A Randomized, Controlled Study on the Safety and Ecacy of Maraviroc and/or Favipiravir Vs Currently Used Therapy in Severe COVID-19 Adults. (COMVIVIR, clinicaltrials.gov NCT04475991)

Background: Multiple studies have now established that hyperinammatory response induced by SARS CoV-2 is a main cause of complications and death in infected subjects. Such dysfunctional immune response has been described as a dysregulated and exacerbated production of cytokines and chemokines that attracts and activates inammatory cells, which start and sustain pulmonary and systemic damage, thus causing complications that lead to multi organ failure and death. Therefore, we suggest that blocking key inammation receptors could help to reduce migration and activation of Th17, monocytes/macrophages and neutrophils, thus mitigating the cytokine storm and averting severe complications and death. Importantly, the optimum treatment for COVID-19 severe patients could combine a modulator of the immune response with a direct antiviral drug against SARS-CoV-2, in order to address both the viral load and the hyperinammatory effects of the immune dysregulation. Methods: Maraviroc (MVC), a CCR5 antagonist, and Favipiravir (FPV), an antiviral, will be evaluated single and combined, added to the treatment currently used at the Hospital General de México for severe non-critical COVID-19 patients. One hundred patients will be allocated in four arms [Current treatment only (CT), CT+MVC, CT+FPV, CT+MVC+FPV]. Percentage of patients free of mechanical ventilation or death at day 28, immunophenotyping and viral load will be compared between groups Discussion: New immune focused therapies are targeting strong inammation mediators such as IL-6 and IL1-B; nevertheless, to our best knowledge, controlling chemotaxis has not been explored. The use of a drug therapy that addresses both the regulation of the immune response and the inhibition of viral replication could at the same time, help to alleviate the hyperinammatory condition and reduce the time of the viral clearance process, therefore improving treatment outcomes Trial registration: Clinical Trials (www.clinicaltrials.gov) NCT: 04475991.


Introduction Background and rationale {6a}
The infection by SARS-CoV2 can cause a dysregulation characterized by an exacerbated immune response that leads to a generalized hyperin ammatory condition, which in turn may cause multiple complications, and eventually death. The cells accountable for such dysregulation express receptors like CCR5, which mediate their activation and tra cking to the lungs. Therefore, CCR5 could be considered a therapeutic target. MVC is a CCR5 antagonist that could also have an antiviral effect, albeit it has not been evaluated in the context of COVID-19. Alongside, the results could be potentiated by the direct effect of an antiviral such as FPV. Currently, there is not a vaccine able to effectively prevent the disease, and the pharmacologic strategies used for treatment have not proven completely effective. Thence, more studies of different therapeutic targets are needed to search for resources that help to improve the patients' prognosis. The use of a drug therapy that addresses both the regulation of the immune response and the inhibition of viral replication could at the same time, help to alleviate the hyperin ammatory condition and reduce the time of the viral clearance process. At the present time (August 2020), there are no published studies of the use of MVC in COVID-19; the only reports are three trials registered in www.clinicaltrials.gov, one of which is this . In regard to FPV in , an open, randomized study in 80 mild patients found that FPV reduced the time of viral clearance by 50% compared to Lopinavir/Ritonavir with less adverse effects (1), however, the study population had no risk comorbidities, and subjects with O2 saturation <93% were excluded. Another open randomized study in moderate patients reported FPV to be more effective in clinical recovery compared to Arbidol (2). An in vitro study found that FPV is capable to suppress the SARS-CoV-2 infection at high concentrations (3). Finally, a report from March 2020 (4) mentions 3 ongoing clinical trials registered in the Chinese Clinical Trials record (www.chictr.org.cn) to evaluate FPV in COVID-19 patients, all in recruiting phase.

Objectives {7}
Increase the percentage of patients free of mechanical ventilation or death by 30% at day 28 post-start of treatment.

Trial design {8}
This is a randomized, controlled study consisting of four arms. One hundred subjects will be randomized and allocated in the study arms (25/ arm; 1:1:1:1 ratio)

Study setting {9}
The study will be conducted at the facilities of the Hospital General de México "Dr. Eduardo Liceaga", located near downtown Mexico City, All candidates must read and sign an Informed Consent Form (ICF) before enrollment. The ICF will be obtained by certi ed researchers, physicians and nurses of the Hospital staff participating in this study (APG, MLHM, EOMH, and MLH). A model of the ICF can be provided upon request.

Additional consent provisions for collection and use of participant data and biological specimens {26b}
Not applicable since there are no additional samples to be collected.

Interventions Explanation for the choice of comparators {6b}
Comparison between groups was based upon treatment with MVC or FPV or both or none. If patients progress to critical condition, tablets will be crushed and administered using a nasogastric tube. The treatment will be discontinued in the occurrence of treatment-related adverse effects ruled so by a physician.

Strategies to improve adherence to interventions {11c}
Not applicable since all participants are inpatients.

Relevant concomitant care permitted or prohibited during the trial {11d}
Not applicable since all participants are inpatients, and such care will be provided by nursery staff if needed.
Therefore, 25 patients were allocated by group; 100 total.

Recruitment {15}
Participants will be recruited from the adult COVID-19 population of patients admitted to the Hospital.

Assignment of interventions: allocation
Sequence generation {16a} The allocation order will be generated randomly by EPIDAT 4.2 to assign the subjects to the A, B, C or D arms. Each patient's medical record number will serve for identi cation of the assigned treatment.

Concealment mechanism {16b}
Not applicable since this is not a blinded study.

Implementation {16c}
The allocation and enrollment of patients will be performed by certi ed researchers and nurses from the Hospital who are members of the staff of the study. (MLHM, ARCM, APG)

Assignment of interventions: Blinding
Who will be blinded {17a} Not applicable since this is not a blinded study

Procedure for unblinding if needed {17b}
Not applicable since this is not a blinded study

Data collection and management
Plans for assessment and collection of outcomes {18a} Data will be collected from the patients in printed forms by the nursery staff and then captured in a specially designed Excel data collection tool (Project EXCELEN-19 currently being conducted in the Hospital) by the study staff (LMPN), or their authorized surrogates. Double capture will be applied. Laboratory results will be uploaded to the patients database and incorporated to each participant's information.
Plans to promote participant retention and complete follow-up {18b} After discharge, patients will be contacted by the study staff (LMPN, MMSM, MLH) or their authorized surrogates to ask them about their general health and some speci c issues addressed to evaluate their pulmonary condition and the appearance of possible respiratory sequels.

Data management {19}
Data will be captured in a specially designed Excel data collection tool (Project EXCELEN-19 currently being conducted in the Hospital) by the study staff (LMPN), or their authorized surrogates. Double capture will be applied. Data will be stored in a Hospital's server with restricted access rights.

Con dentiality {27}
Participant's names will be collected only at admission, and will not be used for the study. A consecutive ID number and the patient unique le number (assigned by the Hospital database) will be used instead.
Plans for collection, laboratory evaluation and storage of biological specimens for genetic or molecular analysis in this trial/future use {33} The following diagram describes the planned collection of samples Blood samples will be collected by certi ed nursery personnel. Samples will be processed in three different ways: Fresh samples immediately processed in laboratory.
Serum collection and freezing at -80°C. Samples will be analyzed by ow cytometry at a later time Obtaining and preservation of leukocytes in DMSO at -80°C. Samples will be analyzed by ow cytometry at a later time.
Saliva and nasopharyngeal exudate samples will be collected by certi ed nursery personnel and frozen at -80°C. Samples will be analyzed for viral load at a later time.

Statistical methods for primary and secondary outcomes {20a}
The primary endpoint (Percentage of patients free of mechanically assisted ventilation [time frame: day 28]) will be compared between the 4 arms using a Cochran-Mantel-Haenszel test strati ed in time.
The secondary endpoints will be compared between arms as follows: Change rate in expression of proin ammatory cytokines and chemokines in different leukocyte subpopulations [Time frame: day 10-1]: One-way ANOVA will be used to compare change rate of each cytokine/chemokine. Additionally, a Principal Component Analysis (PCA) will be performed for cluster identi cation and their role in the response to treatment.
Change rate in the patterns of activation, tra cking and exhaustion in peripheral blood lymphocytes, monocytes and neutrophils [Time frame: day 10-1]: Data will be analyzed for subpopulations, percentages and mean uorescence intensities for each molecule By subsets: Gating using Flowing Software By clusters: PCA using RStudio Data will be controlled by confounding factors (BMI, sex, hypertension and diabetes). A Cox regression survival analysis adjusted by age, BMI, sex and comorbidities will be performed to estimate the relative risk of each of the following variables: Discharge by improvement or death, days of hospital stay and days free of ventilatory support.

Interim analyses {21b}
An interim analysis will be carried out when data from 50 patients had been processed. If such analysis has a minimum of 50% power, a group analysis will be performed, and the results will be published.

Methods for additional analyses (e.g. subgroup analyses) {20b}
Not Applicable since there are no subgroups Methods in analysis to handle protocol non-adherence and any statistical methods to handle missing data {20c} We are foreseeing no issues with non-adherence, because all the subjects are inpatients. To prevent inconsistencies or biases from missing data due to interruption of treatment, the modi ed intention to treat (mITT) will be calculated, based on the criterion of at least one dose taken and at least one measurement after basal of the endpoints.
Plans to give access to the full protocol, participant level-data and statistical code {31c} Access will be given on the basis of inter institutional exchanges upon request, for collaborative research purposes.
Oversight and monitoring Composition of the coordinating centre and trial steering committee {5d} The study will be monitored by the Committees of Ethics, Research and Biosafety of the Hospital General de México "Dr. Eduardo Liceaga" The Ethics Committee has a valid registration in the National Commission of Bioethics.
Composition of the data monitoring committee, its role and reporting structure {21a} The Quality Manager, and a MD from the Clinical Pharmacology service, along with their authorized surrogates, will form the Data Monitoring Committee. They will review the data and will check for consistency and completeness of the records.

Adverse event reporting and harms {22}
All adverse events will be immediately recorded and reported to the MDs who serve as O cials (MLHM, EOMH). They will assess if the AE is related to the medication under study, and if the participation of the patient should be terminated for safety reasons.
Frequency and plans for auditing trial conduct {23} Auditing will be a mixture of internal and external monitoring. Internal will be an in-house quality control, while external will assure international quality standards. Both will be performed on a regular basis during the protocol. Internal monitoring will be performed by inhouse personnel, whereas external will be carried out by a third independent party Plans for communicating important protocol amendments to relevant parties (e.g. trial participants, ethical committees) {25} Every relevant change to the protocol is of mandatory noti cation to the Committees of Ethics, Research and Biosecurity of the Hospital in the form of an amendment, which will be evaluated for approval.

Dissemination plans {31a}
The results will be available for the participants upon request. Publication in a peer-reviewed journal is being prepared. The process to register the protocol in the National Commission of National Institutes and High Specialty Hospitals (CCINSHAE for its acronym in Spanish) is already being completed.

Discussion
Despite it is known that blood samples of positive patients do not contain SARS CoV2 (5), they will be handled according to the Good Clinical Practice protocol for these samples, following the guidelines of a BSL-3 laboratory (6) and the o cial ruling NOM087 (7), applicable to our Normalized Operation Procedure PNO-CE-05 Trial status The submitted version of the protocol is 5.0, September 2020. Recruitment is estimated to start on the 1 of October 2020, and estimated to end on January 2021.

Declarations
The protocol will be funded by Federal Government funds as a part of the budget that the Hospital receives. Those documents are out of access to the authors. The funding party will have no involvement in the design of the study, analysis and interpretation of data, nor in writing the manuscript.

Availability of data and materials {29}
All data generated from this protocol will be kept in o cial Hospital computers. Only the members of the staff who work at the Hospital will have access to them (APG, MLHM, LMPN, EOMH, AMEG, AVO, MLH, GMLGA, RSL,

Consent for publication {32}
Not applicable since no details, images or videos relating to an individual person will be used in the publication Figure 1 The diagram describes the planned collection of samples. NPE: Nasopharyngeal Exudate