Appropriate use of tocilizumab in COVID-19 infection

Abstract

Objective: This study aimed to describe the effectiveness and optimum use of tocilizumab (TCZ) treatment by the support of clinical, laboratory and radiologic observations.

Methods: All patients were followed up in the hospital with daily interleukin-6 (IL-6), C-reactive protein (CRP), ferritin, d-dimer, full blood count, and procalcitonin. Thoracic computed tomography (CT) was performed on admission, when oxygen support was necessary, and seven days after TCZ started. Disease course of the patients was grouped as severe or critical, according to their clinical, laboratory and radiologic evaluations.

Results: Forty-three patients were included: 70% were male; the median age was 64 years (minimum-maximum: 27-94); and six (14%) patients died. The median duration of oxygen support before the onset of TCZ was shorter among the severe patient group than the critical patient group (1 vs. 4 days, p < 0.001). Three cases of 21 (14%) who received TCZ in the ward were transferred to ICU, and none of them died. The levels of IL-6, CRP, ferritin, d-dimer, and procalcitonin were significantly lower in the severe cases group than the critical cases group (p = 0.025, p = 0.002, p = 0.008, p = 0.002, and p = 0.001, respectively). Radiological improvement was observed in severe cases on the seventh day of TCZ. Secondary bacterial infection was detected in 41% of critical cases, but none of the severe ones.

Conclusion: Earlier use of TCZ in COVID-19 infection was beneficial for survival, length of hospitalization and duration of oxygen support. The recommendation for administration of TCZ was based on an increase in requirement of oxygen support, progression in thoracic CT, and elevation of inflammation markers, including IL-6, CRP, ferritin, and d-dimer, and decrease in % lymphocytes.

Keywords: COVID-19; Cytokines; Interleukin-6; Therapy; Tocilizumab.

Figure 1

Flow diagram for the management among patient groups.

Figure 2

Laboratory parameters 3 days before and after tocilizumab among severe and critical cases.

Figure 3

A 59-year-old woman with Covid-19. Same level of mid-axial (A, C and E) and mid-coronal (B, D and F) chest CT scans on admission (A–B), on the day of tocilizumab given because of requirement of oxygen support and progressive lung imaging (C–D) and 7 days after onset of tocilizumab (E–F), retrospectively. A–B: Focal peripheral ground-glass opacities. The left upper lobe lesions were accompanied by consolidation with bronchiectasis. C–D: Chest CT showed that the lesions had become larger with some peripheral newer small consolidation. E–F: The lesions were suppressed and improved.