Tocilizumab and liver injury in patients with COVID-19

Abstract

Current mortality rate in patients with COVID-19 disease is about 2%, whereas 5% of patients require admission to the intensive care unit. It is assumed that interleukin (IL)-6 may be involved in the pathogenesis of severe COVID-19 infections; therefore, in the absence of a specific antiviral therapy, some authors have suggested that tocilizumab – a drug used to block the signal transduction pathway of IL-6 – could have beneficial effects in the management of severe COVID-19 disease. However, mild-to-moderate elevation in transaminases and drug-induced liver injury have been observed in patients treated with tocilizumab. We present seven cases of patients with elevated liver enzymes [up to five times the upper limit of normal (ULN)] at baseline who received tocilizumab for life-threatening COVID-19 disease. All patients had no history of liver or pulmonary disease and were admitted for acute hypoxemic respiratory failure, dyspnea and fever due to COVID-19 bilateral pneumonia. IL-6 was available in six patients, and was significantly increased particularly in those with severe impairment of lung function. All patients received tocilizumab (8 mg/kg/day) for two consecutive days because of lack of improvement after hydroxychloroquine, azithromycin and lopinavir/ritonavir treatment. After tocilizumab administration, clinical condition rapidly improved and liver function test normalized within 3 weeks of treatment. Tocilizumab may be effective for the treatment of severe COVID-19 disease, even in patients with elevated liver function tests. Further studies are needed to evaluate the impact of tocilizumab use on liver function tests in patients with pre-existing chronic liver disease.

Abnormal Liver Biochemistry Tests and Acute Liver Injury in COVID-19 Patients: Current Evidence and Potential Pathogenesis

“…One of the female patients had a mild increase in ALT and AST levels two days post-administration of the drug which quickly normalized, whereas the male initially had mildly elevated liver function tests that did not further increase post-tocilizumab therapy [93]. Similarly, the study by Serviddio et al reported normalization in transaminases levels, 3 weeks after tocilizumab administration in seven cases of patients with baseline values up to 5 times the upper limit of normal [94]. Therefore, further studies are warranted in examining the effect of tocilizumab administration on liver function tests in severe COVID-19 patients with pre-existing chronic hepatic diseases.…”

Hepatitis: An emerging presentation in child with coronavirus disease 2019

“…It is possible that younger patients mount a more robust immune and inflammatory response to infection, and that higher peak SGPT is a manifestation of it [12]. Role of immunomodulators like tocilizumab in cases of ALF in COVID-19 patients has been investigated with adult patients showing improvement but its role in pediatric patients should be investigated [13].…”

Liver injury in COVID-19: Detection, pathogenesis, and treatment

“…Similarly, Qin et al [ 37 ] reported that up to 70% of critically ill patients received systemic corticosteroid therapy. Furthermore, a case report from Italy suggested that tocilizumab, a drug used to reduce inflammation by blocking the IL-6 signal transduction pathway, played a beneficial role in the management of severe COVID-19 disease[ 59 ]. In the case of poor efficacy of azithromycin, hydroxychloroquine, and lopinavir, the administration of tocilizumab rapidly improved the clinical condition.…”