Monday, February 15, 2021

New(old) treatments for COVID: inhaled budesonide & the -umabs

 - Jennifer Middleton, MD, MPH

Although the Biden administration appears to be on track to meet its goal of 100 million COVID vaccines given in its first 100 days, the United States (US) is still unlikely to get most adults fully vaccinated before early 2022. With nearly 97,000 persons a day diagnosed with COVID-19 in the US last week, the need for effective COVID-19 treatment measures isn't going away any time soon. Researchers have identified two classes of medications that may benefit patients with symptomatic COVID-19, both well-known medications already in use for other conditions.

A small trial in the United Kingdom (UK) randomized 146 persons with mild COVID-19 to receive either inhaled budesonide (Pulmicort) or "usual care;" as with many COVID studies, this study's results have been publicized prior to full peer review and publication. The researchers used a composite end point of urgent care visit, emergency department visit, or hospitalization and found a number needed to treat of 8 to prevent 1 of those events. The small size of this trial may make it tempting to dismiss its findings, but as inhaled budesonide is generally well-tolerated and is relatively inexpensive, it still may be reasonable to use. Several other larger trials are currently underway evaluating inhaled budesonide, including the PRINICIPLE trial in the UK. 

Persons with more severe COVID-19 may benefit from tocilizumab or sarilumab, interleukin-6 receptor antagonists currently used for persons with rheumatoid arthritis. Last week, the UK's National Health Service informed its physicians that a trial randomizing 800 participants in intensive care for COVID which compared these two medications to usual care found that "[h]ospital mortality was 28.0% (98/350) for tocilizumab, 22.2% (10/45) for sarilumab and 35.8% (142/397) for [the] control [group]." Smaller trials had been less promising for this class of medications, though these studies were conducted earlier in the pandemic:

More studies will be needed to clarify when, and in which patients, tocilizumab and sarilumab work best, and to untangle why their benefits cropped up clearly in some studies, but not others.... It’s also challenging to compare studies coming out now to earlier trials that were conducted when the virus was much less understood, treatments were doled out with less know-how and mortality rates were even higher.

It remains to be seen whether the US Food and Drug Administration (FDA) and/or the Centers for Disease Control and Prevention (CDC) will follow the UK's lead and formally recommend these treatments for COVID-19, though it's heartening that research efforts continue to identify ways to lessen its burden. The AFP By Topic on Coronavirus Disease 2019 (COVID-19) has a section on "Treatment" which includes this Rapid Evidence Review of Outpatient Management of COVID-19 if you'd like to read more.