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“Organizations are encouraged to consider prescribing either tocilizumab or sarilumab in the treatment of patients admitted to intensive care with Covid-19 pneumonia,” says the new directive from British health authorities. Dr Gordon noted that this is the strongest official advice issued to date on the immune drug pair.
Some experts outside of Britain are being more cautious. Dr Schwartz and Dr Kaplan-Lewis noted that while the data may be enough to persuade the FDA to authorize tocilizumab and sarilumab for emergency use in the United States, the jury is still out on these drugs. And Dr Boghuma Kabisen Titanji, an infectious disease physician at Emory University, pointed out that only about 4% of study volunteers identified as black, which may make the results less applicable to the general population given the increased vulnerability of communities of color to Covid19.
Further studies will be needed to clarify when and in which patients tocilizumab and sarilumab work best, and to understand why their benefits have been evident in some studies, but not others, Dr Kaplan-Lewis said. It is also difficult to compare the studies that are coming out now with previous trials that were conducted when the virus was much less understood, treatments were delivered with less know-how, and death rates were even higher.
“If patients received better supportive care, their outcomes might be much improved,” said Dr. Krutika Kuppalli, an infectious disease physician at the University of South Carolina who was not involved in study. “Yes, the therapies are helpful. But it is also about improving the level of care for people.
The new study and others have hinted that the window of opportunity for drugs is narrow – within the first day or two after admission to an intensive care unit, Dr Kaplan-Lewis said. Given too early, the drugs might not make a measurable dent in the immune response; delivered too late, and the damage may have already been done. “Maybe that’s when a person has just slipped into criticism,” she says.
This inflection point is not always easy to define. Patients enter intensive care in different states, and the threshold for critical illness may not be uniform across hospitals. And, like all other immunosuppressive drugs, tocilizumab and sarilumab can increase your risk of infection with other viruses or bacteria.
The data are “encouraging”, said Dr Kuppalli. “But I think we need to understand why this data is different from other studies, before we start implementing this widespread policy.”
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