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COVID-19 - Inpatient
Tocilizumab

Tocilizumab

Background

Tocilizumab for treatment of COVID-19 requires approval from Critical Care or Infectious Diseases service

  • Tocilizumab was approved via Emergency Use Authorization (EUA) from the FDA for treatment of COVID-19
  • Randomized-controlled trials show mixed outcomes, with a more recent study (REMAP-CAP) showing a modest mortality benefit among patients given tocilizumab within 24 hours of decompensation to ICU-level status
  • Another study (RECOVERY) found a similar mortality benefit when given to severely ill patients with elevated CRP
  • Per the EUA, must provide the Fact Sheet for Patients, Parents, and Caregivers and communicate the information contained within the document prior to administration, or as soon as feasible if providing information would delay administration and endanger the patient
  • There is no written consent required
  • Age ≥ 18 years
  • Hospitalized with confirmed COVID-19
  • Severe pneumonia requiring respiratory support such as high-flow nasal oxygen (at least 40 LPM/60% FiO₂), non-invasive mechanical ventilation, or invasive mechanical ventilation
  • Respiratory function is acutely deteriorating leading to increased respiratory support in the last 24 hours
  • Mechanically ventilated for greater ≥ 12hrs
  • Strongly suspected or known bacterial or fungal infection
  • Significant current gastrointestinal disease (i.e. perforation, active diverticulitis, IBD, colitis)
  • AST/ALT > 5 x ULN (caution use with AST / ALT > 1.5 x ULN)
  • Neutropenia: ANC < 1,000 cell/mm³
  • Thrombocytopenia: platelets < 50,000/mm³
  • Long-term anti-rejection or immunomodulatory medications
    • CAUTION using with concomitant high dose corticosteroids (e.g. dexamethasone ≥ 10 mg daily) as risk is unknown (see More Information)
  • Pregnancy
  • Known hypersensitivity to tocilizumab or excipients
  • > 14 days of hospital days with symptoms of an acute illness due to COVID-19 infection

Dosing

Tocilizumab (Actemra®) 8 mg/kg, given once only

  • <61 kg: 400 mg IV x 1
  • 61-85 kg: 600 mg IV x 1
  • >85 kg: 800 mg IV x 1

Treatment Considerations

  • Gastrointestinal perforation
  • Anemia
  • Hepatitis
  • Infusion reaction

Availability of Tocilizumab will determine ability to provide to our patients

More Information

  • REMAP-CAP study used concomitant corticosteroids in >80% of patients and details of drug, dose, duration are unknown
  • Majority of patients enrolled after announcement of dexamethasone result from RECOVERY trial and due to this, patients may have received corticosteroids that were equivalent to dexamethasone ~6 mg every 24 hours