Infectious Disease

No difference in MIS-C recovery results between IVIG, glucocorticoids, combined therapy

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McArdle does not report any relevant financial information. Please refer to the study for all relevant financial information from the other authors.

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There is no evidence that recovery from multisystem inflammatory syndrome in children differs after treatment with glucocorticoids alone, intravenous immunoglobulin alone, or a combination of both.

“Because the coronary artery aneurysm is an important overlapping feature of both [multisystem inflammatory syndrome (MIS-C)] and Kawasaki disease, intravenous immunoglobulin (IVIG), the proven treatment for Kawasaki disease, has been widely adopted as first line therapy and withholding IVIG is viewed by some clinicians as unacceptable. ” Andrew J. McArdle, MB, BChir, from Imperial College London, and colleagues wrote in the New England Journal of Medicine.

There is no evidence that recovery from MIS-C differs after treatment with glucocorticoids alone, IVIG alone, or a combination of the two according to the data.

“However, some children with MIS-C recover from supportive care alone, so aggressive attempts to suppress the inflammatory response may not necessarily be of clinical benefit,” they added. “Randomized trials are needed to establish the most effective treatment for MIS-C.”

To provide evidence for MIS-C treatment recommendations, McArdle and colleagues conducted an international observational cohort study of clinical and outcome data that doctors uploaded to an online database. Because the accuracy of the definitions currently used for MIS-C is unknown – with experience suggesting a spectrum of inflammatory diseases post COVID-19 – researchers included children who met the published criteria as well as those with suspected inflammatory disease according to SARS-CoV. 2 infection.

In total, McArdle and colleagues included data from 614 pediatric patients from 81 hospitals in 34 countries, all uploaded from June 20, 2020 to February 24. Of these children, 246 received primary IVIG treatment alone, 208 received IVIG plus glucocorticoid combination, and 99 received glucocorticoids alone. In addition, 22 patients received other treatment combinations, including biologics, while 39 received no immunomodulatory therapy.

Researchers used inverse probability weighting and generalized linear models to analyze IVIG alone as a reference, compared to glucocorticoids alone and combination therapy with both. There were two primary endpoints: a combination of inotropic assistance or mechanical ventilation through day 2 or later, or death, and a reduction in disease severity on an ordinal scale by day 2. Secondary endpoints included treatment escalation and time to reduction in organ failure and inflammation.

According to the researchers, 56 patients treated with IVIG plus glucocorticoids received inotropic or ventilatory assistance or died with an adjusted odds ratio of 0.77 compared to IVIG alone (95% CI 0.33-1.82). Meanwhile, 17 patients who received glucocorticoids alone experienced inotropic or ventilatory assistance or death (0.54; 95% CI 0.22-1.33). The adjusted ORs for reduced disease severity were similar between the IVIG alone (0.93) and combination groups (0.9) compared to IVIG alone. The time to reduction in disease severity was similar in all three groups.

“In a pragmatically defined international cohort of patients with suspected MIS-C, we found no evidence of significant differences in the two primary endpoints in children who received the three most common treatments for this disease (IVIG alone, IVIG plus glucocorticoids and glucocorticoids alone). ), ”Wrote McArdle and colleagues.

“However, when we limited the analyzes to patients who met WHO criteria for MIS-C, we found modest evidence of benefit with glucocorticoids alone versus IVIG alone for both primary endpoints,” they added. “The confidence intervals for inferences about the treatment effect allow the possibility of an actual benefit of one or more of the treatments in comparison to the others.”

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COVID-19 and rheumatology

COVID-19 and rheumatology

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