Preliminary Results of Tocilizumab and Interferon a-2b Treatment of SARS-CoV-2.

Seven patients receiving Hydroxychloroquine (HCQ) and Zinc (Zn) for CoVid-19 with PCR positive results were admitted to hospital after failing to improve. Following NCT04349410 protocol and failure to improve with elevated interleukin-6 and ferritin levels, patient’s treatment were changed following measurement of Corona Virus Pneumonia (CVP). Follow up measurements of CVP conrmed improvement with combined intravenous Tocilizumab, Interferon a-2b nebulizer, Atrovent nebulizer and SQ heparin treatments.


Introduction
Currently there are no clear treatment protocols for individuals infected with SARS-2 (CoVid-19). Multiple investigations are currently underway and social media is replete with commentary on the appropriate treatment regimen from anecdotal reports. Unfortunately clear evidence of treatment responses have focused only on survival data and discharge times. In this rst of several papers resulting from international investigation of CoVid-19 patients, we look at outcomes following failure of HCQ and Zn.

Methods
Recruitment of CoVid-19 patients began in April 2020 and completed ve months later. All patients were recruited from outside the United States. In addition to the original IRB approval of the protocol, each participating institution approved the study in accordance with the rules and regulations of their institution and country.
Entry into the study required a con rmed test for CoVid-19 de ned as a positive PCR and symptoms consisting of fatigue, dyspnea, myalgias and/or elevated temperature of 38 0 C.
On day-1 of entry into the study subjects underwent initial FMTVDM [1] measurement of corona virus pneumonia (CVP) and blood tests including ferritin and interleukin-6 levels. Following measurement patients were assigned one of 11-treatment arms shown in gure 1. Individuals in this subset all had elevated interleukin-6 (IL-6) and ferritin levels and were de ned as having an In ammoThrombotic response (ITR) to CoVid-19. According per protocol they were placed on treatment arms 7 and 9.
In this subset of patients, we looked at 7-patients who had initially received HCQ and Zn as outpatients and became symptomatically worse. They were admitted for further evaluation and treatment per protocol as de ned below.
TREATMENT Treatment with intravenous Tocilizumab 8mg/kg (not to exceed 800 mg) was infused over 60-minutes. If clinical improvement was not noted, an additional three doses were provided at 8-hour intervals for a total of 4-doses maximum.
Interferon a-2b 5 milllion units were provided by nebulizer every 12-hours in addition to Atrovent nebulizer treatments every 4-hours. Finally, heparin 5000 units subcutaneous (SC) were provided every 12-hours.

EVALUATION OF TREATMENT RESPONSE
Following 3-days of treatment these patients underwent a second FMTVDM measurement of CVP to determine treatment response. An increase in FMTVDM denotes deterioration and progress of CVP while a decrease in FMTVDM denoted improvement. An absence of change in FMTVDM indicates either a failed treatment response or stabilization of CVP [2].

Results
As shown in table 1, the study subset included 6 men and 1 woman ranging from 49 to 91 years of age (73 +/-13 years) with weights ranging from 79 to 95 kg (84.8 +/-5 kg). Two of the patients had known coronary artery disease (CVD) and ve had documented diabetes mellitus.
An example of FMTVDM measurements is shown in gure 2. Where more than one region of CVP was present, the greatest measurement was used denoting the greatest level of disease present in the individual on that date. Results from the rst set of measurements revealed an average FMTVDM of 182.86 +/-21.74. Following 3-days of treatment repeat FMTVDM measurements was 124.14 +/-8.82.
The results were statistically signi cantly different with a p-value of 0.0002.

Discussion
CoVid-19 has been responsible for the deaths of hundreds of thousands of people worldwide. These deaths are the result of In ammoThrombotic responses [3] resulting from immune activation following infection and replication of the virus.
In the absence of clinical trials and measurement of CVP many clinicians have been promoting and using anecdotal information to treat CoVid-19 patients. One popular treatment approach has been the use of HCQ and Zn in the outpatient setting. Participation in this clinical trial required con rmation of CoVid-19 by PCR testing; concurring signs and symptoms, and admission to a health care facility.
The hypothesis behind the proposed HCQ and Zn treatment is that (1) HCQ works by interfering with Sprotein binding, inhibition of glycoprotein IIb/IIIA, inhibition of the toll 7-receptor, interference with cytosol removal of viral envelope for viral replication, and enhancement of the Zn ionophore channel; and (2) Zn interference with viral replication and the p53 protein morphologic folding.
CVP is the result of both the attachment and replication of the virus and the immune response to the viral infection -both of which result in increased metabolic and regional blood ow changes that can be measured using FMTVDM -allowing for measurement of the severity of CVP and treatment responses. In these 7-individuals, each improved as shown by the reduction in FMTVDM numbers. We also note an appreciable variability in response to treatment as shown by the change in FMTVDM.
This small subset of patients represents the rst known reporting of individuals treated with HCQ and Zn as outpatients who subsequently required hospitalization for further treatment. Inclusion into the combined treatment arms required both the requirements to be entered into the study as well as elevated IL-6 and ferritin levels indicating ITR.
Since these patients had no prior outpatient FMTVDM, IL-6 or ferritin levels for comparison, treatment failure was determined by their lack of improvement and the reporting of symptoms worsening resulting in admission. We therefore cannot quantitatively state that they failed treatment with HCQ and Zn, only that they required admission and with worsening of symptoms were clinically determined to have failed HCQ and Zn treatment.
The combination of treatments including immune support, bronchodilator therapy, Tocilizumab and interferon a-2b makes it impossible to state whether the improvement seen was the result of one or a combination of these treatments.

Conclusion
To the best of our knowledge this is the rst reported study looking at patients anecdotally treated with HCQ and Zn who required hospitalization. It does not provide information about the numbers of patients that receive this treatment and were not admitted. It does demonstrate a potential treatment for patients with CVP who require hospitalization after failing outpatient treatment. In this instance each of the patients demonstrated improvement following treatment with Tocilizumab, Interferon a-2b, Atrovent and SQ heparin -all focusing on the reduction of viral replication and ITR. Further work is needed to determine the bene t of this treatment regimen. Figure 1 Treatment arms. Legend. Each participant received the same immune and respiratory support. Patients were randomly assigned one of 11 treatment arms unless there was evidence of In ammoThrombotic response (ITR). Patients with ITR were automatically assigned treatment including a combination of treatment arms 7 and 9.