Time to Reassess Tocilizumab’s Role in COVID-19 Pneumonia

Type Journal Article Author Jonathan B. Parr URL https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2772184 Series Editorial Publication Jama Network | Internal Medcine Date 20/10/2020 DOI 10.1001/jamainternmed.2020.6557 Abstract In this issue of JAMA Internal Medicine, 3 important articles1-3 explore the use of tocilizumab in coronavirus disease 2019 (COVID-19) pneumonia. Tocilizumab is a humanized monoclonal antibody that binds human interleukin 6 (IL-6) receptors. It is used routinely in inflammatory arthritis, giant cell arteritis, and cytokine release syndrome after chimeric antigen receptor T-cell therapy. Its use recently proliferated after early observations from China showed increased risk of death in patients with COVID-19 and elevated IL-6 levels,4 and nonrandomized studies5,6 suggested benefit from tocilizumab treatment. In many centers across the United States, off-label use of tocilizumab became standard of care for patients with COVID-19 and evidence of hyperinflammation. However, practice patterns have varied, and guidelines from the National Institutes of Health7 and the Infectious Disease Society of America8 now recommend against the use of tocilizumab except in the context of a clinical trial. Although an increasing number of observational studies9-11 have suggested mortality benefit, data from randomized clinical trials (RCTs) of tocilizumab in COVID-19 are sorely needed to inform clinical practice. The studies reported by Salvarani et al for the RCT-TCZ-COVID-19 Study Group (RCT-TCZ-COVID-19)1 and Hermine et al for the CORIMUNO-19 Collaborative Group (CORIMUNO-TOCI-1)2 provide clinicians with their first look at peer-reviewed RCT results. In addition, preliminary results from COVACTA12 and EMPACTA,13 2 multicenter, randomized, double-blind, placebo-controlled trials, have just been released. These studies, complemented by the largest observational study of tocilizumab in COVID-19 published to date, from the Study of the Treatment and Outcomes in Critically Ill Patients With COVID-19 (STOP-COVID) investigators,3 supply the raw material needed for a critical appraisal of tocilizumab use in COVID-19. For clinicians practicing on the front lines of the COVID-19 pandemic and weary of the deluge of research findings coming their way, now is the time to step back and reconsider the proper placement of tocilizumab in their COVID-19 treatment algorithms.