Tocilizumab for treatment of severe COVID morbidly obese patient with comorbidities

Abstract

COVID-19, caused by the novel severe acute respiratory coronavirus 2, emerged in Wuhan, China, in 2019 and has resulted in the current pandemic. The disease continues to pose a major therapeutic challenge. Patient mortality is ultimately caused by acute respiratory distress syndrome (ARDS). Because interleukin-6 (IL-6) is known to play a key role in inflammation, IL-6 receptor inhibitors such as tocilizumab may potentially treat COVID-19 by attenuating cytokine release. Tocilizumab is a recombinant humanized monoclonal antibody that serves as an IL-6 receptor inhibitor. Tocilizumab is beneficial for the treatment of inflammatory and autoimmune conditions and rheumatoid arthritis, giant cell arteritis, and systemic juvenile idiopathic arthritis. It is also under used in the treatment of severely ill patients with COVID-19. Patients with moderate-to-severe disease with progressively increasing oxygen requirements, with inadequate response to corticosteroids, and with raised levels of inflammatory markers (MoHFW, June 2020). It is used in dose of 8 mg/kg in 100 ml NS over 60 minutes (maximum dose 800 mg/infusion). It can be repeated once after 12 − 24 hours if needed. Careful monitoring for secondary infection and neutropenia should be done. It is contraindicated in people with HIV, active infections, tuberculosis, active hepatitis, ANC is <2000/mm3 and platelet count <100,000/mm3. We present the first case of our institution in which we administered tocilizumab, a 57-year-old female with moderate-to-severe COVID-19, on the verge of meeting intubation requirements, who needed progressive oxygen support for respiratory distress. The patient was treated with tocilizumab to prevent the cytokine storm. We chose early administration of an IL-6 inhibitor because of the gradually increasing levels of inflammatory markers and her deteriorating respiratory status. The treatment was well-tolerated in conjunction with standard drug therapies for COVID-19 (hydroxychloroquine, tazar, and zinc). The patient subsequently experienced marked improvements in his respiratory symptoms and overall clinical status over the following days. We believe that tocilizumab played a substantial role in her ability to overcome clinical decline, particularly the need for mechanical ventilation. Ultimately, the patient was shifted from the intensive care unit (ICU) and discharged within few days. We highlight the potential of IL-6 inhibitors to prevent the progression of respiratory disease to a point requiring ventilator support. This case underscores the potential importance of early serial measurements of IL-6 and cytokine storm-associated inflammatory markers, such as serum ferritin, D-dimer, and C-reactive protein, in guiding clinical decision-making in the management of patients with suspected COVID-19. The early identification of inflammatory markers should be implemented in the treatment of COVID-19 in order to screen for a primary contributor to mortality − the cytokine storm. This screening, when followed by aggressive early treatment for cytokine storm, may have optimal therapeutic benefits and obviate the need for mechanical ventilation, thereby decreasing mortality. In addition, we review current evidence regarding cytokine release syndrome in COVID-19 and the use of IL-6 receptor inhibition as a therapeutic strategy and examine other reported cases in the literature describing IL-6 antagonist treatment for patients with COVID-19.