Adding Infliximab to Immunoglobulin in COVID-Related MIS-C Appears Beneficial

NEW YORK (Reuters Health) – For multisystem inflammatory syndrome in children (MIS-C), initial therapy with intravenous immunoglobulin (IVIG) plus infliximab is associated with better outcomes than IVIG alone, according to new study.

Children treated with IVIG plus infliximab were less apt to need additional therapy, had better cardiac outcomes, a more rapid decline in C-reactive protein and left the intensive-care unit sooner than peers given IVIG only, report researchers from the University of Colorado and Children’s Hospital Colorado in Aurora.

The best treatment for MIS-C, a hyper-inflammatory syndrome associated with COVID-19 infection, remains unclear. Adding methylprednisolone to IVIG as initial treatment may improve outcomes, but less is known about adding infliximab, Dr. Lyndsey Cole and colleagues note in Pediatrics.

They took a look back at 72 children with MIS-C who were treated with IVIG alone or with infliximab at their center.

The primary outcome was need for additional therapy 24 hours or more after treatment initiation.

Additional therapy was needed in 13 of 20 (65%) children who received IVIG alone versus 16 of 52 (31%) who received IVIG plus infliximab (P=0.01).

Median time spent in the ICU was 3.3 days with IVIG alone versus only 1.8 days with IVIG plus infliximab (P=0.001).

“Importantly, our study revealed improved cardiac outcomes in patients who received IVIG plus infliximab,” the researchers write.

New or worsened left ventricular dysfunction developed in four of 20 (20%) children given IVIG only versus two of 52 (4%) given IVIG with infliximab (P=0.05) and new vasoactive-medication requirement developed in three of 20 (15%) and two of 52 (4%), respectively (P=0.13).

Twenty-four hours after treatment, there was no change in CRP levels in the IVIG-only group compared with a 46% median decline in the IVIG plus infliximab group; at 48 hours, median declines were 5% and 70%, respectively (P<0.001).

There was no significant difference in hospital length of stay, time to fever resolution, vasoactive-medication duration or need for diuretics.

Summing up, the researchers say this retrospective study shows improvement in several outcomes with initial intensified therapy consisting of IVIG plus infliximab.

The researchers say limitations of their study include the single-center, retrospective, observational design. Also, they did not perform propensity-score matching because of the small sample size and relative similarity between groups.

Because there is no definitive diagnostic test, some patients who did not have MIS-C might have been included. However, only patients who met the CDC MIS-C case definition were included, and the demographic, clinical, and laboratory characteristics of the cohort were similar to those previously reported.

“Future randomized controlled trials are necessary to confirm these findings and to compare initial therapy with IVIG alone, IVIG plus infliximab, and IVIG plus corticosteroids. Comparative effectiveness trials, which may be more feasible, may also provide insight into optimal initial MIS-C therapy,” the study team says.

The study had no external funding and the authors indicate no relevant disclosures.

SOURCE: Pediatrics, released November 19, 2021.

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