Teamwork tackles Tocilizumab

One of the most difficult challenges during the pandemic is supporting patients who are struggling to breathe. COVID-19 patients who require significant amounts of oxygen to breathe may sometimes benefit from a drug called Tocilizumab to help address the inflammation in their lungs.

Tocilizumab is traditionally used as an arthritis medication to target inflammation and life-saving cancer treatment. Before the third wave, outcomes from studies and a major global trial prompted the recommendation for use of tocilizumab in new provincial guidelines.

As the third wave hit, confusion and the absence of a standardized process prompted the need to understand more about the timing, dosing and criteria for its correct use, especially as demand quickly impacted the supply. Soon, the province suggested a lower dose to manage stock levels.

With mounting supply issues, we often had no idea what size vial we would get or when we would get more. Tocilizumab is very expensive, so we were extremely cautious not to waste a single vial.

QCH pharmacy, medicine, rheumatology, and infectious disease (ID) physicians worked together to develop an internal process for dispensing Tocilizumab based on patient demand and available doses. The group established a time of day to determine which patients needed the drug at that time, and then they would prepare just enough for those patients.

A carefully planned approach

The approach was established in combination with ethics counsel and an overall decision by the QCH Medical Advisory Committee. Physicians would identify patients, consult infectious diseases, and track to determine who would be eligible for the one-time dose. Each day, the ID physician would round with our ASP Pharmacist to assess each patient for appropriateness and potential safety concerns with Tocilizumab administration. If there were more eligible patients than doses available, a randomization process would need to occur to determine which patient would receive the dose.

Thankfully, we never had to randomize the dispensing of Tocilizumab for our patients, due to our careful stewardship.

Cameron Forbes, QCH Infectious Diseases Pharmacist

A regional solution

These experiences resulted in a regional dashboard created by QCH Infectious Diseases Pharmacist, Cameron Forbes. Patients can be submitted centrally and randomized (if needed) to determine who will get the doses, ensuring an equal and ethical opportunity for those patients across our region to get their dose. Joe Dagenais, QCH Director of Pharmacy, serves as co-chair on this regional working group.

Working hard behind the scenes

Supporting COVID-positive patients during the pandemic has been extremely challenging for all our nurses and physicians. The pharmacy team has worked tirelessly to ensure that the burden of medication availability is never a concern for the care team. Despite the immense behind-the-scenes work to ensure stock levels and battles with backorders, these tense moments are often unknown to those who continue to provide exceptional patient care.