Skip to main page content
Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Review
. 2020 May 3;102568.
doi: 10.1016/j.autrev.2020.102568. Online ahead of print.

Tocilizumab for the Treatment of Severe COVID-19 Pneumonia With Hyperinflammatory Syndrome and Acute Respiratory Failure: A Single Center Study of 100 Patients in Brescia, Italy

Paola Toniati  1 Simone Piva  2 Marco Cattalini  3 Emirena Garrafa  4 Francesca Regola  5 Francesco Castelli  6 Franco Franceschini  5 Paolo Airò  1 Chiara Bazzani  1 Eva-Andrea Beindorf  7 Marialma Berlendis  8 Michela Bezzi  9 Nicola Bossini  10 Maurizio Castellano  11 Sergio Cattaneo  12 Ilaria Cavazzana  1 Giovanni-Battista Contessi  13 Massimo Crippa  14 Andrea Delbarba  15 Elena De Peri  16 Angela Faletti  17 Matteo Filippini  1 Matteo Filippini  16 Micol Frassi  1 Mario Gaggiotti  10 Roberto Gorla  1 Michael Lanspa  18 Silvia Lorenzotti  19 Rosa Marino  16 Roberto Maroldi  20 Marco Metra  21 Alberto Matteelli  6 Denise Modina  8 Giovanni Moioli  19 Giovanni Montani  22 Maria-Lorenza Muiesan  23 Silvia Odolini  19 Elena Peli  16 Silvia Pesenti  13 Maria-Chiara Pezzoli  19 Ilenia Pirola  15 Alessandro Pozzi  13 Alessandro Proto  14 Francesco-Antonio Rasulo  2 Giulia Renisi  19 Chiara Ricci  24 Damiano Rizzoni  25 Giuseppe Romanelli  26 Mara Rossi  22 Massimo Salvetti  23 Francesco Scolari  27 Liana Signorini  19 Marco Taglietti  1 Gabriele Tomasoni  28 Lina-Rachele Tomasoni  19 Fabio Turla  2 Alberto Valsecchi  8 Davide Zani  29 Francesco Zuccalà  28 Fiammetta Zunica  3 Emanuele Focà  6 Laura Andreoli  5 Nicola Latronico  30
Affiliations
Free PMC article
Review

Tocilizumab for the Treatment of Severe COVID-19 Pneumonia With Hyperinflammatory Syndrome and Acute Respiratory Failure: A Single Center Study of 100 Patients in Brescia, Italy

Paola Toniati et al. Autoimmun Rev. .
Free PMC article

Abstract

A hyperinflammatory syndrome (HIS) may cause a life-threatening acute respiratory distress syndrome (ARDS) in patients with COVID-19 pneumonia. A prospective series of 100 consecutive patients admitted to the Spedali Civili University Hospital in Brescia (Italy) between March 9th and March 20th with confirmed COVID-19 pneumonia and ARDS requiring ventilatory support was analyzed to determine whether intravenous administration of tocilizumab (TCZ), a monoclonal antibody that targets the interleukin 6 (IL-6) receptor, was associated with improved outcome. Tocilizumab was administered at a dosage of 8 mg/kg by two consecutive intravenous infusions 12 h apart. A third infusion was optional based on clinical response. The outcome measure was an improvement in acute respiratory failure assessed by means of the Brescia COVID Respiratory Severity Score (BCRSS 0 to 8, with higher scores indicating higher severity) at 24-72 h and 10 days after tocilizumab administration. Out of 100 treated patients (88 M, 12 F; median age: 62 years), 43 received TCZ in the intensive care unit (ICU), while 57 in the general ward as no ICU beds were available. Of these 57 patients, 37 (65%) improved and suspended noninvasive ventilation (NIV) (median BCRSS: 1 [IQR 0-2]), 7 (12%) patients remained stable in NIV, and 13 (23%) patients worsened (10 died, 3 were admitted to ICU). Of the 43 patients treated in the ICU, 32 (74%) improved (17 of them were taken off the ventilator and were discharged to the ward), 1 (2%) remained stable (BCRSS: 5) and 10 (24%) died (all of them had BCRSS≥7 before TCZ). Overall at 10 days, the respiratory condition was improved or stabilized in 77 (77%) patients, of whom 61 showed a significant clearing of diffuse bilateral opacities on chest x-ray and 15 were discharged from the hospital. Respiratory condition worsened in 23 (23%) patients, of whom 20 (20%) died. All the patients presented with lymphopenia and high levels of C-reactive protein (CRP), fibrinogen, ferritin and IL-6 indicating a HIS. During the 10-day follow-up, three cases of severe adverse events were recorded: two patients developed septic shock and died, one had gastrointestinal perforation requiring urgent surgery and was alive at day 10. In conclusion, our series showed that COVID-19 pneumonia with ARDS was characterized by HIS. The response to TCZ was rapid, sustained, and associated with significant clinical improvement.

Figures

Fig. 1
Fig. 1
Brescia COVID-19 Respiratory Severity Scale (BCRSS). BCRSS is freely available at: https://www.mdcalc.com/brescia-covid-respiratory-severity-scale-bcrss-algorithm
Fig. 2
Fig. 2
Brescia COVID-19 Respiratory Severity Scale (BCRSS) trend over time after Tocilizumab administration in patients treated in the ICU (panel A) and in the general ward (panel B).

Similar articles

See all similar articles

References

    1. Italian Ministry of Health 2020. http://www.salute.gov.it/imgs/C_17_notizie_4370_1_file.pdf
    1. Grasselli G., Zangrillo A., Zanella A., Antonelli M., Cabrini L., Castelli A. Baseline characteristics and outcomes of 1591 patients infected with SARS-CoV-2 admitted to ICUs of the Lombardy region, Italy. JAMA. 2020 doi: 10.1001/jama.2020.5394. - DOI
    1. Grasselli G., Pesenti A., Cecconi M. Critical care utilization for the COVID-19 outbreak in Lombardy, Italy: early experience and forecast during an emergency response. JAMA - J Am Med Assoc. 2020 doi: 10.1001/jama.2020.4031. - DOI
    1. Mehta P., McAuley D.F., Brown M., Sanchez E., Tattersall R.S., Manson J.J. COVID-19: consider cytokine storm syndromes and immunosuppression. Lancet. 2020;395:1033–1034. doi: 10.1016/S0140-6736(20)30628-0. - DOI - PubMed
    1. McGonagle D., Sharif K., O’Regan A., Bridgewood C. Interleukin-6 use in COVID-19 pneumonia related macrophage activation syndrome. Autoimmun Rev. 2020;102537 doi: 10.1016/j.autrev.2020.102537. - DOI
Feedback