ABSTRACT
The COVID19 pandemic has pushed healthcare workers to utilize available therapeutics, often with limited evidence. Theoretically, IL6 inhibitors could help to stop or reverse the damage caused by COVID19 cytokine storm. Published evidence from the United States is conflicting and is largely from academic institutions and nonminority populations. This study assessed the clinical utility of open-label tocilizumab in two multiethnic community hospitals in Queens, NY.Tocilizumab (8mg/kg) was given to 114 patients for treatment of COVID19- related respiratory failure between April 4 and May 19 2020 (96% received 1 dose). A retrospective cohort study was performed to determine 28-day clinical success, defined as achieving a score of 1 using a 6-point scale (1=no O2 requirement or discharged home on 2L/min;2=low-flow O2 in hospital ≤6L/min;3=O2 >6 to ≤15L/min;4=high-flow, CPAP, or BiPAP;5=mechanically ventilated (MV);6=expired). The decision to administer tocilizumab was made by a committee based on unstable or worsening respiratory status. Mean patient age was 60 years (SD=11);77(67%) were male. 25% were Asian, 23% black (31% black Hispanic), 36% white (73% white Hispanic), and 14% other. A majority of patients had at least 1 significant comorbidity, including HTN 56%, DM 40%, HLD 43%, and COPD/asthma 16%. Median days of symptoms at dose was 14(IQR 10-19);SpO2 on RA at admission was 82%(IQR 67-88%). Baseline status by ordinal scale was as follows: 2= 9(8%);3=33(29%);4=38(33%);5=34(30%) (IQR 1-2 days on vent). Median CRP=19.9, d-dimer=1658, ferritin=593, and LDH=1561. 28-day success was achieved in 35(31%) patients;62(55%) patients expired or were MV on day 28. Of patients who were on high-flow, CPAP, BiPAP or MV at baseline, 80% expired or were on MV on day 28. Estimated mortality in all hospitalized patients during the time frame at these hospitals was 36%. No significant differences were seen in labs, comorbidities or age between patients who did and did not have clinical success. Higher baseline ordinal scale score was predictive of mortality.Tocilizumab provided little to no clinical utility, especially in those with high oxygenation needs at time of dosing (success rate <20%). The main limitation is lack of a control group;however mortality was strikingly high. This in part may be due to the demographic and clinical characteristics of our sample.
ABSTRACT
New York City was one of the first epicenters of the COVID19 pandemic in the United States, and continues to be the hardest hit in terms of the number of total hospitalizations and deaths. As the pandemic has spread, it has become evident that the virus disproportionately affects minority populations and may result in more adverse outcomes. The multi-ethnic communities of Queens, NY, some of which include large proportions of low socio-economic and immigrant families, provide a unique opportunity to observe the COVID19 experience at the height of the pandemic. This information allows clinicians and researchers to learn more about the presentation and course of disease in a diverse sample. An estimated 2800 patients admitted for COVID19 were seen between March 10 and May 31 2020 (not including asymptomatic positive patients). A sample of 1651 were included in these preliminary analyses (806 from hospital A and 845 from hospital B).Most patients were male(62%) with mean age 67(16.1). Ethnicities were 33% Hispanic, 24% Black, 18% Asian, 17% White, and 8% other/unknown. At presentation, half had HR>100 and/or RR>20;25% had fever>100.5F. Symptoms included dyspnea(69%), cough(60%), fever(58%), weakness/fatigue(42%), myalgia(24%), AMS/confusion(21%), and GI complaints(20%). Comorbidities were HTN(65%), DM(43%), HLD(43%), CAD(19%), CKD(15%), CVA(10%) and COPD/asthma(10%). Complications included sepsis(44%), AKI/ARF(36%), intubation(24%), and arrhythmias(7%). Disposition included 29% home, 18% to skilled nursing facility, and 36% expired.In our cohort of mainly minority patients from low to middle class urban neighborhoods, presence of comorbidies was higher than in other reported cohorts in the region. Though presenting symptoms were similar to other New York City hospitals, clinical course was poorer, with over 1/3 of patients expiring. Further analyses will concentrate on predictors of poor outcome within and between racial/ethnic groups in the complete cohort of eligible patients.