key: cord-0945310-9wycjlj5
authors: Dravid, A.; Kashiva, R.; Khan, Z.; Memon, D.; Kodre, A.; Potdar, P.; Mane, M.; Borse, R.; Pawar, V.; Patil, D.; Banerjee, D.; Bhoite, K.; Pharande, R.; Kalyani, S.; Raut, P.; Bapte, M.; Mehta, A.; Reddy, M. S.; Bhayani, K.; Laxmi, S. S.; Vishnu, P. D.; Srivastava, S.; Khandelwal, S.; More, S.; Shinde, R.; Pawar, M.; Harshe, A.; Kadam, S.; Mahajan, U.; Joshi, G.; Mane, D.
title: Combination therapy of Tocilizumab and steroid for management of COVID-19 associated cytokine release syndrome: A single center experience from Pune, Western India
date: 2021-02-06
journal: nan
DOI: 10.1101/2021.02.04.21249959
sha: b1da6f681232487cbc9e8ab38b3b555b56012243
doc_id: 945310
cord_uid: 9wycjlj5

Background: Cytokine release syndrome (CRS) or cytokine storm is thought to be the cause of inflammatory lung damage, worsening pneumonia and death in patients with COVID-19. Steroids (Methylprednisolone or Dexamethasone) and Tocilizumab (TCZ), an interleukin-6 receptor antagonist, are approved for the treatment of CRS in India. The aim of this study was to evaluate the efficacy and safety of combination therapy of TCZ and steroids in COVID-19 associated CRS. Methods: This retrospective cohort study was conducted at a tertiary level private hospital in Pune, India between 2nd April and 2nd November 2020. All patients administered TCZ and steroids for treatment of CRS were included. The primary endpoint was the incidence of all-cause mortality. Secondary outcomes studied were the need for mechanical ventilation and incidence of infectious complications. Baseline and time-dependent risk factors significantly associated with death were identified by Relative risk estimation. Results: Out of 2831 admitted patients, 515 (24.3% females) were administered TCZ and steroids. Median age of the cohort was 57 (IQR: 46.5, 66) years. Almost 72 % patients had preexisting co-morbidities. Median time to TCZ administration since onset of symptoms was 9 days (IQR: 7, 11). 63% patients needed intensive care unit (ICU) admission. Mechanical ventilation was required in 242 (47%) patients. Of these, 44.2% (107/242) recovered and were weaned off the ventilator. There were 135 deaths (26.2%), while 380 patients (73.8%) had clinical improvement. Infectious complications like hospital acquired pneumonia, bloodstream bacterial and fungal infections were observed in 2.13 %, 2.13 % and 0.06 % patients respectively. Age [≥] 60 years (p=0.014), presence of co-morbidities like hypertension (p = 0.011), IL-6 [≥] 100 pg/ml (p = 0.002), D-dimer [≥] 1000 ng/ml (p < 0.0001), CT severity index [≥] 18 (p < 0.0001) and systemic complications like lung fibrosis (p = 0.019), cardiac arrhythmia (p < 0.0001), hypotension (p < 0.0001) and encephalopathy (p < 0.0001) were associated with increased risk of death. Conclusions: Combination therapy of TCZ and Steroids is likely to be safe and effective in the management of COVID-19 associated cytokine release syndrome. Efficacy of this anti-inflammatory combination therapy needs to be validated in randomized controlled clinical trials.

In December, 2019, Wuhan city, the capital of Hubei province in China, became the centre of an outbreak of viral pneumonia. By Jan 7, 2020, scientists had isolated a novel RNA, beta coronavirus from these patients. It was named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) due to its sequence homology with SARS-COV-1 [1] . The disease caused by SARS-COV-2 was later designated coronavirus disease 2019 in February 2020, by World health organization (WHO) [2] . COVID-19 spread rapidly worldwide and India was no exception. By 2 nd November 2020 there have been more than 9 million infections and 0.14 million deaths due to COVID-19 in India [3] .

The clinical presentation of COVID-19 is highly heterogeneous, ranging from asymptomatic cases, mild infection and severe pneumonia. In severe and critical cases, which occur in approximately 15 % and 5 % of patients, pneumonia can lead to acute respiratory distress syndrome (ARDS) that could need invasive mechanical ventilation [1, [4] [5] [6] [7] . Critically ill COVID-19 patients have a mortality rate ranging from 35 to 62% [8] [9] [10] .

The disease is characterized by 2 phases; viral replication phase and the host inflammatory response phase [11] . Host inflammatory response phase leading to inflammatory lung damage is usually seen 7 days after symptom onset. SARS-CoV-2 can replicate within the pulmonary tissue, activate innate immune response, leading to production of cytokines (Interleukin-1 beta (IL-1B), Interleukin-6 (IL-6) and Tumor necrosis factor (TNF)) by alveolar macrophages which are required for recruitment of adaptive immunity cells. The transition between innate and adaptive immune responses is critical for the clinical trajectory of SARS-CoV-2 infection [11] [12] [13] [14] [15] . Adaptive immune response controlled by immune regulatory cells can be a protective immune response or a dysregulated and exacerbated inflammatory response [12] . The protective response is T cell dependent, with CD4 cells helping B cells to produce specific neutralizing antibodies against viral spike (S) protein and cytotoxic CD8 cells eliminating virus infected cells. Protective immune response is present in patients with asymptomatic, mild and some moderate infections that do not progress to severe disease [12] . However, amongst severe and critically ill COVID-19 patients, there is a dysregulated pulmonary and systemic immune response. This dysregulated immune response also known as cytokine release syndrome (CRS) or cytokine storm is characterized by activation of innate immune system, elevation in systemic . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 6, 2021. ; https://doi.org/10.1101/2021.02.04.21249959 doi: medRxiv preprint inflammatory markers (C-reactive protein (CRP), ferritin, lactate dehydrogenase (LDH) and Ddimer) and aberrant pro-inflammatory cytokine secretion (IL-6, soluble IL-2 receptor [IL-2R], IL-10, TNF-α) by alveolar macrophages. It is also accompanied by depleted adaptive immune response. Lymphopenia (decline in CD4+ T cell, CD8+ T cell, Natural killer cell but not in B cell subset) and decreased Interferon Gamma (IFN-γ) expression in CD4+ T cells (CD4+ T cell dysfunction) are immediate consequences of decline in adaptive immunity [12] [13] [14] [15] . Cytokine storm leads to destruction of alveolar epithelial cells, increased pulmonary vascular permeability, worsening pneumonia, worsening oxygenation, increased risk of thrombosis and progression to acute respiratory distress syndrome (ARDS) [15] . Rising levels of interleukin-6 (IL-6) in severe COVID-19 have been associated with increased likelihood of ARDS, mechanical ventilation and mortality [16] [17] [18] [19] .

Steroids, namely Dexamethasone and Methylprednisolone have been extensively used to resolve hyperinflammation and inflammatory lung damage in COVID-19 [20] [21] [22] [23] . After the publication of RECOVERY trial, Dexamethasone was approved by World health organization (WHO) as an immunomodulatory drug for use in hospitalized COVID-19 patients who require oxygen. The benefit of Dexamethasone was greatest for patients who were receiving invasive mechanical ventilation at the time of randomization [21] . In patients with moderate to severe COVID-19, an early short course of methylprednisolone had a reduced rate of the primary composite endpoint of death, ICU transfer, and mechanical ventilation [22] . In patients already on mechanical ventilation, use of Methylprednisolone was associated with increased ventilator-free days and higher probability of extubation [23] . However steroids alone might not be able to tackle cytokine storm in all patients. Other Immunomodulatory drugs such as selective cytokine inhibitors could be of incremental benefit to suppress the hyperinflammation if used in combination with steroids. Tocilizumab (TCZ) is a recombinant humanized monoclonal interleukin-6 receptor (IL-6R) antibody of the IgG1 subtype. TCZ specifically binds and inhibits soluble and membranebound IL-6 receptors (sIL-6R and mIL-6R) and terminates downstream intracellular signal transduction [24, 25] . It has been approved for the treatment of rheumatoid arthritis [26] and systemic juvenile idiopathic arthritis [27] . In addition, it has also been used in treatment of Castleman disease [28] and Crohn's disease [29] . In August 2017, the United States Food and Drug . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted February 6, 2021. ; https://doi.org/10.1101/2021.02.04.21249959 doi: medRxiv preprint Administration (FDA) approved TCZ for the treatment of cytokine release syndrome (CRS) caused by chimeric antigen receptor T-cell (CAR-T) immunotherapy [30] . Indian council of Medical research (ICMR) guidelines published by Government of India for guidance of physicians in clinical management of COVID-19, have included TCZ as investigational therapy for off label use in patients with moderate disease with progressively increasing oxygen requirements and in mechanically ventilated patients not improving despite use of steroids [31] .

This recommendation stems from multiple retrospective and small prospective studies , that have suggested strong benefits due to use of TCZ in form of reduced risk of invasive mechanical ventilation or death in patients with severe COVID-19. On the other hand, data from randomized controlled trials (RCT) has shown disappointing results with evidence of modest efficacy and no mortality benefit [59] [60] [61] [62] [63] . RCT's have shown that TCZ reduces need for ICU admission and mechanical ventilation in patients with severe COVID-19 [61, 62] . However, out of the 4 RCT's, only the EMPACTA trial [62] used concomitant TCZ plus steroids in management of COVID-19 induced hyperinflammation. As a result more evidence regarding positioning of TCZ as an immunomodulatory therapy in COVID-19 needs to be published. Data from resource limited settings like India regarding use of TCZ and steroids in treatment of CRS has also been scarce [64, 65] . The aim of this single center retrospective cohort study conducted in Pune, India was to estimate the efficacy and safety of combination therapy of TCZ and steroid in management of COVID-19 associated CRS. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted February 6, 2021. ; https://doi.org/10.1101/2021.02.04.21249959 doi: medRxiv preprint alternative medical systems, primary level COVID care centers (both government run and private owned) and other tertiary level hospitals. Data of all hospitalized COVID-19 patients is entered into an electronic database (Lifeline electronic database, Manorama infosystems, Kolhapur, India). Data was obtained from electronic health record of each individual by manual abstraction. It included hospitalization dates, demographics, co-morbidities, clinical examination data, laboratory data (including inflammatory markers), microbiology reports, imaging reports (X ray chest and High resolution computerized tomography scan (HRCT chest)), data on use of supplemental oxygen, ventilation parameters (noninvasive or invasive ventilation) and hospital outcomes. Ordinal scale for COVID-19 severity was noted for all patients at hospital admission, during hospital stay and at discharge or death. The 8 level ordinal scale is as follows: 1 = ambulatory and no restriction of activities; 2 = ambulatory and restriction of activities due to use of home oxygen therapy or complications; 3 = Hospitalized but no oxygen therapy; 4 = Hospitalized with oxygen therapy by nasal prongs; 5 = Hospitalized with oxygen therapy by Non Re-breathing mask; 6 = Hospitalized with severe disease and on high flow nasal oxygen (HFNO) or Noninvasive ventilation; 7 = Hospitalized with severe disease and on invasive mechanical ventilation; 8 = Death.

Patients were eligible for inclusion in this analysis if they were admitted between 2 nd April 2020 and 2 nd November 2020 and were administered TCZ. Criteria for prescribing TCZ were developed by the Department of Infectious Diseases and Department of Critical care medicine. Patients were administered TCZ if they satisfied following criteria for hyperinflammation or CRS: 1) Reverse-transcriptase polymerase chain reaction (RT-PCR) test positive for SARS-CoV-2 RNA or positive COVID antibody test.

2) Lung Imaging: Moderate or severe pneumonia on High resolution Computerized tomography scan (HRCT) of chest (CT severity index ≥ 8 [66] ) or X ray chest showing evidence of pneumonia.

3) Day 7 to 14 since onset of symptoms.

. CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted February 6, 2021. ; https://doi.org/10.1101/2021.02.04.21249959 doi: medRxiv preprint 4a) Rapidly worsening respiratory status despite use of steroids and antiviral drugs:

Hypoxia (room air oxygen saturation (SPO2) < 90 %) and tachypnea (respiratory rate > 30 per minute) at rest or after minimal exertion which requires supplemental oxygen. OR 4b) Rapidly worsening respiratory status despite use of steroids and antiviral drugs:

Requirement of noninvasive or invasive ventilation to resolve hypoxia and tachypnea. OR 4c) PaO2/FiO2 ratio of less than 300 mm Hg on room air. 5) Elevated inflammatory markers: IL-6 (> 100 pg/ml or 5 fold increase from prior level) or one out of D-dimer (> 1000 ng/ml), Ferritin (> 1000 ng/ml) and CRP (> 10 mg/ml) being elevated.

Exclusion criteria: Following patients were not prescribed TCZ during hospital admission or were excluded from the analysis. Tocilizumab was given intravenously at 8 mg/kg bodyweight (up to a maximum of 800 mg in two infusions, 12 hours apart). Additional doses were administered if patients were morbidly obese (body weight > 100 kg) or to treat persistent hyperinflammation and worsening ARDS. Patients or their immediate family members signed an informed consent form prior to TCZ administration. The language in the consent form was non-prescriptive, saying that TCZ can be used off-label in patients with COVID-19 induced hyperinflammation as per ICMR guidelines. The consent form cautions that the evidence for benefit is modest; a risk for infectious complications exists but in view of limited treatment options in patients with severe pneumonia, therapy can be considered. The cost of TCZ (approximately 500 dollars for 1 vial of 400 mg) was borne by the patient as an out of pocket expense or by third party reimbursement via medical health insurance.

. CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted February 6, 2021. ; https://doi.org/10.1101/2021.02.04.21249959 doi: medRxiv preprint For all patients administered TCZ, we also scrutinized inpatient case files until hospital discharge, death, or December 2 nd 2020-the date on which the database was locked-whichever happened first. Number of TCZ doses given, type of concomitant steroid and dose of steroid given and other concomitant medication prescribed to patient were noted. Time to TCZ administration since onset of symptoms and time to TCZ administration since admission in hospital was calculated. Oxygenation and ventilation outcomes in patients administered TCZ plus steroids were noted. Systemic complications (including infectious complications) developing in patients during hospital admission were also noted. All patients who died during hospital admission were identified and a death audit to look for complications and cause of death was undertaken. All patients who showed clinical improvement, got discharged from hospital and had outpatient follow-up at 15 and 30 days after discharge were identified. Their outpatient follow-up visits were traced from electronic database to look for delayed complications. There was no control group in our study as all patients with suspicion of hyperinflammation or CRS ended up getting TCZ and steroid.

NHRC follows the ICMR guidelines published by Government of India for COVID-19 management [31] . These guidelines get updated from time to time. All hypoxic COVID-19 patients who received TCZ in our cohort were already receiving antiviral agents, intravenous steroids (Dexamethasone 6 mg per day or Methylprednisolone 40 mg twice a day) and systemic anticoagulation (Low molecular weight heparin (Enoxaparin) or Unfractionated Heparin) as a standard of care. Intravenous steroids were continued for a maximum of 10 days followed by shift to oral Prednisolone in tapering doses over next 10 days. Hydroxychloroquine and Lopinavir/ritonavir were initially recommended as standard antiviral therapy. Once clinical trial and observational study data about lack of efficacy and toxicity was published, their use as antivirals was discontinued [67] [68] [69] . Remdesvir was used as antiviral of choice at our institute since July 26 th , 2020 and was administered to all patients presenting with moderate or severe pneumonia [70] . Convalescent plasma therapy (CPT) was also used in a subset of patients presenting within 7 days of symptom onset as an antiviral agent. Adjunctive antibiotic and antifungal therapy in patients to prevent bacterial and fungal super-infections was decided by the infectious disease physician. After administration of TCZ, anti-fibrotic agents like Pirfenidone . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) 1 0 (daily dosage ranging from 800 to 2000 mg per day) and Nintedanib (daily dosage of 150 mg twice a day) were added to the treatment protocol for patients suspected of developing lung fibrosis.

Primary endpoint: 1) Deaths in the cohort after TCZ and steroid administration. and renal complications (acute kidney injury) was estimated. Hepatitis was defined as increase in total bilirubin or serum glutamate oxaloacetate/pyruvate transferase (SGOT/SGPT) value more than three times above baseline value. Acute kidney injury (AKI) was defined as abrupt (within 48 hours) reduction of kidney function manifesting as a percentage increase in serum creatinine of 50 % or greater (1.5-fold from baseline) or a reduction in urine output, defined as less than 0.5 ml/kg/hour for more than 6 hours [71] .

Encephalopathy was defined as change in personality, behavior, cognition, or consciousness (including clinical presentations of delirium or coma) in patients without evidence of brain inflammation (increased cerebrospinal fluid (CSF) protein and CSF pleocytosis) [72] .

The use of database for clinical research was approved by the institutional review board (IRB) of Noble hospital and Research Centre, Pune, India.

Continuous variables were summarized using median and interquartile range (IQR), while categorical variables were summarized using frequency and percentages. Continuous variables were compared using a Mann Whitney U test. Categorical variables were compared using Chi-square test, Proportion test and Fishers' exact test. Baseline and time-dependent risk factors significantly associated with death were identified by Relative risk estimation. Baseline risk factors included were age (< 60 years or ≥ 60 years), gender, co-morbidities like diabetes, hypertension, ischemic heart disease and chronic kidney disease and baseline investigations like IL-6 (≥ 100 versus < 100 pg/ml), absolute lymphocyte count (< 1000 versus is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 6, 2021. ; https://doi.org/10.1101/2021.02.04.21249959 doi: medRxiv preprint hypotension, thrombocytopenia, hepatitis, acute kidney injury and encephalopathy. The p value ≤ 0.05 was considered as statistically significant. All data was analyzed by SPSS version 12.0.

Out of the 2831 COVID-19 patients admitted in NHRC, 515 were administered TCZ.

Median age of the cohort was 57 (IQR: 46.5, 66) years and it included 24.3 % females. Two Obesity (Body mass index > 30 kg/m 2 , 9.5 %) being the commonest (Table 1) . Preexisting comorbidities, presenting symptoms in patients at admission and investigations performed prior to TCZ therapy are enumerated in Table 1 and 2 respectively. Fever (81%), dry cough (77%), dyspnea on exertion (81%) and bodyache or myalgia (49 %) were the commonest symptoms seen in patients (Table 1) . Two hundred and twenty (220/515, 43%) patients had lymphocytopenia (absolute lymphocyte count < 1000 copies/ml) while 16 % (80/515) patients had thrombocytopenia (Platelet count < 150,000 cells/mm 3 ) prior to TCZ administration. One (Table 3) . Intensive care unit (ICU) admission was needed . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (Table 3) .

Systemic complications (fatal and nonfatal) observed in patients in our cohort are enumerated in Table 4 . Septic shock (persistent hypotension requiring vasopressors to maintain systolic blood pressure > 100 mm Hg and a serum lactate level greater than 2 mmol/L) was noted is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 6, 2021. 18 .837)) were also associated with increased risk of death ( Figure 1 , Table 5 ).

Out of the 380 patients (73.8 %) who recovered and were discharged from NHRC, 72 (18.9 %) needed short term home oxygen therapy after hospital discharge. Of these, two patients reported worsening of respiratory symptoms at home leading to respiratory failure and death, while 70 patients could be weaned off short term oxygen therapy. Four patients developed late infectious complications (multidermatomal herpes zoster, herpes zoster opthalmicus, acute bacterial cholecystitis and Escherichia coli (E. coli) bacteremia and septic shock) within 1 month of discharge from hospital. Three patients recovered after treatment, but the patient having E.

coli bacteremia progressed to septic shock, ARDS and died. One patient developed midbrain encephalitis, 27 days after discharge from hospital and died (Total number of deaths: 139).

The goal of this retrospective observational cohort study conducted at a tertiary level, private hospital in Pune, India was to assess efficacy and safety of combination therapy of TCZ and steroids in treating CRS developing in patients with severe COVID-19. Our cohort consisted of a relatively elderly population (43 % patients ≥ 60 years of age) with pre-existing comorbidities (72 % having co-morbidities) who developed pneumonia, hyperinflammation and ARDS (100 % patients having increased inflammatory markers, 62.5 % having CT severity score ≥ 15 and 83 % having PaO2/FiO2 < 200 mm Hg). Almost 63 % patients in our cohort required . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 6, 2021. ; https://doi.org/10.1101/2021.02.04.21249959 doi: medRxiv preprint ICU care while 47 % patients needed noninvasive or invasive ventilation to maintain oxygenation. In such a cohort of severely ill patients, administration of TCZ and steroid resulted in clinical improvement in 74 % patients, while 26 % died due to respiratory failure. The response to TCZ was rapid and sustained in majority of patients. Almost 44 % patients could be weaned from ventilator support. However, there was a subset of patients on mechanical ventilation who did show initial improvement after TCZ but subsequently had clinical deterioration and died. This cohort includes 91% of all ICU admissions due to COVID-19 and 96% of all patients receiving mechanical ventilation at NHRC during the said period. To the best of our knowledge, this cohort is the largest reported database of patients who were administered TCZ plus steroids for management of COVID-19 induced CRS and ARDS. Two retrospective cohort studies on TCZ usage from India have been published till date. The strengths of our study compared to the earlier studies include the large number of enrolled patients [64] , strict inclusion and exclusion criteria applied while administering TCZ [64, 65] , availability of data about ventilatory outcomes [64, 65] , availability of data about systemic complications (including infectious complications) [64, 65] and lower mortality rate [65] .

In our cohort, 37% patients could be managed in isolation wards without need for intensive care. In an ideal scenario, all patients were candidates for ICU care, but overburdened healthcare system and shortage of ICU beds and ventilators meant that they were managed in wards. In addition, 53% patients required only supplemental oxygen prior to recovery and did not progress to mechanical ventilation. As per the CORIMUNO-19 RCT, use of TCZ among patients on supplemental oxygen reduced the need for intensive care, noninvasive or invasive mechanical ventilation by almost 40%. The effect of TCZ was numerically higher if combined with steroids [61] . According to the EMPACTA RCT [62] and the TESEO cohort [32] , the likelihood of progression to mechanical ventilation was significantly lower among patients who received TCZ plus standard care than among those who received placebo plus standard care.

Reduction in need of ICU care can reduce the risk of long-term complications including death and improve health-related quality of life. Preventing progression to mechanical ventilation greatly alters patient outcomes and leads to better utilization of scarce healthcare resources.

Mortality rate in our cohort was 26 %, while mortality rate amongst patients requiring ICU was 40 %. Overall mortality rate was similar to that seen in multiple retrospective cohort . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 6, 2021. ; https://doi.org/10.1101/2021.02.04.21249959 doi: medRxiv preprint studies [35, 36, 54, 57, 64] . Mortality rate amongst patients requiring mechanical ventilation (NIV/IMV) was 56 %. This was higher as compared to other cohort studies [40] . It could be related to delayed intubation and delayed invasive mechanical ventilation policy followed at our hospital. On Relative risk estimation, age ≥ 60 years, presence of multiple co-morbidities, increased baseline inflammatory markers (IL-6 and D-dimer), high CT severity index and development of systemic complications like lung fibrosis, arrhythmia, encephalopathy, thrombocytopenia and hypotension were significant risk factors associated with death. Females had a higher mortality rate than males in our cohort (30.4 % versus 24.9 %, Table 2 ). Early evidence indicates that males have higher overall burden, but females have a higher relative-risk of COVID-19 mortality in India [73] . Marked sex differences in access to health services, with women being less likely to be admitted to hospital than men might result in more severe cases of COVID-19 among women than men in hospital settings and higher mortality [74] .

TCZ and steroid combination therapy was safe and well tolerated. Infectious complications like confirmed bacterial and fungal infections (including HAP/VAP and bloodstream infections) were seen in 2% patients in the cohort. Low incidence of infectious complications could be because of adequate, prophylactic antibiotic and antifungal therapy prescribed to patients. Meropenem, Teicoplanin and Fluconazole were the commonest antibiotic and antifungal drugs prescribed along with TCZ. Transaminitis or hepatitis, which is an adverse event associated with TCZ, was seen in approximately 10% of patients. However, in view of prescription of multiple drugs like Remdesvir, Fluconazole, Doxycycline, Pirfenidone and Nintedanib along with TCZ, it was difficult to identify the cause of drug induced liver injury.

Intestinal perforation after TCZ administration was noted in two patients. Pulmonary (progression of lung fibrosis) and infectious complications were noted even after discharge from hospital. As a result, close follow up of patients for a period of 3 months after hospital discharge is essential for immediate identification of delayed complications.

Our study has several limitations. First, it is not a randomized controlled trial, and therefore unmeasured confounding cannot be ruled out. Second, as for all retrospective studies, some individuals administered TCZ and steroids may be unreported leading to measurement bias and overestimation of safety and efficacy of the combination therapy. Third, a comparator arm . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. workforce and lack of exhaustive reporting could be responsible for underestimation of comorbidities, presenting symptoms and complications amongst patients in our cohort. Sixth, Body mass index (BMI) could not be calculated for patients who were bed ridden or those requiring mechanical ventilation. Seventh, CT severity index and PaO2/FiO2 ratio was not available for all patients in our cohort. Eighth, Sequential organ failure assessment (SOFA) score was not performed in patients admitted in ICU [75] . Ninth, ventilator parameters like positive end expiratory pressure (PEEP) and plateau pressure were not available for all patients started on NIV or IMV. Tenth, patients were followed up after discharge from hospital for 1 month. As a result long term complications due to immunomodulatory therapy could not be identified.

Despite these limitations, this retrospective cohort study from Western India adds to the growing body of literature on use of TCZ and steroids as an anti-inflammatory combination therapy in treating cytokine storm and resultant ARDS in COVID-19.

Combination therapy of TCZ and Steroids is likely to be a safe and effective treatment modality in management of COVID-19 associated cytokine release syndrome. Efficacy of this anti-inflammatory combination therapy needs to be validated in large randomized controlled clinical trials.

. CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 6, 2021. is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 6, 2021. ; https://doi.org/10.1101/2021.02.04.21249959 doi: medRxiv preprint 0 . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 6, 2021. ; https://doi.org/10.1101/2021.02.04.21249959 doi: medRxiv preprint 1 . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted February 6, 2021. ; https://doi.org/10.1101/2021.02.04.21249959 doi: medRxiv preprint . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

The copyright holder for this preprint this version posted February 6, 2021. ; https://doi.org/10.1101/2021.02.04.21249959 doi: medRxiv preprint is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted February 6, 2021. 

Elevated levels of IL-6 and CRP predict the need for mechanical ventilation in COVID-19

An inflammatory cytokine signature predicts COVID-19 severity and survival

The Role of Cytokines including Interleukin-6 in COVID-19 induced Pneumonia and Macrophage Activation Syndrome-Like Disease

Association Between Administration of Systemic Corticosteroids and Mortality Among Critically Ill Patients With COVID-19: A Meta-analysis

Effective treatment of severe COVID-19 patients with tocilizumab

Outcome of COVID-19 patients with use of Tocilizumab: A single center experience

Tocilizumab treatment in COVID-19: A single center experience

Early tocilizumab treatment could improve survival among COVID-19 patients

Safety and efficacy of anti-IL6-receptor tocilizumab use in severe and critical patients affected by coronavirus disease 2019: a comparative analysis

Tocilizumab among patients with COVID-19 in the intensive care unit: a multicentre observational study

Tocilizumab for treatment of mechanically ventilated patients with COVID-19

Early use of tocilizumab in the prevention of adult respiratory failure in SARS-CoV-2 infections and the utilization of interleukin-6 levels in the management

Methylprednisolone added to tocilizumab reduces mortality in SARS-CoV-2 pneumonia: an observational study

Compassionate use of tocilizumab for treatment of SARS-CoV-2 pneumonia

Profiling COVID-19 pneumonia progressing into the cytokine storm syndrome: results from a single Italian Centre study on tocilizumab versus standard of care

Outcomes in patients with severe COVID-19 disease treated with tocilizumab: a casecontrolled study

Tocilizumab treatment for cytokine release syndrome in hospitalized COVID-19 patients: survival and clinical outcomes

Use of tocilizumab in kidney transplant recipients with COVID-19

Tocilizumab in patients with severe COVID-19: a single-center observational analysis

Efficacy and safety of tocilizumab in severe COVID-19 patients: a single centre retrospective cohort study

Tocilizumab and steroid treatment in patients with COVID-19 pneumonia

in Patients Hospitalized with COVID-19 Pneumonia: A Randomized Clinical Trial

Efficacy of Tocilizumab in Patients Hospitalized with Covid-19

Effect of Tocilizumab vs Usual Care in Adults Hospitalized With COVID-19 and Moderate or Severe Pneumonia: A Randomized Clinical Trial

Tocilizumab in Patients Hospitalized with Covid-19 Pneumonia

Tocilizumab in hospitalized patients with COVID-19 pneumonia

Safety and efficacy of tocilizumab in the treatment of severe acute respiratory syndrome coronavirus-2 pneumonia: A retrospective cohort study

Tocilizumab improves survival in patients with persistent hypoxia in severe COVID-19 pneumonia

Chest CT score in COVID-19 patients: correlation with disease severity and short-term prognosis

Chloroquine and Hydroxychloroquine for the Treatment of COVID-19: a Systematic Review and Meta-analysis

A Trial of Lopinavir-Ritonavir in Adults Hospitalized with Severe Covid-19

Lopinavir-ritonavir in patients admitted to hospital with COVID-19 (RECOVERY): a randomised, controlled, open-label, platform trial

Remdesivir for the Treatment of Covid-19 -Final Report

Acute kidney injury (AKI) guidelines. Available at

Neurological associations of COVID-19

Equal risk, unequal burden? Gender differentials in COVID-19 mortality in India

Sex differences in COVID-19 case fatality: do we know enough? Lancet Glob Health

The Sequential Organ Failure Assessment score for predicting outcome in patients with severe sepsis and evidence of hypoperfusion at the time of emergency department presentation

Blood Urea (mg/dl)