Encouraging effectiveness results and lack of adverse events with tocilizumab and remdesivir in premature twins with COVID-19 “have important implications for their potential expanded use in younger children and infants,” researchers report. “We encourage a thorough risk-benefit analysis for each specific case in considering use of remdesivir and tocilizumab with severe COVID-19.”
The twins, a boy and a girl, were 6 weeks old when they developed symptoms of COVID-19. “Our 2 cases had apnea as the presenting symptom for their SARS-CoV-2 infection and subsequently developed severe COVID-19 pneumonia 5 to 7 days after initial presentation,” the authors write. “Given their worsening illness, we treated both cases with dexamethasone and remdesivir and observed significant improvement in case 2. For case 1, his persistent and severe hypoxic respiratory failure prompted us to provide escalation of therapy with tocilizumab. At that time, we assessed his mortality risk from hypoxic respiratory failure to exceed the potential risks of treatment with tocilizumab. The risk of the FDA black box warning of serious infections from the immunomodulatory properties of tocilizumab were believed to be relatively low. We conducted a careful review of benefits and risks with pediatric infectious disease and rheumatology specialists and obtained informed consent from parents before administering tocilizumab. Although it is not possible to ascertain a causal relationship from this report, he did show gradual improvement after receiving tocilizumab. [In one study,] adult patients who were treated with tocilizumab for severe COVID-19 and 22% of the patients did receive a second dose of tocilizumab. Interestingly, the patients who received a second dose had poorer clinical outcomes, likely because of selection bias as those who were sicker were more likely to receive an additional dose. There is insufficient data for NIH guidelines to recommend for or against a second dose of tocilizumab, but we would have considered a second dose for case 1 if the patient showed evidence of clinical worsening (sustained fevers, increasing inflammatory markers, or worsening respiratory status) had the putative immunomodulatory effects of the medication waned.”