A Case Series of Severe Hospitalized COVID-19 Patients Treated with Tocilizumab and Glucocorticoids: A Report from Saudi Arabian Hospital

Abstract

Background: The clinical spectrum of COVID-19 is variable and ranges from asymptomatic, mildly symptomatic, moderately severe and severe disease. A small proportion might develop severe disease and may have cytokine storm. One of the therapeutic options to treat such cases is Tocilizumab (TCZ). In this study, we present cases of severe COVID-19 treated with TCZ and glucocorticoids and discuss the treatment responses. Methods: This is a retrospective observational study of severe COVID-19 cases treated with TCZ and glucocorticoids. The case series examined the characteristics and outcome of those patients. Results: This study included 40 Severe Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) confirmed patients who received TCZ and glucocorticoids. The mean age of the included patients was 57.55 (±Standard deviation 12.86) years. There were 34 (85%) males, 19 (47.5%) were obese (BMI >30), 13 (32.5%) over weight, and five (12.5%) normal weight. The mean days from positive SARS-CoV-2 polymerase chain reaction (PCR) test to admission was 1.641 (±3.2) days. Of the patients, 18 (45%) had diabetes mellitus, 14 (35%) had hypertension. The mean days from hospital admission to ICU was 1.8 (±2.6), 20 (50%) required mechanical ventilation, 39 (97.5%) had received prone position, seven (17.5%) had renal replacement therapy, 13 (32.5%) required inotropes, four (10%) had plasmapheresis, one (2.5%) had intravenous immunoglobulin, all patients received steroid therapy, and the majority 31 (77.5%) did not receive any anti-viral therapy. Of all the patients, six (15%) died, 28 (70%) were discharged and six (15%) were still in hospital. Conclusion: The overall mortality rate was lower than those cited in meta-analysis. As our understanding of the COVID-19 continues, the approach and therapeutics are also evolving.

Early use of tocilizumab in solid organ transplant recipients with COVID‐19: A retrospective cohort study in Saudi Arabia

“…Patients with mild to moderate symptoms constitute the majority of COVID‐19 cases and up to 20% may develop severe illness including pneumonia, acute respiratory distress syndrome, and multiorgan failure requiring ventilatory support 3 . The same pattern of COVID‐19 severity was reported in Saudi Arabia with various clinical presentations including mild, moderate, and critical cases; in addition to asymptomatic cases 4–8 …”

“…Tocilizumab is a recombinant humanized anti‐IL‐6 receptor monoclonal antibody studied to reduce the cytokine syndrome in patients with severe COVID‐19 disease 14 . Several retrospective case‐control studies and randomized trials evaluated the role of tocilizumab in reducing the mortality of severe COVID‐19 and had conflicting results 7–11,15–20 . However, SOT recipients were not included in these studies except for one study, which only included nine cases (6%) 21 …”

Clinical Features and Outcome of Low and High Corticosteroids in Admitted COVID-19 Patients

“…The protocol called for the use of steroid in adults with a respiratory rate ≥30/min, blood oxygen saturation equal to or less than 93%, a ration of the PaO 2 /FiO 2 of less than 300, the presence of lung infiltration of 50% within 24–48 h [ 20 ]. In a recent study from Saudi Arabia, 40 patients with severe COVID-19 were treated with a combination of corticosteroid and tocilizumab and the mortality rate was 15% [ 13 ]. The patients in the high-dose steroid had a higher rate of the use of favipiravir than those in the low-dose steroid.…”

“…The physiologic description of the 2019 Coronavirus Diseases (COVID-19) consists of an initial viral replication phase and then the immune system reactions would lead to the development of inflammatory responses with a wide range of clinical findings [9,10]. The second phase of immune response may lead to a disproportionate and unregulated cytokine releasing storm resulting and subsequent emergence of acute respiratory distress syndrome, and death [11][12][13]. Based on the clinical presentation and the pathophysiology of COVID-19, the case fatality rates varies from 61.5% in those requiring intensive care admission in earlier studies [14] and may be lower as cited in more recent studies of a fatality rate of 25.8% [15].…”

Myocardial injuries among patients with COVID-19: a systematic review

“…These clinical presentations may be related to the viral dynamics and the presence of the virus in the different tissues [18]. Additionally, severe cases may occur due to hyperinflammatory response with resultant multiple organ failure [19,20]. However, different studies have used different definitions for cytokine storm [21].…”