A new report has described a multiple myeloma patient with COVID-19 who recovered after being treated with the interleukin 6 (IL-6)-blocking agent tocilizumab. The case report published in Blood Advances1 details the disease course of a man aged 60 years in China who was diagnosed with COVID-19 in early February 2020 after developing a fever, cough, and chest tightness.
The patient — who was originally diagnosed with multiple myeloma in 2015 and after initial therapy with dexamethasone, bortezomib, and thalidomide — experienced a disappearance of symptoms. The patient remained on thalidomide maintenance therapy after his initial treatment in 2015.
Once diagnosed with COVID-19, the patient was given tocilizumab. This medication was given to him after a test revealed high serum levels of IL-6. He experienced a reduction in IL-6 levels and COVID-19 symptoms in the days following administration of the medication.
For this patient, how likely is it that the tocilizumab was responsible for the improvement of his condition? Could other medications and/or the natural immune response be responsible for his recovery?
“I think any of these [scenarios could be] possible; he also got high-dose corticosteroids, too, and improved temporarily until he got the tocilizumab,” said Randy Cron, MD, PhD, professor of pediatrics and medicine at the University of Alabama, Birmingham. “My guess is that it would be the tocilizumab — it definitely works for cytokine release syndrome (CRS) during CAR T-cell therapy, so it’s possible, but it is just 1 case report,” added Dr Cron.
On day 2 after admission to hospital, the patient began treatment on methylprednisolone, receiving 40 mg per day for 5 successive days. On day 7, his serum IL-6 level was measured and found to be high at 122.6 pg/mL, and tocilizumab was administered at a dose of 8 mg/kg intravenously on day 9. The patient then experienced a decrease in serum IL-6 level to 20.8 mg/mL 10 days post-tocilizumab administration and a reduction in symptoms of chest tightness.
“I look at this with a bit of caution and optimism,” said Joseph Alvarnas, MD, hematologist/oncologist and professor in the department of hematology and hematopoietic cell transplantation at City of Hope in Duarte, California. “It isn’t the only case report that has demonstrated that tocilizumab might be able to mitigate the effects of the cytokine storm in the most serious manifestations of COVID-19 infection, but what’s so interesting about it is this is the use in a critically ill cancer patient.”
In patients with cancer or other preexisting conditions, or otherwise healthy individuals with COVID-19, a critical question still remains: How much is the cytokine storm elicited by SARS-CoV-2 dependent on IL-6 or other specific cytokines that could be potential targets for therapeutic intervention?
“This is an open area of investigation.” said Dr Alvarnas. “It’s not just IL-6 produced in exuberant amounts by the immune system, there’s lots of cytokines — and you aren’t getting the normal balance. As we understand more about these viral infections, we can be more specific with treatments,” he said. “For the time being, an anti–IL-6 strategy has been chosen because we have a therapy and in a different context [CAR-T], it’s relevant,” said Dr Alvarnas.
Other than after CAR-T therapy, CRS has also been seen in cases of SARS and MERS, as well as in rare cases of influenza and even noninfectious diseases such as multiple sclerosis and pancreatitis. Although case reports are undoubtedly useful, results from larger, ongoing trials are needed before making definitive conclusions about tocilizumab’s role in treating COVID-19-related CRS.