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Baricitinib versus tocilizumab in critically ill COVID-19 patients: A retrospective cohort study
Grace M Conroy1, Seth R Bauer1, Andrea M Pallotta1
1Department of Pharmacy, Cleveland Clinic, Cleveland, Ohio, USA.
Insights
Baricitinib showed better outcomes than tocilizumab in critically ill COVID-19 patients. This study compared these immunomodulators, finding baricitinib associated with improved clinical progression scores.
Area of Science:
- Immunology and Infectious Diseases
- Critical Care Medicine
- Pharmacology
Background:
- Immunomodulators like tocilizumab and baricitinib are used for severe COVID-19.
- Comparative data on their clinical outcomes is limited.
- A tocilizumab shortage necessitated a shift to baricitinib, enabling direct comparison.
Purpose of the Study:
- To compare clinical outcomes in critically ill COVID-19 patients treated with tocilizumab versus baricitinib.
- To evaluate the impact of these immunomodulators on patient recovery trajectories.
Main Methods:
- Retrospective, observational cohort study.
- Generalized estimating equation models used for analysis.
- World Health Organization Clinical Progression Scale (WHO-CPS) at days 7 and 14 as primary and secondary outcomes.
Main Results:
- 507 critically ill COVID-19 patients included (217 tocilizumab, 290 baricitinib).
- Tocilizumab use was associated with significantly higher odds of worse WHO-CPS scores at day 14 (aOR 1.65) and day 7 (aOR 1.65) compared to baricitinib.
- No significant differences in mortality or adverse events were observed between the groups.
Conclusions:
- Baricitinib demonstrated superior clinical outcomes compared to tocilizumab in critically ill COVID-19 patients.
- Baricitinib use was linked to better recovery as measured by WHO-CPS scores.
- Findings suggest baricitinib may be a preferred immunomodulator for this patient population.
Objectives:
The immunomodulators tocilizumab and baricitinib improve outcomes in severely ill patients with coronavirus disease 2019 (COVID-19); however, comparative analyses of clinical outcomes related to these agents are lacking. A tocilizumab national shortage shifted treatment to baricitinib in critically ill patients, allowing for an outcome comparison in a similar population. The purpose of this study is to compare clinical outcomes in critically ill COVID-19 patients who received tocilizumab and those who received baricitinib.
Design:
Retrospective, observational cohort study using generalized estimating equation models, accounting for clustering by hospital and known confounders, to estimate the proportional odds of the ordinal World Health Organization Clinical Progression Scale (WHO-CPS) score at day 14, the primary outcome. Secondary outcomes included WHO-CPS score at day 7.
Setting:
Multiple hospitals within the Cleveland Clinic Health System.
Patients:
Adult patients admitted for COVID-19 between January 2021 and November 2021.
Interventions:
Receipt of tocilizumab, before its shortage, or baricitinib, during shortage.
Measurements And Main Results:
In total, 507 patients were included; 217 received tocilizumab and 290 received baricitinib. Over 96% of patients required ICU admission and 98% received concomitant dexamethasone. Tocilizumab recipients had higher (worse) baseline WHO-CPS scores. After adjustment, tocilizumab use was associated with higher odds of a worse day 14 WHO-CPS score compared with baricitinib (adjusted odds ratio [OR] 1.65 [95% confidence interval (CI) 1.10-2.48]). Similarly, after adjustment, tocilizumab use was associated with higher odds of a worse day 7 WHO-CPS score (adjusted OR 1.65 [95% CI 1.22-2.24]).
Conclusions:
Baricitinib use was associated with better WHO-CPS scores at day 14 and day 7 compared with tocilizumab in a cohort of critically ill patients with COVID-19. The odds of having a one unit increase in WHO-CPS score at day 14 was 71% higher with tocilizumab than baricitinib. No difference in mortality or adverse effects was noted.
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