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Randomized Controlled Trial
. 2021 Apr:66:103288.
doi: 10.1016/j.ebiom.2021.103288. Epub 2021 Mar 19.

Itraconazole for COVID-19: preclinical studies and a proof-of-concept randomized clinical trial

Laurens Liesenborghs  1 , Isabel Spriet  2 , Dirk Jochmans  3 , Ann Belmans  4 , Iwein Gyselinck  5 , Laure-Anne Teuwen  6 , Sebastiaan Ter Horst  3 , Erwin Dreesen  7 , Tatjana Geukens  8 , Matthias M Engelen  9 , Ewout Landeloos  10 , Vincent Geldhof  6 , Helga Ceunen  11 , Barbara Debaveye  9 , Bert Vandenberk  9 , Lorenz Van der Linden  2 , Sofie Jacobs  3 , Lana Langendries  3 , Robbert Boudewijns  3 , Thuc Nguyen Dan Do  3 , Winston Chiu  3 , Xinyu Wang  3 , Xin Zhang  3 , Birgit Weynand  12 , Thomas Vanassche  9 , Timothy Devos  13 , Geert Meyfroidt  14 , Wim Janssens  5 , Robin Vos  5 , Pieter Vermeersch  15 , Joost Wauters  16 , Geert Verbeke  4 , Paul De Munter  11 , Suzanne J F Kaptein  3 , Joana Rocha-Pereira  3 , Leen Delang  3 , Eric Van Wijngaerden  11 , Johan Neyts  3 , Peter Verhamme  9
Affiliations
Randomized Controlled Trial

Itraconazole for COVID-19: preclinical studies and a proof-of-concept randomized clinical trial

Laurens Liesenborghs et al. EBioMedicine. 2021 Apr.

Erratum in

  • Corrigendum to "itraconazole for COVID-19: Preclinical studies and a proof-of-concept randomized clinical trial Laurens".
    Liesenborghs L, Spriet I, Jochmans D, Belmans A, Gyselinck I, Teuwen LA, Ter Horst S, Dreesen E, Geukens T, Engelen MM, Landeloos E, Geldhof V, Ceunen H, Debaveye B, Vandenberk B, Van der Linden L, Jacobs S, Langendries L, Boudewijns R, Dan Do TN, Chiu W, Wang X, Zhang X, Weynand B, Vanassche T, Devos T, Meyfroidt G, Janssens W, Vos R, Vermeersch P, Wauters J, Verbeke G, De Munter P, Kaptein SJF, Rocha-Pereira J, Delang L, Van Wijngaerden E, Neyts J, Verhamme P. Liesenborghs L, et al. EBioMedicine. 2021 Jul;69:103454. doi: 10.1016/j.ebiom.2021.103454. Epub 2021 Jun 26. EBioMedicine. 2021. PMID: 34186486 Free PMC article. No abstract available.

Abstract

Background: The antifungal drug itraconazole exerts in vitro activity against SARS-CoV-2 in Vero and human Caco-2 cells. Preclinical and clinical studies are required to investigate if itraconazole is effective for the treatment and/or prevention of COVID-19.

Methods: Due to the initial absence of preclinical models, the effect of itraconazole was explored in a clinical, proof-of-concept, open-label, single-center study, in which hospitalized COVID-19 patients were randomly assigned to standard of care with or without itraconazole. Primary outcome was the cumulative score of the clinical status until day 15 based on the 7-point ordinal scale of the World Health Organization. In parallel, itraconazole was evaluated in a newly established hamster model of acute SARS-CoV-2 infection and transmission, as soon as the model was validated.

Findings: In the hamster acute infection model, itraconazole did not reduce viral load in lungs, stools or ileum, despite adequate plasma and lung drug concentrations. In the transmission model, itraconazole failed to prevent viral transmission. The clinical trial was prematurely discontinued after evaluation of the preclinical studies and because an interim analysis showed no signal for a more favorable outcome with itraconazole: mean cumulative score of the clinical status 49 vs 47, ratio of geometric means 1.01 (95% CI 0.85 to 1.19) for itraconazole vs standard of care.

Interpretation: Despite in vitro activity, itraconazole was not effective in a preclinical COVID-19 hamster model. This prompted the premature termination of the proof-of-concept clinical study.

Funding: KU Leuven, Research Foundation - Flanders (FWO), Horizon 2020, Bill and Melinda Gates Foundation.

Keywords: COVID-19; SARS-CoV-2; antivirals; drug repurposing; itraconazole.

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Conflict of interest statement

Initial dug screening and discovery of the antiviral effect of itraconazole was done in collaboration with Johnson & Johnson, who also provided funding for this initial drug screen. Later in vitro drug screening was done independently from the company (e.g. antiviral activity of other azoles). Another manuscript in which an extensive panel of data is presented on the in vitro antiviral activity of itraconazole will be published together with authors from Johnson and Johnson. (Currently available as preprint [1]) Scientists from Johnson & Johnson performed drug measurements on hamster samples and provided guidance on the dosing regimens for the preclinical studies, but had no additional role in these experiments. The company had no role in the design, execution, analysis, publication or funding of the clinical trial. P Verhamme reports grants from KU Leuven during the conduct of the study and grants and personal fees for lectures and consultancy from Bayer Healthcare, Daiichi Sankyo, Pfizer, BMS, Bayer and Boehringer outside the submitted work, and personal fees for consultancy from Boehringer Ingelheim and Portola, outside the submitted work. Other authors have no conflict of interest to declare.

Figures

Figure 1
Figure 1
In vitro antiviral activity. (a) Antiviral activity of itraconazole and hydroxy-itraconazole at different concentrations in the SARS-CoV-2 / VeroE6-eGFP assay system. Green fluorescence indicates cells surviving SARS-CoV-2 infection. Itraconazole was tested in two independent experiments while hydroxy-itraconazole (17-OH-itraconazole) was tested in one experiment. (b) Antiviral activity of azithromycine, hydroxychloroquine and GS-441524 in two independent experiments. (c) Antiviral activity of itraconazole and other azoles different concentrations in the SARS-CoV-2 / VeroE6-eGFP assay system. VC indicates “Virus Control” i.e. infected untreated cultures; CC indicates “Cell Control” i.e. uninfected untreated cultures; GS-441524 is the parent nucleoside of remdesivir.
Figure 2
Figure 2
Preclinical Evaluation of Itraconazole. (a) Acute infection model set-up. Hamsters (n=18) were intranasally infected with SARS-CoV-2 (2x106 50% tissue culture infectious dose, (TCID50)). Treatment with vehicle or itraconazole 30 or 70 mg/kg/day in two gifts via oral gavage, started one hour before infection. Hamsters were sacrificed at day 4. (b-d) Viral RNA levels quantified by RT-qPCR in (b) lungs, (c) ileum and (d) stools. (e) Lung infectious viral load assessed by endpoint dilution on cell cultures and expressed as TCID50 per mg of lung tissue. (f) Pathology score of the severity of inflammation on H&E stained lung sections at day 4. (g) Day 4 plasma and lung trough concentrations (Ctrough) of itraconazole and hydroxy-itraconazole in hamsters treated with either 30 or 70 mg/kg/day itraconazole. The dashed line indicates the EC50 of itraconazole against SARS-CoV-2. (h) Design of the viral transmission study: From day -1 on sentinel hamsters (n=2x5) received itraconazole (70 mg/kg/day) or vehicle. Index hamsters (n=2x5) were intranasally infected with SARS-CoV-2 (2x106 TCID50) on day -1. From day 0 onwards index and sentinel hamsters were co-housed, while treatment of sentinel hamsters continued (n=18). (i) Viral RNA levels quantified by RT-qPCR on day 4 in index hamsters and sentinel hamsters in lung, ileum and stool. (j) Lung infectious viral load in the lung expressed as TCID50 per mg of lung tissue. Bars represent median ± interquartile range (IQR). Data were analysed with the two-sided Mann-Whitney U-test. No statistically significant differences were found. LLOD denotes lower limit of detection.
Figure 3
Figure 3
Enrolment and Randomisation of Clinical Trial Participants
Figure 4
Figure 4
Clinical outcomes. (a) Bar chart of daily clinical status according to the WHO 7-point ordinal scale. (b,c) Cumulative estimates of (b) time to sustained clinical improvement (c) time to weaning from oxygen (d) Evolution of SARS-CoV-2 viral load from nasopharyngeal swabs assessed by RT-qPCR. Samples were available from 31 patients. Box plot shows median and interquartile range. Whiskers are drawn at (Q3 + 1.5 x IQR, Q 1- 1.5 x IQR). (e) Exposure-Response relation between itraconazole trough concentrations and cumulative clinical score day 1-15. Q1, Q3 denotes 1st and 3rd quartile, WHO denotes World Health Organization, IQR interquartile range.
See this image and copyright information in PMC

References

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