Tocilizumab in Hospitalized patients with severe Covid-19 Pneumonia 

Rosas, I.O., et al., Tocilizumab in Hospitalized Patients with Severe Covid-19 Pneumonia. New England Journal of Medicine, 2021. https://www.nejm.org/doi/full/10.1056/NEJMoa2028700 

I chose to present this article about the use of Tocilizumab in treating patients with Covid-19 since most of the patients I saw in this urgent care came for Covid-19 testing. This article was a randomized trial, where patients either received tocilizumab or placebo for the treatment of Covid-19. Covid-19 leads to a hyperinflammatory state including elevated levels of interleukin-6 (IL-6), and levels of IL-6 correlate with Covid-19 severity. Tocilizumab is a monoclonal antibody (MAB) against IL-6, case reports and retrospective observational studies have shown better outcomes in patients with Covid-19 pneumonia treated with tocilizumab, but data from randomized control studies was still needed. 

In this randomized control trial the researchers randomly assigned hospitalized patients with severe Covid-19 pneumonia to receive a single dose of intravenous (IV) tocilizumab 8mg/kg or placebo treatment. One quarter of the participants received a second dose of tocilizumab or placebo 8-24 hours after the first dose. The primary outcome being researched was clinical outcome on day 28, ranging from a score of 1 (discharged/ready for discharge) to 7 (death). 

438 patients were included in this study 294 received tocilizumab and 144 received placebo. Results showed that adverse events occurred in 34.9% of the tocilizumab group and 38.5% in the placebo group. On day 28 mortality in the tocilizumab group was 19.7% and in the placebo group 19.4%. The researchers concluded that based on this analysis the use of tocilizumab did not result in clinically significant better outcomes or decreased mortality rate compared to placebo.   

There were some limitations to this trial, this trial included patients from several different sites and there was lack of standardized treatment otherwise. For example some patients were given corticosteroids and other antiviral medications which could interact with tocilizumab, this is important to consider because more patients in the placebo group received corticosteroids than in the tocilizumab group. There may have been a selection bias as well when considering who received the second dose of tocilizumab or placebo. Patients were considered for a second dose only if their condition was not improving after the first dose, and those who received second doses had worse clinical outcomes.

The researchers acknowledged that while they initiated their trial, treatments for Covid-19 were constantly evolving, and currently there is still much change in the way Covid-19 is being treated and to interpret the results of this trial with that context in mind. 

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