Low-dose Tocilizumab Versus Standard of Care in Hospitalized Patients With COVID-19

Study Overview
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Brief Summary
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Tocilizumab is an effective treatment for severe coronavirus disease 2019 (Covid-19) pneumonia and related inflammation. Given limited global supplies, clarification of the optimal tocilizumab dose is critical. We conducted an open-label, randomized, controlled trial evaluating two different dose levels of tocilizumab in Covid-19 (40mg and 120mg). Randomization was stratified on remdesivir and corticosteroid at enrollment. The primary outcome was the time to recovery. The key secondary outcome was 28-day mortality.

Detailed Description
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COVID-19's high mortality may be driven by hyperinflammation. Interleukin-6 (IL-6) axis therapies may reduce COVID-19 mortality. Retrospective analyses of tocilizumab in severe to critical COVID-19 patients have demonstrated survival advantage and lower likelihood of requiring invasive ventilation following tocilizumab administration. The majority of patients have rapid resolution (i.e., within 24-72 hours following administration) of both clinical and biochemical signs (fever and CRP, respectively) of hyperinflammation with only a single tocilizumab dose. The investigators hypothesized that a dose of tocilizumab significantly lower than the EMA- and FDA-labeled dose (8mg/kg) as well as the emerging standard of care dose (400mg) may be effective in patients with COVID-19 pneumonitis and hyperinflammation. Advantages to the lower dose of tocilizumab may include lower likelihood of secondary bacterial infections as well as extension of this drug's limited supply. The investigators conducted an adaptive single-arm phase 2 trial (NCT04331795) evaluating clinical and biochemical response to low-dose tocilizumab in patients with COVID-19 pneumonitis and hyperinflammation. This multi-center, prospective, randomized controlled phase 2 trial -- designed as two sub-studies to allow for the possible emergence of data demonstrating the clinical efficacy of tocilizumab 8mg/kg or 400mg -- formally tests the clinical efficacy of low-dose tocilizumab in COVID-19 pneumonia. Sub-Study A Primary Objective A: To establish whether low-dose tocilizumab reduces the time to clinical recovery in patients with COVID-19 pneumonitis and hyperinflammation, when compared to a tocilizumab-free standard of care. Hypothesis A: The investigators hypothesize that low-dose tocilizumab, when compared to a tocilizumab-free standard of care, decreases the time to recovery in hospitalized, non-invasively ventilated patients with COVID-19 pneumonitis and hyperinflammation by three days or more. Sub-Study B Primary Objective B: To establish whether low-dose tocilizumab is near-equivalent to high-dose tocilizumab (400mg or 8 mg/kg) in reducing the time to clinical recovery in patients with COVID-19 pneumonitis and hyperinflammation. Hypothesis B: The investigators hypothesize that low-dose tocilizumab is near-equivalent to high-dose tocilizumab in reducing the time to clinical recovery in hospitalized, non-invasively ventilated patients with COVID-19 pneumonitis and hyperinflammation.

Official Title
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COVIDOSE-2: A Multi-center, Randomized, Controlled Phase 2 Trial Comparing Early Administration of Low-dose Tocilizumab to Standard of Care in Hospitalized Patients With COVID-19 Pneumonitis Not Requiring Invasive Ventilation

Conditions
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COVID-19

Intervention / Treatment
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* Drug: Tocilizumab
* Drug: Tocilizumab
* Other: Standard of Care
* Other: Standard of Care


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Adults ≥ 18 years of age Approval from the patient's primary inpatient service Hospitalized Fever, documented in electronic medical record and defined as: T ≥ 38 degrees C by any conventional clinical method (forehead, tympanic, oral, axillary, rectal) Positive test for active SARS-CoV-2 infection Radiographic evidence of infiltrates on chest radiograph (CXR) or computed tomography (CT) Ability to provide written informed consent on the part of the subject or, in the absence of decisional capacity of the subject, an appropriate surrogate (e.g. a legally authorized representative). Exclusion Criteria: Concurrent use of invasive mechanical ventilation Concurrent use of vasopressor or inotropic medications Previous receipt of tocilizumab or another anti-IL6R or IL-6 inhibitor in the year prior. Known history of hypersensitivity to tocilizumab. Diagnosis of end-stage liver disease or listed for liver transplant. Elevation of AST or ALT in excess of 10 times the upper limit of normal. Neutropenia (Absolute neutrophil count < 500/uL). Thrombocytopenia (Platelets < 50,000/uL). On active therapy with a Bruton's tyrosine kinase-targeted agent, which include the following: Acalabrutinib Ibrutinib Zanubrutinib On active therapy with a JAK2-targeted agent, which include the following: Tofacitinib Baricitinib Upadacitinib Ruxolitinib Any of the following biologic immunosuppressive agent (and any biosimilar versions thereof) administered in the past 6 months or less:: Abatacept Adalimumab Alemtuzumab Atezolizumab Belimumab Blinatumomab Brentuximab Certolizumab Daratumumab Durvalumab Eculizumab Elotuzumab Etanercept Gemtuzumab Golimumab Ibritumomab Infliximab Inotuzumab Ipilimumab Ixekizumab Moxetumomab Nivolumab Obinutuzumab Ocrelizumab Ofatumumab Pembrolizumab Polatuzumab Rituximab Rituximab Sarilumab Secukinumab Tocilizumab Tositumumab Tremelimumab Urelumab Ustekinumab History of bone marrow transplantation (including chimeric antigen receptor T-cell) or solid organ transplant Known history of Hepatitis B or Hepatitis C (patients who have completed curative-intent anti-HCV treatments are not excluded from trial) Positive result on hepatitis B or C screening Known history of mycobacterium tuberculosis infection at risk for reactivation Known history of gastrointestinal perforation Active diverticulitis Multi-organ failure as determined by primary treating physicians Any other documented serious, active infection besides COVID-19 - including but not limited to: lobar pneumonia consistent with bacterial infection, bacteremia, culture-negative endocarditis, or current mycobacterial infection - at the discretion of primary treating physicians Pregnant patients or nursing mothers Patients who are unable to discontinue scheduled antipyretic medications, either as monotherapy (e.g., acetaminophen or ibuprofen [aspirin is acceptable]) or as part of combination therapy (e.g., hydrocodone/acetaminophen, aspirin/acetaminophen/caffeine [Excedrin®]) CRP < 40 mg/L

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Interventional Model Description: Two sub-studies in parallel, each of three arms (maximum).
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Sub-study A, Tocilizumab-Free Standard of Care<br>Patient assigned to Sub-study A by primary treating physicians. Patient enrolled on trial sub-study A and randomized to receive no tocilizumab. | Other: Standard of Care<br>* Tocilizumab-Free Standard of Care<br>|
| Experimental: Sub-study A, Tocilizumab 40mg<br>Patient assigned to Sub-study A by primary treating physicians. Patient enrolled on trial sub-study A and randomized to receive tocilizumab 40mg. | Drug: Tocilizumab<br>* Tocilizumab 40mg<br>* Other names: Tocilizumab 40mg;|
| Experimental: Sub-study A, Tocilizumab 120mg<br>Patient assigned to Sub-study A by primary treating physicians. Patient enrolled on trial sub-study A and randomized to receive tocilizumab 120mg. | Drug: Tocilizumab<br>* Tocilizumab 120mg<br>* Other names: Tocilizumab 120mg;|
| Active Comparator: Sub-study B, Tocilizumab 400mg or 8mg/kg Standard of Care<br>Patient assigned to Sub-study B by primary treating physicians. Patient enrolled on trial sub-study B and randomized to receive standard of care tocilizumab dose (400mg or 8mgkg). | Other: Standard of Care<br>* Tocilizumab 400mg or 8mg/kg<br>|
| Experimental: Sub-study B, Tocilizumab 40mg<br>Patient assigned to Sub-study B by primary treating physicians. Patient enrolled on trial sub-study B and randomized to receive standard of care tocilizumab 40mg. | Drug: Tocilizumab<br>* Tocilizumab 40mg<br>* Other names: Tocilizumab 40mg;|
| Experimental: Sub-study B, Tocilizumab 120mg<br>Patient assigned to Sub-study B by primary treating physicians. Patient enrolled on trial sub-study B and randomized to receive standard of care tocilizumab 120mg. | Drug: Tocilizumab<br>* Tocilizumab 120mg<br>* Other names: Tocilizumab 120mg;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Time to Recovery | Day of recovery is defined as the first day on which the patient achieves one of the following two categories from the seven-point ordinal scale: 6) Hospitalized, not requiring supplemental oxygen or ongoing medical care or 7) Not hospitalized. Time to recovery is the number of days from randomization to achievement of this status. Note that the ordinal scale is measured once daily, with the patient's worst clinical status during the 24-hour time period (0:00-23:59) being documented. | 28 days | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Achievement of Recovery | This will be defined as the percentage of patients in a given arm of the study achieving one of the above two categories on the ordinal scale on day 7. Note that the ordinal scale is measured once daily, with the patient's worst clinical status during the 24-hour time period (0:00-23:59) being documented. | 7 days | 
| Overall Survival | This will be defined as the percentage of patients in a given arm of the study who are alive thirty days following randomization. Patients who are discharged to hospice will be counted as deceased on the day of discharge. Patients who are transitioned to inpatient hospice or inpatient comfort measures only will be counted as deceased on the day of transition. | 28 days | 
| Hospital Length of Stay | This will be defined as the number of days that pass between the day of a patient's randomization and his or her discharge from the hospital. | Up to 1 year | 
| Clinical Response: Maximum Temperature (Tmax) Response | Maximum temperature within 24-hour periods of time immediately prior to, immediately following, and then every 24 hours thereafter randomization. The primary endpoint is a measured Tmax in the 24-hour period immediately following randomization that is lower than the measured Tmax in the 24-hour period immediately preceding randomization. | 24 hours | 
| Clinical Response: Rate of Non-Elective Invasive Mechanical Ventilation | This will be a binary outcome defined as worsening COVID-19 disease resulting in the use of invasive mechanical ventilation during the course of the patient's COVID-19 infection. | Up to 28 days | 
| Clinical Response: Duration of Non-Elective Invasive Mechanical Ventilation | This will be a continuous outcome defined by the amount of time between initiation and cessation of non-elective invasive mechanical ventilation. | Up to 28 days | 
| Clinical Response: Time to Non-Elective Invasive Mechanical Ventilation | This will be a continuous outcome defined by the amount of time between randomization and the initiation of non-elective invasive mechanical ventilation. This will be treated as a time-to-event with possible censoring. | Up to 28 days | 
| Clinical Response: Rate of Vasopressor/Inotrope Utilization | This will be a binary outcome defined as utilization of any vasopressor or inotropic medication. | Up to 28 days | 
| Clinical Response: Duration of Vasopressor/Inotrope Utilization | This will be a continuous outcome defined by the amount of time between initiation of first and cessation of last vasopressor medications. | Up to 28 days | 
| Clinical Response: Time to Vasopressor/Inotrope Utilization | This will be a continuous outcome defined by the amount of time between randomization and the initiation of any vasopressor or inotropic medication. This will be treated as a time-to-event with possible censoring. | Up to 28 days | 
| Clinical Response: Duration of Increased Supplemental Oxygen from Baseline | This will be an ordinal outcome defined by the number of days counted from randomization over which the participant requires supplemental oxygen in excess over his/her baseline supplemental oxygen requirement. The supplemental oxygen requirement is defined as the highest liters-per-minute flow of supplemental oxygen required by the patient each day over the course of the hospitalization. | 28 days | 
| Biochemical Response: C-reactive Protein Response Rate | This will be a binary outcome defined as the presence or absence of a decline in CRP of ≥ 25% from baseline CRP in the 27 +/- 3 hours after tocilizumab administration, as compared to pre-treatment baseline. | 24 hours | 
| Safety: Rate of Secondary Infection | This will be defined as the percentage of patients in a study arm who develop serious non-COVID-19 viral, bacterial, or fungal infections (e.g., bloodstream infection, hospital-acquired pneumonia, ventilator-associated pneumonia, opportunistic infection) following randomization and up to the 28-day assessment of overall survival. | 28 days | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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COVID-19, Tocilizumab