Development of a novel, pan-variant aerosol intervention for COVID-19

  1. Robert H. Shoemaker
  2. Reynold A. Panettieri
  3. Steven K. Libutti
  4. Howard S. Hochster
  5. Norman R. Watts
  6. Paul T. Wingfield
  7. Philipp Starkl
  8. Lisabeth Pimenov
  9. Riem Gawish
  10. Anastasiya Hladik
  11. Sylvia Knapp
  12. Daniel Boring
  13. Jonathan M. White
  14. Quentin Lawrence
  15. Jeremy Boone
  16. Jason D. Marshall
  17. Rebecca L. Matthews
  18. Brian D. Cholewa
  19. Jeffrey W. Richig
  20. Ben T. Chen
  21. David L. McCormick
  22. Romana Gugensberger
  23. Sonja Höller
  24. Josef M. Penninger
  25. Gerald Wirnsberger

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Abstract

To develop a universal strategy to block SARS-CoV-2 cellular entry and infection represents a central aim for effective COVID-19 therapy. The growing impact of emerging variants of concern increases the urgency for development of effective interventions. Since ACE2 is the critical SARS-CoV-2 receptor and all tested variants bind to ACE2, some even at much increased affinity (see accompanying paper), we hypothesized that aerosol administration of clinical grade soluble human recombinant ACE2 (APN01) will neutralize SARS-CoV-2 in the airways, limit spread of infection in the lung and mitigate lung damage caused by deregulated signaling in the renin-angiotensin (RAS) and Kinin pathways. Here we show that intranasal administration of APN01 in a mouse model of SARS-CoV-2 infection dramatically reduced weight loss and prevented animal death. As a prerequisite to a clinical trial, we evaluated both virus binding activity and enzymatic activity for cleavage of Ang II following aerosolization. We report successful aerosolization for APN01, retaining viral binding as well as catalytic RAS activity. Dose range-finding and IND-enabling repeat-dose aerosol toxicology testing were conducted in dogs. Twice daily aerosol administration for two weeks at the maximum feasible concentration revealed no notable toxicities. Based on these results, a Phase I clinical trial in healthy volunteers can now be initiated, with subsequent Phase II testing in individuals with SARS-CoV-2 infection. This strategy could be used to develop a viable and rapidly actionable therapy to prevent and treat COVID-19, against all current and future SARS-CoV-2 variants.

One Sentence Summary

Preclinical development and evaluation of aerosolized soluble recombinant human ACE2 (APN01) administered as a COVID-19 intervention is reported.

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  1. Version published to 10.1101/2021.09.14.459961v2 on bioRxiv
  2. ScreenIT

    SciScore for 10.1101/2021.09.14.459961: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    EthicsIRB: All experiments involving SARS-CoV-2 or its derivatives were performed in Biosafety Level 3 (BSL-3) facilities at the Medical University of Vienna and performed after approval by the institutional review board of the Austrian Ministry of Sciences (BMBWF-2020-0.253.770) and in accordance with the directives of the EU.
    Sex as a biological variablenot detected.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.
    Cell Line AuthenticationAuthentication: Filter samples were analyzed for levels of APN01 using high performance liquid chromatography (HPLC) with UV wavelength detection according to a validated method.

    Table 2: Resources

    Experimental Models: Cell Lines
    SentencesResources
    After one-hour incubation at 37°C, the dilutions were transferred to wells containing Vero E6 target cells (MOI 0.001).
    Vero E6
    suggested: RRID:CVCL_XD71)
    Experimental Models: Organisms/Strains
    SentencesResources
    Activity of APN01 in a mouse model of SARS-CoV-2 infection: Ten-week-old BALB/c mice (Charles River) received daily intranasal treatments with 100 µg APN01 or the respective dilution of vehicle in endotoxin-free PBS (Gibco).
    BALB/c
    suggested: None
    Software and Algorithms
    SentencesResources
    Blank well readings were subtracted from sample dilution readings, and nonlinear regression to derive EC50 values was performed through a 4-parameter logistic equation by GraphPad Prism v.
    GraphPad Prism
    suggested: (GraphPad Prism, RRID:SCR_002798)

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    A limitation of our toxicology results is that only a single species of experimental animals is included. Additional confidence in the results could be generated by including non-human primates in the analysis. Of note, mice also did not show any signs of pathologies when they received APN01 or mouse soluble ACE2 into their respiratory system for 5 day efficacy studies. Moreover, the prior experience in clinical administration of APN01 in severe COVID-19 patients via the i.v. route, without serious adverse events (manuscript in preparation), supports moving ahead with Phase I testing using a conservative dose escalation strategy. A starting clinical dose of ¼ the maximum feasible concentration for 15 minutes provides an estimated 100-fold safety margin assuming 100% aerosol deposition when compared to the NO(A)EL observed in dogs. Escalation to twice per day and then increasing concentrations of ½ to the maximum feasible concentration is the anticipated design. A Phase I trial for safety and tolerability of aerosolized APN01 in healthy volunteers is currently underway (NCT number pending) which will be followed by Phase II trials in individuals infected with SARS-CoV-2. The latter trials will use viral clearance as the primary endpoint with severe disease and hospitalization as secondary endpoints. In summary, our study demonstrates both the potent preclinical activity of locally administered APN01 in a mouse model of COVID-19 as well as the feasibility and excellent safety p...

    Results from TrialIdentifier: We found the following clinical trial numbers in your paper:

    IdentifierStatusTitle
    NCT04335136CompletedRecombinant Human Angiotensin-converting Enzyme 2 (rhACE2) a…
    NCT04647695RecruitingIFN-beta 1b and Remdesivir for COVID19

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    Results from scite Reference Check: We found no unreliable references.

    About SciScore

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  3. Version published to 10.1101/2021.09.14.459961v1 on bioRxiv