SCCM Pod-504 CCM: Baricitinib or Tocilizumab for Severe COVID-19

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Host Marilyn N. Bulloch, PharmD, BCPS, FCCM, is joined by Joy Peterson, PharmD, BCPS, BCIDP, and Neha Paranjape, MD, MPH, to discuss the article, "Outcomes and Adverse Effects of Baricitinib Versus Tocilizumab in the Management of Severe COVID-19,” (Crit Care Med. March 2023 51(3):337-346) which delves into the comparative outcomes, mortality rates, and adverse effects of baricitinib and tocilizumab in severe COVID-19 cases. Dr. Peterson is a Clinical Pharmacy Specialist in infectious disease, and Dr. Paranjape is an Infectious Disease Specialist at Wellstar Health System in Marietta, Georgia.

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Transcript:

Dr. Bulloch: Hello and welcome to the Society of Critical Care Medicine podcast. I’m your host, Dr. Marilyn Bulloch. Today I’ll be speaking with Dr. Joy Peterson, PharmD, BCPS, BCIDP, and Dr. Neha Paranjape, MD, MPH. We will be talking about the article, “Outcomes and Adverse Effects of Baricitinib Versus Tocilizumab in the Management of Severe COVID-19,” published in the March 2023 issue of Critical Care Medicine. To access the full article, visit ccmjournal.org.

Dr. Peterson is a clinical pharmacy specialist in infectious disease at Wellstar Kennestone Hospital Pharmacy in Marietta, Georgia. Dr. Paranjape is an infectious disease specialist practicing infectious disease and internal medicine, also at Wellstar Health System in Marietta, Georgia. I want to welcome you ladies. Before we start, does anybody have anything to disclose?

Dr. Paranjape: I do not.

Dr. Peterson: I just need to disclose the off-label use of tocilizumab that we’ll be discussing.

Dr. Bulloch: Thank you again, both of you, for joining us today. I was really excited to read your article. I do think everybody in critical care has done a lot of COVID-19 over the past three years. Let’s talk about how this project first began back in October of 2021. I think we’d probably been using both of these drugs for a while by that time, and right around that time period there were other studies that had really showed a mortality benefit with the two drugs individually. What was the big driving factor for the two of you to begin developing your study? We can start with Dr. Paranjape, if you will.

Dr. Paranjape: Sure. This was really more of a collective idea and credit to Joy since she thought of this and and thought of doing this study. Clinically, we had both the drugs available for some periods of time, and there were times when tocilizumab was not available due to a shortage. In those cases, we were using baricitinib and, really, the decision to decide which drug to give was dependent on the preference of the treating physician, and we didn’t really have data to support one over the other. This question was raised as to which drug would be the better option to use in our patients, maybe the safer option to use with better outcomes. That was the driving force for this study. Joy, if you want to add.

Dr. Peterson: I think you really described it very well. It was a very obvious question that we had within our health system. The NIH guidelines were really recommending either agent with no preference for one versus the other, and there was really no other data out there to help with that decision of one versus the other. It’s probably the most common question I received during this time frame was, which of these two agents should I be prescribing for this particular patient? I know we all like to be data driven when we can and practice evidence-based medicine, but I think a lot of us during this time frame were thrown into a situation where there was no evidence and there was no data.

In our weekly team meetings throughout the system, where we were discussing updates for COVID-19 management, this question came up, so we knew that we needed to review the data. But knowing the size of our health system and the number of patients that we saw, we felt like we would really be able to have a sufficient amount of data to contribute and help answer this question for other physicians, other health systems as well. So I immediately reached out to Dr. Paranjape as a respected colleague and friend and asked if she would be interested in embarking on this.

Dr. Bulloch: One of the things that has been interesting for hospitals across the country is, not every hospital can store both of these drugs or can afford to store both of these drugs. They’re both very expensive. I know the hospital that I’ve worked in, we early on made the decision maybe not to use baricitinib right away. Did cost of the drug impact the decision either at the health system level or even the individual prescriber level, or was it solely driven by what was available?

Dr. Peterson: We were very, very fortunate that our leadership was willing to allocate whatever funds were possible and necessary to be able to have the best treatments that we could. The limitation and drivers for use were not really cost based, but definitely availability began having a huge impact. That’s another reason that we felt like we may have some good data to contribute because, due to a shortage of tocilizumab, we knew that there were patients who ended up receiving baricitinib who otherwise would have received tocilizumab. So we knew that we would have potentially pretty comparable populations there to look at between the two groups and evaluate the outcomes.

Dr. Paranjape: Just to add very quickly, the subset of patients who were on mechanical ventilation or ECMO, tocilizumab was the preferred agent at that point just prior to the study and during the study period. But due to the shortages of tocilizumab, we were able to use baricitinib in those patients. Then, like was mentioned earlier, we had a comparable population because of that.

Dr. Bulloch: Dr. Paranjape, I was going to ask you to follow up on what Dr. Peterson was talking about. Does that sound pretty consistent between availability and maybe mechanical ventilation status in terms of how you as a prescriber choose between the two drugs? Are there ever any other considerations that you think about?

Dr. Paranjape: On the clinical side of things, yes. I think, from the beginning, the shortage of tocilizumab was an issue, specifically at our health system, and I’m pretty sure at other health systems around the country. Also, depending on the acuity of how sick these patients were, that would definitely be a driving force personally for me in choosing one agent over the other.

Dr. Bulloch: Dr. Peterson, will you walk our audience through your study just a little bit? It is a retrospective study; I think most of us are probably familiar with that design. But can you tell us how you decided to set up, for example, the methods and what triggered your decision to do propensity score matching and everything else that went into this study?

Dr. Peterson: Sure. As you mentioned, it is a retrospective observational design. As I had previously mentioned, we felt like we would have a good enough population size of comparable patients that this would be worthwhile to pursue. First, of course, we defined the population that we were wanting to study and pulled in all patients who had received at least one dose of one of these drugs and were alive at 24 hours after admission. As long as those main criteria were met, we included those patients in our study.

Then, after reviewing the preliminary results there with respect to the two populations, the baricitinib and the tocilizumab groups, we reviewed in what ways they were similar and some key differences. As Dr. Paranjape mentioned, with tocilizumab being the one with the most data in the mechanically ventilated or ECMO patients and the ones recommended in those patients, we were anticipating that we would see a higher acuity in that group. Of course we did, and that’s where the propensity score matching came in.

We worked with a couple of really wonderful colleagues, statisticians who helped us with that process. They selected propensity score matching as the best way to create some comparable groups and ended up with very similar populations between the baricitinib and the tocilizumab groups. With respect to the outcomes that we selected to measure, of course we were primarily interested in: were either of these drugs impacting in-hospital mortality differently? That was our primary outcome.

Secondarily, one of the main things that we wanted to look at was if there was a difference in the adverse events that patients were experiencing. We knew that these drugs, each of them had some adverse events listed. Most of them were found with the long-term use in rheumatologic conditions that they’ve been used for for years. So we were especially interested in if those were relevant to the short-term use as we were doing for COVID-19. We wanted to look at those and see if there were any differences there and some other things to just kind of help describe the course of the patients over their hospitalization. Was there faster improvement or things of that nature?

Dr. Bulloch: I want to get both of you to weigh in on this next question. Just for our audience purposes, your study found that there was really no difference in mortality between these two drugs. Was that about what you expected to find or was that a surprising result?

Dr. Paranjape: We were not expecting a big difference. Of course we were curious to see if one agent was better than the other and, as mentioned earlier, both these drugs have been used in otherwise stable outpatients. So most of our adverse effects data comes from the outpatient world when these drugs are used for rheumatological illnesses. Now, in patients with severe COVID, we have extensive cytokine disturbances. They’re in this hyperinflammatory state and, with the effect of these drugs that have different pharmacological profiles, also different half-lives, would that actually affect mortality and adverse events in patients? That was kind of what we wanted to study and look for. Joy?

Dr. Peterson: Yeah, I would have to agree. In the knowledge vacuum that we were in, it was really hard to have any idea what we were going to see. I think for me personally as a pharmacist, I was really thinking of the PKPD of the drugs, and part of me maybe expected to see a more pronounced effect with tocilizumab, but I really wasn’t sure what was going to come out.

Dr. Bulloch: I think that’s fair, Dr. Peterson. I’m a pharmacist too, so I tend to have my biases sometimes when we start things out like that. You think about the half-lives of the drugs and almost your own clinical experiences going into it. Now, before you did the study, just anecdotally, is that kind of what you thought you were seeing in clinical practice, or is this just purely more the pharmaceutical sciences part of it that maybe were making you think tocilizumab might do do a little bit better?

Dr. Peterson: Again, as you said, sometimes these biases slip in when we sort of know some of the background information. I did feel like I was seeing more pronounced effects with tocilizumab and maybe some faster onset. However, I also felt like I was seeing a few more issues later on down the road for some of these patients. But we also, as I mentioned, typically were using it in the more seriously ill patients, so it was very difficult to know how much was drug related, how much was severity of illness with COVID-19. It just felt like a really muddy picture and I was very, very eager to get in and try to tease out the data in a more methodical and clear way.

Dr. Paranjape: Joy and I had multiple conversations. Joy, if you remember early in the pandemic, where we would see these really sick patients who would get secondary bacterial infections possibly because of the prolonged hospital stay and then we’d wonder, was it the toci, was it something else? So yeah, that was one of the other driving forces to look at this data.

Dr. Peterson: Absolutely. I know for me, and I would assume I speak for you as well, Dr. Paranjape, but just the whole concept of using immunosuppressive therapies during an infection was very uncomfortable.

Dr. Paranjape: I agree.

Dr. Bulloch: When I was reading this article, even with the propensity scoring matching, there were so many different subanalyses that I kept thinking I would love to look at just this group. I just want to look at just those who are vaccinated or just those who are unvaccinated, maybe look at, you had BMIs that are very similar to the area of the country that I practice in. What about ICU versus not ICU? Were there any of these subgroups that, in a future study you would just really like to look at with a little bit more intentional focus? Or do you think that, really, the results of what you found are just going to be very applicable across the board?

Dr. Peterson: That is a great question. You mentioned the vaccinated versus unvaccinated. We had such an incredibly large percentage of our patients who were not fully vaccinated that we likely would not have had sufficient power to make very meaningful comparisons there. It would be interesting to see now that typically we’re seeing larger percentages of vaccinated patients. But as we mentioned in the writeup, while I do think vaccination would have an impact on whether or not a patient is going to progress to severe COVID, I think it would be unlikely that vaccination status would have much effect on the way that these drugs work and outcomes if a patient does progress to that point. That is something that I have debated about a good bit.

Another one, the ICU, as you mentioned, ICU versus non, that’s another interesting breakdown. There was a significant difference in the overall population with ICU status at baseline. In the propensity score matched groups, that was equal between groups. There were no significant differences there. So I’m not sure that we would see much difference with that population or with that drilldown than what we saw in our overall population. What are your thoughts, Dr. Paranjape?

Dr. Paranjape: I completely agree with you, Joy, I think you summarized that very well. Again, the fact that we had such a high number of unvaccinated patients is a testament to how effective the vaccination is because it was really those unvaccinated patients that we were seeing who got admitted with the severe disease. But, yeah, I agree with everything else you said.

Dr. Bulloch: Let’s talk about drug dosing just for a minute. The NIH guidelines are a living guideline. They change regularly, and they’re updated based on new data. Tocilizumab is pretty easy. For most patients, it’s just going to be one dose. I think maybe I’ve used that second dose once in the past three years. But baricitinib, it’s a two-week course of therapy unless you go home before that two weeks is up. In your study, even though you can get the drug for two weeks, the median duration was only eight days. Do you think that the course of therapy based on data from your study and from other studies out there, do you think maybe it could or even should be reduced? Or do you feel like leaving it at 14 days is really where it needs to be?

Dr. Peterson: I was actually wondering that exact same question as I’ve been looking at some of the other studies that have come out since ours was published. They’re typically finding a very similar duration as we were, in the eight- to nine-day range. I’m not really sure exactly why 14 days was selected as the treatment duration in some of the original trials, but I do suspect that something more like a 10-day treatment duration is probably sufficient.

Dr. Paranjape: Yeah, and it’s really up to 14 days. Most patients, if they get better and go home, I don’t think we’re really recommending baricitinib as an outpatient to complete the 14-day therapy just like we would with steroids. So, yeah, I think we do need more data, but I suspect that’ll probably be the case.

Dr. Bulloch: This is one of the largest retrospective studies that we have on this topic. Have either one of you thought about moving forward and doing a big prospective study?

Dr. Peterson: As much as I would love to, that would be a massive undertaking for us. But I’m certainly not going to count it out.

Dr. Paranjape: Yes, and both Joy and I are full-time clinicians. This study was something we both wanted to do, we had to put in several hours of work to get this out. But, yeah, I mean, we would love to, but, yeah, we’re not ruling it out yet.

Dr. Bulloch: We’re almost to the end of our time today, but I do want to give both of you an opportunity to leave our listeners with any final thoughts. What are the big take-home messages that you would like readers and listeners to this podcast to have from your study? We’ll start with Dr. Peterson.

Dr. Peterson: I think that it really gave me more peace with that decision about using baricitinib or tocilizumab in situations where it really could go either way. It’s helpful to know that there really was not a difference in the in-hospital mortality. But knowing that we saw a lower rate of adverse events with baricitinib, it does cause me to lean more toward that as the therapeutic option. So I think, just, again, that uncertainty that we’ve all faced and dealt with over the past few years and the lack of information that we’ve had, having a little bit more comfort with having some more good-quality data to help drive some of those decisions is what I hope everyone is able to get from this study.

Dr. Paranjape: We would also like to have a little more long-term data. I think our study period was shorter just to see whether these adverse effects are different or similar over a longer period of time. That would be something I’d be interested in looking at in the future.

Dr. Bulloch: This concludes another episode of the Society of Critical Care Medicine Podcast. I want to thank Drs. Peterson and Paranjape for being our guests. If you’re listening on your favorite podcast app and you liked what you heard, consider rating and leaving a review. For the Society of Critical Care Medicine Podcast, I’m Marilyn Bulloch. Thank you for listening.

Announcer: Marilyn N. Bulloch, PharmD, BCPS, FCCM, is an associate clinical professor and director of strategic operations at Auburn University Harrison School of Pharmacy. She is also an adjunct associate professor in the Department of Family, Internal, and Rural Medicine at the University of Alabama in Tuscaloosa, Alabama, USA, and the University of Alabama, Birmingham School of Medicine.

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