Clinical efficacy of tocilizumab treatment in severe and critical COVID-19 patients

Identification of Clinical Response Predictors of Tocilizumab Treatment in Patients with Severe COVID-19 Based on Single-Center Experience

Hyperinflammation in COVID-19 plays a crucial role in pathogenesis and severity; thus, many immunomodulatory agents are applied in its treatment. We aimed to identify good clinical response predictors of tocilizumab (TCZ) treatment in severe COVID-19, among clinical, laboratory, and radiological variables. We conducted a prospective, observational study with 120 patients with severe COVID-19 not improving despite dexamethasone (DEX) treatment. We used parametric and non-parametric statistics, univariate logistic regression, receiver operating characteristic (ROC) curves, and nonlinear factors tertile analysis. In total, 86 (71.7%) patients achieved the primary outcome of a good clinical response to TCZ. We identified forty-nine predictive factors with potential utility in patient selection and treatment monitoring. The strongest included time from symptom onset between 9 and 12 days, less than 70% of estimated radiological lung involvement, and lower activity of lactate dehydrogenase. Additional predictors were associated with respiratory function, vitamin D concentration, comorbidities, and inflammatory/organ damage biomarkers. Adverse events analysis proved the safety of such a regimen. Our study confirmed that using TCZ early in the hyperinflammatory phase, before severe respiratory failure development, is most beneficial. Considering the described predictive factors, employing simple and widely available laboratory, radiological, and clinical tools can optimize patient selection for immunomodulatory treatment with TCZ.

Stratification of COVID-19 Severity Using SeptiCyte RAPID, a Novel Host Immune Response Test

SeptiCyte® RAPID is a gene expression assay measuring the relative expression levels of host response genes PLA2G7 and PLAC8, indicative of a dysregulated immune response during sepsis. As severe forms of COVID-19 may be considered viral sepsis, we evaluated SeptiCyte RAPID in a series of 94 patients admitted to Foch Hospital (Suresnes, France) with proven SARS-CoV-2 infection. EDTA blood was collected in the emergency department (ED) in 67 cases, in the intensive care unit (ICU) in 23 cases and in conventional units in 4 cases. SeptiScore (0-15 scale) increased with COVID-19 severity. Patients in ICU had the highest SeptiScores, producing values comparable to 8 patients with culture-confirmed bacterial sepsis. Receiver operating characteristic (ROC) curve analysis had an area under the curve (AUC) of 0.81 for discriminating patients requiring ICU admission from patients who were immediately discharged or from patients requiring hospitalization in conventional units. SeptiScores increased with the extent of the lung injury. For 68 patients, a chest computed tomography (CT) scan was performed within 24 h of COVID-19 diagnosis. SeptiScore >7 suggested lung injury ≥50% (AUC = 0.86). SeptiCyte RAPID was compared to other biomarkers for discriminating Critical + Severe COVID-19 in ICU, versus Moderate + Mild COVID-19 not in ICU. The mean AUC for SeptiCyte RAPID was superior to that of any individual biomarker or combination thereof. In contrast to C-reactive protein (CRP), correlation of SeptiScore with lung injury was not impacted by treatment with anti-inflammatory agents. SeptiCyte RAPID can be a useful tool to identify patients with severe forms of COVID-19 in ED, as well as during follow-up.

Retrospective analysis of influencing factors on the efficacy of mechanical ventilation in severe and critical COVID-19 patients

BACKGROUND

The novel coronavirus disease 2019 (COVID-19) has spread widely around the world with strong infectivity, rapid mutation and a high mortality rate. Mechanical ventilation has been included in the Diagnosis and Treatment Protocol for Novel Coronavirus Pneumonia (Trial Version 8) as an important treatment for severe and critical COVID-19 patients, but its clinical efficacy in COVID-19 patients is various. Therefore, it is necessary to study the influencing factors on the efficacy of mechanical ventilation in severe and critical COVID-19 patients.

AIM

The aim of this study was to determine the influencing factors on the efficacy of mechanical ventilation in severe and critical COVID-19 patients.

METHODS

A total of 27 severe and critical COVID-19 patients were enrolled in this study and treated with mechanical ventilation at the Optical Valley Campus of Hubei Maternal and Child Health Care Hospital (Wuhan, Hubei Province) from February 20, 2020 to April 5, 2020. According to the final treatment outcomes, the patients were divided into the "effective group" and "death group." The clinical data of the two groups, such as the treatment process and final outcome, were retrospectively analyzed in order to determine the specific curative effects on the two groups and the reasons for the differences in such curative effects, as well as to explore the factors related to death.

RESULTS

This study enrolled 27 severe and critical COVID-19 patients, including 17 males (63.0%) and 10 females (37.0%). Their ages were 74.41 ± 11.73-years-old, and 19 patients (70.4%) were over 70-years-old. Severe COVID-19 patients over 70-years-old who were treated with mechanical ventilation died in 14 cases (82.4%); thus, this was the peak age. A total of 17 patients died of basic disease, 16 of whom had more than two basic diseases. The basic diseases were hypertension, diabetes, and cardiovascular and cerebrovascular diseases. At the same time, 13 patients (76.5%) died from an abnormal increase in blood glucose. Among them, eight had diabetes before contracting COVID-19 and five had a stress-induced increase in blood glucose after contracting COVID-19. Diabetic ketoacidosis occurred in one case. The use of tocilizumab may be a double-edged sword that carries a certain risk in clinical usage. Among the patients who died, 16 (94.1%) went into septic shock at the end. There were significant differences in the degree of infection, cardiac and renal function, and blood glucose between the death group and effective group.

CONCLUSION

Age, blood glucose, cardiac and renal function, and inflammatory reaction are important indicators of poor prognosis for mechanical ventilation in severe and critical COVID-19 patients.

Beneficial and harmful outcomes of tocilizumab in severe COVID-19: A systematic review and meta-analysis

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.

Antibody-Based Immunotherapeutic Strategies for COVID-19

Global efforts to contain the coronavirus disease-2019 (COVID-19) include the development of novel preventive vaccines and effective therapeutics. Passive antibody therapies using convalescent plasma, SARS-CoV-2 (Severe-Acute-Respiratory-Syndrome-Corona-Virus-2)-specific neutralizing antibodies (NAbs), and the development of monoclonal antibodies (MAbs) are among the most promising strategies for prophylaxis and treatment of SARS-CoV-2 infections. In addition, several immunomodulatory antibodies acting via several mechanisms to boost the host immune defense against SARS-CoV-2 infection as well as to avoid the harmful overreaction of the immune system are currently under clinical trial. Our main objective is to present the current most up-to-date progress in some clinical trials registered at ClinicalTrials.gov. We highlight the pros and pitfalls of several SARS-CoV-2 antibody-based immunotherapeutics.