Lean Toward Tocilizumab as an Add-On to Steroids for COVID-19

You'll need to apply the latest evidence for IL-6 inhibitors and Janus kinase (JAK) inhibitors to treat hospitalized COVID-19 patients.

Continue to use a steroid for COVID-19 patients on supplemental oxygen. But compare add-on options...and know when to use them.

A large meta-analysis suggests IL-6 inhibitors, mainly tocilizumab (Actemra), decrease mortality in COVID-19 patients receiving supplemental oxygen...and also taking a steroid.

And now tocilizumab is authorized to treat hospitalized COVID-19 patients meeting these criteria.

There are also new data for adding a JAK inhibitor...baricitinib (Olumiant) or tofacitinib (Xeljanz)...to steroids in patients on supplemental oxygen.

Explain that some of this new JAK inhibitor evidence isn't peer reviewed yet...and it's too soon to confirm a clear mortality benefit.

But it's triggered a change in baricitinib's authorization, allowing it to be used ALONE...instead of only with remdesivir...in patients on any oxygen support, including mechanical ventilation.

This will spark interest, since baricitinib is oral and costs up to $2,200/course...versus up to $4,600 for a single tocilizumab IV dose.

But lean toward tocilizumab if adding a med to steroids.

Point out that tocilizumab has more overall mortality evidence.

Continue to focus on patients who are most likely to benefit.

Consider adding tocilizumab to a steroid in a patient who develops increased oxygen needs, such as high-flow nasal cannula or BiPAP...and has an elevated inflammatory marker (C-reactive protein, etc).

Think about further limiting to a patient early in their hospitalization...timing likely matters. In studies showing benefit, most patients start tocilizumab within a few days of admission.

And generally stick with a single tocilizumab dose. So far, there isn't good evidence that a second dose improves outcomes for COVID-19.

Avoid tocilizumab in some cases...such as patients with another serious infection (bacteremia, etc).

Don't add JAK inhibitors to tocilizumab...due to lack of data.

Get updates about the latest therapeutic options in our chart, Treatments of Interest for COVID-19.

Key References

  • JAMA Published online Jul 6, 2021; doi:10.1001/jama.2021.11330
  • N Engl J Med 2021;385(5):406-15
  • www.covid19treatmentguidelines.nih.gov/about-the-guidelines/whats-new/ (7-30-21)
  • medRxiv Published online May 30, 2021; doi:10.1101/2021.04.30.21255934
  • Medication pricing by Elsevier, accessed Jul 2021
Hospital Pharmacist's Letter. August 2021, No. 370820

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