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0 0.5 1 1.5 2+ Mortality -67% Improvement Relative Risk Recovery -100% Famotidine  I-SPY COVID  LATE TREATMENT  RCT Is late treatment with famotidine + celecoxib beneficial for COVID-19? RCT 67 patients in the USA (July 2020 - June 2021) Worse recovery with famotidine + celecoxib (p=0.02) Files et al., eClinicalMedicine, March 2023 Favors famotidine Favors control

Report of the first seven agents in the I-SPY COVID trial: a phase 2, open label, adaptive platform randomised controlled trial

Files et al., eClinicalMedicine, doi:10.1016/j.eclinm.2023.101889, I-SPY COVID, NCT04488081
Mar 2023  
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RCT severe COVID-19 patients requiring ≥6 L/min oxygen, showing worse recovery with the addition of celecoxib and famotidine to remdesivir and dexamethasone. The treatment group mean age was 9 years older, and the treatment group had more patients on high-flow nasal oxygen or ventilation at baseline (27% to 14%). Remdesivir and celecoxib have shown nephrotoxicity, hepatotoxicity, and cardiotoxicity, and the combination of both in late stage patients may further increase risk. Authors defined AKI as an adverse events of special interest for celecoxib, but do not report results (only RRT which depends on clinical condition and survival, and is only reported including non-concurrent controls). Celecoxib 400mg BID for 7 days, famotidine 80mg QID for 7 days followed by 40mg BID for 14 days. Publication was delayed over 1.5 years after completion without explanation. This study is excluded in meta analysis: contribution of famotidine unclear with combined treatment, remdesivir and celecoxib have shown nephrotoxicity, hepatotoxicity, and cardiotoxicity, and the combination of both in late stage patients may further increase risk.
risk of death, 67.0% higher, HR 1.67, p = 0.18, treatment 12 of 30 (40.0%), control 8 of 37 (21.6%), adjusted per study, day 60.
risk of no recovery, 100% higher, HR 2.00, p = 0.02, treatment 15 of 30 (50.0%), control 8 of 37 (21.6%), adjusted per study, inverted to make HR<1 favor treatment, day 60.
Effect extraction follows pre-specified rules prioritizing more serious outcomes. Submit updates
Files et al., 3 Mar 2023, Randomized Controlled Trial, USA, peer-reviewed, 91 authors, study period 30 July, 2020 - 11 June, 2021, this trial uses multiple treatments in the treatment arm (combined with celecoxib) - results of individual treatments may vary, trial NCT04488081 (history) (I-SPY COVID).
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Report of the first seven agents in the I-SPY COVID trial: a phase 2, open label, adaptive platform randomised controlled trial
D Clark Files, Neil Aggarwal, Timothy Albertson, Sara Auld, Jeremy R Beitler, Paul Berger, Ellen L Burnham, Carolyn S Calfee, Nathan Cobb, Alessio Crippa, Andrea Discacciati, Martin Eklund, Laura Esserman, Eliot Friedman, Sheetal Gandotra, Kashif Khan, Jonathan Koff, Santhi Kumar, Kathleen D Liu, Thomas R Martin, Michael A Matthay, Nuala J Meyer, Timothy Obermiller, Philip Robinson, Derek Russell, Karl Thomas, Se Fum Wong, Richard G Wunderink, Mark M Wurfel, Albert Yen, Fady A Youssef, Anita Darmanian, Amy L Dzierba, Ivan Garcia, Katarzyna Gosek, Purnema Madahar, Aaron M Mittel, Justin Muir, Amanda Rosen, John Schicchi, Alexis L Serra, Romina Wahab, Kevin W Gibbs, Leigha Landreth, Mary Larose, Lisa Parks, Adina Wynn, Caroline A G Ittner, Nilman S Mangalmurti, John P Reilly, Donna Harris, Abhishek Methukupally, Siddharth Patel, Lindsie Boerger, John Kazianis, Carrie Higgins, Jeff Mckeehan, Brian Daniel, Scott Fields, James Hurst-Hopf, Alejandra Jauregui, Lamorna Brown Swigart, Daniel Blevins, Catherine Nguyen, Alexis Suarez, Maged A Tanios, Farjad Sarafian, Usman Shah, Max Adelman, Christina Creel-Bulos, Joshua Detelich, Gavin Harris, Katherine Nugent, Christina Spainhour, Philip Yang, Angela Haczku, Erin Hardy, Richart Harper, Brian Morrissey, Christian Sandrock, G R Scott Budinger, Helen K Donnelly, Benjamin D Singer, Ari Moskowitz, Melissa Coleman, Joseph Levitt, Ruixiao Lu, Paul Henderson, Adam Asare, Imogene Dunn, Alejandro Botello Barragan
eClinicalMedicine, doi:10.1016/j.eclinm.2023.101889
Background An urgent need exists to rapidly screen potential therapeutics for severe COVID-19 or other emerging pathogens associated with high morbidity and mortality. Methods Using an adaptive platform design created to rapidly evaluate investigational agents, hospitalised patients with severe COVID-19 requiring ≥6 L/min oxygen were randomised to either a backbone regimen of dexamethasone and remdesivir alone (controls) or backbone plus one open-label investigational agent. Patients were enrolled to the arms described between July 30, 2020 and June 11, 2021 in 20 medical centres in the United States. The platform contained up to four potentially available investigational agents and controls available for randomisation during a single time-period. The two primary endpoints were time-to-recovery (<6 L/min oxygen for two consecutive days) and mortality. Data were evaluated biweekly in comparison to pre-specified criteria for graduation (i.e., likely efficacy), futility, and safety, with an adaptive sample size of 40-125 individuals per agent and a Bayesian analytical approach. Criteria were designed to achieve rapid screening of agents and to identify large benefit signals. Concurrently enrolled controls were used for all analyses. Findings The first 7 agents evaluated were cenicriviroc (CCR2/5 antagonist; n = 92), icatibant (bradykinin antagonist; n = 96), apremilast (PDE4 inhibitor; n = 67), celecoxib/famotidine (COX2/histamine blockade; n = 30), IC14 (anti-CD14; n = 67), dornase alfa (inhaled DNase; n = 39) and razuprotafib (Tie2 agonist; n = 22). Razuprotafib was dropped from the trial due to feasibility issues. In the modified intention-to-treat analyses, no agent met pre-specified efficacy/ graduation endpoints with posterior probabilities for the hazard ratios [HRs] for recovery ≤1.5 between 0.99 and 1.00. The data monitoring committee stopped Celecoxib/Famotidine for potential harm (median posterior HR for recovery 0.5, 95% credible interval [CrI] 0.28-0.90; median posterior HR for death 1.67, 95% CrI 0.79-3.58). Interpretation None of the first 7 agents to enter the trial met the prespecified criteria for a large efficacy signal. Celecoxib/Famotidine was stopped early for potential harm. Adaptive platform trials may provide a useful approach to rapidly screen multiple agents during a pandemic.
Appendix A. Supplementary data Supplementary data related to this article can be found at https://doi. org/10.1016/j.eclinm.2023.101889.
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Late treatment
is less effective
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