We discussed phenomenon of giving it to the elderly comorbid patients and ending up with no death, but persistent ventilator dependence, need for trach and very long term care with severe debilitation. Not sure this is a positive for them. You hate to play "God" but I think it's pragmatic medicine in a pandemic. So we are limiting its use in these patients.

Age cutoff? Other than liver other comorbidities that exclude pts?
Thanks for posting the info.

No physician discretion.

Most hospitals are not using tocilizumab because most guidelines recommend not using it outside of a clinical trial. Dangerous drug to play around with with no good evidence to back it up. I'm sure Recovery trial investigators would have already tweeted results if they were positive.

Anecdotally have seen some unusual infections in patients that received toci.

We have been giving it our ICU. Not sure of our protocol, but apparently it's part of a trial.

A patient on our step down floor received two doses of 400mg on consecutive days. That's likely what we do in ICU. Pulmonologist wanted him in ICU but beds were scarce. Guy in his 50s with no known medical history, but likely had some underlying hypertension and maybe some other things. Typical working class guy that never went to the doctor.

It's really sad throwing the kitchen sink at some people and just nothing seems to make them better. We put some older folks on hospice this week rather than continue with aggressive treatment. Not really much else we can do but hope they get better on their own. It's depressing being helpless.

There have been 3 pos non RCT trials with toci. One neg RCT suspended recently because they couldnt reach an endpoint (mortality). However in that paper there was a decreased need for mech vent in toci arm. The NiH RCT is ongoing. To say it's not being used is inaccurate. All major hospitals in my city using it in some capacity. Anecdotally it works from my experience. Ive posted numerous cases on here.

I'm not at all trying to call you out but you said the same about hydroxy. I just don't believe in using a potentially dangerous drug without some real RCT evidence. IDSA and mass general guidelines discourage use except as part of a trial. Thats good enough for me.

I'm not seeing anywhere the results from dexamethasone i had hoped either.

Marcus Aurelius said:

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HCQ post was from 3/20. The beginning. Before we had any data. Toci is different. We are much further into this. My pts are dying. Alot of them. Including younger salvageable ones. Hard to sit back and do nothing with a drug that has some evidence it works. Not sure what your background is but it's easy to play ivory tower from the sidelines.

And I haven't posted positively about HCQ for mos BTW.

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I am trying to preserve my anonymity a bit but suffice it to say I am in a similar position as you. I am not in an academic institution. I am in a large city and there is very little toci usage here. This is agreed upon between ID, pulm, rheum. Surely you must admit that the evidence supporting it is very, very thin. Mainly a few very small observational studies with no control groups. This is a drug with serious potential for adverse effects.

I certainly do agree with you that it is hard to sit there and do nothing but sometimes that is the evidence based way to practice.

I have been following this board for a few months but not posting here. Really not trying to argue and glad that your patients have such a dedicated physician. If anything, it's interesting that there seems to be some significant regional variations in practice. Our group has been primarily following the Mass General guidelines which I think are very well thought out and evidenced based. They quickly dispelled all of the BS about this being a "different" sort of ARDS, etc.

Well. We will agree to disagree. I will continue to use it as will my partners. For patients who would otherwise die anyway. Especially as I have seen success anecdotally. Some of it amazingly so. If the NIH and other studies refute its benefit and it's denied, so be it. For now - during an unprecedented pandemic, when the TIMI level evidence is lacking, I will do what I can. I admit the pos evidence isnt overwhelming but what else is so far into this? Even the dex and remdisivir data isn't overwhelming.