Acute Estradiol and Progesterone Therapy in Hospitalized Adults to Reduce COVID-19 Severity: A Randomized Control Trial
Dragana Lovre, MD
Coronavirus SARS-CoV-2, causing COVID-19, has killed over 2.8 million people globally, including 550,000 in the US as of March 2021. Apart from corticosteroids, most available therapeutic options are at best marginally efficient in reducing disease severity and mortality and extremely expensive. Therefore, the systematic investigation of clinically approved drugs is a priority in order to determine what does improve the disease. Our current understanding of the disease is that COVID-19 deaths result from an inappropriate immune response leading to cytokine storm and resulting in multiorgan failure. Men with COVID-19 have a uniformly more severe outcome than women. It is established that women exhibit heightened immune responses to viral infections compared to men and that the main female steroids (17β-estradiol and progesterone) exhibit potent immuno-modulatory and anti-inflammatory actions. We hypothesize that a short treatment with the combination of well-studied, widely available and inexpensive estradiol (E2) and progesterone (P4) administered early and as a prevention in addition to standard of care (SOC), will prevent or mitigate the cytokine storm while increasing antibody production and prevent severe outcomes. This study aims to determine to what extent a short systemic E2P4 therapy, administered early to hospitalize and confirmed COVID-19 positive patients of both sexes in addition to SOC can reduce the severity of symptoms and outcomes compared to SOC alone. 120 patients will be enrolled in a 1:1 ratio of 5 day treatment with drug and placebo. Clinical status will be assessed at day 14 and day 28 and 60 with primary outcome of clinical improvement from moderate disease to mild disease on the 9-point World Health Organization ordinal scale. The study has been reviewed by the FDA and granted IND#152499.
Sex Differences in COVID-19 Outcomes: Role of Sex Hormones, Inflammation, Comorbidities, and Socio-demographics
Yilin Yoshida, PhD
Adult men of all ages are at higher risk of severe illness and death from coronavirus disease 2019 (COVID-19) compared to women. Sex differences in COVID-19 epidemiology are insufficiently understood. The lower mortality from COVID-19 in women may be due to the protective and immunomodulatory actions of female sex hormones. Post-menopausal women with COVID-19 may be at higher risk for adverse outcomes compared to those who were pre-menopausal. Moreover, menopause hormone therapy may protect against COVID-19 severe outcomes. Additionally, inflammatory biomarkers are likely to be associated with sex heterogeneity in COVID-19 severe outcomes. In previous studies, men were more likely to exhibit systemic inflammation compared to women, with increased procalcitonin, ferritin, a neutrophil-to-lymphocyte ratio (NLR) >6, and a greater percentage of monocytes. In our study of hospitalized COVID-19 patients in New Orleans, we found that increased NLR and ferritin were independent determinants of mortality in women only. In contrast, elevated D-dimer, a marker of hypercoagulability, was an independent predictor of severe outcomes or death in men, but not in women. Further, comorbidities, such as hypertension, diabetes, chronic pulmonary disease, and cardiovascular disease, associated with poor prognosis of COVID-19 are also known to produce higher mortality in men. Therefore, underlying comorbidities could contribute to the male-biased mortality from COVID-19. Finally, risk factors for COVID-19 outcomes may differ by sex across races/ethnicities and regions. The specific aims of this study are to:
- Determine if pre-menopausal status and menopausal hormone therapy are protective against COVID-19 severe outcomes
- Determine the sex-specific role of inflammatory biomarkers as determinants of COVID-19 severe outcomes
- Determine the sex-specific role of comorbidities alone or in combination in COVID-19 severe outcomes
- Assess the socio-demographic variations of sex difference in these associations.
This study will leverage the population-based datasets such as the Viral Infection and Respiratory Illness Universal Study (VIRUS) and the National COVID Cohort Collaborative (N3C) data, to examine COVID-19 epidemiology in a sex-specific manner. This analysis is expected to provide a new understanding of the biological, clinical, and social determinants of COVID-19 severity and the role of sex in COVID-19 outcomes across races/ethnicities and regions.