Low dose vs high dose tocilizumab in COVID-19 patients with hypoxemic respiratory failure

• Published in: Journal of critical care Vol. 76; p. 154291
• Main Authors: Chung, Juri, Brosnahan, Shari B., Islam, Shahidul, Altshuler, Diana, Spiegler, Peter, Li, Wai Kin, Wang, Wai Man, Chen, Xian Jie Cindy
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.08.2023; Elsevier Limited
• Subjects: Biomarkers; Body mass index; Coronaviruses; Corticosteroids; COVID-19; COVID-19 Drug Treatment; Cytomegalovirus; Dehydrogenases; Drug dosages; Hospitals; Humans; Immunosuppression; Infections; Interleukins; Medication therapy management; Monoclonal antibodies; Mortality; Pandemics; Patients; Respiratory failure; Respiratory infections; Respiratory Insufficiency - drug therapy; Retrospective Studies; SARS-CoV-2; Severe acute respiratory syndrome coronavirus 2; Steroids; Treatment Outcome; Tumor necrosis factor-TNF; Ventilators; Immunosuppression; Corticosteroids; Interleukins; Respiratory failure; Medication therapy management; Respiratory infections
• ISSN: 0883-9441; 1557-8615
• DOI: 10.1016/j.jcrc.2023.154291

Tocilizumab has been shown to decrease mortality when used concomitantly with steroids in COVID-19 with 8 mg/kg (max 800 mg) being the standard dose. Our study sought to assess whether a low dose (400 mg) shows similar benefit compared to a high dose for COVID patients concurrently on the same median dose of steroids. A retrospective, multihospital observational study of COVID-19 patients who received tocilizumab in conjunction with steroids between March 2020 and August 2021 was conducted. A total of 407 patients were analyzed with low dose group being significantly more ill at baseline as a higher percentage of patients received vasopressors, were admitted to the ICU and on mechanical ventilation. In the propensity-matched analysis, both groups receiving a median dexamethasone equivalent dose of 10 mg showed no difference in 28-day mortality (p = 0.613). The high dose group had a higher rate of fungal and viral infections. Compared to low dose tocilizumab, the high dose did not provide additional efficacy and mortality benefit but resulted in higher fungal and viral infections. This study illustrates that low dose tocilizumab can be an alternative to high dose during a drug shortage of tocilizumab without compensating for efficacy and safety, conserving resources for more patients. •A fixed, 400 mg dose of tocilizumab may be as effective as 8 mg/kg dose in mortality benefit for critically ill COVID-19 patients concomitantly on corticosteroids.•Compared to high dose tocilizumab, the low dose group was found to have a lower rate of fungal and viral infections.•Using the low dose provides an alternative, cost-saving option and reserves resources to benefit more patients without compensating for efficacy and safety.