key: cord-0055633-4qyv26vz authors: Jiménez-Brítez, Gustavo; Ruiz, Pablo; Soler, Xavier title: Tocilizumab plus glucocorticoids in severe and critically COVID-19 patients. A single center experience date: 2020-11-13 journal: Med Clin (Engl Ed) DOI: 10.1016/j.medcle.2020.07.009 sha: 6435db112dec53f9e3ed20214eb5013b60f4be46 doc_id: 55633 cord_uid: 4qyv26vz nan patients with a strong suspicion of HIT, heparin treatment should be suspended and/or continued with an alternative anticoagulant treatment, to avoid the high risk of HIT-induced thrombosis. Dear Editor: The cytokine storms (CS) mediated by overproduction of proinflammatory cytokines have been observed in a large population of critically ill patients infected with COVID-19. 1 In previous studies, severe patients that have been hospitalized for COVID-19 have had laboratory results that show an increased level of cytokines, specifically interleukin 6 (IL-6). Tocilizumab is a recombinant humanized monoclonal antibody that has an antagonist effect on the IL-6 receptor, and could play a role in treatment for severely ill patients with COVID-19. 2 Corticosteroids such as methylprednisolone (MP) are the conventional agents used to treat CS, but usually are related with risk of side effects, the most common the secondary bacterial superinfection. There are observational studies on the frontline in China and Italy that suggest the use of methylprednisolone was associated with better clinical outcomes in severe patients with COVID-19 pneumonia. 3, 4 This was a single centre observational study. We report the outcomes of patients tretaed with tocilizumab plus glucocorticoids in severe and critical severe COVID-19 patients between March 26 and April 17, 2020 in a Intensive Care Unit (ICU) Hospital in Barcelona, Spain. We included patients with high suspicion of CS (persisten fever, increase in inflammatory parameters (CPR, d-dimer, ferritine), and excluded patients with confirmed bacterial superinfection at the start of the tretament. All patients enrolled met the severe or critical severe criteria defined by the Diagnosis and Treatment Protocol for Novel Coronavirus Pneumonia (6th interim edition) sponsored by National Health Commission of the People's Republic of China. 5 The diagnose of severity was defined if any of the following conditions was met 1 : respiratory rate ≥30 breaths/min 2 ; SpO 2 ≤ 93% while breathing room air 3 ; PaO 2 /FiO 2 ≤ 300 mmHg. A critical case was diagnosed if any of 1 : respiratory failure which requiring mechanical ventilation 2 ; shock 3 ; combined with other organ failure, need to be admitted to ICU. A single dose of tocilizumab was administered in 21 patients and two doses in 4 patients. Methylprednisolone were adminstered 1 mg/kg/day during the inflammatory phase. Afther that, decreasing doses were administered. Twenty five patients (14 males and 11 females) with COVID-19 were included in this study. The characteristics of patients, status, laboratory and clinical outcomes are summarized in Table 1 . The media age of the patients was 62.4 years. Eight (32%) patients were severe ill, and 17 were critical severe ill (68%), 15 of them with invasive mechanical ventilation, 2 with non invasive ventilation and 8 with high doses of oxigen (O 2 mask more than 50% FiO 2 , or high flow oxygen) at the start of the treatment. The body temperature of 19 patients (76%) returned to normal in the first 72 h after receiving the treatment. The total number of lymphocytes increases in 17 (68%) patients and CRP decreased significantly in 92% patients at 72 h after the start of treatment. At the same time this was related to a clinical improvement of most patients (Appendix A). There were 8 (32%) patients with subsequent bacterial superinfection, all these patients with long ICU admission. The median of days of hopitalization was 25 (8-52) days. At this time (May 31, 2020), 18 (72%) patients were discharged from hospitalization, 2 patients remain hospitalized, 1 patient in ICU, and 5 deaths (20%). The time that the anti-inflammatory treatment with tocilizumab was started since the hospital admission was variable among patients, the treatment were started earlier in patients who survived than those who died (7.6 ± 5 vs. 13.6 ± 7.7 days; p: 0.03). In our study we observed a significant decrease in fever, CPR, ddimer, ferritine, and an increase in the total number of lymphocytes at 72 h after ther start the anti-inflammatory treatment in critical COVID patients. The reported mortality in critically ill patients infected by COVID-19 is high between 18 and 66%. 5 For this reason, pharmacological strategies should be sought to mitigate the inflammatory phase. Although data from several ongoing randomized, controlled trials will soon provide more evidence regarding the different treatments, the outcomes observed in this report specifically the improvements in the inflamamatory parameter, with a 72% of the patients discharge from the hospitalization and overall mortality of 20%, suggest that tocilizumab plus glucocorticoids appears to be an effective treatment option in COVID-19 patients to attenuate the CS. Dr. Jiménez-Brítez has a grant for research (Becas Carlos Antonio López). Dear Editor, On 31 January 2020, the new SARS-CoV-2 coronavirus touched Spanish turf for the first time. It was not until the beginning of ଝ Please cite this article as: Rogado J, Serrano-Montero G, Pangua C. Características y evolución de los pacientes con cáncer de pulmón e infección Covid-19 en un hospital de segundo nivel durante los 3 primeros meses de pandemia. Med Clin (Barc). 2020;155:411-13. March when intra-community transmission was detected, transforming it into a major public health problem and causing an unprecedented health alert. During this period, cancer patients and those with serious chronic diseases were the only ones who continued to received their usual healthcare. For this reason, together with their status of immunosuppression, it seems they have had a higher incidence of Covid-19, as we have seen in different case series from China. 1-3 Furthermore, we ourselves have observed a higher cumulative incidence of cases among the general cancer population in our centre during the first month of the pandemic, 4 with an increase in mortality, 1-4 which was even higher in patients with lung cancer, as shown in the TERAVOLT study. 5 Our study is a retrospective study, describing the characteristics and progression of lung cancer patients who developed Covid-19, between 5 March and 2 June 2020. Additionally, we observe whether there is higher mortality among patients with Why tocilizumab could be an effective treatment for severe COVID-19? The cytokine release syndrome (CRS) of severe COVID-19 and Interleukin-6 receptor (IL-6R) antagonist Tocilizumab may be the key to reduce the mortality Risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease 2019 pneumonia in Wuhan China National institute for the infectious diseases "L. Spallanzani" IRCCS. Recommendations for COVID-19 clinical management Interpretation of "Guidelines for the diagnosis and treatment of novel coronavirus (2019-nCoV) infection by the National Health Commission (Trial Version 5 Xavier Soler a a Intensive Care Unit Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/ j.medcli.2020.07.001.