Abstract
Data on therapy of COVID-19 in immunocompetent and immunosuppressed children are scarce. We aimed to explore management strategies of pediatric rheumatologists. All subscribers to international Pediatric Rheumatology Bulletin Board were invited to take part in an online survey on therapeutic approaches to COVID-19 in healthy children and children with autoimmune/inflammatory diseases (AID). Off-label therapies would be considered by 90.3% of the 93 participating respondents. In stable patients with COVID-19 on oxygen supply (stage I), use of remdesivir (48.3%), azithromycin (26.6%), oral corticosteroids (25.4%) and/or hydroxychloroquine (21.9%) would be recommended. In case of early signs of “cytokine storm” (stage II) or in critically ill patients (stage III) (a) anakinra (79.5% stage II; 83.6% stage III) or tocilizumab (58.0% and 87.0%, respectively); (b) corticosteroids (oral 67.2% stage II, intravenously 81.7% stage III); (c) intravenous immunoglobulins (both stages 56.5%); or (d) remdesivir (both stages 46.7%) were considered. In AID, > 94.2% of the respondents would not support a preventive adaptation of the immunomodulating therapy. In case of mild COVID-19, more than 50% of the respondents would continue pre-existing treatment with immunoglobulins (100%), hydroxychloroquine (94.2%), anakinra (79.2%) or canakinumab (72.5%), or tocilizumab (69.8%). Long-term corticosteroids would be reduced by 26.9% (< = 2 mg/kg/d) and 50.0% (> 2 mg/kg/day), respectively, with only 5.8% of respondents voting to discontinue the therapy. Conversely, more than 75% of respondents would refrain from administering cyclophosphamide and anti-CD20-antibodies. As evidence on management of pediatric COVID-19 is incomplete, continuous and critical expert opinion and knowledge exchange is helpful.
Highlights
ACR American College of Rheumatology ADE Antibody dependent enhancement autoimmune/inflammatory diseases (AID) Autoimmune/inflammatory disease COVID-19 Corona virus disease 2019 Food and Drugs Administration (FDA) Food and Drug Administration HCQ Hydroxychloroquine intravenous immunoglobulins (IVIG) Intravenous immunoglobulins JAK Janus kinase MERS Middle east respiratory syndrome coronavirus SARS Severe acute respiratory syndrome coronavirus based on case series, retrospective cohort studies, pathophysiological considerations, or are derived from data on adult populations
It became apparent that the shared expertise of rheumatologists and clinical immunologists is critical in the treatment of COVID-19 patients, as a significant proportion of adult and few pediatric patients develop hyperinflammatory disease [1,2,3,4,5,6,7]
While the course of COVID-19 in healthy children is usually asymptomatic or mild when compared to adults [8, 9], a hyperinflammation syndrome timely associated with SARS-CoV-2 has been described in a subset of pediatric patients in Europe and North America [2, 10,11,12,13]
Summary
ACR American College of Rheumatology ADE Antibody dependent enhancement AID Autoimmune/inflammatory disease COVID-19 Corona virus disease 2019 FDA Food and Drug Administration HCQ Hydroxychloroquine IVIG Intravenous immunoglobulins JAK Janus kinase MERS Middle east respiratory syndrome coronavirus SARS Severe acute respiratory syndrome coronavirus based on case series, retrospective cohort studies, pathophysiological considerations, or are derived from data on adult populations. As low-quality evidence and expert opinion prevail, continuous inter-collegial discussion facilitate clinical decision making. We present results of an online opinion poll among international pediatric rheumatologists on: (a) possible general therapy concepts in COVID-19 in children and adolescents and (b) clinical management of pediatric patients with AID-receiving immunomodulation treatment in the context of SARS-CoV-2 pandemic
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