Multidisciplinary Guidance Regarding the Use of Immunomodulatory Therapies for Acute Coronavirus Disease 2019 in Pediatric Patients

Journal of the Pediatric Infectious Diseases Society - Tập 9 Số 6 - Trang 716-737 - 2020
Daniel E. Dulek1, Robert C. Fuhlbrigge2, Alison C. Tribble3, James A. Connelly4, Michele Loi5, Hassan El Chebib6, Shanmuganathan Chandrakasan7, W Otto8, Caroline Diorio9, Garrett Keim10, Kelly Walkovich11, Preeti Jaggi12, Jennifer E Girotto6,13, April Yarbrough14, Edward M. Behrens15, Randy Q. Cron16, Hamid Bassiri8
1Division of Pediatric Infectious Diseases, Department of Pediatrics, Vanderbilt University Medical Center , Nashville, Tennessee , USA
2Section of Rheumatology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
3Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan, USA
4Division of Pediatric Hematology Oncology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
5Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine, Denver, Colorado, USA
6Division of Infectious Diseases and Immunology, Department of Pediatrics, Connecticut Children's, Hartford, Connecticut, USA
7Division of Pediatric Hematology/Oncology, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
8Division of Infectious Diseases, Department of Pediatrics, Children’s Hospital of Philadelphia, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania, USA
9Division of Oncology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
10Division of Critical Care Medicine, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
11Division of Pediatric Hematology Oncology, Department of Pediatrics, University of Michigan Medical School, Ann Arbor, Michigan, USA
12Division of Pediatric Infectious Diseases, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
13University of Connecticut School of Pharmacy, Storrs, Connecticut, USA
14Department of Pharmacy, Children's of Alabama, Birmingham, Alabama, USA
15Division of Pediatric Rheumatology, Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
16Division of Pediatric Rheumatology, Department of Pediatrics, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama, USA

Tóm tắt

AbstractBackgroundImmune-mediated lung injury and systemic hyperinflammation are characteristic of severe and critical coronavirus disease 2019 (COVID-19) in adults. Although the majority of severe acute respiratory syndrome coronavirus 2 infections in pediatric populations result in minimal or mild COVID-19 in the acute phase of infection, a small subset of children develop severe and even critical disease in this phase with concomitant inflammation that may benefit from immunomodulation. Therefore, guidance is needed regarding immunomodulatory therapies in the setting of acute pediatric COVID-19. This document does not provide guidance regarding the recently emergent multisystem inflammatory syndrome in children (MIS-C).MethodsA multidisciplinary panel of pediatric subspecialty physicians and pharmacists with expertise in infectious diseases, rheumatology, hematology/oncology, and critical care medicine was convened. Guidance statements were developed based on best available evidence and expert opinion.ResultsThe panel devised a framework for considering the use of immunomodulatory therapy based on an assessment of clinical disease severity and degree of multiorgan involvement combined with evidence of hyperinflammation. Additionally, the known rationale for consideration of each immunomodulatory approach and the associated risks and benefits was summarized.ConclusionsImmunomodulatory therapy is not recommended for the majority of pediatric patients, who typically develop mild or moderate COVID-19. For children with severe or critical illness, the use of immunomodulatory agents may be beneficial. The risks and benefits of such therapies are variable and should be evaluated on a case-by-case basis with input from appropriate specialty services. When available, the panel strongly favors immunomodulatory agent use within the context of clinical trials. The framework presented herein offers an approach to decision-making regarding immunomodulatory therapy for severe or critical pediatric COVID-19 and is informed by currently available data, while awaiting results of placebo-controlled randomized clinical trials.

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