COVID-19 Immunomodulator (Baricitinib, Tocilizumab, Sarilumab) Orders

NOTE: supply of these medications can vary week to week and facility to facility. It is important to follow local updates about medication availability and the latest recommendations for preferred medications.

Baricitinib

Baricitinib ("Olumiant") is a Janus kinase (JAK) inhibitor typically used for treatment of rheumatoid arthritis. In addition to immunomodulatory effects, it is thought to have potential antiviral effects through interference with viral entry. It may be used to treat hospitalized patients with severe acute COVID-19 pneumonia, if specific conditions are met.

Clinical Requirements

  • The patient is experiencing significant progressive respiratory failure due to COVID-19 pneumonia, characterized by:

    • Invasive or non-invasive ventilation (e.g., Continuous Positive Airway Pressure or Bilevel Positive Airway Pressure) OR

    • Supplemental oxygen to achieve a minimal SpO2 of 90%, in the form of one of the following:

      • Heated high flow oxygen with FiO2 > 0.5 (e.g., Optiflow, Airvo)

      • Oxygen delivered via nasal prong at a rate >6 L/minute

      • Mask-delivered oxygen with FiO2 > 0.5 (e.g., non-rebreather or Venturi mask)

    • AND

      • The patient has not received tocilizumab for the treatment of COVID-19 during the current hospitalization

Administration

    • Treatment is limited to a 14-day course (or until discharge, whichever is sooner) of the following doses based upon eGFR:

      • eGFR 60 ml/min/1.73 m2 or greater: baricitinib 4 mg po/ng once daily

      • eGFR 30-59 ml/min/1.73 m2: baricitinib 2 mg po/ng once daily

      • eGFR 15-29 ml/min/1.73 m2: baricitinib 2 mg po/ng every other day (q2d)

      • eGFR < 15 ml/min/1.73 m2: avoid baricitinib

  • Active highly suspect or proven non-COVID infections and severe underlying immunocompromise are relative contraindications to receipt of baricitinib --> specialist consultation (e.g., internal medicine, infectious disease, critical care) is recommended in these cases

Resources

Tocilizumab

Tocilizumab ("Actemra") may be used to treat hospitalized patients with severe acute COVID-19 pneumonia, if specific conditions are met.

Clinical Requirements

  • The patient was admitted to hospital due to COVID-19 seven or fewer days prior OR developed symptoms due to hospital-acquired COVID-19, while in hospital for other reasons, seven or fewer days prior

  • AND

      • The patient is experiencing significant progressive respiratory failure due to COVID-19 pneumonia, characterized by:

        • Invasive or non-invasive ventilation (e.g., Continuous Positive Airway Pressure or Bilevel Positive Airway Pressure) OR

        • Supplemental oxygen to achieve a minimal SpO2 of 90%, in the form of one of the following:

          • Heated high flow oxygen with FiO2 > 0.5 (e.g., Optiflow, Airvo)

          • Oxygen delivered via nasal prong at a rate > 6 L/minute

          • Mask-delivered oxygen with FiO2 > 0.5 (e.g., non-rebreather or Venturi mask)

Timing

  • Mechanically ventilated patients

    • Administer tocilizumab no more than 24 hours after initiation of mechanical ventilation

  • All other patients

    • Consider administration of tocilizumab as soon as possible once the above clinical criteria have been met in a context concerning for progressive respiratory failure

Administration

  • Use is restricted to a SINGLE DOSE per patient per hospitalization, based on the following weight-based dosing:

    • 40 kg or less: 8 mg/kg

    • Greater than 40 kg: 400 mg

  • Specialist consultation (e.g., internal medicine, infectious disease, critical care) is recommended prior to starting therapy if the ordering clinician is not familiar with tocilizumab use

Resources

Sarilumab

Sarilumab ("Kevzara") may be used to treat hospitalized patients with severe acute COVID-19 pneumonia, if Tocilizmab is not available and specific conditions are met.

Clinical Requirements

    • The patient was admitted to hospital due to COVID-19 seven or fewer days prior OR developed symptoms due to hospital-acquired COVID-19, while in hospital for other reasons, seven or fewer days prior

      • AND

        • The patient is experiencing significant progressive respiratory failure due to COVID-19 pneumonia, characterized by:

          • Invasive or non-invasive ventilation (e.g., Continuous Positive Airway Pressure or Bilevel Positive Airway Pressure) OR

          • Supplemental oxygen to achieve a minimal SpO2 of 90%, in the form of one of the following:

            • Heated high flow oxygen with FiO2 > 0.5 (e.g., Optiflow, Airvo)

            • Oxygen delivered via nasal prong at a rate > 6 L/minute

            • Mask-delivered oxygen with FiO2 > 0.5 (e.g., non-rebreather or Venturi mask)

      • AND

        • The patient has not received baricitinib for the treatment of COVID-19 during the current hospitalization.

Timing

    • Mechanically ventilated patients

      • Administer sarilumab no more than 24 hours after initiation of mechanical ventilation

    • All other patients

      • Consider administration of sarilumab as soon as possible once the above clinical criteria have been met in a context concerning for progressive respiratory failure

Administration

    • Use is restricted to a SINGLE DOSE of 400 mg sarilumab intravenously per patient per hospitalization

Consultation

  • Specialist consultation (e.g., internal medicine, infectious disease, critical care) is recommended prior to starting therapy if the ordering clinician is not familiar with sarilumab use, when severe immunocompromise is present or when active non-COVID infections are highly suspected or proven.

Resources

Resources