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Editorial
To immunosuppress: whom, when and how? That is the question with COVID-19
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  1. Kevin L Winthrop1,
  2. Xavier Mariette2,3
  1. 1 Divisions of Infectious Diseases and Public Health, Oregon Health and Sciences University, Portland, Oregon, USA
  2. 2 Rheumatology, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Paris-Sud, Hôpital Bicêtre, Le Kremlin Bicêtre, France
  3. 3 Université Paris-Sud, Center for Immunology of Viral Infections and Autoimmune Diseases (IMVA), Institut pour la Santé et la Recherche Médicale (INSERM) UMR 1184, Université Paris-Saclay, Le Kremlin Bicêtre, France
  1. Correspondence to Dr Kevin L Winthrop, School of Public Health, Oregon Health and Science University, Portland, OR 97239, USA; winthrop{at}ohsu.edu

https://doi.org/10.1136/annrheumdis-2020-218694

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    In ARD, Ramiro et al report a number of sophisticated primary and sensitivity analyses from an observational cohort study conducted in the Netherlands during the height of the COVID-19 ‘first wave’ in Europe.1 After a difficult March 2019 of high hospitalisation and death rates with COVID-19, on 1 April their institution started a standard protocol of treating patients with COVID-19 with high-dose methylprednisolone for 5–7 days during which time individuals not showing clinical improvement were also given the interleukin 6 (IL-6) receptor-blocking agent tocilizumab. The authors of the present study observed outcomes with this strategy and retrospectively compared these outcomes with similarly ill patients with COVID-19 treated with standard of care within the month prior. This comparison group included no patients treated with either methylprednisolone or tocilizumab. Patients eligible for the study included those with hypoxia, evidence of COVID-19 pneumonia and an elevation of at least two of the following: high C-reactive protein (>100 mg/L), high serum ferritin (>900 µg/L at one occasion, or a twofold increase of the level at admission within 48 hours) and high D-dimer level (>1500 µg/L). It should be noted that only one patient enrolled into this interventional study was on mechanical ventilation at the time of enrolment. While the two cohorts appeared similar in levels of illness, slight differences in anticoagulation use between the two groups were observed and the authors could not control for other potential unmeasured confounders related to the two different time periods (eg, changing practices in ventilation). The authors explicitly and elegantly discuss the potential for such unmeasured confounding, acknowledge the limitations of observational studies and conducted a number of sensitivity analyses to mitigate these concerns. All of their analyses suggest the same direction and magnitude of effect, namely that patients in the steroid with/without tocilizumab group fared …

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