Baricitinib Versus Tocilizumab for the Treatment of Moderate to Severe COVID-19

Clinical Outcomes among Hospitalized COVID-19 Patients Who Received Baricitinib or Tocilizumab in Addition to Standard of Care

COVID-19 infection is caused by the novel severe acute respiratory syndrome coronavirus 2 (SAR-CoV-2). This novel virus has transformed into different resistant variants (e.g., omicron; delta; alpha; epsilon) since its first emergence in 2019. The National Institutes of Health and Infectious Diseases Society of America guidelines currently recommend adding either baricitinib or tocilizumab to the standard of care for severe COVID-19 treatment. An outcome comparison between baricitinib and tocilizumab is needed to determine which agent is more appropriate and safer in clinical practice when deciding treatment. We aimed to compare mortality and clinical outcomes between tocilizumab and baricitinib in the management of severe COVID-19 infection. A total of 5638 adult patients from 16 acute care hospitals in a large healthcare system in Texas were included in this multicentered retrospective cohort study. The median age of the patients was 56 years and 46.67% of them were female. Severe COVID-19 patients were treated with standard of care and either tocilizumab or baricitinib. The primary outcome of hospital admission mortality rates was found to be higher with tocilizumab (odd ratio (OR) of 1.56; p = 0.001; 95% CI 1.19 to 2.008) compared to that with baricitinib (OR 0.65; p = 0.001; 95% CI 0.50 to 0.84). For one of the secondary outcomes, patients who received tocilizumab were 3.75 times more likely to be admitted to the ICU than those receiving baricitinib (p = 0.001; 95% CI 2.89 to 4.85). Among the 1199 COVID-19 patients who were admitted to the ICU, the ICU length of stay was shorter among patients receiving baricitinib with a mean difference of 4.42 days and a median difference of 2.54 days, compared to those receiving tocilizumab (p < 0.0001; 95% CI -5.97 to -2.62) as another secondary outcome. Our large retrospective observational study showed that baricitinib reduced mortality; the likelihood of ICU admission; and the ICU length of stay compared to tocilizumab in patients with severe COVID-19 infection.

Baricitinib versus tocilizumab in critically ill COVID-19 patients: A retrospective cohort study

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.

Targeted degrader technologies as prospective SARS-CoV-2 therapies

COVID-19 remains a severe public health threat despite the WHO declaring an end to the public health emergency in May 2023. Continual development of SARS-CoV-2 variants with resistance to vaccine-induced or natural immunity necessitates constant vigilance as well as new vaccines and therapeutics. Targeted protein degradation (TPD) remains relatively untapped in antiviral drug discovery and holds the promise of attenuating viral resistance development. From a unique structural design perspective, this review covers antiviral degrader merits and challenges by highlighting key coronavirus protein targets and their co-crystal structures, specifically illustrating how TPD strategies can refine existing SARS-CoV-2 3CL protease inhibitors to potentially produce superior protease-degrading agents.

Comparison of Tocilizumab vs Baricitinib in Clinical Outcomes Among Hospitalized Patients With COVID-19: Experience From a Public Hospital System in New York City

Background

Tocilizumab and baricitinib are immunomodulators that have been repurposed for the treatment of coronavirus disease 2019 (COVID-19). Whether one medication should be preferred over the other has not been established.

Methods

This multicenter retrospective cohort study comprised hospitalized patients with COVID-19 who received either tocilizumab or baricitinib. The primary outcome was improvement in respiratory status (at least 1-point reduction on the respiratory ordinal scale) at day 7 and up to day 28. Secondary outcomes included mortality, disposition, deep vein thrombosis, pulmonary embolism, or positive blood culture. Outcomes were stratified by baseline respiratory status and variant-predominating periods. Results were reported for the overall and propensity-matched cohorts.

Results

A total of 921 patients received tocilizumab and 638 received baricitinib. The propensity-matched cohort included 597 patients in each group. At day 7 in the overall and propensity-matched cohorts, significantly more patients had improvement in respiratory status in the baricitinib group. These improvements were seen in patients requiring supplemental oxygen and noninvasive ventilation/high-flow oxygen but not in patients requiring mechanical ventilation. Favorable outcomes with baricitinib were observed during the Alpha and Omicron periods. By day 28, there were no differences in the changes of respiratory status for the treatment groups in either cohort. Also, no differences were seen in mortality, disposition, development of deep vein thrombosis/pulmonary embolism, or bloodstream infections.

Conclusions

Baricitinib treatment was associated with more favorable respiratory improvement at day 7 when compared with tocilizumab, but no differences were observed up to day 28.