Rheumatoid arthritis drug tocilizumab advances as a COVID-19 treatment, as other regimens fall back, studies show

The list of drugs shown effective for treating COVID-19 got longer Tuesday, even as another well-used drug lost some of its luster.

In a large clinical study, tocilizumab, an immune modulator long used to treat rheumatoid arthritis, showed it can save lives if given to critically ill COVID-19 patients within the first two days of being admitted to an intensive care unit. 

The study, published in JAMA Internal Medicine, showed just over 27% of ICU patients treated with tocilizumab died within a month, compared with 37% of those just as seriously ill but did not receive the drug. 

Tocilizumab, a so-called monoclonal antibody, has been used during the outbreak because of its effect on tamping down immune overreactions, which have been common with COVID-19. Smaller studies, including one published at the same time by the same journal have shown mixed results, with some finding the drug did not reduce deaths.

Dr. David Leaf, the senior author on the new paper, said that's why it's so important during the pandemic to have large, randomized trials comparing a drug option against a placebo, especially among the sickest patients. 

Most randomized studies conducted so far in COVID-19 haven't been large enough or included enough very ill patients to know whether a drug can improve survival, he said.

"They're just not anywhere close to being adequately powered to assess mortality," he said.

Leaf, a kidney specialist at Brigham and Women's Hospital and Harvard Medical School, collaborated with researchers at 67 other hospitals across the U.S. to conduct their new study, tracking 4,000 critically ill patients early in the pandemic. The group has already published several studies, including one showing heart attacks are very common among critically ill COVID-19 patients and tend to lead to poor outcomes, even in those who receive CPR. Future research will look at other treatments for very ill patients, he said. 

Leaf said his study reinforces the idea that different drugs should be used at different times during COVID-19 treatment. Tocilizumab appeared to be particularly helpful for patients admitted to an ICU within three days of developing symptoms, he said.

"If you wait too long, you're waiting for irreversible organ injury to have occurred," he said, and the drug may no longer be effective.

About 20% of the ICU patients examined had symptoms for just a few days before landing in intensive care, he said. For that subset of patients, unlike any other, tocilizumab appears to offer a substantial survival benefit.

Many patients with serious COVID-19 cases, like President Donald Trump, receive steroids to tamp down an immune overreaction. Leaf compared steroids to a sledgehammer, acting on the entire immune system, while tocilizumab is a scalpel, targeting a particular immune molecule called IL-6. 

Tocilizumab is usually given to COVID-19 patients just once, through an intravenous injection. A second dose can be given if needed several days later.

In an unrelated result, the World Health Organization found four other drug regimens given to hospitalized COVID-19 patients did not reduce deaths, hospital stays, or the likelihood of requiring ventilation. 

That study, which has not yet been peer-reviewed and is at an earlier stage than would usually be made public, found the drugs remdesivir, hydroxychloroquine, lopinavir and interferon appeared to provide no benefit for hospitalized COVID-19 patients.

Trump received remdesivir, along with steroids and an experimental monoclonal antibody, when he was treated for COVID-19.

Most mainstream doctors long ago moved away from using hydroxychloroquine in their COVID-19 patients, and the WHO discontinued testing hydroxychloroquine and lopinavir back in July because the treatment did not prevent deaths. 

Dr. Rajesh Gandhi, an infectious disease specialist at Massachusetts General Hospital, said he thinks it's too soon to give up on remdesivir, which has been shown in other studies to reduce hospital stays. "We will continue to use remdesivir in our patients hospitalized with COVID-19," he said.

Contact Karen Weintraub at kweintraub@usatoday.com

Health and patient safety coverage at USA TODAY is made possible in part by a grant from the Masimo Foundation for Ethics, Innovation and Competition in Healthcare. The Masimo Foundation does not provide editorial input.