Optimal Management of Rheumatic Disease During COVID-19 - Episode 4

IL-6 Receptor Blockade in ICU Patients With COVID-19

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Amar Majjhoo, MD: John Stone, MD, PhD, presented a late-breaking abstract at the ACR Convergence [American College of Rheumatology annual meeting] on the use of interleukin-6 [IL-6] inhibition in patients with COVID-19 [coronavirus disease 2019] not on mechanical ventilation. This is important information. This was a randomized, double-blind placebo-controlled trial, a fairly large trial randomizing patients to interleukin-6 inhibition along with standard therapy versus standard therapy alone in patients hospitalized with COVID-19 who had elevated acute phase reactants.

They had to have 2 out of 3 other factors, including temperatures greater than 38 °C, pulmonary infiltrates on imaging, or the need for supplemental oxygen. These were very sick patients, and they were randomized 2:1 to receive standard therapy plus interleukin-6 inhibition versus standard therapy alone. The outcomes they were looking at were the time to ICU [intensive care unit] admission and time to a requirement of mechanical ventilation.

Those were the primary outcomes. The secondary outcomes they were looking at were the time to worsening of clinical picture as well as the time to not requiring oxygen. Basically, this was a negative study. There was no difference in terms of the risk for requiring mechanical ventilation, ICU admission, or death between these 2 groups, the ones that were receiving interleukin-6 inhibition versus those that were not. And similarly, time to improvement and time to worsening of clinical picture was the same as well.

During the course of this pandemic we’ve all been confronted with patients calling and asking about their therapies, and I think this was more true earlier in the pandemic when we knew less. It was nice to see at the ACR Convergence that there was a lot of information that supported the decisions we were making earlier on. We may have been more conservative in the beginning. And there are data to support that a lot of the treatment changes that were being made prior to the ACR coming out with their recommendations in early, mid-April, that a lot of the treatment decisions and changes in therapies were driven by patient preferences.

The patients were making changes to their therapies. After the ACR recommendations, a lot of the treatment decisions that were occurring were physician driven. That’s because we have a better foundation. In terms of what I’ve been doing with my patients, it’s been reinforced by what my colleagues have been doing and what was presented at the ACR Convergence, and that is in stable patients on therapy, we are not recommending that they stop or interrupt therapy.

It’s important for them to practice all the measures that we all need to be practicing. That includes social distancing, handwashing, the use of masks. The nice thing was that early in the pandemic we had these concerns that we might see a lot of infections in our patients or worse outcomes. That wasn’t the case, at least in my practice and from the colleagues I’ve talked to and the experiences that I’ve heard. I think part of that has to do with the fact that our patients, prior to the pandemic or during the pandemic, didn’t need a lot of convincing.

They were the first ones to buy into using masks and social distancing and handwashing. They were well aware that they had a chronic underlying autoimmune inflammatory disease and they needed to be very careful. There was a lot of concern about the continuation of medication, and we got a lot of questions in the beginning. But as things have played out, we’ve made the right treatment decisions in encouraging our patients to continue on therapy because the benefits seem to be outweighing the risks.

And certainly, our patients, based on the information that we have, are not at an increased risk of COVID-19 or complications thereof based on their disease or their therapies. Perhaps it’s the other factors and comorbidities that play a bigger role.

Transcript Edited for Clarity