To describe the experience of treatment with baricitinib (BARI) and/or tocilizumab (TCZ), in monotherapy or combined, in patients admitted for interstitial pneumonia secondary to COVID19, and for 30 ...days after discharge.
Medical records of patients admitted with COVID19 and IP with PaO
/FiO
<300, treated with BARI and/or TCZ, and compared with patients who did not, were retrospectively reviewed.
Sixty patients were included; 43 (72%) are males, mean age 67 (SD: 14) years (<50 years: 17%; 51-70: 30%; >70: 53%), with 8.5 (SD: 1) days of symptoms. Sixteen (27%) patients required ICU (94% in <70 years). Fifteen (25%) patients died, 67% in >70 years; 11 (18%) patients died in the first 15 days of admission and 4 (7%) between days 16 to 30. Twenty-three (38%) patients received BARI, 12 (52%) monotherapy (Group 1), during 6 (SD: 2.6) days on average, none required ICU and 2 (17%) died. Thirty-one (52%) patients received TCZ, 20 (33%) as monotherapy (Group 2), 16 (52%) patients required ICU and 4 (20%) died. In the 11 (18%) patients who received BARI (2.8 SD: 2.5 days average) and TCZ combined (Group 3), 3 (27%) required ICU and died. There were no severe side effects in BARI or TCZ patients. In the 17 (28%) patients who received neither BARI nor TCZ (Group 4), none required ICU and 6 (35%) died. Mean (SD) PaO
/FiO
at admission between groups was respectively: 167 (82.3), 221 (114.9), 236 (82.3), 276 (83.2).
Treatment with BARI and TCZ did not cause serious side effects. They could be considered early in patients with NI secondary to COVID19 and impaired PaO2/PaFi.
To describe the experience of treatment with baricitinib (BARI) and/or tocilizumab (TCZ), in monotherapy or combined, in patients admitted for interstitial pneumonia secondary to COVID19, and for 30 ...days after discharge.
Medical records of patients admitted with COVID19 and IP with PaO2/FiO2<300, treated with BARI and/or TCZ, and compared with patients who did not, were retrospectively reviewed.
Sixty patients were included; 43 (72%) are males, mean age 67 (SD: 14) years (<50 years: 17%; 51–70: 30%; >70: 53%), with 8.5 (SD: 1) days of symptoms. Sixteen (27%) patients required ICU (94% in <70 years). Fifteen (25%) patients died, 67% in >70 years; 11 (18%) patients died in the first 15 days of admission and 4 (7%) between days 16 to 30. Twenty-three (38%) patients received BARI, 12 (52%) monotherapy (Group 1), during 6 (SD: 2.6) days on average, none required ICU and 2 (17%) died. Thirty-one (52%) patients received TCZ, 20 (33%) as monotherapy (Group 2), 16 (52%) patients required ICU and 4 (20%) died. In the 11 (18%) patients who received BARI (2.8 SD: 2.5 days average) and TCZ combined (Group 3), 3 (27%) required ICU and died. There were no severe side effects in BARI or TCZ patients. In the 17 (28%) patients who received neither BARI nor TCZ (Group 4), none required ICU and 6 (35%) died. Mean (SD) PaO2/FiO2 at admission between groups was respectively: 167 (82.3), 221 (114.9), 236 (82.3), 276 (83.2).
Treatment with BARI and TCZ did not cause serious side effects. They could be considered early in patients with NI secondary to COVID19 and impaired PaO2/PaFi.
Describir la experiencia con baricitinib (BARI) y/o tocilizumab (TCZ), en monoterapia o combinados en pacientes ingresados por neumonía intersticial (NI) por COVID-19 y durante los 30 días después del alta.
Se revisaron retrospectivamente las historias clínicas de los pacientes ingresados por COVID-19 y NI, con PaO2/FiO2<300, tratados con BARI y/o TCZ y se compararon con pacientes que no los recibieron.
Se incluyeron 60 pacientes; 43 (72%) varones, edad media 67 (DE: 14) años (< 50 años: 17%; 51-70: 30%; > 70: 53%), y 8,5 (DE: 1) días de síntomas. Dieciséis (27%) ingresaron en la unidad de cuidados intensivos (UCI) (94% < 70 años). Quince (25%) fallecieron (67% > 70 años); 11 (18%) de ellos en los primeros 15 días del ingreso y cuatro (7%) entre los días 16 y 30. Veintitrés (38%) pacientes recibieron BARI, 12 (52%) en monoterapia (Grupo 1), durante seis (DE: 2.6) días de promedio, ninguno de ellos ingresó en UCI y dos (17%) fallecieron. Treinta y un (52%) pacientes recibieron una dosis de TCZ, 20 (33%) en monoterapia (Grupo 2), 16 (52%) ingresaron en UCI y cuatro (20%) fallecieron. Entre los 11 (18%) pacientes que recibieron BARI (2,8 DE: 2,5 días de promedio) y TCZ combinados (Grupo 3), tres (27%) ingresaron en UCI y fallecieron. No hubo efectos secundarios graves entre los que recibieron BARI y/o TCZ. Entre los 17 (28%) pacientes que no recibieron ni BARI ni TCZ (Grupo 4), ninguno ingresó en UCI y seis (35%) fallecieron. La PaO2/FiO2 media (DE) al ingreso entre los grupos fue respectivamente: 167 (82,3), 221 (114,9), 236 (82,3), 276 (83,2).
El tratamiento con BARI y TCZ no provocó efectos secundarios graves. Podrían considerarse precozmente en pacientes con NI secundaria a COVID-19 y deterioro de PaO2/PaFi.
Hepatopulmonary syndrome consists of a clinical triad: arterial blood deoxygenation, intrapulmonary vasodilation, and liver disease. Both acute and chronic cases of this syndrome have been reported, ...and the most common cause is cirrhosis. The principle disease mechanism is dilation of the pulmonary blood vessels causing alterations in gas exchange. Increased pulmonary production of nitric acid has been implicated as the primary pathogenic mechanism of vasodilation although it has also been associated with imbalance between vasodilators and vasoconstrictors. We describe the case of a patient with hepatopulmonary syndrome and adenocarcinoma of the colon with metastases to a previously healthy liver.
El síndrome hepatopulmonar comprende una tríada clínica caracterizada por desoxigenación arterial, dilataciones vascu-lares intrapulmonares y hepatopatía. Se han descrito tanto ca-sos agudos como crónicos, y la causa más frecuente es la cirro-sis. El mecanismo fisiopatológico principal es la dilatación de los vasos pulmonares, que produce una alteración del inter-cambio gaseoso. Se ha implicado la mayor producción pulmo-nar de óxido nítrico como mecanismo patogénico principal de la vasodilatación, aunque también se ha relacionado el dese-quilibrio entre sustancias vasodilatadoras y vasoconstrictoras. Describimos un caso en el que se produjo un síndrome hepatopulmonar en un paciente afectado de un adenocarcinoma de colon con metástasis hepáticas en un hígado previamente sano.
Hereditary alpha-1-antitrypsin (α1-AT) deficiency predisposes to pulmonary emphysema. The objective of this study is to demonstrate the limitations of some laboratory methods used in the study of the ...deficiency, and which may produce errors in interpretation and detection of uncommon alleles. Two clinical cases are described: the index patient, who had pulmonary emphysema with α1-AT levels less than 12 mg/dL, was erroneously classified as a homozygote of the normal allelic variant PI MM using a rapid genotype method; the mother of the patient, asymptomatic, with low levels (60 mg/dL), was also classified as PI MM. The gene sequencing classified the index patient as a carrier of the PI Clayton null allele and PI Mmalton deficient. The mother was a PI Clayton/PI heterozygote carrier. These results highlight the difficulties in diagnosing the deficiency, as the well as the need to reach a consensus on methods for this study.
Abstract Hereditary alpha-1-antitrypsin (α1-AT) deficiency predisposes to pulmonary emphysema. The objective of this study is to demonstrate the limitations of some laboratory methods used in the ...study of the deficiency, and which may produce errors in interpretation and detection of uncommon alleles. Two clinical cases are described: the index patient, who had pulmonary emphysema with α1-AT levels less than 12 mg/dL, was erroneously classified as a homozygote of the normal allelic variant PI MM using a rapid genotype method; the mother of the patient, asymptomatic, with low levels (60 mg/dL), was also classified as PI MM. The gene sequencing classified the index patient as a carrier of the PI Clayton null allele and PI Mmalton deficient. The mother was a PI Clayton/PI heterozygote carrier. These results highlight the difficulties in diagnosing the deficiency, as the well as the need to reach a consensus on methods for this study.
Although the clinical practice guidelines recommend continuous adjustment of asthma treatment and reducing the maintenance drugs when achieving control (step-down), there are few studies of standard ...clinical practice aimed at collecting information on the factors that determine step-down failure.
To determine the factors that determine step-down failure in standard clinical practice of patients with moderate-severe asthma controlled by a combination of inhaled glucocorticoids and long-acting beta agonists.
A multicentre retrospective study included 374 patients with moderate-severe asthma controlled with inhaled glucocorticoids and long-acting beta agonists for whom the physician indicated a step-down in 2016.
The step-down failed in 41.7% of the patients. The following factors were related to failure: greater patient age (p=.006), presence of at least 2 comorbidities (p=.016), greater severity level (severe persistent vs. moderate persistent) (p<.001), greater age at diagnosis (>40 years) (p=.045), the higher the therapeutic step before (p=.003) and after the change (p<.001), the shorter the time of improvement/control prior to the change (p=.019), lower FEV1 (p=.001) and a poorer Asthma Control Test score or Asthma Control Questionnaire score before the step-down (p<.001). The logistic regression analysis showed a higher probability of step-down failure in the more elderly patients (OR, 0.983; 95% CI 0.969–0.997) and those with severe asthma compared to those with moderate asthma (OR, 0.537; 95% CI 0.292–0.985), as well as an increased probability of success if the patients had the disease controlled for more than 6 months (OR, 2.253; 95% CI 1.235–4.112).
In standard clinical practice conditions, step-down fails in a high percentage of patients, and the suggestion is to indicate step-down when the patient has had more than 6 months of disease control.
Aunque las guías de práctica clínica recomiendan un ajuste continuado del tratamiento del asma, reduciendo la medicación de mantenimiento cuando se alcanza el control (step-down), existen pocos estudios de práctica clínica habitual orientados a recabar información de los factores que condicionan su fracaso.
Determinar los factores que condicionan en la práctica clínica habitual el fracaso del step-down en los pacientes asmáticos moderados-graves controlados con una combinación de glucocorticoides inhalados/agonistas beta-2 adrenérgicos de acción larga.
Estudio multicéntrico retrospectivo sobre 374 pacientes con asma moderada-grave controlada con glucocorticoides inhalados/agonistas beta-2 adrenérgicos de acción larga en quienes el facultativo indicó en 2016 un step-down.
El step-down fracasó en el 41,7%. Los factores relacionados con el fracaso fueron: la mayor edad del paciente (p=0,006), la presencia de 2 o más comorbilidades (p=0,016), el mayor nivel de gravedad (persistente grave vs. persistente moderada) (p<0,001), la mayor edad al diagnóstico (>40 años) (p=0,045), cuanto más alto es el escalón terapéutico previo (p=0,003) y posterior al cambio (p<0,001), cuanto menor sea el tiempo de mejoría/control previo al cambio (p=0,019), el FEV1 más bajo (p=0,001) y un peor Asthma Control Test o Asthma Control Questionnaire antes del step-down (p<0,001). El análisis de regresión logística mostró que existe una mayor probabilidad (odds ratio IC 95% de fracaso del step-down en los pacientes más añosos: OR 0,983 0,969-0,997, con asma grave vs. moderada: OR 0,537 0,292-0,985 y mayor probabilidad de éxito si llevan más de 6 meses con la enfermedad controlada: OR 2,253 1,235-4,112).
En condiciones de práctica clínica habitual el step-down fracasa en un porcentaje alto de pacientes y se recomienda indicarlo cuando el paciente lleve más de 6 meses controlado.
PDF
