As a hospital pharmacist, you will hear renewed interest in tocilizumab for COVID-19, based on new data suggesting it reduces mortality in some patients. IL-6 inhibitors, such as tocilizumab (Actemra), sparked early interest in COVID-19 to block cytokines and reduce inflammation. But trials haven’t consistently demonstrated a benefit.
Now early data from the RECOVERY trial suggest that adding tocilizumab to standard care reduces mortality in severely ill COVID-19 patients those requiring supplemental oxygen or respiratory support. And the REMAP-CAP trial also suggests tocilizumab reduces mortality in ICU patients needing respiratory or CV support. Help tease out details that may affect risk-benefit balance.
Emphasize that the majority of patients in these studies also received a systemic steroid to treat COVID-19 and got just one dose of tocilizumab, even though protocols allowed up to two. And timing may matter. Most patients in these trials started tocilizumab early within a few days of hospital admission. Point out limitations. Both studies are open-label, RECOVERY isn’t peer reviewed yet and tocilizumab is expensive. Follow a cautious approach with tocilizumab pending more data. For now, consider saving it for COVID-19 patients receiving a steroid with inflammation (elevated C-reactive protein, etc) and worsening status, such as progression to high-flow oxygen or mechanical ventilation.
Also think about further reserving it for those who are earlier in their hospitalization. And generally limit tocilizumab to a single dose when treating COVID-19.. so far, it’s not clear that a second dose adds benefit. Avoid starting tocilizumab in some cases based on risks. For example, don’t add tocilizumab to COVID-19 patients with another serious infection, such as bacteremia. Some data suggest that even a one-time tocilizumab dose may increase infection risk.
REFERENCES
Infectious Diseases Society of America Guidelines on the Treatment and Management of Patients with COVID-19. [online] Available at: https://www.idsociety.org/practice-guideline/covid-19-guideline-treatment-and-management
COVID-19 Treatment Guidelines. Information on COVID-19 Treatment, Prevention and Research. [online] Available at: https://www.covid19treatmentguidelines.nih.gov
Horby, P.W., Pessoa-Amorim, and others (2021). Tocilizumab in patients admitted to hospital with COVID-19 (RECOVERY): preliminary results of a randomised, controlled, open-label, platform trial. available at: https://www.medrxiv.org/content/10.1101/2021.02.11.21249258v1
Interleukin-6 Receptor Antagonists in Critically Ill Patients with Covid-19. (2021). New England Journal of Medicine. Available at: https://www.nejm.org/doi/full/10.1056/NEJMoa2100433
Rubin, E.J., Longo, D.L. and Baden, L.R. (2021). Interleukin-6 Receptor Inhibition in Covid-19 — Cooling the Inflammatory Soup. New England Journal of Medicine. Available at: https://www.nejm.org/doi/full/10.1056/NEJMe2103108