Effects of tocilizumab on mortality in hospitalized patients with COVID-19: a multicentre cohort study
Javier Martínez-Sanz, Alfonso Muriel, Raquel Ron, Sabina Herrera, José A Pérez-Molina, Santiago Moreno, Sergio Serrano-Villar
Clinical Microbiology and Infection, doi:10.1016/j.cmi.2020.09.021
Objectives: Tocilizumab has been proposed as a candidate therapy for patients with severe coronavirus disease 2019 (COVID-19), especially among those with higher systemic inflammation. We investigated the association between receipt of tocilizumab and mortality in a large cohort of hospitalized patients. Methods: In this cohort study of patients hospitalized with COVID-19 in Spain, the primary outcome was time to death and the secondary outcome time to intensive care unit (ICU) admission or death. We used inverse probability weighting to fit marginal structural models adjusted for time-varying covariates to determine the causal relationship between receipt of tocilizumab and outcome. Results: Data from 1229 patients were analysed, with 261 patients (61 deaths) in the tocilizumab group and 969 patients (120 deaths) in the control group. In the adjusted marginal structural models, a significant interaction between receipt of tocilizumab and high C-reactive protein (CRP) levels was detected. Tocilizumab was associated with decreased risk of death (adjusted hazard ratio 0.34, 95% confidence interval 0.16e0.72, p 0.005) and ICU admission or death (adjusted hazard ratio 0.39, 95% confidence interval 0.19e0.80, p 0.011) among patients with baseline CRP >150 mg/L but not among those with CRP 150 mg/L. Exploratory subgroup analyses yielded point estimates that were consistent with these findings. Conclusions: In this large observational study, tocilizumab was associated with a lower risk of death or ICU admission or death in patients with higher CRP levels. While the results of ongoing clinical trials of tocilizumab in patients with COVID-19 will be important to establish its safety and efficacy, our findings have implications for the design of future clinical trials.
Appendix A. Supplementary data Supplementary data to this article can be found online at https://doi.org/10.1016/j.cmi.2020.09.021 .
References
Fewell, Hern An, Wolfe, Tilling, Choi et al., Controlling for time-dependent confounding using marginal structural models, Stata J Promot Commun Stat Stata
Grasselli, Zangrillo, Zanella, Antonelli, Cabrini et al., Baseline characteristics and outcomes of 1591 patients infected with SARS-CoV-2 admitted to ICUs of the Lombardy region, Italy, JAMA
Guaraldi, Meschiari, Cozzi-Lepri, Milic, Tonelli et al., Tocilizumab in patients with severe COVID-19: a retrospective cohort study, Lancet Rheumatol,
doi:10.1016/S2665-9913(20)30173-9
Hanley, Kezouh, Suissa, Problem of immortal time bias in cohort studies: example using statins for preventing progression of diabetes, BMJ
Hern An, Brumback, Robins, Marginal structural models to estimate the causal effect of zidovudine on the survival of HIV-positive men, Epidemiology
Hm Hospitales, COVID data save lives
Hoffmann, Kleine-Weber, Schroeder, Krüger, Herrler et al., SARS-CoV-2 cell entry depends on ACE2 and TMPRSS2 and is blocked by a clinically proven protease inhibitor, Cell
Horby, Lim, Emberson, Mafham, Bell et al., Dexamethasone in hospitalized patients with COVID-19dpreliminary report, N Engl J Med,
doi:10.1056/NEJMoa2021436
Jordan, Adab, Cheng, COVID-19: risk factors for severe disease and death, BMJ
Kalil, Treating COVID-19doff-label drug use, compassionate use, and randomized clinical trials during pandemics, JAMA
Kuba, Imai, Rao, Gao, Guo et al., A crucial role of angiotensin converting enzyme 2 (ACE2) in SARS coronaviruseinduced lung injury, Nat Med
Liang, Liang, Ou, Chen, Li, Development and validation of a clinical risk score to predict the occurrence of critical illness in hospitalized patients with COVID-19, JAMA Intern Med
Luo, Liu, Qiu, Liu, Liu et al., Tocilizumab treatment in COVID-19: a single center experience, J Med Virol
Navarro, Taroumian, Barroso, Duan, Furst, Tocilizumab in rheumatoid arthritis: a meta-analysis of efficacy and selected clinical conundrums, Semin Arthritis Rheum
Radbel, Narayanan, Bhatt, Use of tocilizumab for COVID-19einduced cytokine release syndrome: a cautionary case report, Chest
Ridker, From C-reactive protein to interleukin-6 to interleukin-1: moving upstream to identify novel targets for atheroprotection, Circ Res
Roche, Actemra/ RoActemra in hospitalised patients with severe COVID-19 associated pneumonia
Sciascia, Apr A F, Baffa, Baldovino, Boaro et al., Pilot prospective open, single-arm multicentre study on off-label use of tocilizumab in patients with severe COVID-19, Clin Exp Rheumatol
Toniati, Piva, Cattalini, Garrafa, Regola et al., Tocilizumab for the treatment of severe COVID-19 pneumonia with hyperinflammatory syndrome and acute respiratory failure: a single center study of 100 patients in Brescia, Italy, Autoimmun Rev
Williamson, Ravani, Marginal structural models in clinical research: when and how to use them?, Nephrol Dial Transplant
Xu, Han, Li, Sun, Fu, Effective treatment of severe COVID-19 patients with tocilizumab, Proc Natl Acad Sci U S A
Yokota, Miyamae, Imagawa, Iwata, Katakura et al., Therapeutic efficacy of humanized recombinant antieinterleukin-6 receptor antibody in children with systemic-onset juvenile idiopathic arthritis, Arthritis Rheum
Zhang, Wu, Li, Zhao, Wang, Cytokine release syndrome in severe COVID-19: interleukin-6 receptor antagonist tocilizumab may be the key to reduce mortality, Int J Antimicrob Agents
Zhou, Yu, Du, Fan, Liu et al., Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study, Lancet
Zuin, Rigatelli, Zuliani, Rigatelli, Mazza et al., Arterial hypertension and risk of death in patients with COVID-19 infection: systematic review and meta-analysis, J Infect
DOI record:
{
"DOI": "10.1016/j.cmi.2020.09.021",
"ISSN": [
"1198-743X"
],
"URL": "http://dx.doi.org/10.1016/j.cmi.2020.09.021",
"alternative-id": [
"S1198743X20305735"
],
"author": [
{
"affiliation": [],
"family": "Martínez-Sanz",
"given": "Javier",
"sequence": "first"
},
{
"affiliation": [],
"family": "Muriel",
"given": "Alfonso",
"sequence": "additional"
},
{
"affiliation": [],
"family": "Ron",
"given": "Raquel",
"sequence": "additional"
},
{
"affiliation": [],
"family": "Herrera",
"given": "Sabina",
"sequence": "additional"
},
{
"affiliation": [],
"family": "Pérez-Molina",
"given": "José A.",
"sequence": "additional"
},
{
"affiliation": [],
"family": "Moreno",
"given": "Santiago",
"sequence": "additional"
},
{
"affiliation": [],
"family": "Serrano-Villar",
"given": "Sergio",
"sequence": "additional"
}
],
"container-title": "Clinical Microbiology and Infection",
"container-title-short": "Clinical Microbiology and Infection",
"content-domain": {
"crossmark-restriction": false,
"domain": []
},
"created": {
"date-parts": [
[
2020,
9,
23
]
],
"date-time": "2020-09-23T14:10:59Z",
"timestamp": 1600870259000
},
"deposited": {
"date-parts": [
[
2022,
2,
1
]
],
"date-time": "2022-02-01T01:40:24Z",
"timestamp": 1643679624000
},
"funder": [
{
"DOI": "10.13039/100010877",
"doi-asserted-by": "publisher",
"id": [
{
"asserted-by": "publisher",
"id": "10.13039/100010877",
"id-type": "DOI"
}
],
"name": "ViiV Healthcare"
},
{
"DOI": "10.13039/100015756",
"doi-asserted-by": "publisher",
"id": [
{
"asserted-by": "publisher",
"id": "10.13039/100015756",
"id-type": "DOI"
}
],
"name": "Janssen-Cilag"
},
{
"DOI": "10.13039/100005564",
"doi-asserted-by": "publisher",
"id": [
{
"asserted-by": "publisher",
"id": "10.13039/100005564",
"id-type": "DOI"
}
],
"name": "Gilead Sciences"
},
{
"DOI": "10.13039/100007054",
"doi-asserted-by": "publisher",
"id": [
{
"asserted-by": "publisher",
"id": "10.13039/100007054",
"id-type": "DOI"
}
],
"name": "MSD"
},
{
"DOI": "10.13039/100007054",
"doi-asserted-by": "publisher",
"id": [
{
"asserted-by": "publisher",
"id": "10.13039/100007054",
"id-type": "DOI"
}
],
"name": "MSD"
},
{
"DOI": "10.13039/100005564",
"doi-asserted-by": "publisher",
"id": [
{
"asserted-by": "publisher",
"id": "10.13039/100005564",
"id-type": "DOI"
}
],
"name": "Gilead Sciences"
},
{
"DOI": "10.13039/100010877",
"doi-asserted-by": "publisher",
"id": [
{
"asserted-by": "publisher",
"id": "10.13039/100010877",
"id-type": "DOI"
}
],
"name": "ViiV Healthcare"
},
{
"DOI": "10.13039/100007054",
"doi-asserted-by": "publisher",
"id": [
{
"asserted-by": "publisher",
"id": "10.13039/100007054",
"id-type": "DOI"
}
],
"name": "MSD"
},
{
"DOI": "10.13039/100010877",
"doi-asserted-by": "publisher",
"id": [
{
"asserted-by": "publisher",
"id": "10.13039/100010877",
"id-type": "DOI"
}
],
"name": "ViiV Healthcare"
},
{
"name": "Janssen"
},
{
"DOI": "10.13039/100007054",
"doi-asserted-by": "publisher",
"id": [
{
"asserted-by": "publisher",
"id": "10.13039/100007054",
"id-type": "DOI"
}
],
"name": "MSD"
},
{
"DOI": "10.13039/100005564",
"doi-asserted-by": "publisher",
"id": [
{
"asserted-by": "publisher",
"id": "10.13039/100005564",
"id-type": "DOI"
}
],
"name": "Gilead"
}
],
"indexed": {
"date-parts": [
[
2025,
4,
19
]
],
"date-time": "2025-04-19T04:16:51Z",
"timestamp": 1745036211484,
"version": "3.37.3"
},
"is-referenced-by-count": 52,
"issue": "2",
"issued": {
"date-parts": [
[
2021,
2
]
]
},
"journal-issue": {
"issue": "2",
"published-print": {
"date-parts": [
[
2021,
2
]
]
}
},
"language": "en",
"license": [
{
"URL": "https://www.elsevier.com/tdm/userlicense/1.0/",
"content-version": "tdm",
"delay-in-days": 0,
"start": {
"date-parts": [
[
2021,
2,
1
]
],
"date-time": "2021-02-01T00:00:00Z",
"timestamp": 1612137600000
}
},
{
"URL": "http://www.elsevier.com/open-access/userlicense/1.0/",
"content-version": "vor",
"delay-in-days": 365,
"start": {
"date-parts": [
[
2022,
2,
1
]
],
"date-time": "2022-02-01T00:00:00Z",
"timestamp": 1643673600000
}
}
],
"link": [
{
"URL": "https://api.elsevier.com/content/article/PII:S1198743X20305735?httpAccept=text/xml",
"content-type": "text/xml",
"content-version": "vor",
"intended-application": "text-mining"
},
{
"URL": "https://api.elsevier.com/content/article/PII:S1198743X20305735?httpAccept=text/plain",
"content-type": "text/plain",
"content-version": "vor",
"intended-application": "text-mining"
}
],
"member": "78",
"original-title": [],
"page": "238-243",
"prefix": "10.1016",
"published": {
"date-parts": [
[
2021,
2
]
]
},
"published-print": {
"date-parts": [
[
2021,
2
]
]
},
"publisher": "Elsevier BV",
"reference": [
{
"article-title": "Dexamethasone in hospitalized patients with COVID-19—preliminary report",
"author": "Horby",
"journal-title": "N Engl J Med",
"key": "10.1016/j.cmi.2020.09.021_bib1",
"year": "2020"
},
{
"DOI": "10.1001/jama.2020.4742",
"article-title": "Treating COVID-19—off-label drug use, compassionate use, and randomized clinical trials during pandemics",
"author": "Kalil",
"doi-asserted-by": "crossref",
"first-page": "1897",
"journal-title": "JAMA",
"key": "10.1016/j.cmi.2020.09.021_bib2",
"volume": "323",
"year": "2020"
},
{
"DOI": "10.1016/j.semarthrit.2013.08.001",
"article-title": "Tocilizumab in rheumatoid arthritis: a meta-analysis of efficacy and selected clinical conundrums",
"author": "Navarro",
"doi-asserted-by": "crossref",
"first-page": "458",
"journal-title": "Semin Arthritis Rheum",
"key": "10.1016/j.cmi.2020.09.021_bib3",
"volume": "43",
"year": "2014"
},
{
"DOI": "10.1002/art.20944",
"article-title": "Therapeutic efficacy of humanized recombinant anti–interleukin-6 receptor antibody in children with systemic-onset juvenile idiopathic arthritis",
"author": "Yokota",
"doi-asserted-by": "crossref",
"first-page": "818",
"journal-title": "Arthritis Rheum",
"key": "10.1016/j.cmi.2020.09.021_bib4",
"volume": "52",
"year": "2005"
},
{
"DOI": "10.1161/CIRCRESAHA.115.306656",
"article-title": "From C-reactive protein to interleukin-6 to interleukin-1: moving upstream to identify novel targets for atheroprotection",
"author": "Ridker",
"doi-asserted-by": "crossref",
"first-page": "145",
"journal-title": "Circ Res",
"key": "10.1016/j.cmi.2020.09.021_bib5",
"volume": "118",
"year": "2016"
},
{
"DOI": "10.1016/S0140-6736(20)30566-3",
"article-title": "Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study",
"author": "Zhou",
"doi-asserted-by": "crossref",
"first-page": "1054",
"journal-title": "Lancet",
"key": "10.1016/j.cmi.2020.09.021_bib6",
"volume": "395",
"year": "2020"
},
{
"DOI": "10.1016/j.ijantimicag.2020.105954",
"article-title": "Cytokine release syndrome in severe COVID-19: interleukin-6 receptor antagonist tocilizumab may be the key to reduce mortality",
"author": "Zhang",
"doi-asserted-by": "crossref",
"first-page": "105954",
"journal-title": "Int J Antimicrob Agents",
"key": "10.1016/j.cmi.2020.09.021_bib7",
"volume": "55",
"year": "2020"
},
{
"DOI": "10.1016/S2665-9913(20)30173-9",
"article-title": "Tocilizumab in patients with severe COVID-19: a retrospective cohort study",
"author": "Guaraldi",
"doi-asserted-by": "crossref",
"journal-title": "Lancet Rheumatol",
"key": "10.1016/j.cmi.2020.09.021_bib8",
"year": "2020"
},
{
"article-title": "Pilot prospective open, single-arm multicentre study on off-label use of tocilizumab in patients with severe COVID-19",
"author": "Sciascia",
"first-page": "529",
"journal-title": "Clin Exp Rheumatol",
"key": "10.1016/j.cmi.2020.09.021_bib9",
"volume": "38",
"year": "2020"
},
{
"DOI": "10.1073/pnas.2005615117",
"article-title": "Effective treatment of severe COVID-19 patients with tocilizumab",
"author": "Xu",
"doi-asserted-by": "crossref",
"first-page": "10970",
"journal-title": "Proc Natl Acad Sci U S A",
"key": "10.1016/j.cmi.2020.09.021_bib10",
"volume": "117",
"year": "2020"
},
{
"author": "Radbel",
"key": "10.1016/j.cmi.2020.09.021_bib11",
"series-title": "Use of tocilizumab for COVID-19–induced cytokine release syndrome: a cautionary case report",
"year": "2020"
},
{
"DOI": "10.1002/jmv.25801",
"article-title": "Tocilizumab treatment in COVID-19: a single center experience",
"author": "Luo",
"doi-asserted-by": "crossref",
"journal-title": "J Med Virol",
"key": "10.1016/j.cmi.2020.09.021_bib12",
"year": "2020"
},
{
"DOI": "10.1016/j.autrev.2020.102568",
"article-title": "Tocilizumab for the treatment of severe COVID-19 pneumonia with hyperinflammatory syndrome and acute respiratory failure: a single center study of 100 patients in Brescia, Italy",
"author": "Toniati",
"doi-asserted-by": "crossref",
"first-page": "102568",
"journal-title": "Autoimmun Rev",
"key": "10.1016/j.cmi.2020.09.021_bib13",
"volume": "19",
"year": "2020"
},
{
"DOI": "10.1097/00001648-200009000-00012",
"article-title": "Marginal structural models to estimate the causal effect of zidovudine on the survival of HIV-positive men",
"author": "Hernán",
"doi-asserted-by": "crossref",
"first-page": "561",
"journal-title": "Epidemiology",
"key": "10.1016/j.cmi.2020.09.021_bib16",
"volume": "11",
"year": "2000"
},
{
"DOI": "10.1177/1536867X0400400403",
"article-title": "Controlling for time-dependent confounding using marginal structural models",
"author": "Fewell",
"doi-asserted-by": "crossref",
"first-page": "402",
"journal-title": "Stata J Promot Commun Stat Stata",
"key": "10.1016/j.cmi.2020.09.021_bib17",
"volume": "4",
"year": "2004"
},
{
"DOI": "10.1001/jamainternmed.2020.2033",
"article-title": "Development and validation of a clinical risk score to predict the occurrence of critical illness in hospitalized patients with COVID-19",
"author": "Liang",
"doi-asserted-by": "crossref",
"first-page": "1",
"journal-title": "JAMA Intern Med",
"key": "10.1016/j.cmi.2020.09.021_bib18",
"volume": "180",
"year": "2020"
},
{
"DOI": "10.1001/jama.2020.5394",
"article-title": "Baseline characteristics and outcomes of 1591 patients infected with SARS-CoV-2 admitted to ICUs of the Lombardy region, Italy",
"author": "Grasselli",
"doi-asserted-by": "crossref",
"first-page": "1574",
"journal-title": "JAMA",
"key": "10.1016/j.cmi.2020.09.021_bib19",
"volume": "323",
"year": "2020"
},
{
"DOI": "10.1016/j.cell.2020.02.052",
"article-title": "SARS-CoV-2 cell entry depends on ACE2 and TMPRSS2 and is blocked by a clinically proven protease inhibitor",
"author": "Hoffmann",
"doi-asserted-by": "crossref",
"first-page": "271",
"journal-title": "Cell",
"key": "10.1016/j.cmi.2020.09.021_bib20",
"volume": "181",
"year": "2020"
},
{
"DOI": "10.1038/nm1267",
"article-title": "A crucial role of angiotensin converting enzyme 2 (ACE2) in SARS coronavirus–induced lung injury",
"author": "Kuba",
"doi-asserted-by": "crossref",
"first-page": "875",
"journal-title": "Nat Med",
"key": "10.1016/j.cmi.2020.09.021_bib21",
"volume": "11",
"year": "2005"
},
{
"author": "Roche",
"key": "10.1016/j.cmi.2020.09.021_bib23"
},
{
"DOI": "10.1136/bmj.m1198",
"article-title": "COVID-19: risk factors for severe disease and death",
"author": "Jordan",
"doi-asserted-by": "crossref",
"first-page": "m1198",
"journal-title": "BMJ",
"key": "10.1016/j.cmi.2020.09.021_bib24",
"volume": "368",
"year": "2020"
},
{
"article-title": "Arterial hypertension and risk of death in patients with COVID-19 infection: systematic review and meta-analysis",
"author": "Zuin",
"first-page": "e84",
"journal-title": "J Infect",
"key": "10.1016/j.cmi.2020.09.021_bib25",
"volume": "81",
"year": "2020"
},
{
"DOI": "10.1136/bmj.b5087",
"article-title": "Problem of immortal time bias in cohort studies: example using statins for preventing progression of diabetes",
"author": "Lévesque",
"doi-asserted-by": "crossref",
"first-page": "907",
"journal-title": "BMJ",
"key": "10.1016/j.cmi.2020.09.021_bib26",
"volume": "340",
"year": "2010"
},
{
"DOI": "10.1093/ndt/gfw341",
"article-title": "Marginal structural models in clinical research: when and how to use them?",
"author": "Williamson",
"doi-asserted-by": "crossref",
"first-page": "ii84",
"journal-title": "Nephrol Dial Transplant",
"key": "10.1016/j.cmi.2020.09.021_bib27",
"volume": "32",
"year": "2017"
}
],
"reference-count": 24,
"references-count": 24,
"relation": {
"has-preprint": [
{
"asserted-by": "object",
"id": "10.1101/2020.06.08.20125245",
"id-type": "doi"
}
]
},
"resource": {
"primary": {
"URL": "https://linkinghub.elsevier.com/retrieve/pii/S1198743X20305735"
}
},
"score": 1,
"short-title": [],
"source": "Crossref",
"subject": [],
"subtitle": [],
"title": "Effects of tocilizumab on mortality in hospitalized patients with COVID-19: a multicentre cohort study",
"type": "journal-article",
"volume": "27"
}