Table 4.

Medical Treatment of MIS‐A With Cardiac Involvement

Category	Glucocorticoids	Immunoglobulin	Anakinra	Tocilizumab
Population	All patients without contraindications	As corticosteroid‐sparing therapy or in combination as first‐line therapy	Patients with moderate to severe disease resistant to glucocorticoids	Patients with moderate to severe disease resistant to glucocorticoids
Medication and dose use	Methylprednisolone intravenously or orally 0.3–0.4 mg/d in moderate‐ to low‐risk disease Methylprednisolone intravenously up to 1 g intravenously for 3 d, followed by 1–2 mg/kg in high‐risk disease (eg, fulminant myocarditis or CS)	2 g/kg in 1 or 4 divided infusions within the first ten days from the disease onset alone or in combination with glucocorticoids	100 mg daily by subcutaneous injection. Consider higher (often intravenous) doses, up to 10 mg/kg daily in cases of severe hyperinflammation	8 mg/kg intravenously (to a maximum of 800 mg). If clinical improvement does not occur within 24 h after, up to 3 additional doses may be administered
Mechanism of action	Glucocorticoids produce anti‐inflammatory and immunosuppressive effects through inhibition of proinflammatory cytokines and chemokines and inhibition of T and B cells	Immunoglobulin accelerates the clearance of circulating immunocomplexes, promotes the inhibition of complement deposition, and promotes the enhancement of regulatory T cells	Anakinra is a recombinant human IL‐1 receptor antagonist that promotes the downregulation of the downstream cascade events secondary to IL‐1 release	Tocilizumab inhibits the IL‐6 receptor and prevents the downstream activation of the IL‐6 pathway, the differentiation of CD4+ T cells, and the inhibition of T‐regulatory cells
Adverse effects	Hyperglycemia and iatrogenic diabetes, psychiatric disturbances, immunosuppression, hypertension, peptic ulcer, osteoporosis, weight gain, adrenal suppression	Fever, dermatological adverse effects, arrhythmia, neutropenia, prothrombotic effects	Increased risk of serious infection, hepatitis, injection‐site reactions	Increased risk of serious infection, gastrointestinal perforations, neutropenia, and thrombocytopenia, increased level of hepatic indexes
Contraindications	Systemic fungal infection, diabetes with poor glycemic control, known hypersensitivity, osteoporosis, glaucoma, joint infections	Active infective disease, known hypersensitivity, IgA‐deficient patients	Active infective disease, known hypersensitivity	Active infective disease, known hypersensitivity

CS indicates cardiogenic shock; IgA, immunoglobulin A; IL‐1, interleukin 1; IL‐6, interleukin 6; and MIS‐A, multisystemic inflammatory syndrome in adults.