We have one dose of toci left in pharmacy. No access to remdisivir. Told IL-6 inhibitors becoming unobtainable. 400 bed non-academic hospital. No clinical trials in hospital. Others experience? We have many hovering cytokine storm. Many will die until these drugs are available. I strongly think these will be shown to be efficacious with due science. Is it best to be admitted to an academic center if you're really sick with COVID-19 until the research is completed? I'm beginning to think so. Food for thought.
Remdisivir and tociluzimab / sarilumab availability????
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Last: 4 yr ago by FCBlitz
I do believe it is best to be admitted to an academic hospital based on what you said. I don't believe this is fair but it is the sad reality. One thing to consider is some of the inclusion/exclusion criteria for these studies. A few of the criteria that I am aware of for the remdesivir study is no other concurrent treatment(no HCQ, IL 6 inhibit is), a positive test in the last 4 days, etc.
Sorry. .. has to be frustrating.
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Terribly. I have 2 50 y/o males circling the drain. 1 toci dose left. Plus 2 90 somethings with it. Rationing. These pts are so miserable. Unrelenting fever. Resp rates in 40s. Pain. No sleep. Misery. Really scary to see it firsthand. I want it to be over.
Are you using convalescent plasma Marcus?
I think it was infectious Ag that gave a half dose of Toci recently to preserve and got good results?
Have'nt yet. We are looking into it.
Normal dose 800mg. Yes we gave 400mg. We have 400mg left.
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Sounds like a terrible situation and you seem to be doing the best you can. Have you had any luck proning, anticoagulating, nitric oxide?
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AG
Sorry, that's brutal to hear.
How hard do we think it's going to be to get those drugs kick started into high gear production?
How hard do we think it's going to be to get those drugs kick started into high gear production?
can anyone explain the hurdles that Gilead and Roche have to go through to fast track and mass produce these drugs. Is it "raw material" issues or the length of time to make, etc?
Yeah. Doing all I can with this stuff. These drugs are game changers.Slaytebeling said:
Sounds like a terrible situation and you seem to be doing the best you can. Have you had any luck proning, anticoagulating, nitric oxide?
With the oxygenation problems, have transfusions helped at all? And any tries of anti TNF drugs?
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Haven't tried transfusions at non academic center. But I am interested in your idea. Haven't seen terrible anemia in these pts. Even though we draw the COVID-19 lab panel daily essentially (CBC diff, LFTS, CRP, ferritin, BMP, D Dimer, BNP).
Very interested in this as well
Is there any potential to try Anakinra or siltuximab (Sylvant) against the storm without the availability of the other two?
I do not think it is anemia. I think the virus messes with the rbcs ability to oxygenate. Which is also one of the theories behind hydroxychloroquine helping due to its effect on the porphyrin stuff in rbcs.
I might even consider drawing a couple of units off and transfusing a couple of healthy units. What can you lose?
I might even consider drawing a couple of units off and transfusing a couple of healthy units. What can you lose?
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Only thing that disputes this. Their Po2 is damn low. and correlates with O2 sat. i.e. no "rogue COVID-Hgb" species. But who the hell knows. Damn thing is not natural. WUHAN.
https://www.biopharma-reporter.com/Article/2020/03/25/Roche-ups-Actemra-production-for-coronavirus-trialsAggie95 said:
can anyone explain the hurdles that Gilead and Roche have to go through to fast track and mass produce these drugs. Is it "raw material" issues or the length of time to make, etc?
I'm pretty sure they're going balls out on this but it seems to be really expensive for its intended purpose of treating rheumatoid arthritis so I imagine the production process isn't easy to ramp up quickly
Marcus,
Dermdoc mentioned TNF inhibitors. Have you guys considered it? We have had 2 Covid patients that I would classify as mild compared to what you have been dealing with. We have discussed using TNF inhibitors as a last resort if we ran out of Toci. Several studies out there where the TNF inhibitiors improved survival in lab mice after infection with H1N1 and subsequent cytokine storm. What are your thoughts?
Dermdoc mentioned TNF inhibitors. Have you guys considered it? We have had 2 Covid patients that I would classify as mild compared to what you have been dealing with. We have discussed using TNF inhibitors as a last resort if we ran out of Toci. Several studies out there where the TNF inhibitiors improved survival in lab mice after infection with H1N1 and subsequent cytokine storm. What are your thoughts?
Are you giving high dose statins to low/medium risk patients with + Covid 19 patients as they enter the hospital?
Have you considered reaching out to CytoDyn for leronlimab? I believe their initial usage for cytokine storm in Covid-19 patients looked promising.
UTSW is participating in both siralumab and remdesivir clinical trials and we have access to compassionate convalescent plasma as well. They have toci in house as well though not sure what the stock is right now (I'm off service this week at Clements). We have toci at the Dallas VA as well. Not sure what Parkland is looking like as far as toci stock as I haven't been on service there since this started.
My understanding of the transfer process to CUH for COVID is minimal but it wouldn't hurt to look into that if you have a patient who needs something you can't offer right now.
My understanding of the transfer process to CUH for COVID is minimal but it wouldn't hurt to look into that if you have a patient who needs something you can't offer right now.
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With limitations getting these drugs, all of our severe patients with CRS are getting at least three rounds of plasmapheresis and solumedrol with decent results. Albeit most of this cohort are on ECMO, those of which on ECMO and not intubated having fewer complications.
When you say "many" can you give a range?
Spoke with Genentech rep. They are shipping toci on case by case basis. We have one dose. 2 pts teetering on storm. Haven't pulled trigger. No access to sirulimab here.
Transfer idea interesting. At this stage sadly I don't think that is viable option as university hospital taking the large burden of COVID-19 already.
Maybe someone knows a rheumatologist who has a patient with extra actpens. Would be a huge ask but it's literally a life or death situation as it stands
Marcus what criteria are you guys using for IL6 inhibitor initiation? To my knowledge I am not sure any has been used in our system. Is it respiratory rate of 30 breaths/min or more, SpO2 of 93% or less, and PaO2/FiO2 of 300 mm Hg or less?
Thanks
Thanks
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Upon the onset of cytokine storm. When inflammatory markers skyrocket. Hypoxia worsens dramatically. LFTs elevate dramatically, renal fxn worsens. You can't miss it if you are ordering the "COVID-19 orderset."
In those patients in downward spiral who get toci, what percentage are you able to stabilize and avoid intubation/escalation in care?
All the cytokine storm patients I've seen have been intubated. I haven't experienced a death in anyone who received toci so far. But, relatively small numbers. Anecdote, once again, interestingly I've haven't see any cytokine stormers since we started pushing these patients and are avoiding intubation. Makes one think.....
WTH, bad news on Remdisivir
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