A Pediatric Rheumatologist’s Approach to Severe COVID-19 Illness
Severe life-threatening and life-taking COVID-19 illness has been devastating for many patients and families. More successful treatment is desperately needed. [1, 2] In this article a pediatric rheumatologist’s suggestions for improved treatment of severe COVID illness are summarized. This set of suggestions is best viewed as a hypothesis, regarding how treatment of severe COVID illness might be improved.
Hypothesis: A high percentage of patients with severe, life-threatening COVID-19 Illness could be successfully treated, if an aggressive, compulsive pediatric rheumatology treatment approach were implemented.
This hypothesis posits that the number of COVID deaths and the stress of COVID on ICU capacities, could be markedly reduced, if patients with severe COVID-19 illness were proactively studied for viral load (using SARS-CoV-2 PCR Ct values for guidance, as explained in a companion article) and treated in a timely and precise fashion with anti-viral therapies (when needed) and appropriately aggressive immunosuppression (when anticipatory monitoring reveals presence of hyperinflammatory, hyperimmune reactions).
The bases for this hypothesis, and details about a “pediatric rheumatology approach,” are fully explained and referenced in a longer article (LONG VERSION) entitled, Treatment of Severe COVID-19 Illness—A Pediatric Rheumatologist’s Perspective and Proposed Treatment Protocol, which may be found on the “Notes from the Social Clinic” website: https://notesfromthesocialclinic.org/treatment-of-severe-covid-19-illness/
The above hypothesis is based on an understanding that in many cases of severe COVID-19 illness (the exact percentage is not yet known) the main problem is not ongoing active viral infection, but an array of excessive, life-threatening immune reactions triggered by the virus (hyperinflammatory, hyperimmune, autoimmune reactions, often with “cytokine storm”) [3-13]—reactions that need to be suppressed in order to save life. Many severely ill patients may need only immunosuppression (because their viral infection has already come under adequate control). Others may need only anti-viral therapies (because their main problem is difficulty eradicating the virus, and they are not experiencing excessive immune reactions). Some patients may need both immunosuppression (e.g., corticosteroid and/or anti-cytokine therapy) and antiviral therapies (e.g., remdesivir, monoclonal antibodies, convalescent plasma, or interferon alpha 2b, or combinations of these). Treatment needs to be tailored to the patient’s specific situation and must be timely and precise.
The exact percentage of severely ill patients that fall into each of the above categories has not yet been determined. Preliminary data suggest that the largest category may be those who are suffering primarily (even only) from severe hyperimmune/hyperinflammatory reactions and, therefore, primarily (even only) need timely immunosuppression. [3-13]
According to this hypothesis: If patients with early, brewing severe COVID-19 illness are promptly recognized, carefully monitored, accurately interpreted, and promptly treated with appropriately aggressive immunosuppression (when indicated) or anti-viral therapies (when indicated), or both (in a timely fashion and in proportion to need), it is more likely that they can be saved, often without need to go to the ICU, often without residual long-term complications.
The life-threatening hyperimmune/hyperinflammatory reactions mentioned above are not new or unique to COVID-19 infection. For many years it has been known that life-threatening hyperinflammation and “cytokine storm” occur with many bacterial infections and with many other viral infections, including seasonal influenza infection. 
Over the past 40 years pediatric rheumatologists have developed extensive experience with excessive immune reactions (hyperinflammatory, hyperimmune, autoimmune, and cytokine storm reactions), including how to bring them under control. [14-32] Much of this experience has come from managing systemic onset juvenile idiopathic arthritis (formerly called juvenile rheumatoid arthritis) that has become complicated by “macrophage activation syndrome” and “cytokine storm.” The pediatric rheumatology approach to hyperinflammatory states is characterized by early, anticipatory, appropriately compulsive, serial monitoring; prompt and appropriately bold immunosuppression of hyperinflammation, carefully using corticosteroid and specific anti-cytokine therapies (e.g., anakinra); and careful, anticipatory, tailored adjustments along the way—always balancing concerns about risks versus benefits.
Pediatric rheumatologists have experienced remarkable success with this approach to treatment of hyperinflammatory/hyperimmune reactions, whether triggered by infection or occurring as a complication of rheumatic disease. [14-32] This approach can dramatically bring life-threatening cytokine storm under control, often within 1-4 days. Prior to development of this treatment approach, morbidity and mortality were high.
To date, the pediatric rheumatology approach described in this article (and succinctly detailed in the Appendix of the longer, full article) has not been commonly or fully applied to treatment of adults with severe COVID illness. For example, Ct values have not been routinely used to estimate viral load; use of corticosteroid has been hesitant; anakinra has not been frequently used; and when anti-cytokine therapies have been used, they have often been used late in the disease course, rather than early.
In short, the hypothesis presented in this article is: A “pediatric rheumatology approach,” when applied to management of severe COVID-19, has great potential to save lives, prevent organ damage, reduce ICU admissions, minimize need for mechanical ventilation, shorten length of hospital and ICU stays, prevent “long hauler” COVID complications, and reduce hospital costs; and, in the process, could reduce fears, angst, moral stress, hopelessness, and a sense of powerlessness among patients, families, physicians, nurses, other health care workers, and the public. Details of this approach are provided in the long, full article mentioned earlier.
There is already considerable scientific support for this hypothesis. [3-13] Further study, of course, is needed, and urgently so. In the meantime, the public, especially patients who develop severe COVID illness, deserve to know what approaches and treatment options are available for management of severe COVID-19 illness.
Robert M Rennebohm, MD
About the Author: https://notesfromthesocialclinic.org/about-me/
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