Fostamatinib for Hospitalized Adults With COVID-19

National Heart, Lung, and Blood Institute (NHLBI)59 enrolled

Overview

Background: COVID-19 is a new disease caused by SARS-CoV-2 that was identified in 2019. Some people who get sick with COVID-19 become ill requiring hospitalization. There are some medicines that may help with recovery. Researchers want to see if a drug called fostamatinib may help people who are hospitalized with COVID-19. Objective: To learn if fostamatinib is safe in patients who are hospitalized with COVID-19 and gain earlier insight into whether it improves outcomes. Eligibility: Adults age 18 and older who are hospitalized with COVID-19. Design: Participants will be screened with a physical exam, including vital signs and weight. They will have a blood test and chest x-ray. They will have a COVID-19 test as a swab of either the back of the throat or the back of the nose. They will take a pregnancy test if needed. Participants will be randomly assigned, to take either fostamatinib pills or a placebo twice daily for up to 14 days in addition to standard of care for COVID-19. If they can swallow, they will take the pills by mouth with water. If they cannot swallow or are on mechanical ventilation, the pills will be crushed, mixed with water, and given through a tube placed through the nostril, or placed in the mouth, down the esophagus, and into the stomach. Blood samples will be taken daily. Participants will return to the Clinical Center for safety follow-up visits. At these visits, they will have a physical exam and blood tests. If they cannot visit the Clinical Center, they will be contacted by phone or have a telehealth visit. Participation will last for about two months

Coronavirus Disease 2019 (COVID-19) is the disease caused by Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2). SARS-CoV-2 primarily infects the upper and lower respiratory tract and can lead to acute respiratory distress syndrome (ARDS) in a subset of patients with a known high mortality rate. Additionally, some patients develop other organ dysfunction including myocardial injury, acute kidney injury, shock along with endothelial dysfunction and subsequently micro and macrovascular thrombosis. Much of the underlying pathology of SARS-CoV-2 is thought to be secondary to a dysregulated immune response and more recently a hypercoagulable state leading to immunothrombosis. Currently, two therapies have shown efficacy in large multicenter trials for the treatment of COVID-19, one of which is an antiviral (remdesivir) and the other is an immunosuppressant corticosteroid meant to dampen the immune response (dexamethasone). Spleen tyrosine kinase (SYK) is a cytoplasmic tyrosine kinase involved in the intracellular signaling pathways of many different immune cells. In this pilot study we propose to use fostamatinib (an SYK inhibitor) as a targeted therapy for the immunological complications of hospitalized patients with COVID-19. The biological mechanisms by which SYK inhibition may improve outcomes in patients with COVID-19 include the inhibition of pro-inflammatory cytokines by monocytes and macrophages, decreased production of neutrophil extracellular traps (NETs) by neutrophils, and inhibition of platelet aggregation; three pathways that are mediated through Fc receptors (FcR) recognition of antigen-antibody complexes or activation of c-type lectin receptors (CLEC). This is a randomized, double-blind, placebo-controlled trial of fostamatinib for the treatment of hospitalized patients with COVID-19. We will randomly assign fostamatinib or matched placebo (1:1) to 60 eligible COVID-19 patients who are a 5 to 7 on the 8-point scale (requiring supplemental oxygen via nasal canula or noninvasive ventilation, requiring mechanical ventilation or extracorporeal membrane oxygenation).

Eligibility

Sex: ALLMin age: 18 Years

Medical Language ↔ Plain English

* INCLUSION CRITERIA: 1. Patient must be hospitalized, or had their inpatient stay extended, for COVID-19. 2. Age \>=18 years 3. Subject (or legally authorized representative) provides informed consent prior to initiation of any study procedures. 4. Subject (or legally authorized representative) understands and agrees to comply with planned study procedures. 5. Females of childbearing potential must agree to be abstinent or use a medical acceptable form of contraception from the time of enrollment through 30 days after last day of study drug 6. Laboratory confirmed SARS-CoV-2 RT-PCR test within 7 days of enrollment 7. Illness of any duration with SpO2 of less than 94% on room air requiring supplemental oxygen via nasal canula or non-invasive mechanical ventilation, or mechanical ventilation or ECMO (5 to 7 on the 8-point scale) EXCLUSION CRITERIA: 1. ALT or AST \> 5 times the upper limit of normal (ULN) or ALT or AST \>= 3 x ULN and total bilirubin \> 2 x ULN. 2. Estimated glomerular filtration rate (eGFR) \<30ml/min 3. Pregnancy or breast feeding 4. Anticipated discharge in the next 72 hours 5. Allergy to study medication 6. Uncontrolled hypertension (systolic blood pressure \>160mmHg or diastolic blood pressure \>100mmHg) 7. Shock or hypotension at the time of enrollment 8. Neutrophil count \<1000/microliter 9. Concern for bacterial or fungal sepsis 10. Received immunomodulatory treatment within 30 days prior to enrollment e.g., Bruton's tyrosine kinase/phosphoinositide 3 kinase/Janus kinase inhibitor or cytokine-targeting biologic therapy (anti-TNF, IL-6) 11. Received a live vaccine the last 4 weeks 12. Those who were cognitively impaired or mentally disabled prior to COVID diagnosis 13. Participation in another clinical trial for the treatment of COVID-19.

Outcomes

Primary Outcomes

Number of Participants With at Least 1 Serious Adverse Event

Number of participants with at least 1 serious adverse event by day 29 using Common Terminology Criteria for Adverse Events (CTCAE) version 5.0. CTCAE is a list of common adverse event (AE) terms. Each AE term is defined and accompanied by a grading scale (1 to 5) that indicates the severity of the AE. Grading ranges from Grade 1 which is mild to Grade 5 which is death.

Time frame: Day 29

Secondary Outcomes

Number of Participants With Sustained Recoveries Defined by Ordinal Scale Score of 3 or Less

Time to sustained recovery determined by ordinal scale score of 3 or less and defined as time to recovery \[either discharge from the hospital or hospitalization for infection control reasons only\], with the recovery status sustained through day 29. The ordinal scale is an assessment of the clinical status. The scale is as follows: 8) Death; 7) Hospitalized, on invasive mechanical ventilation or extracorporeal membrane oxygenation (ECMO); 6) Hospitalized, on non-invasive ventilation or high flow oxygen devices; 5) Hospitalized, requiring supplemental oxygen; 4) Hospitalized, not requiring supplemental oxygen - requiring ongoing medical care (COVID-19 related or otherwise); 3) Hospitalized, not requiring supplemental oxygen - no longer requires ongoing medical care; 2) Not hospitalized, limitation on activities and/or requiring home oxygen; 1) Not hospitalized, no limitations on activities.

Time frame: day 29

Number of Participants Who Progress to Mechanical Ventilation

Number of participants who progress to mechanical ventilation by day 29

Time frame: day 29

Number of Participants With Cumulative Clinical Endpoint of Death

Number of Participants with Cumulative Clinical Endpoint of Death at Day 14, Day 28 and Day 60

Time frame: day 14, day 28, day 60

Number of Grade 3 and 4 Adverse Events Through Day 60

Number of Grade 3 and 4 AE through day 60 using Common Terminology Criteria for Adverse Events (CTCAE) version 5.0. CTCAE is a list of common adverse event (AE) terms. Each AE term is defined and accompanied by a grading scale (1 to 5) that indicates the severity of the AE. Grading ranges from Grade 1 which is mild to Grade 5 which is death.

Time frame: Day 60

Participant Score on Ordinal Scale

Participant score on ordinal scale at day 15 and day 29. The ordinal scale is an assessment of the clinical status. The scale is as follows: 8) Death; 7) Hospitalized, on invasive mechanical ventilation or extracorporeal membrane oxygenation (ECMO); 6) Hospitalized, on non-invasive ventilation or high flow oxygen devices; 5) Hospitalized, requiring supplemental oxygen; 4) Hospitalized, not requiring supplemental oxygen - requiring ongoing medical care (COVID-19 related or otherwise); 3) Hospitalized, not requiring supplemental oxygen - no longer requires ongoing medical care; 2) Not hospitalized, limitation on activities and/or requiring home oxygen; 1) Not hospitalized, no limitations on activities.

Time frame: Day 15, Day 29

Change in C-Reactive Protein Levels From Baseline

Change in C-Reactive Protein (CRP) blood levels from baseline. The upper limit of normal is 5 mg/L (milligrams per liter).

Time frame: Day 3, Day 5, Day 8, Day 11, Day 15, Day 29

Change in Fibrinogen Levels From Baseline.

Change in Fibrinogen blood levels from baseline. The upper limit of normal is Fibrinogen 466 milligrams per decilitre (mg/dL).

Time frame: Day 3, Day 5, Day 8, Day 11, Day 15, Day 29

Change in D-Dimer Levels From Baseline

Change in D-Dimer blood levels from baseline. The upper limit of normal is 0.50 mcg/mL (microgram per milliliter).

Time frame: Day 3, Day 5, Day 8, Day 11, Day 15, Day 29

Change in Ferritin Levels From Baseline

Change in Ferritin levels from baseline. The upper limit of normal for Ferritin is 400 mcg/L (micrograms per liter).

Time frame: Day 3, Day 5, Day 8, Day 11, Day 15, Day 29

Change in Interleukin 6 (IL6) Levels From Baseline

Change in Interleukin 6 (IL6) blood levels from baseline. The upper limit of normal for IL6 is 1.8 picograms per milliliter (pg/mL).

Time frame: Day 3, Day 5, Day 8, Day 11, Day 15, Day 29

Median Days Participants Were Admitted to Intensive Care Unit

Median days participants were admitted to Intensive Care Unit (ICU) by day 29

Time frame: Day 29

Relative Change in SpO2/FiO2 Ratio

Relative change in PaO2/FiO2 or SpO2/FiO2 ratio.

Time frame: Day 3, Day 5, Day 8, Day 11, Day 15, Day 29

Change in SOFA Score From Baseline

Change in SOFA score from baseline (day 1). The Sequential Organ Failure Assessment (SOFA) Score is a mortality prediction score that is based on the degree of dysfunction of six organ systems. The score is calculated on admission and every 24 hours until discharge using the worst parameters measured during the prior 24 hours. Each organ system is assigned a point value from 0 (normal) to 4 (high degree of dysfunction/failure). The "worst" measurement was defined as the measure that correlated to the highest number of points. The SOFA score ranges from 0 to 24.

Time frame: Day 3, Day 5, Day 8, Day 11, Day 15, Day 29

Median Days on Participants Received Supplemental Oxygen

Median days on participants received supplemental oxygen through day 29

Time frame: day 29

The Number of Participants That Experienced Acute Renal Failure

The number of participants that experienced acute renal failure by day 29. Acute renal failure defined as increase in serum creatinine by ≥0.3mg/dL within 48 hours or increase in serum creatinine by ≥1.5 times baseline which is known or presumed to have occurred within the prior seven days.

Time frame: day 29

Number of Participants That Experienced a Deep Vein Thrombosis (DVT) or Pulmonary Embolism (PE)

Number of participants that experienced a deep vein thrombosis (DVT) or pulmonary embolism (PE) by day 29

Time frame: day 29

Change in Absolute Lymphocyte Count Levels From Baseline

Change in Absolute lymphocyte count blood levels from baseline.

Time frame: Day 3, Day 5, Day 8, Day 11, Day 15, Day 29

Change in Absolute Neutrophil Count Levels From Baseline

Change in Absolute neutrophil count blood levels from baseline.

Time frame: Day 3, Day 5, Day 8, Day 11, Day 15, Day 29

Change in Platelet Count Levels From Baseline

Change in Platelet count blood levels from baseline.

Time frame: Day 3, Day 5, Day 8, Day 11, Day 15, Day 29

Fostamatinib for Hospitalized Adults With COVID-19

Overview

Conditions

Interventions

Eligibility

Locations (2)

Outcomes

Primary Outcomes

Secondary Outcomes