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April 03, 2020
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Tocilizumab may be effective for patients with COVID-19, blood cancer

Source/Disclosures
Disclosures: The authors report no relevant financial disclosures.
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The immunosuppressant tocilizumab may be an effective treatment for very ill individuals with COVID-19 and hematologic malignancies, according to results of a case study from China published in Blood Advances.

However, more research is necessary to evaluate the efficacy and safety of tocilizumab (Actemra, Genentech) in this setting, researchers emphasized.

Older individuals with hematologic malignancies are at high risk for COVID-19 due to immunosuppression.

Early research suggests the novel coronavirus triggers an excessive immune response and “a strong cytokine storm” that may include high levels of interleukin-6 and granulocyte-macrophage colony-stimulating factor, according to study background.

“What are the characteristics of COVID-19 in patients with blood cancers? What is the optimal treatment approach? Everything is unknown, and that was the motivation for this study,” Changcheng Zheng, MD, of University of Science and Technology of China, said in a press release.

Zheng and colleagues highlighted the case of a man aged 60 years who had been diagnosed with multiple myeloma in 2015 and had been on maintenance therapy.

The man — who worked in Wuhan, China — was hospitalized in February after experiencing shortness of breath and chest tightness. He did not show symptoms of fever or cough — typical COVID-19 symptoms — but tested positive for the novel coronavirus, and clinicians characterized his illness as severe.

Chest CT scan showed multiple ground-glass opacities in the man’s lungs, suggestive of pneumonia. He also exhibited high levels of interleukin-6, a pro-inflammatory cytokine.

The man underwent treatment with antiviral and corticosteroid therapies, including 400 mg moxifloxacin daily via IV for 3 days, as well as 200 mg umifenovir tablets orally 3 times daily.

He received 40 mg methylprednisone daily via IV on days 2 to 6, after which his breathing had improved but his chest tightness remained.

On day 8 in the hospital, chest CT scans continued to show multiple ground-glass opacities in the man’s lungs.

On day 9, he received one dose of tocilizumab (8 mg/kg via IV), a humanized interleukin-6 receptor antagonist approved for treatment of cytokine release syndrome that develops after chimeric antigen receptor T-cell therapy.

His interleukin-6 levels declined gradually after tocilizumab administration over the following 10 days — from 121.59 pg/mL to 20.81 pg/mL — then increased rapidly to 317.38 pg/mL and declined again to 117.1 pg/mL.

“The transient rebounding of the IL-6 level to the peak does not mean COVID-19 relapse; instead, this might be attributed to the recovery of the normal T cells,” Zheng and colleagues wrote.

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The man’s chest tightness resolved on day 12. On day 19, chest CT showed obvious decline in the range of ground-glass opacities, and he subsequently was discharged from the hospital, showing no symptoms of myeloma and exhibiting laboratory findings within normal ranges.

The results suggest tocilizumab may address the acute severe inflammatory response triggered by COVID-19, Zheng and colleagues concluded.

“Tocilizumab was effective in the treatment of COVID-19 in this patient with multiple myeloma, but further prospective and randomized clinical trials are needed to verify the findings,” Zheng said.

The FDA last month approved a randomized double blind, placebo-controlled phase 3 trial to evaluate the efficacy and safety of IV tocilizumab for treatment of adults with COVID-19.

In addition, the fact the man’s symptoms did not match those observed in most patients with COVID-19 is notable, according to researchers.

“Common symptoms of COVID-19 include fever and cough, but the patient in our study had chest tightness and shortness of breath, indicating that the clinical symptoms of COVID-19 are not typical in patients with coexisting comorbidities such as multiple myeloma,” Zheng and colleagues wrote. – by Mark Leiser