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Uemura Y, Ozaki R, Shinozaki T, Ohtsu H, Shimizu Y, Izumi K, Saito S, Matsunaga N, Ohmagari N. Comparative effectiveness of tocilizumab vs standard care in patients with severe COVID-19-related pneumonia: a retrospective cohort study utilizing registry data as a synthetic control. BMC Infect Dis 2023; 23:849. [PMID: 38049729 PMCID: PMC10694888 DOI: 10.1186/s12879-023-08840-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 11/23/2023] [Indexed: 12/06/2023] Open
Abstract
BACKGROUND The severity of coronavirus disease 2019 (COVID-19) infections has led to the development of several therapeutic agents, with tocilizumab becoming increasingly used to treat patients with COVID-19-related pneumonia. This study compared the use of tocilizumab treatment with the standard of care (SOC) to determine its efficacy against severe COVID-19-related pneumonia in Japan. METHODS This retrospective cohort study was designed to evaluate the efficacy of tocilizumab in two different databases: the JA42434 single-arm study and COVID-19 Registry Japan (COVIREGI-JP), with a synthetic control group from the COVIREGI-JP cohort as a benchmark for the tocilizumab group. The study's primary objective was to evaluate the efficacy of tocilizumab in treating severe COVID-19-related pneumonia compared to the SOC among patients included in the above two databases. The SOC group was extracted as the synthetic control group using exact matching and a propensity score matching in sequence per subject. As a secondary objective, the efficacy of tocilizumab compared to the SOC was evaluated exclusively among patients included in the COVIREGI-JP database. In each objective, the primary endpoint was defined as the time to discharge or the status of awaiting discharge. RESULTS For the primary endpoint, the hazard ratio (HR) of the tocilizumab group against the SOC group was 1.070 (95% confidence interval [CI]: 0.565-2.028). The median time from Study Day 1 to discharge or the state of awaiting discharge was 15 days in the tocilizumab group and 16 days in the SOC group. The HRs for the secondary endpoints, namely, time to improvement in the clinical state, time to clinical failure, and time to recovery, were 1.112 (95% CI: 0.596-2.075), 0.628 (95% CI: 0.202-1.953), and 1.019 (95% CI: 0.555-1.871), respectively. Similarly, the HR of the primary endpoint for the secondary objective was 0.846 (95% CI: 0.582-1.230). CONCLUSIONS Tocilizumab did not demonstrate a positive effect on time to discharge or the state of awaiting discharge. Furthermore, no statistically significant differences in other clinical outcomes, such as time to improvement in the clinical state, time to clinical failure, and time to recovery, were observed among the groups.
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Affiliation(s)
- Yukari Uemura
- Biostatistics Section, Department of Data Science, Center for Clinical Sciences, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjyuku-ku, Tokyo, 162-8655, Japan.
| | - Ryoto Ozaki
- Biometrics Department, Clinical Development Division, Chugai Pharmaceutical CO., LTD, Tokyo, Japan
| | - Tomohiro Shinozaki
- Department of Information and Computer Technology, Faculty of Engineering, Tokyo University of Science, Tokyo, Japan
| | - Hiroshi Ohtsu
- Clinical Pharmacology and Regulatory Sciences, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Yousuke Shimizu
- Biostatistics Section, Department of Data Science, Center for Clinical Sciences, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjyuku-ku, Tokyo, 162-8655, Japan
| | - Kazuo Izumi
- Center for Clinical Sciences, National Center for Global Health and Medicine, Tokyo, Japan
| | - Sho Saito
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Nobuaki Matsunaga
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Norio Ohmagari
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
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Jafrin S, Aziz MA, Islam MS. Elevated Levels of Pleiotropic Interleukin-6 (IL-6) and Interleukin-10 (IL-10) are Critically Involved With the Severity and Mortality of COVID-19: An Updated Longitudinal Meta-Analysis and Systematic Review on 147 Studies. Biomark Insights 2022; 17:11772719221106600. [PMID: 35747885 PMCID: PMC9209786 DOI: 10.1177/11772719221106600] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 05/26/2022] [Indexed: 01/08/2023] Open
Abstract
Objectives Disruption in the natural immune reaction due to SARS-CoV-2 infection can initiate a potent cytokine storm among COVID-19 patients. An elevated level of IL-6 and IL-10 during a hyperinflammatory state plays a vital role in increasing the risk of severity and mortality. In this study, we aimed to evaluate the potential of circulating IL-6 and IL-10 levels as biomarkers for detecting the severity and mortality of COVID-19. Methods This study was conducted according to the Cochrane Handbook and PRISMA guidelines. Authorized databases were searched to extract suitable studies using specific search terms. RevMan 5.4 was applied for performing the meta-analysis. Mean differences in IL-6 and IL-10 levels were calculated among COVID-19 patients via a random-effects model. NOS scoring, publication bias and sensitivity analyses were checked to ensure study quality. Results A total of 147 studies were selected, with 31 909 COVID-19 patients under investigation. In the severity analysis, the mean concentration of IL-6 was significantly higher in the severe COVID-19 cases than in the non-severe cases (MD: 19.98; P < .001; 95% CI: 17.56, 22.40). Similar result was observed for IL-10 mean concentration in severe COVID-19 cases (MD: 1.35; P < .001; 95% CI: 0.90, 1.80). In terms of mortality analysis, circulating IL-6 showed sharp elevation in the deceased patients (MD: 42.11; P < .001; 95% CI: 36.86, 47.36). IL-10 mean concentration was higher in the dead patients than in the survived patients (MD: 4.79; P < .001; 95% CI: 2.83, 6.75). Publication bias was not found except for comparing IL-6 levels with disease severity. Sensitivity analysis also reported no significant deviation from the pooled outcomes. Conclusions Elevated levels of circulating IL-6 and IL-10 signifies worsening of COVID-19. To monitor the progression of SARS-CoV-2 infection, IL-6 and IL-10 should be considered as potential biomarkers for severity and mortality detection in COVID-19. Systematic review registration INPLASY registration number: INPLASY202240046.
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Affiliation(s)
- Sarah Jafrin
- Laboratory of Pharmacogenomics and Molecular Biology, Department of Pharmacy, Faculty of Science, Noakhali Science and Technology University, Sonapur, Noakhali, Bangladesh
| | - Md Abdul Aziz
- Department of Pharmacy, Faculty of Pharmacy and Health Sciences, State University of Bangladesh, Dhaka, Bangladesh
| | - Mohammad Safiqul Islam
- Laboratory of Pharmacogenomics and Molecular Biology, Department of Pharmacy, Faculty of Science, Noakhali Science and Technology University, Sonapur, Noakhali, Bangladesh
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3
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Kyriakopoulos C, Ntritsos G, Gogali A, Milionis H, Evangelou E, Kostikas K. Tocilizumab administration for the treatment of hospitalized patients with COVID-19: A systematic review and meta-analysis. Respirology 2021; 26:1027-1040. [PMID: 34605114 PMCID: PMC8661720 DOI: 10.1111/resp.14152] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 08/26/2021] [Accepted: 09/07/2021] [Indexed: 12/15/2022]
Abstract
Tocilizumab has been repurposed against the ‘cytokine storm’ in the setting of coronavirus disease 2019 (COVID‐19). Our aim was to evaluate the efficacy of tocilizumab in the management of hospitalized COVID‐19 patients. We searched MEDLINE, CENTRAL and medRxiv for studies of tocilizumab in hospitalized COVID‐19 patients. Primary objective was the effectiveness of tocilizumab on mortality. Secondary objectives included the need for invasive mechanical ventilation (IMV), composite endpoints of mortality or IMV and intensive care unit (ICU) admission or IMV, length of hospitalization and differences in mortality in subgroups (ICU and non‐ICU patients and patients receiving or not receiving concomitant corticosteroids). We included 52 studies (nine randomized controlled trials [RCTs] and 43 observational) with a total of 27,004 patients. In both RCTs and observational studies, the use of tocilizumab was associated with a reduction in mortality; 11% in RCTs (risk ratio [RR] 0.89, 95% CI 0.82 to 0.96) and 31% in observational studies (RR 0.69, 95% CI 0.58 to 0.83). The need for IMV was reduced by 19% in RCTs (RR 0.81, 95% CI 0.71 to 0.93), while no significant reduction was observed in observational studies. Both RCTs and observational studies showed a benefit from tocilizumab on the composite endpoint of mortality or IMV. Tocilizumab improved mortality both in ICU and non‐ICU patients. Reduction in mortality was evident in observational studies regardless of the use of systemic corticosteroids, while that was not the case in the RCTs. Tocilizumab was associated with lower mortality and other clinically relevant outcomes in hospitalized patients with moderate‐to‐critical COVID‐19.
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Affiliation(s)
- Christos Kyriakopoulos
- Respiratory Medicine Department, University of Ioannina Faculty of Medicine, Ioannina, Greece
| | - Georgios Ntritsos
- Department of Hygiene and Epidemiology, University of Ioannina Faculty of Medicine, Ioannina, Greece
| | - Athena Gogali
- Respiratory Medicine Department, University of Ioannina Faculty of Medicine, Ioannina, Greece
| | - Haralampos Milionis
- Internal Medicine Department, University of Ioannina Faculty of Medicine, Ioannina, Greece
| | - Evangelos Evangelou
- Department of Hygiene and Epidemiology, University of Ioannina Faculty of Medicine, Ioannina, Greece
| | - Konstantinos Kostikas
- Respiratory Medicine Department, University of Ioannina Faculty of Medicine, Ioannina, Greece
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Rubio-Rivas M, Forero CG, Mora-Luján JM, Montero A, Formiga F, Homs NA, Albà-Albalate J, Sánchez L, Rello J, Corbella X. Beneficial and harmful outcomes of tocilizumab in severe COVID-19: A systematic review and meta-analysis. Pharmacotherapy 2021; 41:884-906. [PMID: 34558742 PMCID: PMC8661749 DOI: 10.1002/phar.2627] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 09/05/2021] [Accepted: 09/07/2021] [Indexed: 12/15/2022]
Abstract
Introduction The results of studies of tocilizumab (TCZ) in COVID‐19 are contradictory. Our study aims to update medical evidence from controlled observational studies and randomized clinical trials (RCTs) on the use of TCZ in hospitalized patients with COVID‐19. Methods We searched the following databases from January 1, 2020 to April 13, 2021 (date of the last search): MEDLINE database through the PubMed search engine and Scopus, using the terms (“COVID‐19" [Supplementary Concept]) AND "tocilizumab" [Supplementary Concept]). Results Sixty four studies were included in the present study: 54 were controlled observational studies (50 retrospective and 4 prospective) and 10 were RCTs. The overall results provided data from 20,616 hospitalized patients with COVID‐19: 7668 patients received TCZ in addition to standard of care (SOC) (including 1915 patients admitted to intensive care units (ICU) with reported mortality) and 12,948 patients only receiving SOC (including 4410 patients admitted to the ICU with reported mortality). After applying the random‐effects model, the hospital‐wide (including ICU) pooled mortality odds ratio (OR) of patients with COVID‐19 treated with TCZ was 0.73 (95% confidence interval (CI) = 0.56–0.93). The pooled hospital‐wide mortality OR was 1.25 (95% CI = 0.74–2.18) in patients admitted at conventional wards versus 0.66 (95% CI = 0.59–0.76) in patients admitted to the ICU. The pooled OR of hospital‐wide mortality (including ICU) of COVID‐19 patients treated with TCZ plus corticosteroids (CS) was 0.67 (95% CI = 0.54–0.84). The pooled in‐hospital mortality OR was 0.71 (95% CI = 0.35–1.42) when TCZ was early administered (≤10 days from symptom onset) versus 0.83 (95% CI 0.48–1.45) for late administration (>10 days from symptom onset). The meta‐analysis did not find significantly higher risk for secondary infections in COVID‐19 patients treated with TCZ. Conclusions TCZ prevented mortality in patients hospitalized for COVID‐19. This benefit was seen to a greater extent in patients receiving concomitant CS and when TCZ administration occurred within the first 10 days after symptom onset.
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Affiliation(s)
- Manuel Rubio-Rivas
- Department of Internal Medicine, Bellvitge University Hospital, Bellvitge Biomedical Research Institute-IDIBELL, University of Barcelona, Barcelona, Spain
| | - Carlos G Forero
- School of Medicine, Universitat Internacional de Catalunya, Barcelona, Spain
| | - José María Mora-Luján
- Department of Internal Medicine, Bellvitge University Hospital, Bellvitge Biomedical Research Institute-IDIBELL, University of Barcelona, Barcelona, Spain
| | - Abelardo Montero
- Department of Internal Medicine, Bellvitge University Hospital, Bellvitge Biomedical Research Institute-IDIBELL, University of Barcelona, Barcelona, Spain
| | - Francesc Formiga
- Department of Internal Medicine, Bellvitge University Hospital, Bellvitge Biomedical Research Institute-IDIBELL, University of Barcelona, Barcelona, Spain
| | - Narcís A Homs
- Department of Internal Medicine, Bellvitge University Hospital, Bellvitge Biomedical Research Institute-IDIBELL, University of Barcelona, Barcelona, Spain
| | - Joan Albà-Albalate
- Department of Internal Medicine, Bellvitge University Hospital, Bellvitge Biomedical Research Institute-IDIBELL, University of Barcelona, Barcelona, Spain
| | - Laura Sánchez
- Department of Internal Medicine, Bellvitge University Hospital, Bellvitge Biomedical Research Institute-IDIBELL, University of Barcelona, Barcelona, Spain
| | - Jordi Rello
- School of Medicine, Universitat Internacional de Catalunya, Barcelona, Spain.,Centro de Investigación Biomédica en Red (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.,CRIPS, Vall d'Hebrón Institute of Research, Barcelona, Spain
| | - Xavier Corbella
- Department of Internal Medicine, Bellvitge University Hospital, Bellvitge Biomedical Research Institute-IDIBELL, University of Barcelona, Barcelona, Spain.,School of Medicine, Universitat Internacional de Catalunya, Barcelona, Spain
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Khan FA, Stewart I, Fabbri L, Moss S, Robinson K, Smyth AR, Jenkins G. Systematic review and meta-analysis of anakinra, sarilumab, siltuximab and tocilizumab for COVID-19. Thorax 2021; 76:907-919. [PMID: 33579777 PMCID: PMC7886668 DOI: 10.1136/thoraxjnl-2020-215266] [Citation(s) in RCA: 66] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 01/10/2021] [Accepted: 01/21/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND There is accumulating evidence for an overly activated immune response in severe COVID-19, with several studies exploring the therapeutic role of immunomodulation. Through systematic review and meta-analysis, we assess the effectiveness of specific interleukin inhibitors for the treatment of COVID-19. METHODS Electronic databases were searched on 7 January 2021 to identify studies of immunomodulatory agents (anakinra, sarilumab, siltuximab and tocilizumab) for the treatment of COVID-19. The primary outcomes were severity on an Ordinal Scale measured at day 15 from intervention and days to hospital discharge. Key secondary endpoints included overall mortality. RESULTS 71 studies totalling 22 058 patients were included, 6 were randomised trials. Most studies explored outcomes in patients who received tocilizumab (60/71). In prospective studies, tocilizumab was associated with improved unadjusted survival (risk ratio 0.83, 95% CI 0.72 to 0.96, I2=0.0%), but conclusive benefit was not demonstrated for other outcomes. In retrospective studies, tocilizumab was associated with less severe outcomes on an Ordinal Scale (generalised OR 1.34, 95% CI 1.10 to 1.64, I2=98%) and adjusted mortality risk (HR 0.52, 95% CI 0.41 to 0.66, I2=76.6%). The mean difference in duration of hospitalisation was 0.36 days (95% CI -0.07 to 0.80, I2=93.8%). There was substantial heterogeneity in retrospective studies, and estimates should be interpreted cautiously. Other immunomodulatory agents showed similar effects to tocilizumab, but insufficient data precluded meta-analysis by agent. CONCLUSION Tocilizumab was associated with a lower relative risk of mortality in prospective studies, but effects were inconclusive for other outcomes. Current evidence for the efficacy of anakinra, siltuximab or sarilumab in COVID-19 is insufficient, with further studies urgently needed for conclusive findings. PROSPERO REGISTRATION NUMBER CRD42020176375.
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Affiliation(s)
- Fasihul A Khan
- Respiratory Medicine, University of Nottingham, Nottingham, UK
| | - Iain Stewart
- Respiratory Medicine, University of Nottingham, Nottingham, UK
| | - Laura Fabbri
- Respiratory Medicine, University of Nottingham, Nottingham, UK
| | - Samuel Moss
- Respiratory Medicine, University of Nottingham, Nottingham, UK
| | | | - Alan Robert Smyth
- Division of Child Health, Obstetrics and Gynaecology, University of Nottingham, Nottingham, UK
| | - Gisli Jenkins
- Respiratory Medicine, University of Nottingham, Nottingham, UK
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Jiang W, Li W, Wu Q, Han Y, Zhang J, Luo T, Guo Y, Yang Y, Zhu P, Xia X. Efficacy and Safety of Tocilizumab Treatment COVID-19 Patients: A Case-Control Study and Meta-Analysis. Infect Dis Ther 2021; 10:1677-1698. [PMID: 34244956 PMCID: PMC8269405 DOI: 10.1007/s40121-021-00483-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 06/15/2021] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION As the pandemic progresses, the pathophysiology of COVID-19 is becoming more apparent, and the potential for tocilizumab is increasing. However, the clinical efficacy and safety of tocilizumab in the treatment of COVID-19 patients remain unclear. METHODS To assess the efficacy and safety of tocilizumab treatment in COVID-19 patients, we performed a retrospective case-control study. The study was conducted, including 95 patients treated with tocilizumab plus standard treatment and matched controls with 95 patients treated with standard treatment therapy by propensity score from February to April 2020. We searched some databases using the search terms for studies published from January 1, 2020, to June 1, 2021. RESULTS Our case-control study found a lower mortality rate in the tocilizumab treatment group than in the standard treatment group (9.47% versus 16.84%, P = 0.134), but the results were not statistically significant. We also found that the mortality rate in tocilizumab treatment groups was significantly lower than in the standard treatment group in the stratified ICU analysis (OR 0.52, 95% CI 0.44-0.61, P = 0.048 and OR 0.31, 95% CI 0.10-0.99, P = 0.044). We selected 49 studies (including 6568 cases and 11,660 controls) that met the inclusion criteria in the meta-analysis. In the overall analysis, we performed a meta-analysis that showed significantly decreased mortality after patients received tocilizumab (OR 0.81, 95% CI 0.69-0.95, P = 0.008). We also revealed significant associations within some subgroups. The sequential trial analysis showed a true-positive result. No significant associations were observed between tocilizumab and elevated secondary infection risk, discharge, adverse events, and mechanical ventilation in the overall analysis. CONCLUSION Tocilizumab significantly decreased mortality in COVID-19 patients with no increased discharge, secondary infection risk, adverse events, and mechanical ventilation in a meta-analysis. Our data suggest that clinicians should pay attention to tocilizumab therapy as an effective and safe treatment for COVID-19 patients.
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Affiliation(s)
- Weijun Jiang
- COVID-19 Research Center, Institute of Laboratory Medicine, Jinling Hospital, Nanjing University School of Medicine, The First School of Clinical Medicine, Southern Medical University, Nanjing, 210002, Jiangsu, China
| | - Weiwei Li
- COVID-19 Research Center, Institute of Laboratory Medicine, Jinling Hospital, Nanjing University School of Medicine, The First School of Clinical Medicine, Southern Medical University, Nanjing, 210002, Jiangsu, China
| | - Qiuyue Wu
- COVID-19 Research Center, Institute of Laboratory Medicine, Jinling Hospital, Nanjing University School of Medicine, The First School of Clinical Medicine, Southern Medical University, Nanjing, 210002, Jiangsu, China
| | - Ying Han
- COVID-19 Research Center, Institute of Laboratory Medicine, Jinling Hospital, Nanjing University School of Medicine, The First School of Clinical Medicine, Southern Medical University, Nanjing, 210002, Jiangsu, China
| | - Jing Zhang
- COVID-19 Research Center, Institute of Laboratory Medicine, Jinling Hospital, Nanjing University School of Medicine, The First School of Clinical Medicine, Southern Medical University, Nanjing, 210002, Jiangsu, China
| | - Tao Luo
- COVID-19 Research Center, Institute of Laboratory Medicine, Jinling Hospital, Nanjing University School of Medicine, The First School of Clinical Medicine, Southern Medical University, Nanjing, 210002, Jiangsu, China
| | - Yanju Guo
- COVID-19 Research Center, Institute of Laboratory Medicine, Jinling Hospital, Nanjing University School of Medicine, The First School of Clinical Medicine, Southern Medical University, Nanjing, 210002, Jiangsu, China
| | - Yang Yang
- COVID-19 Research Center, Institute of Laboratory Medicine, Jinling Hospital, Nanjing University School of Medicine, The First School of Clinical Medicine, Southern Medical University, Nanjing, 210002, Jiangsu, China
| | - Peiran Zhu
- COVID-19 Research Center, Institute of Laboratory Medicine, Jinling Hospital, Nanjing University School of Medicine, The First School of Clinical Medicine, Southern Medical University, Nanjing, 210002, Jiangsu, China
| | - Xinyi Xia
- COVID-19 Research Center, Institute of Laboratory Medicine, Jinling Hospital, Nanjing University School of Medicine, The First School of Clinical Medicine, Southern Medical University, Nanjing, 210002, Jiangsu, China.
- Joint Expert Group for COVID-19, Department of Laboratory Medicine and Blood Transfusion, Wuhan Huoshenshan Hospital, Wuhan, 430100, Hubei, China.
- Department of Laboratory Medicine and Blood Transfusion, Wuhan Huoshenshan Hospital, Wuhan, 430100, Hubei, China.
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Mahroum N, Watad A, Bridgewood C, Mansour M, Nasr A, Hussein A, Khamisy-Farah R, Farah R, Gendelman O, Lidar M, Shoenfeld Y, Amital H, Kong JD, Wu J, Bragazzi NL, McGonagle D. Systematic Review and Meta-Analysis of Tocilizumab Therapy versus Standard of Care in over 15,000 COVID-19 Pneumonia Patients during the First Eight Months of the Pandemic. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:9149. [PMID: 34501738 PMCID: PMC8431489 DOI: 10.3390/ijerph18179149] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 08/14/2021] [Accepted: 08/23/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND Tocilizumab is an anti-IL-6 therapy widely adopted in the management of the so-called "cytokine storm" related to SARS-CoV-2 virus infection, but its effectiveness, use in relation to concomitant corticosteroid therapy and safety were unproven despite widespread use in numerous studies, mostly open label at the start of the pandemic. METHODS We performed a systematic review and meta-analysis of case-control studies utilising tocilizumab in COVID-19 on different databases (PubMed/MEDLINE/Scopus) and preprint servers (medRxiv and SSRN) from inception until 20 July 2020 (PROSPERO CRD42020195690). Subgroup analyses and meta-regressions were performed. The impact of tocilizumab and concomitant corticosteroid therapy or tocilizumab alone versus standard of care (SOC) on the death rate, need for mechanical ventilation, ICU admission and bacterial infections were assessed. RESULTS Thirty-nine studies with 15,531 patients (3657 cases versus 11,874 controls) were identified. Unadjusted estimates (n = 28) failed to demonstrate a protective effect of tocilizumab on survival (OR 0.74 ([95%CI 0.55-1.01], p = 0.057), mechanical ventilation prevention (OR 2.21 [95%CI 0.53-9.23], p = 0.277) or prevention of ICU admission (OR 3.79 [95%CI 0.38-37.34], p = 0.254). Considering studies with adjusted, estimated, tocilizumab use was associated with mortality rate reduction (HR 0.50 ([95%CI 0.38-0.64], p < 0.001) and prevention of ICU admission (OR 0.16 ([95%CI 0.06-0.43], p < 0.001). Tocilizumab with concomitant steroid use versus SOC was protective with an OR of 0.49 ([95%CI 0.36-0.65], p < 0.05) as was tocilizumab alone versus SOC with an OR of 0.59 ([95%CI 0.34-1.00], p < 0.001). Risk of infection increased (2.36 [95%CI 1.001-5.54], p = 0.050; based on unadjusted estimates). CONCLUSION Despite the heterogeneity of included studies and large number of preprint articles, our findings from the first eight of the pandemic in over 15,000 COVID-19 cases suggested an incremental efficacy of tocilizumab in severe COVID-19 that were confirmed by subsequent meta-analyses of large randomized trials of tocilizumab. This suggests that analysis of case-control studies and pre-print server data in the early stages of a pandemic appeared robust for supporting incremental benefits and lack of major therapeutic toxicity of tocilizumab for severe COVID-19.
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Affiliation(s)
- Naim Mahroum
- Zabludowicz Center for Autoimmune Diseases, Department of Medicine B., Sheba Medical Center, Ramat Gan 5265601, Israel; (N.M.); (A.W.); (O.G.); (Y.S.); (H.A.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel;
- International School of Medicine, Istanbul Medipol University, Istanbul 34810, Beykoz, Turkey
| | - Abdulla Watad
- Zabludowicz Center for Autoimmune Diseases, Department of Medicine B., Sheba Medical Center, Ramat Gan 5265601, Israel; (N.M.); (A.W.); (O.G.); (Y.S.); (H.A.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel;
- Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), University of Leeds, Leeds LS7 4SA, UK; (C.B.); (D.M.)
- Rheumatology Unit, Sheba Medical Center, Ramat Gan 5265601, Israel
| | - Charlie Bridgewood
- Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), University of Leeds, Leeds LS7 4SA, UK; (C.B.); (D.M.)
| | - Muhammad Mansour
- Department of Surgery A, Galilee Medical Center, Nahariya 2210001, Israel;
- Faculty of Medicine of the Galilee, Bar-Ilan University, Safed 13100, Israel
- Division of General Surgery, St. Michael’s Hospital, Unity Health Toronto, University of Toronto, Toronto, ON M5B 1W8, Canada
| | - Ahmad Nasr
- Department of Pathology, Papa Giovanni XXIII Hospital, 24127 Bergamo, Italy;
- Department of Pathology, University of Milano-Bicocca, 20126 Milan, Italy
| | - Amr Hussein
- Medical Faculty, University of Parma, 43125 Parma, Italy;
| | - Rola Khamisy-Farah
- Clalit Health Service, Akko, Azrieli Faculty of Medicine, Bar-Ilan University, Safed 13100, Israel;
| | - Raymond Farah
- Department of Internal Medicine, Ziv Medical Center, Safed 13100, Israel;
| | - Omer Gendelman
- Zabludowicz Center for Autoimmune Diseases, Department of Medicine B., Sheba Medical Center, Ramat Gan 5265601, Israel; (N.M.); (A.W.); (O.G.); (Y.S.); (H.A.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel;
| | - Merav Lidar
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel;
- Rheumatology Unit, Sheba Medical Center, Ramat Gan 5265601, Israel
| | - Yehuda Shoenfeld
- Zabludowicz Center for Autoimmune Diseases, Department of Medicine B., Sheba Medical Center, Ramat Gan 5265601, Israel; (N.M.); (A.W.); (O.G.); (Y.S.); (H.A.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel;
- Medical Department, Saint Petersburg State University, 199034 Saint Petersburg, Russia
- Ariel University, Kiryat HaMada 3, Ariel 40700, Israel
| | - Howard Amital
- Zabludowicz Center for Autoimmune Diseases, Department of Medicine B., Sheba Medical Center, Ramat Gan 5265601, Israel; (N.M.); (A.W.); (O.G.); (Y.S.); (H.A.)
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel;
| | - Jude Dzevela Kong
- Laboratory for Industrial and Applied Mathematics (LIAM), Department of Mathematics and Statistics, York University, Toronto, ON M3J 1P3, Canada; (J.D.K.); (J.W.)
| | - Jianhong Wu
- Laboratory for Industrial and Applied Mathematics (LIAM), Department of Mathematics and Statistics, York University, Toronto, ON M3J 1P3, Canada; (J.D.K.); (J.W.)
| | - Nicola Luigi Bragazzi
- Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), University of Leeds, Leeds LS7 4SA, UK; (C.B.); (D.M.)
- Laboratory for Industrial and Applied Mathematics (LIAM), Department of Mathematics and Statistics, York University, Toronto, ON M3J 1P3, Canada; (J.D.K.); (J.W.)
- Postgraduate School of Public Health, Department of Health Sciences (DISSAL), University of Genoa, 16132 Genoa, Italy
| | - Dennis McGonagle
- Leeds Institute of Rheumatic and Musculoskeletal Medicine (LIRMM), University of Leeds, Leeds LS7 4SA, UK; (C.B.); (D.M.)
- Chapel Allerton Hospital, Chapeltown Road, Leeds LS7 4SA, UK
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8
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Conti V, Corbi G, Sellitto C, Sabbatino F, Maci C, Bertini N, De Bellis E, Iuliano A, Davinelli S, Pagliano P, Filippelli A. Effect of Tocilizumab in Reducing the Mortality Rate in COVID-19 Patients: A Systematic Review with Meta-Analysis. J Pers Med 2021; 11:jpm11070628. [PMID: 34357095 PMCID: PMC8307114 DOI: 10.3390/jpm11070628] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 06/27/2021] [Accepted: 06/28/2021] [Indexed: 02/07/2023] Open
Abstract
Data supporting the use of Tocilizumab (TCZ) in COVID-19 are contrasting and inconclusive. This meta-analysis aimed to assess TCZ effectiveness in reducing the mortality rate in COVID-19 patients. PubMed, Scopus, Embase, Cochrane, WILEY, and ClinicalTrials.gov were searched to evaluate observational studies and RCTs. The outcome was the mortality rate. Forty observational studies and seven RCTs, involving 9640 and 5556 subjects treated with Standard Therapy (ST) + TCZ or ST alone, respectively, were included. In patients treated with ST+TCZ, a higher survival (Log odds ratio = −0.41; 95% CI: −0.68 −0.14; p < 0.001) was found. Subgroups analyses were performed to better identify the possible interference of some parameters in modifying the efficacy of TCZ therapy on COVID-19 mortality. Separating observational from RCTs, no statistically significant (p = 0.70) TCZ-related reduction of mortality regarding RCTs was found, while a significant reduction (Log odds ratio = −0.52; 95% CI: −0.82 −0.22, p < 0.001) was achieved regarding the observational studies. Stratifying for the use of Invasive Mechanic Ventilation (IMV), a higher survival was found in patients treated with TCZ in the No-IMV and IMV groups (both p < 0.001), but not in the No-IMV/IMV group. Meta-regression analyses were also performed. The meta-analysis of observational studies reveals that TCZ is associated with reducing the mortality rate in both severe and critically ill patients. Although the largest RCT, RECOVERY, is in line with this result, the meta-analysis of RCTs failed to found any difference between ST + TCZ and ST. It is crucial to personalize the therapy considering the patients’ characteristics.
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Affiliation(s)
- Valeria Conti
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Salerno, Italy; (V.C.); (C.S.); (F.S.); (C.M.); (N.B.); (E.D.B.); (A.I.); (P.P.); (A.F.)
- Clinical Pharmacology and Pharmacogenetics Unit, University Hospital “San Giovanni di Dio e Ruggi D’Aragona”, 84125 Salerno, Italy
| | - Graziamaria Corbi
- Department of Medicine and Health Sciences, University of Molise, 86100 Campobasso, Italy;
- Italian Society of Gerontology and Geriatrics (SIGG), Via G.C. Vanini, 5, 50129 Firenze, Italy
- Correspondence: ; Tel.: +39-0874404771
| | - Carmine Sellitto
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Salerno, Italy; (V.C.); (C.S.); (F.S.); (C.M.); (N.B.); (E.D.B.); (A.I.); (P.P.); (A.F.)
| | - Francesco Sabbatino
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Salerno, Italy; (V.C.); (C.S.); (F.S.); (C.M.); (N.B.); (E.D.B.); (A.I.); (P.P.); (A.F.)
- Oncology Unit, University Hospital San Giovanni di Dio e Ruggi D’Aragona, 84125 Salerno, Italy
| | - Chiara Maci
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Salerno, Italy; (V.C.); (C.S.); (F.S.); (C.M.); (N.B.); (E.D.B.); (A.I.); (P.P.); (A.F.)
| | - Nicola Bertini
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Salerno, Italy; (V.C.); (C.S.); (F.S.); (C.M.); (N.B.); (E.D.B.); (A.I.); (P.P.); (A.F.)
| | - Emanuela De Bellis
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Salerno, Italy; (V.C.); (C.S.); (F.S.); (C.M.); (N.B.); (E.D.B.); (A.I.); (P.P.); (A.F.)
| | - Antonio Iuliano
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Salerno, Italy; (V.C.); (C.S.); (F.S.); (C.M.); (N.B.); (E.D.B.); (A.I.); (P.P.); (A.F.)
| | - Sergio Davinelli
- Department of Medicine and Health Sciences, University of Molise, 86100 Campobasso, Italy;
| | - Pasquale Pagliano
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Salerno, Italy; (V.C.); (C.S.); (F.S.); (C.M.); (N.B.); (E.D.B.); (A.I.); (P.P.); (A.F.)
- Infectious Diseases Unit, Hospital San Giovanni di Dio e Ruggi D’Aragona, 84125 Salerno, Italy
| | - Amelia Filippelli
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Salerno, Italy; (V.C.); (C.S.); (F.S.); (C.M.); (N.B.); (E.D.B.); (A.I.); (P.P.); (A.F.)
- Clinical Pharmacology and Pharmacogenetics Unit, University Hospital “San Giovanni di Dio e Ruggi D’Aragona”, 84125 Salerno, Italy
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9
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Gupta A, Chun HJ. Interleukin-1- Receptor Kinase 4 Inhibition: Achieving Immunomodulatory Synergy to Mitigate the Impact of COVID-19. Front Immunol 2021; 12:693085. [PMID: 34248990 PMCID: PMC8262608 DOI: 10.3389/fimmu.2021.693085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 06/08/2021] [Indexed: 01/20/2023] Open
Affiliation(s)
- Akash Gupta
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States
| | - Hyung J. Chun
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, United States
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10
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Ruiz-Rodríguez JC, Chiscano-Camón L, Palmada C, Ruiz-Sanmartin A, García-de-Acilu M, Plata-Menchaca E, Perurena-Prieto J, Hernandez-Gonzalez M, Pérez-Carrasco M, Soler-Palacin P, Ferrer R. Hemadsorption as a Treatment Option for Multisystem Inflammatory Syndrome in Children Associated With COVID-19. A Case Report. Front Immunol 2021; 12:665824. [PMID: 34140949 PMCID: PMC8204690 DOI: 10.3389/fimmu.2021.665824] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 05/04/2021] [Indexed: 12/27/2022] Open
Abstract
Multisystem Inflammatory Syndrome in Children (MIS-C) associated with COVID-19 is characterized by hypercytokinemia leading to overwhelming inflammation. We describe the use of a hemadsorption device as part of the supportive treatment for cytokine storm.
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Affiliation(s)
- Juan Carlos Ruiz-Rodríguez
- Intensive Care Department, Vall d'Hebron University Hospital, Barcelona, Spain.,Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
| | - Luis Chiscano-Camón
- Intensive Care Department, Vall d'Hebron University Hospital, Barcelona, Spain.,Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
| | - Clara Palmada
- Intensive Care Department, Vall d'Hebron University Hospital, Barcelona, Spain.,Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
| | - Adolf Ruiz-Sanmartin
- Intensive Care Department, Vall d'Hebron University Hospital, Barcelona, Spain.,Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
| | - Marina García-de-Acilu
- Intensive Care Department, Vall d'Hebron University Hospital, Barcelona, Spain.,Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
| | - Erika Plata-Menchaca
- Intensive Care Department, Vall d'Hebron University Hospital, Barcelona, Spain.,Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
| | - Janire Perurena-Prieto
- Immunology Division, Vall d'Hebron University Hospital, Barcelona, Spain.,Diagnostic Immunology Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Manuel Hernandez-Gonzalez
- Immunology Division, Vall d'Hebron University Hospital, Barcelona, Spain.,Diagnostic Immunology Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Marcos Pérez-Carrasco
- Intensive Care Department, Vall d'Hebron University Hospital, Barcelona, Spain.,Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
| | - Pere Soler-Palacin
- Pediatric Infectious Diseases and Immunodeficiencies Unit, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ricard Ferrer
- Intensive Care Department, Vall d'Hebron University Hospital, Barcelona, Spain.,Shock, Organ Dysfunction and Resuscitation Research Group, Vall d'Hebron Research Institute (VHIR), Barcelona, Spain
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11
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Hariyanto TI, Hardyson W, Kurniawan A. Efficacy and Safety of Tocilizumab for Coronavirus Disease 2019 (Covid-19) Patients: A Systematic Review and Meta-analysis. Drug Res (Stuttg) 2021; 71:265-274. [PMID: 33401328 DOI: 10.1055/a-1336-2371] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Currently, the data regarding the effectiveness and safety of tocilizumab as treatment for COVID-19 infection is still conflicting. This study aims to give clear evidence regarding the potential benefit and safety of tocilizumab in improving the outcome of COVID-19 patients. METHODS We systematically searched the PubMed and Europe PMC database using specific keywords related to our aims until November 1st, 2020. All articles published on COVID-19 and tocilizumab were retrieved. Statistical analysis was done using Review Manager 5.4 software. RESULTS A total of 38 studies with a total of 13 412 COVID-19 patients were included in our analysis. Our meta-analysis showed that tocilizumab treatment is associated with reduction of mortality rate from COVID-19 [OR 0.54 (95% CI 0.42-0.71), p<0.00001, I 2=79%, random-effect modelling], but did not alter the severity of COVID-19 [OR 1.05 (95% CI 0.92-1.20), p=0.47, I 2=84%, random-effect modelling] and length of hospital stay [Mean Difference 1.77 days (95% CI -0.61-4.14 days), p=0.15, I 2=97%, random-effect modelling]. Tocilizumab also does not associated with serious adverse events compared with standard of care treatment [OR 0.91 (95% CI 0.71-1.15), p=0.42, I 2=46%, random-effect modelling]. CONCLUSION Our study does not support the routine use of tocilizumab for COVID-19 patients. Future studies should focus more on other potential therapies for COVID-19 patients.
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Affiliation(s)
| | - Willie Hardyson
- Faculty of Medicine, Pelita Harapan University, Karawaci, Tangerang, Indonesia
| | - Andree Kurniawan
- Department of Internal Medicine, Faculty of Medicine, Pelita Harapan University, Karawaci, Tangerang, Indonesia
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