key: cord-0979666-g7cp75s3
authors: Afra, Kevin; Chen, Luke Y.C.; Sweet, David
title: Tocilizumab for hospitalized patients with COVID-19
date: 2021-04-12
journal: CMAJ
DOI: 10.1503/cmaj.210066
sha: 19dd0d9ce28da2aea3831e8431d1cc85c5c7d4ea
doc_id: 979666
cord_uid: g7cp75s3

nan

Two large randomized controlled trials evaluating tocilizumab in patients with COVID-19 in hospital have been conducted. The Randomized, Embedded, Multifactorial Adaptive Platform Trial for Community-Acquired Pneumonia (REMAP-CAP) involving patients who were critically ill found that tocilizumab was superior to standard of care for 21-day mortality and organ support-free days. 3 In-hospital mortality was 28.0% in the tocilizumab group versus 35.8% in the standard-of-care group (number needed to treat [NNT] = 12). The preprint publication of the Randomised Evaluation of COVID-19 Therapy (RECOVERY) trial showed that tocilizumab improved 28-day mortality: 29.5% of patients in the tocilizumab group died versus 33.1% in the standard-of-care group (NNT = 27). 4 This benefit is additive to the benefit of corticosteroids.

Patients in the RECOVERY trial were eligible for treatment with tocilizumab if they had hypoxia (oxygen saturation < 92% on room air or requiring supplemental oxygen) and systemic inflammation (C-reactive protein ≥ 75 mg/L). Benefits of tocilizumab appeared consistent in this trial across all levels of initial respiratory support. 4

Patients who are eligible for tocilizumab should not have treatment delayed. Both RECOVERY and REMAP-CAP, the only trials to show mortality benefit, administered tocilizumab in the early stages of hospital admission (median 1-2 d). 3, 4 5 Tocilizumab appears to be safe for the treatment of COVID-19

Hypersensitivity, cytopenias, hepatic injury and gastrointestinal perforation are notable adverse effects of tocilizumab but have been uncommon in COVID-19 trials. However, patients with an aminotransferase level 5 times the upper limit of normal or a platelet count of less than 50 × 10 9 /L were excluded from the REMAP-CAP trial. 3 PRACTICE | FIVE THINGS TO KNOW ABOUT ...

Kevin Afra MD MHA, Luke Y.C. Chen MD MMEd, David Sweet MD n Cite as: CMAJ 2021 April 12;193:E521. doi: 10.1503/cmaj.210066; early-released March 10, 2021

Confronting the controversy: interleukin-6 and the COVID-19 cytokine storm syndrome

Mississauga (ON): Hoffmann-La Roche

Interleukin-6 receptor antagonists in critically ill patients with COVID-19

Tocilizumab in patients admitted to hospital with COVID-19 (RECOVERY): preliminary results of a randomised, controlled, open-label

The authors would like to acknowledge the dedication and hard work of the B.C. COVID-19 Therapeutics Committee throughout this pandemic.

Competing interests: Kevin Afra and Luke Chen are members, and David Sweet is chair, of the B.C. COVID-19 Therapeutics Committee, which provides guidance on the most current research on use of therapies in management of COVID-19. Luke Chen has received support from GlaxoSmithKline for an ad board for mepolizumab. No other competing interests were declared. This article has been peer reviewed.