Angiotensin Receptor Blockers for the Treatment of Covid-19: Pragmatic, Adaptive, Multicentre, Phase 3, Randomised Controlled Trial

Overview

Journal BMJ

Specialty General Medicine

Date 2022 Nov 17

PMID 36384746

Authors

Meg J Jardine

Sradha S Kotwal

Abhinav Bassi

Carinna Hockham

Mark Jones

Arlen Wilcox

Carol Pollock

Louise M Burrell

James McGree

Vinay Rathore

Christine R Jenkins

Lalit Gupta

Angus Ritchie

Ashpak Bangi

Sanjay DCruz

Andrew J McLachlan

Simon Finfer

Michelle M Cummins

Thomas Snelling

Vivekanand Jha

Affiliations

Soon will be listed here.

Abstract

Objective: To determine whether disrupting the renin angiotensin system with angiotensin receptor blockers will improve clinical outcomes in people with covid-19.

Design: CLARITY was a pragmatic, adaptive, multicentre, phase 3, randomised controlled trial.

Setting: 17 hospital sites in India and Australia.

Participants: Participants were at least 18 years old, previously untreated with angiotensin receptor blockers, with a laboratory confirmed diagnosis of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection who had been admitted to hospital for management of covid-19.

Intervention: Oral angiotensin receptor blockers (telmisartan in India) or placebo (1:1) for 28 days.

Main Outcome Measures: The primary endpoint was covid-19 disease severity using a modified World Health Organization Clinical Progression Scale (WHO scale) at day 14. Secondary outcomes were WHO scale scores at day 28, mortality, intensive care unit admission, and respiratory failure. Analyses were evaluated on an ordinal scale in the intention-to-treat population.

Results: Between 3 May 2020 and 13 November 2021, 2930 people were screened for eligibility, with 393 randomly assigned to angiotensin receptor blockers (of which 388 (98.7%) to telmisartan 40 mg/day) and 394 to the control group. 787 participants were randomised: 778 (98.9%) from India and nine (1.1%) from Australia. The median WHO scale score at day 14 was 1 (interquartile range 1-1) in 384 participants assigned angiotensin receptor blockers and 1 (1-1) in 382 participants assigned placebo (adjusted odds ratio 1.51 (95% credible interval 1.02 to 2.23), probability of an odds ratio of >1 (Pr(OR>1)=0.98). WHO scale scores at day 28 showed little evidence of difference between groups (1.02 (0.55 to 1.87), Pr(OR>1)=0.53). The trial was stopped when a prespecified futility rule was met.

Conclusions: In patients admitted to hospital for covid-19, mostly with mild disease, not requiring oxygen, no evidence of benefit, based on disease severity score, was found for treatment with angiotensin receptor blockers, using predominantly 40 mg/day of telmisartan.

Trial Registration: ClinicalTrials.gov NCT04394117.

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