Tocilizumab therapy in five solid and composite tissue transplant recipients with early ARDS due to SARS‐CoV‐2

Morillas, Jose A.; Marco Canosa, Francisco; Srinivas, Pavithra; Asadi, Tannaz; Calabrese, Casandra; Rajendram, Prabalini; Budev, Marie; Poggio, Emilio D.; Narayanan Menon, KV; Gastman, Brian; Koval, Christine

There is emerging data depicting the clinical presentation of COVID‐19 in solid organ transplant recipients but negligible data‐driven guidance on clinical management. A biphasic course has been described in some infected with SARS‐CoV‐2, beginning with a flu‐like illness followed by an intense inflammatory response characterized by elevated c‐reactive protein (CRP), interleukin 6 (IL‐6), and acute respiratory distress syndrome (ARDS) associated with high mortality. The exuberant and possibly dysregulated immune response has prompted interest in therapeutic agents that target the cytokines involved, particularly IL‐6. Tocilizumab is an IL‐6 receptor antagonist with a record of use for a variety of rheumatologic conditions and cytokine release syndrome due to CAR T‐cell therapy but experience in solid organ and composite tissue transplant recipients (SOT/CTTRs) with SARS‐CoV‐2‐related ARDS has not been previously reported in detail. We present the clinical course of five SOT/CTTRs with SARS‐CoV‐2‐related ARDS that received tocilizumab with favorable short‐term outcomes in four. Responses were characterized by reductions in CRP, discontinuation of vasopressors, improved oxygenation and respiratory mechanics, and variable duration of ventilator support. Four bacterial infections occurred within two weeks of tocilizumab administration. We discuss safety concerns and the need for randomized comparative trials to delineate tocilizumab’s clinical utility in this population.