The aim of this study is to evaluate the efficiency and safety of immunoadsorption for the treatment of post-COVID syndrome (PCS). Efficacy will be measured (1) subjectively as an improvement of the score of questionnaires like the multidimensional fatigue inventory (MFI-20), Chalder fatigue scale, Bell-score, modified medical research council dyspnea scale (mMRC) and the Post-COVID functional scale (PCFS) and (2) objectively as an improvement in neurocognitive testing with the Montreal cognitive assessment (MoCA) and the improvement of the hand-grip strength. 40 participants with symptoms of PCS and a PCFS score of at least 2 will be included in each group (Addendum from February 2024: An additional 40 patients with the same inclusion and exclusion criteria will be treated using the devices and materials of another manufacturer, following the same design, and the results will be evaluated separately.). After excluding other causes of the symptoms and evaluating the baseline burden of symptoms, each participant will undergo 5 sessions of immunoadsorption with an immunoglobulin-binding adsorber and 5 sham treatments, or vice versa. The order of treatments (immunoadsorption first or sham first) will be randomized. Each participant will be blinded to the type of treatment they receive. An 8-week therapy-free period will separate the two treatment blocks. All examinations will be conducted before the first treatment, 2 weeks after the first treatment cycle, before the second treatment cycle, and 2 and 6 weeks after the second treatment cycle. The results of the study will inform future treatment strategies for PCS and will contribute to a better understanding of the pathophysiological insights behind the ongoing symptoms.
Post-COVID syndrome (PCS) refers to symptoms that develop 3 months from the onset of COVID-19 with symptoms that last for at least 2 months and cannot be explained by an alternative diagnosis (Soriano, Murthy et al. 2022). The nature of the symptoms has not been a factor in the definition of PCS. The prevalence of PCS is estimated to be 43% of all severe acute respiratory syndrom coronavirus 2 (SARS-COV-2)-infected patients, with hospitalized patients more likely to suffer from persistent symptoms (54%) than non-hospitalized patients (32%). Women are more likely to experience PCS than men (incidence, 49% vs 32%, respectively) (Chen, Haupert et al. 2022). The most common symptoms are fatigue (23%), memory impairment (14%), dyspnea (13%), sleep disturbances (11%), and joint pain (10%) (Chen, Haupert et al. 2022). Headaches, myalgia, anxiety or depression are also frequently reported. In terms of the type, variety and duration of symptoms, PCS resembles a clinical picture observed after various viral infections, such as Eppstein-Barr virus, herpes simplex virus or influenza virus, namely myalgic encephalomyelitis and chronic fatigue syndrome (ME/CFS). Here, too, patients mainly suffer from fatigue, impaired concentration and memory, and non-restorative sleep. Some authors consider post-COVID as a form of ME/CFS triggered by the SARS-CoV-2 infection or the immune response to the infection. The underlying pathophysiology likely depends on the different viruses but is incompletely understood. Similarly, the causes of PCS are unclear to date. Autoimmunity is suspected to play a major role in all post-virus syndromes. It may be triggered by the defense against infections and is probably maintained by similarity of endogenous proteins with pathogen components (molecular mimicry). In the context of this autoimmunity, antibodies against endogenous structures can also be formed, such as antinuclear antibodies, which are directed against components of the cell nuclei. Antibodies against α- and β-adrenergic receptors and muscarinic acetylcholine receptors, among others, have been detected in patients suffering from ME/CFS as well as in patients with PCS. Many patients are limited in their daily lives by the symptoms that develop or persist after SARS-COV-2-infection and suffer from a diminished quality of life. To date, there is little evidence on potential therapies for these complaints. Immunoadsorption (IA) efficiently removes (auto-)antibodies from the circulation and has been proposed as a potential therapy for PCS. The current trial will investigate the efficacy of IA for the treatment of PCS. 40 participants with PCS and a PCFS-score of at least 2 will be included in each. Each participant will undergo 5 sessions of IA with an immunoglobulin-binding adsorber and 5 sham treatments or vice versa. Sham treatment will be performed in the same ways as IA, but the IA device will not be set up with an adsorber. The order of treatments (immunoadsorption first or sham first) will be randomized. The participants are blinded to the order of treatments. An intervention-free interval of 8 weeks will separate both treatment blocks (Addendum from February 2024: 40 patients additional with the same inclusion and exclusion criteria will be treated using the devices and materials of another manufacturer, following the same design, and the results will be evaluated separately.). The primary outcome of the study is the efficacy of IA vs. sham, measured as changes in the PCFS (0-4), Chalder-fatigue scale (0-33), MFI-20 (20-100), Bell score (0-100), montreal cognitive assesment and the hand-grip strength before therapy compared to values after immunoadsorption and after sham-treatment. Secondary outcomes are (1) the number and severity of adverse events, (2) the prevalence of auto-antibodies like antinuclear antibodies, antibodies against adrenoreceptors and antibodies against muscarinic acetylcholine receptors in patients with PCS and (3) the change in concentration of the auto-antibodies in context of therapy and sham-treatment. In addition, various assessments (Complete blood count with differential, Antinuclear antibody Thyroid-stimulating hormone, C-reactive protein, Vitamin B12, Vitamin D, 25-dihydroxy, Ferritin, Urinalysis, ECG, spirometry, psychological questionaires) will be performed during screening period to be able to exclude other diseases as the cause of the PCS symptoms. In addition, safety-relevant parameters such as heart rate, blood pressure, electrolyte concentra-tions, fibrinogen concentration and the concentration of the immunoglobulin fractions are measured before and after each treatment. The results of the study will inform future treatment strategies for PCS and will contribute to a better understanding of the pathophysiological insights behind the ongoing symptoms.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
SINGLE
Enrollment
40
Immunoadsorption (IA) is a well-established extracorporeal therapy for several autoimmune diseases such as systemic lupus. Its therapeutic effect is based on the removal of antibodies (ABs) from the plasma including auto-ABs and it is used if an immediate response to therapy is necessary. Side effects (SE) of the IA are rare, but angiotensin-converting enzyme (ACE)-inhibitors are prohibited concomitant medication. Notable SE may include increased susceptibility to infection, transient disorders of blood coagulation, or allergic reactions to materials of the adsorber or tubing system. To ensure an effective therapy, a blood flow of at least 45 ml/min is necessary. In some patients, adequate blood flow can be achieved by cannulation of peripheral veins but in most patients is the placement of a central venous catheter necessary. Central venous catheter placement carries potential risks such as injury to the lung or mispuncture of the carotid artery.
Sham-apheresis is a procedure without any known therapeutic effects. As there are no known therapeutic effects there are also no known side effects excepted the risk of an allergic reaction to materials of the tubing system or to citrate, which is necessary to prevent clotting inside the extracorporeal system. To ensure a smooth operation a blood-flow of at least 45ml/min is necessary. In some patients, adequate blood flow can be achieved by cannulation of peripheral veins. However, in most patients, placement of a Shaldon catheter into the internal jugular vein is necessary. Shaldon catheter placement carries other potential risks such as injury to the lung resulting in pneumothorax or mispuncture of the carotid artery. However, since the catheter placement is sonography-guided, the risks for such adverse events are minimized.
UNIVERSITÄTSMEDIZIN der Johannes Gutenberg-Universität Mainz I. Medizinische Klinik und Poliklinik
Mainz, Rhineland-Palatinate, Germany
Improvement of Post-COVID symptoms as measured by PCFS score
The PCFS serves as a self-report instrument to better objectify perceived symptom severity at Post-COVID. Patients are asked to describe states presented as a questionnaire. A value is assigned to each described state. The greater the symptom severity is described by the condition, the greater the score from 0-4. The PCFS has been validated in cohorts of patients with Post-COVID-syndrome and is therefore particularly suitable for assessing symptom severity.
Time frame: 2 weeks after completion of immunoadsorption and sham-apheresis
Change of physical and/or mental fatigue as measured by Chalder-Fatigue-scale
The Chalder Fatigue Scale is an 11-item question battery that captures two dimensions of fatigue symptomatology, both the assessment of physical functioning and the assessment of mental functioning. Each question is answered using a 4-point Likert scale. The answering takes an average of 2-3 minutes and a re-survey can be done every 4 weeks.
Time frame: 2 weeks after completion of immunoadsorption and sham-apheresis
Change of impairment due to fatigue as measured by Bell-Score
The Bell score is an assessment instrument that can be collected by both the patient and the examiner and measures the degree of restriction in daily life caused by fatigue symptoms. In 11 grades, the restriction can be indicated from 0 (bedridden) to 100 (no restrictions, normal resilience in all activities of daily living).
Time frame: 2 weeks after completion of immunoadsorption and sham-apheresis
Change of physical and/or mental fatigue as measured by MFI-20
The MFI-20 captures the phenomenon of fatigue in the 5 subscales general fatigue, physical fatigue, reduced activity, reduced motivation, and mental fatigue. It is a self-report questionnaire in which patients rate statements such as "I was able to concentrate well" or "I was rested" in 5 levels for the latter time, including today. The result is a score in the range from 20-100 whereby a higher score indicates more severe fatigue.
Time frame: 2 weeks after completion of immunoadsorption and sham-apheresis
Change of Hand grip strength measured as hand-grip-strength test with a dynamometer
Grip strength serves as a surrogate parameter for physical performance or changes in it. Grip strength is measured three times on each hand in neutral position using a dynamometer and the mean value is documented.
Time frame: 2 weeks after completion of immunoadsorption and sham-apheresis
Change of cognitive impairment as measured by Montreal cognitive assesment (MoCA)
The Montreal Cognitive Assessment (MocA) is used to test various neurocognitive functions. It is a ten-minute test with various tasks that can be scored with a total of up to 30 points. It tests abilities in the areas of memory, attention, verbal abstraction, visuospatial abilities, concentration and language comprehension.
Time frame: 2 weeks after completion of immunoadsorption and sham-apheresis
number of treatment-emergent adverse events (TEAE), serious adverse events and discontinuation of therapy because of adverse events
1\. The number of treatment-emergent adverse events (TEAE), serious adverse events and discontinuation of therapy because of adverse events and the comparison of them under immunoadsorption with the number of events under sham apheresis. Events are recorded for comparison two weeks after the end of each treatment cycle.
Time frame: 2 weeks after completion of immunoadsorption and sham-apheresis
Prevalence of anti-adrenergic and anti-muscarinic autoantibodies in patients with PCS:
1. Proportion of subjects with evidence of anti-α1-adrenoreceptor antibodies (AB) 2. Proportion of subjects with evidence of anti-α2-adrenoreceptor AB 3. Proportion of subjects with evidence of anti-β1-adrenoreceptor-AB 4. Proportion of subjects with evidence of anti-β2-adrenoreceptor AB 5. Proportion of subjects with evidence of anti-β3-adrenoreceptor-AB 6. Proportion of subjects with detection of anti- M1 acetylcholine receptor AB 7. Proportion of subjects with detection of anti-M2 acetylcholine receptor AB 8. Proportion of subjects with detection of anti-M3 acetylcholine receptor-AB 9. Proportion of subjects with detection of anti-M4 acetylcholine receptor-AB
Time frame: at the time of the first examination before randomization for the first treatment-modality
3. Concentration of autoantibodies before and after IA and sham treatment (before therapy cycle 1/after therapy cycle1 as well as before therapy cycle 2/after therapy cycle 2)
1. Concentration anti-α1-adrenoreceptor antibodies (AB) 2. Concentration of anti-α2-adrenoreceptor AB 3. Concentration of anti-β1-adrenoreceptor-AB 4. Concentration of anti-β2-adrenoreceptor AB 5. Concentration of anti-β3-adrenoreceptor-AB 6. Concentration of anti- M1 acetylcholine receptor AB 7. Concentration of anti-M2 acetylcholine receptor AB 8. Concentration of anti-M3 acetylcholine receptor-AB 9. Concentration of anti-M4 acetylcholine receptor-AB
Time frame: before therapy cycle 1/after therapy cycle1 as well as before therapy cycle 2/after therapy cycle 2
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