Latest COVID-19 research finds benefit from prone positioning, arthritis drugs

Prone positioning was helpful in patients not on mechanical ventilation, and two very small studies found positive outcomes with drugs used to treat rheumatoid arthritis. ACP members can join a bulk purchase of N95s and gowns.

Prone positioning improved oxygenation in patients with respiratory failure who weren't yet intubated, according to a study published as a research letter by JAMA Internal Medicine on June 17. It included 25 patients who spent at least an hour in a prone position; four eligible patients declined and were intubated immediately. An hour after initiation of the position, the patients' oxygen saturation (SpO2) had increased (range, 1% to 34%; median, 7%) with no change in the level of supplemental oxygen, and 19 patients had SpO2 of 95% or higher. “In this small single-center cohort study, we found that the use of the prone position for awake, spontaneously breathing patients with COVID-19 severe hypoxemic respiratory failure was associated with improved oxygenation,” the authors said. They called for randomized trials. An editorial agreed about the need for trials but cautioned that a potential concern with this intervention is that it could delay intubation and mechanical ventilation.

The risk for severe COVID-19 infection may vary among different blood types, a recent study found. The genomewide association study, published by the New England Journal of Medicine on June 17, involved 835 severely ill COVID-19 patients and 1255 control participants from Italy and 775 and 950, respectively, from Spain. It found genes that were associated with severe COVID-19, some of which coincided with the ABO blood type. A blood-group-specific analysis found increased risk in blood group A (odds ratio, 1.45; 95% CI, 1.20 to 1.75) and a protective effect in blood group O (odds ratio, 0.65; 95% CI, 0.53 to 0.79). “Our genetic data confirm that blood group O is associated with a risk of acquiring Covid-19 that was lower than that in non-O blood groups, whereas blood group A was associated with a higher risk than non-A blood groups. The biologic mechanisms undergirding these findings may have to do with the ABO group per se … or with other biologic effects of the identified variant,” the authors said.

Two recent studies suggested potential benefits from arthritis drugs in patients hospitalized with COVID-19. The first, published by CHEST on June 15, gave tocilizumab, an interleukin-6 receptor (IL-6R) antagonist, to 153 patients, according to an algorithm targeting cytokine release syndrome (CRS), and looked at outcomes by baseline severity of illness. Among tocilizumab-treated patients requiring mechanical ventilation, survival was 75%. Both oxygenation and inflammatory biomarkers improved after treatment with the drug, but D-dimer levels increased significantly. “Of interest was the observation that survival for severe and non-severe patients in tocilizumab-treated patients did not differ (83% vs 91%; P=0.10), perhaps suggesting that treating CRS, rather than disease severity at admission, may play a role in survival and does so based on the pattern of changes in biomarkers and oxygenation after tocilizumab administration,” the authors said. “Our observation that D-dimer levels increased in tocilizumab-treated patients, unlike the experience in Italy, is concerning, and suggests that IL-6R antagonism may interrupt only part of the hyperinflammatory response of CRS.” The authors called for randomized trials of the drug in COVID-19.

The other study, published by The Lancet Rheumatology on June 16, compared 13 Italian patients who did not require mechanical ventilation at admission and were given the investigational drug mavrilimumab, an anti-granulocyte–macrophage colony-stimulating factor (GM-CSF) receptor-α monoclonal antibody, to 26 controls given standard care. No one in the treatment group died, compared to seven of the controls (P=0.086). Mean time to clinical improvement was significantly faster with the drug (8 days vs. 19 days; P=0.0001). The authors reported that the drug was well tolerated, with no infusion reactions. “These encouraging preliminary results represent the first evidence of a treatment effect in COVID-19 with GM-CSF inhibition; further testing in controlled trials is warranted, and multicentre, double-blind, randomised, placebo-controlled studies are planned on the basis of the signal obtained here,” they said.

In other news of drugs for COVID-19, the FDA warned on June 15 that co-administration of remdesivir and chloroquine phosphate or hydroxychloroquine sulfate is not recommended as it may result in reduced antiviral activity of remdesivir. ACP updated its practice points about use of chloroquine or hydroxychloroquine alone or in combination with azithromycin for prophylaxis or treatment of COVID-19 in a June 17 letter in Annals of Internal Medicine. Six new studies were found; they added support to the College's previous conclusions but resulted in no conceptual changes to the practice points released on May 13.

ACP also published a joint op-ed with the American Medical Association (AMA) on ethical lessons learned from COVID-19. ACP President Jacqueline W. Fincher, MD, MACP, and AMA Immediate Past President Patrice A. Harris, MD, MA, discussed inequities in the health care system in “A Wake-Up Call for American Health Care: Emerging Ethical Lessons from Covid-19,” published June 16 by Modern Healthcare. The op-ed focuses on how the COVID-19 pandemic brought attention to inequities, including distribution of limited health care resources and the disproportionate health impact on communities that have suffered decades of neglect, disinvestment, and marginalization.

To help ACP members who are having trouble acquiring personal protective equipment, the College is partnering with Project N95, a not-for-profit organization, to make a bulk purchase of low-cost, high-quality N95 respirator masks and disposable isolation gowns. This offer is only available to U.S.-based ACP members. All orders must be received by 3 p.m. ET on Friday, June 26. Visit the ACP website for more information and to order.