Background: Multiple case reports have shown promising results with remdesivir, tocilizumab and convalescent plasma. We evaluated the efficacy and safety of combination therapy with remdesivir, tocilizumab, steroids, antibiotics and convalescent plasma in COVID-19 patients. Objectives: To assess whether a multi-pronged approach to tackling SARS-CoV-2 had an impact on our primary end goal of decreasing the need for mechanical ventilation and identify some of the complexities involved with combination treatment regimens. Methods: In this retrospective, single center study, six confirmed SARS-CoV-2 patients with similar demographics and comorbidities treated with a combination of remdesivir, tocilizumab, antibiotics, steroids and convalescent plasma were followed. Results: At the time of initiation of treatment, all six patients were requiring at least 3 liters of supplemental oxygenation via nasal cannula. All patients received remdesivir for 5 - 10 days, tocilizumab for a total of 4 doses each across 2 days, methylprednisone and antibiotics. Commonly used antibiotics were cefepime, azithromycin, ceftriaxone and piperacillin/tazobactam. Convalescent plasma was given to three out of the six patients. Despite combination therapy with remdesivir, tocilizumab, steroids, antibiotics and convalescent plasma, four out of the six patients (66.67%) deteriorated and required invasive mechanical ventilation. Conclusions: There are currently no set treatment guidelines for COVID 19. Most institutions appear to be utilizing some form of combination therapy against COVID-19. In this study, invasive mechanical ventilation was avoided in only two of six patients despite robust use of combination therapy in all patients. Our study suggests that multiple medications may not be the answer. Instead, a clearer understanding of the pathophysiology along with timing at which medications are introduced might play a more important role. We propose judicious use of combination therapy in a methodical and sequential use in patients requiring three or more liters of supplemental oxygen. Use of any of these medications, either by itself or in combination, after mechanical ventilation has minimal if any benefits and should be used as a last resort. Currently, a few clinical trials in the recruiting stage are underway that look at various combination therapies that could provide a more comprehensive understanding regarding the efficacy of combination therapy against SARS-CoV-2.
Background:Giant cell arteritis is the most common chronic systemic vasculitis in older adults. Permanent visual loss is the most concerning complication can occur in up to 20% of patients (1). Diagnosis is based on a combination of clinical findings, laboratory evidence of inflammatory markers, and temporal artery biopsy (TAB) confirming histologic evidence of inflammation. There are no definitive markers of the disease when TAB is negative.Objectives:The objective of this study was to illustrate the clinical features of subjects suspected with GCA evaluated at the Dallas Veterans Affairs Medical Center (VAMC) and identify those features that would differentiate between TAB positive GCA, TAB negative GCA and non-GCA patients.Methods:This retrospective study searched the Dallas VAMC database for subjects between January of 2010 until December 2019 with ICD-9 and ICD-10 entry code for GCA. Based on the 1990 ACR clinical classification criteria for GCA, suspected patients were classified as TAB positive GCA, TAB negative GCA and non-GCA. Subjects with incomplete data needed for classification were excluded. Group comparisons were performed with Fisher’s exact test for categorical variables and the Mann-Whitney test for continuous variables.Results:One-hundred and sixty-nine subjects had ICD-9/10 entry code for GCA. Ophthalmology was the specialty who did the initial evaluation in 46% of the suspected cases. Seventy-one patients were excluded due to incomplete data. Of the remaining 98 patients, 42 (42.9%) were diagnosed with GCA out of which 10 patients had a positive TAB. Seventy-six percent of patients diagnosed with GCA had negative temporal artery biopsies. In 56 (57.1%) patients GCA was ruled out (Figure 1). New-onset headache was the predominant symptom suggestive of GCA affecting 88.9% TAB positive and 100% of TAB negative cases compared to 56.6% of non-GCA patients (p< 0.001), followed by scalp tenderness in 33.3%, 58.1% and 10.9%, respectively (p< 0.001), jaw claudication in 57.1%, 34.5% and 14.9% (p=0.021), and elevated sedimentation rate in 33%, 65.6% and 33% (p=0.013) (Table 1). Polymyalgia rheumatica was present in 28.6% and 21.7% of patients diagnosed with GCA compared to zero percent in non-GCA cases (p=0.017). More than 30% of patients with GCA had normal acute phase reactants in this cohort.Table 1.Comparison of demographics and clinical features of patients with suspected GCAGCA TAB Positive (n=10)GCA - TAB Negative (n=32)non-GCA (n=56)n%n%n%pAge (mean/sd)71.3 (7.8)67.3 (8.1)67.3 (8.9)0.367Male99030/3293.851/5691.10.885Clinical findingsNew onset headache8/988.932/3210030/5356.6<0.001Visual symptoms9/109022/3268.842/5477.80.351Jaw claudication4/757.110/2934.57/4714.90.021PMR2/728.65/2321.70/3000.017Scalp tenderness2/633.318/3158.15/4610.9<0.001Fever0/505/2321.72/355.70.117ESR > 501/333.321/3265.618/5433.30.013CRP > 101/333.35/3016.76/5411.10.473Anemia (hemoglobin < 12 g/ dl)2/728.615/3246.921/5240.40.642Thrombocytosis (platelets >400)2/728.63/329.44/517.80.228Conclusion:There is clinical heterogeneity within the patients diagnosed with GCA regardless of TAB. A high index of clinical suspicion needs to be the cornerstone of diagnosis. There is need for new classification criteria to include patients with negative TAB.References:[1]Soriano A, et al. Nat Rev Rheumatol. 2017 Aug;13(8):476-484.Disclosure of Interests:Adela Castro: None declared, Jiby Mathew: None declared, Ola Azzouqah: None declared, Jesus Diaz: None declared, Andreas Reimold Consultant of: Lilly, Grant/research support from: AbbviePfizerGilead, Kyawt Shwin: None declared
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