More data on risk factors for poor COVID-19 outcomes, mixed results from treatment trials

A risk calculator, genetic findings, and red blood cell distribution width helped predict severity of and death from COVID-19. Tocilizumab showed benefit, but a number of other treatments, including CPR, did not, according to recent research.

Several recent studies have provided insight into variation in outcomes from COVID-19. An analysis of 832 patients admitted with COVID-19 to five Johns Hopkins system hospitals led to development of a model to predict disease progression. According to results published by Annals of Internal Medicine on Sept. 22, predictive factors included age, nursing home residence, comorbid conditions, obesity, respiratory symptoms, respiratory rate, fever, absolute lymphocyte count, hypoalbuminemia, troponin level, and C-reactive protein level. The resulting COVID-19 Inpatient Risk Calculator allows clinicians to use factors present on admission to inform clinical and resource allocation decisions, the study authors said. Two genetic studies, both published by Science on Sept. 24, found potential explanations for differences in severity of disease, including between men and women. The potential causes include the presence of autoantibodies and genetic mutations, according to a press release from the NIH, which funded the research.

Red blood cell distribution width (RDW) may be another predictor of mortality in patients hospitalized with COVID-19, according to a study published by JAMA Network Open on Sept. 23. A cohort study of 1,641 Boston patients found that RDW greater than 14.5% (present in 34% of patients) was associated with an increased mortality risk in patients of all ages (11% vs. 31%). Patients whose RDW increased during hospitalization also had increased mortality risk. “RDW is routinely measured and may be helpful for prioritizing patients for early, aggressive intervention and managing local hospital resource use,” the authors said.

Another study of 4,688 hospitalized patients found that sleep apnea was a risk factor for mortality from COVID-19 “highlighting the need for close monitoring of patients with sleep apnea who become infected,” said the study published by the American Journal of Respiratory and Critical Care Medicine on Sept. 18.

In positive treatment news, tocilizumab appears to reduce mortality in patients with COVID-19, according to a meta-analysis of 10 studies published by Clinical Infectious Diseases on Sept. 23. The authors calculated a number needed to treat of 11 patients with severe COVID-19 to prevent one death. They called for randomized controlled trials to confirm the results.

A shortcoming of most COVID-19 research—the exclusion of older patients—was highlighted by a research letter published by JAMA Internal Medicine Sept. 28. Based on an analysis of 847 trials, the authors concluded that people ages 65 to 80 years “are likely to be excluded from more than 50% of COVID-19 clinical trials and 100% of vaccine trials.” One small phase 1 study, published by the New England Journal of Medicine on Sept. 29, did look at the safety and immunogenicity of a SARS-CoV-2 vaccine in 40 patients ages 56 to 70 years and 40 patients age 71 years or older. Adverse events were mostly mild to moderate and antibody responses appeared to be similar to those previously reported in trial participants 18 to 55 years of age.

Some recent studies reported lack of success with potential treatments. A randomized trial of 50 patients with prolonged SARS-CoV-2 positivity found that leflunomide did not shorten the duration of viral shedding, according to results published by Clinical Infectious Diseases on Sept. 21.

An observational study, published by The Lancet Respiratory Medicine on Sept. 24, looked at prescriptions for patients with chronic obstructive pulmonary disease and asthma and found that the risk of COVID-19-related death was higher in those who had received inhaled corticosteroids, suggesting that these medications should not be used for protection against COVID-19. A randomized trial of 135 hospitalized patients published by Clinical Infectious Diseases on Sept. 23 found that high-dose N-acetylcysteine did not affect outcomes.

Finally, a research letter published by JAMA Internal Medicine on Sept. 28 indicated that CPR is very unlikely to be successful in patients with COVID-19 who have in-hospital cardiac arrest. It looked at 54 patients at one hospital who had an arrest and underwent CPR. None survived. “These outcomes warrant further investigation into the risks and benefits of performing prolonged CPR in this subset of patients, especially because the resuscitation process generates aerosols that may place health care personnel at a higher risk of contracting the virus,” the authors said. An accompanying editorial cautioned about drawing definitive conclusions from this small study but added that “we have enough data to conclude that it is important to implement programs to promote conversations about values and goals in the community and early goals-of-care discussions for patients hospitalized with COVID-19.