Emerging pharmacological therapies for ARDS: COVID-19 and beyond
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NARRATIVE REVIEW
Emerging pharmacological therapies for ARDS: COVID‑19 and beyond Shahd Horie1, Bairbre McNicholas2, Emanuele Rezoagli1,3,4, Tài Pham5, Ger Curley6, Danny McAuley7,8, Cecilia O’Kane7, Alistair Nichol9,10,11, Claudia dos Santos12, Patricia R. M. Rocco13, Giacomo Bellani3,4 and John G. Laffey1,2* © 2020 Springer-Verlag GmbH Germany, part of Springer Nature
Abstract ARDS, first described in 1967, is the commonest form of acute severe hypoxemic respiratory failure. Despite considerable advances in our knowledge regarding the pathophysiology of ARDS, insights into the biologic mechanisms of lung injury and repair, and advances in supportive care, particularly ventilatory management, there remains no effective pharmacological therapy for this syndrome. Hospital mortality at 40% remains unacceptably high underlining the need to continue to develop and test therapies for this devastating clinical condition. The purpose of the review is to critically appraise the current status of promising emerging pharmacological therapies for patients with ARDS and potential impact of these and other emerging therapies for COVID-19-induced ARDS. We focus on drugs that: (1) modulate the immune response, both via pleiotropic mechanisms and via specific pathway blockade effects, (2) modify epithelial and channel function, (3) target endothelial and vascular dysfunction, (4) have anticoagulant effects, and (5) enhance ARDS resolution. We also critically assess drugs that demonstrate potential in emerging reports from clinical studies in patients with COVID-19-induced ARDS. Several therapies show promise in earlier and later phase clinical testing, while a growing pipeline of therapies is in preclinical testing. The history of unsuccessful clinical trials of promising therapies underlines the challenges to successful translation. Given this, attention has been focused on the potential to identify biologically homogenous subtypes within ARDS, to enable us to target more specific therapies ‘precision medicines.’ It is hoped that the substantial number of studies globally investigating potential therapies for COVID-19 will lead to the rapid identification of effective therapies to reduce the mortality and morbidity of this devastating form of ARDS. Keywords: Pharmacologic therapy, Acute respiratory failure, Acute respiratory distress syndrome, Coronavirus, Mesenchymal stromal cells Introduction Acute respiratory distress syndrome (ARDS) is the commonest form of acute severe hypoxemic respiratory failure in the critically ill. First described in 1967, the *Correspondence: [email protected] 1 Lung Biology Group, Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, Biomedical Sciences Building, National University of Ireland, Galway, Ireland Full author information is available at the end of the article Shahd Horie and Bairbre McNicholas joint first authors.
management of ARDS remains supportive [1]. Despite considerable advances in our knowledge regarding the pathophysiology of ARDS
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