Immunoadsorption Study Mainz in Adults With Post-COVID Syndrome (IAMPOCO)

Johannes Gutenberg University (JGU)

Status: Active, not recruiting

Conditions: Post COVID-19 Condition; Post-COVID Syndrome; Post-COVID-19 Syndrome

Treatments: Device: Sham-apheresis; Device: Immunoadsorption

Study type: Interventional

Funder types: Other

Identifiers

NCT05841498

IAMPOCO

Details and patient eligibility

About

The aim of this study is to evaluate the efficiency and safety of immunoadsorption for the treatment of post-COVID syndrome (PCS).

Efficacy will be measured (1) subjectively as an improvement of the score of questionnaires like the multidimensional fatigue inventory (MFI-20), Chalder fatigue scale, Bell-score, modified medical research council dyspnea scale (mMRC) and the Post-COVID functional scale (PCFS) and (2) objectively as an improvement in neurocognitive testing with the Montreal cognitive assessment (MoCA) and the improvement of the hand-grip strength.

40 participants with symptoms of PCS and a PCFS score of at least 2 will be included in each group (Addendum from February 2024: An additional 40 patients with the same inclusion and exclusion criteria will be treated using the devices and materials of another manufacturer, following the same design, and the results will be evaluated separately.). After excluding other causes of the symptoms and evaluating the baseline burden of symptoms, each participant will undergo 5 sessions of immunoadsorption with an immunoglobulin-binding adsorber and 5 sham treatments, or vice versa. The order of treatments (immunoadsorption first or sham first) will be randomized. Each participant will be blinded to the type of treatment they receive. An 8-week therapy-free period will separate the two treatment blocks. All examinations will be conducted before the first treatment, 2 weeks after the first treatment cycle, before the second treatment cycle, and 2 and 6 weeks after the second treatment cycle.

The results of the study will inform future treatment strategies for PCS and will contribute to a better understanding of the pathophysiological insights behind the ongoing symptoms.

Full description

Post-COVID syndrome (PCS) refers to symptoms that develop 3 months from the onset of COVID-19 with symptoms that last for at least 2 months and cannot be explained by an alternative diagnosis (Soriano, Murthy et al. 2022). The nature of the symptoms has not been a factor in the definition of PCS. The prevalence of PCS is estimated to be 43% of all severe acute respiratory syndrom coronavirus 2 (SARS-COV-2)-infected patients, with hospitalized patients more likely to suffer from persistent symptoms (54%) than non-hospitalized patients (32%). Women are more likely to experience PCS than men (incidence, 49% vs 32%, respectively) (Chen, Haupert et al. 2022). The most common symptoms are fatigue (23%), memory impairment (14%), dyspnea (13%), sleep disturbances (11%), and joint pain (10%) (Chen, Haupert et al. 2022). Headaches, myalgia, anxiety or depression are also frequently reported.

In terms of the type, variety and duration of symptoms, PCS resembles a clinical picture observed after various viral infections, such as Eppstein-Barr virus, herpes simplex virus or influenza virus, namely myalgic encephalomyelitis and chronic fatigue syndrome (ME/CFS). Here, too, patients mainly suffer from fatigue, impaired concentration and memory, and non-restorative sleep. Some authors consider post-COVID as a form of ME/CFS triggered by the SARS-CoV-2 infection or the immune response to the infection. The underlying pathophysiology likely depends on the different viruses but is incompletely understood. Similarly, the causes of PCS are unclear to date. Autoimmunity is suspected to play a major role in all post-virus syndromes. It may be triggered by the defense against infections and is probably maintained by similarity of endogenous proteins with pathogen components (molecular mimicry). In the context of this autoimmunity, antibodies against endogenous structures can also be formed, such as antinuclear antibodies, which are directed against components of the cell nuclei. Antibodies against α- and β-adrenergic receptors and muscarinic acetylcholine receptors, among others, have been detected in patients suffering from ME/CFS as well as in patients with PCS.

Many patients are limited in their daily lives by the symptoms that develop or persist after SARS-COV-2-infection and suffer from a diminished quality of life. To date, there is little evidence on potential therapies for these complaints. Immunoadsorption (IA) efficiently removes (auto-)antibodies from the circulation and has been proposed as a potential therapy for PCS. The current trial will investigate the efficacy of IA for the treatment of PCS.

40 participants with PCS and a PCFS-score of at least 2 will be included in each. Each participant will undergo 5 sessions of IA with an immunoglobulin-binding adsorber and 5 sham treatments or vice versa. Sham treatment will be performed in the same ways as IA, but the IA device will not be set up with an adsorber. The order of treatments (immunoadsorption first or sham first) will be randomized. The participants are blinded to the order of treatments. An intervention-free interval of 8 weeks will separate both treatment blocks (Addendum from February 2024: 40 patients additional with the same inclusion and exclusion criteria will be treated using the devices and materials of another manufacturer, following the same design, and the results will be evaluated separately.).

The primary outcome of the study is the efficacy of IA vs. sham, measured as changes in the PCFS (0-4), Chalder-fatigue scale (0-33), MFI-20 (20-100), Bell score (0-100), montreal cognitive assesment and the hand-grip strength before therapy compared to values after immunoadsorption and after sham-treatment. Secondary outcomes are (1) the number and severity of adverse events, (2) the prevalence of auto-antibodies like antinuclear antibodies, antibodies against adrenoreceptors and antibodies against muscarinic acetylcholine receptors in patients with PCS and (3) the change in concentration of the auto-antibodies in context of therapy and sham-treatment. In addition, various assessments (Complete blood count with differential, Antinuclear antibody Thyroid-stimulating hormone, C-reactive protein, Vitamin B12, Vitamin D, 25-dihydroxy, Ferritin, Urinalysis, ECG, spirometry, psychological questionaires) will be performed during screening period to be able to exclude other diseases as the cause of the PCS symptoms. In addition, safety-relevant parameters such as heart rate, blood pressure, electrolyte concentra-tions, fibrinogen concentration and the concentration of the immunoglobulin fractions are measured before and after each treatment.

The results of the study will inform future treatment strategies for PCS and will contribute to a better understanding of the pathophysiological insights behind the ongoing symptoms.

Enrollment: 40 patients

Sex: All

Ages: 18 to 70 years old

Volunteers: No Healthy Volunteers

Inclusion criteria

• Meeting the WHO diagnostic criteria for PCS
• Written informed consent to participate in the study
• Previous participation in the Gutenberg Post-Covid Study or previously conducted comparable preliminary examinations
• Minimum age of 18 years
• Value on the Post-COVID functional scale of at least 2

Exclusion criteria

• Psychiatric diagnosis
• Allergy to adsorber materials, materials of the tubing systems or to the substances used for immunoadsorption
• Pregnancy
• Medical contraindications to immunoadsorption such as severe blood clotting disorders or immunodeficiency syndromes
• Existing antibody-mediated autoimmune disease
• Intake of ACE-inhibitors 7 days prior to the inclusion in to the study or during the study period

Trial design

Primary purpose: Treatment

Allocation: Randomized

Interventional model: Crossover Assignment

Masking: Single Blind

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40 participants in 2 patient groups

Immunoadsorption

Active Comparator group

Description:

Immunoadsorption will be conducted with the Plasauto Sigma extracorporeal therapy system in combination with the TR-350 adsorber (Addendum February 2024: or with the Miltenyi Life-21 system in combination with the Ig-Omni adsorber) over 7 days (3 times daily, 2 times every other day). During each session 2-2.5 times the participant's plasma volume will be treated. This therapy regimen is proven by studies with groups of patients suffering from other autoimmune diseases (Boedecker, Luessi et al. 2022). The material needed for the immunoadsorption is provided by Diamed, the provider of Plasauto Sigma and TR-350 adsorber (Addendum February 2024: or by Miltenyi Biotec, the Provider of Life-21 and IgOmni) . To exclude possible beneficial or adverse effects of heparin on participants' symptoms, regional anticoagulation will be performed using citrate. This is a cross-over study: Each participant will receive immunoadsorption and sham treatment with a wash-out period of 8 weeks in between.

Treatment:

Device: Immunoadsorption

Sham-apheresis

Sham Comparator group

Description:

The sham procedure will also be conducted with the Plasauto Sigma extracorporeal therapy system (Addendum February 2024: or the Miltenyi Life-21 therapy system) without an inserted adsorber. To ensure that sham treatment is indistinguishable from immunoadsorption for the subjects, the therapy regimen is identical except for the missing adsorber. For both verum therapy and sham procedure, the devices are placed behind a portable wall and covered with a curtain not visible to the patient. However, since the setup of the machines differs depending on the procedure, it is not possible to blind the supervising staff as well. To exclude possible beneficial or adverse effects of heparin on participants' symptoms, regional anticoagulation will be performed using citrate. If a subject does not have sufficiently large peripheral veins, a large-bore central venous catheter will be placed for both IA and sham treatments.

Treatment:

Device: Sham-apheresis