key: cord-0742456-j79agexa
authors: nan
title: Evolving evidence for immunosuppressants in COVID-19
date: 2021-02-01
journal: Aust Prescr
DOI: 10.18773/austprescr.2020.086
sha: 4fe473484b3d5b4100ff08273e1f617a40dd5512
doc_id: 742456
cord_uid: j79agexa

nan

Evidence in COVID-19 continues to evolve at a rapid pace. While the promise of certain therapeutic options has not materialised, other medicines have emerged from clinical trials with proven clinical efficacy.

While early observational data were promising, tocilizumab failed to improve clinical status and reduce mortality in the COVACTA trial 1 or prevent intubation in the BACC Bay trial. 2 Dexamethasone, in contrast, has demonstrated some clinical and mortality benefit in advanced disease in the RECOVERY trial. 3 As Ajay Shukla points out, the adverse effects of corticosteroids are broad and potentially long-term and should be closely monitored. 4, 5 Despite dexamethasone, mortality rates remain high. Successful strategies potentially hinge on strategic selection of the mode and timing of immunomodulation in appropriate clinical settings. Refining this treatment paradigm may only be achieved through rigorous clinical trial evaluation.

Trials evaluating the efficacy and safety of multiple immunosuppressive therapies, including tumour necrosis factor inhibitors 6 and tyrosine kinase inhibitors, 7 continue as we still grapple with this evolving global health crisis. Resources such as the Australian National COVID-19 Clinical Evidence Taskforce's Living Guidelines 8 provide a useful reference point, with important clinical information and summation of emerging evidence for healthcare workers.

While evidence evolves, therapies will either be discounted as unsafe or ineffective or be validated and approved as standard of care. As therapeutic validation occurs, it is important to remember that prescribing outside of clinical trials remains off label and should be conducted in an ethical and considered manner. 9 

Immunosuppression for COVID-19: repurposing medicines in a pandemic

Altered lipid metabolism in recovered SARS patients twelve years after infection

RECOVERY Collaborative Group. Dexamethasone in hospitalized patients with Covid-19 -preliminary report

COVACTA trial raises questions about tocilizumab's benefit in COVID-19

BACC Bay Tocilizumab Trial Investigators. Efficacy of tocilizumab in patients hospitalized with Covid-19

RECOVERY Collaborative Group. Dexamethasone in hospitalized patients with Covid-19 -preliminary report

Saudi Critical Care Trial Group. Corticosteroid therapy for critically ill patients with Middle East respiratory syndrome

Use of corticosteroids in coronavirus disease 2019 pneumonia: a systematic review of the literature

Accumulating evidence suggests anti-TNF therapy needs to be given trial priority in COVID-19 treatment

Baricitinib improves respiratory function in patients treated with corticosteroids for SARS-CoV-2 pneumonia: an observational cohort study

National COVID-19 Clinical Evidence Taskforce. Caring for people with COVID-19. Living guidelines

Off-label prescribing