Therapeutic approaches to pediatric COVID-19: an online survey of pediatric rheumatologists

Abstract

Data on therapy of COVID-19 in immunocompetent and immunosuppressed children are scarce. We aimed to explore management strategies of pediatric rheumatologists. All subscribers to international Pediatric Rheumatology Bulletin Board were invited to take part in an online survey on therapeutic approaches to COVID-19 in healthy children and children with autoimmune/inflammatory diseases (AID). Off-label therapies would be considered by 90.3% of the 93 participating respondents. In stable patients with COVID-19 on oxygen supply (stage I), use of remdesivir (48.3%), azithromycin (26.6%), oral corticosteroids (25.4%) and/or hydroxychloroquine (21.9%) would be recommended. In case of early signs of "cytokine storm" (stage II) or in critically ill patients (stage III) (a) anakinra (79.5% stage II; 83.6% stage III) or tocilizumab (58.0% and 87.0%, respectively); (b) corticosteroids (oral 67.2% stage II, intravenously 81.7% stage III); (c) intravenous immunoglobulins (both stages 56.5%); or (d) remdesivir (both stages 46.7%) were considered. In AID, > 94.2% of the respondents would not support a preventive adaptation of the immunomodulating therapy. In case of mild COVID-19, more than 50% of the respondents would continue pre-existing treatment with immunoglobulins (100%), hydroxychloroquine (94.2%), anakinra (79.2%) or canakinumab (72.5%), or tocilizumab (69.8%). Long-term corticosteroids would be reduced by 26.9% (< = 2 mg/kg/d) and 50.0% (> 2 mg/kg/day), respectively, with only 5.8% of respondents voting to discontinue the therapy. Conversely, more than 75% of respondents would refrain from administering cyclophosphamide and anti-CD20-antibodies. As evidence on management of pediatric COVID-19 is incomplete, continuous and critical expert opinion and knowledge exchange is helpful.

Keywords: Autoimmune disease; COVID-19; Children; Inflammation; Opinion poll; Pediatric rheumatology; SARS-CoV-2; Treatment.

Fig. 1

Therapeutics considered for pediatric COVID-19. The number of respondents expressing their opinion on each treatment option is depicted in each line next to the drug name; number of respondents supporting the particular treatment is shown within the bars; their length reflects proportion of positive responses in case of the given treatment. For better comprehension, the treatment options are split into two main categories (anti-viral and immunomodulatory therapy), though the therapeutic effects might be overlapping. *prednisolone ≤ 2 mg/kg/d, **high-dose prednisolone (10–30 mg/kg/d)

Fig. 2

Opinion on the possible earlier use of particular treatment modalities in course of COVID-19 in patients with increased risk for severe course of viral infections (n = 72 respondents). Number of respondents supporting the given approach is shown at each bar; its length reflects proportion of positive responses

Fig. 3

Opinion on how to approach established anti-inflammatory/immunomodulatory treatment in patients with autoimmune/inflammatory disease (AID) and confirmed mild COVID-19 disease. The number of respondents expressing their opinion on each medication is depicted next to the graph; the number of respondents supporting a particular approach is shown for each bar; its length reflects the proportion of positive responses. The treatment options are arranged in descending order with respect to how strongly physicians felt about continuing treatment despite mild COVID-19