Immunothérapie du COVID - Pr Barbara Seitz-Polski Laboratoire d'Immunologie Unité de Recherche Clinique de la Côte d'Azur CHU de Nice
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Immunothérapie du COVID
Pr Barbara Seitz-Polski
Laboratoire d’Immunologie
Unité de Recherche Clinique de la Côte d’Azur
CHU de Nice
Histoire naturelle du COVID-19
• Description des premiers cas d’infection à • Evolution classique en 2 phases avec une
SARS-Cov-2 (COVID-19) a rapidement présentation clinique initiale modérée,
Articles suivie
montré des tableaux cliniques différents: d’une possible aggravation après J7
– 95% des patients présentent des formes faibles à
were sputum production (11 [28%] of 39), headache
modérées (three [8%] of 38), haemoptysis (two [5%] of 39), and
Onset Admission
Dyspnoea
diarrhoea (one [3%] of 38; table 1). More than half of
patients (22 [55%] of 40) developed dyspnoea. The median Acute respiratory
–
Stades de COVID-19
Terrain
1. Physiopathologie de l’infection à SARS-Cov-2
La réponse immunitaire contre le SARS-Cov-2
1.1 Déficit de la Réponse IFN
Produit principalement par
les Cellules dendritiques et
macrophages
Stimulation TLR
Interagissent avec
le récepteur IFNα
IFNAR
Type II
Type I
Déficit de la Réponse IFN
Baisse des d’activation de LT
Surexpression des marqueurs d’épuisement
medRxiv preprint doi: https://doi.org/10.1101/2020.04.19.20068015. The copyright holder for this preprint (which was not peer-reviewed)
is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
It is made available under a CC-BY-NC-ND 4.0 International license .
medRxiv preprint doi: https://doi.org/10.1101/2020.04.19.20068015. The copyright holder for this preprint (which was not peer-reviewed)
is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
It is made available under a CC-BY-NC-ND 4.0 International license .
medRxiv preprint doi: https://doi.org/10.1101/2020.04.19.20068015. The copyright holder for this preprint (which was not peer-reviewed)
is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
It is made available under a CC-BY-NC-ND 4.0 International license .
Surexpression des gènes de protéines de l’inflammation
N=50 Baisse de l’expression des gènes de l’IFN
Hadjadj et al. Science 2020
INTRODUCTION: Clinical outcomes of human the general hypothesis that life-threatening RESULTS: We found an enrichment in variants
severe acute respiratory syndrome corona- COVID-19 in some or most patients may be predicted to be loss-of-function (pLOF), with a
smesCauses dudu
déficit
défauten IFN dans les formes graves
virus 2 (SARS-CoV-2) infection range from caused by monogenic inborn errors of immu- minor allele frequency
200000
IL - 1 7 A
IL - 6 (
IL - 4
IL - 1
Production d’IFN chez les sujets à risque dewCOVID grave
100 50
Journal of the American Society of NEPHROLOGY
e
10000 100000
v i
e
0 0 0 0
R
D
D
N
N
D
N
D
N
H
H
M
M
r
H
M
H
M
Insuffisance rénale E Mélanome métastatique
ee
F MAI G Baisse associée à l’âge
P
S. Boyer-Suavet, et al. S. Boyer-Suavet, et al.
r
P = 0 .0 0 0 5
Table 1 Table 1 4000 P = 0 .0 4
o
1000 P < 0 .0 0 0 1 150000
Baseline characteristics of the end-stage kidney disease cohort (n = 54).
Baseline characteristics of the end-stage kidney disease cohort (n = 54).
F
Demographics Median Stimulated IFN-γ Demographics Median Stimulated IFN-γ
800 (95%CI) IU/mL (95%CI) IU/mL
IL - 1 2 p 7 0 ( p g / m L ) 3000
Age (median, yr) 68 [32–88] 85.4 [26.2–280.5] Age (median, yr) 68 [32–88] 85.4 [26.2–280.5]
IL - 1 0 ( p g / m L )
( p g /m L )
Sex Sex 100000
Male 600 38 (70%) 77.2 [13.2 – 181.3] Male 38 (70%) 77.2 [13.2 – 181.3]
Female 16 (30%) 89.2 [27.1 – 339.5] Female 16 (30%) 89.2 [27.1 – 339.5]
End-stage kidney disease End-stage kidney disease 2000
Conservative management 11 (18.0%) 42.3 [4.9–77.4] Conservative management 11 (18.0%) 42.3 [4.9–77.4]
Hemodialysis 400 30 (49.2%) 96.3 [23.6–261.3] Hemodialysis 30 (49.2%) 96.3 [23.6–261.3]
IN F -
Peritoneal dialysis 13 (21.3%) 62.5 [25.3–347.5] Peritoneal dialysis
5 0 0 0 013 (21.3%) 62.5 [25.3–347.5]
Etiology of nephropathy, n (%) Etiology of nephropathy, n (%)
Diabetes 12 (22%) 53.0 [1.5–281.7] Diabetes 12 (22%) 53.0 [1.5–281.7] 1000
Nephroangiosclerosis 2 0 0 7 (13%) 58.6 [2.7–238.1] Nephroangiosclerosis 7 (13%) 58.6 [2.7–238.1]
Toxic* 4 (8%) 49.6 [32.3–241.3] Toxic* 4 (8%) 49.6 [32.3–241.3]
Autoimmune nephropathy ** 6 (11%) 56.9 [19.1–174.3] Autoimmune nephropathy ** 6 (11%) 56.9 [19.1–174.3]
Uropathy 5 (9%) 62.5 [18.7–365.5] Uropathy 5 (9%) 62.5 [18.7–365.5]
ADPKD 0 3 (6%) 230.0 [2.5–372.0] ADPKD 03 (6%) 230.0 [2.5–372.0]
0
Others*** or unknown 17 (31%) 93.0 [30.1–190.5] Others*** or unknown 17 (31%) 93.0 [30.1–190.5]
D
N
D
D
N
N
H
M
H
H
M
IFN-γ, interferon gamma; ADPKD, autosomal dominant polycystic kidney IFN-γ,dis-
interferon gamma; ADPKD, autosomal dominant polycystic kidney dis-
M
ease; * drug-induced kidney disease: penicillin, cotrimoxazole, non-steroidal
ease; * drug-induced kidney disease: penicillin, cotrimoxazole, non-steroidal
anti-inflammatory drugs; ** IgA nephropathy, membranous nephropathy, anti-inflammatory
sys- drugs; ** IgA nephropathy, membranous nephropathy, sys-
Figure 1.
temic lupus erythematosus, ANCA vasculitis; *** amyloidosis, chronic temic
inter-
lupus erythematosus, ANCA vasculitis; *** amyloidosis, chronic inter-
stitial nephritis, septic shock, nephrectomy, cardiorenal syndrome stitial nephritis, septic shock, nephrectomy, cardiorenal syndrome
Categorical variables were expressed as frequencies. Continuous variables
Categorical
were variables were expressed as frequencies. Continuous variables were
expressed as median and interquartile intervals. expressed as median and interquartile intervals.
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
1
2
3
4
5
6
7
8
9
Fig. 2. Comparisons of stimulated IFN-γ production by QuantiFERON Fig.
Monitor
2. Comparisons of stimulated IFN-γ production by QuantiFERON Monitor
Fig. 2. Comparisons of stimulated IFN-γ production by QuantiFERON Monitor among various study groups: Healthy donors (n = 19); CKD 3–4 (n =among
7) andvarious study groups: Healthy donors (n = 19); CKD 3–4 (n = 7) and
among various study groups: Healthy donors (n = 19); CKD 3–4 (n = 7) and
Boyer-Suavet CCA 2020
ESKD patients (n = 54): on HD (n = 30), on PD (n = 13) and on conservative Gérard et al submitted
ESKD patients (n = 54): on HD (n = 30), on PD (n = 13) and on conservative
Crémoni et al FI 2020
management (n = 11). Medians of stimulated IFN-γ level were compared
management
using
Données issues de la cohorte
ESKD patients (n = 54): on HD (n = 30), on PD (n = 13) and on conservative
(n = 11). Medians of stimulated IFN-γ level were compared using
management (n = 11). Medians of stimulated IFN-γ level were compared using
Mann-Whitney test. IFN-γ: interferon-gamma; CKD 3–4: stages 3–4 chronic
Mann-Whitney test. IFN-γ: interferon-gamma; CKD 3–4: stages 3–4 Mann-Whitney
kidney disease; * p < 0.0001 compared to healthy donors; +++ p <
chronic
kidney
CovImmune 2 n=558 sujets sains
test. IFN-γ: interferon-gamma; CKD 3–4: stages 3–4 chronic
0.001disease; * p < 0.0001 compared to healthy donors; +++ p < 0.001
kidney disease; * p < 0.0001 compared to healthy donors; +++ p < 0.001 compared to CKD-3–4; ++ p < 0.01 compared to CKD 3–4; + p compared = 0.03 to CKD-3–4; ++ p < 0.01 compared to CKD 3–4; + p = 0.03
compared to CKD-3–4; ++ p < 0.01 compared to CKD 3–4; + p = 0.03 compared to CKD 3–4. compared to CKD 3–4.
compared to CKD 3–4.
Table 2
Publications de notre équipe utilisant le test QF Monitor
Table 2 Table 2
Test Quantiferon Monitor
Stimule l’Immunité Innée Stimule l’Immunité Adaptative
Dosage ELISA du taux d’IFNγ
Ajoute billes stimulants
(Anti-TLR7/8, Anti-CD3)
1 ml de sang total sur tube
Héparinate de Lithium Incubation 16h à 37°
Test produit par Qiagen
Cellules stables 8h à température ambiante ou 48h à 4° 5000 tests disponibles
Test faisable en routine dans tout laboratoire de ville, aucune contrainte structurelle462 IL1β (pg/mL) 521 519
34,869 (22,395; 65,475) 30,284
463 (22,371; 39,873)
Stimulated IL6 28,386 (15,100; 55,727) 62,032 (33,230; 135,877) 69,042 (33,065;
36,792 (26,906; 51,355) 35,922 (27,333; 43,741) 32,890 (25,031; 46,975) 133,094) 48,567 (35,469;522al. HCWs and Immunity Against COVID-19
Etude fonctionnelle de la réponse IFN dans des formes pauci-symptomatiques de
COVID
Après appariement
Âge et sexe
Objectif du traitement à Renforcer la réponse IFN
Cremoni et al. Front in Med 2020- serologic results. Common findings included increased D-dimers,
o lymphocytic inflammation, vascular damage on skin biopsy results,
9 and a significant interferon-alpha response compared with
Etude fonctionnelle de la réponse IFN dans les atteintes cutanées de COVID-19
patients with PCR-positive, acute COVID-19 infection.
Meaning Patients presenting with chilblain-like lesions during the
COVID-19 pandemic all had negative PCR results for COVID-19 at
the time of the diagnosis and developed antibodies in only 30% of
cases, and had histologic and biologic patterns of type I
interferonopathy.
-
e
,
- 40 patients consécutifs en 30j
Table. Demographic and Clinical Characteristics of All Patients
With Chilblain-like Lesions
-
Research Brief Report Clinical, Laboratory, and Interferon-Alpha Response Characteristics of Patients With Chilblain-like Lesions During t
- Characteristic No. (%)
h Epidemiologic data Aspect d’Interferonopathie mimant atteintes lupiques
Clinical, Laboratory, and Interferon-Alpha Response Characteristics of Patients With Chilblain-like Lesions During the COVID-19 Pandemic Brief Report Research
, Age, median (range), y 22 (12-67)
, Female sex, No./total No. (%) 21/40 (52.5) Figure 2. Comparison of IFN-α Response in Chilblain Population With Ambulatory and Hospitalized Mild or Severe Cases of Coron
- Contact with patients presenting criteria 24 (60.0) Figure 1. Clinical and Histologic Presentation of Chilblain-like Lesions (COVID-19)
for possible COVID-19 infectiona
-
Patients with criteria for previous possible 11 (27.5) A IFN-α levels after stimulation B IFN-α levels paired by age
- COVID-19 infectiona
A Purpuric lesions on the toes B Papules with bullous evolution
4000 4000
, Clinical data
IFN-α level after in vitro stimulation, pg/mL
IFN-α level after in vitro stimulation, pg/mL
a Delays between, median (range), d
- Previous symptoms and onset of chilblain 21 (2-77) 3000 3000
- Onset of chilblain and clinical assessment 14 (3-47)
n Onset of chilblain and last follow-up 27 (18-68)
c 2000 2000
Other manifestations at clinical assessment
e
Livedo reticularis 3 (7.5)
-
Facial erythema 3 (7.5) 1000 1000
e
Cold toes/acrocyanosis (cyanotic extremities) 19 (47.5)
-
Laboratory test results
h 0 0
COVID-19 tests
- Chilblains Ambulatory Chilblains Ambulatory
Hospitalized, Hospitalized,
Positive rt-PCR (nasopharyngeal 0
- and/or stool swabs)
mild-severe mild-severe
d Serologic positive results 12 (30.0)
A. Interferon alpha (IFN-α) levels after stimulation in the population with levels, 9.8 (1.6-84.9) pg/mL. B. Results when population
Abnormal d-dimers 24 (61.5) C Original magnification ×25 D Original magnification ×400 chilblains compared with patients with ambulatory or hospitalized mild or dots represent the level of IFN-α detected for each patien
Positive antinuclear antibodies 9 (22.5) severe forms of COVID-19. Results are shown for all the patients tested. The represents the median. Chilblains: n = 25; median (range
dots represent the level detected for each patient and the bar represents the mean (range) IFN-α levels, 751 (224-1468) pg/mL; ambula
Positive antiphospholipid antibodies 5 (12.5)
median. Chilblains: n = 25; median (range) age, 32 (16-38) years; mean (range) (range) age, 41 (16-73) years; mean (range) IFN-α levels, 2
Abnormal CH50 10 (25) A, Red-to-violaceous
IFN-α levels, 751 (224-1468) purpuric
pg/mL; ambulatory: n lesions
= 10; median (range) age, 41 hospitalized mild or severe: n; = 7; median (range) age: 4
Cryoglobulinemia, No. positive/tested (%) 0/25 (16-73); mean (range)onIFN-α
the toes. Note
levels, 262the bullous and
(95.5-1015) pg/mL; hospitalized mild or (range) IFN-α levels, 89.2 (4.9-777) pg/mL.
9 necrotic
severe: n = 58; median evolution.
(range) age: 64 (22-89) years; mean (range) IFN-α
Parvovirus B19 serology, No. positive/tested (%) 0/33
r B, Red-to-violaceous papules with
Abbreviation: COVID-19, coronavirus disease 2019; rt-PCR, real-time marked bullous evolution. C, Dense
- terferon response can contribute to immune
polymerase chain reaction. superficial and deep lymphocytic
e a
European Centre for Disease Prevention and Control Clinical Criteria for Discussion inflammation with perivascular and observed a significantly higher IFN-α res
- peri-eccrine arrangement
tients with chilblains compared with those
Coronavirus Disease 2019.
f
-
In less than 2 weeks,
(hematoxylin-eosin stain).
40 patients
D, Interface presented
dermatitis extending with
to chilblains to our Hubiche et al. JAMA Derm 2020severe COVID-19. The production of IFN-
dedicated multidisciplinary COVID-19
the intra-epidermis portion ofconsultation clinic. This fancy and young adulthood, and then dec
h arterial disease, deep venous thrombosis, or pulmonary em- 500 µm 100 µm
acrosyringium (hematoxylin-eosin
occurrence is unusual in temperate areas, and corresponded with Severe COVID-19 cases, often observed in oStades de COVID-19
a IL-6 IL-8 TNF-α IL-1β
Fever 100.4 ****
1.2 Cytokine Storm
O2 >95
Saturation 90–95 **** * NS NS
**** **** NS **
**** **** NS
% 95% (normal)increased 95 IL-6 lo, O2SAT_MIN 95 IL-6 hi, O2SAT_MIN 95
0
TNF-α hi, O2SAT_MINSepsis Bactérien vs COVID
Dong et al. Bacterial Sepsis vs SARS-CoV-2 Sepsis
Bacterial Sepsis vs SARS-CoV-2 Sepsis
FIGURE 1 | Flowchart of included and excluded patients.
A B C D
TABLE 1 | Baseline characteristics of patients with bacterial sepsis and SARS-CoV-2 sepsis.
A B C
Bacterial sepsis SARS-CoV-2 sepsis
Total Survivors Nonsurvivors Total Survivors Nonsurvivors
(n = 64) (n = 41) (n = 23) (n = 43) (n = 29) (n = 14)
Agea,b, years 58.0 (51.0, 63.0) 54.0 (50.0, 62.0) 61.0 (57.0, 66.0) 57.0 (50.0, 68.0) 53 (48.5, 63.0) 63.5 (59.0, 71.0)
Age rangea,b, years
20–39 3 (4.7) 3 (7.3) 0 2 (4.7) 2 (6.9) 0
40–59 32 (50.0) 24 (58.5) 8 (34.8) 21 (48.8) 18 (62.1) 3 (21.4)
≥ 60 29 (45.3) 14 (34.1) 15 (65.2) 20 (46.5) 9 (31.0) 11 (78.6)
Female 23 (35.9) 15 (36.6) 8 (34.8) 14 (32.6) 10 (34.5) 4 (28.6)
SOFA scorea,b 5.5 (4.5, 7.0) 4.0 (3.0, 6.0) 6.5 (5.0, 8.0) 5.0 (4.0, 7.0) 4.5 (3.0, 5.0) 6.0 (4.5, 8.0)
APACHE II scorea,b 16.0 (12.0, 20.0) 14.5 (11.0, 18.5) 20.0 (16.0, 22.5) 17.0 (14.0, 18.5) 16.0 (13.5, 17.0) 19.0 (16.0, 20.0)
Chronic medical illness
Hypertension 13 (20.3) 7 (17.1) 6 (26.1) 10 (23.3) 6 (20.7) 4 (28.6)
Chronic obstructive pulmonary disease 9 (12.5) 5 (12.2) 4 (17.4) 3 (7.0) 2 (6.9) 1 (7.1)
Diabetes mellitus 7 (10.9) 5 (12.2) 2 (8.7) 5 (11.6) 3 (10.3) 2 (14.3)
Coronary artery disease 2 (3.1) 1 (2.4) 1 (4.3) 1 (2.3) 0 1 (7.1)
Cerebrovascular disease 1 (1.6) 1 (2.4) 0 0 0 0
D EE F F
Data are shown as median (interquartile range) and number (percentage). aBacterial sepsis survivors vs. nonsurvivors is statistically significant. bSARS-CoV-2 sepsis survivors vs.
G
nonsurvivors is statistically significant. SARS-CoV-2, severe acute respiratory coronavirus 2; SOFA, Sequential Organ Failure Assessment; APACHE II, Acute Physiology and Chronic
Health Evaluation II. Statistics obtained from chi-square tests and Fisher exact probability test.
Blood Routine and Infection Biomarker levels were higher in SARS-CoV-2 sepsis nonsurvivors than in
Results Were Similar for Both Types survivors, which was due to secondary bacterial infections in
of Sepsis some nonsurvivors (Figure 2F). Lymphocyte and monocyte
Overall, the results of blood routine (neutrophil, lymphocyte,
and monocyte counts) and infection biomarkers (C-reactive
Déficit IFN dans une
counts, C-reactive protein and ferritin levels did not differ
significantly between the two sepsis groups (Figures 2B–E). In
protein, ferritin, and procalcitonin levels) in SARS-CoV-2
sepsis patients and bacterial sepsis patients showed the same
réponse virale
addition, there was a difference in lymphocyte counts between
bacterial sepsis survivors and nonsurvivors, as well as between
upward and downward trend relative to normal ranges (Figure 1). SARS-CoV-2 sepsis survivors and nonsurvivors (Figure 2B).
Neutrophil counts and procalcitonin (PCT) levels increased more Taken together, the two types of sepsis were similar in terms of
significantly in bacterial sepsis patients, which is consistent with blood routine and infection biomarker results, except for
the characteristics of bacterial infections (Figures 2A, F). PCT neutrophil counts and PCT levels.
ytokine levels in bacterial sepsis and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) sepsis patients. Comparison of the levels of
R (B), IL-6 (C), IL-8 (D), IL-10 (E), and TNF-a (F) between bacterial sepsis and SARS-CoV-2 sepsis patients. The p-value of the comparison between
Frontiers in Immunology | www.frontiersin.org 3 November 2020 | Volume 11 | Article 598404
s and SARS-CoV-2 sepsis groups is shown in italics, and the p-value of the comparison among the survivor (S) and nonsurvivor (NS) subgroups is
FIGURE 5 | The results of the lymphocyte subset counts and functions in bacterial sepsis and severe acute
lar font. The shaded region indicates the normal range of the indicated index. Bacterial represents the bacterial sepsis group (n = 64, S: n = 41, NS:
Dong
respiratory syndrome coronavirus 2 (SARS-CoV-2) et al. FI 2020adjusted for multiple testing by controlling the false discovery rate. SD denotes standard deviation, and IQR denotes interquartile
range.
SARS-
CoV-2
(n = 79)
Healthy
Control
(n = 16)
Influenza
(n = 26)
COVID19-
Healthy
comparison
COVID19-
Influenza
comparison
Influenza
vs COVID
Demographics
Downloaded from http://advances.sciencemag.org/ on November 16, 2020
61 ± 15 32 ± 7 42 ± 17 p < 0.001, p = 0.007,
Mean ± SD (range) age, in
(25-89) (22-49) (18-89) OR = 0.85 OR = 0.93
years
44% 58%
Female 50% (8/8) p = 1, N.S. p = 1, N.S.
(35/44) (15/26)
Downloaded from http://advances.sciencemag.org/ on November 16, 2020
Ethnicity
80% 65%
African American 44% (7/16) - -
(63/79) (17/26)
18% 27% p < 0.05, OR =
White 56% (9/16) p = 0.718, N.S.
(14/79) (7/26) 9.592. Immunothérapie du COVID-19
2.1 Limiter l’entrée du virus dans la cellule cible
Objectif: Neutraliser l’interaction Spike / ACE2
à bloquer l’entrée du virus dans la cellule cible2.1.1 Hydroxychloroquine
• CQ et HCQ augmentent le Ph intracellulaire limiter fusion
membranaire
• Modifie glycosylation ACE et Spike limitant entrée du
virus
Non traité 34.3% des virions sont transportés endosome-lysosome
(LAMP1)
CQ 2.4% et 0.03% HCQ p2.1.2 Anticorps polyclonaux thérapeutiques
1891-1894
Les premiers anticorps sur le marché…
• Purification de la fraction Ig
• Recours plasmas humains
Améliorer la Tolérance
Watier H. De la sérothérapie aux anticorps recombinants « nus »,
Sérum
plusde
d’unchevaux
siècle de succès en thérapie ciblée. Med Sci. 2009; 25: 999-1009.
immunisés
Sérothérapie anti-tétanique, anti-diphtérique, anti-pesteuse ou anti-méningococciqueMécanismes d’action des Ig polyvalentes issus de patients convalescents Protéine à spicule
ARN viral
Récepteur de l’ECA2
Cellule hôte
Anticorps anti-SRAS-CoV-2 :
Quatre mécanismes d’action possibles
A. Neutralisation virale B. Virolyse dépendante des anticorps
Les anticorps empêchent la liaison d’une Les anticorps peuvent activer le mécanisme classique du
protéine à spicule à un récepteur de l’ECA2. complément et de la virolyse. Ce type d’immunité ne peut pas
Ce type d’immunité est le seul qui puisse être être mesuré au moyen de tests de neutralisation.
Entrée du SRAS-CoV-2
RECHERCHE
mesuré au moyen de tests de neutralisation.
dans une cellule hôte
Complexe d’attaque membranaire
Anticorps
Protéine à spicule
ARN viral
Récepteur de l’ECA2
Cellule hôte
Anticorps anti-SRAS-CoV-2 :
Quatre mécanismes d’action possibles
A. Neutralisation virale B. Virolyse dépendante des anticorps C. Présentation antigénique médiée par les anticorps D. Cytotoxicité dépendante des anticorps
Les anticorps empêchent la liaison d’une Les anticorps peuvent activer le mécanisme classique du Les anticorps se lient aux particules virales, ce qui stimule Les anticorps se trouvant à la surface de la cellule infectée
protéine à spicule à un récepteur de l’ECA2. complément et de la virolyse. Ce type d’immunité ne peut pas les cellules présentatrices d’antigène et active une réponse permettent aux cellules tueuses naturelle de la repérer et
Ce type d’immunité est le seul qui puisse être être mesuré au moyen de tests de neutralisation. immunitaire à médiation cellulaire. Ce type d’immunité ne de la détruire. Ce type d’immunité ne peut pas être mesuré
mesuré au moyen de tests de neutralisation. peut pas être mesuré au moyen de tests de neutralisation. au moyen de tests de neutralisation.
Complexe d’attaque membranaire Cellule présentatrice
Anticorps d’antigène
Cellule tueuse
naturelle
Peptide viral
Lymphocyte T
auxiliaire Cellule infectée
C. Présentation antigénique médiée par les anticorps D. Cytotoxicité dépendante des anticorps Figure 1 : Mécanismes d’action possibles des anticorps contre le coronavirus du syndrome respiratoire aigu sévère 2 (SRAS-CoV-2) en cas de maladie à
coronavirus 2019 (COVID-19). Cette figure illustre le mécanisme normal d’entrée du SRAS-CoV-2 dans une cellule hôte, au cours duquel la fusion mem-
Les anticorps se lient aux particules virales, ce qui stimule Les anticorps se trouvant à la surface de la cellule infectée
les cellules présentatrices d’antigène et active une réponse permettent aux cellules tueuses naturelle de la repérer et Devasenapathy et al. CMAJ 2020
branaire est induite par l’interaction entre les glycoprotéines à spicules du SRAS-CoV-2 (en rouge) et les récepteurs de l’enzyme de conversion de
l’angiotensine 2 (ECA2) [en vert] de la cellule hôte, interaction qui se produit au niveau de la membrane plasmique ou d’une membrane endosomique.Applications au COVID19
10 patients présentant des formes sévères àtraités 200 ml de Plasma de patients convalescents (Ac anti-SARS Cov2 1:640)
Table 4. Comparison of serum neutralizing antibody titers and SARS-CoV-2 RNA load before and after CP therapy
Before CP transfusion After CP transfusion
Serum Serum
Table 3. Comparison of laboratory parameters before and after can be an easily accessible, promising, and safe rescue option
CP transfusion Serum neutralizing SARS-CoV-2 RNA load Serum neutralizing SARS-CoV-2 RNA load
CP transfusion for severe COVID-19 patients.
Patient no. It is,
date nevertheless, Dateworth men-antibody titers (Ct value) Date antibody titers (Ct value)
Before CP After CP tioning that the absorption of pulmonary lesions often lagged
1
behind the improvement February
of clinical 9
symptoms, February
as shown 8 in pa- 1:160 37.25 February 1:640 Negative
Clinical factors transfusion transfusion
tients 9 and 10 in this trial. 10
CRP (mg/L, normal range 55.98 (15.57 18.13 (10.92 2
The first key factor associated February
with CP 9 therapy
Februaryis 8the neu-Unavailable 35.08 February Unavailable Negative
0 to 6) to 66.67) to 71.44) tralizing antibody titer. A small sample study in MERS-CoV 11
Lymphocyte (109 per L, normal 0.65 (0.53 0.76 (0.52 3 the neutralizing
infection showed that Februaryantibody
13 February 12
titer should ex- 1:320 38.07 February 1:640 Negative
range 1.1 to 3.2) to 0.90) to 1.43) ceed 1:80 to achieve effective CP therapy (12). To find eligible 14
Alanine aminotransferase (U/L, 42.00 (28.25 34.30 (25.75 donors who have high4 levels ofFebruary 13
neutralizing February 12
antibody is a pre- 1:160 37.68 February 1:640 Negative
normal range 9 to 50) to 61.85) to 53.90) requisite. Cao et al. (23) showed that the level of specific neu- 14
Aspartate aminotransferase 38.10 (28.50 30.30 (17.30 5 SARS-CoVFebruary
tralizing antibody to decreased12 gradually
February411 mo after 1:640 Negative February 1:640 Negative
(U/L, normal range 15 to 44.00) to 38.10) the disease process, reaching undetectable levels in 25.6% (IgG) 14
to 40) 6
and 16.1% (neutralizing February
antibodies) 12
of patients February
at 36 11mo after 1:640 Negative February 1:640 Negative
Total bilirubin (μmol/L, normal 12.40 (11.71 13.98 (12.20 disease status. A study from the MERS-CoV−infected patients 14
range 0 to 26) to 22.05) to 20.80) 7
and the exposed healthcare February
workers 12 that
showed February 11
the prevalence 1:320 34.64 February 1:640 Negative
SaO2 (%, normal range 93.00 (89.00 96.00 (95.00 of MERS-CoV IgG seroreactivity was very low (2.7%), and the 14
≥ 95) to 96.50) to 96.50) 8
antibodies titer decreased rapidlyFebruary
within 312mo (24).February
These11 studies 1:640 35.45 February 1:640 Negative
suggested that the neutralizing antibodies represented short- 14
SaO2, oxyhemoglobin saturation.
9
lasting humoral immune February
response, and12plasma February
from11recently 1:160 Negative February 1:640 Negative
MEDICAL SCIENCES
recovered patients should be more effective. In the present 14
10
study, recently recovered COVID-19 February 9
patients, February
who were8infected 1:640 38.19 February 1:640 Negative
significantly higher than in those who did not require ICU con-
14
ditions (2, 18). CP, obtained from recovered COVID-19 patients by SARS-CoV-2 with neutralizing antibody titer above 1:640 and
who had established humoral immunity against the virus, con- recruited from local hospitals, should be considered as suitable
tains a large quantity of neutralizing antibodies capable of neu- donors. The median age of donors was lower than that of re-
tralizing SARS-CoV-2 and eradicating the pathogen from blood cipients (42.0 y vs.and
52.59)y).
in Among
our studythe showed a rapidinvestigated,
nine cases increase of lymphocyte counts Duan et al., PNAS 2020
CP therapy, as well as the optimal concentration of neutralizing an-
circulation and pulmonary tissues (19). In the present study, all and a decrease
the neutralizing antibody of CRP,
titers of five with increased
patients remarkable toabsorption
1:640 of lung lesions tibodies and treatment schedule, should be further clarified. Third, the
investigated patients achieved serum SARS-CoV-2 RNA neg- in CT.
within 2 d, while four Notably,
patients keptpatients
the same who received
level. CP transfusion after 14 dpoi dynamic changes of cytokines during treatment were not investigated.
The antibody
ativity after CP transfusion, accompanied by an increase of showed much
titers in CP in COVID-19 less significant
seem thus higher thanimprovement,
those used insuch as patient 10. Nevertheless, the preliminary results of this trial seem promising, jus-
However, the (1:80)
dynamics(12).of the viremia of SARS-CoV-2 was un-
à Etude Coviplasm en France
oxygen saturation and lymphocyte counts, and the improve-
ment of liver function and CRP. The results suggest that the
the treatment of MERS
The second key factor
patient
clear, associated
so the optimal transfusion
with efficacy is thetime point needs to be deter-
treatment
tifying a randomized controlled clinical trial in a larger patient cohort.
In conclusion, this pilot study on CP therapy shows a potential
inflammation and overreaction of the immune system were
alleviated by antibodies contained in CP. The case fatality rates
time point. A bettermined
SARS patients who were
in the future.
treatment
In thegiven
present
outcome was observed among
CPstudy,
before no14severe
Bras: plasma de patients convalescents pour le COVID 19
dpoi adverse
(58.3% effects
vs. were observed.
therapeutic effect and low risk in the treatment of severe COVID-19
patients. One dose of CP with a high concentration of neutralizing
200 patients convalescents prélevés – 60 patients COVID inclus
(CFRs) in the present study were 0% (0/10), which was com-
parable to the CFRs in SARS, which varied from 0% (0/10) to
15.6%; P < 0.01), One of the risks
highlighting
potential
therapy (9). The mean time from
the of
pathogen.
onset of
plasma transfusion
importance
Methylene
of timely is
illness to CP
the transmission of the
rescue
bluetransfusion
photochemistry was applied
antibodies can rapidly reduce the viral load and tends to improve
clinical outcomes. The optimal dose and treatment time point, as
12.5% (10/80) in four noncomparative studies using CP treat-
ment (9, 20–22). Based on our preliminary results, CP therapy
in this
was 16.5 d. Consistent withstudy
maintain the
receiving plasma transfusion
to inactivate
previous
activity
given
research, the
beforeof14 neutralizing Bras: plasma de sujets contrôles
potential
all three
dpoi (patients
residual virus and to
patients
antibodies
1, 2, as much as pos-
well as the definite clinical benefits of CP therapy, need to be
further investigated in randomized clinical studies.Mortalité des patients COVID-19 traités par plasmas issus de patients convalescents medRxiv preprint doi: https://doi.org/10.1101/2020.08.12.20169359; this version posted August 12, 2020. The copyright holder for this preprint
(which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.
All rights reserved. No reuse allowed without permission.
CLINICAL MEDICINE The Journal of Clinical Investigation
N=35 000
Figure 1. Participation in the US
COVID-19 convalescent plasma
expanded access program, includ-
ing data extracted on May 11, 2020.
(A) Choropleth map displaying the
number of cumulatively enrolled
patients in the expanded access
program (EAP) within each state
of the contiguous US, with lower
enrollment values displayed in a
lighter hue of blue and higher enroll-
ment values displayed in a darker
hue of blue. Registered acute care
facilities are represented as yellow
circles, with larger circles indicat-
ing greater numbers of registered
facilities within the metropolitan
area of a city. The choropleth
map does not display data from
noncontiguous US locations,
including registered facilities in
Puerto Rico, Hawaii, Alaska, Guam,
and Northern Mariana Islands.
(B) The chronological line charts
represent the cumulative number of
enrolled patients (blue line) and the
cumulative number of patients that
have received a COVID-19 conva-
lescent plasma transfusion (yellow
line). The chronological bar charts
represent analogous values — the
number of enrolled patients (blue
bars) and number of patients that
have received a COVID 19 convales-
cent plasma transfusion (yellow
bars) by day. The difference between
the blue and yellow bars highlights
a fulfillment gap in COVID-19 con-
valescent plasma, which was most
acute at the onset of the EAP and
has substantially improved. 519
à520
Impact sur
Figure 2. la mortalité
Seven day (A, B)siand
injection
30-day (C,dans les 3 mortality
D) adjusted jours à stratified
fortes doses d’IgG
by antibody
521 groupings in patients transfused with COVID-19 convalescent plasma. Adjusted mortality
Joyner et al. Medrxiv 2020
à522
Risque depresented
rate is sélection devertical
on the souchesaxis, and the height of each bar graph represents adjusted
with the Mayo Clinic and national blood banking community opment of antimicrobial therapy in the 1940s (9). Convalescent
523 mortality with 95% confidence interval denoted. Data are stratified by groupings of antibody
developed a national expanded access program (EAP) to collect plasma was used during the 1918 flu epidemic and reduced mortal-2.1.3 Ac monoclonal Isolate spleen
cells from mouse
immunized
Antigen X
with antigen X
Technique de l’hybridome (1970):
Immortaliser et faire proliférer des clones de cellules B de souris produisant un Mutant myeloma line; FIGURE
Mixture of spleen cells, antibodi
unable to grow in HAT
seul type d’Ac par la fusion de clones B avec cellules myélomateuses immortelles. including some producing
anti-X antibody
Fusion selection medium; does
not produce antibody
a mouse
antigen o
an enzym
Polyclonaux à Monoclonaux : dirigés contre un seul épitope. Mixture of
with use
glycol th
fused and membran
Souris à l’humain. unfused cells that retai
partners.
that does
In vitro selection cells are
Monoclonal Antibody in HAT medium that perm
hybrids;
Faible efficacité des
single ce
of the
chimérique
medium
monoclonaux thérapeutiques Only fused cells
and thym
medium.
(hybridomas) synthesis
murins lié à leur grow needs te
that use
-ximab
immunogénicité et leur faible humanisé -zumab
phosphor
cells that
and they
Ingénierie moléculaire : -(m)umab
demi-vie (x: OKT3) anticorps recombinants Isolate clones derived from single cells synthesis
tetrahydr
defect in
a specifi
namely, i
cells rece
humain have the
from the
hypoxant
make DN
As a res
medium.
Screen supernatants of each clone for anti-X antibody
Par génie génétique and expand positive clones
- Remplacement progressif des domaines constants Hybridomas
producing
- Remplacement des régions charpentes des domaines monoclonal
anti-X antibody
variables des Ig murines par leurs homologues humainsa S-GFP
Anticorps neutralisant : COVID19 NATURE COMMUNICATIONS | https://doi.org/10.1038/s41467-020-16256-y
SARS-CoV SARS-CoV-2 MERS-CoV
S-GFP
a S-GFP
Hybridoma SARS-Secto SARS-S1 SARS-S1A SARS2-S1
0,1
ELISA reactivity hybr. sups
anti-SARS-S1A
SARS-CoV SARS-CoV-2
# hybr sups
23
MERS-CoV
44B3 2,5 2,7 3,3
45E10 3,0 0,8 1,7 0,0 anti-SARS-S1 (but not binding S1A) 22
46F11 2,4 2,7 3,3 0,0 anti-SARS-Secto (but not binding S1) 6
47D11
39F9 2,9 3,3 3,5 0,0 Total 51
41A7 2,6 1,0 1,9 0,0
28 E3 2,4 2,3 3,2 0,0
34C10 1,3 1,0 1,9 0,0 S-GFP
16C10 2,4 0,6 1,7 0,1
Prot S1 Sélection de l’hybridome
14B1
30B1
2,6
0,6
2,9
0,5
3,3
1,1
0,1
0,0
28G10 1,0 1,3 2,6 0,0 Overlay
28F6 2,4 2,9 3,0 0,0
40H10 1,2 0,7 1,9 0,0
39A4 1,7 1,5 2,8 0,0
37G1 1,3 0,9 1,7 0,0
44E11 2,8 3,3 3,5 0,1
19C1 1,9 0,4 1,2 0,1 47D11
b SARS-S pseudotyped virus SARS2-S pseudotyped virus
58D2 2,6 2,8 3,4 0,1
14C1 2,8 1,2 2,6 0,0
45H1 2,3 3,1 3,6 0,0 150 150
24F5 3,3 3,4 3,6 0,0
52D9 1,5 1,6 2,3 1,3
Infection (%)
Infection (%)
45E6 2,4 2,6 3,3 0,0
47D11 3,4 3,0 0,0 1,5 100 100
47G10 2,6 2,8 0,1 0,0
48G1 3,3 3,4 0,1 0,0
49F1 1,8 2,0 0,0 1,3
50 50
43C6 3,1 3,4 0,1 0,1 Overlay
22E10 3,2 3,4 0,1 0,0 Iso-CTRL Iso-CTRL
28D11 2,7 3,1 0,1 0,0 47D11 47D11
28H3 2,8 1,8 0,0 0,0 0 0
Souris tg codant pour Ig chimérique 25E7
22E8
3,1
1,2
3,3
1,2
0,1
0,1
0,1
0,0
10–3 10–2 10–1 100 101 10–3 10–2 10–1 100 101
MAb concentration (µg/ml) MAb concentration (µg/ml)
Chaine lourde humaine 35F4
43G5
3,2
3,2
3,6
3,3
0,1
0,1
0,0
0,1
c SARS-CoV SARS-CoV-2
47F8 1,4 1,4 0,0 0,0
b SARS-S pseudotyped virus SARS2-S pseudotype
Chaine légère rat 43B4
49B10
3,2
1,1
3,3
0,6
0,1
0,0
0,0
0,2
150 150
à Humanisé
51C11 1,9 1,9 0,0 0,0
36F6 1,7 2,7 0,1 0,3 150 100 150
100
Infection (%)
Infection (%)
65H8 3,2 3,3 0,1 0,1
65H9 1,6 1,7 0,1 2,5
48D5 3,3 3,5 0,1 0,0
Infection (%)
Infection (%)
35E2 2,5 3,3 0,2 0,0
44G3 2,4 2,8 0,1 0,0 100 50 50
100
Wang et al. Nature Com 2020
9H9 1,8 0,1 0,0 0,1
Iso-CTRL Iso-CTRL
25C3 3,0 0,1 0,1 0,1
29E6 1,1 0,1 0,1 0,0 47D11 47D11
43F11 2,8 0,1 0,1 0,0 0 0
47C4 1,5 0,0 0,1 0,0 50 10–3 10–2 10–1 100 101 10–3 1050
–2 10–1 100 101
13F11 3,0 0,0 0,0 0,0
MAb concentration (µg/ml)
Iso-CTRL MAb concentrationIso-CTRL
(µg/ml)
Supplementary Table 1. ELISA cross-reactivity of antibody-containingcellular cytotoxicity (ADCC) theandFab antibody- the pandemic
region of REGN10933 bindsspreads
the RBD or by virus escape mu- structural insights into the mechanism by which
Regeneron (Casirivimab – Imdevimab)
dependent cellular phagocytosis from(ADCP)
the topactiv-
direction,tants
wherethat might be selected
REGN10933 will for in response to noncompeting pairs of antibodies can simul-
ity in primary human cell bioassays utilizing
have collisions pressure
with ACE2. Tofrom
avoida competi-
single-antibody treatment (7). taneously bind the RBD and can thus be ideal
natural killer (NK) cells and tion monocyte-derived
with REGN10933, Thus, we examined
REGN10987 canouronlynine most-potent neu- partners for a therapeutic antibody cocktail.
phagocytes. All four lead antibodies
bind to the demon- tralizing
HDX-defined antibodies
protected in cross-competition bind-
regions REGN10987 and REGN10933 represent such
strated the ability to mediatefrom ADCCthe andfront
ADCP, or theing assays
lower left(fig. S7)(in
side andthe
identified several pairs a pair of antibodies: REGN10933 targets the
albeit to slightly different degrees. REGN10987
front view of REGN10987 of noncompeting
in Fig. 3). This mAbs
wouldwith picomolar neu- spike-like loop region on one edge of the ACE2
displayed superior ability to mediate ADCC with
be consistent rel- thetralization potency
neutralization that
data, as could potentially be interface. Within that region, the residues that
ative to the other three mAbs, whereas itwould
REGN10987 per- orient
combineditselftoinform antibody cocktails. To fur-
a position show the most notable HDX protection by
formed similarly to REGN10989 and REGN10933 thertostudy the with
binding regions of our mAbs on REGN10933 face upward, which suggests that
Cocktail de 2 Ac monoclonaux l’un issu de souris Tg l’autre issu de sérum de sujets convalescents
that has high probability interfere ACE2.
Confirming the above data, single-particle cryo–
ES EARCH | R E P O R T electron microscopy (cryo-EM) of the complex
Fig. 3. HDX-MS determines mAb of SARS-CoV-2 spike RBD bound to Fab frag-
interaction on spike protein ments of REGN10933 and REGN10987 shows
RBD. 3D surface models for the that the two antibodies in this cocktail can
structure of the spike protein RBD simultaneously bind to distinct regions of the
domain showing the ACE2 RBD (Fig. 4 and table S5). A three-dimensional
interface and HDX-MS epitope (3D) reconstructed map of the complex with
mapping results. RBD residues nominal resolution of 3.9 Å shows that the two
that make contacts with ACE2 Fab fragments bind at different epitopes on the
(21, 22) are indicated in yellow RBD, which confirms that they are noncom-
(top). RBD residues protected by peting antibodies. REGN10933 binds at the top
anti–SARS-CoV2 spike antibodies of the RBD, extensively overlapping the binding
are indicated with colors that site for ACE2. On the other hand, the epitope for
represent the extent of protection, REGN10987 is located on the side of the RBD,
as determined by HDX-MS away from the REGN10933 epitope, and has
experiments. RBD residues in little to no overlap with the ACE2 binding site.
purple and blue indicate sites of We report notable similarities and consis-
lesser solvent exchange upon tencies in the antibodies generated from
antibody binding that have genetically humanized mice and from con-
greater likelihood to be antibody- valescent humans. The scale of the genetic-
binding residues. The RBD engineering approach used to create the VI
structure is reproduced from mouse (involving genetic-humanization of
PDB 6M17 (21). more than 6 Mb of mouse immune genes)
has resulted in the ability to effectively and
indistinguishably mimic the antibody responses
of normal humans. The genetically humanized–
mouse approach has the advantages that it
can potentially allow for further immuniza-
tion optimization strategies and that it can be
applied to noninfectious disease targets. By
g. 1. Paired antibody repertoire for human- and mouse-derived SARS-CoV-2 neutralizing antibodies. (A and B) Variable (V) gene frequencies for paired heavy combining the efforts from two parallel and
axes) and light (y axes) chains of isolated neutralizing antibodies to SARS-CoV-2 for VI mice (A) (N = 185) and convalescent human donors (B) (N = 68). The color Fig. 2. Neutralization potency high-throughput
of anti–SARS-CoV-2approaches
spike mAbs. for (A) generating
Serial pVSV-SARS-CoV-2-S(mNeon) in Calu-3 cells. (C) Neutralization potency of
d size of the circles correspond to the number of heavy and light chain pairs present in the repertoires of isolated neutralizing antibodies. Neutralization is defined dilutions of anti-spike mAbs, IgG1antibodies to the and
isotype control, RBDrecombinant
of the SARS-CoV-2
dimeric spikeindividual anti-spike mAbs and combinations of mAbs against replicating
ACE2 (hACE2.hFc) were added protein, we generated a sufficiently to Verolarge col-VSV-SARS-CoV-2-S virus in Vero cells. Cells were infected with a multiplicity
>70% with 1:4 dilution of antibody (~2 mg/ml) in VSV-based pseudoparticle neutralization assay.
Autorisation FDA sans aucune publication
with pVSV-SARS-CoV-2-S(mNeon)
cells, and mNeon expression waslection
measured of 24
potent
hours and
after diverse
infection antibodies
as a thatof infection (MOI) 1 of the virus and stained for viral protein 24 hours after
readout for virus infectivity. Datawearecould meet
graphed as our prospective
percent goalrelative
neutralization of identi-infection to measure infectivity. (D) Neutralization potency of individual
overlaid sequences (fig. S2) showed strong tion. The antibodies bound specifically and tion of SARS-CoV-2 in VeroE6 cells (Fig. 2, B to to virus-only infection control. (B)
recombinant dimeric ACE2, andcould
des essais de phase 1/2/3.
fying highly potent
Neutralization
be combined
IgG1 isotype
individual
potency antibodies
of anti-spike
into nonreplicating
control against
mAbs, thatanti-spike mAbs and combinations of mAbs against SARS-CoV-2-S virus
a therapeutic anti-in VeroE6 cells.
erlap in the repertoire of isolated kappa with high affinity to monomeric SARS-COV-2 D). All neutralization assays generated similar
Visée préventive sujets à risque de formes
body cocktail. Inclusion of such antibodies
ains between VI mouse and human-derived RBD [dissociation constant (Kd) = 0.56 to potency across the four mAbs, and no combi- into an antibody cocktail may deliver optimal
Hansen et al., Science 369, 1010–1014 (2020) 21 August 2020 3 of 5
tibodies. Although the repertoire of lambda 45.2 nM] and dimeric SARS-COV-2 RBD (Kd = nations demonstrated synergistic neutrali- antiviral potency while minimizing the odds
ains did not overlap well, that may be because 5.7 to 42.8 pM). Because recombinant ACE2 zation activity (Fig. 2, C and D). As previous graves éviter la surcharge des hôpitaux.
of virus escape (7)—two critical, desired fea-
tures of an antibody-based therapeutic for
ly two lambda mice were included in this receptor is being considered as a COVID-19 studies indicate pseudoparticles contain-
al. The average complementarity-determining
gion (CDR) lengths (fig. S2D) for heavy chains
therapeutic (13), we tested the potency of re-
combinant dimeric human ACE2-Fc (hACE2-hFc)
ing the SARS-CoV-2 spike are precleaved by
furin-like proteases at the polybasic S1-S2
30/10 Arrêt de l’essai de phase 3 chez les
treatment and prevention of COVID-19. Such
an antibody cocktail is now being tested in
human trials (clinicaltrials.gov NCT04426695
Hansen et al. Science 2020
as similar between VI mouse and human-
rived antibodies, with average lengths of 13
in our neutralization assay. Although recom-
binant ACE2 was able to mediate neutraliza-
cleavage site during biogenesis in HEK293T
cells, we assessed the impact of this cleavage
patients hospitalisés
and NCT04425629).n Outpatients with Covid-19
Etude de Phase 2 LY-COV555
-
-
-
101 Patients were enrolled and assigned
to 700 mg of LY-CoV555 monotherapy
(Bamlavinimab)
Neutr alizing Antibody in Outpatients with Covid-19
Interim Analysis The n e w e ng l a n d j o
Positive SARS-CoV-2 test ≤3 days Table 2. Change from Baseline in Viral Load.
107 Patients were enrolled and assigned before infusion
to 2800 mg of LY-CoV555 monotherapy Mild or moderate Covid-19 symptoms
LY-CoV555 Placebo Difference
Primary end point: change from
baseline to day 11 (±4 days)
Variable (N = 309) (N = 143) (95% CI) A Viral Load in All Patients
m 101 Patients were enrolled and assigned in SARS-CoV-2 viral load
Primary outcome Nonhospitalized Hospitalized
1 to 7000 mg of LY-CoV555 monotherapy Secondary end points include safety,
symptom severity, hospitalization, 10
a Mean change from baseline in viral load at day 11 −3.47
and time points for viral clearance
143 Patients were enrolled and assigned Neutr alizing Antibody in Outpatients with Covid-19
e to placebo
700 mg, −3.67 −0.20 (−0.66 to 0.25) 15
d 2800 mg, −4.00 −0.53 (−0.98 to −0.08) 20
Cycle Threshold
l The n e w e ng l a n d j o u r na l of m e dic i n e 7000 mg, −3.38 0.09 (−0.37 to 0.55)
measure
Figure 1. Enrollment and Trial Design. of viral neutralization, since viral RNA 25
- Table 3. Hospitalization.*
may persist for some time even in the absence of Pooled doses, −3.70 −0.22 (−0.60 to 0.15) 30
)
replication-competent virus. Since theline severity
was
Secondary of (95%
−0.53
outcomes* Key Secondary
confidence LY-CoV555
interval [CI], −0.98 Placebo Incidence
g Table 1. Characteristics of the Patients at Baseline.* Outcome 35
illness is primarily driven by lung to injury
Mean −0.08;from
change Pfrom
= 0.02), forinaviral
baseline lower
load atviral
day 3load by a −0.85
n regarding these methods are provided in Section 40
SARS-CoV-2LY-CoV555infection in the lowerfactor
Placebo respiratory
of 3.4 (Table 2). However, smaller differ-
no. of patients/total no. %
- 6.10 in the statistical analysis plan.) (N = 309)
Characteristic (N = air
143)spaces would be a
700 mg, −1.27 −0.42 (−0.89 to 0.06)
tract, the viral load in the ences from placebo in the decrease from base- 45
n Hospitalization 9/143
2800 mg, −1.50 6.3 −0.64 (−1.11 to −0.17)
Age better reflection of the injury response linethan
werethe observed among the patients who re- Day 1 Day 3 Day 7 Day 11
, 700 mg, 1/101 7000 mg, −1.27 1.0 −0.42 (−0.90 to 0.06)
Median (range) — Ryre sult s viral load 45 in nasopharyngeal
(18–86) secretions.
46 (18–77) However,
ceived the 700-mg dose (−0.20; 95% CI, −0.66 to
- 2800 mg, 2/107 1.9 B Viral Load on Day 7 in Each Trial Group
65 Yr or older — no. (%) assessments of the lower
33 (10.7) respiratory0.25;
20 (14.0) tractP =were
0.38) and the 7000-mg dose (0.09; 95% Pooled
CI, doses, −1.35 −0.49 (−0.87 to −0.11)
t Patients
not practical owing to precautions that −0.37
Mean were
to
changere-fromP baseline
0.55; = 0.70). in viral load7000 mg,7 2/101
at day 2.0
−2.56 1.00
- From
FemaleJune
sex —17no.
through
(%) August 21, 2020, 171 a(55.3)
total 78 (54.5)
quired in treating these highly infectious patients. Pooled doses, 700 mg, −2.82 1.6 −0.25 (−0.73 to 0.23)
d ofRace
467orpatients underwent
ethnic group — no./ randomization to re- 5/309
Therefore, the nasopharyngeal viral swab
Secondary was Viral Outcomes 2800 mg, −3.01 −0.45 (−0.92 to 0.03)
d ceive either LY-CoV555
total no. (%)† (317 patients) or placebo
the most pragmatic way of getting a sense On of viral
day 3, among the patients who received the 0.75
f (150 White
patients), and the patients in the269/305 LY-CoV555 (88.2) 120/138 (87.0) * Data for patients who presented to 7000
the mg, −2.85
emergency department are included in−0.28 (−0.77 to 0.20)
load as a surrogate marker of the viral 2800-mgload dose
in ofthis LY-CoV555,
category. the observed differ-
Cumulative Probability
- groupHispanic
were assigned
or Latino to one ofthe three135/309
dose sub- Pooled doses, −2.90 −0.33 (−0.72 to 0.06)
lungs and(43.7) 63/143
to correlate (44.1)
with clinical outcomes.
ence from placebo in the decrease from baseline
- groups. Of the patients who had undergone
Black However, the(7.2)
22/305 nasopharyngeal
7/138 (5.1)viral load
* in
Data has
the not hospitalization,
mean
regarding log viral load was key
another −0.64 (95%outcome,
secondary CI, are provided in Table 3. 0.50
e randomization, 452 met the criteria for inclusion
Body-mass index‡ been validated as a predictor of clinical −1.11disease
to −0.17) (Table0 2). The other two doses of
- in the primary analysis (309 in the LY-CoV555
course. LY-CoV555 showedHospitalization
similar improvements in viral domains that were
Valuegraded
(95% CI) from 0 (no symp-
LY-CoV555 observation in Covid-19–Related
Median 29.4 29.1 LY-CoV555, 700 mg
. group and 143 in the placebo group). An unanticipated this trial was
Delta
≥30 toA Pulmonary Ordinal Outcome on Day 5
Etude de Phase 3 Category
LY-CoV555 Placebo
no. of patients (%)
100
Category
Can independently undertake usual activities with
LY-CoV555
1 31 (19.3) 33 (22.0) minimal or no symptoms
Better
No supplemental oxygen; symptomatic and unable
80 to independently undertake usual activities
2 50 (31.1) 48 (32.0)
Cumulative Percentage
Supplemental oxygen 14)
40 Invasive ventilation, ECMO, mechanical circulatory
LY-CoV555 Placebo Total support, renal-replacement therapy, or vasopressor
Characteristic (N = 163) (N = 151) (N = 314) 5 25 (15.5) 22 (14.7)
Death
Median age (IQR) — yr 63 (50–72) 59 (48–71) 61 (49–71)
20
6 8 (5.0) 5 (3.3)
Worse
Female sex — no. (%) 66 (40) 71 (47) 137 (44)
Current pregnancy — no. (%) 1 (1) 2 (1) 3 (1)
7 1 (0.6) 0 (0.0) 0
Race or ethnic group — no. (%)† Summary Odds Ratio
5
o
0.85 (95% CI, 0.56– 1.29)
55
eb
White 76 (47) 71 (47) 147 (47)
oV
ac
P=0.45
Pl
-C
Hispanic 41 (25) 33 (22) 74 (24)
LY
Black 33 (20) 34 (23) 67 (21)
Other 13 (8) 13 (9) 26 (8) B Time to Sustained Recovery C Time to Hospital Discharge
Body-mass index — no. (%)‡ 100 100
≥30 81 (50) 83 (55) 164 (52)
≥40 20 (12) 22 (15) 42 (13)
80 80
Cumulative Incidence (%)
Cumulative Incidence (%)
Coexisting illness — no. (%)
Any 117 (72) 98 (65) 215 (68)
Hypertension requiring medication 82 (50) 72 (48) 154 (49) 60 60
Diabetes requiring medication 54 (33) 36 (24) 90 (29)
Renal impairment 24 (15) 9 (6) 33 (11) 40 40
Asthma 14 (9) 14 (9) 28 (9) LY-CoV555 LY-CoV555
Heart failure 12 (7) 1 (1) 13 (4) Placebo Placebo
20 20
Median no. of days since symptom onset (IQR) 7 (5–9) 8 (5–9) 7 (5–9)
Medication — no. (%) Recovery Rate Ratio Discharge Rate Ratio
0 1.06 (95% CI, 0.77– 1.47) 0 0.97 (95% CI, 0.78– 1.20)
Remdesivir 60 (37) 66 (44) 126 (40)
Antibacterial agent 54 (33) 36 (24) 90 (29) 0 10 20 30 40 0 10 20 30 40
Glucocorticoid 80 (49) 74 (49) 154 (49) Days from Randomization Days from Randomization
Antiplatelet or anticoagulant agent§ 106 (65) 95 (63) 201 (64)
No. at Risk No. at Risk
ACE inhibitor or ARB 41 (25) 31 (21) 72 (23) LY-CoV555 87 86 41 9 3 LY-CoV555 163 38 17 6 3
NSAID 17 (10) 16 (11) 33 (11) Placebo 81 81 41 10 4 Placebo 151 36 13 6 4
Oxygen requirement — no. (%)
Supplementary oxygen
Figure 1. Pulmonary Ordinal Outcome at Day 5 and Time until Sustained Recovery and Hospital Discharge.
None 44 (27) 42 (28) 86 (27) Panel A shows the pulmonary ordinal outcome at day 5 in the LY-CoV555 group and the placebo group. The summary odds ratio was es-November 30, 2020
Place des Monoclonaux ATU
Tenant compte de l’avis de l’ANRS-Maladies Infectieuses Emergentes, les
Take CME Exams populations éligibles à ces deux associations d’anticorps monoclonaux
sont définies comme suit :
1. Les patients ayant un déficit de l’immunité lié à une pathologie ou à
des traitements :
Table 1. Eligible Patients Considered High Risk1
- Chimiothérapie en cours
-19 Patients with ≥1 of the following:
- Transplantation d’organe solide
▶ BMI ≥35 - Allogreffe de cellules souches hématopoïétiques
onal ▶ Chronic kidney disease - Maladie rénale avec DFG 15 mg/semaine
▶ Currently receiving immunosuppressive treatment
mild ▶ ≥65 years old - Traitement immunodépresseur incluant rituximab
≥12 Patients ≥55 years old and ≥1 of the following:
high 2. Les patients à risque de complications :
▶ Cardiovascular disease
○ Les patients parmi la liste suivante quel que soit l'âge :
d/or ▶ Hypertension
▶ COPD or other chronic respiratory disease - Fibrose pulmonaire idiopathique
- Sclérose latérale amyotrophique
Patients 12-17 years old and ≥1 of the following:
may - Pathologies rares du foie y compris hépatites auto-immunes
▶ BMI ≥85th percentile for their age and gender2
- Myopathies avec capacité vitale forcée 30)
BMI = body mass index; COPD = chronic obstructive pulmonary disease - BPCO et insuffisance respiratoire chronique
1. Patients ≥12 years old who weigh ≥40 kg with ≥1 of the criteria listed - Hypertension artérielle compliquée
are considered at high risk for progressing to severe COVID-19 and/or
hospitalization. FDA fact sheet for health care providers emergency use - Insuffisance cardiaque
authorization (EUA) of bamlanivimab. Available at: https://www.fda.gov/
media/143603/download. Accessed November 19, 2020.
- Diabète (de type 1 et de type 2)
Risque
ATU de sélection de souches
en France
s to 2. Based on CDC growth charts (https://www.cdc.gov/growthcharts/ - Insuffisance rénale chronique Risque de sélection de souches
clinical_charts.htm).
n of 3. Les patients de plus de 80 ans809 866
810 867
811 868
812 869
2.2 Renforcer la Réponse IFN
813 870
814 871
815 872
FIGURE 3 | The evolution of cytokine levels in individual patients following their clinical outcome. The levels of IL6 in non-stimulated plasma (A,B; n = 13 and n = 6,
816 873
respectively) and the levels of IFNγ after in vitro non-specific stimulation of innate and adaptive immune cells (C,D; n = 6 and n = 3, respectively) were compared
817 874
between the patients who recovered from their SARS-CoV-2 infection (A,C) and the deceased patients (B,D). Differences between groups were compared with a
818 Wilcoxon matched pairs signed rank test. 875
819 876
820 877
821 878
822 879
823 880
824 881
825 882
826 883
827 884
828 885
829 886
830 887
831 888
832 889
833 890
834 891
835 892
836 893
837 894
838 895
839 896
840 897
841 898
842 899
843 900
844 901
845 902
846 903
847 904
848 905
849 906
850 907
851 908
852 FIGURE 4 | The efficacy of in vitro treatment with different drugs commonly used in COVID-19 to modulate cytokine expression. The levels of IFNγ (A), IL1β (B), IL6 909
853 (C), and IL10 (D) after in vitro pretreatment with drugs, followed by non-specific stimulation of innate and adaptive immune cells, in 18 COVID-19 patients. Differences 910
854 between groups were compared with Kruskal-Wallis test using Dunn’s post hoc test. 911
855 Ruestch*,
912 Brglez* et al. Front Med 2020You can also read
