Guide Use of Tocilizumab for COVID-19 Based on New Data

You'll hear renewed interest in tocilizumab for COVID-19...based on new data suggesting it reduces mortality in some patients.

IL-6 inhibitors, such as tocilizumab (Actemra), sparked early interest in COVID-19 to block cytokines and reduce inflammation.

But trials haven't consistently demonstrated a benefit.

Now early data from the RECOVERY trial suggest that adding tocilizumab to standard care reduces mortality in severely ill COVID-19 patients...those requiring supplemental oxygen or respiratory support.

And the REMAP-CAP trial also suggests tocilizumab reduces mortality...in ICU patients needing respiratory or CV support.

Help tease out details that may affect risk-benefit balance.

Emphasize that the majority of patients in these studies also received a systemic steroid to treat COVID-19...and got just one dose of tocilizumab, even though protocols allowed up to two.

And timing may matter. Most patients in these trials started tocilizumab early...within a few days of hospital admission.

Point out limitations. Both studies are open-label...RECOVERY isn't peer reviewed yet...and tocilizumab can cost up to $4,600/dose.

Follow a cautious approach with tocilizumab...pending more data.

For now, consider saving it for COVID-19 patients receiving a steroid...with inflammation (elevated C-reactive protein, etc)...and worsening status, such as progression to high-flow oxygen or mechanical ventilation.

Also think about further reserving it for those who are earlier in their hospitalization.

And generally limit tocilizumab to a single dose when treating COVID-19...so far, it's not clear that a second dose adds benefit.

Avoid starting tocilizumab in some cases based on risks.

For example, don't add tocilizumab to COVID-19 patients with another serious infection, such as bacteremia. Some data suggest that even a one-time tocilizumab dose may increase infection risk.

Use our chart, Treatments of Interest for COVID-19, for summaries about corticosteroids, convalescent plasma, and more.

Key References

  • www.idsociety.org/practice-guideline/covid-19-guideline-treatment-and-management/ (3-2-21)
  • www.covid19treatmentguidelines.nih.gov/ (3-2-21)
  • medRxiv Published online Feb 11, 2021; doi:10.1101/2021.02.11.21249258
  • N Engl J Med Published online Feb 25, 2021; doi:10.1056/NEJMoa2100433
  • N Engl J Med Published online Feb 25, 2021; doi:10.1056/NEJMe2103108
  • Medication pricing by Elsevier, accessed Feb 2021
Hospital Pharmacist's Letter. March 2021, No. 370319



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