Australian cases show favourable outcomes for tocilizumab use early in COVID-19 disease

Australian patients with severe COVID‐19 pneumonia treated with tocilizumab have had favourable clinical outcomes, a small case series shows.

The positive findings make a case for tocilizumab be included in randomised controlled trials of treatment for patients with severe COVID‐19 pneumonia, and for it to be considered for compassionate use  pending the results of these trials, according to Dr Timothy West of the Department of Immunology and Allergy, Campbelltown Hospital, Sydney.

The cases reported in the International Journal of Rheumatic Diseases comprise five male patients aged 46-74 years requiring ICU management in one of two tertiary hospitals in NSW and a third tertiary hospital in Victoria in late March and early April.

At the time of tocilizumab administration, three patients met the Berlin ARDS definition, had undergone endotracheal intubation and were mechanically ventilated due to type 1 respiratory failure.

The other two patients had rapid, progressive type 1 respiratory failure but did not meet the Berlin ARDS definition as continuous positive airway pressure was not applied due to concern for aerosolisation of the coronavirus.

The case series authors said the decision to treat with tocilizumab was made by consensus between the involved intensive care, respiratory, infectious diseases and immunology specialists.

The time from tocilizumab administration to improvement in oxygenation, defined as a 25% fall in fraction of inspired oxygen (FiO2) required to maintain peripheral oxygen saturation (SpO2) >92%, ranged from 7 hours to 4.6 days.

Radiographic improvement occurred between 41 hours and 9.8 days.

At 13-26 days follow-up, two of the men had been discharged home and three had left ICU but remained hospitalised. Two of the men still in hospital remained on oxygen and a third required renal dialysis.

The case report noted there were several adverse events, including bacterial ventilator‐associated pneumonia, hepatitis, myositis and bacteremia attributed to central venous catheterisation.

“Tocilizumab could be implicated in these events, but these findings are not uncommon in the critically ill and we await the results of randomized controlled trials to clarify the safety of tocilizumab in this population; LPV/r could also have contributed to hepatitis,” it said.

The authors said their data added to the evidence that interleukin‐6 receptor antagonists could be useful in severe COVID-19.

“The Australian Society for Clinical Immunology and Allergy (ASCIA) recommends IL‐6 blockade be considered early in critically ill patients with severe COVID‐19 pneumonia,” they wrote.

“We concur with these recommendations and advocate for collaborative, multidisciplinary management of such patients, including judicious use of tocilizumab, while awaiting the results of large multicentre placebo‐controlled randomised trials.”

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