ABSTRACT
Severe acute respiratory coronavirus-2 (SARS-CoV-2) still presents a public threat and puts extra strain on healthcare facilities. Without an effective antiviral drug, all available treatment options are considered supportive. Tocilizumab as a treatment option has to date shown variable results. In this retrospective study, we aimed to assess predictors of mortality of COVID-19 patients (n = 300) on tocilizumab and the clinical effectiveness of this drug. The results showed that ICU admission OR = 64.6 (95% CI: 8.2, 507.4); age of the patient OR = 1.1 (95% CI: 1.0, 1.1); and number of tocilizumab doses administered by the patient OR(two doses) = 4.0 (95% CI: 1.5, 10.9), OR(three doses) = 1.5 (95% CI: 0.5, 5.1), and OR(four doses or more) = 7.2 (95% CI: 2.0, 25.5) presented strong correlation factors that may be linked to COVID-19 mortality. Furthermore, our study showed the beneficial effects of early administration of tocilizumab OR = 1.2 (95% CI: 1.1, 1.4) and longer hospital length of stay OR = 0.974 (95% CI: 0.9, 1.0) in reducing COVID-19 mortalities. High blood D-dimer concentration OR = 1.1 (95% CI: 1.0, 1.2) and reciprocal blood phosphate concentration OR = 0.008 (95% CI: 0.0, 1.2) were correlated to high mortality under SARS-CoV-2 infection. The short-term effect of a single dose of tocilizumab was a significant increase in blood BUN and liver enzymes (ALT, AST, and LDH) above their normal ranges. Furthermore, it significantly reduced CRP blood concentration, but not to normal levels (13.90 to 1.40 mg/dL, p < 0.001). Assessing the effect of different doses of tocilizumab (in terms of the number of doses, total mg, and total mg/kg administered by the patients) indicated that administering more than one dose may lead to increases in ICU length of stay and hospital length of stay of up to 14 and 22 days after the last dose of tocilizumab (6 to 14, p = 0.06, and 10 to 22, p < 0.001), with no improvement in 28- and 90-day mortality, as confirmed by Kaplan-Meier analysis. There were also clear correlations and trends between the number of doses of tocilizumab and increased blood CO2, MCV, RDW, and D-dimer concentrations and between number of doses of tocilizumab and decreased CRP, AST, and hemoglobin concentrations. Microbiology analysis showed a significant increase in the incidence of infection after tocilizumab administration (28 to 119, p < 0.001) with a median time of incidence within 6 days of the first dose of tocilizumab. A significant correlation was also found between the number of tocilizumab doses and the number of incidences of infections after tocilizumab administration r (298) = 0.396, p = 1.028 × 10-12. Based on these results and depending on the pharmacokinetic parameters of the drug, we recommend single-dose administration of tocilizumab as the optimal dosage for COVID-19 patients who do not have active bacterial infection or liver diseases, to be administered as soon as the patient is admitted to the hospital.
ABSTRACT
BACKGROUND: The newly emerged coronavirus pandemic (COVID-19) has collapsed the entire global health care system. Due to these settings, a lot of strategic changes are adopted by healthcare facilities to ensure continuity in patient-centered services. OBJECTIVE: This study aims to evaluate the effectiveness of structural and operational changes made in ambulatory care pharmacy services during the COVID-19 pandemic. METHODS: A retrospective comparative study was conducted to evaluate the impact and effectiveness of patient-centered interventions and consequent access to medication management care within Johns Hopkins Aramco Health Care ambulatory care pharmacy services during the COVID-19 pandemic by comparing patient-centered key performance indicators before and during COVID-19 pandemic for a total of 4 months. RESULTS: As a result of the structural and operational changes made in patient-centered ambulatory care pharmacy services during the COVID-19 pandemic, a 48% prescriptions requests and 90% prescriptions fills are increased through online health portal application. A three-fold increase in the pharmacy call center utilization resulted in around 10% abandoned calls. In the number of physical visits to ambulatory care pharmacies, a 37% reduction was also noted. The decrease in staff schedule efficiency and an increase in average prescription waiting time were also noticed. The prescription collection through remote area pick up locations, and medication home delivery services were successful during COVID-19 pandemic as supported by statistical data. CONCLUSION: The access to ambulatory care pharmacy services during COVID-19 pandemic has been successfully maintained via medication home delivery, remote area pickup locations, pharmacy call-center consultations and refill requests, online health portal application services, and other measures, while reducing the number of physical visits to the JHAH hospital/clinic to ensure compliance with infection control and prevention measures.