What is the role of IL-6 inhibitors in the treatment of COVID-19?

Updated: Jan 12, 2021
  • Author: Setu K Patolia, MD, MPH; Chief Editor: Zab Mosenifar, MD, FACP, FCCP  more...
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Answer

Answer

Tocilizumab, a recombinant humanized monoclonal antibody against the IL-6 receptor, is used in the treatment of rheumatoid arthritis. It was approved in 2017 for the management of cytokine storm syndrome in patients receiving chimeric antigen receptor (CAR) T-cell therapy. As mentioned, patients with COVID-19 may develop an intense inflammatory condition that may respond to the inhibition of IL-6–dependent inflammation. A multicenter cohort study of 3924 patients with COVID-19 pneumonia requiring ICU admission showed that patients who were treated with tocilizumab within 2 days of ICU admission had lower in-hospital mortality as compared with patients whose treatment did not include the early use of tocilizumab. [39] In a randomized controlled trial by Stone et al, tocilizumab use in moderately ill hospitalized patients did not prevent intubation or death as compared with placebo. [40] Salvarani et al randomized 126 patients with a PaO2/FiO2 ratio of 200-300 mm of Hg. [41] This study did not find any benefit of tocilizumab in reducing risk of clinical worsening. Preliminary results from the COVACTA trial showed that as compared with placebo, use of tocilizumab in the hospitalized patients with severe COVID-19 pneumonia did not result in improvement in a seven-category ordinal scale at week four. [42]

In a randomized controlled trial conducted by Hermine et al in hospitalized patients with moderate-to-severe COVID-19 pneumonia, tocilizumab use led to a reduction in the need for mechanical and noninvasive ventilation at day 14. [43] However, there was no reduction in mortality at day 28. Preliminary data from the EMPACTA trial have shown that use of tocilizumab in hospitalized patients was associated with a 44% less likelihood of progression to mechanical ventilation or death. [44] However, the study did not demonstrate any benefit in reducing 28-day mortality as compared with placebo. For hospitalized patients with COVID-19, IDSA guidelines recommend against the use of tocilizumab. [35]


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