“Leonard was deteriorating quickly and escalation to ITU for ventilation was not an option”, Dr Gentile explains. “As the patient wasn’t prepared to be artificially ventilated, the outlook was very grim.”
During this period, Dr Gentile was regularly reviewing the medical literature and maintaining regular contacts with his network of Italian colleagues involved on the frontline against Covid-19. Through this, he had become aware of multiple anecdotic reports of people in very severe conditions who had dramatically improved after treatment with tocilizumab – an immunosuppressive drug, commonly used in the treatment of rheumatoid arthritis.
“The AIFA, which is the Italian equivalent of the Medicines and Healthcare products Regulatory Agency, had just approved a large trial with tocilizumab and was actively recruiting people”, Dr Gentile continues. “The Italian experience seemed to mirror a preliminary yet promising experience from Chinese scientists, who used tocilizumab in 21 patients with very encouraging results.”
“Our patient had all the laboratory signs of the so-called ‘cytokine storm’ [an over-reaction of the body’s immune system], which I was aware of thanks to a paper published in the peer-reviewed journal, The Lancet. The same paper speculated that tocilizumab, among other anti-interleukin 6 drugs, could be used to treat patients with severe COVID-19 pneumonia and hyper-inflammation, who are at high risk of progression towards acute respiratory distress syndrome and death.”
“I was desperate to try to save the patient”, explains Dr Gentile. “To me, tocilizumab seemed like the only viable option left to try and save his life. Luckily, we have brave, compassionate and open-minded leadership here at the RCHT. They gave me the greenlight to use tocilizumab on compassionate grounds. The patient agreed to receive the treatment, which was then quickly administered.”
Registered Nurses Natalie Cookman and David George administered the treatment on Wheal Prosper ward. Mr Whitehurst received two infusions of tocilizumab 12 hours apart. Before the infusion, the patient’s oxygen saturation was 75% on 19 litres of oxygen. After the infusion, his clinical conditions and his oxygen saturation improved very quickly, and then kept improving gradually and steadily over the subsequent days. In parallel, his oxygen requirement decreased gradually over time.
“At the time, we were at the very beginning of the Covid-19 crisis in the UK and the national lockdown had just been declared. So, it is quite possible that the RCHT has been the first NHS trust in the UK to successfully treat a patient with tocilizumab”, Dr Gentile adds. “We’re certainly among the first. This kind of innovation and collaborative learning would not be possible without such a dedicated staff and our colleagues going above and beyond to provide the best care for our patients.”
Dr Gentile would like to highlight the work of nurses Natalie Cookman and David George, and the whole Wheal prosper Team, for their care and support; Dr Becky Davies for her care of Leonard and her enthusiasm for this treatment; Iain Davidson, Chief Pharmacist, who procured the medication out of hours; Andy Pothecary, who gave additional guidance on drug administration; as well key leaders from RCHT, including Chief Executive Kate Shields, Medical Director Allister Grant and Deputy Medical Director Gillian Derrick, who supported the appeal for treatment.
Last week, Mr Whitehurst was discharged from hospital. “David and I saw the patient on Wheal Prosper to say goodbye and wish him well”, Dr Gentile continues. “He was happy and smiling and overjoyed to go home.”
Dr Gentile concludes: “Although tocilizumab did work for our patient, I would like to emphasize that further evidence from rigorous randomised controlled trials is necessary to fully establish the role of this drug in Covid-19 pneumonia. The largest of those studies is the RECOVERY trial, coordinated by Professor Peter Horby at the University of Oxford, which is currently trying to establish the role of tocilizumab, hydroxychloroquine, dexamethasone, azithromycin and lopinavir/ritonavir in patients with Covid-19.”
Mr Whitehurst adds: “I would like you to pass on my heartfelt thanks to all the staff on Wheel Prosper ward. I was quite overwhelmed on leaving the hospital, and I am truly grateful for everything the teams have done for me.”
Sarah Budden, Clinical Matron for Renal, Endocrine and Medical Day Unit, adds: “We are extremely proud of the successful treatment for Leonard and Wheal Prosper ward have been delighted to be part of this gentleman’s care.”
Speaking on behalf of the Trust, Chief Executive Kate Shields adds: “This brave clinical leadership helped to save a patient’s life. We are proud of Dr Gentile and everyone involved in making this innovative treatment possible and overwhelmed by the care, compassion and dedication of our colleagues during this difficult time.”