The mortality rate of the disease caused by the corona virus induced disease (COVID-19) has been estimated to be 3.7% (WHO), which is more than 10-fold higher than the mortality of influenza. Patients with certain risk factors seem to die by an overwhelming reaction of the immune system to the virus, causing a cytokine storm with features of Cytokine-Release Syndrome (CRS) and Macrophage Activation Syndrome (MAS) and resulting in Acute Respiratory Distress Syndrome (ARDS). Several pro-inflammatory cytokines are elevated in the plasma of patients and features of MAS in COVID-19, include elevated levels of ferritin, d-dimer, and low platelets. There is increasing data that cytokine-targeted biological therapies can improve outcomes in CRS or MAS and even in sepsis. Tocilizumab (TCZ), an anti-IL-6R biological therapy, has been approved for the treatment of CRS and is used in patients with MAS. Based on these data, it is hypothesized that TCZ can reduce mortality in patients with severe COVID-19 prone to CRS and ARDS. The overall purpose of this study is to evaluate whether treatment with TCZ reduces the severity and mortality in patients with COVID-19.
Background and Rationale
The Acute Respiratory Syndrome by Corona Virus 2 (SARS-CoV-2), first discovered in December
2019 in Wuhan/China, is causing a worldwide pandemic with potentially lethal implications on
an individual basis, and, on the large scale bringing the health care systems and the economy
to its limits. The mortality rate of this COronaVIrus induced Disease, COVID-19, has been
estimated by the World Health Organization (WHO) to be 3.7%, which is more than 10-fold
higher than the mortality of influenza.
An infection with SARS-CoV-2 may cause an excessive host immune response, leading to an Acute
Respiratory Distress Syndrome (ARDS) and death. Reports from China and from Italy describe an
overwhelming inflammation which is triggered by the virus, causing a cytokine storm with
features of Cytokine-Release Syndrome (CRS) and/or Macrophage Activation Syndrome (MAS).
Pro-inflammatory cytokines such as Interleukin-6 (IL-6) are elevated in the plasma of
patients and features of MAS in COVID-19 include elevated levels of ferritin, d-dimer and low
platelets.
There is increasing evidence, that cytokine-targeted biological therapies can improve
outcomes in CRS or MAS and even in sepsis. In recognition of the dramatic development of the
COVID-19 pandemic, and in a pragmatic manner, already approved and safe therapies should be
evaluated for the use in severe COVID-19.
Tocilizumab (TCZ), an anti-IL-6R biological therapy, has been approved for the treatment of
CRS and is used in patients with MAS (and in other rheumatologic conditions like Rheumatoid
Arthritis (RA) or Giant Cell Arteritis (GCA), with a good safety profile also in the
elderly).
Collectively, the data strongly suggest that neutralization of the inflammatory pathway
induced by IL-6 may reduce mortality in patients with severe COVID-19 prone to CRS and ARDS.
Drug: Tocilizumab (TCZ)
Patients get one dose (= 8 mg/kg bodyweight, max. single dose 800 mg) Actemra® (active ingredient: TCZ) intravenously in 100 mL NaCl 0.9% after confirmation of progressive dyspnoea. Infusion time: 60 min. The procedure is repeated once if no clinical improvement in the 8-point WHO scale is observed.
Other Name: Actemra
Drug: Placebo
The placebo-controlled intervention is one dose (100 mL) NaCl 0.9% intravenously administered after confirmation of progressive dyspnoea. Infusion time: 60 min. The procedure is repeated once if no clinical improvement in the 8-point WHO scale is observed.
Other Name: NaCl 0.9%
Inclusion Criteria:
I (first step):
- Admission to hospital
- Male or non-pregnant female, ≥60 years of age or ≥30 years of age plus one or more
known risk factors (arterial hypertension, diabetes mellitus, coronary heart disease,
heart failure, pre-existing chronic pulmonary disease)
- Confirmed SARS-CoV infection
- Radiographic evidence compatible with Covid-19 pneumonia (X-ray/CT scan, etc.)
- Signed Informed Consent Form
II (second step; indication for intervention):
- CRP ≥50mg/L plus 3 out of the following 5 criteria need to be fulfilled:
- Respiration Rate ≥25
- SpO2 <93% (on ambient air)
- PaO2 <65 mmHg
- Persistent or increasing dyspnoea as defined by a one point increase on the mMRC
dyspnoea scale (over 1 hour)
- Persistent or increasing oxygen demand (over 1 hour)
Exclusion Criteria:
I (first step):
- Patients >80 years of age
- Patient included in any other interventional trial
- Indication for imminent or immediate transfer to ICU
- Treatment with TCZ (or other anti-IL-6R treatment) within 4 weeks prior to baseline
- Uncontrolled bacterial superinfection according to investigator
- History of severe allergic reaction to TCZ
- History of diverticulitis requiring antibiotic treatment or history of colon
perforation
- History of primary immunodeficiency (e.g. CVID) or progressing malignancy
- History of chronic liver disease (>Child-Pugh A, or according to investigator)
II (second step; contraindication for intervention):
- Alanine transaminase/aspartate transaminase (ALT/AST) >5 times of the upper limit of
normal
- Hemoglobin <80 g/L
- Leukocytes <2.0 G/L
- Absolute neutrophil count <1.0 G/L
- Platelets <50 G/L
University Hospital Bern (Inselspital)
Bern, Switzerland
Centre Hospitalier Universitaire Vaudois (CHUV)
Lausanne, Switzerland
Ospedale Regionale di Lugano (EOC)
Viganello, Switzerland
University Hospital Zurich
Zurich, Switzerland
Peter M. Villiger, Prof. Dr. med., Study Chair
University Hospital Bern (Inselspital)