Marcus Aurelius said:

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It's down a bit. mid upper 20s. We have people still dying, but probably less so than beginning. IMO there seems to be a subset of pts with this who get bad sick, get the kitchen sink thrown at them, yet don't respond. Frustrating. Those mainly older pts. The med school hospital has over 120. Think hospitalization declines will lag behind

Our group has been called out for a meeting Thursday about "the overuse" of tociluzimab. It can only be given by a pulmonologist. An unabashedly for profit hospital.They are quick to point out a dose is $2000. 1-2 are usually given. They say we are an "outlier". Not sure who they are comparing us to, but I assume within the corporate hospital chain. It is the largest thus highest acuity hospital in the chain of 250 or so. So there's that.

Still an experimental drug, with papers so far showing some pro some con. But - I've seen it work. And all my partners and colleagues who I've spoken to agree. And these people are the sickest of the sick. We use the standard guidelines - sudden rise in inflammatory markers, associated with worsened multi-organ failure.

I will say that many of these families expect everything done. No matter what the cost or evidence. I have a man on the vent 100% FIO2 for 4 weeks. No improvement. He has received everything. The wife asking me still why we didn't give him HCQ when he was admitted after 8 days of COVID. She asked to have CTS consult for ECMO who appropriately said he wasn't a candidate. So many very unrealistic. Difficult and high pressure/stress to take care of them.

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Marcus Aurelius said:

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Update for those interested. Meeting with hospital not too bad. We came up with criteria for tociluzimab eligibility.
For uniformity. Here it is:



Tocilizumab (Actemra) Criteria*
Inclusion

ARDS with worsening oxygenation PLUS worsening radiographic imaging, and at least one of the following:
Vented with PF ratio <200 or increasing FIO2 > 70%
Increasing oxygen requirements > 6L/min or < 93% saturation

PLUS
Markers of Inflammation in Cytokine Storm (2 or more of the following):
Ferritin > 1000 ng/ml
LDH > 250 IU/L
CRP > 200 mg/L
D-dimer > 1000
Lymphocytes < 800
Persistent Fever > 101 F
Exclusion
AST or ALT > 5 X ULN

Active bacterial or fungal infection (Relative exclusion; weigh risk/benefit ratio)

*Consider weighing risk/benefit ratio (i.e., age, comorbidities) as very limited evidence to support the safety and efficacy of IL-6 inhibitors for the treatment of Covid-19 at this time.


Curious as to thoughts of other hospital docs. Comments and comparisons to other protocols.

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