Glucocorticoids may serve as an alternative to IVIG or combination therapies for MIS-C

In patients with the multisystem inflammatory syndrome in children (MIS-C), glucocorticoids alone showed similar recovery rates, including incidence and resolution of coronary artery aneurysms, as intravenous immunoglobin (IVIG), or combination therapy with both, according to findings published in The Lancet Rheumatology.

Dr. Samuel Channon-Wells and co-researchers analyzed the data collected from the Best available Treatment Study to compare glucocorticoids with IVIG therapy in a propensity-weighted cohort study. The analysis of 2101 children reported no significant differences among treatment groups (primary treatment with IVIG, IVIG + glucocorticoids, glucocorticoids alone, other biologics, and no immunomodulators). Compared to IVIG alone, the adjusted odds ratios for ventilation, inotropic support, or mortality were 1.09 (p=1.00) for IVIG with glucocorticoids and 0.93 (p=1.00) for glucocorticoids alone, respectively. For IVIG + glucocorticoids, the adjusted average hazard ratios for time to improvement were reported as 1.04 (p=1.00), whereas for glucocorticoids alone, they were 0.84 (p=0.22). Compared to IVIG alone, treatment escalation was less common with IVIG + glucocorticoids (p<0.0001) and glucocorticoids alone (p=0.014). Experts reported a reduced risk of persistent fever in the IVIG and glucocorticoids group compared to the other groups. Therefore, in terms of cost-effectiveness and the limited availability of IVIG in many countries, glucocorticoid therapy was reported to be a safe alternative to IVIG or combination therapy.

A 2021 study compared IVIG treatment and methylprednisolone to IVIG alone among children with MIS-C. They found a better fever course with combined treatment, as well as with IVIG alone. Similarly, the current study also reported a lower fever course with IVIG and glucocorticoid treatment. The use of second-line therapy (odds ratio [OR], 0.19), hemodynamic support (OR, 0.21), acute left ventricular dysfunction occurring after initial therapy (OR, 0.20), and length of stay in the pediatric intensive care unit were all significantly reduced when IVIG and methylprednisolone therapy was used instead of IVIG alone (median, 4 vs. 6 days). The IVIG and methylprednisolone treatment was associated with a favorable fever course. A lower risk of treatment failure was also associated with IVIG and methylprednisolone treatment than IVIG alone (OR, 0.25; P =.008).

The current study suggests that glucocorticoid therapy may be a safe and cost-effective alternative to IVIG or combination therapy for MIS-C, considering the limited availability of IVIG in many countries.

References

  1. Channon-Wells S, Vito O, McArdle AJ, Seaby EG, Patel H, Shah P, Pazukhina E, Wilson C, Broderick C, D’Souza G, Keren I. Immunoglobulin, glucocorticoid, or combination therapy for multisystem inflammatory syndrome in children: a propensity-weighted cohort study. The Lancet Rheumatology. 2023 Feb 14.
  2. Ouldali N, Toubiana J, Antona D, Javouhey E, Madhi F, Lorrot M, L├ęger PL, Galeotti C, Claude C, Wiedemann A, Lachaume N. Association of intravenous immunoglobulins plus methylprednisolone vs immunoglobulins alone with course of fever in multisystem inflammatory syndrome in children. Jama. 2021 Mar 2;325(9):855-64.