Good News: Tocilizumab (Actemra) & Sarilumab (Kevzara) for COVID 19
Tocilizumab (Actemra) & Sarilumab (Kevzara) are IL-6 inhibitors studied for COVID 19. Good news came from a preprint of a trial run by REMAP-CAP, a multihospital group of researchers investigating multiple treatment options for COVID 19 simultaneously. Patients in the U.K.’s intensive care units with COVID 19 might be eligible to receive tocilizumab, a medication used to treat rheumatoid arthritis, other inflammatory diseases, and cytokine storm.
The potential benefits of this drug include saving lives and reducing hospitalizations by seven to 10 days. U.K. researchers reported in a recent study that is yet to be peer-reviewed that patients receiving standard care have a mortality rate of 36%. In comparison, those receiving tocilizumab or sarilumab have a mortality rate of 27%, a reduction in relative risk of mortality of 24%.
Tocilizumab and Sarilumab
The REMAP-CAP study, which has not been peer-reviewed but shows good results led to the recommendation to make tocilizumab available for ICU patients. The study is a randomized controlled study that enrolled over 800 patients. Patients received either tocilizumab, sarilumab, or standard care. The study’s Eligibility criteria included being admitted to the ICU with severe pneumonia and requiring respiratory support with a positive diagnosis of COVID 19.
Contraindications to receiving tocilizumab include an allergy to the medication, a coexisting infection more than 24 hours after being admitted to the ICU, elevated liver enzymes, low platelet counts, low white blood cell counts, or being immunocompromised. Patients could also receive dexamethasone or Remdesivir as indicated.
One of the main issues with COVID 19 is the severe respiratory distress associated with the disease. Severe respiratory distress has been linked to a cytokine storm. One molecule involved that stimulates the hyperinflammatory state or cytokine storm is interleukin-6 ( IL-6). The level of IL-6 has been tracked as a marker for the severity of COVID 19 disease.
Tocilizumab is a recombinant humanized monoclonal antibody approved to treat cytokine storm by targeting IL-6. Isolated observational studies early in 2020 showed that tocilizumab decreased other inflammation markers, such as C-reactive protein. Tocilizumab targets IL-6, whether membrane-bound or free in the blood. Side effects include upper respiratory infections, sore throats, headache, elevated blood pressure, and abnormal liver function.
There are many drug-drug interactions with tocilizumab. Tocilizumab stays in the blood for about 14 days. During this time, patients are at increased risk of having undiagnosed infection progress and, therefore, are warned to report any infection’s first signs or symptoms. The patient will not exhibit fever and signs of inflammation while on this medication. This means that a hidden infection can advance without notice. The results of the study released by the REMAP-CAP investigators were more optimistic than previous studies’ results.
Dr. Mike Hansen, MD
Internal Medicine | Pulmonary Disease | Critical Care Medicine