Mixed results for tocilizumab in COVID-19

Three studies - two randomised controlled trials and one retrospective cohort study - have found no clear mortality benefit from the monoclonal antibody.

Welcome to The Medical Republic’s COVID Catch-Up.

It’s the day’s COVID-19 news in one convenient post. Email bianca@biancanogrady.com with any tips, comments or feedback.

21 October

• Three trials examine tocilizumab for COVID-19 but find no clear benefits.
• Mortality in patients hospitalised with COVID-19 five times higher than in those hospitalised with influenza.
• Latest confirmed COVID-19 infection numbers from around Australia.

• With growing evidence of the role that hyperinflammatory response plays in worse outcomes from COVID-19, there has been interest in drugs that could attenuate that response.
  However three studies, all published today in JAMA Internal Medicine, have found mixed results for the monoclonal antibody tocilizumab, which targets the pro-inflammatory cytokine IL-6 and is already used to treat inflammatory arthritis, giant cell arteritis, and cytokine release syndrome.
  The first study – an open-label randomised controlled trial in 130 people with moderate to severe COVID-19 and pneumonia needing oxygen but not mechanical ventilation – found no difference in mortality at 28 days between those treated with tocilizumab or usual care. There was some effect in reducing the need for mechanical ventilation.
  The second study – also a randomised controlled trial, in 123 patients with COVID-19 pneumonia and acute respiratory failure – found the same rate of clinical worsening between the treatment and control groups, and the trial was stopped early because of ‘clinical futility’.
  But the third study – a retrospective cohort study of 3924 admitted to intensive care with COVID-19 – found a 29% lower risk of death among those treated with tocilizumab. However the authors acknowledged the potential for uncontrolled confounding, and indeed the patients treated with tocilizumab were also more likely to receive corticosteroids, were generally younger and with fewer comorbidities than those who weren’t treated with the drug.
  An accompanying editorial commenting on the three studies said that for now, the evidence from the randomised trials didn’t support routine use of tocilizumab for COVID-19, but they stressed that longer-term outcomes “may tell a different story”.
• The risk of death among patients hospitalised with COVID-19 is five times higher than for those hospitalised with influenza, a new study has found.
  A report in Morbidity and Mortality Weekly Report presents retrospective analysis of electronic health record data for 3,948 patients hospitalised with COVID-19 during March-May 2020 and 5,453 hospitalized patients with influenza between October 2018 and February 2020.
  Twenty-one percent of patients hospitalised with COVID-19 died in hospital, compared to nearly 4% of those hospitalised with influenza, representing a five-fold higher rate of in-hospital mortality with COVID-19. Those with COVID-19 also had a nearly 19-times higher risk of developing acute respiratory distress syndrome, more than double the risk of myocarditis, 2.8-times higher risk of deep vein thrombosis, 2.1-times higher risk of pulmonary embolism, and more than three-fold greater risk of acute hepatitis or liver failure.
  Twice as many patients with COVID-19 were admitted to intensive care than those with influenza, and they stayed in hospital for three times as long.
  The study also found that Black and Hispanic patients were at significantly higher risk of respiratory, neurological and renal complications, and sepsis, compared to White patients, even after adjusting for age and other medical conditions.
  While the patients with COVID-19 were slightly older on average than those with influenza, they had a lower prevalence of underlying medical conditions.
• Western Australia’s tally of new infections has shot up by 24 overnight, all of which are crew from the AL Messilah livestock carrier, which is currently docked at Fremantle. The infected crew members and 12 close contacts have all been brought to shore and are in hotel quarantine.
  Meanwhile, Victoria may have its first case of COVID-19 reinfection in a man who first tested positive in June, and has just tested positive again. However there’s no genetic data yet available to confirm whether this is a different strain of virus from his first infection.
  Here are the latest confirmed COVID-19 infection numbers from around Australia, to 9pm Tuesday:
  National – 27,430, with 905 deaths
  ACT – 113 (0)
  NSW – 4347 (5)
  NT – 33 (0)
  QLD – 1164 (0)
  SA – 484 (0)
  TAS – 230 (0)
  VIC – 20,321 (1)
  WA – 738 (24)