The anti-inflammatory drugs used for rheumatoid arthritis are very useful even against Covid. Doctors had noticed this during the weeks of emergency at the beginning of the pandemic, but the studies carried out had never given clear results, also due to the difficulty of designing rigorous trials in the pandemic era. Now the World Health Organization has included two drugs that block the interleukin-6 receptor, tocilizumab and sarilumab, among those officially recommended for the treatment of Covid patients. The decision came following the review of 27 clinical studies, involving over 10 thousand patients, conducted by the World Health Organization Rapid Evidence Appraisal for COVID Therapies (REACT) working group and published in Jama.
The indications
The two drugs are indicated for patients in serious conditions who are already being treated with corticosteroids, the first drugs to obtain WHO’s recommendation in the management of Sars-Cov-2 infection. Tocilizumab and sarilumab are two monoclonal antibodies that block interlukin 6 (IL-6), a molecule that produces inflammation and is one of the causes of the excessive immune reaction that often develops in Covid patients. The review found that adding either drug to corticosteroids leads to a 13% reduction in deaths compared to standard care and a 28% reduction in the likelihood of mechanical ventilation. In other words, 15 fewer deaths per 1000 patients and 23 fewer intubated patients.
How to use IL-6 antis
To date, there are several agents that are used to manage Covid patients, as underlined by Micheal Matthay and Anne Leutkemeyer, both in force at the University of California, in an editorial commenting on the study review. In this scenario, how should tocilizumab and sarilumab be used? First of all, experts say, always together with corticosteroids, because the results refer only to the combination of the two types of medicines. Second, patients should be chosen who have not already received mechanical ventilation for several days. Third, it is still unclear how to choose between these drugs and others, for example JAK inhibitors such as baricitinib and tofacitinib. These molecules have also been shown to be useful in combination with corticosteroids and there are no studies that have directly compared them with anti IL-6. Neither is anything known about the risks or benefits that could be obtained by combining anti-rheumatoid arthritis drugs with anti-Sars-Cov-2 monoclonal antibodies, which can be used in non-severe patients. So it takes caution. Fourth, now that mortality and intensive care use have fortunately decreased, at least in Western countries, the benefit of adding tocilizumab and sarilumab may not be justifiable in terms of additional costs and toxicity. But the scenario, the experts point out, could change and the fact that there are valid treatment options is certainly a good thing.
In Italy, the Italian Medicines Agency, as part of the continuous re-evaluation of drugs that can be used for COVID-19, had already decided in the middle of last June to include tocilizumab in the list of drugs for the treatment of adults hospitalized with COVID -19 severe and / or with high levels of systemic inflammation indices, in rapidly worsening clinical conditions.
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