pathogens
Article
Prescription of Anti-Spike Monoclonal Antibodies in
COVID-19 Patients with Resistant SARS-CoV-2 Variants in Italy
Daniele Focosi 1, * and Marco Tuccori 2
Citation: Focosi, D.; Tuccori, M.
Prescription of Anti-Spike
Monoclonal Antibodies in COVID-19
Patients with Resistant SARS-CoV-2
Variants in Italy. Pathogens 2022, 11,
823. https://doi.org/10.3390/
pathogens11080823
Academic Editors: Meng Yuan and
Xueyong Zhu
Received: 14 June 2022
Accepted: 21 July 2022
Published: 22 July 2022
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4.0/).
Pathogens 2022, 11, 823. https://doi.org/10.3390/pathogens11080823
1 North-Western Tuscany Blood Bank, Pisa University Hospital, 56124 Pisa, Italy
2 Division of Pharmacovigilance, Pisa University Hospital, 56124 Pisa, Italy; marco.tuccori@gmail.com
* Correspondence: daniele.focosi@gmail.com
Abstract: Anti-Spike monoclonal antibodies have been considered a promising approach to COVID-
19 therapy. Unfortunately, the advent of resistant lineages jeopardized their effectiveness and
prompted limitations in their clinical use. Change in the dominant variant can be fast to such
an extent that, in the absence of timely medical education, prescribers can keep using these drugs for
relatively long periods even in patients with resistant variants. Therefore, many patients could have
been exposed to drugs with unlikely benefits and probable risks. We show here that about 20% of
bamlanivimab+etesevimab, 30% of casirivimab+imdevimab, and 30% of sotrovimab courses were
administered in Italy during periods in which a fully resistant variant was dominant. Additionally,
for monoclonal antibody cocktails, the vast majority of usage occurred against variants for which
one of the mAbs within the cocktail was ineffective. Given the high costs of these drugs and their
potential side effects, it would be important to consider a frequent review of the appropriateness of
these drugs and timely communication when the benefit/risk balance is no longer favorable.
Keywords: SARS-CoV-2; COVID-19; monoclonal antibodies; bamlanivimab; etesevimab; casirivimab;
imdevimab; sotrovimab; tixagevimab; cilgavimab; Ronapreve™; Evusheld™
1. Introduction
Anti-SARS-CoV-2 Spike monoclonal antibody (mAb), either as monotherapy or as
a cocktail of mAbs, was a pillar of COVID-19 outpatient treatments in the second half
of 2021, when sensitive variants of concern (VOCs) ravaged the globe. As for any other
European Medicine Agency (EMA) member nations, the Italian Drug Agency (Agenzia
Italiana del Farmaco, AIFA) promptly granted mAb authorization. Despite growing evi-
dence of treatment-emergent resistance [1,2], the use of mAbs continued even after oral
antivirals became available, particularly in frail patients with contraindications to the use
of small molecule antivirals. Unfortunately, the advent of the Omicron VOC led to a loss of
effectiveness for most of the authorized mAbs [3–6].
While randomized controlled trials (RCT) that led to product authorization by regu-
latory authorities were led at the time of sensitive VOCs, in vitro data have consistently
shown that the Omicron BA.1 VOC was notoriously resistant to both bamlanivimab and
etesevimab [7–17] and casirivimab plus imdevimab [7–14,18,19], while the Omicron BA.2
VOC is notoriously resistant to sotrovimab [20–25].
The tixagevimab plus cilgavimab mAb cocktail, approved to date only for pre-exposure
prophylaxis, represents a special case: while the tixagevimab component has been inef-
fective against any Omicron sublineage so far (BA.1 [7,10–13,16,26], BA.2 [26,27], and
BA.4/BA.5 [26,28]), the cilgavimab component is ineffective against BA.1 [7,10–13,16] and
BA.4/BA.5 [26,28] but has preserved efficacy against BA.2 [26,27]. A similar scenario
occurred for both the other two mAb cocktails. Against the Beta and Gamma VOC, casiriv-
imab lost in vitro activity [29–31] while imdevimab [30–33] preserved it. Against the Delta
https://www.mdpi.com/journal/pathogens
Pathogens 2022, 11, 823 2 of 8

VOC, bamlanivimab lost in vitro activity [34–39], but etesevimab preserved it [37]. Un-
der these scenarios, the chances for immune escape much grow, theoretically as when
delivering a monotherapy [1,40].
Total changes in dominant VOCs were relatively fast (once every 2–3 months), ques-
tioning whether continued medical education was timely in place to avoid hazardous
and expensive prescriptions. While only a few patients had viral genome sequencing
performed to confirm definitive resistance, statistical inferences can be made moving from
prevalences detected by epidemiological surveillance. In this article, we investigated the
use of anti-SARS-CoV-2 Spike mAbs in patients affected by resistant SARS-CoV-2 VOCs
in Italy.

2. Materials and Methods

We collected prevalence data of different SARS-CoV-2 variants in Italy from the reports
of the flash surveys led by the Italian Istituto Superiore di Sanità (ISS) from 25 May 2021
to 27 May 2022, available at https://www.iss.it/web/guest/cov19-cosa-fa-iss-varianti
(accessed on 15 June 2022). Briefly, according to the indications from the Italian Ministry
of Health, every 15 days about 2000 newly diagnosed COVID-19 patients with positive
RT-PCR are further processed with whole-genome sequencing (WGS), and the sequences
are attributed to PANGOLIN phylogeny using a dedicated web portal (ICOGEN).
We collected absolute prescription counts for each authorized anti-Spike mAb (or
mAb cocktail) from the Italian Drug Agency (Agenzia Italiana del Farmaco, AIFA) web
portal, available at https://www.aifa.gov.it (accessed on 15 June 2022). The monitoring
registry was established according to a Ministry of Health decree issued on 6 February
2021. Briefly, every 7 days (every 15 days since May 2022) a report is issued showing the
cumulative count of prescriptions for each anti-Spike mAb. In order to keep the graph at
a weekly sampling, 15-day counts were manually estimated as 7-day counts, assuming a
homogenous within-period daily distribution. In order to account for the high standard
deviation related to the small sample size, we considered two different thresholds of SARS-
CoV-2 VOC diffusion in the population (50% and 99%) to identify periods in which the
prescriptions of the mAbs could have likely occurred in patients harboring a resistant VOC.

3. Results
Figure 1 shows the changes in the prevalence of SARS-CoV-2 VOC in time in Italy
according to flash survey reports. Based on established thresholds of SARS-CoV2 variant
diffusion, we identified 20 June 2021 as the date in which the Delta variant accounted for
50% of the infections and 15 August 2021 as the date in which the Delta variant accounted
for 99% the of infections. The dates of Omicron BA.1 and BA.23 of
Pathogens 2022, 11, x FOR PEER REVIEW
50%
9
diffusions were
20 December 2021 and 20 March 2022, respectively. The dates of Omicron BA.1 and BA.2
99% diffusions were 31 January 2022 and 4 May 2022, respectively.

Figure
Figure 1. Prevalence of various
1. Prevalence SARS-CoV-2
of various variants in Italy
SARS-CoV-2 since December
variants 2020 according
in Italy since Decemberto ISS2020 according to ISS
flash
flashsurveys
surveysreports.
reports.
Figure 2 shows that in Italy about 60% of the bamlanivimab plus etesevimab cocktail
was prescribed while Delta was dominating (hence making bamlanivimab delivery inap-
propriate), and that about 20% was prescribed at the time the fully resistant VOC BA.1
was dominating. Figure 3 shows that about 30% of the casirivimab plus imdevimab cock-
tail was prescribed after the fully resistant VOC BA.1 became dominant, and that (albeit
Pathogens 2022, 11, 823 3 of 8

The bamlanivimab and etesevimab cocktail was authorized by the AIFA on 17 March
2021. The casirivimab and imdevimab cocktail was authorized by the AIFA on 26 November
2021, while sotrovimab was authorized on 23 December 2021. Finally, the tixagevimab plus
Figure 1. Prevalence of various SARS-CoV-2 variants in Italy since December 2020 according to ISS
cilgavimab
flash cocktail was authorized by the AIFA on 25 March 2022. At the time of writing,
surveys reports.
neither the EMA nor the AIFA have withdrawn authorization for any of these mAbs.
Figure 2 shows
Figure 2 showsthat that
in Italy aboutabout
in Italy 60% of60%
the bamlanivimab plus etesevimab
of the bamlanivimab cocktail cocktail
plus etesevimab
waswas prescribed while Delta was dominating (hence making bamlanivimabinap-
prescribed while Delta was dominating (hence making bamlanivimab delivery delivery inap-
propriate), and
propriate), thatthat
and about
about20%20%waswas
prescribed at theattime
prescribed the fully
the time resistant
the fully VOC BA.1
resistant VOC BA.1 was
was dominating.Figure
dominating. Figure 33 shows
showsthatthatabout 30%
about of the
30% of casirivimab plus imdevimab
the casirivimab cock- cocktail
plus imdevimab
tail was prescribed after the fully resistant VOC BA.1 became dominant, and that (albeit
was prescribed after the fully resistant VOC BA.1 became dominant, and that (albeit largely
largely reduced) prescriptions are still happening while BA.2 is dominating. Figure 4
reduced) prescriptions are still happening while BA.2 is dominating. Figure 4 shows that
shows that about 30% of sotrovimab was prescribed after the fully resistant VOC BA.2
about 30% of sotrovimab was prescribed after the fully resistant VOC BA.2 became domi-
became dominant, and usage is still ongoing and undisturbed at the time of writing. Fig-
nant, and usage is still ongoing and undisturbed at the time of writing. Figure 5 shows the
ure 5 shows the usage of the tixagevimab plus cilgavimab cocktail, which occurred during
theusage
BA.2 of the against
wave, tixagevimab plus cilgavimab
which tixagevimab cocktail, which occurred during the BA.2 wave,
was ineffective.
against which tixagevimab was ineffective.
2500

2022 -01-31 : BA.1 Omicron VOC 99% in Italy

2021 -08-15 : Delta VOC 99% in Italy

2021-12-20 : BA.1 Omicron VOC >50% in Italy

2021 -06-20 : Delta VOC >50% in Italy

2000
BAM+ETE prescrip�ons

1500

1000

500

0
04/01/2022
12/01/2022
19/01/2022
26/01/2022
02/02/2022
09/02/2022

23/02/2022
2021-04-08
2021-04-15
2021-04-22
2021-04-29
2021-05-06
2021-05-13
2021-05-20
2021-05-27
2021-06-03
2021-06-10
2021-06-17
2021-06-24
2021-07-01
2021-07-08
2021-07-15
2021-07-22
2021-07-29
2021-08-05
2021-08-12
2021-08-19
2021-08-26
2021-09-02
2021-09-09
2021-09-16
2021-09-23
2021-09-30
2021-10-07
2021-10-14
2021-10-21
2021-10-28
2021-11-04
2021-11-11
2021-11-18
2021-11-25
2021-12-02
2021-12-09
2021-12-16
2021-12-21
2021-12-28

2022-02-16

2022-03-02
2022-03-09
2022-03-16
2022-03-23
2022-03-30
2022-04-06
2022-04-13
2022-04-20
2022-04-27
2022-05-04
2022-05-11
2022-05-18
Figure 2. Absolute prescription counts of bamlanivimab + etesevimab (BAM + ETE) in Italy. Areas
Figure 2. Absolute prescription counts of bamlanivimab + etesevimab (BAM + ETE) in Italy. Areas
with yellow shading indicate partially inappropriate usage (bamlanivimab being ineffective against
with yellow shading indicate partially inappropriate usage (bamlanivimab being ineffective against
VOC
VOC Delta).
Delta). Areas
Areas withwith red shading
red shading indicate
indicate likely inappropriate
likely inappropriate usage (prevalence
usage (prevalence of resistant of resistant
Pathogens 2022, 11, x FOR PEER REVIEW 4 of 9
VOC
VOC BA.1 higher
BA.1 thanthan
higher 50% 50%
according to ISS flash
according to ISSsurveys). As a reference,
flash surveys). dates of FDA
As a reference, advice
dates or advice or
of FDA
withdrawals
withdrawals are are
reported.
reported.

Figure 3. Absolute prescription

Figure 3. Absolutecounts of casirivimab
prescription + imdevimab
counts of casirivimab (CAS
+ imdevimab + IMD)
(CAS + IMD)ininItaly. Areas
Italy. Areas with
with
red shading
red shading indicate likely indicate likely inappropriate
inappropriate usage (prevalence
usage (prevalence of resistant
of resistant variant(s)higher
variant(s) higher than
than50%
50%
according to ISS flash surveys). As a reference, dates of FDA advice or withdrawals are reported.
according to ISS flash surveys). As a reference, dates of FDA advice or withdrawals are reported.
Pathogens 2022, 11, 823 Figure 3. Absolute prescription counts of casirivimab + imdevimab (CAS + IMD) in Italy. Areas with4 of 8
red shading indicate likely inappropriate usage (prevalence of resistant variant(s) higher than 50%
according to ISS flash surveys). As a reference, dates of FDA advice or withdrawals are reported.

Pathogens 2022, 11, x FOR 4.

Figure PEER REVIEWprescription counts of sotrovimab (SOT) in Italy. Areas with red shading indicate 5 of 9
Absolute
Figure 4. Absolute prescription counts of sotrovimab (SOT) in Italy. Areas with red shading indicate
likely
likely inappropriate inappropriate
usage usage (prevalence
(prevalence of resistant
of resistant BA.2 VOC BA.2higher
VOC higher
thanthan
50%50% according to
according toISS flash
ISS flash
surveys). As a reference, dates of FDA advice or withdrawals are reported.
surveys). As a reference, dates of FDA advice or withdrawals are reported.

Figure 5. Absolute prescription

Figure 5. Absolutecounts of tixagevimab
prescription + cilgavimab
counts of tixagevimab (TIX + CIL)
+ cilgavimab in+Italy.
(TIX The
CIL) in entire
Italy. The entire
area isbecause
area is yellow-shaded yellow-shaded becausewas
tixagevimab tixagevimab was at
not effective notneutralizing
effective at neutralizing againstBA.1
against Omicron Omicron
or BA.1
or BA.2, was
BA.2, while cilgavimab whileeffective
cilgavimab was
only effective
against only against BA.2.
BA.2.

4. Discussion 4. Discussion
Our analysis
Our analysis showed that showed
a relevantthatproportion
a relevant proportion of anti-SARS-CoV-2
of anti-SARS-CoV-2 Spike mAbSpikepre-
mAb pre-
scriptions
scriptions in Italy in Italy
could have could have
occurred occurred
in patients within patients
resistantwith resistant
disease. Givendisease. Given that na-
that national
tional regulatory
regulatory authorities authorities
within Europe within
usually actEurope usually act
in alignment in alignment
with with recommenda-
recommendations by
tions byexclude
the EMA, we cannot the EMA, wein
that, cannot exclude of
the absence that,
anyin communication
the absence of any bycommunication
the EMA, theby the
situation couldEMA, the situation
be similar in many could beEuropean
other similar in many other To
countries. European
the best countries. To the best of our
of our knowledge,
knowledge, no other study investigating this issue has been published so far using data
no other study investigating this issue has been published so far using data from other
from other European countries. In this regard, the policy of access to COVID-19 treatments
European countries. In this regard, the policy of access to COVID-19 treatments deployed
deployed by the FDA appeared suitable to limit the use of these drugs in patients with
by the FDA appeared
probable suitable to limit[4,5].
resistant disease the use of these drugs in patients with probable
resistant disease [4,5].
Despite the time shift of a couple of weeks between sample collection and flash sur-
Despite the vey reporting,
time shift ofthis explanation
a couple is clearly
of weeks betweennot enough
sample tocollection
account forandthe large
flash share of mAbs
survey
reporting, this used inappropriately. The alternate reasons for this delay in the adjustmentmAbs
explanation is clearly not enough to account for the large share of of prescrip-
tion habits
used inappropriately. Theshould be analyzed
alternate reasons forin detail. We believe
this delay in the that the lack of
adjustment RCTs to support in
of prescription
vitro evidence plays a prominent role in driving prescribers’
habits should be analyzed in detail. We believe that the lack of RCTs to support attitudes: e.g., most clinicians
in vitro
tend not to read or underestimate in vitro
evidence plays a prominent role in driving prescribers’ attitudes: e.g., most clinicians tendduring
evidence, which was promptly released
the pandemic. Nowadays, resistance can be highly predicted on the basis of Spike muta-
tional patterns observed in vitro (Figure 6). Our hypothesis is substantiated by publica-
tions reporting usage in Italy of bamlanivimab against Gamma [41] despite notorious in
vitro resistance [29–31,42], or the AIFA-sponsored MANTICO trial, authorized by the Eth-
ical Committee of the National Institute of Infectious Diseases (INMI), which reported
Pathogens 2022, 11, 823 5 of 8

not to read or underestimate in vitro evidence, which was promptly released during the
pandemic. Nowadays, resistance can be highly predicted on the basis of Spike mutational
patterns observed in vitro (Figure 6). Our hypothesis is substantiated by publications
reporting usage in Italy of bamlanivimab against Gamma [41] despite notorious in vitro
Pathogens 2022, 11, x FOR PEER REVIEW 6 of 9
resistance [29–31,42], or the AIFA-sponsored MANTICO trial, authorized by the Ethical
Committee of the National Institute of Infectious Diseases (INMI), which reported usage of
casirivimab plus imdevimab against BA.1 [43].
Bamlanivimab
Etesevimab BA.1
S371L (7, 6)
Sotrovimab
G446S (7, 8, >290)
G496S (6)
Casirivimab N856K (8)
Imdevimab
Q493R (>1000, 16, 7, 42)
Tixagevimab# K417N (>10,000, 43)
Cilgavimab # N440K (96)
E484A (>291, 48, 5, 9)
N969K (15)
BA.2/XE G339D (4) BA.4/BA.5
S371F (6, 26, 14, 87)
D405N (16, 11)
R408S (4)
L452R* (>1000, 5, 5)

Delta

Figure6.6.Mutational
Figure Mutationalpatterns
patternsofofSpike
Spikeproteins
proteinspredicting
predictingresistance
resistancetotoSARS-CoV-2
SARS-CoV-2VOCs.
VOCs.Values
Values
represent
represent thethe geometric
geometric mean
mean neutralizing
neutralizing antibody
antibody titertiter fold-reduction
fold-reduction causedcaused by specific
by specific muta-
mutations.
tions. Sourced
Sourced from https://covdb.stanford.edu/page/susceptibility-data/
from https://covdb.stanford.edu/page/susceptibility-data/ (accessed
(accessed on on). # approved
15 June 2022).
# for prophylaxis
approved only; * L452occur
for prophylaxis in all BA.4/BA.5
only; * L452occur in all lineages,
BA.4/BA.5 butlineages,
only in abut
minority
only inofa BA.2 subline-
minority of
ages (e.g., BA.2.11 and BA.2.35).
BA.2 sublineages (e.g., BA.2.11 and BA.2.35).

AnAnalternative
alternativehypothesis
hypothesisisisthat,
that,when
whenfrail
frailpatients
patientscannot
cannottolerate
toleratesmall-chemical
small-chemical
antivirals(which
antivirals (whichhave haveretained
retainedefficacy
efficacyagainst
againstallallOmicron
Omicronsublineages),
sublineages),available
availablemAbs
mAbs
can apparently offer a tolerable option, particularly when other
can apparently offer a tolerable option, particularly when other supposedly effective mAbs supposedly effective
mAbs (bebtelovimab
(bebtelovimab [24]) are [24]) are not in
not available available
Europe in Europe
yet. In thisyet. In this
regard, regard,
we note thatwe note that
COVID-19
COVID-19 convalescent
convalescent plasma (CCP) plasma (CCP)
collected collected
from fromretains
vaccinees vaccinees retains
efficacy efficacy
against against all
all Omicron
Omicron sublineages
sublineages [44], but we [44],regretbut we
that, regretbeing
despite that,encouraged
despite being by bothencouraged
CDC/IDSA by and
both
CDC/IDSA
ECIL-9 and ECIL-9
guidelines, guidelines,
CCP collection and CCP collection
usage has been and usageabandoned
almost has been almost abandoned
in Europe. CCP
isinalso
Europe. CCP
superior toismAbs
also superior
in terms to
of mAbs
the riskinof
terms
immune of the risk of[2].
escape immune escape [2].
AAthird
thirdpossibility
possibilityisispressure
pressurefrom
fromregional
regionaladministrators
administratorstotouse uselarge
largestocks
stocksthat
that
havebeen
have beenordered
orderedand andwould
wouldotherwise
otherwiseremain
remainunused.
unused.InInthis thisregard,
regard,fine-tuning
fine-tuningofof
ordersand
orders andpay-by-performance
pay-by-performancemechanismsmechanismscould couldmitigate
mitigatethe therisk.
risk.
AlthoughmAbs
Although mAbsgenerally
generallyhavehaveaafavorable
favorablesafety
safetyprofile,
profile,their
theirprescription
prescriptionininpa-pa-
tientswith
tients withresistant
resistantCOVID-19
COVID-19disease
diseasecomes
comeswithwithseveral
severaldrawbacks:
drawbacks:under underconstrained
constrained
resources(as
resources (asititcommonly
commonlyoccurs occursininpandemic
pandemicsettings),
settings),wastage
wastageofofmoneymoneyinvariably
invariably
translates into less investment in alternative and possibly effective therapeutics.These
translates into less investment in alternative and possibly effective therapeutics. These
considerationsalso
considerations alsoapply
applytotomAb
mAbcocktails
cocktailswhere
whereone oneofofthe
theingredients
ingredientsisisnot noteffective.
effective.
InInsummary,
summary,the thetimely
timelymedical
medical update
update of of the
the prescribers
prescribers should
shouldbe beimplemented
implementedin
insituations
situationsininwhich
whichthethe epidemiological
epidemiological scenario
scenario of the disease
of the disease isissosodynamic.
dynamic.InInthese
these
scenarios, regulatory agencies should consider closer monitoring of the epidemic patterns
of the resistant variants of the disease and react with timely actions and communications.

Author Contributions: D.F. designed the study and wrote the first draft. M.T. revised the manu-
script. All authors have read and agreed to the published version of the manuscript.
Pathogens 2022, 11, 823 6 of 8

scenarios, regulatory agencies should consider closer monitoring of the epidemic patterns
of the resistant variants of the disease and react with timely actions and communications.

Author Contributions: D.F. designed the study and wrote the first draft. M.T. revised the manuscript.
All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: The data are freely available at the sources provided in the Methods
section.
Conflicts of Interest: The authors declare no conflict of interest.

Abbreviations
VOC: variant of concern; ISS: Istituto Superiore di Sanità; AIFA: Agenzia Italiana
del Farmaco.

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