followed to ensure that clinic visits are carried out safely minimizing exposure to the public and study staff. Upon arrival, the participant will call the study coordinator from the car. The coordinator will advise the participant when to come into the clinic. For participants who are unable to drive to clinic visits, a chauffeur will be arranged by the study team.
8. Safety Assessment
Blood work will be collected prior to the peginterferon lambda injection but will not be used to determine eligibility. Hepatotoxicity has been noted in studies of peginterferon lambda in patients with chronic viral hepatitis. Transaminase elevations were reported, and hepatic decompensation has been reported but only in people with a prior history of decompensation prior to dosing. The study team has extensive experience managing patients with underlying liver disease (3 investigators are hepatologists) and multiple investigators have experience with peginterferon lambda use as well. If baseline laboratory results are suggestive of cirrhosis (unlikely), patients will be informed of this and followed carefully for signs of hepatic decompensation (ascites, hepatic encephalopathy, variceal hemorrhage) during follow-up, with prompt referral to the hospital should these signs/symptoms occur.
The most relevant other concern would be unrecognized renal impairment. Dosing advice is unclear for patients with estimated glomerular filtration rate (eGFR) below 50 mL/min. Participants found to have a reduced eGFR (<50 mL/min) after dosing will be advised of the test result and the need for follow-up. The consequences of dosing during renal impairment are not well understood but may lead to increased concentrations of systemic interferon lambda. Participants will be followed virtually frequently with in-person visits at day 7 and 14 with repeat blood tests on those days. Those with unexpected renal impairment will be followed according to the standard follow-up in the protocol, however, additional investigations may be performed at the discretion of the treating physician.
9. Optional Consent: Genetic Testing
A genome-wide association study (GWAS) performed on people treated with interferon-alpha therapy for hepatitis C virus (HCV) infection identified a single nucleotide polymorphism (SNP) near the interleukin 28B (IL28B) gene that was strongly associated with response to treatment. See Ge D et al., “Genetic variation in IL28B predicts hepatitis C treatment-induced viral clearance,” Nature, September 2009; 461(7262):399-401. Doi:10.1038/nature08309. Subsequent studies confirmed the association and found that this SNP was also associated with spontaneous HCV clearance. See Thomas D L et al., “Genetic variation in IL28B and spontaneous clearance of hepatitis C virus,” Nature, October 2009; 461(7265):798-801. Doi:10.1038/nature08463. Although the originally identified SNP was in a non-coding region, a later study identified a novel mRNA transcript induced by viral infection in hepatocytes. The transcript codes for a novel Type III interferon called interferon lambda 4 (IFNL4). See Prokunina-Olsson L et al., “A variant upstream of IFNL3 (IL28B) creating a new interferon gene IFNL4 is associated with impaired clearance of hepatitis C virus,” Nat. Genet., Feburary 2013; 45(2):164-71. Doi:10.1038/ng.2521. A deletion in the IFNL4 gene prevents production of a functional protein. The lack of the functional IFNL4 is associated with HCV treatment response to interferon-based therapy and with spontaneous HCV clearance. In contrast, production of functional IFNL4 is associated with non-response to interferon-based therapy for HCV. The prevalence of the IFNL4 mutation varies by ethnicity, with 80% of East Asians producing no functional IFNL4 whereas approximately 75% of Africans produce the functional protein. The difference in prevalence explains the bulk of the difference in HCV treatment response by ethnicity. It is unknown whether the IFNL4 genotype affects response to interferon lambda treatment and/or the natural course of COVID-19. Currently no other genes have been identified that modify the course or response to treatment of COVID-19.
Study participants will be asked to sign an optional consent giving permission to study genetic associations between disease outcome and treatment response during COVID-19 infection. Participants who agree to genetic testing will have a tube of whole blood taken on Day 0 for DNA extraction and storage. The IFNL4 genotype will be determined in all consenting participants and DNA will be stored for future analysis in case other relevant genes are identified.
10. Optional Consent: Peripheral Blood Mononuclear Cell
To evaluate SARS-CoV-2-specific immune responses, a subset (˜30%) of participants will be asked to consent to provide additional blood for peripheral blood mononuclear cell (PBMC) isolation. Those who agree will have 5 ACD (acid citrate dextrose) tubes collected on Day 0, 7 and 14. The magnitude and change in SARS-CoV-2-specific immune responses will be evaluated using standard interferon-gamma ELISPOT assays to over-lapping peptides of SARS-CoV-2. Participants will be asked to consent to provide additional blood for PBMC isolation at Day 90+ post-dosing (up to 1-year post-dosing). Provision of blood for the Day 90+ PBMCs will be requested of all participants irrespective of whether they agreed to PBMC collection during the course of treatment. The rationale for the late PBMC collection is to assess the degree of T cell immunity and antibodies targeting SARS-CoV2 and to determine whether the PBMC responses are influenced by peginterferon lambda treatment.
11. Optional Consents: Antibody Testing
The presence of antibodies to SARS-CoV-2 will be assessed at Days 0, 7, 14, 28 and 90+. Although the clinical significance of the presence of IgM/IgG antibodies is not fully understood, the presence and quantity of anti-COVID-19 antibodies on day 14 of the study to day 90+ visits will be compared; including assessing whether the administration of peginterferon lambda may affect the emergence or quantity of antibody. In addition to collecting plasma, the utility of collecting blood by finger-prick onto a dried blood spot card will be assessed. The sample would be eluted from the card and will also be analyzed on one of the Health Canada approved platforms. Dried blood spots have been widely used in resource-limited countries for the presence of hepatitis B, C and HIV antibodies, and several countries are also implementing this collection method for seroprevalence studies of COVID-19. However, to date, there are few head-to-head comparisons of venipuncture to finger-prick collection for COVID-19 antibodies; and the ability to collect by both methods in this study will provide data as to whether this method is feasible and comparable to testing from plasma.
12. Study Withdrawal
An investigator may advise a participant to withdraw from the study if there are concerns for participant safety. Data from participants who discontinue for safety will still be collected unless the participant withdraws consent. Participants who discontinue prematurely before assessment of the primary endpoint will be counted as treatment failures for analysis. Participants who discontinue prematurely due to safety concerns will not be replaced.
Participants may withdraw from the study at any time. The reason for withdrawal must be documented. Participants who discontinue prematurely will be included in the analysis of results (as appropriate) and may be replaced in the enrollment. If agreeable, participants who choose to discontinue the study prematurely, will be asked to have a final study visit to document final virologic results. Participants may decline the final study visit at the time of withdrawal.
13. Data Analysis
The assessment of endpoints—safety, clinical and virological efficacy—will be determined by study staff blinded to the treatment assignment of the participant. Descriptive statistics will be used to summarize demographic and clinical baseline characteristics of enrolled participants. Continuous variables will be summarized with mean, median, SD, quartiles, and minimum and maximum values, as appropriate. Categorical variables will be summarized using counts and proportions. For the primary clinical endpoint, the association of peginterferon-lambda with ER/hospitalization will be evaluated by logistic regression as univariate analysis and as bivariate analysis controlling for baseline viral load. The primary virological outcome will be assessed with a log rank test comparing the two survival curves of SARS-CoV-2 RNA negativity over the first 14 days. Once Day 14 information has been collected for the last participant, the study will be unblinded and the data will be made available for analysis to allow for prompt dissemination of the results. Day 28 information will still be collected thereafter for the remaining participants, but this only pertains to outcomes of potential home transmission so will not influence the primary or key secondary outcomes. RNA negativity for determination of the primary virological endpoint will require two consecutive negative specimens but will be counted as occurring on the first of the two negatives. Participants who die before reaching RNA negativity will be counted as never reaching negativity. Participants who withdraw from the study prior to reaching RNA negativity will be counted as never reaching negativity for the intent to treat (ITT) analysis. For the secondary endpoint of incident infection in household contacts, infections with symptom onset within 3 days of study enrollment will be deemed to have occurred prior to study enrollment and thus not counted as post-study enrolment incident infections.
A secondary analysis will be performed on the modified ITT population, including anyone who took a dose of peginterferon lambda or placebo. Factors associated with severity of disease and clinical course will be evaluated by uni- and multivariable logistic regression. Secondary endpoints will be described and analysed depending on the outcome with chi-2 test for proportions, log-rank test for time to event and repeated measurement modelling for multiple outcomes per patient over time. Viral kinetics will be determined using quantitative SARS-CoV-2 RNA and correlated with inflammatory and cytokine profiles. If feasible, quantitative results will be plotted to develop a model of peginterferon lambda activity against SARS-CoV-2. A complete statistical analysis plan will be created prior to data analysis.
14. Symptoms and AE/SAE Reporting
Symptoms will be collected by phone/videoconference or by self (depending on the study day). Participants will be asked about specific symptoms known to be common in COVID-19 or to be reported with interferon use. Symptoms will be rated as: none, mild, moderate or severe. They will also be asked about their overall state of health and an open-ended question about additional symptoms and again rate them by severity and change over time. The following symptoms will be specifically explored:
An adverse event (AE) is any adverse change from the participant's baseline (pre-treatment) condition, including intercurrent illness which occurs during the course of the trial, after the consent form has been signed, whether the event is considered related to treatment or not. The Common Terminology Criteria for Adverse Events CTCAE v 5.0 will be used for grading severity of Aes.
A serious adverse event (SAE) is any adverse event that at any dose:
Unexpected adverse events are those which are not consistent in either nature or severity with information contained in the investigator brochure or product monograph.
Adverse events considered related to protocol treatment are those for which a relationship to the protocol agent cannot reasonably be ruled out.
All serious adverse events which are unexpected and related to protocol treatment must be considered reportable, and therefore be reported in an expedited manner.
Medical and scientific judgment will be exercised in deciding whether expedited reporting is appropriate in other situations such as important medical events that may not be immediately life threatening or result in death or hospitalization but may jeopardize the patient or may require intervention to prevent one of the events listed above. These should also be considered serious.
All SAEs meeting the above criteria must be reported to the sponsor site to either the PI or the TCLD research coordinator in an expedited fashion. SAEs should be reported to the sponsor within 24 hours. In many instances, complete clinical information may not be available. Whatever information is available on the SAE should be provided to the sponsor within 24 hours. As new information becomes available, it should be forwarded to the sponsor. Each site will report unexpected Aes or SAEs to their REB as per their local site regulations.
A serious adverse event, which is unexpected and is related, will require expedited reporting to the appropriate oversight committees or entities, as per local site regulations. In conclusion, this is the first antiviral therapy to show benefit among outpatients with COVID-19. Peginterferon-lambda accelerated viral clearance, particularly in those with a high viral load at baseline. This treatment has the potential to avert clinical deterioration, shorten the duration of infectiousness and limit time required in isolation.
15. Preliminary Trial Results
Preliminary Trial Summary: Patients were randomized 1:1 single injection of interferon lambda vs. placebo within 7 days of symptom onset and positive SARS-CoV-2 test. The real world population included non-hospitalized, mild, or moderate COVID-19 patients at high risk for COVID-19 disease progression. High-risk criteria defined by patients having at least one of the following criteria, including but not limited to: over age 50, diabetes, hypertension, cardiovascular disease, lung disease, kidney disease, obesity, etc. as described above. 84% of the patients had received a least a single dose of any vaccine (16% unvaccinated). The study was pan-variant, including patients with any SARS-CoV-2 variant infection. The primary endpoint was reduction of hospitalizations or emergency room visits through Day 28 following treatment. A key secondary endpoint is a risk reduction in death. Patients were enrolled from July 2021 to February 2022. Final analyses evaluated data from 1,936 patients (the intent to treat (ITT) population). The data from these analyses is shown in Tables 8-15 and
Final analyses using a Bayesian analytic framework showed:
In addition, viral sequencing was conducted on all patients. Lambda demonstrated pan-variant efficacy in all variants tested, including omicron, with potential for efficacy to any new arising variants.
As shown in
16. Final Trial Results
Final Trial Summary: To evaluate peginterferon lambda's effect on important clinical endpoints, a large, randomized, placebo-controlled trial was conducted among outpatients with SARS-CoV-2 in Brazil and Canada using the TOGETHER adaptive platform trial. As described in this example, a master protocol defines prospective decision criteria for discontinuing interventions for futility, stopping due to superiority against placebo, or adding new interventions. See Reis ,G. et al. GOR 2021. For the current study, peginterferon lambda versus placebo was evaluated (protocol 2). Strengths of the study include the rapid recruitment and enrolment of high-risk patients. Only participants with confirmed symptomatic COVID-19 within 7 days of symptoms (average of 3.3 days) were enrolled.
For this evaluation, 931 patients received peginterferon lambda and 1018 received placebo. 84% of the population were vaccinated, and the trial occurred across waves of multiple COVID-19 variants. In the intention-to-treat analysis of patients, the risk of COVID-19—related hospitalization or retention in an emergency setting was reduced by 51% in the peginterferon lambda group vs. placebo group (relative risk 0.49, 95% Bayesian credible interval 0.30-0.76, posterior probability>99.9%). This effect was maintained in the per-protocol and the modified intention-to-treat populations across all secondary outcomes, including COVID-19-related hospitalization alone (relative risk 0.57, 95% Bayesian credible intervals 0.33-0.95, posterior probability 98.5%) and the composite outcome of COVID-19-related hospitalization or death (Hazard ratio 0.59, 95% Bayesian credible interval 0.35-0.97, posterior probability 98.1%). The effects were consistent across dominant variants and vaccination status. Patients initiating treatment early (≤3 days of symptom onset) experienced greater treatment effects on all outcomes. For example, a 65% risk reduction in COVID-19-related-hospitalization or COVID-19-related-death was demonstrated (Hazard ratio 0.35, 95% Bayesian credible intervals 0.15-0.75, posterior probability 99.6%). Among unvaccinated patients receiving early treatment, we found a risk reduction of 89% in the outcome of COVID-19-related-hospitalization or COVID-19-related-death. Peginterferon lambda also significantly lowered viral loads by Day 7. The incidence of adverse events that emerged during the treatment period was similar in the two groups.
A. Methods
(i) Inclusion Criteria
Upon presentation to one of the trial outpatient care clinics, potential participants were screened with respect to eligibility criteria. Key inclusion criteria were: 1) age≥18 years; 2) presenting within 7 days of symptom onset to an outpatient care setting with an acute clinical condition consistent with COVID-19; 3) positive rapid test for SARS-CoV-2; and 4) 79.5% of participants had at least one high-risk criterion for deterioration including: age≥50 years, diabetes mellitus, hypertension requiring medication(s) for treatment, cardiovascular disease, lung disease, smoking, obesity (body mass index>30 kg/m2), organ transplant, chronic kidney disease (stage IV) or receiving dialysis, immunosuppressive therapy (10 mg prednisone daily or equivalent), cancer diagnosis within 6 months, or receiving cancer chemotherapy. Further inclusion/exclusion criteria are documented in the study protocol. See Reis ,G. et al. GOR 2021. If a patient met the above eligibility criteria, study personnel obtained written in-person informed consent and performed a rapid antigen test for SARS-CoV-2 (Panbio®, Abbott Laboratories).
(ii) Site Description and Timing
The TOGETHER platform trial began recruitment for its first investigational arms in June 2020. The evaluation for patients randomized to the peginterferon lambda treatment arm or placebo arm occurred between 24 Jun. 2021 to 7 Feb. 2022. Local and national research ethics boards approved the protocol in Brazil and in Canada. Twelve Brazilian clinical sites and five Canadian clinical sites participated in this study. Participants were recruited by local investigators, in partnership with local public health authorities, at community health facilities, supplemented by social media outreach.
(iii) Outcome Measures
The primary outcome was a composite endpoint of COVID-19-related hospitalization, defined as referral to a tertiary hospital setting due to the progression of COVID-19 or admission to a COVID-19 emergency setting for >6 hours, both within 28 days of randomization. Because many patients who would ordinarily have been hospitalized were prevented from admission due to hospital over-capacity during peak waves of COVID-19, the composite endpoint was developed to measure both hospitalization and a proxy for hospitalization, retention in a COVID-19 emergency hospital setting. Brazil implemented mobile hospital-like services in the emergency settings with 50-80 bed units providing services including multi-day stays, oxygenation, and mechanical ventilation. The 6-hour threshold referred only to periods of time recommended for observation by a clinician and discounts wait-times. The Event Adjudication Committee, who were blinded to treatment assignment, judged the reason for hospitalization as related or not related to the progression of COVID-19. Guidance for the validity of composite outcomes indicate that outcomes should have a similar level of patient importance. See Montori et al. 2005.
Initially, one of the endpoints of the study was emergency care extended treatment of at least 12 hours. However, during the initial weeks of the trial, it was found that patients rarely stayed for more than 12 hours at emergency units for extended care and were later discharged home due to the progressive overcrowding of emergency units and referral centers for COVID-19. From March 2021, the health units in Minas Gerais State in Brazil experienced a depletion of their hospital bed capacities with >90% occupancy. During the period from May to mid-July 2021, there was >100% occupancy of available hospital beds, leading to situations of “hospitalization” in the corridors of the units as there were no longer available hospital beds. The lack of available hospitals to accommodate patients with moderate to severe COVID-19 was then reflected in the emergency units, where the only option available to frontline medical teams was to release patients as quickly as possible to give others the opportunity to be treated with a minimum decent standard of medical care.
Thus, patients presenting with O2 saturation between 85-93% and dyspnea without overt respiratory failure (i.e. FDA criteria of severe COVID-19 as described in Torres et al. 2020) were treated, undergoing initial respiratory stabilization which included high-dose intravenous corticosteroids, supplemental oxygen, full inhalation therapy, and sometimes antibiotics, and a short stay at ER observation bed unit to monitor O2 saturation and assess for progressive deterioration of respiratory status.
Usually after 4-6 hours, these patients under ER observation were re-evaluated with a decision made for being discharge home or hospitalized. In general, many ER patients were discharged home in less than 6 hours, and the majority of patients were discharged in less than 12 hours so long as they were able to maintain their O2 saturation at 90%. Patients discharged after prolonged ER observation were followed at a homecare program designed especially for persons with COVID-19. Persons unable to be maintain their O2 saturations above 90% were prioritized for hospital admission.
Due to the limitations in health system capacity, it was realized that a minimum observation period of 12 hours was unrealistic to capture participants with moderate/severe COVID-19. For this reason, we asked the National Research Ethics Commission in Brazil to modify the protocol endpoint to be at least 6 hours of ER observation instead of 12 hours. This change, based on the real world of care provided by the public emergency services of the Health System, was approved. This change was registered on clinicaltrials.gov on Mar. 21, 2021. No data were analyzed prior to this change, and all blinding was maintained.
These persons presenting with O2 saturation between 85-93% and dyspnea who underwent >6 hours of observation are consistent with the U.S. FDA definition of severe COVID-19.1
Secondary outcomes included: 1) SARS-CoV-2 viral clearance; 2) time to hospitalization for any cause or due to COVID-19 progression; 3) time to death from COVID-19; 4) days in hospital and on ventilator; and 5) adverse events, and adverse reactions to the study medications. Based on external clinical trials, and according to the CONSERVE 2021 statement reflecting modifications to COVID-19 trials, an outcome was added that allows comparison with previously authorized therapies for COVID-19 outpatient treatment, a composite outcome consisting of COVID-19-related hospitalization or all-cause death at 3 or 7 days of symptom onset. All secondary outcomes were assessed through 28 days following randomization.
(iv) General Procedures
Study personnel collected outcome data via in-person, and via telephone or WhatsApp using video-teleconferencing on Days 1, 2, 3, 4, 5, 7, 10, 14, and 28. Adverse events were recorded at the time they occurred. All serious and non-serious adverse events were reported to study personnel as per local regulatory requirements. Reportable adverse events included serious adverse events, adverse events resulting in study medication discontinuation, and adverse events assessed as possibly related to study medication.
(v) Trial Intervention
All participants received usual standard care for COVID-19 provided by healthcare professionals in Brazil and Canada. Patients allocated to the peginterferon lambda arm received a single subcutaneous dose of peginterferon lambda on the day of randomization. Peginterferon lambda for subcutaneous injection was supplied as a single-use prefilled syringe with a rigid needle shield. It is labelled with a dose indicator used to administer 0.45 mL containing 180 mcg peginterferon lambda. Control patients received an identical saline placebo injection or placebo matching another study arm. As this is a platform trial, patients in the control arm could receive injectable, capsule or tablet placeboes to correspond to other study arms.
The injectable placebo-containing kit contained one syringe and a 5 mL sealed vial with normal IV saline. For administration, the syringe was filled with approximately same volume as the active drug (around 0.4 mL).
Participants were randomly assigned using a block randomization procedure for each participating site, stratified by age (<50 years versus 50 years). Preparation and administration of Lambda or placebo was carried out by an independent unblinded pharmacist or member of the research staff. To maintain the blind, no other team members were present during administration. Study personnel involved in screening or randomization were not involved with any study-related activities after randomization. Study drug was blinded to the treating physician and the TOGETHER study staff involved in the conduct of the study, as well as the patient.
(vi) Virological Assessments and Methods
Self-collected mid-turbinate nasal swabs were performed on Day 3 and 7 post-injection and symptom/event assessments were performed virtually. Participants at the Brazilian sites collected swabs on Day 0, 3, and 7 to allow for viral kinetic data; Canadian sites collected swabs daily up to 14 days. SARS-CoV-2 quantification was performed at the central laboratory of Precision Medicine Labs (Belo Horizonte, MG, Brazil) using the quantitative real-time PCR CDC protocol for the N gene with N1 and N2 primers. See Lu et al. Emerg. Infect. Dis. 2020. RnaseP was run on all samples to confirm sample integrity. Samples negative for RnaseP with undetectable SARS-CoV-2 RNA were counted as missing for all analyses. To convert cycle threshold (Ct) values to quantitative values, a standard curve was generated using a plasmid-derived cDNA standard. The limit of detection was determined to be 10 copies/μL for the N2 primer. Samples below the limit of detection were counted as undetectable. Samples from the Canadian cohort were quantified similarly using a protocol for the E gene (Feld et al. 2021) as well as the CDC protocol for N gene (Lu et al. Emerg. Infect. Dis. 2020). Determination of SARS-CoV-2 variant was performed using exclusion PCR for mutational analysis according to Table 16.
(i) Subgroups
Subgroups were determined a priori, as in previous drug evaluations in our trial. These include: age (≤/>50 years), sex, symptom onset (≤/>3 days), dominant SARS-CoV-2 variant of concern, COVID-19 vaccination status, and obesity (≤/>30 BMI). We applied the ICEMAN tool for subgroup credibility. See Schandelmaier et al. 2020.
Of the 13,416 potential participants screened for inclusion in the TOGETHER trial, 1,949 were recruited, of whom 931 were randomized to peginterferon lambda and 1,018 to concurrent placebo (
A search of Pubmed was done to determine how COVID-19 affects people of different ages, sex, race and pre-existing conditions. See Gang 2020, Carethers 2021, and Kopel et al. 2020. Age. Age is one of the key factors, if not the most significant risk factors for severe disease. Infection rates and deaths increase with age, as 62% of infections are in people>50 years, and 95% of deaths from COVID-19 are for those >50 years Sex. COVID-19 affects men more than women, with men at higher risk than women to develop severe disease. The fatality rate is also increased in men compared to women. A review shows that men are 50% more men requiring hospitalization than women, and the ICU admission is between 3-4 times higher for men. Race. COVID-19 affects different races disproportionately, however this is thought to be due to factors such health care access and exposure risk. Most studies investigating these differences were based in the United States. Compared with white Americans, African Americans were 1.5-3 times more likely to be hospitalized, 3.6 times higher risk of mortality, and Hispanics were 3.2 times higher risk of mortality. These differences are thought to be caused by socioeconomic factors. Pre-existing conditions. Pre-existing conditions is another key risk factor for COVID-19. According to COVID-NET, 89% of hospitalized patients had a pre-existing condition, most commonly hypertension (49.7%), obesity (48.3%), chronic lung disease (34.6%), diabetes mellitus (28.3%) and cardiovascular disease (27.8%). Other considerations. Most of the data gathered on the different effects of COVID-19 on different groups were gathered from the US, China and Europe, as data was lacking for Brazil. Some of these aspects, especially the differences in race, will not translate directly to Brazil as many of findings were related to socioeconomic differences in the United States. Overall representativeness of the trial. Participants were asked their age, sex, race and pre-existing conditions during the screening visit. The participants in the trial were split between 41.8% male to 58.2% female. The proportion of race was 95.2% mixed rice, 0.9% black/African American, and 2.9% unknown. The age distribution was also evenly split, with 53.8% of participants<50 years, while 46.2% were 50 years. The study had a higher representation of females and those<50 years, which represented the course of the pandemic at that time. The distribution of females and males was split evenly between the peginterferon lambda arm and placebo.
(ii) Statistical Methods and Analyses
A Bayesian framework was applied to all analytics and report the posterior probabilities of superiority. The Adaptive Design Protocol and the Master Statistical Analysis Plan provide details of sample size calculation and statistical analysis (as described below), including sample size re-assessment. See Reis et al. GOR 2021. In planning for the trial, it was assumed a minimum clinical utility of 37.5% (relative risk reduction) was needed to achieve 80% power with 0.05 two-sided Type 1 error for a pairwise comparison against the placebo (saline) assuming a control event rate of 15%. This resulted in a planned minimum recruitment of 681 participants per arm and allowed for the Data and Safety Monitoring Board (DSMB) to recommend recruitment discontinuation or continuation. As the incidence of events emerges in waves, the SAP provided an option for re-assessing the sample size at the time of the first interim analysis.
Baseline characteristics are reported as count (percent) or median and interquartile range (IQR) for continuous variables. Posterior probability for the efficacy of peginterferon lambda on the primary outcome was calculated using a Bayesian Cox proportional hazard model. A Modified Intention-to-Treat (mITT) population was defined as receiving treatment for at least 24 hours before a primary outcome (i.e., if events occurred prior to 24 hours after randomization, they were not counted in this analysis). A per-protocol analysis was conducted examining only patients receiving injectable placebo. Subgroup effects were assessed in accordance with the pre-planned statistical analysis plan.
Time-to-event outcomes were assessed using a Bayesian Cox proportional hazard model, binary outcomes using logistic regression, and continuous outcomes using linear regression. A longitudinal mixed effects linear regression (Ime4 in R), with participant entered as a random effect, was used to look for treatment effects over time. A treatment by time interaction was used to look for differential changes in viral load from baseline between the groups accounting for variants. Ct values were converted to copies/ml using a standard curve obtained from the same machine, and analysis were carried out on log10 (copies/m L). Days since randomization was entered as a factor, with Day 0 as the reference category. Baseline load was categorized, a priori, as high (the 15% of patients with the highest baseline load) or low as a three-way interaction with treatment and days since randomization. In addition, the analysis controlled for age, sex, days since onset of symptoms and vaccination status at randomization, and whether Omicron B.11529 was the dominant variant at the time of randomization. For tests where the N2 target was not detected, they were assigned a viral load of 0 for calculation purposes.
All analyses were performed using R version 4.1.0. Code, and priors for Bayesian analysis are described below. A frequentist analysis was conducted as a sensitivity analysis. The trial was coordinated by Platform Life Sciences and CardResearch conducted the trial and collected the data. The manuscript was written by the investigators.
All analyses involving dichotomous outcomes, including the primary outcome, were performed using the Bayesian beta-binomial model with uniform prior distributions for the individual arm event rates. Relative risks and posterior efficacy were evaluated based on size 106 Monte Carlo samples from the resultant Beta posterior distributions. The choice of uniform priors was, in part, made to minimize the impact of prior information, or lack thereof, on the statistical inference. However, given the study size, no major impact of said choice was expected on the estimation, while interim analysis decision boundaries were calibrated to meet frequentist criteria of power and type I error rate. See the statistical analysis plan for more detail.
Time-to-event analyses that were not adjusted for competing risks, and numeric secondary outcomes, were performed using the default Bayesian implementation of the Cox proportional hazards model in the brms R library (see www.jstatsoft.org/article/view/v080i01) with four independent Markov Chain Monte Carlo (MCMC) chains of size 4,000 each and a flat prior distribution assigned to the treatment assignment coefficient. For numeric outcomes, a Box-Cox power transformation was also applied, to satisfy normality requirements. Finally, cause-specific Bayesian competing risks time-to-recovery analysis, adjusted for death, was performed using the method of Mahani and Sharabiani 2019 with parametric Weibull models for the individual survival curves and MCMC samples of size 5,000. The 14-day restricted mean survival time difference, as described in Royston et al. 2013, between the treatment groups was used as the treatment effect for reporting.
B. Results
(i) Primary Outcomes
In the intention-to-treat population of the primary outcome (Table 19), there was a 51% reduction in the primary outcome for participants receiving peginterferon lambda vs. placebo, with 2.7% (25 of 931) of participants allocated to peginterferon lambda experiencing a primary outcome event, compared with 5.6% (57 of 1018) (relative risk 0.49, 95% Bayesian credible interval 0.30-0.76, posterior probability >99.9%) among patients allocated to placebo.
Among patients who at high-risk for severe complications or death from CVOID-19, treatment with Lambda results in a significant reduction in the risk for Hospitalization or ER visit>6 hours. Treatment with Lambda also results in clinically meaningful reductions in the risk for hospitalization or death. Overall, for patients assessed in Brazil, a total of 1525 of a total of 1919 participants (79.5%) would be considered high-risk patients based on underlying conditions as outlined by the U.S. Centers for Disease Control and Prevention (www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html) as well as patients at least 50 years of age. These risk factors include an age of at least 50 years old; cancer; chronic renal disease;chronic liver disease; chronic lung disease, including but not limited to asthma (moderate to severe), bronchiectasis, chronic obstructive pulmonary disease (COPD), including emphysema and chronic bronchitis, and cystic fibrosis; dementia; Type 1 and Type 2 Diabetes Mellitus; cardiovascular disease including but not limited to coronary artery disease, cardiomyopathy, and hypertension; infection with HIV; and immunocompromised.
The high risk population excludes patients who: (1) had fever as an inclusion criteria and/or (2) had COVID symptoms as an inclusion criteria and (3) had no other risk factors.
Although the study was not powered for the sub-group analysis of high-risk patients, the results show a significant treatment effect for the primary endpoint as well as positive clinically meaningful treatment-related trends on the important clinical secondary endpoints (see Table 21):
Similar results are obtained using pooled data from the Brazil+Toronto populations see Table 22:
(ii) Secondary Outcomes
Table 19 includes findings from secondary outcome analyses. Lambda was consistent in the direction of effect on all outcomes. Risk of hospitalization was reduced (hazard ratio 0.57, 95% Bayesian credible interval 0.33 to 0.95, posterior probability 98.5%). A low number of deaths occurred: in the intention-to-treat population there was one COVID-19 death in the treatment arm and 4 in the control arm (hazard ratio 0.22, 95% Bayesian credible interval 0.01 to 1.64, posterior probability 90.7%). Details of deaths in Table 23.
When restricted to patients receiving treatment within 3 days of symptom onset, secondary endpoints demonstrated larger treatment effects. These include 65% risk reduction of COVID-19-related hospitalization (hazard ratio 0.35, 95% Bayesian credible interval 0.15-0.75, posterior probability 99.6%) and 81% risk reduction in all-cause death (relative risk 0.19, 95% Bayesian credible interval 0.01-1.57, posterior probability 93.4%). There were no deaths in the peginterferon lambda arm in early treated patients.
With respect to adverse events, there were no important differences in the number of treatment emergent adverse events (TEAE) among patients in the peginterferon lambda compared to placebo arms (Table 19).
(iii) Subgroup Analyses
The prespecified subgroup analyses showed consistent evidence of treatment benefits of peginterferon lambda compared to placebo, for sub-groups of age, sex, days since symptom onset, or vaccination status (
The predominant SARS-CoV-2 variant during the TOGETHER trial was the Omicron variant. The study was not designed or powered for the endpoint of all-cause mortality or COVID-19-related hospitalization; however, analyses for all-cause mortality and COVID-19-related hospitalization specific to the Omicron variant was conducted and the results are provided in Table 25. Data are shown for Brazil+Toronto patient populations combined. For all-cause mortality or hospitalization due to COVID-19 the analysis shows a RR 0.66, (CrI 0.40, 1.07, Pr 0.951). In a Time-to-Event analysis, the HR is 0.65 (CrI 0.39, 1.05, Pr 0.956). Among patients infected with the Omicron variant treated within≤3-days of symptom onset, the outcome met the 0.976 threshold (RR 0.14, Crl 0.00, 0.96, Pr 0.977. In a Time-to-Event analysis, the results were HR 0.00, Crl 0.00, 0.35, Pr 0.998.
A similar analysis was conducted for the primary endpoint of hospitalization or in observance in an ER for at hours due to COVID-19 and the Omicron variant. The results show that the outcome meets the 0.976 threshold for RR as well as HR across almost all subgroups evaluated (Omicron subgroup, Omicron and onset 3 days, Omicron and vaccinated) (Table 26).
(iv) Virology Results
The omnibus model revealed a significant three-way interaction between treatment, days since randomization, and baseline viral load. Among the patients with a high baseline viral load (defined as the 15% of patients with the highest baseline load, all≥192,841,278 copies/mL), we observed a significant treatment effect at Day 7 (Beta=−1.01 [95% Bayesian credible interval −1.65 to −0.36], posterior probability 99.9%, with patients assigned to lambda showing a greater reduction in viral load by Day 7 compared to placebo (8.29 median log decline for peginterferon lambda vs. 5.16 median log decline for placebo). In these patients with high baseline viral load, there was also a greater proportion of patients in the peginterferon lambda arm who were below the limit of quantitation (defined as≥1000 copies/mL) at Day 7 than for patients receiving placebo (50.5% for peginterferon lambda vs. 32.9% for placebo, odds ratio 2.13, 95% Bayesian credible interval 1.14, 4.00, posterior probability 99.0%). We did not observe a treatment effect on viral load within the low baseline viral load group (Beta 0.22 [95% Bayesian credible interval −0.09, 0.52], posterior probability 92.5%). The results remained unchanged when we controlled for potentially confounding variables.
(v) Findings in Comparable Non-Vaccinated Population
In order to place the study findings in the context of available oral therapies for outpatient treatments, the effect of peginterferon lambda on the composite of risk reduction of COVID-19-related hospitalization or all-cause death, as used in the unvaccinated populations of nirmatrelvir/ritonavir (PaxlovidTM) and molnupiravir trial arms, was examined. The study results indicate that peginterferon lambda has a 41% risk reduction in this composite endpoint (Hazard ratio 0.59, 95% Bayesian credible interval 0.35-0.97, posterior probability 98.2%). When patients initiated on treatment within 3 days of symptom onset were examined, as in the nirmatrelvir study, this increases to 65% (Hazard ratio 0.35, 95% Bayesian credible interval 0.15-0.75, posterior probability 99.5%). When this was examined among the unvaccinated patients receiving peginterferon lambda within 3 days of symptoms, the same patient population in the nirmatrelvir study, there was a hazard reduction of 89% in the primary outcome in the peginterferon lambda arm vs. placebo (Hazard ratio 0.11, 95% Bayesian credible intervals 0.01-0.75, posterior probability 99.2%).
There is ongoing assessment of patient data from the TOGETHER trial as described in Example 7 and future studies planned to further assess the use of interferon lambda in the treatment of subjects with recurrent COVID-19, whether by reinfection or by reemergence of a prior infection) or with extended COVID-19, also referred to as “long COVID” or “post-COVID conditions.”
With the emergence of new SARS-CoV-2 variants, it is possible that some recurrent infections are due to infection with a newer variant, though it is possible that a reinfection could occur with the same variant given sufficient exposure and other conditions. Additionally, it has become apparent that some subjects that have been treated with Paxlovid™ (nirmatrelvir and ritonavir) have a “rebound” infection, in which subjects to which the drugs were administered have reolution of symptoms and undetectable viral load and which return after some number of days. It is anticipated that treating recurrent patients in any of these circumstances with interferon lambda will result in reduction in symptom severity (consistent with the primary and secondary outcomes reported above in Example 7) and sustained clearance of the virus. Weekly treatment with lambda for at least 1 week or 2 weeks as described in this disclosure will be assessed.
Post-COVID conditions are a wide range of new, returning, or ongoing health problems that people experience after first being infected with the virus that causes COVID-19. Most people with COVID-19 get better within a few days to a few weeks after infection, so at least four weeks after infection is the start of when post-COVID conditions could first be identified. People with post-COVID conditions may experience health problems from different types and combinations of symptoms happening over different lengths of time. Most patients' symptoms slowly improve with time. However, for some people, post-COVID conditions may last months, and potentially years, after COVID-19 illness and may sometimes result in disability. Common symptoms associated with long COVID are listed in Table 27 (see also “Long COVID or Post-COVID Conditions”, U.S. CDC website, last updated Jul. 11, 2022, available at tinyurl.com/4c53v894). Patients that develop long COVID will be assessed for reduction/resolution of one or more symptoms following treatment with lambda for at least 1 week or 2 weeks as described in this disclosure. Treatment may continue on a weekly basis until threshold reducton or resolution is observed and, thus, may continue for several weeks or even months.
According to various embodiments of this disclosure, additional information relating to diagnostic criteria, viral load, medical history, and relevance to disease severity can be found in:
Gastrointestinal Tracts Resistant to Viral Infections, JOURNAL OF VIROLOGY, June 2010, p. 5670-5677 Vol. 84, No. 11.
Sheppard, P. et al. IL-28, IL-29 and their class II cytokine receptor IL-28R. Nat Immunol 4, 63-68, doi:10.1038/ni873 (2003).
Modification Analyses (ICEMAN) in randomized controlled trials and meta-analyses. Canadian Medical Association Journal 2020; 192(32):E901-E906. DOI: 10.1503/cmaj.200077
All publications and patents cited in this specification are herein incorporated by reference as if each individual publication or patent were specifically and individually indicated to be incorporated by reference and are incorporated herein by reference to disclose and describe the methods and/or materials in connection with which the publications are cited.
It should be understood that although the present invention has been specifically disclosed by certain aspects, embodiments, and optional features, modification, improvement and variation of such aspects, embodiments, and optional features can be resorted to by those skilled in the art, and that such modifications, improvements and variations are considered to be within the scope of this disclosure.
The inventions have been described broadly and generically herein. Each of the narrower species and subgeneric groupings falling within the generic disclosure also form part of the invention. In addition, where features or aspects of the invention are described in terms of Markush groups, those skilled in the art will recognize that the invention is also thereby described in terms of any individual member or subgroup of members of the Markush group.
This application is a continuation-in-part application of U.S. application Ser. No. 17/760,279, filed Aug. 5, 2022, which is a national stage application, filed under 25 U.S.C. § 371, of International Patent Application No. PCT/US2021/016963, filed on Feb. 5, 2021, which claims the benefit of and priority to U.S. Provisional Application 62/971,194, filed on Feb. 6, 2020, U.S. Provisional Application 63/017,614, filed on Apr. 29, 2020, U.S. Provisional Application 63/021,552, filed on May 7, 2020, U.S. Provisional Application 63/091,881, filed on Oct. 14, 2020, and U.S. Provisional Application 63/093,334, filed on Oct. 19, 2020, each of which are incorporated by reference in their entireties for all purposes. This application also claims the benefit of and priority to U.S. Provisional Application 63/269,448, filed on Mar. 16, 2022, and U.S. Provisional Application 63/369,762, filed on Jul. 28, 2022, both of which are incorporated by reference in their entireties for all purposes.
| Number | Date | Country | |
|---|---|---|---|
| 62971194 | Feb 2020 | US | |
| 63017614 | Apr 2020 | US | |
| 63021552 | May 2020 | US | |
| 63091881 | Oct 2020 | US | |
| 63093334 | Oct 2020 | US | |
| 63269448 | Mar 2022 | US | |
| 63369762 | Jul 2022 | US |
| Number | Date | Country | |
|---|---|---|---|
| Parent | 17760279 | Aug 2022 | US |
| Child | 17819254 | US |
