Use of tocilizumab may result in lower mortality in patients hospitalized for coronavirus disease 2019 (COVID-19) with evidence of cytokine release syndrome (CRS), according to the results of an observational study published in CHEST.1
COVID-19 disease severity is hypothesized to result from CRS, marked by C-reactive protein elevations, which may represent a key pathophysiologic process that contributes to elevated morbidity and mortality.1 Tocilizumab is indicated for the treatment of several inflammatory conditions, including CRS. A small clinical case series of patients with COVID-19 treated with tocilizumab demonstrated improvement in oxygenation, inflammatory biomarkers, and high hospital discharge rates.2-4 However, little is known about its safety or how it affects mechanical ventilation and survival.
Therefore, researchers studied whether tocilizumab would benefit hospitalized patients with COVID-19 and found that in 239 patients, severe disease was associated with lower survival rates (78% vs 93%; P <.001), a higher percentage requiring mechanical ventilation (44% vs 5%; p<0.001), and more days requiring mechanical ventilation (5.5 vs 1.0 days; P =.003).1
Patients treated with tocilizumab (N=153; 64%) involved 90% of severe patients, and 44% of nonsevere patients with evolving CRS. Although patients with severe disease who were treated with tocilizumab had higher admission high sensitivity C-reactive protein levels (120 vs 71 mg/L; P <.001) and received tocilizumab sooner (2 vs 3 days; P <.001), their survival was similar to that of nonsevere patients (83% vs 91%; P =.11). In patients treated with tocilizumab who required mechanical ventilation, the survival rate was 75% (95% CI, 64%-89%).
After tocilizumab treatment, few adverse events occurred, and oxygenation and inflammatory biomarkers improved; however, D-dimer and soluble interleukin-2 receptor levels increased significantly. Researchers also found that survival in Blacks and Hispanics, after controlling for age, was significantly higher than in Whites (log-rank P =.002).
“A treatment algorithm that included tocilizumab to target CRS may influence mechanical ventilation and survival outcomes,” the researchers wrote.1 They added that randomized trials should confirm their findings.
1. Price CC, Altice FL, Shyr Y, et al. Tocilizumab treatment for cytokine release syndrome in hospitalized COVID-19 patients: survival and clinical outcomes [published online June 15, 2020]. CHEST. doi:10.1016/j.chest.2020.06.006
2. Xu X, Han M, Li T, et al. Effective treatment of severe COVID-19 patients with tocilizumab. Proc Natl Acad Sci U S A. 2020;117(20):10970-10975.
4. Sciascia S, Aprà F, Baffa A, et al. Pilot prospective open, single-arm multicentre study on off-label use of tocilizumab in patients with severe COVID-19. Clin Exp Rheumatol. 2020;38(3):529-532.