Individualising management of COVID-19 based on real-time inflammatory responses

An open-access paper in CID proposes further individualising management of COVID-19 to include choice of treatment to reduce immune inflammation and anti-cytokine treatment in selected patients. Current studies, for example using the IL-6 blocker tocilizumab, are used as COVID-19 treatment without entry criteria that include baseline markers.

For example, the inflammatory response – the cytokine storm – in progressing COVID-19 has been compared to conditions that include classical acute respiratory distress syndrome (ARDS), macrophage activation syndrome (MAS) or hemophagocytic lymphohistiocytosis (HLH), but that is likely different to all of these.

The paper describes current understanding of immune responses to COVID-19 and highlights a range of therapeutic responses that might help, although with a caution that treating these symptoms might still not improve clinical responses. For example, prostaglandin E1, ketoconazole and GM-CSF have not been effective with ARDS (in studies that did not individualise immune profiles of participants).

The paper suggests that drugs like tocilizumab or anakinra might only be appropriate in a subset of patients with the most severe elevations in systemic pro-inflammatory cytokines (e.g. IL-6 levels >1,000 pg/mL).

It also suggests that treatment should be guided by real-time changes in the immunophenotype and using short-acting drugs so that protocols can adapt to the dynamic nature of immune response over time.

The paper concludes that management of immune modulation in COVID-19 has wide inter-patient variability and should adapt to the dynamic nature of the individual pathogenesis and related immune response.