1
|
Aydeniz E, van Bussel BCT, de Jongh S, Schellens J, Heines SJH, van Kuijk SMJ, Tas J, van Rosmalen F, van der Horst ICC, Bergmans DCJJ. Serial electrical impedance tomography course in different treatment groups; The MaastrICCht cohort. J Crit Care 2024; 80:154506. [PMID: 38113747 DOI: 10.1016/j.jcrc.2023.154506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 10/16/2023] [Accepted: 12/01/2023] [Indexed: 12/21/2023]
Abstract
PURPOSE To describe the effect of dexamethasone and tocilizumab on regional lung mechanics over admission in all mechanically ventilated COVID-19 patients. MATERIALS AND METHODS Dynamic compliance, alveolar overdistension and collapse were serially determined using electric impedance tomography (EIT). Patients were categorized into three groups; no anti-inflammatory therapy, dexamethasone therapy, dexamethasone + tocilizumab therapy. The EIT variables were (I) visualized using polynomial regression, (II) evaluated throughout admission using linear mixed-effects models, and (III) average respiratory variables were compared. RESULTS Visual inspection of EIT variables showed a pattern of decreasing dynamic compliance. Overall, optimal set PEEP was lower in the dexamethasone group (-1.4 cmH2O, -2.6; -0.2). Clinically applied PEEP was lower in the dexamethasone and dexamethasone + tocilizumab group (-1.5 cmH2O, -2.6; -0.2; -2.2 cmH2O, -5.1; 0.6). Dynamic compliance, alveolar overdistension, and alveolar collapse at optimal set PEEP did not significantly differ between the three groups. CONCLUSION Optimal and clinically applied PEEP were lower in the dexamethasone and dexamethasone + tocilizumab groups. The results suggest that the potential beneficial effects of these therapies do not affect lung mechanics favorably. However, this study cannot fully rule out any beneficial effect of anti-inflammatory treatment on pulmonary function due to its observational nature.
Collapse
Affiliation(s)
- Eda Aydeniz
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands; Department of Intensive Care Medicine, Laurentius Hospital Roermond, Roermond, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands.
| | - Bas C T van Bussel
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands; Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
| | - Sebastiaan de Jongh
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Joep Schellens
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Serge J H Heines
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Jeanette Tas
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands; School for Mental Health and Neuroscience (MHeNS), Maastricht University, Maastricht, the Netherlands
| | - Frank van Rosmalen
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands
| | - Dennis C J J Bergmans
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands; School of Nutrition and Translational Research in Metabolism (NUTRIM), Maastricht University, Maastricht, the Netherlands
| |
Collapse
|
2
|
Li X, Liu H, Gao L, Sherchan SP, Zhou T, Khan SJ, van Loosdrecht MCM, Wang Q. Wastewater-based epidemiology predicts COVID-19-induced weekly new hospital admissions in over 150 USA counties. Nat Commun 2023; 14:4548. [PMID: 37507407 PMCID: PMC10382499 DOI: 10.1038/s41467-023-40305-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 07/19/2023] [Indexed: 07/30/2023] Open
Abstract
Although the coronavirus disease (COVID-19) emergency status is easing, the COVID-19 pandemic continues to affect healthcare systems globally. It is crucial to have a reliable and population-wide prediction tool for estimating COVID-19-induced hospital admissions. We evaluated the feasibility of using wastewater-based epidemiology (WBE) to predict COVID-19-induced weekly new hospitalizations in 159 counties across 45 states in the United States of America (USA), covering a population of nearly 100 million. Using county-level weekly wastewater surveillance data (over 20 months), WBE-based models were established through the random forest algorithm. WBE-based models accurately predicted the county-level weekly new admissions, allowing a preparation window of 1-4 weeks. In real applications, periodically updated WBE-based models showed good accuracy and transferability, with mean absolute error within 4-6 patients/100k population for upcoming weekly new hospitalization numbers. Our study demonstrated the potential of using WBE as an effective method to provide early warnings for healthcare systems.
Collapse
Affiliation(s)
- Xuan Li
- Centre for Technology in Water and Wastewater, School of Civil and Environmental Engineering, University of Technology Sydney, Ultimo, NSW, 2007, Australia
| | - Huan Liu
- Centre for Technology in Water and Wastewater, School of Civil and Environmental Engineering, University of Technology Sydney, Ultimo, NSW, 2007, Australia
| | - Li Gao
- South East Water, 101 Wells Street, Frankston, VIC, 3199, Australia
| | - Samendra P Sherchan
- Department of Biology, Morgan State University, Baltimore, MD, USA
- Department of Environmental Health Sciences, School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA
| | - Ting Zhou
- Centre for Technology in Water and Wastewater, School of Civil and Environmental Engineering, University of Technology Sydney, Ultimo, NSW, 2007, Australia
| | - Stuart J Khan
- Water Research Centre, School of Civil and Environmental Engineering, University of New South Wales, Sydney, NSW, 2052, Australia
| | - Mark C M van Loosdrecht
- Department of Biotechnology, Delft University of Technology, Julianalaan 67, 2628 BC, Delft, the Netherlands
| | - Qilin Wang
- Centre for Technology in Water and Wastewater, School of Civil and Environmental Engineering, University of Technology Sydney, Ultimo, NSW, 2007, Australia.
| |
Collapse
|
3
|
Tobin RJ, Wood JG, Jayasundara D, Sara G, Walker CR, Martin GE, McCaw JM, Shearer FM, Price DJ. Real-time analysis of hospital length of stay in a mixed SARS-CoV-2 Omicron and Delta epidemic in New South Wales, Australia. BMC Infect Dis 2023; 23:28. [PMID: 36650474 PMCID: PMC9844941 DOI: 10.1186/s12879-022-07971-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 12/26/2022] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The distribution of the duration that clinical cases of COVID-19 occupy hospital beds (the 'length of stay') is a key factor in determining how incident caseloads translate into health system burden. Robust estimation of length of stay in real-time requires the use of survival methods that can account for right-censoring induced by yet unobserved events in patient progression (e.g. discharge, death). In this study, we estimate in real-time the length of stay distributions of hospitalised COVID-19 cases in New South Wales, Australia, comparing estimates between a period where Delta was the dominant variant and a subsequent period where Omicron was dominant. METHODS Using data on the hospital stays of 19,574 individuals who tested positive to COVID-19 prior to admission, we performed a competing-risk survival analysis of COVID-19 clinical progression. RESULTS During the mixed Omicron-Delta epidemic, we found that the mean length of stay for individuals who were discharged directly from ward without an ICU stay was, for age groups 0-39, 40-69 and 70 +, respectively, 2.16 (95% CI: 2.12-2.21), 3.93 (95% CI: 3.78-4.07) and 7.61 days (95% CI: 7.31-8.01), compared to 3.60 (95% CI: 3.48-3.81), 5.78 (95% CI: 5.59-5.99) and 12.31 days (95% CI: 11.75-12.95) across the preceding Delta epidemic (1 July 2021-15 December 2021). We also considered data on the stays of individuals within the Hunter New England Local Health District, where it was reported that Omicron was the only circulating variant, and found mean ward-to-discharge length of stays of 2.05 (95% CI: 1.80-2.30), 2.92 (95% CI: 2.50-3.67) and 6.02 days (95% CI: 4.91-7.01) for the same age groups. CONCLUSIONS Hospital length of stay was substantially reduced across all clinical pathways during a mixed Omicron-Delta epidemic compared to a prior Delta epidemic, contributing to a lessened health system burden despite a greatly increased infection burden. Our results demonstrate the utility of survival analysis in producing real-time estimates of hospital length of stay for assisting in situational assessment and planning of the COVID-19 response.
Collapse
Affiliation(s)
- Ruarai J. Tobin
- grid.1008.90000 0001 2179 088XMelbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
| | - James G. Wood
- grid.1005.40000 0004 4902 0432School of Population Health, University of New South Wales, Sydney, Australia
| | - Duleepa Jayasundara
- grid.416088.30000 0001 0753 1056System Information and Analytics Branch, New South Wales Ministry of Health, Sydney, Australia
| | - Grant Sara
- grid.416088.30000 0001 0753 1056System Information and Analytics Branch, New South Wales Ministry of Health, Sydney, Australia ,grid.1013.30000 0004 1936 834XNorthern Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Camelia R. Walker
- grid.1008.90000 0001 2179 088XSchool of Mathematics and Statistics, The University of Melbourne, Melbourne, Australia
| | - Genevieve E. Martin
- grid.1008.90000 0001 2179 088XDepartment of Infectious Diseases, Melbourne Medical School, The University of Melbourne, Melbourne, Australia ,grid.1002.30000 0004 1936 7857Department of Infectious Diseases, Central Clinical School, Monash University, Melbourne, Australia ,grid.1008.90000 0001 2179 088XDoherty Institute for Infection and Immunity, The Royal Melbourne Hospital and The University of Melbourne, Melbourne, Australia
| | - James M. McCaw
- grid.1008.90000 0001 2179 088XMelbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia ,grid.1008.90000 0001 2179 088XSchool of Mathematics and Statistics, The University of Melbourne, Melbourne, Australia ,grid.1008.90000 0001 2179 088XDoherty Institute for Infection and Immunity, The Royal Melbourne Hospital and The University of Melbourne, Melbourne, Australia
| | - Freya M. Shearer
- grid.1008.90000 0001 2179 088XMelbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
| | - David J. Price
- grid.1008.90000 0001 2179 088XMelbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia ,grid.1008.90000 0001 2179 088XDoherty Institute for Infection and Immunity, The Royal Melbourne Hospital and The University of Melbourne, Melbourne, Australia
| |
Collapse
|
4
|
Effect of Tocilizumab on "Ventilator Free Days" Composite Outcome in SARS-CoV-2 Patients: A Retrospective Competing Risk Analysis. Rom J Anaesth Intensive Care 2023; 29:1-7. [PMID: 36844963 PMCID: PMC9949015 DOI: 10.2478/rjaic-2022-0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2023] Open
Abstract
Background SARS-CoV-2 infection demonstrates a wide range of severity. More severe cases demonstrate a cytokine storm with elevated serum interleukin-6, hence IL-6 receptor antibody tocilizumab was tried for the management of severe cases. Aims Effect of tocilizumab on ventilator-free days among critically ill SARS-CoV-2 patients. Method Retrospective propensity score matching study, comparing mechanically ventilated patients who received tocilizumab to a control group. Results 29 patients in the intervention group were compared to 29 controls. Matched groups were similar. Ventilator-free days were more numerous in the intervention group (SHR 2.7, 95% CI: 1.2 - 6.3; p = 0.02), ICU mortality rate was not different (37.9% versus 62%, p = 0.1), actual ventilator-free periods were significantly longer in tocilizumab group (mean difference 4.7 days; p = 0.02). Sensitivity analysis showed a significantly lower hazard ratio of death in tocilizumab group (HR 0.49, 95% CI: 0.25 - 0.97; p = 0.04). There was no difference in positive cultures among groups (55.2% in tocilizumab group versus 34.5% in the control; p = 0.1). Conclusion Tocilizumab may improve the composite outcome of ventilator-free days at day 28 among mechanically ventilated SARS-CoV-2 patients; it is associated with significantly longer actual ventilator-free periods, and insignificantly lower mortality and higher superinfection.
Collapse
|
5
|
Subramaniam S, Kothari H, Bosmann M. Tissue factor in COVID-19-associated coagulopathy. Thromb Res 2022; 220:35-47. [PMID: 36265412 PMCID: PMC9525243 DOI: 10.1016/j.thromres.2022.09.025] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 09/24/2022] [Accepted: 09/28/2022] [Indexed: 11/17/2022]
Abstract
Evidence of micro- and macro-thrombi in the arteries and veins of critically ill COVID-19 patients and in autopsies highlight the occurrence of COVID-19-associated coagulopathy (CAC). Clinical findings of critically ill COVID-19 patients point to various mechanisms for CAC; however, the definitive underlying cause is unclear. Multiple factors may contribute to the prothrombotic state in patients with COVID-19. Aberrant expression of tissue factor (TF), an initiator of the extrinsic coagulation pathway, leads to thrombotic complications during injury, inflammation, and infections. Clinical evidence suggests that TF-dependent coagulation activation likely plays a role in CAC. Multiple factors could trigger abnormal TF expression and coagulation activation in patients with severe COVID-19 infection. Proinflammatory cytokines that are highly elevated in COVID-19 (IL-1β, IL-6 and TNF-α) are known induce TF expression on leukocytes (e.g. monocytes, macrophages) and non-immune cells (e.g. endothelium, epithelium) in other conditions. Antiphospholipid antibodies, TF-positive extracellular vesicles, pattern recognition receptor (PRR) pathways and complement activation are all candidate factors that could trigger TF-dependent procoagulant activity. In addition, coagulation factors, such as thrombin, may further potentiate the induction of TF via protease-activated receptors on cells. In this systematic review, with other viral infections, we discuss potential mechanisms and cell-type-specific expressions of TF during SARS-CoV-2 infection and its role in the development of CAC.
Collapse
|
6
|
Association of mortality and early tracheostomy in patients with COVID-19: a retrospective analysis. Sci Rep 2022; 12:15406. [PMID: 36104383 PMCID: PMC9474557 DOI: 10.1038/s41598-022-19567-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 08/31/2022] [Indexed: 12/15/2022] Open
Abstract
COVID-19 adds to the complexity of optimal timing for tracheostomy. Over the course of this pandemic, and expanded knowledge of the disease, many centers have changed their operating procedures and performed an early tracheostomy. We studied the data on early and delayed tracheostomy regarding patient outcome such as mortality. We performed a retrospective analysis of all tracheostomies at our institution in patients diagnosed with COVID-19 from March 2020 to June 2021. Time from intubation to tracheostomy and mortality of early (≤ 10 days) vs. late (> 10 days) tracheostomy were the primary objectives of this study. We used mixed cox-regression models to calculate the effect of distinct variables on events. We studied 117 tracheostomies. Intubation to tracheostomy shortened significantly (Spearman’s correlation coefficient; rho = − 0.44, p ≤ 0.001) during the course of this pandemic. Early tracheostomy was associated with a significant increase in mortality in uni- and multivariate analysis (Hazard ratio 1.83, 95% CI 1.07–3.17, p = 0.029). The timing of tracheostomy in COVID-19 patients has a potentially critical impact on mortality. The timing of tracheostomy has changed during this pandemic tending to be performed earlier. Future prospective research is necessary to substantiate these results.
Collapse
|
7
|
Ramón A, Zaragozá M, Torres AM, Cascón J, Blasco P, Milara J, Mateo J. Application of Machine Learning in Hospitalized Patients with Severe COVID-19 Treated with Tocilizumab. J Clin Med 2022; 11:jcm11164729. [PMID: 36012968 PMCID: PMC9410189 DOI: 10.3390/jcm11164729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 08/05/2022] [Accepted: 08/07/2022] [Indexed: 11/16/2022] Open
Abstract
Among the IL-6 inhibitors, tocilizumab is the most widely used therapeutic option in patients with SARS-CoV-2-associated severe respiratory failure (SRF). The aim of our study was to provide evidence on predictors of poor outcome in patients with COVID-19 treated with tocilizumab, using machine learning (ML) techniques. We conducted a retrospective study, analyzing the clinical, laboratory and sociodemographic data of patients admitted for severe COVID-19 with SRF, treated with tocilizumab. The extreme gradient boost (XGB) method had the highest balanced accuracy (93.16%). The factors associated with a worse outcome of tocilizumab use in terms of mortality were: baseline situation at the start of tocilizumab treatment requiring invasive mechanical ventilation (IMV), elevated ferritin, lactate dehydrogenase (LDH) and glutamate-pyruvate transaminase (GPT), lymphopenia, and low PaFi [ratio between arterial oxygen pressure and inspired oxygen fraction (PaO2/FiO2)] values. The factors associated with a worse outcome of tocilizumab use in terms of hospital stay were: baseline situation at the start of tocilizumab treatment requiring IMV or supplemental oxygen, elevated levels of ferritin, glutamate-oxaloacetate transaminase (GOT), GPT, C-reactive protein (CRP), LDH, lymphopenia, and low PaFi values. In our study focused on patients with severe COVID-19 treated with tocilizumab, the factors that were weighted most strongly in predicting worse clinical outcome were baseline status at the start of tocilizumab treatment requiring IMV and hyperferritinemia.
Collapse
Affiliation(s)
- Antonio Ramón
- Department of Pharmacy, General University Hospital, 46014 Valencia, Spain
| | - Marta Zaragozá
- Department of Pharmacy, General University Hospital, 46014 Valencia, Spain
| | - Ana María Torres
- Institute of Technology, University of Castilla-La Mancha, 16002 Cuenca, Spain
| | - Joaquín Cascón
- Institute of Technology, University of Castilla-La Mancha, 16002 Cuenca, Spain
| | - Pilar Blasco
- Department of Pharmacy, General University Hospital, 46014 Valencia, Spain
| | - Javier Milara
- Department of Pharmacy, General University Hospital, 46014 Valencia, Spain
- Department of Pharmacology, Faculty of Medicine, University of Valencia, 46010 Valencia, Spain
- Centre for Biomedical Research Network on Respiratory Diseases (CIBERES), Health Institute Carlos III, 28029 Madrid, Spain
- Correspondence:
| | - Jorge Mateo
- Institute of Technology, University of Castilla-La Mancha, 16002 Cuenca, Spain
| |
Collapse
|
8
|
Chen CC, Yang YP, Tsai HL, Tung TH. Effects of Tocilizumab on Adults With COVID-19 Pneumonia: A Meta-Analysis. Front Med (Lausanne) 2022; 9:838904. [PMID: 35433719 PMCID: PMC9005748 DOI: 10.3389/fmed.2022.838904] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Accepted: 02/14/2022] [Indexed: 12/23/2022] Open
Abstract
Background Coronavirus disease-2019 (COVID-19), a worldwide disaster, has already affected lots of people. Effective care and therapy are currently being evaluated in full swing. Purpose Our purpose was to investigate the effects of tocilizumab, an interleukin-6 receptor inhibitor, on treatment of adult patients with COVID-19 pneumonia. Data Sources, Study Selection, and Data Extraction We conducted a meta-analysis and searched for relevant studies on Pubmed, Embase, and the Cochrane Library without restrictions on language from inception until February 1, 2021. Fifteen studies were included for this meta-analysis. Two authors independently selected and screened these studies, assessed the quality of included studies, and extracted related information. Results Fifteen studies were included in this meta-analysis. The main studies showed that tocilizumab was associated with lower mortality (risk ratio = 0.62, 95% confidence interval = 0.46–0.83; and hazard ratio = 0.61, 95% confidence interval = 0.51–0.72). Using tocilizumab might also affect biochemistry indicators (lowered C-reactive protein and ferritin, increased lymphocyte count). Conclusion These current bodies of evidence could indicate that early use of tocilizumab was associated with lower mortality in adult patients with COVID-19. Early use of tocilizumab could reduce the mortality rate of adult patients with COVID-19 without obvious fatal side effects, which may be a treatment option in patients with COVID-19 pneumonia. Systematic Review Registration The study protocol was registered on PROSPERO (ID:242811).
Collapse
Affiliation(s)
- Chi-Chung Chen
- Department of Emergency Medicine, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Yu-Pei Yang
- Department of Hematology, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Linhai, China
| | - Hsien-Lung Tsai
- Department of Emergency Medicine, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Tao-Hsin Tung
- Enze Medical Research Center, Affiliated Taizhou Hospital of Wenzhou Medical College, Taizhou, China
| |
Collapse
|
9
|
Evaluation of Treatment with a single (400mg) versus double dose (800mg) of Tocilizumab in Acute Respiratory Distress Syndrome Associated with COVID-19Pneumonia. JOURNAL OF CONTEMPORARY MEDICINE 2022. [DOI: 10.16899/jcm.1031086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
10
|
Koritala T, Pattan V, Tirupathi R, Rabaan AA, Al Mutair A, Alhumaid S, Adhikari R, Deepika K, Jain NK, Bansal V, Tekin A, Zec S, Lal A, Khan SA, Garces JPD, Abu Saleh OM, Surani SR, Kashyap R. Infection risk with the use of interleukin inhibitors in hospitalized patients with COVID-19: A narrative review. LE INFEZIONI IN MEDICINA 2021; 29:495-503. [PMID: 35146357 PMCID: PMC8805476 DOI: 10.53854/liim-2904-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 11/12/2021] [Indexed: 02/05/2023]
Abstract
INTRODUCTION To date, only corticosteroids and interleukin-6 (IL-6) inhibitors have been shown to reduce mortality of hospitalized patients with COVID-19. In this literature review, we aimed to summarize infection risk of IL inhibitors, with or without the use of corticosteroids, used to treat hospitalized patients with COVID-19. METHODS A literature search was conducted using the following evidence-based medicine reviews: Cochrane Central Register of Controlled Trials; Cochrane Database of Systematic Reviews; Embase; Ovid Medline; and Epub Ahead of Print, In-Process, In-Data-Review & Other Non-Indexed Citations, Daily and Versions 1946 to April 28, 2021. All relevant articles were identified using the search terms COVID-19 or SARS-coronavirus-2, infections, interleukins, inpatients, adults, and i ncidence. RESULTS We identified 36 studies of which 2 were meta-analyses, 5 were randomized controlled trials, 9 were prospective studies, and 20 were retrospective studies. When anakinra was compared with control, 2 studies reported an increased risk of infection, and 3 studies reported a similar or decreased incidence of infection. Canakinumab had a lower associated incidence of infection compared with placebo in one study. When sarilumab was compared with placebo, one study reported an increased risk of infection. Nine studies comparing tocilizumab with placebo reported decreased or no difference in infection risk (odds ratio [OR] for the studies ranged from 0.39-1.21). Fourteen studies comparing tocilizumab with placebo reported an increased risk of infection, ranging from 9.1% to 63.0% (OR for the studies ranged from 1.85-5.04). Infection most commonly presented as bacteremia. Of the 6 studies comparing tocilizumab and corticosteroid use with placebo, 4 reported a nonsignificant increase toward corticosteroids being associated with bacterial infections (OR ranged from 2.76-3.8), and 2 studies reported no increased association with a higher infection risk. CONCLUSIONS Our literature review showed mixed results with variable significance for the association of IL-6 inhibitors with risk of infections in patients with COVID-19.
Collapse
Affiliation(s)
- Thoyaja Koritala
- Division of Hospital Internal Medicine, Mayo Clinic Health System, Mankato, USA
| | | | | | - Ali A. Rabaan
- Molecular Diagnostic Laboratory, Johns Hopkins Aramco Healthcare, Dhahran, Saudi Arabia
- Department of Public Health and Nutrition, University of Haripur, Haripur, Pakistan
| | - Abbas Al Mutair
- Research Center, Almoosa Specialist Hospital, Al-Ahsa, Saudi Arabia
- College of Nursing, Princess Norah Bint Abdulrahman University, Riyadh, Saudi Arabia
- School of Nursing, Wollongong University, Wollongong, Australia
| | - Saad Alhumaid
- Administration of Pharmaceutical Care, Al-Ahsa Health Cluster, Al-Ahsa, Saudi Arabia
| | - Ramesh Adhikari
- Department of Hospital Medicine, Franciscan Health, Lafayette, USA
| | - Keerti Deepika
- Translational Health Disparities Science Research Program, Nemours Healthcare System for Children, Wilmington, USA
| | - Nitesh Kumar Jain
- Division of Community Critical Care, Mayo Clinic Health System, Mankato, USA
| | - Vikas Bansal
- Research Fellow, Mayo Clinic College of Medicine and Science, Rochester, USA
| | - Aysun Tekin
- Research Fellow, Mayo Clinic College of Medicine and Science, Rochester, USA
| | - Simon Zec
- Research Fellow, Mayo Clinic College of Medicine and Science, Rochester, USA
| | - Amos Lal
- Critical Care Internal Medicine Fellow, Mayo Clinic College of Medicine and Science, Rochester, USA
| | - Syed Anjum Khan
- Division of Community Critical Care, Mayo Clinic Health System, Mankato, USA
| | | | | | - Salim R. Surani
- Adjunct Clinical Professor of Medicine and Pharmacy, Texas A&M University, College Station, USA
- Research Collaborator (limited tenure), Mayo Clinic, Rochester, USA
| | - Rahul Kashyap
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, USA
| |
Collapse
|
11
|
Taramasso L, Magnasco L, Portunato F, Briano F, Vena A, Giacobbe DR, Dentone C, Robba C, Ball L, Loconte M, Patroniti N, Frisoni P, D'Angelo R, Dettori S, Mikulska M, Pelosi P, Bassetti M. Clinical presentation of secondary infectious complications in COVID-19 patients in intensive care unit treated with tocilizumab or standard of care. Eur J Intern Med 2021; 94:39-44. [PMID: 34511338 PMCID: PMC8403658 DOI: 10.1016/j.ejim.2021.08.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 08/17/2021] [Accepted: 08/24/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVES The hypothesis of this study is that tocilizumab should affect common signs of infection due to its immunosuppressive properties. Primary aim of the study was to investigate whether the administration of tocilizumab to critically ill patients with COVID-19, led to a different clinical presentation of infectious complications compared to patients who did not receive tocilizumab. Secondary aim was investigating differences in laboratory parameters between groups. METHODS Single-centre retrospective study, enrolling COVID-19 patients who developed a microbiologically confirmed infectious complication [ventilator associated pneumonia or bloodstream infection] after intensive care unit [ICU] admission and either treated with tocilizumab or not [controls]. RESULTS A total of 58 patients were included, 25 treated with tocilizumab and 33 controls. Median time from tocilizumab administration to infection onset was 10 days [range 2-26]. Patients were 78% male, with median age 65 years [range 45-79]. At first clinical presentation of the infectious event, the frequency of hypotension [11/25, 44% vs. 11/33, 33%], fever [8/25, 32% vs. 10/33, 30%] or hypothermia [0/25,0%, vs. 2/33, 6%], and oxygen desaturation [6/25, 28% vs 4/33, 12%], as well as the frequency of SOFA score increase of ≥ 2 points [4/25, 16%,vs. 4/33, 12%] was similar in tocilizumab treated patients and controls [p>0.1 for all comparisons]. Among laboratory parameters, C-Reactive Protein elevation was reduced in tocilizumab treated patients compared to controls [8/25, 32% vs. 22/33, 67%, p=0.009]. CONCLUSION The clinical features of infectious complications in critically ill patients with COVID-19 admitted to ICU were not affected by tocilizumab.
Collapse
Affiliation(s)
- Lucia Taramasso
- Infectious Diseases Unit, Department of Internal Medicine, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences, Genoa, Italy.
| | - Laura Magnasco
- Infectious Diseases Unit, Department of Internal Medicine, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Federica Portunato
- Infectious Diseases Unit, Department of Internal Medicine, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Federica Briano
- Infectious Diseases Unit, Department of Health Sciences [DISSAL], University of Genoa, Genoa, Italy
| | - Antonio Vena
- Infectious Diseases Unit, Department of Internal Medicine, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Daniele R Giacobbe
- Infectious Diseases Unit, Department of Internal Medicine, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences, Genoa, Italy; Infectious Diseases Unit, Department of Health Sciences [DISSAL], University of Genoa, Genoa, Italy
| | - Chiara Dentone
- Infectious Diseases Unit, Department of Internal Medicine, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Lorenzo Ball
- Anesthesia and Intensive Care, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences, Genoa, Italy; Department of Surgical Sciences and Integrated Diagnostics [DISC], University of Genoa, Genoa, Italy
| | - Maurizio Loconte
- Anesthesia and Intensive Care, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Nicolò Patroniti
- Anesthesia and Intensive Care, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences, Genoa, Italy; Department of Surgical Sciences and Integrated Diagnostics [DISC], University of Genoa, Genoa, Italy
| | - Paolo Frisoni
- Anesthesia and Intensive Care, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Raffaele D'Angelo
- Anesthesia and Intensive Care, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences, Genoa, Italy
| | - Silvia Dettori
- Infectious Diseases Unit, Department of Health Sciences [DISSAL], University of Genoa, Genoa, Italy
| | - Malgorzata Mikulska
- Infectious Diseases Unit, Department of Internal Medicine, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences, Genoa, Italy; Infectious Diseases Unit, Department of Health Sciences [DISSAL], University of Genoa, Genoa, Italy
| | - Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences, Genoa, Italy; Department of Surgical Sciences and Integrated Diagnostics [DISC], University of Genoa, Genoa, Italy
| | - Matteo Bassetti
- Infectious Diseases Unit, Department of Internal Medicine, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences, Genoa, Italy; Infectious Diseases Unit, Department of Health Sciences [DISSAL], University of Genoa, Genoa, Italy
| |
Collapse
|
12
|
Gopcsa L, Bobek I, Bekő G, Lakatos B, Molnár E, Réti M, Reményi P, Sinkó J, Szlávik J, Tatai G, Vályi-Nagy I. Common points of therapeutic intervention in COVID-19 and in allogeneic hematopoietic stem cell transplantation associated severe cytokine release syndrome. Acta Microbiol Immunol Hung 2021; 68:240-255. [PMID: 34797216 DOI: 10.1556/030.2021.01620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 10/22/2021] [Indexed: 11/19/2022]
Abstract
Allogeneic hematopoietic stem cell transplantation (HSCT) and coronavirus disease 2019 (COVID-19) infection can both lead to severe cytokine release syndrome (sCRS) resulting in critical illness and death. In this single institution, preliminary comparative case-series study we compared clinical and laboratory co-variates as well as response to tocilizumab (TCZ)-based therapy of 15 allogeneic-HSCT- and 17 COVID-19-associated sCRS patients. Reaction to a TCZ plus posttransplant cyclophosphamide (PTCY) consolidation therapy in the allogeneic-HSCT-associated sCRS group yielded significantly inferior long-term outcome as compared to TCZ-based therapy in the COVID-19-associated group (P = 0.003). We report that a TCZ followed by consolidation therapy with a Janus kinase/signal transducer and activator of transcription (JAK/STAT) inhibitor given to 4 out of 8 critically ill COVID-19 patients resulted in their complete recovery. Non-selective JAK/STAT inhibitors influencing the action of several cytokines exhibit a broader effect than TCZ alone in calming down sCRS. Serum levels of cytokines and chemokines show similar changes in allogeneic-HSCT- and COVID-19-associated sCRS with marked elevation of interleukin-6 (IL-6), regulated upon activation normal T-cell expressed and secreted (RANTES), monocyte chemoattractant protein-1 (MCP-1) and interferon γ-induced protein 10 kDa (IP-10) levels. In addition, levels of IL-5, IL-10, IL-15 were also elevated in allogeneic-HSCT-associated sCRS. Our multi-cytokine expression data indicate that the pathophysiology of allogeneic-HSCT and COVID-19-associated sCRS are similar therefore the same clinical grading system and TCZ-based treatment approaches can be applied. TCZ with JAK/STAT inhibitor consolidation therapy might be highly effective in COVID-19 sCRS patients.
Collapse
Affiliation(s)
- László Gopcsa
- 1Central Hospital of Southern-Pest, National Institute of Hematology and Infectious Diseases, Department of Hematology and Stem Cell Transplantation, Albert Florian ut 5-7, H-1097, Budapest, Hungary
| | - Ilona Bobek
- 2Central Hospital of Southern-Pest, National Institute of Hematology and Infectious Diseases, Department of Intensive Care Unit, Albert Florian ut 5-7, H-1097, Budapest, Hungary
| | - Gabriella Bekő
- 3Central Hospital of Southern-Pest, National Institute of Hematology and Infectious Diseases, Department of Central Laboratory, Albert Florian ut 5-7, H-1097, Budapest, Hungary
| | - Botond Lakatos
- 4Central Hospital of Southern-Pest, National Institute of Hematology and Infectious Diseases, Department of Infectious Diseases, Albert Florian ut 5-7, H-1097, Budapest, Hungary
| | - Eszter Molnár
- 2Central Hospital of Southern-Pest, National Institute of Hematology and Infectious Diseases, Department of Intensive Care Unit, Albert Florian ut 5-7, H-1097, Budapest, Hungary
| | - Marienn Réti
- 1Central Hospital of Southern-Pest, National Institute of Hematology and Infectious Diseases, Department of Hematology and Stem Cell Transplantation, Albert Florian ut 5-7, H-1097, Budapest, Hungary
| | - Péter Reményi
- 1Central Hospital of Southern-Pest, National Institute of Hematology and Infectious Diseases, Department of Hematology and Stem Cell Transplantation, Albert Florian ut 5-7, H-1097, Budapest, Hungary
| | - János Sinkó
- 1Central Hospital of Southern-Pest, National Institute of Hematology and Infectious Diseases, Department of Hematology and Stem Cell Transplantation, Albert Florian ut 5-7, H-1097, Budapest, Hungary
| | - János Szlávik
- 4Central Hospital of Southern-Pest, National Institute of Hematology and Infectious Diseases, Department of Infectious Diseases, Albert Florian ut 5-7, H-1097, Budapest, Hungary
| | - Gábor Tatai
- 1Central Hospital of Southern-Pest, National Institute of Hematology and Infectious Diseases, Department of Hematology and Stem Cell Transplantation, Albert Florian ut 5-7, H-1097, Budapest, Hungary
| | - István Vályi-Nagy
- 1Central Hospital of Southern-Pest, National Institute of Hematology and Infectious Diseases, Department of Hematology and Stem Cell Transplantation, Albert Florian ut 5-7, H-1097, Budapest, Hungary
| |
Collapse
|
13
|
Agarwal N, Biswas B, Singh C, Nair R, Mounica G, H H, Jha AR, Das KM. Early Determinants of Length of Hospital Stay: A Case Control Survival Analysis among COVID-19 Patients admitted in a Tertiary Healthcare Facility of East India. J Prim Care Community Health 2021; 12:21501327211054281. [PMID: 34704488 PMCID: PMC8554553 DOI: 10.1177/21501327211054281] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Length of hospital stay (LOS) for a disease is a vital estimate for healthcare logistics planning. The study aimed to illustrate the effect of factors elicited on arrival on LOS of the COVID-19 patients. MATERIALS AND METHODS It was a retrospective, record based, unmatched, case control study using hospital records of 334 COVID-19 patients admitted in an East Indian tertiary healthcare facility during May to October 2020. Discharge from the hospital (cases/survivors) was considered as an event while death (control/non-survivors) as right censoring in the case-control survival analysis using cox proportional hazard model. RESULTS Overall, we found the median LOS for the survivors to be 8 days [interquartile range (IQR): 7-10 days] while the same for the non-survivors was 6 days [IQR: 2-11 days]. In the multivariable cox-proportional hazard model; travel distance (>16 km) [adjusted hazard ratio (aHR): 0.69, 95% CI: (0.50-0.95)], mode of transport to the hospital (ambulance) [aHR: 0.62, 95% CI: (0.45-0.85)], breathlessness (yes) [aHR: 0.56, 95% CI: (0.40-0.77)], number of co-morbidities (1-2) [aHR: 0.66, 95% CI: (0.47-0.93)] (≥3) [aHR: 0.16, 95% CI: (0.04-0.65)], COPD/asthma (yes) [ [aHR: 0.11, 95% CI: (0.01-0.79)], DBP (<60/≥90) [aHR: 0.55, 95% CI: (0.35-0.86)] and qSOFA score (≥2) [aHR: 0.33, 95% CI: (0.12-0.92)] were the significant attributes affecting LOS of the COVID-19 patients. CONCLUSION Factors elicited on arrival were found to be significantly associated with LOS. A scoring system inculcating these factors may be developed to predict LOS of the COVID-19 patients.
Collapse
Affiliation(s)
- Neeraj Agarwal
- All India Institute of Medical Sciences, Bibinagar, Telangana, India
| | - Bijit Biswas
- All India Institute of Medical Sciences, Patna, Bihar, India
| | | | - Rathish Nair
- All India Institute of Medical Sciences, Patna, Bihar, India
| | - Gera Mounica
- All India Institute of Medical Sciences, Patna, Bihar, India
| | - Haripriya H
- All India Institute of Medical Sciences, Patna, Bihar, India
| | - Amit Ranjan Jha
- All India Institute of Medical Sciences, Patna, Bihar, India
| | - Kumar M Das
- All India Institute of Medical Sciences, Patna, Bihar, India
| |
Collapse
|
14
|
Schumertl T, Lokau J, Rose-John S, Garbers C. Function and proteolytic generation of the soluble interleukin-6 receptor in health and disease. BIOCHIMICA ET BIOPHYSICA ACTA-MOLECULAR CELL RESEARCH 2021; 1869:119143. [PMID: 34626681 DOI: 10.1016/j.bbamcr.2021.119143] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 09/03/2021] [Accepted: 09/08/2021] [Indexed: 12/20/2022]
Abstract
The pleiotropic cytokine interleukin-6 (IL-6) is involved in numerous physiological and pathophysiological functions that include development, immune cell differentiation, inflammation and cancer. IL-6 can signal via the membrane-bound IL-6 receptor (IL-6R, classic signaling) or via soluble forms of the IL-6R (sIL-6R, trans-signaling). Both modes of signaling induce the formation of a homodimer of the signal transducing β-receptor glycoprotein 130 (gp130) and the activation of several intracellular signaling cascades, e.g. the Jak/STAT pathway. Intriguingly, only IL-6 trans-signaling is required for the pro-inflammatory properties of IL-6, while regenerative and anti-inflammatory functions are mediated via classic signaling. The sIL-6R is generated by different molecular mechanisms, including alternative mRNA splicing, proteolysis of the membrane-bound IL-6R and the release of extracellular vesicles. In this review, we give an in-depth overview on these molecular mechanisms with a special emphasize on IL-6R cleavage by the metalloprotease ADAM17 and other proteases. We discuss the biological functions of the sIL-6R and highlight attempts to selectively block IL-6 trans-signaling in pre-clinical animal models as well as in clinical studies in patients with inflammatory bowel disease.
Collapse
Affiliation(s)
- Tim Schumertl
- Department of Pathology, Otto-von-Guericke-University Magdeburg, Medical Faculty, Magdeburg, Germany
| | - Juliane Lokau
- Department of Pathology, Otto-von-Guericke-University Magdeburg, Medical Faculty, Magdeburg, Germany
| | | | - Christoph Garbers
- Department of Pathology, Otto-von-Guericke-University Magdeburg, Medical Faculty, Magdeburg, Germany.
| |
Collapse
|
15
|
Kyriakopoulos C, Ntritsos G, Gogali A, Milionis H, Evangelou E, Kostikas K. Tocilizumab administration for the treatment of hospitalized patients with COVID-19: A systematic review and meta-analysis. Respirology 2021; 26:1027-1040. [PMID: 34605114 PMCID: PMC8661720 DOI: 10.1111/resp.14152] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 08/26/2021] [Accepted: 09/07/2021] [Indexed: 12/15/2022]
Abstract
Tocilizumab has been repurposed against the ‘cytokine storm’ in the setting of coronavirus disease 2019 (COVID‐19). Our aim was to evaluate the efficacy of tocilizumab in the management of hospitalized COVID‐19 patients. We searched MEDLINE, CENTRAL and medRxiv for studies of tocilizumab in hospitalized COVID‐19 patients. Primary objective was the effectiveness of tocilizumab on mortality. Secondary objectives included the need for invasive mechanical ventilation (IMV), composite endpoints of mortality or IMV and intensive care unit (ICU) admission or IMV, length of hospitalization and differences in mortality in subgroups (ICU and non‐ICU patients and patients receiving or not receiving concomitant corticosteroids). We included 52 studies (nine randomized controlled trials [RCTs] and 43 observational) with a total of 27,004 patients. In both RCTs and observational studies, the use of tocilizumab was associated with a reduction in mortality; 11% in RCTs (risk ratio [RR] 0.89, 95% CI 0.82 to 0.96) and 31% in observational studies (RR 0.69, 95% CI 0.58 to 0.83). The need for IMV was reduced by 19% in RCTs (RR 0.81, 95% CI 0.71 to 0.93), while no significant reduction was observed in observational studies. Both RCTs and observational studies showed a benefit from tocilizumab on the composite endpoint of mortality or IMV. Tocilizumab improved mortality both in ICU and non‐ICU patients. Reduction in mortality was evident in observational studies regardless of the use of systemic corticosteroids, while that was not the case in the RCTs. Tocilizumab was associated with lower mortality and other clinically relevant outcomes in hospitalized patients with moderate‐to‐critical COVID‐19.
Collapse
Affiliation(s)
- Christos Kyriakopoulos
- Respiratory Medicine Department, University of Ioannina Faculty of Medicine, Ioannina, Greece
| | - Georgios Ntritsos
- Department of Hygiene and Epidemiology, University of Ioannina Faculty of Medicine, Ioannina, Greece
| | - Athena Gogali
- Respiratory Medicine Department, University of Ioannina Faculty of Medicine, Ioannina, Greece
| | - Haralampos Milionis
- Internal Medicine Department, University of Ioannina Faculty of Medicine, Ioannina, Greece
| | - Evangelos Evangelou
- Department of Hygiene and Epidemiology, University of Ioannina Faculty of Medicine, Ioannina, Greece
| | - Konstantinos Kostikas
- Respiratory Medicine Department, University of Ioannina Faculty of Medicine, Ioannina, Greece
| |
Collapse
|
16
|
Rubio-Rivas M, Forero CG, Mora-Luján JM, Montero A, Formiga F, Homs NA, Albà-Albalate J, Sánchez L, Rello J, Corbella X. Beneficial and harmful outcomes of tocilizumab in severe COVID-19: A systematic review and meta-analysis. Pharmacotherapy 2021; 41:884-906. [PMID: 34558742 PMCID: PMC8661749 DOI: 10.1002/phar.2627] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 09/05/2021] [Accepted: 09/07/2021] [Indexed: 12/15/2022]
Abstract
Introduction The results of studies of tocilizumab (TCZ) in COVID‐19 are contradictory. Our study aims to update medical evidence from controlled observational studies and randomized clinical trials (RCTs) on the use of TCZ in hospitalized patients with COVID‐19. Methods We searched the following databases from January 1, 2020 to April 13, 2021 (date of the last search): MEDLINE database through the PubMed search engine and Scopus, using the terms (“COVID‐19" [Supplementary Concept]) AND "tocilizumab" [Supplementary Concept]). Results Sixty four studies were included in the present study: 54 were controlled observational studies (50 retrospective and 4 prospective) and 10 were RCTs. The overall results provided data from 20,616 hospitalized patients with COVID‐19: 7668 patients received TCZ in addition to standard of care (SOC) (including 1915 patients admitted to intensive care units (ICU) with reported mortality) and 12,948 patients only receiving SOC (including 4410 patients admitted to the ICU with reported mortality). After applying the random‐effects model, the hospital‐wide (including ICU) pooled mortality odds ratio (OR) of patients with COVID‐19 treated with TCZ was 0.73 (95% confidence interval (CI) = 0.56–0.93). The pooled hospital‐wide mortality OR was 1.25 (95% CI = 0.74–2.18) in patients admitted at conventional wards versus 0.66 (95% CI = 0.59–0.76) in patients admitted to the ICU. The pooled OR of hospital‐wide mortality (including ICU) of COVID‐19 patients treated with TCZ plus corticosteroids (CS) was 0.67 (95% CI = 0.54–0.84). The pooled in‐hospital mortality OR was 0.71 (95% CI = 0.35–1.42) when TCZ was early administered (≤10 days from symptom onset) versus 0.83 (95% CI 0.48–1.45) for late administration (>10 days from symptom onset). The meta‐analysis did not find significantly higher risk for secondary infections in COVID‐19 patients treated with TCZ. Conclusions TCZ prevented mortality in patients hospitalized for COVID‐19. This benefit was seen to a greater extent in patients receiving concomitant CS and when TCZ administration occurred within the first 10 days after symptom onset.
Collapse
Affiliation(s)
- Manuel Rubio-Rivas
- Department of Internal Medicine, Bellvitge University Hospital, Bellvitge Biomedical Research Institute-IDIBELL, University of Barcelona, Barcelona, Spain
| | - Carlos G Forero
- School of Medicine, Universitat Internacional de Catalunya, Barcelona, Spain
| | - José María Mora-Luján
- Department of Internal Medicine, Bellvitge University Hospital, Bellvitge Biomedical Research Institute-IDIBELL, University of Barcelona, Barcelona, Spain
| | - Abelardo Montero
- Department of Internal Medicine, Bellvitge University Hospital, Bellvitge Biomedical Research Institute-IDIBELL, University of Barcelona, Barcelona, Spain
| | - Francesc Formiga
- Department of Internal Medicine, Bellvitge University Hospital, Bellvitge Biomedical Research Institute-IDIBELL, University of Barcelona, Barcelona, Spain
| | - Narcís A Homs
- Department of Internal Medicine, Bellvitge University Hospital, Bellvitge Biomedical Research Institute-IDIBELL, University of Barcelona, Barcelona, Spain
| | - Joan Albà-Albalate
- Department of Internal Medicine, Bellvitge University Hospital, Bellvitge Biomedical Research Institute-IDIBELL, University of Barcelona, Barcelona, Spain
| | - Laura Sánchez
- Department of Internal Medicine, Bellvitge University Hospital, Bellvitge Biomedical Research Institute-IDIBELL, University of Barcelona, Barcelona, Spain
| | - Jordi Rello
- School of Medicine, Universitat Internacional de Catalunya, Barcelona, Spain.,Centro de Investigación Biomédica en Red (CIBERES), Instituto de Salud Carlos III, Madrid, Spain.,CRIPS, Vall d'Hebrón Institute of Research, Barcelona, Spain
| | - Xavier Corbella
- Department of Internal Medicine, Bellvitge University Hospital, Bellvitge Biomedical Research Institute-IDIBELL, University of Barcelona, Barcelona, Spain.,School of Medicine, Universitat Internacional de Catalunya, Barcelona, Spain
| |
Collapse
|
17
|
Peng J, Fu M, Mei H, Zheng H, Liang G, She X, Wang Q, Liu W. Efficacy and secondary infection risk of tocilizumab, sarilumab and anakinra in COVID-19 patients: A systematic review and meta-analysis. Rev Med Virol 2021; 32:e2295. [PMID: 34558756 PMCID: PMC8646369 DOI: 10.1002/rmv.2295] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 08/04/2021] [Accepted: 08/30/2021] [Indexed: 12/29/2022]
Abstract
As the pandemic progresses, the pathophysiology of coronavirus disease 2019 (COVID‐19) is becoming clearer and the potential for immunotherapy is increasing. However, clinical efficacy and safety of immunosuppressants (including tocilizumab, sarilumab and anakinra) treatment in COVID‐19 patients are not yet known. We searched PubMed, Embase Medline, Web of Science and MedRxiv using specific search terms in studies published from 1 January 2020 to 20 December 2020. In total, 33 studies, including 3073 cases and 6502 controls, were selected for meta‐analysis. We found that immunosuppressant therapy significantly decreased mortality in COVID‐19 patients on overall analysis (odds ratio = 0.71, 95% confidence interval = 0.57–0.89, p = 0.004). We also found that tocilizumab and anakinra significantly decreased mortality in patients without any increased risk of secondary infection. In addition, we found similar results in several subgroups. However, we found that tocilizumab therapy significantly increased the risk of fungal co‐infections in COVID‐19 patients. This represents the only systematic review and meta‐analysis to investigate the efficacy and secondary infection risk of immunosuppressant treatment in COVID‐19 patients. Overall, immunosuppressants significantly decreased mortality but had no effect on increased risk of secondary infections. Our analysis of tocilizumab therapy showed a significantly increased risk of fungal co‐infections in these patients.
Collapse
Affiliation(s)
- Jingwen Peng
- Department of Medical Mycology, Institute of Dermatology, Chinese Academy of Medical Science and Peking Union Medical College, Nanjing, Jiangsu, China.,Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Institute of Dermatology, Chinese Academy of Medical Science and Peking Union Medical College, Nanjing, Jiangsu, China
| | - Meihua Fu
- Department of Medical Mycology, Institute of Dermatology, Chinese Academy of Medical Science and Peking Union Medical College, Nanjing, Jiangsu, China.,Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Institute of Dermatology, Chinese Academy of Medical Science and Peking Union Medical College, Nanjing, Jiangsu, China
| | - Huan Mei
- Department of Medical Mycology, Institute of Dermatology, Chinese Academy of Medical Science and Peking Union Medical College, Nanjing, Jiangsu, China.,Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Institute of Dermatology, Chinese Academy of Medical Science and Peking Union Medical College, Nanjing, Jiangsu, China
| | - Hailin Zheng
- Department of Medical Mycology, Institute of Dermatology, Chinese Academy of Medical Science and Peking Union Medical College, Nanjing, Jiangsu, China.,Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Institute of Dermatology, Chinese Academy of Medical Science and Peking Union Medical College, Nanjing, Jiangsu, China
| | - Guanzhao Liang
- Department of Medical Mycology, Institute of Dermatology, Chinese Academy of Medical Science and Peking Union Medical College, Nanjing, Jiangsu, China.,Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Institute of Dermatology, Chinese Academy of Medical Science and Peking Union Medical College, Nanjing, Jiangsu, China
| | - Xiaodong She
- Department of Medical Mycology, Institute of Dermatology, Chinese Academy of Medical Science and Peking Union Medical College, Nanjing, Jiangsu, China.,Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Institute of Dermatology, Chinese Academy of Medical Science and Peking Union Medical College, Nanjing, Jiangsu, China
| | - Qiong Wang
- Department of Medical Mycology, Institute of Dermatology, Chinese Academy of Medical Science and Peking Union Medical College, Nanjing, Jiangsu, China.,Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Institute of Dermatology, Chinese Academy of Medical Science and Peking Union Medical College, Nanjing, Jiangsu, China
| | - Weida Liu
- Department of Medical Mycology, Institute of Dermatology, Chinese Academy of Medical Science and Peking Union Medical College, Nanjing, Jiangsu, China.,Jiangsu Key Laboratory of Molecular Biology for Skin Diseases and STIs, Institute of Dermatology, Chinese Academy of Medical Science and Peking Union Medical College, Nanjing, Jiangsu, China.,Center for Global Health, School of Public Health, Nanjing Medical University, Nanjing, China
| |
Collapse
|
18
|
Russo G, Solimini A, Zuccalà P, Zingaropoli MA, Carraro A, Pasculli P, Perri V, Marocco R, Kertusha B, Del Borgo C, Del Giudice E, Fondaco L, Tieghi T, D’Agostino C, Oliva A, Vullo V, Ciardi MR, Mastroianni CM, Lichtner M. Real-life use of tocilizumab with or without corticosteroid in hospitalized patients with moderate-to-severe COVID-19 pneumonia: A retrospective cohort study. PLoS One 2021; 16:e0257376. [PMID: 34506608 PMCID: PMC8432821 DOI: 10.1371/journal.pone.0257376] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 08/31/2021] [Indexed: 12/15/2022] Open
Abstract
Objective To evaluate the effectiveness of Tocilizumab (with or without corticosteroids) in a real-life context among moderate-to-severe COVID-19 patients hospitalized at the Infectious Diseases ward of two hospitals in Lazio region, Italy, during the first wave of SARS-CoV-2 pandemic. Method We conducted a retrospective cohort study among moderate-to-severe COVID-19 pneumonia to assess the influence of tocilizumab (with or without corticosteroids) on: 1) primary composite outcome: risk for death/invasive mechanical ventilation/ICU-transfer at 14 days from hospital admission; 2) secondary outcome: COVID-related death only. Both outcomes were also assessed at 28 days and restricted to baseline more severe cases. We also evaluated the safety of tocilizumab. Results Overall, 412 patients were recruited, being affected by mild (6.8%), moderate (66.3%) or severe (26.9%) COVID-19 at baseline. The median participant’ age was 63 years, 56.5% were men, the sum of comorbidities was 1.34 (±1.44), and the median time from symptom onset to hospital admission was 7 [3–10] days. Patients were subdivided in 4 treatment groups: standard of care (SoC) only (n = 172), SoC plus corticosteroid (n = 65), SoC plus tocilizumab (n = 50), SoC plus tocilizumab and corticosteroid (n = 125). Twenty-six (6.3%) patients underwent intubation, and 37 (9%) COVID-related deaths were recorded. After adjusting for several factors, multivariate analysis showed that tocilizumab (with or without corticosteroids) was associated to improved primary and secondary outcomes at 14 days, and at 28-days only when tocilizumab administered without corticosteroid. Among more severe cases the protective effect of tocilizumab (± corticosteroids) was observed at both time-points. No safety concerns were recorded. Conclusion Although contrasting results from randomized clinical trials to date, in our experience tocilizumab was a safe and efficacious therapeutic option for patients with moderate-to-severe COVID-19 pneumonia. Its efficacy was improved by the concomitant administration of corticosteroids in patients affected by severe-COVID-19 pneumonia at baseline.
Collapse
Affiliation(s)
- Gianluca Russo
- Department of Public Health and Infectious Diseases, Policlinico Umberto 1 Hospital, Sapienza University of Rome, Rome, Italy
- * E-mail:
| | - Angelo Solimini
- Department of Public Health and Infectious Diseases, Policlinico Umberto 1 Hospital, Sapienza University of Rome, Rome, Italy
| | - Paola Zuccalà
- Infectious Diseases Unit, S. Maria Goretti Hospital/Sapienza University of Rome, Latina, Italy
| | - Maria Antonella Zingaropoli
- Department of Public Health and Infectious Diseases, Policlinico Umberto 1 Hospital, Sapienza University of Rome, Rome, Italy
| | - Anna Carraro
- Infectious Diseases Unit, S. Maria Goretti Hospital/Sapienza University of Rome, Latina, Italy
| | - Patrizia Pasculli
- Department of Public Health and Infectious Diseases, Policlinico Umberto 1 Hospital, Sapienza University of Rome, Rome, Italy
| | - Valentina Perri
- Department of Public Health and Infectious Diseases, Policlinico Umberto 1 Hospital, Sapienza University of Rome, Rome, Italy
| | - Raffaella Marocco
- Infectious Diseases Unit, S. Maria Goretti Hospital/Sapienza University of Rome, Latina, Italy
| | - Blerta Kertusha
- Infectious Diseases Unit, S. Maria Goretti Hospital/Sapienza University of Rome, Latina, Italy
| | - Cosmo Del Borgo
- Infectious Diseases Unit, S. Maria Goretti Hospital/Sapienza University of Rome, Latina, Italy
| | - Emanuela Del Giudice
- Infectious Diseases Unit, S. Maria Goretti Hospital/Sapienza University of Rome, Latina, Italy
| | - Laura Fondaco
- Infectious Diseases Unit, S. Maria Goretti Hospital/Sapienza University of Rome, Latina, Italy
| | - Tiziana Tieghi
- Infectious Diseases Unit, S. Maria Goretti Hospital/Sapienza University of Rome, Latina, Italy
| | - Claudia D’Agostino
- Department of Public Health and Infectious Diseases, Policlinico Umberto 1 Hospital, Sapienza University of Rome, Rome, Italy
| | - Alessandra Oliva
- Department of Public Health and Infectious Diseases, Policlinico Umberto 1 Hospital, Sapienza University of Rome, Rome, Italy
| | - Vincenzo Vullo
- Department of Public Health and Infectious Diseases, Policlinico Umberto 1 Hospital, Sapienza University of Rome, Rome, Italy
| | - Maria Rosa Ciardi
- Department of Public Health and Infectious Diseases, Policlinico Umberto 1 Hospital, Sapienza University of Rome, Rome, Italy
| | - Claudio Maria Mastroianni
- Department of Public Health and Infectious Diseases, Policlinico Umberto 1 Hospital, Sapienza University of Rome, Rome, Italy
| | - Miriam Lichtner
- Department of Public Health and Infectious Diseases, Policlinico Umberto 1 Hospital, Sapienza University of Rome, Rome, Italy
- Infectious Diseases Unit, S. Maria Goretti Hospital/Sapienza University of Rome, Latina, Italy
| |
Collapse
|
19
|
Jiang W, Li W, Wu Q, Han Y, Zhang J, Luo T, Guo Y, Yang Y, Zhu P, Xia X. Efficacy and Safety of Tocilizumab Treatment COVID-19 Patients: A Case-Control Study and Meta-Analysis. Infect Dis Ther 2021; 10:1677-1698. [PMID: 34244956 PMCID: PMC8269405 DOI: 10.1007/s40121-021-00483-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 06/15/2021] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION As the pandemic progresses, the pathophysiology of COVID-19 is becoming more apparent, and the potential for tocilizumab is increasing. However, the clinical efficacy and safety of tocilizumab in the treatment of COVID-19 patients remain unclear. METHODS To assess the efficacy and safety of tocilizumab treatment in COVID-19 patients, we performed a retrospective case-control study. The study was conducted, including 95 patients treated with tocilizumab plus standard treatment and matched controls with 95 patients treated with standard treatment therapy by propensity score from February to April 2020. We searched some databases using the search terms for studies published from January 1, 2020, to June 1, 2021. RESULTS Our case-control study found a lower mortality rate in the tocilizumab treatment group than in the standard treatment group (9.47% versus 16.84%, P = 0.134), but the results were not statistically significant. We also found that the mortality rate in tocilizumab treatment groups was significantly lower than in the standard treatment group in the stratified ICU analysis (OR 0.52, 95% CI 0.44-0.61, P = 0.048 and OR 0.31, 95% CI 0.10-0.99, P = 0.044). We selected 49 studies (including 6568 cases and 11,660 controls) that met the inclusion criteria in the meta-analysis. In the overall analysis, we performed a meta-analysis that showed significantly decreased mortality after patients received tocilizumab (OR 0.81, 95% CI 0.69-0.95, P = 0.008). We also revealed significant associations within some subgroups. The sequential trial analysis showed a true-positive result. No significant associations were observed between tocilizumab and elevated secondary infection risk, discharge, adverse events, and mechanical ventilation in the overall analysis. CONCLUSION Tocilizumab significantly decreased mortality in COVID-19 patients with no increased discharge, secondary infection risk, adverse events, and mechanical ventilation in a meta-analysis. Our data suggest that clinicians should pay attention to tocilizumab therapy as an effective and safe treatment for COVID-19 patients.
Collapse
Affiliation(s)
- Weijun Jiang
- COVID-19 Research Center, Institute of Laboratory Medicine, Jinling Hospital, Nanjing University School of Medicine, The First School of Clinical Medicine, Southern Medical University, Nanjing, 210002, Jiangsu, China
| | - Weiwei Li
- COVID-19 Research Center, Institute of Laboratory Medicine, Jinling Hospital, Nanjing University School of Medicine, The First School of Clinical Medicine, Southern Medical University, Nanjing, 210002, Jiangsu, China
| | - Qiuyue Wu
- COVID-19 Research Center, Institute of Laboratory Medicine, Jinling Hospital, Nanjing University School of Medicine, The First School of Clinical Medicine, Southern Medical University, Nanjing, 210002, Jiangsu, China
| | - Ying Han
- COVID-19 Research Center, Institute of Laboratory Medicine, Jinling Hospital, Nanjing University School of Medicine, The First School of Clinical Medicine, Southern Medical University, Nanjing, 210002, Jiangsu, China
| | - Jing Zhang
- COVID-19 Research Center, Institute of Laboratory Medicine, Jinling Hospital, Nanjing University School of Medicine, The First School of Clinical Medicine, Southern Medical University, Nanjing, 210002, Jiangsu, China
| | - Tao Luo
- COVID-19 Research Center, Institute of Laboratory Medicine, Jinling Hospital, Nanjing University School of Medicine, The First School of Clinical Medicine, Southern Medical University, Nanjing, 210002, Jiangsu, China
| | - Yanju Guo
- COVID-19 Research Center, Institute of Laboratory Medicine, Jinling Hospital, Nanjing University School of Medicine, The First School of Clinical Medicine, Southern Medical University, Nanjing, 210002, Jiangsu, China
| | - Yang Yang
- COVID-19 Research Center, Institute of Laboratory Medicine, Jinling Hospital, Nanjing University School of Medicine, The First School of Clinical Medicine, Southern Medical University, Nanjing, 210002, Jiangsu, China
| | - Peiran Zhu
- COVID-19 Research Center, Institute of Laboratory Medicine, Jinling Hospital, Nanjing University School of Medicine, The First School of Clinical Medicine, Southern Medical University, Nanjing, 210002, Jiangsu, China
| | - Xinyi Xia
- COVID-19 Research Center, Institute of Laboratory Medicine, Jinling Hospital, Nanjing University School of Medicine, The First School of Clinical Medicine, Southern Medical University, Nanjing, 210002, Jiangsu, China.
- Joint Expert Group for COVID-19, Department of Laboratory Medicine and Blood Transfusion, Wuhan Huoshenshan Hospital, Wuhan, 430100, Hubei, China.
- Department of Laboratory Medicine and Blood Transfusion, Wuhan Huoshenshan Hospital, Wuhan, 430100, Hubei, China.
| |
Collapse
|
20
|
Pinzon RT, Wijaya VO, Buana RB. Interleukin-6 (IL-6) inhibitors as therapeutic agents for coronavirus disease 2019 (COVID-19): A systematic review and meta-analysis. J Infect Public Health 2021; 14:1001-1009. [PMID: 34153723 PMCID: PMC8204364 DOI: 10.1016/j.jiph.2021.06.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 05/29/2021] [Accepted: 06/01/2021] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION Preliminary studies showed that coronavirus disease 2019 (COVID-19) disrupts body immune system, including dysregulation of cytokine interleukin-6 (IL-6). IL-6 inhibitors agents have been used as treatment options for COVID-19, yet their benefit as therapeutic agents remains unclear. OBJECTIVE We performed a systematic review and meta-analysis to synthesize the available evidence on the potential therapeutic effect of IL-6 inhibitor agents for the treatment of COVID-19. METHODS Two authors initially screened and reviewed the relevant studies from available databases. The data extracted will be tabulated and analyzed for the outcomes. The primary outcome was mortality. Secondary outcomes included discharge from the hospital, length of stay, and requirement for mechanical ventilation. The quality of each study was assessed using OCEBM ratings. RESULTS We reviewed 18 studies with a total of 3303 subjects. Tocilizumab was the most commonly used in the studies (15 studies). Meta-analysis of included studies revealed significant reduction in mortality with tocilizumab and sarilumab (RR = 0.61, 95% CI 0.49-0.76). Other outcomes including hospital discharge (RR = 1.04, 95% CI 0.86-1.24), length of stay (mean difference -1.96 days, 95% CI -4.24 to 0.33) or requirement for mechanical ventilation (RR = 0.68, 95% CI 0.32-1.45) revealed no differences of IL-6 inhibitor agents compared to controls. CONCLUSIONS Available evidence suggests that IL-6 inhibitor agents reduce the risk of mortality in COVID-19, especially in severe conditions. Further well-designed trials are needed for assessing its efficacy and safety for COVID-19.
Collapse
Affiliation(s)
- Rizaldy Taslim Pinzon
- Faculty of Medicine, Duta Wacana Christian University, Yogyakarta, Indonesia; Bethesda Hospital, Yogyakarta, Indonesia.
| | - Vincent Ongko Wijaya
- Faculty of Medicine, Duta Wacana Christian University, Yogyakarta, Indonesia; Bethesda Hospital, Yogyakarta, Indonesia
| | - Ranbebasa Bijak Buana
- Faculty of Medicine, Duta Wacana Christian University, Yogyakarta, Indonesia; Bethesda Hospital, Yogyakarta, Indonesia
| |
Collapse
|
21
|
Al-Baadani A, Eltayeb N, Alsufyani E, Albahrani S, Basheri S, Albayat H, Batubara E, Ballool S, Al Assiri A, Faqihi F, Musa AB, Robert AA, Alsherbeeni N, Elzein F. Efficacy of tocilizumab in patients with severe COVID-19: Survival and clinical outcomes. J Infect Public Health 2021; 14:1021-1027. [PMID: 34153727 PMCID: PMC8166045 DOI: 10.1016/j.jiph.2021.05.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 04/23/2021] [Accepted: 05/04/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND SARS-CoV-2 is associated with a severe inflammatory response contributing to respiratory and systemic manifestations, morbidity, and mortality in patients with coronavirus disease 2019 (COVID-19). METHODS Tocilizumab (TCZ) efficacy on mortality and length of hospital stay was retrospectively evaluated in patients who received TCZ and compared with that in controls with a similar severity of COVID-19. The primary endpoint was survival probability on day 28. The secondary endpoints included survival at day 14 and length of hospital stay. RESULTS Of the 148 patients included in the study, 62 received TCZ and standard of care, whereas 86 served as a control group and received only standard of care. The two groups were similar, although TCZ-treated patients were more likely to exhibit hypertension (46.7% vs. 29.8%), chronic kidney disease (14.5% vs. 1.1%), and high Charlson score (1.18 vs. 1.00; p = 0.006) and less likely to receive corticosteroid treatment (48.5% vs. 93.0%). TCZ was associated with lower mortality on both day 28 (16.1% vs. 37.2%, p = 0.004) and day 14 (9.7% vs. 24.4%, p = 0.022). The hospital stay was longer in the TCZ-treated than in the control group (15.6 ± 7.59 vs.17.7 ± 7.8 days, p = 0.103). Ten patients (16.0%) in the TCZ-treated group developed infections. CONCLUSION TCZ was associated with a lower likelihood of death despite resulting in higher infection rates and a non-significant longer hospital stay.
Collapse
Affiliation(s)
- Abeer Al-Baadani
- Infectious Diseases Unit, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Nazik Eltayeb
- Infectious Diseases Unit, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Eid Alsufyani
- Infectious Diseases Unit, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Salma Albahrani
- Infectious Diseases Unit, Dhahran General Hospital, Dhahran, Saudi Arabia
| | - Shareefah Basheri
- Pulmonary Medicine Unit, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Hawra Albayat
- Infectious Disease Unit, Imam Abdulrahman Al Faisal Hospital, Riyadh, Saudi Arabia
| | - Enas Batubara
- Pulmonary Medicine Unit, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Sulafa Ballool
- Infectious Disease Unit, Imam Abdulrahman Al Faisal Hospital, Riyadh, Saudi Arabia
| | - Ayed Al Assiri
- Infectious Disease Unit, Imam Abdulrahman Al Faisal Hospital, Riyadh, Saudi Arabia
| | - Fahad Faqihi
- Infectious Disease Unit, Imam Abdulrahman Al Faisal Hospital, Riyadh, Saudi Arabia
| | - Ali B Musa
- King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Asirvatham A Robert
- Department of Endocrinology and Diabetes, Prince Sultan Military Medical City, Saudi Arabia
| | - Nisreen Alsherbeeni
- Infectious Diseases Unit, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Fatehi Elzein
- Infectious Diseases Unit, Prince Sultan Military Medical City, Riyadh, Saudi Arabia.
| |
Collapse
|
22
|
Yin P, Meng J, Chen J, Gao J, Wang D, Liu S, Guo Q, Zhu M, Zhang G, Liu Y, Li Y, Zhang G. Antiviral drugs arbidol and interferon alpha-1b contribute to reducing the severity of COVID-19 patients: a retrospective cohort study. Virol J 2021; 18:142. [PMID: 34238341 PMCID: PMC8264997 DOI: 10.1186/s12985-021-01617-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 07/02/2021] [Indexed: 12/15/2022] Open
Abstract
Objectives The aim of this study was to evaluate the role of antiviral drugs in reducing the risk of developing severe illness in patients with moderate COVID-19 pneumonia. Methods This retrospective cohort study included 403 adult patients with moderate COVID-19 pneumonia who were admitted to Shenzhen Third People’s Hospital, China. The antiviral drugs arbidol, interferon alpha-1b, lopinavir–ritonavir and ribavirin were distributed to the patients for treatment. The primary endpoint of this study was the time to develop severe illness. Results Of the 462 patients admitted, 403 had moderate COVID-19 symptoms at hospital admission and were included in this study. 90 of the 403 (22.3%) patients progressed to severe illness. The use of arbidol was associated with a lower severity rate 3.5% compared to control group 30.5%, p-value < 0.0001; the adjusted hazard ratio was 0.28 (95% CI: 0.084–0.90, p = 0.033). The use of interferon alpha-1b was associated with a lower severity rate 15.5% compared to control group 29.3%, with p-value < 0.0001; the adjusted hazard ratio was 0.30 (95% CI: 0.15–0.58, p = 0.0005). The use of lopinavir–itonavir and ribavirin did not show significant differences in adjusted regression models. Early use of arbidol within 7 days of symptom onset was significantly associated with a reduced recovery time of − 5.2 days (IQR − 3.0 to − 7.5, p = 4e−06) compared with the control group. Conclusion Treatment with arbidol and interferon alpha-1b contributes to reducing the severity of illness in patients with moderate COVID-19 pneumonia. Early use of arbidol may reduce patients’ recovery time. Supplementary Information The online version contains supplementary material available at 10.1186/s12985-021-01617-w.
Collapse
Affiliation(s)
- Peng Yin
- Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, 518055, China
| | - Juan Meng
- National Clinical Research Center for Infectious Diseases, Shenzhen Third People's Hospital, Southern University of Science and Technology, Shenzhen, 518112, China
| | - Jincheng Chen
- Savaid Medical School, University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Junxiao Gao
- Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, 518055, China
| | - Dongqi Wang
- Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, 518055, China
| | - Shuyan Liu
- National Clinical Research Center for Infectious Diseases, Shenzhen Third People's Hospital, Southern University of Science and Technology, Shenzhen, 518112, China
| | - Qinglong Guo
- National Clinical Research Center for Infectious Diseases, Shenzhen Third People's Hospital, Southern University of Science and Technology, Shenzhen, 518112, China
| | - Muchun Zhu
- Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, 518055, China
| | - Gengwei Zhang
- National Clinical Research Center for Infectious Diseases, Shenzhen Third People's Hospital, Southern University of Science and Technology, Shenzhen, 518112, China
| | - Yingxia Liu
- National Clinical Research Center for Infectious Diseases, Shenzhen Third People's Hospital, Southern University of Science and Technology, Shenzhen, 518112, China.,Savaid Medical School, University of Chinese Academy of Sciences, Beijing, 100049, China
| | - Ye Li
- Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences, Shenzhen, 518055, China.
| | - Guoliang Zhang
- National Clinical Research Center for Infectious Diseases, Shenzhen Third People's Hospital, Southern University of Science and Technology, Shenzhen, 518112, China.
| |
Collapse
|
23
|
Conti V, Corbi G, Sellitto C, Sabbatino F, Maci C, Bertini N, De Bellis E, Iuliano A, Davinelli S, Pagliano P, Filippelli A. Effect of Tocilizumab in Reducing the Mortality Rate in COVID-19 Patients: A Systematic Review with Meta-Analysis. J Pers Med 2021; 11:jpm11070628. [PMID: 34357095 PMCID: PMC8307114 DOI: 10.3390/jpm11070628] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 06/27/2021] [Accepted: 06/28/2021] [Indexed: 02/07/2023] Open
Abstract
Data supporting the use of Tocilizumab (TCZ) in COVID-19 are contrasting and inconclusive. This meta-analysis aimed to assess TCZ effectiveness in reducing the mortality rate in COVID-19 patients. PubMed, Scopus, Embase, Cochrane, WILEY, and ClinicalTrials.gov were searched to evaluate observational studies and RCTs. The outcome was the mortality rate. Forty observational studies and seven RCTs, involving 9640 and 5556 subjects treated with Standard Therapy (ST) + TCZ or ST alone, respectively, were included. In patients treated with ST+TCZ, a higher survival (Log odds ratio = −0.41; 95% CI: −0.68 −0.14; p < 0.001) was found. Subgroups analyses were performed to better identify the possible interference of some parameters in modifying the efficacy of TCZ therapy on COVID-19 mortality. Separating observational from RCTs, no statistically significant (p = 0.70) TCZ-related reduction of mortality regarding RCTs was found, while a significant reduction (Log odds ratio = −0.52; 95% CI: −0.82 −0.22, p < 0.001) was achieved regarding the observational studies. Stratifying for the use of Invasive Mechanic Ventilation (IMV), a higher survival was found in patients treated with TCZ in the No-IMV and IMV groups (both p < 0.001), but not in the No-IMV/IMV group. Meta-regression analyses were also performed. The meta-analysis of observational studies reveals that TCZ is associated with reducing the mortality rate in both severe and critically ill patients. Although the largest RCT, RECOVERY, is in line with this result, the meta-analysis of RCTs failed to found any difference between ST + TCZ and ST. It is crucial to personalize the therapy considering the patients’ characteristics.
Collapse
Affiliation(s)
- Valeria Conti
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Salerno, Italy; (V.C.); (C.S.); (F.S.); (C.M.); (N.B.); (E.D.B.); (A.I.); (P.P.); (A.F.)
- Clinical Pharmacology and Pharmacogenetics Unit, University Hospital “San Giovanni di Dio e Ruggi D’Aragona”, 84125 Salerno, Italy
| | - Graziamaria Corbi
- Department of Medicine and Health Sciences, University of Molise, 86100 Campobasso, Italy;
- Italian Society of Gerontology and Geriatrics (SIGG), Via G.C. Vanini, 5, 50129 Firenze, Italy
- Correspondence: ; Tel.: +39-0874404771
| | - Carmine Sellitto
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Salerno, Italy; (V.C.); (C.S.); (F.S.); (C.M.); (N.B.); (E.D.B.); (A.I.); (P.P.); (A.F.)
| | - Francesco Sabbatino
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Salerno, Italy; (V.C.); (C.S.); (F.S.); (C.M.); (N.B.); (E.D.B.); (A.I.); (P.P.); (A.F.)
- Oncology Unit, University Hospital San Giovanni di Dio e Ruggi D’Aragona, 84125 Salerno, Italy
| | - Chiara Maci
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Salerno, Italy; (V.C.); (C.S.); (F.S.); (C.M.); (N.B.); (E.D.B.); (A.I.); (P.P.); (A.F.)
| | - Nicola Bertini
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Salerno, Italy; (V.C.); (C.S.); (F.S.); (C.M.); (N.B.); (E.D.B.); (A.I.); (P.P.); (A.F.)
| | - Emanuela De Bellis
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Salerno, Italy; (V.C.); (C.S.); (F.S.); (C.M.); (N.B.); (E.D.B.); (A.I.); (P.P.); (A.F.)
| | - Antonio Iuliano
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Salerno, Italy; (V.C.); (C.S.); (F.S.); (C.M.); (N.B.); (E.D.B.); (A.I.); (P.P.); (A.F.)
| | - Sergio Davinelli
- Department of Medicine and Health Sciences, University of Molise, 86100 Campobasso, Italy;
| | - Pasquale Pagliano
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Salerno, Italy; (V.C.); (C.S.); (F.S.); (C.M.); (N.B.); (E.D.B.); (A.I.); (P.P.); (A.F.)
- Infectious Diseases Unit, Hospital San Giovanni di Dio e Ruggi D’Aragona, 84125 Salerno, Italy
| | - Amelia Filippelli
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84081 Salerno, Italy; (V.C.); (C.S.); (F.S.); (C.M.); (N.B.); (E.D.B.); (A.I.); (P.P.); (A.F.)
- Clinical Pharmacology and Pharmacogenetics Unit, University Hospital “San Giovanni di Dio e Ruggi D’Aragona”, 84125 Salerno, Italy
| |
Collapse
|
24
|
SARFRAZ A, SARFRAZ Z, SARFRAZ M, AFTAB H, PERVAIZ Z. Tocilizumab and COVID-19: a meta-analysis of 2120 patients with severe disease and implications for clinical trial methodologies. Turk J Med Sci 2021; 51:890-897. [PMID: 33244947 PMCID: PMC8283492 DOI: 10.3906/sag-2010-131] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 11/26/2020] [Indexed: 12/18/2022] Open
Abstract
Background/aim Since the outbreak of the COVID-19, numerous therapies to counteract this severe disease have emerged. The benefits of Tocilizumab for severely infected COVID-19 patients and the methodologies of ongoing clinical trials are explored. Materials and methods A systematic search adhering to PRISMA guidelines was conducted in PubMed, Cochrane Central, medRxiv, and bioRxiv using the following keywords: “Tocilizumab,” “Actemra,” “COVID-19.” An additional subsearch was conducted on Clinicaltrials.gov to locate ongoing tocilizumab trials. Results A total of 13 studies were included in the meta-analysis comprising 2120 patients. The treatment group had lower mortality compared to the control group (OR = 0.42, 95% CI = 0.26 to 0.69, P = 0.0005, I2 = 55%). A descriptive analysis of 50 registered trials was conducted. Conclusion This review meta-analyzed the therapeutic benefits of tocilizumab in COVID-19 patients with severe disease for mortality, mechanical ventilation, and the characteristics of COVID-19 registered trials.
Collapse
Affiliation(s)
- Azza SARFRAZ
- Department of Pediatrics and Child Health, Aga Khan University, KarachiPakistan
| | - Zouina SARFRAZ
- Research Department, Fatima Jinnah Medical University, LahorePakistan
| | - Muzna SARFRAZ
- Department of Physiology, CMH Lahore Medical and Dental College, LahorePakistan
| | - Hinna AFTAB
- Research Department CMH Lahore Medical and Dental College, LahorePakistan
| | - Zainab PERVAIZ
- Research Department CMH Lahore Medical and Dental College, LahorePakistan
| |
Collapse
|
25
|
Ramos da Silva S, Ju E, Meng W, Paniz Mondolfi AE, Dacic S, Green A, Bryce C, Grimes Z, Fowkes M, Sordillo EM, Cordon-Cardo C, Guo H, Gao SJ. Broad Severe Acute Respiratory Syndrome Coronavirus 2 Cell Tropism and Immunopathology in Lung Tissues From Fatal Coronavirus Disease 2019. J Infect Dis 2021; 223:1842-1854. [PMID: 33837392 PMCID: PMC8083355 DOI: 10.1093/infdis/jiab195] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 04/05/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) patients manifest with pulmonary symptoms reflected by diffuse alveolar damage (DAD), excessive inflammation, and thromboembolism. The mechanisms mediating these processes remain unclear. METHODS We performed multicolor staining for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) proteins and lineage markers to define viral tropism and lung pathobiology in 5 autopsy cases. RESULTS Lung parenchyma showed severe DAD with thromboemboli. Viral infection was found in an extensive range of cells including pneumocyte type II, ciliated, goblet, club-like, and endothelial cells. More than 90% of infiltrating immune cells were positive for viral proteins including macrophages, monocytes, neutrophils, natural killer (NK) cells, B cells, and T cells. Most but not all infected cells were angiotensin-converting enzyme 2 (ACE2) positive. The numbers of infected and ACE2-positive cells are associated with extensive tissue damage. Infected tissues exhibited high levels of inflammatory cells including macrophages, monocytes, neutrophils, and NK cells, and low levels of B cells but abundant T cells consisting of mainly T helper cells, few cytotoxic T cells, and no regulatory T cells. Robust interleukin-6 expression was present in most cells, with or without infection. CONCLUSIONS In fatal COVID-19 lungs, there are broad SARS-CoV-2 cell tropisms, extensive infiltrated innate immune cells, and activation and depletion of adaptive immune cells, contributing to severe tissue damage, thromboemboli, excess inflammation, and compromised immune responses.
Collapse
Affiliation(s)
- Suzane Ramos da Silva
- Cancer Virology Program, University of Pittsburgh Medical Center Hillman Cancer Center, Pittsburgh, Pennsylvania, USA.,Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Enguo Ju
- Cancer Virology Program, University of Pittsburgh Medical Center Hillman Cancer Center, Pittsburgh, Pennsylvania, USA.,Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Wen Meng
- Cancer Virology Program, University of Pittsburgh Medical Center Hillman Cancer Center, Pittsburgh, Pennsylvania, USA.,Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Alberto E Paniz Mondolfi
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sanja Dacic
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Anthony Green
- Tissue and Research Pathology Core, University of Pittsburgh Medical Center Hillman Cancer Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Clare Bryce
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Zachary Grimes
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mary Fowkes
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Emilia M Sordillo
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Carlos Cordon-Cardo
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Haitao Guo
- Cancer Virology Program, University of Pittsburgh Medical Center Hillman Cancer Center, Pittsburgh, Pennsylvania, USA.,Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Shou-Jiang Gao
- Cancer Virology Program, University of Pittsburgh Medical Center Hillman Cancer Center, Pittsburgh, Pennsylvania, USA.,Department of Microbiology and Molecular Genetics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
26
|
Almas A, Mushtaq Z, Moller J. Acuity level of care as a predictor of case fatality and prolonged hospital stay in patients with COVID-19: a hospital-based observational follow-up study from Pakistan. BMJ Open 2021; 11:e045414. [PMID: 34049912 PMCID: PMC8166477 DOI: 10.1136/bmjopen-2020-045414] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 05/17/2021] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES To determine if there is an association between acuity level of care (ALC), case fatality and length of stay in patients admitted to hospital due to COVID-19. DESIGN A hospital-based observational follow-up study. SETTING Internal Medicine Service of the Aga Khan University Hospital, Pakistan, from 26 February 2020 to 30 June 2020. PARTICIPANTS Adult patients with confirmed COVID-19, aged ≥18 years. METHODS ALC was categorised into low, intermediate and high level and patients were triaged using the standard emergency severity illness score. All patients were followed until the end of hospital admission for the outcome of case fatality and length of stay. RESULTS A total of 822 patients with COVID-19 were admitted during the study period and 699 met inclusion criteria. The mean age was 54.5 years and 67% were males; 50.4% were triaged to low, 42.5% to intermediate and 7.2% to high acuity care. The overall case-fatality rate was 11.6%, with the highest (52%) in high acuity level followed by 16.2% in intermediate and 2% in low acuity care. Acuity level was associated with case fatality, with an HR (95% CI) of 5.0 (2.0 to 12.1) for high versus low acuity care and an HR of 2.7 (1.2, 6.4) for intermediate versus low acuity care, after adjusting for age, sex and common comorbidities including diabetes, hypertension, ischaemic heart disease and chronic lung disease. Similarly, acuity level was also associated with length of hospital stay. CONCLUSION High and intermediate acuity level is associated with higher case fatality rate and prolonged length of hospital stay in patients admitted with COVID-19. In resource-limited settings where the provision of high acuity care is limited, the intermediate care acuity could serve as a useful strategy to treat relatively less critical patients with COVID-19.
Collapse
Affiliation(s)
- Aysha Almas
- Medicine, Aga Khan University, Karachi, Pakistan
| | - Zain Mushtaq
- Medicine, Aga Khan University, Karachi, Pakistan
| | - Jette Moller
- Global Public Health, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
27
|
Wei Q, Lin H, Wei RG, Chen N, He F, Zou DH, Wei JR. Tocilizumab treatment for COVID-19 patients: a systematic review and meta-analysis. Infect Dis Poverty 2021; 10:71. [PMID: 34001244 PMCID: PMC8128625 DOI: 10.1186/s40249-021-00857-w] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 05/07/2021] [Indexed: 02/08/2023] Open
Abstract
Background Coronavirus disease 2019 (COVID-19) has killed over 2.5 million people worldwide, but effective care and therapy have yet to be discovered. We conducted this analysis to better understand tocilizumab treatment for COVID-19 patients. Main text We searched major databases for manuscripts reporting the effects of tocilizumab on COVID-19 patients. A total of 25 publications were analyzed with Revman 5.3 and R for the meta-analysis. Significant better clinical outcomes were found in the tocilizumab treatment group when compared to the standard care group [odds ratio (OR) = 0.70, 95% confidential interval (C): 0.54–0.90, P = 0.007]. Tocilizumab treatment showed a stronger correlation with good prognosis among COVID-19 patients that needed mechanical ventilation (OR = 0.59, 95% CI, 0.37–0.93, P = 0.02). Among stratified analyses, reduction of overall mortality correlates with tocilizumab treatment in patients less than 65 years old (OR = 0.68, 95% CI: 0.60–0.77, P < 0.00001), and with intensive care unit patients (OR = 0.62, 95% CI: 0.55–0.70, P < 0.00001). Pooled estimates of hazard ratio showed that tocilizumab treatment predicts better overall survival in COVID-19 patients (HR = 0.45, 95% CI: 0.24–0.84, P = 0.01), especially in severe cases (HR = 0.58, 95% CI 0.49–0.68, P < 0.00001). Conclusions Our study shows that tocilizumab treatment is associated with a lower risk of mortality and mechanical ventilation requirement among COVID-19 patients. Tocilizumab may have substantial effectiveness in reducing mortality among COVID-19 patients, especially among critical cases. This systematic review provides an up-to-date evidence of potential therapeutic role of tocilizumab in COVID-19 management. Graphical abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1186/s40249-021-00857-w.
Collapse
Affiliation(s)
- Qiu Wei
- Department of Respiratory and Critical Care, The Fifth Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530022, People's Republic of China.,Clinical Medical Laboratory Center, The Fifth Affiliated Hospital of Guangxi Medical University, 89 Qixing Road, Nanning, 530022, Guangxi, China
| | - Hua Lin
- Clinical Medical Laboratory Center, The Fifth Affiliated Hospital of Guangxi Medical University, 89 Qixing Road, Nanning, 530022, Guangxi, China
| | - Rong-Guo Wei
- Clinical Medical Laboratory Center, The Fifth Affiliated Hospital of Guangxi Medical University, 89 Qixing Road, Nanning, 530022, Guangxi, China
| | - Nian Chen
- Department of Infectious Diseases, The Fifth Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530022, People's Republic of China
| | - Fan He
- Department of Hematology, School of Medicine, Washington University in St Louis, St. Louis, MO, 63130, USA
| | - Dong-Hua Zou
- Clinical Medical Laboratory Center, The Fifth Affiliated Hospital of Guangxi Medical University, 89 Qixing Road, Nanning, 530022, Guangxi, China.
| | - Jin-Ru Wei
- Clinical Medical Laboratory Center, The Fifth Affiliated Hospital of Guangxi Medical University, 89 Qixing Road, Nanning, 530022, Guangxi, China.
| |
Collapse
|
28
|
Hu Q, Xu Y, Xiang Y, Wang B, Yuan Z, Shan Y, Zhang W, Wu N, Xia T, Li C, Xie W, Jia X, Yu Z, Bai L, Li Y. Inflammation characteristics and anti-inflammation treatment with tocilizumab of severe/critical COVID-19 patients: A retrospective cohort study. Int J Biol Sci 2021; 17:2124-2134. [PMID: 34131411 PMCID: PMC8193270 DOI: 10.7150/ijbs.56952] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 05/03/2021] [Indexed: 01/09/2023] Open
Abstract
The efficacy of tocilizumab on the prognosis of severe/critical COVID-19 patients is still controversial so far. We aimed to delineate the inflammation characteristics of severe/critical COVID-19 patients and determine the impact of tocilizumab on hospital mortality. Here, we performed a retrospective cohort study which enrolled 727 severe or critical inpatients (≥18 years old) with laboratory-confirmed COVID-19 from Huoshenshan Hospital (Wuhan, China), among which 50 patients received tocilizumab. This study confirmed that most recovered patients manifested relatively normal inflammation levels at admission, whereas most of the deceased cases presented visibly severe inflammation at admission and even progressed into extremely aggravated inflammation before their deaths, proved by some extremely high concentrations of interleukin-6, procalcitonin, C-reactive protein and neutrophil count. Moreover, based on the Cox proportional-hazards models before or after propensity score matching, we demonstrated that tocilizumab treatment could lessen mortality by gradually alleviating excessive inflammation and meanwhile continuously enhancing the levels of lymphocytes within 14 days for severe/critical COVID-19 patients, indicating potential effectiveness for treating COVID-19.
Collapse
Affiliation(s)
- Qin Hu
- Department of Epidemiology, College of Preventive Medicine, Army Medical University (Third Military Medical University), Chongqing 400038, People's Republic of China
| | - Yu Xu
- Department of Respiratory and Critical Care Medicine, the Second Affiliated Hospital of Army Medical University, Chongqing 400037, People's Republic of China
| | - Ying Xiang
- Department of Epidemiology, College of Preventive Medicine, Army Medical University (Third Military Medical University), Chongqing 400038, People's Republic of China
| | - Bin Wang
- Department of Respiratory and Critical Care Medicine, the Second Affiliated Hospital of Army Medical University, Chongqing 400037, People's Republic of China
| | - Zhiquan Yuan
- Department of Epidemiology, College of Preventive Medicine, Army Medical University (Third Military Medical University), Chongqing 400038, People's Republic of China
| | - Yifan Shan
- Department of Epidemiology, College of Preventive Medicine, Army Medical University (Third Military Medical University), Chongqing 400038, People's Republic of China
| | - Wenjing Zhang
- Department of Respiratory and Critical Care Medicine, the Second Affiliated Hospital of Army Medical University, Chongqing 400037, People's Republic of China
| | - Na Wu
- Department of Epidemiology, College of Preventive Medicine, Army Medical University (Third Military Medical University), Chongqing 400038, People's Republic of China
| | - Tingting Xia
- Department of Epidemiology, College of Preventive Medicine, Army Medical University (Third Military Medical University), Chongqing 400038, People's Republic of China
| | - Chengying Li
- Department of Epidemiology, College of Preventive Medicine, Army Medical University (Third Military Medical University), Chongqing 400038, People's Republic of China
| | - Weijia Xie
- Department of Epidemiology, College of Preventive Medicine, Army Medical University (Third Military Medical University), Chongqing 400038, People's Republic of China
| | - Xiaoyue Jia
- Department of Epidemiology, College of Preventive Medicine, Army Medical University (Third Military Medical University), Chongqing 400038, People's Republic of China
| | - Zubin Yu
- Department of Thoracic Surgery, the Second Affiliated Hospital of Army Medical University, Chongqing 400037, People's Republic of China
| | - Li Bai
- Department of Respiratory and Critical Care Medicine, the Second Affiliated Hospital of Army Medical University, Chongqing 400037, People's Republic of China
| | - Yafei Li
- Department of Epidemiology, College of Preventive Medicine, Army Medical University (Third Military Medical University), Chongqing 400038, People's Republic of China
| |
Collapse
|
29
|
Hariyanto TI, Hardyson W, Kurniawan A. Efficacy and Safety of Tocilizumab for Coronavirus Disease 2019 (Covid-19) Patients: A Systematic Review and Meta-analysis. Drug Res (Stuttg) 2021; 71:265-274. [PMID: 33401328 DOI: 10.1055/a-1336-2371] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Currently, the data regarding the effectiveness and safety of tocilizumab as treatment for COVID-19 infection is still conflicting. This study aims to give clear evidence regarding the potential benefit and safety of tocilizumab in improving the outcome of COVID-19 patients. METHODS We systematically searched the PubMed and Europe PMC database using specific keywords related to our aims until November 1st, 2020. All articles published on COVID-19 and tocilizumab were retrieved. Statistical analysis was done using Review Manager 5.4 software. RESULTS A total of 38 studies with a total of 13 412 COVID-19 patients were included in our analysis. Our meta-analysis showed that tocilizumab treatment is associated with reduction of mortality rate from COVID-19 [OR 0.54 (95% CI 0.42-0.71), p<0.00001, I 2=79%, random-effect modelling], but did not alter the severity of COVID-19 [OR 1.05 (95% CI 0.92-1.20), p=0.47, I 2=84%, random-effect modelling] and length of hospital stay [Mean Difference 1.77 days (95% CI -0.61-4.14 days), p=0.15, I 2=97%, random-effect modelling]. Tocilizumab also does not associated with serious adverse events compared with standard of care treatment [OR 0.91 (95% CI 0.71-1.15), p=0.42, I 2=46%, random-effect modelling]. CONCLUSION Our study does not support the routine use of tocilizumab for COVID-19 patients. Future studies should focus more on other potential therapies for COVID-19 patients.
Collapse
Affiliation(s)
| | - Willie Hardyson
- Faculty of Medicine, Pelita Harapan University, Karawaci, Tangerang, Indonesia
| | - Andree Kurniawan
- Department of Internal Medicine, Faculty of Medicine, Pelita Harapan University, Karawaci, Tangerang, Indonesia
| |
Collapse
|
30
|
Pelaia C, Calabrese C, Garofalo E, Bruni A, Vatrella A, Pelaia G. Therapeutic Role of Tocilizumab in SARS-CoV-2-Induced Cytokine Storm: Rationale and Current Evidence. Int J Mol Sci 2021; 22:3059. [PMID: 33802761 PMCID: PMC8002419 DOI: 10.3390/ijms22063059] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/15/2021] [Accepted: 03/15/2021] [Indexed: 12/15/2022] Open
Abstract
Among patients suffering from coronavirus disease 2019 (COVID-19) syndrome, one of the worst possible scenarios is represented by the critical lung damage caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2)-induced cytokine storm, responsible for a potentially very dangerous hyperinflammatory condition. Within such a context, interleukin-6 (IL-6) plays a key pathogenic role, thus being a suitable therapeutic target. Indeed, the IL-6-receptor antagonist tocilizumab, already approved for treatment of refractory rheumatoid arthritis, is often used to treat patients with severe COVID-19 symptoms and lung involvement. Therefore, the aim of this review article is to focus on the rationale of tocilizumab utilization in the SARS-CoV-2-triggered cytokine storm, as well as to discuss current evidence and future perspectives, especially with regard to ongoing trials referring to the evaluation of tocilizumab's therapeutic effects in patients with life-threatening SARS-CoV-2 infection.
Collapse
Affiliation(s)
- Corrado Pelaia
- Department of Health Sciences, University "Magna Graecia" of Catanzaro, 88100 Catanzaro, Italy
| | - Cecilia Calabrese
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", 80131 Naples, Italy
| | - Eugenio Garofalo
- Department of Experimental and Clinical Medicine, University "Magna Graecia" of Catanzaro, 88100 Catanzaro, Italy
| | - Andrea Bruni
- Department of Experimental and Clinical Medicine, University "Magna Graecia" of Catanzaro, 88100 Catanzaro, Italy
| | - Alessandro Vatrella
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84084 Salerno, Italy
| | - Girolamo Pelaia
- Department of Health Sciences, University "Magna Graecia" of Catanzaro, 88100 Catanzaro, Italy
| |
Collapse
|
31
|
Olbei M, Hautefort I, Modos D, Treveil A, Poletti M, Gul L, Shannon-Lowe CD, Korcsmaros T. SARS-CoV-2 Causes a Different Cytokine Response Compared to Other Cytokine Storm-Causing Respiratory Viruses in Severely Ill Patients. Front Immunol 2021; 12:629193. [PMID: 33732251 PMCID: PMC7956943 DOI: 10.3389/fimmu.2021.629193] [Citation(s) in RCA: 69] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 01/29/2021] [Indexed: 12/21/2022] Open
Abstract
Hyper-induction of pro-inflammatory cytokines, also known as a cytokine storm or cytokine release syndrome (CRS), is one of the key aspects of the currently ongoing SARS-CoV-2 pandemic. This process occurs when a large number of innate and adaptive immune cells activate and start producing pro-inflammatory cytokines, establishing an exacerbated feedback loop of inflammation. It is one of the factors contributing to the mortality observed with coronavirus 2019 (COVID-19) for a subgroup of patients. CRS is not unique to the SARS-CoV-2 infection; it was prevalent in most of the major human coronavirus and influenza A subtype outbreaks of the past two decades (H5N1, SARS-CoV, MERS-CoV, and H7N9). With a comprehensive literature search, we collected changing the cytokine levels from patients upon infection with the viral pathogens mentioned above. We analyzed published patient data to highlight the conserved and unique cytokine responses caused by these viruses. Our curation indicates that the cytokine response induced by SARS-CoV-2 is different compared to other CRS-causing respiratory viruses, as SARS-CoV-2 does not always induce specific cytokines like other coronaviruses or influenza do, such as IL-2, IL-10, IL-4, or IL-5. Comparing the collated cytokine responses caused by the analyzed viruses highlights a SARS-CoV-2-specific dysregulation of the type-I interferon (IFN) response and its downstream cytokine signatures. The map of responses gathered in this study could help specialists identify interventions that alleviate CRS in different diseases and evaluate whether they could be used in the COVID-19 cases.
Collapse
Affiliation(s)
- Marton Olbei
- Earlham Institute, Norwich, United Kingdom
- Gut Microbes and Health Programme, Quadram Institute Bioscience, Norwich, United Kingdom
| | | | - Dezso Modos
- Earlham Institute, Norwich, United Kingdom
- Gut Microbes and Health Programme, Quadram Institute Bioscience, Norwich, United Kingdom
| | - Agatha Treveil
- Earlham Institute, Norwich, United Kingdom
- Gut Microbes and Health Programme, Quadram Institute Bioscience, Norwich, United Kingdom
| | - Martina Poletti
- Earlham Institute, Norwich, United Kingdom
- Gut Microbes and Health Programme, Quadram Institute Bioscience, Norwich, United Kingdom
| | - Lejla Gul
- Earlham Institute, Norwich, United Kingdom
| | - Claire D. Shannon-Lowe
- Institute of Immunology and Immunotherapy, The University of Birmingham, Birmingham, United Kingdom
| | - Tamas Korcsmaros
- Earlham Institute, Norwich, United Kingdom
- Gut Microbes and Health Programme, Quadram Institute Bioscience, Norwich, United Kingdom
| |
Collapse
|
32
|
Nugroho CW, Suryantoro SD, Yuliasih Y, Rosyid AN, Asmarawati TP, Andrianto L, Setiawan HW, Mahdi BA, Windradi C, Agustin ED, Fajar JK. Optimal use of tocilizumab for severe and critical COVID-19: a systematic review and meta-analysis. F1000Res 2021; 10:73. [PMID: 33763201 PMCID: PMC7953915 DOI: 10.12688/f1000research.45046.1] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/28/2021] [Indexed: 01/09/2023] Open
Abstract
Background: Several studies have revealed the potential use of tocilizumab in treating COVID-19 since no therapy has yet been approved for COVID-19 pneumonia. Tocilizumab may provide clinical benefits for cytokine release syndrome in COVID-19 patients. Methods: We searched for relevant studies in PubMed, Embase, Medline, and Cochrane published from March to October 2020 to evaluate optimal use and baseline criteria for administration of tocilizumab in severe and critically ill COVID-19 patients. Research involving patients with confirmed SARS-CoV-2 infection, treated with tocilizumab and compared with the standard of care (SOC) was included in this study. We conducted a systematic review to find data about the risks and benefits of tocilizumab and outcomes from different baseline criteria for administration of tocilizumab as a treatment for severe and critically ill COVID-19 patients. Results: A total of 26 studies, consisting of 23 retrospective studies, one prospective study, and two randomised controlled trials with 2112 patients enrolled in the tocilizumab group and 6160 patients in the SOC group, were included in this meta-analysis. Compared to the SOC, tocilizumab showed benefits for all-cause mortality events and a shorter time until death after first intervention but showed no difference in hospital length of stay. Upon subgroup analysis, tocilizumab showed fewer all-cause mortality events when CRP level ≥100 mg/L, P/F ratio 200-300 mmHg, and P/F ratio <200 mmHg. However, tocilizumab showed a longer length of stay when CRP <100 mg/L than the SOC. Conclusion: This meta-analysis demonstrated that tocilizumab has a positive effect on all-cause mortality. It should be cautiously administrated for optimal results and tailored to the patient's eligibility criteria.
Collapse
Affiliation(s)
- Cahyo Wibisono Nugroho
- Department of Internal Medicine, Faculty of Medicine, Airlangga University, Surabaya, East Java, 60132, Indonesia
- Universitas Airlangga Hospital, Surabaya, East Java, 60115, Indonesia
| | - Satriyo Dwi Suryantoro
- Department of Internal Medicine, Faculty of Medicine, Airlangga University, Surabaya, East Java, 60132, Indonesia
- Universitas Airlangga Hospital, Surabaya, East Java, 60115, Indonesia
| | - Yuliasih Yuliasih
- Department of Internal Medicine, Faculty of Medicine, Airlangga University, Surabaya, East Java, 60132, Indonesia
| | - Alfian Nur Rosyid
- Universitas Airlangga Hospital, Surabaya, East Java, 60115, Indonesia
- Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, Airlangga University, Surabaya, East Java, 60132, Indonesia
| | - Tri Pudy Asmarawati
- Department of Internal Medicine, Faculty of Medicine, Airlangga University, Surabaya, East Java, 60132, Indonesia
- Universitas Airlangga Hospital, Surabaya, East Java, 60115, Indonesia
| | - Lucky Andrianto
- Universitas Airlangga Hospital, Surabaya, East Java, 60115, Indonesia
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Airlangga University, Surabaya, East Java, 60132, Indonesia
| | - Herley Windo Setiawan
- Universitas Airlangga Hospital, Surabaya, East Java, 60115, Indonesia
- Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, Airlangga University, Surabaya, East Java, 60132, Indonesia
| | - Bagus Aulia Mahdi
- Department of Internal Medicine, Faculty of Medicine, Airlangga University, Surabaya, East Java, 60132, Indonesia
| | - Choirina Windradi
- Department of Internal Medicine, Faculty of Medicine, Airlangga University, Surabaya, East Java, 60132, Indonesia
| | | | - Jonny Karunia Fajar
- Department of Internal Medicine, Faculty of Medicine, Brawijaya University, Malang, East Java, 65145, Indonesia
| |
Collapse
|
33
|
Tleyjeh IM, Kashour Z, Damlaj M, Riaz M, Tlayjeh H, Altannir M, Altannir Y, Al-Tannir M, Tleyjeh R, Hassett L, Kashour T. Efficacy and safety of tocilizumab in COVID-19 patients: a living systematic review and meta-analysis. Clin Microbiol Infect 2021; 27:215-227. [PMID: 33161150 PMCID: PMC7644182 DOI: 10.1016/j.cmi.2020.10.036] [Citation(s) in RCA: 130] [Impact Index Per Article: 43.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 10/26/2020] [Accepted: 10/29/2020] [Indexed: 01/22/2023]
Abstract
OBJECTIVES Cytokine release syndrome with elevated interleukin-6 (IL-6) levels is associated with multiorgan damage and death in severe coronavirus disease 2019 (COVID-19). Our objective was to perform a living systematic review of the literature concerning the efficacy and toxicity of the IL-6 receptor antagonist tocilizumab in COVID-19 patients. METHODS Data sources were Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily, Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, Web of Science, Scopus up, preprint servers and Google up to October 8, 2020. Study eligibility criteria were randomized controlled trials (RCTs) and observational studies at low or moderate risk of bias. Participants were hospitalized COVID-19 patients. Interventions included tocilizumab versus placebo or standard of care. We pooled crude risk ratios (RRs) of RCTs and adjusted RRs from cohorts, separately. We evaluated inconsistency between studies with I2. We assessed the certainty of evidence using the GRADE approach. RESULTS Of 1156 citations, 24 studies were eligible (five RCTs and 19 cohorts). Five RCTs at low risk of bias, with 1325 patients, examined the effect of tocilizumab on short-term mortality; pooled RR was 1.09 (95%CI 0.80-1.49, I2 = 0%). Four RCTs with 771 patients examined the effect of tocilizumab on risk of mechanical ventilation; pooled RR was 0.71 (95%CI 0.52-0.96, I2 = 0%), with a corresponding number needed to treat of 17 (95%CI 9-100). Among 18 cohorts at moderate risk of bias with 9850 patients, the pooled adjusted RR for mortality was 0.58 (95%CI 0.51-0.66, I2 = 2.5%). This association was observed over all degrees of COVID-19 severity. Data from the RCTs did not show a higher risk of infections or adverse events with tocilizumab: pooled RR 0.63 (95%CI 0.38-1.06, five RCTs) and 0.83 (95%CI 0.55-1.24, five RCTs), respectively. CONCLUSIONS Cumulative moderate-certainty evidence shows that tocilizumab reduces the risk of mechanical ventilation in hospitalized COVID-19 patients. While RCTs showed that tocilizumab did not reduce short-term mortality, low-certainty evidence from cohort studies suggests an association between tocilizumab and lower mortality. We did not observe a higher risk of infections or adverse events with tocilizumab use. This review will continuously evaluate the role of tocilizumab in COVID-19 treatment.
Collapse
Affiliation(s)
- Imad M Tleyjeh
- Infectious Diseases Section, Department of Medical Specialties King Fahad Medical City, Riyadh, Saudi Arabia; College of Medicine, Alfaisal University, Riyadh, Saudi Arabia; Division of Infectious Diseases, Mayo Clinic College of Medicine and Science, Rochester, MN, USA; Division of Epidemiology, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.
| | - Zakariya Kashour
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Moussab Damlaj
- Division of Hematology and HSCT, Department of Oncology, King Abdulaziz Medical City, Riyadh, Saudi Arabia; King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Muhammad Riaz
- Department of Public Health, College of Health Sciences, Qatar University, Doha, Qatar
| | - Haytham Tlayjeh
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; King Abdullah International Medical Research Center, Riyadh, Saudi Arabia; Department of Intensive Care, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | | | | | | | - Rana Tleyjeh
- College of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | | | - Tarek Kashour
- Department of Cardiac Sciences, King Fahad Cardiac Center, King Saud University Medical City, Riyadh, Saudi Arabia
| |
Collapse
|
34
|
Coloretti I, Busani S, Biagioni E, Venturelli S, Munari E, Sita M, DallAra L, Tosi M, Clini E, Tonelli R, Fantini R, Mussini C, Meschiari M, Guaraldi G, Cossarizza A, Alfano G, Girardis M. Effects of cytokine blocking agents on hospital mortality in patients admitted to ICU with acute respiratory distress syndrome by SARS-CoV-2 infection: retrospective cohort study. Multidiscip Respir Med 2021; 16:737. [PMID: 34040779 PMCID: PMC8139121 DOI: 10.4081/mrm.2021.737] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 02/19/2021] [Indexed: 01/08/2023] Open
Abstract
Background The use of cytokine-blocking agents has been proposed to modulate the inflammatory response in patients with COVID-19. Tocilizumab and anakinra were included in the local protocol as an optional treatment in critically ill patients with acute respiratory distress syndrome (ARDS) by SARS-CoV-2 infection. This cohort study evaluated the effects of therapy with cytokine blocking agents on in-hospital mortality in COVID-19 patients requiring mechanical ventilation and admitted to intensive care unit. Methods The association between therapy with tocilizumab or anakinra and in-hospital mortality was assessed in consecutive adult COVID-19 patients admitted to our ICU with moderate to severe ARDS. The association was evaluated by comparing patients who received to those who did not receive tocilizumab or anakinra and by using different multivariable Cox models adjusted for variables related to poor outcome, for the propensity to be treated with tocilizumab or anakinra and after patient matching. Results Sixty-six patients who received immunotherapy (49 tocilizumab, 17 anakinra) and 28 patients who did not receive immunotherapy were included. The in-hospital crude mortality was 30,3% in treated patients and 50% in nontreated (OR 0.77, 95% CI 0.56-1.05, p=0.069). The adjusted Cox model showed an association between therapy with immunotherapy and in-hospital mortality (HR 0.40, 95% CI 0.19-0.83, p=0.015). This protective effect was further confirmed in the analysis adjusted for propensity score, in the propensity-matched cohort and in the cohort of patients with invasive mechanical ventilation within 2 hours after ICU admission. Conclusions Although important limitations, our study showed that cytokine-blocking agents seem to be safe and to improve survival in COVID-19 patients admitted to ICU with ARDS and the need for mechanical ventilation.
Collapse
Affiliation(s)
| | | | | | | | - Elena Munari
- Intensive Care Unit, University Hospital of Modena
| | - Marco Sita
- Intensive Care Unit, University Hospital of Modena
| | | | - Martina Tosi
- Intensive Care Unit, University Hospital of Modena
| | - Enrico Clini
- Respiratory Disease Unit, University Hospital of Modena
| | | | | | | | | | | | | | - Gaetano Alfano
- Nephrology Dialysis and Transplant Unit, University Hospital of Modena, Italy
| | - Massimo Girardis
- Intensive Care Unit, University Hospital of Modena.,Respiratory Disease Unit, University Hospital of Modena.,Infectious Disease Unit, University Hospital of Modena.,Immunology Laboratory, University of Modena and Reggio Emilia.,Nephrology Dialysis and Transplant Unit, University Hospital of Modena, Italy
| |
Collapse
|
35
|
Abstract
The primary objective was to evaluate ICU mortality at 28 days in patients with severe hypoxemic respiratory failure due to coronavirus disease 2019 infection who received tocilizumab. The secondary objectives were to evaluate ICU-, hospital-, mechanical ventilation-, and vasopressor-free days at day 28 and development of secondary infections. Design Retrospective, observational, multicenter, cohort study between March 15, 2020, and May 31, 2020. Using propensity score matching based on ICU admission source, C-reactive protein, Sequential Organ Failure Assessment score, vasopressor use, age, race, weight, and mechanical ventilation, patients who received tocilizumab were matched to patients who did not receive tocilizumab. Setting Ten hospitals within the Cleveland Clinic Enterprise. PATIENTS Adult patients admitted to a medical, surgical, neurosciences, or mixed ICU with severe acute respiratory syndrome coronavirus 2 infection. Interventions None. Measurements and Main Results Four-hundred forty-four patients were included: 342 patients (77%) did not receive tocilizumab and 102 patients (23%) received tocilizumab. Of those, 82 patients in each arm were matched. Before matching, patients who received tocilizumab had higher Sequential Organ Failure Assessment scores (6.1 ± 3.4 vs 4.7 ± 3.6), higher C-reactive protein (21.0 ± 10.2 vs 13.7 ± 9.6 mg/dL), higher frequency of intubation, vasopressor requirement, and paralytics. After matching, characteristics were more balanced and over 85% of patients required mechanical ventilation. ICU mortality was lower in tocilizumab group (23.2% vs 37.8%; risk difference, -15%; 95% CI, -29% to -1%), with more ICU-, hospital-, and vasoactive-free days at day 28 compared with those who did not receive tocilizumab. There was no difference in mechanical ventilation-free days at day 28 or development of secondary infections. Conclusions Tocilizumab use was associated with a significant decrease in ICU mortality in critically ill coronavirus disease 2019 patients with severe hypoxemic respiratory failure. Future randomized controlled trials limited to tocilizumab administration in critically ill coronavirus disease 2019 patients, with severe hypoxemic respiratory failure, are needed to support these findings.
Collapse
|
36
|
Huang T, Sun L, Kang D, Poongavanam V, Liu X, Zhan P, Menéndez-Arias L. Search, Identification, and Design of Effective Antiviral Drugs Against Pandemic Human Coronaviruses. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1322:219-260. [PMID: 34258743 DOI: 10.1007/978-981-16-0267-2_9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Recent coronavirus outbreaks of SARS-CoV-1 (2002-2003), MERS-CoV (since 2012), and SARS-CoV-2 (since the end of 2019) are examples of how viruses can damage health care and generate havoc all over the world. Coronavirus can spread quickly from person to person causing high morbidity and mortality. Unfortunately, the antiviral armamentarium is insufficient to fight these infections. In this chapter, we provide a detailed summary of the current situation in the development of drugs directed against pandemic human coronaviruses. Apart from the recently licensed remdesivir, other antiviral agents discussed in this review include molecules targeting viral components (e.g., RNA polymerase inhibitors, entry inhibitors, or protease inhibitors), compounds interfering with virus-host interactions, and drugs identified in large screening assays, effective against coronavirus replication, but with an uncertain mechanism of action.
Collapse
Affiliation(s)
- Tianguang Huang
- Department of Medicinal Chemistry, Key Laboratory of Chemical Biology, Ministry of Education, School of Pharmaceutical Sciences, Shandong University, Jinan, China
| | - Lin Sun
- Department of Medicinal Chemistry, Key Laboratory of Chemical Biology, Ministry of Education, School of Pharmaceutical Sciences, Shandong University, Jinan, China
| | - Dongwei Kang
- Department of Medicinal Chemistry, Key Laboratory of Chemical Biology, Ministry of Education, School of Pharmaceutical Sciences, Shandong University, Jinan, China
| | | | - Xinyong Liu
- Department of Medicinal Chemistry, Key Laboratory of Chemical Biology, Ministry of Education, School of Pharmaceutical Sciences, Shandong University, Jinan, China
| | - Peng Zhan
- Department of Medicinal Chemistry, Key Laboratory of Chemical Biology, Ministry of Education, School of Pharmaceutical Sciences, Shandong University, Jinan, China
| | - Luis Menéndez-Arias
- Centro de Biología Molecular "Severo Ochoa", Consejo Superior de Investigaciones Científicas & Universidad Autónoma de Madrid, Madrid, Spain.
| |
Collapse
|
37
|
Chen CX, Hu F, Wei J, Yuan LT, Wen TM, Gale RP, Liang Y. Systematic review and meta-analysis of tocilizumab in persons with coronavirus disease-2019 (COVID-19). Leukemia 2021; 35:1661-1670. [PMID: 34002026 PMCID: PMC8127467 DOI: 10.1038/s41375-021-01264-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 04/08/2021] [Accepted: 04/26/2021] [Indexed: 02/04/2023]
Abstract
We performed a meta-analysis to determine safety and efficacy of tocilizumab in persons with coronavirus disease-2019 (COVID-19). We searched PubMed, Web of Science and Medline using Boolean operators for studies with the terms coronavirus OR COVID-19 OR 2019-nCoV OR SARS-CoV-2 AND tocilizumab. Review Manager 5.4 was used to analyze data and the modified Newcastle-Ottawa and Jadad scales for quality assessment. We identified 32 studies in 11,487 subjects including three randomized trials and 29 cohort studies with a comparator cohort, including historical controls (N = 5), a matched cohort (N = 12), or concurrent controls (N = 12). Overall, tocilizumab decreased risk of death (Relative Risk [RR] = 0.74; 95% confidence interval [CI], 0.59, 0.93; P = 0.008; I2 = 80%) but not of surrogate endpoints including ICU admission (RR = 1.40 [0.64,3.06]; P = 0.4; I2 = 88%), invasive mechanical ventilation (RR = 0.83 [0.57,1.22]; P = 0.34; I2 = 65%) or secondary infections (RR = 1.30 [0.97,1.74]; P = 0.08; I2 = 65%) and increased interval of hospitalization of subjects discharged alive(mean difference [MD] = 2 days [<1, 4 days]; P = 0.006; I2 = 0). RRs of death in studies with historical controls (RR = 0.28 [0.16,0.49; P < 0.001]; I2 = 62%) or a matched cohort (RR = 0.68 [0.53, 0.87]; P = 0.002; I2 = 42%) were decreased. In contrast, RRs of death in studies with a concurrent control (RR = 1.10 [0.77, 1.56]; P = 0.60; I2 = 85%) or randomized (RR = 1.18 [0.57,2.44]; P = 0.66; I2 = 0) were not decreased. A reduced risk of death was not confirmed in our analyses which questions safety and efficacy of tocilizumab in persons with COVID-19.
Collapse
Affiliation(s)
- Chong-xiang Chen
- grid.488530.20000 0004 1803 6191Department of Hematologic Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China ,grid.470124.4State Key Laboratory of Respiratory Disease, Guangzhou Institute of Respiratory Health, First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong Province China ,grid.488530.20000 0004 1803 6191Department of ICU, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Fang Hu
- grid.488530.20000 0004 1803 6191Department of Hematologic Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Jin Wei
- grid.413387.a0000 0004 1758 177XDepartment of Hematology, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan China
| | - Le-tao Yuan
- grid.12981.330000 0001 2360 039XSchool of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Tian-meng Wen
- grid.12981.330000 0001 2360 039XSchool of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Robert Peter Gale
- grid.7445.20000 0001 2113 8111Department of Immunology and Inflammation, Haematology Research Centre, Imperial College London, London, UK
| | - Yang Liang
- grid.488530.20000 0004 1803 6191Department of Hematologic Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| |
Collapse
|
38
|
Chen JJ, Zhang LN, Hou H, Xu L, Ji K. Interleukin-6 signaling blockade treatment for cytokine release syndrome in COVID-19 (Review). Exp Ther Med 2021; 21:24. [PMID: 33262810 PMCID: PMC7690237 DOI: 10.3892/etm.2020.9456] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 09/24/2020] [Indexed: 12/15/2022] Open
Abstract
A severe immune response in patients with coronavirus disease 2019 (COVID-19) can cause a potentially lethal unconstrained inflammatory cytokine storm, known as cytokine release syndrome (CRS). The present study provides an overview of the biology underlying CRS and how targeted inhibition of interleukin (IL)-6 signaling may improve outcomes and the survival of patients suffering from COVID-19. Preliminary clinical results have indicated that antagonism of the IL-6 receptor (IL-6R), including with the FDA-approved humanized monoclonal antibody tocilizumab, can improve the outcomes of patients with severe or critical COVID-19 while maintaining a good safety profile. The available clinical data support the expansion of clinical trials using IL-6R targeting inhibitors for severe and critical COVID-19 treatment.
Collapse
Affiliation(s)
- Jia-Jie Chen
- Department of Biochemistry and Molecular Biology, Health Science Center of Shenzhen University, Shenzhen, Guangdong 518060, P.R. China
| | - Li-Na Zhang
- Department of Biochemistry and Molecular Biology, Health Science Center of Shenzhen University, Shenzhen, Guangdong 518060, P.R. China
| | - Hu Hou
- Department of Clinical Laboratory, Shenzhen People's Hospital, Shenzhen, Guangdong 518020, P.R. China
| | - Lingqing Xu
- Department of Clinical Laboratory, The Sixth Affiliated Hospital of Guangzhou Medical University, Qingyuan People's Hospital, Qingyuan, Guangdong 511518, P.R. China
| | - Kunmei Ji
- Department of Biochemistry and Molecular Biology, Health Science Center of Shenzhen University, Shenzhen, Guangdong 518060, P.R. China
| |
Collapse
|
39
|
Han Q, Guo M, Zheng Y, Zhang Y, De Y, Xu C, Zhang L, Sun R, Lv Y, Liang Y, Xu F, Pang J, Chen Y. Current Evidence of Interleukin-6 Signaling Inhibitors in Patients With COVID-19: A Systematic Review and Meta-Analysis. Front Pharmacol 2020; 11:615972. [PMID: 33384605 PMCID: PMC7769953 DOI: 10.3389/fphar.2020.615972] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 11/17/2020] [Indexed: 12/16/2022] Open
Abstract
Background: Interleukin-6 (IL-6) is known to be detrimental in coronavirus disease 2019 (COVID-19) because of its involvement in driving cytokine storm. This systematic review and meta-analysis aimed to assess the safety and efficacy of anti-IL-6 signaling (anti-IL6/IL-6R/JAK) agents on COVID-19 based on the current evidence. Methods: Studies were identified through systematic searches of PubMed, EMBASE, ISI Web of Science, Cochrane library, ongoing clinical trial registries (clinicaltrials.gov), and preprint servers (medRxiv, ChinaXiv) on August 10, 2020, as well as eligibility checks according to predefined selection criteria. Statistical analysis was performed using Review Manager (version 5.3) and STATA 12.0. Results: Thirty-one studies were included in the pooled analysis of mortality, and 12 studies were identified for the analysis of risk of secondary infections. For mortality analysis, 5630 COVID-19 cases including 2,132 treated patients and 3,498 controls were analyzed. Anti-IL-6 signaling agents plus standard of care (SOC) significantly decreased the mortality rate compared to SOC alone (pooled OR = 0.61, 95% CI 0.45-0.84, p = 0.002). For the analysis of secondary infection risk, 1,624 patients with COVID-19 including 639 treated patients and 985 controls were included, showing that anti-IL-6 signaling agents did not increase the rate of secondary infections (pooled OR = 1.21, 95% CI 0.70-2.08, p = 0.50). By contrast, for patients with critical COVID-19 disease, anti-IL-6 signaling agents failed to reduce mortality compared to SOC alone (pooled OR = 0.75, 95% CI 0.42-1.33, p = 0.33), but they tended to increase the risk of secondary infections (pooled OR = 1.85, 95% CI 0.95-3.61, p = 0.07). A blockade of IL-6 signaling failed to reduce the mechanical ventilation rate, ICU admission rate, or elevate the clinical improvement rate. Conclusion: IL-6 signaling inhibitors reduced the mortality rate without increasing secondary infections in patients with COVID-19 based on current studies. For patients with critical disease, IL-6 signaling inhibitors did not exhibit any benefit.
Collapse
Affiliation(s)
- Qi Han
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China
- Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Chest Pain Center, Qilu Hospital of Shandong University, Jinan, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China
- The Key Laboratory of Cardiovascular Remodeling and Function Research, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China
| | - Mingyue Guo
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China
- Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Chest Pain Center, Qilu Hospital of Shandong University, Jinan, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China
- The Key Laboratory of Cardiovascular Remodeling and Function Research, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China
| | - Yue Zheng
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China
- Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Chest Pain Center, Qilu Hospital of Shandong University, Jinan, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China
- The Key Laboratory of Cardiovascular Remodeling and Function Research, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China
| | - Ying Zhang
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China
- Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Chest Pain Center, Qilu Hospital of Shandong University, Jinan, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China
- The Key Laboratory of Cardiovascular Remodeling and Function Research, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China
| | - Yanshan De
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China
- Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Chest Pain Center, Qilu Hospital of Shandong University, Jinan, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China
- The Key Laboratory of Cardiovascular Remodeling and Function Research, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China
| | - Changchang Xu
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China
- Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Chest Pain Center, Qilu Hospital of Shandong University, Jinan, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China
- The Key Laboratory of Cardiovascular Remodeling and Function Research, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China
| | - Lin Zhang
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China
- Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Chest Pain Center, Qilu Hospital of Shandong University, Jinan, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China
- The Key Laboratory of Cardiovascular Remodeling and Function Research, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China
| | - Ruru Sun
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China
- Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Chest Pain Center, Qilu Hospital of Shandong University, Jinan, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China
- The Key Laboratory of Cardiovascular Remodeling and Function Research, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China
| | - Ying Lv
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China
- Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Chest Pain Center, Qilu Hospital of Shandong University, Jinan, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China
- The Key Laboratory of Cardiovascular Remodeling and Function Research, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China
| | - Yan Liang
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China
- Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Chest Pain Center, Qilu Hospital of Shandong University, Jinan, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China
- The Key Laboratory of Cardiovascular Remodeling and Function Research, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China
| | - Feng Xu
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China
- Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Chest Pain Center, Qilu Hospital of Shandong University, Jinan, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China
- The Key Laboratory of Cardiovascular Remodeling and Function Research, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China
| | - Jiaojiao Pang
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China
- Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Chest Pain Center, Qilu Hospital of Shandong University, Jinan, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China
- The Key Laboratory of Cardiovascular Remodeling and Function Research, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China
| | - Yuguo Chen
- Department of Emergency Medicine, Qilu Hospital of Shandong University, Jinan, China
- Shandong Provincial Clinical Research Center for Emergency and Critical Care Medicine, Institute of Emergency and Critical Care Medicine of Shandong University, Chest Pain Center, Qilu Hospital of Shandong University, Jinan, China
- Key Laboratory of Emergency and Critical Care Medicine of Shandong Province, Key Laboratory of Cardiopulmonary-Cerebral Resuscitation Research of Shandong Province, Shandong Provincial Engineering Laboratory for Emergency and Critical Care Medicine, Qilu Hospital of Shandong University, Jinan, China
- The Key Laboratory of Cardiovascular Remodeling and Function Research, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Chinese Ministry of Education, Chinese Ministry of Health and Chinese Academy of Medical Sciences, Qilu Hospital of Shandong University, Jinan, China
| |
Collapse
|
40
|
Zhou Z, Price CC. Overview on the use of IL-6 agents in the treatment of patients with cytokine release syndrome (CRS) and pneumonitis related to COVID-19 disease. Expert Opin Investig Drugs 2020; 29:1407-1412. [DOI: 10.1080/13543784.2020.1840549] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Zeyun Zhou
- Program of Advanced Professional Master of Public Health, Global Health, Yale School of Public Health, New Haven, CT, USA
| | - Christina C. Price
- Section of Rheumatology, Allergy & Immunology, Yale University School of Medicine, New Haven, CT, USA
- Department of Allergy and Immunology, VA Medical Center, West Haven, CT, USA
| |
Collapse
|
41
|
Blaess M, Kaiser L, Sommerfeld O, Rentschler S, Csuk R, Deigner HP. Rational Drug Repurposing: Focus on Lysosomotropism, Targets in Disease Process, Drug Profile, and Pulmonary Tissue Accumulation in SARS-CoV-2 Infection/COVID-19. Front Pharmacol 2020; 11:584881. [PMID: 33692684 PMCID: PMC7938238 DOI: 10.3389/fphar.2020.584881] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 10/06/2020] [Indexed: 01/11/2023] Open
Affiliation(s)
- Markus Blaess
- Institute of Precision Medicine, Medical and Life Sciences Faculty, Furtwangen University, Villingen-Schwenningen, Germany
| | - Lars Kaiser
- Institute of Precision Medicine, Medical and Life Sciences Faculty, Furtwangen University, Villingen-Schwenningen, Germany.,Institute of Pharmaceutical Sciences, University of Freiburg, Freiburg, Germany
| | - Oliver Sommerfeld
- Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Simone Rentschler
- Institute of Precision Medicine, Medical and Life Sciences Faculty, Furtwangen University, Villingen-Schwenningen, Germany
| | - René Csuk
- Department of Organic Chemistry, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Hans-Peter Deigner
- Institute of Precision Medicine, Medical and Life Sciences Faculty, Furtwangen University, Villingen-Schwenningen, Germany.,EXIM Department, Fraunhofer Institute IZI Leipzig, Rostock, Germany.,Faculty of Science, Tuebingen University, Tübingen, Germany
| |
Collapse
|
42
|
Reply to Wang et al.: Tocilizumab treatment should be used in a timely manner, at suitable dose, and in suitable patients. Proc Natl Acad Sci U S A 2020; 117:30898-30899. [PMID: 33203670 DOI: 10.1073/pnas.2017204117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
|
43
|
Kaye AG, Siegel R. The efficacy of IL-6 inhibitor Tocilizumab in reducing severe COVID-19 mortality: a systematic review. PeerJ 2020; 8:e10322. [PMID: 33194450 PMCID: PMC7643559 DOI: 10.7717/peerj.10322] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 10/18/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND In the absence of highly effective antiviral therapies against SARS-CoV-2, it is crucial to counter the known pathophysiological causes of severe COVID-19. Evaluating the efficacy existing drugs may expedite the development of such therapeutics. Severe COVID-19 is largely the result of a dysregulated immune response characterized by lymphocytopenia, neutrophilia and critical hypercytokinemia, or "cytokine storm," which is largely mediated by the cytokine interleukin-6 (IL-6). The IL-6 inhibitor tocilizumab (TCZ) could potentially suppress the effects of the pro-inflammatory cytokine and thereby lower mortality from the disease. This systematic analysis aimed to investigate and synthesize existing evidence for the efficacy of TCZ in reducing COVID-19 mortality. METHODOLOGY PubMed and SearchWorks searches were performed to locate clinical studies with primary data on TCZ treatment for severe COVID-19. Sixteen case-control studies comparing mortality between TCZ and standard of care (SOC) were identified for quantitative synthesis. The systematic analysis was pre-approved through PROSPERO (CRD42020193479). RESULTS Combined mortality for the TCZ-treated and SOC groups were 26.0% and 43.4% respectively. In all but one of the studies, the odds ratio of mortality from COVID-19 pointed towards lower fatality with TCZ vs the SOC. A combined random effects odds ratio calculation yielded an odds ratio of 0.453 (95% CI [0.376-0.547], p < 0.001). Additionally, 18 uncontrolled trials were identified for qualitative analysis producing a raw combined mortality rate of 16.0%. CONCLUSIONS Important caveats to this research include the lack of prospective randomized control trials and the absence of data from the large COVATA study from the published literature. However, results from this systematic analysis of published research provide positive evidence for the potential efficacy of TCZ to treat severe COVID-19, validating the ethical basis and merit of ongoing randomized controlled clinical trials.
Collapse
Affiliation(s)
| | - Robert Siegel
- Human Biology, Stanford University, Stanford, CA, USA
- Microbiology & Immunology, Stanford University, Stanford, CA, USA
| |
Collapse
|
44
|
Podlasin RB, Kowalska JD, Pihowicz A, Wojtycha-Kwaśnica B, Thompson M, Dyda T, Czeszko-Paprocka H, Horban A. How to follow-up a patient who received tocilizumab in severe COVID-19: a case report. Eur J Med Res 2020; 25:37. [PMID: 32854774 PMCID: PMC7450912 DOI: 10.1186/s40001-020-00438-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 08/19/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND COVID-19 is characterized by fast deterioration in the mechanism of cytokine storm. Therefore, treatment with immunomodulating agents should be initiated as soon as hyperinflammation is established. Evidence for the use of tocilizumab (TCZ) in COVID-19 is emerging, but the drug in this setting is used "off label" with limited data on both effectiveness and safety. Therefore, Hospital for Infectious Diseases in Warsaw established a Standard Operating Procedure (SOP) for the use of TCZ in severe COVID-19 cases. CASE PRESENTATION Here, we present a case of 27-year-old, otherwise healthy man, who was successfully treated with chloroquine, azithromycin, tocilizumab and a standard of care. Initially the magnitude of lung devastation, clinical deterioration and the need for mechanical ventilation suggested unfavorable prognosis. However, we observed complete regression in radiological changes and rapid clinical improvement. Irrespective of this, patient's serum interleukin 6 and aminotransferases remained elevated even after a month from treatment. CONCLUSIONS An overlapping effect of hyperinflammation, hypoxic organ injury and drug-related toxicity warrants a long-term follow-up for COVID-19 survivors. In addition, residual IL-6 receptors blockage may mask new infections. A standardized approach to follow-up for COVID-19 survivors is urgently needed. Current and future research should also investigate the impact of experimental therapies on lung tissue healing and regeneration, as well as long-term treatment toxicities.
Collapse
Affiliation(s)
| | - Justyna D Kowalska
- Department of Adults' Infectious Diseases, Medical University of Warsaw, Warsaw, Poland.
| | - Andrzej Pihowicz
- Intensive Care Unit, Hospital for Infectious Diseases in Warsaw, Warsaw, Poland
| | - Beata Wojtycha-Kwaśnica
- Department of Diagnostic Imaging, Hospital for Infectious Diseases in Warsaw, Warsaw, Poland
| | | | - Tomasz Dyda
- Molecular Diagnostics Laboratory, Hospital for Infectious Diseases in Warsaw, Warsaw, Poland
| | - Hanna Czeszko-Paprocka
- Central Analytical Laboratory, Hospital for Infectious Diseases in Warsaw, Warsaw, Poland
| | - Andrzej Horban
- Department of Adults' Infectious Diseases, Medical University of Warsaw, Warsaw, Poland
| |
Collapse
|