COVID-19: Tocilizumab (Guidelines)

CRITERIA FOR USING TOCILIZUMAB (INTRAVENOUS)
NB must meet ALL criteria

• Adults aged 18 or over
• COVID-19 infection confirmed or suspected using clinical and/or radiological information
• Admitted for treatment of COVID-19 pneumonia
• Have not received tocilizumab during this admission
• Already be receiving steroid as per current recommendations  (dexamethasone or equivalent) unless contra-indicated 
• AND
  • Hypoxemia with a measured CRP of 75mg/L or more AND oxygen saturation of less than 94% (see local NHS Highland oxygen policy) or on low flow oxygen
• OR
  • Within 48 hours of commencing additional respiratory support defined as high flow nasal oxygen, continuous positive airway pressure (CPAP) or non-invasive ventilation or invasive ventilation.

Note: therapy with tocilizumab should be considered within 24 hours of meeting the inclusion criteria.

• Known hypersensitivity to tocilizumab 
• Administration of another interleukin-6 inhibitor during this admission

CAUTIONS (from SmPC)

• Clear evidence of active bacterial, fungal, viral (other than COVID-19) or other infection that might be worsened by IL-6 inhibitor therapy.
• Baseline ALT or AST levels at 5 times the upper limit of normal.
• Pre-existing condition or treatment resulting in ongoing immunosuppression
• Current neutropaenia or thrombocytopaenia

Pregnancy and breast feeding are not contra-indications but tocilizumab should not be used during pregnancy unless clinically necessary.  Follow the Royal College of Obstetrics and Gynaecology guidance on coronavirus (COVID-19) infection and pregnancy.  Women of child-bearing potential should be advised to use effective contraception for 3 months after treatment.

See manufacturer’s summary of product characteristics (tocilizumab)for more information, section 4.6. 

Tocilizumab use in a child should be agreed following MDT discussions with paediatric infection specialists.  

Tocilizumab

Dose is 8mg/kg as an intravenous infusion with a maximum dose of 800mg.  A second dose should not be considered due to uncertainty of additional benefit and to maximise available supply.

Use the dosing table below as per RECOVERY trial.  

• Dilute the required dose in 100mL of sodium chloride 0.9%
• Give over one hour at the following rate:
  • 10mL/hour for 15 minutes.
  • 130mL/hour for the remaining 45 minutes.

There is no interaction expected between tocilizumab  and dexamethasone, hydrocortisone or remdesivir.  For further information, please visit the University of Liverpool COVID-19 Drug Interactions

Any suspected adverse drug reactions (ADRs) for patients receiving tocilizumab for this indication should be reported directly to the MHRA via the new dedicated COVID-19 Yellow Card reporting site

Tocilizumab can cause immunosuppression that renders patients at risk of bacterial and fungal infections.

• Low clinical threshold for identification and management of infection must be used. 
• CRP level may be a less reliable marker of active infection and procalcitonin may be negative.

The Deputy Chief Medical Officer recommends that data on all patients with COVID-19 should be captured through the ISARIC 4C Clinical Characterisation Protocol (CCP) case report forms (CRFs), as coordinated by the COVID-19 Clinical Information Network (CO-CIN) (link to forms).

• RoActemra SPC
• RoActemra PIL
• Risk materials, including RoActemra (tocilizumab) Patient Card