WO2021191900A1 - Methods for treating infectious diseases caused by coronavirus - Google Patents

Abstract

Disclosed are methods for treating infectious disease caused by coronavirus by using a pharmaceutical composition comprising human alpha 1- antitrypsin (AAT), or a derivative or analog thereof.

Description

METHODS FOR TREATING INFECTIOUS DISEASES CAUSED BY

CORONAVIRUS

FIELD OF THE INVENTION [0001] Disclosed are methods for treating infectious diseases caused by coronavirus, using human alpha 1-antitrypsin (AAT), derivative or analog thereof.

BACKGROUND OF THE INVENTION

[0002] AAT is a heavily glycosylated plasma protein of 52 kDa in size produced by the liver and secreted into the circulation, and is also produced locally by lung epithelial cells. Circulating levels of AAT increase during the acute phase response. This increase is due to the presence of IL-1 and IL-6 responsive elements inside the promoter region of the AAT encoding gene. AAT functions as a serine protease inhibitor that primarily targets elastase, trypsin, and proteinase-3, three inflammatory and immune cell-derived enzymes that are involved in protease-activated receptor (PAR) activation and the onset and progression of inflammation (Vergnolle N. 2009. Pharmacol Ther 123(3):292-309). AAT induces the production and release of anti-inflammatory mediators such as IL-10 and IL-1 -receptor antagonist (IL-IRa) (Lewis E C et al. 2008. Proc Natl Acad Sci USA. 105(42):16236-41).

[0003] International application W02005/027821 discloses a novel composition of purified, stable, active alpha- 1 antitrypsin (AAT) for intravenous administration and inhalation.

[0004] Coronaviruses are enveloped, positive-sense single-stranded RNA viruses. They have the largest genomes (26-32 kb) among known RNA viruses, and are phylogenetically divided into four genera (alpha, beta, gamma, delta.), with betacoronaviruses further subdivided into four lineages (A, B, C, D). Coronavirus disease 2019 (COVID-19) is an infectious disease caused by the betacoronavirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) where aerosol droplets is the main means of transmission.

[0005] The high case-fatality rate, and absence of effective prophylactic or therapeutic measures against coronaviruses have created an urgent need for effective therapeutic agents. SUMMARY OF THE INVENTION

[0006] Provided herein are methods for treating infectious diseases and disorders caused by and/or associated with, coronavirus, the methods include use of human alpha 1- antitrypsin (AAT), derivatives or analogs thereof. [0007] Surprisingly, as exemplified below, COVID-19 patients treated with AAT showed clinical improvement within several days associated with full functional recovery, reduced respiratory distress, decreased viral load and reduced inflammation. Thus, the clinical results indicate that AAT is a suitable candidate for the treatment of COVID-19. In view of the fact that during 2020 between 21.1 and 24.5 % of hospitalized COVID-19 patients die, the disclosed use of AAT introduces an exceptional benefit to COVID-19 patients.

[0008] An additional advantage of the disclosed methods arises from the fact that it is addressing patients with mild COVID-19 or asymptomatic infections whereas to date therapeutic options for these populations are scant. In fact, based on the clinical studies disclosed herein, AAT treatment is efficient at early disease stages and in severe COVID-19 disease. Moreover, the clinical studies show that low concentrations of AAT are effective for treating COVID-19 via infusion and/or inhalation. Needless to emphasize that treatment via inhalation is non-invasive and may be applied in outpatient settings, especially in early stages which do not require hospitalization. Another benefit rendered by the methods disclosed herein is that AAT is therapeutically safe for intravenous and inhaled treatments (e.g. Stolk, Tov et al., Eur Respir J., vol. 54(5): 1900673, 2019). In this regard, it should be noted that at the present time, there are no efficacious drugs available that can be applied non-invasively and decrease the likelihood of disease progression towards organ failure. [0009] There is provided, according to some embodiments, a method of treating

COVID-19, the method comprising administering to a subject in need thereof a therapeutically effective amount of a pharmaceutical composition comprising human alpha 1 -antitrypsin (AAT).

[0010] According to some embodiments, the pharmaceutical composition is in a dosage form suitable for intravenous delivery. According to some embodiments, said administering is administering via intravenous infusion. [0011] According to some embodiments, the pharmaceutical composition is in a dosage form suitable for inhalation. According to some embodiments, said administering comprises via intravenous infusion and via inhalation. According to some embodiments, said administering comprises administering in a combined treatment regimen comprising administering via intravenous infusion and administering via inhalation.

[0012] According to some embodiments, the COVID-19 is mild or moderate. According to some embodiments, the COVID-19 is severe or critical.

[0013] According to some embodiments, the AAT is plasma derived, recombinant or transgenic.

[0014] According to some embodiments, said administering comprises at least one course of administration.

[0015] According to some embodiments, said administering comprises administering AAT once daily for a plurality of consecutive days.

[0001] According to some embodiments, said subject in need thereof is a subject being connected to breathing support, and wherein following said treating the subject in need thereof is breathing spontaneously. According to some embodiments, the breathing support is selected from the group consisting of oxygen support, non-invasive ventilation, high flow oxygen, mechanical ventilation and ECMO. Each possibility represents a separate embodiment.

[0002] According to some embodiments, the breathing support is selected from oxygen support, non-invasive ventilation and high flow oxygen. Each possibility represents a separate embodiment.

[0016] According to some embodiments, said subject in need thereof has a P/F ratio lower than 300 and wherein said treating comprises increasing the P/F ratio. According to some embodiments, said subject in need thereof has a P/F ratio lower than 200 and wherein said treating comprises increasing the P/F ratio above 200. According to some embodiments, said subject in need thereof has a P/F ratio lower than 300 and wherein said treating comprises increasing the P/F ratio to 300. [0017] According to some embodiments, said subject in need thereof has a SOFA score above zero and wherein said treating comprises reducing the SOFA score. According to some embodiments, said subject in need thereof has a SOFA score above 4 and wherein said treating comprises reducing the SOFA score to 2 or below. According to some embodiments, said subject in need thereof has a SOFA score above 4 and wherein said treating comprises reducing the SOFA score to 2. According to some embodiments, said subject in need thereof has a SOFA score above 4 and wherein said treating comprises reducing the SOFA score to 1. According to some embodiments, said subject in need thereof has a SOFA score above 4 and wherein said treating comprises reducing the SOFA score to 0.

[0018] According to some embodiments, said subject in need thereof has a SOFA score above 8 and wherein said treating comprises reducing the SOFA score to 2 or below. According to some embodiments, said subject in need thereof has a SOFA score above 8 and wherein said treating comprises reducing the SOFA score to 2. According to some embodiments, said subject in need thereof has a SOFA score above 8 and wherein said treating comprises reducing the SOFA score to 1. According to some embodiments, said subject in need thereof has a SOFA score above 8 and wherein said treating comprises reducing the SOFA score to 0.

[0003] According to some embodiments, said treating comprises at least one treatment selected from the group consisting of enhancing viral clearance; reducing hospitalization period; reducing dependency on oxygen support; reducing the need for intensive care; reducing the need for mechanical ventilation; ameliorating at least one symptom of COVID-19 and reducing morbidity. Each possibility represents a separate embodiment.

[0019] According to some embodiments, the method further comprises administering one or more additional antiviral agents. According to some embodiments, the one or more additional antiviral agent is selected from the group consisting of a protease inhibitor, a helicase inhibitor, a viral replication inhibitor and a virus cell entry inhibitor.

[0020] According to some embodiments, there is provided a pharmaceutical composition comprising human alpha 1 -antitrypsin (AAT) for the treatment of COVID- 19. According to some embodiments, there is provided use of a pharmaceutical composition comprising human alpha 1 -antitrypsin (AAT) for the treatment of COVID- 19. According to some embodiments, there is provided a kit comprising at least one dosage form of a pharmaceutical composition comprising human alpha 1-antitrypsin (AAT) for the treatment of COVID-19 and instructions for use.

[0021] According to some embodiments, the pharmaceutical composition is in a dosage form suitable for intravenous delivery. According to some embodiments, said pharmaceutical composition comprises at least one daily dose of AAT for intravenous administration. According to some embodiments, said pharmaceutical composition comprises a plurality of daily doses of AAT for intravenous administration.

[0022] According to some embodiments, the pharmaceutical composition is in a dosage form suitable for inhalation. According to some embodiments, said pharmaceutical composition comprises at least one daily dose of AAT for administration via inhalation. According to some embodiments, said pharmaceutical composition comprises a plurality of daily doses of AAT for administration via inhalation. According to some embodiments, said pharmaceutical composition comprises a plurality of doses of AAT comprising at least one dose for administration via inhalation and at least one dose for administration via inhalation.

[0023] According to some embodiments, the COVID-19 is mild or moderate.

[0024] According to some embodiments, the COVID-19 is severe or critical.

[0025] According to some embodiments, the AAT is plasma derived, recombinant or transgenic.

[0004] According to some embodiments, said treatment comprises removal from breathing support to spontaneous breathing. According to some embodiments, the breathing support is selected from the group consisting of oxygen support, non-invasive ventilation, high flow oxygen, mechanical ventilation and ECMO. Each possibility represents a separate embodiment. According to some embodiments, the breathing support is selected from oxygen support, non-invasive ventilation and high flow oxygen. Each possibility represents a separate embodiment.

[0026] According to some embodiments, said treatment comprises increasing P/F ratio. According to some embodiments, said treatment comprises increasing P/F ratio to above 200.

[0027] According to some embodiments, said treatment comprises reducing SOFA score. According to some embodiments, said treatment comprises reducing SOFA score to 2 or below.

[0005] According to some embodiments, said treatment comprises at least one treatment selected from the group consisting of enhancement of viral clearance, reduction of hospitalization period, reduction of dependency on oxygen support, reduction of the need for intensive care or mechanical ventilation, reduction of at least one symptom of COVID-19 and reduction of morbidity. Each possibility represents a separate embodiment.

[0006] According to some embodiments, the pharmaceutical composition is provided in combination with one or more additional antiviral agents. According to some embodiments, the one or more additional antiviral agent is selected from the group consisting of a protease inhibitor, a helicase inhibitor, a viral replication inhibitor and a virus cell entry inhibitor. Each possibility represents a separate embodiment.

[0028] According to certain embodiments, said administering comprises single or multiple administrations.

[0029] According to certain embodiments, said treating comprises preventing or limiting one or more symptoms and/or complications associated with infection by the coronavirus. According to certain embodiments, said one or more complications associated with infection by the coronavirus are selected from the group consisting of bronchitis, pneumonia, neutrophilic lung injury, chronic lung injury, and ARDS.

[0030] According to certain embodiments, said administering is performed by intravenous, intraarterial, subcutaneous, intramuscular, intraperitoneal, intrauterine, or intrathecal administration.

[0031] According to certain embodiments, said administering is performed by intravenous administration. According to certain embodiments, the pharmaceutical composition is administered at a dose of from 0.5 mg/kg to about 500 mg/kg. According to certain embodiments, the pharmaceutical composition is administered at a dose of from 50 mg/kg to about 120 mg/kg. According to certain embodiments the multiple administrations are repeated every 24, 48, and 72 hours up to 1 month.

[0032] According to certain embodiments, each dose comprises 0.5, 5, 15, 30, 60, 90, 120, 240, or 500 mg AAT/kg BW. According to certain embodiments, the multiple doses are administered at intervals of from about 1-4 days to about 2-4 weeks. According to certain embodiments, the intervals are selected from constant intervals and variable intervals. According to certain embodiments, the multiple doses contain the same amount of AAT. According to certain embodiments, the multiple doses contain variable amounts of AAT. According to certain embodiments, the multiple doses are administered at intervals of two days. According to certain embodiments, the amount of AAT is descending from the first dose administered to the second dose administered.

[0033] According to certain embodiments, said administering is performed by inhalation. According to certain embodiments, the pharmaceutical composition is administered at a dose of from 1 mg to about 320 mg per day. According to certain embodiments, the multiple administrations are repeated every day up to 1 month.

[0034] According to certain embodiments, said administering of the pharmaceutical composition results in at least one outcome of enhanced viral clearance, reduced hospitalization; reduced oxygen dependence, reduced intensive care or mechanical ventilation need; reduced healthcare utilization or burden; reduced absences from school or work; decreased antibiotic need; decreased steroid need; decreased relapse frequency; and, decreased morbidity.

[0035] According to certain embodiments, the method further comprises at least another therapeutic agent. According to certain embodiments, the method further comprises at least another antiviral agent. According to other embodiments, the other antiviral agent is selected from the group consisting of a protease inhibitor, a helicase inhibitor, a viral replication inhibitor, and a virus cell entry inhibitor.

[0036] According to certain embodiments, the method further comprises at least another anti-inflammatory agent. According to certain embodiments, the other antiinflammatory agent is IL-6.

[0037] Other objects, features and advantages of the present invention will become clear from the following description. BRIEF DESCRIPTION OF THE FIGURES

[0038] Figure 1 represents the hospitalization course of patient number 1 in terms of P/F ratio (circles) and SOFA score (squares), over time.

[0039] Figure 2 represents the hospitalization course of patient number 2 in terms of P/F ratio (circles) and SOFA score (squares), over time.

[0040] Figure 3 represents tire hospitalization course of patient number 3 in terms of P/F ratio (circles) and SOFA score (squares), over time.

[0041] Figures 4A - 4E represent the respiratory status of five COVID- 19 patients from the day of hospital admission through discharge on a scale of 1 (spontaneous breathing) to 6 (ECMO). Day of AAT administration, at combined administration routes (IV and inhalation), is indicated by downward arrows treated.

DETAILED DESCRIPTION OF THE INVENTION

[0042] The present invention discloses methods for treating infectious disease caused by coronavirus, the methods comprising use of human alpha 1 -antitrypsin (AAT), derivative or analog thereof.

[0043] As exemplified herein, AAT treatment improves the clinical status of

COVID-19 patients. Specifically, AAT induces respiratory improvement as demonstrated by enhanced P/F ratios, reduced SOFA scores and reduced respiratory status scores, among other therapeutic effects.

[0044] Commonly, P/F ratio, namely, the arterial oxygen partial pressure (“P” or "p0₂") divided by the fraction of inspired oxygen that the patient is receiving, (“F” or "FIO2") where a P/F ratio less than 300 indicates acute respiratory failure. Hence, one of the aims of the methods disclosed herein is to increase the P/F ratio of subjects afflicted with coronavirus infection, which exhibit low P/F ratio, typically, lower than 300, lower than 250 or lower than 200. As exemplified herein, this aim was achieved by the use of AAT.

[0045] Another aim of the methods disclosed herein is to reduce the SOFA scores of subjects afflicted with coronavirus infection. As exemplified herein, this aim was achieved by the use of AAT. SOFA scores, stands for sequential organ failure assessment score (previously known as sepsis-related organ failure assessment score), is used for monitoring patients' status at an intensive care units (ICU) in order to determine the extent of the organ function or rate of failure. The score includes six different scores, each for a different organ/system, as follows: respiratory, cardiovascular, hepatic, coagulation, renal and neurological systems. The SOFA scores of subjects afflicted with severe coronavirus infection, who require mechanical ventilation and /or ECMO is usually higher than 0, namely, they exhibit some extent of organ failure.

[0046] Without being bound by any theory or mechanism of action it is postulated that the beneficial clinical effect of AAT in the treatment for SARS-CoV2, as disclosed herein, is due to the fact SARS-CoV2 uses ACE2 as a receptor to enter host cells, a process that requires priming by the host cellular serine protease TMPRSS2 wherein AAT is known to effectively inhibit this protease in a dose-dependent manner. The viral essential nonstructural protein 3-chymotrypsin-like protease is another promising drug target for COVID-19. It is hypothesized that due to its structural similarity with Chymotrypsin, AAT could effectively block the 3CL protease as well. In addition to its wide-spectrum anti-proteinase activity, AAT also participates in regulation of the immune response to various stimuli, resulting in down-regulation of several pro- inflammatory cytokines, including IL-6. Taken together, AAT may have multiple potential targets, both on the early "viral" phase of SARS-CoV2 infection, as well as on the later highly inflammatory phase of COVID-19 characterized by a "cytokine storm".

[0047] According to some embodiments, there is provided a method of treating

COVID-19, the method comprising administering to a subject in need thereof an effective amount of a pharmaceutical composition comprising human alpha 1- antitrypsin (AAT).

[0048] As used herein, the term "COVID-19" is interchangeable with the terms "coronavirus disease", "COVID-19 disease", "SARS-CoV2 disease", and further refers to diseases, disorders, and symptoms associated with the COVID-19 infection. SARS- CoV2 belongs to a family of coronavirus, a family of positive-sense, single-stranded RNA viruses that are known to cause severe respiratory illness. Viruses currently known to infect human from the coronavirus family are from the alphacoronavirus and betacoronavirus genera. Additionally, it is believed that the gammacoronavirus and deltacoronavirus genera may infect humans in the future.

[0049] Coronaviruses infect a wide range of avian and mammalian species, including humans. Of the six known human coronaviruses, four (HCoV-OC43, HCoV- 229E, HCoV-HKUl, and HCoV-NL63) circulate annually in humans and generally cause mild respiratory diseases, although severity can be greater in infants, elderly, and the immunocompromised. In contrast, the Middle East respiratory syndrome coronavirus (MERS-CoV) and the severe acute respiratory syndrome coronavirus (SARS-CoV), belonging to betacoronavirus lineages C and B, respectively, are highly pathogenic. Both viruses emerged into the human population from animal reservoirs within the last 15 years and caused outbreaks with high case-fatality rates.

[0050] MERS-CoV was isolated in 2012 from a patient in Saudi Arabia and is still circulating across the Arabian Peninsula. Primary transmission, most likely from camels, is now considered to be the most common route of transmission, and camels are thought to be a secondary or intermediate reservoir for MERS-CoV, with bats serving as the primary reservoir. Human-to-human transmission, especially as a result of close contact between patients and hospital workers within health care settings, is another important route of transmission, and was responsible for an outbreak of MERS-CoV in South Korea. The high pathogenicity and airborne transmissibility of SARS-CoV and MERS-CoV have raised concern about the potential for another coronavirus pandemic.

[0051] COVID-19 was first identified in Wuhan, Hubei province and quickly spread across over whole China and other 30 countries. Despite intensive research conducted with the aim of identifying practical treatments or any possible medicines, there is as yet no consensus as to any recommended antiviral therapy. It has been confirmed that the immune system played a vital role in defense against SARS-CoV and MERS infection. Immunological changes in patients with SARS, MERS, and influenza, especially changes in peripheral blood T lymphocyte subsets, contribute to understanding of the characteristics, diagnosis, monitoring, prevention, and treatment of the disease

[0052] As used herein, the term “Alpha- 1 Antitrypsin” (AAT) refers to a glycoprotein that in nature is produced by the liver and lung epithelial cells and is secreted into the circulatory system. AAT belongs to the Serine Proteinase Inhibitor (Serpin) family of proteolytic inhibitors. This glycoprotein consists of a single polypeptide chain containing one cysteine residue and 12-13% of the total molecular weight of carbohydrates. AAT has three N-glycosylation sites at asparagine residues 46, 83, and 247, which are occupied by mixtures of complex bi- and triantennary glycans. This gives rise to multiple AAT isoforms, having isoelectric points in the range of 4.0 to 5.0. The glycan monosaccharides include N-acetylglucosamine, mannose, galactose, fucose, and sialic acid. AAT serves as a pseudo-substrate for elastase; elastase attacks the reactive center loop of the AAT molecule by cleaving the bond between methionine358 - serine359 residues to form an AAT-elastase complex. This complex is rapidly removed from the blood circulation and the lung airways. AAT is also referred to as “alpha- 1 Proteinase Inhibitor” (API). The term “glycoprotein” as used herein refers to a protein or peptide covalently linked to a carbohydrate. The carbohydrate may be monomeric or composed of oligosaccharides.

[0001] It is to be explicitly understood that any AAT, derivative or analog thereof as is or will be known in the art, including recombinant, or transgenic AAT can be used according to the teachings of the present disclosure. "Recombinant AAT" as used herein, refers to AAT that is the product of recombinant DNA or transgenic technology. The phrase, "recombinant AAT," also includes functional fragments of AAT, chimeric proteins comprising AAT or functional fragments thereof, fusion proteins or fragments of AAT, homologues obtained by analogous substitution of one or more amino acids of AAT, and species homologues. "Recombinant AAT," also refers to AAT proteins synthesized chemically by methods known in the art such as, e.g., solid-phase peptide synthesis. Amino acid and nucleotide sequences for AAT and/or production of recombinant AAT are described by, e.g., U.S. Pat. Nos. 4,711,848; 4,732,973; 4,931,373; 5,079,336; 5,134,119; 5,218,091; 6,072,029; and Wright et al., Biotechnology 9: 830 (1991); and Archibald et al., Proc. Natl. Acad. Sci. (USA), 87: 5178 (1990), are each herein incorporated by reference for its teaching of AAT sequences, recombinant AAT, and/or recombinant expression of AAT.

[0053] The term "subject" as used herein, refers to any animal, individual, or patient to which the methods described herein are performed. Generally, the subject is human, although as will be appreciated by those in the art, the subject may be an animal. Thus, other animals, including mammals such as rodents (including mice, rats, hamsters, and guinea pigs), cats, dogs, rabbits, farm animals including cows, horses, goats, sheep, pigs, etc., and non-human primates (including monkeys, chimpanzees, orangutans, and gorillas) are included within the definition of subject.

[0054] A "subject in need thereof," as used herein, refers to a subject afflicted with, or at risk of developing, a disease, specifically, coronavirus disease. The subject in need thereof may be a subject being hospitalized with symptoms of coronavirus disease, a subject having symptoms of coronavirus diseases and is under ambulatory setting or at home, or a subject having asymptomatic coronavirus disease and is under ambulatory setting or at home.

[0055] Symptoms associated with mild coronavirus illness (disease) include, but are not limited to, fever of about 38°C, cough, sore throat, malaise, headache, muscle pain, nausea, vomiting, diarrhea, and loss of taste and smell. Typically, subjects with mild coronavirus do not have shortness of breath, dyspnea on exertion, or abnormal chest imaging. Most of the mildly ill subjects can be managed in an ambulatory setting or at home through telemedicine or telephone visits. Treatment of a mildly ill subject does not usually require imaging or specific laboratory evaluations. Elderly subjects and subjects with underlying comorbidities are at higher risk of disease progression and hence may require continuous monitoring by health care providers until clinical recovery is achieved.

[0056] It should be noted that any shortness of breath combined with the aforementioned mild symptoms may indicate the presence of moderate to severe, or severe disease and should be checked. Mild coronavirus infection may include mild form of pneumonia and moderate coronavirus infection may include moderate form of pneumonia. Despite having only mild to moderate symptoms, mild, moderate, or mild to moderate, forms of pneumonia may require hospitalization and antibiotics, along with supplemental oxygen. According to the World Health Organization (WHO) a mild to moderate case of COVID-19 will typically run its course in about two weeks. In addition, 80% of laboratory confirmed cases of COVID-19 cases exhibited mild to moderate symptoms according to data from WHO. [0057] Yet, the vast majority of patients who have mild or moderate symptoms can heal by resting, drinking plenty of water, and staying home. Some patients, typically those who are elderly or with underlying health issues, may develop moderate symptoms that could require supportive care, such as i.v. infusion of fluids for dehydration.

[0058] In addition, in some of the worst cases, the virus can enter lung cells and start replicating. When the immune system creates inflammation to fight the virus, this can sometimes result in a more severe form of pneumonia.

[0059] Thus, according to some embodiments the method disclosed herein is for the treatment of mild or moderate COVID-19.

[0060] In about one in five patients with mild coronavirus infection, the disease will worsen, with about 14% of cases developing into severe disease in which patients may need hospitalization and supplemental oxygen. Of the patients with severe infection, about 6% cases become critical and may develop septic shock that can lead to stroke, heart or respiratory failure, failure of other organs or death. Symptoms can worsen in some patients in a matter of days, or even hours.

[0061] According to some embodiments, the method disclosed herein is for the treatment of severe or critical COVID-19.

[0062] The term “pharmaceutical composition” is intended to be used herein in its broader sense to include preparations containing the composition used for therapeutic purposes. Accordingly, the pharmaceutical composition contains a therapeutic amount of the active ingredient, namely, AAT. The pharmaceutical compositions may be formulated in a conventional manner using one or more physiologically acceptable carriers, which facilitate processing of the active compounds into preparations that can be used pharmaceutically. Proper formulation is dependent upon the route of administration chosen.

[0063] According to any one of the above embodiments, the pharmaceutical composition further comprises one or more pharmaceutically acceptable excipients.

[0064] The term "pharmaceutically acceptable excipient" as used herein is exchangeable with the term "pharmaceutically acceptable carrier" and refers to any and all solvents, dispersion media, preservatives, antioxidants, coatings, isotonic and absorption delaying agents, surfactants, buffer, a stabilizing agent, and the like that are compatible with pharmaceutical administration. The use of such media and agents in pharmaceutical compositions is well known in the art. The compositions may contain other active compounds providing supplemental, additional, or enhanced therapeutic functions.

[0065] As used herein, the term "therapeutically effective amount" is exchangeable with any one of " therapeutically effective dose" or "sufficient/effective amount or dose," and refers to a dose that produces the required therapeutic effects. Specifically, an effective dose generally refers to the amount of the composition disclosed herein sufficient to induce immunity, to prevent and/or ameliorate coronavirus infection, or to reduce at least one symptom associated with the coronavirus infection and/or to enhance the efficacy of another therapeutic composition. An effective dose may refer to the amount of the composition sufficient to delay or minimize the onset of an infection. An effective dose may also refer to the amount of the composition that provides a therapeutic benefit in the treatment or management of infection. In addition, an effective dose may be the amount with respect to the composition alone, or in combination with other therapies, that provides a therapeutic benefit in the treatment or management of a viral infection. An effective dose may also be the amount sufficient to enhance a subject's (in particular, human's) own immune response against a subsequent exposure to coronavirus. The exact effective dose depends on the purpose of the treatment, and is ascertainable by one skilled in the art using known techniques.

[0066] The terms "treating” or “treatment” as used herein refer to taking steps to obtain beneficial or desired therapeutic results. Beneficial or desired therapeutic results include, but are not limited to, alleviation or amelioration of one or more symptoms associated with an infectious disease, delaying or slowing down the propagation of the disease, amelioration, palliation or stabilization of said disease, among other beneficial results. According to some embodiments, the term “treating” has the meaning of “preventing”. According to any one of the above embodiments, the treatment or prevention of a disease is selected from inhibiting viral replication in a subject, inhibiting viral protein synthesis, preventing and/or inhibiting an increase in cell death in a mammal, and preventing and/or inhibiting death. The term "prophylactic treatment" refers to taking steps to prevent the disease, and in particular infectious disease. [0067] Thus, according to some embodiments, the treatment disclosed herein comprises one or more of reducing the rate of progression of the disease, inhibiting progression of the disease, preventing the disease and attenuating at least one symptom induced or associated with coronavirus disease.

[0068] According to some embodiments, the subject in need thereof is a subject being connected to breathing support, wherein following said treating said subject is breathing spontaneously.

[0069] According to some embodiments, the breathing support is selected from the group consisting of oxygen support, non-invasive ventilation, high flow oxygen, mechanical ventilation and ECMO. Each possibility is a separate embodiment of the present invention.

[0070] According to some embodiments, the breathing support is selected from oxygen support, non-invasive ventilation and high flow oxygen. Each possibility is a separate embodiment of the present invention.

[0071] Mechanical ventilation is a treatment that applies a mechanical ventilator that typically is positive -pressure ventilation which pushes airflow into the patient’s lungs to help them breathe. Mechanical ventilation also include negative- pressure ventilation, that sucks the air into the lungs by making the chest expand and contract. Mechanical ventilation may be invasive ventilation with a tube inserted into the patient’s airway, performed in the intensive care unit in the hospital. Noninvasive ventilation can be used at home by people with respiratory difficulties.

[0072] Mechanical ventilation is part of the arsenal of supportive care clinicians use for COVID-19 coronavirus disease patients with the most severe lung symptoms. A COVID-19 infection can cause fluids and mucus in the lungs that block oxygenation of lung tissue. Mechanical ventilation can help support COVID- 19 patients breathing until their immune system and treatment can clear the infection and proper lung function is restored.

[0073] Extracorporeal membrane oxygenation (ECMO) is an extracorporeal technique of providing prolonged cardiac and respiratory support to patients whose heart and lungs are unable to provide an adequate amount of gas exchange or perfusion to sustain life. Both ECMO and mechanical ventilation are applied under anesthesia, and are considered as treatment to patients, including COVID-19 patients, with severe respiratory status.

[0074] According to some embodiments, the subject in need thereof is a subject having a P/F ratio lower than 300 and wherein said treating comprises increasing the P/F ratio. According to some embodiments, the subject in need thereof is a subject having a P/F ratio lower than 200. According to some embodiments, the subject in need thereof is a subject having a P/F ratio lower than 100. According to some embodiments, the subject in need thereof is a subject having a P/F ratio within the range of 50 to 250. According to some embodiments, treating a subject having P/F ratio lower than 300 with a pharmaceutical composition comprising AAT results with increase of the P/F ratio up to 300, at least up to 290, at least up to 270, at least up to 260, at least up to 250. As exemplified herein, treating a subject having P/F ratio lower than 300 with a pharmaceutical composition comprising AAT results with improved P/F ratio.

[0075] According to some embodiments, said subject in need thereof has a P/F ratio lower than 200 and wherein said treating comprises increasing the P/F ratio above 200. According to some embodiments, said subject in need thereof has a P/F ratio lower than 200 and wherein said treating comprises increasing the P/F ratio to 300.

[0076] According to some embodiments, said subject in need thereof has a SOFA score above zero and wherein said treating comprises reducing the SOFA score. According to some embodiments, said subject in need thereof has a SOFA score above 1 and wherein said treating comprises reducing the SOFA score to zero. According to some embodiments, said subject in need thereof has a SOFA score above 2 and wherein said treating comprises reducing the SOFA score to 1 or below. According to some embodiments, said subject in need thereof has a SOFA score above 3 and wherein said treating comprises reducing the SOFA score to 2 or below. According to some embodiments, said subject in need thereof has a SOFA score above 4 and wherein said treating comprises reducing the SOFA score to 2 or below. According to some embodiments, said subject in need thereof has a SOFA score above 5 and wherein said treating comprises reducing the SOFA score to 2 or below. According to some embodiments, said subject in need thereof has a SOFA score above 6 and wherein said treating comprises reducing the SOFA score to 2 or below. According to some embodiments, said subject in need thereof has a SOFA score above 7 and wherein said treating comprises reducing the SOFA score to 2 or below. According to some embodiments, said subject in need thereof has a SOFA score above 8 and wherein said treating comprises reducing the SOFA score to 2 or below.

[0077] The Sequential Organ Failure Assessment (SOFA) score is a simple and objective score that allows for calculation of both the number and the severity of organ dysfunction in six organ systems (respiratory, coagulatory, liver, cardiovascular, renal, and neurologic). The score can be used to measure individual or aggregate organ dysfunction. SOFA creates a standardized, numeric score that is familiar to critical care physicians. Physicians can use it to compare patient status and the score has been shown to have a significant correlation with outcome in certain conditions. This can be helpful for the clinical teams as a comparative factor. In fact, of the scoring systems available, SOFA achieves a good balance between easily available data and good prediction. When calculated daily it can also be used to establish trends in the individual patient’s course. With respect to respiration, SOFA score of 0 is considered normal, SOFA score of 1 corresponds to P/F ratio below 400, SOFA score of 2 corresponds to P/F ratio below 300, SOFA score of 3 corresponds to P/F ratio below 200 (with respiratory support) and SOFA score of 4 corresponds to P/F ratio below 100 (with respiratory support). Accordingly, a patient whose SOFA score is 2 is much more likely to survive than a patient who scores an 11.

[0078] According to some embodiments, the treating comprises at least one treatment selected from the group consisting of enhancing viral clearance, reducing hospitalization period; reducing dependency on oxygen support, reducing the need for intensive care or for mechanical ventilation, ameliorating at least one symptom of COVID-19 and reducing morbidity. Each possibility is a separate embodiment of the present invention.

[0079] According to some embodiments, the method further comprises administration of one or more additional antiviral agents.

[0080] According to some embodiments, the antiviral agent of the one or more additional antiviral agents is selected from the group consisting of a protease inhibitor, a helicase inhibitor, a viral replication inhibitor and a virus cell entry inhibitor. According to some embodiments the antiviral agent is selected from the group consisting of: remdesivir, IFNb, chloroquine, hydroxychloroquine, tocilizumab and sarilumab.

[0081] According to some embodiments, said treatment is prevention of the occurrence of coronavirus infection. According to some embodiments said treatment is preventing infection induced by the coronavirus. According to some embodiments said treatment is prophylactic treatment.

[0082] The terms "prevent" or "preventing" includes alleviating, ameliorating, halting, restraining, slowing, delaying, or reversing the progression, or reducing the severity of pathological conditions described above, or forestalling the onset or development of a disease, disorder, or condition for a period of time from minutes to indefinitely. Prevent also means reducing risk of developing a disease, disorder, or condition.

[0083] "Amelioration," or "ameliorate," or "ameliorating" refers to a lessening of at least one indicator, sign, or symptom of an associated disease, disorder, or condition. The severity of indicators may be determined by subjective or objective measures, which are known to those skilled in the art.

[0084] The term "administering" includes any method of delivery of a pharmaceutical composition or agent into a subject's system or to a particular region in, or on, a subject. In certain embodiments, the pharmaceutical composition disclosed herein is administered via intravenous and/or via inhalation. As used herein, and as based on context, the terms "administration" or "administrations" encompass a singular or multiple instances, respectively. As used herein, "administration" is synonymous with "delivery".

[0085] Thus, according to some embodiments, the pharmaceutical composition is administered at least once. According to some embodiments, said administering comprises one course of administration, namely, a single administration. According to some embodiments, the pharmaceutical composition is administered a plurality of times. According to some embodiments, the plurality of administrations comprises three administrations. According to some embodiments, the plurality of administrations comprise once daily dosage regimen for at least three days. According to some embodiments, all administrations of the plurality of administrations include the same dose of AAT. According to some embodiments, the various administrations of the plurality of administrations include various doses of AAT.

[0086] According to some embodiments, the pharmaceutical composition is administered no more than 4 weeks after onset of COVID-19. The onset of COVID-19 may be at the day of appearance of the first symptom(s). Alternatively, the onset of COVID-19 may be at the day of receiving positive diagnosis of COVID-19 (e.g. positive detection of COVID-19 via PCR test). According to some embodiments, the pharmaceutical composition is administered no more than 3 weeks after onset of COVID-19. According to some embodiments, the pharmaceutical composition is administered no more than 2 weeks after onset of COVID-19. According to some embodiments, the pharmaceutical composition is administered within 1 to 3 weeks after onset of COVID-19.

[0087] According to some embodiments, the pharmaceutical composition is administered via intravenous infusion.

[0088] According to some embodiments, the pharmaceutical composition is administered via inhalation.

[0089] According to some embodiments, the pharmaceutical composition is administered via combined administrations, also termed herein 'combined treatment regimen', namely, via combined routes of administrations. According to some embodiments, the combined treatment regimen comprises administration via intravenous infusion combined with administration via inhalation.

[0090] According to some embodiments, the pharmaceutical composition administered via intravenous infusion is administered once daily for at least two days. According to some embodiments, the pharmaceutical composition administered via intravenous infusion is administered once daily for at least three days. According to some embodiments, the pharmaceutical composition administered via intravenous infusion is administered in once daily for three days.

[0091] According to some embodiments, the pharmaceutical composition administered via inhalation is administered once daily for at least two days. According to some embodiments, the pharmaceutical composition administered via inhalation is administered once daily for at least three days. According to some embodiments, the pharmaceutical composition administered via inhalation is administered once daily for at least four days. According to some embodiments, the pharmaceutical composition administered via inhalation is administered once daily for at least five days. According to some embodiments, the pharmaceutical composition administered via inhalation is administered once daily for at least six days. According to some embodiments, the pharmaceutical composition administered via inhalation is administered once daily for at least a week. According to some embodiments, the pharmaceutical composition administered via inhalation is administered once daily for at least eight days. According to some embodiments, the pharmaceutical composition administered via inhalation is administered once daily for at least nine days. According to some embodiments, the pharmaceutical composition administered via inhalation is administered once daily for at least ten days. According to some embodiments, the pharmaceutical composition administered via inhalation is administered once daily for ten days.

[0092] According to some embodiments, the pharmaceutical composition is administered via combined administration treatment regimen, comprising different routes of administration, including, but not limited to, at least two routes of administration, from the following routes: intravenous, sublingual, rectal, topical, parenteral, buccal, oral, nasal, via inhalation, subcutaneous, transdermal and intramuscular. According to some embodiments, the pharmaceutical composition is administered via combined administration treatment regimen, comprising, intravenous infusion once daily for at least two days and inhalation once daily for at least six days. According to some embodiments, the pharmaceutical composition is administered via combined administration treatment regimen, comprising, intravenous infusion once daily for at least three days and inhalation once daily for at least six days. According to some embodiments, the pharmaceutical composition is administered via combined administration treatment regimen, comprising, intravenous infusion once daily for at least three days and inhalation once daily for at least eight days. According to some embodiments, the pharmaceutical composition is administered via combined administration treatment regimen, comprising, intravenous infusion once daily for three days and inhalation once daily for ten days.

[0093] According to some embodiments, a combined administration regimen which includes, for example, intravenous infusion once daily for two days and inhalation once daily for six days, refers to six days of treatment, wherein in the first two days the patient receives two AAT doses per day, namely, one dose via intravenous infusion and another dose via inhalation, wherein during the remaining four days of treatment the patient receives AAT only via inhalation. Thus, each day in the first days of the combined treatment regimen usually includes two dosages of AAT, one via intravenous administration and one via inhalation, and the rest of the days in the combined treatment regimen, may include only one dosage of AAT, typically delivered via inhalation.

[0094] According to some embodiments, a combined administration regimen which includes, for example, intravenous infusion once daily for two days and inhalation once daily for six days, refers to eight days of treatment, wherein the patient receives two AAT doses per day via intravenous infusion for two days and six additional AAT doses for six days, one dose per day via inhalation.

[0095] The term "inhalation" refers to administration of a compound to the tissues of the lungs or lower respiratory tract by inhalation of the compound by the subject, thereby drawing the compound into the lung. The terms "pulmonary delivery" and "respiratory delivery" refer to delivery of AAT to a patient by inhalation through the mouth and into the lungs.

[0096] For administration via inhalation a nebulizer, an inhaler or any other device suitable for inhalation of AAT can be used. AAT may be inhaled through a suitable nebulizer, such as the eFlow nebulizer. The term “eFlow nebulizer” refers to the nebulizer disclosed in international application WO 01/34232. The term "inhalation nebulizer" refers to a nebulizer comprising the basic elements of the eFlow nebulizer and any equivalent nebulizer.

[0097] As used herein the term "about" refers to the designated value ± 10%.

[0098] According to some embodiments, the pharmaceutical composition is in a dosage form suitable for intravenous delivery. According to some embodiments, the pharmaceutical composition is in a dosage form suitable for inhalation.

[0099] Pharmaceutical compositions for use in accordance with the present invention thus may be formulated in a conventional manner using one or more acceptable diluents or carriers comprising excipients and auxiliaries, which facilitate processing of the active compounds into preparations, which can be used pharmaceutically. Proper formulation is dependent on the route of administration chosen.

[00100] The pharmaceutical compositions can be formulated into various compositions for any route of administration well-known to the skilled person. The choice of the optimal route of administration of the pharmaceutical compositions is influenced by several factors including, e.g., the physio-chemical properties of the active molecules within the compositions, the urgency of the clinical situation and the relationship of the plasma concentrations of the active molecules to the desired therapeutic effect. The preparations and pharmaceutical compositions disclosed herein are preferably formulated for intravenous administration or aerosol administration. Pharmaceutically suitable formulations of AAT can be prepared according to methods known to the person skilled in the art (see Remington's Pharmaceutical Sciences, 18th edition, A. R. Gennaro, Ed., Mack Publishing Company (1990); Pharmaceutical Formulation Development of Peptides and Proteins, S. Frokjaer and F. Hovgaard, Eds., Taylor & Francis (2000); and Handbook of Pharmaceutical Excipients, 3rd edition, A. Kibbe, Ed., Pharmaceutical Press (2000)).

[00101] Typically, pharmaceutical compositions must be sterile and stable under the conditions of manufacture and storage. The preparations and/or pharmaceutical compositions comprising the AAT can be in powder form for reconstitution in the appropriate pharmaceutically acceptable excipient before or at the time of delivery. In the case of sterile powders for the preparation of sterile injectable solutions, the preferred methods of preparation are vacuum drying and freeze-drying (lyophilization) that yield a powder of the active ingredient plus any additional desired ingredient from a previously sterile-filtered solution thereof.

[00102] Alternatively, the AAT can be in solution and the appropriate pharmaceutically acceptable excipient can be added and/or mixed before or at the time of delivery to provide a unit dosage-injectable form.

[00103] According to certain embodiments, the pharmaceutical compositions of the present invention are formulated in a form suitable for intravenous delivery. [00104] According to certain embodiments, the pharmaceutical compositions of the present invention are formulated in a form suitable for inhalation.

[00105] The term "carrier" refers to a diluent or vehicle that does not cause significant irritation to an organism and does not abrogate the biological activity and properties of the administered compound. An adjuvant is included in this category. Such pharmaceutical carriers can be sterile liquids, such as water and oils, including those of petroleum, animal, vegetable or synthetic origin, such as peanut oil, soybean oil, mineral oil, sesame oil and the like, polyethylene glycols, glycerin, propylene glycol, or other synthetic solvents. Water is a preferred carrier when the pharmaceutical composition is administered intravenously. Saline solutions, isotonic buffers and physiological pH and aqueous dextrose and glycerol solutions can also be employed as liquid carriers, particularly for injectable solutions.

[00106] The term "excipient" refers to an inert substance added to a pharmaceutical composition to further facilitate administration of an active ingredient. Suitable pharmaceutical excipients include starch, glucose, lactose, sucrose, trehalose, gelatin, malt, rice, flour, chalk, silica gel, sodium stearate, glycerol monostearate, talc, sodium chloride, dried skim milk, glycerol, propylene glycol, water, lipids, phospholipids, ethanol, and the like. The composition, if desired, can also contain minor amounts of wetting or emulsifying agents, or pH buffering agents such as acetates, citrates, or phosphates. Antibacterial agents such as benzyl alcohol or methyl parabens; antioxidants such as ascorbic acid or sodium bisulfite; chelating agents such as ethylenediaminetetraacetic acid; and agents for the adjustment of tonicity such as sodium chloride or dextrose are also envisioned.

[00107] According to some embodiments, the AAT provided herein is a purified stable composition of AAT. Preferably, a liquid composition of purified, stable of AAT is provided, preferably 90% pure, preferably 95% pure, more preferably 99% pure AAT as disclosed in WO 2005/027821.

[00108] The following examples are presented in order to more fully illustrate some embodiments of the invention. They should, in no way be construed, however, as limiting the broad scope of the invention. One skilled in the art can readily devise many variations and modifications of the principles disclosed herein without departing from the scope of the invention.

EXAMPLES

Example 1: Clinical Results (1) - treatment of COVID-19 patients with moderate and severe lung disease [00109] Patients were treated at Meir hospital in Israel under 29c off-label use. The patient population included patients infected with SARS-CoV-2 who were hospitalized with moderate and severe lung disease (pneumonia and ARDS).

[00110] The treatment comprised three AAT treatments, each treatment (dose) was 60 mg/kg, administered intravenously, at time 0 and then 48 and 96 hours post the initial treatment.

[00111] All COVID-19 patients in the hospital were admitted to dedicated isolated wards and 15 receive supportive treatment as required. Thromboprophylaxis with low- molecular weight heparin (subcutaneous enoxaparin 40mg once daily) is universal unless contraindicated. Most patients were offered specific therapies for COVID-19, according to Israeli Ministry of Health and local protocols. Experimental treatment for COVID-19 requires informed consent from the patient or from close relatives if the patient is unable to provide it.

[00112] Indications for treatment with hydroxychloroquine, lopinavir-ritonavir, or darunavircobicistat include: a modified National Early Warning Score (modified NEWS) >5 age >65, significant co-morbidities, or according to treating physicians' assessment. Additional experimental therapies including tocilizumab, intravenous AAT, and 25 convalescent plasma, were offered to patients with severe disease on an individual case by-case basis, after specific multidisciplinary discussion including the treating physicians, respiratory and critical care specialists and infectious disease specialists.

[00113] Hydroxychloroquine was given as tablets twice daily, 400mg/dose for the first 2 doses, and 200mg/dose afterwards, for 5-10 days. Lopinavir-ritonavir was given at a dose of 30 200mg and 50mg orally twice daily for 10 days. Darunavir-cobicistat tablets were given 18 once daily at a dose of 800mg and 150mg for 10 days. Tocilizumab was infused intravenously once over 60 minutes dosed at 8mg/kg, not exceeding 800mg. Remdesivir was unavailable, neither as compassionate therapy nor as part of a clinical trial.

[00114] Human liquid preparation of 2% AAT (GLASSIA®, Kamada, Ness 5 Ziona, Israel) was administered intravenously over 2 hours of i.v. infusion in three doses of 60 mgl/kg each on time 0 (the time of the first dose), and 48 and 96 hours thereafter. [00115] AAT was administered at a relatively low dose since in a preclinical study, low concentrations of a protease inhibitor (camostat) were shown sufficient to efficiently inhibit SARS-CoV2 entry into host cells. Thus, it was assumed that a dose of 60mg/Kg will be adequate to establish similar inhibitory effect in patients. This low dose enabled to avoid positive fluid balance and volume overload in our patients. [00116] A summary of all four patients treated with AAT in Meir Hospital is provided in Table 1.

[00117] Table 1: Summary of Clinical data (1)

[00118] The clinical status of three out of four patients was markedly improved upon treatment with AAT, as the endotracheal tube was removed from those patients 9 to 13 days after initiation of AAT treatment. More details of two exemplary patients (patients nos. 1 and 2) are provided below. It is noted that these two patients were critically ill and deteriorating. Both were given the AAT therapy relatively early in their disease course (after 12 and 10 days of symptoms; Table 1), and in both cases significant improvement and stabilization was exhibited within a day following the initiation of AAT treatment, manifested by objective measures such as improvement in the SOFA score and Pa02/Fi02 ratio (P/F ratio), as shown in Figs. 1 and 2.

[00119] Patient No. 1 : A 64-years-old man was admitted for symptomatic COVID- 19. He started to suffer from fever, cough and dyspnea 5 days prior to admission. Past medical history included morbid obesity (body mass index, BMI=42), hypertension, dyslipidemia, urolithiasis and diverticulosis, for which he was treated with ramipril, atorvastatin and ezetimibe. On admission he was febrile 38.9, oxygen saturation was 93% on room air, and bilateral 15 consolidations were noted on chest X-ray (CXR). Due to persistent fever, worsening laboratory tests, and worsening CXR, he began therapy with hydroxychloroquine and darunavir-cobicistat on the 4th hospital day. However, on the 5th hospitalization day his condition worsened with increasing dyspnea and desaturation, requiring oxygen supplementation with a facial mask and later with a high- flow nasal cannula, and he was transferred to the intensive care unit (ICU). During the ensuing 24-hours he developed progressive hypoxemic respiratory failure leading to intubation and mechanical ventilation with need for muscle relaxants, and hemodynamic instability requiring vasopressor support.

[00120] Starting on the 7th hospitalization day he was given 3 doses of AAT (2% AAT, 60 mg/kg) on hospital days 7, 9 and 11. A significant hemodynamic and respiratory improvement was noted after the second dose of AAT, with lower requirements for vasopressors and oxygen support, and radiographic improvement. His course was complicated by sepsis with proteus bacteremia secondary to a urinary tract infection on the 12th hospitalization day (Figs. 1A and IB), but his overall status continued to improve, and he was extubated after 11 days of mechanical ventilation (Figures 1A and IB). His condition continued to improve, and he no longer required oxygen support on hospital day 23. While his COVID-19 swabs remained positive for over a month, he regained full ambulation.

[00121] Patient No. 2: The patient was admitted to the hospital for increasing dyspnea six days after he started to complain of fever and cough and was diagnosed with COVID-19. He was a 56-years old morbidly obese (BMI=44) man with a history of hypertension, diabetes, severe obstructive sleep apnea, gout, psoriatic arthritis, and mild chronic kidney disease. His regular medications were lercanidipine, atorvastatin, aspirin, sulfasalazine, ramipril, spironolactone, ahopurinol, bezafibrate, bisoprolol, colchicine, glimepiride, metformin, lansoprazole, insulin glargine and dulaglutide. On admission he was noted to be severely hypoxemic and required prompt intubation and mechanical ventilation in the ICU. Therapy with hydroxychloroquine and lopinavir- ritonavir was initiated. Gas exchange parameters worsened during the following days and he required muscle relaxation, prone positioning and inhaled nitric oxide (NO) to maintain oxygen saturation, with vasopressor therapy for hypotension. On his 3rd hospital day he was treated with 800mg of tocilizumab, but his respiratory deterioration continued over the next 24 hours. Therapy with A AT initiated on the 4th hospital day and significant improvement was noted during the ensuing day allowing to discontinue prone positioning and inhaled NO, gradually taper down oxygen requirements, and discontinue vasopressors support. There was concomitant improvement of the CXR. His status remained stable, leading to an extubation attempt on the 13th day of hospitalization (Figures 2A and 2B). However, post-extubation he became very dyspneic and was re-intubated. Although his oxygen requirements remained low, a prolonged mechanical ventilation secondary to his co-morbidities was anticipated. Tracheotomy was done to facilitate treatment and respiratory rehabilitation which led to stable, fully alert clinical status and then to the process of weaning from mechanical ventilation, breathing spontaneously with a fraction of inspired oxygen (Fi02) of 30%.

[00122] Patient No. 3 received AAT treatment about one month (28 days) from symptom onset and did not survive. Accordingly, it is concluded that AAT treatment is more effective when given at earlier stages, such as a week or two from symptoms' onset.

[00123] The aforementioned results suggest that AAT exerts a therapeutic effect in COVID-19 patients, preferably, when administered less than a month after the onset of COVID-19 symptoms.

[00124] Given the extensive safety data and a high potential for positive effects, it is believed that the risk/benefit ratio of treating severe COVID-19 patients with AAT is favorable, and warrants an adequately powered prospective trial.

Example 2: Clinical Results (2) treatment of COVID-19 patients with moderate lung disease

[00125] AAT was administered to COVID-19 patients hospitalized at Saarlands University Hospital, Homburg, Germany. Four patients were treated with daily inhalation of 100 mg AAT over 15 min for a maximum of 7 days. Five patients were treated with combined administration routes of AAT: intravenous and inhaled treatments which included daily inhalation of 80 mg AAT and infusion of 60 mg/kg body weight at day 1, 3 and 5. [00126] Based on prior evaluations of anti-viral and anti-inflammatory activities of AAT, the inhaled or combined (inhaled + intravenous) AAT treatments were administered to patients with mild to moderate COVID-19. Specifically, four patients were treated with inhaled AAT, via nebulizer, at a dose of 100 mg/day for 7 days, and five patients (3 females; 2 males) were treated with inhaled AAT at a lower dose (80 mg/day for 7 days) and intravenous AAT infusion at a dose of 60 mg / kg body weight, on days 1, 3 and 5. All patients received, in parallel, standard treatment for COVID-19 and associated complications (e.g. antiviral agents, such as, Remdesivir, and antiinflammatory agents, such as, dexamethasone, and oxygen). Viral load was measured in respiratory specimens.

[00127] Table 2 summarizes the demographic characteristics and baseline (day to AAT treatment = 0) of physiology of COVID-19 patients (n=5) treated with a combination of inhaled and IV AAT.

[00128] Table 2: Demography and baseline physiology of five COVID-19 patients treated with combined AAT administrations

[00129] All patients treated with AAT survived and were discharged from the hospital in good functional status. Furthermore, the respiratory status of eventually improved in all patients. The respiratory status of five COVID-19 patients treated with combined routes of AAT administration, namely, via IV infusion and via nebulizer, from hospital admission to discharge is shown in Figures 4A - 4E, on a scale of 1-6: 1 - spontaneous breathing in ambient air; 2 - oxygen support; 3 - Non-Invasive Ventilation; 4 - High flow oxygen; 5 - mechanical ventilation; 6 - ECMO. Downward arrows indicate the day of AAT administration (treatment).

[00130] Three patients experienced an initial deterioration (results not shown). Serum CRP levels decreased over the days after initiation of the AAT application with individual variations. Virus load was monitored at irregular intervals and turned negative in all patients. No drug-associated side effects, such as allergic reactions, have been observed, mild to moderate COVID-19

[00131] The aforementioned results demonstrate that administration of AAT to patients with mild to moderate COVID-19 is associated with clinical improvement, specifically with decreased inflammation and great functional reconstitution. Hence, the results indicate that AAT is an excellent candidate for the treatment of COVID-19.

[00132] The foregoing description of the specific embodiments will so fully reveal the general nature of the invention that others can, by applying current knowledge, readily modify and/or adapt for various applications such specific embodiments without undue experimentation and without departing from the generic concept, and, therefore, such adaptations and modifications should and are intended to be comprehended within the meaning and range of equivalents of the disclosed embodiments. It is to be understood that the phraseology or terminology employed herein is for the purpose of description and not of limitation. The means, materials, and steps for carrying out various disclosed functions may take a variety of alternative forms without departing from the invention.

Claims

1. A method of treating COVID- 19, the method comprising administering to a subject in need thereof a therapeutically effective amount of a pharmaceutical composition comprising human alpha 1- antitrypsin (A AT).

2. The method of claim 1, wherein the pharmaceutical composition is in a dosage form suitable for intravenous delivery.

3. The method of claim 1, wherein the pharmaceutical composition is in a dosage form suitable for inhalation.

The method of claim 2, wherein said administering is administering via intravenous infusion.

5. The method of claim 1 , wherein said administering comprises administering in a combined treatment regimen comprising administering via intravenous infusion and administering via inhalation.

6. The method of claim 1, wherein the COVID- 19 is mild or moderate.

7. The method of claim 1, wherein the COVID-19 is severe or critical.

8. The method of claim 1 , wherein the A AT is plasma derived, recombinant or transgenic.

9. The method of claim 1, wherein said administering comprises at least one course of administration.

10. The method of claim 9, wherein said administering comprises administering A AT once daily for a plurality of consecutive days.

11. The method of claim 1, wherein said subject in need thereof is a subject being connected to breathing support, and wherein following said treating the subject in need thereof is breathing spontaneously.

12. The method of claim 11 , wherein the breathing support is selected from the group consisting of oxygen support, non-invasive ventilation, high flow oxygen, mechanical ventilation and ECMO.

13. The method of claim 12, wherein the breathing support is selected from oxygen support, non-invasive ventilation and high flow oxygen.

14. The method of claim 1, wherein said subject in need thereof has a P/F ratio lower than 300 and wherein said treating comprises increasing the P/F ratio.

15. The method of claim 14, wherein said subject in need thereof has a P/F ratio lower than 200 and wherein said treating comprises increasing the P/F ratio above 200.

16. The method of claim 1, wherein said subject in need thereof has a SOFA score above zero and wherein said treating comprises reducing the SOFA score.

17. The method of claim 16, wherein said subject in need thereof has a SOFA score above 4 and wherein said treating comprises reducing the SOFA score to 2 or below.

18. The method of claim 1, wherein said treating comprises at least one treatment selected from the group consisting of enhancing viral clearance; reducing hospitalization period; reducing dependency on oxygen support; reducing the need for intensive care; reducing the need for mechanical ventilation; ameliorating at least one symptom of COVID-19, and reducing morbidity.

19. The method of claim 1 , wherein the method further comprises administering one or more additional antiviral agents.

20. The method of claim 19, wherein the one or more additional antiviral agent is selected from the group consisting of a protease inhibitor, a helicase inhibitor, a viral replication inhibitor and a virus cell entry inhibitor.

21. A pharmaceutical composition comprising human alpha 1 -antitrypsin (AAT) for the treatment of COVID-19.

22. The pharmaceutical composition of claim 21, wherein the pharmaceutical composition is in a dosage form suitable for intravenous delivery.

23. The pharmaceutical composition of claim 21, wherein the pharmaceutical composition is in a dosage form suitable for inhalation.

24. The pharmaceutical composition of claim 21, wherein the COVID-19 is mild or moderate.

25. The pharmaceutical composition of claim 21, wherein the COVID-19 is severe or critical.

26. The pharmaceutical composition of claim 21, wherein the AAT is plasma derived, recombinant or transgenic.

27. The pharmaceutical composition of claim 22, wherein said pharmaceutical composition comprises at least one daily dose of AAT for intravenous administration.

28. The pharmaceutical composition of claim 23, wherein said pharmaceutical composition comprises at least one daily dose of AAT for administration via inhalation.

29. The pharmaceutical composition of claim 27, wherein said pharmaceutical composition comprises a plurality of daily doses of AAT for intravenous administration.

30. The pharmaceutical composition of claim 28, wherein said pharmaceutical composition comprises a plurality of daily doses of AAT for administration via inhalation.

31. The pharmaceutical composition of claim 21, wherein said treatment comprises removal from breathing support to spontaneous breathing.

32. The pharmaceutical composition of claim 31 , wherein the breathing support is selected from the group consisting of oxygen support, non-invasive ventilation, high flow oxygen, mechanical ventilation and ECMO.

33. The pharmaceutical composition of claim 32, wherein the breathing support is selected from oxygen support, non-invasive ventilation and high flow oxygen.

34. The pharmaceutical composition of claim 21, wherein said treatment comprises increasing P/F ratio.

35. The pharmaceutical composition of claim 34, wherein said treatment comprises increasing P/F ratio to above 200.

36. The pharmaceutical composition of claim 21, wherein said treatment comprises reducing SOFA score.

37. The pharmaceutical composition of claim 36, wherein said treatment comprises reducing SOFA score to 2 or below.

38. The pharmaceutical composition of claim 21, wherein said treatment comprises at least one treatment selected from the group consisting of enhancement of viral clearance, reduction of hospitalization period, reduction of dependency on oxygen support, reduction of the need for intensive care, reduction of the need for mechanical ventilation, reduction of at least one symptom of COVID-19 and reduction of morbidity.

39. The pharmaceutical composition of claim 21, provided in combination with one or more additional antiviral agents.

40. The pharmaceutical composition of claim 39, wherein the one or more additional antiviral agent is selected from the group consisting of a protease inhibitor, a helicase inhibitor, a viral replication inhibitor and a virus cell entry inhibitor.

41. The pharmaceutical composition of claim 21, wherein said pharmaceutical composition comprises a plurality of doses of AAT comprising at least one dose for administration via inhalation and at least one dose for administration via inhalation.