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180-Day Outcomes in Critically Ill Patients With COVID-19

Half-year outcomes in critically ill patients with COVID-19 show similar outcomes with interventions in any of 6 common treatment domains. Patients in the REMAP-CAP ongoing adaptive platform trial who received treatment with an IL-6 receptor antagonist had a greater than 99.9% probability of improved 180-day mortality, and those treated with an antiplatelet agent had a 95.0% probability of improved 180-day mortality compared with patients randomized to the control.

In Mar. 2020 until Jun. 2021, 4,869 critically ill patients with COVID-19 randomly received 1 or more interventions within 6 treatment domains: immune modulators (n = 2,274), convalescent plasma (n = 2,011), antiplatelet therapy (n = 1,557), anticoagulation (n = 1,033), antivirals (n = 726), and corticosteroids (n = 401). The following results were identified based on a main outcome of survival through day 180: “Among 4,869 randomized patients (mean age, 59.3 years; 1,537 [32.1%] women), 4,107 (84.3%) had known vital status and 2,590 (63.1%) were alive at day 180. IL-6 receptor antagonists had a greater than 99.9% probability of improving 6-month survival (adjusted HR, 0.74 [95% credible interval {CrI}, 0.61-0.90]) and antiplatelet agents had a 95% probability of improving 6-month survival (adjusted HR, 0.85 [95% CrI, 0.71-1.03]) compared with the control, while the probability of trial-defined statistical futility (HR >0.83) was high for therapeutic anticoagulation (99.9%; HR, 1.13 [95% CrI, 0.93-1.42]), convalescent plasma (99.2%; HR, 0.99 [95% CrI, 0.86-1.14]), and lopinavir-ritonavir (96.6%; HR, 1.06 [95% CrI, 0.82-1.38]) and the probabilities of harm from hydroxychloroquine (96.9%; HR, 1.51 [95% CrI, 0.98-2.29]) and the combination of lopinavir-ritonavir and hydroxychloroquine (96.8%; HR, 1.61 [95% CrI, 0.97-2.67]) were high. The corticosteroid domain was stopped early prior to reaching a predefined statistical trigger; there was a 57.1% to 61.6% probability of improving 6-month survival across varying hydrocortisone dosing strategies.”

Editorial: “One unavoidable limitation of the present study and its applicability to current practice is that COVID-19 as a disease has changed,” editorialists write. “Although infection with SARS-CoV-2 is still very much with us, preexisting population-level immunity, from vaccination, prior infection, or both, has made severe disease progressively less common. There is also laboratory evidence that the widely circulating Omicron variant exhibits decreased lung infectivity, making pneumonia—the clinical entity most commonly leading to intensive care unit admission—a less likely manifestation of disease. The evidence in this study remains valuable given that COVID-19 will continue to be a common cause of critical illness globally. However, the most effective strategy to reduce mortality and critical illness will be prevention through a global effort to expand COVID-19 vaccination.”

Source: JAMA