key: cord-0716731-dovujk88 authors: Borku Uysal, Betul; Ikitimur, Hande; Yavuzer, Serap; Ikitimur, Barıs; Uysal, Harun; Islamoglu, Mehmet Sami; Ozcan, Erkan; Aktepe, Emre; Yavuzer, Hakan; Cengiz, Mahir title: ''Tociluzumab challenge: A series of cytokine storm therapy experience in hospitalized Covid‐19 pneumonia patients'' date: 2020-06-02 journal: J Med Virol DOI: 10.1002/jmv.26111 sha: 4cfee82a87747e695b2148bd99a770eeb5041341 doc_id: 716731 cord_uid: dovujk88 OBJECTIVE: To recognize the period of exaggerated cytokine response in patients with Coronavirus disease 2019 (COVID‐19) pneumonia, and to describe the clinical outcomes of using tocilizumab as a treatment option. METHODS: The data of 12 adult COVID‐19 pneumonia patients who were followed in the inpatient clinics of Biruni University Medical Faculty Hospital (Istanbul, Turkey) were retrospectively analyzed. Diagnostic tests, laboratory examinations, clinical findings and computed tomography of the thorax imaging results were evaluated. RESULTS: A dramatic laboratory and clinical improvement was observed in 83% (10/12) of patients after tocilizumab. In 17% (2/12) of our patients, short‐term ventilator support was required in the intensive care unit. The longest hospital stay was 18 days. However, in the end, all of our patients were discharged home with health. While arterial oxygen saturations (87.58±3.12%) dropped in room air in the pre‐tocilizumab period, post‐tocilizumab they normalized in all patients (94.42±1%). None of them had fever after tocilizumab treatment and the levels of c‐reactive protein (13.08±12.89) were almost within normal limits. Eosinophil values were quite low at the time of diagnosis (10±17.06), but increased significantly post‐tocilizumab (155.33±192.69). CONCLUSION: There is currently no proven treatment for COVID‐19 induced by novel coronavirus SARS‐CoV‐2. Based on our experience with twelve adult COVID‐19 pneumonia patients, we can say that tocilizumab, an IL‐6 inhibitor, is more beneficial in preventing the damage caused by excessive cytokine response in the body if administered at the right time and provides clinical and radiological recovery. This article is protected by copyright. All rights reserved. antiparasitic drugs such as ivermectin (9) , antimalarial drugs such as hydroxychloroquine (10) , corticosteroids and drugs with anti-inflammatory activities such as colchicine (11) are being investigated and their effectiveness is being discussed. Tocilizumab, a recombinant humanized anti-human IL-6 receptor monoclonal antibody, is also thought to be useful in COVID-19 treatment (12) . COVID-19 is clinically classified as mild, moderate, severe and critical disease (13) . At various stages of lung involvement is mostly observed when the disease has reached the moderate level (13) . The reason why tocilizumab, a blocker of IL-6, is considered a promising treatment in COVID-19, is that SARS-CoV-2 causes a condition similar to cytokine storm syndrome, and it is known that IL-6 plays an pro-inflamatory role in this inflammatory cascade (12) . Therefore, tocilizumab has begun to take place in treatment guidelines of several countries like China and Italy (14) . Since December 2019 the process of outbreak was being followed very closely by the Republic of Turkey Ministry of Health. Precautions were taken against COVID-19 infection and preparations were made for the possibility of being involved in the pandemic. The first case in our country was reported on March 10 th , 2020. In our center, COVID-19 patients were started to be admitted since March 18 th 2020. We followed the treatment guidelines of our Ministry of Health that were recommended and updated regularly by National COVID-19 Scientific Committee, to treat our patients. In our country, as in China and Italy, tocilizumab was presented as a treatment option, considering that a cytokine storm was introduced during COVID-19. As of March 18 th , 2020, we started tocilizumab treatment to 12 patients who were admitted with COVID-19 pneumonia and thought to be in cytokine storm. By sharing our experience in this clinical series, we aimed to guide at which point we should choose tocilizumab and what were the clinical, laboratory and radiological outcomes. Twelve patients who were followed and treated with the diagnosis of COVID-19 pneumonia between March 18 th -April 8 th , 2020 at Biruni University Faculty of Medicine Hospital (Istanbul, Turkey), and who received tocilizumab treatment because it was considered that they entered cytokine storm during this period, were included in the study. Approval was obtained from the Biruni University Medical Research Ethics Committee for the study. Informed consent was obtained from all patients that they agreed to publish their data in this case series. We will protect patients' privacy and comply with the Helsinki Declaration. Computed tomography (CT) of the thorax were taken at the time of admission to all patients included in the study. As suggested in the guidelines of our Ministry of Health an oropharyngeal sample was first taken with a swab, then a nasal sample was taken using the same swab and placed in the same transport medium for diagnosis (15) . Samples were tested by real-time reverse-transcriptase-polymerase-chain reaction (RT-PCR) assay developed from the virus sequence. Since the drugs used in the treatment (especially azithromycin and hydroxychloroquine) may cause prolonged QT duration, the patients' ECGs were taken. The biochemical parameters such as complete blood counts (CBC), the levels of creatinine, sodium, potassium, alanine aminotranferase (ALT), aspartate aminotransaminase (AST), lactate dehydrogenase (LDH), D-dimer, ferritin, troponin and C-reactive protein (CRP) were measured with fasting blood samples by routine methods with commercial kits. All laboratory tests and vital signs (temperature, systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), arterial oxygen saturation (SpO 2 ), respiratory rate (RR)) of our patients retrospectively on the day of diagnosis, the day before tocilizumab application and two days (48 hours) after the second tocilizumab application. Clinical syndromes associated with COVID-19 have been classified by the World Health Organization (WHO) as mild disease, pneumonia, severe pneumonia, acute respiratory distress syndrome, sepsis and septic shock (15) . Indication for hospitalization begins at the stage of pneumonia. In addition to fever or suspected respiratory infection, the presence of one of respiratory rate> 30 breaths / min, or severe respiratory distress, or SpO 2 ≤ 93% on room air were the criterias used to diagnose severe pneumonia. In the next step, patients are recommended to evaluate the indication of intensive care in accordance with the specified criteria. After the examinations for the diagnosis, we hospitalized our 12 patients that were diagnosed COVID-19 pneumonia to our inpatient special COVID clinic (nonintensive care unit). According to the WHO classification, all of them had severe pneumonia (Table 1) . As suggested in the COVID-19guideline of our Ministry of Health, initially all of our patients were treated with hydroxychloroquine (1st day 2x400mg loading + 4 days 2x200 mg maintenance), oseltamivir (2x75 mg, 5 days), azytromycin (1x500 mg, number of days depending on the disease) or moxifloxacin (1x 400 mg, depending on the condition of the disease) (16) ( Table 1) . We also provided nasal oxygen support to all of our patients according to their needs. Despite the standard treatment used, we concluded that the patients with increased acute phase reactants, persistent fever, decreased SpO 2 and deepened respiratory distress progress to the cytokine storm period. We decided to use tocilizumab, which can regulate the immune system overreaction when patients are on this threshold of intensive care. A volume of liquid equal to the tocilizumab concentration calculated for the patient under aseptic conditions (10 mL for 200 mg, 20 mL for 400 mg and 40 mL for 800 mg) was taken from sterile 100 mL of isotonic sodium chloride (0.9%) infusion solution. The amount of tocilizumab concentrate to be applied is drawn from the vial and added to the 100 mL infusion bag. The final fluid volume in the infusion bag was adjusted to be 100 mL and the solution in the bag was slowly turned upside down and mixed without foaming. It was administered intravenously within one hour. As suggested in the guidelines of our Ministry of Health, when the first dose of tocilizumab was administered as 400 mg, a dose of 400 mg was repeated within 24 hours, taking into account the changes in clinical and laboratory findings (16). Data on patients' gender, age, concomitant diseases, clinical symptoms, treatments used, swab sample and presence of thorax CT findings, laboratory findings and vital signs on the day of diagnosis pre-tocilizumab and post-tocilizumab, hospital stay and discharge methods were recorded. Statistical analyzes were performed with Number Cruncher Statistical System (NCSS) 2020 Statistical Software (Utah, USA) package program. In addition to descriptive statistical methods in the evaluation of the data, the distribution of variables was examined with the Shapiro-Wilk normality test. One-way analysis of variance paired in time comparisons of normally distributed variables, Newman Keuls multiple comparison test in subgroup comparisons, Friedman Test in time comparisons of variables that do not have normal distribution, Dunn's multiple comparison test in subgroup comparisons, and in the comparison of qualitative data, Stuart Maxwell Test and Mc Nemar's test were used. The results were evaluated at the significance level of p <0.05. There were a total of 12 cases, half of whom were male (50%, n = 6) and half were female (50%, n = 6) ( Table 2 ). The average age of the cases was 65.83 ± 11.30 years, and ranged between 47-79 years. All of the patients complained of cough (12/12, 100%). Fatigue and fever were also present in most patients (11/12, 92 %). The most frequent complaints were, respectively, loss of smell after-taste (9/12, 75%) and dyspnea (8/12, 67 %). Two of our patients had diarrhea (2/12, 17 %) ( Table 2) . As for the concomitant diseases of the patients, diabetes mellitus (7/12, 58 %) and hypertension (7/12, 58 %) were in the first place (Table 2 ). RT-PCR was positive in 11 of 12 patients (92 %) in the swab taken from the oropharyngeal and nasal samples of the patients (Table 2 ). In the comparisons between the data on the values of white blood cell count (WBC), neutrophils (Neut), lymphocytes (Lymp), eosinophil, hemoglobin (Hb), hematocrit (Htc), platelet (Plt), mean platelet volume (MPV), CRP, LDH, D-dimer were statistically significant on the day of patients' admission, pre-tocilizumab and posttocilizumab and advanced multiple variance tests were applied (Table 3) . Initially, eosinophil values (10±17.06), which were significantly low in almost all patients, increased (155. 33±192.69) significantly after tocilizumab treatment (Graphic 1). A statistically significant difference was observed between the eosinophil averages on the day of diagnosis, before the tocilizumab, after the tocilizumab (p = 0.0001). Averages of eosinophils on the day of diagnosis were found to be statistically significantly lower than before the tocilizumab and after the tocilizumab (p = 0.012, p = 0.003), and averages before the tocilizumab were statistically significantly lower than the post-tocilizumab eosinophil averages (p = 0.041). CRP values, which were moderately high at baseline, showed significant increases in the pre-tocilizumab period, while decreased significantly in the post-tocilizumab period. A statistically significant difference was observed between the the day of diagnosis, before the tocilizumab and after the tocilizumab CRP averages (p = 0.0001). Post-tocilizumab CRP averages were found to be statistically significantly lower than the day of diagnosis and pre-tocilizumab CRP averages (p = 0.019, p = 0.003). No statistically significant difference was observed between the averages of Neut, Lymp, ALT, AST, ferritin, troponin, creatinine on the day of diagnosis, before the tocilizumab, after the tocilizumab respectively (p=0.087, p=0.235, p=0.233, p=0.640, p=0.138, p=0.186, p=0.761). While patients' SBP and DBP values and heart rates tended to increase compared to the day of admission on the day of pre-tocilizumab, they regressed below the day of admission after treatment with tocilizumab ( Table 3) . The most critical change in patients' fever was recorded on the day after tocilizumab. Because, high fever on the diagnosis day and pre-tocilizumab dropped dramatically after treatment. This was one of the most important outcomes of treatment. A statistically significant difference was observed between the the day of diagnosis, pretocilizumab and post-tocilizumab fever distributions (p = 0.01). Post-tocilizumab, the presence of fever was found statistically significantly lower than the diagnosis day (p This article is protected by copyright. All rights reserved. = 0.002), and no statistically significant difference was observed between the presence of fever on the day of admission and pre-tocilizumab (p = 0.999). SpO 2 on room air values, which were relatively low at the time of admission in all patients, decreased in the pre-tocilizumab period significantly and exceeded the initial values after treatment (Table 3 , Graphic 2). When the patient group was evaluated for the development of clinically significant arrythmias, no untoward rhythm disturbances or significant QTc prolongations (>500 milliseconds) attributable to tocilizumab use could be detected. Including these cardiological conditions, no additional adverse events were seen in patients after tocilizumab administration All of our patients were hospitalized with the diagnosis of COVID-19 pneumonia. Therefore, tomography features of all patients were abnormal at the time of admission. All had ground-glass involvement compatible with COVID-19 in thorax CT ( Table 2 ). The the admission time of our patients range from March 18 to March 31, 2020 (Table1).Since we had only one patient who was hospitalized for the 3-week period that was required to see the radiological improvement, we were able to share the thorax CT images of this patient before and after tocilizumab (Figure 1 ). COVID-19 is a brutal disease that affects the whole world, causing morbidity and mortality, collapse in healthcare system and economy. SARS-CoV-2 is concerning for scientists as it can be transmitted from one person to another easily due to its high virulence, it might cause an infection in a short time and the need for mechanical ventilation in severe illness can exceed the number of intensive care unit beds present globally (17). Unfortunately, there is currently no clear-proven treatment for COVID-19 or a vaccine developed to prevent transmission. For this reason, the primary goal is to reduce contact with the virus. However, when the person is infected and the disease develops, the treatments that will prevent the hospitalization of the patient or shorten the duration of hospitalization and reduce the need for intensive care should be applied. This will save the lives of patients, reduce the burden of health systems and reduce costs. We retrospectively analyzed the laboratory and clinical findings of 12 patients who received tocilizumab. According to the disease classification of WHO, all of the patients we found to be classified as severe pneumonia had ground glass appearance in thorax CT, while RT-PCR was positive in 11 of 12 patients. We applied the initial treatment to all of our patients, as suggested in the guidelines of our Ministry of Health. Some of the drugs used in the treatment scheme recommended in our country were applied in the earlier stages of the disease, unlike those recommended from other parts of the world. For this reason, our country's healthcare workers who undertook the COVID-19 treatment always had an advantage. However, despite this standard treatment, all of our 12 patients exhibited a clinical deterioration graph, such as increases in acute phase reactants, fever, heart rate and respiratory rate, and deepening of low arterial saturation. As in every other part of the world, our Ministry of Health's guidelines are updated frequently frequently by National COVID-19 Scientific Committee. The recommendation for tocilizumab therapy was also available in updates prior to March 22nd. However, it was not a standard treatment and was left to the discretion of the physician in patients deemed appropriate. In this interim period, we thought of using tocilizumab before going into intensive care for our patients, who we think had entered the macrophage activation syndrome, namely cytokine storm. However, in later updates (18) , tocilizumab was taken to the standard treatment of the patients who were hospitalized in the intensive care unit. After tocilizumab treatment, 10 patients (83%) had dramatic improvements both in the laboratory tests and clinical conditions. Although two of our patients (17%) needed ventilator support in the intensive care unit for a short period of time, all of our patients were discharged home with health without the need for oxygen support. The immune system response to SARS Cov-2 infection is becoming excessive, a cytokine storm is developing that causes significant organ damage in the lungs and other organs (19) . In order to suppress this excessive response out of control, it has been thought many times that stopping IL-6, which started the uprisings, would benefit COVID-19 treatment (20-22). Our experience with 12 patients allows us to conclude that recognizing this inflammatory response from the very beginning and blocking IL-6 will increase the success of tocilizumab treatment. A study by Luo et al., evaluating the data of 15 patients, whose severity was classified as mildly, moderately, seriously and critically ill showed that 46.7% of the patients included in the study were seriously ill and 40% were critically ill. In other words, the majority of patients were critic. In the end, three patients had died and two had clinical deterioration (22) . In another study by Xu et al, 19 patients of totally 21 patients could be discharged. In this study, 4 of the patients were critically ill and 17 were severe. As a result, nineteen patients (90.5%) recovered including two critical patients. In another study evaluating 25 patients who were treated with tocilizumab with the diagnosis of COVID-19, all patients needed treatment in intensive care unit, 3 (12%) of them died (23) . The reason why our treatment results were better than theirs is that, the patients were given tocilizumab later than necessary in their series. The most valuable conclusion from the results of these three studies and our own experience is that the use of IL-6 inhibitor tocilizumab in the earliest period possible when the cytokine storm has just begun is crucial. Applying tocilizumab at a point where cytokine response is very advanced in the patient would not be as beneficial. In three studies that shared their experiences before us, an evaluation was made regarding the limited laboratory parameters (21) (22) (23) . We found that eosinophil values were very low at baseline, even zero in 6 of our patients (50%), and there were serious increases in the post-tocilizumab period. This raised the question as to whether Covid-19's initial low eosinophil level may be predictive for the course of the disease towards severe pneumonia. The fact that the serious increase in eosinophil levels accompanied the dramatic good clinical outcome after tocilizumab treatment also supported this idea. We applied two doses of tocilizumab to our patients at 24-hour intervals. However, there are studies in the literature that try different routes of administration, such as the subcutaneous route (24) , or administration of one or three doses (21) (22) (23) . A metaanalysis reviewing studies evaluating COVID-19 patients treated with tocilizumab, a total of 29 cases from 11 studies were examined. Similar to our study, a significant decrease was detected in CRP values after tocilizumab treatment. Among these cases, 6 patients (20.7%) died but in our study we did not have any exitus. (25). Two cases with acute elevated inflammatory biomarkers consistent with acute pancreatitis and acute hypertriglyceridemia have been reported after the application of tocilizumab with the diagnosis of COVID-19 (26). In our study, tocilizumab treatment in severe COVID-19 emerged as a treatment option without acute side effects. There are some limitations to be considered in this study. First of all, the number of patients is low. However, COVID-19 is a rapidly spreading disease that has not yet been cured and it is highly mortal. For this reason, sharing experiences, even in a small number of patients, is very important to protect patients' lives. In addition, the IL-6 level was not examined, since this is not a routine examination due to its high cost and low availability. In order to predict the onset of cytokine storm, we believe that the increase in acute phase reactants and routine clinical evaluation of the patient are sufficient and allow to use the time wisely and decrease health costs. The virus, SARS-CoV-2, whose origin is still an enigma, has led to an outbreak that resulted in a pandemic. COVID-19 stands across the world as a catastrophic problem with many puzzlers, such as lack of approved specific treatment methods, whether it provides immunity after recovery or whether there will be re-infection or latent infection. All scientists fighting COVID-19 try to find answers to all these puzzlers, but also try to save time in this war. With our experience from our patients, we have seen that with the use of tocilizumab, patients who would have needed intensive care in the near future could regain their health without the need for intensive care or even if they needed intensive care, the duration of the ICU treatment was shortened. 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