Tocilizumab (Actemra) shortages will continue to raise questions about using an add-on to steroids for COVID-19.
This IL-6 inhibitor is the go-to add-on. But supplies are low...plus hospitals are balancing stock for other indications.
Continue to apply creative solutions. For example, if you have tocilizumab subcutaneous prefilled syringes, consider using them to make IV doses...lab data suggest similar stability. Infuse with a filter.
If tocilizumab runs out, think about these strategies.
Baricitinib (Olumiant). Turn to this oral Janus kinase (JAK) inhibitor in most cases. It's authorized for COVID-19.
Baricitinib may decrease mortality when added to a steroid in patients on supplemental oxygen. But the data with mechanical ventilation or extracorporeal membrane oxygenation (ECMO) aren't published yet.
Ensure safe baricitinib use. Don't give it to patients with acute kidney injury or eGFR less than 15 mL/min/1.73 m2. And use special handling (N95 mask, etc) if crushing...since it has hazardous-med properties.
Also avoid JAK inhibitors in patients with a VTE history...due to a boxed warning for thrombosis. VTE rates don't seem higher when using JAK inhibitors for COVID-19, but data don't include patients with a prior VTE.
Sarilumab (Kevzara). Consider this IL-6 inhibitor as another option for adults in the ICU...or those unable to take baricitinib.
Sarilumab isn't authorized for COVID-19...but some evidence suggests it works as well as tocilizumab in critically ill adults.
Keep in mind, sarilumab's single IV dose is more convenient than baricitinib...which is used for 14 days or discharge, whichever is first.
Use the subcutaneous formulation of sarilumab to prep IV doses. Mix 400 mg in 100 mL of normal saline and administer with a filter.
Tofacitinib (Xeljanz). Save this oral JAK inhibitor for NON-critically ill patients if baricitinib runs out.
Tofacitinib reduces respiratory failure or death...but not mortality alone. Plus evidence is mostly in patients using low-flow oxygen...there aren't data in those requiring more than high-flow oxygen.
See our chart, Treatments of Interest for COVID-19, for monitoring and prep details...plus other meds, such as anakinra (Kineret).
- Lancet Respir Med Published online Sep 1, 2021; doi:10.1016/S2213-2600(21)00331-3
- N Engl J Med 2021;384(16):1491-502
- N Engl J Med 2021;385(5):406-15
- www.covid19treatmentguidelines.nih.gov/ (9-29-21)
- medRxiv Published online Jun 25, 2021; doi:10.1101/2021.06.18.21259133