Sarilumab for COVID-19: real-time meta analysis of 11 studies
Abstract
Meta analysis using the most serious outcome reported shows
0% [-17‑21%] higher risk, without reaching statistical significance. Currently all studies are RCTs.
All data to reproduce this paper and
sources are in the appendix.
Sarilumab for COVID-19 — Highlights
Meta analysis of studies to date shows no significant improvements with sarilumab.
Real-time updates and corrections,
transparent analysis with all results in the same format, consistent protocol
for 102
treatments, outcome specific analyses and combined evidence from all studies.
Figure 1.
A. Random effects
meta-analysis. This plot shows pooled effects,
see the specific outcome analyses for individual outcomes.
Analysis validating pooled outcomes for
COVID-19 can be found below.
Effect extraction is pre-specified, using the most serious outcome reported.
For details see the appendix.
B. Timeline of results in sarilumab studies.
SARS-CoV-2 infection primarily begins in the upper respiratory
tract and may progress to the lower respiratory tract, other tissues, and the
nervous and cardiovascular systems, which may lead to cytokine storm,
pneumonia, ARDS, neurological injury1-10 and
cognitive deficits3,8, cardiovascular
complications11-13, organ failure, and death.
Minimizing replication as early as possible is recommended.
SARS-CoV-2 infection and replication involves the complex interplay of 50+
host and viral proteins and other factorsA,14-18, providing many
therapeutic targets for which many existing compounds have known activity.
Scientists have predicted that over 8,000 compounds may
reduce COVID-19 risk19, either by
directly minimizing infection or replication, by supporting immune system
function, or by minimizing secondary complications.
We analyze all significant
controlled studies of
sarilumab
for COVID-19.
Search methods, inclusion criteria, effect extraction criteria (more serious
outcomes have priority), all individual study data, PRISMA answers, and
statistical methods are detailed in Appendix 1. We present random
effects meta-analysis results for all studies, individual outcomes, and Randomized Controlled Trials (RCTs).
Figure 2 shows stages of possible treatment for
COVID-19. Prophylaxis refers to regularly taking medication before
becoming sick, in order to prevent or minimize infection. Early
Treatment refers to treatment immediately or soon after symptoms appear,
while Late Treatment refers to more delayed treatment.
Currently all sarilumab studies use late treatment.
Figure 2. Treatment stages.
Table 1 summarizes the results for all studies, for Randomized Controlled Trials, and for specific outcomes.
Figure 3, 4, 5, 6, 7, 8, and 9
show forest plots for random effects meta-analysis of
all studies with pooled effects, mortality results, ventilation, ICU admission, progression, recovery, and viral clearance.
| Improvement | Studies | Patients | Authors | |
|---|---|---|---|---|
| All studies | -0% [-21‑17%] | 11 | 2,231 | 332 |
| Randomized Controlled TrialsRCTs | -0% [-21‑17%] | 11 | 2,231 | 332 |
| Mortality | -0% [-21‑17%] | 11 | 2,231 | 332 |
| VentilationVent. | -62% [-290‑33%] | 3 | 158 | 54 |
| ICU admissionICU | 2% [-57‑40%] | 3 | 421 | 51 |
| Recovery | -10% [-47‑18%] | 2 | 345 | 28 |
| RCT mortality | -0% [-21‑17%] | 11 | 2,231 | 332 |
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Figure 3. Random effects meta-analysis for all studies.
This plot shows pooled effects,
see the specific outcome analyses for individual outcomes.
Analysis validating pooled outcomes for
COVID-19 can be found below.
Effect extraction is pre-specified, using the most serious outcome reported.
For details see the appendix.
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Figure 4. Random effects meta-analysis for mortality results.
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Figure 5. Random effects meta-analysis for ventilation.
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Figure 6. Random effects meta-analysis for ICU admission.
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Figure 7. Random effects meta-analysis for progression.
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Figure 8. Random effects meta-analysis for recovery.
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Figure 9. Random effects meta-analysis for viral clearance.
Currently all studies are RCTs.
Heterogeneity in COVID-19 studies arises from many factors including:
The time
between infection or the onset of symptoms and treatment may critically affect
how well a treatment works. For example an antiviral may be very effective
when used early but may not be effective in late stage disease, and may even
be harmful. Oseltamivir, for example, is generally only considered effective
for influenza when used within 0-36 or 0-48 hours20,21.
Baloxavir marboxil studies for influenza also show that treatment delay is critical
— Ikematsu et al. report an 86% reduction in cases for post-exposure
prophylaxis, Hayden et al. show a 33 hour reduction in the time to
alleviation of symptoms for treatment within 24 hours and a reduction of 13
hours for treatment within 24-48 hours, and Kumar et al. report only 2.5
hours improvement for inpatient treatment.
| Treatment delay | Result |
| Post-exposure prophylaxis | 86% fewer cases22 |
| <24 hours | -33 hours symptoms23 |
| 24-48 hours | -13 hours symptoms23 |
| Inpatients | -2.5 hours to improvement24 |
Figure 10 shows a mixed-effects meta-regression for efficacy
as a function of treatment delay in COVID-19 studies from 102 treatments, showing
that efficacy declines rapidly with treatment delay. Early treatment is
critical for COVID-19.
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Figure 10. Early treatment is more effective. Meta-regression showing efficacy as a function of treatment delay in COVID-19 studies from 102 treatments.
Details of the patient population including age and comorbidities may
critically affect how well a treatment works. For example, many COVID-19
studies with relatively young low-comorbidity patients show all patients
recovering quickly with or without treatment. In such cases, there is little
room for an effective treatment to improve results, for example as in
López-Medina et al.
Efficacy may
depend critically on the distribution of SARS-CoV-2 variants encountered by
patients. Risk varies significantly across variants26, for
example the Gamma variant shows significantly different characteristics27-30. Different mechanisms of action may be
more or less effective depending on variants, for example the degree to which
TMPRSS2 contributes to viral entry can differ across variants31,32.
Effectiveness may depend strongly on the dosage and treatment regimen.
The use
of other treatments may significantly affect outcomes, including supplements,
other medications, or other interventions such as prone positioning.
Treatments may be synergistic33-43, therefore
efficacy may depend strongly on combined treatments.
The
quality of medications may vary significantly between manufacturers and
production batches, which may significantly affect efficacy and safety.
Williams et al. analyze ivermectin from 11 different sources, showing
highly variable antiparasitic efficacy across different manufacturers.
Xu et al. analyze a treatment from two different manufacturers, showing 9
different impurities, with significantly different concentrations for each
manufacturer.
Across all
studies there is a strong association between different outcomes, for example
improved recovery is strongly associated with lower mortality. However,
efficacy may differ depending on the effect measured, for example a treatment
may be more effective against secondary complications and have minimal effect
on viral clearance.
The
distribution of studies will alter the outcome of a meta analysis. Consider a
simplified example where everything is equal except for the treatment delay,
and effectiveness decreases to zero or below with increasing delay. If there
are many studies using very late treatment, the outcome may be negative, even
though early treatment is very effective.
All meta analyses combine heterogeneous studies, varying in population,
variants, and potentially all factors above, and therefore may obscure
efficacy by including studies where treatment is less effective. Generally, we
expect the estimated effect size from meta analysis to be less than that for
the optimal case.
Looking at all studies is valuable for providing an overview of all research,
important to avoid cherry-picking, and informative when a positive result is
found despite combining less-optimal situations. However, the resulting
estimate does not apply to specific cases such as
early treatment in high-risk populations.
While we present results for all studies, we also present treatment time and
individual outcome analyses, which may be more informative for specific use
cases.
For COVID-19, delay in clinical results translates into
additional death and morbidity, as well as additional economic and societal
damage. Combining the results of studies reporting different outcomes is
required.
There may be no mortality in a trial with low-risk patients,
however a reduction in severity or improved viral clearance may translate
into lower mortality in a high-risk population.
Different studies may report lower severity, improved recovery, and lower mortality,
and the significance may be very high when combining the results.
"The studies reported different outcomes"
is not a good reason for disregarding results.
We present both specific outcome and pooled analyses.
In order to combine the results of studies reporting different outcomes we use
the most serious outcome reported in each study, based on the thesis that
improvement in the most serious outcome provides comparable measures of
efficacy for a treatment. A critical advantage of this approach is
simplicity and transparency.
There are many other ways to combine evidence for different outcomes, along
with additional evidence such as dose-response relationships, however these
increase complexity.
Another way to view pooled analysis is that we are using more of
the available information. Logically we should, and do, use additional
information. For example dose-response and
treatment delay-response relationships provide significant additional evidence
of efficacy that is considered when reviewing the evidence for a
treatment.
Trials with high-risk patients may be restricted due to ethics for treatments
that are known or expected to be effective, and they increase difficulty for
recruiting. Using less severe outcomes as a proxy for more serious outcomes
allows faster collection of evidence.
For many COVID-19 treatments, a reduction in mortality logically
follows from a reduction in hospitalization, which follows from a reduction in
symptomatic cases, which follows from a reduction in PCR positivity. We can
directly test this for COVID-19.
Analysis of the the association between different outcomes across studies from
all 102
treatments we cover confirms the validity of pooled outcome analysis for COVID-19.
Figure 11 shows that lower hospitalization is very strongly associated
with lower mortality (p < 0.000000000001).
Similarly, Figure 12 shows that improved recovery is very strongly associated
with lower mortality (p < 0.000000000001).
Considering the extremes, Singh et al. show an association between viral clearance and
hospitalization or death, with p = 0.003 after excluding one large
outlier from a mutagenic treatment, and based on 44 RCTs including 52,384
patients.
Figure 13 shows that improved viral clearance is strongly associated
with fewer serious outcomes. The association is very similar to
Singh et al., with higher confidence due to the larger number of
studies. As with Singh et al., the confidence increases
when excluding the outlier treatment, from p = 0.00000042 to p = 0.00000002.
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Figure 11. Lower hospitalization is associated with lower mortality, supporting pooled outcome analysis.
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Figure 12. Improved recovery is associated with lower mortality, supporting pooled outcome analysis.
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Figure 11. Improved viral clearance is associated with fewer serious outcomes, supporting pooled outcome analysis.
Currently, 48 of the treatments we analyze show statistically significant efficacy or harm, defined as ≥10% decreased risk or >0% increased risk from ≥3 studies. 89% of these have been confirmed with one or more specific outcomes, with a mean delay of 5.1 months. When restricting to RCTs only, 56% of treatments showing statistically significant efficacy/harm with pooled effects have been confirmed with one or more specific outcomes, with a mean delay of 6.4 months.
Figure 14 shows when treatments were found effective during the
pandemic. Pooled outcomes often resulted in earlier detection of efficacy.
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Figure 14. The time when studies showed that
treatments were effective, defined as statistically significant improvement of
≥10% from ≥3 studies.
Pooled results typically show efficacy earlier than specific
outcome results. Results from all studies often shows efficacy much earlier
than when restricting to RCTs.
Results reflect conditions as used in trials to date, these depend on the
population treated, treatment delay, and treatment regimen.
Pooled analysis could hide efficacy, for example a treatment that is
beneficial for late stage patients but has no effect on viral clearance may
show no efficacy if most studies only examine viral clearance. In practice, it
is rare for a non-antiviral treatment to report viral clearance and to not
report clinical outcomes; and in practice other sources of heterogeneity such
as difference in treatment delay is more likely to hide efficacy.
Analysis validates the use of pooled effects and shows significantly faster
detection of efficacy on average.
However, as with all meta analyses, it is important to review the different
studies included. We also present individual outcome analyses, which may be
more informative for specific use cases.
Publishing is often biased
towards positive results. Trials with patented drugs may have a financial conflict of interest that
results in positive studies being more likely to be published, or bias towards more positive results. For example with molnupiravir, trials with negative results remain unpublished to
date (CTRI/2021/05/033864 and CTRI/2021/08/0354242).
For sarilumab, there is currently not
enough data to evaluate publication bias with high confidence.
Funnel
plots have traditionally been used for analyzing publication bias. This is
invalid for COVID-19 acute treatment trials — the underlying assumptions
are invalid, which we can demonstrate with a simple example. Consider a set of
hypothetical perfect trials with no bias. Figure 15 plot A
shows a funnel plot for a simulation of 80 perfect trials, with random group
sizes, and each patient's outcome randomly sampled (10% control event
probability, and a 30% effect size for treatment). Analysis shows no asymmetry
(p > 0.05). In plot B, we add a single typical variation in COVID-19 treatment
trials — treatment delay. Consider that efficacy varies from 90% for
treatment within 24 hours, reducing to 10% when treatment is delayed 3 days.
In plot B, each trial's treatment delay is randomly selected. Analysis now
shows highly significant asymmetry, p < 0.0001, with six variants of
Egger's test all showing p < 0.0547-54.
Note that these tests fail even though treatment delay is uniformly
distributed. In reality treatment delay is more complex — each trial has
a different distribution of delays across patients, and the distribution
across trials may be biased (e.g., late treatment trials may be more common).
Similarly, many other variations in trials may produce asymmetry, including
dose, administration, duration of treatment, differences in SOC,
comorbidities, age, variants, and bias in design, implementation, analysis,
and reporting.
Figure 15. Example funnel plot analysis for simulated perfect trials.
Summary statistics from
meta analysis necessarily lose information. As with all meta analyses, studies
are heterogeneous, with differences
in treatment delay, treatment regimen, patient demographics, variants,
conflicts of interest, standard of care, and other factors. We provide analyses for specific
outcomes and by treatment delay, and we aim to identify key characteristics in
the forest plots and summaries. Results should be viewed in the context of
study characteristics.
Some analyses classify treatment based on early or late
administration, as done here, while others distinguish between mild, moderate,
and severe cases. Viral load does not indicate degree of symptoms — for
example patients may have a high viral load while being asymptomatic. With
regard to treatments that have antiviral properties, timing of treatment is
critical — late administration may be less helpful regardless of
severity.
Details of treatment delay per patient is often not available.
For example, a study may treat 90% of patients relatively early, but the
events driving the outcome may come from 10% of patients treated very late.
Our 5 day cutoff for early treatment may be too conservative, 5 days may be too late in many cases.
Comparison across treatments is confounded by differences in
the studies performed, for example dose, variants, and conflicts of interest.
Trials with conflicts of interest may use designs better suited to the
preferred outcome.
In some cases, the most serious outcome has very few events,
resulting in lower confidence results being used in pooled analysis, however
the method is simpler and more transparent. This is less critical as the
number of studies increases. Restriction to outcomes with sufficient power may
be beneficial in pooled analysis and improve accuracy when there are few
studies, however we maintain our pre-specified method to avoid any
retrospective changes.
Studies show that combinations of treatments can be highly
synergistic and may result in many times greater efficacy than individual
treatments alone33-43.
Therefore standard of care may be critical and benefits may diminish or
disappear if standard of care does not include certain treatments.
This real-time analysis is constantly updated based on
submissions. Accuracy benefits from widespread review and submission of
updates and corrections from reviewers. Less popular treatments may receive
fewer reviews.
No treatment or intervention is 100% available and
effective for all current and future variants. Efficacy may vary significantly
with different variants and within different populations. All treatments have
potential side effects. Propensity to experience side effects may be predicted
in advance by qualified physicians. We do not provide medical advice. Before
taking any medication, consult a qualified physician who can compare all
options, provide personalized advice, and provide details of risks and
benefits based on individual medical history and situations.
Abraham et al. present a review covering sarilumab for COVID-19.
SARS-CoV-2 infection and replication involves a complex interplay of 50+ host
and viral proteins and other factors14-18,
providing many therapeutic targets.
Over 8,000 compounds have been predicted to reduce COVID-19
risk19, either by directly
minimizing infection or replication, by supporting immune system function, or
by minimizing secondary complications.
Figure 16 shows an overview of the results for sarilumab
in the context of multiple COVID-19 treatments, and Figure 17 shows a plot
of efficacy vs. cost for COVID-19 treatments.
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Figure 16.
Scatter plot showing results within the context of multiple COVID-19 treatments.
Diamonds shows the results of random effects meta-analysis.
0.6% of 8,000+ proposed treatments show efficacy56.
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Figure 17. Efficacy vs. cost for COVID-19 treatments.
Meta analysis using the most serious outcome reported shows
0% [-17‑21%] higher risk, without reaching statistical significance. Currently all studies are RCTs.
Branch-Elliman:
RCT 50 hospitalized moderate-to-severe COVID-19 patients showing higher mortality with subcutaneous sarilumab compared to standard of care. The study was stopped early due to a high probability of futility and potential harm.
García-Vicuña:
RCT 30 hospitalized moderate-to-severe COVID-19 patients showing no significant difference in 30-day mortality, clinical improvement at day 7, or time to discharge with sarilumab compared to standard care.
Gordon:
RCT 803 critically ill COVID-19 patients showing improved outcomes with tocilizumab and sarilumab. There was only 48 sarilumab patients and the model used shrinks the posterior distribution for each intervention effect toward the overall estimate for the combined drugs. The concurrent event counts for sarilumab may be more accurate.
Hermine:
Two open-label RCTs of 97 and 91 critically ill COVID-19 patients in France showing no significant differences with tocilizumab or sarilumab.
Lescure:
RCT 416 hospitalized severe or critical COVID-19 patients showing no significant difference with intravenous sarilumab compared to placebo for clinical improvement, survival at day 29, or other secondary outcomes.
Mariette:
RCT 148 hospitalized patients with moderate-to-severe COVID-19 pneumonia in France showing no significant differences with sarilumab treatment.
Mastrorosa:
RCT with 176 severe COVID-19 patients showing no significant difference in time to clinical improvement or 30 day mortality with sarilumab treatment.
Merchante:
RCT 115 hospitalized COVID-19 pneumonia patients in Spain showing a trend towards reduced progression to severe respiratory failure requiring high-flow oxygen, non-invasive ventilation, or mechanical ventilation, and reduced mortality, with sarilumab 400mg compared to standard of care.
Sancho-López:
RCT 201 hospitalized COVID-19 pneumonia patients under standard oxygen therapy in Spain showing no significant difference with sarilumab treatment.
Sivapalasingam:
Phase 2 and phase 3 RCTs with 1,365 hospitalized COVID-19 patients showing no significant improvement with sarilumab vs placebo. Post-hoc analysis suggests a potential mortality benefit with sarilumab in mechanically ventilated patients receiving corticosteroids at baseline. Phase 2 and phase 3 results are listed separately66,67.
Sivapalasingam (B):
Phase 2 and phase 3 RCTs with 1,365 hospitalized COVID-19 patients showing no significant improvement with sarilumab vs placebo. Post-hoc analysis suggests a potential mortality benefit with sarilumab in mechanically ventilated patients receiving corticosteroids at baseline. Phase 2 and phase 3 results are listed separately66,67.
Zulueta:
Estimated 60 patient sarilumab late treatment study with results not reported over 3 years after estimated completion.
We perform ongoing searches of PubMed, medRxiv, Europe PMC,
ClinicalTrials.gov, The Cochrane Library, Google Scholar, Research
Square, ScienceDirect, Oxford University Press, the reference lists of other
studies and meta-analyses, and submissions to the site c19early.org.
Search terms are sarilumab and COVID-19 or SARS-CoV-2. Automated searches are performed twice daily, with all matches reviewed for inclusion.
All studies regarding the use of sarilumab for COVID-19 that report
a comparison with a control group are included in the main analysis.
This is a living analysis and is updated regularly.
We extracted effect sizes and associated data from all studies.
If studies report multiple kinds of effects then the most serious
outcome is used in pooled analysis, while other outcomes are included in the
outcome specific analyses. For example, if effects for mortality and cases are
both reported, the effect for mortality is used, this may be different to the
effect that a study focused on.
If symptomatic
results are reported at multiple times, we used the latest time, for example
if mortality results are provided at 14 days and 28 days, the results at 28
days have preference. Mortality alone is preferred over combined outcomes.
Outcomes with zero events in both arms are not used, the next most serious
outcome with one or more events is used. For example, in low-risk populations
with no mortality, a reduction in mortality with treatment is not possible,
however a reduction in hospitalization, for example, is still valuable.
Clinical outcomes are considered more important than viral test status. When
basically all patients recover in both treatment and control groups,
preference for viral clearance and recovery is given to results mid-recovery
where available. After most or all patients have recovered there is little or
no room for an effective treatment to do better, however faster recovery is
valuable.
If only individual symptom data is available, the most serious symptom has
priority, for example difficulty breathing or low SpO2 is more
important than cough.
When results provide an odds ratio, we compute the relative risk when
possible, or convert to a relative risk according to69.
Reported confidence intervals and p-values were used when available,
using adjusted values when provided. If multiple types of adjustments are
reported propensity score matching and multivariable regression has preference
over propensity score matching or weighting, which has preference over
multivariable regression. Adjusted results have preference over unadjusted
results for a more serious outcome when the adjustments significantly alter
results. When needed, conversion between reported p-values and
confidence intervals followed Altman, Altman (B), and Fisher's exact
test was used to calculate p-values for event data. If continuity
correction for zero values is required, we use the reciprocal of the opposite
arm with the sum of the correction factors equal to 172.
Results are expressed with RR < 1.0 favoring treatment, and using the risk of
a negative outcome when applicable (for example, the risk of death rather than
the risk of survival). If studies only report relative continuous values such
as relative times, the ratio of the time for the treatment group versus the
time for the control group is used. Calculations are done in Python
(3.13.0) with
scipy (1.14.1), pythonmeta (1.26), numpy (1.26.4), statsmodels (0.14.4), and plotly (5.24.1).
Forest plots are computed using PythonMeta73
with the DerSimonian and Laird random effects model (the fixed effect
assumption is not plausible in this case) and inverse variance weighting.
Results are presented with 95% confidence intervals. Heterogeneity among studies was
assessed using the I2 statistic.
Mixed-effects meta-regression results are computed with R (4.4.0) using the metafor
(4.6-0) and rms (6.8-0) packages, and using the most serious sufficiently powered outcome.
For all statistical tests, a p-value less than 0.05 was considered statistically significant.
Grobid 0.8.0 is used to parse PDF documents.
We have classified studies as early treatment if most patients
are not already at a severe stage at the time of treatment (for example based
on oxygen status or lung involvement), and treatment started within 5 days of
the onset of symptoms. If studies contain a mix of early treatment and late
treatment patients, we consider the treatment time of patients contributing
most to the events (for example, consider a study where most patients are
treated early but late treatment patients are included, and all mortality
events were observed with late treatment patients).
We note that a shorter time may be preferable. Antivirals are typically only
considered effective when used within a shorter timeframe, for example 0-36 or
0-48 hours for oseltamivir, with longer delays not being effective20,21.
We received no funding, this research is done in our spare
time. We have no affiliations with any pharmaceutical companies or political
parties.
A summary of study results is below. Please submit
updates and corrections at https://c19early.org/sarmeta.html.
Effect extraction follows pre-specified rules as detailed above
and gives priority to more serious outcomes.
For pooled analyses, the first (most serious) outcome is used, which may
differ from the effect a paper focuses on.
Other outcomes are used in outcome specific analyses.
| Branch-Elliman, 2/25/2022, Randomized Controlled Trial, USA, peer-reviewed, mean age 72.3, 21 authors, study period 10 April, 2020 - 3 February, 2021, trial NCT04359901 (history). | risk of death, 350.0% higher, RR 4.50, p = 0.047, treatment 6 of 20 (30.0%), control 2 of 30 (6.7%), day 30. |
| risk of death/intubation, 650.0% higher, RR 7.50, p = 0.03, treatment 5 of 20 (25.0%), control 1 of 30 (3.3%), day 14, primary outcome. | |
| risk of mechanical ventilation, 500.0% higher, RR 6.00, p = 0.16, treatment 2 of 20 (10.0%), control 0 of 30 (0.0%), continuity correction due to zero event (with reciprocal of the contrasting arm), day 14. | |
| risk of ICU admission, 50.0% higher, RR 1.50, p = 0.67, treatment 3 of 20 (15.0%), control 3 of 30 (10.0%), day 30. | |
| García-Vicuña, 2/23/2022, Randomized Controlled Trial, Spain, peer-reviewed, median age 61.5, 13 authors, study period 13 April, 2020 - 30 October, 2020, trial NCT04357808 (history) (SARCOVID). | risk of death, 300.0% higher, RR 4.00, p = 0.54, treatment 2 of 20 (10.0%), control 0 of 10 (0.0%), continuity correction due to zero event (with reciprocal of the contrasting arm). |
| risk of mechanical ventilation, 450.0% higher, RR 5.50, p = 0.53, treatment 3 of 20 (15.0%), control 0 of 10 (0.0%), continuity correction due to zero event (with reciprocal of the contrasting arm). | |
| relative median improvement in clinical status, 33.3% worse, RR 1.33, p = 0.36, treatment 20, control 10, day 14. | |
| relative median improvement in clinical status, 50.0% worse, RR 1.50, p = 0.32, treatment 20, control 10, day 7. | |
| Gordon, 4/22/2021, Randomized Controlled Trial, multiple countries, peer-reviewed, 62 authors, trial NCT02735707 (history) (REMAP-CAP). | risk of death, 26.3% lower, RR 0.74, p = 0.39, treatment 10 of 45 (22.2%), control 19 of 63 (30.2%), NNT 13, concurrent control patients. |
| risk of death, 50.2% lower, HR 0.50, p = 0.048, treatment 45, control 397, inverted to make HR<1 favor treatment, including non-concurrent control patients. | |
| Hermine, 2/3/2022, Randomized Controlled Trial, France, peer-reviewed, 6 authors, study period 31 March, 2020 - 20 April, 2020, trial NCT04324073 (history) (CORIMUNO-SARI-2). | risk of death, 26.0% lower, HR 0.74, p = 0.44, treatment 14 of 48 (29.2%), control 13 of 33 (39.4%), NNT 9.8. |
| Lescure, 5/31/2021, Double Blind Randomized Controlled Trial, placebo-controlled, multiple countries, peer-reviewed, median age 59.0, 8 authors, study period 28 March, 2020 - 3 July, 2020, trial NCT04327388 (history). | risk of death, 1.6% lower, RR 0.98, p = 0.96, treatment 173, control 84, all patients. |
| risk of death, 2.9% lower, RR 0.97, p = 1.00, treatment 18 of 173 (10.4%), control 9 of 84 (10.7%), NNT 323, 400mg, day 60, Table S6. | |
| risk of death, 0.2% lower, RR 1.00, p = 1.00, treatment 17 of 159 (10.7%), control 9 of 84 (10.7%), NNT 4452, 200mg, day 60, Table S6. | |
| risk of ICU admission, 4.7% higher, RR 1.05, p = 0.89, treatment 114, control 56, all patients. | |
| risk of ICU admission, 19.3% higher, RR 1.19, p = 0.82, treatment 17 of 114 (14.9%), control 7 of 56 (12.5%), 400mg, day 60, Table S6. | |
| risk of ICU admission, 10.2% lower, RR 0.90, p = 0.80, treatment 11 of 98 (11.2%), control 7 of 56 (12.5%), NNT 78, 200mg, day 60, Table S6. | |
| risk of no improvement, 7.9% lower, HR 0.92, p = 0.47, treatment 173, control 84, all patients. | |
| risk of no improvement, 12.3% lower, HR 0.88, p = 0.40, treatment 173, control 84, inverted to make HR<1 favor treatment, 400mg, day 29, Table 2. | |
| risk of no improvement, 2.9% lower, HR 0.97, p = 0.86, treatment 159, control 84, inverted to make HR<1 favor treatment, 200mg, day 29, Table 2. | |
| Mariette, 1/31/2022, Randomized Controlled Trial, France, peer-reviewed, 6 authors, study period 27 March, 2020 - 6 April, 2020, trial NCT04324073 (history) (CORIMUNO-SARI-1). | risk of death, 30.0% lower, HR 0.70, p = 0.40, treatment 10 of 68 (14.7%), control 16 of 76 (21.1%), NNT 16, adjusted per study, day 90. |
| risk of death, 35.0% lower, HR 0.65, p = 0.35, treatment 8 of 68 (11.8%), control 14 of 76 (18.4%), NNT 15, adjusted per study, day 28. | |
| risk of death, 32.0% lower, HR 0.68, p = 0.50, treatment 6 of 68 (8.8%), control 8 of 76 (10.5%), adjusted per study, day 14. | |
| WHO CPS>5, 0.6% higher, RR 1.01, p = 1.00, treatment 18 of 68 (26.5%), control 20 of 76 (26.3%), day 4, primary outcome. | |
| non-invasive ventilation, mechanical ventilation, or death, 10.0% higher, HR 1.10, p = 0.70, treatment 68, control 76, day 14, primary outcome. | |
| Mastrorosa, 3/31/2023, Randomized Controlled Trial, Italy, peer-reviewed, median age 61.0, 94 authors, study period 11 May, 2020 - 5 May, 2021, ESCAPE trial. | risk of death, 30.0% higher, HR 1.30, p = 0.67, treatment 10 of 107 (9.3%), control 4 of 52 (7.7%), Kaplan–Meier, day 30. |
| risk of no improvement, 6.5% lower, HR 0.93, p = 0.69, treatment 121, control 55, inverted to make HR<1 favor treatment, Kaplan–Meier, day 30. | |
| risk of no viral clearance, 7.6% higher, RR 1.08, p = 1.00, treatment 17 of 79 (21.5%), control 7 of 35 (20.0%), day 30. | |
| Merchante, 2/15/2022, Randomized Controlled Trial, Spain, peer-reviewed, median age 59.0, 20 authors, study period 13 July, 2020 - 5 March, 2021, trial NCT04357860 (history) (SARICOR). | risk of death, 35.2% higher, HR 1.35, p = 0.71, treatment 39, control 39, all patients. |
| risk of death, 99.0% lower, HR 0.01, p = 0.21, treatment 0 of 39 (0.0%), control 3 of 39 (7.7%), relative risk is not 0 because of continuity correction due to zero events (with reciprocal of the contrasting arm), 400mg, Cox proportional hazards, day 28. | |
| risk of death, 41.0% higher, HR 1.41, p = 0.67, treatment 4 of 37 (10.8%), control 3 of 39 (7.7%), 200mg, Cox proportional hazards, day 28. | |
| risk of mechanical ventilation, 22.2% higher, HR 1.22, p = 0.70, treatment 39, control 39, all patients. | |
| risk of mechanical ventilation, 22.0% lower, HR 0.78, p = 0.76, treatment 3 of 39 (7.7%), control 4 of 39 (10.3%), NNT 39, 400mg, Cox proportional hazards, day 28. | |
| risk of mechanical ventilation, 68.0% higher, HR 1.68, p = 0.43, treatment 6 of 37 (16.2%), control 4 of 39 (10.3%), 200mg, Cox proportional hazards, day 28. | |
| HFNO, NIMV or IMV, 36.0% lower, HR 0.64, p = 0.23, treatment 39, control 39, all patients, primary outcome. | |
| HFNO, NIMV or IMV, 59.0% lower, HR 0.41, p = 0.10, treatment 5 of 39 (12.8%), control 11 of 39 (28.2%), NNT 6.5, 400mg, Cox proportional hazards, day 28, primary outcome. | |
| HFNO, NIMV or IMV, 13.0% lower, HR 0.87, p = 0.76, treatment 10 of 37 (27.0%), control 11 of 39 (28.2%), NNT 85, 200mg, Cox proportional hazards, day 28, primary outcome. | |
| Sancho-López, 10/17/2021, Randomized Controlled Trial, Spain, peer-reviewed, median age 60.0, 22 authors, study period 4 August, 2020 - 23 March, 2021, SARTRE trial. | risk of death, 3.0% higher, RR 1.03, p = 0.98, treatment 2 of 99 (2.0%), control 2 of 102 (2.0%), adjusted per study, day 28. |
| risk of ICU admission, 30.0% lower, RR 0.70, p = 0.50, treatment 7 of 99 (7.1%), control 10 of 102 (9.8%), NNT 37, adjusted per study, day 28. | |
| Brescia ≥ 2, 14.0% higher, RR 1.14, p = 0.66, treatment 40 of 99 (40.4%), control 40 of 102 (39.2%), adjusted per study, day 28. | |
| Brescia ≥ 3 at any moment, 3.0% higher, RR 1.03, p = 0.94, treatment 40 of 99 (40.4%), control 40 of 102 (39.2%), adjusted per study, day 28. | |
| Brescia ≥ 3 at any moment, 3.0% higher, RR 1.03, p = 0.94, treatment 40 of 99 (40.4%), control 40 of 102 (39.2%), adjusted per study, day 14, primary outcome. | |
| Sivapalasingam, 2/26/2022, Double Blind Randomized Controlled Trial, placebo-controlled, USA, peer-reviewed, median age 61.0, 40 authors, study period 18 March, 2020 - 2 July, 2020, trial NCT04315298 (history) (REGENERON P2). | risk of death, 6.8% higher, HR 1.07, p = 0.89, treatment 180, control 90, adjusted per study, all 400mg patients. |
| risk of death, 1341.2% higher, RR 14.41, p = 0.03, treatment 9 of 51 (17.6%), control 0 of 25 (0.0%), continuity correction due to zero event (with reciprocal of the contrasting arm), 400mg, severe patients, phase 2, day 60. | |
| risk of death, 30.0% lower, HR 0.70, p = 0.28, treatment 23 of 88 (26.1%), control 15 of 44 (34.1%), NNT 13, adjusted per study, 400mg, critical patients, phase 2, day 60. | |
| risk of death, 2.0% higher, HR 1.02, p = 0.97, treatment 17 of 41 (41.5%), control 9 of 21 (42.9%), NNT 72, adjusted per study, 400mg, MSOD patients, phase 2, day 60. | |
| risk of death, 22.4% higher, HR 1.22, p = 0.41, treatment 187, control 90, adjusted per study, all 200mg patients. | |
| risk of death, 300.0% higher, HR 4.00, p = 0.55, treatment 2 of 50 (4.0%), control 0 of 25 (0.0%), continuity correction due to zero event (with reciprocal of the contrasting arm), 200mg, severe patients, phase 2, day 60. | |
| risk of death, 21.0% higher, HR 1.21, p = 0.55, treatment 38 of 94 (40.4%), control 15 of 44 (34.1%), adjusted per study, 200mg, critical patients, phase 2, day 60. | |
| risk of death, 15.0% higher, HR 1.15, p = 0.74, treatment 20 of 43 (46.5%), control 9 of 21 (42.9%), adjusted per study, 200mg, MSOD patients, phase 2, day 60. | |
| risk of no improvement, 4.4% higher, RR 1.04, p = 0.91, treatment 180, control 90, all 400mg patients. | |
| risk of no improvement, 292.2% higher, RR 3.92, p = 0.04, treatment 16 of 51 (31.4%), control 2 of 25 (8.0%), 400mg, severe patients, phase 2, day 22. | |
| risk of no improvement, 39.7% lower, RR 0.60, p = 0.006, treatment 35 of 88 (39.8%), control 29 of 44 (65.9%), NNT 3.8, 400mg, critical patients, phase 2, day 22. | |
| risk of no improvement, 7.1% higher, RR 1.07, p = 0.79, treatment 23 of 41 (56.1%), control 11 of 21 (52.4%), 400mg, MSOD patients, phase 2, day 22. | |
| risk of no improvement, 12.2% lower, RR 0.88, p = 0.30, treatment 187, control 90, all 200mg patients. | |
| risk of no improvement, no change, RR 1.00, p = 1.00, treatment 4 of 50 (8.0%), control 2 of 25 (8.0%), 200mg, severe patients, phase 2, day 22. | |
| risk of no improvement, 20.9% lower, RR 0.79, p = 0.14, treatment 49 of 94 (52.1%), control 29 of 44 (65.9%), NNT 7.3, 200mg, critical patients, phase 2, day 22. | |
| risk of no improvement, 15.4% higher, RR 1.15, p = 0.60, treatment 26 of 43 (60.5%), control 11 of 21 (52.4%), 200mg, MSOD patients, phase 2, day 22. | |
| Sivapalasingam (B), 2/26/2022, Double Blind Randomized Controlled Trial, placebo-controlled, USA, peer-reviewed, median age 61.0, 40 authors, study period 18 March, 2020 - 2 July, 2020, trial NCT04315298 (history) (REGENERON P3). | risk of death, 7.5% higher, HR 1.08, p = 0.59, treatment 567, control 286, adjusted per study, all 400mg patients. |
| risk of death, 17.0% higher, HR 1.17, p = 0.71, treatment 21 of 137 (15.3%), control 9 of 70 (12.9%), adjusted per study, 400mg, severe patients, phase 3, day 60. | |
| risk of death, no change, HR 1.00, p = 1.00, treatment 114 of 338 (33.7%), control 59 of 170 (34.7%), NNT 102, adjusted per study, 400mg, critical patients, phase 3, day 60. | |
| risk of death, 32.0% higher, HR 1.32, p = 0.35, treatment 40 of 92 (43.5%), control 16 of 46 (34.8%), adjusted per study, 400mg, MSOD patients, phase 3, day 60. | |
| risk of death, 11.6% lower, HR 0.88, p = 0.45, treatment 477, control 286, adjusted per study, all 200mg patients. | |
| risk of death, 36.0% lower, HR 0.64, p = 0.31, treatment 12 of 140 (8.6%), control 9 of 70 (12.9%), NNT 23, adjusted per study, 200mg, severe patients, phase 3, day 60. | |
| risk of death, 19.0% lower, HR 0.81, p = 0.24, treatment 70 of 242 (28.9%), control 59 of 170 (34.7%), NNT 17, adjusted per study, 200mg, critical patients, phase 3, day 60. | |
| risk of death, 27.0% higher, HR 1.27, p = 0.43, treatment 40 of 95 (42.1%), control 16 of 46 (34.8%), adjusted per study, 200mg, MSOD patients, phase 3, day 60. | |
| risk of no improvement, 5.9% higher, RR 1.06, p = 0.47, treatment 567, control 286, all 400mg patients. | |
| risk of no improvement, 23.5% higher, RR 1.23, p = 0.58, treatment 29 of 137 (21.2%), control 12 of 70 (17.1%), 400mg, severe patients, phase 3, day 22. | |
| risk of no improvement, 5.8% higher, RR 1.06, p = 0.64, treatment 164 of 338 (48.5%), control 78 of 170 (45.9%), 400mg, critical patients, phase 3, day 22. | |
| risk of no improvement, 3.3% higher, RR 1.03, p = 0.85, treatment 62 of 92 (67.4%), control 30 of 46 (65.2%), 400mg, MSOD patients, phase 3, day 22. | |
| risk of no improvement, 11.4% lower, RR 0.89, p = 0.13, treatment 477, control 286, all 200mg patients. | |
| risk of no improvement, no change, RR 1.00, p = 1.00, treatment 24 of 140 (17.1%), control 12 of 70 (17.1%), 200mg, severe patients, phase 3, day 22. | |
| risk of no improvement, 16.2% lower, RR 0.84, p = 0.11, treatment 105 of 242 (43.4%), control 88 of 170 (51.8%), NNT 12, 200mg, critical patients, phase 3, day 22. | |
| risk of no improvement, 4.8% lower, RR 0.95, p = 0.85, treatment 59 of 95 (62.1%), control 30 of 46 (65.2%), NNT 32, 200mg, MSOD patients, phase 3, day 22. | Zulueta, 12/30/2020, Spain, trial NCT04661527 (history) (STRIKESARS). | Estimated 60 patient study with results unknown and over 3 years late. |
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