Survival and outcomes of tocilizumab use in severe and critically ill Covid-19 patients not responding to steroids

BackgroundMortality and morbidity are highest in severe and critically ill patients with COVID -19 pneumonia. We used interleukin-6 (IL-6) receptor inhibitor, tocilizumab in the above patients who failed to show any clinical improvement after initial treatment with steroids. MethodsThis is a retrospective observational study conducted at a tertiary care hospital in India. Severe and critical COVID-19 patients, who got admitted to intensive care unit and subsequently received tocilizumab were included. Patients who worsened clinically or had no change in oxygen requirement even after 24hrs of receiving intravenous methylprednisolone at a dose of 1-2mg/kg/day received a maximum total dose of 800mg of intravenous tocilizumab. The day 28 all-cause mortality and progression to mechanical ventilation were the primary outcome measures. Clinical improvement and oxygen requirements after tocilizumab administration along with trends in inflammatory markers and secondary infections rates were also noted. ResultsA total of 51 patients who did not show clinical improvement even after 24 hours of intravenous steroids had received tocilizumab. In these patients, there was a significant decrease in oxygen requirement and clinical progression by day 7 of tocilizumab administration. Baseline median values of CRP (114.2 mg/L), IL-6 (69.8 pg/ml) and neutrophil-lymphocyte ratio (12.4) in these patients were elevated. Out of these, only CRP showed a significant decrease after the drug administration. 13 (26.5%) of the 49 patients on non-invasive oxygen support progressed to mechanical ventilation and the day 28 all-cause mortality was 10/51(19.6%). 10(19.6%) of the 51 patients had life threatening infections. ConclusionEarly and timely administration of tocilizumab is a viable option in selected severe and critical COVID-19 patients who do not respond to initial steroids. When given along with steroids, a high suspicion of secondary infections should be kept.