Does timing matter on tocilizumab administration? Clinical, analytical and radiological outcomes in COVID-19

Clinical Disease Characteristics and Treatment Trajectories Associated with Mortality among COVID-19 Patients in Punjab, Pakistan

BACKGROUND

Data on Pakistani COVID-19 patient mortality predictors is limited. It is essential to comprehend the relationship between disease characteristics, medications used, and mortality for better patient outcomes.

METHODS

The medical records of confirmed cases in the Lahore and Sargodha districts were examined using a two-stage cluster sampling from March 2021 to March 2022. Demographics, signs and symptoms, laboratory findings, and pharmacological medications as mortality indicators were noted and analyzed.

RESULTS

A total of 288 deaths occurred out of the 1000 cases. Death rates were higher for males and people over 40. Most of those who were mechanically ventilated perished (OR: 124.2). Dyspnea, fever, and cough were common symptoms, with a significant association amid SpO2 < 95% (OR: 3.2), RR > 20 breaths/min (OR: 2.5), and mortality. Patients with renal (OR: 2.3) or liver failure (OR: 1.5) were at risk. Raised C-reactive protein (OR: 2.9) and D-dimer levels were the indicators of mortality (OR: 1.6). The most prescribed drugs were antibiotics, (77.9%), corticosteroids (54.8%), anticoagulants (34%), tocilizumab (20.3%), and ivermectin (9.2%).

CONCLUSIONS

Older males having breathing difficulties or signs of organ failure with raised C-reactive protein or D-dimer levels had high mortality. Antivirals, corticosteroids, tocilizumab, and ivermectin had better outcomes; antivirals were associated with lower mortality risk.

Should We Interfere with the Interleukin-6 Receptor During COVID-19: What Do We Know So Far?

Severe manifestations of COVID-19 consist of acute respiratory distress syndrome due to an initially local reaction leading to a systemic inflammatory response that results in hypoxia. Many therapeutic approaches have been attempted to reduce the clinical consequences of an excessive immune response to viral infection. To date, systemic corticosteroid therapy is still the most effective intervention. More recently, new hope has emerged with the use of interleukin (IL)-6 receptor inhibitors (tocilizumab and sarilumab). However, the great heterogeneity of the methodology and results of published studies obfuscate the true value of this treatment, leading to a confusing synthesis in recent meta-analyses, and the persistence of doubts in terms of patient groups and the appropriate time to treat. Moreover, their effects on the anti-infectious or pro-healing response are still poorly studied. This review aims to clarify the potential role of IL-6 receptor inhibitors in the treatment of severe forms of COVID-19.

Severe acute respiratory syndrome coronavirus 2 infection: Role of interleukin-6 and the inflammatory cascade

Since December 2019, a novel coronavirus that represents a serious threat to human lives has emerged. There is still no definite treatment for severe cases of the disease caused by this virus, named coronavirus disease 2019 (COVID-19). One of the most considered treatment strategies targets the exaggerated immune regulator, and interleukin (IL)-6 is a crucial pro-inflammatory mediator. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) cases show an elevated level of IL-6 related to disease severity. IL-6 activity can be inhibited by the following: IL-6 itself, IL-6 signaling pathways such as Janus kinase and signal transducer and activator of transcription (JAK-STAT), gp130, IL-6R, and downstream activated ILs, such as IL-17 and IL-6 cytokine. Currently, according to these studies and their results, IL-6 blockade with anti-IL-6 or its receptor antibodies such as tocilizumab in COVID-19 is beneficial in severe cases and may reduce the mortality rate. JAK-STAT inhibitors block the cytokine storm by inhibiting several crucial pro-inflammatory mediators such as TNF-α and IL-6 and have shown various results in clinical trials. IL-6 induces IL-17 secretion, and IL-17 is involved in the pathogenesis of inflammatory processes. Clinical trials of anti-IL-17 drugs are currently recruiting, and anti-gp130 antibody is preclinical. However, this agent has shown positive effects in inflammatory bowel disease clinical trials and could be tested for SARS-CoV-2. This study aimed to review the role of IL-6 in the cytokine storm and studies regarding IL-6 and blockade of its inflammatory pathways in COVID-19 to determine if any of these agents are beneficial for COVID-19 patients.

Hyperhemolysis in a patient with sickle cell disease and recent SARS-COV-2 infection, with complex auto- and allo-antibody work-up, successfully treated with tocilizumab

BACKGROUND

Hyperhemolysis syndrome (HHS) is a severe delayed hemolytic transfusion reaction seen in sickle cell disease (SCD) patients, characterized by destruction of donor and recipient RBCs. It results in a drop in hemoglobin to below pretransfusion levels and frequently reticulocytopenia.

CASE REPORT

We report a case of a man in his 30s with SCD with a recent hospitalization two weeks prior for COVID-19. His red cell antibody history included anti-Fy(a) and warm autoantibody. At that time he was given two units of pRBC and discharged with a hemoglobin of 10.2 g/dL. He returned to the hospital approximately 1.5 weeks later with hemoglobin 6.0 g/dL and symptoms concerning for acute chest syndrome (ACS). Pretransfusion testing now showed 4+ pan-agglutinin in both gel-based and tube-based testing. Alloadsorption identified an anti-N and a strong cold agglutinin. Three least incompatible units were transfused to this patient over several days, with evidence of hemolysis. Further reference lab work revealed anti-Fy^a , anti-Fy^b , anti-Le^a , anti-Le^b , and an anti-KN system antibody. The patient's hemoglobin nadired at 4.4 g/dL. The patient was treated with a single dose of tocilizumab, his hemoglobin stabilized, and he was discharged.

DISCUSSION

We present a case of HHS proximate to recent SARS-CoV-2 infection with multiple allo and autoantibodies identified. Information on the relationship between SARS-CoV-2 infection and HHS is limited, however, it is possible that inflammation related to COVID-19 could predispose to HHS. Tocilizumab is an approved treatment for COVID-19. Additionally, tocilizumab appears to be a promising treatment option for patients with HHS.

The Impact of Tocilizumab on Radiological Changes Assessed by Quantitative Chest CT in Severe COVID-19 Patients

(1) Background: We aimed to analyze the characteristics associated with the in-hospital mortality, describe the early CT changes expressed quantitatively after tocilizumab (TOC), and assess TOC timing according to the oxygen demands. (2) Methods: We retrospectively studied 101 adult patients with severe COVID-19, who received TOC and dexamethasone. The lung involvement was assessed quantitatively using native CT examination before and 7−10 days after TOC administration. (3) Results: The in-hospital mortality was 17.8%. Logistic regression analysis found that interstitial lesions above 50% were associated with death (p = 0.01). The other variables assessed were age (p = 0.1), the presence of comorbidities (p = 0.9), the oxygen flow rate at TOC administration (p = 0.2), FiO2 (p = 0.4), lymphocyte count (p = 0.3), and D-dimers level (p = 0.2). Survivors had a statistically significant improvement at 7−10 days after TOC of interstitial (39.5 vs. 31.6%, p < 0.001), mixt (4.3 vs. 2.3%, p = 0.001) and consolidating (1.7 vs. 1.1%, p = 0.001) lesions. When TOC was administered at a FiO2 ≤ 57.5% (oxygen flow rate ≤ 13 L/min), the associated mortality was significantly lower (4.3% vs. 29.1%, p < 0.05). (4) Conclusions: Quantitative imaging provides valuable information regarding the extent of lung damage which can be used to anticipate the in-hospital mortality. The timing of TOC administration is important and FiO2 could be used as a clinical predictor.

Analysis of the factors predicting clinical response to tocilizumab therapy in patients with severe COVID-19

Background

Controversy remains about the efficacy of tocilizumab (TCZ) for the treatment of severe COVID-19. We aimed to analyze the profile of TCZ-respondent patients.

Methods

We retrospectively analyzed a cohort of patients with severe COVID-19 who received off-label TCZ after recommendation by a local committee and were admitted to the University Hospital “12 de Octubre” until May 2020. The primary end point was a significant clinical improvement (SCI) on day 14 after administration of TCZ. Factors independently related to SCI were analyzed by multivariate logistic regression models.

Results

Of 428 (63.3%) patients treated with TCZ, 271 (63.3%) experienced SCI. After adjustment for factors related to unfavorable outcomes, TCZ administration within the first 48 hours from admission (odds ratio [OR]: 1.98, 95% confidence Interval [95% CI]: 1.1–3.55; P = 0.02) and ALT levels >100 UI/L at day 0 (OR: 3.28; 95% CI: 1.3–8.1; P = 0.01) were independently related to SCI. The rate of SCI significantly decreased according to the time of TCZ administration: 70.2% in the first 48 hours from admission, 58.5% on days 3-7, and 45.1% after day 7 (P = 0.03 and P = 0.001, respectively).

Conclusion

TCZ improves the prognosis of patients with COVID-19 the most if treatment starts within the first 48 hours after admission.

Treatment with Tocilizumab in Adult Patients with Moderate to Critical COVID‐19 Pneumonia: A Single‐Center Retrospective Study

Objectives

This study aimed to assess if tocilizumab (TCZ) timing is associated with improved survival.

Material and methods

Data obtained from adult patients with moderate/severe/critical COVID-19 and treated with TCZ, who were admitted to the Teaching Hospital of Infectious Diseases, Cluj-Napoca, Romania (April 2020-April 2021), were retrospectively analyzed. The database included demographics, clinical data, computed tomography scan results, the kinetics of IL-6, laboratory variables, and the outcome until discharge.

Results

A total of 221 patients received dexamethasone, antivirals, anticoagulants, and 1-2 doses of TCZ, 8 mg/kg. In 2021, more patients received high-flow oxigen/non-invasive ventilation compared to those hospitalized in 2020, but demographics, in-hospital mortality, and laboratory data did not differ significantly. In-hospital mortality was associated with age, disease severity, lung damage, intensive care unit (ICU) admission, cardiovascular comorbidities, and IL-6>100 pg/mL at TCZ administration. In multivariate analysis the risk of death was significantly higher in patients with a persistent inflammatory state, adjusted odds ratio (aOR) 16.6 (95% CI 3.07-108.96); lung damage>40%, aOR 11.68 (95% CI 2.05-224.98); and cardiovascular comorbidities>2, aOR 3.65 (95% CI 1.06-12.53). TCZ initiation at ≤3 days after admission showed improved survival, odds ratio (OR)=0.39 (95% CI 0.16-0.9). Severe infections were found in 11 (4.9%) patients.

Conclusion

Early initiation of TCZ seems beneficial and safe in patients with moderate to critical COVID-19 pneumonia.

Decreased mortality and increased side effects in COVID-19 patients treated with IL-6 receptor antagonists: systematic review and meta-analysis

There is controversy whether IL-6 (receptor) antagonists are beneficial in treating COVID-19 patients. We therefore update our systematic review to answer the following research questions: (1) Do patients hospitalized for COVID-19 treated with IL-6 (receptor) antagonists have lower mortality compared to standard of care? (2) Do patients hospitalized for COVID-19 treated with IL-6 (receptor) antagonists have more side effects compared to standard of care? The following databases were search up to December 1st 2020: PubMed, PMC PubMed Central, MEDLINE, WHO COVID-19 Database, Embase, Web-of-Science, COCHRANE LIBRARY, Emcare and Academic Search Premier. In order to pool the risk ratio (RR) and risk difference of individual studies we used random effects meta-analysis. The search strategy retrieved 2975 unique titles of which 71 studies (9 RCTs and 62 observational) studies comprising 29,495 patients were included. Mortality (RR 0.75) and mechanical ventilation (RR 0.78) were lower and the risk of neutropenia (RR 7.3), impaired liver function (RR 1.67) and secondary infections (RR 1.26) were higher for patients treated with IL-6 (receptor) antagonists compared to patients not treated with treated with IL-6 (receptor) antagonists. Our results showed that IL-6 (receptor) antagonists are effective in reducing mortality in COVID-19 patients, while the risk of side effects was higher. The baseline risk of mortality was an important effect modifier: IL-6 (receptor) antagonists were effective when the baseline mortality risk was high (e.g. ICU setting), while they could be harmful when the baseline mortality risk was low.