NHS Highland Guidance on use of interleukin-6 inhibitors (tocilizumab or sarilumab) for adult hospital in-patients with confirmed SARS-CoV-2 infection
(based on CEM/CMO/2021/016 interim clinical commissioning policy published 12th September 2021)
NOTE: this is an unlicensed indication for tocilizumab and sarilumab – prescriber takes full responsibility for use
Tocilizumab and sarilumab are monoclonal antibodies that bind to the receptor for IL-6, blocking IL-6 signalling and reducing inflammation.
Tocilizumab is licensed for use in patients with rheumatoid arthritis and for use in patients aged at least 2 years with chimeric antigen receptor (CAR) T-cell induced or life-threatening cytokine release syndrome.
Sarilumab is licensed for use in combination with methotrexate (MTX) for the treatment of moderately to severely active rheumatoid arthritis (RA) in adult patients who have responded inadequately to, or who are intolerant to one or more disease modifying anti rheumatic drugs (DMARDs).
Severe COVID-19 is associated with a hyper-inflammatory state with elevated ESR, C-reactive protein, D-dimers, lactate dehydrogenase, ferritin and increased levels of pro-inflammatory cytokines including IL-1 and IL-6. There have been published and unpublished (pre-print) case series reports of the successful treatment of COVID-19 patients with IL-6 inhibitors.
A single UK Interim Clinical Commissioning Policy has now been published, recommending that equal consideration is given to two potential interleukin-6 (IL-6) inhibitor treatment options - tocilizumab or sarilumab - for adult patients (aged 18 years and older) hospitalised due to COVID-19 in accordance with the agreed criteria. The combined policy replaces previous separately published policies for sarilumab and tocilizumab respectively. The policy takes into account evidence from the RECOVERY and REMAP-CAP trials, a rapid evidence review undertaken by the National Institute for Health and Care Excellence (NICE), updated guidelines (July 2021) from the World Health Organization (WHO) and currently available supplies of both medicines as a treatment for COVID-19 and other existing (routine) indications.
NB: Sarilumab should only be used when tocilizumab is unavailable due to supply disruption