‘Strongly recommended’: new ERS advice on anti-IL-6 mAbs and JAK inhibitors in COVID

Use of IL-6 receptor antagonist monoclonal antibodies (mAb) and JAK inhibitors for the management of COVID-19 in hospitalised patients has received strong backing from the European Respiratory Society (ERS).

In the second version of the ERS Living Guideline on the Management of COVID, published in the European Respiratory Journal, the recommendation on IL-6 receptor antagonist mAb was upgraded to ‘strongly recommended’ on the back of data from 12 randomised controlled trials (RCTs) which better clarified their benefit with regard to mortality and the need for ventilatory support.

JAK inhibitors, particularly baricitinib, received a strong recommendation following a completed review of data from the RECOVERY trial, which showed a 20% reduction in mortality in patients hospitalised with COVID-19.

“Importantly, 95-96% of patients were receiving corticosteroids and 23% were receiving tocilizumab in RECOVERY and the efficacy and safety of baricitinib was not affected by co-administration with tocilizumab,” noted the authors, which included Professor James Chalmers of Dundee University, Scotland.

“This therapy therefore receives a strong recommendation and … may be administered as an alternative to anti-IL6 therapy, or in combination with anti-IL6 therapy in patients at the highest risk”.

The expert group also backed mAb treatment with casirivimab and imdevimab but opted to limit its use to patients who are seronegative and known to have, or are likely to have, infection with a susceptible variant, as this group is most likely to experience a mortality benefit from treatment based on current data.

On the flip side, conditional recommendations for use of azithromycin, azithromycin and hydroxychloroquine in combination and colchicine were downgraded to ‘strongly against’, after further RCTs confirmed a lack of benefit in hospitalised patients.

The review also found no evidence suggesting a benefit from use of convalescent plasma, and as such the group issued a strong recommendation against this treatment, but the authors did note that this “does not exclude the possibility of this treatment being effective in highly selected patient subgroups that were not included in the trials (e.g., highly immunosuppressed patients with prolonged disease and viral excretion)”.

Other changes include: a recommendation for first line use of CPAP, as this was shown to reduce the need for mechanical ventilation, and conditional backing for high flow nasal oxygen in patients who cannot tolerate or are not suitable for CPAP.

As in the first version of the living guideline, systematic corticosteroids remain the standard of care for patients with severe COVID-19 who need oxygen therapy or ventilatory support.

Also, while anticoagulation “should continue to be standard care for hospitalised COVID-19 patients”, the evidence “does not conclusively favour either prophylactic or therapeutic dose and so both may be appropriate in different patients based on their risk of bleeding versus embolic complications,” the group noted.

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