Abstract:Highlights
Dexamethasone, or alternative steroids, are recommended in severe COVID-19.
The use of tocilizumab in COVID-19, with or without steroids, is still controversial.
Risk for mortality was assessed in 186 COVID-19 patients receiving tocilizumab.
Mortality was associated with older age, chronic heart failure and liver disease.
In tocilizumab-treated patients, the additional use of steroids was beneficial.
“…Excluding 1157 non-pertinent titles or abstracts, we retrieved in complete form and assessed 11 studies according to the selection criteria. ( Figure 1 ) Six studies were further excluded because of our prespecified exclusion criteria: five because not randomized 18 , 19 , 20 , 21 , 22 and one because not reporting outcomes of randomized patients. 23 Figure 1 Flow-chart of articles selection.…”
Conclusions: Corticosteroids may be considered in severe critically ill patients with COVID-19 but must be discouraged in patients not requiring oxygen therapy. Urgently, further trials are warranted before implementing this treatment worldwide.
“…Excluding 1157 non-pertinent titles or abstracts, we retrieved in complete form and assessed 11 studies according to the selection criteria. ( Figure 1 ) Six studies were further excluded because of our prespecified exclusion criteria: five because not randomized 18 , 19 , 20 , 21 , 22 and one because not reporting outcomes of randomized patients. 23 Figure 1 Flow-chart of articles selection.…”
Conclusions: Corticosteroids may be considered in severe critically ill patients with COVID-19 but must be discouraged in patients not requiring oxygen therapy. Urgently, further trials are warranted before implementing this treatment worldwide.
“…This effect was already described in another small trial that showed that a course of high-dose methylprednisolone, followed by tocilizumab if needed, may accelerate respiratory recovery, lower hospital mortality, and reduce the likelihood of invasive mechanical ventilation [ 30 ]. Moreover, another large cohort study showed that the use of corticosteroids in addition to tocilizumab therapy decreased in-hospital mortality [ 31 ]. By contrast, a meta-analysis on tocilizumab that included mostly observational studies did not show any additive effects if corticosteroids and tocilizumab were administered together [ 24 ].…”
The mortality of COVID-19 patients in the intensive care unit (ICU) is influenced by their state at admission. We aimed to model COVID-19 acute respiratory distress syndrome state transitions from ICU admission to day 60 outcome and to evaluate possible prognostic factors. We analyzed a prospective French database that includes critically ill COVID-19 patients. A six-state multistate model was built and 17 transitions were analyzed either using a non-parametric approach or a Cox proportional hazard model. Corticosteroids and IL-antagonists (tocilizumab and anakinra) effects were evaluated using G-computation. We included 382 patients in the analysis: 243 patients were admitted to the ICU with non-invasive ventilation, 116 with invasive mechanical ventilation, and 23 with extracorporeal membrane oxygenation. The predicted 60-day mortality was 25.9% (95% CI: 21.8%–30.0%), 44.7% (95% CI: 48.8%–50.6%), and 59.2% (95% CI: 49.4%–69.0%) for a patient admitted in these three states, respectively. Corticosteroids decreased the risk of being invasively ventilated (hazard ratio (HR) 0.59, 95% CI: 0.39–0.90) and IL-antagonists increased the probability of being successfully extubated (HR 1.8, 95% CI: 1.02–3.17). Antiviral drugs did not impact any transition. In conclusion, we observed that the day-60 outcome in COVID-19 patients is highly dependent on the first ventilation state upon ICU admission. Moreover, we illustrated that corticosteroid and IL-antagonists may influence the intubation duration.
“…Multiple drugs have been repurposed to treat severe SARS-CoV-2 infections presenting with systemic hyperinflammatory syndrome, some of them having an immunosuppressive effect such as corticosteroids, tocilizumab, anakinra, etc. [ 4 , 5 , 6 , 7 ]. Therefore, reactivation of several dormant infections, including latent tuberculosis infection (LTBI), is of concern among COVID-19-treating physicians.…”
Performance of the QuantiFERON-TB Gold Plus (QFT-Plus) assay could be affected by conditions of immune dysregulation. Little is known about the reliability of QTF-Plus in COVID-19 patients. Our aim was to determine the prevalence and the factors related to an indeterminate QFT-Plus test in COVID-19 hospitalized patients, and to analyze its relationship with in-hospital mortality. A retrospective analysis of all hospitalized COVID-19 patients on whom a QTF-Plus assay was performed in a tertiary care public hospital during the first epidemic wave in Spain (March–April 2020). Out of a total of 96 patients included, 34 (35.4%) had an indeterminate result, in all cases due to a lack of response in the mitogen control. Factors related to COVID-19 severity, such as higher lactate dehydrogenase (LDH) (odds ratio [OR] 1.005 [95% confidence interval [CI] 1.002–1.008]) and previous administration of corticosteroids (OR 4.477 [95% CI 1.397–14.345]), were independent predictors for indeterminate QFT-Plus assay. Furthermore, indeterminate results were more frequent among COVID-19 patients who died during hospitalization (29.1% vs. 64.7%; p = 0.005). We conclude that QFT-Plus assay yielded an unexpected, high prevalence of indeterminate results in severe COVID-19 patients. Factors related to worse COVID-19 outcome, such as LDH, as well as corticosteroid use before the QFT-Plus assay, seem to be predictors for an indeterminate result. The role of an indeterminate QFT-Plus result in predicting COVID-19 severity and mortality should be evaluated.
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