Impact of tocilizumab administration on mortality in severe COVID-19
Andrew Tsai, Oumou Diawara, Ronald G Nahass, Luigi Brunetti
Scientific Reports, doi:10.1038/s41598-020-76187-y
The novel coronavirus disease 2019 (COVID-19) worldwide pandemic has placed a significant burden on hospitals and healthcare providers. The immune response to this disease is thought to lead to an aberrant inflammatory response or cytokine storm, which contributes to the severity of illness. There is an urgent need to confirm whether the use of tocilizumab provides a benefit in individuals with COVID-19. A single-center propensity-score matched cohort study, including all consecutive COVID-19 patients, admitted to the medical center who were either discharged from the medical center or expired between March 1, 2020, and May 5, 2020, was performed. Patients were stratified according to the receipt of tocilizumab for cytokine storm and matched to controls using propensity scores. The primary outcome was in-hospital mortality. A total of 274 patients meeting inclusion and exclusion criteria were identified and 132 patients were included in the matched dataset (tocilizumab = 66; no tocilizumab = 66). Approximately 73% of the patients were male. Hypertension (55%), diabetes mellitus (31%), and chronic pulmonary disease (15%) were the most common comorbidities present. There were 18 deaths (27.3%) in the tocilizumab group and 18 deaths (27.3%) in the no tocilizumab group (odds ratio, 1.0; 95% confidence interval, 0.465 -2.151; p = 1.00). Advanced age, history of myocardial infarction, dementia, chronic pulmonary disease, heart failure, and malignancy were significantly more common in patients who died. The current analysis does not support the use of tocilizumab for the management of cytokine storm in patients with COVID-19. Use of this therapeutic agent should be limited to the context of a clinical trial until more evidence is available. With the rapid progression of the coronavirus diseases 2019 (COVID-19) pandemic, healthcare providers around the globe have been searching for potential treatment options to combat this disease, which can induce a rapidly progressive and difficult to treat pneumonia that leads to acute respiratory distress syndrome (ARDS). The disease is caused by a novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV 2). Other highly pathogenic coronaviruses, such as severe acute respiratory syndrome CoV (SARS-CoV) and Middle East respiratory syndrome CoV (MERS-CoV), similarly cause severe pneumonia and often lead to ARDS. Pulmonary inflammation and excessive lung damage have been attributed to a cytokine storm, or aberrant systemic release of cytokines including tumor necrosis factor α (TNF-α), interleukin (IL)-1β, IL-2, IL-6, interferon (IFN)-α, IFN-β, IFN-γ, and monocyte chemoattractant protein-1 (MCP-1) 1,2 . The release of these cytokines can be triggered by the interaction between tumor and effector cells. However, it can also manifest from host immune cells. Clinically, patients with cytokine release syndrome (CRS) present with high-grade fevers, hypotension, and hypoxia 3 . As a result, therapies that..
Author contributions All authors take responsibility for the integrity of the data and the data analysis. A.T., O.D., R.N., and L.B. were responsible for the study concept and design. A.T., O.D., and L.B. were responsible for data acquisition and adjudication. A.T. and L.B. drafted the initial manuscript. R.N. and L.B. provided critical review and expert context. L.B. performed the statistical analysis. All authors reviewed and provided input at each step.
Competing interests The authors declare no competing interests.
Additional information Correspondence and requests for materials should be addressed to L.B. Reprints and permissions information is available at www.nature.com/reprints . Publisher's note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
Bastida, Fixed dosing of intravenous tocilizumab in rheumatoid arthritis. Results from a population pharmacokinetic analysis, Br. J. Clin. Pharmacol
Channappanavar, Perlman, Pathogenic human coronavirus infections: Causes and consequences of cytokine storm and immunopathology, Semin. Immunopathol
Coomes, Haghbayan, Interleukin-6 in COVID-19: A systematic review and meta-analysis, medRxiv
Gritti, Raimondi, Ripamonti, Riva, Landi et al., Use of siltuximab in patients with COVID-19 pneumonia requiring ventilatory support, medRxiv
Guan, Liang, Zhao, Liang, Chen et al., Comorbidity and its impact on 1590 patients with Covid-19 in China: A nationwide analysis, Eur. Respir. J
Herold, Elevated levels of IL-6 and CRP predict the need for mechanical ventilation in COVID-19, J. Allergy Clin. Immunol,
doi:10.1016/j.jaci.2020.05.008
Kernan, Carcillo, Hyperferritinemia and inflammation, Int. Immunol
Lee, Current concepts in the diagnosis and management of cytokine release syndrome, Blood
Mehta, COVID-19: Consider cytokine storm syndromes and immunosuppression, Lancet
Murthy, Iqbal, Chavez, Kharfan-Dabaja, Cytokine release syndrome: Current perspectives, Immunotargets Ther
Nikolich-Zugich, Knox, Rios, Natt, Bhattacharya et al., SARS-CoV-2 and COVID-19 in older adults: what we may expect regarding pathogenesis, immune responses, and outcomes
Parodi, O'donnell, Roche rheumatoid arthritis drug fails to help COVID-19 patients in Italian study
Perrone, Piccirillo, Ascierto, Salvarani, Parrella et al., Tocilizumab for patients with COVID-19 pneumonia. The TOCIVID-19 phase 2 trial, medRxiv
Richardson, Hirsch, Narasimhan, Crawford, Mcginn et al., Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York city area, JAMA
Roumier, Paule, Groh, Vallee, Ackermann, Interleukin-6 blockade for severe COVID-19, medRxiv
Ruan, Yang, Wang, Jiang, Song, Clinical predictors of mortality due to COVID-19 based on an analysis of data of 150 patients from Wuhan, China, Intensive Care Med
Rubin, Harrington, Hogan, Gatsonis, Baden et al., The urgency of care during the Covid-19 pandemic-Learning as we go, N. Engl. J. Med
Schmitz, Kurrer, Bachmann, Kopf, Interleukin-1 is responsible for acute lung immunopathology but increases survival of respiratory influenza virus infection, J. Virol
Tate, Brooks, Reading, The role of neutrophils in the upper and lower respiratory tract during influenza virus infection of mice, Respir. Res
Von Elm, Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: Guidelines for reporting observational studies, BMJ
Xu, Han, Li, Sun, Wang et al., Effective treatment of severe COVID-19 patients with tocilizumab, Proc. Natl. Acad. Sci
Ye, Wang, Mao, The pathogenesis and treatment of the 'Cytokine Storm' in COVID-19, J. Infect
Yi, Lagniton, Ye, Li, Xu, COVID-19: what has been learned and to be learned about the novel coronavirus disease, Int. J. Biol. Sci
Zhang, Wu, Li, Zhao, Wang, The cytokine release syndrome (CRS) of severe COVID-19 and interleukin-6 receptor (IL-6R) antagonist tocilizumab may be the key to reduce the mortality, Int. J. Antimicrob. Agents
Zhou, Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: A retrospective cohort study, Lancet
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"abstract": "<jats:title>Abstract</jats:title><jats:p>The novel coronavirus disease 2019 (COVID-19) worldwide pandemic has placed a significant burden on hospitals and healthcare providers. The immune response to this disease is thought to lead to an aberrant inflammatory response or cytokine storm, which contributes to the severity of illness. There is an urgent need to confirm whether the use of tocilizumab provides a benefit in individuals with COVID-19. A single-center propensity-score matched cohort study, including all consecutive COVID-19 patients, admitted to the medical center who were either discharged from the medical center or expired between March 1, 2020, and May 5, 2020, was performed. Patients were stratified according to the receipt of tocilizumab for cytokine storm and matched to controls using propensity scores. The primary outcome was in-hospital mortality. A total of 274 patients meeting inclusion and exclusion criteria were identified and 132 patients were included in the matched dataset (tocilizumab = 66; no tocilizumab = 66). Approximately 73% of the patients were male. Hypertension (55%), diabetes mellitus (31%), and chronic pulmonary disease (15%) were the most common comorbidities present. There were 18 deaths (27.3%) in the tocilizumab group and 18 deaths (27.3%) in the no tocilizumab group (odds ratio, 1.0; 95% confidence interval, 0.465 – 2.151; p = 1.00). Advanced age, history of myocardial infarction, dementia, chronic pulmonary disease, heart failure, and malignancy were significantly more common in patients who died. The current analysis does not support the use of tocilizumab for the management of cytokine storm in patients with COVID-19. Use of this therapeutic agent should be limited to the context of a clinical trial until more evidence is available.</jats:p>",
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