In this Phase 2, open-label, randomized, multicenter study of patients with severe or critical COVID-19 pneumonia, Auxora, a novel, intravenously administered CRAC channel inhibitor, demonstrated a potential therapeutic benefit in mitigating the respiratory complications of COVID-19. At the recommendation of the US FDA, this study was halted prior to completion of the originally planned 120 patients in order to transition to a randomized, placebo-controlled, double-bind study.
CRAC channel activation in the pulmonary endothelium is linked to the breakdown of the alveolar-capillary barrier.7-9 CRAC channel activation also initiates the production and release of proinflammatory cytokines from immune cells.10,11 The resulting development of pulmonary edema, hypoxemia, and ultimately ARDS contributes to the significant morbidity and mortality seen in COVID-19 pneumonia, particularly in those who eventually require invasive mechanical ventilation.14,18 As demonstrated in animal models, inhibition of CRAC channels stabilizes pulmonary endothelial cells, blocks the release of proinflammatory cytokines and decreases vascular inflammation and permeability.7,9,14 Given the direct effects on the pulmonary endothelium and the indirect effects on proinflammatory cytokine production, Auxora may be an attractive therapy for the management of patients with severe COVID-19 pneumonia.7-9 Auxora has also demonstrated rapid distribution to the lungs, resulting in a fast onset of action that is reversible in 24 to 48 hours (unpublished observations).
The data available at the time of study termination indicate an encouraging safety profile for Auxora, with no increase in the proportion of patients experiencing AEs or SAEs when compared with standard of care. Furthermore, while the sample size was small, patients receiving Auxora appeared to have a more favorable clinical course than patients receiving standard of care as reflected by the rapid time to recovery, the decreased need for steroids, remdesivir, convalescent plasma, or invasive mechanical ventilation, and greater improvement in clinical outcomes as documented by the difference in 8-point ordinal scale. Analysis of the ordinal scale over time also suggested greater odds of improvement in patients treated with Auxora beginning on Day four, with the most pronounced clinical benefit in patients with a PaO2/FiO2 ratio between 101-200. These efficacy signals will need to be confirmed in a larger, double-blind, placebo-controlled study.
The ideal timing and duration of intervention in the course of COVID-19 pneumonia remains unknown.19 There are some concerns that premature immunomodulation may inhibit host anti-viral immunity and delay viral clearance, while delaying immunomodulation may prove futile if acute pulmonary injury is advanced. The PaO2/FiO2 ratio, imputed from the SpO2/FiO2, could serve as a simple means of determining both the optimal timing of intervention and the patients most likely to benefit16,17; it should be incorporated into other studies of therapies for COVID-19. Currently, patients are only being categorized by the receipt of either low flow supplemental oxygen or high flow supplemental oxygen, but this approach may not capture the severity of lung injury, may mask patients who are likely to respond to treatment and is limited by substantial inter-institution variations in practice.
Our findings, and those from recent remdesivir and RECOVERY trials, raise consideration for a two-pronged approach for the treatment of COVID-19 pneumonia.19,20 Preliminary results of remdesivir for the treatment of COVID-19 demonstrated reduced time to recovery, but treatment alone with an antiviral therapy is unlikely to be sufficient in improving outcomes.19 It may be possible, however, to improve patient outcomes by combining an antiviral treatment with immunomodulation to address the inflammatory response. Results from the RECOVERY trial demonstrated that after up to 10 days of receiving oral or intravenous dexamethasone once-daily, the 28-day mortality was lower than that in the usual care group among patients receiving invasive mechanical ventilation (29.3% vs. 41.4%, respectively) and among those receiving oxygen without invasive mechanical ventilation (23.3% vs. 26.2%, respectively).20 The 28-day mortality rates in the RECOVERY trial for patients receiving low flow supplemental oxygen versus high flow supplemental oxygen were not presented. Finally, there was a non-significant decrease in a composite outcome of death or invasive mechanical ventilation among patients not receiving invasive mechanical ventilation at randomization who were treated with dexamethasone compared to those treated with usual care (25.6% vs. 27.3%, respectively).20 As Auxora is associated with a rapid onset of action and a rapid cessation of action, it appears to work quickly to reduce proinflammatory cytokines while preserving pulmonary endothelial integrity, without excessive immunosuppression15 but further research is needed in patients with severe COVID-19 pneumonia. Coupled with the low 28-day mortality rate (10%) presented here, Auxora may allow for improved patient outcomes when used in combination with dexamethasone. Additional clinical trials are needed to understand the effect of these combinations of therapy.
The interpretation of the results of this study is limited by the open-label design and small sample size. Additionally, the significant imbalances in age and medical comorbidities between the three patients receiving Auxora and one patient receiving standard of care in Arm B prevented a meaningful direct comparison between the two groups with critical COVID-19 pneumonia. It was observed that the proportion of patients treated with Auxora who had diabetes, a co-morbidity associated with poorer outcome in COVID-19, was double that for patients receiving standard of care alone. Manufacturing and administration of a placebo was sacrificed given the need to initiate the study rapidly during the global pandemic with associated constraints on healthcare resources. These constraints, including adequate personal protective equipment, also limited the ability of research teams to obtain research-specific cytokine levels, which if obtained, may have further supported the mechanisms of Auxora.