Use of Anakinra to Prevent Mechanical Ventilation in Severe COVID‐19: A Case Series

Navarro‐Millán, Iris; Sattui, Sebastian E.; Lakhanpal, Amit; Zisa, Diane; Siegel, Caroline H.; Crow, Mary K.

OBJECTIVE: To report the clinical experience with anakinra for preventing mechanical ventilation (MV) in patients with COVID‐19, features of cytokine storm syndrome (CSS), and acute hypoxic respiratory failure (AHRF). METHODS: In this retrospective case series, patients must have had SARS‐CoV‐2, fever, ferritin >1,000 ng/mL with one additional laboratory marker of hyperinflammation, and AHRF. AHRF was defined as requiring 15L of supplemental oxygen via non‐rebreather mask combined with 6L nasal cannula or use of ≥95% oxygen by high flow nasal cannula. We excluded patients with suspicion for bacterial infection or on immunosuppressants. Subcutaneous anakinra was initiated at 100 mg q6 hours and gradually tapered off completely. Primary outcome was prevention of MV. RESULTS: Eleven of 14 patients meeting criteria received anakinra for a maximum of 19 days. Seven of those who initiated anakinra ≤36 hours after onset of AHRF did not require MV, and all were discharged home. Four patients who started anakinra ≥4 days after onset of AHRF required MV. Of those, 3 patients were extubated (2 discharged home, 1 remains hospitalized) and 1 died. All 3 patients who met criteria but did not receive anakinra required MV. Two were extubated (1 discharged and 1 remains hospitalized) and 1 remains on MV. CONCLUSIONS: Our data suggest that anakinra could be beneficial in COVID‐19 patients with evidence of CSS when initiated early after onset of AHRF. Our patient selection and treatment approach should be considered for investigation in a clinical trial to determine the safety and efficacy of anakinra in patients with COVID‐19 and features of CSS.