Can the Early Warning Score (ANDC) Predict Tocilizumab Efficacy in Patients with COVID-19 Cytokine Storm?

Background: The aim of this study is to assess the effectiveness of the Early Warning Score [ANDC (age
(A), neutrophil-to-lymphocyte ratio (NLR (N)), D-dimer (D), and CRP (C)] in predicting the treatment
response in patients receiving tocilizumab for Coronavirus Disease 2019 (COVID-19)-related cytokine storm.

Methods: A retrospective review of medical records was conducted for patients treated with tocili-
zumab for a cytokine storm related to COVID-19 between April 1, 2020, and April 1, 2021. Patient
demographics, clinical characteristics, and laboratory parameters within 24 hours before tocilizumab
were recorded. 1.14 × (age − 20) (years) + 1.63 × NLR + 5.00 × D-dimer (mg/L) + 0.14 × C-reactive
protein (CRP) (mg/L) was used as the formula for the ANDC score. The study population was divided
into 2 groups: those who died within 28 days of receiving tocilizumab and those who recovered. A
comparative analysis was conducted.

Results: Within 28 days of tocilizumab treatment, 59 (35.32%) patients died. In comparison with living
patients, deceased patients exhibited considerably higher levels of interleukin (IL)-6, lactate dehydro-
genase (LDH), ANDC score, and CRP (P < .05). Lactate dehydrogenase was an independent predictor
of response to tocilizumab treatment (P < .001) in a multivariate logistic regression analysis. In patients
who did not receive steroid therapy before tocilizumab treatment, the ANDC score had the highest
area under the curve (AUC). The optimal cut-off value was determined to be 92.56, with a sensitivity
of 91.67% and a specificity of 60.61% (P < .001). In patients receiving steroids before tocilizumab, LDH
had the highest AUC. The optimal cut-off value was 484.5 U/L (P < .001).

Conclusion: Lactate dehydrogenase was identified as an independent predictor of response to tocili-
zumab treatment. The ANDC score showed the highest AUC value in steroid-naïve patients before
tocilizumab, whereas LDH showed the highest AUC value in patients receiving steroids before tocili-
zumab. Both the ANDC score and LDH levels show potential as valuable tools to guide treatment
decisions.

Cite this article as: Kılıç Ö, Tecer D, Nur Kaya M, Çınar M, Yılmaz S. Can the early warning score (ANDC) predict tocilizumab efficacy in patients with COVID-19 cytokine storm?. EurJRheumatol. 2025, 12(1), 0048, doi: 10.5152/eurjrheum.2025.24048.