Impact of a Monoamine Oxidase Inhibitor on the Phenotype of Blood Mononucleated Cells in Patients With COVID-19

Study Overview
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Brief Summary
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The principal objective is to determine the impact of phenelzine on the activation phenotype of T cells and myeloid cells during SARS-CoV2 infection

Detailed Description
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Investigators want to test in vitro (in France Stage 1), and in vivo in a phase 1b/2 clinical trial (Stage 2 in Australia) a widely used antidepressant (the monoamine oxidase inhibitor (MAOi) Phenelzine (Nardil*), repurposed as an antiviral drug to treat SARS-CoV-2. Indeed this proposal leverages extensive existing data on the epigenetic mechanism of action of phenelzine and new data suggesting that it has an anti-viral action against the SARS-CoV-2 virus. Epigenetic drugs are promising antiviral treatments capable of modifying epigenetic tags and re-programming host and viral genomes. Epigenetic modulation could be useful at least at two steps: the entry of the virus, and the regulation of the immune response. The SARS-Cov-2 depends on ACE2 and TMPRSS2 to gain cellular entry. The reduction of the expression of these proteins could therefore be protective. Recent clinical studies have demonstrated that, in addition to their effects on neurotransmitter regulation, anti-depressants also possess anti-inflammatory characteristics via impacting pro inflammatory cytokines production which are involved in the 'cytokines storm' during severe disease. (2). These patients also have fewer circulating functional T cells and NK cells and greater numbers of dysfunctional, exhausted CD8+ T cells (3). These abnormalities are probably deleterious and reduce the efficacy of anti-viral responses. The in-depth and patented epigenetic, cellular, and structural analyses of human cell lines harbouring the SARS-CoV-2 infective machinery and capable of propagating the virus have shown that: The epigenetic enzyme (histone demethylase) LSD1 directly regulates the SARS-CoV-2-binding domain of ACE2 and the protease active sites of TMPRSS2 (patented), which are critical for viral entry and propagation within the host. MAOi, which target LSD1 activity, inhibit the ACE2/TMPRSS2 machinery, which investigators hypothesize will prevent viral entry into the host cell to reduce viral load, disease burden, and the emergence of cytokine storms. In support of novel dual targeting viral blockage strategy recent work have shown that targeting TMPRSS2 or ACE2 alone has anti-viral activity (4). LSD1 inhibition with Phenelzine in recent, successfully completed phase 1B clinical demonstrate that Phenelzine reverses the dysfunctional T cell phenotype and restores durable memory responses in vivo in advanced, metastatic breast cancer patients. Importantly, no adverse impact on healthy volunteer immune systems was recorded as part of the phase 1B clinical trial (5). Preclinical data shows that aged individuals have exhausted T cells compared to young individuals and MAOi re-waken these T cells resembling younger people. Thus, investigators propose that in patients with severe COVID-19 infection, who are predominantly elderly; where dysfunctional T cells is also a feature, Phenelzine would have additional benefits on their immune function without adverse effects. Therefore, this proposal exploits a clear mechanism of action of Phenelzine: epigenetic regulation and is the first study to explore epigenetic mechanisms in SARS-CoV-2 infection. Modulation of the epigenetism could directly counteract the virus via an antiviral effect, and indirectly via the restoration of a functional immune response. Phenelzine has been used for nearly 60 years to treat major depressive disorder. Its side-effects, most of which are minor, are well characterized, including in the elderly or immune vulnerable. Investigators approach is highly flexible, since LSD1 inhibition targets two immune mechanisms - a specific viral uptake pathway and the efficacy of T cell responses. Give the safety and easy applicability of Phenelzine, it lends itself to combinatorial therapeutic approaches as and when other anti-viral show efficacy. From the mechanistic perspective, investigators epigenetic approach complements and contextualises genetic studies on COVID-19.

Official Title
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Impact of a Monoamine Oxidase Inhibitor on the Phenotype of Blood Mononucleated Cells in Patients With COVID-19

Conditions
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SARS-CoV2 Infection

Intervention / Treatment
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* Other: blood sample


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: 1. Individuals male or female ≥18 years of age at time of enrolment 2.Subject (or legally authorized representative provides non opposition form prior to initiation of any study procedure. 3. Understands and agrees to comply with planned study procedure. (Agrees to the collection of venous blood per protocol). 4. Has laboratory-confirmed SARS-CoV-2 infection as determined by PCR, or other commercial or public health assay in any specimen<72hours prior to enrollment and/or a chest CT scan reported as highly likely SARS-CoV2 infection. The different scales for severity are as follows: 5. Non severe patients: Clinical assessment (evidence of rales/crackles on exam) or CT scan involvement AND SpO2> 94% on room air, or ≤ 94% on room air but > 94% with nasal Oxygen with a flow rate <= 3l O2/min For the severe infection's patients' group: 6. Patients requiring mechanical ventilation and/or supplemental oxygen >= 6l O2/min For the obese patients 'group: 7. Obese patients will be defined as an BMI > 30 8. Co inclusion in non-interventional researches is possible Exclusion Criteria: Pregnant and breast-feeding women Patients previously treated by phenelzine (Nardil®) Persons unable to give their no opposition Persons under guardianship or curatorship No affiliated to social insurance. Inclusion in interventional researches

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Female, BMI≥30, mild<br>Females: Obese BMI≥30 With Mild infection n = 10 | Other: blood sample<br>* One blood sample of 60 mL (EDTA)<br>|
| Female, BMI≥30, severe<br>Females: Obese BMI≥30 With severe infection n = 10 | Other: blood sample<br>* One blood sample of 60 mL (EDTA)<br>|
| Female, BMI<30, mild<br>Females: Non-Obese BMI<30 With Mild infection n = 10 | Other: blood sample<br>* One blood sample of 60 mL (EDTA)<br>|
| Female, BMI<30, severe<br>Females: Non-Obese BMI<30 With severe infection n = 10 | Other: blood sample<br>* One blood sample of 60 mL (EDTA)<br>|
| male, BMI≥30, mild<br>males: Obese BMI≥30 With Mild infection n = 10 | Other: blood sample<br>* One blood sample of 60 mL (EDTA)<br>|
| male, BMI≥30, severe<br>males: Obese BMI≥30 With severe infection n = 10 | Other: blood sample<br>* One blood sample of 60 mL (EDTA)<br>|
| male, BMI<30, mild<br>males: Non-Obese BMI<30 With Mild infection n = 10 | Other: blood sample<br>* One blood sample of 60 mL (EDTA)<br>|
| male, BMI<30, severe<br>males: Non-Obese BMI<30 With severe infection n = 10 | Other: blood sample<br>* One blood sample of 60 mL (EDTA)<br>|
| Healthy donors from the EFS (Etablissement Français du Sang, St Louis)<br>Healthy donors from the EFS (Etablissement Français du Sang, St Louis) including 5 men and 5 women | Other: blood sample<br>* One blood sample of 60 mL (EDTA)<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| levels of lymphocytes T DR + CD38 + and of monocytes CD14 dim + CD16 +. | evaluate the levels of the activation of T cells and myeloid cells after phenelzine exposure by the levels of the % of DR+ CD38+ T cells and CD14+dim CD16+ monocytes. | through study completion, an average of 1 year | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| level of immune checkpoints | evaluate the levels of the expression of immune checkpoints on T cells by flow cytometry | through study completion, an average of 1 year | 
| cytokine production and proliferation | evaluate the modification of functional capacities of T cells by cytokines production, and proliferation, after mitogenic and antigen recall stimulations including SARS-CoV-2 antigens | through study completion, an average of 1 year | 
| levels of neutrophils | assess if there is an impact of phenelzine on the activation levels of neutrophils | through study completion, an average of 1 year | 
| level of immune responses in obese patients | Determine if the immune responses in obese patients (a strong risk factor for severe Covid19) can be modulated in the same way compared with lean patients | through study completion, an average of 1 year | 
| level of immune responses for men and women | Determine if the immune responses can be modulated in the same way in men and in women (men being affected by more severe disease) | through study completion, an average of 1 year | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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SARS-CoV2 Infection, Monoamine Oxidase Inhibitor, Activation phenotype of T and myeloid cells