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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The degree of disease severity with COVID-19 varies and can become fulminant or fatal&#46; The World Health Organization &#40;WHO&#41; estimates that severe disease can occur in about 13&#46;8&#37; of cases and 6&#46;1&#37; are critical&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> When cases are fulminant&#44; patients may develop sepsis&#44; acute respiratory failure syndrome &#40;ARDS&#41; or multiple organ failure&#44; which are not exclusive to coronaviruses&#46; Cytokine release syndrome &#40;CRS&#41; refers to an uncontrolled and exaggerated release of pro-inflammatory mediators into the activated immune system&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> This disturbance may be present in various clinical entities&#44; including the rheumatology setting&#44; Still&#39;s disease&#44; systemic juvenile idiopathic arthritis&#44; systemic lupus erythematosus and catastrophic antiphospholipid syndrome &#40;APS&#41;&#46; CRS is involved in the immunopathogenesis of many pathological processes&#44; such as ARDS&#44; sepsis&#44; Macrophage activation syndrome &#40;MAS&#41;&#44; etc&#46;&#44; several of which are described in severe acute respiratory syndrome &#40;SARS&#41;&#44; Middle East respiratory syndrome &#40;MERS&#41; and also in the new COVID-19 infection&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> While treatment directed against the virus is desired&#44; treatment of the systemic response is possibly the most important aspect of patient care and should be viewed aggressively&#46; Finally&#44; patients with COVID-19 who develop a severe condition may have a procoagulant pattern&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Therefore&#44; this review synthesizes the evidence related to therapies with an anti-inflammatory role that can play a relevant role in the management of patients with severe COVID-19&#44; briefly mentioning the role of antithrombotic therapy in the treatment of complicated patients&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Glucocorticoids</span><p id="par0010" class="elsevierStylePara elsevierViewall">Glucocorticoids &#40;GC&#41; are some of the most widely used anti-inflammatory agents&#59; they are commonly prescribed in the treatment of patients with COVID-19 &#40;72&#37; in the ICU&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> However&#44; as mentioned in the Chinese COVID-19 guidelines&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> physicians must be careful in the use of GCs because of their uncertain benefits in the context of viral respiratory infection&#46; Several studies have reported inferior results in SARS patients treated with GC&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> due to delayed purging of the virus&#46; Other concerns with GCs are short-term and long-term adverse effects&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Antimalarials &#40;chloroquine and hydroxychloroquine&#41;</span><p id="par0015" class="elsevierStylePara elsevierViewall">Recent publications have drawn attention to the possible beneficial effect of hydroxychloroquine &#40;HCQ&#41; and chloroquine &#40;CLQ&#41; in the treatment of patients infected with the new SARS-CoV-2 coronavirus&#46; It has been observed that the growth of several different viruses &#40;including SARS coronavirus&#41; can be inhibited in cell cultures by both CLQ and HCQ&#46; In addition&#44; these drugs are weak bases that can affect acidic vesicles and inhibit several enzymes&#46; This characteristic enables inhibiting of viral entry into cells when endocytosis is pH dependent&#46; They also inhibit the enzyme glycosyltransferase &#40;inhibition of virus glycosylation&#41;&#44; post-transcriptional viral modifications and replication of some viral families&#46; As it is known that COVID-19 infection can on occasion lead to severe pictures with SARS&#44; which can be due in part to the increase of proinflammatory cytokines such as interleukin 6 &#40;IL-6&#41; and tumour necrosis factor-alpha &#40;TNF-&#945;&#41;&#46; CLQ is highly effective in combination with remdesivir in controlling SARS-CoV-2<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> in vitro&#46; There is now already some evidence in humans&#46; In an open observational study conducted in France&#44; they evaluated the role of HCQ in combination with azithromycin on respiratory viral load in 20 patients with COVID-19 compared with 16 controls&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> A significant reduction in viral load was shown &#40;70&#37; at day 7&#41; compared to the controls&#46; When azithromycin was added&#44; more efficient elimination of the virus was found &#40;100&#37; reduction&#41;&#46; Gao et al&#46; described results in 100 patients in China where they demonstrated the superiority of CLQ over the control treatment in inhibiting exacerbation of pneumonia&#44; improving lung imaging findings&#44; promoting negative virus conversion&#44; and shortening the course of the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> However&#44; the details of this study are not known in depth&#46; A recent study reported the results of a retrospective analysis of 368 hospitalized patients with confirmed SARS-CoV-2 infection &#40;U&#46;S&#46; Veterans Health Administration&#41; of evaluation of exposure to HCQ alone or in combination with azithromycin&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> The mortality rates in the HCQ alone&#44; combined HQC&#44; and no HQC groups were 27&#46;8&#37;&#44; 22&#46;1&#37;&#44; and 11&#46;4&#37;&#44; respectively&#46; Ventilation rates in the HCQ&#44; combined HCQ and no HCQ groups were 13&#46;3&#37;&#44; 6&#46;9&#37; and 14&#46;1&#37;&#44; respectively&#46; In this study&#44; no evidence was found that the use of HCQ alone or combined reduces the risk of mechanical ventilation in hospitalized patients with COVID-19 and that patients receiving HCQ alone had the highest mortality rate&#46; These findings highlight the importance of waiting for the results of the prospective randomized studies that are underway before widely adopting these drugs&#46; There are currently about 14 clinical trials registered to prove the benefit of antimalarials&#46; Although antimalarials are relatively safe drugs&#44; it should be remembered that their most frequent effects are gastrointestinal&#44; pruritus&#44; and dermal changes in 10&#37; of patients&#46; The most serious effects are of low incidence&#44; such as cardiomyotoxicity&#44; neuromyopathy&#44; and irreversible retinopathy &#40;large doses and long term&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Tocilizumab&#44; inleukin-6 inhibitor</span><p id="par0020" class="elsevierStylePara elsevierViewall">There has recently been much interest in the possibility of using tocilizumab&#44; a humanized antibody targeting the IL-6 receptor&#44; on the grounds of preventing or treating the cytokine storm that has been observed in patients that progress to cardiovascular collapse&#44; multiorgan dysfunction&#44; and death&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Inflammatory cytokines and chemokines&#44; including IL-6&#44; IL-1&#946;&#44; induced protein 10&#44; and monocyte chemotactic protein-1&#44; have been found to be significantly elevated in Covid-19 patients&#44; and are more often elevated in severe patients than in non-severe patients&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> In patients with COVID-19&#44; with elevated inflammatory cytokines&#44; post mortem pathology revealed tissue necrosis and infiltrations of macrophages and monocytes in the lung&#44; heart and gastrointestinal mucosa&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> which suggests an uncontrolled immune response&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Studies have shown that ARDS occurs in some SARS patients despite a reduced viral load&#44; suggesting that an exuberant immune response rather than viral virulence is possibly responsible for the pathology at tissue level&#46; Therefore&#44; antiviral therapy alone may not be sufficient&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> As previously mentioned&#44; IL-6 is one of the cytokines that plays a role in the pathogenesis in patients with severe COVID-19&#59; it has also been suggested as a biomarker of severe disease&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> and therefore blockade may be a promising strategy for COVID-19-induced CRS&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">IL-6 is essential for the generation of T-helper 17 &#40;Th17&#41; lymphocytes in the interaction between T-lymphocytes and dendritic cells&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Therefore elevated IL-6 may explain the excessive Th17 activation observed in patients with COVID-19&#44; as reported by Xu et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Although no data are available on IL-6 blockade in CRS induced by viral infection&#44; animal studies of SARS-CoV have shown that they inhibit nuclear factor kappa-B&#44; an essential transcription factor of IL-6&#44; increasing animal survival with reduced levels of IL-6&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> Tocilizumab&#44; which blocks IL-6&#44; binds to the IL-6 receptor in both soluble and membrane-bound forms to inhibit IL-6-mediated signals&#46; This drug has been approved by the Food and Drug Administration for the treatment of CRS associated with CAR T-cell therapy&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Data on the use of this molecule in the treatment of SARS-CoV-2 infection are still preliminary but promising results have prompted the Chinese Health Commission to update its national guidelines&#44; which include tocilizumab for the treatment of severe COVID-19&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> The Italian guidelines also support the use of tocilizumab &#40;at a dose of 8&#8239;mg&#47;kg&#44; with a second dose 12&#8239;h after the first and a possible third after 24-36&#8239;h&#44; depending on the clinical response&#41;&#44; in the event of rapid clinical or radiological worsening&#44; after excluding contraindications to its use &#40;levels of transaminases &#62;5 times the upper limit of normal&#44; neutrophil count &#60;50&#44;000 cells&#47;&#956;l&#44; presence of documented sepsis complicated by bacteria&#44; diverticulitis&#47;intestinal perforation&#44; skin infection&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">There are case reports of improvement in patients with severe COVID-19 after the administration of tocilizumab&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;22</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Interleukin 1b inhibitors and protein kinase inhibitors JAK1&#47;2 &#40;roxulitinib&#41;</span><p id="par0045" class="elsevierStylePara elsevierViewall">Several laboratory markers related to MAS&#47; haemaphagocytic lymphohistiocytosis &#40;HLH&#41; are elevated in severe COVID-19&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> Therefore&#44; treatments aimed at controlling MAS&#47;HLH have been suggested for the management of severe COVID-19&#46; The recombinant human IL-1 receptor antagonist&#44; anakinra&#44; has been used for the treatment of MAS&#47;HLH associated with autoimmune rheumatic diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> Data from a reanalysis of a phase <span class="elsevierStyleSmallCaps">iii</span> controlled trial found that anakinra was associated with significant improvement in the survival of patients with sepsis with concurrent MAS&#47;HLH&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Small molecule inhibiting Janus kinases&#44; such as the JAK1&#47;2 inhibitor ruxolitinib&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> are capable of blocking signals from IL-6&#44; interferon &#947; &#40;IFN-&#947;&#41; and other cytokines involved in MAS&#47;HLH&#46; Therefore&#44; this drug could have potential in the treatment of serious complications in patients with COVID-19&#46; More recently&#44; the use of anti-IFN-&#947; antibodies has been contemplated in the management of this serious complication&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Intravenous immunoglobulin and plasma from recovered patients &#40;&#8220;convalescent plasma&#8221;&#41;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Individuals with a weakened immune system appear to be at greater risk of developing complications associated with COVID-19&#46; Immunotherapy using IgG in combination with antiviral drugs could be used to treat or prevent SARS-CoV-2 infection and strengthen our immune system against this virus&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">28&#44;29</span></a> They have also have been administered as anti-infective agents against viruses&#44; bacteria and fungi in experimental models and in humans&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> IVIGs can modulate the immune response by several mechanisms&#44; including blocking various pro-inflammatory cytokines&#44; Fc receptors&#44; and leukocyte adhesion molecules&#44; suppressing Th1 and Th17 cell subtypes&#44; and neutralizing pathogenic autoantibodies&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> IVIGs can also expand regulatory T lymphocytes&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> However&#44; IVIGs have adverse reactions&#46; During the SARS outbreak in 2003&#44; IVIG was used extensively in Singapore&#46; However&#44; some critically ill patients developed venous thromboembolism &#40;VTE&#41; including pulmonary embolism despite the use of prophylactic low molecular weight heparin&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> This is due to the increased viscosity in hypercoagulable states of SARS patients&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Convalescent plasma samples have been used to treat SARS in Hong Kong and China and may be valuable because&#44; unlike standard IVIG preparations&#44; they have high levels of anti-SARS-CoV antibodies&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> Pyrc et al&#46; showed that human serum from adult humans inhibited infection by HCov-NL63&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> Furthermore&#44; they described that IVIGs can also neutralize HCoV-NL63&#46; Boukhvalova et al&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> demonstrated that&#44; in contrast&#44; the commercially available therapeutic polyclonal IgG products&#44; IVIG obtained from donors with antibodies at high titres against respiratory syncytial virus &#40;RSV&#41;&#44; have great potential in improving RSV outcomes in immunocompromised subjects&#44; not only controlling viral replication&#44; but also reducing damage to the lung parenchyma and the epithelial lining of the respiratory tract&#46; The use of convalescent plasma or serum was also suggested by the WHO under the Blood Regulators Network should vaccines and antiviral drugs not be available in an emerging virus&#46; In the current pandemic&#44; there are reports that convalescent plasma has been used in China to treat patients with COVID-19&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> In a pilot study of 10 patients with severe COVID-19&#44; investigators collected convalescent plasma with neutralizing antibody titres at a dilution of 1&#58;640 or more&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> The convalescent plasma transfusion resulted in no serious adverse events in the receivers&#46; All 10 patients had improvement of symptoms &#40;e&#46;g&#46;&#44; fever&#44; cough&#44; shortness of breath&#44; and precordial pain&#41; within 1-3 days of the transfusion&#59; they also showed radiological improvement in lung lesions&#46; Similarly&#44; an undetectable viral load was found in most of them&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">IgG immunotherapy could be used to neutralize the virus causing COVID-19&#46; The efficiency of IgG could be improved if these immune IgG antibodies were collected from patients who had recovered from COVID-19 in the same city&#44; or surrounding areas&#44; as donor subjects who have dealt with the virus&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Plasma interchange</span><p id="par0070" class="elsevierStylePara elsevierViewall">Therapeutic apheresis encompasses a large number of techniques the main basis of which is to process a patient&#39;s blood through an extracorporeal device with the aim of eliminating antibodies and preformed immunocomplexes to prevent tissue damage&#44; eliminating inflammation mediators as a complement and cytokines that could contribute to damage&#44; and providing deficiency factors&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> Among the different types of apheresis&#44; some of the most used are therapeutic plasma exchange &#40;PE&#41; and immunoadsorption&#46; Therapeutic PE is a technique for purifying extracorporeal blood&#44; through which plasma is removed&#46; A variable volume of plasma is removed from the patient and replaced with replacement solutions that maintain volume and oncotic pressure&#46; The term &#34;plasmapheresis&#34; should be reserved for situations in which only plasma removal without replenishment is performed&#44; such as plasma donation by apheresis for transfusion or subsequent industrial plasma fractionation&#46; This procedure extracts less plasma &#40;around 600&#8239;ml&#41;&#44; without replenishment solution&#44; in less time and with simpler separation techniques than those used in PE&#46; The host response to infection has been described and involves a complex interaction of cytokine storm&#44; inflammation&#44; endothelial dysfunction&#44; and pathological coagulation&#46; Plasma exchange is a pathway that offers benefit at multiple levels by removing inflammatory cytokines&#44; stabilizing endothelial membranes&#44; and restarting the hypercoagulable state&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Busund et al&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> showed a trend towards improving mortality with therapeutic PE as an adjuvant treatment in adults with sepsis and multiple organ failure in a controlled clinical trial&#44; while a meta-analysis by Rimmer also showed benefit in adult patient mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> Addressing this information&#44; Patel et al&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a> used therapeutic PE during the 2009 A &#40;H1N1&#41; influenza epidemic in 3 paediatric patients with a fulminant condition similar to the current pandemic&#46; All 3 patients developed ARDS with haemodynamic compromise that continued to deteriorate despite rescue treatment for ARDS including inhaled nitric oxide and extracorporeal venous membrane oxygenation&#46; All 3 patients made a full recovery from their disease after receiving rescue PE&#46; Recently&#44; 3 patients were described with COVID-19 in Wuhan&#44; China&#44;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a> characterized by deep inflammation and treated with blood purification therapies&#44; including PE and adsorption&#46; A potent effect on cytokine storm management and pathogenic antibodies was shown&#46; Of these 3 patients&#44; 2 maintained a stable state and could be discharged from the Intensive Care Unit&#44; while one developed disseminated intravascular coagulation &#40;DIC&#41; and died&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Antithrombotic therapy</span><p id="par0080" class="elsevierStylePara elsevierViewall">Severe COVID-19 can often present a marked elevation of D-dimer&#44; thrombocytopenia and coagulation disturbances that are considered to be regulated by various inflammatory cytokines<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">43&#44;44</span></a> and that correlate with mortality&#46; Another biomarker that has been found to be elevated in patients with severe COVID-19 is ferritin&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> which is also impaired in other severe conditions&#44; including APS in its most severe form&#44; catastrophic APS&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a> Recently&#44; a group from China described 3 cases with COVID-19 and antiphospholipid antibodies&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a> Recent statements by the International Society on Thrombosis and Haemostasis &#40;ISTH&#41; and the American Society of Hematology &#40;ASH&#41; suggest that all patients hospitalized with COVID-19 should receive thromboprophylaxis or full-dose therapeutic anticoagulation&#46; The efficacy of anticoagulation therapy in patients with COVID-19 was recently evaluated retrospectively&#46; Lower mortality at 28 days was found in patients who used heparin &#40;40&#37;&#41; compared to those who did not &#40;64&#46;2&#37;&#41;&#44; mainly in those with sepsis-induced coagulopathy or with a markedly elevated D-dimer&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> summarizes the antithrombotic recommendations for patients with COVID-19&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conclusions</span><p id="par0085" class="elsevierStylePara elsevierViewall">COVID-19 is a viral infection with potentially serious complications that can increase the risk of death in infected patients&#46; Several of these disturbances are secondary to an uncontrolled immune response where a cytokine storm plays a similarly important role in preventing the thrombotic complications to which these patients are exposed&#46; Although antiviral treatment and respiratory support therapies are essential in the treatment of severe cases&#44; it is necessary to assess the risk-benefit of therapies aimed at controlling the immune response to decrease the mortality rate&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Funding</span><p id="par0095" class="elsevierStylePara elsevierViewall">This research study has received no specific support from public sector agencies&#44; the commercial sector&#44; or non-profit entities&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conflict of interests</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare</p></span></span>"
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          "identificador" => "xres1584153"
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              "identificador" => "abst0005"
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        1 => array:2 [
          "identificador" => "xpalclavsec1425603"
          "titulo" => "Keywords"
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          "identificador" => "xres1584154"
          "titulo" => "Resumen"
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              "identificador" => "abst0010"
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          "identificador" => "xpalclavsec1425602"
          "titulo" => "Palabras clave"
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        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Glucocorticoids"
        ]
        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Antimalarials &#40;chloroquine and hydroxychloroquine&#41;"
        ]
        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Tocilizumab&#44; inleukin-6 inhibitor"
        ]
        8 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Interleukin 1b inhibitors and protein kinase inhibitors JAK1&#47;2 &#40;roxulitinib&#41;"
        ]
        9 => array:2 [
          "identificador" => "sec0030"
          "titulo" => "Intravenous immunoglobulin and plasma from recovered patients &#40;&#8220;convalescent plasma&#8221;&#41;"
        ]
        10 => array:2 [
          "identificador" => "sec0035"
          "titulo" => "Plasma interchange"
        ]
        11 => array:2 [
          "identificador" => "sec0040"
          "titulo" => "Antithrombotic therapy"
        ]
        12 => array:2 [
          "identificador" => "sec0045"
          "titulo" => "Conclusions"
        ]
        13 => array:2 [
          "identificador" => "sec0055"
          "titulo" => "Funding"
        ]
        14 => array:2 [
          "identificador" => "sec0050"
          "titulo" => "Conflict of interests"
        ]
        15 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
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    "fechaRecibido" => "2020-04-28"
    "fechaAceptado" => "2020-05-08"
    "PalabrasClave" => array:2 [
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1425603"
          "palabras" => array:3 [
            0 => "COVID-19"
            1 => "Coronavirus"
            2 => "Cytokine release syndrome"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1425602"
          "palabras" => array:3 [
            0 => "COVID-19"
            1 => "Coronavirus"
            2 => "S&#237;ndrome de liberaci&#243;n de citocinas"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The novel SARS-CoV-2 human coronavirus in Wuhan&#44; China&#44; has triggered a worldwide respiratory disease outbreak &#40;COVID-19&#41;&#46; Acute respiratory distress syndrome &#40;ARDS&#41;&#44; multiorgan dysfunction and thrombotic events are among the leading causes of death in critically ill patients with COVID-19&#46; The elevated inflammatory cytokines suggest that a &#8220;cytokine storm&#8221;&#44; also known as cytokine release syndrome &#40;CRS&#41;&#44; may play a major role in the pathology of COVID-19&#46; In addition to anti-viral therapy and supportive treatment in critically ill patients&#44; unique medications for this condition are also under investigation&#46; Here we reviewed therapeutic options&#44; including the antibody therapy that might be an immediate strategy for SARS-CoV-2 therapy&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">El inicio del nuevo coronavirus humano del s&#237;ndrome respiratorio agudo grave &#40;SARS-Cov-2&#41; en Wuhan&#44; China&#44; ha desencadenado un brote respiratorio mundial &#40;COVID-19&#41;&#46; El s&#237;ndrome de insuficiencia respiratoria agua &#40;SIRA&#41;&#44; el fallo multiorg&#225;nico y eventos tromb&#243;ticos est&#225;n entre las causas que llevan a la muerte en pacientes cr&#237;ticamente enfermos con COVID-19&#46; Las citocinas inflamatorias elevadas sugieren que una &#8220;tormenta de citocinas&#8221;&#44; tambi&#233;n conocida como s&#237;ndrome de liberaci&#243;n de citocinas &#40;SLC&#41;&#44; puede jugar un papel principal en la patolog&#237;a de COVID-19&#46; Adicionalmente al tratamiento anti-viral y la terapia de apoyo respiratorio en pacientes cr&#237;ticamente enfermos&#44; est&#225;n en investigaci&#243;n medicamentos &#250;nicos para esta condici&#243;n&#46; En esta revisi&#243;n sintetizamos la evidencia m&#225;s actual de opciones terap&#233;uticas&#44; incluyendo anticuerpos anti-citocinas como una estrategia intermedia para la terapia de SARS-Cov-2&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Mendoza-Pinto C&#44; Garc&#237;a-Carrasco M&#44; Mungu&#237;a Realpozo P&#44; M&#233;ndez-Mart&#237;nez S&#46; Opciones terap&#233;uticas en el manejo de la COVID-19 grave&#58; una perspectiva de Reumatolog&#237;a&#46; Reumatol Clin&#46; 2021&#59;17&#58;431&#8211;436&#46;</p>"
      ]
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        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
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        "fuente" => "Source&#58; Bikdeli et al&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a>"
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          "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">DOA&#58; direct oral anticoagulants&#59; DIC&#58; disseminated intravascular coagulation&#59; LMWH&#58; low molecular weight heparin&#59; INR&#58; international normalized ratio&#59; VTE&#58; venous thromboembolism&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Patients with mild COVID-19 &#40;outpatient&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>For outpatients with COVID-19&#44; increased mobility should be encouraged&#46; Although indiscriminate use of pharmacological VTE prophylaxis should not be pursued&#44; assessment for the risk of VTE and of bleeding is reasonable&#46; Pharmacologic prophylaxis could be considered after risk assessment on an individual case basis for patients who have elevated risk VTE&#44; without high bleeding risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>There is no known risk of developing severe COVID-19 due to taking antithrombotic agents &#40;i&#46;e&#46;&#44; antiplatelet agents or anticoagulants&#41;&#46; If patients were taking antithrombotic agents for prior known thrombotic disease&#44; they should continue their antithrombotic therapy as recommended&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>For patients on vitamin K antagonists who do not have recent stable INRs&#44; and are unable to undergo INR testing&#44; it is reasonable to transition the treatment DOACs if there are no contraindications and no problems with drug availability&#46; If DOACs are not approved or available&#44; LMWH &#40;enoxaparin 40&#8239;mg&#47;day&#41; can be considered&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Patients with moderate or severe COVID-19 without DIC hospitalised</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hospitalized patients with COVID-19 should undergo risk stratification for VTE prophylaxis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>For hospitalized patients with COVID-19 and not in DIC&#44; prophylactic doses of anticoagulation should be administered to prevent VTE &#40;enoxaparin 40&#8239;mg&#47;day or dalteparin 5000 U daily&#59; subcutaneous heparin 5000 U twice daily may be considered for patients with kidney failure &#91;e&#46;g&#46;&#44; creatinine clearance &#60;30&#8239;ml&#47;min&#93;&#41;&#46; If pharmacological prophylaxis is contraindicated&#44; it is reasonable to consider intermittent pneumatic compression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>For hospitalised patients with COVID-19 and not in DIC&#44; there are insufficient data to consider routine therapeutic or parenteral therapeutic doses with LMWH &#40;e&#46;g&#46;&#44; enoxaparin 1&#8239;mg&#47;kg&#47;day&#44; or enoxaparin 40&#8239;mg twice a day&#41; or unfractionated heparin &#40;with an activated PTT target of 50&#8722;70&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Routine screening for VTE is not recommended &#40;e&#46;g&#46;&#44; bilateral lower extremity ultrasound&#41; for hospitalized patients with COVID-19 with elevated D-dimer&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Patients with moderate to severe COVID-19 hospitalised and suspected DIC</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>For patients with moderate to severe COVID-19 and in DIC but without overt bleeding&#44; prophylactic anticoagulation should be administered&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>For hospitalized patients with COVID-19 with suspected or confirmed DIC with no overt bleeding&#44; there are insufficient data to consider routine therapeutic-dose parenteral anticoagulation at therapeutic doses with LMWH or unfractionated heparin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>For patients with moderate or severe COVID-19 on chronic therapeutic anticoagulation&#44; who develop suspected or confirmed DIC without overt bleeding&#44; it is reasonable to consider the indication for anticoagulation and to weigh with risk of bleeding when making clinical decisions regarding dose adjustments or discontinuation&#46; It is recommended to reduce the intensity of anticoagulation in this clinical circumstance&#44; unless the risk of thrombosis is considered to be exceedingly high&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>For patients with moderate or severe COVID-19 and an indication for dual antiplatelet therapy &#40;e&#46;g&#46;&#44; percutaneous coronary intervention in the past 3 months or recent myocardial infarction&#41; and with suspected or confirmed DIC with no overt bleeding&#44; in the absence of evidence&#44; decisions for antiplatelet therapy need to be individualized&#46; In general&#44; it is reasonable to continue dual antiplatelet therapy &#40;aspirin plus a P2Y receptor inhibitor such as clopidogrel&#41; if platelet count is &#62;50&#44;000&#44; reduce to a single therapy if platelet count is 25&#44;000 and 50&#44;000&#44; and discontinue if platelet count is &#60;25&#44;000&#46; However&#44; these guidelines may be revised depending on the individualized relative risk of thrombotic complications vs&#46; bleeding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>For patients who were admitted and are now being discharged for COVID-19 and now discharged&#44; routine screening for VTE risk is reasonable for consideration of pharmaceutical prophylaxis for up to 45 days post-discharge&#46; Pharmacological prophylaxis should be considered if there is elevated risk for thrombotic events&#44; without bleeding risk&#46; Ambulation and physical activity should be encouraged&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Patients without COVID-19 who have previously known thrombotic disease</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>There is no known risk of developing COVID-19 due to the administration of antithrombotic agents&#46; Patients should continue treatment with antithrombotic agent as recommended&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>To minimize risks associated with health care worker and patient in-person interactions&#44; follow-up with e&#46;visits and telemedicine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Patients without COVID-19 who develop new thrombotic disease</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>To minimize the risks associated with health care worker and patient in-person interactions&#44; in-home treatment or early discharge should be prioritized with electronic or telemedicine follow-up&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Patients without COVID-19 but with comorbid conditions &#40;e&#46;g&#46;&#44; prior history of VTE&#44; active cancer&#44; major lung disease&#41; who are homebound</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Recommendations include increased mobility&#44; and risk assessment for the risk of VTE and risk of bleeding is reasonable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Administration of pharmacological prophylaxis could be considered after risk assessment on an individual case basis based on their risk for thrombosis and bleeding risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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Special Article
Therapeutic options for the management of severe COVID-19: A rheumatology perspective
Opciones terapéuticas en el manejo de la COVID-19 grave: una perspectiva de Reumatología
Claudia Mendoza-Pintoa,b, Mario García-Carrascoa,b,
Corresponding author
mgc30591@yahoo.com

Corresponding author.
, Pamela Munguía Realpozob, Socorro Méndez-Martínezc
a Unidad de Investigación de Enfermedades Autoinmunes Sistémicas, Hospital de Especialidades, UMAE-Centro de Investigación Biomédica de Oriente, Instituto Mexicano del Seguro Social, Puebla, Mexico
b Departamento de Reumatología e Inmunología, Facultad de Medicina, Benemérita Universidad Autónoma de Puebla, Puebla, Mexico
c Coordinación de Investigación en Salud, Delegación Puebla, Instituto Mexicano del Seguro Social, Puebla, Mexico
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The degree of disease severity with COVID-19 varies and can become fulminant or fatal&#46; The World Health Organization &#40;WHO&#41; estimates that severe disease can occur in about 13&#46;8&#37; of cases and 6&#46;1&#37; are critical&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> When cases are fulminant&#44; patients may develop sepsis&#44; acute respiratory failure syndrome &#40;ARDS&#41; or multiple organ failure&#44; which are not exclusive to coronaviruses&#46; Cytokine release syndrome &#40;CRS&#41; refers to an uncontrolled and exaggerated release of pro-inflammatory mediators into the activated immune system&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> This disturbance may be present in various clinical entities&#44; including the rheumatology setting&#44; Still&#39;s disease&#44; systemic juvenile idiopathic arthritis&#44; systemic lupus erythematosus and catastrophic antiphospholipid syndrome &#40;APS&#41;&#46; CRS is involved in the immunopathogenesis of many pathological processes&#44; such as ARDS&#44; sepsis&#44; Macrophage activation syndrome &#40;MAS&#41;&#44; etc&#46;&#44; several of which are described in severe acute respiratory syndrome &#40;SARS&#41;&#44; Middle East respiratory syndrome &#40;MERS&#41; and also in the new COVID-19 infection&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> While treatment directed against the virus is desired&#44; treatment of the systemic response is possibly the most important aspect of patient care and should be viewed aggressively&#46; Finally&#44; patients with COVID-19 who develop a severe condition may have a procoagulant pattern&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Therefore&#44; this review synthesizes the evidence related to therapies with an anti-inflammatory role that can play a relevant role in the management of patients with severe COVID-19&#44; briefly mentioning the role of antithrombotic therapy in the treatment of complicated patients&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Glucocorticoids</span><p id="par0010" class="elsevierStylePara elsevierViewall">Glucocorticoids &#40;GC&#41; are some of the most widely used anti-inflammatory agents&#59; they are commonly prescribed in the treatment of patients with COVID-19 &#40;72&#37; in the ICU&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> However&#44; as mentioned in the Chinese COVID-19 guidelines&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> physicians must be careful in the use of GCs because of their uncertain benefits in the context of viral respiratory infection&#46; Several studies have reported inferior results in SARS patients treated with GC&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> due to delayed purging of the virus&#46; Other concerns with GCs are short-term and long-term adverse effects&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Antimalarials &#40;chloroquine and hydroxychloroquine&#41;</span><p id="par0015" class="elsevierStylePara elsevierViewall">Recent publications have drawn attention to the possible beneficial effect of hydroxychloroquine &#40;HCQ&#41; and chloroquine &#40;CLQ&#41; in the treatment of patients infected with the new SARS-CoV-2 coronavirus&#46; It has been observed that the growth of several different viruses &#40;including SARS coronavirus&#41; can be inhibited in cell cultures by both CLQ and HCQ&#46; In addition&#44; these drugs are weak bases that can affect acidic vesicles and inhibit several enzymes&#46; This characteristic enables inhibiting of viral entry into cells when endocytosis is pH dependent&#46; They also inhibit the enzyme glycosyltransferase &#40;inhibition of virus glycosylation&#41;&#44; post-transcriptional viral modifications and replication of some viral families&#46; As it is known that COVID-19 infection can on occasion lead to severe pictures with SARS&#44; which can be due in part to the increase of proinflammatory cytokines such as interleukin 6 &#40;IL-6&#41; and tumour necrosis factor-alpha &#40;TNF-&#945;&#41;&#46; CLQ is highly effective in combination with remdesivir in controlling SARS-CoV-2<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> in vitro&#46; There is now already some evidence in humans&#46; In an open observational study conducted in France&#44; they evaluated the role of HCQ in combination with azithromycin on respiratory viral load in 20 patients with COVID-19 compared with 16 controls&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> A significant reduction in viral load was shown &#40;70&#37; at day 7&#41; compared to the controls&#46; When azithromycin was added&#44; more efficient elimination of the virus was found &#40;100&#37; reduction&#41;&#46; Gao et al&#46; described results in 100 patients in China where they demonstrated the superiority of CLQ over the control treatment in inhibiting exacerbation of pneumonia&#44; improving lung imaging findings&#44; promoting negative virus conversion&#44; and shortening the course of the disease&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> However&#44; the details of this study are not known in depth&#46; A recent study reported the results of a retrospective analysis of 368 hospitalized patients with confirmed SARS-CoV-2 infection &#40;U&#46;S&#46; Veterans Health Administration&#41; of evaluation of exposure to HCQ alone or in combination with azithromycin&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> The mortality rates in the HCQ alone&#44; combined HQC&#44; and no HQC groups were 27&#46;8&#37;&#44; 22&#46;1&#37;&#44; and 11&#46;4&#37;&#44; respectively&#46; Ventilation rates in the HCQ&#44; combined HCQ and no HCQ groups were 13&#46;3&#37;&#44; 6&#46;9&#37; and 14&#46;1&#37;&#44; respectively&#46; In this study&#44; no evidence was found that the use of HCQ alone or combined reduces the risk of mechanical ventilation in hospitalized patients with COVID-19 and that patients receiving HCQ alone had the highest mortality rate&#46; These findings highlight the importance of waiting for the results of the prospective randomized studies that are underway before widely adopting these drugs&#46; There are currently about 14 clinical trials registered to prove the benefit of antimalarials&#46; Although antimalarials are relatively safe drugs&#44; it should be remembered that their most frequent effects are gastrointestinal&#44; pruritus&#44; and dermal changes in 10&#37; of patients&#46; The most serious effects are of low incidence&#44; such as cardiomyotoxicity&#44; neuromyopathy&#44; and irreversible retinopathy &#40;large doses and long term&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Tocilizumab&#44; inleukin-6 inhibitor</span><p id="par0020" class="elsevierStylePara elsevierViewall">There has recently been much interest in the possibility of using tocilizumab&#44; a humanized antibody targeting the IL-6 receptor&#44; on the grounds of preventing or treating the cytokine storm that has been observed in patients that progress to cardiovascular collapse&#44; multiorgan dysfunction&#44; and death&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Inflammatory cytokines and chemokines&#44; including IL-6&#44; IL-1&#946;&#44; induced protein 10&#44; and monocyte chemotactic protein-1&#44; have been found to be significantly elevated in Covid-19 patients&#44; and are more often elevated in severe patients than in non-severe patients&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> In patients with COVID-19&#44; with elevated inflammatory cytokines&#44; post mortem pathology revealed tissue necrosis and infiltrations of macrophages and monocytes in the lung&#44; heart and gastrointestinal mucosa&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> which suggests an uncontrolled immune response&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Studies have shown that ARDS occurs in some SARS patients despite a reduced viral load&#44; suggesting that an exuberant immune response rather than viral virulence is possibly responsible for the pathology at tissue level&#46; Therefore&#44; antiviral therapy alone may not be sufficient&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> As previously mentioned&#44; IL-6 is one of the cytokines that plays a role in the pathogenesis in patients with severe COVID-19&#59; it has also been suggested as a biomarker of severe disease&#44;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> and therefore blockade may be a promising strategy for COVID-19-induced CRS&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">IL-6 is essential for the generation of T-helper 17 &#40;Th17&#41; lymphocytes in the interaction between T-lymphocytes and dendritic cells&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Therefore elevated IL-6 may explain the excessive Th17 activation observed in patients with COVID-19&#44; as reported by Xu et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Although no data are available on IL-6 blockade in CRS induced by viral infection&#44; animal studies of SARS-CoV have shown that they inhibit nuclear factor kappa-B&#44; an essential transcription factor of IL-6&#44; increasing animal survival with reduced levels of IL-6&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> Tocilizumab&#44; which blocks IL-6&#44; binds to the IL-6 receptor in both soluble and membrane-bound forms to inhibit IL-6-mediated signals&#46; This drug has been approved by the Food and Drug Administration for the treatment of CRS associated with CAR T-cell therapy&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Data on the use of this molecule in the treatment of SARS-CoV-2 infection are still preliminary but promising results have prompted the Chinese Health Commission to update its national guidelines&#44; which include tocilizumab for the treatment of severe COVID-19&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> The Italian guidelines also support the use of tocilizumab &#40;at a dose of 8&#8239;mg&#47;kg&#44; with a second dose 12&#8239;h after the first and a possible third after 24-36&#8239;h&#44; depending on the clinical response&#41;&#44; in the event of rapid clinical or radiological worsening&#44; after excluding contraindications to its use &#40;levels of transaminases &#62;5 times the upper limit of normal&#44; neutrophil count &#60;50&#44;000 cells&#47;&#956;l&#44; presence of documented sepsis complicated by bacteria&#44; diverticulitis&#47;intestinal perforation&#44; skin infection&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">There are case reports of improvement in patients with severe COVID-19 after the administration of tocilizumab&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21&#44;22</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Interleukin 1b inhibitors and protein kinase inhibitors JAK1&#47;2 &#40;roxulitinib&#41;</span><p id="par0045" class="elsevierStylePara elsevierViewall">Several laboratory markers related to MAS&#47; haemaphagocytic lymphohistiocytosis &#40;HLH&#41; are elevated in severe COVID-19&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> Therefore&#44; treatments aimed at controlling MAS&#47;HLH have been suggested for the management of severe COVID-19&#46; The recombinant human IL-1 receptor antagonist&#44; anakinra&#44; has been used for the treatment of MAS&#47;HLH associated with autoimmune rheumatic diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> Data from a reanalysis of a phase <span class="elsevierStyleSmallCaps">iii</span> controlled trial found that anakinra was associated with significant improvement in the survival of patients with sepsis with concurrent MAS&#47;HLH&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Small molecule inhibiting Janus kinases&#44; such as the JAK1&#47;2 inhibitor ruxolitinib&#44;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> are capable of blocking signals from IL-6&#44; interferon &#947; &#40;IFN-&#947;&#41; and other cytokines involved in MAS&#47;HLH&#46; Therefore&#44; this drug could have potential in the treatment of serious complications in patients with COVID-19&#46; More recently&#44; the use of anti-IFN-&#947; antibodies has been contemplated in the management of this serious complication&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Intravenous immunoglobulin and plasma from recovered patients &#40;&#8220;convalescent plasma&#8221;&#41;</span><p id="par0055" class="elsevierStylePara elsevierViewall">Individuals with a weakened immune system appear to be at greater risk of developing complications associated with COVID-19&#46; Immunotherapy using IgG in combination with antiviral drugs could be used to treat or prevent SARS-CoV-2 infection and strengthen our immune system against this virus&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">28&#44;29</span></a> They have also have been administered as anti-infective agents against viruses&#44; bacteria and fungi in experimental models and in humans&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> IVIGs can modulate the immune response by several mechanisms&#44; including blocking various pro-inflammatory cytokines&#44; Fc receptors&#44; and leukocyte adhesion molecules&#44; suppressing Th1 and Th17 cell subtypes&#44; and neutralizing pathogenic autoantibodies&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> IVIGs can also expand regulatory T lymphocytes&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> However&#44; IVIGs have adverse reactions&#46; During the SARS outbreak in 2003&#44; IVIG was used extensively in Singapore&#46; However&#44; some critically ill patients developed venous thromboembolism &#40;VTE&#41; including pulmonary embolism despite the use of prophylactic low molecular weight heparin&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> This is due to the increased viscosity in hypercoagulable states of SARS patients&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Convalescent plasma samples have been used to treat SARS in Hong Kong and China and may be valuable because&#44; unlike standard IVIG preparations&#44; they have high levels of anti-SARS-CoV antibodies&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> Pyrc et al&#46; showed that human serum from adult humans inhibited infection by HCov-NL63&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> Furthermore&#44; they described that IVIGs can also neutralize HCoV-NL63&#46; Boukhvalova et al&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> demonstrated that&#44; in contrast&#44; the commercially available therapeutic polyclonal IgG products&#44; IVIG obtained from donors with antibodies at high titres against respiratory syncytial virus &#40;RSV&#41;&#44; have great potential in improving RSV outcomes in immunocompromised subjects&#44; not only controlling viral replication&#44; but also reducing damage to the lung parenchyma and the epithelial lining of the respiratory tract&#46; The use of convalescent plasma or serum was also suggested by the WHO under the Blood Regulators Network should vaccines and antiviral drugs not be available in an emerging virus&#46; In the current pandemic&#44; there are reports that convalescent plasma has been used in China to treat patients with COVID-19&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">36</span></a> In a pilot study of 10 patients with severe COVID-19&#44; investigators collected convalescent plasma with neutralizing antibody titres at a dilution of 1&#58;640 or more&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">37</span></a> The convalescent plasma transfusion resulted in no serious adverse events in the receivers&#46; All 10 patients had improvement of symptoms &#40;e&#46;g&#46;&#44; fever&#44; cough&#44; shortness of breath&#44; and precordial pain&#41; within 1-3 days of the transfusion&#59; they also showed radiological improvement in lung lesions&#46; Similarly&#44; an undetectable viral load was found in most of them&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">IgG immunotherapy could be used to neutralize the virus causing COVID-19&#46; The efficiency of IgG could be improved if these immune IgG antibodies were collected from patients who had recovered from COVID-19 in the same city&#44; or surrounding areas&#44; as donor subjects who have dealt with the virus&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Plasma interchange</span><p id="par0070" class="elsevierStylePara elsevierViewall">Therapeutic apheresis encompasses a large number of techniques the main basis of which is to process a patient&#39;s blood through an extracorporeal device with the aim of eliminating antibodies and preformed immunocomplexes to prevent tissue damage&#44; eliminating inflammation mediators as a complement and cytokines that could contribute to damage&#44; and providing deficiency factors&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> Among the different types of apheresis&#44; some of the most used are therapeutic plasma exchange &#40;PE&#41; and immunoadsorption&#46; Therapeutic PE is a technique for purifying extracorporeal blood&#44; through which plasma is removed&#46; A variable volume of plasma is removed from the patient and replaced with replacement solutions that maintain volume and oncotic pressure&#46; The term &#34;plasmapheresis&#34; should be reserved for situations in which only plasma removal without replenishment is performed&#44; such as plasma donation by apheresis for transfusion or subsequent industrial plasma fractionation&#46; This procedure extracts less plasma &#40;around 600&#8239;ml&#41;&#44; without replenishment solution&#44; in less time and with simpler separation techniques than those used in PE&#46; The host response to infection has been described and involves a complex interaction of cytokine storm&#44; inflammation&#44; endothelial dysfunction&#44; and pathological coagulation&#46; Plasma exchange is a pathway that offers benefit at multiple levels by removing inflammatory cytokines&#44; stabilizing endothelial membranes&#44; and restarting the hypercoagulable state&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Busund et al&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a> showed a trend towards improving mortality with therapeutic PE as an adjuvant treatment in adults with sepsis and multiple organ failure in a controlled clinical trial&#44; while a meta-analysis by Rimmer also showed benefit in adult patient mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a> Addressing this information&#44; Patel et al&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a> used therapeutic PE during the 2009 A &#40;H1N1&#41; influenza epidemic in 3 paediatric patients with a fulminant condition similar to the current pandemic&#46; All 3 patients developed ARDS with haemodynamic compromise that continued to deteriorate despite rescue treatment for ARDS including inhaled nitric oxide and extracorporeal venous membrane oxygenation&#46; All 3 patients made a full recovery from their disease after receiving rescue PE&#46; Recently&#44; 3 patients were described with COVID-19 in Wuhan&#44; China&#44;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">42</span></a> characterized by deep inflammation and treated with blood purification therapies&#44; including PE and adsorption&#46; A potent effect on cytokine storm management and pathogenic antibodies was shown&#46; Of these 3 patients&#44; 2 maintained a stable state and could be discharged from the Intensive Care Unit&#44; while one developed disseminated intravascular coagulation &#40;DIC&#41; and died&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Antithrombotic therapy</span><p id="par0080" class="elsevierStylePara elsevierViewall">Severe COVID-19 can often present a marked elevation of D-dimer&#44; thrombocytopenia and coagulation disturbances that are considered to be regulated by various inflammatory cytokines<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">43&#44;44</span></a> and that correlate with mortality&#46; Another biomarker that has been found to be elevated in patients with severe COVID-19 is ferritin&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> which is also impaired in other severe conditions&#44; including APS in its most severe form&#44; catastrophic APS&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">45</span></a> Recently&#44; a group from China described 3 cases with COVID-19 and antiphospholipid antibodies&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a> Recent statements by the International Society on Thrombosis and Haemostasis &#40;ISTH&#41; and the American Society of Hematology &#40;ASH&#41; suggest that all patients hospitalized with COVID-19 should receive thromboprophylaxis or full-dose therapeutic anticoagulation&#46; The efficacy of anticoagulation therapy in patients with COVID-19 was recently evaluated retrospectively&#46; Lower mortality at 28 days was found in patients who used heparin &#40;40&#37;&#41; compared to those who did not &#40;64&#46;2&#37;&#41;&#44; mainly in those with sepsis-induced coagulopathy or with a markedly elevated D-dimer&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> summarizes the antithrombotic recommendations for patients with COVID-19&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conclusions</span><p id="par0085" class="elsevierStylePara elsevierViewall">COVID-19 is a viral infection with potentially serious complications that can increase the risk of death in infected patients&#46; Several of these disturbances are secondary to an uncontrolled immune response where a cytokine storm plays a similarly important role in preventing the thrombotic complications to which these patients are exposed&#46; Although antiviral treatment and respiratory support therapies are essential in the treatment of severe cases&#44; it is necessary to assess the risk-benefit of therapies aimed at controlling the immune response to decrease the mortality rate&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Funding</span><p id="par0095" class="elsevierStylePara elsevierViewall">This research study has received no specific support from public sector agencies&#44; the commercial sector&#44; or non-profit entities&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conflict of interests</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare</p></span></span>"
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        0 => array:3 [
          "identificador" => "xres1584153"
          "titulo" => "Abstract"
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              "identificador" => "abst0005"
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        1 => array:2 [
          "identificador" => "xpalclavsec1425603"
          "titulo" => "Keywords"
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        2 => array:3 [
          "identificador" => "xres1584154"
          "titulo" => "Resumen"
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            0 => array:1 [
              "identificador" => "abst0010"
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          "identificador" => "xpalclavsec1425602"
          "titulo" => "Palabras clave"
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        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Introduction"
        ]
        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Glucocorticoids"
        ]
        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Antimalarials &#40;chloroquine and hydroxychloroquine&#41;"
        ]
        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Tocilizumab&#44; inleukin-6 inhibitor"
        ]
        8 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Interleukin 1b inhibitors and protein kinase inhibitors JAK1&#47;2 &#40;roxulitinib&#41;"
        ]
        9 => array:2 [
          "identificador" => "sec0030"
          "titulo" => "Intravenous immunoglobulin and plasma from recovered patients &#40;&#8220;convalescent plasma&#8221;&#41;"
        ]
        10 => array:2 [
          "identificador" => "sec0035"
          "titulo" => "Plasma interchange"
        ]
        11 => array:2 [
          "identificador" => "sec0040"
          "titulo" => "Antithrombotic therapy"
        ]
        12 => array:2 [
          "identificador" => "sec0045"
          "titulo" => "Conclusions"
        ]
        13 => array:2 [
          "identificador" => "sec0055"
          "titulo" => "Funding"
        ]
        14 => array:2 [
          "identificador" => "sec0050"
          "titulo" => "Conflict of interests"
        ]
        15 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
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    "fechaRecibido" => "2020-04-28"
    "fechaAceptado" => "2020-05-08"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1425603"
          "palabras" => array:3 [
            0 => "COVID-19"
            1 => "Coronavirus"
            2 => "Cytokine release syndrome"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1425602"
          "palabras" => array:3 [
            0 => "COVID-19"
            1 => "Coronavirus"
            2 => "S&#237;ndrome de liberaci&#243;n de citocinas"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The novel SARS-CoV-2 human coronavirus in Wuhan&#44; China&#44; has triggered a worldwide respiratory disease outbreak &#40;COVID-19&#41;&#46; Acute respiratory distress syndrome &#40;ARDS&#41;&#44; multiorgan dysfunction and thrombotic events are among the leading causes of death in critically ill patients with COVID-19&#46; The elevated inflammatory cytokines suggest that a &#8220;cytokine storm&#8221;&#44; also known as cytokine release syndrome &#40;CRS&#41;&#44; may play a major role in the pathology of COVID-19&#46; In addition to anti-viral therapy and supportive treatment in critically ill patients&#44; unique medications for this condition are also under investigation&#46; Here we reviewed therapeutic options&#44; including the antibody therapy that might be an immediate strategy for SARS-CoV-2 therapy&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">El inicio del nuevo coronavirus humano del s&#237;ndrome respiratorio agudo grave &#40;SARS-Cov-2&#41; en Wuhan&#44; China&#44; ha desencadenado un brote respiratorio mundial &#40;COVID-19&#41;&#46; El s&#237;ndrome de insuficiencia respiratoria agua &#40;SIRA&#41;&#44; el fallo multiorg&#225;nico y eventos tromb&#243;ticos est&#225;n entre las causas que llevan a la muerte en pacientes cr&#237;ticamente enfermos con COVID-19&#46; Las citocinas inflamatorias elevadas sugieren que una &#8220;tormenta de citocinas&#8221;&#44; tambi&#233;n conocida como s&#237;ndrome de liberaci&#243;n de citocinas &#40;SLC&#41;&#44; puede jugar un papel principal en la patolog&#237;a de COVID-19&#46; Adicionalmente al tratamiento anti-viral y la terapia de apoyo respiratorio en pacientes cr&#237;ticamente enfermos&#44; est&#225;n en investigaci&#243;n medicamentos &#250;nicos para esta condici&#243;n&#46; En esta revisi&#243;n sintetizamos la evidencia m&#225;s actual de opciones terap&#233;uticas&#44; incluyendo anticuerpos anti-citocinas como una estrategia intermedia para la terapia de SARS-Cov-2&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Mendoza-Pinto C&#44; Garc&#237;a-Carrasco M&#44; Mungu&#237;a Realpozo P&#44; M&#233;ndez-Mart&#237;nez S&#46; Opciones terap&#233;uticas en el manejo de la COVID-19 grave&#58; una perspectiva de Reumatolog&#237;a&#46; Reumatol Clin&#46; 2021&#59;17&#58;431&#8211;436&#46;</p>"
      ]
    ]
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      0 => array:9 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
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        "fuente" => "Source&#58; Bikdeli et al&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">48</span></a>"
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            "detalle" => "Table "
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          "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">DOA&#58; direct oral anticoagulants&#59; DIC&#58; disseminated intravascular coagulation&#59; LMWH&#58; low molecular weight heparin&#59; INR&#58; international normalized ratio&#59; VTE&#58; venous thromboembolism&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Patients with mild COVID-19 &#40;outpatient&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>For outpatients with COVID-19&#44; increased mobility should be encouraged&#46; Although indiscriminate use of pharmacological VTE prophylaxis should not be pursued&#44; assessment for the risk of VTE and of bleeding is reasonable&#46; Pharmacologic prophylaxis could be considered after risk assessment on an individual case basis for patients who have elevated risk VTE&#44; without high bleeding risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>There is no known risk of developing severe COVID-19 due to taking antithrombotic agents &#40;i&#46;e&#46;&#44; antiplatelet agents or anticoagulants&#41;&#46; If patients were taking antithrombotic agents for prior known thrombotic disease&#44; they should continue their antithrombotic therapy as recommended&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>For patients on vitamin K antagonists who do not have recent stable INRs&#44; and are unable to undergo INR testing&#44; it is reasonable to transition the treatment DOACs if there are no contraindications and no problems with drug availability&#46; If DOACs are not approved or available&#44; LMWH &#40;enoxaparin 40&#8239;mg&#47;day&#41; can be considered&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Patients with moderate or severe COVID-19 without DIC hospitalised</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hospitalized patients with COVID-19 should undergo risk stratification for VTE prophylaxis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>For hospitalized patients with COVID-19 and not in DIC&#44; prophylactic doses of anticoagulation should be administered to prevent VTE &#40;enoxaparin 40&#8239;mg&#47;day or dalteparin 5000 U daily&#59; subcutaneous heparin 5000 U twice daily may be considered for patients with kidney failure &#91;e&#46;g&#46;&#44; creatinine clearance &#60;30&#8239;ml&#47;min&#93;&#41;&#46; If pharmacological prophylaxis is contraindicated&#44; it is reasonable to consider intermittent pneumatic compression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>For hospitalised patients with COVID-19 and not in DIC&#44; there are insufficient data to consider routine therapeutic or parenteral therapeutic doses with LMWH &#40;e&#46;g&#46;&#44; enoxaparin 1&#8239;mg&#47;kg&#47;day&#44; or enoxaparin 40&#8239;mg twice a day&#41; or unfractionated heparin &#40;with an activated PTT target of 50&#8722;70&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Routine screening for VTE is not recommended &#40;e&#46;g&#46;&#44; bilateral lower extremity ultrasound&#41; for hospitalized patients with COVID-19 with elevated D-dimer&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Patients with moderate to severe COVID-19 hospitalised and suspected DIC</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>For patients with moderate to severe COVID-19 and in DIC but without overt bleeding&#44; prophylactic anticoagulation should be administered&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>For hospitalized patients with COVID-19 with suspected or confirmed DIC with no overt bleeding&#44; there are insufficient data to consider routine therapeutic-dose parenteral anticoagulation at therapeutic doses with LMWH or unfractionated heparin&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>For patients with moderate or severe COVID-19 on chronic therapeutic anticoagulation&#44; who develop suspected or confirmed DIC without overt bleeding&#44; it is reasonable to consider the indication for anticoagulation and to weigh with risk of bleeding when making clinical decisions regarding dose adjustments or discontinuation&#46; It is recommended to reduce the intensity of anticoagulation in this clinical circumstance&#44; unless the risk of thrombosis is considered to be exceedingly high&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>For patients with moderate or severe COVID-19 and an indication for dual antiplatelet therapy &#40;e&#46;g&#46;&#44; percutaneous coronary intervention in the past 3 months or recent myocardial infarction&#41; and with suspected or confirmed DIC with no overt bleeding&#44; in the absence of evidence&#44; decisions for antiplatelet therapy need to be individualized&#46; In general&#44; it is reasonable to continue dual antiplatelet therapy &#40;aspirin plus a P2Y receptor inhibitor such as clopidogrel&#41; if platelet count is &#62;50&#44;000&#44; reduce to a single therapy if platelet count is 25&#44;000 and 50&#44;000&#44; and discontinue if platelet count is &#60;25&#44;000&#46; However&#44; these guidelines may be revised depending on the individualized relative risk of thrombotic complications vs&#46; bleeding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>For patients who were admitted and are now being discharged for COVID-19 and now discharged&#44; routine screening for VTE risk is reasonable for consideration of pharmaceutical prophylaxis for up to 45 days post-discharge&#46; Pharmacological prophylaxis should be considered if there is elevated risk for thrombotic events&#44; without bleeding risk&#46; Ambulation and physical activity should be encouraged&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Patients without COVID-19 who have previously known thrombotic disease</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>There is no known risk of developing COVID-19 due to the administration of antithrombotic agents&#46; Patients should continue treatment with antithrombotic agent as recommended&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>To minimize risks associated with health care worker and patient in-person interactions&#44; follow-up with e&#46;visits and telemedicine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Patients without COVID-19 who develop new thrombotic disease</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>To minimize the risks associated with health care worker and patient in-person interactions&#44; in-home treatment or early discharge should be prioritized with electronic or telemedicine follow-up&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Patients without COVID-19 but with comorbid conditions &#40;e&#46;g&#46;&#44; prior history of VTE&#44; active cancer&#44; major lung disease&#41; who are homebound</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Recommendations include increased mobility&#44; and risk assessment for the risk of VTE and risk of bleeding is reasonable&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Administration of pharmacological prophylaxis could be considered after risk assessment on an individual case basis based on their risk for thrombosis and bleeding risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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Idiomas
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