Best Treatments for COVID-Related MIS-C Save

The RECOVERY trial focused on pediatric MIS-C patients treated with immunomodulators and anti-cytokine therapy demonstrated the benefits of first-line therapy with intravenous methylprednisolone or second-line tocilizumab in children refractory to initial treatment. Neither IV immunoglobulin nor anakinra benefitted the duration of hospital stay.

The pediatric outcomes of the RECOVERY trial assessed outcomes in multisystem inflammatory syndrome in children (MIS-C) patients were treated with either intravenous immunoglobulin or corticosteroids (versus usual care); or if refractory with tocilizumab or anakinra. The primary endpoint was the duration of hospital stay.  This was a randomised, controlled, open-label, platform trial in 51 UK hospitals and included patients younger than 18 years hospitalized for MIS-C.

A total of 237 children were enrolled and 214 patients entered the first randomisation (73 IVIG; 61 methylprednisolone, 80 usual care). For those not responding, 70 children entered the second randomisation (28 receives tocilizumab, 14 anakinra, and 28 usual care). Mean age was 9·5 years.  The mean duration of hospital stay was :

• IVIG: 7·4 days
• Usual care: 7·6 days
• Methylprednisolone: 6·9 days
• Tocilizumab (2nd line): 6·6 days
• 2nd line Usual Care: 9·9 days
• Anakinra: 8·5 days

Two persistent coronary artery aneurysms were reported among patients assigned to usual care in the first randomisation. There were few cardiac arrythmias, bleeding, or thrombotic events in any group. Two children died; neither was considered related to study treatment.

Optimal therapy in COVID related MIS-C appears to be first-line intravenous methylprednisolone, and if needed, second-line tocilizumab.