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Int. J. Infect. Dis. · Oct 2020
Early identification of COVID-19 cytokine storm and treatment with anakinra or tocilizumab.
- Annette Langer-Gould, Jessica B Smith, Edlin G Gonzales, Rhina D Castillo, Judith Garza Figueroa, Anusha Ramanathan, Bonnie H Li, and Michael K Gould.
- Los Angeles Medical Center, Department of Neurology, Southern California Permanente Medical Group, 1505 N Edgemont, 5thFloor, Los Angeles, CA 90027, USA. Electronic address: Annette.M.Langer-Gould@kp.org.
- Int. J. Infect. Dis. 2020 Oct 1; 99: 291-297.
ObjectiveTo examine outcomes among patients who were treated with the targeted anti-cytokine agents, anakinra or tocilizumab, for COVID-19 -related cytokine storm (COVID19-CS).MethodsWe conducted a retrospective cohort study of all SARS-coV2-RNA-positive patients treated with tocilizumab or anakinra in Kaiser Permanente Southern California. Local experts developed and implemented criteria to define COVID19-CS. All variables were extracted from electronic health records.ResultsAt tocilizumab initiation (n = 52), 50 (96.2%) were intubated, and only seven (13.5%) received concomitant corticosteroids. At anakinra initiation (n = 41), 23 (56.1%) were intubated, and all received concomitant corticosteroids. Fewer anakinra-treated patients died (n = 9, 22%) and more were extubated/never intubated (n = 26, 63.4%) compared to tocilizumab-treated patients (n = 24, 46.2% dead, n = 22, 42.3% extubated/never intubated). Patients who died had more severe sepsis and respiratory failure and met COVID-CS laboratory criteria longer (median = 3 days) compared to those extubated/never intubated (median = 1 day). After accounting for differences in disease severity at treatment initiation, this apparent superiority of anakinra over tocilizumab was no longer statistically significant (propensity score-adjusted hazards ratio 0.46, 95% confidence interval 0.18-1.20).ConclusionsPrompt identification and treatment of COVID19-CS before intubation may be more important than the specific type of anti-inflammatory treatment. Randomized controlled trials of targeted anti-cytokine treatments and corticosteroids should report the duration of cytokine storm in addition to clinical severity at randomization.Copyright © 2020 Southern California Permanente Medical Group. Published by Elsevier Ltd.. All rights reserved.
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