Clinical Trial of the Use of Anakinra in Cytokine Storm Syndrome Secondary to Covid-19 (ANA-COVID-GEAS)

This protocol has been prepared by the Systemic Autoimmune Diseases Group (GEAS) steering
committee from the Spanish Society of Internal Medicine (SEMI) in response to the current
urgent situation that are living in Spain because of the COVID-19 pandemic. The GEAS member
are experts in the treatment of autoinflammatory diseases and the use of biologic drugs in
general, and anakinra in particular. importantly, in Spain, internal medicine physicians are
currently involved in the treatment of patients infected with SARS-CoV-2.

The objective of this study is to investigate new possibilities to reduce the number of
patients requiring mechanical ventilation. This is intended to address the most urgent need
to preserve the access to intense care unit support to the lower possible number of patients
and may potentially reduce mortality.

In December 2019, a respiratory condition caused by what was later identified as a new
coronavirus (SARS-CoV-2) was detected in Wuhan Province, China. In these four months, the
virus has spread throughout the world's population, in more than 100 countries and affecting
thousands of people. The WHO declared in March that we were facing a pandemic because of this
virus, in which Europe could now be considered the epicenter. The strict containment measures
implemented in China, the mass detection of the virus with subsequent isolation of cases and
contacts that has been carried out in countries such as Singapore, Taiwan or South Korea seem
to have been useful in limiting the virus´ spread. Consequently, in our country, and given
the extension of the infection, a state of alarm has been decreed, at least for four weeks.
Despite the containment measures, numerous cases are still being diagnosed every day, with an
approximate lethality of 3.7%, especially in those considered at risk such as patients over
60 years of age and with comorbidities (Report nº 17. COVID-19 situation in Spain on 27 March
2020. COVID-19 team. SiViES. CNE. CNM. ISCIII).

When SARS-CoV-2 infects the respiratory tract, it causes the disease called COVID-19. From
the point of view of the natural evolution of the disease, this can be a mild respiratory
syndrome, which will occur in approximately 80% of cases, or a more serious disease, with the
appearance of pulmonary infiltrates and in some patients a respiratory distress with rapidly
progressive worsening. This second phase, which is only reached by a subgroup of patients, is
usually seen in the interval between day 7 and day 10 of the infection from the onset of
symptoms. So far, there is no proven explanation for this great variability in its clinical
expression.

The treatment used in our country so far is based on the combination of hydroxychloroquine,
azithromycin and antiretrovirals (protease inhibitors, lopinavir), based on previous
experiences. Several clinical trials are currently underway in Spain: PanCOVID-19
(Azithromycin + Hydroxychloroquine + lopinavir/ritonavir), GS-US-540-5774 (Remdesivir),
EFC16844 (Sarilumab) and WA42380 (Tocilizumab) as well as international projects such as
Discovery (NCT04315948), Solidarity and REMAP-CAP which include other treatment alternatives
such as interferon-beta-1B or Anakinra.

According to recent data from the Chinese cohorts, a subgroup of patients with COVID-19 shows
a very marked increase in inflammatory test data, such as lymphopenia, thrombocytopenia,
C-reactive protein (CRP) levels, lactate dehydrogenase (LDH), IL6 (> 40 pg / mL) and D-dimer
(> 0.28 μg / L), the latter two being predictive of the development of severe pneumonia
(sensitivity 93.3%, specificity 96.4%). Accumulating evidence suggests that a subgroup of
patients with severe COVID-19 might have a cytokine storm syndrome (CSS). In this group of
patients in which this "inflammatory profile" is detected, the damage observed is not a
direct consequence of the viral infection (viral necrotizing pneumonia) but rather a
secondary hyperimmune response, mainly related to the monocyte/macrophage activation, which
has also been observed in autopsy studies and previously in other infections by other types
of coronavirus. This CSS is superimoosable to that observed in patients with secondary
hemophagocytic lymphohistiocytosis (sHLH), often triggered by viral infections or macrophage
activation syndrome (MAS), secondary to systemic and autoinflammatory autoimmune diseases.

In this group of patients there is a significant release of pro-inflammatory cytokines,
including interleukin (IL) -1β and IL-6. Of these, IL-1β has a greater pathogenic relevance,
given that it promotes the inflammatory cascade and also induces the synthesis of several
inflammatory genes such as IL-6 itself, IL-8, MCP-1, COX-2, IκBα, IL-1α, IL-1β and MKP-1.
Numerous case reports and case series have been published supporting the use of IL-1β
blockade in the MAS. At this time, there is some experience in the treatment of COVID-19 in
the subgroup of patients in the inflammatory phase with Tocilizumab (IL-6 receptor blocker),
but no controlled studies have been completed as yet. However, IL-6 is not a key molecule in
the cytokine storm that triggers MAS.

Anakinra (IL-1Ra) is a recombinant IL-1 receptor antagonist with a very short half-life of
4-6 hours, requiring a daily subcutaneous injection of a 100 mg dose. It has also been shown
to reduce levels of other pro-inflammatory cytokines (including IL-6 and IL-18) and acute
phase reactants such as PCR and ferritin. Therefore, it has been used in the control of
autoinflammatory syndromes and in patients with MAS. In addition, data have been reported
from a phase 3 randomized controlled trial of IL-1 blockade with anakinra in sepsis with
characteristics of MAS, which showed a significant improvement in the 28-day survival rate
(65.4% anakinra vs. 35.3% placebo), with HR for death 0.28 (0.11-0.71, p = 0.0071), with no
increased adverse events.

As shown by the data available in the most recent literature generated from the Chinese
experience, and by the most recent data made available by the different Spanish hospitals
responsible for the management of these patients, hyper- inflammation, caused by a cytokine
storm resulting from an exaggerated response of the immune system to the presence of the
virus (CSS-like pneumonia), is considered to represent one of the most important negative
prognostic factor in patients infected with SARS-CoV-2. The inclusion criteria for COVID-19
used in this protocol is based on the analysis of routine blood chemistry data obtained from
patients with SARS-CoV-2 infection. This criterion has been designed with high sensitivity
(>90%) for patients who require ICU admission. This constitute the rationale for testing
drugs specifically targeted to reduce the cytokine storm.

This protocol has been prepared for the purpose of addressing the current medical emergency,
given the severity of the disease and the extremely high number of individuals affected. The
objective of this study is to investigate anakinra to reduce the number of patients requiring
mechanical ventilation. This is intended to address the most urgent need to preserve the
access to intense care unit support to the lower possible number of patients and may
potentially reduce mortality.

The potential applicability of the results of this clinical trial, in an extraordinary health
emergency such as COVID-19, is obvious. Positive results could help to define the standard
treatment of severe COVID-19 pneumonia and have a dramatic impact on both local and global
morbidity and mortality. Negative results would constitute very useful scientific evidence
for abandoning unfounded empirical approaches and would help redirect resources and efforts
in another more promising direction. The expected length of time needed for recruitment is
3-4 weeks, depending on the epidemiological progression of the pandemic in our centers, so
results could be available in early May 2020.

Anakinra is a recombinant form of the human IL-Ra, r-metHuIL-1Ra, which is produced by
recombinant DNA technology in an E. coli expression system. Therapeutically, anakinra
neutralizes the biological activity of IL-1 (IL-1α and IL-1β) by competitively inhibiting its
binding to the IL-1RI.

Kineret (anakinra) was first approved for treatment of RA in the US in 2001 and subsequently
in the EU/EEA in 2002. In 2012, an sBLA on anakinra for treatment of NOMID was approved in
the US. Kineret is also approved for treatment of CAPS (in EU/EEA, Israel and Australia),
Still's disease, including SJIA and AOSD (in EU/EEA) and SJIA (in Australia).

The initial IND for anakinra was granted in 1991. The estimated cumulative exposure to
anakinra in completed company sponsored clinical studies up to 1 May 2018 is 6404 subject-
years, in 8518 subjects with various indications. Anakinra is administered s.c. at doses of
100 mg/day (RA) or in weight-based doses of up to 8 mg/kg/day (NOMID). In clinical studies in
sepsis, doses up to 2 mg/kg/hour i.v. over 72 hours were administered to >500 patients and
were well tolerated.