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      Nafamostat mesylate treatment in combination with favipiravir for patients critically ill with Covid-19: a case series

      , 1 , 2 , 1 , 2 , 3 , 1 , the COVID-UTH Study Group 1 , 2 , 3 , 4 , 5 , 6

      Critical Care

      BioMed Central

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          Abstract

          Development of specific therapy against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is urgently required. Several drugs such as antimalarial and anti-Ebola virus drugs are under investigation for coronavirus disease 2019 (Covid-19). Transmembrane protease serine 2 (TMPRSS2) plays a crucial role for SARS-CoV-2 entry into the cytoplasm [1]. Inhibition of TMPRSS2 protease activity is assumed to prohibit viral entry of SARS-CoV-2. Through high-throughput screening of 1017 existing drugs, a clinically available serine protease inhibitor nafamostat mesylate was identified as a potent inhibitor of Middle East respiratory syndrome coronavirus entry into human epithelial cells [2]. More recently, nafamostat mesylate was shown to inhibit the entry of SARS-CoV-2 into the human epithelial cells at EC50 of ~ 10 nM [3, 4]. Nafamostat mesylate has been clinically used for the treatment of acute pancreatitis and disseminated intravascular coagulation in Japan. By intravenous administration, its blood concentrations are maintained at 30–240 nM, which are sufficient to block the virus entry [3]. An anti-influenza A H1N1 virus drug favipiravir exhibits antiviral activity against other RNA viruses and therefore is expected to have antiviral action against SARS-CoV-2. This drug has been approved in Japan for novel influenza virus disease. Eleven adults with reverse transcriptase polymerase chain reaction-confirmed SARS-CoV-2 infection were admitted to the intensive care unit (ICU) at The University of Tokyo Hospital between April 6 and April 21, 2020, and treated with nafamostat mesylate in combination with favipiravir. The demographic and clinical characteristics and the laboratory and radiologic findings at ICU admission are listed in Table 1. All the patients needed oxygen therapy. Eight patients (73%) needed invasive mechanical ventilation (MV), and 3 patients (27%) needed venovenous extracorporeal membrane oxygenation (VV-ECMO). Table 1 Clinical characteristics, laboratory data, and imaging results at ICU admission Characteristic Measurement Age, median (IQR), years 68 (60–69) Male, no. (%) 10 (91%) Body weight, median (IQR), kg 71 (69–82) Number of patients with coexisting disorders, no. (%)  Asthma 0 (0%)  Cancer 1 (9%)  Chronic kidney disease 0 (0%)  Chronic obstructive pulmonary disease 1 (9%)  Diabetes mellitus 3 (27%)  Hypertension 4 (36%) Duration of symptoms before admission, median (IQR), days 8 (7–11) Number of patients with symptoms, no. (%)  Fever 9 (82%)  Cough 5 (45%)  Shortness of breath 8 (73%) Laboratory data  White blood cell count, median (IQR), per mm3 6900 (5800–10,850)  Lymphocyte count, median (IQR), per mm3 851 (759–1164)  Hemoglobin, median (IQR), g/dl 15.0 (13.5–16.3)  Platelet count, median (IQR), per mm3 19.6 (18.6–26.4)  Lactate dehydrogenase level, median (IQR), U/l 518 (417–752)  Aspartate aminotransferase level, median (IQR), U/l 54 (49–90)  Alanine aminotransferase level, median (IQR), U/l 47 (35–58)  Serum creatinine level, median (IQR), mg/dl 0.85 (0.70–1.03)  Creatinine kinase level, median (IQR), U/l 213 (129–579)  Prothrombin time, median (IQR), international normalized ratio 1.08 (1.03–1.13)  Activated partial thromboplastin time, median (IQR), s 28.8 (28.4–32.1) d-dimer level, median (IQR), μg/dl 1.4 (1.1–11.8)  PaO2/FiO2 ratio, median (IQR) 131 (114–198)  SOFA score, median (IQR) 3.0 (2.5–4.5)  APACHE II score, median (IQR) 14.0 (12.0–15.5) Computed tomography findings  Patients with consolidation, no. (%) 6 (55%)  Patients with ground-glass opacities, no. (%) 10 (91%)  Patients with pulmonary infiltration, no. (%) 2 (18%) APACHE Acute Physiology and Chronic Health Evaluation, FiO 2 fraction of inspired oxygen, ICU intensive care unit, IQR interquartile range, PaO 2 partial pressure of arterial oxygen, SOFA sequential organ failure assessment Patients received combination treatment with nafamostat mesylate [0.2 mg per kg per hour by continuous intravenous infusion, median treatment 14 days (IQR, 10 to 14 days)] and favipiravir [3600 mg on day 1 and at 1600 mg per day on day 2 and subsequently median treatment 14 days (IQR, 12 to 14 days)]. No interruption of antiviral treatment occurred due to adverse drug reactions except for one patient who developed hyperkalemia on day 9 (by nafamostat mesylate). All 11 patients had at least 33 days of hospital follow-up. As of May 22, 1 patient, who had a do-not-resuscitate order, died on ICU day 7. Seven patients were successfully weaned from MV [median duration of MV 16 days (IQR, 10 to 19 days)] and 9 and 7 patients were discharged from the ICU and the hospital, respectively (Fig. 1). Fig. 1 Respiratory support and outcomes of individual patients. As of May 22, 2020, 1 patient had died, while 7 patients had been extubated. All the patients receiving follow-up monitoring for at least 33 days. ICU, intensive care unit; ECMO, extracorporeal membrane oxygenation; IMV, invasive mechanical ventilation; DNR, do-not-resuscitate This is the first report on nafamostat mesylate treatment in combination with favipiravir against Covid-19. In comparison with previous reports about critically ill patients with Covid-19, our case series also demonstrated a high number of patients (8 [73%]) who required MV requirement; however, the mortality rate was low (1 patient [9%]). Patients with severe Covid-19 often suffer from microvascular thrombosis and hemorrhage with extensive alveolar and interstitial inflammation in the lung [5]. Nafamostat mesylate might thus be effective, because it inhibits intravascular coagulopathy, in addition to directly targeting the virus entry in host epithelial cells. In conclusion, nafamostat mesylate therapy in combination with favipiravir may allow blockade of virus entry and replication, as well as inhibition of pathogenic host response, i.e., hyper-coagulopathy. Although the number of patients in this case series was very small, this low mortality rate suggests that combination treatment of favipiravir and nafamostat mesylate may be effective for critically ill Covid-19 patients. A clinical trial for the combination treatment of nafamostat mesylate and favipiravir against Covid-19 will be initiated in Japan (jRCTs031200026).

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          Author and article information

          Contributors
          kdoi-tky@umin.ac.jp
          COVID.UTH@gmail.com
          Journal
          Crit Care
          Critical Care
          BioMed Central (London )
          1364-8535
          1466-609X
          3 July 2020
          3 July 2020
          2020
          : 24
          Affiliations
          [1 ]GRID grid.26999.3d, ISNI 0000 0001 2151 536X, Department of Acute Medicine, , Graduate School of Medicine, The University of Tokyo, ; 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033 Japan
          [2 ]GRID grid.412708.8, ISNI 0000 0004 1764 7572, Department of Infection Control and Prevention, , The University of Tokyo Hospital, ; 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655 Japan
          [3 ]GRID grid.26999.3d, ISNI 0000 0001 2151 536X, Department of Infectious Diseases, , Graduate School of Medicine, The University of Tokyo, ; 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033 Japan
          [4 ]GRID grid.26999.3d, ISNI 0000 0001 2151 536X, Department of Molecular Pathology, Graduate School of Medicine, , The University of Tokyo, ; Tokyo, Japan
          [5 ]GRID grid.26999.3d, ISNI 0000 0001 2151 536X, Department of Gastrointestinal Surgery, Graduate School of Medicine, , The University of Tokyo, ; Tokyo, Japan
          [6 ]GRID grid.26999.3d, ISNI 0000 0001 2151 536X, Senior Professor Office, Graduate School of Medicine, , The University of Tokyo, ; Tokyo, Japan
          Article
          3078
          10.1186/s13054-020-03078-z
          7332736
          © The Author(s) 2020

          Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

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          © The Author(s) 2020

          Emergency medicine & Trauma

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