Category Archives: Genetic Medicine

In the center of the COVID-19 pandemic, hospitals are racing to maintain quality care for patients with severe disease while facing a shortage of resources and limited understanding of the novel coronavirus.

One physician on the front lines Ariel Jaitovich, a pulmonary and critical care physician at the Albany Medical Center in New York sought out a collaboration with investigators at the Morgridge Institute for Research and the Department of Biomolecular Chemistry at the University of Wisconsin School of Medicine and Public Health (SMPH) to better understand the molecular profile of COVID-19 and provide insights that may improve treatment.

Its a new disease. Two months ago, we knew nothing about it, says Jaitovich. What we are trying to do now is do systematic work to better understand what this disease is about.

By analyzing approximately 150 patient COVID-19 samples from the Albany Medical Center, the collaborative research team is hoping to better understand what factors influence whether a patient will suffer from complications such as acute respiratory distress syndrome (ARDS).

One example is the immunological concept of a cytokine storm where the inflammatory response of the immune system goes into overdrive as a possible trigger for ARDS.

Theres no clear understanding of whether these people who do really bad are the ones who have a toxic level of inflammation if this cytokine storm is necessarily associated with worse outcomes in COVID patients, Jaitovich says.

Josh Coon

Katie Overmyer

Jaitovich reached out to Morgridge investigator, SMPH professor, and mass spectrometry expert Josh Coon to help because, he says, Josh runs one of the most sophisticated and advanced labs to investigate proteins.

Coon leads the Laboratory for Biomolecular Mass Spectrometry at UWMadison and had been looking for a way to leverage his labs technology to help with the pandemic. The labs efforts will be managed by LBMS associate director Katie Overmyer and assistant staff scientist Evgenia Shishkova.

Its what we do. We take a problem, we apply our technologies. We help our collaborators solve this problem, says Overmyer.

The research team is using an approach called mass spectrometry to measure lipids, proteins and other small molecules called metabolites in samples from patients hospitalized with COVID-19. They will be compared to control samples from hospitalized patients who tested negative for COVID-19.

The technology allows scientists to identify different compounds and better understand their properties. Coon says it may help them identify molecular signals that might distinguish a mild case from a severe case.

What we are trying to do now is do systematic work to better understand what this disease is about.

Ariel Jaitovich

Much of the previous research on coronaviruses and influenza has typically focused on proteomics (proteins), lipidomics (lipids) and metabolomics (metabolites) separately, Overmyer notes. This multi-omic approach is fairly new and not well adopted yet, she says. I think thats going to be the really powerful tool here, to be able to link those and maybe make better inferences about whats going on than a single [approach] would allow.

In addition to the cytokine storm process, Coon says there are other potential indicators of disease severity that involve blood clotting factors in the vessels of the lung. The research team hopes that studying the different proteins, metabolites and lipids involved in these unique disease mechanisms can reveal more about what is happening in patients with COVID-19.

Can we stratify those patients based on those molecular measurements and help predict what an outcome might be? I think those are the overall goals: to really try to understand whats happening at a molecular level, Coon says.

While the Coon laboratory works on characterizing the molecular signatures, Jaitovichs team will also work to identify the genetic influences on the disease. To analyze this data, which involves RNA sequencing, Jaitovich is collaborating with Morgridge bioinformatics experts Ron Stewart and Scott Swanson.

Ron Stewart

Scott Swanson

We should be able to get an idea about what genes or gene sets are involved in things like inflammation, and how that might differ between COVID-19 and other ARDS cases, says Stewart, principal investigator and associate director of bioinformatics at Morgridge.

Swanson will lead the analysis to determine if there are unique gene expression profiles that might differ between the mild and severe cases. I can look at those genes, and we have all kinds of databases available to us that tell us about which genes are related to different physiological characteristics, he says. Were following the footsteps of established techniques that have produced results in this specific domain of ARDS, if not necessarily for coronaviruses. So, Im optimistic that something intelligible and meaningful will come out of even just that first pass of analysis.

By combining the mass spectrometry data with the RNA sequencing data, Jaitovich says the ultimate outcome of this project is to identify potential targets to help treat the disease.

This is extremely important for many reasons, because you can, for example, intervene early with people who are more likely to do worse over time based on these early identified markers, he says. You can better allocate resources in a moment in which there is a shortage of resources to deal with this pandemic.

The team is working to analyze patient samples as soon as they arrive.

Certainly, as long as weve been in business theres never been a pandemic like this with such urgency to really come up with a scientific solution, says Coon.

It is difficult, because we deal with real-world problems of patients who are suffering from it or losing loved ones. You know, a lot of anxiety, says Jaitovich. On the other hand, there is a lot of support, including health care workers, patients and families. There is massive support by the institutions leadership they are all committed to working together toward the common goal: alleviating peoples suffering.

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Teams from Wisconsin, New York search for molecular clues to defeat COVID-19 - University of Wisconsin-Madison

The National Institute of Allergy and Infectious Diseases the agency run by Anthony Fauci has launched the first randomized, controlled trial of remdesivir, enlisting about 1,060 patients worldwide. Results are expected in late May.

Two Chinese trials were halted this month because of a lack of enrollment, purportedly due to a lack of patients with Covid-19 as Chinas outbreak wanes.

Outside of the trials, Gilead is still allowing patients to access the intravenous drug via a compassionate use program. Its donating 1.5 million doses enough to treat more than 140,000 patients for use in clinical trials and compassionate use programs.

Approved in Japan in 2014 to treat the flu, Fujifilms antiviral brand name Avigan never hit the market because of concerns it could cause birth defects. Its now being tested against the coronavirus in Japan and the U.S. The Japanese government is also stockpiling 2 million treatment courses of the drug, betting that it will be effective because it disrupts the process by which the coronavirus, and related viruses, replicate.

Fujifilm launched a Phase III clinical trial in Japan on March 31 to assess favipiravirs safety and efficacy. The company did not provide any further details on the trials design or duration.

The company also started a Phase II trial this month for about 50 patients at three Boston-area hospitals, including Brigham and Womens Hospital, Massachusetts General Hospital and the University of Massachusetts Memorial Medical Center.

Zhang Xinmin, an official at Chinas science and technology ministry, told the China Daily last month that favipiravir produced encouraging results in clinical trials of 340 patients in Wuhan and Shenzhen.

First approved by the FDA in 2010 to treat rheumatoid arthritis, Roches drug marketed as Actemra blocks a type of severe inflammation, called a cytokine storm, seen in the lungs of some coronavirus patients. Studies from China have shown that neutralizing cytokine storms helps to reduce deaths in severe cases of Covid-19. Last month, China approved the use of Actemra to treat Covid-19, but clinical trials of the drug are continuing.

Results from an open-label trial in France showed improved outcomes for people taking the drug who had moderate or severe Covid-19 pneumonia. The trial compared 65 participants randomly assigned to receive tocilizumab and 64 who were given standard care.

Roche is sponsoring a Phase III trial of 330 hospitalized patients with severe Covid-19 pneumonia in the U.S. and Europe. It will evaluate the efficacy and safety of tocilizumab compared with a placebo in combination with standard treatment. A Roche spokesperson said the results could be released in early summer.

The National Cancer Institute of Naples has enrolled 2,111 people across Italy in a Phase II single-arm trial which means that every patient will receive tocilizumab, and there is no control group. The researcher leading the trial told POLITICO that results are expected in the next three weeks.

At least four other trials are ongoing at hospitals across China, Roche said, but they are not placebo-controlled.

Approved by the FDA to treat rheumatoid arthritis, this Eli Lilly drug a.k.a. Olumiant was identified as a potential coronavirus treatment by a U.K.-based artificial intelligence system. Lilly initially expressed caution about using baricitinib in Covid-19 patients because it suppresses the immune system, according to The New York Times, but eventually agreed to test the medication because doctors had started using it off-label. The drug company is working with the National Institute of Allergy and Infectious Diseases to study baricitinib as part of a placebo-controlled trial in the U.S., Europe and Asia that also includes Gileads remdesivir. Data on baricitinib is expected in the next two months, according to Lilly.

AstraZenecas drug, also known as Calquence, is approved to creat a pair of blood cancers: chronic lymphocytic leukemia and mantle cell lymphoma. Now its being eyed as a treatment for coronavirus patients in the grip of cytokine storms. The drug company said last week that it will undertake a randomized, controlled trial of Calquence. NIH Director Francis Collins said this week that he was surprised by the early clinical data, but he also said hell wait for the trial results before drawing any conclusions about the drugs usefulness.

Convalescent plasma is a decades-old treatment that involves giving sick patients the antibody-rich blood plasma of people who have recovered from the same illness. The approach has a mixed track record, but its being tried again with the coronavirus as is a treatment known as hyperimmune globulin, which is derived from convalescent plasma and also contains high levels of antibodies.

New Jersey-based Hackensack University Medical Center is running a Phase IIa study with 55 participants to determine the best dosing for convalescent plasma treatment.

Erasmus University Medical Center in the Netherlands is recruiting 426 patients for a Phase II trial to compare convalescent plasma with the standard of care.

Nine hospitals in Spain will enroll 278 hospitalized patients with Covid-19 to compare convalescent plasma with the standard of care.

The FDA is also helping to coordinate a study of hyperimmune globulin that will be conducted by the National Institute of Allergy and Infectious Diseases.

Hospitals in China have used corticosteroids in an attempt to tamp down inflammation in coronavirus patients, but its not yet clear whether this strategy is effective, according to the Centers for Disease Control and Prevention. The agency has warned against using the drugs to treat Covid-19, because patients with the MERS coronavirus or flu who were given steroids were more likely to die than those didnt get the drugs. Still, there are multiple trials now testing various steroids against the coronavirus.

A U.K. government-funded study of 5,262 Covid-19 patients at 167 sites that began in March is testing four different treatments, including a low dose of the steroid dexamethasone.

Scientists in South Korea are recruiting 144 people to investigate whether the steroid ciclesonide alone or in combination with hydroxychloroquine could help patients with mild Covid-19.

The malaria drugs have been at the center of a media storm, after President Donald Trump and his allies began aggressively promoting them as coronavirus treatments despite a lack of data. Pharmaceutical companies have donated millions of doses to the U.S. Strategic National Stockpile, and almost 100 clinical trials have sprung up since the FDA issued an emergency use authorization in early April to distribute the both drugs to coronavirus patients.

At least one clinical trial of hydroxychloroquine was halted because the drug caused life-threatening cardiac side effects a risk long known to doctors who use the drug to treat lupus and rheumatoid arthritis.

The NIHs National Heart, Lung and Blood Institute is helping to conduct a blinded, placebo-controlled Phase III trial to evaluate the safety and effectiveness of hydroxychloroquine in 510 adults hospitalized with Covid-19. The trial began enrolling patients in Tennessee on April 2, and will extend to 44 sites nationwide. A spokesperson for Vanderbilt University Medical Center said results will come in a couple of months.

The University of Minnesota is conducting a Phase III trial in 3,000 participants to determine if hydroxychloroquine can help prevent or treat Covid-19. Results are expected about two weeks after the trial is fully enrolled, a university spokesperson said.

Trials at the University of Utah and Intermountain Medical Center in Utah are comparing hydroxychloroquine and azithromycin in 300 patients hospitalized with Covid-19. The timing of its results depends on how quickly researchers can enroll participants, said Dr. Samuel Brown, Intermountains director of pulmonary and critical care research.

Three hospitals in New Jersey are conducting a 160-person randomized trial that will compare hydroxychloroquine alone and in combination with the antibiotic azithromycin to a control group that receives standard care for the first six days. After that point, any patients with symptoms of the coronavirus will receive the malaria drug.

The University of Pennsylvania is conducting a three-part trial that includes a randomized, controlled study of hydroxychloroquine as a treatment for home-bound coronavirus patients; a randomized trial testing different doses of the drug in hospitalized patients; and a randomized, controlled trial of low doses of hydroxychloroquine as a preventative treatment for health care workers.

It took just 63 days from the time the company started designing its vaccine to launch the first clinical trial, a rapid pace made possible in part by Modernas use of genetic material called messenger RNA. When that mRNA is injected into a patient, it directs cells to make a protein found on the coronavirus and stimulates the production of antibodies.

No mRNA vaccine for any disease has yet won approval, but the technique has tantalized public health experts because churning out doses using this technology would be cheaper and easier than making traditional vaccines. The U.S. governments Biomedical Advanced Research and Development Authority has pledged up to $483 million to accelerate the Moderna vaccines path to FDA approval.

In March, the Kaiser Permanente Washington Health Research Institute in Seattle began enrolling patients in a Phase I safety trial. Emory University in Atlanta is also enrolling patients in the trial, which is aiming for a total of 45 participants across the two sites. Participants will receive two shots of the experimental vaccine approximately one month apart and will be followed for about one year.

Moderna is already ramping up production of the vaccine for a potential Phase II trial that could begin as early as June. A Phase III trial could begin next fall. If the early data is promising, the company says it could churn out enough doses by next fall to vaccinate health care workers and other priority groups.

This experimental vaccine, developed in China, was created to combat Ebola. It uses an inactivated version of a virus that causes the common cold to carry a gene that causes cells to make a protein found on the coronavirus with the goal of sparking an immune response. Phase I testing began last month in China, and CanSino and the Beijing institute have enrolled almost 300 people with Covid-19. Based on preliminary data, the company says it plans to launch a Phase II placebo-controlled trial with 500 participants.

Johnson & Johnson is working with the Biomedical Advanced Research and Development Authority and Boston-based Beth Israel Deaconess Medical Center on a vaccine that uses an inactivated version of the common-cold virus to carry genetic material into cells. That material prompts the body to pump out proteins found in the coronavirus in the hopes of drawing an immune response. The company expects to kick off human studies by September at the latest. If the vaccine works, J&J says the first batches could be available for emergency use in early 2021.

The two companies one American, one German are partnering on an mRNA coronavirus vaccine. This week, German regulators approved a Phase I/II trial of the vaccine; its first stage will enroll 200 people. Pfizer is paying BioNTech $185 million upfront as part of the collaboration, and the companies said they have the potential to supply millions of doses by the end of 2020 if the vaccine is promising, and scale up to produce hundreds of millions of doses in 2021.

This experimental vaccine combines Sanofi technology that produces a protein found in the coronavirus, which aims to trigger an immune response, with an adjuvant made by GlaxoSmithKline designed to heighten that immune response. The companies plan to begin Phase I trials of their vaccine in the second half of the year, and if the results look good, a vaccine could be available by the second half of 2021. Phase I clinical trials are expected to initiate in the second half of 2020 and, if successful, a vaccine could be available by the second half of 2021.

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The drugs and treatments that could stop Covid-19 - POLITICO

If we take the advice of health experts, we wont be attempting a return to normal life in the US until we get better at identifying people infected with the novel coronavirus. That need is driving researchers across the nation to look for ways to expand our toolbox of testing options. And now a new test, developed using CRISPR gene editing technology, has been added to the mix.

About 5.4 million tests have been done in the US, according to the COVID Tracking Project, in a population of 328.2 million. That might sound like enough to keep ahead of an infectious disease that has only killed in five figures, but such an assumption grossly oversimplifies the situation.

Controlling the pandemic in the US is going to require a daunting number of diagnostic tests not just for the sick, but to verify when theyre better (two tests 24 hours apart for hospital discharge), in contact tracing to limit spread, and in the many individuals whove been infected but have few or no symptoms.

In a few countries, the use of diagnostic testing on a massive scale has been a cornerstone of successful containment strategies, write Matthew P. Cheng, MDCM. McGill University Health Centre and colleagues in a recent article in Annals of Internal Medicine. The US isnt on that list and has been struggling to catch up.

Simply put, we need faster, cheaper and more accurate tests than what we currently have. If they can be administered at home or in informal settings, all the better. Among the potential solutions for this challenge are efforts to turn everyones favorite gene editing tool, CRISPR, against the coronavirus. If successful, we could see a shift in access to tests. Imagine being able to use a nasal swab that delivers a yes or no verdict on coronavirus infection in under 40 minutes essentially like a home pregnancy test.

A CRISPR-based diagnostic is in the sights of researchers at the University of California, San Francisco Medical School and Mammoth Biosciences, which recently revealed plans for an inexpensive, compact test.

I can run it now myself at home, said Dr. Charles Chiu, professor of laboratory medicine at UCSF and co-lead developer of the new test, in an interview with NPR. Still, he acknowledged the test, which is being submitted for FDA approval, isnt yet simple enough for the average person to operate. He expressed confidence that a home-based test for nonexperts is within reach.

What we really want to develop is something like a handheld, pocket-sized device using disposable cartridges, he told NPR.

So, where would such CRISPR-based tests fit within the universe of coronavirus diagnostics? Theres little reason to think they would replace other testing options. Rather, think of them as offering another option for hospitals, clinics, doctors, and even consumers. That said, lets take a look at where we are in testing.

Diagnostic tests use a version of the polymerase chain reaction (real-time reverse transcriptase PCR) to amplify pieces of the RNA genome of SARS-CoV-2, the virus behind COVID-19. Dr. Deborah Birx, Coronavirus Response Coordinator, suggested that antigen-based tests be added to increase the supply, but these detect protein antigens on the viral surface, not the genetic material, and may be less likely to indicate infectious virus. For influenza diagnostic testing antigen tests are less accurate than the PCR-based tests.

PCR is simple in concept, but not always easy to carry out. It requires raising and lowering the temperature repeatedly as nucleic acid sequences are copied. Reagents may run out, and it requires specialized equipment. A PCR-based test that could diagnose infection in a few hours often takes more than a day because the sample must be sent to a lab.

False negatives can occur if viral RNA in a sample degrades during shipping, or if not enough collects on the swab. If either happens and a patient worsens, another test is required. But if the virus descends into the lungs, not enough may remain in the throat for a test to pick it up, even though the patient is actually sicker.

And so some people with obvious symptoms of COVID-19 must have two or three tests before a result is positive.

But PCR-based tests are what we have. Regulations shifted into emergency mode to bolster supplies.

On February 4, the Food and Drug Administration (FDA) greenlighted the Emergency Use Authorization (EUA) of the Center for Disease Control and Preventions (CDC) PCR test, making it available to to state and local public health labs and the Department of Defense. The EUA enables rapid roll-out of a still-experimental test. Even though PCR has been used in clinical diagnostics for decades, the virus is new and therefore so is the test.

A PCR-based diagnostic for COVID-19 amplifies RNA sequences unique to the novel virus, as well as gene parts common to other coronaviruses and a control sequence (encoding an enzyme, RNase), to make sure the test is working.

But at the end of January, bits of viral RNA in the CDC facility tainted some of the first test kits, so that they could yield false positive results, delaying their use.

On February 28, FDA took further action, announcing that clinically-licensed labs can use in-house developed tests while awaiting the EUA. These labs are CLIA-compliant,which means that they satisfy the standards of the Clinical Laboratory Improvement Amendments set by the federal government.

So places like Meridian Health, the Cleveland Clinic, Stanford Medicine, and many others began to do part of the PCR work-up, so that they didnt have to outsource samples. It was a little like people addicted to going to Starbucks learning how to make their own brew at home maintaining standards but taking on more of the task. (In fact, a study was just published on how to make the healthiest at-home brew.)

Michelle N. Gong, MD, Chief of Critical Care Medicine at Montefiore Medical Center in the Bronx, said on a JAMA Network webinaron March 23 that bringing the testing in-house immediately escalated testing.

We started with sending samples to the Department of Health, but it became increasingly clear that it was not going to be adequate. It took days. Our hospitals epidemiologist worked to bring testing onsite and that has changed the game. The ability to test onsite and turn it around fast made it much more efficient to get patients what they need.

The FDAs list of diagnostics granted EUA status continues to grow. The last time I checked it had 62 entries.

On March 27, the EUA granted Abbott Labs use of a test that they had under development that detects two viral genes (N and RdRp), one of them different from the CDCs recipe. According to the company, the test can deliver positive results in 5 minutes and negative results in 13 minutes.

The Abbott test runs on an existing platform, ID NOW, and uses a gene amplification technology that doesnt require the temperature shifts of PCR. The test is done in a lightweight box about the size of a toaster thats already used in doctors offices, urgent care facilities, and emergency departments to rapidly diagnose influenza, strep, and respiratory syncytial virus.

But the companys initial forecast of providing 50,000 tests a day, starting soon, may need to await further validation. A researcher at the Cleveland Clinic, Gary Procop, MD, tested five products on 239 patient samples known to be positive for COVID-19. Abbotts test missed 15 percent.

The World Health Organization (WHO)also provided many tests early on and continues to do so.

On April 21, FDA re-deployed the Emergency Use Authorization of LabCorpsPCR-based test for use in a home-kit that the company provides. Its being rolled out for health care workers first; consumer tests may follow in a few weeks.

Another way to boost test kit supplies is to harness the gene editing tool CRISPR. It may be faster and simpler than PCR.

The team from Mammoth Biosciences and UCSF reported on CRISPRCas12-based detection of SARS-CoV-2 in April 16s Nature Biotechnology. Company co-founder is Jennifer Doudna, PhD, co-inventor of CRISPR.

Mammoths visual readout strip works at the bedside, is fast, and in trials so far, picks up 100% of negatives and 95% of positives although much more extensive evaluation is needed. The report considers findings in 36 patients with COVID-19 and 42 people with other respiratory illnesses.

On February 15 Mammoth unveiled the protocol for their point of care test in a white paper that describes it as useful in areas at greatest risk of transmitting SARS-CoV-2 infection, including airports, emergency departments, and local community hospitals, particularly in low-resource countries.

We need faster, more accessible and scalable diagnostics. The point-of-care testing space is ripe for disruption and CRISPR diagnostics have the potential to bring reliable testing to the most vulnerable environments, said Mammoths Chief Technology Officer Janice Chen, PhD.

The test uses the companys DETECTR technology; that stands for DNA Endonuclease-Targeted CRISPR Trans Reporter. The platform had already been in the works for human papillomavirus, described in a April 27, 2018 report in Science.

The company started revamping its system for the novel coronavirus as soon as cases were reported from Wuhan, and within two weeks was testing it on the first patient samples. Because CRISPR can be programmed to detect any DNA or RNA sequence, we reconfigured our DETECTR platform within days to detect the SARS-CoV-2 virus from one of the first confirmed cases in the U.S., said Dr. Chen.

The system collapses the two steps of PCR-based tests into one: copying viral RNA into DNA and amplifying it fast, without temperature shifts. The test snips off a reporter molecule that generates the stain on the paper read-out strip, and uses the Cas12enzyme, which makes more precise cuts than conventional Cas9.

The test zeroes in on three gene pieces:

It picks up 70 to 300 DNA pieces of genetic material per microliter of fluid from a nose or throat swab. A microliter is one-millionth of a liter.

SHERLOCK, for Specific High Sensitivity Enzymatic Reporter Unlocking, is a testing platform coming from work on Zika virus disease and Dengue fever published in 2018 in Science. Sherlock Biosciences provides the test and Cepheid.com provides their GeneXpert Systems cartridge device. The approach licenses work from the Broad Institute, home of another CRISPR founder, Feng Zhang, PhD.

The system can identify any genetic target, and therefore any infectious disease. The test for COVID-19 may reach the market as a dip stick, paper strip, or even an electrochemical readout that can be read with a mobile phone, according to company information.

The system zeroes in on genome pieces unique to SARS-CoV-2 that encode the spike (S) protein and apolyprotein that commandeers the host cell. (My blog post from the start of the pandemic, COVID-19 Vaccine Will Close in on the Spikes, explains the genetic make-up of the virus.)

It uses powerful Cas12 and Cas13 enzymes and can reportedly detect down to the single molecule level. Its fast, accurate, and works directly on body fluids. And with 23,000 GeneXpert Systems already at health care facilities, popping in a COVID test may be the best idea yet.

To biologists and many others it was clear from the start that fighting this pandemic would require far more testing than for just the people who show up at health care facilities with symptoms. An epidemic is a population phenomenon that must be addressed at that level. It is comforting to know that regulations were in place to allow implementation of variations on the testing theme, and that the companies that have long expected a viral pandemic are collaborating to rapidly adapt existing tests, tools and technologies to put the pandemic of 2020 behind us.

Ricki Lewis is the GLPs senior contributing writer focusing on gene therapy and gene editing. She has a PhD in genetics and is a genetic counselor, science writer and author of The Forever Fix: Gene Therapy and the Boy Who Saved It, the only popular book about gene therapy. BIO. Follow her at her website or Twitter @rickilewis

Read more:
'At home' coronavirus test? How CRISPR could change the way we search for COVID-19 - Genetic Literacy Project

Newswise A novel means to prevent HIV infection was developed at the University of Nebraska Medical Center that could allow people with or at risk of acquiring the virus to take medicines once a year. The advance has the potential to eliminate complications that arise from missing doses of life-saving medicines, according to the study published today in Nature Materials, a leading peer-reviewed biomedical research journal.

The research team led by Benson Edagwa, Ph.D., assistant professor, UNMC Department of Pharmacology and Experimental Neuroscience, and Howard Gendelman, M.D., chairman and professor of the department, developed the worlds first potential yearlong antiretroviral (ARV) for prevention of HIV infection by converting a month-long ARV drug into a once-per-year therapeutic.

This pharmaceutical development has the potential to not only treat but also prevent viral transmission, said Dr. Gendelman, who designed the pharmacological testing. This may certainly be a therapeutic milestone.

The study describes what could function as a vaccine mimetic to protect the body against HIV infection for an extended time period.

While viral vaccines and long-acting modified ARVs have very different modes of action, they can both function to protect against infection, Dr. Gendelman said.

Currently, individuals with HIV must take their medicine daily to control the disease. If proven safe and effective in clinical studies, the UNMC treatment would allow people with HIV to receive an injectable medicine once yearly.

The innovations now in development could prevent HIV transmission in individuals vulnerable to infection. Although existing ARV regimens allow individuals with HIV to live with minimal health complications and prevent HIV transmission to sexual partners, the risk of missing daily treatment is a major health care concern. Missing daily doses of ART can cause the virus to rebound and cause associated comorbidities.

Drs. Edagwa and Gendelman credited a large team of scientists within the department for work on the project, including instructor Aditya Bade, Ph.D., and graduate student Tanmay Kulkarni.

The scientists created a year-long-acting medicine from the parent drug cabotegravir (CAB). CAB is a potent HIV-1 drug that blocks the virus from inserting its genetic material into human cells. By chemically converting CAB into a nanocrystal and allowing the bodys own enzymes to slowly convert the modified drug into an active form, the drug can be slowly released from tissue stores.

This occurs for extended time periods, and in laboratory and animal testing, up to a year, said Dr. Edagwa, who designed and produced the required modifications of the new prodrug. A prodrug is a classification of pharmaceutical products where an inert compound is converted into an active form by the body.

The UNMC team developed its ARV treatment by modifying the molecular structure of prodrugs produced and engineered in laboratories on the UNMC campus and tested in mice and non-human primates. Human testing has not yet begun, but the development necessary to achieve this goal is ongoing with the assistance of scientists from the Clinton Health Access Initiative (CHAI). Paul L. Domanico, Tai-Yuen Yue and Gary Moore of CHAI are co-authors on the Nature Materials paper and are actively engaged with UNMC scientists to facilitate transitioning from animal to human testing.

Current active research in drug properties, administration and potential toxicities are now underway and required before the vaccine mimetic could obtain U.S. Food and Drug Administration approval to eventually enter the market. To date, no adverse side effects have been demonstrated in any of the animal testing models.

CAB was originally developed by ViiV Healthcare, a pharmaceutical subsidiary of GlaxoSmithKline that specializes in the development of therapies for HIV infection. The prodrug nanocrystal approach invented by Drs. Edagwa and Gendelman enhanced the prior version of the medicine.

Partnerships and collaborations will take what we did in the Nebraska Nanomedicine Production Plant (NNPP) and develop the drug for potential use by HIV patients and those vulnerable to infection, said Dr. Gendelman, who also serves as interim director of the NNPP, a resource that provides support for product research, development and manufacturing of nanoformulated drugs.

The drug reformulation is an important avenue for advancing the science-based treatment of maladies that range from HIV to other viral outbreaks, potentially including COVID-19, Dr. Gendelman said.

Other UNMC contributors to the Nature Materials report include: Brady Sillman Ph.D, Bhagya Laxmi Dyavar Shetty, Melinda S. Wojtkiewicz, Nagsen Gautam Ph.D., James R. Hilaire, Ph.D., Sruthi Sravanam, Adam Szlachetka, Benjamin G. Lamberty Brenda M. Morsey, Howard S. Fox, M.D., Ph.D., Yazen Alnouti, Ph.D., JoEllyn M. McMillan, Ph.D., R. Lee Mosley, Ph.D., and Jane Meza, Ph.D.

This research is supported by the University of Nebraska Foundation with donations from the Carol Swarts, M.D., Emerging Neuroscience Research Laboratory, the Margaret R. Larson Professorship/Research Fund, the Frances and Louie Blumkin Foundation, and the Harriet and Lazier Singer Professorship Fund; the UNMC Office of Vice Chancellor for Research; and grants from the National Institutes on Drug Abuse, Mental Health, Allergy and Infectious Diseases, and Neurological Disorders and Stroke.

We are Nebraska Medicine and UNMC. Our mission is to lead the world in transforming lives to create a healthy future for all individuals and communities through premier educational programs, innovative research and extraordinary patient care.

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Link:
Potential new HIV treatment could mean once-a-year injection - Newswise

KEY POINTS

Chloroquine and hydroxychloroquine are generally well tolerated, but clinicians and patients should be aware of serious adverse events that can occur, even during short courses of treatment.

Potential risks of treatment include prolongation of the QTc interval (especially in patients with preexisting cardiac disease or if coprescribed with azithromycin), hypoglycemia, neuropsychiatric effects, drugdrug interactions and idiosyncratic hypersensitivity reactions.

Genetic variability in metabolism of these drugs is considerable and influences their safety and effectiveness.

Chloroquine and hydroxychloroquine are extremely toxic in overdose.

As we await stronger evidence on the role, if any, of these drugs in the treatment or prevention of coronavirus disease 2019, uncommon but serious harms of treatment can be mitigated by careful patient selection and monitoring.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread rapidly around the globe in recent months. With deaths from its associated disease, coronavirus disease 2019 (COVID-19), projected to reach into the millions and a vaccine unlikely in the near term, the search is on for existing drugs that might prevent COVID-19 or improve outcomes for patients who have COVID-19. Chloroquine and its derivative hydroxychloroquine, which have been used for decades in the treatment and prevention of malaria as well as chronic inflammatory diseases such as rheumatoid arthritis and systemic lupus erythematosus, have received much attention as potential therapies.

Optimism for repurposing these drugs stems from 2 lines of evidence: inhibition of Coronaviridae (including SARS and SARS-CoV-2) in vitro13 and preliminary but contradictory clinical data from studies conducted in China and France.48 Of these, an open-label nonrandomized study by Gautret and colleagues5 that involved treatment using hydroxychloroquine (combined in some patients with azithromycin, an azalide antibiotic with putative antiviral properties9) has garnered an unusual degree of attention. Despite this studys small sample size and serious methodologic limitations, on Mar. 21, 2020, President Donald Trump touted the drug combination as having a real chance of being one of the biggest game-changers in the history of medicine.10 Within days of this pronouncement, chloroquine-related deaths were reported in Africa and Arizona (www.theguardian.com/world/2020/mar/24/coronavirus-cure-kills-man-after-trump-touts-chloroquine-phosphate; http://www.cnn.com/2020/03/23/africa/chloroquine-trump-nigeria-intl/index.html).

As we await further evidence on the role, if any, of these drugs in addressing the SARS-CoV-2 pandemic, many clinicians have already begun using them to treat COVID-19. The most typical regimen is 5 days of hydroxychloroquine at daily doses of 400600 mg, which delivers a cumulative dose comparable to what might be given over 48 hours for chloroquine-sensitive malaria caused by Plasmodium falciparum. The US Food and Drug Administration has granted emergency authorization for the use of chloroquine and hydroxychloroquine for treatment of COVID-19,11 and the Indian Council of Medical Research COVID-19 National Task Force has advocated extended hydroxychloroquine prophylaxis for health care workers.12

This review provides a general overview of potential harms associated with use of chloroquine and hydroxychloroquine and to a lesser extent azithromycin and a discussion of the management of adverse events, based on best available evidence (Box 1).

A search of PubMed from 1966 until 2020 was conducted for publications related to adverse events involving chloroquine, hydroxychloroquine and azithromycin. No restrictions were placed on article type; however, reviews were prioritized where available and their bibliographies were examined for articles that might have been missed in the broader search.

Along with common adverse effects such as pruritus, nausea and headache, chloroquine and hydroxychloroquine can predispose patients to life-threatening arrhythmias, an effect that may be enhanced by concomitant use of azithromycin. Other uncommon but serious potential harms include hypoglycemia, neuropsychiatric effects, idiosyncratic hypersensitivity reactions and drugdrug interactions, with genetic variability playing an important role in each of these. Chloroquine and hydroxychloroquine are also extremely toxic in overdose.

Both chloroquine and hydroxychloroquine interfere with ventricular repolarization, leading to prolongation of the QTc interval and an increased risk of torsades de pointes (TdP). This effect is dependent on dose: studies involving volunteers found mean increases in QTc of 6.1 ms after a dose of 600 mg and 28 ms after a dose of 1200 mg.13,14 However, the effect varies among individuals and can be pronounced. Among 30 children given short courses of chloroquine for malaria, 1 experienced an increase in the QTc interval of 64 ms after just 1 day of treatment.15

Azithromycin itself does not usually cause clinically significant prolongation of the QTc interval,16 but its use in combination with either chloroquine or hydroxychloroquine could theoretically increase the risk of TdP. Reassuringly, an animal model found no evidence of such an interaction,17 and the combination has been used safely in patients with malaria.18,19 Nevertheless, given limited experience in patients with COVID-19 and the potential for use of these drugs in patients with cardiac disease or those taking other drugs that delay repolarization, monitoring of the QTc interval at baseline and daily for the duration of treatment is advised, especially if azithromycin is coprescribed. Daily monitoring is impractical during prophylactic treatment, but assessment of the QTc interval at baseline is advised, especially for individuals with cardiac disease. It is prudent to correct electrolyte disorders and, where possible, avoid or minimize use of other drugs known to prolong the QT interval (Box 2).

Case reports have described severe hypoglycemia with both chloroquine and hydroxychloroquine in patients with malaria as well as those with lupus and other chronic diseases.2023 The basis of this effect (aside from malaria-related hypoglycemia) is multifactorial and includes reduced insulin clearance, increased insulin sensitivity and enhanced pancreatic insulin release.24 Among 250 patients with poorly controlled type 2 diabetes who were unwilling to start insulin, hydroxychloroquine (400 mg/d) was associated with marked reductions in fasting plasma glucose, hemoglobin A1c and body weight, whereas hypoglycemia developed in 2% of participants over the 48-month study period.25

Physicians should warn patients who are being treated with chloroquine or hydroxychloroquine about the possibility of hypoglycemia and describe its manifestations. Management of hypoglycemia involves cessation of the drug and administration of supplemental glucose or parenteral dextrose as needed. For patients with severe or recurrent hypoglycemia, octreotide (50100 g administered intravenously or subcutaneously every 8 h) is a well-tolerated somatostatin analogue that inhibits pancreatic insulin release and may be helpful in mitigating the rebound hyperinsulinemia than can ensue after large doses of intravenous dextrose.26

Chloroquine and hydroxychloroquine are known to cause a wide spectrum of neuropsychiatric manifestations, including agitation, insomnia, confusion, mania, hallucinations, paranoia, depression, catatonia, psychosis and suicidal ideation.27 These can occur at all ages,28 during acute or chronic use,2932 and in patients with and without a history of mental illness.28,32 Resolution is expected upon stopping the drug, although symptoms may not resolve quickly.33 Patients and clinicians should recognize new or worsening neuropsychiatric symptoms as possible adverse effects of treatment. Indeed, given the speculative nature at present of antimalarial agents in the prevention or treatment of SARS-CoV-2 infection, an argument can be made for avoiding these drugs in patients with underlying mental illness until more data are available.

Many clinicians associate antimalarial agents with oxidative hemolysis, particularly in patients with severe variants of glucose-6-phosphate dehydrogenase (G6PD) deficiency. Primaquine is well known to cause this, but chloroquine and hydroxychloroquine are much less likely to do so. In a chart review of 275 rheumatology patients with established G6PD deficiency, no episodes of hydroxychloroquine-related hemolysis were identified over more than 700 months of treatment.34 Hematologic abnormalities including lymphopenia, eosinophilia and atypical lymphocytosis can be features of immunologically mediated idiosyncratic drug reactions, as discussed below.

Both chloroquine and hydroxychloroquine are metabolized by hepatic cytochrome P450 enzyme 2D6 (CYP2D6), the expression of which varies among individuals as the result of genetic polymorphisms. 35,36 Roughly 7% of white North Americans have no functional CYP2D6 (the poor metabolizer phenotype) and 1%2% have gene duplications conferring an ultrarapid metabolizer phenotype, although the prevalence of these varies based on ethnicity.37 This genetic variability influences the response to treatment for malaria and chronic inflammatory diseases, as well as the risk of adverse events.38,39

In addition to being substrates for CYP2D6, chloroquine and hydroxychloroquine inhibit its activity, most likely by competitive inhibition.40 This has the potential to influence the fate of other drugs reliant on CYP2D6 for metabolism. For instance, hydroxychloroquine increases systemic exposure to orally administered metoprolol levels by about 65% and peak concentrations by 72%.41 Although data are limited, it is reasonable to assume that chloroquine and hydroxychloroquine potentiate other CYP2D6 substrates (including carvedilol and many others), and undermine the effectiveness of prodrugs reliant on CYP2D6 for activation such as codeine and tramadol.42 Indeed, the potential exists for chloroquine and hydroxychloroquine to precipitate opioid withdrawal in patients who are taking these drugs regularly.

Unlike the related drugs erythromycin and clarithromycin, azithromycin exhibits little inhibition of cytochrome P450 enzymes or drug-transport proteins such as P-glycoprotein.43 As such, azithromycin is far less likely to precipitate clinically important drugdrug interactions (Box 2).

Chloroquine and hydroxychloroquine have been implicated in severe cutaneous adverse reactions, including StevensJohnson syndrome,44 toxic epidermal necrolysis,45,46 DRESS (drug reaction with eosinophilia and systemic symptoms)47,48 and others. Although rare, these entities should be considered in patients with new-onset fever, exanthem or mucositis in the weeks after the start of treatment, particularly when accompanied by new hematologic abnormalities (such as lymphopenia, eosinophilia or atypical lymphocytosis) or unexplained liver or kidney injury.

There is no evidence that chloroquine, hydroxychloroquine or azithromycin are harmful to the developing fetus, and pregnancy is not a contraindication to their use.49,50 Long-term risks of treatment include retinopathy, vacuolar myopathy, neuropathy, restrictive cardiomyopathy and cardiac conduction disturbances. 5153 These risks are negligible in the context of treatment of SARS-CoV-2 but may be relevant if they are used for extended prophylaxis.

Chloroquine and hydroxychloroquine are extremely toxic in overdose, sharing several manifestations in common with cyclic antidepressant poisoning. Deliberate or inadvertent overdose leads to rapid onset of central nervous system toxicity (seizures and coma), cardiovascular collapse (including inhibition of cardiac sodium and potassium channels resulting in QRS widening and QT interval prolongation, respectively) and hypokalemia resulting from intracellular shifting.54 Treatment of overdose is largely supportive and includes prompt administration of activated charcoal, intravenous benzodiazepines and vasopressors as needed, sodium bicarbonate or hypertonic saline for substantial QRS widening and related arrhythmias, and judicious management of hypokalemia while taking care to avoid overcorrection. Urgent consultation with a poison control centre is advised in all cases.

More:
Safety considerations with chloroquine, hydroxychloroquine and azithromycin in the management of SARS-CoV-2 infection - CMAJ

One of the most fascinating and ominous things about COVID19 is that as clinicians and researchers have learned more about it that knowledge has not simply filled out the details of a broadly understood story. Rather, more knowledge has confirmed how little we knew and still know about the disease. For lay people like most of us the original story was that COVID19 was a viral respiratory tract infection. It was more deadly, less predictable in its course and had no known therapies to treat it. But broadly speaking a disease that attack the lungs, leads in severe cases to pneumonia and from there a cascading series of failures that can lead to death. Doctors had a more sophisticated but broadly comparable understanding. Four months plus into the history of the disease they know that COVI19 can attack most of the bodys major organs heart, liver, kidneys, brain, et al. Its far more insidious and copious in its range of potential attacks on the human body than they realized only six weeks ago.

A new emerging issue is how COVID19 attacks or disrupts a patients blood specifically the delicate and critical balance of regulating when to flow and when to clot. When I first read articles about this I assumed these clotting issues were just part and parcel of the failure or near failure of the various organ systems. COVID19 attacks your liver or kidneys and clotting issues are just a manifestation of injury. But that does not seem to be the case. It seems to be a distinct way COVID19 attacks the body.

This article in The Washington Post, which describes one of new studies of this clotting issue, notes that on autopsy lungs of COVID19 patients which doctors expected to find with typical evidence of pneumonia instead were filled with numerous blood clots. This article reports how young and middle aged COVID19 patients, with very limited symptoms, are dying from strokes. One doctor interviewed in the article describes removing a clot from a patients brain and seeing new clots forming in real time as he worked something he said hed never seen before. (Heres another write-up of the same study in Medscape.) According to the article, the clotting issue is so concerning that some doctors have discussed giving all COVID19 patients limited blood thinning therapy as a way to head off the problem. But this study notes that many patients with severe COVID19 die from bleeding disorders and hemorrhages. So it appears that the disequilibrium is operating on both sides of the spectrum excessive clotting and excessive bleeding.

One surmise that comes in expert discussions of COVID19 is that the seeming randomness of who gets and doesnt get severe disease may not be so random. Many suspect that there must be some logic, some genetic dimension or some as yet unknown underlying factor, which makes the disease progress so differently in different people, even after controlling for age and the big preexisting conditions. Some of the discussions Ive linked above appear to hint at the possibility that subtle, pre-existing differences in blood chemistry ones which may have little or no impact on health in general may drive these very different outcomes in COVID19 disease.

Let me conclude by noting another emerging discussion in COVID19 treatment. About three weeks ago I mentioned this odd video by a emergency medicine doctor in New York who said that the cases of pneumonia and ARDS (Acute Respiratory Distress Syndrome) his team were seeing seemed very different from what they expected and suggested that doctors may be moving too quickly to put these patients on ventilators. While the implications for treatment were not clear, doctors in other parts of the country were seeing similar things. What unites all these discussions is that many COVID19 patients present with blood oxygen levels which should leave them gasping for air or even on the verge of death. And yet, theyre neither. Indeed, doctors report patients using their iPhones or being otherwise aware and functional just before being intubated. This has led some to ask whether earlier and less invasive breathing assistance could be a better approach for at least some patients.

Its this issue that is at the center of an opinion column which appeared on April 20th in The New York Times. Dr. Richard Levitan is an emergency medicine doctor whos been in practice for thirty years and is also the inventor of a system for teaching intubation. In other words, hes literally in the intubation business. Levitan spent ten days volunteering at Bellevue hospital in New York during the height of the crisis and he saw the same issue: patients coming into emergency rooms with mild shortness of breath already had blood oxygen levels that made it surprising they werent in acute distress or even still alive.

The earlier discussions I note above suggested doctors were rushing to invasive treatments when less invasive approaches might have been outcomes. And that may be the case. But Levitan makes a different point. Many of these patients had already become critically ill at home without even knowing it, without the symptoms that would lead someone to know they were in critical condition. That may be even more the case since public health systems are telling people not to come to the hospital unless they become seriously ill. As Levitan put it, Their pneumonia had clearly been going on for days, but by the time they felt they had to go to the hospital, they were often already in critical condition.

The next part is worth quoting at length.

Patients compensate for the low oxygen in their blood by breathing faster and deeper and this happens without their realizing it. This silent hypoxia, and the patients physiological response to it, causes even more inflammation and more air sacs to collapse, and the pneumonia worsens until oxygen levels plummet. In effect, patients are injuring their own lungs by breathing harder and harder. Twenty percent of Covid pneumonia patients then go on to a second and deadlier phase of lung injury. Fluid builds up and the lungs become stiff, carbon dioxide rises, and patients develop acute respiratory failure.

What Levitan draws from all this is that pulse oximeters those little gadgets doctors sometimes put on the end of your finger to get a quick pulse and blood oxygen read could be critical for patients to be using at home. If youre riding out COVID19 at home with generally mild or moderate symptoms, you test your blood oxygen levels a few times a day. If it stays in the normal range of 94% to a 100% you keep at it. But if it starts to drop you know to get medical assistance right away.

It wasnt clear to me from the Times piece or a separate interview Levitan in Medscape what different treatment doctors would provide. The issue seems more than earlier intervention could prevent the lung damage which leads to a rapid deterioration for many patients. If we could detect it earlier, Levitan told Medscape, we could initiate treatment earlier. We need to change messaging to the public, to physicians, to get earlier recognition of the disease.

Public service announcement: dont rush out to buy a pulse oximeter! Theyre relatively cheap and low tech. But medical supply chains are not remotely up to the challenge of producing enough of these to allow every household to have one on hand just in case. Levitans twitter feed is already awash in discussions on this point: and the need to prioritize their use first in assisted living facilities and then in people whove been diagnosed with COVID19. The relevant point is that the progression of COVID19 can often occur without the patient knowing it, especially the progression of COVID19 pneumonia that gets to a critical stage before patients and their remote physicians even know theyre in trouble.

Read more from the original source:
Our Evolving Knowledge of the Insidious Disease, COVID19 - TPM