Examining the use of immunomodulatory medication to treat MIS-C

When treating multisystem inflammatory syndrome in children (MIS-C), does an initial treatment with intravenous immune globulin with glucocorticoids perform better than just intravenous immune globulin?

In late April 2020, a mysterious condition, likely a post-COVID-19 complication, was reported in children in the United Kingdom, the United States, and other countries and was subsequently named multisystem inflammatory syndrome in children (MIS-C). A study in the New England Journal of Medicine reports on the efficacy of using immunomodulatory medications for treatment.1

The investigators examined the surveillance data on patients aged younger than 21 years who had MIS-C and were admitted to 1 of 58 hospitals in the United States between March 15 and October 31, 2020. Intravenous immune globulin (IVIG) given on day 0 was compared to IVIG plus glucocorticoids. The primary outcome examined was cardiovascular dysfunction, which was a composite of left ventricular dysfunction or shock resulting in the use of vasopressors, either on or after day 2 treatment. Secondary outcomes included being administered adjunctive treatment on or after day 1 as well as a persistent or recurrent fever on or after day 2.

There were 518 patients with MIS-C who were given at least 1 immunomodulatory therapy. Seventy-five percent of the patients had been previously health and 9 subsequently died. Initial treatment with IVIG with glucocorticoids was linked to a lower risk of cardiovascular dysfunction than treatment with IVIG alone (17% vs. 31%; risk ratio, 0.56; 95% CI, 0.34 to 0.94). The chance of the components of the primary outcomes was lower in patients who received IVIG plus glucocorticoids: left ventricular dysfunction occurred in 8% and 17% of the patients, respectively (risk ratio, 0.46; 95% CI, 0.19 to 1.15), and shock resulting in vasopressor use in 13% and 24% (risk ratio, 0.54; 95% CI, 0.29 to 1.00). Adjunctive therapy was used less in patients who had IVIG plus glucocorticoids than in patients who only received IVIG alone (34% vs. 70%; risk ratio, 0.49; 95% CI, 0.36 to 0.65). Fever risk was roughly the same for both groups (31% and 40%, respectively; risk ratio, 0.78; 95% CI, 0.53 to 1.13).

The investigators concluded that the use of IVIG along with glucocorticoids initially to treat MIS-C was tied to a lower risk of both new or persistent cardiovascular dysfunction.

Reference

1. Son M, Murray N, Friedman K, et al. Multisystem inflammatory syndrome in children — initial therapy and outcomes. New England Journal of Medicine. 2021;385(1):23-34. doi:10.1056/nejmoa2102605