One of the beauties of practicing in the ICU is that although many of my patients take up a lot of resources, the pharmacy-cost component of it isn’t too high. I like my cheap IV fluids, norepinephrine, run-of-the-mill antibiotics, heparin, PPI’s, tube feeds, sedation meds, etc. None of these are too outlandishly expensive. People generally do well. Reading the ongoing studies regarding COVID-19 I have come across tocilizumab in cytokine storm over and over again. Some people around here may already take it or know someone taking it for for their rheumatoid arthritis. Time to take a quick dive into this. This medication is currently being used off-label.

What is Tocilizumab?

Tocilizumab is an IL-6 receptor antagonist, a monoclonal antibody (hence the -mab at the end of the name). Per UpToDate, this “leads to a reduction in cytokine and acute phase reactant production.” Sounds good, right? It’s supposed to treat the “cytokine storm” or more formally “cytokine release syndrome”. Let’s simply define that bad-boy while we are here. We still have a lot to learn and clinical trials are ongoing.

What is Cytokine Storm?

Cytokine release syndrome is a “supraphysiologic response to immune therapy (in this case we’re looking at it in COVID-19) that activates or engages T cells and/or other immune effector cells. The systemic reaction is associated with increased levels of inflammatory cytokines and activation of T lymphocytes, macrophages, and endothelial cells” -UpToDate.

The postulation is that this CRS is what is causing people to decide to die. “In more severe CRS, patients may have hypotension and uncontrolled SIRS with circulatory collapse, vascular leakage, peripheral and/or pulmonary edema, renal failure, cardiac dysfunction, and multiorgan system failure.” Sounds like what is being described in the COVID literature.

Labs: Elevated labs: CRP, ferritin, IL-6, and other nonspecific markers of inflammation. I plan to trend these daily.

Adverse effects of Tocilizumab in Cytokine Storm:

We need to recognize that we are effectively knocking out the immune system to an extent with this medication and could potentially cause harm. There’s a black box warning about this. Increased LFTs are commonly noted here (less than 36%). For the nurses, we can see a local site reaction as well.

Cost: it’s expensive.

Not FDA approved: currently there is a phase III clinical trial as of 3/26. There are other clinical trials ongoing that have beat the FDA to the punch. Hopefully we will have that data sooner rather than later. There are numerous studies listed on clinicaltrials.gov.

Click here for breakdowns of other COVID-19 Articles.

Citations

https://www.drugs.com/price-guide/actemra

Link to UpToDate

Chinese non-peer reviewed data

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