Weekly Update: January 28th - February 4th

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Welcome to the McGraw Hill COVID-19 channel. This week we have information about the differences in clinical presentation of the British strain, more information about outcomes in pregnancy, and a revised NIH recommendation on ivermectin (now “insufficient data to recommend either for or against”). We also have a revised NIH recommendation for tocilizumab and sarilumab.

Loss of smell and taste are less common with the British variant B.1.1.7 while sore throat, cough, myalgias and fatigue are more common. This is a report covering cases in England from 15 November 2020 to 16 January 2021 reported by the British Office for National Statistics. They looked at 3583 positive COVID-19 samples of whom 52% were positive for B1.1.7. Fewer patients with the B1.1.7 variant presented with loss of smell and taste, but they were more likely to have cough, myalgias, sore throat and fatigue.

There are two take home points. First, B1.1.7 has rapidly become a common strain in Britain, reflected its increased infectivity. Second, don’t ignore patients with “atypical” symptoms. They may still have COVID-19. The full report can be found here.

Mhase E. Covid-19: Sore throat, fatigue, and myalgia are more common with new UK variant BMJ 2021; 372 doi: https://doi.org/10.1136/bmj.n288 (Published 29 January 2021)

We have more data about the outcomes of pregnancy in those infected with SARS-CoV-2. This is a retrospective study using the “Premier Healthcare Database” which encompasses about 20% of US hospitalizations. 406,446 women were hospitalized for delivery between April and November 2020 of whom 1.6% had COVID-19. Overall mortality in those with COVID-19 was low (0.1%) although it was higher than in those with COVID-19 (adjusted OR 26 (CI 95% 11.26—60.38)). Pre-eclampsia (but not eclampsia) was higher in those with COVID-19; stillbirths were the same in both groups. Venous thromboembolism was higher in those with COVID-19  (0.2% versus 0.1% p<0.001). The full study can be found here.

This data is reassuring and consistent with other studies. While risks to the pregnant woman with COVID-19 are higher than in those who are not infected, the absolute risks are still low.  The full study can be found here.   

Jering KS, Claggett BL, Cunningham JW, et al. Clinical Characteristics and Outcomes of Hospitalized Women Giving Birth with and without COVID-19. JAMA Intern Med. Published online January 15, 2021. doi:10.1001/jamainternmed.2020.9241

NIH guidelines have changed the recommendation for ivermectin to “there are insufficient data to recommend either for or against the use of ivermectin”. This is an upgrade from the previous “recommend against” status. The NIH statement points out that much of the data is not randomized/blinded and that outcomes were often not well defined. They call for more data from randomized controlled studies.

This gives cover for those prescribing ivermectin for COVID-19. By report, randomized controlled studies are in the pipeline which should give “definitive” answers on the use of ivermectin. The full NIH statement  can be found here.

NIH COVID-19 Treatment Guidelines. The COVID-19 Treatment Guidelines Panel’s Statement on the Use of Ivermectin for the Treatment of COVID-19, Last Updated: January 14, 2021 https://www.covid19treatmentguidelines.nih.gov/statement-on-ivermectin

Lastly, the status of tocilizumab and sarilumab have also been upgraded to “there are insufficient data to recommend either for or against the use of” for some patients. The panel still recommends against tocilizumab and sarilumab in those not in the ICU. The consideration here is a bit more nuanced than for ivermectin with a separate recommendation for those in the ICU versus those on a regular hospital floor. The panel suggests:

  • “For patients who are within 24 hours of admission to the ICU and who require invasive or noninvasive mechanical ventilation or high-flow oxygen (>0.4 FiO2/30 L/min of oxygen flow), there are insufficient data to recommend either for or against the use of tocilizumab or sarilumab for the treatment of COVID-19.
    • Although many trials of tocilizumab for the treatment of COVID-19 have included patients who meet the above criteria, the collective data available to date preclude a definitive recommendation for or against the use of the drug.
    • In view of the results from the REMAP-CAP trial, some Panel members would administer a single dose of tocilizumab (8 mg/kg of actual body weight, up to 800 mg) in addition to dexamethasone to patients who meet the above criteria and who are also exhibiting rapid progression of respiratory failure.
    • Too few patients in REMAP-CAP received sarilumab for the Panel to assess its efficacy in the treatment of patients who met the above criteria.
  • For patients who do not require ICU-level care or who are admitted to the ICU but do not meet the above criteria, the Panel recommends against the use of tocilizumab or sarilumab for the treatment of COVID-19, except in a clinical trial (BIIa).”

Even though sarilumab are included together as a class, the panel points out that the studies of sarilumab are limited. For now, tocilizumab has better data. The panel has suggested criteria and a dosing schedule to follow for tocilizumab pending more data on both drugs. The full NIH statement can be found here.

  • NIH COVID-19 Treatment Guidelines. The COVID-19 Treatment Guidelines Panel’s Statement on the Use of Tocilizumab (and Other Interleukin-6 Inhibitors) for the Treatment of COVID-19 Last Updated: February 3, 2021 https://www.covid19treatmentguidelines.nih.gov/statement-on-tocilizumab/

 

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