2021 update of the EULAR points to consider on the use of immunomodulatory therapies in COVID-19 (Part 3)

We now take a look at the overarching principles and points to consider on the use of immunomodulatory treatment in Coronavirus disease (Covid), with levels of evidence (LoE) and levels of agreement (LoA).

The phenotype of SARS- CoV- 2 infection is heterogeneous which
ranges from asymptomatic to severe disease that can be deadly.

With SARS- CoV- 2 infection the treatment approach is multifaceted which may include antiviral, oxygen therapy, anticoagulation and/or immunomodulatory treatment applied at different stages of the disease.

For non- hospitalized patients infected with SARS- CoV- 2 virus, there is no solid evidence suggesting the use of immunomodulatory therapy.

Moreover, for hospitalized Covid patients with SARS- CoV- 2 that do not need oxygen therapy, there is no solid evidence showing that immunomodulatory therapy may help in treating the said infection.

Hydroxychloroquine is something that should not be used as treatment as it does not provide any additional benefit and could worsen the prognosis in patients with severe form of the disease particularly if the patient also takes azithromycin.

For Covid patients who need supplemental oxygen, it best to use
non-invasive or mechanical ventilation, and systemic glucocorticoids. These drugs may help decrease the chance of mortality.

For Covid patients who need to have supplemental oxygen,
non-invasive or mechanical ventilation combination of glucocorticoid, the use of tocilizumab is something to be considered as it is able to drastically lower the chances of mortality or reduce disease progression.

More data are needed to fully appreciate the effect of other types of inhibitors.

There is no solid evidence showing that the use of anakinra or
canakinumab can be helpful in treating Covid infection at any stage
of the disease. The use of low- dose colchicine is not helpful at any
stage of Covid infection.

For Covid patients needing oxygen therapy, non- invasive ventilation or high- flow oxygen, it is best to consider the use of combination of glucocorticoids and baricitinib or tofacitinib.

In an evolving landscape of protocol based on studies and randomized control trials, experts do not recommend the use of Granulocyte-Macrophage Colony-Stimulating Factor (GM- CSF)!inhibitors, such as mavrilimumab, otilimab, lenzilumab, for the treatment of Covid.

Convalescent plasma should not be used in patients without
hypogammaglobulinemia and with symptom onset less than 5 days.

For patients at risk of severe Covid, symptom onset less than 5 days or still seronegative, monoclonal antibodies against SARS- CoV- 2 spike protein should be administered.

We will be adding more guidelines as we continue our discussion
next week.